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BETTS, Cletii of (Ac ScnUhgm Diitria of Ntw-'faiK PREFACE BY THE AMERICAN EDITOR. The exalted reputation acquired by this Dictionary having obtained for it almost exclusive preference in Great Britain, on the Continent, and throughout the United States, it will be altogether unnecessary for the publishers to in- troduce the work or its distinguished author to the American public by any new testimonials. Nor will it be expected of the American editor to attempt a laboured commendation of this compendium of surgical literature, with the view of attracting a larger share of attention from the profession than it has already received in its former publications in this country. It has long been esteemed a standard work, is adopted as a text-book in our universities, colleges, and schools of medicine generally, and finds a place in the library of every surgeon in the country. The first republication in this country was edited by the late distinguished Dr. Dorsey, of Philadelphia ; whose valuable improvements carried it through a second and third edition ; and under the title of “ Dorsey’s Cooper,” it rapidly gained upon public favour. The author availed himself of most of the Ameri- can additions in revising his -work for a fourth edition, from which it was again reprinted in America, with an appendix, by Mr. Wm. Anderson, of New-York. Since that time, Mr. Cooper has published a fifth, and recently a sixth edition, improving and enlarging the work by availing himself of the new and valuable discoveries in surgical knowledge to which he has access ; and from this last revision of 1830, the present stereotype edition is republished. And as it has passed through two revisions by the author since it was printed in America, and the last includes all that is novel and interesting among British and conti- nental surgeons down to the present year ; its republication, even without any semblance of improvement, will be acknowledged to be a desideratum by all who would keep pace with their improving profession. As in eveiy^ species of human science our highest attainments are but an approximation towards perfection, so in the science of surgery, each succeeding year demonstrates that all that is known of the principles or practice of our art, is but the prelude to still higher exhibitions of science and skill, alike honourable to the profession, and valuable to the cause of humanity. To con- '^ense and arrange all the novel and interesting facts which clinical experience is furnishing, and upon which alone the edifice of true science can be erected, is a task worthy of the immense labour which Mr. Cooper has bestowed on each succeeding reprint of his Dictionary, and one to which he has proved him- self entirely adequate. The extensive and multiplied resources to which he has access, furnish him with facilities possessed by few ; and in availing himself of these, he has exhibited an industry, and, for the most part, an impartiality, worthy of all praise. A 2 IV PREFACE. Within the last few years, our profession, and especially the department of Chirurgery, has been making steady, and even rapid advances in almost every country. Many diseases forrnerly among the opprobria of our profession have yielded to the sciencea^ skill of modern surgeons. Besides the vast improve ments made in th^#^fe^ment of surgical diseases, operations have been per- formed with entire success for the relief of injuries, but a few years ago esteemed irremediable ; and some of them of so bold and difficult a character, that to propose them would have been a hazard of reputation which but few could have then survived. Learning is not indigenous to any country ; and although national pride sometimes prompts to exclusive pretensions, yet the history of surgery, so far as this is concerned, forbids such presumptuous arrogance. The question, “ Who hears of American surgeons ?” is no longer tauntingly repeated ; since the discoveries and operations of some of them have extorted a tribute of admi- ration from almost every country where this science is cultivated, and given to their names professional immortality. In this, as in the other departments of learning, we may be allowed to say, without the imputation of vanity, that our countrymen have shown to demonstration, that when the tree of science is trans- planted across the Atlantic, it is capable of taking as firm a root as in its native soil. The improvements which surgery has received in the United States, and especially within a few years, although highly important to the interests of the profession and to the cause of suffering humanity, are far from being generally known even in our own country, and still less to the profession abroad. Our periodicals containing them have but a limited circulation, and local views have multiplied their number, until many of the States, and most of our medical institutions, have a vehicle of their own ; thus still farther contracting the sphere of their usefulness. And although several of them are most ably con- ducted, and are adapted to general circulation, we are yet without the advantages which would result from a periodical, strictly national, in which the whole pro- fession might combine their energies for the promotion of science, and to which all might have free and equal access. From these periodicals our European brethren obtain their information relative to the state and progress of medical and surgical science among us, and some of them never find their way either into Great Britain, France, or Ger- many. Hence foreign authors are so often charged with criminal remissness in their notices of American surgery. But when we advert to the small pro- portion of the surgical improvements of this country which have ever been published at all, and recollect that of these but a few are ever seen by our British or continental brethren, we may find an apology for much of the neglect of which we have complained. That there has been a disposition on the part of some European writers to pass over in silence every thing American, has long been a subject of remon- strance ; and in relation to some of these, there is doubtless just ground of complaint. How far Mr. Cooper will be found in the same condemnation will be estimated by those who peruse the present edition, and who will, of course, award him due praise for so much as he has said of American surgery. It is difficult to believe that he has introduced all he knew on this subject, and it is certain that he might have known much more equally worthy of his notice. In preparing the present edition for the press, the publishers have desired that it might include all that is novel and interesting among American surgeons ; and PREFACE. V have committed to the present editor the task of collecting and arranging the materials furnished by our periodicals and original publications, and of con- densing these with such original matter as he might be able to obtain, sufficiently important to merit introduction into this Dictionary. To perform this duty in a manner which should be acceptable to the profes- * sion and useful to the community, no pains or labour has been spared. How far he has succeeded in this humble task of compiling from the productions of his fellow-countrymen an epitome of American surgery, remains to be ad- judged by those for whose benefit he has been thus employed. He claims no merit for himself, other than that of having rendered, as far as possible, equal and exact justice to the claims of gentlemen in every part of our common country, whether living or dead ; and for this purpose, he has availed himself of every accessible means. He has corresponded with distinguished surgeons in various and remote parts of the land, from many of whom he has received communications of great merit and practical importance. To the periodicals of the last few years he has had frequent recourse, and from most of them he has extracted improve- ments and inventions which cannot fail to interest and instruct. He must also acknowledge his obligations to Dr. Gross’s edition of Tavernier’s Operative Surgery; Dr. Sterling’s translation of Valpeau’s Surgical Anatomy ; and to the late Philadelphia edition of Cooper’s First Lines, with notes by Professor Stevens, of New-York, and the “ Philadelphia Editor.” To a number of his professional friends in New-York, as well as in dis- tant parts of the United States, the editor is greatly indebted, not only for the assistance rendered, but for the encouragement they have given him in the performance of this duty. And although he has not heard from some who had promised communications, yet he has availed himself of their pub- lished works, and introduced all the operations they claim, so far as his limits would permit. The limits assigned him by the publishers for enlarging the work, have rendered it necessary to abbreviate and condense many new and important surgical improvements more than was agreeable to his own wishes ; and this must be his apology for so frequent reference to the works and periodicals in which they are recorded at length. The same reason will account for the brevity of many of the notes, which consist of mere hints, upon which some amplification would have been more congenial to his own views, and perhaps more acceptable to the profession. It is but an act of justice, however, on the part of the editor towards the publishers to state, that they have sufiered him to transcend their limits very considerably, and allowed him a brief ap- pendix for the purpose of introducing some articles unavoidably omitted under their appropriate heads. It will be perceived by those who have the opportunity of comparing this with the late London edition, as revised and enlarged by the author, that it contains the whole of the matter of that edition, although the size of the type has somewhat diminished the number of pages. Although many of the terms, doctrines, and operations are now obsolete, and might very plausibly be omitted, yet as Mr. Cooper has seen fit to retain them, it has been thought* best to make no alteration whatever in the work, and hence also the long catalogue of references at the end of each article is preserved, although many of the works cannot be obtained in this country. The original matter introduced by the American editor will be found im-» vi PREFACE. bodied in the text, in immediate connexion with the subject to which it refer s, except where an occasional foot note for obvious reasons has been preferred. To distinguish it from the rest, it is included within brackets, and at the close of each of these additions will be found the surname of the editor. This method of making mterpolations in the body of the work may ap- pear less imposing than an array of additions in an appendix at the end of the book, or a display of notes at the foot of the pages, distinguished by asterisks, obelisks, .• r' •;‘=J ^ •tW*-'' • - ' "• T , 1 ,,, -. _ I . - ^ -7 f'c -f'^.’SHU'*. ; . .s'ii,'-' f' , . ./*.. ■. . ■ . ,.«/. > i -ti t t •, .n.tf , A ..Vjy-I .f**-. » , »- .A . v. XirfV" ■if'^V ^ ■• : i i 1.15 f 7. ' ^ J •••v. l Ht ii I li;', ' • . : , . '-iUJit ; . I * ',4 . A/ 1 ^4 ,' '■ 'i: !-‘. ' ■ 17-= . . .1*- ' ' ‘•-■? •lor^ •■•',. ' '^^f-.. i - 'V^ ^ ‘ . \ . ,•»• . '* / '■n m*. ^ - -.vv *.? v' ' nitiitTf ’ i ■.■ .'*■: / " . -, .v fjt -iv^ f ■; X, ii ^ 3 * ' ' ' * I . ' j ■ ' Vf.r<75/ir v: ; .-Ki7r;i:.Iir ■■- t j'Uv/^ [lit I'; ■' . •; -i^O nurij '^i' ■‘- >l .,J:- . ;-‘ i r’ilj 't‘j 'i-^:,j.^'u. '. '. if. 1 - ^;....jc ;a '' ■ I- • ni'^ird^iitv w fi /. Vy ffjffs/ L -i I y-^.- ' , Aii;fii»tm j rt tUhA i d'>hhr oJ i inf. .-V - ' ■ 4 ’. " ' ■ ■^• Oi ' it’ ■ SURGICAI. DICTIONARY. ABD A BA.PTISTON. (From d, priv. and Panr^uj, im- mergo, to sink under.) Galen, Fabricius ab Aqua- pendente, and especially Scultetus, in his Armamemta- riam Chirurgicum, so denominate the crown of the trepan, because it formerly had a conical shape, which kept it from penetrating the cranium too rapidly, and plunging its teeth in the dura mater and brain. While, however, it is admitted by modern surgeons that mischief may be done by letting the saw penetrate too deeply, they do not find it necessary to obviate the possibility of such an accident, by using a conical tre- pan, with which it would be difficult to make any per- foration at all ; but they guard against the danger, by observing particular rules and cautions laid down in another part of this book.— (See Trephine.) ABDOMEN. The Belly. When a surgeon speaks of the cavity of the abdomen, he confines his meaning to the space included witliin the bag of the peritoneum. Hence, neither the kidneys nor the pelvis viscera are, strictly speaking, parts of the abdomen. Anatomists have divided the abdomen into different regions, the terms allotted to which are so frequent in the language of surgical books, that some account of them in this Dictionary seems indispensable. The middle of the upper pa^l of the abdomen, from the ensiform cartilage as low down as a fine drat^ directly across the greatest convexity of the cartilages of the ribs, is called the epigastric region. The spaces at the sides of the epigastric region are termed the right and left hypochondria or hypochon- driac regions. The umbilical region extends from the navel up- wards to the line forming the lower boundary of the epigastric region, and downwards to a line drawn across from one anterior superior spinous process to the ileum of the other. The middle space, below the last line, down to the os pubis, is named the hypogastric region. The parts of the abdomen situated on the outside of the umbilical region to the right and left, or externally with respect to two perpendicular lines drawn from the greatest convexities of the cartilages of the seventh true ribs, are named the ilia or flanks. On each side of the hypogastric region is situated the inguinal re- gion or groin. The whole of the back part of the ab- domen has only one technical appellation, viz. the lum- bar region or loins. As the abdomen is the frequent situation of several important surgical diseases; is much exposed to wounds ; and various operations on different parts of it are often indispensable ; it claims the particular no- tice of every practical surgeon. One of the most com- mon afflictions to which mankind are subject, is that in which some of the bowels protrude. This disetise is called hernia, and ought to be well understood by every practitioner, who, however, can never acquire the ne- cessary knowledge without being minutely acquainted with the anatomy of the abdomen. In dropsical cases it is frequently proper to tap the abdomen ; and this operation, named paracentesis, simple as it may seem, requires more consideration and attention to the ana- tomy of the parts than many surgeons bestow. — (See Hernia, Paracentesis, and Wounds.) Abdomen, Abscesses of the, may take place either within the cavity of the belly, or at some point of its cir- cumference, may be either of an acute or chronic nature. Women are generally considered more liable than men to abscesses in and about the abdomen ; the abscesses named lumbar, being elsewhere treated of, are here ex- cluded from consideration. Collections of purulent matter, resembling turbid whey, and containing whi- tish or yellowish flakes, are not unfrequently formed in ABD the cavity of the peritoneum, as one of the effects of inflammation accompanying puerperal fever.— (StoW, Rat. Med. t. 4, p. 103 ; Lassus, Pathologic Chir. t. \,p 137, nouvelle Mit. 8vo. Paris, 1809.) In lying-in women, abscesses frequently form be- tween the abdominal muscles and the peritoneum, es- pecially just above the groin. They are cases which have been very correctly described by Conradi. Be- Ibre the integuments project, the diagnosis is often attended with difficulty, and sometimes an obscurity prevails several weeks; for the patients seem as if affected with slight colic pains, which yield to com- mon treatment, particularly external applications, but soon return. Thus, unless the vicinity of Poupart’s ligament be carefully examined, where some painful point, hardness, or elevation can be detected, the ab- scess may remain concealed until a large prominence, or the extension of the matter down the thigh, lame- ness, &c., makes the nature of the case completely ma nifest. As the peritoneum adjoining the abscess is always thickened by the preceding inflammation, Con- radi assures us that there is no danger of the collection of matter bursting inwards. Some abscesses, indeed, have been so enormous, that the matter actually pushed the viscera out of their places, yet all this hap- pened without any inward bursting of the disease. The whole danger depends upon the duration of the complaint and the extent to which the matter spreads. A timely detection of the nature of the case, the use of emollient applications, and the making of an early open- ing, generally bring the disease to a speedy and favour- able termination. — (See Arnemann's Magazin fur die Wundarzneiwissenschqft, b. 1, p. 175, 8vo. Gbtt. 1797.) Chronic tumours of the mesentery, which in scrofu- lous children sometimes terminate slowly in suppura- tion, and diseases of the ovary and other abdominal viscera, bringing on the formation of matter, are often the cause of purulent extravasation, great emaciation, hectic symptoms, and death. . However, sometimes salutary adhesions are produced between the viscera, by which means an OKtlet is obtained for the matter through the bladder, anus, or vagina. Thus (says Lassus) in the case of a woman who had had for a long while pains in the right lumbar region, supposed to proceed from suppuration of the kidney, because pus was voided with the urine ; the right kidney was found after death in the natural state ; but there was an ab- scess in the right ovary, which was adherent to the bladder, into which the pus had passed through an ulcerated communication. In another patient, who had voided pus by the anus, the right kidney was sup- purated and adherent to the colon, with which it com- municated by a preternatural aperture. For many years a woman had a hard tumour of considerable size in the abdomen : at length the pain of it became intolerable ; and just at the moment when her death was apprehended, an immense quantity of pus was sud- denly discharged from the vagina. The pain abated ; the swelling of the belly subsided ; merely the remains of the induration were now perceptible ; and the woman’s health was perfectly re-established.— (Lossils, Patho- logic Chir. t. \,p. 138.) The abscesses which sometimes form between the peritoneum and abdominal muscles, or between the layers of these muscles, or under the integuments of the abdomen, are attended with considerable variety, according as they happen to be chronic or acute, cir- cumscribed or diffused, small or extensive. Those of the acute or phlegmonous kind, sometimes following stabs and contusions, are particularly noticed in the article Wounds. They are cases which demand es- 1 pecial care, because if not checked they may prove iO ABDOMEN. fatal, many examples of wliich arc upon record. — (Sec Cotumerc. l^Uerar. J^oric. 1741, p. 100; Eller, Medic, and Chir. .^nvierkuvffen, p. 108, &c.) As for chronic external ab.scesses of the abdomen, they should be opened early, and treated on the principles explained in the article Lumbar abscess. Hard, indigestible substances, after being swallowed, are not unfrequently discharged from abscesses in some of the abdominal regions. — (See De l..a Grange, in Museum der HcUkunde, b. 4, p. 154 : a fish-bone, which had been swallowed, found in the abscess ; Petit, Traili dc Mai. Chir. t. 2, ^.226 ; an awl, without a handle, ex- tracted from an abscess of the abdomen ; and many other analogous cases.) Encysted tumours are sometimes formed between the peritoneum and abdominal muscles, and attain an iinmense size before they burst ; a remarkable specimen of which is detailed by Gooch.— (CAir. JVorks, vol. 2, p. 144, S,-c. 8vo. Loud. 1792.; In this case the sponta- neous opening in the navel was enlarged with caustic, and the cyst extracted ; but before a cure could be ef fected it became necessary to make a depending opening, and introduce a seton. Swellings of this nature, how- ever, are only noticed here on account of their resem- blance to circumscribed chronic abscesses of the parie- les of the abdomen. Abdomen, pulsations in the. From the article rism the reader will understand that, though it be the common nature of tliis disease to be attended with throbbing, it is not everj' jmlsating tumour that is an aneurism. The cases usually called abdominal or epigastric ptdsations often furnish a proof of the cor- rectness of the preceding remark. 'I'he authors who have treated of the latter affection with the greatest dLscrimination, are Dr. Albers, of Hremeii, and Mr. Allan Burns, of Glasgow, two gentlemen whose high reputation and useful labours will long survive the re- cent tenninatioii of their meritorious lives. Some of the pulsations here referred to are the consequence of organic disease, and cajjable of demonstration by dissec- tion; while the rest are not attended with any such apiMjarance, and have therefore been regarded as ner- vous. I'he pulsation is not always produced by the impulse communicated to some solid tumour or sub- stance between the hand and the artery, but was con- ceived by Mr. Burns to be sometimes dependent on a nervous affection of the vessel itself. — (0« the Dis- eases of the Heart, p. 263.) Hippocrates, in his book “ De Morbis I’opularibus,” makes mention of three patients afi’ected with extraordinary pulsations in the abdomen. As one of these cases seemed to depend ujion obstructed menses, it was probably not the re- sult of any organic disease. — {Hippocratis Opera Om- \ nia, ex edit. Fwsii. Francof. 1621, lib. 5, sect.l, p. 1144.) In order to remove a difliculty in believing how an artery, not affected with aneurismal enlargement, can communicate to the superincumbent parts such move- ments as are frequently remarked in cases of abdomi- nal pulsations, a fact pointed out by Mr. Hunter shouid be remembered : in speaking of the actual dilatation of an artery, he says, that when the vessel is “ covered by the integuments, the apparent effect is much greater than it really is in the artery itself ; for in laying such an artery bare, the nearer we come to it, the less visi- ble is its pulsation ; and when laid bare, its motion is hardly to be either felt or seen.” — ( Treatise on the Blood, 6rc. p. 1 /'S, 4to. Lond. 1794.) And this observation will apply to all tumours and indurations situated over a large artery. In the epigastric region of a certain pa- tient Taberranus felt not only a pulsation, but a tumour as large as the fist, with all the other usual symptoms of an aneurism. On opening the body after death, he was therefore surprised to find, instead of this disease, a considerable scirrhous tumour in the middle of the mesentery, so closely connected to the large vessels as to compress the aorta, by the pulsations of which it had been lifted up.— ( Obs. Anat. ed. 2, JVb. 9.) Dr. Albers quotes an extraordinary case from Tul- pius ; the patient, a laborious man, but subject to bi- lious attacks, was sometimes affected with violent throbbings of the spleen. These were not only very painftil, but could be heard at a distance, and their number distinctly counted when the hand was applied to the part. What seems almost incredible, it is alleged that Tulpius could hear them at the distance of thirty feet ! Their violence increased or diminished accord- ing as the patient was more or less bilious, and some- times they entirely ceased, when his health improved ; but always recurred as soon as the chyloj>oietic organs became disordered again. After the patient’s death, l)ermission could not be obtained to open lus body.— ( Tulpii Obs. Medicee, Arnst. Um 2, lib. 2, cap. 28.) According to Bonetus, jmlsations in the left hypo- chondrium are not unfrequent, and it was lus belief that they were produced by the cmliac artery. He cites several cases of this disorder from other writers, the tenour of wliich is to prove that the cceliac artery and mesenteric vessels must have been affected, as they were found after death dilated and filled with black blood. — {Sepulchretum Anatomicum, lib. 1, sect. 9. Obs. 9, 25, 27, 30, 38, 42, 44, 45, and 46., The conjec- ture of Bonetus and others, however, respecting the frequency of abdominal pulsations from dilatation of the cteliac and mesenteric arteries, by no means coincides with the results of modern observations. 41r. Wilson, whose dissections were numerous, met with only one instance of true aneurism affecting any ofthe branches of the aorta, distributed to the abdominal viscera. This case was an aneurism of the left branch of the hepatic artery. — (Lectures on the Blood, and on the Anatomy, Physiology, and Surgical Pathology of the Vascular System, S,-c. p. 379, 8vo. Lond. 1819.) Bontius was present at the opening of an inhabitant of Batavia, who had been afflicted three years with a disease, the exact nature of which could never be made out during life. When the hand was applied above or below the navel, a pulsation was felt like that of the heart or an artery, and as forcible as the motion of a child in the womb. It was synclu-onous to the pulsation of the heart and arteries. Hence Bontius. concluded, that the case was owing to sotne affection of the heart. The vena cava, instead of containing blood, was filled with a medullary substance, which, pressing against the aorta, is supposed to have excited the extraordinary pulsa ions in that vessel. The heart was unusually dilated and flabby. The txvo ventricles were very large, and filled with dark-coloured blood. The liver was of nearly twice its natural size. The gall-bladder resembled that of a bullock, and was filled with viscid bile nearly as thick as an extract. — (Jacobi Bontii de Medicina Indorum, libri 4, Lugd. 1718, Obs. 8, p. 101.) Lewenhoek met with an instance of a similar pulsa- tion, which he imputed to irregular action of the dia- phragm, the pulse at the wrist not being affected. The disorder lasted three days, during winch the functions of the alimentary canal were so much disordered that the patient was expected to die. — (Philosoph. Trans, from 1719 to 1733, abr. by J. Fames, iS-c. Lond. 1734, vol. 7, p. 683.) j Dr. Albers has described the particulars of a case recorded by Burggraf, and entitled “ Diuturna, magna, et valde molesta pulsatio in epigastrio.” — ( Vid. Acta Matur. Cur. JVorirnb. 1740, vol. 6, Obs. 131.) Burg- graf gives his reasons for believing that in this in- stance, the pulsation arose neither from the aorta nor from the cccliac artery ; and suspects that it was caused by a dilatation of that considerable branch of the in- ferior mesenteric artery, which inosculates with the branch of the superior mesenteric. This idea, how- ever, which was merely surmise, could not be correct, as the patient was cured by taking, every morning and evening, half a drachm of a mass composed of equal parts of gum ammoniac, extr. centaur, minor, and Venice soap. In an example recorded by Stork, the symptoms were found to have arisen from disease of the pancreas, which weighed thirteen pounds, and contained a large cyst filled with lamellated blood. — (Annus Medicus, Vin- dob. 1760, p. 245.) ■ The subsequent case somewhat analogous to the former, is from a different author. A man, aged 60, complained of pain in the left side of the abdomen, midway between the umbilicus and crista of the ileum. Emaciation, weakness, distress of countenance, anorexia, constipation succeeded At length a large pulsating tumour was discovered in the epigastric region. The case was now pronounced aneurism of the abdominal aorta. There was no nausea nor vomiting, except that some days before death a quantity of fetid blacKish fluid was twice or thrice voided. J^To fever. The swelling caused a sense of constriction rather than pain, and the throbbings became more perceptible. The pulse was feeble, but slow and regtdar. After death, the stomach was found ABDOiMEN. 11 adhering to the liver, pancreas, and abdomen ; and a cancerous tumour occupying its internal surface from the duodenum to the insertion of the oesophagus, the coats of the stomach being an inch thick. The sur- face of the pancreas was also diseased, and the pylorus, situated in the midst of the cancerous mass, was con- tracted by the thickening of the parietes of the stomach, and obstructed by numerous fungi. The liver was large, but apparently sound ; the spleen small. The aorta.) the caliac trunk) and its branches, were quite na~ turaZ.— (See Journ. de Med. per Leroux, Oct. 1815, and Medico-Chir. Journ. vol. 1, p. 289.) Morgagni describes the case of a woman 44 years of age, who, after a simpression of the menses for some months, was attaclred with palpitations in the epigas- trium. Morgagni, on applying his hand to the part, felt a large hard body moving forcibly. At first, it was regarded as an aneurism in the abdomen ; but, as there were no similar throbbings in the chest, and there was nothing extraordinary in the pulse at the wrists, Mor- gagni concluded that the movements in question could not depend upon the heart. Neither did he take the disease for an aneurism, because the throbbings did not correspond to the pulse. As for the large indurated mass, it appeared to him more easy to say what it was not, than what it was : it could not be merely a globus hystericus, which never beats like an aneurism. Mor- gagni (ionsidered the case as an hysterical spasmodic complaint, ordered the patient to be bled, and the fol- lowing day the pulsations ceased. — {Morgagni, de Sedibus et Causis Morborum, t. 2, Epist. 39. 18.) Senac has spoken of these abdominal pulsations as occurring in hypochondriacal and chlorotic patients ; and, as they frequently subside without leaving any vestige behind, he sets them down as nervous affec- tions . — ( Traiti des Mai. da Cceur.) De Haen had under his care a hypochondriacal patient, affected with pulsations in the abdomen ; which, with other com- plaints, were dispelled by means of brisk opening medicines . — {Heilungs Methode, iibersetzt von Platt- ner, Leipz. 1782, b. 2, s. 29.) Thilenius observed a flatulence of the stomach, which he represents as having been epidemic, and attended, in some patients, with pulsations at the scrobiculus cordis. — {Med. Chir. Bemerk. Frankf. 1789, s. 211—217.) My friend Mr. Hodgson, also, in speaking of pulsa- tions in the epigastrium, which are not the consequence of organic disease, and occur in irritable hypochondriac subjects, states his opinion, that, in some instances, these pulsations were a consequence of distention of the stomach with air, which was thrown against the abdominal muscles by the pulsation of the great blood- vessels ; and in such cases, the throbbing was dimi- nished by the eructations . — {On the Diseases of Arte- ries and Veins, p. 96.) Abdominal pulsations are also described by Zidiani, as a symptom of hypochondriasis and hysteria . — {De Apoplezia, JJps. 1790, p. 79.) They also happen in certain ferbrile diseases . — {Versuch iiber den Pemphy- gus und das BlasevJieber,von C. O. C. Braune, I^eipz. 1795, s. 23; and Dr. R. Jackson on the E'evers of Jamaica, 8vo. Fond. 1791.) In a dissertation on cramp in the stomach, Haii re- marks, “ Quin immo, ubi diutius vexavit gastrodynia, continues tegrotans persentit spasmos, ut et baud rare pulsationem quandam plane singularem, in cardia et ventriculo, pulsui autem cordis minime synchrone.” — (Diss. de Gastrodynia, Upsal, 1797.) In the same essay, there is an account of a man, who had violent palpitations in the epigastric region, apparently first excited by the larvae of the musca pendula, many of which were vomited up. Pinel is another vmter who describes these abdo- minal pulsations as an occasional symptom of hypo- chondriasis. “Palpitations du cceur, et quelquefois une sorte de pulsation irreguliere, dans quelque partie de I’abdornen .” — {JToeographie Philosophique, t. 2, p. 25, Paris, an. 6.) Dr. Albers details some cases which fell under his own notice. A young woman, whose menses were upon her, and who had been for some days constipated, was seized with frequent fainting fits and febrile symptoms, occasionally voiding from the bowels a quantity of dark matter, each evacuation of which was followed by a swoon. One morning at five o’clock Dr. Albers was sent for, as it was feared the patient was about to die. She was extremely exhausted, and the fainting fits followed each other with hardly any intervals. She could just say “ I feel a throbbing in the belly and, when Dr. Albers applied his hand to the part, he felt a violent pulsation extending from the ensifonn cartilage down to about the bifurcation of the aorta. The action of the heart was weaker than na- tural ; the pulse at the wrist very small, but not quicker than it had been on the preceding day, and not synchro- nous to the throbbing in the abdomen. Dr. Albers confesses, that, at first, he took the case for an aneu- rism. Dr. Meyerhoflf was of the same opinion. An- other physician, however. Dr. Weinholt, entertained doubts of the complaint being aneurismal, saying, that he recollected having read similar cases in Morgagni. These gentlemen decided to persevere in the employ- ment of opening medicines and clysters, combining opium with the former. Under this plan, the pulsa- tions in the abdomen and tightness of the chest dimi- nished in a few days. The stools were at first of the colour of chocolate, but afterward resumed their natu- ral appearance. The throbbings, in a weakened form, however, were perceptible for six weeks longer. The patient at length got qiiite well, and was remaining so four years afterward. A man about 40, severely afflicted with hypochon- driasis, great opi)ression of the chest, constipation, and tension of the abdomen, tendency to fainting, &c., complained to Dr. Albers that he felt as if his heart had fallen down into his belly, where he was annoyed with an incessant throbbing. Indeed, when Dr. Al- bers examined the abdominal parietes he could feel a very strong pulsation, and, what is curious, could trace it not only along the track of the aorta, but in the course of the left iliac artery. The pulse at tire wrist, which was small, freejuent, and hard, did not correspond with the abdominal pulsations. For several days the evacua- tions from the bowels had been as black as pitch. After the employment of gentle purgatives, all the complaints quickly abated, though the throbbings were feebly perceptible for nine months afterward. The next case which Dr. Albers met with is very interesting. A robust sailor, whose bowels were so constipated, that hardly the strongest purgative could affect them, was seized with constant pain in the left hypochondrium. With this complaint was soon joined great pain in the back, and a sensation as if something alive moved about in the belly from one side to the other, and thence extended up to the neck, followed by the vomiting of a greenish matter. At the same time, he felt in the left side a pulsation which he took for that of the heart, and which continued the whole of his illness. The pulse at the wrist was natural, and synchronous with that in the abdomen. In ',” is unquestionably one of the most curious facts wliich can present themselves to the no- tice of the physiological inquirer. In Mr. Hunter’s time the doctrine was a new one ; but he informs us, that he had long been able to demonstrate its truth, and that he received the first hints of it from the waste of the sockets of the teeth and of their fangs at the pe- riod of their being shed. “ It may be difficult at first to conceive how a part of the body can be removed by itself; but it is just as difficult to conceive how the body can form itself ;” yet they arc both equally facts. Without dwelling on the exai't mode in which such changes happen, he gives it as his belief, that “ whenever any solid part of oar bodies undergoes a diminution, or is broken in uixin, in consequence of any disease, it is the absorbmg sys tern wluch does it. “ When it becomes necessary, that some whole liv- ing part should be removed, it is evident that nature, in order to effect this, must not only confer a new ac- ti\'ity on the absorbents, but must throw the part to be absorbed into such a state as to yield to this opera- tion.” — See Hunter on the Blood, <^c. p. 439 — 442.) For an account of ulcerative absorption, vide Ulcera- tion. With regard to the difficulty which there may be in conceiving how such small tubes as the Ijmphatics can take up solid substances, Bichat points out that the distinction between the solids and the fluids can only be said to prevail when they fonn a mass ; but that when reference is made to their separate particles, they do not differ from each other. This, he says, is so pertectly true, that the very same particle will alter- nately enter into the composition of a solid and a fluid, just as the elements of water are the same, whether it be in the liquid or frozen state. Now as the absorp- tion of solid substances takes place by the removal of these separate particles or atoms, no greater difficulty can present itself in understanding how this may be elfected than in conceiving how fluids may be absorbed. — s^ee Jinat. Gen. t. 2, p. 92.) I come now to a very difficult question, and one that has hitherto received no satisfactory answer ; not be- cause the subject has not been earnestly, deeply, and ably considered, but because its difficulties and obscu- rity seem to defy all successful investigation : the ques- tion here referred to, is. On what principle and by what power are the lymphatics, suppnsing them to be ab- sorbent vessels, enabled not only to take up the old parti- cles of various organs and different fluids secreted in different textures and cavities, but to convey them frequently with considerable velocity and through a long tract, intercepted also by those complicated organs, the absorbent glands, into the venous system near the heart? In other words, what is their mode of action? As Mr. Hunter has observ'ed, the principle of capillary tubes was at first the most general idea, because it was familiar one; but this is too confined a principle; nor will it account for every kind of absorption. Capil- lar- i.'bes can only attract fluids; but as solids were often absorbed, such as firm tumours, coagulated blood, the earth ofbones, Ac., the advocates for tliis hyqiothesia were compelled to suppose the existence of a solvent. “This may or may not be true ; it is one of those hy- potheses that can never be proved or disproved, and may for ever rest uixin opinion.” But Mr. Hunter’s conception of this matter was, that nature leaves as little as jiossible to chance, and that the whole opera- tion of absorption is performed by an action in the mouths of the absorbents ; but even under the idea of capillary tubes, physiologists w'ere still obliged to have recourse to the action of those vessels to carry the lymph along after it had been absorbed ; and they might as well therefore have extended this action to the mouths of the vessels . — (On the Blood, 6,-c. p. 443.) The question still continues without satisfactory answer, whether Hunter’s language be adopted, and we say that absorption is effected by an action of the lymphatics and their orifices ; or whether we employ the language of Bichat, and ascribe the performance of the functions of these vessels, and the circulation of the fluid in them, to what he ingeniously (but not much to the edification of his readers) calls organic sensibility and insensible organic contractility. This imagined kind of sensibility confers upon every ab- sorbent vessel a power of feeling quite unconnected with the brain, by w'hich it is presumed to be sensible of the presence of matter fit for removal, which is then imbibed and conveyed along the tube by the insensible organic contractility, by which is signified a pow’er of contraction, not admitting of demonstration, not ex- citable by stimulation or irritation, but inferred to take place in some inexphcablc manner, chiefly because the fluid in the absorbents is knotvn to be constantly in motion, and always flowing towards the thoracic duct. In fact, Bichat’s explanation is merely a reference to two principles, which are themselves hypothetical, and more calculated to amuse a playful fancy than t» satisfy a sound judgment. Organic sensibility, and insensible organic contractility, he observes, tire the ABSORPTION. 15 Riore remarkable in the absorbent system, as they sur- vive for a certain time death itself. A fluid, injected while the animal retains some degree of heat, is ab- sorbed both on serous and mucous surfaces, and also in the cellular tissue, though with less freedom. This power of absorption after death, he says, may even be lengthened by keeping up artificial heat by means of a bath, though the plan is less efficacious than he at first supposed, vital heat seeming to be essential. — (^nat. Getu t. 2, p. 117.) All these observations, how- ever, merely amyount to a recital of the facts, that ab- sorption may proceed for a short time after death (never later than two hours from this event, p. 118), and that it is promoted by artificial heat ; but how, or by what exact mechanism it is accomplished, is not revealed to us. The lymphatics are not regarded by Bichat as endued either with what he terms animal sensibility, or with animal contractility. His proof of the first of these statements is, that when a lacteal vessel, full of chyle, a lymphatic filled with serosity on the surface of the liver, or even the thoracic duct, is punctured, the ani- mal betrays no mark of pain. But the little faith which he himself put in the doctrine, may be conceived from the question to which it leads him, namely, what inference can be drawn from a circumstance where, in consequence of the belly being laid open, the many agonies produced would comparatively annihilate any slight sensation, even were it to exist ? He also ad- verts to the acute sensibility of the absorbent vessels in their inflamed state. — (P. 115, t. 2.) Hunter admitted a vital contractile property in the lymphatics, or, as Bichat would express it, sensible organic contractility. The former adopted this belief, because those vessels readily empty themselves of the chyle that is pervading them, and contract when sulphuric acid is applied to them. On the other hand, Bichat argues, that sulphuric acid, like every other concentrated acid, and also heat, produce the same effect upon all animal substances, even afler death, namely, a shrinking of them. When the absorbents, and particularly the thoracic duct, are touched with the point of a knife, they do not contract. If they are capable of contraction, Bichat maintains that it is when they cease to be distended, and not when they are irritated ; consequently, it appears to him to be by virtue of their contractility of tissue. The opinion at which he finally arrives is, that sensible organic con- tractility in them is at all events doubtful, and that, if it exist, it is very obscure, and at most not greater than that of the dartos. — (T. 2, p. 117.) This last inference, and, indeed, the whole of Bichat’s doctrine respecting the non-existence of sensible organic contractility in the absorbent ves- sels, are very difficult to reconcile with certain observations made by himself, in other parts of his work. Thus, he informs his readers (f, 2, p. 95), that he had frequently noticed in living animals, especially in dogs, manifest expansions in the course of a lym- jfhatic, and containing a limpid fluid. These appear- ances were mostly met with on the concave surface of the liver, and on the gall-bladder. WTien the dilated portions of the vessel were pricked with a lancet, the fluid ran out, and they immediately disappeared. “ On another occasion, I saw two or three of these small dilatations on the gall-bladder, and having then let the liver descend while I examined the bowels, I was much astonished the next instant at not being able to find them again; no doubt (says he) the contraction of the vessel had made them disappear.'" He adds, that the liver is the organ on which these vessels can be best seen in living animals ; but its concave surface must be looked at the instant the belly is opened, for the contact of air, by making them contract, soon hinders them from being distinguished . — (See Jinat. Q6n. t. 2, 7 >. 95, 96.) And in another place he says, “in drop- sies where the absorbents are full, if the skin be lifted up, they may easily be distinguished by their transpa- rency; but very soon, notwithstanding their valves, they empty themselves, and can no longer be discerned with the eye.”— ( V. 108.) The fact of the absorbents expelling more or less of their contents, when they have been punctured, might he very well ascribed to what Bichat calls con- trnctiUty of tissue, or even to elasticity ; but, the propulsion of the fluid from a dilated portion of an unwounded lymphatic into another portion of the same I vessel, certainly docs not admit of the same explana- tion. The valves may determine the direction which such fluid must follow, if it move at all ; the anasto- moses may facilitate the passage of it ; and contrac- tility of tissue, or elasticity, may have an auxiliary effect ; but its first motion can only be accounted for by supposing either that there is an impelling power in the vessels themselves, or in some organ or organs with which they are connected ; or else that their con- tents are set in motion by external pressure, the swell of muscles in action, or the pulsation of neighbouring arteries. Now, in some of the cases mentioned by Bichat, no doubt can be entertained that the impelling power was in the lymphatics themselves, because he distinctly adverts to the contraction so speedily excited in them by exposure to the air, that the concave sur- face of the liver must be looked at immediately on the animal’s belly being opened, or else they will not be distinguished. Dr. Bostock conceives, that “an attraction exists between the mouths of the lacteals and the chyle^ which seems to be analogous to, or identical with, the elective attraction, which unites different chemical substances ;” and “ that the lacteals, as well at theii* extremities as through their whole extent, are pos- sessed of contractility, by which the fluids, when they have once entered, are propelled along them ; an effect which is probably promoted by the pressure of the neighbouring parts, while the numerous valves with which they are finnished prevent the retrograde mo- tion of their contents.” — (Elem. Syst. of Physiol. voU 2, p. 580.) The principle on which the lacteals im- bibe the chyle can scarcely be referred to any thing so fixed and determinate as chemical attraction, or so independent of life. On the contrary, the absorption of chyle from the bowels may be looked upon as a pro- cess liable to be accelerated, or retarded, by various states of the constitution, habits of life, and different affections of the mind. If it were a chemical operation, and the abundance of chyle happened to exist on the villous coat of the small intestines, at the period of any sud- den death, the process would be expected to go on as long as that fluid and the villi remained in contact ; yet we have no proof of this being the case : indeed I cannot comprehend any similarity between elective attraction and the absorption of chyle ; the former being an operation in which the action of vessels or their orifices, and the influence of life, are considerations totally separated from the subject; whereas, in the latter, they form in reality the main topics of inquiry. Elective attraction, however, may only be intended as a comparison applicable to the disposition which the lacteals have to take up certain substances, but to reject others: though, even in this sense, the comparison would be very imperfect. Dr. Bostock’s opinion is probably true, that an eluci- dation of the action of the lymphatics must be attended with even greater difficulty, than what presents itself to the inquiry into the principle on which the chyle is taken up and conveyed into the system. The increased difficulty chiefly proceeds from our having no positive information respecting the extremities of the lymphatic vessels, or the mode in which their contents are first received; “for there is reason to suppose that the transmission of the fluids themselves is conducted upon the same plan with that of the lacteals.” As the same author remarks, we do not know where the mouths of the lymphatics are situated ; with what parts they are connected; how they are brought into contact with the substances which they receive ; nor by what power they are enabled to take them \ip.—(Vol. 1, p. 582.) The source of the lymph is also less certain than that of the chyle ; for, even at the present day, M. Ma- gendie, influenced by the possibility of injecting the lymphatics from the arteries, and by the uniform nature of the lymph, and its analogy to the blood, proffesses a belief, which was common many years ago, that it is not formed by the decomposition of the old par- ticles of the body, nor by fluids absorbed from vari- ous surfaces; but that it is composed of tlie thin ner parts of the blood, which, instead of returning by the veins to the heart, pass into the lymphatics, and are conveyed to that organ through the thoracic duct. The lacteals certainly have little disi)Osuion to take up any thing but chyle ; but, as Dr. Bostock has explained,- “ the lymphatics are capable of absorbing a great va- riety of substances, diflering from each other most 16 ABSORPTION. widely in their nature, so that it would almost appear as if, by a certain inode of application, any substance might be forced into them. Nor (says Dr. Bostock) is this conclusion affected by the hypothesis of M. Ma- gendie ; for, although we might agree with him in sup- posing that in the ordinary operations of the sj stem, the veins are the pnncipal, or even the sole instru- ments in removing the materials of which the body is compost^, yet we have unequivocal evidence, that when certain poisonous or medicinal agents are applied to their extremities, they may be received or forced into them, and conveyed into the circulation. The case of metallic or other medicinal substances that are taken up by the lymphatics, may apjiear to be less difficult to explain, because the absorption is generally produced by friction, or some mechanical process, which may be supposed to force the substance into the mouths of the vessels, or to produce an erosion of the epidermis, which may enable the substances to come into more iimnediate contact with the mouths of the vessels. We may also imagme that when the component parts of the body are brought into close appro.ximation with their capillary extremities, they are then taken up in the same way that the chyle is absorbed from the intestines.” — {F.Um. Syst. of Physiol, vol. 2, p. 583.) For my own part, 1 believe, that if the modern doctrine of absorption can be effectually de- fended and retained, the general presence of the orifices of the lymphatics at every point of the variously organ- ised textures of the body must be received as one of its leading principles. Many physiologists have little difficulty in conceiving how fluids can be taken up by the lymphatics, but rather stagger at the notion of this being also the case with the hardest solids. Others, however, accommodate their creed to both hypotheses, reconciling themselves to them by the argument that, if the minute capillary anerles can secrete this dense, hard matter, the small lymphatics can remove it. One example is not more difficult to comiirehend than the other. Yet, such reasoning throws little light on the questions, how are the solids prepared for absorption, and in what manner are they taken upJ These in fact remain completely unanswered. “ What (inquires a judicous physiologist) are we to conceive of the intimate nature of this ojieration ? If solution of the substance be necessary, we are at a loss to find a proper solvent ; many of the substances are insoluble in water, or in the serous fluid which is found in the vessels ; whue, on the other hanu, it is perhaps not easy to conceive how the substances can be absorbed without being previously dis.solved, and still more so, how the solids can have their texture broken down, and enter the vessels, particle by particle, as it were, and be suspended in the lymph in a state of extreme communition ?” As I have already men- tioned, these difficulties some physiologists, including Bichat, endeavour to diminish by arguing that the Ijin- phatics must be supposed to act only upon the elements of every texture, and that, on this principle, the ab- sorption of solids is as readily intelligible as that of fluids, the same elements frequently contributing to the composition of both. However, it must be ac- knowledged, that all this kind of reasoning is entirely visionary. It is conjectured, that while parts retain the vital principle, they are capable of resisting the action of the absorbents. According to Dr. Bostock, dead mat- ter is more easily acted upon by the absorbents than living ; and, in fact, “ no part can be absorbed until its texture is destroyed, and, consequently, until it is de- prived of life. No substance can possibly enter the absorbents, while it retains its aggregation, so that it necessarily follows, that the preliminary step to the ibsorption of the body is its decomposition.” — (Elem. Syst. of Physiol. voL 2, p. 585.) He afterward explains, that by the death of a part preceding its absorption, is here signified only, “ that it is no longer under the influ- ence of arterial action. It therefore ceases to receive the supply of matter which is essential to the support of all vital (living ?) parts, and the process of decom- position necesseirily commences.” To me a better ac- count of the subject appears to be that which, dismiss- ing all metaphysical and chemical reflections upon the supposed death and decomposition of parts, previously to their absorption, represents the absorbents as acting directly upon the individual atoms, particles, or ele- ments of the various textures. We kiiow nothing about the vitality of these atoms, or elements, in their separate capacity ; supposing them to possess it, we know nothing of the moment when they part with it previously to their entrance into the absorbent system, just as we are completely ignorant both of the manner in which such elementary materials acquire the vital principle, and of the exact moment when they become thus endued. With regard to the ijunphatic glands, their use is not precisely known, though various conjectures have been offered concerning it. As Dr. Bostock observes, we may presume that they seive an important purpose, from the circumstance of every absorbent vessel, in some part of its course, passing through one or more of these glands, as was first remarked by Nuck. Mr. Ilewson in one subject injected the lymphatic vessels from the groin to the neck, without filling any lymphatic gland, so as to prove a fact which, he says, is contradictory to the received opinion, that such ves- sels always pass through glands in their way to the blood-vessels. He found, with regard to the abdomen, the observation not strictly true, as, besides the lym- phatic vessels which enter glands, there are others which escape them. He declares, that some of the lacteals in the mesentery do not p-ass into glands. — {Exp. Inq. vol. 2, p. 44, vol. 3, p. 54.) On the other hand, Mascagni, in his numerous injections, never met with the circumstance {Eas. Lymph. Hist. pt. 1, sect. 4, p. 25; ; and Dr. Bostock refers us to Gordon’s Anat. p. 74, in confirmation of the rarity of such an arrange- ment.— <£fem. Syst. of Physiol, vol. 2. p. 548.) The fact of every lymphatic vessel commonly entering a gland m some part of its course, seems to Dr. Bostock to warrant the inforence, that some imiiortant change is effected in the chyle and lymph by means of the lymphatic glands. “But (says he) the same mode of reasoning might lead us to conclude, that although the absorbent glan.ds are necessary to the existence of the higher orders of animals, they are not so for the pur- poses of nutrition and growth generally, as it appears that there are large classes of animals, which resem- ble the mammalia m many of their nutritive functions, and in the vascular part of the absorbents, which are without any lymphatic glands, or are very sparingly furnished with them. It is not easy to point out any circumstances that belong exclusively to the mam- malia, which can assist us in explaining the necessity for these appendages to their lymphatic system.” — {Eol. l,p. 554.) Malpighi fancied that the Ijunphatic glands had a muscular covering, which enabled them to act as or- gans for propelling the IjTnph from their cells into the vasa efferentia, and thence towards the thoracic duct, so that they were, according to his notions, hke so many little hearts distributed through the system. This hypothesis, which is contradicted by anatomy, receives no confinnation from observation in the living animal. If it were true, we should expect to find the ceils larger, and not so minute as to render even their exist- ence in the human absorbent glands a questionable point ; some pulsating movement, gentle or strong, would be perceptible in the situation of every super- ficial gland ; or, if the contraction were of a slower kind, the gland would sometimes be enlarged, and sometimes considerably reduced. Y'et none of these circumstances prevail. It is likewise to be remembered, that no jet of fluid takes place from the vasa eflferentia when they are cut, as they frequently are in surgical operations. It is also t© be taken into consideration that fishes are destitute -of IjTnphatic glands (see Blumenbach's Comparative Jinat. by Lawrence^ p. 256) ; yet the fluid in their lymphatic vessels must be presumed to have its due degree of motion. In the mesentery of a turtle, no glands are observable ; still, “ in this animal, na- ture does her business as well, though the apparatus is differently constructed.”— (ifeicson’s Exp. Inq. vol. 3, p. 60.) Malpighi’s hypothesis is, therefore, decidedly untena- ble ; and whatever difficulty we may feel in agreeing with Bichat, that the absorbent vessels are destitute of animal contractUity, we can have no hesitation in adopting this conclusion with respect 'to the absorbent glands, considered as entire organs, without any refer- ence to the nature of the congeries of lymphatic© within them. The existence oLa white thick fluid in the lymphatic ABS glands was noticed by Haller in the following terms : “ Succum glandulis conglobatis inesse, album, serosum, lacte tenuiorem, in juniori potissimum animali con- spicuum, id quidem certum est. Eum cremori similem dixit Thomas Vi^arton, cinerum Malpighius, diapha- num Nuckius, album Morgagnius, recte et ad naturam, ut puto omnes. —(SZem. Physiol, t. 1, p. 184.) According to Hewson, the fluid formed in the lym- phatic glands, if diluted with a solution of Glauber’s * salts in water, or with the serum of the blood, and viewed with a len^ of one twenty-third of an inch focus, presents numberless small white solid particles, resembling in size and shape the central particles found in the vesicles of the blood. — (Ex;»er. [nq. vol. 3, p. 67.) The supposition of Ruysch and Nuck adopted also by Haller; that one use of the Ij'mphatic glands is to produce a fluid for the dilution of the lymph, is desti- tute of proof, inasmuch as the lymph is not known to be thinner after its egress from, than previously to its entrance into, a gland ; and one notion sometimes pro- mulgated is, that it is thicker. The investigations of Dr. Prout certainly show, that it contains a larger quantity of albumen and fibrine in proportion to its vicinity to the subclavian vein. — [See Thomson's Jln- nals of Philosophy, 1819.) According to Mr. Wilson, the absorbent glands contain numerous arteries ; and, in a horse, this vascularity gives to the inner lining of the cells the usual appearance of a secreting membrane ; but whether it does actually secrete, or what it se- cretes, we have no means of thoroughly knowing. — ( On the Blood and Vascular System, p. 209.) The appearance of the lining of the cells of the lymphatic glands of the whale, is in favour of the opinion, that some secretion takes place from it, as an addition to the lymph. — ISee Mernethy's Obs. in Philos. Trans. 1796, pt. 1.) Other speculators imagined, that the ab- sorbent glands were like so many filters, through which the lymph, or chyle, was strained. Another idea was, that they drew some crude liquid from the nerves and returned it to the blood. — (Glisson, dc He- pate, p. 439.) As to the conglobate glands, they were also sometimes contrasted with the conglomerate, and represented as organs for making good the loss pro- duced in the sanguiferous system b\" the secretions from the latter. Another suggestion was, that their office was to form the central particles of the globules of the blood. But, as Mr. Wilson justly observed, all these opinions are nierely suppositions, without a shadow of proof. Dr. Bostock considers it most probable either that these glands are proper secreting organs, and intended to prepare a peculiar substance, which is mixed with the chyle and lymph, or that they offer a mechanical obstruction to the progress of these fluids, by which means their elements are allowed to act upon each other, and thus some necessary change in the nature of the chyle and lymph may be produced. — (See Elem. System of Physiol, vol. 2, p. 554.) Richerand’s opi- nion embraces both these views ; for he says it was necessary that the lymph should be retarded in the glands, that it might undergo all the changes which these organs had to communicate to it. Although he confesses his ignorance of what these changes pre- cisely are, he represents the intention of them to be the production of a more intimate mixture, a more per- fect combination of the elements of the lymph, and to give it a certain degree of animalization, as, he says, is proved by the greater tendency of the lymi)h to con- crete, taken from the vasa efferentia, or discharged from the glands. He also supposes that another use of the glands is to deprive the lymph of its heteroge- neous parts, or, at least, to alter them so that they may do no harm by passing into the circulation. The yel- low colour of the glands, in which the lymphatics fVom the liver ramify ; the black colour of the bron- chial glands ; the redness of the mesenteric glands in animals fed with madder or beet-root ; their whiteness at the period when the chyle is pervading them ; are circumstances regarded by Richerand as proving that the glands tend to separate the colouring matter from the lymph, though their action in this respect may not always be completely efficient. He adds that, from numerous arteries in the texture of c-onglohate glands, a serous secretion occurs, which dilutes the lymph, incrca-scsits (juantity, and at the same time animaiizes it.— (.VoMueaur EUm. t. 1, p. 276, ed. 5.) These obser- vations, however, are only conjectures, wluch absurdly ACK 17 enough endeavour to blend together the doctrine of tho glands rendering the lymph thinner, yet more disposed to concrete. Mr. Wilson, and some other anatomists prior to him, affirmed, that they- had succeeded in tracing filaments) of nerves into the substance of the absorbent glands ; the possibility of which, however, is. not generally ad- mitted. These contradictory statements are to be reconciled by the consideration, that one anatomist would set dowji as a minute nervous filament, appa- rently derived from a large unequivocal nerve, what another would doubt, or deny, to be a real continua- tion of such nerve ; for anatomy, like most other pur- suits, cannot be prosecuted to extreme minuteness without leading to conjectures, difference of opinion, doubts, and obscurity. According to Bichat, when the lymphatic glands are irritated in various ways, which is easily done, they do not appear to be endued with animal sensibility ; but it may be developed in them, as well as in the absorbent vessels, by inflammation, which raises their organic sensibility to a great height . — {See .Mnat. Gdn. t. %p. 116.) The changes in the structure and size of the lym- phatic glands, brought on by the progress of age, jus- tify the presumption, that the action of the lymphatic system undergoes modifications at different periods qf life ; but, on this point, as M. Magendie has remarked, no precise information exists . — {See Precis El6m. de Physiol, t. 2, p. 202.) Halier believed that the absorbent glands were of greater consequence to young than adult animals ; and Mascagni, Bichat, and all the best modern anatomists, coincide respecting their greater size and turgidity in children than in grown-up persons. Whatever use may be ascribed to them, it is natural to suppose, as Dr. Bostock remarks, that, during the growth of the body, a larger quantity of nutritive matter will be conveyed into the blood, and must pass through these organs. — {Elem. Syst. vol. 2, p. 554.) In the foregoing observations on the functions of the lymphatic system, its vessels have been presumed to be the true instruments of absorption ; by which is meant, not merely that they contain lymph, and transmit it into the venous system, a fact of whicli.no doubt is entertained by any class of physiologists; but, that such lymph is really produced by the operation of these vessels upon the various kinds of matter presumed to be taken up by them, and to consist of alt the old par- ticles of every texture of the body, the fat, the earth of the bones, and the superfluous quantity of many different secretions, naturally undergoing continual renovation, besides the chyle which is taken up by the lacteals, and conveyed to the thoracic duct, or common trunk of both descriptions of vessels. To this view of the subject, some physiologists of eminent talents do not accede, and even if it should hereafter be de- cidedly proved that the lymphatics possess the power of absorption, the tendency of numerous experiments performed by M Magendie, Fodera, and others, is to show that, at all even:s, they are not the only ab- sorbents, and that the veins are "■ery actively concerned in the function. As the doctrine of absorption is one that is insepara- bly interwoven with the theory of disease in general, and always has a powerful influence on practice, and the choice of remedies, I have considered the subject highly deserving of notice in this work ; but my thanks are due to Professor M'Kenzie, of Glasgow, for his kind- ness in having suggested the want of such an article in the book. ACETIC ACID. Vinegar. Distilled Vinegar. Vine- gar is of considerable use in surgery- ; mixed with fari- naceous substances it is frequently applied to sprained joints, and, in conjunction v/ith alcohol and water, it makes an eiigible lotion for many ca.ses, in which it is desirable to keep up an evaporation from the surface of inflamed parts. Vinegar was once considered useful in quickening exfoliations, which effect was ascribed to its property of dissolving phosphate of lime. Its application to this purpose, however, seems hardly ad- missible, for reasons which will be well understood from a perusal of what is said on the subject of JSTecro- si.t. The good eflects of vinegar, as an application to burns and scalds, were taken particular notice of by Mr. Clegtiorn, a brewer in Edinburgh, whose senti- ments were deemed by Mr. Hunter worthy of publica- tion. — (See Med. Facts and Obs. vol 2, and the art. Barns.) 18 ACU ALV Diluted vinegar is sometimes applied to the eye. — | (See CoUyrium .^cidi Acelici.) In the fonn of ac ol- lyrinm it is alleged to he the best lotion for clearing the eye of any small particles of lime which happen to have fallen into and become adherent to it on the inside of the eyelids. — .See T. Thomson's Dispensatory, p. ed 2. Conc-entrated vmegar is sometimes employed for stopping violent hemorrhage from the nose. With tliis view it may be used either as an injection or a lotion, in wnich lint is to be dipped and introduced up the nostril. Vinegar is sometimes employed for obviating the smell of sick rooms. The strongest acevic acid which can be made is found also to be one of the most certain and convenient applications for the destruction of wans and corns, care being taken not to injure the sur- rounding skin with it. Acetic acid has occa-sionally been recommended as an antidote to the narcotic poisons ; but the proofs of this are quite unsatisfactory, and the chemical history of opium and other narcotics by no means sanctions the practice. — (Brandt's Jilanual of Pharmacy, p. 9, 8co. Load. 1825. The pyroligneous acid, which i.s merely strong acetic acid impregnated with empyreumatic oil and bitumen, is much used by Mr. Buchanan, of Hull, as an ingre- diciU in applications to the ear in certain cases of deaf- ness. — See Illustrations of Acoustic Surgery, 8vu. Land. 1825.1 ACHILLES, Tendon of. See Tendons. AC’ID. See Acetic Add} Muriatic Acid ; and JW trous and jYitric Ands. ACTUAL CAUTEllV. A heated iron, formerly much used in surgery for the extirpation and cure of diseases. Its shape was adapted to different cases, and the instrument was of tenapplied through a cannula, in order that no injury might be done to the surround- ing parts. Actual cauteries were so called in opposi- tion to other applications, which, though they were not really hot, produced the same effect as fire, and conse- quently were named virtual or potential cauteries. The actual cautery is still in uke upon the continent ; and by foreign surgeons we are not unfrequcntly criti- cised for our general aversion to what they distinguish by the appellation of an heroic remedy. I’outeau, Percy, Dupuytren, Larrey, Roux, Deljiech, and Mau- noir are all advocates for the practice ; and the latter gentleman, when he was in England, took the opportu- nity of reminding British surgeons of their error, in totally abandoning, as they now do, the employment of heated irons in the business of tiieir profession. — (See Obs. on the Use of the Actual Cautery, Med. Chir. Trans, vol. 13, p. 364, Ac.) ACUPUNCTURE. ' From acas, a needle, and i> nngo, to prick.; The operation of making small punctures in certain parts of the body with a needle, for the pur- pose of relieving diseases, as is practised in Siam, Ja- pan, and other oriental countries, for the cure of head- aches, lethargies, convulsions, colics, Ac. — See 1 hil. Trans. JYo. 148; and If .lh. Ten. Hhyne, de Arlhri- tide Man issa Schcmatica, (S-c. 8ci;. J.ond. 1683., Dr. Elliotson has tried acujiuncture very extensively, and his experience coincide.s with that of Mr. Churchill, con- firming the fact, that as a remedy for chronic rheuma- tism it answers best where the disorder is seated in fleshy parts. He also finds that one needle, allowed to remain an hour or two in the part, is more eliicient than several, used but for a few minutes. — See Med. Chir. Trans, vol. 13, /<. 467. i Neuralgia is a disease in which the practice may deserve trial. Local paralysis is another. In a modern French work it has been highly commended; but the author sets so rash an extunple, and is so wild in his expectations of what may be done by the thrust of a needle, that the tenour of his observations will not meet\\ith many approvers. For instance, in one case, he ventured to pierce the epigastric region so deeply, that the coats of the sto- mach were supposed to have been perforated : this was done for the cure of an obstinate cough, and is alhtred to have effected a cure I But if this be not enough to excite wonder, 1 am sure the author’s suggestion to run a long needle into the right ventricle of the heart, in cases of asphyxia, must create that sensation. — (See Berlioz, Mint, snrles Maladie.‘i Chroniques, et sur V Acupuncture, p. 305 — 309, 8co. Paris, 1816. Churchill on Acupuncture, 1824; Duntu, Traite de V Acupunc- ture, 1826.) [ ADHESIVE INFLAMMATION. That kind of in- flammation which makes parts of the body adhere or grow together. The process by which recent incised wounds are united without any suppuration, and fre- quently s>Tionymous with union by the first intention. — See Union by the First Intention.) iEGYLOPS. ' From a goat, and iSi//, an eye.) A disease so named from the supposition that goats .were very subject to it. The term means a sore just under the inner angle of the eye. The best modern surgeons seem to consider the ffigy- lops only as a stage of the fistula* lachryinalis. Mr. Pott remarks, when the skin covering the lachrymal sac has been (or some time inflamed, or subject to fre- quently returning inflammations, it most commonly hapjiens that the puncta lachrymalia are aflTected by it, and the fluid, not having an opiKirtuiiity of passing off by them, di.stcnds the inflamed skin, so that at last it becomes sloughy, and bursts externally. This is the state of the disease which is called jierfect aigylops or aegylops. il^lgylops was a common tenn among the old surgi- cal writers, who certainly did not suspect that obstruc- tion in the lachrymal parts of the eye is so frequently the cause of the sore as it really is. The skin over the lachrymal sac must undoubtedly be, like that in every other situation, subject to inflammation and abscesses ; but we do not find that sores unconnected with disease of the lachrymal sac are here so frequent as to merit a distinct appellation. AG.\RIU. A species of fungus growing on the oak, and formerly much celebrated for its efficacy in stop- ping bleeding. — See Hemorrhage.) ALBUGO. (From albus, white.) A white opa- city of the cornea, not of a sujierficial kind, but affect- ing the very substance of this membrane. The disease is similar to the leui;oma, with which it will be consi- dered. — See I-eucoina.) ALFHON'SIN. The name of an instrument for ex- tracting balls. It is so called from the name of its in- ventor, Alphonso Ferricr, a Neapolitan physician. It consists of three branche.s, wluch separate from each other by their elasticity, but are capable of being closed by means of a tube in wliich they are included. ALUM. An Arabic word.) Alum either in its sim- ple state, or deprived of its water of crystallization by being burnt, has long been used in surgery. The in- genious author of the Fhannacopoeia C'hirurgica re- marks that, except for external use as a dry powder, the virtues of alum are not improved by exposure to fire. Ten grains of alum made into a bolus with con- serves of roses are given thrice a day at Guy’s Hospi- tal in internal hemorrhages, gleets, and other case» demanding jiowerful astringent remedies. In a relaxed state of the urinary passages, or want of pow er of the sphincter vcsicie, small doses of alum have been found of ser\ice. Alum is employed as an ingredient in several astringent lotions, gargles, injections, and col- lyria. Ur. Groshuis, a Dutch physician, first recom- mended its use in colica pictonum, and Dr. Perceval subsequently joined in the advice. The principle on which it acts is that of decomposing the common pre- parations of lead, and converting them into sulphates, which are comparatively innoxious. Burnt alum, which is a mild caustic, is a principal ingredient in many styptic powders. ALMNE CONCRETIONS. Comprehending under this head both gall-stones and intestinal concretions, an interesting subject presents itself, certain parts of which have been cltiefly elucidated in modern times, as will be hereafter explained. When the concretions voided are very numerous they are generally gall- stones. Thus Dr. Coe relates an instance in which seventy were discharged in one day. In the same short time Petemiarm knew of seventy-tw'o being voided from one individual ; Birch, one hundred ; Bar- bette, Sloane, and Vogel, two hundred ; and Russell, four hundred. A patient under the care of Van Swie- ten had voided two hundred, and was still continuing to expel others. Riverius speaks of another patient who had voided calculi from the bow'els (or several years whenever he went to stool. — Obserz. Cominun.) Femelius likevzise adverts to cases in which the con- cretions evacuated were innumerable. — Pathol, lib 6, cap. 9. If we take a view of alvine concretions gene- rally, and include all their different kinds, we shall \ find that they are of various sizes. Most of them aia ALVIN E CONCRETIONS. 19 not target than a pea or nut ; but others are as large as an orange, and weigh four pounds. — tSee Monro’s Morbid Anat. of the Human Gullet, &c. and Medico- Chir. Journ. vol. 4, p. 188.) Morgagni saw one which equalled in size a moderate finger, and Gooch, Guet- tard, Heuermann, Mar^schal (M^m. de I’Acad. Royalc de Chir. t. 3, p. 55 i, and others, have seen concretions of this nature which were too bulky to pass out of the rectum without surgical aid. In certain examples, re- corded by Heuermann and Mar^schal, the passage of the concretion outwards lacerated the sphincter ani. Horstius speaks of one concretion which was as large as an apple (Epist. 1. 2, sect. 2, Opp. 2, p. 237), and Marcellus Donatus, Schwind (Schmucker’s Verm. Schriften, b. 2, p. 129 . Hooke, Venette, and Hecquet give the particulars of other examples in which the concretions discharged were as large as a hen’s egg. Mr. C. White extracted two from the rectum, which were nearly as big as the fist (Cases in Surgery, p. 18) ; and in a boy who had died in an emaciated state, after continued pain in the abdomen, attended with frequent attacks of ileus, Mr. Hey found in the transverse arch of the colon so large a concretion that it could not pass any farther along, the bowel, and appeared to have been the sole cause of the boy’s death.— ^Practical Obs. in Surgery, p. 509, ed. 2.) An analogous case is also reported by White (p. 28). It is stated in the Mem. de I’Acad. de Chir. that Duhamel saw a concretion that had been discharged, which was two inches and a half in length, one inch and a half in diameter, three inches and a half in circumference, and the weight of which was three drachms and a half. But, judging by their weight, how much larger those must have been which were seen by Scroekius and Lettsom, and weighed ten drachms; that reported by Dolaeus, wliich weighed two ounces ; that recorded by Orteschi, which, besides weighing two ounces two drachms and a half, is said to have been eight inches in circumference, and to have been taken out by force; that recorded by Schaar- schmidt, which weighed four ounces ; and lastly, the specimen cited by Plouquet Literatura Med. Dig. vol. 1, p. 171), the weight of which is alleged to have been half a pound.— (Samml. Med. Wahr. nehm. b. 9, p. 231.) It is observed by Rubini, that although examples of alvine concretions being discharged by vomiting are not so frequent as the foregoing cases, yet they are tolerably numerous. Many of them have been col- lected by Schenck, and others are collected by Breyn (Phil. Trans. No. 479) ; by Orteschi in his Journal ; by Moreali, Dell’ Uscita di una Pietra, per la Via del Esophago, Modena, 1781) ; by Borsieri ; and by a long list of other writers, whose names and publications are specified by Plouquet.- Lit. Med. Dig. art. Calcu- lus, Vomitus, &c.) — With this class of substances, says Rubini, may also be arranged those concretions which are found upon dissection either in the intes- tines or stomach, whence probably in time they might have been expelled. Facts of this description are re- corded by Portal, Vicq d’Azyr, Jacquinelle, Chandron, &c. The ca-ses recited by White and Hey, in which the colon was completely obstructed, I have already mentioned; and to the.se may be added the instance quoted by Rubini, in which Meckel found the jejunum entirely blocked up by a similar substance.— See Pen- sieri sulla varia origine e natura de corpi calcolosi, che vengono talvolta espulsi dal tubo gastrico, Merno- ria, p. 5 and 6, 4to. Verona, 1808.) Rubini ob.serves that, with respect to the origin of alvine concretions, whether discharged from the ali- , mentary canal upwards or downwards, some of them appear to be formed in that canal itself, while others pass into it from other situations; and they all admit of being distinguished according to the place of their origin and formation into three kinds : 1. hepatic, or biliary; 2. gastric, or intestinal; and 3. (what this author tenns , mixed, or hepatico-gastric. Hepatic al- vine concretions, as the name implies, are derived from some point of the hepatic system ; the gastric, or intestinal, are formed within the alimentary canal ; ' and the mixed commence in the hepatic organs, but afterward get into the bowels, where they acquire an increased size. On the subject of hepatic concretions, or biliary cal- culi, or gall-stones ^as they are usually named , there is no iH)int of the system where they do not occasion- ally form. Riedlin found them in the surface of the liver. Sorbait met with a biliary calculus as large as B2 a goose’s egg, adhering to the peritoneal covering of the liver, and a similar case is recorded by Benivenio. Tallon, Pomme, Saurau, and Heberden have seen cal- culi within the substance of the liver ; while Blasius, Fallopius, Columbus, Ruysch, Henricus ab Heers, and Morgagni record examples, in which the concretions were in the parenchyma of that organ. Plater, Rever- horst, Glisson, Morgagni, and Walter have seen them in the biliary ducts, as probably were those which Co- lumbus and Camenicus say they found in the vena portae. Walther and Dietrick found calculi in the ductus hepaticus; Ruysch and Soemmering in the ductus cysticus ; and Dietrick, Galeazzi, and Richter, in the ductus choledoclts. Greisel, Benivenio, Eller, Morgagni, Dargeat, and D’Hervillay have seen calculi included in morbid cysts, attached either to the liver or the gall-bladder. The place, however, where calculi are found in the greatest number, and with most fre- quency, is the cavity of the gall-bladder itself. Here they are sometimes single, their size varying up to a magnitude completely filling that cavity, as Saye ( Joum. des Savans, Sept. 1697;, Halle, and Isenflamm have noticed : while sometimes their number amounts to a hundred, or even a thousand, of diflerent sizes. Rubini possesses a gall-bladder, which contains above a hun- dred small calculi, and formerly I had a similar num- ber, which I found in the body of a female. Van Swieten met with a hundred ; Haller, a hundred and Ibrty ; Stieber, two hundred ; F. Plater, three hun- dred; Walther, five hundred; Mentski, seven hundred; Bailiie, a thousand ; Hunter, eleven hundred ; Parb, six- teen hundred ; Stork, two thousand ; and Meckel, several thousands. — Handb. der Pathol. Anat. b. 2, p. 400.) All hepatic concretions, however, are not calculated to pass from the place of their origin into the intes- tines, but only such as are situated in the ductus hepa- ticus, or its main branches, in the gall-bladder, the ductus cysticus, or the ductus choledocus. When their size is not disproportionate to the diameter of the ducts, they pass with facility; but, when their dimen- sions are larger than those ducts can naturally athnit, the latter becomes stretched and dilated, whence arise -the sharp pains and colic which attend the disorder, analogous to the sufferings produced by the descent of large calculi from the kidneys to the bladder. Tlie reality of these dilatations of the hepatic ducts is proved by dissection. Heister found the orifice of the ductus choledocus, which is usually very small, so much enlarged that it could receive a finger; and Vita| d’Azyr satv this duct enlarged through its whole ex- tent in a similar degree. — Hist, de la Sociitfe Royale de Medecine, an. 1779, p. 220.) Galeazzi, in di.ssecting a body, found the ductus choledocus so dilated, that it resembled a kind of bag, in which several calculi were included. Mr. Thomas has likewise seen two cases, in which the point of the fore-finger readily passed from the duodenum into the gall-bladder.— i See Med. Chir. Trans, vol. 6, p. 105. Morgagni saw this duct in one instance large enough to hold a coujile of lingers, and he quotes many similar instances from Bezold, Trew, V’erney, and others. W’e may conceive how dilated this tube must have been in a case recorded by Rich- ter, where, though it was not completely obstructed, a calculus weighing three ounces and a half was lodged within it. — (Rubini, op. cit. p. 7 — 10.) With regard to those concretions tvhich are distin- guished by the epithet gastric, or intestinal, some are formed in the cavity of the stomach ; the rest in one or other of the intestines. They remain for a greater or less period in the place of their formation, according as they happen to be lighter or heavier, smoother or rougher, more or less adherent, or as local or general circumstances are more or less favoura- ble to their retention or expulsion- Sometimes, they continue undischarged until they have attained a very considerable size. In particular instances, instead of remaining constantly in one place, they successively pass through the whole intestinal tube, lodging at dif- ferent points for a greater or less. time. In the works of Haller and (Jonradi may be seen representations of the fKiints of the inte.stinal canal, where these concre- tioihs have been found. The alvine concretion, of whi(;h Mari'.schal has given an account, was some years in traversing ali the convolutions of the bowels. These gastric or alvine concretions, which are very common in animals, are less freciuent in the hujnan subject, as is proved by the observations of Fourcroy 20 ALVIXE COXCKETiOXS. and Vauquelin, inserted in their valuable essay on this subject in the Aimales du Museum Nationale d’His- loire Naturelle de Pans. In the horse they are some- times of an enormous size, as we may learn from an in- stance on record, in which the concretion weighed thirteen pounds. — (Voigt, .Magazin Kir das Neueste der Naturkunde, b. 3, p. 578.) As for the third species, which Rubini names mixed, or hepatico-gastric, they have their beginning m the hepatic organs, and augment in the intestinal tube. Here, if the extraneous body be detained, and the con- tents of the bowels have a di.sposition to become thick- ened and condensed round it, as a nucleus, it may be rendered larger by additional strata of matter, and would increase sine fine, it a stop were not put to the augmentation by the narrowness of the canal, or an efi'ort made for the expulsion of the concretion. Morgaigni cites two instances of this sort of concre- tion; one from Gemma, the other from IJezold; and he gives his ojiinion that another alvine calculus, spoken of by Vater, must have been of the same nature. Dr. Coe describes another interc.sting specimen; and others are referred to by Vandermonde, (Moreali, Por- tal, Ac. Perhaps, says Rubini, tlie instances ol this kind would have been more numerous if all the con- cretions discharged from the bowels had been noted with greater attention, and the hepatico-gastric sub- stances not confounded w ith the hcjiatic. The lodge- ment of the.se concretions i’.i trie intestinal cuiial is of uncertain duration, and depends ui>on a vanety of cir- cumstances. Vandermonde give.s the history of a cal- culus, wliich, as far as could be judged of by the pain in the right hypochoiidrium, and the change of symp- toms, must have passed into the duodenum in the month of January, and then continued m the bowels until August, when it was discharged from the rectum. The crystallized aiipearance of alvine concretions is generally so conspicuous, that it has not escaped the attention of several of the old writers, as we may con- vince ourselves by referring to the works of Corn, Gemma, Greisel, Haglivi, Scultctus, Ac. It was no- ticed by Haller in his Rleinenta Physiologiae, vol. 6, and by Morgagni in his Episi. 3., de Sedibus ct t'au- sis, Ac. If, says Rubini, these crystallizations are not ' always plainly visible, distinct, and regular, this de- pends either upon their imperfection, th6 heteroge- neous nature of the accumulated matter, or particular unfavourable circumstances, which wouid equally af- fect the process of crystallization out of the body. Now, as all crystallizatiotis dej,end u])on the fluids in wlxich they form, and from which they receive their crystallizing elements, it must be evident that, in- asmuch as the fluids of the hepatic organs difler in their constituent principles from the fluids contained m the intestinal canal, the concretions produced in the first system must differ from those originating in the second; while tfie hepatico-gastric calculi will com- bine the nature and jiroperties of both togeixier. The fluid from which hepatic concretions are fonned IS unquestionably the bile, either some or all its ingre- dients entering into their comiiosition. Indeed, pre- viously to the new chemical doctrines, hepatic calculi were generally considered as being simply condensed indurated bile. From investigations made in more modern times, how- ever, when the art of analysis ha-s attained a precision of which the old chemistry was not susceptible, it ap- pears, that although human biliary calculi yield the same products as the bile, there is contained in them more or less of a peculiar substance, which was named by the celebrated Fourcroy, adi^cere. — M^m. de I’Acad. des Sciences, 1789, p. 323. The presence of this substance in the concretion is of such import- ance, that, when it is abundant and in large propor- tion, the calculus is regular and the crysttdlization well finished ; and, when it is in small quantity, the crystallization is confused and disordered, the calculus only exhibiting an irregular misshapen concretion, more like a clot than true crystals. The kind of adipocere constituting the base. of all human biliary calculi, has some resemblance to spermaceti. Both Fourcroy and Dr. Bostock, who analyzed it, found it cornpo.sed en- tirely of carbon, hydrogen, ai;d oxygen. It melts, but requires a heat .superior to that of boiling w'ater ; in fusion it has a smell like wax, and on cooling, forms a substance, w’hich breaks into crystalline laminae. It is not soluble in aicoaol in the cold; but when the al- cohol is boiled on it, it is dissolved in a proportion, ac- cording to Fourcroy, of one part in nineteen — accord ing to Dr. Bostock, one m thirty. — .Nicholson’s Jour- nal, 8vo. vol. 4, p. 137.) The solution, when it cools, dejiosites light brilliant scales. It is soluble in ether m the cold, and more abundantly if the ether be heated. Oil of turpentine generally dissolves biliary calculi ; and, according to Gren, it dissolves those which con- sist almost entirely of this pecuhar matter; yet Dr. Bostock has remarked, that oil of turpentine acts on it with dirticulty, and even when digested with it, at a boiling heat, dissolves it only in a small degree. Pure soda and potassa dissolve it completely, and reduce it to a saponaceous state. Ammonia, as Dr. Bostock has remarked, exerts little action on it, except w hen boil- ing. Nitric acid dissolves it, and, according to Four- croy, converts it into a sjxscies of liquid sniular to the oil of camphor. This becomes concrete, but w ithout any cry stalline structure, and is more soluble in ether and the alkalis than the original matter. “This substance Fourcroy has observed' is con- tained in greater or less quantity in nearly all human biliary calculi, more or le.ss intermixed with other mat- ter, but sfill so far predominant as to form their basis. Hence, they iiarlake of its jiroperties; are fusible, in- flammable, and more or less -soluble in the agents which dissolve it.” — See Murray’s Syst. of Chemist, vol. 4, j). 591, ed. 2. Fourcroy, on exjiosing the above peculiar substance to the action of oxygenated muria- tic acid, saw it whitened, and afterward resume its former silvery hue. However, Jlubiiii repeated this exiieriment, and found that the whiteness which was contracted remained penuaiient. While the hejiatic system contains a fluid which is always nearly of the same quality, viz. the bile, the alimentary canal, as Rubini observes, contains a hun- dred diflerent fluids, and is continually occupied by substances of various natures, kinds, and properties, consisting of food, drink, and several secretions. All the princijiles which are to serx'e for the fonnation and renewal of the different species of living solids, and of the many kinds of fluids^ at first remain more or less time in the alimentary canal, and there undergo pecu- liar changes. All the princijiles w liich, under different rircumsiances, may contribute to the jiroduction of morbid concretions, either in the gall-bl.adder, the uri- nary bladder, the kidneys, or in any other part of the body, where they ever occur, pass at first into the in- testinal canal, where they continue for some time. Such a niultijilicity of principles, disposed to crystal- lize, and be converted into calculi, would very often, almost daily, produce these concretions in the bowels, were there not many circumstances wtiich counter- act this tendency, as, for instance, exercise, the in- ce.ssant motion of the matter itself along the intestinal tube, the variety of these element-s, whereby their re- quisite tendency to 'onite is disturbed, and the decom- posing and reconijmsing influence of the gastric secre- tions, whereby parts are united, disposed of, dissolved, and analogous matter kept divided, Ac. But when- ver these circumstances tire not actively operating, as may be the case in a noose, or fold of the bowels, or in some preternatural cyst belonging to them ; when- ever the intestinal fluids undergo such an alteration that the production of these concretions cannot be pre- vented ; or, lastly, whenever some favourable circum- stance, such as an extraneous nucleus, forms a centre of reunion for particular elements ; then the saline matter, w liich is most disjiosed to crystallize, and the earthy and mucilaginous substances, Ac., are attracted together, and produce more or less perfect crystalliza- tions. A chemical analysis of some intestinal calculi, first made by Konig, and aftenvard by Slare Philo- sophical Transactions;, proves, that when they are ex- posed to a strong heat in distillation, they yield water, ammonia, and a lixivious salt, a caput mortuum re- mtiining behind. Cadet, in analyzing a similar concre- tion, found, in addition to the above jiroducts, phospho- ms. The muriate of ammonia was afterward disco- •vered; and Gioberti, Fourproy, and Vauquelin, in their histones of the intestinal concretions met with in ani- mals, describe them as comjio.sed of the acidulous phospate of lime, phosphate of magnesia, and of the ammoniacal-mague.sian phosphate. Some specimens lontained in the Edinburgh mu- seum were very carefully examined by Dr. T. Thom- s'c.a : they at first swam in v. ater, but afterward sunk ; ALViNE CONCRETIONS. 21 the specific gravity varying from 1.376 to 1.540. Cold water acquired from them a brownish tinge, and took up albumen, wltich separated in white flakes by boil- ing. There was also a peculiar brown substance, at first dissolving in water, but rendered nearly insoluble by slow evaporation ; soluble in alcohol ; and most nearly resembling vegetable extract. The specimens likewise contained muriate of soda, crystallizing on spontaneous eva^toration of the water; phosphate of lime, precipitated b7 ammonia; sulphate of soda in minute proportion; and, perhaps, sulphate of lime. Alcohol dissolved the peculiar brown matter and some of the salts ; caustic potash, the albumen, brown mat- ter, and perhaps some of the salts ; and muriatic acid a proportion of phosphate of lime. After ail, there re- mained a peculiar substance, having the colour and texture of the calculus ; in very short threads, light, resembling cork, or rather agaric ; tasteless, insoluble in water, alcohol, other, potash-ley, and muriatic acid ; being blackened, and partly reduced to charcoal by sulphuric acid; slowly dissolving by heat, without effervescence, in nitric acid ; and leaving on evapora- tion a whitish residue, of bitter taste, and imperfectly soluble in water; burning with a bright flame; but differing from all other animal and vegetable substances hitherto examined, and distinguishable from wood, by its insolubility in potash-ley. The calculi consisted of alternate layers, or intimate mixtures of this sub- stance and phosphate of lime, to which the albumen and brown matter served as a cement, the other sub- stances being in small proportions. Phosphate of lime mixed with a brown animal matter, formed the exter- nal crust of some of the specimens. On the surface of a few were noticed crystals of phosphate of ammonia and magnesia. The presence of neither potash, am- monia, carbonate of lime, uric acid, nor urea could be detected. Varieties' have also been found by Dr. Henry and Mr. Brande, exclusively composed of magnesia, of which the patients had been in the habit of taking vast quantities. — See Thomson’s Obs. in Monro’s Morbid Anatomy of the Human Gullet, &;c. p. 36, or in Medico- Chir. Journ. voj. 4, p. 188, 189.) From observations made by Dr. Wollaston, it ap- pears probable, that the above fibrous, light, thready substance is derived from oats, which are so commonly taken as food in Scotland. • If the oat-seed be divested of its husk, minute needles or beards, forming a small brush, are seen planted at one of its ends. Dr. Wollaston, on examin- ing these needles and comparing them with similar ones detached from the calculi, and forming the velvet substance in question, satisfied himself, beyond all doubt, of their perfect identity.” — Marcet on Calcu- lous Disorders, p. 130, 8vo. London, 1817.) The specimen analyzed by Dr. Ure, he inferred to be a modification of ambergris. — Diet, of Chemistry, art. Intestinal Concretions, j As for the mixed or hepatico-gastric calculi, they have for their nucleus a biliary concretion, round which other substances contained in the bowels adhere; hence, it is evident, that as they are formed at two dis- tinct periods in two different situations, and among va- rious fluids, two distinct compositions must Be the re- sult. Although, says Kubini, there has hitherto been no scientific analysis of tliis species of calculus, ex- cepting the very imperfect one by Moreali, reason shows clearly enough, that, if two separate analyses were made, one of the nucleus, the other of the sur- rounding matter, there would be obtained from the nucleus the same elements as those of an hepatic cal- culus, and from the rest those of an intestinal concre- tion. — :See Pensieri sulla Varia Origine, , particularly Morgagni and Soemmer- ing, to comprehend, that any criterion deduced tVom their colour is most fallacious, every species of them presenting great variety in this particular. And it is to be remembered, that the bile and the intestinal fluids, whence these concretions arc formed, differ in colour in different individuals, according to a variety of cir- cumstances, in health and disease. One species of hepatic calculus has a white colour, but is sometimes yellow or greenish. Another is of a round or poly- gonal shajie, and often of a gray colour externally, and brown within. A third is of a deep brown or green colour.— (See Ure’s Diet, of Chemistry, art. finll- stones.) The smaller intestinal concretions examined by Dr, T, Thomson, destitute of coating, resembled bad yellow ochre ; the larger were encrusted with an earthy matter, of a coffee colour, and puri)le or some- times white. — (See Monro on the Human Gullet, «fcc,, and Med. Chir. .lourn. vol. 4, p. 188.) Third criterion. The presence or absence of a nu- cleus will enable one to judge w'hether a calculus be gastric or hepatic. A biliary concretion has no nucleus, proper!*/ so called ; that is to say, it h;is no foreign body in its centre. When a transverse .section is made of such a calculus, one'finds either a cavity in its mid- dle, or else nothing by which this part of its substance can be distinguished from the rest; or if a nucleus dif- ferent from the other part of the concretion be apparent there, it consists merely of bile, either grumous, dif- ferently coloured, or more or less fluid than the rest of the calculus, but wliich is nevertheless invariably bile. On the contrary, every gastric concretion has, as it were, an extraneous nucleus, as Fourcroy and Vauquelin have explained in their essay upon the intestinal calculi met with in animals, Ruysch in the Phil, Trans, gives an account of some alvine concretions which were formed round grains of seed, Birch records an example of a crystallized calculus formed round a leaden bullet. Haller met with a calculus in the centre of wiiich was an iron nail. Concretions formed upon fruit-stones are recorded by Clarice, White, and Hey, and also in the Edinb. Med. Essays. Instances in which the nucleus was a small portion of bone are related in the latter work, and also by Hooke and Coe. Homberg and others describe alvine concretions formed round indu- rated excrementitious matter ; and many similar cases are specified by Vallisnieri, Van Swieten, and others. In the hepatico-gastric calculus the biliary concretions serve as a nucleus for the gastric. According to Dr. T. Thomson, the nucleus is commonly a cherr^^-stone. a small piece of l)onc,or a biliary calculus.— (See Med, Chir. .louni. vol. 4, p. 188.] A fourth criterion is deduced fVom a certain unctu- osity which belongs to biliarj- calculi, but not to those of the gastric class. This character is more palpable w hen the calculus has been recently voided, or w hen it is handled with warm fingers. The unctuasily is still more evident when the concretion is cut or sawn, as then the knife, saw, or fingers become smeared with saporm- ceous particles, which adhere to them. In order to denote an hepatic calculus, however, the umtuosity mu.si per\’ade its whole substance, and not merely ap- pear towards its outside ; for a gastric, earthy, saline concretion may by accident become coated, as it passes through the bowels, with a stratum of bile or sapona- ceous matter. When the unctuosity is deficient exter- nally, or in the outer laminae of a calculus, but is found in its interior, it is a clear indication of the hepatico- gastric formation of the concretion. Fifth criterion. The specific gravity of a calculus, the property which it has of floating or sinking in wa- ter, has been long considered as a test of its species. The hepatic calculus is generally specifically lighter than w ater, as most oily substances are : on the con- trary. gastric calculi a: sfiecifically heavier than wa- ter, like all earthy saline matter, and of course sink in that fluid. Tliis criterion was often employed by Re- verhorst, Fernelius, and others, for distinguishing va- rious concretions. But it is by no means regular, as many hiiiary calculi swim only a little w hile and then sink. The specific gravity of that analyzed by Dr, Ure, of Glasgow, was 1.0135. — See Med. Chir. Journ. vol. 4, p. 179.) As Rubini observes, this test will not answer for hepatico gastric calculi, which are subject to great anomalies. — Pensieri, A-c. p. 22.) Neverthe- less, the most correct modem examinations prove, that gastric concretions have a specific gravity varying from 1.376 to 1.540 ; Dr. T. Thomson in Mpnro’s Morb. .\iiat. Ac. , and consequently their general character is to be heavier than biliary calculi. A sixth criterion is that proposed by Vicq d’Azyr in the .M^ni. de I’Acad. Royale de Med., and deduced from the figure of the crystallization. According to this writer, intestinal concretions crystalli.;e in concentric laminte, shaped like a cock’s comb, while the crystalli- zations of biliary calculi are radiated and needle-shaped. Although this criterion is ingeniously founded upon the known laws by which ever)' crystallized substance assumes a peculiar and determinate shape, yet it may be generally ohserx-ed with respect to the mark of dis- tinction here proposed, that the concretions of which we are now speaking are usually too compound, and too much disturbed in their crystallization to exhibit a regularity, for which simplicity and quietude are indis- pensable. Hence many of these concretions do not present the slightest vestige of crystallization, while others scarcely show a trace of it, in the midst of a large misshapen mass. I'he white-coloured hejiatic calculus when broken is said to present crystalline plates or stri®, brilliant and white like mica. The round or polygonal one which is often of a gray colour exter- nally, and brown within, is described as consisting of concentric layers of inspissated bile, msually with a nucleus of the white crystalline matter in the centre. Lastly, the hepatic calculi, of a deep brown or green colour, when broken, are said to exhibit a number of crystals of the substance resembling spennaceti, mixed with inspissated bile. — See Ure’s Diet, art. Gall-stones,) With respect to the special shape assigned by Vicq d’Azyr to the two classes of alvine concretions, it may be observed that his specimens were taken from animals, and that consequently the inferences made from them are not applicable to substances of an analogous nature discharged from the human body ; because, as the bile varies in different animals, so must the formative prin- ciples of the calculous crystallizations. It is farther remarked by Rubini that the substance termed adijio- cire, which is the basis of biliary concretions, was not found by Poulletier in hepatic calculi taken from homed cattle. A seventh criterion is founded upon the inflammabi- lity of an alvine calculus. A biliary concretion being commonly made up altogether of unctuous matter, liquefies when subjected to heat, smokes, emits a flame, and burns. When this experiment is made in close vessels, the products are hydrogen, carbonic acid sas, oil, and ammonia : some carbon and eartii remaining ALVINE CONCRETIONS. 23 behind. An intestinal concretion, on the other hand, decrepitates or turns black, but generally does not burn. One specimen examined by Dr. Ure, when heated to the temperature of 400° F., fused into a black mass, and exhaled a copious white smoke, in the odour of which was recognised that of ambergris, mixed with the smell of burning fat. Exposed in a platina capsule to a dull red heat, it burned with much flame and smoke, leaving no appreciable residuum. — See lire’s Diet, of Chemistry, art. Intestinal Concretions.) The eighth criterion depends upon the solubility of calculi in an oily menstruum. Haller dissolved biliary calculi in oil of turpentine; Dietrick found them solu- ble in oil of sweet almonds ; and Gren in oils in gene- ral. But intestinal calculi are not so readily dissolved by any of these menstrua. The ninth criterion is founded upon the solubility of the calculus in alcoho'. In biliary calculi this solubility is not always the same; but as this point has been already spoken of, it is unnecessary to dwell upon it ; and I shall merely add, that while hepatic concretions are almost always more or less dis.solved by alcohol, those of the gastric kind resist this menstruum. Though the above criteria are interesting, as tending to establish distinctions between the different species of alvine concretions, it merits attention that not one of them taken separately is at all certain and pathogno- monic. It may happen, says Rubini, that some pecu- liarity in the biliary secretion, and an irregularity in the crystallization and accumulation of the matter, may cause salts and earths to predominate in hepatic con- cretions, in which circumstance their usual oily quality will be defective. On the other hand, in the formation of an intestinal concrefion, oily adipooe matter may accidentally adhere to it, so as to disguise Its wonted character. If uniformity of characters and physical properties depend upon uniformity of elementary con- stituent principles, it can hardly happen even in the natural healthy state of the secretions, because age, sex, and other particular circumstances of- the indivi- dual will always make a difference in the proportions of those principles. How then can identity of results be expected in a diseased state of the process of secre- tion?— Such reflections may explain how Morgagni among others met with many biliary calculi which were not inflammable; with others which did not give a yellow tinge to water ; and with some which floated or sunk in water, according as they had been recently or long discharged ; while Gren found some of these calculi insoluble in alcohol, t6 Royale de Med. 1779. A valuable production, particularly with reference to the kinds of crystallization obsers'able in hepatic and intestinal cal- culi. Durande, Memoire sur les pi^rres biliaires, et sur refficacitii du melange d’ether vitriolique et d'esprit de t^rebinthine dansle colique hepalique produite par ces concretions, vol. 1 des M^m. do I’Acad. de Dijon, 6vo, p, 199, an 1763. S. T. Soemmering, De Concce- mentis biliariis corporis humani, 8vo. Traj. ad Rhen. 1795. B. Brunie, Essai sur les Cafruls biliaires, 4to. Paris, 1803. Fourcroy, Mem. de I’Acad. des Sciences, 1789, et Syst. des Connoissances Chim. t. 10, p. 53— 60. Dr. Bostock, in .Nicholson’s Journal, vol. 4, p. 137. Marcet’s Chemical History and Medical Treatment of Calculous Disorders, 8vo. Lond. 1317. J. F. Meckel, Handbuck der Pathol. Anat. b. “2, p. 455, Ac. Leipz. 1818. P. Riihini, Pensieri sulla varia Origine e Natura de Corpi calcolosi die vengono talvolta espulsi dal Tubo Gastrico Memona, 4to. Verona, 1808. James Kennedy, An Account of a .Morbid Concretion dis- charged from the Rectum, and in its Chemical Charac- ters closely resembling .Vmbergris; with Historical Re- marks: see Medico-Chir. Journal, vol. 4, p. 177, Ac. 1817. Monro’s Morbid Anatomy of the Human Gullet, Sto- mach, and Intestines, 8vb. Edinb. 1811. The account of alvine concretions in this work is one of the best and most comprehensive. Diet, des Sciences Med. art Bezoard, et Calculs biliaires. Nothing of much con- sequence in either of these articles. Moscovius, Diss. de Calculorum Anirnalium eorumque impnmis bilioso- rum origine et natura. Berol. 1812. Cases in Surgery, by C. White, 8vo. Lond. 1770, p. 17. Philos. Trans, abridged, vol. 5, p. 256, et seq. Edinb. Med. Essays and Obs. vol. 1, p. 301. Ibid. vol. 5, p. 431. Essays, Phys. and Literary, vol. 2, p. 345. Leigh’s Natural History of Lancashire, plate 1, fig. 4. W. Hay’s Practical Obs. in Surgery, p. 507, ed. 2. Richerand, Nosographie Chi- rurgieale, t. 3, p. 433, ed. 4. Thomas in Med. Chir. Transactions, vol. 6, p. 98. T. Brayne, An Account of Two Cases of Biliary Calculi of extraordinary di- mensions : Med. Chir. Trans, vol. 12. lire’s Chemical Diet, articles. Intestinal Concretions and Gall-stones. AMAUROSIS. (From a^avpaij, to darken or ob- scure.) Gutta serena. Suffusio nigra. Fr. L’Amau- rose ; Germ. Schwarzer Staar. According to Beet , the term amaurosis properly means that diminution or total loss of sight which immediately depends upon a mor- bid state of the retina and optic nerve, whether this morbid state exist as the only defect, or be complicated with other mischief ; whether it be a primary affection, or a secondary one induced by previous disease of other parts of the eye. Or we may say, Avith a critical wri- ter, that the terra amaurosis designates all affections of the nerves of vision, which produce either complete or partial loss of sight, whether this arise fiom obvious or inferred organic disease, or from a diminution or loss of sensibility in the eye, which cannot be traced to change of structure or any other evident cause. — See Journ. of Foreign Med. and Surgery, vol. 4, p. 166.) The definition given by Mr. Lawrence in his Lectures appears to be correct and comprehensive. Amaurosis an 1 gutta serena, he remarks, are names applied indif- ^ ferently to those forms of blindness which result from an affection of the nervous structure of the eye, whether it be seated in the retina, optic nerve, or sensorium ; or I whether this affection be produced immediately by vas- , cular congestion, infiamrnation, or organic change ; or j indirectly by sympathy with other organs. I From these definitions, w'hich comprehend every I form of amaurosis, it is evident that this affection does not uniformly take jdace as a single independent disor- der ; hut not unfrequently presents itself as a symptom- atic effect of some other disea.se of the eye ; a fact e.xemj)lified in cases of hydrophthalrnia, cirsophthalmia, glaucoma, Ac. And, a.s Mr. Wardrop observes, amau- rosis in its usual acceptation signifies a symptom of disease as well as a distinct affection. — Essays on the .Morbid Anatomy of the Human Eye, vol. 2, p. 165, 8vo. Lond. Ibid.) With respect to the mere name of the kind of disease here implied by amaurosis, its correct- ness w ill remain the same, whether the iris be moveable or immoveable ; whether the pupil be preternaturally enlarged or contracted; and whether it be perfectly clear and transparent, or more or less turbid ; for the name only refers to the morbid state of the retina and optic nerve, and not to the condition of the sight in general. When the long-established name of amauro- sis is received with this precise meaning, there will not be the slightest danger of confounding the disease with other affections of the eye. How'ever, when it is wished to make out the very different fonqs and kinds of amau- rosis, the foregoing apjiearances of the iris and pupil are considerations of great importance. — .See Beer’s Lehre von den Augeiikrankheiten, b. 2, p. 420, Ac. Wien. 1817.) I think it also of importan«e that surgeons should well understand what Mr. Travers has particularly mentioned, that the tenn “ amaurosis” comprehends all those imperfections of vision which depend upon a morbid condition, whether affecting structure or func- tion of the sentient apparatus proper to the organ. — (See his Synopsis of the Diseases of the Eye, p. 293.) Beer reckons four species of amaurosis. The first is a genuine uncomplicated amaurosis, the characteristic symptom of wliich consists peculiarly and entirely in an impairment or loss of vision, without any morbid change in the organic matter of the eye. To tliis case the epithet “proper functional,” used by Mr. Travers, would be applicable. Secondly, there is an amaurosis, which, besides being attended with a diminution or total loss of vision, is also accompanied with appearances of di.sease in the organic matter of the ey . Thirdly, there is another amaurosis, in which, to- gether with the above principal symptom, viz. weak- ness or loss of sight, there are also morbid phenomena exhibited in the form of the eye in general, or its parti- cular textures, and especially in the action of its irrita- ble parts. Lastly, Beer says, he can offen point out an amau- rosis in which all the characteristic symptoms of the three preceding cases are more or less combined. — (See Lehre von den Augenkr. b. 2, p. 478,) The genuine uncomplicated amaurosis, consisting of a mere diminution or loss of sight, without the appear- ance of any other defect, is one of the most uncommon forms of complaint, not only because singly operating causes are few, but because they can rarely operate directly upon the optic nerves. In the true uncomplicated amaurosis, merely the vital qualities of the optic nerve and retina are affected, and after death nothing preternatural can be traced in those parts either within or on the outside of the eyeball. It is, in short, the case in which the functions of the retina have become imperfect or destroyed, the eye appearing in other respects sound. According to Beer, this simple unmixed form of amaurosis is subdivisible into that amaurotic weak- ness of sight or blindness, which depends upon the vi- tality or rather sensibility of the optic nerve and retina being too highly raised, and into another case, the proxi- mate cause of which is peculiarly and entirely refera- ble to depression of such vitality or sen.sibility. The first example is much less common than the second. Amaurosis does not constantly attack both eyes at the same time ; frequently one is attacked some time after the other, and it is not unusual even for one eye to remain sound during life, while the other is com- pletely blind. This depends, in part, upon the dispoai- AMAUROSIS, 25 tion to the disease in one eye being quite local, and in part upon the causes giving rise to the complaint ex- tending their operation only to the eye affected. Where also the origin of amaurosis seems to depend altogether upon constitutional causes, one eye is not unfrequently attacked much sooner than the other ; though in these examples, it is more rare to find the eye which does not suffer at first continue perfectly unaffected. — Beer, b. 2, p. 422.) As a general observation. Mr. Wardi'op thinks it may be remarked, that when only one eye be- comes at first amaurotic from a sympathetic affection, there is little danger of the other eye becoming blind ; hut that when amaurosis is produced by any organic change in one eye, the other is very liable to be sympa- thetically affected. — Essays on the Morbid Anatomy of the Human Eye, vol. 2, p. 190.) Amaurosis may not completely hinder vision, a diminished power of seeing often remaining during life. Hence the division of cases into perfect and imperfect ; which latter, how- ever, sometimes attain a degree in which the patient is only just able to distinguish light, the direction of its rays, and its degree. Imperfect amaurosis, besides being characterized by a considerable weakness of sight, approaching to real blindness (Amblyopia Arnaurotica , is mostly compli- cated with a greater or less number of other morbid appearances, which merit serious attention. Among the most important of these symptomatic appearances of imperfect amaurosis is a defective in- terrupted vision visus interruptus). For instance, when the patient is reading, single syllables, words, or lines cannot be seen, unless the eye be first directed to them by a movement of the whole head, and greater or less portions of other objects are, in the same manner, indistinguishable. Sometimes, amaurotic pa- tients can see only the upper or lower, or the left or the right half of objects f Visus dimidiatus; Amau- rosis dimidiata ; Hemiopia; Hemiopsia.) Sometimes when the patient shuts one eye, he can only distingui.sh the halves of objects ; but if he open both eyes, he sees every thing in its natural form In this case, according to Schmucker, one eye is sound, and only some fibres of the nerve of sight are injured in the other. — Vermischte Chir. Schrift. b. 2, p. 12.) There are likewise some not very uncommon cases of imperfect amaurosis, in which the patient can- not see an object, unless it be held in a particular direction before the eye ; but when the eye or head is moved in the least, he loses all view of the thing, and cannot easily get sight of it again. — Beer, Lehre von den Augenkrankheiten, b. 2, p. 424.) On this part of the subject, it is remarked by Richter, that patients who may be said to be entirely blind, sometimes have a small part of the retina which is still susceptible of the impression of light, and is usually situated towards one side of the eye. This obliquity of sight was long ago pointed out by the late Mr. Hey, as common in the present disease. — See Med. Obs and Inquiries, vol. 5.) Richter mentions, that in one man, who was, in other respects, entirely bereft of vision, this sensible point of the retina was situated obliquely over the nose, and 80 small, that it was always a considerable time before its situation could be discovered ; he adds, that it was so sensible, as not only to discern the light, but even the spire of a distant steeple. According to this au- thor, it is the centre of the eye that seems to be the first and most seriously affected. Hence, the generality of patients, who have a beginning imi^erfect amaurosis, see ^objects, which are latterally situated, better than such as are immediately before them. — (Anfangsgr. der Wundarzn. b. 3, kap. 14.) One of the most common symptoms of a beginning amaurosis, is an appearance in the patient’s fancy, as if gnats or flies were flying about before his eyes (Visus Muscarum, Myodesopsia). Sometimes, trans- parent, dark-streaked, circular, or serpentine diminu- tive bodies appear as if flying in greater or less num- bers before the eyes, often suddenly ascending, and as quickly falling down again, and chiefly annoying the patient and confusing his sight when he looks at strongly illuminated or white objects. The substances thus appearing to fly about before the patient’s eyes, are termed Musete volitantes ; Mouches volantes. — (Beer, Lehre, .) The general symptoms of the simple uncomplicated species of amauro.sis, putting out of consideration the morbid increa.se, or diminution of the sen.sibility of the optic nerve, are thus described by Beer. In the first place, all morbid appearances are absent, which might be produced in the amaurotic eye by any one preternatural change in the texture, form, or state of llal organ. Hence we are obliged to trust almo.st ex- clusively to the patient’s assertion that his sight is bad, or quite gone ; and not unfrequently it is necessary, especially in judicial ctLses, to employ political artifices in order to determine whether such as.sertion be true, particularly when the patient affirms that the blindness is restricted to one eye Secondly, wlien the amau- rusKs n* indeed nearly or quite formed in one eye, a slight degree of strabl.smus is at most perceptible, aris- ing from the circumstance of the patient’s not fixing the eye affected upon any object. This degree of stra- bismus is noticed by Ackerman and Fischer as the surest sign of amauro.sis. — <,See Klinische Annalen von Jena st. 1, p. 144.) And it is particularly pointed out by Richter as an invariable attendant upon amaurosis. The patient, says he, not only does not turn either eye towards any object, in such a manner, that the ob- ject looked at is in the axis of vision, but he does not turn both his eyes towards the same thing. This was regarded by Richter as the only symptom which we can trust, where implicit confidence should not be put in the mere assurance of the patient that he cannot see, while all the coats and humours of the eyes pre- sent their natural appearance — See Anfangsgr. der Wundarzn. b. 3, kap. 14. i Provided this observation be correct, it must be highly interesting to the military surgeon, amaurosis being a common affliction of sol- diers, many of whom, liowever, endeavour to avoid service by pretending to labour under a disqualification which they well know does not necessarily produce any very considerable alteration in the natural ajipearance of the part affected. Thirdly, while the disorder is only in the stage of amblyopia, the patient always com- plains of continually multiplying muscae volitantes, or of the visus reticulatus, or nebulosus. Fourthly, lu- minous forms appear before the eyes, especially in the dark, even when the patient is entirely blind. Fifthly, the deer ase of vision goes on to complete blindness, without any material interruption, or retrogression. Sixthly, when only one eye is quite blind, and the eye- sight on the other side is perfectly undisturbed, there is one infallible symptom of this amauro.sis ; namely, if the sound eye be very carefully covered, the pupil of the blind one immediately expands, and the iris be- comes quite motionless, notwithstanding the diseased eye be exposed to the strongest light possible. How- ever, this criterion is mostly wanting, because the amaurosis, unattended with any perceptible effect, ex- cept loss of vision, is seldom confined to one eye, but usually affects both. — ^See Lehre von den Augenkr. b. 2, p. 481, 482.) Mr. I'ravers divides amaurotic affections into two classes, the organic and the functional. The first comp eheuds alterations, however induced, in the tex- ture or position of the retina, optic nerve, or thalamus. The second includes suspension, or loss of function of the retina and optic organ, depending upon a change, either in the action of the vessels, or in the tone of the sentient apparatus. As causes of organic amaurosis, Mr. Travers enu- merates; 1. Lesion, extravasation of blood, inflamma- tory deposition upon either of its surfaces, and loss of transparency of the retina. 2. Morbid growths within the eyeball, dropsy, atrophy, and all such disorganiza- tions as directly oppress or derange the texture of the retina. 3. Apoplexy, hydrocephalus, tumours or ab- scesses in the brain, or in or upon the optic nerve or its sheath, and thickening, extenuation, absorption, or ossification of the latter. As causes of functional amaurosis, Mr. Travers specifies; 1. Temporary de- termination ; vascular congestion, or vacuity, as from visceral or cerebral irritation ; suppressed or deranged or excessive secretions, as of the liver, kidneys, uterus, mammae, and testes; various forms of injury and dis- ease ; and hidden translations of remote morbid ac- tions. 2. Paralysis idiopathica, suspension or ex- haustion of sensorial power from various constitu- tional and local causes ; from undue excitement or exer- tion of the visual faculty ; and from the deleterious action of poisons on the nervous system, as lead, mercury, &c. From this description, says Mr. Travers, it will be understood that organic, and many forms of functitwial amaurosis are incurable ; and the functional, by con- tinuance, lapses into the organic disease. Functional amaurasis is subdivided by Mr. Travers into, 1st, the Symptomatic, or that which is only a symptom of some general disease, or disorder of the system; as, for example, general plethora, general de- bility ; 2dly, the Metastatic, or that produced by the sudden translation of the morbid action from another organ of the body; as, for example, from the skin, the testicle, «kc. : 3dly, the Proper, or that which de- pends upon a peculiar condition of the retina ; as, for example, the visus nebulosus, muscie volitantes — (9>'nopsi6, p. 139—155.) 28 AMAUROSIS. On the whole, genuine local amaurosis, that is to say, a diminution or total loss ol’ the eyesight, uiiat- teniled with any other apparent local or constitutional defect, may be said to be a very rare case, the disorder being usually more or less comiilicated. To the local complications, says Beer, belong the ca- taract ; glaucoma; a general varicose state of the eye- ball cirsophthalmia ; exophthalmia ; atrophy of the eye ; spasms in the organ and surrounding parts ; para- lysis of one or more muscles of the eye oj)hthalmoi>- legia ; paralysis of the eyelids ; ophthalmia in general, and internal ophthalmia in particular ; a scorbutic blood-shot apiiearance of the eye ^hy^^oema scorbuti- cum ; and finally, wounds or contusions of the eye or adjacent parts. With these cases should also be men- tioned that imiiortant ca.se, fungus Inematodes of the I eye. From this siinjile enumeration of local complica- j tioas one may .see how frequently amaurosis is only a j symptomatic effect of another disorder of the eye, with | which it is conjoined, and how ollen it is connccteil | with the same common causes which jiertain to another i or several other diseases of the eye. Among the general comjilications Beer enumerates ' those which are purely nervous : impairment of the I health in various forms by infection, contagion, or mias- ' niata ; a bad habit of body ; typhoid fevers, the aniau- i rotic effects of which Ujion the eye the author of tins j work has frequently noticed; asthma ; internal and ex- ternal hydrocephalus ; organic defects of the abdominal ; viscera ; worms ; chlorosis; consumption ; old ulcers of { the legs; organic disease of the brain and skull ; com- i plaints arising from pregnancy ; hemorrhage, Ac. In ! the.se general com|)licatioiis Beer remarks that the casual connexion between amaurosis and some remote ^ disea.se of another organ, or of the whole constitution, | cannot be mistaken; and in these cases we otlen see the disease of some other distant part Irom the eye sud- denly Of gradually diminish, and immediately ap|Miar again as a sympathetic action in the form of amaurosis, tif which the most remarkable instance is seen after the sudden healing of old ulcers of the legs. — (Beer, Lehre von den Augenkr. b. 2, p. 133. From the above general remarks upon amaurosis it is <}uite manifest that the symptoms of the disease vary considerably according to the violence of its causes, and of the local and general complications, though the ! seat of the disease and what is particularly the proximate | cause of the loss of vision be in the ojitic nerve ; and it depends esfiecially on the nature of the causes, whether this or that morbid apiiearance take place in the eye. One may consider as the only really inseparable symptom of amaurosis that weakness of sight ambly- opia , or that complete blindness, in which neither wirh the unassisted or assisted eye the least defect can be jierceived in the structure and shape of the alfected or- i gan. Hence Beer names such impairment of vision, or blindness, amaurotic. But how rarely this essential symptom is met with alone, and how frequently it is | obscured by some other defect in the structure and i form of the eye, is proved by daily experience. | The incidental symptoms of amaurosis have hitherto | been set down as merely consisting of a considerable dilatation of the pupil, and immobility of the iris, be- cause these appearances are indeed the most freijuent ; but, as Beer observes, this is another proof what igno- rance has prevailed respecting the true mature of that disease of the eye and its modifications, which are usually termed amaurosis. The' incidental symptoms of amaurosis may consist in the faulty size and shape of the pupil. In many cases the pupil is very much dilated, immoveable, and possesses i; s natural black colour and usual transpa- rency. It cannot be denied that this Is the state of numerous cases, but it is etjually true that there are many exceptions. Sometimes, according to Richter, in the most complete and incurable cases the pupil is of its proper size, and even capable of free motion (Turbes, Recueil Periodique, &c. t. 2, p. 319 ; and oc- casionally, it is actually smaller and more contracted than natural. This aperture often continues extraordi- narily large in the .strongest light ; but in some instances it is unusually small in every kind of light. — Arra- chard, Recueil Period. &c. t. 1, p. 273. Richter, An- fangsgr. Ac. b. 3, p. 424. Beer, Lehre, Ac. b. 2, d. 435.) According to the latter writer, the pupillary edge of the ins rarely has its primitive shape, being generally more or less angular , either at some indeterminate point, or above and below, .so as to resemble in some measure the pupil of the cat race ; or towards the nose or tem- ple, so as to have some similitude in its form to the pupil of ruminating animals. These apiiearances are highly imjiortant, having great inftucnce over the diagnosis. Frequently not only the size and shajic of the pupil are faulty, but the position of that opening is (luitc un- natural, being inclined either upwards or downwards, or outwards or inwards ; but most commonly in a dia- gonal line between inwards and upwards, and in these cases the pupillary margin of the iris never describes a regular circle, but is always more or less angular. — (Beer, vol. cit. p. 436.) The pupil of an eye affected with amaurosis fre- quently does not exhibit the clear shining blackness w hich is seen in a healthy eye. In general it is of a dull, glassy, honi-like blackness, which symptom alone is frequently enough to apprize a well-infonneil prac- titioner of the nature of the disease. It is, in the words of Mr. Travers, “little more than the healthy appear- ance of the humours in the eye of a horse.” — Synop- sis, J). Ifii.i Sometimes the colour of the pupil has an inclination to green ; while in other examples this aperture seems to be dense, white, and cloudy, so that the complaint might ea.sily be mistaken for the begin- ning of a cataract. This error, into which inexpe- henced surgeons are liable to fall, may generally be avoided by attention to the following circumstances : — The mi.'ty ajijicardnce is not situated close behind the pupil in the place of the crystalline lens, but more deeply in the eye. iNor is it in proportion to the im- painnent of sight, the patient being quite blind, while the misty apjiearance is so trivial, that if it arose from the opacity of the crystalline lens, it could at most only occa.sion a slight weakness and obscurity of vision ; at the same time Richter acknowledges that it must be more dillicult to avoid mistake when a beginning amau- rosis is accompanied with this cloudiness of the eye, and consequently when the degree of blindness seems to bear .some proportion to the degree of mistiness in the pupil. However, in this case he maintains that the true nature of the disea.se may generally be known by comparing the ordinary symptoms of the two diseases. — Anfangsgr. b. 3, p. 14.) And, according to Beer, when the pupil is of a true dark-gray, or greenish-gray colour, a lateral inspection of the eye will show plainly enough, that the cloudiness is in the vitreous humour or behind it. Sometimes the pupil appears reddish, quite red. or of a yellowish-white colour Lehre von den Augenkr. b. 2, ji. 436) ; while in other ca.ses the inte- rior of the eye a good w'ay behind the pupil seems quite white, and a concave light-coloured surface may be ob- served, upon which the ramifications of blood-vessels can be plainly seen. In particular instances this white surface extends over the whole back part of the eye, while in other ca.ses it only occupies a half or a small portion of it. This peculiar appearance has been ascribed to a loss of transparency in the retina itself, and a consequent reflection of the rays of light.— (Hal- ler, Element. Physiol, tom. 5, p. 409 ) Mr. Travers in- clines to the opinion, that it arises from a deficient secretion of the choroid pigment, a preternatural adhe- sion between the choroid coat and the retina, and a discoloration or resplendent appearance of the latter from this cause. — (Synopsis, p. 148.) One of the strongest characteristics of amaurosis and an incipient cataract, and one most to be depended upon in practice, is reported by Mr. Stevenson to be the dif- ference whii;h the flame of a candle exhibits in the two affections. In incipient cataract it appears as if it were involved in a generally diffused, thin mist or wbJte cloud, which increases with the distance of the light ; but in amaurosis a halo or iris appears to encircle or emanate from the mist, the flame seeming to be split, when at a distance. — vOn the Nature, Ac. of Amauro- sis, Lond. 1821.) There can now be no doubt that the whitene.ss be- hind the pupil must sometimes have originated flrom the diseased mass which, in cases of fungus haematodes of the eye, grows fVom the deeper part of this organ, and gradually makes its way forwards to the iris, being always attended with total loss of sight. Putting out of present consideration the change of colour within the eye, produced by fungus htematodes, the othei palish changes behind the pupil are not confined, as Kieser supposes, to very old cases of amaurosis, be- cause the alteration is described by Schmucker as taking AMAUROSIS. 29 place especially in examples the formation of which was quite sudden t.Vermischte Cltir. Schrili. b. 2 ; and Langenbeck has recorded cases in which the same ap- pearance happened in the early stage of the disease. — (NeueBibl. b. 1, p. 64, «fec.) Besides the above appearances in the pupil itself, and in the pupillary margin of the iris. Beer adverts to several important phenomena with respect to the mo- tion of the iris. Sometimes the iris moves but very inertly, and frequently not at all, though the light be strong, and the upper eyelid be rubbed over the eyeball. While in other examples a very moderate light will bring on such a rapid contraction of the iris and closure of the pupil, as are never witnessed in a healthy eye. We have also the authority of Richter for asserting, that in particular instances the iris not only possesses the power of motion, but is capable of moving with uncommon activity, so that in a very moderate light, it will contract in an unusual degree, and nearly close the pupil. — vAnfangsgr. der Wundarzn. b. 3, p. 424, edit. 1795.) Two or three remarkable instances of the active state of the iris, in cases of amaurosis, were some years ago shown to me by Dr. Albert, then staif-surgeon at the York Hospital, Chelsea, and 1 have seen other similar cases in St. Bartholomew’s Hospital. Most of the pa- tients in question had not the least power of distin- guishing the difference between total darkness and the vivid light of the sun, or a candle placed just before their eyes. Janin sometimes found the pupil capable of motion in this disease, and Schmucker twice noticed the same fact. Such cases, Mr. Travers thinks, can only be explained by concluding the organ to be sound, and the cause of the amaurosis remote or external to it. Thus, says he, in a case of circumscribed tumour, compressing the left optic nerve, immediately behind the ganglion op- ticum, although the blindness was complete, the iris was active. In two young ladies, in whom the eyes, as in the former case, were perfect, and the blindness com- plete, the iris was even vivacious ; and there was the strongest presumptive evidence from the symptoms that the amaurosis was in the cerebral portion of the nerve. — (Synopsis, p. 18H.) In some anomalous cases, when the strength of the light is suddenly incretised, the pupil expands with more or less celerity. I have already adverted to the occasional moveable- ness of the iris, notwithstanding the insensible state of the retina. Let me next take notice of a case which sometimes presents itself, and is quite the reverse of this la.st. The nerves of the iris may be paralytic, while those of sight continue unimpaired. Schmucker was acphoid fevers, of which I have seen several instances, jiroceed from debility, or from too great a determination of blood to the head, ma> admit of dispute; but I conceive, that in many of such cases, tonic treatment is clearly indi- cated, if not for the eye itself, certainly for the generally enfeebled state of the healtii, with which the amaurosis is connected. Yet Mr. Lawrence’s doctrine, that ful- ness and congestion of the vessels originally lead to the amaurotic affection, may be more correct than the theory which refers the blindness simply to weak- ness. How'ever, as the amaurosis generally does not show itself till an advanced stage of fever, or that of great debility, and as it only recedes as the patient regains strength, it can hardly be considered as a ca.se in which any other treatment than tonic can be avail Respecting the causes of amaurosis, the following remarks by Beer claim attention. Various swellings 111 the orbit, as, for instance, encysted tumours, tophi, hydatids in the sheath of the optic nerve, may and must gradually produce complete amaurosis by their pressure upon the optic nerves and retina. Some of these cases are usually characterized by a protrusion of the eye from its socket. — See Exophthairnia.) In Mr. Langstaff’s museum is a siiecimen of two amau- rotic eyes, in which the optic nerves are shrunk to about one-third of their natural size. Similar instances are recorded by Dr. Monteilh. — See Weller’s Manual.) According to Mr. Lawrence, Mr. Langstaff has also some interesting sfiecinieiis of enlargement in front of the third ventricle, the parietes of which bulge so as to jiress 111)011 the optic nerves, and thus to account for the amaurosis under which the patients laboured. In the same manner dift'erent morbid changes in the brain itself, and in the bones of the cranium in par- ticular, may be the direct cause of amaurosis : for ex- ample, h\ drocephalus iiiternus, caries, and exostoses at the basis of the skull. .lust as amaurosis is frequently a pure symptomatic eftect of various disordered states of the constitution, so may dift'erent morbid changes, occasioned in the eye by those suites of the health, become the proximate cause of amaurosis, as hydrophthalmia, cirsophfhal- mia, fungus haematodes, dissolution of the vitreous humour, glaucoma, ice. From a contagious atmosphere, which is generally Alt «VlllV.tt «I1J V^AIIVt ei XlllAlt IV/ttIV. V. lA 1 I I A 1 I 1 I AA « Vr . I A < VT AA A * I I 41 V > . W 4 4 Ax . A 44., ^ Vx .4 AX4 AA44 J ing. It is right to state that Mr. Law' rence* himself, | injurious to the eyes, an amaurotic blindness may origi- notwithstanding his belief in amaurosis being a kind of inflammation of the retina, modifies the antiphlogistic treatment according to the state of the constitution. The third class of causes consists of irritations, most of which are asserted to lie in the abdominal viscera, whence they sympathetically operate upon the eyes. The observations of Richter, Scarpa, and Schmucker, all tend to support this doctrine. Many amaurotic patients are found to have suffered much trouble and long grief, or been agitated by repeated vexations, anger, and other passions, which have great effect in disorder- ing the bilious secretion and the digestive functions in general. Richter tells us of a man who lost his sight, a few hours after being in a violent passion, and reco- vered it again the next day, upon taking an emetic, by which a considerable quantity of bile was evacuated. A woman is also cited, who became blind whenever she vvas troubled with what are termed acidities in the stomach. — (See Anfangs. der Wundarzn. b. 3, kap. 14.) However, according to Beer, imperfect amaurosis sel- dom depends upon disorder of the gastric organs, excepting the case from worms. (Lehre von den Augenkr. b. 2, p. 456 ; a very important difference from the sentiments entertained by Schmucker, Richter, and nate, though but very rarely, and, as it would seem, only through the powerful iiitiuence of such state of the air over the whole sanguiferous and nervous sys- tem. Debilitated, nervous, weak-sighted persons, by remaining long in the atmosphere of a privy iChomel, Mem. de Paris, 1711, Obs. Anat. 5, and Ramazzini, De Morbis Artificum, c. 13 , that of a deep cellar, or exposed to other e/Ruvia, may be suddenly attacked with amaurosis ; and Beer assures us, that his expe- rience coufirms the truth of these reports. — Lehre, &c. b. 2, p. 452.) A sympathetic affection of the nerves of the eye, with a carious grinder in the upper jaw-bone, is one of the most uncommon causes of amaurotic blindness. A case, not yet duly con.sidered, and very like the amblyopia senilis, consists of an incessantly diminish- ing secretion of the pigmentum nigrum upon the tunica Ruyschiana. choroidea, and uvea, which secre- tion indeed, in some individuals earlier, and more con- siderably, in others later and in a slighter degree, re- cedes with other secretions of a difiererit nature. — (See Beer’s Lehre von den Augenkr. b. 2, p. 151, ’ of the supra-orbitary nerve, frequently resist.s every endeavour made to relieve it, and this, whether it come on directly after the blow or some weeks subsequently to the healing ‘of the w'ouiid of the eyebrow ; but it is not always ab.solutely incurable. Scarpa only knows of one such cure, viz. the example recorded by Valsalva. — ; Dissert. 2, ^ 11.) But additional instances are reported by Iley Med. Obs. and Inq. vol. 5), by Larrey M^m. de Cliir. Mili- taire, t. 4, p. 181), and Dr. liennen Principles of Mili- tary Surgery, p. 316, ed. 2). According to Mr. War- drop, it is only when this nerve is wounded or injured, and not divided, that amaurosis takes place ; for the blindness may sometimes be cured by making a com- plete division of the trunk nearest its origin. — ^ Essays on the Morbid Anatomy of the Iluiiiaii Eye, vol. 2, p. ISO.) Perfect inveterate amaurosis, attended with organic injury of the substance constituting the immediate organ of sight, says Scarpa, is a disease absolutely incurable. Imperfect recent amaurosis, particularly that which is periodical, is usually curable ; for it is mostly dependent ujion causes which, though they affect the immediate organ of sight, are capable of being dispersed, without leaving any vestige of impaired or- ganization in the optic nerve or retina. When amaurosis has prevailed several years, in per- sons of advanced age, whose eyesight has been weak from their youth ; when it has come on slowly, at first with a morbid irritability of the retina, and then with a gradual diminution of sense in this part, till total blindness was the consequence; when the pupil is motionless, not circular, and not much dilated; when it is widened in such a degree that the iris seems as if it were wanting, and the margin of this opening is irregular and jagged ; and when the bottom of the eye, independently of any opacity of the crystalline lens, presents an unusual paleness like that of horn, some- times partaking of green, and reflected from the thick- ened retina, the disease may be generally set down as incurable. Kieser joins Scarpa in representing this alteration as an unfavourable omen, adding, that it only takes place in examples of long standing, and that when it is considerable, the diseese is incurable. Lan- genbeck differs, however, from both these authors, and particularly from Kieser ; assuring us, not only that he has often seen this discoloration of the bottom of the eye in the early stage of amaurosis, but seen patients in this state soon cured. The cases which he has published in proof of this statement, I have read with care, and find them completely satisfactory. Langen- beck agrees with other writers in imputing the appear- ance to a morbid change of the retina ; and the treat- ment which he prescribes consists in the internal exhibition of the oxymuriate of mereuxy in small doses, and friction with mercurial ointment on the eye- brow and temple. — iSee Langenbeck’s Neue Bibl. fur de Chirurgie, b. 1, p. 64 — 69, &c. Gottingen, 1815.) Cases, says Scarpa, attended with pain all over the head, and a continual sensation of tightness in the eye- ball ; or preceded by a violent, protracted excitement of the nervous system, and then by general debility, I and languor of the constitution, as after masturbation, j premature venery, and hard drinking ; or connected i with epileptic fits, or frequent spasmodic hemicrania ; ! or which are the consequence of violent, long-continued, internal ophthalmia, may be set down as incurable. Nor can any cure be exjiected when amaurosis pro- ceeds from a direct blow on the eye ; foreign bodies in the eyeball ; lues venerea, or exostoses about the orbit ; or when it is conjoined with a manifest change in the figure and dimensions of the eyeball. Recent, sudden cases, in which the pupil is not exces- sively dilated, and its circle remains regular, while the bottom of the eye is of a deep black colour ; cases un- accompanied with any acute, continual pain in the head and eyebrow, or any sense of constriction in the globe of the eye itself ; cases which originate from violent anger, deep sorrow, fright, gastric disorder, general plethora, or the same jiartial affection of the head, sup- pression of the menses, habitual bleedings from the nose, piles, Ac., great loss of blood, nervous debility, not too inveterate, and in young subjects, are all, ge- nerally speaking, curable. Amaurosis is also mostly remediable, when jiroduced by convulsions or the eflbrts of difficult jiarturition ; when it arises during the course, or towards the termination of acute or intermittent fevers; and when it is periodical. — (Scar- pa, Osservazioin sulle Mallatie degli Occhi, cap. 20, Venez. D02.) According to Mr. Travers, it is rather the degree than the nature and origin of the symptomatic ftme- tional amaurosis, that stould in most cases influence our jirognosis ; yet the latter circumstances, it is equally clear, afford more or le-ss encouragement, in proportion as the pre-existing states of disease ordinarily admit of relief or not. Thus, says he, the amaurosis from gas- tric di.scascs, from jilethora, from irritation, are all of then, rclievable, and if treated at an early period, reme- diable. Whereas jiaralysis, the sequel of fever, or of ejiileiisy, or severe constitutional diseases, whether acute or chronic, or depending upon habitual cerebral congestions combined with organic visceral disease, or induced by the ojieration of noxious agents on the system, is a hopeless form of the malady. — tSynopsis, p. 296 ) I may remark, however, that various examples of recovery from amaurosis induced by fevers have fallen under my own notice. In general, when the treatment proves successftil, the return of the power of vision is accompanied with a regression of the same characteristic effects, which were disclosed in the gradual advance of the disorder, viz. appearances as if there were before the eyes flashes of light, a cobweb, net-work, mist, or flaky substances. — Beer, Lelire von den Augenkr. b. 2, p. 460. Wien, 1817.) Upon the commencement of the cure, there is also a return of the obliquity of sight ; one of the most con- stant symptoms of imperfect amaurosis. This is a circumstance which Hey took particular notice of ; he says, that it was most remarkable in those persons who had totally lost the sight in either eye ; for in them the most oblique rays of light seemed to make the first perceptible impression upon the retina; and, in jiro- portion as that nervous coat regained its sensibility, the sight became more direct and natural. — (See Med. Obs and Inq. vol. 5.) TREATMENT OF AMAUROSIS. When amaurosis is to b« fundamentally cured, no! upon empirical, but scientific principles, all the causes of the disorder must be ascertained, and, if possible, removed, as in the treatment of every othei’ complaint. How often, however, it is impossible to accomplish either the one or the other of these objects, must be clear enough from the preceding observations, particu- larly those concerning the etiology of the disease ; and hence it is not surprising, that amaurosis should so frequently resist every endeavour to cure it. The plan of treatment is to be regulated, first by the number and kinds of circumstances, which determine the form of the disorder ; secondly, by its presence, degree, and duration. When only the chief causes can be ascertained, a scientific mode of treatment may always be instituted ; though here it is very necessary to pay the utmost attention to those morbid effects in the constitution, and in the eye in particular, which appear to have no connexion with the causes of amau- rosis, and merely exist as accidental contemporary de- fects. If no particular circumstances can be assigned as the cause of amaurosis, the surgeon Ms no alternative AMAUKOrilS. 35 but the adoption of some empirical method of treat- ment ; but, exclaims Beer, wo to the patient whose surgpon, under these circumstances, draws from a heap of what are considered remedies for amaurosis, as from a lottery, the first as the best ! In order to avoid this erroneous metliod, and not render a half-blind person completely blind, instead of improving, or at least preserving, whatever remnant of vision there may be, the surgeon should act with great caution, and constantly bear in his mind, first, the con- stitution, sex, and age of the patient ; secondly, his ordinary employments, and general mode of living ; and thirdly, the principal morbid appearances under which the amaurosis originated and was developed. — (Beer, Lehre von den Augenkr. b. 2, p. 462.) But what will be the greatest assistance is a correct acquaintance with the remedies for amaurosis in general, and the circumstances under which the use of this or that particular means is likely to be useful or detrimental. I know of no writer who has been so minute on this part of the subject as Beer, whose sen- timents (be it also remarked) are here in manyrespects different from those of Richter and Scarpa ; for, like the surgeons of 'this metropolis, he rarely employs the emetic plan of treatment, which, according to his prin- ciples, is not only ineffectual, but hurtful, whenever the blindness is attended witti determination of blood to the head and eyes, plethora, an accelerated circula- tion, or (what is understood by) a i)hlogistic diathesis. Beer’s opinions, respecting the employment of emetics and other means for the cure of amaurosis, may be partly collected from the sequel of this article, but more especially from the fuller statement which will be made at afhture opportunity. — (See Gutta Serena.) In the mean time, I shall endeavour to offer a general account of the practice recommended by Schmucker, Richter, Scarpa, Travers, and Lawrence, according to the arrangement of causes adopted by the second of these valuable writers ; for I need not repeat, that whenever the method of cure can be directed against the causes of the disease, it is the most proper and sci- entific. The present article will, then, close with some practical observations, chiefly taken from Professor Beer. In that species of amaurosis, which arises from the first class of causes, or those which induce the disease, by means of a preternatural fulness and dilatation of the blood-vessels of the brain or eye, the indication is to lessen the quantity of blood, and the determination of it to the head. For this purpose, the patient may be bled in the arm, temporal artery, or, as is often pre- ferred by foreign surgeons, in the foot. This evacua- tion is to be repeated as often as seems necessary, and it will be better to begin with taking away from twelve to sixteen ounces. The efficacy of bleeding, in the cure of particular cases of gutta serena, is strikingly exemplified by numerous well-authenticated obser- vations. Richter informs us of a woman, who, on leaving off having children, lost her sight; but reco- vered it again by being only once bled in the foot. A spontaneous hemorrhage from the nose also cured a young woman, who had been blind for several weeks. — (Arffangsgr. der Wundarzn. b. 3, p. 442.) That bleeding is sometimes hurtfully and wrongly practised in amaurotic cases, is a fact which admits of no doubt. Mr. TraVers particularly refers to one descrip- tion of cases where the lancet does harm : these are cases of undue determination of blood to the organ, which are especially common after deep-seated chronic inflammation or distress from over-excitement, by which its vessels have lo.st their tone ; an effect decidedly in- creased by depletion. In one interesting ca.se of this kind, a gradual but perfect recovery followed a regti- lated diet, and a course of the blue pill, with saline aperients. — (Synopsis, p. 159.) All cases of direct de- bility and proper paralysis of the retina (says Mr. Tra- vers are aggravated by loss of blood, and the great prevailing mistake in the treatment of amaurosis, is the indiscriminate detraction of blood. — (Synopsis, p. 303.) When, in addition to general bleeding, topical is also necessary, leeches may be applied to the temples, or cupping-glasses to the back of the neck, or temples. Besides bleeding, purgatives, blisters, bathing the feet in warm water, low diet, repose of the organs, an.3j. Sap. venet. ) Rhei optim. 3 iss. Tart. emet. gr. xvi. Sue. liquerit. 3 j. fiant pilulae gran, quinque. Three are to be taken every morning and evening, for a month or six weeks. When the state of the stomach has been improved, and the restoration of sight partly effected, such reme- dies must be employed, as strengthen the digestive or- gans, and excite the vigour of the nervous system in general, and of the nerves of the eye in particular. With th^ intention Scarjia prescribes bark and vale- rian in powder, and recommends a diet of tender suc- culent meat, and wholesome broths, with a moderate quantity of wine, and proper exercise in a salubrious air. For exciting the action of the nerves of the eye, the- vapour of liquor ammonise, properly directed against the eye, he says, is of the greatest service. I'his remedy is applied by holding a small vessel con- taining it sufilciently near the eye to make this organ feel a smarting, occasioned by the verj’ penetrating va- pours with which it is enveloped, and which cause a copious secretion of tears, and a redness, in le.ss than half an hour after the beginning of the application. It is now proper to stop, and repeat the application three or four hours afterward. The plan must be thus fol- lowed up till the incomplete amaurosis is quite cured The operation of these vapours may be promoted by other external stimulants, applied to such other parts of the body as have a great deal of sympathy with the eyes. Of this kind are blisters to the nape of the neck ; friction on the eyebrow with the anodyne liquor ; the irritation of the nerves of the nostrils by sternuta- tive powders, like that composed of two grains of tur- beth mineral, and a scruple of powdered betony leaves ; and, lastly, a stream of electricity.— (See Gutta Se- rena.) Bark, which is efficacious in intermittent fevers, and other periodical diseases, far from curing periodical amaurosis, seems to aggravate it, rendering its return more frequent, and of longer duration. On the other hand, this disease is most commonly cured, in a very short time, by exhibiting, first, emetics, then the above laxative pills, and lastly, corroborants, and even bark, which was before useless and hurtful. Such is Scarpa’s statement, w'hich agrees with that of Richter, respecting Ihe effect of bark in periodical amaurosis. As if, however, practitioners were doomed alw'ays to differ, and learners to be puzzled, Beer tells us, that he has seen only two cases of periodical inter- mittent amaurosis, both of which were soon perfectly cured by large doses of bark. Other periodical amau- rotic affections he has seen, how'ever, attendant on in- termittent fever, but they spontaneously subsided with the febrile paroxysms, without any particular treat ment being applied to the eyes. Somefimes, when the paroxysms recurred frequently, a considerable weak ness of sight remained after them; but this always went off of itself, except in a single instance, in which the functions of the eyes .were perfectly re-established by the exhibition of arnica joined with bitters. — (Lehre, von den Augenkr. b. 2, p. 5S5.) In the two cases, which \vere unaccompanied with fever, the vitreous humour had the appearance of be- ing turbid during the attacks, but regained its natural clearness on each return of vision, the loss of which used to be complete. Here we see another instance, in W'hich a cloudiness behind the pupil in amaurosis did not impede the cure, and went away in the most ready manner. Possibly, the opacity, which, in speaking of the prognosis, I said that Langenbeck had not found to prevent the cure of certain cases, might also have had its seat in the vitreous humour, and not depended upon disease of the retina. Cases, in the formation of w'hich manj other causes operate, demand the employment of particular curative means, in addition to those which have been already described. Such is, for example, the miperfect aniau- AMAUROSIS, 37 rosis, whic-h occurs suddenly in consequence of the body being excessively heated, or exposure to the sun, or violent anger in plethoric subjects. This case re- quires, in particular, general and topical evacuations of blood, and the application of cold washes to the eyes and whole head. An emetic should next be given, and afterward a purge of potassae tartras, or small re- peated doses of antirnoaium tartarizaturn. Uy means of bleeding and an emetic, Schmucker often restored the eyesight of soldiers who had lost it in making forced marches, with very heavy burdens. In amau- rosis, suddenly occasioned by violent anger, an emetic is the more strongly indicated after bleeding, as the blindness, thus arising, is always attended with a bit- ter taste in the mouth, tension of the hypochondria, and continual nausea. Richter mentions a clergyman, who became completely blind after being in a violent passion, and whose eyesight was restored the very next day, by means of an emetic, given with the view of relieving some obvious marks of bilious disorder in the stomach. Scarpa’s treatment of the imperfect amaurosis brought on by fevers, deep sorrow, great loss of blood, intense study, and forced exertions of the eyes on very mi- nute or brilliant objects, consists also in removing all irritation from the stomach, and afterward strengthen- ing the qervous system in general, and the nerves of the eye in particular. In the case originating from fe- vers, the emetic and opening pills are to be given ; then bark, steel medicines, and bitters ; while the vapour of the liquor ammoniae is to be applied to the eye itself. When the disorder has been brought on by grief, or fright, the stomach and intestines are to be emptied by means of antimonium tartarizaturn and the opening pills ; and the cure is to be completed by giving bark and valerian ; applying the vapour of liquor ammonia) to the eyes ; ordering nourishing, easily digestible food ; diverting the patient’s mind, and fixing it on agreeable objects, and recommending moderate exercise. The amaurosis from fright is said to require a longer per- severance in such treatment, than the case from sor- row. — (Scarpa’s Osservaz. cap. 19.) In this country, the emetic practice, wlfich has proved so decidedly efficacious on the continent, has not been attended with much success ; Mr. Travers even states, that he does not recollect an instance of decided benefit from it, though he has often tried it fairly. He agrees, however, in tne indication, as he remarks, that the removal of an irritating or oppress- ing cause, will often effect a sudden and marked relief, as by clearing the intestinal canal of vitiated secre- tions, restoring the digestive functions, or taking away blood where the necessity is indicated. In gastric cases for which emetics have been particularly recom- mended, he prefers a long-continued course of the blue pill, with gentle saline purgatives and tonic bitters. — (Synopsis, p. 299—304.) Beer is also a high authority against the use of eme- tics, even in the amaurosis from disorder of the gas- tric organs. When, says he, the saburrse have a ten- dency to be discharged upwards, as indicated by con- tinual nausea and disposition to vomit, emetics, which never operate without some violence, are to be most carefully avoided in plethoric individuals, or those who have a manifest determination of blood to their heads and eyes, or any acceleration of the circulation. The caution here given must be observed, even though eme- tics may on other accounts seem advisable ; and, ac- cording to Beer, the determination of blood and the state of the system here mentioned, are commonly at- tendant upon this species of amaurosis. Indeed inoi- withstanding the testimony of Schmucker, Richter, and Scarpa, in favour of emetics in this case). Beer posi- tively affirms, that the violent operation of an emetic frequently converts this sympathetic amaurotic weak- ness of sight all on a sudden into blindness. Although 1 apprehend that Beer may here be somewhat preju- diced against emetics, candour obliges me to add, that in this country, their efficacy in the present disease is by no means equal to the representations of Richter and Scarpa. When there is less tendency to vomiting, but the case is attended with an oppressive sense of weight about the stomach, freiiuent eructations, as if arising from rotten eggs, an infiated belly, and terise hypochondria, a gentle aperient clyster may be ordered, especially when the bowels have been for some days confined, in which circumstances Beer has found, that tolerably brisk purgatives are always of the greatest service, both in regard to the general complaints, and the amaurotic weakjiess of sight ; the removal of the offensive matter from the alimentary canal being im- mediately tbllovved by a cessation of the determination of blood already mentioned. Lastly, when this amau- rosis originates altogether from the presence of worms in the bowels, common anthelmintics are to be pre- scribed. In all these cases, says Beer, mere local treatment is quite inapplicable, and may do mischief. — (.Beer, Lehre von den Augenkr. b. 2, p. 617—521.) The third species of gutta serena, or that which arises from debilitating causes, is of two kinds; in one, the disease is the consequence of a general weakness of the body ; in the other, it is the effect of debility, which is confined to the eye itself, and does not extend to the whole constitution. According to Scarpa, the incomplete amaurosis from general nervous debility, copious hemorrhage, convul- sions ab inanitione, and long-continued intense study, especially by candle-light, is less a case of real amau- rosis, than a weakness of sight from a fatigued stale of the nerves, especially of those constituting the im- mediate organ of sight. When this complaint is re- cent, in a young subject, it may be cured or diminished, by emptying the alimentary canal with small repeated doses of rhubarb, and then giving tonic cordial reme- dies. At the same time, the patient must abstain from every thing that has a tendency to weaken the nervous system, and, consequently, the eyesight. After empty- ing the stomach and l?ovvels, it is proper to prescribe the decoction of bark wdth valerian, or the infusion of quassia with the addition of a few drops of sulphuric ether to each dose, with nourishing easily'-digestible food. The aromatic spirituous vapours (mentioned in the article Ophthalmyi may then be tojiically applied ; or, if these prove ineffectual, the vapour of liquor am- rnoniae. The patient must take exercise on foot, horse- back, or in a carriage, in a wholesome dry air, in warm weather, and avail himself of sea-bathing. He must avoid all thoughts of care, and refrain from fixing his eyes on minute shining objects. The impression of vivid light on the retina is always to be moderated by means of flat green glasses. — iSaggio di Osservaz. cap. 19.) One case of temporary palsy of the retina from over-excitement, mentioned by Mr. Travers, yielded to blistering the forehead, and a gentle salivation excited by calomel joined wdth opium. — (Synopsis, p. 164.) Another case, brought on by the use of telescopes and sextants, gave way to a copious bleeding, brisk purg- ing with jalap and calomel, blisters to the temples, and a course of mercury. — (Op. cit. p. 166.) Mr. Travers remarks, that the amaurosis from de- pletion is sometimes mistaken for the opposite case, viz. that from plethoric congestion : this is owing to the coincidence of a dilated and immoveable pupil, muscae, and a deep-seated pain in the head, with occa- sional vertigo ; and its frequent occurrence in a corpu- lent* habit. By a cautious use of tonics (says Mr Travers) it is relieved ; by whatever lowers or stimu- lates, whether diet or medicine, it is decidedly aggra- vated. In this form of amaurosis, vision is farther enfeebled by the loss of as much blood as flows from two or three leech-bites. — (Synop.sis, &c. p. 160.) When the weakness is confined to the eye, Richter thinks corroborant applications alone necessary. Bath- .ing the eye with cold water, says he, is one of the most powerful means of strengthening the eye. The pa- tient should dip in cold w'ater a compress, doubled into eight folds, and sufficiently large to cover the whole face and forehead, and this he should keep applied, as long as it continues cold. Or else he should frequently apply cold water to his eyes and face with his hand, on a piece of rag. The eye may also be strengthened by repeatedly ap- plying blisters of a semilunar shape above the eye- brows, just long enough to excite redness. Richter likewise speaks favourably of rubbing the upper eye- lid, several times a day, with a mixture of the tinctura lyttae and spiritus serpilli. — (Anfangsgr. der Wundarzn. b. 3, p.452.) When no probable cause whatsoever can be assigned for the disease, the .surgeon is justified in ernploying such remedies, as have been proved by exjierience to be sometimes capable of relieving the affection, al- though upon what principle is utterly unknown.— (See Gutta Serena.) To this article I would refer the reader, 38 AMAUROSIS. before he makes up his mind about any empirical method of treatment, because he will there find many cautions and instructions given by Beer, respecting the remedies for amaurosis in general. To his remarks, I have al.so annexed such others, on the same topic, as appeared to me interesting. Cat-eye amaurosis. This species of the disorder, of which Beer met with but one form, rarely increases to complete blindnes.s ; it occurs chietiy in very old persons, and it is i)erhaps this affection to which some oculists have given the unmeaning name of ‘‘ amblyopia senilis.” Sometimes, however, this kind of amaurosis takes place in young persons and children ; and one circumstance that de- mands particular notice in its nosology is, that it al- ways takes place either in tliin, dwindled, old, gray- headed subjects, nearly in the state of marasmus senilis, in whom consequently the exchange of organic matter is carried on but tardily, or else in young subjects, who are unhealthy, and disposed to consumption, hectical adults, emaciated children, and as a con.sequence of severe injuries of the eye. While this amaurosis is not perfectly formed, the iris retains its mobility, and the pupil is neither preternaturally dilated nor con- tracted; but when once the patient is quite beretl of vision, the motions of the iris are slow, and the pupil larger than in a healthy eye in at} equal degree of light. At the bottom of the eye, very far behind the pujiil, a concave pale-gray, bright-yellowish, or variegated red- dish opacity is develojied. By this the eyesight is not merely weakened, but rendered quite confused, since all objects, but esjiecially smallish ones, apjiear to be confounded together, particularly when the patient tries to inspect closely any determinate body. The far- ther the disease advances, the brighter and more visible m the bottom of the eye, the paler is the colour of the iris a thing very consjiicuous in dark-eyed persons ; gnd when once the amaurosis is complete, so that no susceptibility of the iinjire-ssion of light is left, then, upon an attentive e.xamination of the eye, one can mo.stly perceive, at the troubled deeper pan of the eye, a very slender vascular plexus, which merely consists of the ordinary ramifications of the central artery and yeiu, which are now visible at the pale-coloured bot- tom of the eye. In a half-darkened place, stich an eye resents a shining yellowish or reddish appearance, ut only in certain positions of the eyeball; and, in this respect, it is somewhat similar to the eye of a cat, whence Beer chooses to term the complaint cat-eye amaurosis. The disorder is also not accompanied with any other essential morbid appearances, except the de- cline of vision or complete blindness. — (Lehre von den Augenkr. b. 2, p. 4%,) Beer, in fig. l,tab. 4 of his second vol, has given from nature an admirable repre- sentation of this very remarkable species of amaurosis. The differences in the appearances at the bottom of the eye, in this case, from those presented in the early stage of fungus hrematodes of that organ, will be best understood by referring to the article Fungus Haema- todes. On this point, however, I may here briefiy state, that in the cat-eye amaurosis, there is no projec- tion, but, on the contrary, a concave depression in the axis of vision. Cat-eye amaurosis may be known from incipient cataract, by the opacity being more deeply situated, and having a shining, pearly lustre, — (See Journ. of Foreign Med. vol. 4, p. 168.) Beer observes that the causes of this species of amau- rosis are so obscure, that whatever is offered upon the subject can be received only as conjecture. After what has been said jn the foregoing paragraph is considered, about the particular individuals who are liable to be affected, and the change of the iris to a pale colour, as a constant symptom of this case, a suspicion may be entertained that a deficiency of the pigmentum nigrum and of the tapetum of the uvea, in consequence of the stoppage of this secretion, may be the cause of the dis- ease. Beer justly remarks that much might be learned on this iKiint from the dissection of eyes thus affected; but he has nevpr met with the opportunity. The prognosis cannot but be very unfavourable ; for, as the surgeon is ignorant of causes, he cannot know what means ought to be adopted for their removal. It is fortunate, however, that this amaurosis rarely attains its highest degree, but almost constantly remains in the form of a more or less considerable amblyopia. J.USt as little is yet known respecting any well-regu- lated mode of treatment ; but the disease may some- times be kept from getting worse by the careful em- ployment of such general remedies, regimen, and diet, ;ls are calculated to improve the health. However, in the most fortunately managed cases. Beer never knew a step made towards the removal of the disease.^ '.Lehre von den Augenkr. b. 2, p. 497, 498.) .Amaurosis produced bybitte.rs, certain articles of food in particular constitutions, or the poison of lead. ■ The reality of the first alleged cause is sometimes doubted in this country. The following treatment is recommended by Beer. In the first stage he advises gentle antiphlogistic means. When plethora exists, a few ounces of blood may be taken away by venesection, or leeches applied behind the ears, when after bleeding a determination of blood to the head and eyes still continues in full habits, or there is any tendency to infiamma- tion. The same topical bleeding without venesection, but with lukewarm pediluvia, containing salt or mus- tard, is proper when no general plethora exists; and merely a determination of blood to the head and eyes and some acceleration of the circulation prevail. Inter- nally, lemon-juice or the liquor ammoniae acet. has ex- cellent eftects ; and externally, poultices composed of bread-crumb and vinegar, or fomentations containing oxycrat, are the means which Beer has found most suc- cessftil ill the first stage of this form of amaurosis. As in the first stage, a moderate antiphlogistic gene- ral or local treatment is the only one w’hich can be adopted, and which in urgent cases may yet save the liatieiit from blindness, so in the second stage the in- ternal and external emplo\inent of fluid stimulants is of great service ; Ibr example, naphtha combined with camphor inwardly, liniments to the eyebrow, and the vapours of ether to the eye. The amaurosis produced altogether by the poi-son of lead, and complicated with lead-colic and ileus, will require, in addition to the fore- going means, such remedies as are known to be of service in these latter disorders. — (Beer, Lehre vou den Augenkr. b. 2, p. 499—503.) Symptomatic amaurosis in individuals affected with hysteria, hypochondriasis, epilepsy, and convulsions. This amaurosis is rarely permanent, and usually subsides as soon as the spasmodic, epileptic, or convul- sive attack is over. However, the complaint may be- gin at two penod#, viz. either during such an attack, or (what is more uncommon) afterward, and it never loses its symptomatic character. The pupil always remains perfectly clear, and of a shining blackness, even when the di.sease has induced entire blindness ; but a slight dull pain in the forehead, especially about the eyebrow, constantly preceding and accompanying the blindness, generally lasts a good while after the amaurosis has completely subsided. Besides the foregoing general symptoms, the follow- ing characteristic appearances present themselves in hysterical and hypochondriacal patients, who suffer frequent attacks of violent spasm. The pupil is much dilated, and the iris, which is immoveable, seems evi- dently to project in a convexity forwards, when the eye is inspected sidewise ; consequently, the anterior chamber is lessened. The eye itself does not move freely in its socket, the patient experiencing an annoy- ing and sometimes a truly painftil sensation, as if the eyeball w'ere forcibly compressed (Ophthajmodymia). Every attempt which the patient himself makes to move the eye, or the surgeon to push it out of the position which it has assumed, is unavailing and excessively painftil. The eyelids are either painftilly shut, or in- capable of being shut at all ; the eyesight is very weak, but seldom quite impeded ; and at the termination of each attack vision returns, though every paroxysm leaves it more and more debilitated, until at length the spasmodic attacks of bUndness frequently occurring, and lasting a long wliile, it is entirely lost. But w’hen the disorder has acquired its utmost degree, the eye always still retains the power of discerning the light, and it seldom happens that vision is abolished by the first or second attack. It is different with respect to the characteristic phenomena of this amaurosis, in hysteric.al or hypochondriacal patients, especially when often affected xvlth spasms, before, ijuring, or after which the impairment of sight originates ; for though the pupil may continue quite clear, it cannot escape the notice of an attentive observer, that, together wth a AMAUROSIS. 39 pupil of diminished diameter, there exists a peculiar motion of the iris, a constant fluttering of it between expansion and contraction, technically called hippus pupillae. I'his convulsive state of the iris is mostly accompanied \vith a similar affection of the eyelids, namely, with an involuntary blinking (nictitatio; , and not unfrequerttly with an involuntary pendulum-like rolling of the eyeball (nistagmus). In these patients the amaurotic injury of sight hardly ever proceeds di- rectly to complete blindness, but more commonly re- mains as a weakness of vision, characterized during the rest of life by ceaseless oscillations of the eyeball, aversion to light, and frequent sensations as if there were shining fiery objects before the eyes. This case of symptomatic amaurosis is distingiiished by an untroubled, but very expanded pupil ; considera- ble diminution of the motion of the iris ; a dilated state of the pupil, even under the .stimulus of the strongest light, and tremulous motions of the eyeball, which con- tinue during life, after the epilepsy and amaurosis are cured ; and the case is farther characterized by ambly- opia, which rarely increases to complete blindness. According to Beer, the amaurosis connected with convulsions is most frequent in children. The first and most prominent symptom of this incomplete or complete amaurosis consists in an extremely violent convulsive rotation of the eyeball, especially upwards, not un frequently attended with the most violent con- vulsive motions of the eyelids. The pupil is exces- sively dilated, and scarcely the least movement of the iris is distinguishable on exposing the eye to the strongest light. When the general twitchings are over, and only an amaurotic weakness of sight is left, stra- bismus occurs in both eyes in various directions, though the eyes very seldom deviate from the axis of vision in the direction towards the inner canthus. When the general convulsions happen frequently, and are violent and of long duration, the amaurotic weakness of sight usually changes into perfect blindness, in which the pupil, though it be regularly clear, and of a shining blackness, is greatly expanded, and the eyes constantly retain their faulty position and pendulum-like motion. With respect to the prognosis, it is observed by Beer, that even when merely an amaurotic weakness remains, the prognosis is always serious; but it is naturally still more unfavourable, when the blindness is complete, and when the loss of sight has suddenly recurred after violent spasmodic, epileptic, or convul- sive attacks, without such attacks them.selves ever returning. Under these circumstances. Beer has not hitherto seen more than two instances of such blind- ness partially cured. Generally some hope of recovery may be entertained, when the amblyopia, or even com- plete amaurosis, begins with these attacks, but always terminates with them, without leaving any serious im- pairment of vision. On the contrary, it is a very bad sign, not only in regard to the removal of this symptom- atic amaurosis, but likewise to the cure of the original disease, when the amaurosis invariably precedes these attacks, and lasts a considerable time after their cessa- tion. As yet. Beer says, he has not known any such patients cured, either of their spasms, epilepsy, or con- vulsions, much less of their blindness : on the contrary, after three or four attacks, perfect amaurosis remains, and some of the patients die in one of these paroxysms. As this amaurosis is merely a symptomatic effect of the above general disorders, its removal must entirely depend upon the success with which their treatment is conducted. Were the blindness to continue, however, after the cure of the original disease, the surgeon could do nothing more than try an empirical mode of .treat- ment, and ascertain what good could be effected with antispasmodic and tonic medicines. — (.Beer, Lehre von den Augenkr. b. 2, p. 606 — 510.) Rheumatic amaurosis. According to Beer, rheumatic amaurosis is not very uncommon, and is so plainly denoted by certain symp- toms, that it cannot well be mistaken ; namely, a per- fectly clear pupil wavers in the mid state between con- traction and dilatation, the iris seeming to be nearly motionless ; the eyes weep from the slightest causes, and constantly betray more or less aver.sion to light ; the case is invariably attended with wandering, irrita- ting pains, sometimes affecting the eyeball itself, some- times the vicinity of the eye, and in other instances, the teeth or neck. Also when both eyes are affected to- gether, which is not regularly the case, a cast of the eye, which cannot be called actual squinting, may be remarked, and frequently the motion of the eyeball is chiefly obstructed O'nly in one direction, though some- times a true obliquity of the organ exists (luscitas). In nearly every instance there is considerable weak- ness of the levator muscle of the upper eyelid, and not unfrequently a complete blepharoplegia ; but total blindness is seldom produced. According to Beer, this amaurosis, which is to be considered as chronic rheumatism, often arises from keeping the head long exposed to the air, and is chiefly met with in individuals who, while sweating proftisely from the scalp and brow in warm weather, have taken off their hats, and remained with their heads a long while uncovered. As, however, in warm weather, the generality of persons expose themselves in this man- ner, and few are attacked by amaurosis, I infer that something more is requisite for the production of the disease. Under certain circumstances the prognosis is by no means unfavourable, and Beer mostly succeeded in ef- fecting a perfect cure, when the amaurosis was not completely formed, and not of very long standing, the patient had no tendency to gout, and when during the treatment every thing likely to bring on an attack of that disease was avoided. The treatment consists not simply of local means, which indeed are always needful, but likewise of ge- neral remedies. With regard to the latter. Beer as- sures us that manifold experience has convinced him of the preference which ought to be given to the extract of guaiacum joined with camphor, and given alternately with the compound powder of ipecacuanha; which remedies, as soon as the wandering pains about the eye and eyebrow begin to be milder, and more fixed to one part, are to be succeeded by the extract of aconi- tum, antimonial preparations, and flowers of sulphur. Externally, the most powerful operating means are not to be omitted, especially blisters applied successively behind the ears, to the temples, and eyebrows ; and as soon as the pain has completely subsided in these last parts, and is perhaps more concentrated in the eye, frictions are to be made on the eyebrow with liniments, containing at first a moderate quantity of opium, and afterward of the extractum conii. At length, when the pain in and about the eye is nearly subdued, but some degree of amaurotic weakness of sight is left, frictions with naphtha and a small proportion of tinctura lyttae and tinctura opii will be found exceedingly beneficiat Afterward, when a considerable time has transpired without the recurrence of the slightest rheumatic pain in the eye, its vicinity, or the head, but the eyesight is not perfectly re-established by perseverance in the above general and local treatment, and especially when the pa- ralytic affection of the levator of one or other of the upper eyelids continues (as often happens), galvanism may be tried, with the cautions elsewhere premised. — (See Gutta Serena.) And in the most desperate cases. Beer approves of making an issue in the depression between the angle of the jaw and the mastoid process, and keep- ing it open for a fortnight after the recovery seems complete. — (Lehre von den Augenkr. b. 2, p. 526 — 529.) Traumatic amaurosis. Beer applies the epithet “ traumatic” to such cases of amaurosis as are the consequence of a considerable wound of the eye itself, its surrounding parts, or the skull. Here, consequently, is first arranged the amau- ro.sis produced by the laceration and stretching of the branches of the frontal nerve from irregular scars about the eyebrow. Secondly, Beer reckons the amaurosis arising from external violence directed in such a degree against the upper or lower side of the orbit, that the retina is torn, and many of the internal softer textures of the eye forced out of their natural situations. Thirdly, Beer includes every weakness of sight or per- fect amaurosis, which is the result of such injuries of the eyeball itself as extend to the retina, so as either violently to bruise or lacerate it, or cut or pierce it. For the prognosis and treatment of all these cases, he refers to his observations upon mihthalmy. Nor does he choose here to treat of the perfectly complicated amaurosis, which is a direct consequence of a coup-de-.soleil, be- cau.se it never hapi)ens unpreceded by a violent general inflammation of the eyeball, and therefore is to be re- gardeil as an eflect both of the injury and the infiain- 40 AMAUROSIS. mation togetlier; but which, like the symptomatic amaurosis, Ibllowing common and genuine internal ophthalmy, may be easily knowm by the total insensi- bihty to light, and the evident changes in the texture find shape of the eye ; and is quite as incurable as the other example to w liich we have alluded. — (Lchre von den Augenkr. b. 2, p. 542.) Gouty amaurosis. According to Mr. Travers, gout attacks the eye through the medium of the stomach. Vomiting occurs with pain in that organ, on the subsidence of an in- flammation in the extremities, and is succeeded by vio- lent jiain in the head. The loss of sight, he adds, is sudden and pennanent. — (Synopsis, er. Modern practitioners have materially simplified all £lie cliief operations in surgery ; an object which has been aci-omplished not merely by letting anatomical science be the main guide of their proceedhigs ; not siiiqily by devising more judicious and less painful methods ; not only by diminishing the number, and improving the construction, of instruments ; but also, in a very essential degree, by abandoning the use of a multitmle of e.xternal applications, most of which were useless or hurtful. The Greek, Roman, and Arabian practitioners ampu- tated limbs with feelings of alarm, and, in general, with the most melancholy results; while modern sur- geons proceed to the operation completely fearless, well knowing that it mostly proves successful ; hence, as Graefe justly remarks, nothing can be more evident, than that the patient’s safety must depend very much upon the kind of practice. — (See Normen fur die Ablo- sung gro.sserer Gliedma.ssen, p. 1.) By practice is here implied the mode m which the operation is per- formed, the way in which the wound is dressed, and the whole of the aller-treatment. But, much improved as amputation has been, it can- not be dissembled, that it is an operation at once terri- ble to bear, dreadM to behold, and sometimes severe and fatal in the consequences which it itself produces, while the patient, if saved, is left for ever afterward in a crippled, mutilated state. Hence it is the surgeon’s duty never to have recourse to so serious a proceeding without a perfect and well-grounded conviction of its necessity. Amputation should be generally regarded as the last expedient to which a surgeon ought to re- sort ; an expedient justifiable, as a late waiter says, only when the part is either already gangrenous, or the seat of so much injury or disea.se, that the attempt to preserve it any longer, would expose the patient’s lile to the greatest danger. — tDict. des Sciences Med. t. 1, p. 472.) Although, says a distinguished modern surgeon, this amounts to a confession, that the cure of some local disorders is not within the limits of our art, yet, on the other hand, it furnishes a proof, that surgery may be the means of saving life under circumstances which, without its assistance, would infallibly have a fatal termination. The operation is adojited as the safest measure : the cause is removed for the prevention of consequences. — Graefe, op. cit. p. 14.) Nothing can be more absurd or more misapplied, than the censures sometimes passed upon amputation, because the body is mutilated by it, «fcc. Although, as a modern writer remarks, the objection proves the limitation of human knowledge and ability, it must be very unfair on this account to tlnovv blame on surgery, or the practitioner who thus saves the patient’s life. For, without dwelling upon the fact, that a humane surgeon w ould never amputate through a mere love of operating, and without urgent cause, one may simply ask, are all diseases in their nature curable ? Does not the surgeon cure such as are curable without mutila- tion ? And are not cases, wliich were in the begin- ning remediable, often first brought to the surgeon when, from neglect, they have become totally incu- rable 1 Is it not his duty then to employ the only means left for saving the patient? And is not the preserva- tion of a long and healthy life a compensation for the sacrifice ? Would it not be just as reasonable to blame an architect, when the irresistible force of lightning or a bomb destroys liis building ? Indeed, is it not rather a greater honour to surgery, that even when death has already taken possession as it were, of a part, and is threatening ineritable destruction to the whole, a means is yet furnished, not only of saving the patient’s life, but of bringing him into a state in which he may recover his former good health? — (Briinninghausen, Erfahrungen und Bemerkungen fiber die Amputation, p. 11, 12mo. Bamberg, 1818.) Though amputation is in eve^ respect much better than in former times, and its right performance is by no means difficult, I would not wash to be thought to say, that it is always, or even usually done secundum ariem, because long opportunities of observation have convinced me of the contrary ; and the reason of the knife being yet so badly handled in this part of sur- gery, may generally be imputed to carelessness, slo- venly habits, or, what is as bad, a want of ordinary dexterity. Tliere are several egregious faults in the method of amputating, which even many hospital sur- geons in tliis metroiMilis are guilty of; but these w'e shall find, when we criticise them, are for the most part easily avoidable, without any particular share of skill being required. A greater difficulty is to ascer- tain with precision the cases w'hich demand the opera- tion, those in which it may be dispensed with, and the exact periods at which it should be practised. These are considerations requiring profound attention, and the brightest talents. The most expert operator (as Mr. O’Halloran observes) may not always be the best surgeon. To do justice to the sick and ourselves, we must, in many cases, rather avoid than perform capital operations ; and with respect to amputation, if we consider the many cases in which it has been unneces- sarily undertaken, or done at unseasonable periods, it may be suspected, that this operation, upon the whole, may have done more mischief than good. At all events, it is not enough for a surgeon to know how to operate ; he must also know when to do it. — (See O’Halloran on Gangrene and Sphacelus : preface.) For such reasons I shall first take a view' of the cir- cumstances under which the best surgeons deem am- putation necessary ; though it may be proper to ob- serve, that in each of the articles relative to the parti- cular diseases and injuries which ever call for the ope- ration, additional information will be oflfered. 1. Cnvipound fractures. In a compound fracture the necessity for amputation is not altogether proportioned to the seriousness of the accident, but also frequently depends in part upon other circumstances. For example^ in the field, and AMPUTATION. 45 on board of a crowded ship, it is not constantly in the surgeon’s power to pay such attention as the cases de- mand, nor to procure tor the patient the proper degree of rest and good accommodation. In the field, there is often a necessity for transporting the wounded from one place to another. Under these circumstances it is proper to have immediate recourse to amputation, in numerous cases of bad compound fractures, some of which, perhaps, might not absolutely demand the ope- ration, were the patients so situated, as to be capable of receiving all the advantages of the best and most scientific treatment in a well-ventilated quiet house or hospital, furnished with every desirable convenience. At the same time, daily experience proves, that there are many other cases, in which it would be improper to have recourse to the knife, even under the most un- favourable circumstances of the above description. So, when a compound fracture occurs, in which the soft parts have not been considerably injured; in which the bones have been broken in such a direction that they can be easily set and kept in their proper position, or in which there is only one bone broken, amputation would be unnecessary and cruel. But when the soft parts have been more extensively hurt, and the bones have been so badly broken, that perfect quietude and incessant care are required to afford any chance of re- covery, it is a good general rule to amputate whenever these advantages cannot be obtained. The bad air in crowded hospitals and large cities, a circumstance so detrimental to wounds in general, is another consideration which may seriously lessen the chances of saving a badly broken limb, and should be remembered in weighing the reasons for and against amputation. On this part of the subject, I find the sentiments of Graefe interesting : besides an absolute, says he, there is a relative, necessity for amputation ; it is the most moum.ful, and proceeds altogether from unfavourable external circumstances, though, alas ! in many cases nearly unavoidable, when life is to be preserved. In war, every bloody action furnishes proof of what has been stated. The number of the w'ounded is immense ; the number of surgeons for the duty too limited. The supplies most needed are at a distance. In these emer- gencies, though the military surgeon may, from routine and genius, be able to suggest the quickest method of obtaining what is wanted, know how to avail himself of every advantage which circumstances permit, and contrive tolerable substitutes for such things as are de- ficient, yet this will not always do. Were we (says Graefe; here to complain of the government not pro- viding due assistance for the defenders of our native soil, to many the remonstrance would only appear rea- sonable. Yet they who manage the medical affairs of the Prussian army may not constantly have it in their power to avert the inconvenience. The general cannot foretel the number and nature of the wounds which may happen, so as to enable the medical, department to take with them exactly the apparatus required, without encumbering the army with a redundance of useless articles. The enemy, perhaps, captures the' medical store.s, or the rapid movements of particular corps cut us off from ihe principad depots. Detachments often skirmish at remote points. The hospitals may lie se- veral miles in the rear of the line; and, for want of means, the transport of the imperfectly-d ressed wounded may continue night and day. Hardly are the sufferers brought into the nearest hospital, in the most pitiful state from pain, anxiety, and cold, when an order is given to break up, and they must be conveyed still far- ther towards their grave ; ami a thousand other circum- stances, as Graefe observes, which deprive the wounded of the requisite attendance, and essential . number of surgeons, together with the most necessary stores, make it desirable to simplify every wound as much as possible ; which, indeed, is the only means of shunning the reproach, that, while we are eiideavouring to save one man’s limb, we let anoftier die. Who doubts, says Graefe, that a soldier with a gun- shot wound, complicated with a smashed state of the bones, may sometimes be saved, without loss of his limb, by employing all the means wliich the resources of surgery offer 1 But these very resources are often wanting in a campaign ; and the business of dressing the patient would occupy the surgeon several hours daily, during which his useful assistance could not be extended to other sufferers. Notwithstanding the ut- most care, the removal of patients from one place to another frequently makes their wounds extremely dan- gerous, or fatal ; and we now lose many a man, who,, had he undergone amputation, would have been able to bear the journey.— (See Normen flir die Ablosung grosserer Gliedmassen, p. 15, 16.) From what I have seen of the ill effects of moving patients with bad compound fractures of the lower ex- tremity, produced by gun-shot violence, I am convinced that, as a general rule, it is better to perform amputa- tion ; but if this be not done, and an attempt is to be made to save the member, it will be more humane, when the army is retreating, and the enemy are not savages, to leave such wounded behind, than subject them to all the fatal mischief of hastily and roughly transporting them in such a condition. It gives me particular pleasure to find the preceding sentiment con- firmed by Dr. Hennen, whose knowledge and experi- ence in military surgerj' entitle all hi.s opinions to the greatest attention : in noticing what ought to be done with the wounded, when the amiy is compelled to re- treat, he says, “ it then becomes the duty of a certain proportion of the hospital staff to devote themselves for their wounded, and become prisoners of war aloii|g with them; and it may be an encouragement to theim experienced, while it is grateful to me, to observe, that I have never witne.s6ed, nor traced, on inquiry, an act of unnecessary severity practised either by the French or English armies on their wounded prisoners.” Compound fractures of the thigh, produced by gun- shot violence, too often have an unfavourable termina- tion, especially when the accident has been caused by grape-shot oi- eveti a musket-ball, fired from a mode- rate distance, and the pati nt is moved from one place to another after the receipt of the injury. In the mili- tary hospital at Oudenbosch, in the spring of 1814, 1 had charge of about eight bad compound fractures of the thigh, of which cases only one escaped a fatal ter- mination. This was an instance in which the femur was broken a little way above the knee. Another pa- tient was extricated by amputation from the perils immediately arising from the splintered displaced state of the bone, the serious injury of the muscles, and enormous abscesses, but was unfortunately lost by se- condary hemorrhage. All these patients had not merely been struck by grape-shot, or else by balls fired from a short distance, but they had been moved from Bergen-op-Zoom into my hospital five or six days after the receipt of the injury, the very worst period possible on account of the inflammation being then most vio- lent. From the ill success of these cases, many a sur- geon who saw them might be inclined to think that immediate amputation ought generally to be performed for all compound fractures of the thigh as soon after the receipt of the injury as possible. And such is my own sentiment, whenever the accident has been caused in the violent manner above si)ecified, or when- ever the patient must be moved any distance in a wa- gon after the occurrence of the injury. It may be right to state, however, that I have known more than one compound fracture of the thigh cured, where the acci- dent had not been occasioned by gun-shot violence, and I have been informed of one or two .succe-ssful cases where the bone was broken by a pistol-ball. In St. Bartholomew’s hospital, two compound fractures of the thigh were pointed out to me some time ago, a& cases likely to end favourably. However, these may only have been lucky escapes, deviations from what is- common, and not entitled to any stress, with the view of affecting the general excellent rule ol’ amputating where the thigh-bone is broken by gun-shot violence. As Mr. Guthrie has accurately observed, one circum- stance winch increases the danger of fractures of the femur from gun-shot violence is, that the bone is very often broken obliquely, the fracture extending far above and below the point immediately struck by the ball.— (On Gun-shot Wounds, p. 189, 190.) This disposition of the thigh-bone to be splintered for several inches when hit by a ball, and the increased danger arising from the occurrence, are also very particularly com- mented upon by (he experienced Schmucker, who was surgeon-general to the Prussian armies in the cam- paigns of Frederick the Great. — See his Vermischte Chirurgische Schriften, b. 1, n. 39, 8vo. Berlin, 1785.) In several of the cases under the care of Dr. Cole and myself in Holland, the bone was split longitudinally to ; tlie extent of seven or eight inches. 46 AMPUTATION. According to Schinucker, all fVactures of the middle or upper part of the femur are attended with great danger. “ Bur ,say.s he; if the fracture be situated at the lowest part of the bone, the risk is considerably less, the muscles here not being so powerful ; in such a case, therefore, amputation sliould not be performed before every other means lia-s been fairly tried ; and very frequently I have treated fractures of this kind with success, though the limb sometimes continued stiff. But says Schmucker; if the bone be completely fractured or splintered by a ball at its middle, or above that point, I never wait for the bad symptoms to commence, but amputate ere they originate ; and when the operation has been done early enough, most of my patients have been saved, lloweverj when some days had transpired, and inrtarnmation, swelling, and fever had come on, I must candidly confess that the issue was not always fortunate. Yet the operation should not on this account be dispensed wiili ; for if only a few can thus be saved out of many, some benefit is ob- tained, as, without this step, such few would also pe- rish.” — Vemuschte C'hir. richrifleii. b. 1, p. 42.) What I saw of compound fractures of the thigh, after the as- sault on Bergen-op-Zoom, we may remark, coincides with the results of Schmucker’s ample experience ; for the only two patients who survived the bad symptoms proceeding directly from the fracture were, one whose femur was broken near the knee, and another whose limb I took off on account of a Iracture of the middle of the bone, accompanied with abscesses of surjirising extent. The latter was a case, however, in which the limb ought to have been removed earlier. The follow- ing remarks, by Mr. Guthrie, 1 consider judicious and correct. “ The danger and dilficulty of cure attendant on frac- tures of the femur from gun-shot wounds, deiiend much on the part of the bone injured ; and in the considera- tion of these circumstances it will be useful to divide it into five parts. Of these, the head and neck in- cluded in the capsular ligament, may be considered the first; the body of the bone, which may be divided into three parts, and the spongy portion of the lower end of the bone exterior to the capsular ligiunent, form- ing the fifth part. Of these, the fractures of the first kind are, I believe, always ultmiatelV final, although life may be prolonged for some time. The upper third of the body of the bone, if badly fractured, generally causes death at the end of six or eight weeks of acute suffering. I have seen few escape, and then not with a useful limb that had been badly fractured in the mid- dle part. Fractures of the lower or fifth division are in the next degree dangerous, as they generally affect the joint ; and the least dangerous are fractures of the lower third of the body of the bone. Of these even I do not mean to conceal, that when there is much shat- tered bone the dairger is great, so that a fractured thigh by gun-shot, even without particular injury of the soft parts, is one of the most dangerous kinds of wounds that can occur.” — .See Guthrie on Gun-shot Womids, p. 190.) In compound fractures, as Mr. Pott has correctly- pointed out, there are three points of time when ampu- tation may be proper. The first of these is immedi- ately or as soon as possible after the receijit of the in- jury. The second is, when the bones continue for a great length of time without any disposition to unite, and the discharge from the wound has been so long and is so large that the patient’s strength fails, and general symptoms foreboding dissolution come on. The tliird is, when a mortification has taken such complete pos- session of the soft parts of the inferior portion of the limb quite down to the bone, that upon the separation of such parts the bone or bones shall be left bare in the interspace. The first and second of these are matters of very se- rious consideration. The third hardly requires any. When a compound fracture is caused by the pas- sage of a very heavy’ body over a limb, such, for in- stance, as the broad wheel of a wagon or loaded cart, or by the fall of a very ponderous body on it, or by a can- non-shot, or by any other means so violent as to break the bones into many fragments, and so to tear, bruise, and wound the soft parts, that there shall be good rea- son to fear that there will not be vessels sufficient to carry on the circulation with the parts below the frac- ture, it becomes, as Mr. Pott observes, a matter of the most serious consideration, whether an attempt to save . such a limb w ill not occasion loss of life, Tliis consider- ation iniLst he before any degree of infiammation has seized the part, and therefore must be immediately after tlie accident. When inilammation, tension, and a dispo- sition to gangrene in the limb have arisen, the period is highly disadvantageous for operating, and the patient’s (diances of being saved by amputation under these cir- cumstances are much smaller than before the changes here spoken of had taken place. At the same time, there arc certain examples of mortification from external causes, where, as far as one can judge from the results of later exjierience than that of Mr. Pott, the surgeon should not defer amputation, even though the disorder be yet in a spreading state, attended with considerable swell- ing and tension reaching far up the limb. This is a sub- ject, however, which will require more explanation hereafter. — See what is presently said on Mortification.) Nor are the cases to which reference is made meant to aflect the general truth of the observation delivered by the most experienced surgeons of every age, that when a iimb is extensively swelled and inflamed, with a part of it either in a state of spreading mortification or ready to become gangrenous, the period is so unfa- vourable for amputation that very few patients so cir- cumstanced ever recover after the operation. Nor is it meant to be insinuated, that in the very cases which form exceptions to the general rule of not amputating before the tendency to gangrene has ceased, the pa- tient might not have had an infinitely better chance of his life, had the operation been done immediately after the first receipt of the injury, before any disposition to gangrene bad had time to be produced. The necessity of immediate or very early decision in this case makes it a very delicate part of practice ; for however pressing the case may seem to the surgeon, it will not, in general, appear in the same light to the patient, to the relations, or to bystanders. They will be inclined to regard the proposition as arising from ignorance, or an inclination to save trouble, or a desire to operate ; and it will often require more firmness on the part of the practitioner, and more resignation and confidence on the part of the patient, than is generally met with, to submit to such a severe operation in such a seeming hurry, and upon so little apparent delibera- tion ; and yet it often happens, that the suffering this point of tune to pass decides the patient’s fate. This necessity of early deci.sion arises ft-om the quick tendency to mortification which ensues in tlte injured limb, and too often ends in the patient’s death. That tliis is no exaggeration, says Pott, melancholy and fre- quent experience evinces, even in those whose consti- tutions previous to the accident were in good order ; but much more in those who have been heated by vio- lent exercise, or labour, or liquor, or who have led very debauched and intemperate lives, or who have habits naturally inflammable and irritable. This is often the case when the fracture happens to the middle part of the bones, but is much more likely to happen when any of the large joints are concerned. In many of these cases a determination for or against amputation is really a determination for or against the patient’s ex- istence. That it would have been impossible to have saved some limbs which have been cut off, no man will pre- tend to say ; but this does not render the practice in- judicious. Do not the majority of those who get into the above liazardous condition, and on whom amputa- tion is not performed, perish in consequence of their wounds 1 Have not many lives been preserved by am- putation which, from the same circumstances, would otherwise most probably have been lost 1 Pressing and urgent as the state of a compoimd frac- ture may be at this first point of time, still it will be a matter of choice whether the limb shall be removed or not ; but at the second period the operation must be submitted to, or the patient must die. The most unpromising appearances at first do not necessarily or constantly end unfortunately. Some- times, after the most threatening first symptoms, after considerable length of time, great discharges of mat- ter and large exfoliations of bone, success shall ulti- mately be obtained, and the patient shall recover his health and the use of his limb. But sometimes, after the most judicious treatment through every stage of the disease; after the united efforts of physic and surgery; the sore, instead of granulating kindly, and contracting daily to a smaller amputation. 41 «izG, shall remain as large as at first, with a tawny, spongy surface, discharging a large quantity of thin sanies, instead of a small one of good matter ; the fractured ends of the bones, instead of tending to ex- foliate or to unite, will remain as perfectly loose and disunited as at first, while the patient shall loose his sleep, his appetite, and his strength; a hectic fever, with a quick, small, hard pulse, profuse sweats, and colliquative purging, contributing at the same time to bring him to the brink of the grave, notwithstanding every kind of assistance : in these circumstances, if amputation be not performed, Mr. Pott asks, what else can rescue the patient from destruction ? The third and last period is a matter which does not require much consideration. Too often the inflam- mation consequent upon the injury, instead of producing abscess and suppuration, tends to gangrene and morti- fication, the progress of which is often so rapid, as to destroy the patient in a very short space of time, con- stituting that very sort of case in which amputation should have been immediately performed. But some- times even this dreadful malady is, by the help of art, put a stop to, but not until it has totally destroyed all the surrounding muscles, tendons, and membranes quite down to the bone, which, upon the separation of the mortified parts, is left quite bare, and all circulation between the parts above and those below is by this totally cut off. In this instance, whether the surgeon saw through the bare bone, or leave the separation to be effected by nature, the patient must lose his limb. — (See Pott’s Remarks on the Necessity, &c. of Ampu- tation in certain Cases, «fcc. Chir. Works, vol. 3.) For the consideration of a variety of complicated cases which affect the question of amputation in com- pound fractures, I must refer to the article Gun-shot Wounds. 2. Extensive contused and lacerated wounds. These , form the second class of general cases re- quiring amputation. Wounds without fracture are not often so bad eis to require this operation. When a limb, however, is extensively contused and lacerated, audits principal blood-vessels are injured, so that there is no hope of a continuance of the circulation, the immediate removal of the member should be recommended, whether the bones be injured or not. Also, since no effort on the part of the surgeon can preserve a limb so injured, and such wounds are more likely to mortify than any others, the sooner the operation is undertaken the better. In these cases, as in those of compound fractures, though amputation may not always be necessary at first, it may become so afterward. The foregoing observations, relative to the second period of compound fractures, are equally applicable to badly lacerated wounds, unattended with injury of the bones. Some- times a rapid mortification comes on ; or a profuse suppuration, which the system can no longer endure. — (Encyclop^die M^thodique ; partie Chir. t. 1, p. 80.) 3. Cases in which part of a limb has been carried away by a cannon ball. When part of a limb has been torn off by a cannon- ball, or any other cause capable of producing a similar effect, the formation of a good and serviceable stump, the greater facility of heating the clean, regular wound of amputation, and the benefit of a far more expedi- tious, as well as of a sounder cure, are the principal reasons which here make the operation advisable. This was an instance, in which some former sur- geons disputed the necessity of amputation. They urged as a reason for their opinion, that the limb being already removed, it is better to endeavour to cure the wound as speedily as possible, than increase the pa- tient’s sufferings and danger, by making him submit to amputation. It mu.st be remembered, however, that the hones are generally shattered, and reduced into numerous fragments; the muscles and tendons are unequally divided, and their ends torn and contused. Now, none of the old surgeons questioned the absolute' necessity of extracting the splinters of bone, and cut- ting away the irregular extremities of the tendons and muscles, which operations would require a longer time than amputation itself. Besides, we should recollect that, by making the incision above the injured part, so as to be enablfS to cover the bone with flesh and integu- ments perfectly free from injury, the extent of the wound is so diminished, that the healing can be accom- plished in one-third of the time which would otherwise be requisite, and a much firmer cicatrix is also obtained. Such reflefftions mpst convince us, that amputation here holds forth very great advantages. It cannot in- crease the patient’s danger, and as for the momentary augmentation of pain which he suffers, he is amply compensated by all the benefits resulting from the ope- ration. — (See Gun-shot Wounds.) 4. Mortification. Mortification is another cause, which, when ad- vanced to a certain degree, renders amputation indis- pensably proper. We have noticed, that bad compound fractures and wounds often terminate in the death of the injured limb. Such surgeons as have been deter- minetl,*at all events, to oppose the performance of am- putation, have pretended, that the operation is here totally useless. They assert, that when the mortifica- tion is only in a slight degree, it may be cured, and that when it has spread to a considerable extent, the patient will perish, whether amputation be performed or not. But this way of viewing things is so contrary to facts, and the experience of every impartial practitioner, that I shall make no attempt to refute the assertion. W’hile it is allowed that it would be very bad practice, to am- putate on every slight appearance of gangrene, it is equally a fact, that when the disorder affects the sub- stance of a member, the operation is generally the safest and most advantageous measure. Nay, there are, as we shall presently see, certain forms of n)orti- fication, in which the early performance of amputation is the only chance of saving the patient. Practitioners have entertained very opposite oiunions, concerning the period when one should operate in cases of mortification. Some pretend, that whenever the dis- order presents itself, and especially when it is the effect of external violence, we shpuld impntate immediately the mortification has decideaiy begun to form, and while the mischief is in a spreading state. Others be- lieve, that the operation should never be undertaken before the progress of the disorder has stopped, even not till the dead parts have begun to separate from the living ones. The advocates for the speedy performance of ampu- tation declare, that the farther progress of the mortifi- cation may be stopped, and the life of the patient pre- served, by cutting above the parts affected. However, according to the reports of the greater number of emi- nent surgical writers, this practice is highly dangerous, and undeserving of confidence. Whatever pains may be taken, in the operation, only to divide sound parts, there is no certainty of succeeding in this object, and the most skilful practitioner may be deceived. The skin may appear to be perfectly sound and free from inflammation, Avhile the muscles which it covers, and the parts immediately surrounding the bone, may actually be in a gangrenous state. But even when thq soft parts are found free from apparent distemper, on making the incision, still, if the operator should not have waited till the mortification has ceased to spread, the stump will almost always be attacked by gangrene. Surgeons who have had opportunities of frequently seeing wounds which have a tendency to mortify, en- tertain the latter opinion. Such was the sentiment of Pott, who says that he has often seen the experiment made, of amputating a limb in which gangrene had begun to show itself, but never saw it succeed, and it invariably hastened the patient’s death. The operation may be postponed, however, too long. Mr. S. Sharp, in particular, recommended too much delay, advising the operation never to be done, till the natural separation of the mortified parts had considera- bly advanced. Mr. Sharp was a surgeon of immense experience, and his authority carries with it the great- est weight. But, perhaps, he was too zealous in his opposition to a practice, the peril of which he had sa often beheld. When the mortification has ceased to spread, there is no occa.sion for farther delay. We now obtain, just as certainly, all the benefits of the operation, and get rid of a mass of putridity, the exhalations from which poison the atmosphere which the patient breathes, and are highly detrimental to his health. Nay, according to the reports of writers, patients in these circumstances may actually fall victims to the absorption of the putrid matter which is suffered to remain too long. However, this danger would not be 48 AMPUTATlOxN. 80 considerablfi as that which would arise from too precipitate an operation ; and it is better to defer ampu- tation a little more than is absolutely re<]uisilc, than run any risk of doing the oi)eralion before it is certain that the parts have lost their tendency to gangrene. In the article Mortification, we have noticed particu- lar ca.ses of gangrene, where, according to Larrey’s e.xperience, the surgeon is not to wait for the line of separation being formed, but have recourse to the im- mediate performance of amputation. The e.xperience of Mr. Lawrence tends also to confirm the propriety of such practice. — (See Medico-Cliir. Trans, vol. 6, p. 156, &c.) In an example, where a large part of the arm was deeply affected with gangrene from external violence, and the disorder was yet making rapid progress, I once recommeinled the performance of amputation at the shoulder-joint. On the whole this instance was fa- vourable to the practice ; for, though the patient died at the end of a fortnight, probably he would not have lived twenty-four hours, had the operation not been done ; nor was the stump attacked with mortification, a cir- cumstance worthy of attention, because it is a danger particularly insisted upon by the opiionents of amputa- tion, under the preceding circumstances; and, had it not been for a large abscess, which formed in the back, as was supposed, from a violent blow received in the fall which produced the original injury, there were well-grounded hopes of recovery. The patient, here spoken of, was attended by Dr. Illicke, of Waltham- stow. There is likewise a species of gangrene, which is pointed out by xMr. Guthrie as requiring early amputa- tion. “ A soldier isays he) shall receive a flesh-wound from a musket-ball in the middle of the thigh, which passed through the limb apparently, on a superficial inspection, without injuring the main artery ; or it shall pass close behind the femur, where the artery turns to the back part of the bone ; or it may go through the middle of the bone, from behind forwards, between the condyles of the femur, into the knee-joint, and the patient .shall walk to the surgeon with little assistance, be superficially dre.ssed, and, in many ca.ses be consi- dered slightly wounded ; yet the femoral artery and vein of the whole of these cases, and, indeed, in many others, shall be wounded, or cut across, and the local Infl.'inmation be so slight as to obtain little aflention. On the third or fourth day, the patient shows his toes discoloured, and complains of pain and coldness in the limb below the wound, the constitution begins to sym- pathize with the injury, and the surgeon jirobably thinks the case e.xtraordinary. Terhaiis he suspects the real state of the injury ; but is surprised that a wound of the femoral or popliteal artery, with so little attendant injury, could cause mortification, &c. lie is anxious to do something ; but mortification, or at least gangrene, having commenced, he must, according to general rule, await the formation of the line X)f separation. The temperature of the leg, a little above the gangrene, is good, perhaps higher than natural ; he hopes it will not extend farther, and it probably does remain station- ary for a little time. At last, the parts originally affected, the toes, become sphacelated, and gangrene quickly spreads up the leg as far as the wounded ar- tery, by which time the patient dies.” For the purpose of preventing such a disaster, where the artery, or artery and vein, have been dhided, Mr. Guthrie recommends the performance of amputation as soon as the gangrene is perceived to extend beyond the toes; and the swelling and slight attendant inflam- mation, which is marked more by the tumefaction, than the redness of the part, has passed higher up than the ankle. — (See Guthrie on Gun-shot Wounds, p. 60, 61.) 5. White stcellings. Scrofulous joints, xvith diseased bones, and distem- pered ligaments and cartilages, is another case, in which amputation may become absolutely necessary. As Mr. Pott remarks, there is one circumstance attend- ing this complaint, often rendering it particularly un- pleasant, which is, that the subjects are most frequently young children, so as to be incapable of determining for themselves, which inflicts a very distressing task on their nearest relations. All the efforts of physic and surgery often prove absolutely ineffectual, not only to cure, but eVen to retard, the disease in question. Notwnthstanding many cases admit of cure, tliere are numerous others which do not .so. The disease often begins in the very inmost recesses of the cellular texture of the heads of the bones forming the large articulations, such as the hip, knee, ankle, and elbow- ; the bones become diseased, in a manner which we shall exi>lain in the article Joints, sometimes w ith great pain and symptomatic fever ; sometimes with very little of either, at least in the beginning. The cartilages covering the ends of these bones, and designed for the mobility of the joints, are totally destroyed; the epi- physes in young subjects are either partially or totally separated from the said bones ; the ligaments of the joints are so thickened and spoiled by the distemper, as to lose all natural appearance, and become quite unfit for all the purposes for which they were intended : the parts appointed for the secretion of the synovia become disteiniiered in like manner ; all these together ftirnish a large quantity of stinking sanious matter, which is discharged either through artificial openings, made for the purpose, or through small ulcerated ones These openings commonly lead to bones which are diseased through their wliole texture. When the dis- ease has got into this state, the constant pain, irritation, and discharge bring on hectic symptoms of the most destructive kind, such as total loss of appetite, rest, and strength, profuse night-sweats, and as proAiso purgings, which foil all the efforts of medicine, and bring the patient to the brink of destruction. It is an incontestable truth, that unless amputation be i)erfonned, a patient thus situated must perish ; and it is equally true, that numbers, in the same circum- stances, by submitting to the operation, have recovered vigorous health. — See Pott on Amputation.; It is a fact, highly important to be known, that in these cases amputation is attended with more success, when performed late, than when undertaken at an early period, before the disea.se has made great ad- vances. This is particularly fortunate, as it affords time for giving a fair trial to such remedies as are best calculated to check the progress of the disorder, and obviate all necessity for the operation. — (Encyclop^die M^thodique, tom. 1, p. 83. See Joints, White Swell- ing-) 6. Exostoses. Here it will be sufficient merely to mention, that this disease may render amputation necessary, when the tumour becomes hurtful to the health, or insup- ponable, on account of its weight or other circum- stances, and cannot be removed by any of the plans specified in the article Exostoses, 7. J^ecrosis. Another distemper, sometimes producing a necessity for amputation, is necrosis, or the death of the whole, or of a very considerable part, of the bones of the ex- tremities, accompanied with such extensive abscesses, such disease of the soft parts, such disorder of the constitution and prostration of strength, that every hope of a cure being effected by a natural process must be renounced. By necrosis, is here meant, not merely some disease which destroys the surface of a bone, but one which extends its depredations to the whole of the internal substance, and that from end to end. Por- tions of the bones die from a variety of causes, such as struma, lues venerea, deep-seated abscesses, pressure, &c. ; and bones in this state, when properly treated, often exfoliate and cast off their dead parts. But when the whole substance of a bone becomes diseased from end to end, frequently no means will avail. In the words of Mr. Pott, the use of the scalpel, the rasp- atory, and the rugine, for ti.e removal of the diseased surface of bones ; of the trephine, for perforating into the internal texture of the diseased bone, and of exfo- liating applications if there be any such which merit the name ), will prove in many instances unavailing, and, unless the whole bone be removed by amputation, the patient will die. Mr. Pott’s refutation of Bilguer, who asserts that amputation is not requisite in these instances, is a masterly and most convincing produc- tion ; but I would not exactly do as the former of these writers has done, and positively affirm, that every ex- tensive necrosis, affecting a bone nearly its whole length, must inevitably require amputation. The power of nature in restoring the bones is sometimes wonder- ful, as will be hereafter explained — (See Necrosis. i The very late period at wluch an extensive necro- AMPUTATION. 49 sis may follow the injury of a bone, and make am- putation necessary, is sometimes almost incredible. Schmucker details the case of a captain who received a musket-ball through the left arm, four or five inches above the elbow. The bone was violently struck, but not broken; several exfoliations followed, aiid after more than a year’s treatment, the patient appeared per- fectly cured. For nine years this officer remained well ; but at the end of this time, being on a journey, he was attacked with pain and inflammation in the wounded part, and febrile symptoms. He hastened to Berlin, and put himself under the care of Theden and Sctoucker, who found an abscess in the situation of the former wound, and as an opening had been already made, the bone could be felt stripped of its periosteum. At length a piece of bone exfoliated, and became loose, precisely under the brachial artery, which interfered with its removal. Notwithstanding the discharge, the elbow-joint continued swelled, and there were red points observable, not only above that joint, but also over the heads of the ulna and radius, indicating disease of those bones. Amputation was therefore performed by Theden, and the patient got quite well. On examin- ing the os brachii, a splinter was found, three inches in length, and one in breadth, its edges being thin and sharp, while its centre was more than three lines thick. The bone, every where about the place where it had been struck by the ball, seemed to consist of callus without any medullary cavity, and the whole of it dotvn to the elbow had no periosteum. The car- tilage appeared also dispose,d to separate, and the peri- osteum was detached from the radius and ulna, which were likewise affected with necrosis.— (See Schmuck- er’s Vermischte Chir. Schriften, b. 1, p. 23, ed. 2.) 8. Cancerous and other inveterate diseases, such as fungus hcematodes. Cancerous, inveterate diseases, and malignant incura- ble ulcers on the limbs, sometimes render amputation a matter of necessity. In treating of cancer, we shall remark that little or no confidence can be placed either in internal or any kind of topical remedies, and that there is nothing, except the total separation of the part affected, upon which any rational hopes of cure can be built. Cancer is not frequently seen on the extremi- ties. Every man of experience, however, must occa- sionally have seen, in this situation, if not actually cancer, diseases quite as intractable, and which cannot be cured except by removing the affected part. This may often be accomplished without cutting off the whole limb. But when the disease has spread beyond certain bounds, amputation above the part affected is the only thing to which recourse can be had with any hope of success. Sometimes, when the operation has been delayed too long, even amputation itself will not effect a cure. In a few cases of fungus haematodes, the operation has succeeded, however, after the dis- esise had reappeared, and a cure had been seemingly achieved by the excision of the diseased parts. Yet, from what I have seen of fungus hajmatodes, I should much doubt whether the benefit obtained by amputation would be lasting ; as when this disease shows itself only externally, internal organs are mostly at the same time similarly affected. — (See Fungus Hasrnatodes.) Besides cancerous, there are other ulcers, which may render amputation indispensable. Thus, when an ex- tensive ulcer, of any sort whatsoever, is evidently im- pairing the health ; when, instead of yielding to reme- dies, it becomes larger and more inveterate ; when, in short, it puts life in imminent danger; amputation should be advised. 9. VarioxLS tumours. That there are numerous swellings, which destroy the texture of the limbs, rendering them useless ; caus- ing dreadful sufferings, and bringing the patients into the most debilitated state, no man of observation can fail to have seen. When such tumours can neither be dispersed nor cut out with safety, amputation of the limb is the only resource. Mr. Pott has particularly described a tumour affect- ing the leg, for which the operation is sometimes re- quisite. It has its seat in the middle of the calf of the leg, or rather more towards its upper i)art, under the gastrocnemius and soleus muscles. It begins by a small, hard, deep-seated swelling, sometimes very painful, sometimes but little so, and only hindering the VoL. l.-U patient’s exercises. It does not alter the natural colour of the skin, at least until it has attained a considerable size. It enlarges gradually, does not soften as it en- larges, but continues through the greatest part of it in- compressibly hard, and when it is got to a large size^ it seems to contain a fluid, which may be felt towards the bottom, or resting, as it were, on the back part of the bones. If an opening be made for the discharge of this fluid, it must be made very deep, and through a strangely distempered mass. This fluid is generally small in quantity, and consists of a sanies mixed with grumous blood ; the discharge of it produces very little diminution of the tumour, and very high symptoms of irritation and inflammation come on, and, advancing with great rapidity, and most exquisite pain, very soon destroy the patient, either by the fever, which is high and unremitting, or by a mortification of the whole leg. If amputation has not been performed, and the patient dies after the tumour has been freely opened* the mortified and putrid state of the parts prevents all satisfactory examination; but if the limb was re^ moved, without any previous operation (and which Mr. Fott, in his experience, found to be the only way of -preserving the patient’s life), the posterior tibial ar- tery will be found to be enlarged, distempered, and burst ; the muscles of the calf to have been converted into a strangely morbid mass ; and the posterior part of both the tibia and fibula more or less carious.-- (Pott on Amputation.) It seems only necessary to adduce another species of tumour to illustrate the necessity of amputation^ The following case is related by Mr. Abernethy. A woman was admitted into St. Bartholomew’s Hospital with a hard tumour in the ham. It was about four inches in length, and three in breadth. She had also a tumour in front of the thigh, a little above the patella* of less size and hardness. The tumour in the ham, by its pressure on the nerves and vessels, had greatly les- sened the sensibility, and obstructed the circulation of the leg, so that the limb was very cedematous. As it appeared impossible to remove this tumour, and its ori gin and connexions were unknown, amputation was performed. On examining the amputated limb, the tumour in the ham could only be divided with a saw. Several slices were taken out of it by this means, and appeared to consist of a coagulable and vascular sub- stance, in the interstices of which a great deal of bony matter was deposited. The remainder of the tumour was macerated and dried, and it appeared to be formed of an irregular and compact deposition of the earth of bone. The tumour on the front of the thigh was of the same nature as that of the ham, but contained so little lime, that it could be cut with a knife. The thigh-bone was not at all diseased, which is mentioned, because, when bony matter is deposited in a limb, it generally arises from the disease of a bone. — (Surgical Observations, 1804.) Before the late facts and improvements relative to the treatment of aneurisms, these cases, on the extremi- ties, were generally set down as requiring amputation. Even Mr. Pott, and J. L. Petit, wrote in recommenda- tion of such practice, and their observations on this subject are among .the few parts of their writings which the enlargement of surgical knowledge, since their time, has rendered objectionable. The surgeon to whom the honour of first correcting this erroneous doctrine belongs is A. N. Guenault, who opposed the advice delivered on this subject by Petit. — (Haller, Disp. Chir. vol. 5, p. 155.) I shall conclude these remarks on the cases requir* ing amputation, with advising surgeons never to un- dertake this serious operation, without consulting the opinions of other professional men, whenever their ad- vice can be obtained. The best operators are often de- ficient in that invaluable kind of judgment by which the cases absolutely demanding amputation are dis- criminated firnm others, in which the operation may be wisely postponed, and a chance taken of preserving the limb. Historical remarks on Jlmpvtation. The history of amputation evinces that the steps of surgery to perfection are slow, and that they even sometimes deviate from the straight path, though upon all essential points no retrogration has ever taken place. Here nature has acted as the guide, and the surgeon’s chief merit has con.sisted in obeying the 50 AMPUTATION. liinls which site herself has thrown out. As already mentioned, r he following natural occurren:e, no doubt, was one of the circumstances which first led to the bold preiclice of amputation ; in consequence of dis- ease and grievous local injuries, whole limbs were sometimes seized with mortification. In the majority of cases, this was attended with so much constitutional disturbance that the patients died ; byt in other less numerous instances, the mortification was confined to the part ; suppuration was established between the dead and living parts ; the whole of the mortified limb fell oflT; the suppurating surfaces healed up ; and thus, by the powers of nature, the patients were re- store to health. Here was clearly proved the possi- bility of recovery, notwithstanding the loss of a limb. The surgeon, as Brunninghausen remarks, viewed ■with surprise this course of nature, and hardly ven- tured to promote it by the feeble means formerly em- ployed, which, liowever, were not really needed. But as the mortified i)arts. previously to their detachment, caused great annoyance hy their fetor, a surgical at- tempt was at length made to get rid of them ; in doing which the knife was always kept from touching the living flesh, on account of a well-grounded fear of bleeding, for the suppression of which no effectual methods were known. Such was the practice that prevailed from Hippocrates down to Celsus. — .Erfahr. dec. iiher die Arnp. p. 14.) “ Partes autem corporis, qu® infra temiinos denigrationis fuerint, ubi jam pror- sus emortu® fuerint et dolorem non senserint, ad ar- ticulos auferend® ea cautione ut ne vuluus inferatur,” &c. — (De Articulis, sect. 6.) Here we find that the earliest mode of anipumtion was that done at the joints. A. C. Celsus, who lived in the reign of Tiberius, and whose book, Ue Re Medica, should be read by every surgeon, has lefl us a short description of the mode of amputating gangrenous limbs. — 'Lib. 7, c. 33.) It has been often remarked, that Celsus has left no in- structions for securing the divided blood-vessels ; but it has not been comnionly noticed, that in his chapter on wounds he directs us to stop hemorrhage by taking hold of the vessels, then tj-ing them in two places and dividing the intermediate portion. If this measure cannot be adopted, he advises the use of a cauterizing iron. Several hints are to be met with in the writings of Celsus, ft-oin which it may be inferred that the liga- ture of bleeding vessels was sometimes practised at the early age in which he lived ; and this supjiosi- tion is strengthened by a fragment of Archigenes pre- served by Cocchius, on the subject of amputation, where he speaks of tying or sewing the blood-vessels. VVe are not, however, in po.ssession of all the w ritings of medical authors prior to the time of Galen, and must therefore remain in doubt upon this point. — (Rees's Cy- clop®dia, art. Amputation.) This anonymous writer argues, therefore, with some appearance of reason, that if amputation often proved fatal in the days of Celsus, “ s®pe in ipso opere,” as the expression is, it was owing to the want of some efficacious method of compressing the blood-vessels during the operation itself ; for whether the use of the ligature were known to the ancients or not, no doubt exists about their ignorance of the.tourniquet. But admitting that the ancients were not altogether uninformed of the plan of tying arteries, it caimot be credited that they adopted the practice to any extent ; for if they had, they would not have continued so par- tial to the cautery, boiling oils, and a farrago of as- tringent applications. They would also never have had recourse to the barbarous method of cutting the flesh with a red-hot knife, with the view' of stopping the hemorrhage by converting the whole surface of the stump into an eschar. Painful in its execution and horrid in its consequence as this burning operation was, it seldom proved a lasting antidote to the bleed- ing, which generally came on in a fatal manner, as soon as the sloughs were loose. On this part of the sub- ject my own ideas fully agree with those of a distin- guished foreign surgeon, who says, that although the document left us may prove that the ligature was ^own to the ancients, and employed in cases of aneurisms and wounded blood-vessels, nay, that the arteries were secured with a needle and ligature ; yet the practice could not have been extended to the operation of ampu- tation, since, with the custom of making the incisions in the dead parts, the method scarcely admitted of being put in execution. —(Briinninghausen, Erfalir. fiber die Amput. p. 29.) Ambrose Pare, therefore, seems to me .to deserve as much praise for the introduction of the ligature into common use, as if no allusion to this me- thod whatsoever had existed in the writings of Celsus and other ancients. The diflerent parts of the operation meriting parti- cular attention are, the choice of the part of the tiq)b where the incisions are to begin ; the measures for guarding against bleeding during the operation ; the dinsion of the integuments, muscles, and bones, which is to be accomplished in such a manner that the whole surface of the stump will afterward be covered with skin ; tying the arteries, which should be done with- out including the nerves or any other adjacent part ; jilacing the integuments in a projier position after the oiieration; and, finally, the subsequent treatment of the w oiiiid. At the period of making the incision, the ancients confenied themselves with having the skin forcibly drawn upwards by an a.ssistant ; they next divided, with one sweep of the knife, the integuments and flesh down to the bone, and afterward sawed the bone on a level with the soft parts, which were drawn upwards, Celsus considered it better to let the incision encroach upon the living flesh than leave any of the diseased parts behind. “ Et potius ex sana parte aliquid exci datur, quam ex ®gra relinquatur.” — (De Medicina, lib. 7, c. 33.) It appears, how'ever, that his views extended farther than those of most of his contemporaries, and even his followers, almost downto modern times. After cutting the muscles down to the bone, he says that the flesh should be reflected and detached underneath with a scalpel, in order to denude a portion of the bone, which is then to be sawn as near as possible to the* healthy flesh which remains adherent. He states, that when this plan is pursued, the skin around the wound will be .so loose that it can almost be made to cover the extre- mity of the bone. It is to be lamented that this ad- vice, inculcated by Celsus, should not have been com- prehended, or that it should have been so neglected as to stand in need, as it were, of a new discoverer, and that a suggestion of such importance should have re- mained so long useless. But the fact is, hemorrhage formerly rendered amputation so dangerous, that the ancient surgeons could not devote much attention to any thing else in the operation, and practitioners am- putated so seldom, that we read in Albucasis that he positively refused to cut oflf a person’s hand, lest a fatal hemorrhage should ensue, and the patient did it him- self and recovered. Over that part of the stump which the small quantity of preserved skin would not cover, Celsus recommended compresses, and a sponge dipped in vinegar to be laid. — fUe Re Medica, lib. 7, c. 33.) Archigenes, who was bom at Apamia, in Syria, was the disciple of Aga'.hinus, and physician to Philip, king of that countr>'. He repaired to Rome, where he prac- tised physic and surgery in the reign of the emperor Trajan, about 108 years after the birth of Christ. — (Por- tal, Hist, de I’Anatomie et de la Chirurgie, vol. 1, p. 61.) In the history of amputation the name of Archigenes is conspicuous, not only because he is supposed to have been acquainted with the use of the needle and ligature for the stoppage of bleeding, but because his descrip- tion of the operation is in some respects more minute than that of Celsus. For the hindrance of loss of blood in the operation, says Sprengel (Geschichte der Chir. b. 1, p. 404, Halle, 1805), he first of all tied up the vessels, and often the whole limb, over which he also sprinkled cold water. The integuments w'ere then drawn upwards from the wound, and confined there With a band ; and after the limb was off, he cauterized the stump, and applied folded compresses. The band was now loosened and a mixture of leeks and salt laid on the stump, to which were also applied oil and ce- rate.— (Nicet, Coll. Chir. p. 155.) Such was likewise the practice of Heliodorus, who thus early made objec- tions to the plan of cutting off a limb by a single stroke, a proposal that was renewed in far later days. The same author has also spoken of amputating at the joints ; a method of which he disapproves. — (Nicet, Coll. Chir. p. 155.) However, Galen entertained a fa- vourable opinion of it, on account of its safety and ex- pedition. — (Comm. 4, in lib. de artic. p. 650.) Galen’s precepts concerning amputation are, upon the whole, very like those given by Hippocrates ; for he directs only dead parts to be cut, and the stump to be caute- AMPUTATION* 51 fized.— (i)e Arte Curativi ad GlaUconem, lib. 2.) By dll the old writers, amputation was entirely restricted to cases of mortification ; farther they Avere afraid to , go ; and this precept, and all the other doctrines of Galen, may be said to have been the guide of the whole surgical profession for full fourteen centuries. The timid Arabians were not partial to amputation, and even in cases of mortification generally preferred a farrago of Useless applications, like Armenian bole, (fee. Paulus .a^ginet^ like Galen, deviated from Celsus’s good rule of making the incisions in the healthy parts, and only approved of making the requisite division near them. — (Lib. 4, c. 19, p. 140.) Avicenna, however, re- peated the directions left by the Greek writers (Can. lib. 4. Fen. 3, tr. 1, p. 454), and Abu’l Kasem proposed doing the operation with a red-hot knife. — (Chirurg. lib. 1 , sect. 52, p. 99.) In the middle ages, little was done for the improvement of amputation. In the 14th cen- tury gunpowder Was invented, and soon applied to the purposes of war, so that an abundance of cases must have presented themselves in which the wise maxim of not deferring amputation until mortification had come on, but of preventing the mischief by the opera- tion, ought to have struck an intelligent surgeon. One might also expect that practitioners would now have been led to make the incisions in the sound flesh. Unfor- tunately, the invention of gunpowder and its immediate consequences in surgery, happened at a period when practitioners were ill qualified to profit by the new les- sons of experience set before them. The writings of their predecessors furnished them with no directions how they ought to act, and they were themselves too much confounded at the sight of the mischief for which they were consulted, to be able to form any correct opinion about causes and effects. Their first idea was, that the terrible symptoms proceeded from the parts be- ing actually burned, and they afterward inclined to the belief that gun-shot wounds were poisoned. Hence the most absurd modes of treatment were insti- tuted, and, as Briinninghausen expresses himself, hu- man nature groaned under a new evil, for which there were for some time no true plans of relief. — (Erfahr. &c. fiber die Amp. c. 19.) This deplorable state was the natural result of the depression of science in general, and of the healing art in particular, in the days to which I now refer. In these middle ages, as they are called, the population of all Europe was plunged in the deep- est ignorance ; and whatever little knowledge remained, either of the arts or languages, was monopolized by the priesthood, the physicians of those times, who, instead of studying the volume of nature, wasted most of their time in discussing the doctrines of Galen. Surgery itself sunk to the lowest ebb, as may be well conceived from the decrees issued at Rheims by Pope Boniface the Eighth, forbidding any of the clergy to do any thing themselves which drew blood ; and of course all the operative part of surgery, that which required the most skill and science, was transferred to a set of illiterate, low-bred mechanics, far inferior to the worst country farriers of modern times. Yet the clergy, who were here scrupulously averse to soiling their own hands with blood, or hurting their own tender feelings by Alewing the agony of their fellow-creatures submitted to operations, had no hesitation in taking the chief emo- luments and honours of the profession, or in turning over these poor sufferers to men more qualified to tor- ture and murder than to give relief; and, what nearly staggers all credulity, the same professors of Christian- ity, who shuddered to spill a drop of blood themselves on a proper occasion, as Haller observes, eagerly had a hand, and acted an important part, in every sangui- nary war, where it was jmssible for them to interfere. In these dismal days of surgery, the advice delivered by Celsus was renewed by Theodoricus, who used to administer opium and hemlock previously to the ope- ration, for the purpose of rendering the patient less sensible to pain, and afterward vinegar and fennel were given, with the view of dispersing the intoxica- ting effects of the pre<;eding medicines. — (Chirurg. lib. 3 , c. 10.) The renowned Guido di Cauliaco was the inventor of the plan of taking oiT limbs without any bloodshed. It is better, says he, for the limb to drop off than be cur off ; as in the latter circumstance the conduct of the surgeon is viewed with spite, because it is supposed that the part might have been saved. Guido’s practice eoiwisted in covering the whole membrane with pitch- plaster, and applying round one of the joints so tight a band, that the parts below the constriction ultimately dropped olf.— (Chirurg. t^|[|6, Doctr. 1, cap. 8.) As Sprengel next observes, the method of amputating sug- gested by Celsus was again revived by Gersdorfj who after the operation not only drew down over the stump the skin which had been retracted, but applied a hog’s or bullock’s bladder over the stump, so as to rend'ir all burning and stitching of the parts needless. — (Feldbuch der Wundarzn. fol. 63.) Bartholomew Maggi also en- deavoured to preserve a considerable flap of integu- ments for covering the stump. — (De Vulner. bombard, et sclopet. 4to. Bonon. 1552 ; see Sprengel’s Geschichte der Chirurgie, p. 404. 406, 8vo. Halle, 1805.) At length, in the 15th century, the revival of learning occurred first in Italy. Men now began to think for themselves again, and physicians turned from compila- tions and scholastic nonsense to the consideration of nature. Anatomy was cultivated with great ardour* and made brilliant progress under the eminent charac- ters of the time : De la Torre, Berengarius Carpi, Ve- salius, Fallopius, Eustachius, and others, who were also for the most part very distinguished surgeons. “ In Italia scientiarum matre medici se nunquam chi- rurgia abdicarunt. Seculo 15 et 16, professores medici academiae Bononiensis, Patavinae, et aliarum in Italia illustrium scholarum et manu curaverunt, et consilio, et inter istos viros summi chirurgi exstiterunt.’ — (Hal- ler, Bibl. Chir. b. 1, p. 161.) Practitioners now ven- tured to amputate limbs in the sound part for other incurable diseases besides mortifications ; but the art of stopping hemorrhage after the operation continued imperfect. Though the method of applying the ligature in cases of wounded arteries and aneurisms was under- stood, yet from some unaccountable causes the practice was never thought of in amputations. Even Fallopius knew of no other means for stopping the bleeding but the cautery. — (De Turn, praetern. p. 665.) On the whole, the stoppage of bleeding was not attended with a de- gree of success proportionate to the advances of the healing art in general. Straps, bands, and compresses were indeed put round the member; but as the cir- culation of the blood was not yet correctly known, they were not applied in the proper places, being ar- ranged either close to the wound, or several of them put at random round the limb. The effects of such immoderately tight, long-continued constriction could be nothing less than gangrene ; and hence the actual cautery was still chiefly employed, The other means for suppressing hemorrhage scarcely merit the name. Terrified at the insecurity and ill consequences of such expedients, J. de Vigo (Practica in Chirurgia Copiosa, 491, Romae, 1514), and Fabricius ab Aquapendente (Op. Chir. Venet. 1619), disapproved of amputating in the sound flesh, and returned to the principle inculcated by the ancients, of making the incision in the mortified parts. Others endeavoured to lessen the peril of the bleeding by the rapidity with which the limb was re- moved, and the instantaneous application of the cau- tery. For this purpose L. Botalli invented a sort of guillotine, by means of which a member was severed from the body in an instant (De Ciirandis vulneribus sclopetorum, Lugd. 1560), while others laid a sharp axe upon the limb, and effected the dismemberment by the blow of a wooden mallet. An example of this barba- rous practice is recorded by Fabricius Hildanus, called by his countrymen the patriarch and ornament of the German surgery. In consequence of this fear of bleed- ing, before he knew of the use of the ligature, he was himself accustomed to amputate with a red-hot knife, the representation of which is given in his Avork. — (De Gangraena et Sphacelo, Op. ) Hildanus became a better surgeon, however, as he grew older, and in the end partly contributed to the improvement of amputation, inasmuch as he made the incisions completely in the sound parts, and adopted the method of tying the arte- ries, as then recently proposed by Pare ; but, unfortu- nately, in weak persons he still preferred the actual cau- tery to the ligature. — (Op. p. 814.) One of his inven- tions was a linen bag or cap for the stump ; and a sort of retractor for holding back the muscles. According to Sprengel (Geschichte der Chir. b. 1, p. 407), his ob- serA’^atioiis on the pain folloAving the operation are in- teresting, — (Op. p. 807. 814.) ^ . Ambrose Part;, a French surgeon, who flourished in the 16th century (Opera, Parisiis, 1582), and to whom I have already alluded, made some beneficial innova- U. OF iUL ua AMPUTATION. A2 tions with regard to the ojicration of amputation. It is to his industry, good sense, and skill that we are chiefly indebted for the abolition ^ cauterizing instruments, and the general use of a needle and ligature for the suppression of the bleeding.— (Lib. 6, c. 28, p. 224.) An anonymous writer has given the following ac- count of the practice and opinions of this distingui-shed su.^,on in relation to amputation. “ Pare recommended to cu off the whole of the gangrenous part if the limb be mortified, but to encroach as little as possible upon the living flesh. At the same time, he laid It down as a rule not to leave a very long stump to an amputated leg ; because the patient could more conveniently make use of a wooden leg, with the stump only five finger- breadths long below the knee, than if much more of the flesh were to be preserved. In the arm, however, he left the whole of the living and healthy portion of the member, only separating the diseased part from the sound. In i»reparing for amputation, he directs the skin and muscles to be drawn npward.s, and bound tight with a broad bandage a little above the jiart where the incision is to be made. This fillet was intended to answer a threefold purpose : — 1st, to afibrd a quantity of flesh for covering the bone, and facilitating the cure; 2dly, to close the e.\tremities of the divided blood-vessels; 3dly, to dull the patient’s feelings by jiressure on the subja- cent nerves. When this linn ligature has been applied. Pare directs an incision to be made down to the bone, either wth a common large scalfiel or a curved knife. Then with a smaller curved knife we are carel'ull v to divide the muscle or ligatneiu remaining between the bones of the forearm or leg; after which we may proceed to saw oft’ the bone as high as possible, and to remove the asperities occasioned by the saw. With the assistance of a curved pair of forceps he drew out the extremities of the bleeding arteries, either by themselves alone, or with some portion of the sur- rounding flesh, to be firmly tied with a strong double thread. He now loosened hia bandage, brought toge- ther the lips of the wmund over the face of the stump, and kept them as clo.se :ls he could without actual stretching, by means of four stitches or sutures. If the larger tied vessels should accidently become loose, he desires the ligature or bandage to be again passed round the limb ; or el.se, what is better, to let an assist- ant grasp the limb firm with both hands, and press with his fingers over the course of the bleeding ve.ssel, so as to stop the hemorrhage ; then with a square edged nee- dle, about four inches long, and a thread four times doubled, the surgeon must .secure the artery in the fol- lowing manner. 'Phrust the armed needle into the outside of the flesh, half a finger’s breath from the ves- sel which bleeds, and bring it out at tlie same distance from the bleeding orifice; then surround tl»e vessel with the ligature, pass it back again to within one nn- ger’s breadth of the place where it first entered, and tie a fast knot upon a folded slip of linen rag to prevent its hurting the flesh. By this means, says Par6, the ori- fice of the artery will be agglutinated to the adjoining flesh so firmly, as not to yield one drop of blood ; but if the hemorrhage were not considerable, he contented himself with the application of astringent powders, cpoTfxv> 7 , p. 76.) What, asks Briinninghausen, was the reason why the ligature of the arteries, which is now regarded by the surgeons of all civilized nations as the best, easiest, and safest method of stopping hemorrhage after ampu- tation, should so long have remained unadopted 1 Be- sides the prejudice for the opinions of the ancients, already mentioned, another cause was undoubtedly the imjjerfect knowledge of the circulation of the blood, a correct description of which was first delivered by the immortal Harvey early in the 17th century. — (Exerci- tatio Anat. de Motu Cordis et Sanguinis in Animalibus, Francof. 1628.) For some time this grand discovery met with violent opjiosition ; but after it hud been ac- knowledged as an eternal truth, a hajipy application of it was made to surgery by a French surgeon, named Morell, who, at the siege of Besangon, in 1674, invented the field tourniquet, by means of which more certain pressure was made on the trunk of the artery. By this simple invention, founded, however, on a know- ledge of the circulation, the surgeon could at option let the blood of the stump spirt out, or stop its jet entirely ; and now both during and after the operation, he w'as first enabled to command the hemorrhage, and coolly and judiciously employ whatever measures were indi- cated ; for the most powerful bandages and pressure previously in use either stojiped the circulation in the whole limb, or could not be made to have the right effect with sufficient quickness. — (Briinninghausen, Erfahr. &c. fiber die Amp. p. 36.) Morell’s tourniquet, however, was very imperfect, and it was not till the year 1718, that J. L. Petit, whose name shines so brightly in the history of surgery, invented the kind of tourni- quet now employed. Richard Wiseman, who is justly considered as the father of good English surgery, saw the necessity of making the incision in the sound parts, because gan- grene does not always spread evenly, but frequently extends much higher up one side of the limb than the other. He deemed the actual cautery objectionable, as .. AMPUTATION. 53 the sloughs were so long in being thrown off. He ap- plied a ligature round the limb, two inches above the limits of the mortification, and, drawing up the mus- cles, made the incision with a large curved knife, with the back of which he scraped off the periosteum. The bag, or sort of retractor, employed by Fabricius Hilda- nus, Wiseman thought unnecessary, as the muscles spontaneously drew themselves up as soon as divided. He tied the blood-vessels after the manner of Par6, and deprecated all burning of the stump. After the opera- tion, he drew the flaps over the bone, and either fastened them in this.position with stiches or a tight bandage, though he generally preferred the former, as the surest means of keeping the end of the bone from protruding. Across the slump he laid a pledget of wax-cerate, and over this a thick layer of Armenian bole and other styptics, and the whole was covered with a bullock’s bladder and a roller, applied spirally from the upper part of the remaining portion of the limb down to the extremity of the stump. On the third day, the dress- ings were taken off, and a digestive ointment applied. — (Chirurg. Treatises, vol. 2, p. 220, 8vo. Lond. 1690.) From this time, amputation may be considered as being an infinitely safer proceeding than what it used to be ; for, as we have explained, the ligature of the arteries was now practised and commended in Germany by F. Hildanus, in England by Wiseman, and in France by Dionis. Much, however, remained to be done. The wound was large, and suppurated long and pro- fusely ; the healing was slow ; the ends of the bones perished, and, projecting far beyond the soft parts, re- tarded the cure so long, that the patient was not unfre- quently worn' out. Hence the best surgeons began seriously to consider what farther could be done, with a view of lessening the exposed surface of the wound, and making a better covering of flesh for the ends of the bones. According to Sprengel, most of the old surgeons preserved a flap of flesh, and he is therefore by no means disposed to regard our countryman, Lowdham, as the inventor of this method, though it is acknow- ledged that the latter surgeon’s practice was novel, inasmuch as the flap was formed by making an oblique incision through the integuments from below' upwards. —(See James Yonge’s Currus Triumphalis e Terebintho, 8vo. Lond. 1679 ; and Sprengel’s Geschichte der Chirur- gie, b. 1, p. 408.) Here, if Sprengel means that many of the old surgeons endeavoured to preserve a partial covering of flesh for the bone, there can be no doubt of his correctness ; because we find, that they drew back the flesh before they divided it, and Celsus and some others even did more, for, after cutting down to the bone, they detached the flesh farther from it upwards, previ- ously to taking the saw ; but, on the contrary, if Spren- gel wishes us to believe, that there were practitioners who, previously to Lowdham, in the operation of am- putation formed what in England is usually under- stood by a flap, that is, a portion of flesh, generally of a serriilunar shape, and saved particularly from one side of the member for covering the bone, I cannot see any reason for coinciding with Sprengel’s observation. Upon the merit of Lowdham’s suggestions, and the practice and principles inculcated by J. Yonge, some reflections lately sent me by Mr. Carwardine I insert with great pleasure, as perhaps he is right in thinking that the third edition of this work did not do justice to the memory of the latter ^vriter. “At the time Yonge wrote (1679),” says Mr. Car- wardine, “ it was supposed impossible to heal a stump before the bone had exfoliated, and therefore no sur- geon would venture upon an attempt at uniting the surface by the first intention. Now this union by the first intention was the chief object of Mr. Yonge in proposing the flap-operation, and it is to him, and not to Mr. Alanson, who wrote precisely 100 years after him, that we must attribute the honour of tliis improve- ment. It is related in a letter addressed to his friend Thomas Hobs, chirurgeon, in London, dated Plymouth, August 3, 1678, and published, 1679, at the end of his Currus Triumphalis e Terebintho. It begins thus : ‘Sir, I find by yours that you are surprised with the intimation I gave you, of a way of amputating large members, so as to be able to cure them per sym- jihysin in three weeks ; and without fouling or scaling the bone. It is a paradox which I will now evince to you to be a truth, after I have first taken notice of what you affirm, that there is a necessity of scaling the ends of those bones left bare after the usual manner of dismembering, before the stump can be soundly cured ; that you never yet found it otherwise, but that where it hath been attempted, the stumps have apostu- mated, and the caries come off thereby.’ Yonge then acknowledges, that it was from an ingenious brother, Mr. C. Lowdham of Exeter, that he had the first hint thereof. He then describes the ope- ration — the laying down the flap over the face of the stump, and sewing it by four or five stitches, &e. After this, Yonge proceeds with a methodical enumeration of the advantages of this mode of operating over all others then in use, viz. that it is more speedy — the cure not occupying a fourth of the usual time — no sup- puration— no exfoliation — less danger of hemorrhage — not liable to break open again from slight injury — and lastly, much better adapted to the pressure from an artificial leg, &c. The foregoing abstract will show (says Mr. Car- wardine) how far Mr. O’Halloran’s method, presently to be described, in which he dresses the flap and the stump as distinct surfaces, can be regarded as a revival of Lowdham’s operation, or whether it has been super- seded or improved upon by the mechanical ingenuity of the Dutch and French surgeons ; — the apparatus of M. de la Faye and Verduin appear to have been merely clumsy and unscientific contrivances for the suppres- sion of hemorrhage. Garengeot’s operation had also for its object to supersede the use of the ligature, which, however, after twelve years’ practice, he was obliged to give up, and tie the vessel before he laid down the flap (the particulars of all these methods the reader will presently meet with' . Opinions, therefore, founded upon the practice of these gentlemen, I conceive, can- not fairly be admitted as evidence against the flap-ope- ration of Lowdham, which nevertheless appears sinking in the estimation of the best modern surgeons ; perhaps no material advantage is gained by it over the common mode of operating in the lower extremities, as now practised — but even here cases may occur where we are glad to resort to it : a few years since, I attended a patient in consultation with a friend at Dunmow, in Essex, where we thought it necessary to remove a man’s leg for a caries of the tibia. An ulceration in front extended so high, that no integument could be saved, and the limb would have been removed above the knee, if I had not suggested the propriety of making, a flap from the calf of the leg. The tibia was obliged to be sawed as high as possible, but the flap was left sufficiently long to cover the surface, and that most important object, the bend of the knee, was preserved, to bear the pressure of a wooden leg. In the removal of the arm at the shoulder-joint, doubtless the advan- tages of making a ffap from the deltoid, &c. are suffi- ciently established ; but in the mode of dressing, I pre- sume that no English surgeon will admit, that the practice of M. Larrey (perhaps the most eminent sur- geon that has been formed by the wars of Buonaparte, and whose practice will be hereafter noticed) can super- sede the method of Yonge (or Low'dhara), who wrote 140 years before liim ! Larrey introduces cha'rpie beneath the dap to prevent union by the first intention 1 Lowdham’s object is simply to lay the flap over the wound to prevent exfoliation, and to heal the surface ‘ per symphysin’ in three weeks.” — To the correctness of these sentiments of Mr. Carwardine, I believe that every impartial surgeon will bear witness; and it merely remains for me to thank him for his obliging communication, and say, that I have recently looked over the copy of the Currus Triumphalis e Terebintho, preserved in the valuable library of the Medical and Chirurgical Society, and find, that what he had stated is fully confirmed by the contents of that ancient work. At the same time, I retain the belief, that the example set by Mr. Alanson, with respect to the proper method of dressing stumps and obtaining a speedy union of the wound, is entitled to the praise of posterity ; because his advice was so well enforced that it soon produced a revolution in practice, while the correct suggestions of Lowdham and Yonge, like the hint in Celsus, of the double incision, had sunk into oblivion, or were only known to a few admirers of surgical antiquities. As Sprengel remarks, Purmann, Dionis (Cours d’Op6r. de Chir. p. 611), De la Vauguyon (Trait6 Compel, des Optr. de Chir. p. 531), and most other surgeons of the seventeenth century, continued the method of first drawing up the integuments, and then 54 AMPUTATION. applying a baud round the member. Dion is also took particular pains to recommend the ligature of the ves- sels, and expresses a strong aversion to the actual cau- tery. Neither did he approve of amputation at the knee-joint, because he thought that the patella, which must be left behind, would impede the healing of the stump, and he was apprehensive of the articular sur- face of the femur becoming diseased. De la Vaugu^ on relied ujion the styptic properties of vitriol, and he praised drawing back the muscles by means of the kind of bag invented by Fabricius Hildanus. Taking off the limbs at the joints was first com- mended again in modern times by J. M unnicks, who was more partial to styptics than the ligature ; and for dressing the wound employed compresses and sticking- plaster. — (Chirurgia, p. 101.) Mauquest de la Mot he adopted the plan of operating recommended by Dionis ; he was also one of the first who made common use of the tourniquet in amputa- tions, afterward drawing out the vessels with the forceps and tying them.— iTraite Compl. de Chir. vol. 3, p. 171.) Lowdham’s original suggestion of amputating with a flap has been briefly noticed. About eighteen years after Yonge’s publication, I’eter Vorduin, an emi- nent surgeon at Amsterdam, submitted to the judg- ment of the ])rofession a new kind of flap-amputation, which he had put in practice. — (See Dis. Ejiistolica de Nov4 Artuum decurtandorum rationo, 8vo. Amst. 1090.) The following are the chief particulars of Verduin’s flap-operation. Two compresses were applieil, one under the ham, and the other on the course of the large vessels. The thigh was wrapped in a fine linen cloth, which was sustained by some turns of a roller. This apparatus was covered with a jiiece of leather, six inches broad, fhrnished with tlu’ee straps with buckles, to secure it round the part. The tourniquet was placed in the usual manner. The part above the place intended to be amputated was surrounded with a leather strap. The point of a crooked knife, which was niade to pass as near to the back part of the bones as possible, w as thrust in on one side of the leg, and made to come out on the other. The knife was then carried down nearly to the tendo achillis, and thus it separated almost the whole calf of the leg. The flap being formed, the operation w'as finished in the ordi- nary manner. The wound was then washed with a wet sponge, in order to clear it from the fragments of sawed bone. The leather strap, which served to secure the flesh, was next loosened, and the flap laid over the stump. The wound was dressed with lyco- perdon, lint, and tow, over which was put a bladder, sustained by strips of sticking-plaster, Upon this bladder was placed an instrument called a retinacu- lum, consisting of a compress, and a concave plate, Avhich were made to press upon the stump, by means of two straps, which crossed each other and were at- tached to the broad leather strap surrounding the thigh. In 1702, Sabourin, an able surgeon at Geneva, gave an account of Verduiii’s practice to the Royal Academy of Sciences, which, however, decluied to pronounce any judgment about it, without farther experience. Though this method of amputation was objected to by CiJnerding, in a tract published at Amsterdam in 1705, it was afterward highly extolled by P. Mas- suet, on account of the quickness with which the stump healed, the safety with which the flap served for the stoppage of the hemorrhage, and the avoidance of exfoliation by the non-exposure of the bone. He also dwelt upon the excellency of the stump for the application of an artificial foot.— (De I’Amputation h lambeau, 8vo, Paris, 1756.) Heister disapproved of the flap-amputation, because it appeared to him, that the irritation of the flesh by the projecting bonds was apt to cause pain and inflammation : he operated himself after the manner of Dionis, and was- strongly in favour of the use of ligatures. Some excellent precepts were delivered by J. L. Petit concerning amputation. He improved the tour- niquet ; and, instead of the large crooked amputating knife formerly employed, first brought into use the straight more moderate-sized knives with sharp backs, now seen in the hands of the best surgeons, because much better calculated than crooked knives for divi- ding the flesh by a sawing movement, which is the only right and surgical way of attempting to cut any part of the human body. He proved that making the division in the mortified parts was (Vequently followed by hemorrhage ; and for the suppression of bleeding he thought it the best principle to promote the forma- tion of acoagulum. — (M^m. de I’Acad. des Sciences, an 1732, p. 285. See Hemorrhage.) For compressing tlje vessels, he employed an instrument wliich covered the stump, like Verduin’s retinaculum, and made pressure by means of a screw. His only objection to Verduin’s method was, that the extension of gangrene up the limb frequently hindered the formation of so large a flap. He laid down the valuable general maxim of al- ways removing as much bone, and as little flesh, as possible ; for which purpose he invented what is termed the double incision, or dividing the business of cutting through the soft jiarts into two stages. About an inch higher than the place where he meant to saw through the bones, he first made the circular cut through the integuments down to the muscles; the skin was then pulled up so as to leave the flesh unco- vered to the extent of an inch, and the muscles were now divided at the highest point of their exposure. Lastly, the flesh was held out of the way with a retractor, and the bone was sawed through high enough up to allow of its extremity being well covered with flesh and in- teguments. The greatest defect in the doctrine of Petit, relative to amimtation, was the confidence he put in pressure, instead of the ligature.— (Traits des Malad. (.'hir. vol. 3, p. 126.) The first performance of amputation at the shoulder-joint, by Le Dran, and the improvements and alterations of that operation sug- gested by Garengeot, De la Faye, Desault, &c. I shall notice in a ftiture section. In chronological order, the next eveirt claiming no- tice in the history of amputation, was the promulga- tion of an opinion by T. R. Gagtiier, that Verduin’s flap-amputation might be traced back to times of great antiquity, the method described by Celsus being very similar. — (Haller, Diss. Chir. vol. 6, p. 161.) On this point, with reference to Lowdham, the true inventor of the flap-operation, I have already delivered my own sentiments. The flap-amputation of the leg, after Verduin’s man- ner, was tried by De la Faye, who found that the pres- sure of the flap was not enough to check bleeding from all the vessels, as it only operated on the anterior tibial artery, and by pressing the flesh more firmly against the end of the bones, he thought the risk of mortification would be occasioned. Verduin and iSabouriri, as we have seen, made only one flap. Two French surgeons, Ravaton and Ver- male, afterward thought that it would be better to save a flap from each side of the limb. They were also ad- vocates for tying the vessels, and bringing the two flaps into contact, so as to procure their speedy union, and hinder exfoliations and profuse suppuration. However, there is some difference in their methods of forming the flaps. Ravaton, who submitted his plan to the French Academy in 1739, made three deep incisions down to the bone ; first, a circular one, with a crooked knife, within four finger-breadths of the bone intended to be sawed ; and then with a somewhat larger knife, the two others perpendicularly to the first, one at the fore part, and the other at the back of the limb ; and, taking care not to touch the principal vessels, he detached the two flaps from the bone. Verraale formed the separate flaps by two incisions. After applying the tourniquet, he surrounded the part with two red threads, at the distance of four finger- breadths from each other ; one at the place where the bone was to be sawed, the other at the place where the incision of the flaps was to terminate. He after- ward thrust a long bistoury down to the bone, at the fore part of the limb ; turned it round the circumfe- rence, so that it might come out at the opposite part ; then, directing the edge of the knife along the bone, he cut down to the inferior thread, where he separated the first flap, which, as the author says, was of a round or conical figure at its extremity. The second flap was made in a similar way on the interior side of the mem- ber. — (Traits des Playes d’Armes a feu, par Ravaton, 8vo. Paris, 1750. De la Faye, in Mem. de I’Acad. de Chir. t. 5, ed. 12mo. Vermafe, Obs, de Chir. 8vo. Man- heim, 1767.) In presence of M. Quesnay, Garengeot performed the flap-apiputation according to the method of Ver- duin and Sabourin. We know that they made no liga- ture on the vessels, and that their intention was, that tlw AMPUTATION. 55 flap, when applied to the stump, and sustained by a par- ticular apparatus, should reunite, and stop all bleeding. Garengeot’s patient died on the third day after the operation ; hemorrhage having had a considerable share in producing death. The multiplicity of machines described by Verduin, La Faye, &c. had no other end but that of keeping the flap near the orifices of the vessels, so as to compress and close them. In consequence of the difficulty of making this compression precisely as required, the most ‘considerable vessels being situated between the two bones, and when cut, generally becoming retracted, Garengeot determined in future to employ ligatures. With these views, twelve years after the foregoing case, Garengeot performed a flap-amputation of the arm, pre*rving two flaps, according to the method communicated to the Academy by Ravaton. The bra- chial artery was tied, and the patient was cured, with- out any exfoliations. Garengeot made a third trial of this operation on a soldier dangerously wounded in the right foot by the bursting of a bomb, which fractured the interior part of the two bones of the leg, and several of the foot : the patient recovered in twenty-seven days. In this operation one single flap was made. Garen- goet was fearful, however, that the quick union might create some difficulty in withdrawing the ligatures, and he therefore took a means of hindering adhesion where they were situated; but of tiffs objectionable plan I shall not speak. He rightly preferred dressing and bandaging the stump to the use of the compressing machines invented by Verduin and La Faye ; and his choice of a straight knife, instead of a crooked one, was equally judicious. The preceding case dictated a truth, which will last as long as surgery itself, viz. that it is advantageous to apply the ligatures in such manner as to embrace no more than the vessel, so that they may fall off the sooner, and the parts more quickly unite.— (M. de Ga- rengeot, in Memoires de I’Acad. de Chir. t. 5, 12mo.) At one time, an objection frequently urged against the foregoing methods was, that when the fr^sh cut flap was immediately laid over the stump, inflamma- tion and abscesses were apt to ensue. Hence, in 1765, Sylvester O’Halloran, a surgeon at Limerick, was led to make the experiment of deferring laying down the flap till the end of the first eight or twelve days after the operation, when it was conjectured that the risk of inflammation and abscesses would be diminished. The tenor of O’Halloran’s book is apparently corroborated by the facts brought forward. Here we see one of the grand points, insisted upon by our worthy countryman James Yonge, viz. the chance of an immediate union of the wound from laying down the flap without delay, suddenly givon up, and because the wound could not always be healed without suppuration, it was deter- mined that it never should do so. However, it is con- solatory to find, that O’Halloran’s suggestion now exists only in the history, and not in the practice, of surgery. Alexander Monro, senior, was a great opposer of cer- tain methods which originated among the French sur- geons, and, in particular, he disapproved of the tourni- quet : he secured the vessels with needles and liga- tures ; and was the inventor of a bandage, which has been extensively approved of under the name of Monro’s roller. — iMedical Essays of EdinU. vol. 4, p. 257.) Bromfield, like Le Dran, restricted amputation to a few cases ; and he did not acknowledge its necessity, as a matter of course, in every case of gangrene, much less in every instance of white swelling or caries. From a passage which I have cited from Dr. Rees’s Cyclopae- dia, it would seem that the tenaculum was known to the ancients ; yet, according to general opinion (and I cannot affirm that it is incorrect from any passage in my recollection;, Bromfield is allowed to be the first modem surgeon who employed this very useful instru- ment.— (Chir. Cases and Obs. vol. 1, p. 41, 8vo. Lond. 1773.) About the year 1742, the removal of thighs without bloodshed was a subject a good deal broached. A sin- gle case recorded by Schaarschmid, where a mortified thigh separated without hemorrhage, was the founda- tion of the scheme. The .arteries were completely blocked up, and the parts insensible. — (Haller, Diss. Chir. vol. 5, p. 155.) A similar occurrence was related by Acrel (Chir. handels. p. 557) ; and Lalouette pro- fessed himself a believer in the security from hemor- rhage, on account of the vessels being filled with coa- gula, and therefore he also approved of letting dead parts be removed, or rather fall off, without bloodshed. — (Haller, Diss. Chir. vol. 5, p. 273.) In cases where the projecting bone of the stump was affected with necrosis, Bagieu, an experienced military surgeon, ventured to amputate a second time, and urged a variety of arguments in defence of the practice. — (M6m. de I’Acad. de Chir. t. 2, p. 274.) He coincided \vith Le Dran and Bromfield, however, about the propriety of restricting amputation to few cases, and has related numerous examples of limbs being saved, which, according to the doctrines then in vogue, ought to have been cut off — (Deux Lettres d’un Chir. de l’Arm6e, 12mo. Paris, 1750.) M. Louis, a French surgeon of extraordinary talents, introduced the plan of diviffing the loose muscles first, and lastly those which are closely connected with the bone. He noticed that the muscles of the thigh, after being divided, were retracted in an unequal degree. He observed that the superficial ones extending along the limb, more or less obliquely, without being attached to the bone, were drawn up with greater force, and in a greater degree than others, wlffch are deeply situa- ted, in some measure, parallel to the axis of the femur, and fixed to this bone throughout their whole length. The retraction begins the very instant when the miis- cles are cut, and is not completed till a short time has elapsed. Hence, the effect should be promoted, and be as perfect as possible, before the bone is sawed. In the amputation of the thigh, Mr. I.ouis was always desirous of letting the muscles contract as far as they could, and for this reason he was rather averse to using the tourniquet, as the circular pressure of this instrument in some measure counteracted what he wished to take place ; and hence, at one time he preferred letting an assistant make pressure on the artery, though he subsequently expressed his approbation of the tourniquet proposed by M. Pipelet for compressing the femoral artery. — (M6m. de I’Acad. de Chir. vol. 4, p. 60, 4to.) Actuated by such principles, Louis practised a kind of double incision different from that of Cheselden and Petit, and different also from Alanson’s method, which I shall hereafter notice. By the first stroke he cut, at the same time, both the integuments and the loose su- perficial muscles ; by the second, he divided those muscles which are deep and closely adherent to the fe- mur. On the first deep circular cut being completed, Louis used to remove a band which was placed round the limb, above the track of the knife. This was taken off in order to allow the divided nrascles to become retracted without any impediment. He next cut the deep adherent muscles on a level with the surfaces of those loose ones which had been divided in the first in- cision, and which had now attained their utmost state of retraction. In this way he could evidently saw the bone very high up, and the painful dissection of the skin from the muscles was avoided. Louis was conscious that there was more necessity for saving muscle than skin ; and he knew that when an incision was made at once down to the bone, the retraction of the divided muscles always left the edge of the skin projecting a considerable way beyond them. Hence he deemed the plan of first saving a portion of skin by dissecting it from the muscles and turning it up, quite unnecessary. As the bone should always be sawed rather higher than the division of the soft parts, Louis, like J. L. Petit, and most other judicious surgeons, highly approved of the employment of a retractor. He was likewise the author of some valuable instructions for preventing the protrusion of the bone after the operation.— (See M6m. de I’Acad. de Chir. t. 2, p. 268 — 410, &c. 4to.) The im- partial reader, who takes the trouble to read the remarks on amputation published by this greatest of all the French surgeons of the last century, with the excep- tion perhaps of J. L. Petit and Desault, will be im- pressed at once with the force and perspicuity of his matter, and with the evident propriety of a good deal of the practice inculcated. In England, Cheselden, and not J. L. Petit, is re- garded as the surgeon who revived Celsus’s method, by proposing to divide the soft parts by a double incision, that is, by cutting the skin and cellular substance first, and then, by dividing the muscles down to the bone, on a level with the edge of the skin, so that the bone miuht be sawed higher up, and its end be more com- 56 AMPUTATION. pletely covered with skfn. Wliether Cheselden had the priority in this impiovement, I cannot presume to say ; but he gave an account of it in Gataker’s transla- tion of Le Dran’s treatise on the operations, as early as 1749, which was long prior to the appearance of Petit’s posthumous writings ; and Mr. Cheselden farther men- tions, that during his apprenticeship to Mr. Fern he had communicated to that gentleman his sentiments about the double incision. In order to hinder the stump from assuming a pyra- midal or sugar-loaf shape, which sometimes happened notwithstanding every improvement hitherto men- tioned, a circular bandage was employed, which acted by supporting the skin and muscles, and preventing their retraction. This handage, when properly applied, from the upper part of the limb dowinvard, fulfilled in a certain measure the end proposed, though many stumps yet tunied out very badly. Mr. Stiarp was in- duced, therefore, to revive the ancient plan of bringing the edges of the skin together with sutures ; but the pam and other inconveniences of this method were such that it was never extensively adopted, and Mr. Sharp himself ultimately abandoned it. The cro.s.s- I bandage, however, which he used to put over the end of the stump, remains in fashion even at the jiresent day. — (Treatise on the Oiier. p. 210 , Critical Inquiry, p. 268.) It is to be regretted that an excellent modern surgeon, the late Mr. Iley, should have commended so much as he has done the use of sutures, in bringing to- gether the edges of the wound alter amputation. — J’rac- tical Observations in Surgery, p. 534, edit. 2.) in opposition to Louis, fhe inefiiciency of his method for hindering the protrusion of the bone was as.serted by Valentin, who thought the object might be better at- tained by dividing the parts while they were in a state of tension ; for which purpose he recommended chang- ing the posture of the limb, according to the parts which he was about to cut. — Recherches Critiques sur la Chirurgie Modeme, 8vo. Amst. 1772.) Valentin’s proposal seems never to have made much impre.ssion on the profession ; whether on account of its incon- venience or inelficacy, I know not ; certain it is, many cases present themselves, in which the posture of a limb absolutely cannot be changed during the operation, owing to the nature of the disease, -or cannot be altered xvithout extreme agony. At this period arose the celebrated controv ersy about the propriety of amputation in general. As Sprengel remarks, several French surgeons now began to be convinc^, with Le Dran and Bagieu, that the operation was undertaken on too slight grounds, and in parti- cular that many bad complicated fractures might be cured without amputation. Such was the doctrine of Boucher (Mem. de I’Acad. de Chir. t. 2, p. 304), Ger- vaise (Anfangsgr. der Wundarzn. 8vo. Strasb. 1755), and Faure iM6m. qiti out concoum pour le Prix de I’Ac. de Chir. vol. i, p. 100). The latter especially urged the prudence of delay in gun-shot wounds, and comminut^ injuries of the bones. But the writer who at this time made the most noise in the world by his general condemnation of amputation, was Bilguer (Diss. de Membrorum Amputatione, 8vo. Hal. 1761), whose sentiments received a complete refutation from his own contemporaries, Pott (Chir. Works, vol. 2;, Morand (Opusc. de Chir. t. 1, p. 232), and de La Mar- tini^re (Mem. de I’Acad. de Chur. vol. 4, p. 1), and also from later writers, to whom reference will be made in speaking of Gun-shot Wounds. Even Bilguer himself was compelled to admit the necessity of amputation in cases of gangrene. — (Anweis. fiir die Feldwundarzie, 8. 170.) Bilguer’s colleague, the celebrated Schmucker, in- clined to the same doctrines, and has detailed several cases, where limbs were not only shattered, but actu- ally carried away by balls, yet where a cure followed xvithout amputation. One of his maxims was, that it was better for the member to be taken off by gun-shot than by the surgeon’s knife, as the ball operated on a healthy subject, and the knife on a person debilitated by an hospital. — (Chir. Wahrn. th. 2, s. 493.) In a later valuable essay on this subject, he restricts amputation to shattered limbs affected with gangrene. His mode of operating was that of M. Louis. He sanctioned joint-operatiotmi on the hip and shoulder; but con- demned those of the knee and elbow as never answer- ing. — (Verm. Schrift. th. 1, s. 3.) Soon after the middle of the last century, the prac- tice of amputating at the joints began to excite Increased attention ; but as this is a topic to wliich I must pre sently return, it is unnecessary now to dwell upon it The writings of Ihithod, Wohler, Brasdor, Barbet, Sa- batier, Park, Moreau, and Vennandois, in relation to tliis subject, deserve particular notice. I now come to Mr. Alanson, whose name is as con- spicuous in the history of amputation as that of any surgeon yet mentioned. His chief objects were to hin- der a protrusion of the bone, and to promote union by the first intention. He rejectt*d the band which was formerly put round the limb for the guidance of the knife, as altogether useless, and an impediment to the quick performance of the circular incision through the skin. Wlien the tourniquet had been applied, an as- sistant grasped the integuments with both bands, and drew them and the muscles firmly upwards. The ope- rator then fixed his eye upon the proper part where he was to begin the incision, which was made with consi- derable facility and despatch, the knife passing xvith greater quickness in consequence of the tense state of the integuments. After the incision through the skin had been made, the assistant still continued a steady support of the parts, while Mr. Alanson separated the cellular and ligamentous attachments xvith the point of his knifie till as much skin had been drawn up as would, with the muscles divided in the particular way hereafter recom- mended, fully cover the whole surface of the wound. Then, instead of appljing the knife close to the edge of the integiunents, and dividing the muscles in a circular perjiendicular manner down to the bone, Mr. Alanson proceeded as follows : when operating upon the tnigh, and standing on the outside of the limb, he applied the edge of his knife under the edge of the supported inte- guments, upon the inner margin of the vastus intemus muscle, and cut obliquely through that and the adja- cent muscles upwards as to the limb, and down to the bone, so as to lay it bare about three or four finger- breadths higher than is usually done by the common perpendicular circular incision. He now drew the knife towards himself ; then keeping its point upon the bone, and the edge in the same oblique line already jiointed out for the former incision, he divided the rest of the muscles in that direction all round the limb ; the point of the knife being in contact with and revolving round the bone through the whole of the division. According to Mr. Alanson, the speedy execution of the above-directed incision will be much expedited by one assistant continuing a firm and steady elevation of the parts, and another taking care to keep the skin from being w’ounded as the knife goes through the muscles, at the under part of the limb. Mr. Alamson censures the old method of depriving the bone of its periosteum to a considerable extent above and below t’...e part where the saw was to pass, not only as creating unnecessary delay, but, since the periosteum serves to support the vessels in their passage to the bone, as apt to produce exfoliations above the part where the bone is to be di- vided with the saw. Instead of this practice he re- commends first the application of the retractor, as ad- vised by Gooch and Bromfield ; and then denuding the bone at the part w here the saw is to pass, whereby the bone may be sawed off higher than is usually practised ; a material object for hindering a projection of the bone and forming a small cicatrix. If the flesh of a stump formed in the thigh agreeably to the foregoing plan, be gently brought forwards after the operation, and the surface of the wound be then viewed, it may be said to resemble in some degree a conical cavity, the apex of which is the extremity of the bone; and the thus divided Mr. Alanson thought the best calculated to prevent a sugar-loaf stump. The part where the bone is to be laid bare, whether two, three, or four Anger -breadths higher than the edge of the retracted integuments ■; or, in other words, the quantity of muscular substance to be taken out in mak- ing the double incision, must be regulated by considerr ing the length of the limb, and the quantity of skin that has been previously saved by dividing the membranous attachments. The quantity of skin saved, and muscu- lar substance taken out, must be in such exact propor- tion to each other, that the whole strrface of the wotmd w'ill afterward be easily covered, and the limb not more shortened than is necessary to obtain this end. After the removal of the limb, Mr. Alanson drew each AMPUTATION. 57 bleeding artery gently out ■with the tenaculum, and tied it as nakedly as possible with a common slender liga- ture. When the large vessels had been tied, the tour- niquet was immediately slackened, and the wound well cleaned, in order to detect any vessel that might other- wise have remained concealed with its orifice blocked up with coagulated blood ; and before the wound was dressed, its whole surface was examined with the great- est accuracy ; by which means Mr. Alanson frequently observed a pulsation where no hemorrhage previously appeared, and turned out a small clot of blood from within the orifice of a considerable. artery. He is very particular in recommending every vessel to be secured that is likely to bleed on the attack of the s)Tnptomatic fever ; for, besides the fatigue and pain to which such an accident immediately exposes the patient, it seriously interrupts the desired union of the wound. He used always to clean the whole surface of the wound well with a sponge and warm water, as be thought that the lodgement of any coagulated blood would be a consider- able obstruction to the quick miion of the parts. The skin and muscles were now gently brought for- wards ; a flannel roller was put around the body, and carried two or three times rather tightly round the upper part of the thigh, as at this point it was intended to form what Mr. Alanson called a sufficient basis, which materially added to the support of the skin and muscles. The roller was then carried down in a cir- cular direction to the extremity of the stump, not so tight as to press rudely or forcibly, but so as to give an easy support to the parts. The skin and muscles were now placed over the bone in such a direction that the wound appeared only as a line across the face of the stump, with the angles at each side, from which points the ligatures were left out, as their vicinity to either angle might direct. The skin was easily secured in this posture by long slips of linen or lint of the breadth of about two fingers, spread with cerate or any cooling ointment. If the skin did not easily meet, strips of sticking-plaster were preferred. These were applied from below upwards, across the face of the stump, and over them a soft tow-pledget and compress of linen; the whole being retained with the many-tailed bandage, and two tails placed perpendicularly, in order to retain the dressings upon the face of the stump. Mr. Alanson censured the plan of raising the end of the stump far from the surface of the bed with pillows, as the posterior mhscles were retracted by it ; and he considered it best to raise the stump only about half a hand’s breadth from the surface of the bed, by which means the muscles were put in an easy relaxed posi- tion. The many-tailed bandage Mr. Alanson found much more convenient than the woollen cap, frequently used in former times to support the dressings ; and he observes, that though thi,s seems well calculated to an- swer that purpose, yet if it be not put on with particu- lar care, the skin is liable to be drawn backwards from the face of the stump ; nor can the wound be dressed without first lifting up the stump to remove the cap.— (See Alanson’s Tract. Obs. on Amputation, 8vo. Lond. 1779.) The chief peculiarity of Alanson’s method of ope- rating, namely, the mode in which he recommended the oblique division of the muscles to be performed, did not, however, meet with universal approbation, and his extensive dissection of the skin from the muscles was complained of as excessively painful. The forma- tion of a conical wound by following Alanson’s direc- tions, was regarded by several as impracticable. — (See Marten’s Paradoxieen, b. 1, s. 88; Loeffler, Beytrage 1, No. 7 ; Wardenburg, Briefe eines Arztes, b. 2, p. 20 ; Richter, Anfangsgr. vol. 7 ; Graefe, Normen, &c. p. 8 ; Hey, Pract. Obs.) In my opinion there can be no doubt of the truth of some of the criticisms made by these and some other writers on the impossibility of making a wound with a regular conical ca-vity, by ob- serving the directions given by Alanson; for if the knife be carried round the member with its edge turned obliquely upwards towards the bone, it -will pass spi- rally, and of course the end of the incision will be con.si- derably higher than the beginning. But though Alanson probably never did himself exactly what he has stated, 1 am sure that his proposition of making an oblique division of the muscles all round the member has been the source of great improvement in amputations iti general, and is what is usually aimed at by all the best mode/n surgeons. It is true they do not actually per- form the oblique incision all round the limb by one stroke or revolution of the knife round the bone, as Alanson says that he did ; but they accomplish their purpose by repeated, distinct, and suitable applications of the edge of the instrument turned obliquely upwards towards the bone or bones. Among others, Mynors found fault with some of Alan- son’s instructions, and thought every desideratum might be more certainly attained by saving skin enough, and then cutting through the muscles. The first inci- sion, however, he directed obliquely upwards through the integuments, wiiilo they were drawn up by an as- sistant, and he then cut down to the bone. — (Pract. Thoughts on Amputation, 8vo. Birming. 1783.) Spren- gel considers Mynors’s plan merely as a revival of Cel- sus’s method, as it had in view only the preservation of skin, and not the formation of a fleshy cushion. — (Geschichte der Chir. b. 1, p. 426.) Kirkland endeavoured to improve Mynors’s plan by cutting off a piece of skin at each angle of the stump, so as to keep the integuments from being thrown into folds ; and in opposition to Pott, he defended the .senti- ments of Bilguer concerning the successful manage- ment of desperate cases without amputation. — (On the present State of Surgery, p. 273, and Thoughts on Am- putation, 8vo. Lond. 1780.) B. Bell used to operate very much in the same way as Mynors ; and when it seemed advantageous to make a flap, he did not disapprove of the plans suggested by Ravaton, Verduin, and Alanson. — (Syst. of Surgery.) An interesting paper on amputation was some years ago published by Loder ; its chief purport was to de- fend Alanson’s method -with some slight modifications. —(Chir. und Medic. Beobacht. b. 1, p. 20, 8vo. 1794.) However, the alterations suggested by Loder do not seem to Graefe at all adequate to the removal of the difficulties with which the mode of cutting the flesh ex- actly after Alanson’s directions is complicated. — (No6- men fiir die Abl. grosserer Gliedmassen, p. 8, 4to. Ber- lin, 1812.) The removal of limbs, without bloodshed, proposed by Guido di Cauliaco in the 14th century, has met with modern defenders in J. Wrabetz and W. G. Plouquet. J. Wrabetz, with a ligature, which was daily made tighter, took off an arm above the elbow. In the fissure he sprinkled a styptic powder. On the fourth day, the flesh was severed down to the bone, which was sawed through. — (Geschichte eines ohne Messer abgesetzten Oberarms, 8vo. Freyb. 1782.) Plouquet thought the plan suited to emaciated timid subjects, but not well adapted to the leg or forearm. — (Von der Unblutigen Abnehmung der Glieder, 8vo. Tub. 1786.) Some other modes of doing flap-amputations, and in particular the suggestions and improvements made by Hey, Chopart, Dupuytren, Larrey, Lisfranc, and other modern practitioners, will be noticed in the description of the amputation of particular members. In the mean time, I shall conclude this section with mentioning the laudable attempts made at different periods to render the patient less sensible of the agony produced by the removal of a limb. Theodoricus, as we have said, ad ministered for this purpose opium and hemlock, and though he was imitated by many of the ancient sur- geons, few moderns have deemed the practice worthy of being continued. Guido made the experiment of benumbing the parts with a tight ligature ; but a ma- chine devised a few years ago in England expressly for the object of stupifying the nerves of a limb pre- viously to amputation, is perhaps not undeserving of farther consideration. — (See J. Moore’s Method of pre- venting or diminishing Pain in several Operations of Surgery, 8vo. Lond. 1784.) The great reason of the latter plan 'being given up is, that some patients have made more complaint of the sufferings occasioned by the process of dulling the sensibility of the nerves than of the agony of amputation itself without any such ex- pedient. Yet daily experience proves that the pressure caused on the sciatic nerve by sitting with the pelvis in a certain position, will completely benumb the foot and leg, and this with such an absence of pain, that the person so affected is actually unaware of his foot being asleep, as it is termed, until he tries to walk. On the little good done by warming and oiling the cut- ting instruments, a method once much commended (Faust und Hunold fiber die Anwendung des Oehls und der Warine, p. 3 — 23, Leipsic, 1806), I am sure it is un- necessary for uio to comment. 58 AMPUTATION. AMPHTATIOS OF THK THtOn. The thigh ought always to be amputated as low as the disease will allow, so that as little of the limb may be cut off as possible, the pain may not be greater than necessary, and the surface of the wound have less ex- tent than would otherwise happen. — Sabatier, Med. Obs. p. 350, t. 3, ed. 2.) The patient is to be placed on a firm table, with his back properly supported by pil- lows and assistants, who are ^so to hold his hands, and keep him from moving too much during the ojie- ration. The ankle of the sound limb is to be fastened by- means of a strong band or garter to the nearest leg of the table. Here, how'ever, through an imprudent solicitude to obtain the above advantages, let not tlie surgeon ever be unmindAil of the great axiom in surgical operations, that all the diseased jiarts should be removed; but let him be assured of the truth of what Graefe inculcates, that it 18 more pardonable to cut away too much than too little. — i.Normen fiir die Abldsung grdsserer Gliedm. p 60.) At the same time, I do not agree with some modern writers, who deem it necessary to amputate beyond the limits of every abscess and sinus, wliich may extend very far above a diseaseil joint or compound fracture. Many of these suppurations are only like ordinary abscesses, and finally gel well aAer the main disease or injury is removed, as I have often seen. Were it an invariable rule to cut off a limb above every collection of matter, sometimes five or six inches more of the thigh -would be sacrificed than circumstances absolutely demanded, and the greater danger of a high than a low amputation would be encountered. How- ever, in all cases where the bone is susjiected to be un- sound, or the muscles are affected with the morbid changes peculiar to fungus htematodes or other incurable diseases, the operation should be practised sulficiently high to take aw ay all the distem}»ered pans. In second- ary amputations, where there has been much suppura- tion in the limb, an^ i sinus runs up, Mr. Guthrie says, that if the sinus extend only a short way between the muscles, the membrane lining it may be dissected out ; but if the matter has lain upon the bone, this will have become diseased, and amputation should be done high enough to remove the affected part of it. — (On Gun-shot Wounds, p. 67.) Many writers disapprove of amputating too close to the knee (Graefe, Op. cit. p. 60) ; and Langenbeck urges one objection to it not specified by any other author, viz. that if the operation be done lower dow n than tw'o hand-breadths above the knee, the femoral artery shrinks into the aponeurotic sheath, which it here receives from the vastus internus and triceps, and cannot be drawn out with the forceps, so as to be separately tied, without first slitting up that sheath. Hence, he recom- mends cutting through the muscles at the distance above the knee already mentioned. — (Bibl. flirdie Chir. b. 1, p. 571, 12mo. Gott. 1806.) But w hen I come to look at the breadth of two adult hands, and see how much of the limb would be sacrificed at all events, only to save a little trouble, 1 cannot bring my mind to concur with Langenbeck — the remedy being worse than the alleged evil. The next tlung is the application of the tourniquet. — (See Tourniquet.) The pad should be placed exactly over the femoral artery in as high a situation as can be conveniently done. When the tliigh is to be ampu- tated high up, it is better to let an assistant (impress the femoral artery in the groin wath any commodious instrument, furnished with a round blunt end, calcu- lated for making direct pressure on the vessel without injuring the integuments. Some authojs indeed give a general preference to this method, whether the thigh be amputated high up or low down. — (Paroisse, Opus- cules de Chir. p. 188. Briinninghause^ Erfahr. fiber die Amp. p, 273. Langenbeck, Bibl. Chir. p. 564. See also Liston’s Obs. in Ed. Med. and Surg. Joiim. vol. 20, p. 43.) Were the-patient, however, in a debilitated state, and unable to bear loss of blood, as there might, in this way, be some considerable bleeding, by reason of the anastomoses with the branches of the internal iliac artery', I should feel disposed to employ the tour- niquet whenever circumstances would admit of its application. In amputations of the thigh, the great objection to the use of this instrument is, that it im- pedes the free and immediate retraction of the loose muscles after they have been cut ; the consequence of which is, that the surgeon cannot divide so high as he otherwise could do, the deeper muscles which are more fixed and attached to the bone. Yet in order to have the bone well covered with flesh, and no danger of a sugar-loaf stump, the latter object is one of vast im- portance. Perhaps the best general rule is to abandon the application of the tourniquet in amputations done a.s high as the middle of the thigh, except where the patient is remarkably weak, so that he cannot bear the smallest loss of blood, and no steady intelligent assist- ant is at hand, to w hom the compression of the artery in the groin can be prudently confided. When, how- ever, the operation is to be done much higher up, of course the employment of a tourniquet is wholly inad- missible. \N hether the right or left thigh is to be removed, it is customary for the operator to stand on the patient’s right side. The great advantage of this situation seems to be, that the surgeon’s left hand can be thus more conveniently and quickly brought into use than if he were always to stand oil the same side as the limb he is about to amputate. This seems to be the only as- signable reason for this habit ; for w hen the left thigh is to be amputated, it is certainly some inconvenience to have the right limb between the operator and the one that is to be removed. But this is found less inconve- nient than not ha-ving the left hand next the wound. Mr. Guthrie, in speaking of amputations on the two lower thirds of the thigh, observes, that “ in these cases the tourniquet should be used but in ope- rations high up the thigh, he joins all other surgeons in recommending the inguinal artery to be compressed against the os pubis. — (On Gun-shot Wounds, p. 202.) The utility of slackening the tourniquet completely, however, as soon as the principal vessels are secured, a piece of advice delivered by this excellent surgeon, I presume, cannot be right on the ground which he spe- cifies, vi/. the impediment made by the strap of the in- strument to the retraction of the muscles, and the con- sequent difficulty in high operations of sawing the bone, because in common practice the bone is always sawed before any of the vessels are secured ; and loos- ening the tourniquet entirely, while any arterial branches still require the ligature, must generally be objectionable, if loss of blood be a disadvantage. In flap-amputations high up the limb, indeed, where the arteries are sometimes tied, before the division of the bone, the employment of a tourniquet at all is quite out of the question. We know that it was an opinion of the late Mr. J, Bell, that the flow of blood through a large artery could not be cwnpletely stopped by pressure ; and the late Mr. Hey adopted a similar notion, in consequence of seeing a case in w hich the application of two tour- niquets to the thigh did not restrain the hemorrhage from a fungus haimatodes of the limb. He says, the pressure of the tourniquet does not completely obstruct the passage of blood in the arteries ; it only diminishes so much of the force of the current as to enable the vessels, in a sound state, to exert their natural con- tractile power so effectually tis to prevent hemorrhage, (See Hey’s Pract. Obs. p. 257, 258, ed. 2.) Of the inac- curacy of this doctrine no man can doubt, who sees the femoral artery with its open mouth on the face of a stump not blee^ng, while the tourniquet is tight, or skilful pressure is kept up, but throwing out its blood to a great distance the instant the pressure is disconti- nued. Nor, I apprehend, can any surgeon, who has amputated at the shoulder, and seen how completely pressure commands the flow of blood through the open- mouthed axillary artery, join in the sentiment of John Bell and Hey upon this particular point. Here I can speak with confidence, because I have myself ampu- tated at the shoulder, and assisted at this operation seve- ral times, and found the statements of the preceding writers perfectly and clearly contradicted. Were any farther testimony required, I might cite that of Dr Hennen, who mentions, among other facts, that in a shoulder-joint case, operated upon by Mr. Dease, the amount of blood lost from the principal artery was no more than the quantity contained between the point of pressure and the point of incision through the ves- sels.— (Principles of Military Surgery, p, 257, ed. 2.) The same fact presented itself in the example, where I recently assisted Dr. Biicke in private practice. Mr. Liston, of Edinburgh, confirms the preceding statement, observ'ing that pressure complete enough not only to stop the pulsation of an artery in a limb, AMPUTATION. 69 but also to arrest completely the flow of blood, can be easily applied by means of the fingers only. And, in or- der to prove the correctness of this remark, he has re- peatedly, when no proper assistant was at hand, com- pressed both the femoral and humeral arteries with the fingers of one hand, while with the other hand he re- moved the limb, and this, as he affirms, with the loss of much less blood than if he had followed the ordi- nary mode. His common practice, however, is to let the pressure be made by an assistant, and to employ no tourniquet. — (See Ed. Med. and Surg. Journ. vol. 20, p. 44.) If, then, the flow of blood through an arterj' can easily be commanded by pressure, how are we to ex- plain the occasional continuance of bleeding, notwith- standing the pressure of one, or even two, tourniquets ? Without doubt, by the fact that the pads of these in- struments, when not duly arranged, do more harm than good, by raising the band off the vessel, and per- haps also, in Mr. Hey’s example, by the additional con- sideration, that tumours of the fungus haematodes kind include a large quantity of blood, and will bleed pro- fusely, and for a considerable time, after the main sup- ply of blood to them is cut off. The same thing hap- pens in the disease called aneurism by anastomosis, as I have had several opportunities of witnessing, but in no instance more strikingly than in one, where, some time after Mr. Hodgson had tied the radial and ulnar arte- ries, Mr. Latvrence divided every part of the finger, excepting the tendons and bone, and yet a considerable bleeding went on from the farther side of the wound. — (See Med. Chir. Trans, vol. 9, p. 216.) The application of the tourniquet is generally left too much to assistants ; but, as far as my judgment ex- tends, no operator is justified in commencing his inci- sions before he has examined, and fully satisfied him- self that the instrument is correctly applied. Mr. Guthrie candidly tells us, that he once lost an officer, in consequence of hemorrhage during the operation, although the tourniquet was in the charge of a sur- geon of ability ; and the advice with which he follows this statement is worth recollecting : “ In a case of this kind, where it (the tourniquet) is found of little benefit, the surgeon should not continue twisting and turning it, while his patient is bleeding, but quit it altogether, and compress the artery against the pubes.” This maxim, I think, cannot be too highly commended. The shape and size of the pad of the tourniquet are matters of importance. At St. Bartholomew’s, the pads employed are very firm, being composed of wood, or cork covered with leather, and rather thicker than the thumb, the upper surface being flat, and the lower, which is put against the thigh, being convex. They are about an inch and a half in length. Such pads an- swer extremely well, as I can affirm from the observa- tion of some hundreds of amputations in that hospital. A common fault formerly was the employment of pads which were too large and soft, and not judiciously shaped. As Mr. C. Hutchison remarks, the principal objection to a large pad is, that the band of the tourni- quet is so much raised by it, that a considerable space is left on each side of it, where no compression is made on the limb, however closely the instrument may be screwed, and thus there will be a risk of hemor- rhage from such vessels as happen to be in these situa- tions. The same gentleman uses a pad which is not thicker than a finger, and places it obliquely over the artery, so as to preclude the possibility of displace- ment. — (Pract. Obs. in Surgery, p. 21 — 23.) Mr. Guth- rie says, “ the pad should be firm and rather narrow, and carefully held directly over the artery, while the ends of the bandage in which it is contained, are pinned on the thigh. The strap of the tourniquet is then to be put round the limb, the instrument itself being directly over the pad, with the screw entirely free. The strap is then to be drawu tight, and buckled on the outside, so as to prevent its slipping, and not interfere with the screw, which is to be turned until the pres- sure is sufficiently forcible to stop the circulation. If the screw require to be turned for more than half its number of turns to effect this, the strap is not suffi- ciently tight, or the pad has not been well applied, and they must be replaced.”— (On Gun-shot Wounds, p. 204.) In two amputations at St. Bartholomew’s Hospital, I saw the tourniquet break after the soft parts had been divided, and as in one of these cases a good deal of blood was lost, because another tourniquet happened not to be in the room, and i)ressure on the artery in the groin was not immediately adopted, I coincide with such writers as recommend the rule of always having two tourniquets ready. Graefe even goes so far as to advise putting both of them round the limb before the operation commences (Normen ftir die Ablosung gros- serer Gliedmassen, p. 48) ; but the frequency of a tour- niquet breaking is not so great, I believe, as to demand such precaution, and the plan would be very objectiona- ble in thigh-amputations, where it is a material advan- tage to have plenty of room between the place of the incision and the band which goes round the limb. An assistant, firmly grasping the thigh with both hands, is to draw up the skin and muscles, while the surgeon, beginning with that part of the edge of the knife which is towards the handle, makes a circular incision as quickly as possible, through the integu- ments down to the fascia, or, as Mr. Guthrie and Dr. Hennen recommend, even completely through it. Ac- cording to Mr. Guthrie, the skin cannot be sufficiently retracted, unless the fescia be divided, which he ap- pears to think ought rather to be drawn up with the in- teguments than dissected from them. — (On Gun-shot Wounds, p. 205. Also, Hennen’s Military Surgery, p. 263.) On the contrary. Professor Langenbeck is very particular in enjoining surgeons to avoid cutting through the fascia by the first sweep of the knife, be- cause he finds that the muscles are better held together, and can be more regularly divided, by cutting them and the fascia at the same time. — (Bibl. fur die Chir. b. 1, p. 004.; Nor does M. Roux divide the fascia by the first incision. — (M6m. sur la Reunion immddiate de la Plaie apr^s I’Amputation circulaire, p. 9, 8vo. Paris, 1814.) At St. Bartholomew’s, the surgeons rarely or never cut through the fascia with the integuments, but aim at carrying the knife perfectly down to it all round the limb. This at least ought to be done without fear of doing rather more ; for, as Graefe observes, if the outer layers of the muscles be here and there a little touched, this occasions less pain than the additional strokes of the knife for dividing any portion of the skin and cellular substance not completely cut through in the first instance. Graefe also dissents from My- nors and others, who are advocates for cutting the skin obliquely instead of perpendicularly, because he finds the thin edge of the integuments thus separated from the subjacent cellular membrane, very apt to slough. — 'Normen fiir die Abl. grosserer Gliedmassen, p. 102.) In a thigh of ordinary dimensions, the first incision should be made four inches below where it is intended to saw the bone. When the thigh is bulky, the large amputation knife will be found the best. Be- fbre beginning this first cut, the arm is to be carried under the limb, till the knife reaches almost round to the side on which the operator stands. With one sweep penetrating at least to the fascia, the knife is then to be brought round to the point where it first touched the skin. Thus, the wound is more likely to be regularly made, than by cutting first on one side, and then on the other, while the patient is saved some degree of pain, in consequence of the un- interrupted quickness with wliich the incision is made. At the same time, I ought to confess, that the late Sir C. Blicke, and some other surgeons, whom 1 have seen operate, used to complete the circle by two strokes of the knife, so well and expeditiously, that their capri- cious attachment to this plan could hardly be found fault with. The next object is the preservation of as much skin as will afterward, conjointly with the muscles, cut in an oblique direction, cover the end of the stump with the utmost facility. It is rather difficult to lay down any other general principles for the guidance of the surgeon in saving integuments. I am disposed to agree with several modern w'riters, that the painful dissection of the skin from the muscles has been re- commended and practised to a very unnecessary extent, that is to say, unnecessary if the division of the mus- cles be performed in the most advantageous manner. Graefe, one of the best surgeons at Berlin, does not dissect the skin from the muscles at all in amimtating the thigh, but takes care, after making the cutaneous incision, to have the integuments and subjacent flesh very firmly drawn up before commencing the oblique division of the muscles. ’I’his retraction he also strongly advises to he done uniformly and smoothly all round 60 AMPUTATION. the member, lest in dividing the muscles any irregular projection of the skin interfere with the requisite move- ments of the knife. — (Normen fiir die AbL griisse- rer Gliedmassen, p. 103.) Instead of dissecting back the skin, Dupuytren cuts all the soft parts at once to the bone, which he next removes, after retracting the muscles. — Syme, in Edinb. Med. and Surg. Journal, voL 14, p. 32.) Ilowever, Langenbeck, another of the most skUfttl operators on the continent, prefers detach- ing the integuments from the ftiscia for about two tin- ger-breadths (Bibl. fur die Chir. b. 1, p. 567), as is per- haps the most common practice in the London hospi- tals. Some late writers, particularly Mr. Syme, in ex- pressing their preference to muscle as a covering for the end of the bone, seem to forget one fact which I have often noticed, viz. that the muscular cushion, though at first thick and good, soon shrinks to a com- paratively small mass. This is con.sonant to a general law in the animal economy, prevailing whenever the natural action of a muscle is lost or prevented. Sir Astley Cooper states, that the covering for the end of the bone must be integuments and not muscles ; for if muscular fibres are preserved with the integuments they will contract, and retraction of the skin covering the stump will be the result. — Lancet, vol. 1, p. 148., Briinninghausen also thinks skin a better and more durable covering for the end of the bone than muscular fibres, which after a time dwindle away ; and hence he computes the quantity of integuments which ought to be saved, by the measure of the circumference and dia- meter of the member. Thus, when the limb Is nine inches in its circumference, the diamcici in ntiuui three ; therefore, one inch and a half of skin on each side is to be saved.— (Erfahr. &,c. iiber die Amp. p. 75.) But this atithor cuts the muscles perpendicularly, so that he is obliged to separate much more skin from the flesh than is necessary when the incision through the mus- cles is carried obhquely upward.^. Mr. Iley’s method of calculation, which I shall presently notice, appears more adapted to ordinary practice ; and he says, “ the di^ ision of the posterior muscles may be begun at half an inch, and that of the anterior at three quarters, above the place where the integuments were divided.” — (Pract. Obs. in Surgery, p. 528, ed. 2.) With the view of preventing the necessity of dissecting the skin from the fascia, Mr. Guthne, as already noticed, commends the plan of cutting through the fascia, together with the integuments, by the first stroke of the kinfe, and re- tracting these parts at the same time, instead of de- taching them from each other. If this method be found perfectly efficient, and it be not objectionable, as ex})Os- ing the muscles to be cut unnecessarily, I think the reason specified against it by Langenbeck, and ex- plained in a preceding page, not weighty enough to form a just ground for rejecting a practice which comes with the alleged advantage of superseding the neces- sity for all painful dissection of the skin from the muscles. However, in secondary’ amputations of the thigh, if the integuments be unsound and will not re- tract, Mr. Guthrie approves of their being dissected back to an equal distance all round. — (On Gun-shot Wounds, p. 205 — 208.) Dr. Hennen, by gi\’ing an oblique direction to all the incisions through the mus- cles, obviates the necessity for much dissection of the integuments, and he says that in a small limb he has repeatedly performed the operation with one sweep of the knife, cutting obliquely inwards and upwards at once to the bone.— (Principles of Mihtary Surgery, p. 265, ed. 2.) This author, like Mr. Guthrie, also recom- mends carry’ing the knife through the fascia in the first circular incision ; and so does Mr. C. Hutchison, who makes no mention of dissecting back the skin, but simply states, that the “ integuments and fascia being divided by a circular incision, and retracted upwards as high as is judged necessary’, the superficial muscles should next be divided,” &c. — (Pract. Obs. in Surgery, p. 23, 8vo. Lond. 1816.) We are therefore to conclude, that he joins Graefe and others in thinking the separa- tion of the skin from the fascia unnecessary. My own observations in practice lead me to believe, that the dis- section of the integuments from the subjacent parts used formerly to be carried to an extent beyond all mo- deration and necessity, and that, as it is a most painful proceeding, and hurtful by forming a large loose pouch for the lodgement of matter, it ought to be abandoned by every surgeon who follows the method of sawing the bone considerably higher than the first cut through the superficial muscles. I am not, however, prepared to assert, that no dissection at all is generally requisite, but am rather disposed to believe the moderate adop- tion of it, as recommended by Mr. Hey. the most pru- dent. This gentleman, like Desault (CEuvres Chir. t. 21, p. 545), is an advocate for amputating with a triple incision, and for preserving such a quantity of muscular flesh and integuments as arc proportionate to the dia- meter of the limb. By a triple incision, he means first an incision through the integuments alone ; secondly, an incision through all the muscles, made somewhat higher than that through the integuments ; and thirdly, another incision through that part of the muscular flesh which adheres to the bone, made round that point of the bone where the saw is to be applied. The proper distance of these incisions from each other, he says, must be determined by the thickness of the limb upon which the operation is to be performed, making allow’- ance for the retraction of the integuments, and of those muscles which are not adherent to the bone Supposing the circumference of the limb to be twelve inches where the bone is to be divided, the diameter is about four inches, and if no retraction of the integuments were to take place, a sufficient covering of the stump would be afforded by making the first incision at the distance of two inches from the place where the bone is to be sawed, that is, at the thstance of the semi-dia- meter of the limb on each side. But as the integu- ments, when in a sound state, always recede after they are divided, it is useful to make some allow’ance for this recession ; and to make the first incision in this case at least two inches and a half or three inches below the place where the bone is to be sawed. As the posterior muscles of the thigh retract a great deal in the process of healing, Mr. Hey advises their division to be begun half an inch above the place where the integuments were cut, and the anterior muscles three quarters of an inch. The integuments, says he, will retract a lit- tle both above and below the place where they were di- vided ; but the distance from that place must be com- puted from the mark left upon the surface of the mus- cles in dividing the integuments. Thus, in fact, in a common thigh-amputation, Mr. Hey deemed it neces- sary to detach the skin from the muscles merely to the extent of half an inch at the back part of the limb, and of three quarters in front ; a very different practice from the old custom of making quite a bag of integu- ments, and turning them back as the upper piece of a glove is turned down, or rather as the sleeves of a coal are turned up. In common amputations of the thigh, Roux strongly disapproves of separating the skin far from the muscles, as a circumstance highly unfavourable to the healing of the wound by adhesion ; he divides only a few of the cellular bands between the integuments and fascia ; and occasionally he has imitated M. Louis in cutting through the skin and superficial muscles together. — (Mem. sur la Reunion de la Plaie apres 1’ Amputation, &c. p. 9.) I believe the generality of the best modem operators are now con\’inced of the impropriety of dividing the muscles exactly in the manner directed by Mr. Alanson, viz. by letting the knife revolve unintenuptedly all round the bone, with its edge turned obliquely upw’ards tow’ards the point w’here it is intended to apply the saw. It is a topic, indeed, to which I have already called the reader’s attention in the foregoing columns. Langen- beck says, that he is perfectly convinced of the impos- sibility of forming a conical wound with one stroke of a large amputating knife, and joins Mr. Hey in approv- ing of the triple incision. — (Bibl. ftir die Chir. b. 1, p. 564.) The objections first urged by Wardenburgh against Alanson’s method are mathematically correct, inasmuch as the course of the edge of the knife, in this gentleman’s method, must be spiral, and the end of the incision be considerably higher than the begin- ning of it. Such must be the result of performing the division of the muscles all round the limb by one con- tinued stroke of the knife, w’ith its edge directed obliquely upwards ; for the idea of making the knife revolve in this manner while its point is confined to an imaginary’, regular, determinate circle on the bone, I believe, is now abandoned as not really practicable. Yet with the exception of Desault, who confined himself to the trinle incision conducted on the principles of M Louis (CEuvres Chir. t. 2,p. 547), few experienced sur- geons refuse to acknowl^ge, that in this operation im- AMPUTATION. 6 ( mense advantage does proceed .from the oblique divi- sion of the muscles, the honour of bringing which me- thod into practice Mr. Alanson still unquestionably merits, however he may have erred in recommending the conical wound to be made with one sweep of the knife. Nor are there many living surgeons who enter- tain a doubt of the excellence of the principle incul- cated by M. Louis respecting the utility of dividing the loose superficial muscles first, and then such as are deeper and adherent to the bone. In fact, a combina- tion of this last method with the oblique division of the muscles, not exactly by one but several strokes of the knife, constitutes the mode of amputating at pre- sent most extensively adopted, and sometimes termed, as already mentioned, amputation by a triple incision. Thus, after the skin is cut, and as much of it retracted and saved as is deemed necessary, the operater cuts through the loose muscles of the thigh at the edge of the retracted skin, first those on the fore part of the limb, and then such as are situated behind. For this purpose he makes two or more sweeps of the knife, as may be found necessary, carefully directing them obliquely upwards towards the point where he means to saw the bone. The oblique division of the muscles does not merely enable the operator to saw the bone higher up than he could otherwise do, and leaves at the same time more muscle for covering its extremity, but it is a preservation of sound, undetached integu- ments, which assuredly form the most efficient and durable covering to the stump. I say this without pre- cisely coinciding with Briinninghausen, who, trusting entirely to skin for covering his stumps, makes an extensive detachment of it from the muscles, and then cuts straight down to the bone. The loose muscles ac- tually cut through now retract considerably, leaving those which are deeper and attached to the bone in a condition to be cut higher up than could have been pre- viously done. Lastly, these are also to be divided with the edge of the knife directed obliquely upwards to- wards the place where the saw is to be applied. Some operators do more than this; for, alter cutting down to the bone, they follow the plan of Celsus, and detach the flesh from its whole circumference upwards with a scalpel, to the extent of about another inch, in order to be enabled to saw the bone still higher up. “ Inter sa- nam vitiatamque partem incidenda scalpello, caro usque ad 08 , reducenda ab eo sana caro, et circa os subse- canda est, ut eH quoque parte aliquid ossis nudetur.” This method, I think, deserves commendation, because it may have considerable effect in hindering a protru- sion of the bone, if it does not, in conjunction with the foregoing method of operating and judicious dressings, render this disagreeable event quite impossible. As long as I live, however, I shall never forget a poor sol- dier, whose thigh had been amputated in Bergen-op- Zoom, and who was brought about ten days after the operation into the military hospital at Oudenbosch, un- der my care. Not the slightest union of any part of the wound had taken place ; abscesses had formed un- der the fascia on every side of the stump ; the loose skin was literally a large bag of purulent matter ; the muscles were wasted to almost nothing, and their re- mains retracted and shrinking still farther away from the extremity of the bone, which protruded at least three inches beyond the soft parts. This unfortunate man had been attacked with chronic tetanus soon after the oj)eration, and probably it was to the disturbance of the stump by the effects of that disease, and to the strong and continual tendency of the muscles to retract thern-selves, induced by this state of the system, the deplorable state of the stump was to be attributed. He lingered nearly a fortnight in the hospital before he died ; previously to which event large abscesses, communi- cating with the hollow of the stump, surrounded the greater part of the pelvis. As I had every reason to believe that the ojieration had been skilfully done, per- haps when I say that the above mode of amputating will make a protrusion of the bone impossible, it is not exactly correct, as the occurrence may sometimes ori- ginate from causes which are quite independent of the particular way in which the operation has been ex- ecuted. 'I'he practice of detaching the bone from the circum- jacent flesh to the extent of about an inch, after the other principal incisions are completed, as advised by t.'elsus and Louis, I have sometimes seen done at St. Bartholomew’s Hospital, and have practised myself on other occasions, with the decided advantage of letting the bone be sawed higher up than could otherwise have been effected. Mr. Guthrie, after the incisions down to the bone, even recommends dissecting back the mus- cles from it “ for the space of two or three inches, as the size of the limb or other circumstances may re- quire but I should be reluctant myself to imitate the practice to this extent, though inclined to think most fa- vourably of it within more moderate limits. If we reckon that three inches of the member lie between the first circular cut in the skin and the place where the knife arrives at the bone, and then take away two or three inches more of the femur, it is clear that in many examples we should be getting very high up the limb, and if a detachment of the muscles from the bone to the extent of two or three inches were thus made, it would at all events be of no service unless the bone would admit of being sawed at this great distance from the termination of the oblique division of the muscles. However, if this were truly practicable (a point which I leave for others to discuss), it would certainly be con- sonant to the excellent general maxim laid down by J. L. Petit, that in amputation as much of the bone and as little of the flesh should be taken away as possible. — (See Traits des Mai. Chir. t. 3, p 150.) When this final detachment of the deep muscles from the bone is adopted, particular care, as Roux observes, should be taken al- ways to dmde the thick aponeurosis connecting the triceps to the linea aspera. — (M6m. sur la Reunion de la Plaie aprds 1’ Amputation, p. 10.) With respect to Desault’s method of amputating the thigh by a circular incision, already mentioned, he con- sidered turning the knife obliquely upwards quite unne- cessary : his plan v/as, to cut through the muscles, layer after layer, with the precaution of retracting the first stratum before he divided the second ; the latter was then cut through on a level with the flesh that had been previously divided and retracted, and so on down to the bone. This, says he, is the right way of forming a true hollow cone, of which the integuments, which were drawn up before the muscles were cut, form the base, from which are gradually continued the various layers of muscles, and the highest point of which is the bone itself. Desault owns, that this method is somewhat tedious and painful, but in his opinion, these disadvantages are more than counterbalanced by the benefits procured for the patient. — (CEuvres Chir. de Desault par Bichat, t. 2, p. 547.) All the muscular fibres, on every side, having been cut doAvn to the bone, a piece of linen, somewhat broader than the diameter of the wound, should be torn at one end, along its middle part, to the extent of about eight or ten inches. This is called a retractor, and is applied by placing the exposed part of the bone in the slit, and drawing the ends of the linen upwards on each side of the stump. In this manner, the retractor will obviously keep every part of the surface of the wound out of the way of the saw, Graefe thinks, that in am- putations of parts, where there is only one bone, the unslit portion of the linen should always be applied over the anterior muscles, as these ought constantly tch be most evenly kept back, so that no projection of them may interfere with the action of the saw. — (Normere fur die Ablosung grbsserer Gliedm. p. 105.) This is a preference, however, which may not be of great import- ance, though 1 confess that there appears some reason in what Graefe has stated. That meritorious surgeon,- J. L. Petit, whose name I always mention with plea- sure, strongly commends the use of the retractor, the ends of which he drew over the anterior muscles : he says that he has employed this simple and natural means, but that it did not suit the taste of every body^ especially of those who consider all the merit of an ojjeration to consist in the quickness of its performance, or who think it satisfactory reasoning to say, this is not their way.— (Traite des Mai. Chir. t. 3, p. 152.) I have seen the saw do so much mischief, in consequence of the operator neglecting to use the retractor, that my conscience obliges me to censure such surgeons as neglect to defend the soft parts by this simple contri- vance. There are some who have rejected the use of the retractor, because they have seen it get under the teeth of the saw, and obstruct the action of the instru- ment ; but this very circumstance adduced against the retractor is, when considered, the strongest one that could possibly be brought forward in its favour, as the surface of the wound itself, and particularly the edges 62 AMPUTATION. of the skin, would, in all probability, suffer the same | fate as the linen, by getting under the teeth of the saw, j if no retractor were employed, in attempting to saw | the bone high up, as closely as possible to the soft {•arts. 1 think no ono can urge any but the most frivo- lous objections to the use of the retractor, and I know that many who have been with myself eye-witnesses of the mischief frequently done by the saw in amputa- tions, are deeply impress^ with an aversion to the ne- glect of this bandage. I have often seen the soft parts skilfully divided, and I have, in these same instances, seen the operators directly afterward lose all the praise which every one was ready to bestow, by their actually sawing through one-half of the ends of the muscles together with the bone. Men who have had fortitude not to utter a sigh, nor to let a groan be heard, in their previous sufferings, have now had their invo- luntary cries e.xtorteil from them by unneces.sary, un- justifiable torture. But besides defending the surface of the stump from the teeth of the saw, the retractor will undoubtedly enable the ojierator to saw the bone higher up than he could otherwise do. Mr. Liston, of Edinburgh, endeavours to show, that the saw is the only necessary thing in the case of am- putating instruments ; and he adds (alluding, as 1 suppose, to operations at the joints), that it was sel- domer required than might be supposed ; and he par- ticularly declares all kinds of retractors superfluous. Here it should be rememberetl. that this gentleman’s practice is that of flap-amputation, to which he gives the universal preference ; a method in which unques- tionably the retractor may be disfiensed with, as, while the saw is acting, one or both of the flaps can be effect- ually held out of the way by an assistant. The same preference also e.xplains, in some measure, this sur- geon’s rejection of the tourniquet, the apphcation of which is inconvenient in certain flap-amputations. — (See Edinburgh Med. and Surg. Journ. vol. 20, p. 43 — 45.) Here, however, I am treating of amputation by the circular incision, in which practice I consider both the tourniquet and the retractor too useful to be com- monly relinquished. Another proceeding, which seems fit for reprobation, and which, indeed, Mr. Alanson very projierly con- demned, is the practice of scraping up the periosteum with the knife, as far as the muscles will allow. No- thing seems more probable, than that this may be the cause of the exfoliations which occasionally happen after amputations. At all events, it is a superfluous, useless measure, as a sharp saw, such as ought to be employed, will never be inqieded by so slender a mem- brane as the periosteum. All that the operator ought to do is, to take care to cut completely down to the bone all round its circumference. Thus a circular di- vision of the periosteum will be made, and upon this precise situation the saw should be placed. This is the method which was approved of by J. L. Petit. — (Traite des Mai. Chir. t. 3, p. 159.) It is what I have always done and recommended ; yet it must be con- fessed, that differences of opinion prevail about the ne- cessity and modes of dividing the periosteum. Graefe, in common with several others, entertains considerable apprehensipn of the effects of the periosteum being lorn and lacerated by the saw, exfoliations of the bone and abscesses up to the joint being possible conse- quences of the rude separation and inflammation of this membrane. Hence he is an advocate for mtiking a circular cut through at the place where the saw' is to be applied, and then scraping away all below this point in the direction downwards. — (N’ormen flir die Abl. grbsserer Gliedm. p. 105 and 165.) Perhaps no very- great objection may lie against this mode, which is not uncommonly followed, though I have some doubts of its real utility-, as it scarcely seems practicable in the midst of the oozing of biood to hit with the saw the precise line at which the remains of the periosteum terminate ; and in confirmation of the safety of Petit’s practice, Mr. Guthrie’s experience may be adduced, who says, “I have often sawed through the bone, w-ithout previously touching the periosteum, and the stumps have been as soon healed, and with as little in- convenience as any others.” — ^On Gun-shot Wounds, p. 88.) A very modern author, impressed, like many others, with the fear of tearing the periosteum with the saw, differs from them, in thinking it best to scrape the periosteum upwards ; by which means, he says, that at least half an inch of this membrane, and a nro- portionate quantity of muscular fibres, may be pt(U served for covering the end of the bone, ina.smuch as the muscular fibres adherent to the periosteum will remain connected with it ; an advantage which this author deems very important while the edges of the bone are sharp. In amputation below the knee, he con- siders the method highly useful, as the sharp edge of the tibia may be not merely covered with skin, but peri- osteum and the cellular membrane connected with it. Since his adoption of tliis practice, he assures us that he has not for a very long time seen any exfoliation of the tibia, and never any protrusion of the bone of a stump. — (Brunninghausen Erfahr. &c., fiber die Amp. p. 65, 66, 8vo. Bamb. 1918.) Such are the sentiments of a gentleman who has published a valuable tract on amputation, as well as some other works of deserved reputation. His opinion is unque-stionably the reverse of what is most prevalent in England ; and I think his practice liable to the objection, that the disadvantages of scraping the bone at all, and denuding it, may exceed the benefit supposed to proceed from afterward bringing down the detached membrane over its sharp margin, even admitting this to be always practicable. But in no part of the operation of amputation do ope- rators in general display more awkwardness, than in sawing the bone ; though, if we except directing the saw against the flesh, the faults are here less yiemicious in their conseipiences than the errors already noticed. At the time of sawing the bone, much depends upon the assistant who holds the limb. If he elevate the lower jiortioti of the thigh bone too much, the saw becomes so pinched that it cannot work. On the other hand, if he allow the weight of the leg to operate too much, the thigh bone breaks before it is nearly sawn through, and its extremity is splintered. It is one of the most common remarks of such persons as are in the habit of frequently seeing amputations, that the part of these operations, which a plain carpenter would do well, foils the skill of a consummate surgeon, and few operators acquit themselves w ell in the manage- ment of the saw. Many of them begin the action of this instrument by moving it in a direction contrary to the inclination of its teeth. Many, seemingly through confusion, endeavour to shorten this part of the o|'igh for the change of the dressings. He allows, however, that if the smell of the wound snould become offensive, the outer dressings may be removed sooner. Even when the dressings are to be taken away, it will frequently be found useftrl not to remove one strip of plaster; but the stump must be made clean, and any discharge washed away. These and other valuable precepts, derived from the eminent Dr. A. Monro senior, are worthy their great source, and the correctness of them promises to be acknow- ledged for ever. The imipner of renewing the dressings of stumps is indeed, a very important business, which should never be inti-usted to mere novices; for in taking off the straps of sticking plaster, if great care be not taken, the slight and newly-formed adhesions may be torn asunder. Thus, as Mr. A. C. Hutchison lias remarked, if the strap be pulled off by holding one end of it at nearly a right angle with the adhering part, the flap will be raised up with it, and thus a separation of the newly-united parts wall be produced. “ My plan,” says he, “ is to reflect the raised end of the strap close down upon the adhering part, and to bring it gently forwards with one hand, while the removing part of the strap is followed by tw'o fingers of the other placed upon the skin, roso- graphie Cliirurg. p. 475. 477, edit. 4.) Hut notwithstanding these and other encomiums on the practice, llicherand, like other French surgeons, is not an advocate for it in certain ca.ses ; as, fbr instance, limbs shattered by gun-shot wounds, or affected with hospital gangrene. Here, he maintains, that it hardly ever succeeihi. — (1*. 478.) Hut though it be true that amputations afler gun-shot wound.s do not generally heal so well as many other cases, it cannot be denied that they do sometimes unite more or less by the first intention ; and why should not the chance be taken ? It is productive of no danger; there is nothing better to be tried; and if it fail, what is the harm? Why, the wound will then heal by suppuration and the gra- nulating process, just as soon as if the hollow of the stump had been filled w’ith charpie or left open ; it will in fact heal in a way which is less advantageous than union by the first intention, but which is the best which can now happen. From what has been said, it appears that the practice of healing the wound by the first intention after am- putation IS less general in I’Yance than it is in Fngland ; a circumstance which may perhaps be explained by Uie fact of its being much newer to the French than to us. Ever}' improvement must eiiconuteT fora time the opposition of prejudice ; but one so important as that which we are considering, must at length jirevail and meet with universal adoption. Our extraordinary par- tiality to union by the first intention arises from a con- viction of its superior efficacy, and is a decisive proof of the goodness of English surgery in respect to wounds. The observations of Roux and Richerand tend to prove, that they are not altogether unaware of its advantages, and they therefore recommend it for certain cases ; but their backwardness to extend it to all ampu- tations without exception, is little in favour of the comparison wdiich they are so fond of making of French with English surgery. Even the justly emi- nent Dupuytren still fills the hollow of the stump with charpie. — (Syme, in Edinb. INIed. and Surgical Journ. No. 78, p. 32.) However, that stumps may fall into a state in which the pressure of all plasters and bandages whatever should be most carefully avoided and emollient poul- tices used, is a truth of which every surgeon of e.xpe- rience must be fuljy convinced. This happens when- ever the parts are affected with considerable tension, inflammation, and swelling, or i)ainful acute abscesses. There is also no utility in keeping the edges of the ■w'ound very closely compressed together when all chance of adhesion is past, and the parts must heal by the granulating process. My friend Mr. Guthrie, afler amputations performed from necessity in parts not in a healthy state, as in most secondary amputations after compound fractures of the thigh, does not insist upon the edges of the wound being brought into close contact by sticking plaster, compress, and bandage. In these cases, he also recommends the bone to be sawed an inch shorter than usual, or than w'ould be necessray under other circumstances, in order to prevent its protrusion, and the ligatures to be cut off close to the knots, so as to lessen irritation. The integuments and muscles are to be brought forwards and retained so by a mode- rately tight roller, but not laid down against the bone. Some fine lint, smeared xvith cerate or oil, is to be put between the edges of the wound ; and a piece of linen and a Malta cross over it, supported by a few light turns of the roller. “ In some cases,” says Mr. Guth- rie, “ I have put one and even two straps of plaster over the stump to keep the edges approximated withtdie being in contact ; and where the parts are but little diseased, this may be attempted ; but if the stumi* be- comes uneasy they should be cut, and a poultice applied., When only a part of the slump has appeared to slough, I have found the spiritus camphone, alone or diluted wntli a waterj’ solution of opium, applied with the lint, very useflil.” — (On Gun-shot Wounds, p. K>4.) The reasons which led Mr. Guthrie to incline to the plan of not bringing together the edges of the wound in cases of this description, must be learned by refer- ence to his own valuable work. His cases and ar- guments are entitled to serious consideration ; and t hough they, as well as the observations of Roux (Mem. sur la Reunion immediate de la Plaie apr^s rAmimta- tion, 8vo. Paris, 1814), leave me unconvinced of the use- fulness of not bringing the edges of the wound to- gether immediately after the amputation of bad com- IKiund fractures, tliere are some of liis observations re- specting the injurious effects of too much pressure in certain conditions of the stump, perfectly agreeing with my own sentiments. At preisent, I have never seen any case of amputation in which I should not have thought the surgeon wrong, had he not brought the sides of the wound together directly afler the operation, so as to af- ford the chance of union by the first intention [A mode of amputating the thigli with two flaps was projKised a few' years since by Profes-sor .1. H. ?>avidge, of the University of Maryland, which combines several iinportaiit advantages. The first incision is made with the large knife on the outside and inside of the thigh through the integu- ment, so as to surround the limb, with the e.xception of an inch or more in the centre above and below. The surgeon having calculated the size of the flaps required, which are to be as long as the semi-diameter of the limb, ’makes with a scalpel a second and third inci- sion through the skin, in form of the letter V, com- mencing above the centre of the space left vacant on the superior and inferior surface, and continued until its lUverging extremities reach the ends of the semi circular cuts first mentioned. The flaps of integu- ment are then dissected back until they eijual in length a little more than the semi-diameter of the limb, to al- low for the retraction that may occur. A circular inci- sion is then made through the muscles down to the bone with the large knife. The bone is then denuded for an inch or two, the retractor employed, and the bone sawed off at the edge of the divided flesh. The arte- ries are then secured, the muscles drawn down, the ligatures so arranged as to come out of the superior and inferior angles of the wound, and the flaps are brought together and kept in place by adhesive straps, supported by a cross bandage, roller, ’PL he had operated in this way on nineteen patients, thirteen of whom recovered. But, at a subsequent period, he and his colleagues had amputated at the shoulder, in the above manner, in upwards of a hundred cases, more than ninety of which recovered. — (M^m. de Chir. Mil. t. 4, p. 432, 8vo. Paris, 1817.) In his latter operations he adopted the innovation of first making a longitudinal incision from the acromion to about an inch below the neck of the humerus down to the bone, so as to divide the fleshy part of the del- toid into two even parts. This cut, he says, facili- tates and renders more exact the rest of the operation. From this wound the incisions for the flaps are con- tinued. Having made the foregoing incision, “ I di- rect an assistant to draw up the skin of the arm to- wards the shoulder, and I form the anterior and poste- rior flaps by two oblique strokes of the knife made from within outwards and doAvnwards, so as to cut through the tendons of the pectoralis major and latis- simus dorsi. There is no risk of injuring the axillary vessels, as they are out of the reach of the point of the knife. The cellular connexions of these two flaps are to be divided, and the flaps themselves raised by an as- sistant, who, at the same time, is to compress the two divided circumflex arteries. The whole joint is now exposed. By a third sweep of the knife, carried circu- larly over the head of the humerus, the capsule and tendons running near the articulation are cut ; and the head of the bone being inclined a little outwards, the knife is to be carried along its posterior part in order to finish the section of the tendinous and ligamentous attachments in that direction. The assistant now ap- plies his 'fore-fingers over the brachial plexus, for the purpose of compressing the artery, and commanding the current of blood through it. Lastly, the edge of the knife is turned backwards, and the whole fascicu- lus of axillary vessels is cut through, on a level with the lower angles of the two flaps, and in front of the assistant’s fingers. The patient does not lose a drop of blood ; and ere the compression is remitted, the ex- tremity of the axillary artery is readily seen, taken up with a pair of forceps, and tied. The circumflex arte- ries are next secured, wliich completes the operation.” — (Mem. de Chir. Mil. t. 4, p. 428, Paris, 1817.) In addition to these important deviations from his earlier method, he subsequently preferred bringing the flaps together with two or three straps of adhesive plaster, and interposes no charpie. — (P. 429.) It should be ob- served also, that he lays no stress on first making the outer flap, though, from the description, it does not ex- actly appear which flap he now begins with. He has changed likewise, on another point of importance, viz. instead of preferring La Faye’s plan in certain exam- ples already specified, he affirms that the above-de- scribed way of operating is applicable to almost every case met with in military practice. First, because ail gun-shot wounds, generally, which mutilate the arm so as to create the necessity for the operation, partly or entirely destroy the centre of the deltoid, while there is always enough flesh left at the sides for mak- ing the two flaps. Secondly, because, in the very rare instances where the lateral parts of the shoulder are destroyed, and the middle untouched, no advantage would be gained by operating in La Faye’s manner, as Larrey conceives that the detached flap would slough, or become, as he terms it, disorganized. He now prefers dividing the middle piece of flesh, and giving the flaps the same shape as if they were uninjured. He even asserts, that the operation, done without any flaps at all, answers better than any method in which the sur- geon preserves flaps not naturally intended for the part. Thus, when all the flesh of the shoulder has been shot away, he has seen surgeons cover the gle- noid cavity with a flap saved from the soft parts of the axilla ; but such flaps invariably sloughed, hemor rhages ensued, and the patients died.— (P. 430 — 431.) Some of these latter observations are, clearly enough, the result of great partiality to a particular method of ojierating ; because who can doubt, when the lateral parts of the shoulder are injured, as they frequently are (and not very rarely, as Larrey asserts), by the ])assage of a musket-hall through the shoulder, from before backwards, that the right method is that of La Faye ; or the same operation, with the slight difler- ence of making the flap of a semicircular shape ? It was for cases of tliis descriinion that Mr. Collier and 1 operated afler La Faye’s plan, with perfect success, after the battle of Waterloo; and a poor fellow of the AMPUTATION. 81 rifle brigade, who was brought in too late for operation, and died of sloughing, had his shoulder injured in the same way, the middle of the deltoid being untouched, and shot-holes existing behind, and in front of, the ar- ticulation. But if it required any farther arguments to prove, that Larrey is wrong in wishing to extend his, or rather Desault’s method, to all cases, I might criticise his assertions about the sloughing of the flap, when it is not cut into two portions, and its preserva- tion by the singular expedient of making a division of it, and, of course, injuring it still more than it may have been injured underneath by the bullet. The cases, however, which have fallen under my own per- sonal observation, and numerous others on record, fur- nish an adequate proof, that excellent as Larrey’s me- thod is for many cases. La Faye’s answers very well in others. Thus, in an example where a Prussian hussar had had his arm amputated,and a projection ofthe bone. took place, to the extent of three inches, with hospital gangrene commencing in the stump, Klein felt obliged to remove the limb at the shoulder. He operated in La Faye’s manner; the separation was finished in one minute; and on the eighteenth day the stump was perfectly healed. — (See Praotische Ansichte Chir. op. h. 1, p. 1 — 10, 4to. Stuttgart, 1816.) The same practitioner had five other secondary amputations of the same kind ; but one patient was afterward carried off by hemorrhage, and another by hospital gangrene. Klein, however, in common with the majority of army surgeons, considers the idea of applying any one plan of operating to different cases, totally absurd. — (P. 12.) After the storming of St. Sebastian’s, nine shoulder-joint amputations were done with success ; seven of them by raising the deltoid as a flap. — (See Guthrie on Gun- shot Wounds, p. 108.) After tlfb battle of Waterloo, 1 adopted La Faye’s plan ; but wnth this difference, that I did not cut the brachial artery till I made the last stroke of the knife, which separated the limb ; and consequently I did not tie that vessel till the time when I had nothing but the hemorrhage to occupy my attention. The circumflex arteries, however, I tied as soon as the external flap was made. The modification of thrusting a knife under the deltoid, quite across the shoulder, and mak- ing the flap by cutting dow-nwards, until the instru- ment comes out again through the skin, is practised by some surgeons of eminence. — (Klein, Lisfranc, &c.) An excellent lithographic plate illustrative of this last method is given by Maingault, pi. 4, fig. 17. — (See M6d. Operat. p. 24, fol. Paris, 1812.) When the state of the integuments will permit the choice, Mr. Guthrie thinks their preservation best ef- fected by Larrey’s first method; but he particularly insists upon the advantage of raising the shattered arm or stump to nearly a right angle with the body before the operation begins, and even before the assist- ant makes pressure on the subclavian artery, as some change in the mode of accomplishing the latter object might be rendered necessary by elevating the limb dur- ing the operation itself. Mr. Guthrie commences the first incision immediately below the acromion, and, with a gentle curve, extends it downwards and in- wards, through the integuments only, a little below the anterior fold of the armpit. The second incision outwards is made after the same manner, but is car- ried rather farther down, so as to expose the long head of the triceps at the under edge of the deltoid. The third incision, commencing at the same spot as the first, but following the margin of the retracted skin, divides the deltoid on that side down to the bone, and exposes the insertion of the pectoral is major, which must be cut through. This flap is now to be raised, so as to expose the head of the bone. The fourth incision out- wards divides the deltoid muscle down to the bone, when the posterior flap is to be well turned back, so as to bring into view the teres minor and infra-spina- tus pas.sing from the scapula to the great tuberosity of the humenis. The outer and inner flap being now raised, the head of the bone may be rolled a little out- wards, the teres minor and infra-spinatus cut, and an opening made into the joint. The capsular ligament, supra-spinatus, and long head of the biceps are then divided. The inner side of the capsule is now cut through, together with the subscapularis muscle, as it approaches its insertion into the lesser tuberosity of the humerus. The long head of the triceps is next divided, and lastly, with one sweep of the knife, the rest of the Von. I — F soft parts are cut, together with the axillary artery, veins, and nerve. — (On Gun-shot Wounds, p. 274 — 270.) Larrey, in his latest method, takes no measures in the first stage of the operation for commanding the flow of blood, as the assistant merely presses the ax- illary artery between his fingers just before it is di- vided. Some of the modern French surgeons were earlier than Larrey in dispensing with the compression of the axillary artery, and following a method which ren- ders it unnecessary. Richerand, for instance, describes nearly the same plan as that advised by La Faye ; but after making the deltoid flap, cutting the tendons, and dislocating the bone, he dissects down close to the in- side of the humerus, so as to enable an intelligent as- sistant to put his thumb on the cut surface behind the artery, which, with the aid of the fingers apjilied to the skin of the axilla, can then be grasped and com- pressed so as to command the flow of blood through the vessel. The operator now, fearless of hemorrhage, completes the internal or inferior flap. — (Richerand, Nosographie Chir. t. 4, p. 509 — 511, edit. 4.) Baron Uupuytren amputates at the shoulder, in a manner which seems principally commendable on ac- count of its celerity. The arm being raised and held at a right angle with the trunk, Dupuytren stands at the inside of the limb, with one hand grasps and ele- vates the mass of the deltoid muscle, and plunges under it a two-edged knife, from before backwards, on a level with the end of the acromion. Gutting in this way close to the head of the humerus, he con- tinues the incision downwards between this bone and the deltoid, and at length, bringing out the knife, com- pletes the external or superior flap. The rest of the operation does not essentially differ from Richerand’s, except that Dupuytren takes hold of the lower flap it- self, before dividing it, and compresses the artery until he has cut through it and tied it. Dupuytren’s plan would be difficult on the left side, unless the surgeon were an ambidexter ; but, in other respects, it cannot be found m\ich fault with. This surgeon has also proposed making one flap in front, and the other behind, in order to prevent the lodgement of matter. Richerand justly observes, however, that frequently a good deal of the wound unites by the first intention, and that as the patient after the operation lies in the recumbent posture on an oblique plane, he cannot see what advantage one way of making the flaps has over another, in regard to affording a ready issue to the discharge. — (Op. cit. p. 515.) For the sake of celerity, of which the French are rightly admirers in all capital operations, another plan of amputating at the shoulder has been proposed by Lisfranc. Supposing the left extremity is to be re- moved, the patient is placed on an elevated seat, one assistant pressing the artery against the first rib, while another draws the arm forwards ; the operator, stand- ing behind the patient with a long-bladed catling, pierces the integuments on the inner edge of the latis- simus dorsi muscle, opposite the middle of the axilla, and pushes it obliquely upwards and forwards, till its point strikes against the under surface of the acromion ; then, by raising the handle of the knife, its point is lowered, and protruded just in front of the clavicle at its junction with the acromion. By ctitting down- wards and outwards, he then forms a flap from the superior and posterior part of the arm, including the whole breadth of the deltoid muscle, and a part of the latissimus dorsi. This being held back by the assist- ant, the joint is cut through from behind forwards, and a corresponding flap is formed by cutting down- wards and outwards, between the muscles and bone, on the inner side of the arm. When the operation is on the right side, the patient should be seated on a low chair, and the catling thrust from above downwards, from the part just in front of the point where the clavi- cle is connected with the acromion, the surgeon raising his hand as the instrument proceeds downwards and backwards, until its point has come out at the inner edge of the latissimus dorsi, when the flap is to be made, and the operation finished as above directed.— (See Averill’s Operative Surgery, p. 135. Also Lis- franc de St. Martin, et Charnpesme, Nouveau Froc«';d6 Op()ratoire pour I’amputation du bras dans son articu- lation scapulo-hnmerale. Paris, 1815.) Speaking of this mode of operating, Richerand re- marks; “en I’employant, on parvicut ^ ddsarticuler 82 AMPUTATION. I’hurn^rus, et a s^parer Ic bras en aussi peu de temps qu’en met un habile decoupeur A detacher I'aile d’un perdrix.” — (P. 514.) The last method which I shall describe is that of M. Scoutteten. It is done on the left arm, as follows : — The surgeon first takes hold of the middle of the arm with his left hand, and raises it four or five inches from the side. With his right hand he then applies the point of the scalpel immediately below the acromion, and passes it into the flesh until it touches the head of the humerus. He then depresses the handle, and forms the first incision, which extends downwards four inches from the point of the acromion, and divides the posterior third of the deltoid, and the greater part of the fibres of the Jong portion of the triceps down to the bone. The second incision is next commenced with the point of the knife directed downwards upon the inner side of the limb, and in front of the biceps, on a level with the place where the first incision ended. The wound is then extended inwards and upwards to the acromion, where it terminates by joining the first. These two wounds form a triangle, which nartly con- sists of relinquished integuments, and has its base downwards. In order to find the joint with greater ease, the sur- geon may now detach a little of the deltoid from the bone. An assistant can also keep the edges of the in- cision asunder, so that the operator may be enabled to see and divide the capsular ligament, and the tendons of the suprpi-spinatus, infra-spinatus, and teres minor, which are inserted into the greater tubercle of the hu- merus, and the tendon of the subscapularis, which is inserted into the lesser tubercle. 1 he operator, who constantly keeps hold of the arm, now communicates to it some rotatory movements, in order to bring the above tendons, one after another, under the knife, and dmde them with the capsule. Iimnediately the cap- sule and tendons have been cut through, the head of the bone readily quits its socket. The surgeon luxates the bone by pushing it a little upw'ards, and, at the same moment, inclining the condyles towards the side. The next proceeding is to divide the flesh on the inner side of the limb as closely as possible dowm to the bone ; but when the knife approaches the artery, this vessel is to be taken hold of and compressed by an as- sistant, before the incision is completed. In this way, no hemorrhage need be apprehended. When it is the right limb, the only difference is, that the first incision is made at the inner side of the arm, and extended uj) to the acromjon. Scoutteten consi- ders a single assistant sufficient, and compression of the subclavian artery unnecessary. — (II. Scoutteten, La M^thode Ovalaire, ou Nouvelle Methode pour amputer dans les Articulations, Paris, 1827, 4to.) When the scapula is shattered, of course the loose fragments should be taken away, and if the acromion be broken, and the remnant of it pointed and irregular, this sharp rough portion should be saw’ed off, as tvas practised longago by M. Faure. — (See Mem.de I’Acad. de Uhir. t. 6, p. 114.) In one case, indeed, Larrey found it necessary to take away more than two-thirds of the scapula, and the humeral end of the clavicle. — (M^m. de Chir. Mil. t. 4, p. 432.) Sawing off part of the acro- mion and coracoid process, as a general rule, seems to me quite unnecessary (see Fraser on the Shoulder-joint Operation, 8vo. Loud. 1813) and improper, not only as producing delay, but wounding other parts which should not be at all disturbed. — (See Guthrie on Gun- shot Wounds, p. 235, 2St5, .art of the integuments and muscles, and making a transverse as Well as a longitudinal incision. These disagreeable things may be avoided by following the method of Mr. Hey, or that of Mr. C. Bell. For re- moving the metatarsal bone, either of the little or great toe, the latter gentleman directs us to carry a scalpel round the root of the toe, and then along the side of the foot. The flaps are then to be dissected back, the metatarsal bone is to be separated from the next, and its square head is to be detached from the tarsus. — (Operative Surgery, vol. 1, p. 390.) The removal of the central metatarsal and metacar- pal bones is an operation of much difficulty, and the sawing of them is hardly practicable, without injuring the soft parts. Hence, I am decidedly of opinion with Mr. C. Bell, that instead of a formal amputation, it is better to extract the diseased bones from the foot or hand, as, indeed, Mr. Hey was in the habit of doing. That skilful surgeon, Langenbeck, however, has de- vised a ready mode of taking away the middle finger with its metacarpal bone from the os magnum, or the ring-finger, with its metacarpal bone, from the articu- lation of the latter with the os magnum and os cunei- forme. In order to find out these articulations, he draws a line from the upper head of the metacarpal bone of the thumb straight across to the metacarpal bone of the finger to be extirpated, and at this place he begins his first incision, which runs towards each side of the finger like an inverted V. The bone is then separated all round from the soft parts, an'd dislocated from the carpus, when nothing remains to be done but to cut the parts towards the palm, where the wound is also made to resemble an inverted V, but does not ex- tend any farther than is necessary, to complete the se- paration. — See Langenbeck’s Bibl. b. 1, p. 575, and plate 3, f. 1.' , This is unquestionably a simple and excellent method of operating, which Langenbeck also recommends as the best way of removing such bones of the metatarsus, as are not situated at the sides of the foot ; care being taken to save a flap from the sole. It is often difficult, however, to know with certainty whether the disease is confined to the metacarpal or metatarsal bones ; and if it be not, and the carpus or tarsus be affected, the operation wall not answer, and amputation be indispensable. This happened in one of Langenbeck’s cases, in which he had removed one of the metacarpal bones. IModern surgeons never amputate the whole of the foot or hand, when there is a reasonable chance of preserving any useful portion of it, though the rest may be most severely shattered. Thus, when a sol- dier had been struck by a grape-shot, which shattered the metacarpal bones of the little and ring-fingers, grazed the middle finger, and tore up the integuments on the palm and back of the hand, Mr. Guthrie suc- ceeded in saving the two fingers and thumb, although, in the removal of the other parts, no regular flaps could be made for covering the wound.— (On Gun-shot Wounds, p. 382.) In winter campaigns, the toes, and more or less of the foot, are often attacked with morti- fication from cold. In this circumstance, when the disorder does not extend beyond the middle of the foot or the toes, it is only necessary to cut away the gan- grenous part. On the first entrance of the French army into Holland, after the revolution, Paroisse met with many of these cases, in which it was necessary* merely to take away ‘the metatarsal bones, or some- times those of the tarsus. All the patients operated upon in this maimer for the effects of cold were cured ; walking allerwartl with more or less diffi- culty, according as the portion of the foot taken away had been greater or smaller. — (Opuscules de Chir. p. 218.) M. Roux, in his late publication, finds fault with our ignorance of Chopart’s method of removing a part of the foot. He says, “ I am certain, the principal sur- geons in England have never practised, and are even totally unacquainted with, the amputation of the foot at the junction of the two halves of the tarsus, or Chopart's operation.” — (Voyage fait d Londresen 1814, ou Paralltlle de la Chirurgie Angloise avec la Chirur- gie Franqoise, p. 338.) As it is an operation of consi- derable merit. I think it will be useful to introduce a description of it in the present work. It is performed in the nearly parallel articulations of the as calcis with the os cuboides, and of the a.stragalus with the os na- viculare. Thus the heel is jireserved, on which the patient can afterward walk. The perl'orn i a of i.* i.s simple. The tourniquet having been ap^Ji.cd, the AMrUTATlON. 87 surgeon is to make a transverse incision through the skin 'W'hich covers the instep, two inches from the ankle-joint. He is to divide the skin, and the extensor tendons and muscles in that situation, so as to expose the convexity of the tarsus. He is next to make on each side a small longitudinal incision, which is to be- gin below and a little in front of the malleolus, and is to end at one of the extremities of the first incision. After having formed in this way a flap of integuments, he is to let it be drawn upwards by the assistant who holds the leg. There is no occasion to dissect and reflect the flap ; for the cellular substance connecting the skin with the subjacent aponeurosis is so loose, that it can easily be drawn up above the place where the joint of the calcaneum with the cuboides, and that be- tween the astragalus and scaphoides, ought to be opened. The surgeon will penetrate the last the most easily, particularly by taking for his guidance the emi- nence which indicates the attachment of the tibialis anticus muscle to the inside of the os naviculare. The joint of the os cuboides and os calcis lies pretty nearly in the same transverse line, but rather obliquely forwards. The ligaments having been cut, the foot falls back. The bistoury is then to be put down, and the straight knife used, with which a flap of the soft parts is to be formed under the tarsus and metatarsus, long enough to admit of being applied to the naked bones so as entirely to cover them. It is to be main- tained in this position with three or four strips of ad- hesive plaster, which are to extend from the heel, over the flap, to the inferior and anterior part of the leg. Chopart used to tie every artery as soon as it was diinded. On the instep, the continuation of the ante- rior tibial artery will require a, ligature ; and in the sole, the internal and external plantar arteries, in the thickness of the flap of soft parts, must generally be taken up. One-half of each ligature is to be cut away, and the other one is to be left hanging out between the plasters, at the nearest and most convenient jxiint. Walthei and Graefe have given some very precise directions for the performance of this operation. A cut is first made, beginning half an inch below the outer ankle, and extending forwards along the side of the foot two inches. Another similar incision is then made from one inch below the inner ankle. The foot is now to be bent upwards, and the first two cuts united by a transverse incision, two finger-breadths from the front of the tibia. A flap is then dissected up, as far back as the commencement of the lateral incisions, or a line corresponding to the articulation of the astraga- lus with the os naviculare, and of the os calcis with the os cuboides. An assistant now checks the bleed- ing by applying the points of his fingers on the mouths of such vessels as bleed profusely, and holds up the flap. The extremity of the foot is now to be firmly in- clined downwards, so as to stretch the ligaments con- necting the tarsal bones together. The ligaments be- tween the astragalus and os naviculare are to be first cut, when the foot may be twisted somewhat outwards, and the ligaments between the os calcis and os cu- boides divided. The division is lastly completed by cutting through the soft parts regularly from above downwards, with the precaution of directing the am- putating knife so as to leave a flap composed of jiart of the sole of the foot. — See Abhandl. aus dcm Ge- biete der Prakt. Med. &c. Landshut, 1810, b. 1, p. 152 ; aan Graefe, Normen furdieAbl. grcissr. Gliedm. p. 142.) Sometimes, in consequence of the soft parts of the instep being all gangrenous or otherwise destroyed, it is necessary to make the flap entirely from the sole of the foot, a.s Klein was obliged to do in one of his cases.— (Practische Ansichten bedeutendsten Chir. Ope- rationen, h. 1, p. 28. t Indeed, Richerand thinks this mode generally advantageous, as the line of the cica- trix is not placed at the lower end of the stump, where it would be most exposed to injury. — (Nosogr. Chir. t. 2, p. 502, &c. ed. 4.) Langenbeck and Klein also condemn the painful and unnecessary measure of dissecting up a flap from the instep, as advised by Walther and Graefe. Chopart himself, as we have seen, merely drew back the integuments of the instep, without making any detachment of them from the sub- jacent parts. When the ends of the flexor tendons of the toes jiroject too much from the inner surface of the lower flap, they are to be cut shorter, as Klein particu- larly directs ; and 1 consider his advice, not to use sutures for keeping the flap applied, but merely strips of sticking-plaster, perfectly judicious.— (Op. cit. n 33—34.) [For amputation of the lower jaw see note on “ Jaw- Bone.” For amputation or excision of the upper jaw as first performed in this country by Dr. David L. Ro- gers, of this city, see note on “ Osteosarcoma or for the details of the case, reference may be had to the N. Y. Med. and Phys. Journal for 1824, vol. 3, p. 301. For amputation or exsection of the clavicle, an opera- tion performed for the first time by Dr. Mott, in 1829, see also note on “ Osteosarcoma.” — Heesc.] The following sources of instruction, on the subject of amputation, are particularly entitled to notice : L'el- sus de Re MedicA. tEnvres de Par^, livre 12, chap. 30 et 33. James Yonge., Ctirrus Triumphalis e Terebin- tho, 8vo. Lund. 1679. R. Wiseman., Chir. Treatises^ 4to. Lund. 1692. Sharp's Operations of Surgery, chap. 37, ayid Critical Inquiry into the present state of Surgery, chap. 8. Ravaton, Traite des Plaies d'Jtr- mes d Feu, Paris, 1768. Bertraudi, Traite des Ope- rations de Chirurgie, chap. 23. Le Dran's Obs. de Chir. Paris, 1731, and his Traite des Opera- tions de Chirurgie, Paris, 1742, and the English Translation loith the additions of Cheselden, by Gata- ker. Land. 1749 ; Heister's Instit, Chirurg. pars 2, sect. 1. JSTouvclle MeUiode pour faire V Operation de I' Amputation dans V Articulation du Bras avec V Omo- plate, par M. de La Faye. P. H. Dahl, Dis. de Hu- meri Amputatione ex Articulo. Gott. 1760. His- toire de V Amputation, suivaiit la Meihode de Verduin et Sabourin, avec ta Description d'un nouvel instru- ment pour cette Operation, par M. De la P'aye. P. H. F. Verduin, Dis. Epistolaris de JVova Artuum dc- curtandorum Ratione, l2mo. Amst. 1696. Moyens de reudre plus simple et plus sure V Amputation d Lam- beau, par M. de Garengeot. Observation sur la Re- section de I' Os, npres V Amputation de la Cinsse, par M. Veyret. Me moire sur la Saillie de I' Os apris L' Amputation des Membres ; ou ion examine les causes de cct inconvenient, les moyens d'y remedier, et ceux de la prevenir, par M. IjOuis. Seconde Metnoire sur i Amputation des Grandes Extremites, par M. Louis. The foregoing Essays are in Mem. de I’Acad. de Chirurgie, t. 5, edit. 12//io. R. de Vermale, Obs. et Remarques de Chirurgie pratique, Manheim, 1767. Essai sur les Amputations dans les Articles, par M. Brasdor, in t. 15 Mem. de VAcad. de Chir. J. U. Bil- guer de Membrorum Amputatione rarissime adminis- tranda aut quasi abroganda, 4fo. Halce Magd. 1761. White's Cases in Surgery, 1770. Brumfield's Chirur- gical Observations and Cases, vol. I, chap. 2, 8vo. 1773. O' Halloran's complete Treatise on Gangrene, S,'c., with a new Method of Amputation, 8vo. Dublin, 1765. Alanson's Practical Observations on Amputa- tion, ed. 2, 1782. ./. L. Petit, Traite des Maladies Chir. t. 3, Paris, 1774, or the later ed. 1790. R. My- nor's Practical Thoughts on Amputation, Birmingh. 1783. T. Kirkland, Thoughts on Amputation, S-c. 8vo. J.,ond. 1780. I^oder, Comment, de Mova Alan- soiii, Ampututiunis Methodo, Progr. 1,7, Jen. 1784, or Chir. Med. Beobachtungen, 8vo. Weimar, 1794. ./. F. Tschrpius, Casus de Amputatione Femoris non Cruenta, Halw, 1742. (^Haller, Disp. Chir. 5, 239.) Mtirsinna, Mtue Med. Chir. Beobacht. Berlin, 1796; P. F’. Walther, Abhandl. aus deni Gebiete der Prakt. Medicin, besonders der Chirurgie and Augenheil- kunde, b. 1, Landshut, 1810; Kern. Ueber die Hund- lungsweise bey der Absetzung der Glieder. Wien, 1814 ; G. Kloss, De Amputatione Humeri ex Articulo, 4to. F'rancof. 1811; W. Fraser, An Essay on the Shoulder-joint Operation, 8vo. Lond. 1813. H. Robbi, De Via ac Ratione, qua olim membrorum Amputatio instituta est, ito. Lips. 1815. J. P. Roux, M^moire et Obs. sur la Riunion Immediate de la Plaie apris V Amputation, 8vo. Paris, 1814. .7. G. Havse, Ampu- tationis Ossium prweipua queedam momenta, fJps. 1801. .7. F. D. Evans, Practical Observations on Ca- taract and closed Pupil, and on the Amputation of the Arm at the Shoulder, frc. 8vo. Lond. 1815. H. J. Brun nin ghausen, Flrfahru ngen und B emerkn ngen iiber die Amputatiunen, 8vo. Bamb. 1818. J Aingenbeck, Bibl. fiir die C.hirurgie, b. 1, p. 562, (S'C. 8vo. Gott. 1816. P. G. Van Hoorn, De Us, quee in partibus Mernbri, prwsertim osseis, amputatione vulneratis notanda sunt. Ato. IjUgd. 1803. Graefe, Monnen fiir die Ab~ losung grbsserer Gliedm.. Alo. Berlin, 1813. Klein, P r act ische Ansichten bedeutendsten Chir. Op.h.l, 4to. 88 ANA ANC Stuttg. 1816. C. Hutchison, Practical Observa- tions in Surgery, Svo. Land. 1816. And farther Obs. on the proper Period for amputating in Gun-shot fVounds, (S-c. 8«o. Land. 1819. Dr. Hennen, Princi- ples of Military Surgery, 2d ed. Suo. Lond. 1820 ; a work full of valuable practical information. Pott's Remarks on Amputation. Sabatier, Medecine Opera- toire, t. 3, cd. 2. Hey's Practical Observations in Surgery, edit. 2. Remarques et Observations sur V Amputation des Membres, in CEuvres Chir. de De- sault par Bichat, t. 2. P. J. Roux, De la resection, ou du retranchement de Portions d' Os malades, soit dans les Articulations, soit hors des Articulations, Ato. Paris, 1812. Rees's Cyclopmdia, art. Amputation. Vermischte Chirurgische Schriften, von J. 1 j. Schmuc- ker, band 1. J. Bell's Principles of Surgery. Cases of the Excision of carious .Joints, by Park and Mo- reau, published by Dr. Jeffray. Operative Surgery by C. Bell, vol. 1. Richter's Anfangsgriinde der Wundarzneykunst, band 7. Richerand, JVosographie Chir. t. 4, edit. 4. B. Bell's Surgery, vol. 5. Pelletan, Clinique Chirurgicale, t. 3. Gooch's Chirurgical Works, — various parts of the 3 volumes. Jjarrey, Relation Chirurgicale de I'Armie d' Orient en Egypte et Syrie ; also Mem. de Chirurgie Militairc ; books which should be in the library of every surgeon. Guth- rie on Gun-shot Wounds, 8vo. I^ond. 1815 ; of which a new edition has since appeared : a publication which cannot be too attentively studied by every surgeon who wishes to know when, as well as how, to amputate in cases of gun-shot injury. Roux, Parallile de la Chi- rurgie Angloise avec la Chirurgie Francoise, p. 336, and un/'> eye.) Same as iEgylops. ANCHYLOSIS. (From ayvvXos, crooked.) This denotes an intimate union of two bones w'hich were naturally connected by a moveable kind of joint All joints originally designed for motion may become an- chylosed, that is, the heads of the bones forming them may become so consolidated together that no degree of motion whatever can take place. Bernard Conner (De stupendo ossium coalitu) describes an instance of a general anchylosis of all the bones of the human body. A still more curious fact is mentioned in the Hist, of the Acad, of Sciences, 1716, of a child 23 months old affected with universal anchylosis. In the ad- vanced periods of life anchylosis more readily occurs than in the earlier parts of it. The author of the ar- ticle Anchylosis in the Encycloptdie Methodique, men- tions a preparation in which the femur is so anchylosed with the tibia and patella, that both the compact and spongy substances of these bones appear to be common to them all without the least perceptible line of sepa- ration between them. In old subjects the same kind of union is common between the vertebraj and between these and the heads of the ribs. Anchylosis is divided into the true and false. In the true, the bones grow together so completely that not the smallest degree of motion can take place, and the caso ANCHYLOSIS. 89 Is positively incurable. The position in which the joint becomes thus unalterably fixed makes a material difference in the inconvenience resulting from the oc- currence. In false anchylosis the bones have not com- pletely grown together, and their motion is only dimi- nished, not destroyed. True anchylosis is sometimes termed complete ; false, incomplete. In young subjects in particular, anchylosis is seldom an original affection, but generally the consequence of some other disease. It very often occurs after frac- tures in the vicinity of joints ; after sprains and dislo- cations attended with a great deal of contusion ; and after white swellings and abscesses in joints. Aneu- risms, and swellings, and abscesses on the outside of a joint may aJ so induce anchylosis. In short, every thing that keeps a joint for a long timem otionless may give rise to the affection, which is generally the more com- plete the longer the cause has operated. When a bone is fractured near a joint, the limb is kept motionless by the apparatus during the whole time requisite for uniting the bones. The subsequent in- flammation also extends to the articulation, and attacks the ligaments and surrounding parts. Sometimes these only become more thickened and rigid : on other occa- sions, the inflammation produces a mutual adhesion of the articular surlaces. Hence fractures so situated are more serious than when they occur at the middle part of a bone. After the cure of fractures, a certain degree of stiffness generally remains in the adjacent joints, but this is different from true anchylosis; it merely arises from the inactivity in which the muscles have been kept, and their consequent loss of tone. The position of an anchylosed limb is a thing of great importance. When abscesses form near the joints of the fingers, and the tendons mortify, the fingers should be bent, that they may anchylose in that position, which renders the hand much more useful than if the fingers were permanently extended. On the contrary, when there is danger of anchylosis, the knee should always be kept as straight as possible. The same plan is to be pursued, when the head of the thigh-bone is dislocated in consequence of a diseased hip. When the elbow cannot be prevented from be- coming anchylosed, the joint should always be kept bent. No attempt should ever be made to cure, though every possible exertion should often be made to prevent a true anchylosis. The attempt to prevent, however, is not always proper, for many diseases of joints may be said to terminate when anchylosis occurs. When the false or incomplete anchylosis is appre- hended, measures should be taken to avert it. The limb is to be moved as much as the state of the soft parts will allow. Boyer remarks, that this precaution is much more necessary in affections of the ginglymoid than of the orbicular joints, on account of the tendency of the former to become anchylosed, by leason of the great extent of their surfaces, the number of their ligaments, and the naturally limited degree of their motion. The exercise of the joint promotes the secretion of the synovia, and the grating first perceived in conse- quence of the deficiency of this fluid soon ceases. A cer- tain caution is necessary in moving the limb : too violent motion might create pain, swelling, and inflammation, and even caries of the heads of the bones. It is by pro- portioning it to the state of the limb, and increasing its extent daily, as the soft parts yield and grow supple, that good effects may be derived from it. — (See Boyer, Mai. des Os, t. 2.) The use of embrocations and pump- ing cold water on the joint every morning have great I)Ower in removing the stiffness of a limb remaining after the cure of fractures, dislocations, Iott has since repeated the operation with the same success on a gentleman from Louisiana. In the North Amer. Med. and Surg. .Journal for April, 1828, Dr. J. Rhea Barton has published a most success- ful operation performed on a case of anchylosis at the hip-joint, attended with very great deformity, after it had existed for more than eighteen months. The object of the operation was to substitute an artificial joint for the loss of the natural articulation at the hip, and it is most honourable to Dr. Barton, and alike gratifving to the profession and to humanity, to record, that it has been most completely successful . An abrid ged account of this novel and most interesting exhibition of consum- mate surgical skill is given in the Appendix to the late Philadelphia edition of Cooper’s “ First Lines,” of 1828. It was performed on a sailor at the Pennsylvania Hos- pital in Nov. 1826. In Dr. Francis’s edition of Denman’s Midwifery is described a peculiar affection of the hip-joint, in some respects novel and important. It is in effect an anchy- losis, and is denominated “ a displacement of bone without fracture or dislocation,” inducing a morbid change in the form and cavity of the pelvis, such as might wholly defeat the process of natural labour. The patient, an adult subject, fell on the right hip ; the injury done to the external parts was comparatively slight ; but an inflammatory action took place in the bottom ofthe acetabulum, which caused total absorption of the bone, and the protrusion of the head of the thigh- bone Itself into the cavity of the pelvis. Nor was the diseased action limited to these changes ; large deposites of osseous matter were made within the pelvis sur- rounding the absorbed acetabulum ; and the head of the thigh-bone was by the same material augmented to more than double its original size. The neck of the bone and also both trochanters were considerably in- creased in bulk. The capacity of the pelvis was dimi- nished about two inches in its superior and lateral portion. — Reese.] ANEURISM, or ANEURYSM. (From avcvpvvo), to dilate.) The tumours which are formed by a preterna- tural dilatation of a part of an artery, as well as those swellings which are occasioned by a collection of arte- rial blood, effused in the cellular membrane, in conse- quence of a rupture or wound of the coats of the artery, receive the name of aneurisms. According to these opinions, aneurisms are of two kinds ; the first being termed true ; the second spurious or false. Some mo- dern writers have ventured to reckon another form of aneurism, which is said to happen when the exter- nal coats of an artery being weakened by mechanical injury or disease, the internal coat protrudes through the breach in the outer coat, so as to form a tumour distended with blood. This case has been denominated the internal mixed aneurism, or aneurisma herniarn arteriae sistens. The reality of this form of disease was believed by Dr. W. Hunter ; and some delicate experiments, instituted by Haller on the mesenteric ar- teries of frogs, appear to have been the first ground of the opinion. Such an aneurism, however, has not been universally admitted, not that any body doubted the correctness of what Haller advanced, but because there I might not always be a perfect analogy between the I results of an experiment on animals, and those afforded by the observation of the diseases of the human body, j Wlien Haller asserted, that by separating the mus- cular from the inner coat of the arteries he could, when he pleased, produce an aneurism in these animals ; and when Hunter declared that such an experiment made the artery firmer than ever, in consequence of the adhesive inflammation taking place ; the character and veracity of these eminent men naturally lead to the question, whether the experiments were conducted ex- actly in the same manner. Now, says Mr. Wilson, w'hen we know that Haller did not suffer the surround- ing parts to unite, and that John Hunter did, w^e can no longer be at a loss to account for the different con- clusions — (See Wilson’s Anatomy, Pathology, ’ commonly met with. — (See Lectures, vol. 2, p. 37.) The most remarkable case, however, proving the existence of a disposition to aneurisms in the whole arterial system, is mentioned by Pelletan : “ J’ai pourtant vu plusieurs fois ces nom- breux aneurismes occupant indistinctement les grosses ou les petites artdres, mais surtout celles des capacites : j’en ai comt6 soixante-trois sur un seui hoinme, depuis le volume d’une aveline jusqu’a celui de la moitie d’un ceuf de poule.” — (Clinique Chir. t. 2,p. 1.) Aneurisms, and those diseases of the coats of arte- ries which precede the formation of aneurism, are much less frequently met with in women than men. — (I.as- sus, Pathologie Chir. t. 1, p. 348.) A few years before John Hunter died, Mr. Wilson heard him remark, that he had only met with one woman affected with true aneurism. — (Anatomy, Pathology, &c. of the Vascu- lar System, p. 376.) Mr. Hodgson drew up the follow- ing table, exhibiting the comparative frequency of aneurisms in the two sexes, in different cases of this disease, and also in the different arteries of the body, as deduced from examples either seen by himself, during the lives of the patients, or soon after their death. Of the ascending aorta, the arteria in- nominata, and arch of the aorta . . Descending aorta ....... Carotid artery Subclavian and tixillary Inguinal artery Femoral and popliteal This table does not include aneurisms arising from wounded arteries, nor aneurisms from anastomosis. — (On the Diseases of Arteries and Veins, p. 87.) Sir Astley Cooper c-jnfirms the fact of the much greater frequency of aneurism in the male than the fe- male sex. Women, he says, rarely have aneurism in the limbs. In forty years’ experience, he has seen only eight cases of popliteal aneurism in women, but an immense number in men. Most of the aneurisms which he has seen in females have been in the ascending aorta, or the carotids. — (Lectures, vol. 2, p. 41.) It was observed by Morgagni, and it has been noticed in this country, that popliteal aneurisms occur with particular frequency in postillions and coachmen, whose employments oblige them to sit a good deal with their knees bent. In France, the men who clean out the dissecting rooms and procure dead bodies for anato- mists, are stud almost all of them to die with aneuris- mal diseases. Richerand remarks, that he never knew any of these persons who were not addicted to drink ing, and he comments on the debility which their in- temperance and disgusting business together must tend to produce. — (Nosogr. Chir. t. 4, p. 74, < dit. 2.) Aneurisms are supposed by Roux to be much more frequent in England than France ; a circumstance which, before he proves it to be a fact, he vaguely re- fers to the mode of life and kind of labour to which a 5 p- Males. 1 Females. 21 16 5 8 7 1 2 2 5 5 12 12 15 14 1 63 56 7 ANEURISM. 101 large portion of the population of England is subjected Indeed, he connects this surmise with a reason for the very cultivated state of this part of knowledge in Eng- land : thinks that we have been placed in favourable circumstances for perfecting the treatment of aneu- risms, and acknowledges that we have contributed more than his countrymen both in the last and present century to the improvement of this branch of surgery. — ;Roux, Parall^le de la Chirurgie Angloise avec la Chirurgie Frangoise, &c. p. 249.) But ere M Roux ventured into such conjectures, he ought at least to have specified what particular occupations and kind of labour are known by Englishmen themselves to be fre- quently conducive to aneurism; for, with the excep- tion of postillions and coachmen, of v/hom there is also abundance in France, I am not aware that any determi- nate class of persons is found in this country to be af- fected with particular frequency. In some instances aneurisms of the axillary artery appear to have arisen from violent extension of the limb. — 'See the cases recorded byPelletan in Clinique Chir. t. 2, p. 49 and 83.) In other examples related by the some practical writer, aneurism arose from reite- rated contusions and rough pressure on parts.— (Op. cit. p. 10 and 14.) The extremity of a fractured bone may injure an ar- tery and give rise to an aneurism, instances of which are recorded by Pelletan (Op. cit. t. 1, p. 178) and Durver- ney (Traite des Mai. des Os, t. 1). In Pelletan ’s case, the disease followed a fracture of the lower third of the leg. An aneurism of the anterior tibial artery from such a cause, is also described by Mr. C. White. — (Cases in Surgery, p. 141.) The following case of an aneurism of the humeral artery after amputation is recorded by Warner : C. D. was afflicted with a caries of the joint of the elbow, which was attended with such circumstances as ren- dered the amputation of the limb necessary. The ope- ration was performed at a proper distance above the diseased part, and the vessels were taken up with needles and ligatures. In a few days the humeral artery became so dilated above the ligature upon it as to be in danger of burst- ing. Hence it was judged necessary to perform the operation for the aneurism, which was done, and the vessel secured by ligature above the upper extremity of | its distended coats. Every thing now went on for some time exceedingly well, when suddenly the artery again dilated, and was in danger of bursting above the second ligature. These circumstances made it necessary to repeat the operation for the aneurism. From this time every thing went on successfully till the stump was on the point of being healed ; when, quite unexpectedly, the artery appeared a third time diseased in the same manner as it had been previously, for which reason a third operation for aneurism was determined on and performed. The last operation was near the axilla, and was not followed by any relapse. Could the several aneurisms of the humeral artery (says Mr. Warner) be attributed to the sudden check alone which the blood met with from the extremity of the ves.sel being secured by ligature ; or is it not more reasonable to suppose that the coats of the artery nearly as high as the axilla were originally diseased and weakened ? ITie latter, in the opinion of this judicious writer, seems the most probable way of accounting for the successive returns of the disease of the vessel; since it is found from experience that such accidents have been very rarely known to occur after amputa- tion, either of the arm or thigh, where nearly the same resistance must be made to the circulation in every subject of an equal age and vigour, who has undergone such operation. If it should be supposed that the several dilatations of the coats of the vessel, continues Mr. Warner, arose merely from the chock in the circulation, it will not be easy to account for the final success of this operation ; and especially when we reflect that the force of the blood is increased in proportion to its nearness to the heart.— (See Cases in Surgery, p. 1.39, 140, edit. 4.) Ruysch has related an observation somewhat similar. — 'Obs. Anat. Chir. t. 1, p. 4.) Aneurisms sometimes follow the injury of a large artery by a gun-shot wound. The passage of a bullet through the thigh, in one example, gave rise to a femoral aneurism. — (See Parisian Chirurgical Journal, vol. 2, p. 109. ) The same cause produced an aneurism high up the thigh of a soldier who was under the care of my friend Mr. Collier, at Brussels, after the battle of Waterloo. PROGNOSIS. In cases of aneurism the prognosis varies according to a variety of important circumstances. The disease may generally be considered as exceedingly dangerous ; for, if left to itself, it almost always terminates in rup- ture, and the patient dies of hemorrhage. There are some examples, however, in which a spontaneous cure took place, and aneurismal swellings have been known to lose their pulsation, become hard, smaller, and gradually reduced to an indolent tubercle, which has entirely disappeared. After death the artery in such instances has been found obliterated, and con- verted into a ligamentous cord, without any vestige of the aneurism being felt. Aneurisms are also some- times attacked with mortification ; the sac and adjacent parts slough away ; the artery is closed with coagu- lum; and thus a cure is effected. Lastly, tumours having all the character of aneurisms have been known to disappear under the employment of such pressure as was certainly too feeble to intercept entirely the course of the blood. Such examples of success, how- ever, are not common, and whenever they happen, it is because the entrance of blood into the sac is prevented by the coagulation of that already contained in it, and because the artery above the swelling is filled with coagulum. They must, in fact, have been cured on the very same principle which renders the surgical operation successful. Nothing is subject to more variety, than the duration of an aneurism previously to its rupture ; the tumour bursting sooner or later, according as the patient hap- pens to lead a life of labour, or ease, temperance, or moderation. Even the bursting of an internal aneu- rism may not immediately kill the patient ; a stone- cutter died in the hospital Saint Louis with an enor- mous aneurism, situated on the left side of the lumbar vertebrae. The body was opened by Richerand, who found that the external tumour consisted of blood, which, after making its way through the muscles, had been effused into a cyst formed in the midst of the cellular substance of the loins. The track through which it came led into another aneurismal sac con- tained in the abdomen, and situated behind the peri- toneum, on the left side of the lumbar vertebrae. In endeavouring to discover whence the extravasated blood proceeded, Richerand found that the abdominal aorta was entire, though in .Contact with the swelling. The original affection consisted of an aneurismal dila- tation of the interior portion of the thoracic aorta, which had burst at the point where it lies between the crura of the diaphram. Tiie blood had probably escaped very slowly, and it had accumulated in the cellular sub- stance round the kidnej', so that three cysts had burst successively before the patient died. — (Nosogr. Chir. t. 4, p. 82, edit. 2.) Every aneurism, so situated that it can neither be compressed nor tied above the swelling, has generally been considered absolutely incurable, except by a natu- ral process, the establishment of which is not suffi- ciently often the case to raise much expectation of a recovo’-y on this principle. But it should be recollected that sometimes the size of the swelling appears to leave no room for the application of a ligature above it, while things are in reality otherwise, in consequence of the communication between the sac and the ar- tery bearing no proportion to the magnitude of the tumour itself. At the present day, also, enlightened by anatomical knowledge, and encouraged by successftil experience, surgeons boldly follow the largest arteries, even within the boundaries of the chest and abdomen, as we shall pre.sently relate, and numerous facts have now proved that few external aneurisms arc beyond the reach of modern surgery. It being certain that aneurisms cannot commonly be cured, except by an obliteration of the affected artery, it follows that the circulation must he carried on by the superior and infe- rior collateral branches, or else the limb would mortify. Experience proves that the impediment to the jiassage of the blood through the diseased artery obliges this fluid to pass through the collateral branches, which gradually acquire an increase of size. It is therefore a common notion that it must be in favour of the success of the operation, if the disease be of a certain standing ; 102 ANEURISM. and in direct opposition to the sentiments of Kirkland, Boj er even asserts that the most successful operations have been those performed on persons who have had the disease a long while.— (Maladies Chirurg. t. 2,p. 116.) There is this objection to delay, however, that the tumour becomes so large, and the effects of its pres- sure so e.xtensive and injurious, that after the artery is tied, great inflammation, suppuration, and sloughing often attack the swelling itself, and the patient falls a victim to what would not have occurred had the opera- tion been done sooner. The large size of an aneurism, as Mr. Hodgson has rightly observed, is a circumstance which materially prevents the establishment of a collateral circulation. When the tumour has acquired an immense bulk, it has probably destroyed the parts in wliich some of the principal anastomosing branches are situated ; or by its pressure it may prevent their dilatation. — ;Oii the Dis- eases of Arteries and Veins, p. 259.) The practice of permitting an aneurism to increase, that the collateral branches may become enlarged (says this gentleman), is not only unnecessary but injurious, inasmuch as the increase of the tumour must be attended with a de- struction of the surrounding parts, which will render the cure of the disease more tedious and uncertain.— (P. 266.) The most successful operations which I have seen were performed before the aneurismal swellings were very large. However, notwithstanding the great dis- advantages of letting the swelling become bulky before the operation, the fact appears scarcely yet to have made due impression, and surgeons are yet blinded with the plausible scheme of giving time for the col- lateral vessels to enlarge ; at least, 1 infer that things are so, from having lately seen a patient who has been advised to let the operation be postponed on such a ground, though the swelling in the ham was already as large as an egg. The surgeon should not be afraid of operating, al- though appearances of gangrene may have taken place on the tumour ; for, as Mr. Hodgson remarks, should it burst afterward, it is probable that both extremities of the artery in the sac will be closed with coagulum. — (Hodgson, p. 305.) Sir Astley Cooper tied the e.xter- nal iliac artery in two cases of inguinal aneurism, when gangrene existed, and though the tumours burst no hemorrhage ensued. The coagulum was discharged ; the sac granulated ; and the sores gradually healed. — (Medico-Chir. Trans, vol. 4, p. 431.) The effects of the pressure of aneurisms upon the bones are justly regarded as an unpleasant complica- tion, when they take place in an extensive degree, and, according to writers, they may sometimes induce a ne- cessity for amputation. — (Boyer, Traite des Mai. Chir. t. 2, p. 117.) However, 1 have never seen a case of this description ; and Mr. Hodgson, as we have already ex- plained, informs us that the aflection of the bones is hardly ever attended with exfoliations, or the forma- tion of pus, so that if the aneurism can be cured, the bones will generally recover their healthy state, with- out undergoing those processes which take place in the cure of caries or necrosis. — (On Diseases of Arte- ries and Veins, p. 80.) At the same time there can be no doubt, that where the tumour has been allowed to attain a large size before an attempt is made to cure it, and where from this cause both the neighbouring soft parts and the bones have suffered considerably, the completion of a cure, that is to say, the full restoration of the use of the limb, must be far more distant than in other cases where the cure is attempted in an earlier stage. Here then we see another reason against the pernicious doctrine of waiting for the enlargement of the anastomising vessels in^ addition to that which has been urged above. The age, constitution, and state of the patient’s health are also to be considered in the prognosis ; for they undoubtedly make a great difference in the chance of success after the operation. The operation, however, should not be rejected on account of the age of the patient, if the circumstances of the case in other respects appear to demand it : for it has often succeeded at very advanced periods of life. “ 1 have seen several aneurisms cured by the modern operation in patients above sixty years of age.” — (Ilodgson, p. 304.) Similar cases have fallen under my own notice. Sir Astley Cooper, already noticed, has operated with success for a popliteal aneurism on one patient aged 85, and on another 69 years old, with the same favourable result. When an aneurism exists in the course of the aorta, the violent action of the heart, excited by an operation in the extremities, may cause it to burst, and prove in- stantaneously fatal. Two cases occurred a few years ago in this metropolis, in which the patients died from such a cause during operations for popliteal aneurisms. — (See Hodgson on Diseases of Arteries, p. 306 ; Lon- don Med. Review, vol. 2, p. 240 ; and Burns on Dis- eases of the Heart, p. 226.) Were the co-existence of the internal aneurism known, the operation for the other tumour would be improper, and the surgeon should limit the treatment to palliative means. Experience proves, however, that the circumstance of there being two aneurisms in the limb should not prevent the operation, which is to be practised at sepa- rate periods. Facts in support of this statement are quoted by Mr. Hodgson. — (P. 310.) OF THE SPONTANEOUS CURE AND GENERAL treatment of aneurisms. The obliteration of the sac in copsequence of a depo- sition of lamellated coagulum in its cavity, as Mr. Hodgson has well described, is the mode by which the spontaneous cure of aneurism is in most instances ef- fected. The blood soon deposites upon the inner sur- face of the sac a stratum of coagulum ; and successive depositions of the fibrous part of the blood by degrees lessen the cavity of the tumour. At length, the sac be- comes entirely filled with this substance, and the de- position of it generally continues in the artery on both sides of the sac as far as the giving off of the next large branches. The circulation through the vessel is thus prevented ; the blood is conveyed by collateral channels ; and another jirocess is instituted whereby the bulk of the tumour is removed. — (On the Diseases of Arteries, &;c. p. 114.) Such desirable increase of the coagulated blood in the sac is indicated by the tu- mour becoming more solid, and its pulsation weak or ceasing altogether. Another mode, in which the disease is spontaneously cured, happens as follows : an aneurism is sometimes deeply attacked with inflammation and gangrene ; a dense, compact, bloody coagulum is formed within the vessel, shutting up its canal, and completely interrupt- ing the course of the blood into the sac. Hence, the ensuing sphacelation and the bursting of the integu- ments and aneurismal sac are never accompanied by a fatal hemorrhage ; and the patient is cured of the gangrene and aneurism if he has strength sufficient to bear the derangement of the health necessarily at- tendant on so considerable an attack of inflammation and gangrene. When a patient dies of hemorrhage, after the morti- fication of an aneurism, it is because only a portion of the integuments and sac has sloughed, without the root of the aneurism, and especially the arterial trunk, being similarly affected. For cases illustrative of this statement, refer to Hodgson on Diseases of Arte- teries, p. 103, ' ; ‘‘ Q.u:e (arteriae) sanguinem fun- dunt apprehendendae, circaejue id (juod ictum est duo- bus locis deligandae intercidendmque sunt, ut in se ii)sa3 coeant, et nihilominus ora reclusa habeant.” — (De Me- dicine, lib. 5, c. 26, ^ 21.) The fact is curious, though I I mention it without the least intention of detracting from the great merits of several modern surgeons, that the Greeks were acquainted with the practice, lately recommended, of tying and dividing the trunk of the artery high above the tumour, as will appear from the following extract : — (.^hius, 4, Serm. Tetr. 4, cap. 10.; At vero quod in cubiti cavitate fit aneurisma. hoc modo per chirurgiam aggredimur : primum arteria superne ab ala ad cubitum per internam brachii parte simplicem sectionem, tribus, aut quatuor digitis infra alam, per longitudinem facimus,ubi maxime adtactum arteria occurrit : atque ea paulatim denudata, dein- ceps incumbentia corpuscula sensim excoriamus ac separamus, et ipsam arteriam caeco uncino attractam duobus fili vinculis probe adstringimus, mediamque inter duo vincula dissecamus; et sectionem polline thuris explemus, ac linamentis inditis congruas deliga- tiones adhibemns. Afterward we are directed to open the aneurismal tumour at the bend of the elbow, and when the blood has been evacuated, to tie the artery twice and divide it again. If the ancients had only omitted the latter part of their operation, they^would absolutely have left notliing to be discovered by the • moderns. This method of applying two ligatures to the artery, and dividing the vessel between them, was revived in France about sixty years ago by Tenon, who, as well as some later surgeons, was totally unacquainted with its antiquity.— (See Pelletan, Clinique Chir. t. 1, p 192.) At one time it had also modern advocates in Mr. Abernethy and Professor Maunoir of Geneva, each of whom supposed the plan an invention of his own. — (See Surgical and Physiol. Essays, part 3, 8vo. Lond. 1797 ; and Memoires Phisiologiques et Pratiques sur I’Aiieurisme, &c. 8vo. Geneve, 1802.) When an artery is laid bare and detached from its natural connexions, and the middle of such detached portion tied with a single ligature, as was Mr. Hun- ter’s practice, Mr. Abernethy conceived that the vessel so circumstanced would necessarily inflame and be very likely to ulcerate. The occurrence of bleeding from this cause at first led to a practice, which this gentleman justly censures, viz. applying a second liga- ture above the first, and leaving it loose, but ready to be tightened in case of hemorrhage. As the second ligature, however, must keep a certain portion of the artery separated from the surrounding parts, and must , as an extraneous substance, irritate the inflamed ves- sel, it must make its ulceration still more apt to follow. The great object, therefore, which Mr. Abernethy in- sisted upon, was that of applying the ligature close to that part of the artery which lies among its natural connexions ; a just principle, the truth and utility of Avhich still remain incontrovertible, though there may be a better way of accomplishing what Mr. Abernethy intended than the measures which this gentleman was led to recommend. The peculiarity in Mr. Abemethy’s first operation, consisted in applying two ligatures round the artery, close to where it was surrounded with its natural con- j nexions. For this purpose, he passed two common- sized ligatures beneath the femoral artery, and having shifted one upwards, the other downwards, as far as the vessel was detached, he tied both the ligatures firmly. The event of this case was successful. An uneasy sensation of tightness, however, extending from the wound down to the knee, and continuing for many days after the operation, made Mr. Abernethy deter mine, in any future case, to divide the artery betweerr the two ligatures, so as to leave it quite lax. Mr. Abernethy next relates a case of popliteal aneu rism, for which Sir Charles Blicke operated, and divided the artery between the ligatures. The man did not experience the above kind of uneasiness ; and no he- morrhage ensued when the ligatures came away, al- though there was reason to think, that the whole arte- rial system had a tendency to aneurism, as there was also another tumour of this kind in the opposite thigh. The reasoning which induced this gentleman to re- vive this ancient practice was ingenious; for when the artery was tied with two ligatures, and divided in the foregoing manner, it was argued that it would be quite lax, possess its natural attachments, and be as nearly as possible in the same circumstances as a tied artery upon the face of a stump. Strictly si»eaking, I however, as Mr. Hodgson first pointed out, an artery tied in two places, and divided in the intersjiace, can- not be regarded as placed exactly in the same condi- tion, as an artery tied in amputation. In the latter case, the retraction of the vessel corresponds with that of the surrounding parts, which are divided at the same instant, and therefore its relative connexions stand as belbre the operation. But in the operation for 110 ANEURISM. aneurism, the retraction of the artery takes place, without being attended with a corresponding retrac- tion of its connexions. How far the retraction of the artery is beneficial or injurious is by no means evi- dent ; and the advantages arising from it may in most situations be obtained without dividing the vessel, by placing the limb in a bent jwsition. One important object, however, is gained by the divi.sion of the artery ; namely, that it is generally in that case tied close to its connexions, and it is very evident how liable the ap- plication of the ligature in the middle of a denuded ex- tent of the vessel must be to produce ulceration or sloughing of its coats. The same object, however, will be gained by tying the undivided artery close to its connexions at the end nearest to the heart ; and the existence of a single ligature at the bottom of the wounJ will be less liable to give rise to .suppuration and the formation of sinuses than the employment of two. When an artery is divided, the portions situated beyond the ligatures must slough, and prove an addi- tional cause of suppuration in the wound. Experi- ence has amply proved the safety of employing a sin- gle ligature, and it is at present used by many of the most experienced operators in this country. — (See Hodgson on the Diseases of Arteries, &c. p. 221, .fcc.) According to Scarpa, numerous examples of the fail- ure of the plan of applying two ligatures, and cutting through the artery in the interspace, are already gene- rally known to the profession, and there are many expert and ingenious surgeons, who do not dissemble the disadvantage and uncertainty of this practice. He speaks of one failure which occurred to Mr. Abernethy himself. But I entertain doubts how far any inference against the method can be drawn from Monteggia’s in- stance, in which a ligature of reserve had been used. Nor can I understand how a circumstance which Scarpa strongly insists upon, can be well founded ; I mean the danger of the ligature being forced off the mouth of the artery by the impulse of the blood. Any risk of this kind cannot exist if the ligature be duly applied, as Dr. Jones has particularly explained ; and at all events, how can it be greater here than after amputation, where it is not usually made a subject of complaint ? Indeed the several examples of secondary hemorrhage after this method, quoted by Scarpa from the practice of Monteggia, Morigi, and .\.ssalini, may be more rationally imputed either to reserve-ligatures having been also used, or the common fear in Italy of applying the ligatures tightly ; in which event one can readily suppose that the ligature might really slip, or by remaining a long time on the vessel might give rise to dangerous ulceration. Thus Morigi speaks of one case in which the bleeding occurred on the nineteenth day. — (Scarpa on Aneurism, p. 14, ed. 2.) On the whole, I am disposed to believe, that when this method has been executed precisely according to Mr. Aberne- thy’s directions, it has not often failed ; and I am ac- quainted with only one case in London in which it wras followed by secondary hemorrhage. However, in the year 1807, Mr. Norman of Bath tied the femoral artery wth two ligatures, and divided the vessel between them ; the upper ligature came away on the sixteenth day after the operation ; the lower one on the fifteenth ; and the following day a pro- fuse hemorrhage came on, the patient losing a pound of blood. Pressure with a compress and wet bandage was continued for some time, and the wound healed. — (See Med. Chir. Trans, vol. 10, p. 123.) This is the only case of secondary hemorrhage, which he has met with after operating tor aneurisms. Scarpa very properly urges, that the application of two ligatures and dividing the artery in the interspace can never be an eligible mode, where the smallness of the space, the dejith of the artery, and the importance of the surrounding parts, do not permit the vessel to be separated and insulated to such an extent as is re quired for dividing it, with a probability of the division of it being sufficiently distant from the two ligatures. Such, for example, are the cases of ligature of the caro- tid in the vicinity of the sternum ; of the iliac above Poupart’s ligament ; of the internal iliac, a little below its origin from the common iliac ; of the axillary artery between the point of the coracoid process and the acromial portion of the clavicle; or of the subclavian in its passage between the scaleni muscles. Scarjia then comments on the difficulty and even impossibility of taking up the end of the truncated artery again iii many situations were hemorrhage to ensue ; and he joins Mr. Hodgson in thinking the advantages of the method, even where it is practicable, by no means de- monstrated. Nay, he goes farther ; for he agrees with Heister, Callisen, and Richter, in setting it down as worse than useless, on account of the portion of the artery between the ligatures being converted into a dead and putrid substance, which rests upon the bot- tom of the w'ound, from which it cannot be removed until the two ligatures are separated. Here, deeply impressed with the truth of principles which perhaps he has rather lost sight of in speaking of his own par- ticular method, he comments on the little probability of the wound uniting, under the disadvantage of tw'o ligatures hanging out of it, and of sloughs at its bot- tom. He argues correctly, that the laying bare and insulating a large portion of artery would often be ob- jectionable on the ground that it could not be done w ithout the surgeon being obliged to apply the prin cipal ligature too near the origin of a large lateral branch ; as, for example, would happen in a case of inguinal aneurism, situated an inch and a quarter be- low the origin of the profunda. Thus a coagiilum could not be formed, and the artery would be in dan- ger of not being closed. On the contrary, by employ- ing only a single ligature at an inch and a quarter be- low the origin of the profunda, the operation would be equally simple and successful. — ^Scarpa on Aneurism, p. 19—21, ed. 2.) ITie above considerations would certainly lead me to avoid the practice of detaching an artery from its surrounding connexions any more than is absolutely necessary for the conveyance of a single ligature under it ; but I fully concur with Sir Astley Cooper in the prudence of using two ligatures, and applying them in the way recommended by Mr. Abernethy, whenever the artery has been extensively separated from its sheath in the operation. — .See Lancet, vol. 1, p. 433.) The frequent occurrence of accidents after the intro- duction of Mr. Hunter’s operation might have been ascribed to more probable causes than the condition of an undivided artery, upon which the ligature was ap- plied. The employment of numerous ligatures gradu- Mly tightened, or the introduction of extraneous bodies into the wound, were alone sufficient to produce ulcer- ation of the artery ; and such practices were adopted in most of the cases in which secondary hemorrhage took place. After the reasons which have been urged against the plan of tying the artery vvith two ligatures, and dividing it in the interspace, it may appear superfluous to notice a modification of this practice, intended as a security against the slipping of the ligature. But as the proposal has had the approbation of some men of eminence, and I heard of an instance in which it was practised not long ago, the subject may still be worthy of notice. Sir Astley Cooper has published a case of popliteal aneurism, in which the femoral artery had been tied with two ligatures, as firmly as could be done without ri.sk of cutting it through. “But (says he,, as I was proceeding to dress the wound, I saw a stream of blood issuing from the artery, and when the blood was sponged away one of the ligatures was found detached from the vessel. Soon after, the other was also forced off, and thus the divided femoral artery was left with- out a ligature, and unless immediate assistance had been afforded him, the patient must have perished from hemorrhage.” The same kind of accident has occurred in Mr. Cline’s practice. For the prevention of it Sir Astley at first tried the method of conveying the liga- tures by means of two blunt needles under the arterj', an inch asunder and close to the coats of the vessel, excluding the vein and nerve, but passing the threads through the cellular membrane surrounding the artery. When these were tied, and the artery had been divided between them, the ligatures were prevented from slip ping by the cellular membrane tlu-ough which they passed. Afterw'ard, however, he preferred a different mode of securing the ligature suggested to him by Mr. H. Cline, and it was imt to the test of ex)>eriment in 0 ]>e- rating fora popliteal aneurism on Henry Figg, aged 29. “An incision being made on the middle of the inner jiart of the thigh, and the femoral artery exposed, the artery was sejiarated from the vein and nerve and all the surrounding parts, to the extent of an inch ; an ANEURISM. Ill eyc-prooe, armed with a double ligature, having a curved needle at each end, was conveyed under the artery, and the probe cut away. The ligature nearest the groin was first tied ; the other was sepa- rated an inch from the first and also tied. Then the needles were passed through the coats of the artery, close to the ligatures between them, and the ends of each thread were again tied over the knots made in fastening the first circular application of the ligatures. Thus a barrier was formed beyond which the ligature could not pass.” The event of this operation was suc- cessful. — (Med. and Phys. Journ. vol. 8.) A similar proposal appears to have been mentioned by Dionis, and to have been noticed by some subse- quent writers. In the 13th chapter, in Richter’s An- fangsgriinde der Wundarzneykunst, we read the fol- lowing passage : “ The artery when drawn out, is to be twice sur- rounded with the common ligature. This is to be tied in a knot, and, when the artery is targe, one end of the ligature is to be passed by means of a needle through the vessel before the knot, then both ends are to be tied together and left hanging out of the wound as in the ordinary way.”— (Ed. 3, 1799.) What power can possibly force the ligature, when tied with due tightness, off the extremity of the vessel 1 No action of the heart or artery itself, no turgid state of this vessel, could do so. If a piece of string were tied round any tube for the purpose of preventing a fluid from escaping from its mouth, provided the string were applied with due tightness, and the knot in such a manner as not to yield, no fluid could possibly escape, however great the propelling power might be, as long as the string and structure of the tube did not break. And if a ligature were applied so slackly as to slip, who can doubt that hemorrhage would still follow, even though the ligature were carried through the end of the vessel and tied in the foregoing way? Where ligatures have slipped off very soon after being applied, I conclude that the arteries either could not have been tied with sufficient tightness, perhaps through an unfounded fear of the ligature cutting its way completely through all the coats of an artery, or else that the knot or noose became slack from causes which will be understood by considering what is said on this matter in the article Hemorrhage. The inner coats of the artery, we know from the experiments of Dr. Jones, ought to be cut through when the artery is properly tied, because the circumstance is always use- flil in promoting the effusion of lymph within the ves- sel, and the process of obliteration by the adhesive inflammation. The preceding method is so contrary to the grand principle of always avoiding the detachment of the artery from its surrounding connexions, and is so in- consistent with the wise maxim of doing the operation with as little disturbance of the vessel as possible, that it is not surprising that it should have met with only a small number of followers. In fact, it is not only liable to every objection which can be urged against the double ligature and division of the artery, as formerly proposed by Celsus and a few of the moderns, but on account of its greater tediousness, more extensive sepa- ration and destruction of the vessel, and other reasons, is still less worthy of imitation. With respect to ligatures of reserve, the interposition of agaric, cork, and other hard substances between the knot and the artery, these contrivances are now so fully rejected by all good surgeons, for reasons Avhich will be quite intelligible after the perusal of an- other part of this work (see Hemorrhage), that I shall not at present detain the reader with animadversions on their danger. As for several kinds of metallic com- pressors intended to be applied to the exposed artery for the purpose of rendering it impervious, they are inventions which have been made and extolled by some surgeons of high repute, whose names would give im- portance even to a less meritorious proposition. Dubois conceived that hemorrhage might sometimes proceed from the circumstance of a ligature making its way loo fast through the artery. He thought, also, that the sudden stoppage of the current of blood by a tight ligature might bring on gangrene of the limb, particularly when the aneurism was not of long stand- ing, so that the collateral branches had not had time to enlarge. Dubois, therefore, proposed a method of gradually stopping the flow of blood through the artery ; and by tms ingenious imitation of the process of na* ture, to promote the gradual dilatation of the collateral arteries, and obviate all risk of gangrene in the lower part of the limb. This gentleman put his plan in exe- cution, and two instances of success are recorded. The cases were popliteal aneurisms. A ligature was passed under the artery in the manner of Hunter ; its two ends were then put through an instrument called a sorre-ncBud, with which the compression was gra- dually increased. It is stated, that in one of these cases the plan made the artery inflamVand become im- pervious in the course of the first night, so that on the following day the throbbing of the tumour had ceased. — (Richerand, Nosogr. Chir. t. 4, p. 109, edit. 4.) Here, however, it is to be suspected that the pressure of the apparatus was greater than was calculated ; and that the stoppage of the pulsation was more owing either to this cause, or to the coagulation of the blood in the sac and adjoining portion of the artery, than to the process of obliteration, which could hardly have been so rapidly accomplished. Assalini’s compressor is an instrument calculated, as its inventor states, to produce an obliteration of the trunks of arteries, without dividing or injuring their coats. It is nothing more than a small pair of silver forceps, the blades of which are broad and flat at their extremities, between which the artery is compressed. A spring, composed of a piece of elastic steel, is at- tached to the inside of one of the handles, and by pressing against the opposite handle retains the flat ends of the blades in contact. This spring is intended to be very weak in its operation ; but by means of a screw, which passes through the handles, the pressure admits of being regulated and increased at the option of the surgeon. A representation of Assalini’s compressor may be seen in his Mannale di Chirurgia, parte prima, p. 113. In the same book, or in my friend Mr. Hodgson’s valu- able Treatise on the Diseases of Arteries and Veins, which every practical surgeon ought to possess, a case may be perused in which this instrument was success- fully employed by Professor Monteggla, and withdrawn entirely as early as sixty hours after its application. Tliis last distinguished surgeon also used the compres- sor in an example in which the femoral artery was wounded and bled in an alarming degree. After forty hours the pressure was lessened, and in four hours more, as not a drop of blood issued from the vessel, and there seemed to be no good in leaving an extra- neous body in the wound any longer, the instrument was taken out altogether.— (See Assalini’s Manuale di Chirurgia, p. 110.) When Assalini was in England, he acquainted Mr. Hodgson that in two cases of popliteal aneurism, in which he had himself employed this means gf oblite- rating the femoral artery, the instrument was removed at (he expiration of twenty-four hours ; no pulsation returned in the tumours ; and the patients were speed- ily cured. With respect to the particular merit of this inven- tion, it certainly posse-^ses the recommendation of in- genuity ; but it operates much in the same manner as several other mechanical contrivances, the serre-nceud of Desault, the presse-art^re of Deschamps, that of Mr. Crarnpton (see Med. Chir. Trans, vol. 7), the pincers of Baron Percy, &c. If there be a real advantage in the division of the internal coats of an artery by the ligature, as the experiments of Jones seem to prove, and as many of the best surgeons in this country in- culcate (.see Hemorrhage and Ligature), then the com- pressor cannot be an eligible means of obliterating an artery. It may be said, however, that experience has proved its eflicacy ; but let it be recollected, that al- most every method of operating for aneurisms has sometimes answered. Farther experience is requisite to determine whether Assalini’s compressor would succeed as often as, or more frequently than, the scien- tific application of the right kind of ligatures (see Liga- ture), which may perhaps soem slower in their effect, only because they are not in general removed as early as Assalini’s instrument. In fact, the experiments of Mr. Travers have now proved that the ligature is the quickest in its pperatio'n. — (See Med. Chir. Trans, vol. 6, p 643, &c.) In 1816, some ingenious observations were publi.shed by Mr. Crarnpton, on the effects of the ligature and of compression in obliterating arteries. The purport of 112 ANEURISM. his remarks is to prove, like the later observations of Scarpa: 1st, That the obliteration of an artery can very certainly be effected, independently of the rupture or division of any of its coats ; 2dly, That this operation the ligature, so far from being essential to the process not unfrequently defeats it— (See Med. Chir. Trans, vol. 7, p. 344, 345.) With respect to the first of these assertions, I pre- sume that all practical surgeons have known and ad- mitted it, especially if the words very certainly be left out. Every system of surgery for half a century past, has recorded the occasional cure of aneurism by differ- ent modes of compression, by which the adhesive in- flammation is excited in the artery, or the coagulation of the blood in the aneurismal sac brought about. As, however, the most experienced surgeons have found the method less certain than the use of the ligature, it is not represented by any modern writers as deserving equal confidence ; though there are circumstances, in which simple pressure may be sometimes tried with the hope of doing away all occasion for an operation. The cases, however, in which compression is applied directly to the artery itself by means of ligatures, with the intervention of other substances as advised by Scarpa, &c. or by various contrivances, like those of the serre-nceud, the presse-artdre, and Assalini’s for- ceps, all require the exposure of the artery ; and if commendable, therefore, cannot be so on the principle of saving the patient the pain of an operation, but be- cause they are more effectual than the employment of the ligature. This last point remains to be proved. From the comparatively small number of instances in which the preceding modes of compression have been practised, several examples of failure might be quoted. With regard to Mr. Crampton’s second assertion, that the division of the inner coats of the vessel, so far from being essential to the process of obliteration not unfrequently defeats u, I think the last part of the ob- servation is altogether unproved. We must admit that the division of the inner coats is not essential, because arteries sometimes become obliterated under a variety of circumstances in which such division is not made ; but still the great question remains whether it renders the process more certain. Mr. Crampton founds his conclusion, that it not unfrequently prevents the oblite- ration and gives ri the 8th day after the operation 1 The salivation appeared to be connected with the state of the digestive appara- tus ; for, as soon as ale and a generous diet were al- lowed, it gradually subsided. I am at a loss to assign the cause of the numbness and debility of the whole of the right side of the body (which were only observed when he first left his bed), unless they originated in a greater quantity of blood circulating in the left hemisphere of the brain than in the right, which undoubtedly would be the case after the application of a ligature to the common carotid. What tends to confirm this opinion is, that now (13 weeks after the operation) the balance of circulation in the brain being re-established, the numbness and debi- lity of the right side of the body have nearly disappeared. In conclusion, it is worthy of notice, that, since the operation, he has become more irritable in temper, and his memory is evidently weaker. So far as this ca.se has yet proceeded, it amply jus- tifies the operation; and the man probabl ow'es his life to Mr. Wardro])*s fortunate suggestion and exam- ple. Should any untoward circumstance occur, lead- ing to any other conclusion, it shall be communicated. It is now five weeks since he resumed his usual avocations, and he regularly attends the markets and fairs of Derby, a distance of seven miles. — Reese.) That Brasdor’s operation must sometimes fail, and par- ticularly that it should have failed in the trials made of it by Deschamps and Sir A. Cooper, is not at all sur- prising. These cases w’ere both inguinal aneurisms ; and it does not follow, because the method will answer in carotid aneurisms, that it will answer in aneurisms in every other situation. I should say, indeed, that unless it retard, in a certain degree, the circulation through the sac, it will never answer in any case; and how much this must depend upon the existence or not of one or more branches between the sac and the ligature, is completely obvious. The memorable instance in which Sir A. Cooper tied the aorta, in a case of inguinal aneurism, extending very high up, and already burst, I shall notice under the head Aorta. I shall finish these general observations on the treat- ment of external aneurisms, or such as admit more particularly of surgical treatment, with observing, that in England, surgeons now lose few patients either from gangrene in the limb or secondary hemorrhage ; and this, notwithstanding they may sometimes prefer ap- plying a ligature above the profunda to cutting open the aneurisrnal tumour. I firmly believe, that such matchless success is to be totally ascribed to their per- fections in the mode of operating; the choice of a proper kind of ligature ; the right plan of applying it ; the rejection of the employment of several ligatures at a time ; and the great care which is taken to promote the healing of a wound as quickly as possible ; the avoidance of all unnecessary and hurtful extraneous substances in the wound ; and above all, the relin- quishment of the formidable proceeding of cutting open the tumour. In the consideration of particular aneurisms, I shall begin with those which may be cured by a surgical operation : and here we shall be fully satisfied that “ Part de guerir ne triomphe jamais plus heureusement que lorsqu’il peut employer la mddecine efficace, e’est a dire, les moyens chirurgicaux ou operatoires.’'-^^ei- letaii, Clinique Chir. t. l,p. 110.) OF THE POPLITEAL ANEURISM, AND OPERATION FOR ITS CURE. Notwithstanding the solitary example in wliich M. A. Severinus, early in the 17th century, tied the femo- ral artery near Poupart’s ligament in a case of aneu- rism {De Efficac. Med. lib. 1, p. 2, c. 51), the practice of tying arteries wounded either by accident or in the per- formance of surgical operations, and even the plan of tying the humeral artery for the cure of the aneurism at the bend of the arm, were known long before the operation for the relief of the popliteal aneurism was attempted. The considerable size of the femoral artery, its deep situation, the urgent sjTnptoms of the disease, and ignorance of the resources of nature for transmit- ting blood into the limb after the ligature of the vessel, are the circumstances which appear to have deterred former surgeons from this operation. Valsalva treated popliteal aneurisms on the debilita- ting method, and published one or two equivocal proofs of its success. In Pelletan’s first memoir on aneuri.sm, and in the third vol. of Sabatier’s Medecine Operatoire, as I shall hereafter notice again, are two cases of axil- lary aneurisms, which were cured by Valsalva’s treat- ment. But encouraging as such examples may be, experience is not yet sufficiently favourable to this practice to allow it to bear a comparison in point of efficacy with the surgical operation, or to justifv the general rejection of this last more certain means ol‘ cure. As Pelletan admits, Valsalva’s treatment is ex- tremely severe ; the event of it doubtful ; and should the plan fail, the patient might not be left in a condition to bear an operation, for the success of which it seems necessary that a certain strength of vascular action should exist, in order that the blood may be freely transmitted through such arterial branches as are to supply the places of the main trunk after it has been tied. The time, therefore, has not yet arrived when surgi- cal operations for the relief of aneurisms should be re- linquished. — {Clinique Chir. t. l,p. 114.) The cure of popliteal aneurisms by means of com- pression is occasionally effected ; but it happens too seldom to claim a great deal of confidence, or to lessen in any material degree the utility and importance of operative surgery in this part of practice. Pelletan records the cure of one popliteal aneurism by compres- sion and absolute repose during eleven months {t. 1, p. 115); Boyer relates two instances ( TVaftc des J/af. Chh. p. 204, t. 2); one is mentioned by llicherand Diet, des Scieiices Mid. t. 2, p. 96); the practice of Dubois is said to iKive ftirnished several examples of ANEURISM. 119 the same success {vol. cit. p. 97) ; and a case, in which Dupuytren effected a cure by compressing the femoral artery by means of an instrument applied just above the place where the vessel perforates the tendon of the triceps muscle, is detailed by Breschet. — {FV. transl. of Mr. Hodgson's work, t. 1, p. 249, iSc.) The circumstances under w'hich the employment of compression affords the best chance of success have been already mentioned, as well as the prudence of as- sisting this plan with perfect quietude, venesection, spare diet, and cold astringent applications, especially ice, which was first recommended by Donald Monro, and subsequently highly praised by Guerin. Aneurisms in general, and among them the popliteal case, are all attended with some little chance of a spon- taneous cure ; yet this desirable event is too uncom- mon to be a judicious reason for postponing the opera- tion, especially as it is the usual course of the disease to continue to increase ; while in the early stage the cure may be more speedily accomplished. In fact, the experience of modern operators leaves no room for ap- prehending that the anastomoses will not suffice for the due nourishment of the leg, and consequently proves that waiting beyond a certain time for the enlargement of the collateral vessels to take place is altogether an unnecessary and disadvantageous method. Popliteal aneurisms, as well as other external tumours of the same nature, stand the best chance of a spontaneous cure, when any cause induces a general, violent, and deep inflammation all over the swelling ; for then the communication between the sac and the artery is likely to become closed with coagulating lymph, and the pul- sation of the tumour to be suddenly and permanently stopped. If in this state the disease sloughs, and the patient’s constitution holds out, the coagulated blood in the sac and the sloughs are gradually detached, leav- ing a deep ulcer, which ultimately heals. An example, in which a popliteal aneurism was cured by such a process, is related in the Trans, for the Improvement of Med. and Chirurgical Knowledge, vol. 2, p. 268. In former times, when all hopes of curing a popliteal aneurism by Valsalva’s method, by compression, or a natural process, were at an end, amputation of the limb was considered as the sole and necessary means of saving the patient’s life. But about fifty years ago, the confidence of surgeons in the sufficiency of the anastomosing vessels or the continuance of the circu- lation began to increase, and, in opposition to the tenets of J. L. Petit and Pott, experience soon proved, that in general, not only might the patient’s life be saved, but his limb also, and this without any operation that could be compared with amputation in regard to se- verity. On looking back to the history of amputation, we shall find that A. N. Guenault was one of the ear- liest writers who disapproved of amputation as not truly indispensable for the cure of popliteal aneu- rism. It is alleged that Teislere, Molinelli, Guatlani, Ma- zotti, and some other celebrated Italian surgeons, were the first who ventured to tie the popliteal artery for the cure of aneurism. The path, as Pelletan remarks, had been pointed out to them by Winslow and Haller, whose valuable descriptions and plates of the arterial anastomoses about the knee-joint, showed by what means the lower part of the limb would be nourished, after the ligature had been placed on the principal arte- rial trunk. For almost thirty years, however, the practice of tying the popliteal artery was confined to the Italian surgeons. Pelletan believes that he was the first who attempted such an operation at Paris nearly thirty years ago (alluding to about the year 1780, the Clinique Chirurgicale being dated 1810). However, this operation of opening the tumour and tying the popliteal artery itself, was a severe and ofien fatal proceeding, and does not admit of being compared with the Hunterian operation, in point either of sim- plicity, safety, or success, as I shall explain, after the detail of a few particulars relating to the popliteal aneurism. On whatever side of the artery the tumour is pro- duced, it can be plainly felt in the hollow between the hamstrings, and in general its nature is as easily as- certained by the pulsation in every jiart of the tumour. Though the disease may not occur in the iiopliteal artery so often as in the aorta itself, U certainly is seen more frequently in the former vessel than any other branch wliich the aorta sends off. As Sir E. Home has observed, this circumstance has never been satis- factorily explained ; and, what is rather curious, in many recent instances of this disease the patients have been coachmen and postillions. Morgagni found aneu- jsisms of the aorta most frequent in guides, postboys, and other persons who sit almost continually on horse- back ; a fact, which he imputes to the concussion and agitation to which such persons are exposed. Some allusion to this subject has already been made in the foregoing pages. Whether an explanation of the fre- quency of popliteal aneurisms can be correctly referred to the obstruction which the circulation in the artery must experience when the knee is in a state of flexion, may be questioned, though it is on a similar principle that the great frequency of aneurisms of the curvature ol' the aorta is attempted to be solved. — {Home in Trans, for the Improvement of Med. and Chir. Know- ledge, vol. 1, iS'C. and Monro in Ed. Med. Essays, vol. 5.) Were this the only, or even the principal cause, surely one would have reason to expect aneurisms to be at least as frequent in the axilla, and in the bend of the elbow, as in the ham. The popliteal aneurism was generally supposed to arise from a weakness in the coats of the artery, inde- pendently of disease. If this were true, we might rea- sonably conclude, that except at the dilated part the vessel would be sound. Then the old practice of opening the sac, tying the artery above and below it, and leaving the bag to suppurate and heal up, would naturally present itself. As the arterial coats were found to be altered in structure higher up than the tu- mour, and the artery immediately above the sac sel- dom united when tied, but, when the ligature came away, the patient was destroyed by hemorrhage, Mr, Hunter concluded, that some disease affected the coats of the vessel before the actual occurrence of aneurism,. Dissatisfied with Haller’s experiments on frogs, show.- ing that weakness alone could give rise to aneurism, he tried what would happen in a quadruped, whose vessels were very similar in structure to the human. Having denuded above an inch of the carotid artery of a dog, and removed its external coat, he dissected off the other coats, layer after layer, till what remained was so thin, that the blood could be seen through it. In about three weeks the dog was killed, when the wound was found closed over the artery, which was neither increased nor diminished in size. It being conjectured that the prevention of aneurism, perhaps arose from the parts being immediately laid down on the weakened jiortion of the artery. Sir E. Home stripped off the outer layers of the femoral artery of a dog, placed lint over the exposed part of the vessel to keep it from uniting tp the sides of the wound, and in six weeks killed the animal and injected the artery, which was neither enlarged nor diminished, its coats having regained their natural thickness and appear- ance. These experiments strengthened Mr. Hunter’s belief that aneurismal arteries are diseased ; that the morbid affection frequently extends a good way from the sac along the vessel ; and that the cause of failure in the old operation arose from tying a diseased artery, which was incapable of uniting before the ligature separated. These reflections led him to propose taking up the artery in the anterior part of the thigh, at some dis- tance from the diseased portion, so as to diminish the risk of hemorrhage, and be enabled to get at the vessel again in case it should bleed. The stream of blood into the sac being stopped, he concluded that the sac and its contents v/ould be absorbed, and the tumour gradually disappear, so as to render any opening of it unnecessary. [Dr. David Hosack was the first surgeon who per- formed tliis Qperation in America, which he did suc- cessfully as early as 1808. Three cases of aneurism were cured by him, by the ligature of the femoral arte- ry, and will be found reported in his valuable volume of “ Essays on Medical Science,” by which it will be seen, that this distinguished gentleman in the former* part of his life was an operative surgeon of more than ordinary skill. He has since devoted his energies to teaching the theory and practice, and in the less osten- tatious character of a general practitioner has acijuired a reputation second only to Rush, with whom his name will be transmitted to posterity as among the most eminent in their profession in this or any other 120 ANEURISM. country. He began his distinguished career as a sur- geon, and, like many others, thus laid the foundation of professional distinction. — Reese.] The first operation of this kind ever done was per- formed on a coachman by Mr. Hunter, in St. George’s Hospital, December, 1785. An incision was made on the anterior and inner part of the thigh, rather below its middle, which wound was continued obliquely across the inner edge of the sartorius muscle, and made large in order to facilitate the performance of- whatever might be necessary. The fascia covering the artery was then laid bare for about three inches, after which the vessel itself could be felt. A cut about an inch long was then made through the fascia, along tlie side of the artery, and the fascia dissected off. Thus the vessel was exposed. Having disengaged it from its connexions by means of the knife and a thin spatula, Mr. Hunter put a double ligature under it with an eye-probe. The doubled ligature was then cut, so as to make two separate ones. The artery was now tied with both these ligatures, but so slightly as only to compress the sides together. Two additional ligatures were similarly applied a little lower, with a view of compressing some length of artery, so as to make amends for the want of tightness, as it was wished to avoid great pressure on any one part of the vessel. The ligatures were left hanging out of the wound, which was closed with sticking jilaster. On the second day, the aneurism had lost one-third of its size, and on the fourth, the wound was every where healed, except where the ligatures were separated. On the.ninth, there was a considerable discharge of blood from the apertures of the ligatures, but It ceased on applying a tourniquet, and did not recur. On the fif- teenth day after the operation, some of the ligatures came away, followed by a small quantity of matter ; and about the latter end of January, 178G, the man went out of the hospital, the tumour having become still less. In the course of the spring, abscesses in the vicinity of the cicatrix followed, and some pieces of ligature were occasionally discharged. In the begin- ning of July, a piece of ligature about an inch long came away, after which the swelling went off' entirely, and the man left the hospittd again on the 8th, per- fectly well, there being no appearance of swelling in the ham. This subject died of a fever in March, 1787 ; and oil dissection, the femoral artery was found im- ])crvious from the giving off" of the arteria profunda down to the place of the ligature, and an ossification had taken place for an inch and a half along the course of this part of the vessel. Below this portion the ves- sel was pervious, till just before it came to the aneu- rismal sac, where it was again closed. 'What re- mained of the sac was somewhat larger than a hen’s egg, and it had no remains of the lower opening into the popliteal artery. The rest of the particulars of this dissection are very interesting. — See Trans, for the Improvement of Med. and Chir. Knowledge, vol. 1, p. l.-iS.) This celebrated case completely established the im- portant fact, that simply taking off the force of the circulation is sufficient to cure an aneurism, as the tumour is afterward diminished and renioved by the action of the absorbent vessels. In order to confirm the same fact, Sir E. Home re- lated a case of femoral aneurism which got well with- out an operation, but on a similar principle to what occurs when the artery is tied. A trial of pressure had been made without avail. The tumour became very large, and such inflammation took place in the sac and integuments that mortification was impending: no pulsation .could now be felt in the timiour, or the artery above it. The correct inference of Sir E. Home was, that a coagulum, which we know always occurs in an artery previously to mortification, seemingly to prevent bleeding, had formed in this instance, and in conjunction with the effusion of coagulable lymph about the root of the aneurism, had kept the blood from entering the sac. Mr. Hunter’s second' operation was on a trooper. Instead of using several ligatures, wliich were found hurtful, he tied the artery and vein with a single strong one; but unluckily the experiment was made of dress- ing the wound from the bottom, instead of attempting to unite it at once ; and the event was, that the man died of hemorrhage. After this case Mr. Hunter’s practice was to tie the artery alone with one strong ligature, and unite tha wound as speedily as possible. Having recorded Mr. Hunter’s cases, which first es- tablished the present method of operating for tlic cure of popliteal aneurisms, I shall not repeat the strong reasons which exist against the employment of reserve- ligatures ; metallic compressors ; two ligatures, with the division of the vessel between them ; the interpo- sition of pieces of linen, wood, cork, agaric, &c. be- tween the knot and the vessel ; the use of large liga- tures ; and other contrivances, the merits or rather demerits of which have been already fully considered in the preceding section. My next duty is, to explain the method of performing the Hunterian operatioa, as brought to its modern state of improvement, and adapt- ed to the M'ise principles which first emanated from the valuable experiments and investigations of Dr. Jones. — (See Hemorrhage.') In the arrangement of the assistants, one of them should be so placed, that if required, in consequence of any accidental wound of that vessel in the operation, he can compress the femoral artery as it passes over the brim of the pelvis : but, as Scarpa justly observes, no pressure of this kind is to be made, unless the acci- dent referred to should happen, because the pulsations of the artery, inasmuch as they indicate the track of the vessel, must tend materially to facilitate the opera- tion. The surgeon is to explore with his fore-linger the course of the artery from the crural arch down- wards, and when he comes to the place, where the vibration of this vessel begins to be less distinctly felt, this point is to be fixed upon for the lower end of the external incision. This angle of the wound will fall nearly on the inner edge of the .sartorius, just where this muscle crosses the track of the femoral artery, and at the very apex of the triangle formed by the con- vergence of tile triceps and vastus internus. A little more than three inches above the place here fixed upon, the surgeon is to begin with a convex -edged bis- toury the incision through the integuments and cel- lular substance, and carry the wound down the thigh in a slightly oblique line from without inwards, so as to make it follow the course of the artery, as far as the apex of the above-mentioned triangular space, or the point where the vessel passes under the inner edge of the sartorius muscle. In order to make this first exter- nal incision with correctness, I consider it a good rule always to take particular notice of the line described by the sartorius on the thigh, the inner margin of which muscle at the place where it meets the artery, as we have seen, forms at once the lower boundary of the incision, and an important guide to the vessel itself. By observing the track of the sartorius attentively, we shall likewise avoid all^chance of making the wound too low down, so as to have this muscle intervening between the in- cision and the artery ; a greater source of embarrass- ment in the operation, and of troublesome consequences afterward, than perhaps any other error ; for when this has happened, and the surgeon has not room enough afforded by the higher part of the wound to get at the artery above the sartorius, he is compelled to dissect and raise up this muscle from its natural connexions, ere he can plainly discover the vessel. This inconve- nience made a deep impression on me in the first case where I tied the femoral artery ; for the intervention of the sartorius in a stout soldier upon whom the ope- ration was done, threw me into the dilemma of either dissecting at the outer edge of this muscle, and draw- ing it inwards, or of enlarging the wound upwards. The latter proceeding was that to which I gave the pre- ference, because it seemed to me an excellent maxim in this ojjeration to avoid making any farther detachment of parts from their natural connexions than is abso lutely necessary ; and I knew that when the wound was extended a little higher up, the artery would pre- sent itself more superficially, quite unconcealed by any muscle whatever. Strongly, therefore, as my prin- ciples have led me to condemn Scarpa’s modification of the ligature, his use of from four to six threads, and his interposition of a roll of linen between the knot and the vessel, I feel plea.surc in expressing my con- viction of one excellence in his mode of operating ; an improvement which is now obtaining, if it has hot al- ready obtained, the universal approbation of the sur- gical profession. This amendment consists in making the incision in the upper third of the thigh, or a little higher than the place where Mr. Hunter used to make ANEURISM. 121 the wound. Scarpn’s reason for this practice is to avoid the necessity of removing the sartorius muscle too much from its position, or of turning it back, to bring the artery into view, so as to be tied. I have seen the best operators, even professors of anatomy, embarrassed by having the sartorius muscle imme- diately in their way after the first incision ; and as the vessel is more superficial a little higher up, the place is farther from the diseased part of the artery, and there is no hazard of the anastomoses failing to keep up the circulation : this part of Scarpa’s practice is highly deserving of imitation. “ The part of the limb (observes Mr. Hodgson) in which the femoral artery can be tied with the greatest facility, is between four and five inches below Pou- part’s ligament. The profunda generally arises from the femoral artery an inch and a half or an inch and three-quarters below Pou part’s ligament ; it very rarely arises so low as two inches. If, therefore, the ligature be applied to the femoral artery at the distance of four or five inches below Poupart’s ligament, the surgeon will not be embarrassed by meeting with the profunda during the operation, and the chance of causing se- condary hemorrhage, by tying the artery close t(* the origin of this vessel, will be obviated.” — (On the Dis- eases of Arteries^ «S-c. p. 434.) The trouble arising from cutting too low down, so as to have the sartorius intervening between the outer wound and the artery, may be more accurately estimated, when it is known that Desault, for the re- moval of this inconvenience, considered it right actu- ally to make a complete transverse division of that muscle, a thing which, it is said, may be done without any ill consequences. — (Boyer, Traiti des Mai. Chir. t. 2, p. 145.) I shall not presume, however, to second this last piece of advice, because, though it may have been done by Desault, it appears to me that the artery can always be taken up very well without the pro- ceeding here recommeaided. A few years ago Mr. C. Hutchison published a tract, in which he is an advocate for the practice of making the incision at the outer edge of the sartorius, and then raising that muscle and drawing it inwards, in order to arrive at the artery. This advice proceeded from the apprehension that the plan of taking up the femoral artery at the inner edge of the sartorius was attended with risk of injuring the saphena vein and large lym- phatics. — (Letter on the Operation for popliteal Aneu- rism, 1811.) The same method is commended by Boyer and Roux (Nouveaux EUmetisde Med. Operatoire, 1. 1, p. 729), when the operation is done low down in the thigh. But as oprating in this situation is liable to the several objections of ajtproaching too near the dis- ease, of aiming at taking up the artery where it lies more deeply than it does higher up, and of every in- convenience which may arise from the interposition, dissection, and reflection of the sartorius muscle, the method must be rejected, unless it can be proved that so many disadvantages are fully counterbalanced by other considerations. If the plan which I shall pre- sently recommend be adopted, there will never be the slightest risk of wounding the saphena vein : and, therefore, I do not consider it advisable or necessary, for the avoidance of this accident, to make the wound precisely upon the sartorius, as my intelligent friend Mr. Hodgson suggests ; a method attended with the inconvenience of having the fibres of that muscle be- tween the external wound and the artery, and perhaps inconsistent with the excellent directions which he af- terward delivers concerning the right mode of per- forming the external incision, when he says, with Scarpa, that this cut should be “ continued down to the fibres, which form the inner margin of the sarto- rius.” — (On, the Diseases of Arteries, (Vc. p. 436.) Now, if the point where this margin first lies over the artery be the proper place for the lower termina- tion of the external incision, we shall clearly be devi- ating from the precise course of the vessel by letting the higher portion of the wound be over the fibres of that muscle. And when it is farther reflected, that the serious evils of wounding the trunks of the lym- phatics in this operation are not demonstrated in mo- dern practice, while the saphena vein may always be avoided with certainty and facility, I cannot admit, that there is any solid reason for letting the situation and direction of the external wound be determined by such apprehensions. At all events, for the motives above explained, it should be a fixed maxim in this operation never to extend the wound lower than the point where the inner margin of the sartorius crosses the artery : and then all detachment and displacement of this muscle will be unnecessary, and every embar- rassment which might proceed from its interposition between the outer wound and the artery, will be com- pletely avoided. With the view of preventing injury of the femoral vein, Mr. Cannichael recommends the needle to be in- troduced on the pubal side of the artery, where the vein presents itself to view, and can be most easily avoided. He remarks, that the only part of the thigh from Poupart’s ligament to the tendon of the triceps, in which the femoral vein is not completely covered by the artery, lies within the space which extends from Poupart’s ligament to the point where the artery meets the sartorius muscle. At the part of this space most distant from Poupart’s ligament, the vein begins to disclose itself at the pubal side of the artery, from be- neath which it emerges more and more as it ascends. — (See Trans. S,-c. of the Fellows, 4-c. of the King's and Queen's College of Physicians, Ireland, vol. 2, p. 357.) The skin and cellular substance are to be divided in the situation and to the extent above specified, down to the femoral fascia, under which the artery lies, and may be felt beating. The next object, therefore, is, to divide the fascia, which is here much thinner than at the outer side of the limb, and may be cut with another stroke of the bistoury ; or (what is safer, with the view of abstaining from all chance of wounding the artery), a slight cut may first be made in the fascia, the division of which may then be made to the requisite extent by introducing under it a grooved director, on which the farther incision may be made with perfect security. Tlie fascia is to be divided in the direction of the external wound ; but to what extent, is a point on which surgical writers differ, and, indeed, they must here differ, as long as they are not unanimous about the method of applying the ligature round the artery ; because if it be intended to use a broad liga- ture, with a cylindrical piece of linen interposed be- tween it and the artery, or especially if it be designed to apply two ligatures and divide the vessel in the in- terspace, more of the artery must be exposed, and of course more of the fascia must be cut, than when it is simply meant to surround the vessel .with a single small ligature. Such operators also as have contracted the pernicious habit of insulating the artery all round sufficiently far to let them thrust their fingers under it, will likewise require an extensive opening in the fascia. This detachment of the vessel for an inch or more, for the purpose of placing the finger under it, is a mea- sure which deserves to be condemned in the strongest terms, as it is the very thing which produces some risk of injuring the saphena vein, and has a tendency to bring on secondary hemorrhage, inasmuch as it oc- casions unnecessary handling, stretching, and disturb- ance of the artery and surrounding parts, and an in- evitable division of the vessels by which the arterial coats are supplied with blood. According to Mr. Hodgson, the extent of the cut in the fascia should be about an inch; for he wisely avoids all unnecessary separation of the artery from its surrounding parts. On the contrary,.^j^a, who insulates and raises the vessel, previously tS^ying it, insists upon the prudence of cutting the fascia the whole length of the external wound ; for, says he, if this practice be neglected, it most frequently happens, that in the succeeding inflammatory stage, the bottom of the wound swells and becomes very tense, and the matter which is formed under the fascia, not finding a ready exit, occasions abscesses which seriously retard the cure. Btit Scarpa, instead of planning a method of relieving the consequences, might have employed him self more to the purpose in considering how they were to be prevented, and why in his method they most fre- quently happen. Now, without laying any stress upon two waxed ligatures, each composed of six threads, with an additional extraneous substance, viz. a roll of linen, in the noose, we should be more surprised to hear that the wound after his method did not become affected with swelling, tension, and suppuration, than that these were the usual effects. After describing the division of the fascia, he observes : “ IVith the point of the fore-finger of the left hand, already touch- ANEURISM. ing the femoral artery, the surgeon will separate it from the cellular substance, which ties it laterally and posteriorly to the contiguous muscles ; and making the point of the same finger pass gradually uyider and behind the femoral artery (supposing the sur- geon has not enormously large fingers), he will raise it alone from the bottom of the wound, or (when it cannot be avoided) along with the femoral vein. If it is along with the femoral vein, the surgeon, hold- ing the artery and vein thus raised, and almost out of the wound, will cautiously sejmrate the vein from the artery with a bistoury or spatula, or simply with his fingers," &c.— (See Scarpa on Aneurism, p. 280, ed. 2.) \Vhen we combine the irritation and mischief of all this work with the ill effects of filling the bottom of the wound with soft lint, I would ask, what more cer- tain plan could Scarpa or any other person have sug- gested for bringing on the unpleasant state of the wound which he describes as most frequently tak- ing place 1 I shall suppose the fascia has now been divided, un- der which the surgeon distinctly fe'els the pulsations of the femoral artery, whiclj is still invested by the cellular sheath. The femoral vein lies directly under this vessel, while the branches of the anterior crural nerve, separated from it by dense cellular substance, are more externally, yet somewhat more deeply situ- ated. The next object, therefore, is to pass a single ligature round the artery, without including, or in any manner meddling with, the subjacent femoral vein, or detaching and disturbing the artery. For this purpose the best direction is that given by my friend Mr. Law- rence, especially when combined with Mr. Carmi- chael’s plan of letting the needle be introduced on the pubal side of the artery : “ after dissecting down to the artery, a slight scratch or incision may be made through the sheath, close to the side of the vessel. Then, with a narrow aneurism-needle, nearly pointed at the end, and made as thin at its edge as it can be without cutting, a single silk ligature is to be conveyed round it, the point of the needle being kept in contact with the artery. A needle of this form makes its way easily through the cellular substance, and the vessel is detached only in the track of the instrument.” — (See Med. Chir. Trans, vol. 6.) Of the kind of ligature to be emploj'ed, I need only say here, that, it should be a single one composed of firm materials, in order to avoid the necessity for in- creasing its diameter more than would be desirable for reasons elsewhere considered. — (See Hemorrhage and Ligature.) The ligature having been put under the artery, one end of it is to be drawn completely through the track made for it by the needle, which instrument is then to be taken away, leaving the ligature under the vessel. The ligature is now to be tied in a steady, firm manner, but without any immoderate force, which can never be necessary even for the division of the in- ner coats of the vessel. In this part of the operation, a few practitioners give the preference to what is termed the surgeon's knot ; and commend this plan of fastening the ligature ; a plan which consists in put- ting the end of the cord twice through the noose, be- fore the constriction is made. The only good of the surgeon’s knot is, that it does not so readily slip and loosen agjLcsmmon one ; but Scarpa thinks a simple knot best, as it does not, like the other, prevent the sur- geon from calculating the force with winch the artery is constricted. — (On Aneurism, p. 281, ed. 2.) And besides this reason against the surgeon’s knot, another objection to it is the irregularity with which a ligature in this form will lie round the vessel. A simjde noose should therefore be finst made and tightened, and then a second one, so as to form a common knot ; and now, as a matter of precaution against the possibility of the ligature slipping and becoming loose, the surgeon, if he pleases, can tie the knot once again. One end of the ligature is next to be cut off near the knot ; and the sides of Ihc wound are to be brought together with strips of adhesive plaster, the irritation of sutures be- ing carefully avoided. The remaining end of the liga- ture should always be brought out at the nearest point of the external wound to the knot on the artery. The effects which in general immediately follow the operation are, a total cessation of the pulsation of the aneurismal tumour ; a manifest sinking and flaccidity ol’ tlie swelling ; a diminution of pain in the seat of the disease : and a strong vibration of the articular ar teries round the knee. As Mr. Hodgson has remarked, the unusual influx of blood into the minute ramifica- tions, when a main artery is suddenly rendered imper- vious, is generally attended with a remarkable increase in the temperature of the limb. After tying the femo- ral artery for the cure of popliteal aneurism, the same phenomenon occurs, at least after a short time, during which the temperature of the leg and foot frequently coiitinues lower than that of the sound limb. But in a few hours it generally rises, and is sometimes seve- ral degrees higher than that of the opposite member. This state lasts several days, at the end of which time, the heat of the limb which has been operated upon will be found to be about the same as that of other parts of the body. — (Hodgson on Diseases of Arteries, &, c. p. 256.) It is only while the limb is colder than natural, that it ought ever to be fomented or covered with flannel. In particular examples, there is no in- crease of temperature in the limb, at any period after the operation ; a fact which Mr. Hodgson refers to the probability of a collateral circulation having already been established, in consequence of the obstruction to the passage of the blood through the main artery by the accumulation of the coagulum in the aneurismal sac. Of course, unless a collateral circulation be es- tablished, the operation cannot succeed, as the limb will mortify ; it behooves us, therefore, to be aware of the circumstances which may prevent the due transmis- sion of the blood to the inferior part of the limb. These are ably explained and commented upon in Mr. Hodg- son’s work : 1st, An extensive transverse wound, by which the principal anastomosing branches are divided. 2dly, Tight bandages and pressure operating so as to obstruct the same vessels. 3dly, The immense bulk of the tumour, and the pressure upon the principal colla- teral arteries. 4thly, Calculous depositions in the coats of the arteries of the limb. 5thly, Advanced age. 6thly, A languid state of the circulation ; a fact indi- cating the wrongness of venesection, as a general practice after the operation, though it may yet be right to adopt this treatment, where the pulsations re- turn in the tumour with unusual strength, and appear to stop the diminution of the swelling, as already men- tioned. 7thly, The abstraction of heat from the limb by cold evaporating lotions ; a plan which can only be right when there is a great increase of heat in the limb, a tendency to inflanunation, ora return of strong pulsations in the tumour. Sir Astley Cooper saw a case, in which the application of whitewash occasioned mortification and the patient’s death. In cold weather, he always covers the limb with flannel or a stocking, and sometimes puts jars filled with hot water to the feet.— (See Lancet, vol. 2, p. 42.) When the operation is done according to the princi- ples laid down in this article, the patient is not too old, nor enfeebled, and the after-treatment is properly con- ducted, mortification cannot now be said to be a fre- quent event. In one case, operated upon by Sir Astley Cooper in 1823, the whole of the foot and part of the leg mortified ; but it should be noticed, that in this in- stance the whole limb was extremely swollen previ- ously to the artery, being taken up.— (See Lancet, vol. 1, p. 436.) In all his extensive practice, he has seen but three or four instances of a failure of the operation from gangrene. -(Lectures, S. c. vol. 2, p. 60.) Mr. Liston has related one example which he ascribed to the impro • per use of fomentations with hot salt water. — (See Edinb. Med. Jorum. No. 90, p. 3.) As, however, the patient seems to have been of a very phlogistic diathe- sis, and to have been attacked with inflammation of other parts, the reality of the alleged cause appears ques- tionable. I have seen but one example of gangrene, and in that, only one toe, and a portion of the skin of the instep, sloughed in a very debilitated subject. This partial gangrene of the foot has been particularly no- ticed by Deschamps and Scarpa, the latter of whom regards it as an unusual thing, only likely to happen in old, weak, or unhealthy subjects ; and “ at any rate (says he) if this should happen in any of these ener- vated individuals, the patients may console theinselves for the loss of one or two of their toes, with the cure of a popliteal aneurism, and the avoidance of a painftil and dangerous incision in the ham, and of the tedious sup- puration which would have followed it.” Sir Ast. Cooper has known retention of urine brought on by the ojjerution in one cr two examples, and the use ANEURISM. m of the'catheter indispensable.— (Lecfiires, ^c. vol. 2, p. 58.) Mr. C. Bell met with a case in which the femoral artery divided below the profunda into two equal branches, the most superficial of which was alone noticed and tied in the operation. The patient died of constitutional disturbance, arising from inflammation in the whole course of the sartorius. After two or three days, the pulsation of the tumour, which had been very strong, ceased, in consequence of the coagulation of the blood within the sac ; another fact, exemplifying that this desirable change will not be prevented by a current of blood being still propelled through theaneu- rismal cavity.— (See Quarterly Joum. vol. 3, p. 607.) Mr. Liston has recorded a case, in which the pulsa- sation and tumour returned several months after the operation. “ On consulting with Dr. Thomson, it was agreed to try the effect of methodical bandaging, from the points of the toes upwards, and a compress over the j tumour, with rest, cold applications, and moderate diet.” These means had the desired effect ; and the patient did not complain much of those pains which so frequently remain after the operation for aneurism. According to Mr. Liston, these pains are in general distinctly referable to the sacro-ischiatic nerve and its branches, and are explained by the state of the ves- sels in the substance of the nerve. In the natural state the neurilemal vessels, when injected, are not larger than sewing threads : but when the enlargement of the collateral branches is requisite, owing to the ob- struction of the trunk, they also are called on to con- tribute their share in the new circulation ; and they become enormously distended. In one remarkable specimen, in which the limb was injected and exa- mined fifteen years after the superficial femoral atery had been secured for aneurism in the ham, the vessels in the sacro-ischiatic nerve had attained the size of crow- quills, and were convoluted in an extraordinary man- ner. The pains in the limb, noticed by Mr. Liston as occurring after the operation, he acknowledges, how- ever, are by no means so severe as those experienced previously, and which are produced by the compression and stretching of the nerves by the sac. — {Edin. Med. Journ. No. 90, p. 2.) WTien the operation succeeds, a considerable portion of the artery above the aneurismal tumour is rendered impervious, the vessel indeed being sometimes con- verted into a solid cord from the origin of the profunda to that of the tibial arteries. — (A. Cooper, Med. Chir. Trans, vol. 2, p. 254.) In general, however, the oblite- ration of the artery is less extensive ; a fact particularly noticed in one of Mr. Hunter’s cases {Trans, of a Soc. for the Improvement of Med. and Chir. Knowledge, vol. 1, p. 153), and vaiidy urged by Deschamps, as a proof of the insufficiency of the new method.— (See Obser- vations et inflexions sur la Ligature des principales Attires blesses, et particulierement sur VAneurisme de VArtire poplitie, p. 76, Paris, 1797.) It appears from the observations of Mr. Hodgson, that the artery ge- nerally becomes impervious, for the space of three or four fingers’ breadth, at the place where the ligature is applied ; below whi< h part its tube is unclosed, and continties so for some distance, when the obliteration again commences, and descends along a considerable extent of the popliteal artery to the origin of the infe- rior articular, or tibial arteries. Thus, says this author, uninsulated portion of the femoral artery preserves its cavity, from each extremity of which considerable anastomosing branches arise ; the upper branches con- vey blood into the vessel, and the lower transmit it into anastomosing channels, that originate below the knee. — {On Diseases of Arteries, Src. p. 278.) Now, as Mr. Hodgson is unacquainted with any case, except that recorded by Sir Astley Cooper, where, after the mo- dern ojjeration, the artery was obliterated from the seat of disease in the ham to the part at which the ligature was applied, he thinks it probable that, in most instan- ces, a double collateral circulation exists in the limb, after this method of cure. In consequence of the motion of the blood being more or less impeded in the aneurismal sac by the application of the ligature to the femoral artery, the aneurismal cavity soon becomes completely filled with coagula, which even block up the adjoining portion of the arte- rial tube. The coagulated blood in the sac is afterward absorbed ; and a gradual diminution and final dis- appearance of the aneurism in the ham ensue ; with the exception of a slight induration, which sometimes remains, composed of a remnant of the sac itself, or of the fibrous part of the blood. This slight hardness in the cavity of the ham Occasions no inconvenience, and does not hinder the patient from performing the mo- tions of the knee and leg with quickness and safety. — {Scarpa, p. 257, edit. 2.) After the operation, the circulation is carried on prin- cipally by the arteria profunda, whose branches commu- nicate with the articular arteries of the poi)liteal, and with arteries sent to the knee by the anterior and pos- terior tibial. Large branches in the sciatic nerve, sent off by the arteria profunda, communicate very freely with the popliteal artery, the articular, and branches of the posterior tibial. As Sir Astley Cooper has farther explained, the freedom of anastomosis sometimes leads to a reproduction of an aneurism. The femoral artery was tied by Mr. Key, and the patient, after being dis- j charged cured, returned with a painful tumour in the ham, attended with an obscure pulsation. The limb was amputated, and a large artery, passing to the tu- mour, and situated nearly in the usual place of the femo- ral, required a ligature.— (Z/Cc^Mre.s, Ac. vol. 2, p. 60.) When the advantages of the foregoing method of operating are contrasted with the dangers and seventy of the practice of laying open the aneurismal tumour, and applying ligatures round the diseased part of the vessel, it is surprising to find any living surgeons still expressing a preference to the latter mode of treatment under any circumstances whatsoever. Yet Boyer, Roux, and a few of the modern French surgeons, are in this way of thinking, which reminds me of their slow- ness to adopt, at every opportunity, union by the first intention, one of the greatest and most decided advances to perfection ever made in the practice of surgery. The severity and difficulties of the old method of operating, in cases of politeal aneurism, are most faithfully de- picted by Scarpa. In the ham, says he, the artery lies very deep. The space is limited and narrow, within which it can be brought into view and tied, without risk of tying along with it, or of destroying, some of the principal anastomoses formed by the articular arteries of the knee. On account of the depth of the artery, it is difficult to pass any instrument round it, vrithout inclu- ding other parts ; and it is no less difficult to draw the ligature on the vessel with a proper degree of tightness. Scarpa then comments on the disadvantages of tying the lacerated, diseased part of the vessel, which is some- times so high up, that, in order to apply the ligature above it, it is necessary to cut through the long head of the triceps, and make a passage through into the thigh. Or, the diseased or lacerated part of the artery is situa- ted so low down in the calf of the leg, that it is impos- sible to avoid including, either in the incisftn or the ligature, the lower anastomosing articular arteries, on the preservation of which the circulation and life of the subjacent part of the limb in a great measure depend. We must add to all this the violence unavoid- ably done to the great sciatic nerve, which an assistant must hold drawn to one side of the wound nearly the whole time of the operation. The proceeding is also liable to other great difficulties, as may be seen from a case reported by Masotti {Dis. sul Aneurysma, p. 54), where the popliteal artery was so firmly united, and, as it where, confused with the vein, the nerve, the tendons of the neighbouring muscles, and the periosteum, that the cavity of the ham presented the appearance of an intricate mass of parts, not easily separable from one an- other. Lastly, the operation leaves a large deep wound, laying open the whole cavity of the ham, and followed by copious suppuration, sinuses and necrosis of the heads of the femur and tibia. If the patient be not hurried into the grave by these affections, and even if the parts in the ham heal, he is almost always left with an incurable contraction of his knee, and perpetual lameness. Thus, Masotti {Op. cit. p. 17) relates one case, where the subsequent effect caused such destruction of the soft parts in the ham, that not a vestige of artery, vein, or sciatic nerve was left, and the patient remained all the rest of his life with a paralytic leg, and ulcers and fis- tul® all round the knee . — {Scarpa on Aneurism, p. 251.) I shall now advert to a few facts in the history of surgery, which eventually led to the bold atid success- ful operations adopted in modern times for the cure of aneurisms of the femoral and popliteal arteries The earliest case of which the particulars are recorded, amounting to df satisfactory proof that the lower ex- tremity might be duly sujjplied with blood, notwith- 1S4 ANEURISM. standing the femoral artery had been tied mgn [up in the thigh, is the example related by M. A. Severinus of a false aneurism of the thigh, about eight fingers’ breadth below the groin, caused by a musket-ball wound. In this instance, Severinus tied the femoral arterj’ above and below the aperture in it, and not only was the pa- tient’s life saved, but the use of the limb also preserved. — {Chirurgia Ejficacis, p. 2, Enarratoria.) The next authentic case of the ligature of the femoral artery, is that reported by Saviard, where Bottentuit, in 1688, tied this artery on account of a false aneurism, the result of a sword-wound, at the inner and upper part of the thigh. The surgeons called into consultation were immediately convinced, that the only thing to be done was to take up the femoral artery ; but they were fear- Ail lest the patient should perish of bleeding ere the opening in the vessel could be found ; and in case the artery were secured, they apprehended the obstruction of the circulation would be followed by mortification of the limb. The patient was therefore first prepared for his fate by the administration of the sacrament. A band was then applied round the upper part of the limb, and tightened by means of a stick with which it was twisted, a piece of pasteboard being put under the knot, in order to render the constriction less painful. The tumour was then opened, the clotted blood ex- tracted, and the opening in the artery detected by slackening the tourniquet. A curved needle, armed with a double ligature, was then introduced under the femoral artery, and one of the cords was tied above, and the other below the wound in the vessel. Then follows a curious passage, showing the operator’s judg- ment at that time, respecting the impropriety of inter- posing any cylinder of linen between the knot of the ligature and the artery, as some of the old surgeons at that time used to do, as well as a few of the moderns. “ On ne mit point de petites compresses sur le corps de Vartere au-dessus du noeiul, comme font quelques uns, parceque Von jugea qu'il etoit d'une grande con- sequence de Her tres-etroitement une drtere si consi- derable, ce que Von n'auroit pas eti sur de faire en interposant la petite compresse,” &c. For greater secu- rity, assistants who relieved each other in turn kept ap constant pressure on the tied part of the vessel for twenty-four hours. In six weeks, the patient recover- ed, and afterward enjoyed such good health that he went through several campaigns. — {Saviard, Nouveau Recueild' Observations Chir. Obs. 63, 12mo. Paris, 1702.) Now, with respect to these two cases, it merits atten- tion, that though Heister, Morgagni, and others, en- deavoured to explain the success, by supposing that each of the patients in question must have had two iemoral arteries, both Severinus and Saviard were wise enough to avoid making any such erroneous inference themselves. At a later period, Guattani laid bare the femoral artery, as it passed under Poupart’s ligament, ■compressed it against the ramus of the pubes, by means of graduated compresses retained with a firm roller, and thus obtained the speedy obliteration of the vessel, and cured the aneurism, which had been first injudiciously opened. — {De Extemus Aneurismatibus, Hist. 15, 4«o. Romce, 1772.) In the same book is given the case of an inguinal aneurism, which, when it had continued three months, and become equal in size to a large fist, was attacked with gangrene, whereby the nneurismal sac was quickly destroyed, and the femoral artery was obliterated for a considerable extent from the crural arch downwards. The sloughs were tlirown off, however, and the ulcer had in a great measure healed, when the patient fell a victim to debility. — (Hist. 17.) Here it is to be remarked, that during the jfive weeks this man lived after the obliteration of the femoral artery above the origin of the profunda, not only the circulation and life of the whole limb were preserved, but the auxiliary arteries, coming from within the pelvis, proved capable of limiting the progress of the mortification of the parts round the aneurism, and of commencing the healing process in a manner which raised great hopes of a cure. A similar fact is also recorded by Dr. Clarke. — {Duncan's Med. Com- ment. vol. 3.) [In cases of aneurism in the thigh, it is not always practicable to decide with absolute certainty whether the disease is situated in the femoral artery, or in the profunda; and even when it obviously originates with the former, the latter is often deeply i^olved, particu- larly when the disease has been of long standing. Many unsuccessful cases have been reported ; and I know of one which has failed in the hands of a distin- guished surgeon, the aneurismal tumour still remain- ing, although the femoral artery was tied above the tumour. In this case the disease is no doubt seated in the profunda. Many surgical WTiters and teachers have inculcated the doctrine, that tvhen the aneurism is situated in the thigh, the ligature must always be applied below the bifurcation, lest the circulation of the limb should suf- fer. A distinguished surgeon of Philadelphia, prefer- red opening the sac of a femoral aneurism, and apply- ing his ligature below the proftinda, rather than ven- ture to tie the artery higher up. The operation failed, however, and the tumour still remains. That such fears are wholly groundless, may be confidently as- serted from analogy, furnished as we are with the knowledge that the innominata, the common iliac, and even the aorta itself, may be obliterated, and yet the anastomosing vessels continue the circulation. But Dr. Whitridge, an accomplished surgeon of Charles- ton, S. C., has afforded a demonstration in a case of aneurism in the thigh from a gun-shot wound, in which he tied the femoral artery just below Poupart’s ligament, and of course above the point at which the proftinda goes off. This case has been completely suc- cessful, and the patient recovered without any sensible interruption in the circulation, and without any unto- ward symptom. The cases in which the femoral artery divides high up, which Professor Godman has shown are by no means unfrequent, may account for the occasional failures of this operation, and should not be lost sight of by the judicious surgeon. As a general rule, how- ever, applicable to all other cases, when the aneurism is sittiated immediately below the bifurcation, and in the vicinity of the profunda, it is safer, and also better surgery, to apply the ligature above. The action of the profunda may endanger the success of the operation, and the most profound surgeon may sometimes mis- take the seat of the disease. — Reese.] These and other cases which might be quoted, fur- nished ample proof of the efficiency of the anasto- mosing vessels in the support of the limb, though the femoral artery had been tied, or obliterated in a very high situation. Besides these facts, surgeons derived every encou- ragement to attempt the cure of popliteal aneurism, by the ligature of the artery above the tumour, from the elucidations given by Winslow and Haller concerning the numberless inosculations which exist between the upper and lower articular arteries. Haller even drew the conclusion, that if the course of the blood were in- tercepted in the popliteal artery, between the origins of the two orders of articular branches, such anasto- moses would suffice for carrying on the circulation in the leg. And at length, Heister, weighing the ana tomical observations of Winslow and Haller, and the facts recorded by Severinus and Saviard, first proposed applying to popliteal aneurisms an operation, which, with the exception of those two cases, had until his time been restricted chiefly to aneurisms of the bra- cliial artery. — {Dis. de Genuum Structurd eorumque Morhis. Disp. Chir. Halleri, t. 4.) It was in Italy that the earliest operations were un- dertaken for the cure of popliteal aneurisms, by Guat- tani, or rather by a German surgeon named Keysler, as would appear from a letter written by Testa to Cotunni. — (See Pelletan, Clinique Chir. t. 1.) The success obtained by those surgeons soon led others to imitate them, and by degrees, the practice of tying the femoral artery became common both in cases of aneu- rism and wounds ; and from the observations of Heis- ter {Haller Disp. Chir. t. 5), Acrell {Murray de Aneu- rysm. Femoris), Leslie {Edin. Med. Comment.), Ham- ilton {B. Bell's Surgery, vol. 1), Burschall {Med. Obs. and Inq. vol. 3), Leber {Dehaen, Ratio Medendi, t. 7), and .Tussy {Ancien Joum. de Med. t. 42), if was proved beyond the shadow of a doubt, that the circu- lation might continue in the limb after the obliteration of the femoral artery, whether such obliteration were effected by direct pressure or the ligature. The exact period when the first operation of laying open the tumour and tying the popliteal artery was performed in F.ngland, is not, as far as I know, particu- larly specified. However, judging from the observa- tions made on this practice in the writings of Fntt ANEURISM. (ftemarks on Palsy, S,'C. Svo. Ixmd. 1779), of Wilmer (Cases and Remarks in Surgery, 8vo. Lond. 1779), of Kirkland (Thoughts on Amputation, 8vo. Lond. 1780), and of others, it is clear that this method of treatment had been often done in this country earlier than the dates of those works, and as would appear with little or no success. The earliest attempt of this kind in FYance was made by Chopart in 1781 (Rnux, Nou~ veaux Elimens de Mid. Op^ratoire, t. 1, p. 556), about five-and-tweuty years after the examples set by Guat- tani in Italy; but Chopart failed in his endeavours to repress the bleeding from the exposed cavity of the tumour, and was therefore obliged to amputate the limb. Subsequently to this attempt, the operation was undertaken by Pelletan in two instances, the termina- tions of which were successful : consequently, this surgeon may be regarded as entitled to the honour of having proved to his countrymen the possibility of curing the popliteal aneurism, by laying open the tu- mour, and securing the artery in the ham. The severity and frequent ill success of this method of operating I have already noticed, nor shall I repeat the objections to it. With respect to . the Hunterian practice, the great peculiarities of which were tying the artery at some distance above the disease, and not opening the swelling at all, Richerand seems offended that Hunter’s name should be affixed to an operation, which he conceives was in reality the invention of Guillemeau. Here we observe, ^Etius again puts in a prior claim, and with much more effect, because the method of which he speaks truly resembled Mr. Hun- ter’s, inasmuch as the vessel is directed to be tied at some distance above the swelling, while Guillemeau only tied the artery close above the disease, and opened the swelling, a serioits deviation from the Hunterian practice. Guillemeau, a disciple of Ambrose Par^, having to treat an aneurism at the bend of the arm, the conse- quence of bleeding, exposed the artery above the tu- mour, tied this vessel, then opened the sac, took out the coagulated blood, and dressed the wound, which healed by suppuration. After more than a century, Anel, on being consulted about a similar case, tied the artery above the swelling, which was left to kself. The pulsation ceased, the tumour became smaller, and hard, and after some months no traces of the disease were perceptible. In 1785, Desault operated in the same manner for a popliteal aneurism : the swelling diminished by one- half, and the throbbings ceased ; on the 20th day it burst, coagulated blood and pus were discharged in large quantities, and the wound, after continuing a long time fistulous, at length healed. Towards the end of the same year, says Richerand, Hunter applied the ligature somewhat differently ; instead of placing it close to the swelling, or directly above it, he put it on the inferior part of the femoral artery. — (See Nosogr. Chir. t. 4, p. 98, 99, edit. 2.) Unquestionably, Anel did, in one solitary instance, tie the humeral artery immediately above an aneurism at the bend of the arm, and effected a cure without opening the swelling (Suiti de la Nouvetle Mfthode dc guerir les fstules lachrymales, p. 251, Turin, 1714) ; but he did not think of applying the plan to the femoral artery, or draw the attention of French surgeons sufficiently to the matter, to make them imitate this operation ; on the contrary, the method fell into obli- vion, and was never repeated. With regard to De- sault’s operation, said to have been done in an earlier part of 1785 than Mr. Hunter’s first operation, it is only necessary to say, that Desault tied the popliteal artery it.self, while the grand object in Mr. Hunter’s method was to take up the femoral artery, at a distance from the disease, and that it is this last mode alone which has gained such approbation, and been attended with unparalleled success. The French surgeons have not practised the Hun- terian operation \vith the same degree of success with which it is now perfonned in England, and conse- quently they very commonly pursue the old method of opening the sac, &c. Even Boyer avers his relinqui.sh- ment of what he calls Anel’s plan. — (Traits des Mai. Chir. t. 2, p. 148.) But we shall not be surprised at their ill success, when we hear that they neglect the right principles on which ligatures ought to be applied to arteries, as explained by Dr. Jones in his work on hemorrhage. Even Baron Dupuytren adheres to the 125 use of ligatures of reserve ; and Boyer applies four loose ligatures round the artery, besides two tight ones ; and consequently, a large portion of the vessel lies separated from its natural connexions, and irritated by these e.xtraneous substances. Hunter’s first operation nearly failed also on account of so many ligatures, none of which were tightened so as to cut through the inner coats of the artery, and thus promote its closure. —(See Hemorrhage.) With reference to the operation of popliteal aneurism, Rosenmuller's Chir. Anat. Plates deserve to be consulted, Part 3, Tab. 8 iS* 9. Scarpa’s and Tiedemann’s matchless engravings, and Haller’s leones should likewise be examined. ANEURISMS OF THE LEG, FOOT, FOREARM, AND HAND. Doubts were not long ago entertained respecting the possibility of curing an aneurism at the upper part of the calf of the leg by tying the femoral artery in the middle of the thigh. — (Instituto di Ital. Scienze ed Arti, vol. I, parte 2, p. 266.) The author here referred to was led by this uncertainty to have recourse in one instance to the severe method of laying open the tu- mour, in order to get at the vessel lower down. On this case, Scarpa makes some correct reflections : the operator (says he) assured himself, that, on compress- ing the femoral artery at the upper part of the thigh, the tumour at the top of the calf ceased to pul- sate ; and that, when the compression was cooitinued for some time, thv swelling partly disappeared, and became softer. It ought to have been evident, there- fore, that the aneurism might have been cured by tying the trunk of the femoral artery, as described in the foregoing section. In Scarpa’s work is a case in which an aneurism at the bifurcation of the popliteal artery was cured by the ligature of the femoral artery, —(See p. 451, ed. 2.) Mr. Hodgson has seen three an- eurisms situated at the commencement of the tibial arteries, cured by the same operation. — (On Diseases of Arteries, drc. p. 437.) But, as Scarpa remarks, though the Hunterian operation answers in the cure of aneurism in the bend of the arm, and at ihe upper part of the calf of the leg, it is not so effectual for aneurisms situated on the back or palm of the hand, or the dorsum or sole of the foot. The free communi- cation which the ulnar and radial arteries keep up with each other in the hand, and the tibial arteries have have in the foot, prevent the operation from succeeding whether the brachial or femoral artery, or one of the two large arteries of the forearm or leg, be tied. In proof of this statement, Scarpa cites two cases of aneurism seen by himself ; one on the instep, the other in the sole of the foot ; and a third case of the same dis- ease in the latter situation ; all of which were found to be incurable by the ligature of the anterior tibial artery. — (P. 311.) He thinks, however, that the operation of tying this vessel where it passes over the dorsum of the foot might succeed, if aided by compression, applied so as to stop the current through the other main chan- nel ; and he seems to approve of this practice, be- cause the plan of tying the artery above and below the disease (which is the most certain means of cure) could not be done, without extensive incisions in the sole of the foot. In an aneurism at the lower part of the leg, Mr. Hodgson judiciously insists upon the prudence of tying the artery, as near as possible to the tumour, because the recurrent circulation through the large inosculations in the foot might still cause the swelling to enlarge, in consequence of the blood sent into the sac from the lower extremity of the vessel, passing through the aneurismal cavity into branches arising from the artery between the aneurism and the ligature. — (P. 438.) However, in one case of aneurism of the ante- rior tibial artery, Mr. H. Cline applied a ligature just above the tumour without success, and Sir Astley Cooper expressly recommends making an incision in the sac, and applying a ligature both above and below the swcW'mg.— (Lectures, S,-c. vol. 2, p. 63.) When an aneu- rism arises from the radial, ulnar, or interrosseous ar- teries near the elbow, tying the brachial will suffice ; but if the disease be lower down, the vessel from which it proceeds must be taken up near the swelling. — (Hodg- son, p. 393.) A case, strikingly illustrative of this truth is recorded by Mr.Liston. J. M. P., aged 19, ap- plied to him on the 28th of July, on account of an an- eurism of the left radial artery, about the middle of the forearm, occasioned by a wound. The tumour was as Inrce as a walnut, and so compressible, that it could 126 ANEURISM. easily be made to disappear. Pressure was tried at first, with apparent benefit ; but as it did not succeed, the humeral artery was tied on the 8th of August, and with the efifect of completely removing the tumour. On the eighteenth day afterward, however, a small slough was detached from the cicatrix, and about three o’clock next morning, a violent hemorrhage took place. Mr. Liston then deemed it necessary to lay open the sac, and tie the artery above and below the wound in it. — (See Edinh. Med. Joum. No, 90, p. 4.) Scarpa mentions a case, where the dorsal artery of the thumb was wounded ; but as the hemorrhage re- turned several times, and pressure failed in suppress- ing it, the surgeon took up the radial artery at the wrist. After cutting off this direct current of blood towards the injured vessel, pressure on the wound proved effectual. Three months afterward, the pa- tient having died, the radial artery was found impervi- ous for three fingers’ breadth below where the ligature had been applied, and the dorsal artery was likewise obliterated from the root of the thumb to the begin- ning of the palmar arch. Mr. Todd has published a case in which he cured a large aneurismal swelling of the posterior side of the forearm, by tying the brachial artery. From the de- scription, I conclude that the disease w^as an aneurism by anastomosis, as it is termed ; but the particulars given by the author leave us in doubt on this point. — (See Dublin Hospital Reports, vol. 3, p. 135.) The manner of exposing and tying the principal ar- teries of the leg and forearm, will be described under the term Arteries. OF ANEURISMS HIGH UP THE FEMORAL ARTERY. Several facts already specified in the preceding co- lumns as having occurred many years before the ope- ration of tjdng the external iliac artery was attempted, amounted to a full proof, that the circulation might go on in the lower extremity notwithstanding the artery in the groin were tied or obliterated. On this point, some of Guatfani's cases were most decisive. The ligature of the external iliac artery, for aneu- risms of the femoral artery in the bend of the groin, has now been practised so frequently, and the instances of success are so numerous, that all doubt concerning the propriety and utility of the attempt has entirely ceased. The French, who have evinced great back- wardness in espousing the Hunterian method of ope- rating for aneurisms, though it is decidedly one of the greatest improvements in modem surgery, have also shown great reluctance even to believe, much less to practice, the operation of tying the external iliac artery. A Parisian surgeon, however, who was in London a few years ago, saw the thing done, and the eyes of his brethren in the capital of France have since been a little more open. Still, as Roux remarks, “ We can- not but blame the indiflTerence with which the opera- tion is mentioned in some of the latest French surgical publications. At this moment (1815) we can reckon twenty-three facts relative to tying the external iliac artery, and on fifteen of the patients it has perfectly suc- ceeded. In these twenty-three operations, I compre- hend the two which Avere done in France ; one at Brest, by Delaporte, and the other at Lyons, by Bouchet ; cases, the authenticity of which cannot be doubted. In the number of successful cases, is to be comprised Bouchet’s operation, since the patient lived more than a year afterward, and then died of the con- sequences of an inguinal aneurism of the opposite side. Of the other twenty-one operations, fifteen were performed in London only, in the several hospitals of this metropolis, by Abernethy, Ramsden, A. Cooper, Brodie, and Lawrence ; gentlemen who would never publish forged cases. “ Sir A. Cooper alone had tied the external iliac ar- ery six times before my journey to London, and dur- ing my stay there. I saw him perform the operation once. Four of his patients were entirely well ; one of the three others died, the thirteenth week after the operation, of the bursting of an aneurism of the aorta. At this period, the circulation in the limb had been re- established. I saw the limb after it had been injected among Sir A. Cof^per's anatomical prejtarations. Large and beautiful anastomoses exist(!d round the pelvis, bctw'een the dilated branches of the internal iliac and femoral arteries. With respect to the sixth patient, the leg mortified, and the thigh was amputated with- out success. The seventh died of hemorrhage, which took place the fourteenth or fifteenth day after the ope- ration.”- — {ParalUle de la Chir. Angloise avec la Chir. Francoise, p. 275, 276.) Sir Astley Cooper has now tied the external iliac artery in nine cases.— (See Lan- cet, vol. 2, p. 44.) The many facts already published, exemplifying the propriety of this operation, must be highly gratifying to Mr. Abernethy, by whose judgment it was first sug- gested, and by whose enterprising hand it was first practised. Mr. Abernethy has been called upon in several cases to take up the external iliac artery, and they all prove that the anastomosing vessels were fully capable of conveying blood enough into the limb below, and that a vessel even of this size could become permanently closed after being tied. Three of the operations done by this gentleman, I was an eye-witness of, and it is therefore with confidence that I can speak of the ease and simplicity of the requisite measures for securing the external iliac artery.— (See Abemethy's Surg. and Physiol. Essays ; and Surgical Observations, 1804 ; Edin. Med. and Surg. Journal for January, 1807 ) In Mr. Abemethy’s first operation, performed in 1796, an incision, about three inches in length, was made through the integuments of the abdomen, in the direc- tion of the artery, and thus the aponeurosis of the ex- ternal oblique muscle was laid bare. This was next divided from its connexion with Poupart’s ligament, in the direction of the external wound, for the extent of aliout tw'o inches. The margins of the internal ob- lique and tran.sverse muscles being thus exposed, Mr. Abernethy introduced his fingers beneath them to pro- tect the peritoneum, and then divided them. Next he pushed this membrane, with its contents, upw’ards and inwards, and took hold of the external iliac artery with his finger and thumb. It now only remained to pass a ligature round the arter>q and tie it ; but this required caution, on account of the contiguity of the vein to the artery. These Mr. A. separated with his fingers, and introducing a ligature under the artery Avith a common surgical needle, tied it about an inch and a half above Ppupart’s ligament. — (Surg. Essays.) 'The folloAving was the method which Mr. Aber- nethy adopted, the second tune of tying the external iliac artery. An incision three inches in length w^as made through the integuments of the abdomen, beginning a little above Poupart’s ligament, and extending upwards ; it was more than half an inch on the outside of the up- per part of the abdominal ring, to avoid the epigastric artery. The aponeurosis of the external oblique mus- cle being exposed, was next divided in the direction of the external wound. The lower part of the internal oblique muscle w’as thus uncovered, and the finger being introduced beloAv the inferior margin of it and of the transversalis muscle, they AA'ere &vided with the crooked bistoury for about one inch and a half. Mr. Abernethy now introduced his finger beneath the bag of the peritoneum, and carried it upAvards by the side of the psoas muscle, so as to touch the artery about two inches above Peupart’s ligament. He took care to disturb the peritoneum as little as possible, detach- ing it to no greater extent than was requisite to admit his tAvo fingers to touch the vessel. The pulsations of the artery made it clearly distinguishable, but Mr. Abernethy could not put his finger round it Avith fa- cility. In order to be able to do so, he was obliged to make a slight incision on each side of it. Mr. A. now dreAv the artery gently down, so as to see it behind the peritoneum. By means of an eye-probe, two ligatures were conveyed under the vessel ; one of these Avas carried upAvards as far as the artery had been detached, and the other downwards ; they were finnly tied, and the vessel was divided in the interspace between them. — (Surg. Observ. 1804.) In a third instance of tying this vessel, Mr. Aber- nethy operated exactly as in the foregoing case, and with comj)lete success. — (See Edin. Surg. Joum. Jan. 1807.) Mr. Freer, of Birmingham, Avho may be said to claim the honour of having seconded Mr. Abernethy in this neAV practice, made an incision about one inch and a half from the spine of the ileum, beginning about an inch above it, and extending it doAvniAards about three inches and a half, so as to form altogether an incision four inches and a half long, extending to the ba.se of the tumour. The tendon of the external ob- liquc being exposed, was carefully opened, and also the internal oblique, when the finger being introduced between the peritoneum and transversalis, served as a director for the crooked bistoury, which divided the muscle. Avoiding all unnecessary disturbance, Mr. Freer separated the peritoneum with his finger, till he could feel the artery beating, which was so firmly bound down, that he could not get his finger under it without dividing its fascia. The vessel having been separated from the surrounding parts, a curved blunt needle, armed with a strong ligature, was put under it, and tied very tight, with the intention of. dividing the internal coats of the vessel. The operation led to a perfect enre.— {Freer on Aneurism, 1807.) Mr. Tomlinson, of the same town, was also an early performer of the operation : he applied only one liga- ture, and, of course, left the artery undivided : the event was attended with perfect success. The following is Sir Astley Cooper’s mode of ope- rating as described by Mr. Hodgson : — A semilunar in- cision is made “ through the integuments in the direction of the fibres of the aponeurosis of the external oblique muscle. One extremity of tliis incision will be situated near the spine of the ileum : the other will terminate a little above the inner margin of the abdominal ring. The aponeurosis of the external oblique muscle will be exposed, and is to be divided throughout the extent and in the direction of the external wound. The flap which is thus formed being raised, the spermatic cord wdl be seen passing under the margin of the internal oblique and transverse muscles. The opening in the fascia which lines the transverse muscle through which the spermatic cord passes, is situated in the midspace between the anterior superior spine of the ileum and the symphysis pubis. The epigastric artery runs precisely along the inner margin of this opening, beneath which the external iliac artery is situated. If the finger, therefore, be passed under the spermatic cord, through this opening in the fascia, it will come into immedi5,e contact with the artery which lies on the outside of the external iliac vein. The artery and vein are con- nected together by dense cellular membrane, which must be separated to enable the ojjerator to pass a ligature by means of an aneurism-needle round the former.”— (On Diseases of Arteries, p. 421, 422.) The foregoing incision, the convexity of which is turned outwards and downwards, extends from within and a little above the anterior superior spinous process of the ileum, to above and a little within the middle part of Poupart’s ligament. As soon as the tendon of the external oblique muscle has been divided, the knife may be put down, and the internal oblique and trans- verse muscles raised from Poupart’s ligament by intro- ducing the finger behind them. Care must be taken to avoid the epigastric arterj^ which runs from the pubis side of the external iliac to the inner side of the inci- sion. Baron Dupuytren, when performing the opera- tion at the Hdtel-Dieu in Paris, in the autumn of 1621, wounded the epigastric artery.— (See Averill’s Opera- tive Surgery, p. 37.) The hemorrhage was so copious that two ligatures were required. The patient aller- w'ard died of peritonitis, which, in all probability, was brought on by the disturbance of the parts in the pro- ceethngs requisite for securing the ends of the wounded vessel. The external iliac vein must also not be in- cluded in the ligature, as such a proceeding would cause a dangerous interruption to the return of the blood. Wlien little of the artery is exposed, one liga- ture will suffice ; in the contrary circumstance it is best to apply two.— (See Lancet, vol. 2, p. 44, 45.) Mr. Nonnan, of Bath, who has tried both modes of operating, found that proposed by Sir A. Cooper a more easy way of finding the external iliac artery than the longitudinal incision practised by Mr. Abernethy. “ The objection (says Mr. Norman) to Sir A. Cooper’s mode of operating in cases where the tumour extends high up, is by no means well founded; for the lower part of the bag of the peritoneum lying on the edge of Pou- part’s ligament, must in every case be exposed and de- tached, in order to get at the artery which lies behind the pasterior part of that membrane, and this is most easily effected by an incision in the direction of Poujiart’s ligament; while two-thirds of the longitudinal incision are made on a i»art of the peritoneum, which lines the abdominal muscles, and the lower portion only of the incision reaches that part of the membrane which is kO be separated. The consequences of this are, that KISM. J27 the peritoneum is in much greater danger of being wounded, and that the probability of a hernia forming after the cure is much increased by the extensive divi- sion of the oblique muscles.”— (See Med. Chir. Trans, vol. 10, p. 101.) As far as I am able to judge, these re- marks are well founded, and they coincide with some observations which were made some years ago by Roux, who, wliile he inclined to Mr. Abernethy’s method, saw the disadvantage of letting the direction of the wound in this instance correspond to the course of the artery. Hence, after many trials on the dead subject, he laid down the rule that the beginning of the wound should never be farther than half an inch from, and a very little higher than, the anterior superior spine of the ileum, and that it should be carried very obliquely down- wards to the middle of Poupart’s ligament. — (See Nou- veaux Elemens de Med. Op. t. 1, p. 747, d c.) Mr. Todd, also, after repeated trials of Mr. Aberne- thy’s and Sir Astley Cooper’s methods on the dead sub- ject, concluded that the plan recommended by the lat- ter afforded the greatest facility of applying the ligature to the artery, because more room was obtained by it, and with less disturbance of ( he peritoneum, than in the other way. Where, however, it becomes necessary to apply a ligature to a higher part of the artery, in consequence of secondary hemorrhage, Mr. Todd con- ceives that Mr. Abernethy’s method should be adopted —(See Dublin Hospital Reports, vol. 3, p. 92.) In a case operated upon by Mr Kirby, a hernia fol- lowed in the situation where the abdominal muscles had been divided. — (Sec Cases with Observations, p, 109, 8vo. Land. 1819.) In one case. Dr. Post found the peritoneum so thickened and diseased that he could not raise it from the subjacent parts, and he was obliged to make an opening in it. The jjrotruding viscera were then pushed back, and with a needle a ligature was introduced un- der the artery, the peritoneum being also included in the ligature. Notwithstanding the disadvantageous method of operating, and the return of pulsation in the swelling, the patient had so far recovered in three months that he had regained the use of the limb.— (See American Med. and Phil. Reg. vol. 4, p. 443.) In one remarkable case, Mr. Newbiggin, by tying the external iliac artery, cured both an inguinal and a popliteal aneurism together.— (See Edin. Med. and Surg. Journal, for Jan. 1816, p. 71, <^c.) The many operations which have now been done on the external iliac artery have impressed me with a con- viction that in subjects under a certain age there is no reason to fear that the anastomoses will not generally suffice for the supply of the lower extremity. Out of twenty-five cases I only know of three in which the limb was attacked with gangrene. These three were patients of Sir A. Cooper, Bouchet of Lyons, and Mr, Collier. The proportion is not so much as one in eight. The three instances cf gangrene were not all in the circumstances which permitted the event to be imputed to the anastomoses not having had sufficient time to enlarge, though perhaps Mr. Collier’s case was such. On the other hand, we are to notice that Dr. Cole’s patient was operated upon a few days after the wound, and yet the limb w'as duly supplied with blood, and did not become gangrenous. It appears, therefore, to me, that the occasional occurrence of gangrene cannot be admitted as a just reason for delay, until the collate- ral vessels have had time to enlarge. I believe that in all aneurismal diseases, early operating is the best and most judicious practice. This was one principal cause, as Kirkland observes, which occasioned the bad suc- cess of the old surgeons in the treatment of popliteal aneurisms, and he foretold, many years ago, that ope- rations for the cure of aneurisms would answer bet- ter if not deferred so long as formerly.— (See Thoughts on Amputation, iS’-c. 8vo. Lmd. 1780.) I join Kirkland in this sentiment, not without recollecting that all aneurisms are attended with a chance of getting well spontaneously in the course of time. In saw the in- guinal aneurism which did so under Dr. Albert in the York Hosi)ital ; but as this also is a rare incident, I do not believe that it ought to influence us against liaving speedy roeourse to an operation. Besides, the cure by inflammation and sloughing appears to me to be at- tended in reality with more peril than a well-executed operation, and consequently has less recommendations than many may imagine. Had not Dr. Albert’s patient been a very strong man, he would certainly have fallen 128 ANEURISM. 6 victim to the extensive disease which the bursting and sloughing of the tumour created. Thus Dela- porte’s patient died of the mass of disease which the tumour itself made ; for it had been suffered to attain too large a size, so that when it inflamed the effects were fatal.— (See Richer and, Nosogr. Chir. t. 4, p. 113, edit. 4.) I believe Dr. Wilmot’s observation is perfectly cor- rect, that if a comparison were made between the ope- ration of tjnng the external iliac artery and that of ty- ing the artery in the thigh, we should find the reco- veries ^lfter the first more frequent in proportion to the number of times it has been done, than after common operations lower down.* — (See Dublin Hospital Rep. 6rc. vol. 2, p. 214.) The greatest artery that conveys blood into the lower extremity, after the external iliac has been tied, is the gluteal; but, besides it, the ischiatic, the obturator, and the external pudic, which anastomoses freely with the internal pudic, are important vessels in keeping up the circulation. I subjoin a list of some of the successful examples of this operation. Mr. Abemethy, 2 cases (Surgical Works, vol. 1 ) ; Freer and Tomlinson, 2 (Freer on Aneu- rism, 1807) ; Sir A. Cooper, 4 (Hodgson on Diseases of Arteries, p. 417); Goo^ad, 1 (Edin. Med. and Surg. Journ. vol. 8, p. 32) ; Brodie, 1 (Hodgson, op. cit. p. 419) ; Lawrence, 1 (Med. Chir. Trans, vol. 6, p. 205) ; J. S. Soden, 1 (Same work, vol. 7, p. 536): G. Nor- man, 1 (Same work, vol. 10, p. 95, d c.) ; E. Salmon, 1 (Same work, vol, 12) ; Bouchet, 1 (Roux, Med. Ope- ratoire, t. 1, p. 744); J. S. Dorsey, 1 (Elements of Surgery, vol. 2, p. 180, Philadelphia, 1813) ; Mouland, i (Bulletin de la Faculte de Medecine de Paris, t. 5, p. 535) ; Dupuytren, 1 (French Transl. of Mr. Hodg- son's work, t. 2, p. 215); Dr. Cole, 1 (Rapport des Travaux de la Societe dl Emulation de la Ville de Cam- brai, 1817, or Land. Med. Repository) ; Dr. Wilmot, 1 (Dublin Hospital Reports, vol. 2, p. 208, &c.) ; Kirby, 1 (Cases with Observatioois, 6,-c. Suo. Lond. 1819) ; Dr. Post, 1 (American Med. and Philos. Register, vol. 4); Newbiggin, 1 (Edin. Med. and Surg. Joum. Jan. 1, 1816); J. C. Warren, 1 (New-England Journal, or Anderson's Quarterly Journal, vol. 1, p. 136). In this ctise the epigastric arterj’ arose from the anterior and inner part of the sac, and gave origin to the obttuutor, while the circumflex ilii originated from the outer part of the sac. Ail these vessels were greatly enlarged, and the epigastric rendered the necessary detachment of the external iliac troublesome. Some particulars of the case of ruptured inguinal aneurism, in which Sir A. Cooper tied the aorta, tvill be hereafter noticed.— (See Aorta.) Rosenmuller’s Chir. Anat., Tiedemann’s and Scarpa’s Plates, in illtistration of the operation of tj-ing the ex- ternal iliac artery, merit notice. CASES or GLUTEAL ANEURISM CURED BY TYING THE INTERNAL ILIAC ARTERY. Tne gluteal artery is large ; from its situation liable to wounds; from its size subject to aneurism. Dr. Jeffray, of Glasgow, was consulted in a case where the gluteal artery had been wounded. He urged the propriety of mng the vessel where it had been in- jured. Tills sensible advice was at first rejected, and when the friends at last consented, tbe operation was too late, as, while preparation was making for it, the tumour burst, and the patient expired in a few moments. Thenden also mentions an instance in which the gluteal artery was wounded in the dilatation of a gun- shot wound, and the patient lost his life. — (See Scarpa on Aneurism, p. 407, ed. 2.) Mr. John Bell, how'ever, tied the gluteal artery in a case where it was wounded, and the patient was saved. [The late Dr. Cocke and Davidge, professors in the University of Maryland, tied the gluteal artery for an aneurism of immense size, with entire success. The patient was one whose gluteal muscles were exceed- ingly large, and the extent and boldness of the incision rivalled the herculean case reported by Mr. Bell. It wall presently be seen that even when the extent of the disease forbids tliis attempt, the ligature of the in- ternal iliac will afford a means of relief.— Jfeesc.] Mr. Stevens, surgeon in Santa Cruz, the gentleman [* Dr. Mott has tied the external iliac four times with complete success.— iJce5e.] who has proved the practicableness of putting a liga- ture round the internal iliac artery, informs Us that “one of the first surgeons in London had a patient with gluteal aneurism. The tumour was large; al- low'ed to burst ; and the person bled to death. “ I sincerely trust,” says he, “ that the following case may be the means of preventing such tm occurrence in future. “ Maila, a negro woman from the Bambara country in Africa, was imported as a slave into the West In- dies in the year 1790. She was purchased for the es- tate of Enfield Green ; now the property of the heirs of P. Ferrall, Esq. I saw her first in the beginning of December, 1812. She had a tumour on the left hip, over the sciatic notch. It was nearly as large as a child’s head, and pulsated very strongly. She could assign no cause for the disease. It had commenced, about nine months before, with slight ptiin in the part ; and had gradually increased to its present size. She was now much reduced, in great misery, and ready to submit to any operation.— (See Medico-Chir. Trans, vol. 5, p. 425.) Mr. Stevens had tied the internal iliac on the dead body, and believed that it might be done with safety on the living. The following is some ac- count of the operation : “ On the 27th of December, 1812 (says Mr. Stevens), I tied the arteiy in the pre- sence of Dr. Lang, Dr. Van Brackle, Mr. Nelthropp, and Mr. Ford, the manager of the estate. An incision, about five inches in length, was made on the left side, in the lower and lateral part of the abdomen, parallel with the epigastric artery, and nearly half an inch on the outer side of it. The skin, the superficial fascia, and the three thin abdominal muscles, were successively di- vided; the peritoneum was separated from its loose connexion with the iliacus intemus and psoas magnus ; it was then turned almost directly inw^ards, in a di- rection from the anterior superior spinous process of the ileum, to the division of the common iliac arterj'. In the cavity which I had now made, I felt for the in- ternal iliac, insinuated the point of my fore-finger be- hind it, and then pressed the artery between my finger and thumb. Dr. Lang now felt the aneurism behind ; the pulsation had entirely ceased, and the rumour was disappearing. I examined the vessel in the pelvis ; it w'as healthy and free from its neighbouring connex- ions. I then passed a ligature behind the artery and tied it about half an inch from its origin. The tumour disappeared almost immediately after the operation, and the w'ound healed kindly. About tbe end of the third w'eek the ligature came away, and in six weeks the woman was perfectly well. This is the first example in which the internal iliac was tied. The operation was not attended with much difficulty or pain, and not an ounce of blood was lost. Mr. Stevens had no difficulty in avoiding the ureter, which, when the peritoneum was turned inwards, fol- low'ed it. Had it remained over the artery, Mr. Ste- vens saj's that he could easily have turned it aside with his finger. — (See a particular history of this case in Medico-Chirurg. Trans, vol. 5, p. 422, i,-c.) A second instance, in which the internal iliac artery W'as tied, was some time ago communicated to the pub- lic. The operation w as performed by ]\Ir. Atkinson, of York, on account of a gluteal aneuri.'«m. The follow'- ing are a few of the particulars, as related by this gen- tleman : — Thomas Cost, aged 29, presented himself at the York County Hospital, Apnl 29th, 1817. He w'as a tall, strong, active bargeman, not corpulent, but very muscular. He was enduring great pain from a large, renitent, pulsating tumour, situated under the glutehs of the right side ; an obvious aneurism. It had existed about nine months, and was the consequence of a blow from a stone. In a consultation with Dr. Lanson and Dr. Wake, the necessity of the operation w'as deter- mined upon, and it was performed on the 12th of May w'ithout any material difficulty or interruption, except such as was the consequence of the division of, and bleeding from, the small muscular arteries. Having got command of the internal iliac arterj' within the pelvis, w'hich, says Mr. Atkinson, required the complete length of the fingers to accomplish, it was tied. Suf- ficient proof of its being the identical artery w'as re- peatedly obtained by the pressure upon it stopping the pulsation and causing a subsidence of the tumour. Dr. Wake, Mr. Ward, and all the pupils were quite sus- sured of the circumstance. The arterj' being then tied, the pulsation of the swelling entirely ceased. Some delay in placing the ligature arose from the needle not being sufficiently pliable ; but for future operations of this kind Mr. Atkinson very properly recommends the ligature to be put round the artery by means of an in- strument resembling a catheter, the wire of which has a little ring at its extremity, and can be pushed out some way beyond the end of the tube. The patient went on tolerably well for some time after the operation ; the pulse never exceeded 130, and after a time sunk to 85 or 90. He became exhausted, how- ever, partly by the discharge, and partly by hemor- rhage, and died on the 31st of May, about nineteen days after the operation. In the dissection, the cavity on the external part of the peritoneum, in the situation of the incision, was completely filled with coagulated blood. “ The ligature, on moving a part of this^dood) with a sponge, readily followed it, and without doubt had been disengaged for some days.” The internal iliac, which appeared to have been tied, had separated ibout an inch and a half from the bifurcation with the external iliac. By “ separated” I conclude Mr. Atkin- son means, that the upper part of the internal iliac was separated from the continuation of the same vessel. — (See Medical and Phys. Journ. vol. 38, p. 267, A c.) A.lthough this gentleman has not given a very dear- account of some part of the dissection, and he has also amitted to describe the place of his external incision, »r the exact parts which he divided in the operation, Ket I think that all the circumstances of the case taken •ogether leave not the» smallest doubt of the internal Hiac artery having been actually tied. The complete stoppage of the pulsation as soon as the ligature was tpplied, and the testimony of several respectable prac- titioners who were present, seem indeed to remove all ambiguity. The profession is much indebted to Mr. Atkinson for this important communication, which was in some measure required, in order to confirm Mr. Ste- vens’s similar case, as it is well known that some distinguished anatomists and surgeons in this metro- uolis formerly expressed very strong doubts of the practicable nature of the operation. The internal iliac artery is also said to have been tied with success by an army surgeon in Russia, upon whom the late Emperor Alexander settled a pension as a reward for the skill displayed in the treatment of the case. — (See AveriWs Operative Surgery, p. 39.) [The internal iliac has also been tied in this country successfully for the (tiire of gluteal aneurism by Pro- fessor White, the younger, of Berkshire Med. Institu- tion. This case is published in the second number of the American Journal of Medical Sciences, and is also referred to in Johnson’s Medico-Chirurgical Review for April, 1828. It is the fourth instance in which it has been ever attempted ; and three out of the four have been successful. The only time it was ever per- formed in Great Britain is the only instance of its failure. — Reese.] In a modern publication are given a few particulars of a case, which was supposed to be an aneurism of the gluteal artery, and cured by means of pressure, a light vegetable diet, gentle laxatives, and digitalis. — (8ee Trans, of the Fellows, A-c. of the King's and Qv.een's College of Physicians in Ireland, vol. 1, p.41, Svo. Dub. 1817.) From the very imperfect account here given of the tumour, it is impossibl# to form any con- clusion respecting its nature. .Sandifort has recorded an instance of an aneurism of the internal iliac artery itself. — (See Tabulcs Ana- tomiccB, ifC. Prascedit Ohs. de Aneurismate ArterieB Iliacae intenuB, rariore ischiadis NervoscB causa, fol. Ltigd. 1804.) The common iliac has never been tied in any case of aneurism of tiie external or internal iliac ; but Pro- fessor Gibson had occasion to put a ligature round it in an example of gun-shot wound. “ The patient lived fifteen days after the operation, and then died from peri- toneal inflammation, and from ulceration of the artery. The circulation in the limb of the injured side was re- Bstablished about the seventh day after the artery was tied.” — (See American Med. Recorder, vol. 3, p. 185 ; a>td Gibson’s Institutes of Surgery, vol. 2, p. 145. Philadelphia, 1825.) [As an act of justice to my distinguished fViend Profes.sor Mott, I here insert a detailed account of this Herculean operation, which Dr. Cooper admits has never before been performed. It is alike honourable to him, to the profession, and to our country. It is introduced Vol. I -I RISM. 129 entire, as communicated to me by the doctor at my soli- citation. A detailed account of the first operation ever per- formed upon the arteria iliaca communis for the cure of aneurism, and especially of the first attempt to apply the ligature to so great a vessel, without dividing the peritoneum, may prove interesting to the profession generally, and must be immediately serviceable to practitioners of surgery. “ On the 15th of March, 1827, 1 was requested to visit a patient with Dr. Osborn (of Westfield, New-Jersey, about twenty-five miles distant from New-York), whom we found labouring under a large aneurism of the right external iliac artery. Israel Crane, aged thirty-three years, by occupation a farmer, of temperate and regular habits, having gene- rally enjoyed excellent health, says, about the middle of January he felt some pain about the lower part of the belly, which he attributed to a fall received during the winter. He is in the habit of using great efforts in lifting heavy logs of wood, as his employment at this season consists in carrying wood to market. It, however, was not until a fortnight since that he per- ceived any tumour about the lower part of the abdomen. Upon examination, the abdomen on the right side was considerably enlarged from about the crural arch, as high as the umbilicus. When the hand was applied to the parietes of the abdomen, a pulsation was felt and rendered visible to some distance. To the touch the tumour beat violently, and appeared to contain only fiuid blood. It commenced a little above Pou- part’s ligament, and reached, judging by the touch, from without near the navel, inwards almost to the linea alba, outwards and backwards filling up all the concavity of the ileum, and reaching beyond the poste- rior spinous process of that bone. The rapid increase of this aneurismal tumour occa- sioned, as the countenance of our patient indicated, the most extreme agony. His sufferings at times were so great that his screams could be heard at a distance from the house. He had been bled several times, taken light food, and was kept constantly under the effect of opium. He was now informed of the serious nature of his case, and that without an operation very little chance of his life f emained ; with great composure he immediately consented to whatever would give him the best prospect of saving his life. From the extent and situation of the tumour he was apprized of the uncertain nature of the operation, as well as the difficulty of performing it, and indeed that it would require an artery to be tied, which never had been before operated upon for aneurism. With these views of his situation, he cheerfully submitted to be placed upon a table of suitable height, in a room which was w’ell lighted. Then, in the presence of Dr. Osborn, Dr. Liddle, and Dr. Cross, the following operation wa.s performed : — The pubes and groin of the right side being shaved, an incision was commenced just above the external abdominal ring, and carried in a semicircular direction half an inch above Poupart’s ligament, until it termi- nated a little beyond the anterior spinous process of the ileum, making it in extent about five inches. The integuments and superficial fascia were now dmded, which exposed the tendinous part of the external ob- lique muscle ; upon cutting which in the whole course of the incision, the muscular fibres of the internal ob- lique were exposed ; the fibres of which were cau- tiously raised with the forceps and cut from the upper edge of Poupart’s ligament. This exposed the sper- matic cord, the cellular covering of which was now raised with the forceps, and divided to an extent suffi- cient to admit the fore-finger of the left hand to pass upon the cord into the internal abdominal ring. The finger serving now as a director, enabled me to divide the internal oblique and transversalis muscles to the extent of the external incision, while it protected the peritoneum. In the division of the last-mentioned muscles outwardly, the circumflex ilii artery was cut through, and it yielded for a few minutes a smart bleed- ing. This, with a smaller artery upon the surface of the internal oblique muscle between the rings, and one in the integuments were all that required ligatures. With the tumour beating furiously underneath, I now attempted to raise the peritoneum from it, which we found difficult and dangerous, as it was adherent to it in every direction. By degrees we separated it with 130 ANEURISM. great caution from the aneurismal tumour, which had now bulged up very much into the incision. But we soon found that the external incision did not enable us to arrive to more than half the extent of the tumour upwards. It was therefore extended upwards and backwards about half an inch within the ileum, to the distance of three inches, making a wound in all about eight inches in length. The separation of the peritoneum was now continued, until the fingers arrived at the upper part of the tu- mour, which was found to terminate at the going oIT of the internal iliac artery. The common iliac was next examined by passing the fingers upon the pro- montory of the sacrum, and to the touch appearing to be sound, we determined to place our ligature upon it, about half way between the aneurism and the aorta, with a view to allow length of vessel enough on each side of it to be united by the adhesive process. The great current of blood through the aorta made it necessary to allow as much of the primitive iliac to remain between it and the ligature as possible, and the probable disease of the artery higher than the aneurism required that it should not be too low down. The depth of this wound, the size of the aneurism, and the pressure of the intestines downwards by the efforts to bear pain, made it almost impossible to see the vessel we wished to tie. By the aid of curved spatulas, such as I used in my operation upon the innominata^ toge- ther with a thin, smooth piece of board, about three inches wide, prepared at the time, we succeeded in keeping up the peritoneal mass, and getting a distinct view of the arteria iliaca communis, on the side of the sacro-vertebral promontory. This required great effort on our part, and could only be continued for a lew se- conds. The difficulty was greatly augmented by the elevation of the aneurismal tumour, and the intercep- tion it gave to the admission of light. When we elevated the pelvis, the tumour obstructed our sight ; when we depressed it, the crowding down of the intestines presented another difficulty. In this part of the operation I was greatly assisted by Dr. Os- born and my enterprising pupil, Adrian A. Kissam. Introducing my right hand now behind the perito- neum, the artery was denuded with the nail of the fore- finger, and the needle conveying the ligature was in- troduced from within outwards, guided by the fore-finger of the left hand in order to avoid injuring the vein. The ligature was very readily passed underneath the artery, but considerable difficulty was experienced in hooking the eye of the needle, from the great depth of the wound and the impossibility of seeing it. The distance of the artery from the wound was the whole length of my aneurismal needlq. After drawing the ligature under the artery, we suc- ceeded by the aid of our spatulas and board in getting a fair view of it, and w'ere satisfied that it was fairly under the primitiva iliac, a little below the bifurcation of the aorta. It was now tied ; the knots were readily conveyed up to the artery by the fore-fingers ; all pulsa- tion in the tumour instantly ceased. The ligature upon the artery was very little below a point opposite the umbilicus. The wound was now dressed with five interrupted sutures, passing them not only through the integu- ments, hut the fibres of the cut muscles, so as to bring their divided edges together at all parts of the incision which was muscular. Adhesive plaster to assist the stitches, lint and straps to retain it, completed the dressing. The operation leisted rather less than one hour. He was removed from the table, and put into bed upon his back, with the knee a little elevated upon pillows to relax the limb as much as possible, and to avoid pressure upon it. It was considerably cooler than the opposite leg, and flannels were applied all over it, and a bottle of warm water to the foot. From the habit he had been in of taking largely of anodynes, a tea-spoonful of the tinct. opii was administered, with directions to repeat it in an hour if the pain should be severe. In less than one hour from the operation, considerable reaction of the heart and arteries took place ; he felt, as he stated, eltogether relieved from the excruciating agony he had suffered since the aneurism commenced. The whole limb had now recovered its natural tempe- rature. March IQth. The day after the operation, pulse eighty ; skin moist ; limb warm ae the other ; com- plains of some pain at the ligature ; ordered a purgative of neutral salts. nth. Pulse eighty, and ftiller than yesterday ; took 1 X. of blood from his arm ; skin moist ; tongue brown } considerable uneasiness m the limb ; no pain at the ligature ; leg of natural heat ; salts had a good effect. Pulse seventy-five ; skin moist ; tongue white ; pain in the limb considerable ; no pain at the ligature or in the wound ; limb warm. 19th. Bled him to-day ten ounces, the pulse being tense, and beating eighty strokes in a minute ; repeated the cathartic ; suppuration appearing to have taken place, the dressings were removed. 20th. Pulse seventy and soft ; skin moist ; wound looks ^vell ; pain in the limb continues; leg warm as the other ; cathartic operated well. Pulse seventy and soft; wound looks well; repeated the laxative ; pain in the leg rather less ; con tinues warm. There has been at no time tension of the abdomen or any particular uneasiness in that part. The patient thus far has been altogether more comfort- able than could have been imagined. He takes more or less opium daily, from the long habit he has been in of taking anodynes. 26th. No unpleasant symptom ; wound looks well ; bled again to | xij., as there was a little tumefaction and inflammation about the wound. 30th. Our patient continues to do well; wound dressed daily. April 3d. Not being able to leave the city, I requested Dr. Prondfoot, my late pupil, ^nd a most promising young surgeon, to visit the patient. He reports that he was free of fever ; wound all healed but where the large ligature was passing. The ligature appearing to be detached, the Dr. took hold of it and removed it: this was on the eighteenth day from the time of its application. Limb of the natural temperature ; en- joined upon him to keep very quiet and in bed. 8th. There are no disagreeable appearances what- ever ; he appears to be doing remarkably well ; has been bled once since the last report ; takes a purgative every other day, and an opiate every night ; pulse as in health ; no pain ; says he is entirely comfortable ; wound is dressed with dry lint. 16th. Has improved rapidly since the last report. Two days after the ligature came away he very im- prudently got out of bed, without experiencing any dif- ficulty except weakness. Rode out to-day; wound perfectly healed. April 26th. He has been using crutches for a few days to favour the lame leg, which as yet feels rather weak. General health greatly improved. 30th. Is perfectly restored in health; has a little stoop in his walk, which he says is occasioned by the external cicatrix. Leg is not yet of its full size, nor quite so strong as the other. From the period of the operation to the recovery of our patient, he did not ap- pear to suffer more pain, or have more unpleasant symptoms, than would ordinarily take place in a flesh wound of equal extent. Much of this, in my opinion, is to be attributed to the prompt and judicious antiphlo- gistic treatment pursued by Dr. Osborn, to whom I am indebted for the daily reports of the case. Map 29th. My patient visited me to-day, having come twenty-five miles ; he was so much improved in health that I did^iot recognise him. Examined the cicatrix, and found it perfectly sound ; could not dis- cover any remains of an aneurismal tumour; felt the epigastric artery much enlarged and beating strongly, and a feeble, though distinct pulsation in the femoral artery immediately below the crural arch. The leg has its natural temperature and feeling, and he says it is as strong as the other. Much credit is due the patient for his firmness on the . occasion ; although apprized of the great danger attend- ing so formidable an experiment, and the uncertainty of its result ; yet with a fortitude unshaken, and a full con- viction that it was the only chance of prolonging his life, he cheerfully and resolutely submitted to the operation The gratification his visit afforded me is not to be imagined, save by those who have been placed under similar circumstances. The perfect success of so im- portant and novel an operation, with the entire restora- tion of the patient’s health, was a rich reward for the anxiety 1 experienced in the case, and in a measure compensated for the unexpected failure of my opera- tion on the arteria innominata." ANEURISM. 131 Professor Bushe has lately tied common iliac in a child less than two months old for a congenital aneu- rism of one of the labia. She recovered from the ope- ration, but perished a few weeks afterward from abscess Of the knee-joint. — Reese.] ANEURISMS or THE BRACHIAL ARTERY. Surgical writings contain many histories of aneu- risms in the bend of the arm, produced by the punc- ture of the brachial artery in venesection, or caused by a deep wound inflicted at the bend of the arm along the inner side of the humerus or in the axilla. Such cases must indisputably be formed by effusion. Although Morand and others have found, that, along with aneu- risms caused by a wound of the brachial artery, the diameter of the vessel is sometimes unusually enlarged through its whole length above the seat of the tumour, this enlargement, which is very rare, might have ex- isted naturally before the puncture occurred. Even were it frequent, such an equable longitudinal expan- sion of the tube of the artery could not explain the form- ation of the aneurismal sac in the bend of the arm, along the inner side of the humerus, or in the axilla, after wounds. — (Scarpa, p. 160.) The proximate cause of these cases may invariably be traced to the solution of continuity in the two pro- per coats of the artery, and the consequent effusion of blood into the cellular substance. The effect is the same, whether from an internal morbid affection, ca- pable of ulcerating the internal and fibrous coats of the artery, the blood be effused into the neighbouring cel- lular sheath surrounding the artery, which it raises after the manner of an aneurismal sac ; or the wound of the integuments having closed, the blood issue from the artery, and be diffused in the surrounding parts. The cellular substance on the outside of the wounded vessel is first injected, as in ecchymosis ; the blood then distends it, and elevates it in the form of a tumour, and, the cellular divisions being destroyed, converts it at last into a firm capsule or aneurismal sac. — (Scar- pa, p. 167.) The circumscribed or the diffused nature of the aneu- rism, and the rapidity or slowness of its formation, de- pend on the greater or less resistance to the impetus of the blood, during the time of its effusion, by the in- terstices of the cellular substance surrounding the ar- tery, and by the ligamentous fasciae and aponeuroses, lying over the sac. The aponeurosis of the biceps muscle being only half an inch broad, and situated lower than the common place for bleeding, cannot, at . least in most cases, materially strengthen the cellular substance surrounding the artery, as is commonly sup- posed.— (Scar/ja, p. 168 — 170.) This author refers the greatest resistance to the intermuscular ligament, which, after having covered the body of the biceps muscle, extends over the whole course of the humeral artery, and is implanted into the internal condyle. This ligamentous expansion ha.s a triangular shape, the base of which extends from the tendon of the biceps to the internal condyle, while the apex reaches upwards along the inner side of the humerus towards the axilla, in the course of the artery. The humeral artery and median nerve, kept in their situation by the cellular sheath and this ligamentous expansion, run in the furrow formed between it and the internal margin of the biceps. — (Scarpa, p. 171.) This author anatomically explains many circumstances relative to the diffu.sion, circum- scription, shape, &c. of brachial aneurisms by this intermuscular ligament. While aneurisms, from an internal cause, are not unfrequent in the aorta, thigh, and ham, they are very rare in the brachial artery ; though a few such instances are recorded. — (Scarpa, p. 174. Pelletan, Clinique Chir. t. 2, p. 4.) The mode of distinguishing a wound of the brachial artery in attempting to bleed, a«d the method of trying to effect a cure by pressure are described in the article Hemorrhage. Anel was the first who tied the brachial artery for the cure of the aneurism at the bend of the arm, in the same way that Hunter did the femoral for the cure of aneurisms in the ham, viz. with one ligature above the tumour, without making any incision upon or into the sac itself. The operation is performed as follows : — The surgeon having traced the course of the brachial artery, and felt it.s pulsations above the aneurism, he may either cut (low.'i to the vessel immediately above the tumour. I 2 or much higher in the long space between the origins of the superior and inferior collateral arteries. The integuments are to be divided in the course of the ar- tery, and also the cellular sheath for the space of about two inches and a half. The surgeon, now introducing his left fore-finger to the bottom of the wound, will feel the denuded vessel, and if it is not sufficiently bare, he must divide the parts which still cover it, observing to introduce the edge of the knife on the side next to the internal margin of the biceps, to avoid dividing any of the numerous muscular branches which go off from the opposite side of the artery. He is then to insulate with the point of his finger the trunk of the vessel, alone if he can, or together with the median nerve and vein, and raise it a little from the bottom of tiie wound. He is to separate the median nerve and vein for a small space from the artery, and with an eyed needle is to pass a ligature under the latter, and then tie it with a simple knot. In the operation it should always be recollected that the median nerve lies on the inside of the artery, and, therefore, that the instrument used for putting the liga- ture under the vessel should be passed from within outwards, by which means the inclusion of the nerve may be most easily avoided. — (Boyer, Traite des Mala- dies Chirurgicales, ' from above the clavicle ; nor can it be wondered, that without such a.ssistance, the ope- ration should have baffled even so skilful a surgeon as Sir A. Cooper. — (See Bond. Med. Review, vol. 2, p. 200.) The follov/ing example is the first in which the at- tempt to tie the subclavian artery by cutting above the clavicle was ever accomplished. John Townly, a tailor, aged thirty-two, addicted to excessive intoxication, of an unhealthy and peculiarly anxious countenance, was admitted into St. Bartholo- mew’s Hospital on Tuesday, the 2d of November, 1809, on account of an aneurism in the right axilla. The 134 ANEURTSxM. prominent part of the tumour in the axilla was about half as big as a large orange, and there was also much enlargement and distension underneath the pectoral muscle, so that the elbow could not be brought near the side of the body. “ The temperature of both arras,’* says Mr. Rams- den, “ was alike, and the pulse in the radial artery of each of them was correspondent. After the patient had been put to bed, some blood taken from the left arm, an^ his bowels emptied, his pulse, which on his admission had been at 130, became less trequent ; his countenance appeared more tranquil ; and he experienced some re- mission of the distressing sensations in the affected arm : his relief, however, was of short duration.” The pulsation of the radial artery of the affected arm gradually became more obscure, and soon after either ceased or was lost in the oedema of the forearm and hand. On the evening of the twelfth day, a dark spot appeared on the centre of thp tumour, surrounded by inflammation, which threatened a more extensive de- struction of the skin. A farther jwstponement of the operation being deemed inadmissible, Mr. Ramsden performed it the next day in the following manner. “ A transverse incision was made through the skin and platysma myoides, along and upon the upper edge of the clavicle, about two inches and a half in length, beginning it nearest to the shoulder, and terminating its inner extremity at about half an inch within the outward edge of the stemo-cleido-mastoideus muscle. This incision divided a small superficial artery, which was directly secured. The skin above the cla%'icle be- ing then pinched up between my own thumb and fin- ger and those of an assistant, I divided it from within outw’ards and upwards, in the line of the outward edge of the stemo-cleido-mastoideus muscle to the extent of two inches. IVIy object in pinching up the skin for the second incision, was to expose at once the superficial veins, and by dissecting them carefully from the cellular mem- brane, to place them out of my way without wounding them. This provision proved to be useful, for it ren- dered the flow of blood during the operation verj' tri- fling, comparatively with what might otherwise have been expected ; and thereby enabled me with the great- est facility to bring into view those parts which were to direct me to the artery. My assistant having now lowered the shoulder, for the purpose of placing the first incision above the clavicle (which I had designedly made along and upon that bone), I continued the dis.section with my scalpel, i until I had distinctly brought into sight the edge of the anterior scalenus muscle, immediately below' the angle which is formed by the traversing belly of the omo-hyoideus and the edge of the sterno-cleido-mastoi- deus; and having placed my finger on the artery at the point where it presents itself betw'een the scaleni, I found no difficulty in tracing it, without touching any of the nerves, to the lower edge of the upper rib, at which part I detached it with my finger nail, for the pur]tose of applying the ligature. liere, however, arose an embarrassment which (al- though I was not unprepared for it) greatly exceeded my expectation. I had learned, from repeatedly per- forming this operation many years since, on the dead subject, that to pass the ligature under the subclavian artery with the needle commonly used in aneurisms would be impracticable ; 1 had, therefore, provided my- self with instruments of various forms and curvatures to meet the difficulty, each of w'hich most readily con- veyed the ligature underneath the artery, but would serve me no farther ; for being made of solid materials and fixed into handles, they would not allow of their points being brought up again at the very short curva- ture, which the narrowness of the space between the rib and the clavicle afforded, and which, in tips parti- cular case, was rendered of unusual depth by the pre- vious elevation of the shoulder by the tumour. After trying various means to overcome this diffi- culty, a probe of ductile metal was at length handed me, w’hich I passed under the artery, and bringing up its point with a pair of small forceps, I succeeded in passing on the ligature, and then tied the subclavian artery at the part where I had previously detached it for that j)urpose. The drawing of the knot w as unat- tended with pain ; the wound w as clo.sed by the dry suture, and the patient was then returned to his bed.” — (See Practical Observations on the Sclerocele, h c., to which are added four cases of operations for Aneu risins, p. 276, ($-c.) It only seems necessary' for me to add, that imme- diately the artery' w’as tied the pulsation of the swelling ceased ; that the arm of the same side continued to be freely supplied with blood, and was even rather warmer than the opposite arm ; that the operation, which was severe from the length of time it took up, w as after a time followed by considerable indisposition ; that the patient died about five days after its performance ; that after the artery had been tied, the cedema of the arm and the aneurismal tumour partly subsided ; and that, on examination after death, nothing but the vessel was found included in the ligature. In this publication are descriptions of instruments which will be of great service to any future perfonner of this operation. The chief one is a needle, resembling that which was invented and used by Desault, and of which I have already endeavoured to give an idea. I’y means of this instrument, I conceive that the main dif- ficulty of the operation will in future be avoided. Had Mr. Ramsden had its assistance, his patient would have been detained a very little time in the operating theatre, and the event of the case might have been completely successful. Ha^ing witnessed all the cir- cumstances of the case, the inference that I drew' from them was, that if the operation could have been done in a moderate time, which now' seems practicable with the aid of the aiguille a ressort, or the instrument sold by Mr. Weiss, the case in all probability would have ended well. The preceding ca.se is particularly me- morable, as being the first instance in which the sub- clavian artery was scientifically tied, without any ran- dom thrust of a needle, and without the inclusion of any part besides the artery in the ligature. It fur- nished encouragement to repeat the experiment ; held out the hope, that axillary aueurisms might be cured as well as inguinal ones'; and confirmed the compe- tency of the anastomosing arteries to nourish the whole upper extremity, when the subclavian is tied where it emerges from beliind the anterior scalenus muscle. In the year ISll, the subclavian artery was tied in the London Hospital, in a case of axillary aneurism, by Sir W, Blizard, who found no difficulty in getting the ligature under the artery, with a common aneurism- needle. A single ligature w'as applied. At first hopes of recovery w'ere entertained; but the patient, who was old and debilitated, afterward sunk and died on the fourth day. — (See HedgS' n's Treatise, p. 375.) In the year 1815, Mr. Thomas Blizard tied the sub- clavian artery in the same hospital. The case w'as an aneurism in the left axilla, and, like all the other ex- amples of this kind upon record, was attended with great pain in the tumour and limb. There was no pulse in the left radial artery, though there was scarce- ly any difference in the temperature of both arms, “ An incision about three inches in length was made through the integuments at the root of the neck, on the acromial side, and parallel w'ith the external jugu- lar vein. The platysma myoides being divided, the cellular membrane was separated with the finger, until the pulsation of the subclavian artery was felt where the vessel passes over the first rib. The finger being pressed upon this part of the artery, the cellular sheath investing it was carefully opened with the point of a knife. A ligature was then conveyed underneath the artery, by means of a common aneurism-needle, with the greatest facility.” As soon as the ligature was tied, the pulsation in the tumour ceased. On the second day after the operation the left arm began to have more feeling, and was as warm as the right. However, difficulty of breathing, twitchings, delirium, ture of the iliacus communis, confers upon American surgery imperishable laurels. As an cAddence of the estimation in which this operation is held in Europe, I feel a national pride in inserting the following extract of a letter from that distinguished surgeon. Professor Colies, of Dublin, Avritten to Dr. Mott soon after his case of ligature on the innominata had reached him. I think this tribute to the able operator is the more im- portant, since efforts have been made by the envious to detract from the merit of the operation ; and it has been publicly stated that the same operation has been performed in Europe, and even by Dr. Codes himself That this is not the fact will be obvious from the ex- tract which follows, and which I introduce without any farther comment. “ I shall not attempt to say how much the profession is indebted to you for this bold and splendid operation. That it did not succeed I lament on your account ; that it will hereafter succeed, there cannot be a doubt in 138 ANEURISM. the mind of any reasoning man. Your feelings during the first twenty-two days after the operation are to be envied. The hopes of success continued so strong and so well founded, while the slight degree of uncertainty as to the issue must have exalted those feelings to the liighest intensity. I have never read the account of an operation in which I would rather have been the ope- rator,”— Keesc.] The arteria innominata was also tied by Graefe on the 5th of March, 1822, in the Clinical Hospital of the University of Berlin, on account of a subclavian aneu- rism. The carotid was exposed and traced down to the innominata, to which a ligature was applied by means of a blunt tenaculum constructed for the pur- pose, the vessel being tied at most about an inch from the curvature of the aorta, ami two inches from the heart. As soon as the ligature was tightened, the pul- sation of the arteries of the right arm, right caro- tid, and right temporal artery ceased; at the same instant the throbbing of the aneurism stopped, and the tumour became flaccid. The constriction of the cord produced no disturbance of any function. The patient went on so well for several weeks afterward, that no doubt was entertained of las recovery. How- ever, when the wound was nearly healed, hemor- rhage came on, and though it was suppressed, and hope began to be again indulged, the bleeding recurred, and the patient died on the sixty-seventh day. Below the ligature the innominata was (bund closed with lymph. Graefe has written a distinct essay on the method in which the operation was done; the daily particulars of the case, and preparation from it, are placed in the Royal Anatomical Museum at Berlin. — (See Joum. der Chirurgie vcra C. F. Graefe, and Ph. v. Walther, b. 3, r- 596, ^-c., b. 4, p. 587.) Of Mr. Wardrop’s prac- tice of tying the subclavian artery in aneurism of the arteria innominata itself, we shall presently speak. CAROTID ANEURISMS. There is no part of the body where the diagnosis of aneurisms is more liable to mistake than in the neck. Here the disease is particularly apt to be confounded with tumours of another nature. We have already cited in this article examples in which aneurisms of' the arch of the aorta so resembled those of the carotid as to have deceived the surgeon who was consulted. The swelling of the lymphatic glands, or of the cellu- lar substance which surrounds the carotid artery, the enlargement of the thyroid gland, and especially ab- scesses, may resemble an aneurism by the pulsations communicated to them by the neighbouring artery. On the other hand, aneurisms of long standing, which no longer throb, and the integuments over which are changed in colour and likely to burst, may the more easily be mistaken by an inattentive practitioner for chronic abscesses, as the neck is remarkably often the seat of such diseases.— (Boyer, Traite des Maladies Chirurgicales, t. 2, p. 185.) Scarpa mentions one unfortunate patient who was killed by a knife being plunged in a carotid aneurism, on the supposition that the case was an abscess. I need scarcely observe, that by opening a carotid aneurism a surgeon would expose himself to the dis- grace and mortification of seeing the patient die under his hands, as happened in the example cited by Har- derus.— (Apior. Observationum, Obs. 86.) The possibility of tying the carotid artery in cases of wounds and aneurisms, without any injurious ef- fect on the functions of the brain, is now completely proved. Petit mentions that the advocate Vieillard had an aneurism at the bifurcation of the right carotid, for the cure of which he was ordered a very spare diet, and directed to avoid all violent exercise. Three months afterward the tumour had evidently dimi- nished ; and at last it was converted into a small, hard, oblong knot, without any pulsation. The patient having died of apojilexy seven years afterward, the right carotid was found closed up and obliterated from its bifurcation, as low down as the right subclavian artery.— (Acrtd. des Sciences de Paris, an 1765.) Hal- ler dissected a woman whose left carotid was imper- vious . — (Opuscula Pathol. Obs. 19, tab. 1.) An ex- ample of the total closure of both carotids in conse- ^luence of ossification, is stated by Koberwein to be recorded by Jadelot.— (Ger/nara transl. of Mr. Hodg- son’s work, p. 293.) Hebenstreit, vol. 4, p. 266, ed. 3, of Ills translation of B. Bell’s Surgery, mentions a case in which the carotid artery ■was wounded in thti extir- pation of a scirrhous tumour. The hemorrhage would have been fatal had not the surgeon immediately tied the trunk of the vessel. The patient lived many years afterward. This is probably the earliest authentic instance in which a ligature was applied to the carotid artery. Mr. Aberncthy’s case is perhaps the second : and that in which Mr. Fleming, a naval surgeon, tied the common carotid in a sailor who attempted suicide, and who was saved by the operation, is still later, not having occurred till the year 1803.— (See Med. Chir. Joum. vol. 3, p. 2.) Dr. Baillie knew an instance in which one carotid was entirely obstructed, and the diameter of the other considerably lessened, without any apparent ill effects on the brain.— (See Trans, for the Improvement of Med. and Chir. Knowledge, vol. \,p. 121.) Sir Astley Cooper has also recorded an example in which the left carotid was obstructed by the pressure of an aneurism of the aorta ; and yet during life no paralysis nor im- pairment of the intellects had occurred. — (See Med. Chir. Trans, vol. 1, p. 223.) A similar case is related by Pelletan . — {Clinique Chir. t. 1, p. 68.) Mr. Abernethy was under the necessity of laying the trunk of the carotid in a case of extensive lacerated wound of the neck, w'here the internal carotid and the chief branches of the external carotid were wounded. The patient at first went on well : hut in the night he became delirious and convulsed, and died about thirty hours after the ligature was applied. This case fell under my own notice, and the inference which I drew was, that the man died more from the great quantity of blood which he lost, and the severe mischief done to the jiarts in the neck, than from any efiect of the ligature of the artery on the brain. In another instance in which the common carotid was tied, on account of a wound of the external caro- tid by a musket-ball, complicated with fracture of the condyle and coracoid process of the lower jaw, every thing went on favourably until the seventh day after the operation. Neither the intellectual faculties nor the functions of the organs of sense had been at all disturbed. But at that period stupor, confusion of ideas, restlessness, a small unsteady pulse, discolor- ation of the face, and loss of strength came on, fol- lowed in the evening by a violent paroxysm of fever. On the eighth day three copious hemorrhages took place from the whole surface of the wound, and on the ninth the man died. In this case, however, the aflTection of the brain, and the other unfavourable symptoms, would be ascribed by nobody to the effects of the ligature on the carotid, but every one would see the cause in the severe and extensive local mischief produced partly by the rnusket-ball, and partly by the mode in which the operation was performed, the surgeon having extended his incisions from the parotid gland to within an inch of the clavicle ! — (See Joum. General de Med. ' after it emerges from between the scaleni muscles, Mr. Wardrop conceived, that such would yet be the diminution of the impetus of the blood in the sac, that the future increase of the tumour would be prevented, and even a permanent obliteration of the aneurismal cavity would be accomplished. — {On Aneurism, p. 58.) The knowledge of this principle, indeed, he thinks, may be useful in the cure of many aneurisms, which have hitherto been considered be- yond the reach of an. In an aneurism of the innomi- nata, Mr. Mackelcan found that nature had nearly completed a cure of the disease on this principle. The carotid artery was plugged up, and the large aneuris- mal swelling was filled with a coagulum, leaving only a comparatively small channel for the passage of the blood into the subclavian artery. — (See Appendix to Wardrop em Aneurism.) Mr. Wardrop has seen some cases, and several are on record, which illustrate the same important pathological fact, and prove beyond a doubt, that blood can coagulate in an aneurism so as to strengthen the parietes of the sac, and ultimately fill its cavity, without the circulation in the sac being in the first instance either suddenly or entirely inter- rupted. It was the knowledge of this fact that led Mr. Ward- rop to perform the operation, which he has related. Nature, in the case alluded to, had already instituted a curative process by diminishing the circulation in the carotid artery ; and when he found this alone not suffi- cient to stop the enlargement of the aneurism, he de- termined to place a ligature on the subclavian. In doing this, he conceived that he was strictly imitating the process which nature herself had commenced. — (P. 61.) The case of Mrs. Denmark, aged 45, in whom he tied the subclavian tirterj’, and thus cured an aneurism of the arteria innominata, is highly interesting. The par- ticulars may be read in his own publication, or in the Lancet for 1827. Suffice it here to state, that the dis- ease was completely cured. In the appendix to Mr. Wardrop’s publication, and in the Lancet for Novem her, 1828, is another highly important case, confirming the accuracy of the principles explained by this in- genious surgeon. It is an example in which Mr. Evans, of Belper, Derbyshire, successfully treated an aneurism of the innominata mid root of the carotid, by tying the latter vessel. In the end, the patient, a but- cher and horse-dealer, thirty years of age, was well enough to attend regularly the markets and fairs of Derby, seven miles from his home. In the course of the case, three remarkable circumstances occurred ; 1st, An obliteration of the large arteries of the right arm. 2dly, A profuse salivation. 3dly, A disposition to paralysis of the right side, supposed by Mr. Evans to have arisen from a greater quantity of blood being sent to the left hemisphere of the brain than to the 1 right. However, as such paralysis has not attended ANEURISM. 141 other operations in which the carotid was tied, the truth of the explanation seems doubtful. The palsy aAerward nearly subsided. [It affords me high gratification to record, that Pro- fessor Mott, of this city, has lately performed this ope- ration for the first time it has been attempted in Ame- rica, by tying the carotid artery for aneurism of the arteria innominata, involving the subclavian and root of the carotid. This is the first time in America in which aneurism has been treated by tying the artery on the anticardial side of the tumour. The report of the case, and its successful result, is contained in the American Journal of the Medical Sciences, No. 10, for February, 1830. Since that report was published the patient has died, and the tumour having been re- moved, fully establishes the success of the operation. I have had an opportunity of examining the prepara- tion, and found the carotid entirely obliterated and im- pervious above the aneurismal sac, although the liga- ture was applied very high on that vessel. The death was occasioned by the displacement and distortion of the trachea and larynx, which are seen lying on the side of the neck, and in no wise connected with the operation, but was the consequence of the long exis- tence of the disease before the oper tion was submitted to. — Reese.] OF ANEURISMS OF THE AORTA, AND VALSALVA’s TREATMENT. This affhcting and fatal disease is by no means un frequent, and the arch of the aorta is its most com mon situation. Dr. Hunter was of opinion that th» latter circumstance depended on the forcible mannei in which the blood, propelled from the left ventricle o the heart, must be driven against the angle of the cur- vature of the vessel. Mr. A. Burns considered aneurism of the thoracic aorta more frequent, perhaps, than that of any othei vessel in the body. “ I have had (says he) an oppor- tunity of examining fourteen who had died of this dis- ease, but have not seen more than three instances of external anenrism.”— {On Diseases of the Heart, 6,-c.p. These proportions, however, would not correspond to common observation, external aneurisms, taken col- lectively, being supposed to be about as numerous as those of the aorta alone, a calculation long ago made by Dr. A. Monro, primus. It was the opinion of Dr. W. Hunter that the aiieu- nsmal sac was composed of the dilated coats of the artery, which parts nature thickened and studded with ossifications after the origin of the disease, for the pur- pose of resisting its increase. Mr. Hodgson, also, in his late excellent publication declares his decided belief and adduces facts to prove, that many aneurisms of the aorta are formed by dilatation. Scarpa argues, how- ever, that the generality of aneurisms of the aorta are the consequence of a rupture of the proper coats of this large vessel ; and that the cellular sheath of the artery is what becomes distended into the thickened and os- sified aneurismal sac. Dr. W. Hunter considered the ossifications of the sac as consequences of the disease: but Haller looked upon such scales of bone in the aorta as the very cause of the affection, by rendering the artery inelastic, and incapable of yielding to each pulsation of the heart. It is unquestionably true that aneurisms of the aorta are most common in persons who are advanced in life and it is equally well known, that the aorta of everv old subject, whether affected with aneurism or not is almost always marked in some place or another wuth ossifications, or rather with calcareous concretions Such productions appear to occasion a decay or absorp- tion of the muscular and inner coats of the vessel, so lliat at length the force of the blood makes the artery pve way, and this fluid, collecting on the outside of the laceration or rupture, gradually distends the external sheath of the artery into the aneurismal sac, which it- self becomes at last of considerable thickness, and studded with ossified specks. “ If any person who is not prejudiced in favour of the common doctrine with regard to the nature and proximate cause of this disease (says Scarpa), will ex- amine, not hastily and superficially, but with care and by dissection, the intimate structure and texture of the aneunsm of the aorta, unfolding with particular atten- tion the proper and common coats of this artery, and in succession those which constitute the aneurismal sac, in order to ascertain distinctly the texture and limits of both, he will clearly see that the aorta, pro- perly speaking, contributes nothing to the formation of the aneurismal sac, and that, consequently, the sac is merely the cellular membrane, which in the sound state covered the artery, or that soft cellular sheath which the artery received in common with the neigh- bouring parts. This cellular substance, being raised and compressed by the blood effused from the corroded or lacerated artery, assumes the form of a circum- scribed tumour, covered externally, in common with the artery, by a smooth membrane, such as the pleura in the thorax and the peritoneum in the abdomen.” Scarpa then comments upon the differences of mere dilatation of an artery from aneurism, a subject which has been already fully considered in the foregoing pages. — (Scarpa on the Anatomy, Pathology, and Surgical Treatment of Aneurism, transl. by hart, p. 55, 56.) As I have already explained in the preceding co- lumns, the sentiments of this eminent anatomist are not adopted by the generality of surgeons ; or rather, his doctrine is not carried by others to the extent which he has insisted upon j and it would be useless repeti- tion to bring before the reader again the facts which prove that his statements are liable to many exceptions. A case, however, recited by Roux, which I have met with since the foregoing pages were printed, merits no- tice ; it was an instance in which a popliteal aneurism, unattended with pulsation, had been mistaken for an abscess and punctured, whereby the patient lost his life. On dissecting the limb, Roux says, “ the three coats of the artery participated in the dilatation, and the case was one of the clearest specimens which I have ever seen of a true aneurism.”— (iVowueaiAr EL~ mens de M-d. Op, ratoire, t. 1, p. 517.) All arguments brought against the possibility of a dilatation of the inner coat, and founded on the inelas- tic structure of that membrane, must likewise be com- pletely refuted by another fact demonstrated by morbid preparations, collected by Dubois and Dupuytren, where the inner coat of the aorta is alone dilated, pro- truding through the outer tunics in the form of a distinct swelling somewhat like a hernia.— (Rowa?, op. cit. p. 49.) In whatever manner aneurisms of the aorta are formed, there are no diseases which are more justly dreaded, or which more completely fill the surgeon as well as the patient with despair. No affliction, indeed, can be more truly deplorable ; for the sufferings which are occasioned hardly ever admit even of palliation, and the instances of recovery are so very few, that no consolatory expectation can be indulged of avoiding the fatal end to which the disease naturally brings the mi- serable sufferer. The existence- of aneurisms of the aorta is scarcely ever known with certainty before they have advanced so far as to be attended with an external pulsation and a tumour that admits of being felt or even seen In very thin subjects, the throbbing of the abdominal aorta is sometimes unusually plain through the inte«ertion makes the throbbing more evident. The occasionally turgid states of the tumour produces sacs of blood in the cellular substance, or dilated veins, and these sacs form little tender, hvid, very thin iwints, which burst from time to time, and then, like other aneurisms, tliis one bleeds so profusely as to induce extreme weakness. The tumour is a congeries of active vessels, and, ac- cording to Mr. John Bell, the cellular substance through which these vessels are expanded, resembles the gills of a turkey-cock or the sub.sfance of the pla- centa, spleen, or womb. The irritated and incessant action of the arteries fills the cells with blood, and from these cells it is reabsorbed by the veins. Tlie size of the swelling is increased by exercise, drinking, emo- tions of the mind, and by all causes which accelerate the circulation. In this peculiar disease Dupuytren regards the arte- ries as being in an aneurismal state ; but, besides this circumstance, he says, their extreme ramifications in- termix in a thousand different ways, intercepting spaces, and representing cavities like those which are found in the corpora cavernosa ; and he imputes the disease to increased activity of the capillary circulation. — {Fr. transl. of Mr. Hodgson's work, t. 2, p. 300.) It is obser\’ed by INIr. Syme, that most surgeons have fol- lowed John Bell in believing this disease to consist of a morbid cellular structure through which the blood passes in its course from the arteries into the veins. However, he has long been one of those who maintain that the apparent cells are really sections of enlarged vessels.— (See Edin. Med. Joum. No. 98, p. 72.) In the dissection of a pulsating tumour of the scalp in a patient who had died after the operation of tying the carotid artery. Dr. Maclachlan found the branches of this vessel on the head “ degenerated into dilated tubes of extreme thinness and transparency ; which, apparently yielding to the impetus of the blood, had become elongated, contorted, and ultimately convoluted on themselves, so as to form by this species of dou- bling the tumours w hich constituted this singular dis- ease.” They felt like placenta, and the larger portion immediately over the ear looked precisely like a bundle of earthworms coiled together. — (See Glasgow Me- dical Journ. vol. 1, p. 85.) Two cases are given by Pelletan, fully confirming the view taken of the nature of the disease by Dr. Maclachlan and Mr. Syme. — (See Clinique Chir. t. 2.) Boyer, who saw' one of these cases, describes all the arteries of the swelling as being dilated, tortuous, knotty, and though very large in some places, in others contracted . — {Traite des Mai. Chir. t. 2, p. 295.) In the tumour described by Dr. Maclachlan none of the cells spoken of by Mr. John Bell were found ; no parenchyma as in the spleen ; the bulk of the tumour w'as formed almost entirely by convoluted, dilated arterial trunks, the veins being but little changed from their healthy state. He adds, that these arteries did not appear to communicate more freely than by their ordinary inosculations. Some of these conclusions, as it appears to me, require corroboration by a careful anatomical injection of the vessels. In the ff male subject the hemorrhage from the aneu- rism by anastomosis is sometimes a substitute for menstiTiation, as the following example illustrates : Ann Vachot, of St. Maury, in Bresse, was born with a tumour on her chin, of the size and shape of a small strawberry, xvithout pain, heat, or discoloration of the skin. As it produced no uneasiness nor inconvenience whatever, it excited little attention, particularly as it did not seem to increase with the growth of the child. For the first fifteen years there was but little alteration ; but about the menstrual period it increased suddenly to double the size, and became more elongated in its fonn. A quantity of red blood was observed to ooze from its extremity. This flux became, in some measure, periodical, and sometimes was sufficiently abundant to produce an alarming degree of weakness. Each pe- riod of its return was preceded by a violent pain in the head and numbness. Before and after the appearance of these syTnptoms there was no alteration in the size of the tumour ; the only difference was a small enlargement of the cuta- neous veins, with an increase of heat in the part, oc- casioning some degree of tenderness. The menses at length took place, but in small quan- tity and at irregular periods, without influencing the blood discharged from the tumour or the frequency of the evacuation. The breasts were not enlarged till a late period, nor did the approach of puberty seem to have its accus tomed influence on those glands, &c. — (See Parisian Chir. Joum. vol. 2, p. 73, 74.) As far as my observations extend, the true aneurism by anastomosis is a disea.se with which a surgeon shoiild never tamper ; and if it be decided to try any treat nent at all, the only prudeiv plan is cither a com- plete removal of the di.sease witi i a knife, or tying the chifi arteries which supply tlR swelling with’ blood. ANEURISM. 149 The first is the surest mode of relief, and should be preferred, when not forbidden by the magnitude or si- tuation of the tumour. In performing such an operation, as Mr. Wardrop remarks, the surgeon should avoid cutting into the substance of the tumour ; for if this be done, the he- morrhage is violent ; whereas, by making the incisions beyond the diseased structure, the flow of blood is much more moderate. — {Med. Chir. Trans, vol. 9, p. 212.) In a few nievi pressure may be safely tried ; but all attempts to get rid of a true aneurism from anas- tomosis by caustic I should think by no means advi- sable. “ This aneurism,” Mr. John Bell observes, “ is a mere congeries of active vessels, which will not be cured by opening it ; all attempts to obliterate the disease with caustics, after a simple incision, have proved unsuccess- ful, nor does the interception of particular vessels which lead to it affect the tumour ; the whole group of vessels must be extirpated. In varicose veins, or in aneurisms of individual arteries, or in extravasations of blood, such as that produced under the scalp from blows upon the temporal artery, or in those aneurisms produced in schoolboys by pulling the hair, and also in those bloody effusions from blows on the head which have a distinct pulsation, the process of cutting up the varix, aneurism, or extravasation, enables you to obli- terate the vessel and perform an easy cure. But in this enlargement of innumerable small vessels, in this aneurism by anastomosis, the rule is, ‘ not to cut into, but to cut it out.’ These purple and ill-looking tu- mours, because they are large, beating, painful, co- vered with scabs, and bleeding, like a cancer in the last stage of ulceration, have been but too often pro- nounced cancers ! incurable bleeding cancers ! and the remarks which I have made, while they tend in some measure to explain the nature and consequences of the disease, will remind you of various unhappy cases, where either partial incisions only have been practised, or the patient left entirely to his fate.” — {Principles of Surgery, vol. 1.) That Mr. John Bell has comprised in his account of aneurism by anastomosis certain swellings called naevi cannot be doubted; nor, indeed, are the differences between this kind of aneupism and some naevi at all defined even by the best writers on surgery. To the consideration of naevi, however, I have allotted an ar- ticle, in which the method of extirpating particular forms of the disease by means of a ligature will be ex- plained. The following case, recorded by Mr. Wardrop, af- fords a valuable illustration of the nature and struc- ture of one form of this disease. A child was born with a very large subcutaneous nsevus on the back part of the neck. It was of the form and size of half an ordinary orange. The tumour had been daily in- creasing, and when Mr. Wardrop saw it, ten days after birth, the skin had given way, and a profuse hemor- rhage had taken place. I’he swelling was very soft and compressible; when squeezed in the hand it yielded like a sponge, and was reducible to one-third of its original size. On removing the pressure, how- ever, the tumour rapidly filled again, and the skin re- sumed its purple colour. “ Conceiving the immediate extirpation of the tumour the only chance of saving the infant (says Mr. Wardrop), I removed it as expe- ditiously as possible, and made the incision of the in- teguments beyond the boundary of the tumour ; aware of the danger of hemorrhage, where such tumours are cut into. So profuse, however, was the bleeding, that though the whole mass was easily removed by a few in- cisions, the child expired. The tumour having been injected by throwing co- loured size into a few of the larger vessels, its intimate structure could be accurately examined. Several of the vessels, which, from the thinness of their coats ap- peared to be veins, were of a large size, and there was one sufficiently big to admit a Ml-sized bougie.” This vessel was quite as large as the carotid artery of an infant. The boundaries of the tumour appeared distinct, some healthy cellular membrane, traversed by the blood-vessels, surrounding it. On tracing these vessels to the diseased mass, they penetrated into a spongy structure composed of numerous cells and canals, of a variety of forms and sizes, all of which were filled with the injection, and communicated di- rectly with the ramifications of the vessels. These cells and canals had a smooth and polished surface, and in some parts resembled very much the cavities of the heart, fibres crossing them in various directions like the columnae teiidinae. The opening in the skin, through which the "blood had escaped during life, com- municated directly with one of the large cells, into which the largest vessel also passed.” — {Wardrop, in Med. Chir. Trans, vol. 9, p. 203.) In the section on Carotid Aneurisms I have mentioned the cases in which Mr. Travers and Mr. Dalryinple cured aneurisms by anastomosis in the orbit by tying the common carotid artery. Professor Pattison also cured an immense anastomosing aneurism of the cheek and side of the face by taking up the carotid artery. — (See Med. and Phys. Joum. vol. 48, July, 1822.) These facts prove that aneurism by anastomosis, like many other diseases, sometimes admits of being cured on the principle of cutting off or lessening the supply of blood to the part affected. However, surgeons must not be too confident of be- ing always able to cure the disease by tying the main artery from which the swelling receives its supply of blood ; and the great cause of failure is the impossi- bility of preventing in some situations the transmis- sion of a considerable quantity of blood into the tu- mour, through the anastomosing vessels. A case is recorded by Maunoir, in wliich he applied a ligature for three days to the carotid artery, and obliterated it ; yet the benefit effected seemed to be only temporary, as in a short time the tumour was as large as before.— (See Med. and Phys. Journ. vol. 48.) In fact, every vessel, artery, and vein around the disease seems to be enlarged and turgid ; and the inosculations are so in- finite that no point of the circumference of the swell- ing can be imagined which is free from them. Etienne Dumand was born with two small red marks on the antihelix of the right ear. Until the age of twelve years the chief inconveniences were, a sensation of itch- ing about the part, occasional bleeding from it, and the greater size of this than of the other ear. The disease now extended itself over the whole antihelix, and to the helix and concha; and the upjter part of the ear became twice as large as natural. Slight alternate dilatations and contractions began to be perceptible in the tumour, which was of a violet colour, and covered by a very thin skin. Soon afterw^ard any accidental motion of the patient’s hat was sufficient to excite co- pious hemorrhages, which were difficult to suppress, and at the some time that they produced great weak- ness, caused a temporary diminution of the tumour and its pulsations. At length the disease began to raise up the scalp for the distance of an inch around the me- atus auditorius, and the hemorrhages to be more fre- quent and alarming. Pressure was next applied to the temporal, auricular, and occipital arteries; but as the patient could not endure it, the first two of these ves- sels were tied, the only benefit from which was a slight diminution in the pulsation and bulk of the swell- ing. This treatment did not prevent the return of he- morrhage, and therefore forty-three days after the first operation a ligature was applied to the occipital artery, which {>ro eedingwas equally ineffectual. As the dis- ease continued to make progress, the patient entered the H6tel-Dieu, where, on the 8th of April, 1818, Dupuy- tren tried what ©fleet tying the trunk of the carotid ar- tery would produce on the swelling. As soon as the liga- ture was applied, the throbbing ceased, and the tumour underwent a quick and considerable diminution. On the 17th day, slight expansions and contractions of the diseased part of the ear were again perceptible, though the swelling had diminished one-third. An attempt was now made to compress the tumour by covering it with plaster of Paris ;- a plan which was somewhat painful, though it lessened the size of the disease. After being sixty-three days in the hospital, the patient was discharged, at which period the tumour was dimi- nished one-tliird ; the throbbings had returned, but no unpleasant noises continued to affect the ear.— (See BrescheVs tr. of Mr,. Hodgson's work, t. 2, p. 296.) An infant, six weeks old, was brought to Mr. Ward- rop, on account of an aneurism by anastomosis (a sub- cutaneous najvus) of a very unusual size, situated on 1 the left cheek. The base of the tumour extended from the temple to beyond the angle of the jaw, completely enveloping the cartilage of the ear. At its upper part there was an ulcer, about three inches in diameter, presenting a sloughing appearance. The tumour waa 150 ANEURISM. soft and doughy ; its size could he much diminished by pressure ; there was a throbbing in it, and a strong pulsation in the adjacent vessels. The disease was daily increasing, and several profuse hemorrhages had taken place from the ulcerated part. Mr. Wardrop, knowing, from the case to which I have already ad- verted, the danger of attempting to extirpate so large a tumour of this nature, was led to trj' what benefit might be obtained by tying the carotid artery. A few hours after this operation, the tumour became soft and pliable ; its purple colour disappeared, and the tortuous veins collapsed. On the second day, the skin had re- sumed its natural pale colour, and the ulceration con- tinued to extend. On the third, the tumour still dimi- nished. On the fourth, the swelling had considerably increased again ; the integuments covering it had be- come livid, and the veins turgid. The inosculating branches of the temporal and occipital arteries had become greatly enlarged. A small quantity of blood had oozed from the ulcer. After remaining without much alteration, the tumour on the seventh day had again evidently diminished. On the ninth, the ulcera- tion was extending itself slowly, and the tumour was lessened fully one-half. On the twellth, the child’s health was materially improving. The auricular por- tion of the swelling had now so much diminished, that the cartilage of the ear had fallen into its natural situ- ation. After a poultice had been applied for two days, the central portion of the swelling, which appeared like a mass of hardened blood, was softened, and Mr. Wardrop removed considerable portions of it. On the thirteenth, the child became very ill, and died the fol- lowing day, exhausted by the irritation of an ulcer, which had involved the whole surface of an enormous tumour. Mr. Wardrop thinks the advantages likely to occur fl-om the plan of tying the main arteries supply- ing tumours of this nature tvith blood are, the diminu- tion of the size of the disease ; the lessening of the danger of hemorrhage, if the ulcerative process has commenced ; and the rendering it practicable to re- move the swelling with the knife, though the operation may previously have been dangerous or impracticable. — (See Med. Chir. Trans, vol. 9, p. 206 — 214, ' structure of the parts, they had no conception that it could be cured by any means but by removal with a cutting instrument, or by destruction with escharotics ; and therefore they immediately attacked it with knife or caustic, in order to accomplish one of these ends; and very terrible work they often made. That abscesses formed near the fundament do some- times, from bad habits, from extreme neglect, or from gross mistreatment, become fistulotis, is certain ; but the majority of them have not at first any one charac- ter or mark of a true fistula ; nor can, without the most supine neglect on the side of the patient, or the most ignorant management on the part of the surgeon, de- generate or be converted into one. Collections of matter from inflammation (wherever formed), if they be not opened in time and in a pro- per manner, do often burst. The hole through which the matter finds vent is generally small, and not often situated in the most convenient or most dependent part of the tumour : it therefore is unfit for the discharge of all the contents of the abscess ; and instead of clos- ing contracts itself lo a smaller size, and becoming hard at its edges, continues to drain off what is fur- nished by the undigested sides of the cavity. When an abscess near the anus bursts, the small- ness of the accidental orifice ; the hardness of its edges ; its being found to be the outlet from a deep cavity ; the daily discharge of a thin, gleety, discoloured kind of matter ; and the induration of the parts round about, have all contributed to raise and confirm the idea of a true fistula. Abscesses about the anus present themselves In dif- ferent forms. Sometimes the attack is made with sj-mptoms of high inflammation ; with pain, fever, rigor, &c., and the fever ends as soon as the abscess is formed. In this case a part of the buttock near the anus is considerably swollen, and has a large circumscribed hardness. In a short time the middle of this hardness becomes red and inflamed ; and in the centre of it mat- ter is formed. This (in the language of our ancestors) is called in general a phlegmon; but when it appears in tliis parti- cular part, a phyma. ' The pain is sometimes great, the ftever hlghj the tu- mour large and exquisitely tender; but however dis- agreeable the appearances may have been, or however high the symptoms may have risen before suppuration, yet when that end is fairly and fully accom.plished, the patient generally becomes easy and cool ; and the mat- ter formed under such circumstances, though it may be plentiful, is good. On the other hand, the external parts, after much pain, attended with fever, sickness, »fec., are sometimes attacked with considerable inflammation, but without any of that circumscribed hardness which character- ized the preceding tumour ; instead of which the in- flammation is extended largely, and the skin wears an erysipelatous kind of appearance. In this the disease is more superficial ; the quantity of matter small, and the cellular membrane sloughy to a considerable extent. Sometimes instead of either of the preceding ap- pearances, there is formed in this part what the French call une suppuration gangreneuse ; in which the cel- lular and adipose membrane is affected in the same manner as it is in a carbuncle. In this case, the skin is of a dusky red or purple kind of colour ; and although harder than when in a natural state, yet it has, by no means, that degree of tension or resistance, which it has either in phlegmon or in ery sipelas. The patient has generally, at first, a hard, full, jar- ring pulse, with great thirst, and very fatiguing rest- lessness. If the progress of the disease be not stopped, or the patient relieved by medicine, the pulse soon changes into an unequal, low, faltering one ; and the strength and the spirits sink in such manner, as to imply great and immediately impending mischief. The matter formed under the skin, so altered, is small in quantity, and bad in quality ; and the adipose mem- brane is gangrenous and sloughy throughout the ex- tent of the discoloration. This generally happens to persons, whose habit is either natunilly bad, or has been rendered so by intemperance. Sometimes the disease makes its first appearance in the induration of the skin, near to the verge of the anus, but without pain or alteration of colour; which hardness gradually softens and suppurates. The mat- ter, when let out, in this case, is small in quantity, good in quality ; and the sore is superficial, clean, and well-conditioned. On the contrary, it now and then happens, that although the pain is but little, and the inflammation apparently slight, yet the matter is large in quantity, bad in quality, extremely offensive, and proceeds from a deep crude hollow. The place also where the abscess points, and where the matter, if let alone, would burst its way out, is various and uncertain. Sometimes it is in the buttock, at a distance from, the anus ; at other times, near its verge, or in the perinaeum ; and this discharge is made sometimes from one orifice only, sometimes from seve- ral. In some cases there is not only an opening through the skin externally, but another through the intestines into its cavity : in others, there is only one orifice, and that either external or internal. Sometimes the matter is formed at a considerable distance from the rectum, which is not even laid bare by it ; at others, it is laid bare also, and not perforated : it is also sometimes not only denuded, but pierced ; and that in more places than one All consideration of preventing .suppuration is ge- nerally out of the question : and our business, if called at the beginning, must be to moderate the symptoms ; to forward the suppuration ; when the matter is formed, to let it out ; and to treat the sore in such manner as shall be most likely to produce a speedy and lasting cure. When there are no symptoms which require particu- lar attention, and all that we have to do is to assist the maturation of the tumour, a soft poultice is the best application. When the disease is fairly of the phlegmo- noid kind, the thinner the skin is suffered to be- come before the abscess is opened, the better; as the induration of the parts about will thereby be the more dissolved, and, consequently, there will be the less to do after such opening has been made. This kind of tumour is generally found in people of full, sanguine habits; and who, therefore, if the pain he great, and the fever high, will bear evacuation, both by phlebo- tomy and g ntle cathartics ; which is not often the case of those, who are said to be of bilious constitu- ANUS. 159 lions ; in \Vhom the luflammation is of a larger ex- tent, and in whom the skin wears the yellowish lint of the erysipelas ; persons of this kind of habit, and in such circumstances, being in general seldom capa- ble of bearing large evacuation. Wh.eri the inflammation is erysipelatous, the quan- tity of matter formed is small, compared with the size and extent of the tumour; the disease is rather a sloughy, putrid state of the cellular membrane than an imposthumation ; and, therefore, the sooner it is opened the belter: if we wait for the matter lo make a point, we shall wait for what will not happen ; at least, not till after a considerable length of time : during which the disease in the membrane will extend itself, and, consequently, the cavity of the sinus or abscess be thereby greatly increased. When, instead of either of the preceding appearances, the skin wears a dusky purplish-red colour ; has a doughy unresisting kind of feel, and very little sensibility ; when these circumstances are jouied with an unequal, faltering kind of pulse, irregular shiverings, a great failure of strength and spirits, and inclination to doze, the case is formidable, and the event generally fatal. The habit, in these circumstances, is always bad ; sometimes from nature, but much more frequently from gluttony and intemperance. What assistance art can lend must be administered speedily ; every minute is of consequence ; and if the disease be not stopped, the patient will sink. Here (says Pott) is no need for evacuation of any kind ; recourse must be immedi- ately had to medical assistance; the part affected should be frequently fomented with hot .spirituous fo- mentations ; a large and deep incision should be made into the diseased part, and the application made to it should be of the warmest, most antiseptic kind. This also is a general kind of observation, and equally applicable to the same sort of disease in any part of the body. Our ancestors have thought fit to call it in some a carbuncle, and in others by other names : but it is (wherever seated) really and truly a gangrene of the cellular and adipose membrane : it al- ways implies great degeneracy of habit, and, most commonly, ends ill. Strangury, dysury, and even total retention of the urine are no very uncommon attendants upon ab- scesses in the neighbourhood of the rectum and blad- der : more especially if the seat of them be near the neck of the latter. ■ They sometimes continue from the first attack of the inflammation, until the matter is formed, and has made its way outwards ; and sometimes last a few hours only. The two former most commonly are easily relieved by the loss of blood, and the use of gum arabic, with nitre, &c. But in the last (the total retention), they who have not often seen this case, generally have im- mediate recourse to the catheter : but the practice is es- sentially wrong. 7’he neck of the bladder does certainly participate, m some degree, in the said inflammation. But the principal part of the complaint arises from irritation, and the disease is, strictly speaking, spasmodic. The manner in which an attack of this kind is generally made ; the very little distention which the bladder of- ten suffers; the small quantity of urine sometimes contained in it, even when the symptoms are most pressing ; and the most certain as well as safe me- thod of relieving it ; all tend to strengthen such opi- nion. But whether we attribute the evil to inflammation or to spasmodic irritation, whatever can, in any de- gree, contribute to the exasperation of either, must be manifestly wrong. The violent passage of the cathe- ter through the neck of the bladder (for violent in such circumstances it must be) can never be right. If the instrument be successfully introduced, it must either be withdrawn as soon as the bladder is emptied, or it must be left in it : if the former be done, the same cause of retention remaining, the same effect returns; the same pain and violence must again be submitted to, under (most likely) increased difficulties. On the other hand, if the catheter be left in the bladder, it will often, while its neck is in this state, occasion such disturb- ance that the remedy (as it is called) will prove an exasperation of the disease, and add to the evil it is de- signed to alleviate. Nor is this all ; for the resistance wluch the parts while in this stale make, is sometimes so great that if any violence be used, the instrument will make for itself a new route in the neighbouring parts, and lay the foundation of such mischief as fre- quently baffles all our art. The true, safe, and rational method of relieving this complaint (says Pott) is by evacuation and anodyne relaxation : this not only procures immediate ease, but does, at the same time, serve another very material pur- pose ; which is that of maturating the abscess. Loss of blood is necessary ; the quantity to be determined by the strength and state of the patient : the intestines should also be emptied, if there be time for so doing, by a gentle cathartic ; but the most effectual relief will be from the warm bath or semicupium, the application of bladders with hot water to the pubes and perinaeum, and, above all other remedies, the injection of glysters, consisting of warm water, oil, and opium. There may have been cases which have resisted and baffled this method of treatment ; but Pott never met with them. A painful tenesmus is no uncommon attendant upon an inflammation of the parts about the rectum. If a dose of rhubarb, joined with the confect, opii, does not remove it, the injection of thin starch and opium or linct. thebaic, is almost infallible. The bearing down in females, as it proceeds, in this case, from the same kind of cause (viz. irritation), ad- mits of relief from the same means as the tenesmus. In some habits, an obstinate costiveness attends this kind of inflammation, accompanied, not unfrequently, with a painful distention and enlargement of the he- morrhoidal vessels, both internally and externally While a large quantity of hard feces is detained within the large intestines, the whole habit must be disor- dered ; and the symptomatic fever which necessarily accompanies the formation of matter, must be consi- siderably heightened. And while the vessels surround- ing the rectum (w'hich are large and numerous) are distended, all the ills proceeding from pressure, in- flammation, and irritation must be increased. Phle- botomy, laxative glysters, and a low, cool regimen must be the remedies : while a soft cataplasm applied externally serves to relax and mollify the swollen, in- durated piles, at the same time that it hastens the sup- puration. When the abscesses have formed, and are fit to be opened, or when they have already burst, they may be reduced to two general heads, viz. 1. Those in which the intestine is not all interested : and, 2. Those in which it is either laid bare or perfo- rated. In making the opening, the knife or lancet should be passed in deep enough to reach the fluid ; and when it is in the incision should be continued upwards and downwards in such manner as to divide all the skin co- vering the matter. By these means, the contents of the abscess will be discharged at once ; future lodge- ment of matter will be prevented ; convenient room will be made for the application of proper dressings ; and there will be no necessity for making the incision in different directions, or for removing any part of the skin composing the verge of the anus. Notwithstanding all these collections of matter are generally called JistulcB, and are all supposed to affect the rectum, the abscess is sometimes really at such a distance from the gut, that it is not at all interested by it ; and none of these cases either are or can be originally JistulcB. In this state of the disease, w’c have no more neces- sarily to do with the intestine than if it were not there ; the case is to be considered merely as an ab- scess in the cellular membrane. A short time ago, some interesting remarks on fis- tula in ano were published in France by Hr. Ribes, whose opinions, however, like those of many other valuable writers, are not invariably free from error ; and I have no hesitation in extending this observation to one of his statements, though what he has said is alleged to be deduced from the dissection of not less than 75 persons who had died with fistulae. No man who has seen much of this part of surgery, can doubt that the most frequent form of the di.sease is that in which the abscess has only an external opening, and does not perforate the rectum at all, from which, indeed, the matter is sometimes more or less distant. Nor can any experienced surgeon question the truth of Mr. I’ott’s account resitecUng the diversity of the 160 ANUS. nature of the cases of fistui®, some being phlegmo- nous, some erysipelatous, and others more like the carbuncle in their origin, progress, and consequences. But besides these circumstances, another one \vorth5' of notice is, that the presence of fistula in ano by no means implies the previous or present existence of piles. However, notwithstanding these considera- tions, the doctrine started by Dr. Ribes is, that a fis- tula is formed by the bursting of an internal pile into the rectum, and the consequent passage of a portion of the contents of the bowel into the orifice. He far- ther asserts that such orifice is always within five or six lines above the junction of the internal membrane of the bowel with the external skin, and that it may usually be seen, if the patient forces the gut gently down, as in going to stool. The only correct part of these statements is, I believe, the account of the common situation of the internal opening, when the abscess communicates with the bowel, which is not always the case. — (See Recherches sur la Situation de VOri- Jice interne de la Fistule de UAnus, S,-c. Quarterly Joum. of Foreign Med. No. 8. Oct. 1820.) Tliis part of the account is confirmed by the observations of Larrey. — {Mem. de Chir. Mil. t. 3, p. 415.) Suppose a large and convenient opening to have been made by a simple incision ; the contents of the abscess to have been thereby discharged ; and a sore or cavity produced, which is to be filled up. The term filling up. and the former opinion, that the induration of the parts about is a diseased callosity, have been the two principal sources of misconduct in these cases. The old opinion, with regard to hollow and hard- ness, was that the former is caused entirely by loss of substance ; and the latter, by diseased alteration in the structure of the parts. The consequence of which opinion was, that as soon as the matter was discharged, the cavity was filled and distended, in order to procure a gradual regenera- tion of flesh ; and the dressings, with which it was so filled, were most commonly of the escharotic kind, in- tended for the dissolution of hardness. On the other hand, the surgeon who regards the cavity of the abscess as being principally the effect of the gradual separation of its sides, with very little loss of substance, compared with the size of the said cavity ; and who looks upon the induration round about, as nothing more than a circumstance which necessarily accompanies every inflammation, will, upon the small- est reflection, perceive that the dressings applied to such cavity ought to be so small in quantity, as to permit nature to bring the sides of the cavity towards each other, and that such small quantity of dressings ought not by their quality either to irritate or de- stroy. If the hollow, immediately it is opened, be filled with dressings (of any kind), the sides of it will be kept from approaching each other, or may even be farther separated. But if this cavity be not filled, or have little or no dressings of any kind introduced into it, the sides immediately collapse, and, coming nearer and nearer, do, in a very short space of time, convert a large hollow into a small sinus. And this is also constantly the case, when the matter, instead of being let out by an artificial opening, escapes through one made by the bursting of the containing* parts. True, this sinus will not always become perfectly closed ; but the aim of nature is not therefore the less evident ; nor the hint, which art ought to borrow from her, the less palpable. In this, as in most othur cases, where there are largo sores, or considerable cavities, a great deal will deiiend on the patient’s habit, and the care that is taken of it ; if that be good, or if it be properly corrected, the sur- geon will have very little trouble in his choice of dress- ings ; only to take care that they do not offend either in quantity or quality ; but if the habit be bad, or inju- diciously treated, he may use the whole farrago of ex- ternals, and only waste his own and his patient’s time. By light, easy treatment, large abscesses formed in the neighbourhood of the rectum will sometimes be cured, without any necessity for meddling with the said gut. But it much more frequently happens, that the in- testine, although it may not have been pierced or eroded by the matter, has yet been so stripped or denuded, i that no consolidation of the sinus can be obtained, but by a division ; that is, by laying the two cavifics, viz. that of the abscess and that of the intestine, into one. When the intestine is found to be separated from the surrounding parts by the matter, the operation of di- viding it had better (on many accounts) be performed at the time the abscess is first opened, than be deferred to a future one. For, if it be done properly, it will add so little to the pain, which the patient must feel by opening the abscess, that he will seldom be able to dis- tinguish the one from the other, either with regard to time or sensation ; whereas, if it be deferred, he must either be in continual expectation of a second cutting, or feel one at a time when he does not expect it. The intention in this operation is to divide the intes- tine rectum from the verge of the anus uj) as high as the top of the hollow in which thematt-r was formed; thereby to lay the two cavities of the gut and abscess into one ; and by means of an open, instead of a hol- low or sinuous sore, to obtain a firm and lasting cure. For this purpose, the curved, probe-pointed knife, with a narrow blade, is the most useful and handy in- strument of any. This, introduced into the sinus, while the surgeon’s fore-finger is in the intestine, will enable him to divide all that can ever require division ; and that with less pain to the patient, with more fa- cility to the operator, as well as with more certainty and expedition, than any other instrument whatever. If there be no opening in the intestine, the smallest de- gree of force will thrust the point of the knife through, and thereby make one ; if there be one already, the same point will find and pass through it. In either case, it will be received by the finger in ano ; will thereby be prevented from deviating ; and being brought out by the same finger, must necessarily divide all that is between the edge of the knife and the verge of the anus : that is, must by one simple incision (w hich is made in the smallest space of time imaginable) lay the two cavities of the sinus and of the intestine into one. Authors make a very formal distinction between those cases in v/hich the intestine is pierced by the matter, and those in which it is not ; but although this distinction may be useful when the different states of the disease are to be described, yet in practice, when the operation of dividing the gut becomes necessary, such distinction is of no consequence at all : it makes no alteration in the degree, kind, or quantity of pair? which the patient is to feel ; the force required to push the knife through the tender gut is next to none, and when its point is in the cavity, the cases are exactly similar. In this statement every man of experience and discernment must agree, notwithstanding the pro- hibition to the operation, delivered by Dr. Ribes, in every case, in which the internal opening cannot be fotind : a piece of advice (as it seems to me) fully ad- mitting the occurrence of cases which could not be formed in the manner in which he conceives all fistulte in ano to be produced, viz. by the bursting of a pile, and the entrance of feces into the orifice. Immediately after the operation, a soft dossil of fine lint should be introduced (from the rectum) between the divided lips of the incision ; as well to repress any slight hemorrhage, as to prevent the immediate reunion of the said lips ; and the rest of the sore should be lightly dressed with the same. This first dressing should be permitted to continue, until a beginning sup- puration renders it loose enough to come away easily ; and all the future ones should be as light, soft, and easy as possible; consisting only of such materials as are likely to promote kindly and gradual suppuration. The sides of the abscess are large ; the incision must necessarily, for a few days, be inflamed ; and the dis- charge will, for some time, be discoloured and gleety : this induration, and this sort of discharge, are often nustaken for signs of diseased callosity and undis- covered sinuses ; upon which presumptions, escharo- tics are freely applied, and diligent search is made for new hollows: the former of these most commonly in- crease both the hardness and the gleet ; and by the latter new sinuses are sometimes really produced. These occasion a repetition of escharotics, and, perhi»i).s, of incisions ; by which means, cases which at first, and in their own nature, were simple and easy of cure, are rendered complex and tedious. To quit reasoning, and speak to fact only : In the ANUS. 161 great number of these cases, which must have been in St. I3artholomew’.s Hospital, within these ten or twelve years, I do aver (says Pott), that, I have not met with • one, in the circumstances before described, that has not been cured by mere sirhpie division, together with light, easy dressings : and that I have not, in all that time, used, for this purpose, a single grain of precipi- tate, or any other escharotic. Let us now suppose the case in which the matter is fairly formed ; has made its point, as it is called ; and is (it to be let out. Where such point is, that is, where the skin is most thin, and the fluctuation most palpable, the opening most certainly ought to be made, and always with a cutting instrument, not caustic, as was formerly done. When a discharge of the matter by inei.sion is too long delaj’ed or neglected, it makes its own way out, by bursting the external parts somewhere near to the fundament, or by eroding and making a hole through the intestine into its cavity; or sometimes by both. In either case, the discharge is made sometimes by one orifice only, and sometimes by more. Those in which the matter has mad» its escape by one or more open- ings through the skin only are called blind external fstulae; those in which the discharge, has been made into the cavity of the intestine, without any orifice in the skin, are named blind internal ; and those which have an opening both through the skin and into the gut are called complete fstulae. Thus, all these cases are deemed fistulous, when hardly any of them ever are so ; and none of them ne- cessarily. They are still mere abscesses, which are burst without the help of art ; and, if taken proper and timely care of, will require no such treatment as a true fistula may possibly stand in need of. The most frequent of all are w^hat are called the blind external, and the complete. The method where- by each of these states may be known is, by ituro- ducing a probe into the sinus by the orifice in the skin, while the fore-finger is within the rectum: this will give the examiner an opportunity of knowing exactly the true state of the case, with all its circumstances. Whether the case be what is called a complete fistula or not, that is, wdiether there be an opening in the skin only, or one there and another in the intestine, the appearance to the eye is much the suiue. Upon di.s- charge of the matter, the externa! swelling subsides, and the inflamed colour of the skin disappears; tlie orifice, which at first was sloughy and foul, after a day or two are passed, becomes clean and contracts in size; but the discharge, by fretting the parts about, renders the patient still uneasy. As this kind of opening seldom proves sufficient for a cure (though it sometimes does), the induration, in some degree, remains ; and if the orifice happens not to be a depending one, some part of the matter lodges, and is discharged by intervals, or may be pressed out by the fingers of an examiner. The disease, in this state, is not very painful ; but it is troublesome, nasty, and offensive : the continual discharge of a thin kind of fluid from it creates heat, and cau.ses excoriation in the parts above ; it daubs the linen of the jiatient ; and is, at times, very fetid : the orifice also sometimes con- tracts so as not to be sufficient for the discharge ; and the lodgement of the matter then occasions fresh dis- turbance. The means of cure proposed and practised by our ancestors were three, viz. caustic, ligature, and inci- sion. The intention in each of these is the same, viz. to form one cavity of the sinus and intestines by laying the former into the latter. The first two are now com- pletely, and most properly, exploded. Hitherto wc have considered the disease either as an abscess, from which the matter has been let out by an incision, made by a surgeon ; or from which the con- tents have been discharged by one single orifice, form- ed by the bursting of the skin somewhere about the fundament. Let us now take notice of it, when, in- stead of one such opening, there are several. This state of the case generally happens when the quantity of matter collected has been large, tlie inflam- mation of considerable extent, the adipose membrane very sloughy,, and the skin worn very thin before it burst. — It is, indeed, a circumstance of no real conse- quence at all ; hut from being misunderstood, or not properly aiteiided to, is made one of additional terror VoL. I. L to the patient, and additional alarm to the inexperienced practitioner ; for it is taught, and frequently believed, that each of these nrilices is an outlet from, or leads to, a distinct sinus, or hoilow : whereas, in truth, the case is most commonly quite otherwise; all these openings are only .so many distinct burstings of the skin cover- ing the matter ; and do all, be they few or many, lead and open immediately into the one single cavity of the abscess : they neither indicate, nor lead to, nor are caused by, distinct sinuses ; nor would the appearance of twenty of them (if possible) necessarily imply more than one general hollow. If this account be a true one, it will follow, that the treatment of this kind of case ought to be very little, if at all, ditferent from that of the preceding; and that all that can be necessary to be done, must be to divide each of these orifices in such manner as to make one cavity of the whole. . This the probe-knife will easily and expeditiously do; and afterward, if the sore, or more properly its edges, should make a very ragged, uneven appearance, the removal of a small portion or such irregular angular jiarts will answer all the pur- poses of making room for the application of dressings, and for producing a smooth even cicatrix after the sore shall be healed. When a considerable quantity of matter has been re- cently let out, and the internal parts are not only in a crude undigested state, but have not yet had time to collapse and ajiproach each other, the inside of such cavity will appear large ; and if a probe be pushed with any degree of force, it will pass in more than one direction into the cellular membrane by the side of the rectum. But let not the unexperienced practitioner be alarmed at this, and immediately fancy that there are so many distinct sinuses; neither let him, if he be of a more hardy disposition, go to work immediately with liis director, knife, or scissors : let him enlarge the ex- ternal wound by making his incision freely ; let him lay ail the separate orifices open into that cavity ; let him divide the intestine lengthwise by means of his finger in ano; let him dress lightly and easily; let him pay proper attention to the habit of the patient ; and wait and see what a tew days, under such conduct, will produce. By this he will frequently find, that the large cavity of the qbscess will become small and clean ; that the induration round about will gradually lessen ; that the probe will not pass in that manner into the cellular membrane ; and, consequently, that his fears of a multiplicity of sinuses were groundless. On the contrary, it the sore be crammed or dressed with irritating or escharotic medicines, all the appearances will be difTerent : the hardness will increase, the lips of the wound will be inverted, the ca vity of the sore will remain large, crude, and foul ; the discharge will be thin, gleety, and di.scoloured ; the patient will be un- easy and feverish ; and, if no new cavities are tbnned by the irritation of parts and confinement of matter, yet the original one will have no opporiunity of contracting itself, and may very possibly become truly fistulous. Sometimes the matter of an abscess, formed juxta anum, instead of making its way out through the skin externally near the verge of the anus, or in the but- tock, pierces through the intestine only. This is what IS called a blind internal Jistula. In this case, after the discharge has been made, the greater part of the tumefaction subsides, and the jm- tient becomes easier. If this docs not produce a cure, which sometimes though very seldom hajqiens, some small degree of induraiioa generally remains in the place where the original tumour was; upon pressure oil this hardness, a small discharge of matter is fre- quently made per anum; and sometimes the expulsion of air from the cavity of the abscess into that of the in- testine may very palpably be felt and clearly heard ; the stools, particularly if hard, and requiring force to be expelled, are sometimes smeared with matter ; and although the patient, by the bursting of the abscess, is relieved from the acute pain which the collection occa- sioned, yet he is seldom perfectly free from a dull kind of uneasiness, especially if he sits for any considerable length of time in one posture. The real difference be- tween this kind of case and that in which there is an external opening (with regard to method of cure), is very immaterial ; for an external opening must be made, and then all ditlerence ceases. In this, as in the former, no cure can reasonably be expected until the cavity of the abscess and that of the rectum are made 162 ANUS. one ; and the only difference is, that in the one case we have an orifice at or near the verge of the anus, by wliich we are immediately enabled to perform that ne- cessary operation ; in the other, we must make one. We come now to that state of the disease, which may truly and properly be called fistulous. This is generally defined, sinus angustus, callosus, profun- dus : acri ganie diffluens : or, as Dionis translates it, “ Un ulcere profond, et caverneux, dont I'entree est itroite, et le fond plus large; avec ussue d'un pus acre et virulent ; et accompagne de caUosites.” Various causes may produce or concur in producing such a state of the parts concerned as will constitute a fistula, in the proper sense of the word ; that is, a deep hollow sore, or sinus ; all parts of which are so hard- ened or so diseased, as to be absolutely incapable of being healed while in that state; and from which a frequent or daily discharge is made; of thin discoloured sanies, or fluid. These are divided into two classes, viz. those, which are the effect (rf neglect, distempered habit, or bad ma- nagement, and w hich may be called, without any great impropriety, local diseases ; and those which are the consequence of disorders whose origin and seat are not in the immediate sinus or fistula, but in parts more or less distant, and which, therefore, are not local com- plaints. The natures and characters of these are obviously different by description ; but they are still more so in their most frequent event ; the former being generally curable by proper treatment, the latter frequently not so by any means whatever. Under the former are reckoned ail such cases as were originally mere collections of matter within the coats of the intestine rectum, or in the cellular mem- brane surrounding the said gut ; but w hich, by being long neglected, grossly managed, or by happening in habits which w'ere disordered, and for w’hich disorders n» proper remedies w^ere administered, suffer such al- teration, and get into such state, as to deserve the appellation of fistulce. Under the latter are corriprised all those cases in which the disease has its origin and first state in the higher and more distant parts of the pelvis, about the os sacrum, lower vertebrae of the loins, and parts ad- jacent thereto; and are either strumous, or the conse- quence of long and much distemperate habits ; or the effect of, or combined with, other distempers, local or general ; such as a diseased neck of the bladder or prostate gland, or urethra, &c. .• 150, edit. 17l)2.) Others have used perforated balls of ivory. Callisen found the introduction of a piece of sponge wthin the rectum, fastened to a silver probe, give effectual sup- port. In France, instruments made of elastic gmn have been employed with advantage for supporting the rectum. — {Richerarid, Nosogr. Chir. t. 3, p. 444, cd. 4.) On account of the elasticity and unirritating quality of this substance, I conceive it is better calculated than any other material for the construction of such instruments. It cannot be denied, however, that all foreign bodies in the rectum create serious annoyance. In the female sex, a vaginal pessary, rather prominent behind, usually hinders the recurrence of a prolpsus ani. The late Mr. Hey published some highly interesting remarks on the cure of the procidentia ani in adults. In one gentleman the disease took place whenever he had a stool, and continued for some hours, the gut gra- dually retiring, and at last disappearing, until he had occasion to go to the privy again, .viler each stool, he used to place himself in a chair, and obtain a little re- lief by making pressure on the prolapsed part ; and he then was in the habit of going to bed, where the intes- tine by degrees regained its natural situation. While the bowel was down there was a copious discharge from it of a thin mucous fluid blended vvith blood. When the part was up, the anus was constantly sur- rounded by a thin, pendulous flap of integuments, ge- nerally hanging down to the extent of three-fourths of an inch. Around the anus there were also several soft tubercles of a bluish colour, situated at the basis and at the inner part of the pendulous ilap. These were evi- dently formed by the extremity of the rectum. The patient,. previously to the establisltrnent of these habit- ual attacks of prolapsus am, had been afllicted lor se- veral years with pain after each stool, protuberances at the extremity of the rectum, and di.-^chaigj of bl md and mucus. For these complaints he applied to Mr. Sharp, who gave him an ointment to be applied after each stool, some soapy pills to be taken, and recom- mended the use of a clyster a little before the time of going to stool. The latter remedy, however, could not be adopted, and no material benefit was derived from the others. Some years afterward, when Mr. Hey was consulted, the foregoing symptoms continued ; in addi- tion to which there was the grievance of the prolap- sus, which came on at every time of going to stool, and lasted for several hours. This judicious surgeon at first advised the patient to wash the prolajised part with a lotion composed of an infusion of oak-bark, lime-water, and spirit of wine, and keeping on the tu- mour compresses, wet wiih this fluid, and supported by the T bandage. The disease, however, was too ob stinate to be cured by this treatment. Nor could Mr. Hey succeed in reducing the bowel when it came down. ‘‘ Although, (says he) the prolapsed part of the intestine consisted of the whole inferior extremity of the rec- tum, and was of considerable bulk, yet the impediment to reduction did not arise from the stricture of the sphincter ani ; for I could introduce my finger with ease during the procidentia; but it seemed to arise from the relaxed state of the lowest part of the intes- tine and of the cellular membrane which connects it with the surrounding parts. My attempt proved vain as to its immediate object, yet it suggested an idea which led to a perfect cure of this obstinate disorder. The relaxed state of the part which came down at every evacuation, and the want of sufficient stricture in the sphincter ani, satisfied me that it was impos- sible to afi’ord any effectual relief to my patient unless I could bring about a more firm adhesion to the sur- rounding cellular membrane, and increase the proper action of the sphincter. Nothing seemed so likely to etfect these purposes as the removal of the pendulous flap and the other protuberances which surrounded the anus.” This operation was performed on the 13th of November. On the 15th the gut protruded atid did not gradually retire as it used to do. Mr. Hey at tempted to procure ease by means of opiates and fo- mentations, and avoided immediately trying to reduce the prolapsed part. However, the prolapsus conti nuedso long that the appearance of the part began to alter, and therelbre, on the 16th he made an attempt at reduction, and succeeded vvith great ease. However, as a good deal of pain in the hypogastrium was still complained of, the patient was bled in the evening, and gently purged with the oleum ricini. These means gave relief ; but as some pain in the belly yet continued, an opiate was given. A low diet, linseed tea, lac amygdalae, Ac. were ordered, and a little of the oleum ricini every morning, or every other morning, with an opiate after a stool had been procured. “ By proceed- ing in this manner lor some days, regular stools were procured without any permanent inconvenience. My patient recovered very well, and was freed from this distressing complaint, which had afllicted him so many years.— (See Hey's Tract, Obs. p. 438, A c. ed. 2.) This and some other cases which this gentlem.an has related, convincingly exemplify the necessity of paying attention to the removal of excrescences, he- morrhoids, and other tumours, situated about the lower part of the rectum, in cases of prolapsus ani ; for un less this object be accomplished, the disease may resist every other treatment. Mr. Howship prefers the liga- ture for the extirpation of the protuberances; but heartily commends the principle of the treatment pro- posed by Mr. Hey. — {Tract. Obs. on Diseases of the Lower Intestines, p. 163, ed. 3.) An elderly gentleman, whom I know, was troubled for many years with a prolapsus ani, which used to come on several times a week, sometimes at the privy, and sometimes on other occasions. Several of the first surgeons were con- sulted, w'ho failed in affording permanent benefit, be- cause they omitted to extirpate some hemorrhoidal ex- crescences, situated at the lower part of the rectum ; for, w hen thesb were afterward removed, the prolapsus ani entirely disappeared. Hupuytren, finding that the excision of piles, which so often accompany prolapsus ani, commonly prevented the return of the latter complaint, was led to cut olf more or less considerable portions of the internal mem- brane of the rectum. However, as in one case a juo- fuse hemorrlnige took jilace, and, in another, a tedious snppuraiion, he ha.s subsequently adopted tlie plan of ANUS. 165 removing a certain number of the projecting folds, which may be seen converging from the circumference to the margin of the anus. He lakes hold of them with liga- ture-forceps, a little flattened at osne end, and cuts them Oif with scissors curved on their flat side. This prac- tice is similar to that employed by the late Mr. Hey. Dupuytren, in his first method, used to cut away the mucous membrane itself ; in the last, only the folds of skin at the margin of the anus are removed. A woman had had a constant prolapsus ani for ten years ; when she was in the upright posture, the swelling was ten inches in one diameter, and seven in the other ; it hin- dered her froLn walking, and continually discharged a mi.vture of blood and mucus. Dupuytren removed five or six of, the projecting folds from without inwards. The patient, who used to have more than twenty stools a day, now went six days without one ; on the seventh, however, an abundant evacuation took place, and the prolapsus never returned. ■ Merely simple dressings are needed. — ' See Joum. Universel des Sciences M d. No. 81, Sept. 1322.) The last indication in the treatment is the removal and avoidance of all such causes as are known to have a tendency to bring on the complaint. In infants, a fresh protrusion of the rectum may sometimes be pre- vented by making them sit on a high close-stool, with their feet hanging freely down. Every thing tending to cause either diarrheea or costiveness should be avoided. In the generality of cases, however, there is an inclination to costiveness, which must be obviated by the mildest means. For this purpose, Mr. Hey used to prescribe half an ounce of the oleum ricini, which is to be taken every morning, or every other morning, as circumstances may reiiuire. The same practitioner sometimes al so emiiloyed, in addition to this medicine, a clyster composed of a pint of water-gruel, and a large spoonful of treacle. The tone of the relaxed intestine is to be restored by the continued use of cold clysters, made with the decoction of oak-bark, alum, and vine- gar. In one obstinate case, under the care of Mr. Hey, he recommended the following lotion for washing the part during the state of prolapsus, and he also advised its application to the anus in the intervals, by means of a thick compress, supported by the T bandage. E;. Aquie calcis simplicis Ibij. Cort. quercus contus. ; iv. f. infusum per hebdomadam, et colaturas adde sp. vini reel. 3 iv. ft. lotio. — (See Hey^s Pract. Obs. p. 412, ed. 2.) Irritability of the rectum may be lessened with opium. The intussusception of the higher part of the bowel, especially of the colon, or ccecum, causing a protrusion at the anus, is always incurable, as it is not in the power of art to rectify the displacement. Some extra- ordinary cases prove, however, that large portions of the intestinal canal thus inverted, may be separated and voided, and the patients recover.— (See Intussuscep- tion.) According to Mr. Travers, when an artificial anus is complicated with prolapsus, the case very rarely ad- mits of cure.— (See Inquiry into the Process of Nature in repairing Injuries of the Intestines, p. 374.) Surgical writers have been too much in the habit of confounding together prolapsus ani and intussusception. In the l.atter dksease, they have even fallen into the error of supposing, that the whole of the rectum be- comes everted, in consequence of the relaxation of the sphincter and levatores ani, and that it then draws after it other jiortions of the intestinal canal. But they ought to have been undeceived by the strangulation, which sometimes occurs under such circmnstances, and wlricli not only throws a great obstacle in the way of the re- duction of the displaced part, but even sometimes brings on mortification. Besides, the connexions of the rec- tum with the neighbouring parts, by means of the cel- lular substance, which surrounds it, and the attachment of this intestine to the posterior surface of the urinary bladder, render the above origin of the complaint im- possible. Such an explanation could only be admitted with regard to those protrusions of the rectum which come on in a very slow manner. It could not apply to certain cases, in which the everted intestine presents itself in the form of an enormous tumour. Fabricius ab .Xquapendente met with cases of prolapsus of the rectum, where the tumour was as long as the forearm, a;id as large as the fist. In the M langes des Curicuv dr la Nafvre, is the de«cription of a tumour of this sort, wJiich was two feet long, and occurred in a woman from parturition. Nor is a more satisfactory reason assigned for these cases, by supposing, that they originate from a relaxation of the villous coat of the rectum, and its separatioii from the muscular one. We are not authorized to imagine, that such a separation can take place to a considerable extent, nor so suddenly as to give rise to the pheiii>mena sometimes remarked in this disease. Accurate observations long ago removed all doubt upon this subject. In the Memoires de VAr.ud mie de Chirurgie, t. II, ed. in i2'/no. is an account of a pre- tended prolapsus of Ihe rectum, which, after death, was discovered to be an eversion of the coccum, the greater part of the colon being found at the lovrer end of this intestine, and most of the rectum at its upper part. This eversion began at the distance of more than eleven inches from the anus, and terminated about ‘ five or sLv from this opening, the tumour formed by the disease having been reduced some time before the child’s death. It was impossible to driw back the everted jtart, in consequence of the adhesions which it had contracted. Another dissection evinced the same fact. A child, having suffered very acute pain in the abdomen, after receiving a blow, had a prolapsus of intestine through the anus, about six or seven inches long. This was taken for a prolapsus of the rectum. After death, the termination of the protruded bowel was found to be the ccecum, which had ])assed through the colon and rectum. — (See Intussv.sception.) Schacher de Morbis a Situ Intestinorum PreUrnatu- rali, 1721. Luther, de Procidentia Ani, Erf. 1732. Heister, Recti Prolapsus Anatome, Helrnst. 1734. Gooch's Chir. Works, vol. 2, p. 150, 1702. Rechcrches HUtoriques sur la Gastrotomie, ou VOiivcrture, du bus Ventre, dans le cas du Volvulus, iS-c., par M. Hevin, in Mm. de I'Acad. Roy ale de Chir. t. 11, p. 315, ed. in \2mo. Mmteggia, Ease. Pathologici, p. 91, Tur. 1793. Jordan, De Prolapsu ex Ano, Goett. 1793. J, Howship, Obs. on the Diseases of the Lower Intestines, c. ed. 3, Land. 1821, chap. 4. Richter's Anfangsgr. der Wun- darzn. b. 6, p. 403, ed. 1802. Callisen's Syst. ChirurgicB Hodiernae, t. 2, p. 521, ed. 1800. Hey's Practical Obs. in Surgery, p. 438, c. 6vo. ed. 2, 1810. Jenirn. Univ. des Sciences M'd. No. 19, Sept. 1822. M. J. Chelius, Hanb. der Chir. b. I, 773, Heiddb. 1826 ANUS ARTIFICIAL. This signifies an accidental opening in the parietos of the abdomen, to which opening some part of the intes- tinal canal tends, and through which the feces are, either wholly or in part, discharged. An artificial anus is always preceded by an injury of the intestinal canal, either a penetrating wound of the abdomen, ulceration of the bowel, and the bursting of an ab.scess externally ; an operation, in which the pre- ternatural opening is jmrposely made, with the view of savjng life., in particular cases of imperforate anus; an accidental wound of the gut in the operation lor hernia; or, lastly, and most commonly, mortification of the bowel, the effect of the violence and long con- tinuance of the strangulation of the part. All the.se cases are farther divisible into such as are attended with a destruction of a portion of the inte.stinal tube ; and into those which are not accompanied with any such loss of substance. Whatever may be the kind of injury wliich the bow'el has sustained, one thing here invariably happens, viz. the adhesion of the two divided portions of the intes- tine to the edge of the opening in the parietes cf the abdomen. This occurrence, which has the most salu- tary effect in preventing extravasation of the contents of the bowel in the cavity of the abdomen, is produced by inflammation, which precedes gangrene, and follows wounds.— (See (Euvres Chir. de Desault, t. 2, p. 352 — 354.) When, in strangulated hernia, the case is not re- lieved by the usual means, or when the necessary ope- ration has not been practised in time, the protruded bowel sloughs ; the adjoining part of it adheres to the neck of the hernial sac ; and the gangrenous mischief spreads from within outwards. If the patient live long enough, and an incision in the tumour be not now jiractised, one or more openings soon form in the in- tegumentn, and, through these ajiertures, the feces are discharge 1 until the separation of the sloughs gives a freer vent to the excrement. But when an incision is made, the feces are more re.ndily discharged, and, as 166 ANUS. Mr. Travers has related, this is sometimes the best mode of relief. “ 111 the ordinary situation of hernia (as this gentle- man has correctly e.xplained), the portions of intestine embraced by the stricture occupy a position nearly parallel. Their contiguous sides mutually adhere ; in the remainder of their circumference they adhere to the peritoneum, lining or Ibrming the stricture. The existing adhesion of the contiguous sides, strengthened by the adhesion of the parts in contact, ensures a par- tial continuity uiion the separation of the sphacelated part. The line of separation is the line of stricture. It commences on that side of the gut which is in • direct contact with the stricture. As the separation advances, the opposite adhering sides may perhaps recede some- what, and a little enlarge the angle of union. But it is ever afterward an angle; and, where the perito- neum is deficient, the canal is simply covered in by granulations from the cellular membrane of the pa- rietes, coalescing with those of the external or cellular surface of the peritoneum.”— (O m the Process of Na- ture in repairing Injuries of the Intestines, p. 360.) It must be confessed, that few surgeons have enter- tained sufficiently accurate ideas of the changes which happen around the wounded or mortified portion of in- testine, when an artificial anus is produced ; and, though Desault’s account was excellent, as far as it went, it was not until the year 1809, when Scarpa pub- lished his valuable worjc on Hernia, that the whole process of nature on such occasions was completely elucidated. The hernial sac (says he) does not always partake of gangrene with the viscera contained in a hernia, and even when it does slough, since the sepa- ration of the dead parts happens on the outside of the abdominal ring, there almost always remains in this situation a portion of the neck of the hernial sac per- fectly sound. It may be said, therefore, that in all ca.ses, immediately after the detachment of the morti- fied intestine, whether it happen within or on the out- side of the ring, the two orifices of the gut are en- veloped in the neck of the hernial sac, which, soon becoming adherent to them by the effect of inflamma- tion, serves for a certain time to direct the feces to- wards the external wound, and to pre\ent their effu- sion in the abdomen. In proportion as the outer wound diminishes, the external portion of the neck of the her- nial sac also contracts ; but, that part which ernbraces the orifices of the intestine gradually becomes larger, and at Lengm forms a kind of membranous, funnel- shaped, intermediate cavity, which makes the commu- nication between the two parts of the bowel. How- ever, according to Scarpa’s investigation, this adhesion of the neck of the hernial sac, round the two orifices of the gut, does not hinder the latter from gradually quitting the ring, and becoming more and more deeply placed in the cavity of the abdomen. The base of the above- described funnel-shaped membranous cavity corres- ponds to the bowel, and its apex tends towards the wound or fistula. But in relation to this part of the subject, there are some other circumstances, which every surgeon should well understand, and his ignorance of them would not be excusable, on the ground of their not having been, like the funnel-shaped membranous cavity, forming the communication between the two orifices of the bowel, only a discovery of recent date ; for they were fully explained many years ago. I here allude to the exact position of the two portions of the bowel, with respect to each other, the direction of their orifices, the angle or ridge between them, and the difference in their diameters. The first of these circumstances, viz. the position of the two parts of the bowel, was correctly described by Morand, and, as we have seen, is pointed out by Mr. Travers, who represents them as occupying a position nearly parallel, and cites an interesting ob- servation recorded by Pipelet. The patient was a wo- man, 56 years old; the loop of spoiled gut was fiom five to six inches long ; fhe contents of the bowel were discharged through the wound for a considerable time, and an artificial anus was established. Some acci- dental obstruction occurred ; a purgative was given, which operated in the natural way ; and, in fifieen days, the wound was healed. She lived in perfect health to the age of 82, when she died of a disease not connected with this malady. Pipelet examined the body, and has given a figure representing the union. The line of the intestine formed an acute angle, where it adhered to the peritoneum, opposite to the crural arch The cylinder is evidently much contracted. Pipelet particularly dwells upon the angular position and con- striction of the tube at the point of union. The lower continuation of fhe intestinal tube was also remarked to be more contracted than the upper portion ; a cir- cumstance correctly referred, by Mr. Travers, to the undilated state of the bowels, situated between the artificial and the natural anus.-^(See Mem. de VAcad. de Chir. t. 4, p. 164 ; and Travers on Injuries of the Intestines, p. 364) The two ends of the bowel, as Scarpa has observed, are always found lying in a more or less parallel manner by the side of each other ; the upper, with its orifice open, and directed towards the external wound by the feces, which issue from it, while the lower, which gives passage to nothing, be- comes less capacious, and is retracted farther into the abdomen. Hence, the breach in the intestinal canal is never repaired by the orifices of the upper and lowei portions of the bowels reuniting, coalescing, and run- ning, as it were, into each other. Indeed, they meet at •a very acute angle ; the axis of one does not corres- pond to that of the other ; and their orifices never lie exactly opposite each other. It is in short by means of the funnel-shaped cavity, formed by the remains of the hernial sac, that the two parts of the bowel com- municate, and the feces, in order to get from the upper into the lower continuation of the intestine, must first pass in a semicircular track through that funnel-shaped cavity ; there being between the orifices of the bowel, directly opposite to the communication between the cavity of the intestine and that of the funnel-shaped membrane, a considerable projection, or jutting angle, forming a material additional obstacle to the direct passage of the feces from the upper into the lower por- tion of the intestinal tube. — (Scarpa sulV Ernie Me- morie, Nat. Chirurgiche, Milano, 1809.) Desault, after noticing tlie efficiency of the adhesions, between the injured part of the bowel and the edge of the opening in the parietes of the abdomen, in prevent- ing extravasation, remarks, that if such adhesions were entire, the abdominal parietes would form a substitute for the portion of the canal which has been destroyed, and the contents of the bowel would continue to pass as usual towards the anus, if the portions of the intes- tine, separated and adherent to the neighbouring parts, did not form such an acute angle as obstructs the pas- sage of the intestinal matter. The more acute this angle is, the greater is the obstruction ; when the two parts of the bowel lie nearly parallel, the entrance into the lower portion of the canal is completely prevented ; but, if they meet at a right angle, then more or less of the contejits of the upper portion may be transmitted into the lower. The first disposition chiefly happens, when a considerable part of the intestinal canal has been destroyed, or when the tube has been completely divided ; while the second posture is principally re- marked in all cases where the injury has been less extensive. And it is plain, that the possibility of a cure depends materially on the kind of angle at which the two portions of bowel meet, and that the projection of the internal fraenum, or jutting membra- nous ridge between the two orifices, is always a greater or less obstacle to the cure. With respect to the diminution which occurs in the diameter of the part of the intestinal canal between the artificial opening and the natural anus, Desault admits the correctness of the observation, but entirely dissents from such authors as have spoken of the change as sometimes proceeding so far, that an oblite- ration of that portion of the intestinal tube is the con- sequence. The mucus secreted within it suffices for preventing this obliteration ; a . secretion which, in these cases, is copious, and is partly voided from the rectum in the form of white flakes. And if any far- ther proof were needed, that the bowels between the artifioial and natilral anus remain pervioiis, it is fur- nished by the fact, that in cases of artificial anus, the lower continuation of the tube ftequently becomes in- verted, and protrudes. On the other hand, the kind of obliteration above spoken of, has never been demon- strated by dissection; it was not observed by Lecat, in the examination of the body of a person, who died twelve years after the entire cessation of the passage of feces per anum; nor was it found to exist by Do- ANUS. 167 sault, when he opened a patient who died of marasmus in the Hdtel-Dieu, in consequence of an artiticial anus, which communicated with the ileum, and had lasted two years. — {(F.uvr. de Default, t. 2, p. 354—356.) However proper the formation of an artilicial anus may be, in many cases, iri which the patient’s life de- pends upon the event, it must be confessed that the consequence is a most afflicting and disgusting in- firmity. This truth cannot be denied ; though the I'eces which are discharged, from not having been so long retained in the bowels, may not be so fetid as those which are evacuated in the ordinary way. As the opening, which gives vent to the excrement, is not en> dued with the same organization as the lower end of the rectum, and as, in particular, it is not furnished with any sphincter capable of contracting and relaxing itself as occasion requires, the feces are continually escaping without any knowledge of the circumstance on the part of the patient. Hence the uncleanly state of the parts around the external opening ; and their frequently excoriated fungous state. Some persons in this state, among the number of those whose histories are on record, made use of a metal box, in which their excrement was received. Schenckius relates the case of an officer, who was wounded in the belly, and who allowed his feces to escape into a vessel made for the purpose. Dionis mentions a similar case. Moscati also communicated to the Academy of Sur- gery the history of a wounded man, in whom an artifi- cial anus took place, in consequence of a wound in the abdomen below the right hypochondrium. His excre- ment used to be received in a tin box, fastened to him with a belt. The wound received a leaden cannula, to which the tin box was accommodated. Uncleanliness is not the only inconvenience of an artificial anus. Persons have been known to be quite debilitated by the affliction, and even ultimately to die in consequence of it. This is liable to happen, when- ever the intestinal canal is opened very high up, so that the aliment escapes before chylification is completed, and the nutritious part of the food has been taken up by the lacteals. In this circumstance, the patient be- comes emaciated, and sometimes perishes, as Desault had an opportunity of observing ; and examples of which are al.so recorded by Hoin and Le Blanc. In cases of this description, the matter voided has little fetor, and is frequently sourish. In all instances, the matter is evacuated involuntarily, because there is nothing like a sphincter. But when the opening only interests the lower convolutions of the ileum, or, what is more frequent, when it has occurred in the large in- testines, the danger is less serious, and patients in this state are often noticed performing all their functions very well ; and, with the exception of colic, to which they are subject, enjoying as good health as they did previously to their having the present disease. In such examples, the matter voided is more fetid, its discharge does not follow so quickly its introduction into the stomach, and it is retained for a longer time. Many patients afflicted with an artificial anus void no feces at all from the rectum ; but occasionally, a thick whitish -substance, which is the mucous secre- tion of the portion of the large intestines nearest to the anus. Under certain circumstances, the quantity of this mucus discharged is more copious. — {Desault, vol. cit.p. 359.) The most grievous occurrence to which persons with an artificial anus are exposed, is a prolapsus of the bowel, similar to what sometimes happens through the anus, with respect to the rectum. The descent of the bowel is sometimes simple, only affecting a portion of the intestinal canal just above or below the opening. On other occasions the complaint is double, the bowel both abovie and below the opening being prolapsed. This descent of the intestine forms a tumour, the dimen- sions of which vary considerably in different subjects. When the protrusion is caused by the upper part of the intestinal canal, the feces are voided at the extre- mity of the tumour, and when the swelling consists of the lower portion of the bowel, the excrement is evacuated at the base of the prolapsed part. By ob- serving this evacuation when the tumour is double, it is easy to know to which end of the intestinal canal each protruded portion belongs. This consequence of an artificial anus is very serious, because it greatly increases the inconvenience which the patient suffers. Sometimes the tumour is exquisitely sensible ; and occasionally, when the eversion of the intestine is con- siderable, a strangulation is produced, which puts the patient’s life in danger. I apprehend no well-informed surgeon of the pre- sent day can doubt that formerly the frequency of arti- ficial ani alter hernia was seriously increased by the absurd measures sometimes adopted for the express purjiose of preventing them ; and as Mr. Travers has rightly observed, the cases reported by the old surgeons, if they prove any thing, prove this ; “ that the canal had been very generally restored,when the artificial anus was reckoned upon as inevitable, and tuat where an offi- cious solicitude had been at work to prevent it, showing itself in an active interference with the arrangements of nature, the case has terminated in artificial anus ; so that the event either way has been a matter of sur- prise to the surgeon. The fear of doing too little, or too much, applies only to the pernicious customs of di- lating the stricture, displacing, amputating, and sew- ing the intestine ; the general adoption of which prac- tice fully accounts to my mind for the number of arti- ficial ani, which are the sequelai of hernia.”— (Op. cit. p. 367.) The treatment of an artificial anus is either pallia- tive or radical. The first consists in obviating the ha- bitual uncleanliness produced by the involuntary dis- charge of the intestinal matter, and in relieving such bad symptoms as may arise from the disorder. The first indication is fulfilled by the employment of silver or tin machines, which are either kept applied to the external opening by means of a spring, or form receptacles jilaced more or less off the artificial anus, from which the intestinal matter is transmitted through a tube, kept constantly in the opening. In general, says Desault, as elastic gum is supple, light, and ca- pable of taking any shape, it is the best material for the construction of such instruments, which, however, rarely answer their purpose completely, and always give the patient a great deal of trouble. As for the second indication, Richter, with the view of hindering the too quick escape of the intestinal mat- ter, and the death of the patient from this cause, pro- po.sed covering the opening for a certain time with a piece of sponge, supported by an elastic bandage or truss. But Loeffler found this method objectionable, as it was apt to bring on colic, constipation, and an inflamed excoriated state of the skin. When the outer opening is disposed to contract too much, and inconveniences arise from this change, Sa- batier is an advocate for preventing such closure by means of a tent, or skein of silk, introduced into the aperture, and changed very ofleii for the sake of clean- liness ; while others prefer a ring of ivory for the pur- pose. But the irritation produced by the matter im- bibed by this sort of tent, and in particular the liability of the bowel to protrude, and be strangulated in the opening of the ivory ring, are found strong objections to these practices ; and according to Desault, the sponge employed by Richter also occasions a great deal of ex- coriation by the irritation of the fluid which is lodged in it. For the purposes of hindering a protrusion of the gut, of keeping the opening suflicieiit'y pervious, of relieving any uneasiness and tenesmus, of hindering the intestinal matter from escaping in the intervals of dres-sitig, and confining it long enough for the adequate nourishment of the patient, Desault preferred a linen tent or stopper covered by a pad of charpie, compresses, and a tight bandage. At first, says he, the patient feels some uneasiness from this plan, and slight colics may be the consequence of it ; but, by degrees, the parts become habituated to their new state, and every thing goes on well. With respect to the employment of tents and plugs with the views above indicated, I am disposed to think the practice can rarely be advisa- ble ; and that any necessity for it may be obviated by attention to diet, and the occasional exhibition of laxa- tive medicines and clysters, as will be hereafter no- ticed. When the gut protrudes, its reduction is to be effected in the same way as a common prolapsus ani : but serious difficulty will occur when the protruded part is inflamed, thickened, and of considerable size. Indeed, surgeons have usually regarded the reduction as impracticable in these circumstances ; but accord- ing to Desault this is not the case, as compression with a bandage, kept up for some days, will succeed. Care must be taken, however, to leave a sufficient opening 168 ANUS. for the passage of the feces. \Miatever may be the size of the protrusion, Desault argues, that it should be the invariable rule of the surgeon to endeavour to return the part by the means here suggested. — (See ULuvres Chir. de Deaault, t. 2, p. 361 , .i c.) The radical cure is what is next to be considered. The business of the surgeon is to prevent, if possible, the formation of an artificial anus; but when the event has occurred, and particularly, when the whole or the greater part of the stools is discharged in this way , no attempt must be made to stop up the opening without a great deal of consideration ; for any eflbrt of this kind, made under circumstances which do not justify it, may be the means of exposing the patient’s life to the most alarming danger. Sometimes, indeed, without any interlereuce of the surgeon, the outward opening contracts, and the issue of the intestinal matter being obstructed, pain and tene.smus are excited ; and the same consequences may be produced by any swelling and enlargement of the projecting ridge, situated be- tween the two portions of the bowel. In two cases Puy found this sweliing take place in such a degree, that the patiuuts fell victims to the complete stoppage of the intestinal contents. The synnptoms which arise are then sunilar to those which happen in strangu- lated hernia. Hoin, Le Blanc, and Sabatier also cite Instances, in which the patients lost their lives by gan- grene, brought on by this species of strangulation. — (Desault, vol. cit. p. 360.) There is a period (say s Mr. Travers), at which the function of the lower portion of the canal, tvith a little assistance, may be restored. The natural order of events connected with this recovery has been mis- taken and inverted. Practitioners have closed the wound instead of conducting tlie matter by purga- tives and clysters into the large intestines. Now, the wound will never fail to heai, when the matter reco- vers its accustomed route ; but this condition cannot be reversed. The restoration is safest when most gradual; when there is evidence of an existing sym- pathy betw'een the repair of structure and the return of function. According to the same gentleman, there is reason to believe, that the well-timed exhibition of' a single purgative might often prove effectual. “ If' the food IS rapid and little changed in its pa.ssage, it should be pultaceous and nutritive, and given in mode- rate quantity at short inten’als ; while injections of the same kind should be administered at least twice in twenty-four hours, and retained as long as possible.” He states that by such means patients n.ay be nou- rished for m?ny weeks. If the discharge is sparing, and does not readily escape, he recommends an occa- sional purgative in less than ordinary quantity. He disapproves of other medicines, especially^ stimulants, and all such food as is difficult of digestion, giving a general preference to animal food in a gelatinous form. He bestows just praise on strict attention to cleanli- ness, and, in opposition to Desault and Sabatier, con- demns the employment of tents and sponges. — (Op. cit. p. 371. 373.) Numerous cases on record furnish abundance of proof, that the feces, after being voided for several months fro.m the wound produced by the operation for hernia, frequently resume their natural course. Facts of this kind, wliich in general may be said to be com- mon when the intestine is without loss of .substance, are not very rare even when more or less of the bowel has been destroyed by gangrene ; and many illu.stra- tions of this remark may be found in the writings of De la Peyronie, Louis, Petit, Pott, Le Dran, &c. The greater number of the.se instances of succes.s, as al- ready stated, were the result of the most simple, un- officious treatment, or rather of the undisturbed, and yery little assisted, efforts of nature. In the radical cure of an artificial anus, the follow- ing are the general indications laid down by Desault : 1. To reduce the gut when it protrudes and is everted. 2. To prevent the issue of the feces from the wound, so that they may be obliged to pass on towards the rectum, at the same time that the healing of the exter- nal opening is to be promoted. 3. To obviate any in- ternal impediments to the passage of the matter into the lower part of the intestinal catial. How the first of these objects i.s to be aecom.plished in the case of greatest difficulty, that is, when the pari- ctes of line bowel are thickened, has been already ex- plained. Experience proves, says Desault, liiat tho second indication cannot be lul filled by metins of sn- tures. The best thing for this purpose he represents to be the linen stopper, above spoken of as a means for preventing the protrusion of the bowel. Here it answers the double object of hindering such a protru- sion, and filling up the fistulous opening, so as to make the contents of the bowel tend towards the anus. De- sault argues that the surgeon need not be apprehen- sive of the tent doing harm by keeping the wound from healing. The first aim, he says, shouid be to determine the feces to take their natural route ; and when this has been done by closing the external open- ing, the tent may be removed, and this opening will spontaneously close. However, when the internal impediment is too great, it must be overcome ere such treatment can be suc- cessful. According to Desanlt, the most frequent im- pediment here alluded to, is the angle formed by the two portions of the intestine, and it must be enlarged, and rendered less acute, in order that the feces may continue their route. This desirable change he re- commends to be effected by introducing long dossils of charpie into the two ends of the bowel, and gradually altering their direction so as to bring it into one same straight line. WTien the dilatation is sufficient, and the inner angle or ridge is effaced, the long dossils need not be continued. The linen tent, with the pre- caution of not introducing it too deeply, lest it obstruct the course of the feces itself, will then suffice. When this plan is skilfully managed, Desault says, there will be a great chance of its succeeding, and its bene- ficial effect will be denoted by a rumbling in the bow- els, and frequently by slight colics. At first wind is discharged from the rectum, and soon afterward, the feces begin to come away. On the contrary, if they should not pass tvith facility, the colic be violent, and an accumulation happen in the upper iiortion of the inte.stinal canal, the tent must be withdrawn, and the other cause of obstruction be considered, and, if possi- ble, removed. — (Vol. cit. p. 355, Ac.) In the preceding columns, I have given a ftill ex- planation of the impediment made to the passage of the feces into the lower orifice of the intestinal canal, by the projecting septum or ridge between the two parts of the bowel, and the matter havitig to traverse the funnel-shaped membranous cavity in quite a semi- circular track. A representation of this septum may be seen in Scarpa’s work, tab. 9, fig. 1, and also in the sixth plate of Mr. Traver’s Inquiry. In one example in which this septum was plainly visible in the w’ound, Dupuytren introduced into the orifice of the upper part of the bowel a curved needle, and passing it through the projecting septum, brought it out again through the orifice of the lower portion of the gut. Thus he in luded a considerable part of the septum in a liga- ture, which was daily made thicker with a view of first exciting inflammation in the two layers of this septum, and thus ensuring their adhesion together, and his next plan consisted in making a division through the part embraced by the ligature, whereby the passage for the feces into the lower jiortion of tha bow'el was made quite free. But as the section made by the ligature was too superficial, Dupuytren com- pleted the division of the septum with a knife ; but peritonitis and the death of the patient ensued. Ac- cording to Dr. Breschet, the ligature also proved in- effectual, because its operation was so slow, that adhe- sions and cicatrization took place behind it as fast as it made its way through the rest of the septum. Hence, the expectation that the feces would sufficiently pass through the aperture made by the ligature was hot realized ; and in one case quoted by Breschet, though some amendment followed the operation, still the cure was far from being accomplished, as only some of the feces passed out of the natural anus, w hile th^remain- ing and greater part of them still came through the fis- tula. — (See Graefe’s Journ. b. 2, p. 300.) In another case, Dupuytren tried to render the layers of the sep- tum adherent by compressing them between the blades of a pair of forceps of particular construction, and af- terward he effected the division of the part by augment- ing the compression by means of a screw traversing the handles of the instrument. In a case which followed the operation for bubonocele, attended with mortification of the bowel, Dupuytren began w idi tU.'ating the outer open- ing with a bistoury, and after a.scei tai niug the position of the sfqiium, bet ween the two orifices of the bow el, he in- ANUS, 169 troduced one of the blades of the forceps into each portion of the gut, and closed the instrument with the screw. The part of the instrument situated externally to the ridge or septum, he covered with charpie and a compress. The constriction was soon followed by colic pains and tendency to vomit, complaints which were quickly removed by fomenting the belly. They recurred, however, the instrument became loose, and some dLscharge ensued. On examination, the septum was found to be partially divided. After the breadth of the instrument had been lessened it was applied again ; but when the screw was turned, the patient began to suffer such violent pain over the whole of the abdomen, that it was necessary to diminish the pressure ; and as the instrument was afterward se- parated from the parts in a fit of vomiting, it was withdrawn. A trial was now tnade to determine the feces towards the rectum by pressure on the externa) apening; but the plan could not he endured, and the hindranc-e to the egress of the intestinal matter was so oppressive that it was discontinued. As the forceps used on the foregoing occasion did not take sufficient hold of the septum, nor divide it properly, the in- strument was somewhat altered. A particular de- scription of its improved make has been inserted by Breschet in G aefe's Journal, b. 2, p. 302. Dr. Rei- singer has published three ca.ses in which it was suc- cessfully employed by Dupuytren. In the first of these examples, when the instrument had been applied, it embraced the septum so well, that it could not be displaced from it. The colic attacks, vomiting thirst, furred tongues, and loss of appetite, which en- sued, soon gave way alter the belly had been fo- mented; the constriction was then increased, and found to produce less and less indisposition. On the 29th, very little of the feces came out of the artificial anus, and after a short time, five natural evacuations took place. The blades of the instrument were now completely closed, and on taking it out, a slough of membrane was found between the blades ; a proof that the septum was destroyed. On the 30th, the pa- tient's health was undisturbed. Clysters were now' administered with the view of promoting evacuations in the natural manner ; and the next day, the patient had a proper motion without any assistance, and a very small quantity of the feces jiassed out of the fis- tulous opening. This aperture was now merely co- vered with charpie ; but as some high granulations were rising, the powder of colophonium was sprin- kled on them, and compresses and a bandage were ap- plied. The use of clysters was also daily continued, though the patient voided his feces in the natural way. On discontinuing the external pressure, the quantity of discharge from the fistulous opening increased ; and, therefore, on the first of October, the compresses vrere again aiiplied, and kept on the part with a spring truss. The treatment ended in a perfect cure. In another ca.se, Dupuytren enlarged the low'er an- gle of the outer opening with a bistoury, and after feel- ing with his finger that both orifices of the bowel were close to that ot>ening, he applied the forceps. In the eveninc, the constriction was increased, which was followed by severe colic pains over the whole abdo- men. They subsided, however, the following day. From the outer opening, a great deal of slimy excre- ment was discharged. The constriction was not aug- mented. On the 5th day, the patient was attacked in the night with pain and vomiting. The following night he was also very restless. Though the belly was not tense, it could not bear to be touched. On the 11th, and 12th days, the patient was nearly free from pain, and by means of clysters, two natural motions were procured; and on the 13th, as the patient was easy, Dupuytren began to make pressure on the fistulous opening. On the 26th, the edges of the aperture were touched with lunar caustic; and on the 28th, a com- press supported by a spring truss was applied. The patient was kept constantly in the horizontal posture ; the feces began to be voided the natural way regularly, and the opening contracted in the most favourable manner. I think the generality of surgeons will agree with Dr. Rcisinger, that the foregoing treatment cannot be indiscriminately adopted in all descriptions of patients without danger. It should never be tried too soon after the formation of an artificial anus ; but time should be allowed lor tiie irriiabiluy and sensibility of the gut, and especially of the septum, to be lessened by the effect of the air and the pressure of the feces. Nor should the trial ever be made ere it has been fully as- certained that nature cannot herself bring about the cure. Breschet mentions an example in which the foregoing method could not have been practised, in consequence of the mouth of the lower portion of the bowel having been obliterated by the pressure of a. large tent three inches long, which had been worn by the patient two years, and the projecting ridge could not be detected.- (See Grae/e’s Joum.der Chir. b. 2, p. 298.) Many other interesting observations on this new proposal may be perused in the memoir by Dr. Breschet, and in Dr. Reisinger’s tract, the title of which is given in the list of works at the end of the pre.sont article. In order not to incur the risk of ex travasation of the feces in the abdomen, tiie constric- tion of the septum should never be increased with im- prudent haste before the adhesive inflammatiori has had time to be produced between the layers of which that part is composed. In cases of artificial anus, the appearance of the mu- cous coat of the bowel undergoes some change, in con- sequence of exposure to the air and the contact of ex- traneous bodies; it becomes redder and less villous, but does not cea.se to secrete a great quantity of mu- cus : this is one of the principal reasons why it is so difficult to close the fistulous opening, even when the passage for the feces has been re.stored. The skin around an artificial anus is also generally very irritable, and rendered exceedingly painful by the contact of the excrement.--(Breschet, in Grae/e’s Journ. b. 2, p. 303.) If after the destruction of the septum, and the re-es- tablishment of a free communication between the two portions of the bow'el, the external fistula were not to admit of being healed by pressure and other ordinary means, no doubt could be entertained of the propriety of revsorting to the plan ol' attempting to cure it by par- ing off the edges and bringing them together with su- tures, as is sometimes done by Dupuytren, or on the Taliacotian principles, as successfully exemplified by Mr. G. F. Collier. — (See Med. mui Physical Journ. for June, 1820.) Dupuytren. for the purpose ol' making the sides of the fistula remain in contact, or making them approach each other, occasionally applies an in- genious little instrument consisting of two pads, which by means of a screw can be made to embrace the part. An engraving of it may be seen in Grae/e’s Journ. b. 3, tqf. 2,/g. 9. For the closure of the fistula, Dupuy- tren also sometimes has recourse to the actual cau- tery. I shall conclude with the relation of an interesting case of artificial anus complicated with prolapsus, as recorded -by my friend Mr. Lawrence. “ If the complaint (a mortified hernia) terminates in the formation of an artificial anus, we must endeavour to alleviate those distressing inconveniences which arise from the involuntary discharge of wind and feces through the new opening, by supplying the patient with an aiiparatus in which these may bo received as they pass off. An instrument of this kind, the con- struction of which appears very perfect, is described by Richter (Anfangsgr. der Wundarzn. vol. 5), from the Trait. d'S Bandages of.]uville. , The patient will be best enabled to adapt any contrivance of this sort to the particular circumstances of his own case. It has been found in some instances, that a common elastic truss with a compress of lint under the pad, has been more serviceable than any complicated instrument (Parisian Journal, vol. 1, p. 193) in preventing the continual flow of feculent matter from the artificial opening.” — (Treatise on Hernia, p. 206.) “ 1 know,” says Mr. Lawrence, “ a patient with an artificial anus, in whom the gut often protriules to the length of eight or ten inches, at the same time bleeding from its surface. This is attended with pain, and compels him to lie down ; in w’hich position tlie intes- tine recedes. The patient has now discharged all his feces at the groin for fifteen years, and has enjoyed to- lerable health and strength during that time. His evacuations are generally fluid, but sometimes of the natural consistence. Whenever he retains his urine after feeling an inclination to void it, a quantity of clear inoffensive mucus like the white of an egg amounting to about four ounces, is expelled from the anus ; and this may occur twoor three times in the day ** —(P. 208.) 170 ANU AOR When the protruded intestine is strangulated, an operation may become necessary for the removal of the stricture. — {Schmucker, Vermischte Chirurgische Schri/ten, t. 2.) Two cases which terminated fatally from this cause are mentioned by Sabatier, in a me- moir in the 5th torn, de I’Acad. de Chir. Mr. Lawrence also refers to Le Blanc. — {Precis d'Op rations de Chir . tom. 2, p. 445.) We should always endeavour to pre- vent such protrusions when a disposition to their form- ation seems to exist, by the use of a steel truss, which should indeed be worn by the patient independently of this circumstance. If the tumour has become irredu- cible by the hand, an attempt may be made to replace it by keeping up a constant pressure on the part, the patient being at the same time confined to bed. By these means, as we have already noticed, Desault {Pa- risian Joum. vol. 1, p. 178) returned a very large pro- lapsus, and by pressure on the opening, the ffeces were made to pass entirely by the anus, although for four years they had been voided only through the wound. — {Lawrence, p. 209, 210.) In cases of mortified hernia, the wound sometimes closes, except a small fistulous opening which dis- charges a tliin fiuid and cannot be healed. Mr. Law- rence has related, in his excellent treatise on hernia, a case in which the feces came from the wound some time after an operation, although the bowel did not ap- pear gangrenous when this proceeding was adopted. — (P. 211.) In the appendix to this work, the author adds some farther account of the case of artificial anus wdiich he has related.— (P. 208.) The man is sixty years of age, and appears to be healthy, active, and even younger than he really is. He had had a scrotal hernia which ended in mortification, and involved the testicle of the same side and a large portion of the integuments in the destruction. It is now nearly seventeen years since this event, and the feces have during all this time been discharged from the groin. He has never made use of a truss, nor taken any step, except that of always keeping a quantity of tow in his breeches. The prolapsed portion of intestine varies in length and size at different times. It was four inches long when Mr. Lawrence saw it, and the basis, which is the largest part, measured nearly six inches in circum- ference. The prolapsus never recedes entirely, and it has occasionally protruded to the length of eight or ten inches, being as large as the forearm, and emitting blood. This occurrence is painful, and only comes on when the bowels are out of order. Warm fomentations and a recumbent position afford relief and accomplish a reduction of the bowel. The projecting part is of a uniform red colour, simi- lar to that of florid and healthy granulations. The surface, although wrinkled and irregular, is smooth, and lubricated by a mucous secretion. It feels firm and fleshy, and can be squeezed and handled without exciting pain. The man has not the least pow'er of re- taining his stools. When these are fluid, they come away repeatedly in the course of the day, and with considerable force. When of a firmer consistence, there is only one stool every one or two days, and the evacuation requires much straining. Such feces are not broader than the little finger. When the patient is purged, the food is often voided very little changed. This is particularly the case with cucumber. In this state he is always very weak. Ale is sometimes dis- charged five minutes after taken, being scarcely at all altered. The bowels are strongly affected by slighf doses of.porgatives. Consult Sabatier, in Mem. de VJicad. de Chirvrgie, t. 5, 4t/i., and m Medecine Opiratoire, t. 2. Richter's yjvfangsgr. der fVundarzn. b. 5. J. R. Tieffcvbach, Vulnerum in intestinis lethalitas occasione casus ra- rissimi, quo colon vulncratum, inversum per 14 antios ex abdominepropendens exhibetur ; Halleri Disp. Chir. 5, 61. Desault, in Parisian Chir. Journal, u. 1, or iEuvres Chirurg. par Bichat, t. 2, p. 352, ^c. Schmucker's Chir. Schnften, vol. 2. Jjowrence on Hernia, ed. 1. Callisen's Sijstema Chirurgim Hodi- ernoe, t. 2, p. 710, Src. B. Travers, Inquiry into the Process of Mature in repairing Injuries of the Intes- tines, chap. 8, 8vo. Bond. 1812. Scarpa sull' Krnir. Mernorie Jinatomico- Chirurgiche, fol. Milano, 1809. F. Reisinger, jlnzeige eiwr von dem H. Professor Dupuytren erf undenen, und mit dem gliicklichst.cn Erfolge aasgefiihrten Operationsweise zur Ileilung des Jinvs Artijicialis, nebst Bemerknngen, Jlugshurg, 1817. Brosse. in Rust’s Mag. b. 6, p. 239. Liordat^ Diss. sur le Traitement de I'Anus contre Mature, Paris, 1819. Breschet, in Journ. der Chirurgie von C. F. Graife und Ph. von Walther, b. 2, p. 273. 479, Ber- lin, 1821 : this memoir, containing the fullest descrip- tion of Dupuijtren's practice, well deserves the careful perusal of every surgeon who wishes to be completely acquainted with the present subject. Hennen’s Mili- tary Surgery, p. 407, .J'c. ed. 2, 8vo. Edin. 1820. Three cases from gun shot wounds; the cure effictid by aiding nature with the exhibition of occasional laxa- tives and clysters. j9ll irritating plans were avoided. Scarpa represents the artificial ani which follow wounds, as far more difficult of cure than those which are the consequence of hernia with mortification ; yet I have known many of the first description of cases cured. AORTA. Aneurisms of this vessel have already been treated of ; but there are a few other particulars relating to it which merit notice in a dictionary of sur- gery. WOUND OF THE AORTA NOT ALWAYS FOLLOWED BY INSTANTANEOUS DEATH. A case exemplifying this fact was recorded by M. Pelietan. In the month of May, 1802, a young man was brought to the Hotel-Dieu. In a duel, he had been run through with a foil, which penetrated above the right nipple, and came out at the left loin. The most alarming symptoms were apprehended ; but se- veral days elapsed without any serious complaints taking place. The patient was bled twice, and kept on a very low regimen. Every thing went on quietly for a fortnight. He now complained of severe pains in his loins, and he was relieved by the warm bath. He seemed to be recovering, got up, and went to walk in the garden allotted for the sick ; but the pain in his loins quickly returned, attended with difficulty of breath- ing, constipation, and wakefulness. He now became very impatient, and out of temper with the surgeons for not relieving him. On the 15th of July, two months after the accident, a deformity of the spine was remarked about the eighth dorsal vertebra. The patient grew rapidly worse, and died in the utmost agony, saying that he felt suffocated ; and tearing ofiT his shirt, that his chest might be free from the pressure of all kinds of clothing. On the body being opened, the right side of the chest was found full of blood, coagulated in various degrees, and an opening, the diameter of which was equal to that of a writing pen, was detected in the aorta above the crura of the diaphragm. All the adjacent cellular substance was injected with blood, and three of the dorsal vertebrae were found carious. No mark of injury was perceptible in any of the thoracic or ab- dominal viscera. — {Pelietan, Clinique, Chir. t. 1, p. 92—94.) THICKENING AND CONSTRICTION OF THE AORTA. Meckel met with two cases in which the aorta was thickened and considerably constricted just below its arch ; yet in both subjects there was every reason to believe that the abdominal viscera and lower extremi- ties had been duly supplied with blood. This fluid, which could only pass from the heart with great difficulty and in small quantities, had, by regurgitating, lacerated the semilunar valves. — {Mem. de I’Acad. Royale de Berlin, 1756. Ohs. 17 and 18.) A similar example is recorded by Stoerck. — {Ann. Med. 11, p. 171.) An instance, in which a stricture was met with in the aorta opposite to the termination of the canals arteriosus, is described by Sir Astley Cooper. The little finger could hardly pass through the constriction, which impeded the course of the blood through the heart and lungs, and was attended with a considerable dilatation of the right ventricle. — {Sur gical Essays, vol. 1, p. 103, Suo. Land. 1818.) OBLITERATION OF THE CAVITY OF THE AORTA. It is observed by Professor Scarpa, that the whole body may be regarded as an anastomosis of vessels, a vascular circle ; and he contends that this remark is so true, that even an obliteration of the aorta itself, immediately below its arch, may take place, without the general circulation of the blood in the body being stopped. Such a disease of the aorta was seen by Paris in the body of a woman. While she lived, the AORTA. 171 Wood which was expelled from the heart was trans- mitted into the trunk of the aorta below the constric- tion, and it got there by passing through the subclavian, axillary, and cervical arteries, into the mammary, intercostal, diaphragmatic, and epigastric arteries. From these latter arteries the blood passed into the vessels of the thoracic and abdominal viscera and those of the lower extremities. -(See Desault's Jour- nal, t. 2, p. 107. Brasdor, in Recueil Periodique de la Soc. de MU. t. 3, No. 18.) Dr. Graham, of Glasgow, published another example, in which the aorta was completely obstructed, just be- low the canalis arteriosus. The particulars are de- tailed in the Med. Chir. Trans, vol. 5, p. 287. Dr. Goodison, of Wicklow, in examining the dead body of a woman in the Hospice de la Pitie at Paris, and endeavouring to trace the origin of the inferior jnesenteric artery, discovered a hard tumour placed upon the aorta, and accompanied with an obliteration of that vessel from the origin of the inferior mesenteric artery downwards the remainder of its length ; the let! iliac being also rendered impervious down to its bifur- cation, and the right for more than one-half of its length. The corpora sesamoidea of the semilunar valves of the aorta were considerably enlarged, and the mitral and tricuspid valves pre.sented the appearances termed by Corvisart “ vegetations.” The arch of the aorta was greatly enlarged, and internally was studded with patches of bone. The vessels given off from the trunk, and especially the lumbar arteries, were all noticed to be considerably increased in size. At the obliterated part of the abdominal aorta, there was a firm bony sheath, covering the vessel for about two inches, and filled with a hard fleshy substance which extended farther upwards, and was firmly adherent to the coat of the artery. It was the inner coat itself which was ossified. For a particular account of the vessels which were chiefly enlarged for the purpose of continuing the circulation, I must refer to Dr. Goodison’s description. The general appearance of the body was not unhealthy ; and the lower extremities, which were not emaciated, must have been well supplied with blood. The history of the case could not be traced. Mr. Crampton having carefully compared Dr. Goodison’s narrative with the preparation taken from this subject, refers the oblitera- tion of the aorta to the effects of the process by wdiich an aneurism had been spontaneously cured ; in which particular this case is quite different from those re- ported by M. Paris and Dr. Graham. — (See Dublin Hospital Reports, vol. 2, p. 193, <^-e. 800. 1813.) The next case which I shall notice is one of the most memorable in the annals of surgery, since it was nothing less than an operation in which a ligature was applied to the aorta of a living subject, under circum- stances which, at a time when the successful repeti- tion of Brasdor’s operation had not been made (see Wardrop on Aneurism, 1829), perhaps warranted even this desperate attempt to preserve life. Sir Astley Cooper had often placed ligatures round the aorta in dogs, and found that the blood was readily carried by the anastomoses to their posterior extremities (see Med. Chir. Trans, vol. 2, p. 158), and he has ascertained, that if the aortic plexus be tied with the artery, the lower extremities are rendered paralytic, and the ani- mal ultimately dies ; but if care be taken to include only the vessel in the ligature, these consequences do not take place.— (See Lancet, vol. 2, p. 47.) A porter, aged thirty-eight, was admitted into Guy’s Hospital, April 9, 1817, for an aneurism in the left groin, situated partly above and partly below Poupart’s ligament. The swelling was considerably diffused, and pressure upon it gave a great deal of pain. On the third day from his entrance into the hospital, the tumqur increased to double its former size, and the pulsation became less distinct. The blood could be felt in a fluid state within the sac, which was so large that no operation was practicable without opening the peri- toneum. Sir Astley Cooper therefore waited, in order to let the man have the chance of a spontaneous cure. Notwithstanding the practice of venesection and com- pression, the swelling continued to increase, and, on the 20th of .lune, a bleeding took ))lace from a point of the tumour, where a slough had formed. The bleed- ing recurred from time to time, and on the 25th'he was so much exhausted by loss of blood that his feces passed involuntarily, and his immediate death was only prevented by pressure on the opening. At nine o’clock in the evening, this experienced surgeon made a small incision into the sac above Poupart’s I gament, and introducing his finger, tried if it was practicable to pass a ligature round the external iliac artery within the cavity ; but the thing was found impossible, as in- stead of the vessel, “ only a chaos of broken coagula” could be perceived. Ai the moment of withdrawing the fiiig r, two students compressed the aorta against the spine, and the incision was then closed with a dossil of lint. Sir A. Cooper now determined to apply a ligature to the aorta itself. “ I made (says he) an incision three inches long into the linea alba, giving it a slight curve to avoid the umbilicus. One inch and a half was above, and the remainder below the navel,” the cut being inclined towards the left side. “ Having divided the linea alba, I made a smalt aperture into the peritoneum, and introduced my finger into the ab- domen ; and then with a probe-pointed bistoury, en- larged the opening into the peritoneum to nearly the same extent as that of the external wound. Neither the omentum nor the intestines protruded ; and during the progress of the operation only one small convolu- tion projected beyond the wound.” With his finger- nail he scratched through the peritoneum on the left side of the aorta, and then gently moving his finger from side to side, he gradually passed it between the aorta and spine, and again penetrated the peritoneum on the right side of the aorta. A blunt aneurismal needle, armed with a single ligature, was next conveyed under that vessel, and tied, with the precaution of excluding the intestines from the noose. The wound was then closed by means of the quilled suture and adhesive plaster. During the operation the feces were dis- charged involuntarily, and the pulse both immediately and for an hour after the operation was 144. An opiate was given, and the involuntaty passage of feces soon ceased. The sensibility of the right leg was very im- perfect. In the night, the patient complained of heat in the abdomen ; but he felt no pain upon pressure ; and the lower extremities, which had been cold a little while after the operation, were regaining their heat, but their sensibility was very indistinct. At six o’clock the fol- lowing morning, the sensibility of the limbs was still im- perfect ; but at eight o’clock the right one was warmer than the left, and its sensibility returning. At noon the temperature of the right limb was ninety-four; that of the left or aneurismal one, eighty-seven and a half. At three o’clock, an enema was ordered. The heat of the right leg was now ninety-six ; that of the left or diseased limb, eighty-seven and a half. It is un- necessary here to detail all the various circumstances .which preceded the patient’s death. Vomiting, pain in the abdomen and loins, involuntary discharge of urine and feces, a weak pulse, cold sweats, &c. were some of the most remarkable symptoms. At eight o’clock on the second morning after the operation, the aneurismal limb appeared livid and cold, more particu- larly round the aneurism ; but the right leg was warm ; and between one and two o’clock the same day, the patient died. On opening the abdomen, there was not the least appearance of peritoneal inflammation, except at the edges of the wound ; and the omentum and in- testines were of their natural colour. The ligature, which included no portion of intestine or omentum, was placed round the aorta about three-quarters of an inch above its bifurcation. When the vessel was opened, a clot of more than an inch in extent filled it above the ligature; and below the bifurcation another clot an inch in extent occupied the right iliac artery, while the left contained a third, which extended as far as the aneurism. The neck of the thigh-bone was also found broken within the capsular ligament, and not united; an accidental complication. As there were no appear- ances of inflammation of the viscera. Sir Astley Cooper refers the cause of the man’s death to the want of cir- culation in the aneurismal limb, which never recovered its natural heat, nor any degree of sensibility, though the right leg was not prevented from doing so ; hence, says this experienced surgeon, “ in an aneurism simi- larly situated, tl e ligature must be applied before the swelling has acquired any considerable magnitude. — {Surgical Essays, vol. 1, p. 114, Ac.) Indeed the most important conclusions from this case are:— First, that where no other impediment exi-sts, the circulation will continue in the lower extremities though the abdominal aorta be tied or suddenly ob- structed. Secondly, that sutfering aneurismal swell- 172 AOR APP ings to become very large before the operation is done, exposes the patient to considerable disadvantage, on account of the pressure of the disease upon the sur- rounding anastomoses, Mdiereby the continuance ol the circulation is rendered less certain than it would be were the operation done at an earlier period. Sir Astley Cooper mentions, that if he were to per- form the operation again, he would cut olf the two por- tions of the ligature close to the knot on the vessel, because the irritation of the bowels by them seems to him a source of considerable danger. [This formidable operation of tying the aorta has again been performed by Mr. James, of Exeter, Eng., very lately, with the hope of preserving the life of an individual afllicted with aneurism, not admitting of the common mode of treatment; but, like the former, it was unsuccessful. “ For cases in which aneurismal tumour is so situ- ated as not to admit of a ligature being applied to the artery leading to the disease, Brasdor’s proposal, and the facts and arguments in its favour related by Mr. Wardrop and others, and noticed in the article Aneu- rism of tliis Dictionary, deserve serious reflection. In weighing the various reasons both for and against this practice, as well as those either in favour or con- demnation of the desperate expedient of tying the aorta, the judicious surgeon will always regard the oc- casional spontaneous cures of aneurisms as facts of much importance.”— Fr^l The numerous cases in which the aorta has been found obliterated has emboldened Sir Astley (looper, Mr. James, and others, to advocate the propriety of tying this vessel in certain cases, and to maintain that it will yet succeed. It should be recollected, however, that in all these cases the obliteration of the vessel was gradually produced by disease, and the anastomosing branches became enlarged by a slow and safe process, because one that is perfectly natural. The case, how- ever, is very different when the vessel is suddenly closed by a ligature ; and this want of parallel in the cases very obviously vitiates the argument drawn from analogy. Professor Jamieson, of Baltimore, in a valuable paper on traumatic hemorrhage, published in the American Med. Recorder for January, 1829, has detailed a number of experiments performed on inferior animals, in some of which he passed a seton through large vessels, with a view of obstructing; their circulation, and thus effect- ing their gradual obliteration. His success was cer- tainly encouraging, and Dr. Webster, of Philadelphia, has repeated these experiments with similar results. The latter gentleman, in the late Philadelphia edition of “ Cooper’s First Lines,” has introduced some highly interesting and practical remarks on this subject in a note on the subject of aneurism, to which reference may be had, as containing hints of the most invaluable importance. Future experiments, however, will be necessary to enable the surgeon to aiTive at definite conclusions on .this most interesting subject. — Reese.^ RUPTURE OF THE AORTX WITHIN THE PERICARDIU.M . The surgical writings of Scarpa in relation to the formation of aneurisms have now gained extensive ce- lebrity in the world. It is well known that this author maintains the doctrine, that in all aneurisms the inter- jial and muscular coats of the artery are ruptured, and that the aneurismal sac is not formed of the.se tunics, 'but of the dilated cellular sheath which surrounds the vessel. When a large aneurism bursts, there is al- ways a double rupture ; one of the artery, another of the aneurismal sac. The last is that which is the im- mediate cause of the patient’s destruction, by altering the circumscribed state of the aneurism into the dif- fused.. There are some exceptions, however, to the foregoing statement, and Scarpa has not failed to point them out. When the internal and muscular coals of the aorta are ruptured in a situation where the outside of the vessel is only covered by a thin, tense, closely adherent membrane, such membrane may be ruptured at the same time with the proper coals of the artery, and sud- den death be occasioned by the effusion of blood in the cavity of the thorax. These events are liable to hap- pen whenever the proper coals of the aorta are rup- tured within the iiericardium, where the vessel is only covered by a thin layer reflected from this membra- nous bag. Waller has recorded one example ol this kind, and Morgagni several others. A similar case is related by Scarpa. — (See Haller, Disput. Chir. tom. 5. Acta Medic. Berlin, vol. 8, p. 86. Morgagni de Sed. et Causis Morb. Epist. 26, art.!. 17. 21. Epist. 27, art. 28. Scarpa on Aneurism, transl. by Wish art, p. 81. Also, Hodgson on the Diseases of Arteries and Veins.) STEATOMATOUS TUMOURS OF THE AORTA. Two steatomatous tumours were noticed by Stenzel in the body of a male subject. They were situated in the substance in the membranes of the aorta, immedi- ately below its arch. IXolwilhstanding these swellings rendered the vessel almost impervious, the man had the appearance of strength and of having been well nourished. Hrec corpora fere cor magnitudine eequa- bant ut omnem propemodum exeunti e sinistri cordis thalamo sanguini spativm preecluderent. De Slea- tomatibus in principio arleriae aortae, &c. Wittemb. 1723. This is another striking fact, illustrating the great power of the inosculations to carry on the circulation. Al'llJiRESIS. (From aiPuipio). to remove.) Tliis term was formerly used in the schools of surgery to signify that part of the art which consists in taking off any diseased or preternatural portion of the body. APONEUROSIS. Matter often collects under apo- neuroses, particularly under those which cover the muscles of the thigh, leg, and forearm. Abscesses are also sometimes met with under the temporal, the palmar, and the plantar fasciae ; in the tendinous thecae, which include the flexor tendons of the fingers ; and occasionally also in the aponeurotic sheath, in which the rectus abdominis muscle is situated. One particular effect of an aponeurosis, or any kind of tendinous expansion lying between a collection of matter and the skin, is materially to retard the progress of 'the pus towards the surface of the body. Hence, if . the case be allowed to take iis own course, the quan- tity of matter increases, the pus spreads extensively under the aponeurosis in every possible direction, se- parates the rauscles from such fascia and the muscles from each other, and the abscess does not burst till a vast deal of mischief has been produced, together with more or less sloughing of the fascia, tendons, &c. These circumstances cannot happen without a consi- derable degree of constitutional disturbance, and a per- manent loss of the use of certain muscles. Even when a spontaneous opening is formed, and some of the iiiafter escapes, it is often only a very imperfect discharge ; for the aperture generally occurs, not in a depending situation, nor over in the main collection of pus, but at a part where the aponeurosis is thinnest, and consequently where the matter has the least re- sistance to overcome in going to the surface of the body. In all such cases the cliief indication is to make an early and a depending opening with a lancet, so as to prevent the extension of the abscess, and to let the matter escape as fast as it is formed. If a spontane- ous opening should have occurred in an unfavourable place, a new aperture must be made in a proper situa- tion ; or if the former should be sufliciently depending and near the principal accumulation of matter, but too small, it must be rendered larger with a curved bis- toury and a director. Whenever any black dead pieces of fascia or tendons present themselves at the opening, they must be taken hold of with a pair of forceps and extracted. APPARATUS. Every thing necessary in the per- formance of an operation, or in the application of dress- ings. The apparatus varies according to circum- stances. Instruments, machines, bandages, tapes, compresses, pledget.s, dossils of lint, tents, sponges, basins of water, towels, «tc. &c. are parts of the a()pa- ratus, as well as any medicinal substances used. It is a rule in surgery to have the apparatus ready before an operation is begun. All preiiarations of this kind should be made, if possible, out of the patient’s room and presence, as they might agitate and render him timid. We have been lately censured by a French surgeon for our* too common neglect of what has been here re- commended. “ In France (observes M. Roux) we are careful not to let a iiatient who is to undergo a serious operation see any of the requisite preparations lor it. ARS ARS 173 Wo haston as mucTi as possible the immediate prepara- tory measures, in order not to prolong unnecessarily the restlessness and moral agitation which the expect- ation of an operation, and sometimes of the slightest one, always produces. These precautions are neglected by the English surgeons, at least by most of those whom 1 saw operate. They even neglect them in pri- vate practice, where, more commonly than in hospitals, we have to deal with pusillanimous individuals, who are easily alarmed, and whose extreme susceptibility it is of importance to spare. It was in the very room where the patient lay, of course under his eyes, that the table and all the necessary instruments for litho- tomy were arranged, at an operation which I saw done in London, during my stay in that capital, by a gentleman at the head of his profession.”— (See Parol- Ule de la Chirurgie Angloise avec la Chirurgie Fran- ioise, p. 105.) M. Roux, in his visit to London, had also too good reason to complain of the slovenly, objectionable prac- tice of leaving the application of the tourniquet and the dressing of the wound, after a surgical operation, to mere novices and students. 1 entirely coincide with him, that, in respect to the dressings in particular, a surgeon is bound to extend his attention and solicitude a little beyond the moment when the operation termi- nates. APPARATUS MINOR; APPARATUS MA.TOR ; APPARATUS ALTUS. Three ways of cutting for the stone.— See Lithotomy.) AQUA PICIS LIQUIDS. DuU. Take of tar two pints ; water a gallon. Mix them with a wooden rod for a quarter of an hour, and after the tar has subsided let the liquor be strained, and kept in well-corked bot- tles. This lotion is often used in porrigo and ulcers surrounded with .scorbutic redness.— (See ARGENTI NITRAS. {Nitrate of silver, lunar caustic.) One of the best caustics Its utility in sti- mulating indolent ulcers, and keeping granulations from rising too high, is well known to every surgeon. Mr. Hunter sanctions the use of the argentum nilra- tum on the first appearance of a chancre, before absorp- tion can be supposed to have taken place. He directs the caustic to be scraped to a point, like a black lead pencil ; so that when it is applied every part of the surface of the chancre may be touched with it ; and he advises the repetition of this process till the last slough which is thrown off leaves the sore florid and healthy. This treatment, when the sore is very small, may sometimes be advisable as a means of lessening the chance of the constitution being infected by absorption. In general, surgeons combine with the plan the mode- rate use of mercury. The important use of the argentum nitratum, in the cure of numerous diseases, we shall have occasion to remark in various articles of this work ; particularly Cornea, ulcers of ; Iris, prolapsus of; Ulcers ; Ure- thra, strictures of, on the subject : “ In a dis- eased bursa, as in a relaxation of the knee-joint, that disease which, with but a little indulgence, a very Uttle encouragement of fomentations, poultices, bleeding, and low diet, would end in whites welling of the knee, may be stopf^ even by so simple a matter as a well-rolled bandage.”— ( Yof. 1, p. 127.) The uniting bandage, or spica descendens, used in rectilinear wounds, consists of a double-headed roller, w'iih a longitudinal slit in the middle of three or four inches long. The roller, h-aving one head passed through the slit, enables the surgeon to draw the lips of the wound together. The wmole must be manag^ so that the bandage may act equally. WTien there are suturesq this bandage supports the stitches, and prevents their tearing through the skin. When the wound is deep, writers advise a compress to be applied on each side, in order to press the deeper part of its sides together W hen the wound is veiy long, two or three bandages should be employed, and great care t£iken that the pressure be perfectly equable. Heister, Henckel, and Richter describe a sort of uniting bandage that allows the surgeon to see the wound, over w'bich only small ligatures cross. This contrivance will be best understood bv reference to an engraved representation of it in RichtePs Elentents, b. 1. W hen we make use of a single-headed roller as a retentive bandage only, w'e should remember always to begin the application of it on the side opposite the wound. The obvious reason for so doing is to prevent a farther separation of the lips of the wound, as the contrary manner of applying the roller would tend di- rectly to divide them.— (GoocA, vol. 1, p. 143.) The intention of the expellent bandage is to keep the discharge sufficiently near the orifice of the wound to prevent the formation of sinuses. In general, a compress of unequal thickness is necessary ; the thin- ner part of the compress being placed next, and imme- diately contiguous to, the orifice of the wound ; the thicker part below. Before the bandage is applied the pus must be completely pressed out, and the rolling be- gin with two or three circular turns on the low'er part o< the compress. The bandage must then be carried spirally upwards, but not quite so tightly as below. It is after- w ard to be rolled downwards to the place where it began. The creeping is a simple bandage, eveiy succeeding turn of which only just covers the edge of the pre- ceding one. It is employed in ca.ses in which the ob- ject is merely to secure the dressings, and not to make any considerable or equable pressure. A bandage is termed compound when several pieces of linen, cotton, or flannel are sewed together in differ- ent directions, or when the bandage is tom or cut so as to have several tails. Such are the T bandage, the sus- peii.sory, the capistrum, &c. The eighteen-tailed bandage is one of the most com- pound. It is now in general use for all fractures of the leg and thigh, sometimes for those of the forearm, and frequently for particular wounds. Its great recom- mendation is the facility with which it can be undone so as to allow the parts to be examined, and its not cre- ating on such an occasion the smallest disturbance of the disease or accident. The eighteeii-tailed bandage consists of a longitudi- nal portion of a common roUer, and a sufficient number of transverse pieces or tails, to cover as much of the part as is requisite. Each of the cross-pieces is to be proportioned in length to the circumference of the part of the limb to w'hich it is to be applied ; so that in making this sort of bandage for the leg or thigh, the upper tails will be tw'ice as Tong as the lower ones. After laving the long part of the bandage on a table, fix the upper end of it in some way or another. Then arrange the tails across it in sufficient number to cover such part of the limb 3LS requires the bandage. Each tail must be long enough tc e.xtend about two inches beyond the oppo- site one, when they are both applied. The tails being all arranged across the longitudinal band, they are to be stitched in this position with a needle and thread. When the bandage is intended for the leg, a piece of the longitudinal part of the roller below is to extend beyond the tails. Tliis is usually brought under the sole of the foot, and then applied over the inner ankle directly after the bandage has been put under the limb. Then the surgeon lays down the first of the lower tails and covers it with the next. In this way he proceeds upwards till all the cross-pieces are applied, the upper- most one of which he fastens with a pin. This band- age has a very neat appearance. The tails are said to lie better when placed across the longitudinal piece a little obliquely.— (Fo«.) The T bandtige is for the most part used for covering parts of the abdomen and back, and esiiecially the scro- tum, periiia-mn, and parts about the anus. Its name is derived from its resemblance to the letter T, and it is, as Mr. John Bell remarks, the peculiar bandage of the body. If the breast or belly be wounded, we make the transverse piece which encircles the body very broad ; and having split the tail part into two portions, one of BAN BEL 179 these is to be conveyed over each side of the neck and pinned to the opposite part of the circular bandage, so as to form a suspensory for the latter, and prevent its slipping down. But, says Mr. John Bell, if we have a wound, or disease, or operation near the groin or pri- vate parts, the tail part then becomes the most impor- tant part of the bandage : then the transverse piece which is to encircle the pelvis is smaller, while the tail part is made very broad. When the disease is in the private parts, perinsum, or anus, we often split the tail according to circumstances ; but when the disease is in one groin we generally leave the tail part of the band- age entire and broad. The scissum Imtmm, or split-cloth, is a bandage ap- plied occasionally to the head, and consists of a central part and six or eight tails or heads, which are applied as follows : When the cloth has six heads, the middle or unsplit part of the cloth is applied to the top of the head. The two front tails go round the temples and are pinned at the occiput ; the two back tails go also round the tem- ples, and are pinned over the forehead ; the two middle tails are usually directed to be tied under the chin ; but, as Mr. John Bell observes, this suffocates and heats the patient, and it is better to tie them over the top of the head or obli 4 uely so as to make pressure upon any particular point.— (Principles Surfer f/,uoZ. l,p. 131.) The old surgeons usually split this middle tail into tw'o parts, a broad and narrow one. In the broad one, they made a hole to let the ear pass through. This broad portion was tied under the chin, while the nar- row ends were tied obliquely over the head. As Mr. John Bell has observed, though this gave the split-cloth the effect of eight tails, yet the ancient surgeons did not name it the split-cloth with eight tails. When they split the cloth into eight tails, and especially when they tied the eight tails in the followdng particular man- ner, they called the bandage cancer, as resembling a Srab in the number of its legs. The cancer, or split- cloth of eight tails, w'as laid over the head in such a manner that four tails hung over the forehead and eyes, while the other four hung over the back of the head. They were tied as follows ; first, the two outermost tails on each side in front were tied over the forehead, while the two middle tails in front were left hanging over the knot. Then the two outermost or lateral tails behind were tied round the occiput. Next the middle tails were tied, the two anterior ones being made to cross over each other and pass round the temples, to be pinned at the occiput ; while the two middle tails be- hind were made to cross each other and pass round the temples so as to be pinned over the ears or near the forehead.— (See John Bell's Principles, vol. 1, p. 132.) The triangular bandage is generally a handkerchief doubled in that form. It is commonly used on the head, and now and then as a support to the testicles when swelled. The French term it couvre-chef en triangle. The nodose bandage, called also scapha, is a double- headed roller, made of a fillet four yards long, and about an inch and a half broad. It must be reversed two or three times, so as to form a knot upon the part which is to be compres.sed. It is employed for the stoppage of hemorrhage, or for securing the compress alter the performance of arteriotorny in the temples. The most convenient bandage for the forehead, face, and jaws, is the four-tailed one, or single split-cloth. It is composed of a strip of cloth about four inches wide, which is to be torn at each end, so as to leave only a convenient portion of the middle part entire. This unspht middle portion is to be applied to the fore- head if the wound be there, and the two upper tails are carried backw’ards and tied over the back part of the head, while the two lower ones are to be ,tied either over the top of the head or under th§ chin, as may seem most convenient. When the wound is on the top of the head, the mid- dle of the undivided part is to be applied to the dress- ings. The two posterior tails are to be tied forwards, and the two anterior ones are to be carried backwards, so as to be tied behind the head. This is sometimes called Galen's bandage. It is curious, that writers ou bandages should use the terms Acad and ZaiZ, synony- mously ; and hence this fonr-tailed bandage is often called the sling with four heads. Such confu.sion of language is highly reprehensible, as it obstructs the comprehension of any, the most simple subject. If the upper lip be cut, and a bandage needed, which M 2- is seldom the case, it is almost superlluous to say, that this bandage will serve the purpose. It serves also in cuts of the lower lip, though in them a!.so we trust rather to the twisted suture than a bandage The single spht-cloth is particularly useful for sup- porting a fractured lower jaw, and in such cases, is the only one employed in modern surgery. This band- age, when used for this particular purpose, namely, supporting the lower jaw, is named capristrum or bri- dle, because it goes round the part somewdiat like a bridle. “ In .some cases (says Mr. John Bell), the circum- stances require us to support the chin particularly, and then the unslit part of the bandage is applied upon the chin with a small hole to receive the point ; but where the jaw is broken, we pad up the jaw-bone into its right shape with compresses pressed in under the jaw, and secured by this bandage. When we are in fear of hemorrhage after any wound or operation near the angle of the jaw, we can give the sling a very remark- able degree of firmness. For this purpose, we tear the band into three tails on each side, and we stitch the bandage at the bottom of each slit, lest it should give way when drawn firm,” «fcc . — {PriiLciples of Sur- gery, vol. 1.) We have already described one way of ajiplying a handkerchief as a bandage to the head, in our notice of the triangular one, or couvre-chef en triangle. The other manner of applying the handkerchief, called the grand couvre-chef, is as follows : You take a large handkerchief, and fold it, not in a triangular, but a square form. You let one edge pro- ject about three finger-breadths beyond the other, in order to form a general border tor the bandage. You lay the handkerchief upon the head, so as to make the lower fold to which the projecting border belongs lie next the head ; while the projecting border itself is left hanging over the eyes till the bandage is adjusted. The two corners of the outermost fold are first to be tied under the chin ; the projecting border is then to be turned back and pinned in a circular form round the face, while the corners of the fold next the head are to be carried backwards and tied. After the outer corners of this bandage have been tied under the chin ; after the inner corners have been drawn out and carried round the occiput ; and after the border has been turned back and pinned ; the doubling of the handkerchief over each side of the neck hangs in a loose, awkward manner. It remains, theretbre, to pin this part of the handkerchief up above the ear as neatly as can be contrived. — (See J. Bell's Principles.) The grand couvre-chef has certainly nothing to re- commend it, either in point of utility or elegance. A common nightcap must always be infinitely preferable to It. In the event, however, of a cap not being at hand, it is proper that the surgeon should know what contrivances may be substituted to fulfil the objects in view. Having, in the numerous articles of this Dictionary, noticed the mode of applying bandages in particular cases, and allotted a few separate descriptions for such bandages as are not here mentioned, but which are of- ten spoken of in books, we shall conclude for the pre- sent with referring the reader for farther information to Rees's CyclopcBdia ; John Bell's Principles of Sur- gery, vol. 1. Diet, des Sciences Med. art. Baiidage. Galen and Vidus Vidius are reckoned tHe best of the old writers mi the subject ; M. Sue, Thillayc, Heister, Juville, Lombard, Bernstein, and J. Bell, of the mo- dem ones. BARK, Peruvian. See Cinchona. BELLADONNA. {Deadly Nightshade.) A power- ful sedative and narcotic. The leaves were first u.sed externally for discussing scirrhous swellings, and they have been subsequently given internally in scirrhous and cancerous diseases, amaurosis, ing leeches with his hand. Bring a leech towards the part whereon you intend to fix it, and as soon as it begins to extend the head to seek an attachment, endeavour that it may affix itself to the place required.” When it evinces no disposition to bite, a little puncture may be made with a lancet, when the animal will fix itself. “ When the patient is fearful of the lancet, and one leech only shall have bit- -ten where several are required, it may be of use to re- 7move it, which is readily done by inserting the nail of fthe finger between its mouth and the skin. The blood then flowing from the orifice will induce the remainder to bite with the greatest avidity. As soon as the leeches are gorged they drop off ; this usually happens within ten or fifteen minutes. Sometimes they remain affixed a considerable time, and become indolent ; but they are quickly aroused froin this state by sprinkling them with a few drops of cold water.” — {Johnson, op. cit. p. 141.) When they fall off, the bleeding may be promoted, if necessary, by fomenting the part. When the bleeding continues longer than is desirable, a slight compress will usually stop it ; but in more troublesome cases the compress must be dipped in brandy or spirits of wine. In young infants the hemorrhage from the bites of leeches has sometimes proved fatal, and the same thing may happen in adults. An example of each fact is related by Beauchene {Gazette de Sant.r, Sept. 1815). When the bleeding is very trouble.somc, Autenrieth advises pieces of charpie to be pushed into the orifices of the bites a method which he assures j us is perfectly effectual.— {Tubinffe?i Blatter, b. 2, st. I,p.57.) In order to make a leech disgorge, it is usual to throw a little salt upon it : in a few seconds the blood is ejected, the leech assumes a coiled form, and is seldom I found fit for use again before the end of (bur or five j days. As salt, however, frequently blisters the leech, | it has been proposed to empty the animal by regular . and uniform pressure ; but though Dr. Johnson consi- j ders this plan better than the other, he admits that it is scarcely practicable without injuring the internal struc- ture of the leech. He says, the best method, and that from which the animal suffers the least inconvenience, is pouring a small quantity of vinegar upon its head. Leeches which have been recently applied should al- ways be kept by themselves, and allowed to retain for their nourishment about one-third of the blood which they extract. For a great deal of valuable information respecting leeches, see Dr. Johnson’s work, the title of which is above specified. When leeches are very scarce, their tails may be snipped off while they are sucking, and the blood will then flow, drop by drop, from the artificial opening, as fast as the animals suck it ; or, with the same view, an incision may be made with a lancet close to the tail. —{Johnson, op. cit. p. 144.) SCARIF1C,\TI0N WITH A LANCET is mostly done in cases of inflamed eyes. An assistant is to raise the upper eyelid, while the surgeon himself depresses the lower one, and makes a number of slight scarifications w'bere the vessels seem most turgid, try- ing particularly to cut the largest completely across. ILL CONSEQUENCES SO.METIMKS FOLLOWING BLEEDING IN THE ARM. 1. Ecchymosis. The most common is the thrombus, or ecchyanosis, a small tumour around the orifice, and occasioned by the blood in.sinuating itself into the adjoining cellular sub- stance at the time when it is flowing out of the vessel. Changing the posture of the arm will frequently hinder the thrombus from increasing in size, so as to obstruct the evacuation of the blood. But, in some instances, the tumour suddenly becomes so large that it entirely interrupts the operation, and prevents it from being finished. In these cases, however, the most effectual method of preventing the tumour from becoming still larger is to remove the bandage. By allowing the bandage to remain, a very considerable swelling may be induced, and such as might be attended with great trouble.’ If more blood be required to be taken away, it ought to be drawn from another vein, and, what is still better, from a vein in the other arm. The best applications for promoting the absorption of these tumours, are those containing spirit, vinegar, or the muriate of ammonia. Compresses wetted with any lotion of this sort may be advantageously put on the swelling and confined there with a slack bandjige. 2. Ivjiammation of the integnments and subjacent cellular substance. According to Mr. Abernethy, the inflammation and suppuration of the cellular substance in which the vein lies, are the most frequent occurrences. On the subsi- dence of this inflammation, the tube of the vein is free from induration. Sometimes the inflammation is ra- ther indolent, producing a circumscribed and slowly suppurating tumour. Sometimes it is more diffused, and partakes of the erysipelatous nature. On other occasions it is phlegmonous. When the lancet has been bad, sb as rather to have lacerated than cut the parts ; when the constitution is irritable, and especially when care is not taken to unite the edges of the puncture, and the arm is allowed to move about, so as to make the two sides of the v ound rub against each other, inflammation will most probably ensue. The treatment of this case consists in keeping the arm perfectly at rest in a sling, applying tlie satur- nine lotion, and giving one or two mild saline purges. When suppuration takes place, a small poultice is the best application. 3. Absorbents inflamed. Sometimes, particularly when the arm is not kept properly quiet after bleeding, swellings make their ap- pearance about the middle of the ann, over the large vessels, and on the forearm, about the mid-space l>e- tween the elbow and wrist, in the integuments covering the flexor muscles. The swelling at the inner edge of the biceps is sometimes as large as an egg. Before such swmllings take place, the wound in the vein often inflames, becomes painful, and suppurates, but without any perceptible induration of the venal tube, either at this time, or after the subsidence of the inflammation. Pain is felt shooting from the orifice in the vein, ia BLEEDING. 189 lines up and down the arm, and upon pressing in the course of this pain, its degree is increased On ex- amining the arm attentively, indurated absorbents may be plainly felt, leading to the tumour at the side of the biceps muscle. The pain and swelling often extend to the axilla, where the glands also sometimes enlarge. Cord-iike substances, evidently absorbents, may sometimes be felt, not only leading from the puncture to the swelling in the middle of the arm, but also from this latter situa- tion up to the axillary glands, and from the wound in the vein down to the enlarged glands at the mid-space between the eibow and wrist, over the flexor mus'^les of the hand. The enlarged glands often proceed to suppuration, and the patient suffers febrile symptoms. It may be suspected that the foregoing consequences arise from the lancet being envenomed, and from the absorption of the viruient matter ; but the frequent descent of the disease to the inferior absorbents militates against this supposition. When the absorbents become inflamed, they quickly communicate the affection to the surrounding cellular substance. These vessels, when indurated, appear like small cords, perhaps of one-eighth of an inch in diameter : this substance cannot be the slender sides of the vessels, suddenly increased in bulk^ but an in- duration of the surrounding cellular substance. The inflammation of the absorbents, in consequence of local injury, is deducible from two causes : one, the absorption of irritating matter ; and the other, the effect of the mere irritation of the divided tube. When viru- lent matter is taken up by the absorbents, it is generally conveyed to the next absorbent gland, where its pro- gress being retarded, its stimulating qualities give rise to inflammation, and, frequently, no evident disease of the vessel through which it has passed can be dis- tinguished. When inflammation of the absorbents happens, in consequence of irritation, the part of the vessel nearest the irritating cause generally suffers most, while the glands, being remotely situated, are not so much in- flamed. The treatment of the preceding case consists in keeping the arm perfectly quiet in a sli'ng, dressing the puncture of the vein with any mild simple salve, cover- ing the situation of the inflamed lymphatics with linen wet with the saturnine lotion, and giving some gently purging medicine. When the glandular swelHngs suppurate, poultices should be applied, and if the matter does not soon spon- taneously make its way outwards, the surgeon may open the abscess. — (See Abernethy's Essays on this subject.) 4. Inflammation of the Vein. When the wound does not unite, the vein itself is very likely to inflame. This affection will vary in its degree, extent, and progress. One degree of inflam- mation may only cause a slight thickening of the venal tube, and an adhesion of its sides. Abscesses, more or less extensive, may result from an inflammation of greater violence, and the matter may sometimes be- come blended with the circulating fluids, and produce dangerous consequences, or the matter may be quite circumscribed, and make its way to the surface. When the vein is extensively inflamed, a good deal of sympa- thetic fever is likely to ensue, not merely from the ex- citement which inflammation usually produces, but also from the irritation continued along the membra- nous lining of the vein towards the heart. If, how- ever, the excited inflammation should fortunately pro- duce an adhesion of the sides of the vein to each other at some little distance from the wounded part, this ad- hesion will form a boundary to the inflammation, and prevent its spreading farther. The effect of tlie adhe- sive inflammation in preventing the extension of in- flammation along membranous surfaces, was origin- ally explained by Mr. Hunter. In one case Mr. Hunter applied a compress to the inflamed vein above the wounded part, and he thought that he had thus suc- ceeded in producing an adhesion, as the inflammation was prevented from spreading farther. When the in- flammation does not continue equally in both directions, but descends along the course of the vein, its extension in the other direction is probably prevented by the ad- hesion of the sides of the vein to each other.— (See Obs. on the Inflammation of the internal coats of Veins, in Trans, of a Soc. for the Improvement of Med. and Chir. Knowledge, vol. I, p. 18, <^c.) More information on this subject will be found under the head of Veins. Mr. Abernethy ■mentions his having seen only three cases in which an inflammation of the vein succeeded venesection. In neither of these did the vein suppu- rate. In one about three inches of the venal tube in- flamed, both above and below the puncture The in- teguments over the vessel were very much swollen, red, and painful, and there was a good deal of fever, with a rapid pulse and furred tongue. The vein did not swell when compressed above the diseased part. In another instance, the inflammation of the vein did not extend towards the heart, but only downwards, in which direction it extended as far as the wrist. The treatment is to lessen the inflammation of the vein by the same means which other inflammations re- quire, and to keep the affection from spreading along the membranous lining of the vessel towards the heart, by placing a compress over the vein a little w'ay above the puncture, so as to make the opposite sides of the vessel adhere together. Mr. Abernethy conceives a case possible in which the vein may even suppurate, and a total division of the vessel be proper, not merely to obviate the exten* sion of the local disease, but to prevent the pus from becoming mixed with the circulation. Were such a proceeding deemed right, I think Mr. Bmdie’s method of cutting the vessel would be best. However, I have never heard of any case in which the practice has been adopted. As for the scheme of tying the vein above the diseased part of it, the severe effects fre- quently following this method must, as Mr. Dunn has reminded me, render it iess eligible than an incision. In the case of an inflamed vein. Dr. Chapman states that nothing is so efficacious as blisters ; a practice said to have been first suggested by Dr. Phy sick.— (See a fatal case of Inflammation of the vessel from Vene- section, in Philadelphia Journ. Feb. 1824.) I was lately favoured by Mr. Howship with a view of the state of the parts in a case where a lady had died after an inflammation of the veins of the arm, brought on by venesection : they were considerably thickened, and in some cases quite soiid and impervious. — (See Terns.) 5. Inflammation of the Fascia of the Forearm, or dif- fuse inflammation of the cellular membrane. Sometimes, in consequence of the inflammation arising from the wound of the lancet in bleeding, the arm becomes very painful, and can hardly be moved. The puncture often remains unhealed, but without much inflammation of the surrounding integuments. The forearm and fingers cannot be extended without great pain. The integuments are sometimes affected with a kind of erj'sipelas ; being not very i»ainful when slightly touched, but when forcibly compressed, so as to affect the inferior parts, the patient suffers a good deal. The pain frequently extends towards the axilla and acromion ; no swelling, however, being percepti- ble in either direction. These symptoms are attended with considerable fever. After about a week, a small superficial collection of matter sometimes takes place a little below the internal condyle : this being opened, a very little pus is discharged, and there is scarcely any diminution of the swelling or pain. Perhaps, after a few days more, a fluctuation of matter is distinguished below the external condyle ; and this abscess being opened, a great deal of matter gushes from the wound, the swelling greatly subsides, and the patient^s fottrre sufferings are comi)aratively trivial. The last opening, however, is often inadequate to the complete discharge of the matter, which is sometimes originally formed beneath the fascia, in the course of the ulna, and its pointing at the upper part of the ann depends on the thinness of the fascia in this situation. The collection of pas descends under the lower part of the detached fascia, and a depending opening for its discharge becomes necessary. This being made, the patient soon gets well. In these cases the vein is not inflamed ; but some- times the glands of the armpit and just above the elbow swell. The integuments are not much affected, and the patient complains of a tightness of the foreann. Matter does not always form, and the pliability of the arm after a good while gradually returns again. Mr. Watson relates a case wliich was Ibllowed by a 190 BLE BLE permanent contract ion of the forearm. Mr. Abernethy is of opinion that a similar contraction of the forearm, from a tense state of the fascia, may be relieved by detaching the fascia from the tendon of the biceps, to which it is naturally connected. Mr. Watson seems to have obtained success in his first case by having cut this connexion. In the treatment of an inflammation of the fascia, or of an extensive quantity of the cellular membrane, in consequence of venesection, general means for the cure of inflammation should be employed, especially nume- rous leeches, cupping, purgatives, &c. The limb should be kept quiet, and the inflamed part relaxed. As soon as the inflammation abates, the extension of the forearm and fingers ought to be attempted and daily performed, to obviate the contraction which might otherwise ensue. Mr. C. Bell objects to calling the affection an inflam- mation of the fascia, because he sees no proof of this part being inflamed ; and he conceives that the symp- toms proceed from the iHflammation spreading in the cellular membrane and passing down among the mus- cles and under the fascia. On this point I believe him to be quite correct, and that the disorder partakes of the character of diffuse inflammation of the cel- lular membrane so well described by Dr. Duncan. — (See Edin. Med. Chtr. Trans, vol. 1.) To this subject, however, I shall return in the article Erysipelas. The fascia acts as a bandage, and from the swelling of the parts beneath it binds the arm, but is not itself in- flamed and contracted. When necessary to divide the fascia, Mr. Charles Bell thinks it would be better to begin an incision near the inner condyle of the hume- rus, and to continue it some inches down the arm, rather than perform the nice if not dangerous opera- tion of cutting thp fascia at the point where the expan- sion goes off from the round tendon of the biceps. When the elbow-joint and forearm continue stiff after all inflammation is over, Mr. C. Bell recommends fric- tions with camphorated mercurial ointment, &c., and the arm to be gradually brought into an extended state by placing a splint on the forepart of the limb, — \Ope- rative Surgery, vol. 1, p. 65.) • 6. Ill Consequences of a Wounded Nerve. Mr. Pott used to mention two cases in which the patients suffered distracting pains, followed by con- vulsions and other symptoms, which could only be as- cribed to nervous irritation, arising from ^i partial divi- sion of the nerve, and he recommended its total divi- sion, as a probable remedy. Dr. Monro related simi- lar cases in which such treatment proved successful. Hence, it is highly necessary to know the charac- teristic symptoms of the case, particulariy, as all the foregoing cases would be exasperated by the treat- ment just now alluded to. It is to Mr. Abernethy that we are indebted for several valuable remarks elucidat- ing this subject. He informs us, that the two cutane- ous nerves are those which are exposed to injury. Most frequently all their brain hes pass beneath the veins at the bend of the arm ; but sometimes, although the chief rami go beneath these vessels, many small filaments are detached over them, which it is impossi- ble to avoid wounding in phlebotomy. Mr. Abernethy thinks the situation of the median nerve renders any injury of it very unlikely. If, how- ever, a doubt should be entertained on this subject, an attention to symptoms will soon dispel it. When a nerve is irritated at any part between its origin and termination, a sensation is felt as if some injury were done to the parts which it supplies. If, therefore, the cutaneous nerves were injured, the integuments of the forearm would seem to suffer pain ; if the mediau nerve, the thumb and next two fingers would be pain- fully affected. What are the ills likely to arise from a wounded nerve ? If it were partially cut, would it not, like a tendon or any other substance, unite 1 It seems pro- bable that it would do so, as nerves as large as the cu- taneous ories of the arm are very numerous in various situations of the body, and are partially wounded in operation.s, without any peculiar con.sequences usually ensuing. The extraordinary pain sometimes experi- enced in bleeding, may denote that a cutaneous nerve is injured. The situation of (he nervous branches is such, that they must often be partially wounded in the operation, though they probably unite again, in almost all cases, without any ill consequences. Yet, says Mr. Abernethy, it is possible that an inflammation'cf the nerve may accidentally ensue, which would be aggravated if the nerve were kept tense, in conse- quence of its partial division. The disorder, he thinks, arises from inflammation of the nerve in common with the other wounded parts. This gentleman supposes, rtiat an inflamed nerve would be very likely to commu- nicate dreadful irritation to the sensorium, and that a cure would be likely to arise from intercepting its communication with that organ. I'he general opinion is, that the nerve is only par- tially divided, and that a complete division would bring relief. Mr. Pott proposed enlarging the original orifice. It is possible, however, that the injured nerve may be under the vein, and if the nerve be inflamed, even a total division of it at the aflected part would perhaps fail in relieving the general nervous irritation, which the disease has occasioned. To intercept the communication of the inflamed nerve with the senso- rium, however, promises perfect relief. This object can only be accomplished by making a transverse inci- sion above the orifice of the vein. The incision need not be large, for the injured nerve must lie within the limits of the original orifice, and it need only descend as low as the fascia of the forearm, above which all the filaments of the cutaneous nerves are situated. As the extent of the inflammation of the nerve is un- certain, Mr. Abernethy suggests even making a divi- sion of the cutaneous nerve still farther from the wound made in bleeding. Examples are recorded, in which not only extraor- dinary pain was occasioned by the prick of the lancet, but erysipelas of the skin, ending in gangrene of the whole limb, and the death of the patient.— (/i/c^ierand, Nosogr. Chir. t. 2, p. 390, ed. 2.) A ca.se in which the greater part of the integuments of the arm had been destroyed by erysipelas thus produced, I once saw un- der the care of Mr. Vincent, in St. Bartholomew’s Hos- pital. In former times, it was customary to refer many of the bad symptoms occasionally following venesection to a puncture of the tendon of the biceps ; but this doctrine is now in a great measure renounced, the ex- periments of Haller having completely proved that tendons and aponeuroses are, comparatively speaking, parts endued with little or no sensibility. In the foregoing account, the various ill conse- quences occasionally arising from venesection are re- presented separately : no doubt, in some cases, they may occur together. See R. Butler'. ‘i Essay concerning Blood-letting, 4-c. Hoo. Bond- 1734. J\l. Martin, Traile de la Phlebuto- niieetde I'Jlrteriofonne, 8uo. Paris, 1741. Quesnapy Trnite des F.ffets et de I' Usage de la Saignee, l2mo. Pans. Ci. Vieusseux, Dela Saignee, etde son Usage dans laphtpart des Maladies, 8vo. Pans, 1815. J. J. Walbauvi, De Venasectione, Gott. 1749. {Haller, Di.sp. Chir. 5, 477.) B. Bell's System of Surgery. E.ssay on the ill Consequences sometimes following Venesection, by J. Mernethy. R. Carmichael on Va- rix and Venous Inflammation, in Trans, of .^ssoc. Physicians, vol. 2. Duncan on Diffuse Inflammation of the Cellular Membrane, in Edin. Med. Chir. Trans, vol. 1. Medical Communications, vol. 2. Richerand, Nosogr. Chir. t. 2,p. 416, edit. 4. J. Hodgson on the Diseases of Jlrteries and Veins, Svo. J.,ond. 1815. B. Travers, in Surgical Essays, part l,8i'o. Land. 1818. Chapman, in Philadelphia .Journ. Feb. 1824. Freteau, sur r Eniploi des EinDsiovs Sanguines, 6rc. 8vo. Pa- ris, 1816. Mapleson on the Jirt of Cupping, 12m<;. Dond. 1813; and Dr. J. R. .Tohnson's valuable Trea- tise on the Medicinal J^eech, including its Medical and Natural History, with a description of its .Anatomi- cal Sti'uctiire, and Remarks upon the Diseases, Preser- vation, and Management of Beeches 8t'o. Bond. 1816. BLEEDING. See Heviorrhage and Arteries. BLENORRHAGIA, or Blenorrhuco. (From fiXevva, mucus, and piw, to flow.) A discharge of mucus. Swediaur. who maintains that gonorrhcea is attended with a mucous, and not a purulent discharge prefers the name of blenorrhagia for the disease. However, in treating of gonorrheea, we shall find, that this last appellation is itself not altogether free from objec- tions. BLEPIIAROPTOSIS. (From |3>f(/>«pov, the eyelid, and rrrwo-is, a falling down.) Called also ptosis. Au inability to raise the upper eyelid.— (See Ptosis.) BLI BOU 191 BLEPHAROTIS. An inflammation of the eyelids. BLINDNESS. This is an effect of many diseases of the eye. See particularly, AmaMr-OA'ts; Cafaraci ; Cornea, opacities of; Glaucoma; Gutta Serena, Hy dr ophthalmia ; Leucoma ; Ophthalmy ; Pterygium ; Pupil, closure of ; Staphyloma, A c. BLISTERS. Applications which, when put on the skin, raise the cuticle in the form of a vesicle, filled with a serous fluid. Various substances produce this effect ; but the powder of cantharides is what ope- rates with most certainty and expedition, and is now invariably made use of for the purpose. The blister plaster is thus composed : if. Cantharidis inpulv. sub- tillissimum tritas tbj. Emplastri ceres, Ibiss. Adipis presp. ibss. The wax plaster and lard being melted, and allowed to become nearly cold, the powdered can- tharides are afterward to be added. When it is not wished to maintain a discharge from the blistered part, it is sufficient to make a puncture in the cuticle to let out the fluid ; but when the case requires a secretion of pus to be kept up, the surgeon must remove the whole of the detached cuticle with a pair of scissors, and dress the excori- ated surface in a particular manner. Practitioners used formerly to mix powder of cantharides with an ointment, and dress the part with this composition. But such a dressing not unfrequently occasioned very painful affections of the bladder, a scalding sensation in making water, and most afflicting stranguries. An inflammation of the bladder, ending fatally, has been thus excited. The treatment of such complaints con- sists in removing every particle of cantharides from the blistered part, w'hich is to be well fomented, and administering freely mucilaginous drinks. Camphor is now suspected to prove more hurtful than useful. These objections to the employment of salves, con- taining cantharides, for dressing blistered surfaces, led to the use of mezereon, euphorbium, and other irritat- ing substances, which, when incorporated* with oint- ment, form very proper compositions forkeepingblisters open, without the inconvenience of irritating the bladder. The favourite application, however, for keeping open blisters is the powder of savine, which was brought into notice by Mr. Crowther, in the first edition of his book on the White Swelling. He was led to the trial of different escharotic applications in the form of ointment, in consequence of the minute attention which caustic issues demand ; and, among other things, he was induced to try powdered savine, from observ- ing its effects in the removal of warts. Some of the powder was first mixed with white cerate, and applied as a dressing to the part that had been blistered ; but the ointment ran off, leaving the powder dry upon the sore, and no effect was produced. Mr. Crowther next inspissated a decoction of savine, and mixed the ex- tract with the ointment, which succeeded better, for it produced a great and permanent discharge. At last, after various trials, he was led to prefer a preparation analogous to the unguent um sambuci P. L. The fol- lowing formula answers every desirable purpose ; R. SahincB recemtis contuses IbiJ. Ceres faces ib]. Adi- pis suilleb Ibiv. Adipe et cera liqucfeicta, incoque sabinam et cola. The difference of this formula from that which Mr. Crowther published in 1797, only consists in using a double proportion of the savine leaves. The ceratum sabinae of Apothecaries’ Hall, he says, is admirably made : the fresh savine is bruised with half the quan- tity of lard, which is submitted to the force of an iron press, and the whole is added to the remainder of the lard, which is boiled until the herb begins to crisp; the ointment is then strained off, and the proportion of wax ordered, being previously melted, is added. On the use of the savine cerate, immediately after the cuticle raised by the blister, is removed, it should be observed, says Mr. Crowther, that experience has proved the advantage of using the application lowered by a half or two-thirds of the unguetitum ceraj. An attention to this direction will produce less irritation and more discharge, than if the savine cerate were used in its full strength. He found fomenting the part with flannel wrung out of warm water, a more easy and preferable way of keeping the blistered sur- face clean, and fit for the impression of the ointment, than scraping the part, as has been directed by others. An occasional dressing of the unguentum resinaj flavae, he found very useful in rendering the sore free from an appearance of slough, or rather dense lymph, which is sometimes so firm in its texture, as to be separated by the probe with as much readiness as the cuticle is detached after blistering. As the discharge diminishes, the strength of the savine dressing should be propor- tionally increased. The ceratum sabim* must be used in a stronger or w'eaker degree, in proportion to the excitement produced on the patient’s skin. Some re- quire a greater stimulus than others for the promotion of the discharge, and this can only be managed by the sensations which the irritation of the cerate occasions. Mr. Crowther tried ointments containing the flowers of the clematis recta, the capsicum, and the leaves of the digitalis purpurea. The first two produced no ef- fect ; the last was very stimulating. He also tried caustic potassa mixed with spermaceti cerate, in the proportion of one drachm to an ounce ; it proved very stimulating, but produced no discharge. One grain of the oxymuriate of mercury, blended with two ounces of the above cerate, proved so intolerably painful, that at the end of two hours it became necessary to remove the dressing; and the patient was attacked with a se- vere ptyalism. — {Practical Obs. on the White Swelling, ■V c. 2d ed. 1808.) Instead of keeping a blister open, it is frequently a judicious plan to renew the application of the emjihis- trum cantharidis, after healing up the vesication first produced, and to continue in this manner a succession of blisters, at short intervals, as long as the circum- stance of the case may demand. Where the skin is peculiarly irritable, and particularly in young chil- dren, where the emplastrum cantharidis sometimes acts so violently as to produce sloughing, or, in any cases, where the plaster produces strangury and irri- tation of the urinary organs, I am informed, that the inconvenience may be avoided, and the cuticle raised very well, if a piece of silk paper be interposed be- tween the plaster and the integuments. Dr. A. T. Thomson recommends for the same purpose a piece of thin gauze wet with vinegar, and applied smoothly and closely over the plaster. — {Dispensatory, p. 717, ed. 2.) For infants, a proportion of opium has sometimes been added to the plaster, in order to render its action less violent ; a proposal made, I believe, by the late Mr. Chevalier. Others recommend the plan of not letting the blister continue so long applied to children as to other patients. — (See Paris’s Pharmacologia, vol. 2, p 186, ed. 5.) BOIL. See Furunculus BONES, iJiseases of. See .Untrnm, Caries, Exos- tosis, ./onits, ATollilies, JVecrosis, Osteosarcoma, Rick- ets, and Venereal Disease. The following works re lative to the pathology of the bones, deserve notice F. C. Spoendli, De bensibilitate Ossiniu Alorbosa, 4to. Gott. 1814. ji. Murray, De Sensibilitate Ossium Mor- bosa {Lndw. Script. Metir. 4). O. Murray, Diss. Acad, de Sensibilitate Ossium Morbosa. Frank. Del Op. 12. J. G. Sturmins, De Vulneribus Ossium HelmsL. 1743. A. Bunn, Pab. Ossium Morbosorum prescipue Thesauri Huviani, fol. Amst, 1785 — 1788. C. F. Clossius, veher die Krankheitcn der Knorhen, 12f«o. Tubing. 1799. A. G. Maumanu, lie Ostitide, 4to. Lips. 1818. R. ATesbitt, Human Osteogeny ; two I.,ec- tures on the Mature of Ossification, 8oo. Load. 1736. Siandifort, Aiuseum Anntomicum Lugduno Batavee Descriptum, 2 vol. fol. Lugd. 1793. Weidmann, De Mecrosi Ossium, fol. Francof. 1793. Brodie on Dis- eases of Joints, Svo. Lund. 1818. Howship, in Aled. Chir. Trans. Dr. Cumin, in Edin. Med. and Surgical .hrurn Mo. 82 ; and various other publications speci- fied at the end. of the article Mecrosis. BOUGIE is a smooth flexible instrument which is introduced into the urethra for -the cure of diseases of that passage 'see Urethra) ; and is .so named from its generally containing wax in its composition, and bear- ing some resemblance to a wax taper, in French, bou- gie. However, the kinds of bougies are various, and some of them employed in modern surgery, so far from having any similitude to a wax taper, are formed altogether of metal. They admit of being divided into those which are solid, and others which are hollow, and are more commonly named catheters. — (See Ca- theter.) The exact period when bougies were first used, is a doubtful jioint in the history of surgery. By Andrew Lacuna, a Spanish physician, the invention is ascribed to a Portuguese empiric ; and in 1551, the same author 192 BOUGIE, published what had been communicated to him upon this subject. In the year 1554, Amaius Lusitanus pub- lished a work, in which he refers to several witnesses to prove, that the empirical practitioner above alluded to, had learned from him the use of bougies, while, on the other hand, he candidly owns, that he himself was indebted to Aldereto, of Salamanca, for a knowledge of these instruments. In 1553, however, Alph. Ferri, of Naples, endeavoured to show, that his acquaintance with the utility of bougies reached as far back as 1548, and, of course, that he had anticipated Lacuna, and per- haps even Aldereto. But, instead of representing him- self as the original inventor of bougies, he mentions that they were known to Alexander of Tralles, which, if true, carries back the invention to the sixth century. A. Ferri, also before describing bougies and escharotic ointments, mentions various means of examining the state of the urethra, and, among other things, cylin- ders made of flexible lead and of dilferent sizes. Es- charotic ointments for what were termed carnosities of the urethra, and bougies, were also described by Petro- nius in 1565, and afterward by A. Pare. The oldest bougies, which were wicks of cotton or thread, covered with wax and escharotic plasters, were in time suc- ceeded by those composed of linen smeared with wax. This change was made with the view of letting them have a hollow construction; an improvement which was first noticed by Fabricius ab Aquapendente. — (Op. Chir. 1617.) In the middle of the ITth century, the manner of making and using bougies was -tv’eU known to Scul- tetus, as appears from his Armamentarium Chirurg. tab. U,Jig. 9, 10. The malting of bougies has now become so distinct a trade, that it may be considered superfluous to treat of the subject in this Dictionary. However, though a surgeon may not actually choose to take the trouble of making bougies himself, he should understand how they ought to be made. Swediaur recommends the following composition ; R. Cerae flavae Ibj. Spennatis ceti 3 iij. Cerussae acetatae 3 v. These articles are to be slowly boiled together, till the mass is of proper consistence. Mr. B. Bell’s bougie plaster is thus made : B;. Emplastri lythargyri \ iv. Cerae fla\ a 3 iss. Olei olivae 3 iij. The last two ingredients are to be melted in one vessel and the litharge plaster in another, be- fore they are mixed. In Wilson’s Pharmacopoeia Chi- rurgica, I observe this formula ; B. Olei olivae tbiss. Cerae flavae tbj. Minii ibiss. Boil the ingredients to- gether over a slow fire till the minium is dissolved, which will be in about four or six hours. The compo- sition for bougies is now very simple, as modern sur- geons place no confidence in the medicated substances formerly extolled by Daran. The linen, which may be considered as the basis of the bougie, is to be im- pregnated with the composition, which is generally wax and oil, rendered somewhat firmer by a proportion of resin. Some saturnine preparation is commonly added, as the urethra is in an irritable state, and the mechanical irritation might otherwise increase it. Of w'hatever composition bougies are made, they must be of different sizes, from that of a knitting-kneedle to that of a large quill, and even larger. Having spread the composition chosen for the purpose on linen rag, cut this into slips from six to ten inches long, and from half an inch to an inch or more in breadth. Then dex- terously roll them on a glazed tile into the proper cylin- drical form. As the end of the bougie, which is 'first introduced into the urethra, should be somewhat smaller than the rest, the slips must be rather nar- row’er in this situation, and when the bougies are rolled up, that side must be outwards on which the plaster is spread. Daran and some of the older writers, attributed the efficacy of their bougies to the composition u.sed in forming them. On the contrary, Mr. Sharp appre- hended that it was chiefly owing to the pressure whicii was made on the affected part; and Mr. Aikin adds, that as bougies of very differeni compositions succeed equally well in curing the same diseases in the ure- thra, it is plain that they do not act from any peculiar qualities in their composition, but by means of some common property, probably their mechanical fonn. As the healthy as well as the diseased parts are ex- posed to the effects of bougies made of very active ma- terials, modern surgeons always prefer such as are made of a simple unirritating composition. Plenck recommended bougies of catgut, which may be easily introduced into the urethra, even when it is greatly contracted, their size being small, their sub- stance firm, and dilatable by moisture. It is objected to catgut, however, that it sometimes expands beyond the stricture, and gives great pain on being withdrawn. Formerly, catgut bougies were sometimes coated with elastic gum, a valuable material, of which I shall next speak. The invention of elastic bougies and catheters origin- ated with Bernard, a silversmith at Paris, who in the year 1779 presented some instruments of this kind to the Academy of Surgery, which period was prior to the claim made by Professor Pickel of Wurzburg to the discovery. — (See Jourti. de Med. an 1785.) For the composition of bougies, elastic resin or gum is thought to be very desirable, as it unites finnness and flexibility. Mr. Wilson, m \i\sPharmacopceia Chi- mrgica, is inclined to think that the ait of making these instruments consists in finding a suitable solvent for the Indian gum. As this substance, if dissolved in ether, completely recovers its former elasticity upon the evaporation of this fluid, it is supposed that ether, though rather too expensive, would answer. I find it positively asserted, however, in a modem work of great repute, that the idea of elastic gum being the substance really employed is a mistake, as the material used is nothing more than linseed oil boiled for a considerable time, and used as a varnish for the silk, linen, or cotton tube. — (See Diet, des Sciences Mai. art. Bougie.) Very cheap and good elastic gum bougies are made by Feburier, No. 51 Rue du Bac, at Paris, who has twelve different sizes. His elastic gum catheters are also well made, though for smoothness and regularity 1 think they are not equal to some which are now^ con- structed in London : but I believe Feburier’s smallest size is rather less than any w hich are made in this city; an ads’antage which no doubt our artists will soon be able to give their productions. This ingeni- ous mechanic does not employ catgut in the composition of the elastic gum bougies, for which he is so cele- brated. These bougies are most excellent when you can get them to pass ; for they dilate the stricture with the least possible irritation. But sometimes they can- not be introduced when a wax bougie can ; and from the trials which I have made of them. 1 conceive this arises from their elasticity and continual ten- dency to become straight when they reach the pe- rinaeum. so that the point presses on the lower surface of the urethra. Hence, when the obstruction is on that side, it must be verj' difficult to get the end of the bougie over it. A few years ago, Mr. Smyth discovered a metallic composition of which he formed bougies, to which some practitioners impute very superior qualities. These bougies are flexible, have a highly polished sur- face of a silver hue. and possess a sufficient degree of firmness for any force necessary in introducing them for the cure of strictures of the urethra. The advocates for the metallic bougies assert, that such instruments exceed any other bougies which have yet been invented, and are capable of succeeding in all cases in which the use of a bougie is proper. They are either solid or hollow, and are said to answer extremely welt as ca- theters; for they not only pass into the bladder with ease, but may also be continued there for any conve- vient space of time, and thus produce essential benefit. — (U'. Smyth, Brief Essay on the Advantages of Flex- ible Metallic Bougies, 8vo. Lond. 1804.) The greatest objection which has been urged against them is, that they are attended with a risk of breaking. I have heard of an eminent surgeon being called upon to cut into the bladder, in consequence of a metallic bougie having broken, and a piece of it passing into that or- gan, where it became a cause of the severe symptoms which are commonly the effect of a stone in the blad- der. For the particulars of an interesting case, in which a metallic bougie broke in the urethra, the read- er may consult London Med Repository, vol. 9, No. 51. The manufacture of metallic bdhgies, however, is now brought to such perfection, that though they are used to a great extent in modem practice, we rarely hear of their breaking ; but it is most prudent not to be too bold with those of small diameter. The bougie, with its application, says Mr. Hunter, is perhaps one of the greatest improvements in surgery BRO BRO 193 which these last thirty or forty years have produced. “ When I compare the practice of the present day with what it was in the year 1750, I can scarcely be persuaded that I am treating the same disease. I re- member, when about that time I was attending the first hospitals in the city, the common bougies were either a piece of lead or a small wax candle ; and although the present bougie was known then, the due preference was not given to it nor its particular merit understood, as we may see from the publications of that time.” Daran was the first who improved the bougie and brought it into general use. He wrote professedly on the diseases for which it is a cure, and also of the manner of preparing it ; but he has introduced much absurdity into his descriptions of the diseases, the modes of treat- ment, and the poAvers and composition of his bougies. When Daran published his observations on the bou- gie, every surgeon tried to discover the composition, and each conceived that he had found it out, from the bougies which he composed producing the effects de- scribed by Daran. It was never suspected, that any extraneous body of the same shape and consistence would do the same thing. — (See A IVeatise on the Fe- nertal Disease, p. IIG. Sharp's Critical Inquirxy,, ch. 4. Aikin on the External Use of Lead. Daran, Obs. Ckir. sur les Maladies de U Uretre, Vimo. Paris, 1748 and 1768. Olivier, Lettre dans laquelle on demontre les avantages que I’on peat retirer de I'usage des bou- gies creases, S,-c. Sec. Paris, 1750. Desault, Journ. de Chir. t. 2, p. 375, and t. 3, p. 123, 1792. Smijlh's Brief Essay on Flexible Metallic Bougies, 8vo. Loud. 1804. Diet, des Sciences Medicates, t. 3,».265, Src.8vo. Pa- ris, 1812.) Of armed bougies, as well as of some other kinds, and of the manner of using bougies in general, I shall speak in the article Urethra, Strictures of. BRAIN. For concussion, compression of, &c., see Head, Injuries of. For the hernia of, see Hernia Ce- rebri. BREAST. See Mammary Abscess ; Mamma, Re- moval if; Cancer, Src. BRONCHOCELE. (From ^p(5y%of, the windpipe, and KtiXy, a tumour.) The Swiss call the disease gotre or goitre. Heister thought it should be named tra- cheocele. Prosser, from its frequency in the hilly parts of Derbyshire, called it the Derbyshire neck; and not satisfied respecting the similitude of this tumour to that observed on the necks of women on the Alps, the Eng- lish Bronchocele. By Alibert the disease is called Thy- rophraxia. 1. The .simple bronchocele or thyrophraxia is the most common form of the disease, and is a mere en- largement of the thyroid gland. The integuments covering the part are quite unchanged. Women are observed to be more subject to it than men. It is also well known to be in general free from danger, the office of the thyroid gland not being of stich import- ance in the animal economy as to be essential to the continuance of life. Alibert has seen one example in which the tumour became cancerous, and destroyed the mother of a family. 2. The compound bronchocele is that which pre.sents the greatest variety, and astonishes every beholder. Sometimes a more or less voluminous cyst is formed round it, filled with a pultaceous or purulent matter. Sometimes in compound bronchoceles, calcareous and other heterogenous substances are found. In tAvo cases Alibert found on the outside of the enlarged gland a yellow fatty mass ; and in a third instance the gland itself formed a true sarcoma. —(iVo.s;o/o^ie Naturelle, t. \,p. 464, folio, Paris, 1817.) The term bronchocele always signifies in this country an enlargement of the thyroid gland, Avhicli, with the di.sease of the surrounding parts, sometimes not only occupies all the space from one angle of the jaw to the other, but forms a considerable projection on each side of the neck, advancing forwards a good way beyond the chin, and forming an enormous mass, Avhich hangs down over the chest. The swelling, which is more or less unecjual, in general has a soft, spongy, elastic feel, esiKicially when the disease is not in a very advanced state; but no fluctuation is usually perceptible, and the part is exceedingly indolent. The skin retains nearly us ordinary colour ; but when the tumour is of very long standing and great size, the veins of the neck be- come more or less varicose. VoL. I.-N According to Prosser, the tumour generally begins between the eighth and twelfth years. It enlarges sloAvly during a few years ; but at last it augments rather rapidly, and forms a bulky jiendiilous tumour. Women are far' more subject to the disease than men. and the tumour is observed to be particularly apt to in- crease rapidly during their confinement in childbed. Sometimes bronchocele affects the whole of the thyroid gland, that is to say, the two lateral lobes and the in tervening portion ; and it is in this kind of case, that it is not unusual to remark three distinct swellings, for the most part of unequal size. Frequently only one lobe is affected ; while in many other cases the three portions of the thyroid gland are all enlarged and so con- founded together, that they make, as it Avere, only one connected globular mass. Finally, in some dissections the thyroid gland has been found quite unchanged, the Avhole of the tumour having consisted of a sarcomatous disease of the adjacent lymphatic glands and cellular membrane. — {Postiglione, p. 21.) When only one lobe of the thyroid gland is affected, it may extend in front of the carotid artery, and be lifted up by each diastole of this vessel, so as to have the pulsatory motion of an aneurism. — (A. Burns's Surgical Anatomy of the Head and Neck, p. 195, and Parisian Chirurgical Journ. vol. 2, p, 292, 293.) Alibert believes that he first made the remark that the right lobe was more fre- quently enlarged than the left. — {Nosol. Nat. t. 1, p. 465.) The same thing was invariably noticed in every case seen by Mr. Rickwood in the neighbourhood of Horsham in Sussex.— (See Med. and Phys. Journ. for Aug. 1823.) The ordinary seat of bronchocele, as Flajani remarks, is the thyroid gland ; but sometimes cysts are formed in the cellular membrane. — {Collez. d’Oss. t. 3, p. 277.) And Postiglione also observes, that the sAvelling is sometimes encysted, and filled with matter of various degrees of consistence, resembling honey, &c. ; in some cases it is emphysematous, or filled with air ; and in other instances it is sarcomatous, having the consistence of a gland, which is enlarged, but not scirrhous. These different characters prove, says he, that the treatment ought not to be the same in all cases. — {Memoria suUa Natura del Gozzo, p. 20.) Bronchocele is common in some of the valleys of the Alps, Apennines, and Pyrenees. Indeed, there are certain places where the disease is so frequent, that hardly an individual is totally exempt from it. Larrey, in travelling through the valley of Maurienne, noticed that almost all the inhabitants Avere affected with goitres of different sizes, Avhereby the countenance was deformed, and the features rendered hideous, — Mem. de Chir, Mil. t. 1, p. 123.) And Postiglione rejuarks that in Savoy, Switzerland, the Tyrol, and Carinthia there are villages in Avhich all the inhabitants without excep- tion have these swellings, the position and regularity of which are there considered as indications of beauty. — {Memoria sulla Natura del Gozzo, p. 22.) In many the swelling is so enormous, that it is impossible to conceal it by any sort of clothing. A state of idiotism is another affliction Avhich is sometimes combined with goitre, in countries where the latter affection is en- demic. However, all who have the disease are not idiots, or cretins, as they have been called ; and in Switzerland and elsew'here it is met with in persons who possess the most perfect intellectual faculties. When bronchocele and cretinism exist together, Fodere and several other writers ascribe the affection of the mind to the stateofthe thyroid gland. — (See I'raitisur le Goitre et le Cretinisme, 8vo. Paris, an ci.) However, this opinion appears to want foundation, since the men- tal faculties are from birth weak, and in many the idiotism is complete Avhere there is no enlargement of the thyroid gland, or Avhere the tumour is not bigger than a walnut, so that no impediment can exist to the circulation to or from the brain. — {Burns on the Sur- gical Anatomy of the Head and Neck, p. 192.) The direct testimony of Dr. Reeves also proves that in coun- tries where cretins are numerous many peojile of sound and vigorous minds have bronchocele. — (See Dr. Reeve's Paper on Cretinism , Edin. Med. and Surgical Journal, vol. 5, p. 31.) Hence, as Mr. A. Burns remarked, the combination of bronchocele and cretinism must be con- sidered as accidental ; a truth that seems to derive con- firmation from the fact that in some parts of this country bronchocele is frequent, where cretinism is seldom or never seen. 194 BRONCHOCELE. Broncbocele is not confined to Europe; it is met with in almost every country on the g obe. Professor Bar- ton, in his travels among the Indians settled at Oneida in the state of New-York, saw the complaint in an old •woman, the wife of the chief of that tribe. From this •wfoman Barton learned that bronchoceles were by no means uncommon among the Oneida Indians, the com- plaint existing in several of their villages. He found also that the disease resembled that seen in Europe, in respect to its varieties. He did not indeed himself see the pendulous bronchocele which descends over the breast ; but he understood that it was not uncommon among the women on the banks of the Mohawk river, who wore a particular dress for its concealment. In North America bronchocele attacks persons of every age ; but it is most frequently seen in adults ; a dif- ference from what is noticed in Europe. Bronchocele is said to be frequent in Lower Canada. Bonpland, the com[)anion of Humboldt, intbrined Alibert that the disease was endemic in New Grenada, and that it pre- vailed in such a degree in the little towns of Honda and Monpa, on the banks of the Magdalen river, that scarcely any of the inhabitants were free from it. The blacks and those who led an active, laborious life, how- ever, are reported to escape the complaint. Some of the natives of the isthmus of Darien are said to be ter- ribly disfigured by it. — {Alibert, Nosol. Nat. t. 1, p.469. Also, Observations sur quelques phinomencs pen con- nus qn'offre le goitre sous les tropiques, dans les plaines et sur les plateaux des Andes, par A. de Hum- boldt, in Journ. de Physiologic par F. Magendie, t. 4, p. 109, Paris, 1824.) In European women bronchocele usually makes its appearance at an early age, generally between tlie eighth and twelfth year, and it continues to increase gradually for three, four, or five years, and is said sometimes to enlarge more during the last half year than for a year or two previously. It does not gene- rally rise so high as the ears, as in the cases mentioned by Wiseman. Sometimes, however, this happens, as we see in the case of Clement Desenne, of whom Ali- bert has given an engraving. In this patient, a part of the tumour, as large as a hen’s egg, projected into the mouth. — {Nosol. Nat. t. 1, p. 466.) The swelling extended from the ears to the middle of the breast. A seton produced a partial subsidence of it ; but when it was withdrawn the orifices closed. After two years more, the swelling became painful, suppuration took place, and fifteen pints of matter were discharged ; and six ounces every day after the swelling had burst, came away with the dressings for three months ; but, notwithstanding all this suppuration, and more after- ward, the tumour was only pai’tially lessened. The disease, mostly has a pendulous form, not unlike, as Albucasis says, the flap or dewlap of a turkey-cock, the bottom being the largest part of the tumour. Ali- bert mentions a case in which the swelling hung down to the middle of the sternum, and the large mass, which was quite a burden to the patient, used to become hard and, as it were, frozen in very cold weather. This author, however, cannot be right, when he adds, that it was an inert body, destiOite (^vitality ! — {Nosol. Nat. t. 1, p. 466.) In another curious instance, the tumour formed a long cylinder which reached down to the mid- dle of the thigh, the diameter becoming gradually smaller downwards.— (P. 468.) The common seat of bronchocele is the thyroid gland ; but freiiuently the surrounding cellular membrane is more or less thick- ened, and contributes to the swelling. Sometimes also the neighbouring lymphatic glands are affected, when its base is widened and extends from one side of the neck to the other. In this circumstance, the swelling gradually loses itself in the surrounding parts, and is not circumscribed as in ordinary instances. — {Postig- lionc, Mem. sulla Natura del Gozzo, p. 20.) It is soft, or rather flabby to the touch, and somewhat moveable; but after afew years, when it has ceased enlarging, it becomes firmer and more fixed. When the disease is very large, it generally occasions a difficulty of breathing, which is increased by the patient’s catching cold or attempting to run. In some subjects the tu- mour is so large, and affects the breathing so much, that aloud whizzing is occasioned ; but there are many exceptions to this remark. Sometimes when the swell- ing is of great size, patients sufler very little inconve- nience ; while othens are greatly incommoded, though the tumour is small. In general the inconvenience is trivial. The voice is sometimes rendered hoarse, and in particular cases the difficulty of speech is very con- siderable. — (See Flajani, Collez. d'Oss. t. 3, p. 271.) The difficulty of respiration, produced by the pressure of the tumour and the enlargement of other glands, as this author remarks, is the most dangerous effect of the disease, since by disordering the pulmonary circu- lation, it renders the pulse irregular and intermittent, and a strong throbbing is excited in the region of the heart, followed by fatal disease of the lungs themselves ; consequences often not suspected to have any connexion with the bronchocele, though it is in reality the imme- diate cause of them. — {Vol. cit. p. 278.) The causes of bronchocele are little known. To the doctrine that bronchocele is caused by the earthy im- pregnation of water used for drink, the following ob- jections offer themselves ; 1. The water of Derbyshire, in districts where this disease is considered endemic, contains much supercarbonate of lime ; but that in common use about Nottingham, where the disease is also prevalent, is impregnated with sulphate of lime. How ever, that the disease is not produced by w ater impregnated by sulphate of lime is evident ; for, as Ali- bert observes, the waters of Saint Jean, Saint Sulpice, and Saint Pierre, where bronchocele is frequent, contain much less of this earth than the waters of Upper Mau- rienne, where the disease is hardly ever noticed, though the bouses are built upon avast quarry of gypsum. The same fact was observed by Bonpland in New Grenada. — {Nosol. Nat. t. 1, p. 471.) Nor, as Fodere explained, can the cause of the disease be correctly referred to the use of any particular kind of food. Certain localities, however, seem to contribute to its frequency ; for this author observes, that the disease is not prevalent in very high places nor in open plains ; but that it be- comes more and more common as we descend into deep valleys made by torrents, where there is a good deal of marsh, and abundance of fruit-trees. The air is here constantly humid. 2. Abstinence from un- boiled water does not diminish or interrupt the gradual progress of the disease. 3. Patients are cured of the disease, who still continue to drink water from the same source as before, without taking any precaution, as boiling, «fec. 4. The disease in this country is less frequently found among men. 5. Many instances may be related of a swelling in the neck, sometimes very painful, and generally termed bronchocele, being pro- duced very suddenly, by difficult parturition, violent coughing, or any other unusually imverful effort. — (See Edin. Med. and Surgical Journ. vol. 4, p. 279.) When the gland is suddenly enlarged during a violent e.xertion, the distention is said to be produced by the passage of air from the trachea into the substance of the thyroid gland and surrounding cellular membrane. But w'hether this statement be a fact or not, it is un- questionably true, that in many patients the tumour always increases when they speak loud, sing, or make any effort. — {Flajani, Collez. (TOss. 4 c. t. 3, p. 276 ; and Postiglionc, p. 24.) The disease is sometimes seen in scrofulous subjects ; but there is every reason to believe that it is quite independent of the other dis- order, as Prosser, Wilmer, and Kortum have particu- larly explained. The following are some points of difference between bronchocele and scrofula, as indi- cated by Dr. Postiglione. 1. The true bronchocele is simply a local disease of the neck, the constitution being unaffected. On the contrary, scrofula extends its effects to the whole system, attacking not only the lymphatic glands, but also the muscles, cellular mem- brane, ligaments, cartilages, and bones. 2. Both dis- eases chiefly occur in young subjects; but bronchocele ollen begins at a later age than scrofula, and does not, like the latter, spontaneously disappear as the patient approaches puberty and gains strength. 3. Scrofulous glands often suppurate and ulcerate ; bronchocele rarely undergoes these changes. 4. The thickening of the tipper lips of scrofulous subjects is not an attendant on bronchocele; and while the former patients generally enjoy their mental faculties in perfection as long as they live, the latter disease in certain countries is often joined with cretinism. Scrofula is likewise alwajs hereditary, while bronchocele is not so; no healthy persons become scrofulous by living a long while among scrofulous patients, but many individuals con- tract bronchocele by going from a country where this disease is unknown, and taking up iheir residence in places w here it aboupds. 5. Nature alone often cure* BRONCHOCELB. 195 scrofula, while art is rarely successful ; on the con- trary, bronchocele is seldom cured by nature, but very frequently by art. 6. The muriate of lime, recommended by Fourcroy for the cure of scrofula, is always useless ; but in bronchocele it proves a valuable remedy. — {Postiglione, Memoria sulla Natura del Gozzo, &c. p. 25.) The error of confounding bronchocele with scrofula is now generally acknowledged. At the Hos- pital St. Louis, says Alibert, scrofulous patients are numerous, while those with bronchocele are very rare. (N’osol. Nat. t. I, p. 465.) In Derbyshire, Genoa, and Piedmont, bronchocele has been attributed to drinking water cooled with ice. To this theory many of the objections concerning the earthy imi)regnation of water stand in full force ; with this additional reflection, that “ in Greenland, where snow-water is commonly used, these unsightly protuberances are never. met with, nor (says Watson) did I ever see one of them in Westmore- land, where we have higher mountains and more snow than in Derbyshire, in which country they are very common. But what puts the matter beyond a doubt is, that these wens are common in Sumatra, where there is no snow during any part of the year.” — (Wat- son’s Chemical Essays, vol. 2, p. 157.) The above opinion was also refuted by Fodere, who remarks, that the Swiss who reside at the bottom of the glaciers are the least subject to the disease. Bronchoceles are also said to be unknown in Lapland. Respecting the influence of particular water in bringing on the disease. Dr. Odier gives credit to the opinion, because it has appeared to liim that distilled water prevented the increase of the tumour, and even tended to lessen its bulk. — (See Manuel de Medecine Pratique, 8vo. Genev. 1811.) However, that every e.x- planation hitherto devised of the causes of broncho- cele is quite unsatisfactory, is fully proved by the ob- servations of the celebrated Humboldt. Persons af- flicted with bronchocele (he remarks) are met with in the lower course of the Magdalen river (from Honda to the conflux of the Cauca) ; in the upper part of its course (between Neiva and Honda) ; and on the flat high country of Bogota, six thousand feet above the bed of the river. The first of these three regions is a thick forest, while the second and third present a soil destitute of vegetation; the first and third are exceed- ingly damp, the second is peculiarly dry ; in the second and third regions, the winds are impetuous ; in the first the air is stagnant. To these striking ditferences, we will add those relative to temperature. In the first and second regions, the thermometer keeps up all the year between 22 and 33 centigrade degrees; in the third, between 4 and 17 degrees. The waters drunk by the inhabitants of Mariquita, Honda, and Santa de Bo- gota, where bronchoceles occur, are not those of snow, and issue from rocks of granite, freestone and lime The temperature of the waters of Santa Fe and Mom- pox, drunk by those who have this disease, varies from nine to ten degrees. Bronchoceles are the most hideous at Maricjuita, where the symings which flow over gra- nite are, according to my experiments, chemically more pure than tho.se of Honda and Bogota, and where the climate is much less sultry, than upon the banks of tlie Magdalen river. Perhaps it may be thought that the atony of the glandular system (?) depends less upon the absolute temperature than ujton the sudden refri- geration of the atmosphere, the difference of tempera- ture in the night and day; but in the Magdalen valley, where the constancy of low tropical regions prevails, the extent of the scale that the thermometer pervades in the course of the whole year, is only a small num- ber of degrees, it were. The suffocation is imminent ; the lungs not being expanded, the blood accumulates in them, and the return of the blood from the head is more or less impeded. There can be little doubt, that many pa- tients who have perished under these circumstances, might have been saved by a timely incision in the trachea. The majority of writers who have treated of bronchotomy as a means of preventing suffocation in inflammatory diseases of the larnyx, have regarded this operation as the ultimate resource. Both the Greeks and Arabians were of this sentiment; and Avicenna only recommends bronchotomy in violent cases of cynanche, when medicines fail, and the pa- tient must evidently die from the unrelieved state of the affection. Rhazes also advised the operation only when the patient was threatened with death. Thus, in former times, though practitioners were aware of the principle on which bronchotomy became necessary, they generally found the operation fail, because it was delayed too long, and rarely done ere effusion had commenced in the lungs. Bronchotomy, says Louis, will always be done too late, when only practised as an extreme measure. In cases of inflammation about the throat, the danger of perishing by suffocation, as this author remarks, has been known from the very dawn of medicine. The advice of Hippocrates to remedy this urgent symptom, is a proof of it ; and he observes, that the danger is evinced when the eyes are affected and prominent, as in persons who have been strangled, and when there is great heat about the face, the throat, and neck, without the appearance of any external defect. He recommends fistula in fauces ad maxillas intru- denda, qua spiritus in pulmones trahatur. No doubt he would have advised more, had it not been for the doctrine of his time, that wounds of cartilages were incurable. This method, defective as it was, continued till the time of Asclepiades, who, according to Galen, was the first proposer of bronchotomy. Since Asclepiades, this operation has always been recommended and practised in case of quinsy threatening suffocation, notwithstanding the inculcation of Cielius Aurelia- nus, who treated it as fabulous. The mode of doing it, however, has not been well detailed by any body who put it in practice, except Paulus jEgineta, who is precise and clear. “ We must (says he) make the in- cision in the trachea, under the larynx, about the third or fourth ring. This situation is the most eligible, because it is not covered by any muscle, and no ves- sels are near it. The patient’s head must be kept back, in order that the trachea may project more for- wards. A transverse cut is to be made between two of the rings, so as not to wound the cartilage, only the membrane.” The knowledge of this method, and its advantages in cases of the angina strangulans, w hen practised in time, ought, according to Louis, to have rendered its perforniaiice a general jiraeiice. The convulsive angina of Boerhaave, w hich particu BRONCHOTOMY. 201 larly affects those who can only breathe well in an upright posture, has also been adduced as a case de- manding the prompt performance of bronchotomy. Mead, in his Precepta et Manila Medica, mentions a case, in which the patient had been bled very copiously twice in the space of six hours, but he died notwith- standing this large evacuation. The same author no- ticed in Wales, especially on the seacoast, an epide- mic catarrhal quinsy, which carried the patients off in two or three days. In these instances, bleeding was not of much use, and bronchotomy, which was not performed, was the only means by’ which the patients might have been saved. In angina and croup, some modern practitioners are less sanguine in their expectation of benefit from bronchotomy than Louis was. From the observa- tions of Dr. Cheyne,it would appear that in croup, the operation cannot be necessary for the j)urpose of ad- mitting air into the trachea; for in those who have died of the disease, he has found a pervious canal of two-eighths of an inch in diameter, and through a tube of such diameter, even an adult can support respira- tion for a considerable time. According to the same writer, bronchotomy is equally unfitted for the remo- val of the membrane formed by the effusion of lymph ; for. from its extent, variable tenacity, and adhesions, this is, in almost every case, totally imjiracticable ; and even could the whole membrane be removed, still the function of respiration would be but little improved, the ramifications of the trachea and bronchial cells re- maining obstructed. — (See Cheyne's Pathology of the Larynx and Bronchia.) No doubt, Ur. Cheyne’s statement of what is found in the dead subject is correct ; and yet the operation may be necessary to prevent suffication, which might other- wise be induced, partly by the diminution of the natural passage for the air by disease, and partly by the action of the muscles of the glottis ; a circumstance to which Dr. Cheyne has not assigned sufficient importance. On this point, the sentiments of Mr. C. Bell are more correct ; speaking of the membrane of croup, formed by the effu- sion of coagulable lymph, and of the cause of death in these cases, he says, “ It has not appeared to me that it was the violence of the inflammation which destroyed the patient, nor the irritation directly from the inflamed membrane ; but that the presence of this secreted mem- brane, acting like a foreign bo y, at the same time occa- sions spasms in the glottis, obstructs the passage, and confines the mucus. But I am bound to state in the strongest terms, that death is ultimately a consequence of effusion in the lungs, occasioned by the continued struggle and difficulty ; for on opening the chest I have uniformly found, that the lungs did not collapse, and that the bronchiae were full of mucus. This corres- ponds with the symptoms ; for, before death, the vio- lence of the cough and struggle has given place to cold- ness and insensibility, with a pale swelling of the face and neck, and when the child has fallen into this state, giving freedom to the trachea will be qf no avaiV ’ — {Surg. Obs. p. 16.) In the cases of croup which Mr. Chevalier examined after death, he found the trachea obstructed with mucus, and he believed, that it is more by this secretion than by that of coagulable lymph that suffocation is finally produced. At all events, he succeeded in saving a boy- on the point of suffocation, by making an incision in the trachea, and letting out an ounce, or an ounce and a half, of reddish brown, frothy mucus. And a case, of a very similar description, in which the same practice an- swered, I attended, a few years ago, with Mr. Lawrence and Dr. Blicke. This case, however, was different from Mr. Chevalier’s, in the circumstance of a tube be- ing required for a couple of days after the operation, when the removal of the instrument was followed by no inconvenience. Pelletan joins several modern writers in representing bronchotomy as generally useless in cases of croup; the only example in which he thinks the operation might be serviceable being that in whicht he disease is confined to the larynx ; a case which he sets down as uncommon, and difficult to be distinguished. “ Kn sup- yusant enjin I'angine avec concretion bieii curacterisee, on .‘)e tronvera encore entre la crainte tie pratiquer une operation inutile, si les concretions se yrolongent jus- qitc duns Ics branches, el I'iiirpossibihlS de jnger si ces concretions sunt bornees au larynx. C'esten effe.tdans cc scvl cas quet'oyeriUiov pent etre fructuense ; elle fa- i cilitera la re.spiration yrndant que la nature, aidec de I’art, trarnillera a dis.soudre, detacher, et faire expec- torcr les fausses mcnihranes qui obliterent la glutie et le larynx." — f Unique I 'hir.t. i,p. 28.) Of course, the degree of success which will attend the practice of bronchotomy, in cases of this nature, rnus’t always mainly depend upon the operation being done early enough, and in cases where the lungs are not too seriously affected ; for if the effects of pneumo- nia are far advanced, the patient’s chance of recovery will be hopeless, whether the trachea be opened or not. In order, also, to have a reasonable chance of success, in cases threatening suffocation from inflammation of the parts about the fauces, as sometimes happens, the operation must not be deferr'^d too long. We see this fact exemplified in two cases recorded by Flajani ; in one, where the operation had not been allowed till a late period of the disease, the patient died ; in the other, where the practice was adopted earlier, life was pre- served.— (CoZ^ezione d' Osservazioni, \ c. t. 3, p. 230 —233.) A few years ago. Dr. Baillie published three cases, in which death was produced in the adult subject, and in a very few days, by a violent inflammation of the la- rynx and trachea. The disease had a strong resem- blance to croup ; yet was different from it. There was not the same kind of ringing sound of the voice as in croup, and no layer of coagulable lymph was formed ujion the surface of the inner membrane of the larynx and trachea, which, according to Dr. Baillie, uniformly attends the latter disease. In one of these cases, the cavity of the glottis was found to be almost obliterated, by the thickening of the inner membrane of the larynx at that part. The inner membrane of the trachea was likewise inflamed ; but in a less degree. The lungs were sound. If, in thirty hours, no relief should be derived from bleeding ad deliquium, and the exhibition of opiates, Dr. Baillie conceives, that, in this sort of case, it might be advisable to perform the operation of bronchotomy at the upper part of the trachea, just under the thyroid gland. This operation, he thinks, would probably en- able the patient to breathe till the inflammation in the larynx, more especially at the aperture of the glottis, had time to subside.— (See Trans.for the Improvement of Med. and Chir. Knowledge, vol. 3, p. 275. 289.) An acute affection of the membrane of the glottis, proceeding rapidly to a fatal termination by suffocation, has also been particularly described by Drs. Farre and Fercival.— (See Med. Chir. Trans, vols. 3 and 4.) In some bodies, which Mr. Lawrence examined after death, he found appearances analogous to those mentioned by the above physicians. “ The patients died of suffocai- tion ; but the progress of the complaint was much slower than in those cases; the syinjitoms were not .acute, nor did the inspection of the parts disclose any evidences of active inflammation. The membrane covering the chordag vocales was thickened, so as to close the gloN tis, and a similar thickening extended to a small dis» tance from these parts, accompanied with an oedema- tons effusion into the cellular substance under the membrane. The epiglottis did not partake of the disor- der. In one or two instances, this tliickened state of the membrane was the only change of structure observed ; but in others it was attended either with ulceration of the surface near the glottis, appearing as if it had been formed by an abscess, which had burst, or with a par- tial death of one or more of the cartilages of the larynx, viz. the arytenoid, thyroid, or crycoid. The rest of the air-passages and the lungs were healthy.” — {Med. Chir. Trans, vol. 6, p. 222.) In such examples, this gentleman is a zealous advo- cate lor the early performance of bronchotomy, and he has cited several instances in which this operation was successfully performed, both for the relief of quinsy and the extraction of foreign bodies from the trachea. What Bayle called Voedeme de la glotte, no doubt, was the same kind of disease as that noticed by Mr. Law- rence ; one case of it, in which tracheotomy was per- formed with success, and another in which the jiatient died suddenly, suffocated in consequence of the operation not being done, have been published by Liston. — (See Edin. Med. and Surg. Jowm. vol. 19, p. 568.) The affections of the larynx, requiring bronchotomy, would seem, indeed, to be more numerous and diversi- fied than is usually supposed : thus, Mr. C. Bell men tions the case of a medical student, who was attacked with shivering, fever, and sore throat, and in tl„eedays 202 BROxNCHOTOxMY. died of suifocation. On dissection, no obstruction in the larynx was ohser^'ed, but only an inflammation of its membrane, and a spot like a small-iiox pustule upon the margin of the gloxtis.— {Surgical Ohs. part 1, p. M.) j Children sometimes inadvertently drink boiling water | from the spout of a tea-kettle. “ The effects of this ac- , cident (says Dr. Hail) are not, as might be supposed, d ^ priori, the symptoms of inflammation of the oesophagus . and stomach, but of inflammation of the glottis and la- rj'nx, resembling those of croup ; and the case constitutes another instance, in which the operation ofiaryngotomy, . or of tracheoiomy, may be performed with the effect of preventing impending suffocation, and perhaps of saving Me.”— (Med. Chir.7Vans.vol. \2,p. 2.) The cases and remarks collected by Dr. Hall, Mr Gilman, and Mr. Stanley, on this new subject, cannot fail to be highly in- teresting to practitioners. In a case of the foregoing de- scription, Mr. Wallace, of Dublin, performed tracheo- tomy with success. — (See Loud. Med. and Phys. Jnum. for July, 1822.) Mr. Burgess, who has seen five cases, in which boiling water was taken into the throat, thinks that death, when it follows, is almost always produced by, obstructed respiration. In one of the examples which he has recorded, bronchotorny was the means of saving the child.— (See Dublin Hospital Reports, vol. 3.) Great mechanical injury of the larynx, caused by a blow or fall, may create the necessity for bronchotorny, as is proved by a case lately reported by Mr. Liston.— (See Ed. M d. and Surgical Journ. vol. 19, p. 570.) [There is no inconsiderable diversity of opinion among eminent surgeons as to the propriety of performing bronchotorny in cases of croup ; and those who opixise the operation, very plausibly allege, that in the mem- branous stage of croup no advantage can result from | the operation, however favourable the condition of the j sufferer may be in other respects. The views of the celebrated Cheyne would seem to put beyond doubt the inutility of the operation as already noticed by our au- j thor, because it is inadequate to the removal of the arti- ' ficial membrane which is effused in the advanced stage | of cynanche trachealis. I am not jirepared, from my ! own experience, wholly to decide the difficulty. W’e ! have evidence sufficient, I think, to justify an occasional I recourse to this exercise of surgical skill ; but there is j still another means of relief, not stated by our author, | that may fitly be introduced here, which wdll often ren- | der this operation unnecessary, even in those cases in which it is confidently recommended by some, and cer- tainly ought to be fully tested before we avail ourselves of so doubtf ul a remedy. In that stage of croup which has been aptly termed the fatal stage, from its so generally proving such, and which is characterized by the existence of the mem- brane, the vitriolic emetics have been introduced with decided success. This practice was first introduced by Professor Fran- cis, of New-York, in 1813 ; and since the report of his success, has become very generally adopted in this country, and with .singular success. I have now in my possession a specimen of an entire membrane lining the trachea, detached and thrown up under the power- ful emetic action of the blue vitriol, after venesection, blisters, calomel, polygala senega, and all the approved remedies had been tried ineffectually. I regret that the limits assigned me preclude my insert- ing the interesting detail ofihe cases reported by Dr. Fran- cis, in his valuable paper published on this subject, and have to content myself with referring to the i\". Y. Med. and Phys. Jaurn. vol. 3, p. 58, et seq., only remarking, that in the almost hopeless state in which the sequela of inflammation are so threatening, calermel, in large doses, is among the most efficient auxiliaries to which we can have recourse. “ After the existence of the mem- brane,” observes Dr. F., “ and when the powers of life are on the wane, it is a judicious and sometimes an available resource and he admits, that in the cases in which he found the vitriolic emetics successful, their agency was probably favoured by that potent mercurial. 1 find a similar practice has been adopted by Dr. Hoff- mati, of Vienna, who first used the vitriolic emetics in 1820; and so highly does he estimate them, that he declares their action to be a specific in this stage of croup. This is unquestionabh saying too much in their behalf; yet certainly they are entitled to high consider- ation, and ought never to be omitted in^ these almost hopeless cases. — Reese.] 2 Tbv compression of the trachea by foreign bodies, j lodged in the pharvTix, or by tumours, formed outwardly, and of sufficient size to compress the windpipe, but not admitting of immediate removal, is an equal reason for operating more or less expeditiously, according to the symptoms. Mr. B. Bell mentions two instances of suf- focation from bodies falling into the pharynx. Respira- tion was only stopped for a few minutes ; but the cases were equally fatal, notwithstanding the employment of all the usual means. This author thinks, that broncho- lomy would have been attended with complete success, if it had been performed in time. The operation should also be done, when the trachea is dangerously com- pressed by tumours. The author of the article Bran- chotomie, in I'Encyclopidie Methodique, says, that about twenty years ago he opened a man, who had died of an emphysema, which came on instantaneously. He had had, for a long while, a bronchocele, which was of an enormous magnitude towards the end of his life. The cavity of the trachea was so obliterated, that there was .scarce] V room enough to admit the thickness of a small piece of money. Doubtless, bronchotorny, per- formed before the emphysema made its appearance, might have prolonged this man’s days. In cases of this last description, Desault would have advised the introduction of an elastic gum catheter into the trachea from the nose, in order to facilitate respira- tion. This practice, I believe, has not hitherto been attempted by English surgeons. — (See (Euvres Chir. de Desault, t. 2, p. 236, . 358. J. A. Albers, Comm, de Trachitide Infan- tum, vulgo Croup vocata, 4to. Ups. 1816. C'ase of Chronic Infi. of the. Larynx, in winch laryngotomy was perfurnied. See AHd. Chir. ./ourn. April, 1820. E. J. 508 BUN BUR Bourlant de Bronchntomia Diss. in Coll- Diss. Lo- van. 2, 175. G. Detharding, Epist. Med. de Methodu subveniendi Siibiner.iis per Laryugotomiam, liostochii, 1714. Klein in Chir. Beinerkungen, Stuttgart., 1801; in V. Siebold's Chiron, b. 2, 619; in Oraefe's.Journ. b. \,p. 441, and b. 6, p. 225. Mtchaelir< , in Huf eland ' .<1 Journ. b. 9, p. 2, and b. 1 1, p. 3. Flnjani, Osberim- zioni, SrC; di Chirurgia, t. 3, Roma, 1802 R. Col- lard, Jlbhandlnng iiber den Croup, Soo. Hannon. 1814. T. Chevalier's Case of Croup, in Med. Chir. Trans, vol 6, p. 151, Jindree's Case,in vol. 3, same work, p. 335, with the Obs. of Dr. Farre on Cynanche in the same part of the work ; and those of Dr. Percival on the same subject, in vol. 4, p. 297. C. IV. Eberhard, De Musculis Bronchialibus in Statu et Murbosa Jic- tione. Quo. Marpurg. 1817. R. Sprengel, Geschichte der Chirurgie, th- 1, p. 177, 8vo. Halle, 1805. Diet, des Sciences Med. art. Broncholoniie, t. 3, 1812. Sur- gical Observations by C. Bell, part 1, p. 14, i^c. Quo. Lond. 1816. Case of Cynanche Laryugea requiring Tracheotomy, and the continued use of a Cannula, ever since the Operation, in Med. Chir. .Journ. vol. 5, p. 1, Quo. f^und. 1818. W. H. Porter, Case of Cynan- che Laryngea, in which Tracheotomy and Mercury weie successfully employed', Med. Chir. Trans, vol. 11, p. 414. R. Ijiston, two Cases in which Tracheo- tomy was performed with success ; one for aedemo glottidis, i,-c., the other on account of an injury of the larynx; Edin. Med. and Su g. .Journ. vol. 19. Burgess, in Dublin Hospital Reports, vol. 3. Dr. Hall, in Med. Chir. Trans, vol. 12. JV. J. Hunt, Case of Bronchotoiny ; Med. Chir. Trans, vol. 12, p. 27, ij-c. R. Carmichael, in Trans, of Assoc. Physi- cians, Ireland, vol. 3, p. 170, Si-c. F. JVhite, in Dublin Hospital Reports, vol. 4. Dr. Cullen on Broncho- tomy, ill Edin. Med. .Journ. Mo 94 BUBO. (Boufiwi/, the groin.) Modern surgeons mean by this term a swelling of the lymphatic glands, particularly of those in the groin and a.xilla. The disease may arise from the mere irritation of a local disorder ; from the absorption of some irritating matter, such as the venereal poison ; or from constitu- tional causes. Of the first kind of bubo, that which is named the sympathetic is an instance. Of the second, the vene- real bubo is a remarkable specimen. — (See Venereal Disease.) The pestilential which is a s}Tnptom of the plague, and scrofulous swellings of the inguinal and axillary glands, may be regarded as examples of buboes from constitutional causes. — (See Scrofula.) The inguinal glands often become affected with sim- ple phlegmonous inflammation, in consequence of irri- tation in parts from which the absorbent vessels pass- ing to such glands proceed. 'I’hese swellings ought to be carefully discriminated from others which arise from the absorption of venereal matter. The first cases are simple inflammations, and only demand the application of leeches, the cold saturnine lotion, and the exhibition of a few saline purges ; but the latter diseases render the administration of mercury ad- visable. Sympathetic is the epithet usually given to inflamma- tion of glands from mere irritation ; and we shall adopt it without entering into the" question of its propriety. The sympathetic bubo is mostly occasioned by the irritation of a virulent gonorrheea. The pain which such a swelling gives is trifling compared with that of a true venereal bubo, arising from the absorjition of matter, and it seldom suppurates. However, it has been contended that the glands in the groin do sometimes swell and inflame from the actual absorp- tion of venereal matter from the urethra, in cases of gonorrhoea, and if this were true the swellings would be venereal ; but this doctrine is now nearly exploded. — {Hunter on the Venereal, p. 57.) The manner in which buboes form from mere irrita- tion will be better understood by referring to the occa- sional conseiiuences of venesection, in the article Bleeding. The distinguishing characters of the vene- real bubo are noticed in the article Venereal Disease. BUBONOCELE. (From jS vBwu. the groin, and Kr/Xn a tumour.) .species of hernia, in which the bowels protrude at the abdominal ring. The case is often called an inguinal herma, because the tumour takes place in the groin.— (See Hernia.) BUNyON. An inflainiiiatioii of the bursa mucosa. at the inside of the ball of the great toe.— (See Brodie’s Pathological and Surgical Obs. on the Joints, p. 356, ed. 2.) BURNS are usually divided into three kinds. 1st. Into such as produce an inflammation of the cutaneou-s texture, but an inflammation which, if it be not im- properly treated, almost always manifests a tendency to resolution. 2dly. Into those which occasion the .separation of the cuticle, and produce suppuration on the surface of the cutaneous texture. 3dly. Into others in which the vitality and organization of a greater or less portion of the cutis are either immediately or sub- sequently destroyed, and a soft slough or hard eschar produced. — (See Thomson on Inflammation, p. 585, 586.) Suppuration is not always an unavoidable conse- quence of the vesications in burns ; but it is a common and a troublesome one. “ In severe cases it may take place by the second or third day ; often not till a later period. It often occurs without any apiicarance of ul- ceration ; continues for a longer or shorter time ; and is at last stopped by the formation of a new cuticle In other instances, small ulcerations appear on the sur- face or edges of the burn. These spreading form ex- tensive sores, which are in general long in healing, even where the granulations which form upon them have a healthy appearance.”— (Op. cit. p. 595.) Burns present different appearances, according to the degree of violence with which the causes producing them have operated, and according to the kind cf cause of which they are the effect. Burns which only irritate the surface of the skin are essentially different from those which destroy it ; and these latter have a very different aspect from wiiat others present which have at- tacked parts more deeply situated, such as the muscles, tendons, ligaments, When the living' parts have been preserved (conti- , nues Dr. Kentish), which, according to this treatment, ! will be in the course of two or three days, the dead parts will be more plainly observed, and the beginning I of the process to throw them off will be commencing. 1 This process must be assisted by keeping up the powers : of the system by stimulant m^icines and a generous diet. The separation of the eschars will be greatly promoted by the application of the stimulus of heat by I means of cataplasms frequently renewed. These may be made of milk and bread, and some camphorated spirit , or any essential oil sprinkled upon the surface. Such , means need, only be continued until the suppuration is established. After Dr. Kentish had supported the system to sup- puration, he then found that gradually desisting from his stimulant plan diminished the secretion of pus, and wonderfully quickened the healing process. When some parts are destroyed, there must be others with increased action ; and in this case, according to Dr. Kentish, the foregoing mode will be the best for restoring the living parts, and promoting the separation of the dead.ones. Suppuration having taken place, the exciting of the system by any thing stimulant, either by food or medicine, should be cautiously avoided. Should the secretion of pus continue too great, gentle laxatives and a spare diet are indicated. If any part, as the eyes for instance, remain weak, with a tendency to inflammation, topical bleedings, or small quantities of blood taken from the arm, are useful. For the pur- pose of defending the new skin, camphorated oil, or camphorated oil and lime-water in equal parts, are good applications. Wounds of this kind heal very fast, when the diminution of pus is prevented by attention to diet ; if the patient’s strength require support, small doses of bark taken two or three times a day in some milk will answer that purpose, without quickening the circulation as wine, ale, or spirits are apt to do. By attention to these principles (continues Dr. Kentish), I can truly assert that I have cured very many extensive and dangerous burns and scalds in one, two, three, and four weeks, which in the former method would have taken as many months ; and some which I believe to have been incurable by the former method. After explaining his principles. Dr. Kentish takes no- tice of the various substances which have commonly been employed. Of these he would chiefly rely on alco hoi, liquor ammoniae subcarbonatis, ether (so applied as to avoid the cooling process of evaporation), and spirit of turpentine. In applying these, we are directed to proceed as fol- lows: the injured parts are to be bathed, two, or three times over, with spirits of wine, spirits of wine with camphor, or spirit of turpentine, heated by standing in hot water. After this a liniment, composed of the cera- tum resinae softened with spirit of turpentine, is to be spread on soft cloth, and applied. This liniment is to be renewed only once in twenty-four hours, and, at the second dressing, the parts are to be washed with proof spirit, or laudanum, made warm. When the secretion of pus takes place, milder applications must be made, till the cure is effected. The yellow ointment stops the pores of the cloth, im- pedes evaporation, and thus confines the effect of the alcohol to the burnt surface. The first dressings are to remain on four-and-twenty hours. i)r. Kentish thinks it of importance, that the injured surface should be left uncovered as little as possible. It is therefore recom- mended to let the plasters be quite ready, before the old ones are removed, and then only to take oft' one piece at a time. It will seldom be necessary to repeat the application of alcohol, or that of oleum terebinthinte. The inflam- matory action will be found diminished, and, according to Dr. Kentish’s princijiles, the exciting means should therefore be diminished. Warm proof spirits, or lauda- num, may be substituted for the alcohol, and tb.e un- guentum resinae flav;e is to be mixed with oleum camph. . instead of turpentine. If this should be found too irri- I fating. Dr. Kentish recommends ceraturn plu.mbi aceta- I tis, or cer. calaminai. Powdered chalk is to be used I to repress the growth of exuberant granulations, and to absorb the pus. In the cavities of separated eschars, 212 BURNS, and in the furrows between sloughs and living parts, he introduced powdered chalk. Then a plaster is ap- plied, and, in tedious cases, a poultice over the plaster. With respect to the internal treatment, the author ob- serves, that great derangement of the system arises in certain persons from causes which in others produce no etfect ; and that this depends on a difference in the degree of strength. Hence, he concludes that as strength resists the sympathetic irritative actions of parts, and weakness induces them, we should, in all cases, make the system tus strong as we can, immedi- ately upon the receipt of the injury. In considerable burns, he supposes a disproportion of actio.a to take place between the injured parts and the system at large, or what he styles a solution of the continuity of action ; and that, by a law of the system, a considera- ble commotion arises, for the purpose of restoring the equilibnmn, or enabling the constitution to take on the action of the part. Hence, Dr. Kentish is of opinion, that the indication is to restore the unity of action of the whole system, as soon as possible, by throwing it into such a state as to absorb the diseased action, and then gradually bring down the whole to the natural stand- ard of action by nicely diminishing the exciting powers. Ether and alcohol, or other stimulants, are to be imme- diately given in proportion to the degree of injury ; and repeated once or twice within the first twelve hours, and afterward wine or ale is to be ordered, till suppu- ration takes place, when it will be no longer necessary to excite the system. In a second essay. Dr. Kentish remarks, that, in the first species of burns, in which the action of the part is only increased, he has not found any thing better for the first application than the heated oleum terebintliinffi and ceratum resinte, thinned with the same. In superficial burns, when the pain has ceased, he considers it advisa- ble to desist from this application in about fbur-and- twenty hours, and use at the second dressing a digestive, sulficicntly tliinned with common oil, beginning, on the third day, with the ceratum lap. calaminaris. This author has frequently seen secondary inflammation ex- cited by the remedy. The most certain remedy for this unpleasant symptom is a digestive ointment thinned with oil, or a plaster of cerate, and over that a large warm poultice. The cerate will finish the cure. Should there be much uneasiness of the system, an anodyne, proportioned to the age of the patient, should be given. The growth of fungus, and the profuse discharge of matter, are to be repressed, as already mentioned, by sprinkling powdered chalk on the surface, and by the use of purgatives, in the latter stages. The chalk must be very finely levigated. Dr. Kentish’s theories are, as far as I can judge, vi- sionary : they may amuse the fancy, but can never im- prove the judgment. They are nearly unintelligible ; they are unsupported by any sort of rational evidence ; and, as being only the dreams of a credulous, sportive imagination, they must soon decline into neglect, if not oblivion. However, in making these remarks, it is far from my intention to extend the same animadversion to the mode of treatment insisted upon by Dr. Kentish, which forms a question which cannot be determined by reason, but by experience. OF DRESSING BURNS WITH RAW COTTON. In America, it is asserted that the best application for superficial burns is raw cotton, thinly spread out, or carded, and put directly on the injured part.— (See Dal- lam on the Use of Cotton in Bums, in Potter's Medical Lyceum, p. 22 ; and Gibson's Institutes and Practice of Surgery, p. 62, vol. 1, 8uo. Philadelphia, 1824.) According to Professor Gibson, it is only in superficial bums that this practice answers ; but Dr. Anderson, of Glasgow, who has tried it on a large scale, represents it as applicable to injuries, whether occasioned by scald- ing or actual fire, whether superficial or deep, recent OT old, vesicated or sphacelated. He states, that it has been long adopted by the inhabitants of the Greek islands. One of its advantages, he says, is, that, except in cases of deep injury, the cure is always accom- plished without any appearance of cicatrization. — (See Glasgtnju Med. Journ. vol. 1, p. 209.) Another is the avoidance of the pain always attending the frequent re- newal of other kinds of dressing.^ ; for this is left un- changed a considerable time. Some care, says Dr. Anderson, is necessary, both in preparing and ap- plying the cotton For this purpose, it should be finely carded, and disposed in narrow fleeces,’ so thin ttg to be translucent ; by which means it can be applied in successive layers, and is thus made to fill up and pro- tect the most irregular surfaces. The burnt parts, if ve- sicated, are to be washed with tepid water, and the fluid evacuated by small punctures. Or, if more deeply scorched, they may be bathed with a spirituous or tur- pentine lotion. The cotton is then applied, layer after layer, until the whole surface is not only covered, but protected at every point, so that pressure and motion may give no uneasiness. On some parts, it will ad- here without a bandage, especially when there is much discharge ; but, in general, a support of this kind is useful. Where the vesications have been broken, and the skin is abraded, or where there is sphacelus, more or less suppuration always ensues ; and, in such cases. Dr. Anderson admits, the discharge may be so great as soon to soak through the cotton, and become olfensive, particularly in summer, so that it may be ne- cessary to remove the soiled portions. This, however, he advises to be done as sparingly as possible, care be- ing taken to avoid uncovering or disturbing the tender surface.— (Ojn cit. p. 213.) According to Dr. Ander- son, there appears to be a twofold effect from this kind of treatment. The primary effect arises from the ex- clusion of the air, and the slowly conducting power of cotton, by which the heat of the part is retained, while a soft and uniformly elastic protection from pressure is afforded. The secondary effect, he says, depends en- tirely on the sheath, or case, formed by the cotton, ab* sorbing the effused serum or pus, and giving the best possible substitute for the lost cuticle. “ But in order that the full benefit may be derived from this substitute, and to ensure an equable and continued support to the tender parts, until the new skin is foruied, it is abso- lutely necessary that the cotton should not be removed, except under particular circumstances, until the real cuticle is sufficiently formed to bear exposure.”— (P, 217.) As Dr. Anderson admits, the theory is of little consequence ; and we shall not, therefore, criticise it. The merit of the practice can be determined only by ex- perience. We have noticed, that Gibson restricts the plan to superficial burns ; and when it is recollected, that in other cases the discharge would soon convert the unchanged cotton into a most fetid mass of scabs, putridity, and even maggots, one can hardly doubt that his statement is correct. It is true, the fetor may be counteracteU by wetting the cotton in a solution of chlo- ride of lime ; but directly this is done, the soft elastic property of that substance is lost, and the method is not essentially different from that in which linen and lint are applied, after being wet with thelinimentum calcis, or other fluid applications ; and would equally require frequent change. If much constitutional irritation be evinced after the cotton has been for some time applied, Dr. Anderson confesses, that it may be necessary to let out the discharge, or even remove the cotton altogether. “ We are then to be guided by the symptoms and ap- pearances, whether to reapply the same dressings, or first restore a more healthy action in the constitution,” —{Op. cit. p. 218.) [The “ exclusion of the air" is the tiue indieatiem in the treatment of bums ; but it is imperfectly fulfilled by the carded cotton. In superficial burns, salt has long been a domestic application, and can only act in this way ; yet when the part is completely covered with a layer of salt, the relief is immediate, and in superficial burns is permanent. Some surgeons, in this country, treat all kinds of burns on the refrigerant plan ; among whom Professor Davidge, of Maryland, was among the most prominent. He uniformly directed a saturnine solution to be applied to all recent burns, and persevered in until the acute inflammation was subdued, when he used Turner's ce rate as the subsequent dressing. Dr. Kentish’s plan is, however, most popular in this country, and alcohol, spi- rits of turpentine, and the mixture of linseed oil and lime-water are in almost universal use. As, however, the relief afforded in burns is generally the result of the exclusion of the air from the raw sur- face, the modern practice introduced on the continent of covering burns with wheat flour, or other farinaceous material, will be found by far the most immediate in its action, and the most successful in its results ; and this application is adapted to every species of burns, “ whe- ther occasioned by scalding or actual fire, whether su- perficial or deep, recent or old, vesicated or sphaco- BUR BUR 213 lated.” In the most desperate bums, where the injury i is extensive and the destruction of the cutis almost uni- versal, the patient is unable to sustain either the refri- gerant treatment, or any modification of Dr. Kentish’s plan. In these shocking cases, if the flour be applied all over the injured surface until the air is entirely ex- cluded, the pain is almost annihilated; and from the most excruciating torture, the patient is instantly placed under circumstances of comparative comfort. The flour should be repeatedly applied, and persevered in, until the acute inflammation is removed, or, in common parlance, “ the fire is out.” No other application or dressing will be necessary until the acute stage is past ; and then the plan of Dr. Kentish, modified according to the circumstances of the case, will be found adequate to the restoration of the injured surface, however ex- tensive. I can confidently recommend this practice, having witnessed its success in the most hopeless cases. — Reese.] The cicatrix of a burn is often of great extent, and, on this account, the subsequent absorption of the granula- tions on which the new skin is formed (a process by which the magnitude of the scar is afterward lessened) is so con- siderable, as to draw the neighbouring parts out of their natural position, and occasion the most unpleasant kinds of deformity. Thus, burns on the neck are apt to cause a distortion of the head, or even draw down the chin to the breast-bone ; and in the limbs, such contractions as fix the joints in one immoveable position. Simply di- viding these contractions again mostly fails altogether, or only produces very partial and temporary relief, as, after the cicatrization is completed, the newly formed parts are absorbed, and the contraction recurs. A lew years ago, a proposal was made, by my friend Mr. Earle, to cut away the whole of the cicatrix, and then bring the edges of the skin as much towards each other as possible, in the transverse direction, with strips of adhesive plaster. In one case, in which, from the fore part of the upper arm, to within about two inches of the wrist, a firm tense cicatrix of an almost horny consist- ence extended, which kept the elbow immoveably bent to a right angle, this gentleman performed such an ope- ration. After removing the cicatrix, the flexor muscles at first made some resistance to the extension of the limb ; but by degrees they yielded, and the arm was brought nearly to a right line. The whole limb was kept in this position by means of a splint and bandage. In the end, the contraction was cured, and the use of the limb restored.”— (See Med. Chir. Trans, vol. 5, p. 96, .S c.) Probably, as this patient was a young growing sub- ject, only six years of age, the operation would have proved equally successful, if a simple division of the contracted skin had been made, and the arm kept ex- tended for a length of time by the usd of a splint. It is hardly necessary to observe, that cutting a large cica- catrix entirely away, must always be a severe, and sometimes a dangerous operation ; therefore, the avoid- ance of it, if possible, cannot but be desirable. — (See B . Bell's iiyslem uf isurirery. Medical Tacts and Observa- tions., vul. 2. J. Seddlot, de Jimbustiune Theses, 4.io. Parisiis, 1781. Richter's Anfangsgriinde der IVun darzneyiiunst, b. 1. Earle' s Essay on the Means of lessening the Effects of Fire on the Human Body, 8vo. Load. 1799. Kentish's two Essays on Burns, the’ first of which was published in 1798. Robert By all, in Edin. Med. and Hurg. .Journ. vol. 7. p. 31.3. Hedm, Hiss, sistcns Observationes circa vulnera ex combuslione, Src. Ato. Upsalice, 1804. J^iUrrey, M^moires de Chirur- gie Militaire, 1. 1, p. 93 — 96. Boyer, Traiti des Mala- dies Chir. i. l,p. ICO. Modes Dickinson, Remarks on Burns and Scalds, chiefly in reference to the principles of treatment at the time of their injliction, suggested by a perusal of the last edition of an Essay on Burns, by E. Kentish, M. D. 8vo. Bond. 1818. Bectures on In- flammation, by .John Thomson, p. 5B5, Src. EiZ.'W. 1813. Bassos, Pathologic Chir. t. 2, p. 391. Anderson, in Olasgow Medical Journ. vol. 1. Pearson's Principles of Surgery, p. 171, edit. 1808. (Jibson's Institutes of Suroery, vol. 1, Philadelphia., 1824.) BUR.S^ MUCOSjE. These are small membranous sacs, situated about the joints, particularly the large ones of the upper and lower extremities. For the most part, they lie under tendons. Mr. Hrodie comprehends also under the same head, the membranes forming the sheaths of tendons, as they have the same structure, j and perform a similar oflice. The celebrated Dr. A. Monro, of Edinburgh, published a very full account of the bursae mucosae and their diseases. These parts are naturally filled with an oily kind of fluid, the use of which is to lubricate surfaces, upon which the ten- dons play in their passage over joints. In the healthy state, this fluid is so small in quantity, that it cannot be seen without opening the membrane containing it ; but occasionally such an accumulation takes place, that very considerable swellings are the consequence. Tumours of this sort are often produced by bruises and sprains ; and now and then by rheumatic affec- tions. They are not often attended with much pain, though in some cases it is very acute, when pressure is made with the fingers. The tumours yield, in a certain degree, to pressure; but they rise again, with an appearance of elasticity not remarked in other sorts of swellings. At first they appear to be circum- scribed, and confined to a small extent of the joint ; but sometimes the fluid forming them is so abundant that they extend over a great part of the circumference of the limb. The skin when not inflamed retains its usual colour. In this morbid state of the bursae mucosae, they con fain different kinds of fluids, according to the cause of the disease. When the tumour depends on a rheumatic affection the contents are ordinarily very fluid. They are thicker when the cause is of a scrofulous nature. When the disease is the consequence of a bruise or sprain, the effused fluid often contains hard concre- tions, and as it were cartilaginous ones, which are sometimes quite loose, and more or less numerous. Mr. Brodie states, that they have the appearance of small melon-seeds, and are not unusual when the in- flammation is of long standing. Such substances may frequently be felt with the fingers. In the greater number of instances, inflammation of the bursas mucosae occasions an increased secretion of synovia. In other cases the bursa is distended with a somewhat turbid serum, containing floating portions of coagulable lymph. The inflammation sometimes leads to the formation' of an abscess ; and occasionally the membrane of the bursa becomes thickened, and converted into a grisly substance. Mr. Brodie has seen it at least half an inch in thickness, with a small cellu- lar cavity in the centre containing synovia. In other instances, however, though the inflammation has lasted a considerable time, the membrane of the bursa retains nearly its original structure.— (PafAoZog-fenZ and Sur- gical Obs. on the Joints, p. 351, ed. 2.) According to the same authority, the disease may be the consequence of pressure, or other local injury ; the abuse of mercury ; rheumatism, or other constitutional affection ; and, in such cases, the complaint is fre- quently joined with inflammation of the synovial mem- brane of the joints. — ^See Joints.) Sometimes it has the form of an .acute, but more commonly that of a chronic inflammation. While the swellings are not very painful, an attempt may be made to disperse them, by warm applications, friction (particularly wdth camphorated mercurial oint- ment), or blisters, kept open with the savin cerate. But if these tumours should become very painful, and not yield to the above methods, Dr. Monro recommends opening them. This author was continually alarmed at the idea of the bad effects of air admitted into cavi- ties of the body ; and hence, in the operation, even in opening the bursae mucosae, he is very particular in di- recting the incision in the skin, not to be made imme- diately opposite that made in the sac, III the beginning, Mr. Brodie recommends the use of leeches and cold lotions ; and afterward, that of blis- ters or stimulating liniments. In particular cases, he says, these means should be combined with such con- stitutional remedies as circumstances indicate. When the disease is of long standing, the preternatural secre- tion of the fluid will often continue after the inflamma- tion has entirely subsided. If blisters now fail in pro- curing its absorption, Mr. Brodie recommends friction; and if this be unavailing, he considers it advisable to discharge the fluid by»a puncture. The presence of loose substances in the bursa, he thinks, may of them- selves keep up a collection of fluid. Dr. Monro met with cases in which amputation be- came indispensable, in comsequcnce of the terrible symptoms brought on by opening a bursa mucosa. On account of such evil consequences, which are imputed to the air, though they would as often arise 214 C^S CMS were the same practice pursued in a situation in which no air could have access at all, it has been recom- mended to pass a seton through the swelling, and to re- move the silk, after it has remained just long enough to excite inflammation of the cyst, when an attempt is to be made to unite the opposite sides of the cavity by pressure. This practice is sometimes approved of by Mr. Bro- die on other grounds : he has noticed, that after the whole cavity of tlie bursa has been converted into an abscess, and this has been cured, no fluid gene- rally collects there again. Hence, he has some- times been induced to pass into the puncture a seton or tent, or (what he deems better) the blunt end of a probe, for the irritation of the inner surface of the bursa. This practice I tried very successfully on a young woman who was under my care last year. I punctured the bursa below the patella, and discharged about an ounce of fluid, resembling white of egg. The disease had existed several months, and the bursa was much thickened. I kept the puncture open about ten days, during which time there was a discharge from it of the same kind of fluid without any tendency to sup- puration. I therefore introduced a tent into the open- ing, by which means the necessary degree of inflam- mation was excited, the bursa suppurated, and the dis- ease was soon permanently cured, without any severe symptoms. At the same time, I believe Mr. Brodie to be perfectly right in cautioning surgeons against the indiscriminate adoption of this practice. Inflammation and suppuration of a large bursa (he says) sometimes disturb the constitution so much, that it might be pru- dent merely to make a puncture, and keep the patient afterward perfectly quiet. He mentions a diseased bursa mucosa, which he had seen between the lower angle of the scapula and the latissimus dorsi, and which was not much less than a man’s head. In this case, death followed the constitutional disturbance excited by a puncture and the seton. In another example, seen by this judicious surgeon, where the patient was in bad health, and the due observance of quietude was neglected, puncturing a diseased bursa mucosa was soon followed by death.— (Op. cit. p. 360.) One or two similar cases, which happened in St. Bartholomew’s Hospital, have also been communicated to me. In some instances, the making of too free an incision into the bursa mucosa has been followed by extensive phlegmonous erysipelas of the whole limb, ending in death. When the coats of a bursa mucosa are much thick ened, and cannot be restored to their natural condition, Mr. Brodie says, that the bursa, if superficially situ- ated, may be removed with as much facility as an en- cysted tumour. This practice, however, he has only as yet applied to the bursa between the patella and the skin, though he entertains no doubt of there being other su- perficial bursae which would also safely admit of removal. Consult Muvro's Description of all the Bursw Mu- coS(e,&,-c. with remarks on their accidents and diseases, (S-c. fol. Edin. 1788. C. Jl/. Koch, De Morbis Bnrsa- rum t.evdinum mucosarum. And, particularly, B. C. Brodie's Pathological and Surgical Observations on the Joints, chap. 9, ed. 2, 8>jo. Land. 1822. c I^^SAREAN OPERATION. Called also Hystero- ^ tomia, from varipa, uterus, and ropy, sectio. Pliny, book 7, chap. 9, of his Natural History, gives us the etymology of this operation. “ Auspicatius (says he) enectd parente gignuntur, sicut Scipio Africanus prior natus, primusque CcBsar a, caeso matris utero dictus ; qua de causa caesones appellati. Simili modo natus est Manlius qui Carthaginem cum exercitu in- travit.” From this passage we are to infer that the Caesarean operation is extremely ancient, though no description of it is to be found in the works of Hippocrates, Celsus, Paulus .®gineta, or Albucasis. The earliest accouni of it in any medical work, is that in the Chirurgia Guidonis de Cauliaco, published about the middle of the fourteenth century. Here, however, the practice is only spoken of as jiroper after the death of the mother, and is alleged to have been adopted only at such a conjunciure in the case of Julius Csesar.— (See Cap. de Extractione Foetus.) Vigo, who was born towards the close of the fifteenth century, takes no notice of the Caesarean operation ; and Pare, who greatly improved the practice of midwifery, thinks this measure only allowable on women who die undelivered. — (De Homi- nus Generatione, cap. 31.) Rousset, who was contem- porary with Par^, collected the histories of several cases, in which the operation is said to have been suc- cessfully performed ; and, after the publication of these, the subject excited more general interest. By the Cassarean operation is commonly understood that in which the foetus is taken out of the uterus, by an incision made through the parietes of the abdomen and womb. The term, however, in its most compre- hensive sense, is applied to three different proceedings. It is sometimes employed to denote the incision which is occasionally practised in the cervix uteri, in order to facilitate delivery ; but this particular method is named the vaginal Caesarean operation, for the purpose of distinguishing it from the former, which is frequently called, by way of contrast, the abdominal Cassarean operation. With these cases we have also to class the incision which is made in the parietes of the abdo- men for the extraction of the *fof;tus, when, instead of being situated in the uterus, it lies in the cavity of the peritoneum, in consequence of the rupture of the womb, or in the ovary, or Fallopian tube, in consequence of an extra- uterine conception. VAOINAL C.1';SAREaN OPERATION. Disease, malformation, or a i)reternamral position of the cervix uten, may render this practice indispensable. A scirrhous hardness of the neck of the uterus is the most frequent. When the induration is such that the cervix cannot be dilated, and the patient is exhausting herself with unavailing efforts, the parts should be divided in several directions. This has been success- fully done under various circumstances. Cases have been met with, in w'hich the cervix uteri presented no opening at all ; and yet the preceding operation proved quite effectual. Such is the example which Dr. Sim- son l>as inserted in the third volume of the Edinburgh Essays. A woman, forty years of age, became preg- nant, after recovering from a difficult labour, in which the child had remained several days in the passage. She had been in labour sixty hours ; but the neck of the womb had no tendency to dilate. Dr. Simson, per- ceiving that its edges were adherent, and left no open- ing between them, determined to practise an incision, with the aid of a speculum uteri. The bistoury pene- trated to the depth of half an inch, before it got quite through the substance which it had to divide, and which seemed as hard as cartilage. As the opening did not dilate, in the efforts which the woman made, it became necessary to introduce a narrow bistoury on the finger, in order to cut this kind of ring in various directions. There was no hemorrhage ; and the only additional suffering which the patient encountered, arose fVom the distention of the vagina. As the child was dead. Dr. Simson perforated the head, in order to render the delivery more easy. Strong convulsions at the moment of partuntion, may create a necessity for the vaginal Caesarean ope- ration. These sometimes subside as soon as the mem- branes are ruptured and the waters discharged, so as to lessen the distention of the womb. However, if the convulsions were to continue, and the cervix uteri were sufficiently dilated, the child should be extracted with the forceps or by the feet, according to the kind of presentation. On this subject Baudeloque has re- corded a fact, which was cmnmunicaled to the Academy of Surgery by Dubocq, professor of surgery at Tou- louse. The woman was forty years of age, and had been in convulsions two days. She was so alarmingly pale, that she could scarcely be known. Her pulse was feeble and almost extinct, and her extremities were cold and covered with a clammy perspiration. The edges of the opening, which was about as large as a crown piece, felt, as it were, callous ; and hardly had this a[)erlure been dilated, when delivery took place spontaneously. The child was dead. The sj trip- CiESAREAN OPERATION. 215 totns were appeased, and the woman experienced a perfect recovery. Another case, in which the indurated cervix uteri was successfully divided, is recorded by Lambron, a surgeon at Orleans. — (See Diet, des Sci- ences Med. L 23, p. 297.) A considerable obliquity of the neck of the womb, combined with a pelvis of small dimensions, may also be a reason for the performance of the vaginal Cae- sarean operation. Not that such obliquity always oc- casions that of the rest of the uterus ; nor is the neck of this viscus invariably directed towards that side of the pelvis which is opposite to its fundus, although this is sometimes the case. In the latter circumstance, as the contractions of the uterus do not produce a dila- tation of its cervix, which rests upon the bones of the pelvis, the adjacent part of that organ is dilated and jiushed from above downwards, so as to present itself in the tbrm of a round smooth tumour, without any appearance of an aperture. Such a case may have fatal con-sequences. Baudeloque furnishes us with an instance. A woman in her first pregnancy, not being able to have the attendance of the accoucheur, whom she wished, put herself under the care of'a midvvrife, who let her continue in labour-pains during three dap. When the accoucheur came, on being sent for again, the child’s head presented itself in the vagina covered with the womb. The portion of the uterus which in- cluded the foetus, was in a state of infiammation. The os tincae was situated backwards towards the sacrum, hardly dilated to the breadth of a penny-piece, and the waters had been discharged a long time. The patient was bled, and emollient clysters were administered. All sorts of fomentations were employed. She was laid upon her back with the pelvis considerably raised. The a(Xoucheur had much difficulty in supporting the head of the child, and keeping it from protruding at the vulva, enveloped as it was in the uterus. Notwith- standing such assistance, the patient died. So fatal an event, says Sabatier, might have been | prevented, by making thie woman lie upon the side op- posite the deviation of the uterus, and employing pres- sure from above. If these proceedings had failed in bringing the os tincae towards the centre of the pelvis, this opening might have been brought into such posi- tion by means of the finger, in the interval of the pains, and kept so until it were sufficiently dilated for the membranes to protrude. This is what was done by Baudeloque in one case, where the womb inclined forwards and to the right. The os tincae was situated backwards. The waters escaped and the head advanced towards the bottom of the pelvis, included in a portion of uterus The whole of the spherical tumour which presented itself could be felt with the finger; but no opening was distinguish- able ; and the swelling might also be seen on separat- ing the labia from each other and opening the entrance of the vagina. It became necessary to keep the patient continually in bed, and to have the finger incessantly introduced ; but she was not sufficiently docile to sub- mit to such treatment. Fortunately, the unexpected appearance of two officers of Justice, forty-eight hours after the commencement of the labour, had the effect of making her more manageable. It w-as time for tier to become .so ; for the uterus had now become tense, red, and painful. The abdomen was also so tender, that it could scarcely bear the contact of the clothes. Febrile symptoms had begun, and the ideas were be- ginning to be confused. Baudeloque made her lie down ; and he pressed with one hand on the abdomen, for the purpose of raising the uterus, while with the other he pushed the head a little way back, in order that he might reach the os tincse, which he now brought with his finger towards the centre of the pelvis, and kept there for some time. The efforts of the pa- tient being thus encouraged, she was delivered in about a quarter of an hour. The infant was of a thriv- ing description, and the case had a most favourable termination. When the obliquity of the uterus is such, that the os tinea; cannot be Ibund, and the mother and feetus are both in danger of perishing, it is the duty of the prac- titioner to open the portion of the womb that projects towards the vulva. Lauverjat met with a case of this description in his practice. A woman, pregnant with her first child, suffered such extreme pain in her labour, that l.auverjat was solicited to ascertain the real state ! of things, lie was surprised to find the vulva com- ^ pletely occupied by a body which even protruded ex- ternally and yielded to the pressure of the fingers, e.x- cept during the labour-pains. In examining this tumour Jie could only find .at its circumference a cul-de-sac, half an inch deep, without any aperture through which the child could pass. Other practitioners, who were consulted about this extraordinary case, were also anxious to learn what had happened. They found in the tumour a laceration, which only affected a part of the thickness of its parietes. This laceration was deemed the proper place for making an incision. The operation having been done, the finger was passed into the cavity in which the child was contained. A large quantity of turbid fluid was discharged. The child presented and passed thi'ough the opening, with a tri- vial laceration on the right side. Lauverjat, having passed his hand into the utherus, was unable to find either the os tineas or the cervix. No particular indis- position ensued, and the lochia were discharged through the wound, which gradually closed. In the course of two months the os tincae and neck of the uterus were in their natural position agam.— {Lauverjat, Nouvelle M thode de pratiquer I’Operation Cesarienne. Paris, 1788.) When the case is a scirrhous induration of the cer- vix uteri, or a laceration of the parietes of this viscus at the place where it projects into the vagina, the va- ginal Cssarean operation is attended with no difficulty. It is performed with a blunt-pointed bistoury, the blade of which is wrapped round with lint to within an inch of the point. The instrument is to be introduced, un- der the guidance of the index finger, into the opening presented by the uterus, and the aperture is to be pro- perly enlarged from within outwards, in various direc- tions. But when the scirrhous hardness of the cervix presents no oi)ening at all, or when the part of the ute- rus projecting in the vagina is entire, the incision should be made from without inwards, with the same I kind of knife. Too much caution cannot be used in introducing the instrument, in order that no injury may be done to the child, w'hich lies directly beyond the substance which is to be divided. No general di- rection can here be offered, except that of proceeding slowly, and ot keeping the index finger extended along the back of the knife, so that it may be immediately known! when the substance of the womb is cut through, into the cavity of which the finger ought to pass as soon as the knife. If it should be necessary to extend or multiply the incisions, the cutting instrument should he regulated in a similar manner with the same finger. The cerv'ix uteri having been divided, the expulsion of the child is either to be left to nature, or to be pro- moted by the ordinary means. The operation that has been described requires no dressings. If the bleeding should prove troublesome, we are recommended to apply to the inci.sion a dossil of lint wet with vinegar or spirit of wine.— (See Sabatier, Medecine Op^ratoire, t. 1.) The chief object would here be to prevent adhe- sions between the cervix of the uterus and the upper part of the vagina. — (Diet, des Sciences Mid. t. 23, p. 298.) AUrOMINAL C^SSAREAN OPERATION. This is a far more serious operation than that which has just now been treated of, and is the proceeding to which the term Caesarean operation is more particularly applied. There are three cases in which this operation may be necessary. 1. When the feetus is alive and the mo- ther dead, either in labour, or the last two months of pregnancy. 2. When the fetus is dead, but cannot be delivered in the usual way, on account of the deformity of the mother, or the disproportionate size of the child, 3. When both the mother and child are living, but de- livery cannot take place from the same causes, as in the second example. In many instances, both mother and child have lived after the C®sarean operation, and the mother even borne children afterward.— (See Heister’s Jn-ttitutes of Si{r- gery, chap. 113. Mejyi. de VAcnd. de Chirurgie, t. \, p. C23, t. 2, p. 308, in ito. Edm. Med. Essays, vol. 5, art. 37, 38. Edin. Med. and Surgical Journal, vol. 4, p. 179. Med. Chir. Trans, vol. 9 and 11, ^V-c.) Very recently an example has been recorded, in which Dr. MiiUer, of Lovvenburg, in Silesia, performed the Cffisarean sec- tion, and saved both the mother and the child.— (jVfoira- zin/ur die gesanurJe IkiUcunde, 1828; b. 28, p. 140.) 216 Ci?:SAREAN OPERATION. An instance of similar success is reported by C. H. Graefe. — {Journ. fur Chirurgie, i^-c. b. 9, s. 1.) Two successful cases, in which both women and children were operated on at the hospital of Maestricht, by Bosch.— Med. 1823.) And in a valuable periodical' work, one e.xample is reported from Hufeland’s Jour- nal, where the mother and twins were all saved by the operation. — (See Quarterly Journ. of Foreign Medicine, er die Schu angerscheft ausser- hall der Gebarmutter ; Rostock, 1803, 8v».) Govei, p. 401, relates a case of ventral conception, in which instance the Caesarean operation was done, and the child preserved. A lady, aged twenty-one, had a tu- mour in the groin, which wais at first supposed to be an ejaplocele, but an arterial pulsation was perceptible in it. In about ten weeks the swelling had become as large as a pound of bread. Govei, solicited by the lady, opened the tumour. He first discovered a sort of mem- branous sac, whence issued a gallon of a limpid fluid. The sac was dilated, and a male feetus found, about half a foot long, and large in proportion. It was per- fectly alive, and was baptized. After tying the umbili- cal cord, the placenta was found to be attached to the parts just behind, and near, the abdominal ring ; but it was easily separated. Govei does not mention whether the mother survived ; but the thing would not be very astonishing, considering the situation of the foetus, Bertrandi says, he was unacquainted with any other example of the Cssarean operation being done, in cases I of extra- uterine foetuses, so as to save both the mother and infant. This eminent man condemned operating, in ventral cases, on the ground that the placenta could not be separated from the viscera, to which it might ad- here, or, if left behind, it could not be detached, w ithout such inflammation and suppuration as would be mortal. But if, in addition to such objections, says Bertrandi, the operation has been proposed by many, and practised by none, w'e may conclude, that this depends on the difficulty of judging of such pregnancies, and of the time when the operation should be attempted. He puts out of the question the dilatations which have been indi- cated for extracting dead portions of the foetus, and also Govei’s case, who operated without expecting to meet with a feetus at all.— (Bertrandi, TraiU des Operations de Chirurgie, chap. 5.) Whenever the Caesarean operation, or gastrotomy, has been performed, the practitioner is not merely to endeavour to prevent inflammation, heal the wound, and appease any untow ard symptoms which may arise ; he should also prevail upon the mother to suckle the child, in order that the lochia may not be too copious ; and, after the wound is healed, she should be advised to wear a bandage, for the purpose of hindering the forma- tion of a ventral heniia, of which, according to surgical w riters, there is a considerable risk. [The following case of extra- uterine conception is here inserted as being perfectly unique in its kind. No such case is to be found referred to in PloncqueVs Lit. Med. Digest, nor in any of the numerous periodicals which enrich the profes.sion. It occurred in the prac- tice of Drs. Cotton and Harlow, of Georgia, and w as communicated to Prof. Francis, of New-York. The subject was a negro woman, aged 30 years. On the night of the 23d of .Tan. 1819, she was taken in labour. There apjieared no doubt that she had arrived at the full time of labour. Her labour-pains ceasing, she was attended to for a few days for drop-sical symptoms, un- der which she suffered greatly. On the 4th of Febru- ary, she was again taken in labour. I’he i)ains, how- ever, shortly after entirely ceased ; and after five weeks she expired. On examination after death, the following facts i)resented themselves. In the first place, Drs. Harlow and Cotton drew off from the abdomen three and a half gallons of an extremely turbid and oflensive fluid. On opening the abdomen, the first thing that CESAREAN OPERATION. presented itself was the child, extending itself across the abdomen ; its head in the right, its fhet in the left, hypochondriac regions ; its back immediately to the umbilicus of the mother. It was as large a child as ei- ther of them had ever seen at birth, and perfectly formed. The funis ivas of the usual size, about six inches in length, and inserted into the fundus uteri without the intervention of a •placenta. The uterus was about the size of an orange ; its coats very much thickened and indurated, with a small quantity of a thin glassy fluid within its cavity. The abdominal viscera were all diseased, save the bladder. The liver retained its ori- ginal shape and position, but looked more like a mass of glue than organized animal matter. The spleen had gone into a state of complete decomposition. As to the omentum, there was not the slightest vestige left. The bladder appeared to be the only viscus that had escaped tminjured from this digression in nature. The bowels had firmly adhered in one uniform mass from the stomach to the rectum, and to the posterior and lateral parietes of the abdomen.— (See New-York Med. and Phys. Journal, vol. 1.) The case of extra-uterine foetus in which Dr. Mac- Knight of New-York operated with success, is often referred to. — (See Lond. Med. Society's Trans, vol. 4.) This interesting case confirms the views of those who believe in the entire production and perfection of the human foetus extra‘-uterum — {Thacher's Med. Biogra- phy.) But even this operation is not entitled to the epithet Caesarean, and therefore does not detract from the claims of Dr. Richmond, who opened the uterus itself.— (See the preceding note, p. 221.) Gastrotomy has been performed for the removal of extra-uterine foeti several times in America, with com- plete success. Mr. Wm. Baynham, of Virginia, member of the Royal College of Surgeons, London, succeeded, as early as 1791, in removing an extra-uterine foetus from the ab- domen, after it had lain there ten years. He thus pre- served the life of a valuable woman, who was other- wise sinking into the grave, with hectic fever and the most dangerous symptoms. In 1799, he repeated the operation with the like suc- cess on a servant woman of Mrs. Washington’s, Fairfax Co., Virginia. In the publication of these cases in the N. Y. Med. and Phys. Journal, vol. 1, Mr. B. has per- formed a valuable service to the profession, in the judicious remarks with which he accompanies the re- port. In the same work. Dr. J. Augustine Smith, now Pro- fessor of Anatomy in the University of New-York, has published a case in which he performed this same ope- ration in 1808, in the city of New-York, with the most satisfactory result. I have not been able to find any other cases of success in this operation in this country, except those of Dr. MacKnight, Mr. Baynham, and Pro- fessor Smith, and must refer to the journals I have named for their interesting details. The following cases of Caesarean operation are ex- tracted from the N. Y. Med. and Phys. Journal, vol. 2, for 1823 ; and as two of them were self-performed, and the other accomplished by an illiterate female ac- coucheur, they will be found interesting in a high de- gree. The recovery of these women should be regarded as extraordinary escapes, rather than as affording en- couragement rashly to attempt this great and danger- ous achievement. “In the afternoon of Jan. 29th, 1822, (says Dr. S. M‘Clel!en), I was called upon by Mr. Kipp, of Nassau, to consult with Dr. Bassett on the case of his servant girl, who, he said, was in a deplorable situation . I immediately repaired to his house, and found the patient to be a girl fourteen years of age, one-fourth black. She had a firm pulse, and complained of little or no pain. Dr. B. informed me, that she had a wound in her abdomen, near the centre of the epigastric region, from which he had extracted a full-grown fuetus, that was in part protruded, together with a considerable portion of her intestines. The placenta having two umbilical cords attached to it, he had removed from the same orifice, and had also introduced his hand into the uterus per vaginam, of the gluten, undergoing a continual change and reno- vation. It is incessantly taken up by the absorbents, and secreted again by the arteries. It is this continual absorption and deposition of earthy matter which forms the bone at first, and enables it to grow with the growth of the body. It is this unceasing activity of the vessels of a bone tvhich enables it to renew itself when it is broken or di.seased. In short, it is by various forms of one secreting process, that bone is formed at first, is supported during health, and is renewed on all neces- sary occasions. Bone is a secretion, originally depo- sited by the arteries of the bone, which arteries are con- tinually employed in renewing it. Callus is not a con- crete juice, deposited merely for filling up the interstices between fractured bones, but it is a regeneration of new and perfect bone, furnished with arteries, veins, and ab- sorbents, by which its earthy matter is continually changed, like that of the contiguous bone. Indeed, there could be no connexion between the original bone and callus, were the latter only the inorganic concrete, as it was formerly supposed to be. Notwithstanding the more accurate opinions now en- tertained concerning callus, the supposition is still very common, that the slightest motion will destroy callus, while it is being formed. But, says Mr. John Bell, it is an ignorant fear, proceeding merely from the state of the parts not having been observed ; for, when callus forms, the perfect constitution of the bone is restored ; the arteries pour out from each end of a broken bone a gelatinous matter ; the vessels by which that gluten is secreted expand and multiply in it, till they Ibrm be- tween the broken ends a well-organized and animated mass, ready to begin anew the secretion of bone. Thus, the ends of the bone, when the bony secretion com- mences, are nearly in the same condition, as soil parts which have recently adhered ; and it is only when there is a want of continuity in the vessels, or when a want of energetic action incapacitates them from renewing their secretion, that callus is imperfectly formed. This is the reason why, in scorbutic constitutions, in patients infected with syphilis, in pregnancy, in fever, or in any great disorder of the system, or while the wound of a compound fracture is open, no callus is generated.— {John Belt's Principles of Surgery, vol. 1, p. 500, 501.) How far some of the latter statement is correct, or not, will be seen in the article Fractures. For some time the secretion of earthy matter is im- perfect ; the young bone is soft, flexible, and of an or- ganization suited for all the purposes of bone ; but hitherto delicate and unconfirmed ; not a mere con- crete, like the crystallization of a salt, whicli, if inter- rupted in the moment of forming, will never form ; not liable to be discomposed by a slight accident, nor to be entirely destroyed by being even roughly moved or shaken. Incipient callus is soft and yielding; it is ligamentous in its consistence, so that it is not very easily injured ; and in its organization it is so perfect, that when it is hurt, or the bony secretion interrupted, the breach soon heals, just as soft parts adhere, ajid thus the callus becomes again entire, and the process is immediately renewed. In consequence of the above circumstances, if a limb be broken a second time when the first fracture is nearly cured, the bone unites more easily tlian after the first accident ; and Mr. J. Bell even asserts, that when it is broken a third and a fourth time, the union is still quicker. In these cases the limb yields, it bends under the weight of the body which it cannot support ; but without any snapping or splintering of the bone, and generally without any over-shooting of the ends of the i)art, and without any crepitation. Callus is found to be more vascular than old bone. Mr. J. Bell mentions an instance of a bone, which had been broken twelve years before he injected it, yet the callus was rendered singularly red. When a recently formed callus is broken, many of its vessels are rup- tured, but some are only elongated, and it rarely hap- pens that Its whole substance is torn. U is easy to conceive how readily the continuity of the vessels will be renewed in a broken callu.s, when we reflect on its great vascularity and the vigorous circulation excited by the accident in vessels already accustomed to the secretion ol bone. These reasons show why a broken or bent callus is moresj)et;dily united than a fractured bone. Vv hile the ends of a broken bone are connected to- gether by a flexible substance of cartilaginous consiM- ence, liupuytrcn calls lliis bond ol' union the proii- 226 CAM CAN sional callus, which generally lasts nntil the thirtieth or fortieth day. In a later stage the intervening cartila- ginous matter ossifies ; the swelling of the soft parts subsides ; and in from six to twelve months the callus or new’ bony matter filling the medullary canal is ab- sorbed, whereby the latter is restored. The callus re- maining after the completion of this process, Dupuy- tren terms dijinitive. Wtieu bones granulate, says Mr. Wilson, the granu- lations at first appear exactly similar to those of the soft parts, and, as in the soft parts, take place to restore any loss which the bones may have suffered. This process is very similar to that of the first formation of bone. In the skull membrane was first formed; and here, also, in the process of restoration the granulations change into membrane, and then into bone. In cylin- drical bones, the granulations first produce a species of cartilage, and this is afterward converted into bone. Thus, in the restoration of bone, nature is guided by the same laws which prevail in its first formation. If the granulations thrown out on the surface of a bone be viewed in a microscope, they appear to form a number of small points like villi, the bases of which first become si- milar to cartilage, and then to bone. “ The preparations from the surface of granulating stumps show the ex- treme delicacy of the first bony tlireads, and also their mode of uniting laterally with each other.”— (On the Structure, Physiology, and Diseases of the Bones, i^-c. p. 197, 8uo. Lond. 1820.) And in another place he repeats, “ I have examined several skulls on the death of the persons, at different periods, from days to years after pieces of bone had been removed, and before vacancies had been com- pletely filled up ; but I never could in any of them dis- cover the least appearance of cartilage.” A membrane here always precedes the formation of bone.--(P. 210.) For additional observations on callus see Frac- ture. AT. M. jyiuUer, De Callo Ossium ; 4fo. JVorimb. 1707 ; Duhamel in Jlem. de I' Acad. Royale des Sci- ences, an 1741, p. 92 et 222; Boehmer, De Callo Ossium i rubia tinctorum radicis pa.msuccessful ; in three more the cancer broke out again in different parts ; and, in a fifth, there were threatenings of some tumours, at a distance from the original disease. These tumours, however, did not appear till three years after the operation ; and the woman was carried off’ by a fever before they had made any progress. All the rest of the forty-five con- tinued well as long as they lived ; or are so, says Mr. Hill, at this day. One of them survived the ope- ration above thirty years ; and fifteen were then 232 CANCER. alive, although the last of them was cured in Msirch, 1761. Of the next thirty-three, one lived only four months; and, in five more, the disease broke out afresh, after having been once healed. The reason why, out of forty-five cases, only four or five proved unsuccessful, and six, out of tliirty-three, was as follows : “ The ex- traordinary success I met with (says Mr. Hill) made cancerous patients resort to me from all corners of the coimtry, several of whom, after delaying till there was little probability of a cure, by extirpation or any other means, forced me to perform the operation, contrary both to my judgment and inclination.” Upon a survey, in April, 1764, made with a view to publication, the numbers stood thus ; Total cured, of different ages, from eighty downwards, sixty-three ; of whom there were then living thirty-nine. In twenty- eight of that number, the operation had been performed more than two years before; and, in eleven, it had been done in the course of the last tw’o j^ears. So that, upon the whole, after thirty years’ practice, thirty-nine, of sixty-three patients, were alive and sound ; which gives Mr. Hill occasion to observe, that the different patients lived as long, after the e.xtirpation of the can- cers, as, according to the bills of mortality, they would have done, had they never had any cancers, or under- gone any operation. The remaining twenty-five, which complete the eighty-eight, were cured since the year 1764. Twenty- two of these had been cured at least two years ; and some of them, it may be remarked, were seventy, and one ninety years old. In the year 1770, the sum of the w'hole stood thus : Of eighty-eight cancers, extirpated at least two years before, not cured, two ; broke out afresh, nine ; threat- ened with a relapse, one ; in all, twelve, which is less than a seventh part of the whole number. At that time, there were about forty patients alive and sound, whose cancers had been extirpated above two years before, Mr. B. Bell, who w'as present at many of these cases, bears witness to Mr. Hill’s accuracy; and the former very judiciously states, that “ from these and many other authenticated facts, which, if necessary, might be adduced, of the success attending the extirpation of cancers, there is, it is presumed, very great rea- son for considering the disease, in general, as a local complaint, not originally connected whth any disorder of the system.” With respect to Mr. Bell’s opinion, that a general cancerous taint seldom, or perhaps never, occurs, but in consequence of the cancerous virus being absorbed into the constitution from some local affection, much doubt attends even this supposi- tion, though the practical inference from it is w'hat cannot be found fault with, viz. in every case of real cancer, or rather in such scirrhosities, as from their nature are known generally to terminate in cancer, we should have recourse to extirpation as early as possi- ble ; and, if this were done soon after the appearance of such affections, or before the formation of matter takes place, their return would probably be a very rare occurrence.” — {System of Surgery, vol. 7.) Sir Astley Cooper admits, that the operation is fol- lowed by a return of the disease in many cases, the average number of which, however, he does not state, though he says that they do not amount to one-fourth. • -{Lancet, vol. 2, p. 383.) How often is the operation determined upon, be- cause the nipple is retracted, and true cancer thereby announced ! Yet, says Mr. Charles Bell, with refer- ence to the cause of this change, as previously ex- plained, “it is quite clear, that if the nipple be fully retracted, and if this has been evident for any consider- able time, the operation has been too long deferred ” — — {Med. Chir. Trans, vol. 12, p. 233.) Sir Astley Cooper is adverse to the performance of the operation when dyspnoea is present ; for he has known patients die in two or three days, who had been operated ui)on while labouring under that symptom. On examination after death, water was found in their chests, and tubercles in the pleura. — {Lancet, vol. 2, p. 373.) The same experienced surgeon gives it as his opinion, that a breast should never be removed, unless the pa- tient has undergone a course of alterative medicines, as Plummer’s pills and the compound decoction of sarsaparilla, or (what he pn-fers) the inftision of gen- tian with soda and rhubarb. Thus the constitution may be improved, and the danger of a relapse dimi- nished. — {Vol. cit. p. 379.) After comparing the different accounts of success given by Monro and Hill, well might Richter say: “ Jure sane dixeris, de uno eodemque morbo hos viros loqui, dviitari fere potest.”— {Obs. Chir.fasc. 3.) .MEDICINES AND PLANS WHICH HAVE BEEN TRIED FOR a HE CURE or scirrhus and cancer. It is a contested point, whether a truly cancerous disease is susceptible of any process, by wliich a spon- taneous cure can be effected. It appears certain, how- ever, that a violent inflammation, ending in sloughing, may sometimes accomplish an entire separation of a cancerous affection, and that the sore left behind may then heal. Facts, confirming this observation, are oc- casionally exemplified in cases where caustic is used, and accidental inflammations have led to the same fortunate result, as we may be convinced of by ex- amples recorded by Sir Everard Home, Richerand, &c. The latter writer, adverting to the effort which nature sometimes makes to rid herself of the disease by the inflammation and bursting of the tumour, takes the opportunity to relate the following case. A woman, aged forty-eight, of a strong constitution, was admitted into the hospital of St. Louis, with a cancerous tumour of the right breast. The swelling, after becoming softer, and affected wth lancinating pains, was at- tacked with an inflammation, which extended to the skin of the part, and all the adjacent cellular mem- brane. The whole of the swelling mortified, and was detached. A large sore, of healthy appearance, re- mained after this loss of substance, and healed in two months. — {Nosographie Chir. t. 1, p. 381, edit. 2.) In general, however, it must be confessed that in flanimation renders things worse instead of better, and by converting occult cancers into ulcerated ones, has- tens the patient’s death, or at all events renders the cure more difficult, and forbids any attempts, which, on such a principle, might be made for his relief. Of the general remedies, narcotics, as conium, opium, belladonna, &c have been employed with most hope. Cicuta, or conium maculatum, owed its reputation to the experimenting talent of Storck, who has written several treatises on it. According to him, cicuta pos- sesses very evident powers over cancer, and has cured a great many cases ; but in less prejudiced hands it has not been found successful ; and even in many of the instances adduced by Baron Storck of its utility, it is by no means proved that the disease was really cancer. The public have now little or no reliance on this medicine, as a means of relieving cancer. Mr. J. Bums declares, that in cancerous ulceration, he never knew hemlock produce even temporary melioration. — (See Conium.) Belladonna was highly recommended by Lambergen During its use, he kept the bowels open with clysters, administered every second day. The dose should be, at first, a grain of the dried leaves, made, into a pill. The quantity may be gradually increased to that of ten or twelve grains! The extract is now frequently ex- hibited, the dose being at first one grain, and after- ward increased by degrees to five. The reputation of belladonna has not been supported by any decided success in cases of true cancer. Hyosciamus has often been tried in cancerous cases, and was held in great estimation by the ancients. Mr. •T. Burns says, he has employed it occasionally, but with little effect. The common dose, at first, is three grains of the extract. Aconitum has also been given ; and, as it is a veiy powerful and dangerous narcotic, a patient usually be- gins with only half of a grain of the extract night and morning. Solanum dulcamara, Paris quadrifolia, phy- tolacca, &c. have also been recommended ; but they are now hardly ever employed, which is a sufficient proof of their iiiefficacy. Mr. .1. Burns tried the hydro- sulphiiret of ammonia, without any benefit. Richter prescribed the laurus cerasus, but without any decided success. * Digitalis lessens vascular action, and may act on scirrhi like abstinence, bleeding, &c. It has, however, no specific virtue in curing cant-erous diseases. Opium is seldom employed, with the intention of curing cancer, altuouvb probably it has just as much po'vcr oftius ». • d a- oihcr . urcoius. m u.lU have been CANCER. 233 more frequently used. For the purpose of lessening the pain of cancerous diseases, it is very freely pre- scribed. Tonics sometimes improve the general health ; but they never produce any specific etfect on the local dis- ease. .lustamond thought arsenic a specific for cancers. Farther experience has not, however, confirmed the truth of this opinion, though there are many practi- tioners who continue to think highly of the efficacy of this mineral in certain forms of disease, which have sometimes been classed with cancer ; and in many cases of lupus, and malignant ulcers of the tongue and ocher parts, it may really po.ssess greater claims to farther trial than perhaps any other medicine yet sug- gested. It unquestionably cures numerous ill-looking sores on the face, lips, and tongue, and is one of the best remedies for lupus. Mr. Hill observes: “Expe- rience has furnished me with some substantial rea- sons for considering arsenic as a medicine of consider- able merit, both with regard to actual cancer and scir- rhus. w'hich may one day terminate in that horrible species of ulcer ; and although I cannot as yet say it will remove the one, or cure the other, as certainly and safely as mercury commonly does a syphilitic swelling, or open sore, yet it will, in a great majority of cases, retard the progress of the true scirrhous tu- mour, and often prevent its becoming cancer. In some, it has appeared to dissipate such swellings com- pletely.”— (See Edin. Med. and Surgical Journ. vol. 6. p. 58.) Mercury, in conjunctionwith decoctions of guaiacum, sarsaparilla, &c., has been recommended, but as Mr. J. Burns remarks, no fact is more certainly ascertained, than that mercury always exasperates the disease, especially when in the ulcerated state. Plummer’s pills and the other alteratives approved of by Sir Astley Coo()er, as medicines to be given previously to an ope- ration, with the design of lessening the chances of a return of the disease, have been already noticed. Sulphate of copper has been tried ; but, at present, it retains no character as a remedy for cancer. The same may be said of muriated barytes. The carbonate (rust) of iron was particularly recom- mended by Mr. Carmichael. Besides the carbonate of iron, he sometimes prescribed the tartrate of iron and potass, and the phosphate, oxyphosphate, and subnxy- phosphate of the metal. Some constitutions can bear these preparations only in small quantities ; they affect most patients with constipation, and many with head- ache and dyspnoea. These circumstances, therefore, must be attended to in regulating the dose. The above gentleman has seldom given less than thirty grains, in divided doses, in a day, or exceeded sixty. He prefers the suboxyphosphate for internal use, and states, that It answers best in small doses frequently repeated. It should be blended with white of egg, have a little pure fixed alkali added, and then be made into pills with powdered liquorice. Aloes is recommended for the removal of costiveness. When half a grain is com- bined with a pill containing four grains of carbonate of iron, and taken thrice a day, the constipation will be obviated. When the internal use of iron brings on headache, difficult respiration, a quick, sometimes full pulse, which is also generally hard and wiry, excessive languor, lassitude, &c., and such sympfoms become alarming, the iron is to be left off, and four grains of camphor given every’ fifth hour. At the same time that preparations of iron were in- ternally administered, Mr. Carmichael employed exter- nally, for ulcerated cancers, the carbonate, pho.sphate, oxyphosphate, and arseniate of iron, blended with wa- ter, to the cx)n8istence of a thin paste, which was applieij once every twenty-four hours. To occult cancers, the same gentleman applied a solution of the sulphate of iron ? j. to tlq. of water. The acetate of iron, diluted with eight or ten times its weight of water, was also u.sed. These lotions were put on the part affected by means of folded linen, wet in them, and covered with a piece of oiled silk to prevent injury of the clothes. — (8ce An Es.'iay on tlie Effects of the Carbonate and other preparations of Iron upon Cancer, A c. 2d ed. 8vo. Dnbhn, 18. 50.) In the most common species of caries, a loose futi- gous flesh grows out of the interstue.s formed on tho 238 CARIES. surface of the diseased bone, and bleeds from the slightest causes; while in the soft parts a sinus ge- nerally leads down to the caries, and emits a very fetid, dark-coloured sanies. These symptoms, how- ever, as well as the tendency in the accompanying ulcer or sinus to produce large fungous granulations, are more constant in cases of necrosis than in those of caries, some of which may remain a very consider- able time unattended with any outward sore, abscess, or sinus as we see illustrated in the caries produced by various diseases of the joints. And, indeed, par- ticular Ibrms of caries (if they deserve that name) are rarely accompanied with suppuration : a fact to which I shall again advert. “ The absorption of bone, like that of soft parts (says Dr. Thomson), may be distinguished into interstitial, progressive, and ulcerative. We have ample proofs ol’ the interstitial absorption, or that which is daily- hourly, and unceasingly taking place from every part of the substance of bone, in the deposition and removal of phosphate of lime, that has been tinged with mad- der. If too much earth be removed, the quantity of animal matter will be relatively increased, and a dis- position given to softness of the bones — a state which exists in the bones of children, in the disease called the rickets, and in the bones of older people in that denominated mollities ossium, or the rickets of grown people. I have already had occasion to mention the effects of the progressive absorption of bone, as manifested in the progress of aneurisms and other tumours to the skin ; but the formation of pus is by no means a ne- cessary, constant, or even frequent attendant on the progressive absorption in bone. Hydatids in the brains of sheep, tumours growing from the pia or dura mater in the human body (see Di/ra Mater), or aneurism seated over the cranium, or within the cavity of the chest, are often the cause of the whole substance of a bone being removed, layer after layer, by progressive absorption, without the formation of a single particle of pus.— (See Aneurism.) This state of the bone has often been confounded, but improperly, with that state of the bone which arises from ulcerative absorption, the state which is properly denominated caries, and in which one or more solutions of continuity may be produced upon the surface, or in the substance of the bones. The ulcerations occasioned in bones by the venereal disease afford by far the best marked exam- ples of the effects and appearances of ulcerated ab- sorption, or caries in bones,” ‘d Diseases of the Bones, Spc. p. 263, Pi'o Loud. 16J0. L. iVtssmanv, De Rite Cognoscendis et Cavan dts Nudaiione, Carie et M’ecrosi Ossiuni,8ro. R JJs- ton, Ess:y on Cories, in Edin. Med. and Surg. .Joarii. No. 78. ..d good description of the different kinds of canes is yet a desideratum.) [There is one peculiar and somewhat novel species of caries, which has received the attention of several -American writers, and to which some European wri- ters have recently referred. I allude to the caries of the jaw-bone occurring among children, and which has been denominated by Marshall Hall a gangrenous ulcer, affecting the jaw-bones of children. This dis- ease sdems in a variety of instances to be preceded by febrile irritation, and derangement of the digestive organs. It is often found under circumstances in which a great number of children occupy the same apartments, as in workhouses, alms-houses, peniten- tiaries, gnosis of Its event, and to know what method of oi)erating ought to be adopted. Of these varieties the first is the capsulo-lenticular cataract, conjoined with slight depositions of new mat- ter upon the anterior capsule of the lens. These after- formations upon the front layer of the capsule, as Beer calls them, put on very different appearances, and ac- cordingly receive various appellations. For instance, the marbled capsulo-lenticular cataract, when the chalk- white new-formed substances upon the anterior layer of the capsule are so arranged as to resemble the varie gated appearance of marble. The window or lattice capsulo-lenticular cataract, when the new-deposited substances cross each other, leaving darker-coloured in- terspaces. The stellated capsulo-lenticular cataract, when the new matter runs in concentric streaks towards the middle of the pupil. The central capsulo-lenticular cataract, when a single elevated, white, shining point is formed on the anterior capsule, while the rest of this membrane is tolerably clear, and the lens not com- pletely opaque. The dotted capsulo-lenticular cataract, when the front layer of the capsule presents several dis- tuict unconnected depositions on its surface. The half-cataract, or cataracta capsuio-lenticularis dimidi ata, when one-hall of the front layer of the capsule is co- vered with a white depbsite. In all these, and some other examples, says Beer, the lens is found to be con verted to its very nucleus into a gelatinous or milky substance. The second variety of the capsulo-lenticular cataract pointed out by Beer, is the encysted, indicated by its snow-white colour; sometimes lying so close to the uvea as to push the iris forwards towards the cornea ; and at other times appearing to be at a distance from the uvea. These circumstances, as Beer remarks, almost always depend upon the position of the head ; for when this is inclined forwards, the cataract readily assumes a globular form, and projects considerably towards the an terior chamber. Frequently, this variety of the capsu- lo-lenticular cataract constitutes the kind of case to which the epithets tremulous or shaking, and swim- ming or floating are applied. According to Beer, the reason of such unsteadiness in the cataract is owing to the broken or very slight connexion of the capsule of the lens with the neighbouring textures. The same author has never seen any case of this kind, which had not been preceded by a violent concussion of the eye or adjacent part of the head. Both layers of the capsule are opaque, and sometimes considerably thickened. The third variety of the capsulo-lenticular cataract described by Beer, is the pyramidal or conical, which is one of the rarer forms of the disease, and always brought on by violent internal inflammation of the eye, especially af fecting the lens, its capsule, and the iris. It may be known by a white, almost shining, conical, more or less projecting, new-formed substance, which grows from the centre of the anterior layer of the capsule, and is al- most in close contact with the pupillary margin of the iris. Hence the iris is always quite motionless, and the pupil angular. Sometimes this growth from the capsule extends itself so far into the anterior cham- ber, as nearly to touch the inner surface of the cornea, and sometimes actually to adhere firmly to it : a cir- cumstance, says Beer, which is very constant in the conical staphyloma of the cornea, though not discover- able till the ojieration is performed. The power of dis- cerning light is feeble and indistinct, and sometimes entirely abolished. Mr. Guthrie (as I think) very cor- rectly regards this case as an advanced degree of the disease presently described under the name given to it by Beer, of lymph-cataract : it ought, indeed to be classed as a spurious cataract. — (See Guthrie’s Opera- tive Surgery of the Eye, p. 246.) The fourth variety of the capsulo-lenticular cataract is \hc siliquoai. Though principally met with in yoimg CATARACT. 247 tWldren, it is not one of the most uncommon affections in adults, and in the former it is often falsely regarded ns a congenital complaint. When this cataract is ex- tracted either from children or grown-up persons, Beer says, that the dried shrivelled, capsule is always found round the equally dry nucleus of the lens, like a husk, or shell. In cliildren, however, he says, that the nu- cleus of the lens is often scarcely perceptible, while in adnlts it is always of considerable size, and this may be the reason why this cataract in children does not pre- sent so bright a yellow- white colour as it does in grown- up persons. In infants, in which it is frequently seen in the first weeks of their existence,’ it is manifestly produced by a slow and neglected inflammation of the lens and its capsule, arising from too strong light. In s of light tlirougli it, while the pu, ii. at a du^tHiu-c, seems to be of its natural size and blackness.” A mi- nute inspection, however, shows that the pupil is nearly clo.sed. Mr. Guthrie adds, that the operation for closed pupil, by division (the only proper one), is not advisable as long as the patient can see well enough for the common purposes of life. — (See Operative Sur- gery of the Eye, p. 249.) Another classification of cataracts, which is of great importance to an operator, is that which is founded upon their consistence; for, as Beer remarks, this makes not only a great ifference in the prognosis, but also in the choice of a method of operating. When the opaque lens is either more indurated than in the natural state, or retains a tolerable degree of firmness, the case is termed a firm or hard cataract. When the substance of the lens seems to be converted into a whitish or other kind of fluid, lodged in the capsule, the case is denominated a milky or fiuid cata- ract. W'hen the opaque lens is of a middling consis- tence, neither hard nor fluid, but about as consistent as a thick jelly or curds, the case is named a soft or caseous cataract. When the anterior or posterior layer of the crystalline capsule becomes opaque, after the lens itself has been removed from this little mem- branous sac by a previous operation, the affection is named a secondary cataract. The harder the cataract is, the thinner and smaller it becomes. In this case, the disease presents either an ash-coloured, a yellow, or a brownish appearance : according to Beer, its colour is very dark. The inter- space between the cataract and pupil is considerable. The patient distinctly discerns light from darkness, and, when the pupil is dilated, can even plainly per- ceive large bright objects. In the dilated state of the pupil, a black circle surrounding the lens is ver>’ per- ceptible. The motions of the iris are free and prompt ; and the anterior surface of the cataract appears flat, without any degree of convexity — {Richter^ s Anfangsg. der Wundarzn. p. 177, b. 3. Beer, vol. cit. p. 309.) Beer says, that it is only the genuine lenticular cata- ract which can be hard, and it is chiefly met with in thih, elderly persons ; but, with respect to the opinion that all cataracts in old persons are firm, he says, this is frequently contradicted by experience. In c.ataract8 extracted from thin, aged individutds, the lens is sometimes found dwindled, as hard as wood, nearly of a chestnut-brown colour, and with its two surfaces as flat as if they had been compressed. This esuse has sonctimes been denominated the dark-gray cataract, and is very d fficult to make out previously to an ope- ration, being liable to be mistaken for an incipient amaurosis. Hence, in order to judge of it effectually, the pupil should alwmys be dilated with hyosciamus or belladonna. To the fimiish, consistent kind. Beer refers several capsulo-lenticular cataracts, namely, the encysted and conical, or pyramidal cataracts, that to which he ap- plies the epithet dry siliquose, the gypsum cataract in particular, and the bar cataract, which at least is always partly firm, as well as all the varieties of spurious cataract. — {Beer, b. 2, p. 309.) The fluid or milky cataract has usually a white ap- pearance ; and irregular spots and stress, different in colour from the rest of the cataract, are often ob- sersable on it. These are apt to change their figure and situation, when frequent and sudden motions of the eyes occur, or when the eyes are rubbed and pressed ; sometimes also these spots and streaks va- nish and then reappear. The lower portion of the pupil seems more opaque than the upper, probably because the untransparent and heavy parts of the milky fluid sink dowmwards to the bottom of the capsule. The crystalline lens, as it loses its firmness, coni- mordy acquires an augmented size. Hence, the fluid cataract is thick, and the opacity close behind the pupil. Sometimes, one can perceive no space between the cataract and margin of the pupil. In advanced cases, this aperture is usually very much dilated, and the iris moves slowly and inertly. This happens because the cataract touches the iris and impedes its action. The fluid cataract is sometimes of such a thickness, that it protrude.s into the pupil, and presses the, iris so much forwards as to make it assume a convex ap|)earance. Patients who have milky cataracts, general;,' distin- guish light from darkness very indistinctly, and soma tunes not at all ; ]mray. because tin- cataract, when it IS tiink, lies to close to the in.s that lew or no rays CATARACT. 249 of light can enter between them into the eye ; partly, because the fluid cataract always assumes, more or less, a globular form, and therefore has no thin edge through which the rays of light can penetrate.— (iiicA- ter's Anfangsgr. der Wundarzn. b. 3, p. 174, 175.) — Mr. Travers believes, that fluid cataracts are rarely contained in a transparent capsule, and his experience has taught him, that this membrane is partially opaque, presenting a dotted or mottled surface. Tlie opaque spots are most distinguishable when viewed laterally. — (See Med. Chir, Trayis. vol. 4, p. 284.) According to Beer, a fluid cataract is mostly con- joined with a complete opacity of the capsule : its diag- nosis, therefore, is commonly very ditficult, and some- times its nature cannot, be known with certainty, until an operation is undertaken. When the capsule is opaque only in some places, he states, that the fol- lowing circumstances may be noticed. The cataract lies close to the uvea, and when the patient inclines his head forwards, the cataract presses the iris to- wards the cornea, and the anterior chamber becomes evidently smaller; but when be lies upon his back, the cataract recedes in some degree from the uvea. The power of distinguishing the light is unequivocal. When the head is kept quiet for a long time, a thick sediment and a thinner part can be plainly remarked in the cataract; during which state, that is, while the two substances are undisturbed, the patient can some- times distinguish large well-lighted objects, as through a deJise mist; but when the head or eye is quickly moved, these two substances become confused together again, and the cataract again presents a uniform white colour. — {Vol. cit. p. 312.) It cannot be denied, says Beer, that what is called the congenital cataract, and which presents itself in infants soon after birth, when their eyes have been exposed to immoderate light, is not unfrequently fluid; but, in such cases, it must not be presumed, that the lens is always in this state ; for, in fact, the cataract is often of that sort which Beer describes under the name of dry sili- quose. Sometim*w the opaque lens is of a middling consist- ence, neither hard nor fluid, but about as consistent as thick jellj', cunts, or new cheese. Cases of this de- scription .ire lermed soft or caseous cataracts. The consistence here spoken of may be confined to the two surfaces of the lens, or may exist in its very centre. The first case is the most frequent. The diagnosis is not difficult ; for it always has a light-gray, grayish- white, or sea-green colour. When it is far advanced, it quite impedes the eyesight, and sometinles consider- ably interferes with the perception of light.— (Beer, b. 2,p. 310.) As the lens softens in this manner, it com- monly grows thicker and larger, even acquiring a much greater size than the fluid. It is not unfrequent to meet with caseous cataracts of twice the ordinary size of a healthy crystalline lens. The motions of the iris are very sluggish.— (Ric/ifcr’s Anfangsgr. der Wun- darzn. p. 178, b. 3.) Indeed, Beer says that it is sometimes requisite to u.se the hyo.sciamus (or rather bell.idonna) in order to ascertain that no adhesions ex- ist between the uvea and the cataract, for in such cases the posterior chamber is very often completely abo- lished, as the more caseous the lens is, the larger it is ; and hence likewise the black ring at the edge of the pujiil is not at all owing te the shadow of the iris, but entirely to the dark border of the iris at the margin of that opening. According to Beer, the colour of such cataracts is never uniform, but more or less speckled ; the spots, however, either have no determinate outline, or they seem like mother-of-pearl fragments, into which the cataract crumbles when e.vtracted or couched, or else they assume the appearance of clouds. (Beer, 6. 2, p. 311.) According to Mr. Travers, the ca.seous cataract has a heavy, dense appearance, uniformly opaque, a clouded, not a fleecy whiteness, and some- times a greenish or dirty white tinge.— (ilfed. Chir. Trans, vol. 4, p. 285.) He farther states, that what he terms the Jlocculent or fieecy, and the caseous or doughy cataracts, are most frequently met with ; the fluid or vdlky ca.ses. and tho.se called hard, being com- paratively rare. -fOp. et. loc. cit.) In estimating the consistence of cataracts it is now universally admitted, that their size is a better ciiicrion of it than their colour; and “ the larger and mere protuberant the lens pressing forwards into the pupd and against the iri-s, the grouter i;i Ihc terlaiuty 1 of its being soft.”— (See Guthrie's Operative Surgery of the Eye, p. 209.) As Beer observes, a cataract which is recent and has originated suddenly, especially in young subjects, re- quires much more circumspection, ere an operation is determined upon, than a cataract which has already existed a long while, and the. formation of which has been only gradual, particularly in an old subject ; for the first case is more frequently owing to a concealed slow kind of inflammation than is generally supposed —(Vol. cit. p. 314.) Formerly, cataracts were denominated ripe or unripe ; tenns which, previously to the time of Mr. Pott, who fully exposed their impropriety, often led to the error of supposing that every cataract must acquire an in- crease of consistence with time, a hardness indicated by a pearly colour, and be thereby rendered more fit to be depressed or extracted. “ This opinion (as Mr. Guthrie has observed), founded on the hardness or soft- ness of the cataract, as dependent upon its duration, is contradicted by experience ; for cataracts of fifteen or twenty years’ duration, and of a pearly colour, have been extracted perfectly soft, while others, of one year’s standing and of a milky colour, have been found hard. Neither is the relative state of blindness under these particular circumstances a more just criterion ; patients having been found almost entirely blind with a soft cataract, while through a hard one they could still distinguish objects and colours. -(Operative Sur- gery of the Eye, p. 190.) A cataract was also called ripe as soon as it was in a state which would admit of no increase, whether the eyesight was completely lost or only diminished, and whether the pupil was entirely occupied by it or not. Thus, says Beer, the siliquose cataract, in its most advanced stage, never totally tills the pupil, and the patient can sometimes even discern colours ; nor does the floating capsulo- lenticular cataract fill the pupil in a greater degree ; and yet both these cases are completely ripe tor an operation. On the other hand, to the unripe cataracts belong the central cataract of the capsule and lens, the posterior capsular cataract and the slight degree of lymph cataract. Most of these cataracts, after perhaps remaining for years in this state, not unfrequently jdl of a sudden become complete upon an accidental and slight attack of ophthalmy \ but sometimes they remain unchanged during life.— (Beer, b. 2, p. 316.) Another very useful and practical division of cata- racts is into those which are called simple local, and into others which receive the name of complicated. A simple local cataract is so denominated by Beer when the patient is in every other respect perfectly healthy, and no disease prevails in any other part, however dis- tant from the eye. A cataract may be complicated in three ways ; for it may be attended either with other simultaneous disease in the eye itself or its appen- dages, when the case is termed a local complicated ca- taract ; or there is some other disease prevailing in the system, either unconnected or connected witti the pro-, duction of the cataract, which then has the epithets general complicated applied to it ; or. lastly, both de- scriptions of complication exist together, the complete complicated cataract. According to Mr. Guthrie, idio- pathic or constitutional cataract generally aflects both eyes ; and the local or accidental form of the disease is more frequently confined to the organ that has been injured either by external violence or active inflamma- tion.— (Op. cit. p. 190.) However, from my being ac- (juainted with several cases in which a cataract arose in one eye, without any previous injury or inflamma- tion, and continued many years single, in one case twenty years, I conclude that the exceptions to a part of the foregoing statement are by no means unfrequent. Among the locally complicated cases is the adhe'- rent cataract. The preternatural cohesion may be one of the anterior layer of the capsule with the uvea, pro- duced by effused lymph; it may consist in a very firm connexion of the posterior laver of the capsule with the membrana hyaloidea; or it may he an unusually close cohesion of the whole of the capsule with the lens ; or, says Beer, all the three species of adhesion may exist together.— (P. 318.) 'I'lic adhesion of the capsule of the lens to the uvea (synechia posterior) is generally obvious enough ; for, as Beer has observed, the pupillary margin of the iris is not conqilelcly circular, and is more angular the stronger tUc light is. The caturui’.t lies close to the 250 CATARACT. uvea, and is very white. The motions of the iris are more or less obstructed, and when the adhesion is ex- tensive, are quite prevented. The perception of light is indistinct, often very faint, and .'■ometimes entirely lost, for the preternatural adhesion is always the con- sequence of previous internal ophthalmy, which, be- sides occasioning opacity of the lens and its capsule, readily produces other serious effects upon the retina, the choroid coat, and vitreous humour, quite adequate to account for the loss of sight, and the incapacity of distinguishing the rays of light. When the anterior layer of the capsule is adlierent only at a single point to the uvea, the extent of the adhesion may be readily ascertained by artificially dilating the pupil with hyo- sciamus or belladonna ; and the information thus ob- tained will have great weight in the selection of a me- thod of operating.— (Beer, loco cit.) Some other local complications of cataract are so ob- vious that they cannot fail to be understood ; as, for in- stance, its combination with an adhesion of the iris to the cornea {synechia anterior) ; with closure of the pupil, unattended by any adhesion of the uvea to the anterior capsule of the lens (synechia posterior) •, as in watchmakers, and hysterical and hypochondriacal sub- jects, the complications with atrophy, hydrophthal- mia, cirsophthalmia, specks and scars upon the cornea, pterygium, and various forms of ophthalmy. According to Beer, the combination of cataract with glaucoma is also readily made out by any body who has once seen the case ; for the cataract always pre- sents a greenish, and sometimes quite a sea-green co- lour ; it is of prodigious size, so as to project through the pupil towards the cornea ; the colour of the iris is more or less changed nearly in the same manner as after iritis ; the iris is perfectly motionless ; the pupil very much expanded and drawn into angles, for the most part towards the canthi ; the lesser circle of the iris is nowhere visible, because it lies concealed under the far-projecting soft cataract; the light cannot be perceived, though the blinded patient is frequently con- scious of false luminous appearances within the eye (photopsia) ; and, lastly, the case is invariably accom- panied with more or less of a varicose state of the blood-vessels of the eye. The origin of this sort of cataract is constantly attended with severe obstinate headache. There are, says Beer, two other local complications which are much more difficult to iearn before an ope- ration. The first is a cataract combined with a disso- lution of the vitreous humour (synchysis), the diagno- sis of w’hich, indeed, when the affection prevails m a considerable degree, is tolerably easy, as the cataract trembles, and the iris alw'ays swings backwards and forwards ujwn the slightest motion of the eyeball ; the globe itself is somewhat affected with atrophy ; the eye is quite spoiled, and feels flaccid and unresisting ; the sclerotica immediately around the cornea is bluish, as in infants ; and the perception of light is uncertain. On the other hand, when the synchysis is not far ad- vanced, the only symptoms are a suspicious softness of the eyeball, and a swinging of the iris when the eye is suddenly or violently moved. The other complication of cataract, sometimes very difficult to detect previously to an operation, is amauro- sis. When, indeed, the pupil is extraordinarily large, the iris nearly or quite motionless, and the patient cannot distingui'-h day from night, and of course not the least glimmer of lignt, no great powers of divina- tion are required to predict with certainty that no ope- ration will restore the eyesight, wliich is abolished, not by the cataract, but by the existing amaurosis. On the other hand, when the motions of the iris are nearly as free as in the natural state, tne pupil as small as it usually is in a given degree of light, the patient capable of judging accurately of the strength of the light, and yet the cataract conjoined with amaurosis, which, with the exception of the faculty of perceiving the light, completely impedes vision, it is then only by a careful inquiry into the his»ory of the disease, that certain cir- cumstances attending the origin of the cataract, and indicating in some measure the prevalence of amauro- sis, can be traced; some imes in consequence of one eye being affected with amaurosis, and not with cata- ract, a reasonable suspicion may be deduced, that the eye with cataract is also amaurotic ; yet, says Beer, in such a case nothing certain can be known before an operation is done. | He considers the general complications of cataract to be as numerous as the diseases of the constitution itself, or as the affections of other organs besides the eye ; but the most common are scrofula, gout, syphilis, psora, old ulcers of the leg, and an unhealthy constitu- tion. CAUSES, PROGNOSIS, &C. Persons much exposed to strong fires, as blacksmiths, locksmiths, glassmen, and persons above the age of forty, have been reckoned more liable to cataracts than other subjects.— (Wenzel.) In young persons the dis- ease is by no means unfrequent : even children are often affected, and some are born with it. Beer assents to the general correctness of the opinion that old age is conducive to cataracts, since the disease is most fre- quently observed in old persons. Yet, says he, that age, nay, a very great age, cannot be deemed a regular cause of cataract, is clear from the circumstance of many very old and even decrepit individuals being able, with the aid of spectacles, to read the smallest print : and it would seem that other causes, besides old age, are essential to the production of cataracts , as for in- stance immoderate exenion of the eye during youth, particularly in such employments as expose the organ to a strong reflected light.— (ie/tre von den Augenkr. b. 2,p. 325.) Among the circumstances which promote the forma- tion of cataracts. Beer enumerates rooms illuminated only by reflected light ; and all kinds of work in which the eyes are employed upon shining, small, microsco- pic objects, especially when, during such labour, a de- termination of blood to the head and eyes is kept up by the compressed state of the abdomen, the cataract often seeming to come on more or less quickly with inflammation of the capsule and lens. And, accord- ing to the manifold experience of the same author, one of the most important though least noticed causes pro- moting the formation of cataract, is allowing very strong light suddenly to enter the eyes of a new-born or very young, delicate infant, the consequence of w Inch is, that the cataracts form more or less quickly, with inflammation of the capsule and lens, or remain for life incomplete, as is the case in the central capsulo- lenticular cataract. The habitual examination of mi- nute objects in a depending position of the head, by which an undue proportion of blood is thrown upon the organ, is said frequently to bring on cataracts. — (See Med. Chir. Trans, vol. 4, p. 279.) In the majo- rity of instances, true cataracts arise spontaneously, without any assignable cause. Sometimes, however, the opacity of the lens is the consequence of external violence ; a case which more frequently than any other gets well without an operation. Frequently (says a modem writer) the cataract “ proceeds from an hereditary disposition w hich has existed for several successive general ions ; while in other cases it attacks several members of the same family without any disposition of this kind being re- cognisable in their progenitors. Among others, Janin mentions a whole family of six persons who laboured under this disease.” — (Ohs. sur VtKil, p. 149.) Richter extracted the cataract from a patient whose father and grandfather had been affected with the same malady, and in whose son, at that period, it had begun to manifest itself. He adds, that he had seen three children, all born of the same parents, who acquired cataracts at the age of three years.— (Oti the different Kinds of Ca- taract, p. 3.) “ During my apprenticeship with the late Mr. Hill, of Barnstable, I was present when he operated on two brothers and a sister, all of w hom were adults, and who stated that three of four others of their family were affected with symptoms not unlike those which they had experienced at the commence- ment of the complaint. I myself recently operated on two gentlemen advanced in years, who informed me that they had a brother on his return from India, who was similarly affected.” — (See Adames Fract. Obser- vations on Ectropium, Artificial Pupil, and Cataract, p. 101, London, 1812.) Beer speaks of families in which the children all became afflicted with cataracts at a certain age ; cases, says he, where an operation, though done by the most skilful practitioner, haruly ever succeeds.-^ Le/ire von den Augenkr. b. 2, p. 331.) Long exposure of the head and eyes lO the rays of the sun, together w'ith a bent position of the body, as 1 in some kinds of ffeld labour, is reckoned by Beer a CATARACT. 251 cause promoting the formation of cataracts on the ap- proach of age ; also hard labour near strong fires, as near evens and forges, in glass-houses, &c. In Eng- land, little credit is given to these opinions. Beer says, that he has also learned from repeated ob- servation, that exposing the eye to the vapour of con- centrated acids, naphtha, and alcohol, will sometimes bring on a cataract ; a statement which will be re- ceived in this country with some hesitation, where the vapour of ether has been occasionally recommended for the dispersion of opacities of the lens and its cap- sule. The dust of lime is also supposed to be condu- cive to the disease, cataracts being said to be frequent among the workmen in lime-pits and kilns. In such cases, I conceive that the cataract has mostly been the result of inflammation. Wounds of the eye, where the weapon has pierced the capsule and the lens, and especially violent con- cussions of the forepart of the globe of the eye, though no wound may exist, are in general followed by a cataract as an immediate consequence. This is the case, says Beer, even when no inflammation arises from the injury, the cataract often occurring in a few hours, and in so considerable a degree as not to admit of being mistaken. The cause of cataract thus rapidly produced must depend, in Beer’s opinion, upon the complete separa- tion of the lens from its connexions with the capsule, and not unfrequently in part upon the detachment of the capsule itself from the neighbouring textures ; for in such cases this membrane also gradually becomes opaque. According to Beer, cataracts frequently arise from a slow, insidious inflammation of the lens and its capsule. With respect to the prognosis, it must be evident from what has been premised, that there are many ca- taracts in which the cure is highly problematical, and others in which the impossibility of restoring vision, even in the slightest degree, may be predicted with ab- solute certainty. With the little positive information which surgeons possess concerning the causes of cataracts, scarcely any expectation can ever be entertained of curing opa- cities of the lens and its capsule, by means of medi- cine, so as to supersede all occasion for an operation. A possibility of success, as Beer remarks, can exist only when the cause of the cataract is ascertained, ad- mits of complete removal, and the disease is in an early stage. And he has learned from manifold and repeated trials, that the attempt to cure an incipient cataract will never succeed, except when some deter- minate atid obvious general or local affection of a cu- rable nature has had a chief share in the production of the disease of the eye ; as, for instance, scrofula in a mildish form, syphilis, (?) and the sudden cure of erup- tions, or old ulcers of the legs, (?) or a slow insidious inflammation of the iris and capsule of the lens. In some examples of this kind. Beer could only check the farther progress of the cataract, and even when the eyesight w'as improved, it was never rendered per- fectly clear. And when the cataract was so far ad- vanced and quite developed, with the exception of the general melioration of the health, and an improved state of eye, whereby it was put in a better condition for the operation, not the slightest benefit was de- rived from medicine.— (Z>c/ire, A c. h. 2, p. 333.) In this country no faith is put in these notions re- specting the constitutional influence of rheumatism, gout, scrofula, syphilis, S-c. suite principali malattie degli Oy.chi; Venez. 1802.) There are three different operations practised for the cure of cataracts, viz. one termed couching, or de- pression, of which the method called reclination is a modification, as will be hereafter explained ; another named extraction ; and a third denominated kera- tanyxis, which consists in puncturing the cornea with a needle, the point of which is to be conveyed through the pupil, so as to reach the cataract, which is to be gently broken into fragments. As Beer observes, each of these modes has, in particular cases, manifest ad- vantages over the other two but no single method will ever be exclusively preferred, and invariably fol- lowed, by any man of experience or judgment. In every operation for a cataract, the position of the patient, as- sistants, and surgeon is of great importance. In order fo enable the assistant, who stands behind the patient, to he conveniently near the head of the latter. Beer prefers letting the patient sit on a stool which has no back. However, as I shall presently notice, some emi- nent surgeons have urged good reasons in favour of employing a chair which is completely perpendicular. When the left eye is to be operated uj)on, the same assistant is to apply his right hand under the patient’s chin, and press the head of the latter against his breast, at the same time that he inclines it and himself mftre or less forwards towards the operator, who sits upon rather a high stool, in front of the patient. In this country, a music-stool is commonly prefen-ed, the height of which can be regulated in a moment, by simply turning the seat round to the right or left, whereby the screw, with which it is connected, is made to rise or descend, as may be found most desira- ble. The same assistant then places his left hand flat upon the left side of the patient’s forehead, with the points of the fore and middle fingers somewhat under the edge of the ujiper eyelid ; and, w'ith the fore-finger, he is now to raise the edge of this eyelid as much as possible, following that finger immediately with the middle one, so as to fix the eyelid with greater cer- tainty. The ends of these fingers, however, must be so applied as not to touch the globe of the eye in the slightest manner, much less make any pressure upon it, yet so that the upper part of the eyeball and cornea may be gently resisted by them, when the eye rolls tipwards away firom the instrument about to be intro- CATARACT. 257 ^ced, whereby this position, which is extremely in- convenient to the operator, may be immediately recti- fied. The patient should also sit obliquely opposite a clear window, so that a sufficient light may fall ob- liquely upon the eyes, without any rays being reflected to the cornea, and becoming a hindrance to the ope- rator. Nor should light from any other quarter be ever allowed to fall upon the eyes. The stirgeon should sit in front of the patient, whose head ought to be directly opposite the operator’s breast, whereby the latter will be enabled to see from above, with the greatest correctness, every thing in the eye during the operation, and will not be under the necessity of raising his arms too considerably. Supposing it to be the left eye which is to be operated upon, he next ef- fectually draws down the lower eyelid with the left fore-finger, the end of which must be planed over the edge of the eyelid, towards the globe of the eye. The middle finger is then to be applied in a similar way over the caruncula lachrymalis. The operator now takes in his right hand the requisite instrument for the operation, viz. the needle or knife, which is to be held like a pen, between the thumb and the fore and middle fingers. By this particular arrangement of the fingers of the assistant and operator, which, indeed, is partly ineffectual where the fissure of-the eyelids is very nar- row, and the eyeball is diminutive and sunk in the orbit, the restless eye of the timid patient is fixed ; for a point of the finger is disclosed on every side to which the eye can possibly turn away from the in- strument about to be introduced, and when the cornea is gently touched with the extremity of the finger, the wrong position which the eye is about to take is im- mediately prevented. This method of fixing the eye, says Beer, is not merely indispensable for young ope- rators, but is the only perfectly unobjectionable one which can- be employed on this delicate organ, since all mechanical inventions for this purpose, like the speculum oculi, which keeps the eye steady by con- siderable pressure, or other contrivances, like Rum- pelt’s instrument, which does the same thing by meank of a short pointed instrumep' attached to a kind of thimble, and with which the sclerotica is pierced and held motionless, are found by experience to be worse than useless. And, as a proof of this fact. Beer ad- verts to the numerous patients who come out of the hands of such operators as employ these instruments, with a more or less hurtful loss of the vitreous hu- mour, and other ill consequences ; a statement which nearly agrees with the observations of Wenzel and Ware. While the late Mr. Ware coincided with Wenzel and Beer, respecting the general objections to specula, he remarks, that in some instances of children born with cataracts, he had been obliged to fix the eye with a speculum ; without the aid of which, he found it totally impracticable to make the incision through the cornea with any degree of precision or safety. His speculum was an oval ring, the longest diameter of which is about twice as long as the diameter of the cornea, and the .shortest about half as long again as this tunic. Annexed to the upper rim of (he speculum is a rest or shoulder, to support the ui)per eyelid, and by its lower rim it is fixed to a suitable handle. Beer entertained no higher opinion of other inventions, made for the purpose of enabling surgeons to operate on both eyes with the right hand ; for, says he, the right eye should always be operated upon with the left hand, and the left with the right, and he who cannot learn to be equally skilful with both his hands, must always remain a bungler. — {Lehre von de)i Augenkr. b. 2, p. 347—350.) Mr. Alexander, whose great skill in operations on the eye is universally acknowledged, employs no as- sistant for raising the upper eyelid, or fixing the eye, which objects he accomplishes himself; and in Ger- many, this independent mode of proceeding has been particularly commended by Barth.— (£tit;a.9 uher die Ausziehuag des grauen Staare, fur den geubten Ope- rateur, 8vo. Wu-n, 1797.) The preceding directions, respecting the position of the a.ssistant, the seats for the patient and surgeon, and the mode of fixing the eye, are chiefly tho.se of Professor Beer. Whether these instructions arc in every respect better than the following, which com- bine the sentiments of some other writers of exi»e- nencc, the impartial reader must judge for himself. VoL 1.— R The patient should be seated rather low, opposite a window where the light is not vivid, and in such a manner, that the rays may fall laterally upon the eye about to be couched. The other eye, whether in a healthy or diseased state, ought always to be closed, and covered with a handkerchief, or any thing con- venient for the purpose ; for, so strong is the sympathy between the two organs, that the motions of the one constantly produce a disturbance of the other. The surgeon should sit upon a seat rather higher than that upon which the patient is placed ; and, in order to give his hand a greater degree of steadiness in the various manoeuvres of the operation, he will find it useful to place his -elbow upon his knee, which must be suffi- ciently raised for this purpose, by a stool placed under the foot. The chair on which the patient sits ought to have a high back, against which his head may be so firmly supported, that he cannot draw it backwards during the operation. Th^ back of the chair must no( slope backwards, as that of a common one, but be quite perpendicular, in order that the patient’s head may not be too distant from the surgeon’s breast. — (^Richter’s Anfangsgr. der Wundarzn. p. 207, b. 3.) The propriety of supporting the patient’s head rather upon the back of the chair on which he sits, than upon an assistant’s breast, as Bischoff has observed, is founded upon a consideration, that the least motion of the assistant, even that necessarily occasioned by re- spiration, causes also a synchronous motion of the part supported on his breast, which cannot fail to be disad- vantageous, both in the operation of extraction and of couching. However, as this is not at present the com- mon practice, the inconvenience of having the back of the chair between the assistant and the patient may more than counterbalance the circumstance in which it seems to be advantageous. In certain cases, where the muscles of the eye and eyelids are incessantly affected with spasm ; or where the eye is peculiarly diminutive, and sunk, as it were-, in the orbit, the elevator for the upper eyelid, invented by Pellier, and approved by Scarpa, may possibly prove serviceable : in young subjects, it materially facilitates the operation. The particular sentiments of Wenzel and Ware, con- cerning the mode of fixing the eye, will be farther ex- plained in the description of the extraction of the cata^ ract. OF COTJCHINO, OR DEPRESSION OF THE CATARACT, AND RECLINATION. The operation of couching was once supposed to con- sist altogether in removing the opaque lens out of the axis of vision, by means of a needle, constructed for the purpose ; but it is well known to be frequently ef- fectual on another principle, even when the nature and consistence of the cataract do not admit of the depression of the opaque body. Experience fully proves, that the diseased lens, when broken and dis- turbed, with the needle, and especially when freely exposed to the contact of the aqueous humour by a proper laceration of its capsule, is gradually dissolved and removed by the action of the absorbents. Indeed, couching now means a variety of operations ; for it comprehends not merely the depression of the cataract, not simply its displacement in any direction whatsoever, not only the breaking of it piecemeal and thepushing of the fragments into the aqueous humour, but likewise the mere disturbance of the opaque body, whereby its absorption is sometimes affected, xvithout any kind of depression or displacement of it at all with the needle. When, therefore, the merits of couching are investigated, it is necessary to define precisely wffiat modification of it is meant, and for what parti- cular kind of case its application is designed ; for no surgeon of the present day would confine himself ex- clusively to one method of operating; and, as Mr Guthrie has remarked, “ In considering the advantages or disadvantages from any or all of the different opera- tions for cataract, it is absolutely necessary to recol- lecj, that no individual operation is ap])licable to every species of the disea.se ; that each kind requires an ope- ration for its relief or cure, sometimes of a particular nature, and differing es.sentially from that which is found most advantageous in another. To collect then all the objections which can be urged against any of the operations, from a consideration of every case of cataract to which it is and is not aiiplicable, is CATARACT. 253 merely to confuse the subject, and has generally been done for the purpose of recommending some particular mode of proceeding, rather than to regulate these ope- rations by the general principles of surgery.”— (Opem- tive Surgery of the Eye, p. 365.) In this respect, the doctrines of Pott, Callisen, Hey, and Scarpa arc un- doubtedly wrong, though their .sentiments are blended with many valuable and important truths. Beer, who is by no means a great advocate for depression, ad- mits its utility in particular cases. It is easily com- prehensible, says he, that in this way a firm and large cataract either cannot be removed without injuring the reting, and the attachment of the corpus ciliare to the vitreous humour, or not far enough to prevent the opaque body from rising again at the first opportunity. Hence the former complaints about the frequent re- turn of the cataract, and other ill consequences, tinap- peaseable vomiting, suddenly produced amaurosis, and severe inflammation, - nudeus, breaks into several pieces, it is necessary. in order not to have afterward a considerable second* ary lenticular cataract, to put the larger fragments sepa- rately in a state of reclination, while the smaller ones may either be depressed, or (if the pupil be not too much contracted) they may be pushed into the anterior chamber, where they will soon be absorbed. When the cataract is partially adherent to the uvea. Beer recommends an endeavour to be first made with the edge of the needle (which is to be introduced flat between the cataract and the uvea, above or below the adhesion) to separate the adherent qltrts before the attempt at rechnation is made. Should it be a cataract which always rises ^ain as soon as the needle is taken from it, though the instrument has not pierced it at all, the case is temied the elastic cataract, in which the lens is not only firmly adherent to its own capsule, but this also to the mem- brana hyaloidea. Here Beer thinks that the best plan is first to carry the needle to the uppemiost point of the posterior surface of the lens, and, by means of perpendi- cular movements of the cutting part of the instrument, to endeavour completely to loosen this preternatural ad- hesion of the cataract to the vitreous humour, when re- clination may be tried again, and will perhaps succeed. But, says Beer, w'hen the continual rising of the cata- ract is caused by the operator's running the needle into it, the instrument must either be withdrawn far enough out of the eye to let it be again properly brought into the posterior chamber, when reclination may be effectually repeated ; or, if the cataract be firmly fixed on the nee- dle at the bottom of the eye, the instrument should not be raised again, but previously to being withdrawn, it should bcTOtated a couple of times on its axis, whereby the pierced lens will be more easily disengaged from the needle, and at last continue depressed.— (LeAre ton den Ajj-gernkr. b. 2, p. 356 358.) In addition to Beer’s directions for couching and re- clination, the following observations seem to me to merit attention. ^Mien the case is a fluid or milky cataract, the ope- rator frequently finds, that on passing the point of the couching-needle through the anterior layer of the cap- sule, its white milky contents instantly' flow out, and, spreading like a cloud over the two chambers of the aqueous humour, completely conceal the pupil, the iris, and the instrument from his view ; who, however, ought never to be discouraged at this event. Although it seems to me most prudent to postpone the comple- tion of operations with the needle, m the example of blood concealing the pupil, in the first step of couching, and not to renew any attempt before the aqueous hu- mour has recovered it's transparency ; I am inclined to adopt this sentiment, chiefly because the species of ca- Uiract is, in this circiunstance, generally unknown to the operator ; consequently, he must be absolutely inca- pable of emplojdng that method of couching which the peculiarities of the case may demand. Speaking of this case, however. Beer says, “ the surgeon must has- ten the completion of e-xtraction or reclination, though possibly the operation may not always admit of being continued, or, if gone on with, it must be done, as it were, blindfold.”— (I/cAre, . 35T, it.2, Us CATARACT, 263 sanctions pushing the fragments of semi-firm cataracts through the pupil into the anterior chamber, where, he confesses, that they are soon absorbed. Beer thinks that, in general, depression and reclina- tion are indicated only in cases in which extraction is absolutely impracticable, or attended with too great dif- ficulty, as will be better understood when this operation is considered. As examples of this kind, Beer specifies an extensive adhesion of the iris to the cornea ; a very flat cornea, and, of course, so small an anterior chamber, that an incision of proper size in the cornea cannot be made; a broad arcus senilis; an habitually con- tracted pupil (incapable of being artificially dilated) ; an eye much sunk in the orbit, with a small fissure be- tween the eyelids ; eyes affected with incessant convul- sive motions ; a partial adhesion of the cataract to the uvea ; unappeasable timidity in the patient ; and an im- possibility of managing him during and after the opera- tion, in consequence of his childhood or stupidity. With regard to the question whether depression or reclination should be preferred. Beer is of opinion that the first method is indicated only when the dimensions of the cataract are small, and, consequently, when there is room enough for it to be placed below the pupil, with- out the ciliary processes being torn from the annulus ciliaris. Such cases are the dry siliquose cataract (the primary membranous cataract of Scarpa), when per- fectly free from adhesions to the uvea ; the true lenticu- lar secondary cataract, produced by the small but firm fragments of the lens having been left, or risen again ; and the genuine secondary membranous or capsular cataract. On the other hand, reclination is to be pre- ferred, when, together with the above objections to ex- traction, the surgeon has to deal with a fully formed, very hard lenticular, or capsulo-lenticular cataract ; or with a case of the latter kind, complicated with partial adhesions to the uvea ; or when the case is a secondary capsular cataract, similarly circumstanced ; a second- ary cataract of lymph ; a gypsum cataract ; or there is reason to apprehend a considerable tendency in the blood-vessels of the interior of the eye to become vari- cose. — (Lehre von den Augenkr. b. 2,p. 365.) The manner of operating with the needle upon the congenital cataracts of children will be hereafter ex- plained. EXTRACTION OF THE CATARACT. From some passages in the works of Rhazes, Haly, and Avicenna, specified by Mr. Guthrie, it is suffi- ciently clear, that the practice of opening the cornea for the removal of cataracts was not unknown to the an- cients. Rhazes says, that about the end of the first cen- tury, Antyllus opened the cornea, and drew the cataract out of the eye with a fine needle, in which practice he was followed by Lathyrion. However, while doubts were entertained respecting the true seat of the cata- ract, it is hardly to be supposed, that this mode of treat- ment could have been frequently adopted ; but as soon as it was fully proved that the true cataract was an opacity of the crystalline lens ; that the loss of sight wouid not be occasioned by the removal of this body ; that the cornea might be divided without danger; and that the aqueous humour would be quickly regenerated ; the mode of cure by extracting the cataract out of the eye would naturally present itself. — {Wenzel.) Freytag is perhaps the first in modem times who made an attempt to extract the cataract : this was about the close of the 17th century. After him, Lotterius, of Turin, performed the operation. But nobody has so strong a claim as M. Daviel to the honour of bringing the merits of the practice before the public ; and he not only adopted it himself, but published the first good de- scription of it. — {Sur une Nouvelle Mdthode de guerir la Catnracte par V Extraction du Cristallin, 1747. Also, M' moires de VAcad. Royale de Chirurgie, t. 2, 4to. 1753.) Two cases in which the cataract had accident- ally slipped through the pupil into the anterior chamber, whence they were extracted in the years 1707 and 1708 by MM. Mery and Petit, as related by St. Ives, seem to have had considerable itifiuencc in bringing about the regular performance of this method of removing the ca- taract ; for they served as an encouragement to Daviel, by whom the practice was completely established. The operation was afterward brought considerably nearer to perfection by the ingenuity and industry of Wenzel. —{Itrarnbilla, Jnstrumentarium Chir. Austriacum, J782.P.71.) Indeed, with the valuable Instructions which Ware and Beer have still more recently furnished, the extrac- tion of the cataract may now be regarded as brought to the highest state of improvement. According to Beer, it admits of division into three stages, the first of which, as in depression and reclination, is the most important, because, unless it be performed exactly as it ought to be, the operation will be very liable to fail, and it is ex- ceedingly difficult to make amends for any fault com- mitted in this early part of the proceedings. The first stage consists in making an effectual opening in the cornea with a suitable knife. The second, in dividing the anterior layer of the capsule, which, says Beer, should not be merely punctured, or torn with a bluntish instrument, but cut with a sharp two-edged lance- pointed needle ; and, as much as possible, annihilated. In the third stage, the expulsion of the cataract from the eye is effected either by the well-regulated action of the eyeball itself, or by the assistance of art. But, as Beer remarks, they who have learned the manner of effect- ually and skilfully cutting the cornea, wdll frequently have the pleasure to find the last two stages beneficially converted into one, and the operation in general soon and expeditiously completed . — ( Von den Augenkr. b. 2, p. 366.) The knives used by Richter, Wenzel, Ware, and Beer are all of them more or less different ; but they agree in the common quality of completely filling up the wound, as it is extended, so that none of the vitreous humour can escape before the division of the cornea is finished. Wenzel’s knife resembles the common lancet employed in bleeding, excepting that its blade is a little longer, and not quite so broad. Its edges are straight, and the blade is an inch and a half (eighteen lines) long, and a quarter of an inch (three lines) broad, in the widest part of it, which is at the base. From this part it gradually becomes narrower towards the point ; so that this breadth of a quarter of an inch extends only to the space of about one-third of an inch from the base ; and for the space of half an inch from the point, it is no more than one-eighth of an inch broad. The knife employed by the late Mr. Ware is, in re- gard to its dimensions, not unlike that employed by Wenzel.’ The principal difference is, that Mr. Ware’s knife is less spear-pointed ; in consequence of which when this latter instrument has transfixed the cornea, its lower or cutting edge will sooner pass below the inferior margin of the pupil, than the knife used by Wenzel. On this account, Mr. Ware believed that the iris would be less likely to be entangled under the knife which he recommended, than under Wenzel’s, when the instrument begins to cut its way down- wards, and the aqueous humour is discharged. Mr. Ware particularly advises great care to be taken to let the knife increase gradually in thickness from the point to the handle ; by which means, if it be con- ducted steadily through the cornea, it will be next to an impossibility, that any part of the. aqueous humour can escape, before the section is begun downwards : and, consequently, during this time, the cornea will preserve its due convexity. But if the blade should not increase in thickness from the point ; or if it be in- curvated much in its back or edge, the aqueous humour will unavoidably escape before the puncture is com- pleted ; and the iris, being brought under the edge of the knife, will be in great danger of being wounde;! by it. But a better knife than any other which has yet been proposed, is that emiiloyed by Beer. A very in- genious double cataract-knife is used by Jaeger. “ The instrument is composed of a Beer’s blade affixed to a handle ; a smaller blade of the same form, having its flat side in contact with the other knife ; and a button screw. When not in use, the second blade is situated within the outline of the first, with which the cornea is transfixed. It is introduced in the same way as Beer’s knife, not parallel, but nearly perpendicular to the cornea, and afterward carried across the eye, ex- actly like the single knife, with the posterior surface of the fixed blade imrallel to the iris, at the usual dis- tance from the junction of the cornea with the sclero- tica. When the point of the greater knife has trans- fixed the cornea at the inner side, pressure is made on the button head of the smaller blade, which slides in a groove in the upper part of the handle with the thumb, with which it it pushed steadily Ibrwards, while the greater blade keeps the bull firmly fixed, and thus the 264 CATARACT. section of the cornea is completed,” &c.— (See Lou- don's Short Inquiry into the Principal Causes of the Unsuccessful Termination of Extraction, <^c. 1826.) Among the advantages imputed to Jaeger’s knife are those of not injuring parts at the inner angle ; of not making the incision too small for the extraction of the lens ; and of less of the aqueous humour being dis- charged previously to the iris being out of danger. The sentiments of Richter, Scarpa, Beer, and others, about the position of the patient in the operation, and the mode of fixing the eye, have been already noticed in a foregoing section. The operator is to sit in front of the patient, but upon a considerably higher stool or chair than the lat- ter, as already explained, and his legs are to be placed on each side of the patient, and his right foot suffl- .ciently raised by a stool for his elbow to rest upon his knee, while the knife is on a level with the patient’s eye.— (See Guthrie's Operative Surgery of the Eye, p. 295.) When the right eye is to be operated upon, and the operation is to be done according to the preceding di- rections, the surgeon must of course use his left hand ; but if he be not an ambidexter, “ the patient must be placed on his back on a table, or on a mattress, or a firm bedstead vtdth a head, so that the operator can stand behind without inconvenience. The head being supported on a cushion, the operator raises the upper eyelid himself and fixes the eyeball, Avhile an assistant depresses the lower lid, if nece*ssary. The incision is then to be made with the same precaution as in the other method, the knife being held with its edges to- wards the thumb, and the httle finger towards the temple instead of the cheek. The division of the cor- nea upwards in this manner is the operation generally preferred by ]\Ir. Alexander for both eyes, when not specially contra-indicated.” — (^Guthrie, p. 318.) Baron Wenzel, fearful of the bad consequences of undue pressure, made no endeavour to fix the eye at all at the period of cutting the cornea. The late Mr. Ware did not approve of this plan of leaving the eye unfixed. The danger likely to arise from undue pressure, he observes, can only take place after the instrument has made an opening into the eye ; but the pressure which he recommended is to be removed the instant the knife is carried through the cornea, and before any attempt is made to divide this tunic downw'ards. To understand this subject better, however, the reader should know, that Mr. Ware di- vided the incision of the cornea into two distinct pro- cesses ; the first of which may be called punctuation, and the second section. So long, says Mr. Ware, as the knife fills up the aperture in which it is inserted, that is, until it has passed through both sides of the cornea, and its extremity has advanced some way be- yond this tunic, the aqueous humour cannot be dis- charged, and pressure may be continued with safety. The punctuation of the cornea being completed, the purpose of pressure is fully answered ; and if such pressure be continued when the section of the cor- nea begins, instead of being useful, it will be hurtful. To avoid all bad defects, Mr. Ware recommends the cornea to be cut in the following way. The operator is to place the fore and middle fingers of the left hand upon the tunica conjunctiva, just be- low and a little on the inside of the cornea. At the same time, the assistant who supports the head is to apply one or, if the eye projects sufficiently, two of his fingers upon the conjunctiva, a little on the inside, above the cornea. The fingers of the operator and as- sistant thus opposed to each other, will fix the eye, and prevent the lids from closing. The point of the knife is to enter the outside of the cornea a little above its transverse diameter, and just before its connexion with the sclerotica. Thus introduced, it is to be pushed on slowly, but steadily, without the least intermission, and in a straight direction, with its blade parallel to the iris, so as to pierce the cornea towards the inner angle of the eye on the side opposite to that which it first entered, and till about one-third part of it is seen to emerge beyond the inner margin of the cornea. When the knife has reached so far, the punctuation is completed. The broad part of the blade is now be- tween the cornea and the iris, and its cutting edge be- low the pupil, which of course is out of all danger of being wounded. As every degree of pressure must now r»e taken off the eyeball, the fingers both of the 1 operator and his assistant are instantly to be removed from this part and shifted to the eyelids. These are to be kept asunder by gently pressing them against the edges of the orbit ; and the eye is to be left entirely to the guidance of the knife, by which, says Mr. Ware, it may be raised, depressed, or drawn to either side, as may be found necessary. The aqueous humour being now partly, if not entirely, evacuated, and the cornea of course rendered flaccid, the edge of the blade is to be pressed slowly downwards, till it has cut its way out, and separated a little more than half the cornea from the sclerotica, following the semicircular direction marked out by the attachment of the one to the other. —{Ware.) In the eyes of some persons, the iris is so convex, that it almost impossible to complete the section of the cornea without entangling the iris under the edge of the knife, unless the cornea be gently rubbed down- wards with the finger ; one of the most important di- rections, according to Mr. Ware, in Wenzel’s whole book. If the edge of the knife should incline too much for- wards, and its direction be not altered, the incision iu the cornea will be too small, and terminate almost op- posite the pupil. In this case, there will be great dif- ficulty in extracting the cataract, and the cicatrix afterward may obstruct sight. If, on the contrary, the edge of the instrument be inclined too much back- wards, and its direction be not changed, the incision will approach too near the part where the iris and scle- rotica unite, and there will be great danger of wound- ing them. These accidents may be prevented by gently rolling the instrument between the fingers, until the blade takes the proper direction.— (WcrizeZ.) The late Mr. Ware had seen operators, through a fear of wounding the iris, introduce and bring out the instrument at a considerable distance before the union of the cornea and sclerotica ; in consequence of which the incision from one side of the cornea to the other was made too small for the easy extraction of the ear- taract, although from above downwards it was fully large enough for this purpose. Mr. Ware also some- times observed, that though the punctuation of the cornea from side to side had been properly conducted, and its section afterward, to all appearance, effectu- ally completed, yet, on account of the frictions em- ployed to disengage the iris from the edge of the in- strument, the knife, in cutting downwards, was carried between the layers of the cornea, and, consequently, though the incision appeared externally to be of its proper size, internally it w^ls much too small for the cataract to be easily extracted. In this case, the inci- sion must be enlarged by means of a pair of curved blunt-pointed scissors, w'hich should be introduced at the part where the knife first entered the cornea. — {Ware.) Beer subdivides the first stage of this operation into four, each of which, he says, claims the utmost atten- tion, if it be wished to make the incision in the cornea in every respect proper ; the first is the introduction of the knife through the cornea into the anterior chamber; the second is directing the knife towards the place where its point is to be brought out again ; the third is bringing out the point and guiding the knife in con- tinuing the incision in the cornea ; and the fourth is the finishing of that incision. As Beer states, a com- pletely well-made incision in the cornea must, in the first place, be of sufficient size to let the cataract es- cape from the eye without the slightest impediment ; and it will be large enough, if care be taken to open one-half of the cornea near its edge. Secondly, it must be of a proper shape, its margin not being triangular, nor notched, but evenly rounded. In general, says Beer, no greater disadvantage can happen, than that of having too small an incision in the cornea ; for, even when the cataract is pressed out of such an opening, portions of it are always left behind which afterward cannot be extracted without trouble ; and though the sight may be at the moment restored, it will be fortu- nate if the eye be not afterwasd spoiled by the effects of inflammation. When the incision is triangular or notched, its edges cannot be put smoothly together so as to be healed by the first intention, which, however, is highly necessary, and the conseijuence is a white ugly scar, which is slowly produced with inflamma- tion, and forms a greater or less permanent impediment to vision downwards, though the patient be capable of CATARACT. 265 seeing the smallest objects which are straight before I him. I According to Beer, when the knife is to be intro- i duced, its point should enter the cornea, about one- eighth of a line from its edge, and one-fourth of a line above its transverse diameter, directed obliquely to- wards the iris, with its edge turned downwards, by which means the point will pass immediately into the anterior chamber. As soon as it has arrived there, which is indicated partly by its bright extremity being seen within the space in question, and partly by the tactus eruditus, such a direction is to be given to it, that its point may project from the place of its entrance nearly in a direct line towards the intended place of its exit out of the cornea, but a little higher ; while the posterior surface of the blade is to be conveyed across the anterior chamber exactly parallel to the iris. The knife is to be cautiously pushed on, neither too quickly nor too slowly, with its point continually directed somewhat upwards above the part, where it is to pass out again, until the point arrives near the inner edge of the cornea ; but in the transverse passage of the knife, its edge should not be suffered either to go nearer to or farther from the ins, as every turn of the blade backwards or forwards opens the upper angle of the wound, when the aqueous humour immediately escapes, and the iris not only falls close against the posterior surface of the blade, but sometimes even un- der the edge, so as to. throw the young operator into the greatest embarrassment. If the point of the knife has now been favourably brought out, the surgeon is to continue to push it on without pressing it down- wards, or making a sawing motion with it, until the last stage of the operation, viz. that in which the inci- sion is finished. However, as soon as the point of the knife has passed out of the cornea and reached the inner canthus, attention must be paid, first, to that part of the blade wliich is yet in the anterior chamber, so that the iris may not fall under its edge, and the knife may not take an erroneous direction ; secondly, to the point of the knife, which continually projects more and more, so that the inner canthus may not be wounded, which accident, though trivial in itself, would make the unprepared patient suddenly and in- voluntarily draw back his head. The only way of preventing this injury, says Beer, is regularly to in- cline the handle more backwards and downwards, in proportion as the point passes farther out of the ante- rior chamber. Thirdly, at the period when the last piece of the cornea is to be cut, the knife should be pushed on very slowly, for otherwise the lens, and with it a part of the vitreous humour, may be discharged, as now the muscles of the eye are acting and com- pressing this organ with the greatest force, and, in old persons especially, the loose conjunctiva, after the cor- nea is cut through, comes against the knife, and is apt to be wounded. At the time when the operator finishes the incision in the cornea, the assistant is to let the upper eyelid cover the eye, and a few seconds are to be allowed for the patient to recoverfrom his fright. In the second stage of the operation. Beer directs the assistant again steadily to hold the patient’s head in the same manner as during the cutting of the cor- nea; but the upper eyelid, he says, must be carefully and effectually raised, without touching, the eyeball in the least, or letting the ends of the fingers project be- yond the edge of the tarsus. The operator is to de- press the lower eyelid with his fore-finger, which is not to be removed away from the eye, but gently ap- plied to the lower part of it with the intervention of the eyelid, by which means the cataract-lance or cap- sule-needle may be more readily and easily introduced under the flap of the cornea into the pupil, while the gentle pressure and the projection of the cataract thereby jiroduced considerably enlarge the pupil, and facilitate the proper division of the capsule. In order to complete the latter object, the surgeon introduces one of the sharp edges of the capsule-needle, with the point directed towards the inner canthus, between the cornea and the iris, the wound in the former of these membranes being opened as little as possible, lest the atmospheric air enter the eye ; a circumstance of which Beer entertains great apprehension. After the cap- sule-needle has been cautiously passed to the inferior margin of the pupil, its lower sharp edge is to be ap- plied to the capsule of the lens with its point directly upwards, and one of its flat surfaces towards the I inner, and the other towards the outer canthus. The I operator is now strictly to cut through the capsule, by i making, at small distances from one another, repeated perpendicular strokes with the edge of the needle. Then the handle of .the instrument is to be half turned round on its axis, and similar strokes are to be made with its edge in a somewhat oblique direction, by which means the anterior layer of the capsule will be cut into many squarish fragments, some of which, in the third stage of the operation, are taken out of the eye together with the cataract, and the risk of a se- condary cataract of the anterior layer of the capsule is in a great measure removed. When the capsule- needle has done its business, it is to be withdrawn from the eye in the same position in which it was in- troduced, and the second stage of the operation is thus finished.— (Beer, b. 2, p. 369.) I believe no better instructions than the foregoing can be delivered, respectir g the most advantageous method of dividing the capsule. They are infinitely better than those given by Wenzel and Ware. As soon as the point of the cornea-knife had arrived opposite the pupil, Wenzel used to incline it gently backwards, and thus puncture the capsule ; but Mr. Ware very pro- perly objected to this plan, which, however it might serve to exhibit the dexterity of the operator, was at- tended with no advantage to the patient, and could not be so efficient and safe as the mode of making the di- vi.sion of the capsule a distinct part of the operation. Indeed, Wenzel himself did not recommend opening the capsule of the crystalline in this way when the pupil was much contracted, and the muscles of the eye and eyelids easily thrown into convulsions, or when the posterior chamber was large. For dividing the capsule after the division of the cor- nea, Wenzel and his father used to employ a flat needle, one line, that is, one-twelfth part of an inch, in diameter, having its cutting extremity a little incur- vated. This needle, which they advised to be made of nealed gold, in order that its pliability may allow the operator to bend it in different directions as occasion requires, is fixed in a handle two inches and a half in length, and similar to that of the cornea-knife. At the other extremity of the same handle a small curette or scoop is fixed, made also of nealed gold, which is of use for extracting the cataract. The late Mr. Ware’s method of opening the capsule will be hereafter noticed. When the incision in the cornea has been completed, and the capsule effectually divided, the cataract, as Beer observes, advances into the pupil immediately behind the capsule-needle, and if there be the least ac- tion in the eye itself, it is generally at o.nce discharged, Under these very favourable circumstances, however, it sometimes happens that a portion of the gelatinous or scabrous surface of the cataract is detached at the margin of the pupil, as the opaque body is passing out, and therefore in the second stage of the operation, Beer recommends having Daviel’s scoop always ready, which is to be substituted for the capsule-needle, and employed for preventing the loose fragments from fall-, ing back into the posterior chamber, in the following manner : as soon as the operator remarks that in the passage of the cataract out of the pupil, a portion of it will be scraped off by the edge of that opening, he should introduce the scoop at the lov/er and outer edge of the cataract upwards, between the cornea and the iris, so as to be able to keep the part of the cata- ract which is ready to break off, close up behind the rest of it, and bring the whole out of the eye. But, says Beer, when the third stage of the opera? tion, viz. the removal of the cataract from the eye, cannot be so readily accomplished ; a circumstance not always owing to an imperfection in the incision in the cornea or in the division of the capsule, but sometimes proceeding from a want of proper action in the eye it- self; the operator, if he feels convinced that the fault does not lie in the first or second stage of the opera- tion (in which case it would be necessary to endeavour to rectify what is wrong), should assist in promoting the discharge of the cataract. There are tvyo manners of doing this, and it is not a matter of iridifi'erence which is selected ; for the second should be adopted only when the first will not answer. Hence, says Beer, the operator, like a skilful accoucheur, must first trust to the action of the organ itself, which he should in a certain degree excite, and not proceed immediately 266 CATARACT. to fhe use of a scoop, hook, or forceps. The eye is to be suffered to turn quickly a few times upwards, and in general, during these movements, the surgeon will perceive that the lower edge of the cataract advances farther through the pupil, and at length slips out of the eye without the aid of instruments. If at this period a portion of the cataract were found to be likely to break off, the employment of David’s scoop in the way already explained would be proper. On the other hand, if, during the protracted movements of the eye upwards, this organ evince little energy of its own, the cataract will not enter the pupil, or scarcely do so, much less pass out of the eye, and the operator is under the necessity of resorting to manual assistance, and with the end of the finger, used for keeping the lower eyelid depressed, he is gently to press the lid against the lower part of the eyeball . Such pressure should be gradually increased until the greatest diame- ter of the cataract has passed into the pupil, at which moment the pressure must not be discontinued before the cataract is completely out of the eye, which object may be promoted by supporting the lower part of the lens with David’s scoop, and then the pressure is to be diminished in the same gradual way in which it has been previously augmented. Immediately the ca- taract is completely out of the eye, and the surgeon has paid due attention to the removal of any fragments left behind, the assistant is to let the upper eyelid de- scend, the patient is to be desired to keep both his eyes shut and perfectly still, and his head and eyes are to be covered with a clean white piece of linen, so that the effect of the light may be moderated. When the patient has recovered from the alarm, which, according to Beer, the passage of the cataract outwards, especially when it is large and firm, always produces in a greater or less degree, he is to be placed with his back towards the window, and the linen is to be rai.sed a little from the eye, which is to be very slowly opened, while the other eye, which has not been operated upon, is to be kept well covered. Beer says that the patient should then be shown some objects, not of a shining or very bright description, at different distances; and if he is able to see them plainly, the surgeon may proceed to apply the dressings without delay. Beer confesses, that if possible it would be better to dispense altogether with making any trials of the power of the eye which has just been operated upon, because such attempts must tend to increase the sub- sequent inflammation in the organ ; yet he is of opi- nion that these trials of the eyesight are necessary after extraction of the cataract. First, because the ca- pability of seeing immediately is a thing always ex- pected by the patient and liis friends, and leaving them in ignorance on this point would keep up an anxiety likely to have a bad effect in rendering ophthalmy more severe. Secondly, Beer urges as a stronger mo- tive for the custom, the circumstance of the patient seeing, when his eye is first opened, all, even the smallest objects, though he suddenly loses the fa- culty of distinguishing them at all, or sees them very obscurely ; and now, if he be half turned with his face towards the window, one will find in the pupil, which directly after the passage of the cataract was perfectly clear, some soft or firm fragments of the lens, which are first dislodged from within the capsule* by the va- riations in the eye, produced by the inspection of dif- ferent objects at different distances, and which, with- out these trials of vision, would be long in being loosened by the aqueous humour, and might form a secondary lenticular cataract ; which will not now' be the case, as the surgeon can and ought at once to re- move them. — {Lehre von den Augenkr. h. 2, p. 373.) The preceding mode of operating, as Beer observes, will not answer for every case of cataract adapted to extraction ; but the plan sometimes requires to be mo- dified according to circumstances. Thus, according to the same writer, when the eye is very prominent, and particularly when at the same time the fissure of the eyelids is extremely narrow, the incision in the cor- nea must not be made horizontally, but obliquely out- wards ; for otherwise the edge of the lower eyelid will retard the healing of the wound, and an ugly cicatrix, more or less injurious to the eyesight, be the conse- quence. When the cataract is of middling consistence, nei- Uier very hard nor soft, Beer assures us that the at- tempt ought to be made to extract the cataract and the capsule together.— (il/efftode den grauen Staar Sammt der Kapsel aiLszuziehen, Ac. Wien, 1799.) In such a case, he says, the experiment will mostly succeed if properly conducted, and if it should not, it causes not the slightest detriment to the eye, nor the least ob- stacle to the effectual completion of the operation. The capsule-needle is to be introduced into the pupil, as in the second stage of the operation, and its point is then to be slowly pushed, as far as its greatest diame- ter, into the centre of the lens, so that one surface of the needle may be upwards, the other downwards ; one of its cutting edges turned towards the inner can- thus, the other towards the outer one. And now the needle, with the impaled cataract, is to have sudden but short perpendicular jerks communicated to it, by which means the upper and lower connexions of the capsule with the neighbouring textures will be in part loosened. The needle is next to be suddenly ro- tated without withdrawing it from the cataract, so that one of its flat surfaces may face the inner canthus, the other the outer one ; and one of its edges may be turned upwards, the other downwards ; and then the short sudden jerks of the needle in the horizontal di- rection may be repeated, for the purpose of breaking, as much as possible, the lateral connexions of the cap- sule. Lastly, the capsule-needle is to be quickly with- drawn from the eye, when it is mostly followed by the lens and the capsule, or the cataract comes away fixed on the point of the instrument, at which moment the pupil becomes perfectly clear and black. When the cataract does not follow the withdrawing of the needle, the surgeon is to proceed with the usual cautions to the third stage of the operation. Great as the advan- tage would always be of extracting the cataract, together with its capsule, it is plain that the attempt is not practicable when the case is a very hard len- ticular cataract, because the capsule-needle cannot be effectually introduced into the body of such a lens, situated upon the yielding vitreous humour. Nor would the plan answer if the cataract were very soft, as the movements of the needle in it could have no ef- fect in breaking the connexions of the capsule. Mr. Lawrence has often expressed to me his decided opi- nion that the foregoing method will rarely succeed, and ought not to be attempted ; which is also Mr. Guth- rie’s judgment.— (Operative Surgery of the Eye, p. 308.) In the case described by Beer under the name of en- r.y.tcrior chamber. Beer says, that it ought to be imme- diately removed, lest the patient be left with a second- ary lenticular cataract, which, he observes, is not al- ways so certain of being dissolved and absorbed as some imagine. The fragments may be removed in two ways; and first, the experiment of rubbing the upper eyelid over the eye should be made, because it not un- frequently brings the remains, especially when they are gelatinous, completely through the pupil, and out of the incision in the cornea. But if such manoeuvre should not be effectual. Beer recommends cautiously in- troducing Daviel’s curette to the outer pupillary edge of the iris, with its concavity towards the inner sur- face of the flap of the cornea, without raising this flaj) unnecessarily high, and then the operator is to endea- vour to scoop out at once as much of the opaque mat- ter as he can, and bring it to the inner surface of the cornea. He says, that it will rarely be necessary fre- quently to repeat the introduction of the curette.— kB. 2, p. 3S7.) According to Mr. Ware, an opacity of the capsule can be the only reason for reinoving it. Tlte anterior part, he says, can alone become the object of the operator’s at- tention ; its posterior part is necessarily hidden, while the cataract remains in the eye, and afterward, if disco- vered to be opaijue, it is so closely connected with the capsule of the vitreous humour, that Mr. Ware believes it cannot be removed by any instrument, without ha- zarding a destructive effusion of this humour. When, however, the opaque lens is accompanied with an opacity in the front part of the capsule, the late Mr. Ware recommended the following plan. After cutting the cornea, as usual, a fine-pointed instrument, somewhat smaller in size than a round couching-needle, and a little bent towards the point, should be introduced under the flap of the cornea, with its bent part up- wards, until its point is parallel with the aperture of the pupil. The point should then be turned towards the opaque capsule, which is to be punctured by it in a circular direction, as near td the rim of the pupil as the instrument can be applied without hurting the iris. Sometimes the part included within the punctures may be extracted on the point of the instrument ; and if this cannot be done, it should be removed with a small pair of forceps. The lens, whether opaque or transparent, should next be extracted, by making a slight pressure with the curette, either above or below the circumfe- rence of the cornea. On the preceding subject Beer remarks, that when none of the lens itself is left behind, but there is a slight degree of opacity in the anterior layer of the capsule, easily distinguishable from the cut flakes, and pro- ducing the least obstacle to vision, the opaque mem- brane should be taken away with the forceps, in the manner described in the preceding pages ; for, other- wise, a secondary capsular cataract will follow, which will become of a snow-white colour, and if only a tri vial degree of iritis takes place after the operation, it will become adherent to the iris, and the pupil become contracted and disfigured.— (B. 2, p. 388.) Beer does not agree with Ware in condemning all attempts to remove the posterior layer of the capsule,^ when found opaque, after the extraction of the lens. The case, he says, is indicated by the light-gray speckled appearance of tlie whole pupil, and by the patient see- ing nothing at all, or objects only indistinctly in a thick mivSt. Beer advises a cataract-tenaculum to be passed into the pupil, in the same way as the capsule-needle is introduced in the second stage of extraction, directing its point downwards as it enters, and upwards when it is brought out again. After it has entered the pupil, it is to be made to divide and annihilate, by repeated turns of the tenaculum, the back layer of the capsule, and also the membrana hyaloidea directly behind if, which, in such a case, is always adherent and opaque. Of these membranes a considerable part, closely wound round the hook, may be taken out of the eye, though never without some slight loss of the vitreous humour. In cases of this kind, the patient ought to be informed, that though his sight will be restored, a part of the ca- taract must be left, and will be visible behind the pupil, particularly when it is dilated ; for otherwise suspicions may arise, that the operation has been badly done, and a relapse apprehended. — {B. 2, p. 388.) The late Mr. Ware published some remarks on the bad consequences of allowing foreign bodies of any kind, after the operation, to press unequally on the globe of the eye ; comprehending under this head, the intervention of the edge of the lower eyelid between the sides of the divided cornea ; the inversion of the edge of the lower eyelid ; and the lodgement of one or more loose eyelashes on the globe of the eye. To prevent the first accident, every operator, before applying the dressings, should carefully depress the lower eyelid; and before he suffers it to rise again^ should take care that the flap of the cornea be accu- rately adjusted in its proper position ; and that the upper lid be dropped, so as completely to cover it. After this, the eyelids should not be opened again for three or four days, (hat is, until there is a good reason to suppose the wound in the cornea closed. The inversion of the lower eyelid is hurtful, in con- sequence of its making the eye-lashes rub against the eye. These should be extracted the day before the operation. For the mode of effecting a permanent cure, .see Trichiasis. Besides the danger to which the eye is exposed from the inversion of the edge of the lid, the eye may receive injury from the improper position of the eye- lashes alone; one or more of which, during the ope- ration, may happen to bend inwards, or, becoming loose, may afterward insinuate themselves between the inside of the lid and the eye. An eyelash bent in- wards should be rectified ; if broken off and loose, it should be removed. Lastly, Mr. Ware considers prematurely exposing the eye to a strong light. He censures the plan of ojiening the eyelids within the first two or three days after the operation, because the stimulus of the light increases the ophtlialmy, and the method is ajit to dis- turb the wound in the cornea before it is closed. Mr. Ware, however, wishes it not to be inferred, that he is an advocate for long conlinemcMt after the operation. His mode is to keep the patient wholly in bed, and to direct him to move his head as little as possible, for the first three days after the operation. During this time, a dossil of wet lint is kept on his eyes, covered 270 CATARACT. ■with a saturnine plaster, compress, and bandage, as already described. The dressing is renewed once every day, and the outsides of the eyelids washed with warm water in winter and cold in summer. At each time of dressing, the skin of the lower lid is drawn gently down, to prevent any tendency to an inversion. Ani- mal food is prohibited, and the patient enjoined not to talk much. On the fourth day he is permitted to sit up for two or three hours, and if he has had no stool since the operation, a mild opening medicine is now administered. On the fifth, the time of his getting up is lengthened, and presuming that the wound in the cornea is now closed, Mr. Ware usually examines the state of the eye. After this, no dressing need be ap- plied in the daytime, care being taken to defend it from a strong light by a pasteboard hood or shade, and by darkening the room, so that no inconvenience is felt. The patient may now also look for a short time at targe objects. The following part of the treatment need interfere very little with the wishes of the patient, unless unexpected accidents occur. — (Ware.) As Beer observes, if the patient be very restless, make frequent attempts to open his eyes in the least, and partly lie upon the eye, or if in changing the com- presses the greatest caution be not used, the eye will perhaps be roughly pressed upon, and the iris protrude between the displaced and half-opened edges of the in- cision in the cornea, to which it will become adherent during a slow and seldom very violent inllammation. From the moment when 'he iris thus interposes itself between the sides of the wound, the aqueous humour begins to collect, and at length pushes the iris consi- derably forwards. In this case. Beer recommends care- fully opening the eye in a very moderate light, and adopting the expedients formerly mentioned, for the purpose of making the iris recede. The dressings should be reapplied, and the eye kept closed and very quiet for at least eight or ten days,' so as to hinder a recurrence of this disagreeable accident. But if the iris should be already adherent to the edges of the wound in the cornea j the eye incapable of bearing light, and the aqueous humour more or less accumu- lated in the anterior chamber. Beer says, every thing must be left to time, while the eye is kept lightly co- vered for about a fortnight, and the existing inrtamma- tion properly treated. Then, if the protrusion, or sta- phyloma of the iris should not be diminished by the means calculated for lessening the inflammation, caus- tic or the knife must be employed.— (Beer, b. '2, p. 391.) The same causes which have been above specified, as conducive to a protrusion of the iris, may also produce a discharge of the vitreous humour. The following observations by Beer are interesting : when the dressings have been unskilfully applied; when the incision in the cornea has been made hori- zontally upon a large prominent eye ; when the fissure of the eyelids is exceedingly narrow ; or the patient is restless; a proper cicatrization of the wound in the cornea may not follow. Though the aqueous humour may collect in the anterior chamber, the partially united lamellae of the cornea may be incapable of duly resist- ing the distention of that fluid, and consequently pro- trude in the form of a light-gray, semi-tran.sparent, oval vesicle, extending nearly the whole length of the wound in the cornea, and . being most prominent in the centre. The patient complains of an annoying sense of pressure in the eye. as in cases of protrusion of the iris ; but the discharge of the aqueous humour has completely stopped, and therefore the anterior cham- ber presents its natural appearance, and the pupil its regular round shape, though the edges of the wound in the cornea are whitish and swollen. This case was formerly regarded as a prolapsus of the membrane of the aqueous humour ; but Beer considers it as a sort of hernia of the cornea, termed ceratocele. Merely punc- turing or cutting away the cyst is of no service ; for though the aqueous humour immediately flows out, the wound soon closes again and the tumour reappears, attended also with some risk of the iris falling into the cyst, and becoming adherent to it. EflTectual relief cannot be obtained, unless the tumour be removed, with David’s scissors, as close as possible to the wound ; the dressings skilfully arranged ; and the eye kept closed and quiet for eight days or a fortnight. In such a case, a whitish scar is always permanently left. — (Beer, b. 2, p. 393.) Beer observes, that when the pupil contracts very considerably after the incision in the cornea is made, and the cataract at the same time remains at some dis- tance from the uvea, too small an opening has gene- rally been made, and it ought to be enlarged. But if the cataract cannot be forced though the pupil with- out making pressure on the lower part of the eyeball, and the closure of the pupd should still continue, the circumstance proceeds from the loss of the aqueous humour, and the second stage of extraction must be deferred a little while, until the pupil dilates again, and the operation must then be finished in a very moderate light. — (Also Guthrie’s Operative Surgery of the Eye^ p. 305.) When, in the second stage of the operation, the an- terior layer of the capsule has been properly divided, and yet the cataract will not pass into the pupil, though the eye itself acts with energy. Beer says, that it is indispensably necessary to make pressure upon the lower part of the eyeball, as already advised, and to continue it either until the cataract with its lowermost edge efiectually projects through the pupil and out of the eye, or until it is moved so far directly upwards (without entering the pupil) that its lower margin is brought into view, and quite a black semilunar inter- space is seen between it and the inferior pupillary edge of the iris. At this moment the operator, without in- creasing the pressure of the finger on the eyeball, lest the vitreous humour burst, and a great part of it be lost, and without lessening the pressure, lest the cata- ract sink back into the eye, should introduce Daviel’s curette into the above interspace, with its hollow sur- face applied against the back surface of the cataract, which is to be gently pushed out of the eye. In do- ing this. Beer owns that a small part of the vitreous humour is almost always lost, but the quantity is not at all comparable to what is lost when the hyaloid membrane gives way before Daviel’s curette is intro- duced, which can then only be passed into the eye through the protruded vitreous humour for the pur- pose of pushing out the cataract. Beer notices the occasional protrusion of the iris, in the third stage of the operation, more or less between the edges of the incision in the cornea, immediately after the exit of the cataract. Here, says Beer, the iris should be reduced without the least delay, and the pupil, which is completely oval, made round again ; a thing which the operator may easily perform, by ap- plying his hand flat upon the patient’s forehead, letting the latter shut his eye, rubbing the upper eyelid quickly yet gently with the thumb, and then suddenly opening, the eye, by which means a moderate light will at once strike it, and produce an expansion of the iris. In all patients who have been operated upon for cata- racts, the edges of the eyelids become glued together with mucus on the first night after the operation ; yet, according to Beer, in individuals particularly subject to copious secretions of mucus, it is not unusual for the puncta lachrymalia and lachrymal ducts to be blocked up with thickened mucus, whereby the tears are prevented from duly passing down into the no.se, so that from time to time they are discharged from the inner angle of the eye, and collect under the eyelids. In this case, the patient soon begins to complain of a violent, continual, and increasing sense of pressure on the eye, and the upper eyelid swells, unattended with any redness. Irritable persons also experience a stu- pifying dull headache. These inconveniences may be immediately removed by clearing away the mucus with a little lukewarm milk from the inner canthus, and letting a stream of clean water fall over the cheek. Care must also be taken to hinder a recurrence of the circumstance, and to remove it if it should happen. The inflammation consequent to extraction chiefly^ affects the iris and neighbouring textures. Beer refers its origin principally to the entrance of air into the interior of the eye; which, owing to the size of the wound, he says, is not entirely to be prevented. But another cause is the introduction of different instru- ments into the eye ; and hence the inflammation is ge- nerally severe when it has been necessary to remove fragments of the cataract with Daviel’s curette, or to take away the capsule with forceps, or destroy it with the tenaculum-needle. However, Beer is of opinion, th.it a surgeon who knows how to operate well m every mode, will not find the inflammation, under these cir- cumstances, more violent after extraction than other methods ; and therefoio he thinks that when no con- CATARACT. 271 ftlderable impediment exists, it should be preferred. Beer, who considers extraction as a radical mode of re- moving a cataract, thinks, that when there are no great and insurmountable obstacles to its performance, and the operator can execute it as well as all other methods, and with the requisite skill, it ought to be preferred. But when he is deficient in skill, he is himself the greatest impediment to the success of the operation. The particular cases in which the methods of depres- sion and reclination are indicated, have been already specified, and in these, of course, extraction is not ad- vantageous. There are also some examples, as Beer remarks, in which the latter operation must be hazard- ous for a beginner, and therefore, in respect to such an orperator, by no means eligible, as in cases of har-cata- ract and capsulo-lenticular cataracts with a cyst of purulent matter— {Beer, b. 2, p. 3‘J6.) OF KERATONYXIS. Gleize, having commenced an operation by extrac- tion, was prevented from completing it by a sudden movement of the patient’s head : instead of enlarging the opening in the cornea with scissors, he intro- duced a needle through it, and depressed the lens. This case led to the invention of the new method of opera- ting by keratonyxis, as it is now termed, a description of which Gleize published in 1786. Gleize’s method was simplified by Conradi, who merely opened the cor- nea and capsule of the lens with a lance-shaped knife, and left the removal of the cataract to be effected by the absorbents. Several improvements were subsequently made in this method by Dr. H. Buchhorn, who first gave it the name of Keratonyxis (see this word), and adopted the practice of dividing the lens, as well as the capsule, and of bringing the fragments forwards into the anterior chamber. About the same time Mr. Saunders, in England, perfected a similar operation, and applied it particularly to congenital cataracts.— (See Guthrie's Operative Surgery (f the Eye, p. 331, 332.) This operation requires the pupil to be first artificially dilated. The belladonna (says Mr. Guthrie) should be applied the day before, and on the morning of the ope- ration, in order that the pupil may be completely di- lated, and a few drops of a solution, in the proportion of five grains of the extract to a drachm of water, should be dropped into the eye half an hour before its com- mencement, so as to prevent a contraction of the pupil during the operation. — {Op. cit. p. 333.) Keratonyxis admits of being divided into two stages ; first the intro- duction of the needle through the cornea and pupil as far as the cataract; and secondly, the breaking of the lens to pieces, and the division and laceration of its capsule. For these purposes Beer prefers a common, straight, spear-shaped, sharp-edged couching-needle to any curved one, however fine it may be made ; first, because it pierces the cornea with greater facility ; se- condly, because both a soft cataract and the capsule can be more effectually cut with it, a larger opening being made, through which the aqueous humour may flow over the fragments of the lens, and the dissolution of the cataract be thus rendered more certain ; whereas, with a curved needle, Beer says, the lens can only be disturbed and the capsule torn, under which circum- stances inflammation and a secondary capsular cata- ract are likely to be juoduced. He directs the instru- ment to be introduced either at the lower or at the ex- ternal part of the cornea, one line and a half from its margin, the point being directed obliquely towards the pupil, and the capsule is to be effectually cut by moving the extremity of the needle laterally in various ways-; and, above all things, it is necessary at the time of breaking the lens piecemeal, not to let the instrument continue always within this body, but at every stroke to lift it completely out of the lens and capsule, and then introduce it into them again in different direc- tions. Dr. Jacob prefers, for the performance of this opera- tion, a fine sewing-needle curved at the point. He says, that it rarely or never leaves the slightest mark in the cornea. ‘The cajjsule can be opened to any extent ; a soft or friable lens can be actually broken up into a pulp, by pushing the curved extremity of the needle into its centre, and revolving the handle between the fingers ; large fragments can be taken up on the point of ihe needle ffom the anterior chamber, and forced back out of the way of the iris ; or, if sufficiently soft, may be divided by pressing them against the back of the cornea with the convexity of the neeefie,” L. 1.-6 I I shall now pfoceed to speak of the manner of operas ting upon children. Until the time of Mr. Pott, the intention of surgeons, in couching or depressing the cataract (as indeed the expression itself implies), was to push the opaque crystalline downwards, away from the pupil. Mr. Pott, conscious that the cataract often existed in a fluid or soft state, was aware that it could not then be depressed ; and therefore, in such cases, he recommended using the couching-needle for the express purpose of breaking down the cataract, and of making a large aperture in the capsule, so that the aqueous hu- mour, which he believed to be a solvent for the opaque crystalline, might come into immediate contact with this body. This operation, subsequently to Mr. Pott, has been strongly and ably recommended by Mr. Hey, of Leeds, and Professor Scarpa, of Pavia. In the cases of children, it even received the approbation of the late Mr. Ware . — {On the Operation of Puncturing the Cap' sule of the Crystalline HuJnnur, p. 9.) But, notwithstanding the utility and efficacy of lace- rating the front layer of the crystalline capsule had been so much insisted upon by Scarpa and others, their observ- ations were confined to the cataract in the adult subject, and, before the example set by the late Mr. Saunders, no one (excepting, perhaps, Mr. Gibson of Manchester) ventured to apply, as a regular and successful practice, such an operation to the eyes of infants and children. Indeed, it seems highly probable that even Mr. Gibson himself would have remained silent upon the subject, had not his attention been roused by the reports of the London Institution for curing diseases of the eye, which reports, he says, were dispersed and exhibited in the public news-rooms of Manchester. For the creation and perfection of this beneficial practice, therefore, I am disposed to give the memory of Mr. Saunders great honour. The propriety of operating for the cataracts of children had long ago been insisted upon by a few writers, and the attempt even now and then made ; but tlie method never gained any ground, until Mr. Saunders led the way. It only remains for me to describe the plans of opera- ting, as executed by Mr. Saunders, Mr. Gibson, and Mr. Ware. The principle on which Mr. Saimders proceeded in his operations on the congenital cataract, was founded on the opinion, that the only obstacle to the absorption of the opaque lens is the capsule ; and that, as the latter also is most generally opaque, “ the business of art is to effect a permanent aperture in the centre of this membrane. This applies to every case of congenital cataract which can occur.” Mr. Saunders used to over- come the difficulty of operating upon children, by fixing the eyeball with Pellier’s elevator, having the patient held by four or five assistants, dilating the pupil with belladonna, and employing a very slender needle, armed with a cutting edge from its shoulders to its point, and furnished with a very sharp point, calculated to pene- trate with the utmost facility. Before the operation, the extract of belladonna, diluted with water to the consistence of cream, is to be dropped into the eye, or, to avoid irritation, the extract itself may be smeared in considerable quantity over the eye- lid and brow. In less than an hour, if there be no ad- hesions, it produces a ftill dilatation of the pupil, ex- posing to view nearly the whole anterior surfhee of the cataract. The application should then be washed from the appendages of the eye. In u.sing the needle, Mr. Saunders most carefully ab- stained from doing any injury to the vitreous humour, or its capsule, and it was an essential point with him to avoid displacing the lens. In directing the extremity of the instrument to the centre of the capsule, he passed it either through the cornea, near the edge of this mem- brane (the operation now called Areraf 077 or through the sclerotica, a little way behind the iris. By the first, which is called the anterior operation, Mr. Saunders conceived that less injury w'ould be inflicted, and less irritation excited, than by introducing the needle behind the iris, through all the tunics of the eye. In every case, the first thing aimed at was the permanent de- struction of the central portion of the capsule to an extent equal to that of the natural size of the pupil. If the capsule contained an opaque lens, Mr. Saunder.s used next to sink the needle gently into the body of the crystalline, and moderately open its texture ; cautiously observing not to move the lens at all out of its natural situation. S74 CATARACT. When the case was a fluid cataract, Mr. Saunders Was content in the first operation with simply lace- rating the centre of the capsule, being desirous of avoichng to increase the irritation following the diffusion of the matter of the cataract in the aqueous humour. When the cataract was entirely capsular, Mr. Saun- ders acted with rather more freedom, as he entertained in this case less fear of inflammation : but in other re- spects, he proceeded with the same objects in view w'hich have been already related, and of which the principal consisted in effecting a permanent aperture in For the purpose of fixing the eye, Mr. Ware const- dered Pellier’s elevator requisite in operating upoh infants. When the patient, however, had advanced beyond the age of infancy, Mr. Ware sometimes fixed the eye by means of the fingers alone. For the purpose of puncturing the capsule, and breaking dow n the cata ract, this gentleman gave the preference to an instru ment which resembles one recommended by Cheselden, for the purpose of making an artificial pupil ; but it is somewhat narrower. Its blade, indeed, is so narrow, that it nearly resembles a needle. Its extremity is the centre of the capsule, without detaching this mem- | pointed, and it cuts on one side for the space of about brane at its circumference; for then the pupil would i the eighth of an inch, the other side being blunt. It is have been more or less covered by it, and the operation | perfectly straight, is an inch long in the blade, and imperfect, “ because this thickened capsule is never absorbed, and the pendulous flap is incapable of pre- senting a sufficient resistance to the needle to admit of being removed by a second operation.’’ — (P. 145.) I have already explained, that Mr. Saunders found that the greatest success attended the operation between the ages of eighteen months and four years. One ope- ration frequently accomplished a cure ; as many as five were seldom requisite. The only particularity in Mr. Saunders’s treatment of the eye after the operation, was that of appl>ing the belladonna externally, for the purpose of making the pupil remain dilated, till the inflammation had ceased, so as to keep the edge of the iris from contracting aohe- sions with the margin of the torn capsule. This last practice is found to be so important, that it is never neglected by any good operator of the present day. In forms a complete wedge through its whole length. Upon one side of the handle is a coloured spot ; by at- tending to which, the operator may always ascertain the position of the instrument in the eye. Mr. W'are dilated the pupil with the extractum bella- donnas, softened with a little water, and applied about half an hour before the lime of operating. He believed that, in operating upon infants, the surgeon might per- form the operation wth more composure, if the patient were laid upon a table, wflththe head properly raised on a pillow. The bent end of Pellier’s elevator should be introduced under the upi)er eyelid, and the instrument conunitted to the care of an assistant If the right eye is to undergo the operation, and the surgeon operate with his right hand, he must of course sit or stand behind the patient ; and, in this case, he will himself manage the speculum with his left hand. The eye leaving this part of the subject, I must advise every being thus fixed, Mr. Ware passed the point of the trv inttiir*acsf in /t Tl firTrWJir-Hl Irnif^ nn£>nf surgeon to read the interesting account of Mr . Saunders’s practice, published by his friend and colleague. Dr. Farre. Many minute particulars ^vill be found in this work, highly worthy of the practitioner’s attention and imitation. Mr. Gibson appears to have been unacquainted with the useftjlness of the extract of belladonna in preparing the eye for the operation. A few hours before operating, he was in the habit of ordering an opiate, sufficient to produce a considerable degree of drowsiness, so that the infant generally allowed its eyelids to be opened and properly secured without re- sistance, and was little inclined to offer any impediment to the introduction of the couching-needle ; but, on the contrary, presented the sclerotica to view, naturally turning up the white of its eye. If the infant was more than a year old, and whenever it was necessary, Mr. Gibson used to introduce its body and arms into a kind of sack, open at both ends, and furnished with strings to draw round the neck, and tie sufficiently tight round the legs, so that its hands were effectually se- cured, and the assistants had only to steady its body, and fix its head, while the child was laid on a table, upon a pillow. Mr. Gibson never found it necessary to use a speculum, having uniformly experienced that, after the couching-needle was introduced, he had no difficulty in commanding the eye, aided by a slight de- gree of pressure upon the eyeball with the index and middle fingers of his left hand, w'hich were employed in depressing the lower eyelid. He admits, however, that the speculum can easily be applied, if an operator prefer it. He generally used Scarpa’s needle, because, in infants, the free rupture of the capsule of the lens ought commonly to be aimed at, in order '.hat the milky cataract may escape, and mix with the aqueous hu- mour; or, if the cataract be soft, that the aqueous humour may be freely admitted to its pulpy substance which has been previously broken down with the needle. He thinks that no peculiarity is necessary in depressing the hard cataract of infants. Before Scarpa’s needle was knowu in this countrj’, Mr. Gibson used Mr. Hey’s, which was generally effectual, and, as he conceives, possesses the recommendation of being less liable to have its points entangled in the iris. He says, that when a milky cataract has been thus evacuated, it ren- ders the aqueous humour turbid ; but that within the space of two days, the eye generally acquires its natural transparency, and vision commences. When the cap- sule and substance of the soft cataract have been broken down, and the aqueous humour has come into contact with the lens, the solution and disappearance of the cateiract, in all the cases upon which Mr. Gibson has operated have uniformly taken place in a short time. — (See Edin. Med. and Suro:icalJoitrn.al,vol.8, p. 31)8, 399.) narrow-bladed knife above mentioned through the scle- rotica, on the side next to the temple, about the eighth of an inch from the union of that membrane to the cornea, the blunt edge being turned downwards. The instrument was pushed forwards in the same direction, until its point had nearly reached the centre of the crystalline. The point was then brought forwards, until it had passed through the opaque crystalline and its capsule, and was plainly visible in the anterior chamber. If the cataract was fluid, eind the anterior chamber became immediately filled with the opaque matter, Mr. Ware deemed it advisable to withdraw the instrument, and defer farther measures until the matter w'as absorbed, which absorption usually took place in the course of a few days, and sometimes of a few hours. If no visible change were produced in the pupil, the point and cutting edge of the instrument were applied in different directions, so as to divide both the opaque crystalline and its capsule into small portions, and, if possible, bring them forw ards into the anterior chamber. This may require the instrument to be kept in the ej e for a minute or two ; but if the operator pre- serve his steadiness, he may continue it there a much longer time, w'ithout doing the least injury to the iris, or to any other part. If the cataract be found of a firm consistence (though this rarely happens in young per- sons), it may be advisable to depress it below the pupil ; and in such a case, particular care should be taken to perforate largely the posterior part of the capsule, and to withdraw the instrument immediately after the cata- ract has been depressed, in order to hinder it from rising again. If the opacity be in the capfsule, the instrument will not act so easily upon it as it does on the opaque crj’stalline ; but, notwithstanding this, the capsule, as well as the crystalline, may be divided by it into larger or smaller portions, which, when thus divided, wall be softened by the action of the aqueous humour ; and though in the first operation on such a case, says Mr. Ware, it may not be possible to remove the opacity, -yet, on the second or third attempt, the divided portions may be brought • forwards into the tin- terior chamber, in wffiich place they will then be gradu- ally absorbed, and soon disappear. After the opera- tion, Mr. Ware seldom found it necessary to take away blood from children or persons under the age of twenty. He continued a cooling antiphlogistic treatment a few days. After this, if any opaque matter remained, he expedited its absorption by dropping a small i)ortion of powdered sugar into the eye once or twice a day. When, at the end of a week or ten days, the inflamma- tion was over, and the pupil obstructed with opaque matter, Mr. Ware advised a repetition of the operation. After a similar interval, the operation, he says, may be requisite again. In most cases, Mr. Ware was obliged to operate twice; in a few' instances, ouce proved suftv CAT CAT 275 hient ; and only in three, oUt of the last twenty, did he find it necessary to operate a fourth time.— (On. the Ope- ration of puncturing the Capsule of the Crystalline Humour.) I think any impartial man, who considers the prac- tice of the three preceding operators, will find great cause to admire the superior gentleness and skill which predominate in the operations of the late Mr. Saunders. For my own part, I am so fully convinced of the mis- chief which has been done to the eyes by the rash boldness, awkwardness, and unsteadiness of numerous operators, that it appears to me the inculcation of gen- tleness and forbearance, in all operations for the cata- ract, is the bounden duty of every man who has occa- sion to Write upon the subject. Great manual skill and invariable gentleness, indeed, seem to me to have had more share in rendering Mr. Saunders’s operations suc- cessful, than any particularity either in liis method or his instrument. I have no hesitation in declaring my own partiality to the principles on which his practice was founded, and my belief that they are well calcu- lated to improve most materially this interesting branch of surgery. In conclusion, I shall mention Mr. Guth- rie’s general opinion respecting the kinds of operation suited for the three classes of cataracts, into which he arranges them for the consideration of this important point. The hard admit only of extraction or displace- ment ; the soft seldom of displacement or of extraction, but usually of division; the capsular neither of dis- placement, extraction, nor division, purely considered as such, but b^' laceration, and removal of the opaque body from the axis of vision by different operations, which, although they may partake of the nature of all, are yet not precisely either. All intermediate states of disease, such, for instance, as the caseous and fluid cataracts, admit of some slight deviations from these rules, but are still regulated by the same principles. — {Operative Surgery of the Eye, p. 365.) With respect to extraction, also, it deserves careful recollection, that it is a method, which, though the cataract may be of a hard consistency, is often prohi- bited by various unfavourable circumstances, which I have taken notice of in the foregoing pages. Consult P. Brisseau, Nouvelles Ohs. sur la Cataracte, propo- sftes d VAcad. des Sciences, 1705. Tournay, 1706. Ant. Maitre-Jan, Traiti des Maladies de I'lEil, Mo. Paris, 1707. Charles de St. Ives, Nouveau Traite des Mala- dies des Yeux, \2mo. Paris, 1722. J. H. Frey tag, De Cataracta, Argent. 1721 . A. Petit, Lettre, dans laquelle il demontre que le Crystallin est fort pris de V Uvee, et rapporte de nouvelles Preuves, qui concement VOpera- tion de la Cataracte.— {Haller, Disp. Chir. 5, 570.) L. Heister, De Catara -ta, um.) Cauteries are of two kinds, viz. actual and potential. By the first term is implied a heated iron ; by the second, surgeons understand any caustic application. The high opinion which the ancients entertained of the efficacy of the actual cautery, may be well con- ceived from the following passage. “ Quoscunique morbos medicamenta non sanant, ferrum sanat ; quos ferrbm non sanat, ignis sanat ; quos vero ignis non sanat, insanabiles exislimare oportet.”— (Hipp. sect. 8, aph. 6.) The actual cautery has been employed for the stoppage of bleeding, where the vessels could neither be tied nor compressed. It has been also employed for the destruction of carcinomatous tumours and ulcers, fistulas, polypi, and a variety of fungous diseases. Whoever looks over the writingstof Hippocrates wfil discover, that the actual cautery was a principal means of relief in several chronic afiections, as dropsies, dis- eased joints, &c. In modern times, the actual cautery has been more and more relinquished, in proportion as surgery has attained a higher state of improvement. On the conti- nent, however, it still retains advocates. In France, all the professors recommend and employ it in particu- lar cases. Hospital gangrene, a peculiar disorder, much more frequently seen in foreign and military hospittils than in the charitable institutions for the reception of the sick poor in England, is said to be little affected by any internal remedies. “ Vegetable and diluted mineral acids are the local means employed with effect in mild cases. I have (says Mr. Cress)' al- ready alluded to a case of Pelletan’s, where carbon was applied, and the progress of the disease impeded. But the actual cautery is the only means that has been found effectual in stopping the fatal progress of bad cases of hospital ulcer, and the iron is applied red-hot, so as to produce an eschar on eveiy point of the sur- face of the sore.” — (See Sketches of the Medical Schools of Paris, p. 84, and the article Hospital Gangrene.) Desault often employed the actual cauterv’ to destroy fungous tumours of the antrum. — (See Antrum.) The same practice is still followed by Pelletan and other eminent surgeons in France. Mr. Cross saw it adopted in one such case with good effect. — {P. 86.) That part of the fungus which can be cut away is to be so re- moved, and the deeper portion, out of the reach of the knife, is to be cauterized. If there be any case in sur- gery justifying the use of a red-hot iron, it is a fungus of the antrum. But even in this instance, I should prefer any other certain mode of destroying the root of the disease, and stopping the profuse bleeffing. [The actual cautery has been found exceedingly use- ful in the treatment of the hip-joint disease, though it is seldom employed in tltis countiy for any other pur- pose. It is not easy to perceive, however, in what respects it is to be preferred for the formation of an eschar, which is its chief design, to the potassa fusa, or other caustics. Even in the hip-joint disease, as deep and extensive a destruction of the integument can be effected by some of these, as by the red-hot iron ; without exciting that mental horror which the latter often produces, both in the patient and friends. And although the sloughing is not so early, yet ultimately the effect is the same. In fungus of the antrum, which, according to Mr. Cooper, is the only case in surgery “ justifying the use of the red-hot* iron,” I have known the caustic pottish fully adequate for the destruction of this dis- ease, after the operation with the knife ; and it always arrests the hemorrhage as suddenly and effectually. The use of fire in surgery as an agent for the pur- poses to which it has been applied from time immemo- rial. has gradually fallen into disrepute. But in cases of suspended animation, or sudden injury to the powers of life from casualty, poison, or hemorrhage, in which other means fail, and yet a faint hope is indulged of resuscitation, I apprehend we are perfectly justifiable in resorting to this potential agent. I have employed boiling water to the extremities in cases in which there was no sign of life, after hanging, and hemorrhage from a wound in the throat, and poisoning with opium, and in each of these have met with entire success, although other means offered no hope whatever. The actual cautery applied to the ex- tremities in like manner, had this been convenient, would doubtless have produced the same result. In these and other cases of suspended animation, in which the signs of death, although present, are equivo- cal, it may often be advisable to try this means, for if any portion of vitality remain, fire will find it, and other appropriate means may be then superadded. I believe resuscitation might often be effected by this agent, when other remedial agents are unsuccessful. See article Moxa in this Dictionary, for the farther u.se of fire. Dr. Cogswell, of Hartford, recommends the use of boiling water instead of cantharides, where ve- sication is important, and where an immediate effect is desirable. — K/ v.^e.J CERATOTOME. (From sipai, a horn, and rinvw, to cut.) The name given by Wenzel to the knife with w hich he divided the cornea, or homy coat of the eye. CERATUM CALAMINiE. (L.) A good simide dressing. CERATI M CANTH.\RID18, (T..) lately called the cerate of lyttffi, was once much used for stimulaiiug CHE CHI 281 blistered surfaces, in order to maintain a discharge. The ceratum sabinae, however, which answers much better, and is not attended with danger of bringing on strangury, inflammation of the bladder, &c., has almost superseded the ceratum cantharidis. CERATUM CETACEI. (L.) The spermaceti ce- rate. A mild, unirritaiing salve for common purposes. CERATUM CONII. R. Unguenti conii Unguentum.) Cetacei |ij. CercealbcB ^iij. M. One of the formulae at St. Bartholomew’s Hospital, occa- sionally applied to cancerous, scrofulous, and phage- daenic sores. CERATUM HYDRARGYRI SUBMURIATIS. R. Hydrarg. submuriatis 3 i. Cerati lapid. calamin. 5 ss. M. Some practitioners are partial to this as a dressing for chancres. CERATUM PLUMBI ACETATIS. (L.) A mild, astringent, unirritating salve. CERATUM PLUMBI COMPOSITUM. (L.) An excellent gently astringent salve for common pur- pOS6S CERATUM SABIN.dE. R. Sabinae foliorum re- centium contiLsorum Ibj. Cerae Jlavae Ibss. Adipis praeparatae, tbij. Mix the savin with the melted wax and hog’s lard, and strain the composition. The common application for keeping open blisters, on the plan recommended by Mr. Crowther.— (See Blisters.) CERATUM SAPONIS. R. Plumbi oxydi semi- vitrei lib. j. Aceti cong. j. Saponis unc. viij. Olei olivae, cerae Jlavce, sing. lib. j. The soap cerate of St. Bartholomew’s Hospital. In preparing it, the utmost caution must be used. The first three ingredients are to be mixed together and boiled gently till all the moisture is evaporated ; after which the wax and oil, previously melted together, must be added. The whole composition, from first to last, must be incessantly and eflectually stirred, with- out which the whole will be spoiled. This formula was introduced into practice by Mr. Pott, and is found to be a very convenient application for fractures and sometimes a good dressing for ulcers; being of a con- venient degree of adhesiveness, and at the same time possessing the usual properties of a saturnine remedy. In applying this cerate, spread on linen, to frac- tures of the leg or arm, one caution is necessary to be observed, namely, that it be in two distinct pieces ; for if, in one piece, the limb be encircled by it, and the ends overlap each other, it will form a very indbnve- nient and partial constriction of the fractured part, in consequence of the subsequent tumefaction.— (P/iam. Chirurg.) CERU'MEN AURIS. A degree of deafness is fre- quently produced by the lodgement of hard dry pellets of this substance in the meatus auditorius. The best plan, in such cases, is to syringe the ear with warm water, which should be injected with moderate force. In some instances, deaf^ness seems to depend on a defective secretion of the cerumen, and a consequent dryness of the meatus. Here, a drop or two of sweet oil may now and then be introduced into the ear, and fomentations applied. CERUSSA ACETATA. Sugar of lead. Superace- tate of lead. This preparation is well known as an ingredient in a variety of lotions and collyria. It has the qualities of preparations of lead in general, being highly useful in diminishing inflammation. CHALAZIUM. (From xoAu^a, a hailstone.) A lit- tle tubercle on the eyelid, which has been whimsically supposed to resemble a hailstone. When the hordeo- lum or stye does not suppurate, but changes into a hard fleshy tumour, it receives this appellation.— (See Hordeolum.) CHAMOMILE. The flowers, which are bitter and aromatic, are used in surgery for making fomenta- tions. (JHANCRE. (From KaoKivog, cancer venereus.) A sore which arises from the direct application of the venereal poison to any part of the body. Of course it almost always occurs on the genitals. Such venereal sores as break out from a general contamination of the system, in consequence of absorption, never have the term chancre applied to them. {For an account of the nature and treatment of chancres, see Venereal Dis- ease. ) CHRMOSIS. (From xalcw, to gape.) When oph- Bialrny or inflammation of the eye is exceedingly vio- lent, it frequently happens, that IjTinph or blood is effused in the cellular membrane, which connects the conjunctiva with the anterior hemisphere of the eye. Hence, the latter membrane is gradually elevated upon the eyeball, and projects towards the eyelids, so as to conceal within it the cornea, which appears as if it were depressed. In this way the middle of the eye assumes the appearance of a gap or aperture. It is observed by Mr. R. Welbank, that inflammatory chemosis is generally dependent on the fungous swell- ing of the mucous tissue, but that it may also partly arise from effusion. He notices a very firm, but pale chemosis, as occasionally produced by effusion, and resembling a solid cedema, or fat. In one case of this sort which fell under his own observation, there were numerous white aphthae on the mucous surface. — (See FVick on Diseases of the Eye, note, p. 15.) The time has exjtired when surgeons had faith in the application of the vapour of ether, or of an inspis- sated decoction of the lactuca sissilis, to ah inflamed eye, for the relief of chemosis, as recommended by the late Mr. Ware. In this kind of case, more benefit will result from general treatment than from any local measures. I here particularly refer to the inflamma- tory chemosis ; for, in certain chronic cases, like that spoken of by Mr. Welbank, topical remedies may un- doubtedly promote the cure. Acute ophthalmy, attended with chemosis, demands the most rigorous employment of the antiphlogistic treatment. Both general and topical bleeding should be speedily and copiously put in practice, with due re- gard, however,' to the age and strength of the patient. Leeches should be applied to the vicinity of the eyelids ; or, what is preferable, the temporal artery should be opened. When chemosis is very considerable, Scarpa approves of making an incision in the conjunctiva, near its junction with the cornea, for the discharge of the lymph or blood lodged under the distended mem- brane. — (See Ophthalmy.) CHEVASTER, or Cheva'stre. A double-headed roller, the middle of which was applied to the chin ; the bandage then crossed at the top of the head, and passed on each side to the nape of the neck, where it crossed again. It was next carried up to the top of the head, and so on, till all the roller was exhausted. CHIA'STRE. A bandage for stopping hemorrhage from the temporal artery. It is double-headed, about an inch and a half wide, and four ells long. Its middle is applied to the opposite side of the head : the bandage is carried round to the bleeding temple, and there made to cross over a compress on the wound. The roller is then continued over the coronal suture, and under the chin, care being taken to make the bandage cross upon the compress. In this way, the rest of it is applied round the head. CHILBLAINS are the effect of inflammation arising from cold. A chilbljiin, in its mildest form, is attended with a moderate redness of the skin, a sensation of heat and itching, and more or less swelling, which , symptoms, after a time, spontaneously disappear. The intolerable itching and sense of tingling, accompanying the inflammation of the milder description of chilblains, are observed to be seriously aggravated by exposure to heat. In a more violent degree, the swelling is larger, redder, and sometimes of a dark-blue colour ; and the heat, itching, and pain are so excessive, that the pa- tient cannot use the part. In the third degree, small vesicles arise upon the tumour, which burst and leave excoriations. These often change into ill-conditioned sores, which sometimes penetrate even as deeply as the bone, discharge a thin ichorous matter, and generally prove very obstinate. As Dr. John Thomson has re- marked, “when the serum contained in the vesica tions is let out by a small opening, a portion of new cuticle is usually formed to supply the place of that which has been separated; but when the inflamma- tion is severe, and the affection neglected, or improperly treated, the parts which are the seat of vesication are liable to pass into the state of vitiated ulcers. In this state, they yield a thin ichorous or sanious discharge, and are in general brought, only after a long time, and with much difliculty, to a healthy suppuration. In neglected cases, these ulcers not unfrcquently become covered with foul sloughs. Ulceration often super- venes, and the soft parts covering the bones are de- stroyed .” — (On Injlammatkm, p. f)38.) Tlie worst stage of chilblains is attended with sloughing. 282 CHI CIC Chilblains are particularly apt to occur in persons who are in the habit of going immediately to the fire, when they come home in winter, with their fingers and toes very cold ; they are also frequent in persons who often go suddenly into the cold, while very warm. Hence the disease most commonly affects parts of the body which are peculiarly exposed to these sudden transitions ; for instance, the nose, ears, lips, toes, heels, and fingers. Richter remarks that they are still more frequently occasioned when the part, suddenly exposed to cold, is in a moist, perspiring state, as well as warm. Young subjects are much more liable to this trouble- some complaint than adults ; and females brought up in a delicate manner are generally more afflicted than the other sex. Tile most likely plan of preventing chilblains is to accustom the skin to moderate friction; to avoid hot rooms and making the parts too warm ; to adapt the quantity and kind of clothing to the state of the constitu- tion, so as to avoid extremes, both in summer and win- ter ; to wash the parts frequently with cold water ; to take regular exercise in the open air in all weathers ; and to take particular care not to go suddenly into a warm room, or very near the fire, out of the cold air. Although chilblains of the milder kinds are only local inflammations, yet they have some peculiarity in them ; for they are not most benefited by the same antiphlogis- tic applications wliich are most eflTectual in the relief of inflammation in general. One of the best modes of curing chilblains of the milder kind is to rub them with snow, or ice-cold wa- ter, or to bathe them in the latter several times a day, keeping them immersed each time till the pain and itch- ing abate. After the parts have been rubbed or bathed in this way, they should be well dried with a towel, and covered with flannel or leather socks. This plan is perhaps as good a one as any ; but it is not that which is always congenial to the feelings and ca- price of patients ; and with the constitutions of some it may even disagree. In such cases, the parts agitated may be rubbed with spirits of wine, liniinentum sapo- Bis, a mixture of tincture of opium and hartshorn, tinc- tura myrrhae, or a strong solution of alum or vinegar. A mixture of oleum terebinthinae and balsamum co- paibae, in equal parts, is a celebrated application. A mixture of two parts of camphorated spirit of wine, and one of the liquor plumbi subacetatis, has/ also been praised. Mr. Wardrop speaks highly of one part of the tincture of cantharides, with six of the soap hnunent. — {Medico~Chir. Trarts. vol. 5,p. 142.) With respect to vesications, their occurrence is al- ways hastened, and the inflammation upon which they depend greatly aggravated, by the action of external heat ; and hence the propriety of continuing cold applications to frost-bitten parts, so long as their temperature conti- nues above the natural standard, or the inflammation excited seems to retain an acute character. From the tendency which the inflammation excited has to pass into gangrene, the more stimulating applications, such as spirit of wine, diluted ammonia, or oil of turpentine, may be required. But should these applications prove too stimulating, their strength may be weakened by ad- ditions of greater or less portions of the liiiimentum ex aqua calcis. — {Thomson on Inflammation, p. 648.) When chilblains suppurate and ulcerate, they require stimulating dressings, such as lint dipped m a mixture of the liquor plumbi subacetaiis dilutus, and liquor cal- cis ; tinctura myrrhee, or warm vuiegar. If a salve be employed, one which contains the hydrargyri nitrico- oxydura, or the ungueiitum zinci with myrrh, camphor, opium, or the Peruvian balsam, will be found most be- neficial. Ulcers of this kind frequently require to be touched with the nitrate of silver, or dressed wuth a so- lution of it. Chilblains, attended with sloughing, should be poul- ticed till the dead parts are detached. The sores should then be first dressed with some mildly stimulating oint- ment, such as the unguentum resin® flav®, or unguen- tum zinci. With the first of these, in a day or two, a little of the hydrargyri nitrico-oxydum may be mixed ; but the surgeon should not venture on the employment of very irritating applications, till he sees what the parts will bear, and whether such will be requisite at ail ; for were he too bold, immediately he leaves off the poultices, he might bring on sloughing again. Rees's CydopcBdia, art. Chilblains. Richter's An- fa/ig.', so as to blind and prejudice many a practitioner of good abi- lities, and lead him to adopt injudicious and hurtful me- thods of treatment. Under particular circumstances, bark has undoubtedly the quality of increasing the tone of the digestive or- gans; and, of course, whenever the indication is to strengthen the system by nourishing food, and the ap- petite fails, this medicine may prove of the highest uti- lity, provided it be given in moderate doses, and it be found to agree with the stomach and bowels. But the plan of making the patient swallow as much of it as can be got into his stomach, must, in my opinion, be invariably followed by bad instead of good effects. How can it be reasonably expected that the stomach, which is already out of order, can be set right by hav- ing an immoderate quantity of any drug whatever forced into it ? In fact, if the alimentary canal were in a healthy state, must not such practice be likely to throw it into a disordered condition 1 Bark is an excellent medicine when judiciously ad- ministered ; but, like every other good medicine in bad hands, it may be the means of producing the worst consequences. How much good does mercury effect in an infinite number of surgical diseases, when prescribed By a surgeon of understanding ; what a poison it be- comes under the direction of an ignorant practitioner ! With respect to cases of mortification, bark is often most strongly indicated when the sloughing is not sur- rounded with active inflammation, when the patient is •debilitated, and his stomach cannot take nutritious food. I have always regarded the notion of giving bark as a -specific for gangrene as totally unfounded and absurd. I have watched its effects in these cases, and could never dis- ern that it had the least peculiar pow’er of /Operating directly upon the parts which are distempered. Whatever good it does is by its improving the tone of fhe digestive organs, and making them more capable of conveying nourishment, and of course strength into the constitution. I should feel myself guilty of a degree of presump- ion in speaking thus freely upon this subject, were not ..ny sentiments in some measure supported by those of certain surgical writers, the remembrance of whom will always be hailed with unfeigned veneration and esteem. Mr. Samuel Sharp was not bigoted to bark, and wlfile he allowed it to possess a share of efficacy, he would not admit that it was capable of miraculously accom- plishing every thing which the ignorant or prejudiced alleged. “ i know,” says he, “ it will be looked upon by many as a kind of skepticism, to doubt the efficacy of a remedy so well atte.stcd by such an infinity of cases"; and yet I shall frankly own I have never clearly to my satisfaction met with any evident proofs of its prefer- ence to the cordial medicines usually prescribed; though I have a long a time made experiment of it with a view to search into the truth. Perhaps it may seem strange thus to dispute a doctrine established on what is called matter of fact ; but I shall here observe, that in the practice of physic and surgery it is often exceedingly difficult to ascertain fact. Prejudice or w'ant of abilities sometimes mis- leads us in our judgment, where there is evidently a right and a wrong ; but in certain cases to distinguish how far the remedy and how far nature operate, is pro- bably above our discernment. In gangrenes particu- larly, there is frequently such a complication of un known circiunstances as cannot but tend to deceive an unwary observer. Mortifications arising from mere cold, compression, or stricture, generally cease upon re- moving the cause, and are, therefore, seldom proper cases for proving the power of the bark. However, there are two kinds of gangrene where internals have a fairer trial ; those are a spreading gangrene from an internal cause, and a spreading gangrene from violent external accidents, such as gun-shot wounds, compound fractures, «kc. Yet even hcK we cannot judge of their effect w ith absolute certainty ; for sometimes a morti- fication from internal causes is a kind of critical disor- der. There seems to be a certain portion of the body destined to perish, and no more ; of this we have an in- finity of examples brought into our hospitals, where the gangrene stops at a particular point without the least assistance from art. The same thing happens in the other species of gangrene from violent accidents, where the injury appears to be communicated to a cer- tain distance and no farther; though, by-the-way, I shall remark in this place, contrary to the received opi- nion, that gangrenes from these accidents (where there has been no previous straitness of bandage) are as often fatal as those from internal causes. As I have here stated the fact, we see how difficult it is to ascertain the real efficacy of this medicine ; but had bark in any degree those w onderful effects in gan- grenes which it has in periodical complaints, its pre- eminence would no more be doubted in the one case than in the other. What, in my judgment, seems to have raised its character so high, are the great numbers of single observations published on this subject, the au- thors of which, not having frequent opportunities of seeing the issue of this disorder under the use of cor- dials, &;c., and some of them, perhaps, prejudiced with the common supposition, that every gangrene is of it- self mortal, have therefore ascribed a marvellous influ- ence to the bark, when the event has proved success- ful.” — (Sharp's Crit. Inq. chap. 8, ' canal by the mechanical effects of quantity. CIR COL 28 ^ The sulphate of quinine, or quina, as Dr. Paris terms It, “appears to be the most efficient of ail the salts of bark. We must be careful not to combine it with sub- stances that form insoluble compounds with it. The infusum rosae comp, is objectionable as a vehicle, on ac- count of the astringent matter wliich it contains, and which therefore precipitates the quina from its solution.” The form in wliich Dr. Paris prefers to prescribe it is that of solution, with a minim of sulphuric acid to every grain of the sz.\\..—{Pharmacologia, vol. 2, p. 163.) It is frequently made into pills, with the conserve of roses, or joined with hyosciamus, squills, opium, and other medicines. Professor Brande does not agree with Dr. Paris, respecting the compound infusion of roses being an unfit vehicle for sulphate of quinine, and re- commends tli^ subjoined formula; fit. Quiniae sulpha- tis gr. ij. Infus. rosae comp. 3 xi. Tinct. cort. aurant. syrupi ejusdem a a 3 ss. M. ft. haustus bis in die su- mendus. CINNABAR, ARTIFICIAL {Hydrargyri sulphu- return rubrum), is cMefly employed by surgeons for fu- migating venereal ulcers. An apparatus is sold in the shops for this purpose. The powder is thrown upon a heated iron, and the smoke is conducted by means of a tube to the part affected. CIRCUMCISION. (From circumcido, to cut round.) The operation of cutting off a circular piece of the pre- puce, sometimes practised in cases of phymosis. — (See Phymosis.) CIRSOCELE. (From Kipcrog, a varix, and X 1 /X 77 , a tu- mour.) Cirsocele is a varicose distention and enlarge- ment of the spermatic vein ; and whether considered on account of the pain which it sometimes occasions, or on account of a wasting of the testicle, which now and then follows, it may truly be called a disease. It is fre- quently mistaken for a descent of a small portion of omentum. The uneasiness which it occasions is a dull kind of pain in the back, generally relieved by suspen- sion of the scrotum. It has been fancied to resemble a collection of earth-worms ; but whoever has an idea of a varicose vessel, will not stand in need of an illustra- tion by comparison. It is most frequently confined to that part of the spermatic process, which is below the opening in the abdominal tendon ; and the vessels ge- nerally become rather larger as they approach the tes- tis. Mr. Pott never knew good eflects arise from exter- nal applications of any kind. In general the testicle is perfectly unconcerned in, and unaffected by, this disease ; but it sometimes hap- pens, that it makes its appearance very suddenly, and with acute pain, requiring rest and ease ; and sometimes after such sjuiptoms have been removed, Mr. Pott has seen the testicle so wastd'd as hardly to be discernible. He has also observed the same effect from the injudi- cious application of a truss to a true cirsocele ; the ves- sels, by means of the pressure, became enlarged to a prodigious size, but the testicle shrunk to almost no- thing.—( Pot <’5 Works, vol. 2.) Morgagni has remarked, that the disease is more fre- quent in the left than in the right spermatic cord ; a circumstance which he refers to the left si)ermatic vein terminating in the renal.— (De Sedibus et Cans. Morb. Epist. 43, art. 34.) Cirsocele is, more frequently than any other disorder, rnistaken for an omental hernia. As Sir Astley Cooper 'ernarks, when large it dilates upon coughing ; and it Ewells in an erect, and retires in a recumbent posture of the body. There is only one sure method of distin- guishing the two complaints : place the patient in a ho- rizontal posture, and empty the swelling by pressure upon the scrotum; then put the fingers firmly upon the upper part of the abdominal ring, and desire the patient to rise : if it is a hernia, the tumour cannot reappear, as long as the pressure is continued at the ring ; but if a cirsocele, the swelling returns with increased size, on account of the return of blood into the abdomen being prevented by the pressure. — {A. Cooper on Inguinal Hernia.) Cirsocele can, for the most part, only be palliated, and seldom radically cured. When the complaint is at- tended with pain, cold saturnine and alum lotions may be applied to the testicle and spermatic cord. At the same time, blood should be repeatedly taken away by means of leeches ; the bowels should be kept gently open ; the patient should be placed in a horizontal pos- ture, and the testicle should be supported in a bag- tnws. In general, the patient only finds it necessary to keep up the testicle with this kind of suspensory bandage. [I learn from Dr. H. G. Jameson, of Baltimore, that he has been favoured with singular success in treating cir- socele, by tying the .spermatic artery. He has thus proved that tliis painful and disagreeable disease may be radically cured by this simple operation. The first public account I can find of this operation, is that per- formed by Dr. J. in 1821, and published in the Arn. Med. Recorder for 1825. He reports, that in neither of the cases in which tlus operation was performed, did the patient suffer in the integrity of the testis, nor, so far as could be ascertained, did the ligature interfere with the important functions of that organ, although both these effects had been feared, and even predicted. Dr. Stephen Brown, of New-York, has succeeded In curing varicocele by a similar operation, viz. tying the spermatic vein. Although no evil consequences resulted in this case from the ligature, yet, after the facts before the profession, of the dangerous and fatal results of tying the veins, the propriety of performing this opera- tion for the cure of varicocele may be justly questioned, unless in cases of so much suffering and danger as to warrant this hazard.— (See N. Y. Med. and Phys. Jour- nalfor 1824.)— Reci-e.] Gooch and other writers have related cases of cir- socele, in which the pain was so intolerable and incura- ble, that nothing but castration could afford the patient any relief.— (7. A. Murray de Cirsocele, Upsal, 1784.. Pott on Hydrocele, A-c. Richter in Nov. Comment, Goett. No. 4, and in Obs. Chir. Ease. 2, p. 22. Gooch,- Chir. Works. Most, Diss. de Cirsocele, Halos, 1796.) CIRSOPHTHALMIA. (From Kipaos, a varix, and 6(pdaXpdi, the eye.) A general varicose affection of the blood-vessels of the eye. CLAP. See Gonorrhoea. CLOACA. The openings leading through the new bony shell, in cases of necrosis, down to the enclosed dead bone are termed cloacae. COLLYRIIJM ACIDI ACETICI. R. Aceti distil- lati, |j. Spiritus vini tenuioris, ^ss. Aq rosae, 5viij. Misce. COLLYRIUM ALUMINIS. R. Aluminis purif. 3j. Aq. rosae, ; vj. Misce. COLLYRIUM AMMONIA ACETATE. R. Liq ammon. acet., aq. rosae sing. | j. M. COLLYRIUM AMMON I.E ACETATE CAMPHO- RATUM. R. Collyrii ammon. acet. misturae campho- ratae sing. 1 ij. M. COLLYRIUM AMMONIA ACETATE OPIATUM. R. Collyrii ammon. acet. | iv. Tinct. opii gutt. xl. M. COLLYRIUM CUPRI SULPHATIS CAMPHORA- TUM. R. Aq. cupri suljffiatis camphoratae, 3 ij. Aq distillatae, 5iv. M. Recommended by the late Mr Ware, for the purulent ophthalmy of children. COLLYRIUM HYDRARGYRI OXYMURIATIS. R. Hydrarg. oxymuriatis, gr. ss. Aq. distillat. |iv. M» This collyrium is fit to be employed after the acute stage of oidithalmy has subsided, and it will disperse many superficial opacities of the cornea. COI.LYRIUM OPIATUM. R. Opii extracti gr. x. Camphorae gr. vj. Aquae distillatae ferventis, ?xii. Beat the first two ingredients together in a mortar, and mix the hot water gradually, and strain the fluid. This collyrium is recommended in some ophthalmies attended with great pain and swelling. — (See Wilson's Pharrn. Chir. p. 70.) COLLYRIUM PLUMBI ACETATIS. R. Aqu» rosae, jvj. Plumbi acetatis, 3 ss. Misce; or, R. Aq, distillatae, 5 iv. Liq. plumbi acetatis gutt. x. M. This is a good application to the eyes, when one of a gently astringent, cooling quality is indicated. COLLYRIUM ZINCI SULPHATIS. Zinci sulpha- tis, gr. V. Aq. distillatae, | iv. M. This is the most common collyrium of all : it may be made gradually stronger. COLLYRIUxM ZINCI SULPHATIS CUM MUCI- LAGINE SEMINIS CIDONII MALI. R. Aq. planta- ginis, ?iv. zinci sulphatis, gr. v. et mucil. sem. cydon. trial. 5 ss. M. In order to check the morbid secretion from the eyelids, in cases of fistula lachrymalis, or what Scarpa calls il/tusso palpebrale puriforme, this ce- lebrated Professor re»onimends a few drojis of the above collyrium to be insinuated between the eyelid and the eye. COLPOCELE. (From xdXffoj. the vagina, and a tumour.) A tumour or hernia situated in Uic vagina m CON CON COLPOPTOSIS. (From /f< 5 X 7 rof, the vagina, and ni-nru), to fall down.) A bearing or falling down of the Vagina.— (See Vagina, Prolapsus of.) COxMMINUTED. (From comminuo, to break in pieces.) A fracture is termed comminuted when the bone is broken into several pieces. COMPRESS. (From comprimo to press \ipon.) Folded linen, lint, or other materials, making a sort of pad, which surgeons place over those parts of the body on which they wish to make particular pressure ; and for this purpose a bandage is usually applied over the compress. Compresses are also frequently applied to prevent the ill effects which the pressure of hard bodies or tight bandages would otherwise occasion. COMPRESSION OF THE BRAIN. See Head, In- juries of. CONCUSSION OF THE BRAIN. See Head, Inju- ries of. CONDYLOMA. (From K6vhv\oi, a tubercle or knot.) A small, very hard tumour. The term is generally ap- plied to excrescences of tliis description about the anus. The practitioner may either destroy them with caustic, tie their base with a ligature, or remove them at once with a knife ; the first is generally the worst, the last the best and most speedy method. CONIUM MACULATUM. Hemlock. Cicuta. This is a medicine to which my observations in practice in- cline me to impute considerable eflicacy in several sur- gical diseases* However, there is no doubt, that when it is represented as a certain cure for cancer and scro- fula, exaggeration is employed. It is an excellent re- medy for irritable painful sores of the scrofulous kind, and it will complete the cure of many ulcers in which the venereal action has been destroyed by mercury, though the healing does not proceed in a favourable way. Hemlock is likewise beneficial to several inve- terate malignant sores, particularly some which are every now and then met with upon the tongue. It is an eligible alterative in cases of noli me tangere, porrigo, and various herpetic affections. I have seen several enlargements of the female breast give way to hemlock conjoined with calomel. Some swellings of the testes also yield to the same medicines. Hemlock certainly has not the power of curing cancer ; but its narcotic ano- dyne qualities tend to lessen the pain of that distemper, so as to render it by no means a contemptible remedy in that intractable kind of case. Respecting hemlock, Mr. Pearson observes, that the extract and powder may be sometimes given with evi- dently good effect in spreading irritable sores ; whether they are connected with the active state of the venereal virus, or whether they remain after the completion of the mercurial course ; and it would seem, that the be- nefit conferred by this drug ought not to be ascribed solely to its anodyne qualities, since the same advan- tages cannot always be obtained by the liberal exhibi- tion of opium, even where it does not disagree with the stomach. He states that cicuta is almost a spe- cific for the venereal ulcers which attack the toes at their line of junction with the foot, and which fre- quently become gangrenous. Also, in spreading sores which are accompanied with great pain, and no appear- ance of remarkable debility, hemlock will often do more than bark, vitriol, or cordials. The common mode of exhibiting hemlock is in the form of pills, made of the extractum conii, five grains to each. However, I have always thought three grains sufficient to begin with, the dose being afterward gradually augmented. It is curious how large a quantity may at last be taken in this manner. Mr. .1. Wilson, in his Pharmacopoeia Chirurgica, informs us of a remarkable case of cancer- ous ulcer, for which the patient took a hundred and twenty pills, each consisting of five grains of the ex- tractum conii, in twenty-four hours, and this without any benefit being produced, or any inconvenience to the patient. The stomach being a little disordered, and the head somewhat giddy, is a sign of the dose being sufficiently strong. “According to some writers, but more particularly Dr. Withering, there are several ways in which the views of a medical practitioner, in prescribing this remedy, may be frustrated. The plant chosen for pre- paring the extract may not be the true conium macula- turn, which is distinguished by red spots along the stalk. It may not be gathered when in perfection, namely, when beginning to flower. The inspissation of the juice may not have been performed in a water* bath, but, for the sake of despatch, over a common fire. The leaves, of which the powder is made, may not have been cautiously dried and preserved in a well-stopped bottle; or, if so, may still not have been guarded from the ill effects of exposure to light. Or lastly, the whole medicine may have suffered from the mere effects of long keeping. From any of these causes, it is evident, the powers of cicuta may have suffered ; and it hajjpens, no doubt, very frequently, that the failure of it ought, in fact, to be attributed to one or other of them.” — {Phar- macopoeia Chirurgica, published in lb02, p. 174.) 'Phe activity of hemlock is now found to reside in a resinous element, obtained separately, by evaporating an ethereal tincture of the leaves on the surface of water. A dose of half a grain will prodiuie vertigo and headache. The watery extract of this plant has been proved by Orfila to have but little power. — {J. A. Paris, in Pharmacologia, vol. 2, p. 180, ed. 6.) I have sometimes prescribed as an alterative, with manifest benefit in several surgical diseases, a pill con- taining three grains of extractum conii, or, what is preferable, the dried leaves, one of hydrargyri submu- rias (calomel), and one of antimonii sulphuretum prae- cipitatum. In various cases of scrofulous diseases, and also in several very painful irritable ulcers and swell- ings, it is occasionally employed in the form of foment- ations and poultices. The latter are generally made by mixitig the powder with the common bread and water cataplasm. F. Hoffman, Of Hemlock, 8vo. Lovd. 1763. A. Storck, Libelltcs, quo demonstratur cicutam non solum usu intemo tutissimi exhiberi, sed st esse simul remedium valde utile, &'C. ; editio altera, 8vo. Vindob. 1761. Also, Supplementum Necessarium de Cicuta, 8vo. Vindob. 1761. J. Pearson, On Various Articles of the Materia Medica, &,-c. 2d edit. 8vo. London, 1807. J. A. Paris, Pharmacologia, ed. 6. CONJUNCTIVA, GRANULAR. The following ac count of this subject is given by Dr. Frick. This dis ease is mostly the sequel of purulent ophthalmy. It is characterized by a rough, scabrous, or granulated state of the palpebral conjunctiva, with a gleety or puriform discharge from its surface. The constant friction of the- eyelids upon the globe brings on a varicose state of the sclerotic conjunctiva, and a dusky apjjearance of the cornea. The patient complains of a sensation simi- lar to that produced by sand, or other extraneous matter, under the eyelids ; the eye cannot endure the light, and there is a troublesome epiphora. In the re- cent stage, a cure is easily accomplished by the applica- tion of a few leeches to the eyebrows, and pencilling the part once or twice a day with the vinous tincture of opium, or the ung. hydrarg. nitrat. When these means fail, the sulphate of copper or nitrate of silver may be used, though not so freely as to produce a slough, but only to change the diseased condition of the part. — (See Frick, On Dis. of the Eye, p. 240, ed. 2.) Mr. R. Wel- bank recommends the use' of these means to be followed by ablution with tepid water, and the application of a few leeches. He also recommends counter-irritation and active aperients. The upper eyelid, he says, should be completely everted in examination, as there is sometimes, at the angle where the conjunctiva passes from the globe to the lid, a crescentic fVinged fold, not unlike a cock’s comb, apt to keep up a tedious inflam- mation of the cornea. Dr. Frick considers excision of the granular surface proper only when it is hard, insen- sible, and prominent, or the excrescences hang like peduncles from the surface of the eyelids. In this state. Dr. Vetch recommends the application of a little burnt alum, or verdigris, and then washing it off with a syringe.— (See the article Cornea, and Frick, Vetch, and Travers on Diseases of the Eye.) CONTUSED WOUNDS. See Wounds. CONTUSION. (From conrimdo, to bruise.) A bruise. Slight bruises seldom meet wth much attention ; but when they are severe, very bad consequences may ensue; and these are the more likely to occur, when such cases are not taken proper care of. In all severe bruises, besides the inflammation which the violence necessarily occasions, there is an instanta- neous extravasation, in consequence of the rupture of many of the small vessels of the part. In no otlier way can we account for those very considerable tumours, which often rise immediately after injuries of this na- ture. The black and blue appearance instantly follow- ing many bruises can only be explained by there being COP COR 287 an actual effUsion of blood from the small arteries and veins which have been ruptured. Even largish vessels are frequently burst in tliis manner, and considerable collections of blood are the consequence. Blows on the head very often cause a large effusion of blood under the scalp. I have seen many ounces thus extra- vasated. Besides the rupture of an infinite number of small vessels, and an extravasation of blood, which attend all bruises in a greater or less degree, the tone of the fibres and vessels which have suffered contusion is considerably disordered. Nay, the violence may have been so great, that the parts are from the first deprived of vitality, and must slough. Parts at some distance from such as are actually struck may suffer greatly from the violence of the con- tusion. This effect is what the Fench have named a contrecoup. The bad consequences of bruises are not invariably proportioned to the force which has operated ; much depends on the nature and situation of the part. When a contusion takes place on a bone which is thinly covered with soft parts, the latter always suffer very severely, in consequence of being pressed, at the time of the accident, between two hard bodies. Hence, bruises of the shin so frequently cause slojughing and troublesome sores. Contusions affecting the large joints are always serious cases ; the inflammation oc- casioned is generally obstinate; and abscesses and other diseases, which may follow, are proper grounds for serious alarm. In the treatment of bruises, the practitioner has three indications, which ought successively to claim his attention. The first is to prevent and diminish the inflamma- tion which, from the violence done, must be expected to arise. The bruised parts should be kept perfectly at rest, and be covered with linen, constantly wet with the liquor plumbi acetatis dilutus, or the lotio ammon. acetatis. When muscles are bruised, they are to be kept in a relaxed position, and as quiet as possible. If the bruise be very violent, it \vill be proper to apply leeches, and this repeatedly ; and even in some cases, particularly when the Joints are contused, to take blood from the arm. In every instance, the bowels should be kept well open with saline purgatives. A second object in the cure of contusions is to pro- mote the absorption of the extravasated fluid by discu- tient applications. These may at once be employed in all ordinary contusions, not attended with too much violence : for then nothing is so beneficial as maintain- ing a continual evaporation from the bruised part, by means of the cold saturnine lotion, and at the same time repeatedly applying leeches. In common braises, however, the lotio ammonia! rnuriata: (see this article) is an excellent discutient application ; but most sur- geons are in the habit of ordering liniments for all or- dinary contusions ; and certainly they do so much good in accelerating the absorption of the extravasated blood, that the practice is highly praiseworthy. The lini- men'um saponis or the lininientum camphor® are as good as any that can be employed. — (See Linimen- tum.) In many cases unattended with any threatening appearances of inflammation, but in which there is a good deal of blood and fluid extravasated, bandages act very beneficially, by the remarkable power which they have of exciting the action of the lymphatics, by means of the pressure which they produce. A third object in the treatment of contusions is to restore the tone of the parts. Rubbing the parts with liniments has a good deal of effect in this way. But notwithstanding such ajiplications, it is often observed, that brui.sed parts continue for a long while weak, and even swell amf become oedcmatous, when the patient takes exercise, or allows them to hang down, as their functions in life may require. Pumping cold water two or three times a day on a part thus circumstanced, is the very best measure which can be adopted. A bandage should also be worn, if the situation of the pan will permit. These steps, together with perseve- rance in the use of liniments, and in exercise gradually increased, will soon bring every thing into its natural state again. COPPER. The subacetate and sulphate are used in surgery. The first, often called aerugo, or prepared verdigris, is employed as an escharotic. Mixed with an equal quantity of powdered cantharides, it is some- times applied for the removal of warts and other ex- crescences. At present, the old practice of destroying the surface of chancres with it, with the view of hin- dering the absorption of venereal matter, and rendering the exhibition of mercury needless, may be said to be completely abandoned. CORNEA. (From cornn, a horn.) The anterior transparent convex part of the eye, which in texture is tough, like horn. It has a structure peculiar to itself, being composed of a number of concentric cellular lainell®, in the cells of which is deposited a particular sort of fluid. It is covered externally by a continuation of the conjunctiva, which belongs to the class of mu- cous membranes : and it is lined by a membrane, the tunica humoris aquei, which seems to belong to the serous class. FLESHY EXCRESCENCES OF THE CORNEA. Mr. Wardrop, in his Essays on the Morbid Anatomy of the Human Eye, has published an excellent chapter on this subject. Besides pterygia, which are treated of in another part of this Dictionary, Mr. Wardrop states that the cornea is subject to two kinds of caruncles, or fleshy excrescences. One appears at birth, or soon after it, and resembles the n®vi materni, so frequent on the skin of various parts of the body. The second is described as having a greater analogy to the fungi which grow from mucous surfaces, and being in gene- ral preceded by ulceration. Of the congenital excrescence of the cornea, Mr. Wardrop has seen two remarkable instances. The first was in a girl eight or ten years of age, on whose left eye there was a conical mass ; the base of which grew from about two-thirds of the cornea, and a small portion of the adjoining sclerotic coat. The second example occurred in a patient upwards of fifty years old. The tumour had been observed from birth, was about as large as a horse-bean, and only a small portion of it seemed to grow from the cornea. The other part was situated on the white of the eye, next the temporal angle of the orbit. From the middle of the excrescence, upwards of twelve long firm hairs grew, and hung over the cheek. Mr. Wardrop acquaints us, that a similar tumour, with two hairs growing out of it, was seen at Lisbon by Dr. Barron, of St. Andrew’s. Mr. Crampton also mentions, that he once saw a “ tuft of very strong hairs proceeding from the sclerotica.” — (Essay on the Entro- peon, p. 7.) And De Gazelles met with an instance, in which a single hair grew from the cornea..— (Journ. de M^decine, tom. 24.) According to Mr. Wardrop, this species of excrescence of the cornea greatly resem- bles the spots covered with hair, which are frequent on various parts of the surface of the body. With regard to the second kind of tumour growing from the cornea, a fungus, proceeding from an ulcer of this part of the eye, is stated to be very uncommon. However, it is said that when a portion of the iris protrudes through an ulcer of the cornea, the growth of a large excrescence from the projecting part is not so unusual. Of such a disease, Mr. Wardrop has cited examples from Maitre- Jean’s Traiti des Maladies des Yeux, Voigtel, Beer, and Plaichner. Excrescences growing from the cornea are also quoted from the fol- lowing works : Handbuch der Pathologischen Anato- mie, von F.G. Voigtel, Halle, 1804. Praktische Beo- bachtungen uber den grauen Staar und die Krankheiten der Hornhaut, von Joseph Beer, Wien, 1791. Plaich~ ner's Dissertatio de Furigo Oculi. — (See Wardrop's Essays on the Morbid Anatomy of the Human Eye, vol. 1, chap. 4.) Others are likewi.se de.scribed by Mery, in M: m. de V Acad, des Sciences, 1703 ; by Dupre, in Phil. Trans, vol. 19; and Home, in the same work, vol.B\. The only treatment which excrescences of the cor- nea admit of, is that of removing them with a scal- pel and a pair of forceps, or destroying them with caustic. ABSCESSES OF THE CORNEA. When the matter is collected between the lamellae of thd cornea, it first appears tike a small spot ; and instead of resembling a speck in colour, it is of the yellow hue of common pus. As the quantity of the matter increases, this spot becomes broader, and it does not alter its situation from the position of the 288 CORNEA. head. If it be situated among the external layers of the cornea, or immediately below the corneal conjunc- tiva, a tumour is formed anteriorly, and if touched with the point of a probe, the contained fluid can be felt fluctuating within, or if fhe eye be looked at side- ways, an alteration m the form of the cornea may be readily perceived. When the matter collects between the interior la- mellae, it does not produce any evident alteration in the external form of the cornea ; but if it be touched with the point of a probe, a fluctuation can be more or less distinctly perceived, and the spot alters its form, and becomes somewhat broader. Such collections of matter appear on every part of the cornea. Sometimes they alter their situation by degrees, and sink downwards ; and sometimes they change both their situation and form. They very sel- dom cover more than one-fourth or one-third of the cornea. When the quantity of matter is small, it is often completely absorbed during the abatement of the in- flammatory symptoms, and it generally leaves no ves- tige behind it. In other cases, the cornea is eroded ex- ternally, producing an ulcer and subsequent opacity. In some few instances, the internal lamellte of the cor- nea give way, and the matter escapes into the anterior chamber. When an artificial opening is made, the matter often does not readily flow out ; and it is some- times so tenacious, and contained in a cavity so irre- gular, that it neither escapes spontaneously, nor can it be evacuated by art. It is particularly to the cases in which matter col- lects between the layers of the cornea, that the terms unguis and onyjr are applied. — (See Wardrop's Essays on the Morbid Anatomy of the Human Eye,vol. 1, chap. 6.) According to a late writer, these words should be restricted to what he names “ crescentic in- terlamellar depositions.” — {Travers's Synopsis of the Diseases of the Eye, p. 115.) Where the cornea is af- fected with onyx, this gentleman commends antiphlo- gistic treatment. — (P. 278.) And with respect to a large collection of matter in the cornea, whether the puriform onyx or central abscess, he observes, that it requires “ a supporting constitutional treatment, mild cathartics, and the application of blisters; calomel should be avoided, and the cornea can seld'im be punc- tured with advantage.”— (P. 280.) OPACITIES OF THE CORNEA. Opacity of the cornea is one of the worst conse- quences of obstinate chronic ophthalmy. The term opacity is used when the loss of transparency extends over the whole or the greater part of the cornea ; while other cases of a more limited kind are named specks. The distinction, as Beer observes, is chiefly important in respect to the prognosis.— (Pe/ire V07i den Augenkr. b. 2, p. 77.) Scarpa distinguishes the superficial and recent spe- cies of opacity from the albugo and leucoma (see these words), which are not in general attended with inflam- mation, assume a clear and pearl colour, affect the very substance of the cornea, and form a dense speck upon this coat of the eye. The nebjila, or slight opacity, here to be treated of, is preceded and accompanied by chronic ophthalmy ; it allows the iris and pupil to be discerned through a Kind of cloudiness, and conse- quently does not entirely bereave the patient of vision, but permits him to distinguish objects, as it were, through a mist. The nebula is an effect of protracted or ill-treated chronic ophthalmy. The veins of the conjunctiva, much relaxed by the long continuance of the inflammation, become preternaturally turgid and pro- minent; afterward they begin to appear irregular and knotty, first in their trunks, then in their ramifications, near the union of the cornea with the sclerotica, and lastly in their most minute ramifications, returning from the delicate layer of the conjunctiva, spread over the cornea. It is only, however, in extreme relaxation of the veins of the conjunctiva, that these very small branches of the cornea become enlarged. When this happens, some reddish streaks begiij to be perceptible, in the interspaces of which, very soon afterward, a thin, milky, albuminous fluid is effused, which dims the diaphanous state of the cornea. The whitish, delicate, superficial speck thence resulting forms precisely what is termed nebula, or the kind of opacity here to be considered. And since this extrava- sation may happen only at one point of the cornea, of in more places, the opacity may be in one speck or in several distinct ones, but which altogether diminish more or less the transparency of this membrane. The cloudiness of the cornea, which sometimes takes place in the inflammatory stage of violent acute oph- thalmy, especially differs from the species of opacity expressed by the term nebula. The first is a deep ex* travasation of coagulating lymph in the internal cel* lular texture of the cornea, or else the opacity pro- ceeds from an abscess between the layers of this mem- brane about to end in ulceration. On the other hand, the nebula forms slowly upon the superfices of the cornea, in long-protracted chronic ophthalmy ; is pre- ceded first by a varicose enlargement of the veins in the conjunctiva, next of those in the delicate lamina of this tunic, continued over the front of the cornea ; and finally it is followed by an effusion of albuminous lymph in the texture of this thin layer, expanded over the transparent part of the eye. This effusion never elevates itself in the shape of a pustule. Wherever the cornea is affected with nebula, the part of the con- junctiva corresponding to it is constantly occupied by net- work of varicose veins, more knotty and prominent than other vessels of the same description; and though the cornea be clouded at more points than one, there are distinct corresponding fasciculi of varicose veins in the white of the eye. Scarpa injected an eye affected with chronic ophthalmy and nebula, and he found that the wax easily passed, both into the enlarged veins of the conjunctiva, and those of that part of the surface of the cornea where the opacity existed ; the inosculations all round the margin of the cornea were beautifully variegated, without trespassing that line which bounds the sclerotica, except on that side where the cornea was affected with the species of opacity. Mr. Travers does not adopt precisely the same defi- nition of nebula as Scarpa; for he describes it as a thickening of the conjunctiva, and an effusion of adhe- sive matter between it and the cornea, or betxveen the lamellcB of the latter, commonly the product of acute strumous' ophthalmy. —(Synopsis, A c. p. 118.) According to Scarpa, the superficial opacity, which alone he calls nebula, demands, from its very origin, active treatment ; for though at first it may only oc- cupy a small portion of the cornea, when left to itself it advances towards the centre of this membrane, and the ramifications of the dilated veins upon this coat growing still larger, at length convert the delicate con- tinuation of the conjunctiva upon the surface of the cornea, into a dense opaque membrane, obstructing vision. The curative indication in this disease is to make the varicose vessels resume their natural diameters, or if that be impracticable, to cut off all communication between the trunk of the most prominent varicose veins of the conjunctiva, and the ramifications coming from the surface of the cornea, the seat of the opacity. The first mode of treatment is executed by means of topical astringents and corroborants, especially .lanin’s ophthalmic ointment, and success attends it when the opacity is in an early state, and not extensive. But when advanced to the centre of the cornea, the. most in- fallible treatment is the excision of the fasciculus of varicose veins near their ram i/icat ions, that is, near the seat of the opacity. By means of this excision, the blood retarded in the dilated veins of the cornea is voided ; the varicose veins of the conjunctiva have an opportunity to contract and regain their tone, no longer having blood impelled into them ; and the turbid secre- tion effused in the texture of the layer of the conjunc- tiva continued over the cornea, or in the cellular sub- stance connecting these two membranes, becomes ab- sorbed. The celerity with which the, nebula disai)- pears after this oi)eration is surprising, commonly in twenty-four hours. The extent to which the excision of the varicose veins of the conjunctiva must be per- formed depends ujion the extent of the opacity of the cornea. Thus, should there be only one set of varicose vessels, corresponding to an opacity of moderate ex- tent, it is sufficient to cut a portion of them away. Should there appear several dim specks upon the cor- nea, with as many distinct sets of varicose vessels, ar- ranged round upon the white of the eye, the surgeon must make a circular incision into the conjunctiva, near the margin of the cornea, by which he will cer- tainly divide every plexus- of varicose vessels. But let CORNEA, 289 ft be observed, that a simple incision through the vari- cose vessels is not permanently effectual in destroying all direct communication between the trunks and rami- fications of these vessels upon the cornea, after such an incision made, for instance, with a lancet ; though it be true that a separation of the mouths of the di- vided vessels follows in opposite directions, it is lio less true, that in the course of a few days after the in- cision, the mouths of the same vessels approximate each other, and inosculate, so as to resume their for- mer continuity. Hence, to derive from this operation all possible advantage, it is essential to extirpate with the knife a small portion of the varicose plexus, to- gether with the adherent particle of the tunica con- junctiva. The eyelids are to be separated from the affected eye by a skilful assistant, who is, at the same moment, to support the patient’s head upon his breast. The sur- geon is then to take hold of the varicose vessels with a pair of small forceps, near the edge of the cornea, and to lift them a little up, which the lax state of the conjunctiva renders easy ; then, with a pair of small, curved scissors, he is to cut away the plexus of vari- cose vessels, together with a small piece of the con- junctiva, making the wound of a semilunar form, and as near as possible to the cornea. If it should be ne- cessary to operate upon more than one plexus of vari- cose vessels, situated at some distance apart, the sur- geon must elevate them one after the other with the forceps, and remove them. But when they are very close together, and occupy every side of the eye, he must make ,an uninterrupted circular incision in the conjunctiva, guiding it closely to the margin of the cor- nea all around, so as to divide with the conjunctiva all the varicose vessels. This being done, he may allow the cut vessels to bleed freely, even promoting the hemorrhage by fo- menting the eyelids until the blood discontinues to flow. Scarpa then covers the eye with an oval piece of the emplastrum saponis and a retentive bandage. The eye ought not to be opened till twenty-four hours after the operation, when, usually, the opacity of the cornea will be found completely dispersed ; and, dur- ing the ensuing days, the patient is to be enjoined to keep the eye shut, atid covered with a bit of fine rag. A collyrium of milk and rose-water, warm, may be ap- plied two or three times a day. When the inflamma- tion of the conjunctiva happens, about the second or third day after the operation, particularly in cases in which the incision is made all round, while the greater part of the sphere of the eye reddens, a whitish circle, in the place of the incision, forms a line of boundary to the redness which does not extend farther upon the cornea. This inflammation of the conjunctiva, with the aid of internal antiphlogistic remedies and topical emollients, abates in a few days, and then pus is se- creted along the track of the incision in the conjunc- tiva. The wound contracts, and, growing smaller and smaller, soon cicatrizes. Bathing the eye with warm milk and rose-water is the only local treatment neces- sary in this stage of the complaint. Thus, not only the transparency of the cornea is re- vived, but also the preternatural laxity of the conjunc- tiva is diminished, or even removed. When the con- junctiva subsequently appears yellowish and wrinkled, the use of topical astringents and corroborants, and of Janin’s ophthalmic ointment, may be highly beneficial in preventing the recurrence of the varicose state of the ve.s8els.— {.Scarpa sulle Malattie degli Occhi, c. 8.) According to the experience of Dr. Vetch, Scarpa’s plan of removing the plexus of varicose vessels, toge- ther with a portion of the conjunctiva, produces no good effect, “ except in cases of great relaxation of the membrane covering the eye.” He asserts, that new vessels immediately appear in the room of those re- moved, and the good derived from the bleeding does not compensate for the irritation produced by the ope- ration.— (A Practical Treatiae on the Diseases of the Eye, p. 86.) However, when it is reflected, that Scarpa advises this practice only for advanced cases, and jiar- licularly recommends topical astringents for the more recent stages of the disease, he nearly agrees with Dr. » etch, as far as this point is concerned. But Scarpa’s account of the disease and its treatment is left im- perfect by the omission of any notice of the connexion frequently existing between opacity of the cornea, and • rough, scabrous, granulated state of the lining of the VoL I.— T eyelids. Yet, perh^s, Scarpa was not to be expected to treat of this combination in his chapter on nebula, because his definition of this superficial opacity wilk not altogether suit the affection of the same membrane referred to in the following observations. It is re- marked by Dr. Vetch, that after the complete cessation of conjunctival ophthalmia, as far as regards that por tion of the membrane which covers the eye, the villous elongation of the vessels of the lining of the eyelids, instead of recovering their natural state, acquire a farther increase of size, so as to produce a rough, sca- brous, or granulated surface, with a secretion ofpuri- form matter. The irritation of this unequal surface gradually induces an inflammatory state of the sclerotic vessels, and, consequently, a greater flow of blood to- wards the cornea: the superficial vessels become va- ricose ; the conjunctiva assumes a dusky and loaded .'ippearance ; and the cornea becomes opaque, not par- tially, but throughout the whole extent of its structure. This affection, says Dr. Vetch, is essentially different from those nebulous or partial opacities which take place in primary sclerotic inflammation, and which consist in slight extravasations, accompanied by in- tolerance of light, and in which any affection of the pal- pebral linings is a secondary instead of a primary cir- cumstance. The cornea is of the green colour pre- sented by a broken gun-flint; and while it is sufficiently diaphanous to permit the perception of light, it is yet too opaque to allow the patient to discern external ob- jects, except by their shades. Nor can the colour of the. iris and limits of the pupil be seen. Dr. Vetch also describes the conjunctiva as being sometimes so much relaxed, and its vessels so generally loaded, as to give it a dusky appearance similar to that of the cornea; and, in other instances, without much alteration of its thickness or transparency, it is said to lose for a con- siderable extent its close attachment to the subjacent lamina of the cornea. Along with the opaque state of the cornea, there is more generally an enlargement of individual vessels, which penetrate almost to its cen- tre, increase as they come outwards, and terminate in trunks, which run to the duplicature of the conjunc- ' tiva. Dr. Vetch represents this di.sease of the pal- pebrae as consisting at first in a highly villous state of their membranous lining. This state, if not rectified by proper treatment, gives birth to granulations, which in time become more deeply sulcated, hard, or warty, accompanied by an oozing of purulent matter. Dr. Vetch has explained, that the use of the actual cautery, excision, and friction, for the purpose of curing the dis- eased state of the eyelids, may be traced back to Hip- pocrates, who prefers escharotics. Dr. Vetch ascribes their first employment in these cases to St. Ives. Mr. Saunders, he observes, took au early and a just view of the relations existing between the diseased conditions of the palpebral linings, and the opaque state of the cornea; and he succeeded in establishing the cure of the latter by the removal of the former. In short, Dr. Vetch admits, that in the case which more especially formed the claim of Mr. Saunders to the discovery of the nature of the disease, the practice of excision was attended with complete success. Dr. Vetch contetids, however, that this method is for the most part inade- quate to the cure of the disease ; and that there are very few cases, in which the more certain and consis- tent process of gradually repressing the diseased sur- face by escharotic substances will not produce a more complete and permanent cure. After giving a fair trial to a great variety of escharotics made into oint- ments, and applied to the inside of the upper eyelid, Dr. Vetch found the direct application of the escha- rotic substances themselves was preferable. When there is too much increased action of the vessels of the sclerotic coat. Dr. Vetch recommends the use of escha- rotics to be preceded by cupping the temples; or, when there is any risk of a slough, the application of a leech to the inside of the lower eyelid. Whatever will bring on a determination of blood to the head is to be avoided, and a low regimen observed. The escharotics preferred by Dr. Vetch, are the sul- phate of copper and nitrate of silver, scraped in the form of a pencil and fixed in a portcrayon. In this way. Dr. Vetch says, they should be applied, not, as some have con- ceived, with the view of producing a slough over the whole surface, but with great delicacy, and in so many points only as will produce a gradual change intlxecondi lion and dispo.sition of the part. As long as there is any 200 CORNEA. aecretion of pus, the above application may be mate- rially assisted by the daily use of the undiluted liquor plumbi acetatis. When the disease resists these reme- dies, and its surface is hard and warty. Dr. Vetch ap- plies to the everted surface powder of verdigris or burnt alum, finely levigated; or even lightly touches the dis- eased surface with the kali purum. In employing these remedies, he enjoins confining their operation to the point of contact, so as to prevent them from hurting the eye. Hence, they are to be applied in very minute quantities with a fine camel’s hair pencil, and to be washed off with an elastic gum syringe, before the eyelid is returned. Of the employment of astringent collyria in conjunction with escharotics. Dr. Vetch dis- approves. — (See A Practical Treatise on the Diseases of the Eye, p. 67, Ir. Phipps had opportunities of watching the progress of several cases in which the cornea had become conical, and that he never saw the disease in persons under the age of founeen or sixteen. The same gentleman also observed, that when the cone is once complete, the disease seldom makes any farther progress, except that the apex sometimes becomes opaque. Burgman saw a remarkable case where the cornea of both the eyes of a persoHj who had been hanged, were so prodigiously extended, that they reached down to the mouth like two horns. — {Haller, Disputationes Chirurg. tom. 2.) The chapter of Mr. Wardrop on the preceding subject will be found highly interesting to such as are desirous of farther information concerning this curious disease of the eye.— (See Wardrop's Es- says on the. Morbid Anatomy of the Eye, vol. I, chap. 13.) For information relative to diseases of the cornea. CORNEA. 293 see M. Geiger, De Fistula Corne'stalline lens. CYSTOCELE. (From xt'oris. the bladder, and KrfXii, a tumour.) A hernia formed by a protrusion of the bladder. — (See Hernia.) CYSTOTO^HA. (From Kvang, the bladder, and Teiivu), to cut.) The operation of opening the bladder, for the extraction of a stone or calculus. — (See Lithotorny.j D D .\CRY0!VIA. (From SaKovco, to weep.) An imper- vious state of one or both the puncta laclir 3 Tnalia, preventing the tears from passing into the lachrymal sac. DAUCUS. See Cataplasma Baud. DECOCTUM CHAMCEMELI. R. Florurn chamce- meli, 3 ss. Aquae distillatae, Ibj. Boil ten minutes, and strain the liquor. A common decoction for foment- 1 aUons. — (See Fomentvm.) \ DECOC-TUM DULCAMAR.T:. R. Dulcamarae cau- i lis concisse unciam, aquae eclarium cum semisse. De- j coque ad octarium, et cola. I ilie decoction of bittersweet, or woody nightshade, is I recommended for some cutaneous diseases, proceeding | from scrofula, lepra, and lues venerea. The dose is I one or two table spoonfuls, three times a day. An aro- matic tincture should be added. DEC0CTI:M HELLEBORI ALBI. (Xow the Be- eoctum Veratri.) R. Pulveris radicis hellebcri albi, 3 ). Aquae distillatae, Ibj. Spiritus vinosi rectificati, 3 ij. Boil the water and powder till only one-half the fluid remains, and when cold add the spirit. This is used as a lotion for curing psora, porrigo, and some herpetic affections. DECOCTUM LOBELIA. (Blue Cardinal Flmcer of Virginia.) R. Radicis lobeliae sj-philiticae siccae ma- nip. j. Aqu® distillatae, Ibxij. This is to be boded till only four quarts remain. The lobelia once gained re- pute as an antivenereal, though little reliance is now put in it. The patient is at first to take half a pint twice, and afterward four times a day. It operates, however, as a purgative, and the doses must be regtdated accord- ing as the bowels appear to bear them. DECOCTUM MEZEREI. R. Corticis radicis me 2 e- rei recentis, 3 ij. Radicis glycirrhiz® contusae, 3j. Aqu® (hstdlat®, Ibiij. Bod the mezereon in the water till only two pints remain; and when the boiling is nearly firushed, add the liquorice root. The decoction of mezereon has been much prescribed for venereal nodes and nocturnal pains in the bones, in dases of from four to eight ounces, three times a day. DECOCTUM PAPAVERIS. R. Papaveris soiimi- feri caps ’Icurnm concisarum, yiv. Aqu®, Ibiv. Boil for a quarter of an hour, and strain. In cases attended with great pain and inflammation, this decoction is used as a fomenting fluid. DECOCTUM QUERCUS. R. Quercus corticis, ij. Aqu®, feij. Bod down to a pint, and strain the fluid. 'This decoction forms a very astringent injection, which is sometimes used for stopping gleets from the vagina. It also makes a lotion which is of consiilcrable | use in cases of prolapsus ani. It may be applied to some ; slight rheumatic white swellings, which it wdl some- | times cure, particularlv when a little alum is put into it. DECOCTUM SARSAPARILLA. R. Sarsapardl® radicis concis®, 3 iv. Aqu® ferventis, Ibiv. The sar- saparilla is to be macerated for four hours, near the fire, in a vessel lightly closed. The root is then to be taken 1 out, bruised, and put into the fluid again. The mace- ration is to be continued two hours longer, after which 1 the liquor is to be boiled tUl only two pints remain. ; Lastly it is to be strained. ! DECOCTUM SARSAPARILLA COMPOSITUM. R. Decocti sarsaparills.ferventis, Ibiv. Sassafras radi- ' cis concis®, guaiaci ligni rasi, glycirrhiz® radicis con- ] lus e, singulorum 3 j. Mezerei radicis corticis. 3 iij. | These are to be boiled together for a quaner of an ' hour, and then strained, j This and the preceding decoction of sarsaparilla are ; much prescribed in cases of venereal nodes and pains ; ■ but while some surgeons hold them in high repute in such cases, others entertain an opposite opinion of them. They are also commonly given in several cutaneous dis- eases, and in scrofula. Tlie simple decoction is frequently directed for the restoration of the constitution after a course of mercurj', sometimes mLxed with an equal quantity of milk. The common dose of both the decoctions is from four to eight ounces, three times a day. The compound one possesses similar qualities to those of the famous Lisbon diet drink, for which it is now a common substitute. DECOCTUM ULiH. R. Ulmi corticis recentis con- tus. 3 iv. Aqu®, Ibiv. Boil to two pints, and then strain the liquor. The decoction of elm bark is often prescribed in cuta- neous diseases. Its operation is frequently promoted by giving with it the hvdrargxri submurias. DECOCTUM ^'ERATRI. ' See Becoctmn Hellebori Albi. DEPRESSION OF THE SKULL. See Head, In- juries of. DEPRESSION OF THE CATARACT. See Ca- taract. DETERMINATION. WTien the blood flows into a ptirt more rapidly and copiously than is natural, it is said, in the language of surgery, that there is a deter- miiiation of blo^ to it. DIARESlSs. (From 6iaipio), to divide.) A division of substance ; a solution of continuity. This was for- merly a sort of generic term applied to everj- part of sur- gery, by which the continuity of parts was divided. DIGESTION. (From digero, to dissolve.) By the digestion of a wound, or ulcer, the old surgeons meant bringing it into a state in which it formed healthy pus. DIGESTIV ES. Applications which promote this object. DIORTHOSIS. (From ciop0du, to direct.) One of the ancient divisions of surgery : it signifies the restoration of parrs to their proper situations. DIPLO PIA. (From 5tT,\oCs, double, and a)(^ , the e\e, or drropai, to see.) Vis^es duplicatus is of two kinds. For instance, the patient either sees an object double, treble, Ac. only when he is looking at it wnth both his eyes, and no sooner is one eye shut than the object is s^n single and right ; or else he sees every object double, whether he surveys it with one or both his eyes. The disorder is observed to affect persons in different degrees. Patients seldom see the two appear- ances which objects present with equal distinctness ; but generally discern one much more plainly and per- fectly than the other. The first distinct shape which strikes the eye is commonly that of the real object, while the second is indistinct, false, and visionary Therefore patients labouring under this affection sel- dom make a mistake, but almost always know which is the true and real object. However, there are cases in which the patient sees, with equal clearness, the two appearances which things assume, so that he is incapa- ble of distinguishing the real object from what is false and only imaginary. The disorder is sometimes transitorj' and of short du- ration. and may be brought on in a healthy eye by some accidental cause, getieraily an irritation affecting the organ. .Sometimes the complaint is continual, some- times periodical. In j^articular instances the j>aiient only sees objects double, when he has been straining his sight for a considerable time, as, for e\an!n'e. when no I has been reading a small print for a long while by can* DIPLOPIA. 295 ^le-light. In this case, the disorder becomes lessened by shutting the eyes for a few moments. There are also instances in which the objects have a double ap- pearance only at a particular distance, and not either when they are nearer or farther off. Sometimes the patient sees objects double only upon one side ; as, for example, when he turns his eyes to the right-hand, while nothing of this sort is experienced in looking in any other direction. In certain cases, objects appear double, in whatever way the eyes are turned and directed. The causes of double vision may be divided into four classes. Namely, the object which the patient looks at may be represented double upon the retina ; which is the effect of the first class of causes. Or, the object may be depicted in one eye differently from what it is in the other, in regard to size, position, distance, clear- ness, &c. This is the effect of the second class of causes. Or, the object may appear to one eye to be in a different place from that which it seems to the other to occupy : the effect of the third class of causes. Or, lastly, the sensibility of the optic nerves is defective, so that the image of an object, though it may appear single to one eye as well as the other, yet in one identical situation will seem double to both of them. When the complaint originates from causes of the first and fourth class, the patient sees things double, whether he is using only one or both eyes ; liut when it proceeds from the second and third class of causes, the patient sees objects double only when he is looking at them with both eyes, and no sooner does he shut one than objects put on their natural single appearance. The following are the chief causes of the first class of a single object being depicted upon the retina as if double. 1. An unevenness of the cornea, which is di- vided into two or more convex surfaces. There are cases, which show that such an uneven sha{)e may actually be the cause of double vision.— (i/aZZcr, Ele- nient. Physiol, t. 5, p. 85.) According to Beer, this conformation of the cornea is mostly a result of several preceding ulcers of that membrane; in which circum- stance, the patient sees with the affected eye not merely double, but treble, and quadruple, of which facts Beer has met with some examples. — {Lehre von den Augenkr. A2,p. 31.) However, it must not be dissembled that in a far greater number of instances, such unevenness of the cornea, though equally considerable, does not occa- sion this defect of siglu. We have principally an oppor- tunity of observing cases of this sort after the operation of extracting the cataract. Hence, it would seem that the inequalities must be of very particular shape to produce double vision. The diagnosis of this cause is easy enough, but the removal of it is impracticable ; for how is it possible to restore the original shape of the cornea ? On this case; however. Beer delivers a more favourable prognosis than Richter ; for he states, that when the patient is not decrepit, the double vision, from altered shape of the cornea, will gradually disap- pear of itself, when proper care is taken of the consti- tution, and in particular of the eye.— (R. 2, p. 32.) 2. \n inequality of the anterior surface of the crystalline lens, whereby the same is divided into several distinct surfaces, it is suggested, may akso be the occasion of diplopia. Such an inequality may possibly produce the di.sorder; but it is exceedingly doubtful, whether any case of this sort has ever been met with, and, as Richter properly remarks, the investigation is not worth u;idertaking, as the diagnosis and cure would be equally impracticable. The only possible method of cure would be the e.xtraction or depre.ssion of the crystalline lens ; yet with the uncertainty respecting the nature of the cause, what man would be justified in per- forming an operation, in which the patient is not wholly Hxemin from the danger of losing his sight altogether 1 \ flouble aperture in the iris, or, as the ca.se is termed, » double pupil, and a deviation of the pupil from its natural position, have been enumerated as causes of diplopia —{Haumer, in Act. Soc. Hassiac. t. \,No. 27.) However, Richter deems the reality of the first of these causes doubtful ; lor cases have been noticed, where double vision was not the effect of there being two openings in the iris.— (7anm, Mim. sur ViKil.) But were the disorder actually to originate in this way, the experiment might be made of converting the two aper- (ures into one. The causes of the second class, by the effect of which the object is represented, in regard to its size, vwsiuoii, cu to the bodv , there ar# DISLOCATION. 207 few which require more prompt assistance, or in which the reputation of the surgeon is more at stake, tliaii cases of luxation ; for if much time be lost prior to the attempt at reduction, there is great additional difficulty in accomplishing it, and it is often entirely incapable of being effected. If it remains unknown, and conse- quently unreduced, the patient becomes a living me- morial of the surgeon’s ignorance or inattention. Hence this experienced surgeon forcibly inculcates the careful study of anatomy ; the want of an accurate knowledge of the structure of the joints being the cliief cause of the many errors which happen in the diagnosis and treatment of dislocated bones. The following passage cannot be too deeply impressed upon the surgeon’s mind: “A considerable share of anatomical knowledge is required to detect the nature of these accidents, as well as to suggest the best means o f reduction ; and it is much to be lamented, that our students neglect to inform themselves sufficiently of the structure of the joints. They often dissect the muscles of a limb with great neatness and minuteness, and then throw it av/ay, without any examination of the ligaments, the knowledge of which, in a surgical point of view, is of infinitely greater importance ; and from hence arise the numerous errors of which they are guilty, when they embark in the practice of their profession ; for the injuries of the hip, elbow, and shoulder are scarcely to be detected but by those who possess accurate ana- tomical information. Even our hospital surgeons, who have neglected anatomy, mistake these accidents ; for I have known the pulleys applied to an hospital patient in a case of a fracture of the neck of the thigh-bone, which had been mistaken for a dislocation, and the pa- tient cruelly exposed, through the surgeon’s ignorance, to a violent and protracted extension. It is therefore proper, that the form of the ends of the bones, their mode of articulation, the ligaments by which they are connected, and the direction in which the larger mus- cles act, should be well understood.”— Es- says, part 1, p. 2.) The most important differences of luxations are : 1. With respect to the articulation in which these acci- dents take place ; 2. The extent of the dislocation ; 3. The direction in which the bone is displaced ; 4. The length of time the displacement has continued ; 5. The circumstances which accompany it, and which make the injury simple or compound ; 6. And lastly, with respect to the causes of the accident. 1. Every kind of joint is not equally liable to dislo- cations. Experience proves, indeed, that in the greater part of the vertebral column, luxations are absolutely impossible, the pieces of bone being articulated by ex- tensive numerous surfaces, varying in their form and direction, and so tied together by many powerful elas- tic means, that very little motion is allowed. Expe- rience proves, also, that the strength of the articula- tions of the pelvic bones can scarcely be affected by enormous efforts, unless these bones be simultaneously fractured. Boyer has therefore set down luxations of joints with continuous surfaces as unpossible . — [Traite des Maladies Chirurg. t. 4, p. 17.) And Sir A. Cooper observes, that in the spine, the motion between any two bones is so small, that dislocations hardly ever occur, except between the first and second vertebrte, although the bones are often displaced by fracture.— {Surgical Essays, p. 14.) In the articulations with contiguous surfaces, the facility with which dislocations happen, depends upon the extent and variety of motion in such joints. Thus in the short bones of the carpus, and particularly of the tarsus, and at the carpal and tarsal extremities of the metacarpal and metatarsal bones, where flat broad surfaces are held together by ligaments, strong, nu- merous, and partly interarticular, and where only an obscure degree of motion can take place, dislocations are very unfrequent, and can only be produced by un- common violence. The loose joints, which admit of motion in every di- rection, are those in which dislocations most frequently occur ; such is that of the humerus with the scapula. On the contrary, the ginglymoid joints, which allow motion only in two directions, are, comparatively sjieaking, seldom dislocated. The articular surfaces of the latter are of great extent, and consequently the heads of the bones must be pushed a great way in order to be completely dislocated ; and the ligaments are numerous and strong. 2. With respect to the extent of the dislocation, luxa* tions are either complete or incomplete. The latter term is applied, when the articular surfaces still re- main partially in contact. Incomplete dislocations only occur in ginglymoid articulations, as those of the foot, knee, and elbow. In these, the luxation is almost al- ways incomplete ; and very great violence must have operated, when the bones are completely dislocated. In the elbow, the dislocation is partial, with respect both to the ulna and radius. In the orbicular articula- tions, the luxations are almost invariably complete. However, “ the os humeri sometimes rests upon the edge of the glenoid cavity, and readily returns into its socket.” — (.n. Cooper, Essays, part ' I, p. 14.) The lower jaw is sometimes partially dislocated in a man- ner different from what is commonly meant by this expression, viz. one of its condyles is luxated, while the other remains in its natural situation. As Sir A. Cooper has explained, a partial dislocation sometimes occurs at the ankle-joint. “An ankle (says he' was dissected at Guy’s, and given to the collection of St. Thomas’s, which was partially dislocated : the end of the tibia rested still in part upon the astragalus, but a large portion of its surface was seated on the os naviculare, and the tibia, altered by this change of place, had formed tv\m new articular surfaces, with their faces turned in opposite directions towards the two bones. The dislocation had not been re- duced.” 3. In the orbicular joints, the head of the bone may be dislocated at any point of their circumference ; and the luxations are named accordingly upivards, down- wards, forwards, and backwards. In the ginglymoid articulations, the bones may be dislocated either late- rally, or forwards, or backwards. 4. The length of time a dislocation has existed makes a material difference. In general, recent dislocations may be easily reduced ; but when the head of a bone has been out of its place several days, the reduction becomes exceedingly difficult, and in older cases very often impossible. The soft parts and the bone itself have acquired a certain position; the muscles have adapted themselves in length to the altered situation of the bone to which they are attached, and sometimes cannot be lengthened sufficiently for it to be reduced. Indeed, I believe ihat Sir Astley Cooper’s statement is quite correct, that the difficulty in the reduction, arising from the muscles, is proportioned to the length of time that has elapsed from the period of the accident. — {Treatise on Dislocations, p. 26.) Desault and Boyer believe, that frequently the open- ing in the capsular ligament soon becomes closed, and hinders the return of the head of the bone into its original situation. However, with regard to the doc- trine of the reduction being prevented by the capsular ligaments, it is considered by Sir Astley Cooper as destitute of foundation. — {Surgical Essays, part 1, p. 18 ; and Treatise, S, c. p. 25 ) Lastly, the head of the bone may become adherent to the parts on Avhich it has been forced. 5. The difference is immense, in regard to the dan- ger of the case, arising from the circumstance of a dis- location being attended or unattended with a wound, communicating internally with the joint, and externally with the air. When there is no wound of this kind, the danger is generally trivial, and the dislocation is termed a simple one ; when there is such a wound, to- gether with the dislocation, the case is denominated compound, affd is frequently accompanied with the most imminent peril. Indeed, the latter kind of acci- dent sometimes renders amputation necessary, and in too many instances has a fatal termination. 6. The causes of dislocations are externa! and in- ternal. A predisposition to such accidents may depend on circumstances natural or accidental. The great latitude of motion which the joint admits of; the little extent of the articular surfaces ; the looseness and fewness of the ligaments ; the lowness of one side of the articular cavity, as at the anterior and inferior part of the acetabulum ; and the shallowness of the cavity, as of that of the scapula; are natural predisposing causes of luxations. A paralytic affection of the muscles of a joint, and a looseness of its ligaments, are also predisposing causes. When the deltoid muscle has been paralytic, the mere weight of the arm has been known to cause such a lengthening of the capsular ligament of the shoulder- S93 DISLOCATION. joint, that the head of the os brachii descended two or three inches from the glenoid cavity. Two cases strikingly illustrative of the tendency to dislocation from a weakened or paralytic state of the muscles, are recorded by Sir A. Cooper. The first is that of a junior officer of an India ship, who, for some triffing offence, had been placed with his foot upon a small projection on the deck, wliile his arm was kept forcibly drawn up to the yard-arm for an hour. “ When he returned to England, he had the power of readily- throwing that arm from its socket, merely by raising it towards his head; bur a very slight extension reduced it. The muscles were wasted, also, as in the case of paralysis.” The other example happened in a young gentleman, troubled with a paralytic affection of his right side from dentition. “ The muscles of the shoul- der were wasted, and he had the power of throwing his 03 humeri over the posterior edge of the glenoid cavity of the scapula, from whence it became easily reduced.” In these cases, no laceration of the liga- ments could have occurred, and the influence of the muscles in preventing dislocation and in impeding re- duction is exemplified.— (Sur^ica? Essays, part 1, p. 10.) Mr. Brindley, of Wink Hill, communicated to Sir A. Cooper an account of a dislocation of the os fern oris, which the patient, a man of 50, is able to produce and reduce whenever he chooses . — {Treatise on Disloca- tions, Prefax:e.) The looseness of the ligaments sometimes makes the occurrence of dislocations so easy, that the slightest causes produce them. Some pei^ons cannot yawn or laugh without running the risk of having their lower jaw luxated. On this account, collections of fluid within the knee, causing a relaxation of the ligament of the patella, are often followed by a dislocation of that bone. And whenever a bone has been once dislocated, it ever afterward has a tendency to be displaced again, by a slighter cause than what was first necessary to produce the accident. This tendency, indeed, increases with every new displacement. Diseases which destroy the cartilages, ligaments, and articular cavities of the bones, may give rise to a dislocation. The knee is sometimes, but not frequently, partially luxated, in consequence of a white swelhng ; the thigh is often dislocated, in consequence of the acetabulum and Ugaments being destroyed by disease. Such dislocations are termed spontaneous. In the anatomical collection at St. Thomas's Hospi- tal, there is a preparation of a knee dislocated in con- sequence of ulceration, and in the state of anchylosis ; the leg forming a right angle with the femur directly forwards.— (See Sir A. Cooper’s Surg. Essays, part 1, p.ll.) An enarthrosis joint can only be dislocated by exter- nal violence, a blow, a fall, or the action of the muscles, w-hen the axis of the bone is in a direction more or less oblique with respect to the surface with which it is articulated. Any external force may occasion a dislocation of ginglymoid Joints, which case is generally incomplete ; but in the ball and socket articulations the action of the muscles constantly has a share in producing the accident. So, when a person falls on his elbow, wdiile his arm is raised outwards from his side, the force thus applied wdll undoubtedly contribute very much to push the head of the os brachii out of the glenoid cavity, at the low-er and internal part. Still, the sudden action of the pectoralis major, latissimus dorsi, and teres major, -vhich alw'ays takes place from the alarm, will also tud in pulling dow-nwards and inwards the head of the bone. Under certain circumstances, the violent action of the muscles alone may produce a dislocation, without the conjoint operation of any outward force. But when the patient is aw-are in time of the violence which is about to operate, and his muscles are pre- pared for resi.stanee, a dislocation cannot be produced without the greatest difficulty {Sir .d. Cooper, op. cit. p. 15), unless the posture of the member at the moment be such as to render the action of the strongest muscles conducive to the displacement instead of preventive of it, as is frequently the case in luxations of the shoulder. Dislocations are constantly attended with more or less laceration or elongation of the ligaments ; and in the shoulder and hip, the capsules are always tom, when the accident has been produced by violence. Some instances, in wliich the ligaments are only lengthened , and relaxed, I have already quoted. Sometimes a - movenient of the dislocated limb at the moment of the displace- DISLOCATION. 299 nent, and which it afterward retains. Thus, in luxa- tions of the thigh, the toes and knee are turned outwards or inwards, according as the head of the thigh-bone happens to be situated at the inside or outside of the joint. These two kinds of alteration in the direction of the limb are permanent, when they depend upon a dis- location ; a circumstance quite different from what is observable in fractures, where the same changes occur, but can be made to cease at once, without any particu- lar effort. 3. The absolute immobility of a limb, or, at least, the inability of performing certain motions, is among the most characteristic symptoms of a dislocation. In some complete luxations of particular ginglymoid joints, the dislocated limb is absolutely, or very nearly, incapable of any motion. Thus, in the dislocation of the forearm backwards, the particular disposition of the bones, and the extreme tension of the extensor and fle.xor muscles, confine the limb in the half-bent state, and at the same time resist every sjKtntaneous motion, and likewise almost every motion which is communi- cated. In the orbicular joints, the painful tension of the muscles which surround the luxated bone nearly impedes all spontaneous movements ; but, in general, analogous motions to that by which the displacement was produced can be communicated to the limb, though not without exciting pain. Thus, in the dislocation of the humerus downwards, the elbow hardly admits of being put near the side, nor of being carried forwards and backwards ; but it can be raised up with ease. In the dislocation of the acromial end of the clavicle, the patient can bring the arm towards the trunk, separate it a little from the side, or carry it forwards or back- wards ; but he cannot raise it in a direct way. Lastly, in complete lateral dislocations of such joints as have alternate motions, the patient has the power of per- forming no motion of the part; but the complete de- struction of all the means of union allows the limb to obey every species of extraneous impulse; and this symptom, which is besides never single, makes the nature of the case sufficiently manifest. Sometimes, as Sir A. Cooper has remarked, a consi- derable degree of motion continues for a short time after a dislocation : thus, in a man, brought into Guy’s Hos- pital, whose thigh-bone had just been dislocated into the foramen ovale, a great mobility of the femur still re- mained ; but, “ in less than three hours, it became firmly fixed in its new situation, by the contraction of the muscles . — {Surgical Essays, part 1, p. 3.) 4. In dislocations attended with elongation of the limb, the general and uniform tension of all the muscles arranged along it, gives to these organs an appearance as if they lay nearer the circumference of the bone, and the limb were smaller than its fellow. The muscles, however, which belong to the side, from which the dislocated bone has become more distant, appear more tense than the others, and form externally a prominent line. This is very manifestly the case with the deltoid muscle, when the arm is luxated downwards. On the contrary, in dislocations where the limb is shortened, the muscles are relaxed ; but, being irritated, they con- tract and accommodate themselves to the shortened I state of the limb. Hence the extraordinary swelling of their fleshy part, and the manifestly increased diameter of the portion of the member to which tltey belong. We have a striking example of this in the dislocation of the thigh upwards and outwards, where the muscles at the inside of the limb form a distinct oblong tumour. The parts which surround the affected joint also ex- perience alterations in their form, whenever muscles connected with the dislocated bone occupy that situa- tion. Thus, in dislocations of the thigh, the buttock on the same side is flattened, if the bone is carried in- wards ; but it is more prominent, when the thigh-bone is carried outwards ; and its lower edge is situated higher or lower than in the natural state, according as the luxation may have taken place upwards or down- wards. In the complete luxation of the forearm back- wards, the triceps is tense, and forms a cylindrical ])ro- minence, owing to the displacement of the olecranon bacikwards, in which displacement it is obliged to jiarti- cipatc. 5. The circumference of the joint itself presents al- terations of shape well deserving attention, and in or- der to judge rightly of this symptom, correct anatomi- cal knowledge is of high importance. The form of the joints principally depends upon the shape of the heads of the bones. Hence, the natural relation of the bones to each other cannot be altered without a change being immediately produced in the external form of the joint. The changes which the muscles passing over the luxated joint at the same time undergo in their situation and direction, contribute likewise to the difference of shape, by destroying the harmony of what may be called the outlines of the limb. When the head of a bone articulated by enarthrosis, has slipped out of the cavity, instead of the plumpness which previously indicated the natural relation of parts, fhe head of the dislocated bone may be distin- guished at some surrounding point of the articulation, while at the articulation itself may be remarked a flat- ness, caused by one of the neighbouring muscles stretched over the articular cavity, and more deeply may be perceived the outline and depression produced by this cavity itself. The bony eminences situated near the joint, and whose outlines were gradually effaced in the general form of the member, are ren- dered much more apparent by the displacement, and project in a stronger degree than in the natural state. On this part of the subject Sir A. Cooper is particu- larly correct, when he observes, that the head of the bone can generally be felt in its new situation, except- ing in some of the dislocations of the hip, and its rota- tion is often the best criterion of the accident. Tht natural prominences of bone near the joint either dis- appear or become less conspicuous, as the trochante} at the hip- joint. Sometimes the reverse occurs; for in dislocations of the shoidder, the acromion projects more than usual. — {Surg. Essays, part 1, p. 4.) The lines made by the contour of the limb and the natural relation of the bones, are so manifestly broken in dislocations of ginglymoid joints, that when there is no inflammatory swelling the case is at once mani- fest. More certain knowledge, however, and more correct information respecting the kind of displace- ment, are to be obtained, by attentively examining the changes of position which the bony prominences form- ing the termination of the bones articulated together have undergone, and which are the more obvious in these joints, inasmuch as they give attachment to the principal muscles. The natural relations of these pro- cesses being known, the least error of situation ought to strike the well-informed practitioner. Thus, in the elbow-joint, a considerable difference in the respective height, and in the distances between the olecranon and internal and exterital condyles, can be easily distin- guished. But the thing is less easy when the sur- rounding parts are so swelled and tense as to make the bony projections deeper from the surface and less ob- vious to examination. Even then, however, a good surgeon will at least find something to make him sus •• pec' the dislocation, and the suspicion will be con- firmed when he again examines the part after the swelling has begun to subside. It is of the utmost consequence to make out what the OBse is as early as possible; for the unnatural state in which the soft parts are placed keeps up the swelling a long while ; and if the surgeon wait till this has entirely subsided before he ascertains that the bones are luxated, he will have waited till it is too late to think of reducing them, and the patient must remain for ever afterward deprived of the free use of his limb. — {Boyer, TraiU des Mala- dies Chir. t. 5, p. 45, c.) It is not only the inflam- matory swelling which may tend io conceal the state of the ends of the bone ; sometimes a quicker tumour arises from the effusion of blood in the cellular membrane, and causes an equal ditficulty of feeling the exact position of the heads of the bones.— (See Treatise on Dislocation, by Sir A. Cooper, p. 5.) Dislocations are also sometimes attended with parti- cular symptoms, arising altogether from the pressure caused by the head of the luxated bone on certain parts. The sternal end of the clavicle has been known to compress the trachea and impede respiration : the head of the humerus may press upon the axillary plexus of nerves, and produce a paralytic affection of the whole arm. In one instance cited by Sir A. Cooper, a dislocated clavicle iircssed upon the (esophagus and endangered life.— ( Surg. Essays, part 1, p. 4.) As Kirkland has observed, there are some luxations which are far worse injuries than fractures ; of thia description are dislocations of the vertebrae, cases, which, indeed, can hardly happen without fracture, 300 DISLOCATION. and are almost always fatal ; dislocations of the long bones, with protrusion of their ends through the mus- cles and skin, and severe inflammation, extensive ab- scesses, attended with great risk of being followed by large and tedious exfoliations, and not unfrequently gangrene. According to Sir A. Cooper, young persons are rarely subjects of dislocations from violence ; but he admits that they do sometimes experience them, and relates an instance which happened in a child seven years of age. In general, their bones break, or their epiphyses give way, much more frequently than the articular surfaces are displaced. — (,Surg. Essays, part. 1, p. 16 ; and Treatise, Src. p. 23.) Suspected luxations of the hip in children commonly turn out to be disease of the joint, one instance of which is given by the preceding author, and an example of which I was lately con- sulted about myself. Also, when a dislocation of the elbow is suspected In a child, because the bone appears readily to return into its place, but directly to slip out of it again, the case, according to Sir A. Cooper, is an oblique fracture of tlie condyles of the humerus. Old persons are also much less liable to dislocations than individuals of middle age ; a fact which is accounted for by the extremities of bones in old subjects being so softened that the violence sooner breaks than luxates them.— (Sir Astley Cooper, Treatise, Ir. Pott replies, that when the head of the 08 humeri is draxvn forth from the axilla, and brought to a level with the cup of the scapula, it must be a very great and very unnecessary addition of external force, that will or can keep it from going into it. All that the surgeon has to do is to bring it to such level ; the muscles attached to the bone xvill do the rest for him, and that whether he will or not. 7. Another of Pott’s principles is, that whatever kind or degree of force may be found necessary for the reduction of a luxated joint, that such force be em- ployed gradually ; that the lesser degree be always first tried, and that it be increased gradatim.— (See PotVs Chir. Works, vol. 1.) The supposition of the reduction being sometimes prevented by the capsular ligaments. Sir A. Cooper considers erroneous : he as.sures us, that in disloca- tions from violence, those ligaments are always exten- sively lacerated ; and that the idea of the neck of the bone being girt or confined by them, is altogether un- true.— (Sizi-g. Essays, part 1, p. 18.) But, in addition to the resistance of the muscles, there are, in old dis- locations, three circumstances pointed out by him as causes of the difficulty of reduction. 1. The extre- mity of the bone contracts adhesion to the surrounding parts, so that in dissection, even when the muscles are removed, the bone cannot be reduced. In this state, he found the head of a radius, which had been long dislocated upon the external condyle, and which is preserved in the collection of St. Thomas's Hospital. In a similar state he has also seen the dislocated head of the humerus.— (071 Dislocations, p. 28.) 2. The socket is sometimes filled up with adhesive matter. 3. A new bony socket is sometimes formed, in which the head of the bone is so completely confined that it could not be extricated without breaking its new lodgement, —{Surgical Essays, part 1, p. 21 ; and Treatise, trial of this plan in a compound luxation of the ankle. The example, however, which he published, is decidedly unfavourable to the practice, as the following passage will show : “ 1 was in hopes that this patient would have been able to walk stoutly ; but in this I was disap- pointed. He walked indeed without a crutch ; but his gait was slow, his leg remaining weak, and his toes turning outwards, which rather surprised me, as hi^ leg was very straight when I ceased attending him.” • Mr. Hey did not recite this case with the view of re- commending a similar practice in all cases of this ac- cident ; for he had not always adopted it, nor was he of opinion, that the same mode of treatment, whether by replacing the bones, sawing off their extremities, or amputating the limb, ought to b'e universally practised. When the laceration of the capsular ligament and in- teguments is not greater than is sufficient to permit the head of the tibia to pass through them ; and when, at the same time, the joint or contiguous parts have suf- fered no other injury; Mr. Hey recommends the re- placing of the bone, and a union of the integumenta by suture, with the treatment adapted to wounds of the joints. — {Practical Obs. in Surgery, chap. 11, edit. 2.) That in a few cases recorded by Mr. Gooch and Mr. Hey the patients recovered with a new sort of joint, only proves to my mind the great resources and activity of nature, and her occasional triumph over the opposition she meets with from bad and injudicious surgery. A limb so treated must ever afterward be shorter than its fellow, and consequently the patient be more or less a cripple. We have seen, that in the only instance pub- lished by Mr. Hey, considerable deformity was the consequence of the practice. I cannot help adding my belief, that this gentleman would have experienced more success in the treatment of compound dislocations, had he relinquished the objectionable method of sewing up the wound. In such accidents every' kind of irrita- tion should be avoided as much as possible, and that the wound may be conveniently closed with sticking plaster, the observation of numerous cases in St. Bartholomew’s Hospital has perfectly convinced me. In this munifi- cent institution, under the disadvantage of the air of London, and an hospital, compound luxations used, at the period when I was an apprentice there, to be treated with marked success; and I feel warranted in ascrib- ing the circumstance to the mode of treatment, which was conducted on the principles explained in tliis sec- tion of the Dictionary. The most ingenious arguments which have yet been urged in behalf of the practice of sawing off the ends of the bones in compound dislocations of the ankle, are those recently published by Sir A. Cooper. How- ever, he does not advise the plan without restrictions. If the dislocation (says he) can be easily reduced, without sawing off the end of the bone ; if it be not too obliquely broken to remain firmly upon the astra- galus after being reduced ; if the end of the bone be not shattered, for then the small loose pieces of bone should be removed, and the surface of the bone be smoothed by the saw ; if the patient be not excessively irritable, and the muscles affected with violent spasms, impeding reduction, and causing a displacement of the bones after they have been reduced ; Sir Astley Cooper advises the immediate reduction of the parts, and uni- ting the wound by adhesion.. In the opposite circum- stances, rather than amputate the limb he would saw off the ends of the bones. — {Surgical Essays, part 1, p. 154. Treatise, p. 302.) The only case in which the plan of sawing off the head of the bone can be at all proper, is when a com- pound dislocation cannot be reduced, notwithstanding the enlargement of the wound in the skin, and every other possible means. There is no other mode of pre- venting the formidable symptoms which would ensue were the bone left in a state of protrusion through the integuments ; nor is there any better way of alleviating such symptoms after they have actually begun. M. Roux gives much praise to the English surgeons for the judicious boldness which they have evinced in cases of this description. Although Fabricius Hildanus, Fer- rand, Desault, Laumonier, and several other French surgexms, have, like many British practitioners, ven- tured to remove the whole of the astragalus, when this bone was totally separated from the scaphoides, and protruded in compound luxations, yet M. Roux acknowledges that the bold practice of sawing off the DISLOCATION. m Tower end of the hnmeras, the lower end of the radius, the lower end of the tibia, and also of the fibula, at the same time, originated with, and was first executed by, English surgeons.— {ParalMe de la Chirurgie An- gloise avec la Chirurgie Francoise, p. 208, 209.) DISLOCATIONS OF THE LOWER JAW. • The low’er jaw can only be luxated forwards, and either one or both of its condyles may become displaced in this direction. Every dislocation except that for- wards is rendered impo.ssible by the formation of the parts. The lower jaw cannot even be dislocated for- wards, unless the mouth, just before the occurrence of ^he accident, be very much open. Whenever the chin i.s considerably depressed, the condyles slide from be- hind forwards under the transverse root of the zygoma- tic processes. The cartilaginous cap which envelopes the condyles, and follows them in all their motions, still affords them an articular cavity ; but the depres- sion of the bone continuing, the ligaments give way, the condyles glide before the eminentice articulares, and slip under the zygomatic arches. Hence a dislo- cation mostly happens while the patient is laughing, gaping, - rare kind of displacement must have been facilitated by some preternatural disposition of the articular surfaces, especially that of the glenoid cavity. No dislocation must occur more ft-equently than that downwards, in which the influence of the weight of the body, and of the action of the muscles, is direct. However, the luxation inwards, or, as Sit Astley Cooper and others call it, forwards, is common. In all primitive dislocations from violence, and not from paralysis of the deltoid, and a gradual yielding of the capsule, I believe the latter part is always exten- sively lacerated. In general authors have paid too lit- tle attention to this circumstance, which dissections have repeatedly demonstrated. Desault had two spe- cimens made of wax ; one of a dislocatton inwards ; the other of one downw'ards ; both of which were met with in subjects who died at the H6tel-Dieu. Bell also makes mention of similar facts, and another Eng- lish surgeon, says Bichat, has observed the same oc- currence. I suppose Bichat here alludes to Mr. Tliomp- son, who long ago noticed the laceration of the cap- sule, and particularly called the attention of surgeons to the subject.— (See Med. Obs. and Inquines.) Desault conceives that the capsule may be suffi- ' ciently torn to let the head of the bor.e escape ; but DISLOCATION. 311 that the opening may afterward form a kind of con- striction round the neck of the humerus, so as to pre- vent the return of the head of the bone into the place which It originally occupied. The correctness of this statement, however, is positively denied by Sir A. Cooper, who remarks, that they who entertain this be- lief must forget the inelastic structure of the capsular ligament, and never witnessed by dissection the exten- sive laceration which it suffers in dislocations from violence . — (Surgical Essays, part 1, p. 18.) Several causes may lead to a consecutive luxation. If a fresh fall happen while the arm is separated from the trunk, the head of the humerus, which nothing confines, obeys, with the utmost facility, the power displacing it in this manner, and is again pushed out of the situation which it accidentally occupies. A man, going down stairs, meets with a fall, and dislocates the humerus downwards; he immediately sends for Desault, who defers the reduction till the evening. In the mean time, the patient, in getting upon a chair, slips and falls again. The pain was more acute than when the first accident occurred, and Desault, on his return, instead of finding the head of the humerus as it was in the morning, in the hol- low of the axilla, finds it behind the pectoralis major muscle. The action of muscles is a permanent cause of a new dislocation. When the humerus is lujtated down- wards, the pectoralis major and the deltoid draw the upper part of this bone upwards and inwards, which, only making a weak resistance to their action, changes its position, and takes one in the above double di- rection. The various motions imparted to the arm may also produce the same effect, according to their direction. Thus, in consequence of unskilful efforts to reduce the bone, a luxation inwards frequently follows one down- wards. By the French surgeons, a great deal of im- portance has been attached to the division of disloca- tions of the humerus into primary and consecutive ; and perhaps some of their statements on the secondary change in the position of the head of the bone may be exaggerated. That a subsequent alteration in the situ- ation of the bone may happen, from the causes spe- cified by Desault, can hardly be questioned. The ob- servations of Petit, Hey, and others, confirm the fact ; and I have myself seen a dislocation in the axilla change into one forwards, under the pectoral muscle. However, Sir Astley Cooper believes that, excepting from violence and the effect of absorption, the nature and direction of a dislocation are never changed after the muscles have once contracted.— (Du Dislocations, p. 416.) Perhaps, with the latter qualification, no great difference prevails between him and other writers. SYMPTOMS. In general, the diagnosis of dislocations of the hu- merus is attended with no difficulties. Whatever may be the mode and situation of the dis- location, there always exists, as Hippocrates has re- marked, a manifest depression under the acromion, which forms a more evident projection than in the na- tural state. Almost all the motions of the arm are painful ; some cannot be performed in any degree ; and they are all very limited. The arm cannot move without the shoulder moving also, because the articu- lation being no longer able to execute its functions, both it and the shoulder fbrm, as it were, one body. When the limb is moved, a slight crepitus may some- times be felt, probably in consequence of the synovia having escaped through the laceration of the capsule. — (A. Cooper on Dislocations, p. 418.) To these symptoms, generally characteristic of every sort of dislocation of the humerus, are to be added such as are peculiar to each particular case. When the luxation is downwards, the arm is a little longer than in the natural state ; the natural roundness of the shoulder is lost in consequence of .the deltoid mus- cle being drawn down with the head of the bone ; and the patient cannot use the arm. The elbow is more or less removed from the axis of the bo in such a way that the arm, having a resting-place, may be sheltered from all painfhl motion, especially that of the elbow inwards. By this posture alone Desault often recognised the ac- cident. The head of the humerus may be felt in the axilla; but “ only when the elbow is considerably re- moved from the side.”— (Sir A. Cooper on Dislocations, p. 417.) This last circumstance is worthy of particu- lar notice, as the inability to feel the head of the bone has led to mistakes. With the general symptoms of dislocations of the hu- merus, a luxation inwards has the following ; the elbow, separated from tne axis of the body, is inclined a little backwards ; the humerus seems to be directed towards the middle of the clavicle; motion backwards is not very painful, but that forwards is infinitely so ; a manifest prominence under the great pectoral muscle ; the arm is said by Desault to be a very little longer than in the natural state ; by Sir Astley Cooper it is described as be- ing somewhat shortened (Ort Dislocations, p. 435), and the posture is the same as in the foregoing case. The coracoid process is on the outer side of the headof tlie bone. Were a dislocation outwards to present itself, it would be particularly characterized by a hard tumour under the spine of the scapula ; by the direction of the elbow forwards ; and by the somewhat increased length of the arm. The motions of the arm would be impaired, but not in so great a degree as in the foregoing cases. In one example, related by Mr. Toulmin, of Hackney, the arm could be moved considerably either upwards or dowm- wards ; but motion forwards or backwards was very limited. And from the observations of Mr. Coley, of Brulgenorth, it would seem that this dislocation may be attended with the peculiarity of the arm lying close to the side.— (A. Cooper on Dislocations, p. 441—443.) Many authors, particularly B. Bell, speak of an cede- matous swelling of the whole upper extremity as a fre- quent consetiuence of a dislocation inwards. In the time of Desault and Bichat, this occurrence was not often no- ticed at the Ilotel-Dieu, except in very old luxations ; and when it was, very beneficial effects were obtained, in certain instances, by applying, for a few days, a mo- derately tight bandage from the fingers up to the axilla. Bichat relates a case in which the cedema did not dis- appear with the cause, but even rather increased ; but the day alter a bandage had been applied, the swelling was found diminished by one-half. Considerable sw'ell- ing, which sometimes takes place very rapidly, may render the nature of the accident too obscure for a prac- titioner imperfectly acquainted with all its signs to de- tect it with certainty ; and hence the patient may not have the benefit of right treatment in due time ; the bone at length cannot be reduced ; a permanently crip- pled state of the arm is the consequence ; the surgeon is sued for heavy damages ; and his reputation and pros- pects are ruined. There is another consequence, to which authors have paid but little attention ; though it was known to Avi- cenna, and was several times observed by Desault. This is a palsy of the upper extremity, arising from the pressure made by the head of the bone, when dislocated inwards, upon the axillary plexus of nerves, and some- times resisting every means of relief. Indeed, when the nerves have been long compressed, the affection is very difficult of cure. Desault several times applied the moxa above the clavicle. The success which he at first experienced in some patients did not invariably follow in others. But when the head of the humerus has only made, as it were, a momentary pre.s- sure on the nerves, and the reduction has been effected soon after the appearance of the symptoms, the para lytic affection often goes off of itself, and its dispersion may always be powerfully promoted by the use of vola- tile liniments. OF THE REDUCTION. We may refer to two general classes the infinitely various number of means proposed for the reduction of a dislocated humerus. The first are designed to push back, by some kind of rftechanical force, the head of the bone into the cavity from which it is displaced, either with or without making previous extension. The others are merely intended to disengage the head of the bone from the place which it accidentally occupies, leaving it to be put into its natural situation by the ac- tion of the muscles. By the first means art effects every thing ; by the second, it limits its interference to the suitable dircc- 312 DISLOCATION, tion of the powers of nature. In the first method, the force externally applied always operates on the bone in the diagonal of two powers, which resist each other at a more or less acute angle ; in the last the power is only in one direction. All the means intended to operate in the first way, act nearly in the followng manner. Sometlung placed under the axilla serves as a fulcrum, on which the arm is moved as a lever, the resistance being produced by the dislocated head of the humerus, while the power is applied either to the lower part of this bone, or the wrist. The condyles of the humerus being pushed downwards and inwards, the head of the bone is necessarily moved in the opposite direction, towards the glenoid cavity, into which it slips with more or less facilitj'. Thus operated the machine so celebrated among the ancients and moderns, under the name of the anibi of Hippocrates; whether used exactly in the form described by him, or with the numerous corrections devised by Paul of iEgina, Ambrose Par6, Duverney, Freke, &;c. By this machine a double motion is communicated to the head of the humerus, as above explained. The extension usually moves the bone from its un- natural situation, and is executed in different ways. Sometimes the weight of the body on one side, and the dragging of the end of the dislocated bone on the other, tend to produce this effect. Such was the, action of the ladder, door, &c. described in Hippocrates’s Treatise on Fractures, and repeated in modern works. Some- times the trunk is fixed in an unchangeable manner, while the arm is powerfully extended, as is practised in employing the machine of Oribasius, one of the me- thods formerly adopted in the public places where wrestlers combated. Sometimes no extension is sensibly executed, and while the end of the humerus is pushed outwards by a body placed under the axilla, the surgeon pushes it up- wards into the glenoid cavity. The following are the objections common to all these contrivances. However well covered the body placed under the axilla may be to serve as a fulcrum, there is always a more or less inconvenient chafing, frequently dreadful stretching and laceration of parts in consequence of its application when the trunk is suspended upon it, as in the instance of the door, &;c. In this way Petit saw a fracture of the neck of the humerus ])roduced, and even a laceration and aneurism of the axillary artery. Few surgeons have the different kinds of apparatus at hand. Hence trouble and loss of time in getting them ; time, which is of so much moment, as the re- duction is always more easy the sooner it is accom- plished. When the luxation is consecutive, how can mecha- nical means bring back the head of the bone through the track it has taken ■? For instance, if to a dislocation downwards one inwards has succeeded, the head of the bone ought to be brought down before it can be re- placed. The above means often do not co-operate with the muscles, which are the chief and essential agents in the reduction. Perhaps, however, they might be advantageously employed, when a primitive luxation downwards is quite recent, and when the head of the bone is very near the cavity. Then the inferior costa of the scapula presents an inclined plane, along which the end of the bone can easily glide, when propelled by any kind of ex- ternal fgrce. Desault very often employed the following method with great success. While the patient was seated upon a chair of moderate height, he took hold of the hand on the affected side, placed it between his knees, which he moved downwards and backwards, in order to make the extension and disengage the head of the bone, while an sissistant held back the trunk to effect the counter-extension. This was sometimes executed by the weight of the body and effort of the patient. At the same time the surgeon’s hands, being applied to the arm in such a way that the four fingers of each were put in the hollow of the axilla, and the thumbs on the outer part of the arm, pushed upwards, and a little out- wards, the head of the humerus, which usually returned with ease into its natural cavity. Petit describes this plan, but complicated with the | use of a napkin, passed under the patient’s axilla, and over the surgeon’s neck, who contributes to raise the dislocated end of the bone, by lifting up his head. When the luxation downwards was ver>’ recent, De- sault occasionally reduced it by a still more simple pro- cess. Marie-Louise Favert fell in going down stairs, dis- located her arm downwards, and was conveyed immedi- ately after the accident to the Hotel-Dieu. Desault hav- ing recognised the disorder, placed his left hand under the axilla, to serve as a fulcrum, while with the right, applied to the lower and outer part of the arm, he depressed the humerus towards the trunk, and at the same time raised the upper part of the bone. The head of the humerus, directed upwards and outwards by this double motion, re- turned into the glenoid cavity without the least resistance. Reduction by means of the surgeon’s heel in the pa- tient’s axilla is a well-known method, which is com- mended by Sir Astley Cooper as the best in three- fourths of recent dislocations. The patient (he observes) should be placed in the recumbent posture, upon a ta- ble or a sofa, and near its edge. “ The surgeon then binds a wetted roller round the arm, immediately above the elbow, upon which he ties a handkerchief. Then, with one foot resting upon the floor, he separates the patient’s elbow from his side, and places the heel of his other foot in the axilla.” The arm is then steadily drawn with the handkerchief for three or four minutes, at the end of which the bone in common cases is easily re- placed. If more force be required, a long towel can be used, with which several persons may pull. Sir Ast- ley Cooper generally bends the forearm nearly lo a right angle with the os humeri, because this position relaxes the biceps, and lessens its resistance ; in many cases, however, he makes the extension at the wrist ; a plan in which he finds more force requisite, but the bandage is less apt to slip. Another simple mode of reduction, which Sir Astley Cooper considers proper for recent dislocations, delicate females, and very old, relaxed, emaciated persons, is that by means of the surgeon’s knee, as a fulcrum, in the patient’s axilla. The patient is placed on a low chair, on the side of which the surgeon rests his foot, while he takes hold of the os humeri just above the condyles, and applies his other hand to the acromion. The arm is then drawn down over the knee, and the head of the bone returns into its place . — {On Dislocationns, p. 432.) In some cases the preceding methods are inadequate, and greater extension must be made. The following was the practice of Desault. The patient is laid upon a table covered with a mat- tress ; a thick linen compress is applied to the axilla, on the side affected, and upon this compress the middle of the first extenduig bandage is placed, the two heads of which ascend obliquely before and behind the chest, meet each other at the top of the sound shoulder, and are held there by an assistant, so as to fix the trunk and make the counter-extension. The action of this band- age does not affect the margin of the pectoralis major and latissimus dorsi, in consequence of the pad project- ing over them. If this were not attended to, these mus- cles, being drawn upwards, would pull the humerus ie this direction, and thus destroy the effect of the exte'.,- sion, which is to be made in the following manner. Two assistants take hold of the forearm, above the wrist ; or else the towel, doubled several times, is to be appUed to this part. The two ends are to be twisted together, and held by one or two assistants, who are to begin pulling in the same direction in which the hum» rusis thrown. After this first proceeding, which is de- signed to disengage the head of the bone from its /’.cci- dental situation, another motion is to be employed, which differs according to the kind of luxation. If this should be downwards, the arm is to be gradually brought near the trunk, at the same time that it is gently pushed up- wards. Thus the head of the bone being separated from the trunk, and brought near the glenoid cavity, usually glides into this situtation with very little resistance. When the luxation is inwards, after the extension has been made in the direction of the humerus, the end of this bone should be inclined upwards and forvs ards, in order that its head may be guided backwards; and vice versa, when the luxation is outwards. ’When the head of the bone has been disengaged by the first extension, the motion imparted to it by the rest of the extension, should in general be exactly con- trary to the course which the head of the bone has I taken after quitting the glenoid cavity. When there is I difficulty experienced in replacing the head of the bone, j we should, after making the extension, move the bone 1 about in various mhuners according to the differeiH DISLOCATIOxN. 313 direction of the dislocation, and the principle just no- ticed. This plan often accomplishes what extension alone cannot ; and the head of the bone, brought by such movements towards its cavity, returns into it during their execution. When the dislocation is consecutive, it is the first ex- tension made in the direction of the displaced bone, which brings back its head to the situation where it was primitively lodged, and the case is then to be managed just as if it were a primitive dislocation. Thus we see that, except in a few cases, where the beneficial operation of the muscles had been prevented by the oldness of the dislocation or by adhesions, and where it was necessary to employ means to force, as it were, the head of the bone into its cavity, to which the muscles could not bring it, Desault only employed exten- sion variously diversified, till he had put the muscles in a state favourable for accomplishing reduction. When the muscles are very powerful, or the displace- ment has continued several days. Sir Astley Cooper, instead of the treatment by the heel in the axilla, re- commends the patient to be put upon a chair, and the .scapula to be fixed by means of a bandage which allows the arm to pass through it, and is buckled on the top of the acromion, so that it cannot slip downwards. A wetted roller is next applied round the arm just above the elbow, and over the roller a strong worsted tape, fixed with what the sailors term the dove-hitch knot. The arm should now be raised to a right angle with the body, and, if much difficulty be experienced, even above the horizontal line, in order to relax more completely the deltoid and supraspinatus muscles. iSvo persons are then to pull the worsted tape, and two the scapula bandage, in opposite directions, with a steady, equal, and combined force. After the exten- sion has been kept up a few minutes, the surgeon is to place his knee in the axilla, with his foot resting upon the patient’s chair ; he now raises his knee, while he ushes the acromion downwards and inwards, and the ead of the bone usually slips into the glenoid cavity. Sometimes Sir Astley Cooper has seen a gentle rotatory motion of the limb, made during the extension, bring about the reduction. In old cases, and others attended with great difficulty from the powerful contraction of the muscles, Sir Ast- ley prefers making the extension with pulleys, because with them, when the resistance is likely to be long, jerks and unequal force are more likely to be avoided than in the preceding method of reduction ; and the assistants less apt to be fatigued. The patient sits between two staples, which are screwed into the sides of the room ; the bandages are then applied precisely in the same way as when the extension is made with- out pulleys ; and the force is applied in the same direc- tion. The surgeon is to pull the cord of the pulley gemly and steadily until pain is complained of, when he is to maintain the extension already made, but not increase it. During this stop, he should converse with the patient, and direct his mind to other subjects. In two or three minutes, more force should be applied, and very gently increased, until pain be again com- plained of, when another stop should be made. The surgeoh should proceed in this way for a quarter of an hour, at intervals slightly rotating the limb. When the extension seems great enough, an assistant should hold the cord of the pulley, and keep up the degree of extension, while the surgeon puts his knee into the axilla, and resting his foot upon the chair, gently raises and pushes back the head of the bone towards the glenoid cavity, into which it generally returns without the snap usually heard when the reduction is effected by other means. Sir Astley Cooper precedes the use of the pulleys with venesection, the warm bath, and a grain of tartarized antimony every ten minutes, until faintness is produced, as already noticed in our general remarks. — (Cbi Dislocations, p. 429.) When the head of the humerus is dislocated forwards, or undir the middle of the clavicle, Sir Astley Cooper recommends the biceps to be .relaxed, and the extension to be made obliquely downwards and a little back- wards. In most instances of this kind, he says, the plan of reduction by means of the heel in the axilla will succeed, care being taken to apply the foot rather more forwards than in a dislocation into the axilla, so that it may press on the head of the bone. However, when the dislocation has continued several days, he ,con8iderH gradual extension xvith pulleys necessary. As soon as the head of the bone has been drawn below the level of the coracoid process, it is to be pressed backwards with the surgeon’s heel or knee, and the elbow at the same moment pulled forwards.— (Op. cit. p. 439.) The dislocation on the dorsum of the scapula ap- pears, from some cases in Sir Astley Cooper’s work, to be reducible by nearly the same mode of extension as hat employed for the reduction of the dislocation in the axilla. Mr. Coley, of Bridgenorth, who has met with two cases of luxation backwards, advises the re- duction to be effected by elevating the arm and rotating it outwards, so as to roll the head of the humerus to- wards the axilla, when it is to be kept in this po.sition, while the arm is brought down into a horizontal direc- tion; on the extending force being now applied, the bone is easily reduced. — (Op. cit. p. 444.) In the partial dislocation forwards, or that where the head of the bone lies at the scapular side of the coracoid process, the moder of reduction, according to Sir Astley Cooper, is the same as that employed in the complete dislocation forwards ; but it is necessary to draw the shoulders backwards, and as soon as the reduction is accomplished, the bone is to be kept from slipping for- wards again by maintaining the shoulders in that posi- tion with a bandage.— (Op. cit. p. 449.) The elbow and forearm should also be supported as much forwards as possible in a sling. In the museum of St. Thomas’s Hospital is a prepa- ration, exhibiting a dislocation of the humerus into the axilla, complicated with a separation of the greater tu- bercle by fracture. In Sir Astley Cooper’s valuable work on this subject is also recorded a case of com- pound dislocation of the shoulder, which was under the care of* Messrs. Saumarez and Dixon, of Newing- ton, and was cured by anchylosis. — (P. 450.) Such an accident must be treated on the same principles as other severe compound dislocations. For the purpose of preventing the head of the bone from slipping out of its place again, the arm should be kept for some days quiet, the elbow bandaged close to the side, and supi)orted in a sling. Sir Astley Cooper recommends a cushion to be put in the axilla, and a stellate bandage and sling to be applied. — (O/i Disloca- tions, p. 432.) After the reduction of a dislocation which has happened downwards, the facility of a fresh displacement is said to depend very much upon the extent to which the tendon of the subscapularis muscle has been lacerated.— (A. Cooper's Surgical Essays, part 1, p. 7.) OF SOME CIRCUMSTANCES RENDERING THE REDUCTION DIFFICULT. I. Narrowness of the Opening of the Capsule. While Desault considers this circumstance as one of the chief impediments to the return of the head of the humerus into the glenoid cavity, Pott and Sir Ast» ley Cooper are of opinion that the capsular ligament can never create any such difficulty. According to De- sault, the obvious indication is to enlarge such an open- ing by lacerating its edges. This is fulfilled by moving the bone about freely in every direction, particularly in that in which the dislocation has taken place. Now by pushing the head of the bone against the capsule already torn, the latter becomes lacerated still more, in consequence of being pressed between two hard bodies. The reduction, which is frequently impracti- cable before this proceeding, often spontaneously fol- lows immediately after it has been adopted. In the Journal de Chirvrgie are two cases, by Anthaume and Faucheron, establishing this doctrine. Mr. C. White, of Manchester, also believed that the reduction was sometimes prevented by the head of the bone not being able to get through the laceration in the capsule again. He succeeded in reducing some cases which he supposed to be of this nature, in the following mannPr : having screwed an iron ring into a beam at the top of the patient’s room, he fixed one end of the pulleys to it, and fastened the other to the dislocated arm by ligatures attached to the wrist, placing the arm in an erect position. In this way, he drew up the pa- tient till his whole body was suspended ; but that too much force might not be sustained by the wnst, Mr. White at the same time directed two other persons to support the arm above the elbow. He now used to try with his hands^to conduct the arm into its place, if the reduction had not already happened, as was some- 314 DISLOCATION. times the ease. Occasionally, a snap might be heard as soon as the patient was drawn up : but the reduc- tion could not be completed till he was let down again, and a trial made with the heel in the armpit. When no iron ring was at hand, Mr. White used to have the patient raised from the ground by three or four men who stood upon a table.— (Cases in Surgery, p. 95.) 2. Oldness of the Dislocation. When the head of the bone has lodged a long while in its accidental situation, it contracts adhesions to it. The surrounding cellular substance becomes con- densed, and forms, as it were, a new capsule, which resists reduction, and which, when such reduction cannot be accomplished, supplies in a certain degree the office of the original joint by allowing a consider- able degree of motion. In such cases, the common advice used to be that no attempt at reduction should be made, as it would be useless in regard to the dislocation, and might be inju- rious to the patient from the excessive stretching of parts. This was for some time the doctrine of Desault ; but in his latter years experience led him to be bolder. Complete success obtained in dislocations wliich had existed from fifieen to twenty days, encouraged him to at- tempt reduction at the end of thirty and thirty-five days ; and in the two years preceding his death he succeeded three or four times in reducing dislocations which had existed two months and a half, and even three months, both when the head of the bone \vas situated at the lower and at the internal part of the scapula. In these cases it is necessary, before making the extension, to move the bone about extensively in all directions for the purpose of first breaking its adhesions, lacerating the condensed cellular substance which forms an accidental capsule, and of producing, as it were, a second dislocation, in order to remove the first. Extension is then to be made in the ordinary way, but with an additional number of assistants. The first attempts frequently fail, and the dislocated head of the bone continues unmoved notwithstanding the most violent efforts. In this case, after leaving off the extension, the arm is to be again moved about very extensively. The humerus is to be carried upwards, downwards, forwards, and backwards ; and every re- sistance overcome. Let the arm describe a large seg- ment of a circle in the place where it is situated. Let it be once more rotated on its axis ; then let the exten- sion be repeated, and directed in every way. Thus the head of the bone will first be disengaged by the free motion, and afterward reduced. In these cases, when the dislocation, in consequence of being very old, presents great obstacles to reduction, even though the attempts made for this purpose should fail, they are not entirely useless. By forcing the head of the bone to approach the glenoid cavity, and even placing it before the cavity, and making it form new adhesions after the destruction of the old ones, the mo- tions of jthe arm are rendered freer. Indeed, they are always the less obstructed, the nearer the head of the bone is to its natural situation. Notwithstanding the encouragement given by Desault to making attempts to reduce old dislocations of the humerus, experience proves that when the bone has been out of its place more than a month, success is rarely obtained. And as for the danger which may arise from long-protracted, immoderate force, a case which I have elsewhere cited proves that caution is here a virtue which cannot be too highly commended.— (See First Lines of Surgery, vol. 2, p. 465.) Another instance, in which a woman died from the violence used in the extension, is reported by Sir Astley Cooper. — (On Dislocations, p. 422.) [The late Dr. Colin Mackenzie, of Baltimore, several years since reduced a dislocation of the humerus, of nearly six months’ duration, in the Maryland Hospital, with entire success ; and Dr. James Cocke, also of Baltimore, reduced a luxated humerus after it h^ been displaced 120 days.— Reese.] 3. Contractions of the Muscles. A third impediment to the reduction of every kind of dislocation is the power of the muscies, which is aug- mented beyond the natural degree, in consequence of their being on the stretch. Sometimes this power is so considerable, that it renders the head of the bone im- moveable, though the most violent efforts are made. Here the means to be adopted are such as weaken the patient ; bleeding, the warm bath, nauseating dose.s of tartarized antimony, as advised by Loder, Sir Astley Cooper, &c. ; opium, &c. Should the patient happen to be intoxicated at the time of his being first seen by the surgeon, the opportunity would be verj' favourable to reduction, as the muscles w ould then be capable of less resistance. Extension unremittingly, but not vio- lently, continued for a length of time, will ultimately fatigue the resisting muscles, and overcome them with more safety and efficacy, than could be accomplished by any sudden exertion of force. In all cases of difficulty, pulleys should be preferred. The swelling about the joint, brought on by the acci- dent, usually disappears without trouble. Another consequence, which seldom occurs in prac- tice, but which Desault saw twice, is a considerable emphysema, sudenly originating at the time of reduc- tion. In the middle of sucli violent extension, as the long standing of the dislocation requires, a tumour sud- denly makes its appearance under the great pectoral muscle. Rapidly increasing, it spreads towards the armpit, the whole extent of which it soon occupies. It reaches backwards, and in a few minutes sometimes becomes as large as a child’s head. A practitioner un- acquainted with this accident, might take it for an aneurism, occasioned by the sudden rupture of the axillary artery, by the violent extension. But if atten- tion be paid to the elasticity of the tumour, its fluo- tuation, the situation where it first appears, commonly under the great pectoral muscle, and not in the axilla ; the continuance of the pulse ; and the unchanged colour of the skin ; the case may easily be discriminated from a rupture of the artery.— (CEuvres Chir. de Desault, par Bichat, t. 1.) For dispersing the above kind of swelling, the lotio plumbi acetatis, and gentle compression wdth a bandage, are recommended. I shall conclude the subject of luxations of the shoulder wdth the following singular observation, re- corded by Baron I.arrey. “ Among the curious anatomical preparations (says he) w'hich I saw in the cabinet of the university of Vienna, there was a dissected thorax, shown to me by Professor Prokaska, in which the whole orbicular mass of the head of the right humerUs, engaged between the second and third true ribs, projected into the cavity of the chest. This singular displacement was the result of an accidental luxation, occasioned by a fall on the elbow, while the arm was extended and lifted from the side. The head of the humerus, after tearing the cap- sular ligament, had been violently driven into the hollow of the a.\illa, under the pectoral muscles, so as to sepa- rate the two corresponding ribs, and pass between them. The diameter of the head of the bone sur- mounted this obstacle, and penetrated entirely into the cavity of the thorax, pushing before it the adjacent portion of the pleura. Every possible effort was made in vain to reduce this extraordinary dislocation. The urgent symptoms which arose were dissipated b.y bleeding, warm bathing, and antiphlogistic remedies. The arm, however, remained at a distance from the side, to which condition the patient became gradually habituated, and after several years of suffering and oppression, he at length experienced no inconvenience. The patient was about sixteen or seventeen, when he met with the accident ; and he lived to the age of thirty- one, when he died of some disease, which had no con- cern with the dislocation. His physicians were anxious to ascertain the nature of this curious case, of which they had been able to form only an imperfect judgment. They were much surprised to find, -upon opening the body, the head of the humerus lodged in the chest, sur- rounded by the pleura, and its neck closely embraced by the two ribs above specified. They were still more astonished to find, instead of a hard spherical body co- vered with cartilage, only a very soft membranous ball, which yielded to the slightest pressure of the finger. The cartilage and osseous texture of the whole portion of the humerus, contained within the cavity of the chest, had entirely disappeared. Les absorbans s’en etaient empar^s (says Mr. Larrey ), et comme autant de gardiens fdiles. Us avaient cherchi d ditruire par portions, n'ayant pu Vexpulser en masse, un ennemt qui s'etait furtivement introduit dans un domicile ou sa presence devait itre importuve et nuisible. Of the humerus, there only remained some membranous rudi- ments of its head, and a great part of these seemed to DISLOCATION, 315 belong to the pleura costalis.” — {Mimoires de. Ckirurgie Militaire, t. 2, p. 405 — 407.) DISLOCATIONS OF THE FOREARM FROM THE HUMERUS. Notwithstanding the extent of the articular surfaces of the radius and ulna, the strength of the muscles and ligaments surrounding the joint, and the mutual recep- tion of the bony eminences, rendering the articulation a perfect angular ginglymus, a dislocation of both the radius and ulna from the humerus, is an accident for which a surgeon is sometimes consulted. The radius and ulna are most frequently luxated backwards ; some- times laterally, but very rarely forwards : the latter luxation cannot occur without a IVacture of the ole- cranon. Indeed, it is so uncommon, that neither Petit nor Desault ever met with it. The luxation backwards is facilitated by the small size of the coronoid process, which, when the humerus is forcibly pushed down- wards and forwards, may slip behind it, and ascend as high as the cavity which receives the olecranon in the extended state of the forearm. Sir Astley Cooper’s experience has made him ac- quainted with five different luxations of the elbow; 1. That of the radius and ulna backwards. 2. That of both these bones laterally. 3. That of the ulna alone. 4. That of the radius alone forwards. 5. That of the radius backwards.— (On. Dislocations, p. 467.) In the luxation backwards, the radius and ulna may ascend more or les.s behind the humerus ; but the coro- noid process of the ulna is always carried above the articular pulley, and is found lodged in the cavity des- tined to receive the olecranon. The head of the radius is placed behind and above the external condyle of the humerus. The annular ligament, which confines the superior extremity of the radius to the ulna, may be la- cerated ; in which case, even when the bones are re- duced, it is difficult to keep them in their proper places, as the radius tends constantly to quit the ulna. This accident always takes place from a fall on the hand ; for when we are falling, we are led by a me- chanical instinct to bring our hands forwards to protect tlie body. If, in this case, the superior extremity, instead of resting vertically on the ground, be placed obliquely with the hand nearly in a state of supination, the repulsion which it receives from the ground will cause the two bones of the forearm to ascend behind the humerus, while the weight of the body pressing on the humerus, directed obliquely downwards, forces its extremity to pass down before the coronoid process of the ulna. The forearm is in a state of half flexion, and every attempt to extend it produces acute pain. The situa- tion of the olecranon, with respect to the condyles of the humerus, is changed. The olecranon, which, in the natural state, is placed on a level with the external condyle, which is itself situated lower than the internal, is even higher than the latter. Posteriorly a consider- able projection is formed by the ulna and radius. On each side of the olecranon, a hollow appears. A con- siderable hard swelling is felt on the fore part of the joint, arising from the projection of the lower end of the humerus. The hand and forearm are supine, and the power of bending the joint is in a great measure lost. — {Sir Astley Cooper on Dislocations, p. 468.) The swelling, which supervenes in twenty-four hours after the accident, renders the diagnosis more difficult ; but, notwithstanding the assertion of Boyer, I believe the olecranon and internal condyle are never so ob- scured that the distance between them cannot be felt to be increased. It is true that the rubbing of the coro- noid process and olecranon against the humerus may cause a grating noise, similar to that of a fracture; and some attention is certainly requisite to establish a diag- nosis between a fracture of the head of the radius and a dislocation of the forearm backwards. “ This dislo- cation (says Sir Astley Cooper) is at first sometimes undiscovered, in consequence of the great tumefaction, which immediately succeeds the injury ; but this cir- cumstance does not prevent the reduction, even at the period of several weeks after the accident ; for I have known it thus reduced by bending the limb over the knee, even without great violence being employed.” — {On Dislocations, S, c.}i. A70.) A luxation backwards must be attended with serious injur>' of the surrounding soft parts. The lateral liga- ments are constantly ruptured, and sometimes the an- nular ligament of the radius. In a case dissected by Sir Astley Cooper the annular ligament was entire. The biceps muscle was only slightly put upon the stretch ; but the brachialis was excessively so. Pro- bably the lower insertions of the biceps and brachialis internus would likewise be more frequently lacerated by the violent protrusion of the head of the humerus forwards, were it not that their attachments are at some distance from the joint. This mischief, however, occa- sionally takes place, and then the forearm is observed to be readily placed ip any position, and not to retain one attitude, as is generally the case in dislocations. The lower end of the humerus, indeed, has been known rtbt only to lacerate these muscles, but to burst the integuments and present itself externally ; an instance of which is recorded by Petit, and two such cases I saw myself, during my apprenticeship at St. Bartholomew’s. Boyer justly remarks, that it is difficult to conceive how, under these circumstances, the brachial artery and median nerve can escape. In fact, this vessel has sometimes been ruptured, and mortification of the limb been the consequence ; but this injury of the artery, and the laceration of the muscles and skin, are rare occurrences.- {Tiaitd des Mai. Chir. t. 4, p. 215.) Nor if the artery were wounded, would gangrene be inva- riably the result; for if my memory is correct, an instance in which the limb was saved, notwithstanding such a complication, is mentioned by Mr. Abemethy in his lectures, though no doubt the risk would be great. The following method of reducing the case is advised by Boyer:— The patient being seated, an assistant is to take hold of the middle of the humerus, and make counter-extension, while another assistant makes ex- tension at the wrist. The surgeon, seated on the out- side, grasps the elbow with his two hands, by applying the fore-fingers of each to the anterior part of the hu- merus, and the thumbs to the posterior, with which he presses on the olecranon, in a direction downwards and forwards. This method will generally be successful If the strength of the patient, or the long continuance of the luxation, render it necessary to employ a greater force, extension is to be made with a towel applied on the wrist, and a cushion is to be placed in the axilla, and the arm and trunk fixed as is done in cases of luxa- ticn of the humerus. In Sir Astley Cooper’s method, the patient sits in a chair. The surgeon places his knee on the inner side of the elbow-joint, in the bend of the arm, and taking hold of the patient’s wrist, bends the arm. At the same time he presses on the radius and ulna with his knee, so as to separate them from the os humeri. Thus the coronoid process is pushed out of the posterior fossa of the humerus; and while the pressure is kept up with the knee, the arm is to be forcibly but slowly bent, and the reduction is soon eflTected. According to the same authority, the bones may also be reduced by bending the arm over a bedpost, or by bending it while it is engaged in the opening of the back of the elbow-chair in which the patient sits. — {On Dislocations, p. 469.) A bandage may afterward be applied in the form of a figure of 8, evaporating lotions used, and the arm kept in a sling. The swelling which follows is to be combated by antiphlogistic means. At the end of seven or eight days, when the infiam- malion has subsided, the articulation is to be gently moved, and the motion is to be increased every day, in order to prevent an anchylosis, to which there is a great tendency. In this luxation, the annular ligament which con- fines the head of the radius to the extremity of the ulna is sometimes torn, and the radius passes in front of the ulna. In such cases, pronation and supination are difficult and painful ; though the principal luxa- tion has been reduced, the head may be easily replaced by pressing it from before backwarcte, and it is to be kept in its place by a compress, applied to the superior and external part of the forearm. The bandage and compress are to be taken off every two or three days, and the joint gently bent and extended, in order to prevent anchylosis. In a modern publication, an instance of a dislocation of the heads of the radius and ulna backwards is rela- ted, where the lower end of the humerus protruded through the integuments, and, as it could not be re- duced, it was sawed off. The patient, a boy, recovered the full use of his arm. — (Evans, Pract. Obs. on Cata- ract, Compound Dislocations, iS-c. p. 101 316 DISLOCATION. A luxation forwards should be treated as a fracture of the olecranon, with which it would be inevitably accompanied. Here, on account of the great injury done to the soft parts, it would also be right to bleed the patient copiously,*and put him on the antiphlo- gistic regimen. With respect to lateral luxations, either inwards or outwards, they are always incomplete and easily dis- covered. In the case outwards, the coronoid process is situated on the back part of the external condyle. The projection of the ulna backwards is even greater than in the dislocation of both bones directly back- wards, and the radius forms a protuberance behind and on the outer side of the os humeri. By moving the hand, the rotation of the head of the humerus can be distinctly felt In the lateral dislocation inwards, the ulna may be thrown upon the internal condyle, so as to produce an apparent hollow above it, and the ro- tation of the head of the radius can be distinctly felt. Sometimes when the ulna is throwm upon the internal condyle, it still projects backwards, as in the external lateral dislocation, in which circumstance the head of the radius is in the posterior fossa of the humerus, and the outer condyle forms a considerable projection. — (.4. Cooper, op. cit. p. 471.) Boyer advises the re- duction of lateral dislocations to be effected by ex- tending the humerus and forearm, and at the same time pushing the extreihity of the humerus and the heads of the ulna ^md radius in opposite directions. According to Sir Astley Cooper, in each of the late- ral dislocations, the reduction may be performed by bending the arm over the knee ; but in a recent case, as one which he relates proves, he considers that the business may be most readily accomplished by forcibly extending the arm ; for when this is done, the biceps and brachialis draw the heads of the radius and uliia into their right places again.— (P. 472.) These luxations cannot be produced without consi- derable violence; but when the bones are reduced, they are easily kept in their place. It will be sufficient to pass a roller round the part, to put the forearm in a middle state, neither much bent nor extended, and to support it in a sling. But much inflammation is to be expected from the injury done to the soft parts. In order to prevent, or at least mitigate it, the patient is to be bled two or three times and put on a low diet, and the articulation is to be covered with the lotio plumbi acet. or an emollient poultice. It is scarcely necessary to repeat that the arm is to be moved as soon as the state of the soft parts will admit of it. — {Boyer, sur les Maladies des Os, t. 2.) A dislocation of the forearm backwards is said to /)ccur ten times as frequently as lateral luxations ; and those forwards are so rare, that no comparison what- .ever can be drawn. — {(Euvres Chir. de Desault, 1. 1.) All recent dislocations of the elbow are easily re- xiuced and as easily maintained so ; for a displacement is prevented by the reciprocal manner in which the ar- ticular surfaces receive each other, and by their mutual .eminences and cavities. This consideration, however, should not lead us to omit the application of a bandage in the form of a figure of 8, and supporting the arm in .a sling. DISLOCATION OT THE RADIUS FROM THE ULNA. The majority of writers on dislocations of the fore- arm have not separately considered those of the radius. The subject was first well treated of by Duverney. However, dislocations of its lower end remained unno- Jiced, until Desault favoured the profession with a par- ticular account of them. The radius, the moveable agent of pronation and supination, rolls round the ulna, which forms its im- moveable support, by means of two articular surfaces ; one above, slightly convex, broad internally, narrow outwardly, and corresponding to the little sigmoid ca- vity of the ulna, in which it is lodged ; the other below, concave, semicircular, and adapted to receive the con- vex edge of the ulna. Hence, there are two joints, differing in their motions, articular surfaces, and liga- ments. Above, the radius in pronation and supination only moves on its own axis : below, it rolls round the axis of the ulna. Here, being more distant from the centre, its motions must be both more extensive and powerful than they are above. The head of the radius, turning on its own axis in the annular or coronary ligament. cannot distend it in any direction. On the contrary, below, the radius, in performing pronation, stretches the posterior part of the capsule, and presses it against the immoveable head of the ulna, which is apt to be pushed through, if the motion be forced. A similar event, in a contrary direction, takes place in supina- tion. ITie front part of the capsule being rendered tense, may now be lacerated. Add to this disposition the difference of strength be- tween the ligaments of the two joints. Delicate and yielding below ; thick and firm above ; their difference is very great. The upper head of the radius, sup- ported on the smaller immoveable articular surface of the ulna, is protected from dislocation in most of its motions. On the contrary, its lower end, carrying along with it in its motions the bones of the carpus, which it supports, cannot itself derive any solid sta- bility from them. From what has been said, the following conclusions may be drawn ; 1. That with more causes of luxation, the lower articulation of the radius has less means of resistance ; and that under the triple consideration of motions, ligaments tying the articular surfaces toge- ther, and the relations of these surfaces to each other, this joint must be very subject to dislocation. 2. That, for opposite reasons, the upper joint must, according to Desault, be rarely exposed to such an accident. He here excludes from consideration cases in which the annular ligament of the radius is lacerated in a luxa- tion of both heads of the radius and ulna backwards ; and particularly confines his reasoning to a dislocation of the upper head of the radius from the lesser sig- moid cavity of the ulna, as a single and uncomplicated injury, suddenly produced by an external cause, and, therefore, neither to be confounded with the cases above specified, nor with other examples in which the displacement happens slowly, especially in children, in consequence of a diseased or relaxed state of tha ligaments. However, some instances of dislocation of the upper head of the radius, suddenly produced by external causes, are recorded by Duverney ; the particulars of another case were transmitted to the French Academy of Surgery; and I have been informed of four exam- ples which were met with in this country. Two of these cases occurred in the practice of Mr. Dunn, of Scarborough ; one in that of Mr. Lawrence ; and the other was attended by Mr. Earle. Sir Astley Cooper has himself seen six examples of the disloca- tion of the head of the radius forwards. Baron Boyer says, that many instances are now known in which the upper head of the radius was dislocated backwards ; indeed, ir opposition to what Desault has stated, he as- serts, that dislocations of the lower joint between the radius and ulna are more rare than those of the upper joint between the same bones. The latter accident he has’ twice seen himself.— (ilfaZ. Chir. t. 4, p. 248.) The displacement backwards is descnbed by this author, as occurring more readily and frequently in children than in adults or old subjects. The reason of this circumstance is ascribed to the less firmness both of the ligaments and of the tendinous fibres of the exterior muscles, which fibres, in a more advanced age, contribute greatly to strengthen the external la- teral ligament. In a child, also, the little sigmoid ca- vity of the ulna is smaller, and the annular ligament, extending farther round the head of the radius, is longer, and more apt to give way. Hence, in a subject of this description, efforts, which may not at first produce a dislocation, if frequently repeated, cause a gradual elongation of the ligaments, a change in the natural po- sition of the bones, and at length, a degree of displace- ment as great as in a case of luxation suddenly and immediately efliected.— (IVaite des Mol. Chir. t. 4, p. 239.) Another fact mentioned by Boyer is, that the dislo- cation of the upper head of the radius backwards is always complete, its articular surfaces being perfectly separated both from the lower end of the humerus, and from the little sigmoid cavity of the ulna. The usual cause of the accident is a pronation of the fore- arm, carried with great violence beyond the natural limits. In a dislocation of the head of the radius backwards, the forearm is bent, and the hand fixed in the slate of pronation. Supination can neither be performed by the action of the mu.scles, nor by external force ; and DISLOCATION. 317 every attempt to execute this movement produces a considerable increase of pain. The hand and fingers are moderately bent, and the upper head of the radius may be observed forming a considerable projection be- hind the lesser head of the humerus. In the case which was mentioned to me by my friend Mr. Law- rence, the head of the radius lay upon the outside of the external condyle. Sir Astley Cooper has never seen a dislocation of the upper head of the radius backwards in the living subject ; but a man was brought for dissection into the theatre of St. Thomas’s Hospital, who had such a dis- location which had never been reduced. The head of the radius was thrown behind the external condyle, and rather to the outer side of the lower extremity of the humerus. The fore part of the coronary ligament was torn through, as well as the oblique one, and the capsular was partially lacerated. In the kind of case described by Sir Astley Cooper, where it seems the limb was extended, this experienced surgeon conceives, that the bone would be easily re- duced by bending the arm. The reduction is to be accomplished by extending the forearm, and endeavouring to bring it into the su- pine posture at the same time that the surgeon tries to press with his thumb the head of the radius forwards towards the lesser tubercle of the humerus, and into the little sigmoid cavity of the ulna again. Success is indicated by the patient being now able to perform the supine motion of the hand, and to bend and extend the elbow with freedom For the purpose of preventing a return of the dis- placement, and giving nature an opportunity of repair- ing the torn ligaments, measures must be taken to hinder the pronation of the hand. Boyer recommends with this view a roller, compresses, and a sling ; but it appears to me, that a splint, extending nearly to the extremity of the fingers, and laid along the inside of the forearm with a pad of sufficient thickness to keep the hand duly supine, would be right, in addition to the sling, roller, &c. In the dislocation of the head of the radius forwards, this part is thrown into the hollow above the external condyle, and upon the coronoid process of the ulna. According to Sir Astley Cooper, the forearm is sli^tly bent, but cannof be bent to a right angle, nor com- pletely extended. When it is suddenly bent, the head of the radius strikes against the fore part of the os humeri. The hand is in the prone position, and if rotated, the corresponding motion of the head of the ra- dius can be felt at the upper and front part of the el- bow-joint. The coronary or annular, the oblique liga- ment, the front of the capsular, and a portion of the interosseous ligament, are torn. Sir Astley says, that the cause of this accident is a fall upon the hand when the arm is extended ; in which event, the radius receives the weight of the body, and is forced up by the side of the ulna, and thrown over the external condyle upon the coronoid process. In two of the cases recorded by him, the reduction could not be accomplished : in the third it was affected during a syncope by extending the forearm, while the olecranion rested on Sir Astley’s foot. In the fourth, the patient was placed on a fofa, and hi.s arm bent over the back of it, in which state extension was made from the hand, without including the ulna. The sofa fixed the os humeri, and the reduction was ac- complished in a few minutes. The chief things to be observed are, to let the extension act upon the radius alone, without the ulna, and during the extension to let the hand be supine.— (Dislocations, p. 474—477.) Ill the latter posture the forearm should also be kept by means of a splint, pad, and bandage, until the torn parts are healed. DISLOCATION OF THE LOWER END OF THE RADIUS. The causes are, I. Violent action of the pronator and supinator muscles. Thus, Desault has published the case of a laundress, who dislocated the lower end of the radius forwards, by a powerful pronation of her hand in twisting a wet sheet.— (Boyer, Traiti desMal. Chir. t. 4, p. 249.) 2. External force, moving the radius violently into a state of pronation, and rupturing the back part of the capsule ; or into a state of supination, and breaking its fore part. Hence there are two kinds of dislocation: one of the radius forwards ; the other backwards. The firs! is very frequent; the second is much less so. The latter case is not mentioned by Sir Astley Cooper, and never presented itself to Desault but once in the dead body of a man, both of whose arms were dislocated, and of whom n- particulars could be learned. The head of the ulna was placed in front of the sigmoid cavity of the radius, and in contact with the os pisiforme, to which it was connected by a capsular ligament. — (Boyer, Traite des Mai. Chir. t. 4, p. 249.) The latter writer has also recorded one Instance of this rare acci- dent.— (VoZ. cit. p. 253.; In the dislocation of the lower head of the radius forwards, described by Sir Astley Cooper, this part is thrown upon the front of the carpus, and lies upon the os scaphoides and the os trapezium. The luxations of the lower head of the radius, de- scribed by Desault, are the same as those named by Sir Astley Cooper dislocations of the lower end of the ulna from the radius, and differ Irom the case called by him a luxation of the radius only at the wrist, inas- much as the hand is not thrown in the opposite direc- tion to that of the radius ; but this bone is merely dis- placed from the convex articular surface of the ulna, the hand going along with it. This circumstance makes a material difference in the mode of reduction, with reference to the direction in which the hand is to be pushed. In the luxation of the lower head of the radius forwards, described by Desault, the symptoms are, constant pronation of the forearm ; an inability to perform supination, and great pain on its being at- tempted ; an unusual projection at the back of the joint, in consequence of the protrusion of the little head of the ulna through the capsule ; the position of the radius is more forward than natural ; constant ad- duction of the thumb, which is almost always extended; a half bent state of the forearm, and very often of the fingers, which posture cannot be changed without con- siderable pain. The outer side of the hand is twisted backwards, and the inner forwards. The protuberance made on the fore part of the wrist by the head of the radius is very evident, and, as Sir Astley Cooper ob- serves, the styloid process of the radius is no longer situated opposite to the os trapezium. This case, he says, usually happens from a fall while the hand is bent back . — (On Dislocations, p. 503.) Sometimes the lower head of the radius is driven through the skin at the inside of the wrist, between the radial artery, and the mass formed of the flexor tendons of the wrist and fingers. Cases of this de- scription, when well managed, generally have a favour- able termination, as we see in the case reported by M. Thomassin. — [Jourv,. de Med. t. 39.) If the smallness of the opening in the skin cause an impediment to reduction, the integuments should be divided with a knife. A luxation of the radius backwards is characterized by symptoms the reverse of those above mentioned. They are, a violent supination of the limb ; inability to put it prone; pain on making the attempt ; a tumour in front of the forearm formed by the head of the ulna; a projection backwards of the large head of the radius; and adduction of the thumb. When he dislocation is forwards, an assistant is to take hold of the elbow, and raise the arm a little from the body ; while another is to support the hand and fingers. The surgeon is to take hold of the end of the fore- arm with both his hands ; one applied to the inside, the other to the outside, in such a manner that the two thumbs meet each other in front of the limb, between the ulna and radius, while the fingers are applied to the back of the wrist. lie is then to endeavour to separate the two bones from each other, pushing the radius backwards and outwards, while the ulna is held in its proper place. At the same time, the assistant holding the hand should try to bring it into a state of supination, and consequently the radius, which is its support. Thus pushed, in the direction contrary to that of the dislocation, by two powers, the radius is moved outwards, and the ulna returns into the opening of the capsule, and into the sigmoid cavity. Sir A. Cooper, who describes this case under the name of a dislocation of the lower end of the ulna backwards, reduces it by pressing the bone forwards, and maintains the reduction with splints well padded, and a compress of leather over the end of the ulna.— (On Dislocations, p. 505.) 318 DISLOCATION. If chance should present a dislocation of the lower head of the radius backwards, or, in other words, of the lower head of the ulna forwards, the same kind of pro- ceeding, executed in the opposite direction, would serve to accomplish the reduction. — (See CEuvres Chir. de Desault, <. 1.) In the luxation of the lower head of the radius for- wards, upon the carpus, Sir Astley Cooper effects the reduction by extending the hand, while the forearm is fixed. — {On Dislocations, p. 504.) DISLOCATIONS OF THE WRIST. The carpal hones may be luxated from the lower ends of the radius and ulna forwards or backwards : The case backwards is the most frequent. It is facili- tated by the direction of the convex articular surfaces of the scaphoid, lunar, and cuneiform bones, which slope more backwards than forwards. According to Sir Astley Cooper, the direction of the force determines the direction in which the carpal bones are thrown : thus if a person in falling put out his hand to save himself, and fall upon the palm, a dislocation is pro- duced, the radius and ulna are forced forwards upon the annular ligament, and the carpal bones are thrown backwards. A considerable swelling is produced by the radius and ulna on the fore part of the wrist, and a similar protuberance upon the back of the wrist by the carpus, with a depression above it, and the hand is bent back. When the carpal bones are dislocated forwards under the flexor tendons, and the radius and ulna backwards upon the posterior part of the carpus, the accident has been caused by a fall on the back of the hand. In each of these cases, two swellings are produced ; one by the radius and ulna ; the other by the bones of the carpus. Sprains will often cause a great swelling over the flexor tendons, and give rise to the suspicion of a luxation, from which they may always be known by the swelling being single, and its not having made its appearance directly after the injury. Dislocations inwards or outwards are never com- plete. The projection of the carpal bones at the inner or outer side of the joint, and the distortion of the hand, make such cases sufficiently evident. Recent dislocations of the wrist, particularly such as are incomplete, are easy of reduction : but when the displacement has been suffered to continue some time more difficulty is experienced, and in a few days all attempts are generally unavailing. This observation applies to all dislocations of ginglymoid joints ; and I cannot, therefore, loo strongly condemn the waste of time in trials to disperse the swellings of the soft parts ere the bones are replaced ; an absurd plan, which, I am sorry to say, is sanctioned by Boyer. — {Mai. Chir. t. 4. p. 260.) For the purpose of reducing the dislocated bones, gentle extension must be made, while the two surfaces of the joint are made to slide on each other in a direc- tion contrary to what they took when the accident oc- curred. In dislocations of the wrist, numerous tendons are always seriously sprained, and many ligaments lace- rated ; consequently, a good deal of swelling generally follows, and the patient is a long time in regaining the perfect use of the joint. Hence the propriety of bleed- ing, low diet, and opening, cooling medicines ; while the hand and wrist should' be continually covered with linen wet with the lofio plumbi acetatis, or spirit of wine and water, and the forearm and hand kept in splints, which ought to extend nearly to the end of the fingers, so as to prevent a return of the displacement. The linab must also remain quiet in a sling. When the ruptured ligaments have united, liniments will tend to dispel the remaining stiffness and weak- ness of the joint. DISLOCATION OF THE CARPUS, METACARPUS, FINGERS, AND THUMB. A simple dislocation of the carpal bones from each other seems almost impossible. The os magnum, however, has been known to be partially luxated from the deep cavity formed for it in the os scaphoides and os lunare. This displacement is produced by too great a flexion of the bones of the first phalanx on those of the second, and the os magnum forms a tumour on the back of the hand.— ' imperfectly described by them, and un- der an erroneous denomination. They supposed that the swelling was of the encysted kind, or what they termed matia, talpa, testudo, and that it gradually al- tered and destroyed the cranium. They sometimes mistook the fungous or sarcomatous tumour of the dura mater for coagulated blood, or for ill-conditioned excrescences, like those ,which make their appearance on ulcers attended with caries. Such are the ideas which seem to be conveyeif by some imperfectly dp DURA MATER. 327 tailed cases in the writings of Lanfranc, Guido di Cau- liaco, Theodoricus, and other authors of the thirteenth and fourteenth centuries. Amatus Lusitanus has given the appellation of lupus with caries to a fungous tu- mour of the dura mater. The swelling occurred in a child eight years old, who died in convulsions, two days after an opening had been made in it. — {Centur, 5 , obs. 8.) Another similar case which happened in a child, and was noticed by Camerarius at Paris, is styled a singular bony excrescence. — (Ephemer. curios, natur. decad. 2, ann. 6, 1687, obs. 99.) Lastly, Cattier, a physician of Montpellier, has recorded the history of a lady who died from the consequences of a fungous " tumour of the dura mhter. The disease was so acutely painful, as to compel the patient to cry out. The swell- ing was opened with caustic. Pimprenelle, a Parisian surgeon, recommended the trepan to oe employed; but his advice was overruled. After death a fungus of the dura mater, with a perforation in the skull, was de- tected, and it is described by the author as a hard, stony substance, accompanied with points and aspe- rities. — {Obs. Mid. obs. 15, p. 48. See. Lassus, Patho- logic Chirurgicale, tom. 1, p. 498, id. 1809.) The old surgeons, ignorant of the real character of ftingous tumours of the dura mater, used often to com- mit the most serious and fatal mistakes in the treat- ment. These diseases are of a chronic nature, and make their appearance gradually, in the form of a tu- mour, which makes its way through the bones of the cranium, rises up, and insensibly blends itself with the integuments, which seem, as it were, to make a part of it. Such fungous tumours of the dura mater may ori- ginate spontaneously at any part of this membrane ; but they are particularly apt to grow on the surface, which is adherent to the upper part of the skull, or to its basis. They are firm, indolent, and chronic, seem- ing as if they were the consequence of slow inflamma- tion, affecting the vessels which supply the dura mater, and inosculate with those of the diploe. It is very dif- ficult, one might say impossible, to determine whether, in an affection of this kind, the disease begins in the dura mater or the substance of the bone itself. The general belief, however, is, that the bone is affected se- condarily, and that the disorder originates in the dura mater. The patient, who is the subject of the first case, related in a memoir by M. Louis, had received no blow upon the head, and could only impute his com- plaint to a fall which he had met with four or five months previously, and in which the head itself had not received any violence ; but from this time he expe- rienced a stunning sensation, which continued till he died. The cranium and dura mater were found both equally diseased. Though this case may tend to prove that fungous tumours of the dura mater may form spontaneously, yet it is not the less confirmed by the examination of a vast number of cases, that this af- fection more frequently follows blows on the head, than any other cause. Hence a slow kind of thicken- ing of the dura mater is produced, which ends in a sar- comatous excrescence, the formation of which always precedes the destruction of the bone. In the memoir published by M. Louis in the fifth volume, 4to. of those of the Royal Academy of Surgery, there is a very in- teresting case, illustrating the nature of the present disease. The subject was a young man, aged twenty-one, Who had a considerable tumour on the left side of the head, which was taken for a hernia cerebri.— (See this article.) The swelling had begun in the region of the temple, and had gradually acquired the magnitude of a second head. The external ear was displaced by it, and pushed down as low as the angle of the lower jaw. At the upper part of the circumference of the base of the tumour the inequalities of the perforated bone and the pulsations of the brain could be distinctly felt. Some parts of the mass were elastic and hard, others were soft and fluctuating. A plaster which had been applied brought on a suppuration at some points, from which an ichorous matter was discharged. Shi- verings and febrile symptoms ensued, and the man died in less than four nlonths, in the year 1764. On dissection a sarcomatous tumour of the dura mater was detected, together with a destruction of the whole iiortion of the skull corresponding to the extent of the disease. When a tumour of this nature has decidedly formed, it makes its way outwards through all the parts soft or hard which are opposed to it. The swelling, in be- coming circumscribed, is partly blended 'mth the dura mater, and its pressure produces an absorption of such parts of the skull as oppose its enlargement. It unex- pectedly elevates itself externally, confounding itself with the scalp, and, presents itself outwardly in the form of a preternatural, soft, yielding swelling, which even sometimes betrays an appearance of a decided fluctuation or a pulsation which may make it be mis- taken for an aneurismal tumour. When once the swelling has made its exit from the cavity of the cra- nium, it expands on every side under the integuments, which readily make way for its growth. The scalp becomes distended, smooth, and cedematous over the extent of the tumour, and lastly it ulcerates. The matter discharged from the ulcerations is thin and sa- nious ; the outer part of the tumour is confounded with the integuments and edges of the skull on which it rests, so that in this state it is easy to mistake the tu- mour for one whose base is altogether external. While the swelling thus increases in size externally, it also enlarges internally. The latter change takes place in particular, while the oi»ening in the cranium is not large enough to admit the whole mass of the tumour, which then depresses the brain, and lodges in an ex- cavation which it forms for itself. But this cavity quickly diminishes, and becomes reduced almost to no- thing, as soon as the tumour projects outwardly. The tables of the skull are absorbed to let the swelling ar- rive externally ; but it is remarked, that the internal or vitreous table is alw'ays found much more extensively destroyed than the external one. Sometimes new bony matter is found deposited around the opening in the cranium. It is asserted, that whatever may be the situation of a fungous tumour of the dura mater, the outer layer of this membrane, upon which the disease forms, is alone altered, the inner layer and the pia mater being always unchanged.- (Lassus, Pathologic Chirurgicale, tom. 1 , p. 501, id. 1809.) In one of these cases, detailed by Walther, the inner layer of the dura mater was quite natural, though one- half of the tumour, which was very large, was within the skull, where it had formed for itself a deep excava- tion in the posterior lobe of the brain. And, what is remarkable, notwithstanding this latter change, the patient, the day before her death, retained all her in- tellectual faculties, and the power of voluntary motion. — (Joum. fur Chirurgie von C. Graefe und Ph. v. Walther, b. \,p. 64, 65, Svo. Berlin, 1820.) According to surgical writers, fungous tumours of the dura mater have been caused by contusions on the skull, falls on the buttocks, concussions of the head or whole body, lues venerea, scrofula, inveterate rheuma- tism, &c. The three last of the alleged causes, how’^- ever, seem to be little better than mere conjecture ; and the same may be said of Walther’s idea, that the dis- ease is of a similar nature to white swelling of the joints (Grae/e’s Journ. b. 1, p. 104), beginning rather in the bone than in the dura mater. Even children of the most tender years are liable to the disease. M. Louis has related, that a child, two years of age, died of a fungus of the dura mater, which had produced a swelling above the right ear, attended with a destruction of a portion of the parietal and tem- poral bones. — (Mem. de VAcad. de Chirurgie, tom. 5, 4^0. p. 31.) Though the common opinion is, that these fungi grow entirely from the dura mater, Sandifort asserts that the vessels of the diploe have a considerable share in their production.— Musei Anat. Acad. Lugd. t. l,p. 152.) A similar belief was entertained by Heister and Kaufmann, and is espoused by Siebold and Walther, the latter imputing the disease to a simultaneous affec- tion of the vessels of the dura mater and pericranium, attended with an absorption of the earthy part of the bone. — (Journ. fur Chir. xion C. Graefe, &,-c. p. 91 — 93.) The existence of a fungous tumour of the dura mater cannot be ascertained, as long as there is no external change. The effects produced may originate from so many causes, that there would be great risk of a gross mistake in referring them to any particular ones. This is not the case when there is an opening in the skull. Then a hardness felt from the very first at the circum- ference of the tumour, denotes that it comes from within. When the swelling is carefully handled, such a crackling sensation is perceived, as would arise from 328 DURA MATER. touching dry parchment stretched over the skin. On making much pressure pain is occasioned, and some- times a numbness in all the limbs, stupefaction, and other more or less afflicting symptoms. The tumour in some measure returns inwards, especially when not very large, and gradually rises up and outwards again, when the pressure is discontinued. Sometimes there is pain ; at other times there is none ; which may be. owing to the manner in which the tumour is affected by the edges of the bone through which it passes. The pain is often made to go off by compression, but returns as soon as this is taken off. The tumour has an alternate motion, derived from the pulsation of the brain, or of the large arteries at its base. This throbbing motion has led many practitioners to mistake the disease for an aneurism, as happened in the second case related in the memoir of M. Louis. When the tumour is pushed sideways, and the finger carried between it and the edge of the bone, through which the disease protrudes, the bony edge may be felt touching the base of the swelling, and more or less constricting it. This symp- tom, when distinguishable, added to a certain hardness and elasticity, and sometimes a facility of reduction, forms a pathognomonio mark, whereby fungous tu- mours of the dura mater may be discriminated IVom herniae of the brain, external fleshy tumours, abscesses, exostosis, and other affections wlUch at first resemble them. Probably, however, some variety in the symptoms prevails in different instances ; fbr in the cases recorded by Walther there was no pulsation, strictly so called, but merely an obscure movement, or an alternate dis- tention and flaccidity, arising from the influx of blood into the vessels of the diseased mass ; the tumours could not be pushed within the cranium, in the slight est degree ; nor did the attempt cause any of the effects usually observed to proceed from pressure on the brain. No aperture could be felt in the skull, much less could the irregular edges of the bone around the tumour be distinguished.— (Jour/i. /ttr Chir. b. 1, p. 57—61, 4-c. 6vo. Berlin, 1820.) Whatever' movements also were perceptible in the swellings, Walther is convinced could not be commu- nicated to them by the pulsations of the subjacent brain ; because they were wedged, as it were, in an aperture in the skull, and adherent to the dura mater beneath them, and to the superincumbent periosteum, so that even in the dead subject they did not admit of being pushed in the least more outwards without diffi- culty, and the employment of strong pressure. — {Vol. cit. p. 57.) Indeed, this tight constriction of the tumour not only explains why stupor, paralysis, Tnptoms returned, and the tumour rose up again the moment the compre.ssion was discontinued. There is a fact in the memoir of M. Louis, which seems to evince that good effects may sometimes be produced by compression judiciously employed. A woman brought to the brink of the grave by symptoms occa- sioned by a tumour of the above kind, having rested with her head for some time on the same side as the tumour, found the swelling so suddenly reduced, with- out any ill effects, that she thought herself cured by some miracle. Compression, artfully kept up by means of & piece of tin fastened to her cap, prevented the pro- trusion of the tumour again. The pressure, however, not having been always very exact, the symptoms every now and then recurred, while the tumour was in the act of being depressed again, and they afterward ceased, on the swelling having assumed a suitable position. The symptams were doubtless occasioned by the irrita- tion which the tumour suffered, in passing the ine- qualities around the opening through which it pro- truded. The patient lived in this state nine years, having every now and then fits of insensibility, in one of which, attended with hiccough and vomiting, she perished. As compression cannot be depended upon, the follow- ing safer method may be tried. It consists in exposing the tumour with a knife, which is certainly preferable to caustics, the action of which is very teffious and painful, and can never be limited or extended with any degree of precision. A crucial incision may be made through the scalp covering the tumour, and the flaps dissected up, and reflected so as to bring all the bony circumference into view. Then with trephines re- peatedly applied, or with what would be better, Mr. Hey’s saws, all the margin of the bone should be care- fully removed. Now, if it be true, that the vessels of the diploe are chiefly concerned in the supply of the dis- eased mass, we see that this source of its growth must be destroyed by the foregoing proceeding. The tumour, thus disengaged on all sides, may he cut off with a scalpel ; and such arteries as bleed much should be tied. Then instead of applying caustic, as sometimes advised, perhaps it wcuild be better to re- move every part of both layers of the dura mater im mediately under the situation of the excrescence. By this means, and the removal of the surrounding bone and diploe, all chance of the regeneration of the tumour would be prevented. In attempting the excision of a fungus of the dura mater, it is certainly an interesting point to know whether the tumour has an intimate vas cular connexion with the diploe and pericranium, as as- serted by Siebold, Walther, and some other respectable authorities ; though the importance of the information on this subject to the practitioner is somewhat lessened by his being aware that it is necessary alwmys to begin with sawing away the bone in the immediate vicinity of the diseased mass. In the dissection of one case; Walther found the pericranium thickened for a consider- able extent around the disease, and closely connected with the tumour by vessels. — {Vol. cit. p. 100.) When the tumour is sarcomatous, and its pedicle small and narrow, as sometimes happens, one should not hesitate to cut it off. This method is preferable to tying its base with a ligature: a plan which could not be executed without dragging and seriously injuring the dura mater; and the fatal effects of wliich I saw exemplified in one case that occurred many years ago in St. Bartholomew’s Hospital, and was operated uikmi by the late Mr. Ramsr den. Excision is also preterable to caustics, which cause great pain, and very often coninilsions. In per- forming the extirpation, we should remove the whole extent of the tumour, and, if possible, ita root, even though it may extend as deeply as the internal layer of the dura mater. This step must not be dtlayed, for the disease wdl continue to increa.se so ns to alfeet the brain, become incurable, and even mortal. It us to such EAR EAR 329 decision that we must impute the success which atipuded the treatment of the Spaniard Avalos, of whom Marcus Aurelius Severinus makes mention. The above nobleman was afflicted with intolerable headaches, which no remedy could appease. It was proposed to him to trepan the cranium, an operation to which he consented. I'his proceeding brought into view, under the bone, a fungous excrescence, the destruction of which proved a permanent cure of the violent pains which the disease had occasioned. It is not mentioned in this case whether the internal layer of the dura mater was healthy or not ; but there is foundation for believing that if the extirpa- tion of these tumours be undertaken in time, and bold measures be pursued, as in the instance just cited, suc- cess would often be obtained. Indeed, reason would support this opinion ; for when the disease is not exten- sive, it is necessary to expose a much smaller surface of the dura mater. It appears to me, however, that trepanning can never be warrantable, unless the disease can be indicated by some external changes. I saw my late master, Mr. Ramsden, trepan a man for a mere fixed pain in one part of the head, on the supposition that there was a tu- mour under the bone ; but no tumour was found, and the operation caused inflammation of the dura mater, and proved fatal. No doubt, in some cases, the hemorrhage will be con- siderable, as was exemplified in the instance in which Walther made an incision at the base of one of these fungi, in order to ascertain its nature : two pints of blood being lost from several vessels of very large size ere tliey could be secured ; and the farther use of the knife discontinued. • M. Louis has described other tumours, which grow from the surface of the dura mater, when this mem- brane has been denuded, as after the application of the trephine. They only seem to differ from the preceding in not existing before the opening was made in the skull. Tumour of the dura mater should not be con- founded with hernia cerebri.— (See this article.) See, on the preceding subject, Mem sur les Tumeurs fon- gueuses de la Dure-Mere, par M. Louis, in M' when diseased . — (^Leschevin in Mem. sur les Sujets proposes pour le Prix de I'Jlcad. Roy ale de Chi- rurgie, t. 9, p. Ill, 112, id. \2mo.) It is not many years since the diseases of the ear were a subject on which the greatest ignorance and the most mistaken opinions prevailed ; and indeed bow could any correct pathological information be expected, while anatomists had not given a complete and accu- rate description of the organ itself? Also, notwith- standing what has now been made out respecting dis- orders of the ear, it is generally admitted that they still require farther investigation and renewed industry. Though Duverney, Valsalva, Morgagni, &c. dispelled some of the darkness which covered this branch of Burger>', they left a great deal undone. Since their time, science has been enriched with the valuable dis- coveries of Ootunni, Meckel, Scarpa, and Cornparetti ; the first two of whom demonstrated that the labyrinth is filled with a limpid fluid, and not (as was pretended) w’ith confined air ; while the last two distinguished anatomists favoured the public with the first very accu- rate description of the parts composing the labyrinth, especially the semicircular canals. In 1763, the French Academy of Surgery offered a prize for the best essay on diseases of the ear, and two years afterward the honour was adjudged to that of Leschevin, senior surgeon of the hospital at Rotien. Thft memoir is still of great value, few modem trea- tises being more complete. The most useful contri- butors to our stock of information on the pathology of the ear, subsequently to M. Leschevin, have been Britter and Lenten ( Ueber das schWere Gehoer. Leipz. 1794) ; Trampel (Amemann’s Magaz. b. 2, 1798) ; Pfingsten {Vieljahrige Erfahrung ueber die Gehoer- fehler, Kiel, 1802) ; Alard {Sur le Catarrhe dl Oreille, Hvo. Paris, 1807, tdit. 2); Sir A. Cooper (Phil. Trans. 1802) ; Portal (Anat. Mtd. 1803) ; J C. Saunders (Jinat. and Dis. of the Ear, 1806) ; Baron Boyer (Mai. Chir. t. 6) ; Itard ( Traiti des Mai. de V Oreille, &uo. 2 tomes) ; Saissy, in an essay which received the approbation of the Medical Society of Bourdeaux ; and Professor Rosen- thal, in a short but sensible tract on the pathology of the ear. — (See Joum. Complem. t. 6, 1820.) But notwithstanding the laudable endeavours of so many men of eminence, the pathology of the internal ear, and the treatment of its diseases, are far, I may- say,, very far, from a high state of improvement. To farther advances indeed some discouraging obstacles present themselves : theauditory api)aratus is extremely complicated ; the most important parts of it are en, tirely out of the reach of ocular inspection ; the ana- tomy of the organ is perhaps not yet completely unra veiled ; the exact uses and action of several parts of it, anatomically known, are still involved in mystery ; the opportunities of dissecting the ear in a state of disease are neither frequent nor duly watched ; and even when they are taken, and when vestiges of disease or imper- feetjon are traced to particular parts of the organ, the utmost difficulty is experienced in drawing any usefql practical conclusion, because the natural uses of those parts, and the precise manner in which they contribute to the perfection of the ear, are not known to tlie most enlightened physiologists. We are here nearly in tlie same helpless dilemma as a watchmaker would be, were he, in examining the interior of a watch, to find parts broken and out of order, the exact uses of which, in Bie perfection of the instrument, he had not first stumljd and comprehended. In fact, the physiology of the ear is but very imperfectly understood ; and, gis Rosenthal remarks (Journ. CompUm. t. 0, p. 17), if, notwithstand- ing the progress made in optics, and the complete knowledge of the structure of the eye, a perfect expla- nation has not yet been given of the phenomena of this organ as an'instrument of vision, we cannot won- der that, with far more circumsenbed informatiq;; 330 EAR. about acoustics, and the greater difficulty of unravelling the structure of the ear, so little progress should have been made in the physiology of the latter organ. Were it practicable in acoustics to arrive at that precision and certainty which would enable us to establish laws in the theory of sound as fixed as those which relate to light, this void in physiological science might perhaps be obviated. But Rosenthal justly argues, that hitherto the approach to perfection has not been made, and this notwithstanding the learned and valuable labours of Chladni. — ( AArastiA:. 4fo. Leipz. 1802.) Some facts, however, are admitted to be well ascertained, and the researches of Autenrieth and Kerder {ReWs Jirchiv. fur die Physiol, t. 9, p. SIS'— 376) are honourably men- tioned ; for though they only elucidate the function of the conductor part of the ear, they are of unquestion- able importance to the medical practitioner. It is clearly proved that the difference in the length and breadth of the meatus auditorius, form of the membrana tympani, and the make of the cavity of the tympanum modify sound ; that is to say, that the differences of structure of the auricle and the meatus auditorius externus, which merely receive and concentrate the sonorous undula- tions, as these emanate from a vibrating body, can only influence the degree of force or weakness of the sound ; while, on the contrary, the differences of struc- ture in the membrane and cavity of the tympanum are not limited to this effect, but ihe greater or less tension of the one, and the more or less considerable capacity of the other appear to alter in a greater or less degree the particular character of the sound. — {Joum. Com- pUm. t. 6, p. 20.) 1. Wov.nds and Defects of the external Ear. The external ear, which is a sort of instrument cal- culated for concentrating the undulations or waves of sound, may be totally cut off without deafness being the consequence. For a few days after the loss, the hearing is rather hard; but the infirmity gradt^glly diminishes, the increased sensibility of the auditory nerve compensating for the imperfection of the organic apparatus.— (RicAerand, Nosogr. Chir. t. 2, p. 122, ed. 2.) Dr. Hennen says, that he has met with a case where the external ear was completely removed by a cannon- shot, and yet the sense of hearing was as acute as e-v er. — {Principles of Military Surgery, p. 348, ed. 2.) An- other case, recorded by Wepfer, also proves that a total loss of the auricle may not cause any material injury of hearing, for the patient of whom he speaks had had the whole of the .external ear destroyed by ulceration, and yet could hear as well as before the loss . — {Kriter und Lentin uber das schwere Gehoer,p. 19, Leipz. 1794.) However, if we are to credit the statement of other writers, the recovery is generally far less complete. Thus Leschevin notices, that they who have lost the external ear, or have it naturally too flat oi ill-shaped, have the hearing less fine. The defect can only be re- medied by an artificial ear or an ear-trumpet, w'hich, receiving a large quantity of the sonorous undulations, and directing them towards the meatus auditorius, thus does the office of the external ear.— {Prix de VAcad. Roy ale de Chir. t. 9, p. 120, edit. ]2mo.) Wounds are not the only causes by which the exter- nal ear may be lost : its separation is sometimes the consequence of ulceration, and sometimes the effect of the bites of horses and other animals. In cold climates it is frequently -frozen, and afterward attacked with inflammation and sloughing. When the external ear is not totally separated from the head, the surgeon should not despair of being able to accomplish the re- union of it. This attempt should always be made, however small a connexion the part may have with the skin ; for m w'ounds of this kind, the efforts of sur- gery have occasionally succeeded beyond all expec- tation. Wounds of the external ear, whatever may be their size and shape, do not require different treatment from that of the generality of other wounds. The reunion of the divided part is the only indication, and it may be in most instances easily fulfilled by means of method- ical dressings. Such writers as have recommended sutures for wounds in the ear (says Leschevin), have founded this advice upon the difficulty of applying- to the part a bandage that will keep the edges of the wound exactly together. The cranium, however, af- fords a firm and equal surface, against which the ex- ternal ear may be conveniently fixed. Certainly, d is not more easy to secure dressings on the nose than the ear ; and yet cases are recorded in which the cartilagi- nous part of the nose was wounded and almost entirely separated, and the union was effected without the aid of sutures.— (See Mem. de M. Pibrac sur VAbus des Sutures, in Mem. de I’.dcad.. de Chir. tom. 3.) In wounds of the ear, then, we may conclude that sutures are generally useless and unnecessary. As examples may occur, however, in which the wound may be so irregular and considerable as not to admit of being accurately united, except by this means, it should not be absolutely rejected. An enlightened surgeon will not abandon altogether any curative plans ; he only points out their proper utility, and keeps them within the right limits. When sticking plaster, sim- ple dressings, and a bandage that makes moderate pressure appear insufficient for keeping the edges of a wound of the ear in due contact, the judicious practi- tioner will not hesitate to employ sutures. When a bandage is applied to the external ear, it should only be put on with moderate tightness, since much pressure gives considerable uneasiness, and may induce sloughing. In order to prevent these disagree- able Effects, I,eschevin advises us to fill the space be- hind the ear with soft wool or cotton, against which the part may be compressed without risk.— (Op. cit. p. 119.) Baron Boyer remembers a medical student who was compelled by an ulcer on the sacrum to lie for a long time on his side, in which posture the pressure on the ear caused a slough of the antihelix, and after the sepa- ration of the dead part, an aperture, large enough to receive the end of the little finger, was left in the pinna or auricle. In the application of sutures to the ear, the ancients caution us to avoid carefully the cartilage, and to sew only the skin. They were fearful that pricking the cartilage would make it mortify, “ ce qui est souvente- fois arrive," says Pare. But, notwithstanding so re- spectable an authority, as Leschevin has remarked,- the moderns make no scruple about sewing cartilages. In wounds of the nose, Verduc expressly directs the skin and cartilage to be pierced at once, and the success of the plan is put out of all doubt by a multitude of facts. The same treatment may also be safely extended to the ear. Celsus, lib. 3, c. 6, speaks of fractures of the carti- lages of the ear ; but such an accident seems hardly possible, unless the part be previously ossified. Les- chevin and Boyer have never met with such a case, either in practice or in the works of surgical writers. In this section, a few malformations of the external ear require notice. Sometimes the orifice of the mea- tus auditorius is diminished by the tragus, antitragus, and antihelix being depressed into it. Here the excision of these wrongly formed eminences has been recom- mended as a surer means of perfecting the sense of hearing than the use of any tube or dilating instru- ments. The tyagus has been known to project consi- derably backwards, and to apply itself most closely ,over the orifice of the meatus, which was also a mere slit instead of a round opening. In one case of this description relief was obtained by the introduction of tubes, calculated to maintain the tragus in its proper position.— (Diet, des Sciences Med. t. 38, p. 28.) Sometimes the outer ear is entirely w'anting. Thus Fritelli has given an account of a child in this condition, whose physiognomy at the same time strongly resem- bled that of an ape . — {Orteschi Giom. di Med. t. 3, p. 80.) Oberteuffer has also recorded an example of a total de- ficiency of the auricles in an adult, who yet heard very well. — {Stark's Neues ..drehiv. b. 2, p. 638. J. F. Meckel, Handbuch der Pathol. Jlnat. h. 1, ». 400, Leipz. 1812.) I remember a child which was exhibited many years ago in London as a curiosity ; it was entirely destitute of external ears, and no vestiges of the meatus auditorii could be seen, these openings being completely covered by the common integuments. Yet the child could hour a great deal, though the sense was certainly dull and imperfect. I recollect that the circumstance of the patient hearing so well as he did, was what excited considerable surprise. I am sorry I do not more parti- cularly recollect at the present time the degree in which this sense was enjoyed, and several other circum- stances, such as the child’s age power of speech, dec. The example, however, is interesting, inasmuch as U EAR. 331 proves, that even a deficiency of the auricles, combined with an imperforate condition of both ears, may be un- attended with complete deafness, provided the internal and more essential parts of these organs are sound and perfectly formed. Baron Boyer attended a youtig man, the lobule of one of whose ears extended in a very inconvenient manner over the cheek; the redundant portion was removed with a pair of scissors, and the wound soon healed. The auricle not being a very irritable part, is not often inflamed, and when it is so, the affection is gene- rally of an erysipelatous character. Portal has seen the part nearly an inch thick ; and he takes notice of the prodigious thickness which the lobe of the ear sometimes acquires in women Who wear very heavy earrings, which keep up constant irritation. Small encysted and adipose swellings occasionally grow un- der the skin of the external ear, and demand the same treatment as swellings of the same nature in other situations. — (See Tumours.) Lastly, the external ear is frequently the seat of scrofulous and other ill- conditioned ulcers. These cases generally require cleanliness, alterative medicines, and to be dressed with the ung. hydrarg. nitrat. or a solution of the ni- trate of silver ; and sometimes, when the sores resist for a long time the effects of medicine and the usual dressings, they will soon heal up, if the treatment be assisted with a blister or seton, kept open on the nape of the neck.— (See Diet, des Sciences Mid. t. 38, 'p. 28, 29.) 2. Of the Meatus Jluditorius,. and its Imperfections. This is the passage which leads from the cavity of the external ear called the concha, down to the mem- brane of the tympanum. It is partly cartilaginous, and partly bony, and has an oblique winding direction, so that its whole extent cannot be easily seen. There are circumstances, Jiowever, in which it is proper to look as far as possible into the passage. Such is the case, when the surgeon is to extract any foreign body, to re- move an excrescence, or to detect any other occasion of deafness. Fabricius Hildanus gives a piece of ad- vice upon this subject, not to be despised ; namely, to expose the ear to the rays of the sun, in order to be enabled to see the very bottom of the passage.' Mr. Buchanan recommends the patient to be placed upon a low seat, with the ear exposed to the rays of the sun. The surgeon should then lay hold of the au- ricle with the left hand, by placing the thumb in the concha, and with the index and middle finger of the same hand placed behind the cartilage, take hold of the cavity, and pull it outwards and upwards, so as to elongate the cartilaginous part of the meatus. With the help of a slightly curved probe, by which the tragus is to be drawn a little outwards, and the diameter of the tube increased, the whole of the meatus and mem- brana tympani may then be distinctly seen.- 7 (See Buchanan’s Illustrations of .ficoustic Surgery, p 1.) When the assi.stance of sunshine cannot be obtained, and in the evening, Mr. Buchanan finds great advan- tage from the use of an ingenious kind of lantern which he has invented for examining the ear, and which he terms an inspector auris. When it is used, the room is darkened, and the focus from the lantern directed into the meatus. The surgical operations practised on the meatus au- ditorius are confined to opening it, when preternatu- rally closed, extracting foreign bodies, washing the passage out with injections, and removing excres- cences. The case which we shall next treat of, is the imper- foration of the meatus auditorius externus, a defect with which some children are born. When the malformation e.xists in both ears, it gene- rally renders the subject dumb as well as deaf, for, as he is incajiable of imitating sounds which he does not hear, he cannot of course learn to speak, although the organs of speech may be perfect, and in every respect rightly disposed. In this case the surgeon has to rec- tify the error of nature, and (to use the language of Leschevin) he has to give, by a double miracle, hearing and speech to an animated being, who, deprived of these two faculties, can scarcely be regarded in society as one of the human race. How highly must such an operation raise the utility and excellence of surgery in the estimation of the world 1 When the meatus auditorius externus is -merely closed by an externa] membrane, the nature of the ease is evident, and the mode of relief equally easy. But when the membrane is more deeply situated in the passage, near the tympanum, the diagnosis is attended with increased difficulty, and the treatment with greater trouble. If the preternatural membrane be external, or only a little way within the passage, it is to be divided with a bistoury ; the small flaps are to be cut away ; a tent of a suitable size is to be introduced into the opening ; and the wound is to be healed secundum artem, care being taken to keep it constantly dilated, until the cica- trization is completed. When the obstruction is deeply situated, we must first be sure of its existence, which is never ascer- tained, or even suspected, till after a long while. It is not till after children are pa.st the age at which they usually begin to talk, that any defect is suspected in the organ of hearing, because until this period, little notice is taken whether they hear or not. As soon as it is clear that this sense is deficient, the ears should always be examined with great attention, in order to discover, if possible, the cause of deafness. Sometimes the in- firmity depends upon a malformation of the internal ear, and the cause does not then admit of detection. The most convenient method of making the examina- tion is to expose the ear which is about to be examined to the- light of the sun. In this situation, the surgeon will be able to see beyond the middle of the bony part of the meatus, if he places his eye opposite the orifice of the passage, and takes care to efface the curvature of the cartilaginous portion of the canal, by drawing upwards the external ear. If the passage has been carefully cleansed before the examination, the skin forming the obstruction may now be seen, unless it be immediately adherent to the tympanum. When the preternatural septum is not closely united to the tympanum, its destruction should be attempted ; and hopes of effecting the object either suddenly or gradually may reasonably be entertained. According to Leschevin, the particular situation of the obstruction is the circumstance by which the surgeon ought to be guided in making a choice of the means for this opera- tion. If the membranous partition is so far from the tympanum, that it can be pierced without danger of wounding the latter part, there can be no hesitation in choosing the plan to be adopted. In the contrary state of things, Leschevin is an advocate for the employment of caustic, not only on account of the risk of injuring the tympanum with a cutting instrument, but also because if the puncture were ever so well executed, a tent could not be introduced into it, so as to prevent it from closing again. In the first case, a very narrow sharp-pointed bis- toury should be used ; after its blade has been wrapped round with a bit. of tape to within a line of the point, it is to be passed perpendicularly down to the preternatu- ral membrane, which is to be cut through its whole diameter. The instrument being then directed first to- wards one side, then the other, the crucial incision is to be completed. As the flaps, which are small and deeply situated, cannot be removed, the surgeon must be content with keeping them separated by means of a blunt tent. The wound will heal just as favourably as that occasioned by removing the imperforation of the concha, or outer part of the meatus auditorius. — {Prix de V./icad. de Chir. p. 124 — 126, t. 9.) In the second case, that is to say, when the risk of wounding the tympanum leads us to prefer the employment of caustic, the safest and most commodious way of putting the plan in execution would be that of touching the ob- struction, as often as circumstances may require, with the extremity of a bougie armed with the argentum ni- tratum. In the intervals of the applications, no dressings need he introduced, except a bit of clean sort cotton, for the purpose of absorbing any discharge which may take pkice within the passage. It is manifest, that if the whole or a considerable part of the meatus auditorius externus were wanting, the foregoing measures would be insufficient. The following observations of Leschevin merit attention : “ I do not here allude to cases, in which a malforma- tion of the bene exists. I know not whether there are any examples of such an imperforation ; but it is clear that it would be absolutely incurable. I speak of a temporal bone perfectly formed m all its parts, and the meatus auditorius of which, instead of being merely 332 EAR, lined by a membrane, as in the natural state, is blocked up by the cohesion of the parietes of this membrane, throughout a certain extent of the canal ; just as the urethra, rectum, or vagina is sometimes observed to be not simply closed by a membrane, but by a true ob- literation of its cavity. Such a defect in the ear may be congenital, and it may also arise from a wound or ulceration of the whole circumference of the meatus auditorius externus, lliis canal having become closed by the adhesion of its pa- rietes, on cicatrization taking place. Such an imperforation, whether congenital or acci- dental, must certainly be more difficult to cure than the examples treated of abov? ; but,” says Leschevin, ‘‘ I do not for this reason believe that the case ought to be entirely abandoned. Yet I would not have the ciure attempted in all sorts of circumstances. For instance, if the defect only existed in one ear, and the other were sound, I would not undertake the operation, because as the patient can hear tolerably well on one side, the advantages which he might derive from having the enjoyment of the other ear, would not counterbalance the pain and bad s> mptoms occasioned by such an ex- periment, the success of which is extremely uncertain. I would not then run the risk of making a perfora- tion, except in a case of complete deafness ; and I propose this means only as a dubious one, upon the fundamental maxim, so often laid down, that it is preferable to employ a doubtful remedy, than none at all With respect to the mode of executing this opera- tion,” says Leschevin, “ the trocar seems the most eli- gible instrument. I would employ one that is very short, and the jxiint of which is bluntish, and only pro- jects out of a cannula as little as possible. This con- struction would indeed make the instrument less adapted to pierce any thing ; but still, as the parts to be perforated are firm, their division might be accom- plished sufficiently well ; and the inconvenience of a trivial difficulty in the introduction of the trocar is com- paratively much less, than that which would attend the danger of wounding tvith a sharper point the mem- brane of the tympanum. I would plunge the point of the instrument into the place where the opening of the meatus auditorius externally ou^t naturally to be, apd which would be denoted, either by a slight depression, or at all events by attending to the different parts of the ear, especially the tragus, which is situated directly over this passage. I would push in the trocar gently, in the direction of the canal formed in the bone, until the point of the instrument felt as if it had reached a vacant space. Then, withdrawing the trocar and leav- ing the cannula, I would try whether the patient could hear. I would then introduce into the cavity of the .cannula itseif a small, rather firm tent of the length of the passage, or a small bougie. By means of a probe I would push it to the end of the cannula, which I would now take out, observing to press upon the tent, which is to be left in. The rest of the treatment consists in keeping the canal pervious, making it suppurate, and healing it with common applications. One essential caution, however, would be that of keeping the part dilated long after it had healed : otherwise it might dose again, and a repetition of the operation become necessary. This happened to Heister, as be himself apprizes us, and it occurred to Roonhuysen in treating imperforations of the vagina. If the cohesion of the parietes of the meatus audi- ^orius externus were to extend to the tympanum in- clu.sively, the operation would be fruitless ; but as it is impossible to ascertain this circumstance before the attempt is made, the surgeon would incur no disgrace b> relinquishing the operation, and giving up the treat- ment of an incurable di.sease. If, then, after the trocar were introduced to about the depth of the tympanum, the situation of which must be judged of by our ana- tomical knowledge, no cavity were met with, the ope- ration should be abandoned; and if, in these circum- stances, any one were to impute the want of success to the iuefficacy of surgery, or the unskilfulness of the surgeon, he would act very unfairly. It is also i)lain, that such an operation could cure a congenital deafness, only inasmuch a.s it might dej)end upon the imperforation; for if there should exist, at the same time, in the internal ear any malformation, destructive of the jiower of the organ, the remedying of the external defect would be quite useless.”— (Lcs- chevin, in Prix de V^cad. de Chirurgie, tom. 9, v. 127. 132. ) We find that this author entertains a great dread of wounding the tympanum, and certainty he is right in ge- nerally insisting upon the prudence of avoiding such an accident. It will appear, however, in the sequel of this article, that under certain circumstances puncturing the tympanum has been successfully practised, as a mode of remedying deaf ness. The operation, however, de- mands caution; for, if done so as to injure the con- nexion of the malleus with the membrana tympani, the hearing must ever afterward be very imperfect. 3. Unusual Smallness of the Meat'iis Auditgrius Externus. Imperforation is not the only congenital imperfection of the meatus auditorius ; this passage is occasionally too narrow for the admission of a due quantity of the sonorous undulations, and the sense is of course weak- ened. Leschevin mentions that M. de la Metric found this canal so narrow in a young person that it could hardly admit a probe. What has been observed con- cerning the imperforation is also applicable to this case. If it depends upon malformation Of the bone it is mani- festly incurable ; but if it is owing to a thickening of the soft parts within the meatus, hopes may be indulged of doing good by gtadually dilating the passage with tents, which should be increased in size from time to time, and lastly making the patient wear, for a consi- uerable time, a tube adapted to the part in shape.— (Les- chevin in Prix de PA cad. de Chh'urgie, t. 9,p. 132.) Mr. Earle has published a case in which the diame- ter of the meatus auditorius was considerably lessened by a thickening of the surrounding parts, and espe- cially of the cuticle, attended with a discharge from the passage, and great impairment of hearing. A cure was effected by injecting into the passage a very strong so- lution of the nitrate of silver, which in a few days was followed by a detachment of the thickened por- tions of cuticle. This evacuation was assisted by throwing warm water into the passage.— (See Med. Chir. TVans. vol. 10, p. 411, <( c.) Boyer was consulted fora deafness, which arose from a malformation w hich con- sisted of a flattening of the meatus, its opposite sides being for some extent in contact. The patient was advised to wpar in the ear a gold tube of suitable shape by which means he was enabled to hear perfectly well. 4. Faulty Shape of the Meatus Auditorius Externus, Anatomy informs us that this passage is naturally oblique, and somewhat winding ; and natural philoso- phy teaches us the necessity of such obliquity, which multiplies the reflections of the sonorous waves, and thereby strengthens the sense. This theory, says Les- chevin is confirmed by experience ; for there are per- sons in whom the meatus auditorius is almost straight, and they are found to be hard of hearing. If there is any means of correcting this defect, it must be that of substituting for the natural curvature of the passage a curved and conical tube, which must be placed at the outside of the organ, just like a hearing trumpet. The acoustic instrument invented by Deckers, which is much more convenient, might also prove useftil.— (Ow. cit. p. 133. ) 5. Extraneous Substances, Insects, drc. in the Meatus Auditorius Externus. Foreign bodies met with in this situation are inert substances w'hich have been intioduced by some exter- nal force; in.sects, which have insinuated themselves into the passage; or the cerumen itself, hardened in- such a degree as to, obstruct the transmission of the .sono ous undulations. Worms which make their ap- pearance in the meatus auditorius are always produced subsequently to ulcerations in the passage, or in the interior of the tympanum, and very often .such insects are quite unsuspected causes of particular symptoms. In the cases of surgerj' published in 17T8 by Acrel, there is an instance confirming the statement just of- fered It is the case of a w'oman who, having been long afflicted with a hardness of hearing, was suddenly seized w’ith violent convulsions without any apparent cause, and soon afterward complained of an acute pain in the car. This affection was followed by a re- currence of convulsions, which were still more vehe- ment. A small tent of fine linen moistened with a mix- ture of oil and laudanum, was introduced into the meu- EAR. 333 tusauditorius, and on removing it the next day several small round worms were observed upon it, and from that period all the symptoms disappeared. To this case ■we shall add another from Morgagni. A young woman consulted Valsalva, and told him that when she was a girl a worm had been discharged from her left ear; that another one about six months ago had also been discharged very much like a small silkworm in shape. This event took place after very acute pain in the same ear,- the forehead, and temples. She added, that since this she had been tormented with the same pains at dif- ferent intervals, and so severely that she often swooned away for two hours together. On recovering from this state, a small worm was discharged, of the same shape as, but much smaller than the preceding one, and she was now afflicted with deafness and insensibiltiy on the same side. After hearing this relation Valsalva no longer entertained any doubt of the Inembrane of the tympanum being ulcerated. He proposed the employ- ment of an injection in order to destroy such worms as yet remained. For this purpose distilled water of St. John’s wort, in which mercury had been agitated, was used. In order to prevent a recurrence of the incon- venience, Morgagni recommends the aflected ear to be closed up when the patient goes to sleep, in autumn and summer. If this be not done, flies, attracted by the suppuration, enter the meatus auditorius, and while the patient is unconscious deposite their eggs in the ear. Acrel, in speaking of tvorrns generated in the meatus auditorius, observes, that there is no better re- medy for them than the decoction of ledum palus- tra injected into the ear several times a day. How- ever, as this plant cannot always be procured, an in- fusion of tobacco in oil of almonds may be used, a few drops of which are to be introduced into the ear and retained there by. meads of a little bit of cotton. This application, which is not injurious to the lining of the passage, is fatal to insects, and especially to worms. When caterpillars, ants, earwigs, and other insects, have insinuated themselves into the meatus auditorius, they may be removed with a piece of lint smeared ■with honey ; and when they cannot be extract- ed by this simple means, they may sometimes be taken out with a small pair of forceps. In general, however, the most safe and expeditious practice for the removal of small insects, peas, beads, and other extraneous bodies from the meatus auditorius, is to throw tepid water into the passage with a proper syringe, by which means they are forced out with the fluid. When the bead or globular substance is small (according to Mr. Buchanan), the best mode of extraction will be by- means of a syringe and injection of tepid w-ater. For this purpose the point of the syringe ought to be pressed gently against the edge of the meatus, so that it may occupy as little of the diameter of the tube as possible, and when the injection arrives at the mem- brana tympani, the regurgitation will force the bead or Other substance outwards. If this be rather large, it may perhaps remain at the entrance of the meatus, w'hence it ought to be extracted by means of a pair of forceps.— (See Buchanan's Illustrations of Jlcoustic Surgery, p. 40.) A few days ago (May, 18-29) I was called to a child about two years and a half old, into one of who.se ears a pebble, and into the other a French bean, had been pushed by another child, and remained there for ten months, causing complete deafness and extreme sufler- ing. By throwing tepid water forcibly into the ear, I soon dislodged these foreign bodies, which lay close against the tympanum, entirely hidden by the swollen state of the lining of the ear, indurated wax and dried discharge. With a bent probe their extraction was then readily effected. Several surgeons, previously consulted, had failed in their endeavours to remove the Kubstance.s by other methods. The presence of foreign bodies in the ear often occa- sions the mo.st extraordinary symptoms, as we may' see in the fourth observation of Fabricius Hildanus, (lent. 13 After four surgeons, who had been succes- sively consulted, had in vain exerted all their industry to extract a bit of glass from the left ear of a young girl, the patient found herself abandoned to the most excruciating pain, which soon extended to all the side i of the head, and which, after a considerable lime, was ' followed by a paralysis of the left side, a dry cough, suppression of the menses, epileptic convulsions, and i at length an atrophy of the left arm Hildanus cured < 1 her by extracting the piece of glass w liich had rr- I mained eight years in her ear, and had been the cause ! of all this disorder. Although the extraction must 1 have been very difficult, it does not appear that Hilda- I nus found it necessary' to practise an incision behind ; the ear, as some authors have advised, and among them Duvemey, 'W'ho has quoted the foregoing case. We must agree with Leschevin that such an incision does not seem likely to facilitate the object very ma- terially ; for it must be on the. outside of the extrane- ous substance, w’hich is in the bony part of the canal. The incision enables us. in some measure to avoid the obliquity of the passage, as Duverney has observed ; but it is not such obliquity of the cartilaginous portion of the canal that can be a great impediment ; for as it is flexible it may easily be made straight by drawing • the external ear upwards. Hence Fabricius ab Aqua- pendente rejected this operation first proposed by Pau- lus jEgineta ; and it is justly disapjjroved of by Lesche- vin. — {Prix de I’Acad. de Chir. t. 9, p. 147, edit. l2mo.) Sabatier relates a case in which a paper ball, which had been pushed into the meatus auditorius, made its way by ulceration into the cavity of the tympanum, where an abscess formed, w'hich communicated with the interior. of the cranium. — 'Diet, dcs Sciences Mid, t. 7, p. 8.) 6. Meatus Jluditorius ohstmeted with thickened or hardened Cerumen. The cerumen secreted in the meatus auditorius by the sebaceous glands frequently accumulates there in large quantities, and, becoming harder and harder, at length acquires so great a degree of solidity as en- tirely to deprive the patient of the power of hearing. Galen. has remarked, e numero eorum quae meatum obstruunt, sordes esse qua: in auribus coUigi solent This species of deafness is one of those kinds which are the most easy of cure, as is confirmed by observers, especially Duverney. Formerly, frequent injections either with simple olive oil or oil of almonds were re- commended. The injection was retained by a piece of cotton, and w'hen there was reason to believe that the matter was sufficiently- softened, an attempt was made to extract it by means of a small scoop-like instru- ment. Various experiments were made by Haygarth, at (Chester, in 1769, from which it ajjpears that warm water is preferable to oil. The w'aier dissolves the mucous matter which connects together the truly ceru- minous particles, and w hich is the cause of their tena- city ; other applications only succeeding by reason of the water which they contain. The lodgementof hard pellets of tvax, if neglected, may ultimately produce ulceration of the tympanum and other serious mischief. Thus, in one case, Ribes and Chaussier found the handle of the malleus sepa- rated from its head, partly destroyed and covered with the hardened cerumen that had made its way into the tympanum. — (See Diet, des Sciences Mid. t. 38, p. 30.) ‘‘ The symptoms (says Mr. Sau.nders) whicli are at-, tached to the inspissation of the cerumen are pretty v'ell known. The patient, besides his inability to hear, complains of noises, particularly a clash or con- fused sound in mastication, and of heavy sounds, like the ponderous strokes of a hammer. The practitioner is led by the relation of such symp- toms to suspect the existence of wax ; but he may re- duce it to a certainty by examination. Ahy means capable of removing the inspissated wax may be adopted ; but syringing the meatus with warm water is the most speedy and effectual, and the only means necessary. As the organ is sound, the pa- tient is instantaneously restored.” — {Anatomy of the human Ear, with a Treatise on its Diseases, by J. C. Saurulers, 1806, p. 27, 28.) In order to throw an injection into the ear •vvith effect, a syringe capable of holding from four to six ounces, should be emi)loyed ; and the fluid injected with a good deal of force, care being taken to let it enter in the na- tural direction, and not against one of the sides of the passage. The surgeon must also avoid pressing the pipe too deeply into the car, .so as to hurt the tyiri|)anum. As the fluid regurgitates with con.siderable rapidity, a small basin is to be held close up to the ear at the time of using the syringe, so as to catch the water and hinder it from wetting the patient’s clothes; for the surer prevention of w hich a napkin is also to be laid over the shoulder. In general, it is necessary to throw 334 EAR. the water into the ear six or seven times, or more, ere the pellets of wax are loosened and entirely brought out ; and sometimes the injections will not completely succeed the first day on which they are employed. The evening before the syringe is to be used, it may occasionally be best to drop a little sweet oil into the ear. 7. Imperfect Secretion of Wax. When the wax is deficient in quantity, Mr. Bucha- nan recommends warmth and stimulant applications. He advises two drops of the following mixture to be introduced into the meatus auditorius, every night at bedtime. Acid, pyrolygn., spir. aetheris sulphur., Ol. terebinth, a a M. One tablespooiiful of the fol- lowing medicine is also to be taken at the same time. R. Tinct. colchici 3 iij. Aq. distillat. I vj. M. If cos- tiveness prevail, the pilulte rhei comp, are to be given. — (See Buchanan^ s Jicorastic Surgery, p. 60.) When the quality of the secretion requires improve- ment, the meatus is to be frequently washed out, and a little of the infusion of quassia with rhubarb and mag- nesia given once or twice a day. The warm bath is to be occasionally used at bedtime, and the (bllowing powder exhibited. U. Hydrarg. subraur. gr. ij. Pulv. ipecac, comp. 3j. ft. Pulv. Hora decubitus sutnend. In cases where the ear is preteriiaturally dry, and the cuticle of the meatus peels off, the ensuing injection is to be used every second or third day. It. Acid, pyro- lign. 3ij. AqufB distillalae 3Vj. ft. lofio; or the vapour of a mixture of equal parts of distilled water and pyro- ligneous acid might be introduced' three times a week into the meatus with the aid of a glass retort. A little cotton should afterward be put into the ear.— (See Buchanan's Acoustic Surgery, p. 62.) 8. Discharges from the Meatu? Auditorius. Purulent discharges from the ear either come from the meatus auditorius externus itself, or they originate from suppuration in the tympanum, in consequence of blows on the head, abscesses after malignant fevers, the small-pox, or the venereal disease. In such cases, the little bones of the ear are sometimes detached, and escape externally, and complete deafness is most fre- quently the consequence. However, in a few instances, total deafness does not always follow even this kind of mischief, as I myself have witnessed on one or two occasions. There is greater hope when the disorder is confined to the meatus ; as judicious treatment may now avert the most serious consequences. In Acrel’s surgical cases, there is a case relative to the circum- stance of which w^e are speaking. Suppuration took place in the meatus auditorius externus, in conse- quence of acute rheumatism, which was Ibllowed by vertigo, restlessness, and a violent headache. The mat- ter discharged was yellowish, of an aqueous consist- ence and acid smell. The meatus auditorius was filled with a spongy fiesh. On introducing a probe, our author felt a piece of loose rough bone, which he immediately took hold of with a pair of forceps and extracted. From the time when this was accom- plished the discharge diminished ; and with the aid of proper treatment, the patient became perfectly well. The meatus auditorius, like all other parts of the body, is subject to inflammation. This is frequently produced by exposure to cold. It is hardly necessary to say, that generally topical bleeding and antiphlo- gistic means are indicated. The meatus auditorius should also be protected from the cold air, particularly in the winter season, by means of a piece of cotton. Mr. .Saunders observes, “ When the means employed to reduce the inflammation have not succeeded, and matter has formed, it is generally evacuated, as far as I have observed, between the auricle and mastoid pro- cess or into the meatus. If it has been evacuated into the meatus, the opening is most commonly smali, and the spongy granulations, squeezed through a small ajierture, assume the appearance of a polypus. Some- times the smalt aperture by which the matter is eva- cuated is in this manner even closed, and the patient suffers the inconvenience of frequent returns of pain from the retention of the discharge. When the parts have fallen into this state, it will be expedient to hasten the cure by making an incision into the sinus, between the auncle and mastoid process. It occasionally happens that the bone itself dies in consequence of the sinus being neglected, or the origi- nal extent of the 3Ui)puration. The exfoliating parts are the meatus externus of the os temporis, or the e 36 « ternal lamina of the mastoid process.”— (P. 24, 25.) In some examples of purulent discharge from the ear, and particularly in scrofulous patients, Mr. Bucha- nan employs alterative medicines, as calomel, the tincture of iodine, and the compound rhubarb ihlls of the Edinb. Pharmacopoeia. He also sometimes has re- course to the pyroligneous injection.— (See Illustra- tions of Acoustic Surgery, p. 93, &c.) Some addi- tional cases in favour of the efficacy of iodine, in cer- tain forms of deafness may be found in Dr. Manson’s work. — {See-Medical Researches 07i the Effects of Iodine, 8vo. London, 1825.) 9. Excrescences in the Meatus Auditorius. Though the membrane lining the meatus auditorius is very delicate, it is not the less liable to become thickened, and to form polypous excrescences. This case, however, is not common. As such tumours are ordinarily firmer in their texture than polypi of the nose, they are sometimes not so easily extracted with forceps. When they are situated near the external orifice, and admit of being taken hold of with a small pair of forceps or a hook, and drawn outwards, they may easily be cut away. When the tumours are more deeply situated, Mr. B. Bell recommends the use of a ligature. Here the same plan may be pursued as will be explained in the article Polypus. But it some- times happens, that the excrescences cannot be re- moved in this manner ; as, instead of being adherent by a narrow neck, they have a broad ba.se, which oc- cupies a considerable extent of the passage. In such cases, the use of escharotics has been proposed ; but they cannot be used without risk of injuring the tym- panum. Mr. Buchanan prefers the practice of remov- ing polypi of the meatus with forceps, and afterward touching the part from which they grew with the ung. hydrarg. nitrat., or tinct. ferrt muriati . — {.dcoustic Sur- gery, p. 74.) lie also recommends washing out the l)assage every day with the injection, ht. Acid, pyro- lign. 3 ij. Aq. distillatae svj. ft. Ictio. . 10. Herpes of the Meatus Auditorius. An herpetic ulcerous eruption sometimes affects the meatus auditorius and auricle, producing considerable thickening of the skin, and so great an obstruction of the passage that a good deal of deafness is the consequence. Mr. Saunders remarks, that in this case, “ the ichor which exudes from the pores of the ulcerated surface, inspissates in the meatus, and not only obstructs the entrance of sound, but is accompa- nied with a great degree of fetor. This disease is not unfrequent. I have never seen it resist the effect of al- terative medicines,” the use of injections containing the oxymuriate of quicksilver, and the application of the unguentum hydrargyri nitrati. Mr. Saunders ex- hibited calomel as the alterative, and in one instance, employed a solution of the argentum nitratum as an injection. — (Pag^e 25, 26.) Whenthedisea.se is obsti- nate, a seton should be made on the nape of the neck, or a blister be applied behind the ear. The tincture of iodine should also be tried. 11. Affections of the Tympanum. The ear is sometimes affected with apuriform ichor- ous discharge, attended with a loss of hearing, pro- portionate to the degree of disorganization which the tympanum has sustained. Frequently, on blowing the nose, air is expelled at the meatus auditorius ex- ternus; and when this is the case, it is evident that the discharge is connected xvith an injury or destruc- tion of the ihembrana tympani. However, when the Eustachian tube is obstructed with mucus or matter, or when it is rendered impervious, and permanently closed by inflammation, the membrana tympani may not be perfect, and yet it is clear, no air can in this state be forced out of the external ear in the above manner. An examination with a blunt probe or with the eye, while the rays of the sun fall into the passage, should therefore not be omitted. If the membrane have any aperture in it, the probe will jiass into the ca- vity of the tympanum, and the surgeon feel that his in- strument is in coiitact with the ossicula. In this manner the affection may be discriminated from an herpetic ulceration of the meatus auditorius externus. The causes are various : In scarlatina ma- ligna, the membrana tympani occasionally inflamc.s, and slouglis; all the ossicula are discharged, and if the EAR. 335 patient live, he often continues quite-deaf. An earache, 111 other words, acute inflammation of the tympanum, is the most common occasion of suppuration in this cavity, in which, and the cells of the mastoid process, a good deal of pus collects. At length the membrana tympani ulcerates, and a large quantity of matter is discharged; but as the secretion of pus still goes on, the discharge continues to ooze out of the external ear. Instead of stimulating applications, inflammation of the tympanum demands the rigorous employment of antiphlogistic means. Unfortunately, it is a too com- mon practice in this case to have recourse to acrid spi- rituous remedies. Above all things, the repeated ap- plication of leeches to the skin behind the external ear and over the mastoid process, should never.be neglected. As soon as the inflammation ceases, the degree of deaf- ness occasioned by it will also disappear. This, how- ever, does not always happen. When an abscess is situated in the cavity of the tympanum, Mr. Saunders thinks that the membrana tympani should not be allowed to burst by ulceration, but be opened by a small puncture. — (P. 31 .) However, unless there were the strongest ground for believing that the Eustachian tube were impervious, this advice, I think, ought not to be followed, more especially as the symptoms are generally too vague to afford any degree of certainty in the diagnosis. Sometimes the disease of which we are treating, is more insidious in its attack; slight paroxysms- of pain occur, and are relieved by slight discharges. The case goes on in this way, until, at last, a continual dis- charge of matter from the ear takes place. The dis- order is destructive in its tendency to the faculty of hearing, and it rarely stops until it has so much disor- ganized the tjnnpanum and its contents, as to occasion total deafness. Hence, Mr. Saunaers insists upon the propriety of making attempts to arrest its progress, — attempts which are free from danger ; and he censures the foolish fear of interfering with the complaint, founded on the apprehension, that bad constitutional effects may originate from stopping the dis(;harge. If the case be neglected, the tympanum is very likely to become carious ; before which change, the disease, says Mr. Saunders, is mostly curable. Mr. Saunders divides the complaint into three stages : 1. A simple puriform discharge. 2. A puriform dis- charge complicated with fungi and polypi. 3. A puri- form discharge with caries of the tympanum. ' As the disease is local, direct applications to the' parts affected are chiefly entitled to confidence. Blisters and setons may also be advantageously employed. Mr. Saun- ders’s practice consisted in administering laxative medi- cines and fomenting the ear, while inflammatory symp- toms lasted, and afterward injecting a solution of the sulphate of zinc or cerussa acetata. In the second stage, when there were fungi, he re- moved or destroyed them with forceps, afterward touched their roots with the argentum nitratum, or in- jected a solution of alum, sulphate of zinc, or argen- tum nitratum. Writers describe a relaxed state of the membrana tympani as a cause of deafness. If, says a late author, after a discharge fiom the meatus auditorius externus, or cavity of the tympanum, or a dropsy of the latter ca- vity, the hearing remains hard, there is reason to sus- pect that the infirmity may depend upon relaxation of the membrane of the tympanum or paralysis of the internal muscle of the malleus. This suspicion will be strengthened if the deafness should increase in damp and lessen in dry weather; and particularly, if it be found that the hearing is benefited by introdu- cing into the ear dry warm tonic applications, such as the smoke of burning juniper-berries or other astrin- gent vegetable substances. The decoction of bark, used as an injection, is also said to have done good. The relaxation of the tympanum, alleged to proceed from a rupture of the muscle of the malleus, is deemed incurable ; but it is not so with the case which depends upon paralysis of this muscle. Here tonic injections into the tympanum, through the Eustachian tube, are recommended.— (Hict. des Sciences Med, t 38, p. 50.) Electricity, stimulating liniments, gargles, and a blis- ter, might also be tried. Imperfect hearing is supposed sometimes to arise firom preternatural ten.sion of the membrane of the tym- panum, indicated by the patient hearing better in wet than dry weather, and by his hearing what is spoken in a low tone near his ear better than any thing said in a loud manner. The opinions delivered by writers on the causes of this affection are only uncertain con- jectures. The local treatment recommended consists of injecting into the meatus auditorius emollient de- coctions or warm milk, or introducing into the passage a dossil of soft cotton, dipped in oil of sweet almonds. Nothing certain is known respecting the proper con- stitutional treatment, as must be clear from our igno- rance of the causes of this form of disease of the ear. Hardness of hearing appears sometimes to be caused by a chronic thickening of the membrane of the tym- panum ; and it is alleged, that there are cases of this description wliich proceed from syphilis, and require mercury. An issue in the arm nearest the affected ear, the tincture of iodine, and emollient and slightly stimulant injections, are likewise commended. When the tympanum was so considerably thickened, that there was no chance of restoring it to a healthy sta> 3 . Portal questioned whether it might not be advisable to make a small opening in ill— {Precis de Cliir. Pratique, t. 2, p. 430.) This operation which is said to have been first suggested by Cheselden, wilt be considered in tlte ensuing section'. Morgagni found the cavity of the tympanum inter- sected by numerous membranes, which impeded the movements of the ossicula. — {Epist. an. 6, ^ 4.) Meckel does not mention any example ol'a deficiency of all the ossicula .— des Pathol. Anat. b. \,p. 402.) Mersanni, however, found the incus wanting. — {Bonet Sepulch. 1. 1, sect. ID, obs. 4, ^ 1.) Catdani, the malleus and incus.— (Epist. ad Haller, t. 6, p. 142.) The latter case was unattended with any bad effect on the hearing ; the first with deafness. In a deaf child three years of age, Bailly found the ossicula of only one- third their proper size.— (Bonet Sepulch. t. I,.?4Sc. Acad. Boiioti, 1791, t. 7,p. 422.) Valsalva found the stapes adherent to the fenestra ovalis {De Aure Humana, cap. 11) ; and Reimarus relates a case in which the ossicula were entirely wanting .— der Tliiere, p. 57.) In the first degree of deafness above described, which, when congenital, must excite suspicion of serious malformation of the organ and abolition of the nervous influence; and when acquired, indicates a complete injury of the functions of the nerve, the prognosis, as Rosenthal observes, must be unfavourable. Nor can it be otherwise in the second congenital degree of the disease, though only a partial imperfection of the organ and nerve can here be supposed. On the other hand, when the latter degree is acquired, there is more pros- pect of relief, because merely a partial alteration in the soft parts is to be suspected. 2. Hardness of hearing. Rosenthal also distin- guishes several degrees of what is termed hardness of hearing. In the first, the patient cannot hear a distant noise, and especially high tones ; but he can perceive, though, it is true, not in a very distinct manner, articu- lated sounds, when the voice is a good deal raised. In the second degree, he hears and distinguishes both high and low tones very well, and also words, but only when the voice is somewhat raised. These two cases are better understood, inasmuch as it is tolerably well ascertained that the immediate cause of the infirmity is some alteration in that part of the organ which serves as a conductor for the vibrations of sound, or else an increased sensibility of the nerve, all the internal ear being in other respects right. Among alterations of the conducting parts of the organ, Ro.senthal comprehends : 1. A total obliteration of the meatus auditorius ex- temus, its imperforation, or complete absence. These cases may almost always be detected by a superficial examination, the patient only hearing when some solid bodies are placed between his teeth, while his dull per- ception of sounds does not appear to be much lessened when the ear is covered. 2. Diseases of the cavity of the tympanum, as inflam- mation of its membranous lining, caries of its parietes, or collections of blood, pus, or other fluid, in its cavity. Rosenthal thinks there can be no doubt that inflamma- tion and suppuration in the tj*mpanum are much more Ibequent than is generaily supposed ; the fonner afiec- tion being often mistaken for a slight attack of rheuma- tism. In dissecting aged subjects, he has frequently- found the membrane of the tympanum thickened and opaque, and he could only impute this appearance to previous inflammation. After detailing a case illustrative of the symptoms of inflammation within the tympanum, and a few ob.sers-aftoiis on caries and collections of fluid in that cavity, Rosenthal notices the hardness of hearing con- nected ivith nervous irritability, in the treatment of which case, he insists upon the advantage that would result from a knowledge of the particular species of morbid excitement p-evailing in the patient. But as notV.ing very certain can be made out on this point, and only conjectures can arise from dissections of bo- dies, that the affection consists either in a determina- tion of blood to the part, or in a partial para’^sis of the auditory nerve, the exact nature and form ct which are quite incomprehensible, it is absoluiely necessary to att-nd solely to the diagnosis of the nervous affcc- tio'.- in general. Th.s diagnosis will be fa. ilitated, Isi, If the patient has been previously very sensible to the impression of certain tones, or sound in general ; 2dly, If the power of hearing has been lost all on a sudden, without any mark of inflammation ; 3dly, If the aflec- tion coincides with other nervous disorders. 3. Alteration or Diminution of Hearing. Between the most perfect hearing, congenital or acquired, and this point of diminution of the faculty of hearing, Ro- senthal observes there are a great many degrees, the cause of which is the more difficult to comprehend, a» the circumstances of structure, which enable every part to perform its functions with freedom and perfec- tion, are not yet made out. If, says he, it were in our power to determine what is truly the regular structure of each part, we should then be furnished with a means of judging correctly of the anomalies of function, the changes in which would be indicated quite as clearly as in the eye, by shades of organization, absolutely in the same way as we judge of the modifications which the image of objects must undergo at the bottom of the ocular mirror, by the greater or less convexity of the cornea or lens, or the consistence of the other humours. In the present st^te of physiological and patholo- gical knowledge of the ear, therefore, Rosenthal con- ceives that little can be attempted with respect to a scientific classification of these cases of altered or dimi- nished hearing. As the cavity of the tympanum and its contents are the parts which have principal influence over the intensity of sound, and a great share in the propagation of articulated sounds,their faulty condition must here be chiefly the subject for consideration. And among their numerous defects, traced by dissection, and al- ready specified in the foregoing columns, Rosenthal par- ticularly calls the attention of the reader, 1 . To alterations of the membrane of the tympanum, whether proceeding from congenital malformation or Situation, or from thickening, ossification, perforation, or laceration of the same part. 2. The lodgement of some fluid in the cavity of the t3Tnpanum, more frequently produced than is com- monly supposed by obstruction of the Eustachian tube. In most new-born infants, Rosenthal has also found the cavity of the tympanum filled with a thick, almost gela tinous fluid, which for some days is not absorbed, and is probably the cause of the indifference evinced by new-born children to sounds, which are even so in- tense as to be offensive to the ears of an adult. 3. Alterations Of the membrane of the fenestra ro- tunda, such as its imperfect formation, or erroneous si- tuation, its thickened state, &c. But it is remarked by Rosenthal, that as the differ- ence in the intensity of sound may occasion a modifi- cation in the sensations of the ear, the merely con ducting parts of the auditory apparatus must not be forgotten, as the external ear and the meatus audito- rius externus, which regulate the quantity of sonorous waves striking the auditory nerve. However, the mal- formations 01 the meatus and the state of the cerumi- nous secretion within it, are observed by Kritter and Lentin {Ueber das schuere Gehoere, 1. 10, Leipz. 1794) to have more effect on the hearing than defects of the auricle itself, the whole of which, as we have stated, may be lost without any material deafness being pro- duced. Lastly, Rosenthal calls our attention to the nervous action or influence, which, whether too much raised or depressed, may equally render the hearing dull ; and some useful information may for the most part be derived from attemling to the patient's general sensibility.— (See Joum. Complan. t. 6, p. 21, Ac. Du~ vemey, de rOrgande de rOuie, 12mo. 1683. P. Ken- nedy, A Treatise on the Eye, and on some of the Dis- eases of the Ear, 8vo. Loiid. 1713. A. D. Dieiiert, Quaestio, i^c, an absque MembraiuB Tympani Aper- tura topica injiri in Concham possint, Paris, 1748. Meracire sur la-Theorie des Maladies de rOreille, et sur les Moyens que la Chirurgie pent employr pour leur Curation, in Prix de VAcad. de Chir. t. 9, p. Ill, , to turn.) A turn- ing out or an eversion of the eyelids. Accurding to Scar[»a there are two species of this disease ; one produced by an unnatural swelling of the lining of the eyelids, which not only pustics their edees from the eyeball, but also presses them so for- cibly that they become everted ; the other, arising from Y 2 a contraction of the skin of the eyelid, or its vicinity, by which means the edge of the eyelid is first removed for some distance from the ej e, and afterward turned completely out, together with the whole of the affected eyelid. The morbid swelling of the lining of the eyelids, which causes the first species of ectropium (putting out of present consideration a similar affection inci- denttd to old age), arises mostly from a congenital laxity of this membrane, afterward increased by obsti- nate chronic ophthalmies, particularly that of a scro- fulous nature, in relaxed, unhealthy subjects ; or else the disease originates from the small-pox affecting the eyes. While the disease is confined to the lower eyelid, as it most commonly is, the lining of this part may be observed rising in the form of a semilunar fold, of a pale red colour, like the fungous granulations of wounds, and intervening between the eye and eyelid, which latter it in some measure everts. When the swelling is occasioned by the lining of both the eye- lids, the disease assumes an annular shape, in the centre of which the eyeball seems sunk, while the cir- cumference of the ring presses and everts the edges of the two eyelids so as to cause both great uneasiness and deformity. In each of the above cases, on press- ing the skin of the eyelids with the point of the finger, it becomes manifest that they are very capable of being elongated, and would readily yield, so as entirely to cover the eyeball, were they not prevented by the inter- vening swelling of their membranous lining. Besides the very considerable deformity which the disease produces, it occasions a continual discharge of tears over the check, and, w'hat is worse, a dryness of the eyeball, frequent exasperated attacks of chronic ophthalmy, incapacity to bear the light, and, lastly, opacity and ulceration of the cornea. The second species of ectropium, or that arising from a contraction "of the integuments of the eyelids or neighbouring parts, is not unfreqiiently a conse- quence of puckered scars produced by the confluent small-pox ; deep bums ; or the excision of cancerous or encysted tumours, without saving a suflicient quan- tity of skin ; or, lastly, the disorder is the eflect of ma- lignant carbuncles, or any kind of wound attended with much loss of substance. Each of these causes is quite enough to bring on such a contraction of the skin of the eyelids as to draw these parts towards the arches of the orbits, so as to remove them from the eyeball and turn their edges outwards. No sooner has this circumstance happened, than it is often followed by another one equally unpleasant, namely, a swelling of the internal membrane of the affected eyelids, which afterward has a great share in completing the ever- sion. The lining of the eyelids, though trivially everted, being continually exposed to the air and irrita- tion of extraneous substances, soon swells, and rises up like a fungus. One side of this fungus-like tumour covers a part of the eyeball ; the other pushes the eye- lid so considerably outwards, that its edge is not un frequently in contact w ith the margin of the orbit The complaints induced by this second species of ec tropium are the same as those brought on bj- the first ; it being noticed, however, that in both cases whenever the disease is inveterate, the fungous swelling of the inside of the eyelids becomes hard, coriaceous, and, as it were, callous. Although in both species of ectropium the lining of the eyelids seems equally swollen, yet the surgeon can easily distinguish to wliich of the two species the disease be- longs. For in the first the skin of tlie eyelids and ad- joining parts is not deformed with scars, and by ja-ess- ing the everted eyelid with the point of the finger, the part would with ease cover the eye, were it not for the intervening fungous swelling. But in the second spe- cies of ectropium, besides the obvious cicatrix and con- traction of the skin of the eyelids or adjacent parts, when an effort is made to cover the eye with the everted eyelid, by pressing ui;on the latter part with the point of the finger, it does not give way, so as completely to cover the globe, or only yields, as it ought to do, for a certain extent ; or it does not move in the least fi om its unnatural position, by means of the integuments of the eyelids liaving been so extensively destroyed that their margin has become adherent to the arch of the orbit. In addition to the forms of the disea.se mentioned by Scarpa, Mr. tJuthrie enumerates a case depending on 340 ECTROPIUM. chronic inflammation, accompanied with contraction of the integuments of the eyelid, but xiitfiont any manifest sicatrix. It is described by him as usually taking place after a long continuance of li^rpitudo, and proceed- ing from the excoriation, contraction, and hardening of the skin, “ the result of the passage of the vitiated secre- tions over it, and which, by dropping on it, increase the irritation.” — {On the Oyerative Surgery of the Eye,p. 50—55.) This form of the disease, according to Mr. Guthrie, is rarely attended t^th such a thickening of the inner membrane of the eyelid, as to require removal with the knife or scissors ; for it subsides with the re- moval of the complaint. — (P. 60.) According to Scarpa, the cure of ectropium cannot be accomplished with equal perfection in both its forms, the second species being, in some cases, absolutely in- curable. For, as in the first species of ectropium the disease only depends upon a morbid thickening of the internal membrane of the eyelids, and the treatment merely consists in removing the redundant portion, art possesses many efficacious means of accomplishing what is desired. But in the second species of ectropium, the chief cause of which arises from the loss of a por- tion of the skin of the eyelids or adjacent parts, which loss no knoAvn artifice can restore, surgery is not capa- ble of effecting a perfect cure of the malady. The treatment is confined to remedying, as much as possi- ble, such complaints as result from this kind of ever- sion, and this can be done in a more or less satisfactory manner, according as the loss of skin of the eyelid is lit- tle or great. Cases in which so much skin is deficient, that the edge of the eyelid is adherent to the margin of the orbit, Scarpa abandons as incurable. How far the case can be rectified, he thinks, may always be estimated by remarking to what point the eyelid admits of being replaced, on being gently pushed with the end of the finger towards the globe of the eye, both before and af- ter the employment of such means as are calculated to effect an elongation of the skin of the eyelid ; for it is to this point, and no farther, that art can reduce the everted part, and permanently keep it so replaced. When the first species of ectropium is recent, the fungous swelling of the lining of the eyelid not consi- derable, and consequently the edge of the eyelid not much turned out, and in young subjects (for in old ones the eyelids are so flaccid, that the disease is irremedi- able), Scarpa prefers destroying the fungous surface of the internal membrane of the eyelid by the repeated application of the argentum nitratum. Mr. Guthrie touches the fungous portion of the conjunctiva every four days with a probe dipped in sulphuric acid, and gently applies every day, or every second day, the sul- phate of copper, at the same time not omitting some minor remedies, which he also employs in cases pro- ceeding from contraction of the skin independent of any cicatrix, and which I shall presently notice. — {On the Operative Surgery of the Eye, p. 70.) In recent cases, M'here the patient is weak and irritable (or a child). Beer commences the treatment W'ith simply applying every day the tincture of opium, which after a time is to be strengthened by the addition of naphtha. To the re- laxed conjunctiva he rfterward applies escharotic eye- salves, and last of all the nitrate of silver and muriate of antimony. When the part is hard and callous, the employment of caustic is preceded by scarifications. — (Lehre, .H. b. 2, p. 136.) For remedying the considerable and inveterate form of the first species of the disease. Beer and Scarpa are sdvocates for cutting away the whole of the fungous swelling closely from the muscular substance, on the inside of the eyelid. The following is Scarpa’s descrip- tion of the operation. The patient being seated with his head a little inclined backwards, the surgeon, with the index and middle fin- ger of his left hand, is to keep the eyelid steadily everted, and holding a small pair of curved scissors with convex edges in his right, he is completely to cut off the whole fungosity of the internal membrane of the eyelid as near as possible to its base. The same operation is then to be repeated on the other eyelid, should that be affected with the same disorder. If the excrescence Bhould be of such a shape that it cannot be exactly in- cluded within the scissors, it must be raised as much as possible with forceps, or a double-pointed hook, and dis- sected off at its base, by means of a small bistoury with a convex edge. This last mode is preferred by Beer to the use of scissors, and I confess that it has always appeared to me the most convenient. The bleeding', which seems at the beginning of the operation as if it would be copious, stops of itself, or as soon as the eye is bathed with cold water. The surgeon is then to ap- ply the dressings, which are to consist of two small compresses, one put on the upper, the other on the lower arch of the orbit, and over these the uniting band- age, in the form of the monoculus, or so applied as to compress and replace the edges of the everted eyelids, in order to make them cover the eye. On the first re- moval of the dressings, which should take place about twenty- four or thirty hours after the operation, the sur- geon will find the whole, or almost the whole, of the eyelid in its natural position. The treatment should afterward consist in washing the ulcer on the inside of the eyelid twice a day with simple water, or barley water, and confect, rosae, until it is completely well. If towards the end of the cure the wound should assume a fungous appearance, or the edge of the eyelid seem to be too distant from the eyeball, the wound on the inside of the eyelid must be rubbed several times with the ar- gentum nitratum, for the jmrpose of destroying a little more of the membranous lining, so that when the cica- trization follows, a greater contraction of it may take place, and the edge of the eyelid be drawn still nearer the eye. Proper steps must be taken, however, for re- sisting the principal cause on which the ectropium de- pends, particularly chronic ophthalmy, a relaxed and varicose state of the conjunctiva, &c.— (See Oph- thalmy.) In England the excision of the fungous thickened portion of the conjunctiva, in cases of ectropium, has been very much relinquished for the employment of caustic. The difficulty and almost total impossibility of dissecting off every particle of the fungus render the practice of excision much less certain than the treat- ment with caustic. Thus we see that Scarpa con- fesses its occasional failure, and the necessity of then having recourse to the latter plan. Demours also lets the employment of caustic follow the use of the knife. — {Mai. des Yeux, p. 98.) In the ectropium from a re- laxed fungous state of the conjunctiva, the consequence of purulent ophthalmia. Dr. Vetch begins with a light careful application of the argentum nitratum to the whole granulated villous surface. The everted part is then to be returned, and secured in its place with a compress, and straps of plaster and a bandage. Every time the eye is cleaned, the same things are to be re- peated, and in the course of a few days the tendency to protrude will disappear. — {On Diseases of the Eye,p. 228.) In the second species of ectropium, or that produced by an accidental contraction of the skin of the eyelids, or neighbouring parts, Scarpa observes, that if a con- traction of the integuments has proved capable of evert- ing the eyelid, the excision of a piece of the internal membrane of the part, and the cicatrix which will fol- low must also be capable, for the same reason, of bring- ing back the eyelid into its natural position. But since nothing can restore the lost skin, the shortened state of the whole eyelid, in whatever degree it exists, must al- wa5's continue, even after any operation the most skil- fully executed. Hence the treatment of the second spe- cies of ectropium, he says, will never succeed so per- fectly as that of the first, and the replaced eyelid will always remain shorter than natural, in proportion to the quantity of integuments lost. It is true that, in many cases, the eversion seems greater than it actually is, in regard to the small quantity of skin lost or de- stroyed ; for when the disease has once begun, though the contraction ofthe skin may be trivial in consequence of the little quantity of it deficient, still the swelling of the lining of the eyelid, which never fails to increase, at last brings on a complete eversion of the part. In these cases the cure may be accomplished with such success as is surprising to the inexperienced ; for after the fungous swelling of the internal membrane of the eyelid has been cut off, and the edge of the part approxi- mated to the eyeball, the shortening of (he eyelid re- maining after the operation is so trivial, that it may be considered as nothing in comparison with the deformity and inconvenience occasioned by the ectropium. When- ever, therefore, the retraction of the skin of the everted eyelid, and the consequent shortness of it, are such as not to prevent its rising again and covering the eye, if not entirely, at least moderately, Scarpa directs the surgeon to cut away the internal membrane of the everted eye- ECTROPIUM. 341 lid, as already explained, so as to produce a loss of sub- stance on the inside of the everted eyelid. In invete- rate cases of ectropium, in which the lining of the eyelids has become hard and callous, Scarpa applies to t'he everted eyelid, for a few days before the operation, a soft bread-and-milk poultice, in order to render the part flexible, and more easily separated than it could be in its former rigid state. The division of the cicatrices which have given rise to the shortening and eversion of the eyelid, as Scarpa observes, does not procure any permanent elongation of this part, and consequently it is of no avail in the cure of the presept disease. We see the same circum- stance occur after deep and extensive burns of the skin of the palm of the hand and fingers : whatever pains may have been taken, during the treatment, to keep the hand and fingers extended, no sooner is the cicatriza- tion thus completed, than the fingers become irremedi- ably bent. The same thing happens after extensive burns of the skin of the face and neck. Fabricius ab Aquapendeiite, who well knew the inutility of making a semilunar cut in the skin of the eyelids, for the purpose of remedying their shortness and eversion, proposes, as the best expedient, to stretch them with adhesive plas- ters, applied to them and the eyebrow, and tied closely together. Whatever advantage may result from this practice, the same degree of benefit may be derived from using, for a few days, a bread-and-milk poultice, after- ward oily embrocations, and lastly, the uniting band- age, so put on as to stretch the shortened eyelid in an opposite direction to that produced by the cicatrix ; a practice which Scarpa thinks should always be care- fully tried before the operation is determined upon. The surgeon, with a small convex-edged bistoury, is to make an incision of sufficient depth into the internal membrane of the eyelid, along the tarsus, carefully avoiding the situation of the puncta lachryrnalia. Then with a pair of forceps he should raise the flap of the di- vided fungous membrane, and continue to detach it with the bistoury from the subjacent parts all over the inner surface of the eyelid, as far as where the membrane quits this part, to be reflected over the front of the eye, under the name of conjunctiva. The separation being thus far accomplished, the membrane is to be raised still more with the forceps, and cut off with one or two strokes of the scissors, at the lowest part of the eyelid. The compresses and bandage, to keep the eyelid replaced, are to be applied as above directed. On changing the dressings, a day or two after the operation, the eyelid will be found, in a great measure, replaced, and the dis- figurement which the disease caused greatly amended. The operation is rarely followed by bad symptoms, such as vomiting, violent pain, and inflammation. However, should they occur, the vomiting may be re- lieved by means of an opiate clyster ; and as for the pain and inflammation, attended with a great tumefac- tion of the eyelid operated upon, these complaints may be cured by applying a poultice, or bags filled with emollient herbs, at the same time applying internal an- tiphlogistics, until the inflammation and swelling have subsided, and suppuration has commenced on the in- side of the eyelid on which the operation has been done. After this the treatment is to consist in washing the part twice a day with barley-water and confect, rosas, and lastly, in touching the wound a few times with the argentum nitratum, in order to keep the granulations within certain limits, and to form a permanent cicatrix, proper for maintaining the eyelid replaced. — {Scarpa suite Mallattie degli Occlii.) / In cases in which the eversion is considerable. Sir W. Adams has never found the simple incision of the fungus, as practised by Scarpa, sufficient to effect a ra- dical cure, and he therefore tried a new mode of opera- ting. In his first attempts, he employed a very small curved bistoury, the point of which he carried along the inside of the eyelid, at its outer angle, downwards and outwards, as far as the point of reflection of the con- junctiva would admit. He then pushed it through the whole substance of the everted eyelid and its integu- ments, and cut upwards through the tarsus, making an incision nearly half an inch in length. With a curved pair of scissors, he next snipped off a piece of the edge of the tarsus, about one-third of an inch in width, and he afterward removed with the same instrument the whole of the diseased conjunctiva. When the bleeding had ceased, Sir W. Adams passed a needle and ligature fhrougli the whole substance of the two divided por- tions, and brought them as accurately into contact as possible. Finding, however, that too much integument had been left at the lower part of the incision, he em- ployed in future operations, instead of the sealpel, a pair of straight scissors, with which he cut out an an- gular piece of the lid, resembling the letter V. Latterly Sir W. Adams has found it advantageous to leave about a quarter of an inch of the lid adjoining its external angle, and after shortening the part as much as neces- sary he brings the edges of the incision together with a suture.— (See Practical Observations on the Ectropium, iS-c. p. 4 and 5, Land. 1812.) On the subject of the foregoing proposal, M. Roux ' observes, “ What Sir W. Adams says, with a view of enhancing the value of his own method, about the fre- quent recurrence of ectropium, when the conjunctiva is simply cut out, is a gratuitous assertion, contradicted by experience. I have already in a very great number of cases undertaken the cure of ectropium in the com- mon way : the operation always succeeded as much as the degree or other circumstances of the disease allowed ; and I have not yet observed an instance of a relapse.” — ( Voyage fait a Londres en 1814, ou Parallele de la Chirurgie Angloise avec la Chirurgie Francoise, p. 291.) If this new operation, however, will cure the ectropium, caused by the contraction of cicatrices, a.s its inventor describes, or produce great improvement, aa the experience of Mr. Travers confirms {Synopsis of the Diseases of the Eye, p. 235), it is clear that though it may not be necessary in ordinary cases, its usefulness will not be entirely lost. Mr. Guthrie acknowledges that it may be highly useful in the ectropium from the contraction of a cicatrix.— (On, the Operative Surgery of the Eye, p. 71.) The contracted scar must of course be divided, in addition to the other proceedings. In the form of ectroinum described by Mr. Guthrie as arising from a hardened and contracted state of the integuments of the eye, but without any cicatrix, he observes that the indications are, 1st, to relieve the contraction of the skin externally ; 2dly, to restore and retain the eyelid in its proper situation, until the unna- tural curvature of the cartilage has been overcome, and the chronic inflammation removed. For fulfilling the first indication he recommends washing the external parts with warm water, so as to leave the skin as clean as possible. It is then to be carefully dried, and re- peatedly anointed with the ung. zinci, for three or four days. Being thus protected from the irritation, it be- comes softer, and in a favouralde state to yield to mild extension. For accomplishing the second indication, Mr. Guthrie applies the sulphuric acid : the eyelid having been cleansed so as to prevent its slipping, the conjunctiva is to be gently wiped dry and everted as much as possible, so that the part where it begins to be reflected over the eyeball may be seen. An assistant is to raise the upper eyelid a little, and the patient to look upwards. The blunt end of a common silver probe is then to be dipped in the sulphuric acid and rubbed over the conjunctiva, so that every part of it may be touched with the acid. The round point of the probe is to be carried as tar as where the membrane begins to be re- flected over the eyeball, but no farther. The punctum lachrymale, caruncle, and semilunar fold are to be avoided ; but the external angle, as well as every other part, except what is reflected over the eye, is to be care- fully rubbed. The acid will turn the touched portion of the conjunctiva white; and in order to prevent the acid from affecting the eyeball, a stream of water is now to be directed over the eyelid with an elastic gum syringe. If the conjunctiva should not be turned suffi- ciently white, its application may be repeated. The use of the acid is to be repeated every fourth day ; ‘‘ and when applied in the manner directed it does not cause a slough, but a general contrai tiou of the part, which is, however, only perceptible after two or three applications, by its ef- fect in inverting the lid, which gradually begins to take place. After six or eight applications, the cure will be more tlian half accomplished, and in most cases of this species of eversion, the thickening of the con- junctiva will have subsided.” The ung. zinci is to be constantly applied to the skin, and the ung. hydrarg. nilr. in the proportion of one part to four or six of the ung. cetacei, to the edge of the eyelid. After the eye- lid has reriirned two-thirds ol the way towards its na- tural position, the intervals between the applications of the acid must be longer, lest the contraction within Lhi eyel.d be carried too far, and an inversion of it pro- 342 EMB EMP duced. After the eversion is cured, the lippitudo may yet partly remain, and demand the use of the ung. hy- drarg. nitr. or other gentle stimulants. — (See Scarpa's Osservazioni suLle Malattie degli Occhi ; ed. 5, cap. 6. Richter's Avfangsgr. der Wuadarzneykunst, b. 2, p. 473, A,-c. Wenzd's Manuel de I'Oculiste. Pellier, Re- cueil d'Obs. sur les Maladies des Yeux. Sir W. Adams, Pract. Observ. on Ectropium, or Eversion of the Eye- lids, with a Description of a nesu Operation for the Cure of that Disease ; on the modes of forming an artificial Pupil; and on Cataract, Svo. Load. 1812. M. Bordenave, Mimoire dans lequel on propose un nouveau ProcMo pour traiter le Renversement des PaupUres, in Mem. de I'Acad. Royale de Chirurgie, t. 13, p. 156, et seq. edit. 12/no. It was in this memoir, that the proposal of removing a portion of the inside of the eyelid for the cure of ectropium was first made. Here may also be found the best historical account of the different methods of treatment, which have prevailed from the earliest periods of surgery. Consult also Parallele de la Chirurgie Angloise avec la Chirurgie Francoise, par P. J. Roux, p. 289—292, Paris, 1815. G. J. Beer, Lehre von den Augenkrankheiten, b. 2, p. 133, SfC. Svo. Wien, 1817. Benj. Travers, Synopsis of the Diseases of the Eye, p.234. 356, iV c. Svo. Lond. 1820. Demoairs, Traiti des Mai. des Yeux, p. 98. G. J. Guthrie, Lectures on the Operative Surgery of the Eye, Svo. Loud. 1823.) ECZEMA, or Eczk'sma (from ekI^Iu), to boil out), is characterized by an eruption of small vesicles on va- rious parts of the skm, usually close or crowded together, with little or no inflammation round their bases, and unattended by fever. It is not contagious. — (Bateman's Synopsis, p. ‘250, ed. 3.) There are se- veral varieties of this disease, the most remarkable of which is the eczema rubrum from the irritation of mer- cury. This form is attended with quickened pulse and a white tongue ; but the stomach and sensorium are not materially disturbed.— (See Mercury.) EFFUSION, in surgery, means the escape of any fluid out of the vessel or viscus naturally containing it, and its lodgement in another cavity in the cellular substance, or in the substance of parts. Thus, when the chest is wounded, blood is sometimes effused from the vessels into the cavity of thd pleura ; in cases of false aneurisms, the blood passes out of the artery into the interstices of the cellular substance ; in cases of fistul® in perinaeo, the urine flows from the bladder and urethra into the cellular membrane of the perinaeum and scrotum ; and when great violence is applied to the skull, blood is often effused even in the very substance of the brain. Effusion also sometimes signifies the natural secre- tion of fluids from the vessels ; thus surgeons, fre- quently speak of the coagulable lymph being effused on Afferent surfaces.— (See Extravasation.) ELECTRICITY. Among the aids of surgery, elec- tricity once held a conspicuous and important situation. It has, however, met with a fate not unusual with reme- dies too much cried up and too indiscriminately em- ployed ; that of having fallen into an undeserved degree of neglect. Whatever its effects may be on the system, it cer- tainly possesses this advantage over other topical reme- dies, that it may be made to act on parts very remote from the surface. Electricity, as a topical remedy for surgical diseases, is chiefly used in amaurosis, deafness, some chronic tumours and abscesses, weakness from sprains, or con- tusions, paralysis, &c. In cases of suspended animation, electricity is some- times an important auxiliary for the restoration of the vital functions.— (See J. Curry's Obs. on Apparent Death. &rc. ed. 2, 1815.) ELEVATOR. An instrument for raising depressed portions of the skull. Besides the common elevator, now generally pre- ferred by all the best operators, several others have been invented; as, for instance, the tripod elevator, and another which was first devised by M. J. L. Petit, and afterward improved by M. Louis. EMBROCATIO ALUMINIS. Jk- Aluminis ^ij. Aceti, spiritus vinosi tenuioris, sing. Ibss. For chil- blains and disea.sed joints. . EMBROCATIO AMMONIA. R. Liq. ammon. 5 i. .Athens >aulphurici 5 ss- Spir. lavanduls 5>j- M. For sprains and bruises. EMBROCATIO . AMMONIiE ACETATE CAM- PHORATA. ft. Linim. camph., liq. ammon. acet sing. 3 vj. Liq. ammon. ? ss. M. For sprains, bruises and chilblains, not in a state of suppuration EMBROCATIO AMMONIAC ACETATtE. ft. Liq ammon. acet., lin. sapon. sing. sj. M. For bruises with inflammation. EMBROCATIO CANTHARIDIS CUM CAM- PKORA. ft. Tinct. canth., spirit, camph. sing. 3j. M. This may be used in any case in which the object is to stimulate the skin. It should be remembered, ho wever, that the absorption of cantharides will some- times bring on strangury. EMBRYOTOMIA. (From spSpvov, a foetus, and TEpvu),to cut.) The operation of cutting into the womb, in order to extract the foetus.— (See Caesarean Opera tion.) EMPHYSEMA. ('KpipyayiJia, fronupvadu), to inflate.) A swelling produced by air in the cellular substance. The common cause is a fractured rib, by which the vesicles of the lungs are wounded, so that the air es- capes from them into the cavity of the thorax. But as the rib at the moment of its being fractured is pushed inwards and wounds the pleura, which lines the ribs and intercostal muscles, part of the air most commonly passes through the pleura aiid the lacerated muscles into the cellular membrane on the outside of the chest, and thence is diffused through the same membrane over tile whole body, so as to inflate it sometimes in an extraordinary degree. This inflation of the cellular membrane has been commonly looked upon as the most dangerous part of the disease ; but very erroneously, as will appear in the sequel. — (Hewson,Med. Obs. and In- quiries, vol. 3.) Emphysema is most frequent after a fractured rib, because there is a wide laceration of the lungs, and no exit for the air; it is less fre»iuent in large wounds with a knife or broadsword, because the air has an open and unimpeded issue; it is again more frequent in deep stabs with bayonets or small swords; but it is not so peculiarly frequent in gun-shot wounds as the late Mr. John Bell supposed (On Wounds of the Breast, p. 265, ed. 3), and, in fact, is not nearly so common in them as in cases of stabs, particularly where the ribs are not splintered. Emphysema has also been known to arise from a rupture of the larynx and trachea, produced by a blow or kick, as we find exemplified in the case reported by Dr. L. O’Brien. — (See Edin. Med. and Surg. Joum. No. 72.) The symptoms attending emphysema are generally of the following kind. The patient at first complains of a considerable tightness of the chest, with pain, chiefly in the situation of the injury, and great difficulty of breathing. This obstruction of respiration gradually increases, and becomes more and more insupportable. The patient soon finds himself unable to lie down in bed, and cannot breathe, unless when his body is in an upright posture, or he is sitting a little inclined for- wards. The countenance becomes red and swollen. The pulse, at first weak and contracted, becomes after- ward irregular. The extremities grow cold, and, if the patient continue unrelieved, he soon dies, to every ap- pearance suffocated. The emphysematous swelling, wheresoever situated, is easily distinguished from oedema or anasarca, by the crepitation which occurs on handling it, or a noise like that which takes place on comp'^essing a dry bladder half filled with air. The tumour is colourless and free from jmin. It does not of itself descend into depending parts, though by jiressure it may be made to change its situation. It is elastic, that is to say, it may be pressed down, but it rises up again as soon as the pressure is discontinued The swelling never retains the impression of the end of the finger, or, in the language of surgery, never pits. The iiart affected is not heavy. The tumour first makes its appearance in one particular jilace; but it soon extends over the whole body, and causes an ex- traordinary distention of the skin.— (Ric/ifer’s An fiugsgr. der W undarzn. b. \,p. 451.) The wound of the pleura and intercostals may some- times be too small to suffer the air to get readily into the cellular membrane, and inflate it, but may confine a part of it in the cavity of the thorax, so as lo compress the lungs, prevent their expan.sion, and cause the same symptoms of tightness of the chest, quick breathing, EMPHYSEMA. 343 and j^nse of suffocation, which water does in the hy- drops pectoris, or matter in empyema. — {Hewsmrv.) To understand why the air passes at all out of the wound of the lungs, we must advert to the manner in which inspiration and expiration are naturally carried on. It is well known, that in the perfect state, the surface of the lungs always lies in close contact with the membrane lining the chest, both in inspiration and expiration. The lungs themselves are only passive org^ins, and are quite incapable by any action cf their own of expand- ing and contracting, so as to maintain their external surface always in contact with the in.side of the thorax, which is continually d.idergoing an alternate change of dimensions. Every muscle that has any share in enlarging and diminishing the capacity of \he chest, must contribute tc the effect of adapting the volume of the lungs to the cavity in which thsy are contained, as long as there is no communication between the ca- vity of the pleura and the exterr.al air. In inspiration the thorax is enlarged in every direction, the lungs are expanded in the same way, and the air, entering through the windpipe into the air-cells of these organs, prevents the occurrence of a vacuum. But in cases of wounds, when there is a free com munication between the atmosphere and inside of the chest, no sooner is this cavity expanded, than the air naturally enters it at the same time, anu for the same reasons, that the air enters the lungs througii the tra- chea, and the lung itself remains proportionally col- lapsed. When the thorax is next contracted in expira- tion the air is compressed out of .he lung, and also out of the bag of the pleura through the externa) wound, if there be a direct one ; in which circumstance the em- physematous swelling is never extensive. But in the case of a fractured rib, attended with a breach in the pleura cosialis, pleura pulmonalis, and air-cells of the lungs, there is no direct communication between the cavity of the chest and tlie external air ; in ocher words, there is no outward wound in the parietes of the thorax. There is, however, a preternatural opening formed betvveen the air-cells of the lungs and the cavity of the chest, and also another one between the latter space and the general cellular substance of the body, through the breach in the pleura costalis. The consequence is, that when the chest is expanded in in- spiration, air rushes from the wound in the surface of the lungs, and insinuates itself between them and the pleura costalis. The lungs collapse in proportion, and the place which they naturally occupied when dis- tended, is now occupied by the air. When in expira- tion the dimensions of the chest are every where di- minished, the air now lodged in the bag of the pleura cannot get back into the aperture in the collapsed lung, because this is already full of air, and is equally com- pressed on every side, by that which is confined in the thorax. Were there no breach in the pleura costalis, this air could not now become diffused ; the muscles of inspiration would next enlarge the chest, remove the pressure from the surface of the wounded lung, more air would be sucked out of it, as it were, into the space between the pleura costalis and pleura pulmonalis, and this process would go on till the lungs of the wounded side were completely collapsed. But in the case of a fractured rib or narrow stab, in which there is also a breach in the pleura co.stalis, without any free vent out- wards for the air which gets out of the lung into the cavity of the pleura, as soon as the expiratory powers lessen the capacity of the chest, this air, not being able to pass back through the breach in the collapsed lung, is forced through the laceration or wound in the pleura costalis into the common cellular substance. It is through the communicating cells of this struc- ture that the air becomes most extensively diffused over the whole body, in proportion as the expiratory mmscles continue in their turn to lessen the capacity of the chest, and pump the air, as it were, through the breach in the pleura costalis, immediately after it has been drawn out of the wound of the lung in inspiration, — iSee John Bell, On Wounds of the Breast, and Hal- liday. On Emphysema, 1807.) To prove that the confinement of air in the chest is the cause of the dangerous symptoms attending emphy- sema, Ilewson adverts to the histories of some re- markable cases, published hy Littre. Mery, W. Hunter, and Cheslon.— (See Mem. de I' Acad. Royale des Sci- ences, frjr 1713; Med. Obs. and Inquiries, vol. 2; and \ Pathoioffical Inquiries.) In Littre’s case, the patient, who had been wounded in the side with a sword, could not breathe without making the most violent efibris, especially during the latter part of his disease ; he died on the fifth day. In Mery’s instance, the fourth and filth true ribs were broken by a coach passing over the chest ; the patient’s respiration was much impeded from the first, and be- came more and more difficult till he died, which was on the fourth day after the accident. In Dr. Hunter’s case, the patient had received a con- siderable hurt on his side by a fall from his horse. He had adifficultv of breathing', which increased Ui propor- tion as the skin became elevated and tense , it was la- borious as well as frequent. Ills inspiration was short and almost instantaneous, and ended with a catch in the throat, which was produced by the .shutting oft he glottis; after this lie strained to expire for a moment without £ny noise, then suddenly opeiiidg the glo.tis, forced out his breath with a sort of groan, anu in a hui '-y, and then quickly inspired agam ; so that his end'uvours seemed to be lo keep Ids lungo always full ; inspiration succeeded expiration as fast as possible. He said, his difficulty of breathing was owing to an oppre.ssion or tig’nness across his breast, near the pit of the stomach. He hac a little cough, which exasperated his pain, and he brouglit up blood and phlegm from his lungs. He was relieved by scarifications, and recovered. In Mr. Cheston’s car s, the man had received a blow on the chest. He had a constant cough, bringing up, after many ineffectual efforts, a frothy discharge, lightly tinctured with blood ; he seemed to be in the greatest agonies, and constantly threatened will) sufibcation. His pulse was irregular, and .sometimes scarcely to be felt, his face livid, ar.d when he was sensible, which was only now and then, he complained of a pair, in his head. On passing a bandage round his chest, with a proper compress to prevent the discharge of air into the cellular membrane, and to confine tiie inotioii of the thorax, the patient cried out th.at he could not siifier it. A strong compression by the baud alone affected him in the same way. Notwitlistaiidiiig bieeumg, repeated scarifications, and other means, his sense of suffoca- tion and dilficulty of breathing increased. On the fourth day, the air no longer passed into the cellular membrane, when on a sudden inclining his head back- wards, as it were, for the admission of more air than usual, his breathing became more difficult and inter- rupted, he turned wholly insensible, and soon afterward died. Littre, Mery, and Cheston opened their patients after death. Besides a wound of the lungs and fractured rib, Littre found a considerable quantity of blood in the cavity of the thorax, and was sensible of some fetid air escaping on his first puncturing the intercostals and pleura. The wounded lobe was hard and black, and the other two of the same side were inflamed. In Mery’s patient no blood was extravasated, nor was there any thing preternatural, except the fractured ribs, the wound of the pleura, and that of the lungs. Clieslon found a fracture of the tenth and eleyenth ribs, and a wound of the lungs. The lungs below the wound were livid, and more compact than usual ; but every thing else was natural, no extravasation, iio in- flammation, no internal emphysema. Hewson made several experiments on animals, tend- ing to prove, that air in their chests produced great diffi- culty in breathing, such as occurs in cases of emphy- sema ; and in one case which he examined after death, air was actually discharged on puncturing the thorax. The object of Mr. Hewson’s paper is to recommend making an opening in the chest, for the purpose of giving vent to the air confined in that cavity, just as is done for the discharge of pus in cases of empyema or of water in those of hydrops pectoris. In wounds of the lungs, says this author, w'hether occ^asioned by fractured ribs or other causes, when symptoms of tightness and suffocation come on, so far should we be from dreading the emphysematous swell- ing of the cellular membrane, that we should rather consider it as a favourable symptom, showing that the air is not likely to be confined in the thorax ; and so far should we be from compressing the wound to prevent the inflation or emphysema, that we should rather di- late it (if not large enough already) or perform the pa- racentesis thoracis. We may judge of the necessiiy of this operation from the violence of the symptoms. 344 EMPHYSEMA. such as the oppressed breathing, dtc. For when these are not considerable, and the air passes out of the chest with sufficient freedom, the operation is then unue- cessarj'. If the disease is on the right side, the best place for performing the operation, says Mr. Hewson, will be on the fore part of the chest, between the fifth and sixth ribs ; for there the integuments are thin, and in the case of air no depending drain is required. But if the dis- ease is on the left side, it will be more advisable to make the opening between the seventh and eighth, or eighth and ninth ribs, in order that we may be sure of avoiding the pericardium. As large penetrating wounds are inconvenient on account of the air entering by the aperture in such a quantity as to prevent the expcmsion of the lungs, a small wound \%ill be eligible, espe- cially as air does not require a large one for its escape. Mr. Hewson recommends dissecting cautiously with a knife, in preference to the coarse and hazardous’ method of thrusting in a trocar. There is one error prevailing in Mr. Hewson’s paper, for which he has been justly criticised by Mr. John Bell ; viz. the idea that it is possible and proper to make the collapsed lung expand by making an opening in the chest. Bromfield and B. Bell have both imbibed the same erroneous opinions, and proposed plans for ex- hausting the air and expanding the lung. It is very- certain that it is impracticable to make the collapsed viscus expand, until the breach in it is closed, and this closure is greatly promoted by the quiet state in which the collapsed lung remains; a state also the most favourable for the stoppage of any bleeding from the pulmonary vessels. The true object then of making an opening in the thorax, when the symptoms of suffocation are violent, is not to obtain an expansion of the lung on the affected side, nor to take the pressure of the air from it ; but to remove the pressure caused on the opposite lung by the distention of the mediastinum, and at the same time to diminish the pressure of the air on the diaphragm. The lung on the affected side must continue collapsed, and it is most advantageous that it should do so. The opposite lung is that which for a time must of itself carry on respiration, and it is known to be fully ade- quate to this function, provided the quantity of air on the other side of the chest does not produce too much pressure on the mediastinum and diaphragm. Mr. John Bell concludes his remarks on this subject with advising the following practice : 1st. When the crackling tumour begins to form over a fractured rib, small punctures should be made with the point of a lancet, as in bleeding ; and if the point be struck deep enough, the air will rush out audibly. But as (supposing the lung is not adherent to the inside of the chest) this air was in the thorax before it came into the cellular substance, it is plain that the thorax is still full, and that the lung of that side is already col- lapsed and useless, and must continue so. The pur- pose, therefore, of making these scarifications, and es- pecially of making them so near the fractured part, is not to relieve the lungs, but merely to prevent the air spreading more widely beneath the skin. 2d. If the air should have spread to very remote parts of the body, as to the scrotum and do^vn the thighs, it will be easier to make small pui^ctures in those parts to let out the air directly, than to press it along the whole body till it is brought up to the punctures made on the chest over the wounded part. 3d. If, notwdihstanding free punctures and pressing out the air in this way, you should find by the oppres- sion that either air or blood is accumulating within the cavity of the thorax, so as to oppress not the wounded lung only, which was of course collapsed and useless from the first, but the diaphragm, and through the diaphragm to affect also the sound lung ; then a freer incision must be made through the skin and muscles, and a small puncture should be cautiously made through ‘ the pleura, in order to let out the air or blood confined in the thorax.-^/o/in, Bell, op. cit. p. 278.) In all these cases copious and frequently repeated venesection is generally proper. After a few days the wound in the collap.sed lung is closed by the adhesive inflammation, so that the air no longer passes out of it into the cavity of the chest, and the outer wound may therefore be healed. W^hat air I is already there is ultimately absorbed, and the lung, expanding in proportion, resumes its original ftinctions. I [ The application of a bandage round the chest is some- ‘ times practised in cases of emphysema ; and its utility i when the ribs are broken has been highly spoken of by Mr. Abemethy. — “ Pressure by bandage (says he) not only hinders the air from diffusing itself through the cellular substance, but serves to prevent it from escaping out of the wounded lung, and of course facili- tates the healing of the wound, w-hich would be pre- vented by the constant transmission of air. Its early application, therefore, will often prevent a very trou- blesome symptom, while, at the same time, by keeping the fractured bones from motion it greatly lessens the sufferings of the p&lient.”— {Abemethy' s Surgical Works, vol. 2, p. 179.) Where emphysema is compli- cated with a fractured rib, the latter injury- is unques- tionably a reason in favour of a bandage. But whether the pressure of the roller will be useful or hurtful with respect to the emphysema itself, or the state of the lungs and respiration, may be questionable. As for its ten- dency to resist the diffusion of air in the common cellu- lar membrane, this circumstance does not appear to me important, because the air thus diffused, much as it disfigures the patient, is nearly harmless, at least as long as the interlobular texture of the lungs remains uninflated ; a danger also which no bandaging, as far as I can judge, has any tendency to prevent. Neither will a bandage have so much effect in hindering the diffusion of air eis scarifications, with this important additional consideration, that punctures or small inci- sions, made over the broken rib, prevent the spreading of the air by letting it escape, while a bandage can only do so by more or less resisting its escape from the cavity of the pleura ; which mode of operation in some cases w'ould dangerously interfere with the continua- tion of respiration by the lung of the opposite side. At the same time, I believe, that when the air extravasated within the injured side of the chest is not in such quan- tity as to oppress the sound lung, and a rib is broken, a bandage will generally afford great relief. Indeed, it is but justice to Mr. Abemethy to state, that he does not recommend the employment of a bandage in all cases of emphysema. “Patients (says he) will not always be able to wear a bandage w'hen one lung is • collapsed, particularly if any previous disease has ex- isted in the other, as it equally confines the motions of the ribs on both sides, and as every possible enlarge- ment of the chest becomes necess^' for the due admis- sion of the air into the lung which still executes its functions. Under these circufhstances, if the emphy- sema continues (and its continuance must alw'ays de- note that the w’ound in the lung is not closed), I should esteem it the best practice to make a small opening into the chest, so that the external air might have a free communication with that cavity ; and then the in- jured lung must remain motionless till its wound is healed, tmd the mediastinum will, in ever}- state of the thorax, preserve its natural situation.” — {JJbemethy, vol. cit. p. 183.) The utility of a free incision and scarifications is w'ell illustrated in a case recorded by Larrey. The emphysema arose from a wound of the lungs by a lance. The whole body w^as prodigiously swelled, the integuments so distended that the limbs were inflexible, the eyes buried, and the lips so enlarged that nothing could be introduced into the mouth. TTie pulse and respiration were scarcely perceptible, and the voice feeble and in- terrupted. The lance had entered obliquely under the lower angle of the scapula, and though the external and internal orifices of the wound were not parallel, the surgeon had applied adhesive straps, and closed the external one. Hence the air, as it escaped from the lungs, distended the cellular texture. Larrey im- mediately removed the dressings, and w’ith a bistoury made the openings in the pleura and skin parallel. Cupping-glas.ses were then applied over the wound, and quickly filled with air and blood. The lips of the wound were now brought together, and kept so w ith a suitable bandage. Cupping-glasses and scarificators w ere applied to various parts of the body, and in others incisions were made with a scalpel. The patient revX>- vered. — (See M m. de Chir. Militaire, t. 4.) Emphysema has been known to arise from the burst- ing of a vomica, and ulceration of the surface of the lungs ; but the air which escapes in this instance c.hu- not find its way into the cavity of the thorax, because the inflammation which precedes the abscess and ul- ceration of the air-cells clo.ses tho.se which are adja- EMPHYSEMA. 345 cent, and produces an adhesion of the edges of the vomica or ulcer to the inner surface of the chest, so as entirely to separate the two cavities. We are not ac- quainted with any instance of the symptoms imputed to the continement of air in the chest originating from suppuration and ulceration of the surface of the lungs ; but Palfyn, Dr. Hunter, and the author of the article Emphysema in the Encyclop die Mdthodique, partie Chirurgicale, have seen cases in which emphysema originated from abscesses of the lungs, attended with adhesion to the pleura, and ulcerations in the situation of such adhesion. In these instances, the pus having made its way through the pleura and intercostal mus- cles, the air escapes also through the same track, so as to pass into the cellular membrane on the outside of the chest. A violent effort of respiration has sometimes produced a certain degree of emphysema, which first makes its appearance about the clavicles, and afterward spreads over the neck and adjacent parts. The efforts of labour have been known to occasion a similar symptom ; but no bad consequences followed.— (MedtcaZ Communi- cations, vol. 1, p. 176 ; Blackden, in Med. Facts and Experiments, vol. 2 ; and Wilmer's Obs. in Surgery p. 143.) Louis has described an emphysema of tliis sort, which, on account of its cause, and the indication furnished by it to the practitioner, is highly important. It took place in a young girl, who died suffocated from a bean falling into her windpipe, and he considers it as a pathogno- monic symptom of such an accident, concerning the existence of which it is so essential not to commit any mistake. — (See Bronchotomy.) It made its appearance on both sides of the neck above the clavicles, and came on suddenly on the third day after the accident. Tite inspection of the body proved that the lungs and medi- astinum were also in an emphysematous state. The retention of the air, confined by the foreign body, pro- duced, says Louis, at each attempt to expire, and espe- cially when the violent fits of coughing occurred, a strong propulsion of this fluid towards the surface of the lung into the spongy substance of this viscus. Thence the air passed into the cellular texture which unites the surface of the lung to the pleura pulmonaris ; and by communications from cells to cells it caused a prodigious swelling of the cellular substance between the two layers of the mediastinum. The emphysema increasing, at length made its appearance above the clavicles. This tumefaction of the lung and surround- ing parts, in consequence of air getting into their spongy and cellulai texture, is an evident cause of suffocation, and the swelling seems so natural an effect of the pre- sence of a foreign body in the trachea, that one can hardly fail to think it an essential symptom, though no author has made mention of it. — {Mem. de VAcad. de Chir. t. 4, in 4to.) The emphysematous swelling, sometimes formed in the axilla in the reduction of a dislocated shoulder (see Dislocation), was accounted for by Desault and Bichat on the same principle as the foregoing case, viz. a rupture of one of the air-cells by the patient’s efforts to hold his breath during the reduc- tion of the bone. How far the explanation of the cause may be true has been questioned (see Diet, des Sciences Med. t. 12, p. 15) ; the fact itself admits of no doubt, and is both curious and interesting. The example lately recorded by Dr. Ireland as one of idiopathic emphysema following pneumonia, bears so strong a resemblance to the case above cited from M. Louis, that I cannot refrain from suspecting that it may have been one of the same nature. — (See Trans, of the King’s and Queen’s College of Physicians, vol. 3, art. 4.) An emphysematous swelling of the head, neck, and chest has also been noticed in typhoid fevers. Dr. Huxarn relates an instance of this sort in a sailor of a scorbutic habit . — {Medical Observations and Inquiries, vol. 3, art. 4.) Another example in a case of bilious fever is recorded in a periodical work — (See London Med. Repository, No. 73.) A case of spontaneous em- physema is likewise described by Dr. Baillie.— (See Trans, for the Imjrrove^ncnt of Med. and Chir. Know- ledge, vol. 1, p. 202.) A curious example of what has been called a spon- taneous emphysema is recorded by Mr. Allan Bums; “ The patient was a strong, athletic man, who, about six years previous to his application at the Royal In- firmarj', had received a smart blow on the neck from the keel of a boat. This injury was soon followed by the formation of a firm, tense tumour on the place which had been hurt. The swelling increased very slowly during the five years immediately succeeding its commencement', but during the sixth it received a very rapid addition to its bulk. At this time it mea- sured nearly six inches in diameter, seemed to be confined by a firm and dense covering, and the morbid parts had an obscure fluctuation. From the first to the last the tumour had been productive of very little pain. Judging from the apparent fluctuation that the tu- mour was encysted, it was resolved at a consultation to puncture the swelling, draw off its contents, and then pass a seton through it. By plunging a lancet into it, only a very small quantity of blood, partly co- agulated, and partly fluid, was discharged— a quantity so trifling that after its evacuation, the size of the tu- mour was not perceptibly reduced. A seton was passed through the swelling. At this time the man was in perfect health. About ten hours after the operation, the patient was seized with extremely violent rigors, followed by heat, thirst, pain in the back, excessive pain in the tumour, and oppressive sickness. An emetic was prescribed, but instead of producing vomiting it operated as a cathartic. To remove the irritation the seton was withdrawn. The pain in the tumour, however, and the general uneasiness continued to increase, and thirty hours subsequent to making the puncture, air began to issue from the track of the seton ; and afterward the cellular membrane of the neck, and of the other parts of the body in succession, became distended with a gaseous fluid. In the course of a few hours after the commencement of the general emphysema the man died. Twelve hours after death, when the body was free from putrefaction, it was inspected. The emphysema was neither increased nor diminished since death, and some idea may be formed of its extent, when the scro- tum was distended to the size of the head of an adult. Even the cavities of the heart, and the canals of the blood-vessels, contained a considerable quantity of air. We could discover no direct communication between the tumour and the trachea or lungs, although such was carefully sought for.”— (A. Burns on the Surgical Anatomy of the Head and Neck, p. 51 — 53.) From such cases we may infer, with the preceding writer, that from the mere rupture of a few of the bron- chial cells, occasioned by irregular action of the lungs, or by some other internal cause, a spontaneous diffu- sion of air may take place in the cellular texture of the body. Such examples are dependent on the same cause as the emphysema from injury of the lungs; only the rupture of the bronchial cells in the former cases is less obvious. A partial emphysema is sometimes seen in cases of gangrene. Here, however, it is hardly necessary to observe, the air is the product of putrefaction, and the disorder has not the smallest connexion with any in- jury, or disease of the air-cells of the lungs. ( That very extensive emphysema does occur during the parturient process, without fractured rib, or punc- tured wounds of the lung, is a fact familiar with every 01. stetric jiractitioner whose opportunities are consi- derable ; and it is equally well known, that this kind of emphysema is not attended with any dangerous conse- quences. It doubtless arises from a rupture of one or more of the air-cells by the efforts of the patient to hold her breath. In the Maryland Medical Recorder for January, 1830. a case of spontaneous emphysema is reported by Dr. Yeates, occurring in a child of 4 years old, which proved fatal in a few days. It is to be regretted that punctures and scarifications were not resorted to, re- liance being placed on ipecacuanha and squills, which failed to produce any impression on the stomach or the disease. Dr. .Jameson suggests that probably the dis- ease arose from an accidental opening of tlie bronchia and investing membrane of the lungs, by which the air escaped and thus found its way throughout the body. — Reese.] C. C. Pruysch, De Emphysemate. Haller, Disp. Chir. 2, 567. Hahe, 1733. H. A. Nies, De Miro Emphysemate, Mo.Duisb. ad Rheen. 1751. Hewson's Paper, in Med. Ob.servations and Inquiries, vol. 3. Mem. de I’ Acad. Royale des Sciences, for 1713. Dr. Hunter, in M L Ohs. and Jnquirie.s, vol. 2. Cheston, in Pathological 346 EMP EMP Inquiries. Abernethy's Surgical Works, vol. 2. Rich- ter, von der Windgeschwulst, in Anfangsgr. der Wun- darzneykunst, b 1, 451, A c. John Bell on WouJids, edit. 3, Edin. 1812. Halliday on Emphysema, 1807. Allan Bums on the Surgicd Anatomy of the Head and Neck, p. 52, u-c. Trans, of a Society for the Im- provement of Aledmal and Chir. Knowledge, vol. 1, p. 262. WilmeHs Observations in Surgery, p. 143. F. C. Waltz. De Emphysemate, ito. Lips. 1803. Riche- rand, Nosographie Chir. t. 4, p. 164, ^dit. 2. Lassus, Pathologic Chir. t.2,p. 321, ^-c. Mit. 1809. Diet, des Sciences M d t. 12, 7?. 1, A-c. J. Hennen, Principles of lALhtary Surgery, p. 376, edit. 2, Src. Edin. 1820. C. Bell. Surgical Obs. vol. 1, p. 161, A c. EMPLASTRUM AMMONI4CI CUM ACETO. R. Ammoniaci putiC | ij. Acidi acetici. ?iij. Ammo- niacum in ac«to liquefactu.n vapora in .ase ferreo ad emplastri crassitudinem. EMPLASTRITM AMMONIACI SCILLITICUM. R. Gumm. ammoniaci, |j. Aceti scilliiici, q. s. ut fiant emplastrum, quo pars affacta tegatur. Mr. Ford found this last plaster useful in some scro- fulous affections. If may be rendered more stimulating by sprinkling it with squills. — (Ford on the Hip-joint, p. 59.) It was recommended by Swediaur. — (London AJedical Journal, vol. 1, p. 198.) EMPLASTRUM AMxdOMACI CUM HYORAR- GYRO. Discutient. EMi^LASTRUM AMMONIACI CUM CICUTA. R. Gum. ammon. 3 iij. Extract! conii, 3 ij. Liq. plumb, acet. 3j. Dissolve the ammoniacum in a little vinegar of squills, then add the other ingredients, and boil them all slowly to the consistence of a plaster. Discutient. EMPLASTRUM AMMONL4E. R.Sapon. 3ij. Em- plastr. plumbi 3 ss. Ammon, rnur. 3j. The first two articles are to be melted together, and when nearly cold, the muriated ammonia, finely pow- dered, is to be added. This plaster stimulates the skin, excites the action of the absorbents, and disperses many chronic swellings and indurations. EMPLASTRU.M CANTHARIDIS. Bee Blister. EMPLASTRUM GALBANI COMPOSITUM. L. P. {Olim emplastrum lithargyri comp.) Properties dis- cutient. EMPLASTRUM HYDRARGYRI. L. P. {Olim emplastrum litharg. cum hydrargyro.) Properties dis- cutient. EMPLASTRUM PLUMBI. L. P. (Olim emplas- trum lithargyri cum resina.) The cormnon adhesive or sticking plaster. E.MPLA5TRUM SAPONIS. The plaster commonly used for fractures. It is also frequently applied to bruised parts, and to many indurations of a chronic nature. EMPYEMA. (From h, loithin, and rvov, pus, or matter.) A collection of purulent matter in the cavity of the chest. The ancients made use of the word “ empyema” to express every kind of internal suppuration. It wms .®tius who first restricted the term to collections of matter in the cavity of the pleura, or membrane lining the chest ; and all the best modern surgeons invariably attach this meaning alone to the expression. The operation for empyema properly means the making of an opening into the thorax, for the purpose of giving vent to the matter collected in the cavity of the pleura, though the phrase with several writers de- notes making an incision into the chest, in order to let out any effused or confined fluid, whether matter, blood, an aqueous fluid, or even air. The necessity of having recourse to such an operation, however, does not often present itself I would not wish to be suj)- posed to assert, that inflammation of the lungs, pleura, mediastinum, diaphragm, and even of the liver, does not sometimes terminate in suppuration. Certainly, the latter event is occasionally produced ; but w'hen it does happen, the matter does not always make its way into the cavity of the chest : frequently external ab- scesses form, or the pus is either coughed up, or dis- charged with the stools. Acute and chronic abscesses not unfrequentK form in the cellular substance between the pleura and the ribs and intercostal muscles. A swelling occurs be- tween two of those bones ; the skin does not undergo anv change of colour ; a fluctuation is distinguishable, a 1 sometimes an extensive cedema is observable. With respect to abscesses formed in the cellular substance connecting the pleura costalis to the inter- costal muscles, they rarely burst into the chest, the pleura always being considered thickened. However, in order to keep them from spreading extensively, as well as to obviate any possibility of their breaking in- wards, the best rule is to make an early and, if pos- sible, a depending opening. The motions of respi- ration then both promote the exit of the matter, as well as the coairaction of the cavity in which it wa* lodged ; and the disease, if unattend^ with canes, generally tenninares favourably. It often happens, however, that the ribs are carious, and then the cure is more tedious and difficult. A modem writer, indeed, informs us, that when the in- side of the rib is extensively carious, or when the caries is near the junction of the bone to the spine, the fistula is incurable. — {Lassus, Pathologie Chirurgicale, t. 1, p. 129, iulit. 1809.) On the other hand, another sur- geon of vast experience recommends us to endeavour to separate the diseased bone, either by cutting it away or emplo)ing the trepan. — {Pelletan, Clinique Chir. t. 3, p. 2.' 3.) Were a jiart of a diseased rib to admit of being sawed away, Mr. Hey's convex saw would be a more proper instrument for the purpose than a trepan. An abscess of the preceding kind may be so situated, and attended with such a pulsation, as greatly to re- semble an aneurism of the origin of the aorta. An in- tere.sting case of this description is detailed by Pelletan {Clinique Chir. t. 3, p. 254) ; and another was seen by Baron Boyer {Traite des Mai. Chir. t. 7, p. 333). When the surface of the lungs and that of the pleura costalis have become adherent to each other, in the situation of the abscess, so as to constitute what is termed encysted empyema, the pus, disposed by a law of nature to make its way to the surface of the body, generally occasions ulceration of the intercostal mus- cles, and collects on the outside of them. An abscess of this kind comes on with a deep-seated pain in the part affected ; an tedematous swelling, which retains the impression of the finger ; and a fluctuation, which is at first not verj- distinct, but from day to day be- comes more and more palpable ; and at length leads the surgeon to make an opening. If this be not done when the fluctuation becomes perceptible, the abscess may possibly insinuate itself into the cavity of the pleura, in consequence of the ad- hesion being in part destroyed by ulceration. Sabatier affirms that the case may take this course, even when the ab.scess has been punctured, and while a free ex- ternal opening exists; and this experienced surgeon has adduced a fact in confirmation of such an occur- rence. — (See Mcdecine Operatoire, tom. 2, p. 249.) In a few' instances, the surface of the lung ulcerates, and the matter is voided from the trachea. But in the majority of examples, the pus makes its way outw ards through the pleura costalis. If inflammation occurs in the anterior mediastinum, and ends in suppuration, the abscess ma;- possibly burst imp neither of the cavities of the chest, but make its way outwards, after render- ing the sternum carious, as happened in the example recorded by Van Sw'ieten. — {Comment on BoerhaavRs 895th Aphorism.) But though collections of matter in the anterior me- diastinum are influenced by the general law, whereby abscesses in general tend to the surface of the body, and though it be true that they rarely burst inwardly into the cavity of the pleura, the contrary may happen, as is proved by the 9th case in La Martini^res’s me- moir on the operation of trepanning the sternum. Here the event was the more extraordinary, as there was already an external opening in the abscess. External injuries, such as the perforation of the ster- num with a sword {Vanderwel, Obs. 29, Cent. 1), a contusion, a fracture, or a caries of this bone may give rise to an ab.scess in the anterior mediastinum. Galen has recorded a memorable example, where the abscess was the consequence of a wound of the fore part of the chest. After the injury, which was in the region of the sternum, seemed quite well, an abscess formed in the same situation, and being opened healed up. The part, however, soon inflamed and suppurated again. The abscess could not now be cured. A consultation was held, at which Galen attended. As the sternum was obviously carious, and the pulsation of the heart was visible, every one was afraid of undertaking the ■ treatment of the case, since it was conceived t^i it EMPYEMA. 347 ■would be necessary to open the thorax itself. Galen, however, engaged to manage the treatment, without making any such opening, and he expressed his opinion that he should be able to effect a cure. Not finding the bones .so extensively diseased as was apprehended, he even indulged considerable hopes of success. After the removal of a portion of the bone, tne heart was quite exposed (as is alleged), by reason of the pericardium having been destroyed by the previous disease. After the operation, the patient experienced a speedy recovery. J. L. Petit met with an abscess in the anterior me- diastinum, in consequence of a gun-shot wound in the situation of the sternum. The injury had been merely dressed with some digestive application ; no di- latation, nor any particular examination of the wound had been made. The patient, after being to all ap- pearance quite well, and joining his regiment again, was soon taken ill with irregular shivcrings, and other febrile symptoms. Petit probed the wound, and found the bone affected. As there -was a difficulty of breath- ing, he suspected an abscess either in the diploe or be- beliind the sternum ; and, consequently, he proposed laying the bone bare and applying the trepan. The operation gave vent to some sanions matter ; and as soon as the inner part of the sternum was perforated, a quantity of pus was discharged. The patient was ■relieved, and afterward recovered.— Traite des Mai. Chir. t. p. 80.) Another instance, in which an abscess behind the sternum was cured by making a perforation in that bone opposite the lower part of the cavity in which the matter collected, is recorded by De la Martinidre. — {Mdm. de I'Acad. de Chir. t. 12, idit. 12/rto.) When, in consequence of inflammation, an abscess forms deeply in the substance of the lungs, the pus more easily makes its way into the air-cells, and tends towards the bronchi®, than towards the surface of the U’lgs. In this case the patient spits up purulent mat- ter. When the opening by which the abscess has burst Internally is large, and the pus escapes from it in con- siderable quantity at a time, the patient is in some dan- ger of being suffocated. However, if the opening be not immoderately large, and the pus which is effused be not too copious, a recovery may ensue. Abscesses in the substance of the diaphragm, and collections of matter in the liver may also he discharged by the pus being coughed up from the trachea, when the parts af- fected become connected with the lungs by adhesions, and the abscesses of the liver are situated on its con- vex surface. When the collection of matter in the liver occupies any other situation, the abscess fre- quently makes its way into the colon, and the pus is discharged with the stools. Several cases of this kind are related by authors ; Sabatier has recorded two in his M dicine Operatoire, Le Dr.an makes mention of others, and Pemberton, in his book on the Diseases of the Abdominal Viscera, p. 36, relates additional in- stances of a similar nature. I shall now proceed to the consideration of empyema strictly so called. Sometimes it is a consequence of a penet rating wound of the chest ; occasionally it pro- ceeds from the bursting of one or more vornic®; in a few examples it arises from the particular way in which abscesses of the liver burst {Journ. de MM. t. 3, p. 47 ; M'irqagni, epist. 30, art. 4 ;) but in the greater number of instances it originates from pleuritic inflammation, especially that of the chronic kind. — {Boyer, Traite des Mai. Chir. t. 7, p. 352.) Empyema very rarely take-s place in both sides of the chest, but is almost always limited to one cavity of tVe pleura. According to Baron Boyer, when empyema arises from thoracic inflammation, pleuritis, or pneumonia, the symptom.s characterizing it are always preceded by those of the disease, of which the effusion of pus upon the diaphragm is the effect. Inquiry must, therefore, be made whether the patient has fdeurisy or peripneu- inony, the symptoms of which have lasted longer than a fortnight ; and whether, after a transient amendment, there have been frequent shiverings, followed by a low, continued fever, with nightly exacerbations. Now, these first circumstances justify the belief, that the in- fl imrnatory disorder has terminated in suppuration, and that the symptoms afterward experienced depend upon elfusioTi of matter in the chest. Some of these arise from tlie mechanical action of the pus upon the lungs, heart, and parietes of the chest, and belong also to other efthsions in the thorax ; the rest may be said to be the effects of ulceration and suppuration of the parts on the animal economy, and, therefore, parti- cularly belong to empyema. First, of the common symptoms, respiration is diffi- cult, short, and fteqhent ; the patient suffers great op- pression, and experiences a sense of suffocation, and of weight upon the dia phragm. He cannot move about, even for a short time, without being quite out of breath, and threatened with syncope. He has an almost in- cessant and very fatiguing cough, which is sometimes dry, sometimes attended with expectoration.— (Boyer, Traite des Mai Chir. t. 7, p. 356.) No surgical writer with whom I am acquainted has treated with more discrimination than Mr. Samuel Sharp, of the symptoms produced by collections of matter in the chest. He remarks, that it has been al- most universally taught, that when a fluid is extrava- sated in the thorax, the patient can only lie on the dis- eased side, the weight of the incumbent fluid on the mediastinum becoming troublesome, if he places him- self on the sound side. For the same reason, when there is fluid in both cavities of the thorax, the patient finds it most easy to lie on his back, or to lean for wards, in order that the fluid may neither press upon the mediastinum nor the diaphragm. But it is noticed by Mr. Sharp, that however true this doctrine may prove in most instances, there are a few in which, not- withstanding the extravasation, the patient does not complain of more inconvenience in one posture than another, nor even of any great difficulty of breathing. —(See Le DratVs Ohs. 217, and Marchetti, 65.) On this account, ob.serves Mr. Sharp, it is sometimes less easy to determine when the ojieration is requisite, than if we had so exact a criterion as we are generally sujiposed to have. But, says he, though this may be wanting, there are some other circumstances which will generally guide us with a rea.soriable certainty. He states, that the most infallible symptom of a large quantity of fluid in one of the cavities of the thorax, is a preternatural expansion of that side of the chest where it lies; for, in proportion as the fluid accumu lates, it will necessarily elevate the ribs on that side, and prevent them from cciitractiiig so much in expira- tion as the ribs on the other side. This change is said to be most evident when the surgeon views the back of the chest.- (Boyer, vol. cit. p. 357.) Mr. Sharp also re- fers to Le Bran's Obs. 211, vol. 1, in order to prove that the pre.ssure of the fluid on the lungs may sometimes be so great, as to make them collapse, and almost totally obstruct their function. When, therefore, says Mr. Sharp, the thorax becomes thus expanded after a pre- vious pulmonary disorder, and the case is attended with the symiitoms of a suppuration, it is probably owing to a collection of matter. The patient, he observes, will also labour under a continual low fever, and a particular anxiety from the load of fluid. Besides this dilatation of the cavity by an accumula tion of the fluid, the patient will be sensible of an un- dulation, which is sometimes so evident, that a by slander can plainly hear it in certain motions of the body. Mr. Sharp adds, that this was the case with a patient of his own, on whom he performed the opera- tion ; but the fluid in this instance, he says, was very thin, being a serous matter rather than pus. Some- times, ■when the practitioner applies his ear close to the patient’s chest, while this is agitated a noise can be heard like that produced by shaking a small cask not (juite full of water.— (See Dr. Archer's Case.^ in Trans, of the Fellows, A c. of the King's and Queen's College of Physicians in Ireland, vol. 2, p. 2.) In this instance the fluid resembled whey. According to the same author it will also frequently happen, that though the skin and intercostal muscles are not inflamed, they will become oedematous in certain parts of the thorax ; or, if they are not tedeiiiatoiis, they will be a little thickened ; or, as Boyer states, the inter- costal sjiaces are widened, and, when the empyema is considerable, instead of being dejiresscd, as they are in thin persons, they project beyond the level of the ribs. —{Mai. Chir. t. 7, p. 357.) These symptoms, joined with the enlargement of the thorax, and the preceding affection of the pleura or lungs, seem unqucstionatdy to indicate the projiriety of the oiieraiion. But, observes Mr. Sharp, among other motives to recommend it upon such an emergency, this is one, that if the ojierator should mistake the case, an incision of the intercostal muscles would neither be very paintXil nor dangerous.— (See 348 EMPYEMA, Critical Inquiry into the Present State of Surgery, sect, on Empyema.) “ The difficulty of lying on the side opposite to the .collection of pus,” says Le Dran, “ is always accounted a sign of an empyema. This sign, indeed, is in the af- firmative; but the want of it does not prove the nega- tive ; because, when there is adhesion of the lungs to the mediastinum, the patient may lie equally on both sides .” — {Le Dran's Obs. p. 108, edit. 2.) The expla- nation of this circumstance offered by Le Uran is, that when the cyst, in which the matter is contained, is between the mediastinum and the lungs, the medias- tinum gradually yields to the volume of the pus in proportion as it is formed, and the cyst in which it is contained becomes dilated ; “ whence habitude becomes a second nature.” Whereas, in an empyemal person, in whom the lung is not adherent to the mediastinum, and who lies on the side opposite to that on which the collection of pus is situated, the mediastinum is on a sudden loaded with an unusual weight of fluid. — (P. 111 .) Richerand contends, that the difficulty of breathing which patients with extravasated fluid in the chest ex- perience in lying upon the side opposite to that on which the disease is situated, never originates, as has been commonly taught and believed, from the fluid pressing upon the mediastinum and opposite lung. •“ I have (says he) produced artificial cases of hydro- thorax, by injecting water into the thorax of several dead subjects, through a wound made in the side. This experiment can only be made on subjects in which the lungs are not adherent to the parietes of the chest. In this way from three to four pints of water were in- troduced. I then cautiously opened the opposite side of the chest ; the ribs and lungs being removed, the mediastinum could be distinctly seen, reaching from the vertebr® to the sternum, and supporting, without yield- ing, the weight of the liquid, in whatever position the body was placed. It is evident, then, that patients with thoracic extra- vasations lie on the diseased side, in order not to ob- struct the dilatation of the sound side of the respiratory- organs, one part of which is already in a state of inac- tion. It is for the same reason, and in order not to in- crease the pain by the tension of the inflamed pleura, that pleuritic patients lie on the diseased side. The same thing is observable in peripneumony ; in a word, in all affections of the parietes of the chest. — {Riche- rand, Nosogr. Chir. t. 4, p. 168, 169, edit. 2.) It appears to me, that there may be some truth in the foregoing statement ; but the experiments are far from being conclusive with respect to the assertion, that in cases of empyema, hydrothorax, &c. the fluid on one side of the chest does not compress the opposite lung. In the first place the quantity of fluid is frequently much larger than that which Richerand injected. Secondly, although the mediastinum may not be apt to yield at once to the weight of a liquid suddenly injected into one side of the thorax, yet it may do so by the gradual effect of disease. Thirdly, many of the pheno- mena of empyema seem adverse to Richerand’s infer- ence. Although surgeons should be aware, that patients with empyema can sometimes lie in any position, with- out particular aggravation of the difficulty of breathing, yet it ought to be distinctly understood, that the gene- rality of patients with this disease cannot place them- selves on the side opposite to that on which the collec- tion of pus is situated, without their respiration being ■very materially obstructed. Another circumstance also which deserves to be mentioned while we are treating of the symptoms of empyema is, that the oedema of the integuments is sometimes not confined to the thorax, but extends to more remote jiarts, on the same side of the body as the collection of matter. Both the forego- ing remarks are confirmed by an interesting case which was published by Mr. Hey. Sept. 3, 1788, Mr. Hey was desired to visit John Wil- kin.son, who had been ill ten days of the influenza. The patient was found labouring under a fever, attended with cough, difficulty of breathing, and pain in the left side of the thorax. He was bled once, blisters were repeatedly applied to the chest, and he took nitre and antimonials, with a smooth linctus to allay his cough. “ He was repeatedly relieved by these means, espe- cially by the apiilication of the blisters ; but repeatedly relapsed. At last he became so ill, that he breathed with the utmost difficulty, and could not lie on the right side without danger of immediate suffocation.” Mr. Hey found the patient in the state just now de- scribed on the 17th of September. “ His face, and es- pecially his eyelids, were a little swollen on the left side.” The left side of the thorax was larger than the right, and its integuments were cedematous. Upon pressing the intercostal muscles, they felt distended ; they yielded a little to a strong presstu-e, but rebounded again. The abdomen, especially at its upper part, ap- peared to be fuller than in the natural state. — (See Hey's Practical (%s. in Surgery, p. 476.) This last symjjtom is also particularly noticed by Boyer. — {Mol. Chir. t. 7, p. 357.) Another remarkable symptom which is occasionally produced by collections of matter in the chest, is an alteration in the position of the heart. 1 have seen a patient in St. Bartholomew’s Hospital, who had so large a quantity of matter in the left bag of the pleura, that it completely displaced the heart, which pulsated against the inside of the chest at a considerable dis- tance to the right of the stei-num. This man’s life might perhaps have been saved had paracentesis tho- racis been performed in time. Some suspected an aneurism from the throbbing on the right of the ster- num : and the case was not fully understood till after death, when the body was opened. A little attention to the symptoms, however, might have convinced any man of moderate understanding, that it was an empy- ema, and that making an opening for the discharge of the matter afforded the only rational chance of pre- serving life. There had been pain and inflammation in the chest, followed by shiverings ; there was very great difficulty of breathing ; the heart, which pre- viously used to beat in the usual place, no longer did so ; but now pulsated on the right side of the thorax. That the heart should be displaced in this manner by any large collection of fluid in the right cavity of the thorax, one would naturally expect ; but it is an occur- rence that has not been much noticed by surgical wri- ters. Baron Larrey, however, has related a higlily in- teresting case, where the heart was not only pushed considerably to the right of the sternum, but its action was so much impeded by the derangement of its posi- tion, that the pulse in the large arteries was thereby rendered extremely feeble. In this instance, also, the diaphragm had descended so low down as to force some of the small intestines into the cavity of the pelvis. — {M^oires de Chirurgie Militaire, t. 3, p. 447, Ac.) Pelletan has also recorded an example in which a collection of fluid in the left cavity of the chest dis- placed the heart, the pulsations of which were per- ceptible between the third and fourth ribs of the right side, near the sternum . — {Clinique Chir. t. Z,p. 276.) Baron Boyer speaks of one case in which the displace- ment of the heart was so extensive that its pulsations were felt near the right axilla . — {Traits des Mai. Chir. t. 7, p. 357.) In the anatomical collection at Strasburg is also a preparation exhibiting the displace- ment of the heart into the right side of the chest, by matter in the left pleura, the left lung being nearly an- nihilated. — {Lohstein, Compte de son Museum Anat. p. 39, Hvo. 1820.) The heart is sometimes thrust downwards by collections of fluid in the chest, and its pulsation is distinguishable in the epigastrium. — {Hodgson on the Diseases of Arteries and Veins, p. 95.) When the cavity of the pleura contains fluid, and the surgeon strikes the thorax repeatedly with the ends of his fingers, a dull sound is said to be produced, quite different from what would occur were the chest in its natural state. But, as Boyer remarks, this symptom, to which so much importance has of late been attached, being common to extravasations in the thorax and several other diseases, will not denote em- pyema, unless combined with other signs of this af- fection. Nor will any useful information be derived from the above percussions, except the practitioner has had a good deal of experience in them, and they are repeatedly practi.sed with the patient in difl'ercnt posi- tions. — {Mai. Chir. t. 7, p. 357.) The symptoms of empyema are frequently very equivocal, and the existence of the disease is generally somewhat doubtful. Panarolius opened a man whose left lung was destroyed, at the same time that the thorax contained a considerable quantity of pus. .Al- though the patient had been ill for two months, he had EMP ENC 349 unffercu ilo difficulty of breathing, and had had only a slight cough. Le Dran met with a case of nearly the same kind. A patient who had been for three days af- fected with a considerable oppression and an acute pain on the left side of the chest, got somewhat bet- ter. He felt no material difficulty of breathing on whatever side he lay. The only thing which he com- plained of, was the sense of a fluctuation in his tho- rax, and a little obstruction of his respiration when he was in a sitting posture. These symptoms did not seem sufficiently decided to justify the operation, and it was delayed. The febrile symptoms continued, with cold sweats, and the patient died on the eighth day. Five pints of pus were found collected in the chest. — (See Le Dr art's Observations in Surgery, p. 109, 110, edit. 2.) The symptoms more particularly depending upon empyema itself, that is to say, upon the disease and suppuration within the chest, are nearly the same as those which accompany all large deep-seated ab- scesses. The fever attending the thoracic inflarrtraa- tion which ends in suppuration, gradually diminishes, but does not entirely cease. On the contrary, it soon changes into hectic, attended witlL flushings of the cheeks, heat of the palm of the hands, and exacerba- tions every evening and after meals. In the night, the upper parts of the body are covered with perspiration ; the patient is tormented with insatiable thirst ; his ap- petite quite flails ; his debility becomes extreme ; he is suhjpct to frequent fainting fits ; diarrhcea ensues ; and the ii :. r nails become curved, shining, and of the yel- low til iTe observable all over the body. At length the utmost emaciation and the facies Ilippocratica come on, frequently attended with dilated pupils and enfeebled vision, and indicating the approach of death. As the operation of empyema and some other par- ticulars relating to this subject, are treated of in an- other part of tms Dictionary (see Paracentesis of the Thorax), it will only be necessary for me here to^sub- join a list of works, which may be advantageously consulted for information on empyema. A. Vater, et J. E. Mutillet, Empyema, e vomica pulmonis, rupta in cavitatem pectoris dextram effusa, indeqv.e pulmo hujus lateris compressus petiitusque ab officio remo- tus, Wittemb, 1731. — (^Haller, I)isp. ad Morh. 2, 4031.) Gerardus le Maire, Diss. de Empyemate, 4vork. For the erythema mercuriale, see Mercury. The tenh is often wrongly applied to eruptions attended with redness, and distinct papular and vesicular eleva- tion, as we see in the instance of mercurial erythema, which Dr. Bateman says should be named eczema. [From the extraordinary use and consequent abuse of mercurial remedies, which, I regret to state, too much characterizes the practice of many of the medical pre- scribers of this country, I am induced to add a remark jor two on this very interesting disease. The erythi- mus arising from mercury, which has received several different names by different authors, as the hydrargj ria of Alley, the eczema mercuriale of Pearson, the erythe- ma mercuriale of Spens, the mercurial lepra of Mori- arty, &c., is sometimes compounded with other disor- ders of an eruptive character, supposed to arise from a syphilitic origin. But in adverting to the various causes which exert their influence in producing affec- tions of the skin resembling that under notice, we must not omit to remember the modifying operation of a cachectic condition of the body, and that, independently of mercury, occasionally other agents are capable of producing like morbid appearances. These disordered changes are often difficult to discriminate, and can per- haps only be known by the history of the case, and by a course of experimental treatment. Mr. Carmichael has well pointed out that diseases likely to be con- founded with syphilis, which arise spontaneously from a disordered state of the constitution, frequently as- sume the form of the tubercular eruption, and he adds, “ before ulceration occurs I have seldom been able to distinguish this spontaneous disease from that arising from a venereal infection.” Hence, while in the mercu- rial erythema mercury will often aggravate the evil ; in that species of affection which occurs spontaneously we may derive the greatest benefit from mercurials. Moreover, in that which has taken place in the syphi- litic habit, mercury may do much harm from the pre- vious injudicious use of this remedy. Hence, too, Bate- man has given us an excellent history of a tubercular eruption of a syphilitic appearance, but curable with- out mercury, — (See Medico-Chirurg. Trans, vol. 5.) The history of the mercurial eczema is perhaps best given us by Pearson. Examined by the magnifying- glass, the eruption appears distinctly vesicular, though by the naked eye they can scarcely be distinguished. Notwithstanding the observation of Mr. Pearson, the disorder sometimes proves fatal, and Alley tells us that of forty-three cases which he witnes.sed within ten years eight patients died. The morbid effects of mercury do not seem to depend upon the quantity gi- ven or the preparation administered. The mercurial erj'thema may arise from calomel or corrosive subli- mate, from a few grains of the former as well as from a few drops of a solution of the latter. Hence every practitioner is aware bow serious are at times the mis- chiefs of the mildest mercurial preparations, even in small doses, in some constitutions ; and the same re- mark applies to the mercurial force that is requisite in inducing salivation. From a careful examination of the recorded cases of the mercurial erythema. Professor Francis gives it as his result, that the disease is of more frequent origin from the external application of mercury than from its internal administration, and in- asmuch as unguents are most frequently applied inside of the thighs, so we find the disorder very commoidy to commence at tho.se parts. Mr. Carmichael has done great public service by the facts and reasonings with which he has set forth the advantage of antimonials in the mercurial erythema, and accordingly the Plum- mer's pill is in some degree restored to favour again. Small doses of the antimonium tartarizatum are also among the best alteratives for the mercurial erythema, and these are to be given for sometime with occasional 1 intemitHsions. We are to keep in mind the singular 1 occurrence that in some constitutions antiinonir.l.'; will , excite the salivary discharge, as remarked by Dr. Fran- cis ; yet this circumstance, of rare occurrence indeed, may be considered as the occasional cause of a more speedy cure. The pulvis ipecacuanha in doses of two or three grains is also serviceable. It may be here stated that a decoction of parsley (ap rim petroeh/mrn) has some- times been of service as a lotion for the erythema mer- curiale; It was the favourite prescription in these cases of a distinguished southern practitioner, who was re- markably successful in the treatment of this disease ; and the remedy has proved efficient in other hands. A weak solution of the chloruret of lime will often induce a most salutary change.— Reese.] ESCHAR. (From iaxapow, to fonn a scab or crust.) This tenn is applied to a dry crust, Ibrined by a portion of the solids deprived of life. When any living part has been burned by the actual or potential cautery, all that has been submitted to the action of this applica- tion loses its sensibility and vital principle, becomes hard, rough on the surface, and of a black or gray co- lour, forming what is properly named an eschar, a slough, produced by caustics or actual fire. ESCHAROTICS. (From iaxapdio, to form a crust over.) Applications which form an eschar, or deaden the surface on which they are put. By escharotics, however, surgeons commonly understand the milder kinds of caustics, such as the h ydrargyri nitrico-oxy- dum, subacetate of copper, ' large mass of car- tilage is formed, elastic, firm, and fibrous.” It is not malignant, but often ends in a very extensive disease. — {Surgical. Essays, part 1, p. 173.) In other instances the tumour is perfectly solid, ex- ceeding in consistence that of the hardest bones, and equalling that of ivory. Here the surface is sometimes smooth, and like that of the bone in its natural state ; sometimes irregular, full of little projections, and in some degree stalactical. It is very uncommon to find a large portion of an exostosis converted into a pultace- ous substance ; but it is not at all unfrequent to see this substance composing part of the tumour. Lastly, it very often happens that the same exostosis presents an assemblage of the ivory substance, and of the cellular laminated substance, the cavities of which are partly filled vrith a pultaceous matter, and partly with a sort of gelatinous substance. When an exostosis is not very large, it hardly affects the surrounding soft parts ; but when it has made con- siderable progress, the muscles become stretched and emaciated, the cellular substance is thickened, and its layers being adherent together, a kind of confusion is produced among all the adjacent parts. Exostoses not of considerable size may, hov\’ever, seriously interrupt the functions of certain organs. The action of the flexor muscles of the leg has been known to be obstructed by an exo.stosis in the vicinity of the knee. A similar tu- mour arising near the symphysis pubis need not be very large to impede considerably the functions of the ure- thra. as experience has proved. An exostosis in the orbit has been known to displace the eye and to destroy vision. Lastly, exostoses, when situated near certain important organs, and of large size, may affect with dif- ferent degrees of gravity the functions of these parts, as the brain, the lungs, &c. — (See Boyer, Traite des Mai. Chir. L3, p. 541—544.) Sir Astley Cooper has related a case in which the eyes were pushed out of their sockets by two exostoses, wliich grew from the antra, and one of which destroyed the patient by making its way to the brain through the orbitar process of the os frontis. — {Surgical Essays, part 1, p. 157.) In one instance, reported by the same author, an exostosis from the sixth or seventh cervical vertebra abolished the pulse at the wrist, by pressing u]K)n the subclavian artery.— (P. 159.) In another, a cartilaginous exostosis of the medullary membrane of the lower jaw extended so far back that it pressed the epiglottis down upon the rima glottidis, and caused such difficulty of respiration, and so much irritation, that the patient was destroyed.— (P. 175.) Venereal exostoses, or nodes, are observed to ari.se chiefly on compact boties, and such of these as are su- perficially covered with soft parts, as for instance the bones of the cranium, and the front surface of the tibia. The causes of exostosis do not seem to be at all under- stood. Most writers impute the list-ase to internal causes, such as scrofula and lues ' > h That the latter affection is the cau.se of nodes, w . e certainly a species of exostosis, no one will deu} tl; * scro- fula is ever concerned in producing any h- 'her kinds of exostosis must not be admitted, at 1. -it bt 'ore some evidence is adduced in support of the doctrine. Boyer, however, and all the surgeons of the oontincui EXOSTOSIS. 363 adopt the opinion that scrofula is sometimes a cause of the disease. Hydatids are occasionally found within exostoses, in which circumstance the former are supposed to be the cause of the enlargement of the bone. A remarkable specimen of such a disease in the tibia is mentioned by Sir Astley Cooper. — {Surgical Essays, part 1, p. 163.) He refers also to a humerus, in the museum of St. Tho- mas’s Hospital, where the shell of the bone is consider-, ably expanded, the iteriosteum over it thickened, and in the seat of the cancellated structure, several hydatids, supposed to have been the cause of the enlargement of the e.xlerior surface of the bone, as well as of the increase of its cavity. — {VoL cit. p. l&l.) A most interesting case of a bony tumour on the forehead, containing hyda- tids, has likewise been published by Mr. R. Keate. — {Med. Chir. Trans, vol. 10, p. 278.) The ease with which bony tumours form in some persons, is a curious and remarkable fact, and renders it probable that constitutional causes here have great induence. Thus such a blow as in the generality of persons would hardly excite notice, will in others bring on swellings of the bone which is struck. Sir Astley Cooper adverts to a young friend of his, in whom an exostosis, which was undoubtedly caused by a blow, is growing on the metacarpal bone of the little finger. — (Loc. cit.) Mr. Abernethy mentions in his lectures his having seen a boy from Cornwall, who was so exces- sively afflicted with an apparent predisposition to exos- tosis, or an exuberant deposition of bony matter, that a very trifling blow would occasion a bony swelling on any bone of his body. His ligamentum nuchae was os- sified, and prevented the motion of his neck ; the mar- gins of his axillae were also ossified, so that he was, as it were, completely pinioned. Besides all this, the sub- ject in question haa numerous other exostoses on va- rious parts of his body. Mr. Abernethy gave, in this case, muriatic and acetic acids, with a view of dissolv- ing the lime, which it was conceived might be too abundant in the system ; but even if this theory had been correct, and the acids capable of the chemical ac; tion intended, after passing into the circulation, how could they be expected to dissolve only the redundant depositions of phosphate of lime, and at the same time leave the skeleton itself undissolved ? When an exostosis depends upon lues venerea, it is almost always preceded by an acute pain, which in the beginning extends to nearly the whole of the affected bone; but afterward becomes fixed to the point where the exostosis forms, and it is most severe in the night- time. When an exostosis is caused by scrofula, says Boyer, the pain is duller, or rather it is quite inconsider- able. It is the same with the exostosis which succeeds a blow or contusion, without any manifest general cause. In the latter example the pain immediately ex- cited by the accident subsides in a few days, and the swelling occurs so slowly, that no notice is taken of it till It has attained some magnitude.— (Traffe des. Med. Chir. t. 3, p. 515.) An exostosis constantly feels hard ; but its size is va- rious, and it may be indolent or painful. By these signs, and its firm adhesion to the bones, it may be always distinguished from other tumours. Some exostoses cannot be ascertained before death. Such was the case in which the parietal bone was found, after death, to be throe times thicker than natural. Such also was the exarnble related in the memoirs of the Academy at Di- jon, in which a person died from an exostosis on the internal side of the os pubis, the tumour having pre- vented the discharge of the urine and the introduction of a catheter by its pressure on the neck of tlie bladder. Exostoses may be either acute or chronic in their progress. In the first ca.se, which, according to Boyer, hapi)ens most commonly in the cellular exostosis, de- scribed by authors under the name of laminated, the appearance and formation of the tumour are quick ; tlie swelling rapidly acquires a considerable size, and it is always i)receded by and accornparned with continual violent i)ain, which the external and internal use of opium has little effect upon, and the intensity of which is not increased by pressure. The pain is sometimes so severe that it occasions a good deal of symptomatic fe- ver. Boyer, who seems not be aware of the origin of what he terms the cellular, and what Sir Astley tloojier has named funy,ov.s exostosis, from the medullary membrane, finds difiiculty in accounting for the rapid grounli and great sensibility of the tumour, considering the natural density of the bones, and the little energy of their vital properties. In the hardest kinds of exostosis, says Boyer, the tu- mour is preceded by no pain, or, if any, it is very slight ; the tumour grows slowly, and although it sometimes attains a considerable size, its increase is attended with no particular sensibility, and no disturbance of the ani- mal economy.- {Boyer, op. cit. t. 3, p. 546.) Our ignorance of the pathology of exostoses, particu- larly their causes, accouiits for the imperfection of our treatment of them. With the exception of the vene- real exostosis, or node, there is no species of this affec- tion, for which it can be said that we have any one me- dicinq of efficacy. * Boyer and other writers on the diseases of the bones seem to regard some exostoses as a perfectly inorganic mass of lime, and consequently they entertain no idea that the absorbent vessels can possibly take away the particles of the tumour, just as the secerning arteries have laid them down. Such WTiters, however, are well aware, that nodes are capable of being fflmi- nished, and this can only be efiected by the action of the absorbent system. Boyer does acknowledge, indeed, that he has seen a venereal exostosis of the humerus, as well as a few other bony swellings, subside ; but he represents the event as extremely rare ; and he advances it as a prin- ciple, that the resolution of exostoses hardly ever hap- pens, and that the greater part of the examples recorded in proof of the occurrence, were nothing more than pe- riostoses.— (P. 547.) When an exostosis is hard, chronic, and free from pain and alteration of the structure of the bone, it is a much more common thing for it to cease to enlarge, and remain stationary during life, without producing incon- venience, provided it be so situated as not to impede the functions of any vital organ. But in the cellular exostosis of Boyer, which I take to be the same disease as the fungous exostosis of the medullary membrane of Sir Astley Cooper, the acute and rapid progress of the disease indicates a deeper and more serious alteration of the texture of the bone. A part of the tumour usually consists of a pultaceous or gelatinous matter, and the rest still, endued with its na- tural organization, though altered by the disease, soon presents one or several cavities, in which there is sup- puration. At the same time, the external soft parts, being excessively and rapidly distended, inflame, ulcer- ate, and leave exposed a more or less extensive portion of the tumour, the disease of which has in many cases been very wrongly supposed to be caries. It is not, ob- serves Boyer, that the part of the swelling denuded by ulceration is not sometimes affected with caries ; but then it exists as a complication of the original disease, and as a particularity by no means the result of the ul- ceration of the soft parts, and of the exposure of the diseased bone to the contact of the air. When the soft parts are thus ulcerated, the opening contracts to a cer- tain point, and becomes fistulous. The suppuration is always of bad quality, and in a quantity proportioned to the size of the cavity of the abscess and the strength of the patient. The fever, w'hich commences at an early period of the disorder, assumes a slow type, and its continuance, together with the copiousness of the ichorous discharge, the irritation, &c., may bring on the patient’s dissolution. The following are the symptoms of what Sir Astley Cooper denominates the fungous exostosis of the me- dullary membrane. The disease begins v/ith a general enlargement of the affected part of the hmb, extending a considerable way around the scat of the exostosis it- self. This form of the complaint mostly occurs in young persons, though Sir Astley Cooper has seen it in an individual fifty years old. “ Its increa.se pro- ceeds very gradually ; and even when it has acquired considerable magnitude, although it produces some di- minution of motion in the limb, it does tiot occasion pain, nor prevent the patient from using it. When any pain does arise, it is of an obtuse kind, only being acute in the event of a nerve being stretched by the tumour. Thus an exostosis of the thigh-bone some- times causes great agony, by pressing on the sciatic nerve. Paleness, debility, and irregularity of the bowels, are observed to attend the early stage of the disease ; and afterward the conqilexion becomes sal- low. In the mean time the diseased part of the limb attains an enormous size ; but the skin retains its natu- 364 EXOSTOSIS, ral colour. At many points the swelling feels hard ; at others, it is so elastic as to cause the presence of fluid to be suspected; but if an opening be made, only blood IS discharged. The surface of the tumour next becomes tuberculated, and the prominences tender, and their surface is often slightly inflamed. The rest is now broken, the appetite impaired, and the bowels ex- tremely irregular. At length the tubercles ulcerate ; the skin secretes pus ; but when the swelling itself is exposed, it discharges a bloody-coloured serum. A fungus then forms, w'hicli sometimes bleeds pro- fusely, and after it has risen very high, sloughing oc- curs, and considerable portions of the swelling are thrown off. But although the swelhng may be les- sened by this process. Sir A. Cooper has never known the disea.se cured by it ; and in the end the patient is destroyed by the effects of the repeated bleeding, im- mense discharge, and constitutional irritation.” In this disease, as in common fungus hacmatodes, tu- mours of a similar nature are often formed in other parts of the body, and after the amputation of the af- fected bone frequently make their appearance in organs of the greatest importance to life. The swelling is de- scribed as originating from the medullary membrane, and as removing the muscles to the distance of three inches or more from the bone, so that they represent a thin layer spread over the tumour. The blood-vessels and large nerves are also similarly displaced. The tu- berculated appearance of the skm, which is itself sound, is caused by projecting small masses on the surface of the tumour. Under the muscles is the peri- osteum, pushed to a considerable distance from the bone. A part of the swelling itself is yellow, like fat ; another portion resembles brain ; and a third is com- posed of coagulated blood with interstices filled with serum. In some parts the white substa;'!oe is found nearly as firm as cartilage ; but in general it presents a more spongy appearance ; and is interspersed with spiculae of bone. The shell of the bone itself is in ps . i absorbed ; in some places it is only thinner than usuai , while in others it is immensely expanded, so as to form a case, like wire-wmrk, over the tumour. The fungous granulations, proceeding from the medullary mem- brane itself, are exceedingly vascular, and often shoot from the cavity of the bone beyond the level of the in- teguments.— (A. Cooper, Surgical Essays, part 1, p. 165-16S.) According to Boyer, spherical exostose.s, with an in- ternal cavity, and hypersarcosis, are only attended with violent pain in the beginning, and when they have at- tained a considerable size they become almost indolent. But the successive formation of the fungosities, con- tained in their ca\ity, has the effect of distending its parietes, and rendering them thin, so that such exosto- ses are exposed to fractures and ulceration. This last effect may, indeed, be a consequence of the progress of the disease, and give rise to a series of consectuive symptoms, which may be compared whth those which have been described in the preceding case. The spheri- cal exostosis, however, is less dangerous, jierhaps, be- cause the disease extends less deeply. Such tumours admit of being directly attacked ; and operations for the destruction of the bony shell, and of the fungous growth which it includes, may be successfully practised ; an attempt which would certainly be useless atid dan- gerous in the foregoing instance. One termination of exostosis, not spoken of by wri- ters, but which has been observed, especially in the hard and stalactical exostosis, is that by necrosis. Tu- mours of this description, after acquiring a large size, have been attacked with mortification, separated from the bone, which served them as a base, and been sur- rounded with a reproduction in every respect similar to that whth which nature surrounds sequestra formed under any other circumstances. This termination is undoubtedly the most favourable of all, because nature l)roceeds in it slowly, without any violent disturbance; but, unfortunately, it is the least common. Art can imitate it ; but her means are very inferior to those of nature. A most interesting case oi an enormous exo.s- tosis of the upper maxillary bone, which followed the preceding course, was lately under my notice. — {Boyer, Traite des Mai. Cliir. t. 3, p. 547— 550.') The hardest exostosis, w’hich has grown slowdy, and without causing severe pain, is the least dangerous of all, especially when the constitution is sound,' and the patient not of a bad habit. After the disease has at- tained a certain size, it may become stationary, and continue in this state without inconvenience during life. This is most frequently observed in the ivory ex- ostosis. Without having precisely this extreme hard- ness, however, some exostoses which are tolerably solid, and in v. hich the natural organization of bone is still distinguishable, are capable of undergoing a slight reduction, after the removal of their cause by nature or art. Boyer states, that this sometimes happens in a few scrofulous exostoses, and particularly in such as are venereal, and not of very large size. The cellular exostosis of Boyer, the fungous exos- tosis of Sir A. Cooper, and the cases which are named osteosarcomata, are the most serious of all, especially w'hen the texture of the bone is considerably altered, and the disease is in a state of ulceration. The rapid formation of the disease, the violent shock which it im- parts to the constitution, and the hectical disturbance which it excites, generally bring the patient into immi- nent danger, and commonly leave no other resource but that of amputating the limb. The treatment of exostoses is to be considered in a medical and surgical point of view. When any gene- ral cause of the disease is known or suspected, such cause is to be removed by those m.eans which expe- rience has proved to be most efficacious. Thus Boyer recommends mercurial and antiscrofulous remedies, &c., according to the nature of the case. Whatever may be the species of exostosis, or the na- ture of its cause, relief, says Boyer, may be derived from thi^ outward use of opium, whenever the disease is attenikid with severe pain. He speaks favourably of the apiilication of a linseed-meal poultice, made with a decoction of the leaves of nightshade and henbane, to which a strong solution of opium has been added. But he thinks that an antiphlogistic plan, with bleeding, is hardly ever admissible, because it weakens the patient too much in so tedious a disease, and can only be a palliative, incapable of curing or preventing the ravages of the disorder. When there is no pain, or it has been appeased, during or after any general method of treatment which may have been indicated, the surgeon may try resolvent ap- plications, particularly soap and mercurial plasters, the tincture or ointment of iodine, the liniment of ammonia, bathing in water containing a small quantity of soda, or potassa, hydro-sulphurated washes, &c. Boyer ac- knowledges, however, that the progress of exostoses can scarcely ever be checked by any general methodi- cal treatment. The muriatic and ascetic acids have been administered, but without effect ; nor am I ac- quainted with any remedies which possess efficacy, excepting iodine and mercury, which last we know will rarely answer, except in cases of nodes. In the commencement of any deep-seated disease in a bone, however. Sir A. Cooper thinks that the best medicine for internal exhibition, is the oxymuriate of quicksilver in small doses, together with the compound decoction of sarsaparilla. — {Surgical Essays, part 1, p. 169.) Boyer is firndy of opinion that, w ith the exception of recent small exostoses, the nature of which is even doubtful, the resolution of such tumours is almost im- possible. A slight diminution of the sweliing, and its becoming perfectly indolent, are the mo.st favourable changes which can be hoped for, whether thej occur spontaneously, or are the fruit of surgical assistance. — {Traite des Mai. Chir. t. 3, p. 554—557.) Whether any exosto.ses might be lessened by keeping open a blister over them for a considerable time, is a point, perhaps, worthy of farther investigation. It is certain that such applications tend to diminish venereal nodes, after they have been lessetied as much as they can be by mercury; and we also know that blisters kept open promote the absorption of the dead bone in cases of necrosis. In the local treatment. Sir Astley Cooper approves of the use both of leeches and blisters, a discharge from the latter being kept up w ith equal parts of the mercurial and savin ointments. — {Surgical Essays, part 1, p. 169.) When exostoses merely occasion a deformity, and no pain nor inccnvenience from the pressure which ihe> produce on the neighbouring parts, it is certainly most advisable not to undertake any operation for their remo- val ; for, as Boyer has truly observed, in by far the greater number of instances, the local atfection is muct less to be dreaded than the means used for remov iug it. EXO EYE 365 Caustics and the cautery have occasionally been ap- plied to exostoses ; but they mostly do mischief. Boyer mentions an unfortunate woman, in whom some caustic was applied to an exostosis at the inside of the tibia ; but which instead of removing the tumour, caused a necrosis, of which she was not well two years after- ward. In a few instances, however, after the removal of fungotfs or cartilaginous exostosis of the interior of a bone with cutting instruments, the application of the cautery has prevented a reproduction of the diseased mass, as we find exemplified in a case recorded by .Sir Astley Cooper, where such a disease of the jaw was thus extirpated. — {Surgical Essays, part 1, p. 15d.) The bold and successful manner, also, in which the hydatid exostosis of the head was attacked with the saw, caustics, and the actual cautery, by Mr. R. Keate, IS particularly entitled to the attention of the surgical practitioner.— (died. Chir. Tran.s. voL 10, p. 28S, a c.) As far as my information extends, no attempt to stop the progress, or efiecf the cure of a fungous exostosis, by tying the main artery of the limb, has ever >ct suc- ceeded. Two cases, proving the inellicacy of this prac- tice, are detailed by Sir A. Cooper. — {Vol. cit. p. ITU.j As the fungous exostosis of the medullary mem- brane is evidently connected with a state of the consti- tution analogous to what prevails in fungus hiematodes (see this word), the permanent success of amputation should never be too boldly promised ; but as no medicines have any material power over the disease, and the operation is the only chance of relief, it ought to be advised. Cartilaginous exostoses of the medullary membrane may sometimes be extirpated by removing their outer bony covering, and then cutting away the cartilaginous matter closely from the bony surface to which it is at- tached. Sometimes, as I have noticed, those measures are followed by the use of the actual cautery. Periosteal exostoses are also either cartilaginous or fungous, which latter are attended with less general swelling of the limb, and are more prominent than fun- gous exostoses of the medullary membrane. Ulcera- tion, bleeding, sloughing, and great discharge ensue ; and unless some operation be performed, the patient loses his life. — {A. Cooper, Surgical Essays, part 1, p. 180.) The cartilaginous exostosis, between the periosteum and bone, arises from inflammation of the periosteum and subjacent part of the bone; and a de])osition of firm cartilage adherent to both these surfaces takes place. In this substance bony matter is secreted, which is first thrown out from the original bone. As the car- tilage increases in bulk, the quantity of phosphate of lime augments, and fresh cartilage is constantly deposited upon the outer surface of the tumour. On dissection ; — 1st, the periosteum is found thicker than natural; 2dly, immediately below the periosteum cartilage ; and 3dly, ossific matter, deposited within the latter, from the shell of the bone, nearly to the inner surl'ace of the perios- teum. When the growth of such a swelling ceases, and the disease is of long standing, the exterior surface consists of a shell of osseous matter, similar to that of the original bone, and communicating with its cancelli, in consequence of the primitive shell having been ab- sorbed. {.i. Cooper, Surgical Essays, part 1, p. 186.) The periosteal cartilaginous exostoses constitute the indolent, very hard forms of the disease. In their early stage they may sometimes be checked by small doses of mercury, the decoction of sarsaparilla, and the em- plastrum ammoniaci cum hydrargyro.— (FoZ. cit. p. l'J6.) When large or troublesome they may be sawed away, as Sir A. Cooper states, without danger, if the disease be well discriminated from the fungous swell- ing. When exostoses are productive of much pain, and injure the health, and their situation admits of their be- ing safely removed with the aid of suitable saws, or even with that of a gouge and mallet, the operation may be undertaken. Many tumours of this kind, how- ever, have bases so very exten.sive and deep, that when situated on the limbs, amputation becomes* preferable, to any attempt made to saw or cut away the exostoses and preserve the members on which they are situated. In removing an exostosis, its base must be as freely ex[K)Sfd by the knife as circumstances will allow, and to this part a small fine saw may be applied. In cut- ting away some exostoses, the flexible saw, described t)v Dr. Jeffray, of Glasgow (see Amputation), will be found useful. Mr. Key’s saws, and the semicircular trephine, are now so well known to the profession, that I scarcely need recommend them to be remembered in the present cases. Mr. Machell, a surgeon in London, has invented a saw, well palculated for cutting a bone at a great depth, without injuring the muscles. It is a small, fine, perpendicular wheel-like saw, turned by means of a handle connected with machinery. It is highly com- mended by Sir A. Cooper, who has given a drawing of it in his Surgical Essays, part I. An orbicular saw, invented and used by Professor Graefe, of Berlin, like- wise merits particular notice on account of its inge- nuity. — iSee C. G. E. Schwcilb, . De Serra Orbiculari, ito. Berol. 1819.) I would likewise recommend to the notice of surgeons the ingenious rotation saw*, contrived by Professor Thai, of Coiienhagen, and of which a de- scription and engraving may be found in the Edin. Med. and Surgical Journ. No. 74. A strong pair of bone-nippers, and especially Mr. Liston’s forceps, the edges of which are in the line with the handles, will also be useful. E. Victoria, De Ossibus tuberosis. Upsal, 1717. Haller, Disp. Chir. t. 4, p. 561. P. H. Mcehring, De Exostosi Steatomatode Claviculae, ejusdem felici Sec- tione, Gedani, 1732. J. COspart, De Exostosi Cranii rariore. Argent. 1730. J. R. Fayolle, De Exostosi, Monsp. 1774. Abernethy, in Trans, for the Improve- ment of Med. and Chir. Knowledge, vol. 2, p. 309. Bonn, Descriptio Thesauri Ossium Hoviani. Dumont, Journ. de Mi d. 1 . 13. Hist, de I'Acad. des Sciences, 1737, p. 28. Houstet, in Mem. de VAcad. de Chir.t. 3. Matani, De Osseis Tumoribus, p. 20. Petit, Traits des Mai. des Os, t. 2, Morgagni, De Sedibus, dt c. ep. 50. art. 56. Kulmus, De Exostosi Claviculw. Haller, Collect. Diss. Chir. t. 4. R. Keate, in Med. Chir. TYans. vol. 10. Sir A. Cooper, Surgical Essays, part 1, 8vo. Lond. 1818. J. F. Lobstein, Compte de son Mus. e Anatomique, p. 24, 8vo. Strasb. 1820. # EXTRAVASATION. (From extra, out of, and vas a vessel.) A term applied by surgeons to the passage of fluids out of their proper vessels or receptacles. Thus, when blood is effused on the surface, or in the ventricles of the brain, it is said that there is an extra- vasation. When blood is poured from the vessels into the ca- vity of the peritoneum, in wounds of the abdomen, or when the contents of any of the intestines are effused in the same way, surgeons call this accident an extra-, vasation. The urine is also said to be extravasatedj when, in consequence of a wound, or of sloughing, or ulceration, it makes its way into the cellular substance, or among the abdominal viscera. When the bile spreads among the convolutions of the bowels in wounds of the gall-bladder, this is a species of extra- vasation. In wounds of the thorax an extravasation of blood also frequently happens in the cavity of the pleura. Large quantities of blood are often extravasated in consequence of vessels being rujitured by violent blows ; in the scrotum, on the shoulder, and under the scalp this effect is observed with particular frequency. In the articles Head, Injuries of, and Wounds, I have treated of extravasations of blood in the cranium, chest, and abdomen. EYE, Calcui.us in the interior of. Scarpa dissected an eye which was almost entirely transformed into a stony substance. It was taken from the body of an old woman, and was not above half as large as- the sound one. The cornea appeared dusky, and be- hind it the iris, of a singular shape, concave, and with- out any pupil in its centre. The rest of the eyeball, from the limits of the cornea backward, was unusually hard to the touch. The particulars of the dissection of this case will be read with interest, in Scarpa’s Treatise on the Diseases of the Eye. Haller met with a similar case. — (See Obs. Pathol. Oper. Min. obs. 15.) Fabricius Ilildanus, Lancisi, Morgagni, Morand, Zinn, and I’ellier make distinct mention of calculi in the interior of the eye. 08.sifica- tions of the capsule of the lens, of that of the vitreous humour, and of what was sujiposed to be the hyaloid membrane are noticed by Mr. Wardro]). — (Morbid Anatomy of the Human Eye, vol. 2, p. 128, bvo. Lond. 1818.) EVE, Canckr and Extiri’ation of. One of the well-known characters of carcinoma in general is lo attack persons advanced in age rather than child tu 366 EYE. and young subjects. Hence, an observation made by the experienced Desault, that cancer of the eye is most frequent in childhood, could not but appear a position inconsistent with the usual nature of the disease in general. Yet how was this statement to be contra- dicted, while it was confirmed by the testimony of Bi- chat himself, who says, that more than one-third of the patients on whom Desault operated in the Hdtel-Dieu for cancer of the eye were under twelve yetirs of age ? Here truth and accuracy as in many other questions relative to disease would never have been attained without the aid of morbid anatomy, whereby distem- pers which bear a superficial resemblance to each other, while they are in reality of a totally different na- ture, are prevented from being confounded together. Now, when Scarpa even goes farther than Bichat, and asserts, that in twenty-four individuals affected with what is called carcinoma of the eye, twenty of those at least are children under twelve years of age, this decla- ration, con.sidered with the acknowledged propensity of cancer on all other occasions to attack old rather than young subjects, might have remained a mysterious anomaly in the history of disease, had not the valuable investigations of Mr Wardrop proved, beyond all doubt, that the afflicting disease which rendered it necessary for so many young subjects to undergo a severe opera- tion, was not true cancer, but what is now denominated by modern surgeons, fungus hcematodes. — {Gbs. on Fungus Hcematodes, Svo. Edin. 1809.) As Scarpa ob- serves, this author has afforded a solution of the ques- tion, by .showing from carelul observation, founded on pathological anatomy, that the morbid change of struc- ture in the eyeball of a child, commonly c^led carci- noma, is not in reality produced by cancer, but by an- other species of malignant fungus, to which the epithet haernatodes is applied ; a disease, indeed, equally, and, with regard to the eye, more formidable and fatal than cancer, but distinguished from it by peculiar characters, which, not being confined to age, sex, or part of the body, attack the eyeball both of the infant and adult. — {Scarpa, Transl. by Briggs, p. 502, ed. 2.) According to Scarpa, and, indeed, the sentiments of several other surgeons of ihe present day, cancer is al- ways preceded by scirrhus, or a morbid induration of the part affected. As the disorganization increases in this hard scirrhous substance, an ichorous fluid is formed in cells within it, and afterward extends towards the external surface of the tumour, causing ulceration of the investing parts. The compact and apparently fibrous mass is tuen converted into a malignant fun- gous ulcer, of a livid or cineritious colour, with edges everted and irregularly excavated, and with a discharge of acrid, offensive sanies. The scirrhus composing the base of the malignant fungms, instead of increasing in size, now" rather diminishes, but retains all its ori- ginal hardness, and, after rising a certain way above the ulcerated surface, is destroyed at various points by the same ulcerated process from which it originated. And if any pan of the livid fungous sore seem disposed to heal, it is a deceitful appearance, as, in a little time, the smooth points are again attacked by ulceration. To relate in this place all the differences between cancer and fungus haernatodes of the eye would be superfluous, as the subject is considered in a future article (see Fungus Haernatodes)] but I may briefly advert to a few remarkable points of diversity. 1st, The primary origin of fungus haernatodes is generally in the retina, especially that point at which the optic nerve enters the cavity of the eye. 2dly, True cancer of the eyeball, when it begins on any part of the organ itself, instead of commencing as fungus haernatodes at the deepest part of the eye, originates on its surface in the con- junctiva ; and, as far as present evidence extends, if we excent the lachrj-mal gland, this membrane is the only texture connected with the eye ever pnma- rily affected wnth carcinoma. — {Scarpa, On Diseases of the Eye, p. 526, edit. 2 ; and Tr avers, Synopsis of the Diseases of the Eye, p. 99.) 3dly, Cancer of the eye, as Scarpa truly observes, is less destructive than fungus haernatodes, and that for two important reasons. In the first place, because carcinoma begins on the ex- terior parts of the eye, so that whatever relates to the origin and formation of the disease is open to observa- tion ; and, secondly, because the cancerous fungus of the eye, on its first appearance, is not actually malig- nant, but becomes so in process of time, or from im- proper treatment, previously to which p>criod good sur- gery may be employed with effect. In this light Scarpa views many excrescences on the conjunctiva and ante-' rior hemisphere of the eye, which appear in consequence of a staphyloma of the cornea, long exposed to the air and ulceration ; those which arise from relaxation and chronic inflammation of the conjunctiva ; from ulcera- tion of the cornea, neglected or improperly treated ; from violent ophthalmy, not of a contagious nature, treated in the acute stage with astringent and irritating applications ; from suppuration of the eye, rupture of the cornea, and w’asting of the eyeball ; or from blows or bums on the part. Nothing, says Scarpa, is more pro- bable, than that all these ulcerated fungi were, on their first appearance, not of malignant character, or certainly not cancerous, and that many of them w ere not actually so at the time of a successful operation being done. Now, in the opinion of the same valuable author, there is no criterion as yet known of the precise time when a sarcoma of the eye changes from the state of a common ulcerated fungus to that of carcinoma ; for the exquisite sensibility, darting pains, rapidity of growth, colour, and ichorous discharge are not an adequate proof of cancer. The symptom, how'ever, on which he is inclined to place the greatest dependence, as a mark of the change in question, is the almost cartilagi- nous hardness of the malignant ulcerated fungus, which induration, he asserts, is not met w ith in the benign fungus, and never fails to precede tlie formation of cancer. — (See Scarpa, On the Eye, transl. by Briggs, edit. 2, p. 511-513.) 4thly. The last difference of fungus haernatodes from cancer of the eye here to be noticed, is the pulpy soft- ness of the whole of the di.seased mass in the first of these diseases ; a character completely opposite to the firm almost cartilaginous consistence of the carcino- matous fungus. Before describing the operation of removing an eye affected with malignant disease, the following corolla- ries, drawn by Scarpa, should be recollected. 1. The complete extirpation of the eye for the cure of fungus haernatodes, although performed on the first appear- ance of the disease under the form of a yellowish spot deeply seated in the eye, is useless, and rather acce- lerates the death of the patient. But although this statement, made by Scarpa, may be mostly true, I am happy to say, that modem expe- rience begins to raise a hope that exceptions to the fore- going melancholy inference are possible. Thus Mr. Wishart removed from a boy nine years old an eye that had been affected wnth fungus haernatodes about four months, and no relapse had taken place eighteen months after the operation.-^See Edin. Med. and Surg.Journ. Xo. :4,p. 51.) 2. The exterior fungous excrescence of the eye, com- monly called carcinoma, beginning on the conjunctiva and anterior hemisphere, while it is soft, flexible, and indpy, although accompanied with symptoms similar to those of carcinoma, is not actually this disease, nor does it become malignant and strictly cancerous until it is rigid, hard, coriaceous, warty, and in every re- spect scirrhous. 3. The inveterate fungous excrescence, hard to the touch in all its parts, covered with ulcerated warts, which has involved the whole of the eyeball, optic nerve, and surrounding parts, and rendered the bones of the orbit carious, and contaminated the lymphatic glands behind the angle of the jaw andin theneck, isincurable. 4. On the contrary the partial or total extirpation of the eye will succeed when attempted before the exter- nal fungous excrescence has changed from the state of softness to that of a scirrhous, warty, and carcinoma- tous badness. — ( Vol. cit. p. 526.) The operation of removing the eye was first per- formed in the sixteenth century by Bartisch, a Ger- man, who employed a coarsely constructed instrument shaped like a spoon, with cutting edges, and by means of which the eye was separated from the surrounding parts, and taken out of the orbit. This instrument was too broad to admit of ready introduction to the deep contracted part of the orbit, so that when it was used either a part of the disease was likely to be left be- hind, or the thin bones of the orbit to be fractured in the attempt to pass it more deeply into tliat ca- vity. FabricmsHildanus learned these inconveniences from experience, and in order to avoid them, devised a sort of probe-]X)inted bistoury. Bidloo made use of scissors and a itri^re, whose arm tvas broken as a person was handing her out of a carriage. Louis, who was vexed that no union took place, was not a little surprised to find her thigh-bone experience the same fate one day as she was changing her posture in bed. It was then learned that she had a cancer in her right breast. Leveille assures us, that he has observed similar cases in the Hotel-Dieu, and Sir A. Cooper has met with others .-^( See Cancer.) According to Leveille, the history of two girls is re- lated by Buchner, one of whom died rickety at the age of sixteen, having broken the femur a short time be- fore her death ; and the other, after taking the breast very well for two years, and thriving for a time, be- came affected with rachitis, and met with the same accident as she was merely running along the street. — {Nouvelle Doctrine Chir. t. 2, p. 163.) Many extraordinary instances of fractures from the morbid softness and fragility of the bones are upon re- cord. Suffice it here to refer to the Philosophical Trans- actions; Mem. de I’Acad. Royale des Sciences; Act, Hafnien’s. ; Ephem, Nat, Cur. dec. 1, ann. 3, obs. 112 ; Gooch’s Chirurgical Works, vol. 2; Saviard, Observa- tions Chir. p. 274 ; Gibson’s Institutes of Surgery, voL 1, p. 370, &c.— (See also Fragilitas and Mollities Os- sium.) On the subject of fractures produced by the scurvy, Leveille recommends us to peruse Marcellus Donatus ; Saviard’s Observations; Heyne de Morbis Ossium; Poupart’s Works inserted in the Mem. de I’Acad. des Sciences, 1699; and the Treatise published at Verona, in 1761, by Jean de Bona. To these works I would add Lord Anson’s Voyage, in which the effect of the scurvy in producing the absorption of the callus of old fractures, and a disjunction of the fragments, is very curiously exemplified. Pare, Plainer, Callisen, and several other winters, set down cold as a predispo.-ing cause of fractures. This doctrine has originated from these injuries being more frequent in the winter time, but is quite erro- neous, since, in cold countries, the greater number of falls which happen in winter from the slippery and very hard state of the roads, is a circumstance that fully explains why fractures are then more common than in summer. The remote cause of fractures is external force va- riously applied in falls, blows, &c. In particular in- stances the bones are broken by the violent action of the muscles attached to them ; this is almost always the case with the fractured patella. The olecranon and os calcis have likewise been broken by a violent contraction of the muscles inserted into them. With respect to the heel. Petit records two instances, one of which was communicated to him by Poncelet, and the other seen by himself in Madame La Presidente de Boissire, who met with the accident in walking a gentle pace in the court of the Hotel de Soubise. When the injury happens in leaping, or falls from a high situation, Leveili6 thinks it more probable that a portion of the os calcis is tom off by the powerful ac- tion of the muscles of the calf, than that it is broken by any blow' immediately on the part. He states that Desault used frequently to cite two examples of this kind, one of which is recorded in his CEuvres Chirur- gicales. Whether the long bones can be fractured by the mere action of the muscles is yet an unsettled point. In the Philosoplucal Transactions a fracture of the humerus is ascribed to this cause, and Botentuil saw the same accident produced by striking a shuttlecock with a j battledore. According to Debeaomarchef, as a man I w'as descending a ladder at a quick nite, his heel got i entangled m an opening, and he made a violent exer- ' tion to avoid falling. The consequence was a fracture ' of the lower third of the leg. Curet informs us that a i cabin-boy, aged seventeen, made a considerable cflbrt to I keep himself from being thrown down by the rolling of the ship. The femur was fractured by the powerful ac- I tion of the muscles of the thigh. The lad had no fall, I and, with some difficulty, supported himself on the I other limb till he received assistance. We are told, says l.eveillc, by Poupie Desportes, ! that a negro, about tw’elve or thirteen years old, was seized with such violent sjiasmodic contractions of the muscles of the lower extremities, that the feet were turned backw'ards. and the neck of each thigh-bone w'.'us fractured, the ends of the broken bones also ' protruding through the skin uixai the outside of the FRACTURES. 377 thigh. A cure was effected after an exfbliation. read also, in the Miscellanea Curiosa Acad. Ni Curiosorum, that during a fit of epilepsy, a child ten years old had its left humerus and tibia broken, and that, upon opening the body, other solutions of con- tinuity were observed. Chamseru assisted in dressing a child, eleven or twelve years old, that had broken the humerus in throwing a stone a considerable distance. — {LeveilU, Nouvelle Doctrine Chir. t. 2, p. 164. 166.) Richerand, however, positively denies, that a long bone, when healthy, can ever be broken by the mere contraction of the muscles.— (iVoso^r. Ckir. t. 3, p. 12, edit. 4.) For my own part, making all due allowance for the inaccuracy of some of the reports made by writers, I think the possibility of the long bones being broken by the violent action of the muscles is sufficiently proved. I have never seen but one example ; but it was a very unequivocal one. I once attended, for the late Mr. Ramsden, an exceedingly strong man, at Pentonville, who broke his os brachii in making a powerful blow, although he missed his aim and struck nothing at all. The whole limb was afterward affected with vast swelling and inflammation. This man, I remember, was also visited by Mr. Wei bank, of Chancery-lane. According to Nicod, the greater number of fractures of long bones, by mere muscular action, are preceded by pains in the broken limbs ; and in one of the cases pub- lished by this author, not only was this circumstance remarked, but an abscess and exfoliation of a portion of the fractujgd humerus ensued. In another instance reported by tms gentleman, the clavicle in a state of preternatural fragility from disease, was fractured in an effort to carry the arm far behind the back. After the reunion of the fracture, an abscess took place, and a piece of the bone exfoliated. — (Annuaire MM. Chir. des Hopitaux de Paris, p. 494 — 498, ^c. ito. Paris 1819.) 3. Symptoms of Fractures. Some of the symptoms of fractures are equivocal ; the pain and inability to move the limb, commonly enu- merated, may arise from a mere bruise, a dislocation, or other cause. The crepitus ; the separation and in- equalities of the ends of the fracture, when the bone is superficial ; the change in the form of the limb ; and the shortening of it ; are circumstances communicating the most certain information ; and the crepitus, in par- ticular, is the principal symptom to be depended upon, though occasionally attendant on dislocations, and aris- ing, as Sir Astley Cooper has explained, from a change in the quality of the synovia.— Dislocations, Src. p. 6.) The signs of fractures, however, are so exceed- ingly various, according to the bones which are the subject of injury, that it cannot be said, that there is any one which is invariably present and character- istically confined to them. The writers of systems of surgery usually notice loss of motion in the injured limb, deformity, swelling, tension, pain, &c., as form- ing the general diagnosis of fractures. However, it is ea.sily comprehensible by any one acquainted with anatomy, that numerous fractures cannot prevent the motion of the part, nor occasion outward deformity ; and every surgeon must know, that though at lirst there may be pain in the situation of a fracture, no swelling and tension take place till after a certain period. When, therefore, a limb is broken, and the event is not manifest from the distortion of the part, it is proper to trace with the fingers, the outlines of the suspected bone : if it be the tibia, let the surgeon examine with his fingers, whether any inequality can be discovered along the anterior surface, and along the sharp front edge of that bone. If it be the clavicle, let him trace the superficial course of the bone, in the same attentive manner. Wherever any unusual pain occurs, or any unnatural irregularity appears, let him try if a grating or crepitus, cannot be felt, on endeavouring to make one end of the suspected fracture rub against the 01 her. When the humerus or the os femoris is the subject of inquiry, a crepitus is felt almost as soon as the limb is touched ; and, in the case of the broken thigh, there is a considerable shortening of the extre- mity, except in a few cases of fractures, completely transverse. But when there are two bones, as in the leg and the forearm, and only one is broken, the otner continues to prevent the limb from being short- ened and thrown out of its natural shape, so that a crepitus can only be felt by a very careful examination with the fingers. The difficulty of the diagnosis is in- creased when the surgeon is consulted late, and great swelling has come on. “ Where is the surgeon,” says Boyer, “ that has not sometimes hesitated to deliver an opinion in certain cases of this description?” — {Traite des Malad. Chir. t. 3, p. 27.) When the injured limb is shortened, the surgeon before pronouncing that such change proceeds from the passage of the fragments over each other, must be sure that the bones are not dislocated, and that the limb is not naturally shorter than the other, or in consequence of a previous fracture that has been badly set. In comparing the length of the lower extremities, one should place the pelvis in a horizontal position, and put the two anterior superior spines of the ossa ilium in the same line ; for, if these processes are not on a level, the limb towards which the pelvis inclines, will seem longer than the opposite member. The practitioner who is well acquainted with the anatomy of the limbs, and particularly with the mu- tual relations of the eminences of the bones to each other, will readily perceive the alterations produced by a fracture. Whenever, in consequence of a fall or Now, a limb becomes concave at a part where it ought to be convex ; or straight, et vice versd ; the change of shape and direction must proceed from a fracture with displacement. The inner edge of the great toe, when the leg rests on a horizontal surface, should corres- pond with the inner edge of the knee-pan. If this na- tural relation be altered ; if the inner edge of the great toe correspond with the outer edge of the knee-pan, there can be no doubt of the existence of a fracture of both bones of the leg. — {Boyer, vol. cit. t. 3, p. 25.) 1 ani aware, that considerable harm and great un- necessary pain have been occasioned in the practice of surgery, by too much solicitude to feel the grating of fractured bones, and whenever the case is sufficiently evident to the eyes, the practitioner who gives way to this habit at the expense of torture to the unfortunate patient ought in my opinion to be severely censured. A fracture is an injury necessarily attended with a great deal of pain, and followed by more or less swell- ing and inflammation ; and to increase these evils by roughly or unnecessarily handling the part, is ignorant and cruel, and (if I may use the expression) unsur gical. In some kinds of fractures, the broken bone is so surrounded with thick fleshy parts, that it is diffiult to feel a crepitus, or ascertain the existence of the injury. Some fractures of the neck of the thigh-bone, unat- tended with much retraction of the limb, are cases illustrative of this observation. Whether Laennec’s stethoscope will become practically useful as a means of elucidating the diagnosis, farther time and expe- rience must determine ; Lisfranc is said to have used it with success. — (See Edinb. Med. and Burg. Joum. No. 78, p. 237.) 4. Prognosis of Fractures. The prognosis of fractures varies, according to the kind of bone injured, what part of it is broken, the di- rection of the breach of continuity, and what other mischief complicates the case. Fractures of bones which have many strong muscles inserted into them, are more difficult of cure than those of other bones which have not so many powers attached to them ca- pable of disturbing the fragments. A fracture of the middle part of a long bone is less dangerous than a similar injury near a joint. Frac- tures near joints may occasion a false anchylosis. Thus, in a fracture of the thigh-bone near the condyles, the inflammation and swelling extend to the knee-joint, which is affected with a degree of stiffness that con- tinues for a long while, and sometimes cannot be en- tirely cured during life. Moreover, the inflammation of the joint is attended with more severe symptoms, in consequence of the contusion having been more violent. In a fracture near an articulation, it is to be observed, also, that the splints have little command over the short fragment, so that it is often diflicult to prevent disiilacernent ; and with respect to a transverse frac- ture of the neck of the thigh-bone luitlun the capsular ligament, whether an uiieciuivocal siiecimen of the reunion of such a case by means of bony matter is to be met with in any museum in this country is yet a 378 FRACTURES. disputed point; and notwithstanding the statements in the publications of Messrs. Earle, Ameshury, and Langstaff, doubts still exist in the mind of Sir Astley Cooper and numerous other surgeons of vast expe- rience, concerning the possibility of a bony union in the particular kind of accident here specified. V\hien a bone is fractured in several places, the case is more serious, and the difficulty of cure much aug- mented. But the accident is still worse when a limb is fractured in two different places at once ; as, for in- stance, in the thigh and leg. Here it is almost impos- sible to reduce the fracture of the thigh and maintain the reduction well, so as to preserve the natural length of the limb.— (Boj/er, Traited.es Mai. Chir. t. 3,p. 29.) Oblique fractures are more troublesome and difficult of cure than transverse ones, because an oblique sur- face does not resist the retraction of the lower portion of the broken bone, and consequently it is very difficult to keep the ends of the fracture duly applied to each other. Fractures complicated with violent contusion of the soft parts, or with a wound, rendering them compound, are much more dangerous than others free from such accidents. The bad symptoms which render com- pound fractures so dangerous are of many kinds : he- morrhage ; violent and extensive inflammation of the limb, with extreme pain, delirium, and fever ; large ab- scesses, gangrene, &.c. Fractures of the leg are gene- rally more serious than similar injuries of the upper extremity. The wound of a large artery may add con- siderably to the danger of a fracture. In a debilitated old man, a fracture is less likely to end well than in a healthy child, or strong young sub- ject. In extreme old age, the cure of a fracture is always more difficult and sometimes impossible.— (Bo- yer, t. Z,p. 32.) The scurvy certainly retards the form- ation of callus, and, as I have already noticed, even produces its absorption again ; but it is not true, that pregnancy always prevents the imion of fractures. Some years ago, I attended, for Mr. Ramsden, a wo- man in a court leading out of St. Paul’s churchyard, who broke both bones of her leg when she was several months gone with child. Her pregnancy, however, did not appear to be at all unfavourable to the cure, as she got quite well in the usual time. “ It is not generally settled,” says a modern writer, “ whether pregnancy should be accounted a complication. I have, as well as some other practitioners, seen a pregnant woman get well of a simple fracture in the ordinary time.” — (Leueille, Nouvelle Doctrine Chir. t. 2, p. 159.' And in another place he says, “ Contre Vopinion de Fabrice de Hildan. Vexpiriencem'aprouve que, chezles femmes grosses, le cal etait aussi prompt d se former, que chez toute autre personne.”-^(Op. cit. t. 2, p. 172.) The experience of Boyer also tends to prove, that pregnancy IS not unfavourable to the union of fractures. — (See Traife des Mai. Chir. t. 3, p. 32.) The cases in which fractures remain disunited, will be considered in a future section of the present article. 5. Treatment of Fractures in general. The general treatment of fractures embraces three principal indications. The first is to reduce the pieces of bone into their natural situation. The second is to secure and keep them in this state. And the third is to prevent any unpleasant symptoms likely to arise, and relieve them when they have come on. Thefirst indication is only applicable to cases attended with displacement ; for when the fragments are not out of their relative position, the surgeon mtist strictly re- frain from all avoidable disturbance of the limb. His interference should then be limited to putting up the fracture, resisting the accession of all unfiivourable symptoms, and removing them, if possible, after they have taken place. 6. Of the Reduction of Fractures. The means employed for the reduction of frac- tures in general are chiefly three, viz. extension, coun- ter-extension, and coaptation, or setting. But, as Boyer remarks, these means should vary according to the species of displacement; and surgical writers have (Tcneralized too much in representing them all three as necessary, for the reduction of every kind of fracture. In fact, there are several cases in which extension and r'ounter-cxtension are positively useless ; of this nature are fractures of the patella and olecranon, where the displacement consists of a separation of the fragments. Here the reduction njay be accomplished by putting the limb in a position in which the muscles attached to the upper part of the bone are relaxed, and then pushing the upper fragment into contact with the lower. Extension signifies the act of pulling the broken part in a direction from the trunk, with the view of bringing the ends of the fracture into their natural situation. By counter-extension, surgeons imply the act of mak- ing extension in the opposite direction, in order to hin- der the limb, or even the whole body, from being drawn along by the extending power, which would then be unavailing. It was formerly recommended to apply the extending force to the lower fragment, and the counter-extension to the upper one. Such practice, indeed, was advised by Mr. Pott, and is still generally preferred in this country ; but upon the continent it has been abandoned. The objections made to it by Boyer are, first, that it is fre- quently difficult, and sometimes impossible, to take hold of the; t'Jvo fragments, as, for example, when the neck of the' thigh-bone is broken. Secondly, that by apply- ing the extension and counter-extension to the broken bone itself, most of the muscles which surround it are compressed, and such compression produces in these organs a spasmodic contraction, which often renders the extension and counter-extension useless, and some- times even hurtful . — (fTraite des Mai. Chir. t. 3, p. 34.) The French surgeons, therefore, apply the extending force to that part of the limb which is articulated with the lower fragment, and the counter-ejapnsion to that which is articulated with the upper. :^r instance, in a fracture of the leg, the extending means act upon the foot, and the counter-extending upon the thigh; and in a fracture of the thigh, the extension is applied to the leg, while the counter-extending power fixes the pelvis. One circumstance must here occur to the mind of the surgical reader. In this country, it is properly incul- cated that one of the first principles to be attended to in the reduction of fractures, is to put the limb in such a position as will relax the most powerful muscles connected with the broken bone ; because these mus- cles principally impede the reduction and disturb the ends of the fracture. But, in the French mode of mak- ing the extension and counter-extension, how can this grand principle be observed? If the extending and counter-extending means are not to be applied to the broken bone itself, but to others which are articulated with it, the limb must of necessity be kept in a straight posture at the time of reducing the fracture ; for were the limb placed in a half-bent state, the extension and counter-extension, as practised by the continental sur- geons, would not be in the same line. If, therefore, it be advantageous to bend the limb at the time of re- ducing a fracture, the French mode of practising exten- sion and counter-extfnsion must be relinquished. I am not, however, one of those surgeons who are entirely blinded with the idea of the possibility of relaxing the whole of the muscles connected with the broken bone, by merely bending the limb. On the contrary, I am perfectly convinced, with Desault, that, in general, what is gained by the relaxation of some muscles, is lost by the tension of others. But where it is possible to relax, by a certain posture, the set of muscles most capable of preventing the reduction and disturbing the coaptation of a fracture, that posture I would select. Thus, in a fracture of the leg, the strong muscles of the calf undeniably'possess this powder, and the bent position, which relaxes them, appears to me, therefore, the most judicious and advantageous, not only during the reduction, but during the whole treatment of the case. A few' years ago I had under my care, in the military hospital at Cambray, a fracture of the tibia and fibula, which was at first treated in the straight posture. The gentleman who assisted me reduced the tragments, and made them lie tolerably well. But every time the bandage w-as opened, the bones were ahvays found displaced again. Finding that this incon- venience went on for two or three weeks, we resolved to lay the limb on its outside, in the bent position. Not the least trouble was afterward experienced in keeping the fragments reduced. Unless, therefore, the situa- tion of a wound, abscess, or some particular rea- son, indicate an advantage or convenience from the straight posture, I always reduce a fractured leg in the bent jrosition, wliich wll be hereafter described FRACTURES. 379 Here, therefore, I consider the French mode of making the extension and counter-extension as generally inad- missible. I was also formerly of opinion, that the bent position of the limb on its side, as advised by Mr. Pott, was the best for fractured thighs ; but this sentiment has sub- sequently appeared to me erroneous, and it gives me pleasure to have this opportunity of declaring my en- tire conversion to the principles and practice adopted in these cases by Desault and others, who urge the neces- sity of endeavouring to render the apparatus more effi- cient. The considerations which have led me to tliis change will be related in speaking of fractured thighs. If, then, the straight posture be advantageous in cases of broken thighs, I think it will be universally allowed, that the parts of the limb recommended by the French sur- geons for the application of the extension and counter- extension are the most proper. The evils and difficulties formerly encountered in setting fractured limbs, undoubtedly proceeded, in a great measure, from the violent extension and counter- extension practised by our ancestors. As they were ignorant of the utility of relaxing the muscles which displaced the ends of the broken bone, they had no means but the emplojunent of actual force to effect the reduction. Since, however, the excellent instructions contained in Mr. Pott’s remarks on fractures have re- ceived all the attention due to them, practitioners have generally been careful, in the reduction of fractures, to incapacitate the muscles as much as possible by relax- ing them, and thus the necessity for the employment of violent extension and counter-extension is effectually removed. It is difficult to lay down rules respecting the precise degree of force which should be used in mak- ing extension ; for it must vary in different cases, according to the species of displacement and the num- ber and power of the muscles concerned in pro- ducing it. In transverse fractures displaced only ac- cording to the diameter of the bone, a very moderate extension suffices, as it is merely practised with a view of lessening the friction of the surfaces of the fracture, which are always more or less rough. But whatever be the direction of the fracture when the fragments pass over each other, the extension and counter-extension must constantly be such as to remove the shortening of the limb, and overcome the force of those muscles which, after all attention has been paid to their relax- ation, still oppose the reduction. Extension, however, ought never to be practised in a violent and sudden way ; but in as gradual a manner as possible, the ut- most care being taken not to shake, nor even move, the limb any more than can be avoided. When the practitioner extends a broken member all at once vio- lently, he excites the muscles to strong spasmodic action, and there is some danger of lacerating them, because their fibres are not allowed the requisite time to yield to the force which elongates them. The exten- sion is to begin in the direction of the lower fragment, and be continued in that which is natural to the body of the bone. In every case of fracture with displacement, as soon as the necessary extension has been made, the surgeon is to endeavour to place the ends of the broken bone in their natural situation : this is termed coaptation, or setting. This operation is to be undertaken in differ- ent ways, according to the species of displacement, and the practitioner can almost always execute it by acting upon the lower fragment, without applying his fingers directly to the fracture itself, in order to regulate the contact of the extremities of the bone. When, however, it is judged necessary for this purpose to touch the broken part itself, it should be done with the utmost gentleness, so as to avoid jiressing the soft parts against the jioints and splinters of bone. Although the reduction of fractures may in general be accomplished with tolerable facility, it sometimes hap- pens that the first attempts fail. This is occasionally ascribable to the employment of too much force, and too little management, in making the extension ; whereby the muscles are irritated, and act so power- fully, that the design of the surgeon is completely frus- traletl. Here the grand means of success is putting the liiiib into such a position as will relax the most powerful muscles which oppose the reduction. Sorne- wn.es, however, the irritable and convulsive state of the muscles is not the effect of any wrong mode of pro- , cecding on the part of the surgeon, but arises from the alarm, pain, and injury, caused by the accident itself. Here relaxing the muscles as much as possible is also the most likely method of removing the difficulty. In short, now that the titility of paying attention to this principle is universally known in the profession, a frac- ture is hardly ever met with which cannot be immedi- ately reduced; particularly if a copious bleeding be premised when the patient is a strong muscular sub- ject. This evacuation, indeed, will also prove, for other reasons, highly beneficial, where the limb is much contused and swollen, and the tendency to inflamma- tion is great. 7. Of the Means for keeping Fractures reduced. After the bones have been put into their natural situ- ation, time alone would complete their cure, were there not in the muscles a continual propensity to displace the ends of the fracture again. In cases of fracture the muscles are often affected with involuntary spasmodic action, by which the broken part would certainly be displaced, were no measures taken to maintain the ex- tremities of the broken bone in contact. Besides, the patient, in easing himself, coughing, sneezing, - other will be fruit- less. The points to be aimed at are, the even position of the broken parts of the bone, and such disposition of the muscles surrounding them, as is most suitable to their wounded, lacerated state, as shall be least likely to irritate them, by keeping them on the stretch, or to produce high inflammation, and at best large suppu- ration.” According to Mr. Pott, these cases, of all others, re- quire at first the most rigid observance of the antiphlo- gistic regimen ; pain is to be appeased, and rest ob- tained, by anodynes ; inflammation is to be prevented or removed by bleeding and aperient medicines. And during the first state or stage, the treatment of the limb must be calculated either for the prevention ol inflammatory tumefaction by discutients, or, such tu- mour and tension having already taken possession of the limb, warm fomentation, and relaxing and emollient medicines are required. “ If these, according to the particular exigence of the case, prove successful, the consequence is, either a quiet easy wound, which either heals by the first in- tention or suppurates very moderately, and gives little or no trouble, or a w'ound attended at first with con- siderable inflammation, and that producing large sup- puration, wth great discharge and troublesome fonna- tion and lodgement of matter. If, on the other hand, our * The propriety of having recourse to venesection will depend ujxtn the age, strength, and general habit of the patient. In the young, robust, and plethoric, the practice is, on every account, judicious. FRACTURES. 386 attempts do not succeed, the consequence is gangrene and mortification. These are the three general events or terminations of a compound fracture, and according to these must the surgeon’s conduct be regulated. In the first instance, he has indeed nothing to do but to avoid doing mischief, either by his manner of dress- ing or by disturbing the limb. Nature, let alone, will accomplish her own purpose ; and art has little more to do than to preserve the due position of the limb, and to take care that the dressing applied to the wound proves no impediment. In the second stage, that of formation and lodgement of matter, in consequence of large suppuration, all a surgeon’s judgment will sometimes be required in the treatment both of the patient and his injured limb. Enlargement of the present wound, for the more con- venient discharge of matter ;* new or counter-openings for the same purpose, or for the extraction of fragments of broken or exfoliated bone, will very frequently be found necessary, and must be executed. In the doing this, care must be taken that what is requisite be done, and no more; and that such requisite operatiens be performed with as little disturbance and pain as pos- sible.” Previous to large suppuration, or considerable col- lections and lodgements of matter, evacuation by phle- botomy, an open belly, and antiphlogistic remedies, as well as the free use of anodynes, and such applications to the limb as may most serve the purpose of relaxa- tion, are the remedies which Mr. Pott advises for the relief of the swelling, induration, and high inflamma- tion, attended with pain, irritation, and fever. “ But the matter having been formed and let out, and the pain, fever, &c., which were symptomatic thereof, having disappeared or ceased, the use and purpose of such me- dicines and such applications cease also, and they ought therefore to be discontinued. By evacuation, &c. the patient’s strength has necessarily (and indeed pro- perly) been reduced ; by cataplasm, &c. the parts have been so relaxed as to procure an abatement or cessation of inflammation, a subsidence of tumefaction, and the establishment of a free suppuration ; but these ends once fairly and fully answered, another intention arises, which regards the safety and well-doing of the patient nearly, if not fully, as much as the former; which in- tention will be necessarily frustrated by pursuing the method hitherto followed. The patient now will re- quire refection and support as much as he before stood in need of reduction ; and the limb, whose indurated atid inflamed state hitherto required the emollient and relaxing poultice, will now be hurt by such kind of ap- plication, and stand in need of such as are endued with contrary qualities, or at least, such as shall not conti- nue to relax. Good, light, easily digested nutriment, and the Peruvian bark, will best answer the pur- pose of internals ; the discontinuation of the cata- plasms, and the application of medicines of the cor- roborating kind, are as necessary with regard to exter- iials.”! “ Every body who is acquainted with surgery knows ^says Mr. Pott) that, in the case of bad compound frac- ture, attended with large suppuration, it sometimes hajipeas, evert under the best and most judicious treat- ment, that the discharge becomes too great for the pa- tient to sustain ; and that, after all the fatigue, pain and discipline which he has undergone, it becomes neces- * “ It is a practice with .some, from a timidity in using a knife, to make use of bolsters and plaster compresses for tlie discharge of lodging matter. Where another or a counter-opening can conveniently and safely be made, it is always preferable, the compress some- times acting diametrically opposite to the intention with which it is applied, and contributing to the lodgement by confining the matter; besides which, it requires a gn-ater degree of pressure to make it efficacious than a limb in such circumstances generally can bear.” T “ It is surprising how large and how disagreeable a discharge will be made for a considerable length of time, in some instances, from the detention and irrita- tion of a splinter of bone. If therefore such discharge be made, and there be neither sinus nor lodgement to account for it, and all other circumstances are favour- able, examination should always be made, in order to know whether such cau.se does not exi.st, and if it does it must be gently and carefully removed.” V'uL, L" B b sary to compound for life by the loss of the limb.* This, I say, does sometimes happen under the best and most rational treatment; but I am convinced that it also is now and then the consequence of pursuing the reducing, the antiphlpgistic, and the relaxing plan too far. I would therefore lake the liberty seriously to ad- vise the young practitioner to attend diligently to his patient’s pulse and general state, as well as to that of his fractured limb and wound ; and when he finds all febrile comi)laint at an end, and all inflammatory tu- mour and hardness gone, and his patient rather lan- guid than feverish, that his pulse is rather weak and low than hard and full, that his appetite begins to fail, and that he is inclined to sweat or purge without as- signable cause, and this in consequence of a large dis- charge of matter from a limb which has suffered great inflammation, but which is now become rather soft and flabby than hard and tumid ; that he will in suuh cir- cumstances set about the support of his patient, and the strengthening of the diseased limb, totis viribus ; in which I am from experience satisfied he may often be successful, where it may not be generally expected that he would. At least he will have the satisfaction of having made a rational attempt; and if he is obliged at last to h#ve recourse to amputation, he will perform it, and his patient will submit to it, with less reluctance than if no such trial had been made.” According to Mr. Pott, gangrene and mortification are sometimes the inevitable consequences of the mis- chief done to the limb at the time that the bone is broken ; or they are the consequences of the laceration of parts, made by the mere protrusion of the said bone. They are also sometimes the effect of improper or ne- gligent treatment ; of great violence used in making ex- tension; of irritation of the wounded parts, by poking after, or in removing fragments or splinters of bone ; of painful dressings ; of improper disposition of the limb, and of the neglect of phlebotomy, anodynes, evacua- tion, &c. “ When such accident or such disease is the mere consequence of the injury done to the limb, either at the time of or by the fracture, it generally makes its appearance very early ; in which case also its progress is generally too rapid for art to check. For these rea- sons, when the mischief seems to be of such nature that gangrene and mortification are most likely to en- sue,r no time can be spared, and the impending mis- chief must either be submitted to, or prevented by early amputation. I have already said, that a very few hours make all the difference between probable safety and destruction. If we wait till the disease has taken pos- session of the limb, even in the smallest degree, the operation will serve no purpose, but that of accelerat- ing the patients death. If we wait for an apparent alteration in the part, we shall have waited until all opportunity of being really serviceable is past. The disease takes possession of the cellular membrane sur- rounding the large blood-vessels and nferves some time before it makes any appearance in the integuments; and will always be found to extend much higher in the former part than its apjiearance in the latter seems to indicate. I have more than once seen the experiment made of amputating, after a gangreme has been be gun, but I never saw it succeed ; it has always has tened the patient's de.ttruction.] As far, therefore, as my experience will enable me to judge, or as I may from thence be permitted to dic- tate, I would advise that such attempt should never be made ; but the first opportunity having been ne- glected, or not embraced, all the power of the chirurgic * After the bones had united, Mr. Pott never found it necessary to ain})utate a limb for a compound fracture, on account of the too great discharge. t In the article Gun-shot Wounds, however, the reader will find that there is a species of gangrene, arising from external violence, and totally unconnectc'd with constitutional causes, where the surgeon should deviate from the common rule of deferring amputation until the mortification has ceased to spread. A memoir “ Sur la Gangrene Traumatiqve," which was published a few years ago by Baron Larrey, contains the most decisive facts in regard to the projjriety of such i)ractice. —(See hisMtJm. de Chir. Miiitaire. 1. 2.) The experience of Mr. Lawrence tends also to confirm the truth of Lar- rey’s observations.— (See Med. Ghir. Trans, vol. f), p 184, i c.) 386 FRACTURES. art is to be employed in assisting nature to separate the diseased part from the sound ; an attempt which now and then, under particular circumstances, has proved successful, but which is so rarely so, as not to be much depended upon. If the parts are so bruised and torn, that the circu- lation through them is rendered impracticable, or if the gangrene is the immediate effect of such mischief, the consequence of omitting amputation, and of attempting to save the limb is, as I have already observed, most fre- quently very early destruction ; but if the gangrenous mischief be not merely and iimnediately the effect of the wounded state of the parts, but of high inflamma- tion, badness of general habit, improper disposition of the limb, &c., it is sometimes in our power so to alle- viate, correct, and alter these causes, as to obtain a truce with the disease, and a separation of the unsound parts from the sound. The means whereby to accomplish this erid must, in the nature of things, be varied accord- ing to the producing causes or circumstances : the san- guine and bilious must be lowered and emptied; the weak and debilitated must be assisted by such medicines as will add force to the ins vitae ; and errors in the treat- ment of the wound or fracture must be corrected ; but it is evident to common sense, that for thes^here is no possibility of prescribing any other than very general rules indeed. The nature and circumstances of each in- dividual case must determine the practitioner’s conduct. In general, inflammation will require phlebotomy and an open belly, together with the neutral antiphlogistic medicines; pain and irritation will stand in need of anodynes; and the Peruvian bark, joined, in some cases, and at some times, with those of the cooling kind, at others with the cordial, will be found necessary and useful. So also tension and induration will point out the use of fomentation and warm relaxing cata- plasms, and the most soft and lenient treatment and dressing.” Mr. Pott then offers many just observations against stimulating antiseptic applications to the wound and scarification of the limb, as practised while the gan- grene is forming. The custom of using stimulating dressings to bad compound fractures first began in cases produced by gun-shot, and had its foundation in the opinion that gun-shot wounds were poisonous, and that the mortification in them was the effect of fire ; a doctrine and practice now completely exploded. “ A gun-shot wound (says Pott), whether with or without fracture, is a wound accompanied with the highest degree of contusion, and with some degree of laceration; and every greatly contused and lacerated wound requires the same kind of treatment which a gun-shot wound does, as far as regards the soft parts. The intention in both ought to be to appease pain, irri- tation, and inflammation. Scarification, in the manner and at the time in which it is generally ordered and performed, has never appeared to me to have served any one good purpose. When the parts are really mortified, incisions made of sufficient depth will give discharge to a quantity of acrid and offensive ichor, wll let out the confined air, which is the effect of putrefaction, and thereby will contribute to unloading the whole limb ; and they will also make way for the application of proper dressings. But while a gangrene is impending, that is, while the parts are in the Ifighest state of inflammation, what the benefit can be which is supposed or expected to proceed from scratching the surface of the skin with a lancet, I never could imagine ; nor, though I have often seen it practised, do I remember ever to have seen any real benefit from it. If the skin be still sound, and of quick sensation, the scratching it in this superficial manner is painful, and adds to the inflamed state of it ; if it be not sound, but quite altered, such superficial incision can do no possible service ; both the sanies and the im- prisoned air are beneath the membrana adiposa ; and merely scratching the skin in the superficial manner in w’liich it is generally done will not reach to or dis- charge either. From what has been said it will appear, that there are three points of time, or three stages, of a bad com- pound fracture, in which amputation of the limb may be necessary and right ; and these three points of time are so limited, that a good deal of the hazard or safety of the operation depends on the observance or non- (/bservance of them. “ The first is immediately after the accident, before inflanrunation has taken possession of the parts. If tliis opportunity be neglected or not embraced, the conse- quence is either a gangrene or a large suppuration, with formation and lodgement of matter. If the former of these be the case, the operation ought never to be thought of, till there is a perfect and absolute separa- tion of the mortified parts.* If the latter, no man can possibly propose the removal of a limb until it be found by suflicient trial that there is no prospect of obtaining a cure without ; and that, oy not performing the operation, the patient’s strength and life will be exhausted by the discharge. When this becomes the hazard, the sooner amputation is performed the better. In the first in- stance, the operation ought to take place before inflam- matory mischief is incurred ; in the second, we are to wait for a kind of crisis of such inflammation ; in the third, the proportional strength and state of the patient, compared with the discharge and state of the fracture, must form our determination.”— (Pott’s itemartsoTi Fractures.) 9. Of the Formatipn of Callus, the Consolidation of Fractures, and of the Cases in which they remain without Union. In tile treatment of fractures, the whole business of the surgeon consists in putting the displaced extremi- ties of the bone into their natural situation again ; in keeping thein in this situation by means of a suitable apparatus ; in endeavouring to avert unfavourable symptoms, and in adopting measures for their removal when they have actually occurred. The consolidation of a broken bone is (strictly speaking) the work of na- ture, and is effected by a process to which a state of perfect health is above all things propitious. This consolidation of a broken bone, which is ana- logous to the union of wounds of the soft parts, is termed the formation of the callus, and the new uniting bony substance itself is named callus. \. Of the Time requisite for the Formation of the Cal- lus, and of general Circumstances which favour, re- tard, or even completely prevent it. Surgical writers have been absurdly anxious to spe- cify a determinate space of time which should be al- lowed for the formation of the callus, as if this process always went on in different cases with the same unin- terrupted regularity. Forty days were often fixed upon as necessary for the purpose. This prejudice is not only false, but dangerous, ina.smuch as patients have been thereby induced to suppose themselves cured before they were so in reality, and have, consequently, moved about too boldly, and thus run the risk of occa- sioning deformity or a new fracture. As Boyer ob- serves, it is impossible to determine precisely, and in a general way, the period requisite for the cure, because it differs according to a variety of circumstances. All we know is, that the callus is usually formed between the twentieth and seventieth day, sooner or later, ac- cording to the age and constitution of the patient, the thickness of the bone, the weight which it has to sup- port, the state of the patient’s health, &c. 1. Age. Fractures are consolidated, ccE^en^ parz&7ts, with more ease and quickness in young subjects than in adults or old persons. In general also the callus forms more speedily in proportion as the individual approaches to infancy. In two children, whose arnjs had been broken in difficult labours, De la Motte saw the humerus united in twelve days, by a very simple apparatus. In fact, at this period of life, ever}- part has a tendency to grow and develope itself, and the * Compound fractures are cases of external violence. Now, as the mortification proceeds from the injury, and may not be connected with any internal cause, it is an example of what Larrey calls the Gangrene Trauma- tique ; and the question whether the surgeon ought to be governed by the old maxim of delaying amputation until the spreading of the mortification has ceased, yet remains UTisettled. Were the patient of a sound con- stitution, and not too far gone, I should not fear to imi- tate Larrey, and amputate, though the mortification were actually in a spreading state. A few years ago I assisted at an amputation of tne shoulder in a case of spreading mortification of the arm from a compound dislocation of the elbow ; and though the patient ulti- mately died of a large abscess over the scapula, tli# stump went on favourably, and at one jieriod strong hopes of recovery were entertained. FRACTURES. 387 vitality of the bones is more active, their vascularity greater, their gelatinous substance more abundant. On the contrary, in advanced age, the parts have lost all disposition to developement, the vascularity of the bones is in a great measure obliterated, and (to use the expression of Boyer) their vitality is annihilated under tlie mass of phosphate of lime which accumulates in them. It has been asserted, that in early infancy the cal- lus is generally produced in excess, and may cause deformity by its redundance. But experience does not confirm the truth of this statement. The real cause of deformity always proceeds from the fracture either being badly set, or not kept properly reduced, or else from the part being moved about before the callus has acquired a due degree of firmness. 2. Constitution. A fracture is united much sooner in a strong healthy person, than a weak unhealthy subject. Sometimes, the consolidation is prevented by some inexplicable unknown cause, notlung wrong being remarkable either in the constitution or the part. Ruysch and Van Swieten met with several cases of this kind, in which the patients were apparently quite healthy and judiciously treated ; and there are few surgeons of much experience who are not acquainted with similar examples. 3. Thickness of the Bone, and Weight which it has to support. The bones are thicker and larger, in pro- portion as they have a greater weight to bear, and as the muscles inserted into them are more powerful. It is observed, coiteris paribits, that the larger the bones are the longer is the time requisite for their union. Thus a broken thigh-bone is longer in growing to- gether again than a fractured tibia; the tibia longer than the humerus, the bones of the forearm, clavicle, ribs, &c. As the callus remains a good while softer than the rest of the bone, it follows, that if the newly united bone has to bear all the weight of the body in walk- ing, the patient should defer this exercise longer. Hence one reason why fractures of the arm are sooner cured than those of the tibia, and why six or seven weeks at least are necessary in the treatment of a bro- ken thigh-bone, which of itself has to support in pro- gression all the weight of the trunk. 4. State of Health. Fractures unite with more quick- ness and facility when the patient enjoys good health. The scurvy has a manifest and powerful etfect in re- tarding the consolidation of fractures, and even in caus- ing the absorption of the callus several years after its formation, so that a bone becomes flexible again at the point where it was formerly broken. In Lord Anson’s voyage this phenomenon is particularly recorded. — (See p. 142, edit. 15, in 8uo.) Langenbeck is acquainted with several cases, in which the callus at the end of eight weeks became again soft and the bone flexible, in consequence of the patient’s being attacked with fevers or erysipelas. — (Neue Bibl. b. 1, p. 90.) Cancer, lues venerea, and rickets are also stated by surgical writers to obstruct, and sometimes hinder altogether, the formation of callus. Fabricius Hildanus has cited two cases, which tend to prove that the union of fractures is retarded by preg- nancy.— (CVnt 5, obs. 87. Cent. 6, obs. 68.) Alanson has also related a ca.se in which the union, which had been delayed during pregnancy, took place after deli- very {Med. Obs. and Inq. vol. 4, No. 37); and Werner has published an account of a firaeture of the radius in a pregnant w'oman, where the cure was apparently retarded for a long time by this circumstance, and though the union took place previously to delivery, the callus was not very firm till after that event. — (Richter, Bibl. b. 11, p. 591.) From the facts, however, mentioned in a preceding page of this article, there can now be no doubt that pregnancy frequently does not prevent the formation of callus in the ordinary time, though the observation of Mr. Wardrop is true, that many instances have been observed of bones being fractured during pregnancy, and never showing any disposition to unite till after delivery. — (Med. Chir. Trans, vol. 5, p. 359.) Besides the remarks made here and in a foregoing page, on the causes preventing the union of fractures, a few additional observations on the same subject will be intro noticed. FRACTURES OF THE VERTEBRA. On account of the shortness and thickness of these bones, they cannot be broken without considerable vio- lence. The spinous processes which project back- wards are the most exposed to such injury ; for they are the ;6veakest parts of the vertebrje, and most super- ficially situated. On this account it is possible for them to be broken without any mischief being done to the spinal marrow. The violence, which is great enough to break the bodies of the vertebrae, must produce a gre.ater or less concussion or other mischief of the spi- ral marrow ; from which accident much more perilous consequences are to he apprehended than from the in- jury of the bones abstractedly considered. The dis- placed pieces of bone may press on the spinal marrow, or even wound it, so as to occasion a paralytic affection of all the parts which derive their nerves from the con- tinuation of this substance below the fracture. Sir Astley Cooper divides fractures of the bodies of the vertebrae with displacement into two classes ; first, those which occur above the third cervical vertebra ; and, secondly, others which happen below that bone. The first cases, he says, are almost always imme- diately fatal, if the displacement be to the usual extent. In the second description of cases, death takes place at various periods after the injury. The reason of this difference is ascribed to the circumstance of the phrenic nerve originating from the third and fourth cervical pairs, whence in the first class of cases death is imme- diately produced by paralysis of the diaphragm, and the stoppage of respiration.— (On Dislocations, 552.) As the mere concussion of the spine may occasion symptoms v/hich very much resemble those usually occurring when the vertebrae are fractured, the diagno- sis is generally obscure. An inequality in the line of the spinous processes and a crepitus may sometimes be distinctly felt. The lower extremities, the rectum, and bladder are generally paralytic ; the patient is af- flicted with retention of urine and feces, or with an in- voluntary discharge of the latter.— (Boj/er.) If the lumbar vertebrae be di.splaced, the lower ex- tremities are rendered so completely insensible, that they may be pinched, burnt, or blistered without the patient suffering any pain. The penis in such cases is generally erect. In general, also, according to Sir Astley Cooper’s observations, patients with fractured lumbar vertebrae die within a month or six weeks ; but he knew of one patient that lived two years, and then died of gangrene of the nates. In fractures and displacement of the dorsal vertebrae, the symptoms are very similar ; but the paralysis extends higher, and the abdomen becomes excessively inflated. Death com- monly follows in two or three weeks ; but Sir Astley Cooper remembers one case, in which a gentleman sur- vived the accident nine months. Fractures of the cer- vical vertebrae, below the origin of the j)hrenic nerve, occasion paralysis of the arms, tliough it is seldom com})lete. Soirietiirics, when the fracture is oblique, one arm is more affected than the other. As the inter- 394 FRACTURES. costal muscles are paraljtic, great difficulty of respira- tion prevails. The abdomen is also considerably in- flated. Death generally follows in from three to seven days. Sir Astley Cooper notices the following as the ap- pearances found in the dissection of such cases. The spinous process of the displaced vertebra is depressed ; the articular processes are fractured ; the body of the vertebra is broken through, the separation rarely hap- pening in the intervertebral substance. The body of the vertebra usually projects forwards half an inch or an inch. Between the vertebra and the sheath of the spinal marrow blood is extravasated, and frequently on the lower part itself. When the displacement is slight, the spinal marrow is compressed and bruised. When greater, it is torn by the bony arch of the spinous pro- cesses, and a bulb is formed at each end, but the dura mater continues whole. — (See A. Cooper on Disloca- tionsy^ c. p. 554, i-c.) Fractures of the spinous processes without other se- rious mischief are not dangerous, and are the only instances of fractures of the vertebrae which admit of being detected with certainty. Any attempt to set fractures of the bodies of the ver- tebrae, even were they known to exist, would be both useless and dangerous. General treatment can alone be employed. Cupping will tend to prevent inflamma- tion in the situation of the injury. When the patient is affected with a flatulent distention of the abdomen, vomiting, liiccough, &,e., the belly may be rubbed with camphorated liniment, and purgative clysters and anti- spasraodics given. If requisite, the urine must be drawn off with a catheter. When the bladder, rectum, and lower extremities are paralytic, it is conunon to rub the back, loins, sacrum, and limbs with liniments con- taining the tinctura lytts. — {Boyer.) With respect to the external and internal use of stimulants, however, it can never be judicious, when there is reason to appre- hend much inflammation of the injured parts ; and as for the idea of thus restoring the nervous influence, there can be little chance of success, the cause of its interruption being here of a mechanical nature. — {Del- pech, Mai. Chir. t. 1, p. 222.) Some authors recommend trepanning, or cutting out a portion of the fractured bone, when the compression of the spinal marrow or its injury by a splinter is sus- pected ; but, according to my judgment, the indication can never be sufficiently clear to authorize the opera- tion, which, on account of the great depth of the inter- vening soft parts, must be very tedious, and even diffi- , cult to effect without a great risk of increasing the injury which the spinal marrow may already have received. An unsuccessful operation of this kind was once performed by Mr. H. Cline, and another by Mr. TyrreU. Some cases, published by Mr. C. Bell, tend to prove that the danger to be apprehended from injuries of the vertebrae is the same as that which accompanies inju- ries of the brain. Hence, he joins the generality of practitioners in recommending general and local bleed- ing, and keeping the patient perfectly quiet. And, with respect to operations for the removal of fragments of bone, it is his decided belief that an incision through the skin and muscles covering the spine, and the with- drawing of a portion of the circle of bone which sur- rounds the marrow would be inevitably fatal, the mem- branes of that part being particularly susceptible of inflammation and suppuration. And even if a sharp spi'-ula of fracturgd bone had run into the spinal mar- row, and caused palsy of the lower parts of the body, Mr. C. Bell thinks that exposing the medulla to extract the fragment would so aggravate the mischief, that in- flammation, suppuration, and death would be the in- evitable consequences. — {Surgical Obs. vol. 1, p. 157.) The same author describes inflammation of the spinal marrow as “ attended with an almost universal nervous irritation, which is presently followed by excitement of the brain; in the mean time, matter is poured into the sheath of the spinal marrow, and either by its pres- sure causing palsy, or by its irritation disturbing the functions of the part, so as to be attended with the same consequences. The excitement of the brain being followed by effusion, death ensues.” — (P. 1.59.) Cases are also referred to, where palsy of the lower extremi- ties comes on se-veral moiuhs after an injury of the spine, owing to thickening of the membrane of the medulla, or disease of the latter part itself. Here Mr C. Bell recommends perseverance in local bleeding and deep issues. — (P. 160.) A fracture of the processus deniatus proves instantly fatal, as happened in the example mentioned by Sir A. Cooper.— (On, Dislocations, experience fully proves the possibihty of uniting such fractures of the neck of the thigh-bone as are situatet^ within the capsular ligament ; but he acknowledges tha^ there are certain circumstances which may prevent this desirable event. “ From all that has been hitherto said on the prognosis of a fracture of the neck of the femur, we may conclude (says Boyer) that this fracture is more serious than that of any other part of the same bone, because the difficulty of keeping it reduced is greater. That it may in general be reunited, especially in young, healthy subjects (in whom, however, be it observed, the accident hardly ever occurs) ; but more easily when it is situated near the base of the neck than near the head of the bone. That the languid vitality of one of the fragments, and the impossibility of ascer- taining whether the coaptation be exact, make the cure slow, and the time necessary for their consolidation uncertain. That the neglect of means adapted to main- taining the limb in its proper length and natural straightness, and the fragments sufficiently motionless, may cause them to unite by an intermediate substance. Lastly, that the situation of the fracture near the head of the femur ; the complete laceration of the elongation of the capsule investing the neck of the beme; the great age of the patient ; and particularly the constitution labouring under some diathesis, which affects the os- seous system, may render the cure absolutely impos- sible ; iliat, in this circumstance, one of the fragments is more or less destroyed by the friction of the other against it, and in the joint a disease is formed, which tends to carry off the patient.” — {Traite des Mai. Chir. t. 3, p. 284.) This professor lays much stress on the complete laceration of the continuation of the capsule over the neck of the bone, as an occurrence preventive pf union. But he thinks it does not frequently happen, because the capsular ligament hinders much displace- ment of the fragment {op. cit. p. 278) ; a remark rather at variance with the shortened state of the limb. As for Baron Larrey, he appears to entertain no doubt of the possibility of uniting fractures of the neck of the femur within the capsular ligament, and concludes his tract on this subject with the case of General Fririon, who w'as perfectly cured after a supposed injurj- of this description.— (See Journ. Complem.t. 8,p. 118!) That some French surgeons, however, are now beginning to be less positive in their belief, is sufficiently manifest from the circumstance of a rew ard having been offered in France for the best explanation of the cause of such fractures not uniting by bone.— (;?/> A. Cooper, Appen- dix, p. 43.) How is this discordance to be reconciled and accounted for ? After the very numerous and careful dissectiona w'hich have been j)erformed by Sir. A. Cooper and Dr. Colies, with the view of ascertaining the state of the joint, after fractures of the neck of the thigh-bone, htlle doubt can be entertained that, where the fracture is transverse, and ivithin the capsular ligament, a bony reunion, if not absolutely impossible, is at least so FRACTURES. 403 fate an occurrence as not to be calculated upon. The difference of the French surge«ns upon this question is to be ascribed to their not having duly rliscriininaied from the foregoing kind of case either fractures extend- ing more or less in the direction of the axis of the neck of the bone, or other fractures external to the capsular ligament. How much, however, the safety of a prac- titioner’s reputation will depend upon the progno.sis which is given must be quite evident ; for in the trans- verse fracture within the capsule, lameness is almost sure to follow, though its degree cannot at first be exactly estimated. — {Sir A. Cooper, Surgical Essays, parti, p. 51.) As far as I am able to judge of this subject. Sir Astley Cooper has been the means of introducing clear and discriminate views of it, and, without his able exer- tions, the important differences in the nature, symp- toms, and curableness of the various kinds of fractures of the neck and upper part of the thigh-bone, depending upon their exact situation and direction, might yet have continued very imperfectly comprehended. This re- mark is made without any intention of deducting from the merits of Desault, Platner, and Mr. John Bell ; ail of whom seem to have expressed their belief, that a fracture within the capsular ligament will not admit of union by callus.— (C. Bell on Injuries of the Spine and Thigh-bone, Ato. Lond. 1824, p. 62, iS-c.) Mr. Amesbury, in his late treatise, attem])ts to prove, that all fractures of the neck of the thigh-bone admit of union, whether they be situated quite within the capsular ligament or not, and whether the reflected portion of that ligament be ruptured or not ; and he ascribes the usual want of success, not to the nature of the injury, not to the insufficient circulation in the pelvic portion of the bone, but to the imperfection of the mechanical means employed in the treatment. As, however, the important point under consideration, namely, whether transverse fractures of the neck of the femur, situated entirely within the capsular liga- ment, admit of bony union, is one that can only be de- termined by experience, Mr. Amesbury follows up his arguments by a reference to cases. “ Though,” says he, “ Sir Astley has not, I believe, yet seen a specimen sufficient to convince him that this variety of fracture has ever united by bone, there are now fbur prepara- tions, which satisfy the minds of many other surgeons that osseous union is occasionally produced.” The first case adduced is one that was under the care of Mr. Cribbe, of Holburn, and is described by Mr. Lang- staff, who has the prepartion : “ The woman was about 50 years of age when the accident occurred. The foot was everted, and there was shortening of the limb at this time ; and, after death it was shorter than the other full two inches and a half. She was confined to bed nearly twelve months: during the remainder of her life, which was ten years, she walked with crutches. This (says Mr. Langstaff, alluding to the preparation) is a specimen of fracture of the neck of the thigh-bone within file capsular ligament ; the principal part of the neck is absorbed ; the head and remaining portion of the neck were united principally by bone, and partly by a cartilaginous substance. The capsular ligament was immensely thickened, and embraced the joint very closely. The cartilaginous covering of the head of the bone and acetabulum had suffered partial ab- sorption ; the internal surface of the capsular ligament was coated with lymph. On making a section of the bone, it was evident, that there had been a frac- ture of the neck vnthin the capsular ligament, and that union had taken place by osseous and cartilagi- nous media .” — (See Med. Chir. Trans, vol. 13.) Mr. Amesbury then adverts to Dr. Brulatour’s case re- ported in the same volume of the latter work. This gentleman died about nine months after the injury. Tlie following appearances presented themselves. 1. Th- capsule a little thickened. 2. The cotyloid cavity sound. 3. The interarticular ligament in a natural Slate. 4. The neck of the femur shortened : from the bottom of the head to the top of the great trochanter was only four lines, and from the same point to the top of the small trochanter six lines. 5. An unequal line surrounded the neck, denoting the direction of the fracture. 6. At the bottom of the head of the femur, and at the extenial and po.sterior part, a considerable | bony deposite had taken place. A section of the bone | was made in a line drawn from the centre of the head of the femur to the bottom of the great trochanter, so [ as perfectly to expose the callus. Tlie line of bone in- dicated by the callus was smooth and polished as ivory. The line of callus denoted also that the bottom of the head of the femur had been broken at its superior and posterior parts. In another example communicated to Mr. Amesbury by Mr. Chorley, of Leeds, a gentleman. died twelve months after the accident, and on examming the hip, the synovial covering was found united with the short- ened neck of the bone nearly at the head. Here nature had also thrown out broad ligamentous bands, one on each side of the joint. They were firmly united to the head of the bone. When the soft parts had been re moved, the head of the bone was seen depressed in a line with the shaft. The fracture was slightly oblique, commencing at the upper part close against the carti laginous covering of the head of the bone, and extend- ing downwards and outwards, so as to terminate in a point at the lower surface of the neck, one inch from the cartilaginous covering of the head. The jiosterior surface of the shed of the neck had the appearance of having been splintered, so as to make a part of the fractured end of the pelvic portion extend in one situa- tion a little on the outside of the capsular ligament, and where no union had taken place. In a fourth instance, where the necks of both thigh- bones had been broken at different periods, the parts were examined after the patient's decease. On the right side, the fracture extended througli the neck of the bone, in a direction downwards and outwards. In one part a portion of the reflected membrane remained entire ; but was separated from the neck of the bone in such a manner as not to prevent the retraction of the limb. The head of the bone was somewhat excavated ; and that portion of the neck attached to the trochanter was partially absorbed. There was no soft substance be- tween the surfaces of the fracture. A bond of union, however, consisting of fibrinous matter, adhered to the sides of the ends of the fracture, and in one part it was strong. No surgical attempt had been made to unite the fracture on the right side. On the left, the neck of the bone had been broken within the capsule, and was firmly united. The cervix was nearly absorbed ; and the head was depressed, so as to come within about two lines of the trochanter minor, to which it was united at its base by a small short process of bone. Strong bands of ligament were seen connecting the pelvic portion of bone to the capsule, which had be- come thickened and much smaller than natural. There had been a longitudinal fracture of the trochanter ma- jor, but quite independent of the injury of the cervix. The fracture of the latter part w^as united with the head, about two inches and a half below its natural si- tuation ; which leads Mr. Amesbury to believe, that what he terms the close coverings of the neck of the bone had been nearly or quite divided. A longitudinal section of the head and neck of the bone showed, ac- cording to Mr. Amesbury, that the fracture had taken place close to the head. The uniting callus had be- come cancellated ; but he says that the direction of the fracture could be seen “ by the situation of the tro- chanteral portion of the neck, when examined in dif- ferent parts of Its circumference.”— (See Amesbury on Fractures, (S-c p. 43, i' c. 1828.) Having spoken of the nature of fractures of the neck of the thigh-bone, within and without the capsular liga- ment, I come next to the consideration of the proper practice to be adopted. In the first description of the injury, as osseous union is rare, perhaps even not at- tainable, ought we to endeavour to keep the fragments as nearly in a state of apposition as possible, and sub- ject the patient to rest and confinement, with the view of promoting the other modes of union so well pointed out in Dr. Colles’ paper? Or should we, as Sir A. Cooper does, avoid confining the patient to any long or continued extension, “ as being likely to be productive of ill-health, without the possibility of producing union?” Yet it appears both from this gentleman’s own statements, and from those of Dr. Colles, Mr. Langstaff, Mr. B. Bell, and others, that though a bony union cannot always be effected, other connecting means may be established, and the more perfect these are, the less will be the subsequent lameness. As long, therefore, as these facts are incontrovertible, I should be disposed to recommend surgeons to do every thing in their power to keep the limb quiet, and in a desirable posture for a due length of time. On this point all surgeons must, on reflection, be unanimous. It is one that I have always insisted upon in my surgical wri- tings, and it is one that is very properly defended by Mr. Amesbury in his recent publication. Whether, for this purpose, Boyer’s apparatus, with the limb in the straight posture; or the apparatus with two in- clined surfaces, with the limb in the bent position, and the patient on his back ; or, lasUy, Hagedorn’s ingeni- ous and scientific treatment, as explained in the last edition of the First Lines of Surgery, should be pre- ferred, time and experience must determine. Sir A. Cooper merely places one jiillow under the whole length of the limb, and puts another transversely under the patient’s knee, so as to keep the limb in an easy bent position. In a fortnight or three weeks the pa- tient is allowed to sit upon a high chair, and in a few more days he begins to take exercise upon crutches. After a time, these are laid aside, a stick substituted for them, and in a fe,w months this assistance may be dispensed with. At the end of the treatment, a shoe must be worn with a sole of equal thickness to the diminished length of the \imh.—{S7irgical Essays, part 2, p. 50.) For the management of fractures of the neck of tlie thigh-bone, Messrs. Amesbury and Earle em- ploy fracture-beds, constructed with the view of fulfil- ling all the main indications, and in particular of keep- ing the ends of the fracture at rest in the best posi- tion. Their contrivances display great ingenuity, and well deserve the attention of the profession. In the treatment of such fractures of the neck of the femur as are situated on the outside of the capsu- lar ligament. Sir A. Cooper prefers the position in which the patient lies on his back, with the injured limb in a bent posture, supported on what is termed the double-inclined plane, the kind of instrument al- ready spoken of, as being sometimes employed by Mr. C. Bell. When the limb has been placed over this machine in an easy bent position, a long splint, reach- ing above the trochanter major, is applied to the outer side of the thigh, and fastened to the pelvis with a strong leather strap, so as to press one portion of bone towards the other. The lower part of the splint is also fastened to the outside of the knee with a strap. The limb is to be kept as quiet as possible for eight weeks, at the end of which time the patient may leave his bed, if the attempt should not cause too much pain ; but the splint is to be continued another fortnight.— (Surgical Essays, part 2, p. 59.) Desault’s apparatus has been described in the foregoing columns, and those of Boyer and Hagedoni are explained and represented in the First Lines of Surgery. Larrey, who disapproves of the plan of continued extension, has lately proposed a particular apparatus for fractures of the neck of the femur ; but as it ap- pears to me very inferior to other methods already mentioned, I shall here merely refer to the .Joum. Compl. t. 8, p. 115, where a description of it may be I am glad to find the number of advocates for Pott s method of treatment annually diminishing. Indeed, the bad eflects and painful consequences of having the whole weight of the trunk operating upon the frac- tured ends of the bone, which are often not properly in contact, are too obvious to need any comment. Yet this injudicious pressure is made in the bent position, which also forbids the use of long effective splints, and all assistance from moderate continued extension. A fracture of the neck of the thigh-bone may be com- plicated with a dislocation of the head of the bone. — (See J. G. Haase, De Fracturd Colli Ossis Femoris, cum Luxatione Capitis ejusdem Ossis conjuncta, Lips. 1798.) For farther information relative to fractures of the neck of the femur, the following authors may be consulted. C. G. Ludwig de Collo Femoris ejusque Fractura Programma, Lips. 1755. Bellocq, in Mem. de VAcad. de Chir. t. 3. Aitken's and GoocKs machines are described in B. Bell's Surgery, vol. 4. Sabatier, in Mem. de VAcad. de Chir. t. 4. Duvemey, Traite des Mai. des Os, t. 1 . Unger, in Richter's Bibl. b. 6, p. 520. Theden, Neue Bemerkungen, Src. th. 2. Brun- ninghausen uber den Bruch des Schenkelbeinhalses, iS c. Wurzb. 1789. Van Gescher iiber die Entstellun- gen des Ruckgrats, und iiber der Verrenkungen und Bruch dez Schenkelbeins, aus d. Holland. Hedenus, in Bernstein's Darstellung des Chir. Verbandes, tab. 42, fig. 82 and 83. M. Hagedom iiber der Bruch des Schenkelbeinhalses, frc. Leipz. 1808. J. N. Sauter, Anweisung die Beinbriiche der Gleidmassen vorz'i- glich die complicierten und den Schenkelbeinhalsbruch nach einer neuen, Arc. Methods, ojme Schienen, si- cker zu heilen, 6vo. Konstanz. 1812. J. Wilson on the Structure and Physiology of the Skeleton, &-c. p. 243, Src. Svo. Land. 1820. Dr. Colles, in Dublin Hos- pital Reports, vol. 2. Sir A. Cooper, Surgical Essays, part 2 ; and Treatise on Dislocations, A c. 4to. 1822, tvith Appendix, 1823. H. Eai le. Practical Obs. on Sur- gery, 1823. Lancet, Nos. 5 and 8, vol. 1, p. 302. Boyer, TraiU des Mai. Chir. t. 3. John Bell, Principles of Surgery, Mo. 1801, p. 549, (S c. C. Bell, on Injuries of the Spine and Thigh-Bone, Mo. 1824. G. hangstajf, Cases of Fractured Neck of the Thigh-Bone, within the Capsular Ligament, with the Dissections and Obs. in Med. Chir. Trans, vol. 13. E. Stanley, Cases of In- juries of the Hip-Joint, vol. cit. G. J. Guthrie on the Diagnosis, and on the Inversion of the Foot in Frac- ture of the Neck, Srv. of the Thigh-Bone, vol. cit. p. 103. Syme, in Edin. Med. Jou.in. April, 1826. B Bell, on Diseases of the Bone, 1828. J. Amesbury, Obs. on Fractures of the Upper Third of the Thigh- Bone, (S-c. 2d ed. 1829. OBLIQUE FRACTURES OF THE EXTERNAL OR INTERNAL CO.NDYLE OF THE FEMUR INTO THE JOINT. In these cases. Sir A. Cooper prefers the straight po- sition, because the tibia presses the extremity of the broken condyle into a line with that which is not in- jured. The limb is to be put in the extended posture upon a pillow, and evaporating lotions and leeches are to be used for the removal of the swelling and inflam- mation. “ When this object has been effected, a roller is to be applied around the knee, and a piece of stiff pasteboard, about sixteen inches long, and sufficiently wide to extend entirely under the joint, and to pass on each side of it, so as to reach to the edge of the pa- tella, is to be dipped in warm water, and applied under the knee, and confined by a roller. When this is dry, it has exactly adapted itself to the form of the joint, and this form it afterward retains, so as best to confine the bones. Splints of wood or tin may be used on each side of the joint ; but they are apt to make un- easy pressure. In five weeks, passive motion of the limb may be gently begun, to prevent anchylosis.”— {Surgical Essays, part % p. 101 ; also. Treatise, p. 221.) This author afterward describes a compound fracture of the external condyle, a portion of which was after a lime extracted, and the case ended so favourably, that the patient, who was a boy, was able to bend and extend the leg without pain. For fractures just above the condyles. Sir A. Cooper recommends the bent position, without which, he says, deformity is sure to follow. He advises the limb to be placed over the double inclined plane, and a roller ap- plied round the lower portion of the femur. — (P. 103.) FRACTURES OF THE PATELLA. This bone is most frequently broken transversely, and the accident may be produced either by the action of external bodies, or by that of the exten.sor muscles. In the latter case, the fall is subsequent to the fracture. FRACTURES. 405 and, as Camper has remarked, it is mostly only an ef- fect of it. For instance, the line of gravity of the body is, by some cause or another, inclined backwards ; the muscles in front contract to bring it forwards again ; the extensors act on the patella ; this breaks, and the fall ensues. That it is the action of the mus- cles and not the fall which usually breaks the knee- pan, is well ascertained. Sometimes the fracture oc- curs, though the patient completely succeeds in pre- venting himself from falling backwards, as we find exemplified in two cases reported by Sir A. Cooper. — (Surgical Essays, part 2, p. 85.) A soldier broke his patella in endeavounng to kick his sergeant: the ole- cranon has been broken in throwing a stone. In the operating theatre of the Hdtel-Dieu, both the knee-pans of a patient were broken by the violent spasms of the muscles, which followed an operation for the stone. The force of the muscles occasionally ruptures the common tendon of the extensor muscles, or, what is more frequent, the ligament of the patella. Of these cases. Petit, Desault, and Sabatier met with examples. When the patella is broken longitudinally, the cause is always outward violence. — (CEuvres Chir. de Desault, t. 1, p. 252.) A transverse fracture of the patella may also origi- nate from a blow or fall on the part ; but in common cases it is produced by the violent action of the ex- tensor muscles of the leg. It is only of late years, however, that the true mode in which the bone is usu- ally broken has been understood. As Boyer observes, for the production of a transverse fracture of the knee- pan, the extensor muscles of the leg need not act with a convulsive force, their ordinary action being strong enough to produce the effect in question when the body is inclined backwards, and the patient is in dan- ger of falling upon his occiput. In this stale, the thigh being bent, the extensor muscles of the leg con- tract powerfully, in order to bring the body forwards and prevent the fall backwards; and the patella, whose posterior surface then rests only by a point against the fore part of the condyles of the femur, is placed between the resistance of the ligament binding it to the tibia, and the action of the extensor muscles. A fracture now happens the more easily, because, by the flexion of the knee, the line of the extensor mus- cles and that of the ligament of the patella are ren- dered oblique, with respect to the vertical axis of this bone, which is bent backwards at the point, where it rests upon the condyles.— (Traif^ des Mai. Chir. t. 3, p. 322. C. Bell’s Operative Surgery, vol. 2, p. 201, 8uo. Land. 1809. A. Cooper’s Surgical Essays, part 2, p. 86.) By violent spasmodic action of the extensor muscles, however, the patella may be broken trans- versely, while the limb is perfectly straight. A very singular case is mentioned by Sir A. Cooper, where a patella, which had been formerly broken and united by ligament, was again divided into two portions, in consequence of the destruction of the uniting medium by ulceration. — (Vol. cit. p. 100.) A case is also on record, where the ligamentous uniting substance was so incorporated with the skin, that when the latter happened to be lacerated, the knee-joint was laid open, and amputation became necessary.— (C. Bell, Op. Sur- gery, vol. 2, p. 204.) In transverse fractures, there is a considerable sepa- ration between the two fragments of the bone, very perceptible to the finger when the hand is placed on the knee. This separation is not occasioned equally by both portions ; the upper one, embraced by the ex- tensor muscles, is drawn upwards very forcibly by these powers, which the patella no longer resists ; while the inferior portion, being merely connected with the ligament below, is not moved by any muscle, and can only be displaced by the motions of the leg to which it is attached. Hence the separation is least when the limb is extended, being then only produced by the upper fragment; greatest when the limb is bent, because both pieces contribute to it ; and it may be increa.sed or diminished by bending the knee more or less. As Boyer has particularly noticed, the laceration or not of the tendinous expansion upon the front of the patella, makes a material difference in these cases, because it is a part of great importance in the cure. According to this author, a portion of it in simple fractures of the patella generally escapes laceration, and the separation of the fragments is then not very considerable ; but violent action of the extensor muscles, the fall subse- quent to the fracture or bending of the knee too much, may separate the pieces of bone far from each other, and rupture the tendinous expansion. — (Traiti des Mai. Chir. t. 3, p., 328.) According to Sir A. Cooper, “ when the ligament is but little torn, the separation will be but half an inch ; but under great extent of in- jury, the bone is drawn five inches upwards, the cap- sular ligament and tendinous aponeurosis covering it being then greatly lacerated.” — (Surgical Essays, part 2, p. 84.) The upper portion of bone may be moved trans- versely, and pain is thus excited, but no crepitus can be felt, as the two pieces of bone are not suffi- ciently near each other. When the swelling of the knee, consequent to fractures of the patella, is very great, the symptoms of the injury may be more or less obscure. However, in consequence of the inability of the extensor muscles to move the leg, except in a few cases where the fracture is very low, the patient can- not stand without difficulty, and is unable to walk. In the treatment, the chief indications are to over- come the action of the extensor muscles of the leg, and to keep the fragments as near each other as pos- sible, partly by a judicious position of the limb, and partly by mechanical means. The first indication is fulfilled by relaxing the above-mentioned muscles ; 1st, by extending the leg ; 2dly, by bending the thigh on the pelvis, or, in other w'ords, raising the femur, so that the distance between the knee and anterior su- perior spinous process of the ileum may be as little as possible ; which object, however, will also require the body to be raised, and the pelvis somewhat inclined forwards. In short, as Richter long ago advised, the patient should be almost in a sitting posture, the trunk forming a right angle with the thigh. — (Bill. Chir. b. 6, p. 611, Gottingen, 1782.) 3dly, The muscles are to be compressed with a roller. The second indica- tion, or that of placing and maintaining the fragments in contact, or as nearly so as circumstances will al- low, is in a great measure already answered by the above-recommended position of the limb and trunk ; but it is not perfectly fulfilled unless the upper portion of the bone be also pressed towards the lower frag- ment, and mechanically held in this situation by the pressure of an apjjaratus or bandage. And, in push- ing the upper fragment towards the lower one, the surgeon should always be careful that the skin be not depressed and pinched between them. Having described the principles which ought to be observed, I do not know that any great utility would result from a detail of the various methods of treating a broken patella, preferred by different surgeons. In the last edition of the First Lines of Surgery may be found a description of the plan and apparatus employed by Baron Boyer. Desault’s practice, which was re- lated in the third edition of this Dictionary, I now omit as not being exactly such as modern surgeons would adopt ; not from any of his principles being erroneous, but because his apparatus is more compli- cated than necessary. After putting the patient to bed upon a mattress, and in the desirable posture, with the limb confined, sup- ported, and raised, as above directed, upon a well padded hollow splint. Sir A. Cooper applies at first no bandage to the knee, but covers it with linen wet with a lotion composed of liq. plunibi acet. dilut. 1 v. and spir. vin. 5 j- if) on the succeeding day or two, there be much tension or ecchyrnosis, leeches should be ap- plied, and the lotion continued; but the employment of a bandage is not to commence until the tension has subsided ; for Sir A. Cooper assures us that he has seen the greatest sufi'ering, and such swelling as threatened gangrene, produced in these cases by the too early use of a roller. Instead of a circular band- age, placed above and below the broken bone, and drawn together with tape, &c., so as to bring the upper fragment towards the lower one, this experienced sur- geon prefers the following method. A leather strap is buckled round the thigh, above the broken and elevated portion of bone, and from this circular piece of leather another strap passes under the middle of the toot, the leg being extended, and the foot considerably raised. This strap is brought up to each side of the patella, and buckled to the leather band already applied to the lower part of the thigh. It may al.so be lastened to the foot or any part of the leg with tapes. The limb is 406 FRACTURES. to be confined iu this position five weeks if the patient be an adult, and six if advanced in years. Then a slight passive motion is to be begun, and to be gently in- creased from day to day, until the flexion of the knee is complete. — {Surgical Essays, part 2, p. 91.) But, al- though the impropriety of making any constriction of the knee with a bandage, while the skin is swelled and inflamed, must be obvious, the surgeon ought to be apprized that such swelling and inflammation ought not to occa.sion the least delay in placing the limb in the right posture, and pressing the upper fragment to- wards the lower one. Mohrenheim ascribes the lame- ness formerly so frequent after this fracture, partly to the custom of not thinking of bringing the jneces of bone together until the swelling had subsided, and partly to the fashion of bending the joint too soon, with a view of preserving its motion. But, says he, nothing can be clearer than that It is most advanta- geous to attend to the union of the fracture first, and to the flexibility of the joint afterward. — {Beohach- tungen, b. 2, 8vo. 1783.) Boyer has likewise re- marked, that the uniting substance is apt to yield, and become lengthened, by bending the knee too early, and he therefore never allows this motion to be performed before the end of two months. When the ligamentous substance is long, and the patient very slow in regain- ing the use of the extensor muscles, he should sit every day on a table, and endeavour to bring them into action, and as this increases, a weight may be affixed to the foot, as Hunter, Sheldon, «&c. recommend. Nothing keeps the leg more surely extended than a long, broad, excavated splint, with a suitable pad, ap- plied to the posterior part of the thigh and leg, and fixed there with a roller, while the thigh itself is to be bent by raising the whole limb, from the heel to the top of the thigh, with pillows, which, of course, must form a gradual ascent from the tuberosity of the ischium to the foot. The broken patella is almost always united by means of a ligamentous substance, instead of bone. However, that an osseous union may follow a trans- verse fracture of the patella, and still more frequently a perpendicular one, is a fact of which there is not noAV the slightest doubt. Thus, Lallement has published an unequivocal specimen of a transverse fracture united by bone, with the history of the case, and the appearances after the death of the patient from some other affection. — {Boyer, Traite des Mai. Chir. t. 3, p. 355, &c.) In the collection of Dr. William Hunter, there is one well-marked instance of the bony union of a transverse fracture of the patella, and other exam- ples have been seen in the dead subject by Mr. Wilson. — {On the Structure, Physiology, ^c. of the Skeleton, p. 240.) In Mr. Charles Bell’s museum may also be seen similar specimens. — {On Injuries of the Spine and Thigh-bone, p. 57, 58.) The reason why trans- verse fractures of the patella do not commonly unite by callus, is not owing to the want of power in this bone to produce an osseous connecting substance ; for, as Larrey has several times noticed, if the fragments are kept in perfect contact by means of a suitable appara- tus, their bony reunion becomes so complete, that scarcely any vestige of the injury can afterward be traced. — {Journ. Complrm. t. 8, p. 114.) Indeed, it is a fact, on which Larrey dwells, as affording a proof that callus is produced not by the periosteum, but by the vessels of the bones themselves. And what must add strength to the purport of the foregoing remarks is the consideration, that perpendicular or longitudinal frac- tures of the patella, which are not liable to any displace- ment from the action of the extensor muscles of the leg, readily admit of bony union.— (WiZvon on the Structure and Physiology, vhen several of these swellings occur at the same lime in different places. In the last circumstance they often occasion in children, and even in irritable adults, restlessness, loss of appetite, spasms, &c. They rarely exceed a pigeon’s egg in size, and they may originate on any part of the body. '• Biles commonly arise from constitutional causes. Young persons, and especially subjects of Ihll plethoric habits, are most subject to them. The disease is also observed to occitr with most frequency in the spring. — (Lassus, Pathologie Chir. t. 1, p. 16.) According to Richerand, the origin of biles depends upon a disordered state of the gastric organs. — (Nosographie Chir. t. 1, p. 124, Hit, 2,) Frequently they arise without any evident capse, and apparently in healthy constitutions. At other times they follow emptive diseases and typhus. —(IF. Gibson, Institutes, 430 GONORRHCEA. opiate plaster on the pubes, or the loins, wher«»the nerves of the bladder originate ; or a small blister on the perinaeum. In another place he mentions bark, ci- cuta, sea-air, and sea-bathing, among the proper means. Swelled Testicles. See Hernia Humor alis. For a more full account of gonorrhcea, according to the above doctrines, see A Treatise on the Venereal Disease, by John Hunter, from page 29 to 90. ON THE QUESTION WHETHER GONORRHCEA IS REALLY A FORM OF THE VENEREAL DISEASE. The foregoing remarks, and others in Mr. Hunter’s Work, would lead- one to believe, that the poison of gonorrhcea and the venereal virus are the same. Here it is my duty impartially to state the arguments which have been urged for and against this important doc- trine. Mr. Hunter assures us, that he has seen all the symptoms of lues venerea originating from gonorrhcea only ; that he had even produced venereal chancres by inoculating with the matter of gonorrhoea ; and that he afterward repeated these experiments in a manner in which he could not be deceived.— (P. 293, et seq.) Mr. Hunter’s experiments, it is true, have been re- peated with a different result ; but, a.s a late writer has remarked, can we wonder at this, when we consider from how many causes gonorrhoea may arise, and how impossible it is to distinguish the venereal from any other?— (Oft^. on Morbid Poisons, by J. Adams, M.D. p. 91, ed. 2.) Another argument adduced by Hunter, in favour of the poisons of gonorrhoea and chancre being the same, is the probability that the Otaheitans had the venereal disease propagated to them by European sailors, who were affected with gonorrhcea ; for these can hardly be supposed to have had a chancre during a voyage of five months, without the penis being destroyed. It is impossible, however, to say what time may elapse between the application of (he venereal poison to the penis and the commencement of the ulceration. Therefore, Bougainville’s sailors, alluded to by Mr. Hunter, might have contracted the infection at Rio de la Plata; but actual ulcers on the penis might not have formed till about five months afterward, when the ship arrived at Otaheite. In attempting to explain why a gonorrhcea and a chancre do not equally produce lues venerea, and why the medicine which almost universally cures chancre has less effect on gonorrhcea, a modern advocate for Mr. Hunter’s doctrine says, that we must take into consideration, that the seat of the two diseases is dif- ferent ; that the same cause may produce different ef- fects upon different parts; that the same poison, when mixed with different fluids, may be more or less vio- lent in its operation ; and that there may be greater or less attraction of certain fluids to a part, according to its nature and composition . — ( Inquiry mto some Effects of the Venereal Poison, by S. Saivrey, 1802, p, 4.) Mr. Sawrey very truly remarks, p. 6, that if the gonor- rhceal matter has clearly and decidedly produced chan- cre, or contaminated the system in any one instance, the question is determined. It could in no instance produce these effects, unless it had the power of doing so. This writer brings forward some cases to prove, that the poison of gonorrhcea may ])roduce gonorrhcea or chancre ; but the limits of this work only aflbrd room to observe that these instances are by no means deci- sive of the point, because some objections may be urged against them, as indeed Mr. Sawrey himself allows. 1’hat Mr. Hunter’s cases are inconclusive, I have par- ticularly endeavoured to explain in the last edition of the First Lines of the. Practice of Surgery. Why does not gonorrhcea commonly produce ulcer- ation in the urethra? Mr. Sawrey tries to solve this question, by saying, that the product of the venereal in- flammation, the diseased contents of the small arteries of the urethra, are thrown out of these open-mouthed vessels mto this canal, without any breach of their tex- ture, which otherwise would be a necessary conse- sequence. Why does not gonorrhena equally contaminate the system as chancre ? In gonorrhcea, says Mr. Sawrey, the discharge is very plentiful ; it is not, in general, attended with ulceration ; the poison is much more diluted and mixed with a mucous and puriform fluid. It is deposited in the urethra and its lacunae, where little or no pressure is applied, and it finds easy rgfosS' out of the canal. In chancre, there is breach of sub- stance, the poison is not much diluted, &c. Why does not chancre generally in the same person produce gonorrhcea and gonorrhcea chancre? Mr. Sawrey, in answer, expresses his belief, that these in- cidents are not very unfrequent. He says, he has known persons having a chancre, which continued for months, b^ome affected after that time with a claj), without any farther exposure. His opinion is, that the matter of the chancre had insinuated itself into the urethra and produced the disease ; though he confesses, many would explain the circumstance by supposing that the chancre and gonorrhcea were both communi- cated at the same time by two different poisons. Mr. Hunter remarks, that the presence of one dis- ease renders the adjacent parts less susceptible of the influence of the other. Mr. Sawrey concludes his second chapter with in- clining to the idea, that the matter of gonorrhoea is not strictly pus, but of a more mucous nature than that of a chancre. However, when he mentions chemical at- tractions, as drawing the poison from mucus to the urethra, and from pus to the dry parts, in order to ex- plain thelastofthe above questions, every sober reader must feel sorry that a work which contains some really sensible observations should comprehend this most unfortunate one. Mr. Whately also supported the opinion, that the matter of gonorrhcea and that of chancre are the same. — (On Gonorrhcea Vimlenta.) Another defender of this side of the question is Dr. Swediaur, who endeavours to prove the fallacy of the following positions: 1. That the poison which produces the clap does never, tike that of chancres, produce any venereal symptoms in the mass, or lues itself. 2. That the poison of the clap never pro-- duces chancres, and that the poison of chancres never produces a clap. 3. That mercury never co7itributes to, nor accelerates, the cure of a clap; but that, on the contrary, every ble^iorrhagia may be certainly cured without mercury, and without any danger of leaving a lues behind. His arguments run thus : — the reason why claps do not, like chancres, constantly produce the lues is, that most of them excite only a superficial inflammation in the membrane of the urethra, without any ulceration. Hence, absorption cannot easily take place, the poison being out of the course of the circulation. But he has seen claps with an ulcer in the urethra, followed by the most unequivocal symptoms of lues itself. He mentions the urethra being defended with a large quan- tity of mucus, as the thing impeding the common form- ation of ulcers, which do occasionally occur when the mucus is not secreted as usual, or is washed away. He asserts, that in many cases, where he had occasion to examine both parties, he was convinced that the chancres were communicated by a person affected with a simple gonorrhoea; and vice versd, that a virulent clap had been the consequence of an infection from a person having merely chancres. He says, that if a patient with a venereal running does not take care to keep the prejjuce and glans perfectly clean, chancres will very often be produced. He ov.tis a great many claps are cured without mercury ; j et, repeated expe- rience has shown him a cure cannot be always thus accomplished. Mild cases, without ulcer or excoriation in the urethra, may certainly be radically cured witl>- out a grain of mercury ; and though mercury should be given, it would not have the least effect ; not be- cause the disease does not proceed from the venereal poison, but becau.se it is out of the course of the circu- lation. He contends, that the topical use of mercury in injections acts usefully even in these cases. But when a clap is joined with ulceration in the urethra, it is always cured more safely and expeditiously with mercury, and is frequently incurable without it. A lues also follows ca.ses attended with ulcers in the ure- thra. He allows, that all claps are not venereal. — (See Tract. Ohs. on Venereal Complaints, by J. Swidianr.) One argument urged against the identity of gonorrhmal ami chancrous virus is, that gonorrhoea was described as a symptom till nearly half a century after the other symittoins of the venereal disease were known. Fal- lopius is among the first who observed gonorrhoea a.s a symptom of the venereal disease. “ If. however, ’ says Dr. Adams, “ venereal gonorrhcea was unnoticed GON GRA till about fifty years after the other forms of the dis- ease were described, what does this prove, but that contagious gonorrhoea was so common as to be disre- garded as a symptom of the new complaint? Can there be a doubt, from the caution given by Moses, that gonorrhma was considered as contagious in his days ? During the classical age, we find inconveniences of the urinary passages were imputed to incontinence ; and the police of several states, before the siege of Na- ples, made laws for preserving the health of such as would content themselves with public stews instead of disturbing the peace of families. This is enough to lessen our surprise that gonorrhoea should be unnoticed for some time after the appearance of the venereal disease. But so far is it from proving that the two contagions are different, that the fairest inference we can draw is in favour of their identity. For if by this time the venereal disease began to be so far understood, that secondary symptoms were found the consequence of primary ones in the genitals, it is most probable, that the first suspicion of venereal go- norrhcea arose from the occurrence of such secondary appearances, where no other primary symptoms could be -{Adams, on Morbid Poisons, p. 95, ed. 2.) In relating the arguments maintained by the best modern writers to repel the attacks made on the doc- trine that gonorrhoea and chancre arise from the same poison, we have been compelled to disclose the chief grounds on which the assailants venture to entertain a contrary theory. The sentiments of Mr. B. Bell are quite at variance ■with those of Hunter, Sawrey, Swediaur, Adams, How- ship, &c. ; but my limits •will only allow me just to enumerate a few of his leading arguments. If the matter of gonorrhoea and that of chancre were of the same nature, we must admit that a person with a chancre only can communicate to another, not only every symptom of pox, but of gonorrhoea; and that another, with gonorrhoea only, can give to all with whom he may have connexion, chancres, with their various consequences. This ought indeed to be a very frequent occurrence ; whereas all allow that it is even in appearance very rare. On the supposition that the matter of gonorrhoea and lues venerea being the same, the latter ought to be a much more frequent occurrence than the former, from the greater ease with which the matter of infec- tion must, in every instance, be applied to those parts on which it can produce chancres, than that of the urethra, where, instead of chancre of ulceration, it al- most always excites gonorrhoea. It is difficult to con- ceive how the matter, by which the disease is commu- nicated, should find access to the urethra ; while all the external parts of the penis, particularly the glans, must be easily and universally exposed to it ; and yet gonorrhoea is a much more frequent disease than pox. Cases of gonorrhoea are in proportion to those of chancre, according to Mr. B. Bell’s experience, as three to one. It is obvious that the very reverse should hap- pen, if the two diseases were produced by the same kind of matter. I need not adduce other arguments, as the reader must be already acquainted with any w'orth knowing, from what is said in the previous part of this article. The grand practical consideration depending on the possibility of the venereal disease arising from gonor- rhfea is, whether mercurials should not be exhibited, in all cases, with the view of preventing such a conse- quence. Waving, on my own jiart, all attempts to decide the point, whether the matter of a chancre and that of one species of gonorrhoea are of the same nature, I shall merely content myself with stating, that, as far as my observation and inquiries extend, the majority of the j best practitioners of the present day consider the exhi- bition of mercury unnecessary, and consequently im- proper, in all cases of gonorrhtca. This fact almost amounts to a proof that, if venereal symptoms do ever follow a clap, they are so rare, and, I may add, always so imputable to other causes, that the employment of | mercury, as a preventive, would, upon the whole, do more injury than benefit to mankind ; and this even ailmittiiig (what to my mind has never been unequivo- cally proved) that the matter of gonorrlicea is really capable, in a very few instances, of giving ri.se to the venereal disease. 431 The reader must weigh the different arguments him- self. Some of Mr. B. Bell’s reasoning is certainly un- tenable, as Mr. Sawrey has clearly shown ; but the latter, also, is not invulnerable in many points, which he strives to defend. . /. Andrie, An Essay on the Theory and Cure of the Venereal Gonorrhoea, and the Diseases which happen in consequence of that Disorder, 8vo. Land. 1777. J. Nevill, A Description of the Venereal Gonorrhoea, 8ro. Lond. 1754. /. Norman, Method of Curing the Viru-‘ lent Stillicidium, or Gonorrhoea, with an Account of the Efficacy of Plummer's Al terative Pills, Svo. J. Clubbe, An Essay on the Gonorrhoea Virulenta, in which the different Opinions respecting the Treatment of the Disease are carefully examined, d, c. 8vo., Lond. 1786. W. Thomas, An Essay on Gonorrhoea, with some Obs. on the Use of Opium in the Cure of that Disease, 8vo. Lond. 1780. A Treatise on the Venereal Disease, by J. Hunter, 1788. W. Rowley, The most co- gent Reasons why astringent Injections, Src. should be banished, £rc. 8vo. Lond. 1800. J. H. G. Schlegelf Versuch einer Geschichte des Streites ilber die Iden- titdt des Venus und Tripper gif tes, 12mo. Jenoe, 1796. Whately on the Gonorrhoea Virulenta, 8vo. Lond. 1801. Pract. Obs. on Venereal Complaints, by F, Swediaur, M.D. edit. 3. An Inquiry into som e of the Effects of the Venereal Poison, by S. Sawrey, 1862. Obs on Morbid Poisons, by J. Adams, M.D. edit. 2, 1807. J. C. Jacobs, Demonstration de VIdentiU des Virus de la V&ole et de la Gonorrhee, 8vo. Bruxelles,- 1811. J. F. Hernandez, Essai Analytique sur la Non-identite des Virus Gonorrhoique et Syphilitique, 8vn. Toulon, 1812. R. Carmichael, Essays on the Ve- nereal Diseases which have been confounded with Sy- philis, «S-c. 4to. Lond. 1814 ; and his Obs, on the Symp- toms and Specific Distinctions of Venereal Diseases, Svv. Lond. 1818. John Howship, on Complaints af- fecting the Secretion und Excretion of the Urine, Svo. Lond. 1823. GOKGET. An instrument used in the operation of lithotomy, for the purpose of cutting the prostate gland and neck of the bladder, so as to enable the operator to introduce the forceps and extract the stone. It is, in fact, a sort of knife, at the end of w'hich is a beak that fits the groove of the staff, and admits of being pushed along it into the bladder. Besides cutting gorgets, constructed for the preced- ing design, there are also blunt ones, intended to be in- troduced into the wound, where their concavity serves as a guide for the forceps into the bladder. GRANULATIONS. The little, grain-like, fleshy bodies, which form on the surfaces of ulcers and sup- purating wounds, and serve both for filling up the ca- vities and bringing nearer together and uniting their sides. We must here consider the operations of nature, in bringing parts as nearly as possible to their original state, whose disposition, action, and structure have been altered by accident or disease. Having formed pus, she immediately begins to form new matter upon surfaces in which there has been a breach of conti- nuity. This process is called granulating or incar- nation; and the substance formed is called granula- tions. Granulations are an accretion of animal matter upon the wounded or exposed surface ; they are formed by an exudation of the coagulating lymph from the vessels ; into which new substance the old vessels very pro- bably extend, and in ■w'hich new ones are formed. Hence, granulations are extremely vascular ; indeed,, more so than almost any other animal substance, ‘‘That this is the case (says Mr. Hunter) is seen in sores every^ day. I have often been able to trace the growth and vascularity of this new substance. I have j seen upon a sore a white substance exactly similar, in every visible respect, to coagulating lymph. I have not attempted to wipe it off, and the next day of dress- ing I have found this very substance vascular ; for, by wiping or touching it with a probe, it has bled freely, I have observed the same appearance on the surface of j a bone that has been laid bare. I once scraped off some of the external surface of a bone of the foot, to see if the surface would granulate. I remarked, the following day, that the surfatai of the bone was co- vered with a whitish substance, having a tinge of blue. When I passed my probe into it, I did not feel the bone bare, but only its resistance. I conceived this 43 ^ GRA GUA substance to be coagulable lymph thrown out from in- flammation, and that it would be forced off when sup- puration came on ; but on the succeeding day I found it vascular, and appearing like healthy granulations.” The vessels in granulations pass from the original parts to their basis, and thence towards their external surface, in tolerably regular parallel lines. The sur- face of this new substance has the same disposition to secrete pus as the parts which produced it. The sur- faces of granulations are very convex, the reverse of ulceration, having a great many small points or emi- nences, so as to appear rough. The smaller such points are, the more healthy are the granulations. The colour of healthy granulations is a deep florid red. When livid, they are unhealthy, and have only a lan- guid circulation. Healthy granulations, on an exposed or flat surface, rise nearly even with the surface of the surrounding skin, and often a little higher ; but when they exceed this, and take on a growing disposition, they are unhealthy, become soft, spongy, and without any disposition to form skin. Healthy granulations are always prone to unite to each other, so as to be the metins of uniting parts. Granulations are not easily formed on the side of an abscess nearest the surface of the body. They are not endowed with the same powers as parts originally formed. Hence they more readily ul- cerate and mortify. The curious mode in which gra- nulations contract when sores are healing, and even for some time after they are healed, has been explained in the article Cicatrization. — (See A Treatise on the Blood, Inflammation, ^c. by John Hunter, y. 473, etseq. 1794.) It is a question whether granulations can ever be formed without suppuration I Mr. Hunter seems in- clined to think that they may occasionally be produced without it, and he supports his opinion by the relation of the dissection of a fractured limb, in which he ob- served a substance resembling granulations. Dr. John Thomson, on the other hand, declares that he has never seen any thing which he could regard as an. ex- ample of a granulation, and still less of a granulating surface, where pus was not formed. — (See Lectures on Inflammation, p. 408.) The exact process by which the blood-vessels, nerves, and absorbents of granulations are formed, is still among the secrets of nature. The observations of Mr. Hunter on the subject amount only to conjecture. “The growth of nerves and their developement in new-formed flesh or granulations (says Dr. J. Thom- son), is a subject of equal curiosity with the growth of blood-vessels in the same structure. Their exist- ence in granulations is proved by the pain which is felt on our pinching, rubbing, or wiping, the surface of a sore. Even the granulations which arise from the surface of bone are sensible (a statement not admit- ted by Sir Astley Cooper), though we are not very well able to prove the sensibility of the larger branches of nerves, from which the newly formed and sensible nerves and filaments in the granulation are imme- diately derived. All the difficulties which I formerly mentioned to you, as occurring in the explanation of the manner in which coagulable Ijunph or granulations are penetrated with blood-vessels, present themselves the moment w^e begin to reflect on the manner in which the same granulations are provided wth nerves ; and these difficulties are still increased, when we re- flect that the same granulations are in the course of a few hours provided, not only with blood-vessels and nerves, but also with a system of absorbents. The existence of absorbents in granulations is proved not only by the changes of hulk which we see them daily undergo, becoming gradually, in the healthy state, smaller, firmer, and more compact, but also, by the frequent disappearance in whole or in part of a granu- lating surface by the process of ulcerative absorption.” — (See Thomson’s Lectures on Inflammation, p. 419.) According to Sir Astley Cooper, granulations which spring from parts endued with great sensibility, like muscles, are extremely sensitive; but granulations which arise from bones, he says, have no sensibility whatever. These observations are qualified with the condition that the bone be uninflamcd, and it is ac- knowledged, that granulations arising from the cancel- lated structure of bones are sometimes extremely sen- sitive. He describes granulations from tendons as quite insensible, and those ffom aponeuro.ses and fascia; as jwssessing very little sensibility. — (,See Lancet, vol 1 , p. 22.3.) Every young dresser of sores at an hospital who has been too lavish of the red precipitate oint- ment, must have learned from experience, that granula- tions are furnished with absorbent vessels, and that mercu^ may be absorbed from the surface of ulcers, and bring on an unwished-for salivation of the patient. It is observed by Sir Astley C(»oper, that in recently formed ulcers, the granulations are not good absorbent surfaces; but that when the sores have existed a good ■while, they readily take into the system any substance which may be applied to them. Thus, when old si- nuses are injected with a solution of the oxymuriate of mercury, with the view of stimulating them to heal, the patients are sometimes salivated by the mercury being absorbed into the system. Sir Astley has seen the same effect produced by the ajjplication of the lo- tion of lime-water and the submuriate of mercury to the surface of ulcers. Indeed, the absorbent power of granulations is frequently the means of producing baneful effects upon the constitution, by the introduc- tion of deleterious substances into the circulation. Thus arsenic, applied to sores, is often conveyed into the system, and, on this account, is to be regarded as a dangerous external remedy. Sir Astley Cooper quotes one instance, in which the patient seems to have been poisoned by the indiscriminate application of arsenic to a fungus of the eye. Opium, also, when applied to the surfaces of sores, is very readily absorbed, produc- ing similar effects to those which arise from its intro- duction into the stomach. Thus, when the quantity absorbed is too great, excessive costiveness, extreme pain in the head, and torpor of the system, are the con- sequences, which require the frequent administration of active purgatives for their removal. — (See Lancet, vol. 1, p. 219, £,-c.) A temporary amaurosis has been known to be produced by the absorption of the extract of belladonna from the surface of irritable malignant ul- cers.— (F. Tt/rrelZ; A. Cooper's Lectures, vol. l,p. 169.) GUAIACUM. Many writers of the sixteenth cen- tury contended that guaiacum was a true specific for the venereal disease ; and the celebrated Boerhaave, in the eighteenth, maintained the same opinion. Mr. Pearson mentions, that when he tvas first intrusted with the care of the /.ock Hospital, in 1781, Mr Brom- field and Mr. Williams were in the habit of reposing great confidence in the efficacy of a decoction of guaia- cum wood. This was administered to such patients as had already employed the usual quantity of mercury ; but w'ho complained of nocturnal pains, or had gum- mata, nodes, ozaena, and such other effects of the vene- real virus, connected with secondary symptoms, as did not yield to a course of mercurial frictions. The diet consisted of raisins and hard biscuit ; from two to four pints of the decoction were taken every day ; the hot bath was used twice a week ; and a dose of antimonial wine and laudanum, or Dover’s powder, was com- monly taken every evening. Constant confinement to bed was not deemed necessary ; neither was exposure to the vapour of burning spirit, with a view of exciting perspiration, often practised ; as only a moist state of the skin wa.s desired. This treatment was, sometimes, of singular advantage to those whose health had sus- tained injury from the disease, long confinement, and mercury. The strength increased; bad ulcers healed ; exfoliations were completed ; and these anomalous symptoms, which would have been exasperated by mercury, soon yielded to guaiacum. Besides such cases, in which the good effects of guai- acum caused it to be erroneously regarded as a specific Ibr the lues venerea, the medicine was also formerly given by some, on the first attack of the venereM disease. The disorder being thus benefited, a radical cure was considered to be accomplished ; and, though frequent relapses followed, yet, as these partly yielded to the same remedy, its reputation was still kept up. Many diseases also, w'hich got well, were probably not really venereal cases. Mr. Pearson seems to allow, that, in syphilitic affections, it may, indeed, operate like a true antidote, suspending, for a time, the progress of certain venereal symi)toms, and removing other ap- pearances altogether ; but he observes, that experience lias evinced that the unsubdued virus yet remains active in the constitution. Mr. Pearson found guaiacum of little use in pains of the bones, except when it proved sudorific ; but that it was then inferior to antimonv or ammonia. When the constitution has been impaired by mercurv-and long SUH GUN 433 confinement, a thickened state of the ligaments, or pe- riosteum, or foul ulcers, still remaining, Mr. Pearson says, these effects will often subside during the e.xhi- bition of the decoction. lie says it will often suspend, for a short time, the progress of certain secondary symptoms of the lues venerea ; for instance, ulcers of ■(’ie tonsils, venereal eruptions, and even nodes. Mr. P''arson, however, never knew one instance, in which guaiacum eradicated the virus ; and he contends, that its being conjoined with mercury neither increases the virtue of this mineral, lessens its bad effects,- nor dimi- nishes the necessity of giving a certain quantity of it. He has seen guaiacum produce good effects in cutaneous diseases, the ozsua, and scrofulous affections of the membranes and ligaments. — (See Pearson on the Effects of Various Articles in the Cure of Lues Venerea, edit. 2, 1S07.) Many of the foregoing observations on the virtues of guaiacum in syphilis are considerably af- fected by the fact, now so completely established, that this disease is generally capable, in the end, of a spon- taneous and lasting cure.— ^See Vejiereal Disease.) GUMMA. A soft tumour, so named from the resem- blance of its contents to gum. GUN-SHOT WOUNDS receive their name from the manner in which they are produced, being generally caused by hard, obtuse, metallic bodies, projected from cannons, muskets, or some other species of firearm. With such injuries, it is also usual to comprehend a variety of dreadful accidents arising from the explosion of shells, or the violence with which pieces of stones from ramparts, or splinters of wood on board of ship, are driven about. Gun-shot wounds are the most con- siderable of the contused kind ; and what is to be said of them will apply, more or less, to all contused wounds, according to the degree of contusion. They are particularly characterized by what the French sur- geons are fond of calling a disorganization, of their surface. The excessive contusion and violence ob- servable in gun-shot wounds depend upon the rapidity with which the bodies occasioning them are propelled. The parts touched by the ball are frequently converted into a blackish slougli, the colour of which made our ancestors suppose, that bodies projected by gunpowder became heated, and actually bunted the flesh with which they came into contact. But reason and experience have now proved, that whatever may be the rapidity of a projectile, it never acquires in its jiassage any per- ceptible heat. Indeed, a modern wTiter asserts, that such a degree of heat as would be requisite to make a ball burn parts in its passage, would really melt it. —(Rickerand, Nosographie Chir. t. 1, p. 217, edit. 2.) In general, gun-shot wounds do not bleed much, unless large blood-vessels be injured ; their circumference is often livid ; and the shock that attends their infliction, or the injury done to the nerves, may occasion in the limb or part a kind of toqtor, sometimes extending itself to the whole system. How^ever, as Dr. Hennen most truly observes, “ the effects of a gun-shot w'ound differ so materially in dif- ferent men, and the appearances are so various, ac- cord'ug to the nature of the part wounded, and the greater or less force with which it has been struck, that no invariable train of symptoms can be laid down as its necessary concomitants. If a musket or pistol- ball has struck a fleshy part, without injuring any ma- terial blood-vessel, we see a hole about the size of, or smaller than, the bullet itself, with a more or less dis- coloured lip, forced inwards ; and if it has passed through the parts, we find an everted edge, and a more ragged and larger orifice at the point of its exit. The hemorrhage is in this ca.se very slight, and the pain in- considerable, insomuch that, in many instances, the wounded man is not aware of his having received any injury. If, however, the ball has torn a large vessel, or nerve, the hemorrhage will generally be profuse, or the jiain of the wound severe, and the power of the part lost. Some men will have a limb carried off or shat- tered to pieces by a cannon-ball, without exhibiting the sliglite.st symptoms of -mental or corporeal agitation; tiay, even without being conscious of the occurrence ; and when they are, they will coolly argue on the pro- bable result of the injury ; while a deadly paleness, instant vomiting, profuse per.«piration, and universal tremor will seize another on the receipt of a slight fh'.sh wound. This tremor, which has been so much talked of, and wdiit h tp an inexperienced eye is really terrifying, is soon relieved bv a mouthful of wine or Vox- I.-E e spirits, or by an opiate ; but above all by the tenderness and sympathizing manner of the surgeon, and his as- surance of the patient’s safety.”— (Principles of Mil. Surgery, p. 33, ed. 2.) On the other hand, it is correctly noticed- by Mr. Guthrie, tliat the 'continuance of the constitutional alarm or shock' ought to excite great suspicion of .se- rious injury ; and when wounds have been received in such situal'ions, or bear such appearances, as render it doubtful whether any parts of vital importance have been injured or not, the manner in which the constitu- tional perturbation lasts may be as.sumed as evidence of the fact, when other symptoms more indicative of the injury are wanting ; and under all such circum- stances, a very cautious prognosis should be delivered. — (On Gun-shot Wounds, p. 11, ed. 2.) Respecting the general character of gun-shot wounds not to bleed much unless large vessels be injured, it is a fact which necessarily depends upon the degree of contusion usually attending these injuries. But it is also true, as the preceding author has stated, that al- though some gun-shot wounds bleed but little at first, there is in the greater number of cases more or less of blood ; and in wounds of vascular parts, like the face and neck, the quantity lost is often considerable, though the main arterial branches may not be injured. — (Op. cit.p. 6, ed. 2.) In gun-shot wmunds, another circumstance is ob- served, which is often remarked in other cases, viz. when a large artery is partially divided, the bleeding is more profuse and dangerous than when the vessel is completely severed, and the hemorrhage, if not re- pressed by a tourniquet, or other means, wdll often continue until the patient dies. Thus, Mr. Guthrie speaks of three cases in which life was lost from wounds of the femoral, humeral, and c.arotid arteries, no e(- fectual means of stopping the hemorrhage having been adopted.-^(P. 8.) • Until Ambrose Pare introduced more correct theories upon the subject of gun-shot wounds, ideas the most false, and errors highly prejudicial, prevailed both in their history and treatment, and particularly respecting what have been falsely named wind-contusions. Can- non-balls and bullets Sometimes produce dreadful de- grees-of injury, without occasioning any breach of conti- nuity in the integuments. This observation is so strictly true, that the muscles and bones may actually be crushed and broken to atoms, without the skin being at all wound ed. Such cases were for a long while imputed to the vio- lent motion supposed to be communicated to the air by the ball itself. It was imagined, that this elastic fluid, being rapidly displaced by the shock of the projectile, was capable of making such pressure on surrounding bodies, as to destroy their texture. But how could this violent pressure originate in the midst of the open and unbounded air ? If this theory were true, the effect in question would constantly happen, whenever a ball passes near any part of the body. The contrary, how ever, is so much the case, that pieces of soldiers’ and seamen’s hats, of their feathers, clothes, and even hair, are shot away in everj" battle, without any other mis- chief being done. In consequence of the manner in which such inju- ries of the soft parts, and even of the bones, unatteuded with any breach in the skin, have been supposed to be produced, they have been erroneously termed wind- contusions. In fact, these cases are now universally acknowledged by all the most accurate observers never to proceed from the cause to which formerly they were ■always ascribed. The air does not move with the same rapidity as tlie ball ; but its motion is less in proportion as it is a more subtile matter, and must be too feeble to ai'count for such a violent degree of injury. The air to which the ball must really communicate the greatest motion is what is directly before it; and this never bruises the part untouched by the ball itself. It is only the air si- tuated laterally to the shot that is imaginiMl to do in- jury, and it cannot be greatly agitated. The violent consequences of sudden exi)losions, and the effects pro- duced on the organ of hearing by strong commotions of the air, prove nothing relative to the point in ques- tion. I-.astly, experience does not confirm the reality of such wind-contusions; for cannon-bails often tear off whole members, without the adjacent parts being in. the least injured. — (Sec Lc Vucher, in Mmioires de VAcad. dc Chir. t. 4, p. 22.) 434 GUX-SHOT VVOUxNDS. All eminent professor, who visited the continent for the purpose of seeing tiie wounded after the battle of Waterloo, fully coincides with M. le Vacher and all the moderns upon this subject. “We saw, and were in- formed of many instances in which cannon-balls had ptissed quite close to all the parts of the body, and had re- moved portions of the clothes and accoutrements, with- out producing the slightest injury of any kind. In other instances, portions of the body itself were re- moved by cannon-balls, without the contiguous parts having been much injured. In one case, the point of the nose w£is carried off by a cannon-ball without re- spiration being at all affected ; and in another very re- markable case, the e.xternal part of the ear was shot away, without even the power of hearing being sensi- bly irnpaired.”— (See Report of ObservatioTis made in the British Military Hospitals in Belgium, ij-c. by J. Thomson, p. 33, Edin. 1816.) I could cite many ca.ses, which I have seen myself, in proof of the truth of Le Vacher’s opinions ; but the point is now so universally admitted, that I shall merely add one observation that occurred to the notice of many as well as myself. At the bombardment of the French fleet in the basin of Antwerp early in 1814, a cannon- shot shattered the legs of two officers so badly, that the limbs were amputated. These gentlemen were walking at the moment of the accident in the \111age of Merksam, taking hold of the arm of my friend As- sistant-surgeon Stobo, of the 37th regiment, who was in the middle. Now the ball which produced the injury did not the slightest harm to the latter gentleman, al- though it must have passed as close as possible to his lower extremities, and most probably between them. Neither can what have been improperly called u-ind- contusions be attributed to an electrical shock on the parts, in consequence of the ball being rendered electrical by friction in the caliber of the gun, and giving off the electricity as it passes by (Vide Plenck's Sammlun- gen, 1 theii, p. 99); for metals never aciiuire this pro- perty from friction. The mischief imputed to the air is occasioned by the ball itself. Its producing a violent contusion, without tearing the skin and entering the limb, is to be ascribed to the oblique direction in which it strikes the part, or, in other instances, to the feebleness with which the ball strikes the surface of the body, in consequence of its having lost the greater part of its momentum, and acting principally by its weight, being, in short, what is called a spent ball. Daily observation evinces tha» balls, wliich strike a surface obliquely, do not penetrate, but are reflected ; though they may be impelled with the greatest force, and the body struck may be as soft and yielding as water. This alteration in the course of the ball, not only happens on the surface of the hu- man body, but also in the substance of a limb which it has entered. Thus, a bone, a tendon, &c. may change the direction of a ball w hich touches them at all obliquely. Hence, it is manifest, how it happens that the track of a gun-shot wound is not ahvays straight, and how balls sometimes run under the inte- guments nearly all round the body or limb. The causes of several of the peculiarities, attending gun-shot wounds, are to be sought among the laws by wldch moving bodies are governed, and by which the mechanical effect of a ball, projielled against any part of the body, must therefore be determined. The form, the momentum, and the direction of the shot that is re- ceived; the position, and the variety of structure, or, in other words, the variety of density and powers of resistance, in the part receiving it, must always be con- sidered, in order to account satisfactorily for the effects which it produces. And though, says Mr. Chevalier, in many cases, a mathematical explication of the course of the ball cannot be given, this arises entirety from the want of data, the laws of matter being fi.xed and immutable. But wffien the data are known, as, for in- stance, the velocity and direction of the shot, the posi- tion of the patient, or of the wounded part at the time of the accident, and the structure of the parts pene- trated, a much more probable conjecture of the course of the ball may generally be formed, than if these cir- cumstances had not been regarded. On the principle of the density and resistance of parts, attempts have been made to exjilain the reason of the concussion or shock wffiich is givfn, in many i instances, to the whole system by giui-shol wounds, j and which is represented, by writers on this subject, to be often attended with grave and even alarming ef- fects, extending, not only over the injured part, but af- fectmg the system at large. Thus, a shot striking against a tendon or a bone, in one of the extremities, will produce a greater concussion than if it struck only against softer parts. A shot striking a muscle in action will produce more concussion than if it struck against the same part of the same muscle at rest ; and a shot striking the head or wounding the liver, lungs, or in- testinal canal, will generally bring on instantaneous derangement of the whole system, with which the fmictions of these parts are so closely connected. — (T. Chevalier on Gun-shot Wounds, part 1, sect. 7.) Respecting the mechanical effects of the concussion, I am disposed to think, with Mr. Guthrie, that they have been rather exaggerated, and that in reality a more ac- curate explanation of the disorder of the system might be derived from other considerations ; “ A shot through the lungs (says he) will cause an instantaneous de- rangement of the whole system, but the resistance afforded by the part has little to do with it ; it is the lesion of the organic functions, intimately connected with life, that is the cause of the derangement. In the same manner, I do not conceive, that the general affec- tion of the system depends alone on the shock received, but on the effect the injury committed has on the ner- vous system.” — (On Gun-shot Wounds, p. 26, ed. 2.) A ball, when it strikes a part of the body, may cause four kinds of injurj". 1. It may only occasion a contu- sion, without penetrating the part, on account of its being too much spent, or of the oblique way in which it strikes the surface of the body. 2. It may enter and lodge in the substance of a part ; in which case the wound has only one aperture. 3. It may pierce through and through; and then there are tw'o openings, one at the entrance, the other at the exit of the ball. The cir- cumference of the aperture, where the shot entered, is usually depressed ; that of the opening, from which it came out, elevated. At the entrance, there is com- monly more contusion, than at the exit of the ball. The former opening is generally narrower ; the latter wider and more irregular, especially when the round smooth figure of the ball has been changed by its having struck a bone. 4 . A cannon-ball may tear off a whole limb. — (Richter, Anfangsgr. der Wundarzn. b. I.) Gun-shot wounds differ very much, according to the kind of body projected, its velocity, and the nature and peculiarities of the parts injured. The projected bodies are mostly bullets, sometimes cannon-balls, sometimes pieces of broken shells, and very often, on board of ship, splinters of wood. On account of the contusion w hich the parts suffer, from the violent passage of the nail through them, there is most commonly a part of the solids surrounding the wound deadened, which is afterward thrown Off in the form of a slough, gene- rally preventing such wounds fronri healing by the first intention, and making most of them necessarily sup- purate. This does not take place equally in every gun-shot wound, not in every part of the same wound ; and the difference commonly arises from the variety in the velocity of the body projected ; for where the ball has passed with little velocity, which is sometimes the case at its entrance, but still more frequently at the part last wounded, the injury may often be healed by the first intention.— <7. Hunter, p. 523.) Until I had the pleasure of reading the last edition of a valuable book on gun-shot wounds, I did not know that, at the present day, any surgeons entertained the idea, that the whole track of every gun-shot wound must unavoidably suppurate and slough (Guthrie on Gun-shot Wourids, p. 62, ed. 2); but if this sentiment prevail, it is plain from the preceding statement, that the authority of Mr. Hunter cannot be adduced in its support. At the same time, I believe, that few' army surgeons will be inclined to question the correctness of Mr. Hunter’s account of the general occurrence of a degree of sloughing, or of the deadened state of a part of the surface of a wound, particularly in the vicinity of the entrance of the ball or the truth of hie observations about tha common necessity of the se- paration of such slough before the parts w ill heal ; and whether the dead parts be thrown oft' in small fragments with the matter, or larger jiortions, the fact is still correct. I Foreign bodies more frequently lodge in gun-shot j wounds than aiiy others, and are commonl} of three GlJiN-SHOT WOUNDS. 435 kinds. 1. Pieces of clothing or other things which the ball forced before it into the limb. 2. The ball it- self. 3. Loose splinters of bone. It is only when the ball strikes the naked flesh, touches no bone, and goes quite through the part, that the wound can be free from e.xtraneous matter. Foreign bodies are the cause of numerous unfavourable symptoms, by irritating sensible parts, and exciting pain, inflammation, con- vulsions, hemorrhage, long suppurations, &c. ; and the more uneven, pointed, and hard they are, the more likely they are to produce these evils. Hence spiculte of bone are always the most to be dreaded. — (Richter.) The great obliquity and length of the fissures pro- duced in the cylindrical bones by musket-balls, are such as are not remarked in any common cases of frac- ture. When I was with the army in Holland, in the year 1814, I had in my hospital at Oudenbosch several fatal compound fractures of the thigh, caused by gun- shot violence. The fissures in some of these exam- ples were found to extend two-thirds of the length of the bone. This fact is noticed by Mr. Guthrie ; “ The fractures extend far above and below the immediate part struck by the ball, and, as far as depends upon my information from the examination of limbs that were amputated, farther downwards than upwards ; so that, from a fracture in the middle of the thigh, I have often seen fissures extend into the condyles, and cause ulceration of the cartilages of the knee-joint,” &,c.—(On Gun-shot Wounds, p. 190.) When the ball strikes a bone, the concussion produced is another occasion of bad symptoms, to be added to those already mentioned. When slight, its effects are confined to the injured limb ; but sometimes they ex- tend to the neighbouring joints, in which they produce inflammation and abscesses. It is commonly stated in surgical books, that when a cannon-ball tears off a limb, it produces a violent con- cussion of the whole body, and a general derangement of all its functions. This, however, is by no means always true. I saw, some years ago in London, a young sailor, whose ann had been completely torn off at the shoulder, by a cannon-ball from one of the for s at Guadaloupe, in March, 1808 ; he suffered no dread- ful concussion of his body, nor were his senses at all impaired. This case was very remarkable, as the sca- pula was so shattered that Mr. Cummings, of Antigua, | was under the necessity of removVig the whole of it. The patient recovered in two months. From the ac- counts which I heard, I do not believe that the axillary artery bled immediately after the accident. The young man was shown to the gentlemen of St. Bartholomew’s Hospital, quite well. One curious effect occasionally follows gun-shot wounds ; but I do not pretend to understand the ra- tionale of it: viz. inflammation and suppuration of some internal viscus, especially of the liver. Mr. Rose classes these occurrences among the effects of con- stitutional irritation arising from local injury, and consi- ders them as striking illustrations of the irregular ac- tion in the vascular system to which that irritation may give rise. He is also of opinion that an explanation of the subject may be deduced from the principles laid down by Mr. Travers. — (See Med. Chir. Trans, vol. 14, p. 263 ; and Travers's Inquiry concerning Constitu- tional Irritation, 8vo. Load. 1826.) Several cases of the above nature are related in the M m. de I'Acad. de Chirurgie, and according to Mr. Guthrie many patients in the Peninsula who had undergone secondary am- putations for gun-shot injuries were destroyed by affec- tions of their lungs, liver, ortion of them, in the form of a sac, into the wound, and when such {vortiou of the clothes is withdrawn the ball falls out ; and if thi.s circumstance be not noticed, the jire.' ence of a single opening may lead to the idea, that the bullet is lodged in the part. An instance of this kin^ is cited by Pare for the purpose of refuting the former notion, that the ball burned the part.s. A case in w Inch a piece of a shirt was carried in this manner four inches into the flesh, is mentioned by Mr. Guthrie.— (P. 20, td. 2.) It is possible also for a ball to be stopped immediately it has entered the body, and then to be ejected by the elasticity of the parts against which it strikes, as the cartil.ages of the riba.— {Guthrie, 19, (d. 2.) When there are two apertures made by one shot, the ball has escaped; but jiicces of the clothes, Ac. n ay .stdl he lodged in the part. Care must be taken, however, not GUN-SHOT WOUNDS. 437 to confound with these cases others, in which the plu- rality of openings has been made by ditr.rent balls. As a modern writer has accurately e.Kplained, “It is no uncommon thing for a ball, in striking against the sharp edge of a bone, to be split into two pieces, each of which takes a different direction. Sometimes it happens that one of the pieces remains in the place wliich it struck, while the other continues its course through the body. Of a ball split by the edge of the patella, I have known one half pass through at the mo- ment of the injury, and the other remain in the joint. for months, without its prcsetice there being suspected. In the same manner I have known a ball divided by striking against the spine of the scapula, and one por- tion of it pass directly thrpugh the chest, from the point of impulse, while the other moved along the integu- ments, till it reached the elbow-joint. But the most frequent examples of the division of bullets which we had occasion to see, were those which Avere prbduced by balls St nking againstthe spherical surface of the cranium. It sometimes happens, that one portion of the ball enters the cranium, while the other either remains without, or passes over its external surface. Not unfrequently, in injuries of the cranium, the balls are lodged between its two tables, in some instances much flattened and altered in their shape, and in other instances without their form being changed.’’ From these facts it must be evident, that even when a gun-shot wound has two ori- fices, the surgeon cannot be certain that the bullet has not been divided, and that no portion is lodged, unless the entire ball itself happen to be found. — (See Thovi- son's Obs. in Military Hospitals in Belgium^ p. 37, <:5-c.) As the ends of the torn vessels are contused and compressed, gun-shot wounds have at first less pro- pensity to kleed seriously than most other wounds, un- less vessels of importance happen to be injured, in the beginning there may even be little hemorrhage, though a considerable arterj- be so hurt, that it af.erward sloughs, and a dangerous or fatal bleeding arises. Thus (as I have already mentioned), in one of my own patients Avho had received a musket-ball through the ham, the popliteal artery gave way about ten days after the in- jury, and compelled me to take up the femoral artery ; and in the Elizabeth Hospital at Brussels, among the patients under the care of my friend Mr. Collier and myself, about a week after the battle of Waterloo, the cases of heihorrhage, on the loosening of the sloughs, were tolerably numerous, not at all coinciding with a recent calculation, that the proportion of such exam- l)les, requiring the ligature of arteries, is only three or four in 1000. — {Guthrie Gun-shot Wounds, p. 8, ed. 2.) In Holland, the truth of Mr. Hunter’s observa- tion upon this point appeared to me to bo completely confirmed. It has long been known, that a limb may be torn or shot off, even near to the trunk of the body, and hardly any hemorrhage arise. We had numerous proofs of this fact after the battle of Waterloo. I had under my care a man of the rifle brigade, whose arm was shat- tercl to pieces as high as the shoulder, yet there was no hemorrhage. I amputated the thigh of a Dutch sol- dier whose leg had been completely shot off by a can- non-ball ; but there was no hemorrhage before the ope- ration. At Merksam, in 1814, I saw a case in which the greater part of the clavicle, scapula, and many ad- jacent parts had been carried away by a cannon-ball ; and yet no bleeding of consequence occnirred. Sometimes, after these violent injuries, the large ar- teries do not bleed in amputation. “ We saw a man (says Dr. Thomson), whose leg had been shot off by a cannon-ball ; in amputating his limb above tlie knee, the arteries of the thigh were not perceived to bleed ; nor did any of them afterward require to be tied. A case similar to this also presented itself, in which the arm had been shot away close to the shoulder-joint.” Sometimes the contusion produced by a cannon-ball, or the passage of a bullet in the vicinity of a large ar- tery, seems to cause a laceration of the inner coat of the vessel, and a subsequent obliteration of its cavity by the effusion of coagulable lymph. Facts in proof of ihi.s statement are recorded by Dr. Thomson. — (See Ohs. in the Military Hospitals in Belgiwn, p. 31, 35.) Angular, uneven bodies, such as pieces of iron, cut lead, Ac., produce far more dangerous wounds than round even bodies, like leaden btillets. Wounds occa- sioned by a small shot are frequently more perilous than others produced by larger balls; because their track is so narrow that it cannot be traced, nor con- sequently the extraneous body itself extracted. Such a .shot often injures a viscus, when there is not the smallest external symptom of the occurrence. Some- times a great part ' of the danger also arises from the number of the shots wliich have entered. TKKATMENT OF GU.N-SHOT WOUNDS. The first thing in the treatment of a gun-shot wound in one of the extremities is, to determine whether it be most advisable to amputate the limb immediately, or to undertake the cure of the wound. When a bone, especially at a joint, is very much shattered ; when the fleshy parts; particularly the great blood-vessels and nerves, are lacerated ; when the whole limb has suf- fered a violent concussion, and is cold and senscle.ss ; there is no hope of preserving it. In this case, it is the surgeon’s duty to amputate at once, and not to de- lay till inflammation, fever, and a tendency to morrili- cation come on. But besides this violent degree of injury in which the propriety of amputation is obvious, there are several lower degrees, in which it is often a difficult thing to decide whether the operation be ne- cessary or not. Here the surgeon must look not only to the injury, but also to the patient’s constitution, and even to external circumstances, such as the possibility or impossibility of procuring good accommodation, rest, attendance, and pure air. But it is impossible to de- termine the necessity, of amputation by general rules. In every individual case, the surgeon must consider maturely the particular circumstances, before he ven- tures to decide. The grounds against the operation are, the pain which it causes at the period when the whole system is disordered by a terrible injury ; the privation of a limb ; and frequent examples, in which nature, aided by judicious surgery, repairs the most horrible wounds. The follow'ing are the reasons in favour of the operation. By it the patient gets rid of a dreadful contused wound, which threatens the great- est peril, and which is exchanged, as it were, for a simple incised one. The pain of amputation is not of more moment than the pain which the requisite inci- sions, and the extraction of foreign bodies would cause in case the operation were abandoned. In cases of . gun-shot wounds, the loss of the limb cannot be taken into the account ; for the surgeon only undertakes the operation where he designs to save the patient’s life by that privation, and anticipates that the part itself cannot be preserved. Even if he should deprive the patient of a limb that perhaps might have been pre- served, there is this atonement, that he can furnish him with an artificial leg, which often proves far more serviceable than the lost limb would have proved, had it been preserved. Should the operation be fixed on, it is to be immediately performed above the wound. — {Richter, Avfangsgr. der Wundarzn. b. 1.) When amputation is deemed unnecessary, the sur- geon, according to precepts fonuerly in vogue, is to dilate the w’ound by one or more incisions. Many of the missile weapons employed by the ancients, when received into the body, required incisions before they could be extracted; and this was the case, not only with regard to darts and arrows, but also whh regard to bits of stone, pieces of iron, and leaden bullets, which were thrown by means of slings. Celsus mentions the necessity of enlarging the orifices, through w'hich these bodies had entered, and may therefore be justly- regarded as the first who recommended the practice of dilatation in the treatment of wounds made by leaden bullets. — {Thomson's Obs. in the Military Hospitals of Belgium, p. 39.) Such dilatation has been said to have numerous ad- vantages : to facilitate the extraction of foreign bodies; to occasion a topical bleeding, and afford an outlet lor the extravasated fluid in the circumference of the wound ; to convert the fistulous form of the track of the ball into an open wound ; and, lastly, to divide ligamentous aj)oneuroses, which otherwise might give ri.se to spasmodic and other untoward symiitoms. More m.odern experience proves, however {HvnUr, p. 529), that the utility of such incisions has been over- ratefl ; that they generally increase the inflammation, which in these cases is so much to be appn.-hended ; that wounds which are not dilated commonly heal more speedily than others which are; and that there are only a few cases in w Inch incisions are beneficial. In fact, as Dr. Hennen has correctly stated, the kuifa 438 GUN-SHOT WOUNDS. is now rarely, if ever, employed in the first instance by English surgeons, except for the purpose of ex- tracting balls, splinters of bone, and other extraneous bodies, or for facilitating the application of ligatures to bleeding vessels. — (See Principles of Military Sur- gery, p. 49, ed. 2.) The injuries arising from the practice of indiscrimi- nate dilatation (says Dr. Thomson), were very early pointed out by Botallus ; and it is singular how much the opinions of this author, with regard to this point in military surgery, coincide with those of Mr. Hun- ter.— (Op. cit. p. 40.) The cases of gun-shot wounds are various. Some- times the track of the ball lies superficially under the skin, and only has one opening. When it lies in soft parts, and the ball has neither touched a bone, nor a considerable blood-vessel, all incisions are useless, let the wound have one or two apertures. Though di- lating the wound has been practised with a view' of giving vent to matter, eschars, and foreign bodies, and even its whole track has been laid open when super- ficial ; yet experience proves the inutility of such steps. As when a ball has passed with great force there is often a real loss of substance in the skin, a portion of which is driven inwards before the ball, it follows that the opening of a gun-shot w'ound must be more capacious than that of a punctured one. By the sepa- ration of sloughs, the wound becomes still more di- lated, so that not only matter, but foreign bodies which approach the skin, easily find an exit. Besides, inci- eions commonly close again very soon, and in a few days the wound falls into the same state as if no di- latation at all had been made. — {Hunter, p. 532,) Ligamentous fibres and fasciae are often situated abom the orifice of a gun-shot wound, and some sur- geons have made it a rule always to divide them com- pletely, lest, when the wound inflames, the tension and confinement of parts should cause violent spasms and nervous symptoms, and afterward impede the di.scharge of matter and foreign bodies. When they obviously have the first effects, the propriety of dividing them cannot be doubted ; but with a mere expectation of the other evils I consider the practice injudicious. Here, as Mr. Hunter wisely remarks, the method would be very good if tension and inflammation were not a con- sequence of wounds, or if it could be proved that the effects of dilating a part that is already wounded w'ere different from those of the first wound ; but the em- plojTnent of the knife, being only an extension of the first mischief, must be contradictory to common sense and common obsert'ation.-.--(On. Gun-shot Wounds, p. 534, 4. 1, li. rlin, 1785). With the foregoing high autiiority we have to join one of not less celebrity, namely, that of Baron Larrey, who has proved most convincingly, that when amputation is to be done in cases of gun-shot wound.s, nothing is so pernicious as delay. — (See Me- rnoires de (thirurgie Militaire, tom. 2, p. 451, it c.) it becomes me here to state also, that the principles inculcated by Baron Larrey are, in point of fact, the same as those which were so strennou.sly insisted u;)on by Mr. Pott, whose principal remarks on the ne- cessity of amputation in certain cases are detailed in another part of this publication. — (See Amputation.) Mr. Pott, indeed, Avas not an army-surgeon, and Avhat he says was not particularly designed to apply to military jiractice ; but he has represented, as well as any body can do, the propriety of immediate amputation for inju- ries AA'hich leave no doubt that such operation cannot be dispensed Avith. Mr. .lohn Bell, among the moderns, appears to me likeAvise to have much merit for the able manner in which he defended the propriety of early affiputation, long before the sentiments of later AA'riters were ever heard of. He distinctly states, that “ amputation should, in those cases where the 1 imb is plainly and i rrecoverably disordered, be performed upon the spot.” — (See Dis- courses on the Nature, S,c. of Wounds, p. 488, edit. 3.) In short, notAAdthstandmg all the modern pretensions to novelty upon this interesting topic, we must acknow- ledge, with Dr. Thomson, that the evidence in favour of the advantages of immediate amputation, has always preponderated over that for delay. — (See Report ef Obs. made in the Military Hospitals in Belgium, p. 225.) The strongest body of evidence upon this matter is undoubtedly adduced by Baron Larrey, whose situation at the head of the medical department of the French ar- mies aflbrded him most numerous oiiportunities of judg- ing from actual experieneg. “ Upon this subject (says he), now that twenty years of continual war have car- ried our art to the highest pitch of perfection, there can only be or,e opinion. It is after having incessantly di- rected the medical service, all this time, in quality of head-surgeon and inspector-general of the armies, that 1 proceed to discuss the different opinions delivered in the Academy, and to settle definitively this great question, AA hich I regard as the most important in mi- litary surgery. If we are to be told that the amputation of a limb is a cruel operation, dangerous in its consequences, and al- ways grievous to the ])atient who is thereby mutilated ; that, consequently, there is more honour in saving a limb, than in cutting it off w'ith dexterity and success ; these arguments may be refuted by ansAvering, that amputation is an operation of necessity, which offers a chance of preservaxon to the unfortunate, whose death appears certain under any other treatment ; and that if any doubt should exist of amputation being absolutely indispensable to the patient’s safety, the operation is to be deferred, till nature has declared herself, and given a positive indication for it. We are also justified in adding, that this chance of preservation is at the pre- sent day much greater than at the epoch of the Aca- demy of Surgery. We learn from M. Faure, that of about three hundred amputations, performed after the battle of Fontenoy, only thirty were followed by suc- cess, while, on the contrary (says Baron Larrey), Ave haA'e saved more than three-fourths of the patients on whom amputation has been done, and some of whom also had two limbs removed.” This improvement is ascribed by Larrey, 1. To our now knowing better how to take advantage of the indication and favourable time for amputating. 2. To the bettor method of dn .ssing. 3. To the mode of operating being more simple, less painful, and more expeditious than that formerly in vogue. To the preceding authorities against delaying ampu- tation, in cases of gun-shot wounds requiring .such oj)e- ration, I have to add Mr. Guthrie, deputy-insiiector of military hospitals, whose opportunities of observation, during the late war in S}tain, were particularly exten- sive. In his work he has detailed the opinions of many eminent foreign and British surgeons, respecting the propriety or impropriety of the doctrine of immediate ami)Utation ; and he has introduced some good criti- cisms, particularly on Bilguer’s statement of the suc- cess which was experienced in the Prussian hospitals from not performing the operation. Mr. Guthrie, how- ever, does not recommend amputation to be done immer diately, if the patient be particularly depressed by* the shock of the injury directly after its roceij)t; a [decc of advice, which, 1 believe, has in reality been at ail times followed, not only in respect to amputations in cases of gun-shot wounds, but all other severe loi-al injuries. “ I believe it to be (says Mr. Guthrie) a stretch of fancy in those surgeons aa'Iio conceive that if the knife folloAA'ed the shot in all cases, the patient would have the best 442 GUN-SHOT WOUNDS chance of sticcess. No one will deny that if the shot performed a regular amputation, it would not be better than to have it to do afterward : but if they mean to say the operation should in general be performed im- mediately after the injury, I can only oppose to them the facts above stated, and the general result of my experi- ence, which is decideuiy in favour of allowing the first moments of agitation to pass over before any tiling be done ; a period extending from that to one, six, or eight hours, according to the difference of constitution and the different injuries that have been sustained. But /rom one to three hours will in most cases be found sufficient. — (On Gun-shot Wounds, p. 226, edit. 2, Lond. 1820.) In the first edition of tins gentleman’s book, some little want of precision rather concealed his exact meaning with re.specttothe period of time which should generally be allowed to transpire between the receipt of the injury and the performance of amputation; but after alt the disposition to controversy upon this point, it appears there is little to fight about, as there is rather a misunderstanding than a difference of opinion. All acknowledge the advantage of doing the operation im- mediately, when the patient is not faint and depressed by the shock of the accident ; all admit the prudence of deferring the use of the knife in other cases until the constitution has revived sufficiently to be capable of bearing the removal of the limb.— TTiosis does occur. In other instances, the ball severs the arm from the trunk, and the functions of the thoracic vis- cera are not at all injured. Baron Larrey then relates the following case, which is analogous to one which I saw near Antwerp, and have already mentioned in the foregoing columns. M. Meget, a captain, marching in the front of a square of men, in i the heat of the battle of Altzey, 30th March, 1793, had his right leg almost entirely carried away by a large cannon-shot, without the contiguous limb of his lieute- | nant, who was as clase as possibie to him, receiving the least injury. The violent general commotion ex- cited, and the extreme severity of the weather, made this officer’s condition imminently perilous. The pro- ' gress of the symptoms, however, was checked by am- jmtation, which was instantly performed. M. Meget j WAS then conveyed to the hospital at Landau, fifteen leagues from the field of battle, where he got quite well. Larrey declines relating numerous other analogous amputations, which he has been called upon to practise under the same circumstances. M. Buffy, a captain of the artillery of the army of the Rhine, was struck by a howitzer ; his left arm being injured, and his head so nearly grazed that the corner of his hat, w'hich w^as jilaced forwards over his ■face, was shot away as far as the crown. This officer, the skin of whose nose was even torn off, was not deprived of his senses, and he was actually courageous enough to continue for some minutes commanding his company. At length, he was conveyed to Larrey’s ambulance, who amputated his arm : in about a month the patient was well. Larrey expresses his belief, that what have been er- roneously termed wind c(mtusions, if attended with the mischief above specified, require immediate ampu- tation. The least delay makes the patient’s preserva- tion extremely doubtful. The internal injury of the member may be ascertained by the touch, by the loss of motion, by the little sensibility retained by the parts, which have been struck : and, lastly, by practising an incision, as already recommended. In order to confirm the principle which he endeavours to establish in opposition to many writers, Larrey in- dulges himself with the following digression. At the siege of Roses, two cannoniers, having nearly similar wounds, were brought from the trenches to the ambulance, which Baron Larrey had posted at the vil- lage of Palau. They had been struck by a large shot, winch, towards the termination of its course, had grazed posteriorly both shoulders. In one, Larrey per- ceived a slight ecchymosis over all the back part of the trunk without any apparent solution of continuity. Respiration hardly went on, and the man spit up a large quantity of* frothy vermilion blood. The pulse was small and intermitting, and the extremities were cold. He died an hour after the accident, as I.arrey had prognosticated. This gentleman opened the body in the presence of M. Dubois, inspector of the military hospitals of the army of the eastern Pyrenees. 1'h’e skin was entire; the muscles, aponeuroses, nerves, and vessels of the shoulders were ruptured and lace- rated, the scapula broken in pieces, the spinous pro- cesses of the corresponding dorsal vertebrae, and the posterior extremity of the adjacent ribs, fractured. The spinal marrow had suffered injury ; the neighbour- ing part of the lungs was lacerated, and a considerable extravasation had taken place in each cavity of the chest. The second cannonier died of similar symptoms, three-quarters of an hour after his arrival at the ho.s- pital. On opening the body, the same sort of mischief was discovered, as in the preceding example. In the German campaigns of the French armies, Larrey met with several similar cases, and accurate examination has invariably convinced him of the di- rect action of a spherical body, propelled by means of gunpowder. Sia;th case. According to Baron Larrey, when the articular heads are much broken, especially those which form the joints of the foot or knee, and the liga- ments which strengthen these articulations are bro- ken and lacerated by the fire of a howitzer or a grape- shot, or other kind of ball, immediate amputation is in- dispensable. The same indication would occur, were the ball lodged in the thickness of the articular head of a bone, or were it so engaged in the joint as not to admit of being extracted by simple and ordinary means. — (See also Guthrie on Gun-shot Wounds, p. 197.) Fractures extending into the joints, and accompanied with great laceration of the ligaments, were cases of gun-shot injuries pointed out by M. Faure as indispen- sably requiring immediate amputation. — (See Prix de I’Acad. de Chir. t. 8.) Thus we see, that this author was not so averse to early amputation as several mo- dern WTiters have represented. It is only in this manner that the patients can be rescued from the dreadful pain, the spasmodic affec- tions, the violent convulsions, the acute fever, the con- siderable tension, and the general inflammation of the limb, which, Larrey observes, are the invariable con- sequences of bad fractures of the large joints. But, adds this author, if the voice of experience be not lis- tened to, and amputation be deferred, the parts become disorganized, and the patient’s Ufe is put into imminent peril. It is evident, says he, that in this case if we wish to prevent the patient from dying of the subsequent symp- toms, amputation shoffid be performed before tw'elve or at most tw'enty-four hours have elapsed : even M Faure himself professed this opinion in regard to cer- tain descriptions of injury. — {Mem. de Chir. Militaive, t. 2.) With respect to wounds of the knee, the sentiments of Mr. Guthrie nearly coincide with those of Larrey. “ I most solemnly, protest (says Mr. G.), I do not r^ member a case do well, in xvhich 1 knew the articulat- ing end of the femur or tibia to be fractured by a ball that passed through the joint, although 1 have tried great numbers, even to the last battle of Toulouse. I know that persons w'ounded in this way have lived ; for a recovery it cannot be called, where the limb is useless, bent backwards, and a constant source of irri tation and distress, after several months of acute suf- fering, to obtain even this jiartial security from im- pending death ; but if one case of recovery should take place in fifty, is it any sort of equivalent for ibe sacrifice of the other forty-nine? Or is the preserving of a limb of this kind an equivalent for the loss of one man ?”— (On Gun-shot Wounds, p. 196.) In the attack of the village of Merksam, near Ant- werp, early in 1814, a soldier of the 95th regiment w as brought to our field-hospital, having received a musket- ball through the knee-joint. The stafi-surgeons on duty, and Mr. Curtis, surgeon of the 1st guards, were preparing to amputate the limb, when a surgeon at- tached to the 95fh, urgently recommended deferring GUN-SHOT WOUNDS. 145 the operation. Superficial dressing;? ’vere applied, and , the patient sent tu the rear. He lived several months after the accident, at times affording ho})es of a perfect recovery ; but in the end, he fell a victim to hectic symptoms. Indeed, such is the general unfortunate result of these c.ases, that Dr. Hcnnen lays it down as a law of military surgery, that no lacerated joint, particularly the knee, ankle, or elbow, should ever leave the field uiiamputated where the patient is not obviously sink- \r\g.—{On Military Surgery, p. 41, ed. 2.) -Vccording to Mr. Guthrie, fractures of the patella, without injury of the other bones, admit of delay, pro- vided the bone is not much splintered. Seventh case. Larrey observes, that if a large bis- cayen, asmall cannon-shot, or a piece of a bomb-shell, in passing through the substance of a member, should have extensively denuded the bone without breaking it, amputation is equally indiqated, although the soft |):irts may not appear to have particularly suffered. Indeed, the violent concussion produced by the acci- dent has shaken and disorganized alt the parts ; the medullary substance is injured, the vessels are lace- rated, the nerves immoderately stretched, and thrown into a state of stupor; the muscles are deprived of their tone ; and the circulation and sensibility in the iimb are obstructed. Before we decide, however, Ba- ron Larrey cautions us to observe attentively the symp- toms which characterize this kind of disorder. The case can be supposed to happen only in the leg v/heie the bone is very superficial, and merely covered at its anterior part with the skin. The following are described as the symptoms : the limb is insensible, the foot cold as ice, the bone partly e.\ posed, and, on careful examination, it will be found that the integuments, and even the periosteum, are ex- tensively detached from it. The commotion extends to a considerable distance ; the functions of the body are disordered ; and all the secretions experience a more or less palpable disturbance. The intellectual faculties are suspended, and the circulation is retarded. The pulse is small and concentrated ; the countenance pale ; and the eyes have a dull, moist appearance. The pa- tient feels such anxiety, that he cannot long remain in one posture, and requests that his leg may be quickly- taken off, as it incommodes him severely, and he expe- riences very acute pain in the knee. When all these characteristic symptoms are conjoined, says Larrey, we should not hesitate to amputate immediately : for otherwise the leg will be attacked with sphacelus, and the patient certainly perish. Larrey adduc.es several interesting cases in support of the preceding observations. Eighth case. When a large ginglymoid articulation, such as the elbow, or especally the knee, has been ex- tea.sively opened with a cutting instrument, and blood is extravasated in the joint, Larrey deems immediate amputation necessary. In these cases, the synovial membranes, the ligaments, and aponeuroses inflame, the part swells, and erethismus rajiidly takes place; and acvite pains, abscesses, deep sinuses, caries, febrile svrnpt.ims, and death are the speedy consequences. Larrey has seen numerous subjects die of such injuries, Oil account of the operation having been post])oned through a hope of saving the limb. In his M moires do Chifurgie Militaire, tom. 2, some of these are de- tailed. Although a wmund may penetrate a joint, yet if it be small, and unattended with extravasation of blood, M. Larrey informs us, it xyill generally heal, provided too much compression be not employed. This gentleman believes in the common doctrine of the pernicious effect of the air on the cavities of the body; yet in this place a doubt seems to affect him; speaking of the less dan- ger of small wounds of joints, he says, “ a qnoi tient relte diffirence, pnisque U air penitre dans V articula- tion dans run cmime daius I autre casV' When tw'o limbs have been at the same time so in- jured as to rearrey’s observations, if, at the pe- riod when the sloughs are detached, the urine has not a ready passage outwards, it passes through the wound, and is extravasated the more readily, inasmuch as the separation of the sloughs has occasioned many openings, by which the fluid may insinuate itself into the cellu- lar membrane. Hence gangrenous mischief and death On two points, my own experience would not lead me to join in the sentiments of Larrey : first, in oppo- sition to his statement, I am sure that there is risk of extravasation of urine earlier than the period which he specifies, having known this accident commence, as it were, within a few hours after the receipt of the wound ; and, therefore, I should not depend upon the sloughs being always at first a complete barrier to extravasation of urin’e (indeed, their formation throughout the whole track of a gun-shot wound is by no means a regular occurrence), but invariably pass a catheter as soon aa possible, for the more certain prevention of this dan- gerous consequence. Secondly, the period of the sepa- ration of sloughs may, indeed, often be contemporary with the first appearance or symptoms of extravasation, particularly in cases where the employment of the ca- theter is tbr some time deferred, as in Baron I.arrey’s practice, because then a partial extravasation of the urine, soon after the injury, and previous to the intro- duction of the catheter, will cause rapid sloughing, and actually prevent the adhesive inflammation from closing up the cavities of the cellular membrane in time to prevent a fatal extension of that irritating fluid among the surrounding parts. Were it not for the partial early effusion of urine, no doubt, the adhesive inflammation would, inthese cases, soon have the same effect, in obvia- ting the danger of urinary extravasation,which it has after lithotomy, or paracentesis of the bladder.— (SeeLtodmish or disease. The effusion or extravasation is made into the cellu- lar membrane, which invests and envelopes the sjier- maiic vessels, and has something the appearance of a true hernia. When the case is clear, and the extrava- sated blood does not give way to discutient applications, the only remedy is to lay the tumour fairly ojien through Us whole length. If the vessel or breach be small, the hemorrhage may be restrained by mere compression with dry lint, or by the use of styptics; but if it be large, and these means do not succeed, the ligature must be made use of.” 1 cannot conceive, that in any case of a mere rupture of one of the spermatic veins, it can ever be justifiable to tie the whole spermatic cord, and then perform cas- tration ; though Mr. Pott advises this plan, in case the , bleeding branch cannot be tied singly. Discutient ap- plications, and an occasional purge, wdll almost always disperse the swelling; and if not, opening it, taking out the blood, applying cold, or, if necessary, filling the cavity with lint, and-using compression, would be, ac- cording to my humble judgment, the most judicious treatment. A case precisely of the latter kind is not verj' com- mon, yet Mr. Pott has not omitted it as one of the forms of haeinatocele : but why he has not taken notice of the most frequent of all the varieties of the disease, I am at a loss to conjecture; I mean the extravasation of blood in the loose cellular membrane of the scrotum from blows on the part, and sometimes from lithotomy, castration, &c., quite unconnected v.dth any rupture of the spermatic veins. These are the cases which are mostly met with in practice. I have seen them fol- lowed bj’ suppuration ; but in general the effused blood is gradually absorbed, with the aid of discutient appli- cationsj leeches, fomentations, poultices, and saline purges. A surgeon should generally be reluctant to lay open the tumour, as, in many instances, sloughing and very severe symptoms have been the result. Celsus and Paulus JEgineta are the best of the old writers on hcematocele. For modem information, con- sult Pott’s Chir. Works, vol. 2. B. Bell, On Hydrocele. Flajani, Collezione d’Osservazioni, I'i c., t. 2. Richter, Anfangsgr. der Wundarzn. b. 6. Richerand, Noso- graphie Chir. t. 4. Ossiander, in Arnemann’s Maga- zin fur die Wundarzn. b. 1, p. 355 ; the patient died af ter an openmg had been made in the swellmg. Fol- Let, in Joum,. de M d. continu/ , vol. 13, p. 422 : a case from contusion, cured by an incision.. Harris, in Me?n. of Land. Med. Society, vol. 5. HARE-LIP. {Labia Leporina.) A fissure or per- pendicular division of otie of both lips. The term has arisen from the fancied resemblance of the part to the upper lip of a hare. Occasionally the fissure is more or less oblique. In general, it is directly below the septum of the nose ; but sometimes it corre.sponds to one of the nostrils. The two portions of the lip are generally moveable, and not adherent to the alveolary process; in less common cases they are closely at- tached to the fore part of the jaw. Children are fre 4 uently born with this kind of mal- formation, which is called a natural hare-lip, while that which is produced by a wound is named acciden- tal. Sometimes the portions of the lip, which ought to be united, have a considerable interspace between them ; while in other instances they are not much apart. The cleft is occasionally double, a little lobe or small portion of the lip being situated between the two fissures. The fissure commonly affects only the lip itself, and usually the upper one. In many cases, however, it ex- tends along the bones and soft parts forming the pa- late, even as far as the uvula; and sometimes those bones are entirely wanting. In a few instances, the jaw not only is imperfectly ossified in front, so that a cleft presents itself there, but one side of it projects forwards, and is at the same time inclined too much outwards, drawing with it the corresponding part of the palate, and the septum nasi, so that a very unsightly distortion of the nostril and nose is produced. The case, I believe, has not been described in surgical books. A hare-lip, in its least degree, occasions considerable deformity; and when more marked, it frequently hin- ders infants from sucking, and makes it indispensable to nourish them by other means. When the lower lip alone is affected, which is rare as a malformation, the child can neither retain its saliva, nor learn to speak, except with the greatest imj)ediment. The constant es- cape ol'the saliva, besides being an annoyance, is found to be detrimental to the health; for its loss impairs the digestive functions, the patient becomes emaciated, and even death would sometimes ensue, if the incessant discharge of so necessary a fluid in the animal economy were not prevented. 'I'hus, a lady, who was in this state, consulted Tronchin, who immediately saw the cause of her indis})osition, and recommended the fissure in the lip to be united ; the operation was done, and the dyspeptic symptoms then ceased. And wlien the fis- sure pervades the palate, the jiatient not only articulates very imperfectly, but cannot masticate nor swallow, except with great difficulty, on account of the food readily getting up into the nose. An early removal of the deformity must obviously be 456 HARE-LIP. very desirable ; but, as it cannot be accwnplished with- out an operation attended with some degree of pain, Dionis, Garengeot, and others advise waiting till the child is four or five years old, on the supposuion that, at an earlier age, the child’s agitations and cries would ren^r the operation impracticable, or derange all the proceedings taken to ensure its success. It is plain, however, that such reasons are not of great weight. A child, four or five years old, and very often even one eight or ten years of age, is more difficult to manage than an infant only a few months old. Every child of the above age has a thousand times more dread of the pain, than of the deformity or of the inconveniences of the complaint, to which he is habituated ; while an in- fant of tender years fears nothing, and only feels the pain of the moment. A more rational objection is the liability of infants to convulsions after operations, and this has induced many excellent surgeons to postpone the cure of the hare-lip till the child is about two years old. This custom is also sanctioned by Sir Astley Cooper, who mentions in his lectures several instances, which have either been communicated to him by others, or have occurred in his own practice, where operations for the cure of hare- lips ju very young infants have had a fatal termination, in consequence of an attack of convulsions or diarrhcea. The period when dentition is completed, or the age of two years, he therefore sets down as the most advan- tageous for the operation, and if parents urge its being done earlier, he very properly advises the surgeon to let them be duly apprized of the risk, so that in the event of the child being cut off, he may not incur blame for having operated at a disadvantageous period of life.— (See Lancet, vol. 3, p. 108.) The latter end of 1823, 1 met Sir Astley Cooper in consultation in a case where this very question occurred. The deformity was particularly unsightly, in consequence of the upper jaw-bone being imperfectly ossified in front, and one side of it forming a considerable projection forwards through the fissure which extended into the nostril, at the same time that the nose was seriously distorted to one side of the face. The parents, persons of the first respectability, were therefore uncommonly solicit- ous for an early operation, some instances of the suc- cess of which in very young infants had already been communicated to them by their friends. The projection of bone, they had also learned, might be cut away, so ,as to permit the soft parts to meet, which they now would not do. The risk of an operation on the infant in question, then scarcely two months old, was fairly explained to the parents ; but I doubt whether they could have been prevailed upon to wait three months longer, had not Sir Astley Cooper represented to them the dis- advantages of cutting away the bony projection, and urged the allowance of a little time to reduce the pro- tuberance by means of pressure. As I had not had any previous conference with Sir Astley on the subject, I was particularly gratified in finding his advice agree precisely with what I had already given, when the case was first shown to me. Exactly when the infant was five months old, a period selected on account of its be- ing the latest previously to the usual time of the com- mencement of the ailments of dentition, I performed the operation in the presence of Messrs. Ives, of Chert- sey, and Mr. Ives, jun., of Chobham. By this time the bone had been so effectually depressed, by means of a kind of spring-truss, constructed by Messrs. Salmon and Ody for the purpose, and worn several hours daily, thnt the soft parts admitted of being brought over it with tolerable facility. Union followed very well, and, though it was one of the worst hare-lips ever seen by Mr. Ives, senior, or myself, without an extensive divi- sion of the palate, the disfigurement is now very trivial, and the wrong direction of the nose constantly under- going farther diminution, in proportion as the jaw re- cedes under the pressure of the apparatus, which is still employed. This IS the youngest infant on which I have operated ; but, in October, 1824, I performed the operation on an infant twelve months old, at Walton on Thames, where I was kindly assisted by Mr. Stillwell, surgeon in that town. Union took place very favourably, without any indisposition whatever. Only one pin wtis Uvsed at the lower part of the lip, as I found that the upper part of the division could be perfectly and readily closed with a strip of adhesive plaster. Mr, Sharp observes, “ there are many lips where the loss of substance is so great, that the edges of the fissure cannot be brought together, or at best where they can but just touch; in which case it need not be advised to forbear the attempt ; it is likewise forbid in young chil- dren, and with reason, if they suck; but otherwise it may be undertaken with great safety, and even with more probability of success than in others that are older .” — {Operations in Surgery, chap. -34.) Le Dran performed the operation on children of all ages, even on those at the breast. B. Bell did it with success on an infant only three months old. Muys ad- vises it to be undertaken as soon as the child is six months old. Roonhuysen operated on children ten weeks after their birth, and all his contemporaries Imve praised his singular dexterity and success. As an es- sential step to the success of the operation, he recom- mended hindering the children from sleeping a certain length of time before it was undertaken, in order that they might fall asleep immediately afterward; and with the same view opiates have been prescribed. Putting out of consideration the partial success which has attended the use of blistering plaster for making the edges of the fissure raw and capable of union, all practitioners entertain the same sentiment with regard to the object of this operation, which consists in reduc- ing the preternatural solution of continuity to the state of a simple wound, by cutting off the edges of the se- parated parts throughout their length, and then keep- ing these parts in contact until they have completely grown together. But altliough such principles have been generally admitted, there was formerly some difference of opinion with respect to the best method to be followed in practice; some operators having pre- ferred sutures for keeping the edges of the wound in contact ; while others disapproved of them, believing that a perfect cure might always be accomplished by means of adhesive plaster and a uniting bandage, so as to save the patient from all the pain and annoyance of sutures. M. Louis thought that the use of sutures in the ope- ration for the hare-lip proceeded from a false idea re- specting the nature of the disease ; for, the fissure in the lip being wrongly imputed to loss of substance, it was deemed impossible to keep the parts in contact, except by a suture. “ The separation of the edges of the fissure in the lip,” says M. Lonis, “ is only the effect of the retraction of the muscles, and is always proportioned to the ex- tent of the cleft. Persons with hare-lips are capable of bringing the edges of the fissure together by muscu- lar action, by puckering up their mouths. On the other hand, the separation is considerably increased when they laugh, and the breach appears excessively large after superficially paring off its edges on both sides. The interspace in the hare-lip must not, therefore, be mistaken for a loss of substance. This truth is con- firmed by the effects of sticking-plaster, which has sometimes been applied to the hare-lip, as a preparatory measure before the operation, and which materially lessens the separation of the parts. According to the confession of all who have WTit- ten in favour of the twisted suture, it seems advisable only on the false idea, that the hare-lip is the effect of a greater or less loss of substance : and they say, posi- tively, that we must not have recourse to it when there is only a simple division to be united. The twisted suture must then be proscribed from the operation for the natural hare-lip, since it is proved that this mal- formation is unattended with loss of substance. At the same time, a loss of substance is but too real, after the extirpation of scirrhous and cancerous tumours, to which the lips are very subject. Yet, even in these cases, the extensibility of the lips allows an attempt to be made to reunite the double incision, by which the tumour has been removed, and it succeeds without the smallest deformity, w'hen care is taken to direct each incision obliquely, so that both of them form, where they meet, an acute angle, in the base of which the tu- mour is comprised. Here the means of union ought to be the more efficacious, because the difficulty of keeping the edges of the wound approximated is greater. M. Pibrac, in his memoir on the abuse of sutuics, when speaking of the hare-lijt, has already explained, that they are badly-conceived means, and more hurtftil in proportion as there is a greater loss of substance, be- cause the greater the interspace is between the two parts, the more fear is there of their efforts on the HARE-LIP. 457 needles or pins left in the wound. Hence, care has al- ways been taken to make the dressings aid the opera- tion of the suture. After this consideration, judici- ously made by the partisans of this plan, there was only one more step to be taken, according to M. Pibrac, in order to evince the necessity of proscribing it. The cap or copper headpiece described by Verduc and Nuck, for compressing the cheeks ; the clasps of Ileister ; and strips of adhesive plaster ; are all only inventions for the support of the parts, and keeping them from be- ing disunited. When the suture failed, it was by these means that the original deformity was corrected, to- gether with that produced by the laceration, which would not have occurred without the suture. As then, the dressings, when methodically applied, are capable of effectually rectifying the mischief of the suture, M. Louis inquires, why should they be considered only as a resource in a mere accidental case"? Why should they not be made the chief and primary means of reu- niting the lip, even when there is a loss of substance? Nothing can be opposed to the proofs adduced upon this point. They are even drawn from the practice of those who have employed sutures without success. Such persons have themselves furnished the proofs of the bandage being capable of repairing the mischief resulting from the twisted suture.” M. Louis, with a view of perfecting our notions on this matter, lays it down as a fact, that the retraction of the muscles being the cause of the separation of the edges of the fissure, it is not to these edges we are to apply the force which is to unite them ; but that it should be applied farthec to the very parts, whose ac- tion (the cause of the separation) is to be impeded, and whose contraction is thus to be prevented. A great many means for supporting the wound, only irritate the muscles and excite them to action, and it is this ac- tion which we should endeavour to overcome. The means for promoting union can only be methodical, when directly employed to prevent such action, by an immediate application on the point where it is to be re- sisted. The facility with which the parts may be brought forwards, so as to bring the two commissures of the lips into contact by the mere pressure of the hands, shows what may be expected from a very sim- ple apparatus, which will execute the same office with- out any effort, in a firm and permanent manner, and which will render sutures unnecessary, the inconve- niences of which are too well known. M. Louis, after having explained the reasons of the theory on which he founded his method, relates seve- ral cases, taken either from his own practice or that of others, to illustrate its advantages. He details the his- tory of twenty cases in which his plan perfectly suc- ceeded, both in accidental hare-lips, with considerable loss of substance, and in natural ones. In most of these instances, however, it was thought proper to as- sist the bandage with one stitch at the extremity of the fissure, close to the vermilion border of the lip, for the purpose of keeping the parts securely on a level. Notwithstanding the operation as performed with the twisted suture is opposed by an authority of such weight as that of M. Louis, still it is the method most commonly practised. No modem surgeons doubt that a hare-lip may be cured by means of adhesive plaster and uniting bandages, quite as perfectly as with a su- ture ; and all readily allow, that the first of these me- thods, as being more simple and less painful, would be preferable to the latter one, if it were equally sure of succeeding. But it is considered far more uncertain in its effect. To accomplish a complete cure, the parts to be united must be maintained in perfect contact, until they have contracted the necessary adhesion ; and how can we always depend upon a bandage for keeping them from being displaced? What other means, be- sides a suture, affords in this respect perfect security ? I shall first describe the operation as usually done by surgeons of the present day with the twisted suture. The first thing is to examine whether there is any ad- hesion of the lip to the gum ; and if there be, to divide it with a knife. Some authors (Sharp) recommend the frsnulum, which attaches the lip to the gum, al- ways to be divided : but when the hare-lip is at some distance from this part, it will not be in the way of the operation, and need not be cut. On the other hand, when the frsenulurn is situated in the centre of the di- .vi.sion, it is clear that in operating, we must necessa- jrUv include it in the incision, and it should therefore be divided beforehand, taking care not to encroach too much upon the gum, lest the alveolary process be laid bare ; nor too much upon the lip, because making it thinner would- be unfavourable to its union. When one of the incisor teeth opposite the fissure pro- jects forwards, it must be drawn, lest it distend and irri- tate the pans after they have been brought into con- tact. Sometimes, but particularly in cases in which there is a cleft in the bony part of the palate, a portion of the os maxillare superius forms such a projection just in the situation of the fissure in the lip, that it would render the union very difficult, if not impracticable. In this circumstance, the common plan has been to cut off the projecting angles of bone with a strong pair of bone- nippers. The part was then healed, and the operation for the hare-lip performed. Instead of cutting off the projection of bone, which is always a painful measure, Desault used to employ simple compression, by which means the prominence was usually reduced in a few weeks, and the opportunity afforded of operating for the cure of the hare-lip . — (dluvres Chir. par Bichat, t. 2, p. 207.) Of course, the actual necessity of using bone-nippers, or even of having recourse to compres- sion of the bony projection, will depend upon circum- stances ; for if the prominence of bone be sharp and irregular, no surgeon, I conceive, would hesitate about the removal of such inequalities in preference to the trial of pressure. Mr. Dunn, of Scarborough, has ex- pressed to me his doubts whether cutting off the pro- jections of the alveolary process be ever necessary, as the pressure of the entire lip gradually diminishes the deformity. “ I had (says he) two very unseemly cases, with an immense division of the palate, together with a projection of the alveolary process, which, with the incisor teeth, resembled the talons of a bird. A tuber- cular appendage of skin hung upon the base of the nose. By drawing the teeth in the first case very deli- cately, I avoided fracturing the bony projection. I then cut off one edge of the nasal appendage, and of the lip on the same side, and attached them together with two needles. The wound was sufficiently united in a week or ten days to allow the same operation on the other side. In less than three weeks the boy was sent home quite well, to the astonishment of the neigh- bourhood, where his frightful appearance had made him an object of disgust and ridicule. I succeeded in the other case even without the extraction of the teeth. Both the patients can now articulate labial sounds, re- tain their saliva, and are gradually losing the inconve- nience of the passage of the mucus from the nose into the mouth, as the fissure is more contracted, and the projection by no means so disagreeable.” These facts should lessen the haste with which certain operators proceed to cut off every projection of the alveolary process ; for a moderate prominence of bone without any sharp, irritating edges or angles, will not hinder the success of the operation ; and even the propriety of removing teeth must entirely depend upon their ber ing likely, by their direction, to irritate the lip, and dis- turb the union of the fissure. One serious objection to cutting away the projection of the jaw is the deformity afterward likely to contir nue during life from the deficiency of the incisores teeth ; and another is, the subsequent overlapping of the lower jaw, and its projection beyond the upper one ; communicating to the mouth an appearance seen in very old subjects. These were the considerations which induced me, in the case above mentioned, to emr ploy pressure, which is much more conveniently ap- plied by means of a kind of spring-truss, adapted to the child’s head, than with bandages, which would be seriously annoying, and the right action of which could not be regulated without the utmost difficulty. When also some of the bone must be cut away on account of its roughness and angular prominences, I advise the practitioner to remove only the irritating points, and afterward have recourse to pressure. In the operation, the grand object is to make as smooth and even a cut as possible, in order that it may more certainly unite by the first intention, and of such a shape that the cicatrix may form only one nar- row line. The edges of the fissure should, therefore, never be cut off with scissors, which constantly bruise the fibres which they divide, and a sharp knife is al- ways to be preferred. The best plan is, either to place any flat instrument, such as a piece of horn, wood, or 458 HARE-LIP. pasteboard, underneath one portion of the lip, and then holding the part stretched and supported on it, to cut away the whole of the callous edge ; or else to hold the part with a pair of forceps, the under blade of which is much broader than the upper one : the first serves to support the lip, the other contributes also to this effect, and, at the same time, serves as a sort of ruler for guiding the knife in an accurately straight line. VV'hen tlie forceps are preferred, the surgeon must of course leave on the side of the upper blade just as much of the edge of the fissure as is to be re- moved, so that it can be cut off with one sweep of the knife. This is to be done on each side of the cleft, observing the rule, to make the new A wound in straight lines, because the sides of it can never be made to correspond without this caution. For instance, if the hare-lip had this shape, the incision of the edges must be continued in straight lines till they meet in the manner here represented. A in short, the two incisions are to be per- fectly straight, and are to meet at an angle above, in order that the whole track of the wound may be brought together, and united by the first intention. Two silver pins, made with steel points, are next to be introduced through the edges of the wound, so as to keep them accurately- in contact ; the lowest pir. being introduced first, near the inferior termination of the wound, and the upper pin afterward, about a quarter of an inch higher up. A piece of thread is then to be repeatedly wound round the ends of the pins, from one side of the division to the other, first transversely, then obliquely, from the right or left end of one pin above, to the opposite end of the lower one, Tnptoms are not very pressing, nor the habit very inflammable, this method will prove suffi- cient; but it sometimes happens that the scalp is so tense, the pain so great, and the symptomatic fever so high, that by waiting for the slow effect of such means,- the patient runs a risk from the continuance of the fever, or else the injured aponeurosis and pericranium, becoming sloughy, produce an abscess, and render the case both tedious and troublesome. A division of the wounded part by a simple incision down to the bone, about half an inch or an inch in length, will most commonly remove all the bad symptoms, and, if it be done in time, will render every thing else unneces- sary.” We here perceive that, in this form of inflam- mation, the practice of making an incision had the sanction of Pott ; but the extent of the wound recom- mended is moderate, and very different from what has been recently juoposed for phlegmonous erysipelas of the limbs. With respect to the good effects of such , an incision Desault considers them greatly exag- 462 HEAD. gerated by authors ; and 'while he admits that they are useful when the inflammation extends under the apo- neurosis, he is not inclined to sanction it as a right proceeding in other instances. — (See cEuvres Chir. par Bichat, t. 2, p. 8.) Thus Mr. Pott was of opinion, that the ditferences of the symptoms in the foregoing cases depended upon whether the w'ound only affected the skin and cellular membrane or reached more deeply to the aponeurosis and pericranium ; a doctrine which has been justly re- garded as questionable. With respect to the observa- tion that in a puncture of the aponeurosis the swell- ing is confined within the limits of this fascia, and does not extend to the ears and eyelids, it is a senti- ment which Desault thought arose rather from ana- tomical speculations than the observation of nature. The doctrine, indeed, must ajipear doubtful, when it is recollected, 1st, That the aponeurosis and pericranium are parts of scarcely any sensibility. 2dly, That the opinion had its origin at a period when these parts were imagined to be highly sensible. 3dly, That in other parts of the body, a wound in which a fascia or the periosteum is concerned is rarely attended with the above-described severe sjmptorns. 4tlily, That here the wounds often affect only the sltin and cellular membrane, and yet these symptoms occur even with a phlegmonous character, otly. On the contrary, in other instances, in which the aponeurosis and pericra- nium are undoubtedly wounded, no bad symptoms at all lake place. 6thly, These symptoms may almost always be removed by the exhibition of tartarized an- timony. — (CKuvres Chir. de Desault, t. 2, p. 8.) In the case often named inflammation of the fascia, after bleeding, it is not the fascia itself, wliich is the real and chief seat of the pain, inflammation, such violence is found on the surface of the brain, or between the pia and dura mater, as well as on the sur- face of the latter ; or, perhaps, in all these three situa- tions at the same time. I’he difference of this kind of disease from either an extravasation of blood or a concussion of the brain is great and obvious. “All the complaints produced by extravasation are such as proceed from pressure made on the brain and nerves, and obstruction to the circula- tion of the blood through the former; stupidity, loss of sense and voluntary motioii, laborious and obstructed pulse and respiration, &c., and (which is of importance to remark), if the ffusion be at all considerable, these .symptoms appear immediately or very soon after the acc. dent. The symptoms attending an inflamed or sloughy state of the membranes, in conse(}uence of external vio- lence, are very different; they are all of the febrile kind, atid never at first unply any unnatural pressure : such are pain in the head, restlessness, w'anf of sleep, fre- quent and hard pulse, hot and dry skin, flushed counte- nance, inflamed eyes, nausea, vomiting, rigor ; and, to- wards the end, convulsion and delirium. And none of these appear at first, that is, immediately after the ac- cidend ; seldom until some days are passed.” This last observation, made by Pott, is one that is well worthy of the practitioner’s constant recollection, lest he wrongly fancy his patient secure too soon, and neglect the early use of the only means by which a re- covery can be effected. Thus, as Sir Astley Cooper notices, the time when inflammation of the brain (and, it may be added, of its membranes) follows the violence is generally about a week ; rarely sooner. Frequently it does not come on till a fortnight or three weeks after the injury ; and even more time mu.st elapse before the patient is quite safe, or ought to deviate from a strict and temperate regimen. In confirmation of this re- mark, a case is mentioned, where the neglect to keep the boxvels regular brought on a fatal attack of inflam- mation of the brain, as late as four months after the receipt of a blow on the head. — {Lectures, ire. p. 339-) One set or class of sy^mptoms is produced By an ex- iravasated fluid making pressure on the brain and ori- gin of the nerves, so as to impair or abolish voluntary motion and the senses ; the other is caused by the in- flamed or putrid state of the membranes covering the brain, and seldom affects the organs of sense, until the lattpr end of the disease, that is, until a considerable quantity of matter is formed, which matter must press like any other fluid. “If there be neither fissure nor fracture of the skull, nor extravasation nor commotion underneath it, and the scalp be neither considerably bruised nor wounded, the mischief is seldom discovered or attended to tor some few days. The first attack is generally by pain in the part which received the blow. This pain, though beginning in that point, is soon extended all over the head, and is attended with a languor, or dejection of strength and spirits, which are soon followed by a nau- sea and inclination to vomit, a vertigo or giddiness, a quick and hard pulse, and an incapacity of sleeping, at least quietly. A day or two after this attack, if no means preventive of inflammation are used, the part stricken generally swells, and becomes puffy and ten- der, but not painful ; neither does the tumour arise to any considerable height, nor spread to any great ex- tent : if this tumid part of the scalp be now divided, the pericranium will be found of a darkish hue ; an' little in- jured by the bruise, and in which there is no wound nor any immediate alarming symptoms or appearances, the patient feels little or no inconvenience, and seldom makes any complaint, until some few days are past. At the end of this uncertain time, he is generally at- tacked by the symptoms already recited ; these are not pressing at first, but they soon increase to such a de- gree, as to baffle all our art : from whence it w'ill ap- pear, that when this is the case, the patient frequently suffers f rom what seems at first to indicate his safety, and prevents such attempts being made, and such care from being taken of him, as might prove preventive of mischief. But if the integuments are so injured as to excite or claim our early regard, very useful information may iroin thence be collected; for whether the scalp be con- j siderably bruised, or whether it be found neccssar to divide it for the discharge of extravasated blood, or on account of worse appearances or more urgent symj)- toms, the state of the pericranium may be thereby sooner and more certainly known : if in the place of such bruise, the pericranium be found spontaneously de- tached from the skull, having a quantity of discoloured sanies between them under the tumid part, in the man- ner already mentioned, it may be regarded as a pretty certain indication, either that the dura mater is begin- ning to separate in the same manner, or that, if some preventive means be not immediately used, it will soon suffer ; that is, it will inflame, separate from the skull, and give room for a collection of matter between them. And with regard to the wound itself, whether it was made at the time of the accident, or afterward artifi- cially, it is the same thing ; if the alteration of its ap- l)earance be as related, if the edges of it spontaneously quit their adhesion to the bone, and the febrile symp- toms are at the same time making their attack, these circumstances will serve to convey the same inform- ation, and to prove the same thing. The particular effect of contusion is frequently found to attend on fissures, and undepressed fractures of the cranium, as well as on extravasations of fluid, in cases where the bone is entire ; and, on the other hand, all these do often happen without the concurrence of this individual mischief. All this is matter of accident ; but let the other circumstances be what they may, the spontaneous separation of the altered pericranium, in consequence of a severe blow, is almost always fol- lowed by a suppuration between the cranium and dura mater ; a circumstance extremely well wonh attending to in fissures and undepressed fractures of the skull, because it is from this circumstance principally that the bad symptoms and the hazard in such cases arise. It is no very uncommon thing for a smart blow on the head to produce some immediate bad symptoms, w hich after a short space of time disappear and leave the patient pe»fectly well. A slight pain in the head, a little acceleration of pulse, a vertigo and sickness, sometimes immediately follow such accident, but do not continue many hours, especially if any evacuation has been used. These are not improbably owing to a light commotion of the brain, which having suffered no material injury thereby, soon cease. But if, after an interval of some time, the same symptoms are re- newed; if the patient, having been well, becomes again feverish and restless, and that without any new cause ; if he complains of being languid and uneasy, sleeps disturbedly, loses his appetite, has a hot skin, a hard, quick pulse, and a flushed, heated countenance ; and neither irregularity of diet nor accidental cold has been productive of these ; the mischief is most certainly impending, and that most probably under the skull. If the symptoms of pressure, such as stupidity, loss of sense, voluntary motion, &c., appear some few days after the head has suffered injury from external mis chief, they dp most probably imply an efl'usion of a fluid somew’here; this effusion may be in the sub- stance of the brain, in its ventricles, between its mem- branes, or on the surface of the dura mater ; and which of these is the real situation of such extravasation is a matter of great uncertainty, none of them being at- tended with any peculiar mark or sig?i that can be de- pended upon as pointing it out precisely ; but the in- flammation of the dura mater, and the formation of matter betw'een it and the skull, in consequence of contusion, is generally indicated and preceded by one which Mr. Pott has hardly ever known to fail ; a pvffy, circumscribed, indolent tumoitr of the scalp, and a spontaneous separation of the pericranium froni tine skull under such tumour. These appearances, therefore, following a smart blow on the head, and attended with languor, pain, restlessness, w'atching, quick pulse, headache, and slight, irregular shivenngs, do almost infallibly indi- cate an inflamed dura mater, and pus either forming or formed between it and the cranium.” By detachment of the pericranium is not meant every separation of it from the bone which it should cover. It may be, and often is, cut, torn, or scraped off, without any such consequence; but these sepa- rations are violent ; whereas that which Mr. Pott means is sj>ontaneous, and is produced by the de.struction of those vessels by which it was connected with the skull, and by which the communication between it and HEAD. 465 the internal parts was carried on ; and therefore it is to be observed, that it is not the mere removal of that membrane which causes the bad symptoms, but it is the inflammation of the dura mater ; of which inflam- mation this spontaneous secession of the pericranium is an almost certain indication. Sometimes the scalp is so wounded at the time of the accident, or so torn away, as to leave the bone per- fectly bare ; and yet the violence has not been such as to produce the evil just now spoken of. In this case, if the pericranium be only turned back along with the d.o.tached portion of scalp, there may be probability of its reunion; and it should therefore be immediately made clean and replaced, for the purpose of such expe- riment ; which, if it succeeds, will save time and pre- vent considerable deformity. Should the attempt fail, it can only be in consequence of the detached part sloughing. Hence, removing it with a knife, though allowed by Pott, is now never practised. Frequently, when the scalp does not adhere at once, it becomes at- tached to the cranium afterward by a granulating process. When the detached piece sloughs, the worst that can happen is an exfoliation from the bare skull. Sometimes the force which detaches or removes the scalp also occasions the mischief in question ; but, the integuments being wounded or removed, we cannot have the criterion of the tumour of the scalp for the di- rection of our judgment. Our whole attention must be directed to the wound and general symptoms. The edges of the former will digest as well, and look as kindly for a few days, as if no mischief was. done un- derneath. But after some little space of time, when the patient begins to be restless and hot, and to com- plain of pain in the head, these edges will lose their vermilion hue, and become pale and flabby. Instead of matter, they will discharge a thin gleet, and the pe- ricranium will loosen from the skull to some distance from the said edges. Immediately after this, all the general symptoms are increased and exasperated ; and as the inflammation of the membrane is heightened or extended, they become daily worse and worse, until a quantity of matter is formed and collected, and brings on that fatal period, which, though uncertain as to date, very seldom fails to arrive. “ The method of attempting the relief of this kind of injury consists in two points : vir,. to endeavour to pre- vent the injlammation of the dura mater ; or, that being neglected or found impracticable, to give discharge to the fluid collected within the cranium, in consequence of such inflammation. Of all the remedies in the power of art, for inflam- mations of membranous parts, there is none equal to phlebotomy. To this truth many diseases bear testi- mony ; pleurisies, ophthalmies, strangulated hernias, &e.; and if any thing can particularly contribute to the prevention of the ills likely to follow severe con- tusions of the head, it is this kind of evacuation ; but then it must be made use of in such a manner as to be- come truly a preventive ; that is, it must be made use of immediately and freely.” Acceleration or hardness of pulse, restlessness, anx- iety, and any degree of fever, after a smart blow on the head, are always to be suspected and attended to. Im- mediate, plentiful, and repeated evacuations by bleed- ing have in many instances removed these in per- sons to whom Mr. Pott firmly believes very terrible mischief would have happened, had not such precau- tion been used. In this, as well as some other parts of practice, we neither have nor can have ' any other method of judging, than by comparing together cases apparently similar. Mr. Pott had more than once or twice seen that increased velocity and hardness of puKse, and that oppressive languor, which most fre- quently precede mischief under the bone, removed by free and rejieated bloodletting; and had often, much too often, seen cases end fatally, whose becinnings were fully as slight, but in which such evacuation had been either neglected or not complied with. This ju- dicious writer, “ would by no means be thought to in- fer from hence, that early bleeding will always prove a certain preservative ; and that they only die to whom it has not been applied ; this, like all other hu- man means, is fallible; and perhajts there are more cases out of its reach than within it, but where pre- ventive means can take place, thi.s is certainly the best and the most frequently su.rcessful. ITie second intention, viz. the discharge of matter VoL. I.— G g collected under the cranium, can be answered only by the perforation of it. When from the symptoms and appearances already described, there is just reason for supposing matter to be formed under the skull, the operation of perforation cannot be performed too soon : it seldom happens that it is done soon enough.” In short, whenever the dura mater, after the head has received external violence, separates or is detached spontaneously from the bone underneath it, and such separation is attended with the collection of a small quantity of thin brown ichor, an alteration of colour in the separated pericranium, unnatural dryness of the bone, chilliness, horripilatio, languor, and some degree of fever, Mr. Pott considers the operation indispensably necessary to save the patient’s life. When the skull has been once perforated, and the dura mater thereby laid bare, the state of the matter must principally determine the .surgeon’s future conduct. In some ca-ses, one opening will prove sufficient for all necessary purposes ; in others, several may be necessar}^ Notwithstanding the operation of perforation be abso- lutely and unavoidably necessary, as Mr. Pott remarks, “ the repetition of bloodletting or cooling laxative me- dicines, the use of antiphlogistic remedies, and a most strict observance of a low diet and regimen, are as in- dispensably requisite after such operation as before; the perforation sets the membrane free from pressure, and gives vent to collected matter, but nothing more; the inflamed state of the parts under the skull, and all the necessary consequences of such inflammation, ca’J for all our attention, full as much afterward as before; and although the patient must have perished without the use of the trephine, yet the m.erely having used it will not preserve him without every other caution and cave.'’--{Pott.) In relation to this subject, a remark made by Sir Ast- ley Cooper merits notice : when pus lies between the dura n)ater and skull, the application of the trephine, he acknowledges, is a successful practice ; but, accord- ing to his experience, this situation of the purulent matter is comparatively rare, as it generally collects between the pia mater and surface of the brain, frr which case an operation will he useless . — {Lectures, .?-c. vol. 1, p. 325.) It is stated by Mr. Brodie, that in ho.spital practice, suppuration between the dura mater and the bone, in consequence of fracture, is also less common at the present period than when Mr. Pott wrote ; a change which he refers to the stricter anti- phlogistic plan adopted by modern surgeons, whether the early symptoms be or be not of a dangerous de- scription. — (See Med. Chir. Trans, vol. 14, p. 411.) I think it not improper to recommend again the prac- tice of applying cold wet cloths to the head for the pre- vention and relief of inflammation of the dura mater; a plan to which, as already explained, Schmucker as- cribed a good deal of the success with which he treated injuries of the head. It is favourably mentioned by Dr. Hennen, and has received the recommendation of an- other modern writer, whose opinion must have great weight : “ In the inflammation which succeeds slowly to injuries of the head, a species of inflammation not more insidious in its approach than dangerous in its consequences, cold is by far the most efficacious re- medy that has yet been discovered.”— (See Thomson's Lectures on Inflammation, p. 181.) Both tables of the skull sometimes exfoliate in con- sequence of external violence. The dead bone must be removed, as soon as loose ; and, if necessary, the scalp divided for the purpose. 3. Fissures and Fractures of the Cranium, without Depression . Fractures of the cranium are divisible into “ those in which the broken parts keep their proper level or equality of surface with the rest of the skull, and those in which they do not ; or in other words, fractures without depression and fractures with. These two distinctions are all which are really ne- cessary to be made, and will be found to comprehend every violent division of the parts of the skull (not made by a cutting instrument), from the finest capil- lary fissure, up to the most complicated fracture.” — {Pott.) In most instances, the fracture takes place in the upper part of the cranium ; and it is also correctly noticed by Mr. Brodie, that fractures of its basis arc always the consequence of very great violence, and re- 466 MEAD. coveries from them comparatively rare. — {Med. Chir. Trans, vol. 14, p. 328.) Sometimes the fracture does not occur at the point to which the violence has been directly applied, but elsewhere, as the effect of what the French term a contre-coup. Various explanations of the fact have been offered. Mr. Earle has never known it happen, except when the occiput seemed to have been forcibly impelled against the atlas.— {Brodie, in Med. Chir. Trans, vol. 14, p. 329.) An ingenious at- tempt to account for the circumstance may be found in the writings of Mr. C. Bell ; though certain cases on re- cord will not conform to any princii)les yet offered in ex- planation of them. The disjunction ol the sut ures is much more rare than fractures of the cranium, and can only happen in young subject.s, in whom the sutures are not yet consolidated. They are accidents implying the one- ration of great violence, and in this point of view may be viewed as dangerous.--(See Brodie, in Med.Chir.l'rans. vol. 14, p. 332.) No truth in surgery is now better understood and established, than that the bad symptoms very fre- quently accompanying a broken skull are not produced by the breach made in the bone, nor indicate such breach to have been made. As Sir Astley Cooper re- marks, the danger of fractures of the skull depends upon their being united with concussion or extravasa- tion ; there is also a remote danger from inflammation. — {Lectures, Ac. p. 289.) This was the doctrine so well explained by Pott, who observes “ the sickness, giddiness, vomiting, and loss of .sense and motion can only be the consequence of an affection of the brain, as the common sensorium. They may be produced by its having been violently shaken, by a derangement of its medullary structure, or by unnatural pressure made by a fluid extravasated on its surface, or within its ventricles ; but never can be caused by the mere divi- sion of the bone (considered abstractedly) ; which di- vision, in a simple fracture, can neither press on nor derange the structure of the parts within the cranium. If the solution of continuity in the bone be either produced by such a, degree of violence as hath caused 8 considerable disturbance in the medullary parts of ihe brain, or has disturbed any of the functions of the nerves going off from it ; or has occasioned a breach of any vessel or vessels, whether •sanguine or lymphatic, and that hath been followed by an extravasation or lodgement of fluid ; the syrnihoms necessarily conse- quent upon such derangement, or such pressure, will follow: but they do not follow because the bone is broken ; their causes are superadded to the fracture, and although produced by the same external violence, are yet perfectly and absolutely independent of it ; so much so that they are freijuently found where no fracture is. The operation of the trepan is frequently performed in the case of simple fractures, and that very judi- ciously and properly ; but it is not performed because the bone is broken or cracked. A mere fracture or fissure of the skull can never require perforation, or that the dura mater under it be laid bare ; the reason for doing this springs from other causes than the frac- ture, and those really independent of it : they spring from the nature of the mischief which the parts within the cranium have sustained, and not from the acciden- tal division of the bone. From these arise the threat- ening symptoms ; from these all the hazard ; and from these the necessity and vindication of performing the operation of the trepan. If a simple fracture of the cranium was unattended in present with any of the before-mentioned symptoms, and there was no reason for apprehending any other 'Wil in future, that is, if the solution of continuity in the bone was the whole disease, it could not possibly indicate any other curative intention but the general one in all fractures, viz. the union of the divided parts." Even fractures of the basis of the skull, which are most frequently fatal, prove so, not because this part of the cranium is broken (the fracture itself being here not more dangerous than elsewhere), but “ because it is almost invariably complicated with extensive injury of other and more important parts." — {Brodie, in Med. Chir. Trans, vol. 14, p. 328.) The post mortem ex- aminations which I have attended, lead me to believe that most of these cases are complicated with extravasation. I could relate numerous examj)lcs to the point, if it were any longer necessary, in the present state of sur- gical knowledge, to cite facts in proof of the important truth, that the mere undepressed fissure or fracture of the skull itself cannot be the source of the immediate bad symptoms, but that in these cases the whole of the sudden peril arises from the manner in which the brain and its membranes have been hurt by the same vio- lence which caused the injury of the bone. Professor Thomson had opportunities of witnessing in the Nfether- lands several instances, which can leave no doubt upon this subject. “ In some of the wounds (says he) in which the head had been struck obliquely by the sabre, portions of the cranium had been removed, without the brain appearing to have sustained much injury. In ono case of this kind, where a considerable portion of the upper part of the occipital bone, along with the dura mater, had been removed, a tendency to protrusion of the brain took place during an attack of inflammation j a slight degree of stupor with loss of memory occurred; but on the inflammatory state having been subdued, the brain sunk to its former level, the stupor went off, and the memory returned and in another remarka- ble sabre-cut, more than an inch in breadth of the left lobe of the cerebellum was exposed, and was seen pul- sating for a period of eight weeks, yet the injury was unaccompanied with any particular constitutional symptoms. — (See Obs. made in the Military Hospitals of Belgium, p. 50, 51.) In many cases of simple undepressed fractures of the cranium, it is true that trephining is necessary ; but the reasons for the operation in these instances are, first, the immediate relief of present symptoms, arising from the pressure of extravasated fluid ; and, secondly, the discharge of matter, formed between the skull and dura mater, in consequence of inflammation. The operation of trephining was also recommended by Pott, as a pre- ventive of ill consequences ; a practice, however, which is now never adopted ; and many w riters of the highest reputation, especially Desault, Dease, Mr. John Bell, and Mr. Abernethy, have strongly remonstrated against it. The latter remarks, “ In the accounts which we have of the former practice in France, it is related, that surgeons made numerous perforations along the whole track of a fracture of the cranium ; and, as far as 1 am able to judge, without any clear design. Mr. Pott also advises such an operation, with a' view to prevent the inflammation and suppuration of the dura mater, which he so much apprehended. But many cases have oc- curred of late, where, even in fractures with depres- sion, the patients have done well without an operation,” Mr. Abernethy next relates several cases of fracture of the cranium with depression, which terminated fa- vourably, although no operation was performed. This judicious surgeon thinks that these cases, as well as a great many others on record, prove that at all events a slight degree of pressure may not derange the functions of the brain, for a limited time after its application, and in this circumstance probably never; for all those pa- tients whom he had an opportunity of knowing for any length of time after the accident, continued as well as if nothing of the kind had happened to them. In Mr. Hill’s Cases in Surgery, two instances of this sort are related, and Mr. Hill knew both the patients for many years afterward : yet no inconvenience arose. Indeed, it is not easy to conceive that the pressure, which caused no ill effects at a time when the contents of the cranium filled its cavity completely, should afterward prove injurious, when they have adapted themselves to its altered size and shape. Severe illness, it is true, of- ten intervenes between the receipt of the injury, and the time of its recovery ; and many surgeons might be in- clined to attribute this to pressure ; but it eijually oc- curs when the depressed portion is elevated. If a sur- geon, prepossessed with the opinion that elevation of the bone is necessary in every instance of depressed cranium, should have acted upon this opinion in seve- ral of the cases which Mr. Abernethy has related, and afterward have employed proper evacuations, his pa- tients would probably have had no bad symptoms, and he would naturally have attributed their well-doing to the mode of treatment which he had pursued : yet these cases did equally well without an operation. — (See Aber- nethy's Surgical Works, vol.2,p. A, S,c.%vo. bond. 1611.) Depressed fractures of the skull not being our imme- diate consideration, we need not exi)!itiate upon them ; but it seemed right to make the preceding remarks, in order to show how unnecessary it must be to trephine a patient, merely because there is a fracture in the cra- nium, and with a view o{ pre^ entinshad. consctiuences, Eveji when the fracture is depressed, it is not iieces- HEAD. 467 sary, unless there are evident signs that the degree of pressure thus produced on the brain is the cause of existing bad symptoms. The inflammation and suppuration of the parts be- neath the skull, which Mr; Pott v/ished so much to prevent by trephining early, do not arise from the oc- currence of a breach in the cranium, but are the conse- quences of the same violence which was the occasion of the fracture. Hence it is obvious, that removing a portion of the bone cannot in the least prevent the in- flammation and suppuration, which must result from the external violence which was first applied to the head ; but, on the contrary, such a removal, being an additional violence, must have a tendency to increase the inevitable inflammatory mischief. From what has been said, it is not to be inferred, how- ever, that trephining is never proper, when there is a simple undepressed fracture of the skull. Such injury may be joined with an extravasation of blood on the dura mater ; or it may be followed by the formation of matter between this membrane and the cranium ; in both which circumstances, the operation is essential to the preservation of the patient, immediately, but not before the symptoms indicative of the existence of dan- gerous pressure on the brain begin to show themselves. — (See Trephine.) A fracture of the skull, unattended with urgent symp- toms, and not brought into the surgeon’s view by any accidental wound of the integuments, often remains for ever undiscovered ; and as no benefit could arise from laying it bare by an incision, such practice should never be adoi)ted. The surgeon ought only to be officious in this way, wffien he can accomplish by it some better object than the mere gratification of his own curiosity. And as we shall find from the perusal of this article, and the one entitled Trephine, that in these cases, the removal of pressure otf the surface of the brain is the onfy possible reason for ever perforating the cranium with this instrument ; and as dividing the scalp is only a useful measure when it is preparatory to such ope- ration ; neither the one nor the other should ever be practised, unless there exist unequivocal symptoms that there is a dangerous degree of pressure operating on the brain, and caused either by matter, extravasated blood, or a depressed portion of the skull. If any ex- ceptions can be made to this observation, these are cases in which it is advisable to remove loose splinters and fragments of bone, or balls, plainly felt under the scalp. The true mode of preventing the bad effects, fre- quently following, but not arising from, simple fractures of the skull, is not to trephine, but to put in practice all kinds of antiphlogistic means. For this purpose, let the patient be repeatedly and copiously bled, both from the arm and temporal arteries ; let him be properly purged ; give him antimonials ; keep him on the lowest diet ; let him remain in the most quiet situation possible ; and if, notwithstanding such steps, the symptoms of inflammation of the brain continue to increase, let a large blister be applied to the scalp. If the scalp be wounded, it is to be healed as speedily as possible. Bloodletting and purgatives (as Sir Astley Cooper re- marks) wilT sometimes remove the symptoms of con- cussion and extravasation, when they accompany the fracture, and a few hours will often show that the tre- phine, which was at first thought indispensable, is un- necessary. Irreparable mischief might arise from your making an incision, and converting a simple into a compound fracture. “ If you act prudently (he adds), you will try bleeding and purgatives before you operate ; and the depletion will prove of the greatest possible advantagein preventinginflammation.”— (Lecfitrci', vol. \,p. 299.) These are the cases, al.so, in which the topical application of cold water to the shaved and naked head, by means of cloths kept constantly wet, is an eligible, though in this country a much-neglected practice. Nume- rous instances, however, in favour of the method are re- corded by the experienced Schmucker {Chir. Wahrneh- mungen,b. 1, Berlin, 1774), and the trials which I have seen made of it, give me a high opinion of its superior efficacy. When, in spite of all these measures, matter forms under the cranium, attended with symptoms of pressure, a puffy tumour of the injured part of the scalp, or those changes of the wound, if there is one, which Mr. Pott has so excellently described ; not a mo- ment should be lost in delaying to perforate the bone with the trephine, and giving vent to the confined matter. G g2 Experience teaches that fractures at the basis of the skull are extremely dangerous, because they are gene- rally attended with extravasation, or followed by in- flammation of the brain, in consequence of the violence of the injury. According to Sir Astley Cooper, they are produced by falls from a great height on the summit of the head. The whole weight of the body is received on the foramen magnUm, and cuneiform process of the os occipitis, and, in many instances, the consequence is a transverse fracture through the foramen magnum, the cuneiform process, and part of the temporal bone. A discharge of blood into each meatus auditorius accom- panies the accident. It is supposed, also, that the deaf- ness, which sometimes remains during life, in rare in- stances of recovery, is the result of this kind of injury. -^{Lectures, &-c. vol. l,p. 289.) A fracture within the orbit is sometimes occasioned by the forcible introduction of a stick, weapon, or pointed instrument, and is generally a fatal case, from the pressure and irritation of the depressed splinters of bone, and the simultaneous wound of the brain. The symptoms in the beginning, however, are fre- quently mild and deceitful, and it is not till inflamma- tion and suppuration ensue, that the patient’s condition is always such as to create immediate alarm. A case, exemplifying this fact, is reiwrted by Sir A. Cooper. — (FoZ. cit. p. 295.) The same eminent surgeon men- tions the occasional production of a circular fracture of the entire cranium, by a blow on the vertex ; also the emphysema of the forehead, or the escape of the air, if there be a wound, caused when the nose is blown, in the case of a fracture extending into the frontal sinuses ; the complete detachment, sometimes met with, of the fragments, instead of their depression. His observa- tions confirm the fact, that fractures of the skull, if un- accompanied with concussion or compression, become united like those of other bones ; but, he adds, that it is more slowly, and that where the interspace is wide, it will not be filled up with bony matter.— (P. 297, 298.) 4. Fractures of the Cranium ivith Depression. In simple fractures of the skull, or those in which the parts of the broken bone are not depressed from their situation, Mr. Pott remarks, that “ the chirurgical intention and requisite treatment are the same in each, viz. to procure a discharge for any fluid which may be extravasated in present {provided the pressure of such extravasation produces urgent symptoms, a condition which should here be added), and to guard against the formation or confinement of matter.” The prevention of suppuration will, as we have already remarked, be best accomplished, not by perforating the cranium, as Mr. Pott advised, but by copious bleeding, evacuations, cold washes to the head, blisters, and a rigorous an- tiphlogistic regimen. How'ever, the confinement of matter, producing sjanptoms of pressure on the brain, certainly indicates the immediate use of the trephine. “ But (says the author) in fractures attended with depre.ssion there are other intentions. In these the depressed parts are to be elevated, and such as are so separated as to be incapable of reunion, or of being brought to lie properly, and without pressing on the brain, are to be totally removed. These circumstances are jieculiar to a depressed fracture ; but although they are peculiar, they must not be considered as sole, but as additional to those which have been mentioned at large under the head of simple fracture ; commotion, extravasation, inflammation, suppuration, and every ill which can attend on or be found in the latter, are to be met with in the former, and will require the same method of treatment.” That loose splintered pieces of the cranium, when quite detached, and already in view', in consequence of the scalp being wounded, ought to be taken away, no one will be inclined to question. That they ought also to be exposed by an incision, even when the scalp is unwounded, and then taken away whenever they cause symptoms of irritation or pre.ssure, I be- lieve will be universally allowed. But the reader will already understand, from what has been said in the preceding section, that several excellent surgeons do not coincide with Pott in believing that every depressed fracture of the skull necessarily demands the applica- tion of the trephine. “ There certainly are (says Mr. Abernethy) degrees of this injury, which it would be highly imprudent to treat in this manner. Whenever the patient retains his senses perfectly, I should think it improper to trephine 463 HEAD. him, unless svmptoms arose that indicated the necessity of it.”— (P. 21.) It is extraordinary and unaccountable, but it is not less true, that no calculation of the bad etfects Qan be made by the degree in which a part of the skull is de- pressed. This is a fact which has been long known. It has also been particularly adverted to by an eminent modern writer. “Various instances also presented themselves, in which, though a considerable degree of compression must have been occasioned, sometimes by the depression of both tables, and at other times by the depression of the inner table only of the skull, yet neither stupor, paralysis, nor loss of memory was produced. In one of these cases the middle of the right parietal bone was fractured, and considerably depressed by a ball, which was extracted on the 2flth day. In this case, neither stupor nor paraly.sis appeared. In another, a musket-ball had struck the right parietal bone, fractured it, and was flattened and lodged between the tables of the skull. The inner table was much depressed, yet no bad symptoms supervened.” — (See Thmison's Ob- servations made in the Military Hospitals in Belgium, p. 59, 60.) The same author also saw a singular case, in which a ball, entering behind the right temple, and passing backwards and downwards, had fractured the bones in its passage, and lodged in the surface of the brain, over the tentorium, froni which place it was ex- tracted on the seventeenth day after the injury. No bad symptom had manifested itself previously to the operation, and the man recovered, under the strictest antiphlogistic regimen, with little or no constitutional derangement. Dr. Hennen has recorded two cases, fully proving the correctness of Mr. Abernethy’s opi- nions about the impropriety of using the trephine in cases of depression unattended with urgent symptoms : in one of these instances, the upper and pasterior angle of the parietal, which had been struck by a musket- ball, was depressed exactly an inch and a quarter from the surface of the scal.p, yet no bad symptcrnis foliotoed, and with the aid of bleeding and other antiphlogistic remedies, the soldier recovered perfectly in a few weeks. “ In a similar case, where the man survived thirteen years, with no other inconvenience than occasional de- termination of blood to the head on hard drinking, a fnnnel-like depression to the depth of an inch and a half was formed in the vertex.” — (See Henneids Mili- tary Surgery, p. 287, ed. 2.) If then the violence of the symptoms is not always in proportion to the compression, but is sometimes con- siderable when the pressure is slight, every surgeon cannot be loo fully impressed with the following truth, that existing symptoms of dangerous pressure on the brain, which symptoms will be presently related, can alone form a true reason for perforating the cranium. Although the doctrines of Sir Astley Cooper, gene- rally speaking, coincide very much with the preceding maxim, which I regard as a very important one ; there is an exception to it in his advice, in relation to com- pound fractures of the skull, as will be understood from the Ibllowing passage. “ The old practice used to be, the moment an injury of the brain was suspected, and the least depression of the bone appeared, to make an incision into the scalp. This is putting the jiatient to considerable hazard ; for the simple fracture would by the incision be rendered compound. In simple fracture, then, when it is aitended with symptoms of injury of th^ brain, deplete before you trephine ; and when it is unattended with such s 3 'mptoms, deplete merely, and do not divide the scalp, er- haps scarcely perceptible, and the patient in a condi- tion approaching that of syncope. Such may be his si- tuation for several hours after the accident. V^■hen concussion proves fatal, the cause of death is imputed by Mr. Brodie to this disturbance of the action ot the heart. “ In general, when the patient has lam for some time in the state w hich has been described, a reaciiou of the circulating system takes place, and the pulse beats with greater strength in proportion as the failure of it was greater in the first instance. But where the shock has been unusually severe, there is no such HEAD. 476 reaction. The pulse becomes more and more feeble, more irregular and intermittent ; the extremities grow cold, and at last the action of the heart being altoge- ther suspended, the patient expires. In some cases, even after reaction has begun to take place, it seems as if the constitution were unequal to the effort : there is another failure of the circulation, the result of which is the same as if the patient had never rallied from the beginning.” — {Brodie, in Med. Chir. Trans, vol. 14, p. 341.) The mind, as Sir Astley Cooper remarks, is va- riously affected, according to the degree of injury which the patient has sustained. In some cases, there is a total loss of mental power ; in others, the patient is capable, though with difficulty, of being roused to make a rational answer, but immediately sinks again into coma. Sometimes the memory is lost ; while in other instances, it is only partially impaired. A total forget- fulness of any foreign language is a common effect of concussion. It frequently happens that the patient, when roused, will be perfectly sensible and answer questions rationally ; but if left undisturbed, the mind appears to be occupied by some particular circumstance (often an incoherent one), of which he is constantly talking. Patients recollect nothing about the mode in which their accidents took place. If the injury has been occasioned by a fall from a horse, they can only remem- ber mounting and riding to some distance, but not that the animal ran away or threw them ; nor, however perfectly they may recover in other respects, do they ever have any recollection of the kind of accident. The change produced by injuries of the brain is re- marked to be somewhat similar to the effects of age ; the patient loses impressions of a recent date, and is sensible of those which he received in his earlier years- But, as Sir Astley correctly explains, I he degree of in- jury sustained by the brain varies considerably in dif- ferent cases. Some patients are only stunned, or de- jtrived of sense for a moment ; others recover in a few hours ; some remain in a great degree insensible for fifteen or twenty days. Some recover entirely ; others have afterward an imperfect memory. A par- tial loss of sense will be produced in the function of one eye, or deafness in one ear ; and so of volition, the squinting caused by an injury of the brain being >sometimes permanent. In some cases a degree of fa- tuity ; in some, great irritability ; in others, vertigo, and tendency to severe headache from the slightest e.x- citement, will remain. In one example seen by Sir Astley Cooper, a remarkable irritability of the stomach and disposition to vomit were the permanent conse- quences of a concussion of the brain. In particular Instances, the faculty of readily uttering the pro])er words for expressing ideas is lost and never regained, and wrong terms are used. Often the judgment re- mains enfeebled. — {Le: tures,vol. 1, p. 254, a c.) Many of the observations in the foregoing statement coincide with the accounts given of the subject in the writings of Bichat and Desault. The following passage, extracted from a writer who has already been of material assistance in this article, cannot be too deeply impressed on the memory of every surgical practitioner. “To distinguish between an extravasation am! com- jfiotion by the symptoms only, is frequently a vf ry dif- ficult matter, sometimes an impossible one. The si- milarity of the effects in some cases, and the very small space of time which may intervene between the going off of the one and accession of the other, render this a very nice exercise of the judgment. The first stun- ning or deprivation of sense, whether total or partial, may be from either, and no man can tell from which ; but when these first symptoms have been removed, or have spontaneously disappeared, if such patient is again oppre.ssed with drowsiness or stupidity, or a totai or partial loss of sense, it then becomes most probable, that the first complaints were from commotion, and that the latter arc from extravasation ; and the greater the distance of time between the two, the greater is the pro- bability not only that an extravasation is the cause, but that the extravasation is of the limpid kind, made gra- datiin, and within the brain. When there is no reason to apprehend any other in- jury, and commotion seems to be the sole disease, plentiful evacuation by phlebotomy and lenient cathar- tics, a dark room, the most perfect quietude, and a very low regimen, are the only means in our power; and are sometimes successful.” — (Pott.) When the patient is at all sensible, every thing likely to irritate the mind is to be avoided. — (A. Cooper, Lectures, ^c. p. 21^, vol. 1.) With these means should also be associated the constant application to the head of cloths dipped in very cold water, or 'Schmucker’s frigorific lotion. When the effects of the violence are not necessarily fatal in a very short time after the accident, the great danger which is to be guarded against is certainly in- flammation of the brain. Hence the necessity of freely employing the lancet and antiphlogistic means. The discrimination which Mr. Abernethy introduced into the views of the present subject, by his division of concussion into three stages, has led also to more ra- tional and successful practice. For, though bleeding is now generally allowed to be the great means of re- lief in concn.ssion, it is not rashly practised at the beginning of many cases, when the pulse can hardly be felt, w’hen the circulation scarcely goes on, and every action in the system is nearly annihilated. But the state of the pulse and circulation is closely watched, and the surgeon bleeds in sufficient time and quantity, to prevent in many instances that immoderate frequency and hardness which the pulse always has a tendency in these cases to assume, immediately the first shock of the accident begins to abate. “ Bleed- ing,” as Sir Astley Cooper correctly notices, “ may be carried to excess. You must, in the repetition of bleed- ing, regulate your conduct by the symptoms; observe whether there be any hardness in your patient’s pulse, and whether he complains of pain in the head, if he have still the power of complaining. Watch your pa- tient with the greatest possible anxiety ; visit him at least three times a day ; and if you find any hardness of the pulse supervening after the first copious bleed- ing, take away a tea-cupful of blood ; but do not go on bleeding him largely; for you would, by this means, reduce the strength too much, and prevent the reparative process of nature.” Sir Astley admits, how- ever, that it is frequently necessary to take away blood after the first bleeding ; but he directs this to be generally done in small quantities. He acknowledges, also, that it is sometimes necessary to take away large quantities by repeated bleedings. — (P. 271.) The re- covery of many cases which have fallen under my own observation, I have imputed to the frequent and even copious abstraction of blood, by means of the lancet, leeches, and cupping ; at the same time, 1 know that this practice is often carried beyond all modera- tion, without due attention to those circumstances which I have pientioned as the proper guide. I believe, with Mr. Abernethy and Mr. Brodie, that in the very first stage of concussion, when all the powers of life are depressed, cordials and stimulants can rarely be employed with advantage. The latter gentleman has lately offered some considerations against the method which merit attention. There are, he observes, sufficient reasons why we should regard that condition of the system which approaches to syn- cope, as being mostly conducive to the patient’s wel- fare, and why we should wish to prolong rather than abridge the period of its duration. The same blow which gives rise to symptoms of concussion, he re- marks, frequently occasions the rupture of some small vessels within the cranium. The same state of the system which produces an enfeebled action of the heart, is calculated to prevent the ruptured vessels from pouring out their contents; and the longer it con- tinues, the less is the danger of internal hemorrhage. If we excite the action of the heart with wine and am- monia, we may bring on symptoms of pressure on the brain. If, on the contrary, we watch the gradual re- storation of the pulse, and bleed at the proper moment in quantity sufficient to keej) down the action of the heart, we may often check extravasation. Mr. Brodie also argues, that as the state of depression is followed by one of excitement, it is another strong consideration in favour of avoiding stimuli, and having recourse to bleeding in time to prevent the action of the heart from becoming too vehement. — (See Med. Chir. Trans, vol, 14, p. 377.) With respect to emetics, I have no confidence my- self in their usefulness in cases of concussion, and much doubt even their safety, especially when the dis- order is complicated with extravasation (A. Cooper, Lectures, i^c. vol. 1, p. 276), a point often incapable of positive decision. 476 HE A HEM Purgative an antimoriial medicines siiou’.d be pre- scribed, and a low regimen enjoined. After bleeding has been freely practised and the bowels emptied, blis- ters on the scalp and nape of the neck are frequently very useful in preventing or les.sening the tendency to Inflammation of the brain and its membranes. As bleeding from the arm cannot be employed in young children, Sir A. Cooper recommends the exhibi- tion of calomel, with acescent drinks, so as to purge them ; and leeches, or opening the jugular vein. For the relief of certain symptoms, frequently re- maining after concussion, as pain in the head, giddi- ness, diminution of sight, and deafness. Sir A. Cooper directs the head to be washed with spirit of wine and water, or the use of the shower-bath. Sometimes he orders the ung. canlhar. to be rubbed on the head, and pil. hydrarg. and exir. eolocynth. to be given. In cases of nervous debility of an organ, electricity is sometimes useful; and occasionally, in long-continued pains of the head, he forms an issue in the scalp, benefit sometimes resulting even from slight exfoliations. — {Lectures, vol. 1, p. 280.) These measures are infinitely more prudent than the old custom of trephining. I cannot conclude this article without adverting to the great propensity to relapse, after patients have long appeared out of every danger from wounds of the head, the bad symptoms sometimes coming on again, and proving fatal many years after the original injury, as is stroiigly exemplified in a case related in a work of high character. — (See Schmucker's Vermisckte Schrif- ten, b.\,p. 247.) [In the third number of the Amer. Jour, of the Med. and Pkys. Sciences, Professor Sewall, of Washington city, has reported two cases of fracture of the cranium, with loss of a portion of the substance of the brain. The wound in one of them was inflicted with a spade, which penetrated through the dura mater and into the medullary portion of the brain. The antiphlogistic treat- ment was relied upon from the commencement, and during the suppuration which followed : the brain it- self protruded and sloughed away, and subsequently portions of it were removed by the spatula. This pa- tient, nevertheless, recovered entirely in six weeks after the accident. Professor Dudley has also written a valuable paper on injuries of the head, which may be found in the first number of the Transylvania Journal of Medicine. He reports a number of cases of epilejisy occurring after injuries of the cranium, which he has cured by tre- phining. In confirmation of his views I may here refer to a case published in the 5th vol. of the N. Y. Med. and Phys. Journal, in which epilepsy, originating from depression of bone, was cured by trephining, % Dr. David L. Rogers, of this city. — Reese.] Hippocrates, De Capitis Vulneribus, l'2rno. Lutetm, 1578. Jac. Berengarius, De Fracturu Cranii, Bologna, 1513. James Yonge, Wounds of the Brain proved curable, not only by the Opinion and Experience, of many of the best Authors, but the remarkable History of a Child cured of two very large Depressions, with the Loss of a great Part of the Skull ; a Portion of the Brain also issuing through a penetrating Wound of the Dura and Pia Mater, \2mo. Lond. 1682. J. J. Wepfer, Observationes Medico-practicae de Affectibus Capitis internis et externi.s, Scaphusii, 1727. Murray, An post gravem ab ictu vel casu capitis percussionem, non juvante etiam iterata terebratione, dura meninx incisione aperienda? Lutet. Paris, 1736. (Haller, Disp. Chir. vol. 1, p. 97.) R. C. Wagner, De Contrufssura, Jenon any particular colour of the iris, as several writers have conjectured ; nor upon the largeness of the eyes, as alleged by Hippocrates. — {Lib. 6, sec. 7.) In idiopathic cases, the health does not in general suffer, and, except in the worst stage, the eye is not altered .n appearance. But in cases of long duration the pupil, according to Mr. Bampfield, “ is often con- tracted, and the eyes and actions of the patient evince marks of painful irritation, if the eyes are exposed to a vivid light, or if he looks upw ards. But if they meet the direct rays of the sun, which in the tropics are always powei Ail, or a strong glaring reflection of them, pain and temtiorary blindness are induced, from which the patient recovers by closing his eyelids for a time to exclude the rays of light, and retiring to the shade. The pupil of the eye is considerably dilated both by day and night, in the proportion of about one case in tw-elve, and at night the pupil is often dilated, and does not perform its expansions and contractions when exposed to the moon or artificial light. The cases attended with di- lated pupil were generally those of long duration, &c. “ Europeans, who have been once affected with he- meralopia in tropical climates, are particularly liable to a recurrence of this disea.se as long as they remain in them.” — {Bamjfield, op. dt. p. 42, 43.) In two examples, described by i)r. Andrew Smith, the pupils were observed to contract and dilate regu- larly in the daytime, according to the quantity of light ; but after sunset they seemed a little more dilated than natural, and contracted but sluggishly upon exposure to light, while the eyes themselves sjemed devoid of their usual energy and vivacity.— (See Edinb. Med. and Surgical Jrnim. No. 74, p. 22.) The remote causes of idiopathic hemeralopia are not well ascertained. Sleeping with the face exposed to the brilliancy of daylight, the vivid reflection of the sun’s rays from the sandy shores of hot countries, and bright moonlight, have been enumerated as causes. Dr. Pye thinks the disorder intermittent. — {Med. Obs. and In- quiries, vol 1, art. 13.) But, as Mr. Bampfield properly observes, though the complaint is certainly periodical,- there is nothing in its character tending to prove that it is influenced by the same causes as intermittent fever. The latter gentleman conjectures, “ that too much light suddenly transmitted to the retina, or for a long period acting on it, may afterward render it unsus- ceptible of being stimulated to action by the weaker or smaller quantities of light transmitted to it by night.”^ — (P. 44.) The same sentiment is adopted by Dr. Smith. — {Edinb. Med. Journ. No. 74, p. 23.) Among other objections to this explanation, however, it might be remarked, that the patients do not always see, though the light be good ; and Mr. Bampfield’s own “ patients positively denied the existence of distinct sight by very clear candlelight.” Besides, if the dis- ease were entirely caused by the sudden or long opera- tion of vivid light, one would conclude that all persons subjected to that cause ought to have the effect pro- duced, which is far from being the case. When the tongue is white, and the patient has head- ache and bilious complaints, M. Lassus thinks the cause of the disease is in the stomach and primae vise. The same author likewise states, that hemeralopia attacks debilitated persons subject to catarrhal affec- tions, residing in damp situations, and living on indi- gestible food. From the combination of such causes (says he) the disorder was epidemic in the vicinity of Montpellier {Sauvage, Nosolog. M thod. t. 2, p. 732) ; at Belle-Isle sur Mer. {Recueil d'Observ. de Medecine des Hopita^ix Militaires, par Richard, t. 2, p. 573) ; and hence it is endemic in watery situations where the nights are cold and damp. They who expose them- selves to this humidity (says 1)1. Lassus), or who navi- gate along the eastern coasts of Africa, who traverse the Mozambique channel, or sail along the coasts of Ma- labar and Coromandel, are sometimes attacked by it. — (See Pathologie Chir. t. 2, p. 542, 543.) Hemeralopia sometimes occurs as a symptom of the scurvy. This fact was noticed by Mr. Telford, in Sir G. Blane’s Trea- tise on Diseases of Seamen, and it is likewise con- firmed by Mr. Bampfield, who remarks that hemeralopia should be referred to the same causes as scurvy, “ when the subject of it has for a long period .subsisted on a salted diet at sea, &c., and if any other scorbutic symptom be present, such as spongy gums, ecchy- moses, saline smell of the secretions, ulcers, with liver- like fungus, &c.” — {Medico-Chir. Trans, vol. 5, p. 45.) This disease, according to Scarpa, may commonly be completely cured, and oftentimes in a very short time, by treating it on the same plan by which the imperfect amaurosis is remedied (see Amaurosis) ; viz. by em- ploying emetics, the resolvent powders and pills, and a blister on the nape of the neck ; and topically, the va- pours of ammonia ; lastly, by prescribing towards the end of the treatment bark conjoined with valerian. In cases in which the disease has been preceded by ple- thora and suppressed perspiration, bleeding and su- dorifics are also indicated. — {Cap. 19, p. 322. 333.) Scarpa supports this statement by the relation of three cases in which he cured the disease by such treatment. These patients were all unhealthy, and evidently labouring under disorder of the gastric organs. One hundred cases, hoAvever, of idiopathic, and two hundred of synqitomatic hemeralopia, occurred in the practice of Mr. Bampfield in different parts of the globe, but chiefly in the East Indies. All these cases per- pectly recovered : and hence we may infer that under proper treatment a favourable prognosis may always be given. C’elsus has stated that persons who have been for some time affected with amaurosis, have regained their sight on being attacked by a diarrheea. 'I'liis .seems to Scarpa to be corroborated by the case related by Dr. Pye. — {Med. Obs. and Inq. vol. 1.) Scarpa entertains no doubt that many similar facts, showing the influence of what he terms morbific gastric stimuli over the or- gan of sight, might he found in the records of medi- cine, ami proving the great utility of a siioiuaneous 478 HEM HEM looseness of the bowels in the cure of imperfect amau- rosis. But, says Scarpa, even if such examples of incom- plete amaurosis beitig dissipated in consequence of spontaneous vomiting or copious evacuations from the bowels, produced entirely by nature, were rare, and noticed by few, we now liave many cases evincing the Successful cure of this disease by means of such eva- cuations artificially produced by emetics and purgative medicines. Of this the accurate observations of Schmucker and Richter furnish us with numerous satisfactory proofs, and it is added, that our confidence in the above method of curing the imperfect and pe- riodical amaurosis mu.st increase when we take notice that the most respectable practitioners of past times have, in the majority of cases, cured this disease only by means of emetics and opening medicines, though in their writings they may have imputed the success of* the treatment to other causes, or the efficacy of other remedies which were also prescribed. Scarpa, after several valuable remarks on amaurosis in general, refers to the Mercure de France, for Febru- ary, 1756, where there is an account of the cures per- formed by Fournier, by means of bleeding and emetics. Night-blindness is sometimes congenital, and there- fore constitutional, and altogether beyond the reach of any curative measure. It is said sometimes to be he- reditary, and the writer of the article Nyctalopia in Dr. Rees’s Cyclopaedia was acquainted with an instance in which it occurred to two children of the same family. A case of congenital nyctalopia, which had continued many years without change, and independently of any disease, is related by Dr. Parham. — (See Med. Obs. and Inquiries, vol. 1, p. 122, note.) Pellier {Recueil de Mim. et Obs. sur I’iEil, obs. 132) cured hemeralopia by repeated doses of tartar-emetic, a seton in the nape of the neck, and cooling, aperient beverages. The method of treatment which Mr. Bampfield adopted is certainly quite simple. “ A succession of blisters to the temples (says he), of the size of a crown or half-crown piece, applied tolerably close to the ex- ternal canthus of the eye, has succeeded in every case of idiopathic hemeralopia which I have seen, &c. The first application of blisters commonly enables the patient to see dimly by candlelight, or perceive objects without the power of discriminating what they are. In some slight cases which admitted of easy cure, the first appli- cation succeeded perfectly. The second application of blisters commonly enables the patient to see by can- dlelight distinctly, perhaps, by bright moonlight, and even half an hour after sunset, or the sight is restored for short periods during the night, arid is again abolished. The second application very often effects a perfect re- covery. The third, fourth, or fifth applications in suc- cession generally produce a complete recovery where the first or second have failed ; but some rare instances of very obstinate hemeralopia have required even ten successive blisters to each temple ; or instead of using them in succession, a perpetual vesicatory has been formed on each temple, and maintained until a cure has been accomplished, an event which has generally followed in a fortnight.” — {Bainpjield in Medico-Chir. Trans, vol. 5, p. 47, 48.) In some cases, shades over the eyes were worn during the treatment, and a certain t'me afier the cure. The patients were also often directed to bathe their eyes with cold water two or three times a day. Mr. Bampfield knew of some instances in which electricity was successfully employed as a topical sti- mulus to the eye. He also informs us that a sponta- neous cure sometimes followed the eruption of biles on the head or face, or the formation of abscesses on these parts, or in the ears. Although blisters will generally effect a cure, there were particular cases in w’hich Mr. Bampfield adminis- tered cathartics, such as calomel and the neutral salts. In these examples the patient had bilious complaints, in- dicated by a yellow state of the tongue and .skin, head- ache, and pain about the praecordia ; or symptoms of indigestion ; white tongue, loss of appetite, pain and flatulence of the stomach, Ac. With blisters and ape- rient medicines Mr. Lawrence sometimes combines Clipping on the temples or nape of the neck. The ]iatients treated by Dr. Smith w'ere put into a ward moderately lighted, and their bowels emptied by a gentle cathartic. A blister was then applied to each j temple, and kept open with savin cerate. A little of a solution of the oxymuriate of mercury, in the proportion of two grains to an ounce of water, was dropped into the eyes twice a day. The purgatives were repeated on the third day, and the quantity of light to wiiich the patients were exposed was afterward gradually in- creased.— (See Edinb. Med. Joum. No. 74, p. 24.) In the scorbutic hemeralopia, the application of blis- ters is to be deferred, until the state of the constitution is amended by giving lemon and lime-juice, and fresh animal and vegetable food ; because the hemeralopia often gradually ceases as the scurvy is cured ; and before this last event the blister might produce a scor- butic ulcer. Mr. Bampfield estimates that about one- third of the cases of scorbutic hemeralopia resist the efficacy of the antiscorbutic regimen and medicines , and consequently must ultimately be treated as idio- pathic cases. The frequent recurrence of this disease, during the patient’s continuance in a tropical or hot climate, natu- rally suggests the propriety of recommending him to return to his native climate, by which change the ten- dency to a relapse is in genera] completely removed.—- {Bampfield, in Medico-Chir^ Trans, vol. 5, p. 53.) Consult Celsus de Re Medicd, cap. 6, lib. 6. Galeni Op. Lib. de Oculis, pars 4, cap. II. 22. ,Mi'.tii Sermo Septimus, cap. 48, i^c, Paul. .MgincB, lib. 3, cap. 48/ Actuarius, De Method. Med. lib. 4, cap. II. Rhases^ De JEgritud. Ocul. cap. 4. Avicenna, lib. 3, fen. 3, tractat. 4. Frabricii Hildani centur. I, obs. 24 ; cen- tur. 5, obs. 13, Plainer, Praxis Med. C. A. Bergen et J. C. Weise, De Nyctalopia seu CeBcitate Nocturna;- Haller, Disp. ad JMorb. f\ c. 359. Journal de MMecine et de Chirurgie, an 1756, t. 4. Medical Observations and Inquiries, vol. I. Recueil d' Observations de Mide^ cine des Hopitaux Militaires, par Richard, t. 2. Du- port, Mimoire sur la Goutte Sereine Nocturne ^pidd- mique, au Nyctalopie. Observations on Tropical Nyc‘ talopia, by Mr. J. Forbes, in Edinb. Medical and Surgical Journal, No. 28, p. 417, et seq. Richter's Anfangsgrunde der Wundarzneykunst, b. 3, p. 483, et seq. Schmucker's Chirurgische Schriften, band 2. Saggio di Ossetvazioni e d'Esperienze sullc Principali Malattie degli Occhi di Antonio Scarpa, p. 322, et seq, edit 8vo. Venezia, 1802. Lassus, Pathologic Chirur-- gicale, t. 2,p. 539, edit. 2. Rees's Cyclopaedia, art. Nyc- talopia. A Practical Essay on Hemeralopia, or Night-^ blindness, commonly called Nyctalopia, by R. W. Bampfield, in Medico-Chirurgical Trans, vol. 5, p. 32,- et seq. A. Simpson on Hemeralopia, 8vo. GlasgoiVf 1819. C. H. Weller, A Manual of the Diseases of the Eye, transl. by D. Monteath, vol. 2, p. 142, 8uo. GZas- gow, 1821. Good's Study of Aledicine, vol. 4, p. 203, edit. 3, 1829. Laurence's Ixctures on the Diseases of the Eye, ptiblished in the Lancet. Dr. A. Smith, in Edinb. Med. and Surgical Jonm. No. 74. HEMIOPIA. (From ppiavi, half, and dJi//, the eye.) A certain disorder of the eye, in which the patient cannot see the whole of any object which he is looking at, but only a part of it. Sometimes he sees the mid- dle, but not the circumference ; sometimes the circum- ference, but not the centre ; while on other occasions, it is only the upjier or Imver half which is discerned. Sometimes objects are seen thus imperfectly, w-hether distant or near; sometimes only when they are near, and not at a great distance. The causes of hemiopia are divided by Richter into four kinds. To the first belong opacities of the cornea and crys- talline lens, especially such as destroy the transparency of only a certain portion of these parts. The cure of this species of hemio[)ia depends upon the removal of the partial opacity from w hich it origin- ates, — (See Cataract, and Cornea, Opacities of.) Under certain circumstances, persons whose upper eyelids cannot be properly raised, are affected with hemiopia. They can only driscern the low er half of an object which is near and of large size, unless they go farther from it, draw their heads backwards, or turn their eyes dowmwards. The pupil, in particular in- stances, becomes drawn away from the middle of the iris. This may al.so be a cau.se of hemiopia : it is a case that does not admit of a cure. The aflection may likewise proceed from a separation of the iris from tli^ margin of the cornea by external violence or other caii.ses. Here the cure is equally impracticable. The foregoing species of hemiopia are merely efl'c-na HEM HEM of other diseases. The fourth and last kind is the most important, being generally regarded as an independent disorder. Sometimes it appears rather to be the effect of a sudden and transient irritation, producing a mor- bid sensibility in the optic nerve. The causes of this sort of case, if we can credit Richter, are mostly seated in the abdominal viscera. When the affection is more durable, forming what has been termed amaurosis dimidiata, the same treatment is indicated as in Amaurosis, in which, indeed, it often terminates. — {Richter, Anfangsgr. derWundarzn. b. 3, kap. 17.) HEMORRHAGE. (From a\pa, blood, and pfiyvcpi, to break out.) Bleeding. This is doubtless one of the most important subjects in surgery. The fear of hemorrhage retarded the im- provement of our professihn for a^es ; the ancients, ig- norant how to stop bleeding, were afraid to cut out the most trivial tumour, or they did so with terror. They generally performed slowly and imperfectly, by means of burning irons or ligatures, the same operations which the moderns execute quickly and safely with a knife. If the old surgeons ventured to amputate a limb, they only did so after it had mortified, by dividing the dead parts; and so great was their apprehension of hemorrhage, that they only dared to cut parts which could no longer bleed . — {John Bell’s Principles of Sur- gery, vol. \,p. 142.) But not only as a consequence o<^ surgery is hemorrhage to be feared ; it is also one of the most alarming accidents which surgery is called upon to relieve. “ Un sentiment naturel attache d VMe deperdre son sang ; un terreur machinale, dont V enfant qui commence d parler, et I’homme le plus de- cide, sont igalement susceptibles. On ne pent point dire, que cette peur soit chim rique. Si Von comptoit ceux, qui perdent la vie dans une bataille, on verroit, que les trois quarts ont peri par quelque hemorrhagie ; et dans les grandes op< rations de chirurgie cet acci- dent est presque toujours le plus formidable.” — {Mo- rand, Mem. de I’Acad. Roy ale de Chirurgie, vol. 5, 8vo.) 'As the blood circulates in the arteries with much greater impetus and rapidity than in the veins, it ne- cessarily follows, that their wounds are generaily at- tended with much more hemorrhage than those of the latter vessels, and that such hemorrhage is more diffi- cult to suppress. However, as the blood also flows through veins of great magnitude with much velo- city. bleedings from them are frequently highly danger- ous, and sometimes unavoidably fatal. When an artery is wounded the blood is of a bright scarlet colour, and gushes from the vessel per saltum, in a very rapid manner. The blood issues from a vein in an even, un- broken streatn, and is of a dark purple red colour. It is of great practical use to remember these distinguish- ing differences between arterial and venous hemor- rhage, because, though in both cases the oozing of biood may be equal in quantity, yet, in the latter instance, the surgeon is often justified in bringing the sides of a wound together, without taking farther means to sup- press the bleeding, while it would not be proper to adopt the same conduct were there an equal discharge of arterial blood. Dr. Jones has favoured the world \vith a matchless woik on the present subject; and as one grand object of this Dictionary is to present a careful account of the principal modern improvements in surgical science, I shall first endeavour to make the reader acquainted with the more accurate doctrines first promulgated by this gentleman relative to the subject of hemorrhage. Afterward, the surgical means to be practised in dif- ferent cases will be considered. The sides of the arteries are divisible into three cx)ats. The interned one is extremely thin and smooth. It is elastic and firm (considering its delicate structure) in the longitudinal direction, but so weak in the cir- cular as to be very easily torn by the slightest force fipplied in that direction. Its diseases show that it is vascular, and it is also probably sensible. The middle coat is the thickest and is composed of muscular fibres all arranged in a circular manner; they differ, however, from common muscular fibres in being more elastic, by which they tend to keep a dead artery open, and of a cylindrical form. As this middle coat has no longitudinal fibres, the circular fibres are held together by a slender connexion, ivhich yields readily to any force applied in the circumference of the artery. Tlie external coat is remarkable for its whiteness, density, and great elasticity. When an artery is sur- rounded with a tight ligature, its middle and internal coats are as completely divided by it as they could be by a knife, while the external coat remains entire. Besides these proper coats, all the arteries in their natural situations are connected by means of fine cel- lular substance, with surrounding membranous sheaths. If an artery be divided, the divided parts, owing to their elasticity, recede from each other, aruPthe length/ of the cellular substance connecting the artery-with the sheath admits of its retracting a certain way within the sheath. Another important fact is ; that when an artery is divided, its truncated extremities contract in a greater or less degree, and the contraction is generally, if not always, permanent. Arteries are furnished with arteries, veins, absorb-- ents and nerves ; a structure which makes them sus-- ceptible of every change to which living parts are sub- jected in common ; enables them to inflame when in-- jured, and to pour out coagulable lymph, by which the injury is repaired or the tube permanently closed . — (See Jones on Hemorrhage.) Petit the surgeon, in 1731, first endeavoured to ex- plain the means which nature employs for the suppres sion of hemorrhage. He thought that bleeding from a di- vided artery is stopped by the formation of acoagulum of blood, which is situated partly within and partly with-- OTzi the vessel. The clot, he says, afterward adheres to the inside of the artery, to its orifice, and to the sur- rounding pans ; and he adds, that when hemorrhage is stopi)ed by a ligature, a coaguium is formed above the ligature, which only differs in shape from the one which takes place when no ligature is employed. His theory leads him to recommend compression for the support of the coaguium. In 1736, Morand published additional interesting remarks. He allowed, that a coaguium had some effect in stopping hemorrhage, but contended that a corruga- tion, or plaiting of the circular fibres of the artery which, diminish its canal, and a shortening and consequent thickening of its longitudinal ones, which nearly ren- dered it impervious, had some share in the process. He thought that the cavity of an artery might be ob- literated, by the puckering or corrugation, when circu- lar pressure like that of a ligature was made. Morand erred chiefly in his mode of explanation, and in his belief in the existence of longitudinal fibres, which no modern anatomists admit; lov Vae contraction and retraction of divided arteries are indisputable facts, and as Dr. Jones remarks, this does not affect the truth of his general conclusion, that the change produced on a divided artery, contributes with the coaguium to stop the flow of blood. Mr. S. Sharp {2d edit, of Operations of Surgery^ 1739) supported the same doctrine. “ The blood-ves- sels, immediately upon their division, bleed freely, and continue bleeding till they are either stopped by art, or at length contracting and withdrawing themselves into the wound, their extremities are shut up by co- agulated blood.” Pouteau {Melanges de Chirurgie, 1760) denied that a coaguium is always found after an artery is divided; and when it is, he thought it only a feeble subsidiary means towards the suppression of hemorrhage. He contended that the retraction of the artery had not been demonstrated, and could not be more effectual than a coaguium. His theory was, that the swelling of the cellular membrane at the circumference of the cut extremity of the artery forms the principal impe- diment to the flow of blood ; and that a ligature is use- ful in promoting a more immediate and extensive in- duration of the cellular substance. Gooch, White, Aikin, and Kirkland, all oppose Pe- tit's doctrine of coaguium. The first blends some of Pouteau’s theory with his own, by observing, that “ when a small artery is totally divided, its retraction may bring it under the surrounding parts, and with the' natural contraction ofthe diameter ofits mouth, assisted by the compressive power of those parts, increased by their growing tumid, the efflux of blood may bo stojiped.” White was convinced, from what Gooch had sug- gested and Kirkland confirmed, that the arteries, by their natural contraction, coalesce as far as their first ramification. 480 HEMORRHAGE. Dr. Jones admits, that an artery contracts after it has been divided, and his experiments authorize him to say, that the contraction of an arterj- is an important means, but certainly not the oniy nor even the chief mer.ns, by wliich hemorrhage is stopped. When the artery is above a certain size, the impetuous flow of blood through the wound of the artery would resist the contraction of the vessel in such a degree, that the con- sequences would be fatal in almost every instance, were it not for the formation of coagulum. Mr. J. Bell thinks, that when hemorrhage stops of its own accord, it is neither from the retraction of an artery, nor the constriction of its fibres, nor the form- ation of clots, but by the cellular substance which surrounds the artery being injected with blood. We must refer the reader to Dr. Jones’s work for a complete e-xposure of the inconsistencies and absurdi- ties in Mr. Bell’s account of his own theory. — ^See p. *25, A c.) Dr. Jones concludes his criticisms on Mr. Bell with ob.serving, that if this gentleman really mean to con- fine his doctrine of the natural mean of suppressing he,niorrhage to the injection of the cellular substance round the artery with blood, he dwells improperly on one of the attendant circumstances, to the exclusion of the retraction and contraction of an artery, and the form- ation of a distinct clot, all primary parts of the process. The blood, besides filling the cellular substance round the artery, also fills the cellular substance at the mouth of the artery in a particular manner; for the divided vessel, by its retraction within its cellular sheath, leaves a space of a determinate form, which, when all the circumstances necessary for the suppres- sion of hemorrhage operate, is gradually filled up by a distinct clot. — (Jones.) MEANS OF N.iTlTRE IN STOPPING BLEKDINO FROM niVIDED ARTERIES. Dr. Jones has given a faithful and accurate detail of a series of experiments on animals, which demon- strate “that the blood, the action, and even the structure of the arteries, their sheath, and the cellular substance connecting them with it,” are concerned in stopping bleeding from a divided artery of moderate size in the following manner; “An impetuous flow of blood, a sudden and forcible retraction of the artery within its sheath, and a slight contraction of its extre- mity, are the immediate and almo.st simultaneous ef- fects of its division. The natural impulse, however, with which the blood is driven on in some measure counteracts the retraction, and resists the contraction of the artery. The blood is elfused into the cellular substance, between the artery and its sheath, and pass- ing through that canal of the sheath, which had been formed by the retraction of the artery, flows freely ex- ternally, or is extravasated into the surrounding cellu- lar membrane, in proportion to the open or confined state of the wound. The retracting artery leaves the internal surface of the sheath uneven, by lacerating or stretching the cellular fibres that connected them. These fibres entangle the blood as it flows, and thus the foun- dation is laid for the formation of a coagulum at the mouth of the artery, and which apjjears to be com- pleted by the blood as it passes through this canal of the sheath, gradually adhering and coagulating around its internal surface, till it completely fills it up from the circumference to the centre.— (/o/ie.s-, p. 53.) The effusion of blood into the surrounding cellular membrane, and between the artery and its sheath ; but in particular the diminished force of the circulation from loss of blood, and the speedy coagulation of this fluid under these circumstances, most e.ssentialiy con- tribute, says Dr. Jones, to the desirable effect. It appears then, that a coagulum, which Dr. Jones calls the external one, situated at the mouth of the ar- tery and within its sheath, forms the first complete ob- stacle to the continuance of bleeding ; and though it seems externally like a continuation of the artery, yit, on slitting open this vessel, its termination can be plainly ob.served, with the coagulum shutting up its mouth, and contained in its sheath. No collateral branch being very near the impervious mouth of the artery, the blood just within it is at rest, and usually forms a slender conical coagulum, which neither fills up the canal of the artery nor adheres to Its sides, except by a small portion of the circuinfc- ronce of its bxse near the extremity of the ve.ssel. Thi.s ' coagulum is distinct from the former, and what Dr. Jones calls the internal one. The cut end of the artery next inflames, and the vasa vasorum pour out lymph, which fills up the ex- tremity of the artery, is situated between the internal and external coagula, and is somewhat intermingled with them, or adheres to them, and is firmly united all round to the internal coat of the vessel. Dr. Jones farther states, that the permanent suppression of he- morrhage chiefly depends on this coagulum of lymph ; but that the end of 'the artery is also secured by a gra- dual contraction which it undergoes, and by an effusion of lymph between its tunics, and into the surrounding cellular substance ; whereby these parts become thick- ened, and so incorporated with each other, that one cannot be discerned from the other. Should the wound in the integuments n(jt heal by the first intention, the coagulating lymph, soon effused, attaches the artery firmly to the subjacent and lateral parts, gives it a new covering, and entirely excludes it from the outward wound. The same circumstances are also remarkable in the portion of the vessel most remote from the heart. Its orifice, however, is usually more contracted, and its external coagulum smaller, than the one which at- taches itself to the other cut end of the artery.— (Jonw on Hemorrhage., p. 56.) The impervious extremity of the artery no longer al- lowing blood to circulate through it, the portion which lies between it and the first lateral branch gradu- ally contracts, till its cavity is completely obliterated and its tunics assume a ligamentous appearance. In a few days the external coagulum, which in the first in- stance stopped the hemorrhage, is absorbed, and the coagulating lymph effused around it, and by which the parts were thickened, is gradually removed, so that they resume again their cellular texture. At a still later period the ligamentous portion is re- duced to a filamentous slate, so that the artery is, as it were, completely annihilated from its cut end to the first lateral branch ; but long before this final change is" accomplished, the inosculating branches have become considerably enlarged, so as to establish a free commu- nication between the disunited parts of the main artery. When an artery has been divided at so7ne distance from a lateral branch, three coagula are formed; one of blood externally, which shuts up its mouth ; one of lymph, just within the extremity of its canal ; and one of blood within its cavity and contiguous to that of lymph. But when the artery has been divided near a lateral branch, no interned coagulum of blood is formed. — (Jones, p. 63.) The external coagulum is alw'ays formed w'hen the divided artery is left to nature ; not so, however, if art interfere, for under the application of the ligature it can never form. If agaric, lycoj.erdon, or sponge be used, its formation is doubtful, dejiending entirely upon the degree of pressure that is used ; but the internal coagulum of blood will be equally formed, whether the treatment be left to art or nature, if no collateral branch be near the truncated extremity of the artery ; and lastly, effu-sed lymph, which, when in sufficient quantity, forms a distinct coagulum just at the mouth of the artery, will be always found, if the hemorrhage be per- manently suppressed. — (Jories, p. 71.) means which nature employs for suppressing THE HEMORRHAGE FROM PI.M.TIKED OR PAK- tiali.y divided arteries. The suppression of hemorrhage by the natural means is sometimes more easily accomplislied when an artery is completely divided, than when merely punctured or partially divided. Completely dividin.g a w’ounded ar- tery was one means practised by the ancients for the stoppage of hemorrhage ; the moderns frequently do the same thing when bleeding from the temporal artery proves troublesome. Dr. Jones has related many experiments highly worthy of periLsal, and whh h were undertaken to in- vestigate the present part of the subject of hemorrhage. He candidly acknowledges, however, that in regard to the temporary means by which the bleeding from a (lunctured artery is stopjied, he has but little to add to what I’etit has explained in his third publication on hemorrliage . — (Mem de PAcad. des .Scnuce.v, 1735.) I'he blood is etTuecd into the cellular substance, be- tween the artery and its shenth, for some dlsunce both HEMUKRIIAGE. 48 ) above and below the wounded part; and when the parts are examined a short time alter the hemorrhage has completely stopped, we find a stratum of coagula- ted blood between the artery and its sheath, extending from a few inches below the wounded part to two or three inches above it, and somewhat thicker or more prominent over the wounded part than elsewhere. Hence, rather than say that the hemorrhage is stopped by a coagulum, it is more correct to say, that it is Slopped by a thick lamina of coagulated blood, which, though somewhat thicker at the wounded part, is per- fectly continuous with the coagulated blood lying be- tween the artery and its sheath. — {Jones, p. 113.) When an artery is punctured, the immediate hemor- rhage, by filling up the space between the artery and its sheath with blood, and consequently distending the sheath, alters the relative situation of the puncture in the sheath to that in the artery, so that they are not exactly opposite to each other ; and by this means a layer of blood is confined by the sheath over the punc- ture in the artery, and by coagulating there prevents any farther eflhsion of blood. But this coagulated blood, like the external coagulum of a divided artery, affords only a temporary barrier to the hemorrhage ; its permanent suppression is effected by a process of reparation or of obliteration. Dr. Jones’s experiments prove, that an artery, if wounded only to a moderate extent, is capable of re- uniting and healing so completely, that after a certain time the cicatrization cannot be discovered, either on its internal or e.xternal surface ; and that even oblique and transverse wounds (which gape most), when they flo not open the artery to a greater extent than one- fourth of its circumference, are also filled up and healed by an effusion of coagulating lymph from their inflamed lips, so as to occasion but little or no obstruction to the canal of the artery. The utmost magnitude of a wound, which will still allow the continuity of the canal to be preserved, is difficult to be learned ; for when the wound is large, but yet capable of being united, such a quan- tity of coagulating lymph is poured out, that the canal of the vessel at the wounded part is more or less filled up by it. And when the wound is still larger, the ves- sel soon becomes either torn or ulcerated completely across, by which its complete division is accomplished. Bedard made a series of experiments upon dogs, whose arteries are said not to differ much from th ose of man, though the impulse of the heart is not so strong, and the blood is more coagulable ; two circum- stances which should be duly considered in applying any of the inferences drawn from such experiments to the human subject. “ In his first experiment he pricked the femoral artery wth a needle; the blood flowed, but soon stopped. On removing the coagulum It again flowed, but in a smaller stream ; it gradually ceased to bleed, and finally stopped, though the coagu- lum was again scraped off. On examination of the artery no trace of the cicatrix was found. Several similar experiments had the same result. In experi- ment 4, he denuded the femoral artery, and made a lon- gitudinal cut in it from two to three lines. The lips of the wound were seen in contact during the diastole of the ventricle, and to be separated by a jet of blood during the systole. The blood was stopped by a coagu- lum; this was removed twice, and each time the blood flowed in a diminished stream, but the animal died. In experiment 6, he made the same inci.sion, but did not detach the sheath from the artery, and the wound was left to nature.. The hemorrhage was not great ; there w'as an infiltration of blood into the sheath, the size of an almond, which at the end of some days began to dimi- ni.sh, and disappeared in two or three' weeks. On the limb being examined, fifteen days afterward, a little white ridge was found adhering firmly to the artery a!id to the sheath, and completely closing the wound. In the interior, there was a depressed longitudinal cica- trix of the breadth of the fifth of a line. The canal teas regular and pervvms through its whole extent. I n experiments 7, 8, 9, he made transverse incisions of i, A, and \ of the circumference of the femoral ar- tery separated from its sheath : all the animals died. In exj rirnent 10, he made a transverse incision through ! of the circumference, without disturbing the sheath. The bleeding was stopped by a co.agulunl, but on the animal moving it again flowed, and the dog died. But in the next experiment of the same kind the blood was stojiperl t:y a coagnlnm, and the artery was closed by Voi . T,- -II h nearly the same process as in the 6th experiment. So completely was the cure at the end of six weeks that the external part of the artery did not show any mark of a wound, and the cicatrix was scarcely observable on the interior surface. In his 12th experiment he cut one-half of the circumference : the animal died ; and so did it in several similar experiments. In experiment 13, he cut of the circumference : after the animal was much reduced the bleeding ceased, and the artery was closed in the same manner that it is when the section is complete. From these experiments he concludes wounds of the arteries of dogs are cured by nature when they are only occasioned by a puncture, or a longitudinal incision, whether the artery be denuded or not; but when arising from transverse incisions they are always mor- tal if the artery be laid bare. If the artery retain its sheath, arvd the wound be ^ or 5 of the circumference, it may be cured by the efforts of nature ; but it is al- ways fatal if ^ of it be cut through. — (^e Quarterly Jov.rn. of Foreign Medicine and Surgery, vol. 1, p. 26.) The inferences respecting the curability of a wound extending through | of the circumference, and the incurability of one that affects only ^ of the cir- cumference of the vessel, I should presume must re- quire farther examination, notwithstanding an acci- dental laintness produced by the sudden loss of blood in the first instance may have been the means of saving one or two of the animals on which Bedard made his experiments. This author thinks it probable that a puncture, or longitudinal incision, in the artery of a man may be cured by nature ; but that a transverse wound never cicatrizes properly, as the clot becomes displaced, or, if a cicatrix be formed, it will be distended and torn. One fact made out by the same professor is, that when an artery is deprived of its sheath for an extent greater than its distance of retraction, the hemorrhage is mortal. I have not yet had time to look over the ori- ginal paper; but it appears to me, that it would be de- sirable to know precisely to what sized arteries the author is referring, when he is making some of the above inferences. The size and condition of each ani- mal, the subject of experiment, should also be particu- larly specific ; as experiments made on the femoral artery of a lady’s lapdog would surely not have the same results as those performed on the same artery of a large terrier, setter, or Newfoundland dog. According to Dr. Jones, the lymph which fills up the wound of an artery is poured out very freely both from the vessel and the surrounding parts, and it accumulates around the artery, particularly over the wound, where it Ibrms a more distinct tumour. The exposed sur- rounding parts at the same time inflame, and pour out coagulating lymph, with which the whole surface of the wound becomes covered, and which completely excludes the artery from the external wound. This lymph granu- lates, and the wound is filled up and healed in the usual manner. — (See Jones on Hemorrhage, p. 113, ^-c.) St'RRICAL MEANS OF SUrPRESSING HKMORRHAOE. It must be plain to every one who understands the course of the circulation, that pressure, made on that portion of a wounded artery which adjoins the wound towards the heart, must check the effusion of blood. The current of blood in the veins, running in the oppo- site direction, requires the pressure to be applied to that side of the wound which is most remote from the heart. However, on account of the freedom and facility with which the blood is transmitted through the anastomo.ses, from the portion of the artery above the point of pres- sure into the lower continuation of the artery, such pressure will often only check, and not effectually stop the bleeding, unless the part of the vessel directly below the wound be also compressed or secured. As pre^ssurc is the most rational means of impeding hemorrhage, so it is the most effectual ; and almost all the plans, em- ployed for this purpose, are only modifications of it. The tourniquet, the ligature, the application of a roller atid compresses, even agaric itself, only become useful in the supi)ression of hemorrhage, on the principle of pressure ; the cautery, caustics, and stypics, however, have a different mode of ojje ration. In order to prevent a wounded person from dying of hemorrhage, Celsus advised the wound to be filled with dry lint, over which was laid a sponge dipped in cold water, and pressed on the part with ihe hand. If, not 482 HEMORRHAGE. withstanding these means, the hemorrhage should con- tinue, he recommends repeatedly applying fresh lint, wet with vinegar ; but he is against the use of corroding escharotic applications, on account of the inflammation which they produce ; or only sanctions the employment of the mildest ones. When the hemorrhage resists these methods, he advises two ligatures to be applied to the wounded part of the vessel, and then dividing the portion situated between them : “ Quod si ilia quoque prqfluvio vincuntur, venae, quxB sanguinem fundunt, apprehendendcB, circaque id, quod ictum est, iuobus locis deligandae, intercidendcsque sunt, ut et in se ipscB coeant, et K'ihilominus ora praeclusa habeant.” —{Lib. 5, cap. 26.) When the ligature was imprac- ticable, the wound bled dangerously, and no large nerves nor muscles were situated in the bleeding part Celsus proposed the actual cautery. Galen also mentions tying the vessels for the purpose of stopping hemorrhage ; and there are some traces of the same information in other authors, who lived before him, as Archigenes and Rufus. Probably, however, the ligature was little used at these early periods, as may be inferred from the multitude of astringents, caustics, and other applications, which were advised for stopping bleeding, and in which less confidence would have been put, had the use of the ligature been familiarly known. No one can doubt, that if the old surgeons had had many opportunities of seeing the ad- vantages of the ligature, they would soon have used it after amputations; but so far were they from adopting such practice, that Albucasis, a long w^hile afterward, refused to amputate at the wrist, lest he should see his patient bleed to death. Pare is considered as the first who regularly employed the ligature after amputation. His method having been attacked, he modestly defends it in the part of his works entitled Apologie, where he takes great care to impute the origin of it to the ancients, and cites many of them who have made mention of it. However, he thinks its utility in amputations of such consequence, that he ascribes his first adoption of this practice to in- spiration of the Deity. The method in which the ancients placed most con- fidence for stopping hemorrhage after the amputation of a limb, was the cauterization of the cut vessel, and surrounding flesh. The parts thus affected by the heat formed an eschar, of greater or less thickness, which blocked up the opening of the vessel, and hin- dered the blood from escaping. The separation of the eschar, however, which frequently took place too soon, occasioned a return of hemorrhage, and rendered it the more dangerous, as its suppression was now more difficult than before the cautery had been applied. Sometimes the instrument, being too much heated, im- mediately brought away with it the eschar. At the present time, the cautery is never employed as a means of suppressing hemorrhage, or, at most, only in a few very unusual cases, in which neither compression nor the ligature can be made use of. In Great Britain, the cautery may be said to be entirely exploded ; but in France, the best hospital surgeons now and then employ it to stop bleedings from the antrum and the mouth. The old surgeons also very commonly applied to bleeiling parts pledgets, dipped in boiling turpentine— a practice that has long been most justly abandoned. ASTRINGENTS, STYPTICS, &C. Le Dran, in his Treatise on the Operations of Surgery, says that a button of vitriol, or alum, applied and pro- perly confined on the extremity of the vessel, is suffi- cient JO stop the hemorrhage in amputations. Ileister recommends the application of vitriol, in preference to the ligature, in the amputation of the forearm. Great praises have also been conferred on agaric, and sponge, for their styptic properties. Solutions of iron, and all the mineral acids in various forms, have been recom- mended to the public, as remedies of the same kind, and possessing great efficacy. The ancients, centuries ago, left no application of this nature untried, and the pretended discoveries of new and more effectual styp- tics in later times may almost all be met with in tlieir writings. This fact merits particular notice, because the little success attending their practice, especially when bleeding from a considerable artery was to be suppressed, clearly proves wbat little reliance ought to be placed on means of this description.— C£/tc7/c/optfdM; R.tioiijiie, partie Chir.) Ine most w'hioh styptics can do is to stop hemorrhages from small arteries ; btft they ought never to be trusted when large vessels are concerned. There is no doubt, that cold air has a styqitic property ; by which expression I mean, that it promotes the con- traction of the vessels ; for no styptics can contribute to make the blood coagulate, though such an erroneous idea is not uncommon. We frequently tie, on the sur- face of a wound, every artery that betrays the least disposition to bleed, as long as the wmund continues exposed to the air. We bring the opposite sides of this wound into contact, and put the patient to bed. Not an hour elapses before the renewal of hemorrhage compels us to remove the dressings. The wound is again ex- posed to the air, and again the bleeding ceases. This often happens in the scrotum, after the removal of a testicle, and on the chest, after the removal of a breast. The proper conduct in such cases, is not to open the wound unnecessarily, but to apply pressure, or else w-et linen to the jiart, so as to produce such an evaporation from its surface, as shall create a sufficient degree of cold to stop the bleeding. As all styptics are more or iess irritating, no judicious prtuititioners apply them to recent wounds. However, for the suppression of he- morrhage from diseased surfaces, where the vessels seem to have lost their natural disposition to contract, these applications are sometimes indicated. COMPRESSION. We have already remarked that all the best means of checking hemorrhage operate on the principle of pres- sure ; the actual and potential cautery, and some styp- tics excepted : the first two of which operate by forming a slough, which stops up the mouths of the vessels ; while the latter operate by promoting their contraction. Let us next consider the various modifications of pressure. In a dissertation on the manner of stopping hemor- rhage, printed in the M^m. de VAcad. des Sciences, annie 1731, Petit endeavoured to prove, that different articles, praised as infallible specifics, would seldom or never have succeeded without compression. Even when caustics were employed, it was usual to bind coi ‘presses tightly on the part, so as to resist the impulse of the blood in the artery, and the premature separation of the eschar. Had this precaution not been taken. Petit be- lieves hemorrhage would almost invariably have fol- lowed, and indeed, notwithstanding the pains taken to avert it by suitable compression, it did too frequently take place on the detachment of the eschar. Petit has noticed that the end of a finger, gently compressing the mouth of a vessel, is a sufficient means of stopping he- morrhage from it, and that nothing else would be necessary, if the finger and stump could always be kept in this posture. Hence he endeavoured to obviate these difficulties by inventing a machine which securely and incessantly executed the office of the finger. The instrument was a double tourniquet, which, when ap- plied, compressed at once both the extremity of the di- vided artery and its trunk above the wound. The com- pression on the end of the vessel was permanent ; that on the trunk was made only at the time of dressing the wonnd, or when it was necessary to relax the other. An engraving and particular description of the instru- ment are to be found in Petit’s memoir. Surgeons formerly filled the cavities of wounds with lint or charpie, and then made pressure on the bleeding vessels, by applying compresses and a tight roller over the part. The practitioners of the present day are too w'ell acquainted with the advantages of not allowing any extraneous substance to intervene between the oj>- posite surfaces of a recent wound, to persist in the above plan. They know that the sides of the wound may be brought into contact, and that compression may yet be adopted, so as both to restrain particular hemorrhages, and rather promote than retard the union of the w ound. When the blood does not issue from any particular vessel, but from numerous small ones, compre-ssion is preferable to the ligature. In the employment of ihe latter, it would be necessary to tie the whole surface of the wound. The sides of the wound are to be brought accurately together, and compresses are then to be placed over the part, and a roller to be applied w ith sufficient tightne.ss tomakeeftectual pre.s.sure, but not so forcibly as to produce any chance of trie cir, ula lion in the limb beiug compleitiy stciped HEMORRHAGE. 483 If, in bleedings from large arteries, compression can ever bo prudently tried, it is when these vessels lie im- mediately over a bone. Bleedings from the radial and temporal arteries are generally cited as cases of this kind, though from the many instances of failure which I have seen happen where the first of these vessels is concerned, I should be reluctant either to advise or make such an attempt. Compression is sometimes tried, when the brachial artery is wounded in phlebo- tomy. Here it is occasionally tried, in preference to the ligature, because the latter cannot be employed without an operation to expose the artery. When there is a small wound in a large artery, the following plan may be tried ; a tourniquet is to be ap- plied, so as to command the flow of blood into the vessel. The edges of the external wound are next to be brought into contact. Then a compress, shaped like a blunt cone, and which is best formed of a series of compresses, gradually increasing in size, is to be placed with its apex exactly on the situation of the wound in the artery. This graduated compress, as it is termed, is then to be bound on the part with a roller. In this manner, I once healed a wound of the super- ficial palmar arch, in a young lady in Great Pulteney- street. The outward wound was very small, and though the hemorrhage was profuse, I conceived that it might be permanently stopped, if compression could be so made as to keep the external wound incessantly and firmly covered for the space of a day or two. At first, I tried a compress of lint, bound on the part with a roller; but this proving ineffectual, I took some pieces of money, from the size of a farthing to that of a half-crown, and, wrapping them up in linen, put the smalle.st one accurately over the w'ound, so as com- pletely to cover it. Then the others were arranged, and all of them were firmly confined with a roller, and the arm kept as quiet as possible in a sling. They were taken off after three days, and no hemorrhage ensued. It is to be observed, that the palmar fascia, in this instance, would prevent the compression from operat- ing on the vessel ; but the case shows that this artery, when wounded, is capable of healing, if the blood be completely prevented from getting out of the external wound by the proper application of compression. Were the outer wound too large to admit of this plan, it would probably be the safest practice to cut dowm, at once, to the ulnar artery, and put a ligature round it, though, as this would only certainly stop the bleed- ing from one end of the vessel in the hand, pressure on the wound would yet be necessary. I have never seen a surgeon succeed in taking up the artery in the hand. Besides compressing the wounded part of the artery, some surgeons also apply a longitudinal compress over the track of the vessel above the wound, with a view of weakening the flow of blood into it. Whatever good effect it may have in this way, is more than coun- terbalanced by the difficulty which it must create to the circulation in the arm. If the graduated compress be properly arranged, an effusion of blood cannot pos- sibly happen, and pressure along the course of the ar- tery must at all events be unnecessary. After relax- ing the tourniquet, if no blood escape front the artery, the surgeon (supposing it to be the brachial artery wounded) should feel the pulse at the wrist, in order to ascertain that the compression employed is not so powerful as entirely to impede the circulation in the forearm and hand. The arm is to be kept quietly in a sling, and, in forty-eight hours, if no bleeding take place, there will be great reason to expect that the case will do well. In another work, I have given an engrav- ing and description of an instrument invented by Plenck, for making pressure on the wounded brachial artery, at the bend of the arm, without pressing upon the whole circumference of the limb and consequently without stopping the circulation. No one, however, would prefer compression when large arteries are in- jured, except in the kind of cases to which we have just* now adverted, or in those in which the wounded vc.ssel can be firmly compressed against a subjacent bone. Sometimes the compresses slip off, or the band- ages become slack, and a fatal hemorrhage may arise ; and a still greater risk is that of mortification from the constricted state of the limb. When the method is tried, the tourniquet should always be left loosely round the limb, ready to be tightened in an instant Sometimes the external wound heals, while the open- ing in the artery remains unclosed, and a false aneu- rism is the consequence. tourntqiet. When hemorrhage takes place from a large artery in one of the limbs, where the vessel can be conveniently compressed above the wound in it, a tourniquet. Judi- ciously applied, never fails to put an immediate stop to the bleeding. Before the invention of this instrument, which did not take place till the latter part of the 17th century, surgery was really a very defective art. No important opera- tion could be undertaken on the extremities, without placing the patient in the most imminent peril ; and many wounds w^ere mortal, which, with the aid of this simple contrivance, would not have been attended with the least danger. The first invention of the tourniquet has been claimed by different surgeons, and even different nations. But, whoever was the inventor, it was first presented to the public in a form exceedingly simple ; so much so, in- deed, that it seems extraordinary that its invention did not happen sooner. A small pad being placed on the principal artery of a limb, a band was applied over it, so as to encircle the limb twice. Then a stick was introduced between the two circles of the band, which was twisted : thus the pad was made completely to stop the flow of blood into the lower jtart of the vessel. Although in the Armamentarium Chirurgicum of Scultetus there is a plate of a machine invented by this author for compressing the radial artery by means of a screw, J. L. Petit is universally allowed to be the first who brought the tourniquet to perfection, by com- bining the circular band with a screw, so that the greatest pressure may operate on the principal artery. The advantages of the modern tourniquet are, that its pressure can be regulated with the utmost exact- ness ; that it operates chiefly on the point where the pad is placed, and where the main artery lies ; that it does not require the aid of an assistant to keep it tense ; that it completely commands the flow of blood into a limb ; that it can be relaxed or tightened in a moment ; and that, when there is reason to fear a sud- den renewal of hemorrhage, it can be left slackly round the limb, and, in case of need, tightened in an instant. Its utility, however, is confined to the limbs, and as the pressure necessary to stop the flow of blood through the principal artery completely prevents the return of blood through the veins, its application cannot be made very long without inducing mortification. It is only of use also in putting a sudden stop to profuse hemorrhages for a time, that is, until the surgeon has put in practice some means, the effect of which is more permanent. LIGATURE. The ancients were quite unacquainted with the use of the tourniquet, and though some of their writers have made mention of the ligature, they do not seem to have known how to make proper use of it, nor to have possessed any other certain means of suppress- ing hemorrhage from wounds. In modern times, it is easily comprehensible, that when any great operation was undertaken, while surgery was so imperfect, there was more likelihood of the patient’s life being short- ened than lengthened, by what was attempted. Under these circumstances, it is not surprising that the old practitioners should have taken immense pains to in- vent a great many topical astringents. But now that the ligature is known to be a means which is safer and less painful than former methods, no longer search need be made for specifics against hemorrhage. It may, indeed, be set down as a rule in surgery, that whenever large arteries are wounded, no styptic application should ever be employed, but immediate re- course had to the ligature, as being, when properly applied, the most simple and safe of all methods. In order to quality the reader to judge of the best mode of applying ligatures to arteries, I shall first ex- plain to him their effect on these vessels, as related by Dr. Jones. This gentleman learned from Dr. J. Thomson, of Edinburgh, that in every instance in which a ligature is applied around an artery, without including the sur- rounding parts, the interna! coat of the vessel is tom through by it ; and that this fact had been originally 484 HEMORRHAGE. noticed by Desault. Dr. Thomson even demonstrated 10 Dr. Jones, on a portion of artery taken from the hu- man subject, that the internal and middle coats are divided by the ligature. — {Jones, p. 126.) This led Dr. Jones to make some experiments on the arteries of dogs and ihorses, tending to the conclusion, that ivken several ligatares are applied round an ar- tery with sufficient tightness to cut through its internal and middle coats, although the cords be immediately afterward removed, the ve.ssel will always become im- pervious at the part which was tied, as far as the first collateral branches above and below the obstructed part. Dr. Jones thinks it reasonable to expect that the obstruction produced in the arteries of dogs and horses, in the manner he has related, “ might be effected by the same treatment in the arteries of the human sub- ject ; and, if it should prove successful, it might be employed in some of the most important cases in sur- gery. The success of the late important improve- ments which have been introduced in the operation for aneurism, may perhaps appear to most surgeons to have rendered that operation sufficiently simple and safe ; but if it be possible to produce obstruction in the eanal of an artery of the human subject in the above- mentioned manner, may it not be advantageously em- ployed in the cure of aneurism ; inasmuch as nothing need be done to prevent the immediate union of the ex- ternal wound?” Dr. Jones next questions whether this mode of obstructing the passage of blood through the arteries may not also be advantageously practised in cases of bronchocele 1 — (P. 136.) Subsequent e.xperimenters have not been equally suc- cessful with Dr. Jones in obtaining the obliteration of the cavity of the vessel after this operation. Did this difference depend upon tiieir having tied the vessel only in one place ? Mr. Hodgson tried the experiment in two instances upon the carotid arterie»of dogs ; and in neither of them was the cavity of the vessel oblite- rated. The same experiment has been repeated by several surgeons upon the arteries of dogs and horses ; but in no example, as far as Mr. Hodgson knows, has the complete obliteration of the cavity of the vessel been accomplished. However, as an effusion of lymph is an invariable consequence of the operation, the want of union is owing to the opposite sides of the vessel not being retained in a state of contact, so as to allow of their adhesion. — (See Observations 07 l the Applica- tion of the Ligature to Arteries, iS-c. by B. Travers, vol. 4, Med. Chir. Trayis.) The presence of the liga- ture, in the common mode of its application, effects this object ; and for the success of Dr. Jones’s experi- ment, it appeared only necessary that the opposite sides of the wounded vessel should be retained in contact until their adhesion is sufficiently accomplished to re- sist the passage of the blood through the tube. This object might probably be effected by compression ; but the inconveniences attending such a degree of pressure as shall retain the opposite sides of an artery in con- tact at the bottom of a recent wound, are too great to permit its employment. It occurred to Mr. Travers, that if a ligature were applied to an artery, and suf- fered to remain only a few hours, the adhesion of the wounded surfaces would be sufficiently accomplished to ensure the obliteration of the canal ; and by the re- moval of the ligature at this period, the inconveniences attending its stay would be obviated. The danger pro- duced by the continuance of a ligature upon an artery arises from the irritation which, as a foreign body, it produces in its coats. Ulceration has never been ob- served to commence in less than twenty-four hours after the application of a ligature; while it is an ascer- tained fact that lymph is in a favourable state for or- ganization in less than six hours, in a wound the sides of which are preserved in contact. — {Jones, chap. 4, exp. 1.) If it be sufficient, therefore, to ensure their adhesion, that the wounded coats of an artery be kept in contact by a ligature only three or four hours, ulcer- ation and sloughing may in a great degree be obviated by promoting the immediate adhe.sion of the wound. Justified by this rea.soning, Mr. Travers performed several experiments, by which he ascertained, that if a ligature be kept six, two hours, or even one hour upon the carotid artery of a horse, and then removed, the adhesion is suificiently advanced to secure the per- manent obliteration of the canal. It apiwared probable that the same result would be obtained upon the healthy artary of a human .subjert . — {Hodgson on the Diseases of Arteries, ^c. p. 22.9, et seq.) Mr. A. C. Hutchison, in the year 1800, tied the brach al arteries of two dogs, and removed the ligatures immediately after their application. In both instances, the complete obliteration of the canal of the artery was the conse- quence of the operation.— (See Practical Observations in Surgery, p. 103.) He has also tried this method, as modified by Mr. Travers, in an operation which he performed for a popliteal aneurism in a sailor, in Nov. 1813. A double ligature was passed under the femoral artery. The ligatures were tied with loops or slip- knots, about a quarter of an inch of the vessel being left undivided between them. All that now remained of the pulsation in the tumour was a slight undula- tory motion. Nearly six hours having elapsed from the application of the ligatures, the wound was care- fully opened, and the ligatures untied and removed, without the slightest disturbance of the vessel. In less than half a minute afterward the artery became distended wth blood, and the pulsations in the tumour were as strong as they had been before the operation. Mr. Hutchison then applied two fresh ligatures; he morrhage afterward came on ; amputation was per- formed, and the patient died. — (See Practical Observa- tioois in Surgery, p. 102, Src.) Now, as Mr. Hutchison chose to apply other ligatures, on finding that the pul- sation returned, the above case only proves that the artery was not obliterated in about six hours, and we are left in the dark respecting the grand question, namely, whether the vessel w'ould have become obli- terated by^ the effusion of coagulating lymph and the adhesive inflammation, notwithstanding the return of circulation through it. As for the hemorrhage which occurred, I think it might have been expected, consider- ing the disturbance and irritation which the artery must have sustained in the proceedings absolutely ne- oessary for the application of not less than four liga- tures, and the removal of two of them. According to my ideas, only one ligature ought to have been used, and none of the artery detached. We also have no de- scription of the sort of ligatures which were employed ; an essential piece of information m forming a judg- ment of the merits of the preceding method. The application, removal, and reapplication of ligatures are not consistent tvith the wise principles inculcated by the late Dr. Jones, and have, in more instances than that recorded by my friend Mr. Hutchison, brought on ulceration of the artery and hemorrhage. For farther information on the question concerning the propriety of withdrawing the ligature previously to its detach- ment, see the article Aneurism. From Dr. Jones’s experiments, it appears that the first effects of a ligature upon an artery are, a com- plete division of its internal and middle coats, the bringing of its wounded surfaces into contact with each other, and an obstruction to the circulation of the bloo