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SYSTEM   OF   SURGERY. 


VOL.  III. 


OPERATIVE    SURGERY;   DISEASES    OF    THE    OBGANS    OF 
SPECIAL  SENSE,  RESPIRATION,  CIRCULATION, 
LOCOMOTION,  AND  INNERVATION. 


i 


f 


■■  ■ 


lovdoh: 
fbqitid  bt  kobboit,  utet,  uni  vukkltn, 

□lat  Hew  Sti«et  aud  Fctts  Idiu. 


SYSTEM    OF   SURGEKY, 


TUEORETICAL  AND  PRACTICAL, 


Of 


TREATISES  BY  VARIOUS  A  VTIiO US. 


KDI'l'KU  BT 


T.  HOLMES,  M.A.  Cantab. 

AaaiSTAITT  HQSOBOa  10  tTT.  uniUB'S  nDfiPTTAL,  AlTD  SURCIION  TO  Tim  nOSFItJlt,  FOR 

KICK  OtULUUK. 


IN   POUR  VOLUMES. 

VOLUME  THE  TmBD. 

OPKIiATIVB  SUROERT;  DISEASES  OF  THE  OROAXS  OF- 
SPECIAL  SENSE,  RESPIRATION,  CIRCULATION. 
LOCOMOTION,  AND  INNERVATION, 


LONDON: 
PARKER,  S02J,  AND  BOURN,  WEST  STRAND. 

NEW    YORK: 

WILLIAM  WOOD  ii  OO.,  fil   WALKEH  STItEET. 

iS6z. 


V^o- 


fWT**^ 


PREFACE  TO  VOLUME  THIRD. 


TT^HE  present  Volume  contains  the  Essays  on  Opera- 
-^     live  Surgoiy,  and  on  the  Diseases  ol'  the  Organs 
of  Special  Sense  (the  Ear  and  Nose ;  those  of  the  Eye 
laving  been  placed  in  Vol.  II.  for  the  sake  of  oonveni- 
e),  of  the  Air-passages,  and  of  the  Organs  of  Cir- 
lation,  Locomotion,  and  Inncr\-ation.^     In  treating  of 
"^Opfrrativc  Surgery,  it  was  thought  incxpedipnt  to  offer  a 
^complete  separate  treatise  on  the  whole  subject ;  since,  if 
it  plan  had  been  followed,  a  great  part  of  the  matter 
of  such  .treatise  must  necessarily  have  been  repeated  in 
eating  of  tlio  diseases  of  the  organs  on  which  the  opera- 
tions arc  practised.    The  subject  of  Minor  Surgery  lias, 
"^ihercfore,  been  treated  at  such  a  length  as  seemed  prac- 
.tically  useful ;  then  the  greater  iipcrations  are  illustrated 
&  description  of  the  various  amputations,  and  an  Es- 
%y  on  Ana3sthcsia ;  and  finally,  the  principles  of  Plastic 
Surgery  are  explained  and  illustrated  by  the  description 
[>f  such  operations  as  could   be  conveniently  sei»arated 
am  that   of  the  lesions  for  which  they  are  practised. 
le  Editor  is  aware  that  some  amount  of  confusion  is 
luced  by  this  arrangement  wliile  the  work  is  \m- 


*  Beddec  tbeto  cunigJeicd  Kcctions,  the  Diecoses    of  the  Orgui*  of 
icn  ftra  commenced,  by  a  Ut^tise  on  the  Atri:ctiDns  of  the  Tongue. 
Kmyv  ou  the  Discucs  of  (ho  other  purta  of  the  Muutli,  tuid  the  re- 
dcr  of  the  ulimvntary  tnict,  will  form  the  com mcD cement  of  the 
.  Volume. 


( 


h^rf^ 


vi  PREFACE  TO  VOLUME  THIRD. 

finished;  but  he  trusts  that  the  Index  which  will 
accompany  the  concluding  Volume  will  obviate  such 
confusion  in  the  completed  work,  and  enable  the  reader 
to  find  at  once  the  place  at  which  any  operation  is  de- 
scribed. 

The  Editor  has  to  apologise  for  a  slight  delay  in 
producing  this  Volume ;  but  such  delays  can  hardly  be 
avoided  when  many  men,  all  of  them  in  active  employ- 
ment, have  to  work  together.  The  preparation  of  the 
concluding  Volume  is  considerably  advanced,  and  it  will 
in  all  probability  be  published  in  a  few  months. 


'ENTS  OF  THE  THIIID  VOLUME. 


OPERATIVE  8UEGERY. 


MINOR  SUnGEnY. 
B^'  Thomas  Smith,  Ksq. 

J,nUTA3n  tOkABMI  10  IRE  IHMMtAI.  WU  StCX  CVILDKEX. 

<  tad  their  applicatioa 1 

I  btukgcs.     Tb«  sjiiral 3 

„            Th«  &fra.Tt  i>f  cigbt 3 

.,            Scftlp  MiuUges 0 

[■OoimpotitM]  iMDilagct.    TIm  T-bondagc 6 

Bospenmry  ......  1 

Four-tailed  „,,...  7 

Mmiy- tailed  „ 6 

8 

idAt-e 9 

or  plasUr  of  I'lirtH  Ixtnilngc 9 

pwcht,  {HutcboArd,  miUbouid,  or  leather  HplioU        .  10 

tad  llMir  ai^tntioD II 

The  eoaliRuona  sttUire 12 

„  iiit«TTii[>lcd     „         ...>>.•.  13 

TTirc  sutures 13 

TV  twU(«d  or  harelip  suture lA 

,  ^Itiilled  nitnrc 16 

Snm-fiii<s 17 

UTilAtioii IT 

AnbelKietib — Mixtanl  poultice*,  itc 18 

TiricMiU 19 

CkntkajMliiH 19 

UoBor  UBmouiu       •...••-■  SO 

CUorDfomi 20 

Tbe  Imtvd  iron  (thcnuul  liAOuncir) SO 

TrattmcBt  of  blist«ra    ....                 ,        .  21 

Tilt  tuiertaic  m«tbiKl  of  mcdicatioD 21 

TW  bjrpodwniio  „       „         „ 22 

AcapBnctnre -^ 

.KlMUi>>pnpctarG ■'* 


«ii  CONTENTS  OF  VOL.  IIL 

run 

lasuea 23 

Caustic  issues 21 

IsBuea  made  with  moxa      .......  26 

„             „         the  knife 25 

Setons 26 

The  actual  cauteij 28 

Blood-letting 29 

Local — leeches 29 

„         scarification 30 

„         cupping 31 

drjT  capping 32 

General — veaeseotion 33 

,,          art«riotoniy      ........  35 

Vaccination           ..........  36 

Caustics — potential       .........  39 

'Cauterisation  eu  flSches'  .         .         .         .         .         .         .43 

The  actual  cautery 44 

The  galvanic  caateiy        ........  44- 

Straugulation  of  neri  and  other  tumours 46 

Partially  subcutaneous  ligature 47 

Mr.  Cooper  Poster's  method 4S 

Ur.  FergUBSon's  method      .......  48 

Completely  subcutaneous  ligature 49 


AMPUTATION. 
By  Joseph  Libteb,  Esq. 

fKOVXHOR  OF  EUBOMtl  IK  IlIE  DHIVEBSnT  OP  OLASOOW,  AKD   BOKOEON   TO  TtlB 

KOTJlL  INTIUIAKI. 

L  Akputatioit  in  gensral  : 

History  of  Amputation — precepts  of  Celsus  and  other  ancient 

writers — the  ligature  of  vessels 51 

Amputation  in  the  Middle  Ages        .         .         .         .         .53 

Invention  of  the  tourniquet 55 

Cheselden's  practice — amputation  by  donble  indsion  .        .    56 
Louis's  practice — digital  oompreasion  of  tiie  vessels — forma- 
tion of  flaps 5G 

Alanson's  practice — more  complete  covering  of  the  bone — 

practice  of  Benjamin  Bell,  and  Hey  of  Leeds        .         ■     57 
Flap  amputations — methods  of  Young,  Lowdham,  Yerduin, 

Qarangeot,  Kavaton,  Vermale,  and  Liston    .         .         .57 
Syme's  modified  circular  amputation ,         .         .         .         ,59 

Tesle's  method  by  rectangular  flaps 60 

Modification  of  this  method,  proposed  by  Spence  .         .     62 

Dressing  of  the  atump  after  amputation 64 

Sntures 69 


CONTENTS  OF  VOL.  III.  k 

its  rM]titr«d  for  aiopulaUoiu 70 

lt«tfao(l  uf  iiiiiijf  tli«  kuifo 71 

Other  gencrul  dircctionit  for  tbc  opcintion  .         .  .73 

Pahticulak  AurrrATioNs: 
AtnputAtioiui  ID  Uiv  ttpjier  exlrcmitj        .         ,         ,         .         .73 

„              of  tiic  Ungcrt     .,,,...  74 

„                 „      tliiimh 75 

B                n     I"""! 79 

„                „     fore-Ann .......  76 

„            itt  the  elbow-jobt 77 

„            of  the  ana 77 

,t            «t  tbe  aUouliIer'joint.     LisfVunc's  uetliod      .        .  78 

.,                           „             „          Lttirey'*         „            ,         .  78 

„                           „             „          Olher  metliudH           .  7ft 

AmpuU^ODS  in  tlie  tovcr  extremity 79 

„             of  the  t<«!» 79 

,,                »    grciittoo 80 

„                „    niHBCartal  botioi 80 

,1  »    nietatanus  (tlef»  and  IJsliraiic*s  umputa- 

tioaa) 80 

„             C3iopar(*s  aiuputetion  tbron»h  Ibe  Umua             .  83 

„            at  ueftakle-joiul^Svin«ii  aii>iiututiu[i)        .        .  83 

M                    ■•        u          Maekeuxie'a  metliud        .  84 

»                    »        ..          Pirogoff"*        „               .        .  85 

„              oftbe  li^^  (difTerent  methods)     ....  85 

„               at  tlie  kner-jomt 87 

„  of  the  thigh  (dilTcrcnt  mctliods)  .         .         .88 

„                *t  the  hi]vjoitil                „               .          .          .          .  SQ 
Horse-shoe  cbmp  for  restraining  lupiiiorrh*gc 

to  this  o]}oraUoii 90 


.VN^BTHETICS. 

By  JOHEPH  LiBTKB,  E»Q. 

I     wmarxMmoti  or  Bt<RaauT  ijc  tde  miTRBjiiTT  or  GLLsaow,  A!n>  tuioioii  to  inc 
■K.  BUTU.  ixriuitBr, 

^Bit  nggBstioiD  of  An«et)ieBia  by  Sir  II.  Davy  .91 

^^boovoty  of  suljifatiric  edwr  iu  America,  nud  of  cblorofonn  in  Edin- 

^           boigh 91 

£ffceU  of  diloroform 93 

AdvautaRM  of  cbtoroform  in  Icmening  nbock  and  Mcondar;  bw* 

muiTDago 93 

Dcatlia  from  cUorofbnn 94 

Some  ante  (n»n  abode,  die  adininistration  being  insufiicieut 

t«  produce  canpleto  antesthcaia 94 


CONTEKTS  OF  VOL.  IIL 

run 

Some  from  emotion,  the  uae  of  chloroform  being  merely  a 

coiDcideace 05 

Death  may  occur  from  too  concentrated  state  of  tlie  vapour  .  dS 
Dr.  Snow's  iohaler  contrived  to  prevent  this  .  .07 
Elxperiment  to  show  that  the  ordinary  adminiatratioo  on 

a  cloth  is  free  from  this  risk 97 

In  very  rare  eases  death  seems  to  be  due  to  idiosyncrasy       .  99 
Other  deaths  occur  from  an  overdose  of  chlorofonn  during 

protracted  administration        ......  99 

I^enomena  of  anesthesia 100 

What  ought  to  be  done  on  the  sudden  occurrence  of  asphyxia  101 

Experiments  on  Btertor .         ......  101 

Seat  of  the  stertor  which  accompanies  the  administration 
of  chloroform.     Effect  of  pulling  out  the  tongue  for- 
cibly in  removing  the  obstruction      ....  102 

Minor  importance  of  the  state  of  the  pulse  compared  to  that  of 

the  breathing 105 

It  is  unnecessary  to  examine  the  chest  previously          .         -  105 
Circumstances  calling  for  the  use  of  artificial  respiration  and 
of  laryngotomy     .         .         .         .         .         .         .         .105 

Preparation  for  taking  chloroform       .....  lOG 

Cases  Buit«d  for  the  use  of  chloroform 106 


PLASTIC  SURGERY. 
By  Holmes  Coote,  Esq. 

ASaiBtllKT    BCKQEOS    TO    ST.    BARTIIOLOHXW'S    DOSPITAL. 

Introductory.     Tagliacozzi's  operations  . 
Division  of  deformities  into  congenital  aud  acquired 
Powers  of  reproduction  id  the  human  subject  . 
Parte  used  in  plastic  Surgery  to  replace  those  lost  . 
Mode  of  transplanting  flaps  of  skin 
Unfavourable  symptoms  after  transplantation  . 
Silver  sutures  in  plastic  Surgery      .... 

The  shotted  suture 

Bhinoplastic  operations  ..... 

Taghacoz^'s  method 

Skey'e  „  or  the  Indian  operation 

Cheiloplaetic  operations.     Harelip 

„  „  Bestoration  of  the  lower  lip 

»         ,   »  ,.  ,.       upper  lip 

Plastic  operations  on  the  ear  .... 

„  „        penis        .... 

On  the  treatment  of  contracted  cicatrices 

n  „.  ■  within  the  vagina     . 

»  „  from  bums,  escharotics,  &c. 

Great  success  of  mechanical  extension  in  these  cases  . 


lOS 
110 

111 

112 
113 
113 
115 
116 
116 
116 

lis 

121 
124 
126 
127 
128 
130 
130 
130 
132 


^^H              CONTENTS  OP  VOL.  HI. 

1 

■DISEASES  OF  ORGANS  OP  SPECIAI.  SENSE.          ^M 

1                          DISEASES  OP  TRE  EAIt. 

■ 

^^^^^h                   By  Jaurs  Hiktox,  Esq. 

^H 

^^^^^^^^ 

^^^M 

H  J.  AffcctioDS  of  tli«  citenial  e«r. 

11  ol  formations 

194         ^H 

H             » 

Cutantous  ufff^tions 

139         ^H 

^^^^ 

Ouuty  aiiii  otbur  ile|H)BilB 

13fi         ^H 

^^^^     « 

TlUDOUTS  of  tlie  aaritle :  cysts, 
basinaluuiii.    fibruuH,    futty, 

T 

^^^ 

■teatuniatouii  tumoun 

^H 

■U.  AflecUoiuofthccxtcnialtDcatue.    Exominatinu ofthc rnvntiia 

^H 

^P 

Accumtilntinn  of  ircrutiico 

138          ^^ 

^^^^ 

Oilier   morbid   conditions 

H 

of  cerumen 

140                ■ 

^^R^ 

Abaoeu  in  ibv  meatus 

HI         ^M 

^V^ 

Inilamni&tiou  of  tlie  mea- 

^^H 

tus,  acute  and  clirottio . 

us      ^H 

^^^1 

S}-ijhilit4c  diHeau   of  tbe 

^^H 

^^^1 

mcatuK 

146          ^V 

^^^B 

Poljpi    .... 
Molliuctiu*    or  ■ebaccons 

U6               ■ 

^^^^ 

^^fl 

lumoiint 

U9         ^H 

^K 

Exostones         .          .          , 

^H 

HU.  AffcctioiLS  of  Ihc  menibrtioa 

tfinpani.     ExominatJon  of  thin 

^^H 

H^ 

tD«iubmio  . 

100      ^H 

^^^ 

Itljiiiies 

iffi      ^H 

^^^B 

Inflamnution . 

„      of  its  dermoid 

1«3          ^W 

^^^^^L 

lainiun 

1S2         ^fl 

^^^^^V 

„       fibroid  Uiuina 

^H 

^^^V 

Ulceration  of    „     . 

^H 

^^™^ 

Perforation.    The  urtificini 

^^1 

mcmbrana  tymponi      , 

156              V 

HV.  AfI««tioaa  of  tbe  Eiiitaclii«c 

1  tnli«.     An  opGD  condition  of 

^^B 

■ 

this  tube 

159          ^H 

^B 

Okstniolion    . 

160          ^B 

^^^ 

FsMBge  of  tbe  Eufttadum 
eauoler 

163          ^M 

^^^P 

Puncture  of  tlio  rocmbrana 

■ 

tympnni      . 

US         ^H 

■  T.  Affe«UoiM  of  tlie  t^panum 

.     Acut«   iaflamniiltion  of  tlie 

^^H 

H 

mucoue  numbraoe 

1G6          ^H 

^H 

Chronic  inflammation  of  tbe 

^^H 

H 

mucouf  membrane 

171              ■ 

^^^_ 

Ulceration    of  the    ffiUOOlU 

^^M 

B 

membrane    .         ,< 

174          ^H 

xii  OOKTENTS  OF  VOL.  in. 

y.    Afi^ctions  of  tbe  tympanum.     Sirpfailitic   inflammation    of 

the  tympanum 
„  „  Deposits  in  the  tympanum 

„  „  KembranouB  bands     . 

„  „  Bigidit;  of  the  mucoos  mem 

brane 
a  „        DiseaseB  of  the  oasioula.    Anky 

losis  of  the  stapes 
M  „  „         „       Exostoses  of  the 

ossicula 
„  n  »        »      Fracture,  caries, 

&C.         . 

„  „         Diseases  of  the  mastoid  celb 

VI.  AffniUonB  of  the  labyrinth  and  auditory  nerve.     Anatomical 

lesions 
u  „         NerrouB  and  other  deaftiess 

YH.  Diseases  of  the  ear  implicating  ihe  brain  or  lateral  sinus 
VIII.  Malignant  disease  of  tiie  ear       .         ,         ,         ,         . 


174 

17i 
175 

177 

178 

180 

180 

180 

181 
182 
185 
186 


DISEASES  OF  THE  NOSE. 
By  A.  Urb,  Esq. 

BUROEOM  TO  ST.  HINT'S  BMFITIL. 

Affections  of  the  skin  of  tliD  nose.  Hypertrophy     ....  189 

„  „  Cancer 189 

„  „  Epithelioma      ....  190 

„  „  Syphilitic  ulcer  .  .  190 

„  „  Lupu8(erofliTeulcerofthederma)  191 

„  „  Erosive  nicer  of  the  follicles       .  194 

BMnoIithea 19S 

Occlusion  and  contraction  of  the  nostrils 198 

Affections  of  the  eeptnm.     Blood-tumours     .....  199 

„  „  Abscess 200 

„  „  Cartilaginous  growths  ....  202 

„  „  Perforation 202 

Affections  of  the  pituitaty  membrane.     Hypertrophy      .         .         .  302 

„  „  Chronic  coiyza  .         .  203 

Use  of  the  speculum  nasi 201 

Affections  of  the  bones.    Syphilitic  caries 205 

ITlcera  of  iho  nasal  fosue.     Oiffina 207 

Epistexifl 209 

„       Method  of  plugging  the  nostrils        .....  311 

Polypus.     Common  or  gelatinous 211 

„  Methods  of  removing  polypi 214 

„  Fibrous 218 

„  NoBo-pharyngeal 219 

„  Various  operations  for  tJiese  pol}q)i ....  220 

M  Malignant 223 


CONTENTS  OF  VOL.  Ill  xiii 


SURGICAL  DISEASES  OF  THE  AIE-PASSAGES. 

By  the  late  Kenbt  Gray,  Esq. 
i^McniKBt  ox  AHi,TO)cT  XT  wi.  OBOsaa'i  hobpitai^ 

Acate  lujn^tU 224 

(Edema  of  the  glottis 228 

Erjnpelatoaa  IiUTngitia 231 

Difiose  mflunmation  of  the  cellular  tissue  of  the  larynx .         .  232 

SjphUitic  nlcention  of  the  laTTiix 234 

Tomonra  of  the  lorjiix  and  trachea 335 

HjBterical  affections  of  the  laiynx 239 

Spurn  of  the  glottis 241 

Chronic  luTngitis 243 

„  „         Ulceration  of  the  larynx 244 

„  „         Affections  of  the  lar^geal  cartilages  .        .  249 


THE  LARYNGOSCOPE. 
"By  A.  E.  Ddrhah,  Esq. 

AWIRTAKT  SttBOEOM  TO  OITT'B  HOSPITU^ 

iDTentioo  of  the  inatminent 251 

Description  of  the  laryngoscopes  now  in  use  .....  252 

„  pharyngoscope 253 

Method  of  examination 255 

The  OSes  of  the  laiyngoecope 257 


DISEASES  OF  THE  ORGANS  OF  CIRCULATION. 

DISEASES  OF  THE  ABSORBENT  SYSTEM. 
By  C.  H.  Moore,  Esq. 

BtTBOBOIf  TO  THB  MIDDLEaEX  HOSPITAL. 

Wonnds  of  lymphatics 259 

Inflammation  of  lymphatics  (angeioleucitia) 260 

^  lymphatic  glands  (adenitis) 267 


x!v  COM^NTS  OF  VOL.  IIL 

Hypertrophy  and  atrophy  of  glands       ......  269 

Strumous  disease  of  glands 271 

Lymphatics  in  syphilis 275 

„  gonorrhcBa     ........  276 

„  cancer 276 

„  innocent  diseases 278 

„  „        ulcers 281 

„  „         erysipelas  and  nnvi  .....  281 

Morbid  contents  of  lymphatics 382 

Obstruction,  obliteration,  and  varicosity  of  lymphadca    .         .  283 

Excision  of  glands  by  operation 283 


DISEASES  OF  VEINS. 

By  G.  W.  Callbndbr,  Esg. 
AsnsTAHT  snRoioir  to  St.  UAxTBOuatMfr'a  itoKeiTja. 

AdheeiTe  phlebiUs.     Early  obecrratioDB  by  Pai6  and  otiieia    .  285 
„             „            MorUd  anatomy  of,  according  to  older  writers  286 
„             „            Doubts  respecting  the  accuracy  of  these  obser- 
vations    287 

„  „  Post-mortem  stiuning 287 

„  „  Views  of  Quthrie,  Travera,  and  others     .        .  288 

„  „  Veins  repair  without  inflammation  289 

„  „  Gendrin's  experiments  disproved  by  Lee,  whose 

accuracy  the  author  verifies      .  .  289 

„  „  Summary  of  these  doubts       ....  291 

Obatraction  of  veins  with  clots  (thromballosis)        ....  291 

„  „     caused  by  a  predisposition  in  the  blood   .  292 

„  „  Circumstances  calling  this  into  action  .  292 

„  „     extension  of  clots 295 

„  „  Accompanying  inflammation     .         .         .  298 

„  „  Changes  m  clots  and  in  the  vein-walls         .  299 

„  „     eedema 300 

„                 „          This  sometimes  embairaflses  thereptur  of  frac- 
tures      300 

u  „    Symptoms  and  treatment  of  thromballosis       .  301 

DifiiiSB  or  suppurative  phlebitis 302 

Inflammation  around  the  umbilical  vein         .....  3U5 

PhleUolithes 306 

Hypertrophy  of  veins  .........  306 

Atrophy  „ 307 

Degeneration  of  vein-walls 308 

Toricose  veins 308 

„         „     their  usual  situations 309 


CONTENTS  OF  VOL.  III. 

riac 

of  tlia  lower  extremities 309 

What  vctiM  implitaUd 310 

Oi»cfl 311 

Ati*totnical  disngcs 313 

Sjnnptoins 314 

1V«atoMDt,  gtaenl 316 

„  local 317 

„  „  by  operation 318 

|eia«  compressed  by  ttuuutmt 331 

tites  ID  vdu* 3S3 


DISEASES  OF  THE  ARTERIES. 


ATHEROMA  AND  OBSTRUCTION  OF  THE  ABTERIEa 

^L  By  C.  H.  JiIooRE,  E«j. 

^^^^k  eonoNON  TO  mc  mimilksei  sotriiAin 

HUmIc^  of  atberoiiui :  its  early  appearances        ....  333 

.,                    „          '  Owification'  of  the  arleries    .        .        .  331 

„                    „          Extent  of  arteries  aiTected               .        .  S3S 
„                      „          Diflercut  liability  of  tlie  aortic  and  pul- 

mooary  tyitcta*        ....  336 

„                      „           Microscopical  chantctcrs  of  atbcroma  337 

I  of  the  disease.     1.  Nnrrowing  or  pIu^Dg  of  the  vcHclit  i'2T 
„                  „            3.  DilaUtioQ  of  tbe  vcfwels         .         .         .328 

„                  „            3.  Tortuosity  of  the  rcsseb        .         .         .  338 

,                „           4.  Rougfacniof;  of  Ibe  liniug  membrane       .  3S9 
„           S.  Itupture   (so-CttUed   ulcention)    of  the 

artwy 330 

„            0.  Liability  of  tli«  vc«»elx  to  injury  in  acci- 
dents and  operations           .                  .  330 
-f,                 „            7.  SpoDtaneoiis  gnngreiio  ....  331 
Oedlllioii  of  aitcries.     From  outward  compresnoD,  by  fragin(ut«  of 

bono,  callos  of  fmcture,  tumoora^  kc            .         ■         ■         .  333 

From  impaction  of  a  foreign  body 333 

From  impaction  offibrioe  washed  off  diseased  cardiac  valves 

("embolism") .133 

Facts  wkidi  prove  Ibe  existence  of  this  occluuon  331 

Bymptonw  of  iinpuctiun  of  lll<niie 335 

Seooudary  lesulbi,  ettabliubment  of  collateral  circulatioQ      .  S3S 

„             „       ([angreno 83* 

T^tmeot  of  occltuion  of  nrtcrics 331> 

Qucstiou  of  lunputatioii         ......  338 

A  acrica  of  cases  of  gangrene  in  old,  and  another  in  young,  snb- 

»cu 339 

rit» 343 


ivi  CONTENTS  OF  VOL.  IIL 


Aira:URISM. 
By  T.  Holmes,  Esq. 

nrXaSOITOTBB  EOIPtT.U.  fob  sice  CHIU>BB1I,ASSUTAIIT  BUBOBOIITOBT.OXOKaB'a 

HOSflllXl   AMD 

E.  A.  Hakt,  Esq. 
srKOBOH  TO  IBB  wui-iiOinxu[  bobfitu. 

Patholoot  or  Akeurism  :  ,iai 

Various  classification  a.    AneuriBms  divided  into  common  or  en- 
cysted, arterio- venous,  cirsoid,  and  disaectiog  .     343 
Enc^ited  aneurism,  its  anatomical  varieties : 

1.  The  aneurismal  dilatation,  or  fosiform  aneurism,  where 

all  the  coats  of  a  lai^  part  of  the  vessel  are  dilated     344 

2.  True  aoeorism,  where  ^1  the  eoats  are  dilated  at  one 

point  only 34& 

3.  False  aneurism;  the  sae  formed  hj  only  one  of  the 

coats,  generally  the  external       ....     34& 
A  variety  of  this,  called  hernial  aneunem,  in  vrhicb 
the  sac  is  formed  by  the  internal  coat ;  its  exist- 
ence doubtful 34T 

4.  Consecutive  or  diffused  anearism,  in  which  the  sac  is 

formed  by  the  tissues  surrounding  the  artery       .     347 
Other  classificadons  of  common  anenrism,  according  to  their 
cause,  into  traumatic  and  spontaneous;  or,  according  to 
their  form,  into  tubular,  sacculated,  and  dissecting        .      348 
CdiMW  of  aneurvm,  predisposing;  viz.  atheroma,  exposure  of 
artery  by  sloughing,  pressure  of  tumours,  prob^ly  abuse 
of  ardent  spirits,  perhaps  mercury  and  syphilis  .     348 

„  „  anatomical ;  nature  of  contents  of  vessels, 

Seiure   or  division    of  artery,  pressure  of  foscie  and 
muscles,  exposure  of  vessel  to  movements  of  body .  349 

„  „  exciting,  viz.  temporary  increase  of  circu- 

lation, mental  emotion,  sudden  movement,  abscess  around 
an  artery,  impaction  of  clot ......     359 

Definition  and  causation  of  traumatic  anenrism         .         .         .     354 
J'ngreta  ofaneuritm.    Conditions  which  modify  the  progress  of 
an  aneurism,  such  as  changes  in  the  sac,  depending  on 
position  and  site  of  orifice,  direction  of  growth,  hydraulic 
pressure,  die.        ........     354 

„  „  The  sac  when  it  gives  way  is  reinforced  by 

the  surrounding  parts  .......     355 

„  „  Effect  of  the  nature  of  surrounding  parts 

upon  the  sac 356 

„  „  Communication  with  neighbouring  vessels     35fi 

„  „  Changes  produced  by  aneurism  in  the  parts 

aronud 356 

Openings  on  mucous,  serous,  synovial,  or  articular 

ear&cea,  or  into  the  cellular  tissue        .         .         .     357 


CONTENTS  OK  VOL.  III.  svii 


V^v^Tos  ofanntrum.  OaDgrene  from  preattm  oTUm  uteurism    .  358 
^L        „               „             AtieurifimsuvcasumAlIjrreaommcneegroirUi 

^M               itft«r  «pp8reat  eeHatiuu.     Qrovtli  wiUiout  pubalion  358 
^M        „               „             ClutogF*  iu  tlie  elut.     Tlw  inru  kiuils  of 

^^               dot  found  in  ai)«urianu 3S9 

^^^H                ^ft  cJot  liable  to  be  abaarheH  or  aotUatd  399 

^^^B                 PlicnoRKTHD  of  <lcposition  of  Inmmatxxl  clot  3G0 

^^^B                   1.aniiiiatc(l  clot  Dot  n  arcan-tiou  from  Die  uc  360 

^^^B                   Conitoxion  between  clot  and  mc        .        .        .  SCI 

Tbx  sroiTTAXBOtm  Cuke  or  AxEtiusx  : 

Strong  tendcai^  of  annimm  to  vpontcneoiu  cure     .        .        .  362 
Tba  tdHou*  mode*  of  «poiitan«aua  euro  : 

r     First  ntodt,     it;  nnipU)  rctdrdauoa  of  the  drcuUtion  «ud 

drpooitioD  of  Uminawd  fibrine 3fi2 
Tbeiemodee  of  cure  majr  b«  aiw-tcd  by  methodg  tending 

to  iDcrtaae  the  quuiUty  of  fibrine  in  tins  blood         .  3<>3 

Impoftanoe  of  rvsit  and  siiore  d!«l          ....  SGI 

VJwJva'*  method .ISS 

Uedical  tn»ttncat 367 
Saoentd  mod».     By    prcMuro  of  Uic  ue  upon    the  arhirf 

(doobt/nl) 3«8 

T%ird  atod*.     By  impaeliofi  of  clot 369 
Fourih  mode.    By  retardation  or  impaction  CAuacd  by  n  higher 

aneuriua  .        . 370 
Fifth  mode.    By  iDflanunatory  pTOCMses  around  the  sm,  sup- 
puration. douj[hing,  and  pev baps  nmple  inflsmniation 

cauaiuK  coagnliUon 371 

^    Tbe  «poatuieo4u  aura  may  b«  nooompliNhed  witliout  obliterating; 

H              the  artery 373 

^*          Symptom*  of  vpontaaeous  cure  ......  37'4 

lotemiptuin*  to  Ibc  pnooen  of  epontanmus  cure                         .  37G 

Furtlier  cliADgcs  in  the  clot,  when  formed        ....  377 

SnrPToiu  A.-ct)  Diagnosis  of  AxstmiSK : 

Spnptotni  of  ancturism,  tumour  in  courMi  of  artery,  jmUalioo, 
^  T«hation  in  size  with  circnUtiou,  intcrfcuwco  wttli  pulse 

H             below,  8ii«ariamal  bruit 378 

^     DboMSl  with  whieli  aneurium  may  be  confoanded    .                  .  379 

IK^pMWis  between  aneuri:tm  aud  tumuurs  pressing  on  the  artery  381 

„             „                 „              pulsatile  tumour  of  bono        .  383 

„             n                 »             nierc  diliitaltun  of  an  art«ry    .  385 
TnATimrr  or  AxevRinu : 

The  old  operation,  or  method  of  Antyllus — f:;eueral  dcseriptioa .  38£ 

Case*  in  which  the  old  openvtion  may  Htill  be  used      .  388 

Fake  theory  on  which  the  old  operation  rested    .         .         .  386 

Dtagen  and  great  mortality  of  ihis  prooeai                  .         .  387 

Mr.  Symc  s  method  of  pcrTorming  this  operation    .        .  389 

Tm  IIintmiAv  Opxratiok 389 

Beaommended  by  Greek  and  Amliinn  Surgeons        .  390 
Oiacnanon  of  Anel's  claims  to  the  invention  of  this  mode  of 

treatment 390 

TOL.  m.  b 


A 


xviii  CONTENTS  OF  VOL.  III. 

rtmm 

Deaault's  operotioo  after  Anel's  method       ....  394 

Summaiy  of  objectiooB  to  Anel's  method     ....  395 

Principles  of  Hunter's  oper&tioa      ......  396 

Hunter's  modification g  of  hia  origin&I  method  of  performing 

the  operation •  396 

Silver  ligaturCB  on  arteries 396 

Process  of  core  in  an  anearism  after  ligature  of  the  artery          .  397 

The  collateral  drculatian 397 

Its  various  conditjons 398 

Bapiditj  of  ita  derelopment 399 

Period  at  vhich  it  reaches  ita  full  development       .         .  400 

Symptoms  after  ligature    .......  402 

Causes  of  death  after  ligature 403 

Qreat  mortality  in  patients  operated  on    .         .         .  403 

Gangrene  after  ligature.     Its  causes      ....  404 

Ita  prognosis  and  treatment 406 

Secondary  hoemorrhage         ......  407 

Cases  in  which  the  ligature  Mia  to  cure  the  disease     .         .  40T 

Causes  of  the  failure  of  the  ligature          .         .         .  407 

^^'eatment  of  aneurisms  persisting  after  ligature    .         .  408 

„                 „      recurring  after  apparent  cure     .         .  409 

Cases  in  which  ligature  is  indicated 410 

„               „               ia  contra-indicated         .        .        .  412 

T&EATHENT  BT  iHSTBrUBKTAI.  COHPKESSIOIT : 

Ideas  of  the  older  Surgeons  on  this  subject  ....  413 
History  of  the  invention  of  instrumental  compression        .         .414 

Success  of  tlie  method 415 

Instructions  for  applying  iDstramental  compresuon  .         .416 

Qeneral  treatment  during  compression        ....  418 

[  Period  required  for  cure 418 

Auxiliaries  to  this  treatment 419 

Anatomy  of  caaea  cured  by  oompresuon            ....  419 

Causes  of  failure 420 

Partial  benefits,  in  cases  where  the  treatment  does  not  efiect  a 

cure 420 

Treatuxht  by  DtaiTAL  Pbebsubx,  by  £.  A.  Hart,  Esq.        .        .  421 

Tbkathent  bt  Flixion 425 

Tbbatkeht  bt  MASiruunov,  by  £.  A.  Hart,  Esq.              .        .  428 

Tbe&txbkt  bt  Oaltavo-pukctdbi^  by  E.  A.  Hart,  Eaq.              .  432 

TfiEATMENT  BT  CoAOTTULTiSQ  laJzciioNB,  by  E.  A.  Hart^  Esq.  435 

Various  fiuids  used         ....          ....  435 

Various  acddents  which  may  ensue 435 

Cases  in  which  this  method  may  be  used          ....  436 

Method  of  performing  the  operation 437 

Traukatic  Ajtburisk  : 

Definition  and  usual  method  of  origin  firom  a  wound                   .  438 

Symptoms  of  the  common  traumatic  aneurism    .        .        ■  439 

Varieties  and  progress      .......  440 

Treatment 440 


CONTENTS  OF  VOL.  Tir.  rix 

Tiiom 

Tnuinuttie  an«umiu  from  conbutiM)  or  q>rain  ....  441 

„                ..        froin  fracture 443 

Symptoau  of  Hd»  iajmj 442 

TTMtnKDl-Jolin  B«I]V  tcocbing 443 

Cms  of  RpoatwDcom  cora 443 

Tmbnent  of  cuca  ia  which  spontaneoua  care  doea  not  take 

plwA 445 

Abtsho-Vkrocs  AmjusM,  by  E,  A.  Hart,  £»]. 

T««  principal  forms  of  this  disease 447 

Eithtr  msjr  be  tmQiaatic  or  Bpuntaneoiu                 .        .  448 
Synptonu  commim    both   to    aneuHsmttl  vorix  and  varieOM 

aoeuriun 449 

g|>ccii>l  &ympt(iliis  of  varicuie  utcwism   ....  431 

Treatment  of  aneoriamal  varix 451 

„          vnri«oae  aneurinn 423 

Cirsoid  Akeuiush,  asd  AitKuimit  bt  Akahtomohui,  by  K^  A. 
Halt,  Esq. 

Dtacription  of  cinoid  an«arwtn  and  an<nmiu  by  annatomoeis    .  404 

Ctai»«a                 „            ..             45« 

TreatnMnt            „             „              iSB 

Ligatnre  of  tronlc-Tcsaeli  in  tbU  disease     ....  4f6 

BxtirpatioQ  of  such  tuinoiua  by  ligature     ....  459 

Excision  by  tba  knife        .......  4S9 

Treatment  by  galvano-puncture  and  by  injection          .         .  4fiO 

,  PusECTua  Akkcxixx  -. 

Aaatomj  of  ndi  eaaea 461 

Usual  position  of  the  lenen            46S 

Symptooks  and  diHgnoais         .......  462 

hosju.   SQBaiRT   or  AvBvniaii,   axd  Opeiutioxk   ox   tuk 

rjuuocB  Abtebibs  : 

[<]eaetal  olawriUottS  on  tfae  Ugaturo  of  arteriw                         .  461 

AiuMihetice  io  such  opentioos 46S 

ABcurismfl  tn  the  forc-snn ^67 

Treatment  of  suob  aneurisms 467 

Idgatore  of  the  radial  or  ulnar  artery  nt  tbe  vnst           .  467 

;,             ulnar  Uigher  up 468 

!  An«iiritin  at  the  hew!  of  tbe  elbotr — treatment  by  flexion  4SS 

Ligature  of  tlu)  brachial  artery 4S9 

lUsulla  of  this  operation 470 

Anilary  aiictiriRD 470 

Mr.  Synie's  Ti«wa  on  its  pathology  and  treatment        .         .  (71 
EodeaToor  to  distinguish  eases  of  ruptured  artery  from  those 

ofaDeorinn 471 

Treatment  of  the  various  liiiid«  of  urter'tul  lesion  in  the  axilla  473 

Tbe  (lid  operatioti  ajipliwl  lo  the  uxiUiiry  artery     .  473 

Ligature  of  the  axillury  nrtcry  on  tbe  Hunterian  method  171 

„           MbclaTian— its  third  pnrt  ....  47S 

lie  operation  vnriw  much  in  difficulty    .         .         ,  477 

Oreat  martalitT  after  tins  opcmtion          .         ,         .  iTS 

I  at  the  root  of  the  ccek 479 


XX  CONTENTS  OF  VOL.  III. 

DifficultieB  of  diagnoBii  ta  to  the  yesBel  involved           .         .  ISO 

Appropriate  treatment  of  various  cases           .         ,         ■  463 

Ligature  of  first  part  of  subclavian        ....  483 

„         innominate 481 

Brasdor'B  method  of  treating  aneurism  ....  i85 
Why  this  method  is  now  limited  to  the  carotid  artery 

in  BueurismB  of  that  vessel  at  the  root  of  the  neck  486 

Statistics  of  this  operation      .....  487 

Symptoms  after           „ 487 

la  ^'asdor'a  method  applicable  to  aneurismfl  of  the 

innominate! 488 

^e  old  operation  applied  to  aneurism  in  the  neck          .  488 

Applicability  of  this  operation         ....  489 

Aneurism  of  the  upper  part  of  the  carotid  art«ry      .  490 

„         in  the  orbit 490 

BeasoDS  why  these  aneurisms  are  not  now  regarded  as  anas- 
tomotic       .........  491 

Aneurism  in  the  cavernous  sinus     ......  492 

Symptoms  and  treatment  in  a  successful  case      .         .         .  493 

„                 „               an  unaocoeasful  case                 .  493 

Cerebral  aneurism 494 

Treatment  of  these  various  forms  of  aneurism               .         .  494 

Ligature  of  the  common  carotid  artery           .         .         .  495 

Statistics  of  this  operation 497 

Idg&ture  of  the  external  or  internal  carotid  .                .  498 
„            branches  of  the  external  carotid-nif  the 

lingual 499 

Aneurism  in  the  foot  and  leg fiOO 

IVeatment — ligature  of  the  anterior  tibial  artery          .         .  fiOO 

„          peroneal 601 

„          posterior  tibial  high  up  .         .         .  502 

Cases  in  which  amputation  would  be  preferable  G03 

Ligature  of  posterior  tibial  lower  down                 .        .  SOS 

Popliteal  aneurism £04 

Treatment 505 

Ligature  of  the  superficial  Gsmoral  in  Scarpa's  triangle    •  fi06 

Btatistics  of  this  operation  irom  Norris  and  Porta     .  fiOS 

„                   „            in  London  recently         ,  £10 

Ligature  of  femoral  in  Hunter's  canal   ....  510 

Femoral  aneurism,  and  iti  ti^atment 510 

Ligature  of  the  common  femoral  artery                   .         .  611 

Objections  to,  and  statiatica  o^  this  operation  .         .  512 

Inguinal  aneurism,  and  its  treatment 512 

ligature  of  external  iliac      ......  613 

Satistica  of  this  operation        .....  515 

Abdominal  aneurism,  its  diagnosis  and  treatment     .         .         .  515 

Ligature  of  the  common  iliac 516 

Enormous  mortality  of  this  operation                .          .  617 

Ligature  of  the  abdominal  aorta 518 

Is  this  opinion  justifiable? 619 

Gluteal  aneurism,  traumatic  and  spontaneous,  and  its  treatment  620 

Ligature  of  the  internal  iliac 521 


rA«B 


CONTENTS  OF  VOL.  III.  jod 


DISEASES   OF  ORGAKS  OF  LOCOMOTION 
AND  INNERVATION. 

AFFECTIONS  OF  THE  MUSCULAR  SYSTEM. 

By  T.  Tatum,  Esq. 
■raoum  lo  n.  okobob'b  hosiitai- 

Aftzgtioits  or  Uuscles  : 

SprBuiB  and  contusioDa 522 

Rupture  of  muscles 623 

InflunmatioD  of  muscles         ....-■■  •S^S 

„  „        in  syphilia  (iTphilitio  tumour)     .         .  52& 

Simple  cootnctioa  of  muscles  from  syphilis     ....  529 

Atrophy  and  fatty  degeneration  of  muscles       ....  529 

Osnfication  of  muscles 535 

Tumonrs  „ 539 

Cysts  „ 540 

Cancer  „ 541 

Amcnoxs  or  Tendons  : 

Kuptare  and  section  of  tendoiu      .        .        .        .        .        .541 

Inflammation  of  tendons 544 

WhiUow 544 

Sjphilitic  aflfactions  of  tendons 646 

Tnmoon  of  tendon 547 

AiTECTiOHS  or  BvBsx  Mucosa  : 

Eolarged  bursn 548 

Housemud's  knee 548 

Bursal  abacess .        .        .        .  ' 550 

Bunion.      .........  551 

Enlargement  of  the  bunal  aheatlu  of  tendons     .         .         .  552 

Palmar  bursal  tumour 554 

QasgUoQ  ,.....■■•  566 


ORTHOPEDIC  SURGERY. 
By  Dr.  LrrTLK, 

rarsicus  ro  rat  lovdox  bospital. 

Pathology  of  deformities 657 

Contraction  frvm  disuse,  injury,  Sec         .....  558 

„             „     disease  of  the  nerreHTentres  ....  558 

„            „    congenital  defects 569 


sxii  CONTENTS  OF  VOL.  IIL 

nam 

Clasaificatiou  or  non-congenital  deformities 560 

Chaagea  secondary  to  these  deforatitieB  ,         ,         .         .         .  £61 

General  description  of  the  operation  of  tenotomy  .         .         .         •  S62 
Description  of  indiridnHl  deformities — congenital  dnb-foot  (talipes 

varus  congenltus) 562 

Primary  and  secondary  changes  in  club-foot    ....  563 

Etiology  of  club-foot      ,....,..  565 

Grades             „              56T 

Treatment  in  its  various  d^^es 567 

Section  of  posterior  tibid  tendon 569 

„         anterior       „         „ 572 

„        tendo  Achillis 572 

Instruments  reqiiired  after  operation          ....  573 

Belapsed  club-foot 574 

Talipes  eqiiinns     .........  578 

„       valgus,  equino-valgus,  and  calcaneo-valgua  .         .         .  579 

Dbtortions  arising  at  the  moment  of  birtb       ....  580 

Spastic  contractions  arising  in  infancy  &om  cerebro-sptnal  disease  583 

Flat-foot,  or  spurious  valgus 585 

Contractions  of  the  upper  extremity  &om  spasm  and  paralyus  .  587 

Contraction  of  palmar  fascia  .......  588 

Wry-neck  (congenital)  ........  590 

Division  of  tbe  stemo-mastoid  ......  593 

Spasmodic  wr;-neclc      ........  595 

Paralytic           „             596 

Wryneck  from  disease  of  the  spine 597 

Knock-knee 599 

Ankylosis  of  knee  and  other  joints ......  600 

Treatment  by  gradual  mechanical  eztenrion        .        .        .  604 

„            division  of  hamstring  tendons                 .  608 

„                   „          muscles  near  Mp           .         .  609 

„                   „          flexor  tendons  of  fingers  and  toes .  609 

,                        „            fordble  extension          .....  611 

„                 „              „         under  cbloroform       .  612 

„           section  of  the  neck  of  the  femur   .        .        .  614 


DISEASES  OF  THE  BONES. 
By  T.  Holmes,  Esq. 

BUBGEOy  TO  TUB  UOEPITIL  FOB  SICK  CRTLDaED,  AHC  ABSVTIJiSJ  HDSQEOS  TO 
BT.  OEORUE'B  hospital. 

Simple  iHrLAHKAxiotr  and  its  Cohbequehces  : 

General  sketch  of  the  inflammatory  process  in  bone        .  .  615 

Ostitis  or  simple  inflammation 620 

Periostitis 622 


XXUI 


CONTENTS  OF  VOU  IIL 


DiSittc  periostitis  or  amt«  periosteal  abscess    .        .        .  693 

Oatoomj-clitis  or  diffused  suppuration  in  the  interior  of  boH  6S8 

dutonic  abscess  of  bone 630 

Ouica  or  ulceration  of  boue    ......  633 

T1ttged»ai«  uloeraliou 639 

Ncaons  or  gaagnait  of  bone — geoenO  d«serlptioa   .  640 

Ooeanonu  compliationt 645 

VaiietlM  MCorcUDg  to  extent  auil  seat                  .         .  646 

IVeabnent  by  operation 647 

Abaofption  of  necrosed  portion*          ....  649 

BspnidncttoD  of  bo<n«  after  oacmitis   ....  GAO 

Enotiation  of  diseased  portions  of  bono     .        .        .  623 

Acute  necroeia 601 

lOMAL  ArFicrioNK : 

Scrofula  in  bono 6AS> 

Syphilis  in  bone CflO 

Comparison  betveen  syphiliUc  affections  of  bone  and  skin  663 

Oneralive  treatwent  of  sj-philis  in  biHic       .        .  ^S 

Blieninaluan  in  boue 665 

Goaty  dcpocit  in  Ii<mi«,         .......  667 

UoUities  ontuin — general  feature*         .....  667 

VoruMU  cooditions  indncing  moUities  ;  atrophy        .         .  670 

„                    »                 »              »           cauocr          ,         .  C7l 

„                   H               It             t>          *i^B  moUittes  CTl 

OoDcer  in  bone— ita  nsual  situations 67& 

„  „        porta  of  the  bono  affected  (periosteal,  latcr- 

stitisl,  infiltrated) 67i 

„           „       kinds  of  eaucer  found  in  bones    .        .        .  6TS 

„             „        eymptoma  and  diagnottia      ....  676 

a             „        lM»m*«l 679 

„     Pnlistile  malignant  tiimniir GSO 

„          Question  of  the  eiirtritce  of  "  osteo-aneurism"  683 

„           IVtatmcot  of  piilfiatilG  tmnoiii-       ....  6S5 

„     Osaccrons  ulceration  in  bono      .....  681 

Cox-xauaHAgiT  Tomoobs  or  Bom : 

Efidiondroina      ......         ■..  685 

Exoatous 689 

DiAsed  bony  (or  innocent  osteoid)  tumour                •         ■  693 

Qptie  tomoun 695 

FflvoiiB  and  fibro-cTstic  tumours 696 

Entotoa  in  bono 697 

rLB  HTrSRTBOPBT  &KD  AlBOPHT  OF  BOKK : 

Hypertrophy 699 

Atrophy 699 

Spontaneous  fntctcuc 701 

WovXBs  or  BovE .        .  702 


xxiv  CONTENTS  OF  VOL.  IH. 


DISEASES  OF  THE  JOINTS. 
By  Athol  a.  Johnson,  Ebq. 

LATE  BURGEON  TO  TUB  HOSPITAL  FOa  SICK  CmUaBN. 

PART    I. 

DISE&BBS  OOHUOK  TO  ALL  TBS  JOINTS. 

ClSEASBB  OF  SiKOTIAL  MkHBRAXES  :  Visa 

PhyBioIogical  anatomy  of  synovial  membranes           ■         .         -  701 

InflniniQation  of  Bynovial  membranes       .         .         .         .         ■  705 

Simple  synovitis — acute 706 

Suppuration  in  joints 709 

Chronic  Byuovitis      ........  709 

Treatment  of  BynovitiB 710 

Dropsy  of  joints       ........  715 

Scrofulous  BjuDTitiB  (pulpy  degeneration)  ....  717 

Bbetunatic  synovitis— acute 72S 

Chronic  rheumatic  synovitis  (chronic  Hienmatic  arthritb)  723 

Gouty  synovitis 729 

PyKmic      „              733 

GonorrboBal  synovitis  (gonorrhceal  rheumatism) .  734 

Syphilitic            „ 735 

Loose  cartilages  in  joints 736 

DlSBASEB  OF  THE  AbTICULAS  EzTBXVITISB  OF  THK  BOKXS: 

Simple  inflammation  and  ite  consequences       ....  740 

Scrofulous  inflammation 741 

Bheumatic  and  syphilitic  inflammation    .....  749 

Bhacitic  afieclions          .,.,....  750 
Amours  of  the  articular  ends  of  the  bonee                .         .         .751 

DlBKABKS  OF  THK  AbTICULAS  CARTILAOKS: 

Fhysiolf^col  anatomy  of  articular  cartilage     ....  752 

Hypertrophy  and  atrophy       .......  756 

Gouty  deposits 755 

Fatty  defeneration 755 

OBBification 766 

Ulceration 757 

Diseases  of  other  Tissues  ih  and  abouss  the  Joists  : 

Of  the  ligamentous  structures 761 

„      muscles 762 

„      areolar  and  adipose  tissues  ......  764 

„      synovial  bursa 765 

„      int^;umentB 765 

AvKTLOSis 766 

Abticuiar  Nxubalqia 771 

WouHDS  or  Jomra 774 


COIJTENTS  OF  VOL.  JIL 


XXT 


PAJRT  II. 


DISEA8EB  OF  INDITID0A1<  JODTTS. 

Of  the  hip 7V8 

Strumous  disease 778 

Uorbua  coxk  senilis       ........  783 

Neuralgia 784 

Of  the  pubic  and  sacro-iliac  joints 785 

„     knee 786 

Of  borsn  near  the  knee 787 

ankle 788 

jointo  of  the  foot 789 

stemo-claTicuIar  and  acromio-claTicular  joints      .         .  790 

shoulder 791 

elbow 792 

wrist  and  other  articulations  of  the  hand    ....  793 

temporo-maxillaiy  joint 791 


ON  EXCISION  OF  BONES  AND  JOINTS. 

By  T.  Holmes,  Esq. 
rrKOEOic  TO  the  hobpital  for  sick  ciuldbek,  and  AiiuTAsr  BuaozoN  to 

BT.  GEOBOe's  UOSriTAL. 

Os  EXCISIOKS  IH  QENEOAI.  : 

Geserttl  indications  for  exdaton,  as  opposed,  1.  to  the  expectant 

treatment 796 

„  „  „  2.  to  amputation  .  797 

General  directions  for  the  operations  of  excision       .         ■         -  800 

Subperiosteal  resection 802 

?AKncuuiB  Excisions: 

I.  In  the  upper  extremity.     Of  tie  shoulder  ....     803 
„  „  „      scapula    .         .         -         .805 

„  „  „     clavicle    .         .         .         .807 

„     elbow      .         .         .         .808 
„  ,  „     wrist        .         .         .         .812 

„  „  „     bones  of  the  hand     .        .    813 

II.  In  the  lower  extremity.    Of  the  bip 813 

„     knee         ...         .     817 

„     ankle        .         .         .         .82* 

„  „  „     tarsal  and  metatarsal  bones     827 

Partial  resections  of  long  bones 830 


TOL.  in. 


xxn  CONTENTS  OF  VOL.  IIL 


DISEASE  OF  THE  SPIKE. 
By  A.  Shaw,  Esq. 

SDKOBOR  TO  THE  MIDDLKSBX   HOSPlTtU  ^^^^ 

Caries  of  the  spine — nature  of  the  morbid  action  .         .         •         •  831 
Symptoms  of  the  incipient  stage  of  the  disease.     Angular 

projection 833 

„               „            Swelling  and  heat      .        .        .  834 

„                 „             Rigidity  of  the  spine           .         .  834 

Pain 835 

I^agnosis  from  neuralgia  of  the  spine      .                   .  836 

Description  of  angular  curvature 838 

Abscesses  frum  disease  of  the  spine 841 

Besolution  of  such  abscesses             ....  842 

Ankylosis      ........  643 

Psoas  al»cess      ........  845 

,f           perforating  the  diaphragm        .                  .  847 

„          in  the  iliac  region 848 

„          passing  under  Poupart's  ligament     .        .  848 

„            descent  on  thigh 849 

„            'neck'  of  the  abscess        ....  849 

Eracualion  of  a  psoas  abscess          ....  850 

Consecutive  fever     ......  851 

Lumbar  abscess 853 

Abscess  in  the  cervical  region           ....  854 

Abscesses  discharging  by  the  lungs,  intestines,  &o.    .  854 

Diagnosis  of  spinal  abscess 856 

„         from  cancer 857 

Inclusion  of  the  spinal  cord  in  the  disease                        .  658 

Disorganisation  of  the  cord — paraple^a  ,                   .  8fi9 

Spasmodic  actions  of  the  paralysed  limbs          .         .  862 

Diagnoaia 863 

Fro^osis  of  cases  complicated  with  paraplegia  665 

Disease  of  the  atlas  and  axis 866 

Necrosis  of  the  atlas  with  exfoliation       ,         ,  S71 

Treatment  of  disease  of  the  spine 872 

The  prone-conch 874 

Countei'irritation 875 


DISEASES  OF  THE  NERVES. 

By  C.  E.  Bbown-Sequard,  M.D. 
rmsiaui  to  tub  bobpital  rox  eriLarsT. 
Introdnction.     Kinds  of  symptoms  dependent  on  lesions  of  nerves     676 
Fart  I.     Diseases  of  the  nervous  centres  and  other  organs,  caused 

by  an  injury  or  a  disease  of  a  nerve  ....     877 
Epilepsy 877 


CONTENTS  OF  VOL.  III.  rsvii 

Tetanus 879 

Hysteria 881 

Chorea                          883 

Hydrophobia 883 

Faralyaia  agitans 883 

Rotatoi7  coDvalBiona 883 

Reflex  paralysis   .        .        ^ 884 

„     aiuesthesia 685 

Amaorosis  ..,.,....  865 

Neuralgia 886 

Delirium 668 

Inflammation 886 

Mnscnlar  atrophy           .......  890 

Hypertrophy 890 

EruptioM 890 

Vonous  morbid  alterations  of  nutrition            .                  .  890 

Fut  II.     General  features,  and  rulea  for  the  treatment  of  the  van* 

ons  affections  cansed  by  the  irritation  of  a  nenre      .  891 

NEUBOMA 895 


DISEASES  OF  ORGANS  OF  DIGESTION. 

DISEASES  OF  THE  TONGUE. 
By  HoLHSB  GooTE,  Esq. 

ASeWTJLUT  BUBQEOII  TO  St.  BASTnOLOaEw'S  HOSPITAL. 

Shape  and  general  anatomy  of  the  tongne.     Tongae-tie  897 

Hypertrophy  and  enlargement  of  the  tongue  .         .         .         ■  897 

Acate  inflammation  (glossitis) 900 

„  „  abscess 902 

Chronic  nlceration 902 

Nktus 905 

Tumoon  of  the  tongue 906 

Bannla 906 

Wonnda,  foreign  bodies,  tec. 908 

Syphilitic  affections 908 

OMcer 909 

OperationB  for  cancer 912 

„  complete  extirpation  of  the  tongue     .         .         .  914 

„  dirision  of  the  gustatoty  nerve  ....  915 


NOTE  TO  THE  ESSAY  OX  ANEURISM. 

In  diflcuflsmg  the  question  of  Abdominal  Aueorism  and  its  treat- 
ment (page  519),  the  writer  lias  alluded  to  the  possibility  of 
attempting  the  old  operation.  Since  those  pages  were  in  print,  a 
most  remarkable  case  has  been  put  on  record  by  Mr.  Syme,  which 
will  be  found  in  tlie  fortlicoming  (45th)  volume  of  the  Medico-Chi- 
rurgkal  Transactions.  This  operation,  which  may  be  characterised 
without  hesitation  as  one  of  the  most  daring  and  brilliant  ever  per- 
formed by  any  Surgeon,  consisted  in  laying  open  the  sao  of  a  lai^ 
aneurism  situated  at  the  bifurcation  of  the  common  iliac  artery,  the 
circulation  in  the  aorta  being  controlled  by  the  clamp  described  by 
Mr.  Lister  at  page  90  of  this  volume,  and  tying  the  arteries  which 
commimicated  with  the  sac,  viz.  the  common,  internal,  and  external 
iliac     The  patient  recovered. 


MINOR    SURGERY. 


^HK  foUowing  («Kay  is  not  intondod  to  embrace  all  niHltont  usa- 
uUy  tn4.-liul<Hl  uii<tt;r  tlic  U:nn  "  Minor  Sitr^ry,"  iunca  maoT 
of  theeo  will  be  fouti<l  scattered  through  tliis  work,  being  trcaUxl  of 
under  the  »p«<nHl  iliiteiwus  or  |i»rticulitr  Kiculiti(«  with  whiirh  ihoy  are 
nwro  inunediatoly  connected.  Kor  does  ii  attouifit  to  enter  into  the 
miiinto  dntntk  found  in  RyKtonatic  works  ou  minor  utrgeiy;  but 
id  aim  h  to  describe  briefly  such  proceedings  in  that  brnnch  of 
nr^ry  9W  aru  for  the  most  p:trt  gcttvral  in  tliuJr  npp  It  Lotion  Ui  (lie 
ttvetsl  regiona  of  the  body,  ami  are  ucmkI  in  tlio  treatment  of  many 
uui  variotu  (liseflM!!. 


I 


Basdaoes,  axd  THEin  Applicatiok. 


Bguidftge*  aro  ajtpliunoofl  iulit|iU»I,  nceonlliig  to  clrouiiLstonccs, 
H  mjiintaiit  anifbnn  pressure  on  §ul>jacent  parts,  to  retain  in  poai- 
tira  fractured  or  ditOocat«til  limlm,  to  im^itt  in  iiiuintjiiiiiii^  ontoct 
wWcMi  tlio  c<l^;es  of  large  n-ouuds,  or  to  aid  in  tJio  application  erf 
tofital  remedies  to  vnrioiu  part*  of  tlio  body.  For  ordinary  piir- 
J««  lliey  am  made  of  linen  or  Calico ;  in  particular  instinces  tlan- 
ttl,  or  *oine  oilier  vhufiio  iimtvrial,  is  employed,  in-ill^  torn  into 
*n{Hufappr(^>riate  length  and  width,  and  pieparod  for  applicatioo 
tfrolltDf;  up:  tiiiCAe  pass  under  the  eonwtuional  niunu  of  ii>ller)(. 
Stlluri  may  be  single-hondcd,  where  the  baiulago  is  rolled  up  from 
"io  end  alone,  tlw  other  rcinaitiing  free ;  or  double- head v<l,  whore 
wb  ends  of  the  bondage  are  rolled  up  each  into  a  separate  ooil 
•wardu  il»  centre. 

To  mcci  the  varnng  retjuirementa  of  various  parts  of  iJie  b<«Iy, 
•I  to  fultil  lite  diveritc  eunilitJons  for  which  they  inay  be  needed, 
^pauity  has  de\'ised  a  moat  extensive  variety  in  the  construction 
tfbaadagu  and  in  Uie  inaiuicr  of  tlxdr  appliciition. 

Hie  more  useful  forms  of  baitdage  may,  however,  bo  included 
in  twn  grunp« :  (I)  the  iiimple  or  continuous;  (2)  tlio  compound 
tanbgea.    Under  the  t«nu  'simple'  may  be  indudud  thuvii  in  which 

Tou  ui.  a 


^-       TO 


MINOR  SURGERY. 


8  continuous  roller  is  employed ;  these  are  (he  circular,  spiral, 
figure-of-eight,  and  scalp  bandage.  Compound  bandages  are  such 
as  require  more  tlian  a  continuous  roller  for  their  proper  adjust- 
ment; tliese  may  be  enumerated  as  the  many-tailed,  the  four-tailed, 
the  suspensory,  and  the  T-bandage,  besides  others  wliich  will  not 
here  be  referred  to,  as  their  preparation  and  application  belong 
rather  to  the  province  of  the  instrument-maker  or  bandagist 

Of  simple  bandages,  by  far  the  most  useful  and  most  general  ia 
its  application  is  the  spiral.  It  consists  In  a  continuous  spiral  appli- 
cation of  a  roller,  each  succeeding  fold  overlapping  the  one  that 
went  before  it  by  about  one-third  of  its  width ;  it  is  used  on  the 
fingers,  the  upper  and  Ipwer  extremities,  the  thorax,  and  abdomen. 
This  form  of  bandage  is  in  all  cases  applied  from  bolow  upwards,  or 
from  the  extremities  towards  the  trunk.  So  long  as  the  part  to 
which  it  is  applied  ia  of  uniform  calibre,  as  the  forearm  for  a  short 
distance  above  the  wrist,  the  bandage  may  be  simply  rolled  around 
the  limb,  passing  from  left  to  right  as  it  crosses  the  anterior  aspect  j 
but  if  the  circumference  of  the  limb  gradually  increase  in  size  from 
below  upwards,  as  the  calf  of  the  leg  or  upper  part  of  the  forearm, 


flrL 


BAKDAGtS. 


d 


tV  Un<laf:o  must  bo  fo1d«d  on  itself  ui  tlie  manner  r»pre«cnt«d 
in  fig.  1.  Tliii*  jirfx'fH.iIiiip  cIkhiW  bo  cftVftwI  lit  (yidi  tuni  of  Uio 
roOer,  and  Bhoulil  alwaj's  take  jiluce  opposite  tbo  same  pniiit  in  thv 
cimunfcnmcc  t<f  tlic  liitib,  or  an  unstgbtly  appoaniitciu  will  be  pro- 
duced, lu  effect  is  to  di^tribiite  tlie  proBura  evenly  over  l]ie  oiir- 
fiH»  of  tlic  l>art,  Atid  lo  obnatc  the  risk  of  the  buidagv  slipping. 
By  referring  to  the  adjoining  wooilcut  (fig.  2),  it  may  be  seen  at 
what  parto  of  the  body  it  is  ^neriUly  necessary  to  turn  th«  bandage, 
iu  tlte  tuiuiner  abo\'e  tneniiiUKKl. 

The  spiral  bandage  is  not  well  suited  for  pa«!<ing  smoothly  ocer 
Blie  an^Ciii  of  flexion  or  entt^nsion  of  jointn,  an<l  fur  thiit  roiuuin  (he 
fl&er  variety  of  simple  bandage,  the  figui-e-of-eiglit,  is  enijtloyed  in 
eonjunctiun  with  it  in  bandngtng  certain  purlj*  of  the  body.  I'ltu.i 
lo  bandage  the  lower  extremity,  taking  the  head  of  tlie  roller  in  the 
rif^bt  band  and  iitt  frve  end  in  the  \<.'t\,  the  ontifide  of  tliii*  <>n<l  should 
be  taid  on  the  dorsum  of  the  foot,  and  fixed  by  a  turn  or  two  of  the 
nller.  Pajwinp  over  lli«  limb  from  h-ft  to  ri^^Iit,  paiXTfiilly  kin'ping 
IIm  bandage  in  an  unifi>rn)  stale  of  tension,  with  as  little  of  it  un- 
vmuul  lu  possible,  it  may  be  now  ap])li«l  in  a  8im]>lc  »i>irul  man- 
ner, the  roller  changing  linnds  oaeb  time  it  passes  around  the  foot. 
lite  onUrgemcnt  at  liio  instep  requires  that  the  baiidtif^  I>o  twixtMl 
on  itaelf ;  over  the  ankle-joint  it  must  be  applied  in  a  ftgure-of- 
n;!lit  fashion ;  again,  at  tJi«  lower  part  of  the  leg,  it  may  be  siiiiply 
rolled  around  tlie  limb,  and  higher  up  it  niuft  again  be  twisted  on 
itMlf;  and  to  on,  x'aiying  in  its  mothod  of  application  with  tlie 
varying  eonformation  of  the  part  (fig.  i,  a).  It  may  be  fa^itened  off 
by  pinning  its  eitil  to  tlic  last  fold  applied ;  or  the  cml  may  lie  fplit 
into  two,  ai>d  ilwae,  being  earried  in  opposite  direetious  around  the 
limb,  may  he  lied  together  where  tJiey  meet. 

The  peculiar  i^tajie  of  the  thorax,  inereasing  aa  it  docs  in  cir- 
ramfemwo  fimn  below  upwards,  requires  tliat  u  roller  applii^l  t4> 
thai  part,  commencing  from  below,  Hhunld  lie  turned  on  itself  aa  it 
■Mends.  Before  applying  a  (>andage  to  tlie  thorax,  a  wido  piece 
of  nOer,  about  iivo  li-el  in  length,  »houI<l  ho  split  lengthways  from 
its  centre  for  about  half  a  yard ;  this  being  thrown  over  the  head 
oFUm  pfllient,  the  cmU  mny  lie  allowed  to  hang  down  in  front 
ud  behind.  The  patient  standing  with  his  back  towards  the 
Sorgeon,  his  hand*  rai.->o<)  abiive  hi:*  heiid  and  rcMing  aguinst  some 
•npport,  (he  bandage  may  bo  applie<l  over  the  neck-pieee,  beginn- 

t*  from  below.     It  may  he  finallv  faxteni'd  off  and  wHnircd  from 
ppiitg  it)  the  manner  represented  in  fig.  2,  c. 
The  (igiiro-of-eighi  bandage  is  fonnod  of  a  single  cotilinu<nis 


4  MINOR  SURGERY. 

roller,  and  ia  admirably  adapted  for  passing  over  the  angles  of  the 
joints ;  and  here  indeed  it  is  almost  exclusively  emplojred :  as  at  the 
ankle,  the  knee,  the  groin,  over  the  metacarpal  articulation  of  the 
thumb  or  finger,  over  the  elbow-joint  and  shoulder.  Again,  it  is 
made  use  of  to  keep  the  shoulders  apart,  or  to  draw  them  together, 


flB-S. 


according  as  it  crosses  in  front  or  behiod  the  body.  At  the  ankle 
the  crossing  of  the  bandage  ia  so  arranged  as  to  tall  in  front  of  the 
ankle-joint,  while  the  two  circles  of  the  figure  embrace  respectively 
the  leg  and  foot  (fig.  2).     At  the  groin  tlie  two  circles  of  the  figure 


BANDAGE& 


IcorroTUul,  the  one  the  upper  ])art  of  tli«  diig^i,  ttio  other  the 
tiii«  form  ofliandagtt  ii>  prtnt-rally  appHwi  after  operatioiiii  (or 
at^^tilated  hernia,  the  crossing  of  lii«  mlliT  U-int;  nrraiiKccI  so  as 
I M  over  tfa»  ifitantion  of  the  internal  alxlominal  or  feniond  ring 
|(^  2,  D).  In  upplyinj;  Uie  Rgure-uf-cij^ht  1"  llio  tiiiimh,  one  limb 
^AT  Uw  (ignro  slioald  «irround  the  root  of  tlie  tliumh,  while  the  other 
pMBU  arounil  llic  wrixt,  tlto  crofting  of  thu  tMiidiigt'  liciii;;  .'•itntitMl 
ovw  tbo  anhcotaiicons  margin  of  the  motacarpal  bono  (tig,  2,  k). 
At  the  etlxiw  Uiiit  form  of  ijiuxiugu  einbriuHW  tlw  upper  arm  iind 
fareann.  and  crossing  over  the  t)«xuro  of  the  joint  is  thus  nu<Ie 
amilabl<^  fur  c»ni[>nM»iing  tlw  orilioo  of  tlw  voin  nftwr  von«»cc'tion  as 
wrdinarily  performed  (fig.  2,  r).  In  bandaging  the  sjioalder,  the 
roller  i*  piwMil  arotind  thn  iijippr  jiart  of  tho  artn  on  the  one  ifido, 

I  and  aronud  ibe  root  of  llie  iioi-k,  or  ujider  the  opposite  shoulder,  on 
llm  other ;  tlw  cro«9fiiig  of  the  ii.iinliijfo  will  thns  lie  over  the  promi- 
nence of  Uio  head  of  iho  hnmeriis  (tig.  iJ,  o).  The  fi^ire-of-aight, 
IB  czDploTcd  lor  fractures  of  tiH>  clavicle,  erQfl»es  over  the  situation 
|tf  tlio  iipineA  of  the  upper  dorsal  vertehno,  and  friirminuU  the 
Bbonldcr-jointx  on  cither  side,  passing  in  front  of  them ;  when  it  is 
^CNmblv  iij  bring  the  lihotd- 
den  forward  and  maintain 
tlmm  in  thin  position,  tlie 
.  bandage  is  arranged  so  as 
cross  ov«r  liw  front  of 
fbe  atcmuni  and  xnrrnnnd 
the  •hotikUtr-joiiiis  on  rtiihiT 
•ide,  passing  behind  them 
(fig.  3).  Tliis  form  nfbaad- 
age  mar  he  made  available 
fore>inipre«t!ng  or  support- 
ing one  or  both  broasts,  being  pastsed  roun<l  tlie  thorax  tm<ler  the 
■ffiirted  breast  and  over  the  oppoeito  shoulder.  At  ihe  arl.iciihitioa 
of  the  knee  the  figuiv-uf-eight  ia  MKuiaionally  employed  to  bring 
tdgMbor  Uio  fr^gmenls  of  Iho  patella  after  traaRvw^e  ft'wrturc  of 
tlat  booe;  for  ihi.t  piu'|Miw>  the  ein^lea  of  the  figure  must  the  one 
snrrouod  ifao  leg,  the  otlier  the  thigh,  the  bandage  htaag  cnweed 
n  tho  popliteal  jipano.  Por  ntlior  purposi^t  tlie  bandage  h  n>- 
rersed,  and  so  ap[dii?d  that  the  orosgiog  Jails  over  tho  front  of  the 
Biticulatton. 

Of  tratj'-J^'tffa^f*  there  are  two  prineipal  varieties,  tlie  knotted 
and  llw  reeurrvni;  tl»i>y  are  miployrtj  for  rHotning  IwsJ  a]>pli- 
oattDtu  tu  wounds  of  tlic  scalp,  or  for  cxerciaing  pressure  on  tho 


*«.». 


JOR  SURGERY. 


part  to  ooniro!  luetnorrliagc  TIio  knotted  baiidngc,  wliich  is  gorii 
riilly  <rm]>loyr«l  for  cinnjinwsinf;  tin:  tt'iiijiorul  iirt*rv,  is  iippliwl  in 
the  Ibllowiug  luaiutcr.  A  IjniKlage,  about  twu  iiicIicH  in  width  and 
four  yiirds  in  longtti,  Iwing  rnllwl  iiji  iit  citlior  end  into  two  ite[ii>rau 
and  unoqnnl  [wrtions,  Uio  Surgeon  taking  one  head  of  the  roller 
ill  itiicli  ham!,  and  titandin;;  f»i-inf!  tln'  woiiiuliil  nrtery,  iip|>lit»(  tbu 
unwound  poriiou  ol'  llie  bajidage  over  tlje  compress.  He  ahoul 
now  pn»»  his  luindM  aruuiKl  tlio  houl,  one  on  vtthcr  k!iIo,  »■>  nil 
to  encircle  it  with  ihe  i-oller  until  lie  readies  t!ie  ojiposite  temple, 
wbcii  tlio  two  heads  of  the  bandagi;  being  crossed,  they  may  bfli 
brouglit  hack  ognin  (o  itie  point  of  ilepwture.  Here,  being  croesed 
one  over  the  other,  their  dircetJon  should  be  ehangc<d,  one  end  being 
oarried  under  tlic  cliin,  the  other  over  the  ^'erlex,  no  that  tliej'  may 
agiun  meet  over  tho  opjiosite  tcinpio,  wlivre 
thoy  are  again  to  bo  ertinseil  and  carrii 
around  the  head,  one  on  cither  side,  to  the 
point  whoiipe  tlioy  fimt  Btiirti.il.  Here,  jigain^ 
they  aro  crossed,  earricd  respectively  undoT' 
the  ehiii  and  ovm-  the  vertox,  and  so  on  until 
sufficient  compression  is  exercised  over  the, 
wounded  voH»cl.  I'lie  upj>li<-iitiun  may  bo 
cured  in  position  by  a  few  circular  turns 
tlio  long  end  of  the  roller  (fig.  4). 

The  recurrent  or  capolino  bandage  is  diffi- 
cult of  applioation,  and  easily  liucomeK  displaced.     As  it  in  alti 
impossible  to  convey  a  proper  idea  of  tlio  mannor  in  wHcb 
adjusted  by  a  mei-e  verbal  description,  no  further  allusion  will 
bo  made  to  it. 

Compound  bamla^s.  Tlie  T-bandngo,  tlie  four-tuileil,  the  many' 
tailed,  nnd  tlio  wij-iKtiisnry  bandage,  fall  under  this  denomination. 
Tho  T -bandage  is  formed  of  two  pieces  of  linen  roller  iittached  to 
each  otlier  in  tlio  lOiuiner  indieatcti  by  tJie  namo  of  tho  application. 
It  is  principally  iiawl  in  the  neighbonrlmod  of  the  ]HTiiiji'niii,  wlicns 
it  is  well  iitbij)ted  to  maintain  pressure  on  tho  parts,  or  t^i  retaii|. 
in  position  an)  topical  ujiplieution. 

Ill  iipjflying  the  bandage,  that  part  of  it  represented  by  tlie 
horizontal  limh  oftlmT  being  piKLsird  around  the  body  just  abuvo 
tho  crests  of  the  ilia,  should  bo  fixed  by  tying  together  tbo  enda  iw 
front  of  the  belly,  in  niieh  u  ]>osition  that  the  vvrtieitl  part  of  tli« 
bandage  shall  be  situiited  ovor  tlio  spines  of  tho  lumbar  vertebne ; 
if  the  application  is  to  bo  ut^ustcd  to  a  female,  ibe  loose  end  majf 


w 

^ 
^ 


tt.t. 


BANDAGES. 


<ig.t. 


l>roiig!it.  fiipwanl  between   Uie  nal«s  and  in  front  of  tlio 

ilva,  and  attatrbctl  to  tlw  horizontai  pottioti  in  thv  nwdion  lino  of 

■  ftWumvu.     If  tlic  jintjcnl  is  of  (lie  oi)|)osito  sex,  the  voitioal  [tart 

of  tlw  bandngo  shouM  l«o  split  at  it8  freo  «n<l,  aini  tlic  two  ends 

.  bruuglit  up  one  on  uillivr  »idv  tlie  Kcrotuin  and  |>eiiiH  to  be  allaolK'd 

I  liic  part  of  Uie  bandage  that  enoirclen  tho  body.     As  a  ruady  and 

ciMit  BtilMtititto  for  tiio  linvn  nillor,  two  priflcot- hand kercliiv fit 

ay  be  umhI  in  tbe  ajkplif^tion  of  tliU  form  of  bandagv> 

Sntpenaoty  bandagfg  aro  to  bo  pro- 

rciuly  for  tuo  of  an  inntruinont- 

Iter.  tliougli  occasionally  thoy  Diust 

be  improviMxI  by  tlw)  S«irgeon  ;  for  sueh 

an  emergency,  a  handkerchief  or  a  pioco 

of  iHtndaga  beiiif;  tic-d  an>und  rii<:  nUltv 

men  Just  above  the  eresta  of  the  ilia,  a 

(Ocond  liandkcrcliicf  slioulil  Ih^  piisaed 

beneath  tlie  scrotum,  and  attached  in  the 

mannvr  irprvscntcd  in  tigtuv  5. 

'V\\e  foar'tailnt  bundwje  is  made  by 
taking  n  piuco  of  liiten  about  »ix  inelim 

wide  and  a  yard  an<l  a  half  long,  and  splitting  it  up  tho  middle 
from  oitbiT  und  to  within  tlirco  or  fuiir  uiclics  of  tho  cnntre ;  tliia 
wotikl  form  sueh  a  liandage  an  might  be  applied  over  the  ktice ;  but 
of  coorso  tlto  sixeof  tho  apjuinituK  nuiKt  Itc  rc^tlut^Kl  by  that  of  the 
part  of  the  InmIv  to  whioh  it  is  to  be  adapted,  llie  form  of  Iwindngo 
_ander  con^idomtioti  in  gviiondly  employed  for  ninintaiiiing  in  poi^i- 
^oa  topical  apjtlicationit,  but  is  occasiotially  iniulo  \ms  of  to  fcvuro 
'the  correct  apposition  of  fmctures ;  it  is  applied  over  the  knee- 
joint,  to  Iht!  luvrvr  Jaw,  and  on  tlie  vertex.  To  ailjiiiit  this 
baudago  to  tlio  kiira-juuit,  tlio  contro  of  it  should  be  placed 
on  l\\t>  patella,  tlit!  four  tail.*,  hi-iii^  paHsed  itntiiiid  and 
ni>der  tlie  knee  aud  crossed  behinJ  the  liiub,  should  bo 
[]a<;ht  fi>rwarJ  again,  tlio  lowci-  jiftir  being  tii^d  togtilber 
front  of  lite  tJiigh  above  the  patella,  the  upper  pair  over 
the  liiMd  of  tho  tibia  on  the  aiit^'rior  ns[K!ct  nf  tho  leg.  For  the 
lower  Jaw  tlie  bandage  ahouJd  not  he  more  tlian  three  or  four  inchea 
to  width,  and  a  hole  should  be  out  in  it»  ivntre  to  ailmit  the  ])romi- 
tM-ncc  of  llio  chin  :  in  adjusting  it,  the  centre  of  the  bandage  nliould 
be  placed  under  the  chin,  and  the  tails  being  earned  upwards,  the 
^^■ndermost  |>air  shoultl  be  tied  over  the  vertex  about  tho  nitualion  of 
|^p»  eonuial  suliu-v,  while  the  anterior  ]uiir  of  ends  luv  taken  baek- 
wnrds  and  Ihaiened  togctiior  above  the  occipital  protuberance.    When 


I  niwii 
^fcrmi 
Pro  ft 


8 


MINOR  SURGERY. 


applkfl  to  tlio  vertex,  the  bimtingu  sliould  bo  wider  tlinn  tliat  re- 
quinxi  fur  ibe  chin ;  iU  centre  being  placed  on  the  vaiill  uf'tho  skitll, 
Hk  pcwtorior  tails  should  bo  brought  down  and  tied  togntlicr  bonoatb 
the  chin,  whil«  th«  ajiterior  ]>air  are  carried  ba<^l:wanla  luid  ftiK- 
i/xtud  bcnvatJi  thv  oc-clpul,  or  bruu^lil  ruuud  aguiu  under  ihe  chio 
(fig.  i,  K). 

Tlic  mar^-taiUd  txmdage,  Tho  adraiitage  of  tliia  form  of  appli- 
(^atioti  JA,  that  it  can  be  apphed  and  removed  without  any  di»liirb- 
anco  of  the  part*  to  whi(;h  it  is  ai^ustod ;  and  tbu§  it  is  chiefly  Dsed 
in  tJio  Irenliiunt  of  <<r)nipouud  fraetuivn,  in  L)u'  drcv^iig  of  »tiim]« 
after  umputation,  or  in  iinv  «a«'  where  abeohito  quiotu<le  is  de* 
»imbl<>.  Tiie  bandnKe  is  couiiunictwl  in  tho  fdUowinK  maimer  :  to 
a  wide  picve  of  roller,  rather  longer  than  the  psirt  of  th«  limb  to 
which  tlio  imndii^e  in  t<)  be  applitsl,  xluiuld  l>o  slitehud  in  siiccefr- 
sion  several  shorter  portions  of  a  narrower  bandage ;  tlteM)  hIiouIiI 
be  attactitid  bv  their  centrf!^  in  rih-Ii  a  miinner  tluit  each  piece  a 
.  at  right  anglen  to  the  long  ruUer,  iukI  nwt- 

^  IftjMi  tho  prtrcoilinft  piece  by  o»o-tljird  of  its 

width.  These  sliorter  portions  Klmtiltl  bo 
ea<rli  nbuiil  half  a»  long  agau)  af>  tJie  circura- 
frrence  of  the  limb  tliey  are  to  Kurround. 
Tlii-'t  btindn^e,  like  the  sjiiral,  should  hn  ap> 
phed  from  below  iipwiutU;  the  back  piow 
should  Ik:  drawn  np  behind  the  limb  or  port 
which  is  to  be  bundugwl,  and  the  transverse 
{Hirtions  spread  out  evenly  on  eitlier  side,  tlw 
last  piece  sewn  on  i^tanding  first  in  order  for 
njiplioatiou.  Beguining  fi-om  liolow,  tho  op- 
posite en<U  of  thej**!  triui»ver»e  pioces  should 
be  crossed  over  each  other  aniiiixl  llie  Hmb, 
each  succeeding  [Hiir  overlapping  and  keo])- 
ing  in  ])laco  the  ends  of  bandage  that  im- 
liem  (fig.  0) ;  tlio  last  pair  may  he  tied  together, 


mcdiafelv 

or  kt'pt  iu 


prwe<le*I 

position  with  a  pin. 


\ 


Immovable  Aitabatcs. 

Uiulor  this  head  it  is  proposed  to  consider  those  nietJMxIs  of  ban- 
daging by  which  support  imd  Innni^hilily  are  seeimKl ;  the  «8sential 
prineipio  of  tho  application  being  that  it  admits  of  adaptatiMi  wliite 
in  a  moL»t  and  pliant  condition,  and  Is  thus  enabled  the  more  exactly 
to  aecomniodale  itself  to  tlie  confonnation  nf  tlio  jiartfi  to  wlildt  it  ia 
applied,  before  assuming  itjt  permanent  condition  of  immobili^. 


IMMOVABLE  APPATtATUS. 


9 


^V  Onm  and  chalk,  white  of  r;^  and  flour,  gi'psum,  starch,  dcx- 
Hbine*  leather,  (^iitta-ixirL'liii,  iiiilllxuu-d,  jui.'iU-ltoiird,  an)  i\ny  of  thorn 
Ktoiw)«  use  of  in  couihijiatioQ  with  the  ordinary  bandsjco  for  tbe  above* 
^kiuMil  iiuriK)M\  TIm'iw  fonns  of  immovuhlv  ii]>|iftraUu  arc  i^n|dovi,-d 
^Bk^ie  ireatment  of  fractiiros,  in  chmnit.-  joint-aHeetions,  and  ollu-r 
^Bipw«»  vk'htirv  it  is  luxtsssary  U>  aiaiiitain  ptiruuuicDt  iiumublllty 
or  pTiissare. 

Oum  and  chafk  itt  preparod  kv  rubbing  together  in  a  mortar 
mucilage  witli  a  ^iifKoi^^nt  amount  of  ohalk  to  form  a  mixturo 
aboat  Um}  oonststence  ofthick  creatn.  The  limh  boing  placed  in  tho 
poMtion  in  whii^h  it  i»  doKinihlo  it  shuidd  ho  ntliitned,  fihoidd  be 
protected  over  its  morc!  pruniiuont  points  n-tth  a  hiycr  of  cotton- 
wooL  Having  Ik<<-i)  (irnily  un<i  oioidy  Iinndagod,  llio  ^'iiiii  and 
chalk  may  be  mneared  over  the  roller  with  a  hrusli  or  tho  open 
{lalin  (if  tho  haiHi;  in  doing  llu»  this  hnml  or  tho  hrusli  should  lio 
applied  to  the  port  in  tlie  same  direction  as  the  spiral  of  tho  roller, 
that  is,  uround  tho  Iront  of  tlio  limb  f  roiti  Irtl  to  rjglit.  If  a  groat 
amount  of  rigidity  is  required,  a  aecond  bandage  may  ho  apjklied, 
and  tronh-d  in  the  simo  inannvr;  or  tlio  uiiparnttni  may  bo  »till 
fitrtfaer  streDglhened  by  (^kuibiiiing  with  tJie  handitgo  gutla-pereha, 
leather,  or  pAxtoboaid  spltntii  niouldvd  to  tbi'  {Mrt*  tvhilc  in  a  pliant 
condition.  These  shouM  lip  npplieil  to  tho  linih  inimoiliately  over 
tlku  ix>ltun-wo<d  Adii-athing,  and  they  may  bo  rvtitimxl  u)  (Kwition 
dttriTig  tho  application  of  tlie  fir^t  bandage  by  atrip»  of  iKlbe«ive 
pUator.  Tho  gtiin  an<l  starch  bandage  Inkcs  from  four  to  fivo 
^^Nm  to  dry,  and  dnring  tliiti  time,  if  iliero  ia  any  uonHiderablo 
^■mdiMicy  to  di»|)IaociiK'nt  in  tho  limb,  moans  must  be  uwd  to  ouii- 
^^talptit  tmtil  iJte  apjilication  \m\h  Iii'<-iiiiic  rigid.  For  ihii>  reason  it 
^^BBttt  tfie  {Jastcr  of  Paris,  or  g;vj>$um  bandage  as  it  is  callud,  is 
ppaferred  hy  many  to  the  gum  and  »tarch. 

lite  ifypfum  Itnitdti^K.     For  tills  fonn  of  application   a  roller, 
I     wluch  aliould  be  of  coarse  and  ojx^n  material,  roust  be  previously 
B^r>-parvi>]  by  rubbing  into  ita  texture  dry  powder  of  planter  of  Paria. 
^Khb  burgeon  ahouM  lta\i-  at  hand  a  bag  of  the  same  material  and  n 
^^ttn  oTwsbor.     TIk  limb  being  prott^jtod  with  a  layiT  of  cotton- 
wool, tho  prepared  roller  Klmuld  ))0  immorsod  in  water  for  about  a 
ninute :  it  is  then  ri<ady  for  imniciltato  application.     It  should  he 
railed  unioiul  tho  limb  in  a  nj>irul  muniier,  ju^  as  an  onlinary  baiid- 
aga;  atlcr  every  socond  or  third  turn  of  tlio  roUor,  the  lefl  hand 
■boubl  he  plimged  iuto  wait-r  nixl  Hmearcii  over  tho  jMirt  la»t  a[ipl!tN]. 
Wlien  tho  whole  lias  boon  thus  tri-ati-d,  tho  exterior  of  tlie  bandage 
■kmld  bo  rubbed  over  with  a  pasio  of  planter  of  Piu-is  and  'HUtcr, 


StTRCJERY. 


uTilil  11  Mmootli  HurfHco  an*)  ttnffic-icnt  rig^tUty  )tavi>  been  i 
This  form  of  application,  after  tho  lapso  often  minntes  or  a 
uf  an  h'xir,  will  liiivi!  iiiijiiinMl  iln  jhM'iiiiiik-iiI  <rniuticic>n  of  rif^iclitj. 

Starch,  white  of  egg,  and  doxtrino,  arc  all  used  iu  tlieir  fluid 
Pjmis  as  slillV-riinK  Tnat«rial»  for  handtiiri^  Tin-  roller  may  ho 
soaked  in  a  solmion  of  one  or  tlie  other  of  Ihoso  gubstanL-es  previous 
tu  itit  a|>|)lifntiou ;  or  again,  ihi-  rolk-r  hoiii^  cut  into  ifhort  piecos, 
«aeh  half  as  long  again  as  the  cireiimferonce  of  the  limb,  those  por- 
tions miiy  bo  applied  wpanitcly  ti>  thr  part  from  below  wpwardjt ; 
tlie  opposite  ends  of  each  ]>i(Wfl  crossing  one  anotlier,  over  the  ante- 
rior ajtj>fct  of  the  limb,  and  fjich  siiet^oifling  piece  overlapping  tho 
one  that  wpnt  licfoiv  it  hy  one  third  of  ita  width.  Strips  of  paper" 
Koakcd  in  any  of  iJie  abovo-naniwi  solutions  may  be  advantagoooslj 
applic<l  in  tho  manner  Just  dcscriheiL 

(huta-percfia,  paste/nxirdf  mill/xKird,  or  leather,  may  be  used  in 
enniliinutiiiu  wirti  liny  of  the  above  stiffening  malarial!*  to  {jivc  ml- 
ditioiial  firniiicsB  and  pcnnajieney  to  tJie  application.  These,  being 
out  into  piei'os  of  tlii>  ri'>ijnir<'<l  ilimetisions,  nuist  bo  mouldiHl  to  the 
eliape  of  tho  part  whilo  in  a  pliant  condition. 

(.lutta-jiorulia  is  rendeivil  Hi  for  appHcation  by  plunging  it  for  n 
niinuto  or  two  into  hot  water.  Millboaivl,  pasteboard,  and  leatiier, 
may  h«  j^vpiuxHl  for  use  by  snaking  iheni  for  a  snflieient  time  in 
tmrm  water.  Before  applying  splints  formed  of  tlicsc  materials  to 
a  limb,  the  wholi?  part  should  Iw  carefully  swathi-d  in  a  layer  o? 
cotton  wool.  In  many  hospitals  it  is  the  practice  first  to  envHop 
the  limb  in  a  dry  mllcr,  and,  having  tnotddixl  pasteboard  splints  to 
fit  tJie  parts,  to  fix  ihese  by  applying  a  bandage  previously  saturated 
with  a  f.liick  wlufion  of  starch. 

In  adjusting  tho  immovable  apparatus  to  a  eoinpomul  fracture, 
or  to  any  part  whcru  it  is  desirable  that  an  aperture  should  exist 
for  the  cseupi'  of  matter  or  for  the  dressing  of  a  wound,  the  appli- 
cation should  bo  effeeicd  in  tho  ordinary  manner,  ajid  subsequent]/ 
the  banthige  over  tbo  wound  or  xinus  may  bo  cut  awny  to  tliil' 
necessary  extent. 

One  groat  advantage  atl-acliing  to  the  fitnn  of  ajiparatuii  under 
consideration  is  the  manner  in  which  it  may  bo  adapted  to  ohiuigci 
in  the  sizfl  of  the  linib.  When,  from  swelling  of  the  parts  beneath, 
it  is  necessary  io  loosen  tho  bandage,  tiio  whole  applicalion  should 
be  cut  Irom  en<I  to  end  witli  strong  scissors  or  a  knife,  on  the  ante- 
rior a»[H?ct  of  the  limb  ;  this  will  entirely  relax  the  parts.  Suhi«>- 
quontly  tho  degi-ee  of  siip])(irl  and  presjiure  to  be  exercised  may  ho 
regulated  by  passing  straps  aud  buckles  arouud  the  case  in  wliich 


I 
I 


SUTURES, 
limb  now  liea,  and  tightcninfr  or  loosoning  (lino  as  occasioti 

Where,  from  subaulcnra  of  Awelliiig  or  other  ratno;,  it  hecomes 
necesMiy  to  tiglitca  tho  applicaHon,  a  longiltulinid  Mrl]i  ninv  be 
cnt  oul  nftlte  appuratiui  fmm  (iml  to  r3I(I,  iiml  with  iftmps  and 
hackles  the  sides  of  the  case  roa/  be  brought  mora  neai-l^  into 
nppri^iliol). 

Tticro  is  sometimes  considerablo  difficulty  in  removing  (he  w- 
called  immovalilo  »|i{)ArBlus ;  lhi.<  mny  Ix)  ovoreomo  hy  surrounding 
Uie  partA  with  a  wet  doth  for  some  time  before  the  ronjoval  ih 

*Sttmipt(.-<L  When  ihv  baiitlngit  in  tlmroiiylily  soiikol,  it  may  bo 
nneoiled  from  nbove  dowawardfl  with  little  diSicully,  or  it  may  be 
cnt  witJi  sciseors,  layer  hy  layer." 


I 


Sltcbes,  and  their  Applicatios. 

SiitHns*  nn*  used  ft)r  brin^iif;  fogi^tlier  and  tnnintaintng  in  con- 
tact tJke  op[)osod  HirfucGs  of  womids.  Tlicy  diHcr  liotli  iu  tlio 
toeiliod  of  thr  n{i[>li<.'alion  and  llic  mt)t<;ria!  of  which  they  are  oura- 
pascd :  tliia  difference  is  owing  to  tlie  varying  necessities  of woun<Is, 
u  Ovate  vary  in  i-hiiruetor,  or  occur  in  one  nr  JinothiT  |»iirt  of  tlio 
body.  Tboro  are  four  prinri|>al  varieties  in  tlie  method  of  ajipfjiiig 
mutrm:  (1)  llw  oontiiiuoiis ;  (2)  tlie  infcri-upted ;  (3)  tho  twintrtl; 
(4)  the  (luilled ;  in  these  tho  material  employed  may  be  silken  or 
iln-inpcn  lhn.-3il,  inin  or  siivi-r  wirt-.f  Under  tbo  head  of  Mich  of 
the  principal  fiwrns  of  suture,  tlie  mnterlal  of  which  it  may  he  com- 
p»ed  will  Ik  rcfcrrod  to  more  particularly. 

To  save  siihsMiuent  ropotitinn,  certain  general  pi-ineiple«  appli- 
cablo  to  aJl  fonii^  of  nuture  will  bo  noticed.  In  pn^iiing  thi>  needle, 
the  edges  of  the  womid  may  bo  a<lvjinlagi'ousIy  Iii-ld  in  contact  wHth 
tbo  fbrcfiiiger  ami  thumb  of  tho  left  hand,  or  they  may  bt-  i*iiiuil- 
taneously  tightened  jm>  as  to  bring  theiri  piirulld  lo  each  other,  that 
Ithcir  oppostto  and  c<orre«ponding  parts  may  exactly  coincide.  Tho 
( needle  should  penetrate  tlie  Kiir&co  »t  nn  angle  of  50°,  and  should 
,  pass  tJtrongh  tlw  whole  thickness  of  the  iutcgumont  at  each 


<  •  Or  a  pteoe  nf  wiJo  tope  i«  taid  beooath  tlio  banilAgo  at  the  time  of  its 
^ifi[ir»ti(m.  tli«  lower  »ih1  Iwiiig  lolt  liHiigiii^  out;  Uiia  is  ubuiI  to  i«Ue  lh« 
fauditge  u|i«u,  wliiltf  it  ib  divMi-il  u'itb  tlio  scmtioi'S, 

f  Tho  kltolt«il  Kulnre.  tlie  olnnips  ami  oili*r  foTrnsi  atlncliiug  tlinm- 
MJTvs  lo  >pi)c>ial  t«^ion«  of  lli«  boily.  will  be  (baud  described  iu  tlK*  rt.*ity 
ta  PLMTto  ScKOKBT,  Mtd  In  Ute  account  of  tho  variuu*  pkstiu  operaliona- 


T?  MINOR  SURGERY.  ^^H 

Rtit^ii ;  as  a  general  nilo,  the  thrami  should  poaietratc  to  a  aiifficieni 
dcptli  to  avoid  leaving  beneath  it  in  tlie  wound  any  considerabki  eavj^ 
or  AjMioo  in  which  |iti-->  can  nccumnliiUt.  Tlie  dintance  iiiini  tlie  edga  ^ 
of  the  wound  at  which  the  suture  siionld  enter  and  lwv«  the  part,  fl 
inii-it  nooi'.-Wiirily  vurv  wilh  tlin  rlcjiih  oflho  ununit  and  rho  amount  ^" 
of  tension  to  which  the  thread  will  be  subject ;  but  in  no  cafeu  should 
lliitrv  Ik^  U-k*  than  the  cif;hth  of  an  ineh  ))ctw<H-n  tlw  .«nlui-t>-hol&  and 
the  niargto  of  ilie  wound.  Sutures,  as  a  rule,  ought  not  to  include 
rciwcU,  iKTvvs,  fawiif,  niUfdL-^,  or  tcndoni^  Where  nmre  than  ono 
auture  is  used,  tlie  interval  Iwtween  the  points  of  auturo  in  the  wound 
mIiouU  ho  KuHiciontly  small  to  overcome  any  tendency  thotj  may  ha 
for  the  cdgon  of  ilis  wound  to  evert,  or  the  fat  and  sul>cutaJieoua 
tiiMuc  to  bulge,  Tho  hue  of  the  thread  ought  to  crow  that  of"  the 
woujid  at  right  anglci* ;  and  in  Ciise*  wliPif?  the  thread  ]ias  to  bo 
tied,  care  should  be  taken  that  the  knot  may  tall  on  one  »n]v.  <if  the 
line  of  contact  of  lh«  «lge»  of  the  M-tnuul.  A  HJngle  knot  having 
been  tied,  some  precaution  shoidd  bo  taken  to  prevent  it  i>Ji|>ping 
whilt!  the  second  knot  i*  jirojianiL  Thi.t  may  tie  tied  firmly,  hut 
nowl  not  bo  tightened  by  tlie  exercise  of  any  force  ;  the  tingcre  arO 
suflioiendy  sti'ong  to  effect  it»  pro]nT  adjustment,  witliout  making 
mineccssarj'  or  unseemly  nuiscuiar  efforts. 

Th«  size  of  the  needle  eniplnycd  for  passing  («>ntinuou!i  or  inter* 
rupted  sutures  should  be  ailajitod  to  that  of  tlie  thread  to  bo  carried, 
and  to  tho  dvpth  of  tho  tissues  to  be  traversed.  The  i«b»i>e  oftlw 
needle,  whether  straight  or  e.ur\'e(l,  shcjuld  hear  relation  to  the  situ- 
ation and  nature  of  the  wound.  For  incised  wounds  on  the  ex- 
terior of  the  hotly,  whei-e  the  edgt^s  i:an  only  be  tranafixed  from  the 
cutaneous  surface,  or  where  the  oj>positc  margins  of  the  wound  can 
boti]  he  traver»ed  by  one  plunge,  a  curved  needle  is  bent  adapted ; 
whereas  a  strong  straight  needlo  u  more  convenient  for  the  com-  j 
plelely  free  m;ii-giiis  ot"  extensive  wounds,  such  an  are  left  by  th^j 
removal  of  large  tumours,  or  after  amputations, 

T/ie  nmlinum«  mhire  w  for  the  most  purl  used  for  the  aeeuratoJ 
apposition  of  woujids  having  thin  and  delicate  edges,  sucli  as  tlnoee  j 
of  tlie  eyelids  or  intestines.     The  application  coiisirts  in  tlie  »hn]il«| 
sewing  together  of  the  wound  from  side  to  aide ;  tho  tluwad  being 
knotted  at  its  extremity,  to  prevent  it«  pulling  through.     This  form 
of  suture  may  Iw  faslenetl  off  by  knotting  together  the  free  end  of ' 
the  ihn-ud  with  tho  stitch  last  pawed  ;  it  can  be  removed  by  cutting; 
with  fine-pointed  se-issors  eiu'h   portion  of  the  thread  iis  it  pasecA 
nerofut  tho  lino  of  the  wound,  and  subsequently  withdrawing  tlieee 
portions  separately.     Silk  or  line  thread  is  generally  uw-d  for  the 


A 


SUTURES. 


IS 


l~|M«li. 


e,  oimI  the  ncvdlv  iJiould  bo  nnall  aud  curved  at 


Tht  mUnyrptfd  ntture  w  moru  gvnfiral  In  ite  adaptation  tlian 

ay  other  form,  beiug  naod  in  wound»  of  idinoot  every  dtwcriptiuii, 

UtlioD^ti  from  its  \vry  iinltiix-  it  cluos  not  maintain  the  HtU'faces  of 

Ft  watutul  ill  ntiiOi  ol(>%  aiui  absolute  cotitact  ta  cam  bo  mvtircrl  hy 

tiw  continuous  or  twiRtwl  Huturp,  yet  it  -pomeasep  certain  advantageii 

otw  tb(Mi',  t^otli  in  the  facility  with  w{ii<!li  it  in  applied  niid  suhsis- 

qoently  withdrawn  (piecemeal  if  need  be),  and  in  that  while  it  pats 

ti)c  (nrtti  in  sucti  a  condition  that  union  \»  mmt  likvly  ta  lake  pla«v, 

Hjct.  ill  tlfp  o-ent  of  tine  healing  jtrowss  being  retarded,  it  oHerH  no 

^PttTiouK  <>lw-t{W.'li'  til  till'  iii-*«linr{;c  <if  matter.      F<ir  llu:  iipplicittion 

of  this  suture  the  needle  may  be  either  curved  or  etraiglit,  it»  fonn 

ii-arfinf;  with  the  diopoMtion  of  tbi'  parts  to  which  it  i«  to  Iw  applied. 

The  n*edle,  being  passed  through  the  integuments  a  short  distanco 

from  tlw  edge  of  t^M) wound,  maybe  made  to  Iravemv  it» cavity,  and 

■ppt-nr  through  the  &kin  at  the  same  distance  bc>ond  ib)  opposite 

margin.     Tlie  peculiarity  fnjm  which  is  derived  the  nanie  of  ttiis 

^■ibnn  of  Miture,  coiuiisia  in  liie  ctilting  of  the  thread  after  each  com- 

^kkte  stitch,  and  tying  tlio  ends  together,  over,  or  rather  just  on 

^HP'**''^  "'^'  '^^-  ^'"^  of  llie  wound.     In  woundn  with  odgCH  of  t^nsi- 

derabte  thickness  and  extent,  the  ncodio  is  generally  passed  sejia- 

tately  thmn^h  tbo  opponite  nuirgirn,  being  fimt  intnvluci^d  from 

the  cutaneous  suHaco  towards  ll»o  deeper  aspect  of  the  parts,  and 

nbeeqnviilly  from  t}ic  cavity  of  the  wound  towards  the  suHaoo  of 

tliebody. 

Silken  and  lieinpcn  tlireod,  tbo  materials  formerly  vuuio  uso  of 
fi»r  the  interrupted  suture,  have  now  very  generally  given  place  to 

•  lihrcr  or  iron  wirtw     These  latter  posM-a»  mo^t  dividifi  advanlagcft 
wer  nilk,  or  any  thread  of  vegetable  origin,  in  their  clcanlincw,  and 
in  the  diminished  tendency  they  show  to  excite  irritation  in  tlie 
tisKooi  tlmmgh  wlueh  they  pos^*     For  the  introduction  of  metallio 
wire,  as  a  snbstitntu  for  tlircarls  of  organic  origin,  we  are  greatly 
indebitvl  to  Dr.   SitnpM)n  of  lidiiibnrgh,  who,  by  tlie  pnblication 
^.fif  the  remits  of  his  experiments  on   animals,  and  by  tlie  success 
^niat  attended  Im  use  of  tlio  .>>anie  Miliire  in  man,  iir»t  drew  general 
^EMmtion  to  the  subject  in  this  country.     In  18-19,  I>r.  J.   Marion 
Bfiims  wa»  tlie   fin>t  to  apply  the  ajuno  description  uf  auturo   in 

•  -My  iMTsuniJ  *x|wrii.'npe,  in  ujipmitjoD  to  Dr.  Siupion'a  obscrfslionii, 
Uail*  me  lo  lilvf  a  di-oijcd  pnifcitiiim  lo  silver  over  iron  a*  n  tiuiteiiol  hr 
■cUlUo  ■«!«»,  and  tliia  is,  I  Iidii-vi',  in  UPCOrdnncc  Kilb  tlioopiuion  enter- 
tiiiwd  at  WiMt  of  our  inutropoliiuii  bu>]iitiiJx. 


14 


MIXOB  SURQERT. 


America.*  Dr.  Sims'  claima  to  prioritj  had,  bowerer,  boea 
anticipated  Cat  least  ao  far  oa  the  principle  involved  was  concerned) 
some  two  hundred  years  before  by  Fabricius  ab  Aqaapendente,  who, 
writing  in  1^7,  refers  to  the  impcriections  of  tbo  materlala  for 
suture  at  that  time  in  use,  namely,  that  they  excited  irritation, 
produced  discharge,  and  easily  ulcerated  oot.  As  a  substitute,  be 
recommends  iron  or  brass  wire  sharpened  at  one  extremity  and 
annealed  elsewhere,  thus  forming  both  needle  and  suture  of  one 
continuous  piece  of  mctal.f  Again,  in  oar  on~D  country,  in  tlie 
year  1>*34,  Sir.  Orosaettt  successfully  treated  a  case  of  vesico- 
vaginal fistula  by  silver-gilt  wire  sutures,  and  curiously  enough, 
adopted  the  same  position  for  the  patient  that  is  now  found  most 
convenient  for  the  performance  of  the  operation ;  a  position,  tbe 
advantages  of  which  Dr.  JUarion  Biins  professes  to  have  been  tlie 
tirst  to  discover. 

For  carrying  a  metallic  tliread,  an  ordinary  needle  of  ratlier 
large  size,  and  pretty  deeply  grooved  behind  the  eye,  may  be 
employed,  or  ono  of  those  specially  made  for  passing  this  de- 
scription of  sutnro.  Of  these  tliere  are  three 
^'aricties,  namely,  that  invented  by  Mr.  Price, 
having  two  eyes,  and  being  deeply  grooved 
(fig.  1) ;  Mr.  Lister's,  furnished  with  one  eye, 
and  grooved  laterally  (fig.  2) ;  and  that  re- 
commended by  Mr.  Murray,  having  an  open 
end,  and  a  groove  on  the  side  to  admit  of 
the  end  of  the  wire  being  doubled  on  itself 
(fig.  3).  To  obviate  the  necessi^  of  employ- 
ing a  needle  at  all  in  the  use  of  metallic  su- 
"K-  *■  tures,  a  piece  of  thin  steel  pianoforte-wire  may 
bo  sharpened  off  with  a  file  at  one  end,  while  the  remainder  of 
the  wire  may  bo  annealed  by  keeping  it  at  a  dull  red  heat  for 
some  little  time,  and  allowing  it  to  cool  slowly ;  two  or  three 
short  coils  of  such  wire  are  easily  prepared,  and  form  a  uscfiil 
addition  to  a  pocket-case.  Silver  wire,  if  kept  long,  soon  loses  ite 
softness  and  pliability,  and  becomes  unfit  for  sutures ;  it  may  be 
rcanncaled  at  any  time,  and  best  of  all  just  before  it  is  required 
for  use.      Metallic  sutures  are  fastened  off  by  first  crossing,  and 


fig-i. 


ig.>- 


*  AntiiverHai7  Diti<»)urse,  18&8,  before  tbe  New-York  Academy  of  Medi- 
cine. 

t  See  Dr.  AvelinR'B  letter  to  Medical  Times  and  Gas.,  Jan.  22, 1850,  where 
the  whole  passage  fmiii  I'ubiicius  is  quoied  at  length. 

I  Lancet,  Nov.  20,  l»3l. 


SUTURES. 


15 


h  ftocurp 


til. 


ends  of  tlic 


togetlipr,  niitil  suffi- 


n^irt  tlic  tciisioii  I"  wlijcli  lliey  will  be  GX|KKtud. 
In  >]j|ilyin}{  these  sutures  to  tbe  pre]>uoc  or  elittfwlinrc,  wlioro  the 
tAg»  of  tlir  woun<I  arc  thin  uud  dulicul*^  in  !-triicture  :)iid  itio  tiWuos 
aroutul  of  tux  liisjKiiiitirtii,  mhiw  care  miL^l  lie  tiiki'n  k-'H  the*  vdgm 
of  the  wound  tbcinsL-lvos  he  twisted  luid  bmisod  m  the  process  of 
fining  tJie  Miturc. 
WIh'h  llw;  inttTriiptcd  suture  is  formed  of  silk  or  tliread,  it  is 
if  removed  by  dividing  it  witli  tlie  {Mint  of  tlic  sci^aurt  Jnst 
kmv  friitn  iho  knot,  grasping  ibis  in  the  forocpn,  and  gentlv  draw- 
oui  tlto  KUltin*.  itl('tii1li<r  tiir..-a(U  in«y  bo  renmvwl  by  cutting 
wire  and  etraigbteiiing  tho  entU  before  witbib^wing  it,  or 
r,  lir  oulting  nwav  a  portimi  of  tbc  wire, — noarly  nil  lint  |>art 
to  view, — and  withdrawing  llie  remainder  willi  tlio  for- 
oDpS  [tuUiiig  towiinU  die  line  of  tlie  wound,  ho  as  to  make  the 
wira  d'.-Kcrilw  a  slight  cune  in  its  exit,  suited  to  Uie  shape  which  !c 
ban  aiMuniiil.  Tin;  fon'f^iing  is  one  of  ihu  host  moUtodit  of  rcinov- 
n^  RM-tallic  mtufM,  2  pruwediiig  wliioli  owing  to  the  stiffening  of 
■.■  win.',  i«  liable  to  bo  somewhat  painful  in  its  cxoi^tion,  nnk>»» 
stiirli  plan  as  tho  above  lie  adupt^Hl :  tliix  diliienHy  in  tlieir 
upTul  MH.-DM  to  bo  tiie  great  drawback  to  the  empluyinont  of 
\ic  nitures.  It  is  iiicxpodient,  particidiu'Iy  in  hosjntal  prnc- 
d,  tn  louve  metallic  sutures  in  a  wound,  in  die  hope  that  diey 
•liKigb  out;  tlic  wire,  or  at  least  so  much  of  it  a»  is  bcneadi 
tia,  will  in  tho  iniijority  of  cascA  beeonie  encysted,  and  may 
liiently  prove  a  considerable  source  of  inconvonieneo.*  Ah 
linManoo  of  dm  ttJeownoe  of  metallic  xutures  exhibited  by  certain 
wo  may  mendon  the  case  of  a  woman  who  still  rctniiiK  a 
■utun;  in  die  untwrior  wall  of  the  vagina,  introduced  by  Mr. 
Wiinuakl  several  raoudis  ago  for  Uio  cure  of  vesieo-vaginal  tistula ; 
titik  |aU)4'nt  lias  tinoe  Imnio  a  child. 

Bt^tn-  renlo^■ing  interrupted  sutures,  it  is  nsnal  to  Mupi}ort  tho 
talrrvoJ*  of  the  wound  birtween  dicm  l>v  »tri]i»  of  a<ihe»ive  plaster; 
bat  for  fartber  information  ou  dils  point  tlie  reader  is  referred 
tu  tbv  eMoy  on  WottiiDe,  vol.  i.  ]>.  592. 

TV  iiriitnt  xxfure  wiU  retain  in  immediate  contaet  the  whole 
nf  a  wound  of  oonsider&hle  dc]>th;  it  in  cm]iIovcd  in  the 
ior  lure-Up,  in  many  wounds  of  tlio  face,  e*p(.«cially  such 


L«kii 


A  tluo  "ilvur  liKulo"'.  whtcb  had  been  plftpetl  on  tin-  radial  art«ry  at 
b  vri*t.  wui  remowd  lhi-c«  months  nfteiwurds  hy  luj^cU,  on  aoooimt  of 
Ab  tDouuv^Bienea  it  cuuoi  ihc  pntiont. 


16 


MINOR  SURGERY. 


I 


att  Iny  ojicii  llio  cavity  of  tlie  nioulli,  and  in  extenBi\-o  wonn^  ofl 
tlie  abtloniiDal  vralls.  1 

Hanr-Iiji  piiiit,  (putting  witv-pliwa,  and  silk,  twiiio,  or  sumo  soft: 
thick  tlircail,  aro  requiiwl  for  it«  application.  J 

llio  Vf\}iV9  oi'tlio  wtiiuul  iKtiiig  hiriii  in  t-ontitct,  or  at  all  cvcntai 
Ijoing  oarel'ully  iDaintaioed  in  the  samo  liomotttal  plane,  the  pin 
&I1011I1I  Ix-  u)!itlc  t«  tnin»tix  the  wtniml,  cntcriiif;  tlic  skin  from  half 
an  inch  tt>  an  inch  troui  one  of  its  margins,  and  appoiirin^  al  tho 
same  distuncv  beyond  the  oj>{in!(ite.  The  rc<ii)init«  number  of  pins 
hdving  boon  jinssod,  a  piece  of  silk,  or  wlialever  other  ninteriitl  is 
cboscii  for  tlio  suture,  should  Ijo  twisted  over  cat-h  pin  in  tlic  form 
of  tlio  figure  m,  m  Ihat  the  circles  of  the  ligure  sitrrutnid  tho  cxtre- 
tiiilici!  of  tho  pin,  and  tho  crossing  of  the  tliroad  lies  over  the  line 
of  the  wutiDil.  The  same  thread  may  be  made  to  serve  for  idl  tliA' 
sutures,  provide  it  is  sufticicntly  long,  being  passed  oontinuousIjTi 
from  "lie  pin  Ui  the  next  billow  it.  Tlie  o|>iKisito  eiuU  of  tin.-  liga- 
ture being  tied  togctJicr,  each  pin  may  be  shorleiiod  at  its  pointed 
vxtromity,  antl  adjusted  so  us  to  leave  iilHUit  half  iin  inch  projcctitig 
on  either  side.  Tlie  skin  may  be  profeclcd  from  tlicso  roitgh-cilt 
cuds  by  passing  bon<^alli  tiii-in  n  st  riji  of  sort  lint ;  and  tho  whole  is 
beet  covered  with  the  same  materia)  dipped  in  oil.  In  vrithdrawingfl 
till*  fiirin  vf  siiluif,  the  heads  "f  tho  pitis  sliould  be  grasin-d  in  tJra 
forceps,  and  loosened  by  a  slight  rotatory  mo^'onient;  tJiey  may 
then  Ik-  drawn  out,  wliilo  the  finger  and  thumb  are  placed  on  the 
BUiiire  itself,  to  ])revctit  any  traction  being  exercised  on  the  mar- 
gins of  the  wound.  When  the  cut  surfaces,  to  which  the  twisted 
suluro  is  applied,  are  of  great  thickness,  it  h  sometJnics  necessary 
to  add  a  few  interrupted  sutures  at  the  extreme  edgt's  of  tho  wound 
to  prevent  the  eversion  of  the  fat  and  subeutiuietms  ti,«*iiii. 

In  applying  the  twisted  suture  to  tlio  face,  or  elsewhere  wbcro  ft 
Slightly  cieutiix  is  a  <'oiisidi'riitiiin,  groat  care  is  ni-edod,  in  tran** 
fixing  the  jiarts,  to  keep  tho  margins  of  tho  wound  exactly  on 
tlio  nine  level.  To  avoid  any  douMing-in  of  the  skin,  it  is  well 
to  tilt  up  tlie  edges  of  tlie  wound  while  passing  tho  pin  tiiroti^ 
them. 

For  this  suture  the  softer  vartetl&s  of  thread  possess  a  consi- 
dcnihlo  advantage  over  silk  or  twine;  the  latter,  from  the  firmneos 
of  their  texture,  being  tun  apt  tj>  bruise  the  soft  piulji  b^ieatli  tliem; 
on  tills  account  some  adopt  the  jilan  of  luing  narrow  strips  of  lint 
to  wuid  around  tJie  ends  of  the  pins. 

Tilt  ijUttiM  suture  is  Rda|>tcd  to  wounds  of  greater  depth  than 
those  to  which  tlie  preceding  ^iiriety  of  suture  should  be  apj>liod ; 


SUTUBES.    COUSTEE-IEKlTAXXOil. 


17 


'  tteclf  it  can  mninEain  in  apposition  tbe  deeper  pariA  «f  Rtdl  t 
iimnil.  iiii<l  m  i.»i)juii<:ti<in  with  lliv  intirmipttxl  tttiturc  it  wflllme)) 
m  cantact  Uto  whole  surlaoe.     In  the  haniL*  nf  soino  it  i»  foand 
?ry  iKH'fal  in  iho  Ircatmoul  of  [uccrukxi  p<.'riiuL>uin>  or  it  is  om- 
Jrivul  in  deep  wounds  of  die  hiiiCK-k  and  Hesliy  piirii*  of  tlio  ihigh. 
It  is  bi^  apptiud  with  a  strong  min'ctl  nciodlo,  lixed  in  a  liaodlo} 
having  an  eyo  n«iir  the  point.     This  should  i)0  t!m-:i<lol  witl) 
lie  loop  of  a  doahlv  thi^nd,  fonncd  of  lomo  Rtuut  material ;  and 
buvin^  been  pa-isiil  thmufHi  th<-  wuttiid  from  fhh  to  .lide,  tlie  luojwd 

Eiil  of  rlio  ligature)  may  Im;  detached  trom  tlie  eyo  and  hol<i  witli 
le  lufl  liaiiil,  nhile  tho  iit^illo  tit  withdrawn.     The  needle  should 
Lcrm  tiio  skin  not  nearer  than  an   inch  from  tho  cdgo  of  tho 
ouod,  ajid  ^Iboulil  ImvcRH)  the  tletsjier  parLn,  and  emerge  at  tho 
MiinG  distance  btrvond  its  opposite  niargii].     Tliia  proceeding  vriU 
i<re  a  dntihh;  thread  through  thv  wound  with  a  l<Mip  on  tlie  one 
and  two  free  enda  on  the  opposite.      Hu-ougli  the  loop  (or 
if  more  Uuin  one  siitiux-  he  i-m  ployed)  n  ]iuv(:  of  gum  euilifit**r 
be  passed,  and  iJie  ilnvad  drawn  tightly  over  k.  while  tlio 
pjid»  an  ttod  timily  over  u  ^'itiiihtr  ]>iwo  on  the  opjHwite  ai<l« 
the  wonnd.     To  maintain  perfect  apposition  in  ilio  more  sapor- 
i  fNirta,  it  u  generally  ao(.Tw«:irt,-  to  ad<l  a  few  interrupted  xuliircs 
I  the  extreme  mai^a  of  the  wound. 
By  cutting  the  looped  vtuh  of  the  tiiread»  1\m  form  of  suture 
[*ay  easily  l>e  removed. 

Sirra-jiiif«   are  oecasionally  employed   for  bringing   together 

•diumU  of  voy  tlun  akin  or  miioous  membrane.     They  are  email 

ifring-wire  forceps ;  their  [>oint»  arc  finely  tx-mtted,  and  their  handles 

ows  oue  another,  «o  that  wh«i  at  rest  they  are  clooely  in  contact. 

Tbt  pmntH  are  generally  bent  at  right  angles  to  tlie  spring,  ho  that 

dKbandtea  of  tlie  wrres-fines  may  He  evenly  over  one  another  along 

1^  Edo  of  tho  wound  in  an  imbricated  manner,      in  ndjuHcing 

^^W,  one  ^liouhl  a|>l>iy  them  at  regular  inter\-a]§  to  tlio  lips  of 

iW  woond,  taking  cant  tliat  the  liandles  of  each  giair  are  tunuHl 

'tannic  din*<T<ioR,  w>  ax  to  overtop  tiioAe  of  the  preceding  pair; 

*f»  dressing  that  the  wonnd  inav  need  can  be  Initl  on  it  subse* 

**dly. 

Couynui-iKRiTATiOll. 

-'m'tants,  as  their  name  implies,  arc  used  fi>r  Iho  pitr- 

ng  local  irritation;  tht-y  vary  in  degree  from  simple 

'*»liieicnt«,  -which  meiely  [iroduco   transient  eongestion   of  tJie 
~tB,  tu  MK'b  M  completely  destroy  the  tJseucs  exjiosod  to  tboir 
IvL.  Hi.  0 


16 


MINOB  SURGERY. 


inflnenoc  They  may  con\"cnieiitly  be  studied  in  two  groups — (1) 
ebcMO  wliose  oHVcU  uro  «om[inrittiv<;ly  lraii.<«i<tnt ;  ami  (2)  tluisu  tliat 
excite  a  more  permanent  local  irritation,  or  that  maintain  a  con- 
iiniicil  drain  on  tlio  Mystftm.  Under  liiw  fin»1  liwul  are  inr-lmlnJ 
rubefacients,  vesicants,  acupuncture,  and  the  like ;  umior  liio 
tccond,  the  miixn,  'uttncs  ui'  varimis  kindM,  iictiin.i,  anil  the  actual 
caiitoiy.  Huli'facientg  may  l^e  generally  defined  as  ajiplications  to 
tJitt  nurftiee  uf'tlK!  Iwdy,  whicii  inidilc  (lie  cutis  (intficieiitly  to  pro- 
duce reddening  of  the  parts,  without  leading  to  any  of  the  more 
HCriuiix  ri-^nlli'  of  iiiHaminat.Ion.  Fur  ihiK  purjiitw.!  vjirious  liniuionta 
are  employed,  such  as  the  lininientuni  auimonia?,  I.  coiitbaridiH, 
L  aeidi  acetici,  I.  tvrel>inthin;e,  I.  uiei  eruronis  tjglii;  tlio  potaauo- 
tutrate  of  antimony  in  the  lorni  of  ointment,  and  niualard- flour 
in  the  form  of  jwultice.  With  the  cse^^'ption  of  the  last  naninl,  all 
tliese  anbstancea  may  ho  applied  to  the  aur&oea  by  friction  with 
a  pieoi-  of  )hniiK*I,  the  iskin  "f  liie  jinrt  having  boon  previously 
deansed  with  warm  water;  the  skin  may  be  rubbed  until  it  huH 
■acquired  a  niddy  liue,  and  a  smart  tingling  Henmtioii  is  experienced 
in  tlie  ])artH.  Croton  oil  and  the  [lotassjo-tarti-ato  of  antimony 
difier  I'rom  the  other  su!«tjinces  in  this  group,  in  being  mora 
decided  in  tlieir  oit'cct»,  and  in  producing  a  eluu'acteriittic  pu^tulur 
ompUon. 

Mustard-flour,  the  moHt  jiopular  and  UAeful  of  ndicfaoieiitH,  »}iuu1d 
be  nmdo  into  a  poultice  witli  water  of  a  tenijierHture  Ironi  *iVf  to 
in()° ;  water  of  d  higlier  loiii{H!nitm-i-  than  ihi."  \s  liable  to  coagulate 
the  allmmcn  of  the  mustard -flour,  while  a  much  lower  hinders  the 
diiUMigagement  of  the  volatile  oil  Ujwu  whieh  the  irritant  property 
of  the  application  depends.  Vinegar,  which  is  oflon  mixed  with  the 
[Kiullifi',  liiis  tlio  effect  i)f  diminishing  it*  activily.  Thft  eflect  of 
sinapisms  may  be  iji  a  measure  regulated  by  mixing  with  tlie  mus- 
tard, wheat-Hour  nr  IIiiHciHl-mcal,  and  by  inodiljing  the  duration 
of  the  time  during  which  they  remain  in  contact  with  tlio  skin. 
The  Loudon  Phunune"|>aiia  direct.*  thatequKlproportiumt  oflin«ood- 
mcal  ajid  muslaixl -flour  be  used;  while  the  time  during  which  the 
appliciilion  rshould  remain  on  may  lie  brosully  stated  to  varj'  fi-oni 
ten  minutes  to  half  an  hour.  Il  may  best  Iw  eBliuiatcd  by  olwen- 
ing  liie  ti'xtnn!  of  the  shin  of  the  ptitieut,  and  bcltig  at  the  same 
time  gtiidcd  fiomG\vhat  by  his  ex})res.<itons  of  pain. 

Wlien  itiiiiipixniH  are  enipIoyiJ  to  patients  in  a  com  a  t*>!!»;  condi- 
tion, »|Kx;ial  care  sliould  be  tjiken  lest  they  remain  for  too  long  a 
time  in  cunlart  with  the  skin  ;  and  lliis  not  only  on  acwount  of  tlio 
abticnco  of  anv  indications  for  tlieir  removal  froia  the  sensations  of 


J 


VESICANTS. 


iLc  pAticnt,  bnt  aUo  fhyin  tlic  iiovsibility  Uiat.  tho  part  to  which 
thejr  are  nppHed  ina_v  Iw  alreailv  lowerol  in  vitiility  by  llio  lotw  of 
oerrouH  forco.  Tlii«  fomi  wf  riilHTfiiciviit.  may  ho  einjJoycd  to  any 
p«n  oftlM  surface  of  llie  body,  tliough  it  ia  well  not  to  cxpu«o  tiw 
tkin  of  the  ikuo  tu  it«  influvucc.  Vvry  ddJoato  or  irritablo  skiita 
art!  be^l  guanled  from  lis  undue  actioii  bv  iiitcrpoNiii^  a  ihJii  jiioi-u 
of  cambric  or  ttssuo-papcr  bciioatli  tlio  poultice.  After  tho  rotnox-al 
of  Um  ii{ipliratlii)ri,  the  surfaoo  h)ioii!<I  Ih>  gontly  !>jm>ii^<>i|  wilii  warni 
watrr,  and  a  piece  of  cotton-wttol  may  ha  placod  over  tho  part;  or, 
if  llw  jiaiu  bo  acvere,  a  pic«o  of  linen  or  lint  fl»i«urMl  with  »iiiii>lo 
cerato. 

VfMKmfA  are  snWtancos  which,  in  contact  with  tht*  cxtwrna! 
inte^tunent  of  the  body,  excite  such  initation  of  tbo  ciitis  as  to 
dotcrniino  the  (tft'nxioii  of  HTiim  from  it»  snrfaoir,  l«adi»g  (o  tine 
soparation  of  tbo  outide,  and  the  formation  of  a  vcfliele.     As  a 

tnunil  nii«  llwiy  arc  cmpioywl  aH  dcrivntivcn  or  »TOuntor-irritJint»  in 
nrmic  inflarainatorj'alfeccioiifl;  or  after  tlie  more  active  »ym[>toma 
of  ■nflamiiialioii  have  pa»wd  by,  they  are  uxcd  either  to  qiicnoli 
the  smouldering  rcmaiiu  of  an  aeuie  attack,  or  to  BtJniulate  tlie  ab- 
•orixxite  I"  iIm!  moro  ifiiccfly  removal  of  some  itiflamniatory  product. 
Ti>  produce  vesication,  caiitttaridinc  in  one  of  its  various  lornis 
u  gsncrnlly  employed ;  though  liquor  animonife,  chloroform,  or  iron 
^^nted  to  2li^  F.,  are  occiLiionally  ii.^cd  ;  it  if  hImo  »aid  that  niexe- 
^Pton-bark,  MXiked  tn  %*inegar  and  apgiUcd  to  tlio  skin,  !«  capable  of 
^aiinfT  a  blister  un  the  surface. 

Cantharidino  is  einiiloyed  in  tlio  form  of  tho  cmplnstnun 
Qotliaridts,  blistering  fluid,  and  bli»Ioring  tinKue.  Tlu^  Ain  of 
iIm  part  l>ein;;  prwiously  well  cleansed  with  warm  water,  or 
i^god  with  \'inegar,  llu^  ajipliealiou  nlioiiid  ho  so  adjiiHri-d  that 
it  may  fBinain  in  close  contact  with  the  skin  ;  for  this  purpose  tlio 
RDplMtrmn  ciniltaridis  i^  geiieniliv  vpnuul  upon  diacliyloii  pIiLtler, 
tnd  tlw  blisiering  tissue  can  be  tixcd  with  strips  of  tho  same  mate- 
FnL  In  cmmm  whore,  from  tlio  delicate  texture  of  the  aktn,  or 
f««i  known  idiosj-ncra^y,  tben^  i*  feur  hst  urinary  Irritation  arise 
"4  ahMrptwin  nf  the  cautbaridino,  tho  eurtace  of  tlxi  blister  may 
■  iIiMtod  over  with  powderal  eampbor,  or  better,  a  piece  of  oiled 
^i^o-iiBper  may  W  iiitcrposcil  Ixtwecu  fbn  biisler  and  tho  skin. 
•••0  ease  Altoidd  the  applicjition  In-  made  over  a  raw  siirfitce,  nor, 
"inwibhlc,  on  the  site  of  a  recent  cuppinj;.  The  employment  of 
■fiBa*  is  not  odoiisaible  in  the  case  of  children  suffering  fwm  any 
"*  or  CKhaosting  form  of  disease ;  in  tlicm  sinupisms  will  Im  found 
■  poduoe  quite  as  tnueli  u'ritatioii  of  tbo  cutaneous  surface  ti«  it 


MIKOK  SURGERY. 


is  MJb  to  oiB[>1oy.    Tlio  pflriocl  diinng  whiob  die  preparations  of 
ountharidine  should  bo  allowed  to  roinuin  iii  tioutaot  witli  tiw  clcia 
varies  so  greatly,  and  w  do[>oiideiit  on  *ueb  diverse  oonditjons  of  sex, 
age,  and  idiosyiici-asy,  tliat  wo  cannot  att«mpt  to  lay  down  any  g«no^| 
ml  ndcs  on  tL«  HiiI>j<!Ct ;  tlii>  jBif.iont",t  own  scnflations  will  afford  sonw^ 
gnide  to  the  nmouiit  of  irritation  that  has  hcon  oxciicd :  if  tht'  appli- 
cation ho  slightly  raiiwd,  it  i-nii  lie  aAcwilainml  wheUior  any  effnsio 
of  serum  has  taken  ptiMre.     If  tho  blister  has  been  sp|)lii-d  durii 
somu  boura  without  producing  (iui  dewired  ofilt^-l,  it  will  ho  well 
remove  it;   and  should  any  considerable  reddening  of  tho  eurfa 
exi»t,  R  wanu  linseed-meal  iioiiltiow  apphi^d  Ui  tli«  ]iHrl  will  often' 
auffieo  to  det^nnnine  n  copious  cifusioii  of  senini  6^m  tlie  surface  of 
the  cutis. 

Vowcation  niny  he  more  ra])iilly  piy«iuccd  by  the  applioatjon  of 
the  liquor  ammoniio,  or  iron  healed  in  boiling  water,  tu  tbv  surfaoo 
of  the  body,    niese  nj,'i>nts  iu-e  Imt  rarely  employed  in  ibis  country,, 
though  ttiv  one  or  tbo  otlicr  might  bo  advaiitagvoui'ly  c-inployn 
where  lapid  (leiiti'lution  of  the  cutis  is  re<)uired,  for  tlie  applicati* 
of  rcmodic*  by  tho  endennic  method.     One  of  the  best  ])lanK  of 
DEiing  tlio  lii^uor  aiiimoriiit  is  to  sU^'\>  u  pitco  of  lint  the  size  of  the 
part  to  be  vesicated  in  the  strong  solution,  and  apply  it  to  tho  sltiu 
until  ihe  uiniininin  has  I'aywed  oil' by  cni|>(iratIon;  in  most  «aseA  this 
will  almost  iiiunodiatcly  raise  a  blister.     A  very  nianagoable  and 
speedy  countvr-irritunt,  which  at  tho  »aine  time  appears  to  posMW 
a  certain  local  aiia>stlioti(!  |>roperty,  has  been  inti-odiiced  by  Mr. 
Little,  uf  Siiiga[i.>ri'.     It  eousi»l»  of  a  "inall  pii;co  of  lint  stVffKxl  in 
eldoroform,  and  covered  entirely  with  a  watch-glass,  applied  to 
tho  skill  iiiid  g<'nlly  ]in.'iwe(l  down  with  the  palm  of  tli«  wanu  hand 
It  may  remain  in  oi>ntact  with  ilie  skin  from  five  to  tan  minute 
whcji  it  will  gt'ueniily  be  found  to  have  produced  pmtty  docid 
roddeniiig  of  tlie  part,  and  oocasionally  vesication.    This  apjdioatiun ' 
liu.i  Ih'uii  fuuntl  especially  suited  fur  facial  neuralgia,  or  rlieumatio 
aQ'ections  of  the  sciatic  and  otlier  norv<!«. 

Tu  apply  the  heated  iron  as  a  vesicant,  an  ordinary  hami 
with  a  fiat  head,  or  lii-tter  Dr.  CoiTigaii's  thermal  hiitiimer,  as  it ', 
called,  lihould  bo  plmigod  into  boiling  water  for  about  a  minul« 
dried,  and  innni^lititely  H]>plieil  Ui  the  part  to  bo  blistered ; 
contact  of  ono  or  two  seconds  is  sufficient  to  produce  the  de 
effect.     Such  a  hammer  ininierw^  in  wator  at  120"  F.,  and  hod 
for  two  or  thriK;  seconds  in  contact  v^ith  tho  skin,  will  act  as 
rubefacient;  wltite,  if  iiliowetl  to  mnniii  in  contact  tlrcini  five 
tea  Ki>oonds,  it  will  generally  produce  vesication. 


a  lo 

and^B 

iite^ 


VESICANTS. 


SI 


,     dim 


[  \niateTer  means  are  cmplored  to  pmjuuo  tLo  effastoa  of 
leniia  tHrni-ntii  llio  mitidc,  the  sut>>-oqti«it  treatment  of  llio  v(»iclo 
Wuutbe  pursued  wJUi  iine  of  two  olij«cu  in  \-iewj  chbt-r  to  render 
the  irguty  to  tlto  part  oa  transient  as  possible,  and  to  restore  Um 
integrity  of  ilie  outirle,  or  to  CHtnlili-tli  a  |ii-rniiin<>ntiy  secreting 
nrfaoe.  To  cffret  tJio  fornicr,  the  vehicle,  being  opooed  witli  a 
Urga  ponctnre  at  its  most  di^fH-iKlotit  part.,  may  tw  nllon-od  to  iinpty 
if:  isabwqucntly  it  may  bo  covered  with  a  layer  of  cotton -wool, 
liich  ean  reniaiti  uiidi-^UiriHil  until  iIh"  ww  cuticlw  bo  tbrnivd  bc- 
;  or  aAer  tlie  evacuation  of  the  serani,  the  part  may  be  dnnsed 
wifli  simple!  wRitt!  ^)ri>acl  on  liiivn  or  lint.  If,  ln)we\iT,  tbc  blister 
i»  to  be  kept  open,  ibo  outi<:]o  being  [)incl]rtl  up  witli  ilie  forcops 
nwy  be  dividixl  wil]i  the  KiwMnv  arotuid  the  clrcuraforcnoc  of  the 
Teside,  and  removed  at  onee.  the  raw  surfa«)  being  dressed  with 
tin  OMntuiii  Kil'inn*,  or  wbatvvcr  other  application  is  sclectod  IM 
an  irritant  This  process  of  sunpping  oli'  tJie  eiiticte,  and  at  onee 
expoting  tlur  ilrnndod  cutis  to  an  irritant  oiiitmcuit  and  the  oxfcmol 
air,  is  extremely  painfid ;  the  pain  may,  Ikowever,  be  avoido<l  by 
lca%'ing  the  cntiule  in  contact  with  the  surface  of  (lie  part  afW 
dividing  ita  connexion-t  in  tike  niniinei-  idiovc  d(<i)<>niH>d ;  tlio  dret^sa 
1^  may  bo  applied  ovrr  tliv  cutido,  and  the  latter  will  separato  in 
few  dai-s,  tliuA  leaving  a  raw  sur&ee  that  will  grnduiilly  have 
i«  inured  to  tlio  sHmulns  of  the  external  an*. 
Variout  irriiating  aji[dH3tions  are  in:ul«  iLse  of  to  maintain  n 
t  secretion  from  blistered  surfaces  ;  the  uogaentnm  &ahini«, 
Uw  veratuiD  an<l  nngiieutum  oantluuidis,  arc  usually  employed, 
on  lint  or  linen  rag.  A  convenient  and  ne.irly  painless 
itant  is  found  in  the  papier  ^i»}nuiu/Ht,  which  in  k<'pt  by  most 
at  each  fresh  dressing  tJie  part  should  be  chanscd  with 
rj  H  prtHv**  niwlod  ax  »  goncnil  nilo  every  day,  and  in 
Mtnuner  weather  twice  daring  the  twentj-'four  hours.  TIkti.'  i»  a 
limit  to  tbc  time  during  wliirli  n  bliKlcrtti  snrfuco  should  lio  kept 
diicharging;  wlien  the  granulations  become  large,  spongy,  or  lubcr- 
atcd  in  apjioamtiet!,  it  is  ncii  to  disvimtinno  irritant  npplimtiund, 
an  uneven  and  un»ghtly  cicatrix  be  produced. 
Wbeo  Tcidcation  Itaa  been  employed  Ui  aihtw  of  llio  introrluc- 
tioa  of  drugit  into  the  systcju  by  the  endemiic  method,  the  blister 
■BUT  be  opened  by  a  small  panctorv,  wliioli  nhotdd  not  bo  sitiiatixl 
on  the  nio»t  dependent  asjiiy-t  of  tlie  vesicle.  Tlie  serum  being 
preued  out,  tlie  snlM>Iniico  to  bo  athnini^U-nxi  may  be  intrmhiced 
through  the  opening  in  tolutJon,  by  means  of  a  uiiall  sipTinge,  or  it 
OljJbe  HEidtcd  in  |>owder  to  the  raw  Durfaco  of  the  culia.    The 


M  MINOR  SUBGERY. 

foregoing  method  is  now,  howfl^cr,  RiijiersfKled  by  the  introflliotioB 
of  Dr.  Wood's  Hvringc  and  hollow  iieodic,  by  iuoiiim  of  which  sub-' 
stances  can  ivadily  be  itilro<liiced  into  tlie  Babcutaticous  i-olluli\r 
tiasuc.  M 

This  mannoi-  of  ititriMliiciiig  dnigs  in  jiwulidvly  adaptt-d  to  lli«' 
administration  of  anodynra ;  it  has  now  roceivcd  a  futir  trial  in 
many  of  otir  nierro[iolitiiii  IioNpiuN,  ami  Iihh  met  nith  g^cral  up- 
provit).  The  action  of  morphia  given  in  this  way  i»  iu»  !<]»i>edy,  if 
not  more  so,  lliiiii  wluMi  giv«n  by  iho  month;  it  has  Ihc  adiautago 
of  producing  no  disordering  cffe<?Ifl  upon  the  stomach  ;  wlnlo  from 
the  mainitir  of  iLt  iKlmtiii.<tnition  it  can  W  given  in  coiiditiouH  whoa 
tbo  irritability  of  tliat  orgun  would  otherwise  preclude  it»  u:**.* 

Tlio  Mohitioii  of  morjtliia  genoniliy  iwwl  (for  a  knowledge  of 
-wbicJi  I  ajn  indebted  to  my  friend  Mr.  Slower)  is  one  cwiisiittiug 
of  t«n  grains  of  the  acetate  of  morjiliiu  to  a  dmchm  of  distilled 
water ;  acetic  acid  being  ndiled  in  autiicient  quantity  to  di«*olv<s  the 
Bait;  liquor  ]H>lJU>sa;  is  then  added,  drop  by  drop,  until  a  slight 
film  is  pi-odooed,  so  that  there  may  be  no  excess  of  acetic  acid : 
from  on«-si\th  to  oni'-third  of  a  grain  of  tfic  salt  is  the  uaual  dose, 
or  from  one  to  three  miniui~i  of  tJio  solution. 

IfthegenernI  coiuftitutional  effects  alone  of  the  dnig  ho  required, 
it  may  bo  introduced  into  the  sulxnit-iueoua  tissue  of  tlio  forttarm, 
or  at  any  other  convenient  spot;  but  if,  a»  in  ihe  case  of  some 
neuralgis,  a  more  local  action  is  desirable,  tJie  injection  may  bo 
made  near  (lie  seat  of  j>aln.  Whatever  part  he  scIccUil,  the  skin 
being  jiinched  up  hctMecn  the  foivfingiT  an<l  lliunib,  tho  tubular 
occtllo  may  Iw  thrust  iu,  and  tho  solution  injected. 

Permanent  counter- 1 riiliitlon  iiiiiy  he  miiintaJned  by  means  of 
the  rcjicatt.'d  application  of  blisters,  each  Buececding  one  being  ap- 
plied so  soon  as  tJio  one  that  procoled  it  has  ceased  to  di^targe. 
Thix  plan  seems  to  oxer<;iso  a  more  decidedly  coantcr-irrilant  Vffisd; 
it  is  l»4s  irksome  to  tho  putJcnt ;  and  in  chronic  iiitlaimnatory  affeo- 
liouA  of  the  Joints,  and  analogous  cases,  It  is  an  oxccUont  substitute 
for  some  of  tho  more  formidable  countcr-irrllaiitit. 

Ak  11  vesicant  and  gieneral  counler-uTilant  nitrate  of  silver  has 
been  most  strongly  recom mended  by  Mr.  Hlgglnbottom ;  and  to 
bis  interostuig  pamphlet  on  the  snbjoot  tljo  reader  is  referred  for 


•  In  Mr.  LKwri'nco's  Landa  at  St.  Bnrtbolomew'B,  in  a  caso  of  delii'ium 
trcrapoH.  a  Just-  of  morphia  iDli-oduced  in  ihis  iv«j-  spf-fJily  pi-oduced  Wi 
oflect  which  a  larger  quaallt^f  giren  by  Ihe  muutli  hod  fiui«d  to  do  in  lb* 
B&iii«  pati«nt. 


Hirit 

rvU. 


ELECTRO-PUNCTURE.    ISSUES.  88 

dtboTttte  Rocount  of  ito  actJou,  nnd  ite  varioofl  appHcatioits  to 

AeupuiKturf.      TIiU  ojiiTaUon  coi»i«b4  in  (ho  intrixliidion  of 
-point»l  needles  into  the  subcutaneous  ti^uo  of  tlie  body; 
w>'  nllwwfid  ti)  rumnin  for  a  lonj^er  or  sliorh-r  liuio,  mid  are 
tbeo  n-iUnIrawn,     Its  chief  use  is  in  neuralgic  aiTections,  particu- 
rly  tlmw  of  U>u  «dntic  ncrvcj  where  it  i»  «ni[>Ioy<>(i  for  il*  wmnler- 
ritant  effact.     Its  efficacy  in  rertitn  obscure  cases  of  painfiil  inus- 
[calar  rigidity  i»  Iiijjhly  »i>f'kcii  of  by  Dr.  F.  O^cr  Wiird,  who  re- 
commends lite  insertion  of  tJie  needles  among  the  rausciitnr  fibres, 
retaining  ti>ein  there  for  mjine  time.     As  a  [nirely  inwhaiiiwil  ajpnit 
j{)uncCure  is  made  use  of  to  drain  away  a-demalotu  effusions  in 
'thii  «nlM;TitaiieoiiK  culliditr  tifisuc.     The  needles  for  this  piirjiOM)  ar© 
I      made  short  and  strong,  and  fixeil  in  eyiindriiul  han<Ues.    Tlioy  may 
^bw  introdnced  by  ilriltin^  tiirou^h  tho  skin  with  n  rapid  rotatory 
^■nui^enient,  effected  lietween  the  forefinger  and  tbiinib  of  the  right 
^LltaDdt  llio  »kin  of  tlie  part  being  at  tho  same  time  Ktrt^tclicd  between 
^■tlte  fingers  and  thumb  of  tlte  letV  hand ;  when  tlio  iiet-Llle  is  with- 
^'dravm,  the  rolatoiy  movement  idiuuld  be  ugtiiti  a<lo[)te<l  to  fiieilituto 
iu  KxiL      Acapuneture  is  sometimes  effoi-ted  by  i^^eussion ;  tlio 
point  of  the  neodic  )>ein;;  i>laixsl  ti|>on  tho  skin,  its  handle  is  etnartly 
•tntck  BO  as  to  drive  it  suddenly  through  the  Integuments  :  bstly, 
the  Dccdio  may  l>e  ititroihiL^^  witli  a  sudden  slabbing  movement. 
In  witJ»drawing  tlie  needle  in  either  of  the  last-named  mt^thiKls,  the 
skin  on  eitlter  tiidc  the  pimettire  ebotJd  he  held  down  with  tlic  fingiT 
awl  iliumb.     Of  tlw  three  plans  tlie  first  seems  to  oxercine  the  most 
decidedly  counter-irritant  effect. 

£ibirfn>>^tf future  is  nothing  more  than  tlie  application  of  a  gal- 
vanic Dorreat  to  the  ti«euQS  included  between  two  acapuucturo 
neodW;    titese  are  introdtieoJ  in  the  onliniu-y  tiiaiiniT,  and  the 
^^M^tivo  and  positive  pole  of  the  battery  being  connected  rtvjicftivoly 
^B|o  uao  and  the  oilier  of  ilie  noolle^,  the  cnrn-nt  may  be  established 
^netween  tlwm.     This  form  of  counter-irritation  is  cmployetl  in  tlie 
^KMna  dettiriixion  of  oases  lut  the  itcnpimcture ;  its  application,  liow- 
erer,  is  &r  more  painful ;  its  cliief  use  lies  in  tho  muoUB  which  it 
■flbnU  of  din'i'tiv  actin;;;  iijinn  j>uraIv!*o>l  niuwle*. 
^^        L'ntler  ilio  mure  permanent  forms  of  counter-irritation  are  in- 
^■elnded(l)  iwucs  of  variouK  kinds;  (2)iteton*;  (3)  tho  application 
nf  the  actoal  cautcr^'. 

L  Iwnc»  are  sores  artifieialty  ]>ro)lnecd,  giving  exit  to  a  con- 
^Knaed  d»charge ;  tlicy  are  employed  for  local  causes  a&  eounter- 
^irritaata;  or  for  coDstitutionuI  maladies,  to  establtitli  a  [ieri>ctual 


24 


MINOB  SURGEBT. 


I 


drain  on  tlic  svatom.  When  instituted  for  the  latter  parpows,  some 
piirt  uftlit;  liuily  .-Oiuulil  be  c-hoM^n  wlit-ro  tliv  ntilKMiUkiK-ou!^  cellular 
tissno  U  abundant,  and  also  convciiioiit  bv  ita  position  fur  xub»»>  I 
quoiit  driwii))^  of  tlio  nuru.  Prominent  |K)ii)t«  nf  bono  niid  tha 
n«ighboiirliood  of  large  veiiia,  or  cutaueous  nerves,  should  bo  care- 
fully avoid(xl ;  tho  iipficr  iLod  outer  piu-t  uf  tlio  arm  juot  Mow  tJx) 
insertion  of  tbo  deltoid  is  tho  common  spot  selected  for  tbo  fbnu- 
atjoii  ol'iui  issuo;  or  oil  tliw  lowt-r  Cixlrcniity  they  nu»y  Iw  con- 
veiiiently  placed  on  the  inner  side  of  tlio  tliigh,  just  above  tli« 
kncw-joint,  and  clear  of  the  sji|ihcii»  vein.  Though  tliuro  in  but 
little  room  for  choice  of  situation  wlieti  issues  are  appliwl  for  Ioch] 
purpoMs,  yet  tlio  general  rulwi  that  arc  inciitioncHl  nbovc  should,.^ 
if  poasibh!,  bo  observed. 

laraes  may  be  establtsbecl  by  means  of  (a)  VHriuun  vuustics,  (b) 
the  moxa,  or  (c)  the  nae  of  the  knife. 

(a)  For  the  foriimtion  of  cnuHtic  i^ucH,  either  cnustic  potash  ocj 
Tieinin  {xtnte  is  pmerally  ein|iIi>y(Ki.     To  apjilv  the  caiiMlic  potaah^i 
a  piece  of  plaster  having  a  small  hole  cut  in  its  centre,  half  the  waej 
of  the  int^tntUsl  issuo,  nhoulil  he  «p|)1ied  to  Ute  part  to  pmlwl  tlio 
surroonding  skin ;  a  bit  of  potasli,  tlio  size  of  a  small  )>C3,  may  bo 
plaeed  ovia-  tlio  hole  iu  tlie  plaster,  «id  eo%'«re(l  wttli  a  hiyer  oS^| 
soft  lint ;  the  whole  may  bo  retained  in  position  by  strapping,  and 
aluiuld  remain  undisturbed  until  the  eaiustie  hnx  exerc-i-vol  it.t  ftdl 
eBeot,  that  is,  until  it  has  ilestroycd  tlie  entire  thickness  of  the  ^n  ;i 
and  tJiin  will  generally  take  place  in  about  four  hours.     On  remov-] 
ing  tlie  aj)pliciitioii  iiii  asli-tuiloin-ed  ei-iilrid  stmigh  sliould  be  seoUf  i 
KiuTotiiiJed  by  a  bright  halo  of  eungestion :  simple  droMting  or  aj 
poullioe  may  bo  iii>|ilio<l  until  thu  divid  ]>arli(  separate.*     Tlie  si>is[ 
of  the  slough  will  generally  bo  fully  twice  as  largo  as  that  of  tbo ' 
liolf  ill  the  plaster;  it*  depth  will  [le[>ond  upon  tJie  i^tiaiitily  of  (Jie 
caustic  oni])loyed,  A  njore  convenient  method  of  applyuig  the  canstio 
potanh  is  by  mixing  it  with  soap,  in  tho  ])roi'ertiwTi  of  three  parts 
of  the  former  to  two  of  the  latter  ;  this  diminishes  the  tendency  of 
the  potnAli  to  difl'uso  itself  over  the  surrounding  sidn,  and  at  tliQ 
same  time  doi»  not  uinterially  lasseu  its  activity.      Vifiiua  jxute  tftl 
a  mixture  of  five  parts  of  caustic  [lotash  with  six  parts  of  quick-} 
lime.    Tliis  conipnmid  possesses  decldtnl  advaiitnges  over  tlie  eaustiaJ 
pota»h,  in  tlio  greaiei-  rapidity  of  its  action,  and  in  being  more  f 
easily  ooufinod  to  the  spot  to  whieh  it  is  applied.     Tlie  powdevl 

•  B«rore  applj'iiiH  the  pnHllici",  all  ri-mfllns  of  llic  caHstic  nliouM  bo 
eareAiUy  removed,  nnd  this  U  best  effected  by  BfiengiDg  the  port  with  a 
BOlution  uf  oceiiu  neid. 


i 


ISSUES. 


25 


'saox: 


ilunM  be  made  into  the  coDiiifitence  of  a  paste  \>y  mixing  it  with 
•loobul :  fui<l  iji;iiif;  up[)lji'<l  to  the  skin  lu  tiw  »uik)  [nAiiiior  aiMl 
ritb  the  same  preaautioiiR  aa  Ui«  ojiimtio  potarJi,  may  be  aliowoil 
mniun  in  contact  tor  AOoon  or  twenty  minutes,  or  longer  if 
>  mtegutuetits  of  tlie  part  are  vevy  <leti»-i.  AlW  tlie  removal  of 
puto  the  intiin  may  Ixi  gt?utly  washott  witii  warm  wut«r,  ftiul 
nple  dreoaing  or  a  ]>i>ultioi!  »[i|>li<.-<l  until  llio  jdoiigli  M^imtce. 
(ft)  Tbo  actual  cautery  iu  the  form  of  the  moxa,  though  fpauTally 
employiKl  for  ilJi  iuiiuediuUi  irrittirit  ot)'oct'<,  in  not  uiitWx|u«iitJy 
nudu  0*2  of  for  the  formation  of  iiwtuee ;  for  tliis  purpoeo  it  ia 
prafijrred  hy  some  Surj^mt  as  exercising  a  moru  dvc-idcKlIy  comi- 
ttT-irritanf  HFcct,  especially  in  oorlaiu  afleclioiifi  of  the  joints,  and 
ill  oariouH  diincaAA  of  ibo  houn  of  tliu  spinal  column.  Ttie  nioxa 
a  tightly  paekod  aolid  cyUndnr  of  aitlon-wool,  titttng  into  a 
metallif  tiiix.!.  o|K>n  iit  Ixit.li  mtb-,  and  attached  to  a  liandk.  The 
,livoxa  being  iumxluecd  into  HiU  tube,  one  entl  hIiouU  be  thoroughly 
aiuxl;  uttl  tho  oppuato  «n<l  being  held  in  contact  with  tlio  skin 
of  the  part,  a  eoRtinuoi»  Mim-iil  of  air  nhoiiUl  bo  maintaiuod 
■gun.'^  it»  Mtrfiioo  by  tncaiiH  of  a  blowpipe,  mitil  the  whole  of 
the  coUan-wool  be  ocHi.^niui:il.  Itlcumtinie  tho  Kuri'oundiii^  parts 
may  be  proloctvd  from  iiijurv-  by  ofivering  tliem  with  a  thick  layer 
nf  wet  liiiL  Tlie  nine  of  tln'  iHi^h.-tr  will  Ito  Kuniewhat  groaler  than 
that  of  tho  end  of  tlie  mctalho  tube  employed.  Mosas  may  ho 
p(«|MU«d  by  making  the  ootlnn-wool  in  a  ntmng  nohilion  of  iilti'ato 
ofpotaaU,  and  wibspquontly  dn,-mg  them :  in  the  appheation  oftlioso 
use  of  ilio  blow])ipo  may  bo  dispensed  m-ith.  Tlio  {kuu  of  tlio 
noxa  ia  (uocaeivo  during  its  application,  but  in  not  of  long  dura- 
^^titm  ;  the  rcaulting  nlough  i»  dry,  dark-coloured,  and  cracktHl  on 
Hfai  airfiuM,  and  the  Hnrrounding  iutt'gumonts  are  brightly  con- 
^npMlod ;  the  doogli  may  b<;  treated  in  tho  same  manner  a»  in  other 
V«a«ili«  bntea.  After  the  aepai-utiixi  of  tiio  dead  partu,  the  wound 
n  gmcrally  allowed  to  granulate  and  heal  ap,  but  it  may  sub- 
aei|aeiitly  be  Irt?ated  aa  an  nnliimry  inhuu, 

(i-)  Issues  are  made  with  a  knife  hy  pinching  up  a  fold  of  Bkin 

I  the  forefinger  and  thumb,  rapjilly  trnnHtixing  it,  and  cutting 

through,  ilio  cutting  edge  of  tlie  knifi-  being  tm-uod  upwards;  or 

int4.-gii incut'*  Wing  pat  on  the  ^trcK-h,  a  crucial  iuciaioD  may 

ho  pttdc  extending  into  the  HulwiitaneoiiA  ti^ue. 

Having  de^crilxil  tho  principal  iifiliodH  of  forming  issues,  it 

mw  retnaiuft  to  allude  briefly  to  Uie  \'anouB  plans  adopted  lor  ke^- 

jini;  then  open.     So  woii  aa  tho  e-schar  m^parates  in  the  case  of  tho 

f-«ai»tic  taMM*>  and  at  the  time  of  their  fhnnatiun  when  tlic  knife  is 


^^mos 


26 


MDJOB  SUBGEHY. 


VMd,  one  or  moro  glass  bonds  or  Usuo-pcns  may  be  ii]>{>ltnl  to  U^M 
Bnr&oe  of  tho  sore,  anil  tiiore  retuiiicti  in  finit  contact  nith  tliafl 
jMrts  by  mcwi))  orHtrn]ipmg  lor  luur  or  Hve  day*.  Wlion  eu[ipu-H 
ration  is  fiiUy  established,  tho  woimtl  lOioiitd  bo  cJeanBed  daily,  llmS 
]>oiii'  bciiif;  roiiiovo<l  and  replaced  at  I'acb  dro^iig;  sliould  tliafl 
granulations  beoome  too  cxubin'aiit,  tbcy  may  be  touched  ocwai^f 
^ionally  wilb  iiitratt-  of  silver.  To  prevent  tho  wound  hojillng,  it 
is  oceasioually  iifpciwarj'  to  roiijiply  tin'  naiiMlio  potasli  or  Vienna  ■ 
paste ;  but  a  more  convenient  and  Icstt  painliil  mi'tiiod  of  cflectin^H 
iJie  aanie  jiiirfiono  in  to  drt^ta  tho  surfiuu)  Ironi  lime  to  time  wiili  the 
pnpier  t'pinpastiijw,  or  the  IsflUfl-peos  may  bo  occaaionally  smc 
witli  Homo  irritritiii^  oinlmont. 

Of  the  various  methods  eniployetl  for  establisliing  Iniuc^,  that  bjrl 
mean!<  of  tho  nioxa  Ih  tbo  moHt.  docidiil  in  its  ootuiter-irritimt  pro-l 
pcrlje« ;  its  eflcct«  aro  produced  more  (inickly,  and  tho  issue  tbu 
forroetl  ean  In>  ki'|)t  disehiir;;inf;  (oi-  n  loiij^ir  |MTio<l  than  luiy  nther; ' 
fit  tho  same  time  this  plan  is  exceedingly  ]>ninfui  in  its  application. 
IsHuo!*  formed  by  caustic  i)i>tii.-<'li  nr  Vienna  pnitto  rank  noNt  foiS 
cffieaey  and  |iermaneney;  wliilo  those  formed  by  means  of  the  knife 
ai'o  liutli  (litlii-nlt  to  IciX'p  o[K-n  and  moro  noanlv  in  tliuir  Mrcrelion 
than  others,  though  they  have  the  advantage  of  causing  but  littlo 
pain  in  tlieir  a]i])lioution.  ^m 

SlIOM.  A  Boton  is  an  artifieinlly-prodneod  sinus,  through  tho 
track  of  whioh  come  nniti-rial  in  pa-trttHl  to  excite  au[)puration,  and 
to  maintain  tbo  pateucy  of  it«  orilicog.  They  are  OKtabliftht^l  in  tho 
subcutaneous  tii«sno  of  tho  body,  (a)  as  countor-irritanta,  or  (6)  to 
act  as  TOntinue<i  sources  of  drain  on  tho  system.  As  local  irritants, 
they  are  pa-imvl  thriiu;;)i  viirioiiK  aivilioN  to  excite  intlammation  and 
procure  adliesion  of  the  opposite  aurfacea ;  or  again,  tlicy  are  use^fl 
M  moans  of  grmhialiy  evacuating  the  contontti  of  cysts,  dironifi^ 
abscesses,  and  other  abnormal  cavities.  For  tlio  purposes  of 
cuuntcr- irritation,  sctons  aro  generally  inserted  in  the  ncif;hbou 
hood  of  the  pail  affeotcil ;  as  for  instance,  in  front  or  Iwliind 
ear  in  certain  chronic  afl'eetions  of  the  evt!,  or  over  rho  pnbcii 
certain  diseases  of  the  bladilcr.  But  when  employed  to  act  as 
drains  on  tlie  system  at  largo,  the  napo  of  the  neck  is  tho  part 
generally  selected  for  thoir  insertion.  To  establish  a  seton  in  the 
SubciilaneouA  tiwiic,  a  fold  of  skin  should  lie  grasjiotl  and  raiitcd 
fi-om  the  deeper  structures;  this  should  \ie  transfixed  at  its  baso  by 
tlio  instrument  caiTying  tJic  seton  rather  obliijuely,  so  that  one  of 
tlie  openings  in  tlie  skin  nhaJl  bo  more  dependent  in  position  (ban 


^ 


J 


SETON& 


27 


RM  other.  Tli«  sizo  cif  tli<'  folil  of  akin  tn  Iw  tr.insfixwl  will  depeml 
lltpoa  the  Wngtll  ol'  the  eolon;  )>ut  in  all  cases  tlio  nocllc  ntn»t 
nutM  il*t'])ly  tlinjiiKh  thtf  fubciibiiK'ntis  tiwtio,  wi<l  not  immwiiatoly 

VneitJi  tile  skin,  or  the  latter  will  ^Jougli  over  the  wliolo  trat-k 

_oftIje  n^l^llt<l.       On  iW  iiii|xi  of  llic   nwfc  »  longihiditml  (blil  of 

i>Ter  the  sfttnee  of  tJie  cervical  vwtebr*  ia  generally  raised 

Iwiil  tnuiwlixi^l  iwarly  «t  rtijlit  iinjjlw  to  tJiu  axis  of  tiio  ic]>iii«.     The 

1  iiiitninienta  iistil  van-  with  tlte  material  of  which  the  seton  is  ta 

bo  com^Hjscd  :  tlitH,  onliiinry  noi-(llc8  of  various  nz«t  are  vm)>l«}*ecl 

iwhen  one  or  more  silken  or  wir*^  Ll)n>ailtt  urc  to  he  introduced, 

^hcn.'a»  if  a  ^ni  cliustiu  band  in  iim.iI  to  kco[>  the  woimd  open, 

rlr  adapted  eeloii-nee<il«  aliould  he  employed;  though  iu  tlio 

of  this,  the  parts  may  he  tnuiHfixcd  with  a  dotible-odgt^ 

bistoiinr,  wlu'ch  will  alw  serve  o-i  a  gniilo  tor  the  introduotion  of  tlie 

Nton. 

tAVbatrtier  mntcrinl  is  flmploywl  Ui  kfli-p  the  woun<i  open  a«d 
excite  lUscIwrge,  it  allonld  first  be  sinearal  willi  oil;  and  having 
Uieti  iniriiduccd,  may  ha  nlli>w(sd  to  i-cmnlii  iindi'>.ttirbed  tor  tlnir 
or  five  days,  or  until  suppuration  is  fairly  ofttablished ;  sub8c<]uently 
Um;  dntusiiig  may  In;  duuif^ii  diiily,  jtin!  the  wrtoii  be  jxillcil  oh  iiiiJi 
oocasiou  a  little  tartlier  tlirougli  the  wonnd,  care  being  taken  to 
oil  tfant  part  of  it  wliidi  is  to  occupy  the  wound,  befoiv  moving 
it     If  tfie  seton  be  composed  of  silken  or  other  tlu-eads,  wlien  it  is 
■iy  all  [MtlKxI  thn>ugh  tlm  wound,  h  frwth  piwc  of  the  imme  iiia- 
may  be  attached  to  its  end,  and  thns  drawn  into  tlio  sinus. 
Jotta-pcTvha  or  gum  ela^tio  buntU  iiwd  only  to  be  t(hift«l  cneii  day 
'  way  or  the  otlicr,  the  projecting  ends  Iieing  c-irefuUy  wiped,  so 
ihv  dtsdiargo  doo«  not  aceiimulato  and  harden  upon  tlifrni.      In 
I  BobBeqtienl  prograa*  of  the  case  it  may  be  oi>easiomilly  necessary 
to  nnMM-  the  cncU  of  the  m<on  with  some  irrltuting  ointment  to 

rlttoe  *  more  copious  dischu^  from  the  wouml. 
For  t>:(ciling  local  inflamniatien  and  adhoiion  tlic  Ketcn  is  em- 
ployed in  tlie  treatment  of  hydrocele,  enlarged  bursa*,  ranula,  and 
^—flbcwbdTV.      For  ^iieh  a  |inq>nM.-,  a  single  thrt'ad,  or  better,  a  silver 
^Krire, »  paased  through  the  cavity  nitli  an  ordinary  needle ;  or  if 
tlw  cyst  b<;  large,  u  n^^iUo  fixed  in  a  liimdic,  and  having  an  eye  at 
ito  jmint,  ntay  be  used.     A  needln  has  roccnily  been  iiivvnt^id  by 
H.  Ualtliifiu,  of  PanN,  liaving  an  cyo  at  tlio  point,  which  latter 
diilocati-i  al  i^Ieasuro :  this  needle,  bosidee  Its  special  u!>c  in  vesicrw 
^^ipnal  tvitula  and  ru[4nre  of  thi:  perinanim,  ia  admirably  aduptod 
^fer  punng  ■  wire  thrwigh  the  tunica  vaginalii  in  hydrocele,  or 
^uroDgh  any  cavity  of  coniudurublo  extent. 


28 


MINOa  SUKGERY. 


Setons  aro  nowadays  but  rarely  omjiioyGd  for  emptying  largo 
CT8ts  or  clironin  uUscutiiejif  their  uac-  lor  llii*  )>ur|H>>c  ]ul^'itlg  Ucun 
Hiipersoded  by  the  drainago-tube  of  Si.  Cliii>«aigniic. 

The  actual  (aatfry  is  som*-  metAllic  subfitance  nii»ed  to  an  cle- 
vatwl  ti^mpcratviTf,  imd  applied  to  tlic  ti»«ncs  of  tiw  Ixidy;  8twl  or 
iron  are  the  only  nieutlH  now  «mpIoyed  for  this  purpose.  This  form 
of  cjiutery  Is  made  uw  of  for  arresting  hatmon-liii;^,  for  dfstrtiying 
diseased  surfacea  and  morbid  growtlis,  and  for  exciting  counter- 
irritatiun  of  almost  ei'crj*  d(>^;roc,  from  Hintplc  rulx-faetion  up  to 
complete  lUitit  ruction  of  Uie  nkin  and  .lubcutJincouH  tissue. 

Cauieriet  apo  made  of  steel,  fixed  in  wooden  liandlc« ;  tUoir 
hca<l*  or  i-xtn-niitit's  are  of  varirtiw  ftliapi-H,  Iit-in^  Inilbons,  iK>nicttl) 
ha(<:hct-sha})e<i,  or  liamnier-headeci,  varying  with  tbo  sjwcial  p«r- 
[>iii«i  (ir  jiurt  of  tbv  bmly  U>  wliidi  tJioy  arc  a|)pli4!(L  Tbey  may  bo 
heatod  in  an  ordinary  fire,  or  bj-  means  of  a  spirit-lamp,  'Riroo 
iif;;r*.-c»  oi  t^'mjKTuturc  aiv  ;p'ncriilly  ix-cofjulMsI,  nninoly,  whilo 
heat,  red  heat,  and  an  inferior  degree  when  tlie  metal  is  blaiek,  oc 
as  hot  B*  it  can  bo  without  losinf;  its  nittuntl  volonr.  As  n  gcuorul 
rale,  the  hotter  the  metul  is  at  ttie  timo  of  application,  the  losa 
will  it  produce 

In  ninktnt;  tise  of  the  antoal  cautery  to  n  raw  sur&ee,  wli 
fortlio  KUjipression  of  ha'morrhage  or  for  otber  purposes,  the  «iir- 
faoe  tiliould  first  Iw  carcfiiily  dried  ;  the  iron,  flat-headed  or  conical 
in  shape,  may  then  be  apj>licd  to  the  pan  with  a  light  band,  being 
kept  in  motion,  or  at  nil  oviiits  not  ullowisl  to  remain  in  etintaot 
with  any  one  part  of  the  wound  for  more  than  a  second  or 
otiitTwico  the  diwrgauiwetl  tissues  will  xtick  to  the  molal,  cunsin, 
great  pain,  and  oilen  considenihlo  ha-jnorrhago  wlien  the  instmmeiit| 
is  removed.  ^Vlieii  tbo  hut  iron  is  applied  to  tho  Hound  i>kin 
its  eon  nter-irri taut  etfoftb',  a  liatcliot-shnjied  oantery  is  generally 
employed ;  the  thin  edge  of  this  may  be  drawn  rajfldly  an<l  lijjhtly 
over  the  wrfnco  in  [inrullel  linos  wi  incii  or  more  apart  There  ara 
oortain  parts  of  tho  body  to  wliich  this  remedial  measure  uliould  not 
be  applied ;  tliese  may  be  stated  to  Ih>  th<;  iiiimediutt'  neighlMmrliwid 
of  subcutaneous  bones,  such  as  tlie  vault  of  the  skull  and  the 
num;  salient  points  of  bone,  m  the  acromion,  olecranon,  jKit^lttt; 
tho  eoiirso  of  the  InrjTix  or  trae hoa ;  siijjcrficial  tendons,  and  the 
neighbourhood  of  sueh  sj-novial  membranes  n»  lie  very  near  tho 
Borfaee.  The  eft'eci  of  the  heated  iron  may  ho  varied  ui  degree  hy 
holding  it  at  a  grtMitoT  or  losti  distaneo  froui  the  skin.  lis  indi- 
rect application  is  thus  employed  by  many  Uoutinental  Surgeons 


BLOODLETTING.     LEECHES. 


29 


BLOODLETTDia 


\%  sdmaUnt  tm  nlc«n>  or  iinlteallhj  wonndB ;  Ui«  faiiteiy  being  IkIcI 
lir<t  at  same  distance  frotn  tW  I'^rt,  mid  lii-in;;  f;r»<luidlv  approsi- 
maied  until  tht^  Kiirfucie  nl'iliv  Mtro  U  covttred  with  a  itiiii  drv  Hoiib. 
B  For  (be  de§truction  of  morbid  growtlis  or  vatiMTciiu  nlt-ors,  Ibe 
»duml  amitry  may  be  relnitiod  in  contaot  with  the  disea-aocl  tiMiieti, 
or  freahlj'-ltnted  oniteriea  1>e  fmjuvtitl^  ixinowcd  until  oompletu 
vbuTing  of  tho  parts  luu  been  effcvlotl. 

tFor  the  oonvflnienco  of  doacription,  fliis  rcmcdiaJ  mcasnre  may 
»n»id*!riil  first  in  its  1i«.-j!,  uiiil  M^^indly  in  iw  general  nppliui- 
tioo.  In  local  hloodletdng  the  blood  is  drawn  from  the  capillaiiea ; 
this  may  be  I'fibclwl  by  IcccUinKj  iioarififlalioii,  or  ini[)piiig.  Qencial 
bloodletting  lucludeA  TcnGseKiun  and  arteriotomy. 
H  Ltwhittti.  Locclivti  ttlioidd  be  removc-d  frrim  wn(«r  nii  boar  or 
^  two  before  their  apptii^ation,  and,  having  been  caretnily  dried  in  a 
dean  cloth,  tltey  muj'  be  applied  to  the  skin  of  tlie  part,  itfU-r  it  tiax 

I  been  rairt-fnlly  cleansed,  freed  fi-om  hair,  if  that  exist  in  any  qnan- 
tilT,  and.  if  need  be,  Hmcarcd  with  u  little  milk  to  iii<Iuoe  (he  k'celir.s 
to  bite.  If  the  hloinl  itt  to  be  shHiracloil  trtun  the  external  &ur(iic« 
of  the  body,  the  le«clies  may  be  conveniently  coveri'd  with  an  in- 
vetted  tmwliler  or  wine-glass  nntil  they  have  attached  tJieniselve« ; 
or  tliey  may  be  pUiewI  in  the  hollow  of  a  large  and  loosely  made 
]iad  of  eulton-wool  eoven^  with  lint ;  or  a  clean  towel  iniiy  he 
(bided  BO  as  to  contain  (hem,  and  being  inverted  over  t)ie  part, 
may  be  maintained  in  position  by  gentle  pniwure.  Again,  two  or 
three  may  W  plaecd  together  in  an  open  pill-box,  which  miiJft  bo 
inverted  and  mainlained  in  ounlaet  with  the  part.  When  it  in 
deatraUe  more  exactly  to  localise  the  point  of  ajiplication,  as  in 
ling  tlio  guiiLi,  eyelid,  or  laerymal  kk,  thtj  Iwch  ean  be  re- 
in position,  until  it  has  attached  itself,  by  meonit  of  a  leech- 
or  n  canl  rolled  aji  in  a  cylintlrieal  uliupe.  When  tliere  are 
few  leeches  to  be  applied  to  the  external  surfaro  of  the  bodv, 
Mcfa  may  be  hehl  singly  between  the  forefinger  uikI  tlimnb,  while  its 
maath  u  directed  to  the  p«rt  to  whidi  it  is  intended  it  should  aiTaeh 
ilariC  There  an'  ecrlain  [wirt*  ofllie  ImmIv  where  particular  pre- 
eanliona  fifaould  be  adopted  in  abstracting  blood  by  llitH  ineanx. 
To  lliu  eyelid,  nnsul  mucxHu  membratie,  httri'inal  sac,  and  cavity  of 
tbo  mutilh,  a  leech-glass  or  r()lted  card  ought  always  In  bo  used, 
lo  leeching  the  lyt'lid,  ilio  patient  xhoiild  he  placed  in  the  reciini- 
bant  po«tioaj  and  idtould  lliua  remain  for  some  time;  this  will 


30 


MINOB  SUKGERY. 


"J 

1 


generally  obriato  Hic  imnifjlitly  owhynKiKiw  wlu'cli  is  apt  b 

in  tlift  loose  oellakr  tissue  ot'tho  part."     LoceUea  may  bo  a]t_ 

tho  OS  uteri  by  tint  iiitru(liic-in<r  ii  #|ioc'alimi,  tliue  protecting  the 

vii^ina,  and  [paving  tlic  os  uteri  free  and  ]irojecting  iiitci  tJie  cavity 

of  the  iustruniciit ;  Uk^'v  may  tljon  be  pu«licU  duvrit  tlio  speculiun, , 

nmt  maiutiiinot  i»  oontacrt  with  the  os  by  means  of  a  pli;(l;^-t 

cotton-wooi  until  tlicy  Imvc  uttiiclKrd  tlit-inwIvM. 

A  liealtJiy  leei'hwill  draw  about  Sij-  "f  bi(Mxl,  and  IhJti  quantttj 
may  be  incrojiscd  by  subsequent  fonit-ntaliirti  of  tho  bite  to  about 
%■**.  It  i.t  !>]iid  tJiat  tlie  capacity  for  al>»tracling  blixid  may  bo 
largely  increased  in  Icechc*  by  making  niiuuto  punctures  on  tJieir^ 
dorsal  Htu-fttco,  just  above  tlie  caudal  extremity ;  of  coumo  thisfl 
proceeding  eannot  bo  adojitcd  until  the  leecli  is  finnly  attaclied  aiul 
well  disteiidcil  willi  blood;  Jl  is  a  meawun^,  one  would  (liink,  of 
very  equivocal  ad\ii»tagc.  When  loccbcs,  tliough  fully  distemledfl 
itill  rciniiin  ntluelied  to  tJie  suriiiec,  tlin  )Mipul»r  applications  ofl 
salt  or  snuff  to  their  botiles  will  ytiiorally  induce  tliem  to 
their  1 1  oil] . 

To   obtain  a  further  flow  of  blood  from    flie   Litos    afler  ffiSI 
eoparation  of  the  kfoiien,  wann  linseivl  pduliiccif  or  fomentation  I 
with  warm  flannels  arc  generally  employed,  or  tllo  part,  if  on  ODt 
of  the  extremities  of  iho  body,  may  be  immersed  in  warm  water. 
When  it  is  desirable  to  arrest  the  ha>morrliage  at  onoe,  iJic  bites  ^ 
may  be  Irecly  expo»ed  to  tlio  air,  or  itiv  part  being  covered  withH 
lint  or  a  dry  eloth,  pressure  over  it  may  bo  made  with  the  band, 
or  maintained  bj'  a  bandnip?;  nhould  this  be  inj-uflicient,  a  little 
shrodded  lint  being  placed  over  each  bitfl,  firm  pressiu*  may  1)0  mado 
with  the  finger-ends;  or  again,  ttie  lilw'ding  points  may  be  touebedl 
with  niti-ato  of  silver  or  porebloride  of  iron.     In  cases  wfurci  tlia , 
ha-niorrhago  is  alarming,  or  tlio  foregoing  mcanii  liave  failed  luj 
nrrcat  it,  llie  soft  parU  beneath  the  bite  may  bo  transfixed  by  al 
fine  needle,  and  a  silk  ligature  may  Ik'  wotmd  urotmd  tbeni  Ix^neatllf 
the  noedh--ends.     In  ncloeting  a  spot  for  the  a])plieiiti<)n  of  lcechcfl,j 
it  may  not  bo  amiss  to  bear  in  mind  the  fact  of  tho  cbaraet^ristio  ] 
trirudiatu  eieiitri.v  Icll  by  tlie  bil^,  and  timt  this  is  iii[l[-1li)lo. 

iScaripcatiim  is  employed  in  various  parts  of  the  body,  as  a  meaniJ 
of  directly  relieving  tlie  loeal  conp-slions  of  fi-eo  snrfaevs.     The 
operation  consist*  in  making  small  incisions  on  the  surfaoe  of  ttia 
part  wilh  the  point  of  a  laiiiet  or  scjilpel ;  these  incisioux  varyid 
in  depth  and  extent  with  the  textnro  of  liio  part  afieotetl  and  tliel 


Leeulies  Hbould  uot  be  up^Uvd  u>  tUu  u]i]ter  eyelid. 


CUPPING. 


31 


Blevflritv  of  tlie  loco)  mtMhiet  Tlicy  are  employed  in  dictuosi*  of 
tlie  conjuncliv^  phlej^mooous  inflainmation  ot*  t]w'  iitccgumonts, 
aatbe  ctigorsftiwrnls  of  itio  (i>iifj"c  "'w'  ttiisMi',  nrnl  in  oIIkt  |jart«. 

Vup/iita/  ill  iu  most  ordinary'  fonn  comims  ia  the  lot-al  aWu'ac- 
tioa  of  blood  from  nuuuto  iuci»()ti»  l>y  muai»  of  Rtiuo»|)hcric  prcit- 
Kore;  ua]>|Hng-gl«sw»,  a  BCarificator,  and  a  a)>irit-Iaii)p,  iire  re- 
quired for  tho  pcrfomianoo  of  tlu»  opcTutioiL  Uuppiug-glafisoi 
an;  of  varionei  dinus  and  sixes,  bat,  fM*  tbo  most  part,  narrow  at 
tbeir  necks  mvl  sutnrwlnil  <li)aU>d  at  the  opjxiHito  oxtn-niiiy.  Tlioy 
an  ODiltlojcd  fur  creating  a  partial  raciiuiu  over  tliai  part  of  ilis 
snrftoe  from  wliidi  th<;  blood  m  aUMtnivtod ;  l)ui  air  witliin  tbcm  ix 
iiud  by  iiitriKiiioing  for  a  second  or  two  the  flame  of  a  Hpiril- 
tp;  on  tho  witlidrnwal  of  tliJs,  tlit;  open  iiioiitli  of  tho  glass  is 
fniin«di;ilely  applied  to  ilie  part  to  be  cupped.     This  has  ihe  cH'ef.:t 

'of  prodndn;;  groal  lorn]  c-oii>;cstioii  and  swelling  up  of  Uio  parts 
invluiUil  witliin  llie  rim  of  the  glass.  Tlie  glass  may  be  COQ- 
TGoieatly  romo\-ed  by  tilting  it  to  ono  side,  and  at  tint  same  time 
ioatmuiting  tbe  )>ointoftlie  forefinger  intdor  it^  edge  oti  the  op|>o- 
ut«  aide.  The  leari/icator  is  used  for  siinultuncKiiisly  and  (luickly 
oSbcting  lh(!  ite«»Hary  ineisions  for  tlie  abstraction  of  blowl ;  >t  in 
fismied  of  a  number  of  blades  ti\cd  on  au  axis,  n-hicli  latter  by  a 
rapid  winirotutury  movement  pmjeots  (lie  Muiles  through  a]>pro- 

P^ala  opeoings  in  tho  iustrumont,  and  diridcs  tlio  integument  tu 
S»  rwjuinul  dttpth.  Bt^foi-e  iti*  appltoatioii  tlie  bliulo.i  of  the  scari- 
fieabu-  should  1)e  sot  so  as  to  cut  through  tJio  cutis  lera,  but  not  to 
ODeroach  npou  tho  ^utxiulanooiLt  lisHue ;  thin  licing  iHIi>clod,  tho 
qiring  may  be  drawn  back,  and  sot,  and  tliu  instrument  being  held 
I  prrtty  (irmly  in  wnlact  with  ilw  skin,  the  s|irinf;  may  l«  releuMid. 
k  BeGire  the  application  of  cupping-glasses  the  skiu  of  tho  part 

1  tbtnld  bo  iqtongml  wttli  warm  walor,  and  any  Iiair  thiTn:  may  be 
I  m  the  mir&%  should  be  removed ;  a  basin  of  warm  water  and  a 
I  %htnl  cmadle  shonld  be  at  hand.  TIk  gh*»a*  Wmg  tint  placed 
^L  in  the  warm  water,  sliould  be  a]>plicd,  ui  tho  manner  above  men- 
^M  tMwd,  onv  by  ono  to  tho  pari  front  whicii  tlio  bKxxl  in  to  l>c  drawn ; 
^M  on  being  taki^n  tl;al  sufficient  intervals  are  IcA  between  lJiegln:9se.'t: 
^M  w<]r  toay  bo  allowi'd  to  romain  in  coiitnct  witii  th»  xkiti  for  about 
^m  ^Bumitu;  a»  «^iich  is  withdniwu,  Uie  scarificator  should  he  applied 
^M  to  tbo  swollen  integument  beneath,  luiil  the  glii--^  simuld  be  as 
^1  liiddr  a>  (wmible  n-ailjii»li!tl  to  tlie  [)art.  Tbe  blutKl  will  eoiilitme 
^H  hflnr  from  the  iitdsions  imtil  t)ic<  cxhaustivo  pon'or  of  tlio  gloss 
^M  **>  waanl  by  tlte  vaouum  witliin  being  destroyed;  wtien  tliis 
^M   Omn,  the  gla^  may  be  removed,  and  a  Ireah  one  may  bu  applied 


MINOR  SUfiGERY. 


to  die  samo  spot,  the  sarfacu  being  first  sponged  to  remove 
coa^iln  tliiit  way  \\ava  ronixML     An  each  gl>»»  ia  rcutovcil,  tin 
Itlond  from  it  aiay  bo  emptied  into  a  gmdiuittxL  vessel.     Wlicn  tl 
rcy]uiro<l  nniDtiiit,  Iu.h  U'cn  ii)<striK'.ttil,  tlio  wouiuU  may  be  spoiigtid}* 
dried,  and  cacli  group  covcre<l  with  a  picra  of  diachylon  pinstor. 

It  i»  often  extremely  diffieult  to  procure  llie  rwjuiriHl  Amour 
of  blood  by  menus  of  clipping ;  and  tbis,  tbough  it  may  occur  from ' 
many  ciiii«ev,  it  eUieHy  owiiif;  to  one  of  two  rvnaonK,  niunely,  tb«t 
eitlier  tlie  deptli  of  the  incisions  lias  not  been  rightly  adapted 
the  thiekncM  of  the  skin  ofllie  jinrl,  or  tbiit  the  viienuiu  within 
tlie  glass  itt  insutfieient  or   too  eoiiipk^ti.'.      To  avoid  both  the 
evils  nx|utrcis  some  kuowle<lge  of  the  ilillerent   thickness  of 
iiitegtniipiit  on  various  parts  of  the  body,  and  a  certain  manua 
skill  which  eau  only  l)c  aeijuirtHi    hy  practice.      When   llie  skil 
bas  been  too  freely  divided  by  the  searitieator,  tlie  euhcutaneflv 
tiMme  is  npt  to  bulge  tlirinigii  the  iutnxions  in  tlie  okiu  uiui  hinder ' 
the  How  of  hlood,  while  the  disadvantagos  of  an  iusulficient  divi-_ 
8)on  aro  obvious.     Should  the  iitniosfthcrio  jirpMurv  be  to  great : 
to  constrict  the  cutaneous  cnjiilhiritiii  ar(jun<t  the  rim  of  (lie  gla 
this  prcwuro  may  bo  rclic\cd  by  rotating  the  gla»»  a    htllc, 
by  ftvaylng  it  to  and  fro,  ao  as  to  allow  a.  little  external  ttir  to , 
beneath  ity  margin. 

There  remains  to  speak  of  another  form  of  (^npping,  umalt] 
termed  "dry  cnjiping."     The  object  of  tliis  is  to  abstract  bio 
temporarily  li-om  one  part  of  the  IjimIv  by  detaining  it  for  a  tJi 
in  other  parts.     To  effect  this,  several  cupjiiug-glasscs  ai'e  appUe 
nj)d  renewtxl  at  intenaLt,  their  ]iosilion  being  Hliglilly  varied  eo 
time,  BO  that  tlie  skin  may  not  suffer  from  the  pressure 

As  ft  gi-unnil  rule  en p pi ng-g hisses  xlimilil  not  he  applied  in  tlio 
immediate  ncighhourhooil  ol'intlaniixl  tiwtues,  nor  over  the  niam'^ 
mary  region.  Their  a<yiiKtnH^it  also  is  well-nigh  impoH-sihlc 
certain  silualions,  anch  aa  the  pcrina^um,  or  the  anterior  regions  i 
the  tliorax  hi  emueiatetl  p>atJcutM. 

M.  Junot  has  devised  an  instnimcnt  by  which  ho  considers 
lie  prwiuoes  a  transient  condition  of  general  depletion.     Tlie  nj; 
paratus  conaista  of  a  meiallle  eyliudcr  closed  at  one  extremity,  and 
fcuffieiently  hirge  to  contain  either  the  upper  or  lower  limb ;  at 
tachctl  to  the  cylinder  in  a  ainull  stuji-cock,  to  which  in  fitted 
exfanu.-ttiug  syriugc.     One  of  the  limbs  is  immersed  in  the  metallic 
case,  and  a  verj-  wide  indiii-riibber  band  being  drawn  ovw  lb 
ojten  end  and  around  the  limb,  so  as  to  form  an  air-tight  caWt 
tlie  sj-ringc  is  applied  until  tlie  condition  of  the  pulso  indicates  Uii 


VEyESECTION. 


t  raficicnt  amount  of  air  has  bcun  nMHovccL  Th'n  proceeding  ia 
HJd  to  poflseas  many  of  tlit>  advaniagee  of  ^n^^ral  i]e|iIi;|.ioii  witli- 
ont  exercisiiig  any  {wnnaccatly  dobilitaliug  iiSoct  oa  Uie  oon- 
EtimtKW.* 

H  General  lilooHettmg. 

^H  VfMttvtian,  TiM  operation  may  bo  porfornicd  npon  tliu  voins 
^Bttf  tbc  forearm  or  hand,  the  oxtemal  jugular,  ilie  veins  bem^atli  tlie 
|^Pt»n;;tM!,  Ukihu  nf  tlio  Hcrulum,  and  the  internal  Kiphcna,  ikay  tho 
inner  ankte.  Wliate\'er  vMn  ia  npenod,  it  is  necessai-y,  when  prnc^ 
ticablo,  lo  prodnco  congestion  of  it,  by  compressing  the  vewol  be- 
tween the  jioiiit  to  U*  i>p(iiii((  mill  the*  hwtrt.  A  lani*t,  blooiiing- 
tapv  or  a  narrow  bandage,  Unt,  «  bowl  to  roccivo  llic  blood,  and 
a  basin  of  wmer  and  a  i*poii|^,  nrv  reqitirt>d.  The  oprration,  aa 
Ofxltnnrily  pcrfonned  in  tliis  country,  eonsisis  in  o])ening  one  of  the 
at  the  bend  of  fj»  elbow.  Of  tliiwc  tlic  most  proniiiieni  are 
median  cephalic  and  the  median  basilic,  tho  former  being 
'^ituatefl  to  tlie  m\Ufr  nido  of  Uio  ten<lon  of  tho  liioejn*,  tho  latter  lo 
inner  siiie,  ai>d  immediately  over  tho  eonrso  of  tho  braobial 
•rlen',  iivlts.-d  only  M;pamti.>d  from  the  artery  by  tiie  fascial  at- 
tachment  of  the  bieepB  luiisele.  For  anatomieal  rea§ons,  tlicro- 
Ibrc,  tlK'  inevlian  cephalic  should  1>o  prefiimxl  for  vcnieswtioii;  but 
in  practice  tho  mora  prominent  and  larger  veiu  of  tlie  two  is 
•ck<ctnl. 

The  patient  being  placed  tn  tlio  silting  posture,  the  bleeding- 
tope  or  banda^  may  bo  tied  around  the  Itmh  about  tho  middle  of 
the  upper  arm,  suffioientiv  tij^ht  to  arrest  tlio  venous  eireulntion 
wilboat  affbctiiig  the  pulse  at  tho  wrist.  Tho  forearm  hnvinf;  iiem 
allnwal  to  hang  ilown  until  the  vein.H  are  tense  and  lurgid,  tho 
tor  may  select  one  for  his  purpose,  and  taking  the  hlnde  of 
ihe  lancet  betwwiU  tlio  fiircfiitgirr  and  ihnnib  of  his  right  hand, 
dmtdd  fix  tlic  rein  bv  prcsting  his  left  tinunb  upon  it,  juM  biOow 
the  part  be  is  nl>out  to  open,  t^toadyin^  hiit  hand  by  resting  the 
ntila  of  the  three  inner  lingers  on  the  forearm,  the  jioint  of  tho 
lanert  may  he  introdnccd  obliquely  luitil  the  interior  of  tlie  vein  is 
nached  and  the  blood  risca  up  out  of  the  wound ;  without  |>eiic- 
linp  any  deeper,  tlic  Iniicct  should  now  Ijo  thrust  onwanis,  thus 


In  a  eua  in  wltidi  I  3uid  un  oppurluiiily  of  obs«rving  its  effcvts, 
mtrv   Icsfl   mnrkcil  in   lliu  cumlilutioii   ut   luific   tlinn   in    tlic  limb 
T;  ili«  buter  •cvmi'd  int«iuely  coiigi-Htvd.  and  on  t}ic  mnoval  of  Um 
iaatniiDiwL  wu  covered  wiUi  niinute  uutiuiouua  cochyoioM*. 
Toi-  in.  » 


94 


MINOR  SURGERY. 


laving  open  f lie  voln  loiifriludiiitilly,  anJ  eiitdng  ita  wi 
mlvaiico  of  the  point  of  puncture.  Tlie  veiu  being  well  o[>cned, 
the  thumh  may  be  rvinovwl,  and  tliv  blood  ullowvd  to  flow ;  if  tlio 
ulrciun  be  scanty  and  sluggiab,  tho  ordinary  expedient  may  be 
adopU^],  of  dirvctiiig  tbo  |)utionl  to  clt-iicb  lus  fi«t  firmly  from 
time  to  time,  or  tlie  Sui'geon  may  chnfo  the  veina  on  the  jjoltiiAr 
surfiu^  of  tlic  fiiri'nnii,  nibbing  from  bclovr  npwsnl.  Wbcn  tlio 
rO(|uirfld  amount  of  blood  liaa  been  ab8trai.>tcd,  the  llmmli  (tf  tJio 
left  hand  may  bo  placud  owr  tlic  wound,  and  tliu  lij^turo  aromid 
tiiu  arm  reluxixl ;  a  ^onaU  pad  of  lint  being  placeil  over  tlii>  orifice  in 
the  vein,  tlio  parts  around  should  bu  t-leunscd  from  blood,  and  tlie 
tape  ii]i|)lied  ill  a  figure-of-eight  fashion,  so  that  the  crossing  of  tlie 
tape  lies  over  tho  pad  on  tlio  vein  and  kocpe  it  in  p]acQ,  oxorcisiog 
pretty  firm  profuturo  (fig,  2,  p.  4).  From  a  want  of  v<jincidvni.'0 
between  tlie  wound  in  tho  iatcgumontA  and  that  in  tho  coata  of  tho 
vein,  thfi  blood  may  cease  to  flow  altogi'thcr,  or  may  continno  to 
escape  in  a  dimtnisbeJ  stream ;  tJiis  is  frequently  caused  by  tho 
wound  having  been  made  while  tho  nrm  was  in  tlie  supine  ponilJon, 
and  by  the  isulisequent  pronation  of  the  limb :  it  can  generally  be 
remedied  by  nliding  the  skin  over  the  veiu  until  llic  two  wound);  arc 
made  to  coincide.  In  extreme  cases  of  tliis  kind,  where  the  blood 
C!<ca{M>a  into  tJie  surrounding  cellular  tisKuc,  the  swelling  occurs  to 
which  tbo  tomi  thrombus  is  generally  applied.  Tliis,  if  of  consiiler- 
ablo  size,  may  be  laid  open  with  the  lanei-t,  though  more  generally 
it  needs  no  surgical  intcrforence,  but  may  bo  allowed  to  bocomo 
ttbsorljed.  Afler  tlie  operation,  tho  arm  sliould  bo  carried  for  a  da; 
or  two  in  a  sling. 

In  children,  and  occnsionally  in  others,  where  tho  Hubcuta: 
veins  at  tlje  bend  of  the  elbow  wo  ill-defined  or  of  small  sixe, 
section  is  practised  on  the  csfeniid  jugular.  For  this  a  pretty 
bulky  pad  of  lint  is  required ;  it  ithould  bo  apjtlied  over  tlic  veiu  in 
the  hollow  just  above  the  clavicle  and  cxtonial  to  the  stcmo-mastoid 
miist-lo,  and  sljoutd  bo  secured  by  a  bandage  jiftAsetl  over  it  a»i! 
fastened  in  the  opj>osite  axilla,  so  as  to  e\ercisu  firm  pres8Ui%  on 
tlie  vein.  Tlio  part  of  the  vessel  generally  chonen  for  tho  opera- 
tion is  whero  it  overlies  and  crosses  tho  sterno -mastoid ;  tho  vein 
being  fuced  with  the  thumb  of  the  let),  hand,  tho  incision  may  bo 
made  in  the  same  manner  as  in  bleeding  at  the  bond  of  tbo  elliow,  the 
line  of  tho  wound  being  ijiimiHoI  to  the  fibres  of  the  stvrno-mastoid 
muselo,  tu)  tM  to  secure  a  transverse  division  of  the  platysma  myoidOK. 
The  blood  can  be  directed  uito  a  bowl  by  moan.'*  of  a  piece  of  card- 
board folded  in  tho  form  of  a  gutter,  or  it  may  be  cullectod  tu  a 


>conM) 
ada^ 

vcn«4| 


J 


AKTERIOTOMY. 


35 


EI060  below  tho  n-oiin^.  To  arrest  tJio  biccdinr;,  u  pad 
ii^  over  Ui«  wotuid,  and  retwRcd  by  ^tripa  i<t'  jilaaier ; 
die  oimpresa  ovor  tiu>  clavidc  nuij  Hum  be  romovod.  Tlic  poMt- 
Iwlity  and  Uie  offw-t  of  tlw  piitranoe  of  air  into  lJi«  vein  <iuri!ig  ihe 
fbregmng  operation,  is  t>x>  wirll  kriuwt)  to  ri'iiuirc  more  tliati  a  [kuw- 
iaj;  caution,  to  ewe  ibat  the  pad  applied  to  tlie  v«iti  is  Ihoroughlj 
effectual  in  aiTfstiiig  ttic  droolatiou,  aiid  to  be  (.-aroful  not  to  ro- 
movc  tluK  [Kul  utttil  lifter  tlie  orifine  in  th»  vein  tia^  htxn  closed. 

The  Bapbena  vein  is  but  rarely  opoiiod  for  tlio  purposei  of 
mcMtctiuii,  in  tbiHoooDtry  at  letiait,  thou^li  tbcro  nro  many  ConU- 
nental  Sur^;cans  who  rati«idcr  it  a  mora  favourable  vceeel  for  tlio 
operation  thiui  the  veins  at  the  bend  of  the  elbow.  The  venous 
current  ia  in  tbis  case  nrrcstod  by  a  bandB}:o  around  tliu  limb,  jn«t 
abovu  UivMikltf;  tlic  vein  Ih  openetl  abovo  liiu  iiini^r  ntalleotua,  and 
the  bleeding  i&  eooouraged  by  imm^niiig  tho  foot  in  warm  water. 

Tb(!  outnnoouit  veins  of  the  s<-r«)tinii  )n»y  hn  advaiitageoualy 
opt^^  in  many  cases  of  aento  orcliitis,  tho  blooding  being  vii- 
eooragtxl  by  warm  fomentation*,  and  arrei>t<^l  when  neeeiwary  by 
expouug  tl»e  part  to  the  exlomal  air  or  by  tlie  application  of 
sold  wittrr.  For  tiic  various  miHhn[i«  and  ill  consttKjiifiice*  of 
waetection  and  their  appropriate  treatment,  tho  reader  is  re- 
ferred to  tlw  uwaya  on  Injcrirs  asd  Diseases  vr  thr  Veikr  akd 

AaTSBIEK. 

jirterioton^.  Tlio  only  v<'!twl  on  wliic-h  thi)t  Operation  if*  prnc- 
tawd  »  the  utmporal  artery  ilsolf,  or  one  of  its  principal  branclioa ; 
the  main  trunk  of  tho  w**^  may  lie  fonnd  erowing  the  zyfjoiiiH  at 
rigltl  angles  about  half  an  inch  in  front  of  tiie  pinna  of  the  ear,  and 
JDst  above  this  Hpot  tho  artery  divide:*  into  it«  anterior  and  ])os- 
berior  brancli.  A  small  bistoury  or  a  lancet,  a  narrow  bandage,  ft 
small  firm  comprww,  sponge  and  water,  and  a  bieiilinf;-h<iwl,  are 
mjuirud  for  Uii.i  ojMTation.  The  pasition  of  the  auterioi-  divieion  of 
dm  vessel  being  a«certaine<l,  or  that  of  tlie  main  tnmk  !tM>lf  if  tlie 
bnwr  bo  of  inHutlioienl  si/e,  ita  exact  situation  should  bo  marked, 
and  tlie  TCfflol  may  bo  at  tlie  same  timo  fixed  by  [ilucing  tlie  foro- 
fingir  or  tlmmb  upon  it,  juitt  WIoiv  the  [>oint  where  it  is  to  be 
afwofld.  Tho  blood  sliould  bo  drawn  from  a  transverse  woimd  in 
IIm  tomv^,  madv  by  ciillitij,'  down  upon  it  with  a  bistoury ;  or 
with  a  lancet,  by  tirst  puncturing  its  coats  and  tlien  laying  open 
its  eaoa]  nii>re  fnH'ly.  To  ftiTf.->t  the  Iia-niorrhage  the  urtery  may 
be  nMiipIe<4.^y  divided,  the  pait  sponged,  tho  compress  apjiUcd  to 
tbe  wound  and  wcc'ured  by  the  knotted  form  of  bandage  (fig.  4, 
p.  6).      This  should  bo  most  carefully  adjusted,  so  that  it  uuiy 


w 


MINOR  SUBGEBT. 


nmam  nndtstorbcd  for  four  or  five  diiys,  n-1u>ii  it  may  bo  rcmo 
■Mul  ttie  wound  corei'nl  with  a  strip  or  two  of  plaster. 


VACCIXATIOy. 


J 


In  adtlitjon  to  Oie  common  tanucttt  and  ivory  points,  tlicro  are 
gpccia]  insiniincnts  constructed  for  introducing  vaccine  lyiiiph.  Mr. 
Socluy  of  A}'li.>l>ury  luut  invcii(v<i  u  miiiiil  iirr<)wlic(ulfiha|>od  Iancc4t 
witli  a  groove  on  one  of  its  flat  sidee,  for  carrying  the  hcmpJi.  A 
small  nccdio,  gixiuvod  ii])  to  it!»  [mini,  is  iiImi  niiidn  ii^-  of  by  others. 
A  needle  with  an  aiTowhoad-shaped  point  ban  been  invented  \iy 
Hr.  SpraCtcy ;  this  luw  a  f^roow  on  orio  suHitco,  and  a  Bmall  reot- 
angiilar  slioitider  about  a  twelfth  of  an  inch  from  the  jwint.  Tim 
instrument  is  fixed  in  a  hyUuw  ivon,'  linniUc,  within  wliicli  cupillaiy 
tubes  O'lntaining  lymph  can  be  carried.  Dr.  Husband  unem  an 
instrument  invented  by  l>r.  ^Vcir,  having  a  flat  ivory  handle  fitted 
with  n  liuicet  at  one  end,  aitd  iit  the  otber  four  minute  ii«olle- 
pointft;  by  drawing  the«o  eliarply  over  tho  eurtace,  the  cQtJB  ia 
Blif;:litly  abradfiil ;  two  such  jwnitcliea  are  made,  and  over  tlicvv  tl» 
lymph  is  gently  rubbed.  These  scratcbce  sliould  bo  quite  an  indi 
•]>arl,  siiKM)  lymph  upjilied  in  this  maimer  gttncndly  produces  • 
group  of  confluent  piw^tules.  Vaccine  lymph  should  be  taken 
friiin  the  vesicle  not  bil>>r  thiiii  the  t-igbtti  diiy  iilh-r  inoculation. 
When  fresh  virus  is  to  be  H|iplied  directly  from  a  mature  vesicle, 
tho  iintiont's  left  ann  ttbonld  be  grafixxl  in  tln)  «]MT«t(ir's  Uft  hand, 
just  above  the  insertion  of  the  deltoid  muscle,  and  tlie  skin  on  tiie 
outer  aspect  of  the  part  put  on  tho  ittrettJi.  'rb<t  luneot,  Iwiiig  pre- 
viously armed  with  tlio  vaooine  lymph,  is  held  with  the  flat  of  its 
blade  turned  towards  tJio  siirtW-u,  an<l  is  mado  to  [H^rfurate  tho 
cuticle  very  obliquely,  fio  that  its  point  may  separate  tho  cuticle 
from  tho  cutis  to  a  Hmall  c\1<^'iit ;  this  may  bo  dfoctcd  without 
causing  any  hictnoiTliiigo,  or  iit  uiOEit,  not  more  tliiu)  a  dnij)  of 
bloo<l  need  escape.  As  it  is  withdrawn,  the  lancet  inny  be  prvisved 
against  the  raw  surfaco  of  tho  initis,  or  tho  tlmnd)  of  tho  lefl  hand 
may  be  used  to  press  the  edges  of  tho  puncture  together,  so  as  to 
wij«  the  vim«  oft'  the  point;  two  or  three  Mieli  punctures  slionht 
be  made,  each  about  an  inch  distant  from  the  other,  and  any 
blooil  or  .lerurii  cxtidlug  from  tlicm  should  bo  altgw.xl  to  dry  on 
the  part. 

Ivori-  jioiiite  or  slips  of  quill  may  bo  usctl  to  dip  in  the  ^-ir 
and  insert  into  puncture.*,  iiislead  of  employing  the  lanoct  for 
pur|Mwe.      If  dry  lymph  upon  points  be  imed,   it   mtist   iiret 


VACCINATION. 


ar 


over  tho  (team  of  hot  water,  or  it  vaay  l)o  moii^tcncd  with 
ttvTD  water  before  its  introduction ;  Ivingili  between  glatu  ^liiica 
ibmlil  Im  moisttniixl  hikI  scraped  off  tJio  gloss  with  tlio  Isnntt-point, 
iml  tltOH  ajiplictL  A  vt-ry  cHicient  txit  nv>n  {itiintiil  m«tJi()d  of 
nccitution  is  tbo  plan  of  scratcliing  oW  tlie  cuticle  witli  tho  lancets 
point,  <u)tl  n]i|tlying  tlvA  viru.<  lu  tlio  iIiwiikIihI  oiiit.'*. 

Dr.  William  Hosband.  of  E<Iinburyh,*  has  introduced  and  csta- 
Uiabed  a  method  h^-  wliioh  vnccino  lympli  may  Ihj  prewsrvcd  for 
eonaideraUe  periods  of  time,  amiifluoi)c«d  by  changex  of  climate. 
This  lie  cGTectA  by  hi^nvtically  scaling  it  within  capillary  gla«3 
tabiM;  ho  rroommends  for  this  purpose  Hieli  as  are  &om  two  to 
fibur  ineh«  in  lcn|>;tli,  and  about  -j'^  tli  of  an  ini^h  in  diiimctcr,  their 
walkbcin;^  rir^  ***^'^  '""^  '"  ihicknefts,  llie  following  are  the 
dhvctioiu  given  hy  Dr.  tfueband  for  ghargtnj;  IIk^c  tubos. 

Tho  vesiclea  having  been  opened  with  tli«  Innoet  in  the  usnal 
way,  tha  tube,  held  horizontslly,  is  eliargcd  hy  applying  on«  end  of 
ft  (tho  stnught  «ad  if  they  bo  not  l>otlt  straight,  not  lliut  wliioh 
taper*  to  a  point)  to  llic  exuding  l^niiph,  wliic-fa  enters  inunodiatdy. 
As  mnch  IvTnph  is  allowed  in  <>m*>r  ns  will  fill  from  nimiit  one- 
•ewntti  to  one-half  tin;  Icnjjth  of  ibo  tube.  A»  a  general  ndc,  each 
tube  sboold  not  be  charged  witli  more  than  will  suflRec  for  one 
twcanalioii.  U  may  l»  K-nlod  in  one  or  other  of  tho  following 
wayiL  In  the  first,  Hk  lymph  U  uiiulo  to  gravitate  towards  tlie  middle, 
iy  hoUiog  tlio  tube  vertically,  and  if  necc»ury  giving  it  a  Sow 
aUgbt  Bhocks  by  Atrihing  llie  wrist  on  llio  arm  or  table.  The  end 
by  whirh  tJio  lymph  entered  may  then  be  sealixl,  by  applying  it  to 
the  mir&oe  of  the  lliuno  of  a  candlo.  Tin'  other  end  should  lintt  be 
phingcd  ibont  half  an  inch  into  the  flame,  and  as  quickly  with- 
inwn  till  it  loueJies  tho  mirfiLCJ),  wh<;re  it  nbould  b<;  hold  till  it 
ndts  over  and  is  sealed.  This  precaution,  of  plunging  the  Inbo 
into  the  flame  Wfon!  *enh'iig  it,  is  useful,  in  nrdor  ('>  ox|m>1  a.  portion 
Dftha  air.  Or  tlw  tube  may  be  sealed  thus:  tholj-mph  kiviiig  been 
mtroduc«iI  at  om;  end  of  tho  tnbo,  is  made  to  pass  towardu  the  oppo- 
■to  hy  exhansting  the  air  at  that  end  over  the  flame  of  a  spirit- 
lantp;  this  end  of  the  tube  is  then  seslixl.  On  cooling,  tlio  1>-mph 
iriQ  pan  towards  tho  middle  of  tlie  tube ;  tlw  oriOeo  by  whieh  tho 
fjnnpb  entered  is  then  sealed,  as  in  tho  tint  mclliod.  Xot  more 
^m  a  minute  or  two  sltould  clajwe  between  cliarging  Uie  tube  with 


•  ExfctititM  of  a   Method  oj  Ftfsrtvxn^  Vacnnt  Lymph  fluid  and  aetke: 
vitk  ttimufor  Ike  mor4  f^taent  I'trfomutnce  of  Public  Vacciaalioa.    Loudon. 


m 


MINOB  SURGEUY. 


lym^  Hid  Molhlg  it  up,  or  Hw  U-niph  will  ci>non<tft  nt  tlic  orifioc, 
KDcl  cannot  tJien  bo  forcwl  into  the  cantro  of  the  tube. 

Ill  oixUt  Ui  obtiitn  tlin  Ijiiijili  fVmii  n  IhIk;  tiir  the  prirpom;  of 
Tneoination,  the  seaJod  ends  are  to  bo  broken  oft',  and  the  fluid  con- 
tents blown  out  gently  uu  thu  point  of  iho  biiec-t  or  vacranfitiiig 
iiic>triiinent. 

Tlic  rc»;ilt  of  primaiy  suwi'-ssfiil  vacciniitioii  may  h«  Ktatcd  to 
he  as  follows :"  tho  punoturo  may  be  felt  sliglitJy  elevated  oh  tlie 
second  day;  on  the  thiril  it  w  siirrtnuided  by  ii  ^li{;ht  haloofrod- 
ne«ui ;  by  ihe  fifth  a  diiitinot  \'esiele  will  be  formed,  having  a  sHghtlf 
elevated  margin  ami  a  dc;pn'w<cd  ecntre;  on  iho  vif^htli  day  tho 
w-*i«!o  should  liave  readied  ita  perfect  condition,  when  it  is  pearl* 
coloured,  and  distcndwl  with  clear  lymph,  its  margin  being  turgid, 
firm,  and  sliiuing.  From  this  |»eriod  iJio  redness  around  inerenHti 
in  ostfut  and  intensity  until  tho  tt-nth  day,  when  thorc  i«  often  wcll- 
murkitl  swelling,  and  indtinition  of  ihe  snbjaeent  cellular  liiwuc. 
On  the  eleventh  day  tho  areola  begins  to  eubsitk',  lca%'ing  as  it 
ftdcA  two  or  tJiree  (Toucontric  ring^  of  ralness;  tho  vesiole  Ikcgius 
to  dry  up,  assuming  a  brownish  colour ;  the  remaining  lymph  be- 
eonicit  opa[]uo,  and  grikdually  o<»itTcte«,  Ibrintng  by  tlie  tViurtooiitli 
or  fifteantJi  day  a  dry  reddish-brown  scab ;  tliis  oonti-acts,  driea, 
blackens,  imd  fiually  fulls  otC  nbnut  the  twenty-first,  day.  The 
resulting  cicatrix  is  pcmiancui,  slightly  dcpreesed,  dottod  or  m^j 
nutcly  pittL^d.  ^M 

^Vhen  persons  who  have  once  been  succossfully  vacHnated  are 
some  yearn  afU-rwjirils  re-vacciiiiitcd  wilh  vflWltive  lymj)h,  vcaiclcs 
oeeaaionally  result,  which  in  their  appearance  and  in  the  course 
tlicy  run  canimt  be  di"tingiiishcd  from  thow  produ<-cd  by  primary 
vaccination.  Far  more  genei-ally  tlieae  rmulls  are  \ai'iously  modi- 
fied ;  cither  no  true  vesicle  forms,  or  it  attains  its  maturity  and 
its  course  with  gieater  rapidity  thim  tho  regidar  vesiclo, 
areola;  also  tend  to  diftu»e  themselves  more  widt.-ly  and  lena 
larly  than  in  primary  vaceinulion,  and  the  liical  changes  are  aecoi 
pauicd  by  much  itching,  oficn  by  some  irritation  of  the  axilla 
glands,  and  in  some  cases  by  considerable  febrile  diatui'bancw  ituj 
voning  on  tho  fourth  or  fifth  day. 


*  This  dpsoripiioii  is  tubcii  from  the  aopount  given  in  the  ItLstructioi 
to  pubUc  vaccinators  by  order  of  Uie  Privy  Council. 


[        89         } 


CAirsTica. 


The  various  substances  used 


Hinm  «f  till)  Ixxlv  l>v 


(lestroyiog  morbiti  growtlt*  or 
clirmical  agrncy  are  Kviicrally  termed 


■a. 

Bid' 


ttu 


cauteries.  Ttiey  will  brit-tly  lie  notii-eii  in  imier,  aoconl- 
inf;  la  tliu  cicgrco  in  wliivh  thcr  oxcruitfo  ttioir  diitorganising  e3*ecta. 
And,  fintly,  tbme  sulutanoea  wliioti  oiUifr  fmni  iticir  wiiiit  »r caus- 
tic povfcr  or  fnim  tlio  tanlii)ci>a  of  tlicur  acti<m  are  generally  applied 
only  to  raw  Rurfaciea,  tbough  oocasuonnlly  ta  rniic'iu.t  niuniliranci*. 
Thwe  are  sucii  as  tannic  acid,  siilphato  of  copper,  nitrate  of  silver, 
nlpliato  ttf  xiiic,  aoid  nttratA  of  nw-n-ury,  HrM-nicul  ]«istv,  tlio  clilor- 
Ict  of  antimouy  and  of  itinc. 

TiumK  acui,  iw  a  t-aiiiilii'  a-^nil,  is  but  rarely  iiswl  in  wir^jcrv  ; 
applied  in  tlw  form  of  pow<ier  to  raw  surfaces,  il  produces  a  tliiii 
layrr  of  dt^orgiuiiMid  ti-f-mi.^ 

Salphate  of  etqtper  exercises  snffieient  eaiBtic  aoti*'ity  to  he  em- 
\oyvd  {»r  tlic  dcstrvclioii  of  w;irl.''  mid  condyloninta,  of  fungous  and 
ihealt)iy  graooiation!!,  or  the  scoreting  surfaces  of  cya,i&.     To  pro- 
any  «>nsi<lerablv  effoct,  the  solid  salt  reiiuires  to  bo  rubbed 
n'  tirmly  over  tbe  pai-l  lo  bo  cantoris,  tlio  isurfaoo  boiiig  pro- 
TioDslv  moistened  if  drv. 

jVrfrafi*  Of  tUrer,  a.<t  a  eau.itie,  i«  applied  in  a  soli<l  fonn  or  in  r 
ntnraiod  tiotution ;  it  is  ehiofly  of  uso  in  checking  exuberant  granu- 
(OTO,  in  ftestroying  the  HnrGioos  *if  nnlicaltliy  ulcors  or  docrwting 
Bts,  in  stimulating  flaj^ng  sores,  in  producing  a  snjwrficial 
iigh  on  tJu!  MirfiKW  of  jxiisnnwl  wound*,  tliorcby  iliminisliirig 
absorbent  power,  or  for  destroying  warts  and  small  (-ondylo- 
growtbx.  In  the  solid  form  thin  salt  is  applied  eitbur  by 
■hlly  brushing  it  over  the  part,  jii-oilneing  a  thin  scale  of  dead 
,  of  a  bluisli-whito  colour,  turning  to  black;  or  by  nibbing  it 
fituily  again  and  ngain  over  the  siirfiic*^,  «>  as  tborougbly  to  destroy 
the  part  to  a  moro  considerable  deptli.  Dr»-  surfiiccs  should  (« 
ightly  tn'it«tvni.tl,  and  very  moiMt  or  snj'puniting  aiirfnces  require 
be  partially  dried  before  this  caustic  is  used.  In  solution  nitrate 
ntrer  is  apptinl  wilh^  vwndVhair  linL-<li  or  a  small  ])i4;ce  of 
■ponge,  the  caustic  effect  being  taj-  loss  marked  than  when  used  in 
tlw  w>lid  form.  Thotigli  possessing  but  liniitod  |>owcr  ouni[>arcd 
witb  many  other  luWAnoGa,  yet  lunar  caustic  lias  tlie  advantnges  of 
■eting  with  great  rapidity,  of  causing  but  little  ]iain,  and  of  i>rodu<:- 
in^  but  vliglii  irritation  or  <listnrlinnce  in  the  Hurrouiuling  tisanes. 

Stdphatf  vfrine,  Tbo  introduction  of  this  substance  as  a  eauHtic 
if  due  to  Dr.  Simpson  of  E<linburgfa,  who  rucommvnds  its  use  either 


40 


MIXOR  StTRGERY. 


in  tho  fiimi  of  finolj-  tiri'ifjatod  jkiwiIit,  na  a  paste  oornposcd  <.,  .-..d 
dracliui  of  glycerine  nibbed  up  with  an  ounce  of  tlio  i>ov.-<ler,  or  ax 
an  ointnicnt  inndo  in  tho  projiortion  of  two  draclmi*  4if  lard  u  an 
ounce  of  iJio  dried  Hid|>hate. 

It  is  ainilicablo  to  iiIccnitionH  of  tlio  os  wltri,  rodent  and  lupoa 
Boros,  or  indeed  to  almost  any  form  of  obstinate  or  invctcrati 
idccration.  For  destroying  wart*  and  condylomata,  jind  thv  va» 
culor  growtlm  uliout  the  fi>niidi)  urethra,  it  is  said  to  be  most 
ctous.  Dr.  Simpson  states  tJiat  used  in  the  fonn  of  (Kiwder,  pg 
or  ointment  to  an  open  or  ulwrahid  surfaee,  it  qiiiekly  produces  a 
slough  eon-esponding  in  depth  fo  Uie  tldckucss  of  the  su))eriiu posed 
iayiT  of  oaurtie.  The  sliingh  is  of  «  white  colour,  and  usually  »epa^ 
rates  about  the  fifth  day,  leaving  behind  it  (if  the  whol«  morbid 
tissue  bo  removed)  a  red  granulating,  li«d(hy,  and  rapidly  eieatrift-^^ 
ing  woun<l.  The  disorganised  tissues  show  uo  tendency  to  doconfe^^ 
pose,  but  arc  firm  and  inodorous.  Tliis  caiiRtic  will  only  act  on~ 
ulcerated  or  abraded  surtiices ;  where  llie  epithelium  tlKTclbro  i* 
mttro,  the  part  must  be  prepared  for  its  application  by  tlic  pnyvioos 
use  of  die  nitric  acid  or  tinmc  other  of  tlie  stronger  eaustica.  The 
pBtu  produced  by  tho  sidphato  of  zinc  is  said  to  bo  less  enduring 
than  that  eauKcd  by  caustics  ginerally,  tJie  local  infUmmation  is 
wry  slight,  and  the  eschar  has  been  observed  to  separate  in  most 
eases  about  tin-  filth  or  sixth  day.  Among  other  ailvanlages  claimed 
for  this  substance  by  its  distinguished  invejitor,  arc  tlio  faoili^  with 
which  it  in  ajiplied,  the  rapidity  of  its  action,  and  the  et-rtainty  with 
which  its  etteots  can  be  looaliaed,  since  it  shows  no  ton<lency  to 
deli(|uesce ;  nor  does  its  disorganising  jtower  exert  any  infliuiuco 
over  the  surrounding  surface,  proiHdetl  tlie  epithelial  covering  is 
entire.  i 

Aeid  nitrate  of  mttvury  \%  a  fluid  form  of  cauatJo,  owing  iO^| 
activity  1«  tho  nitric  acid  in  its  composition ;  tJiougli  less  power- 
(idly  cansti<t  than  that  acid,  it  \*  better  littcd  for  applieittion  to 
certain  parts  since  it  does  not  fume  when  exposed  to  the  air.  It 
is  much  ill  use  for  the  dentniotion  of  lupous  and  nMlmt  ulcers,  and 
for  tlie  tiirmcr  of  these  it  is  a  most  convenient  an<l  efficacious  appli-_ 
cation.  The  solution  is  best  applied  with  a  camcl's-hair  brush,  th 
snriaco  of  tJie  part  being  previously  cli-answl  and  dried  :  it  i»  nw« 
sarj*  to  limit  enicfiiily  the  appHcation  to  tho  disoascd  part,  sine 
the  epithelial  covering  of  tJie  mucniia  or  outnneoua  Hurtiicc  affor 
an  insufficient  protection  against  tho  action  of  this  caustic.  Ii  maj 
be  well  to  mention  that  cases  of  poisoning  are  recorded  from 
absor]>tion  of  this  substanco  applied  as  a  caiistio. 


OAtrsucs. 


41 


E parte.  The  only  active  iugTedi«nt  of  Uiis  preparation 
icid ;  t)ii»  in  diltitvd  willi  variotis  inert  8ul>¥tim(;<»i  (u  llio 
reqiiiied  extent.  The  arsenical  |>aste  most  in  nso  in  this  countrjr 
Btliat  first  employod  by  Boron  Dupuytjon;  it  consist*  of  n  ntixtuni 
€f  calomel  and  wtiite  araenio,  in  tbe  proportion  of  from  six  to  ton 
parts,  by  weight,  of  the  latter  to  a  hundnxl  of  tho  former.  This 
bong  muli>  into  a  ])a»ln  nitli  mucilage  or  a  llttJo  water  m.\v  be  ap- 
plied to  tbo  surface  of  ihc  )>art6  cither  directly  or  spread  on  lint  or 
a  piece  of  b1oltiiig-j>aper.  The  efficacy  of  Uii.*  cuiivtii;  is  imdoubtod 
in  tbe  treatment  of  Inpons,  rodent,  and  other  intractable  ulcers ; 
httt  there  exiata  the  obvioua  objection  to  its  um>,  Uiat  it  cannot  bo 
employed  on  a  siir&oe  of  any  oonsiderablo  extent,  on  account  of  the 
dagger  of  ilK  nt»i>r|iti<in  intn  the  nyMem.  Indeed  n  rwe  U  related 
in  dw  practice  of  H.  Itoox  where  tho  ap])lieation  during  a  aingla 
night  of  a  paste,  containinf;  four  per  cent  of  arvonic,  to  a  Aiiriace  of 
little  more  tlian  an  inch  in  diameter  proved  &taL  Considerable 
and  soa)climt-s  eiuliiring  juiin  tbllows  it«  use,  accompimicd  with  no 
little  irritation  and  inflammation  of  the  smrounding  |iart»,  and  the 
fwcfaar  is  slow  to  sojuirate^  Tho  arsenical  paste  is  inert  <m  Burfiuea 
protected  by  epitlieUimi. 

TerehloritU  of  antimony^  or  butter  of  antimony  as  it  is  usually 
termed,  h  a  <inb«>tanee  pos»ef»ing  giowertul  cniutlic  pro(>ertic-'(,  though 
bat  little  iLiod  in  this  country'  at  tlic  present  day. 

»i  Batter  of  antimony  is  st.-iti'd  hy  PtTi^ini  to  consi.-tt  of  a  volution 
of  the  tcrchloridc  of  the  salt  in  liydrochlorio  acid ;  it  is  used  for 
the  deMruction  of  syphilitio  wart«  or  eoTidylomntous  pxurths,  and 
b  recommended  by  Continental  Sorgeons  for  application  to  poisoned 
woands  and  the  bites  of  ral)id  animal*^  The  solution  ni;iy  W  ap- 
plied vrilli  a  camelVbair  brush  until  a  whitish  slough  i%  produced, 
when  tlw!  SHriiicc  of  the  jiart  should  bo  thorougldy  wttshtti  to  re- 
mova  any  remaining  caustic 

(^Imvir.  ^  zme  Ibrms  tJic  acbS-o  ingredient  of  many  of  the  most 
popnlar  and  eSectire  eaoMica ;  mixed  witli  \'ariable  proportions  of 
floor  it  constitutes  Canijuoin's  paste.  It  enters  into  the  fbrmntioit  of 
lAidolphi's  caustie,  combinixl  vritli  equal  jmrts  of  the  ehlorides  of 
ndiiDony,  bromine,  and  gold.  More  recently  otlier  adventurers 
hate  Buxle  n*o  of  tlie  caustic  propertieii  of  this  salt,  and  by  mixing 
it  with  preteuled  remedies  for  cancer  have  endeavoured  to  impose 
oo  IIm  public,  and  conceal  ttie  complete  usclosmees  of  their  suppo- 
■thloas  specifics. 

Cblorido  of  zinc  may  he  tued  in  tho  form  of  solution  by  mixing 
!  port  of  Sir  W.  Burnett's  solution  with  seven  parts  of  wator,  or 


42 


MINOR  SURGERY. 


as  ft  paste  ill  the  proportiiin  of  oii(>  piirt  of  Uie  dry  oJiIovIdft  te'two,' 

It  is  employed  to" 


th 


rla  of  flour  or  plaster  of  I'; 


I 


our  pai'la  ot  flour  or  plaster  ol  l  ans. 
destroy  tilcerateil  surfticiw,  or  to  rmnovo  solid  gnintlis  of  iiirioiLt 
kinda :  it  should  not  be  applied  to  any  but  aii  ulcerated,  abraded,  or 
deintdod  surfaM,  as  its  nction  ujnm  th"  jiurt*  protectt'<l  by  their 
«pillielinl  iwvfiring  is  both  alow  and  extivmely  paiiifuL     Tho  solo-.l 
tion  maybe  Hpplic-d  on  pieces  ofHiil  i-ut  ratlurr  stnjtiler  in  vxtonti 
than  tlie  intended  slough.     Tlie  paste  may  be  spread  on  lint  in  a 
layer  varjHng  in  tliickncss  with  tlio  depth  of  flio  jiort  tn  be  do- 
Btroyeil ;    in  mixing  the  )«i.it<>,  the  oliloriJe  will  generally  absorb 
fiuificicnt  mointuro  from  tho  atmosphere  to  n^ndcr  the  iid<Iition  ofj 
spirit  Miini'^wsarv.     Tliis  oAUHtio  takes  some  hours  to  produce  it 
ftiU  cflect ;  the  pain  it  produeee  in  eonKidcnible,  but  not  »o  acute  otj 
couluring  a»  that  causcil  by  arsenical  ]iaste. 

Tlie  slough  when  fbrmod  is  whitish,  dry.  and  inodorous :  thcr 
18  little  inttununiition  i>xi-il«d  in  surrounding  ti.-wwos ;  and  (U'eoinpch 
sition  in  the  woujid,  ifit  previously  existed,  is  at  onco  arrested. ^^ 
TSar  does  the  slough  itself  show  any  tcndfliiey  to  putrcfv-  A  ood-^| 
BJderable  advantage  attached  to  the  use  of  this  causlic  is  the  very  ' 
eontriiet.ile  mituro  of  the  wound  ri'sulting  from  its  appliealioii,  u, 
coutractiliiy  whieh  becomwi  evident  some  days  oven  before  the  sepa- 
ration of  the  slough. 

In  attacking  solid  p-owths  witJi  the  chloride,  to  save  time 
the  suhsei|iient  progress  of  the  case,  it  in  usual  after  the  first  ap]>li- 
oation,  and  so  soon  an  the  slough  is  fnlly  forineil,  to  make  incisionn' 
through  the  dead  parts:  the*e  being  stuffed  with  slu'eds  of  lint 
dipped  in  tlie  caustic  solution,  or  ftmenml  with  the  paste,  may  fi-om 
time  to  time  be  dec|)cnod  until  tile  whole  substance  of  the  growth  ifl 
destroyed. 

Nitric,  hydrocldoric,  and  sulphuric  aoid,  in  a  concentmt* 
fbnn,  nro  tho  most  |Miwcrfn!  of  the  potwitJal  eautoriw;  tlwir  in-' 
fluenoe  extends  rapidly  tJirough  the  common   integument  of  thsjj 
body  to  tlie  deciwr  textures ;  they  wiU  act  upon  any  part  of 
surface  to  which  they  may  l>e  appiie<I.      In  tlie  li(|uid  form 
causti<!  ia  so  suitable  as  one  or  other  of  the  above  nanioii  for  do 
stroylug  the  auri«oe  of  sloughing  sorea,  or  for  the  local  treatnion^ 
of  hospital  gangrene^     Their  effect  on  such  a  surface  is  decide 
rapid,  and,  in  the  case  of  the  mono  I  lyd  rated  niti'Ie  add,  far  h 


*  This  PiiUBtin.  eilhf-r  Jii  soliilkm  or  in  its  soliil  fonna,mny  be  ailrnn- 
tftgwntl}'  niixt^d  nith  tlic  h,riirr>c)iloi'nti!  of  luorpliia,  ivhicli  in  a  meonuv, 
diiQtaUlies  the  pain  Rttoudiiig  lUc  applioatioD. 


CAUSTICS. 


43 


^ 


^HETthnn  is  generally  siijiposof! :  Iho  resiiltlnp;  csolmr  «q>ara(P8 
|Rlv,  and  UiD  surrotuiding  itifliunnuitiou  is  not  excessive.  In 
ipfdyiit};  tliu  iMrtiiig  iici<l  to  a  mm,  i\u>  sutUvo  of  tito  part  uhould 
he  carefully  driod,  aiid  tln>  skin  Jii  llic  noighboiirhooij  [iroioctnl  by 
being  ittncarcil  with  uil  or  niinjilt;  wraU; ;  uiid  a  glass  bnisfa,  or  a 
]neee  of  ootton-wool  or  lint  tiod  on  tho  end  of  a  pieoe  of  wood,  may 
be  nwd  to  bring  (he  add  in  oonlnot  with  tho  Mirtiieo  of  the  sort-. 

For  apjilieation  io  the  sound  skin,  Uio  ooncentrateil  «i>i(bt  aro 
tonMwliAt  too  difTnM}  in  their  action  :  with  ii  view  to  obviAto  tin's 
teodeney,  they  are  mixed  with  >'arious  inert  sub-ManoeH,  and  niuile 
into  the  consii^tmoo  of X paste;  tliuH  sulplioric  arid  i«  mixed  with 
jiowdered  )nit|>hur,  saffron,  or  Hawdust,  and  in  thia  form  it  iti  fur 
mora  ooavenirnt  :m<I  manageable  for  tho  purpose  nbovo  mentioned. 
The  hm  ofHiuilii^t  for  thin  puqioAC  originated  with  )Ir.  8yme,  who 
mbo  devised  a  most  ingiiiiouH  ]>lii»  for  protoetin"  the  surrounding 
tttrisoe,  a  metlMxl  that  can  be  adopted  witli  great  advantage  when- 
ever eatutie  ia  applied  to  the  tmbrokcn  skin. 

)Ir.  8yi»c  gives  the  following  aceount  of  tlie  method  in  <|neK- 
tioti :  "  A  solution  of  rrntta-pordia  in  chloroform  is  applied  to  the 
tkiti  for  jHimo  tlistniKHt  aroimd  the  parts  to  1*  attacked ;  1ht-n  » 
thick  piceo  of  tlie  same  material,  with  an  apertnro  cm  hi  it  Uie  ro- 
qaisitc  siz<-,  ami  wifieuwl  by  exposiirti  to  heat,  in  preraetl  firmly  so 
as  to  adhere  to  die  eurfaoo  time  prepared ;  a  thin  pieee  is  next 
glued  around  tlie  edge  of  the  opening,  mo  that  when  Kup[>arted  by  a 
Muffing  of  tint  it  may  form  a  wall  enclosing  the  diseased  part. 
Coneentratrd  i^tilpliune  add,  with  iilxnit  an  etjual  weight  of  xaw- 
irtirred  into  it,  until  the  mixture  aagrnnen  a  homogeneous  con- 
eqtud  to  that  of  tliin  porri^fge,  l»  la»tly  applied,  in  quantity 
ioned  to  the  extent  of  tliieknoss  coneented." 

In  the  rauTN;  of  ton  or  tn'olve  houra  a  slough  will  bavc  formed, 
iling  tlie  '•appearanee  of  strongly  eompressed  tow." 

For  destroying  tho  in  teguments,  or  denu<llng  tho  surlaoo  pro- 
fmntarj  io  the  nse  of  some  of  the  lew  aetii-e  fonns  of  eaustie,  Kir. 
Byrne's  mixture  of  Mwdust  and  acid  is  specially  adapted,  or  the 
caastic  putoah  may  be  i»n|)loy<^l  in  the  nauitf  way.  Oaiinlie  polasli, 
bowewer,  haa  the  disadvantage  of  diffusing  itj^clf  rapidly  among 
wuTouuding  parte ;  for  thw  reaifon,  with  a  view  to  eonJine  it»  action, 
it  'f  griirraJly  mixed  with  qnick-Iime  in  the  proportion  of  five  of  tho 
former  to  six  of  the  latter,  forming  the  Viemia  pa,"!*!,  a  more  inan- 
agtable  and  more  active  preparation  than  the  pure  potash. 

Caul^rualiem  en  jHchi^if.  In  I8'i9  M.  Mui-ionneuve  drew  tbo 
Bttwitififi  of  tlie  Acadunie  dos  Sciences  to  a  method  of  applying 


44 


METOR  SURGERY. 


oai»tic  for  tlio  deatniction  or  enncleaUon  of  solid  growths,  and  gave 
to  his  method  the  tmino  at  thu  hiradiiig  of  Uii»  [Mnif^nipli.  Ttie 
cauatic  lio  ein|)]oya  for  UiIh  |>urpa8o  is  a  mixture  of  one  part  of 
cliloriilo  of  zinc  and  throe  of  Hour,  conihiiii.'^d  »o  a«  to  form  u  thivlc 
ji»aLi>.  Thin  being  spread  mit  into  a  Hal  oako,  in  cnl  into  narrovr 
ianoct-shnpod  stri])s,  or  wedjB;o-s]ia)icd  picL-cs,  of  a  suitidilo  sizo; 
l\uiM  ax*i  »iiliHCi'{uoiitly  dri(><l  initil  they  aei|uirn  Mit1ici«nt  conaistenc6 
to  be  available  for  tho  purpose  about  to  be  described. 

One  pliui  otuttuckiiifr  n  hoIIiI  growth  with  tliiA  form  of  canstia 
18  the  following :  tlie  bn^  of  the  tumour  is  surrounded  at  short 
iiitervalH  by  radiating  puncture*,  convurjjing  toward*  iJie  iMtntre  and 
deepest  part  of  the  growth,  and  oomplctely  undermiauig  tho  di»- 
cofuid  tissues;  those  p\UK'tiirc«  aro  inadc  witJi  a  ih>ublo-i;dt;»?i|  »«il- 
pel,  tho  riat  of  the  blade  being  turned  towanls  the  surface  of  the 
stu'rounding  skin,  and  uaeh  should  bv  of  etifliciont  lixc  to  admit  of 
tlie  introduction  of  one  of  tlie  caiittic  arrows  previouflly  prepared ; 
as  each  punetiu'c  iH  made,  the  caustic  should  Im  at  once  phiiigod 
into  the  track  of  tlie  knife,  and  allowed  to  remain.  In  a  period  | 
raryin;!  from  t<>n  to  twenty  days,  the  whole  growth  wiU  generally  | 
separatt),  leaving  a  olenn  gruntilatiii^  wound. 

In  cases  whore  the  growth   cannot   be  circumscribed  in  thaj 
manner  alKwo  nientiniietl,  but  can  ntdv  ho  approached  from   tlie 
surface,  M.  Maisoiineme  jilunges  tho  "  fl^ohcs"  in  parallel  lines] 
into  all  ]>arta  of  the  substance  of  the  tumour;  or  agniii,  when  it  isl 
important  to  preserve  the  skin  over  the  site  of  a  tumour,  one  ori 
more  of  tho  "fleche.s"  may  be  iiitnxlueed  thnnigh  a  lateral  puno- 
tm-e  quite  into  the  centre  of  tlie  growth,  the  resulting  slough  being 
allowed  to  escape  tlu-ough  the  aperture  of  puncture. 

As  a  more  convenient  and  more  ready  form  of  caustic,  Mr. 
Paget  has  recently  made  use  of  sraaJl  lancct-sha])ed  slips  of  woo^H 
di]i|Hxl  in  fused  chloride  of  zinc;  those  are  more  n«»dily  jircpared, 
and  far  more  easily  introdueeil,  than  the  fl^ehos  i-ccommonded  by 
M.  Maisonneuva.  It  is  noodless  to  do  more  than  to  remark  tliat 
this  plan  of  nimoving  tumours  by  enucleation,  which  can  oidy  bo 
roquirod  in  oKcejttional  cases,  is  an  exceedingly  jiaiuful  jtroceea. 

'J'lf  wlual  cauttry  hait  alroiidy  lieen  alluded  to  in  tlie  conioder^ 
tion  of  counter-irritants :  in  its  ordinary  form  it  is  but  rarely  nsed 
for  olhcr  timn  its  counter-irritant  or  ntyptic  ellwtt;  l)ut  as  the 
galvanig  cautery,  tliere  are  manj'  and  various  purposes  for  wluoh  it 
may  bo  advantageously  employed. 

The  (falvanie  caatert/.  This  <;ountry  is  indebted  to  Mr.  Marshall 
for  tho  apphcutiou  of  Uiis  most  commodious  and  ingunious  form  of 


d 


GALVANIC  CAUTERY. 


4& 


DO 

9t 


more  recently  Dr.  MifMcMciriiff,  of  Bnwiltui,  Iijis  Rtfiaod, 

u  it  were  pcrfbetcd,  tJie  mechanical  appliances  of  the  procen ; 

tnun<^ra]>h  on  tlio  «ul>j<>cl  the  reader  is  roftired  for  a  Jult 

t  of  t.lie  mechanism  and  surgery  of  tlie  galvanic  Oftutory.* 

cjiotwry  in  iiwerfiim  |«Mt*ciw^  its  cblcfrapcriority  over  the  nroro 
form  of  actual  cautery,  in  tlie  easily  regulated  intenai^  and 
tJ>r  durutiiHi  of  the  ti!ni[)crii(nnj  cmjJoyed ;  in  the  faciU^  with 
vhivji  its  mechanical  form  can  he  ftuitcd  to  the  externa]  circnm- 
tUnuM  and  otitor  rwjnin-inenU  of  rarious  pEirt«  of  the  body;  in  the 
iiiteuRity  of  Uio  heat  jirodoeed  by  tJie  galvanic  etirr«it,  the  rttiii<lity 
with  wlik'b  thi-t  i*  comnumiciitcd  to  th<?  metal  employed  as  a  caa- 
tery,  and  the  possibility  of  applying  tlie  lieut  Rub.'«|ue:it  to  tho  in- 
trodoctiou  and  proper  a^ju^niont  of  tho  iiistrumenl  to  tho  parts  to 
be  cauterised.  It  cannot  but  ho  ivgMHted  tliiit  tlit)  i.-xjK^n.'ie  of  the 
Dcccesary  appliancfv,  and  the  cumbersome  nature  of  the  apjuiratus, 
totit!  to  i-online  the  use  of  tliiti  fi^rm  of  eAiitery  to  the  exigencies  of 
boepital  practice,  Bv»idc«  tho  more  ob\-ious  and  general  tue  of 
lift  renmly  in  the  treatment  of  Mtm.teH  and  fi»tn1iit  of  »lino«t  every 
kind,  and  aa  a  counter-irritant  or  st\*ptic,  Dr.  Middeldorpft'  extola 
it*  efflcaej-  in  the  tnaitnii>nl  of  ittricturo  of  the  iiretlira;  for  re- 
moval of  polj-pi,  amputation  of  the  penis  and  uvula,  removal  of 
Ihr  trni^ilf,  imd  even  nujicgi'Hf!*  its  ajipIicHtion  for  tho  amjiutatiou 
of  entire  limbs;  indeed  he  allots  to  the  galvanic  oauter*-  a  more 
extended  i>pbcro  of  action  tluui  any  hut  its  most  luxicnt  supporters 
oottld  coneeda 

I'latintirn  is  the  metal  omploycl  for  localising  tho  heat  of  tho 
jialvanio  current,  and  for  traitflmitling  it  to  llio  partjt  to  be  cau- 
terised.  In  all  Dr,  SliddeldorpfTs  instruments  an  apparatus  is  fixed 
in  t])i>r  handle  worknl  by  a  smail  screw,  by  inoati»  uf  which  tlie 
galvanic  cturont  («n  be  established  or  broken  at  will. 

In  treating  fiMnlje  by  tltiH  melliod,  a  |>[)itiiiiitn  wire  may  tie 
tntmdaocd  into  tlte  track  of  the  sinus,  ami  Iieing  subsctpicntly  con- 
neettxl   by  its  ami*  willi  tho  (q>po»ito  poles  of  the  battery,  tho 
don  may  be  clfectcd. 

Dr.  MiddeUlorplf  has  lignrc<]  and  deKcril>eil  n  very  convenient 
Btd  narrow-pointed  platinum  cauterj',  adapted  to  narrow  sinuses 
or  tacn'mal  flMulie;  in  siieli  mv*  ho  rreotiiniendx  the  uko  of  n 
■nail  fljiorulum  to  protect  tho  smromiding  parts.  For  the  removal 
■oftnmofirs,  i«>I>7ii,  and  other  oMtfrrowingpftrt»,a«iK>cicst  of  fcraseur 
i*  provided ;  the  chain  in  this  instrumout  is  replaced  by  a  platiuiun 


«  Dit  OaU*uicc4ittttili,  Dreslau,  1854. 


46 


MINOR  SURGERY. 


Vint,  tiliirli  can  be  tightened  at  wHIl  hy  no  apparatm  attaclieJto 
the  hati<lle.  A^ii,  for  (.'aiittTijiiti;;  Jttri<rtwrc»  of  tho  un-tlira,  Dr.^_ 
MkliMilimitt' liiin  invented  a  flpociea  of  catheter,  containing  a  oon-^| 
cealed  jtlatiuuni  point,  to  be  |irfijcift«d  and  houtod  hy  ail  urranf^ 
intuit  i-(inii[:cted  with  t}io  liiuidle  of  the  in»tmmcnL  An  a  counler- 
trritunt  there  U  no  su[)(.-riority  attaching  itsolf  to  the  a^va 
Cttiirt^rv  nliovt?  l]i<;  ordinary  forma  of  actual  cautery;  but  such 
prefer  (o  employ  it  may  find  Ju  tlic  work  rfforrod  to  nkore 
<]eiicri{ition  and  Hgnro  of  u  small  pon-clain  cone  tturroundftd  hy  i 
spiral  platinum  wire,  expressly  iiit«udtKl  for  tlie  formation  of  caustlfl 


SntAKGL'LATIOS  OF  'SmVI  AOTi  OTBER  TuM0PIL3. 

Kie»'i  and  some  other  small  tumours  may  be  etrangulatod  by 
externa]  or  by  8uh(.-ntun«oiid  Ugatures.  T\i6  most  sinipk-  furni  ofcx* 
temal  ligatiyc,  and  such  as  is  weU  suited  for  small  growths  that  am 
partly  culaneotut  and  ]jiirtly  »ubentaneous  in  tJieir  origin,  con«i: 
in  paiuung  beneath  t!io  growth  two  fine  hare-lip  pins  at  right  an^i 
to  each  othtT.     Tiicsu  should  enter  the  skin  clear  of  tJie  na;v 

Btruoture,  and  passing  completely 
ncatli  \U  base,  should  emerge  through 
the  sound  skin  beyond ;  a  piece  of 
xtrong  twine  being  wotmd  around  bo- 
ncath  the  needle-ends,  the  growtii 
may  bo  stnuigulatod  and  the  whole  se- 


cured by  a  double  knot  (tig.  7).     I''<>^| 
convenience,  the  uoodlc-ends  may  b^^ 
shoi'tfneil,  and  a  strip  of  Hut  may  ho 
wound  beneath  them  to  protect  the 
surroiuiduig  skin,  the  whole  Iwing  loft 
to  come  away  hy  slouglung.     By  some  the  needles  are  made  use 
of  only  to  niiso  the  nitvu.i  during  the  tighteuing  of  the  ligaturo|^| 
being  witklrawn  just  before  the  knot  is  tied.  ^" 

Again,  a  good  jilaii,  and  efliC4icious  for  small  n^rvi,  rceommendcd 
by  Mr,  (.^|ier  Forator,  is  to  tie  the  inevus  upon  the  pins,  withdraw 
them,  and  four  or  five  liours  afterwards  to  cut  or  imtio  tlio  liga- 
ture. The  erunhing  which  tlie  naivus  or  its  vessels  of  supply  un- 
dergo in  thin  process  leads  to  the  wasting  and  Hhrivclling  tip  of  thaH 
growth,  which  separates  in  two  or  three  weeks  in  the  form  of  a  dry,^" 
•cabby  limip;  tJio  resulting  cicatrix  is  loss  con&idcTublu  tbun  that 
left  by  the  oiKliuary  plan  of  exlei'iial  hgatui-e. 


SUBCtlTANEOUS  LIGATURE. 


47 


To  kaaJB'ftt  pain  of  the  ligature,  nnd  to  lia.4t*:n  tli«  !>«jmrstion 

<if  the  slough,  it  is  adviwiblo  to  trace  with  Uie  point  of  a  sniftU  kriil« 

a  in^wvu  in  tW  vkin  in  wliicli  tlie  lif^turc  may  Vm;  tliis  incision 

tfaanU  ruu  orounil  tiie  base  of  the  na^vus,  cotutecting  one  ik!(m1Io< 

inuKtore    witli    aiiotiicr.      Some    niuvi,    tlioiigli    of  coDxidcrablo 

lite,  ure  oovertid  with  aound  t^kin,  or  n  tlLijiroportionatcly  small 

extent  of  this  is  aftec4«xL    In  »ti-an^i]atin^  »ui-h,  bt-furv  |m«sing  the 

Uf^toro  RTOuad  the  pin^,  a  <!ruciHl  incinioii  may  be  miuio  over  tlio 

nir&ce  of  tho  growtli  down  to  its  base  at  tho  points  whcro  tlie  pins 

piorcc  tliu  inU-^iinent ;  the  four  iiichiiltxl  i\si[i»  being  reflecKnl,  tlio 

ligature  is  applied  witliin  tliem,  so  that  after  tlic  separation  of  the 

>luu^i  titey  may  in  jiart  at  leuxt  oovi-r  Uio  dontuled  xurfacc.     It  is 

probable,  liowever,  that  na>vi  eituatcil  at  such  a  depth  beneath  tho 

sor&ixx',  aikI  with  tlw  inlt-^unviits  tut  littlo  aAt-trti-d  as  lo  iidniit  of 

proceeding  being  adopttrd,  would  be  more  suitably  tjieatod  by 

njodion  or  foniploto  vxc-tsioi;. 

SttbctUtateoiu    lufoture.      For    the    oonvenienee    of  description, 
adcr  thiH  term  all  such  It^nturcs  will  be  dcooribed  un  nro  pnsMKl 
itaneouiJy  either  around  the  nievus  or  beneatli  it,  whether 
oompktiJy  or  only  partially  bcnculli  tho  «kin. 

^le  piartially  Rubciitancoua  ligature,  wliieh  iti  ordinarily  in  nae 
Jbr  naixcd  n^evi  of  large  size,  may  bo  so  arrangvd  as  to  strnngulnto 
tbo  growth  (u)  in  liiUveA,  {b)  in  (|uiirtcr»,  or  (c)  in  aa  many  portions 
^^ft  its  size  or  shape  may  require. 

^P  (n)  For  atrangulaling  a  nn;vuit  in  halves,  a  otrong  atout  needle, 
^For  one  Sxcd  in  a  handle  with  an  eye  at  tho 
V  pMtit,  being  sinm^l  with  a  double  thread,  may 
be  passed  benesth  the  growth,  so  as  to  be  quite 
f-or  of  tlw  lUKVoos  ittructurc.  Tho  liiopt-d  tin! 
nf  the  twine  bemg  cut,  the  four  ends  may  be 
and  ti.-<6cl  to  rai.-<«  tlio  growtli,  while  a 
is  poBsed  bci>eath  it  at  right  angles  to  the 
rtraek  of  tlio  ligature.  Tho  opiHisitu  endii  of 
each  |K)rtion  of  die  ligature  may  now  bo  tied 
feqgotber  firmly  boneatli  tlio  end  of  the  |)in  on 
die  aame  side ;  the  latter  being  nhortened  to  a 
oonreaient  length,  tho  growth  mny  bo  allowed 
I  separate  by  sloughing  (fig.  IS),  or  the  pin  may  merely  bo  nued 
raiae  the  d^vuk  U)>oii  ihiring  tho  tiglilmiiig  of  tho  knot,  and 
subwquently  witlidrawn.  It  is  advisable  to  divide  the  skin 
tho  na-vtu  in  the  track  of  the  ligature,  just  bvforv  drawing 
)  latter  tight. 


ai-s. 


48 


MINOR  SURGEKT. 


*• 

Be*. 


For  ram-ing  ligatures  beneath  timvi,  besides  tlje  comtm 
needle  (fig.  !>  a)  and  that  wliicti  has  an  «y6  u^ieiiing  and  dosi 
at  will,  rIiowii  iu  fig.  9  b  nnd  fig.  10,  t]iere  is  a  convenient  needb 

with  a  slit  in  the  side  of  tiic  oyo,  closin 
witli  a  itpring,  tirom  which  the  thread  ca 
be  disengaged  by  m^m\Ay  i>ulltng  on  tl 
loop  (fig.  9  <■). 

(b)  Of  the  plans  in  uitc   for  t^ 
n.'Rvi  in  i|uarters,  there  are  two  of  alma 
equal  t'flicipncy;  the  ono  introduc«i  li 
Mr.  FtTgii.isiin,  the  ntfaer  reeommeni 
by  Mr.  Cooi>er  Fomtor.     The  latt«p  gentleman  uses  a  noodle  wii 
an  ern  near  the  jxiitit,  wliich  o)U!nii  at  will,  so  oh  to  dii 
eiigjtge  tlio  thread  by  pushing  a  button  attached  to 
handle  (fig.   10).     Thu  nei-iUo  being  tlirti»t  Iii>n4>ath  t 
t'pnt.ri.'  of  the  niGi'us,  and  out  at  the  opposite  side,  the 
is  o])ened,  and  tiiu  loop  of  n  long  and  shiing  piece  of  twioc 
i*  introduced,  and  retained  by  closing  tlie  slit  in  tlie  sidj 
of  the  needle,  which  is  withdrawn,  bringhig  wiili  it 
double  ligature,  one  end  of  which  is  divided,  and 
other,  being  cmried  a  quarter  of  the  way  round  the  najv 
i»  thrust  with  the  needle  U^nonth  the  growth  at  ri 
angles  to  its  lliniier  course.     This  thread  in  now  dctachi 
and  one  end  of  the  other  tltread  is  passed  into  theneedla^ 
eye  and  withdrawn  with  it  beneath  tlio  nR:viw ;  tho  skii 
being  dividiMl  to  ri>coivo  tho  ligature  between  the  poloi 
of  porfnrution,  tlic  four  ends  of  tho  ligature  may  bo  tii 
together  two  and  two. 

Mr.  Fcrgusson  makes  use  of  a  strong  curved  sutnrt 
needle,  having  a  Inrge  eye.     TliiK  being  tlireadml  on  til 
niiildlu  of  a  long  and  strong  piece  of  tn-ine,  is  passe 
beneath  the  naiviis,  the  doiihle  thtend  being  drawn  ha 
its   lengt.li  out  on  the  opjiosite  side ;   the   loop  is  no 
divided  on  one  side  of  thi.i  eye  of  lh«  noetlle,  and  the  o| 
pOKilc  end  of  the  tliread  tJiat  was  cut  is  passed  into  tlio  aym 
Tlieso  two  ends  arc  tliou  oarricil  with  tlie  iici'<lle  iHiivafli  tlifi  nietil 
at  right  aiigh-K  to  the  Ibnner  coiu'so  of  the  thread;  the  four  fre( 
ends  can  then  he  tivd  two  luid  (wo,  the  skin  having  been  divided 
in  tlw  track  of  the  ligature  (tig.  11). 

In  addition  to   tho  proceedings  abo^'e  described,   tliore  is 


The  ejre  of  thi>  neudle  in  here  sbowu  open. 


STTBOUTANEOUS  LIGATURE. 


49 


tt  11. 


of  strangnlatin^  a  ra»cti)iir  tumour  in  fotir  quarters,  hy 

bdiwuuh  it  Kl  riglit  angles  two  double  tiirt-uJ.t  in  iu>jiitnit« 

■ad  tyiag  the  eight  ends  to^otiior  two  uid  two  in  four 

nus  phui  is  objivtioiiwblo,  a»  tli<>  tliorougli  HtriLn^ulutiun 

rvut  clependa  upon  the  tying  of  the  la»t 

ids;  wImmi  tluist?  arc  tightuncJ,  they  fru- 

tniw  tl>e  knotA  of  tlie  other  ends  into  the 

tks  in  the  tntcgumont,  and  thus  pii^ciit 

|et«  stnnguLition  of  tli»  growtli. 

1m  dnpe  and  size  of  a  mpvos,  or  the 

aoafomatiou  of  the  piut  upon  which  it 

],  may  bo  sueh  tJiat  tho  abovo-do§cribed 

arc  unntiitahlo  for  eflecting  iU  .■'triiii- 
,    for  FUcli  cusai,  fispecially  where  tlie 

of  oblong  fonn^a  tlintitd  niiiy  he  pnHsi-d 
be  growth  at  suitable  inten-sls,  and  the 
portionH  be  Mjnrat«ly  tic*!  np.  For  this 
[■  targe  curved  sutnre-needle  may  be  threaded  on  ttie 
f  a  long  fiive  of  twine,  ono  liiilf  of  which  Iiiij*  honi  pre- 
tppefl  in  ink,  or  otherwise  «iliiured.  The  net>die  may  bo 
neath  lh«  growtli  at  right  anglos  to  the  long  axis  of  thifl, 
I.'  inirTvab  backwanlx  and  furwanU,  milil  ihr  wiiole  diM>n»e 

included  between  the  threadK.     AH  the  btnck  loajie  of  the 
one  side  k^ingcut,  and  all  tho  whiti:  1i>o]hs  on  the  opposite 
ii  pwr  of  white  enda  may  be  tied  togetJ^er  on  tbo  one  udc, 
6  opposite  each 
tadc  ends  (fig. 

it  be  tliought 
'.  bare-lip  piii» 
n>d  in  conjuuc- 
I  thia  fonn  of 
ang  pa«««d  at 
^■toUlecourw 
read:  tbey  may 
nthur  to  raU*! 
rlli  during  tlio  tightening  of  tho  knots,  or  tbcy  may  he 

feotltil  slougliing  taki«  place,  to  insure  Unit  the  liga- 
»g  its  way  tliRiuf;li,  shall  pass  completely  bcnoatJi  tho 

p/rf^^y  mlmttanfow  Ivtaturf*,  when  applied  for  tho  *trangu- 
'  Taacular  tuinoura,  may  be  so  arranged  as  to  include  the 
n  (a)  a  single  loop,  or  (&)  in  two  portions. 

u 


Rett 


w 


MDfOU  SUBGEEY. 


(a)  To  strangiilato  s  asBrrxai  with  a  Bnbentanocms  ligatnre  in  & 
■iiifrle  kiop.-  A  titrnnj;  cun'od  nnvdlo  <9UT^'iiifr  a  stout  ii^ore  la 
passed  into  Uw  eollulm'  tisftui?,  cIoho  to  the  mev-us,  sdiI  oarried 
uoiiiul  Uw  circumibnmca  uf  tlic  dwciuc  w  far  as  the  nci'illo  wiD 

conreQieiitlr    reach    (of  coorste   the 

concave    wiilo    of  Uio  curve  of  tiie 

nc«iUe  should  be  turned  towards  the 

lucYtu  in  cfibcting  tills) ;  tlic  nwodlo- 

,  j___  point  may  tJien  be  protruded,  and 

V^Hp^  tbc  ligatuTD  and  nocdlu  drawti  oat,  to 

tH^\!\>,  be  again  introdoced  at  the  aaine  hola, 

f  I   ^^  and  carried  onwards  in  tho  sune  di- 

\  roction,   until  the  wliolo  n;e\'iu  ha« 

V  be^n  BiuTounded,  the  noodle  beiiij^  at 

"*■"■  hwt  broii;jht  out  at  the  ]»«int  whrt* 

it  first  piercwl  the  skin  (fig.  13). 

(b)  To  produuo  etrangiiliition  of  a  lar^  nwviu,  it  nuiy  Iw  noco- 
aary  to  tie  up  onch  half  separately;  to  elfaot 
tliis  with  a  KubnilaniK^itx  iigature,  a  doaUt 
thread  being  narried  beneath  the  base  of  (he 
gniwth,  tlic  loop  "n  one  siilo  nf  tho  ew  of  the 
nfeille  inuy  be  divided,  and  each  end  uf  tho 
tliread  be  carried  wparaU'ly  back  ln-ncath  the 
skill,  round  the  opposite  Hemi-circiuufcfetM'w 
of  tho  growth;  tJic  nocdic  bcin^  introduoed 
nt  the  former  point  of  exit,  and  emerging 
where  it  firnt  ]>iercod  tho  t^kin.     Tlie  oppoeit* 

*•■"■  cndd  of  the  Miuno  tJirciuLi  briny  ti<'d  tu^-llier) 

tho  two  hiJvos  of  the  nicvuswill  be  separately  etrangulatod  (fig.  14) 


THOMAS  SUITE. 


AMPUTATION. 


FA  UFUTATIO^  i&  often  regarded  as  an  oi>probrium  of  the  ticalJng 
xX  uL  But  while  tUe  human  Iramc  rranauv*  liable  Ut  derangA- 
— utfrtHD  aocidetit  and  dieeasA,  the  rmnoral  of  hoficdivjijv  dtwmlered 
pirtft,  in  the  wny  nio<tt  conducivv  to  l)io  nafoty  and  future  comfort 
of  the  EufiTcror,  will  ever  be  a  noble  object  of  surgical  vfibrt.  lu- 
dwclf  the  iiro^nwA  of  nu'dical  Hcienee,  wiiilo  funiishin^  tlie  means  of 
florn^  •omo  afibctioiiti  onm  regarded  ns  hojicle<w,  and  tliiiM  in  one 
pcnae  nMricting  the  f»>1d  for  the  appticAtion  of  amiiulntion,  han  in 
anotlier  point  of  view  extended  that  field,  hy  iin[H^ving  tbc  uiude 
rfqpontive  pfiooedure,  and  diveettng  it  of  mutili  of  it*  terror  and 
danger;  8o  tltat  wbereM  in  fiirmer  times  the  remo\-a]  of  a  limb 
waa  only  remrteil  to  in  aun-a  of  the  most  serious  nature,  it  is  now 
often  practised  when  tlie  offending  mem[)cr  Is  merely  n  source  of 
iaoMivcaiieuoe. 

It  ia  inatraotive  to  traee  tlie  history  of  the  improvement  o(  this 
dfpartment  of  rargery . 

Rippocratee  (b.c.  -I.^)  rei»ninien<In(I  only  a  very  rude  kind  of 
amputation,  consisting  of  cutting  through  mortified  limbs  ut  vome 
joiatf  "care  being  taken  not  to  wonnd  aiir  living  parlA.*'* 

On  the  other  band,  Olsus,  who  seems  lo  have  h'vcd  at  the  com- 

nmoement  of  tlte  Clu'Liliiiu  om,  ailviHod  tliat  tliu  rvnioval  ofgan- 

{RQOiu  limbs  shoold  be  dfeeicd  between  the  de»d  and  living  [wrta, 

<i4  to  as  ratlier  to  lake  away  w>me  of  tJiv  lienlt^iT  lexturet^  than 

U*  any  that  ww«  diseaacd ;  and  as  he  interdicted  amputating 

A>M^  an  artioulation,  Itis  o[»crutions  must  often  have  been  per- 

haed  eotirely  through  sound  tissues.     Ue  directed  tliat  the  soft 

I*tii)iould  b«!  <hvidod  with  a  kuifo  down  to  the  bone,  and  then 

^■med  np  from  it  for  aome  distanee^  so  aa  to  allow  the  saw  to  be 

flW  at  a  higher  level.     The  rough  wirfaw  of  thu  sawn  bone  wa» 

■B  Id  be  nnoothed  ofi',  and  tlie  fmft  jkarts,  which,  as  ho  tellii  uf, 

*wbe  lax  if  this  plan  bo  pttnmod,  were  to  bo  brought  down  so  aa 


*  frj^iiinilii  d«  Artia^.  pL  639  of  the  Brdmliaia  Societr'a  tnuisUtioit. 


fiS 


AMPUTATION. 


to  (wvor  tli(!  end  of  tlic  bone  as  much  aa  possible.  Thli  mfifbod 
seenii>  oalcuktcd  to  nttunl  ^ciod  rt-sulu ;  ]>iirticalar1y  a«  it  appears 
probable  from  his  writings  that  Cvtsns  employed  the  ligaturv  for 
arresting  ha^iiiurrliiigo  utter  iimimljition,*  and  dressed  th«  stump  ia 
a  manuor  iiivourablo  to  the  occurrence  of  priinary  union. 


vn^^ 


*  Oa  tliis  IntpreetinF!  point  in  surgioni  histoiT  I  am  dUposod  to  »\ 
with  the  author  of  the  articli;  "  AiQputution"  in  R«08's  Cyckipttiiia,  in  oppo- 
sition to  th<s  pr«val('ut  opinion  that  Ci^Isuh  employed  Uiu  Ufjiiturc  only  fa 
ordiiiAiy  wouuda.  and  u«ed  tlie  auttial  cautery  in  am  pitta  lions.  'Die  dirfc 
tiona  of  CelsuB  ret^iu'din^-  amputation  are  euiilainvd  in  liis  uliiipter  on  llie 
treatment  of  jjiiugieiir.  ia  ivliicli  the  only  inentioii  of  hiL-moiThnge  ia  th6 
stntement  tliul  jmliciita  uftt'D  di«  of  it  diirini!  Uit*  pi^rfumiancc  of  tJlO 
operation  |in  ipso  open),  refi-rring  douHlt-as  to  profuse  lileoding  resulting 
from  ignorimce  of  the  Mrniliitiim  of  the  Hood.  Bwd  of  nny  meanii  of  con- 
trolling it  in  tile  limb.  Certainly  this  exprfstion  is  no  proof  lliat  tlio 
cautery  was  ueed  inther  than  tho  lignture :  for  the  former  is  in  truth  tliu 
more  specdj'  methoil  of  the  two.  Neither  is  tlie  absence  of  alluitiou  to 
tlie  ligature  in  this  passnge  any  cvidi'nee  against  its  employment  alter 
amputation  ;  for  the  ai'giinient  would  njiply  equally  to  the  cautery,  and  no 
one  double  tfant  ono  of  these  two  means  was  used.  Celsus,  who  is  rrtnark- 
abl«  for  his  extremely  concise  style,  leaves  \\n  to  refer  to  his  previoua 
chapter  on  wounds,  in  which  the  subject  of  ha-morrhage  is  very  sbly  dis- 
cussed. In  slight  cases  pressure  with  dry  Util,  and  a  spong«  wrung  out 
of  cold  wster,  is  reeommend<-d,  or  if  this  (toes  not  answer,  lint  stepped  In 
I'inei^ar  is  to  be  utied  :  hut  any  portion  of  drsssinj^  retained  lu  the  wound 
is  said  to  do  inisehief  by  causing  inllammulion  ;  and  on  the  same  principle 
cauRtioi  and  other  powerful  ElypticB,  thou^'h  very  efficient  In  smiling  the 
blooding,  are  jirohibitod  because  they  produce  a  nrust,  whioh  acta  like  a 
foreign  body.  In  inort'  severe  cases  the  vessels  nro  to  be  tied ;  and  finully. 
"  wlii'n  the  eirciimstancoa  do  not  tivon  admit  of  this,"  the  rcddtnt  iruu  may 
bo  n^ed  as  n  last  resort. 

The  only  thing  that  seems  to  mo  to  give  any  colour  for  doubt  Upon  tliii 
subject,  it!  the  manner  in  which  the  ligature  is  described.  "  venie  qua 
sanguinem  fondant  apprrhcndendjc,  eircnque  id  quod  iclum  est  duobttN 
locis  deligsndie  inteieidrndirque  sunt,"  language  which  seems  ratbrr  to 
apply  to  a  partially  divided  ailcry  than  to  one  completely  severed:  butu 
thB  context  shows  that  the  ligature,  as  used  by  Celsus,  was  a))plicablo  in 
tho  niigurity  of  cases,  and  to  more  vessels  than  one  in  tlie  same  wound,  il 
ttn  hardly  he  conceived  possible  tliat  tlie  practice  was  rt-stricicd  to  the  very 
ttra  oaae  of  partial  division. 

Asaia,  tlieiv  can  be  little  doubt  that  in  drawing  down  the  soft  psrta  over 
the  bone  after  amputation,  Cctaus  aimed  at  piimury  union,  the  gre«t  nd' 
vantagea  of  which  are  strongly  insisted  on  in  the  ssme  admirable  cluipttT 
on  wounds:  but  it  in  eertiiiu  that  be  hnew  that  the  use  of  lite  caut«iy  would 
have  destroyed  nny  chance  of  union  by  first  intention. 

One  artiument  that  has  been  urged  on  Uie  otlier  side  is,  that  if  he  had 
employed  the  ligature  in  amputation,  it  would  hardly  have  beeu  neglected 
by  his  sucueasora :  but  tho  elowness  of  tho  Surgeons  of  the  sLxteoiiUi  and 


i 


mSTORT. 


tin 


Arc^iijl^os,  irho  practised  in  Itome  shortly  after  the  time  of 
Otbos,  paid  »]>ecial  attenuon  to  the  control  of  lufmorrluigo  diinng 
A»  performance  of  the  operation ;  and  appears  to  haro  been  the 
first  to  employ  for  thU  pur[xiMt  a  tight  band  or  fillvt  tMiciivling  Uio 
limh  abovu  the  siw  of  amputation.  But  while  in  this  he  did  good 
service,  he  a|)p]i(Al  Uw  rwl-hot  imti  to  th«  Miriacw  of  tiic  i«tiinii>,  acid 
•lao  n«giocted  tb»  dissection  of  tlie  soft  parts  from  the  bone,  sd- 
med  by  Oi»1«iia,  thiiii«h  <!omponjMitiiig  to  a  cortAin  rxtvnt  for  this 
OoiisBiwi  by  retracting  the  integuments  before  dividing  them.* 

Oalen,  who  was  in  truth  inoro  of  a  pbyoioian  Uinn  a  mirgout), 
ilwUDed  still  more  &om  the  Cobian  pre(?t-{>ti>,  and,  reverting  to 
llw  practice  of  Ui|>pocratc«,  advised  ain[>utating  through  tho  dojul 
toBttos,  and  applying  the  oaut«ry  to  tlie  residue  of  the  niortitied 
port  ;t  and  for  wvcral  <'cntiu"ic«  aftor  his  time  cither  thU  iiUJlhod  or 
Others  o(|ualJy  mde  and  oiten  much  more  biu'baruiis  continued  to  be 
employed. 

During  the  midtllo  age*,  tlte  ligatnro,  thongh  used  fi>r  ordinary 
wdoikU,  vna  never  thought  of  in  amputation ;  and  whatever  may 
have  been  tlie  praotioe  of  C«Iaus  in  this  rcspout,  there  \»  no  doubt  that 
tho  great  French  Surgeon  AmbroiBe  Par(5,  *hen  be  so  applied  it, 
ia  the  middle  of  tins  Hixtivntli  century,  had  all  the  merit  of  origin- 

tty.  But  though  he  urged  it^  saperiority  over  the  cautery  with 
le  argiunenl,  Mip|>orted  by  his  oxtensira  experioneo  in  both  mili- 
tuy  and  civil  prsccioe,  yet  his  teaching  failetl  for  a  long  time  to 
infliienaQ  Surgeons  ^nerully,  either  in  his  own  country'  or  in  otlter 
parts  of  Europe. 

The  pniieijial  reason  for  this  appears  to  have  been  that  the 
fillet,  which  was  the  meonjiMill  in  um)  for  oontnitling  the  bleeding 
daring  iho  operation,  did  not  answer  its  purpose  cfToctually,  even 
in  the  abUat  handt) ;  so  Uwt  tliu  dn^ad  [>f  hi^morrliage  led  most 
^krgimnH  to  prefer  tlw  cauten-  as  a  more  expeditious  methoti  than 
^B  ligature.  We  even  find  FiibriciuN  of  Aqiiajjendente  repeats 
tag,  in  1618,  Galen's  timid  doctrine  of  the  danger  of  amputating 


■*feBleenlli  eentQri«s  to  ailojit  It,  in  spite  of  tho  atrcnumu  advocacy  of 
Pan,  villi  alt  t]i«  a<]ran(ag««  of  a  prioteii  liti^ratunr,  abow  how  little  weight 
ia  to  be  atUfliMl  to  this  obJcelioB.  Tb«  utt«r  neglsct,  during  tha  midille 
afn.oriiic  Ci-lsian  m^bud  of  ampiitaiion.  nnd  of  hts  simple  mode  of  treat- 
btf  woaodi.  may  alao  bu  mentiotivd  a-i  niiulogous  eaaea. 

*  SptrnitcV*  llulvrj  of  Medieiat,  Frcoeli  Inuulation,  voL  ii.  p.  61,  aud 
nL  >iL  p.  312. 

t  Ottmu  ad  aiameoium,  Ub.  il  cap.  xi. 


u 


AMPCTAnON. 


thrmigli  Uvrng  parfa  at  all  ;•  and  in  11)33  the  celeLrafed  Fabricins 
Hildunus,  though  dcMrnbin^  the  li'gatnrv,  gt«U-M  thnt  the  timu  whtvli 
H  (KX'iipii-N,  ami  t)in  (XMi^ixjiient  Wa  vt(  blovd,  make  it  (tiiitahle  only 
for  tlie  robust  and  pk'thciric,  and  declaroH  Uiat  lio  "  cannot  snffi- 
oiently  extol  the  excol^noo"  ol"  tJi«  cmitfriwn  cvUfUarr,  or  red-hot 
knife,  hj  which  tbe  oritioea  of  the  voMidH  tverc  sdal^  while  Hvej 
werp  dividwl.t 

In  conseqnenw  of  this  Home  fear  of  bleeding,  the  grciit  object 
lit  this  ppTtod  ecwms  to  Imvo  Iwjcn  to  accomplish  the  work  of  »ev«*- 
onoe  of  the  limb  im  speedily  as  possible,  and  this  was  often  dona 
without  any  attempt  what<*ver  to  provido  a  oovoring  for  this  l]oii«. 
8cultetUH,  in  Xiihf},  depicted  tlie  pertormanoe  of  ainpntadon  oftlia 
band  by  chii^el  and  mallet ;  and  Piirmantiiu,  in  iii«  C/iiru'yia 
C'trvim,  writlv'n  it*  Into  as  16116,  nMfiition»t  having  seen  legs  i»- 
moved  by  two  diHeront  Surgeons  by  modificationB  of  a  bnrbarou 
inatriinient  of  tlie  nilddlu  ngt-s,  a  aort  of  giilllotlno,  *'  whicli,  bj 
it»  groat  weight  and  aharpneas,  cuts  at  <M)ce  the  skin,  fle»b,  and 
bonos  asunder;"  hut  ntjitM  thnt  it  ttpliutercd  the  bone,  and  Iktre- 
/ore,  "  all  things  considered,  tho  ancient  way  of  cutting  throogfa 
tlio  t!i\«h  with  a  knifo,  and  through  tlie  bone  with  a  saw,  is  mort 
practicable,  safe,  and  certain."! 

An  an  example  of  the  ordinary  practice  of  the  seventeenth 
century,  may  be  mentioned  tiiat  of  Iliehiird  Wiseman,  Sergeant- 
Surgeon  to  King  Charles  XL  A  fillet  having  been  tightly  applied, 
Ibr  the  three-fold  pur^Kwe  of  cheoking  hiBmorrlifflge,  rendering  tite 
limb  less  seunJlivo  by  prcstsm-e  on  the  nerves,  and  Btcadjnng  tbo 
•oft  part^,  which  were  retracted  by  an  aasintant,  be  carried  a  erooked 
knife  by  a  single  circular  sweep  down  to  the  bone,  wliich  was 
divided  witli  the  saw  at  the  same  level,  and  the  bleeding  was  ar- 
rested by  the  cautery,  or  aome  kind  of  afyjitic?  Thus  tiie  mode 
of  amputation  employed  by  tiie  father  of  British  Surgery  not  two 


*  Ififronymi  Fahrieii  fili  Aiiiuii>cndenlt  Opera  Chiruri/iiia.  pars  i.  cap.  xcvi. 
t  "  Porro  cxcellmtiara  hujus  eaaterii  non  snlis  exUillere  possum."   OaL 


fabrieii  Hil/iani  Optrra  omnia,  lib.  dn  Gitngrfcna  ct  Sjihucclo. 

;  Pmtnaon's  Oiirmrgta  CurioMa,  VMtfVtsh  transi-  book  iii.  chap.  xii. 

I  Tho  Ugature.  tkou^li  known  U>  Wiseman,  80om»  not  u>  have  bea 
adopted  by  hiin.  AlVr  describing  ililluiciit  modes  of  i4>pt}'iDg  it.  in  u  vty 
thu  shows  pretty  deurly  tluitLe  Litd  not  [iraclised  tliaB.twwritee,  "But  tka 
late  dlsooveiy  of  tht^  ro^ul  alypLiu  liulh  I'eiiiturt'd  them  of  less  u«<<.  But  ia 
the  heat  of  ftght  il  will  be  m^ai-ssary  lo  biLvo  jour  actual  cauu-ry  alwaja 
ready,  for  that  will  sevUT«  the  blc^iliug  lultries  in  a  moment,  and  forti^ 
the  pari  agaiustlhe  future  putrel'iuitioa."  CHmryiad  STrMtum,  bookvi. 


i 


l*. 


insnoRT.  u 


I  ago,  was  preniady  tlutt  and  SBem  hondnd  jram  beforo 
kjrilw  Uomau  Arclu^iaaefl.  And  Tory  nnaattH&ctorv  were  the  roMilla 
vUefa  il  oommouly  idlunkd.  'Ilw  ootl  inurtj*  wMre  in:itulK<^ieiit, 
in  thu:   first  insUnoe,  to  cover  tbe  end  of  the  bono,  whkli 

I  aooonliuglv  cualu-iswl,  with  iiui  objcoi  of  KooekntU&g  iu  in- 
DTiUlile  exfoliation,  and  in  the  further  progreaH  of  tbo  caee  it  tandod 
to  beoome  more  and  mors  exposed  bj  the  oontnuriion  of  the  niu.4> 
gIm;  and  vTeo  if  the  ]>atieut  survived  ttie  protracced  suppuratioa 
Uial  enoool,  he  mlTcrcd  more  or  less  from  iixt  inounrcnienoes  of 
what  ha»  beeo  nUed  Out  migar-loaf  stuntp,  lieiti^  in  the  sbapo  of  a 
tOKBy  tbe  apex  of  uliich  ii-as  foruidi  by  tlie  prominent  bone,  eorered 
nitber  by  a  tore  which  refnwd  to  bead,  or  by  a  thin  pellide  of  caoa- 
Uix,  Tery  liable  bu  abranatu 

A  great  atep  towards  a  Witer  order  of  Ihings  waa  made  in  1674 
by  Un  French  Sorgoon  Morol,  in  the  ioveDtion  of  the  toumi- 
qart(*  whi<^h,  though  nt  Hp<t  but  u  rudo  i-nntrivoiu.'e,  being  a  Htick 
faasoi  btaw^th  the  lillet  aiid  turned  round  bo  as  to  tivi»t  it  up 
la  the  roqnisite  degree  of  tiglitne--4,  fnnmhed  llie  bu-tia  for  tbe 
gnatlr  iniprovod  inBtrronent  devised  in  ilw  early  jiart  of  the  follow- 
ing omtury  \,y  biit  distinguislied  cminlryinan  J.  I~  I'clJt.  This 
oonrirtad  eBaeotJally  of  two  nietalhc  plates,  whioli  could  bo  squratod 
from  oot  another  by  means  of  a  scroir,  so  as  to  ti^'ht'-n  U  Htrap 
which  was  oonnecte<l  wiUi  iheui  and  tiiutt  eixrircieil  Lite  limb ;  and  it 
if  upon  thin  prindplc  that  the  ordinary  screw  tourniquet:  u  i>till  con- 
Mmded.  From  tliiv  time  furwitnl,  except  in  ainpiituLiuna  performed 
Dear  tlie  trunk,  lifemorrliage  during  the  operation  cea»<xl  lu  be  an 
olgect  of  dread,  and  Sui^^n*  were  at  liberty  to  cuiibider  other  qucs- 
tioos  beside*  mere  rapidity  of  execution. 


•  Sagtish  SwrgcoBs  augbt  <Liv]iule  willi  tbe  Freoob  iho  honour  of  tlia 
iamUoa  «f  tli«  UMuiiti|iwt.  In  a  work  wrilteii  iu  101^,  published  in  1619, 
■niiikd  CWhm  rrnrnpAaJii «  TtrrtMHiAo,  Mr.  Jmuhh  Voung  of  riymouth  givta 
MB  MCMiBt  of  a  siuiUiU-  oouirirauee,  apparvutly  pruJuued  iadojiviiiliTDtljr 
bir  kuBMlf.  He  iemetiheit  ii  w  "  n  itMld  of  buil  linuii  ulotk,  or  Um  Uk«. 
Imd^  Um  tfai((lit,  a  Uulv  b«tuw  thu  inguvu :  ih<^ii,  paBsiu);  ■  |i>»'el  roond 
Iha  member,  knit  tb«  mtlJi  of  it  togotber.  uid  uitb  >  IwtCoon  or  b«<Jataff,  or 
the  bk«,  twill  it  till  U  eoraprew  tlic  wnjd  or  boulsttr  lO  verj  Uiaight  on 
ifce  crwvl  veMw]  tbat  (tb«  drcuUtion  boiag  *Ui|>ji«(l  in  tbuui)  their  bleed- 
ia^  wbn)  ditiiltd  hy  tbe  iaosion,  iJuil  W-  Kcaiuu  larg*  enough  to  let  bim 
MW  wboic  to  appljF  bis  rcKtrintiv**,"  p.  .10.  t'urlbur  on  to  tlw  book  he 
Slain  Ibat  tb«  same  |>rii»ci]>l«  is  applii^blo  witb  odvantaKn  iu  umiiuta- 
lioas  of  tbe  npficr  limb.  But  sa  h>>  <\ar*  not  infurm  iiii  Ikkt  Iouk  bu  liad 
■••d  tbi*  expedient  b«for«  ba  wrot«  tha  account  oT it,  tbe  aedit  of  prioiity 
■■St  of  eoorw  be  aeeordsd  to  Moiel. 


iiife 
verfrH 

t  ofl 

niiaM 

th.1 


AMPTfTATION. 

Tlie  improver  of  the  tourniquet,  and  onr  own  great  ooantryma 
Chesclileii,  w^em  to  Imvo  conccivod  inJeiiOHdcntly  ofiwoh  (ittmr  die 
idoa  of  jjftrfiimiing  amputation  by  "  double  incision ;"  in  whidi  tbc 
skin  and  fat  wore  first  cut  throa^b  by  a  ciroidar  nwwp  of  tbu  knife 
and  rotrafrted  for  about  an  inch,  wben  the  miuclea  and  bone  w« 
divided  as  bipb  nn  they  were  wxiwmxi." 

But  tliia,  though  a  great  improvomeiit,  luwi  only  tlie  effect 
dtmini»bing  the  cicatrix  witliout  co\-onng  t]]o  boiiti;!  and  Loiiit|^ 
aiiotiit-r  oniinent  PariAian  Surgeon,  believed  that  in  tJio  thigh 
objects  sought  iniglit  bo  Ijcttor  attAiiiod  by  di%Hdinjj  aU  tbt-  soft  parts 
at  oiifo,  and  sitwlny  tlie  bone  at  a  higher  level.  In  onler  to  allow 
the  muscles  to  contract  frooly  wbon  divided,  ho  avoided  the  use  of 
tbo  ti>Hnii(jnet,  iind  was  tlie  first  t*i  oinjiloy  in  ito  place  digital  com- 
pression of  the  foinoral  artery  at  tlie  groin.  Hu  pointed  out  the 
hnportfliit  ciri.'nniBtiLntt)  that  the  muHcleH  on  tlio  jHisterior  aspect  of 
the  thif;h,  being  divided  fai-  from  tlieir  origin  at  the  polvis,  contrwct 
to  a  much  gruiU-T  extant  than  tlioso  at  the  anterior  jwtrt  of  the  limb|,^ 
whicih  arc  connected  with  tlio  bono  wbcro  they  Eire  cut ;  and  htiH 
hIiowinI  timt,  tilt*  soft  parts  having  boon  sovertHl  to  the  hone  by  a 
circular  incision  and  drawn  up  with  a  hneu  retractor,  the  saw  might 
be  readily  ap])li<Kl  two  and  a  half  inches  higher  up,  att-er  the  knife 
had  been  carried  through  the  attaclunentji  of  the  anterior  muscles.^ 
This  motliod  was  amputjttioD  by  double  incision  on  a  different  prin- 
ciple ;  and  though,  in  tnith,  a  revival  of  tlie  practice  of  Celsns,  was 
not  less  valuable  than  tho  plan  of  Che!>eldcn  an<l  Petit,  luid  8oein»  i 
have  afforded  reanlta  aujierior  to  theirs.§ 


•  It  in  difflnult  to  dot^rmiao  to  whom  the  priority  bolongs  in  this  nil 
Potit  iu  his  prinihiniious  work  slates,  "  Je  euiti  le  premier  qui  nit  coupi  I 
chair*  en  deux  tcmpH;"aii(l  also,  "J'uj  imagine  de cuuper  IcscJiaini  vn  de 
tempi  ;"  and  DitlTi^ubach,  iu  hie  Opfrativt  Surgery.  ^Ives  17tf>  ox  the  da 
oflhu  introduction  of  the  double  iiidsion  hy  Petit.  Oil  Uie  other  haiu 
Cheseldeii  an  ditittnijtiy  vlaiius  the  original  idea  iii  the  following  passage  in' 
bin  notes  tu  Gatiiker's  truuilutioo  of  Lr  Dran't  Surgery:  "  Tlio  llitiig  that 
led  me  tn  Ao  this  whs  whut  huH  too  ofteu  happi^ned — the  ueeeA^ity  of  cutting 
olT  the  eiiJ  of  Ihe  Btiitnp  the  sri-und  time.  This  operaliou  1  proposed  to 
my  master  when  I  was  liis  npprenUi5u ;  Imt  he  treated  it  with  neglect,  though 
he  lipod  ufterivnrdB  to  practise  it  when  he  had  seen  me  perfonn  it  in  tiff 
aanie  hosinljil,"  This  proposal  must  have  been  made  before  I7tl,  when,  at 
tlte  age  of  tu'cnly-rwo,  he  began  to  lei^turc  on  anatomy. 

t  This  is  well  illu&tmti'd  by  the  drawinj;  of  n,  aliimp  given  by  Cheseldea 
ill  Le  Drin'i  Sarjert/,  for  Iho  purjiose  of  showing  the  good  elTucta  of 
doubt  e  iiiciHiuri. 

;  Mrnmirtt  de  TAeadimU  dt  OkiTurgi*,  *eL  U.  p.  386. 

\  Ibid.  vol.  ir.  p.  GO. 


HISTORY. 


57 


8  ront«nt  if  tbo  stump  when  honlod  wsh  fn» 
1^*  and  dill  noL  nim  at  forming  a  complete 
covering  for  the  bonv.  This  wros  vffcctuatly  dono  abotit  a  (]tmrt<9' 
of  a  century  Later  by  Atanson  of  Iiivi-r|iool,  by  dietsocting  up  the 
iiit«gtiinnit«  for  iwino  dutanoo,  and  then  diiHding  tlie  muscles  oIh 
tiqoelT,  BO  that  th«Y  fi>rmtxl  a  hollow  coha,  in  llio  ajxix  of  whioh 
the  Im>u«  was  sawn  "about  threo  or  four  fingers'  breadth  bifibor 
than  wae  moally  done,"  The  efiert  of  tliin  wiis  m  "  fully  cover  the 
whole  mrfacc  of  tlw  wound  with  the  most  perfect  ease  ;"t  but  in 
tbe  Itanda  of  other  Sui^eonn  tlie  obliqiit-  diviiiion  of  tJm  muscles 
proved  to  bo  a  matter  of  considerablo  difficulty,  and  tlic  object  was 
aceomph'fihed  its  ellieiently  and  more  simply  by  Mr.  Uenjaniiu  Bell 
of  ^>iinlMlr<!)l4  and  Mr.  Hey  of  Leeds,  by  a  combinatJon  of  the 
metlioilii  of  Clieeicldfln  and  IjOuin;  or,  uut  Mr.  Hey  I'xprcHsed  it, 
"  with  a  triphi  mcisifMi,'*^  in  which  the  akin  and  fat  wero  first  di- 
vided oir«ularly  and  ditutcctol  tip  for  aoine  diKtnnei',  tbi'ii  the  musclee 
won  cut  at  a  liighcr  loiel,  and  thc«e  wore  retracted  so  oh  to  permit 
the  hone  lo  be  expcmoil  and  jwwn  ooimiihirably  hiphw.  Mr.  Hey 
adJed  the  adri«  to  cut  the  posterior  mnscles  somewhat  longer  tlian 
the  nntcnor,  Ut  eninptiiKRlo  for  tJieir  greater  contraction ;  and  tJiws, 
Inwapls  the  end  of  tlie  last  ocntury,  *'  the  circular  ojieration,"  aa  it 
id  termed,  may  W  w«id  to  have  been  brought  to  iicrfcction. 

Meanwhile  a  diHerent  principle  had  been  long  before  suggested 

■m)  acted  oil.     So  early  as  1678,  Mr.  James  Young  of  Plymouth 

Awcjjhed  "  a  way  of  amputating  large  membent,  so  as  to  l>e  able  to 

one  thvm  /xr  rymphiftin  in  throe  weeks,  and  without  (billing  and 

Miling  the  bone."     Tbo  direetioiw  given  for  thin  method,  the  "  first 

tula"  of  which  he  wys  he  had  "  from  a  very  ingenious  brother  of 

cms,  Mr.  G.  Lowdham  of  Exeter,"  are  as  follow :  "  Ywu  are  with 

ibeeatltng,  or  some  long  iueiui  on -knife,  to  rai§e  (suppose  it  the  leg) 

I hp  of  the  membranous  flesh  ooiering  tJi«  muscl>»«  of  the  calf,  be- 

living  below  tlie  place  where  you  intend  to  make  oxciMon,  and 

nii^  it  thitherward  of  length  eriotigh  to  civer  the  stump  ;  having 

^kxm,  torn  il  back  under  the  hand  of  him  that  gripes;  and  as 

*Mi «  you  have  severed  tlie  member,  bring  tliis  flap  of  cutaneous 

■*  ever  the  stamp,  and  fasten  it  to  the  edges  tlicroof  by  four  w 


'  '  I.*ain|nitatieD  U  |>lu8  [lariiule  mt,  uns  contrtdjt,  c«Uo  dons  lA<|ncUe 
■Aiin  qui  rununit  IVxtrnniU  du  moi^non  consomnt  soseit  de  longurur 
pKtt  naiBtetiir  &u  nivi^su  du  bout  du  IW"     0)>.  oil.  vol.  iv.  p.  41. 

t  Alntson's  Pritetieitl  Obterrationi  on  Arnpnlatiiyn,  9d  ed.,  p.  10. 

'  Bcqiaoiiii  Bi-ll'it  Syttem  o/Harg^g.  llh  >tiL,  ToL  vii.  y.  XOO. 

i  Btfa  Ptaetiad  Obttfratiom*.  3d  «il..  p.  637. 


M 


AMPUTATION. 


sol 

in-J 


fire  atronj^  adti^heB^"*  Eighteen  ^,■e»n  Utcr,  Verdoin,  a.  Sorgcoil 
of  Amstri'daia,  ignonuit  appuronUr  of  what  Lowdliittn  had  lioiie) 
provided  like  tiiiu  »  coveriiij;  for  tJie  end  of  t)ie  ntuiitp  from  ihe  calf; 
but  m^tciul  of  cutting  from  below  upwards,  siid  uuly  raMiag  Uw 
integuiueiiU,  lie  thriLnt  a  knife  twhiiid  the  bone*  kI  tho  part  whers 
ho  intvndod  to  divide  tliom,  and  cutting  downwards  fonuod  a  nins- 
cokr  fluji,  w)iic)i  li«  iif)i-rwiu-(|x  nuppiirtod  by  on  appunlua  deviied 
toK  thu  purpoic  of  pnisung  tfao  cut  aurfiK^es  togetlior  bo  w  to  cbtdt 
bleeding  witJiout  tJio  uita  ofoitbiT  caiiUtr^- or  Itgnturiivt  Hiiama*. 
Celine  being  complicated  and  unsatisfactory,  waa  rejected  in  17S0' 
by  M.  tiar:»ij^t,t  wlio,  »itkKtittiLiiig  Uio  li^turu  for  it,  hut  retain- 
ing in  other  rcHLpei^  the  method  of  Verduia,  brought  atnputatii 
of  the  leg  to  the  form  in  which  it  is  still  ofiou  practised  ut  the  pr^ 
sentdaj. 

The  same  principle  was  applied  to  the  thigh,  in  1739,  by  Itnvo- 
ton,  of  Landau;  but  instead  of  one  long  flap  be  made  two 
oncti.      Having  divided  all  lIio  soft  parts  circularly,   lie  thruxt 
knife  down  to  the  bone  on  Uie  anterior  iutpt>ci  of  the  limb,  a  hand' 
breadth  higher  np,  and  cut  down  to  the  edrcular  wotmd ;  aiidf 
having  made  a  similar  loiifritttdinal  tnc-i«iou  behind,  dissected  up 
tho  square  lateral  flaiia  thus  formed,  and  sawed  the  bone  whore  it 
Wiis  exjiosml  at  tlteir  miglc  of  union,  and  brought  thwti  tog«thi 
after  tying  the  vctteels.  j 

Vermale,  Siu-goon  to   the   Elector  Pnlatinu,   wion   nfterw 
finmed  the  flaps  more  eaaily,  and  of  a  shape  better  adapted  for 
union,  by  introducing  a  knife  at  the  front  of  the  limb  and  pu.thiog 
it  miind  the  bone  at  one  side,  so  as  to  make  it  emerge  at  tho  oi 
poaite  point  behind,  and  tlieu  catting  a  flap  of  rDondi-d   form 
eUTving  tlie  knife  in  a  enrvvd  nutniior  downwarda  and  outw 
the  same  process  being  repeated  on  the  other  side-lj 

Thv  flap  o|>eretion,  perfurmed  eitlit-r  by  ciitling  from  wi 
inwards  or  by  transBsion,  was  occasionally  employed  by  vario 
Surgeotiii  in  tlie  latter  half  nftlie  Ia--4  century;  but  found  ita  moat 
strenuoufl  advocate  in  the  late  Mr.  Listoa,  and  aboot  twenty  yean 


■th«^ 
antaf 


•  JtatiM  Toiin^H  Cum*  TiiumphaJis  e  Terebi»llu}.  p.  IDS.  A  Cftpyof  t 
intdTeRting  ho<'V  niM»  in  the  libnury  of  tho  Medioo-Cliirurglcal  Socie^ 
London. 

f  M/nutim  d*  VAtadinu*  de  ChirurgU,  foL  ii.  p.  SM. 

;  Ibiil.  p.  :JOI. 

S  RavAton'a  Traiti  d'JmM  a  fiu,  p.  40&;  also  iliituAn*  i*  tA^dimii^ 
Tol.  ii.  p.  'if>\. 

II  Li  Dran't  Surdity.  Gnlaker'a  tmuHLalkin,  p.  431. 


=^ 


QENRU^  FRmCIPLES.  M 

I  WOBwd  ySo^y  to  sapenede  the  cirtnbr  mediod  nltogetliPr.  Jtt 
at  merit  in  it»  facility  and  ?ih'".xI  ;  for  Uw  llajw  iirc  cut  witii  grest 
it^,  and  when  thery  «re  drawn  oji  by  the  wiiLibuit,  tlw  bono  is 
wHb  Uw  otmoit  rmlinaMi  at  ^e  part  wbero  it  i»  dwirabk 
'  it ;  wberau  tivs  dtMeotion  of  die  ring  of  intc^ainants  fnm 
Uw  foMsa  is  R  somewhat  t/onbleaonie  and  tcdioos  proccn,  m[Mi^ 
aaSj  in  a  limb  im-Ten-ning  in  diieknitM  ti[)wani.'>  like  tlwt  tliigh.  and 
dw  m*  of  a  retnctor  is  often  necasazj,  in  order  that  tbo  eaw  innjr 
bo  applied  at  a  saificienlly  iiij^i  IcvcL 

As  ngnrds  thu  immediate  resalts  of  the  tno  methods,  tlw  pClD- 

cipal  diffivence  betwot'ii  t)H-m  in,  tliat  tiw  Rajxt,  ultun  Ibrmed  hy 

bamfixion,  contain  a  large  amount  of  mnsRle,  while  the  circular 

Mode  AiniGibn  a  crn-i-n'iif;  obiodjr  from  tiia  integument.    In  this 

tMpact  11m  flap  oi)eniti(>n  was  at  fint  ■upponed  to  have  a  gnmt  ad- 

Tanlaga,  as  providing  a  muscular  eoshion  tor  tho  end  of  the  stump. 

Bat  thia  opinion  was  tfaaketi  by  turther  ezperienns     In  thrr  very 

etaa  in  whidi  tlio  flap  operation  vi-as  first  employed,  via.  in  the 

^fnr  part  of  the  leg,  the  nmacniar  masa  proved  very  inoonvenivnt 

fam  its  redundancy  when  the  calf  was  largely  developed ;  and  even 

■nder  more  fuvoumtiki  riniiniHUuiuuN  tlw  heavy  and  eontractile  Hap 

was  apt  t/i  shift  &o«n  its  position  or  to  drag  down  tho  skin  of  ttie 

frual  of  the  leg,  w  ax  to  «trvt<-li  it  on  the  cut  onil  of  the  tibia,  and 

ndoee  oleeratioo.     IIen(»  Mr.  Liston  himieif,  so  early  as   IH39, 

pnJcrTvd  in  moscular  mbjects  a  short  posterior  Hiip  aiul  an  anterior 

eaa  of  the  some  knj.'tb,  aMnpowd  of  integument  only  ;*  and  itt  the 

iMer  pariixi  ol'hii*  practice  ho  changixl  dii»  for  tho  tbilowing  modi- 

fintion  of  the  ctrctdar  operattoa,  which  was  also  snggested  tnde- 

pMalnntly  by  Hr.  8yme  and  has  been  n;«d  hy  liim  for  mn-eral  years 

jmt  in  all  oaaeeof  ain|>tiiation  in  this  Rituation.    Tho  skin  and  fitt  am 

Prided  by  two  cresoentic  inrhnons  widi  the  convexity  downwards, 

mas  to  fonn  almrt  aut4!ni-pci*t<i-ior  tUp«oflhe  integument',  whtoh  it 

nbed  tmm  tho  &soia  considerably  hi^^ier  dian  dicir  angle  of  nni<m, 

Af  whidi  the  openitioa  i*  complofwl  ai-  in  the  oniinary  circular 

■shad-t    "EhiH  plan  given  anenttally  die  same  rnnilt  i»  the  eir- 

«kr  raodct  whib  Uw  dismction  of  tho  intvgument  is  lacilitahd^ 

■4  ili  edfin  ean  be  aocaraiely  adaptocl  to  each  other  widiont  any 

<f  8m  pDcfcectng  diat  oc«nrrrd  at  tbo  anglM  of  dm  womid  after 

'k  (U  operation ;  and  oxperienoo  shows  tJiat  wfaon  tho  eofl  parts 

■*>«  iem  divided  in  this  way  thoy  are  qnite  as  favourably  dia- 


"  tiiton'a  KUmnti  nf  Svryrry.  Sii  tstition,  p.  7M. 
f  SyuM'a  Frmafitt  ^  Sutgtty.  4lli  editkn.  p.  148. 


60 


AMPUTATION. 


•i 


poMcl  f»r  [irimftry  union  la  when  out  more  smoothly  in  the  fonn 
of  flaps.  ^J 

In  the  1ov>-cr  purt  of  the  tlii^Ii,  i1m>,  tlin  presence  of  the  (Mm^^fl 
tractile  element  in  tho  flaps  was  tband  to  bo  injurious  by  increasing 
the  <lifi(iHsili(iii  lo  protni»i«n  of  the  lionf,  fn>n»  Oio  »«ti»n  of  the 
powerfiil  liaui-i'tj'ing  muscles,  out  ao  far  from  tlioir  origin  at  tirtj 
pelvis,     Mr.  Synie  lia*  ncoordbigly  adaptiil  liis  nimlification  of  iheJ 
circular  metliod  tu  tliat  situalion;*  and  I  eaji  t««tify,  from  cousidicr-j 
able  experience,  to  the  sufficiency  of  tlie  covering  wliifh  it  nffdrds. 

Tiio  lonyer  time  rei|uirfid  for  tliJs  operation  than  that  by  flap 
was  rendered  a  matter  of  no  momeiit  by  the  discover}'  of  aiuc^thesitlj 
in  surgery,  in  tlie  year  t*<4B.t     Inde[>endent]y  of  the  relief 
bodily  anil  mental  sutJ'cring  proeiircd  by  tliis  great  6v«iit,  it  inti»l. 
regiirdtii  m-  an  era  in  thu  hlslAr^' of  amputation,  of  at  least  eqnall 
importance  with  tho  invention  of  the  tourniquet;  bocauxo  Burgvoiit^ 
«ru  now,  ill  tilt)  great  majority  nf  cn-vx,  deprived  of  all  excDse  fat 
eacrificing  any  thing,  either  in  plan  or  csocution,  to  mens  rapidity 
of  pertormance,  and  enabh^d  to  regard  simply  what  will  most  pro- 
mote ihe  two  great  ultimate  objects  in  amputation, — safety  tu  li(o, 
and  unehibiess  uf  tiie  nitunip. 

With  regard  to  the  latter  objeot,  in  <»nnection  with  the  modi- 
fied <'ir<rul«r  openition,  it  was  funnd  that  jiatieiitji  <ni  whom  it  had 
been  pci-formeid  walked  as  well  as  those  who  had  tlie  cushion  whieb 
is  produced  by  a  muscular  flap;  but  on  investigation  it  appeared 
that  in  neither  case  was  the  weight  of  tlie  Ixwly  borne  by  the  end 
of  tlic  xtintip,  wliicli,  in  fact,  tUd  not  touch  the  artificial  limb  at  all; 
the  socket  of  the  apparatus  lieiiig  ajiplied  ])artJy  to  tho  sides  of  the 
Btumj),  hut  chiefly  to  some  Iwny  prominence  resting  on  its  upper 
edge, — tlie  tubei-osity  of  tliK  iHi-ltiuin  when  the  thigh  ia  ooneemed, 
and  ill  tlie  leg  tho  internal  tuberosity  of  tho  tibia,  tho  head  of  the 
fibula,  and  es[ieoially  the  lower  edge  of  the  patella. 

This  subject  has,  however,  been  recently  opened  up  afresh  by 
Mr.  Teale,  of  Leeds,  wlio  has  brought  before  the  profession  a  new 
mode  of  amputating,  with  facts  which  show  that  it  onablcs  patients 
to  Ti»t  the  whole  or  a  large  part  of  tlie  weight  of  tlu^  ImhIv  on  the 
end  of  the  stump  either  of  a  leg  or  thigh  ;  and  he  states  that  vrhea 
the  prcMure  i.-*  pretty  equally  divided  between  that  part  and  tiuise 
which  bear  it  in  ordinary  cases,  tlie  stcadineas  and  comfort  of  looo- 
mution  are  greatly  increased.     The  manner  in  wliicli  thiA  unque*- 


*  Syroe's  Prmciplei.  (tb  ed.  p.  UO. 

f  See  the  Sectioa  oa  Anaislhetics,  whicli  (olloirs  next  in  this  woric 


GEKEHAL  PRnTCIPLES. 


61 


m 


■dvanta^  itf  ottained  by  llr.  Teale  ia  as  follows.  Ha^'ing 
^rtaiDod  hy  niouMwrriiiirnt  (Iio  wnii-riix-(ii»tcr«n(H!  of  the  limb 
where  the  bone  b  to  be  divided,  be  first  traces  with  pen  and  ink 
ll]Hn  tlio  »kin  four  Iin<w  of  that  Ivri-jlh;  two  longitudinal,  oxtomiing 
downwards  frtiin  liie  part  meanurod  along  the  sid«i  of  the  tiinb,  and 
two  tranm'vnc,  of  which  ono  jointt  in  front  the  lowvr  ends  of  tlio 
n^uidinal  lines,  while  the  otiier  nins  acroes  behind  fivmi  one  !on- 
itudinal  lini^  to  llu)  other  al  tlio  dislancv  of  a  qiixrtvr  of  tlioir  length 
from  their  upper  extremitiee.  Two  peetangidar  flaps  of  very  un- 
equal lengths  being  thus  mapptyl  otit,  ho  rni»iK  tbcin  by  cutting  from 
wiilHjut  inwards,  and  saws  the  bono  at  their  an<:]e  of  union  ;  tlien, 
after  lying  tliu  vomcIs,  bon<ls  tlio  long  anterior  fla]>  upon  itself,  that 
it  may  "fomi  a  kind  of  pfmeh  for  tJie  end  of  the  tione,"  turning  up 
Hk  lon*er  wlge  to  moot  that  of  tlio  short  fwistcrior  flap,  to  which  it  18 
earefully  adjusted  and  united  by  a  few  points  of  suture,  some  Htitchea 
being  also  intiwluood  wfaoro  tJio  cdgos  of  tbo  akin  meet  at  the  sides 
of  tbefttumiiL* 

Mr.  Tea]e  also  propoe«e  to  extend  his  method  to  the  arm  and 

,  and  oroii  to  lJii>  fing<>ni;  but  a.t  the  onlinnry  o[K!nttion8 

er  their  purpose  oompletely  for  these  sitiuttions,  it  is  not  likely 

SurgfoiM  goiiendly  will  sulwtitut©  for  ihom  this  coinplicutcd 

Xor  mu«t  it  be  supposed  that  sitnniiwi  in  the  lower  limb  havo 

Hrer  before  borne  the  weight  of  the  body.     Mr.  Alanson,  speaking 

nf  the  condition  of  a  jxilioiit  on  whom  liu  hatl  |)orfonned  ampiitAtion 

tima  the  ankle  by  posterior  flap,  sa^'s:  "He  has  been  ^veral 

wyageato  sea,  and  done  his  bi»>ini.--HN  with  groat  activity.     He  bcnni 

the  preMuni  of  the  machine  totally  upon  tho  end  of  the  ntiunp,  and 

hn  not  been  troubled  witii  tiie  kiMt  excnriation  or  soroncss."t     It 

nut  bi!  adniitiitd,  liotvever,  from  Mr.  Teale's  statistic,  tliat  such  a 

nnh  is  much  more  likely  to  follow  his  nu^hrxl  than  any  other 

*niHy  employed;  and  hence,   in  the  leg  and  thigh,  the  trouble 

•liiA  it  involves  would  be  little  thought  of,  were  it  not  iiccom- 

ptteil  by  otltcr  drawbacks.     But  when  measuromonts  are  made  in 

■nnnlaace  with  this  mode  upon  a  inii^eular  »ul>jeet>,  tlio  ant«.Tior 

^ii  Ibtind  to  pri^u^nt  an  extravagant  length,  such  as,  in  many 

Vnin  aciiial  practice,  the  available  nmicrinl  would  not  suffico  for, 

*tli  in  other*  n  niueh  higher  di^'ision  of  tbo  bone  than  usual  would 

^Hiqiitrod.     Thus  in  a  parcictdar  instance,  wliero  tho  dovolopiuviit 


*  TcnIc  mi  AmpuMlii-a.  pp.  34  el  «eq. 
t  AUuaob  va  AmputitiOH,  [i.  183. 


6S 


AMPUTATIOJf. 


was  by  no  toMM  cxtrtunrdinur^,  tlv^  ilimensionH  w«re  sqc 
suppoHuig  the  aut«nor  transverse  iucUion  made  at  iha  lovvl  of  tha 
upper  bordcx  of  Ujo  put^'Ila,  it  wuitlil  tmv«  bucn  necettar>-,  in  order 
to  presoi've  Mr.  TcaJe's  projMirtioiia,  to  saw  the  bone  eleven  iticJm 
{urUica*  up,  or  full  tivo  in<^'.)K»<  liiglmr  tliati  if  the  mocUfiod  cirL-olar 
operation  were  performed.*     This  nimtt,  e«im»  paniitu,  vary  seri- 
otLsly  initvuM;  Uiu  rink,  whicli  'm  always  f^nnalin'  IIm  nciuvr  llw  M«t 
of  iuuj)utatton  ia  to  tJie  trunk. t     Tiie  cut  wrface  is  abo  very  exwn-, 
BJvc,  and  tins  would  give  rise  to  a  correspondingly  largv  unount ' 
»i]ppitrution  if  tuiniediate  uninu  falltnL     It  tlK-refore  beoumoa  aal 
iiDpurkuit  question  wliotlier  die  advantages  of  Mr.  Tcalo'a  plan  nu^J 
not  Ife  olitiiiiiod  in  sonio  lefts  objectionable  inanuer. 

Now,  iji  the  first  plae«,  it  is  dear  that  ibe  extent  of  cut  Kurftoo' 
miffht  \>f-  ilIu)iiiiHliiH{  witliout  at  all  intcri«nng  tfilh  the  renull,  b^  i 
retracting  the  muscles  before  dividing  the  bone,  instead  oftrust4 
iup  entirely  W  iJic  fliipn  for  oovwring  it.  IIikh,  in  «  limb  nixlnen 
inches  in  circuiufurence,  the  effect  of  an  anterior  flap  eigiit  incbei 
lung,  HiiJ  a.  piMterior  tiiqi  of  two  inclicf,  witli  the  bone  tuiwn  at  tiie 
angle  of  union,  would  be  e4)nally  attained  by  an  anterior  flap 
six  ini;bcj<  witiiiitit  any  jK>i4vrior  fliip  at  all,  I>ut  witb  tiic  inuaclMl 
retracted  to  tlie  extent  of  two  inches  before  division  of  the  bone,  jurt 
Of  is  ilono  in  tlm  cimiJar  o]KTiitii>n.  Seenndly,  iw  this  sinj*!*?  flap 
woul<l  be  only  slightly  longer  than  tJie  diameter  of  the  limb,  it 
irould  be  ncodloMt  to  attempt  to  Ibid  it  on  itaclf ;  but  it  would  adnpid 
it^lf  well  to  tl»e  po&terior  [lart  of  tlie  tliigh  if  il.i  anfrle«  were 
rounded  off;  wliilo,  at  tlio  saiuo  time,  the  ojieration  would  Iw  di- 
vestucl  of  ita  ditfioulty ;  ■»  a  fl&|>  of  audi  form  could  be  readily  aliaped 
by  tlie  eye,  aud  ite  length  deteimined  by  sj)anniiig  the  limb. 

Tliat  Miuba  proei.'dui'v  would  answer  well  la  not,  liowcvcdr,  a  mera 
matter  of  iofeittnoe ;  for,  since  the  appearance  of  Mr.  Teale's  worit, 
Mr.  Speiiee,  of  Edinbur;;li,  hiu  |K.Tfumii.K]  »oino  amputations  of  i 
thigli  accortling  to  his  dii>A-UonH,  and  otiierA  by  cutting  from  wit 
out  inwards  a  large  rotmdc«l  anterior  Hap,  dividing  the  pos 
parts  at  tlie  level  of  itA  baHO  by  a  perj>end!(!ular  sweep  of  the 


i 
i 

leo 
by    I 

"^ 

•en 

'iim 


*  At  9  indiM  abav«  tho  iiRtetIs  lJi«  div.iiinfnvricc  of  the  limb  waj* . 
ioGbeB ;  so  if  tLe  opt^iatiou  w^re  performed  th«ro,  die  len^  of  the  ant 
fitp  (Lho  Kcnii-circuitiri.'i'eiii'r)  Hlmuld  lii>  lU^.  uhicb  would  vnia'aaRb  by  ll 
indi  upon  (lie  iiiinouiid  inltxuiiieul.  At  II  iiidips  nbove  tlie  pRtolln  tJiff 
cireunif-ri"r«>onwa*33}.  siviiic  an  uun-rior  Huji  of  llj.  nliidi  oould  l>im.-ly  b« 
formoil  out  of  tlie  givon  iiiuUMial. 

f  Tills  iiniieipli'  lion  Iti'i^u  jjitliily  cxprensi^d  by  DietToobach  in  tlie  words 
"  aotlwtiae  stejgt  die  GuMir."  Ojuratif*  Ckirurgid,  *oL  U.  p.  6ii. 


OENEBAL  PBINdFLSa 


u 


Mnctiiig  tin  muscles  before  applying  tho  mw.*    I  have  had 
o|i|)artuiuty  of  iwocrtniniag  br  personal  in»]fCction  tlw  fofaiMi 
TUm  coabioD  in  both  cosea ;  and  lir.  Bpenoe  ullx  me  tiiat,  wbere 
<  baa  been  fiinn«<l  aJW  tbo  latter  mode,  it  has  proved  capaUc  t^ 
bnring  a  hirgt  projxirtion  nf  ih«  wedglit  of  Uio  bodr. 

k Still  th'w  prooooding  would  invo)%'e  as  high  a  division  of  the 
e  aa  Hr.  Teale's,  if  tlte  anUrior  flap  hiui  Hie  \enffh  »bo\  e  laeD- 
«d  ;  and  tlte  t^ucation  yet  remains,  wli«thiT  it  oiay  not  be  cor- 
biled,  and  elted  out  with  a  Hburt  )><Mt<Tior  flnp,  without  impiuriiig 
tba  aaetainetK  of  tbo  stump.  Prov-ided  tbo  coveriug  of  the  bone  bo 
■nfficieDtly  full,  lixs  ewMriiltiil  thinf;  U'  bo  attuiiiixl  in,  Unit  ihit  tviidcr 
dcstrix  Bball  bo  so  placed  as  to  be  free  from  any  cliaoce  of  being 
«]uce)U><l  lx:twi>t-ii  thn  Iioiiis  und  the  bottom  of  tlio  iwckw  of  tbo  arti- 
fidal  limb.  Now  it  foituoalely  happens,  both  in  the  calf  of  the  leg 
and  in  the  thi^jli,  tbat  tlw  bona  livs  fur  forward  amun^  tho  inu«clos, 
so  that  even  its  posterior  miHace  h  oonaiderably  aitterior  in  position 
lo  tb«  lonf^tudinul  axis  of  tbo  limb.  Hcticc  a  dap  of  liulf  the 
diameter  of  the  limb  would  more  thaa  txner  the  bone,  and  one  as 
Icng  aa  two-tiiinis  of  tliat  dianiptor  ivould  insiuv  tlw  scar  being 
wail  III  I  a  hij  bebiml  tbe  point  of  prewiuro;  Mpoeially  a»  the  absence 
of  tb«  nm  indtM  of  bone  above  tbe  base  of  the  flap  would  allow  it 
todrup  lower  dun  it  otherwise  would.  Aliwi,  ui  tlio  further  pro- 
pmi  of  the  case,  thf  contraction  of  th«  posterior  muscles  will  draw 
the  dcalrix  still  funJter  bn(4c ;  an  o-fftxl  ton^  sinew  notit^  by 
Alaoaoa,  who  iJatcs,  tjiat  aAer  }iis  circTilar  operation,  "  as  tbo  cica- 
trix is  ao  uoall,  rix.  only  u  »ingl(!  line  dntwn  n<Toi«t  tbo  jiioo  of 
the  snunp  &om  side  to  side,  the  partA  are  sooner  capabltr  of  bear- 
ing the  ri'«iiri.*il«  pnsMture  from  the  U!«c  of  a  wooden  h'^ ;  fof  lbi» 
iom  not  fall  upon  the  new-formed  skin,  which  is  drawn  backwanlB 
bf  iba  actioa  of  tbo  ptKrtenVir  mit:wJes."t 

In  order  to  compensate  for  the  diniinntion  of  the  anterior  Bap, 
■  portmor  QDc  miut  be  made  of  ruthcr  mora  than  half  its  length, 
■1  of  romided  ahajie  for  adaptation  to  it,  and  tiie  integument  of 
duftap  abould  be  dissoctod  up  before  tbo  pn«tvrior  tutuw^Uw  are 
Ji^ided,  so  aa  to  sei  it  free  from  tlia  oBecta  of  thoir  contractian. 
^  ibe  other  hand,  tbo  anterior  fiap,  afli-r  luting  mnrktMl  out  by 
■Bring  the  knife  tlimugh  the  skin  and  fat,  should  be  raised  ao  a> 
'^Mitatn  a  good  deal  of  musclo,  which  will  bo  mteful,  l>oUi  by 
i^DDg  the  vitality  of  the  mther  long  flap,  and  also  by  iuseasing 


*  £4mlmrgk  A/oiUUy  Jmmud,  NoTcffiber  i&>a, 
f  Abutsao  (IK  Amputation,  [i.  U, 


64 


AMPUTATION. 


the  thickne»H  of  tbc  mwhitm  Iwlow  ihr  bwip  ;  while  any  tendewrn 
retriK'tioii  lliat  it  poaseases  (small  eom|)are<i  witli  t}ial  of"  tliu  pos- 
terior tnuBclcs)  will  bo  coiuiteraoU'd  by  tho  foroo  of  graritrj-,  tbrougfa 
wliioli  It  will  imturally  tend  Ui  oei-upy  its  propiir  ptucix  ^B 

By  Hm  inudo  of  amputating,  tiiu  bono  will  bo  divided  about  a^l 
low  HH  ill  the  modified  circular  o|)enitioii ;  and  Uiotigli  I  liavc  not 
jethad  much  opportunity  of  trying  it  upon  tho  living  subject,  I  M 
MidsBecl,  from  tlio  iiltove  consideration.*,  nnd  frxiiii  rx[K'i'tmcnl«  upem 
the  dead  body,  that  it  will  attain  tho  essential  objects  of  Mr.  Teale's 
plan,  wliilv  it  will  oi-cuj>v  Icvw  tiinu  t)iuii  vithor  of  tJic  mothodi 
alluded  to.  Tiio  flaps,  when  brought  together,  will  be  free  from 
tcniuoa,  and  the  stumj),  if  )>ro|)crly  ilressed,  luoitt  farournbly  otC^H 
cumfltaneed  for  safe  and  speedy  healing.  ^" 

The  dressing  of  the  Klunip  ia  a  matter  quite  a»  important  to  tbs 
aucceuful  issae  of  amputation  aa  the  manner  in  whicJi  llio  limb  is 
reinov(>d  :  im<l  therefore  requires  special  notice  here 

'Hio  essential  principles  upon  which  it  ought  to  be  onn<lt>cttd 
will  be  bc«I  understood  from  a  con»idcn)tion  of  the  drcnniHtaoces 
of  the  wound  after  tho  operation.  The  mM^ianieal  irritutioii  rostdt- 
ing  from  the  psvsago  of  tho  in»itniments  through  the  parts  appoaiB 
to  throw  a  tiiin  layer  of  the  tJiwues  at  tlie  cut  riurface  into  a  Mate 
siniilor  to  that  produced  by  tho  action  of  cantharides  upon  tlio  skin^ 
or  Ihicturo  of  iodinn  U|M>n  the  tunica  vaginalis ;  vix.  a  omlitton  of 
euBpondcd  vital  ac-tivtty,  in  which,  the  normal  relations  betn'een  thd 
blood  and  llie  living  .iiilid.t  being  interriiptMl,  tho  minutu  voud> 
become  clogged  with  tlie  blood-(»rpu§c]es,  and  the  liquor  san> 
^iiiis  is  forced  tliroiigh  their  iiarlotos,  and  flows  nut  upon  the 
surlace  of  tho  wound,*  Tho  liquor  sanguinis,  lying  uj>on  tho 
sluggish  tissues,  comp*irts  itself  as  if  in  <,i)ntaet  with  oniimiry  eolid 
matter,  il«  fibrine  coagulating  to  form  the  hinph  which  encrujtta 
tlie  cut  surface,  while  its  other  and  far  larger  constituent,  tJiu 
•erum,  trickling  away  between  the  lips  of  the  wound,  showa  itself 
as  the  discharge  which  soaks  tiie  dressing  during  the  first  twonty- 
fi>ur  hours.  Meanwhile,  the  source  of  irritation  being  no  longiT  in 
operation,  tho  tissues,  if  free  from  any  disturbing  cause,  are  gra- 
dually recovering  their  powers  by  \inue  of  their  inherent  vital 
energy ;  and,  as  tlicy  regain  their  functions,  the  cfliision  of  pliuinia 
oeaMa,  and  a  procciiH  nf  actire  organisation  is  inatitutct],  by  which 
the  lymph  is  differently  affected  according  to  circumstaucc:*.     If  i 


*  See  a  papn",  b,v  tliu  Author  of  tliie  Scctiou, 
luflammaUon,"  PhiL  Ihui:  18S8. 


'  On  line  Kni  Ij  Stagci  < 


DRESSING. 


pbtta  of  iho  ifroTind  are  in  jaxUpMiliDn,  the  Ij-mpli  gluos  tlivm 
It^edRr,  ant],  beiii^  etuToun<Ic(l  on  all  sides  by  hoalthy  ti^ue,  be- 
ecnM<l*^vi:lt>iK.-il  ill  II  ffw  ilays  intu  «  wft  lUAOiilar  ulriicUirc,  wliJofa 
aflOOniUs  a  pen»an«nt  bond  of  union  between  tbcm.  But  if  the 
Hotwoet  of  tbc  wouwi  ur»  sepcnitiKl  by  a  portion  nf  tlin  drtwiing, 
<r  t  dot  of  blood,  or  by  senun  pent  up  in  Uie  interior,  imnie- 
diato  union  ia  of  «»>iiii«o  prft%-«nt«tl ;  vid,  in  the  vicinity  of  the 
fintagn  solid,  or  i\w  decomposing  blood  or  serum,  the  dot'etopnicnt 
of  the  lyinpli  axtntnir^  a  wry  low  ty|Kt,  and  |)ii»  u  the  r«'Mult.  But, 
■Ddepeiidontly  of  any  mechanical  obstacle  to  union,  if  sonic  per* 
atbmt  fiour«.-c  of  IovhI  irritution  bo  prevent,  sucb  at  thi^  dm^r'jing  of 
rtilehca  npnn  an  iiuuBicieiit  oovering  of  soft  pai'ts,  or  a  tighdy  <!on- 
ftricting  bandage,  inflanimation  will  bo  iiiduoed  in  »  roHox  niunnor 
through  tbfl  nic-<liuni  of  the  nervous  system,  and,  in  proportion  to 
hfi  degrwt,  will  interfuro  with  the  procwia  oforganit-  dinnloprnwit ; 
converting  what  pmmi^  primary  union  into  suppuration ;  or,  if 
nore  Mvere,  rendering  the  lips  of  the  wound  entirely  initctixe,  in- 
ca|Nib)e  of  pnxliieing  even  pwi ;  or,  if  still  more  intenite,  dojiriring 
them  of  their  vitality'  and  causing  ttlouglting  of  the  stump. 

Thu--*,  whilo  the  etluuon  of  the  l}'niph  which  Ik  tin?  uuiliuin  of 
primary  union,  depends  on  a  species  of  traumatic  iuHammatioR  of 
tbs  cut  nn^f:l»^,  thi!  h<^aIt]ly  orgnniitation  of  lliat  lyinpli  refiuircs 
ibBOce  of  any  inttanimation  whatever ;  and  tlic  great  objwrt,  of 
brntment  mmtt  Ix!  to  phi«e  tlio  stump  in  such  cirt-umMunoex  that 
the  titfues  may  be  left  undisturbed,  to  recover  irom  tlie  shock  tliey 
haT«  sustaincl  and  then  exert  Uioir  |K>werd  upon  the  product  of 
their  derangement. 

Snpitosing,  tlwtn,  that  th«  operation  hiw  Iwttn  [iropcrly  pcr- 
femed,  so  that  tite  sott  parts  may  meet  oyer  the  bono  witltout  any 
touion,  and  that  the  oriftcvx  of  the  bliiwding  vcjuteln  have  been  caro- 
fuBy  wcnred,  tJie  lollowing  simple  rule  will  ho  found  of  universal 
,  ^ffieation.  Let  the  dre)>»ingi«  be  deittilutv  of  any  irritatiuj:;  r)t]ality, 
'  ■nl  m  Brmmged  ciiat  tlio  sorfacee  of  the  wound  may  he  kept  in 
pHlt  apposition  throughout,  wliilo  free  op[>ortuiiity  is  aflordcd  for 
■KMape  nf  dischai^ie. 

Thi'  last  point  is  of  essential  moment ;  for  a  flow  of  wrum,  copious 
'JnjNMtimi  to  tlm  extent  of  tlie  cut  surface,  is,  as  we  have  seen, 
*  Btviiable  effect  of  tlw  operntton  :  atul  though,  wlicii  it  has  ready 
Vn>,  it  is  firobablr  Iwneikial,  by  washing  out  blood  tliat  may  ooxe 
*»>  the  wound  before  it  has  time  to  coagulate  in  tho  interior,'  yet 

'  Tbc  wixttirv  of  )>t>'ml  nnil  scnim  wltioh  dUuiik  Uiv  [ti'eE.siiigc  is  very 
*^  BitukcB  b]'  i)iatii'DU>  fur  bleeding. 

ItN.  UL  r 


66 


AMPDTATION. 


if  retained,  it  will  provo  mUeliievous,  not  only  by  rendering  anion 
mochanivully  iiii[HHuiiliio  in  tlic  purtx  wheni  it  accuuuikt«H,  but  by 
irritating  the  ^tiintp  tiu'ough  tho  diatenaion  which  it  pruiliictiii,  uod 
tho  acrid  pr(>|>crticj«  wliicli  it  iR-quIrcA  frotn  docoinjwsition. 

In  the  lalcr  stages  of  Uie  ca&a  it  ia  eqiuilly  necei^ai^'  ti>  pro%'ido 
for  tho  froo  escape  of  discharge.  For  in  a  wound  of  flueh  extent 
and  irregularity  as  that  resulting  from  amputation,  w«  can  novcr 
be  EOcuru  against  tlic  fonnntion  of  some  pus  in  tho  interior,  which, 
if  n>taiiie(l,  would  give  rise  to  all  the  oviU  of  ak-ujtwti.  To  gnard 
agwn«t  euL-li  an  ocourroncc,  tho  stiiuip  must  he  from  time  to  time 
carefully  (-\ainiijiKl.  But  if  the  ojH>nitIuii  hi!  pfrformod  tlu^mgfa 
healthy  tissucH,  no  eappuration  will  take  place  till  about  four  day* 
liavo  olap-Hod;*  jh>  tljat  ajiy  nn»ddting  witli  tlit>  sitimip  Iwforo  that 
time  is  unnecessary :  and  such  pivniature  intortL>ronoe  does 
miKchiiTrhy  t«>aring  tlie  yet  itiijierfi?ot  and  doHcatu  uniting  tinsaa 

Tlie  rec-oivis  of  Surgcr)-  show  that  a  rapid  oaro  after  Mnputa-^ 
tioD  huH  dc[H-iKltHl  nmre  upun  tin;  !ttiim|i  having  heou  drossod  in 
accordance  with  these  principles,  than  upon  ttio  shape  in  whi«h  the 
covering  of  siiil  parts  lias  hwn  out-  In  tlio  original  account  of 
Lowdham's  method,  before  quoted,  Mr.  Young  aLites  that  tho  wound 
boalod  per  /•t/mphi/vm  in  f/urf  week*;  and  in  describing  the  dreeaitig, 
he  says,  "  clap  a  dossil  of  lint  into  the  inferior  part,  tliat  oik-  |(ium- 
ago  may  \k  open  tor  ajiy  blootl  or  mutter  that  may  lodge  between, 
but  of  that  there  seldom  oeourreth  any."  The  essential  exit  for 
the  scrum  v/m  thu«  ])rovido<l ;  and  it  is  to  ho  romomborod  that 
Lowitliam's  ttap  was  not  a  hea\'y  and  contractile  mibis  of  Itio  muscles 
of  tho  calf,  but  corisistod  only  of  the  skin  and  fat,  and  tlierefofQ 
would  He  in  its  jilaoe  without  tension. f 

The  stumps  formed  aflor  Itavaton's  fiishion,  with  two  lai 
rectangular  I1a|is.  healed  vory  cpiickly,  both  in  hi.*  IiiuuIh  and  tluM*! 
of  IiO  Dran,  who  states  that  tho  cure  was  completed  in  tJiroe  weckaf 
ttid  accordingly  we  find  tliat  ncillu^r  of  tlio>«0  8urgiMiii.i  cm]iloy< 
any  in-itating  application,  and  that  both  were  carcliil  to  leave 
inferior  lungitudlna!  incision  freely  o]K'u  for  tho  cscjtpo  of  the  liga- 
tures and  tI»o  discharges.}     Itavaton  insists  especially  ujioii  ilii« 
a  gniiul  fiuircw  of  Kafoty  to  the  patient,  and  states  that  "  tlio  drain 
which  exists  below  preventa  ajiy  mishaps,  such  as  swelling,  infl: 


•  Tliii  is  tlir  parioil  in  adults  and  in  c»ol  wcntlier;  in  youDg  subj«el 

mnd  in  uHini  ivciiihcr  It  is  si>n>eu-lini  ahoil  of  ftiur  Jnys. 
+  Carrna  Triurnjihalil.  p.  III. 

;  Hiivutoii,  7'ruif«  dai  I'layei cTamw  n/fUi  P- 408 ;  and  I^ Uian,  Gataker 
traoKlutiua,  p.  43 1. 


DRESSIXa 


& 


abflcess,  &c. ;  no  exfolintJon  of  tlie  bnne  oeciiro,  Anil  Uta 
MffttmUon  i»  inliniU'ly  U-ss  abundant  tlian  in  tbe  old  mctboci,  both 
bMMiae  ihe  Avound  of  the  .ituinji  \ixt  )>tit  a  stmall  mrfiivo  ur  none  at 
■11,  and  becau&G  Ibo  inferior  incision  allona  tbe  pus  to  flow  freely 
snv,  and  in  a  short  time  thiit  grcnt  wutuid  is  »oon  to  bo  eoiindly 
^leakd." 

^p  It  teem*  Hlrnnj^,  that  nAnr  ttnt^i  r&<iiItK  hud  boon  nttflinod  mid 
BUcarly  recorded  in  France,  the  Surgeons  of  that  oounby  ehonld 
VaflerwAnbt  liavw  prefi-m^l  ^uiftin;;  with  clmrpio  the  wound  prodncud 
in  amputation ;  and  that  0*Ha]loran  of  Limerick,  who  wrote  in 
1765,  wnA  piindl  <i>Ti,"i(Ii>raI>le  rirjuitiition  as  a  wupportor  of  the 
flap  m«thod  of  amputiition.  while  priding  himself  on  his  famili- 
arity wiUi  the  wort*  of  the  French  Surnoons  of  his  ttmc,  i^JtouId 
hxn  diecreditMl  altogether  their  reports  of  primary  union,  and 
oon«idcrcd  that  ho  did  great  lwr^-ioc  to  Surgviy  in  asserting  the 
prineiple  that  "  healing  by  inoacutatJon  without  aiipjiuration,  by- 
an  tmmcdiatn  coidoMxtncc  or  by  tlie  fir«t  intontiou,  ia  mordy  cfai- 
merical,  and  is  oppa'-it©  to  ihe  nilss  of  nature,"* 

Bnt  his  influcneo  wa#  happily  cflcctually  counteradorl,  as  far  as 
Britufa  practice  was  concerned,  bv  tiie  teaching  of  Alanxon,  who 
was  a  wann  advocate  for  primary  union,  botli  aRcr  Hap  and  cir- 
oilar  operstioniL  Sooh  auc«e»«  att^^nded  hin  practice,  llmt  out  of 
tlnrn'-fivc  cases  of  amputation  of  the  log  and  tfaigh  at  the  public 
bnapilal  of  Liver[XH>l,  he  lo«t  not  a  nin^lo  ]>utient ;  and  he  idlit  uit 
that  "at  tlie  expiration  of  a  montli  from  tJie  operation,  rfie  wound" 
wss  "  eitlicr  perfeclJy  beolwi  or  Uvu  than  a  BixjH-imy  pi*we."t  These 
rv^ults  cannot  be  attributed  entirely  to  good  fortune ;  neither  can 
thqr  be  eiplained  by  tbe  ]H.-culiar  conical  form  of  tho  wound  made 
Vim  obUqae  divbrnn  of  the  muscles  {which  indeed  did  not  occur 
in  tliB  1^  amputations) ;  but  tliey  arc  eutiieicntly  accounted  for  by 
Ui  iftcMreatmcnt 

In  the  iin4  pIsco,  he  paid  special  attention  to  wnuring  the 
^fmik,  examining  "  the  whole  surfaci;"  of  the  wound  "  with  the 
SiWttt  mncancy,"  and  drawing  out  the  vessclo  with  the  tona- 
"fan and  tying  tliera  "as  naked  as  po-'tsible ;"  and,  tutys  be,  "no 
^aiD  anort  that  in  a  single  instance  I  haw  rcmovt^^]  tho  drcm- 
MpWbre  the  Ofiual  time,  on  amount  of  lia?morrhage."  Secondly, 
'  iBilHitatioiM  of  Ihe  tliigh  ho  vinptorod  n  llitiinel  roller,  fixed 
■^al  tlie  pelvis  and  caiTied  cii-eularly  down  the  limb,  "  not  so 
'V^  n  to  preaft  rud«Jy  or  forcibly,  Iwt  to  giro  an  easy  support  to 


'  OlUQona  on  OAitfiVM,  te.  (i.  aiiO.  (  AUoixm,  pre&ce,  p.  lA. 


68 


AMPCTATION. 


I 


the  pftrta;"  nn<l  tliere  is  no  doubt  that  such  a  I>an<IagR  oHa  bene- 
Bcially,  not  only  by  checking  retraction  of  tho  soft  part»,  but  by 
keeping  tho  miiiHOes  in  n  state  of  rejioKO,  nnil  ihiLt  ])revttnting  tha 
disturbiince  of  tlie  procoes  of  nnion,  which  would  re»utt  from  their 
irn-giiliir  contniction.i.  Thirtily,  tlie  edges  of  tlii'  ckiii,  uftcr  bi» 
mode  of  o|)erating,  generally  met  without  tho  fllightcst  tension,  and 
werft  nrt»ini.N]  in  ai>pU!iitioii  merely  "  by  long  8li|M  of  linen  or  lint, 
simut  two  fingere  in  broadUi,  spread  with  cerate  or  any  cooling 
oiiitineiit,"  botwfcn  whicli  tho  scmm  would  freely  e»c«po  ainl  soak 
into  tlie  re»t  of  tho  dressing,  which  was  simpty  '*  a  soft  tow-])le<lgflt 
and  compress  of  linoti,  tho  wholu  retained  with  tho  many-tailed 
bandage,"  wtiilo  the  exit  of  (litharge  was  favoured  by  tJie  low 
position  in  which  ho  placed  the  stump,  viz.  about  a  haud's-breadtb 
from  llie  siiriiioo  of  the  l)ed.  Tho  dressings  were  first  ohaiigiid  on 
the  itiird  or  fourth  day,  and  he  advises  that  this  should  be  don< 
"with  as  mueh  tenderness  m  |»ossib!c;"  but  tho  flannel  roller  wa» 
not  interfered  with  tiU  some  time  later,  when  the  "adhesions"  Wi 
"  more  ciimjiletc." 

In  short,  the  mode  of  dressing  pursued  by  this  excellent  Sur- 
geon was  ill  all  respects  truly  ailtnirublc ;  and  well  wonld  it  havo 
been  for  the  credit  of  British  Surgery  had   his   successors  been 
equally  clearsighttTd  and  judicioux,     Bnt  though  all  followed  him 
in  attempting  primary  union,  their  very  anxiety  to  obtain  it,  i«tt  ^ 
being  i>up]>ortc<l  by  sound   pathological  knowledge,  often   led  t(riH 
entii-e  faihire,     Tims  Mr.  Syme  hitorms  us,*  lliat  when  he  wag  a 
tlrcssLir  in  the  Edinburgh  Infirmary,  it  was  usual ^in  recent  wounds^ 
to  bring  tho  e<lges  of  tho  skin  into  closo  contact  by  strips  of  ndho'^l 
sive  plaster  overlapping  at  their  edges,  so  as  to  allow  no  escape 
for  blood  or  scnim ;  and  when  tliose  were  removed,  on  tlie  ftuirth 
day,  a  collection  of  fetid  pus  was  almost  invariably  found  separaufl 
ing  the  surface*  of  the  woumi.     So  impresBed  was  ho  with  tho  cvtla 
of  this  pi-actiec,  that  he  published  in  lt*2.''t  a  pajier  on  the  subject,! 
in  which  ho  insisted  on  tho  invariable  occnrrence  of  a  flow  of  senun, 
the  retention  of  which  was  necessarily  injurJoxis;  so  that,  aa  ho 
expressed  it,  "there  can  be  little  difficulty  in  perceiving  why 
«ealing-np  of  wounds  should  be  the  most  certain  means  of  kt-cjiing'-' 
them   open  ;"   and   ho  pointoil  out  "  that  jn-essure  should   be  di- 
rected to  tlie  bottom  rather  llian  to  tho  oulli.a  of  the  wound."     "Hiil 
[lupt-r  had  u  very  important  influence,  the  principles  inculcated  in 


«  Clinl*-al  Tfl-clui-e  in  t1ie  Lttnent.  Msrnh  SJst,  1843. 
t  £dinliursh  Mtttkitl  and  SuT'jkiil  Jvurnal,  vol,  >ii». 


PRESSING. 


69 


it  being  aflerwftTxlii  infiiaod  into  Ixindoii  (n-notioe  by  the  ]a.Uf  Mr. 

hLtMon.  bcsid<.-«  brin^;  Ktciuiily  taii^lit  niid  iictoil  on  by  thdr  author 
in  lite  Edinhurgli  school.  JAr.  LUUm  omiliniioil  to  the  laiit  a  prac- 
tice which  Mr.  Symo  at  fir«t  stiggmt«<l,  vik.  leaving  tho  wound  open 
for  HtTUR  hrtUFK  Ix^fore  the  tiniil  <tn]w»tnf;,  in  onier  to  olilaiii  greulur 
tvcurity   a;^inst  Bocotular)-   luomorrhage.      But  Mr.   Synio  aftcr- 

^■wanU  found  tliat,  exw{>t  in  casv  of  oxtvn«ive  ouxinj?  from  minuto 
TGssele,  the  dititurhancc  of  tlic  wound  involved  in  tliin  plan  was 
an  unn«c**jau-y  inHiciion  on  Iho  ptitit^nt,  and  if  wifficivnt  puins  wurv 

H  bestowed  upon  securing  the  arteries,  tJie  dreaung  might  at  once 
Ijr-  coinptottfd.  This  consisted  of  points  of  tho  int^miptod  suture 
at  sufficient  dtatance  jti>ri  each  other  to  afford  a  free  outlet  for  diti- 
chargw,  and  pads  of  folded  lint  applied  over  the  bodioi;  of  the  Hajw 

■  but  not  extending  to  rhe  lijis  of  tlie  wound,  with  a  broad  piece  of 
lint  over  all,  and  a  bandage  applied  do  as  to  promts  the  <loop  surfaces 
of  the  wound  gsntlj-  togetJwr  tJirouf;li  the  inodinni  of  the  {wda; 
while  tlie  entaneoiu  margins  were  left  free  for  tho  exit  of  tho  dis- 
charge, which  wa-H  alnorlKxl  W  tlio  lint  a»  it  OM-iipinl.  Thin,  tlionjjh 
at  first  a  dry  dr«6sing,  became  praotically  a  motsl  one,  and  pre- 
ventoil  tiie  blivnl  or  iKTum  frtvm  drying  no  a*  U>  form  a  cntKt-  It 
was  lefl  undisturljed  for  aliont  four  days,  wlien  union  was  found 
alreaily  prvtty  firm ;  aivd  a  similar  application  t>cing  afterwards 
rqwaied  at  intervals  of  two  davs,  tho  <iischarge  of  pus  was  eom- 
JBoniy  very  trifling  in  amoiuit,  and  the  cure  speedily  accompli  shod, 
"ntia  was  the  method  followed  during  my  honse-siu-geoney  under 
Mr.  Symc;  at  tiic  expiration  of  which  )ie  was  able  to  stale,*  Uiat 
**  of  tho  last  twenty  i-ttam  in  whieh  )tc  hod  ninpniattxl  the  thigh  in 
that  boepital  for  chronic  disease,  not  one  had  died,  although  some 
of  lliem  were  almoM  ItopcleM  at  tlte  timo  of  tJie  ojtcration,  on 
aecoont  of  the  extreme  degree  to  whieh  they  were  prostrated  by 
Icng-cnntinued  diaclvrge  or  other  caiiM^H."  An<l  (liere  ean  bo  no 
Joabt  that  one  reason  for  this  aucceas  was,  tliat  tlio  stum{)«  were 
trmboi  on  iimin<l  {trinciples. 

Stitebca  arc  certainly  preferable  to  Btrips  of  adhesi\-c  plaster  for 
keeping  the  edges  of  tho  skin  in  contact^  a»  tliey  oecnpj  mueJi  leas 
mnn,  and  m  oppoae  leas  obstade  to  the  escape  of  disohargo;  and 
lie  otdy  objcetion  ever  uFg«d  against  liiom,  vix.  tliat  |}iey  induce 
iiAunmntion  round  the  pmnta  wiiere  they  are  insertod,  has  been 
tntinly  removed  by  tho  introduotion  of  tlu)  metallic  stiture,  which 
no  irritation  whatever  unless  it  subjects  the  part  to  traction, 


*  CUnieal  Lecture,  Lanctt,  April  2Ut,  1600. 


a 


70 


AMPUTATION. 


and  tliiti  otiplit  iierer  In  ha  Ute  oaso  after  amputation.      Wh?n' 
applied   without  teusion,  tin*  wirc-Btit^-liw   may  remain   for   aiijr 
lvii;^)i  of  tinio  witJiout  pr<Ktiicing  more  dUturbani-^  than   a  ring 
of  gold  in  a  lady's  ear;'  thoy  consequently  retain  their  hold  for 
a  much  loii^r  jH^rioil  tJimi  t«ilk  nr  linen,  wi  that  rtnipjiing  mny  ji 
iistui]ly  be  entirely  dispensed  with,  vrliich  greatly  simplifies  tbs^f 
drettsJRg.  " 

A  padding  of  some  soft  material  suited  for  imbibing  tJie  dis- 
charge, and  arrunf;ixl  n»?i>rdin^  to  the  ]>rincip]i^  tni]ical«d  above,  j 
ap[>carH  to  be  uaefut,  by  giving  general  support  to  the  stump,  and 
kooping  tlic  deep  surfaci-js  of  llie  wound  to^othvr,  and  ik>  oliuvking 
oozing  of  blood  and  promoting  union ;  and  by  car«fu!  management 
sueh  a  dressing  may  be  renewi^l  on  thu  tliird  or  fourtli  day  withoat, 
dtt*lin-l>iinc>u  of  the  pWtio  process. 

Bboutd  redness  and  tension  of  the  integument  indioato  inflam-| 
nnation  of  tJie  stump,  any  tight  stitehea  niuiit  be  removed,  and  the 


dry  application  must  give  jtloco  to  a  warm  and  moist  one,  to  be 
renewed  daily.  Wliere  union  h  incomplete,  any  imltt^ltliy  slata 
of  the  granulations  must  be  treated  like  tho  samo  aifoctions  of  ordi- 
nary ulwr!>;  and  if  erysipeiiia  or  hoBpital  gangrene  »liouht  m-iiie, 
thoy  also  must  be  dealt  with  on  general  principles.  ExfoUatJM) 
from  the  honv,  onoo  an  invuriablo  nttonilunt  on  amputation,  in  now 
rarely  met  with,  except  as  the  result  of  mismanagement.  When  it 
does  occur,  tlio  doad  porlinn  must  of  course  be  runiuved  a»  tioon  os: 
examination  with  the  probe  allows  it  to  be  loose. 

Before  considering  the  operations  best  adapted  for  particular 
oaiicH  of  anijiulation,  it  will  he  well  to  allude  in  a  general  way  U>| 
tho  necessary  instruments,  and  the  mode  of  using  them. 

The  amjiulating  knite  should  have  a  straight  and  strong  back^ 
and  a  sliarp  point,  near  which  tho  edge  should  present  a  gentle 
convexity.  In  tlio  old  circular  aniptilntion,  a  curvo<l  kntfe  with  a 
blunt  extremity  was  employed  to  divide  tho  integument  at  one 


I 

I 
4 


*  I  ain  happy  to  bo  nblo  to  confirm  luWy  the  original  etatcmciit  matte  I 
on  this  Butjfct  |jy  Dr.  Sims  of  Nuw  Vorli,  to  wlioiii  illy  pi'ofosslou  is  ia 
debt*(l  fnr  demon  Blunting  tlie  vnUte  of  tlip  itielttllii:  slilcL.  For  passing  tbs 
wire  HmooUity  tlirnugli  tlic  tissues,  a  ni^citl<?  sufiucsli^d  by  m)-»elf  some 
ytars  u;-u.  unil  sione  i!»i)stniitly  otiiploy«iJ  in  the  Kiliiibuitjli  lutii-marj  aiid 
uiauy  utJiLT  plnvcs.  will.  1  believe,  lie  Afuoil  lUi.'  luutit  cuuvenieul.  It  is 
(grooved  nt  eiinii  siilo  fi'»ni  the  eju  lo  tLe  bluut  end,  these  points  t)c-inf[ 
fiirtlii'i'  from  one  anolhoi'  than  iu  aa  ordinary  needle,  Ctire  mUHt  be  tuki^n 
to  iinld  tiie  u-iri;  in  the  grooves  wliittf  tn-istin^'  its  ends  togutber,  after  wliieh 
it  will  be  found  securely  incorporatud  with  the  needle 


I 


4 


GENERAL  DIIlECnONS. 


71 


itinnouK  sweep;  hwt  as  llie  iimilifi(j^!  oiienilion  t»  n!w«j-s  prefcr- 
,  in  wtich  the  skin  is  cut  in  the  form  of  short  Bemilunar  fiajis, 
ioowwlixt  riiinwy  imiilwiiciit.  imiy  nmv  hv.  *:t»uv\y  iliijicriM.tl 
iritk  For  a  flap  operation  porfonned  br  transfixion,  tlie  hlstle 
ihnald  he  wlwitl  halt' as  loiig  a<rnin  an  the  diumotur  ot'  the  limh; 
bat  when  the  nod  partfl  are  cut  froin  without  inwanU,  a  muoli 
lorter  knifu  will  answer  tlio  pur^wMi,  and  shonid  iheroforo  be  pre- 
aa  tho  inovf^inente  of  the  smaller  instniment  onn  lie  directed 
witJi  greater  prec'i"ion  and  speed.  For  removinj;  a  linger  or  toe, 
Bomething  intemicdtnte  between  the  tapering  bintoury  of^n  imed 
in  France  and  the  old  round-ljcllied  English  HeAlj>ct  will  ho  found 
to  combine  llie  adviinta^s  uf  Ixitb  wilhimt  the  iiieonvenieiioes  uf 
•hfaer,  being  eqnallr  adapted  for  piercing  and  cutting. 

In  luting  the  knife,  the  vnmig  prtietltienor  will  hitvo  to  unlearn 
some  of  tlie  habits  he  has  acquired  in  anatomical  study.  TIlO  object 
being  now  dimply  to  ilivi<le  Lti»  r£«ii.«ting  texturem  etiioiontly,  tlio 
sttoking  and  scratching  movements  of  the  dissecting-room  must  be 
diangnd  for  n  free  Hawing  niotioii;  niid  for  ihiM  ]mrpo!>e  the  knife 
mnst  he  held  firmly  in  the  hand,  instead  of  being  kept  in  the  feeble 
poeittua  bml  suited  for  the  iiivwtigalion  of  delicate  ntnictitreit. 

Tbere  is  another  error  to  which  the  habits  of  <litBeetion  may 
lead,  far  niorc  iteri'>nK  than  a  crumped  and  awkward  use  of  Uto 
Imife,  vii.  that  of  directing  the  edge  of  the  inHtrumenl  towards  the 
•kin  in  raiding  a  flap  of  tntcgument.  Such  a  practice,  necesiary  in 
anaU>uiy,  to  avoid  injury  to  the  aubctitaneotu<  i>lniclun:-.->,  will,  if 
oiricd  into  amputation,  most  seriously  endanger  tlie  vibdity  of  tho 
Aap,  wiiich  derives  its  supply  of  nourtHhinent  fmni  ri?<!*eli'  riunifr* 
ing  in  the  fat,  and  must  |>erish  if  those  vessels  are  extensively 
i%-ided  llu^ugh  scoring  of  llie  tela  adijioM.  I  am  nutlAfied  that 
[tegument  designed  to  form  a  covering  for  tho  stump  is  often 
le  to  sicmgh,  for  want  of  fcrupuloiis  attention  to  Una  simple 
ipleh 
The  sicin  shntild  always  i>e  ent  perpen<lieuhirly  to  itm  surface, 
if  it  is  beveled  ofi'  to  a  thin  edge,  it  is  not  only  nnsuitod  in 
for  ad«)>(atH>n  with  a  vit^w  tu  primary  union,  but  the  margin 
may  oliingh  for  lock  of  natrunont. 

In  transfixing  a  limh,  the  ilireetion  of  tho  knifn  mu^t  of  eonrse 
be  ehangul  aa  it  passea  roimd  tlie  bone,  in  order  tliat  it  may 
energe  at  tlie  opposite  aspect.;  but  it  in  desirable  tliitt  this  »houlct 
ho  done  in  a  w>ntinuoa«  manner ;  for  if  tho  Instrument  bo  thruiit  in 
fiir  a  certain  dtslaneo,  and  then  partially  witiulrawu  iiikI  made  to 
foBow  a  new  track,  the  puuctui-vd  wound  first  made  may  cause 


n  AMPUTATION. 

very  tmnllflsome  h»morrhage,  if  &  considerable   arterial 
hap[>CD  to  be  (livtdcd  in  it. 

In  pasaiiig  tJie  kiiifo  round  a  bony  promineni^o,  ttiiclt  ax  tbo 
shoulder,  cure  must  hu  tnknn  U>  lioid  t]ic  limb  in  such  a  position 
•a  fllinU  rolux  tliQ  paits  that  are  to  be  pierced,  otlicrwiHo  vbat 
miglit  be  ([uito  cajiy  may  prov«  inipdH^ibli; ;  and  In  tho  laiter  part 
of  tJio  [iroce.i*,  when  the  point  of  the  knife  is  adianoing  in  n  prcatly 
altored  direction,  it  is  important  to  keep  tho  back  ratlier  tlian  Uw 
edgn  ilirartcd  In  the  aurfaoo,  in  order  to  avoid  cutliii{r  ttio  base  of 
the  flap. 

In  Din  I  >i  I  Idling  at  a  joint,  if  the  tissues  ajt>  lit-althy,  the  division 
of  the  soft  parts  completes  tJic  process,  there  being  no  need  to  take 
•way  th<'  .^^lit■llhu■  cartilage,  which  is  ahnont  iiw  fii\oiinilily  circoin- 
staueed  for  liealiug  as  vascular  structures.  Thns,  when  a  lingi>r  is 
removed  nt  t.Jio  motiitfarpo-phalangeij  ]H>int,  the  whole  wound  may 
nnit^  by  first  intention  ;  and  after  amputation  at  the  shoulder,  wlwro 
complet*'  itnm<^tliat^-  union  eunnot  be  expecltid,  the  cartilage  under- 
goes a  change  into  granulations  by  a  proeess  so  speedy  as  hardly  to 
delay  the  cure. 

The  sAiv,  for  dividing  tit»  hone  in  other  caseA,  should  be  broad- 
blaiktl,  witli  a  stout  back,  like  the  "  fine  saw"  of  the  carpenter, 
anil  should  )javo  ^inall  but  woll-itet  teeth.  In  order  lo  [iriunotc  the 
smoothness  of  its  actioii,  it  mav  be  smeared  with  a  little  olive-oil. 
In  applying  tlio  instrument,  lU  heel  being  placed  ujmn  tho  bone, 
previously  cleared  of  soft  parts  by  a  circular  snecp  of  tho  knife,  it 
b)i(iuI<1  iu  tlio  first  instance'  bo  drawn  with  firm  |ires»uro  towards 
the  operator,  so  as  to  make  a  groove  which  it  will  have  no  dispoii- 
tioti  to  quit  in  the  first  forward  stroke.  The  bone  is  thus  cut  pre- 
eisely  at.  the  place  desired,  while  any  scratching  of  the  noiglilK>ur- 
ing  parti«.of  the  osseous  surfaoo  is  avoided,  wliieh,  beeidos  involving 
loss  of  time,  would  be  apt  to  giie  rise  to  a  small  exfoliation. 

The  assistant  who  holds  tlio  limb  must  lake  care  not  to  press  it 
forcibly  u|iwiirds,  otherwise  the  wiw  will  Iteeoniu  loekod ;  nor  must 
he  draw  it  downwards  to  any  great  degree,  or  the  bono  will  break 
and  splinter  tiTWiinls  the  last.  8houl<l  any  pnyectitig  portion  be 
left,  it  must  be  removed  witJi  a  pair  of  bone-pliers,  which  nwy  be 
•ubstiltitod  entirely  fhr  tlie  saw  when  tlie  I»on«  is  of  very  v^mall  siie, 
aa  in  the  fingers.  In  using  them,  the  fiat  surface  slioold  always  be 
din-fHeil  towiinis  the  part*  tliat  are  to  be  pnwerxcd,  as  the  other  sides 
of  tlie  wedge-sliaped  blades  cru-sh  the  bone  while  tliey  divide  iL 

The  tenaoidimi,  long  universally  einpioycil  for  seising  tho  bleed- 
ing vessels  in  order  to  lie  them,  hu«  been  superseded  by  the  cttt«h- 


IN  THE  UPPER  LIMB. 


73 


I  wWcli,   likv  tlio  Ijofifi-pliers,  wore  iDtroduc(<d  into  snrgkal 

iSy  the  late  Mr.  Luton.      Besides  being  nlwn^s  more  con- 

voBBt,  tbey   liavo  the  f^i.'st  arlvantnge  of  making  the  Surgeon 

iodepaaidcnt  of  aii  aAstHtant  ia  cases  of  emergemiv.     Tliff  li^lure, 

ratntlng   of  Ptay-silk   or  strong  t}irpa<l  wvll  n-axcd,  Should  be 

tightW  and  aecunJy  tied,  by  reversing  in  tlie  itooond  lialf  of  tlie 

knot  the  rvlntion  that  tho  onds  of  the  Uircad  had  to  one  another  in 

tliefbnner  luilf,  or,  in  tiie  luigiutge  ofaailon,  l>y  inuking  n  "roof 

knot."    The  larger  vessels  should  be  drawn  a  little  way  out  of  their 

■heaths,  u  tlic  be»t  mc-juiH  of  avoi<liii<r  non-oitrt  tninkx  mid  othor 

vaneoueary  tissue.     Of  the  smaller  branches,  as  a  general  nde,  aU 

Uuit  nrc  WDD  to  puUato  itfuMiM  be  iml,  taor«  coxing  being  chocked 

by  the  ^entl«  preemire  of  the  dressing ;  but  in  order  to  render  con- 

Ijiicaoins  all  that  rctgnirc  tying,  it  i»  tnkM,  lioforv  dressing  the 

nuinp,  to  put  tlio  surfaces  of  the  wound  in  apposition  for  a  short 

ttmOj  and  bntiw  the  integument  wttli  warm  water,  so  a»  to  induoo 

nlaxatiun  of  iwiitra^t£<i  arteriee  whicJi  might  otherwi»o  cause  seoond- 

UT  hiemorrliage.     Uany  Surgeons  make  a  point  of  cutting  off  one 

end  of  each  ligatart:;  but  thU  ia  wtutte  of  time  and  trouble,  iinletis 

ibfl  threads  are  unusually  numerous. 

When  the  (oumi(|iiol  i«  employed,  it  shuuki  bo  kojit  !ooi»e  till 

tta  oji^ration  is  about  to  oomroonoe,  when  it  sliould  be  screwed  up 

Hra^dly  w<  jioMJble,  to  avoid  an  intermediate  dcgrvo  of  cinstriiv 

6m,  which  would  chock  venous  return  witliout  preventing  arterial 

[  fcw,  and  producu  engorgemcnl  of  tho  limb  with  bkiod  which  would 

I  V  lost  to  the  patient     When  it  ia  of  great  biportanee  to  retain 

BiQi^  of  tho  vitul  fluid  as  poMsiblv,  it  will  be  woll  to  apply  a 

tightly  from  below  upwards,  when  tho  patient  is  under 

n,  so  that  tbo  limb  to  bo  roinoved  may  contain  oven  l^^M 

1  the  umrtl  Miiount  of  blood. 

In  cases  in  which  tho  tourniquet  is  inappliesblo,  or  needless, 
•igita]  minpreMtiim  munt  bo  trusted  to  for  preventing  haemorrhage 
■Ding  tl]e  operation.  The  Glrength  of  the  assistant  on  whom  this 
^  devolves,  i«  often  early  oxhnii.'ilod  by  tmnet-esttary  exertion ; 
htbe  current  through  an  artery  lying  over  a  bone,  or  some  other 
*tiiMing  textnro,  is  completely  arrest<!ii  by  a  \-ery  moderate  amount 
' [RMure  directed  exactly  to  Uie  pro]>er  part. 


AmpuUtliont  in  the  vpper  extrtmittf. 

Tbo  Qpper  limb,  imlependentty  of  its  smaller  eke,  involving  less 
ilMck  to  the  ^'stem  from  tho  operation,  is  more  Eavourably  cu-crum- 


74 


AMPUTATION. 


stancod  for  nmputation  than  tho  lower,  in  consoqncnco,  appartntlv, 
uf  itH  [HiNseKiiii^  a  Ix^iur  viLiiriiltu-  !«ii)>piy  suid  HU]>erior  viUiI  jHiniT. 
Hiub,  to  take  away  tlio  ann  at  tItK  Hhoulder-joiiit,  is  a  much  safer 
prowwlinfj  tliiin  to  ntt  off  n  log  Imlow  tho  Uin^,  i^wi  tlion^h  a 
larger  wound  be  inflicted,  and  a  larger  portion  of  the  body  remov 
in  tho  fornuT  wwo  tlmn  in  tti«  latt<!r. 

The  particular  ampiitalions  in  the  upper  extremity  will  be 
conveniently  t-onsidered  in  tho  onler  in  which  tliey  oceur  froa 
below  upwards,  Tlie  diiital  phalanges,  though  verj'  liable  to  iujui^ 
and  diwKwe,  raroly  require  amputation;  for  the  removal  of  eruabi 
portions  of  bone  in  the  former  case,  or  exfoliation  in  the  laiter,  wil 
generally  leave  a  useful  end  to  tho  finger.  If  it  bo  wished, 
p)iHlan\  iniiy  he  readily  taken  away  by  ojieninjr  the  joint  acroKt 
dorsal  aspect,  iUid,  after  getting  the  knife  round  the  base  of 
bone,  forming  a  jiahnar  flap,  hy  cutting  from  within  oittward«. 
the  palmar  flap  may  be  first  cut  by  transfixion ;  and  this  being  held 
Up  by  an  asaiatant,  lliu  o[ierittion  is  eumploted  hy  cutting  rtraiglit 
through  the  articulation.  If  the  whole  distal  plialanx  be  crnsJied, 
HmjititHtion  through  the  SPPon<l  phalanx  will  lie  U'st  performed  Iiy 
eattJng  two  rounded  lateral  flajia  from  without  iuwanls,  and  di- 
viding the  bone  with  pliers- 
Removal  of  the  entire  finger  is  preferable  to  leaving  tlie  fi 
phalanx  hy  itself,  which,  besides  being  unseemly,  would  bo  n  mci 
ineumhrance,  oxeept  in  the  index  finger;  and  ov^  there  it  is 
Borvico  only  in  some  few  liandierafe.  For  the  middle,  or  the 
finger,  the  operation  i»  best  perrui-nu'd  ncconliiig  to  tlio  lidlnwi 
definite  rule.  Tho  adjoining  fingers  being  held  aside  by  one 
Mit,  while  another  com|tresses  tho  nuliiil  Hn<l  uhiiu*  nrti-rieH, 
Sorgeon  cats  from  tfie  prominence  of  tiie  knuckle  in  a  straight  1 
towards  tho  mi<ldle  of  tlio  web  on  one  sido;  but  ju»t  l>e)«rc  rcaelii 
tlie  woh  carrieLS  the  knife  inwards  to  the  fold  between  the  fi 
■uid  tho  ]Mdm,  and,  alWr  uiukiug  a  similar  incision  on  tho  ol 
BJdc,  accomplishes  the  disarticulation.  The  edges  of  the  akin 
1)0  fouml  to  mwtt  exactly  on  approximation  of  the  adjoining  fiU] 
which  should  1)G  kept  tied  in  that  pusition  to  avoid  disturbing 
proeew  of  union.  Itemarkably  littlo  deformity  rcsulbi  from 
operation,  BO  tliat  removal  of  the  bernl  of  tho  metacaqial  Nino 
tho  wikc  of  appeunmco  is  quite  uncalled  for.  If,  however,  it  is 
any  time  necessary  on  other  groundit  to  twku  away  a  iHirtiiin  of 
mobicarpal  bono,  this  can  be  readily  done  by  tlio  same  metiiod, 
oept  that  the  incisions  are  made  to  ntart  from  the  place  on  the  b. 
of  tlio  luuid,  where  the  bouo  is  to  bo  divided  hy  tlie  cutting  pliers. 


tlu 


IN  THE  UPPER  LIMB. 


76 


ibnovr 


TSe  index  tlnf:cr  may  Iw  removed  in  n  similar  muinor,  can 
;  iRkwi,  in  nuking  the  incision  on  the  sitla  nvxt  the  thnmt),  to 
tbo  kni&  fix>m  tlio  jioint  of  tito  knuckle  in  a  loii^ilti<linal 
to  near  the  level  of  Uie  wob  bctw-coii  the  Qngtira,  before 
it  off  towxnU  the  palm,  othcm'if«e  the  flap  will  Iw  ineiiflj- 
to  oorer  Uiu  raw  ^ur^a(.■e.     A  jirofenihlo  mvUiod,  however,  is 
<  dorsal  and  palmar  flaps  of  rounded  form,  bv  milting  from 
*«b  between  tlin  tiii<;<TH  to  a  [toinc  oii  t)ic  opjxtsito  side  of  the 
at  a  soflicicntlr  hiph  level  to  allow  the  end  of  lh«  n\Hii- 
haae  to  bo  tnkc-n  ofl*  ubliijiu^W,  with  jilicrs,  so  as  to  get 
'wint  would  cause  an  imseomiy  prominence.     But  if  it  bo 
to  remova  a  cotiMitleruhlc  |>ortion  of  tho  metacarpal  hone, 
roetbod,  with  tlie  dorsal  part  of  the  iiiciiiioii  extvndod 
,  will  lie  t)w  hvA 

rules  apply  to  the  little  flnger,  and,  in  caao!i  requiring 

I  wbole  ntctantqud  bone  may  be  romovod,  br  commencing  tlie 

a  little  abo\'e  the  articulation  witli  the  m  vnri/orme,  so  as 

ifmco  tor  dinding  tlio  ligamiMit«  aflcr  clearing  the  bone  of 

<  which  Bunx>nn<l  it 

imtion  of  the  thumb  is  valuable  for  opposition  to  the 

>,  but  if  meoMarf  tliu  whole  of  it  may  bo  tukiii  away  by 

in  a  curve  witlt  the  convexity  downwards,  i'rom  Uie  wob 

it  with  tlie  fore-ftngor  to  tlte  opposite  sido  of  the  joint, 

the  don>a)  and  pidmiu-  iuipc>etj*,  raiiu'ng  the  rounded  flnpa, 

i  dwliculating.     Tlie  whole  metacarpal  bono  may  bo  removed 

with  tlu)  thumb  on  a  similar  plnii,  by  entering  tlio  knifo  a 

I  abovn  tlie  aniculation  wttli  tJic  trapezium,  and  cutting  first 

■hitiiliy,  iui<l  then  with  a  gontic  curvo  to  the  w«'b,  on  each 

I  (itlie  boae,  tlien  dissecting  up  the  flajM,  and  dividing  thohga- 

'  of  thf  joint*     Thia  operation  has  iwcn  often  performed  for 

'  of  the  metaoaqtol  bone ;  but  from  a  ease  lately  published 

Synw,  it  would  appear  tliat  under  such  ciniimNtanovs  a 

I  tbomb  nuiy  be  prwerved  by  excising  tlie  bone  affeeted.| 

tlmtiih  nlnno  or  a  single  finger  being  far  iiioro  lucliil  than 
snilicinl  subeUiuite,  hIhxiM  aluuy^t  be  n>(ained  if  possible  in 
tafinjaiy ;  but  as  a  general  rule,  when  tlio  carpal  articulations 


I  fm  ranoting  tli«  Uiomb  or  1iu1«  finger  with  tho  lactHcnrpsI  bon«, 

of  ai>«r«lin((,  HumeoltiU  uii<re  rapid,  but  in  other  rospeeta  di»> 

\  ligMHH  oTcn  when  applicablv,  with  recommriided  before  llin  intn>> 

I  a  of  anwklbvsia.    At  prrMint  it  iippenn  uolj'  ueovtiBary  lo  moDtioa 

I  n*  walnUaWd  lo  Kiw  Ui«  best  re«iilts. 

I  ia  ObtktU  Bmrytry.  p.  9t). 


76 


AMPUTATION. 


are  openwl,  the  whole  hand  will  require  n>[noraL  (Srcnmstancei 
would  occanioiially  »<liiiit  of  miijmUtion  nt  the  vrr!M-joiiit,  »hj>. 
puKJiig  this  a  desirable  procedure.  But  of  its  two  alleged  advant- 
age* over  am  pit  tat  ion  in  tho  for^^-a^m,  v'a.  the  retention  of  [in>na- 
titiii  and  HU]>ii)ation,  and  a  longer  stump,  the  former,  eupposing 
such  moveravutsufan  artificial  limb  to  he  desirable,  wuulil  prvhablv 
be  (iflen  prevented  by  fibrous  union  between  the  radius  and  ulna, 
wliilc  the  latter  is  found  by  the  inKtnimcDt-makurs  U>  eucroach 
upon  ttie  tipaoe  required  for  adapting  the  artifiuial  limb.  The 
operation,  if  desired,  may  bo  performed  by  ctittin;;  arro«a  the 
biu'-k  of  the  WTiat  from  one  styloid  prooeits  Ui  the  ntlicr,  in  a  line 
presenting  a  slight  concavity  downwards,  in  aeoopdanee  witli  tlie 
form  of  thu  artieiihition,  ojiening  the  Joint  on  iUt  d»n«nl  a»pMt, 
then  shaping  a  roujidcd  fla])  in  the  palm,  raising  it  to  tJio  joint, 
wid  dixartic-iilnting.  Another  method  is  to  cut  tlie  palmar  flap 
from  witliin  uuhvards  after  disai'ticulation :  hut  the  prominence 
of  the  ptHiform  bono  prevenU  thin  troiu  being  satis&ctorily  acociin- 
plished. 

Am  pit  tilt  ion  in  the  fore-arm  is  best  performed  by  nntero-poe- 
terior  flaps.  In  front,  where  the  muscleti  ai-e  Jn  larger  amount, 
tnin«fi]uon  may  be  adopted ;  hut  behind,  the  presenco  of  the  two 
bones  prevent*  this,  exeept  near  the  wriM,,  where  it.  may  be  cH'wlwl, 
provi<led  the  w>fl  parts  have  their  natural  laxity,  by  pinching  up 
the  skin,  and  passing  the  knife  a.t  elu»e  to  tlie  radiuM  and  ulna  a* 
possible,  when,  af^r  the  integument  has  fallen  back  to  its  iwuJ 
position,  tlie  exti'emities  of  the  wound  will  he  plaocd  mo  far  forw: 
that  the  knife  can  he  introduced  through  them  in  forming  the 
tcrior  flap.  Hut  it  is  probably  always  well  to  eut  the  dorsal 
from  without  inwards,  and  to  raise  it  so  tliat  it  shidl  consist  ehieflj 
of  intejiLmi*''''*!  i"  order  that  redundancy  of  muscle  and  eonseqt 
tension  may  be  avoided.  Tlie  Snr^on  standing  on  tJie  (patJimt** 
left  side  of  the  limb,  and  liolding  it  with  (he  dorsal  stu-face  towa! 
him,  cntom  the  knife  a  little  to  tlie  palmar  side  of  the  1)ono  that 
the  further  from  him,  and  cuts  through  the  skin  and  fat  so  as 
shflpe  a  ronndivl  dorsal  flap,  terminating  the  inciftioii  ii  little  to  { 
palmar  side  of  tlio  nearer  bone,  where  he  at  once  pushes  in 
point  of  the  knife,  so  that  it  may  pass  in  fiwnt  of  the  bones 
emerge  at  the  place  where  the  operation  was  commeneed,  and  cufi 
a  flos-hy  jialmar  fljtp  from  within  outwards.  He  then  dissccU 
the  dorsal  flap;  and,  the  sofl  parts  being  drawn  back  by  an 
ant,  clears  both  bones  thor()Ugidy  about  threis-qunrters  of  an  mi 
higher  up,  and  applies  the  saw.     The  interosseous  artery,  whic 


IN  THE  UPPER  LIMB. 


bcsido  tlio  iin^-iolding  interoefleou!)  membrane, 
secured,  as  well  as  tlio  ntilinl  and  uliiar  tnitikii; 
bt  median  or  ulnnr  ncno  is  «xpo§ed  in  ihe  inilniur  flap, 
1  be  •bortcncd  wiUi  Hci9«»n!i,  to  prevent  the  ocourrencfl 
il  symptums  a&  die  aturap  beals.  For  jin^vontiiig  luemor- 
iring  tfae  opi>ratiun,  it  i«  n»  well  to  s[>pl,v  a  tourniquet  to  tlie 
the  free  arteniii  anastomoHb  in  the  u|)[ier  limit  mny  c&xae 
in  spile  of  vffoctual  digital  comprcselun  of  tlie  brachial 

I  is  tw  objection  to  Amputation  at  tho  elbow-joint,  in  caaen 
Ifar  it.  Tbe  most  nliffiblo  ptun  i»  to  «ut  n  lur^^v  imtcrior 
I  iriUiin  ontvards,  after  transfixing  tbe  partia])v-exlen<leii 
ftont  of  tliv  joint,  iM'jkrinf;  in  mind  tbat  tlio  lino  of  the 
KU  is  obliqoe  to  the  axis  of  tbe  humerus,  and  is  onnsider- 
Ukt  botow  tlw  internal  tliim  tho  external  condyle.  Tlio 
tg  tben  held  up  by  an  n.tsistant,  the  points  of  transfixion 
iMted  puetcriorly  by  a  ecraictrcular  stroke  of  the  knite, 
Bsides  dividing  the  integument,  prntxibly  detaehen  tho  ra- 
I  s  few  touches  with  tbo  jioint  of  the  instrument  will  sever 
ntiona  of  the  ulna.  The  iL«!>i!ttinit  nhonld  ki^-cp  the  xkin  of 
of  tho  arm  drawn  upwards  during  the  operation. 
utatioii  of  t)ie  arm  presents  a  jiootl  exomple  of  tho  double- 
atioii  by  traiLinxion.  Tho  jMtint  of  the  knife  being  entered 
it  of  tbo  limb,  avoiding  tbo  site  of  the  brachial  ve««el»  and 
Is  pusbod  on  in  front  of  Uie  Iwne;  and  then,  by  slightly 
JM  handle,  is  made  to  emerge  at  a  place  exactly  opposite 
Ifinr  flap  U  tJwTii  cnt  with  a  brick  nawing  movement  of  the 
nt,  which  is  first  directed  longitudinally  for  a  short  dis- 
1^  then  tumvd  grndtially  towards  tlie  Hurface,  and  brought 
Mndiodarly  to  tbe  integument  Tbe  flap  is  now  lightly 
grtbe  BmiMKnt,  without  any  trnction,  for  this  would  inter- 
h  tnu»fixion  behind  the  bone,  which  is  eft'ectcd  Uvongh 
Mtilics  of  tho  wound  already  made,  and  tbo  posterior 
art  like  tlie  anterior.  The  assistant  now  retracts  tho  flapH 
WtMo  a  firviilar  sweep  of  the  knife  exposes  the  bone  about 
t  ihovB  the  angle  of  union  of  the  flaps,  and  another  »imi- 
I  of  the  inftnimont  preiiares  it  for  the  applii'iition  of  tho 
IW  nlgen  of  the  wound  meot  accurately  when  brought  togo- 
nduring  a  symmetrically  rotmded  stump. 
Ifutetian  at  the  »I»atdcr-joint  is  an  operation  which  yields 
Itfafachirj-  nsults,  as  waj»  strikingly  shown  by  the  cxjiori- 
f  tW  isle  Baron  Larrey,  who,  during  the  wars  of  tlie  first 


78 


AMPTJTATIOBf. 


Kiq>oleonf  saved  ninoty  out  of  n  Imndred  cnsea,  in  spite  ort]i«  tctj 
nnfarotmtblo  rircumHtanwfi  of  military  practice.*  ^ 

Of  tlio  various  iitettuKlM  tlutt  tnv«  been  propoMxl,  that  of  LmA 
frftne  is  tlif!  tDOHt  cspwUliouB.  Tlio  arm  being  raiwd  so  as  to  relax  ' 
tlw  deltoid,  iliA  piiiiil  of  ii  long-bliulud  knifu  In  itiinHluM^d  about 
midway  between  tlie  cwracoid  and  acromion  processes,  and  tUruHt 
round  itio  oiiWr  "id*'  of  tin;  joint  till  it  tvuncw  out  williin  the  |»6- 
tcrior  fold  of  tlio  axilla  (or,  if  the  left  limb  be  the  subject  of  o|>era- 
tion,  tlm  diiTctioii  of  trunHixiuii  is  reversed),  wlivii  n  large  mus- 
cular external  flap  is  rapidly  cut;  and  this  being  held  uji  by  an 
UssifUiit,  aD<l  the  nrni  drawn  d<iwnwardi(  and  forwards,  the  joint  is 
opened  by  cutting  iirmly  upon  the  head  of  the  boDe,t  which  ii 
then  raised  from  its  wjcket  so  that  the  knife  may  be  passed  round 
it,  and  carrietl  downwards  along  the  inner  surface  of  its  niN:'k  and 
shaft,  followed  by  tJio  other  hand  of  the  assistant,  which  grasps 
tlie  ti**iios  that  Ho  between  the  track  of  the  inatrument  and  ilw 
axilla,  so  as  to  prevent  bleeding  from  the  main  artery,  when  it  is 
divided  in  the  completion  of  tlie  »hort  intcmid  Itnp. 

This  operation,  Iiowcvor,  is  rarely  available  in  ])nictice.  Its 
satisttn'torj-  iierfortiiimeo  riH^uirea  tlie  levei-aj^  of  tlie  humerus, 
which  is  generally  broken  in  cases  of  injury  demanding  removal 
of  the  limb,  in  ivliieli  alw>  the  |mrti»  noceswiry  for  tlie  large  exteniid 
flap  are  ofton  encroached  ou  :  and  in  tumour  of  tho  bono,  which  is 
the  other  alfeetion  thut  moftt  frequently  calls  for  ainpiitaliun  in  this 
situation,  transfixion  becomes  impossible. 

On  tho  oilier  hiuid,  Larrey's  mode  of  ojKtrating,  by  lateral  flaps 
of  ec^ual  size,  proved  almost  always  applicable  in  hia  cases  of  giui- 
shot  wound,  >vliile  it  was  as  secure  ngiiinst  lia-morrliago  as  that 
Licfranc     Tlirusting  tlie  point  of  a  knife  of  moderate  lenn^tli  do' 
to  tlio  bono  iiinnwlintely  below  tho  neromioti  process,  Larrej- 
made  ■  longitudinal  inciitton  about  two  inches  in  length,  from 
extremity  of  which  he  cut  in  a  curved  line  at  each  sido  of 
limb  to  the  fi)ld  of  the  axilla;  then  disHOCted  up  the  fla(i«>  so  an 
expose  tho  articulation  completely,  a  finger  of  an  assistant 
placed  u[HiTi  the  divided  eireiinitlex  artery;  and,  having  tev 
tho  cwnncxions  of  the  head  of  tho  humerus,  passed  the  knifo 


*  Memoir*  d*  CliirurfU  Militairt,  pur  Le  Uttron  ]>.  J.  Larrejr,  torn,  it 
p.  4M. 

f  Stri(!tly  spi-nkinK,  tliix  is  DupuybrcMi**  modificution  of  the  uiMhod  i 
I.Urriinc.  who  <l«[>ie6SEii  tlic  niin  lit  llie  eomiiii.'npenicnt  of  llic  ojimtti 
anil  opened  (he  joint  iliiring  tlm  tmn^fixioii:   but  thi«  wnii  a  less  tmsj' ] 
cocdfng,  though  shorter  by  a  tev  seconds  in  very  expert  liauda. 


IN  THE  LOWER  LIMB. 


79 


'a,  ml  Vept  tito  instniini'nl  f'I<i««  to  tlw  iniwr  niilu  (»f  the  bone,  till, 
tuniia^tiie  odge  towards  ilie  surface,  ho  b&t  of  all  dividrtl  iraiis- 
nswlf  tbu  tissdOrt  intcn'(rniii<;  bctwcm  the  axtUiiry'  folds,  cmitain- 
ingdeuten.',  [treriouNi^  oomntandod  by  tlie  luuid  ot'tlie  uMi»tunt 
fclowing  the  kuifu.* 

Tiaa.  operation  is  improved  br  dividing  the  struotiin<H  b«-(wocn 
tin  folds  of  tlio  nxilln  obliquely,  as  part  of  (Ihi  internal  flap,  the 
lower  purtion  of  whiuh  in  rettervcxl  lu  be  viit  from  vrirtitn  onlwanbi, 
it  llw  coacliuion  of  the  operation :  the  reeuh  being  two  proeisely 
■tutUr  »>;milun»r  i\m»,  meotinfr  nlxivi'  nt  tbo  xcromion  and  below 
ct  the  posterior  fold  of  tbo  axilla,  adapted  for  innnediate  union 
throaf^iotit  their  Icn^^h,  luul  pniiH^ntinj^  as  small  a  woond  as  is 
Oomi<Uent  with  an  efficient  eovering. 

When  tlio  Uititt  in  brolcrtn  near  the  joint,  it  will  be  fonnd  uHrfol 
to  adopt  3Ir.  Synio's  expedient  of  iiitrodu4>ing  tltn  finger  into  a 
longitudinal  wound  in  tlio  eapsulo,  for  tho  purposo  of  <Iniwing 
down  the  iiead  of  the  bouo  »o  att  to  gain  ancesa  to  it^  attachments. 
In  (ooic  aue*  of  tumour  it  mnv  bo  nccossary  to  raise  all  the  soft 
{MTta,  incloding  the  axillary  ve»selN,  from  n-itliout  inwanU;  when 
bKraorrha^'  intu>t  tw  restrained  by  compression  of  the  eubclavian 
er^'  over  the  first  rib,  by  the  tliumh  of  an  lus^iifttmt  prvMOtl  down 

tho  collar-bone. 

Somntimes  it  may  be  b(Ht  to  make  a  largo  «iip<>ri«r  flap,  cut 

[frnn  witlKtut  inwarde,  oonlaining  the  whole  width  and  chief  length 

1  if  thi!  delt4>i<l  mtutcle ;  hut  circiimntiuicvH  will  ot^i.-n  uriin-  in  whioh 

I »  nignUr  rule  can  be  followed,  and  the  parte  that  hapjicn  to  bo 

jmiMl  mnol  be  lurn»l  to  tl>e  br»t  advantage,  »cc>onling  to  the  judg- 

[  Bsl  of  the  operator.      Even  when  a  largo  raw  surtaee  is  left,  tlio 

ipiBulating  pmcvHK  will  ivMnpli^te  the  cure,  as  i«  well  ilhmlratwl  by 

■  of  Latrey's  cas?8,  wliieh  tormuiated  satisfactorily  after  oxten- 

'  IcM  of  tlw  Roll  imrt»  of  the  shooldor  and  reiuoviil  of  p<»lions 

rftfa  scapula. 

AmpHtalionf  in  Uk  lower  eietmtiit>f. 

Tbe  dixtal  phalanx  of  tlie  great  toe  may  be  removed  in  llio 
M  way  as  that  of  a  finger.     When  one  of  tlio  amallor  toes  is 


'  Dvriiig  wno  i>erind  of  hia  ptiwtic^.  ho  formed  tho  lower  parts  of  Om 
■ptftntufitiiig  fniin  UmmkI  i>f  the  toncfiluditiiil  iui;i«on  to  (lie  boril*r« 
*'lfe  uilU.  atii)  cutting  from  nitlilii  otilwniili:  t>ut  thn  ittrthod  fitviTn  in 
'^irtl  M  tlut  Ui  whtcfa  lie  ulliiiiAlcI;  ^vc  tlio  jircfrrviioc.  S««  I.ajTc]f'tt 
<^i(w  ClUrwyWJ*,  \tm.  p.  063. 


80 


AMPUTATION. 


er 

i 


i 


iu  a  condition  roqiiiring  »niputation  nt  all,  it  must  be  taken 
entirely,  by  >m  opcratiou  exactly  sitnikr  kt  that  for  a  finger ; 
must  l>o  boniv  in  niiixl  tliut  ttie  artiitulatlun  with  ttiii  nictAlanal 
bnn«,  whicli  is  the  starting  jmint  for  the  inciolona,  is  much  further 
boLiiKl  l.lio  web  than  th«  forrcapimdiiig  joiut  iu  llic  luuul,  in  pro- 
portion to  the  sizo  of  the  digit. 

Whcii  the  whi>l«  KR'iit  lno  i»  removpil,  the  proniinpnt  part 
the  lieod  of  the  melatju-sal  bono  uiuat  bo  cut  off  with  hi)iic-pli«r9; 
M  it  would  ]irovo  ill  con  V  VI)  ion  t  if  left.     In  uiiputattiig  the  great 
or  little  toe,  together  with  the  whole  mctatarHal  bone,  it  i.<  lim*  to 
proc«od  as  in  the  mialo^fous  (i|icr!itiun  for  the  HttJo  linger,  tho  inoi- 
8iou  lieitij;  (tontniencnl  on  tho  dorsum  of  tlio  foot,  about  ii  ({lutrtcr  of 
an  inch  behind  ihu  nrlieidiitioii  with  tlio  tarHU^,  and  carried  longitn- 
dinally  tu  niuir  the  niet;it;u^o-phutatigiml  Joint,  wlmn.!  il  bifurcates 
to  embrace  tho  root  of  tlio  too.    TIio  knife,  wluch  should  be  a  strong  j 
one,  i»  then  u}i|iIIihI  with  n  i^lioi't  auwin^  iictioii  oIohi;  tu  tho  meta- 
tarsal bono  and  its  articulation  with  tho  toe,  so  as  to  clear  theni' 
eompicl^'ly,  and  the  ligiuueiitous  attiichmcntit  of  the  buw)  of  tho 
bone  are  lastly  divided  with  tho  point  of  tho  iiistrumenL     In  the 
cawJ  of  till!  great  toe,  it  i»  c«|iccinlly  im[KiH')nit  to  keep  the  knife  ^ 
well  under  command,  and  avoid  thrusting  its  point  deep)*  into  thafl 
BoW ;  for  this,  Wsides  inflieting  iniiiw-OMSary  punctures,  may  wound  " 
the  pbutar  artery  at  a  part  diffieidt  of  access.     TIii»  mode  of  rc^ 
moving  the  great  or  Httlc  toe  and  its  metatarsal  bone,  though 
not  so  rapid  aa  that  of  dituecting  up  a  flap  from  the  midv  of  the  ^ 
foot,  then  cutting  between  tlio  too  to  bo  removed  and  the  adjoin* 
iiig  one,  and  di^^ai'ticulatiiig,  has  the  great  advantage  uf  avoiding 
any  sear  in  tbo  sole. 

if  more  inclati(r»il  bones  than  one  require  removal,  tho  indsic 
most  be  begun  in  the  same  way,  but  made  to  include  the  rooto  of  1 
all  th<^  toc»  eoiiccriKHl,  so  as  to  form  a.  dorsal  and  a  plantar  flap;' 
and  even  in  case  of  caries  in  tlio  articutatitm  li<;twecii  tiic  lanini' 
and  metatarsus  at  one  side,  a  useful  foot  may  be  lofl  afler  takingj 
away  the  hones  afieoted,  by  moans  of  a  similar  incision  commenced 
further  back. 

The  sc[iaration  of  the  whole  metatarsus  from  the  tarsus  is  an 
opcrntlon  seldom  called  for;  but  it  is  evident,  troni  the  aceouiitj 
given  by  the  late  Mr.  Hoy  of  Leeds,*  who  Introduced  it,  that  it 
nfibnU  cxcellfiit  result*.     When  the  stato  of  the  soft  parts  [H-rmitd,  I 
the  ends  of  the  exposed  tarsal  bones  should  bo  coverod  with  a  longl 


*  Hoj'B  Oburvatiuni,  ]i.  SSS. 


IN  THE  LOWER  T.niB. 


m 


mf  bom  the  no\o,  turned  np  to  ntiito  vriUi  the.  dorsal  intv^incnt, 
oilTwy  *liort ;  so  that  the  ck-atrbi,  being  <m  the  np\wr  pait  of  the 
fwt,  may  \tv  out  of  tlto  way  IwtJi  of  ]iri:s,'>«n>  in  wiiUiitig  and  of 
mitaet  with  objects  in  front  of  it.  In  porforming  tlie  opeiu* 
(ion,  it  mn*K  Ix,'  n-iwrntHTt-d  that,  the  torno-ini-tatJirf-al  orticolii- 
tMU  ar«  not  in  a  regular  lino,  but  that  the  baj^e  of  tlio  m3C!oiu1 
BwbHanal  Wne  »  locked  l>cln-oen  tho  linit  »i<]  tlunl  cunci&nn 
bones,  of  which  iii*  former  is  Ui*  more  prominent,  and  i«  con- 
nected laterally  with  the  wvond  motHtanal  by  a  very  Htrong  in(«r- 
omwHts  ligament.  To  divide  tliis  ligament,  Lisfrnno  tuhipted  Uio 
plan  of  thniRttng  nn  amputating  knife  obliquely  downwartlH  and 
badEwanIa  belweon  the  first  and  Heoond  uieutarNal  Uiuiv  inlii  the 
nb«tanoo  of  tlic  »olc,  the  tissues  of  which  served  as  a  fulcroxn, 
sopportiDg  tbo  point  of  the  inHtrunient,  when  it«  eil^i  wiv  urged 
fiirably  between  tho  hoMs  of  the  hones  by  pushing  the  handle 
baekwarda.  Ttiis,  Imwever,  is  a  nccdletuily  rough  pron^iling ;  for 
by  pTvssing  firmly  b«ck  between 'the  bases  of  the  bones  a  strong  and 
abort  knife,  tiiieh  ii.'<  ought  to  l>e  tiood  for  tho  n'Jit  of  tiio  ogx'nilion, 
the  ligament  may  he  cut  without  difficulty ;  after  which  all  tbe  arti- 
eabuono  nn*  WMidiiy  tiepauritted  hy  scrateliing  thn>ugli  the  dor-ml  and 
ether  ligaments  with  the  point  of4lie  knife,  wfiile  ilie  metatarsua  is 
«n>t(gly  deproeaed. 

Tbe  secret  of  fHeiUty  in  the  operation  lies  in  hitting  the  line  of 

the  artictilutiiiDN;  hnt  iJii*  i»  reatlliy  enough  dono  by  liiuling  first 

iho  joints  of  the  first  and  fifth  metatarsal  bones,  and  beaj'ing  in  mind 

Uat  the  otlxTw  li«  in  a  line  between  tliem  ulightly  convex  forwards, 

tBtompGed  by  tlie  recession  of  tJie  seconil  bone,    Tbe  prominence  of 

ll»  haM-  of  IIh^  fifth  metatarsal  indicatus  the  icitiiation  of  its  joint, 

■>!,  if  tbe  pans  be  in  natural  condition,  the  artieuUtion  of  tbe  first 

Matanud  with  tJio  first  ctineiform  can  also  be  felt.    S)ioukl  tnftam- 

Hlery  thickening  obscure  the  position  of  the  tatter,  it  might  be 

fd  ID  roi:a«uro  the  dintanco  of  tho  corrof^mding  joint  from  tliv 

■tenial  nalleohia  on  t!>e  !M>und  loot ;  or  asaislance  may  be  derived 

■Wn  ihe  rircnm»lnnec  that  tin- joint  lies  midway  between  tli«  maJ- 

nfa*  sod  the  metatarsn-jihalaugcal  articulation. 

Iheae  point*  having  been  precisely  ajfcortainod,  tlic  8nrgooD 
^np  tbe  fi>re  part  of  tlte  ftole  with  his  left  hand,  placing  tho  tip 
■Ihe  li>re(ingcr  at  one  of  tbo  joints,  and  the  tliunili  at  tlie  oliicr,  to 
■rt  ihmr  poflition,  atM)  cuts  firmly  across  the  dorsum  of  the  foot 
■  •  lin"-  i»lig}tlly  ormrrx  forward*,  a  littk'  anterior  t«  tiie  arlicu- 
■»i»,  taking  care  ihat  the  incision  commenoes  an<I  ends  fairly 
fa  ibe  aolo.  He  tlieii  ojwns  tli«  joints  of  the  first  and  fifth  meta- 
TOI.  UL  0 


82 


AMPUTATIOIT. 


(arsal  bones,  so  a*  to  insure  finding  Urn  lino  of  the  uttcnlafions 
Rftcrwardft,  aiid  next  shapes  a  long  plantar  flap  hy  an  inci.4i<>ii  ex- 
tending from  Uio  Gxtromitios  of  tlmt  already  inadc  along  tbo  sidea  of] 
ttio  foot  and  root<>  of  the  tooA,  dia^enU  up  tlie  flujt  from  tlii^  bonee, 
and  completes  tho  disarticulation  in  the  manner  above  dtwcribcd. 

When  the  anterior  part  of  tlie  sole  is  unsound,  a  shorter  plantar 
flap  and  a  proportionately  longer  dorsal  one  may  be  made,  us  reoom- 1 
Diended  by  Sir  Astloy  Coii(ier." 

SoniDtimoB  tho  proceeding  may  be  greatly  simplifiGd  by  sawing  ' 
throuf;h  tho  riii.'latarMuI  bones  a  Uttle  anterior  to  th<iir  iMMt-H,  luid  ho 
avoiding  dieaiticulation  altogotlier.     This  metJiod  would  probably 
bavi>  niiotlier  advantage,  lTi>ni  making  the  stump  of  l.lio  r(>{>t  lunger^  fl 
and  tJierefore  a  more  offeetual  lever  for  opposing  tho  muscles  which  ™ 
act  upon  tlie  calcaneum  througli  the  u-ndo  Achillis;  fur  i^xjicricnoe 
ha»  ahuwii  tJiat  when  tJjo  foot  is  much  shortened,  the  heo!  is  apt  to 
bo  drawn  up,  so  as  to  cause  the  end  of  tlie  stump  to  point  more  and 
more  towards  the  ground,  producing  lameness  or  entire  inability  to 
walk.     Tliia  has  been  notieed  especially  after  Chepurt'n  amputation 
through  tho  tarsus,  which  is  consequently  an  undesirable  operation^ 
even  in  eases  of  injury ;  while  in  caries  it  is  further  object ionable,,| 
because  the  part  of  tlie  tarsus  left  behind,  tliough  apparently  sound;' 
lit  till!  time,  is  apt  to  hceome  afibcted  with  the  suiue  lUscaso  at  A 
later  period. 

If  it  be  wislietl,  however,  Chopart's  operation  maj-  bo  performed 
on  the  same  principle  as  Hey's,  by  making  a  verj-  sliort  dorsal  flap, 
and  a  plantar  one  reaclung  to  tho  halls  of  the  toes,  to  covvr  tho'  ox- 
]K]se<l  anterior  surfaces  of  the  astragalus  ajid  09  calcla.  The  articu- 
lation between  them  and  tho  navicular  and  cuboid  bones  will 
found  in  a  line  running  across  the  foot,  thi-ough  a  point  midway"! 
between  Uio  external  malleolus  and  the  base  of  the  fifth  mctatonsiitl 
bono. 

In  tho  amputation  at  the  ankle  dcvisod  by  Mr.  Syme,  tJie  boni 
of  the  leg  arc  divided  jn.st  above  the  hiises  of  the  malleoli ;  a  cover- 
ing for  tlie  osseous  sm^aces  being  provided  fivjm  tho  integument  of 
the  heel,  fitted  by  tho  oharacter  of  its  epidermic  invcntinciit  and  sui 
cutaiiefius  cushion,  for  bearing  the  weight  of  the  body. 

Hence  thu  end  of  the  stump  Ijeeomes  a^  eajuible  of  miKtaini 
presEuro  as  the  natural  sole ;  and  when  the  deflclcnt  spring  of 
arch  of  tlie  fo<jt  i.t  ei>mp<^!n»ateil  by  some  elastic  m«t»-rial  cunlnit 
in  a  very  simplo  boot,  the  limb  proves  nearly  as  useful  as  in  ii 


I 
I 


•  Surgical  Lectura,  editod  by  Tymell,  vol.  U.  p.  433. 


IN  THE  LOWER  LIMB. 


8S 


condition.     At  Uw  fuune  timo,  the  parts  likely  ta  orifjinats 
.  dneaso  are  ooni|ilctcly  gnt  rid  of;  m>  tliat  ttiia  operation  ia 
to  BUfierseUe  t>ntirely  Umt  of  Chopart,  beaideo  taking  ii» 
of  mmpnta&ioQ  of  Uto  leg  in  ttie  miy'ority  of  the  caws  formerly 
nqipoMd  to  <lemand  it. 

Tlut  operation  should  be  performed  as  follows.     Provision  being 
made  agMiist  hsemorriiage  fi-oDi  the  anterior  luul  poftdrior  tihiol  ar- 
teries, by  the  pressure  of  tlio  thumb  and  finger  of  an  assistant.  pUoed 
iMpactivcly  on  tl»e  middle  of  the  fore  juirt  of  llie  limb  And  behind 
the  libia,  about  two  inches  above  tlio  joint,  or  by  a  tourniquet  ap- 
plied over  tvro  ruUerti  occupying  tha'M^  HltnatJonH,  and  tlie  foot  licing 
tield  at  ri^bt  angles  to  tho  1^,  tlic  Surgeon  puts  hts  lotl  hand  behind 
tlie  bed,  with  [lie  Hngi>r  uixl  thumb  on  the  places  where  tlio  inoUions 
ftre  to  oommcnoe  and  terminate ;  these  being  the  tip  of  tlie  external 
nudlwlns  anrl  tliu  point  oxnc-tiy  opjxMite  on  the  inner  xide,  i  f.  not 
at  the  tip  of  the  internal  mallooluB,  but  considerably  below  and  be- 
hind iL     Witli  a  knife,  Kliori  and  :<lriiiig  buUi  in  bU<Ie  mid  liaiidio, 
he  now  cuts  down  to  tiie  bono  across  the  sole  fixim  one  of  these 
points  to  thv  other,  in  a  plunv  not  qiiilo  vertical,  but  itloping  slightly 
lawards  the  beel,  especially  when  that  part  is  imiisually  prominent; 
and  then,  extending  tlie  foot,  joins  tlio  horn»  of  tlii»  indition  by  an- 
other running  as  straight  as  possible  across  tlio  front  of  the  tinkle. 
Bo  next  dijw.-cts  up  the  posterior  Haji  from  the  os  calcis,  keeping  the 
edge  of  the  knife  close  to  tho  bone  with  the  guidance  of  tlie  loft 
dmrnb-nAil,  till  llio  point  of  tlic  culuonoiim  i*  fairly  tinned,  when 
he  proceeds  to  (^>eti  tho  joint  in  front,  divides  each  lateral  liga- 
nent  with  a  stroke  of  the  knilb  applied  l>ctwecn  tho  malleolus  and 
an,  and  (X«npb?tes  tlio  removal  of  the  foot  by  Hovering  the 
I  AobilUs.     He  then  prepares  the  bones  of  the  leg  for  tho  np- 
flication  of  lite  saw ;  taking  care,  when  cutting  behind  the  tibia,  to 
ks^  oloec  to  its  suriace,  firom  which  the  posterior  tibial  artery  is 
i^mtod  only  by  a  little  Ioom^  ot'liutar  lisxue ;  and  la-HtJy,  he  takes 
*f  tfai  malleoli  along  with  a  thin  slice  of  tho  interveniug  part  of  tho 
flu,  wwtng  |M!i-|K':n!ii-ulnrIy  to  the  axis  of  tlie  limb. 

It  is  a  common  nii^itake  to  make  the  inner  en^l  of  the  incision  at 
w  internal  oullitolus,  ijinUsid  of  opimaite  tlie  extremity  of  the  outer 
■t  This  has  two  bad  effects :  it  renders  llii!  flnj>  uii.tyiiimwtricid, 
1^  wkit  i*  fur  won^,',  it  makeit  it  unnee«issarily  long,  and  tlius  in- 
knbkat  an  element  of  difficulty  and  risk  int^  an  eusy  imd  safe  ope- 
"**■.  For  wlw-n  tbn  infiHi^n  is  carried  forwards  to  the  hollow  of 
fcfcot,  it  becomes  a  most  tioublesoriie  tiL^k  to  turn  baijc  the  inte- 
{Bnoii  over  tho  prominence  of  tho  liccl ;  and  the  knife  being  tlini9t 


84 


AMPUTATION. 


&»  Ofanttar  kHom  not  wti«n>,  Uiv  mlxmUuiMUH  ti»«n«  on  which ' 
ridn  depandft  for  its  noorUhmant  U  punntured  and  scored,  aiid 
haps  the  point  of  tho  inHtruiiR-nt  ii|>]>ciir«  occa;<ioiially  ttirouf^fa  the 
»kin  itself,  wliilfl  the  flap  is  Butijected  to  violent  wrencliing  in  the 
efl'ort  to  draw  it  back  ovt-r  tlio  buTiy  projection.    Under  such  a  cwm- 
binntion  of  iinfuvoumble  oiroQtnBtniioes,  it  is  but  natural 
should  slouch. 

On  tlio  otiier  hand,  when  the  Rap  has  been  made  an  ubovo 
oommoTided,  it  applies  it«elf  with  perfect  unifoiToity  to  the  Horfiioe 
it  i*  Atmgfii-d  to  rovt^r,  iind  hsut  nu  ()i»|to^ition  to  ithill  In  on«  tudc  i 
the  after  prognws  of  the  caj-e  ;  and  every  stroke  of  the  knife  bv  w1 
it  \»  rtiiaiii  being  mad*  under  tli«  aye  of  tie  Surgeon,  without 
forcible  traction,  it  is  as  little  liable  to  slough  as  any  otlier  por- 
tion of  integument  with  an  enuiilly  broiul  bnsn  and  an  Oiinally  rich 
vaM-ular  snppty.  Even  the  integrity  of  the  posiorior  tibial  arteiy, 
thougli  dc«iriihlc,  is  hy  no  moans  essential,  provi<le<l  the  rest  of 
Mibeutanooim  tissue  has  been  left  uninjured.  Many  persons,  in  dis-' 
ctuwing  the  nicrib*  of  thi.t  operation,  Kevin  to  assume  as  an  uiom. 
that  sloughing  of  the  flap  must  occasionally  take  place ;  but  I  a: 
porsuntUyl  I'rom  verj*  extcnxivc  cxpt-rience,  especially  in  Mr.  Syme'i 
practice,  that,  if  the  skin  of  the  heel  be  sound,  such  an  oocurnfU' 
will  always  bo  the  fault  of  tlio  operator.  Traumatic  cjtses,  in  wliioh 
the  Integuments  are  thinner  than  in  ehronio  disesise,  nns  oonsiderod  , 
the  most  unfuvourablo  ;  but  though  I  have  had  occasion  to  [>erti)mi  fl 
the  operation  in  several  cases  of  this  kind,  1  have  never  kii;1  with  ^ 
tlie  slightest  sloughing.  The  last  instance  was  that  of  a  young  man 
who,  lying  in  a  ntute  of  intoxiciitinii  with  his  tect  ujion  n  rail,  Itad 
the  fore  parts  of  both  crushed  by  a  train,  and  I  amputated  both  al 
the  ankle.  Tiio  lut«st  intelligenoe  thut  1  have  pcceivod  of  him 
that  bo  was  able  not  only  to  walk  but  to  run,  and  even  to  " 
tfie  Higlilnn.l  flmg." 

Henec  the  various  modifications  of  the  original  method  that  havi 
been  suggested,  though  cinnmonly  diJieuKsod  chiefly  with  reference 
to  a  fear  of  sloughing,  must  be  judged  of  entirely  on  other  grounds. 
Tims  the  ])laii  introducwl  hy  the  lato  Dr.  Itichard  Mackenzie  of 
Edinburgh,  of  making  the  base  of  the  tlaji  at  the  inner  sidu,  tliat  it 
may  have  a  more  free  supply  of  blood  from  the  posterior  tibial 
artery,  is  not  to  be  regonleil  as  a  substitute  for  the  simpler  molhod 
of  a  ppsti-rior  flap ;  yet  it  proves  usefiil  in  case  of  unsoimdneas  of 
the  integument  on  tlio  outer  side  of"  tlie  heel ;  and  it  is  prubabl« 
that  an  external  fla]>  might  bo  mado  with  equal  advantage  if  the 
in(«niAl  aspect  of  the  limb  were  atlixrted. 


Df  THE  hOWETt  LIMB. 


85 


^^■i  III 


TV  oppration  of  Professor  Pimgoff  of  Pet«r»l>«rg,  in  which 
tM>BUu-)i)r  part  of  Uu)  u»  calt-is  is  »an-n  off  and  tamed  up  ax  part 
of  tbe  flap  to  unite  with  tJte  cut  end  of  the  tibia,  hijut  Uio  (luwdviin- 
t^;e  that  it  ti;ii<[>>  in  dinx-t  towards  the  ,Kroiind  tho  thin  skin  of  the 
haA  of  the  heel  instead  of  tlie  Uiick  vtLshion  of  iiw  ftAc ;  while  the 
incraMed  Icngtli  of  tJio  stunip  which  it  produces  is  rather  ohjectiou- 
aUe  than  otiierwise ;  fur,  with  the  original  i)[K'riitioii,  tho  v\mee 
afforded  tor  tltc  artifiviaJ  foot  is  not  more  than  the  maker  finds 
ooavenient. 

A  •hort  flap,  beside  being  moro  easily  and  safely  made,  is 
preferable  to  a  long  <mv,  becau-'o  it  prcstcnt*  a  vinatlcr  csavity  for  the 
■eeamiilatioo  of  dtscharg«.  To  prevent  any  inoonvenience  at  aQ 
Srom  dib  iXHirt^,  lui  ojicning  may  ho  inndo  tluxtugh  the  thin  kIcih 
t  the  back  of  tJw  heeJ,  as  has  been  recently  ra;ouiraended  hy  Mr. 
le;*  but,  it  novd  i>caro«ly  be  addwl,  |}ie  umnt«titional  oovur- 
renci!  of  a  "  hutton-hoie,"  aoin^iines  .tpoktiti  of  iw  ailvnntiigoous,  ia 
a  sutv  Ktgii  of  must  faulty  operating.  Wire  stitcbes  are  very  luolol 
in  pre^'enting  the  neces&ily  ior  early  strapping  to  kuc]>  ibe  fln]>  in 
in  pontwn.  Ibe  Rtump  hIiouU  bo  lightly  dressed,  upon  gettoral 
la. 
In  cseee  which  do  not  admit  of  Mr,  Syme's  operation,  amputa- 
inunedial^ly  abavc  the  luikk-  r>hould  he  performed  if  powihlc,  in 
"pnAarenco  to  that  at  "  the  seat  of  election,"  a  little  below  the  knee ; 
for  altiwugli  the  lue  of  tli«  knee-joint  may  be  rctatn<,-d  ovon  with  a 
v<T)-  fbort  Bttunp,  the  longer  one  giv«a  greater  cofliiniuid  over  the 
artifldal  limb,  aiul  llu'  ojicmtioti  involves  Itsu  risk  to  life. 

Diflwrent  metliods  may  here  be  employed.  One  mode  Is  to  make 
I  ^ft  semilunar  anterior  tlap  cot  from  without  itiwanU,  and  a 
lirpr  posterior  one  formed  by  tranatixing  behind  tlie  hones  and 
nutisg  downwards  and  outwanU,  tho  saw  being  applied  a  httle 
Aore  ilie  bases  of  the  flaps ;  or  antero-poAterior  !i)(in-tln|M  of  eqnal 
Vnglh  may  be  madv,  and  tho  bonce  divided  sontcwhut  liiglicr  upi, 
Or  again,  the  moditied  circular  oponitJo«t  i^  appUcabte  to  this  situ- 
KiML 

Bat  in  order  to  attain  the  Imiefita  of  a  stinnp  capaUe  of  bear- 
fag  part  of  tho  weight  of  the  body  on  its  extremity,}  it  would 
fniiablT  be  beftt  Ut  make  a  large  rounded  anterior  flap,  to  unite 
■ilh  the  pflfltcrior  integument  divided  trun^^vvntely,  and  to  saw 
>W  boDoa  at  a  oatuidcraltly  liigher  level    The  result  would  then  re- 


•  Obimatiaiu  la  ClimeaJ  Surgtiy.  f.  48. 


1  S«e  p.  M. 


AMPUTATION. 


1 


sembte  that  of  ampntation  nt  the  »nkle,  in  harin^  the  cicatrix  out 
of  tlie  way  of  pn*«tiir«  and  in  tlie  fulness  of  the  covering  provided, 
though  differing  from  it  cntiroly  in  tho  quality  of  the  tcgumL*ntary 
cnshion. 

In  performing  tho  operation,  two  longitudinal  in<7ision8  should 
ho  curried  nlnng  (he  piisti^rior  «dge«  of  the  tibiii  luiil  fihulii  for  n  dis- 
tance equal  to  Uie  diameter  of  the  linih,  and  tliese  should  he  joined 
infuriorly  aertws  tlic  front  of  tli«  anklo  in  u  curved  line,  wilh  tlie 
convexity  domiwards,  and  then  connected  superiorly  hy  a  tranBTerso 
stroke  of  tho  knifu,  dividing  all  the  tiesiics  Ijchimi  tho  hoiios.  In 
dissecting  np  the  anterior  flap,  it  may  he  well,  in  order  to  insure  its 
vitality  and  render  it  more  SHhstantial,  to  raiw  along  wiUi  Umj  skin' 
tlie  muscles  lying  between  tho  bones,  as  is  (lone  hy  Mr.  Tealo  in 
forming  his  long  rectangular  Ba])."  Mr,  Timic  hax  ul.-w  {lointtxt 
out,  that  when  the  attachmont«  of  fhose  muscles  to  the  bonas  have 
been  divided  with  tho  knife,  their  cellular  eoiinrxinns  with  tlie  inter- 
osseous  membrane  are  readily  separated  witli  the  finger,  so  as  to 
avoid  »T\y  risk  of  wounding  tho  anterior  tibial  vessels-f  Tlio  soft! 
parts  lieing  then  retracteil  by  an  a-ssistant,  the  bones  should  b» 
ulearvtf  an  inch  higher  up  for  tlio  application  of  the  saw. 

In  amputating  through  tlic  calf,  with  the  same  object  in  view, 
the  operation  should  be  similar ;  except  that  it  will  not  !>c  necessary 
to  make  tlie  anterior  flap  longer  iliiiri  idxtut  iwo-thinls  of  (he  dia- 
meter  of  tlie  limb,  for  reasons  that  have  been  before  considered  itV 
but  a  posterior  flap  of  half  the  Iciiglh  of  the  anterior  one  will  he 
retjuircd,  and  should  lie  formed  by  dividing  tho  nkin  and  fat  by  a 
semicircular  turn  of  tho  knlfo,  mid  dissecting  up  the  integunicni' 
before  cutting  the  sural  muacloa. 

The  nullified  iiiretilar  operation  employed  by  Mr.  Syme  for  Uii) 
situation  is  executed  as  follows :  the  knife  being  entered  at  one  side, 
about  a  hand's-breailth  below  the  anterior  tuberosity  of  the  tibia,  is 
drawn  across  the  front  of  the  limb  in  a  curved  line,  with  the  con- 
vexity downwards,  to  tho  opposite  point  on  tlie  othiT  itido,  dividing 
merely  tlie  akin  and  fat;  and  a  similar  incision  having  been  made 
poMeriorly,  tlic  semilunar  flaps  of  skin  are  raised,  and  the  direction 
of  tho  integument  is  continued  to  about  an  inch  or  an  inch  and  a 
lialf  above  their  angle  of  union,  when  the  snral  muM^lcs  are  divided 
atiout  half  as  low  as  tliey  are  exjiosed,  in  order  to  allow  for  their 
oontniction,  whicli  brings  them  to  a  lord  with  tliu  rcKt  of  tho  mnsolea 


t  Tcnle  on  Amputdiion.  p.  41. 

f  Medical  Timtt  and  OatelU,  July  Oth,  1601. 


*  See  p.  69. 


IS  THE  LOWER  LIMR 


67 


tLe  latter  have  hecn  cut  wlivro  tlic  boim  arc  to  bo  xawn,  witicb 
'  as  liigli  an  tlic  integumonts  have  been  retracted.* 

Excei>t  that  Uw  ok'Htrix  ]i»  where  it  would  l>c  mibjwted  to 

[,{)K9«uru  if  tlic  end  of  the  stump  were  made  to  rest  on  the  artificial 

limb,  thia  uioltiod   l»  [»rcfi;niblo  to  any  other,  on  aotuiunt  of  tlie 

nnanncss  of  th«  wound  and  the  accuracy  witli  wUidi  its  edges  meet 

"  without  eitlier  iitnuning  or  rtviundaticc." 

Tlw!  old  flap-operation,  in  which  a  large  miisrular  inasa  from  the 
calf  is  turned  up  lo  tiivcr  tlic  bonc»,  though  more  rapid,  is,  as  we 
Imve  M9cn,t  an  andcsirahle  proceeding :  it  is,  however,  atill  employed 
by  many  Surgeons ;  iK^itiH  very  n-atlJIy  accomplishod  by  drawing  the 
knife  in  a  aegment  of  a  circle  across  t)ie  front  of  the  leg  from  one 
bone  to  the  other,  trnnnfixing  behind  them,  ajid  cutting  fimt  down- 
wardit  and  then  gradually  outwards,  next  dissecting  up  the  anterior 

^flap  of  in  tegument,  ami  clou-ing  and  dividing  tlio  boiiw  at  the  lovd 

^bf  its  biMo. 

^P       In  order  to  Avoid  splintering  the  fibtiln,  it  U  l)0<t  to  itaw  both 

yboDCM  at  tho  eamo  time,  ajid  to  6nish  cho  fibula  bt-tbro  the  tibia. 
The  sharp  angle  of  the  »piiic  of  tho  tibia,  being  apt  to  cauw>  ulcora- 
tioD  of  tho  skin  over  it,  should  be  reraoi'ed ;  and  tho  most  conve- 
nient way  of  ertwting  tliiit  is  to  commence  with  wnwjiig  obli((U<'Iy  for 
a  flirart  distance  from  a  point  about  half  on  inch  above  the  place 

^.irbere  the  bonest  are  (o  be  divided  transvcrwly. 

^P  For  restraining  luemorrhage  during  amputation  of  the  leg,  the 
loami4iiet  sIu>Hld  bo  applied  round  a  roller  placcil  between  tlie  ham- 
strings. 

Ampntation  at  tlic  knoc-jotnt  is  an  operation  wbtcli  lias  not  met 
with  much  favour.  Witliin  die  last  few  years,  however,  accounts 
bure  appcanxl  in  the  modical  joumalst  ofcaaos  in  which  it  ban  buca 

j  pefftrmed  with  good  result  at  sttme  of  tJie  I»ndon  hospitals,  by 
raining  a  largo  anterior  Hap  from  the  u[i|kt  part  of  the  leg,  nfMjning 
ihe  joint,  an<l  cutting  a  shorter  ]X)sterior  Haj)  from  within  outwards, 
dw  patdla  being  retained  in  the  anterior  tlup.  It  is  tilated  thai  the 
mi  of  ilte  stump  supported  the  weight  of  tlie  body  imusually  well, 

■  miicfat  have  been  anticipated,  provitknl  utl  wt^it  on  favourably  in 
itber  respects,  from  the  extensive  surface  over  which  the  pressuro 

■  ilietritiulvd,  and  also  from  tlici  intcgumt-nt  on  which  the  patient 
,  nia  having  been  habituated  to  similar  treatment  in  kneeling. 


■  S;ili«'i>  PrimipU*,  p.  146.  t  Se«  p.  M. 

I  /Mttft.  November  Ttb,  1857;  April  Uth  aod  December  lltli.  IBM; 
I  ud  April  SUlb.  1»&». 


88 


AMPUTATION. 


1 


ha 


Tlie  diiKb  i«  differently  drcwiwUnt.H'cl  for  ampufation  in  <Iifii>rent 
parts.    Keiir  the  knee  we  have  seen*  tliat  to  form  two  flaps  by  trans- 
fixion  i»  ol]jix.-tioiinbk-,  on  account  of  ttio  ttnitloncy  to  |)rotruKion  of  tliflfl 
bono,  causeil  by  ilna  pcMUirior  muBcJes  divided  so  far  from  tbeir  origin 
at  lliL'  p<^'lvi« ;  hut  tli<>  tisc  of  tlio  tourniquet  viuiblvN  ux  to  ndopt  pre- 
ferable nietbiHU,  without  rcfercjiee  Ut  tlie  time  they  occupy.    In  thef 
u]H)cr  jwrt  of  tlic  limb,  on  tho  other  hand,  tlio  niuistrlcs  lieiuf;  all  cot 
sliort,  tliiH  iipuriitioii  liu.i  no   longer  the  ioaue  objection,  and  tha 
rapidity  with  wtiic-h  it  is  oxocuted  becomes  a  matter  of  ini|>ortanc«, 
lunee  miiinml  i-oiiiprcHsioii,  wliii-b  in  (hen  trufilixl  to  for  restnunin, 
bicmorrbiige,  though  it  may  command  the  dirtvt  stream  thntogi 
the  iiuiin  trunk,  cannot,  nt  lenst  in  a  niii.tcular  limb,  effectually' 
pre%'ent  a  recurrent  flow  through  anastomosing  brnncbes. 

in  llio  inoilifiitl  similar  iiperatioii,  as  iippIJiHl  u>  Uio  lower  tlurd 
of  the  thigh,  semilunar  skin-Bajis  are  cut  in  the  some  maimer  as 
below  the  knee ;  but  an  there  is  niucJi  gruttt«r  tendency  to  ]>nii.rutuoii 
of  the  bono  in  tlie  present  ooso,  the  soft  porta  are  retracted  to  a  madt 
groaUT  vxteut  bt-foro  the  saw  is  applied.  Tho  divsvction  of  tlio  in- 
tegument from  the  muscles  is  carried  two  inches  above  the  bases  of 
the  lhi[>j>,  when  t!io  jio^torior  muscles  aro  cut  loiij^,  un<l  thv  anterior 
ones  as  short  as  possible;  after  which  the  muscles  are  all  drawn  up 
\>y  nioiins  of  a  retractor  {for  wliicli  a  liandkorcliicf  will  answer  oa 
an  emergency),  OJid  tlie  bono  is  clcju'cj  an<l  ditided  two  inohea 
higlntr  np-t 

But  in  aecordaiico  with  tlie  princi|>les  previously  explained,}  Uie 
effoclx  of  tho  contraction  of  the  posterior  mnscles  may  be  got  rid  of 
as  effectually,  iuid  Iho  cicatrix,  ut  tlm  sunic  time,  be  pluc><il  out  of 
the  way  of  pressnrc  from  tho  artilioial  limb,  by  making  a  large  mus- 
cular anterior  flap,  ttti<I  a  dhort  posterior  vm;  coniposcvi  of  iitt;i>gumcnt). 
in  the  way  recommended  tor  amputation  thi-ongh  tbo  calf,  and  re- 
tracting (lie  mnscles  two  inches  before  sawing  the  btme.  Tlui  unto- 
rior  flap  should  bo  cut  from  without  inwards,  liotli  for  the  sake  of 
sliaping  it  with  pr(V.-tsion,  and  also  to  avoid  rodimdniicy  of  niu$«lo. 

In  other  parts  of  the  linili,  even  although  tlie  tourniquet  cannot 
be  iisfid,  the  same  method  might  probably  be  employed  with  advan- 
tage, as  it  is  niwh  more  (|niekiy  executed  than  tlie  circular  ii|H:m- 
tion,  and  also  avoids  the  risk  of  tension  Irom  excess  of  miisck'  which 
attends  transfixion ;  but  if  the  latter  mode  be  preferred,  tlio  flspa 
should  be  cut  iis  in  the  corresponding  operation  on  tbo  arm,  except 
that  iha  anterior  one  may  be  made  longer  than  the  posterior,  ia 


•  S««  p.  00. 


I  Syme's  PrinmpUt.  p.  U9, 


\  See  p.  98. 


IN  THE  LOWER  LIMB. 


to  throw  back  Uw  cicatrix,  and  the  bone  should  be  divided 
ill  niiil  »  Imlf  abovi!  dio  jut^lv  of  union  ut'tlio  Rap*, 
la  amputation  of  tho  thigh  the  flaps  should  alwava  bo  antoro- 
pnataittr,  bi-uniiim  Uie  iU'xiir  inuHcIc^  Urin^  iio  longur  countoTacted  by 
the  weiglit  of  the  limb,  the  bone  tends  to  become  lilted  (iirwards,  so 
OuLl  i\f  cxtix-iititv  would  bu  apt  to  »liuw  itj^ulf  la  lliu  anterior  ajiglv 
of  lateral  flaps. 

Tliv  tuumiquct  must  be  spplt<xl  as  high  up  a«  pouibtu  in  the 
tldgti,  otherwise  it  would  iiiTcrfero  serioti&ly  m  ith  the  rotraction  of 
th«  mfl  {nrts,  and  the  roller  niuet  lio  ovor  tlie  femoral  iirtcry.  When 
digital  compression  is  rworled  U>,  the  hands  should  gmsp  as  much 
of  tha  circumftTcDcu  of  tho  Umh  as  possible,  n-hile  the  thumbs  aro 
placed  over  llie  vessel,  as  it  lies  on  llie  pelvis,  midway  between  iba 
^^gnnphysis  pubis  and  tho  tliac  spine. 

^H      AmpulalioD  at  die  hip-joini,  llKiiigh  n  mo.*t  formidable  proceed- 
^■ngf  has,  oo-ortlielew,  been  attended  witli  a  sufbcleut  amount  of 
^^taeeen  to  render  it  justifiable  in  cireuinHtiuiecs  Uiul  wotdd  otherwise 
be  de^mteN 

Thi>  caM<sl  uikI  most  rapid  method  is  to  form  a  largo  imt^^rior 
flap  by  translixion,  disartictdate,  and  cut  a  sliort  posterior  flap,  abo 
fhiffl  witluTi  outwiu-dK.  Tim  thigli  Iteing  somuwhat  flexed,  to  relax 
tbe  soft  parts  of  the  front  of  tho  limb,  the  i>oiiit  of  u  knife  with  a 
blade  about  a  foot  leug  i*  cnt«retl  iniilwuy  Iwlwecn  the  aiiterior- 
•aperior  spinous  process  of  tbe  ilium  and  tiie  great  troclianter,  sup- 
pwing  tbe  left  Md«  ojHTat^d  on,  and  ptt««c<l  in  front  of  tlio  bono  tiU 
it  emerg<«  near  the  tuberosity  of  the  ischium,  or  in  the  opposite 
direction  if  it  be  tho  right  limb.  'Dio  knife  is  tlien  carrivd  loiigi- 
\y  with  a  rapid  sawing  movement,  followed  by  the  fingers  of 
of  an  aiwitttant,  which  are  introduced  into  the  wound  so 
to  compress  tlie  femoral  artery  securely  between  Iliem  and  the 
4ndi,  prcvioHHly  plm.-cd  over  it  in  tho  groin,  his  other  hand  being 
WfJored  to  lift  up  the  large  anterior  flap  us  soon  as  it  is  ot^mpleted. 
wlimb  bt-ing  now  extended  and  abdueted,  tlie  Surgeon  opt^na  tlie 
(^nle  of  ibe  joint  by  cutting  firmly  uptm  the  liead  of  the  bone ; 
■j  u  this  darta  from  its  socket  ho  divIdcH  the  round  ligament  and 
w  poMerior  part  of  tbe  capsule,  and  lastly,  tlie  tliigh  having  boon 
■faeted  to  draw  t)Mi  Irocltanter  down  otit  of  tho  way  of  tlio  knife, 
■nnpletCK  tlie  severaiiee  of  the  limb  by  cutting  downward.-*  m\d 
w«vda  tbrongh  tho  muvcolar  mai>«  at  tho  baek  of  the  thigh. 

^"niirv  ia  dow  at  onoe  ilireeted  to  the  bleeding  vesimtU  of  tlie 
pMuiH  flap,  fed  by  the  uitenial  ilijic,  wliidi  aro  covered  in  the 
^imtanoe  with  a  folded  cloth,  or  what  is  better  by  tlie  tJ[)s  of  the 


90  AMPUTATION. 

fingers  of  an  assistant ;  and  when  tihey  liave  been  tied,  the  femond 
trunk  and  any  of  its  branches  which  may  require  it  are  secored  in 
the  anterior  flap. 

When  the  state  of  the  parts  does  not  admit  of  a  long  anterior 
flap,  the  posterior  one  may  be  lengthened  withoat  increasing  the 
basmorrhage,  by  shaping  it  at  the  commencement  of  the  operatioD 
by  an  incision  extending  only  through  the  skin  and  iat,  and  diseeot- 
ing  up  the  intogoment  to  the  part  where  the  muscles  can  be  oonve- 
niently  divided  from  within  outwards,  after  the  anteritv  fiap  hai 
been  ibrmed  and  disarticulation  effected  in  the  usual  way. 

Should  tumour  of  the  bone  render  transfixion  impossible,  it  will, 
I  believe,  be  found  advantageous  te  adopt  an  expedient  lately  sug- 
gested to  me  by  a  veiy  interesting  case  related  by  an  American 
Surgeon  (whose  name  I  regret  being  unable  to  give),  who  disar- 
ticulated at  the  hip-joint,  af^  dissecting  up  the  soft  parts  Scom 
a  large  fibro-cartilaginous  mass,  with  very  trifling  luemorrhage, 
having  the  aorta  compressed  by  an  asustant ;  and  the  patient  mada 
a  good  recovery. 

For  the  purpose  of  compressing  the  aorta  with  precision  and 
efficacy,  I  have  had  a.  large  horse-shoe  clamp  oonstmctcd,  with  one 
end  expanded  and  covered  with  soft  material  for  application  to  the 
back,  while  the  other  end  receives  a  screw,  which  presses  down  an 
appropriate  pad.  This  being  gradually  screwed  down,  at  a  point  a 
little  above  and  to  the  lefl  of  the  umbilicus,  I  find  that  the  pulsation 
in  both  femoral  arteries  can  be  completely  abolished,  without  any 
serious  uneasiness  or  unpleasant  consequence. 

JOSEPH  USTEB. 


ANESTHETICS. 


TO  prerent  or  diminish  pain  in  siu-giral  operation!!  in  on  object  ao 
dtaiintblc,  tliat  nianj  in  rarioo^  agvn  in  the  history  of  MiMlicino 
luTC  maght  to  attain  it,  either  bv  means  of  nureotlo  drugs  designed 
to  aid  on  Hm  body  gonorally,  or  by  oaitipros^ing  ur  othorwiso  locally 
aKwting  the  nerves  of  the  part  concerned." 

"Hie  lint  rually  valimble  Huggwtiuii,  however,  vas  mndo  in  tho 
year  1800  by  Sir  Humphrey  Davj-,  who,  liavuig  liimnelt'  oxperi- 
enoed  rvlicf  from  juiin  wlivti  bn»ittiiiig  nitrous  oxido  gas,  throw  oat 
(be  hint  that  it  might  probably  be  employed  uith  advttntage  to  pro- 
dace  11  Himiliir  effect  in  xurgicjil  practiw.f 

The  same  idea  occurred,  after  the  laptie  of  netirly  hnlfa  centtirj*, 
to  I)r.  Horace  WcUs,  a  d«ntist  in  Hartford,  Connecticut,  who,  in 
1844,  noderwent  the  extrootion  of  u  tooth  without  jiain  afl<-r  inhal- 
ing the  gas,  and  gave  it  willi  satisfactory  rcsnlts  to  Hovcral  of  his 
|iatienta ;  but  he  soon  after  found  tlie  practiiio  ao  uncertiiiti  that  )io 
abandoned  it  entirely,  t 

About  tlie  same  period,  Dr.  W.  T.  G.  Morton  of  Bomton,  in 
AnuTtca,  who  had  pravionsir  been  a  partner  with  Wells,  hut  did 
lutt  as  he  informs  us,  receive  any  suggestroti  fn>iii  him,  Iwcnino 
poMcwcd  witli  the  desire  of  <Iiseovoring  an  efficient  an^esUiotic,  and 
tDomeDoed  a  serieo  of  experiments  ajion  him.tclf  and  thv  lower  ani- 
I  mk,  which  at  last  resulted  in  his  extracting  a  tooth  painlessly  from 
[kpirtient,  to  wliom  he  had  admini>«tered  tlie  vapour  of  niilphurio 
by  inlialation.  This  was  on  tbe  3t^h  of  September  I846.§ 
afterwards  he  pubttoly  exhibiu^l  liiit  muthtxl  at  the  Mawta- 
6«nflra]  Hospital ;  and  tliencpforward  anaesthesia  in  sur- 
|iy  was  on  eatablinhed  blcHiiing  to  iiuuikiml. 

Solpharic   ether  is  still  extensively  used  as  an  anaisthotic  in 
">iaica;  but  in  Europe  cldorofonn  is  generally  preferred  to  it. 

*  for  Bach  eurtdH  iiiromislion  i^g^rding  the  histoiy  of  this  subjecl. 
*■  rnd#r  is  tvfrrrod  to  the  work  of  tho  Uto  Dr.  Snow  on  AiMtthttic*. 
'  '.Iflmnf J  Jitirarfhft.  p.  DM. 

:  Sut*m*nU  </'  ll'iiliam  T.  O.  Utrbtm,  M.D^  <m  Aw  ttabi  to  tht  Di*tcvfrg  ^ 
'  ""fciiUtitw  Pnptrtiu  of  Hihrr,  dt..  Wasliingtoa,  I9D3,  pp.  U,  ±e. 
I  Dt.  Moctoo's  BlaUmtaU,  rfe.,  |i|i.  4a,  Ac, 


92 


ANESTHETICS. 


iwn 


DiHgiiiiiml  iindw  the  name  "  clilorie  etiier,"  in  wliicli  it  pxista 
latod  with  epirlt  of  wine,  t!iis  agent  was  tho  Eubjcct  of  Dr.  Mo: 
firttt  experiiiivnt  iijion  hini.sclf  ;*  nnd  it  wuh  wetl  in  tbo  ftnitie  fm 
St.  Bartliolomew's  Ha«pitAl,  iit  ]>r«feroiico  to  MiIpKuric  other,  hy 
Lawretice  Iti  th<!  Huniiiier  of  lH47.f     In  the  Autiiiiiii  of  tb;tt 
Dr.  Simpson,  who  was  engaged  in  a  series  of  experiments  with 
rioiw  ntirwitii-  vapnnrs,  employed  for  the  first,  timn  (hn  aotive 
ciplc  of  ciJoric  ethor,  at  the  suggestion  of  Mr.  Waldie  of  the  Ai 
tlieeiiri»K'  Kail  of  Livorpixil ;{  luid  finding  thut  tlie  pnr«  clilurula 
was  more  jiotent  than  sulphuric  ether,  yet  caused  less   broncB 
irritAtton,  while  its  odour  was  more  a^reeiiblc  and  iW  inforinr  vq| 
tiltty  rendered  ita  exhibition  more  easy,5  he  seatously  recommco 
it  ti)  tlK!  profcesioii,  and  it  luui  since  bocn  genurally  t-mployed  tbrou 
out  Euro]i«.j| 

Tho  effects  prodncod  by  chloroform  are  such  as  to  fit  it 
markably  for  tho  purpottos  of  tlie  Surgeon,  Like  most  narool 
it  tends  to  cause,  after  toniporary  excitement,  suspension  of 
functions  of  the  nervous  centres,  but  aflectA  them  not  MmuHa 
ousiy,  but  in  a  certain  order ;  and  the  brain  is  the  first  to  show 
of  power  in  failure  of  UMisatlun  and  voluntar>-  motion.  If  iJii!> 
all,  anesthesia  would  bo  a  questionable  boon,  as  tlie  work  of 
Surgeon  woidd  be  interrupted  and  often  marred  by  involnni 
struggles  on  the  part  of  tho  jiationt  But  very  soon  ibe  s: 
cord  also  is  subdued,  and  tlic  reflex  fiinoti(>n9  of  tlio  euTvbro-Ki 
axis  are  abolished  so  far  as  coucems  the  voluntary  muscles,  wi 
consequently  lie  pcrtwlly  relaxed  and  passive,  lietler  siiit'.'d  for 
rative  purposes  than  the  roost  resolute  will  could  render  them, 
this,  however,  tlicro  is  one  remarkable  exception,  viz.  that  tho  p 
ooncemcd  in  tlie  respiratory  movements  remain  active;    and 


*  Op.  cit.  pp.  4ft,  48. 

f  Snow  on  Anainhftiiu.  p.  ^0.  Thnt  cblorin  i^tlier  vttus  cmplojod 
BarUioloTnew's  Hospital,  has  been  (Urther  oontinued  by  iuCamalian  . 
coniniuni oiled  to  tne  by  Mr.  Pueut. 

]  Siiuwuii  Anmih«lk;\i}>.i\,ii;  also  I>r. Simpson's  ori^tJ  Jpuij 
Aemunt  «/a  new  Anirtthelio  Ayrnt,  Ao.  p,  (1. 

$  For  ojiviaiiuus  pprrornivil  by  (iilificjal  liebt.  chloroform  has 
ai]Taii(ut;e  ovt<r  utlier.  in  th«  (act  Ibftt  its  vapour  is  not  iiillannuablo. 

Il  iiHs  bvt^ii  bIiuwi)  by  Dr.  Jaini-s  Ai'iiott,  llint  a  siipeiticiaJ  )iart  ic 
render<>tl  itiBViiniblo  without  iigtiry  by  u  lit-i^ziiig  iiiUluiv  of  iou  anil 
an<i  I  uiidvi-stanil  tbut  for  triHiiig  matUi-s  Uiis  IooaI  utitt<8 (Initio  mc 
freiiiiciitly  eiiipluyoU  iii  Loudon.  The  ice,  liaviug  been  iinvXy  puh 
and  tJiorou ij^lily  mixud  with  about  an  (■qiiul  qiiuiiLity  of  contmoa 
pltiOHil  ill  a  pii^ce  of  niUBliii  uad  upplivd  for  two  or  liueti  nutUtM 
aUu.     See  LaiuM,  Outwbur  SOtit,  ISW. 


ds 


the  cfiM  witlt  the  8rni)uithctic  gaiiglin  of  Uio  heart.  In 
'words,  when  the  administration  of  chloroform  Ih  vitrric<1  to  ft 
point,  ihc  nvnouK  systom  i»  doftrivt-d  of  snch  powers  as 
wraM  cauHe  p»in  to  the  patient  or  inconvenience  to  tiie  Hurjjoon, 
W  ntaiiM  intact  tltc  fac-nltics  essential  to  life. 

There  aiv,  however,  yet  other  iuJvaitt.ageH  derived  from  the  innc- 
ttvitT  of  the  ccTobro- spinal  centre.  It  scorns  now  dearly  eetdtblistied 
tint  the  OMUiation  of  the  contractionti  of  tlio  heart  in  tlie  .tltock  of 
injory  depends  apon  an  action  of  the  brain  and  cord  npon  the  car- 
diao  ganglia  throu^rh  the  medium  of  the  viijpis  and  nymjMithetio 
nervofl;  and  chloroform,  rendering  thix  action  impossible,  protects 
the  heart  from  the  indirect  effect  of  extcniiil  violence.  In  thii*  way 
H  has  diminiBbed  iltc  risk  of  death  upon  the  operating  tabic,  and  also 
boa  oTertlimwii  llutold  rule  of  deferring  ampntntion  in  ciiKeM  of  injury 
tin  the  patient  has  recovered  from  the  state  of  collapse ;  tJms  short- 
cninf;  tlie  [wrioil  of  mtscJiiof  to  tlic  sj-stom  from  the  prewiice  of  the 
mangled  limb,  and  in  extreme  easea  sometimes  saving  life  where  it 
would  bo  hopele*)'  to  wait  for  returning  consctouHness.  Indce<l,  an 
amputation  performed  under  ehlorotbrra  has  often  the  efteet  of  im- 
proving inKtcad  of  lowering  tlic  piiUo.  Tlic  most  striking  instanco 
of  this,  that  has  fallen  under  my  notice,  occurred  in  a  liibonrer, 
riglrt  arm  an<i  thigh  Iiad  been  dc*troye<l  by  a  railway  acci- 
at,  jnst  enough  sound  tiHsue  being  lell  to  admit  of  amjiutalion 
E;h  the  hip  and  shoulder  Joints,  wbicb  vias  accordingly  per- 
tontxd  as  a  forlorn  hope  by  ttte  Surgeon  in  charge  of  the  cafie.  The 
Ttiol  powers  being  in  a  state  of  oxtrrmo  dvprcmlon,  it  is  probable 
ihai  withnat  diloroform  thia  severe  measure  would  hai'e  kill«t  him 
■ntright,  but  by  help  of  the  anicsthetic  it  was  followed  by  marked 
impniriaDent  of  the  pulite,  which  continued  for  »onie  hours,  ao  as  to 
had  DB  to  entertain  liopea  of  his  recovery. 

Faintnem  <ltiriiig  the  upcrntion,  a  species  of  shock,  is  also  got 
ri  of  by  chloroform  ;  and  this,  besides  its  obvious  convenience,  has 
AiadTmnUge  of  lessoning  tlw  eWnec  of  sccondarj-  ha-morrhago;  for 
tb  Teasels  which  re<)nire  ligature  declare  themselvcjt  as  such  by 
'fcediog,  tnstenil  of  dc^'eiiti\vly  dutling  observation  in  consequence 
j  '  dw  feebleness  of  the  heart  and  the  general  artcriid  contraction 
■lieh  eoextst  in  the  state  of  syneojw, 

The  welfare  of  tlie  patient  is  besides  greatly  promoted  by  tho 

■Hal  tnnqnilli^- aritiing  from  the  pni«i>eet  of  immnnity  from  suf- 

^■iiif,  which  also  indnces  persons  to  snbinit  much  more  readily  to 

^ nriuiiiij    opemtioiw,  and  ofUm  to  undergo  without  hesitation 

I  Buiiaiiit  wliich  was  formerly  impracticable  because  intolerable. 


H  ANESTHETICS. 


n 


Sucb  bcinj;  tlio  jifri^at  Wnufitit  conrcircj  bj  this  a^^nt,  it  is  me- 
Innolioly  to  reflect  that  in  many  paria  of  Europe,  antl  oveu  of  tlio 
Unitotl  Kingdom,  it  is  uitlicr  witiihcid  altogether  or  ^v«n  so  Kcantily 
ts  to  be  nearly  useloas,  Thia  arises  fh>m  fear  inspiiwl  by  sevenil 
&tal  cues  that  hitw  occtirrixl.  But  when  I  BUt«  that  Mr.  Symc  has 
given  chloroform  about  &vq  thousand  timt^s  witltout  ever  meeting 
with  a  dcatli,  and  that  l>r.  Simpson's  experience,  also  very  oxteo- 
sivv,  bus,  so  far  as  I  am  aware,  been  atjiitilly  sati.'tfnvtory,  it  is  clear 
tliat  it  may  bo  uaod  so  lu  U>  bo  practically  ireo  &om  any  risk  wliat- 
ovcr. 

How  then  arc  tlio  fatal  caacs  to  bo  account«d  for  ?  Ho«rt-di 
lias  Ijctni  sujiprtsed  to  be  a  comnu>ii  ciuiMt  of  Uicm ;  and  it  happei 
tliat  the  only  death  I  ever  witnessed  under  chloroform  occurred  in 
person  whoso  hwtrt  jirovod,  on  exaniiiiution,  t«  ho  extensively  jifl'isc' 
with  fatty  degeneration,  such  as  would  be  reganlod  an  sufficient  ex.' 
planation  of  suddon  <leath  under  miy  circTumstanoos.  The  particul 
of  lliis  ea»e,  however,  presented  pocutiar  features,  wliieli  lead  me 
take  a  dift'crciit  viow  of  Iho  part  played  by  the  clilorofonn  frma 
wliat  might  at  first  ho  assumed.  The  patient  was  a  man  above  tbft^ 
middlo  period  of  lifv,  uffoctvd  with  cancer  of  the  penis,  for  whidi^l 
amputation  of  tJie  organ  was  to  bo  perfoniKHl.  Tlio  gonUenuui  in 
charge  of  tho  cliloruforni,  considering  tho  momentary  nature  of  tho 
opcraljon,  purposely  abstained  from  giving  it  a»  fully  as  usual,  and 
had  removed  the  cloth  containing  it  from  the  face  before  iJie  opera- 
tion wm  commenced.  The  Surgeon  now  placed  his  finger  on  the 
patient's  wrist,  and,  having  ascertained  that  the  pulne  was  good,  at 
onco  efil-etoci  the  anijmtalioii  almost  iiislntitimoously.  I  ubttoniHl 
tliat  the  passage  of  thi'  kiiifo  llirougii  the  member  wiia  accompanied 
by  a  start  of  the  patient's  body ;  tlie  bandage  used  to  control  the 
bleeding  was  then  removed,  but  no  blood  floweil  from  the  artcricfi ; 
ho  was  found  to  have  no  pulne  at  the  wri»l ;  in  short  he  was  dwul. 
From  llicso  fact«  we  can  hardly  doubt  that  death  was  n  consequenoe 
of  tho  shock  of  the  ojieration  acting  on  a  diseased  heart;  and  Uie 
only  question  is  whotlior  the  circunistaiiee  that  lie  hail  taken  chloro- 
form promoted  that  rtmult.  Proni  tho  foregoing  considerations,  mcfa 
S  thing  seems  altogether  improbable,  as  we  have  si'fn  that  chloro- 
fomi  jirotiHjts  thtf  liciirt  IVuni  tlio  etlwtji  of  slioek.  The  fact  that  the 
patient  started  proved  that  reflex  action  was  not  nitolishcd  in  the 
voluntary  muwbs,  and  confirnuHl  the  >'tatemcnt  of  the  adnitni.iUii- 
tor  tliat  tlio  chloroform  was  iniporfeclly  given.  My  own  iuipressioa 
is,  that  if  it  had  l>een  ]>uslied  to  the  usual  degree,  the  fatal  occur* 
ronce  would  bare  been  arerted. 


CHLOROFORM. 


99 


I  \tase  given  this  case  in  detail  because  I  believe  it  may  be  ro- 
m»  typi(-al  nf  u  ooiuiderablii  olaM  id  wliich  duiitli  Iwe  tatlcen 
•udiieDU-  at  the  commencement  of  an  operation  witli  imperfwC 
administratioii  of  cliloraivrm,  which  )>tni»U  to  the  fatal  wont  in  tin 
nhdun  of  an  accidental  ooncomitant,  or  rathor  a  preventive  inHuHi- 
cicmUjiiscd.*  Adpath«)i»ciitiany  siniiliU',  lWii<;!imoruobvii>uslyun- 
oonnected  witli  chlorofonn,  took  place  on  the  occasion  wEien  it  wm 
tntcndod  to  h^vo  adntinistvroil  it  for  Hw  first  tinio  in  t)i«  Edinburgh 
Infirroarv ;  but  Dr.  Simpson  being  prevented  from  attending,  tlio 
operation  wax  coinm<TiKxid  without  tliu  ana.*.ttbeti(',  and  tlic  patient 
died  suddenly  immediately  after  the  first  inpision.  It  lias  been  often 
(vmarkctl,  that  if  tlio  original  int^rntJoii  luid  hxn  >-iirrii>l  otit,  cliloro- 
Surm  would  never  have  been  heard  of  again  in  Edinbm-gh ;  but  it 
i«  very  likely  Uint  tlio  man  might  tbuo  have  IivmI  to  testify  to  itii 
benefitsL 

TluTe  a  another  class  of  fatal  ossos  in  which  t)io  use  of  chloro- 
form seems  to  bave  been  simply  a  coincidence,  the  real  cauAO  of 
death  being  mental  emotion,  acting  usually  ujmn  a  di>^o^don>d  heart. 
Dr.  8now  mentions  a  dij^ttnct  example  of  tbi-t,  wliere  a  mere  pi'ofcit- 
sioD  of  administering  chlorofonn  was  tnado,  and  the  patient  died  of 
fri^l  ;f  and  I  am  able  to  ^ve,  from  Edinburgh  ox{>nrieiioe,  an  in- 
ituoe  in  n-hich  cblomfonn  was  still  more  remotely  eoncci-ned.  The 
hte  Dr.  HJcJiurd  Mackenzie  being  called  to  »ee  a  gtmlleitian  who  tutd 
fractured  bis  radius,  liad  some  tliought  of  cmploj-ing  chloroform  in 
esuiintng  tlu>  arm,  but,  cluiuging  liis  mind,  miido  tbo  ii(Hi>wtury 
nuutipuladons  witlmut  it.  He  ilit-n  proceeded  to  leave  the  house; 
bat  had  not  got  down  the  stejut  leaiUng  from  the  door  when  bo  waa 
aOod  b«ok  with  the  aimoonccment  that  his  patient  had  suddenly 
weired.  Had  chlorofonn  been  held  near  tlie  fiutt)  a  fnw  itciionda 
before  tliis  oocurreooo,  it  would  certainly  have  been  blamed,  tbongh 
with  manift^Ht  unfiiirnetts;  and  a  Hiniiliir  iiijiistiit;  HCfiim  to  have 
committed  with  r«^gard  to  scni'erid  cnsos  in  which  fatal  syncopo 


m 


•  Aa  obMrruioii  tn»A«  mental  jvtn  ago  b;  Mr.  DIchentcth.  titUnt- 
paot,  bas  an  inu'teotiug  bMriag  upon  this  class  or  oaaes.  Ua  notieod  on 
ikrae  uaeaaianB  tn  Hinpuiatkin  of  tLe  thigh  that  the  pulM  stoppad  stiddcnly 
•t  the  mutneni  the  kuife  oatered  iha  timb.  but  i'«cover«il  lUalf  Ln  a  fovr 
mmtaiM.  The!  pdii«nta  were  under  tlie  liiduitnoo  of  cblin'ofoiin ;  but  us  Mr. 
Krtiislilb  urver  obMrved  tbe  sajna  thina  winin*  tliongb  he  wstclif^il  tlio 
p«faa  emreiallj  at  tli«  same  puriuJ  in  a.  gri'At  numbi-t-  of  capital  «p«vntii>iis 
BBiW  atinTotoTta,  it  se«in«  probuble  tliHt  Ibo  niiir'itbctie  mu  ni>t  a(lniini»- 
IttiJ  ut  iu  full  degnM  in  tlioit  instanues.  iSoc  JfonjUy  Juumai  of  Mediad 
S*]iMMber  I8M.) 

t  Smiiw  on  ^i»«*xA*tM,  p.  301. 


96 


ANAESTHETICS. 


CMS 


enon 


hxA  Inkcn  plnco  «arlj  in  the  administration  of  the  uniMtlieUc,  wl 
tile  brief  j>criud  of  inhalatiou  concurred  with  tho  symptoms  in  tho' 
itifr  dull  t)io  jiiilient  won  tiltlo,  if  iit  al),  under  ibt  intluencov     A 
of  tho  chloroform  itaolf  seems  to  have  been  tbo  exciting  cause 
Homo  of  Ihvwft  ciij*('s;  and  one  retwon  whj-  no  such  iii«tjiiicft  luw 
currod  in  the  Edinburgh  Infirmarj',  is  probably  tho  unlimited  coi 
fideiic«  rt^jHiHtxl  in  tliiK  ugt^nt  by  tlin  inmatt^  uf  Ihut  iiiMitntion. 

It  might,  perhaps,  havo  been  ospectod  a  priori  that  chlorofo 
in  the  unrly  or  oxctiting  Mjif^e  uf  its  o]>omtion,  would  iwt  Ujmn 
diseased  heart  lilta  mental  emotion,  and  cause  irregularit\-  or  cei 
timi  of  i1f(  contntctionti ;  hut  thi«  does  m>t  sctMii  to  be  iIk; 
Judging  from  my  own  experience,  I  should  say  that  it  tends  mtha- 
to  remove  intermission  or  irn'gidarity  of  tlie  pulso ;  and  on  tlic  whole 
I  believe  tJiat  clUnroform,  by  preventing  shock  and  mental  effort 
during  die  o|>cration  utnl  anxiety  before  it,  is  in  reality  n 
Bource  of  safety  in  heart-disease. 

Yet  it  i»  u  conuuon  l«?liff  tliat,  in  the  majoriQ-  of  Uie  fattJ 
death  resulted  from  a  weakening  effeiTt  produced  upon  tljc  heart 
ititelf  by  tlic  nuruolie ;  and  tluit  chloroform  may,  umler  kouu;  cir- 
cumstnnces,  aet  as  a  direct  sedative  upon  the  heart,  was  dearly 
rIu)wii  t<i  me  isight  years  ago  by  the  following  ocntrrpni.-c  An 
eminent  London  physician,  desirous  of  making  some  cx[>erimeiits 
upon  tlie  heart,  selected  a  yotuig  donkey  for  tlw  purpoitc,  and  ro- 
quested  mo  to  maintain  artificial  respiration,  which  was  done  by 
nicantt  of  a  largi'  pair  of  Ijcllows  conncctwl  with  a  tube  tied  into 
the  trachea,  the  animal  having  been  preWously  put  under  the  influ- 
cnec  of  chloroform.  Tlie  clicst  having  been  opened,  Uie  inTcstiKn- 
tion  was  continued  for  a  while,  when  the  creature  began  lo  exliibit 
signs  uf  returning  consciousness.  To  avert  this  I  removed  tlw  bci- 
lowfl,  and  ]ioured  inti)  them  a  considerable  quantity  of  ehloruform, 
and  resiuncd  the  lutificial  respiration  with  energy  for  a  short  time, 
tlie  natural  respiratory  movements  meanwhile  continuing;  wlien 
suddenly  tho  heart,  which  lay  exposed  before  us,  ecost^il  to  boait, 
and  reftisoi]  to  eoutraet  again  even  when  its  ninseular  i<ut»1ance 
was  pinched,  which  showed  that  its  nervous  apparatus  was  para- 
lysed. 

This  was  no  doubt  caused  by  the  air  becoming  highly  charged 
with  chloroform  in  passing  over  the  extensive  evajmrating  nuiaco 
presented  by  the  interior  of  the  bellows.  For  it  had  been  befi>ro 
shown  by  ]>r.  Snow,  fi'om  exiierimentfi  upon  the  lower  aniuiats,  that 
an  atmufphero  containing  more  than  a  certain  jiercentage  of  the 
narcotic  vapour  atups  the  heart  before  breathing  ceases;  whereas  the 


:.0R0FORM. 


i»TTTM»  oocars  wheo  the  chloroform  ia  more  dilated.*    Hen<>e,  with 

view  of  pre%-cntiQg  fatal  syncopo,  Dr.  Snow  contrived  an  iniialer 

regtUatitig  the  ainoutit  of  ohloroforni  vnpoiir  in  the  iiiii[iinKl  iiir; 

and  UNed  it  in  npwardit  of  four  thoiuand  cases,  of  which  only  ono  was 

btal,  and  even  that  seemed  te  bo  so  inde|iendentjy  of  die  ehlorofunn. 

Finding  hi*  inf;i.-ni<^>iis  efforts  crowned  with  sach  siiccbsb,  and  i^lin- 

ritaUy  sappostng  that  all  wore  as  ejireful  as  hinmelf,  he  eoncliidnd 

that  Sual  CBMM  in  thv  liands  of  otfaont  cotdd  result  only  from  »  faulty 

method  ofadminiHtrulion;  and  assuming  tliat  when  clilorornrin  i§ 

?ven  from  a  fbldod  doth  it  ia  apt  to  bo  in  too  cencentraled  a  tbrm, 

attributed  most  of  tlie  dentlu  that  hav«  oocurrett  to  [wndysis  of 

bvMt  from  ihis  eause. 

But  ihe  oiuth  being  the  mean*  which  has  been  ukckI  from  the 
ia  Edinburgh,  with  suocan  even  nuperior  to  Or.  Snow's,  I 
ire  been  long  mtti^fieil  that  his  ar^mont  wiis  ialiavioiis;  yet  as 
bia  s|)ocia]  devotion  to  the  suhjeet,  aiid  the  valuable  faets  wbioh  ht 
has  oomnitinieaii>d  n<ganling  it,  rvtndcr  hU  opinion  inKiientin],  I 
have  diouglit  it  ivorth  while  to  subjcttt  u  matter  of  such  great  pran- 
tieal  iinjH>rtaivcc  to  vxjx-rimcntal  inquiry;  and,  about  tho  usual 
liuntity  of  iJte  liquid  being  employed,  I  find  that,  so  far  from  Uie 
amoutiL  of  ehlnroform  given  off  from  the  clotli  being  in  dangerous 
praportion  to  the  air  inhaled,  ilie  whole  quantity  whieh  evu|>orate8 
from  the  nnder  surfaee,  even  when  the  rate  is  must  rapid,  viz.  just 

C>e  liquid  has  been  poured  iiiion  it,  is  below  Dr.  Snow's  limit 
L^ct  aocurity  against  primary  iaiioro  of  tlie  heart.! 
have  notieml.  faowrerwr.  Hut  different  oninials  differ  \a  ihi-iv  sus- 
Uy  to  dilorofnfm.  Tkux,  frogs  or  mice  taa,j  bo  kept  fur  any  lengCJi 
andor  ita  influence;  but  bats  ua  vary  apt  to  die  wheu  treated  is 
naeUf  the  Mine  wbj. 

t  The  experiments  a-cre  poribmind  in  tile  following'  manlier.  Aelotli, 
liiatlar  in  all  rcs|>cctii  to  whiLt  woiiKI  be  UH>d  in  priK^tk'i-.  was  supported 
Bpoti  •  liffht  wire  rnaie'Worli,  and  suspended  iit  n  litlk-  dtBUm-e  fri>in  the 
Imt  by  >  thrasd,  eoaneeted  villi  one  end  of  tlie  benm  of  u  btilaiic^,  projoctr 
iag  ovar  tbe  edg*  of  the  Ultle  en  nhlelt  it  stood.  Tlio  weii,'Ul  uf  Uie  oledl 
kariag  bean  asearUUDed.  a  nt'lglied  quantity  of  chloi-ofm-tn,  i-orrvupondiag  10 
A-  Slsa.!  wliidi  t«  about  the  auiuunt  i-einiiioiily  used,  wiu  |)our(>il  upon  ibe 
■iddte  of  the  lower  surlkeo  >ir  iLe  vloih,  wliicb  was  tlien  ullowt-J  lu  hung 
dbw  diOTe  my  taet.  so  Iltat  I  niiglil  bii^atlio  fully  upon  it.  wliiie  tiispimtiun 
•im  perfMsteil  ijinmgli  it  lout;  liidin  rubber  tube  to  nvoid  iiiiiaUu);  tlie  ehto- 
Mfanti  npunr.  Tli«  uuount  IikiI  by  Uie  ulolli  was  indii-atcd  by  tbe  ueigltU 
ta  Ibe  nalr  at  tlie  other  end  of  the  beani.  At  the  RoiRRicnccment  of  an  ez- 
ptnaieot  tlui  wcifibt  was  mude  n  fcnr  giuiiis  less  tlisn  the  ■tun  of  the  weigbts 
of  tkw  duth  and  dilorofcifio  togellicr.  and  au  assisUnt  noted  Die  second 
wbm  tlir  •<-«]«  iritli  iLe  weijjhta  in  it  cnuiu  to  |ir<9|)o&dcnito ;  then  removed 
TQL.  UL  K 


AN^STHETICa 


Bat,  considoring  llio  grvnt  ditFti»i1>ility  of  tlio  raponr,  »tid 
liirge  itnintint  blown  away  >n  exjiiration,  it  U  «>'i(leiit  thut  only 
small  proportion  of  that  which  oomcs  from  tlio  lower  KuHkoo  of 
chrt.h  rwilly  entwr*  the  hing*.  Were  it  otherwiiw,  it  woiihl  lie 
tteme\y  dangDrouH  to  give  chloroform  with  tho  cloth  to  infants; 
M  they  iiihiilti  hut  a  »i:iall  uiiiuuiit  of  air,  tliev  would  lltoii  hreitli 
ihe  vapour  in  a  very  concentrated  state ;  yet  all  are  agreed  tliat  it: 
fantji  arc  pi'ciilinrly  favimrublt*  siiliJMrt*  for  chloroform.  In  tru' 
the  quantity  dissipated  into  the  §urrouRiling  air  when  the  doth  ti 
used  involved  oon«fl(iruliI«  wiL''t*^iiilni.«!»  in  iJiis  inuuiis  of  n<Initni: 
tmtion,  which  is  ita  only  disadvantage  aa  compar«l  with  an  inluJer ; 
but  this  is  abundantly  coin  pen  sati^^d  by  iU  f^at«r  simplicity,  and 
conswiuetil  greater  siifety.  For  any  apparatus  which  ha«  the  effect 
of  preventing  tho  fhw  access  of  the  atniuitphcro  must  he  liable  to 
operate  ill  the  Ranie  deadly  mnnjier  a-t  the  betlowa  in  tiie  ease  abore 
related;  and,  ovun  when  oonstructtyl  upon  tho  boat  principles,  wl 


l«n  ei-aias  so  as  to  allow  th«  natie  to  riB«.  and  neaxti  n-atdi^d  tli«  ttin«  oft 
dcsct'iil ;  and  rcponted  tliis  piixjcsti  !)«veral  tiiiiHH,  tliuti  obtaining  a  vtvf 
ftMunitu  rt!0(ird  ofthti  raW  ofalli^nilion  iu  tha  weiglil-  Tlio  lonnr  imvfAi'C 
of  tliL>  cluth.  wbidi  wiLi  miiile  sliglitly  conMT«,  was  (jireumiiijiiitM!d  jiiM  aa  in 
the  cu-1)'  pi'Hod  [)f  tlic!  ndministruLicin  of  ohloroform,  cxccpi  thnt  tho  Inapflwd 
air  wo-i  (Imwii  fifini  n  disljiiice.  In-^pimtion  dona  niit,  liowcvpr.  niawrUlIf 
afloRt  till!  rati!  of  cvnpomtion,  ns  wits  found  by  rxpcriniiinting  nith  a  «Iol]i 
arrnneod  nhovc  the  mouth  of  a  tiibo  iiiM  ivhicli  nir  wno  drawn  bj'  an  appro- 
priate appHiatiis.  Altowftni^t!  bi^iii);  miid<;  for  llin  slight  gain  in  weight  tliat 
iJte  cloth  would  obtain  fivm  absorliing  tho  moisture  frurn  t)i«  bii«itb,  (]» 
amount  of  chlorofoi-m  lost  from  boUi  surfacoH  together  wax  tbus  easily  d» 
t«rmiued.  In  ordur  to  iiHUvrtain  liow  muub  escaped  from  tli«  iippiT  suriaoc^ 
ncpHrimenls  were  made  with  the  same  olntli.  haviui^  fir»l  the  upper  und  tfcca 
tliu  under  side  Hcouruly  covt^ri^J  uiih  oitstUc.  tlie  armngements  b«iif;  as 
abovu  dcai-'ribtfd.  except  lliiit  niy  face  was  not  below  the  eloth.  Tho  qiiao- 
titygivvn  olTfrom  tliouppiT  Bm'fuoe  in  a  uormul  uliiioaphcrv  was  thuadcWf^ 
minod ;  and  tliis  being  siibtrai>tcd  from  tlie  wliulc  loea  horn  both  turhCM 
under  the  aircutnatances  ofinliahttion.gave  tb<?  ninoxmtthnt  cvaporalod  IVoM 
the  lower  siirihce  only.  At  the  tpmpemturo  of  70°  !■'..  tliiii  proT<^  to  b«,  tram 
the  nvonkge  of  seToritl  expei-iments,  nboiit  at  Ihe  mtc  of  24  gnilns  par  mintiU 
diirins  the  firnt  hslf  miniil'^ ;  niid  idlowinR,  with  Dr.  Snow,  that  itO  Kirains  nt 
eblornf.irm  correspond  to  Vr'f  en  bin  inobcs  of  tlie  vapour,  and  llial  4l)0Dubie 
ini'licR  of  nir  are  iitbHted  in  a  niiiiiili',  wi-  e,«l  -1  ri  por  rent  as  ifae  )>roparttoa 
of  thp  chloroforni  to  ibe  i[is|>ii-t'J  nir,  iin  tlie  bypolhe«is  that  all  ibut  «viipO- 
mlo*  from  ihe  lower  Burfat-u  eiitui-s  thelun^-*;  S  porount  bvini;  wliul  X>r.  Siw* 
witH  led  by  his  expffrinicnts  tu  I'egurd  tut  ihe  proportion  ai  which  the  nnpira- 
tlon  was  quite  sure  to  fail  before  tbt>  cirL'iilulioii,  and  Uial  ut  which  bo  ained 
with  hlB  iiihtiWi'  (up.  cit.  p.  Bi).  Oil  tliu  other  hand,  L>r.  Snow  auumad  OmXt 
wbeii  the  cloth  is  used  nl  u  tPinpi'mture  of  10°  k\,  0-ft  per  ecut  of  chlnrofona 
is  really  ittlialed  (op.  ait.  )>.  3t) ;  wbtrreas,  in  truth,  of  the  ti  per  cent  •  Ulft 
amount  is  dissipated  into  tho  sturoiuidiug  uir. 


I 


CHLOROFORM. 


99 


rerfoire  most  careful  management,  an  U  admitted  by  Th.  Snow  wttb 
rtr;:aii)  tn  liiif  owti  iiihulor.*  Go  the  other  liand,  there  can  be  no 
iDi!^iake  abciat  tlto  manner  of  using  the  cloth,  which  »  aUo  always 
■t  hornl  under  all  circunistancee. 

Tite  theory  of  .^ynmipe  from  loo  great  trtreni^h  of  the  arucsthetio 
npom-  -wltcD  the  cloth  is  employed  being  eironeous,  the  greater 
number  of  the  deaths  still  rninain  uiiactwmtvd  for;  and,  if  we  ex* 
Oept  a  way  few  instAncm  for  which  we  seem  to  Have  nothing  to  fall 
bsek  upon  bat  an  i<lioayiicfraj>y  no  rare  that  il  may  prncticidly  Iw  left 
ontatoonsicleration  altogothiH',  their  explanation  will,  I  believe,  be 
toaad  in  an  overdose  of  tJm  potetit  narcotic  from  too  long-continued 
inutnition. 
This  a  what  might  bo  exported  Irom  a  general  vii^w  of  the  sta- 
Wer©  wo  to  ask  ourselves  in  what  sort  of  o]>oration9  w© 
bare  anticijintcd  m»*t  frequent  deaths  during  tlie  omploy- 
mrnt  of  cfaloroftmn,  we  ahonld  say  in  those  whieh  are  likely  to 
iupira  great  dmid  on  anconnt  of  their  magnitude  and  severity,  and 
eaoae  great  ibock  and  great  lia-tuorrlinge.    More  espoeially  nhould 
prejiODderatv  among  fatal  cases  in  general  hospitals,  where 
operattons  oon»lilute  the  majority  of  tho«<t;  pi^rformed.     The 
of  tliis,  however,  is  wliat  we  actually  find.     Of  the  whole 
number  of  casea  reeonled  by  Dr.  Snow  in  IH5^,  aa  due  to  the  use 
of  tdikrolbrm  throughout  tho  world  during  ten  years,  nine  only 
oecurrud  in  any  oonswlerable  unrgical  ]>riKH.'<Iiiri;  at  a  general  1)04- 
pital ;  rTrmarkably  few,  oanaidering  the  enormous  number  of  impor- 
tant operations  that  miMt  liave  been  ]N>rfonno(t  during  ho  long  a 
pnjod,  and  tlio  variety  in  the  <]ita]ilications  of  those  who  adminis- 
Uxvd  ihe  i^iloroform.     On  Uw  ofhor  hand,  fiinrtcim  took  |iIaoe  at 
(imilar  inaUtations  in  connexion  with  the  mosi  trivial  matters,  such 

I a»  th»  reraoral  of  n  toe-nail,  the  atiiputation  of  a  fing*;r,  tbo  pawning 

^Hf  a  catheter,  or  tlie  cauterising  of  a  wart  Tlie  only  rational  ex- 
^■yaaaliim  of  liiix  Kocmi*  to  be,  that  when  some  great  o^wrution  in  to 
^BpB  perloriued,  like  (be  amputation  of  u  thigh  or  the  removal  of  a 
MoDO  fitim  the  hlad^Ivr,  plenty  of  well -qiiali tied  a)«*i»liuit(i  are  pro- 
■eat,  aud  each  of  i)>em,  inchiditig  the  giver  of  tho  chloroform,  ia 
duly  improwcd  witli  the  imj>ortance  of  liis  olHtTt,  and  iiefttiiwa  the 
mjoiahe  pains  apon  it.  But  wht-n  some  Iritle  is  to  bo  done,  tiio 
vbob  oJ&ir  is  apt  to  lie  regarded  too  lightly,  imd  the  mlministra- 
tna  of  the  an«>stbetic  is  perhaps  contidi^tl  to  some  unsuitable  person, 
«bo  aUo  allows  liiii  attention  to  be  distracted  by  other  matters.   This 


Up.  tat,  pp.  lai.  Umi, 


Jfc^Pl 


100  AN^STHETICa 

conclusion  is  entirely  in  accordance  with  my  own  experience,  which, 
while  it  has  convinced  me  more  and  more  of  the  safety  of  chloro- 
form if  properly  given,  has  impressed  me  deeply  with  tlie  necessity 
ibr  more  vigilant  care  in  its  employment  than  is  sometimes  apt  to 
be  bestowed. 

But  an  overdose  of  chloroform  may  be  caused  by  attention  mis- 
applied, as  well  as  by  want  of  attention.  The  requisites  for  safety  in 
using  it  will  be  best  introduced  by  a  short  account  of  what  ordinarily 
occurs  in  the  mode  of  administration  with  which  I  am  most  &mi- 
liar.  A  common  towel  being  arranged  so  as  to  form  a  square  olotli 
of  six  folds,  enough  chloroform  is  poured  upon  it  to  moisten  a  sur- 
face in  the  middle  about  as  large  as  the  palm  of  the  hand,  the  pre- 
cise quantity  used  being  a  matter  of  no  consequence  whatever.  The 
patient  having  been  directed  to  loosen  any  tight  band  round  the 
neck,  and  to  shut  his  cyos  to  protect  them  from  the  irritating 
vapour,  the  cloth  is  held  as  near  the  fece  as  can  be  comfortably 
borne,  more  chloroform  being  added  occasionally  as  may  be  neces- 
sary. After  a  time,  varying  considerably  in  different  individuals, 
but  generally  longest  in  adults  who  have  been  aecustomnl  to  the 
free  use  of  narcotics,  and  shortest  in  young  children,"  signs  of  ex- 
citement begin  to  manifest  themselves  in  various  ejaculations  and 
muscular  eti'orts,  which  soon  give  place  to  a  state  of  complete 
repose.  Tlie  struggles  of  the  patient  are  sometimes  so  violent  as  to 
require  considerable  force  to  restrain  them ;  and,  for  this  reason,  at 
least  one  efficient  assistant  should  always  be  in  attendance.  On  the 
other  hand,  I  have  seen  cldoroform  induce  nothing  but  a  tranquil 
slumber ;  and  it  is  important  to  bear  in  mind  that  the  stage  of  ex- 
citement cannot  be  reckoned  on  as  invariably  declaring  itself  at  alL 

The  most  convenient  test  of  the  patient  being  prepared  for  un- 
dergoing the  operation  is  presented  by  the  eye ;  not  in  the  size  of 
the  pupil,  which  is  inconstant  in  its  indications,  but  in  what  is 
commonly  spoken  of  as  insonsibiUty  of  the  conjunctiva ;  though  in 
trutli  it  has  no  relation  to  sensation,  which  is  abolished  considerablj 


*  I  onco  met  with  an  instance  in  which  chloroform  aeemed  incapable  of 
atTectintf  a  pulient.  It  occurred  in  tlie  [invata  practice  of  Mr.  Syine,  who 
naa  abr>iit  to  iierftiiiii  aa  operation,  for  which  we  proceeded  to  administef 
the  anffiBthelic ;  but  after  wo  haii  uaed  the  cloth  till  we  were  tired  wilhoot 
any  appni'eiit  effect,  Mr.  Syine  wcut  on  with  the  operation  while  the  {>atirait 
was  conncious.  Such  a  case  is,  no  doubt,  cxceasivcly  rare ;  but  it  is  int«r- 
esting  as  giving  aome  colour  to  the  hjpotliesia,  that  idios3'nc™sj-  in  tb« 
opposite  directiiin  has  existed  in  some  very  few  fatal  cases,  which  eeem  to 
admit  of  uo  other  explanuiiun,  as  alluded  to  in  the  text 


CHLOROFORM.  lOI 


■i  but  when  iincontciotui  winkinj;  im  Intij^r  occunt  on  tlw 
Q  liomg  UKtcJtcd  vritli  tlie  ti|i  of  the  finger,  we  liavo  a  good 
enleriun  of  tlio  suspcuision  of  roflox  action  in  tlic  Itodv  gvnorully. 
At  this  period  tlto  )>u1m  n  in  about  n  normal  oonclition,  and  the 
n^nntioD    u  uoaally  ettlter  natura]   or  vary  Klightl_r  stcrloruu.*, 
Ihongh  persona  witli  a  Htrong  tciidottcy  to  snora  maj  do  so  almost 
6001  tlie  commonoement  of  inhalatiQii.    But  tf  tlio  BdministruUaii  of 
the  chloroform  Iw  furtiiiv  ixtriiUlMl  in,  Htrongly  fttertoruua  breathing 
'     iriU  MOQ  be  induced,  aod  will  become  aggra^itvd  till  it  paMM  into 
ooniplcte  obaU-U4!tiun  to  tlw  onitraiipo  of  air  into  tlie  cheat,  though 
tlw  rBS[Mrator}'  niovementa  of  the  tboraoic  walls  rtili  coiitintu;.     Ou- 
awionally,  howovcr,  tlio  jirctnonitorj  »t«»rti>r  i.*  dffii'iont,  and  the 
breathing  becomes  toon  or  less  saddenly  obstructixi.     Thi^  is  a 
point  of  groat  iinjMrtwtoc ;  iW  without  cloM  alunitioii  it  may  escape 
ootin,  wlien  die  patient  will  be  placed  in  imminent  peril.      ]''or 
tboDgJi  iIm  rG«(Hration  may  be  nwurnvd  «pontnnuoii!ily,  tliis  cannot 
be  relied  on,  aod  it  would  seem  tliat  wlien  chloroform  is  given  in  an 
orenlnce,  ihe  caidiac  ganglia  aro  apt  to  bccomo  untvebhKl ;  and  on 
this  account  asphyxia  jiroduces  more  rapidly  fatal  cili>cta  lliai)  under 
ordinary  oircum»tancics.     But  if  tlie  obstructed  «talo  of  the  breatli- 
'      ii^^  is  noticeil  as  soon  as  it  txirum,  and  the  cloth  is  irome<liately 
nnoTod  frotn  the  face,  and  the  tip  of  the  tongue  »oizcd  with  a  pair 
j      of  arter\'  forcejiA*  aitil  <)niwn  firmly  forwards,  the  roipiration  at 
I      oooB  prucpcdx  witli  perfect  ii»edom,  the  incipient  lividity  of  Uio  face 
I      a  diapelled,  and  ati  in  w«tL 

I  I  am  anxious  to  direct  particular  attention  to  the  drawing  out 

of  the  tongue,  Ikioiium)  I  itni  itali>tii-d  tlijil  Avvcral  lives  have  been 
■acrifieed  for  want  of  iL     In  order  tliat  it  may  be  oSectuul,  Una 
metioa  i>  cMential.    1  luive,  more  thai)  once,  itevn  a  jii^r^on  holding 
Ifae  «ad  of  the  organ  coitsiderably  beyond  the  lips  without  any  good 
and,  phiciiig  my  Itnnd  on  his,  haw  givou  an  additional  pull, 
baa  re«atablialied  the  respiration. 
A  aimple  experiment,  wlueli  any  ono  may  ]>crr(>rm  ujwn  himself^ 
■UusQ^tive  of  this  point.     Stertorous  breathing,  such  a»  ooeura 
cliluroli>rui,  may  be  produced  at  will,  and  may  be  carried  on 
while  the  tongue  is  protruded  to  the  extreme  degree     But  if 
^  toogne  IN  bid  Iwld  of  witli  a  hamlki'ivhicf  and  pulled  so  as  to 
miMi  decided  luieaaiuess,  stertoroua  breathing  of  any  kind  becomes 

•  Tli<  ajtrrjr  forecp*  are  Uio  oiont  M>Rvcvi«at  uii-iuis  of  ilnt"inf(  the 
ptttfat  fiirwMjxU.  TIm  puncture  which  xlivy  iullict  is  uf  iiu  o»ii'i«iucnce ; 
thr  fMtMot.  tf  lui  noliws  U  bt  all,  kU|>)i<»cK  ttuit  lio  ba»  bitteo  hia  tongue 
wha  Bwlar  tlw  clilorofona. 


108 


ANESTHETICS. 


1 

f  exiais  to^ 


row, 

stillM 


iinpowiiblo.  Tliat  ftirthor  traction,  vihen  oxtciwion  nlreiwjy 
tiio  ulmoflt,  slioiilil  [ii-txltK^t!  :<iioli  an  otl'i^t^t  in  nn  ajiparciit  anonialy, 
which  it  scomt^l  important  to  explain.  On  inr««li;;iitinf;  \2w  Mib^M 
ject,  r  notiiiwl  in  tlitj  first  plate  iJiat  i«twrt<)miia  l>r«»tliing  is  of  two^ 
VMontiully  difforent  kin<l<i ;  of  which  one,  that  may  be  callol  jialatint, 
ooniuHtt)  in  vil>rati»n!t  nf  tliv  voluiii,  hiiiI  )i:ih  i-iUK^r  a  buccal  or  nasal 
character,  according  as  the  air  pa.>uM>8  ttirongh  tlio  moutli  or  tliu  now ; 
while  the  otlicr,  which  is  tho  pnitmind  slcrtin-  (*«fntiaUy  concerned 
with  uhlorofonn,  depends  on  a  caiiso  seated  fui-tlier  down  cho  tliroiiU, 
anil,  for  rvftflnns  to  b«  given  immcdiatjilv,  niay  li!  termed  laryntfeoL^ 
By  digital  examination  of  my  own  throat,  I  found  that  the  laltc 
varluly,  and  tli«  complete  obstnictjon  into  which  it  jiaiutea,  nould 
bo  produced  when  the  tongue  was  separated  by  a  considerable  intOF' 
val  from  tli(!  buck  of  tlic  pharj-nx,  while  a  free  pawiigo  for  tlie  air 
oxisted  onwards  to  the  lijw ;  wliidi  slii)wt!cl  tiiat  the  general  bcjief, 
Uiat  the  obstruction  depends  on  a  "  falling  back  ()f  tho  tuiigiie,"  is 
erroneous.  Also  the  epiglolli*,  instead  «f  being  folded  back  during 
tlio  obstruction,  n^  some  have  supposed.  Had  its  ant4>Tior  edgu  directed 
ibrwards,  and  though  it  wan  tlimwn  iiitn  vibrations  when  the  slcr- 
tor  was  strongest,  it  was  evident  that  the  cause  of  Uio  »oun(i  wa* 
more  deeply  jilaeed.  1  ul.io  fmind  that,  although  firm  traction  upon 
the  tongue  abuhshcd  the  obstruction  and  the  stcrtor,  it  did  not  ap- 
pear to  produce  tlio  slightost  change  in  the  position  of  the  base  of 
the  tongue ;  nor  did  it  move  the  os  hyoidea  upon  the  thyroid  cani- 
lage,  as,  examined  fi-om  without.  Hence  I  wiut  h-d  to  conclude  that 
the  beneficial  cUbet  of  tliin  procedure  could  not  be  explained  mccha- 
ntcally,  but.  must  be  developed  in  a  reflex  muimw  tliroti|^i  the 
medium  of  the  nervona  system.  Tlio  fact  that,  when  Gettsatlon  i»j 
porfcct,  Dome  ilegreo  of  pain  is  causod  in  the  {iroci^-w,  implying;  '^^ 
irritation  of  the  nerves,  was  in  favour  of  this  view  ;  while  the  gene- 
ral abolition  of  n^ilex  action  by  chloroform  did  ;iot  seem  strongly 
opposed  to  it,  considering  that  the  reftox  respiratory  movemoutx, 
including  those  of  the  glottis,  go  on  in  «  person  under  the  iutiuvnod  i 
of  chloroform. 

For  fiirther  elucidation  of  the  matter,  I  had  recourse  lo 
laryngoscope;  an<l,  after  a  little  patience,  foimd  no  diHiciilty  in  itt 
spectjng  my  own  vocal  a]))iaratus  without  employing  any  depi 
of  the  tongue ;  using  wmply  tlie  small  oblifjuo  long-handled  »pocii^. 
lum  and  a  common  mirror  in  bright  sunlight.     I  then  ascertaii 
tiiat  the  true  laryngeal  etcrtor  results  fi'um  the  vibrittion  of  the 
tioos  of  mucous  membrane  sunnounting  the  apices  of  the  arytjcnoiil 
cartilages,  ir.  the  posterior  parts  of  tlie  aryta-»u-«piglottidcati  folds 


CHLOROFORM. 


103 


^Hfc  and  pulpy  in  the  dead  hoiiy,  but  miicU  non  SO  wbon  their 
BRb  ant  full  of  blood),  which  are  parriod  forwardB  to  toudi  tho 
pbnaof  the  epifrlottis  during  tho  HturtonniA  hruiiUiiug,  siiil  urn  pkoed 
ID  atd)  ^losor  appofiitioft  with  il  H-)ii>n  the  ohstruotioD  becomes  com- 
fleta.  Ha^'iuj;  umi  luuid  ut  liberty',  I  vnts  Me  to  ohfervc  tlin  eKxl 
of  drawing  forward  the  tongw;  inxler  tliuw  cimuniHtances,  and 
atw  that  tint)  travtion  indaoed  the  obstructing  portions  of  diu«ous 
tavmbrane  in  coDtai^t  wJtli  itic  <*|>tglattis  to  retire  Ihini  it  for  about 
an  (-■igtiiii  of  an  inch,  so  as  to  allow  jr«e  passage  for  the  air,  nhilo 
tbe  epiglottis  ii^«lf  wili  not  movod  forwardK  in  tliv  xltfjhtiittt  degree.' 
Wliutbor  pulling  tho  toDguo  o|M>rate8  by  inducing  or  relaxing 
ooatnoLiun  in  tlia  lar>-nx,  may  be  matter  for  diKCU^ion ; 
hut  tlw  main  conclusion,  that  it  does  not  act  merely  mechanically, 
but  ihroDgfa  tbe  nervoiu  system,  appears  sadslaetonly  ewtid)li:ihed. 
]  have  not  hositated  to  give  the  erklence  on  wlitch  it  rests  in  full,  as 
it  appc^ars  u>  mv  to  Ijo  of  tho  liiglicst  practical  moment.    For  it  whowB 

Kiuo  how  grie\'ous  a  mistake  is  ouminilt^d  hj'  tbo60  wlw  oontcat 
While  the  tnui  lari^ngcal  stertur  nas  thus  produced  and  thus  ronoTvd, 
.  of  (porious  SDoring  mipht  bo  >nail«  by  approximation  of  tho  vocal 
;  but  tliis  apurious  sterUir  waa,  like  the  voice,  quitv  uuaJGMeil  by 
_ — jBg  ogt  th«  U>ngu«.  Tfaca«  obwrmlions  were  ni&de  oa  the  31i!t  Sep- 
Mnber  of  tlio  preaent  j-ear.  IMl.  I  fiud  Qiui  ihvru  are  four  way  a  iu  nhiub 
the  {Mimage  llin^ugh  tlic  larjiii  mnj^  be  dusted.  Firnt,  Uie  fuliling  buck  of 
Iha  «[>iglDtti4  ovei*  tlie  apcuin)*  inw  tin;  ]ilitr<r'iix,  as  ia  gt-neriUly  bi-lievcJ  to 
take  place  ui  awallowing.  and  mny  be  i}«iiioiistnit«d  bjr  nrri'tlinit  oii  uct  of 
degtulilion  ia  ita  proRrena.  aiid  inxJDuating  Uie  fiitKcr  bctn-<i!0  the  tongue 
mad  Uie  roof  of  ihi!  moutli  to  the  cpiglnltis,  whiuii  ia  then  Teltto  be  turned 
Welnrards.  and  to  reuim  to  its  usual  poiition  u  tho  not  of  deglutition  ia 
laiahrd.  Sveond,  an  approximntinn  "f  the  liJet  at  th«  superior  oriHue  of 
tbe  IttiTux,  in  whi>^  tbe  cpigtoUls  i«  directed  forwards,  but  folded  lonpt» 
diaaU;.  an  that  lU  odK«*  at»  in  eontae*  with  one  awXher  whUa  the  BtTlvDi^ 
•pt^toUul^Bii  folds  are  also  la  lateral  appoaillon.  This  oociira  In  rcieliitif, 
mi  dnutitleas  also  In  vomitiug,  when  a  folding  back  of  tl)«  epiKlottis,  tn- 
Maa4  al  proteetlog  the  larynx,  would  tend  la  dire<ot  into  it  tho  mnterial 
^■■iltf  ftwa  balo*  upwards  ThirdI}-.  an  iMWro^tfmor  voajitatioii  of  the 
'  ftnietamsof  the  laf^ngeal  atxfrtureataaainewluitdevper  level,  oitbout  nn; 
Aaaga  ia  the  pmitiuu  or  turta  of  the  ^iglottia,  lowarda  whidi  the  folda  of 
■■uc'iia  netnbraae  above  the  apieea  of  tbe  ui7t4i:iioid  eiutikge«  are  carriod 
farwarda,  till  they  are  in  oontuct  with  its  ba.ie.  This  ia  se«n  iu  coughing, 
■Bd  alao  in  huTDgcal  atertor ;  and  it  ia  probable  Uiat  duHug  sleep,  wheu  lh« 
laayiiailiin  ia  ao  apt  to  become  atertorooi,  there  ia  but  a  rery  narrow  uhink 
biaWaai  (he  .epiftlotti*  and  tboag  folda  of  mueoua  meinbiane^  whieh  would 
dm  aarvo  to  protect  the  deeper  parta  of  the  air-pnaaaKes  hom  tbe  inticduc- 
tiim  of  fi>feign  mattjira  in  tlte  rtnte  of  unc^onHciouancaa.  Fourtlily.tliei-lutiure 
ef  t^  rima  flotMit  in  the  produetion  of  viiicc.  ThewhilocADrderivedfiMfotin 
a  (MaatifaJ  ooutrast  with  the  bi^ly  vaauulaf  structures  in  their  riciaitjr. 


104 


ANESTHETICS. 


aad  a» 
oUieifl 

mtioa'H 


thcmwclvee  witli  gently  drawing  the  apcit  of  tlic  tongno  B  litt 
boyomi  tlie  teetli,  or  jmsliuif;  iorwanl  iL*  liase  with  the  finger, 
pcrhnps  ascertaining  that  the  epiglottis  is  not  folded  back.     Sucli>| 
prooefxlings  »rti  iii!itan<H>it  of  iittentioii  niinappliml,  and  waste 
golden  opportunity  for  reficuing  tho  pationt  from  death.   Tlio  prupcvJ 
treatment,  like  niiuiy  oilier  giuHl  things  iu  itioilicjil  praotioe,  owes  it 
OTigin  to  a  laltw  tlieon- ;  but  though  the  erronoous  notion  of  obstmc-! 
tion  by  tilt)  tongue  did  good  i«crviou  in  the  first  instanco  hy  itu^;oet>, 
ing  the  original  method,  it  now  tends  to  encourage  suppoeod  im* 
provemoiiU  U]>i>n  it,  which  roll  it  entinOy  of  its  «ffioacy. 

If  tho  above  description  is  correct ;  if  it  is  true  tliat  when  tha 
adininiMriLtion  of  chlon>forin  willi  iIki  clotli  in  ourrit^  too  fui', 
first  serious  symptom  is  an  obstructed  stat«  of  the  respiration,  whic 
witliout  watoliful  earo  may  octrtir  unnotivml,  xnd,  if  idlowod  to 
tinue,  wilt  endanger  the  life  of  the  patient,  but,  if  promptly  treated, 
will  hnmiloflsly  diNippcMU', — it  fwUowa  that  the  attention  of  the  ml«, 
miniBtrator  ought  to  be  oonoentrated  on  the  breathing,  instead 
WiTig,  UH  it  loo  oHen  is,  diverted  by  the  pul»u,  the  pupil,  or 
matters  still  less  relevant. 

A»  an  example  of  tlie  risk  that  is  ran  by  want  of  clotw  attention'! 
to  the  respii-ation,  I  niaj'  mention  the  following  case,      A  Snrgeon 
of  couitiitvrublo  cxpcrioiico  was  giving  chlorofonn  to  a  patient  on 
whom  an  operation  was  being  [lerformod,  of  which  I  waa  a  mera 
spectator;    but  I  noticed  that  Htortorotis  breathing  camo  on,  andS 
gradually  passed  into  complete  obstruction,  at  a  time  wheii  tbaV 
administrator  was  gazing  with  itilerost  upon  tho  proceedings  of  tb« 
o[>ei-ator.     Seeing  that  the  patient  was  in  danger,  I  suggiwU^i  Iu  the 
giv«r  of  the  chloroform  the  propriety  of  pulling  forward  ihe  tongue. 
Ho  replied  tltat  tliis  was  uncalled  for,  njid  potnttMl  U>  the  lieavings  olH 
tho  chest  as  evidence  that  breathing  was  j)rocecding  froelv.     Know-  " 
ing  from  what  hadgono  before  I  hut  thnai;  ertbrts  were  doing  nothing 
for  tlio  respiratory  fimction,  and  foeluig  that  there  was  no  time  fa 
diwuftslon,  I  stepped  uut  of  my  provinee  so  fur  as  to  seixe  the  tongua^ 
myself  and  draw  it  forward,  when  a  long  and  loudly  stertorous  in- 
ft])iration  denionst rated  the  nwes«ity  for  the  iiiterferoiieo.     Had  thai 
delusive  movements  of  the  chest  been  trusted,  it  is  probable  tliat 
they  might  have  conlinui-d  till  the  heart  had  beeomo  so  enfeebled  bjf 
tho  axphj-xial  state  as  to  cause  no  perceptible  pulse  at  the  wrist ; 
had  death  oocurrod  under  tlieso  cireumstanoes,  tlio  case  would  hav 
been  twt  down  as  ono  in  wliich  the  circulation  failed  before 
resjiiration.     The   administrator  would   thiH   have  liecn   alwoh 
from  all  blamo ;  and  ttie  fatal  event  would  have  boon  attributed 


IW- 

in^H 
thai 


CHLOROFORM. 


105 


S£MjiMTM)-f  or  to  any  timrt-discaao  which  might  have  boen  dis- 
Dovercd  an  pott-tnorUm  insjieciioii. 

The  vctj-  provalont  opinion  that  the  pulso  la  the  moat  important 
^mplMD  in  the  ailminiiitratioii  of  olilomfomi  i*  ccrtiiinly  »  ttio«t 
MnoOB  laiiftiiko.  As  a  £;m«ral  rule,  tho  mfeity  of  the  jutietlt  will  be 
moot  |)«Koat«(l  by  ilLtrogitnlin^  it  (tltof^tiicr,  No  that  tho  att«nti<>[) 
tntr  bo  dovoted  exolnsively  to  the  breathing.  The  ohaaoe  of  the 
niolenoe  of  )>eart-<)J!<c)L4v  miiy  ^wmii  to  imik«  thin  praptico  ilnngvr- 
ou  J  bat  hat'ing  followed  it  myself  with  increasing  eoiifkieiioe  for 
the  but  eight  yvtm,  ami  knowing  tluil  it  lias  bcon  parsiiod  nil  iiloiig 
liy  Mr.  SjToe,  who  hna  also  aeted  on  the  maxim  that  e\'er3-  ease 
far  operation  in  ii  caw  for  cliloruform,  and  muKt,  thrrt^fore,  have 
giraa  H  to  very  many  patienta  in  whom  cardiac  disorder  existed 
mkoowii  lo  htm,  bcifidos  some  In  wliom  il«  prown«)  lia<l  bovii 
aaoortained,  I  feel  no  hesitation  in  recomintMutiiij;  IL  Even  when 
Mnooa  diMmM  of  tho  heart  is  known  to  exist,  it  must  bo  romcmbonxl 
that  there  b  muoli  IctA  riak  of  iiyiu-fiit;  than  of  olistrntttlon  to  the 
twpirstion  ;  and  while  the  latter  will  deniaiid  and  re-pay  imniediato 
attention,  the  tormer,  »houk)  it  bjr  any  elumco  <jceur,  being  in  all 
probability  indepcn<leiit  of  any  exoees  of  chloroform,  nould  not  im- 
pantivcly  d«maiid  iw  disniiitiiiiianci;;  nor  would  it  Ui  much  influ- 
coeed  by  treatment,  supposing  tlie  patient  to  be  already  in  the 
iHmontal  po-tinrc,  which  in  gcncnklly  ouintiderod  tnfost  in  all  coMUt 
hen  chlorolorm  ia  giren." 

From  tbeAO  confidemtionit  it  »p|H;nn  that  proliininivry  c\amtna- 
ooa  of  the  chest,  often  considerod  indispensable,  is  quite  unnc<x«- 
«ary,  and  more  likely  lo  induce  the  dreadul  syntxipc,  by  iiiarming 
tlw  patient,  tlum  to  avert  it. 

The  oljstnicuid  rtato  of  tlw  breathing,  if  nllowwl  to  continue 
long,  would  lead  to  a  far  more  serious  atl'eetion, — paralysis  of  the 
nerrom  centra  conocmod  in  tho  rvspirator>'  movinnciita.     Pulling 

^V     *  From  th«  Ttews  exi>rvHii-iI  tn  Ui«  ti-xt  rv^rdinK  tbe  rolatkin  of  sjmcopa 

^■to  t^  Miiuiniiitraiiou  of(Utlor«fi>mi.U  mt^^bt  l>i-  iuftM'ietl  tliaiiiugi-catdait;^ 

^nMokl  be  Incanvd  by  ^nng  il  in  Uiu  aiitiiiR  posiuiv  nheii  circuiniiljincHa 

parlicuWlji  tmpiini  it:  and  >cei>n}iDgly  I>r.  Snow  iufurma  uh  t)uit  b«  bu 

dnne  Uiis  os  MrenU  ocmuJMU  wiUiout  any  bod  rvaull.   But  i'OTi!d<i«TiiiK  Uia 

pgeidliilit}'  of  nn  OTerdoie.  >nd  Ibc  fbchlrnu«a  of  Utv  heart  wliich  Uiat  tietMnfl 

t»  cubil.  U  U  IM>  dimbt  wb«xt,  an  a  gcncml  ntic,  lu  Iuit(>  tli«  patient  rvclin- 

lK(.     UrntiaU.  it  is  tnie.  nivr  chloroforra  in  the  sittiiit;  poolurc;  but  no  Tar 

■•  I  faarc  Hvii.  thcj  do  not  cany  the  odminUtratioD  bej'oiid  a  ajitjlit  d<^rcc, 

■■■ciBnt  to  diraden  aeniatioD  without  affecting  reflex  action.  dext<.-i-(>UHlj 

■^Mpag  to  open  tbe  montlt  and  operate  upon  it  wbile  the  rouHclen  of  Ui« 

L>»i  an  rigid.  ^^ 


h 


jl 


out  tlie  tofif^fi  wmild  tben  of  <wnir>*c  limn  no  paoi[  (■fli.^ct  of  >u<:>i, 
but  it  sboold  be  done  to  clear  die  way  for  artiticial  respiration, 
wliich  is  the  mcuiis  to  bo  i-KXiiitially  truntcd  to  tuidvr  nucli  circum- 
stances; and  if  the  air  still  fail  to  enter  freely  into  the  eheet,  an 
ojiening  ou^bt  to  be  miido  wiMioiit  ilelay  tbrougli  tbu  cricu-thy 
membrane.    Cold  water  stiould  alxo  be  oooiuionally  daahed  u|)on 
&C6  and  client ;  «iid  if  a  ftu'vanif  baltf  rv  ltii]))ion  to  Iw  In  n-ndii 
one  of  it«  [Jolea  may  he  jiiiiiHiicI  over  rlu?  sj>inoiin  iiroie.Koes  of 
upiwr  cttrvical  vertt-bra?,  and  the  oilier  to  the  pntcordial  rt^pion,  with 
the  object  of  n>urLttig  the  rasjiirutiiry  and  (-itnliaii  ganglia.     This, 
however,  is  a  mcanii  not  vert-  likely  to  prove  benclicial,  and, 
nsed  in  too  inteniw  u  form,  it  may  <lo  harni  in.«teud  of  good. 

Preparatory  to  taking  ehlorofonn  the  patient  should  be  diroeti 
to  omit  tin-  last  moid  wliioli  would  naturally  pRixiin  it^  as  luiy  food 
in  the  stomaeli  ia  alnioat  sure  to  give  riae  to  troublesome  vomiting 
during  the  inhtdBtioii.  The  oidy  aftor-trefitniont  noeeiWHry  is  to 
allow  the  eSccta  of  Uie  ehlorofonn  to  ]iaas  off  ui  a  quiet  sleep ;  and 
tlie  only  hH<l  oonsoquencio  likely  to  ariiw  is  a  tendeney  to  vickncw, 
which  sometimes  causes  antiojanoe  during  Uie  first  twenty-toD 
hoitrM  or  w." 

Chloroform  ia  universally  a(>{>licahIo  in  tlio  various  departmenti 
of  surgery,  exce]>t  in  some  few  cases  in  which  tho  assistance  of  tlie 
patient  is  n^juirod,  and  in  opcratioim  involving  eDpious  hajiiorrhage  . 
into  the  mouth.  Blood  may  trickle  in  small  amount  into  the  pba>^| 
lynx  witliont  risk  of  choking,  deglutition  being  eiirried  on  uiicin-^^ 
sciously  during  ana'stbosia ;  and  even  in  some  instances  when  the 
bl«ixliug  is  more  serious,  as  in  removmg  portions  of  tlm  jaws,  pail^^ 
may  be  avoided  to  a  great  extent  by  giving  the  clJoroform  during^ 
the  more  superfieJal  jnu'ts  of  the  opicration,  and  allowing  tJie  juticnt 
to  recover  partially  betbre  undertaking  its  deeper  stages. 


ntA 


*  It  1iH£  lieen  BUppOEL-d  by  some  tliiit  tile  nee  ori'liloroform  iiici'eiisei>  thfi' 
riBk  of  pjiErnm  urt«ctiHpiUl  upi^Tutiona ;  but  i-xpurkute  bus  uuw  ubuadnntljr 
proved  Uie  ipouadlesstii-^t-  uf  tliia  n)>pn.'liension.  To  iuku  a  einglc  instAnco, 
ths  retns  of  the  pelvic  risct^-n  being  perhaps  more  liable  tiimi  uiiy  otlicn  to 
erigiiiato  plilcbitia  after  Giii'gii'nl  iiiU-i-feieiii^e.  litliotomy  woulil  be  in 
niurc!  filial  now  than  fornieilj,  were  tliere  nny  foundatjon  in  fact  for  ttiQ 
tioii.  The  reveiBc.  hnwevcr,  iippoAi's  to  be  icnlly  the  case.  Thus.  Mr.  Cadgly' 
oue  of  tlie  SurgeniiEi  of tW  Notfulk  and  Nurwii-li  UospiUl,  an  institution  hing 
cclcbnited  fiir  tlie  euL-ccsarul  Irt'atmcnt  of  ktoia-,  in  a  dl8trU4  aboiuxllng  in 
cal.-iilous  diseuae,  iiiroriiis  luu  that  Ilie  nioilalily  aft«r  lilhotomy  has  been 
still  fiii'tlier  rodiK'cd  there  «iiice  thi)  inti'iiduotion  of  cliloi'ufi>i-m.  (Hccent 
etstUiic»  of  liLbotoniy  at  the  Nurfulk  and  Nuruidi  Hospital  will  tie  found  in 
the  Laiteet  for  August  Iblli  and  September  1st,  ibliO^ 


I 


CHLOROFORM.  107 

The  miun  conclusions  arrived  at  in  this  article  may  be  expressed 
in  a  few  words.  It  appears  that  chloroform,  though  resembling 
manr  other  valaable  means  of  treatment,  in  being  deadly  when  mis- 
managed, is  fire©  from  danger  if  properly  nsed;  the  following  being 
the  rules  for  its  safe  administration.  A  drachm  or  two  of  the 
liquid  having  bees  sprinkled  upon  the  middle  of  a  folded  towel, 
bold  it  near  the  fitce,  taking  care  that  &ee  space  is  afforded  for  the 
access  of  air  beneath  its  edges,  till  the  eyelids  cease  to  move  when 
the  conjunctiva  is  touched  with  the  finger.  Meanwhile  watch  the 
breathing  carefully;  and  if  at  any  time  it  should  become  obstructed 
or  strongly  stertorous,  draw  the  tip  of  the  tongue  firmly  forwards 
till  the  tendency  to  obstmction  has  disappeared. 

Iliese  simple  instructions  may  be  B0t«d  on  without  difficulty  by 
any  intelligent  medical  man.  The  nol^on  that  extensive  experience 
iareqaired  ftir  the  administration  of  chloroform  is  quite  erroneous, 
and  does  harm  by  weakening  the  confidence  of  the  profession  in  this 
inTahuble  agent,  and  limiting  tiie  diffusion  of  its  benefits. 

JOSEPH  LISTER. 


PLASTIC  SUBGESY. 


ABOVE  ibree  hundred  years  ago  there  lived  in  Bologna  a  pbyu- 
ciau  of  the  name  of  Qasparo  Tagliacozzi,  who  excited  &r  and 
wide  attention  and  wonderment  by  his  operations  and  cores.  Some 
regarded  him  as  a  sorcerer  and  necromancer;  others  as  a  liar  or 
boaster.  No  one,  however,  conid  comprehend  how  he  accomplished 
his  wonderful  cures.  Equally  little  could  any  one  prove  aught  evil 
in  his  actions  or  behaviour ;  for  he  was  a  man  much  respected  in 
Bologna ;  he  was  Professor  of  Anatomy  and  Medicine,  beloved  of  all 
students,  and  so  honoured  by  his  fellow-citizens  that  they  erected 
to  his  memory  afler  his  death,  in  the  anatomical  theatre  at  Bologna, 
a  marble  statue  with  this  insignia  of  his  art — a  nose — in  his  hand. 
But  he  had  thus  far  a  connexion  with  "  neoromantic"  arts.  Before 
his  time  Surgeons,  as  occasionally  in  the  present  day,  had  sooght  to 
obtain  eminence  by  cutting  off  arms  and  legs,  by  boring  the  skuU, 
and  by  boming  and  cauterising  the  flesh.  He,  however,  regarded 
the  matter  in  a  different  light ;  for  iar  &om  taking  any  thing  away 
irom  the  patient,  he  endeavoured,  and  found  a  pride  therein,  to  re- 
place parts  which  had  been  lost  to  them, — namely  the  nose,  lips,  and 
ears, — and  that  not  by  wood,  pasteboard,  silver  or  gold,  but  (as 
was  at  least  then  currently  believed)  by  true  veritable  flesh.  There 
needs  no  extravagant  phantasy  to  imagine  what  notice  and  envy  he 
thus  excited,  and  how  he  drew  upon  himself  satires  both  in  prose 
and  verse ;  the  more  so  because  his  art  was  regarded  as  a  mystery, 
and  no  one  could  accurately  understand  whence  he  obtauied  the 
new  nose.  So  much,  however,  seemed  certain  to  all,  either  that 
he  obtained  a  real  human  nose  taken  &om  another  person,  or  that 
he  out  the  organ  from  some  tender  flesh,  either  from  chick^iB  op 
calves,  and  patched  it  on  to  the  mutilated  persona.  Tagliacozzi, 
however,  disdaining  to  spread  about  Iiimself  or  his  art  a  mystery, 
wrote,  in  the  year  1537,  a  large  work  in  folio,  De  Chxrurgia  Cwio- 
rum  per  insitionertt,  wherein  he  opened  the  eyes  of  people  how  and 
whence  he  made  these  artificial  pieces,  namely  out  of  skin.     Thus 


TAGLIACOZZI'S  OPERATIONS. 


109 


TV,  Fritze,"  wHo  wrot*  in  1845  a  jurt  tribute  to  tita  talent  and 
iginality  yf  »  {^rxuit  iiuui.    The  linon  in  f/uilSrrtu  have  1>e(N>n)c  Iritc, 
roeauingiess,  and  vulgar ;   while  TagliacoEzrs  experimental   oaa- 
finnation  of  a  ^rcat  pbysicul  triitli  liv<Hi  tu  bo  only  more  hoDOunxl 
^■nd  belktved. 

^^v  It  IB  no  rvfntntion  of  tliv  cUims  of  Tagliacvzxi  to  tar  that  Stir- 
^B^ODCM  are  ttfknn  di^ppointed  in  their  (■xpocrtatioiis ;  that  tbo  descrip- 
^F^DS  giviMi  Ijj-  tho  oarJy  apQitii.-*  ufi>liuitic  imrgary  were  florid  or 
exa^seratcd.  The  fundamental  trntha  remain  tlie  .lame ;  the  tranN- 
plaatation  and  rvuiiion  of  Qa]»  of  intc<niniiMit  is  a  procvcding 
adopted  and  recognised  by  all  Surgeons,  ullltou^h  thev  have  leiiriit 
tint  tlio  ultJinatu  rcenlt  ta  gntvralty  of  no  more  favourable  charaetcr 
tiiui  to  witrraiil  the  proceeding  in  nasea  where  tlie  patitint  oxperi- 
coees  a  positive  e\'il.  Wo  do  not  quite  aecoinpany  Dr.  Fritze, 
wbon  be  wtvA,  in  hiH  glowing  language,  "  A  perturnted  and  oornwhil 
flGehr  knob,  whidi  brings  woo  to  the  powewor  who  carries  it  on  his 
■bmildcni,  and  I«>rmr  u>  «very  one  else,  is  convertcl  by  plas-tic  sur- 
gery into  a  human  phyBiognomy,  and  gives  back  to  the  discarded 
and  avoidwl  [»cr<on  botJi  life  ati<l  wieiwty  ;  tlie  eye,  which,  dcpriv.il 
of  ita  natural  eovcring,  becomes  dn.'  and  inflamed,  and  would  with- 
draw it«olf,  but  ill  vain,  wiih  conviilnive  Hlortu,  fnun  tJio  di'Sinictive 
influeuee  of  liglit  and  air,  socking  the  rep<jse  which  avoids  it,  is 
cwvcrod  again  wilh  [avtecUvc  i-ydid«,  aiai  n-giiin»  life  and  Ml»ep;  a 
nwHitli,  |nickered  np  and  grown  togeihcr  like  an  eyelet-hole,  for 

[which  no  lood  in  niitnbU;  eavu  tmip  and  thin  broth,  and  whoso  vx- 
pnhive  urtiuuialion  reseniblea  tiie  cry  of  the  wild  beast,  again  gives 
forth  human  m>uiids,  reo]M-itM,  and  idlowN  thu  patient  both  to  vat  and 
■peak.  Have  I  yet,"  he  says,  "  occasion  to  relate  that  plastic  sur- 
pny  ha»  the  power  to  licitl  I>i>th  nrtnary  and  fieeal  fistula-,  and  thus 
tn  nanove  the  grwatest  physical  suttering  with  wliieli  man  is  afHietMl 
in  tliia  world  ?"t  i'*-'l  us  divert  the  suhjeet  of  this  high  cdlonring 
and  nurtanoe ;  and,  white  a<JcnowIedging  it^  utility,  remember  that 
"  the  artifleial  noso,  even  tlie  moKt  comph-te,  ean  never  fully  o<|ual 
the  natural ;  tliai  tlio  jiatient  need  never  ex(>eet  it."  "  Natnro  ever 
tniunpha  over  art,  and  hare  is  tbc  buuiidarj'  between  what  is  godlike 
•nd  linnian."! 

Certain  subjects,  tltoao  indeed  most  commonly  illustrative  of 
pUvtic  aui^ry,  will  in  tliis  work  lie  treated  uiHler  otlier  bitul^ 


[)U  PlaUuthe  CKimiyie.  ■■)  ti<-trU>'iil  wirk.  to  uhiuJt  llie  reader  may  bw 
nCm**!  fiw  n  hUtury  of  the  ait  of  I'luBtiu  Suiii'i'Ty. 

t  Ojk  ait  p.  2.  !  Ibid.  i>.  9. 


110 


PLASnO  SURGERT. 


Thus,  fijwtiivd  ptdate,  Ac.  coitu)*  nndi-r  t.li«  Iwatl  of  I>irr\3E3  or  TRiH 
MouTU ;  entropinm,  eotrapiuni,  and  closure  oftlie  laorvmal  sac,  undco^V 
timt  of  DlSKASES  OF  THE  Eye  ;  imjM'rronito  unus,  iiiidcr  Si'iuiiiRr  or 
Childhuod;   recto-  and  ve*ico-vaginal  fistula,  under  Dimkasiu*  ov 

THE  FfiMALB  OlWJAJJS  OF  CJKNEBATIOy.      Wt'  JtrtJI"**''.  tJHTC-forC,  LcFB 

to  dt>al  mora  with  general  priiioiplaa,  and  to  apply  them  to  fliuJtflj 
subji.-L-ti(  as  are  not  hicludvd  in  tho  above  hoailin^ 

Now  all  di'fcirniitiea,  wlicther  remediable  or  irremediable  by 
Burgical  operation,  may  bo  cl»s:<i(.-<l  iindor  two  beads :  tim  congonital. 
Mid  tlio  iion-r^i)^i!nital ;  and  this  diHtiiurt.ioii  must  ha  I>i)rnt>  in  mind 
in  most  of  the  atstm  wo  aro  calk-d  upon  to  tn.'at,  A  0'>ngenital 
(li^ormity  im]ilieH  an  arrcitt  of  deveiapmenl,  ponaibly  a  con^iiitol 
deficienoy  of  parts,  or  a  relation  hicIi  as  should  vxi^^  nnturally 
only  in  fiiit-id  Hfu.  In  tho  iKiii-confrenital  or  ai'(iuin>il  (Ifriiniiiiy, 
parta  already  formed  and  normally  proportioned  have  boon  injured 
or  dostroynl.  Tliere  are  but  few  exc^ptiims  to  ilitA  rule.  T)ic 
treatment  of  tho  former  U  in  severe  eases  more  nntiatisfactoiy 
tluui  tliat  of  tlie  latter.  For  rastanoe,  a  Him{>le  oonjrenitnl  Itwnro 
of  the  lip,  constituting  Iiare-lip,  may  bo  united  in  tho  usual  way; 
but  there  in  niu.«tly  some  abiiormul  tiinrkin;;  on  tlm  intepimcnt, 
which  ever  afterwards  indicates  the  operation  which  lias  been 
porformod.  Moreover,  the  fiwiurc  may  i.'xt<'n<l  into  tho  hard 
sort  palates;  or  the  irregnlaritv  of  development  may  influence 
position  of  the  ineisor  tcotlL  The  case  is  obviously  moro  com[ 
oated  than  one  of  sin)j>lR  division  of  the  upper  lip  by  areident 
fiurgieal  operation ;  and  the  Siu-geon  should  bear  thi:*  point  in  mittd ; 
for  nlttiou^h,  as  re^ardi*  the  moutli,  tlie  statement  is  obvious  enutigb, 
diere  arc  other  situations  where  want  of  attention  to  the  law  of 
fintMl  rt'Ialioiis  may  bo  tollowiNl  by  seiious  consequenow,  Wlicn 
the  bladder  is  open  in  fi-ont  from  congenital  defect  (ostroversi* 
vesioH.'),  tlie  titt^nn;  in  the  organ  and  in  the  abtloitiiniil  parietm  is  not 
the  only  defect.  Bladder,  prostate  gland,  and  pcritona.>um,  rectum 
And  pelvic  Iwni's,  retain  very  mneli  of  those  relations  which  existed 
at  the  moment  when  the  bladder  failed  to  close.  In  other  wordii^ 
from  thill  moment  parts  greiT  in  size,  but  ceascil  to  Iw  developed  to 
the  norma]  hearings  of  the  ailulL  Shimld  the  Surgeon  in  sttdi 
a  ease  endeavoiu*  to  establish  a  rccto-vtwical  tKtiila  (as  bas  been 
aex'oral  times  attempted),  by  passing  a  troeliai-  from  the  rectnm  into 
tht?  bladder  in  order  to  divert  the  stream  of  urine,  be  will  make  the 
discover)'  that  there  is  rarely  any  sufe  sjkiI  which  tho  instrument 
may  traverse :  the  prostate  gland  is  small ;  tile  periton»-urn  comes 
down  to  its  very  border,  aa  it  would  in  the  young  infant ;  the  bladilcr 


Iteen 

apS 
It  o" 


J 


pnrNcrpLES. 


Ill 


^B|  tovn  of  on  nlxlominal  than  a  pehic  viscua.     Uonce  fatal  peri* 

^Hnaitii  eOBitoe  before  tlw  Siii^uoii  lisH   hail  timo  tu  cfttablish  those 

^QooiUliun»,  vrhieli  ho  truHied  would  enable  hmi  to  cKifie,  \>y  n  ]>ladlte 

operation,  tlie  abdominal  fUsuro  through  wliidi  the  nrino  mcapod. 

Tbt*  )M>wi.-r!«  nf  n^jiair  and  of  r(']>roducLion  in  man,  upon  which 
ikfMnd  the  suoons  of  all  pla:^ic  oporatiotts,  aru  very  much  more 
ItmHixl  tlinn  in  the  lower  aiiiniabt.  We  need  not  Iiern  dwol)  upon 
Qtb  well-known  ttutances  of  thu  re-fomi»tioD  of  t]i»  lost  leg  to  tlio 
nlMnandcr  or  the  loiit  daw  ta  tlie  orub,  but  nmy  i-cmark  titat  in 
nuui  tlie  hair,  the  nails,  tiic  cpidannu,  and  epithelium  eeom  alone  to 
poaaem  the  power  orcoin[Jete  n^noratioti.  It  is  doiihtftd  if,  tmdor 
any  lurcmnstanoes,  tJssaes  of  even  the  lowest  organisation  and  of 
thi'  lowcKt  vliemtcsil  eharaoU'rs,  Midi  m»  die  w-Huliir  and  iL'ndiiious, 
bcoome  replaced  completelv,  when  onct>  removed,  with  all  the  clia- 
Tueisn  thoy  Itad  Iwlwrii.  The  tonitnnK  jirts'i-rvwi  in  tho  iiiiiM'tmi  of 
Iba  CQi\ege  of  Surgeons  of  Sn^and  (Xos.  S58,  35»,  &G0),  which 
bare  beon  oAra  hrutigbt  forward  ax  inrt^inn.-*  "f  (xmiplrle  njgwue- 
ration  of  lowh'  organeed  tiaetMS,  do  but  illu^lrate  tl>e  oontnirting 
power  of  n?>eently  effuwtl  lymph,  and  tliu  gmdual  approximation  of 
ihii  tndsi  of  (be  out  t^'odon  so  as  to  form  a  linear  ftioatrix.  In  1 S58 
I  had  the  opfiorlunity  of  uxamining  two  Achilles  tendons,  wliich 
had  been  subcutaneously  divided  at  perioda  of  two  and  throe  montJta 
previoae  to  the  death  of  tlie  patient;'  and  it  was  there  seen,  afler 
making  a  longitudinal  ineinion,  that  tlx^  ilivi(l(-<l  vniU  iif  tin;  normal 
lewlo  Aebilb's.  two  ineliea  apart,  were  united  by  a  liglit  gray  semi- 
tnmipurent  ittnicture,  <|uito  ditlVivnt  from  natural  turiiloii,  and 
raadily  distingnisliable  to  its  vciy  bonndary.  Hail  no  mcclianical 
•xtBfiaion  benn  em[iioyed,  tliin  now  miitirrial  wduM  tia\'e  ii)riti'aetod, 
Ota  any  other  cicatrix,  and  have  gradually  approximated  tlie  squ- 
jl     gated  cmU  of  Ilio  true  l«n)loii. 

jH  Whatever  tlie  microscope  may  reveal,  tlie  feet  is  nndoubtcd, 
^pBnrt  wbon  the  mlire  Itiiekm-M  of  tliti  nkin  luw  Ix-en  de-tlrny<>d,  tlio 
B^MOe  wltieh  re}>iaoea  it  never  exhibita  the  same  diaracten  or  per- 
frciicm  as  brfiin).  A  Miperlidfll  layer  may  bu  diwirganisod,  wlien 
Kpair  pwa  on  by  a  soper^cial  layer  of  gramibitions,  and  no  trace 
of  tlM9  injury  aft«;r  a  tiiinj  i«  ptTeeptible.  But  the  wuie  in  otliprwiso 
wlun  tlie  whole  thickness  of  the  skin  has  [)enshed.  TIic  siimkiiIi 
white  cicatrix  n^inx  it»  own  cliaraeli.n'iKticv,  and  eoiitraeta  for 
amtlw  am]  eren  years,  gradually  drawing  closer  around  it»  do- 
■■■Miiiji,  cirenmfenuioo  tlio  Borrounding  integument,  and  acting, 


*  JVcdMoI  2Imm  cuuI  a<u4U«,  January  Vtb,  1830. 


112  PLASnC  SURGERY. 

thongh  slowly  and  gently,  yet  Trith  a  force  that  m>  tisane,  however 
hard,  can  resist,  distorting  the  features,  and  exercising  an  influence 
on  the  shape  of  the  growing  bone  and  on  the  direction  of  the  teeth. 
Let  no  Surgeon,  who  hopes  to  remove  a  deformity,  ever  trost  to 
the  persistence  of  a  large  cicatrix  ;  let  him  likewise  remember  that 
every  incision  which  he  makes  involves  the  formation  of  this  newly 
efl'used  and  readily  contracting  nniting  medium ;  and  he  may  pei^ 
haps  be  more  wary  than  has  hitherto  been  the  cose  in  attempting 
the  removal  of  contractions  by  operation. 

In  plastic  surgery  the  operator  avails  himself  of  the  tme  skin, 
with  the  subcutaneous  areolar  and  fatty  tissues;  sometimes  like- 
wise of  the  mucous  membrane.  Fritze  justly  remarks  that  the 
transplanbition  and  union  of  bone-fragments,  as  welt  as  of  teeth 
and  hair,  is  very  problematical.  Walther*  speaks  of  the  reunion 
of  a  piece  of  trephined  bone;  Weisemann,!  ofthe  adhesion  of  teetb ; 
DieiTenbach,  of  the  transplantation  of  hair.  Hunter's  experim^itg 
upon  this  subject  are  also  well  known.  They  are  ail,  however,  of 
more  physiological  interest  than  practical  utility. 

"  We  have  to  deal  in  plastic  operations  with  the  integument 
only,"  says  Fritze  ;t  "  and  can  as  little  make  a  new  nose  out  of 
a  fowl's  breast,  as  cut  out  and  form  a  similar  organ  out  of  the 
thick  muscular  flesh  of  the  arm."  The  flap  for  transplantation 
should  be  taken  from  the  individual  on  whom  the  deformity  la  to 
be  rectified.  Thus,  if  a  new  noae  is  to  be  formed,  the  skin  should 
he  taken  eitlier  from  the  immediate  pi-oximity  of  the  damaged 
organ,  aa  the  forehead  or  cheeks,  or  else  from  a  part  which  can  be 
readily  approximated,  such  as  tlie  forearm.  Biinger  relates  a  case 
of  partial  success  in  the  formation  of  a  new  nose  on  a  lady  by  a 
piece  of  integument  completely  cut  away  from  tlie  thigh  ;5  and  Hoff- 
acher,  who  was  officially  appointed  to  attend  at  the  duels  frequent 
among  the  students  at  Heidelberg,  mentions  some  remarkable  in- 
stances, whicli  are  attested  by  Chclius  and  Velpeau,  of  the  reunion 
of  parts  completely  sliced  off  by  sword-cuts ;  e.  g.  portions  of  the 
nose,  lips,  or  chin.  But  no  such  Ucense  can  be  allowed  in  plastie 
surgery ;  the  flap  must  retain  its  connexion  to  tlie  adjacent  living 


*  Th.  v.  Walther,  WUderHnheUung  dtr  ha  dtr  Trtpanation  miigAokrat 
Knockenicheibe. 

f  J.  H.  Weiscmann,  De  Coalitu  parlium  a  reUguo  corpore  proriut  di^taut- 
arum,  Ijeipsice,  If  24. 

I  Op.  cit.  p.  5. 

§  Uungor,  Gelunffener  Fall  einer  Na*enhihhing  am  eintm  tollig  getrtmmUr 
HaaUtuckt  au$  dem  Ucine.    See  Grafa  uad  Wulihoi'a  Journul,  BU,  iv.  p.  HOD. 


PRINCIPLES. 


lis 


ctnre  by  a  pecliole,  wliieh  is  to  be  severed  onlj  after  complete 

unkm  tad  ctcatrUatiun  of  Hm  raw  ^urfaect.     Tho  idea  oi'  (akiug  the 

fiip  of  integumenl  from  another  individuaJ,  and  binding  tlic  two 

^^^Bltft  togctlunLnntil  anion  shall  hare  takvii  plnoc,  is  preposterous 

^H^Higliafa  notionii ;  xlthongli  Htated  to  itave  boen  entertained  and 

H^netued  in  eastern  countncs,  whi*re  pla^tio  surgery  has  been  kuowo 

from  time  ini memorial. 

The  flap  of  intcgutneot,  separated  from  its  connexions  by  the 
laiife,  and  hanging  wily  by  the  fjedittle,  bticouieii  at  tirAt  blanched 
■nd  white  from  toss  of  blood,  and  also  somcn-hat  slirlvellod  or 
•  Bhniuken.  Aller  the  lueuiorrlui^e  liiut  cenwid,  it  may  acquire  a 
marblL-d  aspect  from  irregular  aocumulalion  and  stasis  of  the  blood ; 
and  tilt!  iviiijM^nilure  {>er(-ej>tilily  fiillK.  Soon,  lio»'e\'i*r,  the  rednees 
and  warmth  rotuni  to  it  in  its  new  situation,  and  harmorrhage  may 
mmmeuoe  from  tta  iitidfir  nurlaco  ufrosJi.  TIiuk  it  continues  for 
•oioo  boon,  tlte  flap  sometimes  paler,  somottmes  rodder,  as  the 
vitality  Iosm  or  ae<)uire«  iK>wor,  until  nlLimatoIy,  whon  circum- 
•buwea  are  Eavom'able,  the  latter  condition  prevails,  and  e\*ea  puf- 
ftneM  ami  swelling  may  «ui>er%'6ne  before  the  part«  regain  tboir 
Donnal  as[*eci. 

Now,  inaitinutrh  ta  the  uicccitti  of  all  tlie«o  opemlioiu  dejionds 
delicaey  of  manipulation  and  extreme  accm'acy  in  detail,  let 
tlu'  Miirli'iit  that  tlitii'o  iit  no  more  tVnquont  source  ofiailure 
than  the  presenro  and  persistence  of  a  clot  of  blood,  whether  pri- 
marily or  Mxvindanly  vfliimxl,  undor  tJic  Hup.  Hiemorrhago  is  an 
€v3  in  all  sta^jea  of  plastic  surgery ;  and  therefore  the  Surgeon  ia 
aocawttiraed  to  wait  before  attaclitng  tho  bleeding  flap  to  its  now 
aamoxioa,  well  knowing  tliat  no  time  is  more  favotirahle  for  tlie 
•ffmon  of  plastic  material  than  when  the  parts  aru  dry  and  oven 
•omewbat  glazed.  He  likewise  keeps  the  patient  moderately  cool^. 
maintaining  tlic  natural  heat  of  tho  body  on  one  hand,  and  avoiding^ 
all  causes  likely  to  pi-oduee  excess  of  action  on  the  other ;  fur  should 
Uvoding  rtx-ur,  the  wound  may  need  to  be  reopened. 

Among  the  acoiilentd  which  hefal  the  truiL^ijitaiitt^d  flap  i.i  one  tn 
which  pATlieidar  attoiition  lias  boon  directiMl  by  Mr.  iSkcy.*  "  It 
will  oocauonally  happen,"  lie  obiterves,  "  after  some  duyn  fn)m  that 
of  (br  a[Miration,  that  tho  new  structure  begins  to  losson  in  size,  and 
ontioneA  to  diminish,  till  it  liecoiues  almost  absorbed.  Ikly  ex]i&- 
rianna  in  naac-inaking,  though  not  small,  is  not  sufficiently  great  to 
adilc  toe  to  explain  tliis  fact ;  whether  owing  to  tlte  »nuLll  sizu  of  the 


Tot.  IIL 


•  Skcy,  C^fwtiiv  Sti/gtry,  24  edit.  p.  534. 


lU 


PLASTIC  SUHGERY. 


Htalk,  or  to  the  want  of  general  activitv  in  the  drcn1at!<H), — \ 
is  tho  wise,"  Tlitit  tbo  shrinking  of'Uiw  fln[>  i»  ratluM"  due  to  the 
latter  than  to  the  former  oauae,  was  illustrated  by  a  ease  under  my 
own  L-arv  in  St  Bartlioloincw's  Hospital.  In  1859,  a  Jwy  wsjf  admitt«d 
Rufl'erin^  from  di»ea.4o  of  the  knee  and  ayroptoms  of  early  tuliemular 
deposit  in  tlie  lungs.  1  ainjtutatod  tlio  limb  acMinling  to  the  method 
pmposed  by  Mr.  Teido;  that  ia  to  say,  by  making  a  long  rectjui- 
gular  anterior  Hap  of  uit^tguinont,  and  bringing  tt  undi-r  tliv  &tump 
to  unite  wilJi  a  Khort  fla])  at  the  jmstorior  aspect  of  tlie  linit>.  Tlie 
case  terminated  fiivourably;  but  with  tbo  cicatrisation  of  tlio  wound 
the  anterior  fhip  nlunink  .10  oonaiJerably,  that  it  but  little  extjecded 
in  size  the  smaller  posterior  one  to  whicli  it  had  been  unitod.  He 
limb  bad  the  n.'tpect  of  having  uiulergnne  the  usual  Hap-oiK^mtion.  ^M 

Gangrene  usually  appears  about  tho  third  or  fourth  day.  If  tl^l 
flap  retains  it»  vitality  Iieyon<l  thi.*  time,  union  gwnerally  proeouds 
without  intermption.  Tlio  mortified  parts  a<i$ume  a  gravish  colour, 
look  soft  and  puijiy,  ttii<l  (he  ctitidw  ItHisfin.*;  or  tlio  flap  may  be- 
come dry,  shrivelled,  and  witliered.  But  e\-cn  under  these  circom- 
Btanccs  Ii:t  not  the  SiirgiHiu  rvirnovo  it;  he  should  nitlKT  eover  it 
with  cotton-wool  or  a  soft  broad-and-water  poultice,  or  witli  water- 
dresalug,  Le.  wetted  lint  coverwl  with  oilod  silk  or  gutt«-pcreha ; 
for  he  eannot  tell  either  how  far  or  how  deep  the  loss  of  vitality 
may  extend,  Tiio  edges  of  the  wound  iilone  ntay  die;  or  tJie  super- 
ficial parts  alone  may  be  tlirown  oft'.  If  even  the  smallo!^  portion 
of  skin  remain  in  itd  new  Kittintion,  it  may  afford  the  patient  partial 
relief,  or  serve  as  a  groundwork  materially  to  facilitate  any  future 
procooduigs.  I  will  add  only  this  caution  :  if  tho  wound  happen  to 
be  going  on  unsatisfactorily,  let  the  Surgeon  cover  it  up,  und  tibstoio 
finm  frequent  exaniinations.  He  will  soo  in  a  few  days,  witfaoot 
TOixiattil  insjieotion,  how  much  nature  has  been  enalded  to  dfoct. 

It  is  unnecessary  to  speak  of  tJic  many  inconveniences  attei 
an  Attack  of  erysijx'liiH  tiilvr  the  opi>r;iti<>n,  inasmuch  as  tlii*  disuaW 
has  been  described  eUewherc.     Every  proper  precaution  should  be 
token  to  ])re^'ent  such  an  ai-eident :  the  room  shmiM  bo  clean  and 
airy  ;  ihe  dressings  light,  and  easily  though  not  often  changed.     Tlift 
general  condition  of  the  patieiil  should  \»>  "ueli  iii*  to  mider  ii 
ceesary  purgative  or  other  disturbing  medicines;    lie  sltouM 
suoli  nourishment  a»  his  cireunistaueei  Iwst  admit.      IJy  prcscrvii 
the  standard  of  health  as  near  as  possible  to  its  noi-mal  state,  wo 
tho  patient  in  the  best  coiiilition  to  resist  injurious  morbid  influe: 

The  object  of  the  Surgeon  in  all  eases  is  to  obtain  union  by 
hiUtitk/iu     The  sumo  obsortiitiou  will  apply  to  this  as  was 


PRDfCIPLES. 


US 


^^K  The  surfaora  nhicb  we  wiali  to  unite  sJiotilcI  be  held  ac- 
mnrtrly  big^tor,  witli  t\w  xniulk^t  ttmotmt  of  irritjitioii,  until  a  layvr 
afplactic  Ijiiiph  in  e.\aded;  an  event  which  takes  place  at  aity  time 
Iwtireqi  twenty-four  houra  and  three  daye. 

The  Rap  of  intfgninent  having  been  eut  to  the  poper  nize, 
desned  of  extra\'asat4?d  blood,  and  fiwhionod  to  its  new  situation^ 
we  proceed  to  inquire  into  tlte  beat  method  of  holding  it  there  until 
OBtltre  bax  acyrompliHlicd  her  part.  Although  tlic  employment  of 
taetallie  sutur&i  h  not  a  inudeni  diitcovery,  yet  too  much  eretlit 
cannot  be  given  to  Dr.  Marion  Sims  for  his  energetic  advocacy  of 
Ibsir  ui^e,  and  for  ttie  eomtwIneHA  wilti  wliidi  he  hits  worWl  out 
tlwir  practical  application.  Indeed  tlicy  may  be  said  to  have  falloa 
into  di«4i«e  untQ  the  pnblieation  of  his  gmnivemarv  discourae  before 
the  New  York  Academy  of  Modicmc"  Few  Surgeons  will  fail  to 
todons  his  opinion,  that  "  in  plaHtie  surgery  it  n  the  great  de.side* 
ralum."  **  In  Jlay  1850,"  he  observea,!  "  a  gentleman  liad  the 
nBJbrtnnr*  tn  I've  a  gofid  jnu-t  of  the  letl  ain  nit«i.  In  the  ojHtratioa 
a^t  iniernipted  silver  sutures  were  used.  Thoy  wore  removed  on 
the  fioveutli  day :  union  wait  |)orfoet,  nnd  be  hooii  went  bonii^,  with 
tome  slight  tumefaction  of  the  parts,  which  gradiiallv  sid.isidecl.  In 
the  cooTW  of  a  l!nHniglil  be  returned,  saying  tbiit  in  wiping  the 
pmpiration  from  his  face,  be  diseovered  some  pricking  substance 
at  the  seat  of  the  oi>eration,  whieJi  he  >in]>]>osc<I  to  be  a  bit  of  wire. 
He  was  right ;  the  wire  was  there,  but  easier  felt  than  seen.  IL 
was  removed,  and  found  to  bo  half  au  ineb  long;  it  hud  reniatned 
there  fbnr  weeks,  producing  no  sense  of  soreness,  and  no  intlamma- 
tioB  or  siqtpuratioii,  as  a  silk  tigatiue  would  have  done ;  tbut  eitn- 
the  great  and  important  prineiple  that  silver  was  as  inno- 
iLS  lead,  ajid,  like  it,  might  beooinc  saeeulatod,  producing  no 
int  or  pMsonous  effect  whatever."  In  lJ<5i,  a  liitle  boy,  some 
[  ycar»  old,  received  a  blow  on  the  upper  lip,  near  the  left  enin- 
jre.,  culling  it  through  for  threo-([uarU>ri*  of  an  inch.  Tltree 
ipted  silrer  uitures  wi'ro  applied,  and  no  other  drcKtiiig.  Dr. 
«w  no  more  of  him  liJI  iJie  ninth  day :  "  union  was  perfect, 
remaining  precisely  as  I  bad  placed  them.  Their  removal 
Flike  tlinl  €>f  a  delicate  ear-ring  fn>ni  tlic  ear  long  used  to  wear 
In  18.53  the  «ime  Surgeon  performed  a  serious  operation  on 
gnufenum  Miflering  &om  «anc«r  of  the  li]>.     The  patient  went 

'•irr*  in  Surjny;  the  ftnniv<Twuy  iiU<?ciur«e  before  the  New 
ftiri  ■    of  Meilicinp.  delii'ci«<i   du  tlio  ISih  Nommher  ISnT,  bf  J. 

I  Mui^  M.D..  Surgeoo  in  ihe  Woii>iui'»  Itospital:  N«w  Yerk,  1638. 


tkriuf 


116 


PLASTIC  BUaaERY. 


bomc  (some  80  or  100  milod)  immoiUatoly  aftiT  the  opcrntion,  m 
retiirnwl  to  Dr.  Sims  in  n  week.  Tho  oul  wtriiiots  of  a  V-i»iia[>«l 
infiision  hiid  heaa  unitod  by  four  iitUtrruptcd  silver  Bottires :  union 
wujt  [lerfUct  tliroiigliout,  the  wires  having  produced  uu  iuftninniatoij' 
effect  whatever. 

I  do  not  niultiiily  instanoea  cither  from  mv  own  oxi>eri«iioe  or 
that  of  other  Surgeoni;,  bocatiso  it  Is  only  just  to  Dr.  Sims  to  quote 
Iii.t  own  oiuir!'  uf  tMirly  itticcesw  ;  iitkl  I  holiovo,  however  ultiw  the  l'n>- 
feasion  may  have  been  in  adopting  this  snture,  the  universal  tWling 
woiiUI  now  bo  in  it»  favour  in  nil  mimcs  of  pluetic  o[>cmtions.  Tim 
parts  may  be  covered  with  a  rag  moistened  with  wafer,  or  even  be 
luft  cxpoMHl  to  thu  itir,  according  to  tlie  feelings  of  the  patJont.  Tha 
method  of  introdneing  tlie  wire  sutures  has  been  already  dtseribod  ;* 
the  time  of  their  rciiioval  inuot  be  lell  to  thu  discretion  of  the 
Surgeon :  probably  the  mean  time  would  be  between  a  week  niid  a 
fortnight. 

The  shotted  suture  is  no  modem  invention.  Two  or  more 
pioc»  of  silver  wire  are  passed  neross  aiiy  deep  wotmd,  at  equal 
distances  from  each  other,  by  means  of  a  slightly  t-urvvd  nocdlfe 
Tlio  two  extroniitics  of  cueh  wire  are  passed  through  a  small  bole 
drilled  in  a  bar  of  plated  metul,  Uie  longth  of  wliioh  should  exeood 
that  of  the  wound.  Tlio  wires  are  first  fi.\ed  beyond  the  bar,  OB 
one  siile  of  tlio  wound,  by  inenns  nf  [H^rffsratod  shot,  about  two  of 
which  may  bo  strung  on  each  wire,  and  compressed  by  means  of  a 
pnir  of  pliers.  Tho  opposite  end  of  each  wire  in-ing  now  Etnmg 
with  perforated  shot,  tho  wound  is  drawn  together,  tJie  sliot  puxlied 
U])  to  the  bar  and  comjiressed,  a»  on  the  other  »ido.  Tho  supor- 
fiuons  wire  may  be  cut  ofl'  with  the  cutting -pliers. 


Jihinojilantk  Opemthtu 

TsigHacoxni's  operation  for  making  a  new  noso  was  as  foUo 
After  ]>roper  preliminary'  measmv;a  rcgai-ding  tlie  general 
tho  patient  was  niado  to  sit  during  the  ojieration,  supp<Nled  byj 
Rsaistant;   tlie  operator  stood  in  front.     Tho  piece  of  skiti 
trans[ilanled  was  taken  from  the  left  ujipi'r  arm,  ovor  the  hie 
musele.     The  Surgeon  raised  the  skin  by  moans  of  a  pair  of  1 
bladcd  forceps,  of  somewhat  peculiar  slia]}e:t   and  when  be 
eatisfied  himself  timt  ho  seized  a  piece  of  suftiaient  aizo,  bo  < 

*  Spc  Minor  SmtoKRy.  p.  14.    All  llie  cummon  fi»-ra*  «>r»uttirai 
fuuiiJ  (loorribeil  in  tliut  otiay. 

f  See  Fi'itise,  op.  uit.  pluie  ii.  fig.  t. 


BHINOI 


11? 


OwMades,  and  fixod  the  handlpji  \iy  ra«ans  of  a  einipio  cliwp.  Ho 
then  [wnwd  a  doable-odgcd  knif«  thmiigb  a  horizoiiUil  fiBBtiro  in  tlie 
brawl  blades  of  tbo  forei-ju  mid  tlirotigh  llio  »kin,  Ihtii  iH^iiiinitnig 
tfae  btter  from  the  subjacent  muacular  tissne,  Imt  leaving  it  attached 
bjT  ■  pedicle,  both  townnls  the  sluiwldcr  and  tbo  Rirciirm.  A  piece 
of  lint  soaked  in  oil  or  Hiiu|ile  cerate  wan  inaert«il  luider  the  flap, 
to  pre^'cnt  union  from  taking  pln<^«;  and  it  wa«  retained  in  its 
poiition  nmler  the  ekin  till  the  fourlli  day,  when  the  dressing  was 
dnnged,  and  tvnvwcd  daily  until  Fupptu'ntJon  v-us  cutM'iKhvd.  If 
tbe  flap  had  then  hegnn  to  thicken  and  the  edges  to  become  in- 
trastod,  it  wt»  cut  froc  at  il»  nppcr  end,  prcwnting  a  Iinv  with  the 
aanmtit^  directed  upwards.  It  wao  tln^n  nii»l  carefully  dressed 
nd  attended  to,  until  tlie  under  Eurfaco  had  become  cicatrised  m 
bt  m»  poftsibla  Remaining  atlaciied  bv  one  extremity  to  tlie  arm, 
it  tmderwctit  a  procoM  of  Uilckening,  contraction,  and  wriiiklin}^, 
aaeooifMUiio'l  with  the  growtli  of  bnir,  vrhit^b  Taglijiwiuit  fancifully 
ccmparod  to  different  stages  of  growth.  About  tlio  fourtccntb  day 
niW  the  iKOOud  O|ieration,  it  wa.t  coiiAidennl  to  be  in  a  ittate  of 
raatori^'.  The  patient  was  purged,  cleanly  shaved,  and  nuppliod 
witli  a  leather  jaiJce4,  which  wan  to  serve  a^  a  miiiiHirt  to  the  arm 
when  raised  to  the  fcoe.  The  jacket,  or  jerkin,  consisted  of  a  cap 
Mid  of  a  brenat-pieoe.  The  ocif^m  of  tlm  flap  and  of  iJio  naml  ajKir- 
tare  were  thoa  pared,  and  tbe  two  parts  were  prepared  for  union 
bjr  Buluina. 

Tbe  arm  rested  in  a  semiflexed  position,  on  a  cushion,  while  the 
Eptnnw  were  being  inMrt'xI  and  ttcd :  it  was  rctjilnoil  in  that 
poaitiim  by  a  leathern  apparatus,  tbe  different  parts  of  which  were 
Mmthcd  to  tlw  cap  an<l  brca](t-])i<K?c  by  bands  and  straps.  Tbe 
patient  was  kept  in  bed,  under  a  striiitly  antiphlogistic  treatment. 
Dm  ligaturm  wvre  taken  out  on  tlio  third  to  the  fifth  day ;  but.  the 
la|i  was  left  mting  upon  some  lint  or  rag  covered  with  albiuninous 
■atarial  tmtil  the  twentieth  day.  Tbo  Hurgcon  tlicn  looecnt^l  ]>art 
w[  the  ann-otr^,  severed  the  remaining  attadinient  of  the  flap  to 
Iba  arm,  and  ouvorcd  lite  wound  witli  proper  droiwiiigA.  If  tha 
Mpiun  nasi  was  delicient,  a  piece  woa  taken  from  the  upper  lip  hy 
a  «tfaBP[acnt  ujHtration. 

Acuonljng  to  the  spirit  of  the  age  in  which  bo  lived,  Tagliacozzi 
tba  stages  of  tlic  operation,  tlio  instruments  and  aj>piinitu!<, 
unueocmary  names ;  lie  is  likewise  tediously  minute  in  his 
tiaa,  of  which  the  above  ix  a  very  brief  outline.     But  he  hoa 
daim  to  the  renown  which  has  attached  itself  to  his  nam«, 
dia  hoHitf^ff  with  whidi  ho  instituted  his  procouding!>,  ajid  the 


118  PLASTIC  SURGERY. 

oare  vrith  wbidi  lie  fotlowotl  hin  cawM  to  tlioir  complotion. 
hare  attcniphxl  to  adapt  the  difTcrcnt  stages  of  Tagliacuxzi's  opora- 
tjons  to  the  ideas  of  ntiHluni  »ur(^'rj ;  1>iit  1  ttiiiik  vre  may  aOirtn, 
Uiat  iho  pmctico  of  taking  the  intogumpiit  from  tio  arm  U  ex- 
ploded, aiid  tliat  in  all  caws  llio  Siirg^wn  now  ]>rofiyp»  to  avail 
hiiDMLfof  tbo  parts  adjacent  to  the  nose,  namely  the  forehead  or 
cheeks. 

Among  those  who  have  performed  the  rhinoplaatic  opcratioo 
with  skill  and  8u<v«*!(,  Mr.  Sko_v  holds  a  ppominwit  itoHitioii.  Tlie 
disease  to  wliich  the  dealrurrtion  of  tlto  nose  may  be  usuallr  aa*^ 
signed  is  lupus,  which,  having  involved  tho  eartilaginwM  {(tructoril^l 
leaves  the  bone  untoiichotl.  Occasionally  tlw  ossa  naai  are  also 
dfst.royed  j  and  then,  Mr.  Skcy  boliovc»,  w  may  infw  lliat  »u<^  a 
patient  has  employed  mercury  largely  for  supposed  syphililio  or 
venereal  disease.  "  If  tho  bones  bo  entire,  the  oiwratioii  is  more 
likelv  to  bo  a  aueeessful  one.  Ktho  bones  be  destroyed,  the  con- 
dition  of  the  patient  predudea  the  resort  tu  the  bc«t  o]M.Tation,  and 
the  result  is  far  leas  proTnisijig,  from  tlie  loss  of  the  arch  on  vrl 
tiie  Mijierstructure  is  laid."* 

Before  proeocding  to  the  o]ieration,  Llio  8urgeon  should  take 
dimensions  of  tbo  required  orgau  in  card,  paper,  or  gutta-por 
The  new  material  in  tiiken  iroin  the  furoheud,  and  conneotod 
the  root  of  the  nasal  bones  by  a  narroir  stalk-liko  procoss. 
the  flap  of  the  integument  is  insulated,  this  stalk  is  twisttnl,  so 
to  cnablo  tho  part  to  be  brought  down  vertically.     Tlw  intcf 
cwutimiea  Mr.  Skey,  should  be  removed  longitudinally  from  oit 
half  of  the  forehead,  running  outwards  towards   the  temple, 
order  to  render  the  twist  a&  inconsiderable  tm  peewible ;  and  wl 
the  admeasurement  is  complete,  at  least  a  ijuarter  of  an  inth  on 
eidfK  should  l>o  allowed  for  tJie  contraction  of  tho  skin :  in 
the  flap  con  hardly  be  made  too  large,  and  it  is  surprising  ho 
slight  a  stalk  is  requisite  to  carry  on  the  circulation.     AVhun 
eard  \\aA  been  fitted  over  the  meatus.  It  shnidd  bo  laid  out  ou 
forehead,  and  all  its  dimensions  extended  and  marked  in  ink.     11 
part  that  is  to  represent  thi»  cnhinmu  shuuld  be  very  broad,  pr 
bahly  more  than  half  an  inch.     Mr.  &Vt>y  puis  the  jxitient  in 
borizonttd  posture.     He  eotnmuTn-es  by  paring  the  margin  nrou 
the  nose  protfy  freely,  in  order  Uiat  tho  exposed  odgo  should 
sufGoienlly  large  to  receive  the  corrospundliig  margin  of  tlw 
intogument ;  and  the  skin  on  tiie  lower  surtaco  of  the  ossa : 


•  Skey,  Operativa  Surgery,  id  edit.  p.  Ml. 


RHINOPLASTY. 


119 


itircly  remnvcd  hy  tim  knifo.  "Whan  tliu  tloffs  of  tlio 
coQiplcted,  a  deep  incision  6])ould  be  made  along  tha 
iukod  Gnc  on  tlio  rorulituul,  (Jowly  luicl  cHutiuiistv,  for  ono  (>]i{>  of 
the  knife  may  render  tho  whole  ojieration  iiiigaiorj'.  The  lower 
cigb  of  llii>  inc-iiiiun  will  pas*  acroM  tho  fibres  of  the  oornigutor 
aqiereilii,  which  mu&cle  may  be  detjiched  with  die  integument. 
If  (ho  knifo  be  »o  held  us  to  hIojm)  a  Uttlo  inwanl»,  it  will  give  an 
acme  aiigle  to  the  cutaneooa  surface  of  the  flap,  hy  means  of  which 
tlic  two  xnrfaccs  may  bo  udjiistod  intii  moro  prccrisiun  us  rc;^d« 
tihe  coatliiuity  of  auriaue.  AVlien  the  Hap  tit  detached  in  evei^-  part 
(scept  at  tho  stjilk,  wliicli  of  <.-onrse  is  most  caroftdly  prvwrved 
Emm  injury,  Ota  watmd  iOmxiM  bo  Ivfl  t'l  blc-f^l,  and  no  attempt 
nade  to  adapt  tl»»  surfa«>  until  tlie  bleeding  ha»  entirrUj  cfoufd. 
Before  leaving  die  tlap,  it  li  belt<-r  to  »cw}i>  out  a  little  of  llie  sub- 
rtuce  along  Uio  cootral  line  of  the  oolumna,  in  order  that,  by  being 
bsfcafter  oam|>n<ei»ed,  it  tnav  fo]<i  loj^olhcr  iinri  rmeuible  as  muoh 
u  possible  the  original  structure.  When  brought  down,  tho  co- 
lomtia  Hhoiild  be  Hr»t  united  to  tlio  rnw  surfiico  inadc  for  ibi  roo^- 
tion.  Thoro  is  some  difficulty  in  ajjplying  the  suture  in  iJiie  situa- 
tiao,  (ruin  the  density  of  llui  slruuturo  forming  tho  buno  of  tlie  nose. 
For  this  purpose,  a  much-curved  needle  must  be  employed,  whicli 
thaakl  cmt>nu.«  a  considerable  pi4!co  of  tlio  cartilage.  It  miiy  h& 
adriaable  to  employ  two  suturaa  instead  of  one.  The  sides  are  then 
fir«t  tinitttd  by  about  tlireo  gvod-sizod  sutures,  and  tlio  intervals 
■djttsted  as  exactly  as  possible  by  the  aid  of  six,  eight,  or  ten  of 
liha  finest  autorcs  tlint  can  bo  employed  (fina  silver-wiro  i^utures 
are  now  employed).  The  nostrils  should  lie  elevated  by  means  of 
pieces  of  cork  and  eotton-wool,  and  geniTally  pressuro  of  modc- 
nte  Ibree  made  UtenUl,}'  by  the  sauiu  nuUorial  and  a  bandage,  care 
hung  taken  to  prevent  all  presirure  on  the  dorsum.  Tho  woun<L  ou 
tk  forcbead  should  be  drawn  togi'llior  with  gixul  pliL-<ter.  At  the 
of  abont  a  month,  or  as  soon  as  ihe  new  parts  liave 
Iv  united,  tlie  lump,  alwa^'»  caiiKod  by  Die  twisting  of  tlie  .ttalk, 
hi-  pan-il  away,  and  tho  knife  applied  to  remedy  any  positix'O 
ity  in  ilie  line  of  the  (Tluiitriic. 
Hub  operation  of  bringing  tlie  flap  trom  the  forehead  is  dcs^- 
ibe  Indian  operation,  smd  was  lir«t  introduced  into  Europe 
Cbwpoe  in  18)4,  who  iuiproved  upon  the  origbal  operaUon 
-  adding  a  septum  nasi,  and  by  the  employment  of  suturca.  He 
looa  followed  in  Crcnnauy  by  Griife,  by  Dieffenbach,  and  by 
and  llie  resulu  hat  <t  lii«n  suooeN»ful.  At  tiiv  viid  <if  thn.'a 
fintr  days  tbe  flap  will  be  foimd  tumid,  warm,  and  scnwtlvc. 


120  PLASTIC  SURGEHT. 

but  pole;  and  at  this  time,  5Ir.  Erichsen  reoiHTiiiieiuls  that  tlie  pmg 
in  Uio  n«»o  bo  changed,  Itst  it  ba  rt-iidorMl  offenBivo  by  tlio  dis- 
chorgiM.  lie  rightly,  however,  tulds,  "tbat  itA  witli(lniwnl,  lUic]  tb^| 
BubHtitution  of  another,  mu»t  bo  done  with  the  greatest  gentleness, 
the  Surgeuii  bciu-ing  in  mind  that  ttny  iin<hit!  [in.^Min!  or  triidion 
may  <le6troy  adhesions,  and  prove  fata!  to  the  vitality  of  the  flap."  fl 

8onie  iSnrgL^oni*  niitke  llu!  (roliiningi  iiu»!  in  t.li^'  operation  from 
the  upper  lip,  as  in  the  method  proposed  and  adopted  by  Toglia- 
oosxi.  In  cttscB  where  th(!re  ha*  {tetm  great  di:Ktni(rtion  of  il 
bonofl,  or  where,  as  after  syphihtie  disease,  the  nose  becomes  oom^ 
plettrly  depresseil,  Lari-cy  and  DiffTynbaoli  liavi!  revived  the  of 
tion  of  Celsufl,  and  have  taken  the  integument  from  tlie  che 
"  A  young  girl  luul  lost  llic  proper  bontw  of  the  iioi«o,  tho  vomer, 
tlie  greater  jiart  of  the  nasal  apophysis,  tlie  nialiir  banes,  and 
the  IiiuicIIh;  of  the  ethmoid.  Tho  integiimeiitx  wvro  folded  intBM 
the  niisal  Ibss.'P,  and  presented  tho  general  aspect  of  a  countenance 
sunken  by  deatli.  Dieffenbuch  made  along  the  side*  of  tJio  do- 
pressed  noM>,  in  its  whole  length,  two  incisions  penetrating  to  tliqfl 
bone.  Tlierc  rcsultod  a  band  of  skin,  isolated,  and  adhering  only^ 
at  the  ujiper  and  lower  ends;  it  was  broader  in  the  latter  tluu) 
tho  former :  a  vertieal  incision  along  the  middle  lino  divided  this 
]>nrtion  of  skin  into  two.  Tlio  laleriil  incisions  were  continued 
inferiorly  by  two  semilunar  incisions,  which  Bcparntod  tjio  alsb 
nasi  from  Iheir  cxtt-riial  o-nmesions.  Ho  ilisseeted  lliosu  two  flupt 
from  below  upwards,  separating  them  completely  from  the  aaaal 
cavities  into  wliieli  they  hiitl  been  folfled.  He  then  Mtparated,  for 
some  distance,  tho  thick  substance  of  the  cheek.  Having  eora- 
plotttd  tliesc  str|)i*,  lie  united  by  cix  :<utiires  the  cdg»\*  rif  tJio  m<-dian 
incision,  and  brought  into  contact  the  edges  of  the  lateral  inciai<a» 
by  eight  sufiiR-s.  The  iio!«o  then  seemed  to  regain  tiomo  of  il« 
natural  prominenee  and  fonn,  tlie  nostrils  being  kept  distended  by 
piecoM  of  lint  Koakixl  in  oil.  As  the  la«t  stage  of  the  operation,  ho 
api>roximutod  the  separated  and  dissected  cheeks,  under  llie  iwse, 
by  pa)t»ing  through  llieir  substance  a  long  noedltf."'  Wo  m<^nU0OJ 
this  ojieration,  not  in  terms  of  commendation,  but  rather  to 
what  has  been  attemptol  and  done  with  some  share  of  sticcess.  Wf 
must,  however,  wain  tho  young  Surgeon  that,  in  tlieiw 
de  eoninwncF,  tho  sources  of  mishap  are  ntunorous,  and  diaap 
pointments  will  (jocur  in  spite  of  the  endk-»!t  variety  of  moclitication 
ttdopUtd  by  difl'cront  Surgeons.     Mr.  Skey  givos  a  good  piece  of  aii 


*  MulgaigQi',  Mill,  (^irxtt.  1819.  p.  <21. 


HARE-LIP. 


ISl 


I  wlm  he  Bayti,  "  let  it  be  the  {Mitinnl  who  urges  the  operation." 
opentor  will  bo  thus  released  of  somo  share  of  rcMpoosi- 
ility.  "  III  «na  of  Air.  [iwton' s  cnrlj  com*,  tiio  now  n<)i«o  sloughed 
uulor  an  attack  of  inflammation ;  in  another,  luBtnorrhagc  occorrcd 
Bniler  the  fla)>,  on  iho  ninlli  iIdv,  to  tiw  vxt«nt  ofnioiv  Uutn  a  pint 
ofUood.  Laatly,  tho  o])cration  ia  not  without  its  (langers:  Dicffcn- 
hoeh  lotct  two  pAticnlx  out  of  six  on  whom  he  operated  in  Parli, 
their  constitutions  being  probably  in  an  unfitvourable  Atate."* 

In  tiff  coiL<lnK<tiou  of  a  now  ala  nost,  the  f^urg^-on  takt^  the 
integnment  from  the  cheek.  Ho  must  trust  to  bis  skill,  and  tho 
drcumstanon  t)(  tho  case,  to  guide  his  incision. 


Chfil43plaMtie  Opfratioiu.     Opfratiom /m-  Diyeeti  o/O^e  Lips, 


^0  Bart-Hp.  The  well-known  defomiitr  called  haro-lip  is  a  con- 
jEcnilal  fiMinra  of  tho  upper  lip.  I  never  mvt  with  a  cose  in  which 
the  nnder  lip  was  similarly  affected.  Tlie  fissure  may  bo  single, 
gowrslly  a  ({ttortcr  or  a  third  of  an  inch  froni  tlic  mesial  line — more 
often,  according  to  Mulgaigne,  to  Uie  left  tJian  the  right — an<i  pro- 
•mting  at  dm  lower  angle  a  rounded  anil  cicatrixt^l  a]>[)C«ranoe, 
which  must  be  removed  at  the  time  of  opernlion.  Or  it  may  bo 
double,  in  which  rase  thoro  are  two  fissures,  separated  by  a  median 
ftqiL  Tlie  defoniiity  may  bo  complicated  witJi  fisiture  of  the  bony 
or  of  the  sofl  palate ;  the  fissures  in  ttic  former  may  be  double. 
Tkre  may  he  fiwoires  of  the  soil  pulate  without  any  corresponding 
deft  in  tlio  h'p. 

Tlio  |iiece  of  l>onc  behind  the  mfsdian  flap  in  double  hare-lip  and 
doable  fissure  C^the  palate  is  the  homotype  of  the  preniaxillanr'  bone 
in  tlw  lower  ▼ertebrabi,  and  it  generally  contnins  the  two  front  in- 
(Mor  teeth.  Its  size  and  the  amount  of  projection  vary  consider- 
ably, bnt  it  i*  aiwajTi  a  souroe  of  ojwmtive  com pli'-ji lion. 

We  do  not  propose  to  enter  into  tlie  subject  of  arrcwt  of  deve* 
kpnant  to  whirh  this  deformity  is  due,  but  r<!inind  the  reader  of 
the  •tatement  already  made,  that  in  very  many  cjisos  then*  are  otlier 
magaiita]  dcficienctea  coexistent.  Among  tlicJMi  rank  foremost  tho 
iMtb,  which  are  often  a  source  of  itul»e<|uent  trouble.  I  have  under 
an  carv  an  uifant  with  fissure  of  both  hard  au<l  soft  palate,  double 
iM»-&ct,  with  deficiency  of  the  extenwr  muscles,  and  want  of  mus- 
flokr  power  in  boUi  liands.  It  is  obvious  that  tn  Ruch  oases  surgical 
should  be  postponed. 


•  Ericluwt  8ii«Kt  diul  ^rl  ^  ^u/yfry,  p.  «T0. 


122 


PLASTIC  STJEGERT. 


I 


The  treatmprit  of  liarc-lip  is  of  vpiy  anci«nt  dntiv  Wo  pi 
to  coiitinv  lilt!  I'dUiiu  iiig  rtniiiirk^i  to  tJic  Iwst  iii(ii)«  of  rectUyiug  it 
at  prewnt  pradisetL  The  opemtion  should  W  perfonncd  as  c»tiy 
as  po!t<il)lv ;  vcrluiiily  before  ckittilioii  Ihm  v<>iiiiiioiict!(I.  The  closuro 
of  tJie  6ssiirc  not  only  gives  to  tJie  chilil  the  facility  of  Bucklnj;  even 
imnKiliiili.-ly  nf>cr  the  oporatioii,  but  k^atU  also  to  gntator  re^larity  fl 
in  the  development  of  the  teeth.  l>elmas  operate*!  two  hours  after 
birtli!  Mr,  Luwrcnoe  hoB  ofk-ti  operated  Ix'twwiii  thi!  tliird  and 
fourth  week.  I  have  frequently  done  tlie  fame,  Mr.  FcrKuswn 
recommends  about  the  sixtli  weok,  whieh  Mr.  l-Iriokten  rej^utla  aa 
the  tiroe  of  election.  Mr.  Skey  doubts  the  advantage  of  its  being 
undcrtjkkcit  at  a  period  oarlicr  than  tliroc  or  fmir  in<3iilhN.  Ilichter 
ajid  Hell  rceomniond  a  still  later  jieriod.  But  if  the  child  ts  strong 
and  ncll  nourished,  a  month  or  six  vrct-ks  is  about  Iho  ]>roper  time. 
Clilorofurra  should  of  course  be  given,  as.  infanta  become  rcwlily 
aifocU'd,  and,  lis  far  as  experience  goes,  vrlth  the  smalk'st  amount  of  ^ 
danger.  H 

Opfration,  Tlie  child  having  been  swatlicd  tn  a  pii>ce  of  nhoet- 
ing,  and  tlie  lipH  being  Iield  by  an  aiiHiiitant,  who  grasps  them  in 
their  whole  tltickncw  to  present  hwruorrhago  from  the  connjiuy 
arteries,  the  Surgeon  fii-st  finda  it  necessary  to  separate  the  mucooa 
mcnibranu  and  frKnum  with  a  scalpel  from  the  alvt-olar  border  of 
tlie  u])]:>or  Jaw,  in  ord»r  that  tlie  cd^es  may  l>o  the  more  easily 
proximatcd.  Ho  then  seizes  tliQ  lower  angle  of  each  of  the  Stdcft 
with  tine  sliarp-pointed  spring  foni^ps,  and  eilliur  willi  a  sliarp  knifs 
or  with  knifp-bladcd  scissors  pares  tho  edges  offoctnally.  Witlioai 
waiting  for  the  oeUHntion  oi'  iia'niorrhrige,  which  would  blanch  the 
infant,  the  Sorgoon  then  passes  the  hare-lip  pin  deeply  tluvugli  tho 
Hubslunoo  of  thti  lip,  commencing  from  one-tJiird  to  one- half  of  on 
inch  from  die  cut  sui-faees,  A  strong  silken  thread  is  wound  rouQi 
the  pin,  bringing  tliu  cut  edges  into  contJtct,  in  the  fonn  of  a  tj 
of  eight.  I  then  prefer  to  iittroduoo  a  line  silver  suture  at  tho  upjter 
end  of  the  wound  to  bring  the  nares  into  shape,  and  a  nimnd  at  tli« 
red  of  the  lip  to  preserve  the  continuity  of  that  important  featura. 
The  child  is  allowed  to  sleep,  or  to  suckle  if  it  pleasoM. 

I  prefer  ttio  two  sutures  to  the  practice  of  introdtuung  a  second 
hart-lip  pin,  because  the  farmer  hold  the  parte  more  immovably  i 
contact.     I  operated  »onie  time  ago  on  a  child,  in  whom  I  omi 
to  put  tlio  nuturc  near  the  narcs.    Soon  afltir  the  operation  calarrlial 
dischai-ge  from  tlie  nose  oame  on ;  tho  silk  round  llio  baA^-liji  pi 
be<uune  softened  and  loose  before  its  time,  and  the  fissure  partial) 
reopened.     Mr.  Lloyd  is  in  the  habit  of  preser%'ing  a  small  slip 


n 


hahe-lip. 


123 


iSopof  the  long  half  oflho  Hp  (whensiuli  iitoqunlity  exists),  and 
'  of  attaching  it  to  tho  under  ^ur&oe  of  the  Bhorter  luilf,  that  tliei-o 
BUjr  bo  no  notch  or  tLisurp  wlien  vicatriwntion  lins  taken  plaoo. 

Mr.  Skey  obwrvoe :  "  In  consequence  of  the  greater  «xtciiHi- 
bilitv  of  tlio  luwi'-r  tliuti  li>e  njipcr  jmrt,  tho  rcsuJt  of  tbo  operation 
fiir  hare-hp  is  to  leave  a  permanent  defbrmiU',  oauited  by  ifao  re- 
traction of  the  ciciitrirc,  am)  tJiv  formation  of  an  angle  bolow,  at  tho 
point  of  nnion.  To  obviate  lliis  ovil,  tho  liiion  of  inoiaion  «lioul>l  bo 
curvcii  inwards."" 

Ute  hare-lip  pin  sliould  be  shortened  at  boUi  cndu  by  means  of 
cutting  pitore.  Some  Surgoons  have  omitted  tho  pin«,  and  suben- 
tuUxl  tlie  silver  suturoa ;  bui,  ollJiougli  union  may  be  Uiuh  obtainod, 
J  am  of  opinion  that  a  part  so  movable  aa  the  upper  Up  reqiuroa  the 
finner  support  of  tlio  Atrnng  motiiilic  jtin. 

It  is  castomary  to  remove  the  hai-o-Iip  pin  about  tho  fourth  day. 
It  nlmutd  1)0  gently  witlnlmvrn,  and  \i'  the  driwl  liguro-of-oijjlil  pi«oo 
of  silk  remain  adherent,  it  may  be  led  on  the  lip,  where  it  serves  aa 
k  pIiMer.  'nuinr  are  wonio  who  roIl1(•^'[>  tlio  pin  on  the  third  day ; 
otbera  who  leave  it  till  il)c  sixth  or  seventh.  In  the  one  case  the 
union  iiuiy  be  xtill  too  weak  to  hold ;  in  tbo  other,  the  pin  may  have 
cot  its  way  out  by  ulceration.  If  the  sutures  are  of  silk,  they  should 
bo  taken  away  in  twoiity-four  to  forty-oif;ht  hours;  if  of  silver,  tliey 
iDay  remain  aa  long  as  the  Knrgooii  thinks  proper.  At  tho  tiino  of 
dw  rcmora]  of  tJw  hanvlip  pin,  the  chucks  should  bo  well  pressed 
fowarda  the  middle  line  by  an  otiaiatant,  that  no  accident  may  occur 
to  tha  nowiy-unitcd  parts  by  tlie  act  of  oying,  which  commonly 
aaaea.  Then  a  long  piece  of  adhuaivc  atrap])ing,  a  quarter  of  an 
iocb  wide  and  thrw-quartcrs  of  a  foot  in  length,  sliould  be  parsed, 
MKiM  tite  wound,  rouiul  tlw  Iicoil  juJtt  over  Uki  oars  two  or  tliree 
ttiDae,  by  whicJi  tlio  parts  are  protected  against  all  strain.  I  think 
the  strapping  preferable  to  &Ir.  Hainxby')!  >jiriiig  cliwk-cotnprcasor, 
Dieationod  in  Fergnsson's  Pntcticat  Surfffn ;  but  the  instrument  ac- 
eofopliahm  Mtiafiii^torily  iJie  Nune  puriww. 

In  cases  of  double  hare-lip  it  is  safer  practioo  to  operate  on  and 
to  raiil4>  the  fiitMirts  scpiuTitoly.  Some  Surgeons,  however,  have 
MMOttimended  that  botlt  fissures  should  bo  pared  simultanconiily, 
and  tint  tlie  ham-tip  piat  ^houlcl  im  \tM\uid  tliruugh  the  central 
flap.  Such  a  proceeding  unnecessarily  incroasos  tho  chaiiccH  of  ac- 
adanL  ^Slicn  the  bone  cooUiiniii;;  tlm  in<!ii4or  teetli  projects  so  far 
as  to  interfere  with  or  to  proveut  the  easy  appoaitiuu  of  tbo 


•  Operttii'^  Surgerg,  p.  631. 


124 


PLASTIC  SURGERY. 


pared  edges  of  the  lip,  it  may  bo  cut  away  by  bone-pllera  at  a  se^i^ 
rnto  niK'niliiiti  ;  ami  tlii.*  niviL-tiiiv  i*  not  tinconiimiiily  iiwcvwary. 
But  in  many  cases  gcntio  pi-eesure  will  make  it  rtwede  id  tho  ootirsa 
of  tt  few  wfi'ks ;  a  pn)c<;wliiig  rtronK'y  advocjitcd  by  the  lat«  8ir  A. 
Cooper,  who  objected  to  cutliiig  away  the  boiiy  projection.  A  casft 
is  rclat«d  in  which  an  infant  of  two  months  old,  suflcring  from 
har»<lip  and  pi-ojection  of  the  bone,  was  ^ubjeetfd  to  pressure  for  a 
pcrioti  of  t\]nt^  tnontlis ;  wlum  tbo  bone  had  been  so  otf<x;tuaUy  do- 
pressed  by  means  of  a  kind  of  apring-tmss,  which  waa  worn  several 
liours  daily,  that  the  nod  p»rt«  admitted  of  being  brought  over  U 
wiUi  tolerable  fai'ility.  Union  followed  very  w«ll.*  Uesault  ap- 
plied pressure  by  means  of  a  band  tied  tightly  behind ;  and  it  ii 
mud  that  in  one  cane  he  acooinpli-ihed  Kid  purpose  sudici^Mitly  in 
eighteen  days.  M.  CJcnsouI  seines  the  piece  with  strong  forceps, 
partially  iintaks  mid  fiirees  it  Into  tlii>  {x^qyendiculnr,  and  tins  pro- 
ceeding haH  |>roved  ^ueeessiiil.  Mr,  Lloyd  lias  adopted  the  same 
plan  in  8t.  Bnrl.hdlonicw's  Hu»pltul,  luid  iilso  with  good  r(»ult;  tlift 
preeervHtioii  of  the  Incisor  teeth  being  an  object  of  considerable 
imjKirtaneo.  If  tho  piece  ij<  oonnrseted  ti-j  u  [icrfocl  suptuni  nasi, 
it  is  a  good  plan  sonictimca  to  cut  a  triangular  piece  (base  down- 
wanU)  out  »f  tlic  lii(t«r  beforo  ap]<lying  a  band  to  pn.«s  back 
proJeclioD. 

R^Htoration  of  ihf  Iojpit  lip.     Tlio  reaforntlon  of  a  jwrt  of 
lower  lip,  wlucb  ba«  been  lost  by  accident  or  disease,  is  aoconi' 
pli.-diixl  iiy  a  Himpler  operation  tlijin  tJiat  fttr  tlic  formation  of  a  nc 
nose.     The  new  strncturoB  must  be  taken  from  the  cheeks,  whicll 
readily  aflbrd  a.  sufticient  snpply  of  both  skin  and  mueotLS  mem- 
brane.     Malgaigno  observes,  that  he  had  described  tlie  proneadi 
in  1834;  suid  that  tlio  late  M.  Bonnet,  of  Lyons,  had  put  it  in' 
practice.     Sorres,  of  Mont])ellier,  has  given  a  full  aa<ount  of  it 
his  intcresling  work  ;  but  the  principle  flates  back  as  far  as  Oebtu. 

Operation.    We  suppose  the  case  to  Im  one  of  cancer  iillccting 
the  lower  lip.    All  the  degenerated  part*  iiuist  be  taken  away  either 
by  a  V-sliajied  incision,  according  to  ancient  usage,  or  by  two 
ticul  iiK^siniis  passing  down  to  tJie  base  of  the  jaw-bono,  and  uni 
there  by  a  transverse  incision. 

In  tlio  tint  instance,  there  will  Ite  tho  loss  of  a  triangular  pi' 
of  the  lip  and  chin ;  the  angles  of  the  mouth  must  tlien  be  ])rotnn 
by  a  transverse  ineision  on  each  side  into  the  chock,  so  that  two 


ion 

n 


*  Cooper's  Dietiottary,  p.  094,  1830. 


CHEIL0PLA8TY. 


125 


Bp«  are  obfaiiniKl.     Tho  borders  of  th«  V-nlini>e<l  incision 

lited  by  suture;  while, 
M  reguds  tho  nppiT  border,  all 
that  JB  not  want«l  for  tlio  fur- 
natioo  of  tJic  nrw  lip,  which  is 
fonneil  out  of  the  Hubslanoe  of 
tlifl  check,  is  nnitcd  to  the  part 
ivith  which  it  k  in  contact.  The 
innooas  morobrano  in  tho  moath 
ahould  he  united  to  tlio  ttkin  bv 

•fine  satores. 
WUon  the  lom  of  AuhHt^iicc 
is  qiiadril literal,  two  other  in- 
ciNiufM,  panillixl  to  itio  two  ooiilintiod  from  the  connniaeuren  of  tlic 
mouth,  njOBt  Iw  made  alon^  the  base  of  the  jaw.  Two  quadrilateral 
flfl|M  may  tl)i;ii  lie  dbGW^cti^l  fnini  llio  hone,  brought  forward,  and 
ttnitfid  in  Uie  median  line  by  sutm^s,  as  in  tho  former  oiwratiou. 
Till*  taut  metiiod,  jtays  AlAlgai^rDO  (from  whoite  work  the  ])ri.'codin^ 
pttsaages  have  been  talieii),  is  but  tlio  procoodiiig  of  Oelsue,  badly 
tmdentood  by  hid  Iruuiliitort ;  a  proof  lliat  in  oi-der  to  Lruti^lato  » 
Biu^eon,  it  is  not  only  necessary  to  know  tho  idiom  that  he  uses, 
Wt  likrwiw.-  tlio  KieDctt  of  wliich  liii  tiy^ttt. 

It  follows  from  this  proceeding,  that  tho  checks  alone  contribute 
to  form  the  lip,  tlw  froc  border  of  which  i-t  con.ttitute<l  by  the  bleed- 
'  iog  border  of  the  horizontal  incialon.  Tlias,  tho  new  ]I|>  oontniir^ 
tko  mnsctilAr  tibrvs  belonging  t<o  tlie  urbioiilarlK  and  It*  antagonists; 
il  is  covered  behind  by  the  natural  mucous  membrane,  and  tliLi 
aanbrano  mny  bo  tnrned  over  and  unitinl  to  tlio  skin,  so  as  to 
wesible  more  closely  the  natural  feature. 

The  modification  of  this  ojxiration  commonly  performed  in  this 
•wriiy  oarre-iitoiKLi  in  principle  »o  cUncly  to  the  atmve,  Uiat  further 
nfauioe  is  unnecc>»arT. 

Mr.  Syme  ha.4  introduced  an  0|icratioQ  by  which  the  canoeronH 
tlocT  of  the  tower  lip  is  lirst  remofcd  by  two  incisions,  extending 
iKn  tite  angles  of  the  month  to  the  ohin,  and  unitiiig  below,  so  as 
W  tndndo  a  piece  of  triangular  sliape.  The  cuts  ore  then  carriwi 
iMi^ly  downwards  and  oulwardN  on  each  »ide,  imder  the  body  of 
w)iw,  and  mado  to  terminate  in  a  sliglit  c1lr^'e  outwards  and  np- 
fwk.  Tlie  IIa{M  tImH  formed  are  duUiched  from  tlieir  Aubjaoent 
VuKxions,  and  the  whole  raised  upwards,  so  that  the  original  tri- 
■gihr  inci-->ion  coinca  into  a  horizontal  line,  and  is  made  to  eonsii- 
^  tho  margin  of  the  now  lip ;  the  secondary  indsions,  under  the 


126 


PLASTIC  SURGERY. 


jaw,  coming  together  in  a  vertical  direction,  in  which  they  are 
retained  by  twisted  and  interrupted  sutures.* 

These  operations  are  preferable  to  tliat  of  Chopart,  who  made 
an  incision  on  each  side  of  the  tumour,  verticallj  downwards  over 
the  lower  jaw,  according  to  the  magnitude  of  the  operation,  eran 
donm  to  a  level  with  the  os  hyoides.  Iliis  quadrilateral  flap  is 
dissected  off  the  bone,  in  its  entire  tliickneea ;  the  parts  morbidly 
altered  are  cut  away  by  a  transverse  incision.  The  remuning  por- 
tion of  the  flap  is  then  nused  to  the  proper  level  of  the  mondi, 
where  tt  is  retained  by  snture;  the  head  at  the  same  time  being 
depressed,  to  diminish  tension. 

Mestoration  of  the  upper  Up.  Plastic  Operations  to  restore  loss 
of  substance  in  the  upper  lip  are  rarely  necessary ;  one,  and  per- 
haps the  cliief  reason  being,  that  cancer  is  so  extremely  rare  in  this 
situation  tliat  few  Surgeons  have  ever  been  here  called  upon  to  deal 
with  its  effects.  With  care  a  considerable  amount  of  integoment 
can  be  obtained  from  the  cheeks,  and  united,  as  in  the  case  of  the 
lower  hp,  by  sutures  in  tlie  mesial  line.  The  front  teeth  will  thus 
obtain  a  covering  and  be  protected  from  tJie  oold,  and  the  expres- 
sion of  the  face  will  be  mnch  improved. 

The  first  operation  is  that  proposed  by  Yon  Ammon,  who  d^ 
scribes  a  shrinking  of  the  upper  lip,  sometimes  caused  by  pro- 
longed salivation,  by  which  the  part  is  tightly  stretched  over  the 
arch  of  the  teeth,  and  sometimes  adherent  to  the  gums.      This 

condition  Von  Ammon 
rectifies  in  the  follow- 
ing way.f 

The  lip  is  first  freed 
by  a  scalpel  from  the 
gnm.  Then  an  incision, 
A  B,  is  carried  upwards 
from  the  angle  of  the 
mouth,  for  about  an  inch 
and  a  half,  towards  the 
ahenasi  The  tense  parW 
separate,  and  this  longi- 
tudinal fissure  becomet 
triangular  in  form,  ABC: 


*  Edin.  Monthly  Journal,  1847, 

f  Ammon  und  Baumgarten,  Fiattitekt  GhirvrgU,  p.  IM. 


CHEILOPLASrr. 


127 


txp  of  integument  in  Uxti 
directed  fi\>m  the  clipck, 
B  n  Bf  atui  is  bruiigltt  ilowu 
to  fiQ  tip  tho  BfatK  at  the 
aii^>ofilM<  iiiiiiitli.  Aflw 
the  fi|N'n«tioii  has  been  com- 
pleted on  line  nUUt  of  tho 
DMmtli,  it  i»  to  be  pcrrornied 
Ml  the  opjMjHiu. 

I  h»ro  no  persona]  cx- 

rieuce  of  Uiis  <i|)i-n>ti<iii. 
Wlwrn  tltct-cnlral  [Mirt  of  the 
i)]>per  lip  is  datfroyed,  Um; 
two  side  portione  become 
drftwuDptowanktlioftcptiiin 
and  alir  nasi,  and  the  inciBor 
leeth  ure  e(>iii)ihHely  vx|>us- 
oL  DiefTcnbacb  rectified 
llua  detonnity  hy  brinfpng 
■  sufficient  amount  of  inte- 
rnment fi-diii  the  adjnoviit 
toliBtaace  of  the  cheeks  on 

thhmr  «ide.  Me  carried  an  incision  by  Uio  f'ulo  of  tlie  aW  ntai, 
down  throngh  t]»e  red  of  tlie  Up :  ho  loosened  eaeh  half,  and,  bring- 
bg  them  togotlwr  in  tho  mettiul  iine,  united  thoin  by  bore-lip  pina 
•nd  nttores. 


PUutie  Operaiicm  on  ih  Elar. 

DefeetA  of  t]>o  external  ear  altraet  so  little  attention,  and  are  in 

|(Mnl  so  nuily  concealed  by  tho  hair,  tlmt  plastic  operations  are 

only  required.    I  liavo  removed  e<^n»id<iralilo  ]M>rti(>nii  of  tlie  pinna 

k  yrvty  and  oarcinantatouB  growths,  and  tind  that  tlio  wound 

■mIs  but,  and  witli  \vx*  ih-fnnnity  than  rntf:ht  ho  exjiooted,  without 

Mulu  or  any  dressing  beside  a  piece  of  wet  lint.     Dieffenbaeb, 

■ovtcr,  btLt  rejrlaoed  »  ]>i«ce  of  the  pinna  removed  by  the  stroke  of 

■  *vani ;  but  be  took  tlio  flap  from  the  adjacent  region  of  tJic  scalp, 

■(>Tt  whteh  ii^ui^^eonn  are  fur  tiiv  moHt  pan  kIow  to  touch.    Having 

M  the  edge  of  tlie  e«r,  he  made  an  incision  of  paraUel  length 

1  about  the  same  level  thmiir;)!  the  ndjaci-iit  lUTalp;  fnim  eillier 

■  of  tills  incision,  two  short  cuts  wei-o  e\ton<led  upwards.     After 

bad  oeaddi,  tJio  raw  edge  of  tho  ear  wo*  united  by 


188 


PLASTIC  SURGERY. 


ratare  to  the  coiTesponding  edge  of  tlie  scalp.  Oiled  lint,  wm  ib^ 
serted  uiiik'riictiUi.  At  the  <.^x|iin)t]un  of  tliroo  weeks,  union  lioiiig 
perfect  bt^tween  onr  luid  m-uly,  the  portion  of  rei^iiinito  mIxc  wm 
completely  dttaclicd  from  tho  latter  situutJon.  It  is  said  that  the 
tmitHplaiiled  |i(irtioii  fir%l  IxiiCHiiie  blandi«d,  but  »i^iu  rc^tJni.^  tliu 
oireulution  and  nonnal  warmth.  I  liavo  no  pnnsoual  experience  ia 
the  pruceciliug.     (St«  also  p.  134.) 

Pifwtie  Operaiicm»  on  the  p€Ht». 

Plastic  operations  on  the  penis  for  deformities  or  tni]>crfoi 
Iwtli  acfiuiroil  niul  coii^otiitnl,  at-o,  an  a  rule,  iinflatiHfactorv  in  their 
retiulta.  Nature  seems  hore  able  to  cflbct  a  euro  unaided  hy  an, 
whenever  tlio  gnieral  i.iintlitioiiM  are  favourable  to  recoverj-,  or  when 
the  law  of  development  has  not  been  prcmatiu-ely  arrosted.  Thu* 
fistulous  pii£sugoB  in  the  uretlira  dopeiid  for  tJie  nuKtt  part  uit  Htric- 
turat  of  the  canal,  which  ouoe  properly  dilated  permit  the  ready 
cicatrisation  of  the  artificial  ojifniiif; ;  and  eongenilal  detici(»ici«e  in 
the  ui-ethral  waits  uiiually  indicate  an  imperfect  condition  of  the  canal 
tjoyond  tliis  jwint,  but  the  tulxs  i»  [wrfuot  m)  far  hh  it  i>i  iiroperly 
formed. 

In  the  treatment  of  fistuh^us  passages,  whethei'  uear  tlie  scrotnm 
or  in  Uie  proximity  of  the  glaos,  tlie  careful  cmploj-ment  of  tbo 
catheter  is  the  first  measure  necessary.  The  edges  of  tin-  ftstuloat 
Opening  may  after  a  time,  if  inactive,  bo  stimulated  by  such  reme- 
dies as  tincturu  cantharidis  or  nitrate;  of  silver;  but  in  tho  ourly 
stages  all  Ruch  aj>plicatianH  are  useless.  Cadea  are  seen  in  which, 
afler  tlie  operation  of  lithotomy,  a  long  fistula  communicating  willi 
tho  iinAhru  remains  in  the  perineum.  Such  a  case  I  Iiave  treated 
Bucoessfidly  with  gal vimo -cautery ;  t-  f.  by  introdueiiig  a  piww  <if 
wire  till)  k'ligtii  of  tlie  fintulii,  and  lieating  it  by  attaching  it  to  i 
cirde  through  which  the  electric^  stream  was  pasning. 

Tlie  simplest  method  of  dosing  an  o])ening  in  the  urethra  bjrj 
plastic  operation  is  as  follows  : 

Optmfmi.     The  Surgeon  mu»t  dissect  away  a  1o2enge-Hlia[! 
portion  of  integument  from  around  the  fistulous  opening.     He  i 
brings  the  edges  of  the  nkin  t'.igi-llmr  willi  sutures  ;  lasth,  ho  mo 
a  longitudinal  incision  on  either  side  of  tlio  nowly  united  wound  I 
reliove  tcuBiou.     Thir  (ijicralion  is  itimple  and  t-iisily  j>erfunn<?il, 
looks  well  ill  a  diagram.     But  there  is  difficulty  in  proventiug  tb 
urine  insinuating  itacif  between  tlic  etlges  of  tlio  wound,  cau 
tbo  parts  to  reopen,  or  even  leading  to  mortiftcation  of  the  flap. 


OPERATIONS  ON  THE  PENIS. 


1S8 


Tbe  asme  remark  applies  to  a  similar  operation  in  n-)ii<!h  die  in- 
dnon  i&  made  Irnusvi'noly,  nn<I  tlw  flti[>  of  u>t«>guiticiit  is  drawn 
frnm  bi-liiiitl.  There  ia  no  ditliciilty  in  obtaining  skin  enough)  ^9^6- 
wSiy  towards  tlio  root  of  the  penis. 


Is  luaea  of  §ti1l  grwaler   defect  in   the  wall*  of  (Iif  urethra 


I'i'dnilMcIi  has  mndo  transvcno  incisions  through  the  iiite^iinont 
Wive  and  behind  the  ojwning,  and  brought  ovvr  it  tliu  intervening 
'b  rrotn  the  tip[M.T  NurTaco  of  tlic  organ.  But,  inasmuch  as  tho 
•pntian  ItiLd  }VH  been  promii^ing  in  il-s  riMulU,  [  must  nrfi^r  the 
f'^TT  to  that  Surfjjron's  works  for  matters  of  detail.  The  opora- 
Iwiuf  M.  Alliot*  is  perha[>s  tlio  incwt  inj^i^iitoim,  :u»l  has  moreover 
l«i  rcportrtl  as  sncvoi^fiil.  Ho  cirenmscribM  ami  dissects  a  small 
fadrilalcral  flap;  and  taking  avniy  tVoni  ihe  other  xido  a  portion 
<f  tkin  pqna]  to  thi:i  flap,  ho  so  covers  tlio  fistula  and  tiic  Itw«  of 


*  Frilxe.  op.  at.  p.  )  It. 


Toi.  m. 


130 


PLASTIC  SURGERY. 


— ■'-« 

1 


Rubstnum,  that  tlie  prinoipal  sutures  aro  at  a  distanoe  fr«a  tiw  oritM 
when  it  triL\'i.T»c«  the  urcthni. 

On  the  Treatment  of  Contraeted  Ciaitricf*. 

WUhin  the  voffjna.  The  mucous  mcmhrHiio  of  Uio  vagina  is  snb-l 
ject  in  inl^icy  Ut  a  low  fi)mi  of  inHaniaiation,  wliioh  temiitiiiti-H  iQJ 
slougliing  of  part  or  of  tho  wholo  of  its  circumforonec,  Tlic  sopa-" 
ration  of  tho  sluugh,  and  Mitisoi]iii>nt  (■ioati'iaation  of  the  woiiiul,  is 
foliowml  by  contraction  of  tho  cicatrix,  nud  uarroniiig  of  tho  \-Hgina 
at  n  vnrialjli;  ilistance  train  thu  oh  (•xtin'uuni.  T)i<!m>  lat«!r  cliiitigcs 
ot^en  escape  obsen'ation  until  tlic  patient  attains  a  marriageable  age, 
wlion  nil*'  fiiKU  uonucxion  imjiu&iible,  aiii!  tlie  attttnipt  oxtremely 
painful,  Tlio  cicatrix,  however,  yields  very  readily ;  and  tho  defect 
liiny,  in  many  cases,  Iw  overcomo  inuntiliutvly  hy  tii«  introduction 
of  tlie  fingers  or  any  diiating  instrument,  the  patient  being  und^ 
Uic  inflnt-nfo  of  chlorolbnn.  Bnt  this  procowiing  in  not  unnltcndi^ 
by  danger ;  for  if  the  cicatrix  be  rudely  toni,  a  tow  form  of  pel^io 
ccllulilJN  is  set  up,  extvndiug  perhaps  to  tho  pcnlona^uin,  under ^ 
which  tlio  patient  ninka.  ^ 

I  umnot  dwell  too  strongly  on  the  danger*  of  vjolcnco  in  all  sucli 
caaea.      No  cutting  incttnuneiit  should  be  used ;  for  the  integrity 
of  the  walls  of  the  vagina  must  bo  presened,  aD<l  a  fresh  cicatrix 
would,  by  ils  secondary  contraction,  lead  only  to  furtlier  diflicullies. 
No  laceration  by  sudden  violence  is  jiurmissiblo,  for  iuflammatoiy^ 
misdiiof  may  ensue  themfroni.     Itut  sjionge  tenta  should  be  intro^^ 
duccd,  that  tlic  contracted  orifice  may  bo  slowly,  cimtioiisly,  anJ^ 
painlessly  dilated,  without  liicenition,  but  with  gradual  absurptu 
of  diat  peculiar  material  on  which  the  firm  deiiso  part  of  an 
cicatrix  depends.      Tlie  principle  of  gradual  oxten&ion  is  one  of 
greatest  improvemeulii  in  modem  surgery. 

Cicatnees  /rem  burns,  eschtovties,  ^c     The  apjilication  of 
or  of  powerftd  eschiirotics  will  ciUior  disorganitie  the  «u|>orFicial 
layers  of  the  skin,  or  destroy  its  entire  thickness.      In  the  foruu 
ease,  cieutrination  is  conipjetci;!  without  deformity;  in  the  latter, 
secondary  process,  that  of  contraction,  goes  on  afier  the  new  mal 
rial  i.i  fisrnuil  over  tho  woiuid  ;  and  tliis  eoiitraet.ion  ]>roe«ttU  sIowITi 
almost  impereeptilily,  and  patnles^ily,  but  irresistibly  save  by  niodu' 
nical  treatment,  until  changes  as  regards  tho  limbs  most  serious, 
as  regards  the  fat-e  most  hidi^uis,  are  i)rodueed.     'Hie  smooth  whi 
cicatrix  drags  by  its  contraction  on  the  surrounding  i>it«guni< 
pulling  it  into  folds,  and  pucki^ring  it  up  a»  towards  a  centre, 
becomes  it«clf  elevated  luto  knobs  or  tubercles,  which  suum  to 


CONTRACTED  CICATRICES. 


131 


ker  uxl  thicker  tho  more  comploto  tho  contrsction.     I  know  of 
no  but  aa  Ut   time  wlwn  the  |mlivnt  onn  lie  pr(>i)otin<;e<l  free  firom 
lUitonsioii  of  liic  evil,  c^X!ciall,v  amoog  the  young  during 


I  important  pertod  of  prowth,  Xo  tiasue  !»  oxtiinpt  finm  its  in- 
and  even  the  bones  ni)d«rgo  an  alteration  in  form.  In 
COMB  of  Mvcre  \mn\n  abont  tlio  ncek,  tho  chin  is  drnwn  down,  the 
■IrooJar  border  of  the  jaw  snd  the  front  teeth  aro  everted,  tlic  ii<i»c 
«  dngf^  to  ono  side,  the  lower  vvvlid  turned  (lulnurdH,  and,  when 
[  tile  burn  baa  atfected  one  side  more  than  tho  other,  tlie  whole  bony 
frame-work  of  th(^  oorrvAjtunding  sido  of  tlie  &co  hus  exhibited  the 
Durkc  of  the  contracting  furoe. 

Sttrpcal  in;^n»ity  lins  been  pushed  to  the  uttermost  to  devise 
opcratiaDB  by  which  this  diHtreesing  calamity  may  be  pemov«I ;  but 
JeKprow  till!  opinion  of  most  8urguons  of  cxiit;ricneo  of  tlie  present 
in  ailinning  tJiat  hitherto  all  euob  ojwrations  have  proved 
i;  and  for  this  simplo  reason,  that  whenever  an  incision  is 
a  new  cicatrix  must  be  formed,  and  this  now  cicatrix  will 
ndago  prDcively  tho  same  process  of  contrucrtion  as  tlie  Ibrmcr, 
wUcb  it  was  intended  to  alleviate. 

It  may  be  laid  down  as  a  rulo  almost  wttliont  exception,  that  a 
ciaatru  lAould  never  Ire  louetufd  teith  the  hii/'e,  jViid  we  find  that  tlieso 
fiperalions  have  for  sotno  time  ]>ii-'sl  Ijceti  dii^cardod  a»  uncluti.'i  at  ^ 
BortholoinL-w'a,  and  khuc  other  leading  hospitob  of  London. 


ISS 


PLASTIC  SURGERY. 


1 


Tlw  Intft  Mr.  T^nrlfl  |>r«jir»io<l  to  ml  iiway  tlie  whole  of  the  cica- 
trix, and  then  bring  tho  edges  of  the  healthy  skin  a*  much  towanls 
«ach  oUier  m  poMtible,  in  tlio  tmiisvonw  dircclion,  with  strips 
adhesive  plaster.     Bat  in  most  rasefi  this  mcasiire  U  iiiipriictic:ab)0|; 
Mthcr  fnuii  the  Mitimtion  of  the  bani,  or  from  llie  iihhjuih  nf  tiitc^*' 
ment  already  destroj-ed.     Who,  for  instance,  oould  dissect  away 
larpi  (nuiitrix  from  tlic  front  of  the  nock,  and  dra;:;  forwunl  tho  akin 
from  the  flidea  and  nape  liy  means  of  Htrips  of  adliesive  plaster 
ing  oror  tho  larynx  and  trachea?     Tiie  pratrtioo  of  detaching 
tnmsplantiiig  a  flnp  of  intcguraeiit  has  been  recently  revived  by 
Mr.  Toale  of  Leeds.     But  to  this  proceeding  I  would  4Uote  (he 
words  of  Mr.  Skey :  "  There  is  no  diffieulty  in  obtaining  sound  Kkinfl 
by  autopIa«ni  to  supply  the  deficiency  and  to  fill  up  the  space  OMwed 
by  the  ili^inion  of  tbo  bridlc.t ;  hut  tlie  real  difficult  ooiuuts  IB 
effecting  it«  junction  with  the  diseased  parts,  and  in  n^tjiining  >1^H 
vitfdity,  for  the  hiL'*e  of  tho  wound  so  niiide  is  not  to  be  deemed" 
healthy,  but,  on  tho  contrary,  is  greatly  indisposed  to  cooiwnilo  with 
the  skin  laid  down  and  to  accept  its  union.     It  would  appear 
the  vital  ibrco  of  tliis  structure  is  too  much  exhausted  in  the  stnig^' 
Bgainiit  the  noeostiiiry  agents  of  extension  tu  partacijiate  in  the  healthy 
actions  requisite  for  adhesion  to  the  structure  brought  into  apposi- 
tion with  it ;  and  whon  we  consider  tlie  adventitious  nature  of  thia 
tissue,  and  tlie  probable  condition  of  its  vessels,  tlie  iailure  of  tboM 
o[>t^i'ations  is  not  sru-prising ;  hut  this  failure  is  by  no  meaai  necet- 
sary  or  universal.'"'     Mr.  Skey  has  ]>ropoM?d  to  obtain  extension  of 
tho  cicatrix  by  niciins  of  a  number  of  miinito  divisions  birth  of  the 
skin  and  subjacent  lisBuo,  founding  liis  practioe  on  what  may  bo 
doomed,  he  says,  an  axiom  in  surgery,  viz.  titat  (/«  omhxictwK  of 
wouihIs  is  d'ujht  in  jtroportitm  an  the  lime  eont^tm^  in  the  htaltttg pn>- 
CMS  is  ehort.^     But  even  in  this  practice  the  secondary  coutmvtid 
inseparably   connected   with   a  newly-formed   cicatrix   cannot 
avoided ;    and   I  therefore  would  direct   especial  attention  to 
method  of  lieuting  tliene  CJises  hy  meolmnicAl  extension  alono. 

When  gentle  yet  constant  traction  is  exerted  on  a  liard  and  coi 
tracted  ciculrix,  it  yields,  without  touring,  with  lingular  facility; 
hard  knots  disappi?ai',  the  firm  seams  become  soft  and  pliant,  and  tli 
new  skin  regains  tho  suiiploiie^as,  tliough  nol  tho  eonipletenefw, 
the  natural  structure.    After  extension  has  been  kept  up  a  sufilciwil 
Iffligth  of  time,  the  material  on  which  the  contracting  power  dejieiiill' 
becomes  ahsorbod,  and  tlio  elongation  of  tlio  cicatrix  is  permancot. 


Opmttivi  Surgay,  p.  687. 


f  Of.  dL  p.  68H. 


CONTRACTED  CICATRICEa 


133 


Tin  results  of  tliU  troatmont  arc  mostly  Batis&ctor}*,  and  &ilHro 
proeeeda  fnim  vruiii  of  fati«nce,  which  »ubtitJtut<M  forcilifo,  aiul  as 
it  ware  Bpasmodic,  cffbrte,  for  pcixcvcniig  and  imrooiitttiig  guiitlo- 


To  the  objoct!on,  that  the  system  »  tcdiouB,  1  would  reply,  what 
can  be  tootv  wo-arUiiino  tlmn  tin:  attemjiL  to  hi^al  n  hirgii  oji™  wore 
fii&innng  a  divided  cicatrix?  The  jirinciple  in  all  ajipai-atus  foi-  sush 
casn  «>ii«!!ts  ID  kIhw  cxleiision,  cfl«o.t«d  u.tiinlly  liy  [ni-an.i  of  tlio 
ttigwlteeL  For  the  extension  of  a  cicatrix  in  the  nock  we  emjiloy  a 
pelvic  band  of  stool,  wilJi  two  »!dc— cnitclie:*  and  a  wcbbing-ljwml  in 
bunt  lo  keep  the  in^tminont  steady ;  a  posterior  etccl  upright,  to 
which  is  attached  n  iH-ttdptvco  witJi  hnuichi.-^,  movablu  in  every  di- 
reetioa  by  means  of  oogwheeb  and  a  sirap  passing  under  the  chin.  * 
£vcry  day,  or  every  otiuir  day,  Uio  smallost  pooniblc  amount  of  ox- 
Inuioii  uiuKl  be  made  and  maintained ;  but  Uie  patient  should  suffer 
no  psin,  nor  must  tbo  iJiin  be  alluwMl  to  break.  If  a  sure  fhotJd 
fbm,  tlw  ■]>pariilus  rie(|iiiroH  removal,  and  the  advantagea  tliuA  far 
obtained  vUl  be  lost  during  the  todioin*  cicatrisation. 

The  ivniw  nnnarkit  Apply  to  tlio  oxtcu»ion  of  tlie  eioatrix  of  a 
eootraoted  Umb.  Tba  apparatus,  modifitxl  according  to  drciuu- 
Mbdocs,  muM  b«  worked  by  a  cnj^wlic^cl,  which  inftiircx  tttoady,  un- 
reniitiing,  and  yet  limited  exercise  of  force.  TIio  hardened  imains 
ckmgoU'  and  Iwoonw  «ofl,  and  (Ik;  fmoiloin  uf  movoiiiuut  itt  reined 
fa  more  q>eedily,  elfectually,  and  painlo&sly,  than  by  any  other 


In  slighter  eases  a  great  amount  of  benefit  will  ensue  Srom  direct 
[ireamrD;  a  pieco  of  vnicanisvd  India-rublxir  is  moulded  exactly  to 
ihe  «ontnoted  part,  and  ts  retained  tliere  by  a  bandage,  etrap,  or 
dHtie  roOer,  In  llio  course  of  a  ft^w  wt.i^k«  tlio  hiu-di^u'Kl  Heams 
Uome  M>fler,  and  tiie  ink'^iuutnt  regains  itti  loat  pliancy.  This 
inttioe  IB  awful  io  caws  of  contraction  of  the  vtbow  in  children ; 
ADin  tho  tivatraeut  ofoontractionm  of  the  neck,  especially  in  com- 
tiwian  witJi  the  oxtcoiding  apparatus,  when  tiie  chin  seems  lost  in 
ttidrfniiuty,  and  tlie  t«oth  are  ussuuiing  a  horizontal  diroctiun. 

HOLMKS  COQTE. 


*  For  ilctaila  (w  to  tlicse  insUumoDt*,  see  tlie  Appendix  :  SusaiCAL 


DISEASES  OF  THE  EAR. 


THE  diaoiises  of  the  Ear  naturally  (Uvido  themselvefi  into 
cla^eH,  in  confonui^  witli  the  anatomical  Btnictiirc  of  the 
organ — those  of  the  cxtttnial,  of  tlic  nii<lill«,  luul  of  the  internal 
ear.  The  first  class  includes  tlie  uffeotions  of  tlie  auricle  ami  of  tlie 
external  tnuatus;  tho  Beoond,  those  of  tlw  monibmiia  lyuipani,  tj-m-l 
panuni,  mastoid  cclln,  and  Eustac^liian  tube,  with  the  adjacent 
gions  of  the  throat ;  tho  third  embraeos  the  diwases  of  the  labyrint 
and  of  tho  auditory  nervous  apparntus,  so  far  as  it  comes  wittiiB 
tho  reach  of  our  investigation.  In  addition  to  tboo,  oortain  dia^l 
easeo  not  capuble  of  strict  local  definition,  and  tlie  eSects  produced] 
upon  tho  brain  and  other  organs,  cbiefjy  the  lung^,  by,inflanini»tioii 
oommenciiig  within  tho  ear,  will  require  duscrljilion. 

L  Affectioss  of  the  External  Ear. 

Malftmnalionf.  Tlie  Surgeon  is  occasionally  consulted  for  exJ 
ternal  malfomiationa  of  the  ear.  ITicae  vary  in  oxt4.-nt  from 
mitiro  aliKcnoe  of  flic  meatus  and  its  ajipcndngcs  on  the  one  hand, 
to  the  presence  of  a  double  set  of  oi-gana  on  tho  other.  Tlic  most  fre- 
quent malformation  is  an  imperfect  deveIo|iment  of  the  meatus  and 
Ruricle ;  the  former  being  reduced  to  a  narrow  slit  in  tho  tcmpor 
bfjne,  and  the  latter  existing  only  as  a  slight  fold  of  tlio  integiimont 
Tlie  tympanum  alao,  in  some  of  these  cases,  is  merely  rudimeotapyj] 
consisting  of  an  irrcpdar  aperture  a  few  lines  in  diameter,  and  tJn 
ossioula  are  more  or  less  defective.  Sometimea  a  single  bone, 
Winbling  the  columella  of  birds  and  reptiles,  takw  their  j>liuie.  Thfl 
labviintli  is  in  tlicso  cases  most  frinjuently  normal,  and  a  eer 
anioimt  of  hearing  is  usually  present :  often  it  is  so  winsidcrnblo 
to  enable  the  patient*  to  pertiinn  usel'id  duties.  For  the  most 
extensive  defonnity  is  present,  from  absence  or  defect  of  other 
tions  of  the  skull,  as  the  mnlar  bone,  or  the  zygoma;  and  the  oriKc 
of  tho  meatui!  may  seem  to  lie  vorj'  much  anterior  to  its  nor 
position.     Operative  proceodings  have  not  been  found  beneficial  til 


OF  THE  AURICLE. 


13!) 


i? 


11k*!  cases,  nor  In  those  in  wliidi,  wilb  n  more  or  \c.»»  porfiH-tly 
IbnDed  Miritile,  llic  rairtiU^inous  portion  of  tlio  meatus  is  aIso  per- 
fect birt  ends  in  a  cul  de  ate  Tlie  {jotm  ttonuilli  in  ^tnrnilly  fiiiin<l 
■olid.  In  anotlior  class  of  cues,  howovor,  in  ivhieh  the  defoct  is 
coofioed  to  a  contraction  of  the  mfiatUK  nt  it-t  oHficf,  from  n  fulling 
bock  nf  Um)  tragtu,  or  projection  fonvards  of  tlio  antitra^s,  efticiont 
kasisumce  can  bo  remlercd  hy  tlio  prolongoil  uku  nfii  tuin;  u<la]>to(] 
to  tim  BIZ*  of  Uio  canal ;  or  excision  of  a  portion  of  the  offending 
etltOage.  Congenital  clocttire  of  tlio  nicntua  by  n  laliiu  niciiibrune, 
sowatunca  mpcrficial,  sotnertitoe«  deeply  seated,  near  the  nicmbrana 
nrmpani,  is  said  to  have  occurrixi,  winl  to   have  lM>(rn   roiuodied 

the  divigton  of  the  etructnre,  followed  by  the  introduction  of 
tents. 

Supemnmeraiy  auricles  are  sometJnies  met  with,  growing  from 
the  wdoM  of  lilt)  mx'k.  In  the  ninth  volume  of  tbo  TranmcttOM  of 
the  Pathoiotfiait  Socielif,  Mr.  Birkett  relates  a  case  of  this  kind.  The 
■truetareet  eon»iiit<'d  partly  of  n  tissuo  like  tlio  loJjc  <>i  the  ear,  and 
partlv  of  fibro-oartilago,  tiie  s)ui]io  of  which  "  resenjbled  more  or 
hsM  doocJy,  in  peuiA,  that  of  tlio  proper  auriclo ;  mid  itx  tiMKue*  were 
the  aam&"  Tbey  were  excttted  wiltiout  difficulty,  and  appeared  to 
bo  tnrrely  ctitnneuns  appendages,  not  extending  nioro  deeply  tliun 
the  fibres  of  the  platysma  myoides. 

Injuniw  of  the  auricle,  and  tlie  lodgment  of  foreign  bodies  in  tlic 
meatus,  will  be  found  treated  of  in  the  eattay  on  Injcrieh  ok  the 
Face. 


The  auriele  is  subject  to  rarions  mtaneous  ajj'ections,  herpes^ 
fanpctigo,  i>t;iiiphigiij> ;  but  the  must  inijwrtiuH  iirc  <'lin>nic  orysj- 
pdaa  and  chronic  eczema.  Doth  those  iMiiditions  ni'o  inu»t  frt*<[uont 
in  women  ]>ast  middle  age,  though  the  lattt^'r  is  tdoo  met  with  in 
tliiUren.  In  chronic  erysipelas  the  entire  aiiriclo  become*  gKTiitly 
dnc^cnwl,  so  thul  the  uiillitic  of  its  various  part*  i.i  almost  lost. 
Ibi*  skiu  is  red,  dry,  and  bard,  and  et^rered  with  des<tuiunuting 
Ipidennis.  The  sn^-tliiig  encroaches  on  tho  ineiituw,  tlie  orifice  of 
which  is  narrowed  and  fiwiueiilly  obstructed  with  opidormis.  There 
fii  eoDstant  itching,  but  not  much  pain,  tliougb  tlie  parts  are  tender. 
FftoMtinieH  the  atfeetion  dalw  from  u  previous  attack  of  acute  ery- 
'  ^prlin,  extending  over  the  side  of  the  bead ;  »>nii-tiiiiet<  it  seems  to 
be  local  &om  the  firsL  The  health  is  invariably  deranged.  The 
tnOment  con>isl«  lirst  in  cleaiiline««,  tho  di>>continimnce  of  ivrap- 
pbgi,  ftnd  firee  exposure  of  the  parts  to  the  air.  When  the  iiiflain- 
■■toiy  thiekeDiog  and  irritation  are  considerable,  poultices  may  bo 


}36 


DISEASES  OP  THE  EAR 


tr»tt- 
ityitM 

IttTM-H 

iU«d 

'J 


applied  st  ni^ht.     A  coiitJiuio<l  ukc  of  aHtrm^-nt  lot!onit  is  needdfl 
U>  restore  the  healthy  sction  of  the  skm.     A  solution  of  tiitmtc  aJB 
silver  (gr.  V. — 3j.  to  3J-),  iiscd  alternately  with  otiicm,  luu*  (Wiwidep- 
alile  pfft-ct.     tSlycerino  ia  often  very  H*«>thinj;;  or  the  car  may  Iw 
coverwl  with  collodion,  roiivwcd  daily.      Tli«  <x>tii>tilulioiiiil  tr«»t- 
meiil  fthould  bo  condu(!t«d  on  tlio  uiuial  princifitea.      Debility 
gonorally.  but  by  no  moans  always,  prosont.    A  pernianont  ownt 
tion  of  tlio  ttit'utu.1  NoiiKttiniiis  rutiilts  from  tliU  dliLiiw.     ]ts  efiectfl! 
may  bo  mitigated  by  wearing  a  Hmall  silver  tube  at-cnratcly  fitud 
to  tile  jmrt*. 

In  chronic  eczetna  the  aancle  pre^ente  less  thickoniiig  than 
tho  liut-nici]tioned  affvii^tiun;  but  it  it  coiMidvrably  swollen,  oover 
more  or  less  with  brown  or  yellow  omsts,  and  when  tbt«e  an  not' 
pretiont  oxudos  a  watery  fluid.  A  tumilar  vru[>linn  is  generally 
present  on  liic  scalp,  or  on  other  parta  of  the  body.  The  disessod 
condition  mostly  extends  into  tlio  meatus,  and  more  or  lets  dea&en 
M  |iri!S<'nt.  It  Jjt  atl*!iid«d  witli  great  ttt-hing.  The  tit:atment  b  the 
same  as  for  other  forms  of  ucziMna ;  but  tho  meatus  should  lie  well 
SjTiH(»eil  out  with  warm  wal^r  ii'e(|ueiitly,  to  prevent  discharge 
from  accumulating  witliui  it,  and  in  tho  later  stages  of  t)w  diMMA  ' 
may  bo  wii^lioil  with  a  solutinn  of  the  nitrate  of  silvei',  or  with 
citrine  ointment  diluted  with  glycerine  or  almond  oU.  If,  after  tie 
eruption  ha^t  cenacd,  tliore  remain  any  dojjreo  of  liardiie«s  of  hear- 
ing, dependent  uptm  a  thickening  of  the  mombraua  tynipani,  tho 
cosi;  would  come  witliin  another  class  of  ufiet^tions — ihoso  of  tbe^ 
middle  ear.  B 

Gouty  deposits  aro  froqucnt  in  tho  auricle ;  mid  eongestion  of 
the  cartilage,  arising  from  tho  same  i-^uae,  ia  sometimes  met  with. 
Excoriations  aro  not  uncommon  in  children  ;  but  thity  arc  roadily 
cured  by  oleaidine**,  with  or  without  mild  astringent  lotions.  Great 
eare  sliould  ho  taken  to  dry  tlie  ears  and  hair  of  children  aAeCn 
washing.  In  influinmatory  affuctions  of  tlio  auricle  or  meatus,  tfaaj 
glands  bonealb  iJie  angle  of  tho  jaw  generally  bcoonio  somewhat] 
swollen  and  londer;  oe<»uionally  auppui'ution  occurs  in  them.  Para-( 
lysis  of  the  facial  ner\e  may  result  from  their  pressure. 

Tunwur/i  of  the.  auricle.     Of  these,  three  chief  forms  have 
dcscrilxHl : 

I.  A  fibrous  growth  of  great  hardness,  forming  in  tlio  carti* 
lagiuouM  jHirtion,  mid  giving  rise  soniotimeN  to  great  inconvenioiwft  I 
This  is  rare  in  England,  but  in  the  American  Journal  of  M« 
Sciaiai  for  Octobor  1)^60,  it  is  stated  to  bo  much  more  conimoa  xoA 


OF  THE  MEATUa 


137 


negroes.     Fibrans  tmnoors  aim  fona  tn  tfae  Mie,  oroand  the  liolo 
from  witich  ibc  car-ring  is  suspontlod.     In  either  case  they  are 
^^easQy  reniovixL 

^H  i.  ChvUc  disease.  Under  this  name  two  distbct  affectiona  have 
^BbHD  deacribed :  one  oonsi.iting  of  a  mic  cuntsiiiin;;  :i  ^Iiiiry  tctia- 
Voaw  mbetaooe,  the  other  being  an  infiltration  of  the  ti^iues  of  the 
auricle  with  a  Muif^inuknt  AuhI.  Tlio  latlvr  i»  tho  disease  met 
with  so  frequently  in  the  insane,  known  under  the  name  of  hsema- 
taraa  nuriK.  ^VIlvtIH'^  this  aflbction  artMM  from  injury,  is  Ktill  a 
mailer  of  iliscussioi]  among  tJioee  who  haro  charge  of  the  insane 
for  Uieauneiit,  I>r.  Tlinrnam  (as  quotixl  by  Mr.  To^mbtw)  rccvm- 
Deada,  in  the  aeute  stage,  "  the  uite  uf  o\'»|)omtjng  lotiona ;  at  tlie 
end  of  a  week  or  two  a  seton  should  bo  paiUMxl  lliroiigh  tho  long 
axis  of  the  aweliinj,',  and  tho  cxmunitit  prtv-wtid  oui.  Uiidor  the  une 
of  the  sctoD  the  tumour  gradually  subsides."  h\  the  triMitinoiit  of 
the  ordinary  oy»Lt,  Mr.  ^Vildi)  rcconimtnidit  that  they  should  be  hud 
&«ely  open,  »nd  drc»e(l  from  the  bottom  with  lint. 

3.  ±>it>:itii!uiiU)u»  luul  fiilty  tumours  arc  also  met  with  in  tlie 
auricle,  as  welt  as  a  pendulous  state  of  the  lobe,  which  may  reach 
an  oxtreme  dograo,  oimt^tnlly  if  ;;oitre  be  present.  Tbi.'i  part,  ia 
abo  eolgect  to  noivuH,  whii>h  may  lead  to  its  destruction  to  a  greater 
or  IcH  extent ;  and  oructilo  tumoun<  have  been  mot  with  in  it,  c»ds- 
fng  hemorrhage.  Hie  latter  affection  wilt  bo  treated  of  in  the 
iKStica  oa  VAecVLAB  Tdxodbs. 


n.   AlTBCTIONS  or  THE  ExTEitSAI,  MEATUS. 

In  (tome  eases  in  wtiieh  this  pn.!sago  is  wide  and  sliort,  the 
ptUa  put  of  its  extent  can  tie  exiititini,»I,  mid  tho  mi>iiitiriiiiii  t\-m- 
tmi  rendered  visible,  by  placing  the  patient  in  a  good  light,  and 
^y  elevating  tlie  helix  of  the  ear  with  one  hand,  while  the 
^ogat  'a  drawn  forward  with  the  other.  For  tlie  most  part,  how- 
*^,  this  is  Dot  possible,  au<I  a  siMxmhim  \s  tiix-tNwtry.  Tho  best 
an  of  speeoliun  1  believe  to  be  a  silver  tube,  which  is  made  of 
*il  tliape  to  fit  tlie  oval  form  of  the  meatus,  and  hn.'t  its  smaller 
*1  continactl  of  the  same  diameter  for  about  half  an  inch.  Tliis 
■ftiBiient,  if  of  a  suitable  sixo  (and  it  is  dosinihle  to  ponse^  two 
*lhrae  of  different  sizes),  admitit  tlie  largest  possible  amount  of 
V^  and  adapts  itself  eu-nily  and  painlcNsly  ti>  tho  canal,  in  which 
BaiO  nmain  fixed  while  the  Surgeon's  liands  are  free.  By  mo>-ing 
I  ildffcUy  in  difi'ercot  directions,  the  wltolo  of  thu  iimer  part  of  the 
I^Maaaikdof  tbesurfaeeofthe  membrwui  tympani  can  be  minutely 


laa 


DISEASES  OF  THE  EAR. 


oxammed.  Tho  most  perfect  viow  of  the  parte  is  to  bo  olitaini 
causing  the  my*  of  tho  »iiii  to  IhII  llirougli  this  !>]iiHiiltim  into 
moattis,  whieli  may  be  effected  by  placing  the  patient  in  tli«  »iili 
liglit,  with  1)111  b(:u<l  inclined  at  u  niiilnlili!  iiiij;lu;  but  when 
direct  rays  of  Uie  sun  are  not  available,  an  artificial  illumination 
»e(«si*arj-.  Tlii«  may  b«  Nupiilifti  uitbcr  by  nirans  of  a  jrt  of  gas 
convoyed  by  a  flexible  tube  to  a  small  stanil  iiirni&bed  with  a  reflflC 
tor,  or  by  n  roflcetor  altjichttl  to  an  onliiiary  eandlc,  or  by  mean* 
of  the  very  convenient  lamp  invented  by  Dr.  Chowne,  and  known 
M  Miller's  lamp.  Wliietn^vitr  of  these  metbods  is  tised,  tbe  ftpocn* 
lum  Hhinild  lie  gontly  introduced  into  tho  ineatuH,  and  the  light 
dirooted  by  the  reflector  to  tho  bottom  of  the  canal.  In  j'onng 
chiklrcn  rim  niealns  is  very  shallow,  tlie  ossofius  jmrtion  eonsisting 
only  of  a  small  ring  of  bone  (deficient  at  tho  Upper  part),  to  wliich 
tlio  nicmbninEi  tynipuni  ia  attaohed.  The  sjieoidnm,  tbcrotore, 
should  be  used  in  their  case  with  groat  caution.  Tlie  points  to  bo 
noted  in  tho  examination  of  tlie  inoutuit  arc,  the  !»xt>  and  eidibra 
of  the  canal,  whether  normal  or  infringed  upon ;  the  prcaeiioe  or 
abMOice  of  oxtr;uiouus  iHidie.t  and  of  eenunen ;  th"  eliurac'tem  pre- 
seoted  by  the  latter,  if  present ;  and  tlie  condition  of  tlie  Uni: 
luembranc. 


] 


Atvumulatum  of  cerumen.  Though  a  ^■cry  frequent  affection,  v 
paction  of  wajc  in  the  meatuH  does  not  ootistitute  iw  largo  n  proportion 
of  tho  causes  of  deafne«.%  as  might  have  boon  supposed.  From  my 
own  notes,  the  ]>r<ipoi-tiou  of  ouhos  benufitod  by  the  rcmoi'a]  of  09- 
rumen  would  appear  to  be  about  one  in  six.  But  tlie  preaenee  of 
wax  is  only  in  a  minority  of  the  instances  in  which  it  occurs  tlw 
Bole  oause  of  the  deafnesa  that  accomjianies  it.  Mr.  ToyrdK>o  foond 
n  perfect  restoration  of  heiiring  cSuoted  by  tlie  removal  of  cerumen 
in  sixty  ears  only  out  of  105. 

Besides  interfering  with  the  hejiring,  accumulations  of  hardened 
was  may  jirodiice  various  ill  effects.  They  may  occasion  (probably 
tlirough  pressure  on  tlie  menibrana  tympaiii  and  o»sieula)  very  dis- 
trettsiiig  nervou*  symptoms;  not  only  "  noise.*  in  the  head"  of  va- 
rious kinds,  but  giddiness,  eoniiision,  and  e^-en  unsteadiness  of  gait, 
exeiling  llie  gravest  appieliensioiis  in  ibe  |)utioiit'K  mind.  I<\irthcr 
than  this,  they  may  evcu  cause  absorption  of  the  bony  walls  of  the 
me-atus.  Tliis  mHSurs  especially  in  tin;  <ild,  in  whom  neglectod  aecn- 
mulations  have  existed  for  many  years.  In  some  easea  of  tJii» 
tho  oK-'teouii  jituto  that  Kojiaralcs  tho  cavity  of  Uio  meatus  from 
of  the  mastoid  eells  is  completely  ponotrated. 


AOCUMULATTON  OP  WAX. 


139 


Tkeafiiea  catised  tiy  renimea  for  die  moAt  part  preAAiita  pociiliar 

tfnptaau,  and  a  (olvralily  good  lUagnoeia  may  ofioii  bo  based  oa 

ifao  daaeription  Mid  hi.4torv  of  Uie  case.     Tli«  Iicarin^  gonomlly 

vxrin ;  it  is  often  bcttt^r  in  tlic  moniiti^,  and  is  improved  hy  eating, 

or  by  rubbing  tho  mtntu.-*  with  Uie  tingor.     Vt^ry  often  it  cointM  on 

mdden]y,  especially  after  expoeoro  to  cold.    Tbis  is  probably  dtto  to 

itiglit  infUtnmMlory  xwolliiig  Liking  plitcD  tn  tbo  ni4»tit»,  and  ooii- 

g  a  partial  into  a  complete  occlusion.     Ibis  circumstance  baa 

iifueiiUy  lod  to  tlw  employmnnt  of  Uio  most  mlajilaocd  dciJetoiy 

and  otlier  treatment  in  cjises  in  which  an  inapeotion  of  the  tneatua 

ban  Hut  Ix-CQ  inado.     TIkto  i»,  iiiiwmvr,  unoUier  fonn  of  dMifnetm 

which  eomea  on  suddenly  after  exposure  to  flerere  or  long-continued 

coiil,  or  cnid  and  wd,  and  B|>i«jar«  to  doi>pn<i  (ijxin  an  alfulitimi  of 

the  function  of  Uie  nervous  apparatus.     Tbe  great  degree  of  tb& 

deafiiCM^  however,  comjiared  with  thv  sliglitne-tut  of  the  apjuiniit 

eaaaKf  together  with  the  previous  history,  may  sen-e  to  dintingui^b 

the  effect  of  cerumen  fWim  tbo  ia^l-nained  affvc-tion.     Btil  liowever 

charocterifitiA  the  ax-mjitomR  may  be,  an  examination  of  tbe  jiassage 

Aoold  always  bo  madv ;  and  if  corumim  be  proHiit,  it  is  to  be  ru- 

■oved  by  syringing.     The  tnoi!(t  efH<<ient  fonn  of  syringe  ia  one 

6[ied  with  a  separate  nozzle  of  small  she,  since  a  \ory  lino  jet  of 

Vitor  mM»  inm'h  inure  eflVctively  in  dislodging  the  niast*,  utkI  pre- 

leu  obetruclion  to  the  returning  stream.     Tlie  nozzle  should 

taken  off  eaoli  time  [iie  s>'ringo  itt  filled,  and  replaced  hiifore  it  is 

If  this  form  of  sj-ringe  is  not  used,  caro  must  be  taken  that 

^  noatiia  is  not  oUrtniv^ed  by  ih<;  instrument.     In  Nyriiiging,  tbo 

watOB  should  be  straightened,  by  drawing  back  the  auricle  with 

the  left  Jband,  ami  g>*nlly  pnwting  forward  the  tragus  by  resting  tho 

Hole  of  the  s^Tinge  upon  ii;  and  tlie  ear^pont — a  sort  of  funnel 

ttbe  jiUccd  benontli  tlte  car  and  retained  by  n  spring  ]>ns»iiig  over 

^  head — or  a  tin  basin  fitting  to  the  side  of  the  neek,  are  very 

Bnaiicnt.    'Whatever  fluid  is  usol,  care  should  be  taken  that  it  ia 

■AocDtly  w-arm.     Tbe  patient's  own  feelings  should  regulate  tlie 

',  hot  it  sltould  never  bo  below  that  of  full  blood  heat. 

or  oven  eool  Huids  are  injected  into  the  meatus,  great  giddi- 

B  produood.    In  ordinarj'  cases,  wann  water  only  need  l>e  UMxl. 

Ulh>  wax  i*  .Hoft,  it  speedily  comes  away ;  but  when  hard,  its  romo- 

<ndHiy  require  groat  perseverance,     Tho  use  of  the  dj-ringe  idioulil 

■nr  be  curried  l»evond  a  motiei-ate  extent  at  any  one  time,  and 

■kidil  be  immediately  discontiimctl  if  tbe  [Mlient  complains  of  paiii. 

fe  a  muc-li  lM!Her  to  repeal  the  process  several  times  than  to  run 

^ntik  of  producing  irritation,  tbe  dfocts  of  which  are  Kometiniea 


140 


DISEASES  OF  THE  EAB. 


very  diffionlt  to  allay.  Casos  occur  in  which  tl»  most  distr«m^H 
and  obstinate  nois«e  in  the  ears  littvc  i^upur^x^iK.-ti  uj)on  tliu  rcmovllV 
of  wax  by  tlio  Nvrinj^;  aiid  in  Home  of  these  I  have  found  that  even 
tho  most  gentio  oniployaiont  of  that  iustruinotit  tnuda  to  ii^^f^ni^'ate 
the  Ayniptuiiu.  If  the  wax  itt  not  rouioved  in  a  motkrato  timo, 
warm  oil  or  water  introduced  for  a  few  uight«  will  giimrally  suffi- 
ciently soflun  it  to  rviid<-r  itit  evacuation  oany.  Thin,  however,  is 
not  always  tlie  case ;  somotimes  tho  altered  ocrumcn,  iningltxl  a*  it 
18  witli  opid«nniM,  is  of  almoitt  ntony  liardiiotM,  and  the  partA  at  the 
same  time  aro  acutely  tender,  so  that  the  tnoet  )>raIon<ecd  and  ,(OMitli) 
trcutmuiit  II'  HL^ccMary  to  give  relief.  Wln'iiever  iho  syringe  ia 
employed,  the  ear  nliould  be  frequently  examiued  with  tlie  epeculnm, 
to  a«c«rtatii  whether  any  wax  remains;  since  although  the  IniA  por- 
tion generally  coint^s  awaj'  in  a  large  ma*s,  presenting  a  caat  of  tbo 
moinbrana  ^'mjtani,  tins  is  not  always  the  case.  Small  inoMiat  of 
hard  iwrunion  sometime*  oolleot  in  contact  with  the  membrana  tjio- 
pani,  ami  occaiiion  mneh  annoyance,  in  the  form  of  itching  and  tin- 
nituR.  Tlie  sjieeidum  reveala  tJio  nature  of  the  case,  and  syringing, 
which  sometimes  needs  to  bo  rcj>catcd,  relieves  it.  A  dinular  irri- 
tntion  may  fullow  IViim  (Iid  iitlling  in  of  a  hair  upon  the  membrane}! 
but  probably  in  these  casos  there  already  oJUsts  a  morbid  irnljibilig|^| 
of  the  organ.  ^n 

After  the  removal  of  cemmen,  the  membrana  h^mpani  ia  gwnc- 
rnlly  iicen  to  bo  of  a  more  or  less  tmddou  and  opaque  ajijMtarunoe, 
from  thickening  of  its  epidermoid  layer ;  sometimes  it  is  red  and 
vascular.  In  a  few  days,  however,  if  no  other  diiieaM)  lie  (ircaeot, 
it  recovcra  il«  iiormal  appearanoe.  When  the  hearing  ia  perfectly 
rc«torod  at  once,  the  patient  perceives  sounds  with  grcjit  intensity, 
ao  tliiit  the  voice,  or  the  noisot  of  the  slroet,  may  even  paiidiiUy 
aJ!eot  him.  In  this  ease  a  portion  of  cotton-wool  may  bo  worn  ovw 
the  mimtus  for  a  few  days,  by  wliicli  time  the  excoiuive  sensitivenees 
will  have  abated.  Indeed,  it  in  perhaps  better  in  all  cam;s  to  guard 
tho  passage  with  cotton-wool  for  the  remainder  of  Uie  day,  nt  leMt 
if  the  patient  be  exj>oRed  to  atmospheric  chajigcs.  In  many  caau 
the  hearing  only  gradnallj' ret uni:!i;  and  sometimes,  when  tho  imme- 
diate improvement  hm  bixtn  but  alight,  it  will  rise  by  degrees  almost 
to  itK  normal  amonnt  Time  sliould  thcn.''fore  bo  allowed  for 
result  l>efore  oilier  memturett  are  adopteiL 

TliiH  afTcctioR  is  apt  to  return ;  nor  have  I  seen  suiGcicnt 
dence  to  ediow  that  any  appli<^ati«nH  to  the  nieatuit  can  ward  it  o£,j 

Besides  accumulation,  tho  secretion  of  wax  is  subject  to  ot 
di&ordera.     In  childreu  it  mny  become  increased  in  qoantity,  An 


ABSCESS  OF  THE  MEATUS. 


141 


I  flfignsltc;  this  being  often  the  first  stage  of  Ratarrlinl  infl^mmu- 
'timi  oftho  mcutus.  b\  mliilt'*  il  is  fr(M]iioml_r  entirely  sbeent;  but 
thii  is  lor  the  moHt  part  merely  a  concomitant  of  tntemii]  inorbid 
oonditions,  and  i»  il.-H'lf  cntin-ly  without  infltKitco  on  t)te  function  of 
tbe  rmr.  8umclinti>s,  tbuugb  not  altvays,  ibe  re»|i|K-jLrHnutt  of  tiw 
nnniul  secrctioit  attends  or  prv^;nosttcat«s  a  fiavourablo  iisue  of  the 


In  the  majority  of  tbo  casM  in  which  accuniulationa  of  wax  are 
fmnid,  there  exbts  alao  a  dftifuamatioa  of  Ihr  fpuifrmif,  and  it  is 
not  tmcoQimon  to  romove  Urge  masses  of  the  lattw*,  more  or  feaa 
minfilloil  with  cerumen.  Sometimes  an  olwtiuiito  toiulenwy  lo  dvswiua- 
m«tion  Bxistfi  witbout  any  otlier  apparent  affection  of  the  moatiu, 
■ad  tbi-H  may  or  may  not  l>e  aownipniiiiwi  by  dJ^eiuK'  of  the  int<.^mal 
or  miii'ilc  ear.  It  may  occur  in  connexion  with  a  general  morbid 
irritabilitr  of  tlic  organ,  or  with  tinnitus ;  and  in  the  latter  cane  tho 
trritalton  of  tJie  loose  masses  of  cuticle  may  aggra\aie  tho  noises  to 
a  most  di<ln-M>ing  dognie.  Tbe  treatment  in  stieh  cases  must  oio- 
braoe  tlie  improvement  of  the  general  health  and  the  Htroiigthening 
of  the  nenouB  system.  Local  apph'cations  require  to  Ik<  very  care- 
Mly  emplo%-«d.  The  ordinary  astringents  are  ill  lionia  In  tiii« 
mpect  the  condition  differs  from  the  common  chronic  inflammation 
Lrftbo  meatus.  A  few  drops  of  oil  applied  occaMuiially  tiu^'tatii  tlio 
Innon]  of  the  fUhes. 


Mteitti  in  the  meatm.  Thiii  la  an  twntely  painful,  though  not 
t^lienriso  serious  affection.  It  occurs  gcnvrally  in  per»on«  ulmiit 
tnJiUe  life,  and  conststA  in  tlie  formation  of  a  small  <!ircumHcribed 
ihwMu  in  tho  outer  part  oftho  meatus,  apparently  having  its  scitt 
■  ^  oemminous  ^ands.  Sontetimcs  only  one  almcoFis  forms, 
■Bttrtimes  screral  Ihe  aflcction  is  apt  to  recur,  and  may  coincide 
villi  iIk  formation  of  IkhI.h  in  other  pnrts  oftho  iHxIy.  While  the 
iheM  is  forming,  there  is  acute  pain  of  a  throbbing  darting  clia- 
ncttf  in  llu!  im-utus,  ofWn  exu.-ii<liiig  over  the  side  of  the  head.  The 
I<nU  an  extrvtnely  tender,  and  the  attempt  to  introduce  thu  Rpe- 
(rinm  ouww  great  dit>tn»ui.  The  mcNtut>  is  tumid,  and  its  aperture 
■Wvwed;  the  swelling  of  the  alwccss  is  generally  visible  near  its 
•Bter  part.  Tl»e  Iiearing  may  bo  temporarily  impaired  by  narrow- 
n^  <ir  c%-on  doenre  of  the  canal.  Tbe  denn^  of  tho  ^ttrui-tnrtw  and 
iWf  mpionit  nen'oiM  sii])iily  aocouul  fi>r  tlio  severe  |)ain,  which 
MMtineA  pvos  rise  to  considerable  fever.  Ueli<'f  is  given  by  the 
t«  we  of  poultices  and  fumontatiooH,  which  should  bo  applied  as 
kt  x<i  Utttjy  can  be  borne.     In  a  few  days  thu  abscess  bursts,  and 


143 


DISEASES  OF  THE  EAR 


tlie  (tvmptomB  abate.     Purgatives,  and  depletion  by  leoohos,  may  ' 
«iii])iii_vt'd  in  lilt-  scvurt-r  canv*.    liy  mmio  luitlifirH  it  if  rocummcadcd 
that  tlie  absccse  eliould  be  openod ;  but  the  extreme  paiii  of  the  in- 
oifiion  in  a  {irac-ticul  objection,  unlc«M  cliloroform  bo  fjivt-ii.   lii  ahooet 
all  tliese  cases  a  similar  oonatitutional  treatniout  is  indioattxl  as  fb^^ 
"  boiU"  on  other  parbt  of  tlto  body.    Wbcii  ttiero  Inu  oxi»t«d  a  ten^H 
dency  to  thoir  eonliiiued  n^oiirrenfe,  the  seKiuioxide  of  iron  iu  fre»    ' 
dowft  has  api<oarod  to  ui«  to  be  useful 


J 


Infiammal'ion  of  the  m^attu.  Thia  affection  is  either  acnta 
clironic ;  it  in  fnwiuently  cijniKH!tod  witli  diitea^wd  condittoiw  of 
partA  of  the  ear,  the  membmna  tympani,  tynipauuni,  and  auifitoid 
OoUa,  bat  it  aomctimrs  cxivtA  without  tlio  presenee  of  more  dix-piy- 
seated  diacaae,  esjxK-Jally  in  itfl  earlier  atitgea.  Negleoied  inflam- 
mation of  tbo  meatus,  aggravated  as  it  constantly  is  by  oonlinod 
Olid  d<»om[Hi»ing  diH<.-tiai-giis,  hiiA  it  groat  Inndeney  ia  spread  inwards, 
and  involvo  tho  mueous  nioiubrano  of  tho  tynipauuni.  Tliis  is  es- 
pecially the  caae  in  oliildren,  multitndea  of  whom  may  be  seen 
amon;;  tbo  poor,  ca(;hect!c,  half-nourished  creatures,  in  whom  au 
intlnnnnut  ion  of  tlii;  mt^atus,  attendtNl  witli  diM^luirge,  hiis  <»iis<il 
perforation  of  the  membrana  tympani ;  and  tho  wliolo  cavity  of  the 
ItioatuH  ami  tvm|>anuni  is  red,  swollen,  pulpy,  and  fillwl  witli 
ofiensive  acrid  discharge,  which  ulcerates  the  orifice  of  the  passaga.| 

The  early  mymptonis  of  acute  in tl animation  of  the  meatus 
similar  to  iJiose  which  cliaract*>ri8e  tlie  formation  of  abecesa, 
pain,  however,  is  generally  less  acuto ;  it  is  of  a  dull  aching  el 
ntet^^r,  and  in  incrcnsnl  by  motion  of  the  Jaw.     On  e.iaminatioBj 
tlie  meatus  !s  found  tumeticd  and  tender,  its  surface  is  rc-d  and  va 
culiir.     Afler  ref)catud  attncks,  it  may  l»e  so  swollen  as  almost 
obliterate  the  caual,  hut  no  local  swelling  is  to  bo  observed. 
neigliln)uring  glands  of  the  nvtJc  are  often  onlarged  and  tcnderJ 
Tho  hearing  is  not  much  impaired  unless  the  canal  is  almost  do 
or  tlie  tyiniuuium  is  itnplicate<L     Tbe  hejilUi  is  almost  always  dt 
ordered,  and  some  of  the  severest  and  most  obstinate  cases  I  Iian 
Boeii  have  occurred  in  patients  subject  to  gout.     Tlw  acoess  of  I 
disease  is  g<-ni-rjilly  attributixl  to  cold,  or  blows  on  tlie  head  mal 
occasion  it.     Sometimes  there  occurs  at  an  early  period  of  the  •■ 
fection  an  extremely  )irol'use  watery  discliarge,  almost  equal  to 
which  follows  certain  fractures  of  tlie  skull ;  sometimes  tlic  infl 
mation  subsides  wilJuiut  any  di^ohargu ;  sometimi's  it  is  followed 
a  secretimi  of  viscid  tnuous  or  of  pus ;  or  it  may  run  into  tbo  clironii 
form  of  the  disease. 


INFLAMMATION  OF  THE  MEATUS. 


143 


^V  la  the  treatment,  tlio  more  cleansing  tho  meatus  with  vrarm 
^Fmter  grm  great  rt-lii^r,  wlik-Ji  m  incrvsuwd  by  liot  fomentations  and 
poohioea^  ami  it  is  probable  that  in  some  caam  tlio«  moatit*  might 
iniGoe.  The  health,  howovttr,  is  jrcQvrally  more  or  loss  deranged, 
ud  the  Don&tituliDrml  remedits  eiili«>r  for  debility  or  viKonral  dv- 
tingBinent  aro  indiratvd.  Oftcii  also  tliv  novcnty  of  tho  pain  demands 
]ooi]  depletion,  I>v  leeches,  around  the  online  of  iho  tiit^tiif  (tho 
pteaafce  being  guarded  by  oottou-wool),  and  the  emplojuieut  of 
norphia  in  full  dooea  to  give  rent. 

The  acuto  inflammaUon  of  tho  moattu,  like  tho  formation  of 

■bHOMM,  tit  prone  to  rtx!ur,  and  great  nam  U  needled  on  tiie  {ittrt  of 

tiwse  who  are  convalc«o«it  from  it  to  escape  a  relapse.     Exposure 

to  dniQghtit  «h»uld  bi^  caroftdly  avotdty),  while  at  tho  Hume  tiiiio  cx- 

eroiae  alioald  be  taken,  and  the  car  should  not  bo  kept  wrnppM)  up. 

Tlw  gt-neml  liaidtli,  doraiij^^l  before,  noetn.^  itlninxt  alwaj't*  mon^  Hhat- 

lered  by  tlio  attack  of  anral  disease,  and  should  bo  rccmitod  if  pos- 

dlc  by  PMt  or  change.     Tho  vikpour  or  Turkish  huth  »oeni;t  likoljr 

to  bo  useful  in  these  casos.     Stimulants  should  be  very  sparingly 

Hployod.      A{\VT  IIm)  inflamniiiu>ry  lu^tion  h:i.i  .sulmidod,  tlio  ninl- 

of  the  nitrate  of  mercury  diluted  with  oil  may  bo  smeared 

the  sorface  of  tho  incutn«,  or  it  Holution  of  the  iiitrut«;  of  Kilvcr, 

tm  or  ten  grains  to  the  ounce,  applied  with  a  camers-lmir  brush. 

Cirvnie  intfammatton  of  tJi»  mc»ttit>  Kumvtiiiitw  liilluws  th<:!  acuto 
Em  of  the  disease ;  sometimes  it  resulta  from  repeated  slight  attaeka 
(fiiilUmmator}'  action.  A  oonimon  cause  of  it  is  the  habit  of  pro- 
Wged^Mtthing,  or  diuuping  without  drying  tho  ears  or  hair.  With- 
"OtanT  considerable  amount  of  pain,  a  Reeling  of  nnciL>:im-sH  in  tlio 
{■Mge  ia  coniplniued  of,  a  sensation  of  tension,  and  often  of  iteh- 
bg,  ]>nnnpting  tho  patient  to  ititroditoc  pins  or  other  su1i?>tan<!0« 
■idi  iba  view  of  allaying  the  irritation.  This  praetioe  of  course 
HiDlains  and  aggravates  tlio  disease.  Tlie  mL-^Litus  is  swollen,  and 
lla  <pidermi«  bcoomcs  tliiok  and  peeU  off,  oflcn  a/!eumiilating  to  a 
|nd  extenL  Somedinee  the  onfiro  cnticular  lining  of  tlio  cniud 
heiBei  looMtwd,  and  may  be  withdrawn  in  n  fonn  resembling  the 
Ihpr  of  a  glove,  the  inner  extremity  presenting  an  lu-eurat^  cast  of 
Atnenbraiia  tympimi.  In  iho  worst  i-a-^s  tho  walls  of  the  meatus 
Mof  sduaky-red  colour  beiKatb  the  epi(l<;miiM,  iinil  li-niler.  The 
*K  it  deficient,  tlio  ticaring  U  moKt  fre<]uently  impaired,  and  the 
■Mbraoa  tympani  vascuUr  on  its  extenml  surfutw.  Iiid<'OiI,  this 
Mfitioa  of  the  m<^utiu,  llioitgli  it  is  met  with  alone,  seems  seldom 
b  (UK  witltuut  disease  afleeting  also  some  of  tbo  more  intonial 
*«dttn»  of  the  ear.     In  children  Uiiit  furm  of  disease  is  much  leas 


144 


DISEASES  OF  THE  EA2. 


1 

i  care  {■ 


fiv^nmt  than  ono  attended  with  profuse  dischurge.  Tlio 
ililliciiH;  >.-ouiit(T-iri-ilnti<)ii  }iy  aiiy  of  Hig  various  dori^ante 
the  mastoid  process  Accms  to  be  us(>itil,  and  should  bu  maintained  in 
a  mild  form  und  with  int*.-niiiHitioiiA  for  n  oon.'>i(lt>rabl«  period.  At 
the  samo  time  the  si,Tin^  sliould  he  employed  to  free  tlio  meatus 
from  tht!  de»r|ii»matiii^  epidermis,  whioh  oil  or  glyiscriiie  njiplied  at 
night  will  aitl  in  detaching.  Astringent  lotions,  such  as  a  w«ai 
Solution  of  ucetato  of  lead  or  nttratv  of  silver,  or  tw"  gruins  of  the 
chloride  of  sine  to  the  ounce  of  water,  may  be  applied  with  ad- 
vants^ 

Another  fi^irm  of  clironic  inflammation  of  the  meatus  is  ae- 
oompLUucd  by  discliargc,  gonorally  to  a  lar^  amount.  This  a 
itom<rtimt«  diiitingutjihed  tinder  tlie  name  of  *'  catarrhal."  Tl  is 
most  irequont  in  children,  and  in  tlic  mildest  caso«  constitutes  ono 
of  till!  (Mimmonont  forms  of  '*  oar-aphe."  AfV-r  a  slight  aceotts  of 
paili  there  follows  a  tliin  discharge  from  tlio  meatus,  which  is  ofteo 
lit  finit  diirk-i.i>]nnr(Ml,  us  if  ci>ntii.->ting  of  altnrmt  wax.  (leitnlinns 
by  fyringing,  witli  frietions  around  tho  war,  &c.,  gonorally  snffice  to 
restore  tliu  lu'-ultliy  v<iiulitii>ii  of  llio  purtK.  1'ho  nuiutns  appears  pole 
and  so<ldon ;  it  is  slightly  tender,  and  tho  epidermis  of  tlio  mcmbrans 
tympiiiii  tnuy  In:  thickonod.     'I1ii>  pruhabio  «aiiHO  iit  cold. 

The  sovorcr  form  of  this  afl'ection  may  arise  from  repeated 
attacks  of  tlto  mildor  kind  if  clotuilinos*  bo  ncf^lo(-tv<l,  or  may  re- 
main as  tho  result  of  acute  inflammation,  or  may  follow  measles  or 
other  iebrilc  idfiM^ionn,  t)iough  for  Iho  ini>st  part  there  is  then  ako 
inflammation  witliin  the  tji]ipanum.  It  may  alw  be  indu<!ed  by 
irritating  applic4itions,  or  in  unhealthy  constitutions  may  »n*(^  witk 
out  tiaaignahle  enusc.  Tliere  exists  a  more  or  less  copious  dincliarg 
which  is  of  a  milky  or  floccidcnt  cliaractor,  but  M'hicli  may  bo  i 
giiished  from  di.'icharge  OHcajiIng  frnm  tlio  tympaniiin  tlmiugh 
turo  of  tlie  drum  by  its  never  presouting  a  stringy  or  ropy  af 
ancc  when  mixed  with  walw.  This  fact  was  first  pt^nltfl  out 
Mr.  Toynbee.  The  discharge  is  often  very  offensive.  Pain  is  aeldo 
oompluinod  of.  The  mciitiiM,  wlioii  clcansctl  and  examined  by 
qteculum,  is  aeon  to  be  swollen  and  soft,  and  for  tho  most  {>art : 
In  the  majority  of  ojijick  tho  im-ndjriiTiH  tnnpani  i»  opat|»o  or  va 
lor.  In  the  tj-oatment,  cleanliness  has  tho  first  and  nn«tt  Impor 
place.  'Ilic  mentux  Khoiild  \n?  tliorougldy  washed  out  by  the  srrin^ 
and  warm  watt-r,  at  fii-at  twice  a  day,  or  ofttnor  if  ucCe.'Man', 
cvcrj'  ov<'iiinp,  and  afterwaivJs  at  longer  intervals  as  die  <lUcll 
diminishes.  Also  if,  as  is  frequently  Uie  oasc,  tho  patient  have 
in  the  habit  of  wearing  cotton-wool,  so  as  to  prevent  the  oscape  i 


INFI^MMATION  OF  THE  MEATUS. 


145 


the  matter,  and  convert  tlw  meatus  practically  into  an  abstcoss,  this 
liiouU  be  at  onrc  diaooiitinuMi,  and  tlto  ymrVt  ri-stoivd  to  their  nor- 
mal relation  to  the  atmwplierc  Tlese  meaoa  alone  will  often  suffice 
to  effect  m  cure,  ettjxwiiilty  in  chiUlron ;  for  in  many  instances  the 
iiwtl)id  action  appcan  to  bo  kept  up  entirely  hy  the  oxdiuion  of  the 
■r,  and  th«  irrilatin;;  cf^l^«t  of  tliv  awumiilalvd  disdiarge. 

If,  howerer,  the  diaeaae  do  not  subaide  under  thitt  plan,  or 
thmi^  improvinp  yt  rfop  plmrt  of  [njrfiiA  oiin,',  an  artifiL'ial  dis- 
eharge  may  bo  established  by  mild  cKiiuiter-iiritanta  over  tlie  mas- 
toid proocM  (the  %''iiica(ing  paper  is  viyry  c^onvvim^nt),  and  ostringient 
lodona  injected.  Them  should  be  weak ;  from  two  to  four  grains  of 
almn  or  snlfdiabe  of  zinc  to  tlic  outicti  of  water.  'Dkv  may  bo  tnibee 
injected  will)  the  s^Tinge,  or  dropped  in  after  Uie  pasau^  lias  beeti 
washed  out  with  water,  being  always  used  irarm.  In  tlio  more 
ohtfiiuite  caaea,  a  lotion  oontuining  ai>«tate  of  lead  may  be  applied 
at  night  to  the  orifivu  of  tlie  meatus  on  cotton-wool,  or  tlio  nitrate 
of  ailirar  in  Botutton  waahed  over  the  oanut  twion  a  wiM^k.  I  have 
■metuies  (bond  gjyovrino  diminish  tlio  discbargo  when  the  mildest 
astringents  aceuied  to  produee  irritntion. 

The  health  being  almost  a)wai,'8  deranged,  especially  in  childran^ 

tntioi  are  inib'<-jilMt ;  <iuiiiine,  iron,  nn<l  <xid-tivi'j-  oil.   Mi-.  C  Konitar 

Teiy  highly  of  the  effects  of  chlorate  of  potash  given  in  free 

Often  llie  state  «f  r.li«  throat  rofpiire*  attention.     And  in 

ewry  ease  tlie  greatest  regard  should  be  paid  to  general  hygiene. 

<  \i  will  be  n««swi:y  alw  for  the  Surgoon  to  iiiHtriurt  fhc  |iationt  or 

'\in  Griends  in  llie  mode  of  using  tlie  syringe.     The  most  frequent 

'  Bade  by  tliosa  who  are  uuiu.i|uitiuted  with  uiiutoiny  in  that  of 

fhaing  the  namte  of  tiw  instrument  obliquely  to  the  sido  of  the 

Ind,  in  a  <Iirectton  eorrc«ponding  with  tliat  of  tlii>  tnigiitt,  instead 

t^pbring  it  at  right  anglea  and  pressing  tlic  tragus  forwards.     The 

M«  convenient  form  of  syringe  for  private  use  is  nii  india-rubber 

<  Mfe  eontaintng  about  two  ounC(«. 

BUwr  of  the  abovc-dcMiribed  forms  of  intlninniation  may,  in 
■kallliy  »ubjee(«,  extend  to  the  osseous  walls  of  the  mvatutt,  and 
I  pit  rne  to  caries  or  noLixisis.     This  result  is  chiefly  a]>t  to  occur  in 
|«dKeticehildn?n. 

SonetitDea  a  oonsiderubtc  part  of  the  wall  of  the  meatus  or  of 
ft*  naKoid  proc^t^s  will  come  away ;  and  it  is  remarkable  to  liow 
[iMtt  an  extent  this  may  take  pUec  witJiout  any  considerable  im- 
.  of  the  fnnctions  of  ilie  ear.    With  the  view  of  averting  the 
of  the  disease  inwards,  the  gri.iit<»t  care  sliould  be  taken 
•  a  perfectly  free  e.\it  fur  the  discharge.     A  peculiar  affec- 


IM 


DISEASES  OF  THE  EAR. 


Uon  Ia  mmitioned  by  Kranior  un<l(.'r  tlic  tintne  of  mflammatton 
the  [KTiostoiim,   (.'oiniiKiiK'inf;    wiUumt.  (wiii,  tw  »  red  cjiot  iit  the 
lowpr  pnrt  of  the  oieatua,  and  rapidly  running  on  to  Docrotus ;  but 
bave  DQt  scon  this  form  of  di.-H.'atu. 


I 


Sffpkilitie  disecuf  of  tlie  tnfatm.  This  occurs  cfaiofly  in  the  form 
of  (iKMimK  or  of  amdyloinnta  ni-ound  the  orifiw.  But  I  have  seen 
Uniilhor  condition  whicii  iippcars  ah-o  to  bu  duo  to  die  6|>c<:ific  pojsoii. 
Tho  miHitiis  is  ulcorutml  at  its  outer  puri,  Uie  ulcer  hiving  irre^lar 
edges  and  a  foul  surface,  and  a  copious  discharge  flows  &om  tlw 
panoiff!.  \V)wn  h  If  ck-utiMtxl,  tho  H|Hiculuni  nhow-s  ttii  ourfuoo  re<l- 
dened,  and  excoriated  In  part* ;  the  mombrana  tjinpani  is  vascular. 
I  suspuci  the  diiiM^stt  I'OiinlU  tionietiiricn  fruni  tlui  <lirect  Ujiplii-atioii  o| 
tiie  [KiiHou.  The  treatinoiit  would  be  conducted  an  ordinary  prin* 
ciplcs. 

Polt/pi,    Those  grovk-ths  being  most  frequently  seated  in  tJw  i 
tii8,  tli!»  seems  tli(j  proper  place  to  mention  tboin,  though  tlicy 
also  met  with  growing  from  tlte  surfaoo  of  tlic  memhrana  t^-mpanij 
and  from  tlie  inner  wall  of  the  tymjiaiiuni  when  ihut  niiTmbranO 
perforated.     They  occur  in  a  considerable  proportion  of  the  cases  i 
long-continued  discharge  from  the  moutun,  whatever  may  lie 
nature  of  the  affection  which  causes  it.   They  are  often  sjinptomati 
of  di«e)iM>  scfited  within  the  middle  oiir;  inflammalory  atfocUons 
the  membrane  lining  tho  tymjiannm  or  mastoid  cells,  for  example,  i 
dosure  of  the  Eustachian  tube.    If  not  originally  duo  to  thcM . 
tJona,  tliey  will  at  least  very  frequently  return  again  and  again 
romoval,  tmless  the  internal  disease  is  cured.     Thcw  K'^'*'*hi» 
often  coexist  with  supjmration  in  the  tympanum,  which  is  causie 
or  tlirealening  serious  disease  of  the  brain  ;  and  in  tlioso  ca«» 
rc(|uire  H|>ociid  attention.     On  tlie  one  hand,  a  rash  or  violent 
chanical  treatment  of  them  might  bo  oxtrcmoly  dangerous ;  and ' 
the  other,  they  miyi  by  filling  the  meatus  and  preventing  tlie  eec*{i 
of  pus  from  the  tynipanum,  bo  lliemselvea  tho  causes  of  tho  i 
geroLU)  symptoms,  and  their  careful  removal  may  bo  the  only 
tion  of  the  patient's  safety. 

Tolypi  may  "pring  £K)m  any  |iart  of  tlio  meatus,  but  tlwy  i 
generally  attachoil  to  its  upper  wall  near  tJie  memhrana  tj-mf 
They  may  be  very  .mntill,  or  may  constitul<i  biilk\'  ;rr<>wtli*,  which  I 
tho  entire  meatus  and  project  beyond  its  orifice.    When  lai^>, 
may  oause,  ajiparently  by  pressure  on  the  racmbraua  tymponi  da 
to  their  eompressiuu  by  the  walls  of  the  tube,  many  of  Uio  »ligli 


AtniAL  POLYPL 


I4T 


symptams  of  [nwuniro  on  tii«  brain,  Hirailar,  in  fiu^,  to  tTiuso  which 
tiuiy  rcauh  from  tlui  preaenoo  of  ImnK-tiod  wax.  Proisurc  3i>|iIiL'<I  to 
S  polvpas  [irojccting  oxtemaliy  has  proiiuced  oomjilBU'  iiitriiHibilit}'. 
Tbrae  ptjwihs  ^Ivmy*  exmle  n  purulent,  aitd  ^iierally  otfenaivef 
I      disdurge^   and   may  give  rise  to  oooasional   bleeding   from  Uie 

[■OBtlM. 

^B     Aural  po1_>'pi  have  been  variotialy  cJasaified ;  but  the  uhuilI  divi- 

^Hfion*   of  {HilyjHiid  ^iwtlw  trito  fibrous  and  vaiwiilar  fooitin  to  be 

^Pmffioieiit  for  all  j)rafiici»l  puriMjses.    There  is  mei  with,  liowi^««-,  in 

tltc  oar  a  tbtrd  fonn  of  f^wtli,  a  small  routidod  mass  of  cells,  which 

may  be  u^nned  a  polypus,  aiui  yet  roiiuires  to  be  diiitingui^hed  fi-om 

liie  othcT  two,  M  not  demanding  the  samu  t rt^itinoiit. 

Tbe  ordinary  vaMrular  ])ol}'])ua  "  conaifita  of  numerous  round 
beads  attadted  by  i^inall  fSUunente  to  a  centra)  stem.  When  ox- 
tPitn**i  micrneiioopically,  it  i»  found  to  be  ex)nipo«ed  of  <imiill  rounded 
edla."  TLo  fibro-grUtinoua  polypus  forms  large  roundt-d  inascos 
CDTOrcd  by  a  Uiiok  layer  of  c})ithelium,  wliii;h  may  be  separated 
from  it  by  maceration,  and  oonsistfi  of  *'  corpiisclc^s  and  tibroua 
iMMie,  mryitig  in  projxinioti  in  diA'«roiit  KpcoimoiiH ;  but  tlie  iibroos 
tiame  geooraliy  predominates."  In  addition  to  thoxe  olemonts 
ttan  18  mmetime*  pnwent  a  Ktruptureloi^  gulatinons  Miltntuioo^ 
«hieh  may  constitute  almost  the  entire  mass,  and  a  number  of 
l]ai>(lk-:>ha|>od  cryrtids," 

Kramer  mentions  a  case  in  which  a  polypoid  growth  was  of 
Kmy  iumlniw.'* ;  luid  the  fibrous  polypi  are  Hometimv«)  so  dense  a-t  to 
Went  with  difficulty. 

nSw  tbird  frtnii  of  polypus  is  Himjity  a  rouudoil  mU5$  of  cella 
tt>rli«d  by  »  pediok,  almost  always  to  the  iipjjcr  part  of  tho 
BmUus,  just  in  front  of  tlic  membrana  tympani.  It  sMniiti  to  be 
(■Cued  to  children,  fretjiiently  ensuing  upon  diAoases  of  the  tym- 
fnom  i)rodo<.T«l  by  scarlatina  or  tho  other  diseafie-*  of  child luxxl. 

Botdaii  lliese  jwUfti.  which  have  <iistui(;t  [Kulicliw,  granidationa 
^  farm  in  the  mcattis,  sometimes  connected  with  dittfa^ed  bone, 
^£iapi>eariRg  when  the  cause  of  irritation  is  removed.  Some- 
^M  also  tmdigitant  dtsease,  deeply  seated  withiti  the  jxitrous  bone^ 
^  nake  iu>  appearance  ui  tlie  meatus  in  the  form  of  a  fungoid 
^•ih.  This  is  generally  of  a  Uvid  colour,  unlikis  the  bright  red 
^oTpiilypua  when  sitaatcd  wttiiin  Uie  meatus,  or  the  pale  glossy 


*  Mr,  TornWe.  Dijfotf*  of  iht  Ktir.  p.  Oft.    It  Aavn  not  seem  to  nin  by 
\  tnipOhdiliU-  UuL  Uiese  funnaiiooa  sUould  dilTcr  sUghtl}'  iti  cLBnu>- 
I  ^SattA  «ountiic9. 


148 


DISEASES  OF  THE  EAR 


gnr&4%  it  may  present  vrheia  tt  approarboa  the  orifio&     The 
cachoxiti  ulso,  whicli  a  always  ptrsciit  in  malignant  dlsMM,  will 
ftiti  iite  Surgeon  in  forming  Iiih  judgment.  ^H 

In  tliP  trt-atrnt-nt  of  ])oi_rpu»  two  objcctit  nro  to  bo  soimht ;  tl^^ 
Conipl«>to  removal  of  tli«  growth,  and  tlje  cornw^on  of  f.In;  morbid 
contlition  with  wliicli  it  is  associated.  Of  those  tiic  latter  is  the 
more  im|M>rtant ;  Indeed,  until  it  in  attnimMl,  the  roiiirival  of  n  poly- 
pa<i  is  meroly  piilliiitivo ;  it  is  almost  Kuro  to  rclurii,  or  ti-eiih  ones 
will  dint'Iop.  It  !«  cUw  do«tira1>lo,  as  a  rule,  nut  to  iiit^rfi-rp  with 
poh'poid  growths  until  all  irritation  has  been  subdued,  unless,  as 
bcfon;  ini'titiotuil,  tliere  i.t  reiidon  in  botievii  tliiit  i(»  jirc^-iK-e  i* 
obHtnieting  the  escape  of  discharge.  It  should  be  remembered, 
too,  that  jmlvpi  ivill  Ireqiieiilly  diiMvpjxfar,  or  evon  ctnnv  Hway  in 
miui8,  under  tlio  practice  of  simple  sculping  with  warm  water,  with 
or  without  other  apjili cations.  Tins  nsult,  howoicr,  vnnnot  bo  ■ 
culated  upon,  nor  are  ordinary  astringents  of  any  use;  and  in 
largo  numlK^r  of  (.<uMiri  polj])i  ruquire  to  t>o  removed  bv  o]>vratioii 
or  otherwise  destroyed. 

The  tlireo  forms  of  poIyi)ui!  above  doscriix^l  are  amenable 
this  refipeet  to  ditforent  treatment.    The  small  globular  polyjHm 
bo  caustrd  to  ifi»n|>pcar  bv  strong  astringent  lotions ;  tlie  cot 
Taseular  polvpus  may  be  either  destroyed  by  tlie  din'ot  applicati 
of  caustics,  or  removed  by  suitable  inatrumcnt« ;  the  fibroas  requ 
neeJiimieal  removal. 

The  first-named  growth  presents  a  very  charactoriBtic  app 
ance,  hanging  down  like  ii  nil  curtjiin  in  front  of  the  snf 
portion  of  the  membrana  tvmpani,  and  presenting  a  elearly-r 
bontubirj-.     It  is  necessary,  litiwcvcr,  to  divtinguiitli  thew  catKs 
those  in  which  the  membrane  is  partially  destroyed;  and  the 
red  nuK-ons  mrnibruiie  of  the  tyinpnnum  is  iiecn  iKryond  it,  or 
sometimes — so  tumid  may  it  become — almost  projecting 
the  orifice.     Tlii:<  jKitnt  can  lie  absolutely  dct«-nninod,  if  the  Es 
chian  tubes  are  jiervious,  by  the  use  of  the  otoscope ;  but  the  posit 
of  tilt!  fiolypiis,  c*>nci;altiig  the  entire  «ppor  part  of  tli«  invmb 
and  the  absence  of  all  a|)i>earancG  of  tiie  malleu!)  in  front  of  it, 
also  to  di-tinpiish  it.      If  no  irritability  remains,  there  may  be 
pliwl  to  ihe  meatus  in  tliiR  case  u  few  drojw  of  a  wilulion  of  ac 
of  lead  (from  six  to  twontj'  drops  to  the  ounce),  or  of  acetate  of  s 
(one  or  two  seniplen  t»>  (he  ounce),  or  of  snljihate  of  <:o(ii>w  (fa 
or  six  grains  to  the  ounce),  or  of  a  solution  of  inmiin.     Tlkcse  : 
be  ilro]>ped  into  the  car,  after  it  has  bwiii  lej-ringed  out  with 
wat«r,  onee  or  oftencr  a-day ;  and  a  piece  of  cotton-woul  dipped  i 


AURAL  POLYPI 


U9 


tlie  ttnw  loitun  may  bo  worn  «l  night  Under  this  treatment,  tlie 
|>ol]r]KM  will  tliminish  and  di<iappear ;  but  ibin  aloiw  Uy  no  iiKHtns 
wfficm  for  tlu.-  n-<<tt;rHtion  of  tlio  bearing,  wiiich  most  bo  sought 
bjr  vhalerer  lueaus  Uie  condition  of  tlie  interniil  Mninturott  niay 
rlwiind.  Of  TOUi^e,  if  tlic  nicmbraiis  tympaiii  bo  ruptured,  it  is 
wJariralile  to  introduoc  thne  jiowurful  iiatrlii^entt  in  t.lit-  fluid  fi>rni. 
And  in  lliat  com;,  tho  nitrate  of  silver  may  be  njtpliod  in  subituuioe 
to  tile  growth  by  ia«-anit  of  u  tt^xiblo  probe. 

For  thv  riMitoval  of  the  vascular  polypus,  Mr.  Toynbce  recom- 
nentb  tlie  UAe  of  »  uta^it  iitgeiiiouii  in»t,riinic*nt,  wliich  ho  terms 
ths  levcT-ring  forceps.  It  is  introduced  with  tlic  rings  apart, 
and  when  iliu  polypu.t  in  inuludtil  l»ttwt^>ii  tliiMii,  limy  arc  bi-ought 
togotbw  by  a  slight  tnovenieoi;  the  softest  and  most  phable  tissue 
oan  be  tiiibt  reiuo\-od.  Thi!«  ii*  certainly  tlus  Inst  mutluxl  by  far 
of  destroying  this  form  of  poh-pus ;  but  tJie  ordinary  wirc-snar* 
may  alau  bo  ummI  for  Uh)  [>tiqinnc,  tbongh  it  i*  iimcli  iu<)r<>  dillioutt 
to  »fi>p)y.  U  lias  the  disadvantage  also  of  outting  tlirougli  the  root 
of  tfan  growtii  roUicr  than  drawing  it  away,  Thi*  jwlyptw  may  also 
\k  deatTx>yed  (diougli  t]»e  operation  requires  much  care)  by  strong 
craaticat,  such  as  nttrio  acid,  or  potoMsa  «nm  oatua  The  lutti^i'  nuiy 
btmaile  in  thin  sticks,  and  applied  through  a  glaaa  tube  introduced 
OHmtns,  vrann  water  and  a  syringe  being  cltnu  nt  Itand 
nge  oat  the  meatus  imntnlialety  on  the  eomjiletioii  of  the 
[•(entton. 

Tbe  reoinva]  of  ihe  fibrous  |tolj-]>UH  itt  easily  arn'ompliKlied;  a 
I  Itctfie  armed  with  small  rings,  or  otlierwiso  expanded  extremities, 
'  ■iQ  thai  ht  nxiuirtHl.     The  growth,  being  linnly  grunfKKl,  is  to  be 
Amlily  bat  eauliously  twisted  off  trom  its  attaehmont. 

"Die  application  of  Uie  nitrate  of  silver  to  tlie  rout,  or  injestiona 
tfiodiDc,  &c,,  are  much  insisted  on  by  some  writers,  with  avicrr 
h  jKvenl  the  rtKrurn^ucn  of  tlw  growth.      It  is  doubtful  whether 
^  boiipfit  is  thus  obtained.     The  strong  nitric  acid  ai>|>ear»  mono 
tfaSaal;  Inil  «x)Mn-icncc  seems  to  lead  to  iho  conchision  that  if  the 
wue  from  which  the  polypus  resulted  be  cured,  it  doe«  not  re- 
i;  if  sucJi  diiH»»c  continue,  the  jiolypus  will  numt  jirobably  be 
[^ndoced.     An  apparent  return  of  a  polypus,  however,  is  somc- 
caoMii  by  titc  existenen  of  mon.'  than  ouv  at  the  lime  of  the 
['nwraL      It  v*  freijuenlly  the  case  that  several  smaller  growths  arc 
[Mtwiiwl  to  the  root  of  a  largv  polypus,  and  take  on  a  proeeAS  of 
uptnent  when  the  Utter  i.i  removed. 

Sdotmmu  or  mdliatout  tuatourt  are  enlarged  sebaceous  fulliclca 


150 


DISEASES  OF  THE  EAR 


V  in   tlifl^ 


containing   scales  of  epidcrtniB,  which   form   oc<iasionallv'  in   the 
nieiitiis.      ir  llioir  |irc>grisw  lio  uiictiaikei!,  they  iir«  npt  to  destroy     , 
lite  hy  causing  absorption  of  the  bono  and  pressing  on  tin*  tiniin.^^l 
Tliev  iiiuy  uxii-t  and  even  pnjve  tiitul  in  «arly  lifu,  tJiotigh  tlioy  ar^^ 
most  frequent  in  llie  old,     Tliey  are  generally  attended  with  db* 
char^  and  piiin.     Tlie  tmitrncnt  wonkl  oom^iKt  in  laying  open  tins 
swelling,  evacuating  the  accumulated  laniinie  of  epideniitN  hy  tlio 
syrin^r,  and  then  wilhdruwing  by  moaim   of  a  forceps  iha  thidi 
membiane  lining  tlie  titnionr. 


JCxoiiftwj  soind,ii]ioa  fonn  in  the  walls  of  the  meatus ;  tluwe  may 
grow  from  cither  of  ite  Eurfa«o»,  and  cases  are  not  unfrcquently 
aeai  in  wliioh  two  or  morvofauch  furmatiiniK  appruiicli  each  otJier 
towards  the  mesian  line.  The  hearing  is  impaired  in  proportion  to 
the  cliiMirc  (if  the  canal.  CV-niinon  or  cpldcnnis  may  act-ttmulato 
behind  these  growths,  and  will  tlien  require  great  patience,  and  a 
pwrnevcring  use  of  fluids  »<lapted  to  suflvn  the  tnu^s,  in  order  to 
effect  its  renio\-al.  This  form  of  exostosis  may  occur  in  oomjiara^ 
lively  early  life.  Treiitincnt  is  not  no  inefficacious  as  mijcrht  have 
bei'n  feared.  I  have  seen-a  severe  case,  in  which  the  applicntion  of 
tinctiiro  of  iodine  secnie<l  to  induce  a  diminution  of  the  tumonrr^ 
and  improvement  of  the  hearing.  Mr.  Wilde  speaks  couti<li.-nlly 
of  tJie  power  of  local  depiction,  coimtcr- irritation,  and  mercurials  to 
UTCst  their  progress  in  tlie  early  stage,  when  there  probably  cxisttj 
ohrouic  Htate  of  poriostitia. 

in.  Affections  of  the  Membrana  Tympani. 

TIic  menihrana  tynipnni  is  a  thin  coloiirleas  diaphragm,  vt.retcho 
obliquely  across  the  iniior  extremity  of  the  meatus.     In  its  heaiti 
Mate  it  In  alnm-it  ti'ansparcnt ;  It  reHeet«  light  slron^rly,  and,  owhi 
to  its  peculiar  curvature,  presents  a  bright  spot  of  triangular 
at  its  lower  and  anterior  portion.     This  s])ot  hcconuM  ohscurod 
altered  in  disease.      Although  the  membrane  is  IVcely  pernie«b 
hy  bl<  Hid -vessels,  whicJi  become  turgid  in  coiige--<tion  or  inthuni 
tion,  and  may  give  it  a  deej*  rod  colour,  none  are  visible  in 
normal  condition.     Its  external  surface  is  concave,  with  the  cxe 
tion  of  a  narrow  ring  ai-ound  itjs  border.     For  practical  purj» 
the  mcmbiima  tympani  may  be  con»derod  as  coiisi»tiDg  of 

•  Oiir  liiicinjcdgo  of  this  affei^tion  is  entirely  due  to  Mr.  Toynbee,  P4 
Soe,  Triint.  vols.  ii.  xi.,  Med.-Chir.  Trani.  vol.  xliv.  p.  01,     Mr,  Xo/nbec 
juvfovB  the  iiuiao  "  sebitooous  tumours." 


QUI 

m 


EUURIES  OF  THE  ilEMBBANA  TYJtPANL        151 

Old,  filirouM,  and  Diiicoas ;  each  of  which  may  present 
disrinat  morbul  uumiitiniiK  la  tlio  diagnotiiii  of  its  diMnMs,  tbo 
ihtcfaid*  are  th«  speculum  and  lamp,  bjr  means  of  which  ita  «xter> 
KVfitoe  may  bo  exiuiiinoil.  Infliilioii  oftiw  tynipuniim  tlirouj^b 
Eofltiichian  tube,  Uie  mouth  and  nostrils  being  cloAcd,  may  nliut 
be  bail  nsvuiinK;  l*i ;  wrljiin  t^ffwstit  of  (ho  |>rcs)iaro  of  air  on  tlio 
internal  surface  of  the  monibrane  iiidicatuig  tension,  relaxation, 
r^Mlily,  or  nlccrotion  of  its  layvrs. 

In  addition  to  Uw  diseiues  which  directly  alTect  itii  own  Atmo* 
iIm)  minnbranti  tympani  is  oA«ii  secondarily  imjiHcated  in 
nori>id  conditions  of  more  internal  parts,  and  its  appearanoe  may 
give  mnxt  imjiortant  aid  in  Uwir  diagnoms.  Thus,  in  ubstniction 
of  the  Eustachian  tube  the  m4Mnbrimc  ist  drawn  inwards,  its  natiu-al 
onocavity  being  increased,  and  tlio  polish  of  its  surface  diminished. 
Mooous  or  oilier  accumulationi*  within  ttic  tynijinuum  may,  on  die 
oUmt  hand,  cause  it  to  bulge  outwards ;  and  the  prescneo  of  an 
opaqae  fluid  in  tltnt  cavity  may  M>nictime!(  bo  clearly  recognised, 
«q>eeially  in  children,  through  its  transparent  structure. 

li^ttrU*  of  the  mfirArana  timpani.  This  membrane  is  hable  to 
fce  aocidentally  ruptured  from  vurious  i-nus<'-s,  as  tht;  intrixhictioii  of 
.  fonitMl  tOBtnunents,  a  fall,  or  very  loud  sounds,  such  as  the  esplo- 
I  iaa  of  artillery,  wpocially  if  opcurring  unexpectedly,  so  tliut  the 
I  — brmo  has  not  be«n  prepared  for  tJieir  rDCC|ttioii  by  its  adjusting 
I  wmdm.  A  )iox  on  tlic  car,  of  which  no  wiuTiing  has  Ihx'ii  givon, 
I  *ill  also  prodoce  the  same  efiect,  apparently  by  causing  a  com- 
I  pnsuon  of  tlw  nir  in  tlic  mvatux,  without  the  mi^nlinuiii  lyiii|i»ni 
I  nnning  tlte  necessary'  stale  of  tension.  Sportsmen  arc  liable  to 
I  tail  lecklcnt  from  the  report  of  tlieir  gnns.  Undne  (brco  of  syring- 
I  B^,  violent  blowing  of  the  nose,  vomiting,  paroxisms  of  hooping- 
I  Mgli,  also  hsTO  causetl  rupture  of  tho  membrana  tympnni ;  but  in 
I  An  caaee  there  b  little  doubt  that  the  membrane  was  previously 
I  vtdmcd  by  dLEotts(^  It  may  girc  way  in  death  by  stnmgiilution. 
I  at  symftinta  of  lliia  injury  are  pain,  generally  not  severe,  foil  at 
I  w  bottom  of  tJio  meatus,  soon  followed  by  the  apjM^urance  of  a  few 
I  ^>ft  of  blood.  The  bearing  is  not  necessarily  impaired.  If  an 
I  (Munatioa  is  made  sliortly  after  the  accident,  a  wmall  clot  of  blo<Ml 
I  Bif  be  Men  du«ing  tlio  wound,  which  is  generally  from  a  Une  to  a 
I  aeuid  a  half  in  extent.  In  the  majority  of  casks  it  heals  #|NH<diIy, 
I  Md  without  nny  furtlu-r  sympliim-t.  The  clot  falls  off  in  the  conrw 
[  rfa  few  days,  bnt  a  white  cicatrix  'ut  visible  for  a  long  time.  Oc- 
I  ■HBally,  bcnraver,  ulceration  is  »et  np,  or  a  small  portion  of  the 


193 


DISEASES  OF  THE  EAR 


tnu 


mcqiibrane  Booms  to  slough,  the  apcrtitro  incrcmuiig  in  azo  for 
iiiiy^  In  ill!  tlio  fiattot  [  liave  seen,  however,  in  which  the  mj 
has  occurred  in  &  licaltiiy  mcmbnuiu,  [lorfvct  repair  lias  fiitnllj'  va- 
Buod,  Ritd  wiUiout  injury  to  the  function  of  tlio  organ.  In  the 
trontnicnl,  it  is  iiir  thu  moet  part  only  Doccssary  to  ^ard  tho  natunil 
procoMH  of  n^iHtir  from  interruption.  It  iiiuy  be  advisable,  bow- 
erer,  if  thore  bo  dischar^,  cautiuusly  to  olcanso  the  meatus  by 
axTingv.  A  li-ocli  or  two  may  Iw  ajiplied  to  tiio  orifioo  oftlie  ineai 
if  irritatiou  bo  present  and  tho  oritice  ecem  oxt«nding,  or  thv  cdp.-* 
of  thd  wiiuiid  ni»y  bu  lifihtly  towhini  with  nitrate  «f  nitver.  Indeed, 
under  this  latter  plan,  small  orifices  in  the  membraua  tynjpani,  that 
haw  existed  for  eoin«  liino,  will  iioinotiuies  hoal. 

Inflammation  of  the  rtuynhrana  h/mpaai.      Fnx|uenUy  tho  opidc 
Alia  (xivering  the  exlonial  surface  of  this  menibrane  is  thii^ene 
and  opaque,  no  otlior  morbid  ooiidition  being  prcsml.     DiLs  is 
jio  importanoe  pathologically,  but  it  is  a  frequent  cause  of  what 
described  merely  as  "  opacity  of  the  m«inbrana  tympani,"  vH 
in  itaolf  is  of  cotu-se  not  a  cause  of  deafuetu.     Congestion  of  1 
tnombrano  may  ariso  from  e\|)Oiiuro  to  cold ;  it  is  attendod  with 
feeing  of  iilight  unoasineiw  innlde  the  c«r,  and  .wmetirucA  with  btncz- 
ing  noises ;  and  on  examination,  enlarged  rod  vessels  may  be 
^n  thu  Kiirlaee.   Avoiding  exposure,  stimulating  linim«iiti<,  and  wu 
oil  dropped  into  tlio  meatus,  generally  suffice  for  rebof. 

The  dennoid  lauiina  is  subjiiut  to  acule  and  clironic  iiiAun>| 
tnation. 

Aeule  inflammatitpn  Ik  not  common  us  an  isolated  afToctioo, 
it  seems  to  occur  aomotiuies  from  tho  application  of  cold  or  irrilat*! 
jng  substanous  in  dcbiliUitctl  constitutions.      TIte   sj'mptoms   araf 
pain,  not  very  se^'e^e,  generally  attended  with  tinnitus  and  »odm| 
diminution  of  hearing.     Xlio  surface  of  the  membrana  tympani  be*| 
comes  of  a  red  colour,  large  and  distended  vessels  being  visible; 
appears  swollen  also,  and  there  is  sometimes  a  secretion  from  it 
vi.scid  n)ucii!t.     I  liavc  in  one  case,  that  of  a  child  suffering 
scarlatina,  seen  a  small  abscess  form  in  this  layer  of  the  membrane 
It  diseliargod  itself,  and  healed  witbiait  jwrmanent  injur*'  to 
bearing.     For  the  local  treatment,  one  or  two  leeches  may  bo 
plied  to  tho  on'tioe  of  the  meatus;  gvntle  sjTinging  with 
wafer  should  be  employed;  and  in  tho  later  stages  mild  iu<lriiigvnt 
or  a  weak  solution  of  the  nitrate  of  silver  may  bo  had  reeonrse  to. 

Chronic  inflammation  of  tJie  dermoid  lamina  may  remain  as  : 
effect  of  the  acute  form;  may  arise  from  uold  or  other  oanwa 


SIATION  Ob'  THK  3IEMBHANA  TTMPANL    168 


«nk  or  nugluctoci  oltildren;  nwy  Boperrcno  in  the  octane  of,  or 

■fW,  ibe  nuutthomata ;  or  ni»y  oocxi^L  willi  iifTvutiotM  of  Uiu  skm 

in  otfav  pvtft  of  t1]o  body ;  or  with  iii6acuDmtioi)  of  the  inctttua. 

It  oaeara  chiefly  in  tlw  dasa  of  patients  tunnod  '*  itrumouH,"  and  w 

Mid  to  bare  l>c«n  obfierred  to  altcrnato  with  titruRiouM  uphtkalmiit. 

It  ix  Htt4nul«il  i«4>iii«tunea  tvitii  a  rutlivr  co|>ioii«  mucuua  dieclwrgc, 

It  others  witli  fu)  exoesuTo  secretioD  of  qiidennU,  which  mny  nc- 

oonralatn  in  tiiiok  Hcales  U{kiii  the  *iirliico  of  tlio  aicinbnuia  tym- 

pfttii,  aDd  give  riso  to  deafiicas  and  great  JrritadoTi.     I'he^e  M»il<>9t 

auij  be  nunovi^  by  s.vriiiginf;,  or,  if  ditKoidt  to  difltodge,  may  bo 

wfteneJ  by  the  use  of  warm  oil  or  water.    Th<t  menibruna  tyni|Mini 

in  sonto  of  thuw  cans  bvoonicst  f^roatty  liypcrtroplik-d,  and  gi'iioiila- 

tiOM  of  a  briglit-red  colour,  oiid  easily  bloeditif^,  may  form  iqwii  its 

maboa.     Tlii*  aiFoction  i»  goDontlly  painless;  but  in  tho  Hovurcr 

Cinns  tbo  lieariitg  is  always  miKili  itnpain-il.     In  Uie  tn^tinent, 

JoMiKnnBii  ahuuld  be  maintaincxl  by  tbo  syriogo,  and  tbo  greatest 

iBaaUon  paid  to  tiu;  mate  of  the  hvolth,  which  will  nlmoitl  invuri- 

,ji>ty  be  fi>UTid  moro  or  lew  deranged.     In  children,  quinine,  st«ol, 

^kd  cod-liviT  oil  ant  atmo»t  always  uwTftil.     t^jMiiigiiig,  IViclion  of 

^b  >kin,  and  other  points  of  hygiene,  require  attention ;  and  with 

^^H,  local  mwumrvs  niay  be  ci>inhiiM.-d.     Vcsiration  may  U>  kept 

tip,  gently,  behind  the  ear,  and  astiingent  lotions  di'opped  into  the 

antos :  or  Uh'  nu^inhnmo  mny  l>c  washed  ovt-r  with  a  solatioo  uf 

!■  or  twenty  grains  of  the  nitrate  of  silver  to  the  ounce  of  water. 

Ihtt  before  having  recottrec  to  niiy  topii-id  applications,  it  is  desirable 

to  pit  clamlineH,  oomtMneil  with  good  geti«ral  Inatnient,  a  iair 

kiiL    A  ocunaidonble  improvement  seldom  fails  to  ensue.     Ulcern- 

iMn  ofthJA  layer  of  tlie  membrane  somc-tinie-i  ocoitnt.     It  in  generally 

on&iwd  to  a  small  extent,  and  dtMsanda  no  special  treatment. 

Hot  inAiunmalioiiH  of  lliia  layor  of  the  mombrana  tympani  are 
"itiwtea  Jpcri/ic  in  their  character,  can  hardly  be  doubted ;  bat 
Mfi*tinctit-c  marks  of  the  prvM-ncv  of  Uw  »ypbilitii:,  or  scrofulous, 
VSMty  taint,  have  yet  been  pointed  out  in  the  diseaeod  stntetum. 
*  iiiagno»is  mti.«t  be  dcttirmined  hy  tlw:  history  and  tlie  general 
•aiition  oi  tiie  pattenL  I  believe  also,  that  in  all  such  caM»  tho 
Airfseat  of  tbedisoaMi  ia  in  tiw  deeper  structure*  of  Liie  ear. 

fte  fitirov*  larainse  of  tlie  raembruna  tympaui  are  subject  to 
■QM  and  chrooiic  inflammation,  to  rebucntion  aixl  rigidity,  to  eal- 
Hb«>  (kpMits  in  their  substanue,  and  to  ulceration. 
H  jlotf*  inflammation  of  tlieae  rtrnet.uri'*  gencrnlly  ocnura  in  ihe 
^Bkr  pariods  of  life,  and  wecras  to  be  often  connected  with  a  rlieu- 
^Wie  gr  gunty  diAthmia.     The  aocc»  of  tho  attack   la  generally 


tu 


DISEASES  OP  THE  EAR. 


Teferred  to  cold-     It  nominenws  with  a  focliug  of  heat,  throhhin 
and  tension  within  tho  oar ;  tlicrv  nia^-  bo  also  paiti  K!:Hf-n 
»ide  of  the  liead,  and  hicroa.'Hxl  on  motion  of  the  jaw.    On  examiiui- 
tioii,  th«  inomhrano  prcsoiit*  a  dull  reddish  huo ;  tiwrc.  i»  tinnitus, 
and  the  liearing  is  inijiairod.    This  atfefltioii  is almoat  always  acoMO;^ 
panied  by  iiiflainmatjon  within  tlio  tyiDpaiiiim. 

In  ciirtmii-  iiifhiminuttoii,  tlio  filmju.-  !;i}[iin:i'  ln'i-imie  thicJce 
and  hyjK'rtrophicd,  and  tho  mombrano  jin-i.  m  -  a  l.:ii|''ii  apiwar 
oft«n  with  congested  votuelN  rainifjing  over  iU  siirfaoe.  Tlie  hoar- 
ing  is  groatly  impaired ;  n-liich  is  less  duo,  probably,  to  tho  condition 
of  the  iiiemhninH  tyin]miii,  tiian  to  that  of  the  hiiing  of  tito  \yra- 
panic  cavity.  Tho  membrane  may  appear  flattened,  or  if  it  n>Uiin 
its  fonii  and  (■iir\atnro,  it  is  <Ionso  and  rifjid  ;  and  iftlie  patient  in- 
ilates  tlie  tvnipanum,  wliile  tlie  Surgeon  keeps  his  oye  fixed  on  tie 
membrane  by  mcniut  of  tho  vjK'C-nluni,  tlio  natural  yit^lding  to  the 
8tj«am  of  air  is  not  perreivotl.  Pain  is  seldom  complained  of,  bnl 
thiTo  I*  irx-tjueiitly  a  groat  amount  of  tinnitn».  Tin,*  treatment  of 
both  tliese  aAeetions  is  the  same  as  for  inflammation  of  the  cavity 
of  the  lympaiium.  Ropeatcd  applioation  may  al«i  hv  made  Ui  tlie 
Burfaee  of  tlie  membrane  of  a  solution  of  the  nitrate  of  silver  (ten 
or  twenty  grains  to  the  oimca),  or  of  tho  dilutotl  nitnito  «f  niorcwy 
ointment.  The  tineturo  of  ioduie  also  may  be  oautiously  applied  I 
tho  inner  portion  of  tho  meatus. 

Inhere  is  an  opposite  condition  to  which  the  membrann  t^'m|: 
ts  liable,  and  in  which  its  fibrous  layers  seem  to  he  chioHy 
ccrned — that  of  n-Iaxtttwn.     PatienW  oomo  before  ua  in  wlwin  i 
membrane  has  lost  its  natural  regular  form,  and  appears  almost ; 
if  crumi>led,  sometimes  falling  in  towards  the  [iromonlory.    In  *on 
of  these  cases  the  polioh  and  tran.shinency  of  the  membrane 
sonroely  at  all  diminished;  in  others  it  is  opaque  and  ilnll. 
"  relaxation"  sometimes  cooxisht  with  inflammation,  at  others 
scomo  to  bo  eonnoct*Hl  witli  an  "  atrophy"  of  the  fibrous  laiiiin 
whicJi  oannot  always  bo  traced  to  previous  infbmmalory  action, 
considorablo  amount  ofdcafiic«s  is  jiroscnt;  seldom  tlntiitiis  or  jxiii 
M'hen  the  patient  inflates  tlie  tympainim,  the  merabrana  tympaail 
pot  ujH*!!  tho  stretch,  and  may  \x  soon  to  bulge  outwnrdit  in  frnntt 
anii  behind  tlie  bundle  of  the  uiallcuA.     So  long  a^  this  condilioni 
tension  bsts  (provided  tliero  bo  not  other  disease),  tho  hearing 
improved ;  but  thi:«  improvement  gradually  diminishes  as  tlie  eqail 
brium  of  tho  jtressuro  of  the  air  within  and  without  tbo  tympani 
is  restored,  and  in  tlie  oourae  of  some  mitiutea  is  for  the  moat 
entirely  lust.     A  similar  eScct  is  produced  by  a  strong  attempt 


ITLCERATIOX  OF  THE  MEMBRANA  TYMPAXT.      155 

iftMi  vrith  oloen)  month  and  nose,  whidi  puto  tli»  mcmbraiDi 
Bpttit!  on  (ho  >>trotoIi  in  llie  ojipnitiu)  Jir«ction.  It' no  imiinivit- 
;  is  pniiiitfMl  hv  tlwse  means,  Ihore  is  reason  tn  suspect  a  <limi- 
iiMitiilit^'  oritio  xlniM.**.  In  tlic  trt^ittmcnt  of  tliia  attcctioii,  any 
actjnn  Uiat  may  l>o  preAonl  nIioiiIiI  bt-  i\n=t  rcltovod; 
t^M&eM  contiiiuo  aAcr  Uus  is  done,  or  if  no  intiimiinatJon 
U>aic  remctlies  niAy  be  eniplnyetl,  niiil  n  woak  M)lnt.ion  of  tlto 
r  of  silver,  ur  of  t]>c  chloride  of  zinc,  applied  to  tho  surface  of 
ibnine  by  «  cfflmers-Iuiir  brusli,  or  on  rotti.iii-wiHjl,  ono«  or 
kw«ak.  If  there  be  any  truth  in  the  theory  that  the  ootton- 
mt»  of  iN>rfi>ni[iciti  arttt  by  giving  snpport  to  tlic  oswculn, 
perhaps  be  beneficial  also  in  some  of  tliese  casoa.  Thoy 
I  vm'  dirtirtilt  eilW-tiiiilly  to  roiit-vo. 

In  «itu>exion  n-itb  Urn  state  of  the  memiirana  tynijioiii,  a  morbid 
litian  may  bo  roAnwd  to,  which  i«  somciimcn  found  al^cr  death, 
ill  its  diagnosis  during  life  is  donbtful :  atrophy  or  deyenera- 
fdn'  (I'nwir  tynipani  iiiujwlf.  Probably  it  plays  a  part  in  somo 
lofdealiiixs,  and  may  be  deiK>ted  by  a  w-ant  of  dii»  tcnftioii  in 

ibtmne. 

CUpMremn  depOMtn  are  ft«<]nontly  »een  in  tJio  nicmbrana  tym- 
thi-y  present  chiefly  two  forms :  eitJier  tliat  of  a  small  crea- 
b\er,  rvidcntly  taking  the  courw  of  the  cireular  fibres;  or 
oTaa  irregularly  radiating  nia*8,  which  has  it^  nent  uinid  the 
fibres.     ThsBo  deposits  aro  gonernlly  mot  with  in  eases  of 
ling  inflamnialurk'  diseoae,  and  thon  dmdiuLi.'i  ts  ])r<«ent; 
tlwy  do  not  sc«m  to  be  thenutelvaa  any  considerable  impodi- 
I  to  hearing,  since  tliey  are  al»o  seen  in  pntientn  whoso  hearing 
it  Bcarevly  diminished,  and  in  whom  the  membrane  itself 
I  tv  be  in  otiier  ri:ti|>ecta  in  ittt  noniud  ^tato.     Honietime*  tliQ 
nffects  the  entire  extent  of  the  membrane,  which  a 
cmi\-trt«d  into  a  bony  maifi*.     IJnl  in  tJiwo   aiMit  there  is 
By  alao  extensive  disease  of  the  tympanmn.     These  deposits 
■  chiefly  of  phmplmto  of  lime.    Tliey  are  moHt  frajueiit  when 
Bienbnuie  is  perforated,  and  a  ohronie  inilaunnation  of  the 
Bum  hat  oxbrtod  for  a  long  time ;  but  thvy  sirt-  by  no  luean^ 
Va  tlte  later  perioda  of  life.     In  all  these  eases,  any  inflam- 
I  that  exiMta  may  be  combated  by  ap]>ropriato  nionnit ;  for  the 
itfieif  no  remedy  is  yet  known. 
tion  iif  Um)  fibrous  laminaj  may  occur,  though  not  fre- 
<  a  reault  of  llicir  continued  inflammation.     The  dcrmoi<t 
^ofeoDne  partakes  in  tlio  afFoction,  and  it  is  attended  with  a 
fton  the  mcaliu.     It  may  eitlicr  lead  to  perforation,  or 


156 


DISEASES  OF  THE  EAR. 


rMuU  moiTily  in  a  tliiunlng  of  t]»o  mcrml>rano,  tho  mnpous 
retaining  ibi  continuity.  In  the  latter  vane  Uie  uloentt^l  »: 
a]>poar«  dpprcAsod  below  tho  goiioral  plane  of  tho  incnibnim- ;  it  has 
an  irregularly  oirruliir  iihii|H>,  mikI  noini-tiincs  occupit^H  a  ouiuidorabte 
CxtonU  Wlicn  th«  tyni|iaiium  is  iiitJatod,  tJlo  inu<MUS  nu?inbrane, 
lacking  siipporL,  bulgi.>.t  at  tliin  xpot,  and  may  be  distinctly  Men 
to  form  a  projecting  sac.  This  condition  eoctns  not  to  be  alwajs 
Mcoompaniod  witli  otiier  diM.'!!)*!^,  and  U  i<iit>ceptible  of  benefit,  mpo* 
daily  if  tho  ulceration  be  extending,  by  a  weak  solution  of  nitnto 
of  Mlver  t!»utionnly  )i[i]>li<Kl  to  tlio  tiurfuc«;  generul  troatmeut 
at  the  same  time  adopted. 


bcinM 


I  tptX'M 


P*j/oratum  :  thi'  artijleial  numbrana  li/mpani.  The  mem 
tjnnpani  may  become  pcrfomtod  in  two  wayii;  cltlier  by  discaM 
aJlecting  the  membrane  it»eU',  and  usually  progroH-ting  trum  wilhont 
inwardti.  by  iducration  of  its  lamina?,  or  as  the  result  of  inflammadoa 
witlun  the  tymjuuium,  cuating  not^uinuliition  of  niiii:n!i  or  othw 
morbid  eccrotion  within  that  cavity,  which  at  length  finds  its  way 
through  the  mi?tnbriine  inti>  llie  mttatus.  In  the  luilftr  eauc  Uie  ii[>r-r* 
tuTtf  \s  smooth  and  even,  and  tho  remaining  portion  of  tho  mem- 
brane for  the  mrmt  piirt  retains  it«  normal  [Kwition ;  in  pcrtbralion 
from  primary  ulceration  of  the  lamins,  on  tho  other  hand,  the 
tnre  is  more  iiro^nlar,  nml  its edgp.s  intrnvorti-d,  whilv  the  rvm: 
of  tho  membrane  falls  in  towards  die  tympaiunn. 

Tii«  dia<^i»»i9  of  peHVirali^ni  is  gi-n«rally  uasiy.    AiWr  tho  vaoa 
has  been  cleaned  out  with  warm  water,  the  oritioe  may  for  liie 
part  bo  x'cry  ilistint-tly  »ocn  by  tho  aid  of  tho  speculum.     Or  a 
culiar  pulsation  (first  described  in  tlim  relation  by  Mr.  Wilde)  risi 
in  tho  situation  of  tho  aperture,  and  probably  due  to  tho  presionw 
a  film  or  bubble  of  water,  is  very  cliiiraeterintic.     If  tlie  Kiutaehi: 
tube  is  nut  obstructed,  tho  patient  can  blow  air  through  the 
witli  a  i>rolonged  whistling  sound,  wliieli  i^  perteetly  dlagntHttiti 
the  affection.     Tho  aperture  may  be  of  any  siz«,  from  less  than  that 
of  a  pin'n  heiid  Ut  almost  Uio  entire  ej(ti.^nt  of  the  membrane.    Wbott, 
the  destruction  of  the  membrane  is  considerable,  tlie  remaining 
lion  usiiiilly  presents  a  iliittiiict  lutiat^-d  ettge  ;  and  if  Uio  greater 
is  absent,  tlie  han<lle  of  tho  malleus,  with  a  narrow  strip  of 
brane  on  eiwrli  side,  is  goTicrally  to  iie  :ieen,  eitlicr  occupying 
natural  [wsition,  or  fullen  inwards.     Sometimes  this  porlioii  of 
mmains  with  no  membrane  attached ;  sometimes  the  head  of 
malleus  alone  is  left,  and  forms  a  prominent  and  chaniet' 
objeot  near  tho  roof  of  tho  moatus.     The  border  of  tho  rem: 


PERFORATION  OF  MEJfBRANA  TTMPANT.      157 

lion  of  the  roflrohrane  may  be  iu])icivnt  to  the  promontory,  fbrm- 
I K  morw  or  Im»  ooinplotcly  «lo!ted  crai  ity ;  anrl  if  hy  ihir,  in«ana 
t  is  pverentod  from  e»cs)>ii)f^,  tlio  nioiit  scriouii  coiiaeijui>ii(!Mi 

VutMUtiim  of  the  morokrann  tyinpnni  protlucos,  for  (lio  most 

a  certain  amount  of  deafn«»8,  tliougli  wlioii  tliu  aix-rtore  b 

I  and  till*  our  othonviso  lioaltli}',  this  U  so  sli^lit  as  to  be  Hcan-ely 

lile.     In  recent  cast^,  tlie  elofture  of  tlie  oriti4-4<,  if  hriiiII,  is 

■yi  to  bo  WHigbt :   lite  occAMonal  application  of  iJio  nitrate  of 

to  the  edges  of  tite  woimil,  anil  the  subjugation  of  iiiHumma- 

'  aelian  bv  ap]ii-opriato  means,  will  generally  secure  thin  result; 

I  ifthe  deMmction  of  Miluitiinivt  Iw  (\>iiHii}rTiib]<>,  or  llu^  perti^rnlion 

lafnlil  Ntiuiilio};,  tlw  treatment  consists  in  ibe  nse  of  tbe  cotton- 

,  or  the  artilicial  ni«nibrHna  tympniii.     Tbo  l»tt«r  iippean  to 

I  in  ordinary  catscs,  tbe  most  usefiil  and  convenient  application, 

having  n^tMurM  to  it,  howovor,  i(  i.*  lU'Oiin-trirv  to  iiHcnd  to 

t  condition  of  the  parts  involved.     Almost  invariably  when  tlie 

ina  tympnni  ia  pcrfnmtvd,  iberi'  exiAUt  a  »ti)t«  of  chronic  irri- 

lof  tliv  lining  membrane  of  tbe  tympanum,  atlonded  with  t-ither 

tt  or  na  intermittent  dUclud-ge.     Un  examination,  a  foitid 

I  of  inspiautod  discltarge  will  generally  bo  found  in  the  meatus, 

rnfioifint  to  not  up  inflammation ;  and  on  s\-ringing  this  away, 

membrmne  of  th<'  tympanum  will  i>c  xwn  n-d,  swollen, 

1  irin^ ;  oftftn  so  thickened  as  to  project  almost  to  a  level  with 

lacUoe  in  lb"  membrane.    tV-cntdonally  b  iiolypn*  gmw>f  from  its 

Even  in  this  inJlamed  condition,  the  application  of  tlie  arti- 

I  tBMntinuiv  will  ofli^n  produce  an  immcdiuto  improvement ;  but 

is  bet*«r  deferred  until  a  more  healthy  state  has  Iiet>n  in- 

otlMTwiM!  irriuitinn   may  ensue,  noecssitatin;;  its  discon- 

for  a  time,  and  tlie  patient  may  be  diticourageil.     Tlie 

■honld  \>e  kept  clrau  by  gt-nlle  syringing,  and  a  sttmula- 

lininent  ruhlio<l  around  the  ear.     Thii«  will  nficn  prtcure  • 

licin,  thoui;h  not  a  oomplot«  cessation,  of  tbe  disc-harge.     Or 

mny  be  liiul  to  mil<l  eounl^T- irritation  ov<-r  the  niaMoid 

and  to  astringent  lotions,  one  of  the  mont  useful  of  which 

ichlundfl  of  nine  (two  grain*  to  the  ounce  of  water).  Wltatm'er 

I  an-  applicl  should  bo  used  warm.      Sometimes  the  dinchargo 

•tf«  l»hind  tbe  remaining  portion  of  the  memlirane,  and 

nsoily  removed      This  adds  greatly  to  tbo  difficulty  of  tJio 

•ipociaJly  siitce  tJu>  syringing  must  Ih*  left,  in  part,  to  tlio 

■ir  his  friendit.     Mui-h  dejienda  upon  Uie  skill  with  which 

nmple  operation  is  performed.     In  every  ciute,  however,  Uio 


19« 


DISEASES  OF  THE  EAH. 


baa     , 


Mitire  rcmo\'a]  of  Uto  tuiidoncv  to  ubnonnHl  Miorelion  !.■(, 
alt  mucous  menil>ran(»,  a  todious  task ;  but  tbrtunately  the  iniro- 
duiHion  (iftiio  arliiiciul  nioinbrniio  iiomi  not  be  ddavoil  until  UiU  h 
accompYttAied,  for  it  has  itsolf  a  great  influence,  as  soon  as  the  ox- 
troinc  irritability  nf"  tbi>  mticiouK  nieiiibrttiw  wf  IImj  tyin{iiiiium  bu 
been  relievi?d,  in  restoring  it  to  a  healthy  state. 

Tlio  nrtiliiriiil  mi-mlinuia  tymiiiini  ooimiHtx  ofa  tliiii  circular  pi; 
of  vulcaninecl  india-riihbtr,  to  which  a  silver  wire  is  attached  ol 
qucly,  ns  a  liandlo.     The  iiiiidc  of  intrwluciiirr  jt  {»  thuM  dct^-ribod 
by  its  inventor.     "  After  accurately  noting  tlie  size  of  tbo  inner  ex- 
trotnity  of  tlie  tne^itus  tv  which  tJic  nntural  incinbranv  was  attftchnl, 
Uie  ojK^rator  should  (iroeeod  to  out  the  artiticial  niembrai'.e  as  nearl; 
of  the  size  and  sitapc  of  thu  nutiiral  unc  as  jmssible,  taking  care 
tlio  »univ  liino  to  keep  tJie  mnrgin  quite  smooih  and  regular, 
patient  §houlcI  then  be  placed  witli  tho  head  iaditied  to  tbo 
Khouliler,  while  a  strong  light  is  thrown  into  the  meatus,  w 
if  liable  to  disebargo,  should  liavc  boon  [jrcsHously  syruiged. 
opc-riitror  will  nest  take  ttie  artiticial  meiubrmie,  and  Iutvin|r  inoi 
t«ned  it  with  wann  water,  pass  it,  by  means  of  the  silver  wi 
gontJy  inwards,  until  it  hu-t  rojicbod  what  he  consJdi^i'M  tbt;  natu: 
position,     'riiis  he  will  ascertain  by  tho  oceuiTcncc  ofa  faint  bi 
bling  miund  cauwid  by  the  vscapo  of  the  slightly  w>uiprcH!«cd 
beyond  it ;  he  will  also  feel  a  slight  obstruction  offered  to  its 
paiwiigu  by  the  rcninaiit  of  the  nnturul    nioitibrnflo.      Should 
ftttenipt  bo  made  to  pass  tbo  ai'tificial  membrane  beyond  tbis 
ilio  patient  will  complain  of  pain,  which  up  till  then  h.id  not 
folt.     The  most  certain  tost,  however,  of  tlio  ])roiier  placing  of 
artiBcial  membrane  i»  the  vciiHation  of  Um  patient,  who  di['(»verg 
the  Miiind  of  his  own  voice,  or  that  of  the  Surgeon,  or  by  l)i«  nu>i 
ment  of  Iiis  tongue  and  IrjiN,  that  bis  bearing  has  boon  suddenly  i 
provixi."     U  is  advisable,  when  there  remains  only  a  very  n 
ring  of  the  natural  membrane,  to  cut  tho  artificial  ono  a  It 
largi^r,  no  that  it*  edges  may  turn  slightly  backwards  when  il 
inti'oduoed.      I  bale,  however,  sometimes  found  tliat  a  portion 
incmbraue  cut  to  tlie  shape  uf  the  aperture,  but  a  little  larger 
size,  and  applied  directly  to  Uie  ruptured  spot,  lias  answered 
than  whoii  the  whule  surfaou  has  been  ooven^l.     It  may  be  i 
aary  to  bond  or  to  shorten  the  silver  wire,  to  enable  it  to  lie 
plcIcK',  and  without  prtssunt  ou  any  part,  in  the  meatus.     At 
tlie  artiticial  meiubrano  should  bo  worn  only  for  an  hour  or  two, 
cv«n  a  shorter  time,  daily,  and  should  bo  diweontinutxl  fur  u  tima 
any  irritation  arise.     It  should  always  be  removed  on  retiring 


OF  THE  EUSTACHIAN  TUBE, 


159 


eir  other  di«ca»o  bo  preeont,  as  of  the  ncn-om  apparatiiit, 
a,  &*•,,  tlie  n.'nlorntJoii  of  tlio  hearing;,  ofoourar,  is  not  ef- 
fected. But  in  tli«  great  majority  of  cases  the  niodt  gratifying 
resniu  (ulloiv  front  tJiiit  «iQi|ilc-  aii<l  ing<;tiiou)i  plun.  Tlic  juiticnt, 
wttli  I  liulo  practice,  learns  to  spj>I,y  the  artificial  niemhrane  hiimtclf 
irith  perfect  eaan,  and  oflvn  ohtaiiw  a  power  of  hoitring  thnt  is  liardly 
IcM  tfaan  porfoot.  Often,  too,  it  happeiiH  that  Uie  fum^ion  of  the 
orgut,  lliiui  uwtstcd,  becomes  »o  (greatly  improved,  that  after  tho 
anifit^'ial  membrane  liaa  been  worn  for  •  time,  it  ean  be  atniottt  dis- 
petiM-d  with. 
1  If  tho  mobtened  ootton-wool,  fii-st  brought  into  general  nse  by 

Mr.  Y^-simlt^y,  be  pr«fcm)d.  It  may  bo  introdut-ed  oitiicr  by  a  siiit- 
aUe  pair  of  forceps,  or  by  means  of  a  narrow  tube  througti  which  a 
Ibread  attached  to  tlui  cotton-wool  is  paesod.  It  should  be  chungixL 
daily. 


IV.   AlTKCTlONS  Oy  THE  EuSTACHU.S  TuBK. 

Hie  ordinary  condition  of  the  Kiutachian  tube  appears  to  bo 

of  ctosuro  by  tlw  ^position  of  tt«  walls,  which  tliu«  act  tho 

,  as  deacrihed  by  Mr.  Wharton  Jones,  of  u  "  weak  valve."     It 

kit  opened  by  the  muscles  of  tli<.*  palate  and  pharynx  during  the  act 

>  of  swallowing,  and  }m>lMiI>ly  at  all  times,  when  in  a  Iioallhy  ^tatc, 

I  Remits  tliv  gradual  escape  from  the  t^'mpanum  of  fluids  an  well  as 

><i(air.     Tluit  it  h  not  permiiiiciitlv  ojx-n  i!>  i<)iown  by  the  cflW^ltt  of 

iditing  the  tympanum  with  closed  moutli  and  nostrils,  the  feeling 

jtfdiMetuiQn    within    llio    our    ]in)ilu(.'i!d  by  which  only  griuluully 

■ndta,  tmless  the  act  of  swallowing  bo  performed,  when  it  disap- 

pait  al  onoe.     If  this  exjKTinicnl  bo  inudo  by  a  healthy  per»oii 

*l«le  the  Surgeon  keeps  his  eye  fise<l  upon  tho  membrana  tympani, 

,  lb  DMrmbnuw  may  be  »vca  to  yielil  sli;^hlly  to  tlie  pn»suni  of  tlio 

ling  a  leas  concave  position,  which  is  retained  for  a  time, 

vinlfi  ibo  nalnml  roHpiration  is  carried  on.     If  the  act  of  swal- 

;  be  DOW  pertbnned,  Uie  roeuibrano  may  be  soon  to  fall  burfk 

lo  itH  normal  ixxtilion.     Similar  eflVx-tx  are  said  to  be  ex- 

during  descent  in  a  diving-bell.      In  addition  to  theso 

I otrtjun  ftiDptoiiiK  which  attend  ait  oimv  ctrnditum  of  thtt  ICwiia~ 

bifa,  first  described  by  Dr.  Jago  of  Tnu-o,  give  evidence  in 

direction.    Tliin  afTi-etion  is  uttoiidod  with  ii  buKy.in^  noise, 

^an  uruiaiurally  vivid  hearing  of  all  sounds  which  have  their 

I  at  tho  patient's  own  mouth,  throat,  or  stomach,  to  such  an 

at  greatly  to  tolerfere  with  the  bearing  of  oxtcrual  nouniJ 


160 


DISEASES  OF  THE  EAR 


i 


Thtav.  U  at  Hw  same  time  a  fooling  of  discomfort  in  the 
which  tlie  patient  (■n<loavoiir»i  Ui  iX'lJcvf!  by  rejtpatol  acta  of -twnllow- 
iiig.  The  cause  of  this  oondition  appears  to  be  some  state  of  the 
throat,  but  of  wliat  vhantctvr  is  n»t  cli-ar ;  ptirhupx  .tunio  irritattos 
ke«]>iiig  the  mitacles  attaeliMl  to  the  Eustachian  tube  in  a  state  of 
spasmodic  action.  Tho  H^-mptonm  occiir  most  frc<]uently  dunn^ 
cat«rrh:d  aftiwtionH,  For  the  moat  part  tliey  are  inteniiittent,  the 
rcAtoration  of  tlie  natm-al  nppoMition  of  the  walls  of  tlio  tuho  rumor- 
ing thtaa  at  onee. 

Much  more  frequent  and  more  serious  in  the  opposItA  affoctji 
cbstriKtioH  of  the  Ewtnrhian  fuhr.  Tliis  condition  may  ho  duo 
various  causes ;  thickening  of  tlic  mucous  membrane  of  the  fauces 
or  tympiiiiuin,  or  rohixiition  of  the  faiiciw,  appear  to  bo  tbo  most  fre- 
quent. Stricture  of  tlie  osaeoua  walls  of  the  tube  occurs  sometimes, 
ibon^i  rarely;  firm  incnibninous  adhesions  are  oiwiwioiially  fouiwl 
oompletely  closing  it,  and  [lerhaps  accumulations  of  mucus  may 
havo  a  similar  cfl«cL  TliU,  however,  a]>pvarN  doubifiiL  I  Iwive 
found  mucus  occupying  iho  Eustachian  tubes,  on  dissection  of 
the  jwtroiw  boni»>,  in  a  cj)»c  in  which  the  htsariiig  wn.*  partii^^larly 
obsere'ed  to  ho  quite  perfect  up  to  the  latest  period  before  death  at 
which  it  could  bo  tested,  and  none  of  the  partj*  of  tlio  ear  bctrayad 
tny  of  tlie  efleotit  ]>roduci>d  liy  the  eloanre  of  the  tubes.  It  is, 
ever,  of  course  doubtftd  how  long  tho  mucus  had  been  pi 
On  tlie  other  hand,  a  thickened  condition  of  the  mucoua  niembi 
both  of  tlio  orifice  and  of  tho  course  of  the  Eustachian  tubes, 
dcring  them  ahnost,  if  not  entirely,  impervious,  is  very  fretineni 
met  witli  on  dissection. 

It  is  v<Ty  (pii>!>t.ionnb1e  wlietlier  erdargement  of  the  ton»iU 
be  ro(;koned  among  the  causes  of  obfltruction  of  these  tnbee. 
aiint*)niy  ami  (ibr*er\'ntion  of  disenae  eontradict  the  Ktipposiltoa, 
roferenoB,  therefore,  to  the  que^ion  of  llio  removal  of  these  f^\ 
in  cattx  of  dcafnewi  doiiundent  on  the  condition  of  the  throat,  ihi 
seems  to  l>e  no  reason  for  departing  from  the  rule  which  has 
laid  downi  by  \-arioue  writers,  that  if  tlicir  removal  i»  desirable 
general  grounds,  that  is,  if  they  are  intorfi;ring  with  respiration 
injuring  the  healtli,  they  should  bo  excised,  and  not  ol'n  r  v-i-  ■ ;  i 
lens,  ptrrlinps,  in  oa-Hcs  in  which  oilier  means  hiive  fiiilil.  nijpii 
chance  of  benefit  to  the  hearing  may  bo  weigbeil  ii    lin-r  ihat  of 
jury  Ui  the  pittiont  from  their  losi*.     Tlic  slight  liis-s  "t  l»l()ud  ai 
ing  tbcir  cxcit-ion  may  perhaps  have  a  beneficial  inlluencfl. 

Tli«  <liagnofliM  of  obstruction  of  tho  Euslnehian  tube  may 
made  by  inspection  of  tlie  membrana  tympani,  and  by  tlie  use 


OBSmUCTION  OF  EUSTACHIAX  TUBE. 


ICl 


Ok  fltomvjMj.  Th!H  mntruinvnt  is  n  ficxifilo  tube,  odo  end  of  whinh 
ift  Ib  be  iuerted  into  die  ear  of  tlie  Surgeon,  uhI  llie  othnr  iiiU>  tltat 
of  ibi  patimt,  vrliilo  tlui  latter,  closing  lliu  mouth  and  nostrili,  either 
nukn  a  fiircible  expiration  or  perfomui  the  act  uf  Hwallowinj;.  If 
llȣiHtaehiaii  tabe  bo  porvioos,  tho  air  will  almoet  alna^'s  be  heard 
(lAsr  aomo  practice)  to  paKt  into  thn  eiur  ilurtiig  one  or  oihtir  of 
thaw  opBTBtions.  Tlw  sound  that  r«sulta  nrlieii  tlie  organ  in  in  its 
Mmial  stBte  U  a  peculiiir  t/mJ,  ixiini^n  )jat  like  the  ^trikinf;:  of  a 
toUet  agahut  a  target  heard  at  a  great  distanco,  or  liko  the  blowing 
■KUanl^r  hito  a  kidbII  liog  of  itilver  iui]>cr.  When  disease  is  preaunt 
thi>  aoaod  may  I>e  varioiuly  tnodified ;  a  creaking  or  wliistling  may 
bo  hauti  if  tltti  KiulHcliiiin  tabo  bo  iuirruwi.-<l  by  tJiickening  of  its 
lining  membrane ;  a  "  gnr^^ing"  iixGoatea  tho  presonee  of  mucus 
orothi-r  Huiil  n-ithin  thw  t»l>e  <tr  tTinpimiim.  It  i«  i<mi<Iiiin  tlio  coito 
that  it'  the  Ei^tachian  tid)e  bo  ]>er\'ioufl  no  sound  is  audible,  when 
(ho  patient  htu  lenmt  rifjhtJy  to  moke  tho  Pxi>orinuiit ;  and  if  ncitliur 
■ly  sound  can  be  Iieard  nor  any  roDvemeiit  of  the  membrana  tym- 
pani  is  soon  during  tlic  actioi]»  tiXww  desc-riUti,  and  the  otiicr 
nmptoou  Bj^ree,  ohotmcCion  of  the  tube  mar  be  oonfldontly  in- 
Bat  tltp  appearance  of  tho  membranA  tympaiii  a]fo,  in  theso 
»,  K  very  oltamcteristic,  and  might  iti^t-Jf  often  aufli(«  to  reveal 
an  oxperionwd  eye  the  nature  of  tlie  affection.  Whether  it  be 
lo  abAonAion  of  tlie  air  within  the  t\iiipanuin,  when  it  It  nut 
reoevrcdt  or  to  any  other  cau^o,  llio  membrana  trmpani 
fdm^  when  the  EiuOachiKn  t«U>  is  jiermiuwntJy  eloscil,  IwHjomn* 
csoocaTe  than  natural,  as  if  drawn  or  pressed  in  cowards  the 
lanity  of  tlw;  tnii|>imum.  It  Ixwoitiw  at  tho  Kaine  time  »f  a  dull 
iBdaar,  and  frec|uently  somewhat  opaque,  the  briglit  spot  on  ita  eur- 
Ifaetiein^  ini)i»tinot  and  ditfuKCiL  Tbii>  comiition  of  the  membnino 
■  be  distinguished  frmn  the  resnhs  of  inflammation  by  the  more 
fdnodnl  cOTi«(vity,  without  irrwgnlarily,  and  tlio  aliMtico  of  eo«gc»- 
[tioB  or  thickening. 

Bm  history  abo  is  chantcterivtic  of  tho  discnsc.     Tho  dc!ifiir«« 

fir  the  moat  part  arisen  gradually,  without  any  considerable 

of  pain,  and  after  rup(.«t«<t  attacks  of  cold  or  sore  tliruat. 

the  bearing  will   have  been   suddenly  restored  at  various 

after  a  load  crack  or  report  in  tho  car,  ba\'ing  boon  gra- 

-kat  again. 


dutrvctim  of  the  Ktufarhian  hdie  from  thirkmln/f  off/i/r  mrifmi» 
■  y'Uufcuieet.     llhis  affiKtion  is  more  fi^ucnt  before  than 

Toi.  m.  « 


16S 


DISEASES  OF  THE  EAR. 


rex- 


after  middle  ago  ftlm  dwifnos*  of  iidvanniif;  yoant  Wing  more 
nected  with  morbid  oonditious  of  tlie  tympanum) ;  and  it  is  esped. 
coDituoii  in  scrofulous  or  otliorwisc  uiihcHltby  childron.   The  apj: 
wifio  of  tlie«e  latter  patients  very  often  at  onoo  betrays  the  nature 
die  maludy.    There  is  a  i'ulnvsH  sibout  tiiv  back  part  of  the  Jaw,  and^ 
enpecially  when  the  tonuk  are  aW  enlarged,  they  have  a  peculiar  ex- 
[H'oseion  of  GountcnuiDCC,  arising  firom  Uio  mouth  Iwing  kept  sligl 
open  to  aid  in  respiration.     They  are  also  apt  to  snore  when  asl 
Tho  di'afiicw)  ill  tlitwo  cases  is  considcrahio,  t!io  pationt  requiring 
tm  sjiiiki:^!]  to  in  a  dintinut  voice  witliiii  a  yard  or  two.    A  ''  ittulKng' 
in  the  cars,  and  nioro  or  less  tinnitus,  arc  grnorally  oomplainod 
Tlio  nnicuiis  nicinbrimu  of  tlio  fallow  ta  red  and  tuniiiL     Tim  treal 
tnent  indicated  is  to  restore  the  Iioalth,  and  ta  reduoo  the  thicke: 
invitibraiic  of  tlie  throat  hy  local  astrin^^^iits.     Among  the  hiltiir  I 
nitrate  of  silver,  either  in  stick  or  sohition,  seems  the  ntost  eSJi 
oiouH.     Tt  slionid  Iw  ap|)!ied  to  the  irnniMliat*  neighimurhoo"!  of 
orifice  of  the  Eustachian  tube,  which  may  be  accomplished  eilJ; 
by  moana  of  a  jointed  c»ustie-ho1der,  or  by  tliv  aid  of  a  smaJ]  portf 
of  sponge  fixed  on  a  curved  piece  of  whalebone.     In  some 
CMC»,  howe^ftr,  this  scenis  tu  proilucc  grvat  irritation,  and  mildi 
measures  will  autGcei.    A  strong  solution  of  tannin  in  spirita  of 
may  bo  iipjJiod  oneo  or  twioo  a  day.     Sometimes  a  lopcti  or 
applieil  beneath  die  ears,  or,  by  meaiiA  of  a  tube,  to  tiie   n: 
nmoous  incmbniim  on   the  alfcctod  side,  or  in  hoth  tlioso  sii 
tions  at  onoe,  are  detiirable  at  the  cammencoment  of  tlie  tn>atnie 
Stimulating  and  astringent  gargles  may  also  bo  u»ed,  or  inlialatta 
of  Hteoin  inijiregnutnl  with  the  vajtour  of  iodine,  giiaiactun,  &c 
all  cases  of  deafness  eoimocted  with  affections  of  the  throat  it : 
«  u.->cful  pru(!tic<>  to  draw  cold  wat«r  into  tlie  pharynx  through  ' 
nostrils.     Tliis  may  easily  be  <lono  during  washing,  and  the  act 
gurgling  may  hi;  LlmA  perfunncd  much  mure  efhoiuiitly  for  the' 
sired  purpose  than  by  means  of  liquids  taken  uito  the  mouth, 
tions  aroim<l  the  tJiroat,  either  with  salt  and  water  or  with  jttiOH 
lating  liniments  which  may  contain  salts  of  iodine,  will  of  course  i 
retHjmmonded,  together  with  anijile  exoi-ciso  in  the  ojwn  air, 
cold  or  tepid  sponging.     It  is  possible  that  tho  occasional  use  oft 
Turkish  hath  would  exjicdito  the  cure.     Tonies  arc  often  indicali 
espoeially  ui  children  ;  and  in  their  case  I  have  thought  iron  in 
fiti'ui  of  tint  MWiiui-oxido  very  beiieficijil.    Great  perseverance  is  ofl 
necessary  in  tho  treatment,  but  it  is  nininat  alwaj's  succeswful. 
Ewttactilan  tube  may  also  bo  obstructt4  by  thickening  of  tlio 


THE  ETTSTACHIAN  CATHETER 


163 


I  Immg  iM  tympanic  orifice,  lu  «  result  ol' chronic  inflAOiinttUoa 
ihe  tyiniuinuni. 
Hdatation  of  One  mueoiu  membrane  of  th€  /atuea  wQ]  also  pro- 
ace  cluMurB  »f  tho  Euatechian  Uibea.  Tliui  coiuliticii)  is  different 
I  thai  of  ttiickutiinr;,  anil  oeimn  in  a  ditl'crent  class  of  patients. 
I  a  oiut  wiili  ouiy  in  adulta ;  cliietly  in  j>er!K>n.i  in  nt'iik  iK^tiilth  Ktid 
aficnng  under  geDora)  relaxAlion  of  the  system.  Those  who  smoke 
to  axoew  aw  (-.H|rtwiaUy  liable  to  deafness  from  this  i-jttiKc.  'Diu  lining 
■anbnme  of  Uic  tliniat  a  padc  and  mottled,  the  uvula  is  elongated. 
Hm  mernhnuia  tytnjutni  presents  tlic  c!)iaritct£risti(>  dull  and  wnvavo 
q>(ieanu)oe.  General  braeing  and  tonio  raoasures,  with  stunulating 
and  a»tringmt  a|>j>li<!«tionA  to  ihu  tau«:H  and  tlu!  orilicuts  of  the 
talies,  and  ttie  ahandontneot  of  any  praetiixn  injiu'ious  to  health| 
will  gvnerally  HTwA  a  cure  In  nil  Ihi.i  dtum  of  imm:*  a  k*iiijM>rary 
improvODent  in  the  hearing,  sometimes  amounting  u>  several  iocbea 
m  teated  by  tho  wntcli,  is  pnidntwd  hy  iorvtng  air  into  tho  tyinpa- 
iniro ;  aikd  the  patient  may  be  advised,  as  soon  as  the  power  of 
doing  this  is  oUainod,  to  make  a  practicv  of  uHvctitig  it  two  or 
dme  times  a  dav. 

The  Ettstachian  tnbo  may  also  be  obstructed  by  stricture  of  tt« 
kmT  walls.     Two  caaeit  are  repotted  hy  Mr.  Toynhoo.     Tlie  ctame 
may  be  produced  by  ofiusion  of  fibrine  uniting  its  siu-fauos 
'  ftnnly  organised  tissue.     In  sui^h  catuxi  aa  tlie.4e  the  <;hit-f  jMiint 
be  to  make  an  accumte  diagnosis,  and  to  avoid  ^ubjt'cting 
polwat  to  uAelcibt  tnmnienL     Poittibly  Uie  cxjilomtion  of  tho 
by  a  sound  of  catgut,  or  of  ivor)-  the  point  of  which  has  been 
in  ai-id,  might  bn  useful  tor  tliiii  piirjHise:. 

tho  rarer  causes  of  obstruction  of  those  tubes  may  bo 
on  the  authority  of  Mr.  Wilde,  foreign  hodius;  *' tho 
t  remarkable  ease  on  record  is  that  in  which  an  car  of  barley 
ilimim-crwl  aftor  death  projeeting  from  itt  guttural  orilioc," 
[It  anie  author  also  mentions  that  he  has  seen  deafiicss  induced 
[%alu;ge  llcxhy  nasal  [wlypit.'',  which'  pa«iivd  down  into  the  pha- 


in  whidi  tJic  olwtniction  of  tlio  Ku^taehian  tube  will 

to  4>rdii)ary  rentedial  measures,  riMwiu'se  must  bo  had  to 

«i»c  proocvdings.     Two  methods  pre.tnul  themselves,  in  whiidi 

^  nlief  of  the  dufhess  may  be  attempted :   tlie  passage  of  the 

bian  catheter,  and  puncturing  tin;  niemhruna  tym|iiuii. 


Eu. 


This  instrument,  having   been   first 


164 


DISEASES  OF  THE  EAR. 


warmiMi  find  oiled,  should  bo  pnfscd  very  griitiy  bat  proHy  rapMifl 
rIoii^  tii»  floor  of  th>^  nostril  until  it.  reailion  tlie  pharynx.     At  ihM 
point  either  of  two  meihods  may  bo  adopted  for  conveying  its  poifll 
into   l.hn  ojH>nin}r  of  ihc   (iilx.'.      It  may  bo  ciUTio<l  on,  itA  I>oilfl 
still  turned  downiwarda,  untU  it  readies  tho  posterior  wall  of  Ofl 
pbiirynx,  an<l  then  it  mny  bo  dravm  Klightly  furwarcL'',  beiiif^  g^'^tfl 
rotated  at  tho  same  time  oatwnrds  and  upwards.     In  doing  tlii&  ■ 
will  for  tlio  inont  part  f:wiiy  (tiip  into  tiio  trumpt^l-*itai»cd  oritiM  tM 
the  tube,  and  may  bo  felt  b>  bo  embraced  by  its  walls.      Or  wbql 
tho  iMtiiit  of  tho  <.'!itiict<!r  has  arrived  at  tJio  posterior  nnn!!*,  ih? 
tDHtrument  may  be  gently  rotatenl  outwards  and  slightl)'  upwards, 
and  airried  on  into  tlio  pllarJ^)x.     In  this  way  it  may  hn  pa«Md 
directly  into  the  Eustaehian  tube,   TIio  former  plan,  however,  is  tfae 
easier ;  and  in  the  latti.^r  it  w  noewwary  to  guard  ngiiinNt  entangling 
the  point  of  tlie  catheter  in  a  lacuna  wliich  tioa  directly  in  ita  routa 
"^Vbicbevcr  plan  is  adopted,  tbo  instrument  may  bo  jiulgwl  to  \m 
rightly  jitaeeil  if  it  gives  no  ))ain,  is  pretty  ttrmly  ttxeil,  and  offers 
no  im[iediiiicnt  to  tho  acts  of  swallowing  or  speaking.     No  bleeding 
sliould  follotv  its  uito.     Air  may  now  bo  puH^  Into  the  t\-mpanuiD, 
eitliCT  by  a  8>Tingo  or  by  means  of  a  flexible  tube,  provided  at  one 
end  with  a  iiHiiitlipi(H't>,  at  the  other  witJi  a  small  )ii[ic  tilting  into 
tho  end  of  tlic  eatlieter.     Tlio  otosco{>e  being  now  placed,  one  end  ill 
the  ear  of  the  Surgeon,  and  (h«  other  in  tliiit  of  tlu^  patieTit,  tlie  air, 
if  it  can  be  forced  tltrough  tlie  Eustachian  tube,  niav  bo  board  I0 
pa*!*  int'>  the  tyutpunuin  ainl  i^triko  on  the  nioinbranu  lymjiaii!.    Bf 
this  means  a  temporaiy  relief  from  deafiiess  due  to  closure  of  tbil 
canal  may  toiiietimes  bo  given.     And  btwides  the  eaiXD  of  othcmisll 
irremediable  ohatruetion,  the  catlieter  may  be  had  recourse  to 
those  iii«tunce«  of  tliiekciicd  mucous  niemhruRO,  in  which  au  iini 
diate  restoration  of  tlie  hearing  i>ower  even  for  a  short  period  is 
importance  to  tlie  patient ;  tbo  ncccssarj'  means  for  a  pcrinar 
removal  of  tho  diseosod  condition  Ixting  at  the  same  time  |ierwv( 
ingly  employed.      Formerly  Is  band  round  the  head  to  fix  tlio  ca 
tor,  an<l  an  air-press,  by  means  of  which  hot  air  or  nn^icjiliiii  vap 
were  forced  into  the  tympanum  through  tho  Eusttchian  tubo. 
much  employe*].      Rut  it  soesms  the  almost  ununimonit  e-X)M.Tiei>M4 
English  Surgeons,  that  no  residts  are  attainable  by  tliat 
(which  is  also  not  wholly  free  from  danger)  tlmt  are  not  «({ii 
bo  gained  in  otiier  ways.     It  is  certain  also  tJiat  in  some  e.ise^ 
whieh  (lehiiiiy  or  nervous  irritability  in  present,  the  repeated  inl 
duction  of  the  catheter  ia  productive  of  great  aggravation  of  I 


PUNCTimnfa  the  MEirHRANA  TYMPAXL      165 


The  application  of  steam  or  of  the  i-apoura  of  iodine, 
'ditoiotbnD,  acctia  vthcr,  Sic  to  tlw  throat  or  to  the  ^mpanuin, 
when  tin  Enfttadiiaii  IuIms  in  pen'iuu.1  im  iH--rfcct]y  easy,  aiiil  it  is  a 
pnetifle  which  may  be  employed  in  cases  of  thickening  cither  of  the 
bneul  or  trmiwuii"  imiri)ii-<  inomKriu]!).  tVom  five  to  t.wmty  drops 
•fa  mixtiiru  of  o<iual  porta  of  aonljc  ether  and  tincture  of  iodine, 
far  vxam\>ki,  miiy  be  pUocd  in  uiiy  siinplu  inhaler — a  china  tuapot 
)t  a  Tory  efficient  ono— witli  about  a  quarter  of  a  pint  of  Ijot  watrr^ 
■nd  the  vapour  iH'Jng  dravni  into  the  tiiruiit  in  to  \k:  Mown  gvul]y 
iaio  the  tympanmii  (the  raoutli  and  nostrils  being  closed).  An 
■;n'<'<!«''ki  aenMUton  of  warmth  is  felt  within  tins  twr.  Tin'  inflatioa 
Kuty  be  repented  6rom  six  to  tea  tiroes;  tlie  act  of  swallowing,  to 
foMorv  thtt  normal  ftjnilibritini  of  tho  air,  being  piTfonixHl  pro- 
viooaly  to  eaeh  inhalation.  This  ^.hould  be  done  in  the  evening, 
nd  the  throat  pvglcd  atlom'ards  with  cold  wator  or  a  xlitniilating 

Fliuda  may  be  injoct«d  into  the  tympanum  tlirongli  the  Eiista- 
dtian  catheter.  The  cavity  may  i>o  ivii*lii?ii  out  wiili  warm  water, 
or  medicated  wihitionv  ap]>licd  to  it.  For  this  ptu-puso  nn  iTlaiitic 
Byriiige.  esjiecially  the  one  constructed  for  an  eye  douche,  which  ia 
bniHbcd  with  a  mnzic  attached  to  an  In<l!an-rubhur  tube  tJiat  may 

tly  be  made  to  fit  into  Uie  catheter,  is  very  conyenient 

Puniinrinff  fA«  jnitnirtma  tympanL     ThiK  Is  a  truly  useful  opora- 

ibm,  which,  like  lomo  others,  lias  Buffer«d  negliict  through  ha»-ing 

[ban  pniciiM>d  without  (liM^riminaliuii.     It  is   appltcnbU-   in   two 

!S  of  oases :  tirvt,  in  incnrable  obstruction  of  the  EuNtachian 

jll^  the  other  jiartit  of  the  organ  l>cing,  m  for  a.t  we  can  jud<;e,  in 

latihnjbiy  normal  state;  and  secondly,  in  coses  in  wliicli  accumu- 

TlMfao  of  pmk  or  muctw  within  tlie  (j-mpnnuin  (which  eontiot  find 

■rit  ihmu^i  ilic  Eostschian  tube  owing  to  an  inflamed  condition  of 

)b  ralU)  prttduiXA  wwri-  cun«tituti<jnal  di.sturbance,  or  threatens 

■ation  of  tlie  memhrano.     lliere  is  a  third  form  of  dimasc  in 

lUdi  ihiTt)  in  Miinft  cvidiiu-c  of  it*  Imvtiig  Imvii  occasionally  iisefid, 

'kaf>h  the  rvasou  is  not  perfectly  clear,  viz.  a  condition  of  chronic 

hflatwatJo>n  witiiin  tlM>  1ym])annm,  whicli  luw  given  rise  to  great 

'^^-ning  and  rigidity  of  the  nienihrana  tir-mpani.     Tho  oporatioR 

lii[iiu«a  caution,  sijioc  two  cii«»  havo  b«*n  reported  in  which  death 

•a«Tvd  apparently  in  consequence  of  its  performance.*     Various 


Pr.  Dntcli8rofI>uUliii.iBUiierearltU0.    Stv  WMti'a  Aural  Smrftrg, 


166 


DISEASES  OF  THE  EAR. 


methodfi  hnvfi  been  roAnrt^d  to  for  pnxlucing  an  opening  whicll 
sbonld  not.  h^al.  A  trocar,  si  miniiti?  trvpliitio  nniic)  with  n  spiral 
wire  to  Iiolil  iho  niftnibraiie,  invftiitoil  bv  Fabrizxi,  and  a  variety  of 
knives,  liavo  been  employed  for  tliu  purpose ;  a  iiliiirp  xti^I  pnthe  at 
tnnti^ulnr  t'lirni  !«^ini«,  howfiv«r,  to  luiswflr  every  purpose.  What- 
ever in»triinieiit  is  used,  it  shotdd  bo  introduced  into  the  nnuims 
throiiirli  tlii^  K|)i'i'u1itin,  with  ii  ^oil  light  falling  on  the  membnuie, 
which  elioiild  be  pinictiired  in  its  inferior  portion,  either  in  front  of 
or  liebirid  th<-  tiTiniTiiilion  of  thu  ImndU)  of  tho  nixlleus.  A  anudl 
amount  of  bloediiit:  followe  tlio  incision ;  and  if  tlio  owe  be  a 
fiivoiinihlo  ono,  an  immi'diiite  improvement  of  bearing  oe«ura.  If  it 
bo  desired  to  maintain  a  permanent  aperture,  a  small  portion  of  tlu 
nieinbnuie  shmilJ  he  exciwd,  or  a  triangular  flaj)  turned  down,  and 
the  edgefl  of  the  wound  touched  every  socwnd  or  third  day  with  th* 
nitrato  of  silver,  or  a  probe  may  be  froqnently  passwl  Uirough  iL*^ 


V.  Affections  of  tbe  TniPASUM  and  Mastoid  Cells. 

The  chief  dineaiioa  to  whteli  tlie  tyinpiuiura  i»  liable  are  iiifla 
nmtion  either  of  it«  mucous  membrane  or  osseous  walls;  and 
results  of  Hueh  inflainniutiun,  iu  the  form  of  effuitioni*  or  adhewj 
rigidity  of  it«  lining  membrane,  deposits  within  its  cavity  or 
of  the  mnstoid  oells,  and  ankylosis  either  of  the  nwit^la  U> 
other  or  of  tho  base  of  the  stapes  to  tile  fenestra  ovalis. 

Arutf  inflammation  of  Utt  imieoiu  membrave  of  ifie  lyr"} 
TIii»  affection  may  exist  in  very  various  forms,  from  that  of  a  sUgEl 
degree  of  puln  in  tho  car  and  tlcafiic-*:',  rapidly  i>'tib»iding,  (o 
of  a  most  severe  and  dangerous  disease^     It  may  occur  in 
rently  healthy  [KTwrns,  untl  is  tlivti  gouerally  attributwl  to  cold; 
often  accompanies  an  attack  of  catarrh.     The  mildest  forms,  whifl 
might  ]>urhtip8  be  diMtinguiMlicd  imder  tlio  name  of  oongtvtion,  i 
charaoteriaed  by  an  aching  pain  felt  deeply  ^vithin  tlie  ear,  and 
the  IDOst  part  by  noises  of  a  buzKing  character ;  Uio  hearing  is  in 
paired,  but  lt»s  in  firKt  than  in  aubi^cqiient  attadu.     Tlie  memb 
tympani  may  be  found  on  inspection  slightly  vascular,  and  cit 
retaining  its  transparency,  or  dull ;  tlie  meatus  is  healthy.    Iiifi 


*'  Bitfore  qiilttiiii'  the  eubjeot  of  the  Eustoebian  tube,  I  Mnnot 
reniurk  tbnl  tlie  admirablo  invcDtion  of  the  lai^n^o^eopc.  BAbrding 
SurRcon  ■  pi<i'ri>et  view  of  thin  ri-);ioii  of  the  thi'iiat,  prumides  us  ^rtat  I 
in  tho  [Hn^o^ig  uf  tii#  nfTt^clious  cuTiiiei'led  llierewitli.     It  ia.  liow«\-er, ' 
to  Mr.  Witite  to  obscrvu  tliui  be  lum  long  iiinue  made  use  of  a  minor  (o  < 
ploie  the  posterior  portion  of  tliu  tlu-oaL    See  his  Aural  Saryfry,  p.  340. 


AFFECTIONS  OF  TrMPA>'UlL 


367 


Ml  of  tbo  h-mpannm  b  rather  painfiil;  tho  air  enters  nattirallv, 
^rwrUi  ft  »li^tii  rix-iiking  KniiKl.  Thii*  iifl'wtioii  iK'foHww  nf  ireri- 
Mb  ctitw«<|U(mc(<  hy  rectirrence ;  for  Utough  tJie  attacks  may  soon 
■uWiJef  a  rapcd'tion  of  tlicin  lux-ins  to  be  a  froqiiont  caii«o  of  oon- 
deaAHSB,  protwi>ly  by  producing  Uiickeniiig  and  rigidity  uf 
ilclicmte  inncvuti  lining  of  tho  tj'mpanum.  Tli»  object  to  bo 
at  io  tJ>e  treatment,  in  to  ttulxltie  (^iilirdy  tlie  immediate 
R,  and  to  ;;iLard  against  a  revnrrcnce  of  tho  attHC-kjt.  Tlie 
of  thette  objeciA  may  1>e  attaiiiet)  by  MRipIe  antiplilogistic 
nt :  a  I<vfIi  or  two  below  tlie  meatus,  a  stimuliiting  liiiitncnti 
amall  jwrtion  of  biiiilering-|iu[K)r  wom  nightly  on  the  mastoid 
for  a  short  time.  Two  or  threa  drops  of  warm  oil  may  be 
iiito  the  neutiK  niglit  iiiul  muniiiig.  Iliiliitiitd  oold  spong- 
1  trktMniespciciaUy  around  tlie  ear»,  should  bo  rccunnncnded 
tients  liabb;  to  thia  nAiictJiiii ;  and  rar«  lOionId  bo  tak<>ii  to  keep 
llboat  in  a  healthy  slate.  It  is  desirable  to  pay  especial  atten- 
to  preventive  niiwjuirv*  in  all  tbi«<!  ea»e«,  nineo  tlu'y  pr(sent  to 
me  of  the  moat  common  and  most  baffling  forms  of  dcafnnw  in 
!  nry  proccM  of  it«  formation.  It  irould  probably  lo  »  usettil 
roch  patientA  inflated  Uie  tymfiotium  with  warm  vajiour 
ling  for  some  daya  after  an  attack ;  and  neither  patient 
Hhould  bo  content  union  tho  &11  normal  hearing  power 
[ngained.  It  is  very  Avlilom  that  persons  sutferiug  under  de^if- 
rare  to  onntinne  tnstment  until  hearing  ia  ceuiplete,  since  a 
iniperfectJon  oeca-sions  no  inoonvenienee ;  but  such  ea«e»  il< 
)  mifjht  well  form  an  exception  to  tlio  rule. 

severer  fonim  of  aeiito  inflummatJun  of  the  mucouH  roem- 
oe  iif  thii  ^^lanum  are  attended  wiUi  intcnHO  pain,  of  »  tlimb- 
bini:.  darting,  or  bnrfliiij;  duir.-icti-r,  extending  ovi-r  tlie  side  of  the 
^d,  often  in  the  course  of  the  ner^'es,  and  aggravated  by  Kwallow- 
hg  or  any  otlwr  mutionit  of  the  throat  Ttiorti  are  loud  and  di»- 
kWaing  noiMs,  and  the  hearing  is  always  greatly  imjmirod ;  much 

fct«•l  i»  (irewnl,  imd  <U'!irium  oft«n  BUiKtrveiKii.  Those  aymjc 
may  either  commence  suddenly,  in  which  case  tJicy  giaiorally 
earn  esjiomro  to  cold  or  draught,  or  inJudiciouH  bathing ;  or  Uioy 
r  graiinally  iocroaM  for  two  or  tliree  <lays,  or  the  anute  attack 
kiy  ■upcneiio  upon  a  ittatc  of  chronic  inflammation.  On  oxaniina- 
liw  by  tbs  iqieoiliun,  tlte  meatiu  i*  gvnendly  found  in  a  normal 
Catr,  iltoogh  it  may  bo  tender  and  tumid ;  thu  mcmbrana  tympani 
I  auutelimQa  activeU'  m>iigvstc<]  nnrl  of  a  bright  pink  colour,  at 
than  it  i*  only  ttliglitiy  nnldened,  dull,  and  mottlotl ;  and  the  ^'afl- 
alar  and  twutlen  muooua  mi'mbranc  may  be  tlLicemed  through  it* 


168 


DISEASES  OF  THE  EAR 


velv  in^l 


ritcra^ 


Mmi-transpftront  laminw.  The  throat  is  almoet  always  actively 
flamod.  Th«  not  ofinHtttiiig  llit;  iym|iiiiiiim,  or  of  tivnilovf'mf'  nilli 
cIoAot)  mouth  and  nose,  ia  acutely  painful ;  if  air  enters  the  tjin- 
pamim,  the  souikIn  iirc  a  jutTj^Vmg  or  a  jimlongtMl  croaking.  Tlicre. 
is  often  great  tendenieaa  over  the  maatoid  process  aiid  iiuine<]tatel 
ill  front  of  tlm  trsfi'is-  The  trcatmi-nt  is  ihat  which  U  indiratwl 
the  pathology  of  tho  diaoaao.  In  tin;  ino**  severe  cases  V(-n 
tion  is  rocominomlod  by  some  authors,  or  cupping  behind  tho  con. 
Leecliea  freely  applied  arfmiid  the  eitr,  and  at  lite  SMma  time,  per- 
haps) to  tin;  na«al  miiuous  iiicmhi'aiio,  give  great  relief;  and  then 
may  bo  repented  if  the  severity  of  the  symptoiiiK  iKh«  ru>t  nhatCL 
Fomentations,  steaming,  and  ponlticds,  witlt  all  of  which  sedatives 
uiay  Ih!'  oonihiiicd,  aii<l  which  tlic  fi'dlliifrN  of  thn  jiativnl  denian<,l  to 
bo  used  very  hot,  mar  be  constantly  applied;  while  aperient  and 
cooling  mwlicinc*,  and  morfihia,  or  moq>hia  comhinod  with  hyiu- 
oyamuft,  &c.,  in  full  doses,  to  procure  sleep,  may  be  administered. 
Some  cruKf*  will  improve  rapidly  undor  remedies  of  thtit  kind :  in 
others  the  symptoms  are  more  obstiuat«,  and  all  authors  nnito  in 
rooommcn<ling  tlie  admini«tratioD  of  mercury  in  the  form  of  ealoin^ 
and  opium;  a  jwint  of  ]iractJco  on  vhieh  I  oan  otfer  no  opinion, 
knowing  of  any  evidence  by  wliich  the  comparative  progress  of  tl 
disease,  when  tlieiH)  retiiodie!*  arc  given  or  withheld,  may  be 

Afler  a  few  days  the  severity  of  the  pain  generally  diinii 
rikI  in  the  mo!«t  fu^oiirnlilo  c-iuh^n  the  dise«KO  terminates  either 
resolution,  or  in  discharge  of  mutMis  or  of  pus  through  tJw 
tuehiiui  tulic.     in  the  latter  cauWy  the  {>a«stige  of  tlie  miiiter  into 
pharynx  is  often  distinctly  perooived  by  the  patient,  and  may 
times  bo  seen  by  the  Surgoon.     When  either  of  these  event* 
— the  resolution  of  the  intlammation,  or  the  discharge  of  matter 
the  Eustacliian  tnbe — tho  symptoms  grailnally  subsi<U%     In  tune 
organ  may  perfectly  recover  it«  normal  apjteanmoe  and  fnnotii 
though  it  is  generally  eovoral  months  before  the  roeturattoii  is 
pleti\     Gontinuoil  stimulnlioii  around  the  ear,  and  intUition  of 
tympanum  with  steam    containing   t)io    va)>ours  of  iodine, 
ether,  &c  may  |>erhap.'«  expedite  thin  priK-csw. 

In  another  class  of  castas,  the  matter  discharges  itself  ti 
the  mcinlirnna  t;^^npani,  doubtlewi  bocjiu*o  tho  diickeniog  of 
mucous  niembrano  hliKtks  up  the  Eustachian  tube.     This  also 
result  ill  perfect  restoration.     Tbo  meatus  should  bo  kept  Hean 
gcnlio  syringing  with  wurai  water,  whieh,  without  injoring 
raptured  membrane,  will  avert  any  ill  effects  that  might  result 
the  irritation  of  the  decoinjiu»ing  diachargo  upon  lU  structara. 


AFFECTIONS  OF  TYMPAN DM. 


169 


i  of  water  may  be  directw!  ngainst  the  wall  of  the  moatuH  so 

'to  &il  witti  niiy  furci-  on  tlio  inHamed  portion  of  tlio  or^n, 

ainntor-irritalion  nwy  be  pereei-erinjily  ntiuntniiiod,  and  tonica 

iodidB  of  potaMnum  adminiVtertid,  the  general  atid  locjtl  hy- 

I  being  bIho  wuiHltMUHly  atu-iidcd  to. 

»  related  by  Trjqnet  of  actile  inflaninifitJon  within  t.tio 
arixiiig  tipnn  llu^  diuippiunuicc  of  an  oczomntoiis  affeo- 
of  tito  bIuu.     a  bliflter  was  apf>lied  to  the  nii)M  of  t}ie  neck, 
I  tho  bliatdred  ccuHnoo  becatuo  thu  teat  of  a  similar  eruption,  on 
SOM  of  whlHi  the  aural  disease  Mihsided.      Aeute   inilam- 
of  tlM<  tyiiijwiiuiii  iiiny  nin  on  to  UHrtos  of  tho  bone,  and 
IT  intracranial  discawe;  bat  such  ofTncta  am  fur  more  IW* 
the  chronio  Ibrm  of  tho  di»eaM.     ParalysiB  of  the  {mrtio 
may  abo  acootnpony  it;  but  thiit  complication  iUks  not 
By  roqiiiru  Bpecial  trcaUn^.-tit.     ^V'lien  it  retnainn  after  the 
imation  b  «itretl,  goltmiiAni  i»  uid  to  havo  b«cti  found 

I A  peeuliar  form  of  iiiflainmnUon  of  th«  tymiMimm  lUieompaiiieB 

bbriJo  diMBsoi,  esp<v!ally  the  zymotic  di«oa.<»es  of  ehildhood. 

it  is  eapooially  frvtiiu-nt,  hut  it  ooc-im  iUe^  in  mciu>lv8, 

I  aoaMimM  in  booptog-cough.     I  should  auj«j'>eot  that  it  was 

in  eronp,  since  in  two  fatal  eases  of  that  di^aso,  which  I 

1,  it  wan  preaent  in  Ixtttu     Tlie  t%nii|)anuin  Ifecomtv*  fillod 

I  poa  nr  |inri(brm  mums;  it«  mucous  membrane  thick,  rod,  and 

rt  nfli!»  M>  tiwoJlen  tut  ahnoitt  to  till  tin:  cavity,  unci  it  eafnly 

>  off  from  the  bone;  prmenling  in  all  these  respects  a  marked 

In  ita  in^)]»rt!eN  in  limlth,  witcii  it  i»  iw  thin  and  delicate 

Jy  to  bo  revogniflabh^,  and  adheres  witli  unusual  lirmiiess  to 

walk  of  iJm^  cavity,  to  which  it  scrviw  u»  a  perioMeiiiD. 

I  BtaMoid  oclls  generallv  jMrticipate  in  tho  disease,  and  are  abo 

ilollorHuirl 

pOoa  jMOoliarity  of  tlits  class  of  nRbclions  is,  Uiat  they  are  apt  to 

lie  on  itttimtian.     It  is  seMom  (hat  any  indication,  at  loa«t  any 

would  1)0  nlworvotl  by  a  person  not  on  the  watch  tor  it,  is 

>  of  tlie  inflammatory  action  within  the  ear;  and  the  first  »ymp- 

noticnl  i.4  a  diKcluirp!  from  tti«!  in<'alus,  whioh  oooitra, 

most  part,  only  after  irreparable  injury  has  bt'cn  dono. 

■Id  it  not,  tbcix'foro,  be  a  mk-  with  tho  mimical  uttciidnnta  of 

■ufliTiug  &om  any  of  this  oUss  of  diseases  to  provo  tho 

I  of  tkia  alfoetinn  of  tho  tympanum,  by  oxamining  the  mem- 

wilh  the  speculum  and  lamp,  instead  of  as^inminf; 

It  ia  not  pnteont,  uid«as  palpable  symptouia  force  it  u|>un  their 


170 


DISEASES  OF  THE  EAR. 


held  im'i^l 


notioo?  Such  an  oxnmmation,  it  seems  to  mc,  tliould  be 
p^rativc,  at  least  in  evnry  <!a»o  in  wbidi  anooialous  eymirtoms  arise, 
and  till-  p!itipiit'»  gnioral  <.-on<lition  (<ooin»  worse  tlian  tlii?  progrott 
of  tlie  (itKoase  iiii|;iit  h;ive  given  reason  for  exjjecting,  Tlie  ap- 
pcjtraiiix;  presuntod  by  tlic  iiictnbrann  tympan!  is  ijuitc  «tfBcioDt  to 
determine  iho  jn-ww^nw,  iJie  nature,  and  even  tlie  alage  of  tlie  dis- 
easo.  Tlio  intiaiTitiiatory  action  foiiimcnciug  icHkin  the  tyni])aiitmi, 
the  extcmid  lujeni  of  t.lio  nieiiihnuia  Ixinponi  rct^un  their  trui*- 
paroncy,  and  permit  vitlicr  tlic^  opaque  fluid  or  tlio  tluckeiicd  an 
congettti^d  inticntiii  liiiiiiiiH  of  tlio  iiieinhriiiie  itself  lo  In^  i-lif^rly 
tinguifihed  tlirough  thorn.  This  is  an  appearance  which,  once 
can  luinily  ho  inisitiikon.  In  the  oaily  ntji^i;  of  tho  iitfiM-tioii 
memhrane  presents  an  increased  concavi^',  owing,  I  presume, 
cloftitrv,  liy  thirkvriing  of  itt  lining,  of  the  Eoataohinn  tuhc; 
there  is  often  no  other  alteration  in  its  appearance,  cxoepi  a  brigll 
puik  cwloiir  eoeii  ihivugh  it.  In  the  VaUn  stug4-J«  tlio  iiivml: 
t^onpani  grows  flat,  it  is  dull  and  sodden  in  its  hue,  and  at  leng 
inBiiifi'Mly  bulges  outwardu  before  the  accuniulntod  nvcrction. 
treutniont  would  I>e  guidud  by  ciroiun stances.  In  tlie  slighter 
it  iniglit  he  possible,  by  antiplilogii«tic  iu(^uii»,  to  subdue  or 
tlie  local  inflammatory  action.  In  patients  prostrate  from  se« 
M-itrlutiiin,  or  the  like,  it  might  be  hojK^Jess  to  ntU-mpt  this.  But 
these  more  fonnidable  rases,  might  not  excellent  results  lie  oxpecti 
from  tJie  evacuation  of  the  matter  by  perforation  of  tho  membran 
tympatii?  If,  as  in  a.  case  mentioned  by  Aliercrtimbie,  a  dischn 
of  matter  irom  the  car  restored  to  htialtli  a  woman  who  had 
cotisciousniw,  nii^^lit  it  not  preserve  fi-om  death  »  child  ilepi 
already  to  tho  lowest  point  by  tho  poison  of  scarlatina  ?  Migiit  no 
audi  u  putictil's  li'iideror  brain  and  tWbler  {Hiwt^rs  siiccnmb  entir 
to  a  source  of  irritation  which  could  produce  sj-mptoms  so  grave  i 
an  adult  niiiitfiictitl  by  other  iliscitse?  1  do  not  lie»ilattt  to  av 
my  oonviciion,  that  by  a  prompt  attention  to  tlie  condition  oft 
ear,  and  ]>roiiipt  wacuation  of  pns  fmin  tlie  lym|iannin  when 
dence  was  given  of  its  presence  there,  the  balance  might  often 
turned  between  life  and  death,  and  iho  mortulity  fiimi  scarlet 
and  the  allied  disorders  notably  diminished.  What  else  doee 
following  report  indicati^V  A  girl,  aged  eight,  died  in  con^'ukic 
afti!r  scurlatina.  No  important  disease  was  found,  biit  the 
Jtnnum  on  each  side  wa^i  full  of  purulent  matter,  tho  meml 
tympani  slightly  bulging.  It  is  true  tho  nrine  wa.t  albumii: 
but  is  it  not  so  in  the  vast  miyority  of  eases  of  scarlet  fever 
recover  ?    There  was  no  decided  disease  in  the  kiducju.     A 


■lion  otliie  Membrana 'iytn]MnT;  ^TFave^meE  wifK  one  pa9ft7 

I  itgod  fivo  yoam,  wlio  Ii:iil  h(M,'n  th-Af  si'nco  Iho  ini.>«Hk«,  two 

before,  in  whom  n  mild  attack  of  scarlatina  very  conuderably 

red  liw  luHLTtag.     Tliu  membnuiiu  tvmpaDi  in  Uiis  case  vera 

L 

mtattB  often  supcn'onofl  in  the  course  of  h^ihus  or  typhoid 

Tn  some  of  these  cokch  it  MMMit't  to  he  du^  to  n  |>e(-tilinr  form 
tmnution  of  the  ^rmpanum.  The  cavity  hocomes  tlio  seat  of 
nniAona  effaslttxi,  whidt  »  fotiiid  »f[vr  di^iitli  oitlior  in  h  fluid 
pl\aiod  Hate.  The  miicxitis  mt-nibraiie  Becm»  at  the  same  time 
■tUMid,  and  Htf  omihiiis  wuiU  mny  1m!  -lofl  niid  iiitiltruttx]  with 
Id.  A  oonsiderable  proportion  of  the  eaHca  of  confirmed  deaf- 
tel  with  nfl<T  fi'vor,  arc  probiil)!}'  of  tfiin  kind  ;  but  not  all  of 

For  Mimctim^B  llie  tympanum  is  found  quite  healthy,  and 
whleo,  or  vMtibnle,  or  both,  oontain  mi  ctfueinn  of  blocHly 
somedines  no  appreciable  alteration  of  any  part  of  the  organ 

tibongb  tbo  kwa  of  hearing  btts  hoen  oomjdote. 
fe  mjbmmatian  of  the  mtieoua  mtmhrMU  of  the  U/mpanum, 
BiMition  occurs  in  varioitii  foriiiN.  It  may  produce  an  a4>cuniu> 
of  Piticas  or  of  pas  witliin  Uic  cavity ;  or  may  lead  to  the 
lioa  of  bandii  of  iKllui^ion  Ix^tivct^n  ita  walk  and  iho  oiuticula, 
I  soflADcd  and  thickened  condition  of  the  lining  menihranc,  or 
idity  <»f  tho  Nuno,  impttirini*  Uie  motion*  of  tlio  owicnla,  and 
iQy  those  of  the  stapec  within  Ulc  fenestra  ovalis  (membranous 

mimnlation  ofptiA  or  mucus  witliin  tlie  tj'mpanum  in  a  veiy 
l^fffeotion  in  children,  especially  among  tliosc  who  aro  of  a 


17S 


DISEASES  OF  THE  EAR. 


(hat  Ui«  t\inpaniUD  during  llio  fir><4  period  of  life  »  imliiniUy 
vith  mucus,  and  thai  chiMren  only  begin  to  gain  ll)«?  facair)'  of 
hearing  about  the  third  motitlu  I  havo  convinoixl  itivwlf,  iKiwet-er, 
by  repeated  dissections,  that  the  tympanic  cavity  is,  in  the  healthy 
Mate,  quite  lix<o  from  mucus,  and  tliiit  tJio  mci»bran«  lining  it  is 
thin  and  delicate,  at  t)ie  very  CMrlieat  periods.  But  in  a  hurge 
utnnl>cr  of  childrr-n,  oqMtcially  tliosc  ftutTcring  from  other  aflbctia 
of  tlio  inutMiu.t  mcnil>i'niie»,  tlio  Uiiitig  membrane  of  the  tyrof 
is  thick,  red,  and  8ol\,  and  tho  cavi^-  is  filled  with  mucus,  oft(>n  < 
a  purulent  nhtu-acter ;  tlie  Eu»tii<;liiim  lube,  by  renunn  of  iU)  thic 
ened  lining,  being  impervious  to  tho  fluid.  The  condition,  in  sho 
preciM'Iy  n^H-mblcH  tlmt  wliii-h  ncciirs  in  Hcuilutinu,  ('x»'|il  that  it : 
lees  intense  and  comes  on  less  rajiifUy ;  and  the  membrona  tvTnf 
exliibitn,  on  in^iH-clion,  a  similar  apjieiinint-i'.  I  liavo  so  tW^iuentl; 
found  tluA  state  of  the  lympammi,  in  children,  associated  with  con- 
vulsions or  other  syin]>toms  of  ocrebral  irritation,  that  1  btrliev*  it 
stands  to  them  in  tlie  relation  of  a  cause.  And  if  the  pressure  ofa 
tootli  ii[Kin  the  giun  may  so  act  upon  tho  delicate  nervous  systom  of 
a  child  as  to  cause  con\  uUive  soiiEiu'cit,  .tur^l^'  it  is  not  improbab 
tliot  tlie  prowuro  of  a  mass  of  thick  mucus,  uiiablo  to  escape 
the  tymianum,  and  jirobniily  Ix-ing  cmstiintly  increased  in  quontil 
oven  through  its  own  irritation,  might  have  tho  same  effect, 
mtimate  relation  of  tiic  middle  ear  to  tlio  bmin,  and  the  dose 
|>athy  that  exists  bet«'(i  tl.m,  is  proved  by  many  well-knc 
Ikctfl.  Even  a  strouni  it  loii  \vat<.rr,  ajiptiod  without  fiiree  to 
membrana  tj-mpani,  may  cause  fainting  in  a  strong  man.* 

(^oseo   ilhiKl.rativc  of  thi-   coexistence  of  ciinvulwve  diuMM 
children  with  tlio  above-described  condition  of  the  tynipaniun, 
relatcti  in  the  3t'th  volume  of  the  Affdico-Chirur^u-al  Tr> 
and  in  the  Traunaftiotu  nfthe  Puihohsijxeul  Society  for  1857.    Perlu 
it  would  not  Ijc  unreasonable  that  whenever  a  cliild  has  a  lit," 
manifcAts  any  &ym])toms  of  nervous  irritation  without  an  ohrio 
Kutlieient  cause,  tlio  state  of  the  tympanum  should  be  examinitl: 
short  tlmt  the  ear  should  rei-ei>e  the  aanie  attention  that  is  univ 
aally  given  to  tho  gums.     This  is  the  more  necessary  becauw 
aymptoms  of  ttiiN  morbid  condition  are  veiy  apt  to  cseajw  ob 
▼ation  ;  those  which  I  have  noticed  to  bo  most  fretjnent  are  a 
of  putting  the  bands  to  the  eara,  or  rubbing  them;  a  ory  ofi 


•  Conviilsinns  ai'e  muia^mled  amoug  iLc  ohubos  of  deaMumbiuiM;! 
ma<r  not  tin?  connoxion  of  evenls.  in  suinr  of  these  imhps,  li»  Ibo  i>UMri 
anJ  disease  la  ihc  Lyaipuuuni  bavo  bven  iLa  causa  of  U10  eoavulsioas? 


AFFECTIONS  OF  TYMPANUM. 


173 


ean  are  roughly  washed ;  plt^ibiuro  lakeii  in  Jiaring 
j^Mitl y  irritaUNi,  iw  Uy  thu  lioad  of  a  pin.  Iti  liivm',  as 
Dt'ourebral  irritation,  the  child  oaiiiiot  buiu*  ttt  Ixi  Junipod 
violently  niovml.  Id  ono  iii«taooe  the  child  hod  booo 
\row  liiiuaetf  uprjn  the  ground  und  roll  nttuiit,  upparently 
M>  atraoguly  as  to  attract  pai-tiimlar  atlcution.  The  liahit 
Uu)  imr»  Aoutnit  tho  iiioMt  WHi^tuiit  Myniptoiii,  and  ono  to 
the  parallel  case  ot'  dental  trritatioR)  special  attention 
,id.  TltOM  pationU  itrv  NunK^tiniM  notici?'!  to  bo  deaf; 
ntlv,  espeeiaUy  among  the  poor,  not  so.  Often  they  are 
■tufwl  or  inatlentivo.  And  horo  I  cHiiinot  i-L-fhuii  from 
loir  &«([tiently  this  is  the  ease  with  children  who  labour 
teat  deofuvw,  niid  liow  slroiig  a  claim  thoy  hnvu  upon 
to  atand  between  them  and  their  ill-Judging  guardumti, 
MO  from  tin)  f^riu^'oiM  wrong  un<l  ii^ury  that  aro  too 
etl  upon  them,  under  the  idea  tliat  wlmt  is  truly  <Uie  to  a 
imit}'  results  from  moral  taulu  Too  oiUtn  blows  are 
puiibihmeht,  wliioh  directly  aggravate  the  dittease.  In 
a  youth  who  died  witli  cariL«  of  tlio  potrotis  bono  and 
he  corubrum,  and  hi  wtiom  tJie  symptoms  of  aural  dis- 
early  life,  Ills  &ther  had  boon  ia  the  liabit  of  boxing 
"  inattention." 

itment  of  this  doas  ofease^.,  attention  to  the  general 
the  patient  sooms  to  hold  thu  first  place,  and  the  second 
iy  bo  given  to  hmmiik  by  which  the  thickening  of  lite 
lining  the  Eustachian  tube  might  bo  rolucod,  so  as  to 
kxit  of  tho  fluid  by  that  cliannel.  Tlie  mucoiiH  niemhrano 
is  always  chronicly  infbunctl,  and  is  benefited  by  the 
of  ibe  nitrate  of  mIvit.  I  have  thought  uIho  that  the 
of  ihs  tinolure  of  iodine  to  tbo  »eig)ibourbood  of  the 
inlunial  odmiiiistnitioii  of  the  syntp  of  the  iodide  of 
tutod  favoumbly. 

ilalion  of  mucus  in  tlie  tympuninn,  witliout  perforation 
brana  tyin|>aiii,  In  Ichs  frequent  in  the  adult  than  iti  the 
met  with  somotimi's,  however,  and  may  Iw  diagnosed 
the  oUMOope;  air,  when  blown  into  t)ic  cavity,  either 
ent  himself  or  throiigli  llic  Eustachian  oatlieter,  enters 
iar  gurgling  ^»uiid.  The  membrana  tympojii  is  opaque, 
Donoave  tlian  usoal ;  tlio  hearing  is  impaired,  though  not 
to  a  groat  degree ;  th-i-t)  is  no  pain.  Tinnitus  may  or 
praaenL  In  ihems  cases,  tJic  luu!  of  the  catheter  and  air- 
reootnnieodod.    But  ateam  or  medicated  vaiwurs  can 


174 


DISEASES  OF  THE  EAR 


hen- 


be  blown  into  the  tyinpunum  tiy  tlio  (latient  himself,  if  it  ia  desi 
And  I'll  111  tilatiii^  HpjiliciatioDA  to  tlio  throat,  mild  cuimtiT-irntatiual 
around  or  lM>liind  the  c-an,  with  or  witlioiit  a  leecb  ocoaaionally, 
gciicrnl  toiiip  measures,  for  tho  most  part  give  rvlicf, 

]nflaniniatt>ry  tJiickcniiig  and  liv|ii;rtroi>hy  of  the  mucous  metn- 
brano  of  the  tympanum  ja  met  with,  for  Uio  most  part,  iii  oonucxion 
with  dentruction,  inoru  or  Ip^  i.'oinph-ti>,  of  ilt»  memhrana  bmi[>aiu, 
and  lias  buoii  ^pukoii  of  under  the  head  of  perforation  of  tliat  or]^aii. 
Sometimet),  though  niucli  more  run^ly,  it  cx'txti  wliile  tlie  membrana 
^mpani  is  perfect,  being  due,  in  all  probability,  to  rcrpi<:ato<l  attacks 
of  ftubacute  inflariimiitioii,  especially  in  a  struiiiouH,  gouty,  or  then 
mittic  constitution.  Tlie  membrane  is  red,  soft,  and  velvety, 
may  ho  so  tuiuid  us  nearly  to  nbHtenttc  Iho  o»i'it>'.  The  menib 
tynipaiii  is  niore  or  less  fallen  in,  opaque,  thickctiixl,  and  with 
idightly  rwidish  hue ;  congeskHi  vessels  may  be  vinibl«  on  itj*  nurfaoa. 
Tho  Eustachian  tulw  is  obsti-uctod,  or  air  enters  with  a  croaking 
sound,  AS  if  forcing  its  way  through  an  almost  oblitwalMl  paftuigCL 
Tho  diagnosis,  however,  ir  difficult;  tlie  prognosis  not  favourablft 
Besides  tho  onlitiarj-  local  and  general  measures,  Kinall  dose*  of  tlie 
bichloride  or  biniodideof  moreiiry  may  be  given,  in  bark,  for  a  con- 
sidoralilc  period;  or  any  medicines  adapted  to  combat  the  rhi^uuiatio 
habit,  if  it  be  evidently  present.  Too  much  sttreas,  howler,  cannot. 
Lo  [aid  upon  the  regulation  of  tho  mode  of  life.  A  carclul  diet,  exci 
cise,  avoitbince  of  close  atmosjiherea  or  sudden  variations  of  t«i 
purature,  may  at  least  delay  the  progress  of  tlio  disease.  For  Un 
oaaee,  Triigiiet*  nx^jmnicuds  the  injection  into  tlie  tympanum  of  s 
weak  solution  of  caustic  potash. 

Ulccraiion  of  the  mucous  membrane  of  tlie  tympanum  ts  sdi 
met  with.     When  it  does  occur,  it  is  generally  in  connexion  wt 
strumous  or  otlicr  constitutional  atlV-ctiiins  of  the  organ,  and  for 
most  part  the  bone  is  also  implicated,  leading  on  to  infUmmatii 
wttliin  tho  hcatl.    Tho  treatment  should  htt  very  guiu^ed ;  and  di 
local  astringents  should  be  abstained  from. 

Si/pkilkie  injiummatum  vf  ifte  ti/mpattum.     Tt  cannot  be  doul 
that  deatiieait  is  .lometimea  duo  to  syphilitic  affe\:ti"us  of  the  mtd< 
cur;  but  these  casc«  are  ratlicr  to  hu  distiii^ished  by  the  In 
than  by  the  condition  of  tlie  orgau. 

Depofifn  unl/iin  thf  lymptitium.      Cholcsterine  Is  sometimes 
ill  thin  cuvity  and  the  mastoid  eclla  in  cuuHidcrablo  niaHes ; 


■  MaUniie*  de  VOreillt.  p.  4S'.. 


AFFECTIONS  OF  TYJIPANUM. 


175 


ID  ailvanend  life.  ADot)K-r  fbrm  of  deposit,  which  occurs  for  Uio 
nan  part  iti  tlte  young,  U  ])rohalily  of  u  tuboroiiloiiH  clmnictcr ;  it 
WA  wad  casooos  nuuo,  consLstiog  of  d^ciieratod  c^lls  aod  granular 
mttir.  In  thcxe  latter  mwa  there  is  iiionI  fiiHjuontly  a  sccondnry 
or  ooiocident  nfTection  of  the  brain.  L>r.  Gull'  questions  whether 
tbwe  dopmitt*  un>  of  u  fitruinouH  «hiini(!U>r,  luid  liold»  tliat  Uivy  ooa- 
dst  simply  of  lospisfiatml  and  degenerated  pus.  The  coincident  affeo 
tinn  of  tlin  pt^troiM  iHiiitt  !tvl<l[>ni  prcw^nL-t  UiO  churucterw  of  strumoos 
infiltrolion,  but  rather  iltose  of  ordinary  caries.  Yet  eases  octnir 
in  whicli  tliA  tuiHTculnr  eluiract«r  of  tho  aReclion  can  hurdly  bo 
doabced ;  for  example,  where  tubercle  e.\ista  also  in  the  lungs,  or 
wlien>,  tu*  in  K  «wo  ri'portwi  in  vol,  xxxix.  of  the  Mrxlicv-Cliirui-ffieal 
Tnauaetion*,  tnbervuUr  laasses,  of  a  similar  character,  exist  in  the 
tfmpannin  and  Uh>  adjiux^nt  [wrtiotis  uf  the  brain.  In  the  wuw 
,cf  ftmmous  depOAit  witiiin  the  tympanum,  the  inemWana  tympani 
I'pmerally  ulcerate*,  and  cxpowa  tlio  cavity.  Ttic  Irontinunt  naturally 
ItoggcHtM  iUM>lf;  but  it  is  of  course  doubtful  whether  any  treatment 
.  nmld  be  of  avail. 


JfanftraMMM  bandty  extending;  between  diffeient  parts  of  the  tym- 
|nnm,  and  ammjcting  tbo  ossicula  to  each  otlic-r  or  to  Uie  walls  of 
tin  nvity,  are  frequentjy  met  witli  aAor  death.  Re!)|>ecting  these  I 
hne  made  two  obwrvalions,  which  ni>[icar  to  mo  to  be  of  interest. 
IbeBnt  is,  that  mere  mucus  in  tlte  tynijianuin,  if  expoaed  to  the  air 
b  >  (liaect«d  petrous  bone,  will  in  tlte  c«iu>o  of  a  few  days  dry  up 
ihroad  bands.  im^lisUnguiHhable  by  tlie  eye  from  tbowe  whi<rh  are 
ntJy  nict  wIiIl  It  is  true  the  "  bands"  thus  formed  pixiswit 
IWrucutrc  under  the  micnMope,  while  some  of  the  membranous 
which  aro  fband  already  existing  on  disseetion,  Imve  a 
Iwrilrted  oftpearance.  Yet  it  M^iiiit  probnljle  to  in^  tliat  mucua 
WMf  dry  up  within  tlte  tympanum  during  hfe,  and  may  thus  givo 
om  to  tim  appearnnce  uf  buid.1  in  Hntii^  n\.-f*.  I  ant  induced  to 
Ud  this  opbuon  Irom  the  extreme  livquency  with  whieh  thcso 
■mbnnAus  ban<U  at«  foiuid.  JtamU  wore  present  in  371  out  of 
1149  diMetftioiw  of  diseased  oars  made  bv  Mr.  Tu^mboe,  and  in  3fi 
of  94  meh  diivH;<ctioitM  maile  by  inyttelf.  Tbey  occm*  also  iit 
in  wliicb  tbcine  is  no  other  ap|>eanuieo  of  iiiflninmation,  and 
•kcrv  t!iR  ])nib«l>ility  i.t  very  Hlr(in;r  that  it  has  never  existed. 
i  kare  fuunl  a  very  broad  and  distinct  band  in  tliw  mastoid  ciJll«  of 
1  iahttt  ibar  mvntlts  utd.     It  is  iiard  to  understand  how  real  fibri- 


*  Omi/'t  tl</^U<*l  Htforu,  vol.  KXXitL. 


176 


DISEASES  OF  THE  EAH. 


nouv  acliioNlom  ttliotild  forni  in  iiuoti  a  onvity  at  t)io  tympiiintim  ' 
out  tbe  dfusioQ  of  a  conaiJorablo  quantity  ot"  Ij-mpb,  wliioli  mm*  ^ 
iovulvc,  OQo  wnulil  mi)ii)0«u,  (Ui  attack  of  intluininntioii  of  ■  (bnaiij 
sblo  kind.     I  Itavo  observed,  alito,  tliat  mombranom  bands  in 
tjiRiiaiiiiin  do  not  w»im  to  ntlwt  tiic  hcuriny  to  an  iii<;'>ii\'viiivDl 
dogree,  unless  they  also  interfere  with  the  moUons  of  Uie  ossioula. 

TIw!  tUapnwtis  of  niemhninoiis  b»i<l>>  iKdiffi<;ult.  An  irrngularit 
and  increased  ooncavity  of  the  menibrana  tympani,  the  EiLila«biail^ 
tabe  being  jiorvious,  may  ^vo  grrtund  for  HtHpo»ting  ttioir  proaoneOi 
whidi  will  be  rendereil  mora  probable  if  there  be  a  history  of  pr^ 
vious  inflamniatioiL.  When  tlioy  hiivu  vxiottKl  for  any  length  of 
time,  no  trnatmetit  aecinn  likely  to  be  useful,  so  far  as  ihey  are  con- 
oemod.  Thoir  provuntion  lorms  part  of  tho  treatment  of  inflaiB- 
mation  of  the  tyiii[)jiriic  inu»^us  membrane.  If  any  thing  oonk) 
improve  tho  condition  of  an  ear  in  wliioh  thoy  are  completely  derg 
loped,  it  might  jierluipii  bo  tlie  free  intlation  of  witnn  va{K>urs  toti 
the  trmpaniun. 

Many  ])atii>ntd  tiome.  before  tlio  Surgeon  with  a  more  or 
complete  disorgauisation  of  the  tympanum  from  the  etfocts  of  forma 
inllainniutiuti,  in  whom  tho  membranu  t^-mpuni,  tlioiigh  not 
foratod,  tH  faUon  In  and  lies  in  eontaet,  or  nearly  so,  with  the  pr 
monlory,  and  the  wii  stri»rtur>-s  are  inttltnitMl  with  fibrino 
converted  into  hard  and  rigid  masses.     In  such  cases,  if  tJiere  isi 
oxi:>ting  inthuiiinulion,  it  is  scarcely  iKwsiblo  to  suj^ffcfl  any 
which  are  likely  to  improve  the  organ,  and  the  patient  must 
content  to  obtain  such  allovintton  as  the  usoofa  hcaring-tmmF 
will  afford  him.     The  power  of  hearing,  in  some  of  tliwe  pxtitM 
K  greater  than  the  eonditioii  of  the  visible  portion  of  the  ear  wou 
lead  us  to  antiei)iatA;  and  even  the  worst  cases  need  not  alwMvs 
entirely  abandoned.     It  is  ofU^n  the  oaso  that  vrhcii  one  ear  has 
eo  injtireil  by  intliunmalion  ili  to  I>o  mueh  lesst  M^nsitive  than 
other,  tho  patient  aoquircs  the  habit  of  entirely  disnsing  it,  and  i 
nlying  itiili^ly  upon  tlio  l)utt(T  organ.     Tliu.*  the  function  of ! 
injured  ear  becomes  deadened  and  sluggish  firom  mere  lack  of  i 
creisc,  and  it  'w  capable  of  being  nniwd  by  umo  to  groatly  inc 
sensibility.     Soinetinies  persons  who  have  tlius  snljered  one  ear  I 
fid]  into  (losuetudc,  arc  uiifortuiinto  miough  lo  meet  with  an 
dent,  or  suflcr  a  disense,  whicli  destro^-s  the  other,  and  then 
may  obtain  gn-at  rclit-f  by  bringing  inti>  uw  the  liit«>iit  powers 
tho  neglected  organ.     By  means  of  a  hearing-trumpet,  or 
timeH  without  it,  im  car  long  »up{>OKed  u»cIck»  may  be  broi 
tlirougli  iKjnsevcring  exorcise,  to  play  a  very  serviceable  part. 


AFFECTIO:fS  OP  THE  TYMPAJmir. 


177 


^ 


die  nnw  groutul,  it  ahotild  alwaj-n  be  a  ruin  witli  the  Stirgoon  to 
.fBootmi^  tboBo  who  have  Mistaiiifd  irroparablo  injury  to  one  ear, 
oftiital  dfjifm^i,  III  inuiiiliiin  tl  in  oxim->M>  hv  ii>tiii<;  it  alone 
fcr  ft  cenaia  period  ererj-  day.  Those,  also,  bv  whom  henring  oon 
le  perfoniicd  unlj'  witli  ditiimdly  tliroiigh  disvniw  of  both  ean, 
ibnU  be  instnietcd  to  esercise  what  power  may  remain,  inHtaad 
of  nJring  on  tliv  Mi'ht  alonct;  and  tliuir  frirJi^U  xhoidd  bu  willing  to 
tkl  them  in  this  endeavour. 


tiujidit^  oj  ikf  muivus  tiumlrrane  of  (In  ttfrnpaintm.      Tliis  is  ft 

OODdition  wbidi  firquontly  OM-un  in  ndvanvcxl  btv,  iind  if  |>rulMibly 

tbe  cmuse^  in  a  large  proportion  ofcnfies,  of  the  doafhoss  tliat  ia  k> 

an  at  the  commviiixtmciit  of  old  a;^-.     Tlic  rxt!<lenco  of  tliis 

•tueatt^  luiA  Iieen  ntAblislMxl,  nnd  its  symptoms  illuntratt^,  by  the 

Unara  of  Hr.  Toj'nbcp.     Acconitng  to  that  nuthor,  tbi?  iutpHimicut 

I  of  Wring  b  due  t/i  the  diminntion  of  the  natunil  moliility  oftlte 

'  Bi)ns ;  the  rigid  membrane  fixing  it  moro  or  loss  complctoiy  to  the 

nil  uf  Hm  v(!»tilitde.    Tho  »}-m[)tonit),  therefore,  are  sinnliu-  to  those 

aTtiw  affection  noxt  to  be  mentioned,  tho  tmc,  or  bony,  aniyUsia 

if  At  »tapftL.   The  membrane  lining  tho  tympanic  cavit)'  may  btiL-uiiio 

qpi,  cither  as  the  rcsnh  of  slow  intiammation,  or  from  a  process 

■fpuvatly  of  lU-gt^tTi^tion,  no  indi<!Htion«i  of  infliinimiitorv  nt-tiou 

Wing  been  at  any  time  present.     It  become*  slightly  thieker  than 

Mnl,  but  maiiituiiui  it^  pale  cnloiir  and  normal  [kiIimIi  ;  the  KtApv* 

I  miy  be  moved  by  tlio  exertion  of  force,  whieh  is  sometimes 

I  (nridembkx     On  in-iitoction  of  Ow  car,  tlie  meattii^  in  fitsjnently 

imid  doroid  of  oenunon  j  the  membrana  tympaiii  is  eitlier  natural 

'iGglttIr  opnque;  occiiHiomilly  it  may  eoniaiii  eiileiirtiiiis  di^jioMts. 

I  Tb)  Eosiachian  tube  is  penioiis ;  and  tlie  air  enters  either  with  the 

I  ttfiinil  i-gand,  or,  if  any  inllininnatory  tliickeiiing  l>e  prcnenl,  with 

I  indicative  of  thai  eondition.     Ko  pnin  is  present ;  bat  there 

IfOwnlly  lui  anniiying  tinnitus     Tiio  diagii(if<i»  do[H>nds  portly 

ilko  history  of  the  case,  partly  on  the  peculiar  character  of  the 

,  and  (MUtly  vn  thv  abHinvo  of  tht)  »yrnptoni»  ofutJiiir  dineafte 

,  tlio  ear,  or  of  those  which  cliaractorise  "  nenous  dea&eas." 

F etud*  jtvculiarily  of  ihc  deafni^nit  is,  that  llio  "  adapting  jjowej"" 

organ  is  more  affected  than  tho  mere  ability  tn  distinguish 

The  potknC  i»  cmbarrtviKoti  in  general  eonvenuttlon,  whilu 

Mt  tB  hear  single  voioee  with  tolorublo  ease.     This  symptom,  how- 

(Nr,  suy  alno  wxi«t  in  cnM»  of  nt-rvoud  iteafne.tit,  arising  from  the 

I'ti.mnt  connected  wiih  a  large  eompiiny ;  but  llie  nioUo  of  its 

nAmtioa  is  different,  and  iu  Uie  latter  cases  excitement  produces 


178 


DISEASES  OP  THE  EAR. 


tiic  Himtf  effect  undtT  nil  oircHiiiKtJtiip«».     Hearing  better  in  a  nolw," 
as  wliilt;  riding  iu  n  carriage  or  duniig  the  beating  of  n  dniiiij 
appears  to  bo  oommoii  to  this  with  boric  utLor  morbid  conditions. 

The  troiitiuent  i-ecommondoil  by  tlio  best  imthoril)-  on  tJid  milijc 
ix  tho  spplicatJon  of  a  Hohitiim  uf  the  nitrate  of  silver  (588,  or  ^. 
$j.  (if  wiilAr)  to  the  outor  half  or  two-thirds  of  tiw  nicntti*,  uv 
tliird  or  foiirtb  day.     Or  ihv  mcntbrami  tympaiii  may  be  wasbe 
witli  II  Nitniliir  sohilion,  of  a  fltrength  of  six  giniiiit  to  tho  ounce 
tho  tinnitus  is  severe,  or  there  is  any  congeetion,  leeches  should 
Rpplidd  below  the  eara,  and  vesication  may  lie  kv]>l  up,  with  iiitcr-^ 
missions,  over  the  inaJttoi<l  process.      Small  doses  of  hydrai'gyruiu 
cum  cretji,  or  of  the  bichloride  or  biniiHlido  of  mcrciir}',  iiuiy 
given;  but  these  sliould  Ih)  »u  administered  a^  to  produce  no 
bility,  nor  any  painful  aymptom  whatever.     To  tliiwe  UKumH  mi 
perhaps  bo  added  the  |M;r»ovorin(;  practice  of  inflating  the  tj>-mpanui] 
strongly,  with  warm  or  medicated  va(ioiu-s.     A  warm  bath  may 
taken  every  week  or  ten  days.     Perliajis  tho  Turkish  bath  might 
still  nion>  cffieaciiius.     Wai-m  rooms  ctbould  be  iivoldvd,  and  luuplt 
exercise  taken  in  tho  open  air. 

Thif  ft>nn  of  disease,  together  with  that  next  to  bo  nivntiont-dj^ 
has  been  nseribed  to  a  gouty  or  rheumatic  constitution.     On  tiil 
pointy  however,  farther  invest igiitiim  may  be  needed.     Dr.  Ga 
infonns  me  that  he  doe*  not  find  gouty  or  rheumatic  patients  • 
cially  liable  to  di-afness,  tiie  ear  (brniing  in  this  reK{>oet  a  decide 
contrast  to  tho  eye;   and  Dr.  Gull  has  submitted  to  cxaiuinat 
eomo  de|iositfl  from  tho  tyin|iiumni  supposed   to   contain   aeieuL 
crystals  of  uric  aeid,  and  has  found  them  to  consist  of  fat," 
bcst-markwl  case  of  the  connexion  of  dcjifncss  with  the  gouty  du 
tl;esis  tliat  has  come  under  iny  own  obser^-ation  is  that  of  a  1 
aged  fifty -*even,  subject  to  attacks  of  gout,  and  slightly  deaf, 
tiie  oi-cjLtion  of  tho  sudden  dcatJi  of  lier  husband,  an  int(t)i»c  deoAj 
noes  eamo  on  in  the  coiu^c  of  u  few  hours,  wliieli  subsidod  on 
local  manifestation  of  gout  two  or  tlu'ee  days  afterwiuib. 


Disease»  of  Oif.  Omatla. 

AnfylofU  of  the  ttope*  to  the  /aur&tra  ovalis.     Hiis  is  an  afioi 
tron  which  is  mentioned  by  early  writers  on  ilie  ear ;  but  llw 
quciicy,  imporl.'inee,  and   eh anict eristic  symjitoms  of  which  hati 
been  known  only  since  tlie  publication  of  Mr.  Toynboc's 
Itcouusts  in  a  union,  by  bone,  between  tho  base  of  the  stsjws 


•  aui/$  Uttq>Ual  TUforti,  ItJQT,  ji.  asO. 


ANKYLOSIS  OP  THE  STAPES. 


179 


fba  W^f^  of  the  fenestra  ovnlis.  This  condition  may  exist  in 
nriow  fucnu,  uith<^r  lluit  of  a  siii)i>1e  cx|)aruiioii  of  tliu  buiw  of  tlio 
•upea,  or  an  expansion  oomblnod  niUi  a  calcareous  whiteness  of  tlid 
boae,  iir  with  cflu»i(>n  uf  owteoiui  matter  witliin  ur  around  the  joint. 
In  Mine  cases,  there  is  found  a  tliickoiiing  and  ri^dity  merely  of 
the  Egamcuts  coniiixHing  the  artieulutiii|r  MurGiocs.  Tito  general 
Minptoma  are  the  same  as  thoAO  of  tlie  lastrinentioRed  afleetion. 
How  tkr  treatment  ik  ofuny  clfcct,  there  in  tu  yet  uo  sufficient  cvi-' 
deDce  lo  show. 

In  CanstattV  JaiimilfTirhi  for  1859  i»  an  account  of  a  paper 
by  Voltolini  on  this  subject.  Talcing  into  consideration  the  very 
■light  amunnt  of  motion  nonnalh'  potuicssud  by  tliv  stapcdie-voeti- 
Wir  articulation,  it  appeared  to  Mm  nnlikety  that  the  deafnesa 
vlucli  ucctint  in  ito  anlcyloKed  <.«>nditii>n  oould  arise  from  its  ini- 
ttbility.  Experimenting  upon  the  subject,  he  found  that  vibra- 
were  tnuitimitted  bcAt  from  air  to  a  limited  ourfaoo  of  water, 
litbn  tlie  latter  was  covered  by  a  plate,  which  waa  not  Holiilly  oon- 
I  lected  to  the  boundaries  of  the  aperliin.*.  It  is  to  the  alteration  in 
[  liia  mpoct,  therefore,  and  not  to  loea  of  the  motion  which  uiigbt 
btpvcn  to  it  by  the  muscles  of  the  tympimum,  tlmt  he  a^ribes  tlie 
iMfiMM  which  aoeompanies  oaseoos  ankyWin  of  tlio  stapes.  In 
Mpett  to  the  dia^^nusis,  he  nyects  tlic  relatively  greater  inability  to 
■olsstand  mixed  conversation  tlian  to  diHiinguiKh  xingle  i>oimds, 
d  iriiGS  chiefly  on  the  appoaranve  of  the  external  portions  of  the 
or: — the  nieatwi dry,  widened, » ithout  %il.il  reartioii,  an<\  lenthorj- ; 
Ai  Bttmbrana  tympani  parchment-like,  dry,  thick,  opaqne,  sonie- 
lim  with  eartliy  deposits,  and  immobile,  lliv  atfection  oceurs, 
,  in  dry  and  harsh  constitutions.  The  soand,  on  inflation  of  tJie 
tube,  b  normal,  or  too  full,  and  tho  act  produces  no 
He  rvjc^'ts  all  treatment. 
In  coonexion  with  this  atfection,  Mr.  Toynbeo  has  rojiortod  a 
*  in  which  a  great  tempor:ir}'  improvement  was  effected  by  a 
I  mJ  diout  uttered  rhine  lo  the  ear ;  iliis  Inipruveinont  being  ascribed 
•f  bn  to  a  loosening  of  tho  stapes  within  its  articulaliou.  Perhaps 
Aifalkiwiiig  ca«,  riilaleil  by  Ti-itiuot,  was  mie  of  a  similar  nature. 
I  had  BufTercd  from  deaiiicss,  coming  on  gradually  for  majiy 
vrithuut  any  known  cautte.  It  wm  attendi^l  with  tinnitus, 
of  despondency  lie  fired  a  pistol  Into  the  right  ear.  The 
dvwtniyed  tlte  auricle  unit  fractured  tlio  mctttiis.  passing  out 
I  the  scal[>.  Tho  licnring  in  that  ear  was  raised  by  tlie  shock 
two  to  twelve  centimelri^  Indeed,  tlie  causes  which  will 
ae*  aeem  to  improve  tho  bearing  in  caaos  of  deafness  arc 


^ 


fit 


180 


DISEASES  OF  THE  EAR. 


fthS" 


Bach  as  wo  ooiiUl  by  no  nioan«  anticipate.    An  elderly  lady,  who  hj 
been  nndor  my  care  for  deafness  iittctidod  witli  perforation  of 
meniliraiia  t^-iiijmni,  van  soiled  witli  paraplegia.     The  hearing  be> 
cumc  decidedly  better  at  tlic  time  of  tbo  attack,  and  cunlinood 
for  some  years. 

EjcostoseSf  or  depoxits  of  osseous  matter^  aro  occasionally  fon 
on  the  other  ossiole;*.     One  case  also  i.**  on  record  of/rarturr  of  I 
handle  of  the  malleus.     It  was  found  in  tbo  body  of  a  man  who 
died  in  Guy's  Hnspilal  fi-nni  <lisi^iL<u3  <iuite  unoimnectod  with  thifl 
ear,  and  is  reported  in  the  Ptttholoffieat  TransactimUi  vol.  x.  p.  238,^* 
Tlie  fnicturo  took  pin™  just  abovo  the  ])roeijssus  bnrt'i.*,  at  the  point 
where  the  tensor  tympani  ligament  is  attached ;  the  fra<;tun)d  sur- 
face was  smooth  and  convex,  and  R'tfiiusl  to  )i)ivt>  played  on 
joint  upon  the  body  of  the  malleus,  which  was  displaced  inwards. 

DislocJttion  of  the  nssieiiia  is  niiin>  tWti»cnt ;  it  s<-nerally 
between  the  incus  and  flta[>e8,  and  is  accompanied  with  caries 
the  lioncs,  or  otJior  ofitHrl*  of  inflummiitioii.     h\  tho  »n!vorpr  fbniu 
of  inflammation  of  the  mucous  membrane  of  the  tymiwnum,  indeed, 
caries  of  tlieitc  bones  is  a  not  unfrixjucnt  result.      For  tlic  moit^_ 
part,  when  this  occurs,  the  membrana  tympani  is  perforated;  bii^| 
this  is  not  always  the  ease.     Tiic  hesid  of  the  malleus,  the  incuB,^ 
and  one  crua  of  the  stapes,  have  been  found  to  bo  destroyed 
caries,  tjiat  membrane  being  entire."     The  patient  WM  a  wi 
aged  thirty,  who  died  of  acute  peritimitjs. 

In  ea.«cs  of  perforation,  tho  incus  frcquontly  comos  away  in 
more  or  less  carious  state;  tlio  malleus  also,  but  ieits  frequently;  am 
still  more  raroly,  tho  stapes  may  bo  separated  from  Ha  attachmeii 
and  east  otf.    Whether  t^otul  deufiims  n*.-ocsftarily  rcaultA  from  loits 
tho  Btapce,  invoI\Tng  as  it  must  do  the  disobargo  of  tho  pcrilym] 
from  the  internal  car,  ia  as  yet  unilectilod. 


Dueasea  of  t.he  Mattoid  CcSs. 

Besides  |iarticipating,  as  they  for  tho  most  part  do,  in  infln 
tnatory  disCTsos  of  the  t  j-mpanum,  tho  m.ist«id  cells  are  snbject 
al^tions  wbicli  do  nut  involve  that  caiitv.     Tiiej'  may  be  the 
for  example,  of  deposits,  chiefly  of  cholestorine,  while  tlie  Ij-mp 
num  is  free;  and  iiiflainmatiini  leading  Ui  caries  or  neero»i)t  of  I 
osseous  walls  may  coexist,  though  seldom,  witJi  a  coni])anilive 
healthy  state  of  tlio  ai^act^nt  jiarts.     This  latter  aJTiuction  U 


*  Tri<|uct,  from  the  Oai.  de4  Hap.  Jon.  I6&1. 


^V      AFFECTIONS  OF  THE  INTERNAL  EAR.  181 

HtM^uent  in  eliiMliood  than  in  ndult  lifo,  and,  whether  oonituqnotit 
^M|  disssse  oommeDcing  in  the  trmpanum  or  not,  demands  prompt 
^PHom  to  prurrnt  iixtviiiiioii  of  tlio  iniMiltiei'  to  tliu  intnurruiiiol 
KrgisiH.    Tbe  sjnnptoms  are,  tondeniesa  over  tb«  mastoid  process, 
BbUnwcd  l>v  rwlnww  ainl  Inmi-fiw'tinn;  a  disclHirpt  gcnvniil^-  issues 
rikmi  tbo  meatoa,  alUiough  Uie  walk  of  this  passage  may  bo  perfects 
&iiii0tinMW  RR  oWcuru  fluctuation  may  bo  fvlt  bcltiiid  the  «)nr.    Tlicre 
■■  generally  at  this  stji^e  of  die  disease  beada<!ho,  and  pain  extend- 
ing orer  t\to  hack  iff  Uiv  )h-ji<1  and  iMx^k ;  ofloii  ^ddinosn,  aiid  otiior 
mn|itomji  of  irritation  of  tlie  hrain.     The  most  Cflsential  point  in 
tbe  trntnunt  i«  not  to  m^givet,  nor  to  dofcr  Um  Ion;;,  an  iiii-iKiiin, 
fredr  exjKwhyt  the  bon«.    TTiia  ^liould  he  maJe  in  the  vortical  direc- 
tion alMUl  hnlf  an  inch  behind  the  oar,  and  should  extend  ttie  nliole 
kn||;tb  of  tbe  maittuid  jtrooeaa.     Great  relief  almost  invariably  fbl- 
Imrs,     Sometime*  exit  will  bo  given  to  a  few  drofM  of  pui*,  and  ihs 
knife  will  p(!tietrat£  the  boI^iukI  Ixtne.     Poultiooa  ahould  be  applied, 
tnd  a  (Kwdischar^  iinc«>uragcd.     Portions  of  dead  bono  may  oonio 
■any,  or  iha  wimiikI  may  gradually  lioni  n  ithout  exfoliation.    If  the 
|«r^)ral  irritation  shotdd  continue,  a  eoton  applied  to  tlio  najw  of 
i,  or  an  iiHue  in  ilie  .-irin,  may  be  finiiid  naeful,  the  utmost 
st  the  name  time  taken  to  insura  a  fnio  exit  for  muttvr. 
'  am  of  tbo  trephine  In  remote  a  poriion  uf  ll>0  mafltoid  proceed, 
Hd  to  giv«  exit  to  matter  contained  ui  the  maetoid  cells  or  tym- 
fwu,  has  been  nroonimt-ndoL     Tlie  proi'eoding  in  fenaible,  and 
wif^  be  bad  reoour»e  to  if  othsr  meatu  were  miavailing. 

VL  AiTEcnoNs  or  thx  Ladtbcith  asd  Auditobt  Nerve. 

Tkeae  are  diTisJble  into  two  elaiwio ;  thoHo  in  which  demontilrahle 
I  IttliologMal  chaagM  are  or  are  not  present,  liut  our  knowledge 
I  m  the  ntyect,  aiid  our  moanjt  of  disgnixiin,  ore*  lioth  an  yet  very  im- 
fpffcet  Among  the  morbid  conditions  fuimd  within  tl»o  lab^xinlh, 
J  At  »094  fnrqiii^nt  arv :  vasculiirity  of  the  walls  and  membratu>us 
I  (ahi ;  deficiency  of  the  lab^Tinthine  fluid ;  excewi  of  otoconia ;  eftu- 
of  lymph,  of  r«l  wnim,  or  of  blood,  the  latter  beuig  chiefly 
:  afcr  typhus  or  typlK>i<l  fever.  Tl>e  tymjianic  aperture  of  the 
has  \hvn  found  filled  with  osseous  dsposit.  The  auditory 
It  sometimes,  eApe<ria]]y  in  old  pcnu>ns  who  Itave  boon  long 
atrophied,  and  much  reduced  in  size ;  but  it  is  doubtful 
this  condition  ia  not  rather  a  retult  of  prolonged  disuse 
>  cause  of  deafbosa. 
Two  interesting  caaee  are  quoted  by  TVii^uct  &du  Meniere  (in 


188 


DISEASES  OF  THE  EAR. 


his  tmnslntion  of  Kramer) ;  ono  of  n  girl  cxponod  to  »eren  col 
for  sercra]  hours,  by  having  to  travel  in  an  opt-n  carriage  at,  iiiglii 
during  tlie  cnlamonial  )>crio(l.  In  a  fiMv  hours  »lio  Ix-cumg  cotoi 
plctoly  deaf,  without  pain.  Death  soon  followed.  There  was  foundj 
tliriiiijrhriut  t.lie  liiliyriiith,  "  ii  Sdri.  ofpijwtif,  rt-ddi^li  lymph,  whic 
appeared  to  be  tlie  product  of  ao  inflammation  of  all  the  membran^ 
e)U!«  snrfBces  wliich  liin!  tlic  internal  cjir."  In  anotlit-r  simitar  ■ 
proving  fatal  in  two  months,  there  existed  Uie  same  platitio  Knnphfi 
«fyi'llow  colour,  occuj»yinfj  (ho  lahyriiilli,  witJi  a  niinilx-r  of  small 
gray,  opaque  jjointa  scattere<l  through  it,  rtfteinhliiig  commeneing 
tubercle.  In  some  rare  inntjinces,  tiit-  bony  portion  of  tho  internal 
ear  becomes  necrosed,  and  finds  exit  ihvouyh  this  meiitntt  exterauii 
without  prwtucing  disease  witliin  the  iskidl.  In  a  patient  of  Mr, 
Shaw's,  a  hoy  who  hnd  suflerwl  fmni  seurlatina  two  yisirs  and  a 
half  before,  almost  tJio  whole  of  tlic  bony  labyrinth  was  thus  cast 
off,  being  wunoved  by  the  forceps  fi-oni  tlie  external  meatus.'  And 
in  the  case  of  an  old  man,  who  came  under  my  ovni  observation, 
the  ejiliro  eoclilea,  with  some  of  llie  adjact^nt  hone,  tiud  come 
•way. 

7Vm.-mur  denfne«»,  TIhh  afl^ection  in,  doubtle-sa,  froquontlr  due 
to  one  or  other  of  tho  lesions  mentioned  above;  but  there  can 
be  little  doubt  that  ca-ws  occur,  in  which  the  hearing  jjowcr  )» 
moro  or  leas  completely  lost,  without  tho  existence  of  any  organic 
diungi'  appri'iaabli)  by  our  present  mi-ans  of  ex ntni nation.  TTie 
frequency  of  tliis  affection  has,  probably,  boon  often  exaggerated ; 
bnt  when  all  the  causes  of  ileafnosa  whiult  have  tlicir  seat  in  the 
conducting  portions  of  the  ear  have  had  their  full  weight  allowed, 
and  nil  the  CK*rs  in  whtcii  then?  is  n.uiaon  tii  Iwlieie  tlicre  has  cxtjt<.il 
any  inflammatory  or  degenerative  action  within  tJie  labyrinth  on 
set  apart,  there  still  renuiins  a  considerable  nunilKT  of  persons  in 
whom  there  appears  to  be  a  defect  of  power,  either  of  tli«  n<^rve  lo 
receive,  or  of  tho  brain  to  approcifito,  soiuid.  Tho  characteristics  of 
this  form  of  deafness  are,  a  tioalthy  state  of  the  ear,  mi  fiir  as  it  oui 
bo  ex|tlored ;  an  inability  to  iK^ar  sounds  conveyetl  by  tlio  bonce  of 
tile  skull ;  a  peculiar  constitution ;  frequently  an  hereditan*  ]>rvdif- 
position  :  for  tho  most  part,  a  great  aggravation  of  the  deaftiess,  bv 
excitement  or  dcprissiou  of  mind;  and  luatly,  the  histor}'  of  tlH 
earn.  A  careful  inquiry  seldom  falls  to  elicit  some  circumstances 
or  erenta  of  a  di'[iressing  ehuruct^r,  or  some  shoi'k  cither  to  tbd 
^jtttem  or  tlio  oar,  to  which  tlie  injury  to  the  hearing  power  may  b^ 


*  Tnmtaetiunt  of  the  Patholagkal  Soiitty,  vol,  vH.  p.  333. 


NERVOUS  DEAFNES& 


183 


Tinnitus,  often  constant  and  of  a  very  dtRtrtwing  clia- 
',  m  gcnornlly  |iri'*nit. 
Patieota  duD'ering  from  deafii(-j»  due  to  conditiniiit  nf  tJw  ner- 
tyttam  oomc  under  two  cIa»os;  those  in  whom  the  atlbotioit 
Ksted  (probably)  in  tiie  lutiyrinth,  ur  undibiry  nurrv ;  and  thoee 
in  irbnm  the  ilcnincss  u  accomp&niod  br  jET^ei^id  ncn-ous  debility, 
and  is  lo  bo  refcn-ed  rather  to  tlie  n«rTt<ns  wiit«'j*.  Among  tbo 
Ibntier  CDM-M  ttrx!  to  b*-  plnci-d  th(>«>o  in  nhom  the  deafncos  ih  mid- 
Aeafy  prodiioed  by  n  loud  itound  (wilhnut  injury  to  the  nit;mbrRna 
tjmpoiii),  or  by  a  full ;  or  foUong  immedintply  upon  exposure  bo 
igreat  cold ;  or  comes  on  during  inuiniiH,  witimul  iilrtTutinii  in  tliti 
^■ipfwaninoc  of  the  car.  Among  tbc  latter  are  the  cases  of  deafness 
arising  fVom  prolonged  lactation,  or  tiie  o)iernrion  ol'Dtlu-r  <U'bili- 
Ulint;  ciiUNe:<,  Mich  as  fiitigno  in  tropical  climates,  exeessi\-e  exertion 
rf  body  or  mind,  over  ntudy,  sorrow,  want  of  HufKcii^ut  tJix^p.  In 
]etfnn*  pn.<<ili«po»ed  to  tbe  affection,  veiT  slight  canscs  niny  appa- 
mtly  determine  its  acoe-w.  In  ono  w«^ll-inarki'(I  :ukI  .-Mivi-it;  case, 
ii  Mi[icrrenixi  upon  tJie  administration  of  a  strong  purgative.  This 
Urm  of  deafneas  is  by  uo  mcutiH  eoiiKned  to  ailtilt  life ;  if  any  thing, 
iti«  mnrc  Irngnont  in  the  young;  and  it  may  bo  met  witli  among 
dddren  at  achoo),  or  subject  otlierwiwa  to  exc!<w<  of  Mtndy.  Deid- 
nw  has  a1t*M-natcx]  nHth  ot)icr  affeetions  as  a  rcsnit  of  wonns. 

Loaa  (>f  hearing  h  NoinetimeH  u  .■•yinpl<im  of  tiimuiirK  ))nvwing 
W  Ibo  brain.  Jn  this  case  it  seems  to  be  generally  attended  with 
tAw  aflei^'onii  of  the  nervmw  Mvott-m,  wliidi  n  carcfiii  examination 
W*  detect. 

1  am  of  ojirnion  that  then;'  may  Ims  a  "hysttTical"  ileafnes*;  at 
««,  I  have  met  with  llie  case  of  a  girl  who  suffered  gi-e»tly  t'rom 
■•  conlinnetl  intcmjwraiico  of  hor  motlicr,  and  who  was  lialilo  to 
Wft  complete  tcmpoj-ary  loss  of  hearing.  It  would  cume  on  rajJidly, 
bm|  ili«{i[M>eir  iniddciily,  tlio  hearing  being  good  in  the  iJl^cr^'als. 
Tbf  inspection  of  tijo  ear  revealed  no  disease. 

Ihi' trvalment  of  nervous  deafneits  should  Ixi  guJihtl  by  tlic  na- 

tnreef  the  affectimi  in  eoeh  jiarticuliir  inManee.     If  ijiere  be  reason 

taaupmA  n  nyphilitic  taint,  or  if  ihc  gouty  or  rhtiimutic  diathesis 

fc  well  marked,  ainl  there  exist  signs,  however  obscure,  of  an  iii- 

ianaintorTi'  **■"  irritable  condition  of  the  labyrinth  or  iier\'c — as  for 

eampte,  the  increase  of  deafiiess,  or  of  tinnitus,  by  moderate  stimu- 

hntk,  such  as  a  sin;:lc  glas*  of  wino — a  eommponding  antiphlogistic 

lad  i|>e<cific  trealini-nt  might  bo  had  recoiuve  ta     But  for  the  most 

fan,  if  tbo  ilmfncss  bo  tmiy  seated  on  the  inner  side  of  tho  tym- 

jMium,  Aerere  measiirea  do  unmitigated  liann.    I{e[ieHt(^  blistering 


184 


DISEASES  OF  THE  EAR 


es, 


tnaj  ofiect  a  fotnpurur)'  improvemoat,  at  tbc  cxpcnM^  of  a  pcrman; 
Oggravutioti.     Kli-ctri<'ity,  so  i'lir  a»  it  biiAyot  been  triwl,  mh-iiih  to 
bo  of  iio  permanent  value.     It  i»  not,  however,  hurt&I,  so  far  aa  |fl 
am  aM'.-iro,  »ri(l  l)io  mii^iielii-e)fctri<!  inaotiiiio  fonna  a  ooiivi'iiipnt 
apjMiTAtiiii  nhich  pationlA  may  pasilj'  be  taught  to  apply  tbouiselveSj 
if  tlieir  cai«es  swm  euitnble,  and  they  nnu*  otlin-wiw  bo  vhuti] 
abandoned.     Whenever  t]io  affection  ean  bo  traced  to  any  debill^ 
fating  miiitR,  luiil  it  ir  of  rocent  iKi;«>w,  lJii>  removal  <if  tlio  CROM^ 
with  a  general  tonio  hygiene  may  bo  attended  with  a  perfect  cm*. 
Of  all  nKviieiniM,  a  combinntinii  of(|uininc  and  morphia  iii  Jonajl 
doses,  taken  jier seven ngly  once  or  twice  a  day,  Bcenis  the  most 
naoful.     ^timduting  liniments  aroiimt  tlio  eHni,  ptThajM  eontaininj 
chtorofomi,  if  tinnittia  is  a  prominent  symptom,  are  a)  lea-ii  un- 
objiKitionable ;  and  tlio  ftwo  uso  of  eold  water  and  friction  may 
most  oa.<>es  be  adviMKl.     I  have  never  known  any  benelit  prodtir 
by  strychnia.     Mr.  Braid,  in  the  A»sociatum  Medical  JoHmal  fa 
Sept.  !*<■'».'),  has  reported  some  cases  of  "  nervous  deafne«i*"  bene 
fittod  by  hj-piiotJsm.     The  doafeoss  cauecd  by  falls,  whvn  great 
amount  and  luivarying,  is  on«  of  llie  least  amenable  to  treatmMit. 

If  hcaring-tnimpots  arc  had  recourse  to  in  these  cases,  and  the 
are  advi.tubic  when  tlic  donfti«ss  is  continued,  care  should  Im) 
that  thoy  are  such  as  not  to  try  the  ear,  by  producing  a  loud  me 
tallio  ro^oiiance.     Tlic  patient's  on-n  sciiiiinlions  aro  the  1k^  guid 
in  Bolccling  them,  and  tbey  sliould  not  be  more  poworftd  than 
BbjtoIut4.-ly  necessary.     A  very  convenient  form  is  one  tliat  pnK^J 
by  a  spring  over  the  head ;  and  in  tlie  case  of  women  it  may  b^l 
almoHt  entirely  concealed  by  the  hair. 

Loss  or  dttninution  of  the  nervous  power  may,  doubtless,  ooexis 
with  other  diseased  conditionft  of  the  organ,  and  may  aggravate  I 
effect  of  intlnniniatiiry  lesions  of  tlie  tjmpanum,  membrana  ty 
pani,  or  meatus.     In  tlieso  eases  tho  symptoms  would  bo  of  a  mix 
character,  and  it  secmtt  to  mc  that  this  is  often  the  caaa.     Tlie  di# 
appointment  which  sometimes  attends  the  hcst-adaptod   measnr 
for  the  i-elief  of  patients  sufiliring  under  disenaos  of  tlio  latter 
may  be  due  partly  to  this  cause. 

A  true  neuralffia  of  tho  ear  haJt  Iiccn  describe*!,  though  it 
to  be  a  rare  afTeetion,  except  as  comiected  with  disease  of  iho 
It  in  strictJy  p(!rio<lic  j  the  ear  is  healthy  in  all  respect*,  and 
faearing  power  is  not  duniuishod.     It  demands  notlung  peenliar 
its  treatment. 

For  tinnitus,  when  it  forms  a  prominent  symptom,  and  rationi 
treatment  fails,  varioos  specific  reiiicdi««  have  been  profwsod. 


^^        DISEASES  IMPLICATING  THE  BRADJ.  185 

^*ilds  bdwvM  fbc  tinctoro  of  arnica  has  been  saoe(«sful.  Triqiiot 
ri!|M>rta  rnin  cnred  in  a  few  days  by  daily  iiijortion-t  ut'  tim  viipoiir 
of  eblurofbna  into  the  tjTnpanuio.  Kramer  aitinns,  that  tinnitus 
»  iQ  aQ  cntes  due  to  irritalion  of  t)u>  vhonia  tynipniii,  and  mil  of 
thv  anNiBtic  norve ;  and  say»  that  the  ro])«atod  injection  tbraugli 
Ae  Eiutavliiari  call>et(>r  of  a  drfi]!  or  two  of  a  solution  of  strychnino 
(ooegtam  to  tlw?  ounce  of  water)  will  generally  cnro  it.* 

ExceMJvo  Kctnsiljililj-  to  Hoiiiui  (or  h^-pcratwuxin),  iiii<l  the  jwr- 

crpUoD  of  a  secood  sound,  often  diaoordant,  aocompan}-ing  every 

tone  (paracuuitiB),  nrv  rant  phenomena,  cxocpl  as  oceurriii<;  in  tho 

nrlyet^ea  of  inflammation  within  die  h-nipanum.    Tliey  are,  how- 

Ter,  M)ini^ni«H  [)(!n>t8tvtit,  and  occasion  great  annoyniicu.    A  chko 

i  qtkoted  fimn  Sauvage,  in  which  a  rouAician  waa  oompelled  to  give 

hia  occupation  bocauM  bo  continually  heard  a  second  inlinr- 

nonious  oote  with  even'  note  he  placed. 

Among  the  caiisoa  of  doafnoas,  having  its  seat  prohalily  in  the 
stmctureaofiheear,  niuithn  mentioned  iiercditary  syphilis. 
I&ea>rding  t/i  Mr.  Hntehiuson's  csporiencc,  deafness  of  a  very  ox- 
[  tRne  character  i:*  freiiueni  among  thi»  elastt  ofpcrHon.t,  nnd  in  mmQ 
<f  them,  whom  bo  has  given  me  the  opportuui^  of  examining,  there 
nirtod  an  almottt  total  loss  of  hostriiig,  wlii]t>  tlio  condition  of  the 
fnB  of  the  ear  open  to  examination  was  scarcely  altered  from  that 
tflMdlh. 

VTI.   DlSKASES  OF  TBB  EaR  ntPLICATINO  THE  BrAIN  OB 

Latckal  Sinus. 

lUi  blal  rlawi  of  diwKiRca  haa  been  long  recogniited,  hut  mnch 
■ttfioaal  light  has  been  recently  thrown  upon  their  pathology  by 
winvottigntion*  of  Mr.  Tovnlx-c  and  I>r.  Gull.  The  f'nnner  has 
•^■n  ibat  inflammation  of  any  portion  of  the  ear,  either  of  tho 
"eOok,  the  lym(>aniun,  tho  mastoid  celU  or  labyrinth,  may  extend 
I"  Ae  bone,  and  leaul  lo  a  fatal  issue ;  aiid  hns  establiBhed  it  also  as 
■|tBira]  mle,  tluU  disease  advancing  from  wthcr  of  these  portions 
rflfco  organ  seta  up  morbid  action  in  certain  definite  localitio* 
I  vilUi  the  eraniuni.  Tints  inflammation  of  the  moi» ins  or  mastoid 
I  tanda  to  produce  diaeaite  of  tlie  Interal  sinus  or  cerebtlUun,  ex- 
r^H  in  yonng  childmi,  in  whom  tho  niawtoicl  c<;lli<  are  verf  small, 
find  are  in  relation  rather  witli  the  cerebrum.     Inflammation  of  tho 


*  For  (he  cxperinMotii  ua  vliicb  this  view  is  fouaded,  see  hia  Okrm- 


180 


DISEASES  OF  THE  EAB. 


I  and 


trmpanum  for  the  most  part,  extimds  towards  tho  middle 
lolii-;  uiui  wIk'ti  tiio  lulivi-intti  f^  involve"!,  which  soMom  liappena 
except  by  oxtoDeion  from  tlie  t^-mpanum,  tho  pro(n'(»s  of  the  disoaal^l 
take*  the  ooumo  of  tliv  mulidiry  iiitv»  r^iwiuils  the  medulla  ob- 
longata.    Other  obHei-vers,  while  allow  ing  tho  grrnt  oxoctncKS  and 
importance)  of  th<!  rcIntiuiiK  thus  ]winted  out,  have  lield  that  ex 
tions  occur,  and  that  diseaHe,  eommeiieing  in  any  portion  of 
car,  may  ppoj^nsw  inwards  by  \-nriouB  n>iit«s. 

The  cliiof  secondary  diseases  produced  by  aural  inflammation 
arc  throe:  inRammution  of  the  dura  mater  and  the  otlwr  mem- 
branes ;  abscess  in  tho  siib<<taiice  of  the  brain :  and  inflammation  of 
tli«  lateral  ninwi*,  with  its  t-fFurts.  Tlic  two  fonnor  of  tln-si'  Bi!i-t-iion^| 
are  for  tho  most  pari  found  together;  but  cases  not  luifrwiQcnt!/^ 
oceur  in  wlitcli,  while  the  dura  mater  in  inflanieii,  tlio  cfrehral  ttHsiics 
exhibit  scai'cely  any  npjireiuable  altoration ;  or,  on  tlie  other  liand, 
in  which  one  or  more  abstN^sscs  exixt  within  the  hniin,  whiltr  the 
dura  mater  appears  healthy.  Besides  these  cases  of  demon stralilc 
Secondary  diwiwc  resulting  from  inflnmmntioii  within  thu  «ur,  in- 
atancea  occur  in  which  death  lakes  phice  with  symptoms  of  cerebral 
atftiction,  hut  in  which  no  legion  whatever  is  foiuid  «xot;|)t  witliin 
the  tympaiiiun. 

Tho  early  symptoms  of  impHeatinn  of  the  brain  arc  rigors,  ofti 
at  fii-st  resenibliiij;  iittjieks  of  ague  (so  that  tlicy  have  t>i»n  troai 
with  quinine)  ;  and  pain  in  tho  head,  gradually  becoming  into! 
flhiy  severe.     Thix  pain  for  flat  most  pait  cxleiidx  over  the  back 
tho  neck,  and  it  is  greatly  increased  by  motion.     Deliriimi,  imi; 
mcnt  of  uonHoiousncss,  <if  njimvIi,  nr  of  miiseiilar  jMiwer  may  en 
and  death  follows,  tho  pain  generally  being  intense  imtll  tlio  Ii 
Tlic  sudthm  cessation  of  a  chronic  disehargo  from  tho  mentus,  si 
companied  with  pain  and  fever,  irequently  marks  tho  onsot,  or 
least  the  threatening,  of  an  internal  iiiHammation. 

The  syni]itora8,  however,  are  not  always  of  this  acut«  c 
As  in  oth<'r  fonns  of  abscess  within  the  brain,  there  may  exist  for 
considerable  period  acarwiy  any  indications  of  the  serious  mischii 
that  has  taken  plaiMi,     Nor  do  thero  soom  to  bo  any  general  sym 
tomn  by  which  im  ahsocss  within  the  cerehrinn  can  bo  distinguii 
from  one  situated  in  tho  cerebellum.     Treatment,  in  this  atfi 
in  of  avail  to  save  life  only  in  the  earliest  stag(«t.    When  supjtuni: 
is  establiehrd  within  the  brain,  and  there  exists  a  diw.-ased  bone  i 
its  immeihatc  vicinitj-  acting  u»  a  constant  sonrco  of  irriUition,  it  I 
prohahly  vain  to  hope  to  do  more  than  alleviate  tho  sufferings  of 
patient.     The  first  and  main  indication  in  all  cases  is  to  obtain 


DISEASES  DIPLTCATIXG  THE  BRAIN.  187 


V9  a  pfriWrlly  ft*o  pxit  fiir  matter.  A  ease  i»  rcportwl  by 
GiiU,  in  which,  though  it  !»<uetl  fatnlly,  a  tleoided  mitigation  of 
'  KMiijitnins  fullowcd  a  <]i(teJmr^  of  ntnUcr  thrc<iif;h  t.hv  nosv ;  nnct 
I  ioilkatioa  ia  iJius  afforded  of  the  Surgeon's  chief  task  in  every 
DOC  of  this  itHVxtion.  I'l-rfonitimi  of  tli<;  niriiiiirana  tyinpttiii 
if  it  be  entire ;  or  ita  inctaion,  if  by  adhesion  to  the  promontory  or 
otliemi-iHt  it  not  the  [mrl  of  avslvc;  or  trophiiiin^  of  the  mastoid 
pnwesK,  might  l>e  Iiad  recourse  to,  if  neceflsarj',  to  a^ert  tlio  reten- 
boa  of  pas.  In  soino  caM»  polypi  twcm  to  obstruct  tho  meatiio ; 
tai  tl»eii  their  removal  becomes  a  matter  of  the  utmost  inijnirtance. 
A  caMt  is  related  by  tWrnnfond,  iii  which  tlic  cni»hin<|;  of  a  ]>olyi>iis 
gave  exit  to  a  large  quantiW  of  matter,  witli  immediate  relief  to  the 
^I'cst  cerebral  ^ymptoinif. 

When  iiiHammation  extendit  from  tlio  ear  to  the  lateral  sinus^ 

prorea  fatal  by  »u<»3iidarj'  disease  of  the  lungs,  winch  bocomu 

witli  lol>iilar  pneumonia  and  }>leiirtKy ;  pnetuno- thorax  also, 

^vd  slonghing  of  tlio  lung,  frequently  occur.     Tho  si|-mptonis  aro 

rigorv.  n  it!)  ywcjiUt,  fever,  paiu  in  the  Iieail  and  Imt^k  of  the  neek, 

fcUowed  by  tlie  stcthoscoptc  indications  of  plouHsy ;    vomiting  ilt 

tfien  pTcsviit     Ti-iitlenH^H  luiil  Hvrelllti^r  may  gcnemlly  W  (<iun<l 

in  die  oonrse  of  the  jugular  vein.     On  examination  after  death  the 

{nition  oftbo  maMtoid  <«1Ik,  forming  the  tliH)r  of  the  bti^'ral  xiiiuii,  ia 

ttriotu  to  a  greater  or  less  extent,  and  that  tcmoI  contains  a  disor- 

piUM-d  dot  niixod  wttli  pus. 

Altbougli  when  these  affections  of  tJio  brain  or  lateral  sinns  aro 
■w  crtablitiheH,  tbo  Surfieon  i»  (io«<-rli«i»  to  stay  their  (wiirw ;  yet 
fnj  caaes  occur  in  which  symptoms  of  tho  most  threatening  cha- 
Ww  may  bo  entirely  nrmovMl  \ty  cnn-.      In  tlicHC  pntieiits  either 
wnmnbrana  tympani  lias  been  perfomtod,  and  the  mueons  mcm- 
of  tlio   tympajium   iiiHnmol,  for  a  h>n^  time,  a  purulent 
fVom  tlie  meatus  being  oitlier  constant  or  occurring  at 
Hvnia;   or,  witliout  rupture  of  the  ineinbrana  tympani,  thoro 
>>  chronic  inflammation  of  the  meatus  attended  with  discharge. 
;  a  cold,  or  from  gi-neral  ill  healtb,  or  from  a  blow,  or  evcii 
L  aoeertainable  cause,  tbo  s^nnptoms  become  aggravated,  per- 
he  discharp)  ituddenly  «iwc!!' :  pain  ari*'*  in  th«  (-ar,  exti>i\d.t 
'  tlic'  Elide  of  the  bead,  and  is  greatly  increased  by  motion ;  giddi- 
I  may  follow,  with  inability  to  »toop;  fever  in  wmi^limen,  but  not 
lhray>,  present,  and  there  may  even  be  delirium  ;  or  slight  attacks 
I  if  (be  kit»d  uiay  nx-ur  at  intervals  and  pii-'v  off.     In  the»c  ciu<e»  an 
[oNirp  aUliuenee  from  work,  or  any  kind  of  oscilement,  must  bo 
1;  and,  except  in  the  mildvat  funn«  oftliedi»vaso,  tlie  patient 


188 


DISEASES  OF  THE  EAB. 


slioTild  (rf>  oonfinwl  to  lied.  Lew}ii?s  shouUI  he  trwiy  applied  arotmd 
aiid  bcucath  tlio  car,  and  hy  fbmcntntioDB  and  poultice*  thv  cxtt-mnl 
diftoIiiiT}^,  if  it.  hiivo  waBOil,  slionid  Iw  Piic/iuragt'd  to  return.  Tlw 
meatus  may  also  bo  syringed,  very  gently  so  as  io  avoid  ginng 
paiii,  wiUi  wiittiT  iu<  wnnn  as  it  cjui  l)e  iKintci.  Ailor  Uio  Ivtx^Uos 
counter-irritation  sIiouM  bo  omptoyod ;  and  a  eofon  may  be  worn 
at  the  buck  (if  tiifi  irifk  until  nvery  HymiilMm  nf  ciTn'bra!  irritation 
has  disap|)cared.  Purgative  and  alterative  modieines  may  be  ad- 
miuiNtnrttl,  ncironlitig  to  tlic  judgiuout  of  iJie  Surgwon ;  hat  thdS 
latter  demand  cautiou,  Tlie  injuriouH  cffoet  of  mercury,  when  once 
•nppurativo  action  Lns  commenced  within  tlic  bruin,  i«  well  known, , 
If  there  be  pufGnean  or  tendemesa  over  the  mastoid  prooees,  an  in 
cision  down  to  tlic  bone  in  that  region  should  not  bo  omitted ;  ao^ 
any  obatniction  to  the  csca]>o  of  matter  sSxruld  be  tlioronghly : 
movod.  Under  thc«e  means  symptom*  of  a  rcrj-  serious  asjxx-t  will 
often  entirely  diftapjiear;  but  great  perseverance  and  proIon| 
caution  are  required. 

Another  fatal  oonseqnonoe  of  disease  of  the  ear  is  hremorrhnge. 
Tliis  occurs  from  ulceration  of  the  coat*  of  tht  adjacent  vessels 
Mr,  Wilde  relates  two  c»ses,  following  scarlatina,  in  one  of  wliieh 
the  lateral  sinuH  was  found  ulcerated.     Ono  case  I  have  sovn  in  a 
man  of  middle  age,  in  whom  sovero  pain  in  the  ear  was  foHowivl  byj 
rC|Kiated  attacks  of  bleeding  from  Uio  meatus.     Tlie  patJent  fa 
apparently  exhausted  by  loss  of  blood ;  and  on  examination 
waa  found  caries  of  the  tympanic  nails,  caoamg  ulceration  oft 
eoato  of  the  carotid  nrlcry. 


Till.  Malicsant  DistUBB  07  THE  Ear. 

This  is  an  affection  occasionally  mot  with,  though  it  is  not 
quent.     It  comraencos  in  the  doeply-seatod  parts  of  tlte  oi^^i ; 
a  lai-ge  part  of  the  temporal  bone  and  of  the  adjacent  portions  of  1 
skull  may  l>o  destroyed  before  life  succumbs.    The  affliction  calls  I 
no  B])eeial  remark,  except  that,  as  before  obser\'ed,  it  is  at  son 
ftfjiffc.''  liable  t(i  1)0  mistaken  for  polypus.     Tim  otiIj-  pjuw  in  whif 
real  diilieulty  would  bo  likely  to  arise  in  the  diagnosis,  might 
that  of  a  polj-pua  causing  irritation  uf  the  brain  by  preventing  tfe 
escape  of  matter ;  and  here  the  history,  and  the  difterenoo  of ' 
aymptoms  in  tlie  two  cases,  could  hardly  fail  to  give  tJio  uc 
guidance. 

JAMES  HIKTON. 


DISEASES   OF  THE  NOSE. 


Htfpfrtrophi/  <f/  Ote  Shin. 

TBG  mtcgamflDt  of  tlie  nose,  socordiag  to  Kolliker,  ia  charac- 
terised \>y  a  tbiu  eiiiilcmii-t,  u  (liTunn  cutis  nitli  miiiutv  undo 
T^opcd  papillse  nud  fiae  hair»,  ss  well  »s  br  a  close  ndiposo  tissue 
intimately  connected  with  tJtt;  cartilii^ru,  coritiitiiiiig  large  wbucootu 
UEelw  extauUnj;  into  tlio  latter,  and  minnte  sudoriparous  glands. 
W«  here  oceasionidly  meet  with  an  outgn>wt)i,  akin  to  vlt^piiantiiiiuft 
of  the  scrotum,  and  depending  on  hypertrophy  of  the  *kin,  of  the 
■cbweoos  fbUiciea,  and  of  t  Iio  ^iibeutum^ou.i  (vnuKiutivo  tiKstiv.   W'hun 
ml  into,  it  lias  a  brawny  oonsistcnco,  and  sometimes  is  almost  as  hard 
MCBMilage.  It  may  cxt«9>d  unifonnly,  or  form  irrugiiltir  I'xcrost.'fliiu.'A, 
[fid  gtvo  rise  to  great  deformity.     The  swelling  miiy  enlarge  in  ex- 
I tene  CMW  »o  mi  to  tumgdowii  to  tliucliiD,  and  iiitfrti-re  with  rvspi- 
mion,  tlw  organ  of  voice  and  that  of  vision,  the  patient  being  able 
Miee  m  objVxrt  by  one  «ye  only,  tuid  tliat  by  »Iiiniiig  the  jiosition 
rflliB  head  or  of  xho  nasal  protuberaneo.     Tliis  hyportropbied  eon- 
■itiim  i»  seldom  met  with  in  iiiJividuHls  tuidvr  fil^y  yt<ar«  of  ago. 
ut  tnatiDcnt  conBiels  in  reraovuig  the  outgrowtli  with  the  knife, 
■•Sargvun  ki.vpitig  his  tingvr  in  the  nu:<lril  tio  a»  to  eiiiiiilv  him  to 
'"tnuine  the  extent  to  wliich  be  sbould  carry  hiei  inci.'^ion,  and  to 
agninrt  injtiry  of  the  lining  ini>mbniDo  of  the  nan«.     Tbo 
y>  indieittcd  in  Uie  instanm-  of  tuiiiours  which  are  a  source 
rtl Buiu ixnicncc  from  thvir  azo  and  winght,  and  onglit  not  to  bo 
MwMarately  resorted  to,  bocauno  there  is  alwmys  a  risk  of  danger 
iwrioas  ETrapdas  of  tho  faeo  supervening.     The  most  fa«'our- 
Mi  lor  removal  ore  such  a&  are  nttaulux)  by  •  pedicl&     The  after- 
UhMnoil  consists  in  tho  steady  employment  of  cooling  spjiliuitiDns 
ifli  fut.     When  cicatnniilion  i^  lu-mnijili.tlied,  it  is  remarkable 
'  little  disfigurement  remains.     In  soinv  niro  instaiicos  thorv  has 
I  a  rvpTMJuction  of  tlto  grovrrli  aOer  extirpation. 
Canter  <y*  thf  tk'm.    A  formidable  aftbction  from  whicJi  the  nose 
neoally  fuifTent  i»  eanevr,  both  in  (he  tonn  ofjicirrhuR  imd  of 
Hd.     When  the  latter,  it  presents  a  fungous  appearance,  and 
.  wilti  n:i)v)it4.'d  luemorrha^  luid  iuhorotu  diaeluu-gc    Tho 


190 


DISEASES  OF  THE  XOSE. 


diicf  RiinMly,  ami  i.liat  not  a  \nry  hajtc-ful  one,  ii  the  knife; 
shouM  notable  dufoniiUy  be  likely  to  foUuw  tlie  ogierutioii,  it  will  be 
uxpctliont  to  t'orRi;!.  it  at  nnw>  by  Uiit4iplii!*ty,  aiid  not  to  wait  for  the 
healing  of  tlio  wound.  Kst^barotics  are  alono  adniixttible  whon  the 
koifo  falk  to  n^nuve  tbu  wbolu  of  the  morbid  tissue.  Arsenions 
Acid  is  one  of  the  most  efliciont,  made  into  a  ]iaftt«,  with  the  atldi- 
tioD  of  glycurino,  wlilclt  ha*  a  solvent  action.  This  ought  not  to  be 
applied  l>efure  tlie  ttiird  day  after  e:cdsion,  wid  when  suppunition 
is  fairly  cstidjUshwl ;  mUunto^  may  possibly  be  gained  in  bo: 
infttunoeii  likewise  by  the  employment  of  ohloride  or  sulphate 
zinc,  according  to  the  dirwrtions  given  uudcr  the  head  of"  Lupos, 

Thij  noN)  i*  aometinies  altaeked  with  epithelial  cuncer.  This 
commences  generally  as  a  smidl  wart,  att«udvd  with  itching.  The 
patient  is  iud  to  scratch  it,  and  tlius  iho  jiart  becoiiic.t  excoriated 
and  gets  covered  with  a  crust,  which  ho  j>icks  off  from  time  to  Uiue. 
Presently  uleerution  note  in,  characterised  by  luu-dcitsw  of  the  ba»o, 
and  tbiokened,  callous,  o-ertcd  edges,  with  vessels  ramifying  on 
^KOT  aiirfuee.  In  structure  it  is  chiefly  oonijiosed  wl' cells  of 
aixe,  which  bear  a  i-oscmblancc  to  those  of  the  tosselatod  or 
opillieliuni,  and  wliieli  are  iuiumlnatoil,  so  to  B|ie«k,  in  the  intcrstii 
of  the  skin.  It  makes  progress  but  slowly.  It  seldom  aj«ai 
B^gbhouring  parts,  or  utfects  the  lymphatic  glnnil.t  in  the  vicini 
or  superinduces  the  cancerous  cachexy.  It  is  rarely  mot  with  in  in 
dividuals  under  forty  years  of  age.  It  miiy  generally  be  destroy 
by  escharotics,  such  as  arsenious  acid,  chloride  of  zinc,  sidphate 
zinc,  and  tho  like,  or  else  extirpated  by  tlie  knife.  In  one  wel 
marked  ciuw,  in  an  elderly  man,  I  succeeded  in  effecting  a  core 
moans  of  an  arecnioud  jiaate.  In  anothw  Refractory  cn*c,  which 
under  my  cai-e,  the  patient  being  411  years  of  age,  and  the  di: 
of  fitlecn  years'  staiuling,  there  was  an  ovaJ  »ore  about  the  sixc  of 
florin,  ihocentreof  which  was  studded  withu  few  induratiKl  gnm 
tions,  wbieb  emitted  a  little  ichor,  and  its  edges  thickened,  Jnd 
atud,  juid  of  a  dusky  reil  hue,  from  veaseU  ramifying  over  ihem. 
tried  excision  with  tlic  knife,  then  chloride  of  zinc,  nest  arMni 
acid,  and  at  last  completed  the  cure  by  an  ointment  oomiioticO 
etjual  parts  of  finely  pulverised  sulphate  of  iinc  and  cerate.  I  »a 
this  man  a  year  alhrwanls,  and  the  cicatrice  remained  [mrfuct, 

Sr/jt/iiliii'.'  nicer.  TIic  nofc  is  oecanioiially  the  scat  of  uloeratji 
in  peisons  uth'Cted  with  eonsiitntional  syphilis.  Tliesc  idecnf  attai 
usually  the  nlat  or  the  tip  of  the  nose,  and  commence  moAt  fi 
quently  as  itinull  pimples,  red,  hard,  and  somewhat  pfiinful,  whii 
Qveutuolly  suppurate  aud  tcruiiuatv  iu  ulceration.     At  other  ti: 


ion 

is,*^| 


LUPUS. 


191 


Hat  ikin  oovering  tlie  Bbro-cartQages  inflaraoti  anil  gives  vray,  aomc- 
tuMt  \)j  cntcka  or  fissures.  TIk^!  resulting  ulc«r  linit  nil  iiiilioallhy 
a>p«cl,  aBil  an  im!|>iilur,  fringed  uitirj:;iii.  It  i»tiit.t  aii  ichorous  (!i»- 
efavjp,  vrhicb,  when  allowwl  to  dry,  forms  crusts;  aiid  it  i-rodes, 
fint  tlic  dun,  and  imixL,  if  unchecked,  thii  tlhm-ciirtiln^.  The  »hi> 
Rmodbg  iutegument  proseiits  a  rrd  bltuh.  Tho  trcatjnt^Tit,  wliich 
I  have  (bond  nuMt  uflicaciouit,  (uihhUi.'*  in  the  vxhil>ition  of  iodiile 
of  [KiUmium,  provided  mercuiy  has  Wen  proxHou&ly  admlniHtorcd, 
together  with  thi-  nnphivnioiil  of  ii  lutictn  cmiUtiiiiif;  ii  ^nin  and  a 
hilf  of  hicliWide  of  meroury  dissolved  in  an  ounce  of  water.  In  a 
one,  which  camv  under  my  caru,  wlioro  tticro  vriu  an  ulc^rattjd 
|ntch  cxt«ndtiig  from  tlie  aU  to  the  ti]>  of  the  nose,  and  which  wag 
fif  fiA«en  months'  standing,  a  cure  yvtw  in  n  Khorl  time  accomplished 
by  the  above  mcanK.  The  object,  under  such  oireumstaneeit,  im  to 
Wp  the  coostitutiouat  tUscasc  at  bay,  until  the  arrest  or  extinction 
,lf  tt»  manifc^tutionK. 

Zii^HM,  or  twli  me  taitgere,  is  an  insidious  nnd  obstinate  uWratiun 
rtbe  noee,  or  udjawnit  i"iirljt.     In  a  jiajM^  di"  niinn,  [>iiblish<.rd  in  tho 
[■ioelcent]]  \i>lui»e  of  the  Lcmdtm  Mniiail  Gtuettg,  I  referred  to  it  as 
I  dtt  *'  erosive  nicer  of  tho  d^rnta."     It  attacks  butli  ncxi«  indiitcri- 
■lely  during  ehildhuod  and  adolescence,  nt  tho  period  of  Ijfa 
i^ai  tbere  exitt»  the  grcutcAt  j)ri!dwpositiuti  to  aHuctiuus  of  the 
i  nhnwimii  attd  glandular  systems. 

Ibe  individuals  must  liable  to  fuffur  from  thiK  pjirtioular  uloor^ 

In  ue  UiiMie  of  a  &ir,  occasionally  nmy  coniploxion,  with  light 

wiuro  air,  gray  or  blue  iridos,  and  a  dcliaitc  skin.    To  a  superticitd 

thu  general  tieallh  lu^eina  unaffected ;   hut  on  minutely 

'  BiMigrting  the  state  oftbu  ditfcront  funvtion",  murt;  ur  le»s  do- 

na^nncDt  will,  tn  ilio  majority  of  cases,  be  detected  in  those  of  tho 

I  dflvpoietic  viscera.     Tho  tongue  is  redder  tluin  natural,  OKjiccially 

[irimgllie  margin.^  and  towiinlH  the  extremity;   its  central  portion 

a  creaia-coloured  fur,  tlm>ugh  whtch  tho  red  jHipillie  jiru- 

The  brualh  id  inoro  nr  lew*  otlcDntve ;  the  evacuations  from 

»ela  irregnlar  and  unhealthy.     To  tlicso  wo  find  Hupcrodded 

kwwgns  iiidioHtive  of  «triimon>*  dyspcpMn. 

From  a  survey  of  a  considerable  number  of  eases  of  thiit  diaeiwc, 

I  Inn  M  tn  OKncide  wirh  thu-ie  antbnr.t  who  touk  upon  it  as  a  svmp- 

aOc  affection.     It  U  generally  dependent  on  sonic  diwinlcrt.'d 

ID  tlto  funetiotu  (M>iinix-tf4l  with  ii-tsimilation  and  nutrition. 

:  ever  truly  localised,  it  has  either  been  preiwdod  or  accotn- 

dtninf;  itoroe  period  of  ilit  course  by  unequivocal  marks  of 

I  enon  of  ftmctJon  to  which  allusion  has  just  boon  made. 


IpMUa 


19S 


DISEASES  OF  THE  NOSE. 


Dr.  Macfarlane,  in  hU  Clinical  Hr^pord,  monl!onH  Uint,  in  Ola»* 
gow,  during  tht>  years  1518  and  1811),  when  tlie  working  classes 
were  exoetniinj^ly  iil-fixl,  lie  liiui  oowwinn  U>  »«o  a  gronUn-  number 
of  casoe  of  lupus,  among  the  district  poor  under  tua  charge,  than  at 
«ny  fonner  or  sul»«iuent  period.  According  to  M.  ItaytT,  it  ha* 
at  tunes  been  extremely  prevalent  among  tlio  indigent  in  some  parts 
of  France,  piu-tiuulitrly  tliw  ^tcrilu  ruftioHn  of  tJiv  Uuutu  Auvia-j 
from  scanty  and  unwholesome  nourishment. 

Tlio  itfl'wtion  iw  seated  in  the  dennuid  ti-xtiire;  and,  jud, 
from  the  nature  of  ilio  secretion  emitted  afler  ulceration  is 
blishoii,  in  tlio  ;^Iuii<lular  IkhIv  eocrvting  tliiit  niticu»,  whie?i,  accoid- 
ing  to  M.  Bresi^het,  beoomes  at  a  later  period  Uie  hom*f  tnatler.  On 
atteaitivoly  examining  tho  proccM  «ct  up  prior  to  tlio  ulwnttii'« 
absorption  of  the  epidermic  layers,  the  following  phenmnena  will 
ixtiuurkwl.  In  Home  point  of  the  attcimatiid  and  dt'lit-atw  iiitcg 
inve'*ting  tlie  nose  or  cheek  adjoining,  a  nitiiuie  yellowish 
appcim,  surrounded  by  a  reddish  lialo,  Tlic  point  of  the  skiu  cor- 
responding to  tlie  tinV  ulisci'HN,  Ixtlit-ved  to  exist  in  die  mnci[iaroaf 
njiparutu.*,  is  removed  by  absorption.  A  mode  of  uleiiratioo  is  at 
length  establislie<l,  which  is  giniorully  superficial,  not  extending 
boyund  tlie  derma ;  and  though  accompanied  with  prctcniatural 
redness,  yet  finely  with  any  swelling  of  .Mirrounding  ]>iiru-<.  It  is 
cliuracterised  by  its  ragged  odge«  on  a  le^'el  witli  tho  base ;  by  ila 
pale,  ninminillary  surface,  whunt^-c  iiMitfs  that  peculiar  MHtrclioa, 
wliicli  rapidly  concretes  on  expcisure  to  tho  air  iiUo  grayish-ydkjw 
ornsU;  and,  lastly,  by  its  Ix'ing  the  sent  of  hot  siuartitig  |Mun,  and 
occasional  itching.  Tlie  furliiraceous  crusts  ar«  soon  detached,  and 
fresh  ones  rcpnxhiced  t<i  supjily  tlieir  plaoe;  the  afloctiun  uiisin- 
wliile  creeping  on  with  insidious  certain^. 

After  baling  subsistd  for  some  time,  the  original  ty]w  of  the 
disease  is  mcKiiliod,  and  ui  some  measure  obaciu-ed ;  the  eur^uw 
acquires  a  pink  glaeny  aspect,  and  loses  Uic  ]Mi|)illiiry  iippcaranov  it 
originally  presented.  When  situate  in  a  jwrt  wliero  there  ia  ia 
loose  cellular  ^ubstancu,  tlic  inimetliatcly  adjacent  tcxliins 
indurated,  condensed,  and  asauiiie  a  dusky-red  or  pur]>)tsh  hD& 

Ulcers  of  this  kind  differ  extremely  one  from  anothor  In 
degree  of  virulcuoe.     If  the  nose  is  primarily  invaded,  and 
ticularly  tho  inferior  portion  of  the  septum,  as  frwjucntly  hap| 
the  uliKirHtion  advance;*  by  im[K-refplihle  steps,  corroding  and 
suming  every  tissue,  muscle,  and  cartilage,  down  to  the  very  boB' 
which  at  tinicH  piirttcipiile^  in  the  devastation.     The  disease,  it 
true,  when  Icit  to  itself,  may  wear  out,  and  undergo  a  i>{)«ut«n«ui 


LUPUS. 


19S 


);  tmt  the  mutilation  prerions]^  produoctl  is  otUnr  ImlpoiiR  nad 


•111. 


Thai  this  U  nnt  merely  a  locnl  inalxlj  .■MWmi*  furtJtor  a.-«cor(Ainod 
il»  obstinacy  with  whicli  it  mists  toj>ical  agenta.  I  have  seen 
[ij  erery  da«cri[>lion  of  stimulant  triwi,  ami  mywlf  i-mplnyi^^d 
tnost  mwT^tic  caustics,  but  futvc  iK'^'or  known  any  permanent 
benefit  accrue  unl«tA  iitntHurttt  hare  liceit  cnnjointly  titkon  to  modify 
ibe  state  of  tLo  eystent  at  Ui^<\  No  soonor,  indeed,  haH  tiio  E^Rect 
of  the  GSchorotic  nubsid^d,  tlian  by  a  reflex  notion  tiiv  Hynii>atJiutio 
di>eaM  of  tho  skin  is  a^in  railed  into  activi^. 

An  o|iinio]i  ii>  enlt^rtjiinul  by  ^oinv  modical  men,  that  thiN,  tlie 
vramro  BpedeB  of  lapus,  must  nm  a  certain  ooune  or  exhaust  itcelf, 
ere  it9  career  nm  bo  [Hit  a  Ktup  to  by  any  method  of  art.  This 
Ofonion  is  based  ratlier  on  imperfect  truth  than  on  fundamental 
ermr.  Wht-n  iliw  dintHum  in  long  left  imeontn>lled,  n  nmrbid  habit 
ia  aaperindnoed,  which  ordinary  means  fail  to  eradicate.  Out  if 
Bwaran.'H  Ix;  taken  at  an  fsirly  ulnfic  to  alWT  and  amend  that  jtocu- 
Itar  condition  of  the  system  upon  which  the  ulcerative  proceas  seems 
In  tiep«>(xl,  or  witli  which  it  w  aj«ociat«i,  we  \mv«  every  rt-ason  to 
expect  that  that  eoiu-so  will  be  materially  abridged,  and  much  dis- 
flgurwuMit  and  mulilnlion  pre%-viitcd. 

Xow,  a  diief  imiication  is  to  correct  the  state  of  the  digestive 
l«nd  invigorate  the  wstcm  by  a  proper  regulation  of  diet, 
in  a  pnre  air,  with  free  out-door  excreii*e  sml  proper 
tiimlMm  III  the  stntt^  of  t]>c  cutaneous  exhalation  and  alvino  vvacua- 
tioua.  Uoch  Itenetit  will  be  obtained  in  many  oanea  by  nuWitnting 
for  a  too  stimulating  animal  diet  one  composed  of  farinaceous  arti- 
idcB  and  milk.  TIte  jiaticnt  must  abKlain  fmm  the  uho  of  fi-rmented 
qaon,  and  liavc  occauonal  recourse  to  bathing  and  goiitle  laxalivcfl. 
alterative,  analeptic,  and  tonic  medicineti,  siicli  as  mercmyj 
Inenic,  iodine,  cod-liv'cr  oil,  sarsaparilla,  with  nitric  acid,  steel,  and 
I  fiina,  will  eatJi  in  itn  turn,  acconling  to  circum»<taiieL«it,  constitute 
I  nbabic  auxiliaries.  OF  these,  cod-liver  oil  ranks  high  as  a  hy- 
l^Miie  meuna  in  this  diwow ;  btit  it  nv{uireA  to  im  taken  in  full 
I  Wi,  md  contmned  for  a  considerable  period  of  time  before  iU 
'  Karficiol  effects  are  realimsd. 

When  a  visible  amelioration  is  perceptible  in  the  general  con- 

jttan  of  the  patient,  wIh>ii  tlio  difTcix-tit  fnnetionR  are  all  projicrly 

[fvliinned,  then  is  the  must  favonrable  time  for  resorting  to  those 

remMlied  whieh  act,  not  w  caustiew,  but  a.t  jmwerftd  altor- 

litss  of  the  organic  relations  of  the  part,  among  which  arsenio 

the  preference.     Properly  a{^Ued,  it  produec*  neither  local 

roL.  m.  ^^^^— .  ^BB^Ki^         o 


lU 


DISEASES  OF  THE  NOSE. 


Ids 

I 

„und 
ito  0^^ 


misdiief  nor  constitutional  disturbance.  Tlie  beat  fima  is  it  tmlati 
of  unicnioiis  acid,  in  glycorino,  containing  ^ix  grains  to  tli«  ounca 
The  favourite  application  of  Duimvlrcn  was  a  jKivriler  ooiiHixting  of 
one  puH  of  anteiiiouK  acid  in  nincty-nino  parts  of  cnlomel.  Bi- 
cli!oi-ide  of  ineroury  is  alt«>  beneficial,  in  tlie  pro|»oition  of  two  or 
thrcrc  grainn  to  the  oun«)  of  distilled  water.  Mr.  Symo  reooniniends 
tbe  atlcniate  eniployn)cnt  of  Kulpliate  of  co]>[>er  uid  rod  oxidu 
morcuiy. 

A  topical  stimulant  of  aclnmwledged  utility  In  intomipliiig  t 
progress  of  lupus  is  tlic  rod-hot  iron :  it  often  exerts  a  moat  salii' 
taiy  effci-t  in  nio<lifying  tJic  nature  of  the  sore,  prodni.>iii;r  livjilthf 
granulation  and  abiding  cicatrisation,     Nitric  acid  I  have  found 
useful  lunong  otlii^r  motjitlic  stiinutaiits ;  t}ic  solution  of  nitrato  oi 
silver  is  fonnd  to  do  good  in  slight  oases.     The  cldoride  of 
mony,  too,  ha*  bf^-n  found  sorvi(-i?abl«  uIipii  uhihI  hh  fullows:  lei' 
tlie  whole  extent  of  the  affected  part  bo  touched  with  u  pencnl 
»pun  glaM  iinbuud  with  tlio  chloride :  about  «  coupio  of  miiiub 
after,  the  paiij  ijius  produced  is  fo  be  allayed  by  laying  on 
preiuitts  dij'iHiil   in  cold  wiitor.      in  ihi.t  wav  \\iv  encrgclic  olilori 
is  at  once  transformed  into  an  inert  subdiloride.     This  operation  is 
to  1«!  n-pi'Hied  oncp  every  t«n  days  ontil    tho  sore  heaL      Beforo 
resoi-ting  to  topical  measures  it  is  always  expedient  to  remove  tlia 
cnistjt  by  mcuns  of  omolliont  poultices.     If  thoro  \k  much  jMiin 
heat  about  the  sore,   cold  applications  ought  to  be  emph>y<^  til 
tliLvc  subside      It  i«  sonictitucjf  advoiitngcous  to  add  a  aaroot 
solution  to  tlie  cataplasm. 

Tlic  st-ihility  of  the  euro  may  be  inferred  from  the  charactar 
the  oioatrix.  When  the  now  skin  is  soft,  free  from  tendemeM,  ad 
nearly  of  the  natural  colour,  it  may  bo  considered  sound ;  bat  when 
it  remains  preternatural ly  red  and  indurateil,  or,  on  llie  other  luuid, 
presents  a  delicate,  membranous  as|K-ct  like  an  arachnoid  vrob  tra- 
versed by  minute  tortuous  blood -vessels,  thoro  is  every  likelihood  of 
relapse ;  a  distinctive  feature  of  the  disease,  in  point  of  fact,  is 
proncneNH  to  heal  at  one  {toint  and  1x)  spread  at  anntlu^r. 

Thoro  is  another  form  of  ulcwratiou  of  tho  nose,  whicli 
ohiefly  connt-chfl  with  tho  (whaci-tiim  fii]Ii(d(«.      ]t  in  dci'Cribcd 
tho  above  pajier  as  the  iTOgiee  uLvr  of  the  j'olliclet.     This  frequent!' 
ori^naloi*  like  a  catnrrhul  affection  of  tlic  Schrieidcriuii  nivm 
By  and  by  the  inflammation  being,  as  it  were,  concentrated  in 
particular  [lotnl,  li;ui|»  to  erosivo  ulcorution,  which  is  alino!<t  in 
ably  amocIate<l  with  jwrforation  of  the  carti lag! nous  ooptum. 
only  circumstance:!!  whereby  tlie  patient's  attention  is  direoled 


EROSIVE  ULCER  OF  TOE  FOLTiTCLES. 


195 


fee  nuMfaicf  going  on,  are  a  degree  of  t«ndeme!M  ftnd  rulna!»  in  tho 

nnanlirattc,  T^lt  more  eHpe<riiill_r  on  expoxurv  to  oold  air,  and  the 

i-«oa0bu)t  reproduction  of  crusiA  on  the  point  of  teaion  :  iiftx-r  a 

tbm,  from  c<^d  or  other  di^Utrmining  <.-ntL«c,  HOmo  portion  of  the 

external  surface  of  the  nose  becomes  iuflamed  and  ulGcralat.     On« 

oroUicr  ala,  hy  oonlinuitr  of  (iwiuo,  ia  wimmonly  uttaokod.     Small 

nd  angTT-looking  tubercles  make  their  appeanuioe,  and  are  speodit^ 

coBverteJ  into  a  qircading  olonmtioii.    TIh'  iiloor  nil  nloiii;  prc^-rvos 

tbe  tnbereolar  obaraoter;  the  apices  of  the  tubers W  are  more  or  lew 

ooooaaled  by  <lTy,  hnn)  ttmavions  <!Tu»t».     As  tlio  di«oa«c  procvods 

fireah  tnbercleB  are  dev^oped,  and  encroach  more  and  more  upon 

tits  healthy  intvgnmviit.     The  confine*  of  the  sorv  have  a  <Iii:<ky- 

ttd  hue.     This  alTection  is  usuallv  attended  hv  loss  of  HiibstAncd, 

sad  the  havw  c'imiiiill>vl   by  it  when  uiiro^rainod  i»  otWn  vciy 

fTTML     The  (tarts  ordinarily  destroyed  are  llie  cartilaginooa  septum 

and  ahu      The  diaeaae  may  ht-gin  externally,  and  sprvad  to  the 

Itntng  of  the  noatrila  ttemniLirJly :  it  i>ouHl>«tti,  »»  stated  by  8ir  A. 

Coopor,  in  ulceration  of  the  (>cbacoous  follicles.     IJcticc,  whenever 

the  pfiu£xi»ting  irritation  paiMOA  along  from  the  internal  inuooua 

CTTptK  to  the  extcntal  ducts,  the  ensuing  inflammation  induces 

oedasion  of  the  orititN^,  xutx-oeded  by  ulncrat.ive  iiljs»r|>tioti  of  tlie 

fbOielea.     The  papills,  endowed  with  a  higher  degree  of  sensibility 

•ad  a  greater  caiMaty  for  reAisting  tiie  jiroeem  of  di^organimitioi), 

nay  now  and  then  be  recognised  unduly  developed,  and  forming 

vascular  cmincnocA,  tlio  niijawnl  t«xliiroi<  having  j>revi«usly 

ppeared.     Are  we  to  ascribe  to  this  circumstance  the  extreme 

['■naibilinr  of  tl»c  morbid  nurfiwe  to  tht'  iin|in»«ii)n  <tf  any  ittiiniiluii? 

Tlii*  varieiy  of  corroding  uloer  is  seldom  met  with  before  pu- 

hirtr.      It  birging  most  fmjiicrtly  brtwei.^n  the  ageit  of  foiirt^ten 

•d  thirty ;  rarely  after  the  fortieth  year,  alUiough  M.  Alibert  has 

■Maeed  cases  where  it  occomtl  at  a  later  period  in  lift;.     As  with 

Ai  farmer,  so  with  the  present  aflection ;  the  subjects  chiefly  pre- 

£ifBMd  are  those  of  a  blond  complexion,  with  Itght  hair  uiiil  irides, 

■dunilne  development  of  tlte  siihaoeou.4  t'ollioles  of  tlie  nosa     The 

httir  feature  may  be  said  to  characterise  and  ad-ompnnr  thi«  sort 

if  nlner.     TIit>  |iat!enl»  are  seldom  of  a  robtu^t  eonstitutton,  tliey 

Ulai^ruid.  and  mo^  usually  manifest  signif  of  faulty  assimilation  ; 

■or  lid  thtn'  gi'Jierally  display  the  olcar  and  blooming  oomplexion 

ittCcative  of  health  and  vigour. 

As  n«prci/»  ihe  inimiiiitr  of  its  progress,  we  observe  great  vai-ia- 

Cln  one  individual  its  oounw  is  so  slow  as  to  seem  ahuuet 
iry,  while  in  aiiotlier  it  runs  on  with  rapid  strides. 


m 


DISEASES  OF  THE  NOSE. 


with 
>ratl 


on    M 

m 


Ib  comlMting  tii'a  form  of  alwr,  so  obxtmnte  and  intractablo 
it«  nxtnrc,  it  is  tncliKjwnnihle  towards  restoriojf  a  heaithr  Action, 
■we  should  not  only  (ienlroy  Uie  morbid  Iinbit  of  tlio  jjart,  bat  at  t; 
same  tim«  modiii,'  the  organic  relations  of  adjacent  te^ttures.  Tl 
done,  the  Ie«ioii  will  iipotitiin<.-otHty  licsil.  Now  tJii«  twofold  obj' 
«an  be  at  once  awompliittied  bv  employing  a  thin  liij-cr  of  (>Jdi)ri(I« 
of  lino  paffl'!,  inadi'  by  tritiiniting  one  part  of  efiloride  of  zinc  with 
two  or  three  paru  of  gypsum,  or  powdered  gum  tragmnntb, 
adding  a  few  drops  of  uloobot.  Onv  or  two  applications  at 
of  this  {MBte  wQl  Boffioe,  It  onght  to  remain  in  <.-<Hitact  for 
lent  twclrc  hoora.  So  »oon  a»  tho  iwchar  is  detached,  the  healthy 
sue  i»  to  be  treated  with  water-drewung ;  or  if  tlicro  bo  mnch  cn- 
OTCnnefis  of  sorfaco,  with  narrow  ctrip«  of  &dhesiT«  plaster,  'nieae 
ought  to  be  ttymmetnoally  di«poM<d,  and  not  intertbred  witJi  nntil 
tbev  (In^  off.  Great  cirvumspcctimi  most  bo  obiierved  in  ttfdng 
this  poworfiil  romoiliid  agent ;  for,  injiidiciouHly  employed,  it  may  on 
one  hand  prodnce  a  dangorons  degroe  of  erethiinrn,  on  the  other  onl; 
irritato  the  Kirv  and  exasfwratc  the  distenno.  In  Hight  fonns  of 
nalwly  resort  may  be  had  to  an  ointment,  eomposed  of  a  <lrachni' 
of  fittely  Wtgated  sulplmto  of  zinc  incorporated  with  half  an  ooncs 
of  cerate ;  or  to  one  containing  biniodide  of  mercwry.  Touching 
the  part  with  nitric  acid,  or  with  nitrio  acid  holding  in  solution  the 
nitrate  of  mweury,  will  occasionally  bring  about  eteatriaatioQ. 

AUhoagh  intcntal  remediiit  are  hero  of  minor  imp<H*tanoe,  rUII 
tbc  pcnitaiit-noe  of  cure  will  be  confirmed  by  a  judiciou»  npplicatioii 
of  the  hypenir  and  thempeiitio  pivcepts  formerly  laid  down. 

There  i*  one  aymptom  we  aro  generally  calU-d  to  troat,  ai  »■ 
coneomttant  or  sequoia  to  the  ulcer,  namely,  a  sense  of  teiidi'mea 
or  rawnem  of  the  pituitary  membraiiP  defxnidinjj  on  chronic  in 
ntatioo.     It  is  allayed  by  protecting  the  part  against  oxtcnial 
pmnons,  an<l  t-HixxMuIIy  that  nf  colil,  by  plugging  the  nostrils  wii 
•orapt^t  lint,  or  the  fleecy  down  of  finely  carded  cotton-wooL    W 
Ute  iTTifalioii  lias  pt^rsi^ttvl  for  n  |u-rio<j  of  yearx,  and  is  at 
with  niporficial  ulceration  of  the  mnoouR  membrane,  M>me  dPi 
Hitringcnt  lotion  ought  to  be  tlimwn  up  once  or  twice  every  day, 
dirwHed  under  tlw  heaid  of  ulcers  in  tliis  situation. 

SVveml  eaww  are  detailed  in  the  above  paper,  which  were 
nv  earts  and  which  exemplify  the  effieai^  of  tlie  chloride  of  zinc  t 
eradicating  the  disitwo. 

("iifiti&MM  (VMTTfMfw,  t^molilli*»,  ocoasioimlly  form  in  tbo  n: 
and  inercMB  indefinitely  by  tlie  aidditlon  of  new  lavi 
I  am  progreMJvely  depusitixl  on  their  suriiioc    Bartliolin 


NASAL  CALCULI. 


197 


^Bn  am  of  a  young  Danish  female,  who,  after  saflering  long  from 
^Hwwlache,  voidixl  Inmi  tlio  »».■«  wtvurul  calouii,  of  tlio  »izv  imd  i^inpo 
^Bof  a  dale.  Clauder  witne^^sed  the  caae  of  a  woman,  sixty  years  of 
^u^,  of  a  catairhul  (xinittitutiou,  whoro  a  rouixlcd  vuncrctjon,  very 
^nkard,  of  Oie  size  of  a  hazel-nut,  waa  tliua  evacuated.  Khom,  in 
Vlbka  mannvr,  nutiu-d  Miwral  jiiniform  cnlcuL*,  whivli  hud  cscajHtd 
frocD  the  noatrils  of  a  young  person  labouring  ond^r  violent  cej)hal- 
■l^is.*  NiuDDTouK  othvr  CHMS  arv  rvfunrcd  to  in  an  vlubumu 
tDcmoir  on  the  subjixX,  by  il.  Demaivjuay,  in  the  Slh  volume  of 
ibe  vtreAtwt  GM4raU*  de  M^ded/K,  TIig«o  concruliotu  aru  u»u«lly 
Biet  with  in  tiie  liiwi>r  meatus.  Tliey  may  originate  in  the  frontal 
aiana,  or  in  the  maxillary-  Einus,  and  thvaou  pass  into  tho  nostril. 
Tbey  vary  in  site,  and  may  attain  such  dinien-iiuns  oa  to  block  up 
the  naresf  and  catue  deviation  or  partial  destruotioD  of  tho  wrptuia. 
Tbey  jir^aeotan  uneven  nurfiiov,  kikI  uru  ofu  black,  gray,  or  white 
aspect.  They  are  found  to  consist  of  phosphate  of  lime,  carbon- 
ate of  linw,  mngnv«in,  and  uiuc-us.  Tim  nucloiu  ii*  Minictimes  an 
sxtranooos  body,  as  a  cherry-stone,  or  portion  of  a  tootlu  The. 
MOW  of  tlMiir  tunnatit^n  is,  howttvix,  oft«u  obMuiti.  Uriife  atlri- 
bated  their  production  to  the  influence  of  an  arthritic  dyscraity. 
Chroaic  inflaiumation  of  tlui  nu«al  fount  and  of  tb»  lachrymal  gland 
nay  determine  snch  an  alteration  in  tlie  secretions  as  to  lead  to 
CbIcuIous  d«{x)Mtion.  OrtJiin  tmatomioal  conditions,  moreover,  may 
■mdnoe,  each  aa  a  straitening  of  the  nares,  or  of  the  lowoi'  meatus, 
irhicJi  may  liiiuJi-T  tliu  duo  expulsion  of  tho  proper  eovrutloii.  Thd 
most  frvtjucnt  rause,  on  the  whole,  is  tlie  preaence  of  a  foreign  body 

Iantaniilal  in  tite  cavity.     TIio  onlinaiy  a)-mptoms  arv  dn'now  of 
tbe  aSeeted  nostril,  with  a  sen^e  of  dulnesa  and  weight  of  the  same 
Mie,BaBOc!atedfr(xpH'-ntJywitii  difficulty  of  breathing,  pain  ofim  in- 
tmtitteot  neuralgic  character  referred  to  the  nosm  or  forehead,  and. 
isiaBunatory  tiwollittg  of  tho  atyaumt  partH,  attendtxl  with  t-opioua 
fahargo  of  mucu6  or  pua  from  tlie  nariiti.     'ni»  ^eiine  of  Hmell  may 
I  Ubapairwd  nr  abolj^slwd.    TIh^  oyo  may  sa&'or  sympathetically,  and 
Wtnffiued  or  bathed  with  team. 
I      Tbn  calculus  may,  gvnvrally,  be  detected  by  carnftd  oxploratioa 
t  rfllw  cavi^'.     On  introdu«ing  a  probe  or  difxuiiiig-foi'fwpH,  tho 
IHnnDiiit  will  bo  anwtwl,  and  a  peculiar  doad  soimd  emittod, 
(boaeienMic  of  tlie  preeenoeof  neulculu.i.     Should  tliu  uonorcliun 
ItiBaoeaasiblo,  the  pmctitiooer  may  bo  misled,  as  regards  diagnosJa, 
If  the  <ym[ituiua  manilVwted  by  juitiiMitn ;  thus,  ho  may  coududCf 


Clo^uet,  Oiphretioiagit,  p.  827. 


198 


DISEASES  OF  THE  NOSE. 


he  in^" 


that  the  nffeotion  is  a  poIypon!>  gmwth,  in  oonaeqnenre  of  the 
ability  to  rti»pirc  tliroiigh  ono  or  both  nostrils;  or  oztc^na,  from  tlio 
fetid  and  difigiiHtinj;  cxtour  cxhul^l;  or  a  primury  aiiection  of  the 
boiiM,  iu  con8o>|uciice  of  tbo  defonnity  of  the  organ,  and  Uio  ao- 
fiomjianying  MippiiniLiun. 

Tho  tri-atnit-nt  resolves  itself  into  the  removal  of  tlio  concretji 
or  ooncretionit  from  the  na>utl  foK!<;i.-.  Tliin  may  titi  attended  wi' 
dilli<.nilty  when  tlie  caleuli  are  iitipaet«d  in  the  lower  mcHtns,  or 
the  ujujer  portion  of  the  noiw.  Tii«  most  coiivoiiiftni  in.stniment 
8  sinnll  pair  of  curved  or  dreaaiiig  forceps.  Due  precaution  ougl 
to  be  obiterved  while  ]>orforming  iitntnictioit,  lent  the  calouluM,  from 
asperities  on  Its  surtitce,  or  from  bulk,  shouhl  cause  laceration  of  the 
surroiiiKliitg  jmrts.  In  the  Gazfft«  <fe«  HojiUmtx  fur  lH5y,  u  flaw 
is  mentioned  of  calculus  of  the  nostnl,  marked  by  sttacJcs  of  bt«r- 
mitli.'nt  i)!iin,  miTttahen  at  first  for  iieiinilKi»)  thiMi  fiir  niM-rosU  <if  the 
nasal  bones,  where  tlie  tioiicretiim  was  got  rid  of  by  Uthoirilv  in  four 
•ittiiig»,  ut  iiitvrvaU  of  a  fortnight.  Tho  euro  was  followed  by  slight 
deformity  of  the  nose. 

When  th«  extraction  Is  completed,  resort  ought  to  be  liod  lo 
soothing  measures  to  allay  irritation.  Should  the  calculus  be  con- 
aiiiei'Cil  to  arise  from  any  constltutjoaal  taint,  fl»  gout  for  example, 
then  suitable  remedial  meann  nm.it  be  prescribed  to  counteract  its 
reproduction. 

Oei-tunon  and  ronltwfion  of  the  nottriU.  Infants  have  been  bonta^ 
witti  tlio  nostrils  more  or  less  completely  obBtmcted  by  %  naVodnWHH 
A' tsrcumstance  mentioned  by  Kioherand;*  in  general,  howe^'er,  the 
ooclusion  depends  on  an  extremely  4X>nstrict«d  statu  of  tlw  dbmI 
ajierttires.  This  may  oceitr  at  any  period  of  life,  owing  to  adheaioa 
of  thocartilBgesoftbealieofthe  nose  to  the  septum,  tlie  co«scqu«nt» 
of  ulcei-atinn.  it  is  sometimes  produeiH)  by  udlierenoe  of  tlie  noM 
to  the  upper  lip,  which  may  be  occidental,  or  eongemt:d.  When 
Uie  etvhi.sion  is  eonsiderable,  it  gives  rise  to  more  or  less  defitrmity, 
and  interferes  with  ibe  free  ingress  or  egress  of  air  through  these 
cavitieM.  This  is  attended  with  einb»rrussment  uf  rejipiratiun  and 
of  speech ;  a  troublatome  whi«xing  in  the  nose ;  im[Munnent  or  ab- 
olition of  the  sense  of  smelt ;  a  change  in  the  tone  of  roic«;  imd,  in 
certain  states  of  wealher,  an  uncomfortable  dryiiess  of  the  niuoona 
monibinno  of  the  moutli.  If,  under  those  eireumstnnoes,  it  proves  a 
soiirou  of  continued  distress  t<i  the  patient,  and  dilatation  eaniiol  ba 
proeured  by  tlic  introduction  of  tents  and  the  like,  it  may  bo  rumedied 


*  Notogrttphit  ChimrgiMU,  4tb  ed.  torn.  ii.  p.  lU. 


THE  SEPTCM. 


19B 


I,  in  tbo  fullowing  manner.   The  patient  being  seated,  witli 

I  rating  at  tL  HuitaLilu  lieiglit  ugainnt  Uio  breust  of  an  as))i§c- 

tlt,  At  Sta^ean  carries  into  the  nostril  a  narrow-bladed  sciil]>el 

f  nl^  tlw  edge  ilirevtod  forwards,  uid  in  witliilruwing  tl  Jridsoa  in 

Ml  diiettion  of  tlw  lube  of  tlie  nose,  keeping  clear  of  itn  fibro-oor- 

i;  bo  agun  introtluix'it  Uiu  kiijfu,  but  with  tliu  Made  turnud 

,  aiid  divides  the  noiitril  as  tor  oa  tbe  base  of  the  upfter 

hont,  howmer,  impliciiting  tho  lip.     i^buuld  thu  o|)ciiin<t;  of 

be  excessively  narrow,  a  direotor  may  be  used  aA  a  guide 

!  tbe  knife.     AlW  tlit*  uporution,  a  piucu  of  lint  unbiiod  witli  oil 

intKNluced ;  if  butli  niiHli-ilH  havu  rojulreil  division,  it  may 

to  introduce  an  elastic  cunula  to  permit  tlie  ptusago  of 

As  soon  ait  Mippuratt(>n  is  nilablinhod,  it  may  U'  udviixthlu  to 

n,  or  fiirthcr,  methodical  dilatation  by  means  of  a  spougo- 

I  in  iinler  lo  prvvnit  a  nwurroiico  of  tho  oontmction. 

Wbore  tho  nostril  is  completely  obstmotod  by  a  niembrano,  in 

I  faBtanoe  of  a  iivw-boni  infant,  M.  Kidicrand  rocuinim-nd.t  tho 

vitlioat  delay,  to  plunge  a  narrow  scalpel  or  tenotome 

vkiiHl  tin-  IoIhi  of  tlie  no«w,  and  to  inctao  tliu  mcnibrano  from  bet'oro 

kwnrds,  employing  aAerwarda  nie^is  of  dilatation,  as  in  tbe  pi^e- 

;  tiistjmcv. 
In  a  com]]li«ated  owe,  where  a  niiire  tntcu  romaitis  of  tliu  orilioo 
Fib;  bmttril,  a  tenotome  is  to  be  introduitcd  to  tlie  jiortterior  ex- 
tiXy  of  this  tmoo,  tl>u  back  n.-sting  on  tho  upper  lip,  and  carried 
I  a  (Icptli  88  to  reach  tl»o  con-eapoiidiiig  iiiusal  fos*a.      Then, 
iImj    itkttniinvnt  i»  witlidruwn,   tho    adlicstun    is    to  bo  cut 
h,  in  itft  whole  extent,  from  behind  fom-anU.      If  no  indioa- 
inistji  of  iho  opening  of  Iho  nostril,  tho  adhcront  parttt  must  bo 
by  little  and  little,  aiui  witit  |)recautioii.     Tliu  itaiiio  atlet- 
n  a  nxiuirvd  as  abovu  laid  down. 

<  i^tite  teplnm  prettent  tlu-iiiAchix*  un<l<-r  tlic  appeamnce 
poMOMing  different  characters ;   some  contain  blood, 
pus,  otliera  a  golalinoiu  Uiiid,  lUid  otiiers  again  have  aoinA> 
of  B  cartilaglnona  consifitenco,      Tlie  two  t'ormor  have  bi*n 
t  dtacribed  by  Mr.  Fleming."     Tlic  bloody  tuniount  of  tliu  sep- 
tan always  tlio  result  of  injury.     They  resemble  ccdi^inosis  in 
puta  of  the  body,  and  orv  fonncil  goitundly  within  iho  first 
^Juon  from  tbe  oocurrenoe  of  the  accident.     They  u&ually  occupy 
I  afalm  of  tho  xifrtum,  but  may  bo  confinod  to  one ;  tlu'ir  extent 
fiinn  are  very  variable,  tbe  inuooua  membrane  in  somo  imeos 


•  DMi»  Joirtitil,  vol.  iv.  pp.  ltS-38. 


800 


DISEASES  OF  THE  NOSE. 


detected^ 


presenting  only  a  flattened  elevation,  appearing  as  if  raised  by 
uiiifuna  itlluniuii  uiKJurnviitli,  imJ  in  oUiont  iNjinj;  (Ii.tUin<leil  w 
greater  or  less  degree.  Tliere  is  considerable  resistance  in  tlwifl 
fi»lf  and  thin,  uanibim-d  witli  vxlriMiie  tvimioii  and  surruiindiiig  luinl- 
nesE,  renders  it  ditficult  to  ascertain  tlie  existence  of  flnid  within. 
Tiii'y  tuny  alwiiys  hv  seen  by  jjurilly  prwwinjj  Ui«  tip  «f  IIk:  noeo 
and  dilating  tlie  nares ;  their  colour  is  of  a  dark  purple,  and  they 
pgraMUb  a  amuuth  uiid  ^loiisy  ap{>eantiicv ;  llicir  ouunoxiuii  with  tbo 
septum  is  by  a  broa<i  base,  with  abrupt  limits.  Tlie  principal  symp- 
toms oro  a  g(!t]oral  fulness  aiid  stufbn^;  of  tlie  nairs  prujiortioiiwi  to 
the  extent  of  the  effusion.  In  the  treatment,  the  chief  points  an 
the  prevention  of  inHainination,  auJ  tbe  pruiiiotion  oftlie  ulxwrption 
of  the  extravasuteil  Buid.  Evaluation  by  iuciaion  is  rarely  oallad 
for.  Jarjuvay  ciUm  an  lustaneo  of  looseuinj;  of  the  pituitary  mMii- 
brane  of  tlio  neptuni  caustKl  by  efi'usinl  blood  afW  a  bruise.  The 
swelling  completely  misplaced  the  canity  uf  tbo  nose  on  each  side 
of  the  septum,  and  the  patient  oould  breathe  only  by  the  mouth. 
An  incision  was  made  inte  tlie  swelling,  dark  liqtiid  blood  was  dbl- 
eharged,  and  &  broach  of  continuity  in  tlie  septum  was  de 
with  a  probe 

AliKcess  of  the  septum  may  fiillow  injury ;  hut,  aecortliii^  to 
Mr.  Fk'tning,  is  often  connected  witli  some  scrofidous  taint  in  tho 
eoustitutjon,  or  witli  tbu  pretwmce  of  some  of  the  exantliemata,  as 
variolaf  measles,  soarktina.  It  often  occin^  where  there  is  a  wound 
of  tho  iotegujneiit,  and  Uiat  wouml  situate  near  the  lower  oxtn^uiity 
of  the  nasal  bones.  The  integument  of  the  nose  beoomes  <»)b- 
matou.4,  and  tender  on  jiressure.  Tho  pituitiu-y  ineinbraiu!  i*  iu- 
flamed  tliroughouL,  and  tlie  portion  covering  tho  septum  is  uniformly 
tnrgjd.  The  secretion  of  niuoiu  in  supprvsMKl,  and  there  \»  gene* 
rally  some  febrile  disturbance.  Presently,  matter  is  formed  und 
tlie  mucuuH  mumbrune,  funning  a  pmniiuent  HwdHiig  in  eiUier< 
both  nostrils,  and  a  corresponding  obstruction.  The  pain : 
along  the  mucous  membrane  to  tlic  frontal  siniiWM  and  laelir%'i 
passages ;  tlie  patient  aeoonlingly  suflern  from  headache  and  a  Hoi 
of  t4.'are.  The  aHbction  may  also  sprviid  downworrlv,  causing  swvUii 
of  the  upper  lip  luid  lower  miu*gin  of  the  septum.  Tlie  tumour 
rod,  shining,  t«.'nder  on  pressure,  and  convoys  a  distinct  feeling  of 
fluctuation.  Tho  bii>e  i»  extensive,  and  there  is  usually  communi- 
cation with  hotli  aides  tlirough  tho  septum.  Tlie  indlcatiotis  uf 
treatment  here  uri^  to  prevent,  if  {M>ssiblf,  the  fonuatioii  of  mailer, 
and  to  Ivv)  no  time,  after  it  is  formed,  in  ginng  it  free  vont  by 
mcision.     The  palicut  is  thmi  exempted  from  a  tedious  ailment,  and 


_J 


ABSCESS  OF  TI 


rUM. 


siile«iii«ot  deformily  tlm>ugh  destnietion  of  tho  tioniMixions  of  Ui« 
ib^ga  witli  the  qomlJ  boiics.  In  making  the  opening;,  atteDtion 
be  luu)  to  riii>  tliutki^iKil  MjUo  t>(  the  luuooos  nK'tnlininc,  ]e«t 
orifice  sbouM  close,  sjkI  ti^e  fluid  reaccumulata  Ttie  discJiarge 
geHi-mlly  <>f  »  thin  i«nj-]>urulunt  nature,  but  by  awl  by  iiN<utne« 
j^ain'  coiifiLsU'noc.  To  resioro  the  hoalthy  condition  of  tho  mucvus 
tubnuie,  etiinulunt  and  aMtriitp-iit  a[>i>li<wtioii»  niiiy  be  rwtxttA 
to,  nioh  as  solntiona  of  sulphate  of  zinc,  aoouu^  of  li'ad,  and  enl- 
phatv  of  copfivr,  in  Uk  proportion  of  onv  or  two  f^ina  to  ti>i;  uunoe 
ofdisdllMl  water;  ointments  ooiilaining  calomel,  or  oxide  of  bi»- 
muUi,  will  also  bv  found  uMrful. 

There  k  a  oluYiniis  form  of  abac^a  of  the  xeptum,  ^mntaneous 

in  its  Qrigtn,  and  viary  iniudious  in  its  progrees.     The  inflsmniRtory 

stage  is  .lometimcs  so  tuint  as  to  [xtss  uiilitixlcil,  wid  tlie  patient  u 

not  aware  that  any  thing  b  tbo  matter  till  the  abeooiw  is  iiiUy 

fiwined ;  and  then  not  »o  mucli  from  actual  patri  u»  from  uneaatneM 

fait  in  tho  oamt.     In  tlietwB  cases  tlte  outer  surface  uf  tiw  noso  is 

aansr  invtjvoil.     In  this  form  of  abtfCt^s  then.-  is  lew  rodiicBfl,  ten- 

aoD,  and  tendcme80  (U)  pressure  than  in  the  acute  form.     The 

ibsocte,  btMtilcjt,  i«  more  HCt«nMiv«,  and  likiOy  to  occur  ninj^ly  on 

Btl>erud«  of  the  septont.     It  may  communicate  with  a  coUcctioa 

(if  floid  MtuotA  oul«idv  tliv  now,  in  ttiv  ujiper  lip,  fur  example.    The 

■■Uer  KKSKtad  baa  sometimes  a  highly  otleosive  ancll. 

Tbe  prc^nOM*  in  diawuiw  of  Ibu  sci^tuui  ought  to  be  guarded. 
Ae  danger  is  from  destruction  of  the  bones,  or  cartilages^  or  both  j 
ni  ia»  may  tJtkv  jilncc  long  after  tho  aj>paront  euro  of  the  nilntent. 
iB  tbn  majority  of  cases,  pertbration  vritli  more  or  less  dcstrnctioo 
■  lieeartilaj^iioiuae]>tum  may  bo  anticijmtoil,  botb  in  ^ym|i(iiinatio 
•i  aSopathic  caaee^  This  may  be  otfeoted,  aa  Mr.  Fleming  stat(^«, 
If  mtcntitial  abitorption,  without  ulceration  of  tho  nmoouH  niem- 
B»^  in  which  case  the  mucous  membrane  of  one  nostril  adberoB 
todKothur;  or  alcomtion  may  arim;  and  tlion  an  opening  of  vui- 
iiboxtent  admits  of  a  communication  betwt^w  them. 

An  cvly  opening  of  tho  ubio.^^  is  )>ro|)cr  in  enxc*  of  tliia  do- 
inf6oa.  Benelit  will  he  <lerived  att«r»-iiril»  fi-oiu  pencilling  the 
n&BB  with  a  imlution  of  nitmto  of  silver,  oontjiining  four  graini>  to 
1^0  ouDGe;  and  also  trom  ilie  exhibition  of  mild  alteratives.  Too 
waeb  atteatim  cannot  bo  given  in  onler  to  prevent  extt^itiion  of  thu 
Anae,  and  to  obtain  a  cure  wilfaotil  any  abiding  deformity.  This 
aSntioa  might  be  confoundod  nHth  a  tliickonvd  or  cloiigntod  con- 
jAian  of  tho  mticnu-s  ni<-iiibrane  cohering  the  septum,  but  here  the 
is  mom  in  the  shapo  of  a  told  thiin  a  distinct  awdliu^ 


SOS 


DISEASES  OF  THE  NOSE. 


and  there  is  no  soiiHe  of  fluctuation.     It  might  also  be  roiotjiken 
polypus :  but  polyjius  seldom,  if  over,  ari«(M  troiii  tliitt  jxirtiou  of  the 
Sc!intii<leriaii  inetul)nuie. 

Tumours  (.-ontaining  a  gelatinous  fluid  may  bo  (i;ot  rid  of  b; 
Wii|>|>iti^  awuy  a  [lortiuii  of  tlie  wall,  an<l  oauteri&iiig  tite  interi 
wiUi  nitrate  of  Bilver, 

Curl ilii^iioiiA  groM'thd  are  bv  no  mennit  common.  Tlicy  in' 
fiire  with  breathing  and  artivtilntion,  cause  tho  patient  to  snore,  ttUi 
•TO  utli^iiilotl  with  fn^i^uent  heii<Laohe.  Tlio  ubovv  oyinplnnidi  wen 
present  in  the  inslanco  of  a  young  man  agod  eighteen,  who  \ra» 
routintJy  undi^r  iny  oitro  in  8t.  Aliiry'n  HiiKpitiil.  Hu  bud  Kullt-'ri-d 
ever  since  he  could  remember  from  a  fubioss  in  tlie  right  nostriL 
Oh  vxaniiniition,  I  [«.?rct)ivi'd  a  tumour  «iniiwt<'d  with  liio  w.'j>tu 
and  floor  of  the  nostril,  and  blocking  up  the  inferior  meatus, 
air  oould  oon.-w|uwitly  ixw*.  Tlie  [mliivit  luul  tlic  \Kca\iaT /iv^-fc 
wliidi  characterises  [wlvpus.  Tlie  tumour  had  been  taken  indeed 
ibr  polypiM,  but  it  vrn»  found  ini]>o!>»iblo  to  remove  it  with  polypus* 
fiiroepe.  1  efli'cted  a  cure  as  follows ; — I  made  an  incision  tlirougfa 
the  side  of  tlie  no»e,  in  tho  direction  of  the  line  wliich  cuunectn  the 
nose  and  cheek,  in  order  to  get  room,  and  tJien  gouged  out  the 
gnjwth,  wliifh  wa^^  ext-cedingly  coinpBft  in  structure.  I  sucoccdod 
with  tlio  gouge  in  clearing  out  tlio  lower  moiilu^.  The  operation 
WHS  followed  the  next  day  by  ooziug  of  blood,  and  some  eiyai- 
pelatous  swelling  of  tha  nose,  which  yit^ldfd  to  ivild  Mji|iliraitionjL 
PrpBoiitly  the  wound  cicatrised  nicely,  and  tho  patient  recovered 
rapidly  from  his  Ibrnier  distressing  (lymptoma,  the  noKtril  being 
oomplctciy  pervious.* 

Tlio  »ej)tiim  generally  deviates  to  tho  l«ft  »ido,  }icuce  tJie  rig^ 
noBtril  18  proportionately  more  capacious  than  the  left.  It  ia  some- 
times perforat.pil  iiidei"!n(U'ntly  of  any  xurgicuil  opcralirin  or  di: 

JJi/j)rvtroj>lii/  of  the  jyituitarii  fiieml'raiii^.      It  is  not  uncommi 
to  MX  the  pituitary  inenibruno  hyiMTtntiiliicd  iJiroushout  its  w 
extent,  and  in  both  nostrils ;  frequently  the  thickening  U  Iiinite>d 
the  portion  of  niucoun  membrane  winch  folds  back,  and  lies  uiidci 
neath  tlte  inferior  spongy  bone.     It  ought  to  be  borne  in 
tJiat,  at  tho  border  and  posterior  extremity  of  tJic  inferior 
bone,  the  membrane  in  naturally  tliiek,  and  tlie  thickne^  di 
ftH  Kolliker  [mints  out,  not  on  the  glands  alono,  hut  upon  abujn 
almost  cavernous,  venous  plexuses  in  ita  interior.^ 


jii. 

eed^ 


•  Lmeet,  April  UJtli.  loni. 

i  Manual  nf  fiumait  IlUtologj/,  Sjd.  Soc.  od.  toL  li.  p.  4t7. 


CnUONIC  CORYZA. 


SOS 


Tb  afTection  Bonietiiiies  fullowA  oorrxa,  and  Mrniotimcs  an'ses 
I  ■iiliwiimiilj  ll  oaii»«e  unM»iiic»»  iti  brcalhiiig,  ettpecially  dur- 
[il(ald  uid  ilainj)  weutlier.  Oti  Wking  into  tbo  niwLril,  there 
'  ■  }»fi«ivod  a  tumvfiiction  roeembliiig  poljpus,  but  of  a  d«e]>er 
iM^Mid  not  [teilunculitUxl.  Thcru  is  n  a>se  ik'taikHl  in  tltc-  clinicnl 
llMnm  of  M.  Nulaton.*  In  «u:b  noetril  vtaa  a  globular,  alcuunt 
[■■nil  I  lit  ttuum,  soft  U)  tlio  touch,  not  l>kixlin{;,  niid  voinploMljr 
tbo  noBtril.  Tlte  passage  of  ftir  was  very  diltiailt,  indeed 
cotirvly  cut  utT;  thu  vuivo  nus  na^ul  imd  Uio  noetril  diy, 
tbe  |ali<!ut  waa  obliged  to  breathe  all  the  time  by  Uie  inoutJi. 
|AiOHe  WMa  tnatwd  by  vxci«itig  u  portion  of  t^io  liirbimitcd  bono 
Ivth  Uh>  Miaaors.  In  such  canen  bniietit  will  be  obtained  by  Uyptio 
[■riutnogeiit  injwtions;  toucbiug  tho  surfuvu  vritli  imlution  of  di- 
df  lend  or  iiitrute  of  xUver,  together  with  tli«  approved 
I  Busniu  for  controUiug  scrotuU. 
CUniriial  affections  oftlie  piluiUiry  mucon«  tnombnmv)  are  by 
LM  MMtt  uncommon.  To  thew  tlio  tenn  eor^^za  in  appli(<d.  The 
bno  bocuniea  itwoUen,  mxl  UiLTvliy  dimiiiUhi,«  tliu  ana  of  tlw 
caiititn,  which  is  attended  with  diHiimlty  of  breathing  and 
LlAtw  vt  lean.  Tiiu  pattvnt  oxfMiricncHM  at  the  oulHut  h  lovling  of 
ItyuMi  ill  the  part,  ere  long  followed  by  diwliarge  of  a  tbitt  acrid 
Iliil,t«u0  of  tickling,  fits  of  uiwieing,  and  dull  heavy  pain  aoroes 
(inrelwad.  Coryzu  fmiuontly  runowod  di»[HMic*  to  e|iiplu>ni,  oiid 
ihduTinal  listuUf  uwbg  to  change  of  structure  of  the  mucoua 
!  yiaxxd  Ut  tiut  lower  vxtreuiity  of  tho  Dual  «iuutl.  It  Oiajr 
u  n  symptomatic  afi'eotion  in  polypus  of  the  noae,  in  local 
•  of  iho  ontnun,  and  iw  a  forerunner  of  oui-nu,  or  of  curiw* 
Iff  OMmia  of  die  turbinated  bon«»,  whether  of  a  scrofulous  or  a 
l^flttttJo  origin. 

Uavaic  cortia,  oomrrtng  in  an  individual  labouring  under  a 
!  taint,  [>n>vc»  often  uiost  refractory.     It  (viiimeuocs  liko  a 
ould  iu  the  noHe,  wiUt  increuncd  Mieretioii  of  umvui* ;  this 
I  fcr  ■  long  time  clear,  and  of  the  oonustenco  of  thin  starch, 
of  miieuH  ii  tncTVH»«d  on  cxporaiv  to  cold,  |Ntrtiunhirly 
1  air,  uuil  by  indulgence  in  tlie  use  of  alcoholio  Uquors.     If  the 
.  thuukl  lui]>poD  to  catidi  cold,  tJio  di»chargo  iKtwuncH  profo»e, 
I,  and  ropy,  aasutning  a  yellowiiUi  or  greenish  colour.     Un- 
its occasionally  cxperii-noud  williin  tlio  nostriU,  with  a  fooling 
;  or  obatruvtion,  ud  if  a  tumour  luul  formed  witlun.     Tlie 
rgo  abates  at  intervals,  as  during  sloop,  and  theu  tlie  pitui- 


lolnki 


*  Aiswwui  biuivlutiuti,  b]r  AUcv,  ji.  111. 


SM 


DISEASES  OF  THE  NOSE. 


tu^  membnne  feels  clrii>r  than  natural,  and  cnvts  of  dried  mm 
are  to  bo  mot  with  Movr  l,ti<;  iiili»rior  spongy  bone.     IndividuuU 
thiu  afibcted  are  &e(iuently  blowing  tho  nom  in  oixlur  tv  cleAr 

of  the  redimdimt  secretioi 
ftitd  from  tho  foreo  em 
ployed  tiaoea  of  blood  are 
not  unfroqucnt  On  mi^i 
nutely  (>xamining  the  iH' 
terior  of  the  noatrib  wi 
the  aid  of  Uie  tijiiwulnm, 
figured  in  the  niai^ia,  the 
»tU(!i>UA  nioniliraiie  Li  seen 
of  a  deepor  rad  than  Datu- 
ra), and  »ornetiiiie»  i;ruded 
here  and  thoni.  Tho  affec- 
tion ap]H>antt'>axt«nil  to  the 
lining  membrane  througH- 
oiit  nil  tliu  windings  of  tho 
nasal  cavities;  tlias  by  tho 
superior  niuMiu  it  m  pn>* 
pagatisd  to  the  poelerior 
otiiiiioidid  cvIIh,  and  hy  the 
middle  meatuii  lo  the  aiw 
t«r!or  ethmoidal  rolb,  as 
also  to  Uie  maxillarr  and. 
Irontal  MinuK«.  it  is  eoi 
tiuii^  atteudod  with 
ache,  an  attoration  in  the  chiinivtur  of  tlHi  voioo,  and 
pairmont  or  abolition  of  tlie  sonao  of  nnielL 

Tliiw  exwsitivt'  wocretion,  depending  on  a  morbid  «©' 
dition  of  tho  wido-spread  pituilnry  iiHunbrurio,  iiuiy 
for  year*,  and  vvviituiiliy  Kubvldo  witJiout  any 
Htructural  cliajige.     It  is,  however,  a  wmreo  of  annojano 
to  the  patiuut,  and  inuMt  always  bo  regarded  with  apprt'hi 
sion,  henause  if  persistent  it  may  tttrmitiatc  in  Htipjiuratii 
associatud  with  dlecasc  iu  tlio  nasal  bones  and  canilagest, 
eventually  produce  irremediable  d<}4bnutty. 

Tlio  aiiiifxwd  woodcut  represents  the  tfieeutum  mm, 
contrived  by  Dr.  MeU:  of  Aix-k-Chapulle.     It  conusta 
two  iMTparatu  i>i««»;  one  to  be  heUl  tu  the  ri^t,  the  oi 
in  the  left  band.     When  introduced  within  the  nostril,  thvsu 
to  dilat«,  and  at  tho  sam»  duo  to  refiect  light  into  (ho  cavity. 


lis 

I 

re 

I 


SYPHILmc  CABIEa 


205 


i  Wag  used,  fl>cy  onght  to  !>«  ilijjped  in  warm  water,  to  prevent 

I  poGdwd  plmiw  buing  ilimmod  by  liie  dopoaitiou  of  vajKiur. 

Tim  tnaatinent  oonsistH  iii  the  «x)uI>itton  of  morooiy,  is  con- 

snuUl  doM*.     Tho  bichloride  of  mercury  may  be  givvii,  to 

extent  of  •  nixteenlb  or  oi^rlilii  of  a  grain,  twice  daily,  in  a 

of  onoooe  of  distilled  water ;  and  persevered  in  for  tvro  or 

Ihreo  tnontlu.     ThuH  ndminiKttTnHl,  it  cxorciHCii  both  an  altorattve 

sod  Ionic  action ;  suldom  Ki^'iug:  riite  to  p^'aliHm,  or  producing  any 

inetmvenieiioe  except  a  sltf;bl  Iviniomowt  in  tliP  roof  of  Uie  month. 

Or  a  aiojcle  grain  of  blue  pil]  or  gray  powder  tasY  be  given  every 

xa^it,  for  a  itimiliir  period     In  ctironio  di"«a)«c*,  as  l>r.  (JravoA 

joatly  reinarin,  the  beneficia)  inflnen<'e  of  mercury  is  best  obtained 

L  when  f^iren  in  contincuHu  aina]!  clontw ;  and  tlit^  mh  ii|iplit:«<  t»|>«>d- 

l«lly  to  those  obstinate  oaaes  of  constitutiona]  syphilitic  aifoction  wo 

I  wwHiniw  meet  with,  whtcli  liirt  for  ymre  tn  !tpito  of  all  tivatineiiL 

Bboold  there  bo  any  erosion  of  die  pituitary  membrane,  benefit 

will  aocnie  from   tho  adminiMtration   of  ioclido  of  potantium   or 

■odium,  ahemated  with  the  merour)-,  and  given  in  adequate  doses 

iLMiitahki  nit«rralfi.*     As  rc^^rds  local  treatment,  tho  objoct  Iwro 

a  ta  change  the  action  of  the  miinia't  inenibmne,  and  to  shield  it 

bm  the  infln<-nc«  of  external  impreasions.     Tiio  formor  iiidicatjon 

iiWtfnlliUed  by  peneilltng  the  iniemal  surfaoo,  onoo  in  two  days, 

with  a  ulotjon  of  nitrate  of  siK-er  oontaining  from  four  to  ten 

^Mi  to  the  ounce  of  distilled  water ;  or  by  inje<Hi>ig  ilaily  a  aolu- 

■■  tf  alum  of  two  grains  to  the  ounca     By  acting  in  this  way 

■i  Ike  mnooua  membranio  at  tho  oiitJiil  of  tho  notitrilis  a  healthy 

Mnwill  ohim  bo  iodoced,  which  spn^ds  to  the  vicinity.     Mr. 

wpton  Parker  racommcntl't  the  va|>uur  of  calomel,  dirtx-Led  by  a 

M^  prooess  into  the  naaal  fossse,  for  a  few  minntes  daily.     Blis- 

iK^tbe  tnipeoflho  nwk  i»  another  mwloof  trcatJnonl.     To  shield 

Ik  lining  membrane,  cold  cream,  or  an  ointment  oonlaining  a  Uttlv 

lifamil,  oxkle  of  nine,  or  himnuth,  may  bo  uwxL 

la  patiealB  of  a  delicate  atnunona  bahit,  eypfaiUtao  oztma  is 
ptme  to  npervene.  Thiit  iit  attandod  with  canes  and  neorosis  of 
it  aatai  bones,  as  ako  of  the  vomer  and  perpendicular  plate  of 
tit  fiUnnoid  bone,  with  more  or  less  diiHlniction  of  thtt  citrtilagea. 
Asm  evBUtnjJIy  exftdiste,  and  sinking  of  the  bridge  of  the  nosct  is 
•MDomi  rvtwlL     l>uri»g  tlie  prooum  of  exfoliation,  tiie  dlitoltarge 


•  T^  fotlowinft  formaln  wUI  ficncraJly  bo  found  to  agree:  (tpotnani 
inUi,  iwiaas.  bicarb.  U  i[r.  x.,  njrTup.  nitmn  eo.  ^ij.,  ni|iia  a<l  Jjv.     M.  finl 
■lUu  U>  lerve  la  ilica  Buaicudiui.     The  siirxn  setr<*  an  a  (li'iuulc«nt. 


!06 


DISEASES  OF  THE  NOSE. 


from  tlio  nostrils  acqnircs  an  intolorablo  smoll,  koootneH  pro 
and  niity  lie  atten<lt>il  wilJi  attacks  of  lia^ninrrlDip;  fW>in  tlii; 
iilccrntion  of  ttio  Atuecs,  and  xHolcnt  pain  oictending  from  the 
phai^-nx  along  the  KuMiK-liian  l«l«  to  t,Ii«  tympHiium,  and  deiif- 
neas.  Should  tJio  nBcction  engage  the  delieate,  porous,  and  eeeni- 
ingly  wonn-eaten,  bony  lamoUiv  of  tho  vtlimoidal  ct'IIn,  it  may 
oommtt  end  havoc,  transforming  the  mouth  and  nose  into  one 
cavity  with  nud«  hnny  wnlls.  In  the  mcnt  of  the  intcgurai^nt  in 
this  situation  liaviiig  been  deetroyed,  the  movementii  of  the  epi- 
glottic nru  brought  into  view,  Tiio  hidcons  devastation  tlios  pro- 
duced is  Vfell  exemplified  in  the  instance  of  a  &kiil]  prawrved  in  tJie 
inuMnim  of  St.  Miiri-N  Hns]>iijil,  ns  aW  in  a  wax  model  of  tlio 
patient's  head  and  face  taken  immediately  after  death.  Sho  had 
boon  under  tho  cnrw  of  Mr,  Iiimo,  in  the  Lock  Hospital.  In  this 
skull  there  is  a  large  o]M>ning  threp  inches  wide  hy  two  in  lieight, 
occupying  tlw  wholo  of  the  forelit-ad ;  the  frontal  bone  around  th» 
ia  very  much  thiokentMl,  tlie  frontal  sinuwii  on  tho  left,  itido  ar« 
opened;  the  naaal  bones,  the  ascending  and  palatine  processes  of 
both  Ruperior  maxillary  l>oiu>s,  vrith  ilic  anti-rior  halvoit  of  tliei 
alrooli,  the  inferior  turbinated  bono,  tlio  vomer,  a  part  of  tho 
Iionai.  and  nio«t  of  Iho  cthnioid,  am  f«in|ilft<*]y  ilcnl.niyod  ;  tin'  ei 
moid  and  sphenoidal  cells  are  extensively  opened  ;  and  tlio  a. 
Highmariana  comjiletftly  laid  into  the  ctmiy  of  the  nows.  A 
queetnim  eomi»rises  nearly  tlie  wholo  of  tlie  vertical  plate  of  tba 
fimital  boni.',  the  right  nasal,  tho  iwwnding  prweww  of  llic  supenor 
maxillary  bone,  and  a  small  portion  of  the  alveolus.  The  from 
bone  is  a  good  doat  thicknu'd  fmni  the  ('(Tt^a  of  the  diacase,  ton 
with  the  other  hones,  has  a  slightly  porous  appearance. 

Protracted  oases  of  syphilitic  vnryr.n  must  be  viewed  witi  a] 
prelitiision  also,  from  the  risk  of  danger  of  serious  oen'hral  nfTt 
Hon  supervening,  as  illustrated  in  Dr.  Weber's  jiapcr  on  the  subji 
publislii'd  in  the  43d  volume  of  tJie  MMieo-Chirurtiirat  7'mnM> 
Among  other  cases,  the  author  gives  the  details  of  one  of  s^-phiIiti 
OzXMia,  in  whieh  head  symptoms  a)){u>an-d  Honn  afl^r  ecsMlion  of 
nious  discharge;  rigors  four  da}-8  later;  pyemia;  and  death  on 
thirteenth  day  after  tho  fimt  rigor*.  Catlnverie  inHfic-etiiiti  revej 
thrombosis  of  the  cavernous  sinus  and  ophthalmie  vein  of  the  l 
side,  as  also  of  tho  longitudinal,  and  tn  n  \cstier  degree  of  the  ct 
cular  and  right  cavernous  sinus ;  ]>umleitt  meningitis  on  Uie  inlerii 
aurfaiY!  of  the  lel^  anterior  lobe;  weundary  alwwwjv*  in  tliu 
and  liver,  and  purulent  efi'usion  in  the  left  pleural  eavitr. 

It  liBH  been  iLx»crtcd  that  curies  and  dcslrudioD  of  tim 


[iCERS  OF  THE  NASAL  POSS^. 


207 


rMooi   or   never  observed  oxoept   where   momurv  Itim  been 
nbliero'i.     Buvh  \»  ni^t  llio  fiitrt.     I  liuvo  ttccn  instnnoos  of  de- 
af bone,  and  oons«|UPnt  dpformiy,  the  m><)iii^I  i)f  vwicrt-al 
'  wbcrv  not  a  ]»irticlv  of  iiivrciirr  lutd  Ik^i  taken.     Sir  B.  CL 
roentions  a  cano  in  point.     A  ^imtleninn  had  nhaim-e;   no 
Br}'  was  uxliibiCvd.     In  two  yvtins  iiAcmai-ds  lie  hnd  cxten- 
re  diseaao  of  tlie  bonea  of  the  nose.     He  lind  a  lit  of  epile]wy ; 
bis  m*  socoecdod  by  a  m>ci>ik1  and  a  third,     flu  b(>caino  maniacal, 
died.     Sir  B.  C  Brodie  never  doubt^Kl  that  the  disoaw)  iiiul 
sept  up  the  iHlinxifd  colls,  aftuctcd  the  cribriform  lamella  of  the 
athmokl  bone,  and  ultimately  the  brain  and  iU  membra neji.*     Dr. 
Qnvm,   moreover,  idlwlw  to  two  nnalogoiis  c»isc.%    in  wliich  the 
Krofidouf)  diaUie^s  was  preSminently  marked,  and  the  atlbetion  of 
tbe  lM>ne^,  whic]]  tliv  vviwtvuI  poison  vxhibitofl,  Imniodiatuly  dege- 
■temeil  from  its  usual  course,  and  assumed  all  the  ehiiraeters  of 
•ctoibtoiis   dinawk     In  both  instanee?,  destruction   of  the  nasal 
boon,  and  ronser|nenl  sinking  of  the  bridge  of  the  nosi>,  ooourred-f 
As  rc^rds  treatn>cntt  tlii;  main  rolianoo  must  be  on  tbo  pre- 
[nations  of  iodine„    Tlic  waters  of  Aix-ln-(7li3iielle  have  been  foiiiul 
Kninable,  as  I  learned  from  l>r.  Diemcr,  a  skilful  pliysician  prao- 
tUng  there,  in  virtue  of  tJio  alterative  and  imigoi-ating  influeiioo 
*tedi  they  exerciso  on  the  system.     Cod-Uvcr  oil  and  clialybeatee 
liU  be  ncension.-illy  i»dicate<L     Ah  a  gi-neral  rule,  iiK-rciiry  i^  prc- 
Jkiioal  where  tbo  bones  and  cailila^cs  are  deeply  aileeted ;   but 
Aaii  aontt  of  the  metal  havi;  Inji'u  pri^vioui^ly  exiiihitinl,  miniitit 
i"«»  of  tlie  bicbhirMe  may  prove  advantageous.     Tlie  local  means 
flWia«rtlHt  rcmovid  of  cnists,  warm  fom<;ntation»,  ftii<l  iiytmliotia, 
1  injections,  a  weak  solution  ofcJiloride  of  zino  or  bicblorido  of 
y  may  N^  re»ortcd  to,  in  the  pr«{M>nion  of  Imif  a  i^raiu  Ui  tho 
<nn  of  diAilled  water.     Inhalation  of  mercurial  vapour  is  recom- 
Bn^  by  Nonte  practilioncni.      In  tho  event  of  ln-jid  symptoms 
•■inp  on,  leeching  the  scalp  has  peculiar  advantages,  from  tlie 
iMiniatc  connexion  Jietwixtn  tlii;  w»Ip  and  the  surfaee  of  tbo  brain. 
MMer-6timalant«,  as  bligters,  to  the  nape  are  valuable  auxiliariea. 
CTtcrt  i)ftht  Ttaml  fotur,     Ulccrx  of  tliUKC  cavities  are  sometimes 
Ai  KKiael  of  a  cold.     I  was  oonsultod  by  a  gentleman  aged  fifty< 
••n,  wlw  liad  Ixvn  thirty  ytiirs  in   India,  on  aoount  of  an  oval 
prtefc  of  ulceration  in  Liu.'  right  iio«Nt,ril,  just  by  the  lower  margin  of 
tie  ^Qi'erita'  lal'^ral  earliiage.    It  was  <.H»v<;nKl  with  a  crust,  and  was 


•  ItmAxt  UMiftI  Oaxfttr  for  l»i4. 

t  CIXMfil  l.4cnir*t,  3d  <Klit.  vol.  ii.  p.  tBi. 


m 


DISEASES  OF  THE  NOSE. 


the  aoat  of  irritation.  It  comnierKHMl  !>i\  montiis  proviouslr  fi 
oold.  UWrs  in  (iiia  sitnation  more  frequently  reHiilt,  I»oww%'<'r, 
a  Bcroliilous  or  syphilitic  tniiit  in  thu  ny^U^m.  Thoy  are  ordinarily 
hIow  of  healing,  becanse  the  cellular  tis»ijfl  in  thiit  lociilily  ia  r(>iy 
deiise,  and  by  no  means  fnvotinihlu  to  allowing  tlie  marginn  of  tho 
Roliilion  of  oontinuity  to  come  near  each  othcT ;  Bucordingly, 
resulting  oicatrico  is  always  large,  or  oI«c  there  is  loss  of  tnilxttuna 
vritli  jwrioration.  The  sores,  moreover,  are  oonM-iintly  imhuod 
a  more  or  less  acrid  secretion,  and  being  freqiiently  tlw)  wsit 
itc(ung  or  of  nnensy  sensation  are  frett«d  by  tlio  repttatod  cunlact  ■ 
the  patient's  finger.  Ulceni  may  assail  any  part  of  the  nasal  To 
but  urv  TniKit  OTnmon  on  the  M^.tini,  Junt  wlieru  the  cartilage  ts 
connected  with  the  bone.  Sometimes  tliis  merely  amount.*  to  ero-. 
sion,  tho  mucous  membrane  having  Hcarooly  lo«t  its  polish. 
Otlier  times  it  is  a  distinct  nlceration,  the  surface  of  which  is  plain]] 
granular,  and  coventl  with  a  cnist,  TIii?  [lattents  arc  led  to  de 
the  crust  witli  their  fingers,  when  bleeding  may  ensue. 

Ulceration  hero  iiinv  1*  niuijile  ami  benign,  tho  secretion  «■* 
haling  no  perceptible  odonr;  or  it  may  be  of  a  different  nnlure,  and^ 
wnit  a  highly  offcnwvo  smell :  henco  the  tonn  oantoy  dori^-ed  from 
the  Greek  ^Jij,  stench.  The  cause  of  o7a>na  is  often  obscure.  The 
affection  is  ob^^rccd  in  individuals  of  vigonius  constitution,  as  well 
as  in  tliose  whoso  sj-stem  is  contaminated  by  syphilis  or  iwroliila. 
It  is  often  met  with  in  pcmonti  who  hare  a  broad  and  Rattened  nose, 
whidi  the  French  term  ^cnrni,  and  which  may  havo  rwiultcd  from 
hereditary  sy])Iitlis.  According  to  M.  Trousseau,  one  of  the  earliest 
and  most  characteristic  signs  of  the  aj^pctai'ance  oftiypliilts  in  tho 
infant  is  a  cory/a,  which  begins  at  first  with  mucous  secretion, 
ibilowcd  by  serous  and  purulent  discharges,  and  by  litcmorrhage  of 
greater  or  less  froqueim*,  and  terminates  in  caries  and  di'liimiity 
of  thu  nasid  Iionoa.  Now,  I  lietJevo  a  ptirMiftonco  of  this  eondition 
will  give  rise  to  ozsna.  In  some  of  those  obscure  cases  whidt  ar« 
diarncteriHcd  merely  by  tho  offensive  smell,  when  there  is  no  dia 
ehapge  of  matter,  no  pain,  and  nothing  preternatural  to  be  perwtiif 
in  the  nares,  the  pause  may  be  a  fragment  of  carious  or  oe 
bone  pent  up  in  some  ciTpt  or  otlier  of  this  region. 

Tile  afl'eetion  commences  in  infancy  or  in  adok'sconce,  and 
either  case  frequently  lasts  through  life.    Tlie  stencli  is  the  firrt  sif[ 
whicli  attracts  attention,  and  is  somoliin<«,  as  aboi'o  stated,  the  on 
one.     In  a  case  of  this  description  which  came  mider  my  care 
time  back  in  St  Mary's  Hospital,  tho  subject  was  a  sliort  stout-n 
j-oung  woman,  twenty  years  of  age.     She  had  from  corlicttt 


OZ^XA-     EPISTASIS. 


209 


Inod  li«eii  aiFcctod  with  a  discharge  of  a  greenish  oolour  and  fa>ti(l 

Hiidl  bucn  both  nuiitriU,  with  ocduioiid  pain  of  a  shooting  ehti- 

noter  referrod  to  tlw  root  of  the  iloso.      She  had  tlie  nez  t<<:ran4  at 

flatteiiMi  ttue>e,  vrjth  tiii|>urHcial  tik-vratioa  of  the  loucoun  oiuDibrnna 

flftbe  roof  of  Uie  left  nostril    Here  a  piece  of  curioua  bone  lioil  boon 

ranoved  at  a  former  period  hy  a  Sur^oon.     She  improved  iindiir 

die  me  of  remedies,  but  wtu  not  <!iiro(l.     Indeed,  oxa-na  in  rarely 

eared,  cxocfit  potchanoo  at  its  outset,  and  that  in  young  8ubj<.>cbi. 

lo  some  iattannea  it  ha-i  \>t)c.n  known  to  Hul»i<lA  on  the  eAtablinhment 

of  menstruation,  or  after  ehildltirtii.     Tlie  treatment  reMlvm  itaclf 

into  tlie  ctnploymont  ofehlorinateKl  iiOeotions  to  correct  the  foetor, 

Knd  of  rariona  stimulant  mid  afltringent  applications  to  inodity  tJie 

riialiiy  of  ttie  pituit^iry  membrane ;  snob  a»,  very  dilute  solutions 

of  nitrate  of  silver,  chloride  of  sine,  and  sulphate  of  copper.     Dr. 

GniM  reoommemht  an  injoction  eontaining  three  graiii»  of  tannin 

and  a  qnartcr  of  a  grain  of  sulphate  of  erip[)er  to  an  oance  of  dis- 

lijleil  watur.     A  dilato  solution  ofereosote,  carbolic  aeid,  or  per> 

manganate  of  potash,  will  sometimes  bo  of  fiervtce.     The  insufHntion 

of  eaIom<^,  conjoined  with  an  injection  of  bichloride  of  men;iiry,  ja 

eBttoQoil  by  M.  Trou£»eau.     Wliere  tlie  irritation  has  persisted  for  a 

potiixl  of  y<»nt,  and  is  attended  with  superficial  CTU«ioii  of  tho 

■oeoM  membrane,  I  have  proAoribed  witli  advantage  »  liniment 

eontpoaed  of  one  onnee  of  oUvc-tHl,  with  fifteen  grains  of  ehloriile  of 

tine.     11ms  alfeeted  part  iii  to  be  {leiieillcd  over  with  tlie  liniment 

moe  a  day.     A  peculiar  caostic-tioldor  for  applying  nitrate  of  sil- 

»er,  in  (»*»  of  «»i-na,  Itan  been  (ievi,ieil  by  M.  Cazenave. 

^       Ej/ittarit,  or  bUfdiitff  from  the  nate.     The  arteries  of  tho  nostrils 

BlfRng  from  the  ethmoidal,  splivno-jiidntine,  po»t<:rior  j>idatiiie,  and 

B  fadal  brandiee.    Their  veins  are  ntniost  all  satellites  of  the  arteries ; 

KxaKofthem,  liowever,  (ravciiic  merely  tho  bo<ly  of  the  sphenoid 

H  hne,  and  the  fronto-ethmoidal  foramen,  to  arrive  at  the  sinuses  of 

H  w  dura  miller.     Hieso  last  arc  tlio  emitaart/  reins,  which  tiave  no 

■  Miogf  with  the  arteries  in  their  distribution,  but  which  establish 

I  Wnen  the  nostrils  and  the  cranial  veins  an  intimate  eumiiiuni- 

I  Btinu     This  may  be  noticed,  in  parsing,  as  im^Kirtant  in  a  medical 

H  ptiat  of  vien',  because  it  accounts  for  tlio  bleeding  from  the  no«e 

B  *bdb  oncura  ao  frequently  in  e4U(t-i<  of  obstinate  cephalalgia,  and 

H  riw  fur  the  efBcacy  of  derivative  abstractions  of  blood  from  tlie 

H  Mlrik  oiider  such  eircumstaneoK. 

H     HaUKirringe  from  tho  nose  may  be  either  spontanoous,  as  in 
H  At  insunce  above  alluded  to,  or  trauniatie,  tlie  result  uf  injury  or 
■Mpcd  aperstiuo  implicating  tho  pariotes  of  the  cavi^. 
^^001.  tiL 


SIO 


DISEASES  OF  THE  NOSE. 


Spontniicoiifi  blcc4ing  from  the  noee  may  bo  acitve  or  passis 
In  till'  fonm-r  wiko  it  is  duo  t<>  rupture  of  vfriwlw  wliioli  are 
filled,  or  to  a  mere  Baiigwincous  cxtialation  indcpendciitly  ofsnr 
t>!Xt.uru1  li'siou  ;  und  is  prcctMlcd  liy  a  m^iiko  of  fiiliicsN  luid  weight  in 
the  frontal  suiu§eH,  redness  of  tho  eyes  and  faco,  and  a  peculiar 
bnzsiiiip  in  tli«  oars.  It  tn^cnnt  oliiofly  in  y<miifi  [H*rH>ni«  up  to 
tho  ])criod  of  puberty,  or  a  little  beyond.  In  the  latter  ease,  the 
bn'iniirrbiij^'  is  also  <Iiic  to  an  exhiilatioii  of  blowl,  but  connoclod 
with  an  enfeebled  state  of  the  vaseular  system,  and  not  annoonoed 
by  any  prcftirsory  signs.     It  is  orilinuriiy  (iyinpt«mnticof  hcutvj-. 

Hpontaneoua  bleeding  may  generally  bo  stopped  by  the  aj^li- 
cjition  of  c»id  to  the  fon-hi-ail,  or  inlnxhicinp  a  picw  of  Itnt  soaked 
in  Bome  aicoholie  tincture,  aa  tJial  of  benioin,  or  in  some  slyplio 
eolution,  into  the  no«tril«.  In  nctiw  h^morrhugo  it  hiu  been 
reoonnnended  when  the  blood  flows  from  one  nostril  to  elevate  the 
corresponding  arm  in  u  vortical  position ;  an<l  when  it  flows  Irom 
both  nostriU,  to  elevate  both  armti.  The  propelling  force  of  the 
Iicart  is  thus  diMribntcd,  because,  having  to  urge  a  column  of  blood 
up  t)te  arterii-A  of  the  anna,  it  muni  act  with  loss  inonieutuni  on  the 
cnrotidfk  I  have  seen  tho  plan  successful.  M.  Malgaigne,  in  his 
work  on  FructureH,  meniioiiR  a  case  in  point.  A  young  innn  had 
been  thrown  down  with  his  face  to  tho  gronnd,  and  sustained  a 
Iraeture  of  the  nose,  from  which  there  was  copiotin  bltHidiiig.  Ctdcl 
lotions  having  faikxl  to  check  the  latter,  ho  was  directed  to  raisB 
liU  ann  jHrjit^ndiciilarly ;  ilie  1  Hemorrhage  ceawd  imintHlintely,  snd 
did  not  recur.  Tho  late  Sir.  Vincent  strongly  advocated  tlie  in 
portnnce  of  keeping  the  blci^diiig  voKsel  free  from  all  ciuignhim,  il 
order  to  suppress  li»morrliagc,  Tho  plan  of  proceeding  which 
adoptwl  for  this  purpose  in  epistjixiA  was  to  syringe  tlu!  nostrils,  i 
aa  to  wa«h  tho  blood  out  If  the  sjTinging  be  continued  until 
bleeding  ceaees,  it  will  not  only  stup,  hut  not  rconr.  live  wate 
need  not  be  cold ;  indeed  ho  found  tliat  arteries  will  eonlract  under 
the  use  of  warm  water,  which  liiu'  a  better  ell'wt  in  eh^nng  awajT 
the  clots,  and  keeping  the  piuls  free  from  blood.  In  ejii»taxta 
reuniting  from  »  scorbutJc  taint,  benefit  will  be  derived,  in  many 
cases,  fi-oin  tlie  lulnitnistralion  of  oil  of  turpentine,  IJr.  Onites* 
witnwseii  the  greatest  advantage  from  drj-cupplng  in  some  fomi* 
of  cpistaxis,  in  which  complaint,  he  saya,  much  benefit  is  frwjuently 
deriveii  I'mm  the  application  of  cups  to  the  napo  of  the  nock,  esp«« 
ciiilly  when  employed  to  aircst  the  paroxysms,  in  caiies  whet 


«  Cliaioal  Lfituia,  vol.  II.  p.  310. 


POLYPUS. 


•sn 


ns  of  a  woll-marked  oliaractcr  preoedo  tho  attack 

:  from  Hk  n<Mta 

fibosM  the  ha>inorrhage  not  jielA  to  the  meanK  itbovo  specified, 

lim  nmane  must  be  liiul  to  pinging  the  pontoriar  luirea.     Tliis 

la  tlxMe  cases  in  whtt^h  the  MihxI,  tH^in^r  preveiitod  from 

rio^  out  of  the  nostrils  anteriorly,  makes  its  way  down  th« 

Tliia  may  !»  effected  tn  variouit  way*,  and  infr«iioii»  instni- 

M  tlutt  of  Bcllocq  and  others.  Imvc  hccti  dcvieod  for  tlie  pur- 

i;  bat  peri»]M  the  iiioM  n'nily  motliixj  is  tiint  riH'tii>imeii<Icd  t>y 

T.  SvTiKL    It  is  "  to  paM  a  probe,  «ir%-ed  to  the  form  of  Uie  palate, 

tlte  iiexe  into  tlte  pharynx,  and  th«n  dniw  it  out  of  Uio 

eoavcying  hv  its  means  a  piece  of  strong  ligature,  about 

I  Clot  and  a  lialf  in  Icuf^th.     A  compnisit  of  lint,  lurf^  enotijjh  to 

the  posterior  o|)ening  of  the  nostril,  is  next  tied  secnrolv  to 

middle  of  tJw  tlircjul  w  liieh  issues  from  tlio  nioutli.     Tlic  otJicr 

I  being  palled,  tliis  plug  is  drawn  baekwards,  and,  witli  tlie  itssiat- 

of  iIm'  o[«'rat»>rV  foro-liiiper,  in  lodged  behind  the  »oft  pahito 

lAe  nasal  nrifiee,  where  it  compresses  directly  the  naso-palatino 

Tho  Cvro  end*  <»f  tJie  thre^id  are  then  tteetired ;  and  wlu-n  it 

ijudged  safe  to  remove  the  plug,  the  tlircad  tliat  lies  in  the  moutlt 

I  tJie  niudy  means  of  doing  so."* 

fafyfnu.     The  noae  is  the  most  frequent  wnt  of  polypus.     Tho 

iiT  kind  is  the  mucous,  gelatinous,  or  vesicular,  termed  also 

lea.      TliiH,  an  itA  name  implie.-*,  h  of  a  wt);,   pulpy,   some- 

etastio  consistence ;  of  a  palisli  or  grayish  light-brown,  or 

inih  cciloar,  or  looking  like  a   membrane  ju»t  going  to  be 

!iy,  as  Mr.  Pott  observwl ;  partially  (ransluoent,  and  uivosted 

pi  pTDlongaticin  of  Ihv  mucous  membrane  with  its  peculiar  vibra- 

I  tSim.      Examined  rotoroseopieally,  I  liiul  it  to  eoimiKt  of  an 

>n  of  trant'Iiiceiit,  amorphous  molecular  granules.      Tlio 

speet  of  tlie  IJntn};  membrane  Actuds  ]>ru1ongiitioti!«  into  tJie 

of  tlto  polypus,  dividing  it  into  compartments,  which  are 

Jy  incomplete.     The  «truel.ure  geiK-rally,  in  inct,  is  finely 

Tlie  surface  presents  a  few  straggling  capillary  vessels. 

polypus  u  Mklora  if  ever  painful,  nor  does  it  bueome  ho  on 

prosaod.     It  yields  wheji  submittt>d  to  pressure,  or  when  cut 

a  •junntily  of  limpid  Mrosity.     It  is,  aeeording  t»  Itokitunsky, 

rtud  origin.     It  is  connected  vritii  die  pituitary  membrane, 

.  by  a  narrow  and  more  or  less  elongated  jiodunelo,  some- 

.  bjr  •  iu-oad  base.     It  is  usually  nttaehed  to  the  superior  imd 


•  Pniu'ltia  of  Surytfif,  p.  4>3, 


m 


DISEASES  OF  THE  NOSE. 


exti*rnal  wnll  of  tbo  nostril,  but  occastoitallv  proecods  from 
cthmtii<lal  colls,  tlie  lower  mentiui,  or  the  tliick  macoas  meta^ 
brane  covering  tho  inferior  tiirbinntml  bone.  It  is  soaroi'lv  cv« 
niel  with  on  the  jteptiini.  TlitTft  may  be  but  on«  jjolyims,  but 
not  un&oqnentt)'  happent)  that  tliore  are  several  at  tlic  Hamv  tiin4 
4«eh  of  whivli  iH  pcriirrlly  dintiiK-t  frcmi  tlie  ollicrs,  and  has 
separable  distinct  attaclinient.  When  such  is  the  c-ase,  the  lowo 
or  nioj't  anterior,  Im^iiiK  the  open  luiatril  before  it,  ctwily  nuikes  its 
way  down  nnconiprcRscd ;  while  tiie  otiiers  are  not  only  kept  up 
and  oiit  of  (ligfit,  but  are  nltio  eori.tiiicnibiy  compr<«.iixI.  PolyjM 
tend  to  increase  in  Nze,  and  may  tlius  fill  one-half  or  three-fonrtlis 
of  UiC  nasal  fi.ts«i?  on  t>oth  sich-s,  itnd  pnytwl  oitliirr  f()rwiinls  or 
badc1^'a^da.  The  growth  may  pass  backwards  in  the  fauces  behinil 
tiio  mnila,  and  hang  down  into  tho  pharynx.  It  »oldc>tn  cxotoIm^H 
any  notion  on  the  bones,  beyond  ocoaaionally  stripping  them  o^^ 
tlioir  investing  membrane;  but  tins  of  ctmnio  may  Iwwi  to  nvcroeis. 
In  a  lady,  tliirty-eight  years  of  age,  who  had  been  many  ye 
afflicted  with  mucous  polypus,  and  whom  I  (nentnally  curod 
extritctiun,  I  fumid  the  iiitiinial  a'taeoua  structure  quite  denude 
When  the  polypous  growth  has  advanced  tbrward,  it  may  displg 
tho  (>iirtil»gGS,  and  citu.-<o  conHiili^rablo  expansion  of  tlie  noRtril. 

From  pecaiiarity  of  structure,  this  pol'^'jjus  is  of  a  hygrometric 
ehnnict^^r,  diminishing  in  dry  wiirtii  weatlier,  and  Ixiooming  longcM 
felling  down  lower,  and  looking  fuller  and  paler  in  moist  or  wed 
It  may  owur  nt  any  jMTiod  of  lilb,  hut  w  most  common  in  adulte.    I 

The  symptoms  are,  a  sense  of  fiilness  and  weight  in  the  nostiiU 
as  if  proceeding  from  n  etild.  Indeed,  for  a  cunsiderablc  time  beforfl 
tlie  ])oiyi)us  l)eeomes  \'iMble,  tho  patients  feel  to  be  perpelualm 
catching  cold,  although  seldom  troubled  with  other  symptoms  thafl 
a  stoppage  in  and  discharge  from  the  nose.  In  moist  weather,  fM 
ui  a  sudden  change  from  dry  to  wet,  they  are  also  sultjcet  to  fraJ 
quent  fit^  of  sneezing ;  and  when  the  relaxed  membraiu)  ix  ommI 
atfecttxl,  to  a  considerable  discharge  of  thin  mucus  from  the  aS'ccleq 
nostril.  Presently  other  symptoms  su|>erveno,  a*  tho  growth  Iim 
comes  dei-cloped.  The  respiration  through  the  nares  becomes  mora 
and  more  emlmrraxAod,  so  that  pntiontH  are  ohiiged,  |<artienlariH 
during  the  night,  to  lie  with  tJio  mouth  oi>en  and  the  head  tlirown 
back,  and  tliuy  make  a  louil  snoring  when  luiloi'p.  'Diey  feci,  mar04 
Over,  as  if  there  were  some  fleshy  substance  in  the  nostril,  and  tarn 
prone  to  make  frequent  ami  inclUtctual  efforts  to  gut  rid  of  it  M 
blowing  the  nose.  At  this  sUge  the  polvpiis  ascends  and  dcscenifl 
by  tho  action  of  respiration,  and  the  patient  can  make  it  deaccafl| 


POLYPUS. 


213 


vjr  BtofipiiijK  tho  nostril  whkli  U  fVoo  of  partially  fi%e,  and  tbea 
dnTiiig  (liu  itir  through  UuU  which  Ute  polvpua  ocitujiios.  The  voioo 
seldom  nanains  natural,  but  buooiuM  iiosai,  indistmct,  aad  even 
Bmtttng.  Tho  sense  of  siaall  itnd  that  of  last<t!  uru  iinpuirod,  or 
abofiiiked.  Dcafiii.'sii  is  n  frvquoat  concomitant,  and  ia  due,  m  ISIr. 
Surnbou  inri)^^  me,  Ut  a  co-existent  thiokeiiiii^  of  tlio  muinhrane 
uf  the  tTmpanum.  thus  ahovo  »}-inptoins  an  most  marked  in  damp 
irraUi«r,  fur  the  reason  alwve  awf-igtieiL 

In  order  to  ascertain  tho  presenco  of  polypus,  the  patient's 
raost  Im  UiroH'ii  Utck,  iitkI  tho  nontril  dilatjMl  by  nuvui«  of  tho 
qteoohim  delinnited  at  p.  201  With  a  clear  light  the  advendtioua 
growth  is  then  brought  into  view,  with  !(-■«  gli*t«iiiiig  surfiKV  oicitcd 
with  macufi,  and  round  itA  tower  and  visible  part  a  probe  can 
ntadily  bti  pmrnd,  and  tlwt  to  «omo  Iieight.  In  s<imo  iiiNtaiict^, 
bjr  earryinj;  tho  tinger  underncuth  and  behind  the  soft  palaio,  the 
polrpns  may  bo  tilted  up;  tuoroovcr,  on  dirocting  tho  pnttoiit  to 
breatlie  by  Uie  aflieeled  notitril,  it  i:t  fount!  that  liie  air  doen  not  pass, 
or  does  BO  with  a  wliizzing  sound.  In  these  trials,  the  patient 
ex{nnenoe»  tlie  Kciuuition  of  i«Kn«  ixxly  shilling  itH  place  within  tlie 
■una]  cavity ;  and  at  times  the  Surgeon  porccivos  a  peculiar  noiso, 
which  Dnpuvtnm  lilu^nod  lo  t^ic  Hupping  ofa  tbig. 

As  regards  diagnosis,  polypus  in  its  nascent  stage  may  be  mia- 
(alna  for  ooryza,  but  only  tiivn.  It  i.t  tiiniulatwl  by  thick<;ning  of 
the  membrane  covering  llie  infisrior  turbinated  bono,  which  is  fre- 
qaeat  ui  children,  and  by  dispJaevinvitl  ot'  llio  miptuni,  whlcli  is 
|iraaeiil  in  most  people  to  a  slight  degree,  and  has  occasionally 
■aerMcbed  on  the  nostrU  so  as  to  catvw  inconvt'iiioiicc  In  a  cum 
at  this  dMcriptJon,  an  inex|ierlenced  practitioner,  belie\'ing  ho  had 
to  do  with  a  polypos  in  a  young  lady,  tore  away  a  portion  ui'  tJie 
lliiiliiiiiii,  aiwl  hiid  bare  llie  bone.  Lastly,  an  extraneous  sub- 
aa  a  truit-stone,  or  a  calculus,  lias  b«x^n  taken  tor  a  |>(>ty- 
By  attcntivo  o»n«i<lerati'in,  however,  of  llio  symptoms  abovo 
detailed,  and  the  progress  of  tho  case,  error  may  generally  be 
■raickd  on  tlic  juirt  of  tlic  f>urgeiiii. 

It  ia  uot  always  eiasy  to  ascertain  the  exact  point  of  attachment 
if  ths  polypus,  or  whctlH^r  lliv  growth  is  solitary'  or  multiform,  at 
As  ntiaductMin  o{  a  prubo  to  any  (iimaiice  produces  a  <l^;rM  of 
tMHi*;  which  fc'w  patients  can  well  endure. 

The  polypus  is  a  complaint  which  is  always  tnmblc«ome,  but 
not  genenlly  serious.  Kvcry  now  and  then  it  subsides  spontanea 
iandy  ;  and  is  almost  always  removable  without  much  pain,  ba^mor- 
ijla^  or  hazard  gf  any  kind. 


su 


DISEASES  OF  THE  NOSE. 


ntion  i>^B 


There  iR  a  form  of  polypus  wliicli  in  frornmntly  ftti  clongati^^ 
the  Dicmbnuie  covering  one  of  the  turbinated  bones,  and  which, 
tiioiigb  pliiinly  iHovabto,  u  eonsidcrably  inM  i")  tliim  tin-  opliiiar 
vesknilar,  is  Iosb  liiible  to  alteration  from  uir  and  seasons,  and 
rather  slow  in  its  progress.  &1.  Hobin  hns  dunorilKHl  anotlitx  %'u-ivty^ 
vhiob  ta  due  t«  hvportrophy  of  the  glands  of  tlie  niuooua  mem- 
brane Tlio  tumour  nocurriHl  tliritio  after  removal.  Tho  piitJont^ 
died  of  an  intercurrent  atfection.  Examination  niter  death  reveole^^ 
s  condkli-ruliki  tliickciiing  of  Uic  mucous  membrane  of  the  upper 
part  (jf  ilie  tuisal  eai-ity,  and  a  tumour  imjibtittx)  on  the  cribriform 
fossa  of  tlio  othmoid  bouo.  The  tumour  and  tlic  tliiekencd  mucous 
mombrano  wmtaiiiMl  ii  great  quantity  of  n<^^s  of  eylituiriiail  fipi- 
tbclitim,  similar  to  thoso  which  are  met  with  in  tlic  natural  stale  of^ 
the  ))itiiitjiry  mcnibruiie.  Tliis  dtfTi-rcd  from  tlin  ordinary  pulypv 
botli  in  the  extent  of  implantation  and  in  tllo  thickening  of 
niuooim  membrane.* 

Ttvattnent.     The  metliod  generally  resorted  to  is  extraction  wit 
forceps,  bv  a  sort  of  compound  movement  nf  pulling  ami  turning 
Straight  forceps,  of  moderate  aiite,  commonly  answer  the  pur 
Curved  forceps  may  bo  cmployc<l  wlien  th«  |Ki|ypiia  is  silnale 
back,  and  has  to  he  removed  by  tlie  mouth.     Ordinarily  the 
branehcM  of  the  Ibrceps  liavo  a  fixed  joint;  but  ailvnnta^  will 
casionaUy  be  found  in  using  an  instriunent  no  constructed  tliat 
braiK<iii-s  can  be  introduced  separately,  like  tliowo  used  in  mid 
wifery,  ajid  eonjoiiuHl  at  the  moniont  of  aeizing  the  jiolyixw.     The^ 
{mtietit  is  to  bo  seated  on  s  somewhat  high  chair,  lacing  ilie  light, 
tlte  head  thrown  buck  and  supporlud  by  an  amtiHtant,  who  at  llwi 
same  time  clei'atos  the  point  of  the  noHc.     Tlio  Surgeon  placed 
front  introduces  tlie  forceps,  with  ciONtHl  blado",  into  tlie  nos«,  alon 
tho  septum  ;  and  as  the  spongy  bones  are  attached  to  (ho  outer  wa 
of  the  nasal  ouvity  and  do  not  cxtoiid  U>  \\u:  septum,  th«  foi 
will   be  more  readily  opened  in  a  vertical  than  in  a  tramiver 
direction.     Tho  forceps  is  to  Iw  oiwnod  so  winn  as  tho  polj-pns 
reached,  and  conveyed  as  flir  back  as  practicable,  in  order  to 
Uie  stiilk  or  peduncle.     It  must  then  be  tightly  close*!,  and  traction] 
and  rotation  simidtuneously  porfonned,  till  the  polypus  i.t  ox( 

Fi-equoutly   the  polypus  yields  and  comes  out  of  the 
without  separating,   however,  from   tlie  jiituitary  membrane, 
tliis  onae  it  must  be  grasped  close  to  its  root  with  a  second  for 
and  tlie  same  movements  of  torsion  and  traction  continued  until  il 


•  Qaxetu  <ltt  Uupitcnia,  lesa,  p.  J«. 


POLYPUa 


fi)5 


^klire  avnlnon  ifl  aocomplishod.     Tn  ctnrrying  a  Mtrai^lit  tiiAlriinicnt 
^pnUt  tlte  lon-ttr  1111^1118,  il  should  lie  Ijonii!  in  ntind  tliai  ttio  outer 
nasal  opcoiDga  lie  somewhat  deeper  tbuti  tho  floor  of  tlioiitLialcavitj; 
bence  iht!  proprit^ty  of  pr««»Jng  the  nose  isoinvwiiat  u]>war<ls. 

It  is  uot  al^avs  possible  to  oteur  ttie  iiuotrJl  of  jxilypi  at  a 
single  sitting.  It  is  Utoruforo  nixct«»ry  to  repeat  tlio  inaiiotuvro 
alioTe  drsoribed  at  suitable  iiiU>rvnl»,  until  ilio  jiutient  la  able  to 
bnaulw  tm'Iy  through  the  no»tnI.  Gvcii  then,  polypi  may  forta 
agaiu  in  tlio  course  of  a  few  weeks  or  mouihtt,  and  iieeesattate  a 
runcwii)  of  tJw  prooccding. 

A^'lien  a  potv'jiuA  fa  situate  baolcwnrd  in  the  faucro,  des(!ending 

tlw  phnr^tu,  it  may  bo  sdzixi  through  the  month  nnd  drawn 

fiwuwardd  anil  forward.t  by  a  mrt  of  iKtttrul  inovctnent  of  t!io  in- 

imcot,  for  Itcno  toraion  eannot  bo  executed.     The  forceps  curvwl 

'it  the  extremity,  and  with  hriiiieJii-H  which  {.ttnic  iijuirt,  will  bo  found 

navcntcot.     Ttii«,  though  occasionally  practicable,  is  nioro  c-ueily 

deacribed  tliau  aM-oaijili.«liitl,   intd  in   Minir  p(Vi[ilt'  will  bo  found 

iapnwtkahlo.     '•  The  objection  arises,"  as  Mr.  I'ott  clcirly  pointed 

nt,  "  from  llie  great  dtthcutty  of  kfupin^  t.ho  |/iiij^u  down  in  Aome 

iidiriilaals,  and  in  others  from  their  incapabUitj-  of  permitting  any 

iWg  to  |iiu<-li  t)ie  root  of  that  [Mirt-,  or  anv  part  of  the  fauo-»,  with- 

M  inuaediatcly  producuig  a  spasm ;  lo  which  might  be  added, 

w  in  »otaa  au«s  tlic  jwlypus  i*  »o  expanded  iw  alniont  U}  coiieeal 

4*  vrela,  which  is  therefore  liable  to  bo  litid  hold  of  by  Ote  instru- 

■W,  la  the  DO  small  <lt:trtmeut  of  tlie  patient." 

UiuW  aaeh  cirouinstanoee.,  Mr.  Syrae  considera  that  tlie  prin- 
^•Iptrt  of  the  Inniour  may,  perhap:^,  bo  removed  by  iiilroduoing 
**i>«ip  of  a  doubled  sUver  wire  through  llie  nose  into  the  pliarynx, 
pmag  it  with  the  Snger  roun<[  tlic  body  of  the  growih,  and  tlien 
plOiog  the  wire  ao  as  to  draw  il  up  ti)  the  luwk  or  thin  j)aj-t  iiwir 
■b  not  Itut  it  ui  a  far  better  plan,  he  remarks,  to  d<^t;icb  the 
fijfaa  by  seizing  ita  roots  with  forot^  introduced  tlu'ough  tliu 
■BMril,  and  then  to  push  it  into  the  throat.* 

There  ia  a  method  of  removing  pol)'j)i  of  the  nasal  foiwaj  sim- 
ply with  the  forefingent.  One  of  theitc  is  thntst  into  tJie  noatril, 
*hik  the  other  'm  uitroduoed  iJirough  the  mouth  behind  tlie  palate. 
When  they  have  rcnefaod  the  growth,  they  arc  ])Ui<heil  nlteniutt-ly 
/irwanb>  and  backwards  until  all  rediatanee  has  ceased,  and  the 
mbstaaoe  is  withdrawn  lliroiigh  the  neure«t  opening.  Morand 
wd  ftifmli^  sDCoeeded  thus;  but  die  procedure,  though  aim^ltt>  ia 


•  Op.  (lit.  p.  i'.a. 


916 


DISEASES  OF  THE  XOSK. 


rarely  admissible,  and  only  for  jxiIypHS  occupying  the  floor  of  I 
tifual  fossjfi ;  for  if  implnntecl  high  up,  it  is  obWousIy  iiuicc£'-'»ihle 
tbo  fin^;ors  of  die  Surgeon.  Mr.  Hilton  n^comnicntU  whxt  ho  tc 
a  tnitn-  for  getting  rid  of  tliid  t^ompkiiiL  Dr.  M'Ruer,  ttn  Atae 
can  physician,  oxtols  tho  following  plan :  a  pii-cc  of  oat^t  is 
fixim  the  noNtrilit  to  tlic  nioiirh,  to  whluli  h  fanton^l  a  ]tion<  of  i 
and  dry  epongo,  corresponding  in  gizc,  when  firmly  compressed, 
tlio  narruwei*t  pnrt  of  the  niisal  ptu<Mige;  it  ia  then  dmwn  gotitly 
forwards  by  tlic  poHtcrior  fauces  through  the  nose  He  thus  sno- 
cimhIimI  ill  ut  loiwt  ten  cases  iu  bringing  away  all  tlws  adventiliwu 
growths. 

Formerly  nltcmptj*  were  inndo  to  remove  polypiL*  by  the  uac 
esoUarotics  or  exsiceativcs,  and  by  excision ;  but  ticse  aro  long  sine 
abandon  1x1,  a«  found  impriietioiiblo.  It  only  rcmuinH  to  [loint  attoo.'j 
tion  to  the  emploxinent  of  the  ligature.  The  method  of  ligature,  whe- 
ther of  silk  or  wire,  is  ecrtaJnly  feasible  in  some  instanu.-^:  but,  ai 
Mr.  I'ott*  justly  observed  long  since,  b  by  no  moana  equal  to  that 
by  tho  forceps,  cither  for  its  general  utility,  or  it«  capacity  of  per- 
fectly eradicating  the  excrescence.  It  is  conaiilered  most  siiitah 
for  polypi  which  arc  pcdanculato  and  too  bulky  to  bo  grasped 
forceps*,  and  for  those  which  aro  situate  on  the  floor  of  tJw 
fossa',  or  on  tbo  superior  wall  near  the  pharynx.  To  siunnount 
difficulties  which  are  so  frequently  eneounl<mHl  in  tlie  exeeution 
this  operation,  a  variety  of  ingenious  instruments  have  at  dtffere 
timcM  been  brought  before  the  notice  of  the  profi.^sion,  more  i 
ally  by  Ambrose  Par^,  Desatilt,  Levret,  Brasdor,  and  Hntiii. 
object  of  the  ligature,  which  must  neci.w«irily  bo  drawn  tight,  u 
detflmiinc  strangulation  and  separation  of  the  polypus  iit  the  for 
of  a  slough. 

Mr.  Fcrgufison  ^ves  the  followii^  plain  directions  for  applying 
the  ligature  when  tho  jtolv'pua  is  of  Isrgo  sizo  :  A  piece  of  catgut  or 
of  Btlver-wire,  twelve  or  eighteen  inches  long,  sliould  be  doubli^, 
care  b<'iiig  taken  not  to  injure  its  elasticity  at  tho  bend ;  this 
slioidd  tliL'n  lie  puwheil  along  tin-  floor  until  it  reRch<-»  the  plnni 
where  it  will  be  allowed  to  expand ;  and  at  this  stage  the  point  ■ 
the  B>rc-finger,  or  forceps  of  convenient  length,  should  bo 
along  tlic  moutli  into  the  Uiroat,  and  so  managed  aa  to  push 
catgut  or  wire  behind  and  alxn'o  tho  growtli.  When  thi»  i»  acoon^ 
pliahod,  tho  ends  must  be  introduced  tltrough  a  small  double  canolai^ 
whioL  should  be  slid  along  upon  tlu'in  n.t  high  up  as  the  root  of  I 


ChLrurgieal  Obirrvationt,  p.  AT. 


t' 


to  extend,  and  tbus  the  noose  vrill  bo  further  up  tlian 
ptiftli  it ;  uiu)  tfitd  uftlio  tignturo  may  thou  be  &Htened 
ring  at  tbo  end  of  the  canula,  luul  tlie  other  mu-tt  be  drawn 

I  u  to  olKftruct  idl  circulation  in  Iho  port;  it  may  then,  if 
to  retnaiii,  be  lixed  t<>  tlio  ring  of  tJie  tube,  mid  tighwncd 

to  day  until  ttui  sepitrntioa  is  otTDctod.*  If  it  could  bo 
with  safety',  Mr.  Fergiiwon  noiild  mi  idl  occtt-sioiiH  He))ariito 
t  at  oncL-,  instead  of  letting  it  slough,  b<^<ing  careful  at  tho 
It  it  drop  iiitu  Uie  lowtrr  part  of  tJio  pharynx,  or  cover  rJia 
if  the  lurj'nx,  and  caixM  sutlbcation.  l>uHtij;  tho  proows  of 
ig  ui  thiii  region,  there  is  a  rick  of  falul  coiitiuiiinatiou 
ytUaa  from  morbid  BCoretion,  unless  the  patient  is  steadily 
tb  his  head  iiidiiuMl  fom-ards.     AL  Vidnl  witncswxl  an  in- 

^tn  individual  being  UiUH  poiHoned,  after  a  rhinoplastiu 
Thnv  wan  suppuration  of  tho  flap ;  the  precaution  was 
wed  to  nuintaiii  tlio  Ix^d  Itiit  forwardH,  tlw  matter  gravi- 
■D  tho  nose  into  the  mouth,  was  swallowed  during  stuvp,  and 
Imt  succuinbvd  with  all  tliv  syuiptoiiu  wluch  »r«  attributed 
kl  tnfi'cUon.  On  cudaveric  inA{)cction,  no  lesion  of  tta»uo 
uptihle  wltivh  could  account  lor  doath-t 
K  in  order  to  remove,  at  onoe,  poK'pou»  growths  from  tbo 
P  nuw,  H.  Uaisomieuve  has  resorted  to  what  ho  calls  tho 
bw  palatm,  and  witli  thu  must  satisfiictory  rwulU.  Tliia 
mtiuo  oonsista  in  making  a  button-hol^like  incision  in  tho 
itp,  and  in  dniwing  tho  pol\-pU8  through  thu  ogieniiig  into 
ih,  where  it  is  an  i^cuy  matter  u>  apply  u  lij;;tture,  or  to  use 
b.  Tlio  gn-ut  elasticity  of  tlie  parts  comjMMing  tlie  aoH 
lUowa  the  [iolyj)us  to  hv  drawn  tlimugli  u  uomparatively 
cuing,  and  alter  the  operation  is  eomplelod,  tlio  saino  vlu:*- 

II  generally  serve  to  closv  Uto  ojK-ning  witliout  the  lielp  of 
Ib»  dinxAton  of  the  hutlon-luiU  'a  from  liefore  backwards.  ( 

■latUMr,  Haitu,  a  Surgeon  of  Avignon,  in  tlie  year  1747, 
ffioult  case,  in  which  he  wm  obliged  to  slit  tlie  soft  palate  in 
iao  line  to  rcniovu  at  diU'crent  times  ditluront  [xtrtioua  of 
oar,  and  to  intruduf^  into  tliat  which  remained  sovoral 
forming  a  noose,  with  wliicb  he  drew  furwardM  tho  poly- 
Isl  the  fingers  introiluei'il  thiiingli  the  mouth  pushed  it  in 
I  (lirvotiuD.     Tho  tumour  gave  way,  its  podunolo  ruptured, 


Surftry.  9d  edit.  p.  OBO. 
IM  di  PtithaUfjit  exumt.  \m\.  lorn.  iil.  p.  401. 
f»m  rmim,  ao&t  laav;    and  Uanliiog'B  Jia(f-ftarlg  Abftntt  tot 


m 


SIS 


DISEASES  OF  THE  NOSE. 


»nd  the  noise  which  it  made  in  tra*-ersiiig  the  nostril  rescmhlwl  tl 
HiiwirkiiiK  of  a  bottli?.  A  second  polypus  sliowcsd  itoclf'ii  fuw  liaj 
adorwards,  wliioh  iti  iitt  turn  wan  extracted,  sod  the  cure  wa 
complex  V. " 

Tlio  otiier  form  of  pfilyptiti  which  dcninnds  notice  ia  the  fibrou 
It  iH  distin^i Allied  hy  the  extreme  firmness  of  its  texturo,  and 
composed  of  fibn»,  croHniiig  in  (iifKcn-nf  dircetionK.      It  is  implante 
on  the  fibrous  layer  whieh  linea  the  muoous  membrano,  and  wliic 
nerves  UA   jierioittt'inn  to  tlio    nuHiil   i'ty*»iv.     'riie   biise   is   brond 
poduncidatfi.     Tliis  variety  of  polypus  is  much  more  va*cjdar  tic 
the  gelittinouN,  and  for  tlio  moiit  jmrt  solitary.     It  may  di^iplaee 
bony  structures  nhieh  stand  ui  the  way  of  ita  development,  as  w« 
aa  tlie  iwptnin,  di-prvM  tlio  palate,  cnuMi  the  proper  bones  of 
nose  to  project,  induce  atroi>liy  and  even  perforation  of  the  bono 
and  may  e\**iitually  make  iU  way  into  tlic  orbit  or  oraniuiu. 
tissue  of  this  variety  of  polypus  iti  susceptible,  according  to  M.* 
H.  (Jloipict,  of  l>oeoming  aeeideiitally  incrustcd  with  jiliiBpliaie  nS 
lime,  and  undergoing  ))arlial  osi*ili cation,  by  a  phenomenon  analo* 
gou»  to  what   is  observed  in  certain  wens.     Thin  trannfurmatio 
causes  no  other  Inconvenience  than  that  resulting  from  the  sue  : 
situation  of  the  growth.f 

Die   sjTuptoms  ditler  but   little   from  those  of  tJie  precedii 
Varivfy ;  bunco  the  diagnosis  is  sometimes  pcrplcxin^;.     It  may 
reniarketl,  hoivoier,  that  the  fihrou.i  jiolypus  is  not  influenced  bj 
hvgromctrie  changes ;    and  the  finger  introduced  into  the  niwl 
totii-lies  u  ii^rd  renixtcnt  tumour  iiiKtoad  of  a  sofV  elaittio  substana 
like  an  oyster;  lastly,  when  the  disease  is  of  some  standing,  tJie 
is  the  missliapon  nose,  imparting,  what  has  been  ttrniotl,  the /n 
face. 

Tliis  is  a  more  .■sorlon*  nfTrt'tion  than  the  former,  not 
owing  to  the  bony  distortinn  which  may  enftuo,  but  because 
aro  sent  into  the  %'arious  sinuses  lodged  in  the  (rontal,  ethmoid, 
superior  maxillary  bones,  wliioli  render  the  removal,  iu  totality,) 
difficult  matt^T. 

In  certain  carcs,  the  fibrous  polypus  may  be  extracted  wil 
forceps,    or   tied  when  pedimcul.'itc,   and    csjH-oially   wlien    it 
cleared  tJie  ituntitrior  opt^ning  uf  the  noMlril,  and  i»  pi-ulongcd  in 
the  pharynx.     But  when  those  excrescences  havo  a  larp)  base,  ^ 
fill  tike  nasal  foN-tii,  tho  wnIN  of  nhicti  they  have  nnsplaoed, 
ligation  is  impracticable,  their  avulsion  can  only  be  partial. 


*  H,  Olotiuati  OtphrftiuloifU,  p,  fiS8. 


f  Op.  ciL  p.  «8e. 


NASO-PHARTNOEAL  POLYPUS. 


219 


I  mnains  behind  gron-g  with  fresh  energy,  t«k«!t  on  nn  nnhiMltliy 

r,  ukI  geannlly  lemdn  to  u  fntnl  tormination.      Excision 

I  ionelinim  prov«d  soooeBsfuL     A  {M>Iy|iuii!t  growth  of  Hm  dv- 

fillod  tile  Ifft  nostril,  iesiiod  iti  jiiirt  by  tlie  nmc,  imlarginif 

I  a  Bnuahroom,  and  paa»ed  into  the  thnmt,  wlii^nt  it  ftirtnod  n 

tomoar.     Lcdran  eoizcd  with  tho  fingers  the  portion 

I  emerged  from  Ute  no»e,  and,  drawing  it  toward*  him,  oat  it 

nostril  as  high  as  poMublo,     Uo  next  introduced  liis  fingDr 

I  llie  &IKIM,  beyond  tho  aoft  [uilatv,  and  by  mttitn-t  of  4Mirv«d  sda- 

I  wn  abk)  to  r«fno«'e  considerable  portions  of  the  tumonr.     Tb* 

of  I>kiod  obli^rod  thi.t  cmiiiont  i^iirg^mn  t<>  mi!i{>ond  the 

;    hut  having   introduced  tlie  finger  into  tho  nostril,   ho 

lined  tlio  point  wlwro  tho  tumour  orI<;iita(nl,  and  will)  !<i>iMwini 

1  a  Inslaury  1»  removed  it  entirely.     The  bleeding  was  eonaider- 

,  bat  soon  yi^ddotl  to  ]>higgin<;.     In  a  trotihli.'voino  cim'  of  this 

ription,  Mr.  Whatcly  employed  &ucci-ft*fully  a  narrow  straight 

with  a  probo-puint,  having  a  »hvalh  fixed  upon  iln  odgo  bv 

put  into  a  hole  in  tlio  liniidle;  an  eye  being  made  at  its 

to  rcooivv  ono  end  of  a  thread,  intended  to  bo  pai9H.id  round 

lpo)%'pus,  tiM-  tlic  puqKtso  of  directing  the  knif(>  to  tlie  neck  of 

ttainour.* 

nMwt  fbrmtdablo  rartoty  of  polypous  growth  of  thU  nature 
naBO-pharyiigeal  properly  so-called.  It  has  only  one  mode 
vrtiofi,  luuiirly,  at  the  bnw  of  tlio  cranium  on  tlie  basilar 
(at  tlie  superior  pctrt  of  the  lower  fiuM  of  thin  jtroeess),  and 
part  of  tho  sphenoid  bone  which  articulatcH  with  it  in  tho 
{Mirliona  of  tii«  [>tc-ryfpiid  focMiv  and  tho  inti'riial  winga  of  the 
■Tgoid  proceeses.  Tlietic  insertions  occur  in  a  Kpoco  coTnpriiH.K) 
ftnt  lud*  liotwocn  tho  |iot4cri<ir  wall  of  thu  sphenoidal  aiiiinilation 
tamer,  and  the  insertions  of  llie  rectus  capitis  auticns  major 
(firuin  hair  an  inch  to  an  inch),  and  on  the  other  nide  from 
I  ptofTgoiit  lu&«t  (o  the  otlier.  This  ia  tho  priniarj-  insertion  of 
tffowth,  wludi  springs  IJ-om  the  periosteum  of  the  Ixisllar  pniooss, 
.  rnry  aoUd  and  tliiek  at  tluit  jxiiiit.  The  other  implantations 
,  ODoaacutivo  or  socoudary,  and  more  or  les*  rw^it.  Tliey  iu« 
'  flcoounled  fur,  a.«  follows :  tlio  polypus  may  ulcerate  from 
&om  undergoing  conipresaion,  or  otiicr  caiiHo;  it  b»(^>niw 
,  as  diKW  aJfM)  Uio  ui^aoi.iit  muoous  misiibt-aiK!,  and  the  onli- 
rfwattoftbia  inHaniRUition  is  an  adlieroncc  between  thcpolypoa 


[»  Sew  Gum  (/Mo  itrf/uonfCaary  Polypi  rtaiortd  from  lh»  Nom,  London. 


sso 


DISEASES  OF  THE  NOSE. 


■nd  this  soft  structure.  These  adhesions  poBseas,  in  general,  ht 
litUc  n^istanco,  and  arc  caeily  brukon  up,  Tho  nsuw-phiiryiip^l  poly- 
pus is  invested  by  tlie  nmcoiiH  monibrano,  fm|uenUy  aitenuAtocl  and 
ulcorutixl,  fiotnetimcs  pretomaturally  thick  and  rod.  The  stniotur^H 
b  couijtusal  ufpumlK-l  fibn^  uoil  lji»ci<ruli,  wliifh  nre  inserted  vcr^l 
dcally  on  the  bone ;  tSie  centre  contains  but  lew  blood-ruefwls ;  dto 
surface  is  f'urru)ved  by  iiiii»cn>u.i  eiipilliirlet.  It  seems  Co  poasesa 
but  a  low  degree  of  vitality,  as  is  sliown  by  its  being  occasionally 
de«troyi,il  mid  romcvovl  by  »i>ontancous  slonghiiig.  Two  iiu^tanoea 
of  this  kind  are  pointed  out  in  the  JirUigh  Medical  Jountal  fbf 
Jaiiu^iry  1^58 ;  the  one  a  patient  under  the  can;  of  Mr.  Rirkett,  the 
other  under  that  of  Mr.  U.  C.  Johnson.  Both  patients  oompletely 
recovered,  and  no  trace  could  be  detected  of  any  port  of  the  morbut 
tis.iue  I'wniaiiiing. 

In  addition  to  the  ordinan.-  symptoms  produced  by  polyjiu*  mny  i 
be  notiijeil  dyspnoia,  whidi  is  observable  when  tlie  tumour  is  ratlwr 
bulky,  and  has  dosoended  low  dovni  in  the  phar)'nx ;  doafiiww,  Iho 
conmH|ueuee  of  pressure  on  the  Eustachian  UiK',  and  Iwemorrliag*  j 
more  or  less  copious.  The  di»giio«i»i  is  in  general  obWous;  tbo 
point  most  diHicult  to  ascertain  precisely  is  the  number  «a  also  iha 
size  of  Uie  otTscts. 

The  disease  is  one  of  a  serious  nature.     According  to  H.  NJ 
laton,  who  has  devoted  uiueh  attention  to  the  subject,'  individn 
never  live  long  with  a  growtli  of  this  kind.     Tlie  tumour,  when  ! 
to  itself,  unless  nimoved  by  spontaneous  sloughing,   inihiecs 
deaUt  of  tlio  patient,  either  by  hivmorrhage  or  by  the  obstatJa 
which  itoltm  to  deglutition  and  to  respiration,  as  in  the  o)\-ciIi 
case  of  a  maji  who  died  of  miflocatiou  from  a  poljiiua,  which 
attached  nut  only  to  the  vomer,  but  to  the  adjacent  part  of  the  occt'l 
pital  bone.f     Its  removal,  besides,  neei*silatea  an  opfralion  ofl 
duigerous  character,  luidor  ordinary  circumstances,  and  impracUC 
able  when  the  diwaso  is  far  iidvimtKid. 

The  preliminary  operations  recommended  for  exposing  the  na 
pharvngoal  [wlyjius,  and  liicilitatiiig  its  reino\iiI,  vaiy.     Thus, 
incision  has  been  made  into  the  nostrils,  the  proper  bones  oft 
nose  have  Iictni  removed,  together  with  the  ascending  proct«s  oft 
Kujierior  maxillary  bone ;  the  sort  and  hard  palate  have  been 
through ;  and  lastly,  resort  has  been  had  to  resection  of  tha  im]M 
maxillary  bone. 


•  Comptt  nmrfu.  SoeiiU  <l«  Ckirarsi*,  1W».  _ 
t  Commen.  litttr.  Narimb.  auu.  17SL 


NASO-PHARYNGEAL  POLTPtJS. 


sn 


ladnOD  oftbo  soft  palate  in  not  tttiffiot«nt  wlion  ttio  pol^-pua  is 
Tery  Iv  bade      For  this  rramn  SI.  Xt-laton  has  snpcroddt^l  re- 
Mctiiin  of  lh<!  lianl  palate.    Tho  fltllowiii^  i»  liU  mode  of  proopdnro : 
1.   J'rtlimmttrt/  uperatiom.     Incision  of  tiie  vt^iitn  jtalati   in   tlte 
modtsn  line ;  «  mwiiil  ineiuon  of  tlio  imbtino  timcrxM  invmlinine 
froin  aboT«  downwards  rs  far  as  tho  anterior  haif  of  the  nroh  ;  two 
tmmmo  incn»ioii8  on  cw\i  wile  nf  tliw  anterior  oxlromity  of  the 
IsUer;  lietaclunent  of  tlio  palatine  mncoiifl  membrane  on  «aoh  Hide 
to  the  cxtvnt  of  wairly  half  an  iiicli  with  n  blunt  hook ;  perforation 
of  the  arrb  of  the  palato  br  means  of  a  punch  to  tJio  ri^ht  and  tho 
teftr^t  ^^  it^val  ofthv  point  of  junction  of  tho  two  inciHtons;  sei-tion 
of  the  bonv  portion  infermodiate  hntween  tho  preoeding  jierfovations 
vith  bono-nipiwrt ;   abhition  of  tliu  bony  fragment,  comprising  a 
piirtion  of  the  arch  of  the  palate  and  of  the  oeptum.    2.  Fundamental 
tftration.    Direct  excision  of  tho  polypous  growth  by  moans  of  scis- 
un  eurT«<l  on  the  flat.     3.   Cotupl^mfnlari/  ojMTrttlrm.     No  .inturc  ia 
tn  be  employed,  but  on  the  following  da^-s  the  palatine  mucona  mom- 
banc,  whii'-ii  has  a  tMniloncy  to  reunite,  i*  to  bo  can>fiiily  dvtaclied, 
m  wder  to  allow  of  tho  application  of  caustic  to  Uie  morbid  tissue. 
hbw,  shout  fifteen  dayH  uAer  the  first  operation,  re|>catod  center- 
iatiou  are  to  be  made  to  the  root  of  the  polypus  with  tho  solid 
Twona  cawtio  or  utrong  nitric  ncirl,  which  C!in  tlion  bo  brought 
■beontact  with  the  vault  of  the  nasal  fosss  tlu'ough  the  j>ersistent 
ffWDg  witl>oat  any  difficulty. 

Vm  mucous  membrane  is  readily  detached  both  right  and  loft  by 
ntiid  of  liw  blunt  hook.  Tho  voction  of  the  bono,  too,  is  mpldly 
MWplirfiiod;  it  is  simply  necessary  to  act  transversely  with  the 
■OMiipperB,  in  order  that  each  sidu  of  tho  palatine  arch  may  bo 
M  fiwo  lieforo  backvanU.  If  this  cannot  bo  manage<t,  it  will 
M  "»■■  I  nrj'  to  carry  tlie  nippers  in  this  direction.  The  pituitary 
■ntniMv  if  not  ri-inoved  at  tlie  s:ime  time  with  tiio  bony  frog- 
tamt,  ought  to  bo  firoely  divided  with  a  scalpel 

lU*  (fj"'ntii>ii  U  rwOtoned  prefcrwhlo  tJi  that  by  resoptlon  of  the 
^BW  maxilLari-  bone,  because  iinjmrtaiit  parts  arc  prc9cr^'cd 
■iidi  would  iitlKa-wiwo  bo  necc^iwu'ily  sacrificed.  The  main  point 
Wp  is  the  progreasive  destruction  of  the  polypus  by  tho  iiotcntial 
outlay,  Thii  liaring  been  cUtK^lod,  tho  cletl  in  the  palate  may  be 
■AoiranU  remedied  by  staphyloraphy ;  and  should  it  not  contract 
HSciently,  tho  g:ip  may  Iw  closed  by  a  suitable  obturator. 

M.  Maisonncuve  radically  cured,  without  distigurcmont,  a  for- 
■^dablc  case  of  pol^-pus  by  tlio  following  procedure :  by  means  of  a 
sroog  pair  of  cutting  Ebro^,  one  claw  of  whldi  i&  introduccil  into 


S2» 


DLSEASES  OF  THE  NOSE. 


tlip  nostril  iintl  the  other  into  tho  niouUi,  tlio  p»lnttn«  art-Ii  U 
<)ivido(] ;  with  the  samo  foi-ccpe,  ono  claw  being  retained  in  the 
nostril  whilst  tlio  <>liu;r  ernltniciM  tlii)  outer  surface  of  t.ho  iiiuxillx, 
tlie  mwrator  effects  a  transverse  section  of  the  bone,  wliich,  from  iia 
no  longer  huviiif;  any  »U|i{>ort,  i»  rt-ailily  rcmovcd;  by  this  incan* 
the  iiuicrtion  of  the  polyjius,  which  is  eaaily  extirpated,  is  exposed.' 

It  may  bo  inft;rnHl  Iruiii  wlwt  is  almvo  stattxl,  that  tlic  8ttrgeon 
need  not  hesitate  to  incise  the  sofl  palate  and  to  cut  away  a  portioa 
of  the  palatine  art'h  when  ji  jKiIypiitis  prowth  »itnatv  at  the  back  part 
oftim  tui^I  foHsa*  is  of  considerable  voltnne  or  'la  mulliform,  bcciiiue 
otherwiiw  it  n  hardly  [tossiblo  to  be  sure  that  the  disease  can  be  com- 
pUitely  pxtirjiated.  The  removal  of  tlie  whah  of  the  »ui>erior  max- 
illary bone  affords  imdimbtedly  the  most  certain  method  of  cndi- 
catini;  the  diAcaae.  This  procoture  lin»  beoii  had  reooiintc  to  in 
France  for  this  purpose  diu'ing  the  lajit  fittocn  years,  and  no  death 
is  reported  Ui  have  occurred  after  the  ope  rut  inn.  It  opju-jirx  from  a 
onao  recorded  In  the  Brltieh  MetOcal  Journal  for  January  ll^tt,  that 
Mr.  Tuttim  wna  the  first  who  jwrjimni'd  in  (bis  eountrv  removal  of 
tlio  whole  upi)cr-jaw,  in  order  to  roach  a  fibrous  tumour  attache 
to  tiio  ba«>  of  the  skull.  Tlio  opcriition  was  eotnmciicwl  by  two  id 
fiittlons,  so  as  to  secure  as  free  an  opening  as  possible.  The  tumou 
which  was  attached  to  llic  Ixxlyofthe  sphenoid  bono  between 
two  pterygoid  processes,  was  removed  easily,  and  without 
hwmorrhaKO ;  only  a  small  branch  of  tlic  internal  maxillarr 
nxiuirtHl  to  be  tied.  The  woundii  healed  in  ulioiit  ten  tbiyx,  oikI 
patient,  a  lad  aged  sixteen  years,  made  a  good  recovery.  YfH 
roqwct  to  ttic  preliminary  ateps  of  the  operation,  there  can  be 
doubt  that  the  parte  are  most  clearly  brought  into  view  by  mom* 
of  two  incisions :  one  slightly  convex  downwards  and  backward*, 
eommencing  at  the  comuiissurc  of  the  lips  and  terminating  at 
middle  of  the  inuiar  Ikuic  ;  tJio  other  incision  never*  the  nostril  fn 
tlio  BMcending  process  of  the  superior  maxillaty  bone.  The  excisio 
of  the  bono  is  most  ii'iiiltly  effec-tcd  by  the  aid  of  the  powerful  lev 
bone-iii](pei-8  contrived  by  Mr.  Iloffinan,  formerly  of  Mai-gate, 

There  is  a  form  of  polyinis  so-called  which  is  evidently  malig 
nant  and  cureinoniatous  in  its  nature.     It  attacks  only  adults, : 
begins  with  or  is  piveedctl  by  rcjieatod  discliarges  of  blood,  recur 
without  obviouH  cause  or  ap])arent  lesion,  and  by  conaideruble  i 
frequent  pain  in  the  forehead  anil  iippcr  part  of  the  nose.    Prtscnd 
H  Aiuall  tumour,  either  tita  deeply  rod  or  of  a  dark  purple  oolouff  < 


«  iMiidon  MttlUal  Ibtitw,  no.  iv.  p.  301. 


MALIGNANT  POLYPUa 


223 


«  nen  at  t)to  up]>er  part  of  one  i>f  Uio  nrwldl*.  It  is  pninful  (o 
tanch,  and  wbon  m«J<U«(l  witli  prone  to  bleed.  It  progreMiveJy 
imifunnlv  itu^rcjiAeii  in  size,  and  tln«  e^iiiprtMiemn  which  it  cxcr- 
^  tin  five  \ac\\ryma\  sac,  and  on  tho  nasal  c-anal,  giveii  ruw  to 
^bora  and  to  Uohrymal  tumour.  Aouto  iind  hincinating  pains 
pnipany  its  dcTolopment ;  and  the  cnmmon  actions  of  coiighinj:, 
Vjun^,  and  blowing  tJw  iinim  give  puin,  m-  pnxltK-i!  a  disngrecablo 
palkm  in  tlio  nostril  or  foreliead.  Originating  fi-oin  the  bono,  it 
)  be  found  to  be  fixwl,  uik)  n<jt  ninviible  by  lb*-  nation  of  blowiii;; 
I  aone,  or  of  <lri\Hng  air  through  the  affected  nostril  only.  It 
kmchcs  by  adbtiKtifn  on  iuMghb»uriiig  purl.'',  |iro<liicii)g  tbickcnitig 
I  vtilar^ment  of  the  septum.  In  tlie  course  of  time  the  adjacent 
^  loxtunn  arc  implic-iitixi;  dw  eye  in  frorjiicntly  displaced.  Tho 
Hmr  pnsents  a  fungous  or  medullaiy  consimenoo  and  a  livid 
oar,  pshalefl  h  cadavun>us  (Khmr.  anil  ehtxls  an  oftViisire,  icboroos, 
enlnunsl  dtscbargc  Hw  disease  goes  on  from  bad  to  worse,  and 
f  patient,  cxhiiUftMl  by  pain  and  onrvst,  succumbs  in  a  conditioD 
buioeroia  cadtexy. 

kin  cases  of  tlita  diwcription  n-mo^'a]  by  the  foroops,  or  by  any 

|rr  inf4in.4,  ought  not  to  be  altt-mpttxl,  fur  rcjinonH  obviouitly  (bt- 

^ble  from  th<^'  nature  and  cireum»tancc«  of  tlio  grovk-tli.     On  the 

homl,  il  in  generally  so  i'xt4'n*irve  and  ii«Ihvn<nt  as  to  render 

extirpation  impracticable  ;    and  on  tijo  other,  all  partial 

,  all  iinauC(Mi«fuI  iitleniptd  vn  it,  iiidi'tsi  any  di'grsre  of  iri'l- 

will  only  tend  to  distress  the  patient.    Palliative  treatment  ia 

iniiLiibli'.      In  ct-rtiiin  ca»m  Uic  patient  will  l>i?  timpunirily 

by  the  Surgeon  clearing  the  noatril  with  his  fiuger  of  tlio 

pmdocliun.     In  tlic  evoiit  of  blomling,  tho  cavity  may  lie 

wiib  lint  moistened  with  solution  of  tritoehloride  of  iron.    To 

rc«>r(  inay  bo  lin<l  to  a  lotion  «im|K»(d  of  oii«  jwrt  of 

aulntion  ofopimn  and  two  [Kirtit  of  water;  ortoonecon- 

tltrre  drachms  of  extract  of  hemlock  and  one  drachm  of 

in  a  pint  of  water. 

ALEXANDER  UIi£. 


DISEASES  07  THE  LARTXX. 


Acute  Lartsgitis. 

ACUTK  larjtigitis  is  r  foniiidalile  disease,  which  cy>mes  on  vejy 
BuJdenly,  and  runs  a  ra]>Idly  fatal  course,  itnle»N  rcoogiiiW 
earlv,  and  treated  oiiCTgctically. 

'Hio  early  syniptonis  nro  tliese:  dryncMi  nn<i  iiot«im<i!)«  of  the 
throat,  witli  ditficnit  dcphttilion,  accompanied  hy  general  tever  and 
I>y  much  ro!ttJo!wni>H!i  aiid  iiiixk-tj.  On  inttptwliiig  rhe  throat,  tbs 
fauc(.«  arp  generally  found  deep  red,  and  tho  q)ig!oiti8  erect,  red, 
Biul  tliickenwl,  jironenting  to  tho  finger  SMiintivhnt  tho  wiino  eonah 
tion  as  a  cheny  wotdd  do.  Tho  patient  will  complain  offioreiKM 
iin<l  a  aonso  of  constriction  at  tho  upper  ]iart  of  th«  throat,  and 
tenderness  of  the  larynx  on  prensnre ;  and  will  probably  point  to  the 
]ioruuni  Adaini  na  the  scat  of  his  Biiffering.  Dj-spnaw  (loon  comM 
nn,  and  rapidly  iucrea«»;  ex|)iralaon  ia  at  first  perfonned  with 
oiinjini'ativo  case,  whilu  inifjiiratioii  is  noisy,  hiirsli,  and  whistling, 
and  may  bo  observed  to  be  accompanied  by  diminished  movemoit 
of  tho  che«t  walls,  and  diminution  of  the  rcvpirntori'  intumtir. 
dyspnoea,  though  constant,  is  greatly  aggravated  at  time«, 
Ejiasm  of  tho  muHclvs  of  the  glottis.  Cough,  if  present,  is  freqn 
liarsh,  and  stridulouA.  The  voice,  at  first  harsh,  becomes  at 
hardly  audible. 

As  the  diaense  proceeds  and  the  glottis  is  mom  narrowed 
effusion,  tbo  ]>nticnt  bccomps  extrpmely  restless  and  distressed ; 
is  unable  bo  lie  down ;  or  if  be  docH  so,  he  sUuiit  up  involuDt 
gasping  for  broatli.     The  countenance  is  pale  and  anxious,  iIm 
li\id,  the  eyes  protruding,  sweat  ppurs  profnsely  from  tbefiirclw 
the  pulse  becomes  we.'Ui  and  intermittent,  drowsinesa  and  deliria 
BHper\eiic,  and  the  jiatieiit  dies  8uffi>cated. 

Tliis  disease  generally  mns  a  rapid  course,  its  dunU*on 
pending  on  the   intensity  of  the   intlnirnniition,  on  the  constiC 
tion  of  the  patient,  and  the  natm:^  and  actinty  of  tlie  tre«li 
adopted.     It  is  generally  fatjil  on  the  thin!  or  fourth  day,  and 
Watson  mentions  an  instance  in  which  a  patient  died   in   twe 
hours.     In  some  coses  the  dlacnse  is  of  a  milder  nature,  and  a 


ntil  tbo  cif^lilh  or  niiidi  day;  or  it  mnr  subside,  or  pan 
'graduaUy  irilo  a  chroiii<<  form. 

An  pxaminaliou  advr  dvMth  of  tbo  morbid  dungos  which  hsvo 
taken  pUoe  will  acoount  for  all  the  above  symptomR,  luid  explain 
thic  eanaa  of  tbo  rapidly  l^tal  naturo  of  tliU  di»ord«r.     The  tnucous 
iiM!in]>rane  lining  tliia  c^avilv  of  the  lanux  in  usually  fdiind  rtxl- 
imt&i,  thickened,  and  oov«rod  with  a  layer  of  soft  yvllow  fibrin. 
Hie  B{wnur«  of  tltc  glottis  is  narrowed  fi-om  alight  efftiaion  of  se- 
rum or  pus  into  tbo  otibmacous  ct-lliilar  tis»uv,  llio  conr«quei)Ge  of 
iaBmtntamlnry  congi^oii  of  tlio  mucouo  membrane.     Tlio  aryta-no- 
epi^lottideaQ  fbldii  and  epiglottis  arc  redduiiotl  and  ocdcniatous, 
and  perlwpa  Mvcrcd  wit}i  a  layer  of  tiotl  iibrin.     UlcoraCioii  of 
tame  part  of  tho  inflamoil  macons  tnembranu  may  uocitr,  and  even 
ilonjrliiiig  may  lake  plac(^*     It  i»  iiMinlly  said,  that  inflammation 
of  the  laiynx  does  not  extend  into  tho  trachea ;  in  the  fatal  cowa 
al  St.  Oe<u^gc'ii  Hoitpilal,  huu-evf^r,  tii«i  trat-liea.  and  .lomotimeA  the 
hnmohi,  vere  oocAsionalty  found  to  prui^ent  inflammaton-  ohaiijees 
laimlar  to  what  liav«  been  deaia'ibed  in  the  larynx,  tho  mucouit  m«m- 
l^tMio  being  congested  or  highly  vascular,  and  oocaaionally  covered 
,  thin  layi^r  of  soft  yelluw  tibrliL     Tlie  lungs,  too,  wero  often 
ted,   aud  in  M>me  ua»es  prtmnbeA  patches  of  hepatisation. 
■UfHeully  of  doghilition,  one  of  the  earliest  and  motit  cmiMtant 
ifmptoBu  obeen'cd  in  Uiis  disease,  depends  on  tho  swollen  and 
liiaAil  state  of  the  mucoo*  membrane  of  tlio  pbar\'nx  an<l  lun-n^t. 
1W  naw  of  snjfocation  n-hich  ensues  on  tho  patient  attempting 
hnallow  a  morsel  of  TuihI,  ih  prtidiioetl  by  tlie  epifrlotti-t  luing 
MUe,  bom  its  tense  and  erect  stale,  to  perform  its  nsual  ral- 
"liir  (■fficr.      Hilt    tJte    most    fomiidablo    symptom,    the  ditHcnIly 
•'IrcAtbtDg,  is  caused  by  the  partial  closure  of  the  rima  gbttidis, 
jftHi  the  eSuMMi  of  fltiid  into  tlie  submucous  tissue  immediately 
[Aoft  die  voeal  cords.     A  sufFieient  amount  of  air  does  not  enter 
[fc  hmga  f(>r  tW  piir[ioitc  of  rwjtiratinn,  the   pulmonary  <-ireu- 
jkiiin  is  tlien  retarded,  carbonic  acid  accumulates  in  tho  blood, 
lUi,  aflbcCing  Uw  nene-ii-nlrtit,  pnHliKvs  iloliriiim  and  coma  ;  or, 
I  (Odileo  Ipasinodic  attack  of  the  mtiHclcs  of  tlio  glottis  ensues, 
a  *)uc)i  the  afierturo  nf  tlie  glottis  is  90  narrowed  tliat  the  pa- 
die*  strangled ;  and  such  caaea  are  fetal  c%-cn  in  the  earliest 
■  ef  the  dutvaxe.     A  man  was  once  admitted  into  Hi.  Oeorge'a 
Bcipital,  oomplainiog  merely  of  sore  throat.     He  walked  into  tlio 


*A  fmiMntien  lllDstratlng  tLia  latter  conditioD  is  In  the  moaeum  of 
'b.  Gcoifa's  Ha«l>iUl. 

VOL.  m.  Q 


«S6 


DISEASES  OF  THE  LARYNX. 


ho«pitAl,  and  wmicd  in  Kiioh  f^xxl  health  that  Iio  woald  not 
been  :i(lmitt«<l,  but  for  the  cinnimstanci:-  ot'liin  ktving  cuiiiv  »nme 
distaiiou  trom  ihu  oountiy.  About  tlirix^  hours  after  his  Bdmission, 
the  Iloiiae-Borgeon  was  Mimniont<<]  in  all  hnnto  to  sett  liltn,  an  he 
was  «aid  to  be  dying  of  »iitTc>c-:ilioii.  He  wciit  iminodiately,  but 
found  the  patient  quit«  dead.  The  post-mortem  extimiiiutjoii  re- 
vealed all  the  evidences  of  laryngitis,  supervening  apparently  upon 
iiitluiiiniataou  of  the  pharynx  ;  hut  it  vrtm  e»]m:ia.\\y  reinnrkml,  Uiat 
the  diink  of  the  glottis  was  not  much  narrowed  from  sdema.  In 
tixis  cmti  tliero  can  he  no  doubt  that  deatJi  noa  produced  by  »pu^H 
tnodic  contraction  of  tho  muscles  of  tho  glottis.  ^| 

Aeut4t  laryngitis  gc-nerally  attacks  adults  of  plc-thorie  babit.  It 
is  frequently  produced  by  exposure  to  wet  and  cold,  or  sudden  and 
extreme  changes  ut'  temiieriiture.  It  is  a  cfomnion  rwult  of  mt' 
cbanical  violcnee,  or  of  chemical  injury,  as  in  attempting  to  swalloir 
corrosive  poisons  or  boiling  nutt-r.  It  has  l)een  known  U>  lulldw 
a  bungling  attempt  to  introduce  the  stomach-pump  in  a  case  of 
jmisoTiing ;  and  in  anutJtt^r  ca;«c  folliivrcd  the  ineautioiM  applicati 
of  ammonia  to  the  nostrils.  It  may  also  ocenr  ia  connexion  wr 
tlloite  diseases  which  atii'et  the  parts  in  the  immediate  neighbour 
hood  of  tho  larynx.  Those  who  suft'or  from  ehronio  sore  ll 
npjH'ur  til  1)0  very  liable  to  its  attacks.  I  have  seen  it  riceur  in 
nexion  with  ordinary  glossitis.  It  occasionally  follows  an  altao 
of  cynanche  tousilluris,  or  inflaniniatioii  of  tlte  l!iu<i'!<  and  p 
or  tho  aft'ootion  of  the  throat  in  scarlet  fever,  or  occurs  in  ooniie: 
with  erysipelas  of  the  face  and  sculp ;  and  in  a  few  instanooa 
been  known  to  follow  excessive  salivation  from  the  exhibition 
mercury.* 

I>iaipioin».     The  symptoms  of  this  disease  are  nsunlly  so  distin 
that  tliero  are  few  affections  with  wliidi  it  eim  Ik-  confounded, 
pain,  soreness,  and  sense  of  constriction  in  the  region  of  the  lar}T«i 
the  difficulty  of  respiration  and  deglutition,  iisliercd  in  by  fever  •■ 
rapiclly  followed  by  spasms  of  the  laryngeal  niiwcles,  producing  da 
gorof  suifocation,  arc  very  indicative  of  its  true  nature.    Croup  ma^ 
b«  known  from  lar^nigitis  by  the  ])eculiar  cough,  the  mnrti  striduk 
breathing,  and  tho  presence  of  the  voice     Laryngitis  may  tie 
titigiii.-'hed  from  a  foreign  Ijody  in  the  air-passages  by  tlw  abwnou  < 
fover,  and  the  suddenness  of  tho  accession  of  dyspnoea  in  tlie 
injury.     Groat  diftieulty  of  breathing  may  exist  in  c^-nntM^ 


•  S«e  a  i]re]>iiiiLUoii.  iviili  iu  history,  Ui  tlie  mutriuxi  of  St.  Gt 
Uaspital:  srriua  xv.  mibitoiieo  i.  no.  U. 


ACUTE  LARYNGITIS. 


SS7 


but  titcn  the  swelling  which  produces  it  in  viitible  on  ox- 
lining  the  fauc^c»;  nlicmis  in  turvngilis  tho  amount  of  swelling 
in  this  situation,  if  any  ejiiitta,  ia  quite  in!>titKinoiit  to  uccinint  I'ur 
Um  extreme  diflicuity  of  bix^tliing  and  deglutition.  In  pliann- 
gids  there  is  tittle  or  n»  dyspna-a ;  Liut  di.'jrtut.iiioii  h  fmiiifid  and 
difficnlt,  &nd  pain  i»  folt  on  prcMing  tlio  lar^iix  buckwardB. 

The  Irmttnttd  of  this  dittcase  must  vary  iKX'Oi-diii;;  tu  Hw.  j>ro<Trcss 

it  baa  mndr;  r  mode  of  truabnent  tbnt  might  bo  most  otficncious 

at  tlie  unset  of  the  nialn^Iy,  would  only  hapten  ■  fiiml  l« Tin i nation  if 

adopted  Utor.     If  tlic  ca«i  is  M-on  iu  tlio  early  stA^  of  tlm  disease, 

the  stage,  that  is,  of  actiire  iiiflaminntJon,  tlie  moAt  vigorous  anti- 

pldopKtic  tivatinunt  should  bo  adopted.     The  jintiotit  »liouId  bo 

hW,  the  oinounl  of  blood  to  bo  liikeii  lieing  inoditiiKl  ucoording  tu 

the  a^  and  convtitntion ;  or  cupping,  to  tho  nape  of  the  nock, 

Wdws  or  blisters  at  Ihe  upjier  and  fi-oiit  [>art  of  the  cheat,  may  lie 

tDtd.     Morctiry  slwuld  be  administered,  so  as  rapidly  to  affect  tho 

tft/eoL     Tartar  emetic,  ifumxl,  should  bt)  given  in  sueli  doses  aft 

li  dtmiiiiflb  tha  rarculation,  hut  not  to  cause  vomiting,  since  tho 

wttlewla  of  tl>a  EAomach  might  ent^r  the  larynx,  and  produce  suf!b- 

No  time  should  be  loet  En  adopting  this  treatment;  tho 

■hdiano^  of  iu  suoceAS  \«.  in  enlbroiiig  it  nt  the  ri(;lit  moment, 

nd  in  the  most  ngorous  manner.     The  time  tor  bleeding  has  past 

jiAa  r(S{Mration   becomes  greatly  obstructed;   and  thi.t  may   ho 

kwn  hy  the  leaden  hue  of  tho  features,  bluencss  of  the  lips,  a 

)*litiBDmy  .tkiii,  and  fceblti  pulntv     Ulotidiiig  under  sueli  eireum- 

tattt  voakt  be  worse  than  Injurious ;  it  would  probably  bo  fatal. 

1  Vths  Surgeon  find»  that  tlie  iinti[ilil<igi.itio  treatment  fails,  or  if  be 

W  lent  firrt  simimoned  to  the  case  in  its  more  advanced  Mt^ge,  ho 

Mkqld  at  rnioo  pro]><xw!  tmcheotomy.      The  reeords  of  numerous 

IkMi,  bcnrever,  shew  so  clearly  the  efficacy  of  the  antiphlogistic 

ii)  IIm!  Litrly  .Hla^t.'.t  of  tlie  tlisvane,  that  such  treatment 

J  AwU  never  be  omitted  when  inflammatory  fever  Is  pre«^t     On 

liktMiier  hand,  when  Umi  noi-uwify  for  \\\t:  oporiitiou  is  ap[iaront,  no 

laboald  be  lost  in  performing  il.     There  are  many  iulvaiiUi);«« 

n  perltirmtng  iniulieotomy  curly  in  this  discatte.     It  prevents  the 

>  of  those  frightful  paroxysms  ofdj*spna;n,  in  one  of  which 

i|BtMnt  may  die  itiitl'ocauxl.     It  allows  n'ljose  too  of  Uio  organ,  if 

ttaidioa  is  opened  below  the  obstructed  part.     Tlie  patient  may 

1  OMUiiiic  to  1>re»tlie,  until  the  ititlumniation  of  tho  larynx  sub- 

and  the  thickening  and  <edema  is  roinovetl  by  utMorptiuii. 
Porter  Miys,  "  I  luvv  witnessed  many  operations  in  cnec«  of 
hi^ngitis,  and  as  yet  have  seen  but  few  succvwful ;  and  1 


228 


DISEASES  OP  THE  LARYNX. 


Trauld  attribute  IhiB  not  oitlior  to  the  sm-ority  of  thp  nffection  or 
to  thfl  iiimli-qiiacy  of  tlie  ojitTulion  t«  prtwiiro  TclieX,  but  sulciv  to 
the  circumi'lfliicc  of  a  considerable  portioa  of  time  being  previ- 
owslv  pm]iloyp()  in  trying  to  jttilHliu>  it.  by  tlio  iHual  mcusiirtw  fiir 
combating  inflammation,  and  the  nse  of  the  knifo  being  thus  post- 
poned until  a  pi^iod  wlicii  it  was  only  tried  ax  n  lut  rcioniinu;,  muI 
could  by  no  me&ns  promise  oven  a  probable  chance  of  success."* 
IjOutH,  Iiuwr<rnce,  and  AV'at-wn  also  adviwate  carl^-  porf»ninuio»  of 
the  operation. 

Traehc-otoniy,  liftwe\cr,  is  not  projioned  a*  a  moanit  of<*n' 
this  disease,  and  should  never  be  regarded  as  a  remotiy  to  be  i 
ftdopt«(l  wlicn  otlicr  milder  mennn  have  iiiiinl,  btit  only  m  a  ni^| 
source  for  the  prolongation  of  life  wliile  the  powers  of  nature,  or  ftff 
treatment  luloptcd,  remove  tlie  inRaminatory  ctIui>ioi).  Nor  sliuuld 
the  operation  be  omitted  oven  in  cases  where  tliepe  is  little  appa- 
ront  ebnnco  of  Nucress.  I>r.  Watson  has  reoonlcl  numcroiiit  coxa 
in  which  tracheotomy  has  been  BUccessfuUy  performed  after  tbo 
breatbiiig  and  jiulse  hod  ceased.  In  ravnurabie  rjwcs  Iho  o]>cni- 
tion  is  followed  by  great  relief  to  the  distress  and  anxiety ;  res- 
piration becomes  trei%  and  the  patient  sinks  into  n  deep  rvp<w& 
The  subsequent  treatment  will  depend  on  the  nature  of  iJio  genenl 
symptoms. 

(Edema  of  the  Glottis. 

Althongh  considerable  ondenin  may  exist  tn  oonnnxton 
ordinary  acute  larjnigitis,  it  is  important  to  draw  a  distinction 
twWTi  that  disease  and  the  one  under  consideration.     (KdcnM 
the  glottis  consists  in  an  effusion  of  scnun  or  saro-puruleiU  fluid  i 
the  suhmncons  areolar  tissue  of  the  e[)iglott.i-«,  nryt«;no-«piglotti(fc 
folds,  and  upper  part  of  the  cavity  of  the  larynx ;  the  result 
Dbly  of  a,  low  or  asthenic  form  of  inflammation,  tliu  Iroo  sur&co  ' 
the  mucous  membrane  being  unaffected. 

The  first  tiling  noticoii  Is  a  sensation  of  stiffni-**  of  the 
or  a  feeling  of  uneasiness  in  the  larj-nx.     The  attack  i*  us 
sudden,  the  patient  retiring  to  bed,  jierhaps,  in  pcribct  heahh, : 
awaking  in  the  night  B'ith  extreme  dyapn<»a.     Tliere  is  a  scnoatio 
as  if  Tnucua  or  some  other  fiircign  snbstancv  was  clogging  up 
aperture  of  the  larj-nx,  or  was  lodged  at  tlio  back  of  the  Riu 
and  forcible  attempt.^  at  i>\piration  or  deglutition  an>  made  to 
lodge  it.     The  voice  is  hoarse  and  croupal,  and  rcMpirution  u 


•  Oh$ervatio>ti  on  tht  Surgkal  PaChaleyy  o/tht  Larynx  «itJ  Tntfltea,  p.1 


(EDEMA  GLOTTIDIS. 


S39 


[ ;  bot  th«rc  i»  prutMiMv  iw>  fever,  no  rcdnflM  of  tlie  fauMS,  and 
llie  gntcral  health  U  not  deranged.  In  tlic  course  of  a  fitw  liours, 
or  lal«r,  aoconltn;;  m  Uio  (lii>i.^iiH!  in  nipid  or  not,  Uio  voioe  bot^omiM 
dutf  and  biwiing;  tiiere  ia  a  ho«no  ^nasmodic  oough,  aud  coa- 
Bidenl>lti  dyi>)ii>U'4i ;  vxpirnUon  is  tree,  but  insjiinition  in  <liHi(jiilt, 
and  aooompaQied  with  a  crowing  or  aU'idulouB  sound.  The  ditB- 
ctdty  (tf  iiupinitivn  m  tliU  diftca»c  u  aocountMl  fur  by  the  invcluuii- 
cal  amngement  of  the  awollen  edges  of  the  orilice  of  tiie  larynx ; 
for  on  4!v*!ty  attempt  to  in;ipiro,  tliu  air  rusliing  iroin  t.lie  pharynx  in 
the  directioa  of  the  larynx  proasea  the  aidea  of  t)»>  ofiening  togeiher, 
doting  it  murv  or  kw»  oomplctcly ;  nhorva)!  during  oxpiratiun,  thu 
■tr  passing  fi-om  the  trachea  separateii  the  aides  of  ilie  o^wning,  and 
MCBpew  ewly.  PrcAsnro  on  tho  lnr)iix  produuoM  rcry  littlu  unvani- 
IKB»,  and  there  is  no  difficulty  in  iiM'uIlowing,  as  in  luryngiiis,  unlewi 
llie  Cj)tgl«ttiif  it  involved.  Tho  exiHtoDc>o  of  (Edema  may  be  detodod 
W  iotiMMlucing  Um9  iixlex  tiiigur  into  tltu  faiieCH,  when  tlio  fold* 
■irich  Iwund  ibo  upper  aperture  of  tJw  Uurynx  will  be  felt  aa  two 
iMooth  rouudei]  luinourt  just  liehind  the  Mwollen  q)iglolti».  A« 
f4(«JiMa«o  proceeds,  ll>e  patient  surtera  fi-oni  frequent  fits  of  apas- 
Mdic  dy»))nam ;  in  vome  m«ei>  therv  Are  inlvr^'nlii  of  [wrioctly  calm 
I  nd  nsy  breathing ;  in  otbon,  again,  tho  apaamodie  attacka  ai-e  al- 
1  ■wt  eontinuoua,  and  one  of  tliuin  not  unfriy[uently  produces  deatlu 
On  diMSfe  ia  extremely  tataL  Dr.  Bayle  haa  re<-ordod  only  one 
mnry  in  aoventoaa  cawa;  M.  Valk-ix,  in  his  csaay  on  oidoiiiuUius 
■BjAgtal  disease,  has  ooUeotod  and  reeonled  tbrty  caAen,  out  of 
*i>ck  amnbor  tliirty-oiio  were  fatal;  and  in  M.  Sc»ticr'»  muniolr 
*1  Iba  asme  aobject,  the  reaulta  of  ItiK  coaoa  arc  given,  of  which 
'  127  died.  The  duration  of  tho  disease  ia  usually  from  two 
^fcvilay&  In  aojne  caaem  death  occura  more  ra]>idly,  being  pro- 
■mI  hjr  rapid  inGltrati<)n,  or  spasm  of  the  glottin. 

Ihe  diiHculty  ufrvajiirulioD,  wliicli  is  ilit^  niuHt  marked  siymptom 

■  liu  diawiao,  is  prodocod  by  rapid  eStision  of  eorum  into  tba 

ledlakr  tiasuo  of  the  upjx^r  jmrt  of  ttii;  liu-yn\,  and  oonAei|uent 

of  tho  f'dda  aurrouiiding  t.lie  upper  3[)crtitrc  of  tha 

and  of  the  Upa  of  the  glotUa ;  tlie  ccdema  frequently  dx- 

to  the  baw  and  aides  of  the  epiglottis,  and  the  base  of  the 

jiaqgoe  and  tuuaiU  are  lit^itently  iin|)lii?ut4Hl ;  hut  it  never  exietida 

I  Wow  the  truo  vocal  cords,  a  fact  ctoarly  shown  by  Mr.  Frmeott 

ifiBwietL*     The  6rae  surfaoc  of  the  mucoua  membrane  is  unalfeeted; 

JkasmoOea  porta  are  generjlly  of  a  pale  yellow  colour,  aud  devoid 


•  iMd.  Jmn.  t^ Mtd^  vi>l.  i.  loiii.  p.  lau. 


230 


DISEASES  OF  THE  LARYNX. 


of  vascular ity.  In  tho  nmjont.y  <if  caKO*  of  tliis  BfFpction,  w! 
miiti  a  rapid  rikI  fatal  coitrse,  Hie  eHiiscxl  fluid  in  m>niiii  nr  plastic 
lymph ;  but  in  Hioi-e  jmitnicUt)  nwtn  it  hei-odic-i  scTo-puriJwit  or 
pnrulont.  TIip  causes  of  tJiis  di§c38C  do  not  in  all  cjiws  iip|ieiir  to 
be  very  olearly  iinderstdoi!.  It,  inny  ocjcur  in  ponsoqiienoc  of  cjt- 
postiro  to  cold,  coming  on  Bnddenly,  in  persons  of  fto'"!  Iii'allli,  tind 
proving  (iilal  in  llie  conrs^;  of  a  few  liours.  Baylti  has  noticod  thai 
it  ol^en  arises  during  convalesoenco  from  fovcrs  of  a  typlmiii  olia- 
ractcr.  Not  inifri!i|ui'ntly  it  it  coincident  wilL  annio  otbcr  diwasn 
of  till"  larynx  or  adjoining  parU;  and  it  sometinios  ui-t^onijiauka 
aneurism  of  tho  tlioracic  aorta,  ajdcina  being  pn»dui«d  by  ol»stnii>- 
tion  of  tlio  veins  leading  from  tlio  part.  ^fl 

"nut  truatinout  must  be  modificxl  according  to  tJie  stage  of  th^^ 
disease,  and  tlie  cause  of  the  onlema.     In  the  early  stagra  of  this 
iiffoction,  where   tlic  dlsoasu  is  apparently  j)rnduce<l   by  loL-a!  in- 
flammation, the  usual  lueanx  of  reducing  inftuinmation  should  be 
adoptod ;  but  it  mu«t  bo  remembered  that  the  intliuiiniutioii  is  of 
an  aathenie  oharacrter,  so  tluit  genemi  bleeiling  is  rarely  if  c-er 
required.     Blood  may  be  abstracted  locally,  by  the  application  of 
leeches  in  the  vicinity  of  the  larynx;  blinuira  should  be  appliod  to 
the  back  of  the  neck,  or  upper  part  of  the  front  of  the  elioftt; 
calomel  may  be  given  in  large  doses.     But  in  the  later 
tills  affection,  where  there  is  much  impediment  to  rospimtioi 
where  autfbcation  is  imminent,  lar^^l'^olomv  nliould  be  in. 
performed.     The  operation  should  not  be  delayed  until  the  I 
aro  do  fur  congested  that  tiieir  rocovorj-  is  Iio|nili's.-i.     Before 
forming  tliis  operation,  it  may  be  PX[>edionl  to  trj'  Lisfranc's  remedy 
of  scarifying  the  a'deniatous  swelling,  so  as  to  fRTmit  the  escape  of" 
tlie  effused  fluid.     This  mode  of  tn.'atinent  was  adopted  in  fivo 
by  Lisfranc  with  success;  and  Mr.  Busk  ado|>t<.Hl  it  in  two 
with  permanent,  iMjnotit.     Numerous  punctures  were  made  with 
duurp-pointed  bistoury  into  tbo  back  of  tho  t<^>nguc,  the  uvula,  sin 
tfie  pharyiis,  and  repeiitwl  every  twn  or  liiree  hours;  warm  w 
being  employed  as  a  gargle  in  tlio  infenals.     Tlie  relief  in  cjicli 
wan  very  decided.     If  cedeina  conies  on  in  the  ooursA  of  any  obrani 
laryngeal  afi'oetion,  or  in  oonnexion  with  aneurism  of  the  thoi 
aorta,  larvngotouiy  in  tJiw  only  rcmwly  that  can  bo  adopted. 

Dr.  Horace  Green  strongly  recommends  a  solution  of  tbo 
trate  of  silver,  a  drachm  to  tho  ouneo,  to  bo  fii-ely  appliiHl  to 
epiglottis  and  cavity  of  the  larynx.  The  first  application  ho 
commends  to  be  made  to  the  pharynx  and  u]>per  «urfiivo  of 
epiglottis,  the  application  being  rcpoatod  in  ten  or  fifteen  nurn 


ERYSIPELATODS  LARYNGITIS. 


281 


^Bo  tfac  hue  of  Um>  epiglottis  amt  orifice  of  the  larynx,  and  oonliniied 
Beverjr  Inur  until  llw)  <edenin  HulMidiM.     In  tlie  cues  rocordod  by 
the  BUlur,  eaofa  application  was  foltow<y}  by  abondaiit  cxpnctonf 
^ioa  of  adheaire  mucus,  aiid  au  eurly  subiiideiioe  oftlie  oedema. 

Ebtsipeutocs  Lartooitir. 

Tlii*  IS  an  extremely  dangrrous  afTuctioii,  frequently  seen  ia 

ital  practice  »  hen  ervsijielas  liaa  been  pre\'alent.    It  may  ocirur 

Jimrt  vxtvii»i(iu  of  cn-cipclas  of  tlio  faw  t^i  tlio  tliuces,  and 

tbence  to  Uw  larynx;  but  there  in  another  form  of  the  same  diiicnHe, 

ia  which    tin-    fa»c:«  and  larj-ns  arc  first  aifecttnl,  iind  in  whi(^ 

death  may  lalce  plaw  witlwmt  tlie  a[i|ieanuife  of  external  ory*i|»eIaR. 

Id  such  «a]wa  tliv  diMatto  is  ushered  in  with  tlto  usual  itymptoms  of 

trraipelas  (rigors,  fever,  &<•..),  followrtl  by  sore  lliroat,  redness  ajid 

nrcUing  of  tlw  fauotw,  dvsphagia,  and  frp<|ucntly  pain  and  teiider- 

■MB  alioul  the  larynx ;  lioaRienettf  of  the  xwix  and  urgent  dyspnccn 

Hen  oame  on.    Tlicso  stinptoms  are  occasionally  rolievod  by  the  ap- 

fcannee  of  erysijicIaM  e\t4-ntHlly ;  but  more  ot\en  tJie  patient  sink* 

iuo  a  typhoid  state,  and  dies  oilhcr  from  suffocation  or  oxlmuHtion. 

Hw  poel-niorlein  apjiearaiicw*  kIiow  tlu^  ni>nal  eilitcl^  of  phlcg- 

■BOoBi  eryaipclas.    Ilic  mueous  membrane  of  the  epiglottis,  laryiiN, 

•al  tnwhea,  ia  much  inRnmod  and  a-dciiialotis,  m  that  the  glottis 

■  DSTOwed ;  hut  the  oxlema  docA  not  extend  below  the  trua  vocal 

Wrd^    In  inutrt  caHVN  the  mucous  membrane  is  in  part«  of  a  dirty 

pWBob  colour,  and  the  cellular  membrane  beneath  in  a  sloughy 

M)£tiaii.     Sum>uiM]ing  tlw  glottis,  large  slouglis  of  cellular  liseoe 

■4  mall  a>Ue>ctions  of  pus  are  occanionally  seen.      The  niuooiu 

■Mabrane  of  the  iiiuce*  ia  roddcnvd :  and  that  covering  tlie  base 

■f ihc  tongue  and  tonsib  often  presenta  extenaiva  breaches  of  siUT' 

W,  tlw  nsult  of  sloughing. 

Ikis  diaease  is  of  so  formi<inble  a  character  that  few  patients 
wwrer  from  it;  and  such  a  result  might  bo  expcct<'d,  when  wo 
IJHJiIliI'  liow  seriously  a  deficiency  in  renjiiratidn  must  aSect  thow 
ifrtady  debililultti  by  erysipelas.  It  becomes,  then,  a  matter  of 
peat  moment  to  watch  narrowly  in  all  oaseH  of  erysipelas  about 
lb  liioG  for  tlw  finit  manifcslation  of  laryngitis.  Tlie  post-raoitem 
hrioM  clearly  show  that  thJi*  aifectiun  partakes  of  the  onlinaty 
^mnden  of  erysipelatous  inflammatiou,  so  that  all  uetivc  depleting 
tnatment  must  be  avoided.  \\'lien  ttymptums  appear  indicating 
'  i-rrsipcl.ts  has  extended  to  the  fauces,  it  is  ourdniy  to  arrest 
~  speedily,  before  the  larynx  becomes  aiTected.     An  emetic  should 


DISEASES  OP  THE  LARYNX. 


bo  given,  the  bowels  sthould  be  fireeir  rclie%-ed,  and  «  blister 
be  applied  to  the  bark  of  tho  nock  or  nptxrr  purt  of  lliv 
BciirificHtion  of  tJio  toin'II.t,  faiiras,  and  epiglolti»,  rejwaied  at  inter- 
vals of  a  fenr  hours,  ik  occasiotisiliy  follunod  by  oonsidvrablv  roliuf: 
And  tlie  inlialatiun  of  the  tttoam  of  hot  wat«r  is  frequentJT  fo: 
a  very  soothing  romedy.  Some  Surgoons  rcicommt-iid  tho  faa 
phnryiix,  uid  uj)pcr  part  of  tho  Uirytix  to  bo  mo[>pcd  wiih  a  strong 
eolution  of  nitrate  of  silver.  The  administration  of  intenial  re- 
mwites  mii.*t  l>o  modified  aeeording  Ut  the  winstitution  of  Uie  pa- 
tient; if  tho  disoase  is  reo«nt,  and  there  is  much  ompliiinl  uf  [Mua 
in  the  noiglihourtiood  of  the  litrynx,  ttio  akin  hot,  and  the  puUe 
indionting  grent  feeblenen,  aalinos  M-ith  small  dosm  of  Urtnr  omel 
may  be  given ;  bat  in  the  tstxeti  unmd\y  tieon  in  London  practW 
no  lowering  measures  oan  with  eafeh'  bo  adopttxi,  and  the  patient 
will  require  wine  and  bnuuly,  ([tiinino  or  other  tonica,  and  a  getuh 
TOUB  diet.  If  urgent  dj'spnoea  supervene,  laryngotomy  may  h» 
iwrfonned  j  and  if  tho  oporation  in  determined  on,  no  lime  shoiiU 
be  lost  in  porfoi-ming  it.  In  these  cases  it  is  seldom  of  permaiiMit 
buiietit,  but  lite  nmy  Ik*  prolongtKl  hy  tt,  if  only  for  a  short  tioM^ 
and  the  last  few  hoors  rendered  less  distreesing  by  relieving 
wore  urgent  mymptoms. 


liefj^ 

■ong* 
re- 

P»- 

4 

tlM^ 


DiFFueE  Inflammation  of  the  Cellclar  Tissue  of  the  Labyxx.J 

This  is  a  very  formidable  and  fortunately  a  rare  affection, 
closely  ooiresponds  to  diffuse  inflammation  in  otiier  parts,  and  com-- 
plicate  as  it  so  frequently  in  with  similar  inflammation  of  tho  wboh 
of  tlio  cL'Ilular  tissue  of"  the  neek,  nii^ht  fxi  oon»idcr«l  as  only  pa 
of  a  more  general  affection,  did  not  the  symptoms  in  the  onset  poii 
to  Oil  larynx,  or  tho  parts  in  its  immediate  neiglilKHirhooil,  M 1 
scat  in  which  it  originates.     In  this  disoase  the  froo  surfaoe  of  1 
tniicoiLS   niemhrnno   ii«  unafToetod,   tfio  wbstniction  to   majMratioii  ] 
arising  from  inliltration  of  the  submucous  cellular  tissue  of  tlwJ 
larynx  with  lymph  or  ptw ;  somotimw  tho  cflii.^rd  iiroduol*  aurroimij 
tho  larynx,  trachea,  and  (esophagus,  intiltrato  the  whole  of  tho  ooDii-l 
lar  tiMKDc  of  tJio  nock,  and  extend  <iown  inlo  oiio  or  both  m«li* 
The  history  of  this  affeotion  is  as  follows :  the  patient  for  aome  day 
feels  ttiiwcll,  complainB  of  hi?adachc  and  dcprwwion  of  >^iiritfi, 
followed  by  rigors,  soroneaa  of  the  thniat,  and  symptoms  of  fo 
The  fever  increases,  a  s«7n«atioit  wf  weight  and  oppression  at  tbe  i 
in  (yimplained  of,  there  is  much  dyspnoea  and  sliglkt  hacking 
-with  expectoration  of  a  little  wliito  glairy  mucus.     Tho  luroneta 


.  DIFFUSE  INFLAMMATION. 


£38 


iBonues,  Uwre  ia  great  diflicahy  in  owallowin);,  tho 
atul  tomib  arc  Hwoltun,  of  u  iluxky  rwl  colour,  antl  Bometimefl 
ftted.  On«  or  both  sidoe  of  tlie  Uiroat  become  iiainful,  and  tlio 
in  t}i«  nc'i<;)ilK>url)D(Mt  of  tlio  jaw  »o  enlarged  that  it  is  some- 
witb  diflicuUr  that  the  moath  is  opened.  Occu.«ionmlly  there 
oooMant  fttid  oupimu  diitcl)itr(;«  of  tulivs.  As  the  diKvoso 
Jft,  ifao  neck  becomes  greatly  swollen,  the  broutliing  more 
I,  ttud  llio  HY»[>liiigiR  Mtnpk-t« ;  tho  fovcr  afi»iiiiiu»  »  low 
tTpbo«iJ  ti'pe,  and  the  patient  gradually  ciinka ;  but  more  tVc^uently 
|fa>  ivvatliing  i*  at  la«t  ko  much  ulii'tnirtc<l  thut  bo  dies  asphyxiated, 
■r  bi  may  be  carried  offal  an  earlier  period  of  tlie  dineane  in  a 
iaUm  parox^'sm  of  dyspncca.  Tlirco  cases  of  this  disease  liavft 
in  St.  Ot»rg»''»  Ilonpital  during  the  lost  fow  years;  in 
dtalh  ocvorrcd  on  the  fourth  and  titth  day,  in  tho  third  au« 
I  imtil  the  eighteenth  day.  After  doatli,  benidoH  the  appeanuioes 
Jv  di'M-ribod  of  inflammntorv  (edema  underneath  tho  mucous 
ihrsne  of  Uie  larynx  aixl  .tt'>jiping  at  the  true  vooiit  ciirdH,  much 
[yni[>li  waa  ftiund  in  the  oellutar  tissue  of  tlie  neck.  Sonic- 
'  the  eft'usion  is  liiuitcil  to  one  mcIo,  or  tho  whole  of  the  fixint  of 
nwik  may  bo  involved,  the  initammatory  prodncts  fiurroun<ling 
hn-nx,  trachea,  and  OMophaf^s  «xt4-ii<ling  upwnnU  )>ohiiid  the 
and  downwanla  into  the  tried iithil no.  Oi^cii^iioimlly  the 
tnmnbran«  of  tho  novk  Iwoomes  sloughy,  putrid,  and  iiifil- 
.  with  ptn. 

I  tho  snrly  stAjt^  of  thia  afleotlon  H  ia  a  matter  of  cxtrom* 

b>  detennine  ito  true  nature ;  but  the  dy*pn(ca  and  dys- 

whicji  Mon  t^w  tJtcmselveB,  together  with  tho  roiiici<leut 

of  iIm)  neck,  noon  lead  to  a  oorri-ct  diagnosiw,     Tlie 

tmtmAnt  of  these  eases  sliould  be  tho  same  as  tlint  above 

■mended  for  tlio  huyngitim  which  ocenrn   in  eutaneous  ery- 

If  mneli  pain  in  the  throat  li  oompluined  of,  loechcs  should 

J  exliTiinlly,  iind  wunn  iVuniMitations  cunftaiitly  tiwil ;  and 

rag  iQcreaseo,  becom«  brawny  or  (ense,  and  especially  if 

ix  prwoiit,  deO])  and  free  incisions  dhould  he  miule.     If 

iudammation,  aa  us  sometimes  tlie  eaae,  happon»  to  bo  limited, 

t  liypuration  not  diffused,  great  rolicf  may  bo  afforded  by  tliia 

I  if  trentment.     With  reganl  to  tlie  operation  of  liuy-ngotoiny 

»,  Mr.  Porter  obwrvca :  "  In  all  thwc  ch.'ww  of  diffuse 

aa  (and  er}-»i]>e(iia  l>eaDt  n  flnnxg  similitude  to  tlicui) 

I  of  nny  kind  poems  to  be  nearly  \-ahicI(ws,  and  death  to  be 

{oevttable.     Tlie  ilithi'nUty  of  bn-iithing,  however  apparently 

,  is  only  a  seoondary  oonaideration ;  and  even  if  retnovetl,  tho 


SM  DISEASES  OF  THE  LARYNX. 

pntiont  wouH  porisli  iic\'crtli(rl(i*»  of  that  low  and  i}'p}ioi<l 
wliich  olwn^s  iittonda  theae  aftections." 


SmnuTrc  Ui-ckratiok  op  tiie  liASTSx. 

Hu  larynx  not  anfrequeotly  becomes  affected  in  IIiom  vrf 
luftlth  luw  been  nhattered  by  sv|>Iiiliti<-  iliM-juto  tui<l  iiiU>m|>Qrauce, 
or  wbore  larg;e  quantities  oC  momiiy  have  been  administered  tur 
RV{iIii)iti  ill  |Hi^Aii8  (>f  liiii^niid  and  di-liiliutixl  <»nHtiLtiLioii.  This 
aflcction  most  iroqiiondy  follone  one  of  the  \-srioii£  forms  of  tiloent- 
Iton  whicli  uwur  in  the  fauoeA.  ThiiH  a  sloughing  ulcer  may  invade 
botii  tonsils,  which  rapidly  extends,  all  the  ueighbonriug  sonuil 
)Hu-tn  )xMM)iTitng  Kiict^^Mtivcly  iiiiolrcd ;  and  tJtiiit  U  soon  rnllowcd  by 
acute  ojdema  of  the  glottis  and  deatli.  Or  a  more  clironic  form  of 
ulct-rutioii  may  hari>  altiwlMl  ihu  whole  of  the  {iliiu'^nix  and  back  of 
the  fauces,  and  here  tlic  local  symptoms  arc  of  a  milder  character, 
the  patient  complain iiig  of  little  more  tli)iii  an  uneasy  Henution 
in  tho  part  dm'iiig  tho  act  of  sn-allowing,  not  amounting  to  pain; 
the  eonntiliilionnl  iiympt,(>nis  arc,  howcier,  VL-ry  cluiractoriKtic,  the 
cotuitonance  is  wan  and  haggard,  there  is  great  debility  and  cu 
ciatloii,  loss  of  appetite,  and  want  of  sleep,  wliicJi,  together  with 
history  of  tJio  case  and  tho  presence  probably  of  some  eutan 
eruption,  indiciite  tJie  true  nature  of  tikc  disuase.  In  i«uch  a  < 
as  soon  as  the  ulceration  attacks  the  larynx,  the  voice  becomes 
dlieed  U>  a  wliiH^ier,  and  every  attempt  to  speak  in  aci.'Minpaiiied 
a  suffocating  cough.  The  breatliing  also  is  affected  :  oxpirattOO 
coinparativciv  easy,  but  inspinition  is  j)rotrHc.'ted  aiul  atiendod 
a  j>oculiar  ivheezing  or  rattling  noise.  Pain  is  complained  of  i4 
swallowing  solid  fucK],  and  tJie  attempt  to  swallow  tUiitU  is  folli 
by  gi-eat  pain  and  suflbcative  spasms,  owing  io  the  insufiicie 
tiloBure  of  tiie  glottic.  Tliere  i^  tenderness  nr  pain  in  tlio  n.>gioa  i 
the  lorvitx,  sometimes  so  circumscribed  tliat  it  hecomes  possible  <■> 
diagnosu  nut  only  whicb  porta  of  the  tarj-nx,  but  «vi;ii  wliicli  side  i^ 
tlie  seat  of  ulceration.  Most  of  the  above  eymptoins  are 
but  they  varj'  in  jntCTisitv  at  diflerent  times,  ancl  tlieir  sM^ixtitV  i 
diflerent  individuals  is  not  in  proportion  to  the  extent  of  the  ule 
stion.  Kot  unfreqiieully  tlie  disuneo  is  fatal  from  a  Htidden  atti 
of  tcdema  of  tho  glottis ;  or  the  cartilages  niay  become  iwcroiK'C 
and  HUiTouiided  with  jius,  the  preiiaure  of  whioh  mnv  iKvunioii  titti 
dyspntxa :  or  sudden  spasm  of  the  muscles  of  the  glottis  may 
at  any  moment,  in  which  tlie  patient  may  die  mti'ucateiL 

Thu  jiarts  surrounding  the  u|ij>er  aperture  of  thu  larynx 


at  ut 
The 


lltnse  tDtwt  frcqucnil;'  found  afliwtn]  after  <I(<ath ;  wid  UiiH  is  wliat 
bo  ex|)«H3(«d»  u  the  disease  spreads  by  oontiniiitv  from  Iho 
tu.    Tlw  llDglul  SurfapG  of  tiio  Opiglottiit  iiliiy  jirc^'nt  a  ragged 
liar  aloer,  or  Uic  wholo  cartilage  may  be  oomplou-ly  dtwrroytid. 
olcemMHia  in  dw  kryiix  vtay  in  uxo  from  n  boon  or  olmoad  to 
dnnwter  of  an  inch  or  more.     Sometimes  ulcorntioii  liiyH  Imro 
eumua  of  tlio  OS  ]iyoidos  bikI  lliyroid  cnrtiliigc,  wliioli  project  into 
Tiix.    Till'  or^ijenoid  caitilagos  and  the  tissues  «uiTouading 
an  also  odeti  nffcctod. 

trwUDOnt  of  this  aSeclion  must  dojwtid  on  the  symptoma 
gODcral  condition  of  the  patiiiit.  If  the  disease  ooi-ura  in  a 
ibrtion  not  <l<.4>ilital«d,  and  where  xn  iiwiiorfecl  course  of  mer- 
has  been  give«  for  iho  jirinmry  ronoroal  syniptoni*,  Uio  gentle 
of  (bis  drug  into  tJie  system,  so  as  to  pi-oduco  slight 
of  the  gtimn,  is  often  of  tho  groratoet  sor^'itv.  Somo- 
ihe  locai  ab»traetion  of  blood  by  letvrhns,  frei|uontly  repeated, 
oonaiderablo  relief;  and  in  nearly  all  casea  oowntor-irrita- 
appltoil  in  the  form  of  u  bli^tor  to  tho  nape  of  the  nock  (h- 
part  of  tlMtchoKt,  is  attended,  after  frequent  rp]>otition,  with 
benefit.  In  by  tar  Uio  larger  proportion  of  rnses,  however, 
Mlive  exhibition  of  niercory  is  likely  to  prow  highly  injurious, 
WDstitulion  being  so  shattered  that  no  depleting  mwisuros 
be  borne.  Tonics  shotiM  tlioti  t)u  given,  sueJi  as  sarsaporllla 
larfc,  with  tho  iodide  of  potassium  or  biehlorido  of  menniry. 
ill  oases  it  ia  neccMiary  to  support  tho  pntii^it's  strength  by 
ig  iliet,  and  porfeot  rest  of  t3io  organ  should  be  enjoined. 
daily  local  ap]>lioHtioti  of  a  strong  solution  of  the  nitrate  of 
to  tiic  upper  part  of  the  lan-nx  is  sometimes  of  great  scr^-ioo 
diaiiiuslitug  U»o  e-xeensiw  irritability  ]iroduccd  by  tlie  ulcerated 
;  or  tlw  tnhalatioo  of  tlie  vapour  of  a  strong  inttision  of 
inn  or  opium  may  lie  trioil.  IftlirvnteningofiiulTocadon  should 
«  my  time  be  prwent,  eitlier  from  acute  a?dcnia  or  spo*Hi,  or  tho 
|i«Muni  of  on  Kbwwm,  laryngolomy  should  be  perfnrmiyl  without  de- 
br.  Many  oaea  of  i^hilitic  diseasi'  of  the  Wynx  are  oo  rccon]  in 
vlnob  lifv  has  boon  preserved  by  hu'j-ngotoniy  or  tracheotomy,  and 
Ikfitralioa  lias  been  performed  for  many  years  through  tho  canula.* 

TUUOUM  OF  THK   LaKTOX. 

Uorbid  growlhn  of  various  kinds  arc  ocxywioniilly  found  con- 
tedcd  with  the  tissues  of  the  larynx ;  but  tlie  symptoms  caused  by 


•  &et  Uiltoit  ia  iAine4t,  vol.  ii.  lBb3,  p.  67. 


m 


DISEASES  OF  THE  LARYNX. 


S36 


Bucli  tumoitra  iro  ho  itimilAr  to  tlioae  of  «hn>nio  dieeaflM 
larynx,  Umt  tboir  nature  is  seldom  dfitoctod  during  Ufik 
fuuiul  foit_v-eif;hl  «iioh  <!iwt'S  ujioii  rooord.*  Aa  to  die  nature  of 
the  growilis,  what  arc  descrihed  as  polypi  (a  most  indi^iiito  tcnn) 
wuru  tlio  ntuNt  fri-t|uent ;  tlien  warty  growtliH  from  tlie  tnucooB 
membrano ;  and  more  rarely,  fibrous,  fibro-ccllular,  fatty,  omoo- 
CnrtilBgiiiciuB,  uiid  muHgiiniit  tuinuurn.  A  hydatid  also  in  ono  of  the 
ventricles  of  the  larjTis;  has  been  known  to  project  so  &r  into  Hat 
cavity  as  t«  prndufo  the  syiiipM>m»  uf «  forfign  ixidv.  TTi©  fbrm 
and  size  of  those  tumours  are  vorj-  variable ;  and  in  situation  tliejr 
vary  also,  hut  by  fiy  tho  grc^ator  nunibCT  arc  uttachod  to  a  limited 
part  of  the  larvnx  alxitv  tlio  glottis,  generally  in  the  immodiaM 
RCigiilKiurlioiid  of  the  voi.'al  cords,  muri;  rarely  ut  tlie  aido  or 
of  the  epiglottis. 

lln:  goiieral  tiyniptoin*  jiroduced  l)j-  tlic»0  growtJia  Bo  n 
resemble  those  of  ehronic  disenseft  wf  tlie  laryns,  that,  in  order 
avoid  repetition,  tli«  reader  must  be  referred  to  tlial  soclion. 
intensity  and  promineiico  of  individual  symptoms  will  depend 
the  .-size  and  situation  of  the  tumour.  Thus,  thu  nearer  tJiit  iiniioiff 
is  aituatcd  to  the  voo^  cords,  the  more  will  the  voice  be  interjiirod 
with.  lii-^jiirntiiiu  is  tdways  alTected,  being  somctiinoit  ntiended 
with  a  peouhar  wtiei-ziug ;  ut  other  timot  tliere  ore  occasional  attacks 
of  severe  dyspna-a,  witii  intervals  of  complete  tnao.  In  nearly  alt 
cases  the  dyiipna>a,  tliough  flight  nt  UrM,  alcadily  increases,  and  it 
Boon  followed  by  siiS'ocaLivo  attacks.  The  symptoms  ore  not  i.ic|UalIj^ 
well  marked  in  every  case,  nor  are  they  all  invariably  present;  the 
most  conetant  sj-mptonu  are  alteration  oflhet'oicc  and  dy^t: 
llnfortunutely  tJiem  are  soldoui  any  churaeterintic  signs  by  w 
the  presence  of  a  tmnour  can  be  detected.  In  a  case  of  faOy  j 
dulouH  ttnnour  of  the  plinrynx  and  lnr}'iix  recorded  by  }Ir.  Uolt 
tho  Sth  volume  of  die  J'allioUyioil  'J'ransaetlotta,  die  presence 
tutiuiitr  was  eertjiio,  from  die  fact  of  tho  patient,  four  years 
lus  deaUi,  during  the  act  of  vomiting,  protrudhig  a  largo 
which  he  was  obliged  to  return  as  *i)eedily  iv  possible  to  pi 
imniDiliate  suffocation.  In  a  case  recorded  by  Dr.  Huwkcsier 
the  ytli  vohime  of  Uic  same  Transactions,  the  preJt^ioe  of 
characteristic  cell-forms  in  the  sputa,  together  with  enlargeinwit 
the  Ij-mphutie  glauds  in  the  neighbourhood  of  tlie  larynx,  ap; 


bofa 


•  Namely.  (11  by  Ehrmann ;  9  by  Dr.  Homee  Gre*n ;  1  by  Dr.  W« 
6  in  till-  Paih.  Sob.  Traru.;  1  in  the  Med.Vkir.  'Iran*.;  autl  1  iu  ilic  k 
of  SL  Geui'jjcB  llusiiitul. 


TUMOURS. 


237 


!  M  to  thfi  oonHii^irtn,  prior  to  tleAtli,  Hmt  tiw  sfTiK-fifm  was 

alignant  nature ;  and  it  ^oinctimos  happens  that  portionH  of 

tommr  arft  cjwAoil  wilh  tlio  flxjwyTtoration  ;  lliis  hiu  ocmirrod  in 

casm,  afTording  in  each  the  most  certain  s!;^  of  the  preaenoo 

,  lomdiir.      In  »  (.-aiW  rulntctl  bv  Olto,  tlitt  putiont  (>jwfnl  inassos 

of  the  nunonr  on  three  different  occasions;  and  it  was  this  Dircam- 

■tatica  in  the  cmo  rdatod  hy  Khrmann  that  M  )iini  t^i  jwrfcirm  an 

apenldan  for  the  removal  of  the  growth.     Sometimes  the  tumour 

OM^  ho  Mvn,  and  ooca»toniillj  it  can  ite/fll,  on  vxaminin;;  tho  larynx ; 

to  that  in  aD  cases  in  which  such  a  growth  is  suspected,  the  larynst 

ihmild  be  narrowlj-  cxaminwl  by  ttn^  liirynKiiHCDpo  anil  by  the  finger. 

Dr.  Horace  Green  ha»  in  two  cases  been  able  to  detect  by  sight  tlw 

praenco  of  a  polypus  in  the  larynx,  in  one  iif  which  tho  growtli 

vu  soooefuftilly  removed ;  and  M.  Uoux  detected  the  jiresenoe  "f 

1  jjmwth  by  introducing  the  finger  into  the  month  of  tho  patient. 

Sometimes,  indeed,  tlie  tumour  may  he  Kmrd  or  /-/( to  irwiy  in  tho 

I    Wrnx;  in  the  case  sueccssfhllr  o|H;ni1ed  upon  by  Ehnnann,  the 

ptient  vfia  able  to  imitate  the  sound  of  a  valvo  opening  and  nbut- 

fing  by  a  rapid  movement  of  inspiration  and  expiration. 

Warty  growths  from  llw  mucous  membrane  of  the  larynx  gene- 

nly  aasonte  the  form  of  small  hranchi-d  cxercsconccs,  consisting 

Muly  of  cpitheliMm  an<i  n  liltlts  fibrinous  and  granular  matter. 

IWy  nanally  arise  from  tho  vocal  cor<is  on  one  or  both  sides,  and 

■■ctiDies  BDiaOor  exeroaoencc!*  itra  nwt  with,  springing  from  tlio 

kigttoimDg  mucous  ntembrane  and  from  tho  root  of  the  epiglottia. 

M<»  excrcsconocs  form  one  or  more  large  petlnnculiitol  inastes, 

•K4  fil!  up  the  apper  part  of  the  larynx,  and  almost  completely 

I  die  ritna.     The  affection  would  apijcnr  at  ihw.%  ti>  Ixt  c-ongiv 

fcr  caaea  of  it  arc  recorded  in  wliich  dyspiirea  had  existed 

I  birth.     Death  is  generally  nuddi^n,  and  taken  pbict'  dnring  an 

:of  »pasmodiodYspn<eu.     Tho  fretiucncy  of  tho  affection  at  an 

•rtf  period  of  life,  tho  longth  of  time  during  which  tho  symptoms 

■••  ext*tail,  the  total  failure  of  all  remcdic-s,  and  the  absence  of 

■By  of  the  signs  peculiar  to  otbor  aftV^ctions  of  iIk-  larynx,  may 

W  to  the  tonnotiou  of  a  correct  dia^iosia.     Deglutition  is  seldom 

■Wued  with. 

All  moiicinal  nsnodjc*  have  been  found  useless.  Tho  only 
•win  which  life  can  he  prolonged  is  by  o|K*ning  tho  air-pawage, 
Uiiaa  operation  i»  ix-surti-d  to,  the  patient  may  probably  live  for 
■ftral  veara,  breathing  through  a  tuljo,  U\'1and  rivirds  an  in- 
Mntw  of  this  diseaao  in  which  laryngotomy  was  performed ;  the 
Ikjnil  cartilage  being  tJien  dividwt  from  top  to  bottom,  die  larynx 


338 


DISEASES  OF  THE  LARYNX. 


was  ftiund  full  of  warty  exoreacenoen ;  they  were  cauteriaed  wit 
the  uitnitu  of  Dictrcury,  atid  afWrwards  with  «  liot  iron,  but  thu 
conlinuotl  to  grow.     The  reault  of  the  case  in  not  mentioned. 

In  a  case  recorded  by  Professor  Ehnnanii,  a  woman  a^^  tliirty-"' 
tliree,  who  niitfonHl  from  all  die  aym]>toma  of  a  tuinoiir  witiiin  die 
Iniynx,  was  seized  with  a  fit  of  almost  fatal  suffocation ;  travhootomj 
was  porforiiKxl,  and  on  tlie  following  day  the  iiK^inion  wan  extende 
apwanls  through  dio  junction  of  the  ala>  of  th(?  thyroid  cartila^ 
and  •  oaulifluwer  cxcreacenoe  removed  from  the  left  vocal  cord>| 
The  patient  rocoverod,  with  loss  of  voice     Seven  montlis  aAcr,  th 
wuuiiin  hIl^'ing  tlied  of  ty]ihoid  fe\'er,  the  tumour  was  found  ji 
commencing  to  sprout  again. 

Ilia  thii-dcaHe,  which  came  nmler  the  eareof  Dr.  Honu'e  Green, ' 
the  passage  of  a  small  spongo  probang  satiu-ated  with  a  solution  of 
nitrate  of  nitver,  and  |ias!UKl  tlirough  ttio  glottis  at  certain  itilervals, 
detached  tlie  growths  and  effected  a  complete  cure. 

A  few  cases  have  been  recunled  of  pendulous  tuinouni  growing 
from  the  ptiarynx  and  lar'rnx,  and  interfering  with  the  fiinetjoo  of 
both  thcHO  pai-U.    bi  Mr.  lii)lt's  ea»e,  a  brge  [k-iuIuIoiu  fatty  tumour 
was  detected  filling  the  pharyn.x,  and  roacliing  down  the  atsophagna 
to  the  extent  nf  nine  inches,  attjiched  by  an  envelojie  ofmuc 
membrane  and  fibrous  tissue  to  the  loft  sido  of  tho  epiglottis,  i 
ing  it  down  and  to  die  left  ^de,  so  as  entirely  tu  prevent  ]« 
closure  of  the  larj-nx ;  and  in  Dr.  Arrowsmidi's  case,  a  freely  mor- 
nblo  lobulateil  tumour,  about  thu  s'uo  of  a  waluut  and  of  oellulai, 
texture,  was  discovoi-ed  hanging  by  a  naiTow  pedicle  from  tho  com'> 
nencenient  of  the  Q?.snphagus  immediately  buliind  the  gluttin.*     Thia 
tiunour  not  oidy  obstructed  the  oesophagus,  but,  by  passing  undcrl 
tho  epiglottis  (luring  attempts  to  swallow,  prevented  tho  el<i«un! 
the  glottis,  and  tlius  allowed  fluids  to  pass  into  the  trachea.     Th 
main  symptoms  in  both  of  these  cases  were  nt  first  un  occawiona 
and  then  increasing  sensation  of  choking,  difHcul^  of  deglutitKKli] 
gradually  becoming  more  severe,  and  each  att^^'mpt  aucomjianii-d  bj 
much  spasm  of  the  glottis  and  great  dyspncea,  frequent  and  at  limef] 
•uvcre  cough  excited  by  attempts  to  swallow,  with  eopious  frotlij' I 
expectoration,  and  occasional  huskiness  of  the  voioe.    In  Dr.  Arrow-j 
smith's  ease  d^ith  occurred  from  inanition;  and  in  Mr.  Holt's  froa 
displacement  of  the  growth,  by  which  suffocadon  was  induced. 
diagnosis  in  such  eases  may  be  aitsisli'd  by  careful  exnniinatioD  ■ 
die  back  of  die  throat;  the  mouth  should  lio  widely  o|>eued, 


»  M»d.ChiT.  Trant,  voL  ; 


^tM^ne  draw 


HYSTERICAL  AFFECTIONS.  S89 


drawn  weQ  rorwardii,  and  the  tn(l<>x  finger  psMed  behind 

tbe  epi|^oitti»  i^uHicicntly  &r  to  SAL-ortain  the  presence  of  a  polypna. 

TrealHifTtl.    If  the  existenee  of  a  timiour  iit  (lvt«ct<.yl,  »»rgical 

b  iiD[>i*nitiv(rV  demandvd,  to  nvokl  imjxiniliii;;  <<aB'o(ntion  from 

PHt  of  (he  tumour,  an<t  to  {in-vent  doiUi  fnini  ninititioii. 

tlM^  tuinoar  is  attAclR'd  to  the  sidi-s  of  the  epiglottis  or  back 

"the  Un'nx,  it  muy  be  rauKived  hy  die  kiiifi'  or  enrisitrtr*,"  or  ii 

■btro  nuiy  ho  paseed  round  its  bow ;  hut  before  its  removal  ia 

attempted,  tlie  {iropriety  of  securing  free  rettpirittioii  by  opening  tlia 

windpipe  sltonld  bo  eon«idercd.     When  the  ttunoiir  arises  within  tho 

Ur^mx,  both  tlie  dingiifliUH  uid  treutiiient  pninciit  more  diflieulty. 

If,  howm'cr,  the  Burgoon  is  fortunate  enough  to  satisfy  himself 

without  doubt  of  the  exutlence  of  u  t.uini>ur  in  thiii  locality,  ita 

tvuM'vnl  may  be  attempted  by  freely  laying  open  tlio  cavity  of  tho 

khiynx.     The  operation  in  doublle-tH  n  hazunlotia  one ;  but  an  long 

I M  tiw  tumour  remains,  the  patient  is  in  constant  danger  of  death 

fom  aaffi>catien.     Wh<3i  the  larynx  is  a^c-otod  willi  uctlt^'iiaiil  ilin- 

(ws,  in  whieh  case  the  parts  in  tho  neighbourhood  arc  usually 

,  Bfiknied  and  the  neighbouring  glaiuU  uO'iteted  (whieh  circuni- 

itnen,  tQge4her  with  the  character  of  tJio  sputa  and  tho  consti- 

litimal  eaelkexia,  will  aa^int  tlie  Siirgeen  to  form  a  (liagnoxiit), 

tncbeetoiny  Is  justifiable  in  order  to  prolong  life.     Mr.  Curlingf 

tht*  (^wnitioii  in  a  eJise  of  epitheliouiii  of  the  luryiix, 

the  patient  hvod  for  a  year  aftentards,  and  the  relief  for  a 

Ivas  <rcry  Mriking;  aiiit  Mr.  WurdJ  adopted  the  same  cour»o 

UuioiW  case  with  marked  beuotit. 

Htstebical  AFFnmoss  or  the  Laryvx. 

I  are  certain  aBoction^  of  the  larj-nx  not  unfrcqn<mtly  met 
*illi  b  hysterical  tiubjei-ts,  tlu;  Hvinptuiii.*  of  vrhieh  nxjuii-e  to  bo 
■■tiuDod,  as  they  are  liable  to  be  mistaken  for  those  of  moro 
|>w*  diMioKex.  In  the  firtit  of  thune  tho  uuiwlo.i  of  the  hu^-nx  ara 
■^i^y  irritable,  and  present  a  coiiHtant  disposition  to  spasms.  A 
Qilitit  jMntxvKin  of  ilti'piiu'si  conii-M  on  siiddoidy,  or  It  may  b6 
imdrd  br  a  long-continuo<l  and  con^niUivc  congh,  and  followed 
n  tbe  ■triiluloiiH  bfieathing  peculiiu*  to  iiiHammation  of  the  larynx, 
w  ilripiMPa  being  m  sevoi-e  as  to  threaten  snilbeation.  Such  a 
("noj-nn  may  ucmliuiio  fur  two  or  three  lumni,  and  occoaiotially 


E 


Thin  AfierMieti  vits  Micersafull}'  perronueii  b}'  M.  Laugier,  Itirt.  dtt 
Ptik.  Stx.  Trail*.  «uL  Ix.  p.  39.  I  Ibid.  vol.  x.  p.  M. 


S40 


DISEASES  OF  THE  LARYNX 


torminatcA  in  nn  onliimrj-  liy*1*>ri«al  fit,     TiiU  iiffwlton  is  not 
oonimon  iii  young  hystorieal  fotnalcs,  and  the  dvspiicea  ivliich  attend 
the  iitturkit  IK  s»  Hluriniii;;,  tliut  Inicheotnniy  litis  not  ODfroquontl^ 
been  perfonnotl  for  ita  roliof,  from  the  supposition  that  the  ai-nipJ 
tomK  ilcpctiiltil  nn  inftKiniiintlfni.     An  iiiterMting  case  of  this  kin(I_ 
has  boeii  reeoi-ded  by  Dr.  Watson.*     Another  esse  ia  related 
Ilylanti,  in  whii'h  diingpr  from  itiifrncntiuii  soomed  imminont, 
the  operation  was  commenced ;  but  before  it  ooold  be  coiuplet 
all  tifjni  i»f  obstnii-ted  res|urntion  ilisHp|H'nrod. 

The  peculiar  parosyBma!  nature  of  tlie  attacks,  the  ahiwnce 
fcvcr  aiid  of  pain  and  soreness  in  the  region  of  tli«  Isri'nx,  witli 
cnrefiil  attention  to  the  history  and  progress  of  tlie  disease^  will 
Boldum  fail  to  loud  tn  a  oornv;!  dingnosis.  The  gonoral  treatment 
of  hysteria  should  be  adopted,  and  reourreaioe  of  the  attacks  should 
bo  [ir«vciito(l  by  iinpriiviii;»  the  general  liealtli,  and  by  the  nw 
of  remedies  calculated  to  corrsot  any  disorder  of  the  moustnud 
function. 

Another  affection  of  the  larrnx,  which  not  iinfre^jnently  ocears 
in  liy»t«ric(d  i<ubjuc1«,  consist*  in  lU'ficicncy  or  total  low  of  ncrrDui 
power  in  the  raUBoles  of  the  lai'yns,  which  produeca  temporary  lots 
of  voice — aplionia.  It  oei.-wr>  most  froquvntly  in  young  hys 
females,  is  unattended  by  any  symptoms  of  inflammation  or 
apparent  disease  of  tlie  larynx,  and  appears  to  be  dependent 
great  debility,  irregular  or  disordered  menstruation,  or  exoessit 
exorcise  of  the  vocal  orgaiin  in  a  debtlitatod  constitution.  " ' 
afleotion,"  observes  Sir  Benjamin  Brodie,t  "  takes  plaoa  nuddenlj 
continues  often  for  many  montlis,  even  for  one  or  two  yoam,  and  I 
(liHap[>earH  as  suddenly  as  it  began.  A  patient  thus  aifected 
when  under  the  influence  of  strong  mental  excitement,  find  licr 
apeaking  in  her  natural  voice,  when  for  some  time  before  slw 
spoken  only  In  a  w)ii«per.  Her  recovery  may  bo  pcrnmuent, 
she  may  relapse  into  her  former  condition."  And  again  lliis  dis- 
tinguished aullior  observes :  "  Tins  affection  is  not  unfrequentV 
mot  with  in  the  male  sex,  osiiocially  in  tlio.ie  i)f  the  cli-ricsi)  pro- 
fession, probably  because  tlicy  often  lead  very  sedentary  lives, 
also  becuuse  in  their  profession  they  oi-e  e«Ile<i  «i]n>n  to  ^pcak 
public  ill  a  tone  raised  above  tlio  ordinary  standard."  This 
of  aphonia  may  bo  distinguislied  fi-om  that  ro.tidiing  from  citr 
disease  of  the  larynx,  by  tlie  suddenness  of  the  attack,  and 


♦  LectuTtf  on  the  I'rinripJf*  and  Prtulice  of  Ph}fne,  vol.  i.  p.  C8B. 
t  Leclurtt  on  certain  Lucal  Nervoui  Ai^ietitmt,  p.  Al. 


SPASM  OF  THE  GLOTTIS. 


241 


octaakuftt  temporar)'  return  of  tbe  Toioe  nnder  stroiig  monlal  rx- 
ctteatmt;  by  tlw  lii»tor}'  uf  ibe  ctum,  and  tho  abscnco  of  pain  and 
other  aigns  of  disease. 

Tbe  treatment  inu»t  be  rnriod  according  to  oinmmstanoee.  The 
gOBenl  hunltli  .«hould  be  attended  to,  aiul  the  fiinctioiiti  of  any 
origan  that  appears  dcrun^d  eliould  bo  roctifiod.  Tonics,  tho 
»bow«r-b«tb,  and  horee  excivifte,  are  Ote  conHltliilional  mi^iiiiH  mnist 
Hkel/  to  bo  beneficial.  Trotunoau  etroiigly  advocates  cauterising 
tin  pbar}-nx  and  upper  part  of  the  larynx  with  a  tttronfr  (Solution 
of  tbe  nitrate  of  sQv-er.  Blisters,  i»8uc»,  gnlvaniiim,  and  electricity 
bare  vacb  frequently  been  suuceeuful,  and  a«  lre<iuentJy  tiiiletl  to 
iffiml  anv  relief. 


I 


Spasm  of  the  Glottis. 

"Dip  Sai^con  iit  occaaionally  summoned  to  a  patient  having  all 

4n  nrnptonts  of  impending  KufTocation,  and  ia  probably  told  that 

IKriocu  to   lh«  attitck   the  patietil  wnn  p(!rfc<it1y   wi^ll  ;   tlial  the 

ttack  wa«  sudden;  and  if  ho  is  not  abeady  moribund,  it  may  hai« 

nlui'led,  io  Uial  ho  itiitli-nt  littJe  or  no  ineonvenienco :  it  may  be 

ibft  the  patient  lias  suffered  slipht  occasional  paroxysmH  of  dys- 

lUafor  several  yvar*,  aiToinjiaiiiod  with  wmgh,  pain,  an<l  a  m«»c 

'IfontAriction  abont  the  chest,  and  otlior  symptoms  indicating  tlio- 

diuaae;  tl»e  pnwMit  atlnek  iming  merrly  an  ugpravatod  form 

oomptaint.     If  wo  exclude  those  affections  of  tho  longs  and 

tlic  bcait  and  p«rieardium,  in  which  dj-vipnoca  i^  a  promi- 

symptom,  as  well  as  cases  of  difSeuU  breatliing  produced  by 

fnteoDO  of  abdominal  tumour  or  lu^cilei,  wo  find  that  dyMpntva, 

■Mnnpanied  often  by  spasm  of  tlie  mnscles  of  tlie  glottis,  may  ho 

jnJaoed  by,  Ist,  tiK  prewurc  of  tumours  upon  some  pnrt  of  tho 

tube;  2d,  irritation  of  tJie  nervca  dislril>uted  to  tho 

;  3d,  some  source  of  local  irritation  in  tho  nclghbourhooil 

organ,  fcnch  aa  foreign  l>odieKf  or  inflammation,  or  ulcera- 

•w  of  tbe   larynx.     TIw   most  common   forms   of  intni -thoracic 

haoimi,  wliicli  (iroduoe  ^lyitpnu^  I>y  compreMirig  the  lower  part  of 

k  trachea  and  brrinchi,  are,  thoracic  aneurisms  and  enlargement 

<fli«  bronehial  glumU  from  stnimoiiH  deposit.,  oaneer,  or  commnii 

^Tfcrtrophv.      I>,-sp»u.>a  may  also  arise  from  enlargement  of  tho 

MricaJ   hiuphntic  glainln,  or   from   enhu-gement  of  the   thyroid 

^ad,  compressing  and  displacing  tbe  travlK^-i  or  larynx.      Irrl- 

Uhu  of  the  trunks  or  branehas  of  the  nerves  diiitribiited  to  the 

^vi  may  produce  tlie  same  symptoms.     A  few  yoars  since,  a 

foe  tu.  fi 


S4S 


DISEASES  OF  THE  LABYNS. 


pattont  Ai&\  in  St.  Oeorgo'a  Qospital,  who,  some  davs  previona  to 
her  death  suft'crod  from  much  spasmodic  aflftwtion  of  tlio  glottis, 
producod  appuniiitly  by  HFiisinn  of  n  liirge  inatut  of  lymph  aroum 
the  roots  of  the  eighth  pair  of  nerves  nt  the  base  of  the  brain,  tbs 
larynx  boing  fi>iiii<l  nftvr  dciitb  qwit*;  healtby.     A  lumotir  in  the 
cotirso  of  the  laryngeal  nerves  may  press  upon  tliom,  and  give  rise 
to  similar  cymptoms.     I>r.  Biidd  has  liitijiy  rocijnUil  an    iiwtuii<« 
of  dijath  from  dyapnira,  occasioneci  by  the  growth  of  a  eanoerons 
tumour  in  tho   groove  l>etween  tlio  trachea  and  cc«opbagiut,  wii 
probable  destruction  of  the  left  i-eomrent  nerve ;"   and  instances 
arc  by  no  iduuis  nitcommon  of  aneurism  of  tho  aorta  or  innomi- 
niite  artery  prodnoing  spasm  of  the  glottis,   by  implicating  tfavj 
rrciirrwit  Inryng^yd  n^-rvcs  where  tht-y  Uo  noor  these  vesael*.     In- 
atiinces  of  local   irritation   in   the   neighbourhood   of  the   larynx, 
producing  »pii«m,  are  scon  in  some  cases  where  a  foreign  body  il 
impacted  in  the  np|>er  part  of  tJie  a-sophagus,  or  where  inflam- 
mation or  abfKXwa  exists  in  the  immediate  vicinity  of  the  lar}-nx. 
It  becomes,  then,  a  matter  of  great  im]M>rtance  for  the  Sur] 
to  uxaminu  narrowly  into  every  case  in  which  he  may  ho  coUwl  ta 
relieve  dyapna-a  and  iin|>endiug  siill'oeatioti.      I   liuve  known 
ojKTation  of  Inryngoloniy  resorted  to,  to  relieve  dyspno^  depviid 
ing  on  np|)arent  lar\-ngca]  digcnse,  but  in  which,  after  death^  t! 
larytLX  was  foiuid  hoidthy,  and  the  difficulty  of  breathing  depcndi 
on  pneumonia.     A  cjiretiil  examination  of  tho  che»t  ttliould  in 
case  be  made ;  and  if  thoracic  disease  is  detected,  no  siu'gical  int 
feience  ia  of  any  avail.     If  it  is  possible  to  remove  tho  local 
vhich  produces  tho  spasm,  this  should  at  once  be  done:  if 
■lis(!i?s»  exist,  it  may  Iw  opened ;  if  a  foreign  body  is  impacted  ii 
tlic  pharynx  or  ccsophiigus,  it  eJiould  he  removed.     If  the  symptoi 
arise  from  the  prtwsurc  of  a  tinnour  irritatiiig  tho  larjmgcal  ncrvi 
tho  dj-ajmoja  is  probably  intermittent.      Tho  opt^ratlon  of  iraob 
tomy  is  justifiable,  if  even  only  temjiorury  relief  is  aAurdod; 
wlicTO  tho  tmnour  is  targe,  and  the  dysjmoea  contJiniouA  and  p) 
ducod  by  ita  compressing  and  contracting  tho  nir-passago,  thoro  i 
BO  ho})e  ta  bo  entertained  from  any  surgical  tntorference,  and 
operative  measures  are  juati liable. | 


*  Path.  Trant..  vol.  x.  p.  02. 

f  1  leave  thin  stutemmit  as  my  late  frieDcI  wrnte  it;  but  he  would] 
\>eXi\y  ]iavo  nioiliflod  it.  hud  hi'  lived  to  give  the  final  revision  to  fatti 
ttri'ipt, — SO  fur,  at  aaj'  rati!,  «s  to  Huy  tjiut  wti<u  d.v>>])ii(ta  in  oooaiuoRrd  ' 
prcasure  of  an  cukirgeil  tliyivid  body,  it  is  quili.-  juatifiublc  to  divide 


CHRONIC  LABTNGITIS.  243 


COROirio  Imfiauuation  op  the  Lartkx. 

Tlw  s^TnptoDia  nn<l  effocta  of  thU  dineiuto  vary  ac«nr<litig  lo 
exact  seat  of  tbo  iiiflainimilion,  its  extent,  snd  tlie  cuni^tiLutioii 
ilw  pativnL  In  some  ciuch  the  infliimtnfttion  is  slight,  tlio  local 
tn^CH  triHin;;,  iind  l[i«  symptama  soon  Biibstde.  Probably  niioli  a 
idrurniof'!utlammi)tiuii<rxii>tJ4  in  luiuiy  of  llio  ciiscaof  tlio  aphonia 
miy  tUtulod  to  u  attacking  olerg)'men  and  other  public  speakers 
eaogers.  In  tiieae  oiue<t,  liowvvcr,  (ho  uHbcliim  is  only  n  l«m- 
nnr  inc»nvvtiii'nce,  and  oitlier  subHidos  spontaneously,  or  the 
Ueet  tTBatmeiit  suiRoos  for  ita  cure.  Amrm;;;  cci-tainof  tlio  ]>oorer 
n-lio  are  much  exposed  to  cnlil  and  dainp  (c  g.  waslier- 
(taen)  and  indulge  immodorately  in  ardent  spiritM,  niid  in  NtrvuL- 
:cn  who  are  constantly  straining  Uie  voioe,  tlie  symptoms  are 
permanent ;  tlioro  in  oonfirmod  hourscnoMt  or  jp-ciit  inijMirfoo 
of  tlic  voii-e,  and  further  local  t-hangai  and  nioiv  sovero  syinp- 
I  arc  UabU  u>  occur.  But  tlio  more  sovcro  forms  of  clirouio 
^^otis  are  found  in  patients  who  suftor  from  otlier  afl'ections  of 
^^^oat,  iui  follicular  diiu.'aso,  or  whoso  constitution  is  shatttTcd 
jj'plulis,  by  tlie  use  of  mercury,  or  hy  struma.  In  all  these 
m  tLu  BjTnptoms  are  slow  and  very  iimidioua,  and  the  laiynx  is 
impttrubly  (binia^^l.  The  patirnt  at  (iret  complains  of  hmirso- 
and  a  siMise  of  dryness  in  the  throat,  usually  referred  to  cold, 
in  and  Mirt'neM  in  tliu  region  of  the  larynx,  and  tcn<lerness  on 
',  cume  on,  willi  sliort  dry  oough  and  mucous  expectoration, 
m  a  diktroMing  scnso  of  OQBstrictton  is  experienced  nt  the  u[ipur 
rt  of  tlie  larynx,  inspiration  bcoomoH  difHcult  and  niridulous,  the 
a  liwt,  cou^h  is  constant  and  sometimes  attended  with  spas- 
iljapnoea,  and  Aoreneeui  of  the  tliroat  i»  somotimeti  complained 
vHraif  <m  examination,  ulceration  may  be  detoetod  about  tlio  soft 
kit,  or,  by  deprostng  the  tongue  and  drawing  it  well  forwards, 
ihm  ba«u  of  the  epiglottis.  In  protracted  eases  the  patient  »ink*, 
liar  tlio  cututant  vuugli  and  profuse  ex[>octoraliun,  into  a  hoetic 
nfition. 

Hm  rmt«  of  progrcM  ofclironic  laryngitis  varies  considerably. 
lbs  notes  of  two  cases  now  before  rae,  I  find  that  the  iiatieuta 


■n  order  to  open  tbc  trachea.  A  remiifltsblo  ewe.  in  which  not  only 
iras  priirrvcii,  but  the  onlariirmcnt  of  the  ibyivitl  gradually  diHappearad, 
ibSMi  by  Mr.  Bo'ont  in  liis  CliHieal  Surgery.  Sev  also  Di»asbs  o>  rax 
iiD  Bour.    Editor. 


244  DISEASES  OF  THE  LARYNX. 


.1.:!,.  :_V 


old 


died  within  wiven  vroek*  from  the  onset  of  t]io  !iyin|itoin!<,  whilo  in 
others  the  diM^aso  lia«  lasted  for  several  years.     TIte  affoclion  is 
far  more  coitinKni  wmii  attitr  jiiilK>rty  than  eilhor  in  early  lifo  or  old 
nge,  thoiiyli  hardly  any  period  of  lifo  is  exempt  from  it.     Tlnis, 
55  cases  in  the  roconU  «f  St.  George'»  Ho^pidil,  3  owiirreil  liefo 
tiie  Age  of  IG,  34  between  20  and  40  years,  15  between  40  and 
years,  and  3  between  iid  ami  70  year*  of  age.     It  i»  remarkable 
that  III)  the  patients  eseept  nine  were  males. 

Tile  local  clmiipox  productil  in  the  lar\Tix  by  elironic  inflam- 
mation art>  lis  follows :  In  the  early  stages  increased  vascularity  ofH 
the  mucouB  membrane,  witli  ctTuKJon  of  lyntjih  in  the  8ubmtieoii^| 
tis!«ne,  are  wiid  to  he  the  only  reeognisable  ehanges^  Later  on,  and 
Cipofirtlty  in  the  simple  form  which  ooenrB  from  exposure  to  cold  or 
fiiini  ^tr:iiniiifj  the  voice,  the  lingual  surface  of  the  epighiltiit  anil 
the  folds  which  surround  the  up|)er  orifice  of  the  larA'nx  are  said  to 
become  pi-rmaneiitly  thickened  from  tJic  organisation  of  thocfliintd 
lymph,  and  their  free  suriaco  rough  and  granidar.  But  in  most 
cases,  especially  in  phlliisical  ciilijects,  ulceration  takes  placi;  hot' 
in  the  larjnix  and  on  the  base  of  tJie  tongue,  the  fauces,  and  tonsils 
tubercle  Wing  also  occasionally  found  beneath  the  miicons  mail' 
branc.  Tliis  ulceration  may  be  extensive  or  limited,  and  in  thi 
latter  e^iae  its  position  scrvcit  to  explain  the  syin[)tom»  imtj 
during  life.  Tlie  moat  common  situation  of  limited  ulceration 
over  the  vocal  conls.  Tills  lesion  is  found  in  more  than  lialftlu 
cases  examined,  and  aceouniA  for  the  hoarseness  and  njihonia  sO' 
common  in  these  aflcctions.  Tlic  next  most  common  sc^t  of  ulcon 
tion  is  in  the  cavity  of  the  larynx  or  on  tlie  epiglottis  (usuhIIv  its 
laryngeal  surface);  and  tills  is  fuimd  in  rather  le^s  than  half  lL« 
number  of  cns.ci  examine<t.  Tlio  epiglottia  is  oneti  rendered 
rigid  as  to  be  nearly  immovable.  Ulceration  sbont  the  fauces  nm 
epiglottis  causes  jiain  in  swallowing,  and  a  tendency  for  the  fi)i>ii  t 
pass  intn  the  air-passages.  Ulceration  is  found  in  the  trachea  in 
rather  more  thiin  »  Iburtli  of  the  cases;  while  the  cartilages  oftli9 
larynx  are  afieeted  (i.  e.  either  ex|KJsed  by  ulceration,  carious,  of 
necrosed)  in  nearly  one-fourth  of  the  cases,  the  thyroid  and  ary- 
ticnoid  tieing  those  roost  freqncntly  involved.*  Sometimei  tlw? 
ul<i-riilion  |)enetratos  from  the  interior  of  the  larj-nx  thnmgh  tlw 
cartilage,  and  communicates  with  the  cellular  tissue  of  the  nock. 
Ulceration  in  the  cavity  of  the  larynx,  or  cariiis  and  necrosia 


•  IauU  ntates  that  out  of  nil  aitses  of  phUiisis,  u1c«ratJon  of  tLe  luTtuJ 
oooure  la  about  ou«>-fuun,li. 


CHBOKIC  LABYNGinS. 


246 


U  nsaaOy  associated  with  gr«at  pain,  referrod  to  tho 
\uyia.' 

I  IHoffnona.  Sir.  Porter  says  that  it  is  sometimes  ditHcuH  to 
BbttnguiMli  the  inil<ler  funna  orclirunic  laryoi^itia  from  bronchitis. 
I  latter  affection,  Iwwever,  is  usually  ushered  in  hv  titbrih:  -iyiii|)- 
!»,  gn^  oppmmion  of  tliv  ditwt,  diRicultr  in  taking  a  dcK-p  breath, 
palpitation  or  other  irregular  actioii  of  the  heurt.  Fruni  dironiu 
)>ilitU  ihu  nffLMtiuii  in  quc»lion  is  easily  distiDgiiisIied  by  cxa- 
ling  the  fauces,  and  by  the  absence  of  oough  and  pfosenco  of 
in  vnhirgrmrot  of  tliv  tonsils.  In  hysterical  aScctions 
I  aliMtiee  of  pain  in  the  Iur_\n)x,  ilio  history  of  the  oatto,  ami  tlie 
Dcml  nppvanuico  oftho  patiuiit,  will  usually  lead  to  a  correct 
js,  which  will  ofl^n  be  i^)nverted  ititi.)  a  certaintv  bv  the 
*c  mum  of  tlii>  voice  under  cxcitoincnt.  Tho  dia;^iusis  of 
has  been  aJrfady  ilwclt  on.  A\'lien  cha  nature  of  tlie  alt'ec> 
I  has  been  decided  on,  tho  next  point  is  to  ascertain  its  cause,  in 
to  comI>at  die  eoiiHtitutJonal  cjich<;xiii  wiikli  iiiiiy  In>  prtisunt. 
qrnptonis  should  also  be  carefully  obsenod,  so  tliat  a  correct 
NioD  nay  be  drawn  iu>  to  thti  xitiiutkni  iind  extent  of  the 
action,  and  it  should  bo  ascertained  whether,  and  to  what 
tike  Inn^  an>  oirtM-ted.  t.'n.-H'n  dt>  uecIl.^iotlIlliy,  but  ver}' 
Bwir,  oceur  of  n-ell-niarkixl  strumous  ulceration  of  tlio  larynx  not 
I  nKinied  willi  tho  dejKMition  of  tubercle  elsewhere 

Trtalmtnt.      In  those  cases  where  tlie  atfection  arises  from  ex- 

jwnre  tocnld,  and  in  probably  limiivd  to  intlainniatory  thickening 

^thi  membrane,  ioHammation  shoidd  be  arretted  and  absorption 

l.^maled.     Tho  Urj-nx  should  bo  kept  at  jK-rfcet  rust,  strict  silence 

rvald  be  enjoined,  cuunter-irritation  at  tlie  nape  of  tlie  neck  or 

iffv  part  of  tho  chest  may  bo  used,  and  mercury  in  small  doses 

[itfU  be  administered.     As  a  local  renn^y,  tiie  inhaliituin  of  tlie 

I  of  Iiot  water  is  of  groat  service.     Those  rcinolics  sol*  loui  fail 

kiflbnl  complete  relief  if  the  disease  is  not  neglected,  and  the  voice 


•  lJ]«0«li(Mi  of  the  UnolKB  >oni«time«  uooun  from  ihe  prvvaure  And 

an  of  dlscuod  nUnd*  iu  iu  tici),'Iihoiirho(>d.    A  iiusu  will  bo  Sounii 

1  by  Dr.  J.  W.  Oxlc  >>>  tliu  ^oJA.  Soe.  Trant..  18567.  p.  mi;  aad  aii- 

'  of  a  aonewltal  iliffumnt  cluuuctur  by  l>r.  TJeo  in  tlio  SOtli  vol.  of  the 

Ur.  TVua*.     More  tluin  oae  bns   rec<-iitly  occurtvd   at  HI.  Goorgc's 

The  oonaidimlion,  howtivcr,  of  ibis  ■□mciwtiat  lum  aDVctioa 

rpropcrly  bcjoogs  to  th«  phyaiulan.    Here  it  will  bo  cni>U(]b  to  sny  that 

I  (TaipUMB*  rcMBlbla  those  «f  Muup  to  a  cei-tain  extant,  but  tlterc  is  do 

fever.     Lt  will  W  rvnieiu tiered  that  u  broncliidi  gland  slough- 

into  tb«  U^vhca  Us«  bu«»  lutuu  u  to  net  tbu  pail  of  a  fuieigii  budy  ikuii 

.  a.  p.  30D). 


246 


DISEASES  OF  THE  LARYNX. 


beoonm  pdrfivtly  restored  if  no  altcrntmn  of  stmcture  h»» 
|Jm«  in  tiw  iniicouit  iiiinnliniiii.'.     In  cliriniio  liur)-ng:ilis  i>ccurrin^  i 
a  result  of  the  venereal  poison,  or  from  tlio  exhibiiion  of  merenrvJ 
tliw  IroJitrncnt  clioiild  («>  f,'iii<li'il  liv  tin"  principles  ulroiiiiv  nivntt(in«L 
In  ul(«raiion  of  the  Ia^J^lx  occurring  in  cachectic  conMitutions,  as    i 
a  wyiiicl  i>f  oontinucil  fever,  or  in  oonnexion  witti  phthi^iK,  tonicM 
should  bo  administered,  a  generous  diet  allowed,  witli  change  of  air, 
tlic  orfiiin  iM'iiifj  kept  at  ])erfect  rpat,  and  Iwal  pain  ni»v  be  rern*%i'd^ 
either  by  the  inhalation  of  sedative  vapours  or  by  the  appliMttio 
of  acnie  ctiiintiT-irritont.     Tn  mo«t  forms  of  chronic  laryngitis, 
topical  appliciition  of  a  solution  of  the  nitrate  of  silver  is  conude 
to  bo  alnio»t  &  upocific.     Tlio  application  of  this  remedy  to  ilie 
immediate  neighbourhood  of  the  ulcerated  surface  doubtless  relie\f« 
the  cxccKsivo  irritation,  and  tcmU  to  accelerate  the  c!catri»it!on«f 
the  ulcer.     Thia  practice  has  been  strongly  advocated  by  Trousseau, 
Horacf  Green,  and  J.  Warren,  and  was  employed  many  yeant  pre- 
viously by  our  own  oountryman  Sir  (.'.  Bell.     Tlie  strength  of  the 
solution  should  vary  from  half  a  drachm  to  a  drachm  of  the  »alt  in  i 
an  ounce  of  distilled  water.     Its  mode  of  application  consist!  in 
dcprossing  the  tongue  with  tlic  finger,  and  then  pobf  ing  a  »p(inge  I 
probang,  previimsly  saturated  with  tlio  solution,  into  tlie  fauces  anJ  | 
up|KT  part  of  the  larynx.      In  commencing  this  treatment,  it  a  nw 
in  the  fii'st  in.itnnco  to  apply  the  solution  freely  to  tho  soft  palalt^ 
fauces,  root  of  the  tongue,  and  epiglottis,  having  prwiously  rcmnvea 
with  a  piece  of  dry  Hut  or  sjionge  thi-  viscid  mucus,  which  in  tirt* 
ca«os  accumulates  in  considerable  quantity,  Uld  prevents  tho  wh>' 
tion  from  coming  in  direct  eontnet  willi  the  mucoua  siurluce.*    !I^| 


*  Muub  difference  of  opiuion  exists  us  li>  wbcthei',  ov  to  wlial  rtlwii.*  ' 
sponge  pnibiiiig  ciin  bo  jmsBcd  into  ihe  oavitj  of  tlie  laiynx :  sonm-  |>r»''lt 
tioners  nsHerting  coiilidently  Uie  impossibility  ofguiiiiiiit  tliis  cnvii;,  usii 
others  niRiiilaining  tlie  pmcticability  not  only  of  eiitvi-ing  tlie  cntily,  bat 
also  of  pus  sing  the  inslrument  thraiigli  the  gtottie  into   thn  tntchMiniJ 
bronchi.     It  is  well  known  that  both  in  tliis  country  nnd  in  Amrriu  il  >l| 
commaiily  staled  liy  the  nilvooalex  of  this  treutmcnl  thnt  a  njioDf-O  prob 
eiin  be  eiisily  posaed  into  ibc  ca>'ity  of  thr  taij  nx.  iind  tlironeh  tbn  |[kiUil| 
into  the  tiui'lics,  and  they  ))ivifeHsi>dly  ndopt  tlm  modu  of  tntainxnt  il 
numerous  enscs ;   but  a  tweful  <  xaminalion  of  the  mlijrct  leads  ID*  I 
believe  thst  in  the  grvHl  miijotily  of  oases  this  is  i]uite  impmcticsbk. 
numei'oua  inxtaiious  iu  wliiuh  I  have  aeon  the  sponge  prt>b«ing  ta«d 
thoie  diiily  emplojin;;  it.  I  bolieve  that  the  instnimciit  n«v*r  eulervd  i 
larj'iix.  but  ivHs  psised  througli  the  pbni'.vnx   Into  tlie  <r«>oi>bH|;uii, 
tlie  slight  impediment  to  ita  passage  usually  attributed  to  s)huiiii  oil 
mutclca  iiclini;  on  the  vocal  foi-iIh.  is  produced  bf  th*  contnielion  oS\ 
lower  end  of  tho  pliarjugeul  muoolee,— a  aeusalion  always  ozperieiietd  < 


D  of  treatment  aliould  be  a(lopt«d  daily,  or  every  seoond  day, 
lb  occuional  intermiMions,  and  will  prol)»l>ly  bo  fulion-od  by  con- 
nble  benefit  Some  Surgeon*  prefer  intiuducing  the  <suMtic 
by  means  of  (bo  laiyngtal  tj/rittge,  on  accoant  of  the  iiTi- 
tikely  t«  be  jinxiiK-dd  by  tho  pressure  of  the  sponge,  and  on 
also  of  die  greater  certainty  and  «a»c  with  which  tlio  appU- 
may  be  ofie(;t«d.  Duruig  this  treatment  tlie  larynx  ehuuld 
h6\t.  at  perfect  res«,  strict  aiii^nw  being  enjoined ;  any  tendent-y 
ipMBi  may  bo  rcliv\-cd  by  the  exhibition  of  an  anod\-ne  or  seda- 
tttthalation ;  tonica  are  generally  ueocAwiry,  and  a  goneruus  diet 
nld  be  allowed. 

It  nay  be  asked,  is  tradieotoiny  likely  to  aflord  relief  in  tliese 
M,  and  under  what  circumstaneaa  tthotdd  tlie  ojieration  bo  per- 
Med  ?  During  the  progress  of  tliu  diwMiHo,  if  an  attack  of  ^iimin 
mU  occur  Eo  Kcvere  that  danger  of  HudWaticin  is  imminent, 
Eheotoiny  tit  ju.ttifiable.  Agiiin,  also,  if  tho  8}-mptoni»  am  not 
•rad  by  the  treatment  above  menlioued,  but  the  patient  eon- 
to  MiSur  frniD  ni;geat  d^itpncea,  with  oc^a^ional  paroxyxms 
qaiO),  a  troabteeonie  oougb,  and  piiniloiit  exiHtotoration,  tracho- 
ly  may  be  performed  with  the  view  of  placing  the  organ  in  a 


CHBONIC  LARVKGITIS. 


247 


ifaigl  a  boo^a  into  tlM  (nsophsgus.  When  m  consider  the  poculiai- 
iliiM  of  tlie  Iat^'m,  lu  Uabttitjr  to  spasm  on  lh«  aliglitest  Uiucli  of  any 
mb«t«n«e,  and  th«  il}'Bpn<Ba  that  iiiuhi  viisuu  oa  th«i  inti'oiluclion 
■B  InstruHMnt.  and  lis  r«leu(ioii  va  tlie  air-pHoSKget)  otiXy  tor  e.  few 
ladi.  Ui«  alaost  tiMal  alxtonue  of  tli«  laxusr  ayiDpcuniB  iu  ihv  ciuie*  I 
laimeaKil.  >'beti  tlii^  prutwug  wiu  uhi'U.  Ivuils  me  Uj  Iwlieve  tliut  iu 
paat  nugoriCy  of  vaaet  lhi«  is  ii«vn-  lUMmiupiislinl.  On  Uie  ili-ad  suli- 
it  M  «  putter  of  no  Uiglit  difficulty  to  pua  bu  iuatruiuvut  iuto  or 
M|[h  tli«  UiyiiK;  and  I  baTo  acun  tba«e  wbu  prufuHSi-'Jly  adopt  tbi« 
is  the  tmlment  of  laryiif;«al  dJtriUL-  (bM  in  nearly  m'tfry  iusUnoa 
ilueh  the  attempt  van  made.  The  bllairy  of  this  pnictiiw  is  bIiowd  ir 
iMulla  of  limilar  espcrinintta  conducted  by  the  New  Vork  A>:iLdL>uiy 
itaioa.  In  whinh  tho  apontio  probonit  fniliMJ  U>  pass  in  eveiy  caa«  in 
.  it  wu  tri«4.  Some  pittiont*  manifnst  mui;li  luss  Bensibilily  in  tlieso 
and  [■  WMBO  the  ti>uii«l  eoNlbrnuUion  of  the  ^luoes  iwd  Uu^-iiz  ia 
iliat  tl*«y  ean  b«  moro  itwAy  exposed  and  exumined.  In  auoh  ia- 
by  caniioB  and  grotloneas.  and  employinit  a  pruiiiuie;  with  a  large 
re,  th«  apon^  nay  be  introducxsl  intu  tho  upper  pnit  uf  lk«  cuvity  of 
larynx.  Tbe  ei-nftatioiM  produced.  Loweivr.  iitidcr  these  circumstancf  • 
■ot  leave  mnch  doubt,  eitbcr  in  tho  mind  of  the  Snrgtwn  or  in  that  of 
IWlMll.  tltal  the  larynx  Iub  bi-irii  iv-avhed.  and  any  ntteni)it  to  prolong 
aypUeatioB  by  iryin^  to  {wbi  the  iii*truiu«i>l  beyond  tho  vocal  uoida 
im  atlMidcd  Kith  »ucli  manifriit  nytnptonis  of  autfocuiion  as  to  uoupd 
■antcoa  Ut  wiUidtaw  the  iaamunont. 


S48 


DISEASES  OP  THE  LARYNX. 


state  of  perfect  ropoec,  and  relieving  tlio  patient  from  the  dj-npno 
]in<l  Httack^  of  Hiiusni  from  wliJeli  ho  Im  ■.-< inbuilt iy  MifFcring.     The 
operation  affords  considerable  relief,  and  sueh  remedies  may  a[ler> 
wiirdu  bo  ailo])tc<l  «»  may  Icml  to  llic  oi<.nlrisution  of  tiio  ulcerated 
surfaces.     If  life  by  tliis  moans  is  only  prolonged,  the  fruedom 
trorn  suffering  i»  idoiio  ii  grtiut  «dvantag<.' ;  b»it  n-oovcry  may  oociir, 
though  imperfect,  tlie  patient  continuing  to  breathe  tlirotigli  m  cun- 
ula  for  tlto  rest  of  life;  and  wliure  tho  hiryiix  is  not  so  impaired    , 
by   structural   ohanges  as  to  interfere  witJi  r&(j>i ration,  ooiupiettfl 
recovery  umy  ciisuo,  vsjweially  if  tlio  operation  has  been  resorted^ 
to  at  an  early  period. 

If  dironio  larynfotis  continiics  long  unrelieved,  symptoms  may 
ariw?  wialogou.t  to  those  of  pulmnnnry  li^'lio;  mid  tliix  Jisctuo  ii 
called  plitliisis  laryngea.  It  is  well  known,  tliat  after  a  certain 
pcrioil  of  life  the  eurtilagett  of  t)u>  luryiix  l>evonio  converted  into 
bone,  the  change  being  necompanied  with  no  inconvenience.  But 
in  iiarticnlar  con»titntiiin»,  luid  im  ii  r*Miill  probably  of  long-coD-  ' 
tinued  inflammatory  action,  tliis  change  occurs  at  an  earlior  jxiriol 
of  Viih  ;  and  i»  fre(|uuntly  followed  by  caries,  separation  of  the  peri- 
chondrium, necrosis,  and  tlie  formation  of  atxnec^,  which  prcHluoes 
dtstrCMing  »nd  dun<;6rouB  train  of  symptoms.  The  t^ymptoms  of  tltil 
disease  are  very  insidious ;  its  approach  is  gradual  and  ittt  progrM 
dow.  At  firet  it  resembles  chronic  larjngitis.  If  the  symptomi 
are  unrelieved,  the  difficulty  of  l>n?athing  bcconios  dintrCHiiig,  i 
much  so  that  there  is  constant  danger  of  suifocation,  when 
dcnly  can.<«Iderable  relief  is  experienced  on  tlio  cxptxHonition 
large  qnantity  of  dark  foetid  pus,  in  which  may  probably  be  foDUull 
small  gritty  particles  of  earthy  .'^ulvttancc,  or  a  i)orUon  of  disor-f 
ganised  cartilage.  As  the  disease  proceeds,  the  cough  is  inceesaitCt 
the  expectoration  profuse  and  very  fwtid ;  dy^pncca  is  coluUll^  r 
niid  frequently  aggravated  by  attacks  of  spasm ;  the  lungs  becdoia'j 
aflcct^-d,  the  heiilth  gradually  gives  way,  and  the  patient  sink»,wtllij 
all  the  symptoms  of  hectic. 

This  form  of  laryngeal  disease  not  wnfroquontly  aocompania 
pulmonary  jihthisis ;  in  other  coses  it  would  apf)ear  that  tlio  lar%ia 
is  the  part  first  aRcetod,  the  lungs  becoming  diseased  subs£ijacDtlj> 
This  disease  may  prove  fatal  in  various  ways.     Otic  of  tlic  arytft*  i 
noid  cartilages,  bceoniing  partially  detached  by  ulceration,  may  btj 
displaced,  and  suffocation  onane.     Abscess  may  form  in  the  neigb-I 
boiirhood  of  one  of  tho  cartilages,  wluch,  from  its  preftsure  or  tlttl 
spasm  which  it  inducer,  may  produce  fatal  asphyxia.     Suflboatioal 


IfECROSIS  OF  THE  CAItTILAGES. 


S49 


iw  from  onlenm  of  the  glottJa,  ntuiteJ  hy  t)i«  irritiition  of 
rOMKl  cnrtilugt; ;  or  tlio  constant  miiglt  aiid  oxooasive  j>uni- 
peobvatiou  may  iniuix'  aJow  liectiv,  tu  wliicli  the  puticut 
lisks. 


re  ts  KDoUier  foim  nf  diRPS-ie  of  tlio  cnrtilii;*R*,  in  whi^^i 
nlion  takcA  place  as  tlio  nvult  of  intiniiimation,  tho  cairti- 
iag  found  afW  cIcmJi  w>fl,  of  a  yoIldwiHli  wiiw  sppeusnoe^ 
k  wkI  Ukn  a  piece  of  wvt  and  rutteii  Icatlior,  the  afiBCtod 
p  fyiag  luoso  in  Uic  mvity  of  an  uhHiXMs  formwl  bctwoon  it 
■oft  porta  around.  Tltis  fonn  ofdiacoHo  in  much  lc«8  frc- 
lian  the  jirecMliiig;  iUi  ><yin|>t'nns  htv  Ki'inilar,  bul  ntii  a  vory 
nd  fata]  course,  and  w«l>caiion  doea  not  preoode  tbo  duatli 
■rtilage. 
bow  diamaes  the  organ  should  be  ko]>t  at  peHi>ct  rest,  and 

ttito  Toico  strictly  prohibittxl ;  eough  shoidd  bo  nlIo\'iatiAl 
mediGines,  and  looal  jniii  l>o  relitn'ed  by  oi^unt«i'-irri- 
If  tbtt  Cfugtottia  is  portiidly  or  entirely  dostit>yod,  rviitlc-ring 
ion  difBcult  (V  impassible,  tlie  pativiit  .tlnnild  be  fed  witb  au 
pM  tube,  and  attacks  of  fpa^iin  should  bo  palliated  by  niir- 
If  tliCM  romodiM  £iil,  and  tbo  pationt  in  in  dan^T  of  death 
fibcation,  laryngotMny  sltoutd  be  pcrfuniked ;  tliiei  Srev»  the 
{K'mt  tlxr  diBtn^n^  frtlectM  of  spusm,  and  Iiolds  out  sonio 
of  uliiinuto  nrlief;  fi>r  lli«  dckiiimsI  <wrtib^^,  <Hj>e(nally  if  it 
■jrtnooid,  may  be  expelled  by  coughing,  and  tlw  »%*mptoi»« 
a ;  bat  in  imwt  comm  tike  irtntoturt!  of  tlte  lannx  is  so 
A  tittt  respiration  can  ne^'cr  bo  perfectly  perfonncd,  so  tluit 
cnt  muKt  continue  lu  bmithv  tlirun^i  tlw  cnnula  (or  the 
his  life,"  As  it  is  olniotM  tliat  a  complete  cure  can  only 
rwH  tlio  removal  of  tlw  wiiolo  of  tlic  dim-a'^d  cnrtilnge,  if 
rtioQ  of  it  oon  be  found  to  bo  dead  and  loose,  it  should 
ttcr  rrmovvd.  In  tho  muMmm  of  St.  Geofjje's  HoHpttal  are 
^unions  of  tbyruid  curiilage,  wlitch  were  removed  by  Mr. 
Hawkins  from  the  larynx  of  a  man  wlio  some  Uttw  pre\'!- 


M*  dioaaMd  cvrtilai^  soniotiaiO!)  irxfolittte  inio  Ihi?  iiirpniiMiKB.  snd 
1  of  forriitn  bodJi».  A  cuse  wiu  rvliitcil  U>  th«  Moilii^n-Cliirurgiviil 
If  Hr.  K.  Ilutnbf,  in  wbicb  Mr,  li?t»ii  liiul  <>]i«tioi1  tho  Irwdiva  for 
^dapmdinfloDi'flitiililic  dUiiuc  of  ihu  larjriix.  A  ni^ruicil  porlUni 
ietM  earllh^  ns  rjrctcil  Cn>ni  IW  vruund  durlug  life,  aod  nuiutker 
A  to  tlw  bnadius  aJur  daaih. 


dUk 


250  DISEASES  OF  THE  LARTKX. 

ously  had  attempted  saiaide  by  cutting  his  throat  with  a  razor ; 
the  wound  had  entirely  healed,  with  the  exception  of  a  fistuloos 
opening  leading  down  to  the  thyroid  cartilage,  which  was  exposed, 
and  in  time  necrosed,  and  finally  a^iarated.  The  portions  were 
removed,  the  wound  hfisled,  and  the  patient  was  discharged  cured. 

BENRY  GRAY. 


The  following  essay,  on  the  Latyngosoope,  muat  be  read  in  eonDezioii 
with  this.  Mr.  Gray's  sudden  death  prevented  the  final  revision  of  hii 
Ms. ;  and  in  particular  the  parts  relating  to  the  method  and  oses  of  Ittyn- 
goscopy  were  left  in  a  fiagmeutarf  condition.  The  Editor  has  revised  iIm 
rest  of  the  treatise ;  but  it  was  thought  better  to  erase  all  that  refemd  10 
the  use  of  the  laryngoBcope  in  the  diagnosis  of  tuinoure  and  chronic  diwHei 
of  tlie  kryni:,  and  to  make  that  the  subject  of  a  separate  essa;,  which  mvl 
be  considered  as  an  appendix  to  the  preoeding.    Sditor. 


THE    LARYNGOSCOPE. 


of 


THE  ordinary  Bymptotns  of  laryngeal  disease,  bucIi  as  pain,  diffi- 
citltv  of  rrxpinilioit  anrl  ()i>^luliti()n,  iilu-nilioii  uf  tint  vokv, 
Ac,  frcqnently  fail  to  indicate  the  precise  nature  of  tho  maladr; 
■ml  •omc  additional  aid  to  dingiiosiit  inunt  I>e  obuiiiMl,  or  tlio 
tratmeot  adopted  is  likely  to  be  as  unsuccessful  in  result  as  it  is 
BMUMrOy  uiKHTtain  in  ilirvction.  iSticb  lulditional  aid  i*  aJltmlvd 
Inr  Uie  Laiyogoacope ;  an  instniment  suggested  many  years  ago, 
but  only  yary  n-contly  urgud  upon  Uic  f^ticral  attention  of  tlio 
Bton. 

a,  writing  in  1&40,  was  the  first  to  etat«  definitely  tliat  a 
tho  interior  of  tlie  hirynx  in  tlie  lining  subject  might  lie 
olitMiMxl  by  mcians  of  a  Hpcculuin  "  introduced  with  its  reHeoting 
RT&ce  dowuvrardit  and  exn-ied  well  into  tlie  Ikitces."*  A  t«w  youTA 
Itter,  Mr.  Aveiy  contrived  a  laryngoscope  similar  in  principle  to 
Baw  now  in  vogtM-,  but  w>niewlutt  mure  coinplicuttKl  iu  eoii»truo 
l>n,  and  perhaps  tnore  difficult  to  inanage-t  Mr.  Avery  made 
WaMJre  pnictif.'al  Uiw  of  tbi»  instniment,  anil  iiffiriiit.il  that  with  it 
■  U  been  able,  under  fmourable  cireumittanees,  to  see  as  far 
■nn  live  air-iMASuge  as  the  biftireation  of  tho  tntcliou.  In  IS&S 
weia  published  an  aceount  of  numerous  loiyngoscopicol  obser\u- 
^  mado  uiKm  bini«elf  for  tbv  purjwsu  of  ascertaining  tlio  modo 
rf  fcnoatioQ  of  tfae  v<mo&  He  employed  two  mirrors.  One  fiir- 
^kti  witli  a  king  and  suitably  cnn,'ed  Htein,  he  introduced  into  his 
iMynx,  and  illuminated  by  muiliglit  reKected  truni  the  otiier,  duly 
*tU£i>d  in  froutofhim.  Tbo  imago  of  tbo  larj'nx  funned  in  the 
■a  mirror  was  transmitted  to  the  second,  and  tliero  observed.} 
*W  malts  obtaiiMxl  by  Garcia  liavo  bicn  fur  tbi;  most  part  con- 
fnaed  by  reoent  investigations.     In  1857  Doctor  Tiirck  of  Vienna 


•  Pmrtiatt  ^'aryrry.  IMO,  p.  417. 

tVUc  t^atuxt.  Juno  I6lh.  1»(W.  Mr.  Avery's  laijn  go  scope  liss  b««B 
**t»«wUy  hIiowii  to  me  by  Mc«ara.  Wcias,  bU-auO,  as  hvU  aa  Ui«  uioderB 
*anB«nU  wbtcfa  tl»ey  supply. 


i&2 


THE  LABTXGOSCOPE. 


commoncod  n  scries  of  cxporimcnts  reluUvo  to  the  coiistroetion  cf 
tlie  ]»i-\'iig()sRr){)ti,  and  iu  uue  lui  an  aid  to  diagnosis.*  Sliorlly  aHet- 
wards,  Dr.  Czormak  of  l'c«lh  took  up  tho  Hiibjoct.t  Ho  vciy  mucb 
facrilit^tud  ri'sittiri-li  t>y  lulujiliti^  artJlicU]  light  for  the  iUuiuiiiatiao 
of  his  mijTora.  Previous  observcra,  witJi  tho  exception  of  Mr^ 
Averj  (who  tu^d  a  lump  with  a  pnrrnmled  reflector),  depended  < 
direct  sunliglit;  thoir  obsorvatiotis,  tlit-rcforo,  could  only  be  made 
convenient  places,  «t  ecrtitin  houm,  niul  in  tiivmu-Hhle  weatlier, 
Tiirck  Mid  to  Czeniiak  wo  are  deeply  indebted  for  the  porsove 
tud  Hkill  with  whifh  liiey  Imve  piirHuctI  thoir  ohTK■^^■lllilln»l  uiid  ei^ 
periments,  aiid  ilir  tlie  wide-spread  publication  of  thoir  results.  \ft. 
grant  to  iieitlior  tlie  claim  to  priority,  which  ouch  aj*»ort»,  hut 
willingly  aocoril  to  both  the  full  merit  of  having  done  far  inorti 
tlian  any  of  their  predecessors  to  improve  llio  c<»ii!*t ruction  of  ili9' 
iniitrument,  and  teach  tho  method  of  its  u»e.  During  the  last  twv 
or  tlu'ec  years,  the  subject  has  bc-cn  diligently  studied  by  TurdtiJ 
Cxermuk,  and  otheni,  and  enough  has  been  already  aocomplisWj 
to  justify  the  belief  that  laryngoscopy,  though  at  prcjwnt  riclin 
in  proMii.He  than  in  rtHinlt,  will  neverlheleiu)  ultimately  prove 
very  givat  value,  both  to  tho  scioutific  physiologist  and  the 
tical  Surgeon.  Many  inventions  and  {ILxeovcvIeit  of  iJue  hig 
importance  have  at  the  first  been  coldly  received,  or  ovoo  ino 
ftiderately  condemned.  Such,  to  u  certjiin  extent,  ha.»  been, 
is,  the  case  witli  Uie  laryngoscope.  Wo  must  ever  rememb 
liowcver,  that  it  ia  far  caster  to  decry  a  new  method  of  inve 
gation  lliiin  to  become  familiar  with  its  application ; — tar 
to  speak  slightingly  of  a  new  intnniicnt  than  to  acquire  dc 
in  its  use.  Laryngo«co))ical  examinations,  to  be  Hucccaaful,  alv 
douiund  patience  and  skill  on  tho  part  of  tlio  operator,  and 
quently  also  considerable  M-lf-control,  and  Honie  practice  on 
part  of  the  patient.  Numerous  dil^culties  arising  fi-om  va 
sources  arc  liable  to  occur;  but  in  almost  all  cmnf*  tliev  may 
overcome  by  perseverance,  and  satisfactorj'  results  obtained. 

The  laryngoscojjc  essentially  consists  of  the  laryngeal  i^xwulo 
and  some  contrivance  by  means  of  which  a  good  light  cm  be  thro" 
into  the  pharynx. 

The  laryngeal  speculum  la  a  small  plane  mirror,  fixed  to 
extremity  of  a  thin  but  strong  stem,  of  sufficient  length,  furniR 
with  a  fixed  or  movable  handle.     Tho  mirror  may  be  of  poUs 


•  Zeiltch.  d&T  Oea.  der  Aentt,  no.  17. 
t  (iautU  heldtim.  dc  VUhm,  no.  U. 


DESCRIPTIOX. 


253 


lecnlnm  metal,  or  silver;  or  of  looking-glnM  moimtcd  in  • 
rtal  framo.  It  may  bo  eirculnr,  elliptical,  avato,  tir  quatlri- 
iritli  roDitdeH  angles.  The  t]iri>o  Rrst-itnnK^  form»i,  to  lie 
cording  to  oirctimfititnnv,  arc  recommended  by  Tiirpk  ;*  tlio 
Cz«rmuk.t  For  all  urdinory  oxnminntionv,  tbo  circular  and 
itcml  forms  appear  to  mo  to  bo  the  best,  an<l  to  aiinwcr 
wi'll.  In  KW",  Iiowover,  in  which  it  in  nuccwtary  to  carry 
cnluin  very  deeply  into  tlie  pharynx,  the  elliptic^al  or  tho 
mn  is  prcfiTrabK\     The  mirror*  vary  from  half  an  inch  to 

or  more  in  diameter.  In  every  case,  the  larger  tho  niimw 
u  bo  cmp)o\'cd,  the  better  in  llic  riuw  ohtninod.     Tlie  stem 

rtnigitt  or  Hiiglilly  curved.  It  in  fixed  in  the  quadrilatond 
m  to  one  angle ;  in  ihe  ovate,  to  the  bniiul  end ;  and  in  the 
,  to  any  part  of  tlie  eirctiniference.  The  diameter  of  tho 
Irawn  to  the  point  of  Junction  should  form  nith  the  stem 
D  of  from  120"  to  12S";  niui  fm-iher,  tJie  mirmr  should  Iio 
Bed  as  to  look  slightly  dow-nwards  when  tlie  stem  is  held 
aJly.  Want  of  attention  t«  tliwe  |>oiiit«  in  tlic  eoiiitrucLion 
istnnnent  renders  it  difficult  to  manage. 

tbe  illumination  uf  tiie  fiiHvulum,  when  in  position,  the 
ght  of  tlie  s»n  answerR  perfectly,  but  is  seldom  nvailable; 
iber  Botirce  of  liglit  mutt  fi-cfiucntly  and  tnai/  alwars  Iw 
nL  Turck  at  one  time  ri-c<>nnneniled  Ihe  um*  of  a  lamp, 
iaas  globe  flltetl  with  water,  so  arranged  behind  the  operator 

mys  from  tl>e  lamp,  conct-ntniteii  by  tJie  (^h'bc,  pnii^ed  over 
iMer  into  lite  ]ihnr\-nx  of  tlie  patient  seated  opposite  with 
ifwn  month.}  Tiirck  has  unco  discarded  tin.-*  phin  in  ordi- 
aminattons,  but  ntill  adopts  it  when  sponging  the  hiryiix 
wtic  or  otber  solutions.  §  The  light  of  u  lninj>,  concentrated 
■y  Inrgi*  conenvo  mirror  (both  lamp  and  mirror  being  p1ao»l 
tbe  ob«er%er),  has  l>een  irietl  by  Stork. ||  Mount- Bourou- 
I  a  rMvnt  pnbli«ition,t  hiw  ctrongly  reoommended  an  in- 
t  which  he  calls  the  "  Pharj-ngoscopc."  Tliis  consifita  of 
bieoni-iix  lens  enpablo  of  bringing  to  a  short  focus  the  light 


Iktde  pnui^iu  lb  liirstgoteopu,  pAi'  1e  Doctotir  Tiircb.    Paris,  ISOI, 

l^ryngotropf.  par  1e  Doptcur  Czi'rmiUi.  I'nrie,  ISCO,  p.  18. 
«k.  Ztiuchr.  dtr  Or*.  At  Amir.  no.  a6.  )M8. 
■rk,  iftiluMU  prnHtjw.  pp.  Oft.  06. 
tarAr.  Jtr  Ot*.  dtr  AmU,  nr>.  Ab.  1B9S. 
n  temjttft  tU  iMTj/ngMCO^e,  Paris.  190). 


251 


THE  LARYNGOSCOPE. 


of  a  powerful  lamp,  to  the  stand  of  which  it  is  bo  coniieHcd 
be  auiWy  uiljnstctl,  iin<l  morvd  in  rarioits  ditvctions.     The  whole 
apparatus  is  placed  between  the  operator  and  the  patient,  and  t)io 
vivw  tjikvn  on  one  or  other  vide  of  it.     The  disodvanlnges  of  this 
tiiTangemont,  in  examinations  made  upon  another,  arc  obvious.    For 
aiito-laryngoscopy,  liowovor,  the  pharjiigOBCope  answers  very  weB, 
wtien  a  Urge  plane  mirror  perforated  in  the  niid<ll«>  i»  fitted  fdd 
the  Ions.      MeKsrs.  Marrntt  and  Short  (of  King  William 
JiOiiiluTi  Bridge)  have  lately  made,  at  my  Augge«tioii,  a  modific 
of  an  otxlinRry  magic  laiitom,  in  which  the  lenses  are  arranged 
bring  tlic  light  to  a  focus  about  two  or  tliroe  ftnA  from  the  ex- 
tremity of  tJiO  tube     This  apparatus  is  very  useful  as  a  means  of 
illuminiitiun  in  all  speculum  examinations.      It  Htandit  behind  the 
ol>ser\or,  and  for  laryngoscojjy  is  ao  placed  that  the  light  paua 
over  his  shoulder.     The  head  of  the  |>atient  is  moved  into  proper 
position.      The  advantages  affoi-ded  are  great.     The  face  of 
operator  is  unhnitiperefU  bis  head  is  free  to  move,  tho  equal  nw ' 
both  eyes  is  permitted  him,  and  the  spaoe  between  himM*tf  and 
patient  is  entirely  itnocuiipieti.     For  consulting-room  practice  no 
tiling  could  be  better;  unfortunately,  the  lantern  is  rather  ox|)«iuiv< 
and  not  verj'  jMirtable.     C/ermak  was  tho  first  to  uso  a  nwdifio 
tion  of  the  ojihthalnioscope  as  a  means  of  illumination  in  larjng 
scopy ;'  and  some  such  metJiod  as  is  described  in  his  earlicet 
lieations  on  the  subject  is  in  most  cafe.')  more  reiulily  applicaklu,' 
at  any  rate,  is  at  pa^sent  more  gonornlly  adopted, — than  any  < 
hitherto  suggested.     According  to  audi  method,  a  good  mocln 
or  other  lamji  is  placed  close  to  one  side  of,  and  slightly  behind 
head  of  iho  patient,  who  is  scatod  near  tlio  comer  of  a  tabic, 
light  is  duly  roflortcd  by  a  coucavo  mirror  immediately  in  front  ■ 
tliO  oponitor's  face.    This  mirror  should  be  cireiilar  in  outline,  it 
or  four  inches  in  diameter,  and  should  have  a  focal  di&tiuieK  of 
eight  to  twvlvo  inches.    ]t  may  be  ]>lnced  bclbro  oiio  o)'e,  tlie  ob 
ver  looking  through  a  small  |>erforation  in,  or  near  tho  centre; 
may  be  uniK^rforated,  and  jiluced  betw<H>n  the  eyes,  and  in  front ' 
tho  foreheiid,  the  observer  looking  on  either  side  of,  and  below  i 
It  may  be  held  in  the  hand  when  the  hand  is  not  required  for  otl 
purjiiisea.     It  may  l>e  connected  witJi  a  stand,  in  such  a  uiaunefi 
to  bo  freely  movable  in  all  directions ;  tius  is  by  fur  the  most 
venient  and  agrecaible  arrangement      It  may  be  attached  to 
head  of  the  operator  hy  an  ordinary  spectacle -fruinv,  a 


i.ffn 


*  Oiufttt  hthilom.  itt  Ftmnt,  no.  13,  and  op.  ciL 


METHOD  OF  EXAMINATION. 


255 


L»  iir  iipring  passing  over  the  vertex ;  or  it  may  bo  fixed  in 
ffMJn  hut^o,  to  bo  buld  bL-tn-oeti  ttio  teeth.     The  lfi»t-i)iunod 
B  Mommendod  and  praetued  by  Czortnak ;  but  it  appears 
F||Be  ivkwunl  and  unplc-isaiit.      The  goiieral  arrange ineiit  xhuuld 
litlutdK'  lump,  til"  imiiith  >if  tho  [liiticnt,  and  tho  eye  of  the 
itr.  vidi  the  reflecting  mirror  before  it,  are  aa  nearly  ut  pus- 
jii  dw  MUM  planix     irUii.'  I:iryi);;>-»1  ^fjK-ualum  in  held  in  Uie 
l^ujijtbe  operator,  tJie  lamp  slmuld  1k^  pUnrd  on  tlie  right 
fifctfatient,  and  ricertTsd.     If,  as  is  tmmotimes  eonveniont, 
I  ii  placed  above  and  behind  the  head  of  tlie  patient,  tho 
KJHlphDe  tatut  bo  prcson'od  ;  but  tlui  epoculum  tuay  be  held 

I  tfiHl  idnoitAge  in  eitlier  luind,  witliout  risk  <jfob»Lrucliiig  tlio 

2k  pilietit  to  bo  examined  should,  if  poMihle,  he  »oal«d,  Ins 

lauuRg  somewhat  forward,  bis  licad  inolined  slightly  back- 

■nd  nipportod  if  noocawury  by  u  "  nxl."     Iliiving  o|>cncd 

IBPUth  »s  widely  as  he  is  able,  he  must  breathe  quietly,  put  his 

rather  forward  against  tho  lower  t«<!th,  and  eiidoavour  to 

and  Ratten,  or  render  concave,  its  posterior  part.     After  a 

'  |netioo,  tbo  tongiic  <.-an  UMially  bo  bnjtifjht  into  proper  ]>osi- 

A  fnw  de«p  inspirations,  alternated  with  repeated  ]>ronunoia- 

f  tbe  broad  vowel  a  (ai>),  often  prove  effectual.    If  al[  attempta 

1,  tho  operator  (»oatod  exactly  o|)pu!tit(!)  mity  xntn  a 

i  tongDe-spatula,  which  may  afterwards  be  held  by  the  patient 

TIio  iiitrodnction  of  any  unnecessary  iiislruntcnt  into  tlic 

•tMmId,  liowuvisr,  Iki  carefully  avoided.     Enlarged  tonsihi 

,  or  abeoeasc*  in  tbc  naso-phar^-ngual  cavity,  givo  riso 

.  not  oasily  o\'CrconiCL 

the  Boft  palate,  ntnita,  and  posterior  part  of  tho  pliar^'nx 

II  expoMxl,  tiiu  light  (from  whatever  source)  is  to  bo  directed 
[■pan  tbem.     This  having  been  sccompli«ht<d,  tho  lan,-nf;cal 

I,  prwviouHly  wanned  by  imincrHiim  in  h()t  water  or  olber- 

,  may  be  introduced,  with  its  reflecting  surface  downwards,  into 

ath,  carrivd  iMickwanlit,  and  placed  agaiimt  tlie  soft  paUte 

IbtuU,  or  in  contact  with  the  posterior  wall  of  tho  pliur}'nx. 

lio,  bmitating,  and  ha«ty  riuivoinenta  of  the  instrument  aro 

I  to  give  rise  to  objectionable  litillations.     The  operutioii  must 

deJiboraUily,  confidently,  Htj^iulily,  and  tirmly.      In 

it  is  from  tbe  fint  much  less  irksome  and  insupportable 


A  IroaUl  buid  nuule  for  mo  bjr  -Mr.  UUUkuu,  «f  Sl  Tliomoe's  Street, 
a«lMii||  to  be  deaircd. 


S56 


THE  LARYNGOSCOPE. 


to  the  patiemt  tlmn  migjit  bi>  oxiwcled,  and,  «fter  a  few  rnpetitr 
omAAJoiifl  wiiiipavativoly  little  inooovcnience.  Saffercrs  from  chronic 
larj-ngoal  affix-tioii!*  »re  tlio  baxi  jialii'nts, — mtt  tlio  wortit,  iw  unm* 
Iiiivu  sujijKisud.  Tlii'ir  dosiro  for  benefit  is  a  stmngcr  etimuliu 
to  patienco  and  »olf-«ont.njl  than  is  |>rissi>i4s<Ml  by  tb«  hwiltliy,  ami 
niore«v<!r  ihoy  are  accustomed  to  submit  tboir  throats  for  examina- 
tion, and  t}\f}  application  of  modicamcnbi.  Tbc  examination  of  ouus 
of  acute  tunnigeal  disease  is  very  diflieult.  It  is,  howm'er,  rare^ 
necossar)'.  The  poncml  symptoms  arc,  ss  a  rale,  miflicionlly  ch»* 
ractt-rictic.  ^Vhen  the  parU  are  too  sonaitii-c  to  be  toucl»C(i,  the  ' 
of  bromide  of  potassium  as  a  locaJ  anEesthctic  has  bocn  8tiggcstcd,1 
but  I  uaiiiiot  (iiid  on  re(>ord  any  iimtuin'e  in  wiiich  it  hsH  lieen 
1  Irnve  myself  hitherto  mot  witli  no  case  requiring  resort  to  sue 
an  expedient,  luid  bav-w  tlu^refore  no  oxporiuneo  of  ita  offio4H"y. 

The  apeeulum,  placed  in  position,  will  be  well  illuminated  if 
the  light  is  properly  arranged,  and  conwijunntly  wili  <-xhibit  to  tbe 
obscn-er  an  image  of  those  parts  upon  which  the  raya  are  reflewd 
from  Us  siirfiice.      By  varying  tbe  ini'linallon  of  thu  niirror|, 
ftligbtly  changing  its  position  from  time  to  time,  (Jie  following  ] 
may  be  successively  brought  into  view :  the  baw  of  tl«!  tongwe 
gliiftAo-epigtiiltidean  ligaments,  the  epiglottis  and  ar\'ta'no-e|>iglotli-l 
dean  ligament)*,  tho  curlilngcsof  SHntorini  and  arytn-noid  carUUg^ 
the  true  and  fiilae  vocal  oorda,  the  ventricles  and  anterior  wall  < 
the  larynx,  more  or  less  of  the  anterior  wall  of  the  trachea,  and,  i 
llio  gliittift  is  verj-  widely  open  and  the  light  very  gootl,  eveni 
bifurcation  of  the  trachea.     These  sc«'ral  part*  cannot  ho  seen 
eqiitd  facility ;  in  many  cases.  n-|H-ated  attempts  arc  nueemary  i 
Ruccess  is  attained.     Numerous  rules  have  been  laid  down  aa  to  I 
inclination  anil  imsilion  ofthc  mirmr  projier  for  tlio  «i>ec9al 
mination  of  each  particular  part.|     It  is  needless  to  repeat  tb 
A  few  lionrs'  patient  pnicliee  (in  the  deiul  ittibjeet,  or,  better  Still,  ii 
himself,  will  do  far  more  to  prepare  the  tj'ro  jn  laryngoeoopy  for  I 
suc4X'«sfuI  cxumuiatioti  of  a  patient,  than  the  stitdy  of  many  { 
of  minute  directions. 

Tlie  practical  Surgeon,  who  has  acqutrcil  dexterity  in  ite  mana 
ment,  cannot  fail  to  find  the  lai-yngoscopc  very  serviceable, 
pericnoc  has  proverl  its  value,  and  warrants  its  further  appbcutia 
both  in  the  diagnosis  and  treatment  of  very  many  aU'eetiofu  oft 
larj-nx.     In  acut«'  c.iscs,  which  require  prompt,  decided,  and 
treatment,  its  use,  as  already  intimated,  is  difficult  or  imjHMwib 


«  Oruetudu  //(v'rAnu,  3Ul  Api-il  ]!<00.  \  Tiirck,  o]>.  eit 


JTSUSBa 


SSI 


Hot  ti  amalty  also  onrM>«w«nr.     In  all  eJironic  case^,  hnwovcr, 
^pealed  examinaUons  should  be  mado.    Almmt  invariably  padonca 
uid  ponevvninoe  will  tniini[>)i  owr  the  obntjivloH  juxiiwiitod  by  the 
•ennbility  of  tlio  parts  and  tlw  makdrease  of  the  patient 

HoanwncHW,  aphonia,  and  ttpaJtin  of  tho  glottif  itisy  (wch  ariw 
from  a  variety  of  diflerctit  causes.  The  true  cause  can  afien  be 
poritircly  ascertained  by  larjTiRoscopy,  and  by  larynynm-opy  alono, 
during  the  life  of  the  patJont.  In  some  cases,  treatment  before 
Bothaogfat  of  may  bo  adojitvd,  and  prove  Nuc<.nt«i<ful,  hucatue 
appropriate. 

By  the  aid  of  tlw  laryngoscope,  cc^doma  glottidio  nuty  ho  a«Miircdly 
diagnoaed,  and  the  knife  accurately  directed,  if  scarificatioa  of  the 
part«  should  be  dc«m«d  adWsablcL 

Chronic  inflammation  of  various  kinds,  with  congestion,  or 
tfuckcning  of  tlio  mncous  membrane,  and  thickening  oftliu  vocal 
cord*,  can  be  tswily  recogriiiMiti. 

Certain  of  the  milder  forms  of  chronic  inSamtnation  of  tho 
larmx  are  distinfruinhi^l  from  hronchititi  with  ditficulty.  Tlie  dia- 
pnoB  a  important,  and  may  easily  bo  accomplished  by  a  visual 

■  mainalion. 

I  Xiny  hysterical  aJTections  of  tlio  larynx  very  oloaely  simulate 
H  Vpiue  diaenw ;  and  on  the-  other  hand  tho  symptoms  of  or;^iiic 
H  &Mie  arc  liable  to  be  nttributt^l  to  tiyslnrin  or  some  nervous  nfl'ec- 
H  tiiL  By  aid  of  tho  lanmgoscope  it  can  be  ascertained  whether 
H  I*  Tocal  cords  are  perfert  or  destroyed ;  whether  tho  museios  act 
H  Otn  paralysed  ;  whctlior  the  motion  of  the  cords  is  froo  and  equal, 

■  «  bterfered  witli  on  one  or  both  Nidoa  by  any  obfltruetion. 

H      Oksen,  whether  si'philitic,  phthisical,  or  ortUnary,  can  be  readily 

Hneded;  and  cauHtio,  if  likely  lo  do  good,  can  bo  applie<l  with 

H  ntiility,  and  comparatively  littlo  pain,  by  moans  of  a  long  and 

H  iBpCTly  cnn"ed  iiorte-o-austi<|ue. 

H      Tninotiryof  the  larip-nx  are  oflon  accompanied  by  such  s\*niptoni8 

H  ■dya*  are  equally  cbaractoriMio  of  other  aifections.     Tlie  taryngo- 

H  ■npe,  however,  not  only  reveals  their  presence,  hut  nffonls  fneili- 

Blitt  ibr  their  removal  hy  ai)  Appropriate  inoditication  either  of  the 

HvnHuiareor  ^em*mr.* 

H     Foreign  bodien  in  tlie  Inryns  or  pharjiix  may  he  seized  and 

mAbi  sxtractod  with  comparative  ease,  when  rendered  vLsiblc  by  the 

H    •  S*«  a  eaM  rMxtrded  in  the  fAtneei,  November  1861,  hy  Dr.  Watk«r  »f 

■WnlKimi^h. 

I     f  Dr.  GIbtt  of  Loodoo  (to  whom,  m  well  aa  to  Dr.  Walker,  I  an  luach 


358  THE  LARTWGOSCOPE. 

The  Gmiti  of  the  present  paper  do  not  admit  t^e  introduction  of 
details  of  any  of  the  numeroos  cases  which  might  be  quoted  &oin 
the  experience  of  myself  and  others.  Twenty  cases  are  given  at 
length  in  the  work  of  Gzermak  already  referred  to,  and  which  has 
been  recently  translated  for  the  new  Sydenham  Society  by  Dr. 
Qibb.  Many  cases  are  to  be  fonnd  scattered  through  tlie  foreign 
joomals, — many  more  yet  remain  to  he  published. 

In  oonclosion,  it  is  frequently  asserted  that  the  laiyngosoope  is 
not  adapted  for  general  use,  but  rnoBt  remain  in  the  bauds  of  the 
few.  It  may  or  may  not  be  so.  I  can  only  repeat  my  conviotitni, 
that,  even  in  the  hands  of  the  few,  this  simple  bat  beantifiil  oon- 
tarivance  is  destined  to  do  mnoh  good  to  tbe  many. 

ABTHDR  E.  DQRHAU. 


indebted  for  not«B  of  muif  oases  at  present  unpnbliBhed)  informs  me  Out 
be  has  thus  succeeded  in  eztiaoljng  a  pin  from  tbe  pbuTU  of  a  gentlenua 
seveaiy-twD  yean  of  age. 


DISEASES  OF  THE  ABSORBENT  SYSTEM. 


rS  TeMvIs  and  (i»  glands  of  the  Absorbent  SyRiem  arc  closely 
MBociAtcd  in  ihcir  r[i»caM»,  and  csiitmt  h<i  convenieiillj-  or 
■drantagously  Btiidied  apart  from  one  anotlier.  In  the  following 
«WT,  iherefore,  a  wparate  notloo  of  citiicr  part  of  the  systinn  will 
hitiiva  only  when  some  special  facta  of  patliology  or  of  treatment 
nidcr  it  necauarjf. 

Waaub  <^  lymf^atva.     Althongh  some  of  ihcso  tpmoIb  cnnnot 
to  be  injnrod  in  every  coiiiudcrahle  wonnd^  they  are  rarely 
A  Httlo  Irmpb  doubtless  issaee  from  them,  but  it  is 
1  with  the  more  copious  and  more  in)i>ortnnt  outflow  of  hluod, 
'  with  tiw  subsequent  oozing  of  interstitial  fluids  from  tlie  divided 
The  wounded  lympliatic  ttihes  may  ho  »ca1ed  by  the  oom- 
eoagohiin  of  blood ;  it  is  probable,  lion-over,  that  the  1)-inph 
I  ly  its  own  con-wlidation  oontributix  to  tliiti  cfffct.    "  Dr.  Monro 
a  wound  on  the  receptaculum  chyli  of  a  pig,  whicli  was 
in  a  very  sliort  tirno ;  antl  in  t!io  mean  while  tlio  cffHsion 
fthe  Ivmph  was  prevented  by  its  coagulation."     The  exceptions 
>  lim  rale,  and  lo  the  repair  of  woundc<]  lymphatics  by  tho  ordi- 
r  prooeeses  of  healing,  are  so  few  and  rare,  tJiat  the  following 

of  failure  may  bo  mentiono<L 
"  A  caae  of  this  sort  I  saw  in  a  butdier,  who,  by  letting  his  knife 
hi*  shiti,  cut  •on>e  of  the  largp  l\nnfihntic  vw,*!-!*  whieh 
rer  tho  tibia.      From  tliis  wound  there  flowed  a  considerable 
rty  of  *  dear  lymph,  whicJi,  being  confined  by  tJw  dr<y«ings, 
I;  and  then,  at  first  sight,  ap[>eare<i  like  a  whitish  fimgTis,  but 
hxMi  onuld  be  rcmo^iMi  with  a  Bpatula.      My  patifnl  was 
:  by  tight  prcssm^,  and  lint  di)>peil  in  a  solution  of  vitriol."" 
.  Monro,  after  TOno%'iiig  a  tumour  from  the  arm,  foun<l  the 
heal  and  eontract  "  very  fast,  till  a  yellowisli-whito  sub- 
row  up  (hwn  a  small  pc<tunclfl,  at  the  part  where  the  under 
of  tbe  cephalic  vein  had  been  out  throngh.     From  this  aub- 


•  Bcwaon,  Sjidenluun  Sooiety's  c4iUoD,  by  tiulUv«T,  p.  190. 


S60 


DISEASES  OP  ABSORBEXTS. 


fttanoe  such  a  quantity  of  lymph  oowxi  out  fixrni  impOTocptil 
orifice*  tlifit  Um!  dre(winp«  wero  vvvry  d»y  w«c.  1  out  luul  vrwlcd 
this  substance  away  several  timcB ;  but  it  ijaickty  grew  again,  and 
the  drillinjj  of  lymph  became  wor*c  and  worse,  xo  tJint  in  a  v<it7 
litUo  timo  it  dropt  so  fast  that  I  could  have  gathered  a  spooufy 
of  it  ill  a  very  sbort  time.  What  ciirwl  it  »t  laM  wiut,  mliiif;  tbe 
ftingUH  stuff  and  a  little  of  the  wound  about  with  powder  of  Roman 
vitriiit,  and  dressing  tho  lawliar  with  alcohol,  whicli  kept  it  from 
separating  two  weeks,  in  which  time  tlio  orifices  of  the  small  pipes 
were  wildvred."" 

While  this  volume  lias  been  in  the  press,  a  valuable  paper  bv 
Dr.  H.  Vandyke  Carter,  Professor  of  Anatomy  and  Phywology  is 
the  Bombay  Medical  College,  has  been  i)resenl4xt  to  tJie  Koval 
Medical  and  Chimrf^ical  Society  of  Loudon.  Dr.  Carter  had  ntd 
with  three  cjises  In  which  he  had  reason  to  think  that  chyle  e«caf<d 
by  leakage  or  raplnrc  from  lacteal  absorbent  veGBots.  He 
pres.4ed  rhe  opinion,  with  the  groundii  for  holding  it,  tliat  the  < 
case  known  as  "chylous  urino"  is  not  a  functional  error  ofi 
the  renal  or  <h'^e>tivG  orgonA,  but  :ui  acoidcnUd  adniixlure  oft 
wttli  urino  by  tho  rupture  of  a  lacteal  reasel,  ooncurring  with : 
bre;i<-h  of  tlie  mucous  siirtsiou  in  i^ouie  ]iiu-t  of  tho  uriiian,-  tnicU 
one  of  the  cases  a  eimilar  fluid  sometimes  issued  in  a  verv  Isf] 
quantity  from  a  spontaiieoasly  formed  and  v»jry  minute)  ojwnil^  i 
the  skin  of  tbe  thigh. 

Injlammatkm  of  Ij/mphalicK, — Adenitu,  Antftnoleucitis,     Fn 
Instances  of  infltunmalion  in  the  absorbent  system,  the  vOBBob 
the  ghind-t  are  both  involveil ;  the  glatuU  are  rarely,  tho  Irmph 
vessels  almost  novor,  attacked  alone.     Many  cases  of  infUunmaiio 
of  glnnd:*  ((ȣ>niVui)  are  regiinied  -.at  sjiDtitntitiotift,  or  as  the  renihl 
the  direct  influcnco  of  cold,  until  a  caroful  inquire-  shows  tbonl 
bs  doftendent  on  a  prior  irritation  of  the  ulfcrent  htnphatio  v« 
(angeu^aieUU).     It  is  by  no  means  unlikely,  therefore,  that 
inflammations,  whicli  arc  now  conKidertid  to  lie  iiiKtancm  of  jiriii 
adenitis,  may  yet  be  found  to  be  sccoudaiy  to  some  hJthetto 
diflcovercd  primary  cause  of  the  «ime  kind. 

Inflamniittton  of  the  lyiiijihatiea  occurs  in  many  parts  of  I 
body.     Traces  of  it  are  sometimes  disco^'cred  in  tho  interior  i 
tlic  trunk,  after  death,  by  tho  larious  changes  it  lias  produced ; 
serum  or  pus;  by  thlckoning,  opacity,  or  accumulated  euc 


•  Medical  Etiai/t,  Edioburgll,  vol.  r.  art.  ST. 


DJFLAMStATION. 


361 


I  or  tlwat  tlie  tyniphatii^  vcNM'k     But  it  h  hard]y  ever  sotuUy 

I  except  in  oonnexion  widi  the  ^kin  or  an  ulcoraiud  sarfaoo. 

TbodiMUN!,  M  it  ifiuN  wmv-i  uridrr  tliu  olitkirviiuonuf  Surgeons, 

I  nmally  an  auato  inHamnmtioii,  originating  in  hodio  pronously 

or  infiaiiufl  tissue,  cxt4>iidtng  in  long  nsrmw  lint-H  in  llio 

of  the  alMorbeat  vesaeb,  nnd  involving  the  nearest  glan<l. 

|il  oAoo  ittu<itiI(.N]  witli  bcvil  anil  a  transivnt  nxlnwA  of  tho  ml- 

aldn,  witli  considenible  jmin,  luid  wiiii  ratlier  severe  Bjinp- 

tmtr\  and  it  mity  issue  in  an  oOusioa  of  sonim  uid  lympli, 

I  sap[i(iralion,  and  in  bK^fid-jioiaoning. 

M(N<t  tiiriajtiniutioiM  ot'tho  abeorheats  start  from  au  open  wound. 

a  wound  may  be  in  Hlmont  any  condition,  and  utuny  t'orm. 

■/  bo  puneturod,  cut,  torn,  blistered,  tor]>id,  liealing,  scabbed. 

mere  stat«  of  tlw  wound  docst  nut  dctf^nninu  this  inwiu-ri'iice  of 

I  ittfljunRULtjon.     It  may,  indeed,  manifest  itself  atler  the  absorp- 

I  of  •  puiiKin  witlioiit  a  wijund,  as  wlicn  rod  linen  covor  tlie  penla 

raoontly  cootiaotod  gonorrlicea ;  even  breathing  the  exhala- 

of  OMTUptiug  animnl  matttT  may  occiufion  it,  although  tlie 

finira  which  the  angeioleucitin  atlerwarda  spreadit  be  at  the 

I  aodulotuly  covered ;  but  ttiure  is  iu  must  cases  aniplu  evidcnoo 

Fdiract  infection  of  the  wonnd.     The  morbid  matter  may  be 

U<cal  inHainmatoiy  product,  as  when  the  inflammation  follows 

I  {voloogod  Iric'tiun  of  oxcoriatMl  skin,  or  tlio  oontinvuimit  of  Uio 

tjons  of  a  sort)  by  a  hard  scab.     Uore  commonly,  however, 

irritating  or  poiwnous  mnt«rial  is  known  to  liave  bm^n  ap- 

bi  the  wound  firom  without;  or  some  giueous  poison,  tltuugb 

known,  oiay  bo  Uui  rual,  as  it  is  Aomotimat  tho  aM-ortttinc-d 

of  tbe  inflaimnation.      My  colleague,   Dr.  Greonhow,  do- 

infliinunstjon  of  tbo  absorbents  of  the  arm  as  suL-cuvding 

Idipbiht-ritio  exudation  lieneath  a  veoicle  of  the  hand.*     He  has 

I  tbo  same  oocnrronoo  in  tl)u  nock,  conncctod  with  diplithuria  of 

I  lluNMt,  and  fatal.     Once  only,  luid  in  a  very  rapid  case,  I  hnvv 

an  acittu  inflammation  of  tlie  lymphatics,  witli  rodnoiM  of 

!  ikin,  1(1  aix-oiujuuiy  and  indiotitt!  tli«  tirnt  infection  of  tbe  glanda 

dcooudary  cancer.     .Soo  p.  277. 
Hm  ooarxo  of  thu  inihmiuiatioii  i»  commonly  pointed  out  by  & 
mloeaa  of  the  skin,  which  is  often  many  times  hroadi-r  than 
mael  bouimtli.      Tlui  linos  follow  the  ilirvctioii  of  the  absorb- 
not  of  tlie  voins ;  and  in  the  arm  they  may  cease  at  the  wrist, 
1  lbs  elboir,  or  at  any  inlormodiuto  part  at  wliicb  tiie  inflamed 


(M  ViiihOuria,  p.  ISO. 


8(9 


DISEASES  OF  ABSORBENTS. 


lymplmtic  rouob  end  in  a  gland,  or  lose  rolation  with  the  nl 
but  thoy  never  jiant  tliA  anikpit.     TW  tondftnieie  nlung  sudi 
flamed  tracks  is  excessive,  and  it  coiamonly  extends  to  tlie  ne 
abAorl:)eut  glund,  vrboUier  llio  n.iln««(  reiusli  aa  far  or  not. 
rapidity  witb  wkidi  euch  linen  are  sometimes  formed  is  remarh 
able,  and  is  only  equallwl  by  Uiu  insUmtunoooK  ojilitlislinia  wliJc 
occurs  when  a  foreign  body  eDton  tJie  eye.     "  Mr.  Hunter  saw  i 
catc,  in  wlildi  tlie  ikin  being  pricked  by  a  DMxlk-  wIii<:Ji  luil  n«v( 
been  usod  before  or  touched  any  infectious  or  irritating  &ubHbuice, 
occimioned  the  ]\'Ti){>Iintics  of  tlie  aim  to  iutUime,  and  sbuw  them> 
selves  in  the  form  of  red  lines,  nuining  towards  the  axilla ;  io 
O0suc(]ucnoe  of  tlii^,  »omo  one  oi'Uiti  gkmU  thuru  aW  inHaniixl  and 
swelled,  the  patient  had  rigors  and  sJckneaa,  and  all  this  in  tbo 
space  of  a  fi;w  minutiw."' 

Such  extreme  rapidity  in  the  development  of  intlainnuition  it 
nnquoBtionubl)'  rare,  allbougb  Cmik»liank  &tat«6  that  he  has  *tm 
other  similar  oases  in  the  inatanoe  of  the  absorbentA.  The  red  lint^ 
indeed,  arc  not  un'ariably  formed ;  and  tliis  may  be  readily  unAtt- 
stood,  if  tliey  be  r^arded  an  ocoiirrliig  only  when  tho  inlWiniatios 
is  widely  spread,  and  therefore  rather  intense.  It  is  twt  improbablt 
thiit  tlie  itkin  is  tliu»  in^'lllvo<l  throtigli  t]i«  medium  of  tliv  minute 
cutaneous  lymphatics  connected  witli  tlie  inflamed  vessel;  and  On 
likoneiut  of  tho  local  aj)pearancos  to  tlie  blii;»li  of  cryitij>ela»,  togetlitr 
with  the  ti-ansitoriuoss  of  tlio  a['pearauccs  in  tlie  skin,  whilst  the  t«ii- 
(Jomoss  of  the  inflamed  vossl-I  continues,  rather  ci)nrinM!*  tliU  vie*. 

The  uiflaniiuatory  action,  as  indicated  chiefly  by  tbeae  red  Una, 
sometimes  extends  slowly,  and  a«  it  wore  uontinuou>dy,  by  tlw 
tltiiue  of  the  Ijnnphatic  vessels ;  far  more  commonly  it  attacks  tlutt 
eiinultaneousjy  in  nearly  tlieir  entire  Icngtii,  and  flj>poani  to  bo  oon- 
sequent  on  their  becoming  iilled  witli  fluid  of  an  irritating  qualit| 
That  the  latter  is  the  modu  of  origin  is  further  likely  from  tho 
that  the  disease  travels  only  upward  &om  the  womid  to  tlie  oo 
gland,  and  not  in  the  oppoi^itu  direction.  It  will  extend,  fur 
xtjinco,  from  a  wound  on  a  knuckle  to  tJie  axiUii,  but  nut 
the  finger ;  from  tlio  heel  to  tho  ham,  bnt  not  to  the  fiwt 
are  some  ap)>arent  exeeptions  to  tliis  rule,  but  tliey  are  [irobably  I 
be  explained  by  tho  continued  absorption  of  noxious  matter  at 
wound,  and  its  accumulation  below  some  i>oint  of  obstruction  i|j 
tlie  track  of  the  lymphatic  vcasels.  A  woman  camo  ondor  my  i 
with  a  aurieu  uf  eight  absoussos  between  her  (iiiger  and  armjol 


*  Crulksbauk  m  iht  Abioritnti,  p.  70. 


INFLAMMATION. 


ts» 


higlmrt  waa  on  tbo  iimn'  u>d  poctorior  port  of  tho  upper  arm ; 

I  lowast  was  on  the  back  of  the  haixL     Tlio^  diU'ered  iii  Hixe  bv  a 

gradation  fix>iii  th«  liiglwst,  wliich  oqualleil  a  walnut,  to  tbo 

which  was  no  bigger  than  a  aherry,  iind  was  the  lea^t  ma- 

!  aa  woll  aa  the  smallMt  of  oil.    Thcrv  wa«  no  suppuration  in  the 

Ikey  were  all  punctured,  and  got  well ;  yet  inHammation 

,  if  not  suppuration,  eventually  took  pUco  at  tbo  tiiigur. 

naa  clear  tiiat  liio  higbci4^  alxustMs,  being  llie  Urgeat,  was  tba 

fibrmod ;  and  tltat  each  of  the  others  sueoesBivaly  arose  n«x( 

the  on«  abuvo  it     The  only  cuuho  whidi  A]ip«^Lr3  aHsignnble 

tbr  Inti'f  abacoMoa  ia,  that  fresh  matter  arriving  &om  tbo  tingur 

iiuUt«d  bolow  tlie  proueding  onea,  until  at  liMt,  by  tho  tnlliun- 

n-  actioo  in  tba  finger,  tlie  source  of  the  irritation  was  got  rid 

Wiaeman  d«acrU>o«  a  ainiilar  inHunimntion,  whidi  upptirmitly 

along  the  absorbenta  of  tlie  tJiigh  and  leg.*     A  man 

imder  my  caro  for  eupptu-ation  uprvadiug  trotn  tltu  axilla  nnd 

;  down  the  side  of  tbe  trunk  to  the  loin.     Vast  quantitios 

r  were  ovacuatod  by  dependent  openings,  and  tlie  su]>para- 

rastrained  by  aitpropriale  baodagitig,  injeolions,  medioinea, 

,  bod.     As  tlia  discbu^  avbeided,  tbe  hand  bogan  to  suppuntto 

a  i|K)(  from  wliwli  iiitbutinuilion,  sprending  by  tlio  absorbentSf 

to  have  tirst  originated  the  abacesii  in  the  axilla.    Tim  man 

ifvroi. 

Ute  inflammation  eewn  at  tlie  nearcat  gknd.  Tliis  is  a  fact 
lly  axnnptified  both  in  the  simple  and  tbo  spocific  inHam- 
of  ahMfbunta.  The  known  situations  of  tlie  su{ierficial 
fhnds  an  tltoee  towards  wbioh  inflamed  absorbents  may  bo  traced, 
■ad  al  which  their  inflammation  cnlminati^M  to  iti*  bighoHt  di'^roe  of 
MfcritT,  and  ia  almost  invariably  extingui-nbed.  Tbe  gland  appears 
IB  anwl  the  &ee  progrtMt  of  iho  acrid  lymph,  by  it}>i>lf  lioooniing 
iaSamad.  Sametimes  tbe  current  of  morbid  lymph  tJirongh  it  is 
aanqiiately  etojipud ;  at  other  times  it  gives  passage  to  tlio  lymph, 
m  ilnlf  aupptiea  morbid  material  to  tlio  higher  absorbents  and 
tkr  dfxrulating  blood,  ^vcn  in  that  case,  howc^'or,  tlto  higlier 
(iuda  do  not  inflanw  or  suppurate  I>id  they  do  so,  we  should 
KBinoRly  Ko  abdomimd  abHc«s»es,  peritonitis,  &c.,  in  priniarjr 
■ti'liilia,  and  iiiHaiiunalton  in  the  neck  combined  with  traumatic 
.■itratJon  in  tbe  armpit.  Hie  inSammation  of  a  gland,  which  is 
—vtad  aadur  those  circumatancoa,  may  vary  from  «  slight  incruufl 
ito  use  and  finnueas,  witfa  some  teadorneaa,  to  a  degree  of  so* 


I 


•Cku.Tr*at.i6»i,^4». 


fiU  DISEASES  OP  ABSORBENTS. 

Tcri^,  vhich  isnies  in  oxtcmsKt)  supparation.  The  glaihl 
former  case  may  be  felt  miliiig  in  tiie  tit»ui-i>,  u]iiigi>t  itx  n.'Wily  as 
ill  beaJtb,  and  lU  tondor  and  swollen  stato  outlasts  the  inflammmioa 
ortlie  nflerent  lvni{>liiitio  veitw^l.-*  l>y  u  few  dny»i.  It  may,  lio«ro\-«r, 
enlarge  to  twice  or  thrico  ite  natural  size,  and  continue  BwoUen  and 
Ittndor  for  two  or  more  weeks.  This  is  oBjiecially  uotioeablo  in  the 
caae  of  a  gland  near  the  femoral  ring ;  the  tondornesB,  tension,  even 
SorfitoO)  and  iWRitimi  of  wliiiili  scimulimtis  cansv  Jt,  when  root-ntly  in- 
flamed, to  bo  nuHtaken  for  a  strangulated  heruia,  especially  if  at  lirst 
there  should  concur  with  its  indiuuniatiuii  some  nausoa  and  consti- 
pation. Or,  fortlier,  the  gland  may  nuppurato.  This  event  may 
not  cmne  until  a  woek  or  mor«  after  tho  inHammstion  of  the  lym- 
phatio  vessels  has  passed  away.  It  is  sometimes  indicated  by  t 
renewal  or  intTwiise  of  tlic  local  pain,  and  by  rigors  and  otlurr  oon- 
RtiCutional  symptoms.  But  not  at  all  unt'recjuently  &uppuntiMii 
occurs  in  a  gland  without  any  local  symjrioms  which  attract  notion  i 
Tbe  first  piun  attendinfr  the  inilammation  liaving  suWided,  <j 
patient  may  bo  imconscious  of  any  disoase  in  his  armpit,  wh 
matt«r  to  tlie  extent  of  lialf  a  pint  or  more  may  lie  oollectiiig 
and  behind  tho  pectoral  muscles  Suppuration  is  rarely  limitod  taj 
the  area  of  tlie  g]iin<l.  Tlie  sup]>urating  structure  i«  rather  thil 
loose  areolar  and  adipose  tissue  in  which  the  glaud  is  imbedtloOfl 
anci  which  here,  as  olsewliert.*,  is  observtHl  to  .■iuppurato  witli  a 
degree  of  inflammation  tJian  that  whicli  already  exists,  witbooii 
tfxcitiiig  suppuration,  in  tlie  infliinictl  orgiui.  Absewavs  conn 
with  iiiHamed  glands  may  therefore  roach  any  size  wtiich 
position  allows ;  they  aro,  for  instAnou,  prone  to  bo  larger  ui  tbil 
loose  tissue  and  spacious  area  of  the  axilla  than  in  any  other : 
occupied  by  superficial  glands.  Tbe  iniUtor  dischargixl  irora  tlio 
lA  thick  and  >voll  formoil ;  and  af^er  it  and  any  slough  which  aij 
have  boon  produced  by  tlio  intonsity  of  tho  inilammation  hix* 
been  evacuated,  tlie  cavity  closes.  An  abscess  in  the  armpit 
groin  soon  heals,  but  in  tho  popUteal  spaco  tho  ciux>  is  not 
ircHiuciitIv  !<low. 

Iiilhunmation  and  suppuration  of  Uio  glands  appear  to  be  «]is 
native  lis  regards  tho  »flVTijiit  lymphatics*  and  the   injured 
parts,  and  protective  as  regards  the  circulating  blood.     Uuring  I 
continuance  of  suppuration  in  tlio  axilla,  tho  activity  of  iutla 
tion  in  the  distal  parts  subsides,  as  gonorrhcca  is  often  t«mporarir 
suspended  so  long  as  a  bubo  i»  forming  or  frettly  iliscliarging.1 

t>  "  Ubi  pesUs  mluuB  srvo  motau  laoesdt,  in  malUoivs  deciuubit  gli 


I>-FLAMMATIOJr. 


865 


olher  lumd,  the  poison  wKicIi  has  reached  the  gl«nd  by 
tbs  h-mphaticji  does  not  (him  beyond  it.  ^Vhw),  hmrcvHr, 
Mw  jxiotiilitr  oniptiou  comes  out  on  the  trunk,  or  «ivi«ro 
Mul  t^mptonut,  liko  Uioiu:>  of  pjii-mta,  iiriso,  it  is  clear  that ' 
^  poison  is  not  limited  bv  the  gland  in  the  manner  Rup- 
Of  the  rorious  hy{Mtl)i.«^^  by  wiiifh  thtwc  oocurroncos  may 
lined,  tlioM  seem  most  consistent  with  the  anatomy  and  the 
yaaoi  of  (he  abmrlwnt  n-Htcm,  wltich  lusign  tho  pustular 
1  to  the  anafitomosis  of  minute  cutaneous  lymphatic-'*,  and 
Ktkii  of  tiio  blood  to  tlio  glandular  suppuration  itself.  In 
Bxr  nee,  tho  poisonous  matter  >vhich  is  held  track  by  tho 
tfion  tnivorws  tlw  collateral  channcli>,  and  produces  pus- 
ibvevar  it  filters  oi'er  the  vast  aren  of  »kin  stdjordinato  to 
Mnicttd  f;;IandK.  In  tho  second  case,  tho  matter  from  tho 
llalfii  easumej  to  find  n  rvndy  pUMOgc  along  tlio  vfTcrviit 
•mbt*  into  the  blood. 

setoiCibttiona]  irrmptonis  attending  an  attack  ofacut«  an- 
Mtiiire  Eomotimes  se^-ere.  Iligors,  nausea  and  vomiting, 
if  lUn,  thint,  dryncra  and  coating  of  tho  toiiguc,  with  coii- 
BB,  tlMplessDess,  and  considerable  nervous  agitation,  a  quick 
{ng  poltc,  and  a  fuuling  of  langour,  arc  usually  the  severest 
foimeniA  of  tlie  di)i«nM».  Iftlio  fovi-r  bo  ty|iboid,  if  tlicro 
ifin  ItsUd  sweats,  severe  muscular  pains,  high  excitement, 
hniing  heat  of  tikin,  and  marked  delirium,  tho  jwison  ift 
ip»  Irmitcd  within  tho  Ijmphatic  channels,  but  has  infil- 
tb  nllular  Umuc:*,  and  has  tainted  tho  blood.*  As  tlio 
■limi  eabsidee,  and  local  suppuration,  a  cutaneous  emp- 
rfotid  discliarges  from  tho  bowels,  como  on,  tho  genornl 
U  become  those  of  exhaustion. 

earn  dc^netod  in  tho  foregoing  description  aro  thoM  of 
able  hot  of  ordinary  severity.  Tliere  is  much  variety  in 
Met,  ltovre\'er,  in  different  coses.  Tlicro  may  bo  a  mere 
inrefieBS,  with  some  enlargement  and  hardening  of  a 
kDst  Um.'  intermediate  ^inpliatlcs  between  the  woimd  and 
d  have  either  not  inflamed  or  l>een  so  little  irritated  tliat 
or  inconvenience  bad  been  felt  in  thorn.    A  hard  cord 


I 


m  ad  eotpOfU  »tipvrficiem  prominent;  qusilcs  sunt  ingutnales, 
fee    Si  convai(«««re  tlatur  itgmtaiiii.  lumoven  ii.  uU  iu  varlnlls. 
nancisi-uutur  nippuniiuuuai,  morko^ue  uAtunun  liao  via  exonc- 
«K(1  Je  Curtttiate  Palit. 
EBnutLu,  Amiul  FotsoKt. 


969 


DISEASES  OF  ABSORBENTS. 


jnnv  bo  felt  beneaUt  th«  Bkiti,  loading  to  a  toildcr  swollftn 
but  there  mav  have  been  no  red  lines,  and  there  may  bo  no  say- 
fitiruLioiL     Tliere  'n  w>tuetiinos  un  imillary  aL«cc«»  without  the  pn^| 
.  \'iou§  occurrence  of  rod  lines,  and  the  latter  may  form  wilboi^^ 
oc«a.Ht»iiing  liny  Axillary  tt^idvrneM.     SumotinK>s  the  track  of  th« 
ab»orbente  is  tender  for  a  day  or  more  before  tJie  red  lines  a|^H 
pear,  but   more  commonly  thvy  itrv  nmungxt  tlio  varlicr  Hymp^n 
tonis  of  the  inflsmniation.     In  one   case   I  have  seen  red  line* 
Kpjioiu-  tvriuu  bclwcvn  Uio  wound  and  tlio  armpit.      No  suppura- 
tion took   place  in  tlie  iutlamed  gland,  but  a  pustular  cmplioii 
over  the  trunk  sei^rafd  to  vhow  tlmt  some  puisoii  which  had  passed 
the  gland  was  being  eliminated  by  the  skin.     In  another  case  tbft 
absorbents   iitRamvd   witliont  occasioning  tliv   linear   rodoess  oo 
jthe  skin,  and  three  abacesAos  formed  in  the  axilla.     There  wiu*  in 
this  case  no  cutaneous  eruption.    Whun  suppuration  oocure,  it  mask 
commonly  does  so  only  in  tlie  glatid ;  but  it  may  take  )>lnoe  in  the 
absorbent  track,  without  involving  tlio  gland,  or  may  aifcct  both 
the  vessels  and  the  glandit.     In  the  later  progreHs  of  tho  Mverur 
cases  additional  symptoms   and  pathological  changes   may  resuk 
ironi  partionlar  constitiitionnJ  tendencies  of  the  jiatient     Tbtu  I 
have  known  inflammation  of  tho  absorbents  of  tlie  arm  terminate 
in  fatal  acute  u-tluma  of  tlie  tongue,  llic  ab?orbtiuU  boiug 
trated  from  the  thumb  to  the  submaxillary  gland. 

Simple   triiunijilte  in  Summations  uf  llie  ubsorlients   prevai. 
particular  localities.    Tliey  ai-e  very  much  more  common  in  the 
and  axilla  than  in  any  other  parts  of  the  body.     A  aimiUr  obscrva* 
lion  has  been  made  respecting  plague,  and  the  reason  in  both  casts 
appuiu^  evident.     The  hand,  from  wliicb  tliese  intlaiiunntions 
liat«,  ia  at  once  more  liable  to  injury,  and,  except  the  (aioe, 
cxpONd  than  tlie  rest  of  the  surfaeo.     Glandular  suppuiatioot 
the  mesQDteric,   lumbar,   and   bronchial  glands  are  aa  amall 
they  are  rare,  and  only  some  of  the  casus  of  Iliac  and  pelvic 
scesses  following  upf>n  parturition  are  to  be  comftared  in  e 
with  those  ill  the  armpit.     In  one  situation  glandular  sup] 
calls  for  an  especial  notice,  viz.  at  the  lower  part  of  the  leli  aide 
the  neck.     A  severe  and  deeply  seated  acute  suppuration  is  apt 
fdrin  in  lliat  situation,  and,  as  it  is  bound  down  by  die  &s<ria9 
platysma  of  tlie  r^on,  it  may  oontinuo  long  without  finding 
outlet.      It  occasioiw   great  swelling,  o^ina,  tension,  an<l 
Tlio  root  of  the  neck  is  much  raised   by  tJie  swelling,  and 
clavicle  hidden.     In  all  the  cuses  which  I  have  acen,  tJie  a1 
was  on  tho  loft  side  of  the  nock,  iovolviog  tlw  wbolc  rcgioD 


mate 

larn^ 


DJFIiAMMATION. 


267 


• 


cervical  part  of  the  Uwracio  doci,  and  aot  exi^aditig  into  the 
axilla.  TIk  iiiu»e  of  Unav  gmtil  und  »ur<!rti  MujijninitioRs  is  sojno- 
timos  obacaro,  and  they  may  not  always  ori£:iaate  io  dbease  of  tite 
Ivmphatica ;  but  Miuuliineti  »ucli  u  ntixlo  of  ori^ii  docs  appear, 
ami  in  ono  of  my  casee  an  enlarged  tender  gland  was  described  oa 
Wing  been  first  felt.  It  ahould  also  bo  rmiiumbered  from  how 
Biaay  parU  Ij-tnphadca  cmiverge  towards  the  lofl  side  of  the  nook. 
31us  is  the  only  tituation  in  which  I  have  known  an  acuto  and  b«- 
nre  sapporation  aubaide  without  the  external  discharge  of  ttie  pus, 
Infliuniuatioii  of  thu  lymphatic  glaud»,  adtnitU,  somvtlmos  occurs 
done,  i.  €,  witliout  any  previous  perceptible  inllamniatjon  of  th^ 
■ftncnt  veaaols.  It  doos  so  after  totaa  of  tho  fovoni  of  childhood. 
Hn  higher  cervicad  glands  arc  then  vdy  Uable  to  swell  and  beixini« 
paintiil.  Bcin^;  in  tlio  neighbourliood  of  tiio  lower  jaw,  tongn«,  and 
fdiarynx,  all  movements  of  thi»e  parts  are  resiruined,  and  »  good 
d«l  of  suficring  atttinds  mastication  and  swallowing.  Such  cases 
of  adenitis  follow  scarlatina,  and  are  sufficiently  explained  by  tho 
flato  of  the  throat.  The  cause,  in  other  oases,  is  probflbly  to  be 
$otod  in  Lhe  cuuibinad  iiitlueiiccM  of  external  cold  and  tlie  arculatioo 
fa  tho  glands  of  blood  and  lymph  charged  with  the  nosdous  elcmentB 
of  the  fever.  Thaw  «aiaes  are  iii>t  to  bo  confoiiiKUxl  wttii  thwc  of 
cjnaoche  porotidea.  An  absorbent  gland  in  the  centre  of  the 
till  may  inHiuuo  as  lymphiitic*  inllnine  vlsvwhciro,  but  its  disease 
Dot  produce  tho  characteristic,  contagious,  and  metastatic 
ouniiiionly  known  by  the  tuuuc  of  mumps. 
Treatmatt  of  in^nted  abtorlenU.  Many  of  the  ordinary  duties 
x{>iiso  persons  to  this  painful  afTcction ;  and  it  often  arises 
ctuiuunoes  to  which  busy  manual  labourers  pay  no  attention. 
A  layer  of  collodion  upon  a  small  wound  or  puncture,  or  of  court- 
fbetat  uj/aa  a  longer  wound,  might  avert  many  of  tlie  nttacks  of 
jnflamnd  absorbents;  but,  as  a  matter  of  fact,  little  or  n<i(hii)g  id 
done  in  such  cases  in  the  way  of  jtrevention.*  When  patients  with 
wwinds  of  any  kind  arv  under  medical  advice,  the  eoinuion  procau- 
of  oleansing  the  wound,  stM^uring  the  projier  action  of  tlie  puri- 
iog  organs,  and  avoiding  unhealthy  diet,  air,  and  occupatiuna,  aro 
iiigh  to  prevent  such  attacks.  U)H>n  tlie  occurrence  or  tlu%aten- 
iqg  of  an  inflaaunation  of  the  absorWnt  vessels,  thuMc  mciLMirex  will 
found  to  succeed  be«t  which  rentoifi  tlie  cause,  repress  the  violent 


Th«  pTSctlM  of  RtnMLHiitt  tho  hands  witli  oil  befiire  touching  noxious 
Ua  ia  tonad  to  pnn'«nt  tba  mi*4JiicG>  which  mitiht  arise  lioiu  absorptioD, 
1  ia  of  great  raliu  at  post-iDort«m  tHUUslnations. 


268 


DISEASES  OF  ABSORBENTS. 


,g«i,  a 

irate  ^ 
ipptr  it 

cotH 


local  symptoms,  and  moderate  the  constitutJonnl  rea«t*on. 
wutiiid  Hlioiild  In  III!  cuM»  I>e  tliuroughly  cleansed.  It  sboald 
opened,  put  under  a  Btream  of  water,  syringod,  or  voakol  in  « 
thorouglily  hot  l)»th,  u  may  \w»t  xiiil  itii  form  and  oondicion.  If  re- 
cent, or  punctui'cxl,  it  !>houIcl  be  tuckc<d,  and  thou  twiclH-<l  (lirnii<;h- 
out  with  u  nliok  or  jiencil  of  nitrtito  of  siK'er.  If  6abby,  it  should 
be  stimulated  with  a  suilsblo  mineral  lotioa.  If  fo^id,  it  nhciuld 
bo  wrapjiwl  in  nohitions  of  Condy'ft  or  lJnrti«tt'B  fluid,  or  in  chlori- 
nated lotions.  If  sloughy,  it  should  be  covered  with  Peruvian  ImiI* 
nam  and  a  poultice  of  Iinw.'cl  im-ul,  chm^ioal,  or  heer-ground*.  Heat 
is  in  all  these  cases  grateful  to  the  patient,  and  if  often  changed,  iB 
order  to  Mvure  tho  cleanHiiig  of  the  wound,  u  jfouluoe  will  gem 
be  found  the  beist  local  application. 

Tho  lymphatics  tliemsclvos  ant  heat  treated  by  tho  nitrate  i 
ailver.     It  should  be  wiped  a  few  tjmes  on  tJio  moistened  skin 
along  the  red  or  tender  liite^.     Ciu'c  should  bo  taken  not  U>  apply  it 
too  freely,  as  tho  subcutaneous  tntlammation  can  be  as  eflectniUly 
moderat«d  by  blackening  the  skin  as  by  blistering  it.     AfU-r 
ing  and  applying  ciustio,  the  Surgeon  may  wrap  the  limb  iu  < 
wool,  itnd  enjoin  comjtlete  rest. 

The  glands  in  the  early  stage  may  not  have  ftliarcd  the  irJhiin- 
mation,  yet  tho  nitrate  of  silver  may  be  applied  over  thorn  also,  ai^_ 
the  use  of  it  should  in  all  cases  bo  carried  higher  than  Uie  tcnd^H 
BOSS  and  redness  of  the  surface.  Tho  remo\'a]  of  all  fiirther  irrit»* 
tion  from  tiie  wound,  and  moderating  tho  inHainnuttioii  of  ti>e  lyi^^ 
phatic  vessels,  will  in  most,  but  not  all,  cases  secure  the  pa^lH 
from  mppnration  in  an<I  near  tho  glands.  If  further  means  apf^ar 
requisite  for  this  end,  they  may  bo  found  in  leeching,  and 
application  of  ico  or  a  cooling  lotion  to  tlie  surface.  1  have 
however,  found  cold  ailapted  to  arrest  threatened  stipjiunition 
glands.  Heat  is  commonly  moro  grateful  to  the  paticiii  than 
in  such  cases.  It  may  be  employed  in  a  bath  or  in  the  AnH^ 
Bteam.  Tlie  latter  may  bo  directed  trom  tho  spout  of  a  kettle  a, 
the  tense  mid  painful  part  by  means  of  a  pu{>er  tube.  If  the  i»* 
6ammation  continue,  mercurial  ointment  is  :Usq  useftil ;  it  sboi^ 
be  ].'ii<l  not  only  over  the  gland,  hut  along  the  track  of  tho  |>r0riCPMl 
Ij-mphatic  inflammation,  which  has  already  indicated  the 
channel  for  alisorbed  rumediea  to  reach  tlio  influmod  glimd.  It 
bo  observed,  however,  tliat  in  not  a  few  instances,  when  ones 
glands  have  inflamed,  no  treatment  avorts  suppuration,  and  «| 
attention  must  always  be  dii-octod  to  tliera  for  a  week  or  two 
the  firet  iiiHammaliou,  iu  ooii«e(|uence  of  tho  ooduionally 


HYPERTEOPHY  A»D  ATBOPHT. 


se9 


I  of  abwym  ftflor  adenitis.  Vtlttyn  iicuto  fjlnndnliur  nlisor^ta  is 
Jnncing  to  Ute  sorTat^e,  and  (K<ca»i»iiiiig  much  pain,  it  ehoiild  be 
opoied.  But  if  Ihvru  be  itny  roaMHi  agiiiiiHt  this  treiitiiiviit',  much 
niief  to  the  fiufToring,  and  some  acceleration  of  the  pointing,  are 
cUaincd  by  Iihx4io«.  Frtim  onv  to  tlireo  locch«K  are  quite  cnoiigli  for 
tins  purpoM ;  a  larger  number  would  have  the  effeot  of  retarding 
lad  diflfiuing  tlw  itu[^>uration.  In  like  manner  the  i^low  progreva 
rfa  chronic  abscosa  of  glaiKlH.may  sometimoit  be  quickened  by 
A>  ap{^catJou  of  a  small  blister  upon  tJie  prominent  port  of  tlio 
mlliiig. 

Hio  tmtmont  in  tho  lymphatic  inflammations  of  oon^'aloscoiita 

|iidiielly  thai  which  will  relievo  the  pain  and  guard  against  tho 

Itwiewbat  ran  event  of  suppuration,     8t«am,  foUowtxl  by  an  appli- 

|aiioii  of  ootlon  wool,  ordtnnrily  wrvcs  tliis  purpose,  and  pure  air, 

without  draught,  is  also  of  much  importanoe. 

SfpaitK^hy  andatt^hfoffflatuU.  One  of  the  first  facts  obsen'ed 
I  Mndying  tho  l^mphatie  system  is,  that  in  disease,  and  still  nini-o 
[  it  healthy  its  condition  varies  willi  that  of  the  tiaauee  from  which 
[JbicHela  spring.  So  fiu-  as  age  defines  tho  activity  of  growth  luid 
'anitioti,  tho  glands  varj-  witli  it.  They  are  proportionally  larger 
)  fa  (UUnn  than  in  adulls,  and  in  those  than  in  persons  advanced 
,  faliia  Bat  with  premature  ema«iation  of  other  ttittttiea  glanda  also 
I  bdbro  tlioir  time,  and  they  have  boon  found  lai-gvr  in  a  wcll- 
I  iMriAed  wotnan  at  nijieiy  yetira  of  iige  ttiiui  in  one  who  at  1if\y 
■ddJed  exhauMMl  hy  dtronic  disoaso.*  In  wiry,  slender  people  tho 
jghndi  tn  unall  and  linn  ;  they  iu«  sueeuleiit  and  hirgo  in  persona 
Ifkncterised  by  softiK;ss  of  hbrc,  a  tliin  £iir  skin,  and  vymv  «inlx>n- 
£ven  ill  tlie  same  body  the  l_vm]>haticA  tliU'er  trom  one  an- 
aocording  to  tfao  tumios  with  which  thoy  aro  asNociat^Nl,  the 
ture  or  functional  activity  of  tlio  jtrimary  organ  entailing  some 
bnnqionding  variation  in  the  texture,  the  size,  and  oven  ttie  num- 
of  the  Hubordinato  lyrapliaticx.  Tliero  i»,  for  instance,  less 
lolar  structure  in  the  oourso  of  the  absorbents  of  one  of  the 
extrejnilies  than  of  one  of  tho  lungM,  great  ait  in  the  diifcrcnoe 
I  the  bnUC  of  those  parts.  The  largest  of  all  the  absorlx^nt  vessels 
thoso  (bund  in  cunnexion  willi  the  nlerus  at  the  period  of  par- 
Aod  as  in  size  and  nnmbor,  so  are  there  diflTerrnec^  in  tho 
ofvariiiUH  lymphatics.  "The  ghimU  of  the  tliigh  or  arm 
1  fffff*"in  s  large  colnmn  of  mercury  without  bursting ;  whiUt  tlio 


GnUiver'B  Btirttm,  S«dcnbiun  Society's  edition. 


STO 


DISEASES  OF  ABSORBENTS. 


1 


jllanda  on  the  mesenter)',  or  on  the  lombar  vortobrs,  easily 
F«r  "  tln^tw  last  resomblo  llw;  vinccr*  of  ilii>  iil>Oomi.>ii  and  tlkoraxi 
whose  texture  is  much  more  delicate  and  tender  than  that  of 
eitvmul  muscles."  • 

The  transition  in  im|wrccptihle  from  an  hypertrophy  or  enlnr^ 
m«nt  of  f^lunds,  which  oorre#]H>n<U  witli  the  ttaXo  of  the  tissnes,  (o 
one  which  is  strictly  nmrfiid  ;  and  in  practice  it  is  scaively  to  be 
dcfiiKHl.  A  general  iubiess  of  all  the  glands  concure  in  M>me  per- 
Bons  with  ricketii,  a  largA  hrnin,  and  a  hy;iertrophied  tliyroid  glaiid. 
In  otlior  coses,  the  largo  succident  glands,  which  are  met  with  in 
children  of  soft  loose  fibre,  soem  readily  to  receive  Uie  yvUow  d^ 
poflit  of  actual  disease.  Tliore  is  also  a  class  of  chronic  enlargo- 
tnents  of  the  gland.^,  which  tm-  occasioned  by  no  traooahlo  inflam- 
mation of  the  afferent  lvTn|»halic8,  and  are  attended  by  no  pain,  and 
but  rare  liabiUty  to  wippuration.  Tliey  have  hcen  dcscribwl  by 
Dr.  Hodgtcin  in  the  Medieo-Chintrgieal  Transaeftontf  vol.  xvii.  The 
spccimcnii  (iresorved  in  tli«  Gny's  Hoopital  muMnim  ar«  of  rt-jy 
large  size,  a  single  gland  l>eing  three  innhea  or  more  in  length. 
They  are  smooth,  uninflamcd,  and  oittirely  free  from  scrofulous  do* 
poeit.  Tliey  are  said  to  have  been  of  semicartilaginotts  hardn««, 
ptle,  uitifttrm,  non-vnscnlar,  and  slightly  trani^lucGnt  on  section. 
l3ie^  were  observed  almost  uni\'ersaUy  throughout  the  body,  and 
•ooompaniod  with  an  enlargement  of  similar  appearanoe  in  the 
spleen.  They  occurred  both  in  ehildron  and  in  middle  life ;  wnw* 
times,  but  rarely,  they  suppurated ;  and  they  proved  fetal  by  tlM 
ani^mia  and  exhaustion  whieh  atl«n<le<l  them.  Siieh  gland*,  id 
well  as  those  which  arc  plainly  strumoos,  may  by  mere  bulk  no* 
cwion  great  inconvenience  when  lying  near  ductti,  vcc<«clii„ 
nerves.  Death  has  been  altributod  to  their  encroaohment 
bronchi.  Their  prcsonve  in  the  pelvis  is  said  to  l»e  <.'«]>idile  of  ir 
fering  with  parturition,  and  when  pressing  on  the  trachea  they 
occasioned  so  much  distress  that  the  subcutaneous  (lt\'ision  oft 
stemo-niastoid  has  boon  thought  advisable  to  relieve  the  breatJiill([.f1 

When  thewe  cases  are  excepted,  and  tliose  which  are  referred  W'l 
in  other  parts  of  this  essay,  there  are  few  slow  enlargementa  ofAiB 
glands  IcH  whieJ]  can  be  assigned  to  mere  chronic  inflammaticffl. 
Some  Bueh  cases,  however,  inasmuch  aa  they  yield  to  n  mild  imj- 
curial  course,  arc  assumed  to  be  of  thnt  nature.     Tlie  case  Itad 
be  very  clear  which  could  admit  of  such  treatment ;  but  the  fne** 
ita  occurrence  justifies  the  treatment  in  cases  which  are  ant 


*  CruU{i>Uuitk  on  lAtf  AbiorbtnU,  p.  Tl. 


t  Oro»«,  3nry*rf. 


BTRtTMOUS  GLANDS. 


hy  eonslitutional  disease,  or  which  do  not  pold  to  the  milder  inea- 
SOTM  rwonunendcd  for  Uio  trentmont  of  itcrofulu.  The  iiutmiry 
■hooU  be  [ireAcribeil  m  suiaJ]  <lo)»efl,  and  be  combined  with  some 
tonic  Quinme  and  calomel,  the  biohlorido  of  mercury  in  dococtioa 
of  bark,  Ute  btnk>dide  ot'meroiuy  in  the  form  of  a  |iill,  and  oa- 
hunba,  caMarilU,  qtusaia,  or  sanaparilla, — any  such  combirtnliona 
may  be  ndoptcd.  lit.  Ilodgkin  was  dinpoMd  to  rely  on  the  nae  of 
liquor  pouasga  in  tlw  matta^mcnt  of  the  esses  wliich  ho  described, 
bat  he  had  tw  opjtorliiiuty  of  t«t>tJiig  ttio  remedy,  llie  Htato  of  the 
glands  in  ca«m  of  rickets  rarely  rises  into  importance  as  oomparod 
with  the  olIicT  diJM^ft.'io.  Wlien  it  doe*  m,  it  l»  diiefly  on  aocniint 
of  Euppuration  taking  place  in  Ibem,  with  every  indication  of  a 
ttmniutis  character.  I'ocal  tn»tiiicnt  may  ff^  on  at  tlin  saino  time; 
ointments  or  washes  made  of  mercmry,  iodine,  opium,  or  of  eom- 
Innstions  of  tliew  rcmedic*,  being  contimiotLtly  applie<l.  BIi)it«rs 
are  to  be  avoided  in  glandular  inflammations.  They  neceesariljr 
irritatA  the  Ijinpltatic  vi>t>cU  of  the  i«kin,  imd  t«nd  to  aggravate, 
nther  Uian  moderate  an  existing  inflammation.  A  leathern  plaster 
Isft  constantly  on  tlio  rarlaco  is  more  eSbctivo  in  nxlucing  tlie 
nrelling,  and  it  may  bo  medicated  in  any  manner  suitable  to  the 
case ;  tlie  varioo*  cnij>l]istra  of  tLo  FhamiacoiKJuia  aSunliiig  choice 
igh  for  that  purpose. 


fc 


Stnmma  dvta»«  m  tht  lymphaiict  having  boon  acleoted  to  illus- 
Etratt)  the  snbject  of  Sckohjla,  it  will  not  be  necessar}'  to  repeat 
in  this  place  *a  much  of  tlw  dencrijition  of  the  glandular  diwcuo  as 
was  required  for  the  general  article  on  that  subjotit.  It  may  be 
alm»*t  wh('Ily  studied  in  vol.  i.  pp.  3,10  rt  *c*\.  Some  fiirthcr  facts 
most,  however,  be  here  stated  in  order  to  oompleto  the  surgical 
■ocoont  of  the  disMtse. 

Stnmous  disease  may  oocur  in  glands  with  the  inflammation 
which  often  sneoecds  the  cruptivo  fevers  of  childhood  and  youth. 
MawJhi,  varicella,  scarUtina,  &c.,  are  not  uncommonly  followed  bj 
an  nlarpnnent  of  thv  evrvHcal  glands,  wlitcli  may  become  chronic, 
«hI  aiwnme  the  characters  and  cour»c  of  struma.  Scrofula  may 
abo  ori^nato  in  glands,  npon  some  irritation  or  diNOasc  of  the 
or  organ  witli  which  tJioy  are  connected.  It  appears  to  be 
in  the  onlinary  way  of  in  flam  mat  ion  of  lymplinlics,  but 
modified  by  the  slate  of  the  constitution  in  which  it  oocors. 
an  iajmy,  lar  moro  frnqiietitly  a  slight  cJirunie  ailment 
ibe  ildn,  occasions  an  eiilnrg«mcnt  of  a  gland  or  glands,  the 
[iQution  of  stromuus  matter  in  it,  and  snbsoquuiit  cliaractcristio 


m 


DISEASES  OF  ABSORBEOTS. 


eofteoittg,  wliich  can  hardly  bo  described  at  supparatict 
eiilnrgcineiits  of  die  cervionl  g1an(l«  may  thun  he  traced  to  crupUont 
on  the  scalp;  some  to  inflammation  or  suppuration  of  the  ear; 
other*  to  tiie  irritation  of  decayi\l  ti'fitlt.  Ayiiiri,  tliero  «re  affec- 
tions of  the  glands  with  struma,  traceable  to  primary  disense  of  the 
Mtmo  Tiiiturc  in  the  orgun  to  vrhicb  ilit;  gliuuis  Bre  Htilionliimtc. 
Bcrofiila  is  thus  repeated,  after  the  maimer  of  cancer,  in  tlie  fl|)er- 
nuitic  and  lumbar  glands  from  tubercle  in  ttie  testis;  and,  liko 
cancer,  too,  it  will  increase  in  the  absorbents,  and  prove  fatal 
after  the  extirpation  of  tlie  organ  which  w!l«  primurilv  di*caKd. 
Broncliia]  glands  arc  often  tuberculous  in  correspondence  wttli  the 
lungs ;  a  ghind  over  the  maAi»et«r  with  the  blew  eye,  or  »trumout 
lippitudo,  &a. 

But  there  are  not  vrimting  coses  in  which  n  primary  occasiuo 
for  the  disease  in  Uio  glands  cannot  be  discovered,  and  in  vihieh 
the  cause  may  be  some  undefined  fault  in  the  nutrition  of  tlw 
tJSAues.  For  whilst,  in  some  instancas,  only  the  bronchial  glondi 
arc  tuberculous,  tln're  are  others  in  which  they  only  are  cxcni]* 
from  the  disease.  Some  jiatJents  have  only  an  enlargement  ef  the 
lacteal  glands,  the  lymplinttcs  being  overy  where  natural;  in  oiticn 
tlie  difteaso  is  entirely  limited  to  the  general  abMirbenta,  tltoxe  of 
tlio  bowels  being  healthy.  Some  patients,  again,  have  a  univenal 
di.ioaite  of  the  glajids.  In  these  innt^icott,  the  extentiivc  diiOMiM  can 
only  be  supposed  to  arise  from  some  general  cause,  as  di»tinguisbed 
from  a  locid  irritation. 

The  diagnosis  of  strumous  disease  of  glands  is  rarely  difBculL 
Ibe  Iwge,  clnnteriHl,  movable,  ttibci-ons  miLtses  which  they  cum- i 
monly  make  in  tlie  neck,  axilla,  or  gi-oin,  can  be  ahvays  recognb 
to  be  glandular,  and  there  is  but  one  otiier  diaua»c  which  U  lia 
to  be  confounded  with  tlicni,  Medullaiy  cancer  soraotiniai  grows  iB| 
many  glaixU  and  to  a  largo  size,  and  forms  a  cluster  in  the  Bum* 
ner  of  those  of  scrofulous  nature.  But  gUndular  medullary  oasMfj 
without  n  distinctive  rotiognisable  jirimary  growth  is  cxtremcif  nWij 
and  in  the  presence  of  such  a  growth  tlie  diHiciilty  of  din^iuw>| 
could  not  occur.  In  the  few  in^<tancos  in  whieh  cancer  docs  hsfpd  I 
in  glands  alone,  it  may  at  fir»t  be  but  uncertainly  diMioguifiKaJ 
fixim  strumous  disease,  by  its  more  rapid  growth,  it«  leas 
and  softer  lobes,  ita  elasticity,  and  sometimes  by  ita  electric  jniiL  1 
The  late  progress  of  the  cancer  to  ^*ast  size,  Uvid  elastic  protubc^i 
ances,  and  fungous  bleeding  ofientngs,  are,  plainly  diiitiiiet  fioO] 
t)ic  slow  enlargement,  the  shallow  stijipu rations,  and  the  flaky  pan*! 
form  difiohargeu  of  the  so'ofuluus  tumour.     But  little  aausUnoe  Ml| 


STRUMOUS  GIJVNDa 


273 


\      -1 

^.n  111.-  I 


be  derivod  finoro  Ok  age  of  the  patient,  as  the  majority,  botJi  of 
stntnotn  Mid  inc<(u]liir>'  tlimtuM.-.*  of  gltui(Ii>,  occur  iH-funi  jmlxTtj-. 
A  aingle  stnuiious  gland  is,  very  liable  to  be  mistakon  for  a  tumour 
of  iMImt  nature,  <:»]>ccially  whcu  it  lins  »ii[>pur»tvd,  iiiul  liits  roiuuinixl 
long  encTstetL  The  diHtiiivtion  can  o»l^'  be  drawn  hy  tlie  history 
fllK*  at»o,  llie  »|i[>citraiH-n  of  tliu  [tatlvut,  and  doxtvruuH  miuiipula- 
OD  die  port  of  the  Surgeon. 

TIic  ruppumlion  of  MruniotLs  glands,  thoagh  eonunon]/  s]ow  and 
I,  is  oceoaonally  acute,  eo|)iou»,  luid  attt-niluil  with  riijild 
auuHatioti  and  wenkeniiig  of  ttic  patient.  Tiii«  »ccins  to  bo  par- 
tioalariy  the  case  with  strunioua  glandutur  ub»(-<^4<<ci  in  the  groiu, 
which  »>itKHini(.-?i  vqual  tb»  largest  orange,  and  discharge  as 
noeli  as  tlirt«-<iiiar1eni  of  a  pint  of  muddy,  ill-forniod  pui<,  mixed 
with  large  quantities  of  yollow  scroluloiis  flakes,  E^'en  when 
ci|>ened  comparatively  early,  or  whiii;  yi-t  forming,  iIk^w;  ucuC^ 
itu  abtMXfWcs  are  atttrtidod  with  hcntic,  and  a  genera)  debility 
IcM  aevera  than  tliiit  whieh  acconiptmiois  llit;  sollftiiing  of  tubercle 
ID  tlK-  long. 

I'ar  more  commonly  the  dironic  al»cci*»<s«  iwniicctwl  with  wro- 
liiloaii  glands  aro  remarkable  for  tlieu*  slow  progress,  the  oocafiional 
variatiotifl  in  thoir  condition,  thfir  niUier  fn^nuent  »|>oiitHnoous 
nanoval,  tJteir  fc<>btt>  eflbrts  at  rejiair,  tlioir  burrow iug,  and  Honie« 
tiuiKJt  fur  the  oopioUH  and  even  fntal  IjiuniorrluiKO  which  thoy  ccca- 
■ioo.  Tliey  appear  to  be  most  commonly  fornie<i  otiL-ide  lim  ^bnid, 
aoil  to  Imvc  lliurufi>re  ono  part  of  tlioJr  witrfiiee,  viz.  the  gland,  in  a 
Mate  of  diaeasG.  ITte  matter  wliich  is  fonued  in  them  is  not  pure 
ft»,  raeJt  «!•  IvaiU  to  a  vi^onnix  inf1» minatory  process  In  the  tissual 
tnitmd  it,  but  yellow  tuberculiius  h-uiph,  aiul  a  serum  so  thin 
•nd  nlightly  doudy  a»  to  »uggo«t  lliat  it  may  bo  but  lymph  which 
luB  escaped  from  uidioaled  lympli-tubes  and  oa^itieM  tn  the  gland, 
fionetirnvs  Um  hIkwi^m  iKvomcv  ibcdd,  from  a  part  of  its  euutt^nta 
abeorlied,  or  Temoved  by  the  way  of  the  lymphatic  vossels ; 
aonietimiM  tlie  Hiiid  part  entirely  disappears,  leaving  only  tho 
yellow  material  behind  to  shrink,  and  afUtr  a  long  period  to 
cretaocouiL  A  stninions  abseoKS  rarely  jwiuts ;  it  gi'ncrally 
Iv  midennines  and  de»lix>vs  the  hojilthv  nkin  which  co^-ers  it; 
it  burrows  alw  among  the  lunoolar  tissues,  wliich,  as  hits  Ixx^n  said, 
not  rcfleiit  its  encrouolinient,  and  I'lu^luse  it  by  a  compact  dam 
tymph.  The  opening  of  such  an  abscwui,  Uicruforc,  is  but  the 
■pcningofone  portion  of  a  jtimiouA  uiid  perbapH  branching  canal, 
itu  J^vprr  parts  it  may  extend  to  tlic  vicinity  of  larf;e  lilood- 
U,  anil  dtaastruus  results  may  ensue.  Tlio  internal  jugular 
9V-  IFIi  T 


274  DISEASES  OF  ABSORBENTS. 

vein  is  «omotimos  ob1it«rat»1  and  eontraded  near  such  an 
twti  or  tlirw'  iiic'lK-n  ofil,  mnv  l)«^  ftittirdy  removal,  niwl  it»  nppCT 
and  lower  orifiwB  plugged  with  l^inpli.  Artoriw  in  each  circum* 
Mnnoo*,  on  tln^  wmtrarv,  may  iilwrntv ;  and  not  »  few  autrs  aro  on 
record  in  wliicli  large  quantities  of  arterial  Wood  liave  poiired  from 
stmmoii.i  wlwrs  involving  the  int<;ni(il  carotid.  Mr.  Symo*  d«- 
seribos  such  a  case,  in  wliieh  the  haemorrhage  lasuod  repeatedly,  and 
tvori  attcr  tlio  lignturif  of  tlie  trnnk-vi'siscl,  fivtm  an  nbifctiss  beneath 
the  ear,  but  was  finally  stopped.  My  colleague,  Mr.  De  Morgan, 
ti«l  the  eoiiuHon  oarotid  for  profane  arterial  liainorrhagr  from  the 
tonsil  in  a  ease  ofstmnious  disease  of  the  higher  eei-viojil  glaiids. 
Tiic  ptitifiit  rapidly  Jind  imtirely  recovered  from  phthisieal  as  wril 
as  the  loeal  strnmoiis  H_\-mptoms  under  whieh  he  had  heitn  Inbonrini;. 

The  trmfmnif  of  savfitloxi*  gland »  is  in  •jrcat  part  conHtitutionRl. 
The  disease  heing  of  slow  growth,  and  based  n[>on  gradual  iinpair* 
mont  of  the  gt-nenJ  nutrition,  it  rapid  improvement  i»  not  to  b« 
fixpocted,  and  the  niea&uros  ailopte<l  must  bo  oontiiniouNly  perse- 
verod  in  for  u  long  jwrJod.  ^^'llen  it  is  remembered,  too,  that  in 
(lonie  instaniwa  external  glandular  bus  Ikh'ii  ob-iervwl  to  alteniale 
with  the  Irir  more  jjorilous  tubercular  disease  of  tlie  Kings,  and  lliat 
in  ven-  many  eases  the  snperveni  ion  of  rhe  Iali«r  dtMta'to  upon  tbo 
former  is  fatal,  it  will  be  seen  tliat  any  treatment  is  to  be  eschewci 
which  abrujitty  n>[)n>sseK  tlie  diiwiu'te  in  the  gIniiiR  tiood  ufy 
nntritious  food,  ample  and  ehoerfid  exercise,  act  imi>ereeptibly  but 
continuously  U]ion  the  Ky»lom,  and  wujijjly  Uio  best  means  ofre-^ 
daoing,  as  the  contrary  cireiunatanees  do  of  originatuig,  scroP 
If,  tberofiire,  the  eom|)I<-t4;  reniov.il  of  the  disciiw  and  its  causa  il 
be  aecomplishod,  these  advantages  must  not  be  supplied  for  a  i 
time  only :  the  citizen  nin»t  take  up  \m  residence  in  tfao ' 
and  the  vai'ious  hygienic  conditions  of  good  health  must  be  | 
nontly  adojitcd.  In  the  selection  of  a  locality,  it  is  an  error 
xnppnse  that  the  mild  moist  climates  of  tJie  aoutliern  and  weettnl 
coasts  of  our  ishmd  an?  equally  siiittKl  to  all  patients.  Host  eftltfl 
earlier  eases  do  iKttter  in  the  bracing  air  of  tlio  high«r  lands,  ^hs*  [ 
they  attain  a  better  standard  of  licaltli  and  more  bodily  vigour  lluBj 
in  the  relaxing  regions  near  tlio  sea.  Struma  of  all  funtij,  in  il* 
lattT  stages,  is  nn  quest  ion  ably  benefited  by  sea  air :  but  at  suiial*  j 
seasons  it  is  fur  from  invariably  injiireil  on  tlie  high  lanils. 

TFie  medicinal  management  of  stnunoos  glands  is  amply  d**! 
scribed  in  the  essay  on  ScitannA,  vol.  i.  pp.  355  H  nrq. 


Contriliulitmi.  Ac.,  IM»,  p.  ■iHi. 


GI^NDS  Di  STKUMA  A^^)  SYPHILIS.  275 

Tbe  aculo  ftuj^uraUon^  nfitlmnia  n«cd  early  evacnatioii  fay  the 
Sufgfwn'H  knitc,  as  mucli  as  otlicr  aliscowcs ;  and  in  order  to  avoid 
titu  drain  uiM>ii  llie  [taluMit'A  srrciijjiJt  nliJcli  llii>y  C9it>o,  tliov  skonld 
be  carefiiJIv  syriufiod  oiit,  injected  wiUi  lotions  of  gallic  acid,  jkjw- 
dend  opium,  burk,  iodine,  or  with  tlio  more  ^timidsitin^  invtalJio 
solutions  of  Kilvvr,  copj>cr,  or  zinc,  and  then  accurately  bandnged 
■ud  ount|)rv«iod.  Tiwtr  diiw'liargva,  in  fiuil,  inuHt  bo  Icascucd  as 
mooh  as  is  conBistent  witli  the  ueceosary  espukiou  of  Hmr  un- 
ovganimblv  coiitvntK  and  walk  Tlio  jHtUeiit  will  rcxiuirc  amjde 
^Jbod  and  stiniulaiits  from  tbu  tirst 

H      In  nwpect  to  the  Ircalmont  of  chroiiio  strumouit  abxo^wA,  little 

^raeed  be  added  to  the  general  remarks  made  in  the  essay  on  Scito- 

jVrruu     It  wlknikl  never  hv  fi>rgutt<.iii  tbut  koiiiu  itucli  colioctions  of 

31-bnncd  pus  are  reabsorbed.     There  are  a  few  cases  in  whicJi,  al- 

ibDu^li  the  matter  'w  advancing  to  the  Kiirfaou,  but  withuiit  a^^ually 

foining,  tJie  abscess  msty  be  [>uncturt3d  obliquely  by  meana  of  a 

Imar  of  »aital>le  taxe,  and  freely  and  rejwot«dly  syringed  out.    Tlie 

(UMiire  may  then  be  closed  and  the  cavity  conipiw?«ed,  with  the 

kfti  of  it«  wallit  vohering.     ^\'licn  the  HbHci---«  ha»  undcnainod  a 

Okie  tract  of  integument,  the  attenuato<l  skin  is  otb^n  irrecoverably 

dMBoyvd.     It  becomes  livid,  opens,  mid  is  \'crj'  slowly  tdceratcd. 

i>>  {Rsence  interferea  with  die  free  dischargo  of  the  matter,  luul 

[RnaU  the  cicatrisation  of  tlio  ahsocM.     Very  much  time  is  saved 

^Aea[i[iliKitiun  of  oauntic  to  Uie  whole  integument  no  thiniu'd,  as 

^Ibo  &c[>aratiou  of  tho  stoiigh  the  nholv  base  of  the  abi't'css  is 

^•Md,  and  iUt  margin  is  in  •  .ilate  to  cicatrise.     Long  irregular 

IWei,  which  undermine  the  skin  in  the  same  manner,  luuy  bu  laid 

%*  by  the  knifii  In  their  whole  extent,  or  at  it.uiui1>le  intervals  by 

•itoi  «|>plkatioDS  of  caostic     Tlio  majority  of  sucli  aises  will 

'■9  Ileal  under  prsMunx     In  a  few  persons,  howovor,  no  surgical 

I  hilaiut  whatever  secorea  the  clusurc  uf  these  borrowing  tisluluiw 

ilitnL    Tlwiy  may  I>u  slit  ojien,  eauteri.->ed,  injected,  jiared  along 

.  and  to  their  very  extremities;  yet  thoy  will  burrnw  still. 

but  a  chan^  of  resident.'t!  ami  gnat  improvement  of  tho 

I  ^tral  liealth  proves  sucocssfiil.     Massive  and  |ir<ijeotint;  sU'umous 

I  l^uJa,  to  witieh  tliu  tntvgnnienlA  fiiil  U)  adhere,  and  the  presence  of 

,'tidi  retanU  or  prevents  the  healing  of  the  abscess,  may  bo  de- 

by  piercing  tliciii  with  nharp  slicks  of  caustic     Upon  tlie 

c^  tlie  alough,  such  sore«  become  luvvl,  and  may  heal. 

tIcB   in  typkilU.      Tho  actions  of  the   lymphatics  when 
wilii  Byj^iliit  supply  so  imporlunt  a  port  of  the  general 


S7«  DISEASES  OF  ABSORBENTS. 

doctnnoe  of  tliat  diiACOSO,  nnj  hnve  Ixwn  so  iinipV  (Ie*cril>fld 
Jllr.  Ix'fi's  essay,  that  reference  may  bo  made  to  it  tor  >1)  iutiinna* 
Hoa  (vol.  i.  p.  375).  fl 

Tlicre  is  a  form  of  tnolpcular  abBorption  vrhioh  J  hai-e  nercr  »oe^^ 
a^mbwl  to  ircpliilif,  bitt  which  hn»  a|>]K'aTXHl  to  mo  to  bo  one  of  the 
lut«r  cH«-tfl  of  that  chsonae.     In  persons  wlio  luivp  hail  v«i»fn)al 
nfieetionE  many  yeari"  before,  and  in  soiiio  who  still  present  some 
Irrtiury  furnis  of  that  diseaHo,  the  tips  of  the  fingeni  or  tofi*  bmrnne 
remarkably  vtuntcd.     At  fir«t  »  pit  i*  fotiiid  in  tlio  pnlp  at  the  end 
or  on  tliii  palmar  Hurface  of  the  digit,  having  no  pus  or  kc^Ii,  nor  yH 
healthy  skin  at  the  bottom.     TowsnU  this  pit  the  rest  of  tJie  pulp 
jind  the  nail  aiw  slowly  (h-awn,  ."ind  as  they  n])proarh  ii  nro  «lw)rb«<J. 
Every  stnictiux:  of  tli«  finger,  inoludinj;  the  bone,  is  propressively     j 
removed,  iinril  xt  lengtJt,  in  plaee  of  a  jiliabnx  of  tlnt.ie-lonrlh:'  of    | 
an  indi  in  lenjE;th,  nil  that  reniaini;  htiyorid  the  la^  articidation  i«  > 
roundi^l  Ktiinip  of  the  l)ono,  not  a  quarter  of  an  inch  in  Uniglh,  and 
covered  witli  tightly  etretflicd,  tliin,  dry  skin,  n-ithont  a  vestige  of 
the  luiil.     Tl]0  ivlmle  proc-e*i  may  occupy  many  months  or  yean  in 
progi-e>i8,  and  for  the  whole  time  is  niiaM«iid«l  by  ineiblo  ulceration. 
The  tnifjen*  are  stilf,  and  often  eomparativcly  UM^Iewt,  from  tlwton- 
demess  of  thoir  i-stremitics,  so  long  on  the  disease  is  going  on.    In 
eunie,  but  not  in  all  ca^eK,  the  skin  of  the  band  or  f(H)t.  in  uftrcletl 
with  lepra  aiutstbotica,  or  with  psoria»i»,  or  is  dry  and  scurfy.    1 
Iiavc,  however,  observed  it  to  be  quilo  healthy. 

I,;jniphnlks  in  gimorrhii'ix.  Tlie  lymphutics  in  (his  diiwafa  swiie- 
timen  share  in  the  intensity  of  the  local  in  flam  mat  ion.  "Hie  prni* 
mny  be  ewverwl  «-iih  nwl  line-*,  and  tJm  in^ninal  glands  infliime  tiA 
Huppiirate  on  one  or  on  both  sides.  Tliia  whole  Bobjecl  wiU  b« 
found  tredtetl  in  the  esiwy  on  GoNORRniEA. 

Lj/mp/ititirs  in  rancfv.  For  fiiet*  coiinocted  with  cancer  in  the 
glands,  reference  may  bo  made  to  tJn'  essay  on  that  subji-ct  in  wi.  i. 
p.  5tl^.  Sonic  ndditienul  remarks  bearing  on  diagnosis  will  b* 
f[>tmd  in  the  section  upon  the  state  of  the  fflandu  tn  iNnonml  rfunu» 

An  absorlR'nt  gland  infoctod  with  cancer  may  contain  the  lai' 
niitest  speck  of  the  disease.  1  have  foinid  unihT  iJin  miem»pi>pin 
epithelioma  a  Hitiglo  small  spot  of  characteristic  cells  in  a  whole  li<'^ 
of  perfectly  hoahhy  glandular  stnieturas.  But  it  oitnn  entirely  ccsk* 
to  be  u  ghnid  at  all.  The  whole  structure  is  replaced  by  cancer.  I" 
certain  situations  tlie  disease  extends  lo  nil  atljoining  tixxue*,  uiJ 
invulvcM  and  destroys  all  tho  glands  of  the  region.     Secondary  can-^ 


GLAXDS  IX  CANCEB. 


877 


MfU 


in  tiM>  f^roin,  (■>r  example,  riiIlowtii(;  pridinry  fItneaAe  of  tlia 
M  or  vulva,  laaj  thus  extoruiinato  sU  tlio  inguiiiul  Iyni[>)iatii3 
tyatvat,  and,  wltcn  tjivy  nlwrntv,  iiijiy  <;iv«  iin  Mitlet  for  a  copious 
diaclarge  of  U-nijth.  In  aucli  a  case  1  have  obscneil  not  ouly  coD- 
■idenble  ailvnia  ol'tbu  fuot  aixl  (^'iiitiil  or^an*,  u'lii<-U  wiia  duo  to 
hindered  circulatioii  of  the  lymph,  but  a  wasdiig  also,  and  in 
one  lantMiuv  an  aimont  omiplcto  coiirvreion  uito  iat  of  {^liLtitLi  in  the 
htmbar  ivgion,  aa  if  their  fnaction  bad  been  lessened  or  aboU»]iod 
by  the  iMtlution  of  tlu;  lower  liinb. 

Far  more  commonly  tlw  mle  ia  obBorved  that  canrer  rt»producod 
tJitt  lyiiiphiitii?.''  lx)c<HnoK  ilJfluHcil  liiroiigbotit  Iho  i^yxtcni. 
Cttatxe  of  tJic  lymphatic  glands  ia  rarely  difficult  to  rocognive. 
Is  ike  large  majority  tj(ea»»  ronic  pritiuiiy  tumour  duiniH  ihu  ohief 
attention,  and  dctenninE«  liie  nature  of  ilie  aeooiidary  alfoction, 
Wlxn  tlK  f^huxiular  diMaM  so  far  oxt-ovds  that  of  tJio  primary 
(■me  as  to  be  limt  olvwr^'ed,  it  may  be  dtHtinf^iJHhtHl  to  bo  HcirrhouB, 
MMtnoos  by  tins  oontraclwl  sliot-likc  tuiaours  lo  wliich  ttu?  glands 
nfim  reduced,  »omtiiuti.4  hv  tiieir  being  enlarj^vl,  wmii^nies  by 
Aarbeinf;  cliutvml  (ogccber  into  an  irrD^^iIar  tuniuur.  Thi'  oharao 
Wiitic  hardnc«>  of  acirrhtui  i»  more  commonly  iioticiici  in  tlie  tirat 
we,  uncF,  when  eclrrims  occupies  but  a  part  of  a  gland,  tlie  ro- 
Bnaier  of  it  may  awnll  and  caiwo  thv  wlmU,*  to  fotrl  vouijiaratively 
"A;  and  wlien  it  occupies  one  or  more  entire  glands  and  grows  bo- 
1*1  llMm,  tbo  whoht  Umiour  u  stony  only  du  lung  ajt  dvgi'nerative 
"imiiig  in  it  ia  delayed. 

Ibi  diKtinvtioit*  uf  vnvephaliiid  viiitvcr  of  gliinds  are  Ntated  at 
^  ttt,  and  tlioDo  of  tbe  epithelial  Ibnu  of  tho  disease  in  vol  i. 
t-i». 

Sw  first  occurrence  of  caneer  in  a  gland  may  take  place  quickly 
*lue  after  tlte  formation  of  tbo  primary  tumour.  In  n>Hie  in- 
ftaeci  the  wcondary  disi^aae  in  even  obacrvtHl  fufit;  in  others,  tbo 
Tlpbtics  eseapo  iiifec'tion  altogothcr.  Upon  wliat  tli«»e  various 
■Mdvpaiul  a  tiot  kiti)Wn,  but  it  i.t  inti'j-esling  to  obiterve  that  ili«.'y 
W  ibeir  panllcl  in  the  patliol<^cAl  actions  of  tlio  lymphaliea  after 
tW  iniwrtioD  of  a  poiiuin  into  tl»c  body,  t>ametime8  tbuy  intlanM 
*ilii  great  rapidity,  and  tometimes  they  are  not  ulVtwted  at  alL 
^«BKiniM<  ili«ir  iiillaminntion  !.i  ddaycd,  and  in  tbo  ctuiv  of  the  in- 
Mtktioa  of  smallpox  it  is  not  until  tho  sci-cnth  day  (hat  tho  glands 
ndaini:.  Tbo  advance  of  oaiwer  l«  the  glands,  and  iU  commpntx*- 
oaa  in  them,  am  alatosi  invariably  iumotic<Hl.  in  m  ca»e  of  niinv, 
'''«e««r,  one  of  primary  mikI  still  uniileei'ated  eanecr  of  the  hand, 
Uc  abeorbeuU  ven  first  affected  with  iuflaniiiuitiDD,  red  liuto  sud- 


278 


DISEASES  OF  ABSORBENTS. 


^ 


denlj  Rming  on  tho  skin,  aiul  a  gland  ralarging,  which  soon  as- 
samod  the  cliitract*^  of  ciinoei-.  The  imtieiit  vnta  a  wvll  ^rrowii 
womanJy  girl  of  fourbfen,  and  tlit  tiitH.-aso  of  medullaiy  Datare,  and 
cxtrrmviy  nipid  i«  it-*  progress. 

Wlien  onoe  ostahlishLil  in  a  gland,  cancer  asnally  pnrBiica  its 
oolirso  liko  liny  otiier  Hccoiidiiry  ttiniotir.  It  may  attain  a  very  ino- 
deraw  or  a  vast  si^e ;  it  may  bo  etationary,  or  may  wither ;  it  may  h 
apjK-sir  i|i'[n'ii(I<rnt.  cir  iiidejH'iidcnt  on  Iho  priinnry  pruirth  or  on  th^| 
growlh  of  otiior  tumours  In  lh«  body.  These  fads  are  suffiaootly 
stated  in  tlio  urti('l«  on  C'AsrKR.  It  may  Im  addiil,  that  no  ca.'u^ 
of  an  nniiersal  tainting  of  the  lymphatic  sj-stera  with  cancer  are 
ever  ohscrvod,  n«  i*  sumvtimes  tho  ci»h>  witJi  tuht-rclo.  Cancer 
appears  to  travel  along  tho  alworlients  in  a  manner  which  is  ex- 
plicable by  the  aniitoniicnl  nmmgOuiciiU  of  thoso  vcttuls,  and  not 
to  atlect  tlie  system  as  a  whole. 


4 


Th^  ylnmlii  in  innotmd  di^nttr*.  Lyntplinties  apjwar  to  hiiv« 
qiecial  relation  to  tho  fiinetions  of  the  several  parts  with  which  they 
arft  connected.  Oi'gimit  hiivinj^  only  hi<KKl-veB«K^i»,  a)iil  tluxw  pn^ 
viducl  also  with  nn  excretory-  duct,  eqnally  possess  a  system  of  alv 
aorbentj*.  The  {^liiniU  may  liivn-fnre  Iw  said  to  bi-  appendt-d  lo  tha 
tissues,  as  such,  and  may  be  expected  to  vary  with  Uiow  tissacs  in 
thoir  condition.  That  they  do  Uiui*  van-  within  the  huiitit  of  boaMii 
has  been  already  stated  in  the  section  on  /(//yvrfro^iAy  ofifUmd*:  anA 
the  probability  \*  timt  tht-y  are  omsi^cutiiciy  altiivd  tij-  o\-cry  mor-^ 
bid  variation  in  the  condition  of  the  tissues. 

In  practice,  liowcver,  mcli  morbid  variiitiori»  arc  not  approaxUe. 
imless  lliey  canse  a  change  in  the  siiFe,  form,  or  dt^imity  of 
gland&     So  Ihr  a»  Kitrgery  is  coniwrnod,  glands  not  apprccaaU; 
affectetl  pass  for  being  hcallhy. 

Tlie  iinjiunancc  of  the  qnc^tion  as  to  tlie  state  of  the  giandi*  in 
various  diseases  is  shown  by  the  general  fnrt  already  alleged  u  K> 
tlicir  inipliention  in  cancer,  In  contrast  with  iheir  condition  in  rrf*- 
ticn  with  tliosc  tumourn  which,  prarlically  and  in  n^^fHict  to  thi'  fh' 
ject  of  inqniry,  may  bo  classed  as  not  malignant  Altliongh  st  the 
oommeiioeinonl  of  cimoi-nuM  growtlis  the  glamls  are  rarely  affwl'^T 
yet  they  arc  sometimes  both  early  and  most  extcnuvely  disoK^t 
and  at  wimi>  \n-r\tA  lii'fi>r«  death  they  arc  almost  nniformly  invadwh 
Even  the  bony  substance  of  osteoid  in  nprodiiivil  in  thti  ghonb* 
An  alfcolion  ofiho  U-rnpliatio*  by  any  inn<icent  tiimour,  on  the  eoo* 
trary,  in  tho  same  sense  in  wliioh  they  aro  involved  in  caaocr,  * 
very  rare,  probably  us  ruru  as  thu  cusu  uf  glands  mutffoctod  in  thai 


I 


OI^NDS  IX  LNNOCEXT  DISEASE. 


279 


Tbev  iDMv  indeed  be  enlarged  in  oitniicxion  widi  ait  in- 
'swcont  tatnuiir,  but  tl  is  bfcnusc  irriUitioa  of  tlic  Hkiu  or  tilcerntloD 
Uketriae  vxinu*.  Kucli  enlnrgi-incitt  ia  a.  tTtuinmit  liifliiniinatDry 
BWtflting,  not  a  introduction  of  tlic  priiuanr  dUtasc  in  tho  gland, 
ami  i»  nu  inoiv  Ui  be  tucribi^  U>  Uie  [>i%»c)kuj  of  Uiu  tumour  tliiui  if 
none  existed. 

RAwninfr  tmb  etoegy  I  tnny  cnumcrato  the  followint;  disouses 

in  whiL-li  no  a)>preoUbIo  affection  of  tho  I^-nipliatios  h  observed ; 

kl)  Hiiujil*?   b_v{H'rtTV))tbio»  of  uiiy  orgiui  or  part,  juid  uti  tumuurk 

which  present  some  likeness  to  the  structiuv  in  which  they  m-o 

£in(i*iL      FibrnHs  tunKim-K  of  tho  titcru»  mid  proNlatc,  llicrufore, 

■tiu<i>us  poU'pi,  chronic  maramary  tumours,  cutaneous  thickenuiga 

and  tnolltiAca,  iKl!t)<i«i.i  tiiuiuurs,  luid  cxo^to.'ws,  with  othi.ir  growtlis 

•rfthe  same  character,  are  onattended  by  tlie  development  or  re- 

felitMm  of  tlid  <UiM-asu  in  Uio  fjUtids.     If  (.-yct^  sliuuki  uurxiitt  with 

mlignant  tumours,  Uie  glands  may  be  affected  with  cancer;  but 

(yn»,  ax  mch,  luid  cytto-sarcomn,  are  never  iollowod  by  fjrrc- 

^oading  disease  of  the  lyn3phati(».     TliiH  fact  is  4ib.->ervt^l  in  the 

varr,  tlw  00  uteri,  tho  kidiioy,  tlic  subcutaneous  structuri's,  the 

IHinalio  fiOrd^  ftomelimefi  in  oolloid,  and,  whut  it*  of  lla*  <;ri!iil(;At 

pKbn]  importflnuc,  always  in  the  foniulc  breast     My  colleague 

Kr.  De  Uorgiui  hiut  iii  tlie  pn^^nt  time  under  hiit  catv  a  niiddlv- 

■gaJiriKaan,  whoso  left  breast  was  tho  scat  of  an  enormous  inno- 

ftU  tuiHiur,  and  tliu  right  of  a  WL'li-niiirkiMl  ncirrhoui  growth. 

"*  fcnner  tumour,  growing  rapidly,  and  threatening  tlic  patient 

•ilk  Bpwdy   deMtli,  was   nrmiivtHl,  and  wa»  found  to  be  mixed 

^ifc  and  adenoid,  or  clironio  mammarj-.      The   right   axillary 

t^it  wore  cxtviuivvly  cann>ruu.4 ;  yet  m  on  with  cuiitri'r  ttius  «x- 

^Aig  in  the  body  elsewhere,  the  glands  in  the  left  axilla  wor« 

hr.     8iiti]w  lunioiu>,  coin])<M(.-<i  of  sLniotun^t*  uiiliku  tho  part 

tlhicb  they  grow,  are  not  attondod  by  disease  of  tlio  same 

W  b  tlK'  glnn(l».     An  vnclioiiilroiiia  of  llic  femur,  which  1  ob> 

•"♦ni,  iJiongh  of  vast  sixe  and  fatal  to  life,  was  entirely  liniitud 

hlbal  bunv.      In  tlie  i»chiuin  ilImi  a  oiu-Lilaj^inous  tumour  has 

^  known  to  bo  unattended  by  lymphatic  diacaw.*     The  muno 

ba  n  oomnionly  noliued   in  l)io  eiiohoudromata  which  grow  in 

■fe  Gngeni  and   the  pai-otid  region,      Tlio  oidy  cxcrplion  to  this 

lie  ef  exemption  of  iho  lyinphutiist  from  secondary  cartiln^nous 

■fcotiaa,  ix  a  case  of  enchondroma  of  the  tcstiH.     Tortuous  large 

L^Mk  in  ibe  eoid  woru  Ibund  to  be  filled  with  adherent  fragments 


*  BonucH  on  CaBcroiit,  ^.  110. 


280 


DISEASES  OF  ABSORBENTS. 


of  fflirtilngc,  nrnl  ta  load  to  cnlargwl  plnriils,  mul  to  a  ottrtilagmr 
tumour  of  the  size  of  aii  egg  adjoining  tlie  inferior  cava.  Aii  oul- 
growlli  of  cartiluRC  protrudwl  from  tills  tiiinonr  iiiUi  tlw  voiii,  nnd 
c.irtiliigc,  parriwl  |(erliaps  in  some  form  by  the  venous  blood,  WM 
finitid  ill  tin-  iniliiumiirj-  iirtt^non.  It  ini>;lit  Imvn  lM>eii  iiun-e  nword- 
ant  with  the  u§iia]  clinical  progress  of  enobondroina  if  tbc 
tiln^  in  thix  csva^  hnd  bouu  oaiitKinod  in,  mid  lind  sprctid  by, 
Bp«M-inatie  veins ;  but  the  maaaes  which  it  foiina  appear  to  be  tr 
gliindiiiar  onlurfroinvnt  of  the  cord,  aiid  they  were,  after  long  diM 
section,  regarded  as  lyni|ihatic  by  Paget,  who  recorded  the  ease  id 
Uic  Afciluv-Cliii-imiwdl  Trarmicliotts,  vol  xxxviii.  p,  247,  and  who 
refers  to  it  in  vol  i.  p.  4i)0  of  the  ])rc()ont  work.*  Fibrous,  Sht^m 
cellular,  iibro-nuelcatud,  and  other  tutnotu^  of  heterologous  com- 
position,  do  not  aifect  tliu  glantU ;  but  when,  though  not  adopdiw 
the  structuro  of  nifilignant  dieoase,  they  nssunio  its  clinicwl  charMH 
ters,  they  may  ]>rodii(;it  some  modcrato  hiirdi^niiig  and  entargomeoF 
of  tiio  glands.  Softening  and  a  characteristic  ulcer,  with  csuK-nml 
growth,  novor  occur  in  these  casc^  without  t-ruo  CJUictymufl  inC 
tion.  Of  myeloid  tiimours  of  bone,  it  is  ]>robably  too  much  to  : 
that  ghuiduliir  dis<-:iKe  is  neccr  n  part  of  tlicir  niiturid  progivw,  sir 
like  medullary  cancers,  they  are  often  amputated  before  the  pcrifl 
at  which  the  lyitiptiiitic»  would  Ik^  involvixl.  In  somo  Hiich  < 
however,  the  disease  has  returned,  and  has  been  indistiuguifluih 
from  cnnwr.  Chrwuif  alwcosscs  in  the  sidistaiKr  of  orfrnu",  such  i 
are  sometimes  confounded  with  more  important  tumours,  do 
oociuion  nn  oiilarjCiineiit  of  the  glands.  An  hydaliil  cyil  may 
covered  with  cxtri'tncly  large  lyoi])hatic  vessels,  yet  occasion 
plain  diisoti;!io  of  the  sulwrdtnato  glando.  In  an  instaneu  of  u  lurooD 
in  or  neai'  the  female  bii-ast,  which  contained  echinococci, 
wliich  had  been  HusiKx^lcd  to  bo  of  malignant  nature,  tJi«  g!a 
were  entirely  frro  from  disease.  A  considerable  enlargement  i 
the  inguinal  glands  took  place  in  the  course  of  a  cose  of  cxt 
rough  gouty  disi'iuio  of  tlu-  hip-joint,  stid  was  attendetl  with  ode 
of  the  limb,  The  intercurrent  gUiudular  affection  subsided  liu 
prolonged  ra-it, 

Pyit'inia  is  not  attended  with  any  epoelfic  inRamraation  of  \j 


*  "  M.  VelpfDu  a  pi'vsentA  k  rAoad^mie  de  Mideeint  (seanoe  da  I 
juillet  lf>!'l)  till  etifi-pliiilo  1(1(1  (lu  lealicule.  ntve  des  tialii^s  «anc«rMiiM  1 
long  du  eurtloTi  spi-rmntii^utt.  et  un  uaillot  ij'Hj)paTenco  fibrinouM  drat  I 
vcine  cave,  h  <]ualre  tiiivci's  dc  doigt  onviron  au-deBSiia  de  la  ii«ijwan« ii««( 
deux  vuiiies  iliiiquoM.  I^  Rnillot  otait  fbnn^e  de  mftlieiv  enoipbaloido  no 
nmoUiv."  Kului,  (Jaeettt  MiJicaU,  20  juin  1861. 


GLA5DS  IN  DraOCENT  DISEASE. 


^81 


(bat  tliero  an»  a  few  general  (liscasea  in  whioli  tlift«c  puna 
TlitfHJ  ynlv  of  ihciti,  in  u<Iil)ttun  U<  tliow  which  fonn  the 
wbjeete  of  the  present  essay,  may  l>e  memionod :  vnriola,  vaccinia, 
tTFtnu,  plftf^ic,  hy<lnij>h<)l>iii,  j^laticlunt,  and  farcy.  1  would  a<Id  a 
fct  mnarks  upun  uIcx-Ts,  erysipelas,  and  nns-vi. 

Cfcen,     The  glim<U  nborc  old  iilecrs  are  oftwi  found  enlarged, 

Mil,  on  some  oecasioiis,  tfllwJor.      In  the  case  of  chioiiiit  iilwrs  of 

|1»1p-^,  the  gliin<U  raRily  claim  nttciitton,  and  littk',  if  any  Uiing, 

«  bomi  of  the  resulta  to  llie  glands  from  ohroiiic  ulr^n*  of  tlio 

■  b«*tl  w  trtcms.      But  when  an  ulcer  i»  sitiiutal  near  or  connected 

I irill my  form  of  liimour,  an  enlargement  of  tlie  glands,  smli  an 

attend  any  ulocration,  may  misluid  tlio  practitioner  into  a 

onrittiui  tliat  ibe  case  is  on**  of  cancor.     No  judgment  of  adi.toaiio 

I  IfOnl  to  i>o  cancer  should  ever  be  formed  n[M)n  the  gronnd  of 

cv^itteat  discom!  of  the  glands,  witliotii  considering  the  amount 

■  urilRljoD  of  skin,  and  the  cliuractcr  of  any  ulceration  which  may 
«•».    R«tt,  a  pro|»*r  jiostnrtf  of  tin?  niconitivl  jiart,  and  appro- 

1  PW  MOthing  or  other  treatment,  n-i)l  oflen  eatise  an  enlargement 
[  tf^md*  to  mibside.      I  liuvv  known  thU  to  occur  when   liai  ulwr 
orer  a  vast  cjato-sarooma  of  the  female  brca*.t,  and  oven 

*wi  tl»  priuiiil  irritation  was  nii  iiiHaiiicd  state  of  common  car- 

BBDDu  of  the  mamma. 
Stytipelaf.     The  cxaiitlicmata  wliieli  extend  over  the  whole 

Bfegnment  of  the  body,  as  scarlatJTm   and  rulitxilu,  do   not  per- 

^t5ly  affect  the  lympliatiCif ;  but  almo«t  all  limited  inflammations 
j  ■  Ihe  skin  are  accompanied  with  sfmn-  degree  of  tenderness  or 

Infill  enlargement  of  the  glands  of  the  part.     ARer  blisters,  npon 
[laiBritatton  aritiing  fn>m  many  xnrgicJil  appttentions  to  the  skin, 

■  nttcaria.  in  the  cntaneous  inliammation  following  an  ordinary 
lie,  it  is  often    int-l  with,  but  it  is  by    fiir    ni(»l    fi-eipient  in 

|*Tap«{as.     ^Vhen  that  disease  arises  on  mibroken  skin,  adenitis  is 
ittHr,  alllunigh  a  "light,  symptom,  and  little  noticed  in  oom- 
I  with  the  primary  cutaneous  eniptien.     But  when  ery^iiielas 
Rt  II  wound,  (li«  glands  aru  sometimes  swollen  and  tender 
any  btusb  can  be  discovered  on  tlie  skin.     They  aro  i^tod 
'bw  been   fiiiiiid  rod  in  an  entcritin,  which  was  recognised  as 
ons  ;■  and  tlie  almost  in\'ariabIo  occurrence  of  adenitis  at 
i4t tnininvnoemunt  of  tlic  dismso  goes  fiir  to  Hupport  the  opinion 
in  yoL  L  p.  22«,  that  the  first  inflammation  of  erynipelti.*  is 
I  lymphatic  system.     In  all  cases  except  tliotie  treated  of  iu  tlio 


■  0<tutuiI4dieaU,  ivia  J,  lita.  , 


nSEASES  OF  ABSOnUENTS. 

section  on  in^mmation  of  ifut  <Aaori>enlt,  Uie  glandular  n: 
tnuki>ioiit,  Rn<l  rt<qiiircH  no  sjiccial  trcotmcqit. 

I  hll^'e  iiaiiall>'  found  some  enlargement  of  tlte  local  glan 
jmst-inort^m  osaininutiunv  of  ca«os  of  iV'trri  of  iho  «kin.  Tlii)  nasf 
that  soiiit>  rnrinfi  of  nn-vi  niiiy  lie  dilatations  of  outaneotu  ibeort 
not  of  the  niinutv  vutiia,  bas  led  m«  to  oxamtno  tho  I^miplMtj 
these  cawA;  but  1  have  never  traced  any  ntinattiral  eoininunio 
of  the  blood-veiMek  with  thoBe  bearing  l,vm|>h.  la  *l\  tin 
oaaes  tho  patient  lind  died  in  oonKoquvneo  of  M>ine  ojionitiun  oi 
«!■%■«*,  and  it  wa«  oovored  wilJi  more  or  lew  of  an  unbualvd  w 
No  infeninoi',  (hori'ftjro,  oould  bo  driiwn  fn>m  tlie  oiilargfmn 
llio  gland«f  whiL-h  miglit  have  beeu  conuocti3d  with  tbc  ojwii  wi 
as  much  an  with  tho  iiicvtu. 

Marlnd  contents  of  h/nip!iaties.  Since  it  i&  a  jiart  of  tlic  hoi 
function  of  the  iibMirbt'tit  tiVNtom  to  roc4tivv  tho  matlera  disdui 
into  tt»  radioica  bv  tlie  tiisues,  it  hsp]>en§  that  in  disease  aUo  mi 
auhstanocA  liiul  thoir  way  into  it,  l*u»  i»  fro([uenlly  mvn  in  tb 
sorU'iit  veawU  of  tlie  pelvis  in  caaoa  of  fatal  utorino  iiillamm. 
It  was  fimiiil,  too,  hy  Dr.  Bright  in  tortu»ii»  lvin|>)uilio  v 
ha-go  as  ilinc  arteries,  on  tbo  wnlU  of  a  vast  liepatic  hytbitii)  t 
Virehowf  found  still  roaiaining  in  an  axillari,'  gtaud  tamv  ciniu 
which  had  Ikk^h  inxerte*!  \>y  tdttooin^r  in  tbo  »diin  of  the  luru 
y«tir»  boforo  dcatli.  Similar  but  lens  remarkablo  fact*  hu\'o 
long  knitti-n.  linjiidiiritn  hiivo  tho  kinphaiio  glands  ntat 
brunolii  tilled  with  earthy  ooncretionB,  wliich  are  supposed  to 
flUt  ofinhiilcil  stmii'-diist.  Poncy  saw  tlie  tliorncio  duct 
glnnrls  full  (if  A  -hi.^iy  substanoa  Perhaps  tho  most  oun 
morbid  inaliiial  unit  with  in  this  sjstcm,  Lixoopting  stniatinii 
eanccroua  uiatt^^r,  ja  tiiinie  fonn  of  dialk}'  uoncnrtion. 
maHr^-M  of  it  tun  III  li>iu)d  evni  in  young  nubjoutR,  wIiom, 
have  probably  1-iau  n^iAy  :ift'.-t«I  with  acfofnta.  Asealtai 
it  in  tho  thoracic  duct  >  in  i'  saw  a  calculus  in  tlio  MUtvac 
and  took  it  to  lie  the  caiL-K;  of  a  dro[)tiy.  Choston  obse^^'od  a 
nicic  duet  so  filled  with  bony  matter,  wliicli  had  Ix^-ii  abM 
from  a  spina  vontosa  of  the  ilium,  tltat  air  oould  not  be  h 
through  it.}  Some  glandular  dialky  concretions  in  a  yxiaat 
ore  stated  by  Vulpiim  to  buvu  boon  found  tinted  by  nuuldor, 


•  Quj-'s  Uoipttal  Muieuoi. 

f  tVlular  PafMo^,  tiiin«lnta<t  by  Dr.  F.  Cfaouec,  p.  18ft. 

;  t'KU.  Tram.  vol.  Ixx.  pari  i).  p.  SSJJ. 


ESCISIOX  OF  GLANDS.  283 

bid]  the  anima]  luul  hecn  led.*  Fiiwlly,  it  is  aBMrtod  Uuit 
'<•  hiivo  )>een  dt.'ieoveml  in  liuiiuin  bmnohinl  gtumU,  as  well 
:  tliv  ^LmiU  and  ftbsvrbeiit  vosools  ulttcwlivrcf 

ObttruOioiu  and  tbUteratkiiu  ofOtf  lympiatie  ventU.    Wlien  Mr., 

fterwarda  Sir,  JMkj  Cooper  tied  tlio  llioracio  duct  in  tin.'  iivck» 

f  Mime*  dt^s,  tho  recejHaciUuin  chyli  biu-st,  and  a  copious  estrava- 

maa  nf  Ktnpb  took  plmxt.     A  Htiuiliir  n-*u\t  i»  not  obttervixl  in  tlie 

subject  to  follow  tho  nioro  slowly  formed  obBtruotions  by 

Tho  muAcum  of  tiiiy's  HoHpital  contain*  a  s|tmtncn  of 

lai^ier  titan  a  pullet's  egf;  behind  a  diM>iutcd  ini.>senl«rio 

In  ihc  »mc  museum  is  a  llioracic  duct  cttniiiU-tvly  cotn- 

at  its  up]>er  extremity  by  concerotia  oervicnl  glands.     Tbe 

not  at  all  diluted;  but  as  thit'O  is  another  iiuii>»  of  cancer 

I'ieiiiity  no-ur  tlie  puiicntns,  it  is  not  im[irobablo 

[tbo  inHox,  as  well  as  pfHux,  of  lymph  through  it  was  hindered. 

MDf^i.  attiniipting  to*inj«vl  sotn«  pulmonary  ulj»^orWi>t«,  foniid 

liruoehial  glaiiits  so  obetruotod  that  th<<  mormiry  richer  burst 

-naab  than  tnverso  tlio  glands.     SoMnintTrriiij;,  without  ac- 

Ittine  for  it,  relates  the  instanco  of  a  robust  woman  suffering 

ankylosis  uf  the  kutw,  in  whom  tlio  alusorWnts  of  the  t)ii/;ll 

fariooM,  aud  ho  leniwly  tillixl  that,  itfion  t>oIng  pricked,  their 

U  contents  spulnl  %-iolently  forth,  and  that  tho  foot  was  !iHeet4xl 

tha  kind  i>f  ti-dvtna. 

A  farifOM  oun<Ulion  of  a  lymphatic  vessel  may  possibly  arise 

D  onotJior  cauM   tlian   it«  ohliti^ntlion,   iwntnujtiou,   or   (<nm- 

There  may  Iw  a  r«gurgiuition  at  the  U]>per  orifico  of 

ibuncM  duct,  or  theru  may  l>u  an  at-eidentid  eoinuiimiwtiatt 

an   absorlient   and   a   blood-veiisel,  an  arterio- lymphatic 

M  vcBo-ljtiiphalic  anoorism.     Such  a  case  might  be  that  of  ft 

duct,  figurnd  htit  utiexplaiix^l  by  C'niikHliank.  in  which 

ia  greatly  enlarged  and  tortnous.     Its  di:unet«r  \»  no- 

tlun  four  timcw  Ha  natund  fixe,  and,  being  increased 

h  an  well  aa  in  ealibre  by  the  great  power  or  weight  of 

■tream  wittiin,  it  Ii«s  in  many  clottely  adjoiiiing  loops,  which 

Icb  to  and  firo  across  the  vertebne. 

TTie  (jeuion  o/tfhxnda  is  now  rarely  pmetised,  and  more  rarely 
with   intent.     OccasioDallv  a   tumour   is   removed  &om  tho 


•  Potaln,  /mumw  (to  Otinfliinu  [.ymphiuiqutt  Vitviraut.  |i.  ilS. 
t   Daveinei  TniU  4m  Eniotouirn. 


S84 


DISEASES  OF  ABSORBENTS. 


sxilln  or  neck,  wliii*li  hns  Iioon  of  long  diiratian,  «nd  reoen' 
painlul  or  tticntivviiIiMit,  oikI  vrhic-Ii  tn  foand  ti|ion  cxL-iMuii  to 
a  oluster  of  .itminoiin  gluiida,  or  a  wngle  one  enclixditg  a  little  pi 
Gro«  once  removed  from  tlic  nock  of  a.  middle-aged  stnunoi 
woman  a  sniult  cliiilky  tumour,  wbich  proved  to  be  a  degnnera' 
gland.  But  it  is  lonjs  oinco  Surgcoiu  liavc  given  up  ddibci 
removing  maiMoa  of  flti-umouft  or  merely  enlarged  glaiuU  with 
knifi\  Tim  Urge  t.ul)i;rou»  dtist4.T8  of  alHiorbciit  glands  tu  tlie  nodi 
of Bcrofulona  subjeets  seemed  to  invite  that  treatment;  but  wlie 
on«  undorUiki-ti  it  was  found  to  1»  of  formidable  ebaractcr,  glao 
after  gland  presenting  itself  for  extiqiation  aa  the  more  Hiiperficu 
vvn  removed ;  and  the  o)K^mtion  wa«,  eomtcquently,  often  ftbu 
doned  before  it  waa  comjileted,  and  rarely  hail  any  issae  but  that 
ewly  d(!«tli  by  Iht-  doveloprnont  of  plitlii«is  in  the  hiiig». 

T!i0  extirpation  of  ejuiceroiis  glands  proi^eeds  on  the  saiB 
gmiiniU  ns  those  on  aecoiint  of  w!iich  tlm  primarj'  tumour  is  n 
moved.  If  the  latter  ean  propagate  iltelf  while  conneoled  vH 
tlw  body,  so  mny  the  former ;  and  although  excision  ean  never 
advocated  as  a  means  of  eradieating  the  constittitJonal  nfl'ectioi 
and  obviating  the  rcuuiToiico  of  tlio  diseam  elaewhcre,  yet  it  mat 
bo  aJvifliibte,  on  the  ground  that  lite  presence  of  any  tumour  nuM 
be  rogardwl  as  insuring  and  ha^tpiiing  the  general  progncw  of  tb 
malady.  It  in  not  necensar^-  tu  rejiisit  in  tJiis  place  tlie  facts  on 
argument*  by  wliieh  this  ndo  of  practice  lias  boon  supported  i 
the  essay  on  Canckb  ;  rcferunee  on  the  subjeet  ejm  he  made  to  it 
TIio  ncccMity  of  taking  out  the  whole  gland  and  the  tissue*  suT 
rounding  it  is  ulN«ohit«.  It  i^  not.  enimgh  to  optm  tlio  tough  fawii 
fihcatli,  in  which  such  glands  sometimes  become  imboddcil,  an 
merely  enueleiite  tJiom.  A  eloAr  halo  of  lienlthy  atructures  flbon 
be  rcmovetl  with  them.  The  difficulty  of  cfTiK^ing  this  proUb 
gtxM  far  to  cx|ilaiii  the  fiKTt,  that  little  xuceeas  attends  the  extiff 
pation  of  tho  fenioral  and  higher  cenicaJ  glands,  as  oompan-d  wit 
tium'  in  till!  axilla;  and  tbe  vsL-um  are  oompnmtively  vciy  few 
which  it  is  proper  to  attempt  it  in  the  groin  and  node 

CHABLK8  H.  MOOBE. 


f 


jftrf A^ntv  J'hfetntuT 


HtTNTER  was  the  first  (o  desmbo  iajtrtrnmalion  of  the 
liiKi  membrane  of  rtint.'  Aivtinui«t  li.id  Kmg  btifonj  rofirretl 
B  mieh  dinordcr;  but  the  difKO-te  he  doac-nhod  wm  ko  ill 
!,  that  no  otio  profitt^il  by  or  songlit  to  advHnc«>  bis  cmde 
Craliin-  Rfl<!r  ot^iitMry  SiirgfXinB  continued  to  jiuixttiirc,  flivido, 
eiR-  Veins,  feorU-ss  of  tlie  ro»uIt  iiud  innoct'iit  of  tlicir  infliim- 
.  Tronbli'Muiiio  .'iyin)>tonifl,  It  ih  trui-,  NumetiiiiiM  foIlowT'd  these 
Wis ;  bat  they  WPTO  rolvrrcd  to  iKTv^-a,  tendons,  or  fitMita* — 
g  raihiT  lliiin  th(!  vrins^ — Ut  nerves  nmre  «a|H'wnlly.  '*I 
in  luistc,"  Ktya  jVmbrosfl  Par*;,  "t«  kcc  bis  majpstv.J    Ho 

li-t  blotKl  by  »  SorKi'«>n,  and  »  nvTVC  hmt  lnv-ii  woiiit()e<l  in 
tlw  openilion,  at  wbicb  the  king  cried  out  with  ibr  juiin. 

beicamv  wmtnieti^I,  mid  Ihi-  pain  dttrtiHtvl  tbruughont  the 

lb.  I  ap]>lii?d  a  plast*'r  owr  tlie  wound  to  assure  its  oltiniig, 
y\  the  purt  witJi  wnrm  t,iir[>oriliin;  jiiid  spirJI.-i  of  wine  to 

irnlnlioR,  the  arm  being  bandngod  to  the  slionldi-r,  uid 

le  the  )>>j-inptoms  begun  t«>  ntmtw."  Giingrene,  be  further 
uy  iittnck  an  arm  after  venesection,  nud  may  pri>ve  mortal. 

knon-Q  B  lady  to  die,"  writ^-n  DiotiiM, "  from  diU'uttcd  in- 
ioo  of  tlie  litnb  afhir  a  bleeding  from  the  foot." 


ebili«.9tan«m«dbjrBrMieh«t,  from  iheworii  ^/'^  (^X(|9rfi),  wbich 
'e^ed  by  IIip{ioont««  to  4l«(iig^Ale  tlie  diaunrla  wliicli  eoiivi^j-cd 
!  Icnn  nriiin-  liaviiig  n;f*Tciii-v  In  tlio  lur-jiunige  alone.  Thus, 
inamp  or  tcius  wen.-  iiivludi'd  lli«  «-iiriouii  ttttictoty  eauuU,  u  ili« 
■ndlhourricm;  ■«(!  bi!ii«L- Celsu*  wrote  ■'Bri'iiibu*  »ingti\mm 
<Q,tA  *u»i<i>ni  fcrantur:  ovpiiT^t  Gneci  locxnx"  \De R* Mt£ei,\ 


286 


DISEASES  OP  THE  VEINS. 


Parf ,  trontinj;  of  variiv «,•  obwrvco :  "  <»onieliin<«  in  tlw  lit; 
Uicy  cuntAin  a  throtnbuB  tif  blood,  dry  aiid  liard,  wlli(^ll,  Uto 
boing  ojieiiiHl,  should  be  evatiuaUML"  Potit  wriU4  a  dracri[itu«  J 
the  fbrmatioii  oj' dote  in  obHtru<.-U'd  veins,  and  of  somo  ofUii- 
tliey  aiib!iiN]Ui'iitly  undiTgo.!  ]}itK.'U.4itiun  tvaa  held  n»)>ecling  i 
dot*  or  polypi  {poli/pet  iwietiw),  as  they  wcro  tormod,  wluoh 
found  in  llii!  I)i-iu-t ;  uiid  btttwocii  IlalW,  MorgngnJ,  and  A.  uidj 
Ps£U,  opinions  diSlTi'd  aa  to  the  nuuioer  and  tiniL*  of  ibi-ir : 
tion-t  Ijtnt^wi>rt  wrulo  "do  inHiuiintatioiH)  renanun"  in  i 
lion  of  Ilia  workf  J}f  Morina  Arler'utrum  et  Venarvm  eoitf 
beyond  the  (•ugj^-.-ttivc  luuito  niiulo  no  uilvwiw  upon  the 
Attention,  however,  bad  been  thus  drawn  to  tbe  ill  conso()iu 
whioh  octMwionslly  followed  wounds  of  vcinn,  and  thf  fi>n»iitiMli 
clote  in  their  canals  waa  reoognifiod  in  connexion  with  varioct 
witit  <>li«trncliun. 

Mwk<?l,  Fi-.uik,  and  Sai«c  followed  Unnler  in  dwi^ribing 
flammntion  of  tliu  inner  coat  of  vi-ins;  and  from  their  liino 
disea^  (divided  into  Ute  adhcoive  and  tlie  Mi|>]>urative)  has 
amply  illustrated  by  numerous obserwrK,  and  III  ri<ii:i  nu:-.-- 
tluui  by  Cii-ndi-in,  who  thus  dcwribn  itA  nuTliiil  .mii  lu  . . 

Ho  finds  the  inner  tunio  of  an  inllamcd  vein  at  firet  of  ■  i 
lofK  d(i-|)  rcil  colour;  but  tlit-  uvidoneo  <U'riv«^«l  fn^m  tJiis  euiid 
ofteu  valueless  from  tiu;  ntUnidaiit  bliMid-Htaining.     On  wjn 
the  inner  coat  from  tlii'  middle,  whieh  can  bo  done  more  i 
in  the  heullhy  aUilo,  tliu  injected  capiIliiri<M  biit^-nie  evident, 
the  Mtructurc  connecting  die  inner  with  tbe  niiditle  ooat. 
while  die  inner  coat  beeomts  uiiifurnily  red,  and  ia  li>w 
BO  that  vessels  beneath  are  no  longer  distinguished.     It  lui^ 
polish,  and  even  liiut  U-onino  »oiiU'wlutt  ruu^ti.     It  aoipiii' '^.  Hi 
disease  progresses,  a  swollen  and  villous  app<:araDeu,  and,  but  I 
its  en.4ily  tearing,  can  bo  readily  detaehed  fnun  tlio  midd 
The  latter  quickly  thickens,  so  tliat  tJie  vessel  resenibte«  an  i 


*  CEuvrti  eompleUi  ^Atabrate  Pari,  ■pu  3.  P.  Ualgaiffw.  Una.  ii  { 
et  aeq. 

f  "  Sitdt  que  le  tronc  dm  rnioeaux  CHt  mtienneni  bouebd  par  la  ] 
e^llut.  Ill  sunt;  qui  rvninntn  jutr  lex  bi'onolitfa  m  coa^pile  i  towm  I 
drrivu.  li-  tinucin-  nuKiDrnto  ft  ilovknt  pliin  durp."  He  tbcii  desciibM  t 
tngofUic  tumtiiivthus  inilumUd,  wliSch  lio  uieribes  to  ■cfMUwUmi  of  I 
fniin  Uie  vXax. :  "  c'est  c«tta  sdrosltA  qui  Ut  la  moUMse."     ZVuiM  JmJ 
dirt  Vkir.  ton),  i).  p.  13. 

I  J.  PHMa>  D»  Pingaitieu  CoHtrniotiikiu,  B«rf  sad,  IT0O. 
(  Pnwe,  1103. 

II  Ifitwitt  Amttomiquv  Jm  It^ftammatuMt,  toni.  it  p.  Ifl. 


p — ^^= 


OLD  DESCftlPTIONS  OP  PHLEBITia 


287 


pan 


bit  IB  less  resisting.  The  ostemal  cont  is  also  affected  and  infil- 
tntAl  with  M^niin  or  ))I<hi(1.  'I'tiv  <.i^lluliir  itlifalli  bix>unioj<  invohod, 
m  that  the  whole  fomiH  a  biemlcd  blood-ntained  msiw.  A  membrano 
MiietitnR«  litu'it  tin!  vi-wi^l,  of  litflo  ooiwUti-iiot^,  roniiiiig  n  chowy 
pnlp  wlien  pressed  bi?tween  the  fingers. 

KJIm-!*,  lw>w<-viT,  liiM  obxcrvfd  it  firm  nnd  rwinting,  and  ci-ffii  or- 
pmised,  thoiigli  but  slightJT  adiierent  to  l)io  ndjaoeiit  wall.  Soiue- 
iM  it  ndbcivs  so  firmly  that  it  cannot  Ik-  oumplctcly  (lftjioIii'<l,  and 
occoaioiially  oo\'ers  a  ;rw-:il  e.vtcnl  of  veiii-walt,  as  in  a  case  dc- 
Mnbi?d  hy  CIiaii«ier,*  in  which  the  Icil  renal  nnd  iiiljaconl  vi-ins  wore 
Hat  Boated.  Hic  blood  now  fiirmti  on  tho  wall  of  the  veeeel  fibrinons 
ekits,  nK>ro  or  ic«»  doeolorised.  by  wliicb  the  tube  Ix^coniO)'  bloeked 
n(>.  These  dola  are  not  fonntii  at  one*?,  bwl  "  fresh  fibrinous  layora 
tre  continually  being  a<ldod,  and  in  a  proportionately  very  stiort 
tine  a  plug  ift  formed  which  ttll«  dio  (mtiro  calibre  of  Hiq  vein." 

"Hiis  fibrinouH  coagiiluni  extends  both  abovo  and  bi'low,  far 
Irymd  the  liniilD  of  the  gxirticiii  originally  infiiumxl;  the  jJiig, 
hi«(Ter,  opasing  by  degrees  lo  be  made  up  of  conecntric  layers, 
pkhully  pniiMH  into  n  lujH^ring  coaguhnn,  more  or  lo-.ts  Tingi^l  with 
(becDloor  of  tlie  bloixl,  and  little,  if  at  all,  adherent  to  the  walls  of 
■•twmI.  In  all  lli«  brundica  of  vcini*  which  inimcdiiilcly  k>(id  to 
fcplngged  portion,  save  tJjose  which  have  other  channels  by  ana- 
HiMtis,  till?  bl*>cid  KtagTiato.t  anil  c<ia(iulatc*.  The  jihig  i»  shorter 
•™»,  and  seldom  extends  beyond  the  point  of  junction  with  the 
■Mfwi  venous  lrunk."t 
8dch  b  an  aeeouni  of  changes  which  are  said  to  accompany  adho- 
tnflinnmatioii  of  veins.  In  a  word,  their  inner  and  middle  cxjitta 
inflamed,  hinph  ia  exuded  upon  nnd  clings  to  tlie  siirfiioe 
:  blood,  the  latter  ooflgiilatct>,  and  so  the  vein  ix  filltKl  partly 
lymph  and  parUy  with  dots,  Tlieji,  as  in  every  other  intlam- 
■ttira,  the  mingled  products  midergo  further  chnnj^iw, 

It  i.^  however,  dilKculi  to  recieiie  tlieso  statements  in  the  face  of 
*Q>  wiiich  throw  doubt  upon  tlie  existence  of  an  adliesivc  phlebitis. 
*ni,  be  careful,  su^esta  Kibeii,  to  diKtingiiiKh  all  this  redness  of 
VliHmg  membrano  of  veins  from  post-mortem  congi-Nt  ion.  Vcina, 
■fe  death,  i^uickly  beeonjo  sljiini^d  by  the  fluids  adjacent,  more 
in  some  eases  tlian  in  others.  Their  discoloratiou  is  unt- 
and,  ei^>ectally  in  itnuill  ves.iel*,  extends  to  the  surrcnmding 
and  this  more  particularly  in  tlie  dependent  porta  "  iu  in- 


•  tUrtif  Uttt./ftrafnifi  tt  ilrangere.  inas,  him.  iii.  p.  U. 
f  Uamc's  Path.  AnatQiny,  Kugliall  Imus.  p.  lA. 


SS8 


DISEASES  OP  THE  VEIXS. 


1 


flammatorr  Rubjects  from  the  reader  separation  of  deoolwised  fibrin 
ous  ooncri.'tioDG,  ia  others  from  dissctcniucc  c^  tlu.*  corinuvli.^*" 
Mkiiv  hfti'ii  t)oeii  iiiUltKl  by  thiit  iIiHcoloratioit,  ea»y  aa  its  recogiiiUot 
may  appeal';  for  oxampW,  those  who  ro;;;ar(lwl  phlehitjs  as  tbt 
pruicipal  iwnt  of  ('rvMipclus ;  and  UilH-jt  hiuifM^lf,  ulien  Ik  wrote  o 
an  inflaniniatioi)  invoKHng  tho  rootfl  of  tlie  portal  vein  of  nil  person) 
dying  wilh  ii<]ynBini<!  fever.  TIiimiv  alMi  n-li<>  BA»ert  tliat  ltu>y  lmV( 
eeon  a  plilchitis  extooding  tJirough  many  veins  until  it  roachod  tin 
lictu-t,  are  equally  diHX-nod  by  i]tii>  pfMt-innrtrni  utaining. 

Tile  esporienoc  of  (Jutliric,f  who  iloubts  tlm  oxiatence  of  JU 
lulhcMve,  or,  lu  Iio  t«nu«  it,  a  livaltbj-  inlluminuiiuii  of  vdns,  il 
opposfxl  to  Gendrin'a  description ;  and  TraTors,t  whose  statements, 
by  ibtf  wiiy,  nru  contradidwl  by  BichHt,§  f(>iicludt»  that  ''the  in* 
tcmal  poat  of  a  vein  is,  when  ooinpared  with  an  aitei'y,  difficultly 
»usijt'ptilil«  of  ad!i<'«ivc  infliunntation.  Inilix-d,  tb«  pnici-jis  of  bod* 
ing  and  divisiiin  by  ulceration  .hc-oiiih  to  he  oonducled  without  aoj 
ftign  of  itiRniunintory  at^ion;  but  tb<!  indisposition  of  tho  wikkiI 
membrane  to  infl.-une  in  not,  iw  a[)|Mi^ir8  lo  me,  intwnftistent  with  itt 
toniivtu-y,  umk-r  ailcM^iiato  cxeitcnitnt,  to  inonlinnlt-  and  cxcowirt 
inflammation.  It  is  not  uiiiisiial  Ui  find  llie  morbid  aetion  of  paru 
llmt  arn  difficultly  roused  least  conti'olliible  when  once  set  ttp." 
Frank  and  8usse  niiw  niattiTs  v<rry  dilli-i'ently-  Thej'  uhlvn'ed  s 
deop  roJiicss  of  tlie  internal  coat  dilfuficd  tlirougliout  tlio  vcssdi 
and  after  li^'atiiri.!  "a  sort  of  fulsc  uiuinhrane,  resulting  from  tlv 
inflummatory  action."  || 

Cruvoilliicrll  oljMcrvcd  that  vawsniarity  was  not  soon  in  ilw 
lining  niombraiie  of  veins,  even  when  the  hlood  charged  wiili  iiri* 
tiuil.s  from  iiitl/iiriod  pjirU  aiu«pd  an  inflammation;  for  "  1  do  iiol 
regard  tJie  pidebitis  as  tho  fii-st  change,  but  ooiL-iidcr  the  coagulation 
118  antorior  to  tin;  phlehitin."  Hunter*"  thought  it  difficult  l«  ooa* 
ccive  "  how  adhesions  should  take  place  on  tbo  internal  surfooe  lA 
veins ;  sjnoe  it  it  most  obvions  that  tbo  coagulablo  lymph  throirt 
out  by  the  exlialanta  on  the  utternal  snrfaiur  of  the  win,  Ditxiii| 


*  Gendrin.  op.  dt.  toni.  ii.  p.  fi;  Riboe,  lievue  il/A/.  /raHf,  4t  itraagin, 
torn,  iii.  p.  n.  IM.i. 

+  J  Trtatine  on  Gun  Shot  Wiiundt.  8d  edit.  p.  390, 
(      I  SuTr/inal  KtM!i».  Jiilli  i.  p.  800. 

§  Analomif  Piilhitoijuiue,  deinivr  voura,  ulwp.  xiv.  p,  S6A. 

II  Sylhi/e   Ojiunfitlomm    telfeUirum;    DiagrUttio  Haliir  )<ahita  itHBO  ITfll 
p.  1S5.     AUa  T'lurik.  Epitome  lit  Caranil.  Hominum  Morb.  lib.  i.  p,  161. 

1    Trnil'  J  .hi-iimnie  Palhulwjiiiae  ficuBfale,  tom.  i,  p.  390. 

••  Huator,  fi'urkt.  voL  iii.  p.  OB*. 


nn, 

I 


ADHESIVE  PTTLEBmS. 


389 


ntb  tli^ aamc  Haul  ciratilnling  with  tlio  other  pnrtA  of  tho  bhiocl, 
tmid  be  swept  away  without  producing  any  effoct.  But  siiice 
wA  iiliuLiioiif  <tt>  in  fiict  hapjicii,  llu*  coagiilablii  lyiii)))i  iiiukI  tm- 
mfft  aaate  changti  connoctixl  vritli  Uie  disposition  wliich  produces 
ttenbrnvsiiiitioii." 

Inrers  was  the  first  to  show  that  vein*,  after  ligaturo  or  diri- 
Wi,  repair  willioiit  an  adhf^iro  inflanmuiti'Hi.  Tiin^>  pi-(t[)iirationfl 
iibtiaie  this  fact.  One,  in  tlic  moaeum  of  St.  Thomas's  Hospital,* 
Vlliiu  d<s>crilH*d  :  "  ApiMiariuico  of  a  voiu  dividinl  hy  tliti  li^iiluro, 
«iiicli  came  away  on  tJio  twenty-fiftli  day.  Tlio  upper  part  of  tho 
*m  iH  mivd  willi  lirm  layers  orvuii<;iihi,  which  hd  tt^niit^iou^y  ad* 
Imd  to  tlic  inner  membrane  as  to  bo  scpai'atod  with  diflieulty; 
*bn  Nimntli'tl,  iho  nurljice  wiut  found  to  bo  jierfootly  Min<Hit.h  and 
MnraL"!  1^(^  swond  preparation  shows  tho  rcsidt  of  a  ligature 
^flicd  lo  t)ie  jugular  vein  uf  u  ]ior.-.e  for  twoiity-lour  )i<iiir!>.  The 
iaw  vein-wall,  thrown  into  longitudinal  folds,  is  otherwise  natural 
B  i|i[Kaniuee,  whilst  a  good  deiU  <)flyin|ih  Ik  ti'i:Miniiliil(id  oxter- 
■Draruund  the  lijiature.  The  third,  which,  with  the  preceding, 
>  b  iIm)  mir^ount  of  8t.  Georgia's  Huspitid,}  iiIiowh  tlu!  rtl'c<;ts  of 
*  lipture,  including  part  of  the  parietes  of  tlie  jugular  vein  of  a 
!*<%  S'Hnii  fihrini*  iH  d<;{M»<iti^l  in  tliv  track  of  I.Ik'  tlirc-iid  and 
Bmall  poueh  below,  hut  no  evidence  exists  of  any  intiamui.itioD 
''tb*  linJHf;  niembraiie,  and  (hi»  ihrxH)  days  ulW  a]i|ili(-iitioti  of 
•■ligature. 

Il  tlic  museum  of  -St.  Tlioinav'^  H<^M>i>ital§  in  a  prcpiinil ion  of 

■  jipilar  vein  of  a  horse,  wiiJi  a  circular  a|>erture  furnied  by 

■mtion  of  the  wound  made  in  phlebotomy.      It«  internal  luiu^in 

'  "i  the  suTMinding  membrane  is  coated  with  adhesive  matter. 

;  a*  in  tliid  twso  tlie  interior  of  tho  vwwl  commuiiiciitvi  with  llie 

outside  lliD  vein,  the  adhesive  material  may  have  made  its 

I  the  vewwH  from  dioeniwd  tiwuo^  which  Kurround  it.     But, 

ag  liii»  presemw  of  adhesive  material  witliin  veins,  an  error 

iginatcd  and  pcqwtualod  by  the  cx{>crimont»  of  Ouiidrin. 

:  May  imagine,"  writes  Hasse,  "  thin  false  membrane  to  bo 

tdw  product  of  plaiftio  effitsioit  troin  ttie  eoal.t  of  lliv  vein,  but 

tBnmedtate  deposit  from  the  blood,  let  him  refer  to  the  exgieri- 

iofGeiMlrin.      Haviii;^  sucunxl  «  pi»ili<in  of  an  arti-ry  bt-twcen 

iligaturmf  utd  emirely  cleansed  it  of  blood,  that  experimentalist 

1,  after  throwing  in  un  irritant  injection,  a  phutio  mem- 


hW( 


■  S«^ri*ft  T.  m.  t  Trfnei-s,  Surgieal  Euayi,  plaCo  xiiL 

:  Stfn<T.  SM.  Kul»eries  a,  1,  auJ  7.  1.  J  Seii«  ».  I5». 

VOL.  lU.  D 


S90 


PISEASES  OF  THE  VEHfS. 


lood 


brano  dq>o«it«l  within  tho  part  so  insnlaled,  filling  np  Uie  vhcAe 
oatibre  of  llie  veswl ;  aixi  be  ailinm  lluit  KimiUr  rcmittR  followed  b 
expeiiincrntH  npon  veins."  Kotwiili^^tanding  the  credit  thin  Tiew 
long  obuiiMxi,  and  Uw  iiappiirt  it  received  from  antliorittcs  in  tliii 
country,  its  nccuracr  was  disproved  by  hoc.  Having  found  llut 
inflaininiilinn  nf  llie  cum*  of  the  vmiw  only  oceorrod  whwi  the  blood 
had  prerioosly  ooagnlated  in  them,  be  was  induced  to  beli<n-c 
the  de^iwil  foHnd  in  the  vein*  might  be  derived  directly  from 
blood.  Gendrin's  experiment  was,  therefore,  repeated ;  and  w 
jmseautionx  were  taken  to  exclude  all  blood  fiom  the  vormI,  m 
lyiiil)h  vras  eSiised  in  the  vein. 

In  repMttng  ihi.i  i']Eg>eriDient,  I  find,  howcrcr,  that  lymph  i* 
oocaBionally  fonnd  within  the  veins,  but  that  its  proaenoe  i*  due  to 
an  effusion  external  to  Ums  \-4wtcI.  'Hie  procantion  of  closing,  br 
ligature  or  otherwise,  the  opening  throngb  which  the  irritanU  ara 
introdnood,  eficetniilly  M)eiin>«  ib  aliucnciv.  Tbo  following  espm- 
ments  show  tin  l«eutt  as  this  precaution  is,  or  ia  not,  lakrn.  Tlur 
ehow  lliat  the  Ittd|>1i,  when  prvsent,  fliKls  its  way  into  the  nia 
from  without,  and  is  not  exuded  from  or  through  the  lininf;  nwoi- 
brane.  Neither,  in  animals,  doc*  tlio  intcmal  coal  inflame  who 
irritated. 

1.  Part  of  the  femoral  wia  of  a  dog  being  selected,  free  frois 
anaiitotnosing  brancbea,  a  ligature  was  applied  ao  ait  to  stop 
blood  coming  from  the  extremitr.  The  vein  vras  then  opened 
ft  longitudinal  incision,  and  the  blood  in  the  vtstuiA  vuf  remor 
A  second  tigatare  was  then  a|>pliod  between  the  longitudinal 
and  the  fir»l  ligntiirc,  and  a  third  was  tied  between  the  wound 
the  heart  Aflcr  twenty-four  hour*,  lymjdi  wm  found  in  llie  btttr 
intenpacc,  but  not  in  tbu  £rst.  Thtsv  was  also  au  uhuDdant 
of  ly-mpfa  external  to  tbo  vesnel. 

2.  Part  of  the  femoral  rein  of  a  dog  Iwving  In-en  indndw 
between  two  iigamrw,  was  ptmclurcd,  all  blood  remo\«!  from  i» 
interior,  aiKl  two  omall  pieces  of  lead  introdaoed  within  the 
of  tlie  vessel  isolated  by  the  ligatures,  Twenty-foor  hoora  afUr 
operation  the  (xin  was  ^ummmliif  by  lymph,  a  oonsidorablo 
tity  of  which  b»d  entered  tbe  vessel  through  the  puncture  d 
lug  iu  canal,  as  may  be  seen  in  the  prejutntion. 

i.  Tbe  femoral  vein  of  a  dog  ha%-ing  been  exposed,  nn 
mast  was  made  wbie-h  ren-mUed  the  preceding ;  but  tbe  li, 
nearer  the  heart  waa  thifled  alter  introduction  of  the  foreign  {>odi< 
•0  aa  to  cat  off  tbe  portion  of  vein  in  which  the  plooes  of  Icitd  vi 
^^wlnAt>A  from  OMnmunication  with  tbo  puncture  in  the  wall  of 


COAGULATIOX  IN  VEINS. 


891 


Hie  lining  membrane  of  the  portion  of  rain  tliuii  iHoIated 
ill  a  natural  np|iMnuioc  tvrout^-four  hours  after  the  opera- 

'  4.  A  Mnntl  piece  of  Ii>ail  was  introduced  witliin  the  femoral  vein 
li<[^^'>  and  there  stupentlcd  by  n  thread,  lut  seen  in  the  pn^paru- 
Thi*  pwnc*nro  in  tlio  voin-wail  was  tlicn  closed  by  a  ligature, 
ha<!  the  eRect  of  slightly  narrowing  the  eniiid  of  (lio  vcitHcl. 
■  Uood  traa  tlicn  allowed  to  flow  through  the  vein  for  forty 
At  the  «nd  of  thin  time  tlio  lining  mombruuo  of  tliu  vchscI 
ttx  natural  a))pcanin»>.' 
From  these  considi-ratinnn  it  Ia  mnnifrat  llint  n(lhei4i\'o  phlcbitiK 
hacn  ver^r  vaiionsly  do«;ribt^d  and  aocoiintcd  for,  and  that  its 
has  tioen  ilmiinl  by  Mime  patliologi^.     Thoro  cnii  bo  no 
iint  (liat  VL-ins  arc  reinaircd  without  it«  aid,  and  expcrituonta 
aninialii,   taki^n   for  what  thoi,-  arc  worth,  tihow   lliat  thc»e 
do  not  inHamo  wIicti  irritated.     Absence  of  vcseclft  from 
hning  meinhrane  jKiintj*,  one  would  think,  a  roa.*nn  for  this 
nmitr.     A  tissue  thus  circumstanced  may  ovcntually  be  involvc<l 
I  ailjatvnt  |i(iria  are  aiTecUKl,  but  it  does  not  originnle  di«eft>«e. 
[ike  barrier  between  tissncB  often  inflamed  on  the  one  liand,  and 
1  UoudHttrcam  on  tho  other,  it  would  obviously  dlsclmr^e  an  im- 
Ainctinn  did  it  prevent  lymph  from  Iwing  efluiied  on  the 
mrfiioe  of  the  vt^'m.     For  although  this  lymph  might  he 
sway  without  priHhicIng  any  local  effect,  it  could  not  bo 
%\  with  tlw  blood  n'ithout  risk  of  spoiling  that  fluid,  or  of 
m*ennilary  niUc'hief  by  becoming  entangled  in,  and  ao  ob- 
it, the  capillary  vcbscIb. 

mboeqtient  aeoonnt  of  phlebitis  will  differ  Bomowhat  from 
dcN-riptlon  wsually  given,  first,  liecau so  the  occurrence  of  this 
imialion  of  tliv  lining  nicmbrnne  ist  more  limn  doubtfiil;  and 
Hjr,  beoanso  many  caMs  which  would  otherwise  have  boon 
of  a*  pMebitic  will  Iw  hero  refcmvl  to  the  Aim|)le  process  of 
tlatiiin  of  blood  within  tlie  vessels, — a  subject  which  has  only 
t-ean  aKractcd  tlie  attention  it  dencn'fi*.     Tliese  oaj*OB  may 
,  diaposed  of  before  tlie  dc»cnption  of  phlebitis  is  resumed. 

Tfiromlrallim*. 
[TTjo  eliangea  which  result  from  coa^nlnfion  ofhlood  within  the 
^(tlironibuBf  ns  Fotil  teruiH  itf)  niuy  easily  be  mistaken  for 


Mu'rum,  St.  Biinbo1<)m«w'«,  errivn  xiii,  MtK. 
If  JUao  nain»d  miMuw,  from  ?fi^uXov,  a  plug.    Tlio  t«rn)  ihromhaltoii* 


S9S 


DISEASES  OF  THE  VEIXS. 


proePMPB  of  an  inflummatwrj-  clinractor,  uiilofw  tJio  Ix^iiiiings  of 
thft  di.waso  arc  aocmrately  obwerved. 

Caiuiee.    As  it  lias  bccii  (tlsi-wbcro  shown*  ilmt  tlie  I>l"cMl-fiIirinc, 
miller  certain  oonditioiiH,  in  apt  to  coagulate  Hpontaiieously  within 
tho  vcfflctU,  it  will  hero  siifli™  to  rccal  thti  fiwit.     Coaijiila  may  in- 
deed form,  as  a  means  of  rcipair,  be  the  blood  condition  what  it 
may.     They  do  so  in  art«ric»  after  application  of  a  ligature.     'Hwy 
do  BO  in  veiiJs  when  womided  or  when  torn  aoross,  and  are  then 
sufficient  to  «lo»o  tlio  rent,  and  eventually  to  rc'twir  it      In  tliwe 
fiasea  the  coagula  are  limitod  in  their  extent     But  in  other  case«. 
anil  to  thcso  our  uttiuitinn  is  now  directed,  when  a  clot  ii>  foniuii 
within  a  vein,  it  increases  and  extends  from  one  to  another,  until 
having  eoininuiiei^d  pcrcliiUKx'  in  *  vessel  of  sniall  size,  it  rcaclui 
and  tilU  the  largest 

This  remarkable  tcndcnej'  of  tJio  fibrine  to  eoo^atc  within  tin 
veina  may  exist,  un!<U!<{>oi-t4.'d,  in  tlie  ill-iiourinlicKl  and  feeble,  of 
may  Iw  slowly  induced  during  the  progroBs  of  discaso,  Soim 
trifling  eircunistanoe  is  then  auflicietit  to  eall  it  into  aotion.  Bonil-  , 
laud  statext  that  those  dying  from  )>bthisis  or  from  cancer  i>fteo 
aulTered  from  the  formntiim  ofclotx  in  veins.  ]n  one  osuw  the  ei- 
(emal  iliuo  was  thuB  filled  with  a  coagulum  where  compreswd  byj 
intestine  distended  with  fji^eos.  In  another,  a  tiimmir  pn^wdi 
vena  cava;  in  a  third,  a  cancer  growth  the  internal  iliac; 
where  the  pressure  full,  there  each  veswl  was  eloea^l  by  coa^lam-j 
In  tho  body  of  a  young  man  who  had  long  laiii  in  one  of  tlie 
of  St  Bartholomew's  Ho«|iitjiI  with  hi»  thigh»  drawn  u]>  on 
abdomen,  the  femoral  veins  were  closed  by  cJot*  abo^e  the  June 
of  tho  profunda,  and  as  high  as  Pou|>art'(i  h'giuii»?iit.  Tlic  awn:  flcJ- 
ing  of  the  vew*el»  had  sutliced  to  determine  the  coagulation,  »  bl  j 
slowly  died  with  [jlitliisi!^  of  the  lutigs, 

ITio  ejrcuristanco  wlucli  eatled  tlie  coagulating  predisposilicH  1 
into  activity,  soemit,  in  tliose  cases,  to  have  been  tlie  prcswure  i^mnj 
the  vessel.     So  again  in  the  fullowlng  case.     On  Decombw 
1SI>0, 1  examined  the  body  of  a  male  {Kitietil  who  had  long  mffeRaJ 


more   coTrectl^   indicates    this   disenMu    Ifipiii^t,  A   otot,  and  aXXw^  ' 
change). 

•  Vnl.  i,  p.  370. 
t  TraiU  rliniijat  rfci  MitMif*  rfu  Cemr.     BidntiU  [Ittchtnitet  imr  le$  I 

crftiont  t'lnyuinn  dm  I'Hnri.  I'mis,  ISMl  states  that  Lcunoiix  liitt  dicw  aD 
ttoTi  la  llio  xpnutiuiuuu^  t'orniatiim  ofclot^  ia  veins. 

*  Sen  cnses   In-  FuvbuH  niiU   Hulboi-loii   in  Mtd.-Clar.  Tnmt.  Tol. 
p.  SOS,  vol.  xvL  p.  6i ;  alao  masuuni,  Guj-'s,  WiS^ 


r 


COAGUIATJON  Ei  VEENS. 


S9S 


hndilatadon  of  the  pclvU  of  the  right  kidnej',  in  oonseqticn(»  of 

■nqacted  calculiu.     PcriuinUtJ^  wiw  tiic  iiiiiii<.'cliul«  cauM  of  death. 

Ho  Twna  cava  inferior  was  conipreHsocl  by  the  dilated  pelvis  (which 

kaaed  a  (.•jet  Imldtrij;  four  pinti  of  tUii<l),  iind  wjw  somewhat  iiar- 

imred  above  tl»  jtmntion  of  the  common  iliac  reins.     Tlie  right 

eoaaoou  iliac  vmif.  Gilvd  by  n  coa^iihiin  in  jmrt  and  nnd  blood- 

Mained,   d^oolorised   where    in  contact  witii   lluid  blood  coining 

through  tl>c  opi>o«ito  vein.     It  cxtondod  fiir  townnlH  the  leg,  oven 

to  the  veins  about  the  middle  of  tbe  thigh,  and  the  right  luwei-  ex> 

bvniity  niu<  ath-mntotu. 

Id  these  cases,  Lite  prepare  is  oAen  slight,  and  generally  acts 

cmo  side  of  the  vc^wl,  tlio  win  being  fnxt  to  yield  in  tlio 

direction.     Tliey  ninst  be  distijiguisliod  from  those  cases 

in  wbid)  the  prcmuro  is  made  upon  the  whole  cireiimfcroiioe  of  a 

^prin,  or  if  acting  on  one  sido,  conijirosses  the  vessel  against  a  rosist- 

^ptg  i>a)Htju)L^-  Ktich  as  Iioiiilv     The  voin  vf  then  filled  with  a  votigu- 

1am  distinct  or  mingled  witli  an  ingrowth  fi'oni  any  tumour  which 

my  liapipun  to  surround  it,  and  ovunttiatly,  if  ttio  vessel  bccomo 

tUHefuted,  dots  form  im  tjjo  dUtai  nidn  of  the  obliteration,  jiut  aa 

ibv  application  of  a  ligatura.     This  uccuitcxI,  for  example,  In  the 

««•  of  a  woman,   agtxl   twenty-three  years,   who   suffered   from 

■toeid  cancer,  involving  the  lower  part  of  tlio  h-ll  femur  and  the 

fVpGteal  Sfiaoc.     'Du;  limb  wa^  amputated  at  Kl   Dartiioioniew'g 

Ho^alaL     The  diseased  portion  was  examined  Nov.  23d,  18G1. 

m  popliteal  vein*,  tlwspo  wore  two,  wens  obliterattnl,  and  could 

i>*le  traced  amidst  tbe  substance  of  the  tumour;   but  above  and 

M>«  the  oUiteraliid  ])ortJuna  the  vt^selK  were   (illbd  with  firm 

ttborlcw  ooagola. 

Other  circnmstaoces,  however,  more  often  determine  the  forma- 

finofcoagula,  and  g^^■e  opportunity  for  their  subsequent  exten- 

Ml   1.  InHammatory  ctiang<^!4  in  tho  tissues  which  nurrixuid  veiuM. 

MM  at  tlie  base  of  an  extending  ulcer  the  veins  are  61!txl  with 

Cigala.'     Ever,  as  the  disease  advances,  tJio  clotting  gocn  beti>re, 

fi  plugs  portion  after  [lortion  of  the  adjacent  veins.     Rendered 

[•H,  ihey  may  indrad  soften  and  slough  as  the  diwiuMj  [vrogr'wscs, 

M  fauoorrtiage  is,  as  a  rate,  prevented  by  their  previous  oblitera- 

2.  Laceration  of  a  vein,  as  when  tlie  placenta  is  expoUed 

the  uterus.     Some  bloo«l  escapes  and  coagulates  without,  imd 

bat  Dot  much,  within  the  vessel,  which  is  itself  contracted. 


*  Moscntn,  St.  ButliolooHnV  scric*  xiiL  01  i  Middleeox,  vL  U;  St. 
b's,  aaiiiH  aii,  nilisariM  vi.  1, 2,  3. 


iu 


DISEASES  OF  THE  VEIXS. 


TliUR,  nnd  hy  subneciuent  changes,  the  vein  is  permanently  closed. 
The  cxtoDi»ioo  of  cluts,  which  rt.'sult«  in  cither  <jf  these  drcamttuiw* 
wheal  llie  pntllKixifilioii  im-linoa  to  it,  Uioiigh  of  couinioo  occur- 
renoc,  has  rix-clvod  sc-uttv  attvntiun. 

In  illustration,  I  will  luirrate  two  or  three  cases.     In  the  body 
of  a  mnii  broti^Iit  to  8t.  Bartholonivw's  for  dttwoction,  dcuth  hnving 
reftullt^tl  Ironi  j>hthiRi^,  tlit-  iialcs  uerd  covered  with  sloughing  soree. 
Tho  left  fciuoral,  just  below  Poupart'e  ligament,  wjw  filled  with  u 
finn  coaguluin,  which  ascended  to  the  junction  of  the  opigaatriv 
win.     Atlvntiou  was  drawn  to  numerous  vcuu  about  the  banc  cf 
tiie  skiugiiH,  which  were  uiora  iliim  uMiulIy  coiiKjiicuooii  fixini  be- 
ing distended  with  clots.     They  converged  towards  and  formod  tlie 
left  inti^rnal  eirciimtlcx,  and  m>  cxtundiHl  direct  to  the  feuioral; 
and,  without  doubt,  accounted  for  the  clot  which  had  formed  ihcru 
in  diret^t  continuity  wriUt  thttav  in  llkc  »iiialh-r  vumets. 

My  friend,  tiie  late  l>r,  Baly,  ^cnt  nic  tho  foUowiug  report  of 
the  CJLte  of  a  t'ctimle  a^od  Kixli«ii  yraiH,  a  prinonor  in  Iktilllmnk- 
Ou  tile  UOth  Jannarj'  1844,  efic  was  pUicod  on  tho  sick  MhU  She 
woft  of  a  nti'iinioui*  it^jiect,  and  liad  nulVcred  frmn  aliiicki>  of  iliurrlwrt 
and  of  dysentery,  attended  with  pain  about  tho  head  and  cntiDpL 
The  day  foUuwiiig,  tlic  cruiii|i«  cviisi.'d.  Pain  and  tcndcrnct<K  about, 
the  epigastric  region  persisted.  The  third  day  she  began  to 
{(lain  of  puin  in  the  right  vide  of  her  head,  and  the  right  oide  oft 
taee  was  slightly  swollen.  Tlie  gnnis  ivero  somewhat  aflccUd 
mercnry  kIio  had  taken.  A  glazed  red  struik  vxtendod  Irota 
pustule  on  the  right  side  of  the  nose  to  the  inner  angle  of  the 
teriiiinatiiig  aliniptly.  A  good  deal  of  pus  hud  dLsi-liurged 
the  pustule  during  tliis  and  the  preceding  day.  The  fourth 
ing  she  wa>i  seized  with  convnlsion!'  of  an  epileptic  chamcler. 
became  insensible,  and  on  tlie  fifth  day  she  died.  Tlie  body ' 
examined  twelve  hours  after  death.  The  right  ca^t^mous  vinuj 
filled  with  clots  and  purlform  material,  as  also  was  the  opbtb 
vein.  Elsewhere,  eaeli  sinus  contained  dark  fluid  blood.  T<*J 
veins,  one  from  the  dura  mater,  llie  otbei'  from  the  brain, 
filk'd  with  clots.  Tho  vein  by  the  side  of  tho  nose  also  contu 
coagula.  Part  of  the  brain  lying  over  th«  caveni(iu..>  nious 
ecchynioscd,  the  blood  was  coagulated  in  its  vessels,  and  its 
soileiied.  From  the  pui^tulo  to  the  Hof)ene<l  brain  tisi-ue  the 
grvf!*  of  the  disease  was  distinct,  and  uot  to  bo  mistaken. 

If  examples  are  reignired  to  diow  how  veins,  after  woundi 
rupture  of  their  walls,  become  obstructed  witli  clom,  thry  may 
tskflii  from  Lliooe  casus  of  uudvmu  of  tho  legs,  su  oftcu  follow  iuj;  ] 


COAGULATION  IN  VJEDJa 


295 


famtion,  tKui  frMlureit,  wnl  even  wvcro  vuiitusions.    On  Julv  19th, 
18Ad,  »  woman,  oged  twenty-four  yeare,  was  iulniittetl  into  Si.  Bar- 
tboloiutiw'ii  IliiH|iital,  who  IiikI  eiijoyi'^  pwml  lit-it]tli  miti!,  abuut  sut 
montlis  before,  sho  bad  fallen  fronj  a  beiglit,  and  Moveroly  bruued 
buTielf  obcitil  tliu  {>ulvi».     Tvio  Diontlw  ul^ur,  nliu  wan  omiKnt^l  ut 
tha  fiill  tunc.     A  few  weekn  before,  alio  liad  noticed  »oHie  sweUing 
of  ln^r  Kigs,  and  wiie  !'titini.'i|iii-ntly  sutrmxi  from  til)iM.-un;  ntxlDnilnul 
paitu,  with  occfljiional  haiiuorrbage  from  the  vagina,     tior  ouiacia- 
tiun  became  <!xtn-uiu.     Tlio  lower  i'tr(irnitio»  bcusiiiw  iMrrmanvntly 
axlctnatous,  and  Jiard  cords  ooidd  be  traced  along  tlie  coui'se  of  tlto 
[triuuiiuil  veiri.i.    Kxhauitting  <Liarrligca  baillvtl  trvutiuvnl,  suid,  Kink- 
ing gradually,  she  died  about  eight  mont)ia  ai^er  hor  confinement. 
^IW  feiDonI   Mid  all  tho  iliac  voins  beiu^  ivitiov<til  alltir  death, 
ited  tbe  following  appearanoee.     In  places  tliey  wero  groatly 
l-diitendttl,  &rm,  and  n»i«tinfr.     Between  niieli  purtion.i  they  were 
Eontnetsd  and  empty.     AH  ainaUer  veiriH  opening  inlo  tliosu  trunk)) 
vera  ucmipiod  by  tirni,  dt'culortMKl  cloti>.    The  tiissuca  around  were 
HtnraJ,  save  about  tlio  femoral  veina,  whore  they  were  Bomewhst 
duiened.     'Hw  cou^rtila  i-lung  pretty  finnly  to  thu  walht  of  the 
Ttneb;  tliey  sliowod  aii  arrangement  of  eonci^tric  layera,  easily 
M{UBbxl  oD«  fmin  aiiotlior.     At  the  contracted  puiutit,  tliu  wulU, 
■dwwhere,  presciuod  s  natural  ap])L!.arance,     All  otlutr  parts  of 
B  body,  cxceptinjj  thu  uxlcniuluus  lo;^,  prcscutud  u  uulurid  uji- 
\atmoe. 

Agsin :  ■  wonian,  aged  sixty-two  ycant,  died  in  tlic  same  tio«- 
IW,  forty  daya  after  a  conuninulod  fiacture,  from  direct  violence 
«*m  tbc  upper  Mid  middle  part  of  her  ri^ht  femur.  Ucr  doutlt  re- 
mW  from  exliaustion ;  slie  sank  gradually,  with  ext«n^ve  bed  sores. 
Avriglit  lowf-r  extremity  waa  slightly  ccdoinatouit.  Great  oeehy- 
■uw  were  found  about  the  adductors  and  tlie  vanlua  iiiternua.  Tbe 
fNAiDdn  and  lUt  formative  branehra  wore  plugged  -m  high  ua  tlie 
jiDMion  with  tlie  fouiural  vein  willi  softoniiig  bIu<jd-Btained  clots, 
('tlieexu'tenct;  ofwhiidi  there  was  do  suspicion  dtu'iiig  lifo.  Tho 
odnred  fomur  renuuiied  ununited.  Tlie  relation  between  tlicee 
.  H(  awi  tlw  oecunviu-u  of  uou-union  will  chII  for  »ul>aeiiueat  rc- 
Mttt  Tltc  predisposition  which  inclines  tlio  blood  to  form  theee 
'  ■Dtmtions  clotA  is  llius  caUod  into  activity  by  accidents  of  iwiumon 
owmenoe. 

Thf  eviupila  rjifTul  m  all  «um>s  in  one  of  two  direction:* — (a) 
(&)  with,  tlie  blood-stn^am.     To  assist  in  cxphiiniug  their 
1,  the  Ibrniatitm  of  a  eoagulum  in  an  artorj'  on  whieh  a 
r^ponre  liaa  been  tied,  must  be  rcforred  to.     It  i»  tliua  noticed  by 


296 


DISEASES  OF  THE  VEIXS. 


Jones :  "  From  those  circumstancew  it  appears  that  the  pnlarge^ 
monl  of  thu  portion  uf  Uio  ai-Utry  f)i-tw<H!ii  tlic  WpkI  williiti^nil  ImUK-li 
aDtl  its  cxtrctDtty  is  proreiitetl;  but  it  is  obvious  that  thn-o  must 
bo  II  ttiiiall  <iiiit[itity  of  blood  jiitt  within  the  fixtrtiiiiit y  of  Iho  fti-tvry,^H 
and  which  is  niori?  or  lees  eomplelehf  at  tvtt ;  it  thertfore  coa^fulaletjl^^ 
but  <Ioest  not  iip|i(-iir  in  o^'ory  instjiiiro  t<i  form  it  coii^uluiii  <-ii|Kible 
of  tilling  up  tho  canal  of  tho  artery ;  for,  as  may  be  observed  in 
ninoy  of  tli»  (txpcrimonlit,  si^veral  houm  ut1i>r  lh<-  lu-tt^y  liml  bom 
tie<l.  thoro  was  only  a  slender  ooagulum  formed  in  its  extreroitj'. 
1  iim  theri.'foi'(!  diKpostxl  to  think  ihiit  though  tlie  iuii.'r}-  cannot 
acooinmodato  itself  to  tbo  blood  determined  to  it,  yet  it  undorgoee 
WH'h  a  ilogrue  of  con  true  tiim,  n»  ocoasionn  to"  much  motion  in  tho 
blood  which  it  contains  to  admit  at  once  of  its  coniploto  coagula-j 
tioii.  It  is  n  fact,  that  in  most  cnseft  only  n  sleniler  erKigulum 
formed  at  first,  which  gradually  boeomcs  larger  by  successive  CO'^ 
agulations  of  tho  hloml ;  and  for  tho  same  renson  it  \»  that  tho 
coagidum  is  always  at  first  of  a  tapering  form,  witli  its  base  at  the 
extremity  of  the  iirltTy."*  The  resf^arebes  of  Stellingf  udd  little, 
if  any,  information.  Ho  observes,  that  tlio  arrested  blood  forms  a, 
oonicnl  ma.HS,  wlioso  ajics  iH  near  the  first  lateral  branch,  luiiL  wlioi 
base  is  seated  on  tho  extremity  of  iho  vessel,  and  is  containe 
within  a  fLtnnel  i)f  binod  in  partial  motion. 

Now  respecting  this  coagnlum  (thrombus)  two  facts  deserve  to 
bo  noli'd.     The  fii'st  ia  its  formation  in<le]n.'n<Icnt  of  (bo  iliviiiion  of 
the  middle  and  internal  arterial  coats.    For  if  a  broad  ligature  be  tied 
roiin<l  an  artery  so  as  to  close  its  cansil  without  hieerating  IIh)  coat 
a  clot  is  readily  formed  between  tho  ligature  and  the  first  branch 
tho  c-inliae  sido.J    The  second  faet  ii  that  the  blood  'i»  not  sta^ianij 
above  the  ligature,  that  is  to  say,  in  a  state  of  rest,  as  is  usiuJIjI 
w«uine<l.     On  tin'  contrary,  it  is  n;^'t«t«d  in  an  onlerly  manner,  Ml 
that  tlio  fibrino  is  as  it  were  clnimed  out  of  the  blood  to  fonn 
eoaguUmi.     Thii*  may  bo  ilhwtnit<'cl  by  th«  following  csiK-rimenUj 
Let  an  opening  («)  be  made  in  the  side  of  a  common  glass  tt*l-^ 
tube.     Hetwccn  this  opening  and  the  closed  extremity  of  the  gla 
let  the  latter  be  filled  witli  sand.  A  stream  of  water  directed  ihitHii 


ha* 
be 

°^ 

nedH 


*  Onffam/^rrhtidfijiAtiS.   Soe  also  HaUcri  op.  miti.  t  i.  «sp.  34.  "S«nsbB 
T*ro  in  arli'iitl  li^ula  sHiiguis  eulli'iauH  iu  I'tTu^t  ut  uuUua  supra  viuuulu 
eangliis  mmn'ret,  buL  lino  vvta  oojiioswr  vl  slagnnjis  suiiei-ess*!." 

t  liie  Jlililun;/  iiml  Mflaaurpliou  di4  Blulj^ropfu  oiUr  Jliromlnti  tn  tftUt 
tfit  Jllul-jr/iieaai,  Elsfriath.  1B34. 

;  Miiai'um,  St.  Hartholomew's,  serieB  sStL  Ul. 


COAGULATION  IN  VEINS. 


S97 


V 


:ic  tube  n(Iiij:)l«l  f«  the  orifice  (fr)  of  tlic  glass 
will  quickly  peniovo  tbe  greater  part  of  the  siuiJ 
tliTTKigh  the  Enlvral  mitk-t  (a).  U'lmt  iritiniDfi  will 
BSBume  a  spiral  shape,  whilst  tlio  particles  of  aan<i  n^t 
they  OTP  whisktvl  away  will  indieutc  n  spiral  inuvc- 
tnentofthe  wator'stream,  as  Hhowti  by  tlio  plain  and 

I  dotted  litKM  in  the  annexed  (li»gnuii.  Ax  the  rela- 
fiona  are  x'arieii  botwoen  tJie  velocity  of  the  stream, 
tbe  diameter  of  the  ntitlvt.,  tho  diAinvtor  of  the  tube, 

ind  the  distance  between  tho  closed  extremity  and 

tfao  latcnil  ojieiiing,  to  of  eourw  will  lliu  rvsult  bu 

nodjiied. 

In  llw  nii'Ul  of  "iieli  nii  onlerly  movement,  fibrino 

ta  probably  separato'l  fronj  tlie  blocwl  al><:>\'e  a  ltga~ 

tnre  fln<l  formit  the   clot,  which,  monlded  by  tlio 

blood-strewn,  is  spiral  aiid  conical,  extends  to  the 

Grrt  lalcral  braneJi  (where  tbw  ehuniiniL;  movement 

veaaeei),  and,  oonsisting  of  sejiarated  fibrine,  is  from 

the  fir»t  c"l"t(r!ts>!i. 

I'lider  like  eircnmstances,  dots  form  and  extend  in  an  ohstnictod 

rein  (6ft.  i,  a)  in  opiw^ition  to  thv  stream  as  far  an  the  first  branch, 

w   Rl  &,   wliero    tho    bloixl    ttirns 

bock  through  the  oollak-rut  \t^m\ 
Hie);  tbey  also  form  where  tho  blorxl 
^Bi^gar^tateti,  m  in  the  Mubelnvinii 
^pvein   from  disease  of  tho   heart;* 

bat  ttww  oosgiila  nro  produced  Icm 

rapidly  than  in  arteries,  and  their 

fibrine  is  aHm  lar^fcly  niiiif^led  with  i 

oilier  hlriod  constituents.  The  blood 
1      abo  finds  its  way  into  the  vein  on 

tbe  enrdine  stde  of  an  obstruction 

((f),  and  snppoeing  vessels  (ge)  to 

be  tiim  neJMi^,  whi*t  with  an  ex- 

leroal  dot  (//)  and  the  coa^Ialioa 

within,  BA  at  (/,  lliey  are  soon  phigged  to  their  junction  with  a 

lugcr  vetisel.      Tho  end  of  tlie  clot  in  e<jtitiiot  with  the   bloud- 

■traam  is  round  or  Hoitened,  if  in  a  small  vein  which  opens  into  oiia 
[  of  large  nze;  if,  on  llto  otlicr  hand,  it  oecnpiof  the  large  vc^wl,  'M 
^^xtninuty,  moulded  by  tlie  Intend  current,  is  tapering,  or  otherwise 


•  Museiun.  Oi^'a,  lOSl!^ 


398 


DISEASES  OP  THE  VEINS. 


Diodifiact  in  ite  tituLpc.*    Boyond  uiy  such  [mint  Ui»  fixtetiHioR  of 
vlut  ill  prodispcMMMl  cn«cs  tlL'^tdidi',  as  nbown  by  Virt-liow,  tipoti  d< 
jKwiW  IVoiii  iIk!  IjKhhI  Oh  tbo  latter  flows  over  iho  coagula,  aiiil 
additiuiis  of  fibriiie  iimy  be  nrraiigwd  in  ordwiy  layura  (y),  or 
be  dojKiaitvd  irrti^ilnrly,  l«iivtRg  a  rongli  Rortaae,  an  at  A.f 

tlicjw  accumulatioiut  tlio  largest  rdiut  may  bo  no 
nearly  ()C<ilutIed  that  a  sliglil  ndditionxl  coa^- 
latioD  at  any  momcat  completes  tlioir  clonurfl^H 
VciiseU  tliiw  jiluyged  ])n.'«eiit  the  appcM'aiw^^ 
shown  III  fig,  3,  drawn  from  aii  obstructt'd  i>n>- 
tiindiL  vein,  the  yellowish  or  white  clot,  having  aa 
is  usual  a  spiral  shape,  and  tlio  coloured  uOiLr^Ium 
filling  iu  uitentpacei)  (of\eii  Kfieukled  with  frag- 
Al  f  'M^  n)«Dt*  dorivud  ftom  the  fibrins  inaMOs),  tlio  wl»olo 
P  I  Cj  #  ^  Ixuirinf:;  Ixilow  :m  imprussion  of  tJio  veiii-vaives, 
T!it<  suvoral  ohailgus  hitJiorto  described,  although 
as  oQen  iii(Iii|»fiicl(!iit,  are  trmjiitMilly  associated 
witll  ordinary  uitininniatioii  of  tliu  partn  around, 
iw  may  he  sii-ii  iti  tin-  gn'iitiir  luiiitber  of  the  pn> 
liai'atium  in  the  Iiondon  museumH.  As  a  con- 
)KHjiionci!  of  sueh  iiilbiinmatioii  (nitHnniiiMl  ad- 
hesive phlebitis),  tltL'  amall  vcewle  quiL-kly  till  with  c-tol^ ;  and  if  a 
main  tnmk  be  tliun  csumiiiixl,  iln  iniu-r  Kurl'iicD  will  lie  found  dotted 
over  with  what  at  Hmt  sight  look  like  plates  of  lymph,  but  which 
are  in  reality  tliu  dot*  projecting  fi-oin  the  brandi  v«in»,  •onw 
firmly  altaehod,  some  hanging  loosoly  in  tlio  canah  From  these, 
m  Parting  points,  the  niiiin  vein  becomes  iu  tiirn  olwiructed 
witii  coagula,  more  ospocially  if  it«  outer  walls  arc  implicated  in. 
tlie  iufiaiiiiiiiiti'in,  the  ehit^  having  oikii  a  regular  laininateeL 
arrangcment.     At  the  fii-st  targe  vessel  wbidi  joins  the  aSected- 


*  See  wooUout,  vol.  i.  jt.  Ulii  iiIhu  museuu,  Guy*8, 10Sl"i  MiUdk-sex* 
vi.  03. 

\  It  is  from  lliesi.'  pri'joctiiig  Goni,'uIii  tliat  fingmeula  udJ  «»«n  \mrf9 
muBsi-H  are  Hepwutcd.  puas  iiilo  Uii-  liluoiIali'L'niii,  and  Hre  ou'i'ttM]  by  it  W 
be  cvi'iitu&ll.v  Indeed  in  dbluiit.  oi't^uiH.  titivi;rHl  eueee  ton  rvcorded  in  which 
HuUdoji  dL-iitli  )iu!i  lici-n  ouuaud  hy  the  ludgineut  of  suck  a  libriDo  muii  in 
the  imlmoiiiiry  iii'terita ;  thu  cimsuqucnucB  of  tlicdr  iirrvnt  tn  lln)  nrliTiia 
of  the  bmin,  whithvr  tlicy  arv  usuully  cnmud  from  dqiouta  oii  dix'Aiird 
valves  of  tlin  hi-iirt,  hiive  bui^n  fully  iiitustigiitad  by  Kirkcn ;  iind  tlin  whola 
Bul^cct  ofocuhisiun  of  tlic  itrteric^  from  this  cuiuo  will  bo  founil  trv«t«d 
of  in  Ihi!  fallowing  vaany  (pii.  3S2  et  suq.).  Plnte  vlii.  altscit«d  to  DavU'i 
piiper  in  MnL-Chir.  Tnim.  vol.  xii.,  and  prepamtion  IftSl?  in  Guy's  Hospital 
munoiini.  nre  i!xccll«nt  ilhistiniJoiis  of  cougula  ia  a  poottiou  to  le  ihu* 
WMlied  utThy  tlio  bluod'SUX'ula. 


4 


COAGULATION  IN  VEINS. 


299 


1         tnr^i 


Tein  the  dotting  U  arrested  by  the  incoming  blood-strcam ;  bat  if, 
iw  luu*  betni  nlrvwly  i^tiowii,  tlui  dijtjKwitioii  to  cIut-tbnnati(H)  in 
ag,  it  ia  only  checked  at  the  junction  of  coilatcnd  vessels,  and 
i_v  uxtvrid  with  swirwly  uny  liiiiil  uillicr  tuwHrda  or  uwiij-  I'rom 
the  centre  of  the  circulation, 

Wlii-n  tltcw  cIoIj'  art!  removal,  the  lining  iiieinhruno  of  tlie  vein 
beoeaih  prei^euta  a  natural  appoai-aiicc ;  hut  its  outer  and  middle 
ooat«  are  not  unlmjucnlly  tlni-kciu'd,  mid  if  tliriv  he  much  con- 
:!tioii  of  the  tissuoa  around   suli§e<|UDut  to  their  inflammation, 
vein  uiuy  bo  thrown  tutu  lougitudiiiiU  fuld^,  or  may  hc-uoiiie 
fautuoiis.* 

As  each  cosfrulum  is  fbnned,  it  eontraetti  and  it  ofWii  liappons, 
being  firmly  fixed  by  ita  roots,  as  we  may  term  its  prolongations 
into  tiw  small  hnmchm,  tliat  iho  voin-nnll  is  dniwu  with  It  in  its 
tetractioii,  becoming  condensed  and  tbickeued  in  appearance,  so 
miM^  «o  that  when  etrt  across  rt  rracmhlud  im  artery,  hidcetl  thi.Ti 
condition  is  generally  mistaken  for  an  inflammiitory  tliickening  of 
V  \v».**^  \  hut  in  tltc  cajse  of  thi?  young  woinnu  iiiuruti^  at  page 
'3,  suspecting  tlie  nature  of  the  change,  I  I'omoved  tlie  internal 
which  WHS  contracted,  thick,  ami  Lanl  liko  u  ]>iec«  of 
irlupoord,  aitd  having  injected  water  into  a  [lart  of  tlie  vesael,  easily 
nMored  that  jwrtion  uf  tho  canal  to  its  ordimtry  size  and  tlio  vdii- 
wall  to  ilA  osaal  appearance,  so  that  in  tlie  prejutriitlont  it  forms  a 
marked  contrast  to  that  part  of  tlic  vcescl  whicli  remains  (.■undcuseth 
Hw)  its  walls  been  thickened  by  any  inRaiimiutory  deposit,  thoy 
WDold  nut  have  yielded  to  tlic  slight  j>rG«saro  wliicb  was  cniployed. 

Sometimes  the  coagulum  slu'inks  to  one  ai<Iv,  huJiig  more  tightly 
bsld  by  the  branchcw  in  that  than  ui  the  opposite  direction,  and 
muter  fai'ourahle  cin^uia-ilanws  tlie  bluud,  iIlce^*antly  t:n<leav(turing 
b>  ituiniinte  ttTcIf  into  the  obliterated  vessels,  mav  form  a  channel 
the  side  of  the  clot  between  it  and  tliw  vuin-wull,  or  in  mno 
UMboccs  (rvierrcd  to  by  Itilxs  and  others)  may  drill  for  itself  a 
{mage  through  tlie  centre  of  the  clot  Under  mjcIi  eircuniitluDces 
lie  drculiition  is  nH^tablishcd,  though  still  hindered  by  jiortions  of 
Elmnfl,  which  form  baiuLi  and  cords  Hirctehing  oin-iiiut  tlie  canal.} 

It  more  ooniraoitly  happens  tlint  the  obliteriition  is  permanent 
iod  the  vessel  ts  la'il  to  tlic  ein-nlation,  liio  olot  (fnxjuuittly  organ- 
i»d)  aud  the  vein  ultimately  forming  a  firm,  slirunkeu,  somcttmos 


*  Ma*«iua,  Collciroof  Surgnoos,  liaa. 
■(  Musaum,  St.  liAi'lliolomcw't.  xiii,  lAI. 
;  Uuitettai,  St.  Tboiuos's,  i,  Wi,  ICtk 


300 


DISEASES  OF  THE  VEINS. 


r'' 

aiusM 

-olvo»H 


calcnnvxisi,  pord.  The  ffolUloral  eiroulatioii  carries  off  tlie 
which  should  htivo  [witsod  Hiroiijjh  tho  Io*t  vowwl ;  thoii^Ii, 
thill  i«  pstahlishi^d,  iuid  pven  after,  there  is  (»Joma  of  thowe  jiarts 
fi'om  whcnt'o  thi'  return  of  blood  i»  hiDdontil,  aiid  owiwioimlly  cv«ii 
liHtiiHirrlinga  llie  ('xteiii  and  &ovarity  of  tliis  oedema  {rtkUf  rnvtlUnti) 
will  dL'pcnd,  (fi)  ujKm  tho  wzi-  of  tho  win  olditcnilod,  {h)  upon 
tlio  oxttfnt  of  the  obliteration,  and  (■;)  upon  the  suflioient-y  of  the 
anastomosing  vwsrIs  to  rt'iiitiiv  tho  obwtniotion.  "When  tJio  oedema 
is  attondtMl  with  oonuderablo  pain,  a  Ion-  >itate  of  inflaniniation 
8iip4}nid<lt!(L  Tliu  part  is  ewollon  and  liard,  but  doeit  not  pit  on- 
pntsaaire,  ta  in  annsarca,  and  is  not  red,  as  in  phlegmonous  er}'> 
sipclas.  But  tht^so  alToctionx  oro  nearly  alHM,  a«  tlio  one  oausos 
celhiliir  inflammataon,  and  m^'sipelas  itself  almost  always  occaaioi 
an  affection  of  tho  wins. 

Titiit  oyleinii  often  enibarraises  the  repair  ofjraetaren,  moro 
cially  when  the  breaka;;L-  is  near  a  medullary  fonunon  and  inv 
tlio  laot^ration  of  a  largo  vein,  or  when  tbe  tiKmea  arotin<l  are 
greatly  bniisod  from  tho  direct  violence  of  tho  injuiy,  bo  that  clots 
jonn  in  the  prinripul  vessels.  Aa  this  compiioiition  in  of  nuoti 
common  occurrence,  it  i«  strange  tliat  attention  has  been  so  little 
clireirK-d  to  it  in  eiiswi  of  tardy  <ir  non-union.  It  may  be  i'«s[M'(!t(s'l 
when,  about  the  fourth  week  after  tho  injury,  the  parts  cuntiniti 
or  biiconio  OMloniatouB,  cold,  and  oflon  aching,  llm  remedy  ooi 
BJsta  in  endcavoiu-ing  to  improve  the  circulation  tlirough  the  siipow 
Scia]  veins,  whli.1i  nru  loii.tt  often  i>ti!itructe<i,  by  frietii.in  with  tho 
hand  and  by  position.  It  is,  however,  always  a  serious  affection, 
as  shown  by  tJie  fr(i|ueucy  with  which  oppHntiinitic!*  offer  for  in- 
ajiecting  the  bodies  of  old  and  foohlo  people  who  die  some  weeks 
after  a  fracture  with  no  trace  of  union,  but  with  nuincroiw  occhy- 
nioseH  and  plugged  veins  around  tlie  seat  of  injm'y. 

It  just  depends  ujion  the  giMidness  or  jKiverty  of  tho  fibrine 
whether  it  shall  cause  these  simple  obstructions,  or  whether  it  shall 
tcften  and  tVmnkifTnte,  fonning  a  thick  yellow  fluid,  sometimes 
blood-stained,  which  resembles  pns  (piu-iform)  in  its  a|>jK'aramw, 
and  which,  with  the  com  pi  i  coitions  it  may  givu  riso  to  (pyaemia), 
has  been  already  describetl."  Tlie  |iorlions  of  clot  whon  sofloncd 
arc  usually  shut  off  (scfjiicBtcrcd)  in  an  upward  and  downv*  ard  direc- 
tion by  newly  added  oouguln.  And  here  I  may  observe,  that  the  soft- 
wiing  begins,  as  a  rule,  in  the  eoagula  last  formed,  not,  a»  Virohoiv 
states,  in  Uiose  ftrst  dLposici^L     For  ui  tho  advance  of  tho  niidady 


n^i 


Vol.  i.  p.  aes. 


COAGULATION  DJ  VEINS. 


301 


V^ 


I 


ptiieiitV  failing  <<on(Iitton  (iep;ol!t  on  nx^ncinlod  pnom<<Kt  nf  dto 
SbrnM> ;  so  that  a  disease  begins  witli  libriiie,  wJiich  will  form  an<j 
condnuo  n  lirm  cioiii{iucl  (>!"{;,  but  emU  vrilli  <Ii.-{ioitiU  of  a  worse 
.t«r!al,  which  ra]>iclly  clisinlogratca  and  softens. 

TAs  iiyjnpfomt<i{ti\»truvu<m  of  tlic  deep  v«iti*  ar«  vei^-  obiicniro, 
-en  wltdi  attended  with  ordinary  intlitmmation  of  tlie  parts  around. 
Theru  may  h<!  wune  conHtitutiorml  dintiirhanc*! ;  tUo  Mipcrfiniul  veins 
may  be  congested,  and  after  a  time  the  oceurrenee  of  o?dema  may 
lor  nottucl.  WIri]  the  liiniis  jiro  (iffwlt-d,  thry  fii'l  h'lt,  and  dry,  aro 
n<[aally  flexed,  and  cannot  lie  extended  withont  considerable  pain. 
If  llic  !>ui>crficinl  veiiw  are  involved,  llicy  can  1>C  fflt  lut  hard  cnrdji 
nnder  tl»e  finger,  the  induration  being  duo  to  the  thickening  of  the 
tiwaM  uronnd,  to  tint  eliits  within,  or,  more  "tU-u,  t<>  the  two  con- 
jointly. The  course  of  the  attentlant  intlainniation  is  marked  by 
mliMM  mmI  lirndernc«',  and  raiiy  U.^  diKtiiiguiMhvil  from  intlaitima- 
tinn  about  the  lymphatics  by  tlie  minute  size  of  the  ooi-ds  in  the 
latter,  it»  suiwriicial  character,  tho  luiMK-roiiM  small  kuuti^,  and  tho 
nae-coloureti  rednetui  of  tho  skin.  The  di:ignosis  between  affections 
of  the  d(W]i  vcuisund  of  thu  nli«orbcnt«  i»  not  so  clear.  An  occoni- 
ptui^nng  injury,  ft'om  which  the  miscJiicf  may  have  started,  and 
wliich  is  pjwiorally  n  conliwion  or  an  o]>cn  wound  of  some  kind, 
will  Usually  su^cit  to  uh  tho  probable  condition  of  ttie  ueighl>oiir- 
:g  %-«in». 

In  many  cases  no  danger  is  to  bn  fcan^d ;  but  when  large  and 
important  veins  aro  oxtensirely  affected,  as  those  of  tho  pelvis  and 
lower  cjctmnilies  conjointly,  nutrition  is  m  largely  hind«>red  tint 
dottb  by  no  meand  imfrectuontly  results.  Tlie  obstructions  oftco 
fittue  HoriouH  c»nii'liiuiti<Jii,i,  as  has  IxKm  already  idiown;  and  then 
there  is  further  danger  from  portions  being  separated  from  tho  clots 
in  tin*  voiiL-^,  and  carried  to  kmim:  seuondary  nii»cliii.*f  in  tho  capil- 
laries of  various  organs  (pj-fcmia). 

If  tito  nature  of  thta  ufii^etiun  is  rightly  itndcntfood,  the  do- 
'Kription  of  its  Ireatmeitl  becomes  Dimple  enough.  The  patient's 
budlh  munt  l>e  upheld  by  fidi  doscn  of  Imrk,  or  of  any  other  ap^ 
proved  tonic;  and  a  generous  diet  must  minister  to  his  amendment. 
If  thfm  In!  any  error,  it  will  be  on  tho  sidir  of  not  doing  enough  in 
this  respect.  Locally,  ie«t  must  be  insisted  npon,  if  possible  in 
BiM^  a  pocciUon  a»  ithall  favour  tlio  clrouliition  tlirough  the  part 
affected.  Tlie  circulation  Bbotild  bo  promoled  in  the  supei-ficial 
Tcina,  iw  has  Ixvn  nlrcady  indi(!!it*'(l,  as  the  surest  mejuin  of  rx'lici  - 
ing  the  (edoma.  If  there  be  pain  ft'om  an  inflammation,  it  may  be 
•owtlml  by  warm  fomentations  ;  if  it  bu  chrome  wid  from  oidcmu, 


90S 


DISEASES  OF  THE  VEINS. 


it  18  a?cful  to  givo  opium  in  some  form,  and  thns  for  tlifl  timo 
rolic^t)  it.  Kfti-li  oitM)  in  whinh  iho  itytnpUirns  are  at  all  aerioiu 
will  jirotjably  roquire  patient  watehinfj;  for  tbo  ditwaw,  with  its 
acTioa  of  atn^a,  t\u}  cmifTiiliition,  llic  eventtud  oblitorntimi  and  the 
righting  of  tlic  circulation,  is  of  slow  progress,  and  must,  after  all, 
be  left  pnHty  muoli  tn  nntiiiv.  Our  nnxioty  ta  render  ivuitHCanoe 
i^lioiild  nc%-«.T  lead  lis  to  the  cmploymonl  of  nut-h  rcmpdics  as  bliriers 
applitMi  to  tlii^  (HlcmnloiiM  ltml> ;  nor  ciin  ituglit  hut  harm  he  aiitiri- 
pat(>d  Iroin  d<>pletion,  the  use  of  mercury,  or  of  sudi-liko  povreHiil 
metiicine,  ExM'pt  in  tin'  si.i't-ml  cn.sc9  to  which  I  have  referred,  a 
&t-Durablo  issue  tuay  be  anticipated. 


J 


Suppurative  PhUMtis, 

It  roraninn  for  me,  liaving  already  iiotleed  tke  ndbp*i\'c,  to 
acrilw  the  mp/mratiir  (diffuse)  phttintix.  Tliia  diAease  is,  to 
notlnng  inon-  tliiin  it  diffused  i>h]<:gm<jiiou8  inflammation,  and  ongiit 
(o  tie  reelaxMHl  wilh  disonlors  of  that  eliaracter,  from  winoh  it  ww 
Bq>anitcd  on  account  of  a  prevaJent  ojiinion  that  the  inner  mem- 
hrauo  of  veins  vms  tlio  part  first  and  ehiofly  affected.  Tliin  inflam- 
mation follows  tlif  course  of  veins  whJeh,  acting  as  conductors) 
fiivour  ibi  rapi<I  extension  in  the  direction  of  leiiHt  reiii.4lftiic« ;  nni 
heiiec,  as  a  rule,  the  disease  posses  from  the  small  to  the  I 
vessels,  siniw  the  ot^Iliilnr  surromidinfp*  of  ibo  latter  offer  the 
route  for  its  advance,  Tliat  the  parts  around  arc  first  affected,  and 
not  the  lining  wf  the  veins,  \n  not  oiilv  .shuwii  hv  the  ex  ami  nation  of 
fatal  cases,  but  is  the  more  reasonable  a  proposition,  since  it  does 
Away  with  the  difficulties  which  i^urn)und  tlie  history  of  an  inflam> 
mation  of  the  internal  and  middle  eoata.  Tliere  is  no  prejKWatioji 
of  Ki»-eallrt1  suppurative  plik-liitis  I  am  actpifflinti-d  with  in  wiuch 
tlie  parts  arownd  the  veins  are  not  infinjned  and  thickened. 

No  patient  in  deei-nt  condition  of  licHlth  could  snftcr  from  thii 
disease.  The  worst  tliey  cfjuld  lie  ti-onbtcd  with  would  bo  a  limiivd 
(adbe.«ix'e)  tnflammntion  of  the  ]mu1»  around  the  vessels,  with  al 
tendant  obstruction  of  the  veins  with  clots.  Hut  if  the  system 
tlepresMCfl  and  enfi?ebled,  as  when  suffering  from  extensive  u!' 
from  large  lacerations,  or  from  se\'ere  oiierationa,  this  diiteasn, 
Ijiekiug  wounds  and  adjacent  structures,  extends  along  tlm 
of  tlio  vessels,  jnst  a.«  in  other  cases  it  ha]>penR  to  extend  along 
the  sulwutimeous  cellular  tissue,  and  is  known  as  phlcgmonona 
erj'sipclas.  It  succwds  after  various  and  fUssiinilnr  nindes  of  local 
irritation;  in  one  case,  the  pimctuw  (venesection),  in  another,  the 
division  of  a  vein,  is  its  starting  jwint;  and  it  olVon  occurs 


4 


"mnpntation 


DIFFUSE  PHLEBITIS. 


303 


jpntations,  m  after  other  wounds ;  not,  bowever,  in  cons«]tienoo 
of  lifpiturfc*  a{'{>Iie(l  to  veins  vSicr  any  widi  oiH-rntion.  Wlictlior 
these  vessels  be  doil  or  not,  this  itifLimnifktion  may  siii«?rvOTie ; 
uid<.-v(]  in  i-vwy  ntnjnitntioii,  n»  ruiimrkwl  by  Hlandin,*  tin;  vcm» 
whicJi  anconijiany  sinnll  arteries  are  always  tied;  and  we  bare  no 
Ttj^it  t<i  nr;jtir  tliat  tJi«  iif^turc  of  a  Inrf^v  vein  in  more  likely  to  bo 
followed  by  difi'used  inflammation  of  it^  witll,  than  is  that  of  tho 
nniUlcr  tcbmIs,  Such  an  aMumptton  cannot  bo  justifiud.  More- 
over ligntiu'es  sepai'nte  from  veins,  as  already  shown,  nithout  cx- 
^^iting  ititiainmatory  cliangcs. 

^B     Whilst  remembering  that  varions  degrees  of  severity  exist  bo- 

^Bvraen  tlie  limited  (ndhi?»iv<;)  inflammntioii  of  titc  tixHiic-M  around  a 

^Pr«n,  and  ilio  most  severe  fonn  of  difi'iiwe  supituration  of  the  same 

strocturcs,  wo  will  take  a  bad  catc  of  the  lattor  ns  giving  a  corroct 

idaa  of  tlie  nature  anil  prrigri^s  of  the  dinense. 

On  March  27th,  18()1, 1  cxaminLxl  tlio  body  of  a  man  who  died 
in  St-  BAitltoloinew'a  Hcn))iLil  under  iJte  following  oiroumstanoes.  He 
fell  from  a  height,  and  so  Ufwn  some  iron  spike*,  which  penetrated 
on^  into  t'il)M-r  thigh.  Diflu.'ted  tnilHmmuUon  t)eoame  estiiblislu'd 
along  tlw  track  of  the  wounds,  moro  especially  on  tho  riglit  side. 
On  lln-  fourth  davi  withoul  mari^rial  aggravation  of  ttio  symptoms, 
the  right  sipliena  vein  became  indurated  along  its  entire  length.  Tlte 
become  congi»t<!d,  symptoms  of  dyspnnpa  were  tulilcl,  niid 
I  died  (typhoid)  on  the  seventh  day.  Tho  right  wound  extended 
thu  Uiigh  to  its  inni>r  side,  and  unhenltliy  pus  was  ilitfiLtod 
fir  and  wide  saperficial  to  the  fascia  lata.  The  tissue.^  around  the 
■afilKnii  vein  were  laden  with  «xtmvaiinte<l  binotf,  and  M-ilh  im> 
hidthy  saniouB  pus.  Tho  glands,  Mpecisily  about  the  upper  part 
of  Ibe  thigh,  w<>rft  t-nlargod  and  bliMxl-sbun^td.  Tlie  oiit<r  cunt  of 
dw  aapbona  was  oedematous,  the  internal  surface  of  the  vessel  was 
tmgli,  ami  tlio  inner  coat  wax,  for  tbo  ntoM  part,  w.'intiug.  There 
*i«  no  increased  vascukrity  of  the  veteel.  lis  canal  was  tilled  with 
wdou*  puH,  and  occnHiomil  KhrulM  of  blood-oloUt.  .Just  aliovo  tho 
nnrr  ankle  it  was  siuldenly  contracted,  and  contained  a  tapering 
"tgslitni :  niMl  bore  was  the  limit  of  tbo  siim>im<liug  intlautmatton. 
UK  femoral  vein,  at  its  junction  with  the  sa|)!iena,  was  laden  with 
j  "A  ankKiRid  dow,  which  cxtvnditl  into  ibo  external  iliac  Tho 
rap  were  congested  and  a?denifltoii«. 

Thi'  ohangcN  in  lliis  and  in  allied  cfiscs  may  bo  described  as  an 
■Gkialion  of  tho  tissues  around  each  vein  with  scrum  and  corpus- 


•  Jonmal  HthhmaJatn,  Paris.  It<29,  torn.  it.  p.  AT9. 


304 


DISEASES  OF  THE  VEINS. 


viui 


oolar  lympk     Tliis  quickly  degenerates,   and   fopma  a 
sbMCOKAi.-n,  cir  ratlior  a  difTuseil  willt'Ctitm  of  jnw.     lliw  rapidity  witii 
whicb  these  resull^  follow  each  other  is  most  alarming.     The  veil 
at  firMt  vontravt,  entangling,  us  thoy  <lo  no,  «oni«  few  ooagula  :  bu 
preseully  such  portions  dilate.     Beyond  these,  other  parts  M'  the 
Bame  wmwl  an  undergoing,  a»  tlio  surrounding  di.foa«c-  n<Ivancvs,  tba 
earlier  proeesa  of  poiilrartion ;  and  again,  heyond  sueh  j>ortion»,  elotf^ 
close  their  cvtiiitl  and  niitrk  the  momentary  limit  of  the  disease.  And 
so  it  extends,  following  tho  \'ein-OAurse.     All   hraiioh  v^tiseU  tro 
closwl  witJi  elots,  or  involicd  otherwise  in  tlic  disease,  so  that  no 
blood  flows  throtigli  the  vesac^l,  ajiil  thus  and  from  tlio  cutidition  of 
the  parte  around,  no  nourishment  ean  now  roiieh  tlio  inner  veiij 
<x>at,  80  it  dies,  Vjeeoming  cIou<iy,  fonning  an  inorganii;  friuble  pul]^ 
which  gradually  melts  down  until  no  vestige  of  it  remains.     TIk 
inner  coiit  U-ing  dexU'oyed,  jms  may  find  its  wny  uUo  llic  dilated 
Teesols,  either  direct  from  the  ot]ior  vein-coats,  or  tlirough  them 
from  tlio  parta  uround ;  for  these  eoats,  deprived  like  tlio  inner  of 
their  blood-suppty,  frequently  )>cri»h  in  the  eoiirso  of  tlio  disease,    fl 

'Die  .*_viiiptouis  wbieli  aeeompauy  these  cliiingea  uri)  of  a  loi^ 
even  typhoid  etiaract«r,  ushered  in  with  rigors,  and  a  general  in- 
oreeiie  in  the  i«everity  of  proexiAting  signs.  If  sujierneiid  veins  are 
involved,  the  uecompanyiiig  Induration  and  congestion  of  the  parts 
arouTid  will  mark  the  progroni*  of  the  dlaeiLie ;  if  lito  d4*ep  vcskvIh 
are  implicated,  it  is  upon  the  accession  of  general  s^Tiiptoms,  and 
ujion  tlio  uiiou-iiui-HN  nhotit  the  |iart.4  dlleclt^d,  lliat  we  must  rely  for 
a  diagnosis,  which  indeed  is  not  always  easily  arrived  at.  ^^Tien 
satisfied  tlitit  tlif)iist>  KupjiunttioTi  !.■•  eMtJihli.^hoil,  we  can  have  but 
faint  hojws  of  a  satisfactory  issue,  although  in  the  less  sevftre  cow* 
we  may  succeed  in  limiting  its  oxteusion,  and  ho  in  arresting  the 
disorder. 

To  ett'ect  tlii»,  every  effort  must  lie  directed  to  the  support  of 
the  patient  with  stimulants,  good  aniriuil  food,  and  tonio*;  w-ginii 
fomentations  applied  to  the  parts  afFected,  must  ho  eombtned,  if 
]>ottsible,  witli  free  incisions  to  allow  of  the  eiicapo  of  the  nnlHtdlliJ^ 
material  depositing  along  the  course  of  the  vessels.  Butunough '. 
been  Haiti  in  treating  of  erys!{>ela«  and  of  pyii-niia,  to  n-nder  it 
necessary  to  enter  hero  into  detailK  of  management,  which  would 
merely  a  reiH>tition  of  those  recommended  for  the  di.4ca«et<  afoi 

In  the   cuKcs  of  diffuse  supjiuration,  the  ooaguln  play  an 
important  p.ai1,  very  diDiirent  from  the  position  they  occupy 
cBaes  of  clot-obstruetion,   more  especially  when  they  soDen 
acquire  the  purifurui  condition.     Enough,  I  trust,  has  been 


PHLEBOLITHE& 


SOS 


fetnlbrce  tJm  iatporfaQM  of  distiiiguUhing  between  tlic  two  affcc- 
6aui.  Cxrvful  cxiiminatton  of  individual  ctisv*  wi!I  prcvuit  tlwtr 
kiajt  haatilj'  coqIuhoiI  tiitt  one  with  tlio  otiutr ;  ind<wd  in  these,  as 
in  all  utlicr  cases,  no  jiu't  coticliuion  can  be  arrived  at  witbotit 
4ixnrato  ulMcrvatJun  ttail  tlie  examine  ot'iin  unliiii.HiH<d  judgment. 

UnUks  as  the  two  disease*  mav  be,  fboy  have,  however,  tins  in 
Mamoti,  tlml  either  may  he  the  cjiuMe  of  l\itt*v  Mtoxindary  c<>ni{*l!ca- 
lioms  to  which  tlio  terra  pi/amui  \a  jiroperlv  reotricted. 

IniantB  occasionally  suffer  from  inRainmatioii   nlmut  tlic  um- 

hilical  vein,  as  noli<»d  by  Osiandcr,  Meckel,  and  mora  reoeiitly  by 

Dnplay.*     It  commence*  from  tlio  second  to  the  twcltlli  day,  and 

B  often  proci^Iedby  some  injury  wliii-li  (he  i-Iiilil  Iiiih  AuMiiiiietj,     In 

otber  Basee,  it  would  seem  tn  de[>end  upon  influeneiL'«  tlio  same  na 

tli'»«  oaiiMn^  jiui-r])i-rul  fifviir  and  nllreil   ill.->iir(lt>rn.      l)ii|)l)iv  iiinnd 

in  three  out  of  six  caaoB  tJrnt  ervRipeias  was  associated  with  the 

iflVNTtion  of  t!»e  mr<l ;  and  iiccofionnlly  even  toeal  gangrene  oociirs, 

ftna  showing  tlie  low  phle^rmonous  eharaelev  of  the  atl'oetion.     The 

pneral  had  condition  of  tin'  uhildn-n  iit  also  indicali^  by  di.-><'hargvs 

kam  tha  nincoua  membranes,  and  by  tlie  coocourrcnoe  of  purulent 

a)ibtfaalmtfl.     Death  (Kvnm  fnmi  Ilio  twell^h  to  the  sixteenth  day. 

Ik  entire  cord  is  involved,  thickened,  with  the  structnreji  around, 

Ml)  odifa  witli  jitTilonitis.     Tiic  umbilical  vessels  are  all  obliterated 

iitliA  comuKin  alToKtion,  their  canids  being  filled  with  o!o|j*,  whi.'h 

bre  been  found  to  extvmi  into  the  [lortal  vetn^      Tlie  ditt  of  the 

IcUId  and  the  viirioua  secredona  require   attending  to,  and  warm 

r  fanentalions  may  bo  applied  to  l]io  inflamed  struettircs;  but  the 

hnler  age  of  the  inllint  is  unequal  to  reRint  mo  Keriuuit  a  <Ut»ea»o,  for 

*  btal  result  has  followed  in  all  recorded  casos. 

Home  roiiis  not  infrequently  contain  Ioohc  falruli  or  phlebolilhos, 
pwndly  rouix]  or  oval,  and  sametimea  attacJied  by  a  nan'ow  [tetlicle 
inner  wall.     No  ineonveuienoe  results  from  their  presence, 
'ore  fouiMl  moM  freijiioiitly  in  the  vein»  of  the  pelvi.*  al>out  tlw 
et  and  prostate,  e«}>ecially  when  the  latter  is  enlarged. 
TiM-tr  origin  luu*  been  rniuOi  quiwtioned.     It!ehat|  tlioughl  that 
'  oociUTed  in  veins  exposed  to  slow  circulation  of  tlioir  contents, 
i  found  tlH^n  eonnect^Hl  with  varici'H.     H<>(lg!*on}  hold  that  tliey 
probably  tunned  in  surrounding  parts,  and  made  their  way 


*  Atw  HfJifilt,  1838,  t«ai.iii.  p.  104. 
JlaL  liiL  art.  ST. 

-t  An-a.  tUs.,  par  Biohnl.  p.  lOJ. 
TOU  m. 


Sec  also  MorgHgni,  EpUt.  Anal. 

I  i)it.</Jrurif$,  p.  till. 
X 


SOe  DISEASES  OF  THE  YEEKS. 

into  the  veini  by  absorption.  Cruvoilhier  stated  they  were  (let 
in  tbc  w^iiti-ft  of  a  clot  cirWiKHl.  It  is,  however,  most  probable  tiial 
tliey  are  clots  which  have  tlius  dried  up  and  l>eoome  tmivfomiodlfl 
Hnving  pnilnulwl  from  s(mic  Mtn.-ili  bmiicli,  thoy  receive  additions 
to  their  surface,  and,  eventuallj-  separating  fmiii  the  [Kxliflc  n  liifh 
held  thftn  to  ihoir  or!;;iniil  vt^Hol,  shift  thoir  situation,  and  are 
jterbupn  rolled  along  for  some  distonoo  1^  the  blood-Htrenm  before 
bt'injj  finally  iut<wIi.«1. 

'Hiev  art!  formed  of  eoneentric  layom,  which  conxtst,  according 
to  an  analysis  kindly  inadi-  for  mo  by  my  friend  and  eolleague  Dr. 
Fratikljind,  of  protein  niattei-n  and  pluispliiiw  of  lime.  TIic  former, 
constituting  about  twenty  [)cr  cent  of  the  ealntli,  are  nearly  all 
olbuminouit  or  ilbriiioa'*;  the  liiltor,  thoii;;Ii  mainly  phosptuite  of 
lime,  is  mingled  with  a  little  sulphate  of  pota.'^h  and  siilpiuitc  «f 
lime.  Thai  is  to  wty,  the  ))hIi'l)i>lilli(U(  consist,  a.s  might  bo  ex- 
])eeti»l.  of  the  coagulated  protein  constituentci  and  Uie  less  »olubW 
salts  of  the  blood. 

Bypfrrtrophy  and  Atrt^iliy.  ^^ 

JJi/pertrophrf  of  veins  occurs  when  any  part  of  the  body  is  the 
scat  of  increawd  growth.  It  in  a  natural  nnd  hoallliy  cliaiigc  Tfitu 
during  pregnancy  tliu  tilorus  is  provided  with  enlarged  cliannels  for 
tJie  removal  ofita  venous  bloo<l;  and  lliu»  in  a  ciiw;  ofm(-dulIacT 
CJOTOtT  of  tlio  omentum  1  have  scon  the  |>orta]  vein  twice  itA  nattinil 
size,  in  consetjuonce  of  the  Iwrge  cjuunlity  of  blood  carrivd  to  it 
tho  rapidly-growing  timiour. 

AVith  tiiis  form  ol"hy|H'rlro|)hy  there  is  ])roportionat<.'  dilatation, 
80  that  the  voRst'Is  arc  perfect  to  perform  all  their  functions.  They 
are  thus  adapted  to  new  coixlitinns,  ns  when  an  arterf  is  woiui<h>«l 
through  a  vrin,  and  the  latf^-r  dilates  (aneurisn)iil  vjirix)  abo^c  and 
bolow,  its  walls  Ix'enming  tlitckMicd  so  as  to  resist  the  arterial  impulse 

Hyjicrtrophy  witli  dilatation  also  compensates  for  niiniy  obHtnio- 
tioiis  to  tlie  eircidatitm  by  litting  one  set  of  veins  to  make  up  for  tho 
loss  of  any  other.     Tlius  no  im-onvenienoe  folkiws  when  «n]>or6eia[ 
veins  are  obliterated,  for  by  dilatation  of  anastomosing  branches  thi» 
circulation  is  readily  rei'stahlisheil.     W'btn  t!ie  vt-im  cjivw  inferi' 
even  is  )H>nnanent]y  closed,  it  is  well  known  tliat  tJie  lower  po; 
of  tho  vessel  dilutes  in  common  with  the  brajicbc*  opening  into  itj 
that  varioua  small  voins  become  large, — for  example,  the  supcrft 
abdominal  or  imygtm  major,'— and  mo  carry  to  the  heart  tlie  b! 


frooi^ 


»  Museum,  Cu;'«  UuapiUl,  it>31^ 


HTPEnTROPHY  AND  ATROPHY. 


3or 


.  to  imvtt  rrnfiluMl  th»  right  ntiri(-]i?  hy  Uio  ti.tiinl  cliniineL 

ilurebeen  long  on  record.     One,  described  by  Ilalliinl, 

|f(«0-reel  nt  tim  Ct>1lcgn  of  Surj^xms,  imd  ^Uow*  llic  ili:i«  vein 

lulv  filiated  lielftw  an  obstructing  (jnagiiliim,  a  varicoM  (dilated) 

lofvoins  (iImhiI  llic  ;i«)ins  linvin^  ciHritvl  nn  tint  circuliitioii  for 

I  yrsn  bcCore  <!e;ilii.*     Tliis  kind  of  dilnlAtion  c«u9e.i  wlion 

Tfins  can  eonvcnivntly  airry  the  vxtra  qiuintitj  of  blmnl,  and 

t  (fange  in  peniiiuii^itt  or  temporary  as  tlie  obstruotimi  roinutus 

^»  ttmani,  for  in  tlio  latter  caso  tlis  v<niu  luually  regain  tlioir 

•iu.  * 

The  only  anatomkal  change  wliicli  attcndn  tliis  increnso  of  a 

inUw  addiiiiiti  uf  iraiMTersAfibri'M  w  iLt  iiiiddlt-  ooat;  ito  Vnglli 

iDaalterod,  and  its  walls  remain  smooth  and  uniform,  save  where 

lipk  U'liind  rlu!  valvt-f*  Hivonm  for  uligUt  im;^uliiritioi4;  1>ut.,  iw 

si  liy  BuiUi«  and  Wateon,t  "  the  vessels  are  oftt-n  bent  and 

wlmi   lh(f   curn'iit  f»m-n  ilji  way  backward   against  the 

•inf:  hut  ineffeetual  barrier  of  tjie  valves." 

If  tlw  o()Kinicti<>n  t<>  the  eirculation  i*  in  the  hmrt,  or  in  tho 

Bp,  dint  is  to  say,  in  one  of  the  central  organs  tlinmgh  whidi  all 

I  tuiMt  p*M,  no  rotind-iibout  vliniinciN  can  rvarniii^-  the  eircii- 

Tho  vmtvt  still  dilate,  bnt  tlie  changi?  is  passive,  iind  awom- 

I  tltetu  to  the  blood  which  aceiiniuUtes  within  their  canals, 

I  Its  onwanl  panuigo  lit  impodtril.    "nni.-*  it  in,  with  obstniction 

I  of  one  of  the  valves  of  tlie  heart,  that  the  entire  venous 

I  dilatj^  m  that  veinit  which  can  be  WH-n,  hiicIi  m  the  external 

nkr,  are  tnrgid   and  distended.     Maybe,  with  Ihls  dilatation, 

is  pntportioiiatc  utrtrngtlivning  f>f  tlie  vein-wall ;  but  it  more 

Illy  lci{)[Hni»  tlint  the  yielding  is  simjdy  piisaive,  increasing 

I  nJitn'Ml  by  m]>turD  of  the  wall  (lia-uiorrhagc),  or  by  exudation 

(wiaiMirca). 

Almfihy  nf  veins,  in  common  with  atrophy  of  other  htnicturee, 

lly  iiillnwA  (liNUW  of  a  parU     AfU-r  amputation  above  tlio 

tlw  fomoral  vein  tcisens  to  one-third  of  iU  previous  si^e; 

'  rvmiiiil  of  n  leMtiele,  llio  eorreci'dndinj;  sjwnnatic  veins  shrink 

1  ira*U%     In  a  case  in  which  the  right  kidney  hiul  hcaw  trann- 

fvl  into  a  large  cyst  from  the  impaction  ofs  calculus  in  itit 

r,  iIm!  canal  uf  the  renal  vein  would  not  ailmil  an  unlinary-sixcd 


'*  Uaumm.  tTJll.     8m  mhci  bjr  MortpiRni.  pDrCiU.  Petit.  Cliito.  and 
I :  aliKi  Ff'yTiiiQi].  in  lb*  Joartnil  llebiUnnadnirt.  tnni.  li..  runs.  11^19. 
M«s«nni,  Uitlillpst^  lliMplml.  tx^iJi-H  ii.  3'Jt.    Trunt.  of  a  Sofictji /or 

fttftvrtmmi  i^ittit.  aitd  Ckir,  Kni>\iU<.tgt,  vol.  i.  p.  1ST. 


so» 


DISEASES  OF  THE  TEINS. 


probe.    It  is  necdlcR!!  1o  mnlliply  esamples,  fjr  atropliy  is 
what  would  hu  cxpccUtl  wln'ii  a  [iiirl  l'i-iimh  to  be  of  use,  ns  i 
COW  of  tlie  utubilical  vein  aliortJv  after  birtli. 


jyftfftirration  of  tlie  ooatfl  of  a  voin  never  lunociaten  with  ntr 
of  the  I'OHsel ;  in<Ioofl.  its  raritv  nndiT  any  oimiiriHtaiMrm  olKn  : 
markod  o<intriut  to  itit  fri><|tiont  iiccitrn>iic-«  in  nrtt^ioH.     In 
muwuin  of  St.  George's  Hospital,"  a  \cin  from  tlio  broad  li| 
of  tbo  ntcrun  contiiiiiA  a  nnind  wbiU)  mawt  wittiin  \U  tiitiiv,! 
viiin  ImiDK  pervious;  in  another  ouo,t  *  caOcareoos <le]>i»it  ininlwj 
the  inttfrniil  tmplivua ;  niid  liaillio  mentiotu  «  awo  whore  ■  xinilirj 
depoiut  was  found  in  the  onata  of  tlie  vena  cava  inferior,  tmri 
division  into  tbt-  coTiiniou  iline.'«.     BtVInnI  obMr*c<i  enlpiirwHin  A 
noriitioii  in   tlie  femonil  >'ein,  an<I  Maunrtney  and  Amlnl  in 
internal  sapb^ia.     It  ba«  ako  b<.>cn  mot  witli  in  liiu  ht>piitio  reiw;! 
but  it*  occtnTi^ncp  may  be  oonftidi'iy»l  nf^ciilt-utal  whcrrver  sitmb 
Indeed  it  is  doiibtiul  if  tbi-tio  cnloarvotis  ]>lntes  sb'iuld  \tv  rv^ 
AS  a  dc;^K!rtktion  of  tlie  voin-wall ;  it  \»  mixro  probablo  tint 
depend  upon  an  after  oliang«  in  some  local  de]>o«it  of  filirtno, 

VarieoM  Vfita, 

Varifot*  vHn».     Varij;.  \\     Pklthettasu,     Wlien  a  vein 
dilatod  without  any  jiood  object  or  purpoec,  it  is  said  lu  bo  vi 
In  the  active  or  patuivo  dilutiitioiH  already  dcAerilHtl,  whieh  : 
these  voBsols  to  cortnin  states  of  the  circulation,  the  pur]<o<c  ii  i 
evident  u  i:*  tJie  ^lin  wbiob  rmulltt.    Not  m>  with  raricoa.    N<i] 
comes  from  thorn.     Tliey  arc  useless  and  hurtful. 

Many  of  tlic  I'lirly  nn'ilical  writ*TS  wt-rt'  linuilinr  with  niuoli  I 
is  at  present  kuomi  respecting  varix.     It  is  still  thu  '>  dilalatkai 
a  vein"  d«8Cribfii  by  I'lUilui*  >-I'^gii]i-1a;S  and  our  In'atnicnt  of  I 
dilated  vessel  oontinues  ]tr:ictieuily  uiichangotL     Soinv  veinn,  » 
ft»  ii*  known,  nri'  niiafli'cti.-d  hy  rurici>s,  wliilo  among  tlime  wh 
haro  been  reckoned  as  vurioot<o  a  ounsidoniblc  nuuilx-i'  oti^bt 
to  bo  rcfurrod  to  that  hypertrophy  with  dilatation  wbidi  haa 


*  S«rIos  all.  siibscries  0.  «.  I.  2. 

■|  Xfiiaetim,  St.  TItomns's  Hoopltal,  y,  ITO, 

I  Museum.  Callage  of  Siui;M>n«.  1138. 

y  Fa/iia*,  unequal.    OnedatipTDiaiit  I^'a  HipjiAcntidioilur. 

{  "  Vsrtx  veiin  dilaliitio  hhi.  hIuiuiiiiiIci  in  t^in|>')ri1>ui<.  nliquaodo  la  i 
vcniria  pui'tf.'.  tiiil>  umliilii^o.  iionimmiuiuit  ■■Uuin  i^init  liMiiii^uloii,  aod  I 
io  cTuribua.''    0pm  dt  lit  MiUm,  Lai.  doa.  p.  M,  Paris,  1632. 


varix. 


309 


I 


already  described.  Thus  the  tumoura  formed  of  tortuous  and  dilated 
nbcuUini-ons  vi-ins  (fnncifully  likcnrd  by  Soiorinus*  to  tll«  bead  of 
tlntuiut),  w'htoh  oci.-xtiiinally  oootifiy  t})c  byiKi{!tti«tric  n-gioii,  Hiioply 
roinjiciLKitp  for  the  obiitruction  of  somo  lar^  v«a8i>],  sQch  iia  ttio 
TCiui  ouvii  iiili-riiir,  uiili^su  iiKli^iI  tlii<y  lire  dui^  to  tlint  (i.iiij;;i!liitjil 
ooDununit^iition  in  rare  cauvs  niaintaincd  bt^twceji  the  ]Hu-tal  systoui 
and  !>ul>cutuii<vitL-<  wam-I;.  of  tbi-  Hbiiimion  by  inc«tu(  of  ii  ]mti.^ut  urn- 
bUivaJ  vein,  and  of  wliioli  a  few  instaiKws  are  on  roconi.f 

True  mritvj  arc*  liabituatly  niot  with  in  tliv  subumvoiu  veins  of 
the  bbidder  and  rectom  (bjemorrhoidit),!  in  t!ie  Hjicnnntio  veins 
(%'8ri<iooc1c,  <;intrHX-Ic),§  und  in  Iho  veins  of  tbo  lowur  cxtroniitics. 
They  are  aim,  though  rarely,  met  with  in  the  i'«in»  about  tiio  face ; 
moro  c»pvcially  tbo»c  of  Ok  lijM  nud  cyclitU.  In  ono  H[>ccimiii 
tbey  may  \te  aeon  involving  tlw  internni  jugular  ;||  in  anotJier,  the 
retns  of  tlte  stomach  ;1[  und  they  arc  said  to  af!bct  t)iu  pharynx, 
mn|>hagua,  and  small  inteAtiiie,  tmt  of  tboite  the  rocordi*  aro  utiKnUft- 
fiujtory.  One  cnso  of  varix  at  tlio  bend  of  tbo  elbow  ii  recorded 
br  P«tit ;  and  n  \xiy  is  slated  by  \Varren  to  Imvo  Hutfvrud  from 
vsris  which  formed  between  tho  shoulder  and  elbow  after  violent 
mnw.tdar  i-xijriion  ;"  tun  ])hlebccl«»t8  of  the  upjivr  vxtivmitios  Ik  a 
rare  and  accidental  occurrence. 

Varices  of  tho  town'  esrtfrntUin,  thongli  much  had  boon  written 
TBsjMH'iiny  tht'm,  received  hut  little  attcnrion  from  nnaloniistA.  Tliia 
l))*gl«ct  occasioned  and  mnintainod  the  error  of  Boycr,  adopted  by 
rami  »fll«m>  wlio  wrote  njwn  tlie  8ul>Jcct,  that  vanccn  are  an  on- 
nainral  permanent  dilatation  of  tho  tidinUarieotu  veins,  from  whitrh 
XhK  itfT}'  vviiM  ar<>  at  KrHt  i-xi-injd,  and  that  tlte  Utter,  oonalantty 
soabuned  by  the  mnK^Ics,  receive  from  these  cuntractilu  organs  « 
s^opport  by  which  t.hi'v  ntcajHi  dilatation,  wliilM  the  j^nbi'iitaneouSf 
lc9B  well  supfiortcd,  can  expand  indcfiiiiloly.'t'l'  Tbo  disuiue,  thus 
limited  in  its  ori;;in  to  one  iuA  of  vcuw^lx,  wa*  naid  to  be  caused  by  a 
Totngntde  movement  of  the  blood,  or  by  a  raeclianical  obstado  to 


*  II.  A.  S^verinua,  tk  reca»il.  Alit.  Nalufit,  cap.  ix.  §  19. 
(  CnivtilluiT.  AmM.  PMk.  Uv.  xvL.  pi.  S. 
'  See  DtsKikSH*  or  thb  Rectum. 
i  Sc<!  niaUacB  or  THE  U«iB  OaoiJCfl  OF  GsiiiaATiox. 
I  Uiueum.  St.  Tboians'ii  Huapiial.  r,  ia&. 
%  Kotvam.  ColIcRi!  of  Sur};i^oii8.  IICS. 
*•  Tndu  da  MaltuUrt  C'kir.  torn.  U.  p.  49  i   SMryieai  OttM**.  oa  TtunHirt, 

nut 

H  BofT.  TrtiU  de*  Maloilu*  Chir.  torn.  ii.  p.  451;  Sir  Ererard  Uome, 


310 


DISEASES  OF  THE  VEINS. 


tbc  ixiturn  of  tlio  blood  to  the  heart,  or  by  a  coiiirniinlcatton 
twoett  tlid  arLi'i-ies  unci  votiio,  smal)  vi^ti>U  juu^ing  ilircct)^'  froni 
«no  t«  thi?  othor.    Tlie  last  suggestion,  however  attractivu  in  tbcorj-, 
laihiil  from  tho  ul>KmiLi;  ofuiiutuiniual  proof,  for  ihe  |>t«M>n(»  of  U>e 
anastomosing  veȤ()lH  has  nt>vcr  been  shown  by  tlissi-ctioii.* 

Tlie  vi'i'ur  of  Boycr'n  tlot'trino  rwtctl  iijxiii  iiii>iil1icii:iii  itiialoiiit*^ 
rosatrch ;  for  in  fact  varicea  do  not  invariably  commence  in  the 
trunk  i>f  ihc  Niplieua,  or  in  tluit  of  any  supurlii-inl  vt-in,  Tbe  «enl 
of  varices,  as  shown  by  Voriieuil.t  is  us  otlcn  in  t)io  deep  veinn,  and 
thoy  tlienou  vxteud  to  tlie  subcutaneous  vessel*  by  lliu  nuux^routj 
annstomoses  existing  between  tlm  two  ttels;  ajul  far  from  boiug  ra 
dirt  ilwj)  vnrieo*  are  of  very  fref|ueiit  occurrence. 

Tliere  are  variutut  vtiiiis  In  lliu  tliiukuc-xs  of  a  limb :  some  deefit 
«(ont<xi  in  company  with  t}ic  great  arteries,  the  ]ii>plitoal,  posterior 
tibial,  and  tho  like  ;  miuiu  wliieli  lie  in  itie  tiubeutuneous  tinHue;  uul 
lastly,  intramuscular  veins,  which  convey  blood  from  tho  niiueles  to^^ 
tlie  deep  or  sti|>crtioial  vcsacIn,  aii<l  furui  aimntomoses  Iwtwtx^n  thenk^l 
Tlvse  intramuscular  veins  caiTy  large  <|uantitles  of  blood,  and  tlioir     '' 
capacity  is  yrcut  in  pnipwrtion.     1  (iiiii  thai  the  sis  prineipxl  vetiii^ 
which  pass  in  tbe  adult  male  from  the  eolous  muscle  tu  the  per^| 
oneal   and  pustirior  tibial  vessels,  have  a  united  diameter  of  not 
io»it  thaTi  an  inch.     Where  iheao  vessels  open  into  tho  deep  veins 
(more  esjiociully  tlic  peroneal  and  posterior  tibial),  the  Ulb^r  are 
often  greatly  dilated,  as  may  be  seen  by  tbe  accompanying  diagram, 
wliicli  indicates  itieir  condition  in  a  ease  of  varix  vrhich  1  vxamineti 
in  a  body  brought  to  St  Bartliolomew's  for  dimoction.     Broeit^ 


^rout^ 
rare^ 

>eplj^ 


(juoted  by  Verncuil,  found  deep  varices  equally  with  tlie  siibcu 
oiiH ;  Denueti  observed  that  they  were  less  rajw  than  had  been  sup- 
posed, and  existed  oven  when  the  subcutaneous  veins  were  wiaffected 


*  I'igeaux.  Trailf  pratique  dtt  Maladie»  <ki  I'liUitaux,  Pai'is,  1843. 

t  Gaitlti  MedkaU,  1855. 


tedi^ 


VAltlX. 


31 ! 


IVville  taid  FouclM^,  thoir  attciilion  being  called  to  the  eul^ect,  c-on-l 
tirni  tuB  ^talcuieiiU;  iind  Duinay  oonimunieatGA  a  cum!  Jit  wlitdi,  I 
irbibl  tying  Uhi  iioiiitival  nrtciy,  it  wax  fbtiiid  to  ho  surrounded  by 
Urge  varicoBo  veins  witli  extrecrutly  thin  uiilla. 

Aororxlin^;  to  Vcnivuil,  tlio  intramuei-ular  roini  also  become 
Taneoiie,  and  spoctmena  are  preaervtiit  in  thn  Mtist^n  Dupuytrttii'  to 
■liow  Ufcy  arv  «oinetiniM  nHi-riod  without  cbati^  in  the  subcutano- 
OOH.  In  my  dimicctiona  1  linve  i^iiU<ti  to  iiii!<>t  wilh  llii»  iiitnmiiis- 
imtar  iiuix;  but  front  the  examination  of  bodies  brought  for  di&aeo- 
lioti,  ill  wiiicJi  variety  are  (XM^aitioiuiIly  ilineovt^n^l,  anti  in  which  thi; 
Tnfimlii  bavi'  ixwn  carefully  traced,  I  cnn  oouttnn  dio  xtaccment  of 
Bni|U4!t,  tiuit  at  Uie  »j>ot  wixiro  varioi-ei  are  niont  (-uintnoii,  Inrff; 
trunks  communicate  through  the  muscles  witli  tlie  deep  veins;  aiul 
I  find  the  liitb-r  u-t  euiumonly  dinea.-'i^l  a*  the  Mi[)crti4-ial  vosAolit,  tlte 
diseue  being  inort  advanosd  where  the  inlnunuscutor  veins  empty 
tbdr  blood  into  either  »ot. 

Certain  conditions  of  systom  favour  the  formation  of  rarioes, 

OOBgenilal  prtKiii>]ii>s:tJi>n  anmiip't  otixTn  ;  a  dixpoi'itioii  thought  by 

some  to  be  lieredilary.     Very  little  is  known  about  it.     I'orsona 

'witit  an  indolvut  t'lnpi^rainent,  or  |>cn(on8  rfdnovd  in  hoalth,  sufi«r 

iroRi  a  rclo-ted  and  debilitated  condition  of  the  vein-walls,  which 

Jose  their  tati«  luid  ihvir  elasticity,  an<i  tlicn  offer  littlo  rv&istanco  to 

tbo  presBure  uf  tiio  Mood.     In  aomo  casca,  tlie  heart's  action  >»  re- 

dncrd  in  froqu<.'»cy  ( 1  Itav-  seen  young  adult»  in  whom  it  beat  but 

ftirty  tinii^  in  tlic  minute)  and  in  fori;c,  so  that  it  itlowly  aii<I  with 

difficulty  relievw  itself  of  the  venous  blood.     Such  people,  and 

otlierv  to  a  leM  estetii,  an  mure  likely  to  niilfer  from  varix  if  rhi'ir 

oocupadon   is   one   whicli   habitually  involves  much   standing  or 

'walking,  in  fact,  any   long-con  I  iniiod  muscular  exortion ;  and  m> 

cooks  and  grenadiers  have  been  SiJect«d  by  Brodie  and  by  Home 

«a  w(»«iaJly  [iroiir  to  tho  t'ormation  of  variwise  vciiit.     They  aro 

di3Tclo|w<l  cliiefly  during  tlie  active  middle  period  of  life  ;  but  their 

ftp^iraranci'  may  ^»-'  j)>"*tfmncii  until  old  ajjc,  or  may  ho  rdcrrod  to 

*ariy  lit)!,  xince  ihey  not  unfre<[nent]y  occur  in  children  under  ton 

JtOTofage. 

OhHtniclion  to  the  circulation  is  a  passive  aid  to  their  formation. 
wnoB  they  coincide  with  certain  disetwcs  of  tbo  heart,  of  thehuigs, 
*itii  drriiotic  tiver,  an<l  are  4u>n)uion  when  the  portal  system  a 
**Bdiarf«ed  with  bk>od,  as  with  those  wlio  line  in/',  though  such 
niSer  more  vsiMtcially  from  viu-ii^-s  of  the  rectum  (bsmorrhoids). 


Specuaeatt  S&t,  3&9. 


ZIS 


DISEASES  OF  THE  VEDJS. 


n<i  thu 


Constipatinii  iiivnlviiii;  the  aocumuJatluii  of  f»!cet)  in  the  intoRtini 
and  firctisuro  ujion  llie  iliac  veuis,  tlio  olMttnictioii  of  voids  with 
clol",  I'lii^  |iri'SHiirc  of  LiimourM,  niul  Mich  nrliliobil  presHurc  lut  lhtt( 
of  an  i]l-a(ln])li>(l  lioniia  truss  or  tight  gart^w,  may  bo  cnuDieratMt 
kit  cxiiniiiK-N  of  ('ondttionH  which  rirfiint  On:  eiR'iiUtion,  <liMeii<l  thu 
Toins,  and  prepai-c  them  Ut  bt?eoi»e  varicoso. 

8iidi  (.■onditiuns  havo  more  itiHnriK-v  itpoii  tliv  vci»»  of  t)M>  i 
bcoause  the  pressure  of  ihn  column  of  blood  which  thtse  v« 
huvo  to  rmiKt  i»  iiicTL-ascd  by  gravitation.  Ahhough  thv  cohtmn  of 
venoua  blood,  u.'tciiiidiiig  iij^iiint  its  own  weight,  is  supported  by 
Iho  i-olmnn  of  arterial  blood,  ^ct  the  pivsHuro  of  tlio  fluid  upoii  tlio 
walU  of  tUv-  vi-iiiK  iiKrciii<.tw  by  grmltution,  inoh  by  inch,  towards 
tlic  most  dopondont  portions  of  tlw  body.  To  illuKtratu  this  fact, 
tlio  sniiill  iiit'wtinc,  fn-wd  from  itn  intwiitvry,  niiiy  be  held  so  tlint 
its  upiier  and  lower  oatlcts  aro  u|K>n  tho  same  level,  the  intemio- 
diuto  curve  being  pomlcnt.  If  it»  ciinal  i»  (illoil  with  walor,  it  is 
easy  to  compare  the  lax  ■condition  of  its  walls  above  with  their  ten- 
«oii,  nlnioft  to  liursling,  at  llw  curve  lielow.  lit  tlio  wins  tlus 
tension  is  reliettxl  by  valws,  and  some  dilatation  is  permitted,  ss 
oocwion  reqnireH,  by  ihirir  thin  and  yivhling  wnll« ;  btit  when  tho 
oecasion  passes  by,  the  elastic  >'easels  soon  recover  their  natiird 
capacity,  and  then  tho  slight«et  Ibrco  acting  upon  the  blood -colnuin 
tends  to  ijiiickon  tta  movfimetit  through  the  venous  Rysicin.  If 
tbors  axist  a  t^vnclencv  to  dilatation  by  ob«tnietion,  Fuch  force,  in- 
stead of  nicjviiig  the  blood-L-oluinii,  is  <-x|ii!aidv<)  upon  the  vcili* 
walla;*  and  if  the  foroe  is  represented  by  a  certain  quantity  of 
blond  fiiix'.'d  into  ii  vein,  then  ihcro  i«  addod  an  increaaiHl  tendency 
to  dilatation  bv  exl:^e8s  of  contents. 

In  pormtis  with  relaxed  and  ddiilitatc'l  v«init  tlio  luricoso  con-* 
dition  would  seem  to  be  detcmiiued  hv  the  habitual  otv/-  exi^rcit  (^ 
miucli:-*,  wjMjpially  those  of  the  t-aH'of  tlio  leg,  which  forco  the  blood 
violently  into  vessels  inclined  to  yield  to  the  distension,  and  alrc4M!y 
oierfillrd  by  reason  of  a  rotanled  or  obstnictwl  circulation.  Tho 
diliilatton  whifh  en»tii>s  is  iiHuidly  of  slow  progreaa;  indecxl,  for  a 
tiino  the  veins  aro  oft«ti  incn-iLMd  in  thickness  and  strengtli  to 
roaist  this  dist«nsi<>in  but  Pnrt'  ii-wirds  cases,  luid  hi*  obsonations 
aro  confirmed,  in  which  large  varices  ha\-e  suddenly  appeon^l  iifl«T 
violent  muscular  exertion,!  «ich  iw  rtinning,  dancing,  or  canying 
heavy  weights.     Wherever,  so  far  as  supcrticial  varioes  arc  ooi 


•  Rfo  expoi-imonta  by  Williums.  Principle*  of  Mtitidii*,  Sil  ed-  p.  IS8. 
t  Wan-Mt,  op.  oit    Sue  klsu  Mulgaigne.  (Euirfs  ootnfi,  I.  iL  p.  208. 


ANATOMY  OP  VARIX. 


313 


d,  (iw  intramiiwular  voin«  pitsH  into  Uu!  Kiilxriilnnootts,  there 

inrii  in  first  iit>tin-<l;  th«r«  tlw  force,  that  ia  tlm  blood -«<ri>nin 

front  the  mu»olL-«,  toruL-t  to  net  on  (Iiv  vnin-vrall  sind  to 

I  th«  nvwl ;  for  tho  valves  olwtruct  bolow,  and  Uie  oolutnn  of 

1  «Jow-nioving  blood  rvMHte  abuv«, 

lln  amaiomieal  ekanffe*  in  variootrc  veins  have  bctm  de»cri1>«l  hj 

I;  and  his  dUtinctiunti,  tlunij^li  too  miiiutv,  Imvo  Un-n  |;i-n(i- 

radnptaN].*     In  brief,  it  Is  sufficient  to  Qut!<M>,  that  tho  oo«u  of 

utikk-d  vess«U  may  htn^niw  tliickenC4l,  or  miiy  b*Toino  tliin; 

llhvjr  nwy  Iw  longtliened,  so  that  tlie  veins  are  rendered  tortu- 

i;  that  tbe  dilatution  may  )>v  un<-(|ual,  tho  v<riit  hetiij^  niarkod 

IpoocJiM,  which  fiTin  at  the  sinus  behind  oaeli  valve,  or  result 

llw  greater  yivhlinj^  of  tlie  yctfi^A  wlicro  tlio  blood  is  forced 

it  from  an  intramuBonUir  branch ;  that  viiris:  of  tlie  femoral 

I  whidi  oecaoionally  rccguirrs  to  be  di^tin^ishcd  from  a  iVinornl 

L.t  is  thus  forni««d  by  yii^ldiiig  of  tho  vokmvI  itt  ita  junction  with 

ttntmud  eircumitox,  saphmia,  and  profunda  vctins. 

lAb  liie  vein-cnnal  dtUtit>,  iIh>  vnlvm,  unlws  im^vioiDiIy  niptnred 

fvMtBt  and  sadden  mascnlar  action,  are  unequal  to  close  tlie 

i;  and,  liein^K  u»ek-M>,  they  pn'stinliy  wnsto  and  arc  ruducod 

I  ttbruUft  luandki,  nr  itiKa]>|ienr  a!lo;;i-thfr. {     'J'Ik'  viiUiii  are  not 

nn'ed  liy  tho  httckwiml  pressure  of  the  column  of  blood  obstructed 

liu  jcwia^  Ut  tlw  hrart ;  fur  ttiey  arc  adapted,  as  w  woll  known, 

jriHtt  this  proasore,  and  they  hieeome,  when  neo<lfui.  tliick  and 

E,  to  fit  them  for  iloin<;  so.     Bnt  the  (brco  represented  hy  Uio 

I  of  blood  advanein^  fmin  below,  iukI  from  tlio  intramuscular 

(|naiN»  upon  t}K-ir  rear,  and,  as  (hey  nre  unat>le  to  rvfiet  ii 

IMfiiig  in  thiN  direction,  thttti'ns  their  cukjih  a^nat  the  vein- 

I;  uul  tlMTe,  when  the  vein,  from  the  combined  action  of  suvo- 


'  VtflaM:  tpecii^s  l.  ^itnpl«  dilaUtion.  iilTi>L'titi^  ihc  wliola  liMiKtb  ofa 
L<v  esItliBg  only  at  Inltrrvnla.    3.  Simple  diliitntlon,  witli  tbinniii^  of 
■  (■hetin).     S.  Oalform  dihiulioD.  witli  UikkFiiioi:  or  the  pai-it'lvs.    4. 
■lion  Mt  fatterrala,  niili  tlikkrniiii;  ut  iln-  diluted  points:  In  ibin.  nnd 
b*  itiinl  aiMdn,  ttie  titssuI  bi'init  kntJiticiiL-iI  hb  well  ns  dilated.     A. 
■tion.   witli  111*   rormalion  ofarplH.  whii'h  divitlu  tlii'  iiit«di>r  nf  ibe 
htlu  nun7  cooipartiiK'ntii.  in  vrliicli  tlit  bk>ii<l  I'uu^lnles.    B.  The 
U>  tli«  IsM  of  tantiy  oiiiaU  aiicrinrfi  iti  lli<?  walls,  allowing  iho 
'  of  tiliMid.  0*  in  nvetll*  iniuonn.    J'lillu/hskAl  At>al<niig,  Eng.  trans, 
p.  4  et  Mn^  Dublin,  l»ai. 
I  Si'a  Hnuii*. 

'  MuReuma,  Cult  of  SargMns,  1730.  and  Ilai-lliolonicw'*  Htwpiul,  s«riei 
18. 


314 


DISEASES  OF  THE  VEISS. 


jf 


ral  canw*,  has  Ikioodio  so  lar^p^  llmt  llu!  \:ilv(r-fiw[w  are  invul>1 
iiiot't  and  close  it»  canal,  they  wliriiik  and  atrophy.  It  ibllcuvs  iJial, 
in  variciw,  tlios«  %*alvcs  only  are  thus  destroyed  wliicli  lio  between 
tli«  lowest  varix  a«d  llui  heart ;  and,  when  Uiey  are  deatroyodj  lliai 
tli«  [»riw.surw  «f  tliu  blood-foluiiin,  whiiJi  tliuy  hcl])!^  to 
wdighit  more  Iieavily  ujKin  the  dependent  and  dilstted  vensels. 

The  tissues  whicli  surround  the  disoascd  veins  boeoinc  gradt 
ubHorhed  in  confli<quen<H>  ot'tbtv  i^mtinued  iireMsurtt  cil'tlie  viirix,  mid 
thus,  as  notidxt  by  HodgHoii,*  boiint  oven  bocoiDo  indcnt^^.  80 
thin,  indtfi>(!,  may  the  vovi'iln'^  of  a  varix  Ixscoino,  timt,  n-itti  ^uddai 
exertion,  or  firom  a.  blow,  they  nipture,  :ii]d  hnrinorrhage  ensues.  In 
cnsoM  «f  loity  Ntiuxlin;^,  IiowcvtT,  jt  in  uwiiiil  to  find  llift  ti«i>>lil>i>unii<; 
struetures  tliiekcned  and  hard  from  siini)le  a'dcnia,  or  from  inflam- 
niatury  vxudation,  wliu-h,  Uy  iiivolviiif;  thi*  neigh tiotirin-j  lynijiiia- 
ti«»,  Ganges  many  of  tlieni  to  be  ponnanently  obstnict'xi ;  so  tiiat, 
what  witli  their  obstnictifin  :»nd  tJic  obnlriiclod  veinM^iruuUitiou,  the 
whotfi  leg  Ix-comos  osdenintous,  and  in  time  aocumulales  it  great 
KiiperHnity  »f  fibro-ivlliilar  ti«iKiie,  11  condition  wliieli  in  ecvure  eaen 
in  recognised  aa  the  Arabian  etephantiafli.'t.t 

Variecs  of  ihu  lower  extremity  do  not  affect  especially  the  left 
]inib.  Tlie  ewriona  error  whieli  long  prevailed,  and  gave  [irt^cc^iiitico 
to  tlic  left  k'K.  has  hei'n  e^implett^ly  ex[)osixl.  Statistics  obtained  by, 
Vernenil,  from  oasest  observtJ  at  the  Ifoivl  Dieii,  show  (bat  oh 
limb  is  diseasi-d  just  as  oRen  as  the  other.  In  fact  the  eases  at 
Tare,  if  iJiyy  ever  oeenr,  in  wbiob  tliw  iliKurder  diHW  not  aff«!t  l»ll 
limbs  siinultaiieously,  allliougli  the  greater  progress  in  llie  su|i 
ficial  veins,  which  i*  obwrvwl  in  one  limb,  eunimonly  causM 
condition  of  its  follow  to  he  [Missed  by  imnoticed. 

Spnptom*.    Thoujfh  vjiriecs  may  exist  for  a  kmg  timo,  and  • 
little,  if  any,  inconvenience,  yet  it  is  more  usnal  tor  tlioso  who  si 
from  them  to  complain,  some  time  before  tLo  external  manifests 
of  the  disease,  of  aching  ]min,  det>p  iieat^ed  in  tlie  liniliN,  with 
of  weifjlit,  fulness,  and  fsitignc,  in  some  eases  complicjilcd  willi  i 
{>ertain  nnnibne»<s  and  even  liixit  of  ]H>w(>r  in  tlu;  extremities.     lal 
more  advanced  stage  of  the  disease  tlie  ankles  swell  after  a  lianl  <bT*li 
work,  and  l!io  feut  are  eoiiKtjiiitly  cold.     The-*«  sjTnpt'>ms  indie 
an  embarrassed  state  of  the  <?irculation,  to  which  is  gnidnally  addi 
dilatution  of  the  decp-»ciitoil  veins,  and  moro  oapooially  of  ilie 
terior  tibial 


•  Op.  cit.  p.  S6I. 

f  For  «r4utiIo  tumours,  and  llieir  relaUons  to  v&ricee,  see  N,k*i. 


SYMPTOMS  OF  VAUIX. 


315 


iUkr  a  tiiDC!,  ut  one  or  more  poinu  >ri  Uio  leg  a  siiiitll  tiiinnur 

tnuei,  M>ft,  of  a  blui»li  c<i>lour,  ft-oai  the  ttiirk  bluuU  Hliowiajj 

tbo  intogUDiHit ;  it  (ltHiiji[>i'arii  oil  jircMiire,  hiil  roturiM 

iba  prewiin'  it  rctnovcti,  ur  when  iho  pntient  etaDfls  up,  utid 

hy  a  vein  which  iit  ilibiing  U'h(.-rt<  juiiiod  Ijy  nil  iiitriniiiiit- 

li.     Around  this  tumour  a  series  of  mintilo  >'<«».']«  aru 

I  ufn  dnrk,  hluipli  oi>Iour~-tliv  Ninatl  .iitpirrticial  vein.4  thnitijrii 

lite  piuwiKo  of  iho  blood  is  retarded  U)  u  greater  dogi-ce  than 

L",  becuiov  Ihev  0|M.>n  diroc+!_v  into  that  \>sai  of  the  vcssal 

U  tlilutin;;.     By  degrees  the  dilatation  extends  and  involves 

iiKTviL?tu{;  Ivuj^i  of  vuin,  ant]  tlion  fomw  invKiihir,  knotty,  m^n* 

tomoorB,  soft  and  diinlnitili^d  in  size  by  the  horizontal  ]>os- 

'  P*"'!?  "  hhii^h  tint  to  the  skin,  which  is  strL-t^-Iifd  and  tliin, 

Nimiuridod  by  smaller  veins,  iOho  »<>mowlml  variooae.     Tlieso 

iin*  f^roupitl  around  tbo  points  at  which  thi'  dilatation  fimt 

lUHlf  for  iltt-  nioHt  purt  in  lh<-  mid<llo  of  tho  leg  along  iho 

of  tlK<  exti'rnal  and  internal  sapliena  veins,  but  tlio  <:hL»b-m 

iiius  \-v9aeIa  ofti-ii  exl^tnd  iilonK  tho  entire  length  of  tho  leg 

igh.     To  tho  Kvmptoius  already  enunieraH-d  theit>  ia  oUca 

RJi  iin|ili-nNiint  ileliinf;;  and  wht'U  uervc-tibriU  nru  by  chaneo 

Ivnl,  a  sitiirp  tingling  ]iuiik 

(udiy.  wJM-n  iho  variiwH  gradDalK-  thin  the  nkin  which 
tbmii,  and  biir»l  through  it,  luEmorrhagi;  i'ii»ui-:<,  which  may 
■}t»n>]ic  and  even  ditath  if  nut  ]>roinptiy  arrested;  for  the 
*  '  L'  di-strovi'd  JK'twccn  tlie  varix  and  the  heart,  llio  i^tciiiw 
•  diriviiy  fi-oni  ll»i  proximal  [lortion  uf  the  vessel,  and 
bo  Very  coiuidcrablc.  In  treating  such  a  bleeding,  the  jiatient 
Im!  promptly  laid  on  tliv  gmund,  and  tho  \eg  Hhnuld  be  raised, 
tliH  In-murriiago  will  pi^>bah]y  eease.  If  it  contimio,  tho 
of  a  (Kid  of  iint  applied  to  tho  blcvding  ve«scl,  and  secured 
■  II  u*  turns  of  a  tKU»diig<-,  will  i-ffi'eliiiiUy  iirrest  it. 
11  iiilliiminiition  of  the  tis*ues  around  the  vein*  we  have  the 
'  to  irritable  conditjona  of  tho  skin  and  cexema,  to  obittruo- 
I  the  abaorlM'nta,  and  to  uleeration  ;*  and  wlit-n  the  vein^walla 
Km  ssme  canae  becoDto  ^urrouiitUil  witli  lymph,  the  comlitiuu 
f>cd  (a  whieti,  aa  previously  described,  Uiu  vessels  become 
fKii  V,  ith  dota  and  uhHtruvtetl,  Tliu  knotty  liiniours  aii;  then  hard 
Bd  duuio^t  bv  empli»i  by  prciuiiin^  and  tliis  conKoIiiliition  is  per- 
■nmt,  for  variooi<e  v«ina  once  obstnietod  with  oh)ta  never  have 
lir  auxaia  reopened.    In  this  way  Uic  natural  oure  of  a  varicose 


For  Tariooftc  uIo«r».  acv  vol.  i.  p.  31i. 


816  DISEASES  OF  THE  VEIN& 

cluster  U  ofton  efiected,  witli  modi  temporary  relief  to  th«  patii 
an,  Iiowuvrr,  tln>  pnKlispoKttioii  vimtiiun,'*,  anil  tlio  exciting  CHU»« 
ronmins,  ottici'  adjacent  veins  soon  become  involved  and  poq>eUials 
tbo  <iii»ea«;. ' 

Trmihii'^ii.  Varioea  of  long  standing  are  uiveierate ;  for  al- 
though niticli  may  bo  doim  tor  Ui>oir  rcliol',  tUcy  cannot  be  cnrEiJ ; 
and  lieiiRii  it  is  fortunat**,  although  tliey  occasion  the  putient  much 
hurt  ;iiid  i  n  con  von  i  unci',  tlmt  tlirv  arc  not  ktIous  in  tiicir  coiue^ 
queiicK*.  In  their  earlier  stages  they  are  more  mniingtiibh; ;  aiul 
it  is  mnch  to  bo  rcgrctlod  that  early  symptoma  arc  mostly  unlieeded, 
fur  whilrtt  lliu  (llKCuno  U  liniiloil  to  the  deo])  vuini>,  or  ut  mort  hm 
involved  hut  slightly  the  superficial  vessels,  it  admits  very  readily 
ot'pcnnani.'nt  benefit, 

Tlio  managcmont  of  the  general  health  is  an  important  item  in 
the  trcuttncnt  of  variety  in  «vory  Kt«g('.     TI»o  fcfhln  mid  oOcn  lU- 
nourislied  patients  who  suflor  ti-oni  this  disease,  must  be  invigorated 
by  tonics  unci  a  gi-ncnms  dii-t.     Ttio  plethoric  pativnl,  wilJi  an  em- 
barrassed iwrtal  ciivnlation,  will  gain  niuch  ti-oni  ot^en-rofieaied  !tul 
small  dosc!*  of  purgnlivu  mvdii-ino,  and  by  the  use  of  cold  saline 
Iialhs.     In  each  ease  some  special  Bj-mptoms  will  probably  demand 
attention,  and  muist  bo  mot  by  appropriate  r<.-nicdics;  but  in  tliu 
largo  class  of  cases  in  whicli  tJicre  exist*  a  const!  I^itioiia]  or  bl- 
quirod  laxity  of  tiie  veins,  no  reniedy  equals  the  tincture  of  tite 
»e,'<i([uichlorid(>  of  Iron,  gii'cn  in  drachm  doses   tliretr   timt*  Andy, 
with  an  aperient  pill  cvorj'  other  night  to  obviate  Uie  occnnwice . 
of  con!<tijiiitiun.      Under  its  inl)ut>4ice,  coinbiueii  witli  projicr  lootj 
appliances,  the  laxity  of  iho  veins  disappears,  and  tlie  varic«s,  )£ 
recent,  arc  dispowd  of. 

Provided  always  that  the  disease  is  not  of  long  standing, 
that  ioc^l  c»n«'H  of  ohstriiclion,  mioh  a.-'  tight  gwrton*,  arc  (lcnH| 
uwuy  witli,  it  is  adnsable,  with  lliis  general  treatment,  tliat  the  1 
ehoald  bo  rested  in  the  horixontal  position  for  at  )ca»t  a  montli  ■ 
six  wuekit.     Walking  sliould  be  jirohibiled,  and  only  carriaj^'  MO 
cise  allowed.     The  limbs,  thus  rented,  shoal<l  hv  bandaged  from  I 
tooB  to  above  th«  knee,  the  prtHisure  being  firm  and  c<iual,  and 
bariiUge  (Domett)  should  be  renewed  daily.     At  tiic  time  of 
renewal  the  limb  iihonid  be  well  riiblxid  witli  the  hand  for  nbontl 
quarter  of  an  hour ;  by  this  treatment  the  circulation  througli 
Hubcutancous  veins  a  rendered  brisk,  and  the  tonicity  of  the' 
by  degrees  reestablished.     What  with  the  inaction  of  the  mi 


*  See  ciut»  by  HodgHOu,  op.  cit.  p.  0(1. 


I'KEATMENT  OF  VARIS. 


317 


he  improved  tone  of  the  KuprfL<>ial  vesaoln,  and  the  amendmoat  of 

UCitern]  [mmIi}!,  a  good  result  mar  be  anticipated. 

liut  pniii'iit')  AcMoQ]  have  tlie  inclination  or  the  ojiporttniitv  for 

ubiQittinr;  to  »UL-ti  ri^d  trcatmotit  for  the  euro  of  a  disease  wtitch 

comparatively  little  inoitiivenienoe ;  oiid  when  tliia  h  the  cnae 

iple  ooinpn««ion   of  tho  distended  veins   will   often  ^ive  givat 

f,  auid  even  jireient  the  di»eaHC  from  j^twin^;  wune.    StilHcit-iit 

Dpport  ma_v  Iw  obtained  by  merely  bandaging  the  limb,  greater 

[»r>"'"»tn'  IxMHg  madi"  over  thv  largiT  of  tho  vju-ionw  diislorH  tlian 

L'where  by  means   of  a  ]ia.ti  of  lint    placed  upon   each  of  thorn 

fliofoiv  tb«  bandiigo  ii«  iippliwl.*     Kliwlio   opind  Ixindagea,  or   Uio 

ebfltifi  web  etookings,  are  roeom mended  as  convenientlv  sn]>plying 

the  necettary  Mipjiort.     I'lioy  nliotild  Ixf  mnovi'd  at  nigiit  wln-n  llio 

paiienl  goea  to  bed,  and  repbcod  when  he  gets  ap  in  the  morning. 

klf  any  one  of  tbcm  cauwM  irritation  of  the  skin,  it  niuit  W  vlmngiKl 

aomo  other;  and  it  will  oflen  be  found  ufteful  to  protect  the  in- 

Ifc^untentby  mcan»  of  flannel  bandage  or  cotton  wool  bot<>rc  iIu^ho 

are  put  on.     Tli»  most  diHieult  to  manage  are  tlie  old 

:  saiTonndod  by  a  quantity  of  inilunttcd  tiKsiie,  wliicli  protects 

(rom  ordiiuuy  prefuure ;  the  difKcrulty  may  generally  be  over- 

Eoone  by  tho  cxeretse  of  a  little  ingenuity  in  applying  tlie  Hipporte. 

tTravvr*  cunxl  a  vari^xise  cyst  of  the  saptienii  by  llie  jire^iire  of 

[dpi  of  plaster.     Tlie  varix  should  bo  emptied  of  its  blood,  and  the 

I  ttripSr  of  A  convonifiit  length  mid  broiullb,  slioiild  bo  then  applied, 

I  oouing  one  another  at  right  angles.     A  firm  and  even  pressure 

nay  alM  Iw  obtNim^l  by  iipplyiTig  n  wot  banilagi'.     A  number  of 

t  |iwet  of  nmalin,  tinen,  or  calico  are  prepared,  each   about  two 

■dm  wide   and  twelve  inelic*  long,   and   HuturHt<.Hl  with  warer. 

Two  fif  tliese  strips  are  first  pUeod  beneath  tlie  foot,  and  their  ends 

smed  over  tho  instep  towards  the  ankle.     Otiior  »lripH  are  tiu-n 

Wnd  rmiiKl  the  leg,  their  end»  erosHing  in  front,  so  nrrnnged  that 

fti  one  above  lulf-oovent  the  ono  below,  imdl  the  limb  lui^f  bi:H.<n 

Witged  to  a  suHicient  height.     An  ordinary  roller  in  tiien  placed 

•Rr  all.  and  caeli  day  tlie  applieation  is  renewed. 

Hw-jn)  mosu'iirea  are,  however,  simjily  palliative;  and  in  Uio  do- 
Bn>  to  effect  tlie  euro  of  so  common  and  often  troublesome  a  diiK^aiw, 
Buy  device*  liave,  from  time  to  time,  been  einjiloyed.  N^'ilh  tlie 
tteefition  of  HerajMitb'a  suggestion  for  dividing  tlie  faseia  lata  at 
tta  sapboooufl  o|)eiiing  to  relievo  a  aupposcd   pressui'u   upon   tJto 


*  Local  MiRipresslon  wu  first  rcconimcndcd  by  I>elpoob  and  Sonxon. 
Il>eeli.  MaUuRu  Chif.  torn.  lU. 


318 


DISEASES  OF  THE  TEINS. 


fbtnoral  vpin,  tlicy  all  aim  at  procuring  oUilcration  of  the  variT,  or 
ol'Uw  oliiff  voiii  iMimei-lod  wirli  it.  liiit  tmiii  all  thtwc  nu^nntin^  it 
is  quite  wrtain  iliat  only  a  tcnii>orary  beiierfit  i«  obtaiitcd  ;  for 
Olio  miuut  uf  varittCf  1iil'>  lM*<*n  ixtmovtHl,  tho  iiiiaHtmiiiMiii^  vvinl 
artiund  boou  acquire  a  varicoso  condition,  and  the  cliseaae  is  per- 
|>vtuut«d.  In  deciding  uiroii  jierionninn  nnj-  <mo  of  tlio  many 
operations  open  to  choose  from,  it  must  he  tlie  relief,  not  tlie  cnre, 
of  tho  vsrix  wliioti  in  niUicripiiUtil ;  and  no  douht  iIhmx?  am  oiiscs,  yet 
not  so  many  aa  some  would  have  us  to  helie\-e,  in  which  tlie  pain  of 
th(!  varix,  the  iinpuwihihty  of  hcullnfj  u  lar;^  ulcer,  tin;  iinfittinjK  of 
a  patient  for  his  overy-day  work,  justify  tho  operation  for  tlio  sake  i 
of  tho  tciiiponiry  bonetit.  ^| 

II  has  been  objoctotl  to  these  operations,  that  they  havn  nomc^^ 
times   imjHiTillLTi   the   patient's   life,  and  at  nnc   time   they   were 
hnmjrht  into  ilisrepnte  by  the  ocourrenoe  of  several  dontlis  from 
diffused  inHammittion  extending  along  the  counw  of  tho  vein  which 
hiul  heim  (ipcruleti  upon ;  hut  the  objecliMi  sliould  bo  initde  not  to  tJw 
ojieration,  but  to  tlie  performance  of  it  upon  patients  in  a  had  stat 
of  healili,  who,  to  nvuil  otii^self  of  the  tiuaint  languagn  of  l>toni 
arc  opprest  with  humours  alwaj's  ready  to  cast  themselves  upon 
one  locality.*     If  tlio  OJises  aii!  .lelootfid  with  ejin>,  the  jmlgtnc 
which  decides  in  favour  of  an  operation  will  never  he  re]in«ich 
hy  the  iiiiciirrcnee  «f  w^ritmn  hurt  to  the  patient ;   niul  tho 
troublesome  consequence  will  he  a  languid  condition  of  the  wound 
which,  from  tlio  iiidolciil  eirculntlon  through  the  limb,  are,  as  Btat< 
by  Skey,  often  very  difficult  to  lical. 

The  operations  rceomiiK'inliHl  fbr  the  locid  rcliLtf  of  variees 
modi fiojiti OUR  of  one  another.     Their  practit*  dates  from  tbt-  etahe 
record  of  Snrgcry,  and  some  curious  {iccultarities  of  treatment 
I)e  roferrfnl  to  as  showing  the  uneeilain  reasoning  wliich  reguli 
it.     Tims,  CclsuB  drew  a  distinction  hctweon  straight  and  conv 
luted  varices;  for  the  first  he  reeomnieiid^it  that  tbey  should 
cx|iDscd  by  cutting  through  the  skin,  and  then  dastroyed  by 
actiiul  CJuUery  ;  whilst  the  latler  he  at  once  cul  out  wit]i  the  kr 
Ambrose  Pan5  and  PetitJ  puneturod  thorn,  squeezed  out  their 
tent-t,  and  then  ap]>lie<l  a  roinjire.ss ;  but  wln-n  tbe  hlood  stagnate 
in  all  isolated  tumour,  they  out  down  upon  and  removed  it. 


*  "  roonrhj'inea  ut  accnbUs  d'bumciii's,  toiyoui-s  pi-itea  k  sc  jctter 
qnelqiif  pnilip," 

i  L'f  lif  Medici,  lib.  vii,  cup.  xai, 

I  Train  da  Alaladiet  C'kirarfioalei.  torn.  ij.  p.  04. 


TREATMENT  OF  VARIX. 


319 


PHEjrf  Afti^  old  varices  aboulil  bo  lefl  »lon«,  tost,  Wing  romored,  the 
patient  kIiouI'I  bv  sufTocnttHl.  Buyer  followixl  Pari,  but  tkul  the 
■Bcin  alxive  and  below  licfore  opening  it;  and  Homo,  nficr  ilivjilin^ 
^Biv  i>kin,  pasM^l  a  l)in.-flfl  under  tiic  win,  aitd  ho  tied  t)i«  tci^ol 
leadin);  from  the  varix  towardH  llin  liotirt,  und»r  tlio  impri>8!>ian  that 
be  bUxxl,  a*  it  (wiiUl  no  longwr  flow  tIirouj;li  tbo  vcsseJ,  would  stug- 
»,  Mi'l  ibcn  mandate :  and  in  jiritiftii^c*  liitnie  found  thitl  viiri- 
alocrs  wore  iJins  more  readily  IitMiIod.  From  wliat  has  been 
'  Htiil  rcHfiooting  tlie  oawefl  of  mriroKU  voinit,  it  i»  evident  iJiat 
^Bo  good  «mld  follow  this  operation ;  indeed,  any  benefit  that  pa- 
^Bbrnt*  obtained  from  ilx  jxiHoi-iiinnov  was  probably  duo  to  tlitt  rvst 
^Tihicli  it  net-cwitatod. 

Amonpf  oilier  si^;p;c»tioni>,  Fricko  wlviswl  that  two  or  llirco 
Ihrenda  should  be  passed  through  tho  v«in,  after  tJie  fashion  of  a 
Mtam;  and  Ca|ink'tti'  t^nploycd  galvnno-puneturc  to  induce  «Iot- 
tbig  of  the  blood  within  the  varix ;  whilst  flrafcf  aelually  o[>enod 
iha  ruwclo  »nd  filled  thoir  canals  with  h'lit.  liut  til]  thi-itc  methods 
ware  employed  without  any  fixed  idea  of  what  was  to  bo  acoom- 
|blicd  by  their  nivaiiK. 

Oor  objert  is  now  more  definite,  as  we  seek  to  relime  for  a 

ne  this  varicoM  condition  by  causinj*  congidatton  of  the  blood 

Inliin  tlie  diiatod  veins,  ivhieh  then  sliriiilc  and  eonlniet  jkm-iiiii- 

iMirflr.     This  result  can  bo  attainod,  l§t.  by  tJie  action  of  caustics 

fifflie<]  ovpr  the  eoune  of  tho  vpssd ;  'M,  by  Kubculiineous  divi- 

of  its  wails ;  8d,  by  compressing  it  between  a  steel  pin  and 

ltviti|4-(l  suture,  or  by  wmie  j^iniilur  eontnvuncc      The   ]H>tiW»a 

fca,  or  Vienna  paste, {  may  be  applied  as  ■■eooiiiinended  by  Mayo, 

jatliBiirtilj'  siifficiinii  t"  carise  dlou^liitifj  of  the  ^kin  over  a  varix, 

I'llw  Tenons  trunk  connected  with  it.     The  timnes  beneath  tho 

fi^efa  inflame,  the  vcswel  i*  filleil  with  cowgnla,  and  so  becomes  ob- 

■utnted.     The  dough  should  not  exceed  a  tjuarter  of  an  inch  in  its 

FuDdcr,  ami  th*r  surrounding  skin  shoidd  be  proteded  from  tho 

uf  tlie  eaustio  by  a  ring  of  piaster  engirding  tho  portion  to 

tibwtroyed.      Brodie  reeomineiids  that  sufhcieiit  cnuMic  shall  bu 

\oynl  til  insure  sloughing  of  the  vtiu,  as  a  more  certain  mo<lo 

'•tearing  its  destruction,  tbo  voiscl  becoming  closed  and  con- 


•  S«e  Ar^irti  Urnirala.  1848.  p.  2Z^. 

♦  C.  Bcira  Surffty,  Oi-rni:m  tranit..  prerace. 

J  Coaipou.-il  of  five  partn  i)r<)uick'litn(!  unci  fourofeaustic  potash,  mndo 
I  pute  iritli  spiritn  of  winv  imni<.-i3lutph-  brfdi-e  its  oppltrntion.  Nitric 
nu|'  be  Mub«tttut«il  irliun  it  in  only  rcquireiJ  to  excite  inflarnniatioa 
.  tbe  vein. 


B20  DISEASES  OF  THE  VEINS. 

tract«tl  abow  and  bolow  tlio  Hioa^tu  Aorontiiig  to  ctrcramstanc 
tivii  t)r  more  oflhoMs  Htoughst  will  Ik;  rciiuired,  And  in  iniikm};  them 
tliev  must  lie  carofiilly  kqit  soma  tlUtiincD  anundcr.  WIvbUht  Uio 
Ytirix  ie  itiuii  iucll' ile«tJM_vciI,  nr  lIk;  vonuiu  trni^k  which  jiasjws  fmn 
it,  the  Uootl  wliMi  formerly  passed  thraugli  these  vossola  is  <lri\-en  into 
otlitT  pliiiiiiH'N,  wliiiili  urii'lii.ilN'  iliint*'  into  it  fresh  croj)  of  varicea. 

Subcutaneous  division  of  varioose  veins  ia  eaaiJy  periiirinvd  lir 
moniu  of  a  narrow  poinUnl  bmtoiiry,  liritt  oiii[)loyed  by  Brodie,* 
whreh  is  introdueod  between  the  skin  and  the  vein,  and  i*  nindo  to 
divide  tbe  hittor  a»  it  is  witlidranii.  A  coni|>Tt«s  of  lint  should  )ie  at 
once  a])pHed  to  ivstrain  ha^niorrhage.  Tliis  operation  ha»  the  n<lTan- 
tngo  of  leaving  a  wound  wliicb  Ik-hN  rt-adily,  often  bv  the  tirst  in- 
tention ;  but  iu  mmo  c.a»i»  8U|i))uratIon  has  lolloweti,  and  lU  some  it 
has  failed  to  obliterate  the  vchscI;  bo  that^  says  Brodic,  **  it  really 
^ipcors  it  in  not  wurtb  gint ii-uU'  wbllo  t:0  Nuhmit  to  it  I  hare 
ilways  ob§erved,  that  if  I  cured  one  t-hister,  two  smaller  one*  a|>. 
pcared,  on«  on  cnch  Ride ;  and  tbut  ultimately  I  left  tlic  patient  no 
better  than  I  foiuid  him."  If  this  ojieration  is  perfornteii  lo  liiciti- 
(jite  (ho  healing  of  a  \arit'"*'  uk'cr,  the  vesjwl  iihould  be  divided 
below,  BO  aa  to  interrupt  the  blood  as  it  streams  in  troin  anuHtoino** 
ing  ve.'Wots  iiucl  oauin-s  tbi-  ditleiixinn  of  the  veins  about  the  ulcer. 
After  this  or  any  §iniilar  operation,  the  patient  njust  be  k«pt  quiet 
in  bed  for  at  leswt  four  or  five  days,  and  longer  if  neooseary. 

Volpean,  following  Davat,  employed  a  metal  pin,  which  he 
under  (never  tliroughf)  tlio  vein,  and  on  whieh  ho  applied  a  Iwis 
auture.     'nie  pin  was  allowe<l  to  n^niuhi  in  until  futlicient  inflnni— 
mation  bad  l>een  exeifed  to  promote  obliteration  of  the  vein  ;  hut. 
when  the  irritation  wlncU  (iiIIuwimI  wits  but  slight,  Ihe  pin  wns  left 
to  come  away  by  ulceration  of  the  structures  which  covered 
Some  of  lliese  jiin.*  he  applit^l  («  tlie  varicose  ehwiers,  and  some  ■ 
the  veins  communicating  with  them;  ancl  as  no  vcrj"  bad  rwul" 
iVdIowed  his  ojioration,  it  was  pretty  gcuenilly  tvftoh     But,  lit 
others,  it  affords  only  temporary  relief;  and  beoidea  is  opim  to ' 
objection  that  the  sore*  which  result  arc  of\cn  difficult  to  heal,' 
tJiouglt  this  ia  an  objeetjon  more  espeoinlly  to  tlio  (roatmont 
caustics     To  Ilr^•^■ont  sloughing  of  the  tnlegumeiit,  it   ia  reooi'i'l 
mended  by  some  Surgeons  to  ]>T'otcct  it  from  tlus  twistod  throwl' 


•t  quietj 
IwisttdH 


•  Lfrtvrei  on  ValhoUtgy  and  Surj/frg.  p.  IBfl. 
f  Tiani^fiKmi;  tlic  vc^iu  and  )>A^^iIll;  m  tliii'uil  tliroiiffli  il,  as  propOM^  ^ 
^oIm.  was  fuuniJ  to  occuniou  nuuli  ^real  ii'iitutiua  tbat  iu  UM  was  pr 

abandon  eU. 


OBSTRUCTION  OP  VEINa 


321 


of  a  piece  of  wax  bougie.  Variom  other  dcvioea  for  4!on> 
tviiioiitly  fwcuring  tlw  obliteratioti,  havo  frotn  timi!  to  tiiae  boon 
niggeatccL*  A  good  and  oxptKlitioiui  plaii  m  that  n>ooinrnend«d 
b^  H.  Loo,  by  whom  it  i»  thus  dMcribod:  '^A  nvodJu  it  intro- 
dnoed  bfii«alh  lli»  rein  or  veins  to  bo  obliterated,  and  an  8-Iigatnre 
b  paissod  over  it«  pxtreinities.  Xlio  vein  or  duster  of  veins  is  tliua 
tnelndtid  t><<lw(«n  tlie  needle,  wliioh  ia  below  it,  and  the  ligatiirOf 
which  is  over  tJie  skin.  Tho  ligatiuv  Ls  then  tied  so  as  to  produce 
m  ftligliL  dt-groe  cf  presituro  on  tho  vein,  and  by  tliin  mciiun  ita 
cavity  U  temporarily  closed  by  acupn-twunN  Anotlior  needle  is  then 
ftmmi  umk-r  i1h>  vein  at  about  an  inch  ili^^tHiici-,  and  thr  v<-«<c'l  is 
tbera  clo'^'^i  in  like  mamter.  Tlio  vein  or  eluster  of  veins  thus  in- 
duded  l>elwe«a  tlie  two  tieedlett  i»  entirely  ttejuinited  irom  the  reat 
of  the  circulating  B\'s>tem,  and  may  tlien  be  divided  or  otherwise 
t4ttitenitoi  wiiixnit  ri.-Jc.  ^iibpuluneou.')  ne<!tion  of  tho  \'ein  tH  geno 
lally  all  that  is  necessary,  and  is  preferable  to  any  other  mode  of 
<ip<-ntling,  ax  it  eilrotnally  (>bliliir»li«  tlu^  vei»el»  without  hta^ing 
11  anv  ojien  woimd.  At  tho  expiration  of  about  four  days,  whi'n  union 
Kin  mtablixked  in  tho  dividi^t  ]>»rf<,  tlie  needier  luv  removed,  having 
^Bserved  their  temporary-  purpose." 

B  Except  in  rauMw  wiiich  lutve  been  rcfi^rod  to,  th<MO  opcrntions 
are  nut  to  be  recommended ;  and  the  patient,  if  wise,  will  be  content 
yntii  tho  palliative  measures  of  a  muro  simple  chaiactcr. 

■I 

^K  I  have  WTwal  tim«8  referred  to  tumours  as  causing  obstruction 
^Hfr  Um  tarcolation  of  the  bloiK]  ihi-ougli  vcin.«.  Little  tn<y>nvnnience 
^PKlDowa,  in  eonseciuenee  of  tlio  ready  formation  of  a  eollatend  cir- 
culation. Some  tumoun  compre^H  veinei  againstt  a  retiiHtiiig  sub- 
lAaDoe,  as  bone ;  some  by  tlieir  gron*th  completely  surroimd  them ; 
I  whiktf  otliers  extend  int4>  their  cHnnlH,  a-i  wiLt  first  jiointed  out  by 
1  li>ng!(taS' in  a  ease  of  medullary  cancer.  In  many  instances  they 
^L  (MM)  oUiternlion  of  the  ve^tel  by  interruption  of  ila  canal  and  by 
^B  ikoqition  of  its  coats,  or  they  induce  the  formation  of  clots,  by 
^M  tlucli  it  becomnt  jN^rmanently  i>bNtructe<l.  Now  and  then  u  tumour 
^K  tfms  to  have  its  origin  in  and  to  be  contined  to  a  vein,  as  hnp- 
^1  paed  ID  the  !t](lenic,  a^  n:<cv>rdf<l  by  f  IcHlgnon,  and  in  a  carte,  rehitcti 
^M  ^  Andnl,!  where  tlie  growtli  consisted  of  adipose  tissue  in  the 
^M  «illDfaportal>'cin.) 

^H      *  Hftai  ]>i&fl  for  oomprMflng  veins  ore  descnlicil  ia  tho  iUWitviJ  J^nut 

^m  tGuMt.  vol.  ii.  iMi,  p.  an. 

^m        t  Op.  viL  vol.  ii.  p.  t39. 

^H       ',  Th«  roltoiriuj;  spKimeDB  give  a  good  geuoral  id«a  of  Uiese  vdn  obli- 

^1         TOL.  m.  T 


322  DISEASES  OF  THE  VBDia 

A  few  words  Trill  dispose  of  tiie  sabjeet  of  wonns  and  other 
parasites  which  were  formerly  supposed  to  infest  veins.  The  more 
exact  and  minute  examinations  of  the  present  daj  hare  refused  in 
tixii  matter  to  confirm  the  statements  of  the  past.  Parasitic  animals, 
except  in  the  doubtful  cases  of  migration  of  the  embryo  of  tKnia, 
are  no  l<mger  found  in  these  vessels." 

G.  W.  GAIXENDER. 


terationB.  Middlesex,  series  vi  99,  85 :  Tens  cara  obliterated  hj  pressnre 
from  an  aneurism.  St.  ThoinaB'a,  t,  171:  rein  GUed  with  encepfaaloid 
deposit.  Guy's,  15S1? :  vena  cava  obliterated  by  the  side  of  a  dried-up 
hepatio  abscess ;  and  15217?,  i>j  pressure  from  enlarged  glands.  Guy's, 
lb22l  "  *:  growths  of  cancer  into  superior  Tens  cavn.  St.  Bartholomew's, 
IS.  29:  fleshy  growth  between  vena  cava  and  kidney,  obliterating  the 
former.  Aneurisms  and  abscesses,  though  they  sometimes  bunt  into  adr 
jacent  veins,  may  also  cause  obliteration ;  St.  Bartholomew's,  tS.  B4;  St. 
Thomss's,  T,  154;  St.  George's,  xii.  suba.  5.  1. 

*  Andral,  Duval,  Freubler,  Fabricius,  Bud  Rudolphi,  Virchow,  and  Leo- 
durt,  may  be  referred  to.  I  find  mentioned  by  one  or  other  of  these, 
echiuococcus  aJtereipariens  and  distoma  hepaticum  in  the  hepatic  veins ; 
aoephslocysta  in  the  pulmonary  veins ;  strongylus  and  fllaria  in  the  veins 
of  a  horse ;  and  entoioa  belonging  to  the  class  nematoidea  of  Budolphi  in 
the  right  ventricle  of  a  porpoise.  Hematozos,  as  they  are  termed,  are  said 
to  be  found  in  the  veins  of  birds,  I'eptilea,  and  fiah,  having  perforated  the 
vessels,  as  it  is  assumed,  in  their  wanderings,  and  being  then  washed  along 
the  blood-stream  until  ibey  stick  in  the  capillaries.  Leuchart,  quoted  by 
Kiichenmeister  (Syd.  trans,  vol.  i.  p.  60),  professes  to  have  met  on  four  occs- 
Bions  with  the  embryo  of  tfenia  migrating  through  the  main  branches  of 
the  vena  porta.    See  also  Siebold,  Syd.  trans,  p.  29. 


i 


DISEASES  OE  AE,TEEIE8. 


Atheroma. 

THIS  disoaM  is  of  much  importance  m  practical  Supgerjr,  from 
the  rn.>]ii<Micy  »*itlt  wiiich  its  uHocW  tux;  ubsorvcd  iu  wvokvuiiig, 
enlarging,  and  occluding  arteriea. 

The  oarlivst  »tji^  of  atJmroma  in  Uiat  in  wliich  a  tliin,  sod,  and 
dear  membrane  linea  a  p>arL  or  ihe  whole  of  an  arterial  tube.  It 
tppeun  at  lint  scarcely  diittin^iiitiiililo  from  tlm  nHturnl  inner  coat 
of  tlie  v«esel;  it>t  fi-ee  surface  ha»  th«  shining  smoothiiewi  oflliut 
membranv,  and  a«  it  acquires  firmness  and  a  cluM^r  union  with  tbo 
origiiuti  internal  <xiat,  it  fnrtiisliea  iti  fai^t  a  new  lining  to  the  ar- 
teay.  Hus  structtiro  is  added  to  tho  art«ry  witliout  tho  sUghtcst 
^ipearan«e  of  (ILieiL^e  in  tlie  origitiul  textui-e^  of  tho  vetittil.  IVt 
aro  nvitlwr  intiltcrcd  nor  infUinod.  Thoru  bouig  no  miuiife^t 
tn  the  arter)'  itM^lf  for  tiie  formation  of  llie  new  ineuihrimi;,  it 
ly  be  lookod  ujxjn  aa  probably  deposited  upon  tho  ulterior  of  the 

from  tlio  blood. 

This  opinion  as  to  its  source  is  confirmed  by  tho  iact  Uiat  the 

inser  cuaiA  of  an  artery  an)  untircdy  ile\'oi<t  of  nutrient   blood- 

vaneU,   from  whidi  it  could  be  secreted,  and  by  observmg  the 

fimW  pregreAH  of  tho  <li»eafic.     On  the  inner  ^iirtiu-e  of  the  new 

d«yout  a  layer  similar   to  the  first  forms,  and,  like  it,  becomes 

*tBufi(|iite"l,  (irmly  adbcnMit,   and   in   il«  tuni  Uie  foiiiulalion  of 

■Uilioiial   d^ositions,      ^NTien   many  of  these   strata   have   thus 

*«uralat«d  wilhiii  the  ve«»el,  Uie  whole  muim  i»  no  longer  trana- 

T*Rtit,  but  hecomas  opaque,  dull,  and  concentrated,  by  lossofmois- 

^  or  some  or^inie  ehaii^,  into  u  niateriui  xiuiilnr  to  hardened 

Aanen,  awl  eventually  to  ligament.     The  layer  last  deposited 

*7  nil]  bo  often  detcded,  thin,  wnootli,  soft,  traiwlueenl,  over- 

*Biiig  the  edge  of  tiie  dee[>er  mass,  and  possessing,  both  in  ap- 

pWanoe  anil  on  micnMoopie  examlustiuu,  the  charuulen  of  a  lining 

Wlilinin. 


324 


DISEASES  OF  AKTEEIES. 


Until  t.)i<>  <lopoHit  liiiK  liRcome  oonitaliilat^,  tlic  cnsiia  of  the  : 
remain  unchanged ;  but  aa  by  theU'  adliesion  over  its  iiiduratctl 
mam  tlicir  func^tion  ii<  (Ic-^lroYt'd,  lliey  wtutc,  nnd  lune  llioir  fimM 
n«8H,  elasticity,  and  natural  colour. 

Ono  of  two  fbatipTs  nuiy  kkcut  in  Mich  ftn  indumtod  lining 
pinte  of  an  artery.  It  may  soften  in  its  interior,  or  be  converttxl 
into  a  layvr  of  rrctawcons  imilttT.  In  ciUivr  caw,  iho  ntu-nutied 
coat*  of  llie  arterj-  around  it  will  probably  be  unnaturally  vaf^cular ; 
in6ainu]n1tL>n,  tbongli  not  occasioning  tlio  ditciuM;,  being  aluiust 
always  [iniduoed  by  it. 

Both  the  isoftening  and  the  change  into  bone  tskv  (ilae«  in  the 
deeper  [larts  of  tlio  dejiosit.  In  the  furnier  process  it  degenerate* 
into  a  thick  pulpy  mass  of  cliolesterine,  oil-globules,  and  nlbtmiin- 
oii«  nnd  oretiic<N>uK  moieetilcs.  Tlie  inner  strnrn  ttejuirale  tliis  [mlp 
for  a  time  fi-oin  the  blood ;  but  when  they  give  way,  tlie  whole  i» 
griuUmlly  wa.ilied  out  inUi  tlie  stnmni,  luid  the  buau  of  the  cavity, 
composed  of  the  weakened  walls  of  the  arterj',  is  osjioscd  to  tbo 
Ibrci;  of  tlu!  eitnlino  ini|iul.-<e  nf  tlie  blooil.  'Hie  po^nible  occurrenee 
of  an  aneurism,  particularly  a  dissecting  aneurism,  in  this  condition 
of  the  vessel  will  tie  evident.  M 

Cretefaction,  or  ossitieatjon,  likewise  occurs  only  in  a  thi<^  de- 
posit, ami  in  it»  uxtenial,  oldest,  duejx^t  layers,  1"he  inner  niirfaee 
of  a  bony  plate  of  an  artery  is  for  some  tim©  lined  by  the  most  re- 
cently laid  stratum  of  meuikrano ;  but  at  length  this  also  i>!«'ifiL'!*,  and 
the  plate  is  exposed  in  tlie  vessel.  Externally,  nolliing  intenenes 
between  the  i>lnte  and  the  middle  coat,  for  the  original  lining  mem- 
brano  partukes  in  the  ehaiky  dogeneriition.  The  bony  growili  pre- 
»entJ<  a  murkod  <lifferenee  of  form  lu  different  siieoiniens,  ai>d  rtill 
more  in  different  arteries.  In  the  aorta,  tlie  iniioniinata,  and  the 
common  iliac  sirteries,  it  assumes  that  of  plates  ofdJiferent  sizes, 
in-egular  in  outline,  generally  conoavo  and  smooth  inl*>mal1y, 
nigged  and  convex  cxtvrnally;  whilst  in  al3  smaller  arteries  it 
grows  in  the  shape  of  rings,  whieh  so  exactly  answer  in  tl»eir 
position  and  ilircclion  to  tlio  yellow  circular  fibres,  that  they  have 
been  regarde<l  as  ossifications  of  that  coat.  In  some  of  the  larger 
nrtericj',  a  rough  prominent  mass  of  bono  may  even  project  into 
the  canal,  a  growth  of  so  iiociiliur  an  a.-']>cct  na  to  be  cunipared 
by  ProfcHHor  Uokilansky  to  stalactite.  ■ 

The  other  (Miats  of  an  arlurv  tliii*  disenjxsl  are  neoftwarilv  a1t<^r^ 
K^thcr  the  fibrous  nor  the  cellular  coat  shows  any  change  diu-ing 
the  early  stage  of  the  proocsa ;  but  m  it  advancoi!,  the  fonner  iM-comei 
of  a  dirty-yvUow  colour,  loses  compactness,  and  admits  of  being 


ATHEROMA. 


325 


I 


easily  Klrii>t  off.  With  it#  iiatunil  texture,  it  tocM  tlie  power  to 
twifi  tlw  force  of  tlie  curropt;  it  dilatsH,  and  is  more  or  less  thinned 
out.  £>pijiovs  nru  tints  Ibrnied  l*ctwvcn  its  fibres,  tlirouf;h  which 
the  haay  deposit  oomes  inte  contact  ami  adhesion  with  the  celhi- 
kr  onat  of  iho  wssel.  This  ilo^neratioii  of  the  fikroii«  tunie  is  of 
the  kity  kind.  The  enter  membrane  at  dnt  becomes  unnaturuily 
tascnlur,  swollen  with  infiltration,  and  manifostlr  inflamed.  As  the 
■ctiviir  of  this  proeesa  subsides,  it  ia  converted  into  a.  callous,  white 
membntiie,  closely  adhcrcDt  to  tbo  deposit  and  to  the  remnftnt  of 
the  middle  coat. 

The  e?itLiit  to  wliich  nJlternmn  affects  tbe  system  of  blood-venela 

N     is  very  x-arious.     In  some  instances,  every  artery  mfHeientJy  laq|Q 

^tto  bo  numfd  by  anatomists  is  tlius  discasocl ;  in  others,  oortain 

Bnaaela  or  partA  of  ve^els  are  unafleeteil  bv  i(.     Kxtensive  athe- 

Fimu  of  tbo  aorta  is  almost  invariably  atlendetl  by  disoHKO  of  tho 

other  arterias ;  or,  to  state  the  same  fact  In  tho  fbnn  in  wiiich  it  is 

aeaany  prcmtited  to  the  Surgeon,  if  tbo  vessels  of  tlio  Itnibs  are 

C/uimI  lii.seasuil,  it  may  be  priMiiined  thiiL  tluue  within  (iie  trunk  are 

m  a  simihu-  condition.     It  is  necessary  to  note  tbe  instances  in 

which  the  disitsi.ie  is  limited. 

M  Tlie  aorta  may  bo  diseased  throoglinut,  yet  tho  coronary  ar- 

HtuTMHi  mxy  be  liealthy ;  and  it  is  interesting  to  contrast  the  highly 

B  nourished   stale  of  tho  heart  in  such  a  case  witli  its  condition 

B  ^Iwn   tin  nulHciil  artoricM  are  tliscasod.     Tbe  aortic  valves,  tho 

eomnieneenient  or  the  whole  of  the  arch,  may  be  atlieromatoua, 

and   no  otlwtr  vcjwid  Iw  iiflectcd.     Isolated  patches  of  tiie  disease 

tUMj  ooctiT  between  long  tracts  of  hcaltliy  artery,  and  it  is  of  the 

gmtest  ini|>ortJU)cv  in  Hurgery  to  know  this  fact  in  rt^lation  to  llio 

paflitaal  and  axillary  arteries,  of  which  short  portions  may  bo  even 

oaiiSwi,  while  Uie  femoral  and  sidiclavian,  so  far  as  eunoerns  tlie 

I        pnnbility  of  tlioir  being  aueeessfiiily  tiwl,  are  lieatltty.     ^\'lien  at 

dl  ajrancod,  tlie  disease  is  foiin<l  to  be  symmetrical,  the  arteries  of 

ifipMitu*  limha  being  equally  luul  Hiniilnrly  alleoted.     This  fact  is 

•vO  illustratod  in  tho  not  uiifnxjuent  occ^urrenco  of  [mrallel,  alnioat 

QntemporaneouH,  popliteitl  aneurism^  in  the  same  person.     Some 

TSKeUare  earlier,  if  not  more  fK>qucutIy,  afFcct^^  with  tiio  disease 

than  ntlicirs.     Timre  is  such  a  prejMndei'ance  in  the  lower  extremity 

emr  the  upper,  both  in  tho  proneiicss  of  its  vc^mIs  to  th*!  disease, 

and  in  llic  di-groo  whidi  alliemma  attains  in  the  more  distant  limb, 

Sofae  entire  aiteriea  rarely  become  atheromatous.     Thwsw  of  the 

ntuoiAoli,  liver,  and  iiiteHlities,  are  remai'kably  exempt  from  this 

affectwa,  even  though  it  may  ha\e  attained  au  adviuiood  degree  in 


fli 


8M 


DISEASES  OF  ABTERIES. 


tho  <pl(^i(?  and  tlio  other  nrttfries  of  tli«  hnAy.     As  n  gwit^ra?  uim 
otliorotna  is  a  disaiiK  of  the  arterial  trunks  and  larger  bniri<;ii(>^ 
but  it  is  occMiionnlly  met  vriUi  in  very  itmull  rowtek      On  one  oe4 
cecioii,  when  making  horizontal  sections  in  the  ordinarv  mixje  of 
examininji;  a  biaiii,  I  foiiiid  ull  tlie  niimtto  vcjiwcIk awccnding  lliron 
the  central  vfhite  matter  of  the  cerebrum  eonvertod  into  stiff  wir 
of  bone,  the  first  incision  of  whr^h  I)hiitt<-<1  the  knife     HalW  one 
nMt  with  ftthfiroinn  in  tlie  liypognstrie  artcrj-,  but  it  ii»  llw  onlj 
oese  on  record.     The  nioNt  marked  oxem[>tton,  however,  is  that 
thi>  venous  system,  inohiding  the  pulmonary  artery  and  ifc»  Iwj 
branehes  :  and  it  is  a  very  BUggcstivo  feet  in  rcforene©  to  the  ean 
tion  of  the  wholo  disonse.     Atheroma,  even  in  itfl  early  stH^, 
rarely  found  in  the  vessel*  which  carry  venous  blood ;  and  whe 
•  it  dot's  neenr,  it  U  assoi^iatad  with  a  very  ndvanei>d  und  vxtvnsiv 
degree  of  the  dieetise  in  the  aortic  system. 

St>  mnrk'-d  a  ditt'erenee  in  the  liability  of  the  two  ifyst«nB 
veBsel«i  to  this  disease  might  seem  to  point  to  their  strueturo  aa  iU 
eavtv,  imd  loa<I  to  Uie  error  of  regarding  it  tut  tin  nlfvotion  of  tbifl 
middle  coat  of  the  arteries.     But  that  a  mere  ditferenoe  of  stmo- 
tiiro  eanrnit  account  for  the  oxemption  of  tho  vonoiw  system  b 
evident  from  the  facts,  that  the  contrast  between  tlie  two  avstem^B 
is  cfmtiniuxl  into  the  honrt.  itwlf,  that  tli«  deposit  is  at  least  al 
abundant  in  tho  vein  as  in  the  artery  in  cases  of  arterio-^-i-nons 
ancnirisin,  and  that  it  ts  readily  ftinnwl  within  the  pnlmonary 
tcrles,  when  a  preternatural  onnimunicfltion  admits  nrlerial  hi 
from  the  loft  to  tho  rJ^hl  side  of  tho  heart.     TIip  rapidity  of  t 
arli>rinl  ciirriMit.  lm«  probably  some  eonnexion  wjlh  tho  deiKM*iti< 
though  not  with  the  production,  of  tlio  morbid  material.     As 
tibriii  of  fi-esldy  drawn  blood,  when  whip[XMi  with  a  birch,  ciing» 
in  masses  and  strings  to  onch  twig,  no  this  morbid  material  »dlieM!^| 
tn  all  roughnpMWM  and  obstaclos  lying  in  tJie  course  of  tho  blood  :^ 
to  an  inieven  or  a  porforatctl  aortic  valve,  to  the  sharp  niar^n 
which  dividi's  the  aortic  inln  llio  two  iliac  ttti'canis,  to  the  mouths 
of  branch  arteries,  to  a  cracked  or  prominent  bony  plate,  to  foreign 
bodtc-s.     0-onsi<lcring  tho  fnct«  aln'ady  Mtatol,  an<l  the  great  ac- 
cumulations of  this  substance  which  botJi  lino  the  left  auricle  and 
cncnml>er  ihe  valves  of  the  left  nidc  of  tho  heart,  we  may  conclude 
that  the  alheromatons  deposit  is  a  produet  of  morbid  blood  fmhly 
ehargetl  with  oxygen ;  and  that  imlcss  tlio  niat'-rinl  exist  in  the 
blood  in  verj'  great  abnndauee,  the  power  of  furnishing  a  deposit  is 
cxpwided  as  the  blood  pawtcs  through  tho  capillari**. 

With  regard  to  the  source  of  the  morbid  material,  it  is  to 


ATHEROMA. 


327 


I 


tiserred,  that  the  disease  prevails  chiefly  in  peraoas  vrho  am  in  the 
ilectine  of  life,  mvi  tliat  it  is  assoutatod  with  n  delet-tivc  nutrition  of 
the  normal  siniciuras  of  tlio  body,  and  with  an  a<!cumulation  of  faC 
Aa  albMnpt  haw  Ix-cn  inndc  to  connect  it  with  this  inordinate  mo  of 
alcohol ;  and  thcro  can  be  no  t^ucislion  of  JU  frequent,  if  n»t  iiivari- 
lUe,  oGcarTonou  in  dmnkards.  There  mast  exist,  however,  eoaie 
more  hidden  fault  in  tlie  formation  or  jtiirilication  of  the  blood,  to 
which,  ratlicr  tlian  even  to  alcohol,  the  diseafo  niu»t  be  attributed. 
Vouiig  found  calvareoufl  ootienitioiig  in  the  artericit  of  an  inlutt ; 
Wilson  ill  a  young  child ;  and  jVndral  in  the  aorta  of  a  ohild  of 
eifi^t  year^  of  ogi-.  Tlie  IntUT  author  also  met  with  itMifie  lumina) 
m  the  aorta  in  6ve  or  six  persons  of  fi-om  eighteen  to  twenty-four 
^firan  of  a^!,  and  an  vxti^isivo  otwilitiatiou  of  the  superior  nicKon- 
leric  artery  of  a  person  not  quite  thirty,"  Corfe  records  an  in- 
ftance  of  fatal  aneuri»tn,  aif  arising;  from  this  dixease,  at  the  ago  of 
twenty-eigbl  ;t  and  in  the  Huntorian  BluHcum,  No.  lt>79,  is  a  ape- 
omea  of  it  in  no  alcohol -drinker,  but  in  a  ja^ar.  The  t>''''^5) 
the  aged,  the  rbeinnutit;,  the  jiorsoiiH  whose  ti»siie»  are  imbued  with 
&U,  and  those  wltose  cscrctory  organs  fail  to  purify  the  circulating 
blood,  are  far  more  prone  to  tlie  dincnM  than  tlie  ]>hthinicul,  the 
caneeroos,  or  the  young, 

Tiie  tnicmttfiiipic  examination  of  the  white  un<l  buff-coloured 
deposits  sbowa  them  to  be  chiefly  composed  of  granules  and  oil- 
gtoiiolea.  Mr.  Uullivcr  f\ni  described  tbcm  us  containinr;  eliole- 
Meriae,  oleine,  and  often  some  margarine.!  Chemical  investiga- 
tioiM  of  the  bony  {dates,  by  Ur.  Bostock,  proved  tlicm  to  contain 
"  a  minute  trace  of  albuu)en  and  gelatine,  uiiimiil  matter,  much 
|ihc»phate  of  iiine,  a  little  <»rbunate,  and  a  trace  of  sulphate."§ 

The  atJkeTX>inatous  change  in  an  artery*  h  neccMiarily  slow  tn 
ib  pngrus,  and  can  only  when  far  advanced  be  dotccttvl  in 
tti  tiring  nibjeeL  When  actually  0H.*ili<Kl,  aji  artery  which  can 
b  fcit  at  all  may  be  readily  distinguished  as  thus  diseamd.  In 
lb  radial,  for  instance,  tlio  ringv  of  chalky  matter  can  be  easily 
iwifrniaed  as  the  finger  ia  moved  along  the  vossvl.  But  attention 
ii  alien  tir4  called  to  the  slate  of  tlio  artcrieit  rntlwr  by  some  se- 
MBdar>'  svmi>t<Hn  of  ttteir  disea.te  than  by  tlie  atheroma  it«elf. 

I.  Atheromn  h  at  fir*t  attcn<led  with  a  narrowing  of  llie  calibre 
tf  du  vessel,  in  proportion  to  the  thickness  in  which  it  is  dupo- 
Aed.    Tim  is  mo«t  marked  at  the  bilurcation  of  tnuik»,  and  at 


*  Copknd.  Dirt.  Mrd.  vo).  i.  p.  IIA. 
:  U»i.aar.  Tnuu.  veL  xxtI  p.  M. 


t  Phgtiogiumy  of  DuKuet,  p.  ISA. 
\  Ibid.  roL  xix.  p.  B7. 


528 


DISEASES  OF  ARTEBIES. 


tl)o  moTttlis  of  small  vcs«o1s  pasnng  ofTfroin  large  trank^     Tn  no 
spot  Is  it  more  »:>innKinly  ohMirved  tJian  at  the  ori^ns  of  the  inter- 
costal and  Bimilar  arteries,  which  brunch  ull'»t  right  HitgU-^  froinj 
the  aortn,  nrul  which  art'  itoiiiHhiies  not  only  iiairowetl^  but  M  last] 
completely  cIosihI,  by  tlio  aocumiilated  deposit.     Though  the  lar^t-T  j 
uioricK  arc  perh»p»  never  uli)il4!rut«d  by  tliiH  |in>o«a.<i,  yet  even  (hej 
may  be  much  contractod  by  it.     Tho  canal  of  bo  largo  u  vwiscl  us' 
thft  common  iliac  Ibw  bocn  foumi  ili mi n lulled  by  wni>-half,*  and  tlieJ 
great  ascending  branches  of  the  arch  of  tho  aorta  nearly  obhtcratwl.  ( 
Of  tlic  latter  occnrrtuicc,  l>r.  Yellnly  r*e«rd<xl  an  inBtanoe.     A 
man,  agwl  fith'-six,  who  w«a  siippoBcd  to  be  in  healib,  bnt  who 
had  "iiddftily  ^tntvcl  two  or  thR«  tiiiiwt  in  the  two  years  preceding 
his  death,  fell  and  died  while  at  work  in  liis  garden.     Tlic  arch  of 
the  aorta  was  dilated  and  athcromatoiiM,  and  the  tltr(.-A  great  t'CKsels 
ascending  fivm  its  arch  were  in  a  considerable  degree  plugged  npi 
with  a  gi-owth  similar  to  the  lining  mi'iiihranc  of  the  art^-ry,  an<f 
withmit  any  usnific  dojiosit.f     A  diminution  of  the  size  ofbraucli-j 
ti»«c1b  from  this  causo  may  prove  to  bo  of  BcriouH  !iii|iorlance  iaj 
Bonie  caam,  by  hiudci-ing  Hie  estabiiahment  of  a  ooUaberat  ouroai 
lation. 

2.  A  lufer  crinsef^neiieo  of  the  disoauB  in  dilatation  of  the  ve 
Tbo  power  of  the  outer  coata  being  iiiBiiffieiinit  to  coinpraa  tll4 
deposit,  and  f-o  close  in  n^wn  th<'  Iilooil  by  which  each  cardiao  ayBtc^l 
distends  them,  they  remain  wide  and  tixod  during  tlio  diastolv, 
tlic  artery  slowly  expands.  TIiIk  cnliirgtiiicnt  i^  the  niOHt  marked 
in  those  part*  of  the  vessels  tlirough  whi<:h  the  current  of  tl» 
blood  is  in  any  degree  obslructod.  All  curved  arteriea,  therefore^ 
are  disproportionately  dilateil.  It  is  observed  also  in  all  parts  at 
which  an  arterial  trunk  naturally  widens  in  iln  eourse,  and  ttuHers 
in  eonae<jiieno«  a  more  forcible  internal  hydraulic  pressure  than  tb 
smaller  tube  which  leads  to  it.  Tlio  upjwr  extroniity  of  I  he  commoi 
carotid  is  thus  widened  natiiially,  an*l  dilated  when  alhcromaton 
In  that  situation,  at  the  upper  end  of  tho  innominata,  mid  in  liu 
hig)ier  part  of  the  femoral  artery,  tho  expanded  vessel  may  cl 
attention  as  an  aneurii^m. 

3.  Tim  same  median  Ism  which  converts  an  artery  into  a  fixed 
tnbc,  ine.tpahle  of  contraction,  but  liable  to  dilatation,  produous 
similar  ort'wt  npnii  its  jKiwer  of  retraction.     A  healthy  artary  is 
a  Ht!it«  of  longitudinal  tension.     It  is,  as  it  worv,  too  abort  fur 


•  HunU-rinii  MuHi^um,  1AI4. 

f  Mtd.-Chir.  IVan*.  toI.  xii.  p.  1>79. 


ATHEHOMA- 


339 


wtu'di  it  belongs;  nndf  if  ciit  across,  may  shorten  an  inch 
*     Atborcnnnlous  aiid  hony  ]>lftt«i)  doktroy  tliiit  rviructilo 
But  tJiou^h  in^-]i[iablo  of  shortening  itself,  the  vosael  is  not 
le  uf  being  lengthenocl  hy  the  rc|M'»tnI  injcftioiix  of  Wood 
it.     Arteries,  (horoforv,  in  wKidi  atheroma  hits  rvaohod  an 
<l  4lfgr«e,  keooine  not  only  <lil»t<.Hl,  hut  uIho  tortitou.-k     Tlie 
of  tunvhiid  artcrios  thus  affected  may  he  seen  in  the  bnro 
•vary  palsstion  of  tho  iMiiirt  itu-ri'iL^ing  th<^r  cnrMilnixM.     Tlie 
and  external  iliac  arteries,  um,  bend  ftir  fi-om  their  normal 
the  funiujr  arching  outward  luid  forwiird  hc-tw4M;n   tJio 
and  iiitcnia]  iliac,  the  latter  leaiing  itx  ])lace  u[)ou  tlia  [tsoas, 
carding fkvjJy  into  llit-  jn-hiii  iii  ii  in-w ooiirsc. 

An  OMtficd  artery  does  not  retain  that  Hmoothness  of  its  m- 
rwbteh  duunctei^Mxl  tho  OJirlier  <IqH>sition  within  it.  In  a 
TtBBcl  lika  the  aM-ta,  a  bony  pliito  may  rrai^k  sc-ross,  or  bu 
I  at  itti  <.<dgo  from  llio  wall  of  tho  vessol ;  and  th<:!  dharp  rouf;h 
tbns  exposed  nuiy  eause.  thi^  adhesion  of  fibrin.  String» 
of  this  sidMlaiwo,  a»  it  acctimahitt.-s,  materially  Ivw^n 
imlthre  of  ihe  veiwel,  or,  being  lirokcn  off  and  carried  along 
tlia  stnxun  of  blood,  plog  any  emallLT  artery  in  which  thoy 
n  to  bo  Krro«ted.  Tho  oaulication  of  snialltT  trunkit,  a^t 
KDoral  arterieH,  produces  in  another  manner  a  roughness  of 
'  canal.  Tliti  bony  matter  buing  thickest,  or  somotimra  only 
Eng,  at  the  circular  ringA,  tlie  v(.tt»el  le.  necessarily  at.rongost  at 
part*,  while  H  yields  botvroon  them.  Tho  interior  of  such  a 
ia  WDaetjuently  no  longer  HmiK>lli,  but  is  formed  of  a  aucces- 
of  alt«rttate  tnuisvcrso  ridgee  and  bays ;  tbo  former  answering 
ringn  of  bone,  and  the  latter  to  the  ex|>imdcd  spaces  be- 
ibein.  Such  an  artery  resembles  tho  interior  of  a  piece  of 
,  into  tlw  camal  of  which  foIiU  of  tluf  vuKuliv?  otjnnivenica 
;  and  the  effect  of  tlie  arrangement,  just  as  in  tho  bowel, 
bo  (o  materially  roiard  tlie  «ut«r  portion  of  the  current 
01^  it,  whilst,  by  detaining  witliin  the  cnlargenionta  of  tlio 


Aa  miwry  Miiy  sharton  to  Uii*  pxtoiit.  I  bnv«  obiwrr*^!  the  end*  of 
1  brurlual  artory,  to  a  tmjr  of  ihirteun,  to  bavo  itepnnktei]  mnn  tlutn 
tb  antl  ■  lulf  when  the  elbow  was  estetided.  On  tlio  other  hnii<l.  n 
iir  tliridetl  healthy  cumtnoii  feinoral  Uiery.  ]>re»erveil.  with  ttic  ndjo- 
t  •tm«ttirin.  iii  llie  HuDtcmn  Mum-uui  (No.  l&O^).  Iiilb  neitliiT  retmrtcd 
ni'ulmetcd.  Tlii*  wouml  U  nUti-J  lc»  Imvo  uBiiaed  Tdtal  hiomorrhn^ 
aajr  bo  n-ntarkcd  in  explanation,  tliat  the  bnicliiul  urtei7  la  rery  loosely 
B*«i«tl  with  itH  iihcnih.  iini]  in  not  RxM  hy  bnuiobM :  urhilo  the  common 
RtaJ  la  a  sburt  tniuk,  aikd  nillivr  tutluiatolj  ndhcreal  to  Its  sbutfa. 


880 


DISEASES  OF  ARTERIES. 


vfsisc\  a  mperftuoiis  quantity  of  blocxi,  it  tbcrcbr,  luid  to  tliAt  i 
ini]M>verisbes  the  sytitieni. 

3.  It  liH  beco  already  montioiuMi,  that  an  atlieroiiifttoii.t  artery 
becomes  <litntt;d,  and  Uiiil  il.  iimy  yield  and  become  aneurismiU  at 
a  part  from  wliich  the  sof)«nvd  di-posit  on  it«  interior  liu  boeu 
waslied  away.  It  may  ho.  luitM,  tliut  l!ie  so-called  ulcers  of  ar- 
t<;rics,  which  are  otx-aHioncd  by  the  partial  dotavlunvnt  or  the  crack- 
ing of  calcareouH  di-puxiui,  '*  uro  suinotiiii«(t  >io  deep  as  to  reach, 
and  even  to  perforat*?,  tlie  external  or  o^llular  tunic"*  Bat,  even 
witliont  Fiicli  prvviotw  detachiii«iil  of  itx  inn<tr  jiortimi,  a  dinftaited 
artery  may  be  torn  tlirougli  by  tlio  direct  force  of  the  blood.  Dr. 
J.  Risdon  Dennett  has  recorded  a  case  of  sudden  death,  in  vrhi«li 
the  aorta  gave  way  l>efi>re  the  icnjinlite  of  a  hypertrophied  heart. 
The  "  rupture  was  directly  tliToiigh  all  the  coatii  oi'  the  artery ;  the 
edges  of  Ihc  n|)crture  wero  somnwbnt  niggeol,  and  traversed  a  |>alefa 
of  atheroma,  "f  Messrs.  James  and  Hose  have  published  aimilar 
ctu*!^"  of  ^jRiiitatieoiH  rupture  of  the  aorta,  and  Mr,  Amoit  one  of 
rupture  of  a  di»ea»ed  aorta  from  violenoe.}  It  is  obvious  tliat  theM 
nci-idfiiU  lire  the  more  liable  to  occur,  at  the  diMase  in  limited  in 
extent.     The  artery  yields  aL  ita  one  weak  point. 

6.  in  relation  to  accidents,  and  surgical  ojwrationc  oil  arterial) 
the  <]iseaHo  whii-h  we  Iiave  been  coiiNidering  naauroes  a  serious  im* 
[wrtancc.  No  longer  tense,  mobile,  clastic^  these  vohscIs  bcooBH 
rigid,  hritlle,  and  fixwl.  A  direet  l>low  may  crack  or  crash  tliemi 
a  severe  wreiich,  or  sudden  unusiial  movement  of  a  limb,  may  i 
break  ihcm  ;  the  violence  wliieli  disloeitf.!))  a  bi>nc  may  tear  theoi  i 
two,  and  give  rise  to  a  vast  escape  of  blood.  Mr.  Symc  aileg 
that  he  lias  knotvn  an  axillar}-  aneurism  follow  »iich  aeci<hmts  «] 
the  repeated  sudden  shock  ofa  machine,  against  tlie  elbow,  sn 
quick  unguarded  movement  in  lifting  the  arm  to  tltc  Iiuad  for  I 
puqxjse  of  holding  on  the  hat  in  n  brt-een. 

When  a  ligature  is  tied  upon  an  ossified  artery,  tlio  teiistti 
conveyed  by  eriibibing  the  bony  t.ulie  betrays  its  oondition. 
times  the  ai'tcry  gives  way.     In  the  stump  ofa  leg  just  ampu 
1  hax'e  seen  an  oosificd  tibial  nrtorv  break  three  times  under 
ligature^     The  va'-sel  was  only  secured  at  last  by  inclnding  a  la 
(juaiitity  of  the  adjacent  sofl  ]iHrte  in  the  iiooso  with  iu     In  ano 
case,  tlie  ligature  waa  wound  several  times  round  the  artcrj'. 


btfj 


sad  I 


*  Hflpe,  Cgd.  »fPrael.  Mtd.  vol.  i.  ji.  140. 

+  Metl.Chir.  Trmt.  vol.  xxsii.  [i.  JOl. 

;  London  Med.  and  Phyt.  JounuU,  vol.  Iviti.  pp.  13, 19,  and  xvuL 


ATHEROMA. 


331 


difficalty  experienced  in  safi-ly  truig  micli  a  vessel,  lias  ii»iss«*xl 
ti(i>  pinti  of  dissecting  along  tlio  artoiT,  and  pluming  the  ligature  on 
it  bitter  Qp.  As  it  is  iin»Ttaii]  nhothor  siicli  sn  artoty  would  be 
better  iiilnplt>d  to  bear  a  ligautre  in  any  higher  ]iart  of  its  conrse, 
tJiB  safer  plaii  eccras  to  bo  that  of  socaring  it  in  the  faco  of  the 
snunp. 

To  atbcrotnsi  and  oseification  arc  doubtless  due  the  majoribr  f^ 
the  foiliirt'it  of  ojiemiionA  for  ■iii>iiriMin.     Notoriously  in  tlil-<  tlid 
case  with  iho  old  operation,  in  wliich  the  artery  was  tied  near  the 
iSinullt  of  |In«  uneiiri.iina)  itae.     And  many  tinioit  oIho,   whon   the 
onterian  operation  has  been  adoptwl,  the  result  has  been  disas- 
tniw*  fnini  Uie  Mime  caui*.     The  prwi-w*  of  repiiir  cannot  Ite  per- 
fected in  a  tied  artcn,-,  when  the  lining  niomlirano  is  tough,  or 
omoent-,  or  in  n  xtate  of  fatty  degeneration,  when  the  middle  eoirt  ia 
wasted,  and  tlie  outer  ealloua  and  attenuated,  and  when  the  rigid 
lube  is  tncn]«ibl©  of  eontraotinp  between  the  ligature  and  tiio  next 
braueb.      From  FUeh   an   artery'  tlie   ligatnre  separates,  perhaps 
earlier  than  from  a  healthy  one,  and  hicmorrhage  pours  freely  and 
.frtaily  from  one  or  lioth  of  itji  tuielo»eil  exlreniitie^.     A  prudent 
m  forlican  from  operating  in  sueh  a  ease,  or  from  tightening 
Ittre  if  l>e  luiespeetediy  ennoimter  m  diw-ascd  vetuurl. 
Gangrene  may  occur  at  different  stages,  and  from  variotis 
«rmmNlunc(»,  in  lb«  eoHrwe  of  atheroma;  but,  in  itiwlf,  that  di»- 
We  is  not  capable  of  producing  gangrene.      For,  so  long  as  the 
iu«tU  remain  o]»en,  even  though  rigid,  they  allow  a  enrrent  of 
Hood  to  pass.     And,  in  fact,  any  ebstmotion  which  may  bo  ooea- 
(iwal  by  tlie  rougbne**,  in,  to  i<oine  extent,  oorn(>eii sated  fi^r  by  the 
ion  of  tiK'ir  eanni,  and  the  distal  parts  obinin  their  nonriah- 
Bnt  Khould  any  unuKual  and  conxidorable  demand  u[u>n  tlie 
lation  l)e  made  iiy  a  local  injury  or  in  Ham  mat  ion,  the  circula- 
!»•  will  (irove  inmifiieiuiit ;  and,  lu  trees  with  tangled  rmAn  »omc- 
Inus  periih  in  a  night  ujmn  a  sudden  inei^eate  in  the  rapidity  of 
ft>  flowing  of  tlte  sap,  the  distal  parts  will  die.     Gangrene  \»  ufton 
ive  when  an  oaiified  arterial  trunk  beeoniea  occluded ;  and 
explanation  of  tJio  fact  appears  obvious.     Tlie  collateral  t^n- 
tlinwgh  whieb  alone  this  bifMid  enu  rt-aeb  the  remoter  parta, 
tlirai«ch'es  indurated  or  ossitied.  and  are  incapable  of  adapting 
calibre  to  tlie  larger  irtroiiin  which  pri-!>Hi>-i  tlirough  them.    Hie 
lariehed  stmetures  neoeasarily  die.     These  occlusions  of  arterial 
are  not  tiucti  a.*  arc  very  xlowly  ooiiiploted  by  llio  aeoiima- 
1  of  new  matter  at  their  orifices  or  bifurcations,  but  such  as 
froni  tlto  moTO  rapid  deposition  of  large  maMCS  of  tibrin  upon 


833 


DISEASES  OF  ARTERIES. 


a  rough  part  of  an  artery,  or  from  the  looaoniiig  and  invernion  > 
an  rj«!«Mnw  ]>lat<t,  or  tlic  washing  of  a  tlotacht-d  cardiac  vegetation 
down  the  oiirrwit.  The  first,  occurring  comparatively  earlv  in  tJie 
(IlMyuK',  (Mti  be  tnn'Ui  up  for  hy  the  establishtnont  of  a  cvllalcra]  dr- 
culation ;  tli«  others  liapiion  suddsiily,  in  which  ease  oven  hea 
collutuml  arteries  Homotiincti  fiul  to  proaorro  tho  lUti  of  a  lirnh. 

OrcwiBioK  ov  Ahtekif^ 

The  few  preceding  pages  contain  the  statement  of  the  modes  i 
whidi  artvrin]  caimls  are  narrowod  and  ob!it(!ralv<l  hy   athcroml 
Some  other  causes  of  obstruction  to  the  current  of  btood  remain  to 
l>e  noticod. 

There  are  persons  who,  by  certain  postures  of  their  limbs,  are 
nUe  to  Mtop  the  pulsation  of  the  artttrics.  Tlioir  nidiols  and  tibial* 
cease  to  beat  upon  foiv.ibk)  flexion  of  their  elbows  and  knee& 
Otlion*  L-an  no  depress  t\w  clavielc  ii]iou  tJic  Hulieluvian  arttry,  or 
raise  tliat  vessel  by  a  forcible  expiratory  compression  of  the  lungs, 
that  all  cireulation  ouascs  for  the  tinio  in  tlie  arm.  Artvrioi"  diii- 
pjaced  with  fragments  of  bone  are  often  wiiliout  pnlsation  until 
tiio  fracture  is  set.  An  exuberant  osseous  dcpmitioti  arouitd  the 
fragments  of  a  fracttireil  Ixine  may,  in  at  least  one  situation,  com- 
pnns  tho  adjoining  blood-vcsiwis.  Hie  veins  in  ttueh  a  ease  mSet 
more  than  the  iirtorv :  hut  lK>th  may  be  compressetL  Such  a  sit 
tion  is  tile  fibrous  canal  in  the  adductor  mnselcH  of  the  thigh,  io 
which  the  wimi>n's.iioii  rcti-rroil  to  has  bet*n  observed  U)  happen. 

In  like  manner,  that  is  to  sjiy  by  outward  compression,  nmrbid 
growtliK  in  the  viciiiily  of  blood-vessel.*  (•iifet-lilo  or  slop  llie  cir 
lation.     An  exostosis  once  grow  on  the  first  rib  in  such  a  r>-Jaiio>J 
to  tb<^  subt-lavian  artery  »>i   !•■  gi\'0  riso  to   tho  symptoms  of>s| 
anem-ism  of  that  vessel,  and  lead  tho  Surgeon  who  had  cliarga ' 
tlio  oiwc  to  tii*  tho  artery.     C'aneennw,  raroly  innoconl,  lumo 
compress  and  obliterate  arterial  trunks,  which  are  fonnd  fUtieM^J 
tuid  cither  pervious  or  oeehided  with  cuagula  or  udli«n*nt  Sb 
Even  gangrene  may  follow  tlie  occlusion  of  an  artery  from 
cause.     Thin,  however,  ts  a  rare  event,  as  timo  clapsiw  bi-fiire 
compression  boc()mps  comjilete,  and  blood,  in  some  small  <|uanu9fl 
contiiuiiw  to  be  driven  through  the  fliittviied  v<««tL     'lla)  oWif 
tion  of  aneurism al  vessels  will  be  fomid  exphuned  at  large  in 
essay  on  Akecrlsm. 

One  other  cause  of  tlio  occlusion  of  an  artery  remains  for  i 
Hiduration,  that,  namely,  in  n'bich  tt«  caual  is  closed  by  an  im]: 


OCCLUSION. 


888 


fi>rcign  boJy.  Tbe  casaa  are  now  numeroud  in  which  arteries 
have  beeii  found  plugged  by  fragnicnts  of  morbid  growths,  wliich 
hsTC  bi-int  4t<!la<'hitl  from  oiu>  pan  of  tin;  cirt-ulatiof;  tiy»tvin,  niid 
transported  into  some  other  part  along  tho  su-oam  of  blood.  Tlw 
plug  which  iit  fitund  o«%IucItng  tlx!  dintal  viiwcl  has  oUcd  no  organio 
ooinioxion  with  its  walU,  and  is  dotainod  in  ita  place  merely  by 
baving  rMU'lMil  an  nrttrj'  ton  amall  to  fjivo  it  fortJii-r  passagix.  Tlie 
•ocid^t  is  ustiaJly  mot  with  in  tli«  aortic  sj-steni,  and  the  moitt 
common  xitiuitiini  fViim  whii-h  giieb  fimgiDOUts  are  detncbcd  is  the 
left  side  of  the  lieart  Alauy  morbid  vegetations  adJiero  to  tho 
mitral  and  nortio  valvftt  hioaely  or  br  |H!<Iiclw,  and  may  bo  broken 
off  by  ilie  rush  of  btood  into  or  out  of  tJie  ventricle.  Some,  but 
mialler,  frn^t-iitit  niiiy,  na  Mr.  IjCO  «uggeets,  bo  wajtii<.>d  out  of 
athenitnatouB  parts  of  the  larger  vceseJs.' 

So  long  ngo  iu>  1^37,  it  occurred  to  M.  Legrouxf  to  explain  a 
cue  of  sudden  obstruction  of  the  arteries  of  t}ie  InwtT  vxtromitiM 
by  tho  passage  of  ttic  fibrinouH  p]up«  found  in  them  from  the  heart. 
A  nmihir  explanation  was  given  by  M.  Lauder  to  tho  Anatomical 
Society  of  Paris,  in  IW9,  rc.«|>octiiig  a  yet  more  remarkable  case. 
A  h(«lthy  young  man  died  with  a  noodle  in  tho  lefl  v«>ntric1o  of  his 
heart,  aiKl  with  gangr«ne  of  tho  left  leg.  The  needle  wa»  found 
fixed  in  U»e  ajiex  of  the  ventriele,  wltli  ita  point  din-ctcd  towards 
tbe  aortic  orifice,  and  covered  with  "  decolorised  sanguineous  con- 
tntians,  very  coherent  and  irregular,"  which  were  prolonged  into 
the  aoito.  Tho  lower  cud  of  tho  aorta,  and  the  iliac  nrtorioN  on 
Wfa  sidM,  were  filled  with  an  adhcreiit  olot.  (t  socmod  plain  that 
t]ieph]gging  of  the  latter,  and  the  eoneequont  gangrene,  hiul  their 
oripD  in  the  <k'lacJnm'nt  of  frnymwiU  of  the  lympli  which  had  first 
Aered  to  the  needle,  t  Since  tliat  time  the  re«earcii<T»  of  Dr. 
,S«lnbavc»hown  a  similar  occurrenci^  Ui  take  pluov  in  the  cerebral 
Mr.  Paget  has  demonstrated  it  in  the  piihiionary  artcriM; 
.  Vircliow,  8iiiip(wn,  an<I  olhun  lia^o  made  us  ncijuaioted  with  it 
I  other  leaseb. 
An  accident  precisely  Nimiliu*  in  its  nattuv,  but  occurring  in 
|iortion  of  tho  circulating  system,  is  now  known  to  Ix!  occa- 
Ivhaally  fatal  in  oetilv  rhcunuiti«ni,  as  well  as  to  bring  on  the  niont 
tly  niddcn  deaths  in  some  puerperal  women.     Tho  plugged 


*  Im  oa  (lODgimui  Senilis,  tlritith  and  Foreign  Mnliw-Chiniry.  Sgvitw, 
[Wn.  11.214, 

I  B^Un  de  rAttuL  Aiytib  4*  Xf^dMinf.  torn.  i.  p.  434. 

'  CniTmUiler,  T/aiU  iCAnaioiiiu  PalMogiqtM  MntraU,  torn.  ii.  pp.  301, 


du 


DISEASES  OF  ARTERIES. 


artery  in  these  caws  is  this  pulmonary,  or  ftiiviiml  of  il»  t 
and  tli«  plug,  is  either  formed  in  tbc  rigtit  side  of  tho  beurt,  or 
pasece  through  it  from  inHnined  vbinit.     Cu»v«  of  Iwth  kiuds  are 
reported  in  tlie  pablications  of  tho  day,  aud  Bome  of  tliern  Iuv« 
boon  colluclvd  Uigethcr  hy  Dr.  Siiiipiton  and  ki«  c«liu>n^  Drs.  Prioi^ 
}ey  and  Storer,  in  tlie  Hecond  volume  of  tho  OUtetrtc  Memoir*.       ^| 
Tho  fa«ti«  friMii  wliu'li  lliu  tixplnnation   of  Uit-sc  occlusions  o^ 
arteried  is  ctiiefly  drawn,  have  already  been  partly  HUttcd  :   1.  Hie 
artery  is  of^on  htudthy  at  llw  nitv  of  the  oketructiun.     It  nay,  in- 
d^od,  be  atheromatous,  inasmuch  as  tbe  occurrence   in  quiMion 
pruvails  nioi^t  in  pur>H>n.f  who^ic  arteritd  Bystcai  is  diecascd.     Yet  il 
is  onen  hciilthv,  as  might  be  expected  ujion  Uie  hypothosiit  of  tlie    | 
disease  originatinK  vlnewtivrc.     t>ometiinvs  tli«  vessel  is  dilated  to 
nciirly  twice  itn  natural  size,  and,  in  the  branclim  of  tbv  inttriul 
carotid  especially,  tliii<  enlargement  renders  the  situation  of  tlw  ping 
evident  before  tbe  artery  ja  opened.    The  latter  appeom  to  liavc  been 
forcibly  diktt^tl  by  the  re|>eated  impidsiuu  of  tlio  blood  against  tk 
plug.     2.  Tlte  plug  is  treijuently  not  lulherent  to  tjie  vessel.     Ilie 
cas6B  under  consideration  wore  for  a  long  time  regarded  aa  efi'ubioui 
of  lymph  from  tlie  surface  of  an  inllumed  artnry ;  but  when  tht 
artery  is  healthy,  and  tlio  plug  free,  tJiat  e.vplanation  b  plainly  er- 
roneous.    There  are,  indeed,  not  a  lew  iiiKi«m-«M  in  winch  tho  ceM 
of  the  artery  aro  inflamed,  and  even  suppuratiwi  has  tiiken  plaw 
in  the  !<urrouiiding  Htj'ucturen ;  in  tlitino  circurnst>iiiee«,  the  plug  ■* 
foimd  adlicrent.    Tlie  inflaminatiou,  however,  and  ihe  adhe«ioii,  an 
alike  tho  n«ult  of  tlie  proviuns  pre*cnce  of  tho  fJug.     3.  Tlw  im- 
pacted plug  (lan  bo  distinguishe<l  from  tbe  intlaniniatory  lyniiiksod 
coaguluni  which  are  formed  in  it3  immediate  neighbourhood.     Dr. 
Burrows  aud  RUido  have  given  tlie  most  undeniable  evidence 
tliis  fact,  and  have  idl  but  demonslntbly  traced  tho  plug  to  ati< 
place  of  origin.     Each  of  these  observerii  detected  a  oiilcATCouit  pli 
nooluding  nn  artery,  imd  xiiniUr  cnlcaroous  matt«r  sti)]  attadied 
tJie  wall  of  tlie  heail.*     4.  The  cesaatlon  of  tlie  cireiihitton  in 
occluded  artery  is  too  abrupt  to  have  been  likely  to  have 
from  tlio  gradual  accumulation  of  fibrin.     It  hu»  probably  not 
discoverod  to  be  instuntjmeous,    hceause  the  pulse  ba.4   not 
under  examination  at  the  moment  of  the  occlunion.     ft.  The 
pais  which  first  calls  attention  to  the  accident,  and  death,  as 
liappena  from  such  obstructions  of  the  pulmonary'  artery,  ore 
soawtimes  audden. 


Medioal  Tma,  itiM,  p.  18i ;  Vircbow'a  Arckiv,  voL  v.  p.  ISV, 


OCCLUSION. 


3S5 


\r  pxtrvcd  U>o  limito  of  tliJa  article  to  trace  the  rcsitltil 
lit  En  the  viLr»)U»  pnrtti  luid  orgMM  of  th«  bocl;r  in 
been  shown  to  ocenr.  As  there  is  no  tnink  whidi 
ft  bt  ooduiled  hy  ■  dctnchixl  plug,  the  nUlitminsI  aorta 
ii  escaping,  so  there  is  no  organ  which  may  not  have  itn 
t  tmpniro),  or  it«  ttnicturo  (Iwttrojotf,  br  the  cleprivntton 
I  which  this  accident  oooiiaions.  A\Tiat  ma_v  happen  when 
with  Nin^c  ortvrial  trunks,  as  the  tc^ticlv,  vye,  or  sjilvcn, 
■  rnddenly  deprived  of  their  whole  Happly  of  hlood,  has  yet 
HMrvcd.  8onic  ftiither  remarks  must,  however,  be  ofibn-d 
e  occiureftoe  in  tlie  arterioit  of  a  limb, 
m  Iho  prineipa]  aitery  is  sacldenly  plup^gcd  in  it«  lii^wr 
Mnsition  of  sevore  [win  iH  conintiinty  tlit!  iinranlialc  result 
lOCident  In  some  cases  this  pain  extends  along  the  course 
■ud,  which,  tliough  piikelcss,  is  extriTmely  tender;  in  otliera 
bring  U  referred  to  some  distal  ])art  of  the  limb,  as,  for 
I,  to  tlia  calf.  8igns  of  a  dcHvicnt  circuliition  nucoced;  and 
k^  MDOiuit  to  pallor,  loss  of  temperatnre,  numbness  of  tho 
I  Of  «v«i  to  that  '  torpor'  which  i«  observed  to  pr«e«le  iJio 
Rth  of  a  timb  in  certain  tit»e»  of  injuries  of  vessels.  Such 
nptiw  not  only  a  loes  of  circulating  blood,  but  also  a  OM- 
lt  all  IMing  and  motor  power  in  the  limb.  ThAt  m-tind 
■tian  of  the  limb  may  ennue  ban  been  iUnsu-ated  in  the  ex- 
iriiidi  have  been  already  given  in  this  section. 
)  not  vt-ery  en»e  of  (ilxMriU'tod  uteiy  which  terminates  id 
A,  A  collateral  mrcolation  may  be  establishod,  and  tho  life 
mb  bo  m\-<od.  Verj-  young  subject*  bear  ouch  an  aceident 
mj  ensuing  morlitli'ation.  The  constitutional  vigotir  of  an 
rin  omtiirv  witliont  liii*  of  life  the  niiHleralion  of  e\'en  the 
idf  at  the  termination  of  ita  arch,  Mr.  Savory  has  recorded 
Bkoe,  probably  congenital,  in  which  "  all  the  main  lulerieA 
opper  extremities  aiu]  of  tlie  tetl  Hide  of  the  neck  were  rc- 
I  wild  eonts  j"  yet  no  gangrene  occunrd,  •  But  tlic  pcraoiu 
■aes  ■!«  now  under  conxi^li-i'utiun  are  all  such  as  have,  or 
d,  iltMBMt  iDider  llie  intiucnoo  of  wlucti  the  giuigrciio  may 
in>  readily  occurred. 

MOW  groend  feeUeneea  of  the  system  may  iicoount  for  the 

>  tad  gTMt  mortality  of  tliis  form  of  gangrene.     Some  peiv 

httore  any  line  of  demarcntlon  Li  formed ;  more  sink  daring 

of  aeparating  the  dead  portion  of  the  limb;  afew  survive 


Mtdtco-CKintrsiMt  Trviuactioiu,  vol.  xxius.  p.  itt. 


m 


a36 


DISEASES  OF  ABTERIES. 


untfl  all  its  tissues  are  naturally  sct-oiwI,  except  the  bones  and  : 
toiiJfHi*.     Ujioii  llift  <iiviitian  »f  thoiio  by  Uie  kiiifo  aiid  daw  of  the 
Burgeon,  the  stuntp  may  heal. 

Some  at  Ica^it  of  llic  oltAcurily  which  liiu  hit,licrto  invested 
subject  of  srtfifc  (lan^reiM  is  cleared  away,  ifa  previous  obltber 
of  tli«  urltTioi  1m'  rpwigiiisisl  atmmg  it.t  oiiusiw.  Then)  arc  com- 
mojily,  indeed,  preliaiiuary  8ym])tomB  of  loug  duration:  diillinera 
of  the  foot  or  band,  and  fretiutMit  paiii»  for  many  montlis,  (brobodo 
the  attack,  and  tho  gai);Q;rene  at  lon^h  originates  and  advimoes  hy 
a  local  <Iu;«ky  iuflammutiuTi.  Yet,  though  Mt  uuliko  in  these  par- 
tJculars  to  the  form  of  gangrene  produced  in  young;or  subject*  by 
obslriictvil  arlvric^,  such  an  cxain]>lv  a»  the  followiug  appears  to 
ha^'e  been  thus  caused. 

A  vroinan,  ugod  sixty-six,  wheezing  and  vinphyiwrnatous  in  bcr 
breath,  and  having  a  puW  wliich  indicated  a  diaeane  of  the  lieart, 
was  under  my  care  >n  the  Middlesex  Mu»j)ita!  for  gangroue  of  both 
lower  extremities.  The  death  began  at  the  toes,  and  slowly  it\maA 
ujiwards  in  tlic  course  of  a  previous  dti»ky  uiflammation.  81iesuf- 
fi^red  (teverely  from  tlio  paiti  in  tier  lower  exlreraitiea,  and  died  ID 
about  seven  weeks  from  the  coram  en  cement  of  the  gaiigrene.  Ta 
days  before  her  death  tlie  I«tl  radial  artery  bet?amo  plugged, 
■had  beat  as  usual  at  one  visit,  and  on  the  next  day  it  was 
pultwting  only  in  the  u]>per  half  of  its  course.  In  ono  lowvr 
tremity  about  six  mches  of  tlie  )v>pliteal  artery  wii£  plugged  will 
lulliorciit  fibrin,  coni|)aet  clot,  and  sollenrtl  elof.  Hclow,  tlie  i 
reiuainefl  open,  and  parsed  unclosed  from  the  living  into  the  do 
part  of  the  limb,  the  line  of  wojiwration  boing  at  tJw  calf.  .SimE 
obatniction  existed  in  the  tibials  of  the  opposite  hmb,  iu  wliieli 
mortiheation  reaehc<l  to  tlio  ankles.  Tlic  radial  was  plug;?>l 
about  an  inch  wilJi  firm  adherent  clot,  the  upper  end  only  of  whifl 
tapered  to  an  unadherent  point.  Tlic  vessel  wn*  of  twice  its  n« 
siice  in  the  mi<ldle  of  ilie  closwl  part,  and  was  thickened  by  in 
mation  of  its  outer  coats.  Tlicre  were  a  few  deposits  on  the  lir 
incmhi'uiie  of  the  heail,  on  its  ^'a]ves,  and  on  tlui  large  vewela. 

Trealnuftit.     Tlio  occlusions  of  arterial  triniks  which  are  can 
by  extcnial  c(inipre^i<in  ejui  rarely  ho  relieved.     For  intiocont 
mours  seldom  interfere  witli  the  circulation,  being  rather  themselT 
groovwl  by  an  artery  thim  compressing  it;  luid  malignant  groi 
when  they  have  readied  a  size  and  a  po»tion  in  which  they 
prwiuee  such  an  cflect,  arc  commonly  unsuiluhle  for  an  0)M;ratic 
No  special  suggestion  is  i-oquirwi   for   tlie   treatment  of  artt*i 
imjilicutfd  witii  broken  bones,  and  none  can  bo  ofivrod  for 


OCCLDSION. 


S37 


in  (xTtain  §ituations  by  tlw"  grftwlJi  of  iM>vr  Tjono  about 
fiagmoots.  Tlw!  t-Uii-l"  «tb-iili<'n  will  tKicossarily  be  cliuniutl  b^ 
manifest  omim  of  die  obetruGtion,  at  tlut  sainw  time  that  oJl  ef- 
<  niitst  btf  tliroctvcl  to  pnwvrving  thu  lifb  of  the  limb  by  wiinntli 

Hw  treatment  of  occluded  artcruw  by  an  impacted  pbig  may 
linly  U-  more  properly,  as  it  will  In"  ini>n^  inU'llif^-iitly,  con- 
if  tii«  oaosa  be  reei^ntM.'d ;  perliaps  oven  also  more  autsoess* 
hiSr  tlun  hantofbre.  To  preaen-e  tim  tetnperftturc  of  tho  limb,  to 
iiouur  tlw  eHtablisfanuMtt  of  a  c-oUatrral  circulation,  to  augment  l^ 
wiulilo  n»uri.<)iDiMit  tlm  i{uiiiitity  of  bl<Hx)  in  tliu  IkhIv,  to  rulieve 
liy  methotls  wbieb  ivill  losut  interfere  with  Uie  appetite,  ond^ 
titan  all,  to  ;*iuLr<I  tlio  wi>akttiied  limb  Irom  irritation  and 
wbidi  might  overtask  the  little  vital  jjowor  it  atill  retains, — 
tbft  imiicalions  bcforo  tlie  oocurrouoo  of  gaiigrcno.  WIk-ii  that 
bw  eommenoed,  tlie  coarse  advised  in  tho  Gt^say  on  that  aub- 
>  OUtat  bo  M]o)>t«L*  If  thu  mortiticuitiuii  advance  slowly,  iia  in 
ptagetaiBj  Sir  B.  C.  Brodie  reoommenda  the  application  of  a 
atnv  oorate  to  iJw  dlongliing  porbt,  and  tlicn  swuthing  the  entire 
ab  ior  two  or  throe  da\'s  at  a  time  in  a  very  tliiftk  Iiiver  of  cotton 
Mo  bvttor  plan  eoutd  bo  ado|itod  for  pri'wrving  warmth,  or 
;  fwtiBg  tlio  mind  of  tlio  pationt  Pi)ultici.iN  mnko  ttio  parts 
for  a  time  only,  and  must  be  frequently  reiien-ed,  whilst 
I  wool  jinMervw  tlio  limb  at  nn  «-i]u:d)1e  tcni[>ur»turv,  and  ncctU 
to  be  ilinturbed  until  tho  dlsobargeo  from  tlie  part  ri^uire 
toraL 

Tlht  udministratjon  of  opium  is  cAaontial  in  thette  on^es  on  amount 
tho  «ewri^  of  tbo  pain,  and  »omo  ]>iitionts  prctwrve  a  cloan 
■mi  a  lair  appedto  whilnt  taking  it.      Otberti,   however, 
ut  contiuoe  to  tako  it  by  the  moutli,  who  can  yet  procura  re- 
ag  aiiH  ji  and  other  benetitA  by  t)io  !iiibcutani\>u)t  injei^ion  of  a 
morplua.     Tltis  mode  of  administering  morj>hia  lia«  now  been 
luvcly  nsud  in  the  Mi<lille>«x  Ilnnpital,  not  only  in  the  cancer 
rx^l-,  Kilt  for  many  diseaMw  in  wliioli  the  strongittt  etfcct  of  tbo 
|cj  vjuiroi]  with  tliti  kiwt  piKwible  (lunntity  in  the  nyKtem.     I 

ltd  irk.l  likewise  the  injection  of  a  watery  solution  of  opium,  but 
titmoi  an  abwctw  at  Uio  ]>unctun>.      Tiio  niur|ihin  niny  be 
v«fy  many  tiroes  in  the  same  i>art  without  any  unplciLsant 

qncetion  of  i^ct  and  stimulunta  in  cases  of  gangreoie,  eepA- 


Vol.  i.  pp.  101,  l«tK. 


VOL.  lU. 


■■Mfe 


338 


DISEASES  OF  ARTERIES. 


eially  senile  gimgrcnc,  has  been  warmly  (Ii'hcussoiL     The  adrocato 
of  an  Hnimal  diet  asMirt  t]iat  any  iroatment  which  deteriorates  or 
diniiuihhes  tlio  blood  m  tho  tivstciu,  aiiil  tlicrvioro  in  Uic  limb,  is 
I>r(>iii)itly  (olluwed  by  an  extenaion  of  the  inortitlRation,  aitd  tbiit  Ibo 
patient  is  strongest,  and  consuquvntly  thu  life  remaining  in  tlio  Umb 
iH  Ix'st  miiinlaitit^d,  with  (luc-b  iiourii'hiQenl,  if  only  ita  quality  and 
amount  bo  rightly  ndnjitA^'d  to  thu  digcj^tJvo  powon  of  tbe  patient, 
and  Uio»o  {towers  bo  kept  in  proper  order.     Willi  Sir  Bonjamin 
Brodio,*  Uicv  advocate  the  administration  of  Klimulante  in  modcrato 
quantity;  tluil  Ia  to  Hay, "  any  quantity  of  uint*  tliiil  liuCH  not  owsuton 
heat  of  fikin,  nor  raiM*  tho  pul»v,  nor  miiku  tho  mouth  clammy,  nor 
roudor  the  ]iutiuiil  nervous  or  irritable,  may  lie  given  with  advantage ; 
bat  whatever  dooa  moro  tbaii  tliis  doo^  mischiof."    On  the  contrary, 
the  advocate*  of  a  very  sparing  farinm-coun  and  vegetable  diet  ui^wrt 
that  it  cht^eks  tho  gangrene,  wlnbt  an  animal  diet  and  stimolantc 
cau!*u  it  to  <;)^tGnd.      'i'bo  tlincrejiajiey  bctwoon  the  two  optiiiuna, 
which  are  hotli  entertained  by  practJcal  men,  is  probably  to  bo 
explained  by  Sir  B.  Itrcidi»'H  caution  not  being  ubs^rvi'd.     If  tlioM  • 
patients  take  opium  and  animal   food,  it  is  ea§ential  for  them  to  - 
have  a  calomel  piirgntive  every  tlin^e  or  (bur  days.     Without  mkIi  j 
a  pi-ecaution  the  stomach  may  be  disordered  and  the  g;angroM  * 
spread ;  but  both  IIkwo  cvila  are  avoidi.Kl  in  curable  ou-sea  if  tlie-^^O 
precaution  be  observed. 

It  may  bo  worth  while  to  add  a  word  on  tlie  mHhod  of  orer-  - 
eotning  the  offensive  odour  wliich  is  emitte*!  by  tho  gangrcnoo* 
parts.  Dry  powdered  cluircoal  fi'cely  s|>rinkled  auiongat  tho  colloii 
wool  intercepta  very  much  of  the  noisome  exhalation  ;  but  a  few 
scales  of  piu'c  iodine  arc  Btill  more  effective  for  the  purjKwe.  Home 
iodine,  oontained  in  chip  boxea,  and  covered  with  muslin  uiatod 
of  a  lid,  seems  to  attract  and  to  destroy  the  odorous  emanationa, 
acting  more  |)Owerfully  tlian  chlorine  or  any  other  di^iinfeotant, 
and  being  far  more  convenient  in  use.  Tlie  suggestion  vt  front 
Mr.  Hoffman,  of  Margate. 

Should  tlie  gangrenouB  limb  be  amputated?  Surreal  expe- 
rience and  I'ciisiining  both  proiiijit  it  gi^neriil  reply  in  tlie  negative^ 
In  tnany  cases,  the  obn^tnietion  of  tlie  artery  is  higher  tliau  tlio  sila 
of  the  pro]ioscd  operation,  a^  for  inslaiiec,  in  the  iliae  arteries  or 
the  aorta.  Amputation  in  such  circumstances  can  only  bo  done 
below  the  cause  of  the  gangrene,  anti  in  jtiu^  which  are  ill  snp- 
pliod  wiUi  blood.     Moreover,  if  Uie  operation  bo  performed  on  a 


«  I^clurtt  in  Palhohffy  and  tivrgcry.  p.  368. 


OCCLUSION. 


339 


MU  fa 
■Uc 


level  wiA  or  abova  the  obstrufltion,  as  when  the  popliteal  only  is 

tp'"JW^l>  it  u  ofUtn  uiwtK'w-ssful ;  thcro  rtili   riiiniiiiDi  Qw  con«li- 

iial  exliaiistion,  t!io  natural  or  the  premature  old  age,  or  the 

of  t)io  hput',  niitk-r  tlic  inHucncc  of  wliieh  the  ]>ntieiit  luis  to 

Jtr  from  tlie  shock  of  an  amputation.     And  fiirtlior,  thu  instances 

not  fi^-,  ospociailj'  amongst  tho  younfjor  isnlijo<!t»,  in  which  the 
■tortiJication  cenfies,  and  the  dead  parts  njmntanoonHly  slouch  olf. 
Exwpt  nnd(!T  itpocial  circumstances,  therefore,  ninpiitiitiou  should 
not  bo  jierfornied.  ITie  varioiiH  evenlJt  aro  illustraU'd  in  tlie  follow- 
ing two  series  of  sclucted  ca»os  ;  tlio  tirat  showing  gangrcuo  in  the 
•ged,  and  the  sopoiid  in  yonnger  Miihjoota. 

1.  Gangrene  atlaeked  the  aim  of  a  middle-agoJ  lady,  who  diod 
«xlu[i.ited  in  a  few  weeks,  before  tlie  aepKratioii  of  tlie  dead  part* 
was  complete. — A  man,  aged  seventy-two,  was  attacked  witJi  in- 
lamniation  at  tlie  IkicJc  of  tho  lofl  liaiiil,  whirh  ondi-d  in  hiaok  dry 
gangrmo.  In  bIx  months  death  had  spread,  ^ut;|llui  oaosing  pain, 
[■s  fetr  tu*  the  ollwiw ;  iukI  in  twoKo  niuiilhN  ni«iv,  tf>  tho  xhoulder. 
limh  was  linnl,  as  hinck  as  smoked  moat,  and  without  cada- 
Terotw  sm<-ll  in  uimther  month,  llie  arm  dr(ip[)cd  off  without 
kemorrliagD,  and  tho  womid  healod  without  discharge.  Tlie  man 
WM  «li*x>  anil  pntity  well  fiiur  years  atlerwanU.* — Mr.  Uutlirio 
amputated  low  in  tho  thigh  for  gangnena  senilis,  extending  to  tho 
3auK!.  Tho  femoral  artfrj'  was  plugge<i  lit  tile  groin.  The  stump 
did  not  slongh;  but  the  patient,  an  ehlerly  lady,  after  a  juytial 
■ecnvery,  «uik  exhiuwtwl  before  it  healed,  f — Mr.  Langs tafl"  ampu- 
tated a  thigh  for  mortification  of  tJie  leg  in  a  man  a^tnl  Hcventy- 
five.  All  Ihv  vcMols  wort*  ossified,  luid  eonid  not  bo  tied  so  as  to 
Wop  the  flow  of  hloo(L  TIjo  patient,  already  miii-h  exluuiftlinl,  4h'ed 
within  lwonty-io«r  hoitrs.} — Dr.  A.  P.  Thomson  i-cpoi-tod  a  case  of 

iiiBpatation  in  tiie  thigh  for  dry  gangrene  of  the  leg  in  a  womao 
■jei  sixty-five.  The  arteries  were  porvJous  to  tho  popliteal.  Tho 
IHieDt  tank  on  the  third  day. — A  man,  aged  tuiventy,  died  ae%'en 
*wlu  mflor  am]>utation  in  tlio  thigh  for  gangrunia  senilis.  It  was 
MDecMaar}-  to  tie  any  veiwel  in  the  ojioration ;  all  wi>re  already 
fkgg«d.{ — Amputation  in  another  case  was  sunived  for  a  time, 
Wlihc  M>tl  partu  took  on  no  rejiamtive  action;  they  ithrank  and 
•■ivted  from  the  end  of  the  femur,  and  the  patient  died. — Mr. 
*  AUz,  AIt«nburg,  177l!>;  quolcd  from  Mitsun  Gooil,  Mnheiiu,  1st  «(lit> 
Wl'tp.  9l». 

-  HnatMsn  MuM-um.  141.  j  Mtd.Chir.  TntM.  rol.  ti.  p.  IffS. 

I  Bwitcniui  MuKciuo,  i&H. 


340 


DISEASES  OF  ABTERIES. 


tlnmm,  of  Kseter,  smputntod  in  tliv  tiii^li  fur  Mqiilc  gnn<;TC«(>-    t%6 
operation  was  followed  by  '* constant  tremor  and  Bul>sultMs,  mutter- 
ing delirium,  and  thv  sweat  of  rultixaliou ;"  yot  tho  patient,  a  man 
of  aixty-eight,  eventually  recovered.  •■^Some  sucoe^ul  caaes  of 
ampntation  in  scnJJc  gan^^i^tnu  wltv  rolatMl  in  a  diKcusMton  at  tho 
Royal  il&lieal  and  Chirurpeal  Swietj  of  London,  in  1^53.     Mr. 
Oarlikc,  of  llicktnanswortl],  had  rotnovod  thu  thigh,  near  th«  tmiik, 
four  nionlhi*  ofWr  the  winnietinement  of  gangrene  at  die  tiie»,  the 
patient  in  tho  oourso  of  his  discasu  having  hkcwiso  euBvrMl  firom 
snppuration  in  tUa  leg  and  in  llie  kni!e-joint     Mr.  AdaniH  hnd  Mten 
a  man,  owr  sixty  yoare  of  ago,  rucuver  aiW  a  umilar  op«rs(ion. 
Such  casi^  Am,  liDwnvor,  nxtiviniJy  rare,  and  cannot  be  acc^jited 
u  ostahli&lilng  a  general  rule  of  practice.     Under  |Kx;uhar  circum- 
«t:an(!t»,  att  in  Mr.  Uarliku'tt  (Sia»,  ainputiition  may  bo  performed ; 
hut  all  thai  tho  other  cases  appear  to  show  is,  tliat  i\w  oporation- 
may  jmfuibiy  not  be  falul  in  »  fnw  iiistanouH  in  whidi  tiie  Htrcngtli. — 
of  tho  jiaticnt  is  not  much  rodnce<l,  and  tJio  gangrvno  has  existed—^ 
tor  an  untutual  leii^h  of  tinic     Tlicite,  howei'cr,  aro  just  the  fiiw  — 
ccuwB  which  may  be  capable  of  a  spontaneous  separation  of  tba^w 
dead  parltt ;  tho  grout  majority  of  ciiacs  of  ext«nuvD  senile  gwigroiM^^ 
end  ill  death,  whetlier  the  limbs  are  amputated  or  not 

2.  Two  cits«a  of  gariyreiic  of  tlio  lower  estrt'inily,  in  com 
tivdy  young  subjects,  have  recently  proved  fatal  in  tlie  Middlese; 


Hospital ;  tiie  one  under  tho  cmtc  of  IV.  Stcwun,  tlio  oiIht  of  Dr. 
Goodletlow.     The  heart,  and  the  whole  of  tho  arteries  implii 
in  its  diw^aw),  have  in  each  onso  boon  prc«»rvod  as,  one  vontinuoufl^B 
preparation,  wliich  (■xhibitA  at  a  glance  the  patholog;^-  of  the 
(jurronce :   vast  fragile  polypi  in  tho  lefl  cavStira  of  tho  heart, 
detached  fragments  of  tho  nardiatr  nias»  plugging  several  uf 
urtcrios.      In  neither  case  had  the  ideerativo  jirocww  (iwply  sovfliw^^' 
the  dead  and  living  ]>art8.— A  »eaitistn!»s,  aged  seventeen,  ill  nour—    " 
islie^l,  had  acute  spontaneous  gangrene  of  the  foot  and  tho  nlwlo^^ 
leg.     Tliere  was  im  pulMitioii  in  the  tonioral  artery.     After  ainpn-     " 
tiition,  tho  stump  and  the  groin  sloughed,  and   tho   patient  died. 
But  one  small  artery  needed  a  ligature  in  the  opcrntion,  and  the 
ilifto  artery  was  found  pluggod-f — A  native  Christian  of  Salsette, 
aged  tliirty-tive,  was  afloct^td  with  it]tontanoouA  gangniiic  of  tha 
ann,  and  in  eighteen  days  ulceration  hud  deeply  separated  tlie  dead 
and  living  parts  at  the  eibow,  and  hud  extended  along  tlie  intcgu- 


•  Jameit  on  In/lnmmaliva,  IHSS.  p.  BH. 
't  jViw  YorkJovnai,  SvpL  IBM,  cave  0l 


OCCLUSION. 


341 


I 

( 

i 


Vl«nts  half  wnv  to  tho  ehoiiMvr,     The  limt  was  xmputatMl  about 
firnr  iiuJw?*  below  the  Bhoulder-joiiit,  and  tlio  man  recovered.* — 
iljr  oolloBguo,  I>r.  S<iUi  Tlioiiip»on,  roqucstod  itiA  to  «eo  •  girl, 
of  nineteea  or  twenty  yesrii  of  a^,  ivliom  ho  Imd  admitlod  into 
tbe  Uiddhwex  Ho:s]>ital,  on  iivount  of »  disuuKu  of  Ihv  liuiirt.     ilar 
iUlKM  hod  ooiniiienoi>d  with  rlicuroati&m,  and  in  the  course  of  it 
mdtx-anliti^,  snd  fiulmo(|iicntIy  pcridtrdilin,  had  snpcnciiocl.    WImmi 
1  BrU  8UW  her,  »he  had  loud  mitral  and  aortic  murmurs,  acute 
tdbeave  itiflamination  of  thu  right  posterior  eaphvna  %'(iiii,  uid  u 
nd,  lender,  sikI  cxi^|tii»<i(ely  jiainful  flwetUng  at  the  lower  third  of 
Ibe  right  lo;^.     Tliio  inflitni?\l  [-atcb  hud  not  suppuratvtl ;  hut  the 
)NUn  in  it  was  intense,  an<l  quite  dontruyed  her  reat.     She  was  pale, 
cntaclatcd,  R^rtfiii,  and  dospondinj;.      I  made  aii  incision  intii  it, 
whioli  reliot'oil  her ;  iui<I  after  a  few  ditvt)  a  slough  of  fascia  sepa- 
rated, and  the  wound  healed  with  remarkably  lirtlo  suppuratloit, 
Inflatnmaiion  wajt  next  observiyl  in  tbe  tell  ]>osterior  saptionoua 
rVein.     iVnasarca  followed,  not  only  in  the  loll  log,  but  also  iu  the 
ight ;  nii<!  Ilie  fiuiv  lioiMune  putfy.     Alter  a  fortjiight  of  great  pain 
tod  much  general  depression,  the  lelt  foot  aiid  teg  became  cold  and 
diwkv,  iiiul  ttie  end:*  of  the  tiK^^  nhrivt'Ded  ;iiiil  turned  hliiclc     Com- 
plete  gangrene  of  the  lower  half  or  two-tliirds  of  the  leg  eneuud, 
ind  a  line  of  deinaix^atjim  forniwl,  and  doe]>ttned  tlay  by  day.     At 
kogth,  when  nothing  remained  to  divide  bnt  the  bones  and  a  part 
^•ftho  tfjidon  of  the  giuitrciencniiu:<,  I  tu'ptiriited  them,  and  removed 
tbe  fnetid  limb.     Tbe  stump  had  neai-ly  hoalod  when  she  left  tlie 
iMkfptta]. — -A  gjuiprenous  K'jj  wiw  reiiiovetl  by  aiiipiitut.ion  in  tliO 
thigh  from  a  puerperal  woman,  aged  twenty-five.     Not  a  <irop  of 
fcLuil  flowwl  at  tbo  oiwratioii,  and  tlio  patient  died  tlie  next  day. 
In  another  |>atient,  aged  thirtj'-nino,  gangrene  of  tlio  foot  took 
fJaco  after  [Kirturition,  tlio  thij;''  wiw  lunptitaiiHl  tliree  months  after 
tkr  deliven-,  and   the  patient  reoovored.t — A  man,  agcxl  thirty, 
nftrod  an  "  q>ideuiie  mtiligimnt  fevw,"  which  brought  on  a  mor- 
tiflation  of  die  left  foot.     '\\niGn  idceration  was  going  on  about 
Wo  inclics  above   tho  luikle,  tbo   leg  w(ia  amputjileil  hetow  tlie 
bet   No  blood  flowed  in  the  operation ;  but  the  stump  suppurated 
Mtlu'Ir,  and  Uie  man  got  wclLf 


*  nimt«Tian  MnMium.  2^tl.^. 

t  SiK^taon't  OUutrk  ittmoirt,  editod  b]rDr».Priestlejauil  Stoter,  toLU. 
'  pp.  4B.  IT.  cases  3:1,  2i. 

:  ittJioal  Obtermtiotu  and  Inquiriet,  1764,  vol.  ii.  p.  193. 


342 


DISEASES  OF  AKTERIES. 


Arteritis. 

IiiflunmnLion  of  the   aorU  a]))>oant  to  hare  occunvl   tn 
practice  of  some  pln-siciaoB,  and  to  have  been  trac«ahle  to  tW  » 
6uenco  of  txild.     Oiio  Kiich  Sn»t(uioo  ni«ntJuiH><l  to  me  hy  mr 
leogue,  Dr.  GoodfeUow,  followed  upon  a  young  man's  lying  fi>r 
long  time  ii[»oii  h'm  oheM  on  wet  gnumd.     But  the  «w^  for 
deneribed  by  Surgeons  aa  primarv  inflammation  of  arteries  apix 
by  tho  li^jht  of  Inter  rntcnrdi,  to  have  been  due  to  tlio  iiruvifma 
paction  of  a  plug,  and  the  foreible  diatenston  of  the  >««el  as 
plug  wax  ilrivvii  ftirliier  and  liirthcr  along  the  tube.     ]nfliuiu 
of  on  artery,  and  even  suppuration,  may  then  lake  plaeo,  mb 
been  do«eriliod  in  the  pn-vious  soetiun  of  this  essay.      UfMHi 
eases  in  which  long  ]H>rt.ion!i  of  itrter^*  itre  found  oUitented 
oonrortud  into  fibrous  conU,  no  liirther  observation  needs  to 
oiTcred  than  that  no  evidence  of  any  ]>r«vio(u  arteritis  i$  eren  i 
dueud,  and  that  tlto  mmo  reealt  sometimes  foUovrs  tlw  ^>pli< 
of  a  ligature;. 

CHARLES  n.  MOORE. 


PATHOLOGY  OF  ANEURISM.  343 


ANEURISM. 

pATHOLOOr. 

As  EDcamm  is  defined  to  be  a  titniour  containing  blood,  and  onra- 
ODni'cating  with  the  ovity  of  an  artery.  Tluia  in  vrvt'ty  aneurUm 
t«re  are  two  partA  to  be  conHiil«red,  the  sac"  and  it*  contcnta. 
The  tac  is  formed  either  by  tho  vessel  iteolf,  diliiU'd  from  disease, 
<Tby  tho  condensed  soft  piirts  in  the  rieiglibourhood. 
I  The  varioiL*  vIiL^ilicstionH  of  anourisnt  now  id  coniiiKHi  use  are 
fmtt\  upon  varieties  in  iho  oimtoniy  of  iho  &ai>.  The  most  natural 
■Mimcnrlutiirr!  aj)|icars  to  mo  to  be  that  which  cdU  ui  aneurism 
kbraml  by  the  coats  (one  or  mure)  of  the  artery  a  tmo  ancuriKm, 
I  lid  <nie  Ibrnicd  by  tho  Borrounding  cellular  tissue  a  t'&Ue  aneurism. 
Inrartanati^ly  the  term  *  true  uiiotu-iitin'  ivai*  applied  by  the  oldoT 
intlMm  to  a  Hinumr  in  wliicli  all  the  coats  of  the  vcsnd  wcri'  dilated, 
*IqIo  they  called  one  in  whicli  only  one  of  tlie  caaia  formed  ihe  aao 
*>&1m  aneurisiD  i'  awry  inappropriate  name,  inasmuch  a»  vuoh 
iratiuQs  form  tlie  majority  of  those  met  with  in  practice,  while 
Bitann  'fidso'  up])car8  to  convey  ilio  idea  of  something  csocptional 
*>J  peeatiar.  It  h  undesirable  to  complicate  the  matter  still  further 
I  7 1^  att4!mpt  to  introduce  li'csli  terms.  I  slinll  therefore  sdlioro 
'•flw  old  nomenclature  in  spite  of  iriy  opinion  nf  iLn  incorroolneas ; 
■Wfly  observing  tJiat  these  anatomical  refinements  are  of  veiy  littlo 
B^ortancc  in  praolice ;  iJmt  no  one  troubles  himself  as  to  how  many 
MCa  uf  tlic  artery  enter  into  the  formation  of  a  sac,  or  lia.f  any 
■tan  of  forming  an  opinion  on  the  jioiut  before  dissection.  But 
tua  matter  of  great  import.iucio  whether  the  blood  is  contJiiiit;d  in 
^  uc  or  no,  wlietber  ihat  sue  ih  or  ).i  not  jK-rfect,  and  wliether  the 
"■nrinn  is  of  spontaneous  or  traumatic  origin. 

The  term  *  ditfuM-d  nriouriKni'  iit  itlno,  I  must  confe«a,  on  in- 
l^iriate  one  as  u«od  to  describe  a  tumour  in  which  tlio  »ae  is 
"nnod  out  of  the  cellular  iii<niic;  aince  such  a  tumour  is  as  distinet 
*oi  drcumscribod  as  if  the  sao  were  formed  by  tlio  vessel  itself; 
'  '^  Mcordingly  in  many  workn  an  aneurism  is  said  to  be  difliiaed 
*■»  t}|o  sac  lias  given  way.  But  such  an  affection  is  equally  well 
*  Letter  deacribed  a.s  '  a  ruptured  aneurism.*     Tlie  term  '  diffused^' 


*  Soma  authors  vjimk  of  Rxlraviunlionn  of  bloud  iimong  tfai'  tissues  of  a 
,  ^^bUBlllo  Riving  wuy  of  an  lutciy,  h*  'dimiscU  niieuiistiiB ;'  but  ttiis 

Sto  me  an  *iTor.   I  stiould  terra  this  Icaioii  •  a  rupturei]  aitcij.'  The 
M.  as  1  bopo  to  show,  is  not  n  tiiviol  one. 


Hi 


DISEASES  OF  ARTERIES. 


at  nny  rate,  senses  to  remind  iii*  tlmt  (iw  blood  wM  onoo 
unong  tile  noighbouring  parts,  tbongh  it  is  now  encrsted ;  but  as 
is  liiible  U>  bt>  (^[ifVi.tcd  witli  the  mnw  term  as  nitcd  by  otlK-r  autlwx 
io  designate  oxtravasationa  from  rupture,  I  shall  prefer  to  use  B 
t)ie  svjiiul  tliii  nttiu»  '  vonK-cutivtf  iuieun«in'  for  nui'li  aneiiriKins  ■ 
have  the  sac  formed  out  of  the  tissues  external  to  the  vessel  ■ 
onli-r  lUH  tar  11.1  jmssiblo  to  nvoid  lunbigtittics,  a  tiblc  is  subjoinc« 
fthowing  the  nomenclature  adopted  in  this  essay,  as  i^ntrasled  wiB 
that  hitherto  common  in  Fraiiec  and  England  i  M.  Broca's  trcatin 
being  used  as  an  example  of  rbe  former,  and  the  olmpter  on  Ana 
ourism  in  Mr.  Erichscn's  Scieace  mtd  Art  0/  Surgery  for  the 
(See  the  Table  opposite.) 

Tho  kin<Is  of  anouri&m  to  Tjo  dMcribcd  below  are  as  follows : 
1.  Common  or  encj'st*(l  aiioiirisni,  Aubdiviili-d  into 

(a)  Fnsifonn  aneurism,  or  ancurismal  dilatation. 

(fi)  IViie  iiTii'iiHsm. 

(f)  False  aneuri»<m. 

((/)  Conwecutivo  or  diSuswl  anfluri^n. 


2. 


ArtCT-in -venous  aiieuriam,  subdivided  mto  x-aricose  ane 


(uid  iinpnri»mal  varlx. 

3.  C^rs<riil  nnfiurism,  sometimes  ealled  arterial  vsrix.    Anenris 
\>j  anastomosis  nnll  also  bo  considered  undur  this  head. 

4.  Dissecting  aueuriitin. 


I 


1.  By  common  or  ennyst«(]  anflnrtftm  \n  mmnt  tltat  vuntkv 
tlie  disease,  embracing  by  far  the  greater  number  of  cases,  in  wliic^ 
the  tumour  is  formed  of  a  single  cj-st,  eonm»ini(yitft»  only  with 
ningle  artery,  and  is  limited  to  a  single  pomt  of  the  course  of  llu* 
artorj'.  Some  of  tho  BulMiivij^ion*  of  this  affection  ar«  pnctkalTj 
very  different  from  each  other,  while  between  others  the  difTercne" 
is  unimportant,  and  in  fact  usually  inappreciable  during  life. 

In  the  nnnirvinial  dilalntUm,  or  fnirifimii  iineurum,  the  whole  cir- 
comforenee  of  the  arterj"  haa  yielded  to  the  forc«  of  the  circnUtiod 
for  some  con«i<l(!nible  length  of  the  vessel,  and  so  a  tumour  Ini 
been  dovelopetl,  of  an  elongated  or  somewhat  cj'liudrJcal  shape,  cod- 
tinuous  with  tho  cavity  of  tlie  artery  at  each  end.  The  ooat«  of  the 
vessel  are  generally  much  thinned  and  highly  atboromatoos.  Thi» 
form  of  aneurism  hardly  ever  contains  much  clot.  Il  is  of  more 
common  occurrence  in  lh«  aorta,  but  rare  in  the  arteries  of  tho 
limbs ;  tlic  most  usual  situations  below  tho  aorta  lidng  titu  ini)0> 
tninate,  the  top  of  the  comuion  carotid,  and  the  inguinal  portion  ol 
tho  external  iliac  and  femoral  (p.  328).     Some  authors  supamtc  tb« 


J 


PATHOLOGY  OF  AJfEURISM. 


MS 


tarn  ouD  IS  ran  B>ut. 


X.  Oomnao  or  snoyaMd  uiaur- 


T^B  tumniir  (orninc  a  niutl" 
Mr.  oomBranioiitiDg  «iiA  * 
riliiil*  urtdry  M  k  itoglo 
peM. 

!■)  Atxorteiul  41biUlion  or 
ftaiCMiD  WMrarixu.  Hi* 
«M  bnnad  bjr  all  thra* 
OMU  of  Iho  irUry  iliUt- 
•d  owar  a  mat  »(eirt. 

famed  In:  "ll  ^^  cuaM 
«f  tlw  uurr  diUtcd  M 
«al7  one  paint. 

(4  Mi*  Mnurtiui.  Tb*  MO 
fcnnad  by  ealyom  of  Uk> 
teou  of  tho  Hrtflry. 

(rf)  CanMfutini  or  JilT<unl 
•sewuni.  All  the  coal* 
oftbo  T«ml  tan  alvait 
*mx,  uul  Uw  Mc  b  turm- 
•d  out  of  tbo  uaglibof^ 


fl.  Aitwio-TMHnw       wiovritn, 

bnosl  by  ■  dirtct  or  In. 

dinct    oeaniimSealluii    b*- 

Worn  «B  MtCfT  uid  *  *•'"• 

Mtttrliiaiu: 

(■)  AatonWMl  Tsrii ;  in 
«hlob  tba  oommtinim- 
liea  iadlract.  uuliunour 
totneAnwd. 
(l)VuieDMaMwlan;  whorv 
Uio  oomMonkAUoii  b«- 
VrtBB  ih«  T*in  nod  ar- 
Mrr  I*  ikroagh  tho  In- 
itloa  of  a  toouur. 


1       tU  MBTotaUoiu  of  B  linKU 

ENaaHltiff  wioDrinn  ;  an 
•fcnka  vt  Ih*  rM*al  oec*. 
iteatd  bj  akendon  of  iu 
^big  MiiubrMto.  uid  *0u- 
*»  qf  blood  bolBora  Itao 


BBiOC*. 


Cimunionb«il  uoariHk 


Thi*  In  (ivIiuUkI    [njRI   Br»oa'i 


TWa  ftuouriioii. 


Uliod  oxtonHkl  uuurtan  ;  pibdi- 
Tiilixl  IqM  om^orn.  /iv/orta, 
HO'l  di$tttrittff. 

¥*itf,  at  •Doyitod  uwnruis: 
•uMirided  Inia  primlUve  tad 
ooimoRurv. 

Cr*ta«oii>«  uioniinn ;  (brmnl  bf 
aeyit  doralopad  io  tli«  Ihlck- 
oata  of  the  iritlU  of  tbo  reanl, 
•od  ■ftorvtird*  iwmiiiunUsUufc 
•ilh  iu  miily.  Tliin  ■•  sot  to- 
cognuni  m  Qithot  of  th«  othor 
cluMlflcntMoo, 

ArUrio-TMMU*  Mumiliiii. 


AneuHnanI    tMix,   or    dapla 

t>bLubortary. 


VarlooM  Bnourimn.  Two  fortni 
d«<ior>K^i) ;  tli4i  ona  in  trliiiib 
tho  tuiQour  it  toTtitvii  by  4  di- 
Intali.m  of  tho  vein  (rnrtooie 
AUourittn  by  ililiLtntlanJ ;  thu 
oUmr  kix  whiQli  the  vw  ia  n  dqw 
fonWioii — oiie^nUd  <>r  tiUw 
ao(M(Oati*o  TkriooM  uiuurumi. 

AiWUtwiK. 


UfaKottn^  uienriim,  Mrn*li|(<r«d 
bj  HriKiii  M  *  itrioly  of  hitc 
MWUriank 

BroM  dcocrfbc*  two  klndj  of 
'  diffntd'  kDOuriim.  by  which 
b*  KKBDs  UMUiimw  wlthnul  n 
BU.  Thii,  aoondlag  to  qb.  Ii  a 
coDtnwIioliciA  i"  luiioM.  Hri>oa*a 
ftrtt  fimn  *■?  diffiH*-!  njviirwin 
ii  iIiwcritit-1  !□  [bii  woFk  u 
'rai'lnni  n(  nn  artory;'  lii«  •»• 
Bond  M  'ruiilura  ofm  uioar- 
lioi.' 


EwoBKur. 


I^ulform  or  tubu- 
W  linHurihni. 


Truo     MOdulstod 
aumlrjaii. 


UreumMrlbodhlM 
McculaUd  ausor- 
turn. 

Dlffiuod  Ummo- 
oulatcd  aoour- 
iarn,  undor  wbhik 
b>  alw  inolndM 
etimnuotiona 
■itbout  a  ■u— 
our  ntjiturvd  xa- 
oartBD  or  rii|>- 
turvd  utor;. 


Anaoiumd  mix. 


Utu. 


AnorialruU. 


Dlq«tinK  iiDeitr- 
lam. 

Tbo  ««m«  tvDIBfk 
applko  to  bjoh' 
ii«a*fl 

two. 


JU8 


DISEASES  OP  ARTKRIE& 


anotirisimal  (li1ntnti»ii  <riitjre!y  frum  tins  natpyory  of  jmnirisms,  an3 
treat  of  it  as  s  distinct  disease ;   but  no  patliologica]  distuurtia 
can  bo  mail*  liotwtH'tn  this  and  otlior  lorms  of  diluted  art«ry  whic 
would  not  be  subjoot  to  cndloBs  exceptions  and  mod ifieat ions,  an 
in  [miutiou  tliid  iLtiectiun  i»  otluu  indutiDguLshablti  troin  tliu 
anonrisni.* 

True  unt^urixm  is  dcfinoil  to  be  a  circumscribod  dilatntinn  of) 
artery  in  a  part  only  of  its  rireurafereiioe,  in  which  all  Uu'ee  coa 
ufttw  vessel  arc  dilat«d  to  form  the  sac,  wbilu  iu  a  (so-eaJktl)  _/ii/l 
aneurism  the  two  internal  ooatt  btivo  given  vray  and  disajipea 
und  the  sac  is  formed  only  by  the  oxt«mal,  or  <.-elluIar,  <XNit. 
tme  an«uri«in,  like  the  aueiiriHniol  <liliit»tion,  of  which  it  may 
r^anlod  US  a  variety,  is  much  more  common  in  tho  aorta  than  in" 
any  oilier  ve^-tsol ;  so  niiioh  tiior^t  luj  Uiat  yoar]>a  denied  thai  true 
aiictirism  exists  in  any  other  artety.  It  is  diflicult,  however,  to 
refusa  <"jredi>n(*  U>  tho  tnimin-ouN  aulhoritii'S  who  have  described  the 
dissection  of  small  incipient  true  anem'isnis  in  which  tlic  semn] 
ooafii  could  bft  actually  demonstrat^Hl ;  but  al  a  later  period  they 
bocome  consolidated  together  at  Uie  neck  of  the  sac,  and  the  intenitl 
layerH  caiuiot  bo  followt-d  further,  having  Ik'i'u  worn  off  by  frietioa, 
if  they  were  ever  present :  at  tins  period,  therefore,  there  is  no 
•])pns"iable  difti-renott  iMitww^n  one  auenrisni  niiil  another  «.*  to  their 
mode  of  formation.  Even  if  the  two  internal  coats  can  be  followfd 
f(>r  some  little  ih'stancM)  beyond  tlio  ojK-ning  into  tho  anciiriNni,  ttiii 
does  not  prove  that  it  is  a  true  aneurism,  since  the  part  of  th«  in- 
tt^iriial  coats  which  can  Ik;  traci^J  may  be  merely  that  whicli  i»-ould 
have  lined  the  opening,  and  which  has  now  been  everted  into  tin 
sue,  Tlip  jireaeiicc  of  a  smooth,  shining  membrane  lining  the  >^i 
ift  no  proof  that  the  tumour  is  a  true  aneurism,  since  such  pwadoj 
cpitJieJial  InmiuK  are  very  often  found  in  new  formations,! 


*  Soitio  amount  of  dilatallun,  associated  usuftllj-  witli  ntlicroiuii,  i***"] 
stantly  met  with  in  the  arteries  ofpei'sons  advanced  in  liTi^ ;  but  ihUlianilfT 
cunetitutes  a  tumour,  nnd  no  does  net  deserve  the  munn  luieiirismfll.  TUI 
ai leries hUu  buooiue  toituoue  us  well  as  dilated  in  elder!;'  persons  erroiuN  I 
flints,  aiid  it  seems,  from  the  aci'ouulof  a  prepsration  hy  Mr.  Coultoo  (/'■■'^l 
Haa.  Ttant.  vol.  iil.  p.  UU2),  tliut  LliU  condition  sometimes  siinuUua  i 
H]itMiriiitiial  tumour.  Thu  pnticnt  was  u  wotniui  a};«d  1^4,  who  for  senile  i 
bi^fore  livr  ili-utk  hail  hiid  n  pulsating  tumour,  tlie  sixe  of  an  oisiige,  jv 
aljovt'  tilt-  riRht  daviuk.  in  tliu  situation  of  l.iie  iiirottd.  ll  had  been  ' 
to  liu  ant'urinniul,  but  mx  diasedion  it  wns  found  tliai  ■'  llie  r*«!wU  shmn 
from  thi^  uoi'lu  wci'i!  f  longnted.  nnd  coitnidombl)'  ililuti.>d ;  and  t)i«  tumo 
coiiKistccI  of  n  rcduplioutioii  of  the  coinmoo  ciu'otid  and  of  indunil«d  i 
tissue  around  it." 

f  See  Prcsoott  Uevretl,  in  Jtfft/.-CAir.  Trmi.  vol  xxix.  p.  BO.   j 


I^= 


PATHOIXJOY  OF  AXEUKI8M. 


347 


'.  ptrtxnliu-ly  vrhorc  cuiiRtant  motion  hits  been  taking  plaro.  Ro  that 
liiis  bapoesible  to  |)ercc)v«  niiy  ilitroroitiv  tKdwix-n  tiiio  luid  fiiLw 
Mrarisms  at  llio  tiino  at  which  they  generally  come  under  obser- 
nliaii;  and  it  It  not  n-urth  n-hil«  to  my  moru  i>n  t)ic  Hiiliji-nt,  tH-yond 
Ming  that  the  true  be^^ome  false  as  they  grow  ;  and  expressing  an 
ifinion,  fouiidtnl  dm  lbi)  inannvr  of  tJivir  origin,  Unit  (iil.-«e  acuinrisms 
in  far  the  must  common. 

Anotht'r  fiimi   of  ful*K  nneuriiim   »  describod  by  autbon*  of 

tniit,  and  must  tlicrefore  be  notjoed  here,  although  its  reality  is 

[iMbdiii.      It  in  siiim-tinic\<  valldl  '  hi-niiur  nii<>itnMn,  and  Uitt  Wio 

r%t>nned  by  a  projociion,  or  liemia,  of  the  two  inner  eonts,  or  some 

intion  of  iheni,  llirou^b  a  ront  or  an  ulc*rat«*l  oiwuiiiK  i"  th* 

itHtrmi  tunic.     Whether  the  cases  wbreh  have  been  put  on  record 

Uy  prove  iln>  vxiitteiico  of  this  affection,  mtist  bi;  loft  to  tlio 

IMder  to  decide  for  hiniM^lf.     It  is  a  [joint  rather  of  curiosity  tlian 

^if  practical  intnrcsct.* 

The  otber  form  of  oncj'itted  anfiiiriMn  is  the  coinetutire  or  di/~ 
[Jiwf,  in  which  all  the  coats  of  tlio  artery  (or,  as  frequently  bapjwus, 
ItiKiaeof  a  previou.4  aneurinni)  hiivo  given  way,  and  llie  blood  is 
[ifawl  into  tlio  oellalar  tis§ne.  The  latter  soon  becomes  oondcnKod, 
|iiil  forms,  with  the  mueclov,  ligunit^tntit,  viiic»ra,  or  boneii  in  tlia 
^bbonriiood,  a  sac  for  the  blood,  Irequently  distingnished  from 
l^mt  of  the  previon*  varieties  by  licing  miiltilocnlar.  The  great 
rity  of  aneurisms  are,  if  the  terms  be  strictly  construed,  of  tbo 
[tUMontive  form;  sinw;  few  tumours  of  long  ittamliug  will  he  found 
luvliicb  some  part,  at  any  rate,  of  the  sac  has  not  been  borrowed 
[fcom  nuToimding  tissues.  I  would  wish,  at  tJie  risk  of  U'iiig  accused 
FRfiotition,  again  to  remind  the  reader  that  t!ie  term  '(h'ffused 
is  very  often  applied  to  a  mptured  nuciirimn,  and  even 
flo  a  ruptured  arterp,  Lf.  to  cases  in  which  the  hlood  is  poured  out 
lUdo  the  cellular  tiiHute,  and  infiltnitcs  a  great  part  of  the  limb  with- 
in! the  formation  of  any  «ac.  But  I  tliink  that  I  shall  Iw  ablo  to 
rMUKiiiH  fi>r  (laying  that  it  is  more  correct,  and  is  of  conaider- 
[4b  fraotical  importanoe,  to  aeparuto  tbcjae  cases  altogotlior  from 


tllicre  is  a  pr«pantimi  in  the  museum  of  the  College  of  Surgeons 
to  abvw  this  form  of  aneurism.  Mr.  Erich^o,  huwevor,  reports, 
Inaull  ofhia  Mniuiiuitiuii  of  Uiis  spvuimeii,  Uiut  li«  believes  tlio  ox- 
l«Mt  not  to  have  be«n  origiiiutly  UHiciirul,  but  to  huT«  beeu  itivst-ctiid 
doftri  Smrpeal  Diet..  &tli  vUition.  1801.  p.  140;  ami  in  litis  opuiioa  I 
I  concur.  Tli«  lino  at  wliich  the  cxtcmul  coal  linn  buvn  axt  nwaj',  is 
'  market)  nil  munil  th«  neck  of  tlic  boc.  M.  Itrucu  exprassoa  Ilia 
riu  tb«  reality  of  iliia  tifl'^t^lloa. 


M6 


DISEASES  OF  ARTERIES 


oaaeo  of  nnciiriHin  ])n>pei'Iy  sm   called,  and  to  limit  tliat  term 
tomoars  provided  witli  a  ku^ 

Such  are  the  vurielJca  ofcAiiiinoii  luieurlftin,  clnmtfiiHl  nccardijl 
to  the  anatomy  of  iho  sac  Otlier  priiici|>l(!8  of  claAsi  float  ion  hav^ 
\if!en  ]ir<>|iii!>cd.  T)iii»,  tK>nie  ^jllrgootu(  prnfitr  dividing;  m»>iiri»ini>, 
WMMrtliiig  to  tlieir  form,  into  tubular,  sacculated,  and  disabling ;' 
tuul  ffOt|ui.iiit]v  uiikuHmii*  itro  iiiiini!(I,  Mi'Oonlii)^  to  their  cnusu,  tmi' 
matic  or  spontaneous.  Each  metliod  of  classification  is  occasioaal^ 
useful;  but  lli«  u]i»t»uiicttl  wrrnugoinctnt  i»m<wt  gcuvrnlly  aUoptai 

Ctuuet  ofanevri»m.  In  general  terms  it  may  he  Miid  tltal  anr 
thing  may  be  a  cauw  of  iinuuri.-*ii)  which  dvotroyit  tho  htthuicit  ilml 
ought  to  exist  between  the  expansive  tbrce  of  tlie  circiilalion  nuJ 
Uiu  n.>aoti<jii  of  tho  wall  of  the  artery,  ko  an  to  make  the  former  pi»' 
ponderate.  But  none  of  the  ordinary  evttnt^  whioh  are  looked  Dp 
M  uxeiting  causes  of  tho  dir>ea«c,  can  produeu  it  witliout  a 
posing  cause  in  the  condition  of  the  artery  itself.  This  condition  i 
in  tile  great  miyority  of  cusca,  tho  result  of  atlterotna ;  hut  on  du 
state  of  the  arteries  enough  has  already  boon  »iud,  and  tho  reader  i 
referred  to  tho  previous  section.  Any  other  cause  which  produo 
a  partial  atrophy  of  tlie  artery  renderii  it  Ititblo  to  diliit)iti'>u  at  I 
atrophied  part:  Vidalf  reuinrks  that  the  accid^'Utal  exposure 
an  artery  which  ought  to  bo  rloop  KoHtiid  may  induce  hticuH^ 
both  by  wcakcniug  tlio  coats  of  the  vessel,  and  by  depriving  it 
the  support  of  the  Aoft.  partA.  Uiiiuilurul  and  tong-uontinuod  pr 
suro  may  produce  tho  samo  effect  Thus,  a  case  is  recorded 
wliich  till!  pFcssuro  of  an  exoHlJtniit  priHiiiced  u)iuurism>t  1'he 
quent  ofcurreuce  of  aneurisms  in  both  popliteal  arterieti  atrikii 
proves  tlie  origin  iif  the  afli5(;lion  in  diwoaw)  of  tho  arterial  Bjittewl 
the  same  thing  is  even  more  strongly  shown  by  a  case  •nMvk  i 
reooi'ded  of  the  formiition  of  a  jHipliloiLl  ancnriNiii  in  one  ham,  i*I> 
the  man  was  in  bed  fur  tlio  treatment  of  an  aneurism  in  tlx! 
aite  hum.  In  ext«nsive  disease  of  the  arteries,  a  great  numW< 
aneurisms  may  form,  oonatitnting  what  is  called  tlie  ' ' 
diathesis. '§ 


■    «  Luke,  in  iMiut.  Med.  Oat.,  May  Q,  18ll>;  Ericbaea.  in  Cbopt/i  Sit 
BhHomry,  8th  edit. 

f  Traiti  lU  i'MkoL  «xUnt,  ISAI,  voL  L  p.  tM.    Th«  inotoruN)  whioli  1 
givca  is  oni'  of  cxjitumrn  of  the  fcinoiiil  •rtory  in  lto<i}iital  gangrene. 

I  Boux.  Quarante  Amitei,  Ac.  vol.  li.  p.  ISl. 

\  BrucA  {iie»  .AaeKritme*  ft  de  lair  Traittm^at,  p.  K)  iniilaiiace, 
Atlier  auui  nf  multiple  nncunsins.  ona  ander  th«  oai*  of  PdUelan.  in  i 
tixtj'tliMe  wara  found  in  the  same  body. 


CAUSES  OP  ANEURISM. 


MO 


;  oA«n  hftppeos,  bon-cvcr,  that  aneurisms  aro  found  in  art(iri«8 

appear  benJtby  in  aJI  otiier  paHa  of  Uioir  coumo  ;   and  tbia 

I  to  bo  more  frvqiuMitly  tbo  caso  thv  tartlicr  the  disease  in  from 

llieart.     In  thx-ae.  ousca  the  nntiire  of  thv  i>i-i.H|i^><j;>iiig  cause  is 

It  has  bcvD  alleged  that  mercury  and  syphilis  predJiipotic 

iinam;  but  liifi  aMsortiou  nppoiLn  grutnitiinis.     Tiw  iibuso  of 

qiirits  ia  certainly  an  exciting  cause,  and  may  possibly  pro- 

totno  wwikiH-ss  of  tho  vwwel.*,  k»  ok  to  oiitill*'  iiB  to  consider 

as  a  predisposing  cause     It  is  worthy  of  notice  tliat  the 

aInioMt  miktmnri  tii  v»rly  Itfe;*  tliiit  oxtt^iiil  anctinsma 

aoMinsiDs  of  tlie  linibd)  are  *ery  mre  among  wonien^  «*]ieoi- 

in  ihii  bigltL-r  ratiks  of  Ulv ;  and  tliat  siidi  an«tiri.snis  aro  found 

commonly  upon  those  arteries  which  are  moat  afleclcd  by 

urcmpnts  of  tJio  joints ;  while  aneurisms  gcncraUj  aro  most 

at  thoM  jiointji  whure  the  flexure,  or  liie  cliviAton  of  a  large 

f,  oppoaea  iome  sort  of  check  to  tho  blood-stream.     Tlie  arch 

aofta,  n^ocudly  at  tlie  dilute<l  [)ortion  vallM  llio  '  sinua 

I,*  and  at  tbe  transreme  bend,  is  the  most  familiar  example  of 

I  owurring  at  Uic  flesure  of  an  artcrj- ;  whil«  tlm  dilatation 

l«ndof  the  common  carotid,  tbe  common  aneurism  of  tJie  lower 

taf  the  popliteal,  Bn<I  tlie  tuinourv  which  aSisct  tbo  caliae  axis 

I  ahdum^ial  aorta  iiaually  ut  tho  root  of  one  of  its  brunobot>,  wtU 

tbe  effect  of  division.     The  aorta,  popliteal,  and  axillary 

moU  liable  to  diM^aw,  m  Iwing  the  ino»t  constantly 

to  stretchiug,  and  the  two  latter  to  forcible  ru|>tiire.     Tbo 

impuhui  of  tlie  blood*«tmun  against  the  areb  iniint  kocp 

'  port  of  tbo  aorta  in  more  active  motion  than  any  oUier 

1  of  ib«'  siturial  ifystwni.     TI>c  influwiot  of  forcibln  motion  on  tbo 

artery  is  slwwn  by  an  experiment  of  l{icherand.|     On  a 

subJMTt  let  tlto  bon<!e  of  the  extviidud  leg  be  fbrcihly  drii'eB 

into  liie  bum  till  tbo  ligaments   are  heard  to  crat^k.     TliO 

I  A  r«w  OUM  an,  howcn'cr,  on  record.    Mr.  Huicliinson  found  an 
B>]  carltjr  oonnocb^  with  th«  aorta  if  n  cliilil  four  yean  of  Ngc, 
I  be  wi>i  icicliiii-J  lo  attribata  lo  the  uloorotion  nf n  tubcrculoiiK  nbsotaa 
'  virTy{Patk.  Sot.  7Vmn«.  vol.  ».  p.  104).    Mr.  Symohiiii  opemted  for 
<  M  tb*  age  of  nliie  {Lomt.  rmJ  EJinh.  3f«n(AIy  Journ.  1''44) ;  and  a 
'  rufituTV  of  tbe  a»ria  in  ■  ohilil  att.  seven  uud  n  Imlf  yonr*.  probably 
ilrd  lijr  thi*  fuTTDation  of  a  smiUl  aneurism,  is  rocordad  b;  Dr.  Amil- 
EWi.  S«e.  Tnt»».  Ti>1.  ix.  p.  M). 

f.  Okir.  roL  iv.  p.  13.    Hod^sou  on  DUrairt  of  the  Ariftin  anil  Vtint, 

p.  (U.    Id  nipratiiifT  this  «xperiiu«ii[.  I  have  found  Ibat  this  i^only 

nnallv  liuc.    I  bavo  MmivtimM  found  tlto  artery  entire;  and  on  ona 

Uw  MUanial  coat  wiu  •omowhat  la«eml«d,  while  the  others  ro- 

mtira. 


350 


DISEASES  OF  ARTERIES. 


middle  and  int(^m>il  conta  of  tlx^  [>»))iit)'a1  iirtcry  will  bo  fotinc 
It  in  trill!  that  the  accidenta  4?otuiuauU'  oiled  oa  haumis  nl'  mi  curt  mi  n 
are  not  so  bovctc  at  this  rough  prowxxling;   but  slighter  injury 
to  llio  iLrtcrr  probably  oocum,  and  lava  thd  foundation  for  Hnb- 
eequeiit  diktation.     A^id,  tbu  honrt  is  oBvn  h_vpertrophi«d,  as 
the  ooiL^oqiieiioo  eltlier  of  diaeaae  or  of  tlio  huhiM  uf  life  of  titfi 
patient ;  and  wlicro  tlio  artery  is  wcakciiLvl  by  any  of  tbe  aboni 
causes,   it   i.'Jiti   no  longer  re$>i»t   tlie  inoreuAcd   ini]:>iilM\      Ucnoe 
aneurism  U  r*gardod,  witli  at  any  rate  much  probability,  as  a 
moclmiiicul  cfFccl  of  llio  weai-ing  out  of  lli«  artt-ry  hy  nxs ;  Uie 
circular  muscular  libroi  which  c-onstitutu  the  strongest  [jurt.  of  ilic 
■wall  of  the  viwsi'l  Ixiing,  ii«*'ording  to  this  theory,  ctrwtfhcd,  aud 
partially  separated.     Tiie  fact  tliat  anciu"isra  affec-ts  the  syslemio 
artcrici*  only,  i.f.  only  tliofw  vottswlit  which  vonvry  timI  blood,  has  W_ 
»ii>ino  autJiora  to  believe  that  the  formation  of  these  tumours 
depend,  in  »omo  unknown  innnnor,  tijion  thu  ijuality  of  the  bL 
coni'ojed  by  tlio   artery.     With  our   pi-esent  knowledge  of 
chemiHtr)',  it  woiikl  be  alMurd  oven  to  affect  to  give  an  opin 
upon  tlie  posaibiUty  of  Uiia.      It  seems  quit«  sutticient   to  MaB^ 
thai  tliii  jjnhnoniiry  system  Rwcivci*  the  force  of  tiio  right  ven- 
tricle only,  which   ia   seldom   liyperti'ophied,   and   whieh,   at  it* 
etrongr»t,  is  pcrhapH  incsipable  of  ^-Duniting  the  expansive  fiiroe 
neceaaiiry  to  produce  aneurism.*     In  some  persona  aflectod  wili 
the    so-called   '  :iiiciiri«u)al    diatlieKii>,'    tlic    whole   arterial 
shows  an  esti'»imlinju-y  tendency  to  aneurism,  without,  ojt  in  i 
any  visible  amitoniical  peculiarity  in  the  vessels;  but  in  or 
ca«c«  'if  thin  diuihciiis  the  vessels  are  evidently  anfl  and  wi»1e. 

M'heu,  by  any  of  these  prcdispoi^ing  conditions,  the  wall  ofi 
I'Oasol  is  sHiKeirnlJy  weidcened,  it  will  givo  wgy  at  the  w«ifc 
part  to  tlie  force  of  the  circulation,  and  all  the  more  sureir  ift 
force  18  tumporiirily  increased  by  anj'  uiniatiiil  oircuinstancv,  wlna 
thus  becomes  an  exciting  cause,      Hence,  perhaps,  the  frequent  i 
currcnco  uf  uncnriniii  in  persons  t>f  diasipiiUil  livc-s,  and  in 
who  follow  laborious  occupations ;  by  which  not  only  i»  tlie  hcarti 
action  unduly  increiiaod  from  time  to  tune,  but  nW  the  artcrieef 
the  limbs  are  exjiosed  to  frequent  shocks,     Hence  violent  me 


*  K  case  of  nneurisni  of  the  pulmonar}'  artery  is  on  record  in  wbjcb  I 
ductus  nrteriosus  wna  pervious,  antl  eo  red  blooil  wob  ndmtltol  iato  ' 
arlrry.  UiU  it  ia  not  inipuBsible  that  the  force  of  the  left  Tcntricle  tai) 
hiive  hecn  rcflocinii  «loii«  the  open  duet.  On  the  conBviion  boiween  ' 
qimlitj-  of  the  blood  aud  the  deposition  of  athei'Oiiui,  sM  Um  Hctioa  OB  i 
Uut  head. 


CAUSES  OF  ANEURISM. 


351 


Mmettmn  giv^  rUe  to  aiuntrintn.  TVo  cases  of  aneur- 
tbe  abdominal  aorta,  dating  in  eacli  ease  frum  tiiQ  linio  uf 
tiotil'i  TOccWi«j^  fMHiUTiioc  for  11  (irliuinitl  ufiejtco,  bave  come 
dm  ex|kfritro<'e  of  >Ir,  RcruUo,  Surgeon  U>  ibo  Brixton 
*  Oocu]  lilt  ions  which  nt'uv^silntu  voiii-tant  exercise  of  » 
aad  frei|Uient  stnui»  upon  its  joints,  act  boUi  an  prcttinjxininK 
exciting  caiues  of  aiivurifini  in  Uio  Krtorios  lying  near  such 
Popliteal  aneuriam  oeenis  to  be  caused  in  very  miinv  in- 
by  the  giving  way  of  the  circulnr  ooat  of  the  vo§set  tinder 
Jtt^niutu!  n>oruineiiii>  of  for<>txI  extonsion  and  violent  flexion,  to 
b  tliat  artery  is  cxposi<d  in  tbo  inovemunta  of  Uie  knee.  Sop- 
ion  near  an  artMry  may  leiii)  to  tlic  fonnation  of  a  oonHCcmtivo 
,  the  wall  of  the  vessel  being  perforated  by  ulceration) 
blood  tulmittiMl  into  tlio  !uw  of  tlio  aW'■^'^.  Tbi»  i^oums  to 
rare  event ;  but  suppuration  around  an  artorj-  may  also 
pCodi^XMing  i^iiw,  by  ilriiuiling  tlie  voMiul ;  sa  hiw  been 
out.  Cnmifltakable  tnstjinces,  however,  of  alxtoaieeH 
into  atic-tirUin*  are  on  nixinL  Mr.  Li«ton's  case  is  woll 
t  in  which  lie  ojienod  a  cyst  coinm  union  ting  witli  the  inti»ni.il 
id  artery,  believing  it  to  bo  an  alwouMS,  and  in  which  he  waa 


iwy: 


Ur.  nmill«  lias  favoured  roe  nitli  the  following  note :  "  A  atroni; 

ty  WDDan.  five  fi^ct  uif;ht  indi«s  liigb,  who  htiA  ncvnr  licfonr  bnoii  in 
neelTCid  a  ■cnUtncc  of  tnuisportntina  fur  life.  Immtrtialfls  "n  ro- 
MMUncCi  uid  irliil.it  ■tnnilini!  nt  tbc  ilock.  hIir  nlinnsC  b^ntiiij  friiia 
mw  auddcnly  ■>!iz<>il  nitii  sevcic  pnin  in  the  c|>ii:;i(sl i'i«  region,  and 
llic  ana*  of  nn  MtiinUnt.     Tlic  piiiii  in  lliu  ^pigiiulriu  i'0||!ion  »«vi^ 

Keaaaed:  ainl  just  "ix  wavks  nitcn-,  a  pu)««tiniZ  liitnuur  o(  tni'ill  size 
Bjr  to  ba  felL  Tlils  Ineroaiad  In  siza,  until  it  iviis  us  lurge  as  ilio 
lt>  51m  Ur«d  for  tliraa  or  (bur  yaars,  beln^  euuBtiLiitl;  ki<)iL  in  bed 
m^r  tnairii«rut.  aad  liiou  passed  from  uuder  my  ciuv.  I  buvu  lieea 
l«  lo  Itnd  out  tliQ  r^ull.  This  caae  was  bu  ulearl.v  tntocublti  to  the 
t  oanBc>]u«ut.  on  Twwivtn;!:  a  heary  aentonoe,  aa  to  Ivavv  no  ruasunable 
I  flf  the  Jmro«diiit«  <auM  of  llie  illa«a«e. 

The  tecond  ntne  was  alno  au  anuuriaia  of  the  abdominal  aorta  at  tlie 
a  axil,  and  nsino  ou  attrr  ivceirin};  a  aevore  M-iit^nov,  thouRh  1  couid 
lace  it  so  distinctly  to  th<!  Hi!tit<;ni!ii  us  in  th«  fir«t  caic  When  I  dja- 
•d  tbU  tumour, — Ibc  wumnii  only  complninod  nf  obscure  piiin  in  the 
aad  «-Ki  111  her  work  whea  I  ann-  hrr. — it  wriJ*  nbmit  Iho  nizo  »f  a  nmall 
laant  btratonoo  totlKtiilirmnry.nad  bail  bet*  put  to  bed.  TWiv 
aftar  Mag  ia  bod,  tJte  iu>euri^in  ni|iiui'cil,  nnil  sbo  died  In  forty-eiRht 
I  niade  a  i>o«t-DMrt«m  axamination.  Soth  jiatlonts  wer«  womra 
ihiity  and  forty  ytara  of  ago,  and  otherwiao  hmltliy." 
0»  a  F*«rWily  ttfFnltt  ArunrUm,  Lend.  IMd.  An  intaivstins  ease  of 
iDtrha^  from  oumtmiuioation  b<?lwouu  an  abHCtaa  in  the  neck  and 
is  reoorded  by  Mr.  Jiuak,  Mtd.-Chir.  Tran*.  toL  xxix.  p.  %VI. 


( 


ass  DISEASES  OF  AUTEIIIES. 

obliged,  in  conseqaenoe  of  the  gush  of  blood  that  folloired  tlte  pane 
tore,  to  place  &  ligattiru  on  the  oumiiKiii  uin>tiil.     Tliu  {uitiunt  di«(I 
of  uoondary  haemorrhago,  the  result  of  tlie  ojjoration ;  and  on  post- 
mortem  examinutiua  Mr.  Listuii  found  njisoti  to  bcliovc  tluit  tbe 
diMOM)  WW  ori^nally  an  absoeaa  wliic)!  had  eslablinhod  a  comiiiuni* 
<nition  with  tlio  nrU-ry.     WhutoviT  nutv  he  thought  of  tlw  real  nature 
of  tlii!  tuniutir  in  tliat  oo-ie,  fhere  can  bti  liltte  doubt  that  seven]  of 
tlie  otlior cusctt  nhicli  arc  rclatod  iu  Mr.  Liston's  paper  wore  gcnuino 
instwiocw  of  coiuniunioatioii  Ircitwcon  aliMtssK&H  and  artj^rttsei.*    Tbute 
abscefisea  may  be  tlio  result  of  struma,  caxicor,  or  common  inflam- 
mation.    Iu  the  34th  volume  of  lJi«  .Ufx/im-CAtrHrywia^  TtvmiHwfiOM 
is  a  very  interesting  case  bv  Mr,  DLton,  in  which  a  hydatid  cyst, 
having  lx*ii  laid  o[ien,  ^loiighod,  uud  no  e»t«b!iiduMi  ■  coniinimica- 
tion  witli  the  subclavian  artcrj-.     Tlie  patient  died  of  hxmorrhaj^ 
Tliis  is  the  ordinary  resiult  in  casvs  of  ulcvnttioii  poiwtniliiig  nrtcricM. 
No  aneurism  is  formed,  since  there  is  an  open  wound.     But,  in 
the  rarvr  cawM,  Hiicli  a»  those  alxne,  t)iu  suppurntiou  proocfd«  niln 
cutaneously,  aiid  a  consecutive  anourisni  is  fonned.     Possibly  Mr. 
Listou's  ULsu  may  have  bcuii  an  cxam|)lo  of  llii»  event;  but  llie 
diagnosis  must  be  allowed  to  be  doubtful.     The  following  instance 
wa»  one  in  which  tbe  art«rv  gave  way  witliout  any  known  catua, 
there  being  no  clear  liistory  of  abnceAS,  nor  any  viob-ut  eflorl  ct 
iiyury  to  aow>unt  for  tho  laceration.     A  man  aged  twmty-uiiie  wa 
admitted  into  St.  George's  Iloitpibtl  fur  a  large  purple  »tHi-Iliiig  U 
the  buck  of  the  phiu-ynx,  accompanied  by  swelling  and  much  d»* 
coloration  on  tlie  front  and  left  aide  of  tlie  neck.     Tn'o  daya 
admiwion,  tho  patJL-nt  whilo  kneading  some  bread  folt  a  stahluQ 
])iiin  near  the  byoid  l>otie.     In  tlirw  bout's'  lime  Uie  throat  y^oB  ' 
Bwolleu  tliat  he  could  not  swallow  food,  and  dy^ucea  camo 
AfttT  H  ctliui't  slay  in  tliu  hottjiitHl,  the  diHiiecd  hwcllliig  of  dw 
became  circumscribed,  bard,  and  smaller.     Tlicrc  was  evident 
sation  of  tlio  tiiraotir,  with  n  wliirriug  sound,  which  only 
perceptible  as  the  tumour  diminislied  in  size  and  became  haide 
'J'lii-  pativnt  went  on  well  for  a  nuintii,  the  tumour  Leooming  red« 
to  the  size  (^a  walnut,  when  suddenly  it  increased  in  size  and  i 


*  It  tnny  not  be  out  of  piano  lo  iiuticc  bci'u  the  uxUr>i>nlinary  i 
in  Ml'.  LisUin's  pnpcr.  of  anj'  rafiri'ciii^c  to  nuacullnlioa  as  a  meant  of  i 
finoxi^     lie  nilniits  iliat.  before  he  lantlc  ItU  punitturc,  lie  had  rei-WTed  "I 
hint  thiit  ihe  luniour  might  in  eemv  way  be  oonii<<ctcil  with  tlie  caratiij 
yet  he  never  eecius  to  Lsvo  listened  for  a  bralt.     Hiul  bo  done  m,  iha 
can  be  little  lioubt  that  it  would  luiv«  revealed  th«  exiatcuoc  of  a  i 
nieatlon  with  the  art«r]r. 


CAUSES  OF  aneurism; 


sss 


in  vwioua  dirootion*.  Tlio  gencm!  bcutjng  of  the  tnntottr 
faaiiy  dta^peared,  leaving  nifroly  a  line  of  pulsaiion  in  tlio 
of  tbe  carotid.  GritiltliHiaitiy  tif  swallowing  fiillnwiid  imtue- 
•Ij ;  tbo  tutnoor  becanw  moro  and  mare  t«>nfH>,  and  Ui«  aymplnnis 
'Hm!  piitiont  liicsl  uf dyspncva  six  days  afttr  tin?  «iidd<m 
in  lli«  uimour.  The  parts  ore  in  th&  hospltitl  muneum.  In 
die  [ircporution,  imiiKxUatt'Jy  bcluw  Uio  Liiiircation  of  tho  (carotid 
irtery  ui  a  mud)  opening  in  tlio  yessel  surromiilwl  by  a  fi'W  iiiiiiuto 
atclws  of  athpronta.  TIhtc  \»  a  large  pouch  forin»1  by  tlio  cellidar 
Bue  and  fibrin  of  the  extraii'aaated  blood,  which  completely  piuthcs 
>  larynx  and  tracJioa  ovvr  to  tliu  right  Hide,  and  onoraarhoH  mnch 
I  the  cavity  of  the  larynx.  There  is  no  dintiiict  ruptun>  perwptible 
ia  tbo  sac,  but  it  is  cxtrtinely  tliin  at  one  point  It  is  formod  cliiofly 
by  Uood-ckit,  th»  fibrous  investment  of  which  i»  vi-r)'  thin. 

It  seems  probable  tliat  tho  impaction  of  a  clot  of  fibrin  In  the 

utety   may   lead   to  its  diliitation   l>e)iii)(l   tlio    nliAtniction,   and 

tfnis  to  the  formation  bf  an  iuicurif>m.      Mr.  Tufhcll  has  put  on 

neord*  a  remarkable  case,  iti  which  n  puluiting  tumour  formed 

n  the  luun,  in  a  pationt  who  was  dying  from  rheumatic  disease 

1  of  tfae  aortic   vulven.      'Hio  tum<rur  nubi'ifk'd   with   Kimultniwous 

afaif:einent  oftlie  collateral  branches;  and  atler  deatli  the  artery 

*»  found  plii^ctl  with  fibrin  and   son)cwliat  diUt«d.      In  this 

tm  it  seems  clear  that  the  artery,  being  healtliy  at  the  part  where 

|fttclot  b("caino  imp»ct*vl,  yiddcd  to  tho  forco  of  tho  (hy|icrtro- 

,  fUed)  lieart  to  such  an  extent  as  to  form  a  tolerably  largo  pul- 

iMing  tumour,  but  that,  ns  tho  collatvral  oircitlntion  eiilargi^I,  it 

■  enabled  nearly  to  recover  its  healthy  diinenNions.     If  ttie  same 

I  tnlntt  were  to  tako  plave  in  an  arteiy  enfeebled  by  atheromatous 

I  ligenerauon,  no  doubt  the  aneurism  would  go  on  iiicraasing.     The 

■jtction  which  has  been  urg<xl  against  this  mode  of  formation  of 

'  >nrisro,  viz.  that  aneiirisms  do  not  form  on  arteries  (suddenly 

4mKt<xI  by  ligatorc,  is  an  unsound  one,  since  tliey  do  so  form, 

lllka^  rarely.f    It  is  even  puflfiblo  tlmt  anourinniH  may  sometimes 

W  occasioned,  in  a  healthy  vessel,  by  tho  impaction,  or  embolism, 

<f  k  dot  of  librin.]     To  tlie^c  vnriouH  exciting  causca  some  have 

■tded  pressttro  upon  the  artery,  and  consequent  obstruction  of  the 

\  amlalion,  by  tendinous  or  ligamciitoti*  ImikIh  crosaing  it  below, 


•  IMiim  Quart.  Jour.,  Msjr  l^M. 

t   Srm  WoonoH  or  tna  Vkmkui.  vol.  i.  p.  BIT. 

1  Sea  a  case  i«purted  by  the  writer  In  tlic  Path.  8oe.  Trant.  vol.  xU. 


354 


DISEASES  OF  ABTEBIE& 


or  l>y  tlio  ncfion  of  mosclcs  ;  iTixtancing  tho  prcssoro  of  the  fitroti* 
arch  from  which  the  itoleus  urines  us  a  vatidc  of  jjoplituJ  uHtfuriwio.^ 

Such  nrv  t}ic  causes,  predisposing  aud  exciting,  of  epoiitaneoifl 
aneurisiu.     Tlia  toriii  '  trauiniitic  niRtiirism'   is  iixiiitlly  intviidixl  tn 
include  onl_v  tlioso  instances  in  wliich  aneurism  foilowa  a  woun^ 
known  to  have  been  inlliettid  upnn  un  artery ;  nnd  Uiis  wound  i|fl 
of  cijur«e,  in  the  great  majority  of  cases  an  open  one.     In  such  a 
case,  t!ie  wound  in  tlio  skin  ui*n«lly  unites  tuidcr  prcswurt- ;  the 
issuing  current  of  blood  prevents  the  lips  of  the  orilioe  in  tJie  ves- 
sel fii)ni  e/iining  tjifprtlior,  wliilo  tlie  reaction  of  the  ncighWuring 
parts,  the  presHuro  of  muBclcs  and  £ascis-,  and  the  sui)er%entioo 
of  oyncope  Iroin  Iom  of  blood,  prevent  the  unlimited  inHIlrotitui 
of  blood  into  the  oellniar  tiHsne,  and  the  death  of  tho  patient  from 
that  c»u.-<e.     Tliv  bl(*ud,  being  thus  hcmniod  in,  <]tiickly  loiot  iu 
more  Huid  part  by  absorption,  and  becomes  a  more  or  less  Bolid 
body,  and  is  encysted  in  tlic  samo  way  as  other  foreign  substanco^ 
In  other  cases  no  skin-wouiul  exinU ;  of  which  lite  niost  oommoa 
inttanoe  is  tlie  wound  of  a  vvssol  by  n  fractured  bone,  and  ben 
the  process  of  formution  of  t)ie  aneurism  is  the  same.     The  bin 
of  aneurism  is,  therefore,  t}io  consecutive ;  and,  vice  wr*d, 
consecutive  aneurisms  are  trnuinatic.     Mntiy  are,  however, 
tjmcous,  being  caused  either  by  ulceration  perforating  an  artei^', 
in  liiston's  aise,  or  (which  is  very  common)  from  lliw  rupture 
8  previously  existing  aneurism.      It  has  been  above  noticed  (I 
many,  if  not  most,  of  the  aneurisms  which  Surgeonst  have  to 
are,  in  one  sense,  traumatic,  as  having  been  probably  caused 
injury ;  tho  t«rm  is,  however,  usually  restrict^tl  to  those  caM 
vhich  tlio  vessel  is  known  to  have  been  penetrated,  and  will 
8o  nscd  in  tlio  sequel. 

Progrrsa  of  anrurimt.      When    once   formed,    tho    tumour 
likely  to  go  on  inei-easing  as  long  as  the  conditions  mibsist  in  w! 
it  originated.     Tiie«e  conditiona  viiry  so  much,  according  to 
stute  of  the  800,  of  the  parts  around  it,  and  of  tho  blood  whieli 
contains,  that  it  is  impossible  to  form  «  clear  idea  of  tho 
without  studying  eaeJi  of  tliese  separately. 

The  changes  in  tho  sac  deiieiid  in  a  great  measure  upoa 
position  and  sixe  of  it-*  communication  with  the  artery,  and 
what  upon  the  direction  in  which  the  sac  grows  uikI  iho  jmrt  of 
artery  on  which  the  ojieuing  is  seated  :  thus,  sometimes  the  o| 
is  situated  on  the  concarity  of  tlie  curve  of  a  vessel,  so  tliat 


•  Vcmuuil,  HulUtin  de  la  Soeiiti  Anatomiqat,  IHU,  p.  289. 


PROGItESS  OF  ANEURlSSr. 


355 


i«  rtrMched  over  tho  tumour ;  more  frequontty  on  tijc  con- 
ty  or  liwiil  of  tli«  artorv ;  -toiiitKitm-M  tiio  amtngcmiMit  of  tiio 
ibouring  parta  ifl  such  that  the  tumour  can  only  grow  in  tho 
ppostto  (liroction  to  (lu)  current  of  hlood,  or  tliat  pouches  tire 
HCOMd  in  it.  It  would  carry  iia  beyond  our  limits  to  refer  to  in- 
Jmo!*  of  Mich  unuigvmuntti,  luid  to  point  out  tho  variations  in 
rowth  and  progreaa  to  whicli  the)*  soem  to  have  given  rise.  In  a 
■^form  itDCuri«n,  in  which  tho  oritivcs  of  vxit  and  vntranrc  aro 
ne,  the  btti>ral  pre^Hun)  upon  the  aao  oannot  he  severe.  Hcnuo 
hcM  uioarisms  advance  slowly,  and  do  not  n-adJly  burst.  On  tlie 
Ither  hand,  {leilanculnted  aneuri&ms,  in  which  die  sao  oommuni- 
dftH  hy  a  narrow  channel  with  tho  arterial  stream,  are  seldom 
boml  of  large  «z«,  liavtng  ustudly  bui-st  l>ufore  tlioy  attttin  any 
like  the  site  eometimoe  reached  by  tho  aneurismat  ditata- 
Tlii:  n'OHon  of  tiii»  fact,  no  doubt,  i»,  that  tho  itii])jn-t  of  tlio 
,  of  blood  through  the  narrow  orifice  (supposing  that  orifice 
1)  is  eonc<'iiln»t»il  more  upon  on©  point,  inMeiKl  of  boing 
over  the  whole  wall  of  the  sac,  as  in  tho  previous  variety, 
-ven  tbcso  two  cxtrcin«ii  tliuru  arc,  of  courHo,  all  ])ositihlo  HhmlvA 
fcrein-e ;  hut  in  e\'ery  aneurism,  properly  so  called,  aa  distin- 
from  a  mere  dilatation,  tiie  pressure  on  tho  wall  of  the  sao 
ch  grvatvr  than  tho  natural  pnwmre  of  tho  heart.  ThiK  may 
^3h>lntod  by  a  reference  to  the  scientifio  toy  known  as  the 
|MUttdox,t  in  which  n  «nall  pipv  communii-ut04  with  a 
bellovm,  the  pipe  and  bellows  being  filled  with  fluid.  The 
the  opening  in  tho  bcllow»,  tho  groAtvr  is  the  pr(«»iire  on  it« 
An  ati<'tiri>iii  st.'uiding  out  like  a  bud  from  the  artery,  and 
siinicatiDg  with  it  by  a  small  uponing,  would  boar  a  rcsem- 
to  tliin  machine,  tliougli  not  a  stricUy  accurate  one,  nince 
(ion  would  go  on  in  the  aneurism,  which  is  not  the  case 
I  bdlowa.  In  addition  to  this  it  may  bo  roinarkc<l,  that  IhMft 
I  openings  are  sometimes,  perhaps  alwaj's,  formed  by  the  pv- 
way  of  small  portions  of  tho  atheromatous  wall  of  tho  vcssbL 
Mnnll  atheromatous  patches  are  met  with  in  long  tracts  of 
hy  artery,  whorv  tho  wall  i»  thin  and  weak,  and  where,  thurc* 
,  k  mnll  and  weak  nc  aooii  forms,  and  ia  liable  soon  to  bun<L 
I  &  doee  not  necessarily  follow,  however,  boeause  the  wall  of  an 


,81. 


BokitaimVy,  PalK  Altai.  Syd.  S«o.  vol.  ir.  p.  a«0. 
Or  hydrrisUtic  WUow*.    Tho  mnchino  »ill  be  found  ileseril><-d  in 
I  on  bjdrOBtatias :  «.  f.  that  In  the  Bncye.  Brit.  Sili  <>tl,  vol.  Kii, 


356 


DISEASES  OF  ARTERTES. 


anearism  gifoa  way,  that  tho  tumour  therefore  biuvtB.  The  prooeaa 
is  usually  qniw  a  graflual  one ;  aiid  u»  tlic  old  wall  ii«  iliiniKtl  anil 
•tutorbed,  iaflamiiiation  proceeds  in  the  tjaea«B  Burrounding  the 
aac,  and,  by  coudimaing  tlii^in,  supplies  thr>  tumour  with  a  new 
«iiv4?lope.  On  minute  examination  of  roost  large  aneurUms,  it  will 
booonic  uvidt'tit  that  iMirlions  of  their  sac  arc  fonnwl  by  cellular 
membrane,  musdes,  and  other  tissues,  which  have  originally  bcea 
distinct  troni  the  tnmvar.  In  othor  caxos,  and  especially  when  the 
tumour  hiia  pertVvuUid  a  lM>ne,  ittt  oudJttn  increa.'ie  marks  tlie  oc^iir- 
rence  of  a  large  root  in  its  walls,  and  the  supon-ontion  of  a  larjin 
Oonnocutive  aneurism  u]>nn  the  original  (liscuse. 

AnoUier  very  impMlant  dement  in  the  eondltion  of  the  sac  of 
an  iiiiviirism,  is  the  nntiint  of  the  pnrtn  by  which  it  h  AurronndoJ ; 
since,  when  the  tumour  nieet«  with  the  resistance  of  bone  or  othtr 
donite  tissue,  the  itae  is  ul>forbed  or  worn  away;  whilst,  when  it 
presses  upon  organs  whidi  ai-e  very  sensitive,  or  whose  fiinetion  is 
tinporlnnt',  n^aetion  ami  inthtinmation  are  »oon  excitod  by  tho  pro- 
sure  of  the  increasing  hnnonr ;  and  in  such  oases,  if  the  inflamma- 
tion docs  not  pass  a  curtain  limit,  perhaps  consf^hdntion  may  ensue. 
otherwise  ulceration  will  take  place.  A  singular  eonipUcatian  of 
aneurism  is  where  the  tumour  pn)jef;t«  into  the  cavity  of  a  neigh- 
bouring vessel,  usually  the  pulmonary  artery  or  one  of  tlie  caritic* 
of  tlio  huart.  Here  ulceration  seems  to  take  placo  early,  iinle 
preafture  of  the  sue  produc^x  dcntlu  When  veins  lie  oontiguouil 
an  aneinism,  tlioy  are  usually  closed  by  the  pressure  of  the  tumour. 
Ciuies,  however,  are  on  reoiird  in  which  an  aneurism  has  bnni  iaUj 
the  cavity  of  a  vein.  This  ciretunstance  will  he  again  referred  to  i> 
tlio  sootimi  on  arterio- venous  ancnrinm. 

Tho  changes  which  take  plaee  in  the  neigfabouring  parts 
(hw  citlier  to  tlio  pressure  of  tho  tumour  or  to  tho  inflammatia 
which  it  excites.     Tho  growth  of  an  anenrism  is  often  so  rapi^j 
that  tlic  iTtfccts  of  its  pressure  arc  very  striking.     Veins  are  cio 
neirea  expanded  and  thinned,  muscles  stretched  and  watiud,  I 
roughened  or  pcrforatcti,  and  even  the  skin  it*clf  sometime) 
atrophied  as  to  give  way.     When  ancuri-sm  jirodnces  irritation : 
the  surrounding  parts,  the  latter  may  slongh  or  suppurate.*    H*! 
8ac  is  also  usually  involved  in  the  action,  and  ttien  tho  aneuriSB  Ml 


*  Koux.  QuaranUi  Atintet,  vol.  ii.  p.  3C0,  relates  a  ca*«  in  wliirli  Itw  \f\ 
lievcH  Uiut  an  abscess  formed  over  on  anc^urism.  *ml  cnmmuiiiAttvd  witb  I 
Thin  eti.sv.  however,  must  be  allowed  lo  be  lotiicwhnt  dabious.     And 
■lid  iruicli  ctenrer  cose  of  an   itbseeHs  forniing  over  and  «)>ODtn|[  into  '■ 
■ncuriini  of  the  norla  may  be  foiititl  iu  Ui'ocn,  op,  ell.  p.  106. 


PROGRESS  OF  AN'EURISM. 


«s; 


opCTiOil  b}'  tbe  sepamtion  oflho  iilouf;li,  or  t)i«  burAling  oftlie  alisoeeB. 
Tliis  is  iuilb]]/  accompanied  by  fatal  hieuion-hftge ;  but  it  may  IimuI 
to  tbe  Hjiontaueoun  mm  nf'ibv  tiiM.tuo,  as  will  im  [iiiinttvd  out  under 
thai  bead.  The  great  difieroiioe  ofl«n  obeened  in  tlto  proyntw  of 
ratemftj  iin«tirUrii,  according  as  it  prcMWS  upou  a  mucous  or  a 
teroas  Barfacc,  liaa  been  well  sliown  by  Dr.  Tiairdner.*  Tbo  Im- 
non^iago  prodiioxl  by  thv  uloL-ratioii  of  an  aiM-unfoi  into  a  ihucoih 
cs^~it)%  u  the  pharynx,  (esopba^ruft,  or  intestine,  usually  proooods 
bota  11  miiiutv  oritirv,  and  occurs  by  small  quanlitiM  iit  a  tiine,  the 
Dfieaiuig  bcuig  very  liable  to  obtitniiTtioii  by  a  cJut ;  ivbile  Uie  open- 
ing on  a  acTtnu  enrfaoe,  as  tbe  pleura  or  poricar<liuin,  is  often, 
perfaapa  usually,  a  larg«  rent,  tbrou};li  wliicli  rapidly  fatil  Winor- 
tiage  takc»  pbuM\|  Surgical  aneuriamfl  do  not  very  olVu  couw 
iato  contact  with  eitiicr  of  Uic»i;  dassut  of  niembmiie,  but  tbe  ejtiw- 
vial  cavitiw  boar  a  great  analog}-  with  tho  serous,  in  tbiH  ait  ia 
other  reeipectA;  aocunlingly,  luemorrhagv  into  a  joint  U  generally 
tapii]  and  profiise.  Two  casea  of  great  interest  will  be  foimd  in 
Dr.  tSairdniT'-t  Intatisc,  in  which  the  ispontanooiis  opnnbig  of  an  an- 
eurism througli  the  skin  was  tbllowoil  by  healing  of  the  orifiee,  and 
in  one  caae  possibly  by  a  euro  of  tbo  disooae ;  and  otJier  inatonoeA 
an?  on  record  in  which  aneuri^ni!)  huve  been  accidentally  o|K-iiud 
williuuL  ill  •.■tfect»— nay,  in  eomo  with  good  offiNit,  from  r«lii^f  of  tlie 
tBnaioiL  It  is  more  u^uat  for  an  anouriAin  to  couirounicato  with 
ooe  of  the  large  mui^ous  caTltios  of  the  body,  Uian  with  any  otbor 
[■art.  Then  the  progre-tii  of  itymplotns  UNuully  la,  lliat  a  eligiit 
bnaofrhage  oocun,  which  both  wcakena  and  alarms  the  pnlient  to 
Mne  extent.  The  IiIismIIii};  tiien  (.vu-seK,  wliwtluir  from  H\-nvo|)Of 
from  dispiaocmcut  of  part«  creating  obstruction,  or  from  plugging 
tf  tbe  opening  hy  (jisplao^  clot  j  but  this  cxswiition  is  temporary  : 
te  fiaeuTB  reopens  and  enlarges,  and  the  patient  dim  exhausted 
«fl«a  fow  recurrcocvs  of  bletxling.  tionictimes  tlic  bleeding  occur* 
■  ncii  a  situation,}  or  in  such  fjuantity,  as  to  extingui»li  life  in  a 
■went ;  but  these  cases  are  usually  under  tLe  euro  of  a  I'byaician. 


•  Jlf*J,-fair.  I'raiu.  vol.  xlii. 

f  Mr.  OhiK  rcUtua  n  euriouR  case,  in  which  an  Aneurism  ulcerated  into 
hpmordium  by  throo  small  npooiui^s,  Moli  ofUicm  ouly  about  lai^e 
•"Hh  to  ccntain  two  brittle*.  D«ftUi  wa»  mpiil  In  tliii  ciac-.  but  had  a 
■■ilH  aletnUioM  ocoumd  into  the  pluura.  life  iiiiRlit  have  bevu  suiuiucd 
fcaeftnaldcrabto  (rariod.  or  Uw  openiugs  might  bavo  clox:<l.  I'alK.  Soe. 
Tnm.  Tol.  lii.  p.  907. 

;  fi««.  1b  tbe  P<m,  8-K.  Trant.  rot.  x.  p.  <tt,  two  cssM  In  wbicb  ancurinns 
"f  lit*  alMloiNinal  aorta  bunt,  and  IIib  blooil  was  eStised  around,  and  oou- 
>inct«d,  tli«  (ssopluguii  in  one  «•■«>,  and  the  dutxtCBUB  In  the  other. 


«5« 


DISEASES  OF  ARTERIES. 


4 


SurgicRl  iinouri«ni»,  wlicn  tlioy  burnt,  usually  open  tinder  tlie  «ki 
or  into  a  joint.  In  the  latter  case  Weeding  is  gcuprally  copious,  and 
the  va%'ity  liocomo!*  ko  nmch  dlKt^ndod  tlmt  pulsation  in  Ml  in  it. 
The  bursting  of  an  anenrisni  subeutaneonsly  is  UBJially  accompanied 
bj-  great  pain,  imd  by  rapid  nnd  gmdiiiilly  inrruawiiig  lin-iinjrrImK«, 
producing  faintnoss  and  syncope ;  but  the  symptoms  and  treatment 
oftlicjH)  ticcidt^tK  will  be  more  fully  wmsidered  lieniifU-T. 

Another  t«(nnination  of  a  growing  aneui'Ism,  which  is  freqaentJ^ 
met  with  ill  thoiK!  nffoct.inK  the  extromitiw,  is  by  gnngrenv,  t 
result  of  pressure.     This  takes  tlie  ease  out  of  the  category  of  cwm— 
luou  nncuriHms,  and  it  must  now  bo  trcnted  liku  any  other  tumour 
producing  gnngrone.     Aneurisms  may  remain  stationarj'  for  a  long 
period,  though  this  is  csti'cmoly  rare     Somotuncs,  aAvr  thu  ap- 
parent cnire  of  an  aneurism,  i.  e.  after  it  has  ceased  to  pulsate  and 
become  stationan-,  k  will  ngain  commence  to  grow,  and  the  pol- 
Kiitiiiu  will  rectir;  And  in  a  cjisc  of  this  kind,  which  ha.t  fumicihed  a 
proparntion  to  the  mnsonm  of  St.  George's  Hospital,  increaM  of 
»ir.e  wuH  notiecil  wit)KiiiL  uiiy  return  of  the  pidstition.*    Id  tliat  eaw 
the  artery  had  been  tied  above  the  tumour,  and  tJie  increase  of  thu 
latter,  wliieli  was  very  morkod,  from  the  size  nf  »  hen's  egg  to  (list 
of  the  ogg  of  an  ostrich,  and  which  continued  diuing  twelve  moiitlw, 
I(il  to  the  suspieion  that  tlio  diagiKmls  Ijad  bivn  mistaken,  Hnd  tiie 
disease  not  aneurismal  but  malignant.     However,  the  tumour  fae- 
camr  at  last  »t«tioimry  and  wilid,  and  the  cure  lasted  <luring  the  rert 
of  tlio  patient's  life,  about  one  yeiir.     After  death,  iho  accuraCT  of 
tho  original  diagnosis  was  Chtnblishcd.    In  tins  caso  the  cause  of  tht? 
absence  of  jmlsatien  was  obscure;  but  pulsation  may  aonietinies  l>c 
absent  merely  iu  consotjucucc  of  the  jMwition  of  tho  opening;  ai»" 
in  Rome  ooacs  n»  bruit  may  he  audible,  the  orifJco  being  ut  the  de<*I' 
surface  of  the  tumour,  and  tho  force  of  tho  stream  probably  bmkt?*' 
by  dote.     Such  was  the  ease  in  a  woman  luider  Mr.  Viiii*iit'* 
care  at  St.  Bartholomew's  Hospital,  in  whom  an  aneurism  followO" 
the  oocurrenou  of  a  imigitudinul  rent  in  tho  po.tt'.'rior  tibial  arttsr^'* 
on  its  anterior  face.     Tho  sjic  being  formed  ai  the  jMwioriur  p*-*"' 
of  the  artery,  tho  stream  of  blood  seemed  to  enter  it  indirecil^'- 
Hence  probably  the  absenoo  of  pulsation.     Nor  was  there  an> 
bruit.    The  diagnosis,  therefore,  was  only  made,  after  a  long  coun^' 
of  treatment,  by  an  exjJoratory  incision,  when  amjkutalion  becaia^ 
immediarely  necessary,     I  am  indcbte*!  to  Mr.  Moore  for  tho  note** 

Tlie  cliHJigos  in  tlie  bloixl  contained  in  tho  aao  are  evea  mw* 


•  Proscott  Uewett,  MeiL-Chir.  3'rant.  to),  xxix. 


PROGRESS  OF  ANEURISM. 


359 


i:^ 


Smportaiit  than  those  in  its  walls,  Tliey  refer  to  the  nature  nnd 
amount  ofclot  tbrmod  in  it.  It  is  tins  clot  wlnvh,  by  strengthening 
II*  witll  of  the  aneunam,  cnahlee  it  to  n»i&t  the  aetion  uf  tho  hi^urt, 
and  so  o|>po«c«  further  iticrcnsc,  nnd  which,  bv  its  constant  increaise 
in  ftixe  and  doiisily  (froi>h  clot  forming  as  tJin  old  oontractn),  «n- 
onmcbes  upon  and  finnlly  obliterates  the  cavity.  As  this  is  the 
only  cure  of  which  tlie  disease  admits,  oxcejit  by  ablation  or  in  the 
Terr  rare  case  of  spontaneous  cure  by  sloughing,  it  is  to  obtain 
Ite  deposition  of  an  effiojent  coaguluin  that  all  tlie  cflorltt  of  Sur- 
geons and  Physicians  ore  directed  in  tlie  trontmcnt  of  anearism. 

In  examining  an  ancurbun  .at^r  death,  two  kimU  of  bluoil-clot 
will  be  fband  in  it.  Tho  one,  which  lines  tlic  snc,  and  is  usually 
very  firmly  united  to  >t,  is  tough,  more  or  less  decolori.swl  nnd  lami- 
nated, mueli  rc-sembiing  layers  of  diffcrent-coloiu'wl  leather.  The 
Uminffi,  anal  llie  difltii-t^nc^es  of  colour,  obviously  mark  a  gradiuil  and 
■aeoeMlve  dcpusitioit.  This  laminated  coaguluiii  is  now  frequently 
called,  after  Itroea,  '  iiciivc  olol."  llie  otltor  kind  is  kuI\,  amor- 
pboos,  and  red,  something  like  currant-jelly,  and  is  always  found 
iik<idc  the  former.  This  sitft  clot  (olhenviiii!  'piuutivtt  clirt')  rnay  be 
a  mere  post-mortem  appearance ;  but  it  is  no  doubt  often  funned 
in  Bni>nriHma1  tuninum  duriii;;  lU'n.  It«  formation,  however,  is  not 
a  matter  of  the  same  importance  as  that  of  laminated  coagnlum ; 
indeed,  a  tim  ni])i<l  di-jHuit  ■-■«  to  l<0  di<|>reUHted,  as  leading  to  a 
^usive  ap]>earsnce  of  cure.t  It  is  liubto  to  be  either  moluil  or 
vtihed  away  by  the  circulnlion,  and  then  tlio  tumour,  wliieh 
Mmed  to  bo  cured,  begins  to  grow  again. 

It  will  t)C  rcinvmbiired  that  tlio  first  phenomenon  of  atheroma 
eoBoisU  in  tho  depo^tion,  out  of  tlie  Huid  blcod,  of  a  iibrinous 
■tntum  on  tJio  wall  of  the  artery.  Tho  coinmoneement  of  coagula- 
li«i  in  an  aneurism  bears,  at  any  rate,  a  strong  reM>mblauce  to 
lUt;  but,  unlike  the  formatiou  of  atheroma,  it  seldom,  if  ever, 
Uw  ptaoe  where  the  sac  is  exposed  to  the  full  foreu  of  tlie  bliHxL 
utk«st  diminution  of  the  circulation,  however,  as  Irom  jionchos 
■  tho  sac,  from  roughness  of  its  walU,  or  from  external  causes 


*  Hie  name  iloes  not  seem  a  ver>'  well-chosen  on?,  since  It  in  mtlirr  tJio 
pHna  ilian  lb*  dot  whioh  deserveii  to  be  fiilled  aelivc.  rxmking  at  vuch 
*  dM  wkieb  Itaa  rviaaitied  for  ycurii  uaeLiiri^od  in  a  eaivd  Anauirinn,  on* 
•wli  Iw  inclined  to  siij  ihut  imtliiiig  could  well  ht  iuoi«  jHi»it«. 

t  Very  possibly,  huwev<.>r,  ii  moileiule  de]K»iitiuii  of  loose  I'liil  ninj'  be  tho 
it<t«U(;e  in  llie  fonuntion  nf  tlit.'  liitniiiutvd  eoagutum;  all  tliiit  is  meant  in 
the  mt  is,  that  tliu  filHnt;  of  tbr  wlioU'  nau,  or  a  Ki'est  iiait  ol  it,  with  looee 
(Icu,  ia  oft«])  not  lo  tnueli  an  aid  iu>  u  liiiidrauce  to  tbe  eiuts. 


880  DISEASES  OF  ABIEBIES. 

modeTflting  the  impulae  of  the  heart,  will  load  to  tlie  fbnnati 
tODj;li   fibriiiotiJt  vuagiiluin  on  Uic  wall  of  t)io  aneurism,  tiiuugU 
what  is  the  exact  phreical  cause  of  this  coagulation  is  unknown.    |H 
eeciiu  to  require  for  its  coinmKn<Nnnviil  a  diminution  of  tin;  circtt- 
Istioii,  but  not  its  entire  stojipago ;  indeed  it  sometimeB  seeniB  to  go 
on  l«SH  rvadily  when  thv  i^trvrun  is  otoppcd  itlu>;^hcr.     Wlicii  oua^| 
this  tough  fibrinous  coaguhira  is  farmed,  it  has  a  tendency  to  pro^^ 
|»i;;ute  itjsolf  through  tlic  contiguoui>  layora  of  blood  nutil  Uiu  whole 
aac  is  full,  uiileHs  the  stream  of  blood  ahoold  be  too  strong  for  it 
and  when  oiK^e  formLid,  the  clot  an{uiros  gruater  density,  parti; 
bj  die  inherent  power  of  contraction  posoeased  by  fibrin,  parti; 
bueatuw  It  is,  ta  it  were,  hammerod  out  by  tho  impetus  of  the  ci 
dilation.     It  i»  interesting  to  compare  different  porta  ofUte  eanii 
SHc :  here,  fibrin  aciMimulates  in  strata ;  there,  all  is  worn  a^'xy 
tlie  i«ni^,  tho  Miirrouiiding  Hi>f\  purt^,  the  ))ono<«tcuin,  even  the  Ixim 
A  careful  study  of  the  parte  will  generally  prove  this  to  ho  owi 
to  the  impact  of  the  stitiim  ofbliiud,  and  lo  iho  re»iiil»nM  of 
Burrounduig  parts ;  the  attrition  to  which  the  sac  is  thus  subjectod 
eaiMly  explains  its  absorption.     In  tliiit  proctws  of  al)«Mir])tioR,  it 
socnis  that  tlio  clot  may  also  bo  involved ;  tliat  is  to  aay,  tliat  even 
laminated  ooagiiluiii  may,  in  »onio  (.■ondit40iu  of  tlio  Mac,  bo  r6>, 
moved, — an  etiect  which  can  hardly  bo  attributed  to  any  tiling  bat 
tlu!  action  of  the  vessels  of  tho  »ao  u]>on  it.     But  if  tLc  t'cssu)*  of! 
tlie  sac  can  remove  the  clot,  may  they  not  also  depoeit  it — that  is, 
□lay  not  the  laminated  libriu  which  lines  tho  clot  bo  an  oxudatiua 
from  ita  vesoela,  rather  than  a  kind  of  precipitate  out  of  its  (y>nteiitfi!' 
This  is  tho  opinion  of  some  putliologists,*  who  consider  tJio  pracffiS 
as  soraewliat  analogouci  to  inthunmaiion.     But  if  it  were  so,  ite 
internal  layers  of  clot  ought  to  he  tlio  oldest,  having  been  pnsbod 
inwards  by  tlie  increaBiug  dejmait ;  now  every-rlay  oUiorvation  irf 
their  colour  and  consistence  proves  that  they  are  the  most  rofent- 
Tlie  exact  oiiisc,  how<rt-er,  of  the  formation  of  Uininatcd  clot  mw* 
bo  allowed  to  be  obscure.     It  is  enough  for  our  present  purpow  *■* 
know  that  in  un  aneurism  wieh  clota  have  tho  greatest  jxwsibw 
tendency  to  form,  and  will  form  almost  inevitably  to  some  exten* 
when  the  full  force  of  the  circulation  has  l»e«n  witlnirawn.     Kven  ^ 
tuniours  which  are  nijiiilly  increasing,  it  is  usual  to  find  coagulaiD 
purlM  where  tho  stream  has  been  less  powerful. 

Tho  nature  of  tlie  connexion  between  the  sno  and  ita  lining  Oi 


*  CollesOD  Aneurimnitl  Suea.Dablin  QuarUrti/ Jaunt.  It^aB.vol.  xxLp-M; 
Wardrop,  artiole  "Aneurism,"  in  Costclloa  CycUijutdia  a/ Surtftty. 


PROGHESS  OF  ANEURISM. 


86t 


another  olx«cure  point  in  patlioloj^.     M.  Broca,  in  nn  in« 
:  psT^sa^  of  liis  valuable  work,*  endeavours  to  prove  that 
tJie  laiaijiated  clot  formed  in  on  anctiriiini  (loMirssi's  n  c>urtain  ^ulo 
^pTvitAlity,  however  low.     B«t  the  facta  which  he  adduces  to  prove 
BOte  \-s9cultu-iAiition  of  tiiic)i  coit^iln  do  not  aiipcar  8tri«tly  appiio- 
Bkble  to  anLiirismal  clots.     John  Hunter  and  Blandin  have  injected 
dots  in  arteric!)  nftcr  li^ntnro,  and  Kicmtui  in  a  concretion  form- 
ing in  a  rein  below  n  tuniotir ;  but  in  both  these  cauea  there  are 
evident  sources  of  va#cu]jir  formation,  which  do  not  exist  in  a 
eormi  aaeurisra;  nor  have  I  snceeeded  in  meeting  with  any  un- 
equivocal pr\K>f  that  voMok  pwm  between  the  huc  and   its  lining 
of  omi^aluni,  nor  with  any  foetn  whii^b  prove  that  aueh  clota  ever 
bIotc  in  the  vita)  aetions,  tuflaminatory  or  otlicrwiso,  of  the  ]>arts 
•tmmd  ibem,  exiwpt  die  partial  iibwirption  mentioned  above,  wbidi 
nry  Vikvly  it  an  absorption  merely  of  iJie  watcrv'  parts  of  the  clot; 
to  tliat  tl>e  cure  by  laminated  fibrin,  when  onoe  coni])lete,  may  be 
opected  also  to  be  permanent.     In  coses  where,  after  apjiarent 
nre,  theaneurUm  ha>t  reap|>earcd  moner  or  later,t  it  i^  proimltle 
tint  either  the  clot  was  not  complete,  but  allowed  circulation  to  go 
01  ihrtiufjh  its  cavity,  or  that  a  portion  of  it  was  of  tliu  soft,  not 
IIm  buninate<l,  variety'. 

A*  to  the  ^tRtiMics  of  aneuninn  as  it  uQccts  tlio  diflbrcnt  nrtcrius 

■  die  body,  1  do  not  believe  we  are  in  a  position  to  make  any 

Mancnbt  worthy  of  credit.     In  Dr.  Crisp's  work  may  bo  found  an 

^Aorate  table  of  all  the  ea-teii  pubti^hed  up  to  that  date ;  and  Dr. 

mm  iia«  since  given  still  more  extensive  re^cvchea  as  to  anourimn 

('the  aorta.     But  such  tables,  though  of  great  interet<t  and  utility 

iSMno  other  n«pcc-tB,}  aro  useless  for  the  purpose  of  showing  the 

'Hbiljh'  of  individual  arteries  to  di.tcase,  oinoe  tboy  always  include 

*»  unnatoral  proportion  of '  interesting"  cases.    Tims  in  Dr.  Crisp's 

'•■Ifcof  551   euea,   tlie  popliteal  aneuriwnK  (137)  ore  nearly  as 

!  "•(rona  as  those  of  the  thoracic  aorta,  (17.'j)  ;  and  adding  femoral 

(W)  to  iho  former,  the  proportion  of  surgical  aneuriKms  in  tlie  lower 

jaKtMai^  would  be  greater  than  thoracic, — an  absurd  oonclusion. 

I  ^M  only  way  to  detemiiuc  the  rolativo  frw)uency,  with  any  ap- 

I  Ptaeh  to  corroctness,  would  be  to  take  the  unpublished  and  misccl- 

1  '^mu  Koords  of  our  large  institutions,  Mich  as  our  hospital  n>> 


•  IVHt.pp.  127  sq. 

I  Somttime*  after  manf  months  of  nppnrcnt  inaction. 

I  PriacipaUj  In  rafervoce  to  the  usual  course  and  t^^rmination  of  oneh 

■  aT^aaea. 


363 


DISEASES  OF  AHTERIES. 


gaXen ;  and  even  tliis  would  not  be  absolutely  conrot.  einoe, 
all,  it  would  only  give  tin;  proportion  Ainoii^  tho  worktiig-claitMtt 
Tlie  jioiut  ia  porhajM  bardly  worth  the  trouble  noooasarj^  U>  de- 
cide it. 


I 


Spontaneous  Citrr  op  Anbcuism. 

Since  nneurism  is  a  diaeooo  which  consistfl  essenliiillr  in  din^ 
tnrbuiiow  of  tlm  niitnral  ci]Utlibriuni  botwwii  tlic  foron  of  tho  cir- 
culation and  tlie  elastic  renetion  of  the  arterinl  wnlU  at  the  part 
•fiocted,  and  ?iiiov  the  bloml  which  fillti  tho  nncrurismal  mic  hIiowb  a 
strong  tendency  to  eoagulnle  when  the  full  force  of  the  eireiilntion 
i»  diininiihoil,  it  follows  that  tho  disease  is  onv  peculiarly  otay  of 
cure  in  favourable  easmt ;  for  tlie  cou^la  fonned  b>-  ilie  extoninl 
layoru  of  blond  in  contact  witli  the  wall  of  the  sac  soon  acquire  an 
organic  connexion  willi  it,  nnd  thiiM  Htri^u^rtlion  it,  and,  if  nnifonnly 
deposited,  onablo  It  to  rosiot  tho  impulse  of  the  blood  over  ita  whole 
eiroumferenoe,  and  thna  to  cheek  tlui  furtlicr  j>n><^'!K!«  of  tho  dis- 
ease.    When  this  lias  been  once  eSected,  t.  e.  when  the  whole  waS  i 
of  the  8ac  ban  onoc  n^covered  itn  power  of  rtMiNting  the  distending;! 
force  of  tlio  circulation,  coa^lation  will  generally  ad\-anoe  front] 
without  inwards  until   tho   whol«  siio  is  tilled  with  »olid  (ibriibj 
Tho  process  may  of  course  bo  intermpttil  by  any  tiling  which  tein-' 
porarily  au^niciits  the  force  of  tho  circulation,  such  a*  intcmporsncc, 
disease,  exertion,  or  perhaps  even  great  mental  agitation ;  or  it  may 
Ik)  rt^anlurl  or  susjwndcd  by  iiitunial  causes  which  modilj-  tj>e  co*- 
agulability  of  the  blood.  ' 

Several  condition*  or  modes  of  spontaneous  cure  have  bea*^ 
pointed  out  by  pathologista.     1.  The  moHt  simple,  and  rk  it  sccn^*-* 
tlio  most  common,  is  the  coa^ladon  of  the  blood  In  the  sac  i^^^ 
consequence  of  mere  retai-dation  of  iho  ciriMiIation.     2,  Anotb^^^ 
cause  of  coiigulatiou  In  the  sac,  much  insisted  on  by  writera,  bn 
rarely  if  ever  seen  in  nature,  is  tho  preasura  of  tho  anourii 
tumour  upon  tho  artery  in  the  neighbourhood  of  tho  sae,  whereb" 
the  entrance  of  bloiKl  into  tho  aneurinni  im  hindered.     3.  AnotlwV' 
method,  which  has  often  been  proved  by  dissection,  is  the  stoppage  ^ 
of  circulation  through  tho  tumour  by  a  piece  of  dot  which  liaa  bcc^^^ 
washed  into  the  mouth  of  the  vessel  as  it  leaves  the  aneurittRi,  o^^ 
oven  at  some  ilii^l^mcc  from  the  lutt«r.     This  plugs  tJio  opening  in— ^ 
completely  at  first  (at  least  in  most  cases),  but  inere«si«  gradually^ 
by  deposition  of  fresh  fibrin,  till  the  orifice  is  quito  closed.     Tbff     ! 
drculation  is  then  diverted  into  the  collateral  arterico.    4.  In  »oini?    j 
much  rarer  catma,  a  clot  may  be  carriixl  down  into  tJic  artery  ^bori^H 


SPONTANEOUS  CURE  OF  AKEUBISM. 


363 


tbe  tmnour  from  an  imeuriitni  hig>icr  up,  or  ilm  nrturdation  oaii»<d 
hy  the  latter  may  cause  coaiE^Jatioii  in  tlie  iower  sac.  5.  Auolhor 
metliod  of  s|uintAii4Hiii.'>  i^niro  \n  Uy  itii|ipurutioR  luid  sluiij^liing  of  tho 
tumoar;  and  it  is  believed  that  ancurisiuB  may  be  cured  by  iiiflam- 
inaliuii  of  tlie  wtc  without  b<u]>|iurnl4oii. 

The  fiict  that  few  aDeiiriems  are  found  without  eome  formation 

of  biiiinutml  clot  upon,  at  any  nitv,  a  part  of  Uioir  circimifcrciico, 

AavB  bow  Htrong  is  the  tendency  to  euro.     Wlierever  tho  wall  of 

tlie  ttuiioiir  is  xulfioirntly  rtroiip,  clot  will  form  iijifni  it  during  any 

ttmporarv  diminution  of  ihe  force  of  tho  circulation  ;  and  thin  dot 

will  uiicroadi  ufioti  tho  cavity,  and  may  form  thv  nucleus  for  a 

Oonpi«te  euro.     Unfortunately  it  usually  hapjions,  and  eapepiatly  in 

UMurisms  tutuatod  near  tho  hoiirt,  tlut  this  effort  in  only  transient. 

Ktber  llie  oiroulation,  recurring  with  |rreator  form,  ovcrcomea  alto- 

gHbcr  tfao  bnrriur  «ct  up  agniiist  it,  and  ropro<lacc«  the  unifonn 

Bxpaoaion  of  the  aac,  or  tlie  saa  luia  Nomc  weak  jHiint  where  the 

datdoM  not  form,  or  the  circulation  in  tlio  centre  of  tho  tumour 

u  too  jiowerful  for  coagulation  to  go  on  thure.     The  fortti  of  the 

tumour,  and  the  nature  and  size  of  ita  orifice  of  communicatioa 

wh  the  artery,  must  of  neccHaity  exerciw  p«ttt  influeneo  on  tho 

pobilnlit)- of  this  event.     Tlius  a  tumour  formed  by  a  mere  ex- 

|«non  of  the  artery  (fusiform  dihitntion)  will  have  a  much  more 

pvcrfii]  stream  passing  through  it  tlian  one  which  stands  out  from 

Am  nmel  likt?  u  hud,  and  n  nttacheil  to  it  by  a  kind  of  neck.* 

Thmoors  of  tlje  latter  form  are,  it  ia  true,  comparatively  rare ;   but 

de  intcrnxKlinto  form,  hi  which  the  dilatation  is  coiittned  to  oidy 

•  \m,  and  that  not  a  very  large  part,  of  the  oireuniferenra  of  tlie 

•Wrj-,  an)  the  most  coiiiiiion — At  lejwt  among  surgical  !mouri»ni» — 

"A  are  maeh  more  prone  to  spontaneouA  euro  ihaii  tho  fusiforni 

•wrism.     Then  the  stitt*  of  Ihe  mouth  of  the  sac  will  cxerciflO  an 

<&et  on  tl»e  stream.    If  the  orifice  i>e  smooth,  and  tho  internal  coat 

^iIdo^  into  tho  hoc  and  froo  from  deposit,  tlie  blood  Antbi  no 

<i>)tode  to  its  passage ;  but  in  contrary  conditions,  with  a  rough 

njfioeand  coa^In  prvjeoting  into  the  artery,  tho  tbrco  of  tlie  blood 

■oA  be  much  broken. 

Thft  statement  tliat  aneurism  is  a  mcchanioal  lesion,  and  that 
^  core  b  to  be  sought  by  inecli)uiieal  means  chiefly,  is  not  mount 


*  But  dtouj^  lfa«  Btn-ain  U  more  powerful,  its  littern]  expnnsion,  L  e.  tbo 
ffitMre  «u  lli«  wall  of  the  sac.  U  muuh  If  hs  »«,  Hcnc^c  tlie  fiisirorm  diln> 
'Him  nucljr  altMua  the  auo  of  the  saucular  uucuri»iD,  and  is  not  prone  to 
hstiag. 


364 


DISEASES  OF  ARTERIES. 


to  exclude  from  coti»ideration  tlic  suIvanU^d  thai  mnr  lie  ilxril 
fruni  nil  inrniiute  in  tbe  n<liitive  quiuittly  and  coagulability  uf  I 
librin  of  the  blood.     It  is  true  that  the  atU!ni|>t«  which  Iiavr 
iniulw  to  induce  coaptlation  directly  hy  I'lixniicMl  nieuu  htvo ; 
yet  part.ially  fitiled ;  but  methods,  such  as  bkixling  and  otnrvi 
which  iiicrojwo  the  relative  quantity  of  fibrin,*  an<l  dtmmiiih ' 
foi-oe  of  tlie  circulation,  have  often  succeeded  hy  thomM-K-m, 
vrlicn  not  jiu^la-d  Ijcynrid  what  lit  ]>nidviit,  furni  an  impottant  i 
junct  to  eome  other  plans  of  treatnieat. 

Tlio  student  may  now  he  oskud  to  conHtdnr  briefly  eacb  ofl 
oonditionH  or  proxiniale  cauM3«i  of  agiontaneous  cure  sjxtkon  of  I 
The  fint  is  the  tncro  rotaixLalion  of  tlie  circulation.     Tliia  mtPf  I 
place  under  ronditionft  whtrh  it '»  iniptHwible  to  fiHreoee  and 
to  [irnilucu  ;  but  the  chief  and  hnppily  always  accoMiUo  nsinii 
re»t,  whilst  lias  been  f'nH{uei]tly  known  to  etfeot  the  car«ofi 
whi-tlicr  f^'Xlemal  or  into^al,  uith  little  aMustance  Ihmi  any 
means.   Such  an  inittiuicc  i*  the  following:  A  nuui  was  admitted  i| 
hospital,  tinder  the  care  of  Mr,  Lulie,  on  account  of  a  tubnJar  i 
iiua  of  tlie  fcmoml  artery ,  iiiin(woin|uuii<'<l  by  bruit  or  afTectnm  off 
pulse  in  Uie  lower  part  of  tlie  limb.     The  tumour  was  of  n 
standing ;  it  wajt  coinprei^iblo,  and  could  l>c  emptied  of  ita  i 
A  plaster  and  bandnge  wan  applied,  but  a|i[)nronlly  not  tn  fir 
to  produce  much  pressure,  and  lie  was  put  to  htxL     A  fpn^  iai\ 
pain  waa  felt  und<rr  iJie  pla»t<'r  lor  hidf  tui  hour.     It  wua  l>-A  on  j 
five  (lays,  and  at  the  end  of  that  time  tlie  tumour  waa  found 
and  puliation  tiad  coaMtHi  in  it  and  in  all  l)io  artorwa  of  the 
At  the  last  recorded  examination  of  the  patient,  two  month*  i 
wanJis  the  pul»e  in  the  limb  had  not  rt'«p]>varc<d.t     A  fftvati 
her  of  Buoh  cases  might  be  cited  from  tlie  various  authors  who 
trcatt<d  tilts  Kubji^<ct.     Uliioo  the  first  advice  ^vcn  by  a  tn«li 
man  to  a  patient  in  whom  he  diitcovers  the  exi&tcnoo  of  ana 
M  to  kwp  <]uieL      It  is  a  pity  tliat  tliia  reooKunendaliaii  b 
made  more  stringent.     Tlie  patient,  in.vtr'ad  of  being  merriy 
joined  to  h^d  a  qiiiot  life  and  avoid  all  causes  of  vxdt 
sbotild  be  rigidly  confined  to  hod  and  to  the  recumbent  pnuti 
Itut  a  still  more  powerful  remedy  oonaists  in  aporo  diet, 
tliis  should  nover  ho  used  exoejit  aa  an  aoxiliaiy  to  reat 
followii]g  COM)  deserves  notioo  as   illustrating  the  poesibDttjr 

a  On  the  influrneo  of  bicrdine  nnd  survutiou  on  itie  amouat  of  I 
B«e  Tnd<t  and  itou-mnn.  /'Ayi.  vol.  il,  pp.  SI  1,  312. 

t  Ijukf.  in  I^md.  Jtltd.  Out..  Ma/  IMA.    For  other  cawi  aee  '. 
OM  Jnmrum,  p.  Itti. 


SPONTATJEOUS  CURE  OF  A\Ti:UBI8M. 


365 


omw  won  in  a  conditioii  tmtallr  rrganled  as  qtdte  hopeless.*  A 
pibliein  ciinsuIuKi  Mr.  StanW,  in  C)cl.  ltM7,  for  n  larp»  pd- 
nting  tnmour  in  the  right  hresBt,  which  vat  rajAdly  mertamng. 
Hie  ^mphitns  do  ivA  ounoom  D8  l>ere ;  it  wa»  diagnovnl  to  be 
■Dcnrism ;  and  he  was  advised  to  go  homo  and  keep  Iiimself  per- 
fertly  quiet.  A««niiiij;]y  Im;  wvnt  homw,  iay  in  Ixvl  fiw  «i\  months, 
tnd  fed  only  on  becf<tca,  milk,  and  ligfat  pudding.  At  first  the 
lUBoor  80eiD«l  t"  grow ;  bnt  from  CliriMtiniW  of  llint  year  its  wiiILt 
gndoally  got  harder,  the  pnWtion  (iimintHhed  in  force,  and  by 
March  1848  vroru  ito  longer  pcTcrptibli)  extvmully.  Ho  then  left 
hit  bed,  haWng  be«oine  hy  thii)  time  very  pale,  emaciated,  and 
bcUix  He  lived  very  abstfrmioualy  for  loiir  yean*  uiid  n  half,  when 
*  general  election  '*  excited  him  to  deviate  from  the  tranquil 
Bid  abetomioaa  faabita  he  practised."  Uo  dtod  of  ncuto  pU^tirimy 
after  «x[Kitturei.  A  large  nao  wan  found  communimting  with  the 
uita  by  an  opening  (lin.  by  l^in.)  josl  below  tho  innominate 
Mery  in  the  posterior  wall  of  the  »  eeeel.  There  was  only  a  cavity 
br^e  enoagh  to  contain  a  liors«-chcstnut,  the  rest  was  sdl  fiUod  with 
inn  ooagnlnm.  II10  tmnour  hml  been  of  enonnons  aiKe  (7-^  in. 
htm  aide  to  side  and  4  in.  vertically).  The  disease  which  proved 
fital  apprnrv  to  have  been  (piit«!  iiiicomi^^clcd  witli  the  arK^iirixin. 

Bleeding  is  also  a  powerful  agent  in  this  plan  of  treatment.  It 
iiarcnuxly  now  little  uhwI,  in  conxoipipnco  of  its  nbiiw!  in  tint  time 
of  «ar  fathers ;  bnt  it  may  be  permitted  (o  us  to  doubt  whether  the 
Rlction  ha»  not  Iweri  airric<l  somewhat  too  (hr,  Doubtlt^w  the  re- 
IRIed  sikI  copious  veneseetiona  of  old  times  could  hardly  bo  other- 
"•in  than  injurious.  Valsalva,  it  is  xaid,  wed  to  bloni  hin  ]iittient8 
diy  after  day  till  they  were  unable  to  stand,  and  oould  hardly  raise 
tkeir  inns  from  the  bcd-f  This  if  an  extras  ii>  whieli  our  mtnlem 
Ittltits,  a»  well  us  the  prejudices  of  our  patientii,  would  eiToctually 
prwnjt  Surgeons  of  the  present  day  from  resorting;  and  tlierc  ean 
btBo  question  of  tlio  darker  and  impropriety  of  bleeding,  when  so 
mitted  upon.]     But  the  moderate  use  of  ventseciion  appears  both 


■  PMk.  Sot.  Tntmt.  vol.  r.  p.  lOT. 

f  HodfCMHi.  op-  cit.  p.  14A.  Sotnn  writers  hare  tbonght  tliat  (be  naoal 
'^prtWHtBtioBii  i>f  Valulrft's  pmiTlii.-c  nre  cxiu^enitod ;  but  it  is  clear,  from 
Albaiiiu**  aceoDnt  {Attn  Attid.  Sow*,  vol.  i.),  that  ita  general  prindpU  ia 
*»»ttlj-  nndmitood. 

'  M.  Bmca  M«ms  bvoaraMo  to  the  appIimtUcMi  of  the  mnilinil  at  Tii]> 

^<m  in  Ihe  trcRtmpni  of  anvuri<<in*  of  tho  iliomcic  and  abtloniiiutl  luirUi. 

:  *d  of  Um  subolftfian  artery-.     I  do  not  obwrvc,  luiivevcr.  Uinl  he  Itss  girco 

ll^  lailanc'C*  uftliv  afititivuliou,  auccussful  or  oth«nrise,  of  thio  niclhod. 


366 


DISEASES  OF  ARTERIES. 


TAtionil  am!,  as  far  as  wo  can  ju<lpe  from  recorded 


cases. 


soocoarfiiL 


Bleeding  socins  to  inorcuM)  the  rvlutive  umoiint  ut' fibrin  tn  tlie  blood;^^^ 
iM>rdo<!H  it  appear,  when  moderately  used,  toloaseti  its  ooagulability;^| 
while  its  ofFiift  on  Ihr  ]w>wer  of  tliv  heart  and  tlic  riito  of  the  eirt-nla- 
tion  may  be  calculated  with  some  approach  to  certainty.     Tliat  this 
effect  is  tran»iont  in  very  true,  hut  so  is  tlio  action  of  all  tlio  cam 
for  ani-urism,      A  transient  effoot  on  the  circulation  is  ail  that  ia ; 
needed  for  the  formation  of  liiminutod  clot,  wbicli  will  then,  in  favour-; 
ttblo  circumatancaa,  ^  on  to  extend  itseIC     Bctiidea,  blooding  Itasj 
the  recommendation  that  it  can  be  rcpcut«d,  and  its  quantity  propor- 
tioned exactly  to  the  con<Iition  of  tlio  circulation.     The  great  objec- 
tion to  its  use  appears  to  bo,  that  (in  internal  aneurisms  especially, ' 
but  in  all  ancuriiuua  to  some  extent)  ilie  antagonism  between  the 
heart  and  the  forces  neting  in  the  tiniiour  has  a  tcn^lenc)'  to  cause 
tho  stoppage  of  the  heart,  and  death  from  sj'ncope.*      Thi»  ia^ 
espeoially  likely  to  hKpjM>n  in  the  fluttering  action  which  suocoedl ' 
copious  Teiieiu.'ction,  and  it  is  on  tbm  aeixiunt  mainly  that  hloedii^j 
is  danfjeroua.     Still  thoro  aro  too  many  records  by  dilferent,  aodf 
t\ti.iM>  the  most  coiniiotont,  uhservor^,  t^  allow  of  doubt  an  to  it* 
groat  ulilitv  in    some  cases,  although    probably  in  this,  as    in  so 
many  other  tilings,  the  acute  judgment  of  Ur.  Watxon  lias  hit  the 
mark  when  he  says  that  vencsoction  is  only  admissible  so  far  as  to 
rwlueo  fj-WKTOV  arterial  action.     For  this  purpoao  it  is  certainly  a 
more  manageable  and  more  certain  agent  than  digitalis.    Dr.  Slolt* 
has  suggesteil  a  mm lifi cation  of  Viilsidva's  treatment,  in  which  ibo 
siniill  and  repeated   bleedings  which  Valsalva  prescribeii    are  re- 
tained ;  but  the  diet  is  opposite  to  Valsalva's.     "  It  should,"  wys 
Mr.  Porter,  to  whom  we  owe  our  knowledge  of  this  suggestion, 
"  bo  light  and  very  nutritive,  but  of  course  free  from  any  matcriat 


s 


except  one,  the  refi-reiice  to  ivliicli  I  liave  been  unable  to  verify ;  nor  haiw 
met  witli  any  inslRnne  of  Ibo  applioatiwii  of  Valsalva's  mothoit,  propcrljr 
culled,  in  modem  practice.  In  a  case  brought  befor«  ihe  Pathologitr^ 
Society,  by  Dre.  Sibsan  aed  Bi-oadbeiit.  ut  one  of  their  recent  iiiwUn^^C^ 
dyBpn<Dtt.  the  result  nf  nn  nneurism  of  Lbe  aorta,  liad  been  nmch  relieved  t^ 
bicfdiiiga  prnetiscd  nt  rare  inlci-yiils ;  but  thin  is  of  course  nuite  a  difftre^^ 
tlilnR  from  Valnalva'n  trcalment.  Porter  spvaks  of  huiiiig  bletl  to  nynoop  ■^^ 
soTeral  times,  n  patient  with  aortic  luieurism.  and  atwuys  with  narked  i  ^'7 
bof:  op,  oil.  p.  Sa.  In  Mr,  Hodgson's  work  numcmuB  cases  wriil  be  ftiua  ^^ 
quoted,  where  a  pMolice  more  or  less  cloicly  rcsembUug  that  ivbioli  Koea  \r^^^ 
Iho  name  of  VaWIva  was  follnwod  with  Micress. 

•  "  An  apprehension  has  b^en  cittcitnined  by  Bom«,  that  a  patient  kkS' 
dcnly  reduced  v>  a  mate  of  syncope  mii-ht  never  Tiilly,  and  ucluolly  di*' 
of,  or  be  killed  by,  tliu  operalion,'  nnd  j-'erhape  each  a  ea«u>lty  tu^-  havr 
oaotirred,"    Porter  «n  Jnmi'Min,  p.  t)3. 


;  SPONTANEOUS  CURE  OP  ANEURISM. 


367 


anlitiin;;  nature."     (Op.  cit.  p.  81.)     It  does  not  appear 
J  marked  auocena  luu  iiU«iu1cd  lliia  pimt. 
>  modical  mcatu  available  fi>r  tho  euro  of  aneuriRni,  beyond 
Dst  enuin«nitMl,  are  very  fi-w.     (V-rtaiii  <Iriifr*  wliich  retard 

rition  bavo  been  used  for  this  purpose;  but  without  iiiucU 
J)tj;itiUu  i«  botli  daiii^ruUN  itud  uiiei^rtnin.  Tho  action 
IT  emetic,  or  of  copious  waterj-  purges,  seems  only  lo  bo 
looo  wmiknt.'ws  which  can  l>u  duito  with  lews  distress  by 
ana  above  enumerated.  Acetate  of  leud  dooii  not  seem  to 
■d  BitHiciflnt  HuecuM  to  bruig  it  mudi  into  notiee.  Some 
alkaloids  exert  a  remarkable  influence  on  tlio  heart's  ao- 
aeb  arc  aconito  and  vcratrum.*  Whothur  thcso  have  ever 
wd  in  internal  aiieuri^nt  I  bju  not  a^varv),  liul  it  would 
wtli  while  to  give  thom  a  cautious  triaL  1\I.  DouIIlaud  baa 
•d  A  oliuical  lecture  lutelyt  on  tlio  Treatment  of  Anour- 
loitide  of  PotaMium.  Four  ciues  in  all  are  mentioned.  In 
UlMv  (m  woman  witli  aneuriam  of  tlie  oiirntitl)  a  cure  Ls 
I ;  and  in  the  other  three  more  or  less  benefit  is  said  to  have 
rtaiiied.  In  tlio  vaitc  »ai<l  to  have  ixxm  cured,  tlio  iodidu  wa« 
Aered  at  tir»l  in  tlio  dose  of  a  gramme  (15^  grains)  daily; 
m  the  dose  was  rained  to  two  gramnii?it  daily,  whieh  tho 
r  two  mniitliA.  Gallic  and  tannic  aeiiln  have  l>i>«ii  rvcom- 
|{  but  our  exjjerienoo  of  these,  as  of  otlior  medicines,  ift 
negatirub  In  fiwt,  wlw»  aiieuriMu  is  beyond  operative  in- 
leSit  tlw  b««tt  thing  that  can  bo  done  ap|>cars  to  be  to 
w  patient  quiet  in  bod  for  inorithtt,  and  yi^an  if  tiet^l  be, 
g  all  cauM»  of  excitement,  mental  and  bodily ;  to  administer 
utuitiniulalJng  diet,  but  witliout  denying  birn  sufficient  nu- 
. ;  lo  kw!\>  tiie  jiart  in  such  a  position  as  may  rather  impede 
iply  and  &vour  tlie  nHtim  of  blood ;  to  iiwo  venesection  in 
[ttantities,  and  carefully,  when  the  circulation  appears  at 
ra  ifae  normal  standard,  which,  it  idiould  bo  nrmcnibon-d, 
lo  be  below  tliat  of  lieuttlt ;  and,  finally,  to  surround  him 


At  action  of  vvntnim  seo  Lnjwet,  voL  i.  1S63,  p.  91, 
« Bfit.  and  For.  Jdtd.Olu/.  Jirr.  Jan.  1900. 

)■  powibla  that  an  ui«uri«in.  though  hcyond  operatiK  interflBreDCP, 
II  be  aniMrHili  lo  locul  u]jplioiitiuii«  («.  n-  nt  iho  raot  of  Uia  nvck,  or 
ibM) :  in  auoh  a  umr.  iw  nuy  be  apiilio)  to  tho  tumour.  Sotno  Sui-- 
M  TcMgention.  a*  an  ucccuory  to  prcxsiirc,  in  th>  caM  of  cxtomiil 
M.  Tbo  tneiliod  is  »nc  of  doubtful  oflii-jic}'.  I  have  s«od  It  lrio>l 
mllj,  but  itithwul  any  eSkct.  It  bUuu1<1  not  bo  forgotten,  that  gnu- 
rfdietkln  bB9  been  so  produced.  Vide  Dioca,  op.  cit.  pp.  3-lt)  «t  siiij. 


368  DISEASES  OF  ARTERIES. 


rrv  nra* 


noa 


with  on  «qimbl«  cool  twmpcratura     By  these  maisvs  some  wry  gr«3 
tiding  cures  have  been  wrought ;  and  although,  pOThaps,  thoy  wiU 
not  \}t<  niniiy,  yd  boiik;  liv«i  will  bo  ttparod  by  their  rigorous  oiiforc 
ment,  wliidi  would  be  aacrificed  were  tlie  opinion  acted  npon  that 
diM!n«o  if,  n  nc(.-c<«!irily  fatal  one,  for  whirh  art  can  do  nothing. 

The  second  method  of  ftjiontaneous  ourfi,  alwve  indicjtMi  f[ 
S62),  ii  tliat  in  which  tho  arUrry  is  prosumod  to  bo  oblitcrab 
abore  tlie  saf.  by  the  direct  ranijinwtuon  which  ia  exerciHed  apon 
it  by  tho  anonri!<m.     It  is  thought  tbat  a  tnmoor,  arising  by  a 
narrow  neok  from  th«  artei-y,  may  full  baclt,  m  it  were,  ujMin 
latter  and  close  tho  vossol     This  conclusion  is  drawn  from 
tion  ofcasos  principally  of  |MipIitA>ul  Hnuurisins,  which  tuivc  mlvnnc 
to  a  largo  siito,  and  hare  then  become  obliterated  by  clot     It  maj 
be  remarked  that,  from  tho  very  nature  of  the  ca»w,  such  di*s«cti«i 
must  always  bo  subject  to  much  doubt ;  inasmuch  as,  at  the  peric 
ofthe  di$Aocti»n,  ooagolutioa  has  udvaticcd  to  wicli  un  oxt4>nt  that 
h  is  hardly  poesiblo  to  t«ll  where  it  began ;  and  that  appearances 
neiu-Iy,  if  not  t|uito,  idontical  are  found  in  tuinourc  wln!n>  it  is  clwar 
that  no  such  pressure  could  have  been  exercised ;  and  furilier,  fitat 
the  explanation  anise  froin  tho»e  false  views  of  the  patliology  4fl 
arteries  which  led  Surgeons,  a  few  years  ago,  to  regard  iuHamma- 
tion  of  tlioir  internal  coat  as  a  common  result  of  prcssnro,*  and 
oblitoratioD  of  tlie  art«ry  thereby,  as  a  common,  if  not  a  aeneeeui' 
condition  of  the  cum  of  an  aneurism  by  prcssurcf     So  it  wu 
thottght  tliot  the  preasnre  of  a  targe  tumour  would  ao  irritate  dn 
art«r^'  as  to  make  it  inflamo  and  become  tilled  with  clot,  and  that 
thus  the  ancHrism  would  bo  cured.     We  know  at  the  pri^M»lt  day, 
after  so  many  limbs  have   btieii  dissected  in  whicJi  pressimi  ba* 
been  used,  whether  aucoessiiiUy  or  not,  that  an  artery  will  betfi 
without  tho  least  visible  alteration  of  its  lining  Wombnuio  or  of  it* 
calibre,  an  omomit  of  pressure  miiny  times  greater  than  oouid  b«    , 
exorcised  by  any  tumour.     We  know  also  the  ease   with  wIihIM 
arteries  einde  the  grodunlly-incroasing  pFe«snrc  of  tnmour»:  n''^ 
arc  dissections  wanting  in  which  arteries  placed  in  the  condition* 


•  See  Freor  on  Anmritm,  p.  llS ;  Hodgaou.  op.  cit  p.  106. 

+  Most  of  Ihe  reuoiJeJ  east-B  are  ckiirly  iastiuiufa  of  pbUtemtidD  w 
aitcrles  by  impuL'ted  «lol;  as  in  tbe  ciise  quoted  hy  Hudipon  (op-  ot- 
p.  Ill))  from  AHtiuy  Cooper,  wbere  tlie  uurotid  lurtcr;  wiw  found  obliltrtW^ 
in  A  cnae  of  tuieurintu  of  th«  uui*tu.  Thia  could  liardljr  have  bet-'U  ilic  rvtut' 
ol'  pi'essure,  since  thu  effecU  of  audi  pressure  must  hnvi-  been  nion.-  m«iiiJ 
upon  tlie  livcliea.  pnciimoginlna  iiitvo,  or  JuKiilur  vein  tliiiD  Uic  aiti-rj,  bu' 
is  no  uioi'u  Uiau  what  oftcii  oocura  from  impaclion. 


J 


iPOSlANEOUS  CURE  OF  A^'EUR^SM. 


369 


I  (ouoA  to  bo  complolclj-  pervioiia.  Siu-li  u  iiriimratjon 
Ooorge's  Honpitai  muMnini.  It  cxtiibiu  an  enorniotis 
al  anearisDi,  which  eeeim  to  have  untlurgone  r  proc<-«s  of 
|MMU  cura.  It«  sin),  Iwwovvr,  wii£  so  great,  that  the  preuttire 
Inoed  on  the  veins  occaHioned  gnngreiio.  'I'lio  nmn  wtui  lul- 
lOB  Uiis  iiocounl^  &nd  the  largo  solid  tumour  in  the  ham  waa 
ti  to  be  moligiiaiit.  And  tlio  limb  wait  mn|)ut»t(Ml.  Tiio  cane 
wi  rnanj  yours  ago.  No  furtlior  history  is  preservotl.  T)io 
,  which  lion  ixsea  nuMxl  by  llio  tumour  «nd  «trot«liwl  ov«p  it 
<artl  inchw,  is  uotrcrtlieloss  quite  pervious.  It  oommunicatoa 
bm  niieuriHUi  by  only  a  v«ry  Kmtdl  mouth ;  and,  though  tliu 
a»  been  uijecced,  hardly  auy  of  the  injeoQon  has  passed  into 
Cf  no  firmly  i«  tlio  mnutli  oftho  tumour  oouletl  by  dot.  In 
M,  if  ever,  it  might  be  expected  that  the  artery  wonld  be 
Ktod ;  sinoo  tim  tuuiour,  being  of  imm<niHe  »izo,  must  htivo 
ied  great  preMure.  and  tlie  blood  showed  a  strong  diapoutifm 
fufaUv.  It  mikv  1k),  liownvcT,  that  this  method  oi'ciiro  U  uiily 
je  wben  the  artny  is  caught  between  the  tumour  and  the 

w  in  Hmo  owo  of  poplit*^^  aneurism  deroloped  on  the  pos- 

&oe  of  the  artery;  but  it  is  hardly  eonoeivable  tluit  the 
r  Bhoulcl  over  cxorooso  rcry  vigorous  prossuro  towards  the 
n  ■oeh  a  caac,  »uioe  it  mecM  with  ho  much  leiw  reoiMnnce  in 
har  direction.  For  these  raasona,  the  existenvo  of  this  mc- 
f  euro  Monu  doubtful.  It  is,  at  any  r8t«,  a  matter  of  littlo 
)al  itnportance  (though  no  doubt  of  munh  pathological  inter- 
iaoo  no  onu  would  droum  of  encouraging  the  growth  of  a 
lal  aneurism  on  the  speculation  of  ita  ultimately  curing  ilaelf 
■Bore  oD  its  own  artory. 
^ore  dearfy  proved  mode  of  cure  ia  that  which  is  produced 

impaction,  in  the  distal  portion  of  tho  vossol,  of  ii  portion  of 
Dm  the  aneuriam.  The  oct'urrence  of  this  circumstanoe  in 
terial  syatcm  in  casea  of  fibrinous  ooacrotions  on  tliu  valves 

heoit^  ua  iKtiiited  out  by  Dr.  Kirkes,  luis  now  been  oniver- 
dmitted,  and  is  a  frequent  cause  of  gangrene,  of  sofWning  of 
tin*  Aa  (.ice  p.  333).  It  »ocms  also  to  lie  n  not  iiifreqti«Qt 
joftbe  oUtteration  of  arteries  below  an  aneurismal  tumour, 
fid  in  aomo  eoiiM  hy  gangrcno  of  tho  limb  (or  by  death  if 
td  near  tJie  heart),  in  otliers  by  the  spontaneous  cure  of  tlie 
inn.  Tito  way  in  which  this  latter  rwiult  is  produced  np- 
jtobe  aa  follows:  Ka  branch  oomcs  off  from  the  artery  he- 
D  tha  UMmrism  and  the  part  at  which  tho  clot  i»  intpaoted,  this 
A  may  eiUargc  until  it  roptofiM  tho  original  artery-,  and  tlio 


Ik 


B  C 


370 


DISEASES  OF  ARTERIES. 


'^ 


wholo  proc«88  may  reniitin  withont  result  But  if  no  snoti 
cutneii  off  (afl  is  tlie  cwki  iii  tlic  grcttt  majority  nf  inKtancoaf  tc 
impHctioti  uHoally  oocum  JuNt  us  Uie  artery  leaves  the  mm 
tbea  the  whole  force  of  the  heart,  as  far  as  it  acU  on  tlw  an 
fected,  is  einployotl  in  dilatJii^  die  rac,  the  ortei^  above 
thti  liranobea  of  tlio  latter.  Bomotimea  tbo  aac  yields  to  Um 
anil  t)iv  nnoiiriitin  l)iin«t«,  eMpeciiilly  tin  Jer  undue  muHcubtr  eu 
If  this  doc§  not  take  place,  and  tbo  circnlati<m  through  the 
still  to  ^  on,  the  brajicli  or  l>nuioht«  above  the  aikeuriiun,  at 
ooininuiiioation§  or  anastomosos  wiUi  the  artery  below  it,  m 
lar^'.  ^Vhlm  thin  is  vfToct^l  to  n  aulKuicnt  extent,  the  fit 
of  the  cii-culation  U  witlidrawn  from  the  aneurism,  which  w 
UHiwIly  undttrgo  tlio  procvM  of  congidatiou.  It  ih  quite  i 
that  it  matters  nothing  to  tJiia  process  how  far  below  the  ai 
Uio  <^lt>t  iiiuy  be  inipuoto<l,  providisl  tJiitt  no  c«nHi<Ionibie 
comes  off  in  the  intenal,  sinoe  the  intermediate  portion  ol 
cxcrcJKC!*  no  influence  on  tho  circuhition,  atxl  may,  for  the  ] 
of  this  argument,  be  regarded  as  part  of  the  aneurismal  sao 
proci'«M  of  EtpontanuouH  cure  is  imitjitud  in  the  iiwthods  wki< 
the  names  of  Brasdor  and  Fergusson. 

This  plugging  procoas  may  go  on  gradually  n»  well  as  mii 
a»  is  proved  by  it«  being  found  oociuionully  coni[>lotu  in  perx 
liavo  never  preeented  the  serious  symptoms  known  to  aooc 
tlie  impaction  of  a  clot  in  a  largo  urtirry ;  and  Mill  moro  del 
its  being  somotimos  met  with  in  an  imperfect  oonditioa,  tfal 
being  lini^d  witli  a  tube  of  iibrin,  which  stilt  loarea  »  amalt  ( 
ibr  the  blood-f  It  Beems  po^ible  that  the  existence  of  i 
aneurism  higher  up  may  9>0Ri(:<timi.«  vHoct  the  niiontaneoos 
the  lower  one,  either  in  consequence  of  dot  being  waabcj 
from  the  npjwr  aneurism  into  tho  lower,  or  into  th<*  arlt-r 
enters  or  loaves  the  lower  sao,  or  (as  it  is  said)  by  tJw  rrta 
of  tho  current  caused  by  the  up|ier  anourism.  It  is  dtffiou 
certain  as  to  whether  tlie  latter  mode  of  cure  erer  really 
tlioiigh  caseN  are  on  n.'<cord  which  »ppe»r  to  f/tore  tho  tioc 
occurrence  of  what  is,  at  any  rate,  poeaible,  sboe  feebteiies  i 
ill  tlie  limb  Iwlow  is  a  constant  symptom  of  ai>nuisni.  In  tli 
case,  t.  f.  when  a  piece  of  clot  is  wa-'-hed  out  of  an  aneurism 
tlie  procetis  oxactJy  resi'mblcs  that  wliitrh  has  just  boon  dosed 


*  Sunh  Bc^ems  U>  be  Ui«  tni«  espUnittioa  of  a  case  nponed 

Avery,  in  Path.  Soe.  Trant.  vol.  UL  p.  tt8,  aa  au  i&sUace  of  preiwur 

aucuriiun  on  ilie  artery  above  it. 

fi  Soa  above,  Athroma,  p.  828; 


SPONTANEOUS  CURE  OP  ANKURISJL 


371 


Tboro  remainx  another  process  hy  which  anourisnut  have  be(«i 
wa  tu  IntohinA  otinxJ ;  and  this  coiiHtsta  in  tho  Mippiinitidii  of  the 
'lie  and  tltv  ejection  of  tlie  wliolo  tumoor  by  a  process  of  sloughing. 
In  tliis  prooces,  as  in  other  intttanoes  of  sloughing,  the  artery,  for 
some  dtstanoo  on  either  side  of  tho  gangri>nou»  part,  is  closed  bj' 
eoaguluin,*  i»o  that  hii-inorrliagt)  tU)*»  not  take  pki^-,  mi  might  have 
been  ai^rclRiid«i.t  Or,  in  other  cases,  the  sac  may  slough,  and 
the  artery,  nut  heing  ihiLi  twnled,  may  give  way,  and  iho  putiunt 
turrivo  tliv  hicmorrliago  thos  occasioned  ;  xyncopo  is  produced,  and 
eoagulatton  occurH  during  tlii»  nyitciipe,  aoaling  ilio  niiiutli  of  tho 
Tliis,  at  least,  is  Dr.  Crisp's  opinion,  but  it  is  doubt«d  by 
1 ;  nor  do  I  find  relerenoea  in  I>r.  CriHp'it  work  tii  the  ea.4es 
Itpon  which  such  an  opinion  is  founded.  Inflammation  witliout 
nppamtion,  in  the  neightmurhood  of  the  Rac,  in  aW  ti[H)ken  of  by 
Brocs  and  others  as  an  occasional  caose  of  spontaneous  cure.  I 
have  not  been  able  to  lin<)  any  ca!*!!!*  which  are.  In  my  min<I,  quitd 
Mtit&ctonr'.  Some,  as  tho  case  reported  by  Mr.  Sidey,t  appear  to 
We  been  cures  by  iinpaclion  of  dot. 

Tho  surgical  treatment  of  aneurism,  as  far  as  it  is  successM 

tnd  ralioiial,  is  men-Iy  an  nrtiliciid  imitation  of  the«e  pnictiHHeii. 

Eic  treatment  most  in  use  in  the  present  day,  that  by  compression 

I  if  the  arteiy  above  tlie  tumour,  has  no  other  aim  than  to  imitate 

I  Wore  in  the  first  of  tho  processes  described  above,  so  as  to  slacken 

Ibe  cireulation  through  the  aneurism  and  allow  Uie  bkxKl  in  it  iin 

•fportanity  of  coagulation.     Tlie  Huntcrian  operation  has  essen- 

tilOy  tlto  MUite  <>lij<K!l,  uitluiugli  it  accumplinhox  it  in  a  soniewlutt 

ttitraot  way,  and  by  obliterating  a  portion  of  the  artery  above  tlie 

tttnoor  puts  a  niort)  deci<I>>d,  but  at  tiie  suine  rime  more  |i-ni]K)rary, 

(kili  on  the  current  of  blood.     Tho  cure  by  flexion  (Mr.  Hart's 

■Mtiod)  aims  at  eumbining  this  first  jimcess  witli  the  sei^ond,  in 

'  4idl  tbe  aneuri»n  is  compressed  by  the  parts  around  it,  and  itself 

Uwliapa)  conipressiM  the  ^okocL     Mr.  Fergussnn's  plan  of  rnani* 

pibtion,  or  crushing,  is  derived  from  observation  of  cases  in  wliich 

Ik  Balunl  cure  wius  cflectud,  or  att<'iii]ited,  by  thi>  imjuaelion  of  a 

«>  in  tho  arterj'  leat-ing  the  sac     ISrusdor's  method,  so  fitr  as  it  it 

Mfiabk  at  all  in  practice,  i  e.  with  the  modificationH  hereaB«r  to  be 

.  wribed,  is  identical  witli  this  in  its  object,  and  restf  uiion  the  Kanie 

'  fHliolcigi««l  basis.    Direct  pn^^ure  upjH-juY  to  euru  anuuriant  usually 


*  Sim  Hoxriri(UTiox.  vol.  1.  p.  170. 

f  Sm  the  faa«>  mlntod  by  IloiJgson,  op.  oit.  pp.  lOM. 

:  HdiR.  Mtd,  Joum.  vol.  It.  p.  TOe. 


873 


DISEASES  OF  ABTEItlES. 


bj  (lisplaciug  portions  of  ttio  clut,  and  may  porhape  tiomt-lii 
1^  M-ttiiig  ii|i  inHainniution  in  tiio  hoc  or  porta  iironnii  it,  whiv 
to  coagulation.  Finally,  tlie  old  method,  by  opening  tbe  M 
tying  both  end.-*  of  tliu  nrtvi^,  boars  the  »tninge«t  MitJogr  to  tl 
by  flitppuration,  and  is,  in  &ct,  a  kind  of  exctmon  of  the  tuin 
Tho  motli(Hl»  of  K]iontnneons  ctiro  have  boon  dwdt  u|M>n 
length  with  the  view  of  impresNng  upon  tlie  mind  of  the 
that  nil  8ii<K<i.'N>t\il  pliins  of  Uvtitment  nrc  «ii«H.<«*ful  from 
imitations  (whether  designed  or  fortuitooft)  of  these  tiatan 
cciwes,  in  the  hfi|>«>  tiidt  this  fact  rnny  Iiiid  practilioner*  to  I 
careJiil  study  of  the  workings  of  nature  in  tliis  particular,  s 
conditions  under  which  »ho  works.  Such  a  )f*iidy,  corritHl 
various  obseners,  oould  hnnlly  fail  to  be  fruitlu]  in  rwiults 
woidd  load  to  ttic  pruM-'natton  of  numvroiu  liv«i)  that  wo 
sacriRocd  to  tho  idea  that  internal  aneansin  is  a  di&eaae 
nocoi^sarily  fatal.  What  cl»o  i»  it  than  the  cnrt-fiil  *.Iik1t 
natural  process  of  cure  that  lod  Hunter  to  his  brilliant  and 
])ropoMd  of  tying  tho  ariory  away  from  tho  aoat  of  the  il 
What  else  lod  the  Irish  Surgeons  to  see  tliat  coinprewion,  11 
to  imilutc  naturv,  nctxl  not  suspciid  tho  circ-nlation  entirely,  o 
even  act  oontinuouHly ;  and  thus  to  aubstitute  for  tlw  tiitd 
torture  inflicted  by  the  old  plan  of  eompression  a  trenlinent 
in  ordinary  ruses  is  Immlwis,  and  in  a  few  a)>u<)ui>-ly  pi 
Let  us  remember  bow  eoniparatirelr  short  a  time  it  is  sinoe 
tlio  mo«t  ci-Mjnite<l  Surpin-  .  f  lil*  time"  nnnounemi  hi«  (ml 
for  amputation  over  alloilu.  i  :]iriliijdfl  of  treating  popliteal  MM 
Lot  tu  not  forget  that  one  of  onr  most  justly  valued  living  1 
on  this  subjectt  was  eo  satisfied  with  the  advance  wliich  Iiai 
made  at  tlio  timo  tic  was  then  writing,  as  to  cxpnws  his  < 
that  *'  the  improvements  tlint  have  heen  eB'ected  in  tbe  n 
applying  the  ligature  to  art<^'rieB  have  bronplit  tbe  sui;gkal 
mont  of  aneuriara  to  a  degree  of  perfection  which  leaves  ha 
room  for  advancement."  Nor  was  sncJi  an  appreciation  of  n 
Surgery  at  all  axaggerated  or  unreasonable  to  those  who  loo 
it,  as  Mr,  Hodgson  did,  by  comparison  with  the  mortality  all 
old  operation.  In  our  lime  Surgery  haa  made  such  rapid  adi 
that  tlie  mortality,  which  under  the  system  J>raised  by  Mr,  H 
must  have  amounted  to  a  large  percentage  of  those  niwrnlodi 


•  Pott,  Chirurg.  Wuflu.  vol.  iii.  p,  3*0. 

f  Uodgson,  op,  cil.  p.  100. 

;  I  BID  Avart  Uiat  in  I>r.  Oritp's  Ubin  tb«  morialltr  of  IIS 


-J 


d 


SPONTANEOUS  CUBE  OF  ANEURISM. 


873 


very  much  rvductnl  hy  (inn  invcDtion  of  inHtruinontAl  ouinpn.'*- 
'  Hon,  and  eren  this  will  no  doubt  soon  be  ftulJier  reduced  by  tbe 
man  frequent  u»o  of  ilcxton  tmd  digjtul  im'wurv.  80  it  may  bu  in 
nedica]  practice.  At  tbe  |>ro9ent  day,  it  is  hardly  t»o  much  to  say 
ibal  a  [Mitient  witii  iiitumal  aiicurirsm  is  coiidoinncd  to  di-fttli  att  cer- 
tainly as  uue  with  external  aneui'iBin  U!>ed  to  be  to  amputation.  A 
«!iit(iry  hi.-n«o,  wc  may  hope,  our  dcsccndiuitx  will  liavc  as  «ili<l 
xoason  to  boast  of  their  unprovement  upon  Uie  sdeiice  of  Watson 
aixl  liHibain  iLt  vttf  have  to  congnttulatw  ourselves  on  our  advance 
npoa  the  doctrines  of  Pott. 

'I1m>  extent  to  which  the  deposit  of  cloi  in  spontniieously  cured 
anenrisnia  proceeds,  is  one  of  the  most  curious  and  Ixtautifid  instances 
rf  tbal  power  of  uhi]>tatJou  which  tlio  many  processes  of  diseimo 
in  the  body  furnish  in  such  abundance  to  our  notice.  Generally 
tpeaktng,  tlio  fact  of  Uio  complution  of  this  deposit  implies  tlic  Mitiru 
(Ulitratiou  of  tlie  aneurism  and  of  tho  lU'tery  for  some  distance  on 
wbtr  side  of  it ;  and  so  frrcat  arc  tlio  resources  of  the  collateral  cir- 
'  niatioa,  that  any  part  of  the  arterial  tube  beyond  the  tirst  tJiree 
gnat  WaDches  of  the  aorta  may  be-,  and  has  boL'ii,  oblittratod  with- 
Mcgmpromising  the  lilo  of  tlie  patient.  Thus,  numerouei  canon  of  ob- 
bcfuion  of  tiM  thontdo  aorta  below  tliis  point  have  boon  rcconkd ; 
ik  nDominate  artery  bos  otWi  been  successfully  obtit«rati-d  by 
Wore,  thouffli  never  as  yet  by  art,  and  a  case  is  eveu  ou  record* 
Bwliich  tlie  cceliac  artery  and  all  its  branches,  with  tlie  cummence- 
Mltof  tho  superior  mesenteric,  were  invoh  ed  in  the  obliteration  of 
■  neorisni  seated  on  the  abdominal  aorta,  without  any  toss  of 
w)^-  of  tlw  ri»ecra,  which  must  (although  tJio  &ct  is  not  statttd) 
■n  been  nourishol  from  the  phrenic  arteries  on  the  one  bond,  and 
winfunor  mesenteric  on  the  other. 

But  tJiese  great  channels  of  vital  supply,  though  in  favourable 
Ma  they  may  be  stop{>ed  in  this  gradual  manner  without  los«  of 
ft^  cannot  be  so  witliout  extreme  danger.    In  rare  instances,  how- 


flttinl  aoenriam  opeiatud  on  by  Hunter's  moUiod  is  given  &l  IS  enljr, 

'  nl  to  7  of  Um  others  amputation  rus  nei-ca»my.  luid  sut-'n-eiJeil.    But 

laBi  b  muob  danger  in  drawinR  ennclusions  fi'oni  lists  fonncd  of  jmblislied 

,  wbicb  nsaally  (jicibops  it  mny  be  snid  itlH-nys)  include  fiv  U>o  large 

,  S  fnpaction  of  nu^ci-ntiful  opcralionB.     Fi-om  tlic  compantivt'lj'  (ew  rasea 

I  i  hie*  mjvclf  wiuii-vHcd,  1  ulioiild   GU[>}ioi;e  that  Uio  roortslity  ia  u«ttrly 

dooUe  thai  which  I>r.  Ciisp'*  tabic  giTcs.     Itiit  such  iiucsUntis  can  ni'Tcr 

I  be  Mitlod  till  our  Imi^  biM]>itnJa  can  bi;  pcrnifldci)  to  miiko  cflii^iviit  arrengu- 

its  fcr  lbs  prMcrvntioD  of  coraplot.n  and  uahinssed  slnti^tio*.    A  vcTjr 

Dt  eonimiaiion  of  tbo  mortaliij'  will  bo  fouud  funbcron. 
*  Uod^tsoa.  op.  di.  p-  liti. 


374 


DISEASES  OF  ARTERIES. 


over,  wo  sec  that  tho  euro  of  the  anoiirii^m  i>roM*d»  to  ta^  m 
extent  Ks  tti  iii.4iii-A  tlio  Bno  agoinRt  tbe  force  of  the  circtilation,  but 
that  a  channel  is  still  \eh  by  whicli  tho  blood  paxxos,  it*  it  used 
to  do  tlirough  tin-  hotiltliy  art«rj'.  Of  thin  a  striking  iiiaiance  k 
figiiretl  in  Mr.  Hodgson's  work" — a  tubular  uncuriitm  of  t)w  fe- 
moral artery  which  lias  lioen  ooat«d  throughout  with  a  thick  laypr 
of  laminRtod  fibrin,  whilo  a  channol  is  lofl  in  tho  vi^ntro,  through 
which  tlie  uirciilatiuii  hiut  been  oorried  on,  just  as  if  thi-ough  the 
natural  artery.  ^| 

Another  oano  of  this  sjiecift*  of  euro  was  ex1ii1)ttivl  by  the  prefl^ff 
writor  to  the  Pathological  Society,  and  may  bo  found  dvscribod  ia 
their  Tnttixwlitnis,  vol.  ix.  p.  172.  Tho  preparation  in  St  George's 
Hospital  museum  displays  ao  anourtam  of  the  celiac  n*xis,  of  which 
no  ooinplaiiit  wnH  iniulu  ami  n<t  Kymjrt^ims  o.xistuil  wliile  the  patient 
was  under  observation  during  life.  It  has  been  so  for  filled  with 
laniiiiiikil  cofifjulurn  tliat  the  wsdU  of  tho  sac  ar«  every  where  of 
groat  thickness,  and  there  is  only  a  small  portion  in  the  centre  in 
which  the  clot  wait  loose  and  soft,  filling  it  only  jMirtially,  and  no 
doubt  formed  after  death.  Tlie  throe  branches  of  the  ctcliac  axia 
spring  fmm  the  distal  extremity  of  tlic  aiiouriMU,  and  lu^  in  all 
respects  natural.  Tliere  could  be  no  doubt  that  circulation  Iiarl 
gone  on  through  tho  contml  pstrt  of  the  sac,  wliich  liinl  tluii'  replace^ 
tJie  original  arterj'.f  1 

Si/mptoms  of  fporttaneori^  cure.  Tho  symptoms  of  thu  occurrflnco 
of  spontaneous  cure  in  an  aneurism  appear  to  vary  according  m 
the  cure  is  produced  by  tlio  gradual  dejiositiou  of  laminated  fibrin 
in  the  sao  or  artery,  or  is  the  consequence  of  sudden  occlusion  of 
the  artery  by  clot.  When  it  occurs  by  sloughiMg  of  the  mc,  tHi) 
progress  of  the  disease  is  of  course  entirely  different.  Usually 
nothing  is  reuiarked  except  that  tho  pulsation  Ix-comcs  Ions  violent, 
the  tumour  leas  prominent,  and  the  sac,  when  emptied  by  preMur* 
on  tlie  v€«8cl  above,  more  solid  and  resisting.  Soon  aflcrwanis,  ia 
8  time  varying  acconling  to  their  size  and  position,  the 


1 

t.p.i*r 


•  Plates  to  Hoilgion,  op.  uit.  pi.  vii.  fig.  4. 

+  Sea  bIbo  Sir  AstlL-y  Ci>o|ilt's  wise  rulaii^d  by  Hodgson,  op.  cil.  p.  1 
and  prcpuraliona  fvc)m  two  cnsi-s  hi  the  Huntcrian  Muatfuni,  mm.  IMl,  16*^' 
1088.  Tlio  kttcr  tu<i  pi'irjiiuntions  nre  b  pair;  thcjr  skowauenriMntof^ 
iiitoriiiU  L'umlit]  on  eilbui'  siile  nearly  lilted  with  liuniiitttud  dot.  The  taiDl^'T 
of  tlw  uase  exleiids  ovur  &vc  years,  and  is  reported  by  Sir  0.  Ilkne.  Th* 
Sj^uipteiiis  wiTC!  nil  cerebral :  dimricss  of  vision,  diplapiii.  loan  of  nppe^''' 
niuuiucul  cxoiicinent,  Ao.  Beaedt  was  always  dcnrvd  from  blevdiiii;,  uU' 
mou}-.  uud  abstioetice. 


i 


SPONTANEOUS  CURE  OF  ANEDRISM. 


375 


r 

^^BnUg  branchoft  «'i!l  bo  fcU  enlarging,  in  most  cases  of  saporlicial 

Baneansm.     When  iIiLh  Ia  lIu:  caM'.,  tUa  cure  i»  fftntiraWy  not  fur  I'ff. 

the  uunirism  will  soon  bo  found  traiisfomied  into  a  solid  tumour 

rrouch  lesfl  than  iu  originiil  bulk. 
8oniotimcs  tilings  go  on  ditferently ;  the  cure  being  usherod 
in  by  ajinptonifl  a(  grcMt  »ov«ritj,  [H-incipully  diHturluuHMt  of  the 
Anctioas  of  ports  mpplicd  b;  tko  aSoctod  vessel,  accompaiiiod  by 
awn  or  less  pain,  soinctintoa  very  M^vvre,     TIiuh  in  ii  fiiMt  of  Hpoii- 
tnmwus  euro  of  anetuiBin  of  Uie  iunominato  artery,  reported  by  Dr. 
J.  W.  Ogie,*  the  cure  was  utslioi'nd  in  by  urgent  luwUtyinpUimi*, 
an)]  GOtnplvto  unconsciousness,     Tbo  carotid  artery  was  found  aBer 
«kath  to  Imvo  beeit  oblitvratod ;  and,  no  doubt,  tliu  liead-nyrnp- 
tnnu  coincided  with  snd  were  caused  by  the  impaction  of  a  clot  in 
tke  TOMol  mpjilyiiig  tlw  bniiii.     lu  ii  avw  of  aneurism  of  tins  rigbt 
cuattd,  invoking,  pcrhspfi,  also  tlie  root  of  the  innominate,  treated 
Itj \V»rdrop'ft  method,  ami  rcportwl  in  his  work  on  Arieiirtrm,  p.  98, 
nay  be  seen  tlio  account  of  a  §imilar  seizure,     "  Tlie  patient  wa» 
tUoi  suddenly  worso,  and  apfic-iuxKl  to  bo  dyin^ ;  Km  eotmtvnaiice 
^utly,  and  covered  with  pentjiiration ;  tracheal  rattle,  and  inabiJi^ 
to  ffnllow."     OtJicr  wvcro  symptoms  wore  also  present.     Ho  ro- 
tumd  in  this  state  for  several  hours,  and  llien  rallitxl.     At  tli© 
■ne  lime,  it  wan  tiotiood  that  the  arlorlot  of  tbo  riglil  arm  and 
bNrm,  which  up  to  that  time  hod  pulsated  more  atrougly  tlian 
■lis  of  tlie  toft,  hail  liccomo  pul»clo»if.     Tlio  oiriy  probubl«  cx- 
fouion  of  thif)  train  of  symptoms  U,  that  a  jiortion  of  tlie  clot  in 
m  me  bad  faili^n  into  tliv  subclavian  artcr)',  and  clostxl  tt.     Tlia 
Bnwaa  partly  paralysed  for  siomo  time;  ijiit  ultimately  the  anas- 
taoiing  vCKft.*l»  vnUrgud,  and  the  patient  was  in  all  respects  cured. 
Tbis  process  of  cure  by  impa(!ti<in  seems  generally  to  occupj'  a 
i^tioi  of  at  Ivawt  soit-ra)  liourH;  but  whiLit  these  sbcctA  are  ptixting 
'■rwgb  the  press  I  have  become  aeqtiainttHl  with  on  instance  of  the 
^wannous  OUTO  of  luiourism,  in  all  jirobabiii^  by  impaction  of 
■il,  which  deserves  notice  on  account  of  tlie  extreme  suddenneas  of 
%  MMsttOD  of  tlie  Hyiiiptoin:!^     A  man  was  under  the  (^mru  of  Mr. 
^  Morgan  at  the  Middlesex  llospita]  for  |><>pliteal  aneurism,  which 
••  tn^abfl  by  oniiipn-jwion  of  the  femoral  artery.     Tliix  gave  him 
•nttich  pain  that  he  was  witli  difhculty  induced  to  keep  the  inatru- 
*««l  on,  and  Sir.  IV  Morgan,  at  his  urgent  request,  wa*  alKwt  to 
wlhc  ailery.    The  Housfr-Surgocn  was  sent  (or  in  Uie  afternoon,  as 
wiBao  WMCotnplxiiungofso  much  pain,  tluit  he  iu-fislvd  on  tokioj; 


•  I'atk.  See.  Triau.  voL  ii.  p,  187. 


376  DISEASES  OF  ARTERIES. 

off  the  instrument.     The  titmmir  yras  then  seen  to  be  beating 
icntly.      Tlio  |in'**un!  wiin  i-mmtvwl.      7'tivnty  mmiita  aftenrai 
when  be  was  again  ueen,  all  pulsation  bad  ceased,  and  it  tlKl 
rpcwr.     Till'  tumour,  wlii«li  hud  U.-oii  v>-ry  tt-nw;  iind  pninful  bcfi 
became  softer ;  and  in  twcn^--four  hours  ilie  oireunilert^ncfi  of 
kn(^-  diniiiiiHlied  one  inch.     Tlio  pain  and  cstrvmc  tvnd<imc» 
sided  at  once  upon  the  arrest  of  the  palsation.* 

Tile  prows*  of  s|M)iitunoonii  euro  may  be,  and  rcry  often 
interrupted.     A  portion  of  the  sao  becomes  atrengtbeued  by 
d«poitit  i'lii  of  clot ;   Ijwt  wlwr©  tlio  circulation  in  more  actiro, 
sac  goes  on  expanding,  and  either  burhtii,   or  causes  death 
pressure  on  neighbouring  parts.     Often,  too,  thu  clot,  onco  finn 
is  broken  down  by  the  force  of  tbe  sbmun ;  or  it  bos  been  km 
to  I>u  ili»si>cti.Ml  citl'  from  tlio  wall  of  tlw  aneurism,  and  has  I 
found  inverted  by  the  force  of  the  cuirent,  so  that  the  coas 
])ortion  of  the  clot,  wliicli  had  been  niouldod  to  tho  wall  of  1 
tumour,  was  found  turned  towards  its  centre.     Of  this,  the 
lowing   CHHO    is   a   rumarknble   imttuTico.      In    tlio  PatA.    Ti\ 
vol.  iiu  p.  4fi,  1H50-51,  ia  an  account  by  Dr.  II,  Roe  of  a  fl 
of  aneurism  of  tiw  imtorior  ccrnlinil  artery,  which  proved  fii 
a])parently  from  increase  of  size  and  gradually  advancing  prCM 
ou  tilt!!  brain.     Tlic  tumour  vta»  of  the  mzc  of  a  hen's  egg, 
consisted  of  two  parts ;  the  npper  (farthest  from  the  veaael)   U 
almost  translucent,  and  filksi  with  soft  yollowisb  fibrin,  imporft 
]aminaU><l;   while   the  lower  compartment,   which  direcUy  o 
municatcd  with  tlio  arterj*,  was  tilled  with  coagolatod  red  bh 
like   that  in   the  vessel,   and  separated  trom   the  cavity  oa 
itpjK'r  surface  by  a  dense  laminated  mass  of  fibrin.     This  masa 
atljiini^I  a  eonniderable  degree  of  organi^ition,  containing,  i^ 
blood-discK,  very  numerous  fibres.     The  convexities  of  the  lamil 
were  towanlH  tlio  artery  and  its  Kjtco.ial  compartment  of  llie  emvk 
or  rwf  vergd  tlieir  conrxivitits  corresjwndod  with  tho  upper  pari 
tlie  tnniutu-.     Dr.  Brinton,  in  a  n^port,  on  thin  specimen,  beli 
tliut  this  peculiar  arrangement  of  tho  clot  resulted  from  tho  dia 
tion  off  the  wall  of  the  nneurlKin  of  the  ontinarv  laminated  clot 


*  In  nnother  case  undor  Mr.  De  Moffnn.  at  about  tho  anine  timi 
which  the  tumour  was  ntpiiUy  eularging.  nitliough  pressum  was  aa«d  1 
great  un  extent  as  it  could  be  borne,  he  fan<l  intcntlod  to  tie  Out  arl4)(y, 
lii«  looming  of  tho  pi-opoaed  opemtion.  howevor,  the  piiUalion  stop] 
audilvtily.  ncrnriling  to  the  patient's  Hci^mint.  nnd  U  rODialiwd  abnol 
about  ti-'it  lioufH,  aiiil  then  relumed,  but  not  witli  tb«  aaaH  liol«Ba& 
cane  ultimately  did  well  under  pressui-*. 


SPONTANEOUS  CUBE  OF  A^^:t;RISM:  377 


[rom  tbv  arl«r>',  ami  Uio  subsequent  itivcrsion  of  that  olof ; 

t,  uti  iiiuuTuptioii  of  the  proccaa  of  K])(iiit«ii<!i^uft  cure.      In 

«aue8  whore  tliu  history  cfui  be  foUowtxl,  it  usually  is  foaad  tbat 

sncli   i»ti'!mi]itionH   eorrespond   to,  nnd  are  oc«»Kinneil   l>y,  m>uio 

uouiiual  cKertioii  or  (iiiiotiuii  (if  mind  hy  whlcJi  tho  circulation  la 

Modol.r  excited,  or  tionie  aooident  in  which,  ])«rliiipH  along  with  u 

Similar  aflbctioii  of  tlio  circulation,  tlio  tumour  may  have  keen 

directly  injtii-ixl.      Ilet'ercnce  liaa  liisen  niailo  abovo  (|i.  35^)  to  u 

mute  in  which  the  clot  continued  for  n  long  time  to  grow  without 

^hUaation.    In  Mr.  Fr«acott  Ilowotl*!)  account  of  that  case,  the  reader 

will  be  stmck  by  the  fact,  that  the  cure  was  not  previously  a 

Bound  onv;  tiiat  the  pul.siiLion  recurred  twice  lit  long  |H;rioiLs  niW 

the  operation ;  and  that,  tiierefore,  the  clot  was  probably  formed 

under  the  Jntluenceofa  Uio  powerful  ctpcam  of  blood,  and  wi  might 

fee  looner  and  less  resisting  than  laminated  fibrin  usually  is.      Be- 

Mike,  tfao  fact  that  the  piiLieitt  win*  fnr  lulvanced  in  pliUiiAiA  might 

!■«  modified  the  coagulability  of  tho  blood.     Many  other  cases  are 

I     <•  roomd,  in  which  clots,  both  afttT  "[wmtniicous  anil  artificial  cures, 

I     We  wflcned  and  appeared  to  become  absorbed ;  but  cases  in  whidi 

'iff  grow  without  pnl.ttttioii  are  rare.      Anothor  example  of  this 

ngnlor  event  will  be  found  in  the  foot-note  below. 

AAer  tho  cure  of  aneuri*m  in  eomplctixl,  ic.  after  tlio  whole 
■■nty  is  filled  with  laminated  dot,  no  further  clinitge  takes  plaoe  in 
4e  nrolling  except  «  dcereajw  in  »iiw!,  very  pt-rcoptiblo  «t  fimt, 
*l3e  tho  fibrin  is  in  tlio  proceaa  of  contracting,  and  which  pro- 
Otdi  tlowiy  for  a  couMderablu  time,  until  the  elot  has  aMumed  iti 
vwdiikm  nfgroateet  density,  in  which  condition  it  may  remain  dur- 
Bg  tiie  rest  of  tho  patient's  life  By  this  graduitl  contraction  of  tho 
^  mall  aneurisms  ore  reduced  to  a  size  imperceptible  to  external 
ctunination,  and  eomctimes  ean  tianlly  bo  rvco^ii^ed  even  by  di.-i- 
•WioB.  The  collections  which  used  to  be  described  as  "  steato- 
IBHooaor  atheromatous  tumours  of  arteries"  were  probably  small 
'^■ed  anetiriHms.  Bat  in  sivellings  of  lai^r  size  the  laroinx  of  the 
^  remain  distinct,  though  usually  dccolorisi^d,  during  an  in- 
'Mnita  period.  Otlter  changes,  however,  sometimea  take  place  In 
^CttrioDa  whicli  8p}^M>arcd  to  bo  permanently  (-iinif,  'jlivw,  pro- 
■>%,  depend  on  llie  inipcrfi>et  or  loose  formation  of  the  clot; 
^bt^gh  later  on,  the  wall  of  tho  tunioiu*  takes  port  iu  Hie  action. 
Qk  the  clot  may  be  found  softent-d  and  changed  into  a  grumoua 
hiterial  ;*  or  suppuration  may  tak«  place,  ixirhaiM,  from  ihv  irrita- 


■  la  a  ouo  repurUtl  by  Frocr,  Ob*,  on  Anmritm,  p.  lOOi  and  quoted  fcj 


rs 


DISEASES  OF  ARTERIES. 


Ion  of  thia  docoinposing  fibrin,  and  the  whole  mas§  he  ejected, 
riiit  took  ])1tto«  ill  x  case  opemlcd  on  by  3!r.  I^wrciicc,  n  year 
tfler  the  apparent  our»  of  the  disease.*     Finally,  the  clot  has  been 
Ftuiind  Dioro  or  ivm  mixed  witli  crctaouoiw  niutur. 


Syupto»s  asu  Diagnosis  op  Anelirisu. 

The  symptomn  of  aneurinn  may  be  «a»Uy   ijiforred  from  it« 
definition.     A  tumour  containing  hlood  and  oonunonicating  with 
an  artery  will,  in  all  ordinary  eircumstaiKW«,  receive  puUation  trooi 
the  artery;  it  will  he  situated  on  the  course  of  the  vessel,  and  will 
ho  incapahl"  of  being  removed  from  it ;  it  will  (jw  long  iw  psaX 
of  its  eoiitcnts  are  fluid)  diminisi)  in  ajze  when  the  circulation 
through   llio  vessel   is  stopped  by  iiromuiv  on  tlio  artory  alwvc, 
while,  on  the  contrary,  some  inorease  in  size  may  bo  sometimes 
oltHor^eil  wlivn   prewturo  is  made  bcluw  the  tumour;    imd,  atlcr 
the  cu-calation  has  been  stopped  and  the  tumour  emptied  as  far 
as  poHsililu,  it  rimy  tx)  seen  to  fill  again  gradually,  and  in  a  certain 
definite  number  of  beats  of  the  pulse,  when  the  pressure  is  with- 
drawn.    Ikutides  tliCM  symptoms,  which  may  bo  oh«ervc<l  in  tntij 
oase  of  external  or  surgical  aneurism,  tlie  two  following  must  be 
bonio  in  tninij,  which,  though  not  always  to  be  found,  are  so  con> 
stantly  present  as  to  make  them  of  great  value  in  diagnosis.    Funt, 
tliat  Uic  pnw»urc  of  the  tumour,  and  tho  divvrtictihiiii  which  it  fonttf 
for  the  arterial  curi'otit,  will  mttially  cause  a  diminution  in  the  fores 
of  tlu!  ])ulsc  un  tlio  affected  as  compared  with  tho  nnoffbcted  si<t«; 
and  aeoon<lly,  that  tlie  pii].«iition  in  usuully  accompanied  by  a  pe- 
culiar rough  blowing  sound,  called  the  uneiirismal  bruit.     Tbe 
assemblage  of  these  symptoimi  furniahos  as  decisive  evidence  of  th* 
nature  of  the  disease  as  it  is  possible  to  have  of  any  thing  net  act>l* 
ally  miller  our  eyes;  and  a^  it  '»  rare  for  those  which  are  W^ 
characteristic  to  bo  absent  in  external  aneurism,  tlio  diagnosis  do** 
not  gctierally  present  any  great  <liffi(!ulty.     In  internal  ancuri^i 


Broca.  a  very  Iar({e  ani-iirisin  bad  be«n  rapitlly  oblit«mleil  by  pttamtv-  •*' 
hiul  never  muesli  dimiiijuhcd  in  volume.  7'wmly'iuM  j/furg  afterwMdkU* 
tuiuuur  liiiving  k>'')'*i  dnring  the  inliTviil  t«  lui  ejiomiuuH  tiz«.  lint  biiIwo' 
pulMLlion,  it  burst,  and  a  ninss  of  bi'own  gnimoua  mutenal  was  dUcbjitp"- 
TLe  {latttfiit  diecl,  worn  out  by  foviT  nnd  suppumlion.  It  nwy  be  noUW* 
thai  ill  th«iii-  eiuea  where  the  clot  Artnrtvnnls  softi-ns.  it  t»  usually  reaiK^ 
St  till}  time  Unit  die  luicurism  doc«  not  dtminiDh  mueh  in  sixc  sAk  >" 
apparent  cure.  This  then  is  to  be  regarded  ulwojn  u  a  sua|iicioua  ^ 
«UQistaiie«. 

•  Mid.-Ohir.  Tram,  vol  vi.  p.  204. 


SYMPTOMS  OF  AlfEUHISM. 


379 


BLc  ineariHm  Noiiltxl  in  tlio  clw^t  or  nMntnoi,  it  is  rer\'  diffci'- 

Vcot;  the  tumotir  is  often  iniperoeptible,  or  if  porceptiUo  by  jwr- 

ou^un,  or  cvnn  by  jmlpation,  y«t  tlie  course  of  tlio  vessels  ia  %o 

•arfrtim  tlio  §arfaoe,  and  the  tumour  may  extend  so  vfidcly,  tbat  it 

Is  IiiijiuMibli;  tij  Iki  »urc  tlmt  tlic  ttimoiir  eom-jijioiidH  «xuoLty  to  iho 

]Miiticai  of  an  artery.     Tlie  pulsation  is  frequtmtly  impcrccpUblo, 

ornuT  ho  dcrivwl  from  tlio  noiir  pnixfmily  of  tlio  lionrt  or  great 

vcwls,  witliom  any  real  oonnexion  willi  them, — a  Jrc'cjuvnt  causo 

offlTor  in  the  dtagnixis  of  tumour*,  o»peoi«llr  in  the  abdom^i. 

I|  11  impoRsible  to  atop  tjio  (circulation  above,  and  watcli  tho  tumour 

ftfiling ;  Iho  in<«iiMility  of  the  i>uIno  on  tho  two  sJrW,  though  very 

UmAi]  m  a  corroborative  symptom,  may  be  prodnt-od  by  a  ^reat 

Vmety  of  oilier  caiutw,  wid  tlic  ancurimial  bruit  is  very  frequently 

«Wit     Hence,  while  the  Surgeon  can  usually  pronounce  a  jwr- 

fisoly  clc*r  and  unhoitatin);  opinion  m  to  the  existence  of  aneor- 

iwn  in  the  limbs,  the  Physician  is  beeet  with  so  many  difficulties, 

Uut  atthcKigh  tlioy  in  ^-iktuI  jinr  more  attention  to  diagnosis,  and 

therefore  may  be  presumed  to  excel  more  in  that  brancli  of  our  art, 

Uie  ingenuity  of  Piiy^icianit  has  not  duccowled  aa  jet  in  pointing 

Out  any  unmistakable  signs  of  internal  aneurism ;  and  in  many 

I      t^Hca,  even  whore  tho  Btrongcst  roa«on  exists  for  »uji|»o('ting  it* 

pnunce,  it  ia  impot»ibIe  to  come  to  a  certain  conclusion  during 

the  lifetime  of  tlie  patient. 

It  is  worth  while  to  study  the  above-mentioned  general  symp- 

toit»  of  anoarism  a  iitilo  rooro  in  drlail,  particularly  willi  mferixino 

to  their  bearing  upon  diagnoats.    Tiie  diseases  with  which  aneurism 

^•lar  be  oonfoundcd  are,  tuinoitrs,  or  ahsccs«t*,  lying  u|khi  the  courae 

of  Urge  arteries,  and  malignant  tumours  of  bone,  which  sometimes 

iMkate  from  the  development  of  largo  blood-ccllx  in  them ;  lurthor, 

It  ii  nweasary  to  distinguish  botween  aneurism  and  a  mere  enlarged 

■Qd  rclaxeil  condition  of  tho  artery,  in  which  pulsation  is  much 

lore  [Msveptible  than  usual.     In  tlie  first  place,  then,  ao  anenriHa 

^  a  tumour  oontainnl  in  a  cyst,  or  sac ;  it  is  therefore  se[>ara)>le 

''w  other  parts,  which  latter^  if  no  intlnnimation  has  takeu  plnco, 

I!*  OMtally  be  felt  to  glidu  upon  it,  and  is  more  or  le«ii  movable 

Mncding  to  the  depth  of  its  oounexioiis  and  to  the  extent  of  its 

^*&    Next,  as  to  tlic  natoro  of  its  contents.     These  are,  perhajut, 

^Mv  eommonly  a  mixluro  of  clot  an<I  fluid  than  merely  fluid  blood, 

•i  it   is   rare,  tlwroforo,  to  fiml  pulKation  equally  perwiititilo  in 

•*aT  part  of  tiie  lumour.     Tho  character  of  the  pulsation,  it  must 

«  Rmembercd,   depends  on  two  things ;   on  the  nature  of  tlio 

DMaita,  and  on  the  condition  of  the  orifice     The  usual  character 


3S0 


DISEASES  OF  ARTERIES. 


of  Uio  puliation  of  an  ancuriittn  \»  that  of  a  wave,  gndoaJiy  I 
iiif;  up  iinil  griiiUiully  Mibsidiiig.  Tliere  is  mtiall;'  snperMliU^ 
tliis  general  hoitving,  when  t]i<]  arUary  li«  beiweeti  tJ>e  mw  «i>jl 
hand  of  tliu  ohiierver,  a  diaiinot  line  of  more  rapid  and  tJuillii 
puliiatioii,  whiuli  iiiarkH  tho  oourao  of  tliv  vvrwcl.  TIiih  muv 
rally  he  »liM.*rv(il  very  plainly  in  popliteal  anouriams  wliudi 
growing  towards  tho  knou-joint^  and  havo  thi'  nn<*rv  cnwnng  I 
Tiii>  huaviiig  cliarncter  of  the  pulwition  in  aneuriam  diffen 
the  more  rapid  and  simuitan«otu  pnlMtion  of  all  Its  patt*  iaj 
vattcular  tumour,  which  puWtt'^  from  tho  presence  of  a  nuniW( 
largo  vessdii,  and  in  wliich,  therefore,  thu  inoviin^^nt  coniiumoaa  i 
all  part«  of  the  tuinuur,  iiifU^uI  of  being  propagated  from  ona 
di9cr»  cquiillv  from  the  movement  cnmtnuniuitwl  to  •  ttuiKWir  i 
large  vessel  lying  lyeutuitli  it,  which  i^  Himply  a  rise  and  fidL 
extent  and  power  of  the  pulsation  in  an  aneurisni  d«pciid 
U|)tm  the  uniiiiiiit  uf  dot  in  tho  Aac;  and  thus  the  gnuliial 
of  pulsation  may  bo  watched  trom  day  to  day,  as  an  aiM<unMn| 
becoming  l^tinHoUdHted  umUir  the  u»o  of  [>reRsura.  Palsatina 
be  obstructed  by  cloU  lying  about  the  moutli  of  tlio  am.'uriHB,  i 
Aomctiini-N  nmy  bo  altugt^iur  ahMcnt,  n|i[iurontly  from  the 
cause,  altliough  the  eac  still  oootaios  fluid  blood.  Tkoao  an  i 
most  difHcolt  oases  in  rospoct  of  diagnosis,  wliiob  in  than  b 
incrtOy,  and  almont  us  obscure  an  in  internal  aneortsm. 
the  pulsation  may  oven  havo  disappuanxi,  in  oonMxjUKnoo  of  I 
tumour  having  l>oen  apontnneously  cured,  and  yet  ita  siia 
interference  with  the  iunctions  of  tho  limb  nuiy  cause  itir  (m 
to  apply  for  advioe  to  a  Hurgeon  who  has  not  seen  it  during  | 
earlier  atagos.  In  such  a  case  as  this,  the  pativnt'a  aooeunl  of  ^ 
previous  symptoms,  if  bo  Ijo  h  i«_-r»on  of  intelligence,  will 
great  value ;  while,  if  he  can  give  no  account  of  the  dia 
diagnoi<i»  will  probably  Iw  imoertuin.  Sucli  was  the  cai 
patient  mentioned  on  p.  3fi!J. 

Tho  pnUution  con  be  inndo  to  ocmo  at  onoe  by  prauure  on  ' 
artery  above  tho  tumour, — a  chanoter  common,  of  oeuntc,  tu  : 
tumonnt  which  derive  Uioir  puliation  from  the  vessel,  wlietlier ' 
continuity  with  it  or  not;  whether  aneoriams,  onlargi>l  gl 
abacesM^,  or  any  thing  else  prasing  on  tlic  artery.     I'ulutioBJ 
an  aneurism  is  always  more  powerful  Uian  in  tho  aiterim  ! 
to  it,  whilii  tlio  Me  contains  much  fluid.     Thii«  ifl  a  c»nsc<iueon| 
the  powvrlul  reaction  between  tho  wave  of  fluid  and  ibo  waUaJ 
the  sac  (see  p.  355). 

Ibo  gradual  retun]  of  the  tumour  to  its  fiill  size,  afior  it 


DIAGNOSIS  OF  ANEURISM. 


881 


emptied  bv  prossore,  tlie  circniation  having  been  stopped,  ia 

r«n(her  feature  very  choractei'Utio  of  aiieuriiini ;  uid  it  is  important 

la  note  tho  variations  in  this  rcsi)cct,  which  will  ha  obeened  in 

la  aneurtsni  afi  it  bi  gnulunlly  filling  with  olot.     The  moro  fluid 

t)>.'  Mc  contains,  tho  more  completely  will  it  be  emptied,  and  the 

mon;  readily  will  it  &U.     As  the  deponit  nf  clot  prococdx,  tlie  beat 

beeonMS  h«s  forcible,  and  tho  tumour  varioa  less  in  size  on  prea- 

sannpon  tlie  artery.     It  should  not  Ins  forgotten,  tlint  »ince  pul- 

Mioo  i«  caused  by  the  reaction  which  tho  parts  around  exerdsa 

iguniit  tlw  iiitpulM!  of  the  heart,  it  depends  for  its  perfection  ujion 

4a  integritj-  of  the  sac;  lienco  it  is  fi^uently  not  prceent  at  all 

»hai  tlwrc  i«  no  wmj,  as  in  rupture  of  au  artery  before  a  sac  has 

fanned.     Thus,  in  a  case  where  the  patient  liad  been  eaught  by 

WW  macbinery  in  motion,  and  tho  k-g  violently  twisted,  much 

ttdijrraoned  blood  was  foand  in  all  parts  of  the  limb  below  the 

T^piitnl  space,  bat  no  pulsation  over  H]i[>oarod  in  this  tx>l]cetion. 

Tlie  linib  was  ampDtated  about  a  fortnight  after  the  accident  on 

■mont  of  gangrene,  when  tho  ]JO[i!iteal  art<Ty  was  foimd  brokcm 

mnpletely  aorosi.    So  in  aneurisms  which,  after  advancing  rapiitly, 

nddfloJy  borst  with  a  largo  rt^nt,  the  puWtion  of^n  vanishes  com- 

jMy;  to  reeur,  perliapa  (if  the  accident  ia  not  fiitat),  when  tho 

IMhas  licakd.' 

Having  clearly  l)efore  us  the  sympfomfl  of  surgical  aneurinn, 
lh>  Mowing  rules  may  be  laid  down  for  its  dtttgno§is  from  eaeb  of 
'i^  tlllBCtions  above  spoken  of. 

Dioffttotu  <f  anmri»m  from  tiimonrt  jrratiiig  on  the  artery.  Tho 
pMKr  number  of  tumours  which  lie  agunst  an  artery  do  not  cauae 
ttrtmuL  If  they  do  produce  any  sound,  it  is  a  more  didl  short 
W,or  '  thwl,'  Bi«  it  is  sometimes  called,  and  may  in  tlieso  casea 
*Mihr  bo  imitated  by  pressing  tho  stethoscope  firmly  on  any  largo 
"fnficial  artery.  On  the  contrary,  the  bruit  of  an  aneurism  is 
i^Ully  a  somewhat  prolonged  rasping  or  blowing  sound,  and  c^iu- 
■xt  Iw  artificially  p«Kluced  in  a  healthy  arterj". 

lie  pulsation  communicated  to  a  tiunour  lying  over  on  arterj' 

Van  eqoablo  rise  and  fall,  which  ceases  entirely  wh«i  the  pulse  is 

iltpped,  and  nwors   at  tho  first  renewed  boat  of  tho  artery  as 

ifrongly  as  over.     Tlio  pulsation  of  an  aneurism  ia  generally  a 

wire  of  fluid,  which,  on  the  removal  of  pressure  from  the  vessel, 

Aon  not  attain  its  greatest  height  till  after  a  certain  number  of 

pabei,  awl  wbieb  causes  not  merely  a  rise  and  toll  of  tho  tumour, 


*  See  also  th«  cue  on  p.  SM. 


362 


DISEASES  OF  ARTERIES. 


but  also  an  expansion  in  every  directioo.  Tlte  earcet  ilinpua 
sign,  liow-i;vt*r,  i»,  thut  ttie  tumour  can  he  draggod  nwuj 
th«  vessel,  while  tlio  aneurism  cannot;  but  thts  ia  not  «1k 
tho  oasv,  diiiov  the  tntiiour  may  be  too  deep,  or  loo  tightly 
down  by  fascia,  or  too  cloeely  adherent  to  the  artery,  is 
moved.  To  Hm  it  may  bo  added,  that  if  tho  Hwolling  be 
abitoeae,  the  symptoms  of  that  affection  will  sometimes  be 
but  the  occurrence  of  Kuppumticii  around,  or  in,  anouriniMl : 
muHt  bo  kept  iu  mind ;  bo  that  too  great  atrees  aboaJd  not  { 
laid  ujion  tlio  •jinptoniH  of  RuppumtioD,  ns  if  they  exdndol 
notion  of  aneurism;  and  in  any  case  in  which  there  in  doobt' 
thor  the  Hwelling  is  an  nbitccits  or  an  aneurism,  anacultation  . 
be  carefully  used,  since  the  rough  ancurismal  sound  will  prate  i 
evoD  if  it  be  an  ubttcoss,  tho  iiwvUing  oonununicat««  with  the  i 
bouring  artery.* 

Pulsation  may,  howorcr,  bo  caused  by  the  tnmour  bebg,  i 
were,  enclo»od  in  arteriea.    Tliix  wim  tho  caM)  in  the  jiaticnl  in  wli 
Mr.  Mooro  tied  the  common  iliac  art«ry,  on  account  of  a 
tumour  situated  exactly  in  tlio  |>o»iition  of  on  aneurism  of  iJm  i 
nal  iliac  artery,  and  having  "  a  rough  and  loud  monnur."    Oii( 
MCtJou  it  was  f«un<l  that  tho  tumour  wan  formed  by  oanoer  i 
in  a  majis  of  glands  situated  in  the  bifurcation  of  the  oonnnotl  i 
betwtH^^  the  internal  and  oxtomal  iliac  arteries,  cloeely  bonndi 
to  tlioae  vessels,  and  particularly  to  the  external  iliac,  by  an  i 
lopo  of  fascia,  Itnvlng  tho  obturator  artorj-  bcncslh  it,   and 
{orated  by  tlie  gluteal,  sciatic,  and  pudic  nrt^rii'K.     In  this 
though  tho  question  of  aneurism  or  pulsatile   malignant 
was  discussed,  it  was  foun<!  iin[K>iwible  t»  iwtttblinh  the  <lia 
of  its  cancerous  nature;  nor,  alW  death,  could  any  meaia  uf< 
gnosis  be  suggested,  except  tJiat  the  urinu  in  tlio  bUidder  cont 
cancer-cclIs,  wliich  might  perhaps  have  been  found  by  mic 
examination.     But  u&  tlio  only  Kpci-imiti  of  urine  whicii  had 
seen  was  quite  clear,  it  is  poaaiblo  that  the  cancer-cells  mifzirt  I 
been  only  occasinnally  ]>rvscnt ;  and  it  muM  bo  allowed  tliat 
means  of  certainly  diagnosing  such  cases  are  known  at 
ainoe,  from  ita  shape  ami  dojitli,  tlie  tumour  separated  tlio  fingenj 


a  Grmt  caution  in  neudcd  in  drulitig  niUi  tumour*  lying  i 
arterisa.    Broua  (p.  ijl)  r«lalus  tlul  of  the  rour  succciiuve  staint  8u 
of  Hfitel  Di«u,  Femuid.  DcMult,  rnllotiui.  and  Dupuftmo.  the  atli««  i 
opened  an  aneurism  bf  nistalie  tor  an  abaeeM,  uid  Pi'llctan  laid 
maliKiiant  polaatUo  tumour,  intsuding  to  perfona  tlio  old  opciatloa  I 


oacut'isin. 


DUGNOSIS  OF  ANEURISM. 


383 


a,  M>  an  to  i>iinu1atc  tlio  cxpniiKivo  pulsation  of  anoarism,  ami 
in<I  was  not  appreciably  ilitl'erent  from  wliat  is  found  iti  many 
oietiri)ims.  Even  had  tliv  tumuiir  bvcii  more  superGcial,  it  viaa 
»  HUTuuiuled  and  penetrat«d  by  large  artarica,  that  ita  piiU<itit>u 
DOuM  not  bavQ  been  stopped  by  drawing  it  away.' 

Nlr.  Southf  mentions  a  case  of  vari.i:  of  tho  internal  ju^iliir 
preaerrc^l  in  the  muMum  of  St.  lliomnx's  Hospital,  wliich 
gUui  tl>e  art«ry,  filling  nearly  tbe  whole  side  of  Uio  n«clc,  and 
DMicm  the  diftieiiltie»  wliicli  nuiiit  an«e  in  such  eases  in  separating 
lix  pulfiation  of  the  tumour  from  that  of  the  arteiy  round  whieJi  it 
ii,  as  it  wore,  fulde<l.  In  tlio  case  of  a  varix,  Mr.  South  tluiiks 
tbn  it  miglit  be  distinguiiihod  "  by  pressure  of  tho  swelling  at  Us 
fattbcst  pxtromity  frum  the  heart,  in  whieh  case  its  sue  will  dimi- 
lush ;  vrliiNt  if  ]>resaure  be  made  between  it  and  tlie  heart,  ita  bulk 
Kuit  be  increased,  wliieh  is  tho  very  reverse  to  anourisra."t 

Dioffimu  htlween  anrrurium  and  putnatiU  tuntourx  (ff'liow.  Tho 
diigDons  between  pulsatile  tumours  of  bono  and  aneurism  is  very 
iliBcult;  »o  that  some  of  our  lM.-At  Surgeons  have  been  deceived 
^&»  reaenblaiice.  The  diagnostic  symptoms  are  tlio  following, 
but  iJii.'y  aro  xeldom  or  never  all  present  together :  1.  The  bruit 


*  This  wna  th«  fifth  ctLHo  in  which  the  corumon  iliac  artery  has  been 
Vd  in  London  ;  uad,  out  of  these  fire,  it  wai  lh«  tliirU  in  which  the  disease 
*H  inppuaiHl  to  be  ofaneurismal,  but  proTi'd  to  be  uf  iiinli^'iiHiit,  nature 
IVti-titr.  Trtmt.  vol.  xxxv.  p.  169).  ItectMitly  s  caso  uf^currcd  in  Mr. 
hfn'a  practice,  which  mill  more  otiikiugl;  iUuBtnitt^B  Hip  UiflicuUicu  of 
fagie«i«  irUcU  beset  palmiin);  tumoure  lying  near  tlie  Inrifv  uteni-H  in 
fcriKlomen.  A  man  nua  uiliuitted  for  pulsnUog  tumour  in  the  gtvia  luid 
^  fosn.  Much  doubt  eKtsled  us  lo  it«  nature.  Most  of  those  who  saw 
^isdiocd  lo  the  opinion  that  it  nus  anctirismal :  otltrrs  tliought  it  msllK- 
■bl  It  wa*'d«dded  to  cut  down  on  the  extrmal  iliac,  and  if  the  tumour 
'tfiwtd  to  b«  an  ancurinn  and  usccndvd  too  high  to  nllow  of  ttua  vohscI 
^^  •OCar«d.  then  to  lie  tlic  common  iUan.  The  op«nition  wns  performed 
*Wriin|(ly;  but  the  false  pelvis  wn.-<  founcl  fillrd  with  a  liirco  munn,  partlj* 
^.and  not  puUating.  which  so  diaplai-i^d  thn  nrtcrins  thnt  it  wouhl  huvo 
**■>  bardly  pOMlble  to  tie  the  cnmmaii  ilinc.  However,  under  tlic  im- 
l^lwlim  that  tbc  tumour  wils  mnlifinniil,  tht-  attempt  was  not  made.  The 
^*iMi  V  AingaMd  out  of  the  liair-beal>.''d  wmmtl  of  the  opcialion,  and  tlie  man 
''•ttlarUrtallusinon-hagc.  U  wo*  then  roiuiii  thnt  the  tumour  wiu  really 
^tariuoal,  and  jhuHt  eon*oUdal«d.  Brit.  M»d.  Jotirn.  MOtB.  p.  "iM. 
\  CMtus.  vol.  ii.  p.  iWi. 

;  A  rase  will  be  foiiod  in  the  Mtd  Chir.  Traiu.  vol.  asriii  p.  SU,  in 
^  4iib  Mr.  Eorle  tied  the  subcluvimi  arti>ry  on  sccount  of  a  aiigiponi'd 
BttUify  aaeuriem:  wkldi,  however,  turned  out  to  be  a  tumour  connected 
B.*ith  tho  m«dian  nerve.  It  is  to  be  rcf^retted  that  nothing  la  said  about 
Hlfe  «^p4Mns  beyeod  th«  genersi  stuleuieDt,  that  "  th«  lumour  presented 
r  id  lk«  chaneteis  of  aueurisa." 


DISEASES  OF  ARTERIES. 


1 


aeecns  bat  rarely  as  well  uiRrked  in  ]>iilitnti1o  tumount  a»  in  | 
curism,  and  is  ofUii  altogotlier  absent.     "  It  is  true,"  howeveri 
Mr.  Stanley  remarks,"  *'  that  in  states  of  gt-nwml  aiia^mia,   t 
in  dim-iuHJvi  of  the  aortJo  valval  allowing  of  regurgitation,  lira) 
portions,  or  even  tbo  whok-,  of  tlie  arttTial  sj-rtoni,  willmut  orgi 
cliAiigo  in  tlio  v««8o!s,  nmy  impart  to  the  stothoBcope  a  muni 
approximating  to  tlio  bcllo^vs-HOund  of  aiu'uri!>ni.     And  if,  uq 
simh  oiro-uiniitauoefl,  a  tumour  should  happen  to  form  in  any  r«^ 
of  the  body,  so  closu  to  a  Isrgo  artery  a»  to  itiflui-n(%  itJt  ]>uWtiii 
tbun,  by  the  stethoscope,  the  bruit  or  bellows-soimd  may  be  roa 
nised  in  the  artt^ry  as  forcibly  as  in  an  aneiu^sm."     2.  The  pq 
tion  is  uftiDilly  more  sudden,  ht»  heaving,  and  less  expaneiive  in 
pulsatile  tumour,  and  is  equally  forcible  over  tho  siuuo  spa< 
tumour,  whetlior  tlio  latter  bo  large  or  small ;  while  in  anti 
die  bulk  of  tho  Hwelliug  and  tlie  tbrcv  of  its  pulsation  Increase  j 
decrease  together.     3.  Tbo  condition  of  the  bone  with  which 
tumour  is  oonnoct«l  will  often  aid  in  tho  diagnosis.     Thus,  in 
Stanley's  cnao  (^MttL-Chir.  Tmns.  vol.  xs\-iii.  p.  318),  n  pi 
boue  was  found  in  the  walls  of  the  tumour.     In  another, 
1  saw  at  St-  George's  Hospital  bojuo  y<*r8  ago,  where  it  puis 
tiunour  of  the  iliiun  projoeU'd  in  the  buttock  Bt  tho  sitiution  of 
saoroticriatio  foriiinen,  and  cioaely  njscmblcl  in  many  rcspocU 
aneurism  of  tho  gluteal  artery,  tlie  diagnosis  was  correctly  ea 
lislicil  Iiy  iilisiTving  fiilness  in  the  ilJno  fos^a,  tbo  ilium  lx'ing| 
paiitled  on  both  aides  by  the  tumom'  develojieil  in  JL^     V'l« 
sneurism,  on  the  contrary,  eats  through  a  bone,  it  simply 
out  a  bole  in  it ;  so  that  if  the  sac  can  be  emptied  anil  miu: 
coIla]>se,  the  eilgi^  of  the  hole  will  be  fclU     4.  Thcw  pulsatile 
niours  of  bone  appear  to  be  always,  and  certainly  are  ui 
pancorous ;  so  tliat  the  general  sj-mpfoms  of  the  catiecroiis 
may  h&  present,  or  some  other  ciiniwrous  tuinoiu'  maj-  ltd 
In  the  ])ulsat  iiig  tumour  in  tho  buttock  just  meuttonod,  the 
of  ha'maturia  at  a  later  stage  of  the  eiL-«o  revealed  the  exi 
mischief  al>oiit  the  ki<lucy,  which  was  found  after  death  to  dept 
on  the  deposition   in  that  organ  of  a  large  maatt  of  enocphal 
eancer.     It  must  l^e  nclmitted,  however,  that  the  diagnosis  betnf 
pulsatile  tumour  and  aneurism  is  olten  u  matter  of  tlie  greatest  | 
liculty,  even  if  it  be  possiblo;  and  that  the  diagnoMS  of  o«aflf 


•  Mtd.-Ckir.  Trimt.  vol.  sxviii.  p.  816. 

f  1q  Mr.  Stanley's  esse  also  Uio  tumour  pnyacted  on  botfa  sidos 
iliuaiu 


J 


p 


OLD  OPERATION  FOR  ANEURISM,  385 


aneuristn  iinaocomimniod  by  pulsuititm,  such  as  Uio»o  montionod  OQ 
jp.  'ibS,  317  f  is  sometimes  impossible, 

DioffiuMU  ixttcern  arwrUm  ami  aueurumai  JUatation.  Tlio  di«- 
bc*n-ccn  an  ancurifim  and  a  mere  dilatation  is  usually  <iaito 
ibvious,  nl  li^it  brLwouti  oxlnnno  i;x»tni)lcit  of  Uio  two.  Tli©  tiila- 
tiUioD  is  generally  uiiaocompanied  by  an}'  distinct  tumour  or  fcy 
any  ancunMuiil  bi-uit.  It  ooiitjiiiw  no  dirt,  untl  Iicuco  inuy  b<?  wnn- 
JiUculy  cmptteil  by  pressure  ou  tho  artery  above,  fUling  at  onco 
*iiai  tliat  pR-swuro  in  ri.irai>\'i>i ;  and  tbiTo  is  uittiiOly  iiu  iiitcrfcr- 
tmc  witb  the  pnUe  in  tlie  ai'lerioa  below  the  disease. 

TUKATMEW  OP  Ah'EUBISX.      ThB  OLD  OpKHATIOS. 

He  medical  treatment  of  anonrism  has  been  disoussod  sufficiently 
iffite  purp<Kx«  uf'u  wnrk  on  Ktir^^i'ty.  It  now  remninH  tor  us  to 
Mnujer  tlw  various  plans  of  local  treatment  wlucli  arc  in  use  in 
wAuiy  or  iMicyHli-d  aneurism,  and  to  |x>iiit  out,  an  fur  a»  our  prc- 
Mt  experience  enables  us  to  do  so,  to  what  extent  and  in  what 
Mm  uich  plan  i»  likdy  to  provo  iiimHuI. 

He  first  metliod  of  treatment,  usually  called  the  old  operation, 
w  tbo  iaotho<l  of  Antyiliui,  aims  ut  tho  entire  erndicatiou  of  the 
iwriimal  tomoor.  The  ojieratiou  is  thus  performed :  tlie  artoiy 
^Km  Uw  seat  of  aiwurijtm  ts  to  bo  c-ommaudvd,  if  poeeiblo,  by  a 
tainikiuet,  or  by  the  linger  of  an  awist^it ;  tlien  an  inei»ioii  in  to 
*t  mado  into  tlio  tumour,  caro  baviti<e;  been  token  to  expose  it  by  a 
xAcient  dissection  of  die  iinperficlal  partA,  should  those  involve 
Vj  important  structures ;  die  clots  aro  then  to  bo  rapidly  turned 
*it  of  the  eaCf  and  iJie  ori^oo  by  wiiich  >t  communioateti  witli  the 
Wry  is  to  bo  searched  for ;  a  ligature  is  tlicQ  to  bo  placed  ou  tho 
*«el  above  ami  IkiIuw*  ti)e  un^tiriHiu.  The  o[H-ning  of  llie  vessel 
^  be  found  by  passing  a  proi>e  from  the  sac,  first  u]>wards  and 
Um  downwanLt,  in  iiuuh  where  a  diHlinct  sac  is  found;  but  tn 
liifiued'  aneurism  this  is  oflou  impossible,  according  to  Pulletan. 
■nna  tlie  li^ituruii  hate  tilcentt<^  [.hruii|;li  tlie  vefsol,  and  tlio 
e«my  has  Ix-en  filled  up  by  suppuration  and  granulation,  tho  tu- 
■UMir  u  rudically  «xtirjMit<.>d. 


*  KefiklcTi;.  a  Sui-;;eon  of  IximiiK!.  but  pruL'tiniiig  in  luily,  and  ufao 
[  ^■pears  to  hiTo  rcintnxluocd  the  metLoil  of  Antjlhii  into  Italy.  u»cil  onljr 
t*Hii^*tiin>  «bov»  t]t«  tumour.  Thine  of  his  ou&e«  arc  rvportcd  by  Tcala 
Wferrais  (who  stiinR  to  hnvr  Ipnrnt  the  oiJi-mlJoit  from  liini),  of  nliitli  two 
nra  iMCtt***hlL  Mw>tti.  «bo  hud  ni:nn  Koynlurv  oprmtc,  iiscil  tivu  liga> 
bUH  t-^nanOij,  but  not  olmys.  I'ulkuui,  6'^r.  C'Air,  voL  L  p.  lii. 
VOL.  m.  CO 


DISEASES  OF  ATtTEniBa 

Siich  iit  tlie  dcacriptJon,  in  general  IcrniH,  of  an  nppnitton  ftUj| 
IhuB  BUt«d,  apijears  simpte  enoiigb.     Its  difficiiltiis,  Irawwtr,  i 
oflom  of  Uie  ^nivtwl  chnmoter  vdien  Ui«  BiM'iiriMip  in  dcvpljr  i 
wlien  llie  swteiy  commnniMtcs  witli  its  deepest  part,  and  whoil 
sac  contains  niCT'BWs  or  i«  dowcty  united  to  tho  pnrta  ■rfnind. 
ilH  difficulty,  it  is  often  an  oxtremely  BOTfero  operslion,  requiringl 
incision  of  cxtniordinnry  It'iigth,*  nrccwmriiv  tnvoliing  con 
luRmoirliogc,  and  leaving  an  onormom  ca\'ity  to  fill  np.    The  : 
of  anciviit  8nrgcry  rtliow  tliiit  it  n"od  Ut  W  often  »  Usliotw  awl 
]ierate  proceeding,  which  sometimes  proved  fatal  on  the  sjmjI,  i 
the  »»c('"-jw  of  which  WHS  nt  all  times  vury  in>«TUin,     Hiihi-  h  I 
been  fliiporscded  in  almost  all  cnaes,  and  tew  living  Surgeons  I 
much  vxiwricnoe  of  it     In  popliteal  anvtirism,  for  whicli  it  nstdj 
be  the  only  euro  ex<wpt  amputation,  it  is  now  completely  tit 
Imving  given  place  to  milder  and  more  certain  methods.    In  I 
aneurL^nis,  compre^Nion  or  the  ligature  of  tlie  external  iliac 
alwaj's  be  prelvTred ;  and  so  on  for  most  of  the  common 
Rtu'gioal  aneurism.     Tlien!  are,  however,  some  Hituatiom  in  wt 
the  old  method  still  holds  its  ground  in  the  estimation  ofal 
rat«  some  BurgeoiiH.    In  axilhiry  anouriMn  it  luut  latfly  been  : 
mended  by  the  high  authority  of  Jfr.  Symc,  and  enfi>rood  hf  I 
example  of  his  suecesiffiil  npplicntion  of  it.      In  anotirim  afl 
gluteal  artery,  should  tliat  rare  (liFK'axe  bo  mot  with,  nniny 
geons  would  prefer  cutting  down  on  the  sac  and  turning  onl ' 
dot,  especially  in  a  traumatic  aneurism,  to  the  ittill  more  dang 
oporntion  of  st^curing  the  internal  iliac  artery  ;t  and  in  tnu 
onetiri^n  at  tho  bend  of  the  dbow,  if  tlio  diseaw  reniiit«d  tlM  | 
application  of  prcMure.  it  would  perhaps  be  considored  mors  i 
open  tlie  hik  and  tiu  the  iu-lery  above  and  below,  aiid  wodU 
involve  no  inoro  danger  to  Ufa, 

Tl)e  leiuling  idnt  of  the  old  Snrgooiw  in  operating  rm 
was  doubtless  an  erroneous  notion  that  it  was  necensarj-  to  gA ', 
of  the  clot,  which  tlicy  holiovcd  to  luivo  TieiouM  propertiea,  and  I 
ir\jurious  both  to  the  part  in  which  it  Ur  and  to  the  < 


*  III  a  suacetwriil  case,  Pi-llctaa  imiIu  mi  indviou  ten  InrlMS 
operttttD);  on  a,  reuunt  popUteiil  uienrwm,  whicli  u  ik4  atAlcJ  to  ban  I 
of  nnniu'kitblt)  nixu. 

t  Uiit  till!  diuttniiiiiii  must  bo  mtido  wltb  wttaiiitj.    S«t'  tli*  •Mm>| 
PnlMlilu  Tumours  of  Uooe,     In  Mr,  Sym*'*  tAMrralWN*  ia  Cliine*lS» 
tSOl,  pp.  10&-II3.  will  be  found   twi>  iiitt^re^tini;  cuc«  ofglulMl  ur 
treated,  one  by  the  old  opvniiion,  the  other  bj  llgatur*  of  ibe  inlcrwl  I 
ailtrc,  ui]<]  boU]  ii-illi  nucvoss. 


OLD  OPERATIOX  FOR  ANEURISM. 


387 


S<>  llwt  llii>j-  Uirmtil  it  out,  not  itii-i-i-Iv  that  t\wy  might 
louth  of  tUe  artery,  but  alao,  and  miiinly,  ui  order  to  rid 
tiw  conHtitaU»n  of  :>o  ilxn^rutM  a  socrctjon ;  and  fitn^Vxl  the  caritir 
■vriih  mmjiounds  which  they  believed  to  have  the  proper^'  of  pre- 
venting Itw!  ntpri)(iueti»n  of  cufi^iluin.     All  I liis  ihoory  i»  of  courso 
esploded  now ;  and  if  the  operation  were  undertaken  in  any  case 
■wrtK3«  tlww  WiiK  niuoli  clot,  the  only  objwct  of  tins  Sursoon  in  di«- 
Uutiing  that  clot  would  be  to  find  tlie  month  of  the  sac.    Still,  wtien 
tkeclut  hiM  Ixx-n  dinturbL-d  and  cxjiowxl  to  tho  air,  it  i*  htftlcr  to 
iWiOTe  it;  and  thns  a  large  «avity  ia  left  to  bo  filled  up,  and  tho 
nrtaiuiivc  Hn|>piirulion  which  this  iiivoivos  iiooonnt'*  for  n  lnr(j<^t  por- 
tmtsf^  of  the  great  inorlalily  after  this  procedure,     ffangrene  woa 

»'wyooiiinii>i»  after  the  old  apcrution  for  jM>plttoiil  anvurism,  [losfibly 
ftom  the  <UiBcu]ty  of  tiislingiii>hiug  the  parts  from  eaoli  other,  and 
1*  (onuwjucnt  fruqucncy  witli  which  the  vein  and  jomi-timw  tho 
IiffW  tino  was  included  in  the  ligatures.  Anoilier  and  a  very 
&*^iwnt  cnuAC  of  dcuth  was  tho  prcat  liability  to  secondary  hae- 
I  Bmhage  involved  in  thia  nielhod  as  it  used  to  be  prairti^ed  on 
L  mauui  arteries.     When  uwd  for  trauaiutic  aneurism,  this  uhjec- 

■  lion  does  not  appt)',  since  the  artcr^'  is  aa  likely  to  be  hejilthy  in 

■  b  nvighbourlHKid  of  the  wound  as  in  any  other  part;  but  spon- 
'  'neoiB  aii4>uriMn  uxuiilly  occurs  in  consec|uence  of  aUicmtna  in  that 

F*n  nf  tho  i-cMUel ;  it  is  probable,  thervfbrD,  that  the  ligatures  will 
■Oappliwl  to  a  brittle,  dcgencnitcd  artorv,  and  will  cut  it  through 
'*'i>R  any  union  has  taken  pinco.  This  danger,  it  is  true,  accom- 
[•niei  tlw  Htnitiiriiin  ojieration  also,  tliough  to  s  lent  <!xt«iit,*  and 
'W  is  more  probability  of  finding  the  coat«  of  the  artery  near  tho 
"niiour  siiifKiiiHitly  lii^althy  for  the  ajipliciilion  of  the  ligature  in 
*nfnud  than  in  internal  aneurism ;  but  oven  in  tho  arteries  of  the 
unibs  tlw-  nci^'hhourhood  of  iho  tumour  h  tJie  moHt  in.->e<!uru  place 
**  ulaefa  an  operation  can  be  practised ;  and  this  was  the  main 
'■oreticol  rcawon  which  net  Hunter  ii[)on  thinking  of  a  new  o]>era- 
*»i  fiw  anmirism.t     The  practical  reason  was  donbtlcse  the  excu- 

H     ■  C«p«eia]1)'  111  till*  nrli'rioH  of  tlio  bnlly-     Sue  ihc  account  i>f  on  opitn- 
r '**  on  ike  vsuniul  iUiM'  ftrUtty  by  ^f  r.  Fcr^ii«oii,  Med.  2'imei.  vol.  it.  I8it>, 
^  Ml.     Bev  hIho  iufr.  «n  AbdoaiinAl  An«uhMii. 

(  ~  Mr.  II  unltT.  I'miliDL;  mi  HUi'inlinn  cf  »lru<HuK  in  tli«  onalH  of  the 

Mfrv  iMVTiouH  to  ita  (lilHluUuii,  Hiiil  iJiat  Uio  niti-n-  nlmvc  thn  lue  seldom 

nlm  when  tii-d  a]>  in  Uie  openlioii  for  am'uni-m,  *t)  tlint  na  hood  u  the 

JifMafCMxncsnnaj.  the smoadu}-  bluu<lingdr»ti'>>}«  ilir  ]>iiiictii,  wtuUil  to 

nnelndp  tlint  ■  prcvioai  dti>i.-M«  took  j>lnce  in  Uie  coats  uf  tli«  ajl^ry.  .  .  . 

Jb.  fluiiUT,  Truin  hatiuc  taitAt  tb«-sc  ubsiTvallous,  was  luJ  lu  |>i'»)'OS«  llial 

art07  slwuld  be  Xmkcn  uj>  at  soiue  diBtaucu  tVoui  tlie  diiteiuiti<l  [lai't,  to 


DISEASES  OF  ABTERTEa 


Hive  mortality  occnAtoned  by  the  above-mentioned  ososw, 
tho  liivmurrhftgu  dtiriDg  operation,  wlii(.')i,  in  all  eaan  w 
tounii<)iti>t  coulil  l»o  Applied,  wfi»  frightful,  and  Bomedmea  i 
fatal,'  and  wliicli  was  often  severe  oven  wiien  tho  arttiy  w 
inan<Iwl  above  tho  tumour,  since,  in  a  deep  sac,  it  waa  n 
to  let  r.ho  ve^iaol  bleed  in  nnlcr  to  find  its  inoutb.  Wliat  fi 
taltty  wiw  litter  lliitt  ojicriitjoii,  prK(rli!i«<]  oa  it  usually  m 
popliteal  space,  we  have  no  means  of  judging  oxocpt  by  oo 
tbtf  work*  of  tbo8e  Surgeons  who,  like  Pelletan  and  Itoti 
left  the  records  of  their  iudmduaJ  e3q>erienoe ;  and  it  cattn< 
often  rt'iK^atiid  Uiat  xueh  data,  tbouf;)!  tiM>fitt  in  many  rv*ft 
untrustworthy  as  statistics.  Statistics  of  operations  to  Ix 
««}  or  aiitliority  must  bo  founded  not  on  ciiwrs  ari>itnirily 
for  publication,  not  even  on  the  individual  experiencw  cd 
gui#hc(l  opurntofM,  bowovcr  fully  and  frankly  givon  to  tin 
but  on  tlie  genera]  ex]>erienee  of  tar^  hospitals,  embraett 
<nue  iniliwcriminatoly  for  a  long  scr'n-*  of  \'«ar».  'Ilu*  liaa  n 
been  fiilly  effeetevl  or  even  attempted,  and  till  a  very  few  yi 
wa»  cntii-cly  unthouglit  of.  Tlic  mortality  of  every  opw 
ancient  times  niuttt  have  been  high,  ftiiioe  tbo  after  treata 
far  more  arbiti'ar}'  and  artificial  than  at  present ;  but  what 
portion  of  ili-atli*  may  have  Ixvn  we  cannot  now  aitoortain 
in  tho  well-known  passage  referred  to  on  p.  872,  aaya  of  1 
ration :  *'  I  have  triwl  it  my«'If  more  tlian  onoo  or  twirr 
seen  it  tried  by  olbora ;  but  tJie  e\«it  has  always  been  fall 
AVilmer  of  Coventry  said  that  tn  the  year  178U  there  had 
ourreil  in  thtH  eonntrj'  one  well-authenticated  case  ofaoocCM 
over,  in  I'oUclan's  Cliniqne  Chirurykale  (vol.  ii.  pp.  117-1'j 
will  be  found  notes  of  four  o[)orntinna  of  lua  own  and  tax  \ 
in  Italy,  in  which  success  is  olaiim-d  tn  no  fewer  than  sow 
and  in  Itoux'a  Qnanmte  Anuefa  (vol.  ii.  p.  •lt>8)  tho  only 
corded  cases  of  the  operation  on  the  popliteal  or  fenwral  » 
opening  the  mo  were  MicceflitfuL  It  ia  probaUe,  tbonC 
Fott's   view  of  the  mortality  of  the  operation  was  too  , 


na  tn  diminish  Uie  risk  of  hntaoi'rhiwp,  aod  n4lR)it  Af  Uic  Bitmy  bt 
r«a<lily  st^iMirrd.  sbi>ul<l  onv  mirh  aovidont  l>s|ipon.  Th«  fcwM  < 
ciilmion  boinx  tlms  ukcn  off  fram  tlio  aneiiri»n«l  nc,  Uie  pra^n 
discRsQ  would  bo  ■toppnd:  and  ba  ihauftht  it  prababl*  UMt  tJT 
w«ro  l<-rt  In  ilipmsclvos,  tha  mo  wltli  lis  oonl«nt«  mlslit  be  aban 
the  irhntr  ortlie  lumour  r«muv«d,  wlikk  wcmld  mtiler  any  ofK 
the  inr  iinn.icoMAiv."  Hunter's  IVork*.  vol.  iU.  pp.  M5,  MIL 
>  Roiix.  Qitantnte  Ahum*,  iia.  vol.  U.  p.  40. 


HUOTEIUAN  OPERATION  FOR  AXEURISM.      389 

Jtiiouj^  the  immediate  siic<?e«  rif  rlic  iiitroiliictinn  of  llin  Hiitit<^riikn 
ti<>ii  Ki)nn-«  thut  tlii-  ol<l  motluHl  most  have  been  tnr  more  fataL 
Sow  Uw  UouWrian  oporntioii  on  the  femorul  nrtcry,  n.-<  [irnotiw^  at 
[iniM-iit,  fjivtis  1^  yfo  sluill  »)0,  a  mortality  equal,  or  nearly  so,  to 
th«t  of  aiDjititfttioii  of  t.lift  tJiigli;'  coiiMVjiu'iitJy  tlm  jini]ii>ri,ton  of 
deaths  aft<!r  tlw  old  o|>eration  must  liave  been  §oii)othing  Irig^ititil, 

The  risk  of  tia-niorrliiipi  iluriii^  the  oiMTUtioii  i*  ii  vvrv  foniiid- 
lUe  one  wiion  no  touniiqiK-t  can  I»  appHwL  Mr.  Syme,  however. 
In  iaeeee<le(l  in  Mnnml  t-iiatn)  in  |?'tlinj;  tliroti;^!!  thcnc  (]iiii^-n>u» 
(fcntions  without  fatal  h»morrhajro  by  the  same  espwlicnt  as  he 
tmwith  itnoh  hucccks  in  iymg  tiiu  vowi-l"  for  woiiinl ;  a  jinni«v!ing 
to  which  the  operation  nn<ier  consideration  beai-s  mnch  aiialogj*. 
HcgpeiM  the  wns  at  first  by  n  moderate  puncture,  whii'h  allim-.t  him 
to  iDtrodtiee  a  finger  into  tlie  sac  and  feel  for  the  opening  of  the 
'««l.  If  ihipf  opening  is  not  largo  cuongh,  ho  dilaU's  it  ho  am  to 
pi  in  one  and  another  finger,  and  in  one  ease  the  whole  hand  np  to 
ihswritt,  nntil  llio  point  !»  discovered  at  which  Uio  prowuro  of  Uio 
hgas  arrests  bleetling.  Meanwhile  the  ojiening  in  the  skin  is  of 
owne  phjggud  by  the  fingont  which  have  boon  thnist  into  it,  to 
'In'  no  gnat  goxh  of  blood  takes  iphce.  When  tlie  orifice  of  eom- 
■■Boicatton  between  the  sac  and  the  vessel  lias  thus  been  eomniandc-d, 
Iw  *tc  b  opened  freely  ami  cleared  of  clotA  Then  the  i cwel  ia 
oiied  with  fore«{)S,  if  it  is  fairly  risible,  and  tied.  If  the  artery  is 
Wexpoaed,  the  opf-nitor  muHl  kivp  his  (iniri-r  still  pn'.*.ii!(l  <m  the 
*>we,  while,  with  the  aid  of  his  assistants,  he  scratches  away  tho 
•••wb  tltat  ubsmire  it.  Fwrther  refl-ronee  to  thi^to  operations  will 
•  OHiio  in  tlw  sections  treating  of  (Jarotid,  Axillarj-,  and  Gluteal 
wiiriain. 


ThB  HfSTERIAN  Ol'KBATlON  BY  LlOATURB. 

Tho  trcalmnnt  of  popliteal  aninu-ism  by  Itgaturo  is  on«,  and 
the  most  perfect,  of  the  miuiy  diseoverii's  of  mo<lem  Snr- 
It  reduced  a  dimMisc,  which  before  was  almost  imifonnly 


•  I  do  not,  of  oourao,  mtan  tli&t  tbc  npcratloiiB  «ro  cinnll^  stwere;  but 
Ikl  ibout  tli«  siun«  nutuLer  of  puiiimts  ilio  aftnr  cnrh,  I'liih  »  prohnbl;^  to 
k  t(iMiinl«d  fur  bjr  iho  state  of  the  circulating  >jsl«ui  and  of  tlio  contti- 
tukm  whkil)  givM  Hm  to  an«uriiitii. 

t  It  i«  not  iut«n(i«(l  to  Kssert  that  the  pracUee  of  Ijiag  arteries  i*  tt 
■0<Wm  invnition.  -*'ni«  Greek  and  Arabian  p)i.v»iciaiis,"  buvsMt.  tiodgsoD 
(0p.  cit.  p.  leU).  "  inoie  eapvuially  .lilius  otid  Puuiua  of  .^giiia,  distinctl/ 


390 


DISEASES  OF  ARTEUIEa 


serion^" 


J»tfl 


fatjil,  to  tlin  position  of  on«  of  tlie  moot  manageable  ofa]I  sen'oc 
siirgicitl  iiifoetioiiB.     It  is  true  tJiat  in  still  inoru  rnct^nt  tiuHt  a 
IIm^Jich]  lioA  iH^rti  ili4(H>vi^ns)  which  i«  UMtally  &upi.i?»afiil  nt  even  U-fts 
risk  to  life;  but  thie  in(>thod  of  coniprcstiioii,  tliou^b,  sot  n*c  shall 
ROe,  it  ■nayconiinonly  im  rcckoiit'il  iijxiti  in  p<)[>lit;e:il  aneurinni,  may 
fail  oven  thero,  and  there  arc  many  artpri«s  to  whioh  it  is  iuappH- 
cnble;  m  (Imt  t)io  MuiitvHaii  ojierutioii  of  tying  the  arteiy  abo\'o 
the  sac  still  is,  and  pi-obably  will  long  romdn,  tlio  last  rowuroe  of 
Surgeons  ill  the  gravt-r  ciwm  <)f  aiiewrisin.     Of  so  great  u  dih<;uvery 
and  so  happy  a  triumph  of  our  art  over  difficulties  wliicli  we,  who 
Imvc  btvn  tHiight  Imw  to  coinbal  tJwni  i«iico«wiiilly,  cannot  mtinuito 
in  their  full  nwgiiitudo,  the  liii^tory  is  always  intorosting,  and  the 
right  api)n'(;i(iti(ju  of  tlw  oliiiiiis  of  rivnl  invtMiturs  is  u  utiit1<^  of  n*^ 
slight  importance.     Unfortunately  the  limits  of  the  present  work  i 
not  iiUiitv  iif  ini  mkHjiiato  <lisctiiMion  uf  this  siibji't-t,  iiii  thai  ull  tla 
Clin  bo  said  about  it  must  be  comprised  in  a  very  few  woiils,  and  it 
in  more  with  a  view  of  avoiding  anibigLiity  or  difiimilty  in  nviding 
forotgi)  books,  than  of  writing  a  portion  of  tlie  Historv  of  Surgeir, 
a  tiLsk  til  which  tlio  prownt  wurk  tnakt.'^  no  claim,  lliiit.  the  loiinKinj 
brief  account  is  inserted  of  the  rival  claims  of  Hmiler  and  Anel  to 
the  lioniitir  of  giving  Ills  nimio  to  the  opcmtinu  nmv  in  »n:     This  ^B 
operation  coriaistA  in  scouring  the  artery  by  a  single  ligature  al  *  ^M 
d'iMtinw.  from  tho  sac,  and  betwwm  it  and  the  licart.     TIk  studriil 
will  always  U?ar  in  mind  in  reading  most  modern  Freneh  works  on 
Surgery,  thai  they  intend  by  the  '  nif^tbodc  d'AncI'  tho  wnic  thing 
as  Engtisli,  German,  Itiilian,  and  American  writers  do  by  'iho 
Hunlcriim  operaticiii.'     The  t^ssential  <liflVTfiK;o  betwwn  Hnnti-r's 
and  Aiii-ra  ojjcra lions  has  bi-en  shown  so  often  and  so  clearly,  that 
it  might  have  been  expected  that  the  unworthy  attempt  to  dtT»rivi> 
our  great  Surgeon  uf  his  dm-  honour  would  have  been  long  sijic* 
given  up.    llie  countrymen  of  Petit,  Par^,  Ihipuytrcn,  Larrey,  ««*•* 
a  thoiiAaiid  otlier  famouA  Surgeons,  surely  cannot  be  actuated  by  *" 
puerile  a  motive  as  national  vanity  in  tlio  attempt  to  transfer  to  off*" 
of  tlieir  compatriots  tlm  honour  <if  diswrt  ering  the  bi«l  uperaliou  ft**" 
aneurism.     Yet,  as  tho  mistake  they  have  been  in  the  habit  of  oeiH" 
mitting  on  this  subject  is  a  sonu-wbut  obstiiiiito  one,  and  sutxiiBf 
oven  in  the  latest  Frenoli  work  on  tJie  subject  (tliat  of  W.  Broca^j 


recomineiidi^d  tlm  liaatitrc  otlho  bracliial  Briery  a  few  rmgcrs'  brcaillh  bcb* 
l]ie  nsllk  for  (1i«  auiv  of nimmsm  at  tlie  bend  oftliA  arm."  Uiit,  like  mu} 
tui'gicft]  iiivf^iitions  of  the  nndents.  it  Iiud  (•t-i'ii  1<m<1  until  its  rnntrod action 
by  luoilifra  Surgeons  in  u  moie  complete  and  nioru  procticnblo  ehapn 


I 


HUNTERUN  OPEIIATIOX  FOE  A^'EURISM.      891 


iliMtjnction  botutwii  Aii<-r.«  iiiotinHi  niui  tli»t.  nf  HtiiiU'r  iiiatl  bo 
Itcro,  tliuugh  tliis  wilt  l>o  doiio  oiiiy  cureorilv,  and  as  litilo 
space  as  poeaible  hHI  bo  u-iliU:<1  ujiuii  a  <iuc»t4uu  vrbicli  bus  liocume 
rntlic-r  [K-n«inal  tlum  suiontilic. 

llw  old  inethud  of  o{)eni(iiig  fur  uiourijtm  hiw  buon  di8cu«io(l, 

And  iu  radiunl  error  ban  beon  seen  to  be,  that  iu  authors  conlbiuided 

wbat  is  in  realitv  the  t'tfiiri  of  iiuttiri.^  for  tbu  euro  of  lliv  <liMt!(iiic, 

viz.  dm  deposit  of  laminated  tibriu,  with  Uie  essence  of  t)io  malady 

itself;  and  instead  of  utrivijig  to  viieoiim^!  und  i>roin<)tu  tliito  d«- 

pOMt,  thought  it  notwssary  to  undertake  a  severe  operation  for  the 

jarpoee  of  rouiovtiijr  idl  ituch  clot«  from  tliv  nyvtetn.     Anotbi^r,  tuid 

hardlj'  lc«»  fatal  objecdon  to  it»  genera]  application,  was,  tliat  as  tlie 

old  Surgeond  iu!v<t  oontcnipluted  ilu;  potwitiiHly  of  n  ciiri!  <jr  tlie 

uenruun  without  the  entire  sUHpciLtiou  of  itie  circvilatiou,  it  wa» 

Dooeasary,  in  tlieir  view,  to  tio  the  artcr)-  oto»e  aljovv  the  tumour, 

tnd,  this  having  been  done,  it  wuh  found  out  tliat  the  blood  would 

tmlly  eitc»[)0  from  (ho  lower  end  unless  that  was  idso  tied.*     TliO 

|nu  merit  of  Hunter  con&iata  in  JiIa  having  avoided  botli  tlicse 

Won;  in  hi»  )uivin<;  s<!en,_^cs/,  that  it  was  not  nceessnry  to  turn 

IJM  clots  out  of  tJie  ani-urinmal  tuiuour,  no  tiiat  no  ineiition  wai 

n^uired  to  ojjch  tlic  latter;  and  second,  tliat  it  was  not  ncnswary  to 

^  the  circulation  through  it  abiwlutely,  hut  only,  a»  he  said,  ''  to 

("is  off  UiC  forci'  of  die  eireidatiou,"  so  that  tho  artery  tiiiglit  b« 

t>lxn  up  some  distance  fmm  the  koc,  and  therefore  at  ■  part  where 

"•inilii  ]]rob«bly  Ixj  ibiuid  licaltliy;  aud  further,  in  lus  jwrwiviiig 

''ut  the  ligature  of  the  main  artery  of  lliu  Uiiib  dt^sa  not  involve 

">  gangivne  oi'  the  extremity,  but  that  tlie  ajiastomosing  vL'wul.t 

•Xy  he  Dwiled  to  eany  oti  the  ein-ulalioii.t 

Fioui  theiM;  oon  si  dura  lions  Uunti^r  was  led  to  propose  the  lign- 
''■noftite  artery  at  a  {M>iul  some  diMjinev  aliovo  the  sao  for  tho 
^*tnvraneun»m,  tlio  result  ofdisonse;  and  that  bo,  at  any  rate, 
*'*d  Ins  oonleni[M>rarie»  tiiought  tlial  lie  was  muking  a  proposition  of 
^wtling  originality,  is  clear  from  the  terms  in  whieh  Uunler  cau- 
""Muly  recommended  it  in  his  Lucturets  and  from  titose  in  wliidi 
''(Wtfi^  commented  upon  what  appeared  to  liim  its  rashnou 
'*"i  its  d«iiger«.t     That  it  wiw  vquully  new  to  Anel'a  countrymen 


>  But  nom«  of  ifaa  old  opomtoi-t  used,  n*  we  haro  rntun,  on«  ligaitirii 
^(Pl  386.  uoltf).     Tins  fuui  shonlt]  not  be  fbrijotton,  u  buoiing  ou  Anel'a 
I  to  orijiiiialily  IU  til«  Invention. 

Tliii  biul.  faowuiur.  boeti   pivvioiuly  titutjLt  by  IJollcr  {qiwied  in 
Siupa.  Wiilwrt's  Irunti.  p.  i'i'-l). 
',  See  Unnt«r'»  Workt,  voL  L  pp.  till  et  sof. 


392 


DISEASES  OP  AnTERIES. 


(Rlthowfih  BOventy-five  years  liwl  einjwed  dnring  whicli  Uw  i 
<l(>vii^  by  biiu  might  have  been  oxpcodvl,  luul  il  rct^yl  ope 
now  ];rincii>Io,  t**  rovolutitmwe  Swrgi>iy),  is  equally  clear  (i 
peruxnl  of  die  pleaaant  work  of  Roux.'  Vi'n  Tviw\  iIkti',  that 
in  EngUiid  llio  prciit  K'IioiiI  of  Hunter,  am)  in  lialy,  Pi 
Viicoa,  and  Scarpa,  had  every  where  spread  sbroiad  the  um 
Huiitorian  opcratiin),  tiw  old  method  wim  piititng  grvmnd  tool 
more  firmly  in  Fraiiiy),  nntil  M.  Roux  hims«lf,  after  his  i 
from  Enghind,  ri-imporLtl  Himtrr's  o|xtnitioii,  whi<')i,  m  wt 
see,  had  boon  performed  once  by  DcsatilL  In  (net,  he  saj-s  ( 
■wa»  not  without  artoniidimi-iit  tliat  tlio  Ptu-in  Surf^ns  Imjot 
practitioner  at  An^ra  bat  ing  been  rafth  enough  to  apply  Bu 
niothud  to  a  tmumnlic  anmrimi  in  Ihe  btnii  of' lite  fOve:  Um 
case  on  which  Anel  liad  ojicratecl.  So  ntteriy  had  tl>e  meow 
thin  rcpiiU-d  diMootTni'  iHTi^hnl  with  its  nuthor.  Il  may,  hot 
bo  replied  tliat,  ihou^rli  Aucl'a  o[>eration  fuiled  to  atlratrt  tLa 
tiotiin;  ]i»  Hunter's,  this  dot-s  not  provo  tliat  thvr  arc  not  i(b 
in  jn-iiieiple;  nordocfi  it.  liven  if  it  were  mi,  howe%'er,  thent' 
bo  no  little  iiyustico  in  parting  silently  over  tiw  merits  oftfai 
who  excogilatod  tliu  [irim-iplo  by  profoniid  rea»oniiig,  b|>])Bci 
Spito  of  searching  hostile  criticism,  explained  clearly  the  ihn 
wljicli  it  n«tcd,  and  suecut'ilcd  tints  In  iorcitiK  thv  world's  aUi 
and  imibition,  in  favour  of  one  who  was  <iuile  igiiomnt  of  tb 
principles  on  which  the  curt>  of  the  disease  must  he  foundn 
who,  for  any  tliiiij^  lliat  uppeara  to  the  contrary,  wa*  guid 
pure  chanoe  to  the  selection,  on  perfectly  false  principleSf 
operation  which  he  never  rvp«.<At(<d,  nor  )<crf<tui<hil  otlu-rs  to  r 
This  would  be  so,  bad  Anel  even  liappcnod  to  stumhlo  on  the 
opemlinn  an  Ilmiter ;  but  tlie  tnith  i.t,  tlmt  the  opumtiorw  an 
foctly  difforont>t  and  rost  on  different  princii^cfi;  and  thai 

*  QHarttnu  Amur*.  &e..  vol.  ii.  |i.  el>. 

t  No  better  proof  of  iliu  rndknl  diOernnoe  between  iIm)  turo  npm 
can  be  retiuiivJ  tlmii  is  fiimialiril  l>y  ooinpimng  two  <«nii«AutiTe  jmsi 
wrlt«r  n'liu  perniats  in  mlling  Huiittti's  nintliod  Ibc '  mMtods  iI'AimI 
pp.  nOO,  MOof  M,  Brucn's  tvoik.  In  th«  former  pA^c  ha  Im  oanAdl 
JudiciouHJy  exjilainiof;  tlii.'  uavcniinl  dUleniac*  in  Uwir  nffMt  mi  tl 
lateral  (>ircu1iiiiuu,  nnd  iR-nc?  on  th*  jtMiMtt's  efaaoM  of  nnomy; 
second  |ilii-  imnn|i«  conimondiii;  "ftiiiJlont  iBsintenant'}.  fa*  hu  rei 
to  \i'n  habitual  lauf^initc,  nnd  Rjicaks  ef  Uimb  both  uDd<T  ouo  cvtani< 
slenalinn.  Tu  such  un  rxd^t  U  tliU  pfibnUjr  of  error  earrieil,  tlu 
diStoutc  ut  Hmt  t(i  Hfc  tliat  in  tlin  lalt«r  jHissiit^  tbe  ooninion  or  Hno 
OptnXiaa  is  spoken  of  un(l«r  the  »•■»«  ■mdtlwde  d'Antl:'  while  i 
fonD«r  the  mmo  lona  sigiiiAos  the  now  disused  piiKoeJiiig  iibM 
Surgeon  adopted. 


ANEL'S  OPEIliVTION  FOB  ANEURISM. 


3d8 


one  wiU  pmbiat>ly  succeed,  tbo  other  will  almost  flertainly  fail  in 

duws  where  t\w  miuunvin  is  ttio  ixvult  of  cli$«a»c. 

The  oaae  on  which  Anel  operntetl  has  been  ofit^n  qaotM,  and  is 

KPT  well  known.     It  nowl  not  Iiito  be  related  nt  length.     Tlio  fiieis 

wtn  theM  :  a  nuui  Iiad  received  a  woiirut  (if  tlio  brucliJal  artery  in 

nocMctioiL.     It  n  said  Uint  a  fortnight  af^nvm-dft  an  aiieiirifni 

feimeil,  and  the  wound  reopened  and  ga\«  riw  to  li.-i-iiorrhage, 

whidi  was  anvuttud  by  oumpre-Mion  ;  and  that  after  tltis,  the  tiunour 

Wmie  rery  rohuninons.     Wliat  length  of  llino  hiul  cIiijim^I,  and 

•iuW  liio  state  of  tiic  tumour  wm,  when  Anel  nndortook  his  opera- 

tiou,  we  are  not  infonncd.     Ttie  o[>omti«n  ouiiHixLcd  in  exgHMiiig 

liw  bntcliiid  artery,  tying  it  M  near  tJio  tumtmr  as  posBJblo,  and 

^plmg  "tli»  [irojier  div<Mting  and  bandage.^'     Wit  ure  nut  told 

esimwly  whether  tlio  blood  iii  tlie  sao  "kub  solid  or  fluid;  but  it 

appears  cloiir  ttuit  it  yn»  in  the  lattar  tAaU>,  aii<l  tlmt  the  only  ren- 

mh  "hiob  Anot  had  for  not  opening  the  sac,  aiid  emptying  it  of  its 

■MleiHs,  was  tbni  ho  wibt  able  to  eni]>ly  it  by  prcsxiiro.     Tlmt  tliLs 

*»  m,  appean  implied  in  his  own  observations  on  the  subject. 

n«ttvfi,  "  InnH'adof  tyinf;  the  art<'ry  niiovi-  ami  In-low  tint  tnmour, 

1  cflly  tied  it  above ;  and  besides,  instead  of  opening  tho  sac,  I  did 

■N*  meildle  with  it ;  not  doubting  that  the  bloiHl  which  it  conlaincil 

•toIJ  disappear,  having  tbo  op[K>rtnnitv  of  passing   towards  the 

*uwniity  of  the  limb,  and  tliiil  liic  wic  once  cnijitii-d  would  not 

SO  igain,  but  its  dssses  shrivel  np,  and  tlie  tumour  thus  disap- 

1*n:  and  all  this  occ-urifil  a.i  [  nxju-etiii."     It  eoeins  clear,  then, 

"wirAnel  expected  tlie  blood  in  llio  sac  to  pass  on  towanls  tho 

"ttd,  tliat  blood  inuKt  Iia^'O  boon  fluid,  and  [irobnbly  the  "  suitiiblo 

WMBjijj  iind  bandage,"  which  be  says  he  applied  after  tho  o|>era- 

''*Di  may  have  had  quito  as  much  to  do  with  tho  euro  as  the  liga- 

'"Wof  il»o  artery;  and,  after  all,  the  case  nmy  have  been  cured  by 

"itMt  pmeuro,  an  c\x-nt  not  luieontmon  in  recent  trnuin.itic  an- 

•"fisms  at  Ilic  bend  of  tlie  elbow.     This  is  evidently  quite  a  diflerent 

^pBnlion  from  Hunter's ;  tho  only  priticiplo  it  has  in  common  with 

*'*,  is  that  of  leaving  the  sac  unopene<l ;  and  few  persons  who  read 

"^tiiwit  pnyudiv-e  Aik  I's  oonfnsixl  and  obscnro  account  of  his  ope- 

'^tion,  will  fail  to  see  tJiat  the  reason  of  his  not  meddling  with  the 

^^  was  most  pcobahly  tiuit  it  cotdd  be  emptied  by  pre«»urt<.     This 

^w  is  a^n  sapported  by  tlie  fact  that  Ileister,  who  fuliowixl  Anel'a 

'^'Qomit,  and  apparently  tfoko  on  tho  authority  of  Iiis  single  easo,* 


«  H«stcr.  fnttit.  CUnry.  pars  it.  sec.  i.  <h-  xiii.  §  iO,  Amslclod.  1199, 


394 


DISEASES  OF  ARTEUIES. 


idvised  Hk  n))]ilic»ti<iii  only  iii  '  rcJucilito'  aiiouri«n8.    Tliux  it 
not  &p]H!ar  that  thorc  was  mHtfli  of  novelty  ill  iViiul'it  inclluHl,  sinew  | 
merely  conaiHtod  in  leuviiig  to  the  fluid  oontenta  of  tlu'  lumoor  ui  i 
by  the  lower  end  of  tltu  itrtcry  instuiul  »f  tyin;;  tlio  l»(t<-r.  jurt 
Kvyel^rohiul  dono;  uiid  it  may  very  fairly  bo  doubtMl  m  IteibiT  wli 
BOrelty  tfaoro  wba,  wa»  not  a  niistaku,*  and  wbutltcr  Anvl'H  <-:m>,  'd 
spito  of  itx  Niii<(.'O.HS,  ia  not  only  aiiutlier  iiiaiantH)  of  lutpltazunl , 
furtuiie.  At  any  rate,  tlio  rivtults  wlticli  flowwl  frrjin  i(  lid'ort'  Uw  I 
of  Hunter  did  not  aeeni  to  tetttify  to  tlia  brilliancy  of  the  Hkox 
The  great  learning;  and  evident  bias  of  M.  Broca  havo  only  en 
tiim  to  adduce  what  be  calU  six  infttMicen  of  operations 
on  this  plan  before  tlio  dalv  of  Uunlcr'a  first  optmition,  x  pvriwl  i 
M;vouty-Hve  yearti.     Two  of  tJiette  nre  relnted  in  tlw  Itmaert  way  I 
Bortruiidi,  a«  hn\*ing  occurred  in  tlio  practicu  of  ROBit  anoBj 
Stirj^n,  and  were  failuroa.    Of  tlie  otlioiit,  unowaaof  tJkc  temp 
artery,  and  two  others  of  llio  humeral,  all  most  probably  Ir 
nnd  idl  very  likely  curable  without  dillinilty  by  vnry  niuipio 
The  aixlli  ca»«o  is  tho  colcbrated  oiwratiou  of  Uceaidt     It  woold  1 
i[Dpu»iiible,  without  tuking  too  much  hhux  from  int>rr  imf 
matter,  to  di».'UH«  tbia   oporation   fully  in   its   bearings  u|kid 
Huiiteriitu  method.     It  iit  ^iillieiont  to  say,  that  it  wan 
on  a  coAe  of  popliteal  aueuriam  of  Nmull  aize,  strictly  after 
motliod  of  Alio],  i.  e.  by  tyiii^  the  artcri,-  immediatGly  ou  its  Mil 
tiie  wc.      It  appoors  (uotwitb.itjuidiiig  what  lin»  boon  wid  lo  I 
contrary)  to  luivo  been  successful,  at  least  in  its  tnunodiato ; 
the  ii^Htaro  sejuu^tod  on  tlie  <>i^btwntli  Awy  ;  the  tumour  bunt  i 
disdurged  its  contvnts  on  the  day  following;  this  wound  he 
and   the   tumour  diHapiwanxI.     Tliu   [Mttieut   diod  oloveii   mu 
afterwards  of  a  disfasc  of  the  tibia,  whioh  appears  to  luve 
t4)tnlly  uncontioctod  with  tlio  opcrution.     Thin,  tVii,  was  \\ 
tlio  same  as  Anil's  operation,  and  tberofore  niiMod  the  sm-uoJ  i 
tliinl  prineijilcst  ilWtmtod  by  tho  ini^od  of  Hunter ;  vix.  lint  I 
artery  may  be  tied  at  such  a  diatanoe  %.*  fltill  to  allow  cireuUti 
tiirough  tlio  tumour,  ajid  tlial  tlio  pre\-ious  iaerensu  of  oull 
branobee  is  not  neoossary  io  avoid  gniifp^'ne,  ntid  that  tluircfott  I 
artery  may  be  tiod  at  tliu  most  convenient  spot.} 


*  It  seoBa  03  if  And  expoowd  thai  tbu  sso  would  «Bi]»ty  lUtU.  i 
would  not  aftnin  be  filled:  being  igaonint  vflbo  roHux  eun««t«iitl  oft 
ean  bf  eoHguUiiou. 

\  Soo  p.  301. 

;  It  wi>uld  be  unjiiBl  to  deny  t]|«  neiit  ori>ea«)ilt  In  apptrin^ttel 
mott  forKulteD  loctliod  of  AdoI  to  lli«  tKntineut  of  tli»l  uxmI  funsiJ 


r 


HtJNTERIAN  OPERATION  FOR  ANEURISM.      395 

The  practJcni  objections  to  ^Vncl*s  method  may  bo  Uiim  siimmctil 

upk     It  ktive.'i  lib  (itirroiit  iJiroiijrli  ttit*  aninirimn  ex<«pt  ihe  aligUb 

miul  weak  reflux  flour  rrom  the  artery  below,     Consvtjiwiitly  ihu 

dot  &ni>«l  will  iiKisl  likoly  Imi  wifl  oiid  Iuii»o,  aw]  tiui  tumour  will 

mipjiurate.     It  places  uoder  tlie  ligature  a  part  of  the  ^xmvI,  wliicli 

HoH  more  Ukoly  to  Ix)  (IIw'-il'u^I  tliiiri  iiny  ollior  portion.     Il  la,  in  most 

^■catMrn,  the  most  difScult  of  all  motliodH  of  operation,  Hinec  tlic  artvry 

^pB  pnned  tMivk  by  t)ii^  {>r<>j(!cti[>ii  uf  tlio  Uiiimur,  and  h  t]ii?reforo 

at  ui  unuatimtl  depth,*  while  tlie  operator  has  not  tJia  ^uidu  for 

finding  ii  wliiclt  a  pmbo  pii»»cd  out  of  tbo  sac  would  furnish.     For 

all  tlii'w  reasons  it  aeeioa  that  ui  any  caso  wliere  Anol's  method  was 


i 


ail^Omi  (lu  it  (licit  uns).  popliu-ot  luiciiriam.  and  s^lill  mora  anjust  ti>  (l<-ny 

lhtttlieM[t>^rieiioc  thL-nce  noqiiii-eil  iiiiglit  po&sibly.  Iiiul  he  aurvireil.  ntiii 

■■•d  Hunter  not  bmn  in  existciicG  (in  fuel  hail  all  tlic  nJrvumsUincci  been 

^Ittictl).  have  oondiii'Ici]  him  to  HiinU^r'*  (ii«ciivriy ;  but  it  ii  monitiuus  to 

**lap  Dctaull,  an  M.  tlrorn  H'i<Ji(»i  to  ilo,  an  (he  livnl  i>r  lliintcr,  ivlion, 

•*M»iling  tn  hi«  own  hIiowiuKi  PesniiU  liimnHf  was  qiillo  cniiti-nt  lo  ]>ii%» 

••  Hunter'*   selmUr.     "With  a  aeir-Hl)»«gnLioii,"  »■  M.   Bkm-ii  amuNliigly 

^Ji,"s)ikh  hiH  English  deimctora  hav«  bcvii  uiihI)I«  to  iipgrreeiwte,  this 

^fW  Surifeon,  who  then  hail  boeomc  a<.-i|iiuiiitvd  with  the  upcniiiou  prae- 

^a>d  b;  Htinltfr,  did  not  hetiilme  lo  Mdopt  tlie  p]v<.'«[>ts  tnu^jht  hy  liia  tlhis- 

'rtouj  ri»iJ"  (p.  4911.    Dt-Mullt,  ill  fact,  wiw  uimwaiv  uf  bis  lilli>  li>  llie  glory 

^hid  H.  BruCH  vluiins  for  him.     A<i  tu  llid  iiisiiiuutiuii  wkiuli  M.  lti-ui*H 

'"•Wbiiw  tu  miil:«,  ihut  Huiilt-r  nnii  iDdi'blwl  for  liis  ojiinntJoii  to  Dt^sBuIt 

"^  Owana  of  ABaalitii,  who,  ai!<u>r>Iiii];  to  him,  wua  pveiieiil  ul  Di-suult's 

f^PflWion,  011(1  ri'lnlpd  its  dutaib  to  Hunter  sliortly  »ftiTwwd»  iu  Kiigbind, 

''   nhlrs  its«lf.     The  HuutPiiiin  opemtioii  wuh   tukni  up  iicmhi-iv  iiioro 

^■roly  than  amo&g  the  ctnim-Dt  Ilaliims  who  wen.-  proud  of  Luin^j  «f  the 

I  "**'*ilwi«i  cobooi,  us  <ic  hiive  s«cn  nlmvi-  from  Ihi-  uoiiti-mponu'v  ftt-euuiit 

U.  Kotix.      Iliid  one  of  tlieir  nujnber  conveyed  to  Iluntcr  fiom  Pdria  Iba 

■at  idra  of  tlieopemtion  for  nncurism.  we  mny  be  i|nilc  buvc  ihiit  he,  or 

'^^lafofhiB  MimpntnotK,  would  hnvc  snid  so.     A*anlini,  an  lulinn  Sni^eon, 

^(bu  only  tx'rvon  pr»rnl.  as  fiLr  as  uc  know,  both  at  DoMniiUV  apeintioii 

''d  n  th»  fti^t  oprmlion  uf  Tliiiitcr.     It  viaii  msiiily  lhroii(;b  A*»iilim  tliut 

^^  new  n^thod  of  livniinH  "tieuri*m   wbm  broii/ht  into  lOHne  in   Itnly. 

nt  and  all  olh<^i'  ItHllana  always  Hpeak  ofilint  itit'thod  ax  IIinitcr'». 

**'t]i|J4  ^,1,  have  be^n  so.  had  A^iuliiii  lAiight  it  to  Uunltr  fivn  ivlint  hii 

^1  hliDM-lf  Iranit  of  IWaull  ?     But  Uie   fm-t  aovnia  to  be.  ihat  Pri^nult's 

^Cntloii.  whieh  waa  not  brillinntly  ducevifti-ful,  niid  whieh  he  diil  not  put 

*^*11i  aa  original,  atlnirted  httle  atti-ution  from  himself  oraiiy  body  flue; 

^**1  thai  Lc  had  no  deshe.  as  he  had  eertuiiily  uorinhl.  to  elaiiu  any  priority 

"*«rHltnler.  whom  teUirhiiiRhe.  on  the  contrary,  followed  uilh  gi*8l  iiHelll- 

"*■>(*  anil  great  •uvceiui  in  Ibe  aiuglu  opcrutiou  whieh  he  had  aubg«queutly 

^  opportunity  or  pmctiiiiDg. 

_  »  I  exclude  tha  comparatively  rare  case  of  tJio  artery  b^iu);  raised  and 
~**la»ed  by  ati  oiieurinm  RrowiiiK  into  the  deep  purls.  But  here  ulmr  I 
*haald  Lnin^nc  Ihnt  the  difhetilty  of  diittinguishinfj  the  vesnel  would  iiidiuo 
^  opamtor  ta  ruort  to  tlio  opening  of  the  one. 


898 


DISEASES  OF  ARTERIES. 


fi^aoihle,  the  old  operation  would  lie  equnlly  ])ractM3Rbl0,  «> 

OortJLiu  of  MK.'Ol'AS. 

The  foregoing  obscrx-ationH  will,  it  u  hoped,  mffiee  to 
the  UN}  in  tlio  oontfxl  of  tlie  name  of  niinter  in  d«seribi 
ojiomLion  which  hfl  is  not  dcni«l  to  havo  inwtiUxl  in  Uw  ( 
which  nlono  it  iit  now  prnotiaed,  to  hav«  fli-at  perfonnoi), 
hive  aftornvards,  in  spitv  of  miic-h  oppoution,  tntroduood  into  | 
bvour.  If  tliCMe  Uiinga  do  not  ^vo  olnim  to  an  invent! 
bard  to  eee  how  such  an  honour  ib  to  he  attaimxt. 

Tlie  HiiiiU'riiui  <>)H'rntion  (roiHiHtn  in  tvin^  Uw 
tiie  aneuriAin  is  Httuuted  at  any  convvniont  distanw  abo' 
Tlic  ojtcrution,  an  it  i»  now  praclisod,  diRcn  in  many  imj 
particulars  from  that  whit-h  Hunter  used  to  perfonn ;  |»afl 
which  have  a  moKt  inuti>rial  inHti<.>no«:  ujntn  ito  tiu<-j:«HH,  and 
were  impressed  upon  Hunter  himself,  and  upon  his  adiola 
suoccworfi,  h^-  tho  ti.^iu>hing  of  cx[«riciic(>.  71ium,  }Iunt4!r  i 
tie  the  femoral  artery  at  ita  lower  part  (in  tlic  filmHis  i 
cjditxl  from  thut  circnintitanco  *  Himlor'it  ramal'),  an  op 
much  more  diffipull  and  daiijjeroua  tlian  the  modification  intr 
hy  Scitrpd.*  Htiiitvr,  in  hi«  Brst  o|iuration,  brought  it  taif 
of  the  walla  of  tlie  artery  into  ocHitact  by  four  bcnad  lig 
somewhat  loosely  fastened,  conceiving  this  dtspoution  to  U 
favourable  to  the  «]u*ure  of  tho  artery,  whioli  I»o  dtwcriliiil  a« 
plaee  by  tho  process  of  >  first  intention.*  Hla  own  exporieuM 
erer,  »onn  taught  him  to  niudifv  this  form  of  lipititra,  and 
only  one  string ;  and  the  more  extended  experience  and  n 
of  his  Muecciiftoni  (among  whom  Ur.  Joncnf  luui  duMH-vcdly  ol 
the  fir.<<t  place)  have  proved  to  demonstration,  tltat  t)>e  ba 
of  li^turo  in  a  siiigU»  stout  thread,  dntwn  tightly :  itooQl 
DO  other  form  is  any  longer  in  use.}     Lastly,  Hunter 


1 


*  On  tliis  hesd.  se«  the  section  on  Liitatura  oflhe  FetaonI , 
f  On  Iltrmorriuvjf.  Rrfci-cnce  tnny  nli>i>  b<t  miulv  tn  Liibwtc,  "'I 
aonomirs  da*  div>-rscs  mnthiMlos  ot  dc«  diirnraas  |in>eM4«  ihmu-  TubU 
dsa  art«iM  dan*  le  tniit«in«nt  de*  an^vrUnMS,"  Pari*,  ISM;  Sout 
Um.  voL  li.  p.  3tt9;  Porta.  DtU*  WlMnuiwri  pntolajriob  itOi  JfU 
Milano.  Itua. 

;  Id  Ui«  AmeriMn  JoHrnat  <t/  tht  MrJImt  Sruntrt,  OoU  IMD,  p.  I 
ba  fiMind  a  v«47  inlvi-esting  om»,  in  viUieh  Ur.  Wunvn  StODo.  of  La 
tiril  tW  (lommon  [line  artMjr  wlih  a  oilver  tigaiars.  Tli*  llipuurn 
drawn  tls'it  onoufih  to  out  tlii'uuali  tli«  iitterao]  coals  of  tba  arterj', 
in^  to  Ur. Stone's  judgm^il:  lliveiids  wi-ti;  mt  Hbonand  lunu^l  do 
BO  }ett,  Tlie  (isllenl  died,  nppnrentlj  uf  cnuKes  nneonnvinud  wiili  th 
Uvu,  on  ills  twiMily-eixih  diiy;bui  tLiiB>wptouuafl«rtlK>oiMimtioB 


d 


HUKTERUN  OPERATION  FOR  ANEURISM.      397 

i  xt  all  careful  to  avoid  including  the  vein  wtUi  tJio  artci-y  in  the 

^turc ;  but  tliift  was  an  crrur  which  ho  soon  gAvo  up.     So  that 

the  more  material  iiuprovementa  were  devitted  by  lluiiter  biiriMiU'j 

and  in  f>rincij>l<;  the  fint  oportitioit  which  ho  porfbrmod  was  iden- 

tioal  with  nil  tlul  suooeeded  it. 

^b       The  cfloctii  n|N>n  an  artcrj'  of  the  application  of  a  h'gature  havo 

^fceen  Nlrciidy  di>tailed  in  a  pre\-ioiiB  soction  of  tliis  work  {*wt  vol.  i. 

^^>p.  4i74  ct  f^in-").      W  hilu  thp  changes  thcro  dcscrilx'd  arc  going  on 

in  ttie  artery  itaeif,  the  proceM  of  cure  is  progreAiiiiig  in  Uit!  ancur- 

Um.     Wd  have  soon  almady,  that  on  tho  withdrawal  or  diminution 

of  the  foroe  of  fho  (■M-cnliiLinii,  Uio  priipniuWunoo  of  tlie  lnTsart  iiciiig 

r abated^  the  process  of  spontaneoas  euro  commences.  Tho  ligature 
^cta  to  a  certain  extent  ait  VnlxjtlvuN  iii<'t)i<Kl  lu-Lt ;  that  in  to  »»y,  it 
dimtniahcfi  the  force  with  which  tlie  blood  distondg  the  sac,  and 
tlius  givet  <^>|M>rtunity  for  tluj  ci»i|:uiul)ility  of  tho  blixxl  anil  tlie 
tvulimce  of  tho  part«  to  fiU  the  sac  with  firm  laminated  clot,  and 
so  effect  dte  cure  of  the  dijn.'ii.se.  It  ditlvr*,  Imwevcr,  from  Val- 
■•Ita's  method  in  tliis  important  particular ;  that  its  action  is  local 
lOrtcKlof  gimenil,  and  in  thfrefnrc  incomparably  more  certain  and 
Wow  safr^  As  the  process  by  which  tlie  aneurism  in  filled,  and  the 
dttogCM  wliicJi  it  afWrwanU  nndvrgncs,  are  to  n  great  cxtwnt  the 
■Mw  after  ligatimt  as  in  the  natural  process  of  cure,  tho  reader  is 
'*&fnd  on  tliat  h»id  U>  what  has  been  Miid  above.  But  to  that 
•ccwmt  it  must  be  added,  that  since  the  surrotmding  ]iai'ta  are 
*4i«ily  relieved  from  tension  by  tho  witJidrawal  of  tho  expanwve 
"•fW  of  ibe  aneurism,  tlieir  resilience,  and  the  compression  they 
"Xrctw  n[)on  the  tnnionr,  play  a  much  more  inipijrtaiit  part  la  the 
^Te  after  ligature  than  in  the  spontaneous  cure. 

While  tlte  aneitrisni  is  becoming  consolidated,  tlie  collatera] 
^ircuUtion  is  enlarging,  to  convey  tlio  blwxl  into  tlie  parts  lielow 
'^  ligstuni.     Tbo  meaning  of  Utu  term  !■  aa  follows :  when  an  ar- 


^lyuttefi.  Thu  Ui^tuK.buwtfver.aeemti  to  liHTe  ftiUilU-d  its  purpose.  Tho 
^>J/ aafortunatt'ly  was  not  i-xnmiiied,  so  tluit  l]wi  ooiiilition  of  iLo  ligature 
"■'•u  iiM  Bacrruini-d.  It  ii«(^mi>  to  liuve  been  JiiU'ncletl  by  Dr.  Slone  lo 
■**«iB  OB  Uiu  vcsm)  pi-nnonentl)'.  wiOioul  wHiitiuc  auy  uUwralion,  huiI 
^wtfere  withmit  induHnit  risk  of  m-i^oncliiiv  iiB.-nion-liHj'e,  I  luuch  doubt 
^fc«lh«r  lliU  woulJ  be  so.  At  lomt,  t  Iiiive  jiliiced  u  nilver  li(;alure  on  llm 
.•"aunJ  artery  of  a  dng.  boI  dmirinff  it  tiijlilpr  Ihan  uppi-urpj  aennatuy 
^**n  to  itop  tho  cirentation.  anil  fnund  th«  contu  of  thi.-  vitbhl-I  diviili'd  by  it 
^ra  days  aftcrwardti.  Silver  liffaturcB  do  not  vxeiti!  ulc^urutiuu  wlivn  tlieiii 
**  M  t«B*t<Mi  vpoil  tlwiD ;  Init  hiIvct,  or  nay  oilier  Bulintancv.  ivlifn  ]ii'i-bbhi1 
Valy  on  tfa*  tbMM  (as  a  ligstaro  must  be  upon  ■  lai^  artory)  »ill  ulMUya 
.  tbcm  10  ulcitnto. 


39S 


DISEASES  OF  ARTERIES. 


tery  lia«  bwn  tied  at  any  pvcn  spot,  tlic  branch  whidi  Ireivps  it 
abuve  the  mut  of  tlii^  ojxti'uriiii),  anil  in  tlieir  degree!  tin-  brun< 
abo^'e  thi»,  fi^l  ui  ijicrcii>«cl  pressure,  in  consoquencs  of  the  uei, 
biiuring  column  of  blooil  li:iving  been  barred  in  the  priiic^ijiiil  v> 
Hcnw  llioy  yield  to  tlio  increased  impaUe,  and  become  diatei 
The  ooUatflral  arteries,  by  mnuia  of  wtiinh  tlioy  unastomoso 
the  branc}ii''i  "f  the  parent  trunk  below  (he  ligature,  increafle,  u 
iiierca.'io  probably  in  a  niueli  ^tautr  ratio  tlian  ttie  \airgerr  vessd 
in  proportion  to  the  greater  tenuity  of  their  coata.      The  fiicJl 
Willi  which  llin  ntpillary  luid  nClii'r  mnall  vt^^eU  allow  of  chang 
of  volum<!  is  well  knowu.*     Thus  a  rcadv  way  is  opened  fiir 
blood  to  return  into  tho  [Mirtriil  trunk  belnw  tho  fMMit  of  li, 
To  make  this  clear  by  an  example :  say  lliat  tlie  femoral  has 
tiix)  (n.t  it  generuUy  !»)  some  dis(»tico  below  tlto  origin  nt'  Uio 
funda,  in  a  case  of  popliteal  aneuriam.     The  blood  will  diatend 
nrtiiri"  and  its  bniriclies,  amongst  others  Ihe  ext*TnaI  circumi 
and  its  descending  branch;  whieli,  joining  witli  die  sujierior 
temal  arliciilitr,  an<l  thus  with  the  anastomotic^  magna,  will 
one  of  tho  arteries  to  eonvey  the  blood  round  the  ligaUine  iM 
into  tho  trunk  of  tlio  femoral,  below  thu  oblitttmlcd  spot.      '. 
number  of  such  collateral  arohea  of  anastomosis  is  uncertain,  1 
probjibly  t.lioy  are  numerous  in  most  cases,  and  include  not  oaa 
arteries  only  like  that  above  adduced  a.t  an  example;  but  a  nuinl 
of  mii!«etilar  and  other  branches,  tho  imastomosos  of  which  are 
fine  in  tho  Iiealtliy  state,  tlmt  tlioy  oacapo  our  orduiary  niMhod* 
injecting.! 

*  The  enlAtgcmciit  oftlie  e»llati.>rftl  ve»<tt'lH  must  liepcni]  npoD  tha 
sonee  of  some  ox;gi<n  in  tho  bltind.  as  ut-l]  sa  tlie  sitffii-irncy  of  the  \i 
t^rgo  of  the  h^an.  If  the  fviiiier  be  nbDi^iit.  Uioce  is  no  attmctiOB  ofblo 
to  ih«  i^npilliii-ies  in  ll)ci  [listant  part  of  the  Itmb;  and  a  local  asph}i 
followed  (ly  ^-niiinvae.  ninBt  eDBu«.  Ueflcietil  via  a  t«rgo  would  show  iu 
by  pallor  and  i'»ldiie«s.  with  ahriTikitig  of  th«  dixbil  parts;  a  de(eetir« 
pilhiry  Httnii-tioTi.  witli  sufficient  vis  s  Utrgo,  would  ho  shown  in  a  statiool 
venouH  onnditioii.  pertmps  livid  cunRt'Hiion  of  ihu  limb;  wbili'  iflhtt 
and  the  altructtiuii  be  botli  n*iiDtiii^-,  thu  limb  tnuHt  be  simpiy  oold  i 
inautive — in  fnct,  djiiig.  The  iiitcgi-ity  of  the  whIIh  of  the  aiuulonod 
veHHelH  in  also  nn  iroportant  condition  in  Uio  r«stoi«tion  of  the  coUaN 
cirouiution. 

\  Tlie  iiiimbcr  of  annstAinosiiiit  branches  varies  eonnidcrably.    Pofi 
(op,  eil.)  lii^iiros  n  prepitmtion  in  whieli  he  found  between  fifty  and  >ist; 
Oil  the  other  hnnd.  tlinre  la  n  pi'r-pni'alinn  in  tho  museum  of  St.  Thoim 
Hospital,  in  whiirh  the  blood  is  biixi^ht  down  fi-oni  thi>  npper  tii  ihn  loi 
jiarc  of  the  bniehiul  nitcr^'   by  n  tJnfile  binneh   tho  sine  of  a  erow-ijiill 
Sir  Aslley  Canpcr  states,  jii-ohably  ivfcmn^  to  Uiia  prnpanttion,  as  well 
to  Ilint  of  a  man  whose  thigh  he  amputated  somo  }-«im  aftvir  an  o; 


i 


HUNTERIAN  OPERATION  FOR  ANEURISM.      399 

The  rapiditv  with  wIiipIi  ihis  process  goes  on  ciuinot  well  Ite 

Kjicertaii>«(l  in  the  liumKii  8itt>joct.      In  animaln  it  is  known  Ui  lio 

very  rapid;*  but  in  animak  tbo  prococs  of  repair  in  all  injnriea 

of  veuda  i.-i  vorj'  lar  inoro  nclii-o  rhiui  in  mon,  mi  Uiat  in  ibom 

gmngnae  n*ver  fiilbwa  on  the  ligaturo  of  arteries.     No  soond  oon- 

c]ui)ion«,  tlwrofore,  can  bo  drawn  from  this  exjioriuiiw.     In  men, 

liiiwcvor,  the  process  seema  to  advance  sometimes  very  rapidly  in 

Ute  upper  (Txtrwmily,  whcro  Uio  luiUinil  aiiu.i(«mo!«:*  are  fn-c.    Tiitts, 

in  Anel's  celebrated  case,  it  ia  stated  that  the  pulse  could  bo  telt  at 

Uie  wri*<  on  the  day  after  tlie  Iis«tTin,*  of  i\w  hraoliitil.     In  Mitj'o's 

wae  of  li^tnre  of  the  snhclavian.t  the  pulse  was  felt  in  the  wrist 

on  the  fifth  <biy,  but  disappeared  aftorwiinl.*;  urid  in  a  ciwo  of 

p'pKl*al  anenrism  operated  on  by  Deschamps,  pabation  was,  it  is 

Mid,  felt  in  Uie  aac  sovon  hours  after  thu  o|Ktnition.t     On  thu  other 


'*' f(i1iKt«al  anetnixm,  that  Althonjih  Hie  nna-itomoidaf;  renela  whicli  en- 
■i^  bnmrdiaU^ly  rUpt  th^T  operation  may  he  numcmiLi.  thrir  number 
I  «i2A  'A'nnnU  diniiniaho*.  Ihnio  Inn*  nncrJuMnr  fiddin^t  Ihi^Jr  pinec.  as  ll  wore, 
^^  ^^l  "*  *  bv.  or  prrhnji*  to  a  Mn^lp  tchoI.  which  miiy  bn  found  nearlir  in  tli4 
'-  ^^*  PW  ami  □carlj'  of  ihd  »ic«  of  ihn  originAl  Iruiih.  Wardrop,  op.  ciu  ji,  18 ; 
*K  lUa  Sttd-Chir.  Trmit.  »oI.  «v.  p.  11 T.  Two  Wniilihil  plates,  Oie  back 
Wfroni  view  of  a  preparation  In  which  the  (ollnleml  ci  11111181.100  bus  heeu 
■'("eW  «fter  IJROture  of  the  femoral,  mfly  bo  swii  in  Porta'*  work.  Thi-  very 
■MdomiiiuHiuatioii  belwi-i>ii  Ute  oxt«nial  circumAns,  xupi^rlor  ezl^nml  iirLi. 
*^.  and  aiiastuiaolii-ii  inii^oa.  is  rvty  deai'ty  shown.  Then'  iis  alio  n  largo 
'W  jlirct  aruh  uf  uiuiBtuiiiosis  helwi'eii  the  latter  artery  anil  llie  internal 
'"^Vd^x.  Thus  th(?  feinoriil  and  ])uptiteal  above  the  HOfUriaiii  havi-  beca 
**!<  pfrrioUH.  irliile  below  tbe  anvurisin  tlie  blood  enters  the  popliteal  by 
■■•  pWl  bnuicbea  ftnfi-rior  artieuiar).  which  rei'tiva  Uieir  supply  fi-om  a 
'••It  arterial  DCt-u-ork  in  front  of  ilia  joint,  derived  ft-cin  llie  arlerien  aborc 
"•wUooeil  (via,  profunda,  oiiailoniotiira  inainia,  external  droumllex,  and  mj. 
f*0»r  ■rUeulor) :  a  direet  eommitn  teal  ion  from  tliia  net-work  to  tlte  tibial 
'^ttnent  appntr*  aluo  to  hnvn  rcinforecil  the  anterior  tibial. 

■  See  tlie  expriimctita  of  M,  Itrtica.  op.  eit.  p.  &01,  note.     H«  ptuced  a 

''ffUare  under  ttir  frmomj  nrtcry  of  a  do[*  in  tlio  Rrotn;  tlico  anipiitnted 

^  Its  at  the  knee,  and  noted  tlio  dintiuien  to  wliieh  the  puUnting  Jet 

^^tniilcd,  tmtti  dnnng  the  syt^iole  and  dinKtole  of  the  licoit.     Tho  lijEalui'e 

"  the  ftmii)  was  then  lightened,  by  nbieJi.   of  coiirer.  the  blAodinR  was 

^fdied  tor  the  time:  but  it  recomrnencad  from  the  end  of  the  popliteal 

^'^■y  at  tba  end  of  one  minute,  and  at  the  and  of  five  minntea  the  Jet 

'^liich,  liowever,  no  loitger  pulsated)  had  attained  a  tfiiarler  of  tta  CotTuer 

"^tiinnin,  e>en  though  Ute  qfiianlily  of  blood  Id  lh«  body  was  loaa. 

f  itM  Cliir.  Trans  vol.  xri,  ]>.  803. 

,'  Wardnp  remarks  on  tliis  head:  "Tlw  enlarftrment  of  the  anastoi 
^'o«ini>  vouwIh.  tu  a  certutn  extent,  takes  plai'e  almoat  in»taotly  after  tli« 
^^ik  liaa  b«en  tied.  I  obiervcd  thi«  in  a  chiUI  in  whom  I  had  arrured 
^  awotid  art«ry.  t  could  leu  the  branches  of  ll)«  temporal  and  oeeipital 
^Maimiatli  the  delicate  integument  «nlari{iog,  and  tbua  actively  acijiiiriiig 


400  DISEASES  OF  ARTERIES. 

iuind,  in  a  caso  whcru  tlio  prvsent  writor  hiul  occasion  tn 
axillary  artery  during  an  oporation,  tlie  [jaticnl  being  a  child,  do 
]>u]w  was  ]>crcv|itible  in  tito  ritdial  for  iniiny  motiUis  afkcrwarda. 
In  the  lower  eictremitv,  In  which  the  arteries  are  relativelv  fi^wer 
and  thoir  cohfn  thicker,  dotihtttMN  tho  oollatvral  circulation  ie  rc- 
establtAhi.v]  more  slowly  than  in  the  upjwr;  honoe  the  freqiioucy  of 
gangrene  in  tlic  forruur  nAor  tying  onu  of  Uiv  principal  trunlo, 
while  in  tlie  upper  extremity  it  ia  very  rara"  The  enlargement 
of  the  cullatoralM  hn»  taken  jilacc  to  Momo  extent  bvforo  tho  opera- 
tion in  moat,  if  not  all,  case«  of  aneurism,  being  occaiiiono<]  by  t^ 
obstacle  to  tho  circulation  caused  by  thu  anouriitraal  tumour.  IH 
rcadinais  of  tlte  return  of  pulsation  will  depend  in  a  great  incisure 
upon  tho  agents  by  which  tlio  circulation  is  restored.  Thus,  if  ono 
large  branuh  join  the  artery  below  the  ligature,  the  aiiiuttDinojiiit 
being  very  likely  offoctol  principally  by  a  Ktnglo  arch  of  artery 
joining  tliiit  (as  in  Sir  A.  Cooper's  case),  pulnation  will  be  ruMtored 
quickly ;  if  a  largo  not-work  of  small  branches  carry  on  tho  cir- 
culation, it  may  be  ahwiit  fur  an  indefinite  jM-riod.  Wlint>?vt>r  tlie 
period  may  be,  it  is  ocrtaiu  that  in  a  few  days  at  the  latest,  either 
gangrene  will  Mtt  in,  or  tho  circulation  will  be  »o  far  reu>labIii>h<Hl 
that  the  blood  will  flow  tlirough  tlio  artery,  entering  it  by  tho 
bratioh  which  join*  it  Ixilow  tho  ligature,  and  proliably  by  iniuiy 
of  tho  successive  branches.  Thus,  when  the  ligature  has  been 
■pplietl  far  away  from  the  diseti.«<^,  th<-  blood  rcturiH  into  tlio  vc>nel 
above  the  aneurism;  anil  so,  if  the  tumour  be  not  already  fillwL 
witli  clot,  the  circuiiition  tbruiigb  it  may  be  rvuKUd)li»lK-d. 
circulation  ia  sometimes  suAiciont  to  prevent  coagulation  and 


aim 


great  additional  vigour  inmioiliately  after  the  operation."  On  Jjwktwi. 
p,  IS.  Ab  to  the  liinu  at  wliiob  tli«  prooeas  is  cutuplet«(l,  (be  futluuiriG  )■ 
extnuited  from  l>orta.  op.  cit.  p.  %'iS.  "  It  is  ijiHifutt  lo  det«niuuf  Uiv>  nta^ 
of  the  resiomiion  of  the  aoUat«ral  uiraulaiiou  niWr  the  lignlurv,  iiuBiuucli 
as  it  varii's  in  different  eases.  Sometinies.  aflor  two  or  Ihrci.'  moDtlu.  thi 
aniulumotic  circulntion  is  no  full,  tlint  it  si-Mus  nt  th«  hviglit  of  ita  dvveloP' 
nient:  wliite  in  other  cjiscs.  six  or  ei^lit  iDontli&  aftcrwardii  (alwajv  eottr 
parud  with  the  lieAllhy  limb)  it  may  bo  eitid  to  be  luirdlf  matured.  Fien 
tny  observiitiona.  I  am  led  to  believe  tlint  tlio  collulonil  (lireulalion  i«  d^ 
vulopi^d  in  a  limb  opcinted  an  in  tlic  gjiai'c  of  a  few  month*,  aiid  ifcntatU} 
before  tlie  end  of  tlie  fiiat  ycnri  because,  on  naMl3raing  upccintcnx  at  rraol 
I'pochs,  after  I  Li.  IH.  U-1,  SO  months,  it  ia  not  found  that  tlio  aiiasloimol 
tijnttctn  has  piiigrassfd  faither.  This  system  is  fully  mnntitiilMl  nl 
timii  when  it  hii/t  nltnintid  tlie  aim  uf  its  development,  anil  lias  bron^t 
VhiS  eiruuktion  to  the  nieasuro  of  the  reijuii^iQcnts  of  tho  limb,  and  so 
bivutzhl  to  u,  ^lanilMill." 

•  Sao  on  thia  poLut  the  «eutions  od  Axillary  ami  Bradual  .\u««riata. 


HTJNTERLLN  OPEHATION  FOR  AKEURISM.      401 

■rpecuatc  tlic  clit«eu« ;  mvI  faWiavf  fmin  ttiii*  cniiKO  wre  noouion- 

»Ily.  but  rari.'ly,  uoukL     More  commonly,  the  foroo  of  the  drcola- 

tion  uAufficM^iit  to  i^Titiftn  a  itort  of  niidulaton-  mavetnent  to  bevomo 

H|Kn«{itible  in  tlie  contents  of  the  tumour  a  few  (lays  after  the 

^^ature;  but  coiif^i)»l!on  in  ailviuKtin^,  initl  will  riijiidly  Niijipren 

BpiH  nuvement,  which  soon  ceases  to  bo  ap|jrwiable.     Now  in  these 

H'oKBaftil  ca«.w  the  luialnniiuil  coinHtion  of  j>iiM«  may  be  twofold. 

If  ih*  artery  and  aneurism  form  one  channel,  or  if  the  aneurism 

(bud*  off  like  a  bii<i  from  ihii  arU-ry,  tho  cjinal  oftJiC  vc^j^ol  may 

wlcrft  pCTvioUB,*  and  the  circulation  will  bo  carried  on  tluvmgh  it. 

Kwiii  Ihu  gnial  majority  i>f  nnniritim*,  wbiuli  aiv  m-ilhcr  fiwifonn 

not  pcdnnculated,  hot  sessile,  and  involving  more  or  less  of  the 

cnwjmfwwnoo  ol'  thu  vwjh^'I,  the  obKtiTrtitton  of  the  tumour  Involvfa 

tkil  of  the  affected  artery ;  and  now  another  arch  of  anastomosiB 

»ill  oftt-n  be  reijuirwl.      Tlie  ueeeiwity  for  the  fonnatiou  of  (his 

nWET  arch  of  anastomosis  will  depend  on  tlie  distance  between  the 

'  pwnl  of  ligatim^  and  the  aneuriitm,  and  on  th*-  lumiber  of  branehoft 

["liiA  oomnumicale  with  the  main  tnmk  between  tJiem.     If  the 

ll*int  of  iigaliirc  be  distant,  n»  in  the  eotnmon  openition  for  {wplt- 

tal  ■nenrinn,  or  if  many  branehes  intenene,  the  arteiy  will  be 

I  I>W\TW!t  between  the  Mature  and  the  limionr,  and  therefore  two 

•rttflf  eollaterals  mnst  bo  develo[>ed ;  one  bo  carry  tijo  blood  round 

Wieat  of  ligature,  the  other  round  Uio  ancurii>in.     There  in  no 

•ronoe  to  prove  tiiit  thia  double  call  upon  the  powers  of  nature 

■"•dUB  an  onfarourablo  iufluenec  on  the  proajK-etB  of  the  oix-ra- 

Iva,  tliliough  it  ia  4]uito  possible  that  it  mav  do  so.     Thos,  some 

"tiie  eases  of  mippnration  in  the  »ae  after  lifiature,  »ueh  n*  tliose 

^■fcj  on   pj>.  377,  H,   may  Iw  due  to  imperfect  development  of 

"Utenls  round  ttio  anonri^m,  and  the  consoqiiont  perMistenoc  of 

••ttrMilation  tliroujrh  iJio  tiinioiu',  wliioli  otifiht.  to  be  temporary 

"".''•    It  is  probable,  however,  tliat  the  very  fact  of  tliu  cxi»t«nce 


*  The  lalttir  Ji^jxisiLioD  uf  jiurta  cxiHlril  iu  a  (.'iiii'  ivLltl-  Sir  A.  Cooper 

W  Ae  extenml  iliao.     See  Ibe  acoouiit  uf  Uii!  OiHuyttiun  iii  (Jiiy'i  UotpiUil 

"f*".  "oI.  i.     1  liive  aot  met  ivilb  a  utiat-  of  tliu  fonat^r  (liBpouiiioii  uflw 

■fUBre;  bat  it  niajr  be  ttetn  aSUit  b{>uu1aiii^(iub  euro  in   HuiI^soii'h  i-ue, 

VMmIou  p.  STl;  and  after  Uiu  fiiro  by  prussure  in  n  prepiimiioii  iu  SU 

(iMrrr'a  Uogipttal  mnKeum,  rvfurred  Ut  pii  p.  420.    In  the  Hmt  «asc  uf  liga. 

Iu*  of Ui«  tiiUinia]  iliao.  I>y  I>r.  Stevens,  tlio  pulvts  n'ua  bruu):ht  orvr  to  thi» 

imaitj  for  disMCtion.  tli^  puticnt  having  snrvivud  tlio  opi-rutioii  li.-ii  ycoi^. 

Ar  uootint  (by  Prof.  Uwcn)  of  the  iliM^nlion  mny  be  fi)unil  in  Mai.Chir. 

Tmu.  id),  xvi.,  and  thcrv  it  i*  ntitincd  tliiit  tliu  nn^urisia  (which  wili  of  Uie 

t>li«Ur  kind)  Imd  in  Ibe  ocntre  >  csvity  conuining  onl)'  loose  CDtif^la;  but 

BO  drvuUttnn  had  gone  on  tbi'ougb  it 

VOL.  IU.  D  D 


402 


DISEASES  OF  ABTEWEB. 


!aence  oi^fiB 


of  an  aneurism  csorts  in  most  cases  a  retarding  infinence 
circiilutiim  tlirinigh  tlic  txiiiik  of  the  vomm.'!,  uikI  Uiuh  inducm  a 
preliminary  espansiou  of  tho  branches  immediately  above  it,  so 
that  tijo  iow<!r  arch  of  Hiiiwtfuiuj.'iiM  may  bo  miire  ca»ily  fwrnw-d  than 
tlie  upper ;  or  tho  latter  may  take  the  plaeo  of  botli,  the  collateral* 
abovo  tlie  lifpitiiro  ouinmunieiiting  vritti  Uiu  hranclm  of  the  artcn' 
beyond  the  aneurism,  as  would  bo  the  caeo  in  an  aneurism  scaled  on 
the  couunoii  cyirotid,  wlien^  no  branclien  inUTvciK-  liclw«'t'Q  tlic  liga- 
ture and  the  tumour.  In  most  cases,  dissection  aller  a  sueceteful 
operation  will  pIkhv  the  artery  iililiteriitiMl  at  the  «eut  of  ligature 
and  at  that  of  the  aneurism,  aiid  pervious  between  them.* 

Tho  immediate  effect  of  a  li^^ature  applied  to  a  main  trtmk  a 
of  course  to  suspend  for  the  time  tho  supply  of  blood  and  Un 
vIh  !i  tergo  of  tho  heart.      Hence  eonge^ion  of  tlio  blood  in  tbe 
extremity,  and  henoe  temporary  rise  of  temperatarat     A»<>lbcr 
immcdiiito  and  necessary  eifcct  of  the  ligature  i»  the  tcmiiorary 
loss  (if  power  in  tlie  part^  supplied  by  ibe  obliterated  arUiry,     Tliis 
phcnoineiion  is  nut- so  ofleii  obitcn'cd  in  incn,  since  the  condi- 
tions  of  their   ti-eatment  pi-event  any   attemjit  at  moveiiM'iil  iif 
the  limb  ojx^ratoil  on;}  heniv  a  tingling  and  numbneu  is  g^ae- 
raWy  all  that  is  complauied  of;  but  it  can  easily  be  verified  ua 
flnimnls.     Tlius.  after  h'gature  of  tlic  abdoniitud  aorta  in  a  dog,  HiO 
animal  will  Im>  noticed  to  ilrag  hia  hind  legs  juat  as  if  bo  Iiad  re- 
ceived a  Hcvcro  ii^uiy  to  the  spine.     Sometimes  in  men,  aJtbough 
tho  irnmeilinte  [laralvAis  may  ]iass  nnobsened,  its  effeoi*  will  [lerfiu, 
and  a  p.trtisl  loss  of  motion  in  the  limb  will  be  permanent.     8tiB 
more  <itb-n  the  nutrition  of  Ihe  part  is  impaired,  so  tluit  the  mcotber 
is  thinner,  colder,  and  weaker  than  tho  otlicr.     This  I  have  roysfir 
Udtiei-d  in  tho  easi-  of  the  child  nhova  referred  to,  in  whom  tto 
asiilaiy  artery  had  been  tied.     When  »he  was  last  seen  (more 


«  For  a  oolli^i'liou  vr  si-vcnil   lnihuh  iu  wliioh  lliu  rcmotHl  trterr 
found  pei-Tiuue  betwoen  tlie  liKatuiu  taiii  tiw  aneuriHin.  eee  Wialitn^ 
Sairpii.  pj).  3S3  4. 

f  See  Dr.  J.  R.  Wood's  coac.  ao  Report  of  Surgical  IVactico  of  B«U«  Tii» 
HotpiUl.  A^.  r.Jour.^iVw/.  lese,  p. 339;  and  Mr,  Ijiwrence's.  in  J/rf-flltc- 
Trftni  vo),  vi.  p.  200.  It  will  he  rtinaiktd  iu  ihi-  LulU-r  caav,  oiw  of  U^^UnO 
of  tUo  exlerun.]  iliiic,  Ihut  tliousli  th»^  li"'"  ou  iJ"--  offculvd  side  whs  nwm* 
Ihiin  on  llie  sound  sidu,  the  foul  wiu  alwuj-s  coldt-r,  II  U  intrrtitiDK  W  "^ 
serve,  tbiit  in  expcnmi-nU  on  nnimiiU  this  rise  of  tcmprmturo  dwi  nut 
take  pW'u.  the  activity  of  tlic  cuIIhUt&I  ciiculntion  piwuniing  «ven  WJO- 
porary  consi-stion.     See  Uropn,  p.  S07. 

I  But  sumelimea  slight  unit  Ininsient  pamlysis  of  loAtion  or  »<^iutinn 
is  obsi'rved.  Sue  Mr.  Cbiuiibcrlaine's  cusv  uf  ligiilure  of  tlur  axUlluy  tJUrji 
Mtd.-Chir.  Trant.  vol.  vi.  p.  t31. 


Hr>TEIUAN  OPERATION  FOR  ANEURISM.      403 


ircu*  af^r  Uie  operatJoit),  the  arm,  although  it  tras  tiw  right, 
ilrCMtiHlly  NuaJler  and  vrvnlwr  tlinii  tii«  oUivr.  Tlitu  also  gaa- 
ne,  from  accidental  exposure  to  cold,  roay  occur  long  nftenvards 
'  in  Um!  Iocs  !ii  oucs  w)ii;ru  the  tumoral  nrtviy  luuf  been  tied,  o^'en 
whfD  DO  symptom  of  gangrene  has  followed  imnie<:IialoJy  on  Uie 
opcnlion.  THkm:  imfiivourablc  constHjiicnccs  »lioitld  not  bo  lost 
ririil  of  in  detejTiiining  tlie  question  of  ligature  or  eoni]>rt»!tii>n. 
Thjy  iic|Krn<l  in  all  |irob«biIity  ou  a  dvfcctivo  development,  cither 
in  iiM  or  number,  of  the  collaterals,  by  wbieli  tlie  nutrition  of  ilio 
pan*  it  dimini-'slRHl,  tiic  conductinj;  property  of  the  nerves  prohably 
iupcmled,  ami  the  irritabiliiy  of  die  muacles  impaired.  Mr.  Lijiton 
tkn^lil  that  ihe  cxoossivo  ilcvclopmont  of  anaftomwin;;  branclica 
nnining  in  the  substance  of  nerves,  sudi  as  the  comes  nervi  iscbi- 
»*i«,  might  pnxiucw  ]>ara]ysis.  Tlii»  sevms  iuiprobiihic,  hut  rc- 
eeiiw  a  certain  amount  of  support  from  a  case  related  by  Porta, 
"dfrom  iKimo  o!>.«ervi>tioTW  which  he  has  made  upon  it." 

Cautea  v/ dfal/m/iir  tvfolurt.     The  chief  dangers  following  the 
(fntion  an.'  from  gangrene  and  secondarj'  lia'morrhage,|  oxeluding 


*  Se*  Porta,  op.  cit.  p.  381. 

t  In  Hit  AwitriMH  Jnurnitl  iif  ^ff^^ifal  SvUinef,  new  series,  vols.  x.  xiii.  xir. 
^i  tl.,  mm  some  excellent  »tuii»[ical  jiapvra  upon  the  ligature  uf  tlic  prin* 
•f"!  tn«Ti<«.  vii!.  UiB  tiubdaviHn.  «aroUd,  ferauml.  I'xiorDal,  iiituranl.  itad 
*>■««•  iliue,  showing  tlie  jirupurtion  and  causes  of  diiilli  in  eacbopci-utJon. 
"*  fonuft  pajx-'ru  aru  troui  tlie  pen  of  Dr.  Norris ;  tlu-  lii.it  ih  by  Dr.  Slo- 
("niSmiUi.  Ah  Uwy  dispUy  aiiaiuouiit  of  morlaUty  nfti-t  tbcBc  opi^i-ntioni 
*UA  is  probably  not  geuurully  kuuwii,  it  may  bi;  as  woU  to  qiioto  all  tbesu 
"Wuisii  logrthcr. 


Sn.  of 

X4.  of 

Unbiraor 

CAKJ  TOllOddC 

dutba. 

IM«bL 

SnbuUriaa .     . 

.    .    uu       ... 

S8 

>  .  • 

i1» 

Csrotia  .     .     . 

.     .   I4U          ... 

M 

stu 

>'cin..r«l      .     . 

.     .  S04          ... 

OO 

21S 

>^<-mnl  iltiw?  . 

.     .  IIB 

83 

279 

lDl47Tial  ilino  . 

.     .      7         ... 

a 

«9 

Conwuon  iUua. 

.     .    39         ... 

Sft 

78-1 

Total   .     .    .  tta        ...       108         ...        83-1 

If  ihn  n«d«r  will  compiuv  tJiese  nstums  wilb  ibe  most  eompluto  statis- 
*<  hidifrttf  ablaineii  of  Ibc  mortnlity  nftpr  c)iJic'r  Biiii^ii'al  ojiemtionB.  aa 
*•* of  ■mimtalion  by  Mr.  Kiyant  in  Mfil.-Chir.  7'rant.  vol.  xlii..  be  will  at 
•*••  •«  tluil  ibn  liRntiH'c  of  till?  nmin  artny  of  n  limb  involvi'ii  ihc  Rmvcst 
'■apn,  uiJ  i«  an  o|ifmtioii  wliic-h  shoiiUl  only  be  unilrrtukeii  ia  tlie  face 
''niinnt  necessity.  Tho  abovn  iviui-n*  might  liuvc  been  made  stilt  more 
MrimnLle  hy  oolle«ling  the  cnsca  ofli^ture  ofllic  two  largnt  ortcricit 
*-th«  aorta  anil  inooniinatn — which  havti  proved  uiiirorniiy  fotui;  but  it 
I  ibuugltl  belter  not  to  include  opoiiLtions  which  many  pcmoua  consider 


404 


DISEASES  OF  ARTERIEa 


tho  cflinpti<»tkiti!t  to  whieli  nil  oporatlons  are  csposdxl,  aiut  thr  t^ 
cial  diuigcni  which  ixseult  in  tyin^  itidividuul  arlcric«  trom  tli^ 
aiintomicnl  n'liitJon.*,  and  which  will  be  diaooBBed  m  speaking , 
Uie  fljiprial  operations.     Ganproiio  in  jwrhnp"  n  mom  frfvpiciil 
of  duiitli  tlmti  lin-iiiorrhiigc  after  liguture  of  arteries  tn  ihu 
cxtreuiity.*     In  the  upper  vxtirrmity,  tho  nnaittoniOMM  are  w] 
qucnt,  thitt  tin'  piirbi  are  nearly  in  tlio  same  conditian<i  m.4  io ' 
lower  animals,  in  whom  goDgreno  in,  as  ve  have  twn,  uii] 
The  cauxoi*  ofgiingreno  ore,  a  deRctenoy  in  number  or  in 
bility  of  tile  coUiitonil  brimcbm,  or  a  wiini  of  duo  cano  in 
titinin^;  tlm  tflinjicriitnri'  of  tlie  piirt  ai\er  the  operation,  ootuilric 
the  limb  n-itb  baudagos,  or,  finally,  sonio  injury  flmK  to  tho  prim 
vein  of  tho  limb  during  the  o|H'iiitioii.  f     Liule  can  bo 


l«. 


I  cwtlll 


nqjnstlflalile,  and  wliioli  will  [irob»bly  be  soon  baaisbcd  tron 
praclico. 

By  coinpariii)!  Mr.  BTjanl's  table,  it  will  be  iMii  llial  tlw  UgBlnni 
«flli«  fuinoral  lirturr.  Uio  lowest  ill  llua  liat.  ia  almost  m  fitU}  bb  uupa 
0f  ibe  tliii;!)  |wbiaL  nppcurs  in  Uiat  UbU-  u  fatal  in  2?'31  pvr  cent  uf  c 
whilo  inotl  uf  tliu  atlic»  HppmNcli  tlir  tnorlulity  orpiJiniu^-  aniputAb 

Tlu'ie  ooDiiidi^mtiona  show  stioiiKly  tin.-  propriety  ofaroiiliut;  ti| 
a  barge  luturj  nhunevcr  thnro  i*  luiy  proxpcct  of  curini;  Uir  i 
Otlior  mi^tboil.  The  table  in  I'orta's  work  (p.  401)  giveit  n  Himilar  i 
It  contain*  n  nii'noptiis  of  UOO  caseti.  nnd  uii^ht  perliaps  linvo  Ix-pd  i 
to  bo  snmcwhnt  more  favourable  ihuti  Ihi.'  uliovo  tiati^tics :  as,  oil 
locludcH  II  i-naofl  of  liiratuiw  uf  the  aurta  &rid  innotniuaie  (wlii^j 
«our«o  uiiifotnily  fat")),  il  alou  coraprUn  AH  of  ligature  of  Uw  br 
opentinn  whidi  is  gi>iiemlljr  aiic«e«afi)l.  Still  the  d«ailia  are 
tlian  'it  pn-  ooiit :  nor  iaeri  it  aliow  a  mueh  mere  (kvinuaUe  a* 
opMvtiuLia  ex««])t  llie  li^iature  of  ibc  Hubokriuii  and  connnon  ■ 
ditr(>reaetf .  howuTer.  bi^twcen  Porta's  MtatiBtico  of  tlieB«  opi.*rati<inB  i 
of  NoitU  di-peu  Jb.  1  buve  no  doubt,  n>«rely  on  wntte  of  iliti  puMiibed  i 
caeea  huting  eacup^d  Portu'ii  invest igntion.  The  rail  armi^cB  urt'  pn>b 
JBUTV  uiifavouruble;  fatal  cuB«a  luiiHnf;  rvaioined  tuipubliilird.  At  Unl  I 
eoncluHiuB  U  aupport4!j  bulb  by  wlmt  we  know  of  tlio  oature  of  pulilitl 
eaaes,  aud  by  tbe  i-xpcriciicc  of  Knntiidi  Surttronii  in  Ihalittaliire  od 
aa  ebuwii  in  tlio  »tati>tiea  of  the  JffiittW  Ttiwei  md  Oiumu,  which 
again  refftruil  to. 

*  Of  thi!  fifty  fatal  ea*em  of  ligatuiv  of  t)ie  fpmnral  tatrvj  in  No 
(able,  tivcQty-thrve  are  ataled  to  have  dtcii  ofRRngrrjic  iDd  only  i 
faiciiiorrluih'e ;  bill  tbii  point  will  be  aptla  rafoned  l«  under  ihn 
tile  individuiil  arti'iioH. 

t  TbiK  t;*iit:i  "on  i*  oftm  due  to  injury  of  the  vain  1b  an  opinlno ' 
Mr.  Syiiiu  bns  Klroiiiily  Insisted  on  {PrtHeifiet  i^  S^rffty.  iHiO^  p.  M). 
Oren  nppean  to  ko  so  btr  as  to  allege  IbtHas  the  only  muse  of  i 
crediliiif!  the  reoeivod  opinion  (wliieli  bai>  Just  been  Htaied  nlxiiri  enU 
But  that  KinKiviie  niaj-  ouvur  whei)  no  iiyjury  lias  been  done  t«  tbo  u 
prared  by  numerous  betfi.    Ainongst  otkera,  a  prepanXion  exiMs 
inuaeuui  of  St.  Oeorge'n  Hospital,  with  a  rvuorJ  of  a  oai«lul  i 


HUNTEIIUN  OPERATION  FOR  ANEURISM.      405 

die  first  cause  of  failure.     It  may  be  Buapooted,  in  per»oiis 

,  circulatiuti  and  cxiuuiistvd  by  «M  ngu  or  u^ctMu^  tbut  in  tlw 

tfaeir  arteries  may  poa^bly  not  anaatomose  very  ti-celj, 

(the  Inrtvr  olam  iiro  nearly  ifure  to  liibuiir  iiikIit  an  nthcroniiitoiui 

on  of  tlM>  vceoels.     Hence  both  are  bad  aulijectf  fur  tlu;  lig^- 

lon  of  an  important  ortcr}' ;  but  n»  liK«v  op<;ration«  Hra  now  nwer 

fcrfcniKvd  unl&'**  under  eircnnistances  of  urgcney,  in  whicii  all  ri»ks 

sum  be  ran,  a  knowk-dfjii  of  tbv  !>l«ti!oftln!  artcriis,  ov^n  if  it  cotUd 

t»  cntiiiily  nttiiiiied,  would,  after  all,  only  affect  {irognotuH.     Hucli 

»i»y,  tiowwcr,  bo  done  to  ])rfVfnt  Kimgrtno  by  niaintainiiig  tlio 

(«iil>fT4tun;  of  tin;  p/irt.     It  would  wcin  at  tirst  sight  itit^oiinistent 

lo  talk  of  tlio  necessity  of  kouping  up  tbo  temperature  in  an  cxtr&- 

Biitj  in  wbioh,  as  we  have  oefu,  it  has  already  risen  idx)ve  the 

■tuulanl  of  hoaltli.      liut  tbiu  contradiction  is  only  ajiparait.     Tho 

[  tenipcnture  of  die  toes  risea  aJW  ligature  of  tlio  ti>im>i'al  arlory, 

linm  inwwW'ixi  jjower  in  tlio  ])nrt,  or  inei-eased  vitid  activity-,  in 

.  OAO  it  would  I'lt'urly  Ih-  wnm^  U>  add  ftit-l  to  tlii;  tin',  but 

I  VDadiiiiiuatJon  of  tlie  vis  a  tergo  of  the  bcnrt,  and  cuuscqucnt  stag- 

I  BUianof  tlic  IA\kkI  in  tlie  i-xlniiK-  vessels.     Ex|h)ki  tiio  juirl  In  cold 

—^  tiwttca  will  contract  upon  and  luiload  the  vessels,  whieh  will 

imtuclvx-Jt  aJso  Ije  eonntrictud  by  tlie  cold — and  th<-  part  will  nut  only 

[wJet^vod  of  blood,  but  a  powerfid  obstacle  will  be  offered  to  the 

f*«»fcme<l  uireutatloii  by  tlio  ilyid  and  contracted  stalo  of liio  vi-sseln 

■fel  liw  parts  wliidi  support  tliem ;  an  obstacle  wliieh  most  probably 

*9  be  found   innurnioiintitblo.      lleiioe  the  impor lance  i>f  niain- 

I  luailig  tbo  limb  as  ne^ir  tbu  natural   teiii|KTnturu  of  tliu  body  as 

PiAle.     It  xliould  not  be  mu<-li  wartm-r,  sinco  partit  in  wlileli  the 

I  **mlatiott  is  imperfect  are  as  little  able  to  resist  beat  as  uold  :  tliua 

Qu  iau  foIl4iw(.-d  tho  ii]>plicatioii  of  hut  udt  or  nand-biigst  to 


I**hte  Mr.  Qnty,  in  wliich  the  vnin  was  clearly  proved  to  bo  perfectly 

[**4t  »*''  uninjuTril,  yet  the  patient  died  ofgHuijcene.    The  vein  has  also 

■Mfatawn  to  li«  indudod  in  manj  opemtiouH  on  ib«  TMuornl  mtory  witb- 

Midj  iwiiiptoni  of  gnngrono.    John  Kuuier  at  firat  purpose Ij:  Ued  up  tli« 

*ti>k  Kii)  Roiix  Itas  c»Dr<''a'>od  to  havinj,'  doue  ho  accjijfuttill}-.    Laiiijeiibeak 

(tittir/ir  Kl.  Ckir.  vol.  i.  pi.  I)  auil  Gibson  (Jm.  Joum.  o/.Voi.  Se.  rol. 

^Pl,3u0}  hftve  both  UmI  Qie  luli-niHl  jugular  ruiji  and  caiulid  uiciy  in 

ng  tumours.  CoopOTof  Sail  Knauisvo  (AW  i'ork  Joum.  of  Med.  it*AT, 

.  lii  aor.  iiL  p.  *10J  the  eittenml  iluw  vein  mid  artery  in  a  at.w  of  anutir- 

llhgood  r(iault&    TlMpartial  liffilnn-  ortho  vuin,  iuwlijcli  the  thread 

'lilts  a  wioa  in  the  caiity  of  tliu  rcssL'I,  in  luutb  looiv  lik«ly  to  bo 

by  fiUal  oSwtit.    Mr.  Oarmtchael  and  othetn  have  iipnkm  of  lh« 

•MMnvnea  of  phlebitis  uad  obliteration  of  Hn-  vdn,  hi  met  i  men  followed  by 

jaugrwite.  a»  a  couscqitouco  of  iiytuy  to  Uiu  vein  (»uu  llroca,  p.  410). 


DISEASES  OF  ABTERIES. 


Uie  limb.  The  l>ost  application  U  carded  wool,  wliicli  iii«vly  M.iin» 
till!  natiinil  warmth,  and  lia»  tli«  iidditioniil  meril  of  retaining  it 
without  ri'nuiring  n'nowal,  while  it  allows  tlio  ou-ciwiomil  inii|nvt.i'>ii 
of  thu  limb  if  ri-quinxL  It  is  (wlviniblo,  however,  to  make  snch 
iRspoottoii  only  raivlv,  since  it  cannot  be  done  n-tthout  somo  clmnjps 
of  l'ini[KTat,nro,  wlii«h,  ifofton  rc|ni»tiHl,  mi{;l>t  havt;  a  ]in-jm!icial 
effect.  Tlie  wool  flhoutd  bo  used  in  large  qmmiily,  so  a*  to  fonn  a 
thick  lavvr  around  tlie  whuli?  liinb,  m?arl_v  iw  high  iw  iho  t^-M  of 
operation,  and  secured  bv  a  bandage  loosely  twisted  roand.  It  will 
hti  und<-rHt<)(Ml  tlmt  the  Hriih  Hhuuld  ho  kqit  in  Huch  a  pwitioii  as  to 
facilitate  the  rclum  of  blood.* 

Till-  imtiBrit'ji  dirt  and  n.'giinon  shoukl  not  be  too  rigid.  "ITiw 
will  of  course  bo  regnlat^xl  bv  his  previous  liabits ;  niid  tbo  same 
may  b«  »nid  of  tho  cxliibition  ofopimn.  In  [Hrnton!*  of  dissipated 
lives  and  nervous  temperaments,  stimulants  and  moderate  qnantilii'S 
of  ojiium  must  ix;  allowed  ;  while  robust  iRTKonK,  witli  iHpitible  and 
tolerably  strong  pulse  (who,  howe\er,  are  rarely  the  snbjecta  C^ 
lUiourisni),  will  do  Ix'ttcr  on  a  nourishing  but  uii*^iinnliiLiiig  diet  H 

When  gangrene  has  once  declared  itself,  which  usually  ocenn 
on  thi!  siicond  to  the  fourtli  day,f  tlio  caso  btsxinicfl^  grave ;  but  lii^ 
prognosis  is  not  hopeless.}     All  depends  on  tlie  rapidity  with  whi<H 
the  mint iticiil ion  a<lvancea.      If,  n»  is  soinetimcs  th<;  ciun;,  it  »!iri»» 
itflcif  not  merely  in  tlie  ends  of  the  toes,  but  simultaneously  on  th^ 
dorsum  of  tlic  foot,  and  advances  with  rapidity,  no  time  should  i^ 
lost  in  amputating,  and  tlie  limb  shoiilil  be  remoitxl  na  near 
ecat  of  ligature  a«  may  bo  found  convenient.     Il  is  not  absolub 
necessary  to  operate  at,  or  above,  the  plaoo  where  the  anery  li*» 
bwn  tiwi.    The  jioition  of  the  limb  just  below  this  spot  is  nourished, 
not  from  the  obliteraltil  juu-t  of  the  vt-ssi-l,  but  by  the  branches  of  »i 
Liglii.T  origin,  so  that  tlicre  is  no  fear  of  sloughing  of  tlie  stump.    S 

When  the  gangrene,  on  the  contrary,  appi-urs  only  in  one  tofc" 
or  in  the  contrgiious  portion  of  the  estremity  of  more  tJian  one,  luw 
extends  slowly  In  the  continuity  of  tUc  limb,  Iiojift  may  ntUonall? 
bo  enlortaineil  of  preserving  tJie  member,  Tlie  case  nia»t  1* 
treated  like  any  otlic-r  ease  of  gangrene,  by  local  wtuint.h,  lonJ  f" 
general  stimulants,  and  opimn,  with  duo  regard  to  the  patienl' 
constitution,  nervouri  tempenimont,  and  general  »ympb(Mns.    I  \t!0' 


atliL 

'I 


♦  Mr.  Gullii-it-'s  fui-uiinle  mi-Uioil  fur  obviating  giuigrcDC  was  to  li»M 
U)<--  limb  odiisUntly  olial'uJ  by  Uio  utteniintils. 

f  AUhoiigli  Goiuutiiues  nut  till  tliu  iiooaui]  or  tkitd  ircok.  Porta,  <■]>-  ^^ 
p.  3oa. 

I  'Hhe  taoilalitj  U  eBlimutod  by  Foila  at  Tl  p«r  cent. 


HUNTEMAN  OPERATION  FOR  ANEURISM.      407 


tni>'  to  think  that  tlie  attempt  to  preserre  limbs  after  gangrene  (iie 
n»u!t  (if  ligattiri;  U  not,  generally  spi^kiitg,  oarricd  far  «ii(mgb. 
The  {irognoAiH  of  smputntiori  in  tliese  cirouuiHtaitcei  ia  not  very 
fiiTminililo;  the  wi»t«  closely  resoinbling  thoeo  of  soconiliiry  iinipii- 
tUitiu,  the  most  fatal,  aeconling  t»>  Mr.  Bryant,*  of  all  ctas§f»  of 
ainjnilitlion. t  Suppuration  and  sloughing  of  the  sac  is  a  kind  of 
pngwne,  and  is  one  of  the  ohiofftnnstM  of  death  after  ligature.     It 

»BOi>KtiinM(  givw  riiw  to  hipniorrhttgo ;  but  more  frequently  it  jmiaons 
t™  Hood,  and  leads  to  iWth  either  by  pyicmia,  or  by  that  systemic 
uilM'tiMi  of  whidi  i>y!vinia  is  tht'  local  Dianifcstatiun. 
The  other  cau-so  of  death,  that  from  nfiooiuhiry  hajmorrhage,  liaa 
h«n  alrt'iuly  trviitcd  of  in  the  essay  on  IiiJuniES  OF  thk  V'kssklsi, 
'«l  ii  p.  1)76,  It  is  more  common  in  tins  upper  ostremiU',  where 
loi'  heart  is  near,  the  circulation  powerful,  and  the  pn>ce»soa  more 
'^pw,  than  in  t)ie  lower.  It  Is  also  more  to  be  apprehended  after 
BS«nrc  for  aneurism,  when  the  artery  is  more  likely  to  Iw  disi?asej 
*'  tiic  point  operated  on,  diaii  fur  woood,  when  it  will,  iu  all  ptx>- 
Wiliiy,  be  hoalthj-.J 

IBmides  tbeae  cansea  of  death  after  lignlnrc,  tlie  operation  some- 
'i'lits  lii!l«  to  cnro  the  aneurism,  though  the  patient  sin-vives.  This, 
"Wfcd,  a  rare;  but  it  seema  to  occur  in  two  waya.  Either  tlie  pul- 
"^m  never  dieappctir*  in  the  tumour,  and  the  latter,  pcrhaiM  after 
•  knqiorary  check,  enntinuea  growing  in  aize,  and  will  ultimately 
'"UM;  or  the  aneurism  diuiiiiivlicw,  i>ecomcH  solid,  and  undvrgoen  a 
i  pnoe«  of  apparent  <rure,  but  then,  afwr  a  longer  or  shorter  period 
of  quiescence,  the  pulsation  reappears,  sometimes  with  a  ituddea 
iOCreaae  in  siiie,  and  tlie  diaease  is  said  to  reour. 

IVhvn  Uio  ligature  lails  to  abolish  the  pulsation,  thi>«  de)>enda 

■gain  on  one  of  two  causes.     The  arti^ry  may  ha^e  oonneeted  with 

van  abemtos,'  by  which  tho  blood  a  brought  dirix^tly  (town 

I  tumour.     Sueh  w-aa  the  state  of  jiartH  in  Sir  C  Bell's  ease  of 

taf  tho  fiinioral  artery.^     This  eoudition  of  the  vesnwiji,  how- 

CTW,  will  not  escape  the  attention  of  a  careful  and  well-instructed 

operator ;  awl  ifie  fitet  that  tightening  the  ligature  has  not  it»  mual 

rifoct  on  the  puUation  of  tlie  aneuriam,  will  &how  tliat  the  latter 

HpDuiit  eitlter  be  acatiid  on  some  other  vessi'l,  or,  at  any  rali^,  niuat 

'vmnmuaicate  aa  freely  with  another  veasel  as  with  the  one  tied.    Ac- 


fe 


•  ittd.-Chir.  Tram.  vol.  xlil. 

f  Of  fony-oinc  cancii  of  ^nngrenc  ativr  ligaturo,  fourtvpn  xccovored ;  tea 
of  IbBM  wUiiMii,  and  only  Tuur  Hflcr.  ainpiitntion.  Porta,  op.  cit.  p.  3M. 
',  S«>  alM  llio  BRclionson  ligHtuix'of  lailividiial  arteric*. 
$  LomiM  iltdicfU  and  Phytiaai  JounuU,  Toh  IvLp.  1>^ 


408  DISEASES  OF  ARTERIES. 

conlinslj'  tliis  <rthcr  voswl  nm#l  bv  soii^lit.  for  bv  carofiil  Av 
luul  until  it  is  found  the  original  liguturo  is  nol  to  l»  tiglitened. 
tboro  be  a  viu  nbcmin>s  the  ot)uT  yi:%M.-\  will  be  tit  tio  gnut  divlniJ 
oud  should  ljt>  tiod  at  once.  "When  tliis  lias  been  done,  if  pulsat 
is  qititu  Jibolinliwl  in  fbi-  iinvuri^iii,  it  will  |nTb:i(w  I>d  uniinceffisury 
tie  the  veasel  first  exposed ;  but  it  will  bo  more  pradent  to  leave ' 
li^turc  (which  hit*  bc-cn  alivsidy  i«iwod)  under  it,  to  lin  lied  on 
firet  flyniptoni  of  returning  pulwition  in  the  mmonr.  Tlicse  anal' 
col  anomalins  aro  so  rare  as  to  bo  uicrelj-  Btirj{ic«I  curiositivm ; 
they  should  be  borne  in  iniml.  It  more  fretjuently  occurs  that 
ciroularion  through  the  aneurism,  tcin|x>niril_v  alMiH^hcd  bv  (1k'  I: 
tare,  returns  in  a  few  hours  or  days,  and  continues  to  increase 
rmclKM  it«  prtnHoiis  (onx,  and  tliv  di«c»sc  runs  itK  ctnirxc  hi>[>h^- 
uitalfeclod  by  the  operation."  Tliis  awjident  iniwt  be  due  to  ilie  p] 
tonialuntl  ii(.<livity  oftjiooullatcra]  circulation;  hikI  it  i»  oiu;  whi< 
is  dittioult  to  meet  with  api>ropriate  treatment.  In  the  ftrai  pi 
souinit  rcfb^oiudilu  that  nothing  should  hv  done  until  thv  limb  ap] 
beyond  tlie  risk  of  gangrene,  and  until  the  pulsation  is  plainly 
inanent:  imd  this  cautiot  be  Mud  to  be  the  eairo  tmtil  tlie  tumuor 
been  pidsating  veiy  distinctly  fur  some  inuntK't,  and  the  pii 
hIiows  do  t^'Tidi-ncy  to  abate.  It  should  always  be  bonio  in  mind 
a  slight  undulatorj'  pulsation  in  an  aneuriitiu  on  tlie  second  or 


<*  The  UtnpOTary  return  of  pulsation  is  not  M  iineommon.     Porta 
mnrlia  on  this  hen.i;  "  Out  of  4W  oasos  of  anouiisin  and  nni^urixmat  v 
curcil  Ity  the  Hiinlciinn  operfttioii,  tbor«  was  in  twenty-live  ens*'*  n  rcl 
thai  is  to  nity,  n  TiiRnilVrnt  roapiieai-ance  of  puliation  in  tho  UiiDour;  but 
pulsation  was  t«mporni7.  lasiiuf;  ffom  a  few  weeks  Xt  somn  months, 
ttMU  diMippeariiig.    The  case,  liow^ver.  above  relal«i1  of  Milont.  and 
two  publinlied   Cii)i08  under  Va^  eani  uf  Cuitpur  aad  Roiix.  sliow  Uiat 
in  Ihd  tlii^'li  tlie  auuAlomUBin  may  vnluryu  to  audi  a  point  as  to 
auliori  irif  Lhc  Ui;utuTv.    Kuub  onBeti  arc'  fortunately  moat  nn. 
woiilil  oci'ur  much  moru  fri-tiuenilj  in  Uir  iiuuk  and  ellwn-,  wliero 
touiosus  are  natiinUly  ho  ample  Had  tliri-i-'t,  were  it  nol  lliat  lb*  ai 
howuver  Bniall.  nlreiitly  aontiiini  somu  clot ;  and  Ibv  bluud,  dinwlly  an 
applicutiou  of  tlic  ligutuiv,  licing  roiluccd  fur  saiaa  days  to  tli«  Duaiioiu 
muvrinuut  in  the  trunk  npci-ntiitl  on.  conara  during  tlint  time  t4>  feed 
tumour  and  Iho  ancurismnl  arlet;,  so  allon-Ing  tbo  oblilenilion  of  both 
fn<H)i  clot"  (op.  eit  p.  SSI).     Tho  threo  cnsoa  referred  to  will  be  fi>unil 
Porta,  p.  378:  Aril,  and  For.  Mttl  Ittti.  vol.  n.  p.  6};  Ihllrtino  dt  /Atliy 
an.  siii.  series  2.  vol.  si.  p.  leo.    Another  oaai'.  which  illustrate*  t]>c  rcti 
of  eiruulation  nfler  lignturo,  ocourred  in  Mr.  Stanley's  practice.  lie  tied 
posterior  libiiil  ai'tcry  low  down  in  the  leg  for  wound,  using  two  lifpit 
at  some  dinUnce  frnm  Uie  ojiening.    Hiumonrhafic  contiauvd ;  aad 
to  place  otln'!-  threads  closer  to  the  hole  tn  tho  Brtn7,    Oruarod, 
Cotitctionh  p-  m. 


Ht^TERIAN  OrERATTON  FOR  ANETTRISM.      409 


aRev  ligature  is  a  very  usual  plienometion,  nnd  so  fnr  from 
ing  iif  evil  nupTirv,  is  fonifiikrixil  liy  mjiiiy  nuthonf  to  be  a  favoar- 
!e  sigii,  ivnJi'l'ilig  it  more  jirobiiblo  that  loiuinatctl  olol  will  liinu, 
fbr  ll>i«>  procvw*}  iw  has  bvun  showu,  soiuo  unouiit  of  nrmtlo- 
I  bneoeasary.  It  in  iw>siiiuod  tliat,  previoai  to  tlte  originitl  opo- 
it,  coiapTtaeion  uFtlR^  ftrt^^ry  iLl>ovi!  tli«  tumour  hm  olthor  boen 
!  and  fnilocl,  or  ivoa  ountra-iixiiottml.  Iloiice  it  will  be  [tmlnibly 
•lew  to  rwiir  to  that  motliwl.  Direct  pri-fwiuv,  or  gcimflt-xion 
Mf  forcible  flvxiou  of  tl»e  t'li>i)w,  if  tlio  aneuriitm  be  in  iIk-  liiniinn, 
*itli  iippropriuto  banda^iig  of  tliu  limb,  will  of  course  bo  triod. 
'lufi  thea*  iiieasun^  fail,  two  PourscB  iin>  ojicn,— ^titlwr  lo  tic  tlio 
J  lower  (lonii,  bLtwraii  tlio  li^turu  and  tlio  ancuriitin,  or  to 
lunu  tlw  old  opintition  of  opening  the  aac  and  t^niig  tint  artery 
it  cutoTS  and  leavcH  it.  A»  a  jt^nvral  rule,  Uio  fonni-r  mctliod 
be  preferable  in  the  lower  exlremity,  tlif  latter  in  tho  uii^xt. 
if  tito  Surgeon  luis  sufRcirj>t  conBdonce  in  such  mcosorce,  he 
■  KHort  to  gidvaiio-piincture,  or  to  tlio  iiij«elif>n  of  perdiloritbj  of 
{tea  bdow  tho  sections  which  trcut  of  tlicsc  methods  of  curing 
uriitm).  Tlie  ligiiltin-  nf  tlie  iniiin  trunk  alnii-e  tlic  onginal 
don  has  been  triwl,  but  it  appeiu-s  to  bo  oontra-ttuUcated  botli 
Uieory  uid  pmotic-.* 

Tho  recimvncc  of  anourisia  is,  howcvor,  nsnaUy  observed  at  a 

|)eri<Hl,  alUir  tliu  iM^rciiili.-noo  of  tlw^  ii|i[iurent  win.'    for  wocka 

'  months.     This  was  tJie  case  with  a  patient  of  Mr.  S])enc©,  of 

gh,  in  wlioin  tlic  aiieurisin  wa*  wftwwwnU  cnin,if  by  ^niu- 

The  case  will  be  found  quoted  lower  down.     It  does  not 

■  tiwt  t!i(!  euro  was  «ver  a  sound  oiw  «(l«r  tbc  lij^nturo ;  and 

i  [abation  in  the  aneiu'isia  was  never  abolished,  though  on  the 

QlV  l)r»t  ili:><.-hargv  it  luul  bfcn  rtiduwd  to  n  liiiv  which  wuii 

^h(  not  to  be  more  extensive  tlian  that  nf  the  popliteal  on  tbo 

f  sid<\     CiuwH  wicii  as  this  fail  from  tlic  faulty  foniiatioii  (rf  tbo 

llie  sac  is  filleil  nat  with  laminatMl  coogtdum,  but  in  part,  at 

with  more  soft  clots ;  junl  tlnwo  clot/*  in  the  counm  of  tiino 

and  yield  t<i  the  fureo  of  the  circulation,  or  [wiss  into  ita 

When  this  is  the  cane,  the  affair  bi-comc*  even  UKire  gnivw 

en  tho  diitctwe  recurs  fiiiiii  the  causes  mentioned  ill  the  last 

[>h,  siiioo  the  too  rapid  devclopnteiit  of  the  ei>ll.-it4V!ilH  i^i, 

all,  ratber  a  [ihenoiitenon  of  over  vitality  than  otitcrwiae ; 

*  A«  to  the  llirtHi  nut  nicotioued  In  tb«  provjnu*  Det«s— In  Ast1«y 
I  nue  thv  ar1«cy  was  tU'il  cIim«  abuve  the  siw  sueoM«hiUj :  in  PuiU's 
extenuJ  UJao  mu  tied:  but  Uui  }>ati«nt  died  of  tbo  opuialioa:  in 
■as  no  treatmont  teems  to  liavo  bc«n  ailuptcd. 


410 


DISEASES  OF  AltTERIKS. 


whUo,  on  Iho  contruy,  this  indicpcmition  of  Uic  blood  to  fonnlanuzi- 
alfid  Goagula  uiiJcr  tiio  usual  conditions,  njipenrA  u>  tcHlifv  In  Mttiae 
prt^ound  altt^raljon  in  the  vJUi\  ourrcnt  itself.     Tlic  progrrasU,  there* 
fure,  will  lie  wurito  thiin  in  Um  IntUsr  caae;  but  tlio  trvuuiwiit  must 
be  Uifi  saino,  sinoo  no  moro  rudical  mcasurvs  are  at  hand  cxcvpt 
nntpiiUtion;  fttid  to  tills  no  judioioun  Surgeon  will  liavft  recount: 
tuitU  ho  ie  clearly  certain  tliat  life  is  compromised  by  ite  delay.        ■ 

Siicli  MTc.  \hii  caiues  of  foihire.  and  Uie  mcthodn,  ut  the  heit  verj^ 
tincertain  of  succom,  by  which  thc-y  amy  bo  met.  But  in  tlio  pvs^^ 
majority  of  casCit  in  n-hioh  the  jmticut  survivi»  the  ojieralion,  tnat' 
tcrs  progTMs  quite  otherwiMV  Tlio  h'^turo,  after  a  certain  l(.-ngt}i »» 
tlnio  (which  vnrle.t,  ^iieritlly  boLweon  about  t^n  iliiyn  aiiil  »  imintliT 
according  to  the  size  of  the  vessel,  tlio  neatness  with  wliich  it  Iw^ 
hwn  MimrattKl  from  contiguous  jiarl^,  and  tlie  ra|iidity  of  ^itjJ 
cliaiiges  ill  the  patient  ojwratod  on),  cuts  through  tlio  arterj',  nntl 
comes  away  with  the  diaclmrge.  The  woiukI  llien  hoal:«,  the  ili— 
Tided  ends  of  the  artery  reunite,  and  the  whole  of  the  obliterai 
portion  of  tlie  wmp)  ih-generatos  into  a  flbroiL'>  oinil.  The  tumour 
at  the  same  time,  consolidates  more  or  less  rapidly ;  tlie  uiKluliilJu, 
Diovunient,  which  wait  perc<:^|)ttl)le  in  it  at  limt,  diNiipjx-^irin^ 
Che  deposition  of  laminated  coa^him  adrancos,  tmtil  at  leu^h  u>^ 
whole  J^  eonsoli(Ial«<l,  and  then  he;;ius  to  shrink.  Kinally,  ua  lA^^ 
the  s|>ontaneous  cure,  a  small  hard  tumour  remains,  like  a  walnut) 
which,  if  cut  into,  disjilays  a  stnicture  M>mething  like  thiit  of  oR 
onion.  With  the  exception  of  the  obliteration  of  tlie  artery  at  tliW 
two  points  (for  tlio  jwrsiatfiice  of  circulation  throuf^h  or  past  ilie 
aneurism  ia  rare),  and  tJie  consequent  development  of  oollatcnhj 
every  thing  in  the  limb  is  iiiitural.  Li  othyr  caswsi,  tlie  weakw** 
and  the  faults  of  nutrition,  which  always  attend  at  first  upon  tb* 
ligatiiro  of  the  main  trunk  of  a  limb,  jKrsist,  and  occasion  alio]"? 
of  Uie  rausclt>9,  fatty  degeneration,  &c. 

Such  is  the  modo  of  action,  and  such  the  efTecta  of  tj-ing  •* 
main  artory  of  a  limb  above  the  sao  of  an  anoitrlsm,  as  Hun'^ 
(lireclcd.  If  it  is  nccossHry  t*i  express  an  opinion  its  to  the  caw*" 
which  tills  plan  is  indicated,  the  beet  formuhe  perhaps  would  be  ** 
follows : 

1.  It  is  indicated  whene^-er  the  aneurism  (which  must  nKaJ* 
bo  supposed  to  be  in  an  active  condition,  and  advimciiig,  or  tlircaW"" 
iitg  to  advance)  is  situated  upon  an  artery  inaccessible  to  prwsorti 
but  which  will  allow  a  ligature  to  be  put  rounci  it  wllhoiit  e\cws« 
danger,  and  with  a  sutfieient  apace  between  the  part  tied  aud  die 
tumour,  of  which  the  iliac  arteries  furnish  Uie  bent  exiunplo. 


i 


HUITTERIAN  0PEH.\TION  FOR  ANEURISM,      -ill 


P       2.  When,  in  an  aneurism  differently  tutuatod,  the  patient,  from 
nervous  irritability,  <lrunkoniic*»,  or  any  other  raust-,  is  iiitolorant 
of  more  grndual  methods,  sucIj  as  presaure,  genuflexion,  Ac* 
3.  When  tlicw  iTnttliofis  Lav«  bi-en  tried  suid  failed. 
i.  When  an  aneurisni  liaa  burst  into  one  <if  the  interna!  eavi- 
of  the  bttdy,  e.ff.  a  poplitonl  uiR^urism  ijito  th«  knci'-ji>i»t. 
ra  very  interesting  example  of  cure  by  ligature  of  the  femora], 
afU'r  tliiit  f»rmi<iablc  oi'iiipliwitiun,  the  roadcr  i«  rcfi-m-d  to 
'  which  occurred  at  the  Miildlosox  Hos|)ilaI,  under  ihe  care  of 
Mr.  KIooTv,  and  which  wiU  bo  found  reported  in  tlio  Briiuh  Medical 

rowval,  IXSy,  p.  48H. 
5.  \V)mii  tile  rupture  hax  taken  plaeo  subftitanoously,  ampn- 
l**!!)!!  or  the  ligature  is  generally  indieatwl;  still,  in  some  of  the 
«*S8  gnivo  cia**,  it  may  be  jKissibk-  to  obtain  a  euro  by  coinpros- 
OOB,  bflt  the  attempt  should  ni)t  be  too  lung  pci'nistect  in ;  wliite,  if 
too  Kjnnptums  am  urgwit,  or  if  gangrene  have  commtiucod,  anjpu- 
H  tattoo  is  tlie  only  nwource-t 

B  Interna]  anviirJMn  doca  not  abitolutoly  contm-indicato  the  oper- 
•*ioii.  Dr.  Crisp  (p.  IJ*!))  says  that  several  eattes  are  recorded  where 
Person*  with  ancuriiiin  of  the  thoracic  aorta  have  sun'ivcd  tlio  opo- 
'i'tioii.  But,  in  one  celebrated  i>a.*o,  tJie  piitient  die<l  on  tlie  table, 
*«8i  nipturc  of  an  internal  nneuriitin,  just  as  the  operation  was 
I  wi«»  begun.  Tlii.t  accident  would  now  prolmbty  havo  bucii  avoided 
L      "7  tlie  qiiictuc«s  and  absence  of  agitation  pniduccd  liy  ana'sthcsia. 

I  *  Such  intolcmnce  muxl  not,  however,  bo  too  linsUiy  ndniitted.    Almost 

*<n7pcniaii  of  ordmniy  good  xcDHU,  and  LTcn  of  less  lliiin  oi^linury  ri-solu- 
tKn.  may  he  vdueaU-d.  hy  the  grudital  and  Uiuuiciit  use  i>r  digiUl  jircasuro 
Cnt,  and  ttio  prcuurv  of  in* Ini munis  itflcrvrnrdB,  to  bear  tlie  luiiuunl  luid 
dmiiiHi  of  romprciuioii  wbir.li  U  requisite. 

f  The  lubjvci  of  ruptiiroofnnctiiism  hnsbflim  referred  toftbove  (p.  3SS). 
A  Itiftt  b;  Sniiiitcl  Cnopin'  in  Mrd.Chir.  Tram.,  rnl  hvl.  uill  repay  pnruwil. 
fiepointsoDltluilLlio  pain  in  not  alnn^vs  ecvi're,  tlixl  the  slinpiMif  tbr  tumoar 
^Kf  be  not  much  altered,  noil  tlint.  hcyoiiil  n  litiL-^  purjrlc.  disco loratlOD, 
111)  trac«  of  cciOiymoKit  niny  !>(<  notiireil.  hi  tlicne  eitnes  lie  is  ineiintid  to  lay 
great  titma  upon  tltn  [irrsi«Lrni'c  nl bi'iiit,  iioinbinod  nilli  the  aluvncc  or 
padoal  dUapp«anuic«  of  puUnUon.  nnil  n  Middrii  fnll  in  ihp  tcmpcntlure  of 
tli«  limb.  Mr.  Poland*  paper,  in  Guy'ii  llntjiiuil  llf/nirii,  M  M'lics,  vol.  vi., 
eontitins  tioUi»  of  43  casM  {n  which  th(t  sno  of  a  pnplitrnl  niumnsDi  burftt, 
■ail  of  thv  rv6ult  of  the  treatment.  In  i  no  tvnntiuent  nas  adopted:  fii  I  of 
lh«*c  U)L>  tumour  bnrst  externally,  but  llie  jiaticnt  aurvived  tho  bleeding  and 
mcomvit.  In  M  compreMiou  was  used;  whlrJi  lurceodcd  In  S  cases.  lu 
lA  ibe  femoral  Aiury  u-as  tied :  10  rucovored  witliout,  and  3  atter,  atnputa- 
tkm;  '  died.— 3  of  gangrene,  I  after  amputation  ou  account  o(  dupporation 
oflfaai 


•T 


•f-^y- 


eanses  doath  may  have  been  prociuced ;  and,  still  more 
if  tho  clUc^nsu  for  wliicli  lliv  ojiiTHtiuu  ItiLi  hciii  iiii'U'Ttakt 
kiio^iii  to  be  curetl  1>y  other  iitenns.  To  both  tlioM  ubj 
operations  fur  Hi>curiiig  tliu  aortA  and  iiinuininMtu  art«r 
lixblo.  On  the  first  hciul,  il  may  indt^d  bo  urged  tlwt  I 
vfcasL'H  ofli^.ituro  is  as  yet  insiifBc-iout  to  alluwofov 
tltat  the^so  opt-rutioiin  ilto  utiifui'iuly  fiital.  Tliia  is  a  ] 
must  be  Icfl  to  tlio  JudgmcDt  of  tboM  who  may  be  calli 
docidfl  on  th<i  troiilinciil  of  a  C(U«o  of  tiiia  nature;  but 
cond  hoa<i  tiiere  is  no  doubt.  Aneurisms  at  tlw  root  - 
luid  ill  tlie  bvlly  hiivf  olbMi  yioMcd  to  auMlioitl  irmtDJOQi 
gono  spontaneous  cm-e,  while  they  have  as  yet  never 
ufKirution.  Ho  thut,  if  Hf^tnn!  bo  iiM'd  at  ull  in  Lli 
it  should  only  be  as  a  Wt  resort,  when  they  have 
the  jKtint  uf  bitrrUiti};,  or  when  tlivy  nm  incnviwing  und 
medical  tn^^ttinent  wliieli  can  be  procun<d.t  Again,  t 
should  never  bo  applied  to  any  artery  nliit^  u  »o  »iti 
admit  of  comprensioii,  nnlesA  tluit  tmituieut  haa  bevu 
fiiilod,  or  is  contra-indiciitod  by  some  peculiarity  iu  tfao 
should  the  ligntun:'  1>e  umhI  in  caam  of  recent  tranniatifi 
piirlitnitarly  when  caused  by  6'acture,  without  a  prcvit 
the  resources  of  nnluro,  aided  by  euoh  tneons  as  re«l 


T  faM 

bS 


*  ilfJ.Chir.  Tnvu.  vol.  xui.  p.  9,  ^ 

f  III  auvb  n  euao  ua  die  ou«  iu  nliidi  Sir  A.  CoojMf  ti*< 

vii.  whro  the  an^iriNin  liail  oii(>ti<>d  cxtcnidl}',  wc  m^r,^| 


K   Cisnt 

^ e.i  1 


^tBATMKKT  BY  IssTHCltESTAL  C0MPRES8IOS. 


DiSTRCMENTAL  COMPRESSION  IN  ANEURISM.     413 

eanfiil  Iiwicbging,  and  prc«stiro  direct  adcI  iiidin'ct.  Siil-Ii  cases, 
K.1  wi>  slinll  nee,  «re  peculiarly  likely  to  uixltT^o  BiiontaiioooH  cure. 
■  HortJHJiiliI  ilio  Itgittiirc  he  ii^cd  ifthowhalo  or  »  f^roat  psirt  ofUio 
arterial  sy^em  is  diseased.  In  fliidi  ojusi-h  digital  oompression  is 
the  most  nppruumto  uid  tuifiist  trqatmeot. 

H       "Hio  tnuitinont  of  itnciiriMn  l>j  i.v>mprc9i>ioii  is  a  )»nictic«  ofal- 

H  BKMt  ss  old  a  date  as  that  by  ligature  ;*  but,  like  it,  bad  &llen  out 

W  of  use  from  certain  iitiitorfuctionM  iii  it«  dvtAilit,  uiitU  it  was  taken 

ip  ijgain,  imjiroved,  and  fiLt«d  for  practioal  uao  by  modern  Sur- 

{      gwnH.    The  old  trvntmmit  c^unitt^rlvd  in  tito  ii]>pli cation  of  c'ontinuoua 

pwnre  eitlier  to  the  sue,  U>  tlie  artery  above  it,  or  to  both ;  and 

«»  QUiM  of  its  frofjui^'nt  failiiiv,  or  ratlicr  of  tlio  groat  rarity  of 

>■  KtocetH  in  the  hands  of  tiio  ancient  Surgeons,  arose  from  tlieir 

'P'Wmoi!  of  tlio  natural  procww,  a»  wo  bavo  abovo  attcniptM  to 

■*Eril)e  it,  which  elfecta  the  cure  of  ani->uris»i9.     Not  being  aware 

I      w*!  tiiu  do|w^ition  of  latninatMl  clot,  when  once  bc^n,  woTifd  go 

L   '■!>)  under  fnvouruble  drouniHkinces,  to  the  entJre  oblitforation  of 

H  'w  ni;  in  almost  every  case,  aud  that,  for  tlic  oommenccnii-nt  of 

H  'w  amjiiilation,  only  a  nioilurut^^  ohock  to  the  cirvulation  would 

P  •"Wre,  tliey  always  aimed  at  suj)pri'ssiiig  the  oir«mlation  tbrongh 

"^aneuri*™  altogether,  f  and  ifjuiwtbb)  brinj^iiif;  the  sides  of  the 

"0  iolo  eontact.    It  was  tbortforo  noccssary,  in  Uioir  opinion,  to  um 


*  l!pist4>r  is  6«it)  to  bHre  been  (h«  enrli^Ht  author  wLu  roeominenilcd 

I  piOsmv  in  th«  cuiv  of  aueurisiD,  uiitl  GuiLtliini  the  fmi  Siiri^L-oii  ivlio  us«l 

^  *uii  iuecma :  but  this  >>*hh  direct  |>n:>Mmv.    Si.*t>  D<?Iliiit{liUDi  on  Aneiiriim. 

t  Ilinay  b«  iiiivrvHiint;  to  n-cul  Huiitor's  cbbo:  "  The  luicuriBtu  van  in 

t*j*fcBio*»l  mterf,  and  Ujo  aiii-lliiig  appcmutl  upon  tlic  anlmor  pint  ottli« 

rJ*HJk.«  little  above  the  uiitldtc.  exlciiiJiiiK  ii|)Hm-d»  Hourly  to  I*i)upnrt'a 

J*9'«wot,     An  Bitunipl  win  mmlc,  by  rompri-'tisins  tlit^  iirttn-)'  iibovo  the 

5*<w  by  tniTBtiH  of  nn  initrumcnt  somewlmt  n-w-mblins  a  sIj-i-I  tnm.  to 

i"*!!!!  blood  ill  tliRnac  nduinec  of  «oitgii  latin (T.  nnd  by  Ihnt  mcanx  put  n 

^^  to  Uic  pmtrma  of  tlie  disi^uR.    But,  fmin  the  )inin  whi<'h  it  poconoucd, 

y^  ittcBipl  to   ninlcc  n  pi>rn»ui<rnt  mrnpivsiiion   on  tbi!  artcif   pNived 

^wrtual."     n<t  ihen  jiroeei'iis  to  drmribc  llic  progrpnn  of  tho  nu>e.  tha 

.       **tei«Bi  qndcrgoiiig  a  Hponlancolis  eiirc.     Ituntflr's  W'ofJu,  vol,  iii.  p.  002. 

***  pnuuri)  sppenn  to  Iiavo  hern  Bpplicil  too  stvoncly,  too  con»t«nlIy, 

J      *«  lcr>  muvh  in  oae  plucv*.    Yst  Hiiniei-  was  fully  awnro  that  lUo  curs  of 

L  ^nrinD  was  quite  «Mi)p«iible  tvilli  the  porsistence  of  circulation.    Much 

H  ^  wuolil  SuTfpe&iiii  who  tluiughc  it  neoeasaijr  kltogeiber  to  aboU«]i  ihn 

H  '■'nlstiun  lUl  into  mcb  enors. 


reading  aomtimts  of  (xuattani'a  casca,  and  of  otliera  fai 
old  Siirgt^iins  attoiiijiti-d  tn  ciin;  atiiiirifm  hy  compreiri 
at  onoe  struck  hy  the  f:urt,  that  tlie  firwsure  was  alwaja 
sovoro  or  ap])lifd  to  ttiu  wrung  part,  and  oftvn  botlt. 
tlioiight  tbnt  tlio  principal  point  wua  to  exclude  tlie  bloo 
sac,  «r«uursc  tin;  oliii-f  tntranit  of  doing  no  vtiu  to  t-inpt^ 
direct  proBSore.  ^Mien  Utia  waa  iinpo!»it>lo,  tlie  next  tli 
coiHpn-.is  tin-  urtury  alwvo  «o  fimily  tliat  no  bloixl  voiild 
modoni  svsti-m  is  entirely  difR-rent  in  principle,  and 
imitation  of  the  process  of  sponUmoous  cure  Wo  havi 
when  an  ancurisjii  i.4  cored  !i|>on1iuieously,  it  is  in  cuiu 
thn  viri'iilntion  liaving  rEWoircd  some  partial  chock,  hy  i 
nated  eoa^ilnm  is  d«j)Otitt«<l  within  (he  mic.  Juflt  so  in 
an(!nri:«in  by  compi-essiou.  It  is  miTcIy  nooos«an,'  to 
force  of  the  oircMilutiipti  throiigli  tlie  uiieoH.tni  tluring 
eidt^rablo  part  of  c^ch  day,  and  tlicn  tisually  in  a  fev 
Boinetitiies  not  till  tlie  t^id  of  .weral  wi'i'k.t,  it  n-ill  bo  i 
Uie  o^doina  und  voiiuus  congestion  hate  quickly  sabsido 
puWtion  is  diinliiinliiiig  in  the  tumoiu-,  that  ttx  coiiti^nt 
Solid  (whicli  may  be  known  by  ita  var)-ing  lees  in  sixe  m 
Uie  bUtod  is  idiiit  off  or  Id  in  from  tlio  artory  when  tl 
preifscd  on  it),  and  that  the  anastomosing  brandtcs  arc  in 
as  to  be  fiilt  pulMitJng.  A>'iicn  titcw?  «igiu  arc  prOMmt, 
pnttty  sure  that  tJie  cur«  of  the  aneurism  is  not  far  distal 
It  would  1>n  wrong  to  pnM  over  in  Kiknoo  the  hist 
method,  although  the  length  to  which  \\m  Mksay  iwoe^l 


IXSTUUMENTAL  COJIPRESSION  Df  ANEURISM.    415 


by  Sir  W.  Blizard,"  anil  is  ntwiiigly  lulvooatcil  hy  Sir.  Freer;! 

\jiit  tW  latter  Siirgcon,  oiid   probably  all  vbo  preceded  thoee  of 

til*  Irish  s«Ik>oI,  itnk'i<»i  HihiUt  be  an  pxi'i*|itiiiti,  tlidtij^lit  |,liat  pTv%- 

.«un!  WH5  to  at't  by  oblituraling  tlio  arlciy,     Tlio  |)ain  was  very 

it,  in  coiuic<]iieiico  of  tbo  aKMumtxl  ti<K«ft»ity  of  milking  very 

|ntw>urio  a]n'ay§  in  tho  same  f^|>ot;  nevcrtheloHH  some  fctv  cures 

'wow  obtitii»>(I  iiiiiKrr  ihii  curt!  of  Pt'lloutn    (or  Kdiiird),   IhitxiiM, 

I>npnj-tr».ii,  Boyer,  and  Albers,  and  aro  quoted  in  Dr.  liellingUaui's 

Witrk:  Imt  Ibojw  pa**--*  of  mih^ss  were  Imlaiii'wl  by  f»ibmi>,  wbidi, 

WwrTiling  to  Dr.   Bcllingluun,  were  "still  more  numei'ous ;"  and 

the  treaUnenC  ku»  »o  ]minl\il  aiid  .«>  tiii(^Tl»iii,  Unit  it  neoinnl  likely 

to  fall  into  complete  discredit,  until  Mr.  Todd  of  Ilublin  recom- 

ineitiltxl   lh«   use  of  tbn  plan    tn<  an    ndjuviint    to    tlio    Hiint<.Tiait 

opOfation;  his  object  being,  by  preliminary  pressure  on  the  trunk 

™  IIk  fonioral,  to  cnuw  IIk!  dibitiitiim  of  tlic  oollat<'ral  bninela-it, 

■"d  *t>   to    lesson   tile    risk    of  gangrene.      For  tliis    piorpose  ho 

•^dft  nae  of  (III!  tn.it.riinK-iit  originnlly  invuntwl  by  Hoi*ter ;  but  no 

•Wking  results  followed  from  this  practice,!  which  was  adopted 

■yjome  SnrgKoHd  in  Dublin  and  di-mi'd  by  otluirs,  but  rcpuxbtil 

"y  >II  merely  as  an  accessor}'  to  the  ligature,  until  the  accidental 

•"wtM  of  [>nf««ro  appliod  in  tlio  caw  of »  jiatient  of  l)r.  Mutton's 

(Oct.  3,  IfiJi*),  who   refused  to  submit  to  the  operation,  sliortly 

™*f«ed  by  Kimilar  Biieoww  on  a  p!iti<^-nt  of  Mr.  Cusaek'c,  whoso 

'*«ltJi  appearcl  too  broken  to  enable  lum  to  survive  the  ligature, 

"•l  1o  a  Iwttur  apj>rvciation  of  the  nialttT ;  and  tlic  rtrikiiig  viiecoss 

^**«nod  in  a  patient  of  Dr.  Ilellingham's,  the  aneimsm  being  cured 

*  iwo  dayM,  dr*^'  thv  attttntJon  of  f^iu-geona  in  other  countrita*  to 

'**  matter,  and  successful  cases  followed,  uot  only  at  Dublin,  but 

f*o  u  Univ«nfily  Coilcpo  Hospital  luidvr  Mr.  Ijintou's  earc,  luid 

'"  other  parts  of  the  kingdom.     Still  the  groat  majority  of  the 

*^"*<3  were  treatml  in  Irciland;  and  it  is  to  the  Irinh  Surgnoiw,  and 

^*I*cia]ly  to  Dr.  BoUingham,  that  the  Profession  is  indebted  for 

^*  tnie  tlicory  of  tliis  mirthod  of  curv.     Tlioir  suecesH  in  llio  nppli- 

^^tton  of  the  treatment  has  also  been  much  greater  than  baa  been 

**t»UDC«l  in  IxHidon.     In  l>r.  IlL-llinghiiin':*  small  but  very  valuable 

*OtkooAueurisni5  (.from  which  tlic  above  particulars  are  extracted) 


•  Bfllinsbani.  op.  cit.  p.  2S.  t  ^  JinevHtm.  pp.  M.  vt  aqq. 

:  ll  is  r»U\.  however,  to  hnve  «ll(^ct(>d  a  cure  in  one  unpubtislMiI  caae. 
'"liieU  ea  tht  TncMunt  of  Antvriim  Uy  C'lniprttiiion.  p.  37. 

i  OhttTtatiotu  on  AfUtrimi,  and  it»  Trftimenl  hy  C'ampreinon,  Dublin.  IM', 
'*X<hida  two  com  in  which  galvuniim  vau)  aUo  used,  auO  one  of  which 
JtVMdbta]. 


416 


DISEASES  OF  ARTERIES. 


may  bo  found  short  nutei;  of  twoiilj-fivo  cases  (most  of  them  treat*''! 
ill  Itvliind)  ill  M'liiirh  M)ni{iressioii  was  tuod,  oiiil  witich  im-hi'lvd  nJI 
that  had  been  rpportcd  up  to  that  dativ  In  only  one  of  tlie^e  'wa^ 
it  fiHind  iMK^KtMin,-  to  rt>M)rt  to  Hgntuiv  of  tlio  wlory,  nnd  then  nol 
on  aix'ount  of  the  fniluro  of  the  method,  but  in  obedienoo  to  tiie 
wishet  of  tho  puUeiit,  who  wwins  to  liave  got  tirod  of  the  trcsitniunt, 
though  it  appoarod  on  the  point  of  succeeding.  (See  itko  Tufiiell'* 
work.)  I 

Till-  pxpericnee  of  English  Surgeons  has  been  far  less  fuvotil"- 
dble.      In  tho  Mfiilnl  Tim,K,  vol,  ii.  1H56,  iilid  vol.  i.  It*60,  ar«    to 
be  found  some  ralunhle   slati^ties  of  the  cases  which   httvo  hoeo 
uiid«r  ln>atiii(>nt  during;  lalo  yt^iirs  in  the  nictn)[H)Iitan  and  pro- 
vincial hospilals.     Of  the  soventj'  cases  included  in  the  first  rt-port, 
'n-hich  is  bcliovod  by  llie  roimrter,  Mr.  Hiitctiinmn,  to  be  statistic- 
ally accurate,  as  containing  al!  tlie  eases  which  had  bi^n  inidcr 
tr<MtjiK'itl,  forty-.*ix  wiax;  jiupliUral  aiiourivin,  tmtk'd  by  {>res6tin^ 
The  treatment  succeeded  in  twenty-four  of  tJiem.     Of  the  rcwnin- 
ing  )w»!(ily-lwo,  in  whom  tlic  fi-nitiral  artery  was  tied,  two  ov^y 
died  ofgangi-ono;  white  often  ua»«es  in  which  ihe  artery-  wm  tie'' 
without  preliminary  coniprt-Ksion,  Huixt  died  of  gangrene.     Th« 
period  of  Ireaimeiit  in  the  succe«sfnl  cases  varied  from  sixty  h«ur* 
to  eijjlit  uuiiiths,  nineteen  days  being  the  a^'orago  tin]&     The  \»T& 
proportion  of  eases  in  wliJcti  ]iroftsiire  failed  will  ntriku  tite  rcnilet. 
It  is  prolxdilc  Unit,  it  was  duo  to  the  noielty  of  tlic  method;  sin** 
in  (he  second  rojioil,,  \vhii.-li  eniititin.i  (itly-nine  ciisea,  lixwtod  Mth"^ 
by  ligature  or  cftmpre«iion,  tho  latter  plan  succeeded  in  twenty-|5^' 
CHKOH  out  of  tJi  illy -nine.      E^en   this,  limvc^er,  shuws  n  fur  l^* 
etnking  success  than  was  at  first  augured  fur  tho  mclhcKl,  and  Dii^'" 
lmv«  been  exjiectcd  from  the  ex|icri«nw  of  tho  Irish  Siirgi-ons.        "' 
is  possible  tliat  a  greater  praiwrtion  of  cures  may  be  obUuned-     * 
Surgeons  beeoino  more  ucqiininrtil  with  the  iiiiiIkhI,  and  more  al  ^ 
to  tJie  necessity  of  attending  to  its  minuter  details.      Meanwl*^ 
wc  may  agree  with  Mr,  Hntr-liinwurs  ninark  upon  tlic  alxjvc  ^"^ 
port,  that  all  tho  success  obtained   by  com  press  ion   is  clear  i,.^^ 
unbalanced  gain  j  that  in  the  cases  which  siiwucd,  the  pativnt         "^ 
witli  no  apjuvciahlo  danger  to  his  life,  withdrawn  from  tlie  ''^^^^ 
serious  risk  of  the  Hiinterian  operation,  and  in  tliom  that  fail  U""^ 
dangers  of  that  operation  are  dtminii^hecL 

Tlie  instruments  rec|uired  for  the  compression  trcntiacnl  *^    2 
one  or  two  eonipresaont,  and  a  weight  encased  in  leatlier.     I  eli^*^ 
dwicrilic  the  method  as  applied  to  tlic  cure  of  |ioplitcal  ancurisa*  ■' 
if  the  bracliial  or  Hubclaviitn  were  tho  subject  of  oomprefistoD,  tt*^ 


NSTnniENTAL  COMPRESSION  IN  ANECRISM.  417 


fiOKliona  would  be  easily  made.  The  comprcMorB  now  in  xms 
nade  on  tbo  principle  of  vxvrtiiig  i>r««siiri>  tipnn  a  sm:iU  upaoe, 
int  any  ciroulnr  constriction  of  the  limb,  llipy  c«tL-<i>l  of  u 
,  or  trou;:}i,  whicli  i»  uppHoiI  to  tbo  lower  narfuce  of  the  thigh 
Iff  point  o[)po«ite  to  Lite  artery,  and  a  pad  au]ijM>it«d  on  Lliift 
b^'  B  strong  kivor,  or  arm,  suit]  iiKwnblo  in  all  directions. 
Imer  stands  well  away  from  the  tbigb,  and  tlie  iii»triinii>iit  in 
in  position  by  tlw  oomprcwioii  wliioli  it  oxoreieci.  WTien 
ed,  it  U  screwed  do\vii  upon  ibe  artery  until  llie  »eniiatioii 
nunicat«<l  by  tlii?  aneurism  to  tbo  band  u  oonHidrrably  lessened, 
liinini^bei)  about  one-half;  and  i§  left  ho  until  ibo  ])atieiit  a 
bio  of  inconvcniciiec  from  it.  It  is  by  no  melius  necessary 
up  pulsation  in  the  oao  allogetlter,  nay,  it  is  not  elcnr  llmt 
oxpeditcs  tho  core.  Fatient«  oftiutot  tcnijicrumcnt  and  rather 
t  Mtnitibility  can  ol^en  tolerate  fnr  a  time  the  degree  of  preft- 
necessary  to  utop  the  cireulalion  ;  but  It  will  ^nerally  be 
d  that  even  in  tlient  it  produces  injurious  eonj>oijuoii<n>j,  cither 
use  the  pn^ssure  nets  on  tlio  vein  an  well  as  tlie  artery  and 
usm  cedema  of  the  foot,  or  beeauw  the  nervos  become  in- 
id,  or  perhaps  bocau»c  ttio  sac  (which  of  coni'te  slu-inks  when 
t  of  the  btooil  baa  paxited  out  of  it)  bottomed  too  Yiolfnlly  dis- 
cd  on  Uie  withdrawal  of  tho  prcKSun-,  and  so  the  process  of 
jululiof)  L«  interniptt^.  It  in  bottt^r,  tlien,  In  commence  witli 
'mild  prcsenre,  to  change  tlto  piacooftts  application  &equontIy, 
to  gi\-o  the  patiiMit  ^uch  intervals  of  conipleir  rcpoxe  a»  mny 
sh  his  spirits  and  procure  him  good  sleep.  The  management 
K  comprcMor  tJiould  bo  intnistf!'!  to  some  ono  wlio  know;*  tba 
%  of  tile  artery,  and  can  judge  of  tho  direction  in  which  pres- 
I  ilwuM  bo  ajiplieif  I<i  eiHiunaiul  it.  Tlio  wiiirim  of  the  artery 
be  indicated  by  a  line  drawn  down  the  limb  with  caustic,  and 
inUdligent  patient  or  nurse  soon  leiinifi  wlii-n'  te  apply  the  piul; 
Ifae  applienttoii  of  prerauro  in  the  right  direction  is  more  diflfi- 
*    When  tho  patient  haft  got  tired  nf  tho  Heneutioii  cauMCtI  by 


'  Wsnl  of  iiMUMi  forbidn  «  eoiiipleie  acceuul  of  ibe  various  hinds  of 
Nwwxri  wbirh  boTo  hcca  iownicd  fur  Ibe  trmtnieul  of  ibo  ]KipU(«ftl 
i>lli«r  forms  of  Dneuri.iTn.  I'crhaps  llie  best  funu,  m  obtafning  the 
Itite  d^^grce  «(  pwanuro  with  the  least  diuif^r  uf  producing  >  slough, 
taUlf.  at  lb*  SAiiH!  limo,  Iciut  liable  to  slip,  i«  Dr.  Cnile's  appaiutus, 
lich  iho  STtn  csriyinif  tho  paiJ  is  attached  to  tbl^  lev«r  b;  ineaiis  of 
•nibber  bands,  snd  Is  niornbin  in  nil  dircctionn  on  a  btLllaiid-Bucket 
■  It  Is  vrry  di'sbubl*.  hoiroror,  to  buvu  scrt'Tul  ini>t)uni«iitH  ut  Imnil, 
i»*afT  l]>o  point  ofprfssure.  The  wright  ia  the  (prnm  mnr  bo  sus- 
*il  bjr  mtfaiuf  of  a  atiiiiijor  irii'e,  so  as  just  to  produce  tiic  noteusty 

roL.  m.  E  E  ' 


418 


DISEASES  OF  ABTEUIEa 


tli«  pad  of  the  oomiinwHor,  ho  cod  Ihj-  Ute  weig:ht  u|« 
arU'ry  in  iho  groin,  raising  it  for  »  few  minutos  ot 
\ery  oflcn  tlio  patic-iil  pn<fcr»  6to)i])ing  tbo  pulM  by  tfae  f>raa 
tlio  fiiigijr,  (liU9  pombining  digital  witli  in^trumcmtal  cotnpnM 

Hki  gmorid  tix'ntjiu'iit  duniig  oompn-Midti  U  a  [xiiiit  oa 
aome  variety  of  opinion  exists.  Some  Surgeons,  even  in  th 
sent  dar.  nlivn  stimulntion  in  «o  iniieb  in  vogue,  prefur  tu 
tlio  di'|ilt^luig  ]ilnn,  aldiougli  not  to  the  extent  recummiqiilt 
practifind  by  VslrtiUva ;  but  tlie  m^ority  oontidor  thut  the  a 
age»,  if  any,  derivable  from  tliia  oounte,  do  not  <^i»a\  iIm 
cnlties  whivh  tlic  rcMtli'wnicm,  diacoinfort,  and  distress  it  oci 
to  tJiQ  jiatient,  throw  in  the  way  of  the  treatmenL  1  Iiavn  m 
depleting  plan  triod  once,  but  it  soomod  quito  iuafficiunl>  al 
case  was  ilio  moAt  protntdctl  cure  by  comprewion  whidt  I 
heani  of;  whilo,  on  the  other  liaiid,  a  sufficient  diet  and  a  mo 
allowanoe  of  slimuliuiU,  if  the  jiulit-nt  Imh  hi-un  n<-c-uxi<im<vl  to 
appears  not  to  retard  tlie  cure,  and  certainly  renders  liim 
dispoMHl  to  Htibmit  u>  it.  Smhm  Surg«>oiiM,  ac-ting  ai\  Uie  idea  ij 
out  by  Dr.  Stokes  (see  p.  366),  prefer  to  feed  the  patient  oO' 
almoHt  exeliiHlvtOy  of  nicut,  believing  tliat  iha  blood  in  tliivc 
richer  in  6brto,  and  more  prone  to  coagulaiiotw  Opium  'u 
times  noccsKOry  to  prwuro  s1ooj»;  hut  if  tlio  patient  bv  not 
irritable  dittposition,  and  Ihe  prcaaure  ha^  btien  conuiiun<H<d  d 
}io  (Mn  generally  sleep  quite  well  when  tJic  tnstnunent«  arm 
dranii ;  and  eaAos  occur  ooeosionally  wliere  tlte  patient  cut 
undioturbed  even  whihi  tlie  compreesor  is  applinL 

Tile  time  recjuircd  for  tlt«  sueocM  of  the  vomjin'Mion  tn^ 
rariw  remarkably.  In  i6  socoeBsftil  oasee,  reported  in  tli»  Jl 
TiniH  and  Ga:/^ttr.,  itio  tiin«  variod  from  fiO  Imunt  t»  8  bh 
Uio  average  being  19  days.  In  some  of  tlie  probracted  oaM 
cause  of  delay  ha*  been  the  inefficient  way  in  whidi  the  tiW 
has  bei<n  carried  out.  Tlius  in  tJie  case  of  a  yo<uig  wooiaq 
was  undiT  Mr.  I'n-.'K'olt  He«-utt's  care  in  St,  (j«)rg»'»  JIo*|>iB 
n«eoniit  of  jmpliteal  ancurisni,  some  years  ago,  the  dii^eaw  rko 
stationary,  notwilli.itandiiig  the  enn>t(uit  u|i)>lic«tton  of  ]»»«■) 
montlut,  but  was  cured  in  a  few  days  aAer  her  tnns&reooD  ( 


pmrare  witlinut  fntii{iiing  tho  patknt  by  tiolilinu  it  in  bis  liand.  Ul 
biu  (Mutrivvd  a  plui  by  nliidi  ibe  exact  aaiouui  of  prt-astm  txm4 
rasiit«rcil  upon  tlio  iHinipr««Mir.  Tliis  nuy  be  nautol  in  prwvoMl 
txevm  of  Ton;*  fivm  being  utiadviiu-tli}*  employed.  Ahi«ll  TallMUa  I 
ation  on  tlicBa  and  otfa«T  poinla  i-ouoi-clnl  with  intlnnactita]  n 
will  ba  found  in  Tufa«ll'ti  work  uu  Uiv  subjuut. 


INSTBUMEOTAL  COMPBESSION  IN  ANEURISM.  419 


ItNtiog 


care  of  a  difTcrent  nurso.     It  vras  discovered  that  (ho  proriont 

&ti(rn<iiuil  liarf   Im-cii  in  Uuj  liubit  «f  idlowing  !ior  to  rcinovu  tJw 

inBtntm^nt  aiid  walk  about  tlw  ward.     In  other  cnses,  however,  no 

wicb  rif^lijp'iKH!  ftiu  111'  ilfttected,  yt't  t(i«  oun*  iniiki-.*  no  iirngn-sit 

a  ponsldorablo  time,  wlioii  a  favourable  turn  amldenly  oiunii^, 

dw  [Kiti<Tnl  reeovont  rapi<IIy.     It  snmiu  inipoMsiblo,  with  our 

ent  knowliidge  of  the  procossoi  which  go  on  in  anoiirismal  aaoa, 

tfixplaiti  Ibf  rwwoDS  tff  tlivws  uncortninlii'v ;  but  tbo  prsiotical  in^- 

(Bce  is,  tiiat  as  long  aa  tlie  tumour  ia  not  inereaaing,  and  thi;  patient 

ii  not  Huffcring  from  tho  treatment,  it  in  n:^a<i<>nfib1i>  and  advisable 

Id  persevere.     Auxiliaries  to  the  treatment  by  compreasion  miij-  be 

•wglit  in  position  of  the  limb  aiitl  in  dirt-ct  jrrcman.' ;  but  tlicxe 

nMhoda  muat  not  bo  insiBled  on  if  tliey  appear  to  cause  distress, 

■nd  thus  cndangPT  tho  «uc»'M  of  tho  principal  ag<:-nt  of  tri.-!ttnicnt. 

When  compreaaioii  Rueoetxhi,  the  com  is  preciaely  on  die  wune 

anatomically  &s  wIku  the  discaw  underlets  tho  proccns  of 

9u»  eure,  so  tliat  the  rea<!er  may  bo  reiorred  to  what  has 

I  laid  npon  that  bead  in  a  previous  paragraph,     SomrtimL'ti  the 

(■*TT  btM-oim^  tliiekt'tied  and  o<)nlra<itjiI  whi-n>  tho  i)^'!^!!™  was 

[•J"!!!!™!,  and  it  is  possible  that  it  might  become  obliterated  ;  but 

lAu^  in  tho  arterial  wnlLt  are  of  rare  oocum>l10(^,  and  take  place 

jPnUUy  only  when  compression  lia*  been  exorcised  more  \Hgorously 

I  nuiri' itmtiuunu.sly  njiun  one  s|iot  llinii  t.*  rither  ilmuiI  or  lU^ir' 

i.*    Usually  when  a  limb  is  examuied  after  tlie  suceessfiil  n»e 

fcrajpn'mion,  thi!  nrt*'ry  above  Ibi-  tinnnur  tihuw^  no  trMC*-  of  ifct 

[■Sim,     Tlie  tumour  is  generally  quite  firm,  being  filled  with  laiin- 

1  coHf^Ium ;  bnt  Mometimia  n  elianni'l  h  Hivn,  through  which 

■lion  lias  gone  on  in  it.     All  tliis  will  bo  seen  to  be  identical 

ibo  n^nluntt^iu  euro.     Euliirgtij   miai*t'>niu!<ing  arterii't*  are 

rally  diwovered,  and  tliia  enlargement  is  usually  and  rightly  re- 

I  as  one  of  tlw  earbwt  and  l>e,*t  symptoms  of  cuinmwieing  cure. 

Hm  cure  of  aneurism  by  oomprewiion  does  not,  however,  always 

Jpe  the  oblitcTtttion  of  t.h«  sac,  aiul  docs  not,  thi^Tc-ton-,  always 

.  the   eatablishnient   of  any  new  eiroulation.     ThiB  point  in 

l***nitcd  bj-  a  prqmration  in  St,  Gvorg^-'s  Hospit.il  niii*"'um,t  in 

a  popliteal  aneurism  in  prescrvcil,  «hich  bad  been  troatod 

'  onnpreHSton  of  tlie  femoral  artery  for  more  than  Iwn  itmnths. 

)Mc  lie*  bi.'twc«n  the  itrtery  and  jouit,  and  is  entirely  filled  with 


[>Kdi 


*  la  3Std.-Cliir.  Traiu.  *oL  xliv.  p.  IHO,  will  bo  found  a  ease  ia  which  a 
•  ■nenfisn  bnnwltpoDlaDeausly  at  the  purl  whc^ir  pn^nium  hnd  bvna 
I  loUte  fenoral  art«t>  manj  mouttu  before  for  the  cure  of  ancuhsm. 

f  Scriea  zL  Bubserin  t.  uo.  3S. 


420 


DISEASES  OF  ARTERIES. 


I.imiiiatcd  coagnU,  except  a  channel  at  tlie  back  oontinnons  witJ'" 
the  artery  and  fonning  a  |iart  of  ijs  tulnt.  This  mctWl  of  tmv  i»  ^ 
liovrfivcr,  not  ta  be  desired,  amc«  the  clot  nui^  yield  agniu  to  thc^ 
fiiroe  of  tlis  circulation,*  and  thtu  tlio  i^seaao  may  recur. 

Tilt)  liiiluro  of  tliia  iiiethixl  is  due  sometunra  lo  l)t<?  anutoinivaB 
distribution  of  the  arteries,  a»,  for  instAnoo,  vrhon  a  vas  aberrant 
OHrrI<!Fi  im.lhe  circulation  through  the  aneurisiu  firi>m  n  |u>int  abow 
that  which  Is  coinprGsecd,  an<l  j>robuli]y  with  mure  encrgv-  (lie  more 
tlifl  main  trunk  is  obstract*Kl  ;t  or  it  is  due  to  sloughing  oftbo  tikiii 
under  tho  pressure,  to  tbc  patJciit'it  indocilitj  or  coustitutioraJ 
rcntleaKnctti)  (by  tar  the  luoHt  tVi>iiueiit  cau.io  of  failure),  or  to  some 
deficiency  in  the  toiidcncy  towards  coagulation,  which  renden  the 
hlofHl  in  the  sac  im-apablo  of  going  through  t)ie  procowe*  nccctnaiy 
to  euro  without  a  inoro  complcto  interruption  to  the  oirvalatJoa 
than  <K>in|ireMion  fiiriiialtce,  aud  which  must  therolbru  bo  sought 
by  ligature. 

Olio  great  aiivnntago,  however,  of  Uks  treatment  by  compreasioo. 
is,  that  when  it  fails  it  seldom  fails  totally ;  for  if  it  doct  ntrl  koimxvI 
in  curing  tlie  ancuri.iin,  yet  in  ahiK)»t  uU  cnsi^s  it  places  the  dis6M9 
under  more  favourable  conditions  for  cure.  The  oh('iou8  rMMn  % 
that  it  ]>roiliiees  enlargement  of  tho  collateral  vcnmjIs,  and  thi» 
ob^nates  tJie  tendency  to  gangrene  which  is  so  decided  in  tlie  loiwr 
cjtlremity  nfter  tlw  Hiitit«riaii  «|icration  ujwn  the  femora]  aitery. 
It  seems  highly  probable,  tlierefore,  although  at  prewnl  tho  cuMS 
arc  far  too  icw  to  fomi  any  conclusion,  tliat  the  mortali^'  fhun 
gangi'cne  will  be  found  much  smaller  in  caw:*  trealixl  KnA  by  ca** 
pression,  and  aBcrwanU  by  ligature,  tlian  in  those  where  llio  aitcrr 
has  been  tied  at  tlie  outset  { 

It  might  occur  to  tho  reader  that  this  advantage  will  be  in  som« 
respeet  balanced  by  tlie  iiicreafted  fiteiiity  willi  which  the  blood 
would  lind  it»  way  into  the  artery  above  the  sac,  and  ttnis  eaitvoa 
tlie  circulation  through  it;  but  tliiH  doe*  not  vouin  to  have  bom  tlx* 
ease  in  any  of  the  aneurisms  so  treated. 

Compression,  however,  although  it  is  usually  hamtleas,  ff 
boncficial,  even  In  the  casee  where  it  is  not  entirely  miconnfiil, 
not  always  so.     ('ases  do  no  doubt  occur  in  which  the  ane»rif» 
incrca&eB  with  much  greater  rapidity  afler  llie  applicattoit  of  ■li' 


•  Sea  Mr,  Spetice'e  cose,  quoted  on  p.  4S0. 

i  TJio  cRso  niarkf  <1  24  in  Dr.  Belli iiijliam's  labl«  [Mfd..Ckir.  Tnmt. " 
xxxiv.  p.  1411)  is  an  exu1llI>t(^  of  ibis  peonliarity. 
;  Ma].  Ihiiei  and  Oaz.  Nov.  S9,  ISIitt. 


DIGITAL  COMPRESSION  IN  ANEURISM. 


421 


e,  and  goos  on  rapidly  to  bursting'.     In  one  sudi  case  the 
t^YV  w«j,  Jiii'l  lh«  pniimit  dknl  fiftlte  IinMiiorrliiijii'." 
A*  (o  pressure  on  the  dictid  side  of  the  sae,  I  liave  notliing  to 
^»T,  ucrvr  haviu;^  »W-'ii  u  raiM!  in  wliieli  tliero  was  ajiv  t«in]tt3tion  to 
it.    Its  uneertainty  and  danger  are  so  apparent,  that  it  should 
trer  f»c  nwxJ  wIu-r!  ounippftision  or  ligiiture  cim  b«  tip])U<.'d  ahovci 
s  tumour ;  but  in  aneurisms  at  tlio  root  of  tlie  neck,  it  may  be  in 
MBe<aM»  worthy  of  a  ciiutiuus  trial. 

X  HOLMES. 

DlClTAL  CoMrBESSKW, 

The  treatment  of  iuieiiri»m  by  digital  ooraprGesion  t»  of  veiy 
Hit  origin.  It  has  »pmng  directly  fruni  ihe  successes,  nJid,  it 
1  be  said,  also  from  the  failurcif,  of  tlic  trt'atnitfiit  by  mccliitiiical 
lion.  Tlia  first  reu>ri]od  case  in  which  digital  compression 
tOOGeesiully  diipli^ycd  for  aneurism  ajiix^iuv  to  bo  tliat  of  a 
nl  treated  by  Mr.  Greatrex  in  May  1841,  and  xhoso  i*asc  was 
itcotiIhI  by  that  Surguon  in  tho  Mtdit^Chiruryical  TroMtactumt^ 
Iw \Hh,  In  iJiia  easo  the  thumb  or  fingi-nt  wure  aiipli<!il  mkt  tlirt 
tnqral  arterj'  iu  the  intervals  of  osmprt^ssion  by  a  touiitiquet. 
Hh  uicuri«m,  which  filled  the  pophteal  s[iaec,  milidilied  in  twcnty- 
boors  ondcr  tliis  joint  tr«i!itmont  by  digital  and  instrumental 
sion.  Two  yearn  later,  Professor  JoUillVi  Tufiicl!,!  trosif  iiig 
■  {npt!l«al  aiteurisni  by  comprt-wiion  witli  a  tourniquet  at  the  groin, 
■Iittdhts  [oogroJit  imjieded  by  enlargement  of  thn  inguinal  glumlH, 
<  laogUt  his  patient  to  eomprc6H  tlie  femora)  ai'tcry  ivith  his 
[frunb  until  the  swelling  of  tlie  gland.i  MibnitkHl.  In  both  tluitw 
1  the  pressuro  by  tho  finger  waa  employed  as  a  tem|>orary  aid 
inttrumvntjU  compression,  rather  than  lu  «  niL-aii.-s  eu]iublo  of 
|*feing  the  cnre  of  an  aneurism. 

But  in  184*!  Dr.    Knight,}  of  Nawhuvcn,  Unitwl  Stiites,  for 
ukGisI  time  employed  compression  oftJie  femoral  by  tho  fingers 
I  Bole  meann  of  cure.     The  case  ■wa.n  on«  of  popliteal  uiictu'iiim 
romlatto  forty-eight  years  of  age,  for  whom  every  kind  of 
and  apparatUH  hail  been  vainly  em|ik>yr>d.    Itt-fore  having 
to  ligatm'e.  Dr.  Knight  made  trial  of  ni;inual  eomprei^on 
Ffemoral ;  lio  olttitintiil  the  help  of  n  mimbdr  of  ikSHintjints,  who 
,  each  other,  two  and  two  every  half-hour,  mauitaiiiing  con- 


«  J/m&mI  7hu».  IKSO.  vol.  i.  p.  tlS. 

t  l>Mm  .VtJi«tl  Prt4$,  1641.  vol.  t.  p.  IBD. 

{  3Vyww(WW(/lA*  Jntfrtoofl  jViirfua^vfjwfiiRiM,  I84S,p.  too. 


432 


DISE^^ES  OF  ARTERIES 


loiuini 
ntfli 


tuiiictt  pr«K8urfl  to  An  extent  which  arrested  pobatioD  in  i 
AL  the.  end  oi  iovty  hours  iIk;  tiutiour  wim  oftolhird  Hianllitri 
and  ]>ult(olct«.  Oomfiroi^ioii  wan  sUi|>ped,  the  eure  wm  ooq 
and  four  nionlliH  aUcrwards  tlto  tumotir  eould  IiardJr  be  fijL' 
BucuL-sH  «f  Df,  Kiiiglil  g«ve  rise  to  other  eftbrbt  in  Ain«Ttca, 
Fox,*  in  the  Pennsylvania  Uospibil,  »)>pImkI  digital  compn^ 
the  treatinvnt  of  an  in^innl  ancurixin  wwn  ■fU'r  tito  i<ubli 
of  Dr.  Knight'§  caso.  Ho  dosistod  firom  it«  eni[>lo_',-mcal,  ( 
to  tlio  want  of  lUoiiHULntA,  altliough  niuvh  sutvnM  IumI  attmdl 
trial.  Mechanical  comprcwsion  tuas  not  well  bomef  aiid  oltil 
tho  oxtenmi  iliac  nns  t.i««L  ili.-*  examjili)  was  Aillovrtxl  in  thi 
year  hy  Protcssor  Willard  Parkorf  and  Dr.  J.  It  Woofl,!  ti 
Tork,  u'ho  achii-vAd  Mucoctieu:^  in  tlio  Irvalment  of  fbniuri 
popliteal  anem-i&ms  hy  die  ooinbiimtion  of  digital  and 
coDipreNAitiii. 

Daring  this  interval  tlie  Dublin  Sargeoni)  had  not  pat 
CAM  in  which  diptiil  eoinpruitsion  mut  employed.  In  ISSJ 
Norgate$  recorded  a  case  of  ]>opliteal  aneuriam,  in  which  pn 
hy  tlKi  tliiinib  WM  tcmpuriu-jly  employed  in  miecmsitin  to  ri 
nieal  oompreosion.  The  tumour  niptured,  and  ainpulaticd 
rcsortetl  to  witli  sticce»H.  And  in  18j4  Jainosonfl  oblmiitMl 
by  tlie  -mixed  nicllMKhi;  he  eni])l<ij'ed  a  Reid'o  comprmur 
six  days  inelfectually,  introducing  with  sneceoBfii)  efieot  tax] 
of  digital  oompn.'N'ioii,  In  another  inHtaiice,  Donohne,  a 
of  Mr.  Colles's  in  the  Mcath  Uoapital,  Dublin,  oh-icrt-iug  tM 
eomiirewing  tho  fiimoral  artery  in  the  groin  he  «uwd  the  U 
a  difTtiHcd  popliteal  anouriun,  ijiiietly  performed  tlie  eoapq 
during  thruL-  dayst,  su  tliAt  when  tlio  Sur^gcon  came  to  fit  i 
tii(|uet  he  found  tliat  his  patient  had  cured  himAelf.l 

In  Italy,  ProtcMor  VanKotti,  of  Padua,  obtninvil,  at 
(Noveinl>cr  ld.i>t),  a  striking  auccewt  in  (Ito  treatntent  of  M 
anenrism  by  manual  comi>rc(teion ;  hia  patient  was  a  hoallhjr 
4ged' nineteen,  the  Mibjectof  a  right  popliteal  anenrimnuf  Ihei 
an  orange,  and  of  five  nionllw'  duration.  Methodical  oompej 
was  made,  by  tlte  hands  of  asswtanta,  at  tho  apex  of  Soupa] 
angle,  and  aoUdificntion  of  tho  tumour  was  cfTected  in  forty< 
liourH,  without  {Miii  an<I  without  diuiiuution  of  iho  teuijicrata 
tlic  limb.      In  18&5  Professor  Vametti  treaded  a  Bacood  d 

•  Amfrican  JnunuU  t(fiMif^  SettmcM,  184fl,  rol.  xxxrii.  p.  1H7. 
t  I)n><!«.  p.  FM9.  :   AiMui  M«ii«al  Prwti,  ISU.] 

S  ILtJ.  im:i.  vol.  xxvU  p.  an.  ||  lUtl.  l&M. 

f  IbiJ.  Maj  1,  18U.  p.  07. 


■oapq 


popntcol  fu 


DIGITAL  COMPRKSSIOX  IN  AXEURISM.        423 

it  aiiioirii'ra,  in  tho  person  of  a  yotinj;  officor,  b^  similiir 
oeam,  and  with  men  more  vtHking  ^iuccoka.     It  n-a.H  a  sjionlaDeoaa 
poplitoal  imouruin  of  tM'o  months'  dale;  t)ie  kiioo  was  tnueli  Iwnt. 
Ihe  patient  htntwir  wiu  tan^ht  tu  comprcM  tliti  t'lMnoral   srteiy 
daring  throo  weeks,  and  many  Umos  daily,  each  time  from  six  to 
aght  minult'a;   jinrtiiU  aolidificiitton  followed.      MeUiodiisJ   oom- 
[reAsiati  oftlio  femoral  artor}',  at  the  iianin  point  tin  in  tlio  foniiiM* 
esac,  wai  then  a]))ilifd  during  five  hours,  with  tlic  uHW*  ni'stilidify- 
iig  tin-  tumour,  and  aiTording  a  complete  eure.    I'rofesaor  Vanxc-tii, 
in  reoonling  tltevo  mms*,  mentions  also  that  he  npiilind  Uie  same 
'     netliod  to  the  treatment  of  popliteal  antnirinm  at  the  husi>itnl  of 
■  SarkoT,  in  UiiM>tn,  in  1846.*      After  two  day*,  finding  it  unauc- 
B  tnafii],  ho  passed  at  onoe  to  the  ligattu-e.     It  will  be  otwen'od  that, 
P  ilthDagh  unHuoci!H;>ful  and  not  published  until  18S8,  this  waa  the 
Snt  iitt«iDpt  at  curing  an  aneuriam  hy  manual  compression  soli-ly ; 
jiBl  a*  \)r.  Kin'phl'H  caw,  in  184?*,  provioualy  monliimoil,  was  the 
Brat  instance  of  acure  artmilly  i-tfi'i-ttsl  by  the  sole  use  ofpivsKaro 
*f  lie  land.    Hoirt  Profi-nsor  Vanzetti  claims  a  priority  iw  inventor 
•i^gita]  oomi>n?asion,  which  luw  (vnuiwnly  been  arcorded  to  Dr. 
Kn^ju.1     TIk-  merit  of  ■strongly  insisting  npon  tho  vahw  of  distal 
Mnjirpswoii,  and  studying  it«  applicalioii^  to  stnrgical  treatment  witli 
•  Woocw  which  fixed  tJie  attention  of  Enropcati  SurgixmH,  i*  nn- 
wAtedly  duo   to  Vaii^it-rti.     TIiOjw  oarly  siic('t:H»VA  were  speedily 
IwWfd  by  others  c(|ually  romarknble.     In  Jnly  18r)6,  a  female 
pWifiit  came  uiuU-r  tim  «inf  of  I'rofiiwor  Gioppi.t  of  Padua,  tho 
•*)«t  of  aneorism  of  tho  ophthalmic  artt?rj";  tho  case  was  one  of 
pwtMTerity.     1  have  boforo  mo  tho  portrait  of  tho  |iationt,  which 
"■t confirms  the  written  descriptions:  tho  eye  projoetod  on  to  tlio 
■"k,  it  wait  motionU-:^;  the  cornea  Wiw  infiltrated  and  opaque; 
"*  sight  waa  gone.     Tlie  pulsating  uii(!uri«mal  tumonr  could  bo 
Wlliy  introchicing  tin;  finger  between  the  globe  of  llio  fvc.  and  the 
"•t^  «f  tho  orbit ;  the  bruit  oould  bo  heanl  loudly.      Tim  carotid 
^  tnmpn'iwd  for  periods  of  a  minute  or  two,  and,  with  frequent 
"•''nals,  by  the  eonvaleswnU  of  tho  ward  and  by  tlio  patient  heav 
JjlE    Presmn;  continued  for  more  than  a  minute  pnxlueed  fainting. 
"••WtbcleeK,  at  the  on<l  of  oiw  day  (hi-re  waa  a  visible  improve- 
'^t,  and  bX  tlie  uid  of  four  days  all  pulsations  had  ocaaed.     Four 


'  JuoIJ  rmivTMti  Ji  MMeim,  Milnno,  Gcninjo.  IfiftM. 

f  Prioriiti  4A  MtUt'to  di  euf,trt  <jli  Anftirumi  eoUa  tola  mano.  doruUi  alia 
''^  di  OUnrjiJA  Mf  UttirfrtiUt  di  I'aJoiia.  dil  Pr<ff.  Txto  VanuOi:  An- 
'U  Uainnuli,  vol.  ctxiit.  p.  SO}. 


484 


DISE.VSES  OF  ARTERIES. 


nioDtbs  aftcrwanl*  tUo  eye  rr-rtrd  »n<l  moved  naturally  in  the  orbit 
viisioii  wjLH  rtfttoii-d.  the  patient  rLnnaiiiirifj  only  wnnewhat  sIkii 
wglitod,  aiiJ  with  tlic  pupil  "liKl'^ly  dilated.     A  second  raiao, 
wliicli  n  fonnidable  aneiirismi  of  Uio  ophtlialmio  irtery,  in  n  (Mti«i 
the  miljjfft  of  Horlic  anil  amliw  disease,  was  cured  bv  distal  raw 
pre«8ion,  waa  pidtlisbMl.  in  1S58,  by  Dnt.   Viinzetii  imil  ScaV 
mnazfl.*      IntormilU-nt  cinnpn'swion  of  the  carotid  by  the  Rog 
was  here  alao  employed  for  iive  minutc«  at  a  timv,  aixl  euro  w 
cffeefwd  by  m;v>i\  lionrs  nnd  twenty  minutes  of  compression  spreM 
over  eighteen  days.      Thetw  briliiant  suoccsbvs,  real  iriiiinjilu  d 
ocNineri'Ntivo  8ur;r<^ry,  fiupportvH  n»  they  were  by  sbandant  aJ 
irrefragable  testimony,  sufficed  to  place  digital  oomprtvwion  Hinim^ 
tlie  nioKl  pi-euiouK  reaourctii  uf  ISurgery  in  the  treatment  of  oxtemal 


anminsm. 


Tlio  tiubi»c(pient  exfjcrieiicc  of  Surgeons  who  have  emjdoyed  this 
troatmont  since  Vanzetti,  atiords  numerous  inslancca  of  etu^;  vttaU 
vfdlod  for  sini[)btiitY,  paink-jssnt!**,  wisf,  and  rapidity  in  the  record 
of  t.bc  treatment  of  aneiu-iam  by  any  other  means.  Tlius,  M.  Ml- 
chaiix,  of  ijiitivain,  rcconk-d,  in  1857,  two  cases  of  jxtplilenl  aneoi^ 
ism  ctmxl  rcspeetively  by  113  boure  of  intermittent  com^inMsid 
(during  cigbl  <lay»),  and  fnrty-fonr  hours  I'ontiiuiod  compression; 
whilst  he  cured  a  large  femoral  ancnnsm  by  foi-ty-ciglit  houra  <d 
digital  ooini)n»i4ion.t  Other  SnrHoonx  liavo  hwd  similar  saooeM 
In  nineteen  rases  siujcessfidly  treated  by  digital  pressuri-,  tlw  av«|C 
uge  nnni1>or  of  hi>ure  of  [jn-jwuro  wait  not  more  than  forty-one  tiod 
a  half,  spread,  however,  oveir  a  variable  period  of  time,  owing 
iuturniiitsions  of  tin*  prewurc,  Acconling  to  th«  inuct  favour 
ro[)orts  of  tliose  who  are  greatly  interested  in  tlie  treatment 
mcchanicul  comiiroiwion,  tbo  avcnigo  duration  of  tro-alment  by 
metliod  stands  at  twenty  and  a  quarter  daj's  for  each  ease. 

It  liiL'<  lni'ii  objected  to  ibo  digit;d  mode  of  treatment,  that, 
the  considerable  number  of  assistants  re<iuired,  itc«uld  only  bo  eai' 
ried  out  ill  certain  largo  hospitals,  and  then  a(  grenl  ino'>n^'vnicBC& 
Tliis  objection  is,  however,  of  no  great  force;  for,  tmder  snch  ClTi 
cumstunecjt,  assistants  are  rareJy  wanting,  and  in  nioi-o  than  oaj 
case  the  patient  has  been  able  sucecj«fully  to  complete  the  euro  I^ 
the  miuiiled  jiressure  of  bis  own  fingers.  And  although  a  ful!  stafi 
t^  eight  or  ten  assistants  are  sometimes  retjulred,  yet  a  suaUer  nu 


*  Stumih  Ctuo  dl  Anfuritma  JeW  ArUria  oltiilimai  fwoiSa  eoVf  anrnji 

lioM  a^lalt  Mia  earotidf.  kv..  AtA  Dott.  T.  A'aiuoiti.  Ac  ke...  Pndovit,  Vt 

t  AiUftfa  lb  VAciuUtitU  J*  Midediu  Belgt,  auriw  U.  vol  i.  no.  *. 


FLEXION  TfiEATMENT  OF  ANEURISM.         425 


in  (iftim  MifRc-c  Mwt  Surgoon«  arc,  I  think,  ayruiMl  that  th« 
hoiild,  afl  a  mlo,  be  interniittcitt.  The  opposite  praptioo 
pt^ncuM  «<H.'4iw"imi!y  wiiw;  ni[»(l  and  brilliant  fiiros ;  hut  it  tcniU  to 
[>tv>ctire  oongulation  at  tna»ae  of  the  oantcnta  of  the  aneiirisma]  sao 
wil)i  it»  acGOnipnnj'iiig  danger*,  wliilo  tlic  int«rniittutit  trmiUnent 
fciroars  Ums  safer  form  of  laminat43d  fibrinous  de)H)<<ition. 

Till'  !i])|>licjiti(>n  of  the  finger  to  tlic  cure  of  ativtirtsm  by  indirect 
has  already  yiehled  ndnitrabit!  reoidts ;  and  it  is  probable 
it  viU  oontJnuu  to  movt  with  increasing  favour  among  Sur- 
Not  only  are  the  ouren  thus  offe<*t<Hl  otV>n  rapid  and  pom- 
stivoly  fiainlcti*,  l)Tit  the  method  may  bo  a[>]ilit>d  to  ort^Titit, 
^*Och  u  die  carotid  and  ihe  facial,  which  are  not  easily  aooo^ble  to 
^pn^  tbnii  of  iu«chanical  pressure. 


Treatment  bt  Flexion. 


hp  simple  banda^ng  of  the  limb  in  aeute  flexion,  the  patient 
K'pt  nt  nwt,  may  occasionally  »awccd  in  curing  anuuriitin* 
^'ttated  at  the  bend  of  tlie  limb,  as  in  the  popliteal  spaoe  or  the 
"Oow,  and  jHiitiibly  in  tlic  groin.  Thi.-*  jilan  of  euro  hiul  boon  pn>- 
*ioo«ii,-  tried :  bat  the  merit  of  first  demunatrating  its  Buoceas  is  fairly 
^^Ui  lo  Mr.  l-^niMt  Hart.*  AU  that  is  ret^iiinito  in  tkix  troatnicnt  ift 
^  biioda^  tlio  limb  from  tlio  toes  nearly  to  tlie  knee  wiili  a  roller, 
■"d  tlicn  to  turn  the  roller  round  the  tliigli  flexed  at  an  acuto 
"^^e;  the  limb  should  then  be  bent  uj^ion  the  pelvis,  and  the  knee 
"^stoc!  ugiiinKt  a  pillow.  In  Mr.  Hiut's  case,  the  cure  had  mado 
'*>a»iderable  advanoe  after  the  first  day  of  tho  treatment,  and  waa 
^UDplcttf  on  tho  fourth  tluy ;  on  tlio  Mn'vuth  tho  patient  was  moving 
•"•at.  In  Mr.  Shaw's  case,  the  oure  was  much  more  protradiKl, 
•"J  Un;  «!watioii  of  ]>nl4atiou  was  not  reported  till  the  thirty-eighth 
^y ;  but  then  the  tumour  waa  larger.  In  neither  of  tliese  cases 
*■•  aiiy  rigorous  »y«l<iii  of  diet  enforced,  nor  did  the  patient  coni- 
P'^Jn  of  tljo  least  uiconvenienoe  in  either.  Sevei-al  otlier  suecossfij 
havo  bocu   put  on   record.     Tho  most  IntcrvstJiig  and  im- 


*  PortbedctailR  of  this  ease,  which  1  bad  ibo  opportunity  of  «eeiiig,  ia 
'•foliation  "iUi  Mr.  Huil.  Ijefoi'e  IL^  eoramciiccmcnt  of  the  trtuittneDt, 
***  il<4.-Clnr.  Tntn*.  vol.  xliL  p.  30Ci.  In  the  »Aine  volume  16  th«  report  of 
**^Uar  aaoeenAil  case  uuder  the  oare  of  Mr.  Shnw.  The  plna  is  under- 
''**4  Id  lnT«  been  lri«tl  tome  time  aro  on  a  patient  of  Mr.  Forgimon's  at 
^*i*  CoilcEf  HotipiUil ;  but  it  Merun  \\V»\y  that  th«  trial  waa  not  t^tv  pcr- 
■wqU.  The  d«iatl»  havu  been  ln&t;  end  iho  fact  nas  6r>t  menti<HMd  after 
tk|«bliatxni  of  Mr.  Hart's  cust). 


436 


DISEASES  OF  ABTEBIES. 


portant  of  these,  in  which  genuflexion  mooMKlcd  nftcr 
tiio  Uuiitcrian  opuniliuii,  niid  of  instrumeDtiil  coni|im>ii<iti  a 
femoral  «rterjr,  ia  reported  bj  Mr.  SpcDoe  in  tlio  /Cdmbnryh  ii 
Jmimal  for  November  l^iftit,  p.  AM.  'V\w  pationt  hud  «)>pli4 
addict!  originaJly  in  May  ISJT  on  account  of  on  aneuristiif  1 
hud  only  iKMin  notiood  a  month,  and  which  ineraued  ao  n 
while  he  wua  under  observation,  that  the  femoral  was  tied  bala4 
origin  of  the  [irofiuida  without  furtht^^r  ilclny.  Tltoro  irM  i 
apprehension  of  gangrene  after  the  operation,  abowin^;  a)>[>«i 
that  the  cireiiUtion  was  rL-i.^tnl>li»1)CTl  only  alowly.  'Ilio  lijf 
separated  on  (lie  twenty-ninth  <Iay,  and  then  eome  iindut 
pulsation  was  noticed  in  the  trnnonr,  which,  however,  mi  I 
diininiflhetl  in  flixe.  By  iMUidaging  the  limb,  cautioits  ouni|*4 
of  tlio  fvinoral  artcn-,  and  direct  prowtirc  by  a  comprsM  d 
over  the  tumour,  tlii»  puliation  was  reduced  to  a  tine  cnrre^m 
to  tho  course  of  the  artery,  and  not  larger  than  tlw  poptiled  d 
other  aide.  Tho  patient  woh  Ui«n  dix'luu'ged,  and  relnriHdi 
ai-ocation,  that  of  a  ooal-carter.  In  August  I8A8  ho  oame  ij 
]ioa|iitu1  again,  h»  iho  tumour  tiad  snddeiily  niiTciuM<<l  witltln  t4 
three  days.  It  was  then  found  to  be  as  large,  and  pubatil 
violently,  as  liefure  (ho  artery  was  tied.  Ootnpreaiuon  wm  I 
and  pernlMed  in  for  live  montliH,  but  the  tumour  increased  U 
of  diminishing.  It  was  then  proposed  to  tie  llto  fuDioral  I 
low  clown,  L  e;  ill  HuntvrV  ama),  since  tlie  mwmx  part  of  ths  I 
ficial  femora]  appeared  obliterated.  Proviou*  to  this,  bowvil 
wiu  thought  ri^lit  to  give  a  trial  to  Ui»  tU'xion  ux'uUuKiit ;  aai 
snoeeeded  so  woU,  that  in  a  week  the  pulsation  bad  wrj  1 
diminiMhn<),  and  in  a  nionUi  tlie  anouriitin  was  4]uitc  curvd,  tVi 
tentA  being  perfectly  solid,  and  the  anastomosing  reaaelsenn 
Tlie  nmn  again  rvturnwl  to  his  laborious  avoeatton,  nml  «n4 
sented  to  the  Medico-Cliirurgical  Society  of  Edinbur^i  fixir  td 
oftcrwanU  ;  the  cure  U^ing  quite  compIcl«." 

It  ought  to  be  noticed  here  that  tliia  man  could  not  at  firvt 
the  complete  flexion  of  the  limb :  accordingly  a  slipper,  % 
piece  of  bandage  sewn  to  the  heel,  was  fastened  on  the  foot,  al 
bantlago  was  tlicn  attached  to  a  loop  connected  with  a  brawl 
round  his  jwl^'is,  and  this  loo])  was  gradually  tightened,  aa 
increase  daily  tho  flexion  of  tho  leg  on  tho  tbigli.     The  ouoAiM 

a  A  loconit  cose  under  Mr.  Harl'ii  caiu  lus  be«ii  re^eoll.v  mm 
catad  to  th*  Boyiil  Medical  aiiil  CUinirRical  tsuciety,  in  wlii«b  tb«  in 
•ir«et«l  ill  k  fow  da>-s  Mtiliuut  vTta  vonftacmeiA  to  Um>  r«L'uiul<cnt  |H 
Sao  an  abstract  of  Mr.  Hart's  paper  in  ibu  LnuH  for  Fab.  9,  IMS; 


8.  IMa.    I 


FLEXION  TREATMENT  OF  ANEUIUSSr.         427 

to  bed  flppMis  to  bore  liisted  little  more  titan  a  fortnight  This 
mildiT  plan  of  i;m]>loying  flcxioTi  mny  bo  often  (band  succomful 
viieii  ihe  pationt  caniiot  tolerate  more  rigi<l  coiitineinent. 

Many  casix  are  oLh)  reported  !n  whi<rti  Roxion  has  bocn  sncccws- 
fbn^  uned  in  combination  with  pretciiu'e.  In  one  und«r  tlio  core  of 
Ur.  Pvmbcrton,'  tlie  atnoiuit  of  prc«suro  UHxl  was  «o  sltglit  tliat  no 
great  imporlAnoe  i»  nttsKhtxl  bv  liitii  lo  ita  action.  Yet  tbc  aneuriiiin, 
1  largu  one,  and  pulsating  strongly,  waA  cared  in  lew  tlian  twelve 
boni^     A  Jtoinewbat  :«.imilur  ea'tv  is  iy>)K>rto(l  by  Mr.  A.  Frit^harJ, 

I  of  Bristol,  in  the  British  Af^iiml  Journal,  March  30tll,  l^til.f 
The  tiiilurtst  wliieh  liavo  liithttrto  Imen  reciNrdott  npiteiir  not 
ieyond  wliat  any  other  method  of  treatment  is  cspoeod  to.  Tims 
In  &Ir.  Mooro's  com  above  ruturri4  to  (\\.  411),  tloximt  tvaa  triod 
snaucoiMsfully ;  but  ilien  die  tumour  was  largo,  and  was  growing 
n]iidly  towards  tho  joint ;  and  sueli  oattw  are  i>ootdiarly  intractable. 
In  a  case  under  Mr.  Tagct's  care,J  this  method  was  tried,  and 
fa3«l;  Uit  in  that  ul<u  other  nietbod^  oftjvaUnent  a]»o  failed,  the 
"»e  not  being  one  of  aneurism  in  the  proper  sense  of  the  torm,  but 
of  u]cenit4xl  artery  without  a  «ac 

TIk  eaoes  best  aiiapted  for  tlie  trial  of  flexion  are  the  simplest, 
ni  thaw  caws  whcro  tlio  tumoiu*  i»  not  of  very  large  sine,  whoro 
<*»  F«t«  co^'eriag  it  are  not  much  inflamed,  nor  the  joint  involved, 
w  vlicrc,  ax  lar  as  can  bo  ascertaiiiiKd,  the  tumour  is  seated  on 
™  MperBcial  face  of  the  artery,  wo  infiy  miLioJpiitn  Itenofit  from 
"•"on.  If  tbo  flexion  of  the  limb  entirely,  or  almost  entirely, 
"i^peudfi  tJie  jiuUntJon  and  the  bruit,  tliis  trc^atinent  way  bo  trusted 
V  itsiilf ;  otlierwisc  a  comprcwor  must  be  applied  to  the  iirtt-ry 
•wvo  ia  aid  of  the  flexion.  Btit  the  c^miprttwion  ni.>«<l  not,  in  amrh 
*<^,  be  applied  with  nearly  the  same  severity'  which  would  bo 
''('Utoded  in  an  ordinary  eiL->e. ||  A  vii-y  sli^rht  mniuuit  of  preasore 
*^  often  serve ;  and  if  the  only  advantage  of  this  simple  and 
"'vly  painlcsa  proceeding  were  to  npiire  tlio  patient  the  annoyance 
•fittfro  praaeore,  it  would  bo  no  slight  one.  There  arc,  however, 
*>iiy  cMcti  in  which  th**  amniriNin  will  Iw  outiri.-ly  curtnl  by  it, 
^vtont  the  amallost  risk  either  to  life  or  limb. 

T.  HOLMES. 


•  LMeU,  S«pt.  S.  lUO.  p.  S»«. 

t  S««  alM  a  oajie  bv  Mr.  Colin,  in  thn  Ihihtai  Jloipital  GtutlU,  Jtinn  19, 
JMU:  and  i-at  br  l^r.  T>?ith  A<lfiin4,  Affd.  Tiout  ami  Qomhu,  Jau.  UC,  t»01. 
I  AfnJwol  Tima  and  GatetU,  \tibV.  vol.  n.  p.  Wb. 
I  S«o  Ur.  feinlMrton'a  cam  above  refiirrcd  to.  ^ 


4S8 


DISEASES  OF  ARTERIES. 


Trkatmknt  by  MAsnaiiATios. 


A  method  of  trcattnvnt  has  been  fouiidixl  u]>on  the  con»icI«ration  -J* 
of  tlio  ptitJii)!";!!*!^!  c-haiipuft  which  by  the  <lf>]Joaition  of  tibriu  aiul.^ 
nc«!ii*iitn  of  tho  cavity  of  mi  aticuri><miil  sac  Ivswl  to  ite  cure,  and  " 
the  iiiiuiysix  of  ii'i-luiti  coaoa  in  which  IJk!  acoitleiital  dti^plaooraent 
of  dot  from  n-ithiii  tho  una,  ntid  its  impactioQ  ill  the  arlL-r)'  in  tho 
dUtul  8id«  of  the  »iit>uriHni,  \\w*  nfomad  to  j^ve  rise  to  exoeptional 
cures.  Mr.  Fcrgtiasoii  lias  ciidcavourod  artiliciidly  to  imitate  tliis 
pixxyMO  by  means  of  a  partioular  mani|)ii]atii>n  of  an  an«tn-i!iin, 
whereby  tho  fibrin  within  may  bo  ho  displaced  a«,  t-ithcr  in  part  or 
in  whoifl,  to  block  up  the  main  arhMy  on  the  dht»l  Hide  of  tlie 
disease.  In  a  paper,  which  will  be  found  in  tho  Medieo-C/iininiad 
TnunKifftiimii,  voL  xl.  p.  1 ,  that  Siirgecm  deoei'ibra  two  cawa  whi(^ 
he  8ubmitt4;d  to  tliis  treatment.  Both  were  caxce  of  uibclavian 
aneiirinm.  Tho  first  i>atiant.  wii.k  a  hiHitr.hy -lucking  man  of  middle 
age,  having  a  large  aneurism  of  two  years'  standing,  involving 
ohieHy  the  middle  port  of  the  nrt<ery.  In  the  event  of  any  opera- 
tion by  iigiiturc  having  been  determined  on,  tbo  vessel  must  haiij 
been  tied  either  «»  the  tracheal  sid"  of  the  jcalenun,  xouonlinj'  to  the 
Htniterian  method,  or  on  the  dista]  side,  according  to  the  method 
of  Wardrop  or  Brasdor.  Mr.  Frrgusson  thiia  df*crib<5t  his  ]>r(i- 
cceding :  *'  The  patient  was  seatod  in  a  chair ;  and  I  plaoej  tlia 
flat  end  of  the  thumb  on  the  Hiicurittmul  tumour  so  as  to  cover  tho 
prominciioc.  I  then  pressed,  until  all  tlie  fluid  blood  had  ]>assed 
fnim  tho  NIC,  and  1  eoulil  fi;el  that  the  upjier  side  lyi  tho  aneuriNm 
was  pressed  against  the  lower.  1  now  gave  a  rubbing  motion  to 
the  thumb,  and  fiOt  ii  friction  of  itnrfiiec-*  within  the  flatt<!iied  mass. 
The  movements  were  little  more  tlian  momoiitarv,  hut  tliev  w«« 
eucJi  as  1  hitd  prt!»inoci%'tid."  l1io  immediate  ofiect  was  to  produce 
giddiness  and  mental  eonfiision,  so  that  the  patient  was  for  a  time 
uiiablo  to  stand.  Pulsation  coasc<i  in  the  arteries  below  tho  tumour, 
and  pain  n'as  experienced  in  t]ie  hand  and  fore-arm.  In  the  evcn-fl 
irig,  Iw'wever,  pidsiition  had  returned  in  these  vessels.  Next  day 
tho  manijiulatJon  hi  ihe  way  described  wiis  rejwate*!,  with  niueli  the 
same  immediate  effecta.  Pulsation  returned  slowly  after  some  daj-« 
in  the  arm  and  hand.  The  tumour  wat  couatdered  manift»tly  lees 
and  to  pnlnutc  lc*s  strongly.  It  never  eeased,  bowevor,  to  pnbate; 
nil d  eight  montJia  atWr,  tlie  patient  die<l,  owing  to  ru)>turo  ofthefl 
sac  at  UiG  lower  and  back  part.  It  waa  found  to  ooiitain  solid 
fibrin  of  old  date,  and  rL-ejjiitly  coagidiited  blood.  The  ftxillar}* 
artery  was  filled  with  a  firm  plug  of  fibrin.     In  the  sooond  case 


1 

I 
I 


MANIPULATION  TREATMENT  OF  ANEURISM.   4*9 


lied  by  Mr,  Forgiisson,  paralysis  of  the  left  sidd  of  the  faco  and 

>f  tli9  loft  foru-oriii  and  Iff;  follciwed  iht!  tlmt  ninni|)tilKtioii,  tiu>  piilxe 

Fling  at  the  wrist.    With  this  exception  thoro  was  little  material 

At  tli(!  «ii<l  of  two  montlis  the  pntionL  roxiuned  Iiih  nceiijta- 

ion  as  a  seaman,  having  regained  tJio  use  of  liis  left  side ;  bnt  the 

totLT  iwiii^  «[){»■  ri' It tly  iinullenHL    A  yoar  xfler,  ho  wbk  aguiti  Heei), 

Vid  an  attempt  made  to  keep  up  continued  pressure  on  the  tumour; 

Iwt  it  provwl  HO  uiin!tti»fu(;|j)ry,  that  it  wa.*  jjiven  tip.     Again,  at 

tbo  end  of  the  year,  tliat  is,  two  years  after  the  first  employment 

of  nuuiipuliition,  lio  returned;  ami  now  thr  tuinonr  had  t-oniplotcly 

disappeared,  there  waa  not  a  traee  of  it  to  ho  perceived ;  a  slight 

pulse  c»iil<l  bo  felt  *i  die  wri:tt..     The  arm  seemed  mneh  tlie  mme 

,   "s  it*  fi'llow,  and  in  the  left  side  paralyBis  had  gone  off. 

'  NeitiKT   of  tlwoe  ciwes   uDordi^l   Mitistnetory   evidonoe  of  tlie 

efficncy  or  safety   of  this  mode  of  treatment.     In  tlie  first  ease, 

KlUiou<;h  the  tumour  waii  eonsidi-n-d  to  \te  Homevrhnt  Mklidified,  it 

OBviM*  eeased  to  pulsate ;  and  atVr  a  few  montlis  eaused  the  death 

of  the  |witi<rnt  by  litii-Mtiu;'.      lit  the   second   caws   no  |)epee|)lthl« 

<ir»ot  was  produced  on  the  tumour  at  the  time,  nor  did  it  seem  to 

>>•  tniieh  chaiif^l  at  tht;  nid  of  u  yeur ;   but  aftt^r  two  yearx  of 

'•Wrioos  oeciipation,  tlio  tumour  was  found  to  have  disappeared. 

"  m«*t  bo  conAiderod  doubtful   Imw  fur   (hin  rcHtilt  wax  dae  to 

'P'Wilaneoiw  changes,  or  to  aecidental  displaeomeiit  of  the  contents 

"' thf  tumour  in  the  course  of  the  jintjout's  fRiqueiit  exertions. 

The  sudden  faintness  of  both  these  patients  immediately  after 

7*  manipulation  of  the  lunioun',  and  lln'  paralv!*!*  ivhieh  followed 

'"  t]>e  vecond  case,  indicated  sources  of  danger  eonneeted  with  this 

"•^^tment,  vrhieh   Mr.   Fcrgus-'nti  di<l  not  omit  to  point  out.     It 

"^^eii  prwdihle  that  in  Uio  niani|)uIation  some  of  the  broken-down 

"will  was  sijucexed  towards  the  mouth  of  the  vertebral  or  carotid 

J^twies,  and  by  obstruetJng  the  flow  of  blood  to  the  brain  produced 

"^Wiiplegia  in  tho  manner  suggosted  by   I)r.  Kirke«,  wfio,  in  a 

P"I»F  Ku*\   before  the  Medical   and  f-'liirurgieal  Society  in  May 

^^i,  pointed  out  the  proliability  of  tUi«  coiidilioti  being  pr<Mlueed 

*y  fihrin   from   the  valves  of  tJto  aorta  being  carried  along  me- 

^■Hically  in  the  blood.     A  v-nw  highly  illustnitivo  of  this  danger 

'■•  tinee   l)eeii  descrilM'd  by  I'l-of.  Esmai-eh,'     C'apt,  C.  H.  con- 

"lled  a  friend  of  Prof.  Ewnnrch's  for  tonsillitix,  and  at  thowuno  time 

™^  his  attention  to  a  tumour  on  the  left  side  of  liis  neck,  which 

wl  farmed  suddenly  three  years  pre^ioiuly,  without  ^prcciable 


•  Virchow,  ArrMefiir  Path.  Anal.  unJ  Pht/tialogit,  »ol.  xL  p.  410,  184T. 


430 


DISEASES  OF  ABTERIEa 


cause,  nnd  bad  non-  attained  the  size  of  a  hen's  egg.  It 
eauly  du4piowd  a»  an  aiK-iirinm  of  tlw  common  carotid.  On 
peoting  the  examination  a  few  da^'s  later,  and  exerting  prewi: 
Dpon  thu  tumour  for  thi;  [>uri)OM:  of  mlacin;^  it,  iho  jMttiont  fell 
suddenly  back  witJi  KVDi|itoiiiB  of  a]>oplexy ;  he  was  at  oii<;ii  hUd, 
and  cont'cyod  to  tlw  hoipital,  where  hv  was  plsic«d  under  tiie  caro 
of  Dr.  Kfeinarch.  There  was  right-sulwl  cerebral  |Minil_v»i«;  the 
pupils  ytcrv  dilated,  but  rfncUnl  tu  Uiu  light :  the  tumour  {nUuilfldL 
i»oohronal1y  with  the  carotids,  but  jirewiittxl  no  miinniint,  Profl 
Eamarcfa  diafj^omd  tlic  ilctactmictit  of  fibrin  from  tlie  anenrismaf 
fuic,  and  consequent  obliteration  of  t)ie  It'll  ittnitid.  I)<-nt)i  cn;fiwd, 
three  days  atU'nvards.  At  thu  autopsy,  perfbrmod  by  Prof.  ^Veben 
of  which  the  ia<:tst  careful  details  are  gtvwi,  the  mc  of  th«  larg* 
anourisDi  was  found  to  be  partly  lined  with  more  or  less  finnlr 
altuohcd,  ragged,  fibrinous  coagiila ;  much  looM  fibrin  irrcgnlain 
interwoven  was  also  in  tbo  sa<' ;  s  firm  eoa^;u]uni  was  dniwn  oni 
of  the  inti^rnal  carotid,  luid  lhi»  coaguluiu  was  found  to  csEcnd 
up  to  the  carotid  tbramen.  There  was  no  ooagulutn  in  the  extci 
nal  carotiiL  The  cerobral  «aroti<l,  the  middle  ccn-bnd,  and  tb 
ophthalmic  artery  were  compblely  blocked  up  with  coagula  of 
dark-brown  colour,  cncloifing  numerous  red  and  p«yis)i-whil 
plugs,  which  e\idcntly  were  derived  from  tlie  anctirl.«iii.  Tba 
identity  wait  provod  by  the  mierosco|Hi.  fhcro  was  considerabl 
■ofteniug  of  the  middle  of  tlie  left  hemisphere,  including  Uie  corpi 
callosum. 

A  Mimewhat  similar  an'Jdent  vn»  deAcribcd  by  Mr.  Tcalo 
Leeds,  in  some  olinical  i-emarks  doliverod  in  1859.*  He  mentioil 
that  in  thit  year  1847  hit  wtut  nni)  of  a  nmni^roiH  comtidlation  in 
doubtful  case  of  carotid  aneurism.  The  subject  of  it  was  a  middli 
ngcd  female,  in  gixxl  heultli  in  otiicr  re«]H>ctti.  She  wa«  i<catod  in 
cliair  while  tJie  tumour  was  examined  by  several  persons  in  sneoei 
Kioii,  and  subjected  by  tJiom  to  ri-|i(Mite(l  liaDilling  aiul  com]>r««u1 
"While  tliia  was  going  on,  sJie  suddenly  became  pale  and  sli[)j>«>>l  off 
the  chair.  On  I>cing  rai-^od.  she  win  lT>iin<i  1o  bo  heuiiplepic ;  aflcr 
lingering  in  this  stale  a  few  weeks,  she  died.  The  tumour  WM 
fi)und  aflcr  <k<atb  to  be  aiietirij^mal.  Tlic^e  iwo  cai*os  tfcno  to  show 
very  strongly  tlie  dangers  which,  as  Mr.  Fergusson  himwif  jwintMl 
out,  aru  likely  to  follow  the  manij>ulation  of  aneunsmal  tumoiu-s 
of  tJic  nock.  On  th»  other  hand,  subclavian  aneurtiimM  are  almost 
always  ultimately  fatal,  and  ha>*c  nc\-cr  yet  been  suooessfully  trcai 


*  iled.  Timu  and  Gax..  3kliu*cli  IND,  p.  S6A. 


^ 


MANIPULATION  TREATMENT  OP  ANEtTRISM.   431 


bf  Hm  Hunterian  ligature.  Soon  after  tho  piihliojiriou  rif  Mr.  Fcr- 
pinii's  paper,  Mr.  Robert  Littlo*  aibiuttcd  into  tlio  Donegal  Id- 
bmary  mi  Albino,  aged  fifty-three,  having  mi  luieuridin  of  tho 
ri^iJtt  Mibclai'ian  artery,  of  nine  mouths'  duration,  of  con&idor.nble 
Km,  [iiilHiling  strongly,  linving  x  loml  liruit,  null  uiid  coin prvwti bio, 
wmswhat  rod  and  inflainod  on  the  cutaneous  surfaoe.  Anodjnies, 
mialirM,  Ux:*]  ri'frigei'.intfi,  and  veufaection  vtera  omjiloyiHl  witliout 
(Bwt.  On  tho  first  of  January  185S,  by  making  gentio  but  hteady 
inntiro  with  tlio  t.liuinbA  nltumatoly  over  llio  itnt!iiri.-<iiin1  sue,  Sir. 
iillle  nicoe«ded  in  disjilacing  s()mB  of  tho  coagula,  and  <lirccting 
tiwm  towards  tiiv  diMjd  ojxMiing  of  the  Hrtury.  No  other  local 
tnMnent  was  adopted ;  but  tha  patJont  was  ordered  a  pi-eparatioa 
■rfirott  internally.  For  llw  first  two  dtiy*  no  clianfr<^  was  ]ht- 
Oflible  eitlier  in  tlie  tiuiiour  or  tlio  ami;  but  on  tho  thinl  day  the 
pihs  at  tho  wrist  wan  munifostly  wuakijr,  and  tliv  arm  soinowhat 
*J4ir  than  tlio  opjiosite  one.  Thoso  symptoms  gradually  increased 
^  to  the  tenth  day  atler  tho  ninnipulatioii  of  t)iv  uio,  when  no 
pnlntjoa  4Xiiil<l  be  folt  in  either  the  radial,  bradiial,  or  axillary 
"ttrio.  From  this  time  tiiu  tumour  itMlf  gradually  became  moru 
*'l>d,  and  finally  all  pulsation  ceased.  Tlie  tumour  wastinl  to  tho 
iiWofa  small  wahiut.  and  two  HujieHiciid  art^irid  bnuichcs  could 
*•  traced  rtinning  transversely  across  it ;  one  iinmeiliat^ly  alcove 
•*»  cbiicle,  tJip  other  somewhnt  biglicr  u]\  For  a  time  tlio  arm 
*» partially  jnuiiljstui  and  very  cold,  but  it  sub.wqutmtly  roi'-ovored 
Station  and  motion ;  and  when  tlic  patiotil  was  seen  a  year  aftor- 
*lldi,  hto  euro  was  in  ail  rt^|H>eu  saliAfitelory  iitid  c<>ni|ileti\ 

In  addition  to  tliis  highly  satisfactory  and  intcrGi<ling  cure, 
"'■  Tunlo  of  beoiiii,  uml  ]>r.  O.  i'<.  Ilbi-kman  of  C'inctnnuti,  Iiavc 
*fc  sncoesefiilly  treated  an  aneurism  of  tho  lower  extremity  by 
'"nipulation.  Dr.  Hlackiiianl  rrtn^iied  under  Iiis  care,  in  April 
"i'J,  a  man,  tho  subject  of  a  large  femoral  aneurism,  measuring 
"^iochcs  at  lh(!  Iniso.  AfW  forcibly  mani|)u)arinjr  the  luinour 
*"litl»  view  of  disloilgiiig  tlie  fibrinous  contents,  a  Skey's  toumi- 
1**  Was  ajiplieil  to  tlio  t'emoriil  urtery  inimedintcly  bekiw  Pou- 
fn'n  ligament.  Much  puin  w.is  complained  of  ui  tlic  tumour,  and 
'bpolM  PMo  to  one  himdnnl  and  ten,  t>cing  full  and  strong.  The 
/■tRnt  was  bled  to  nino  ounces,  with  the  effect  of  diminishing  the 
J>iiq  tad  bringing  tlio  puls«  to  (illy,  soft  and  regular.     AlW  four 


3M   Timn  at>4  (lit..  Mny  S8,  18M. 
t  M'aum  LuMMti  JuDG  tO&7i  Htm  I'mk  Juunuil  ^f  Mcdieal Seitnee,  iSOT, 


43S 


DISEASES  OF  ARTERIEa 


iays  tlio  tourniquet  was  tiikoii  ntf,  the  \cg  was  bandagnl,  l 
the  puUu  wiM  Ntlll  liigh,  venesection  woa  iigniii  itnplnrod,  iind 
and  tiu-tarised  antimony  aJniinistcrod  intonially.  Od  the  ten 
pulHation  hud  altogetlier  <»uAcd.  Tlie  ouro  ratnuiwd  ptni. 
friiiural  urtery  i»  descrilx.'d  as  being  plugged  aa  far  u  Ute 
of  tho  prurnixU,  while  in  tins  po)>liUitl  itpsoo  Uw  polMtlun 
artery  was  hardly  pcrceptihio.  It  is  not,  howpvor,  ^c^^■  a 
this  instaiifn  j)r(-eiHely  to  define  the  njBpcctivc  i-fl'wU  tif  tho 
ment  by  coinpri^fision  and  tliat  by  manipulation,  although  iJm 
may  )>o  considered  t<j  have  plnye*]  an  important  piu't  in  pra^ 
the  oure.  In  tho  case  treated  by  Mr.  Teale,  coniprmaioii  i 
fonioriJ  at  llic  groin  hod  lM<eii  omptoyed  for  eonMxiayti,  in  tbft 
ment  of  a  popliteal  aneuriNn,  ™ith  tho  eHcct  of  |>rodiK!)Rg 
doponition  »f  filu'in  in  the  »ac  and  cnlargi-inunt  of  collat^ml  n 
but  no  material  improvement  having  been  etfected,  Mr.  Tei 
tcmpt^nl  to  privltieo  dii*j>laccnM.iit  of  tiio  tibrin  in  tlto  sac  by  n 
ate  manipulation.  Tbo  first  attempt  excitt.'ol  little  change;  b 
repeated  tho  manipulatiun  nitlt  gntator  frceduiD,  "  bnvadil 
tumour  ill  vitrious  du'eclions."  An  hour  and  a  half  aftav  tl 
manipulation,  tlio  luinuur  had  entirely  ceased  to  pulsate,  aa 
become  a  xolid  inaM.  Eleven  dayn  KuWiiuontly,  tlw  {tali4'nl  h 
hospital  cured,  the  tumour  having  dis.'reii»>«^  mpidly  in  sia 
lio  having  bLvn  able  to  walk  about  tlio  ward  a  fow  days.* 
the  data  furnished  by  thera  cosett,  which  are  (he  only  on 
poblisbod  bt-ariiig  on  this  mode  of trratmeut,  ajudgimml  iN 
formed  of  tJie  usca  and  dangers  of  ihe  inguniutw  but  acM 
ba2ardou&  practicv  of  uninipulatioti  in  the  trcauneat  of  atuarj 


Trbatment  bt  Galvaxo-Piwctdbb.        ■ 

In  tho  preceding  modc«  of  treatment  of  ancnrism,  it  tspn 
to  effect  a  euro  either  by  retarding  iJio  courNo  of  tlie  Uoott, 
introducing  elements  which  favour  the  precipitation  of  ito  | 
])rinci{>k-.  Galvano-punoture  aims  at  proilui-ing  .iiioli  a  modiA 
of  the  contenta  of  the  xac  aM  shall  favour  slow  coagulation,  it 
incun-ing  the  risk  of  uitroductng  into  the  carculatioa  fanSg 
perhaps  injurious  mattons.  Tliis  end  it  occnaionally  aocon^ 
but  it  is  not  n-ithout  it«  own  peculiar  accidenb'  and  daiigerih 
out  offifly  cMcti  uf  aneurism  si»  treated,  collected  by  Cini 


•  M<d.  Jlmei  nnd  <lat.  p.  90S.  MaitU  lt*i9. 
f  ShUi  J-:iettri>puniun  nelU  evra  digU  Jnnrumi,  bjr  Dr.  L,  I 
Cremona.  1930. 


GALVANO-PUSCTURE  IS  ANEURISM. 


433 


^*aity*thr«!  wcro  curod,  twenty  were  not  ciire<],  and  in  fvvon 

HttUinoei  death  resulicif.     Ind^xl  the  first  applications  of  clectro- 

piineiuiv  inndti  hy  Ikinjainiii  I'liilliim,*  Lintoii,  niid  Ut'rard,  in  1838^ 

*od  Uie  siibse((ueiit  eauaya  of  Mr.  Keate,t  woixi  eo  little  NutH^es.iful 

■I  to (Itvoorn;^  fui'tlwir  trials;  and  Init  for  M.  Pi'tr('quin,t  whose 

P*WK"mng  applii-ation  of  this  plan  was,  in  184;'),  follownil  h_v  nuo 

"BH,  ilw  prtK-oduro  niij^ht  not  yet  haw  fmind  a,  plat-c  in  ]>ructica) 

"•"Igcn'.    Sinoe  ihe  pnhliiution  of  tJiose  eases,  repeated  npplioiitJona 

f        "*H'  Imjcu  made  hy  Surgeon*  of  every  school  and  to  nil  kiudi!  of 

VMjuT^in.     Rut  iillhoiij^h  these  have  served  to  show  clearly  die 

^—i'l^Wer  of  electricity  to  oSect  tiie  eure  of  atieiiri«Btti,  they  have  sliown 

^P**o  nry  elvsrly  ttic  (liuigt>r  and  aeeideiiLs  to  whieh  it  may  give 

F>ise,    J(  ig  a  radical  detect  of  this  procedure  tliat  it  act»  by  inducing 

I      ^i"ect  (or  "  [M«)iive")  oongnlation  of  tJie  blood  in  the  sac    llonee  it 

"  iniitntitJy  uncoruin,  liable  to  cause  relapse  hy  the  uiclting  of  the 

j       "**«gliIom,  or  inlfHinnijitioii  hy  it.*  Um  Hii<idfn  ileponitioiL 

A^in,  it  is  very  cajmble  of  exciting  inthuiimation  in  the  walls 

"sd  cofitvniK  of  tlic  tioe.     Tluni  too  the  neeiiles  !<oiii«tinieit  produce 

*ofcK»  at  the  pointji  of  their  insertion,  and  thus  give  rise  to  con- 

•^oiitivo  bidnorrhn^^c.    So  tliat  in  forty-tliree  aun-f  whieh  have  lioen 

••tjiiWed,  it  is  slated  that  thirteen  have  been  the  anbject  of  grave 

tit»,  an<i  the  n-nmininj;  thirty  of  »lif;lit  neetilent".     In  faet  tlio 

are  few  in  wliich  a  perfectly  happy  result  has  been  obtained ; 

Mit  lotno  of  thw«  ar«  worthy  iif  partiuuliir  attention.     Thus  a  »nb- 

^■aviaD  anourisni,  forming  a  tiuiiour  as  large  as  a  heirs  epg  beyond 

■•••  elavicle,  wan  eured  by  this  inelliod  by  l>r.  Al)eiilc.§    Tlie  suecoM 

^Has  ceLrU)  uhiiie,  tlie  size  of  the  vessel  affected,  its  proximity  to 

™e  h^^art,  tlio  rapid  inerwwe  of  ti»'  tumour,  and  the  eoind^Iiiice 

^  <Xiiuti(.utionai  disease,  would  sidliec  to  give  importance  to  the 

"'^hoA  by  whieh  it  was  eurvtL     Again,  the  Hucc<-»«ful  appliention 

"phano-iiuneture  by  N^laton  to  cirsoid  aneurism,!  and  to  vari- 

^  annurieni  at  tlie  elbow  by  Vuillemicr,  aDiird  instaiiww  of  sucwss 

*  the  uxuiiineiit  of  varieties  of  the  disease  not  very  amenable  lo 

*•«  inodcji  of  tristtnient.     Two  ca»e«  are  reeonlod  in  whieh  ffxl- 

"•O-piuwrture  has  been  employed  in  the  treatment  of  aneurism  of 

^tteendiug  iiortn;  onev  <]uite  tnetfectually,  and  ouou  with  tlio 


*  EtpiriMmlt  rtmHx^  thit  ArttHn  wan  ^  ohliUriUfd  teilhmit  Ligtilut*. 
&t  tlw  work  ur  l>lulUp«.  Louduii.  183'J  :  anil  bis  Loiter  clumiiift  ptioriigr 
'  (f  intfintiou.  in  Uie  JrdUnw  gm.  lif  Med.  \f<n. 
f  Lnnftt.  183;-8,  Tol.  li.  p.  009. 
;  CitmU  riada  He  tArn^.  dn  Scimett,  1S1&,  vol.  XxL 
{  Arrktrtm  gin.  d«  HetL  Aug.  IMU.  ||  See  iutt.  CirGoii)  Aneurism. 

roi.  m.  F  K 


4^4  DISEASES  OF  ARTERIES. 

result  of  prodiKsng  what  ia  desepibetl  as  "  a  very  ecnsiVilo 
«vi<lt^nt  iDiprovemont."" 

Frvm  tlic  ftmly  of  tiumoi'nii!)  mllficted  oiuk»,  it  may  be  seen  tint 
tlie  modus  operajidi  of  galvano-puncturo  in  cases  wlit-ro  ciire  hat 
followed  itt  npplii'iitidii,  Irns  imt  iilway;*  I>wn  identical.     In  some 
iiiEttanccs.  tbe  introduction  of  the  noodles  into  the  sac  mid  th<>  ii]>{>ti- 
cation  of  tin-  current  liiis  «[ij>nrt'iitly  liwn  fulliHved  b_v  ihe  formatioa 
of  a  dot  vi'hich  onlv  partially  filled  tJic   niicurismal  sac ;  and  \>y 
virtue  of  till.'  ]K>wer  which  freshly  iU'])'iHit'!<i  fibrin  ha-*  nf  iittraoting 
to  itself  fre*h  layers  of  fibrin  from  the  circulating  blood,  the  cliH 
biui  ;;t'adiiallv  iiii-reasi.nl  in  .stxe,  until  tlio  titmnnr  wait  ^)lidil>Ml  and 
cure  eftoctetL     This  is  the  most  favourable  seqacnc«,  and  may  be 
rej^anled  iw  the  typical  n-^ull.     Bui  this  .■^Tjucriee  is  ran>.     In  ocber 
cases,  at  the  end  of  tJie  sitting  the  sac  is  already  filled  with  a  mure 
or  loM  «)li(I  owaf^lmn ;  sometimes  this  m<^lls,  stnnctinii'w  it  remaiiii 
permniteiit  and  yields  a  cure.    Most  commonly,  however,  tJic  inrro- 
duetitm  rif  (lie  nWKllcs  biw  been  followed  by  iiym|iloin«  of  infiant* 
matinn  within  the  sac,  and  the  cure  lias  been  due  to  the  effci  of 
thit  intlanmrntion.      Either  coii^dation  hii»  slowly  followwl  ujhui 
the  intlanimatoiy  action,  or  suppuration  and  obliteration  of  llic  s« 
hfi»  been  indiieiKl.     Tliu  pain  of  tiio  operation  is  in  all  caM»  nrf 
considerahla 

All  tlie«'  methods  of  cum  munt  be  (;on»idored  a»  less  satisfiirtoiT 
than  those  in  which  doptwition  of  strntifie<l  fibrin  is  slowly  obcun 
Tlie  peril  and  the  uncertain^'  which  attends  e\'cry  method  of  trMt 
ment  aiming  at  the  cure  of  aneurism  by  tbe  fomiatinii  of  [lasH'** 
direct  elols,  must  place  it  in  the  Bccoiid  grade.     The  risk  of  e^dtl 
iiitlammiition  in  the  sae  and  itn  cunteiits  h  a  vt^ry  wrrious  haz>i4| 
and  tbo  Matlsties  of  this  method  practically  confirm  (he  ohjV 
U'hieh  we  may  adduce  8im[)1y  fhim  a  kiiuwli'dgo  of  its  mod« ' 
operation. 

(JaK-nno-puncture  ap]>eiir!t,  (ben,  at  present  to  diwrx-o  to  ' 
only  as  an  exceptional  expedient.      Its  claims  will  have  to  be ' 
sidered  by  ihe  practicul  t^iirgeon  ])ritiei[iiilly  when  he  is  collfld«P 
to  treat  either  aneurisms  at  the  root  of  the  neck,  or  internal  an*" 
isms  whi<!li  cannot  bo  rmiidiod  by  digitnl  or  meehanioHl  compi 
and  some  forms  of  varicose  and  oirsoiil  aneurism   *^iied 
iloially-    Hie  dangers  and  imjierfections  of  the  process  most  i 
its  appIicAtioQ  oven  in  this  limited  field.     But  as  a  rcdoiu-ce,  ava 


•  Oat.  Mtilieii  ili  Milano,  1B4T,  w).  S;  ibtiL  1810.  no.  8S;  Gtu.  H* 
IlaL  LimUianl.  iaau,  no.  U. 


INJECTIONS  IN  ANEURISM. 


in  cssca  wliere  neither  compi-cssion  nor  ligature  can  be  advaii- 
ooiuly  applied,  it  1im  a  sjiticro  uf  tuwlul  actiuu. 

Thkatmkst  by  Coaoulatino  IsjBcnoxs. 

The  treatment  of  anourism  by  the  injection  of  coagulating  fluids 
n  ll«  sac.  willi  the  view  uf  imliirin^  tlio  funnatiou  of  a  solid  clot, 
I  Snt  projioscd  by  Jloiitt'ggia. '  He  rorv^  mm  ended  that  tliey  should 
il^fCCCtid  h\  a  troair;  In;  .iijfj^'sUsl  iiU-olnj),  aoi'tnto  of  load,  ami 
fanin,  as  ooagulating  ageiitit ;  and  tliought  that  their  use  might  be 
nnbinMl  wilh  tJiat  of  Brawlor's  lij;ntitri;  or  indirect  ounijirt'Ksion. 
Bus  idoa  of  Montoggia  waa  broaclied  again  by  M.  Vilardelnj.t  JI. 
troy  <l'Elii>IIi'*,t  \Vttnlroi>,5  Pravaj!,  and  Pi'lro<i«in.  |j  ^N'nrdrop 
d  recommended  at^ttic  acid  as  a  coagulating  medium,  ad^ining  also 
e  Aa»i*  of  tjic  blood  in  tlio  tunioitr  by  coiiipru«»ion  ubovc  and 
low.  Pravaz,  struck  by  the  ojiergetic  coagiilative  action  of  |ier- 
lorid«  of  iron  on  the  blood,  made;  some  striking  oxpcrimonts 
1  the  subject,  which  weie  coniniuiitcated  to  tiie  Frt>n(?li  Soi-iety 
Surgifv  by  Lnlltnnaiid,  in  1853..  Lijection  of  this  fluid  was  iin- 
pdiately  applied  succesafiilly  to  an  anetirii^m  of  tlie  nupra-orbita] 
beiy  by  M.  Haoult  Dctdungcliamfio,  Since  that  time  it  has  been 
tployed  in  a  oonsidorablo  nunilmr  of  oispa,  of  which  upward.'*  of 
fty  lave  boon  coIIit-tt-J.  No  doubt  can  now  exist  of  tlio  powerfiJ 
tioD  of  styptic  injections  into  micurinniHl  (jtaci),  and  c»pi%iully  of 
t  power  of  th«  tincture  of  sesijuiehloi-ido  of  iron,  introduced  by 
rava2 ;  but  ex]x;ricnc«  lias  hIiuwu  thiit  tlie  dangem  of  tbia  pro- 
wling are  considerable,  and  its  applicabib'tj-  limited.  Tlio  acci- 
nta  whicli  have  bct^n  found  to  I'nilow  ibc  injiH-tiou  of  jx^rchloride 
to  tbe  aneurismal  sacs  have  been :  1.  Jtt/iammalion  and  suppara- 
tnoftJu;  Irad  of  pfinctitrr.  Tlii.*  ocoun*  especially  wlipji,  in  with- 
tnring  tile  eaiiida  after  injection,  a  drop  of  tlie  pcrchloride  which 
■ngB  about  il»  exln'mity  comes  in  uimtact  with  tlio  tiwuis*;  a 
■inis,  bat  preventable,  accident.  2.  Fen-arterial  afncett.  This 
■if  occur  eilJwr  fnini  tho  extruvai'ation  of  the  injeiiiim  around  the 
ing  to  a  defect  in  manipulation,  or  from  tlie  propagation  of 
Notion  from  the  walht  of  tJie  sac  to  tlie  Hui-round- 
dellular  tiasDo.     3.  InjlaninuilUm  t/  ih  sac.    Tliis  is  Uie  most 


•  IntliltiiiMi  Cliiniryiehf.  Milan,  11*1  Jl,  2i!  edit.  pp.  fiw.  S-».  I2t. 

t  />•  TOjH'riUivit  dt  f^n/iryimff,  p,  103,  Thfsea  ilc  Paris,  IMt. 

t  Ramt*l  4b  LtUrtt  «t  'U  Mtnunrtt.  \i^\.  p.  -J70. 

j  Ceaullo'D  Cgdop.  (j/  PnKtirat  Sufjfry,  vol.  i,  p.  218,  LonJoB,  184t. 

i  AUNk  dt  ia  SoeUti  <Ie  Chir.  vol.  iiL  p.  Mi. 


436 


DISEASES  OF  ARTERIES. 


Kerious  sntl  tlio  most  comnioii  afiei<lont  following  tfae  injoction 
tlie  jHirrliluriiit!  of  11*011.  All  coagiOating  injections  act  by  rnjiitUi 
prodacing  a  passive  clot.  Tliis  of  itadf  is  a  wcll-kwown  caaau  01 
iiiflutninatlnii  of  Uie  sac..  Morecjvtir  tbe  pcrc)il<iri<te  is  a  liiglil] 
iiritnting  fluiJ,  which  not  oulv  piWuti'S  mpid  ooagalatiou  of  tli( 
hlocMl,  hut  hiis  Lh(-  elltxit  ofcnusiiij^  iiitlammiitioti  in  nil  lltu  trsm«t 
with  wliich  it  comes  in  (-ontact.  Ueiice  tho  immixlialo  effect  of  thi 
injuutioa  in  »  immlwi-  of  cam-fi  liH.i  hoc-n  to  oxnttt  tnRiiinnuitioD. 
more  or  less  iutenso,  followed  hy,  5,  Atiseett  of  the  sac;  6.  Otuu^rem 
of  the  foc;  1.  Hupt'ire;  8.  Uteintrriuige ;  9,  (laaffrme  of  tkf  Imih 
In  eighteen  oolloctc<l  cases,  the  injection  proved  fatal  four  tim»! 
twice  &om  giuigreiic  of  tiie  limb,  once  trotn  haiinorrhBgo  following 
gangrene  of  the  sac,  and  onoe  from  phlebitis.  This  iB  a  formidabh 
roll  of  acciduntM  and  a  Itirgo  projwrtion  of  deaths.  It  will  seem 
yet  larger  when  we  remeitiher,  iliitl  it.  la  11  condition  of  priniarj 
necessity  now  recogni^cxl  by  all  Surgeons,  that  before  the  method  of 
injection  can  be  a[>[>licd,  it  nitist  bo  jKinAible  to  arrei>t  the  current 
of  the  blood  by  pressure  on  the  artory  above  and  below  tlie  tumenr. 
Tliuft  it  wouhl  bo  [lossibte  in  nearly  nil  tlicxe  ca-te-t  t^i  i>p]>ly  intlivr 
instrumental  or  digital  compression  or  flexion ;  proeoedings  which 
oiui  <!n\m\  u  lar^i^r  jiroportion  of  sucve»«e»,  and  whicli  an^  nut  ojMiii 
to  the  Bamo  objections.  _ 

The  treutmeiit  by  injoction  hiui  heen  Applied  to  nearly  er^eM 
form  of  external  aneurism:  to  popliteal  aneurism,  by  Nitfjioe,  Le- 
noir,   Minor,   and   I»aae«;    to   eurotid  unvuriKm,  by   Dufonr;  to 
aneurisms  of  tlie  elbow,  hy  Jobert,  Sorres  d'AluLi,  Vallettc,  aai 
Dicuiafoy ;  and  even  to  niieurisms  of  the  innominate,  by  Barrar; 
of  the  subclavian,   by   I'euwjuin ;   anil   of  the  aorta,   by  % 
Tlie  last  tbroo  varieties  are  totally  out  of  the  domain  of  this 
of  trvutnu'iit,   because  tlie^'  avc.   inaecrswible  to   tlie   conipi-f?*!' 
of  the  artery  on  Uieir  cardiac  and   distal  side ;  and  without  ibii 
precaution  the  sniidl  clols  rumied  by  caeh  drop  of  the  pcrchlorii 
on  its  entering  the  sac,  are  capable,  as  has  been  proved  by  eijieri- 
enec,  of  being  ciirri<'d  by  the  blowl  into  the  Tamificationi'  oftli* 
artery  and   producing  gangrene.      To   repeat  Uiose  expetiniaiW 
WDuliI,  therefore,  now  be  ruith.     Aneurifiiii'  of  the  pofiliteal  artoy* 
and  of  tlie  extremities  generally,  are  susceptible  of  sudi  satisfiuto? 
treatment  by  compression  and  flexion,  that  the  more  dang:en'>» 
method  of  injection  would  here  be  out  of  place,    An  exception,  li"''' 
ever,  nnirt  be  made  for  those  varicose  aiK-urisms  seen  nvntX  O^' 
monly  at  the  elhow  after  voncxection,  which  have  not  alwaya  pro™ 
Ajnuuahlo  even  to  digital  compression,  and  tu  which  duligaticQ  ■■ 


I 


INJECTIONS  IN  ANEURISM. 


437 


floid 


'Ui 


That  mmplioatot  and  <IifRcn1l.    Iiijoction  of  jierchlorule  of  iron 

fuur  tiiiHW  liivii  Mioci'twi'ully  n[>jili(xl  to  »uc]i  n  condition  I>y 

SerrPH,  VaIlt*tto,  aiid  Dicalaluy;  luid  jn-opor  pretuiulions 

■wed,  this  mirtliixl  mny  tioro  hu  t»uiid  uilvaiiUigvoiu.     Tlie 

tiiny  also  1>e  said  for  cirsoid  aiid  anaiitoiiiotic  aneuricdii.    (Soc 

Did  AiMMiri.-<J)i.) 

Wlieii  in  any  case  it  is  determined  to  inject  a  coagulating  iluid, 
■bio  to  tulojit  ccrtJiiti  [>rcG»utJoii».  In  tJiv  first  ])hu>,  as 
seleoleiL  VarinuA  iiroparations  of  iron,  Mich  «a  tJie 
0,  tlu)  piTSiilplute,  tile  aoutatv  of  ttio  Hcsijuioxidu  of  iroOf 
■cid,  olcmWIf  and  at^^tic  uuid,  huve  Ix^n  recomniende<l  and 
i;  but  tlio  (-■oagulutin^  power  of  tlic  miliition  of  tlto  jiur- 
I  oo  miidi  greater  Hiux  tlutt  of  arty  of  tlio-tu  tluidfl,  that  it 
the  prcfvronce,  notnntliHtaiiding  its  irritating  qualiliits.  In 
reduee  tliin  irritalin>;  action  to  its  minimum,  it  i^  desir* 
.  to  «ii)])loy  a  neutral  eolution  of  tJie  perchlorido  and  one  of 
dilution.  VvTy  carofid  directions  liavo  been  givwi  for  tlio 
lion  of  tl»e  HolutionH  hy  M.  Burin- Dububaon,*  M.  Soubei- 
and  otlttTV.  In  tliu  carlii^t  Oiiscs  a  Kolution  wn»  vin{ilo)'ci( 
Itbe  rtrength  of  ■l.>"--li>°  UeaumtS  if,  sp.  gr.  l-loJ-l-MO ; 
urience  luui  shown  that  w>lutioiB  of  this  strougtJi  arti  pro- 
of iixocmivc  iiithunmation,  and  linul  aInio»l  inovitidily  to 
I  ■ociileiitH.  Tlie  e}i[>nrienDe  of  M.  Vallctti-  has  shown  that  a 
of  iVf  Bcauint-  [)OT<sc«so"  great  coa;;u!ating  power,  and  no 
degree  of  strength  ijiould  be  employed.  Cnre  idso  Hliotd<l 
nut  to  inject  an  excess  of  the  perchloridc;  for  tliis  not  only 
ibt  tuE«uiM  of  tlio  HOOf  but  diminishes  the  solidity  of  the 
)L  Droca  advises  the  injootion  of  twenty  drops  to  uvety 
litn  (lUOlh  of  a  pint)  of  tlie  vnntonts  of  tlie  aiiouriHintd  ma. 
twvnt  experience  of  M.  Dii'ulafoy  (1859)  soenu  to  show  tliat 
nth  of  tliiH  (piniitity  rniiy  HaRioo ;  and  that  for  an  aDeiirimn  con> 
rtx  twelve  centilitres  or  SJojts,,  Hghteon  to  twenty  dropA  only 
a:-:  in  injiTUn).  Tl)r  Ixuit  inMnniMiit  for  the  purpow!  i*  tho small 
r-intwi  syringe  with  screw  piston  and  glass  body,  made  for  tlio 
Inr^uo  hy  motrt  instnimont-niaken,  and  al»»  unol  for  !«ubi,tutatio- 
*•  bjcotions.  In  ]>crforniing  llie  injection,  it  is  necessary  Brst  to 
idi  lux'itmlu  oonipresBion  of  tlie  aitcry  abovo  niid  hi;low  tlio 
r,  Bu  oa  ooinplutAdy  U>  amst  tlie  blood  in  iL     Tlie  jiointed 


BpcT 


'  "'MpM-r^Bifa  tk  TAeail.  da  Stimei*,  lOtli  Jan.  1804.  rol.  xxxriii.  p.  ^. 
I  Halbtia  .U  Tyraft*tiqiu,  vol.  xlr.  p.  U4,  IMS;  see  duo  Th4t«  dt  M. 


438 


DISKASES  OF  AHTERIES, 


trocftT  [ft  plnngecl  pcrpondiciil-irly  into  the  tumonr,  am* 
taken  on  the  onv  hnnrl  to  uit^r  the  onrity,  mmI  on  th«  otll 
t'l  tniiixlix  it;  tiotlidrwhii-h  aiy^idente hare  }tap[iened  to  ezpH 
operatore,  and  arc  prodtic^ivo  of  obvioiut  iiic«Nivoni<mc«.  Tfa 
oen  of  tho  sloi>  is  Jitdifsiled  by  tlio  issue  afarfrritJ  blonl,  ai 
oatjon  wliicli  slimiltl  bu  looked  for.  The  canals  is  nov  « 
on  to  the  trocar,  and  so  niticli  of  ita  oontenlA  on  may  be  l] 
noccsBary  ijcctrtt  by  siiLictwsivo  tiirn»  of  the  [hMoii.  Encli  i 
iiHoally  eijiiivnleiit  to  half  it  drop,  and  the  (|UiinlJty  inji\'t4M]  i 
AirthcT  ootiinntvd  by  a  ivfcTGnco  to  a  scalir,  whicli  sbould  be  i 
on  tlio  gla.ift  l»ody  of  llie  syriiif^.  Tlw  (Miiiit  of  tlw  tn>n 
K-  din.ict«d  upwards,  downwards,  and  on  oillitT  »ido,  witlicnil 
drawing  it,  ho  as  to  fonn  scvonU  cnntrra  of  coagulation, 
the  tiunotir  Wm  aoqnired  a  certain  consistence  and  tlio  cuag) 
has  fltilliciently  titkou  plaoo,  oiio  turn  bnckwanU  slumU  Im 
to  the  piston,  so  as  to  draw  np  tho  Ii4inid  oontainod  in  the 
and  to  prevent  it-*  irritating  ofntlact  wilk  tli<-  tiiMum;  it  I 
Cfln;f«lly  wttlidrawn.  The  comjn'cssion  of  IJk-  artiTy  on  the  I 
side  of  tho  sue  xhoiild  l)o  vi>ntinii«i]  for  an  lioor. 

It  is  ncccs^aiy  to  attend  to  these  precautions  very  eai 
heciiii.'ir-  C!Xpori«'no>  1ms  shown  that  owiti;;  to  ttioir  nogUwt  m 
those  serious  a<K!identii  (x-eurrtNl  whieh  marred  tlie  suflcow 
earlier  wTit-s  of  ca«*.  Nutwitlistanding  their  obscn'aneo,  il 
bo  cxjiecled  Ibat  inHainnintioii  of  the  fine,  with  itit  iiUiii^in 
a->torM,  will  fl%<]iieiitJr  follow  the  inJL'ctiou  of  titu  pi^rchlM 
iron ;  and  since  tliis  inelliod  in  mainly  apj>licabln  to  tli«M  mfi 
ancuriinis  which  t^n  bo  treated  by  other  pi-ocoedings  not  O 
that  (ihjeotion,  and  not  followed  by  tli<i*c  <Iangi-r#,  tliv  ait|tli«at 
the  treatment  by  injection  are  likely  to  be  liu)it«I.  Tlw  dia 
of  a  lliiid  liferent  cnn{:n>''*t'inK  P^^'iM't  and  dovoid  of  iiritatiq 
jiertioe,  is  a  desideratum  in  this  method.  ^ 

ERNEST  sH 


TRAtiMATtC  AxrPRISK.  ^| 

By  '  tmnmatie  anmn-Iitin'  is  menut  a  tuinonr  Dontatning 
communicating  with  tho  earity  of  an  art<rrr,  and  duo  to  a  wd( 
tlio  v(M«cl.  Tlireo  descriptiotw  of  injury  may  lead  to  klie  fan 
of  a  traumatic  antfurlsm:  1.  a  woond  pcootnting  frixn  tin 
face  ;  2.  a  toariug  or  ntrain  of  tli«  coata  of  the  vanot  w 
wound ;   H.  fiacturc  of  a  neighbouring  bone. 

Tho  first  is  the  most  couuuun,  or  ut  loutl  tlio  iDO«t  wmi 


TRAUMATIC  ANEURISM. 


439 


Tpeognisetl*  caURO  of  trauiuatip  niieurisin.     A  man  recoire*  »  »tab 

or  *  Kiiuil)  inviMid  wound.    It  bk-oU  fn-dy,  uid  most  likely  in  jobi; 

but  tJws  lia-inoiThage  iti  r«wtrnined  liy  (inn  preasurt';  llw  nnuiul  liiMiIs, 

ami  the  iiiiiii  thinks  himself  curucL     Uo  is  conscious,  however,  of 

•ome  loas  of  power  and  some  anuinaluun  sen-Hatiotis  in  Uiu  liuib,  sach 

M  colli,  niiinlnieH);,  tinghn};,  and  a  fueling  of  weight;  and  later  on  ho 

discovers  that  a  [HiWiin^'tuiiiDiirexintH  beneath  tilt!  AoiiruftiK- wound. 

In  nic-li  n  simple  e^uio  it  is  ctasy  to  nee  wliat  lias  }iaj>pened :  Hie 

^MJrtery  has  been  jienetriiltMl  hy  u  ivouikI  whicJi  wiw  too  lurge  to  be 

clewed  by  tlie  mere  offorto  of  nature,!  hut  which  did  not  ent  Uie 

tu.l)e  acrws,  and  did  not  xtop  the  circulation.     The  bluod  has  not 

Iix«<]  a  vcrj-  diroct  exit  by  tlie  skin-wound,  probably  in  eonsequenee 

t»f  tlie  attereil  jxt^ition  wlucli  fii-'cite  and  other  inenibi-anou»  strae- 

tum  uttiunc  in  deep  wounds,  under  vaiying  conditions  of  preasor^ 

l^>xiuoii,  Ac,  and  tliercforc  the  blcudinfj  Iiim  not  interfered  with  the 

"Owling  of  the  opening  in  the  skin.     Mcanwiiilo,  below  the  fascia 

bl«>od  iuu  et^iitinuiid  to  exudo  into  the  eellului'  liwuo  anion';  the 

ttst»»cle6,  forming  a  large  ditfiised  eoeliyraosis.      This  eochvinosis 

"^s^T  «intiiinc  for  some  tinio  to  incresiso ;  sue.h,  however,  is  not  tic- 

•^•warily  the  ease,  since  aa  much  of  the  blood  may  be  withdrawn 

.from  the  4X^IInlar   tissuo   by  tJie   action    of  the  absorbent  vessels 

^(tbv  veins,  and  iionsibly  the  lymphatics),  and  by  reflux  into  the 

"^ery  rhiring  it«  diastole,  as  is  poured  out  during  the  systole. 

'>**oncr  or  later,  however,  the  presence  of  the  blood  aoLi  a.t  ii  sourco 

*■  irnlation,  and  set«  up  iullummation  in  its  neighbourhood.     Xliis 

™a«s  ooiHlen<itioii,  and  then  crmtraetiim  of  the  arwilar  tissue,  and 

*•   a  »ac  is  ibnnetL     By  this  time,  probahlv,  a  grtyit  ]>art  of  the 

"lood  hafi  coiH^iInt^,  luid  so  the  aneurism  (as  it  now  is)  contains 

*  Uiixturo  of  clotted  and  fluid  blood,  as  most  aneurisms  do.     Tliu 

***K)  now  tlifTers  in  no  rcsjH-et  fn>m  "ue  of  simntaneous  anenrUm, 

**Oept,  perhaps,  in  its  greater  pronenoss  to  euro,  since  the  heart 

"i^  arteri<!s  are  pniliuhly  lienlthy ;  while  in  uniny  casca  at  any  rate 

"  ^nlaneouB  aneurism  they  are  diseased. 

The  Hymptomit  of  thiit  kind  of  truiiniatic  imeurisro  are  generally 
••tinct  enough.  The  scai-  of  the  wound  will  be  discovered  oven  if 
■A  hutory  u  obscure,  uid  thu  pulsation  and  bruit  are  generally 


•  If  wo  eoD*ider  lb«  frequency  witli  which  po^teal  and  ether  surgical 
Mill  1 1  in  I  ■»  attribuKd  to  acculeiit,  aud  tlii^ii'  much  more  fl!«qu«iit  uccui-- 
Mm  in  penuHiN  aud  in  silustiotiii  luosl  uxiiosoU  to  vlulcnce.  ne  mi',;lit  ha 
inpud  to  coDoIode  that  such  auutirinius  nrn  usunilj'  trauiuatio,  und  due  to 
cfe  H<x»i4  or  tlie  claw  of  «au8ea  above  ouuiuantlud. 

f  Sm  to),  i.  pp.  eea,  6S6. 


440 


DISEASES  OF  ARTERIES. 


\ 


distinct.     But  it  must  not  be  for^tion,  that  before  the  sac  lia* 
been  iormwl,  piilsiitioti  U  ottwi  indintiiigitioliablv,  tJiougli  iJw;  I)™!*- 
CHI)  almost  nlvTK^'s  be  recngiiiHed.     Such  lesions  aa  those  are  ofter^ 
incoiToctly  Hpoken  of  an  '  Ra*niri«tn* ;'  u  ttfnn  whicli  in  only  applic 
iiblo  n  lien  the  ettc  has  formed.     This  is  not  a  tlieoretioal  or  ptHbinti^^M 
verba]  distinction,  btit  n  [iractical  diUcrcnoo  of  tho  greiiti.<«t  im|>ort      — 
aiuw.     11i«  f'lnnalion  of  a  sao  is  tlie  first  ateji  lowartl'  the  euro  a     m^{ 
the  (U»oEuie,  nnd  abowx  that  the  caw  in  amenable  to  the  contpora-      m- 
tivdy  mild  and  indirect  me^isures  which  are  ad(X|unte  for  thi^ 
of  an  aneurism,  Hueli  as  pros*iirc  on  the  main  trimk,  or  itm  ligat 
nt  a  ooiiviMiient  A|>ot  above  the  tumour,  iiiHl^^a^l  of  n>i|uiriiig  th^K:^^ 
fi«quontly  BC^-cro  and  diffieult  operation  neceesary  for  exposing  an-^W 
eecuriiig  tin*  wotmdi'd  part  of  the  wwMil. 

Tile  rapidity  and  rcadine^  of  formation  of  tranmatic  anenri^ir^^i 
di^^rs  aooinliiig  to  tli«  nature  of  the  iiiwue  with  which  tJto  woni^  J 
oommiinieates ;  wliethor  tho  wound  be  in  a  large  cavity  tilled  wit;— h 
loi)»c  t'lilhiliir  tixsuc,  or  a  sjmci.'  wlicro  iJiv  bloud  will  Ik.'  IhxuuI  doir^* 
and   dif-ijosed  in   exten«ve  membranifonu   layers  by   contigooo" 
fiiww  or  tenso  mtiixdei*.      Thu«  in  tho  axilla  or  orbit,  traunitti* 
aneurisms  of  largo  size  soon  follow  on  injury  to  the  main  an*r;*i^» 
or  twcn  to  a  com])aratively  small  branch.     Tlie  well-known  ca?"  «r»* 
Lieut.  Solon  was  an  example  of  this  fact,     A  wound  of  a  brancr^ 
of  the  external  iliac,  tlio  initiimt  being  sleut  and  the  tvUiiUr  iiiti-rvs»J 
large  and  loose,  occasioned  an  extravasation  of  bloody  whit-It  mm-^ 
large  enough  to  leail  to  tJie  IxOiof  tliat  the  parent  veiwel  bad  W*^ 
iiijuriMl.     Ill  tlie  limbs,  on  tho  contrary,  tlie  formation  of  aiK-uri*!*^ 
as  a  conscquoneo  of  wound  (>f  a  lai'pf  vessel  im  more  rare;  and  wlw-*'"^ 
formod,  tlicy  ivill  ott«n  undergo  a  pnwewi  of  spontaiicons  cure  b^^ 
rest  and  simple  nieasiires.     Tho  reason  for  tins  doubtless  is,  thi'^^ 
before  aneurism  has  formed,  the  bl<iod  itself,  bound  down  by  tem^^^ 
fascia;  antl  strong  expandwl  layers  of  mitsclo,  cxoreisos  prossuro  oi^^ 
tlie  wounded  \cssol,  tending  to  limit  tiie  effusion  and  clow  tbe^^ 
wotnid ;    and   after  tlio  tumonr  has  been  developed,  the  prossiuo 
wliieh  (it  mn.*t.  ne\er  he  forgotten)  the  sac  oxerl*t  npon  il»  contend 
is  materially  aided  by  the  pressure  of  the  soft  parts  u|>on  the  sao. 

The  progrejw  of  trauTniit.ic  aiieurinni!',  tlicirufore,  is  not  aln-ars 
towards  death,  even  if  left  alone ;  and  when  tliey  are  of  small  uxa 
tliey  are  generally  ejisily  cunxL  Direct  prewnro  is  pocnliarly  ap- 
plicable; but  it  should  bo  oai-efidly  regulated  and  ailjii-MtsI,  so  as 
to  avoid  the  danger  of  sloughing.  Perhaps  digital  pressure  is  tbo 
most  ofBcieiit  and  safe,  if  (;ireuinKtaTii;c?>  allow  m  to  nxinro  llio  sur- 
rloes  of  a  relay  of  atteadant«,  who  will  moke  gentlo  and  atuudj 


i 


TRAUMATIC  AIOilURISM.  441 

with  their  haiul»  over  tin)  «iic.  Or  in  vorj-  umall  aiw'nrismB 
oiit  a  bono,  tti6  juitioDt  may  be  dinwtt-U  lo  ki>e]>  Iiis  tinker 
on  the  pulsating  ]>art  whvncvpr  ho  can.  I  have  Been  a  small 
teii)[Hir»]  iinoiiritim,  llie  resulL  of  tlus  lil»vr  of  »  stone,  llnut  Ureated 
with  HUtHctonl  success  to  avoid  tlio  necessitf  of  any  otiier  tr«st- 
menu  Iti  liirger  and  deeper  luniourH  some  form  of  buiidsgo, 
"with  the  intonontion  of  an  air-pad,  may  be  nece3§a]y.  Forced 
&xton  (it'tliu  limb  I*  oi\!Our!«!  nfU^u  mlvisiibic.  With  direct  pre«- 
euro  may  be  combined  the  compression  of  tlie  trunk  leading  to  the 
vnclliiig,'  and  tlio  limb  slioulil  b<;  niisud. 

If  these  means  fail,  iJio  aitory  iiuist  l>e  tied.     Some  authors 

refttr  in  tbow  cums  the  uiethod  of  And  to  tliat  of  Hunter,  arguing 

5*J*dy,  itiat  a&  tlio  artery  will  Iw  found  liealthy  cloiw  to  the  tumour, 

oiM  of  thu  advantagiw  wliicli   Huiitor's  method  ha«  over  Anol's 

peialion,  which  it  will  be  romemlTorud  w«a  fiivtl  iHii-foriuiHl  for 

Innuadc  anourism  at  thv  bond  of  tho  elbow,  is  lost.     Tliis  is 

quite  tnm;  but  the  general  advajiuiyo  of  Aiiol'n  method  over  llun- 

t^r"!,  aetoris  paribus,  is  verv-  slight,  since  tlio  more  fact  of  there 

''**Mig  a  [Wrtjon  of  arti^ry  [it^rvioiis  betwoflii  tlio  ligatiiro  and  the 

tonour  haiiily  ever  atfocts  the  progress  of  the  case.     If,  therefore, 

'lie  tumour  Iw  dcii)ly  iicaiifi,  an<I  it  wiiid<I  Ikj  diliicult  lo  ijxikj!«o  tlio 

^os*!^  as  it  leads  into  it,  no  hesitation  need  bo  enterlaiiiod  in  trust- 

•"g  to  tho  Hiinturinn  mMboil,  whilo  if  (as  is  usually  thi?  case  at 

"■•O  bnul  of  tlie  elbow)  the  tumour  and  the  artery  on  which  it  Is 

'^*tal  he  superficial,  thu  olil  n|icnili<)n  of  opening  tiio  sac  and  t^'ing 

"^th  GiMbi  of  tiie  vessel  offers  no  ajiecJal  diffioultiw,  and  i»  certain 

"*   Mixy'L'd.      It  is  therefore  often  adoptcti :  and  we  shall  sco,  when 

^^tini;  of  axillary  aneurism,  that  it  ha->  \>wi\  rvcoiinncndi-sl  by 

*  Ijigh  authority  for  general  use  in  that  form  of  the  disease.     Still, 

**•  giwat  nuyority  nf  tniuniatic  aneuriHui.*  buvc yielded  lo  the  proper 

S'plicatioii  of  pressure,  and  few  of  those  which  have  not  done  so 

**^  blown  to  liHvo  rnitted  tiin  Hmitorian  operation.     It  is  oidy  in 

•••ai  in  which  the  tumour  is  HuperRciidly  soaltni,  and  tho  operation 

■Slwfojie  comparatively  easy  and  bloodlt;ss,  tliat  tlio  majority  of 

^'I'lgeonii  would  prefer  tli©  old  (ii>firation. 

Traumatic  aneurisms  from  contusion  or  sprain,  without  external 
*<4nd,  arv  too  closely  alHtiil  Ui  tho.->o  of  spontaniv>u8  oi'igiii  to  call 
It  *ny  special  ttotic©  in  this  plaixi.  Tliis  form  of  injury  is  nearly 
itlitod  to  the  olMtruction  of  the  nrti!rl<.w,  which  in  noticed  in  the 

•  Stm  A  eaM  of  unnrnatio  ani-uri'in  ''f  tlio  mdiji!  niVry,  ciirod  by  a 
\  CNliMiMtian  uf  furcml  llvxiuii  of  the  (<lbuw  »»•]  cnniprcs*ioa  of  tho  biiicliial, 
I  aiUrwanlit  by  extouaiou  of  ih«  aim.    Brit.  M«ti.  Joum.  IdOO,  p.  SSU. 


rathiT  than  uf  pritcticiil  iiitcnmt. 

NotwittuUndiug  tlte  reuiitrkable  iminuni^  wlikh  ai 
even  in  tlio  most  fonaidHbte  itijurius,  it  u  not  8urj)rii 
they  litf  so  close  to  (Ji«  bunea  in  nuuiy  Hituations,  they  i 
uunally  bo  vrouiidod  by  splinters,  or  niptuml  fivm  sud 
ing  in  frauturits.  TIiEh  noc-iilt-iil  in  not  cutntnon;  and  it  i 
pens  in  such  severe  injuries  that  amputation  ie  noon 
oaitoB,  howt^vcr,  wu  Ivft,  in  wbiob  ]nc«nitioti  of  on  oj 
as  000  of  the  eomplications  of  a  umple  &«otaro,  or  of 
fracture  in  which  tlio  otlior  injuritM  are  not  very  gni 
latter  case,  no  great  diDieulty  con  exist  in  deciding  ot 
sary  treatment.  If  tJie  limb  in  to  hv  Mvod,  Uie  won 
enlarged,  ai]d  the  wound  of  the  veasel  treated  imvpt 
fructiuv.  Itut  wluin  a.  large  bloud-vee«cI  {«  woundwl 
fivotore,  it  is  not  always  easy  to  make  out  in  the  firat  p 
Hw  wouiidiil  vveinA  \»  fui  artt-Tii'  or  a  vein ;  and  if  the  fbrn 
the  main  artery  of  the  hnib  or  one  of  itA  branches. 
betwCMiu  lui  artery  and  a  vein,  tlie  chief  guide,  of  coun 
the  presence  or  absence  of  ])ulHatioti  in  tlie  nullcetiim  o 
liiuti  pulfation  a  often  not  perceived  at  first, — noi  ti 
has  l>ooonie  oncyated,  and  tiic  ooMt  therefore  baa  chai 
wound  of  the  vosso]  to  a  tniinnnlic  niieurism.  Aiiutlii 
symptom  is  tlie  flate  uf  tin?  pulsv  bHuw  the  injury;  I 
bo  oljwured  by  the  eodi^-mosis  and  other  swelling.  . 
may  be  heard  at  tlui  sent  of  the  injury;  and  tliift,  althc 
not  quite  settle  the  point,|  yet  is  [>erhujia  tlie 


ANEURISM  FBOM  FRACTUBE. 


443 


U 


oiv,  in  8W.li  a  nvo  tv*  tltis  throo  cotu^es  nro  opon :  viz.  to  cnt 
imra  on  the  scat  of  tractiire  and  st^aruli  iVir  ilio  hlomling  vcevtel ;  to 
uiipatnte  liic  limb;  or  to  Icuvo  tlic  case  to  the  powcra  of  naturo, 
iid«l  of  <;oHn*i>  \iy  rest  and  suilnblo  )>o.iitian. 

In  John  ItcU's  Sur^fty  this  species  of  traumatic  siuntrism  ia 
nry  fully  (tiBcutt-^ed ;  and  lio  si-emH  to  tiavc  lioen  of  llic  opiniou 
tluit  it  was  ultVEiys  necessary,  in  cases  not  sfl%-i?ro  eiiough  to  domiuid 
amputiition,  to  cut  down  luid  tie  both  ondn  of  the  vi'ksoI.*  7'but 
tiiin  Dovcro  operation  is,  at  any  rate,  not  always  necessary,  is  clear 
^la  llio  fact  tluit  lour  e«M-Ji  hiivo  oci-urrii!  iit  tin-  M iddlf.-n'X  Hos- 
pitnl,  under  the  care  of  Mr.  Mooro  and  Mr.  Mitchell  Homy,  in 
which  sunli  trntniiitlic  anourixniN  have  formed  and  have  got  wvU 
Bpontaneoasly.  Short  notes  of  one  of  these  eases,  which  was  tmdcr 
Jtr-  Mourc'»  care,  may  h«  apjwtiili.'d,  ne  iUuvti-iiting  llio  mibjcct 
letter  than  a  lengthened  disquisition. 

^  wMinaii,  ii't.  fi>rty-twii,  jtrnsi^ntod  hi'rj«^-If  in  tlio  middlo  of  tlio 

iny,  having  on  the  previous  night  fiillen  down  stairs  and  injured 

isr  right  arm.     The  wbuli;  oftliu  liiuid  and  tbru-arm  and  part  of 

ibe    njiper-iUTU  were  tensely  swollen,  and  covered  with   bullip  of 

^unon^  but  principally  rfinall  »hv,     tScrum  mixed  witli  blood  tilled 

<1»  bai!a>L     It  was  easy  to  make  out  a  fracture  of  the  olera'anon ; 

'"t  il  was  impomililu  to  jitTceivc  any  fnit-tiiro  of  the  humerus,  and 

liio  bonea  of  the  fore-arui  ajjp«ired  to  be  in  plaeo.     iSlm  rotuM-d  to 

vmc  bto  tho  hospitid,  but  was  adi>iitt4xL  next  day.     The  swelling 

■»*  tiien  larger,  aiid  tlie  vesications  more  extonRtvo.     Thero  was  aii 

J*'»rirc.L    Tlie  vHin"!  of  ilw  sounil  roinniiipJ  uIispui'l'.     The  cue  will  be 
™«ftcr  rcfori-od  lo  un(l«i-  the  heaJ  uf  Oi-biWl  Aneuj-iam. 

*  "  Wtieu  ail  t,rU<ry  i"  thus  Ucor'aleil,  along  wiUt  A^auture  of  tfao  bonea, 

t^  luTv  btil  this  alieimittve.  lo  cut  the  Unib  off  at  nnoe  if  it  be  vtryiM- 

'*'*Mf  wouudvil,  or  to  ir^'  tu  nave  it,  by  lutik'mg  iitcieioiia  aud  tvliig  tb« 

•t**?.    The  fracture  is  alieudy  cimiiilieuteJ  with  luiuuriHiu.  and  you  tirv 

*"*'«  the  duiii^eruus  uvut-Heity  of  vDiiverLiuij   tkia  vuiuplicatud  aiieurlsjo 

T**"  >  eompininil  fnli'tiiru.     You  apply  your  toumitjuM.  make  a  long  and 

*^Woi«ion.  luni  out  IIh.-  ccHigulit  uf  lilooj  wiili  jour  Ruuurs,  uleanse  the 

*••  *ith  wfotn^cs,  BcurtU  lor  tliu  arlewy.  luxl  liu  it  up  jibovn  anJ  b«low 

'^*n  il  ti  torn.    Vou  wvsh  out  Ihu  blood  froiu  tlie  snc  witli  syriug^s  auU 

''^jw.  for  wbilv  it  lii-a  betwixt  thu  bouts  tbey  i-nimot  unit*.- ;  what  blood 

J**l  are  foivMl  to  leave  mdts  down  into  bud  mutter  uud  flowB  off;  tho 

r**ptr  porta  of  the  wound  puilunUy  dij;cel.  gnutulutc.  and  fill  up  with  soft 

^^ ;  and  wben  ibc  contiuuity  of  tlio  parts  is  Uius  rvHtored,  tbo  new  bone 

^  calliu  bcitiiu  to  fami.     Such  ia  the  oetLvity  of  a  woiwdi-d  artery  in 

I  ^AUng  it*  MiL-uiisni  and  destroyini^  the-  siimiiuidiuK  parts,  and  no  com- 

W*U«4  b  the  ditonler  whi-n  a  wounded  artery  b  sdJod  to  a  fmoiured 

'''*€,  tlint  ttnlom  tltPMt  o]]i>inti<ins  aix-  prrfoiined  early,  tlin  limb  is  iuevil- 

*^J  Imu"     John  BoU'a  Surgtrg,  Cbailcs  JtcU's  odtl.  1020,  vol.  it.  p.  401. 


4U 


DISEASES  OF  ARTERIES. 


Z 


a»(!urUma1  |>iiU;iti<ni  in  front  of  itie  dhow,  sli-oiig  and  pxpanding, 
but  <!w:jj]y  scaled.      TIm;  iiiif)iiltv  exlciidwi  halfway  ui>  tiie  inner 
aiiln  of  tJin  arm,  and  inoni  iJmn  Imlfway  down  llio  wIhiIo  [lalmu' 
siirfiioc  of  the  forc-ann.   A  di^itinct  bruU  was  benni  with  tlie  s(otho- 
W"]"*  in  fnmt  i>f  tliii  itlliijw,     Tlie  two  lU'turii-s  iit  lliv  wri.it  ixM  >o 
forward  ajid  so  forcibly,  and  appeared  so  inucli  larger  than  those  of 
tJM!  oUicr  mk;  !w  to  ;:ivi!  llio  idwi  lluil  tlii-y  liiul  Ix-cn  rai.'wd  by 
extravasiitod  blood,  and  iliat  die  pulsation  was  communicat«l  lu 
tiiu  distvndod  hIioiiUis  of  tiie  v&mcIk.     11iu  skin  of  (hu  Land  wna 
dusky  from  congestion;  and  when  tlio  colour  was  driven  away  by 
preesura,  it  rotnniol  wry  »lr»w  ly,  showing  Uio  vtnlNU-rasscd  condi- 
tion of  tlie  drculaUon.    Tlio  limb  was  every  where  warm,  tioweveSi 
and  tlitnTK  wtu  no  sign  of  iin|H>iuling  gongnme.     A  conMiltadcj^vA 
was  held,  at  wliicb  various  opinions  wore  exjnvtwed  ait  to  the  n-y 
proprinti^  trfatniont ;  bnt  it  vfM  agreed  that  there  ooidd  be  ^kd^ 
doubt  that  some  lar^  artery,  jjossihly  the  bni(-hiul,  was  wounilf^— iL 
It  wa«  ultimately  decidi-d  to  walch  tlie  ca*c.      In  the  evening  L^^i" 
swelling  Wii.i  found  not  lo  havo  inereasisl,  and  (he  hand  wak  vu-»> 
tainly  lot's  tense,     A  rounded  swelling  was  foiuid  near  the  arnii»  ^^ 
in  the  neighboui-hood  of  the  braehial  arU-rv,  whioh  apjK-arod  to    "^ 
tlie  end  of  the  clot  of  blood.     On  the  following  day  (the  tiiinl  frc^  ^ 
the  Hocideiit)  pnlsalion  had  (-eaited  in  all  other  \»rti;  (uid  wan  jw^t** 
ceptible  only  in  front  of  the  elbow,  over  a  space  aliout  as  large    ^u 
n  half-orfjwn,  and  not  strung.     Nosl  day  tlio  anourismal  pidsad*^^ 
iinally  disapiwaivrd,  and  the  swelling  afterwards  gi-a<luHlly  Milnide^' 
When  the  nub^iih^nco  was  wttHeieiit,  fraeturo  of  the  lower  end    *» 
the  tuiuienia  was  detected.     The  case  did  w«ll. 

Of  the  other  three  e:is(w,  one,  under  Mr.  Henry's  care,  wai*  * 
wound  of  the  posterior  tibial  artery,  in  a  boy  wlio  !(tifl4.-r«l  fro** 
«iniplc  fracture  of  tlii;  leg.     The  diagnosis  rcwt^-d  u)jon  the  abscn*^ 
of  jmlso  in  the  artery,  .ind  tlio  presonoe  of  liruit,  together  *!*■* 
peculiar  rc-stlessness  of  tho  limb.     Tl»  fraoltnv  beale<i  slowly  (^i"^ 
about  two  months),  and  the  above  syni|<to«isgr:idiially. ■subsided;  !>*-*' 
the  puUc  did  not  return  in  tho  affected  arterj'.      In  thii  lliird  ea^^** 
(Mr.  M<iore's  patient),  one  of  siniple  fracture  «f  the  femur  in  a  nic^^ 
ift.  thirty-fivo,  there  was  extensive  swelling,  together  with  urU-ri^^ 
bruit  in  some  urtery, — not  tliL'  tiimoral,  which  ewild  be  felt  bel»"^ 
the  scat  of  injury.     Hero  also  tho  bruit  and  swelling  dl«ip[>ean;^^ 
with  rest,  and  the  frneturn  nuitwl  in   three  months.     The  fiiiirc  ^ 
case,  also  under  Mr.  Moore's  care,  was,  like  iJie  aeoond,  a  wouu  ^' 
of  on«  of  the  tibial  arlvritfs   in   fracture  of  tlie  log.     It  will  b^ 
noticed  that  tho  m^ority  of  those  cases  were  merely  wouimIs  of  th' 


AXBURISM  FROM  FRACTURE. 


445 


TV,  and  not  ancnrisms  in  tbe  strict  sense  of  that  term ;  sineo 
rc4?ov«n.<<l  u-iilumt  tlie  f<>riii»tii»i  of  luivatieitrlMiinl  ftic'  This 
BCcmis  to  testify,  even  more  strongly  than  the  mere  occmrcncc 
8{>on1»ik'<Htii  oiiro,  to  tlio  dt'cidwl  t*'inlriicy  to  rccovw}'  inantfostecl 
f  wounds  of  healthy  ai'icries  when  nnooniplicatt.'d  hy  cxtinuLl 
ury.t  Thv  f(.)niiutii>n  vi'tm  «iiviiri»inal  me,  far  from  being  an 
ifkvonrahle  featm-e  in  tlie  progress  of  th«  ca»e,  is  part  of  iho  pro- 
M  of  curt!.  It  Meeai!*  abiituluntly  clenr,  thrrt-forv,  tlint  surgical 
lerference  in  thew  cases  ean  only  hn  jiiAtitied  hy  the  pre«en<'C  of 
irniinf;  symptuiDit ;  auti  that,  by  the  aid  of  simjilo  position,  and 
rbapa  in  appmjiriato  e:is^.i  light  and  even  eompreiiiuoii,  a  ^rvat 
UntH!T  of  arteries  woiuided  In  frncturc  will  Iieal. 

lite  clot  soinclinicA  MjfienH,  and  Kiippiiiutiun  otH'itrs;  and  this 
nin  niay  lead  to  tlic  spontaneous  euro  of  the  injtu'y.     An  inter- 
ring instaneo  of  thin  HjHiiilaiiCdti^  <-jfcti<>n   of  tliu  clot   lAin'  l>o 
kind  in  Onuorod's  Clinical  Collfr^ions,  p.  143,  after  rupture  of  tJie 
moral  artiTy  in  ii  child,  the  pnticnt  re<.^)v*riiig,  with  only  tlw!  lutw 
'  two  toes  hy  gangrene  ;  but  the  limb  was  useless. 
There  am,  Injwevw,  no  doubt,  cttms  in  which  thin^  do  not 
oceod  so  Ikvourahly ;  and  this  uufaronrable  course  tends  in  one 
two  din-eiions, — wither  that  no  anti»ri''ni  fornin,  but  the  extra- 
Bntion  of  blood  increases,  and  thus  the  oiroulation  is  so  far  din' 
]rt«d  that  gnugreno  ii*  cither  euinniencing  or  appears  iinnunent; 
I  tint  Ml  aneurism  has  formal,  and  its  ineream)  calls  for  souio 
Kniim  to  ehcek  it.     If  no  ancuri«nal  sac  has  been  fortued,  and 
w  1,-xtrai  asation  of  blood  is  increasing,  gangrene  will  soon  eonw 
■WiPc.      The  only  way  to  prevent  it  would  bo  to  cut  down,  n» 
BTOinm ended  by  .lolm   Hell,  ujion  the  wnunded  vessel ;  but  tlie 
■pwtunity  will  rarely  occur.     \Vhon  gangiwne  lias  abtolutoly  »ct 
Kkppeors  theon-tieatly  poH.'<ihle  that  a  Miiiihir  pi-aetii-e  might  ho 
ly  advisable ;  but  in  all  the  cases  of  wliicli  I  lutvu  know- 


K^•«Ml 


UiU 


L-Of  lesion  of  tii-toi'ies  in  fiaotur^  lunj'  be  niMcil  a  ease 
,  in  a  diBeuHSiun  at  the  MiMieiit  and  CLirurRical 
I;.  «n  A ]<apcr  by  Mr.  Svmv  (mu  infr.  AxiUniy  Aiieiiridin).    Thu  patitfut. 
.n.  Kux  NU)>]i(>sci)  to  liuvc  uicl  will]  u  (iisli.'e«tji>ii  of  tlit>  slioulilvr, 
wn.1  tfaongiil  to  liorc  litrii  ri'iluoi-J,     &  xety  lar^n  miriiriHin  furuied 
axilla.     The  lunmur  wai  laiU  ujipii.     Gn-al  bS'inorrliU'-ii  rollowed  ; 
was  »i>on  ofacpkrd.  nnd  botli  pails  of  the  ves»t-l  wert-  lit-d.     T!i« 
died.   It  miK  found  tbiii  tfai--  artcij'  hiid  b«t.-n  wounded  by  tfaa  abup 
of  •  fnuitiireof  tlio  nrclc  of  llin  iiutucruH. 

would  ramiDd  t)i<<  rrndrr  of  tlie  many  iiialnniri-x  in  which  art^riea 
wnundrd  in  subcutaneous  Kctioa  uf  teudoua,  and  ilie  raiilj  of 
,t  tDi»«:luuf. 


446  DISEASES  OF  ARTERIES. 

ledgo,  itmpiitntjnn  *>r  d^otli  liiw  hevti  Um  tUternativc  Still, 
rulicf  to  tie  circulation  afionJod  hy  the  removal  of  the  extmva.^ 
blood  mislili  i"  «*»»<>  mris  Ciuum  of  injiirj-  t<>  tlio  upper  cxtrcmitj', 
<]i>tcriiitn«  the  Surgeon  to  cut  don-n  uj>on  the  seat  of  injury,  as  t, 
last  dfurt  to  save  n  [Htrlion  nt  iiny  nile  of  a  hand  in  which  ganjir^iifl 
liiid  absolutely  comniont'tx!,  Tliis  is  a  matter  wliieh  woiilt!  ditjH^ni 
entirely  upon  iudividciil  judfnncnt,  hnmti  upon  the  syTuptoms  of  the 
case  in  hiuid.  In  tlie  second  case,  that  in  nliicli  an  iui«iirisin  liai 
formed  nnd  is  ailvniu-idf;,  lln-  in-atiiK-rit  differs  in  no  resjiect  from 
tliHl  of  aneurism  in  other  eircnniBtaiiws  and  fix>m  other  oaiines.  Tl« 
two  cases  related  by  I>iipsytivn"  arv  well  known ;  one  occurred  inl 
Iit!«  iiwnprjietieo;  one  under  the  core  of  IJclpedu  In  Ijoth,  wmicaN  j 
terj-  at  the  back  of  the  leg  (the  popliteal,  w"  one  of  its  hrancliBs  ncftf  , 
tJic  diviMnn)  had  been  torn  in  a  coinminnteil  fruoture  of  tlie  bonMJ 
of  Uie  leg;  a  pulsating  swelling  fonned  In  the  liam;  and  ihe  SiiT- 
fiyon,  unwilling  t<j  ]un[iutnte  tho  Ihi^^li,  fejiring  In  lay  open  fo  larpc 
ft  cavity  and  inflict  such  extensive  injury  upon  the  seat  of  fractal^  , 
and  being  uiiawan:!  of  the  rt^parative  [toivi-r  of  nature  in  «ich  ai«^ 
cut  down  on  the  femoral  ai-tery  and  tied  it,  BotJt  patients  t^ 
covonxl,  williout  it  bad  symptom,  llie  cows  are  interesting,  snd 
will  iv\)ay  jierusal.  They  bear  a  striking  resemhlajiot'  to  Mr. 
Moore's  ease,  ijuoted  above  (p.  443);  and  it  M'oms  \oxy  prolmliis 
that,  if  the}-  had  been  similarly  treated,  they  might  have  uiidercoM 
a  »l)ont»iietius  etne,  in  tlie  »]iric  inanncr  as  that  and  the  other  cjW* 
there  referred  to  did.  In  neither  of  the  cases  relau-d  in  the  I^*> 
OraUt  vivut  tliore  nil  nnmriwn,  pro|Hrrly  ^vpcaking,  since  suffioiw*  ' 
time  had  not  elapsed  for  the  formation  of  a  sac ;  but  the  clearB'**  I 
of  the  puWlifm  ntniiei-s  it  proiiuhle  that  the  eccliymosis  wm  W^'\ 
jng  to  become  limited,  and  that  a  sac  would  soon  fonii ;  and  tl''' 
appears  to  famish  an  additional  reason  for  waiting  and  wswlun^  J 
tlie  reaulL  When  aneurism  has  formed,  it  is  a  sign  fhal  the  i 
lular  tissui;  is  eontnicti;ij;  npon  tlic  blood.  Tlus  'i&  verj- likelj' "" 
lead  to  deposit  of  laminated  eongnhim  in  tJie  sac.  At  any  f3"'» 
it  is  highly  iniprobable  (Iiat  the  aneurism  will  begin  to  inciW* 
rapidly,  since  the  patient  is  of  course  at  rest  and  llic  liiiih  in 
appropriate  position.  Shoiild  it,  however,  increase,  comprc*sit.in  * 
the  art«ry  abo;'i?  will  l>c  the  method  most  probably  itidtcatiil,  p-^ 
hnpN  with  gentle  compression  on  the  ssie,  if  tlio  fi-aeture  is  suffi- 
ciently con^ilidated.     If  tlic  l^raoture  be  (umly  united,  it  may  <;vai^ 

•  "Siirlns  An^vrisinosquieompliqueiit  lesFnicturas,*'ic.,i^fUau(ilr(iia, 
torn.  ii.  pp.  oai,  ti«.,  I'liris,  1838. 


AUTERIO-VENOrS  ANECTilSJL 


447 


iidTisablc  U)  rowirt  t"  fiHviMo  fli-xiyn.  In  casct,  tiowovcr,  where 
IDiuu  artery  is  woiiudol,  as  well  oa  in  tliose  wln^re  il  is  tied,  llie 
icturv  iiiiitts  v«ry  slowly.  Tliis  mny  lio  noticod  in  tho  caaes 
)m  Middlesex  [loapital,  quoted  above,  and  liaa  been  obsori'ed  by 
npm'trcn  and  ntlicrs ;  so  tliat  tl)"  (nMitinvtit  of  trnuinatic  niionr- 

from  fraotare,  if  it  int^reaso  while  tlio  patient  h  lying  in  bed^ 
II  bo  bj'  oompromion  or  ligutiiru  of  tlic  main  trunk :  and  in  «t£os 
(kt  resembling  Mr.  Spence's,  quoted  on  p.  -127,  tliat  (be  anotir- 
n  lias  apparently  (.■on?>oL'i:liit«.-d  dtiring  tbo  rcposo  necessitated  by 
» fimdure,  but  recurs  on  the  jjatient  resuming  his  aetive  uvocn- 
Mtfl,  tlio  treatment  there  ptu'^ued  (that  of  forcible  flexion)  will 
ry  prolnbly  be  as  Miceeuiful  as  it  was  in  that  case,  Nhoidd  thu 
uation  of  tho  lumi>ur  render  it  iipplienble. 

Antnirisniti  the  result  of  fraeturo  are  not  confined  only  to  tbo 
feries  of  the  limbs,  but  may  form  in  any  part  where  an  artery 
»  suttteiently  near  to  a  bone  to  I«  invoNwi  in  thu  injury.     Tlnw 

Busk  and  iMr.  Curlin-j  have  eaeh  put  njion  recoi'd  a  case  in 
4rich  a  tnininatie  aneurism  tiirnu^l  ujiim  thu  ophthalmic  uriory  as 
consequenco  of  fi-actiu-e  of  tho  ba«s  oftliosknlL*     In  both  oases 

carotid  urtirry  wiw  tied,  and  with  oom^Jeto  success.  See  boloir 
Cal  Aneurism. 

T.  HOLUES. 


|ie»crihi 


ArTKRIO-VkNOCS  ASETIRIgM. 

Under  this  title  aro  included  tlio  fonns  of  anonrismal  dilatation 
f«n  artery  communicating  with  a  vein.     The  merit  of  accurately 
rihinfi  thi^  kind  of  aneurism  is  diio  to  William  Hunter;  and 
[w  tiieir  sub.HUijnfnt.  litudy  and  den omi tuition,  mainly  t"  Cleghorn. 
f  liis  time  wo  have  roeogniscd  two  forms  of  the  dbeaee,  kuown 
avely  u  varicose  aneurism  an<l  «iie»ri»mal  varix. 

1  anoorism  consists  of  a  circumseribecl  oonsecntive  aneur- 
irliich  communicates  with  tlio  arttrry  on  one  side  ari<I  the  v«in 
Lw  the  other ;  the  vein  is  always  tortuous  and  dilated,  sometimes  to 
h"  tnormoil^  extent.  Alien risnial  varix  pn-sents  a  siin|)Icr  condi- 
[■"n.  Adhesion  has  occurrcxi  Iwtwoen  the  artery  and  vein  at  the 
of  cmnmimication ;  there  is  mi  iuterwuing  aneurismal  sac, 
I  tlie  blood  IS  projected  directly  from  the  ai'toi-y  into  the  vein  at 
pulsation.     Here  also  tho  reins  eanneet4.<il  with  the  diseased 


*  iS*d.-Clur.  Train,  vols,  udu  ucirlt.;  soc  alto  lb«  llrst  of  Hr.  Nuauo- 
IMS,  ia  voL  xJii. 


08 


DISEASES  OF  AKTERIES. 


part  ore  greatly  dilated,  und  it  is  owing  to  tho  omb&msEmcnt         ™ 
Uie  circolstion  Uiutt  {irodunixl  tbnt  the  iiijurv  (mmnionly  be<?oniiw  c^wk 
cauao  of  distreBS  to  the  patient,  and  claims  tJie  csiro  of  the  Sargeor  ^^. 

Doth  of  tlicnc  forms  of  niioriii-v«ii<>uA  aiieurijiin  may  orifpn^^c  AC 
trnuiiialically,  as  the  effect  of  violence,  or  epontanoously,  as  t.;i*^h* 
result  of  diwane.  A  trauinatie  nrtcrio-v^iKniA  aii«4iriHm  may  f(>!l<^^  Jon 
a  wound  at  aiiy  part  of  tlie  body  wliere  a  large  vein  ia  in  so  clc=^  ow 
a  juxtapiwitiiin  with  u  larj^o  ar(on-  tliat  tlic-y  may  hv  niintilinir  ^^nw- 
ouhIv  pierced.  By  far  tlie  most  frequent  cause  is  the  unakilr__X]lii| 
pcrfonimnc'o  of  vinii>»oction  at  ihtt  elliow;  but  any  otlior  pui>ctni:^B::red 
iTound.  tlie  impact  of  small  shot,  injury  finm  tlie  fragment  oftr-Wj 
cominiiintt'd  fnictiire,  and  it  i»  said  evon  itimple  oontusiuu,  lavo  ^  led 
to  tliis  condition. 

In  8pontan<«us  arft'rio-v«n«ui»  anvtirism,  tho  communicat^^^'wi 
witli  the  \t?'in  apjiiirently  tollows  upon  the  de*"eIo]>n>eni  of  a  sini  ^'k 
arterial  an curifini  in  tli«  contiguity  of  a  vi-in.  When  an  anciiri  asm 
is  formed  on  ii  large  artorjj  in  such  a  p.arl  of  the  artery  Jis  to  co-^- 
prcjw  a  neighbouring  %-cin,  it  is  common  to  find  that  win  ok:»fi- 
leriiti'd ;  and  in  ttiL'  muM-um  of  every  liospital  there  may  l>e  BO*n 
preparations  showing  tlie  oblitdration  thus  cfft-clM  of  the  lar|5«*t 
veins,  the  vnnsv  cava-  Wmj^  froijiHUtly  so  oettluded.  Bui  i)c<5«" 
Bionally,  in  lion  of  effecting  tlio  closnro  of  tlio  venous  channel,  tJi^ 
preswnri!  of  tlie  anouriBmul  ]>ouch  of  the  tu-tery  givat  rise  to  aliSoiT*" 
tive  ulctTfition  of  tho  coats  of  tho  vein,  and  the  sac  o|>en8  citb**^ 
l>y  rupture  or  hy  uloeration  xuto  that  vein.  Thin  hapjKiiH  <T)i{»ecinIv 
witliin  tho  thoracic  aud  abdominal  cavities,  when  aortic  aneuri***** 
press  upon  the  great  veimus  trunkii  of  the  tdiesit  unit  idxloinen.* 

Leas  fro(|uently,  artorio- venous  aneurisms  arise  in  the  saio* 
■way  on  the  limbs,  and  on  other  [mwIa  of  the  trunk.  Sonutliufl'* 
tliev  occur  lony  after  the  infliction  of  a  wound  which  liad  affect*^ 
tlie  arti-ry,  but  which  had  bof.'ii  jn'rliiip.-^  jdmost  Ibrgottcn,  Tb*** 
Bokitansky  observed  an  axillary  aneurism  of  this  kind  thirty 
yoam  after  a  shot  had  tjiki.n  cfi'cct  on  tho  siwt.  Ilouxf  n-lai**  • 
case  in  which  art*rio-veiious  aneurism  at  llie  olbnw  fonned  f'""" 
years  afUjr  venesection;  and  Slonneret}  Ims  described  an  aiK'urisni™ 


I 


•  Tlie  curliest  luid  movt  coin]ilete  inonu^'nph  ou  tlicsc  fomx  of  aimtriiX' 
Is  duu  t(t  Tlmrniim,  3trJ.'Clar.  Traitt.  vol.  xsiii.  Si-c  ulna  Rokitariik}-,  id'" 
eiiiige  der  wkhligitcn  Krankheitm  iter  Artrrien,  Wicn,  ISAS,  ji,  id  cl  »*<).. 
Ponvr  oil  ArtL-iiiil  I>iBi^Rsc,  in  Tuitd's  CyolopiTilia  of  AfntaiHy;  Nolatoc'* 
Clinical  Lti-(ares,  by  Atk'i; ;  Mayn,  Dublin  3fcd.  Jourtuit,  lOtML 

+  li-dlelin  tie  fAmd.  lU  Med.,  Piivis.  ISiU. 

.;  liuUeliii  de  Med.  «(  CIdr.,  1803- 


449 


mumeation  bettrcen  the  femorj  artery  and  the  v«5n,  said  to 

irw  iir'iM^ii  twelve  yi'^rs  nfti-r  itijiiir  fiviin  ii  uliol. 

Again,  cpoiitaneous  artcrio-venoua  atieiirisra  liaa  be«Mi  deacribed 

Bmii^y  Cooj^r,"  by  Porry,t  and  P«rl«r,J  sflwling  Itio  fvitiural 

eels  in  oases  where  the  dUea^e  coul<l  not  Ik>  trailed  to  any  other 

than  primitive  di^n»u  and  thinnin:;  ol'tlio  uontfi  ot'thuvtM- 

In  the  liighly  interesting  case  related  by  Mr.  Perry  there  was 

tksa  one  <xiininaniaitioii. 

It  is  usually  a  main  arlery  and  it»  oollateral  vein  which  are 

aflV^-lod;  and  it  may  be  readily  un<lerstood  (hat,  from  their 

eoQiigiiity  and  ofUtn  !4U)K>rri<-i:t]  p».-<ition,  tlx^'!  woiiUI  be  more 

riy  to  bfvomo  the  sabjcct^  of  tliis  diflcfised  connexion;  but  the 

iborate  investigalton  of  FoUin  and  Oiiarnnl.j   and  ttie  casen  of 

■rdebati  and  I'ancoastH  ha^o  •ihov,-|i  tliat  d««ply-scit<.-d  vgm»,  as 

rll  iu(  flujierlioial  vi-inx,  may   Inr  l.liiiit  nfToi'^tMl.      In    tlie  case  of 

.  Fallin,  a  conimutiication  betn-ecn  the  bracliial  artery  and  a  dec]) 

wna  diH^iiiiM^i  diiriiig  life,  and  Hiib.trijiKmlly  |>r<>v<>d  by  the 

^Hiloo  of  JL  OlianiaL      SehotCUl**  lias  seen  a  similar  connuxion 

^^■■n  Otn  rwlial  artery  and  the  (.T|ilinlii-  win. 

^^Bo  symptoms  of  tltese  two  forms  of  arterio-venous  aneurism 

»ve  donio   pwuliarilivs   in  common,  duo   to  llio   cominunivatioii 

tween  arterj'  and  vein.     The  njost  nharaeti^ristio  is  a  vibratory 

HU,  which  rvKiiItx  from  Itic  imj)ulHion  of  the  artvrial  blood  into 

Iial«nt  ajwrture  of  die  vein,  there  to  mingle  with  tlit;  venous 

■n«iil.     Tlio  pnMtvr  tonKton  of  the  arlorla!  than  tlio  venous  wail, 

A  the  greater  toroo  of  iJie  art>>rial  liiiw  of  blood,  rausts  a  con- 

)Mm  injection  of  art«rial  blood  into  the  venous  tumour ;  but  Ui« 

Untioii  of  tlH>  artery  i>r«d«c>»  a  syni-hronous  ini|nd.'«  in  the  flow 

lliB  blood  through  llie  tumour.     Ueuco  the  peculiar  vibratonr 

»»ctcr  nf  the  thrill,  which  iit  otherwise  vontiTiuous.     The  ear 

•*•»*»  a  harsli,  bii7.xing  sound,  which  has  been  variously  comparod 

'  iW  of  a  i^w,  a  tile,  u  l>fO,  lli»  hi»»iii;{  of  burning  nii-tal  plunged 

fctold  water,  and  sunihtr  noisea.     This  sound  too  !b  continuous, 

Wjougti  monwuimly  increawd  during  diastole     It  grows  fainter 

Iwing  propagattxl  along  the  artery,  and  at  some  distance  from 


■  Omi^t  Hoijiitil  RrpnrU,  vol.  v, 

I  ittJ.CMr.  TowM,  vol.  \x.  :  Tod^t  Cgch^..  "  Arleriea,"  p.  U9. 

i  /tvUrtin  dtlttSoe.dt  Chir.  rats.  Ut.  V. 

j  Jtutlttin  dtta  SiK.  Anat.,  1(<31. 
V  Frryiuina't  tl'iiullmok  nf  Surf  fry.  1903. 
"  S«]»i>ilin.    Me/kitiirdiger  Fall  tiner  aaturwiiatUelun  Vm*nsf'ch%ruUt. 

VOL.  UL  0  0 


450 


DISEASES  OP  ABTEBIES. 


tlw  Aneurism  io  which  it  arises  it  seemH  !nt«-inittent,  the  l 
diastolic  sound  only  being  tiitm  huanl.     This  »ntm(l  mnr  '><■  to 
as  to  bf  »u(li1ilc  hy  a  perscm  stoniling  near  Uic  jMiliciit ;  but 
is  exceptional.     It  may,  liowcvor,  ulwavs  bo  ilUtinctJy  bviird 
tho  Ht4.>thoftooiic,  nr  bv  tJie  iiakLil  ear ;  and  ibt  continuoiu  cliai 
sharply  <Iii>tingui«Iioti  an  nrIi.'rio-veiiou8  from  n  pore  arterial 
■itin.     (>nn.«id(?ral)lo   dilatation   of  tlie  veins,  a  third  »yni)>4(ini, 
cunsoijuont  ujwn  tliu  obrtniL-tion  of  tho  venous  circulation  bj 
Mttrniico  of  arterial  blood   flowing  in  an  oppotute  direction, 
upon  tito  gitncral  incrciLso  tlius  mado  to  llie  quantity  of  bUKid  wfai 
Uiovein  muHt  carr}*  towards  tlie  hvsirt.     'I1ie  extent  ufthisiliU: 
variofl  according  to  the  me  and  importance  of  the  vessels 
It  is  moftt  markt^l  in  tiu<  \ovtvr  liinliN,  wlivru  gravity  aidj*  io 
creasing  the  obstructioii   and   cansetjuent  teiid«t>oy  to  varii 
Hero  the  veins  have  Ikvii  doiwnbod  like  knottud  ropes  ImkiwIIi 
fikin  by  Porter,  Peny,  Laugier,  and  others.     In  a  case  wben 
tviiipomt  v*nwi'l»  wci-c  iitlcctod,  and  which  Mr.  Muuru  Tsry 
described  to  the  Medical  and  Chirurgical   Society  of  London, 
a  briof  1>iit  valuable   comnnmictition,  the  veins   vroro 
diUtiil,  :uid  ptdimt«d  so  .itmngly  a«  entirely  to  sitnulate 
during  tho  operation  porfonnod. 

llii.i  jitdsutioii  of  the  votnii  is  a  fourth  imjtortant  f^rmptoci 
deserves  to  lie  borne  in  mind ;  Lecjiiihe  llie  Surgwii  may  be, 
tins  been,  imluM!<l  by  it  (o  place  a  ligature  round  one  of  Um 
thinking  it  to  bo  an   artery.     William  HuDter  notlood  tlat 
iirUTies  below  tho  point  of  common icatioD  beat  more  feeUy 
iu  the  healthy  body ;  and  naturally,  »inoo  a  piut  of  tlicir 
Mipply  of  blood  is  directed  into  tlie  vein.     But  thts  fiymjitom  ii 
always  obsarved.     In  old-sttHn<ting  twww  a  rcnuu-kable  ciinilitioa  i 
dilutiilion  is  observed  in  tho  artcrios  above  the  varix.  They  beoooo 
larged,  tortuous,  and  thinned  in  structure.    Indrod  tho  rcina 
tint  arte rio- venous  aneiu-isni  awumo  more  or  leas  of  tlie 
character,  and  tlie  art^-riiu  approucli  somcwiiat  the  tj'pe  of 
Tliis  ha.4  Ixjcn  ubHcrvod  hy  all  who  have  ilt<MTi1ied  lltcoe  aat*. 
lias  been  well  suntinuriMxl  hy  liokitaufky  in  his  monogmpli  <at 
jiatlKdog}-  of  tlw  arteries.     1  have  now  under  my  ear«  a  mio 
vnnc^  in  years  in  whom  n  disoasod  comnmuication  exists  Ifotvri 
tJie  Hujii-rficiid  veins  of  the  abdonton  and  an  arterial  bnmolii 
l>ably  an  anaslomotio  vcsw«'I  communicating  with  thu  ntj 
e|»igaAtrio  and  internal  manmian-  trunks.    The  veiiw  are 
dision<Ied,   forming  a  convoluted   and   tortuous  tnasa, 
fi-oui  Llie  lowvr  part  of  tlie  abdonieti  from  Uw  tmret  Io  the 


AniERIO-VENOUS  ASEURISM. 


451 


I  irhcrc  ttioy  (wmmuiiicate  with  tlie  left  mphena.    All  the  timvf.  n^s 
are  preaeut.     Tlio  condition  lia«  esiKtud  for  iiciirly  a  scon  of  years, 

•and  baJf  oiiiiwvl  littlo  iDconvenicRoe. 
He  varioo«o  anourism  difft-n  from  tJio  anctirismal  varix  aa  ve 
have  fvn,  in  thai  il  jxixsai-ses  an  aiieunsnial  poucli  which  iM  inttr- 
tnediaK  betwoeii  tho  opcuing  of  artery  and  vein.  It  is,  of  course, 
impcirliuit  in  iiractioo  to  rwrtgniao  thin  difitirnnoc,  Hn<]  mark  it« 
Matecoliar  symptoms,  niis  circiimscrilxid  atiGurismal  tnmour  will 
Vlto  found  of  various  ahe  and  density,  ixnconlinj;  to  Ihc  site  luid 
dnmlion.  It  rarely  attains,  however,  any  considerablo  sjjte.  It  ta 
^Sooted  ill  (Ih!  xnmc  way  an  jiiire  arterial  aiioiiriaiiiH  wlntn  the  artery 

»U  OODipressed  above  or  helow  it,  and  tlic  ear  detects  Uie  bluniiig 
*<>Uoil  i>f  ai)  aiieurimn,  iii  addition  to  tliat  nijiping  bruit  doscribvd 
*s  llie  FMHill  of  the  venous  conitniini cation. 

In  hiitli  fonnK  of  ariurio-wiiouM  aiiuiiri^m,  it  may  bo  xaid  that 

*■«  find  a  soft,  fluctuating,  knotted,  and  imjwrfectly  circam8.-ribed 

*^lwiliinixni)i  tumour.     It  ean  bo  emptied  by  pn^KHure  iijMin  tho 

'•uiwar  itself,  or  the  arterj*  leading  to  it.    It  lias  distinct  pulsations; 

•^t  iIhmg  are  limited  to  a  very  amall  part  of  the  swelling  at  llio  level 

*•  tJie  [loint  of  comnumicatJon  between  the  vessels,  gradually  le- 

^Oiiii^  extinct  in  the  ratio  "f  iiiftamH.t  fnmi  that  point.     In  tliis 

'^  i*  distiii^ished  from  arterial  varix,  or  cirsoid  aneurism,  which 

*f*  pnlsation  of  (-((ual  iiiteiwity  over  tho  wholo  extent  of  tho 

;  it  may  be  further  distinguisliod  from  tJiat  afli-etion  by  tho 

or  purple  colour  of  llie  tumour,  and  by  tho  tortuous  dilatation 

*■  the  veins  loading  to  it.     Fmihcr,  to  distinguish  it  from  arterial 

'^rii,  to  which  it  presents  »o  many  points  of  cxtoniid  resemblance, 

^  teay  lio  aitded,   lliat  while  in  both  auscultiition  detects  a  loud, 

'^'fHDg,  continuous  bruit,  this  soiin<l  is  hoard  over  tlic  whole  Gnrface 

**!  lliu  lulcrittl  varix,  but  only  at  the  point  of  cummunieation  in  tlie 

^terio-venous  aneurism,  or,  if  tt  Ruliatce  tlicrefrom,  It  can  then 

^y  be  traced  along  ttie  courito  of  the  artery,  and  beeomott  gra* 

^'"•lly  extinct. 

Tin  treaimont  of  niienrismal  varix  and  varicose  aneurinm  mu.it 
^nentioncd  sepamtely  ;  that  of  ancmrismal  varix  presents  great 
^Bnltim.  In  many  ea^cs  indeed  the  <lit<ca.so  nianif^Htn  but  little 
Mtnn'  to  advance,  and,  where  tliis  stationary  condition  exists, 
M^;ieal  interli-ii-nec  may  well  hti  omitteti.  In  Mr.  Moore'ft  etuo, 
'Urtfr-aix  years  Iwd  elapsed  beforo  any  o[ieration  was  ncocssary; 
Md  Hunter,  t/lc^lwirn,  I'urter,  aiul  indeed  all  other  authoriti^  on  this 
nbjcct,  have  seen  this  occur.  It  is  especially  tho  case  in  tho  upper 
•xtnouty.     Ill  tli«  lower  limb,  liowever,  the  disease  may  tjxtend  .so 


453 


DISEASES  OF  AKTERrES. 


ppontly  OS  to  <Je*f,roy  tliu  use  of  the  limb,  or  t«  tlirratcn  thp  d 
tioii  of  thf  patit'nt'§  life  bj-  haimorrliagc,     lu  tlic  wise  rcflrrol  to, 
iw  n'liiKul  liy  Mr.   Hftirj,  the  IluiiU^ian  lij^lure  wuk  twice 
formtnl,  but  witliont  I'ffi-ctiiig  the  cure  of  tho  disease     In  a 
in<'iilii>n«i  by  Mr.  liraiiiiby  D«>i>er,  it  wiis  coii.'udvri'd  iKHx-»!*ary 
ani]>utato  t)io  leg.    Sboold  tho  SorgeoQ  now  be  called  upon 
tn>nt,  by  ()[H>rutivft  iiiciins,  iiii  itr((!r%'  m  iiRWTttil  !ii  oilhiT  uf 
extroQiitiot),  ho  would  probably  atU'mpt  to  obtain  tlie  closuro  of  the 
artorinl  ii|ii'rt.urc  by  iII<lire<^t  [inDMiim  o»  the  nrtcry  «b(>v«  tl>o  coibih 
tnoiiicatioi].     The  aso  of  direct  prcfisure  has  rarely  Itecn  of  an" 
gttod  pft'ocL     Tlwjn^  are,  hiiw<!vcr,  two  proo*ntliti;p  wliiirh  arc  more 
pronuBing :  the  injection   of  coa^Iating   tluida  at  the  site  of 
<lisoii]>v,   iipjiiicid  Ciiret'iiily,  willi  thv  niinutu  prouauttons 
for  the  success  of  thai  plan ;  or  ligature  of  tJie  aiti-iy  above 
bolow  it»  (iiK'rtuiM   of  oonitnmiic^tioii.     Ilcfiiro   iinploying  oJtln 
method,  it  would  probably  Ite  dosirable  i«  rwort  to  tUffital  or  instrtK 
montst  coiiiprcwtion,  or,  if  tho  [Hwitiou  aliowod,  to  forcible  HcxiiuL 
But  tho  oonntant  [laHeuige  of  the  arterial  blooi)  llinmgh  tlw  upejliireifl 
rosidting  fmin  tho  artcrio-vcnous  comuiiimcation,  an<i  the  ahi^iifiV 
of  any  detined  mc,  i»i|>e<l0  tho  funnali»n  of  the  tibriiii)u.«  dcjuuit  ti;^, 
wliicli  tlx^Ho  uicthodx  owe  their  xneccss ;  and  ca^cs  of  aneuri«n 
vai'ix  of  this  form  are  not  very  aniviiablv  to  t«!«lmwit  by  luJiP 
eomproK«ion.     An  interesting  case  is  recorded  in  tlie  Pnx^Jinfl 
of  t!w  Anafomimt  .SiKuit/  nf  Paris,   for   1S58,    in    winch    imlinHit 
comitrcssion   having  boon  carcfiilly  tried,  but  without  sui-cc**! 
li^itiirc  was  ajuilifl  by  M.   Kubei-t  Hbi>\i'  and  below  the  nfvt 
in  the  arlcry.     A  few  eases  have  boon  recorded  of  uneui'i.tmal  v«n^* 
within  the  ."Icull.'     In   tmo   of  thew'.   recently,  cuinprrasi'W  "^j 
app)ie<l  over  tho  carotid,  hut  ineft'ectuBtly ;   in  tliis  case,  the  W^ 
ternal  eamlid  arlery  cintiinimieiiti-d  with  the  cavcmouB  stnux ; 
death  occiuTcd  as  tho  result  of  profu-se  haemorrhage  from  tlw  IW*^] 
In  such  ea.H(«,  of  ooimw  oiily  tlio  Hmiterian  Itgaluro  is  possible;' 
where  the  artery  is  more  accessible,  it  is  obvi<iunly  more  thuinhle 
to  ai'ply  a  liffutiiro  alwve  und  below  the  diseased  eotnntanicatioii.     ^ 
The  treatment  of  varicose  aneurimu  if>  oonicwtuit  tliflVroiit  iilH 
kind;  for  licti'  ii  sat'  intervene*  between  the  jirtcrv  and  the  v«n, 
but  it  is  similar  in  principle.     Here  iihio  direct  and  indirect  cum- 
preasion  have  been  iar;p.ily  tried,  but  have  not  yielded  satjsfiwiory 
resultit ;    nevortlioless,  digital   conijin;.ision  nttght  ho  employed  in 
the  leas  aggravated  funn,  not  without  hui)c  of  euru. 


i«na^ 

tireofl 

(I'jtiir^H 


•  BulUtin  dt  ta  SameU  AnaUimiqat,  vol.  xxix.  p.  299 ;  roL  XXX. 


AUTKUIO-VENOUS  ANEURISM. 


SJUHild  it  be  necweary  to  np]>\y  tlto  ligature,  it  is  reqiiisite 
r^eet  the  method  of  Hunter  in  favour  of  the  ancient  prooecdin^ 
Ti»  moot  Himplo  pliin  io  Ut  \»y  n[>en  tlio  sue,  trnoc  it  intit  tlic  artery] 
nd  having  exposed  tlw  aperiuro  in  llie  artery,  tor  whifh  piirpost 
:  i' c'liinioiily  iw.-wiwury  In  flivido  tln'  nw  trunM(T«'ly  on  a dirwtor,! 
en  to  apply  a  Ugntui-e  aliore  an<l  helow  the  artorin)  o|)eiiin^.  TIiIa 
«>i1)ih]  in  morv  Jiiiiipli;  than  tliiit  which  hius  Ik-cii  fmphnod  by  Hotix 
V>«j  I'Vrgusson,  who  liavo  en<loav(>nred  to  isolate  ihi'  aru-r\',  ami  rt>: 
.Un-«  and  below  witJiout  opening  tho  kdc  at  all.  This  is  tho  moro 
i:Scatt,  that  tlte  artcrj'  heJow  its  ytalnt  of  con)  muni  cat  ion  in  iiniall, 
nd  iiarrouti<I<-<l  by  Tviiis  dilat«d  and  vIoMtly  packcx).  Un  tho  other 
•Kxitl,  it  ia  five  fi-om  tlie  ohJ4»ction  attaching  to  tho  ])Ian  timt  dfi> 
ibed,  orisiiig  out  of  tho  danger  of  putting  tn-o  lignliu>.-(f  clow  to 
MB,  and  at  a  )ioint  whore  it  ia  sunvundod  by  diluux)  veiiiA.  In 
ii)"  ca»o  tho  operation  ia  peculiarly  liable  to  one  of  two  secondary 
iikiits,  lucniorrhnge  aiid  gniigroiio :  hainorrhuf^  from  tlio  purt 
of  t4w  artcri'  above  the  sm  whoro  it  is  dilated,  thinned,  and  gives 
nao  to  nnmorouH  oillatt^ml  bmnchi-* ;  and  gangrniK'  of  tho  liinh 
Wlow,  wliich  perhaps  ahre.-Mly.  before  the  operation,  was  cold, 
WiQinbcd,  and  «ilemntoitfi.  Tho  injwtion  of  a  weal:  Kolution  of 
jwdiloride  of  iron  has  been  employed  by  Serrea  and  Jobert,"  Vel- 
fwijt  ond  Valk'tt«,t  twice  with  perfect  »ucoc»«;  once  producing 
(Kpporation  of  (lie  sac,  followed  by  ciire,  and  onoe,  by  M.  Vi'ljH-au, 
■effi-itnally.  Tliwo  facta  anj  in  &vour  of  this  method  of  trentmcnt; 
tBul  as  the  Mifi'jnianlH  at^inat  tJie  accident  of  i>ii|)piirati<in  (ira  more 
^nfnlly  studied,  the  plan  may  recommend  itself  still  more  strongly 
*»  tl»  .Surgiy>n. 

(ialvano-puncUiro  has  been  employed  by  Bosse  and  Capolctti, 

« BoMo'n  cwo  two  stJ^el  »i'«dlea,  connoded  wilJi  thirty -two  pairs 

*■  pJranic  platos.  were  introduced  into  the  ancurisinnl  tumour, 

TftaJmsI  liiere  for  «igliu«n  niinutoit.      Tho  cure  wiLt  completed 

t«n  days.     In  Capdetti's  case  tlie  needle  was  introduced 

suppuration  followed,  and  nltiinatoly  •  cure.     M.  Debout 

also  nx»rd«d  a  suocesafiil  caso.J 


[n»IlfHn  -if  fAt.ul.  At  Mid..  IflU. 
'  TratlMuoat  dc  I'aaaTiteui*  aitmo^eineux,"  BtilUfyt  it  tAoademit  <b 

IHJM. 

|(.w.  <fa  xei.  p«Hf,  Mar  39,  i8ao. 

ttVnihor.  Ila»dh.  d«r  OMr^  »oL  iii.  p.  821.  Cinicolli  tulta  Klellro- 
.■ftid  tmm  Jegli  AiitKriani,  Cromotut.  1860.  Debout,  IluUttiit  d* 
Liyar,  1M7,  p.  1:23. 


464 


DISEASES  OF  AltTEniES. 


Onisom  AHEunigM,  and  Anecrism  bt  Akastohmu. 

By  cirsoid  an«iiriam,  or  artvrial  viuix,  ts  nndentood  a  t 
disciuto  wliicli  oinKiMtN  in  n  siinultHiit'ouN  (■Iim^tiim  tin<l  dll 
of  an  Brterv.  Tlie  Btnicturo  ofite  wall  cxhihiu  in  llie  iiegiiu 
altorntion,  ulilioiigli  Uic  cuhU  boctiinv  tliiniwd  during  the  (irof 
tbo  eulnrgenient.  It  will  bo  oliscrvod  that  this  k'sion  in  not 
indudod  in  ilio  Uirm*  of  tlio  (Minilion  \vhivli  wsm  j^ivcn  of 
ism,  niul  recent  authors  have  agreed  tlmt  the  diwaso  is  imp 
dciioniiiDitvd  (uiouri«ni ;  hi^iw  it  lindi  no  plaot-  in  tho  fiiwt  i 
monograph  on  that  suhjont.  But  both  by  ilc>  chanu^tcr  and  m 
dtlo  it  daiin^  our  coiisidoriitioii  licri\  i 

It  is  oK]H>ntally  the  niii^dlc  coat  of  the  artery  vfhhh  b  | 
when  tliu  ]>rooo«s  of  thinning  contmcncw.  litis  Htructiirftl) 
pale,  tmiif  and  tiun,  ho  tluit  tlie  arl«ries  look  like  thin  tmih 
dilatation  is  cummonly  m^ual  throtigliuut  the  circumfismice 
artery ;  hut  in  the  more  tievere  ciu-eH  the  artery  m  f|frt«tlj:  i 
and  preecnta  unequal  sacLniliu*  pouches,  whioh  tav,  in  tnM,  m 
true  aiiitirisniit,  prnjt>d.ing  UMinlly  towards  tlu^  Miriiim  of  tb 
As  the  artery  clongatn;,  it  hci;oin<.tt  tortuous  and  ^r|>entine; 
timcA  even  Kpiral.  The  <ii9wii*o  is  nir«Iy  oirvttniwrilMxl,  bat 
commonly  aevernl  trunks  and  their  branches.  M.  Drocn,  1m 
has  recently  described  a  case  of  i>erfoctly  circumscribed 
aneurism  of  the  scalp,  treattxl  mieeeiufully  by  tl»e  injection 
chloridt?  of  iron.*  It  may  occur  in  tho  uterios  of  the  Mb 
and  Cruveilhier  lias  rejiorted  a  remarkable  ewe  of  cirsoid  an 
of  tho  external  iliac  artory.  But  it  is  more  ospcciaily  fretji 
tho  arteries  of  tlie  scalp,  and  in  tliia  situation  inoro  in«tano( 
been  rccortled  than  in  all  tlio  otlier  parts  of  tlio  body  taken  tu 
Originating  usually  in  one  of  the  artcri4>s  of  the  RCal|>,  it  i 
it«olf  to  the  branches  of  tho  otlior  sido  of  tho  head,  and  may 
implicate  tlie  connGotod  vesAela.  ()ti  tho  one  liand,  it  nu 
into  tliv  capillaries,  widely  dihiting  tliem,  and  aiToaUng  ei 
terminal  veins  in  its  miu-cli ;  or  on  Uio  otiivr,  hot  in  •  I 
degree,  it  may  affect  by  retrogression  tlw  larger  branclw 
wlticli  the  artrrios  of  tlie  acalp  arise,  passing  wen  into  ihi 
tida.  It  is  tlius  that  it  changes  somewhat  its  aiiatimiituJ  i 
ten.  The  venous  capillariwt  and  trunks  bvoomo  aifeclM  b)- 1 
ttfiiMion  of  tlicdiKcaso,  and  the  art<?rial  network  l)o<xmiinp  big! 
morbidly  developed,  tliis  form  i»  known  by  tlio  naoio 


•  IMUtin  (b  Id  So<h4U  dt  CUnuyU  dt  Pari*. 


k 


CIRSOID  ANEURISJL  455 

2ijr  tmcutwrtOfU.     Ilie  palhalo;;icnI  condition  an<I  tho  priiwiplcs  of 

treatment  aro  eMontinllv  Uie  same;  liut  when  the  ducsse  is  Heatud 

ill  tlio  larger  urU^rJul  lnink»,   it   la  mmmmiiy  known  as  cirsoid 

MAeuriBm ;  when  it  extenda  into  tJie  network  of  <!a[>illiiriDR,  it  Is 

Icnown  as  auviiri-Mn  hy  aaantomosiii,  or  raiTomoso  anctn-i^m.      It 

a  twebt  most  freijiK'ntly  the  &u|ierficial  temjjoi-al,  tlip  [losterior  nu- 

s-icolar,  and   tin  occipital  arteries.     Commonly  tlio  siuroimding 

ftMHiM  Hiiflbr  but  littlo  injm'y ;   hut  nontPtiiue.t  tlie  Mitjciilantintis 

C^^Dular  tissno  may  be  atropliivd,  and  the  skin  dangerously  tliiiined; 

^t,  o)l)i-r  tintcA  tlie  suH  parla  may  ha  thickened  and   indurated  ; 

somrtimm  tbo  bonwt  an>  grooved,  or  wen  perforated. 

Hw  naiueei  whidi  give  rise  to  clntoiil  aneurism  are  not  appii- 

r'^wit.     Oocauionally  its  origin  has  boon  rcfi-rred  to  a  blow,  or  to 

•~VK  injoT)'  of  a  congenital  ere(H.il6  tiitnotir ;  more  often  no  eauoo  oan 

bo  n>ign«d,  and  it  is  not  m-idont  wliy  the  ecnl]>  sliouH  bo  the  cbosun 

1X^1  of  UtiH  tiiMKute.     It  may  be  notiin^d  hore  that  tlio  niajoriiy  of 

•■•^Ws  MOOT  in  pereMia  whoso  ago  varies  from  fifteen  to  thirty.     Tlic 

"^i^Boids  of  tiie  di>«>aM  can  hardly  bo  a  source  of  di(KoiiIty,  ior 

VM^y  Mrpctrtino  and  pulsating  character  of  tlio  turaom"  afl'oi-d  a  dis- 

*'*'^'"liing  "igii-      Tlio  iiiuntKT  of  diagiioving  iJiis  iiftocti<in  I'rnm 

^■^^eoeo  aneurism  or  anourismnl  \-arix  has  been  mentioned  in  the 

"St  Mx-li'>n.     lint  where  it  !«  iwwociatf<l  with  <IiIatalioii  of  tliu  veins, 

**>*»  dilKcuIty  may  arise  in  dislingnUhiiig  it  from  the  so-called 

*''®ct»l«  tumour,  or  tflcangt^icctanijt,  from  whtoh  it  i«,  however,  stJII 

'''♦tingiiislKx!  by  its  pulsations.     Sueli  caseo  liaTO  been  roconled  by 

"®U«tan,*  by  Dupuytrcn,t  and  others. 

Ilto  treatnumt  of  this  disease  eomnioiily  offers  great  difHoultiea 

"id  many  risks.     Tlic  frcqncncy  with  which  direct  tiiiliire  hiw  fol- 

"Weil  various  proceiliires,  ihu  yet  greater  fretjuenoy  of  rela|»e,  and 

w   onastoml  fetal  termination  of  oporationa  which  have   l)een 

""^denaken,  aro  roasons  for  caution  in  dealing  widi  diiH  disease. 

UiiIm!  there  is  c«t»o  to  fear  that  by  its  extension  or  by  it*  wv 

*^y  it  may  prove  fatal  to  lifo,  it  Ih  commonly  tlie  more  prudent 

CWne  to  abstain  from  operative  intorfcrence.     Cinwid  or  anasto- 

■WiBg  anvurium  i^  not  always  n  !u>ur<.x!  of  iinminent  danger,  and  it 

■ay  exist  for  many  years  without  any  other  evil  effect  tJiiui  that  of 

innarenicmv ;  sui<\,  iiid<«d,  in  some  of  the  least  unfortunate  easw 

illaato  continued  after  various  opentuonR.      Even  wlivro  exttn- 

ii»  and  Kvere,  it  cannot  idwaya  be  treated  with  advantage. 


•  P«tktaii.  CTiaifW  ChiruryieaU.  Paris,  IHIt),  vol.  ii.  p.  00. 
\  Dapu>tr«n,  Lipnu  Orala,  Paris,  ItiSi),  vol.  t.  p.  iSk 


456 


DISEASES  OF  AHTEHIEa 


Tito  Bimplest  meUiotl  of  troatmeDt  ie  by  coin)trp<«ion ;  bat  Ihif*^  ^ 
uU'i  liic  mrwl  iiidr«vt«ial.     I  am  i»>t  a(H(iijiiiilitl  witli  any  paw>        '^ 
nhicli  it  baa  proved  successful,  altbongti  triaU  havo  been  recorf^  ^ 
by  Dnpuylrcn,  Uoberl,'  iirni  HrtHliv-t      if  I'lillinlioii  \w  ilwiix^^^sli 
liltlfi  moro  nui  bo  (lone  thnii  to  pr(ivi<ic  a  metal  covering  to  protf-  .^^^^ 
the  nllciTtod  [lart,  wliuru  Uiv  locAlity  inUniti  ofimcli  n  pruvivioii,         tx 
by  bandaging  to  aflorJ  local  support,     Tlic  ligadire  of  th«  brancl^^it 
Jircrtiy  leading  to  tlio  afrt-wUtl  part  bus  been  ufti-n  tried;  lint  tl        lis 
alao  bail  rarely  sucoceded.     In  a  case  in  wbicb  UreHcIict  tied  t  — In 
loinponil  urti-iy  in  a  girl  eightrun  ycnrs  of  agv,  fur  a  sevvrv  form        of 
tho  <UM>a.ie,  dt-iitli  h-oin  ]>y)i:iniii  took  place  on  (lie  fourteoiith  day  ^.( 
tbo  lig»turo  lianng  Imwii  carried  tlirougli  and  not  round  tlie  vcm     "jI. 
Miu>la(-)ila»  ti<Kl   tJift  teiiipond  nrtt-ry,  alfuj  willuiut  siiccefiH,  a~^<l 
IbllowGfl  it  by  ligaturo  of  tlie  common  carotid.  §     In  a  ]>atic3it        of 
Dujiuytreti'ft,  botli  tbe  benijxiriLl  and  ocoi]>iUd  arlericN  bud  been  &-~  "^ 
unsUL-ceuifiillv.  II      Gibson  tied  tbo  main  braiicbi-«  of  tlie  tcmipo^:=~iil 
and  (iccijiitHl  ortory  fur  »  niniilar  wm.-  iimliV-vtuiilly.^     Tli«  roooi^"'!* 
of  tho  results  of  tliis  proceeding  aro  not  in  its  &vonr. 

Tlift  lipiturb  of  tbe  oxtunial  etrotid  ban  been  pcrfornicd  for-  » 
cirsoid  anem"ism  of  tho  scalp  by  Maisoniiouve."  JIo  tied  the  ri^^''* 
cxti-rnal  carotid  for  it  cinmid  lUivuri^ui  of  tbo  right  tvm|"inil  arl^  ^ 
occurring  in  a  woman  thirty  years  of  age  two  months  after  a  bio  "^■ 
Tliu  p;iliciit  wiKs  Mtilli-riiig  ainitu  jiain,  and  tho  di»«aM  lx-giniii:^'j> 
rapidly  to  extend.  Beeidea  tying  tlie  external  carotid,  he  pvt-  ' 
ligature  also  round  tlio  Biijwrior  thyroid  artery.  I'ulwitioii  ceon.*  "i 
the  tumour  diminished,  and  all  went  well  for  lIic  first  lliree  weefc**^ 
Sceondary  hic-m'trrbage  foUvwod  Hio  eoporatiMt  of  tlw  ligatnrr,  av^ 
Mai!<omieuvo  titx!  .luocewiively  the  cnnimun  and  the  inU-rnnl  oarofc-* 
artttrie*.  Tho  latter  operation  was  followed  by  hemiplegia,  aa^' 
after  tliree  da}%  by  tieath.  The  brain  #ulMt'4uioe  of  the  right  hcnK  '' 
vjilK^ro  was  found  to  bo  deliquescent.  This  caso  had,  tbcrcforo,  *■ 
very  iinforttuinte  termination ;  but  it  is  wortlty  of  okjHMiiul  not' 
because  it  i»,  perhaps,  tlie  only  recorded  instance  in  which  ih*' 
exteniol  carotid  artery  Las  been  tied  for  drfuid  aneurism  of  the 


1 


.     •  daz.  Jet  IlijiiUmx,  IRQI.  p.  ISO. 

\  Limcel,  ISaf^-n,  vol.  ii.  p.  SfiH. 

;  Bi«4ohet.  Mimoirt*  Chirurj^icttiu:  tur  Im  d\fftr*nt4*  itfiet*  dA»itnmn,\ 
l*ai-is,  |h;u.  p.  h\. 

§  iMnctt.  1827-8.  voL  i.  p.  TT8. 

tl  Lf^ini  Omlrt,  loo.  yit. 

ii  Inatitutrt  and  I'raHif*  of  Suiyety,  Tol.  i.,  Philadelphifl,  1635. 
«*  Bulletin  dt  la  SodiU  dt  Mtdtaat  lU  Pari*,  I6b\,  ToL  L  p.  400. 


CIRSOID  ANEURISM. 


457 


tp,  aai  Ixwsiisc  tliat  protiixling  wotJd  ap])car  on  nnat<>ini«i] 
(Tutindfi  to  lie  the  best  oalruIatM  to  arrL'st  the  circiiIatioD  in  ihe 
sflbctcfl.      I'rof.  Brun»,*  wlio  liius  given  grcrat  utU'iition  to  tliis 
>jed,  |MintA  out  that  ibo  ligntiiro  of  tho  oxlornnl  oaroLids  bi  tlie 
ing  bt'st  calculated  to  ciit  off  the  supply  of  blood  to  anmir- 
Li  «r  i1m>  ftcalp.      fie    UTgL-n   time  tliu  i-M«t'nid  CitrotidM  of  Infttt 
should  he  ligahirixl  in  snob  oasn,  and  certainly  where  it  is 
y,  fmiii  repejitixt  htcwl  luumorrluigtM  or  tiiri;utj:-iii'd  niphire, 
to  employ  serious  surgical  interfenmoo,  the  ligature  of  ono,  and 
mor©  of  the  two  ostormd  (sin»lidji,  would  k-wt  fliTowt  the  tltmi- 
in  tbo  supply  of  blood  to  Ihe  arteries  in  the  scalp ;  for  then 
lyilie  Hiipm-orbiljii  iind  frontid  branclivs  of  thv  int<!riial  CKrotid 
renuin  capable  of  supplying  blood  in  tliis  direction;  imd 
th(^  di^^flM}  were  sentcd  in  the  forclioad,  their  inlhiiinco  nonl 
lly  be  ft-arcd.     PoBteriorly  the  biwxl  would  reach  Uie  scalp  only 
:|:!i  the  wui»to[DO«iii  of  the  occipital  artoricK  witli  the  nnotixiing 
ical  bmnohea  ofthe  anbclaviaii  nnd  the  muscular  twigs  of  tlio 
ml  arter}' ;  whilst  in  fi-oiit  some  further  amtdanev  woid<)  be 
^Wiliy  tlie  coniii'-xion  of  the  inferior  iJiyroid  branch  of  the  sub- 
wrian  with  tbo  sii(jorior   ilnToid  branch  of  the  carotid.     This 
ight  nut  be  unworilij'  of  the  eoi  mid  em  I  ion  of  Surgoonit  in  future 


Jndging  from   nnntoniieal   datji,  the  ligature  of  tbo  oomrnon 

*i)tid  artery,  while  it  ia  |)regnunt  witli  greater  dangers,  offers 

vver  adviuitiigtv  llinu  the  npplimtion  of  the  same  proocdiira  to  tlie 

teroal  carotids.    It  has,  howe%'er,  been  praetiaed  in  at  leii«t  fifteen 

I,  bill  it«  tUKXiwMies  have  b«en  few.     Tlie  only  superiority  which 

o^cr  the  ligature  of  tlie  tfxtt'mal  caroti<i  is  by  shutting  olV 

ni|>ply  tlin>tig)i  tbo  branches  of  tlio  ophthalmic  artery ;  but  the 

'w^and  numerous  anastomoucx  of  tlie  onrotid  of  tlie  opjtosite  sido 

intio  to  «n]>ply  blood, and  c%-cn  where  a  tcmporan'  improicmiiit 

fbUuwcd  the  operation,  KfKwdy  rttlupvo  has  occurred,  probably 

this  CHUM*.     Again,  the  disturbance  of  tlie  cerebral  cireuUltoti 

Sganire  of  the  ooinrnun  ourotid  hiw  oJ'tnune  it«  own  peculiar 

So  (but  out  of  eighteen  eases  in  which  the  opvratioti  was 

lol,  death  ocuiimNl  under  the  knife  in  three  instances,  and 

licTs  lemn'natcd  fatally  ;  in  Eve  an  early  relapw  followed  (bo 

iprovement ;  m  the  tenth  oitKe  no  final  rejiort  has  been  given ; 

in  onty  two  is  it  state<l  that  there  was  lasting  improvement. 

in  which  tlie  common  carotid  hiu>  been  tied  for  tim  disease 


See  BroDs'  Baadi.  d-fnct,  Chir.  J.,  lubingcti,  16M,  p.  101. 


pcriii*  nro  ^tirrnoiinto*!,  it«  *ncooM  am»t  still  remnin  n 
which  in  the  past  has  only  tliree  tiroes  boen  oomina] 
«ifr)iM>cn  CMiu.'A.  Attompto  Imro  boon  miulu  to  cure  ein 
by  a  method  conecived  afWr  tlio  old  proceeding  of  An' 
anfturirtinx.  It  ha«  been  propowid  to  Itiy  open  tlio  luino 
of  tlio  si'al[«l,  to  stuff  tlio  nrteria]  wound  with  lint,  a 
rhnf^o  bv  finn  comprosaion,  and  tni«t  to  the  inllimitnat 
thus  excited  tor  the  oblitorntion  oflhe  arlfMial  cluumeL 
tluit  this  mi'dhod  coold  only  bo  apjilied  to  tli'wo  eam<i>  of 
cirsoid  tumour  in  which  tlie  ni'Ccn-  foniH  a  limitMl  I 
convolutions,  and  to  coaea  of  limited  aneurism,  nnd  bj 
OrSfn  fintt  umjiloyod  this  ]irouuedinf*  for  a  ointoid  i 
muur  of  the  forehead  in  a  Iwy  aged  tcn.^tJ  He  div 
wilh  a  Htrong  seitlpc^,  Stuffed  tlw  vmuitd  quickly  wil 
sponge,  nnd  firmly  Btra])ped  and  buiidagetl  tho  whole. 
lowing  day,  M  Ibo  pruumre  wss  sligfitly  ruluct-d,  t]i 
nulated,  and  when  tJie  piirtA  hoalcl  tlu-ro  wha  >io  palsati 
ofUic  soL'difk'd  tiunour.     Boll.jfS  Amott,  and  I^wi 

•  Ou.  iU$  UupilaiLe.  IBSl,  pjt.  130.  li»,  and  OHlUtim  lU 
voL  xvL 

t  In  U)ii  ease  of  Diipuytrcn'a  tho  riRbt  common  mn 
1900.  Till!  ttimoiir  rcmninnl  itutionnr;  till  )Kl<t.  nlMn  Itagi 
rnu<!b  ulcL-ruUd.  Kod  gavo  rioR  to  friKfatfiil  lurinorrha^e. 
tkc  ciuro  of  M.  Itobcrt  at  Ui<i  lloipitii)  Boaiyon  in  ItUT,  «lMn 
wag  alti(>  ti<Ml.  n-itli  trmpoiiuT  «ui'rc«ii. 

I  Kiilil.  ()pu$r.  Ae-j>Umina.  r-iitio  dm*;  Upiiic,  I8tS,  { 
^  §  Kfie  York  Jonrnal.  *c.  1810.  vol.  (, 


CIRSOID  A>'ETJBISM. 


459 


nlfo  in  curing  aneiirioni  by  iLnaatamo!^ts,  by  incising  tlio 
I,  iin<l  proiii»tiiig  Mippi  initial  I  in  tJiO  tiiinmir,  miiinUiining 
oompivwion  mo^ntinie.     It  vrould  not  be  rensonnble  to  expect  timfc 
ic  iiblitiTiittDii  iif  II  Hiii^Ii)  \sirff.!  nrtorv  in  a  Nfjiti;  cil'  irii>(>i<l  djliila- 
pun  ciould  conimonlj  bo  satisfactorily  efl'eclod  in  this  way  ;  not  only 
lie  fear  of  wwonclary  tiEcmorrha^  [ircwnlit  iwclf,  but  wc  know  tluit 
tones  are  but  littlo  prone  to  adbt-jiive  inftiimmatian,  and  tlmt  ar- 
jrial  Idrioi)  is  <{ni<-l(  tu  Knd  fi)r  it-iitU' untlets  nn<l  t<:>  niiiki;  Tor  itM'If 
cbannoU.     In  a  case  of  truly  cirsoid  aneurisra  this  proceeding  will 

tliubl«  tn  ntimcmu.t  wniixH.vt  of  tiiibiro. 
A  mora  efficient  meaiiH  of  destroying  circumseril>ed  cirsoid 
eurisni  lA  to  Im)  ffiiin<l  in  vxtir|intion  en  niiu»o  by  tlio  knife  or 
■  ligature.  The  latter  method  was  employed  by  Sir  B.  Brodia 
witli  <m\y  t«in[y>r!iry  8uc<m?ss  in  treating  n  cirsoid  nnd  anastomos- 
injj;  arterial  tuniouf  of  tile  head,  of  tlie  size  of  a  walnut,  wliich 
tlie  cluini«t<T:»ti(;  fwling  as  of  a  oouvohitiwn  of  inonndtTntig 
it  with  strong  pu|j>attaii^  TJie  tiinioiir  was  trani*fixo<l  cross- 
wise, and  ^transidnti.id  by  tour  tlircads  in  as  many  purtjf.  Tlic 
oipo  uaa  reported  at  the  time  t<)  be  Pom|)lete,*  But  Mr.  Prescott 
I  uewi.'tt  mcntionwl  in  a  k-cturi?  at  the  Royal  College  of  Kiirgeonn 
jibe  &et  tbat  the  disease  recun'ed  in  thlit  oa»o,  and  tJial  tlie  patient 
•od  »nmo  years  atWwards,  dcatb  Ix^ing  attributed  to  "  ncnouii 
Waity." 

Excirion  of  tlio  tumour  by  tlic  knifo  has  boon  several  times 

•"imiilishwl,  and  lias  yioldoil  oures  in  oases  of  great  severity.    One 

"'tlte  most  remarkable  oases  on  record  occurred  In  a  young  man 

•jrf  twenty  treatrtl  by  Shnsey,  who  had  on  tlie  fop  of  his  bead  a 

■nwd  ancnrismf  of  great  size.     All  tlio  arteries  of  one  side  of 

w  bead  W4^re  eiiomioiiKly  diltitMl,  anil  ivlioti  tiv>  bnir  wan  shaved 

^*B^  arteries  of  tbe  size  of  a  goose-quill  pidsated  '>n  tlieir  way  to 

w  tmnoai'.     Ijigaturc  of  tlio  lull  cuininon  eurotid  tiiili-d  lo  cure, 

■nddiD  iigaturo  of  the  right  common  carotid  twelve  days  later  also 

Acted  only  a  ti>tnjii<rar^'  ini)>rovenicnL     Extirpation  was  nMolvod 

^KO;  two  semilunar  incisions  being  made  around  the  tumour, 

ttiA  «a»  then  peeled  ntf  from  the  periiT-nin'uin.     Thi^s«  inciHions 

*CN  made  gradually;  the  arteries  wounded  being  tied  at  each  hakf* 

neb,  they  occupied  mtiw  than  un  iionr,  and  forty  ligaturw  wore 

llBqaired.     In  spito  of  all  precautions,  thoro  was  a  great  quanti^  of 

lUwd  lost,  anil  the  jiatieiit  foil  into  nynoojie;  tbe  wound,  however, 

suktcd  locally,  and  the  patient  is  stat^^^l  to  have  recovered  com- 


MttLCiir,  2^aiu.  1820,  vi>I.  xr. 


i  Loe.eil. 


^=1 


460 


DISEASES  OF  AUTEHIEa 


pictcly.  Griifi.',"  Gilwoii.t  Wfitzt-r.t  Buwli,  »nd  Wiirren,  kw 
8lw>  eiH[jloyed  iJiU  mi'thott.  I  emjiloyeJ  il  eiglite»-a  inonUis  sinw 
BOCOiHwfttllr,  IKvziiig  the  ttimour  and  cutting  wido  of  it ;  w  ihil 
th«re  was  vm-  lililo  lo*>  of  lilood.  lU  dittioultiiM  have  proved  »wy 
great,  and  its  dniigi-r  is  coneidi-Tabk-.  The  lia?morrliagi-  in  hmdc  of 
tliese  caaas  was  cxcoMve.  Bitt  tlic  itwue  of  all  the  ixM.y>rde<i!  ca»r»  in 
wliicli  it  liAS  boon  undertaken  lias  been  successful,  and  excision  by 
tlit^  knife  lias  as  y<->t  pi'M^txl  n  nifint  ntpid,  mfv, and  Rti(-(-e6Hfiil  mmnf 
of  troatmunt.  It  is  obvious  that  sometimes  great  caution  is  rw|U!iwi 
to  carry  it  into  cfiWt,  ati<l  in  v«try  oxUTii-five  dttioluinnenta  of  (I* 
disease  it  wiil  be  inapplicable.  It  tnigbt  occasionally  bo  pnifUtit  V> 
prcfac^o  tlie  cxtjqiation  of  the  iiiniour  by  tlio  ligature  of  tlie  aiuD 
trunks  which  food  it ;  when  pmotising  the  inclsjons  aruniiij  die 
tuiiKiur,  till?  knifo  tru\'('].'>  Mlowly,  inid  tho  arteries  Hre  1o  be  tied  tf 
they  are  divid«J.  It  was  by  tlie  combination  of  woll-timod  (wiuiun 
and  n<K^w«:iry  lM>ldni's!t  tbiit  Koiiic  of  Uiow  fonniilnblo  0}ieT8tiiUi' 
ha^o  been  brought  to  a  snL'Ci?8§ful  issue. 

Two  fif  the  miiri!  miidoni  ruBourcc*  of  ^ursi'-'al  i*cii-nce  lia"* 
rooeiitlv  been  brought  to  bear  upon  the  treatment  of  cii'soid  ajienr- 
itm  and  iuieiiri.'>m  by  ana>itommiis :  these  arc  galv:iii()-punctiir«!,  il"" 
galvanic  cautery,  and  tlie  injoetion  of  coagulating  tluids.  Tite  fs* 
of  {;al\'iuio-])unctur<;  is  duo  to  Nt^latoni  lus  patient  wax  a  woiitaa 
aged  twenty,  having  a  front.al  tunioiu'  mado  up  of  veraoU  hi  tr^' 
roluttxl  t.liat  their  windings  could  be  clearly  distingtiishcd  by  li* 
touch ;  it  had  ai'iaen  two  ))r  three  monilis  preipHousty,  after  a  fC^ 
blow.  Two  needloa  connected  with  a  Bunscn's  pJic  of  20-lb.  pW* 
wore  passed  into  the  tumour  wlu-re  tho  pulsations  were  most  violfiii'i 
and  tho  current  transmitted  to  them  dming  ten  minutc«,  Jicxi  d»5» 
where  the  needle  connected  with  tho  positive  pole  had  entered,  (W>>* 
solidation  was  found  to  have  occurred,  and  after  sumo  fiirliier  «'' 
tings  the  wIjoIo  tumour  luul  he<.-omc  a  hiu^  mass,  and  uftcr  a  wI^ia 
was  absorbed.  § 

A  ciise  i)f  Hnouri«ni  by  ann!>tomostH  of  llio  ear  and  M»lp.  un^ 
Mr.  I'rescott  Howett's  care,  ti-oatcd  by  tho  electric  cautery,  i* 
Bome  as  that  previously  inentiontid  at  having  been  suIimv) 
subjected  to  the  ligature  of  the  common  caroti<l  with  a  falal  n-w 
by  Mr,  Tritvers,  jnn.     It  was  treated  by  a  eonibinalion  of  tho  eli 
trie  cautciy,  styptics,  and  the  ligature  of  tho  tumour  en  inaas& 


*  Orii/e  und  IVaUlwr't  Jbunal.  vol.  xiv.  p.  <138. 
+  Op.  Pit.  :  Deviieht  Kliaik.  18M. 

ff  iiuUelin  dt  TH^raptatiqiu,  Idio.  xlii.  p.  ibi. 


DISSECnXG  ANEURISM. 


4411 


Tlie  result  was  for  a  time  very  satisfaclory ;  the  tumour  having 
(Uitigttiil  titt',  t\v.  ulceration  licolod,  and  th«  grcat(!r  part  oi'tlio  liy)>or- 
tropllinl  vessels  rwmiioi!  tlwir  natuml  n ;>{)(■» r»ricw.  Tlir.«  cur«>  was, 
InwcTor,  tiot  jM^niiaiieat.  A  iiirtlier  dcvelopniont  of  thc'  tiimdur 
twnrred,  and  liefimj  Inn;?  il  wjis  iiguiii  il%  bud  iw  t*v<T.  It.  Mo^iim 
ktghly  |ini))«l>l<>  that  had  this  patient  remained  under  obsorvation, 
An  n^petition  of  thc  oriKiruJ  inwwurcjt  mijjlit  Imvo  jir«'Vfiit«d  or 
dtet^Liii  this  itti-iirrenpo,  and  so  ultiniatoly  have  savwl  liis  life. 

The  applicntion  of  <;i)ii;;uliiling  iiij(V3tioiif>  wits  iniulc  by  >L  Itroca, 
»!»  IrtTfltijd  n  «tvum*cril>»xl  aneunsiii  of  Uifi  scalp,  eun^iHtiiig  of 
4e  eonvolutions  of  ti  cirsoid  wrt<;ry,  l>y  injvftiri;;  [HTchlorido  of 
Ml  Many  premiition>4  wors  adopted  for  fM^venting  extravAsatioa 
(f  Uie  (yta^idiiiiiiK  Huid,  and  tlio  casv  a  described  as  having  been 
pwfcrtiv  guwu-jssfuL* 

£ItXEST  UAKT. 


D;(WECTINO  AXKUKISU. 

affixation  whtcli  hc^rs  the  nauto  of  Diiwoc'ting  AiKntrtitni  i« 
reoognised  during  hfe,  and  when  it  ia  the  stibjeot  of 
nt  fallit  HO  iiiuc-h  mora  oummoiily  tindor  the-  care  of  the 
rarndan,  tliat  a  \ery  few  words  muat  HuHice  for  iu  d<>M^i]ition 
^v.  Ili^-  anntomtcid  lc«io«  consists  in  a  rupturo  of  tlio  inlenial 
of  the  arteri'.  by  which  the  blood  in  ullotved  lo  piiM  iu  M) 
channel  between  thc  coats  of  the  vessel,  parullol  to  ita 
'.  until  finally  it  patiiM^i*  n^.iin  through  tlio  vuaU,  •*»  aa  to 
iIk-  cavity  of  thc  artery  if  it*  course  has  been  fom-ards,  or 
Ub  lock  inb)  the  pericardium  if  it  han  niiido  \t»  way  ha^-kwardii^ 
W'  Peacoelkt  has  shon'u  tlut  a  layer  of  the  middle  coal  iisunlly  ia' 
■kextcnial  ro  the  blood,  wliich  io  tlu'rHiirc  extraviL-<atc<I  into  tlu> 
VMfaxMs  of  thiH  coat ;  and  has  aliio  sho»-u  that  tltc  existence  of  this 
■w  n^tstitig  membrane  couRning  th«  blood  reiidem  rupturo  into 
"■  [Kticartliiun  or  thc  cclhdar  tissue  less  prohahle.  When  the  ooveiv 
■^(if  (he  h)»iKl  are  strung,  and  the  lluid  findM  a  ready  paitm^ 
Wi  into  tJie  artery,  life  may  be  prolonged  for  a  considerable 
foiocL  In  fact,  tlie  HvuipiouiK  n-forred  to  thi>  di.'H'iuu!  have  l>ccn 
•bored  to  last  for  years.  It  is  not  impossible  tlmt  in  some  anch 
a  dbwcting  an«tiri)>m  may  ptisM  into  a  common  false  ancurisin.t 


•  BttOttin  de  la  Sontti  dr  Chir.  lU  Parii.  l#m. 

t  f-Wuirilniiioni  lo  ihe  t'otholoyg  of  tht  llturt  and  ArUtin,  "  on  dissecting 
aaeurimin,''  Kdiub.  IStU. 

I  Thus  >  coco  is  cited  by  Dr.  Pcneock  (op.  oit.  |).  1),  yihtn  tba  ]Mti«itt 


462 


DISEASES  OF  AKTEUIES. 


Tbe  pontlion  of  tho  original  rent  M«niH  alwn}-s  to  bo  m 
aorta,  and  f^uiiorully  in  tlio  arch,  quito  close  to  iu  origin, 
it  hiM   boon  kaown  to  bo  ut(uit«d  in  tho  abdotainal  Morla, 
OS  low  uM  iln  liifiirciition.     Tlic  |io<>it)on  of  the  eeoondary 
of  tJic  intier  conts,  by  w)iicli  tli^'  blood  ]hi«k»  back  into  tlw 
of  tho  vc»»cl,  vitrieit  miioli.     A  casa  is  ui«ntione«l  in  whicli 
»e])a]-nlinn  cxtoiuled  into  tho  popliteal  urton- ;  luid  in  UMttbart 
in  wliioli  tbe  priimiry  rent  wii*  in  tlio  trmisveree  arcb,  tbe  i 
opening  wa§  in  tho  enhclaviaii. 

Vvnth  ucciirtt  noon  in  all  va»n>  whcro  Uio  blood  {mums 
the  arlcry,  either  into  tho  pericardium  or  into  tho  sur 
tis»ue» ;  and  in  ino»t  of  those  in  whidi  tlio  blood  inikw  ilt 
back  into  the  artery.  Bui  in  tlie  few  initiaitces  of  tho  Ulttf 
ill  whioh  liH-  hii»  Ihxii  protraotod  for  yvan,  tho  uiinotiLral 
running  along  by  tlie  tQde  of  tlte  nat^tral  artery-  is  Uned  bf  j 
smooth  tuenihrano  roscnibling  o]>itholiiun,  and  tlius  stmnklaBJ 
double  vosHi:t. 

Tho  Bymptoms  of  dissecting  aneurism  are  host  illustruh'd  brj 
very  intAreHting  oaw  rei>ortv<l  by  Dr.  Swayno  an<l  Mr.  Kt-yt 
of  York,*  in  wliidi  the  diagnosis  was  a^cunitcly  inndi^  during  I 
and  coniinncd  by  dtxscction.     In  tliatcaso,  a  man  agi^l  51,  wliol 
fliiflerwl  fill-  some  time  tuidor  flyni])tonis  nifi-n-c*!  to  iliMttftod  '. 
wilh  uoi-tic  re^rgitation  (to  which  diagn<«iH  one  of  tiia  medicall 
tendanlA,  Dr.  LaUuiui,  ha<l  added  di»caso  of  tlio  aorta),  vra» 
fituldonly  one  evoning,  as  he  was  retuminf;  (Vom  a  day  of  sornei 
tion  and  *'X('ilt;«i(-Tit,  with  a  vcrysovon?  tearing  [Mun  tn  liie 
instantly  followed  hy  a  second  agntii.«ing  [laiii,  wltich  aeeuKd  to  i 
from  mid-Hti-niuin  down  thu  Idt  of  the  spinal  colamn,  and  onlrl 
bo  arrested  a  lew  fingers'-breailth  bftlow  and  to  llie  left  of  tho  i 
hilieiir>,  at  nhicli  point  of  arrest  the  patient  tliought  be  hearii 
distinct  crack.    Ho  lost  power  in  iKJtlt  lowtTcxtrvinitieH  ahnuttl 
ni4KliHti-ly,  and  tiiu  pnlw  became  in]percei>tible  in  all  tho 
of  tlio  lower  limbs.     A  bellows  murmur  wa»  Iwani  bokmr  and 
the  left  of  tho  umbtliciis.      Tliu  '  teartng*  pain  nieurrod,  and 
tlicii  fiassod  into  a  slate  <if  B(ynoo]K',  f(illow<yl  by  fp^at  fxl 
and  distres.-i.      Itotctinn  sot  in  next  day,  with  much  eoiij 
gruatly  rolievctl  by  bleeding.      Ho  surviTod  alwnit  lJinn>  njti 
dying  of  dro])»y  luid  hydrothunuc     The  pulse  had  reourrwl 

•arfivcd  nome  >-ean ;  •■  iJio  anc  romiiieiic^il  a1  Ihe  origin  o(  the  >i>rU.  i 
t«nuiMn[«l  in  a  oul-tlesni:  nt  tbo  cotamun  iliite  nrterU-s."     S«>  llial  D«t 
exvept  it«  sbnpe  and  «stcnt  would  diBUoguiab  it  Irotu  Uao  ancuiuu. 
•  Palk.  Sve.  Tran*.  roL  vU.  p.  100, 


DISSECTISG  ANECUISM. 


463 


ia  the  right  fbmoml  itrt«nr  before  dcatli.  The  diagno«s  of  dis- 
seoting  atiiiuriftin,  originating  near  tlio  root  of  tlto  aorta  and  pia«»iug 
dotm  M>  fur  as  to  comprwM  tlio  true  channul  of  tKv  %'osmI  near  ila 
bifurcatiiHi,  wtiii  Taadc.  nt  tlifi  time  of  tlie  Rcizore  and  confirniinl  hy 
diKwction.  A  tranHvorse  ront  vox  found  in  the  arch  of  the  aorta, 
just  bt'ldw  itn  tliroe  larpi:-  brniii'lii-M ;  a  olol  of  blood  was  imjiiK-lml 
wtai  the  bifurcation  of  the  artt-ry,  obstnicting  Uio  left  common  iUao 
c«io]j>l«it!!y  tiiitl  th(!  riglit  partially.  I'ht!  old  canal  of  the  noria 
acvnn  to  luve  been  disused,  and  tlio  artcrie*  to  have  communicated 
_iritli  the  now  phannoL* 

This  caso  will  serve  to  illustrate  the  nsual  mn  of  the  cases  of  dis- 
iin«-urlKniA,  rluiugh  it  is  ntn'  for  llio  nyiiiptniiiN  lo  bo  so  well 
rked  or  so  well  obson'ed ;  and  tliereforo  ilie  diseoM]!  is  seldom 
nincd  or  even  giu^^^l  at  rlnring  life.    Hie  patient  is  iwually  ad- 
f  aiiced  in  life,  \oiT  probably  a  female,  and  snfTering  from  hj-])ertropliy 
tH"  blJKT  liiK^-asc  iif  llio  lii-iirl.     Tlic  tirKt  itvmplom  is  »  laiiciniiling 
1  at  tlie  Beat  of  rupture,  and  thoreforo  usually  in  tho  chost,  fol- 
"h1  by  Hyn^iijH';  j>crliii|)H  by  |min  at  lln;  purt  ^vlK^^(!  tiio  Wood 
[*6ftlters  the  artoiT,  or  whoro  the  tiunour  ceases.     And  this  may 
["o  aoourapanicd  by  tlie  cessalion  of  ]iul.*o  from  impaction  of  clot  in 
'old  channel  of  tho  arfcnr,  aided  by  the  prcMuro  of  the  blood  in 
iMMBuiabiml  elL-uuml.     Thi.t  stiippiige  of  tliw  pul«©  of  course  causes 
or  less  cumplete  loss  of  power.     In  otlier  cases,  wliero  tlie 
ofourji  m-iu-  ibe  lii'iirT.  ami  tho  blood   fill!.''   baek   into  tho 
iliara,  death  is  sudden.     I  can  add  noUiing  as  to  the  dia- 
M  of  the  diiwisc  ivhich  may  not  be  gatliercd  from  the  9>vin]>toms 
(be  aboi-e  case^     Tlio  only  ease  ui  which   I  can  conceive  such 
iffpctton  becoming  tbo  iiiibj(H:t  of  surgical  diajipiosis,  j»  when* 
of  [tower,  loan  of  pulse,  and  tJireatening  gangrene  follow  on 
|*BMtin]S  anctiriinn ;   and  the  diagnusii'  He»  between  thi"  discaso 
f-lidanboUftm  from  tlie  more  ordinary'  causes  of  impacted  clot. 


*  la  tfaiM  e*>c.  Dr.  SwnjTie.  nfur  hflviiic:  his  nlti^ation  iFiiecmUr  ilniwn  ta 
n»1ut  bj  t>r.  IViicnch.  distinctly  njiscrts  tluit  tltc  ).-xliuva;)alioii  ima  heluitm 
lot^mal  and  middle  coats. 


4&i 


DISEASES  OF  ARTERIES. 


GENERAL  OBSERVATIONS  ON  THE  LiaATTRE 

AUTEllIES. 

It  i»  ill  o)terations  for  the  lip>turo  of  arteries  tliat  tho 
iiigs  of  Uiu  ui>erutliig  tiienlrc  iii'Mt  imnrly  reoenibln  thuM 
diMwcting  mom ;  and  it  u  in  tlK-««  o)>iTiition8,  tnont  Unii  i 
others,  tlint  i»ii)tit(!  Minl^iiiiiiinl  kiiowltilf^i  is  lulvuitagcutw. 
uriilei-laking  to  tic  an  artory,  tbo  Surgeon  ought  to  know  it*  ^ 
couiMi.'  imd  it4  relntiorH,  niid  «N{ic<(.'iull,v  lU«  [miiiitni'nt  imn  or 
wliicJi  are  to  guide  Iiiin  to  the  jxwition  of  tlw  vtwscl  (to 
rallying  |"iiiil«,  iw  i\w  Fiviicli  ojiitratow  nay);  lie  (iti;>lit  to 
fiiiuiliai'i'^od  hiin«>olf  by  frwjuejit  dissection"  with  llio  l)ii< 
tim  pniie  covcrin;;  it,  »nd  tbeir  H])|R'«ninni,  u«  fur  ws  tlml 
judgLvl  of  on  tlu.'  dead  Wly ;  nntl,  Rnally,  ho  ought  to  km 
tisual  position  of  its  principal  hranclim,  and  th«  ana»tonKM 
whic'li  the  circuUtion  may  be  «xji(:cu-d  t"  Iw  iiiHtort-d.  It  i*  i 
aide  also  to  Ijo  awaro  of  tho  leading  j)i>culiaritit«  in  cuiinc, 
tioiw,  bifuroation,  Ac,  wliicli  tlw  o[MTiitor  may  imtIiujis  in«l 
and  for  which  ho  ought  to  bo  pre]MmN]. 

Having  all  tboo  anatomical  dol^nU  clearly  proMOt  to  hii 
ami  being  linniliar  willi  tho  various  nn^tbudit  by  whirh  ihu  ^-nM 
be  roaclicd,  tbo  Surgeon  will  bo  projuuxHl  to  adopt  tliat  nii-thnl 
SMni.t  to  bini  liest  iiuiU'd  to  tlio  <-nM;  nbiirh  hi>  lin|i]wn*  to 
before  him.  It  is  better,  if  [lossibk-,  to  avoid  die  part  of  on 
whvrv  largn  branc-lK^  art:  known  to  oumo  off,  tiaiM  in  KUrli 
tlie  clot  timt  should  form  In  llio  vet^wl  during  tJio  prut^^ 
division  will  bo  absent  bulwii-u  the  ligaturv  and  tiio  ufiouu 
tJiat  branch ;  and  althou^  it  is  true,  aa  ha»  be«ii  sluiwu  al 
tliat  tlio  clot  is  not  nvoOMary  a»  a  pn-»)Tv-ativo  against  mtu 
luL'UKirrhage,  inasmudi  aa  the  wound  ui  tlie  artery  utiito*  by  I; 
wliicJi  mala  it,  mud  aeUs  as  a  barrivr  to  Uk'  lilooti ;  yt-t  tliat 
is  certainly  str^^nglhi-ued  by  tho  doi  in  tlie  aricrj',  a*  in  »ln 
Ijic  fact  tluit  secondary  huinion'liagu  is  Iws  common 
where  a  long  internal  coaguluni  la  fomuMJ. 

In  diesuvting  down  upon  an  artery,  it  is  iinportant  to 


IN  «li»in 
in  silua 


*  So  experienced  an  opcraUir  ■•!  Sir  P.  Cmiaphin  n-UUii.  that  I 
IvinK  tlio  (Miiniiuii  ilUc  niiery  li«  praotiMid  ttw  op«nUlan  hcioii  tiij 
tliL-  ilunil  tiiiliji'ol,  and  mys  tJiat  Mcb  limo  li«  dhl  m  Im  I>-uiii»)| 
tiling  townnlH  tli«  MtUSietoiy  perfomiMiM-  of  lite  opontJon. 

i  Smi  Gutliiie'*  Ctmmait..  ed.  lt)M,  p.  Ml;  Porter  9m  Ammeiam,\ 
Aston  Key,  in  Ouy»  /iot/tiial  tl*jH>fU,  roL  L  pp.  60,  M. 


ON  LIGATURE  OF  ARTEHrES. 


4e5 


fir  TM>w  ofi-acb  successive  structuiw  as  it  is  expoaxl;  and  llicre- 

^'tire  bleeding  from  auy  sinall  vein§  or  arifrios  that  may  be  divided 

^bi  tbu  si)|)erAciti]  iiwision  should  hv  at  uiicu  n.«trniiicd  by  lif;ntiir(i 

or  preeeure.     No  attempt  should  be  made  to  liurry  over  the  pm- 

u^;  bat  ait  «!ach  layor  of  I'ussar  is  dividwi,  ibi;  who  Ik-Idw  nliuii]d 

r  caretuUy  exaitiiiied  with  the  eye  and  fiitger.     Moat  larj^e  arteriea 

ill  n  sbcBth  "f  fiiscia,  whicb  iilso  contains  their  Hcnmipimying 

U'hen  t\m  level  of  this  aheath  ia  i-eached,  great  euro  iiiunt  be 

taki-n  in  »|>l>lyi)iK  ili^-'  kiiifiv    Tho  ovlliilar  raembruno  or  muscles  over 

tlm  fibeaili  having  been  properly  divided  or  drawn  aside,  lliat  struo- 

t»irv  it.vli  siiotild  bi-  tO<-aHiMl  by  stTHtchiiig  with  th«  finger,  Ji.wiittcd  by 

the  blunt  point  of  a  director  or  nilver  knife.     When  the  shenth  has 

^^ecn  biriy  cx|>om'<1,  and  tho  Ix^ting  of  tho  artory  can  bi;  plainly  foil 

^Vnw^h  it,  a  small  part  of  the  uicnibrane  alumhl  be  miacd  by  tlie 

fisrcnpe  and  dividv>d  with  the  knife  held  horizontally,  ns  is  done  in 

opi^ning  (Jie  sac  of  a  atrangidated  heruLi.     The  aiiiall  liole  over  tho 

"rter}'  nia*.t  be  oxtetidcd  witli  the  |ioint  of  tho  director  or  uneurisin 

Doodif,*  till  a  little  ehuimcl  lias  been  made  round  tlie  veaael,  through 

'hidi  tin;  thread  caii  be  carried  easily.     Oreat  caro  is  necessary  to 

"se  tin)  iii&tninienta  >vitli  idl  jjeiilleiieMs  at  this  sliig<!  <if  the  prueeed- 

"•R,  nn  aecomit  of  tJie  proximitj-  of  the  vein.     Tho  uocdio  is  to 

•■  puted  under  the  art«?ry,  in  a  dire<'i  ion  away  from  the  vein ;  t. «, 

'"■point  of  tho  needle  is  first  passed  beHveen  the  artery  and  vein, 

"id  limughl  out  on  the  aide  of  the  arti-ry  away  frimi  iho  vcin-f 

•fliMi  Uw  net-xdle  has  been  passed  under  tho  arten,-,  tlio  latter  should 

KoomproMNxl  between  the  [iitini  of  tho  fitifri-r  and  tlio  cnrve  of  the 

""Kill:,  in  onler  to  see  that  tho  beating  in  the  tumour  is  completely 

""I^iecl,  or  the  blw!tlinj:  Oi>inpld*'ly  commanded;  and  to  judge  aUo 

tj*  tho  feeling  that  no  other  structure  haa  been  taken  up  with  tho 

'^■i.     Tliiw  in  the  inon?  iK'c<^'--*»ary  in  eases  when-  the  urtt-ry,  as  in 

w  m»c  of  tlw  subclavian,  lies  very  deeply,  |ji>rhaps  out  of  sight, 

™  toduhiitg  a  hrgn  iktvo  or  other  important  struetuix'. 

Some  diflerenco  of  opinion  exiati  almui  (bo  administration  of 
■nrolunii  iu  opurations  on  artoncs.     M.  Robwt}  advoeat*^  tlte 


•  Mr.  Sjnie,  bi>»**ei',  uboMi  eijicrience  iu  tyiiiR  nrti'Hpii  in  pi-rlmpi 
ncn  txttniBivL'  tiuit  iuoi'«  fai'uurublu  iliun  lliat  of  uxiy  olliur  livind  opnntiir, 
pnltn  clnuiiiit;  tli«  arUry  wilh  tlio  cdiio  of  tliu  knifo,  u^iiit;  it  till  Uin 
■Utlsli  tuml  ot  ili«  artvry  ix  clearly  aeen.  If  tliie  jilnii  U  nili'j'Iril.  givut 
cut  Miut  be  loktrii  in  aimtcliiiit;  the  vcsiel;  and  perhaps  it  will  bo  null  W 
Uuat  Um  edg«  of  Uie  kniie  a  litUn. 

f  I'uribfi  (ltn.-ciion«  u  to  ijiug  Brt«tiea  for  a  wound  wUl  be  fbiinil  In 

TOL  i.  Ii|i.  ti'S  Rl  Kqi|. 


C\m/:  dt  CJisifUtf  Ckir.,  Puria,  imo,  p.  48. 


TOL.  HL 


B  a 


466 


DISEASES  OP  ARTERIES. 


pcrformnncp  of  theso  operations  witliout  amptsthctic*,  bul  tJic . 
trarj'  praotifc  i»  imw  univcrwil,  and  I  tliitilc  rigliUy  «>,  in  llu«  om 
trj-.     Opinions  differ  also  as  to  tho  direction  in  which  llje  iiirinifl 
may  be  most  ticlvantjigciouKiy  miulo.     ilnni  (>[H'nil')r>«  tiinkc  t>M'ir  i| 
ci)iion)i  in  tho  <v>intwr  which  tlio  ves^U  are  known  to  (tiintuv; 
prefer  an  incision  which  rrotwoK  obliqiidy  tho  eoimo  of  the 
The  fornici-  plnti  eniilitpi*  tJio  opemtor  more  cleairlv  to  anliirt[ttta  i 
recognise  tho  BtruL-turcs  ^ucocssixicljr  oxpoHxl ;  tfai-  Ixtlcr  rondm  I 
more  oertnin  not  to  misa  the  veaiel  dtogetber,  and  aim  enablai . 
more  eonvcnieotty  to  investignt«  tho  pnrtii  aronnd,  xliotilil  anyi 
maly,  ntieli  as  a  higfi  hifurcntion  of  tlic  Itrnchinl  or  femoral 
render  it  necesBttry  to  seardi  almut,  nnthoitt  any  dHinito 
g(ii<tc.  for  II  »i>!t,*i'I  not  iijuially  prcsiiit. 

L»rg<^  arteries  ought  not  to  be  ticxi  iink«s  a  rc«M>na)i)i< 
bility  vx'iM-*  of  th<r  rr»cnvcrj-  of  tiio  patient  from  an  (>|ifn«inn  wl 
roust  always  lie  grave,  and  whicb  is  for  more  fatal  tlian  tnoet  ] 
g'wnH  appi-iu'  inclined  to  acbnit ;  but  if  (he  diiv-uiur  or  injury  i 
of  no  otJior  eure,  nothing  need  be  held  to  be  a  fomia)  oontra-a 
cation  t'l  the  operation  j  not  di»cnwj  of  the  ^-ijMfni,  n"t  diMw*  i 
the  lienrt.,  not  even  disease  of  the  artery  itself,  altJH>u<^  it 
bo  allowed  timt  tlie  latter  complication  render*  tbo  case 
liopcless."     Hilt  on  tlm  other  hand,  tlie  mo*)  inatiiri' 
ia  reijiiisite  to  assure  tlie  Surgeon  that  tho  case  is  really  I 
tlic  reaeb  of  other  and  mlkkT  menmirea.     So  miidi  linit  latolyl 
done  to  diminish  the  pen^ntage  of  oases  of  atieurisin  whieli 
ligature,  that  it  may  now  be  wiid  lliat  the  pn-Hiimplion  in 
of  surgical  nneuristn  is  ratlier  tliat  it  is  c*irablc  wit]><>ut 
tlian  that  nn  artery  wilt  require  ligature.     It  will  1*o  my  oljg 
tlie  following  retnnrks  upon  each  jHirtieular  fonu  of  siirgiisl . 
imi,  to  point  out  in  wliat  cases  milder  mcasuras  may  be 
to  siiceeol ;  and  when  tliesc  fail,  by  what  opcrattofia  the 
artericH  or  tho  trunk  above  them  can  lie  reae]>cd ;  and  in 
of  eneb  form,  I  idinll  ot)iten-o  Uie  Mime  order  ■«  in  fiillowed  ia 
ewny  on  Ahittatiok,  taking  tlie  up[>er  limb  first,  with  the 
and  neck,  and  jimei^Mling  fn'jm  tJie  extremity  towarda  the  tnuk-t 

•  If  the  orturjr  on  wliJcJi  tbo  o|>i-rfttian  U  porfiina«l  1m  fouiMl,  *li 
expoacd.  Id  W  fxiitnuivol)*  duinMcl,  t]ii««  eoutMS  Krf  opva.    In  anini 
of  tlic^  c-xlrniiiii<-ii.  tlic  MfioKt  CMine  ivoulit  bo  to  •inpiilal*';  in  mixt 
eaaes  tlt<?  oficmtion  wdiiIiI  mont  lihrlj'  be  ennipletcd  ;  while  lu  «oa>r  the  i 
would  bi'  nlmiidi>nr<j  to  ntttare.    Under  tlw  h^iul  of  Kipttuiv  i>f  Urn  Uum 
DBtO,  a  rrmarkitbln  infituiue  of  tlie  good  retult  of  tho  latter  cottrw  itlQ  i 
laeaUoDei).    Tlio  Sinni^on  must  r«l,v  upon  lii»  own  Jnd^ncnt. 

t  In  >[>itni(ingoftlio  ligature  of  (irlories,  it  baa  li«i;u  found  ini|>oMU)fa| 


AJTEURISM  m  THE  FOEE-ABM. 


467 


AKEmtlSUS  IN  TtTE   FoRB-ABH. 

Aiunirisni!!  dimiitisti  in  frc<)t]eiicy  m  tti«  vcsscU  dimintith  in  «»;; 

lOo  the  disease  is  very  rare  in  the  fore-arm ;  indeed  is  hardly 

»ecn  csce|it  ii*  llio  jvwh  of  ac«itivnt."     Very  Intclv,  however, 

as  enahled,  through  the  kitKinees  of  Mr.  De  Morgan,  to  see  s 
of  anciirisni  uf  l\iv  upjior  piul  of  the  uliiiir  artM'y  among  his 
at  tJie  Middlenes  Hospital.  In  this  inritance,  as  I  sujijioae 
usually  Im  (ho  wi.'^!,  the  whoU^  of  tlie  nrterial  system  was 
Msed,  and  a  IoikI  niurnuir  aecompanied  the  aetion  of  the  heart. 
There  can  Ik;  little  difficulty  at  any  time  in  din^iosing  an 
BuriHin  in  the  hand  or  fin-e-ariii,  nor  in  iletermining  whetlter  it 
mmply  arterial  or  arterio-venous.  The  treatment  of  spontnncouH 
curi^n  of  those  arteries  would  Ix-  exwwMliiigly  aiin[Je  if  tlio  diaeaae 
old  bo  found  in  a  subject  otherwise  hcaltliy.  Digital  pressure  on 
t  artery  leading  to  the  aneurism,  maintained  by  tlie  patient  him* 
tu  long  as  lie  was  able  for  several  days,  much  reduced  the  siico 
i  jnWtJon  of  llie  linnour  in  tli>-  case  ahovo  nieiitionisl.     If  this 

Wbcr  forms  of  pressure  Gtiled,  recourse  would  he  bad  to  the 
unterian  o]>eral.ion;  and  even  in  llitt  limt  resort  the  old  oporutioa 
•old  present  no  great  iliffieulty. 

Tie  arterie*  of  llie  t'on^-ann  far  more  often  require  h'gature  on 
ntiDt  of  a  wound.  It  is  liardly  necessary  to  give  minute  ctireo- 
Ai  fiir  IIh*  jierfiinn^uiee  <it'  Kueh  operiilions  nn  tying  the  uhiiu*  or 
«IJ»1  near  the  wrist.  (Jonimon  wiiso  would  suggoat  to  keep  the 
"Joiw  ialaet ;  and  rhi.*  being  <lc)Me,  luul  oare  tukeii  to  av<)id  mi.'^tak- 
IJInervo  or  piece  of  fascia  for  the  artery,  all  tlio  cautions  nt'c-es- 
"y  tw  the  operation  are  L-xhni»UMl.  It  is  a  matter  of  indifli^renoo 
wiior  llio  veniB  eomites  are  included  in  the  ligatm-e  or  not. 

If  tho  skin  is  unbrokc-u,  ax  when  the  radial  or  ulnar,  or  both) 
"lied  for  a  wound  in  tlie  palm  of  the  hand,  it  is  merely  nccc»- 
Ui  make  an  incision,  from  an  inch  to  two  inehof  in  leiigtli, 

"ren  the  tendons  wiiieh  aeeonipany  tho  vessel,  divide  the  deep 


I  In  which  such  opeiatiuna  are  T«i)uii'eil  fur  sueuriBnt  and 

the  r<jmii.-r  L-lttDs  of  riisus  ia  hy  fsr'  the  la^<,'t^4t,  it  was 

FlMDt  to  iii«lutlo  Ibe  i](f>i>M'ij>lii>n  ofuil  tlie  o]>eintioiiB  iu  ibe  pre««nt 

lypical  «xa/aples  of  miuIi  iraumnUa  aiieurisnts  will  be  founit  in 
*■  CliniftJ  CtltMlion*.  pp.  IAO-1.     A  ciuo  of  spoiilaneuus  uiii^urisin 
■At  mdial  aiUry  wiu  titiilifr  )Ir.  De  Morgit,a'»  rate  at  lb«  Mi<ld]«3<rx  Uus- 
and  rooovcmi]  iponbuiooiulj.    S«e  also  Erioluon,  oji.  oit.  p.  SOI. 


4G8 


DISEASES  OF  ARTERIES. 


lasciii,  wliicb  it  often  Btreiigthen«d  by  a  distinct  thiu  Uver  or«r 
ulnar  aiicnr ;  and  if  tim  (t.-n<ii>n  of  Ui»  tlexor  cur{>i  iilnuru  < 
\ttps  tlic  vcNtcl  (na  ifl  uAiuiUy  the  vaso),  draw  tl  mwanl»,  anil 
tlie  vessel  will  bo  ciX{>UM-(l  1>y  ii  little  i[iw<)ction,  oticlMcd  U 
slicnlli,^ — tlio  nidiiil  ii<-oitm[iuiiiod  merely  l>y  a  hiubII  filafuca 
ncTTOf  lying  above  tbe  ^iscia,  wliieli  probably  will  not  tw  wen, 
ulnar  liaviiij;  Us  ncrvu  on  ittt  inn<!r  side. 

Tlio  radial  can  be  exposed,  if  neoessary,  liighor  ap,  by  a 
operutiim ;  but  now  tlio  initsnilar  belly  of  tlio  mipinator  lot 
rcqiiireti  to  be  drawn  outwards,  and  tlie  position  at  wtiieli  (be 
n«rve  litis  agaiitst  tlu>  artvry  (on  itK  outer  »iide  in  tho  tni<Ull«  tl 
of  the  fore-arm)  roust  be  remcmbored.  Tlie  diiTorvnt  din<ctioi 
the  fibres  oftlie  Nupinotor  loiipiw  and  pronator  t<TO»  mwrt  be  bi 
in  mind.  Their  vertical  direction  will  alwap  dJatinguiah 
the  fonner  niuM.<1e. 

To  tie  the  ulnar  artery  for  a  wound  higli  up,  wlwro 
covered  by  four  of  tho  inui>clc«  which  uriev  from  the  inner  oond 
is  not  an  easy  matter.  When  it  is  required  (o  bo  tied  near 
oonniii'ncement,  the  ulnar  artery  may  be  expotwd  without  any  i 
sion  of  inu-aiiuliir  fdtrea.  Air.  Giillirie*  reeommetKU  tlmi  an 
ci»iou  ithoutd  be  made  through  the  aponeurosis  of  the  hkxft, 
pronator  tores  ex]io!wd  and  drawn  tr)vninls  tho  idna,  and  tba 
section  coutinued  till  the  median  nerve  is  brought  into  riow,  a 
ing  till!  artery  from  without  inwaixU.  Then,  if  it  ia  neocAsiy 
order  to  reach  the  veeaol,  part  or  the  whole  of  ibe  pP' 
Is  to  be  divided.  In  other  cases  it  may  be  more  cnr 
divide  the  muHclds  from  below,  lui  ineUion  being  infid*-  fnioi 
point  nt  wbieh  tho  muscular  and  tendinous  portions  of  the  fla 
carpi  ulnaris  are  felt  to  join,  uitwnrd^  for  foiu*  iiiohf«,  and 
sheath  of  the  vcmoIs  exposed  as  tJiuy  emerge  frnm  bennUli 
flexor  sublimis  digitonmi.  If  tlie  wound  be  hi^K>r  up,  ttw  d 
MOii  of  Iho  latter  mimclc,  and  oven  of  tJioM  adjoining  it,  if  il 
necessary,  may  be  purauMl  from  tliis  [xiint.  Hon  or  letoi  loM 
[mwer  will  probably  follow  (he  (Hrisiou  of  tlio  muscles,  oipKH 
if  extensive ;  but  this  in  likely  to  bo  truncient,  and  if  not,  il  i 
loM  evil  than  tho  loss  of  tJio  hand.  Tlie  nen-e  will  probably  b« 
first  of  the  structurcH  around  Uio  ortorj-  whieli  comes  iuto  view. 

At  f/a'  licnii  d/t/ur  elfxxv  aneuri^mal  nwollingit  are  almost  ahi 
traumatic,  and  generally  ore  of  the  arterio-\-enou8  dniM.     If 


•  CommftiUtriet,  p.  9UL 


LIGATURE  OF  BRACHIAL  ARTERY. 


469 


diMaw  bo 

taocous,  pr 

B  either  by  )' 
^B  crial  onmpli< 


m  )tim]>le  nrbcrtiil  ant-nrUin,  wlu'tlmr  tmiimittic  or  *i>on- 
taocous,  pressure  ujran  tJio  bracliiul  iirtcry  is  tlio  first  resource  of 
-ttu>  Surgeon.  AcuUj  tloxion  fiftlw  linili  will  vi-ry  probably  *MC«cod, 
either  by  Itself  or  aa  an  aectssory  to  tlio  iiidii-ort  oompression.  If 
"the^  irioitiifl  ttlioiild  fiiil,  tbit  iiaturni  oourKC,  irn»jii-i.'tive  ofaiiy  spe- 
cial oomplieation,  will  be  to  tie  tJie  brachial  artery.  The  treatment 
of  anuria -vi*iii>iH  nii<nirit<tii  hmt  ixHiii  (liwiMHcxl  iibovii  (p)ii.  4!}i,  3) ; 
^vv  tUMxl  uot,  theroforc,  detain  tlie  reader  hero  on  ttie  diagiKHtia  or 
^rvatment  uf  atuniriMii  ut  tlio  bend  of  tlic  olbow ;  nor  docs  tlint  of 
sncurifiin  in  tho  arm  call  for  aiiy  further  remark.  We  have,  then, 
otjIv  In  ili-jwribe  tin-  fi]n-nUioii  on  the  brachial  artcrj',  which  ruay 
l>o  required  for  these  aScetions. 

/.i^Mtuir.  of  lAe  limrhud  arffry  for  anoiiri^m,  or  for  woiinil  of 

tl>«!  lower  part  of  the  limb  iu  wliicJi  tho  wounJt^d  artorj'  caiinut  be 

•^^ored,  ix  lliu*  purfonni-d.    An  iiicixioii  iit  made,  nbout  tliriw  inchot 

•*»    length,  along  ilie  hmer  margin  of  the  biceps  muscle  ui  tlie 

'■»i<U!e  of  till-   arm  ;   or  if  that   iniiMcIv  be  obscurwd  by  oedi'mu, 

fat,  or  iiMi>crfect  miispiilarity,  tlien  in  a  line  drawn  fi-om  midway 

"otwem  tlw  Hap  of  the  axilla  to  tho  middle  of  llio   bend  of  the 

•■Ibwir.     Ij»  making  this  incision,  iierliaps  the  basilic  vein  will  bo 

*»^'n.  aiul  should  bn  n%'oided.     Tliu  fascia  having  bct*ii  dividdl  ujxm 

'   Uirectur,  llie  operatur  comes  down  immediately  U*  the  packt-t  of 

'Waeh  an<l   niTvi-s.     Tlic  internal  cutaneous  and  ulnar  nervo  lio 

l"  ibe  inner  side  of  the  artt-ry,  and  may  or  may  not  conie  into 

*»W ;  or  pcrliaps  tho  external  cutaneous  will  he  seen  on  the  other 

■dtoftlie  veflntl*.     The  <lttKcultv  of  Uie  opiration  (wbieh  is  some- 

(Uie*  considcmhle)  consists  in  rocognLsiiig  and  isolating  the  artery. 

"W  renders  this  more  trotd)lesome  is,  lliat  tho  artt-ry,  bi-sides 

wing  closely  eurrotmdod  with  other  sti-ucturcs,  docs  not  always 

*iBilain  tlM!  same  relation  to  thorn.     The  mt^iian  ner^e  is  more 

•■ninoniy  above  the  artery,  and  is  the  first  cord  seen  below  the 

^ia;  but  ucoiL^ionully  it  will  be  founfl  under  the  artery.     Again, 

liraehia!  artery  may  not  Iw  the  oidy  vessel  wbicli  rcquirw  ligJi- 

'.  sinee  atiijther  ctinsidcrahla  veAsol  may  exist  iu  the  neighbour- 

""■l  (probably  a  radial  artery  given  otFlngh  up,  or  a  *ii»  alM*rrurs), 

■■icfc  will  have  tti  l>e  sought ;  it  is,  however,  usually  found  elate  to 

•"(ino  first  exposed.     Tlic  veins  of^en  encircle  the  arterj-  witJl  Ml 

'"'nolo  ploxu-'i  of  onaKtomusing  lirnncbes ;  hence  the  operation  i* 

^noDtly  Ear  less  coay  tlian  the  su|>t'rticial  )iosition  of  the  veiwel 

*'<nld  Mcm  at  8ist  night  Ui  pronuse.      It   is  true  that  a  little 

t*^etKe  and  anatomical  knowledge  will  dispow  of  tJi«se  diffietd- 

I'd;  but  tlwy  should  nut  bu  Ibrgotten  in  deciding  the  question  of 


DISEASES  OF  ABTERIES. 

treating  nn  anterio-vcnniu  anourUni  nt  tlhi  head  »f  Umi  uIImw,  wt 
beeidvt)  lli»  ulltor  olycctjons  to  the  HuDtcriiui  ligaturo,  il  may 
••Id  that,  as  aii  operation,  il  ntil  very  likvly  bo  fooiul  no  OMier,  i 
porhapi*  miti^lt  mure  diiHciilt,  Hum  tiie  old  <>ji«ratioai 

LigntiiTP  of  tlie  britcliitil  artury  ts  ustially  vvry  raoonnAil,  a* 
u  thi;  i>)ii-ratiuti  ilaelf  giicfi.  It  ix  truo  tliut  m  Porta '0  "b 
table  of  siic  htindrod  (.-asm  of  ligature  of  all  arterios,  Uin  irat 
■ixty-eiglit  pasM  of  li|,'»turo  of  tins  braelital  artery  are  uniil  lo 
died ;  but  in  tlio  abscnco  of  details  w©  oaBnot  toll  wholiwr 
ditiil  frwin  tiui  eftocti*  of  tlio  oiionitioii.  Onngrenc  ja, 
beliflved  to  bo  somotimco  a  consequeoce  of  tbe  applicatioa  of  j 
ligature  to  tlie  upjier  ]uirt  of  tbe  brat-liiid  artm-,  the 
between  its  brauohos  and  thoae  of  the  axillary  being  ratbcr 
(vol  i.  1).  67y). 

AxiEUBT  AmnisiL 

Axillary  anenriam,  like  poplit«al,  depcti<b  in  a  large 
vf  ewe*  apon  iiijtii'y,  more  or  Uuk  mivcre,  to  llie  iirtcry,  in  llw 
lent  movements  of  tlie  joint  near  which  it  lies.  Thia  injur)- ; 
ai  it  seems,  vary  fhtm  coinph^  nipttiro  of  the  v«e»ei  to 
alight  conluiiion  or  strain,  only  appreciable  by  ita  resuliei.  In 
fimner  caso  the  anuiirism  is  of  tho  consecutive,  in  tl*e  latier  of  I 
fidso,  Tiuriety.  So  far  there  is  little  c^aontial  difference 
axillary  and  po]ilit<?.il  aneurism.  But  the  dilfcrcnt  anatotnr  of  I 
parta  occunioiLt  a  gi-cat  ditftTence  in  tbe  cumhility  of  tliow 
tiona.  Tlie  cellular  space  of  the  axilla  is  so  loose  and  to  Ui^, ! 
tbe  tiiiTiiiiir  may  attnin  a  very  unmatMgOKhli'  di<vclopnM»t  brfure  t 
treatment  is  called  in.  So  that  the  great  advantage  whidi  ia 
obtaitiml  in  an  ancari«m  by  tlio  c»n<k.'nsntioD  of*  the  puu  1 
tlie  sae,  and  tbe  commencement  of  npontaneotia  care  in  the  < 
tion  of  latnimiU'd  flbrin,  is  loss  likely  to  occur  in  axillaiy 
other  aneurinna;  while  the  growth  of  the  tumour^  even  ifopf* 
by  eoa^E^Ium  in  one  part,  can  eatnly  go  on  in  another.  Fu 
in  ttic  treatment  of  axillary  snenrism  t)i«  fluntcriait  oporatiuD  i 
l(«s  likely  to  1x1  suciMwsfiU,  siueo,  instead  of  an  artery  punniing  1 
long  and  coniinu'atively  it»)K'>rfi(?)Hl  oootm),  witltotit  any  oansid 
braiicbeit,  as  tlx'  !!Uporficial  femoral  docs,  the  vessel  uptm  whldll 
Axillary  .onenriAin  i»  foriiiixl  i«  dliort,  deep,  awl  «o  arowdod 
large  branohoa,  that  a  ligatnte  can  only  be  applied  in  doae 
imily  to  one  or  otJier  of  tlioin. 

It  is  often  said  tiiat  axillary  aneurisais  are  more  difficult  to 


AXILLARY  ASECHISM. 


471 


,  becnuBo  t)iey  are  mi  ollei)  traitmiitic.  But  thia  seems  to 
I  a  confusion  ut'  b-niis.  A  traitmatic  aneurism  is  inui'u  ea»y  to  tretA 
tn  a  spoiitajieouH  aKeuriHni.  What  is  moant  bt,  tliat  there  is  eo 
Btl  iHi  luietirisin  nt  ull,  but  only  a  lucoratci]  nrtory;  Mul  a  lfu:<;rHt«cl 
lery  is  mure,  lait  nut  iiiuvli  iiion:,  iiiiioiiubb  Ut  iiidiroot  mcdiodB 
treatment  tJian  a  noiuidcd  one.  The  prcscnco  or  absence  of  a 
i  detenuinoi  this  ]K>iitt,  anil  tluA  fai^  in  nliowii  liy  tliu  prewnoe  or 
KUOO  of  piJfotitm.  I  vouturo  to  think,  with  all  jKissililu  doforcnvo 
tbe  great  atilliority  of  Mr.  8ynio,  tliat  in  IiIa  rownt  [iiipor  on  the 
lyyct  of  axillary  antnirisni,"  which  has  given  a  new  impetus  to 
»  (IUcn«»)i>n  of  (iie  vory  iiitoiMAting  (|u<Htion  oftiiD  Iri-jiMntint  of 
It  affection,  this  point  tias  hardly  beoa  made  sufficiently  plaia 
the  tt-JKlcr,  although  it  may  have  boea  ptvwnt  Ui  the  mitul  of 
i  aatlior.  Mr,  Syuie  begins  bis  eesay  with  the  rather  slartling 
Ovni  ihat  tJto  dot^'trinc,  whicli  ho  hud  Imhih  tvnctiing  for  more  tlian 
trtv  years,  of  the  siiporioritj-  of  the  Hunt«rian  operation  to  the 
1  Bhxiu  of  treating  iuiiniri«m,  is  (|U(!i<tiouiibltf.  lUit  tii<!  iTitttan<» 
^q  which  be  supports  tills  nMsortion  is  one  in  wiiich,  accurately 
leaking,  thurc  was  no  aii<;uri:!^iu  at  sll.  'lliu  liislor)'  of  an  at^cidcnt, 
to  |ireaen«8  of  a  large  and  tnci'casiiig  collection  of  blood,  an  arterial 
foil,  an<i  no  pulsation,  afford  as  clear  evidence  of  laeoratlon  of  tlie 
Roy,  unaeoom}>anie(l  by  the  fonnation  of  an  uiieurisniiil  mio,  as 
N  be  obtained  ;  and  in  such  e»!ie«,  whether  thoy  bo  in  tile  axillary 
(•n  or  the  popliteal,  tlie  Hunti-rian  ojicrution  may  be  expAoted 
^1l«ltly  to  lail ;  and  the  only  sure  reisoureo  is  to  tie  both  ends 
ffiia  bleeding  vessel.  Still  tlie  nituatioii  ni'  the  injury  ^vill  very 
■ft  modili.-  tlio  treatmeiit  which  would  he  recommended.  Ill 
^QpliUMl  .4pii«e  t.liu  old  o|>erution  i»  \cvy  dJtticidt  and  vei-y  fatal, 
Fuie  the  Unnturian  operation  is  e.isy.  On  this  account,  when 
■pojJilt-al  ;u-tcry  is  ruptured,  tJio  ligiituro  of  iho  femund  art«Ty 
N  been  practised,  though  unsuccessfully,  f  But  in  the  axilla, 
M  <d(|  openitioii  has  Ixhju  ibund,  in  ^ikdlul  liaiids,  not  more  difli- 
rt  ihwi  the  bgature  of  the  subclavian ;  it  is  jjossible  that  it  may 
^*n  IcM  &tul;  and  it  is  certain,  if  nut  futnl,  to  cure  the  dis- 

Eluch  ligature  of  tlio  subclavian  nmy  fail  to  da  Henoc,  in 
of  effusion  of  blood  in  the  axilla  from  aoeideni,  where  no 
ons  of  a  sac  exist,  most  Surgeons  would  agree  with  Mr. 
?iDe  that  the  li^ure  of  both  ends  of  tJte  injured  vessel  i«  a  fiu* 
■n  rational  and  mure  promising  proceeding  than  the  ligature  <tf 


•  MtJ.-Ckir.  Tran*.  ta\.  xliii. 

1  See  btlow,  LigMuro  of  Uiu  Popliteal  Aiterj. 


472 


DISE.VSES  OF  ARTEBIES. 


the  mtbclitvian,  if  eitlier  operation  bo  requisite.  Bot 
i»i(Iab)e  opcraiiouf^,  didicult  to  onrry  uuC  Kali»£ict(>rily.  imd , 
wIk-ii  |><'i-ti>niKHl  ill  tlic  most  dcxlcraufi  moimor  vny  tlnnf^croi 
life.  In  p|K>ntAiK<(iii«  niifunnm,  or  in  traumati*;  luieumm  pnij 
sa  ciilkil,  1. 1',  in  tumours  tho  outlines  uf  nhicli  nni  wdl  •leBnoi 
IHilftalioii  ])laialy  porreptiblf,  iind  which  ran  bo  emptii'd  bjr  p«^ 
if  till!  dtvulution  Iio  ooniniaiidei],  n-liat  cuur«!  Klmuld  \m>  pnr^ 
Mr.  8^-^1c  appcanf  to  bn  in  iavutir  hcru  also  of  empty in;^  tfal 
ntid  tyii)<^  tlio  artery  nbnve  and  below  it,  aitd  Imn  ix'riiirniH 
o]>cr3tiun  oncu  ^ucoitwfidly.  Other  8ur^<ona  would  prefer  I 
ihe  Hubelnvimi,  in  n|iit>!  of  (.he  great  mortality  witli  wliit.'li  tlnlj 
ration  ha<i  bc-i-n  Httonded.*  Pcrhiipe  ttio  <loci«ion  will  be  hen  i 
ncuording  to  the  oirirmnstaiicctt  of  tlie  individual  ckm^  IftJii 
mour  extend  far  np,  so  tliat  tlie  clancle  U  mneli  raised, 
DiH-k  slinrl  itnd  tilt,  tlio  (i])or:itiiin  citi  tho  siiliclaviitn  i)>  on  (! 
and  so  ditHcult  that  it  would  bo  better  to  oj>eralo  on  tbe 
In  eonlrary  circiunstaiiew*  (t.  r.  wlitTo  tUo  Mibelavinn  triatii 
easily  aoeessible  and  tlio  anenrinm  buried  doe]>  in  llie  luilU) 
ftubc-lavinn  may  l>u  tied  with  good  pro^piict  of  cun-.  Thi<  ubj4 
to  die  old  o{>eration,  whi<^i  rests  on  the  proluibly  dif««Mi(l  com 
of  the  artery  luiir  the  tinnour,  liiw  ]w»  forvo  in  this  siliutiaid 
in  the  poplitttiil  njinue ;  since  in  any  ouo  tliv  ligulurc  must  l«  J 
near  tho  aneiirism.  | 

But.  u-ould  not  all  tbcHO  ajfootioiw,  vh.  rtiptitml  artert',  tmq 
anonrism,  and  B|iontaneotis  aneuriain,  be  found  aincniilju  to  d 
tivaliiK'iit  if  it  vroro  mare  porsorcrin^ly  Iriixl?  It  will  strin 
reader  of  most  of  the  ca^es  of  axillary'  ati^iirUm,  in  vrbi4!li  tlw  il 
are  fully  giv('n>  bow  well  iidKpt4Ml  thoy  mxm  to  haw  boiti  li 
treatment  by  di);;ital  pressure,  liail  tlial  metltod  been  known.) 
any  rut'-,  if  m>i(t<^iiito  |ireiuiuru  on  tliD  artery  wlivre  it  cro«M 
first  rib  ean  bo  made  (as  it  of^en  can),  by  nunna  of  tlut  tingm 
pad,  fio  iw  to  eontrol  the  circtdation,  tlio  Siirf*oon  u  notdon^ 
du^  to  his  patient  if  he  expose  liini  to  tlie  ri«k  of  a  great  oftt 


*  Esjieoiully  iu  tbu  pnuitjce  of  Luiiiloii  Surgeonti  during  th«  la 
jcar*.    Sou  bdow,  un  Xjgnturv  of  tho  SubcUTion  Artciy. 

t  Sec  a  i-iuo  deacribeil  by  PcIIoIan.  CUm.  Ckir.  ml.  ii,  p.  SO.  "B 
ing  the  ahouMer  alijilitly,  llio  lubclnrinn  aiUn-  cniilil  ho  fi-U  iiiolat«Hlj 
by  inikiui^  e\en  slig^bt  pivBturs  wltlt  tlio  I1n)t<ir,  lu  (luluilioa  uiil  l) 
llin  ctitii'd  tumour  aould  be  amateA."  So  also  la  Ur.  CroMing's  <4 
Jlffl.-Chir.  Tram.  ra\.  xx\.  p,  944,  preMure  on  tlw  Brl«iT  a«  U  rroUM  ll 
WBR  i-iiHjIy  iimdo ;  Hod  the  Mtnie  may  lie  s«ul  of  Mnyo's  nu#.  ibid.  p.  M 
tntrel}'  iiiatiuioo  LltiMo  cases  auouf  mnny  oiben  to  wliioli  tlM 
a|i|tlies. 


[XlLLAItY  ANEUItlSM.    OLD  OPERATIOX.      473 


I 


ritliriitt  a  careful  guid  patient  trial  of  this  We  and  often  irni^t  siio 
ful  iiM^ihixt.  If  lUrcct  [in-iwtmt  bv  a  |iiiil  in  iho  uxilln,  or  by 
nda^ng  tlio  arm  neross  the  chest,  appenr§  to  assist  in  iy>nti'i)IHrig 
he  piiLtiiiio)!  and  bniit,  it  may  hvt  at  tiie  wmo  ttmo  ornployotL 
amnital  comprc'sion  is  loss  pasy  on  acnount  of  tlio  shape  of 
I  parts,  luid  in  I<ms  likflv  to  Lm'  well  honio  from  [iiiixirnitv  of  tho 
Urge  tKrxea  to  tho  Bul>clavian  artorj- ;  bnt  it  miglit  (uissihly  be  »d- 
vinble  u>  try  it  in  tiii*  nltwiioo  of  a  snBicioitt  stulf  of  tusistantu  to 
make  preMure  with  tho  fiDgovs. 

If  these  means  fail,  one  <w  the  odier  of  tho  opcrMtioiis  aliove 

iltMnKH.ll  mH.<t  be  pcrfoninod.      Mr.  Bymti  thum  describes  the  ojwra- 

HMi  whioh  he  porfomied  on  the  oass  of  ruptured  axillan'  artery  on 

*bip|i  lie  fimt  pnM?ti«xl  tbo  M  (^leratlon :    *'  Cliloroforin  having 

•x^Ji  admin i»t(>redr  I  niade  an  incision  along  the  auU^r  i-dff^  of  tho 

"ernn-majitoid  muselc,  through  tlic  pbtyHinii  myoides  and  fascia 

"'  the  neek,  so  as  to  allow  a  finger  to  be  pusliw!  down   to  iho 

**tuati<»n  wlwre  the  (cubclavian  artery  issiies  from  under   tlio  sca- 

k-'na*  antioiiA,  and  lies  npon  tlu'  first  rilx     1  tlion  (ijM-iu'd  the  tu- 

■WoiiT,  Tchcn  a  trcmeiidoiis  gush  of  blood  showed  that  tlif  nrti-rv 

***  no)  cffVsotiiidly  ciiinpnfwiid  ;  but  wliilo   I  phifr;j'*d  iin    .ijuriiiii; 

"ith  inv  hand.   Mr.  Lister,  who  assisted  me,  by  a  slight  movo- 

"'Wil  ol'tiii*  iitiyiir,  wliit-h  hixl  bci-n  thiULit  dinijily  tinder  the  upper 

Sp)  of  tlie  tumour   and   tlirough  the   oIoIa  cont,ained   in   ii,  at 

"^pii  uncoN.vIi'il  in  {jcttinj^  I'onimand  of  tlw  n-swd.     I  tlli?n  laid  tho 

•*vity  frwdy  open,  and  with  botli  ban<U  scooped  out  nearly  seven 

of  coagtdaUxI  blocnl,  iw  wax  aii<e4'rt.iin<'d  by  nicaMin>ini-iit. 

•iHt  axillary  artery  ajtpeared  to  have  been  torn  arross  ;  aJid  as  tho 

■"tT  orifice  still  ble<l  frcijly,  I  lii^d  it  in  the  firrt  in»tjiiici%     1  next 

'oi  tkrongh  tbo  lesser  pectoral  muscle,  close  up  to  the  clavicle ;  and 

WUllg  tbo  upper  end  of  tho  vc«<cl  bctwcon  my  fin{j;«!r  and  lliiimb, 

f^ti  an  alien risro -needle,  so  as  lo  apply  a  ligatiuv  about  half  an 

»eh  above  the  orifictt"' 

lir.  Syuie  a<ids  tlie  important  remark,  that  tlie  extreme  elevation 
•Ttlie  elaviclc  oeeawoncd  by  tlic  great  eftViition  in  the  nxillii,  whieh 
'**lerpd  llio  artery  w>  iniiocesnible  fi-om  above,  faeilitated  tins  pro- 
'fcfing  from  below.  It  tcss  no  doubt  the  name  eircumstaiico,  of 
■"t  gn»t  (b^)l[i  at  which  ilio  third  part  of  tho  subclavian  was  sita- 
*N,  which  rendered  it  neeessan.-  to  make  an  inuiitiou  over  U 
woogh  tbe  deep  cervical  fasciu  U^fore  etfectual  pressure  could  bo 


"1 


•  iltd.Chir.  Tnait.  vol,  xliii.  p.  I4U 


prouinity  of  Inrgc  brnnchcs  to  tliu  ligalnro  woald 
sooaiidanF'  lueniorrhnj^c.  We  luive,  howc%-«r,  ns  abi 
high  autliority  of  Mr.  Gutlirio,  and  oUiere,  for  ea 
approbenitioii  U  exafrgarMixl.  l1io  <lo|illi  At  wbi< 
lies,  and  tho  necessity  for  cutting  through  a  mass 
oxpOKo  it,  form  nnotbwr,  Iml  not  a  ven-  |)aw«rfu),  ol 
operation,  wliicU  seems,  notwil]istandiitg  Hua,  to  \u 
titoeUnl  without  much  difliciilty.  Clinmbcrhuiiii*  ti 
artery  juat  holow  tJie  clavicle,  by  a  faoriiumtal  tttcia 
tlio  lower  <ylgo  of  tho  bono,  commencing  about  three  S 
from  tlie  sttrnal  end  of  tJic  bone,  nn<l  temiiiuiling 
from  till?  acromion.  "A  tk^cond  incision  of  about  ti 
length  WHH  made  oI>li<|uely  through  tin;  integumontt  o 
nnd  [Kxrtoral  nitiHclos,  moeting  the  first  nearly  in  tlw 
tilt'  i-luviculiir  origin  of  the  iHietoralix  major  wait  w.'|)n 
bono,  and  tho  art<'ry  brought  into  view  by  reroovin 
edlular  nii>mbr:int\"'  Th«  only  ditticully  exportencod 
the  nooiUo,  in  consequence  of  tlio  deptli  of  tlio  cavity 
glcs  of  the  jmtieiil.  It  was  acconiplitdiod  by  paMing 
tmder  the  vessel,  the  blunt  end  liritt,  as  I  uti<lcrMAti< 
Th(;  patient  mad<!  a  good  recover}'.  Roux|  appcan 
oceded  in  tyuig  the  artery'  above  the  ooracotd  proooM, 
parallel  to  t)iu  oonrM;  of  tho  vmsol,  botwom  tfao  del 
toralis  major,  without  dividing  any  mUACnlar  fibre* ;  b 
tion  is  not  very  full.  Moot  Surgoona  would  think  U 
room  mid  hotter  view  of  tlic  part^  obtained  by  the  i 
mnwrulur  tibrcs  would  be  a  great  advantage,  aadjl 


UGATUKE  OF  AXILLARY  AETEBY. 


475 


(tpention  if  tlie  lower  pftit  of  tho  :irt«iT  (that  below  the  pooto- 
ralis  minor)  U  to  bu  ojwrutvd  oil,  ami  hy  which  Mr.  Guthrie 
tay*  that  any  part  of  tlio  art«r^'  eon  bo  expoiiecl,  and  the  vrhol<< 
rcfu^el  traced  up  to  the  first  rib,  if  n^uircd.  An  inotston  thrive 
inclicA  long  is  to  be  mmle  over  the  coutmi  of  the  urti^rv  upwiinl.t 
from  the  lower  edge  of  the  pcctoraHs  major,  and  perpendicular 
^tbo  enunte  of  iu  fibrex.  Those  having  kft-n  dividcxl,  «  full 
of  the  axilla  imd  its  contents  is  obtained.  If  tlio  opersttion 
fa  ilone  for  a  wonnd,  the  bloeilltig  uioutli  of  the  artt^ry  will  l>c  seen 
by  relaxing  (if  neoesearj*)  the  pressure  which,  in  such  a  case,  will 
hwre  bc«n  put  on  the  jiulK-laviim,  Mr.  Giithrio  mi_w,  tbiit  "  tli« 
fingtr  introduced  into  the  upfxr  part  of  the  wound  wonid  enable 
UH  operator  to  divide  thii  peutoruiin  minor  muKclo  if  iioce»*nri',  or 
to  ili«w  it  upwanla ;  when  the  artery,  vein  or  veins,  and  the  plexus 
ofnemw,  mif^ht  bo  Imcod  up  to  tJio  finrt  rib  without  difficidtv." 
"ertrtbeJoM,  in  any  operation  on  this  artery,  the  large  ^ein  which 
•m*  in  &x>ut  niul  to  llw  thi)r«ci(;  side  of  the  vojwci  (somctimtis,  as  Sir. 
Qwhrie  hintA,  double),  the  numerous  large  nonea  whieh  Mirround 
rt,  ini  the  groat  (juantit^'  of  brunches  winch  arc  given  off  from  the 
■it«T,  and  which  give  off  largo  and  numerous  \'e«sels  towards  llio 
ttUur  and  front  parts,  where  the  operation  must  bo  conducted,  will 
*^ocitionally  prove  enibarraMing  to  the  ino.'d  dexterous  o]H>nttor, 
Qhd^  m  other  coses,  as  in  those  above  referred  to,  tlte  Surgeon 
"WT  havi'  the  gijod  tiirtuue  to  ^wcajii'  thi^iii. 

Of  tho  success  of  this  opoRition,  no  sidlicient  data  exist  to  enable 

■•tojwdge;  it  BpiieitrH,  liowever,  both  fnim  piiblislied  ojucs  and 

*frwn  reasoning,  (hat  little  danger  of  gangrene  exists  if  the  artery 

■ttiKl  above  llio  origin  of  tho  sulwoapular,  sinco  tliat  artery  aniu- 

tiWaiee  so  fraeljr  with  .branches  of  a  higher  origin  (posterior  and 

^(n^capnlar),  tluil  ilie  bloixl  is  most  readily  eonvcycti  arnniid  tho 

BgUara     Sccondarj-  liasuorrhage  in  more  to  be  apprelieiided,  and 

*t  may  eoi^-cturo  that  diffuse  suppuration  in  tlio  loose  celltilar 

of  the  axilla  would  often  ensue, 

I  will  not  dotnin  the  reader  with  any  remarks  >n  this  place  npon 

OHUiie<|»eneea  of  wound  of  the  trunk  of  the  axitlor}'  artery,  as 

from  tltwc^  which  follow  tbo  division  of  one  of  its  largo 

iwftr  the  trunlc.     Tlie  pcnuMenee  of  jiulae  at  the  wrist  or 

iio  brachial  artery  is  tlic  main  fcjiture  in  the  diagnosis;  tho  extent 

aflrnnee  of  exlravaNutiim  of  M'hmI  the  eireimistanex)  which 

the  noccssity  of  cutting  down  on  tho  woundvd  vessel* 


[tho 


Sec  Jolm  B«U's  Surgery.  Charles  Bell's  ed.  ISaft,  toL  L  p.  419. 


tile  claviclo  from  tlio  «lge  of  tlio  »tcni(! 
Tlie  .tkiii  is  now  nlloweil  to  retraot,  when 
and  parallul  tu  tlii?  i^la^'iclc  In  tliU  way  llic  cxU-mat  , 
whicli  here  ili]i»  Ix-luw  iho  oluvido,  will  he  ii\oi<tcd, 
tirawn  with  a  blunt  hook  inwards  or  outwanls  (tlto 
generally  be  fouiul  tn»r(!  von^-eniellt)  ilurinj;  tlic  roM 
vct^ings.  If  the  mtusclce  approaoli  iicur  to  ea<.4i  nthni 
maAloi<l  oufjlil  to  III!  jiiirUy  cut  away  from  tliv  <'lavido. 
If  tim  patient  be  stout,  or  tlie  davide  mucli  pusl 
HO  that  tlu!  tii-tvry  lien  at  n  j^rcat  clcfitli,  il  i*  uclviMihl 
tbo  transverse  ii]<rision  with  one  running  opwanU  & 
eiii],  and  disfwct  tlic  flap  outnunK*  Tliu  tvrvical  fiut 
ho  cautiously  divided  on  a  ilireclor  to  tlie  extent  of 
coniniencing  fruni  tlui  ouUt  udgo  of  lliu  Btomif-niaato 
knife  may  be  laid  aside,  and  tlie  j>arU  f«|Kimted  by 
fin^or,  aiutislod  by  tliv  jwint  of  a  director  or  uLlH>r  blun 
TiiL-  tingcr  of  the  ojiemtor  i»  now  ]ia<Md  into  ibo 
trtan^flo,'  a  Kinall  sjiaco  Imundod  by  tJio  otnohyoid  n 
the  cluviole  below,  and  tho  i'tvnio-iiiiL->|i>id  at  tlio  intM^ 
Boraowhat  paruUul  to,  but  deeper  tlian,  the  Btonto-in 
smlenus  miticua  innflcl«,  whicli  must  alwaya  bo  cur 
and  traceil  d"wn  with  the  fore-finger  into  tlte  first  rib 
point  of  rlic  fiii^i>r  i«  jiIjkwiI  ujKtn  tlw  ridge  on  wliicli 
ia  inserted  into  the  ril>  (and  wbioh  tcnninatee  on  tlio 
of  the  buni?,  in  a  vorj-  pcn-fplibk-  liiberciv),  tlw  M 
felt  immediately  under  llio  fiiiyi-r.  Tlie  other  Ktnjvta 
in  tliiii  iriQiiglc  are  two  branchiw  of  tho  thyroid  axU,  t 
(^en-ical  and  supra-aeapular,  tbo  veins  acoonipatiying 


LIGATURE  OF  SUBCLAVIAN  ARTERY. 


477 


it  not  seen.    It  did,  liowcvcr,  come  into  view  in  Dr.  Warren's 

M*e,*  and  it  ww  not  williont  ilitH<rulu-  tlmt  li«  vrw  uiuiMcnI  to  nvoid 

«hicli,  as  Dr.  Warren  remarks,  it  is  important  to  do,  both  on  ito. 

mt  of  till-  difliciiUy  tliat  inighl  1>«  esjH'rioticoil  in  x-piiriiiii  tt,  imd 

Esuse  ii  is  an  inijmrtant  agent  in  tJie  collateral  circulation.     Should 

ftw  of  tiu!  vvim,  or  pviii  tlio  e\t<triijil  jufjiiiar,  bo  miieh  in  the 

IT,  it  may  bo  tied  witli  two  ligatures  and  divided.    The  gland  may 

wim>vv\l  without  ^eruplc  if  iiooo.»aary.t     Mucli  i-aro  is  re<}»ired 

tqnratfl  the  artery  from  ilie  lowest  cord  of  tlie  ptexuA,  which  lies 

cti»o  to  it  tliat  it  ot^cQ  derive-*  ]>nl>iiition  from  the  artery,  and 

ptors  to  be  a  part  of  it.     Tliia  mistake  in  moi-e  liable  to  be  com- 

tlel  wlw;ii  iho  aitcry  in  so  deep  a»  not  to  bo  easily  brought  into 

Ii  i»  on  tbiA  account  that  it  h  of  so  miicli  eonae([iienee  in 

atsat  tu  keep  the  tinger  earofidly  on  t)ie  aiit'.'rior  Healeniu 

le,  iinno  the  artery  is  iiuire  eaHily  reeogiiised  by  ita  position 

\ih.  re«pGet  to  tlmt  tendon  than  by  any  thing  else 

Tlus  operation  vario»  mnob  in  ditHeully.     On  the  deail  itubjoct, 

tiiv  living  n-hen  the  person  i«  ttiiii   and   tlio  parts  natural, 

ig  it  mure  eaity  ;  on  the  ooiitrary,  when  llii)  clavicle  U<  di-ivwii 

,  is  greatly  curved,  as  in   persons  accustomed  to  manual 

,  (intl  tlie  jttti&nt  i>t4)ut  ami  miiMMilur,  it  i*  one  of  the  most 

of  all  tlie  opcratiouH  on  arteries.     In  tlieso  latter  eircum- 

t)i«  artery  li*«  at  tlio  lM)itoin  of  n  deej)  cavity  liable  to  bo 

itli  blood  oozing  from  the  manv  small  vessels  which  will 

ly  bo  diviiUil  in  such  a  cifo,  and  tlic  part*  uiniiot  Im?  dixtin- 

It  b  not  wonderful,  therefore,  that  such  operations  occnp^ 

time,  Hti<i  M.imetim<'!<  ti'ntiiniiir^  in  diNawtcr.     Two  Huecen^ivu 

of  Dupuytren's  are  on  record;  J  iu  one  of  which  every  thijig 

oo  fiivourably;  while  in  tiw  other  tho  operation  occupied  nn 

and  forty-eight  minutes,  and  on  tin-  death  of  the  patient,  four 

^iftcTwards,  it  wa*  found  that   tlie   ligature   1ih<I  been  tlu-ust 

die  Tcesel,  and  included  one  of  tlie  large  nerves  of  the 

■I  ploicus,  along  with  half  the  artery.     Another  aceiilcnt  to 

h  the  operation  is  liable  in  oontplieaied  eases,  is  an  injury  of 

plnirn,  or  disturbanoo  of  the  subserous  ei-llidar  tiit^iio  which 

meet*  that  membrano  to  ilie  first,  and  second  parts  of  tJie  sub- 

ivitn  artery.     Thus,  in  a  ease  of  much  difficulty  oiKTated  on  by 

'■  Warreti  in  Anierica,$    tlie  air  rusliing   into  the  chest  with  a 

•  Infra  dt. 

I  i  See  acaso  by  Mr.  Cro«»!ott.  in  Mfl.-Cidr.  T/ani.  vol.  xri.  p.  3*0. 
i  ;  Sen  QiMiD's  ABitomy.  ed.  1H4»<,  vol.  i.  p.  bfH. 
\i  Mtd^Ciir.  TVtfM.  Tol.  xx^.  p.  Si. 


478 


DISEASES  OF  ARTERIES. 


whiiitling  sound  gave  evi<!enc«  of  the  infliction  of  a  wound  on 
pk-uru.  Tlic  {)!itiviit  ncvcrtli^do-w*  rwi^i^rod.  Mr.  Aston 
conHidera  that  [ileurisy  and  the  inilauiuiation  of  iho  ^ub^^mnil] 
cuilukr  tissue  k-adiiig  to  abscc^  in  tlic  iuit^Tior  nKdiasttnum  w^ 
be  found  to  bo  tlie  most  <;ouanion  causes  of  deatli  in  this  operalioii< 
—sn  opinion  wliich  ttio  statistics  quoted  bolow  go  far  to  sufipurt: 
and  puintd  out  the  niscea^ity  that  tliore  ia,  on  this  acoount,  for 
niccldliiif;  if  possible  with  any  part  of  tlie  vessel  «xccpt  that  whit 
li«a  innnodiatt'ly  on  the  ril),  by  which  means  such  an  injury  Id 
ficrous  mcuibriuio  or  subserous  ti»uo  tvill  be  avoided. 

That  ligature  of  the  subclavinn  artery  ahuuld  bo  •  vvry 
operation,  when  performed  for  axillary  aneurism,  will  siUT>riw  no 
Olio  "lio  eonuders  ttie  conditions  uiuler  vrhioli  it  is  |>erluruK-(L  hi 
the  first  place,  Uie  procedure  resembloe  ^Vncl's  opcraUon  almw* 
as  much  as  HnnterVf  Hi^not^  Mi[ijiur:iti(in  of  tho  atw  from 
formation  of  clot,  and  secondary-  h.T^morrhage  from  discaae  of 
artery,  may  be  anticijinled.  Agiiin,  the  lij;iiturc  inuitt  be  ptaoed 
the  immediate  vicinity  of  lai'ge  hranohon.  Then  again,  the  defiei 
fornuitioii  of  luininat^xl  elot  is  further  liivoured  by  the  abMsice 
loose  Btructure  of  the  aneuriamal  sac,  and  by  the  want  of 
ill  the  piirt.t  wliicli  surround  it  (sec  p.  470).  For  tht-se  n'l 
the  sound  cure  of  tlie  di&eni>e  is  loss  probable,  and  suppuration  in 
Hue  lar  moro  eommon  in  Kxlllary  thiin  in  ulhcr  anotu'isms ;  and 
to  these  aomves  of  danger  thoso  above  notioed,  which  result  fiw* 
tlie  tuiatoniy  of  tlio  parts,  bo  added,  we  shall  have,  1  think,  a  nti^ 
fiwstoiy  exjilanation  of  tlie  high  mortality  of  the  ojjeration. 

In  Norris's  tabloj  of  the  statistics  of  this  o|M.Tation,  six^-niw 
caaca  liav«  hoen  eolleeletl  in  whicli  tli*^  ojH-ration  wiw  jierfiimwdft' 
rariooa  causes.  Tho  result  was  most  disastrous:  tliirty-six  ««>• 
vftrii'S  agaiiiHl  thirty-llircu  dcath.i ;  «  mortality  little  loss  tluin  wt"* 
is  supposed  to  prevail  after  amputation  at  tho  hip-joint,  Tlif  fi'" 
case«  ret«nr.!y  i>pcra(cd  on  in  London,  wid  reported  in  Ihc  .Wrt/i* 
TiW*  and  Ga:eru.^  liave  turned  out  still  more  unfavourably;  o"^ 
of  six  caaiis  twij  only  have  recovered.  Porta'*  tabic  of  the  pui 
cases  gives  a  more  &vourablo  aooeunt,  since  out  of  soventy-fv 


•   Mtil.-Chir.  Trans,  vol.  xiii,  p.  8, 

I  It  diffi-i-H  ill<J(^Fd  in  jiriiiutplo  fram  Anul'a, — ao  &r  ac  Antral 
can  be  eaiil  Ui  hnve  uny  piinciplu ;   for  us  (lie  nRl^u^unl  mmy  bn  s«kl«d  I 
Uie  aoniiiiiu'ilinruL'ia  aitcry.  nn  unailuniuiii^  imili  mny  continiio  lh«  oItobIi', 
tion  throuijih  \X\c  su«  nfti^r  npeniUon ;  hut  tliin  cannot  bo  oa]eulau<J  oU. 

;   Amrr.  Journ.  Mnl.  Sr.  ISift,  vol,  x.  p.  13. 

i  Vol.  ii.  teae;  vol.  i.  l^UU. 


CERVICAL  ANEURISM. 


479 


I  lwenly>Mvcn  only  nro  rcjiorli'd  to  Imvo  died ;  but  nA  Noma's 

Porta's  tables  wore  botb  [>ublished  in  the  same  jear,  and  as 

lliirtr-three  <lMitliH  iti  tliv  tbriniT  table  did  (.'crtsitiily  occur  (for 

icfcrcnocs  to  all  tbe  cases  are  givoii),  it  is  dear  tJmt  Porta 

.  bare  inittflccl  minv  <>(  tbo  fat^il  i»i!<um.     On  tli«  otiicr  barul,  it  is 

siblc  that  Porta  may  have  bad  Mcvesa  to  some  Huccetofiil 

rlilHi  woru  uiik'iiuwii  to  Norriit;  but  iLv  Itidiaii  tables  not 

[>initani«l  by  references,  as  tbe  American  are,  it  m  im- 

»1b  u>  soy  b"w  itifuiy  of  Portti's  scxt-iity-four  ciiscs  correspond 

Norris's  sixty-nino.     Tlie  most  favoui-alile  view  of  Iho  caeo 

be  that  whiob  wotdd  axsumo  that  PortA  had  merely  missed 

[  oot  of  the  thirty-throe  fatal  canea,  and  limi  lal)iiI:iU?fi  nil  the  r<»t. 

Wjwiding  tlicse  to  his  list  would  ^iivc  thirty -IIitl-o  fatal  cai^esoutof 

rtr,  a  mortality  of  41-2.^  ]>or  cent.     It  may  safely  bo  »uid,  thon, 

i  tbe  average  mortality  of  ligatui-o  of  the  subclavian  arterj'  for 

lesosM,  and  in  nil  vii.'o--*  of  huNjiitiil  and  |irivute  |ini(!tice,  towu  aiid 

f,  taken  indiscriminately,  ia  considerably  above  40  per  cent. 

|tO  tliO  ctuwcs  of  ibis  miirtnlity,  wi'  J,^rt  mi  :iH'i>rniatioii  from 

oot  of  the  thirty-tlireo  deaths  in  Korris's  table,  five  are  un- 

nto«l  for ;  of  the  remaining  twcnty-«ij;bt,  iiino  were  vatisod  by 

jrliage,  six  by  ganj^vne,  five  by  sloiigbin^  or  suppuration  of 

ri«m,  fiw  by  intra -tliontci<:  inHammiitioii,  one  by  exlmusdon, 

> by  eftiwion  on  the  brain,  and  one  by  '  inflammation.' 

Hipw  faetM,  as  well  as  the  theory  of  tlic  matter,  ccrtunly  tend 

intlitbit   lif^lnre  of  tlie  mihcUviuti  artery  us  one  of  the  least 

Qtung  of  all  (he  surreal  operations,  and  must  dinposc  Surgvons 

iiii>lh()d  n-oonunende<l  to  tbi^ni  by  Mr.  Syme  in  any  caso 

that  procedure  does  not  appear  too  dangerous. 


Akkcrism  at  the  Root  of  tre  Neck. 

Oiit  is  one  of  tlie  moRt  formidable  diseases  whleli  can  occupy 

llttMtlion  of  iho  Surgeon ;  both  the  dinftnosis  and  troutnieut  are 

with  diftienltii-tt  lh.it  are  usually  found  insujicrablc.    The 

dnity  of  tl»e  heart  is  the  oauso  of  tho  pri;(it«!«t  diDieuhy.      It 

r etocedingiy  ditHcult  to  ilisttnguish  whether  tbe  bruit  is  limited 

jthi!  tumour,  or  ia  propagated  into  it  from  the  cunliac  viJveA; 

the  pulsation  is  limited  to  die  neck,  or  e.xtentU  also  into 

(thorax ;  an<l  whetlier  one  only  of  the  large  vc»»oU  in  inipliciite<l, 

whether  others  of  tho  f^ojit  art*rrie«  in  ttie  neighboiu-bood,  or 

I  whoh^  trunk  leading  fiom  the  heart,  may  not  bo  discasod  and 

Theo  in  tbe  trvatmcut,  the  proximity  of  ao  great  a  stream 


480  DISEASES  OF  AUTEBIE3. 

of  blood  hae  hillicrto  prvveittiHl  lliv  stic-o«w>fu)  (({'{''■^■''i"'*  "'^'^ 
tore  upoit  till'  iiiiioiiiiimtt!  or  tlie  fin^t  part  of  tlw  (>ubi't»\i4U 
tbo  cura  of  anciu'ism  situaUNl  atxtvo  ttui  Hxillu :  and  tlii*  a 
matoiu  d(<|insit,  w]iic-Ii  gonemll^',  whcti  it  existe  at  nil  in 
large  arlet'icd,  intolvcM  tlioir  vrhnlc  L-ulilin:  U>  a  very  f^-nt  d 
has  soitivtiiiivt*  I'VMi  [>rovcDt«l  tin;  Surgeon  from  tying  llis  ■ 
•IW  he  liiis  exposed  it ;  and  tJto  probnbiUty  of  tin  ■■■xi*l«i 
Uiis  KtAiu  iif  tlio  vcMcI  rciidura  it  »lwii}-!i  a  luuwrdoiu  niatl 
attentpt  an  operation. 

V'lM,  fts  to  diaf^noMK.  The  nnouriuiuil  iiattiro  of  tlw  «ri 
does  not  uHiiallv  admit  of  any  doubt;  for  tliou^fh  liore,  as  ebn 
malignant  tiiin«iir»  springing  from  the  iKHin  may  (liTiv«  inili 
from  tlicii'  own  vessels,  or  tuuiour»  of  any  kind  from  proxtni 
tiui  urUTiiit,  »uoh  source*  of  ambi^iity  iim  tuw  voitnnnD  tli 
other  parts  of  lti«  body.  Itefercnce  may  therefon  be  mado  ( 
hcfl<l  of  diagnofiH  betwcvn  aiiinirisnial  and  other  tuniotin*,  to 
hail  bcon,  Auid  in  Uie  floction  on  Diagnoals,  and  to  what  li 
apon  AbdoDiiiinl  Anviirisin.  But  it  it  otitin  k  inatttT  of  pna 
porliiDoe  and  of  gnuit  dilHoulty  to  iltNcoa'or  whellier  the  aw 
invoU'cs  thv  Mabctavian  artcri-,  or  tlw  root  uf  thii  (TanHitl,  t 
inuoininiite,  or  more  tluui  one  of  tliej>c  vtiNwlti,  or  tl>o  iiorta  aa 
Mt.  Wardrop*  lava  down  as  a  ndo  ijy  which  aneurisms  of 
fiovvrsi  lu'tfritv  may  bo  diagnoswl  from  oaeh  oiImt,  that  wb( 
dinenAe  atr<-('U  iho  root  of  tlie  <?arciti(I,  il  will  [ir<»eiit  itaeU*  6 
tlio  Hmall  ti-iiin||i;ular  space  between  the  hoatb  of  the  stirriio-Hl 
miiiH'Io;  whin-eiut  when  tho  innominate  i»  tlie  »eiit  of  dii>«»te, 
generally  be  found  on  tlio  tracheal,  and  whMi  thu  miU-lati 
alVeeUHl,  un  llio  enrviciJ,sido  of  tJiut inuMolc  T\imo  oW-rvalwn 
however,  only  apply  to  cases  seen  in  the  earliest  poriod  of  tJi 
euiie;  aixl  iheir  dcco](tJvtftu»»  even  in  Mieh  ewMw  ta  showa  I 
fact,  tliat  out  of  the  few  eases  eitoil  by  Mr.  AVordrop,  onflf  m 
to  be  of  iIk!  itniominHt>.i  artery,  wjiidi  ought,  aooonling  to  hifl 
to  have  bix'n  of  tlie  siilK-Uvian  ;  but  tbougli  llio  (Jaw  of  tin 
ext()rnul  uppi'immce  of  tlio  aneiirUm  i«  not  diviMivu  lui  tu  i1m 
of  the  artvry  from  wliicli  il  »|>ringB,  it  is  a  symptom  of  miuaaA 
importancD,  uml  tdiinild  always  be  canifitlly  noted,  when  K  a 
clearly  aMcrtaiiietL  Another  iin|>nrtaiit  tiyrn|itot»  la  tlic  oba 
of  tlie  puiHiilicin  in  tlio  brancltcfi  of  the  eauirtid  and  sulwhi^iii 
the  piilM-  in  the  brachial  or  rndiiil,  or  tluit  in  tbo  upfH-r  |>arl 
carotid  or  Uic  (iniipoml,  be  materially  len  on  the  •iS'cvU'd  tlia 


*  Op.  «iL  p.  n,  f  Case  of  Gonltfa,  p. 


CETIVICAL  ANEURISM. 


Ml 


side,  we  hnvo  aomc  n>4uon  for  bclloving  tho  paront  tmnk 

^vnbelntriui  in  one  caae,  «an>lid  in  the  otlicr)  u>  be  afTocted ;  iiniJ  in 

Oppneito  circumstannw  to  bo  uimBvctc4.      But  neither  oonclu- 

l^n  i*  fnte  fn>ni  »oine  unoei'tninty.     The  grnwtti  nf  uiicuriiimit  in 

I  flwlhihr  tissue  of  tho  modtastinum  and  root  of  tho  neck  is  so 

^  nat  iiDtlanctifl  have  iKwn  otifterve<l  of  ancurianiH  ofihc  iiroh  of 

aorta  causing  comproMion  of  tho  subclanan  or  c»rotid,  without 

ty  divoMCoftltom  v««Kfilft;*  whil«  on  i)jr  otlicr  huiKl,  if  thu  iinvur- 

Bpproaches  the  tabular  sliapo,  tlio  pulM»  may  Ik)  uiiaUbckxl  in 

tO»f  brniwhett,  tliough  tlio  trunk  is  cxtcnftiv«)y  disetisixl.      Agnin, 

ttiQ  inflaence  of  the  anomalous  distributions  whicli  so  oflen  affect 

tho  bnnohi}*)  of  tJie  aorta  i»  not  to  be  forj;riti{>:i.t     I'iishIIiIv  mhiio 

■adataiioe  to  the  diagnosis  may  bo  obtained  by  a  cfti-efiil  eomiidi-ra- 

tion  of  iho  ollwr  orgaiis  compro-tMHl  liy  the  tiinioiu*.     TIiuh  |ireH.*iiro 

W  llie  great  veins  will   lea<l  to  li^idi^-,    or  oven  a  permanently 

i7<iuatie  (.imdition  of  tho  oxtremilyt  (hand  and  fore-arm,  or  tiivo 

•nd  ivalp)  ;  pressure  on  the  recuiTcnt  nervo,  to  larrngeal  symptoms ; 

vn  till)  phreiiio  iktvc,  t4i  H|)u.Hnio<li<!  action  of  the  dia|)hntgn) ;  on 

tl*  Inchea,  to  stri<luloits  respiration,  Ac  ;  but  mncli  caution  ia 

ttoa»ary  in  ntl.iniitting  thus<>  i>vmj>toniii,  wliieh   lu'ti   common  to 

■■uncic  aneurisms  as  well  as  cenHcid. 

It  will  Iw  «vii  from  ihiN  extroiiwty  imporfitct  Kkcteii,  hovr  diffi- 
*oU  it  is  to  detei'mine,  when  an  aneurism  is  situated  low  at  tlie  rriot 
*< 'he  ni-ck,  what  or  how  great  a  jmit  of  tho  art^-rial  tntw  is  iii- 
'wvtd.  nw  importance  of  a  pi-eeiso  diagnosis  eouHbts  in  the  faet 
"■St  thrvc  grMt  oi)«ratii>iis  are  nwommvinlod  for  suoh  aneurt»in«, 
*r"i  lliat  their  appheahility  depends  entirely  on  the  limitation  of 
"»  ^MatN^  If  Uhi  sulicliivian  or  <-jin:)tid  wi-re  alono  involved,  n 
^Uuto  applied  to  tJie  innominate  artery-  would  be  analogous  to  the 
''Wintuit  adopted  in  otlior  i»\tU  of  tho  body.  If  tlie  aneurism 
*We  seated  fiir  down  tlie  subclavian  on  tlie  right  side,  it  might  be 
FmAIo  to  tic  tho  tirat  pan  of  the  artery  itself.     If  Uio  root  of  tJic 


*  Sm  iul-utk  bj  Allan  ItiiniB  and  A.  Conpei'.  in  Bums  on  lli*  S>ni/ital 
^■ttaf  ttf  lit*  llriHl  aud  Sfck.  18t4,  pp.  Uil  tt  ■q.]. 

i  I  baTC  •o«n  a  nnxu  in  wliicli.  from  otltcriiyiiiploros,  dicre  wiu  no  iliiB- 
^"J ia  dutgaaMaif  an  nuvuiisRl  of  ilin  nrch  of  the  miila ;  bill  uiic  ciifuiu- 
*'■'(«  wu  ilifllciill  to  account  Tor,  viz.  that  whiln  thti  puUc  in  tho  riubt 
*•«  wtB  niuifr«<i4tii.  that  In  iho  right  wrist  wm  Impnrcnplible.  Aftw 
'"Ol  llMt  anonutluus  liistrikulioo  inis  tbund  in  wltlch  ibo  ri;i[ht  KubolnviHn 
**  Ibr  Ian  branch  of  tLv  aivL,  I'as^in^  bstwrnm  t1i«  Mieurism  aud  th* 
'^e,  ii  hod  been  coai)>TCHSc(l.  wliilu  ihv  caralld  was  niialTuciAd, 

',  Wanlrap,  op.  Pit,  |i.  leiJ:  Oj-k-.  in  Path.  Soe.  Tram.  vi>l.  x.  p.  lOS;  Bel- 
'  Ki^m  «a  tUteoMt  of  Uie  Ihan.  p.  UOI ;  Allaik  Itui-iis,  op.  cit.  p.  HH. 

Tot.  in.  1 1 


482 


DISEASES  OF  ARTERIES. 


carotid  alone  vere  implicated,  a  lignttiro  on  the  diHln)  Hide 
tumour  (known  o»  Ilm»ilor'«  ojH^raliun)  might  proro  sunwAAfiiL ; 
aneurism  affecting  the  innominalo  artory,  it  has  been  |>r<>)x 
cxlviid  tliiit  iiihIkhI,  iind  ti«  Imtli  the  HiiMitviiui  and  oaratad ; 
if  tlie  arcli  of  ili^  oort-i  were  diseased,  no  prudent  Sargnn) 
Utink  any  ojiei'iitinn  jiistifiolile. 

Assuming  that  the  question  of  performing  anj  of  tlxwo 
op»ruti»ns  \n  not  i^ntt-rtainod  till  a  [ntionl  trial  of  judictoo*  i 
and  dietetic  means  has  been  made  and  foiled,  and  that  a  tluir 
exuminiitinn  of  thi^  i-lti<Kt  hnn  given  niuu>nii)>lu  asiiiiranii'  <>f '. 
muuity  from  disease  of  the  heart,  lungs,  and  aorta,  I  will 
vour  to  »UU'  OA  NuccincUy  a«  pomible  tbo  cotwltutions  to  wb 
havo  been  brought   by  observuig  a  few  caaee,  and   n.'oding  | 
axwouut  ofa  guod  nnmlwr. 

L  The  ligature  of  the  iniuimtnato  artery  is  an  operation  wl 
lioA  liitlu^rto  only  prooipitntoti  ibc  fatal  rrwult  impending  ov 
discuso,  and  which  appearii  tu  nffonl  less  prospect  of  cure  tlanJ 
hioUkkIs  of  gonorul  treatment  which  liavo  Immmi  above  ii 
But  if  those  are  obviously  ioiuiRicient,  it  may  in  approprtirt« 
roo»nimon<l  itftt-lf  to  soinv  Surgeons.     It  should  never  lio  pvrfu 
however,  unless  the  artery  i-an  clearly  be  felt  beallhr  iwhiodj 
Btenio-elavioular  joint  ;*  or  the  tumour  is  so  plainly  limilol  i 
atford  a  very  raiAouablo  ho[<o  that  it  wilt  W  fouiul  «o.     In 
tubular  enlargement  of  a  long  tract  of  artery  in  tbe   nrak, 
■wane  than   uMilewi   to  expose  lui   arUiry  wbieb  will  proli 
fbond  so  diseased  as  either  to  prevent  tlie  operator  Irom  the  i 
to  tie  it,  or  to  gi\'e  way  and  ooeusion  futul  bkwding  within  a  { 
hours  if  it  is  tied.f 

II.  Tho  ligature  of  the  first  part  of  Uw  rigbl  aiibeUvian 
is  an  o]]ermion  which  cannot  be  described  in  more  Gi\'oartiblu  t 
than  thut  of  tho  innominate,  iu>  Air  as  ilo  rtvulbt  go;  but  liie  ii 
cations  are,  pcrha]>s,  rather  leas  perplcidng,  since  a  cimir 
ought  to  exi-Ht  between  tho  tumour  nn<l  tlie  traciiea.  \1e 
howp\'cr,  the  aoatomieal  difficulties  of  tJio  operation,  the  douUI 
must  nlways  exint  whi-thcr  tlie  artery  will  bo  fbuiKl  henltliy  i 
to  iinitv  HA  tirmly  aa  is  necessary  to  bear  the  impact  of  sn 
ooluiun  of  bJiKid,  and  the  groat  liability  U>  tecuadury  Im-nMir 
from  tho  neighbourhood  of  large  branchee,  the  operation 


•  If  t)i«  shnpe  ortbaboDM  or  Jciola  is  a]t«i«d,  it  is  idaar  that 
euridin  uiivi  in  tlic  thorax. 

t  See  botow,  Ligaturo  of  tbe  lunomiuate  JuUrj. 


^ 


H        TTIKO  SUBCLAVIAN  OR  IKXOMKATE.         4m 

Unpromising  tliut  moot  Surgcnii»  wdiild  |>r(>f<!r  tlic  |)laii  by  mani- 
pulatioD  (Icvistxl  by  Sir.  Forgiuson,  or  galvnno-puncture,  dangerous 
antl  uncertain  -m  tfaeAO  nieauturct  must  Im.>  nllowtxl  to  \k, 

III.  Brasdor's  operation  for  socui-ing  the  artvuy  ou  tlie  distal 
■ide  of  tlifl  lunioiir  iit  aj)))]!!;!!!)!!.',  lUid  a{>i>lio»l>io  <>xdu«vci_v,  to 
aDeariuDs  affocting  t!ie  lower  part  of  the  common  carotid  arterj- ; 
ia  whi<li,  from  tlio  o<|iiiility  of  tbi>  nidiiil  [ni\M  on  the  two  sides, 
the  distinct  limitation  of  tlie  tumour,  the  freedom  from  oedema  of 
tw  ann  and  hand,  and  the  abMc'iicc  of  iiiiintmr  in  tin*  aorla  or 
■ubclavian,  thoru  is  reason  to  believe  that  tlie  atfocLJoii  is  confined 
*o  tlu  iioiiiiiKHi  carotid.  In  sncli  ea^iw,  it  would  bo  n.'a»oiinbitt  to 
Wnnmencio  the  tfoatment  by  apph-ing  digital  pressure  to  the  artery, 
"»  the  pomitiiin  in  which  it  i«  int<-ndtfd  aftvrwtinl*  to  tie  it. 

IV.  In  discussing  tbo  general  question  of  Brasdor's  method,  I 
*iJlgivc  my  reasons  for  bitiicvjiip  tliiit  it  i*  inu]>plicable  I«  cmisc*  in 
*'"ich  it  would  become  necessary  to  secure  the  subclavian  as  well 
**  lite  carotid. 

lo  the  sections  which  deacribe  the  treatment  of  aneurism  by 
ijinlution,  hy  <-niigulatin^  injections,  and  by  gal  van  «•  puncture, 
"O  reader  will  find  sutScient  data  to  guide  bira  in  forming  an 
'pinion  as  to  the  propriety  of  using  tlioso  rneitsures  in  any  given 
**»c  of  aneurism  in  tbo  nook. 

BraMlor's  mctbod  will  be  found  doM^ribcd  on  a  subsequent  pago, 
^ogotlier  witJi  other  operations  on  the  common  carotid  artery.  It 
tsuatni'  only  to  describe  tlic  opcmtions  on  the  fintt  part  of  the 
■vbclavion  and  on  the  innominate  arteiy. 

!■  Otdor  to  secure  the  yfr*/  fxirt  of  the  rujltl  tuMmntin  arli^y,  ta 
!■  &e  opeostion  ou  the  innotniuiitv,  the  root  of  the  carotid  is  to  bo 
*IpMed  and  traced  down  t^i  the  biftn-cation.  The  e:ctemal  incisions 
"■J  Bopcrficial  rtiswctioii  are  therefore  the  same  for  both  oijerations. 
Ad  bcision  uliould  bi*  intnle  along  the  nj)|ier  bonier  of  the  clavicle,  a 
*"«t()r  passed  luidor  the  stomal  fjorder  of  the  stcmo-mastoitl  muscle, 
'"i  the  wh<ilfi  or  the  gruatcr  part  of  the  iiiiiHole  wpariilrtl  from  the 
■^um  and  clavicle.  An  incision  should  also  l>o  made  upwards 
"HI);  ihe  inner  edge  of  the  nitii«<-]e,  and  tJio  whole  flap  containing 
"•divided  muscle  should  be  reflected  outwards.  The  Btemo-hyoid 
*>i •tenit^tJiyroid  tniiHi-lctt  now  eoiiie  iiit^)  ^lew,  and  may  be  draivn 
**leiritb  a  blunt  hook,  or  cut  across.  This  will  expose  fully  tlic 
■*Uh  of  the  carotid  ve*si^l* — the  internal  jugidar  vein  on  this  side 
■ifiMng  away  from  tlie  artery  so  as  to  leave  an  intenal  in  which 
«t  pncumu-gastrtc  nerve  is  to  be  found.     If  now  the  operator 


m 


DISEASES  OF  ARTERIES. 


(Ici#irM  to  MOiiru  tho  (ir»t  ]>nrtJoii  <>f  Ui«  Nuliclnvian,  1m>  muM  ij 
nicnibei-  that  llie  only  part  of  it  sufficiptilly  ftw  from  impcirti^ 
rolntions  to  admit  of  tlio  0|HTntion  u  tlu.'  humII  [lortion  botiri>li<l  lij 
Uie  ]>noiiin(>-};u.4ti'io  iiertr'o  on  the  inner  side,  and  ttit!  t}i^-rc>id  t^ 
witli  tho  phrenic  norvo  on  tlio  ouItT  sitlo.     Tho  former  nary*  ibiU 
faea  U  to  he  taken  as  the  guide ;  and,  the  curotid  nrutr  h>*fM| 
buCD  traced  don'n  to  the  bifurratiun  of  tho  wtuxsls,  thu  miIr-I  . 
to  bo  followed  outwards  til)  the  pneumo-gaalrio  u>-i^'»  U  rti- 
by  tho  finger.     Tlic  lignturo  n-iU  tlivn  he  tDo«t  nindily  pas- 
it  probo  run-(Hl  abniplly,  or  a  needle  mon  bent  tluin  mtu],  intiw 
dticod  from  bi-foro  hnckwards.  I 

If,  on  tho  onritrury,  t/u  miomittatf  is  lo  bo  tivd,  the  npcnHI 
must  follow  down  tho  lino  of  tlio  carotid  artery  into  tlw  llmno^ 
when  he  will  find  llie  end  af  the  vwstil  bi-hintl  tim  itbmA-olavi 
joint,  snd  must  get  the  lignture  around  it  as  bert  he  em, 
ibo  mcMtt  diRicult  part  of  tlii-  whole  o|H>rBli(m,  wno*  gn-ul  vpim 
cloeo  to  the  artcrj',  the  slightest  wound  of  which  may  gin  Hm 
fatal  Im-morrhagc,  and  tlio  [mrtit  art;  |ir>iliiil>]y  quite  ttul  of  sighL 

On  tlie  dead  subject,  the  innominate  may  Ijc  n-iic-Fu'd  w 
nnyMiicii  extensive  di«M)Ction,  by  ex[>ntiing  tiiv  root  of  tlw 
with  a  fiiifficient  incision,  and  rnnning  tlie  Biiger  down  it  into 
thorax,  wbon-  tlie  arter}-  will  he  fett  crossing  tiie  air-tube  M 
but  in  the  living  body  I  should  think  tho  jpx^iter  frowlom  aixi 
view  of  tho  parts  obtained  by  tlie  division  of  the  mnsplM  at  il 
of  the  nook  would  rv-ivh-r  tJio  operation  atwve  dc^crilwl  pn<fvnUik* 

Tlio  iniioniinate  is  said  aUo  to  have  been  reac-hcil  from  the  ftM^ 
by  removing:  tln.^  t^nd  of  tho  elunium  and  thottonud  end  of  (huct^ 
x-icle.  In  tliis  case  (under  the  care  of  Dr.  Coo]»ct  of  Sm  Fi 
oiseof)  tlio  ujijurr  end  of  the  innoniiuatu  art^-iy  il«c)f  was  iiu 
and  the  aneurism  atfectcd  aUo  tbo  aubclavian  and  carotid, 
ligiitiirv  WM  appliMl,  it  is  said,  only  thn^v-quartcre  of  an  inch 
tho  arch  of  the  aorta.  He  patient  siu'vivol  li\-e  dn\'H,  and  hii 
is  altriliiitod  by  the  operator  lo  dl«easv  of  uno  kidi>cy ;  but  lu 
is  told  ua  about  the  condition  of  tho  ligature,  or  of  tbe  tied 


*  It  U  usual  in  Kpt-ttkioK  or  (li«  UkhIuiv  of  tliv  IniHMaiaaU 
tldiicrlW  varioua  cuiiliivAnrcs  Tuc  miTyiii);  ■  li);Hluie  round  II     I  lt>t«  I 
faund  oil  lh«  deaJ  sulijca  tbm  they  lati  ■ii|>«rni>r  to  Um  kimtil»  uicu 
noodle,  nov  Imvc  I  neon  anjr  cas«  la  wliidi  ihi^r  hate  Ix^-ii  uanl  m  I 
liviox.     Mr.  S,vinc,  in  sjittHkioK  of  tlM  llgaiitre  of  iha  dMnuan  Uiu  uii 
Mj-"  tlial,  la  hit  judgnitnt, "  tbe  »iaii>l»l  tatm  ot  unvtUc  U  Uu  b»»L,"  fA 
in  Cliniat!  Suiyrry.  p.  Hllf. 

t  Atittt.J<itu\f,filcl.8e.,0el.  1858. 


BRASDOR'S  OPERATION. 


US^ 


ofthe  aneurism,  we  cannot  fonn  Any  very  ftecise  idea  oftha 

of  tho  cnsc. 
All  tlie  caae»  in  which  th»  innominate  artery  hoft  been  tied  have 
pr(ive<]  fiital,  vitber  from  eccondar)'  liivmorrhu^  or  irom  iiifluin- 
tnutiofl  of  the  l}ioracI«  s'lM^rn ;  but  in  l}ifi  two  llr»t  casea  in  which 
the  [ipvmtion  was  undcrtokcu,  thi;  paticnb)  lived  no  long  as  to  kIiow 
tli«  possibility  ot'reoovery;  Uott  (tlie  orij^iiial  wpcratror)  having  lost 
hia  jioticnt  on  the  twenty-sixth,  and  Griife  on  tho  sixty-Hcvoiitli  <l»y.* 
Two  rcroarkable  operational  are  on  muinl  in  wliicli  the  artcn,-  was 
«X|XMcd,  but  was  found  to  Aiscascii  tliat  tlie  Surgoou  did  not  voiitnre 
to  pnt  the  ligaturt!  rouixt  iLf  In  »iw  of  llu'-ie  (Mr,  Porter's)  the 
ilia«Hw  was  afterwards  cured  spontaiieotwly,  and  in  tho  oUicr  (Mr. 
Aaton  Key's)  tliu  |>attciit  lived  much  longer  tluin  uaunl  after  the 
U<|>enitK>n. 

H  Tbe  operation  on  tlie  fint  jmrt  ofthe  snWIaviun  hoA  aUo  been 
HiiUieito  uniformly  fatal,  but  has  been  eo  seldom  porformed,  and 
P*ill  probably  in  ftitiirc  \>o  tx>  much  iivoidvd,  that  it  i#  hunlly  worth 
^  winle  to  discuss  tJie  seven  cases  which  are  on  record,  and  which  may 
betntnd  nientiontxl  in  ErlcliM-n  (up.  ciu  p.  bUS).  In  Uic  Mtnn*  plaoo 
Buy  also  be  found  discussed  Mr.  Fcrguason'a  proposal  for  the  troat- 
nwt  of  aneurium  at  the  root  of  Um:  ntick  wliicli  rosinl.-*  lem  heroio 
"wwrrw,  viz,  to  amputate  at  tho  slioulder-joiiit,  trusting  that  Uio 
(dittal)  li^turu  of  I  hi,- axillary  ark-ry  on  ti\e  facu  of  the  stump  would 
<■»«  tbe  aneurism  now  that  the  limb  is  removed,  and  so  no  need 
•Ws  for  n  ci)Ihi(»Tal  cirtrulHtioii.  llio  sugjcc*tioii  has  not  been 
■to!  Ml,  The  operation  must  be  a  most  dangerous  one  to  a  patJvnt 
"Wiring  under  diwnse  "f  tlie  great  vessels,  and  the  cure  of  tlie 
by  it  bigtily  doubtful. 


Bba8D0R*8  MbTHOD  op  TRRATTNO  AXRCRiaH. 

Bratdor  was,  it  is  said,  tho  first  to  propose  the  operation  wliich 

l^i-ver  since  gone  by  his  name,  viz.  the  ligaUiri'  of  an  artery 

■w*ed  by  aneorism  on  tlie  distal  side  ofthe  tumour,  or  that  far- 

'■t  from  tl»o  ht'art,  inototul  ofthe  usual  plan  of  tying  it  between 

'"  liwut  and  tlie  tumour.     Itrasdor,  however,  has  left  no  written 

'  *«nuit  of  hut  |>ro|HiHitioi),  nor  did  he  ever  put  it  in  practice.     It 


*  Iftdt'a  op«rDtion,  ami  ihc  pni-Iiciititrs  uf  t]i<>  posViitorti'tn  txamiualion, 
'''IWbiand  in  GriCoiuul  Walllici''s>'<ju/'R.  vol.  lii.  p.  aut),  and  Uriifi-'s,  iUJ. 

f  Cn*p,  op.  dt.  p.  30*.    The  same  tbiog  wm  done,  according  to  M. 
"Kt,  bf  Post  of  N«w  Yoik. 


486 


DISEASES  OF  ABTERIES. 


was  renewed  by  Desaalt,  «nd  he  has  left  as  a  notice  of  it  ir 
works.*  The  first  person  to  act  iqwii  thi-  siijigixtion  was  Dee- 
dtampa,  in  a  case  of  femonil  aiMmriein ;  but  his  operation  wad 
imdortjikoii  on  such  mistiikcn  principlrs,  nnd  wis  condur^Ml  90 
unBiicoGHsfnlly,  tJiat  litlJe  aae  can  be  made  of  it,  Sir  Astlcv  Cooprrt 
tied  tho  fi.ini)ral  artery  bolow  »n  nnruriiWi  in  tJie  groin,  which 
appeared  to  him  to  have  extended  tw  far  np  ns  to  render  tho  appli- 
oation  of  a  liRnttiro  above  thi'  tumour  i in j)!™.*!! cable.  It  aeems, 
howe\'er,  from  the  terms  in  wtiich  this  operation  is  spoken  of,  ihit 
it  was  only  intendtnl  as  a  temjMjrurj'  exixiciieiit,  and  that  Sir  A. 
Cooper  expeeted  fi-om  it  merely  such  a  diminution  in  tJw  «iu 
of  the  ttinionr  as  would  render  it  atteninrrl.-*  [Hjsvihie  to  apply  a 
li^ture  ill  the  oniinarv  way.  In  this  ho  was  disapptMntnl,  fiT 
the  tunionr  eontimied  to  extend  uiiwarilf,  wid  hurikt  under  tW 
perilon^eimi.  J 

With  tlie  rewjurecs  that  modem  Surgery  pt>«*<'«*^7  «»d,  it  a*p 
be  added,  with  the  knowledge  we  now  possess  of  tlio  very  gm« 
dungerM  attending  on  ligature  of  the  large  vc^elt*,  sueh  »|>eratii>iis 
as  those  above  nihided  to  would  be  universally  repudiated.   TTierei 
no  such  reasouahic  probability  of  curing  an  aneurism  of  any 
artery  of  the  limli.t  by  distal  ligature  as  would  justify  a  Swgwjnl 
exposing  his  patient  to  tho  risk  of  tho  opc-ration. 

Tliere  is,  h<iwei-er,  one  situation  in  which  tJio  operation 
boon  successfully  iMTrformcd,  and  in  which  it  will  l>c  perfinlly  jo 
fiable  to  repeat  it,  ut  least  until  some  more  certxun  and  safe  me 
of  euro  can  bo  suggested;  viz.  in  aneurisms  of  tiio  carotid  arwy 
nt  the  root  of  the  neck.  Mr.  WardropJ  was  tho  first  to  show  li* 
practicabilify  of  this  proceeding ;  and  he  operalt'd  suew-»*ful!y  mj^ 
carotid  aneurism  of  rooi^nt  origin  in  a  lady  aged  seventy-fi%xb 
him  also  must  bo  conceded  the  merit  of  showing  the  ilifTi-rence  ' 
prim^ple  between  the  operation  uc  pnictised  upon  the  carotid 
upon  tlie  arteries  of  the  limbs.  TIio  difforonco  depends  simply ' 
the  fact  that  110  braiiehe*  are  given  olf  by  tho  carotid  artery  ini 
part  of  its  com"se  ;  so  that,  for  this  purpose,  the  whole  of  the  ' 
may  be  regurdoil  as  part  oftlio  nin'uri«mal  sae,  and  a  barrier" 
any  part  of  tho  artery  will  stop  the  circulation  tlu-ough  tlie  tumoui^ 


•  (Eiivra  Chif.  vol,  u.  p.  608, 

I  HodgsoD.  op.  cit.  p.  'HOI.     Mr.  James  atExHw  perioniMd  a  tin 
OpcrnlioD  OH  the  palicnt  hi  whom  tie  aftvrwarila  He«urc<l  the  bmUu  : 
nttrihiited  to  tb«  liistnl  lij^tiire  of  the  TeinonU  a  cvrtnin  amount  of  < 
tinu  of  the  tumour.     Med.-Ckir.  Tram.  vol.  xvi.  p.  I. 

;  Mtd.-CHir.  Tnui$.  vol.  xm.  p.  sill. 


BRASDOU'S  OPERATION. 


487 


at  htd  n  tlio  case  if  tlie  aneurism  Im  not  situated  so  iicitr  tn 
I  nbfamn  (on  tlw  rifjlil  «■<!<')  m  tu  »1iiiru  in  ilio  <rirculaUon  of 
.  msd;  l>ul  such  a  tumour  would  be  ulinoat  as  mucli  au  anbur- 
lo^llw  BttMiiviim  OK  ut'tlio  carutid.     On  nocouDt  of  liia  hucoom 
[  lUl  uutamcu,  nod  his  work  wrilUin  to  recommend  this  iitnn  of 
I,*  Mr.  WNnlruit's  iiiiniu  i»  frotjuoiitly  wwodutod  with  the 
!  »  It  is  now  Mttely  applied,  viz.  to  carotid  nneurism. 
In  tlie  ^nwriniii  Joumat  of  the  Moiiml  Scumceg-,  vol.  xiv.  p.  22, 
(m  fimnd  a  table  bv  Dr.  Norris  of  tifloeii  casen  in  wliich  ttio 
id  arierj-  wiw  liwl  on  this  prinfiplct     Of  tln»c  fifUtni,  four 
I adiuiitud  to  ha^o  died  of  tlic  itiiiiiediate  etfo«t6  of  tJic  operation ; 
to  iJuN  tituiil>or  tlio  thini  cam-  in  tiic  tablet  ought  certainly 
I  kn  widod,  aJid  perhaps  ihe  sixth  also.     At  any  rate,  we  Hholl 
Jy  not  t-n  riinch  in  ri'prcscnting  the  niortjiUty  of  IJrasdor'a 
iuD  oa   the  carotid   arti>ry  at  one-third   of  llie   niunW  of 
Of  Iho  fineon  cases,  foiir  only  are  said  to  have  btfi-n  cured 
operation.     All  of  ihcrn    iippcar   to    have  been    aneurieina 
evrotUi,  unless  one  sliould  bo  cxcejited  {Nu,  S),  in  which 
iBtioininate  was  thought  to  be  nfft^ed ;  but  an  thia  caso  ro- 
txl,  t)u>  diagnosis  was  of  course  not  absolutely  confirmed.^     If 
I  take  tbeee  statistict*  as  Iwing  oorroct,  which  we  ore  obliged  to 
ni   iIk'  want  of  more  exionded  expccienee,    it  is   ahnndantJy 
iluit  iJm>  ri^k  of  llio  u|KTation  is  c(mntvrbalaiic<il  l>\'  a  rutiouiil 
liility  of  suooew  only  when  the  aneurism  is  seated  u}>on  tho 
id  ilM-lf,  and  does  not  share  in  the  pulsation  of  the  niilKrluvian. 
>bIii)vc  amount  ufsuceeas  is,  liowever,  quite  enough  to  justify 
I  adoftlion  of  the  method  in  any  such  uisc,  whore  the  attempt  to 
libit  artery  on  llunler'si  principle  would  be  impracticabto  or  owa 
witli  unuRUal  dangi-r. 
One  eirc-u mutant V,  which  weina  to  occur  pretty  generally  though 
■]ly  in  tluso  cases,  testllics  wry  strongty  to  the  activity 
leSbrts  of  nature  to  cure  the  di^anc.     It  i^,  tlial  the  pulsation 
iti  iIki  tumour  is  usually  not  increased,  l>ut,  on  tho  oontniry,  oflen 
BiH'k  dimiuisited,   by  tho   ligaturo  of  tlie  ve»sel  beyond  it.     In 


»•  0»  JaMfUm,  Li>»di>ii.  liH9. 
t  Orwtii«li*ix  w#T«  fur  aneurism,  supposed  to  nffoct  the  carotid  oitljr: 
iha  mnaiuder.  di*  Iniiotniaat*  was  UioukIiI  to  bo  tlto  Mat  of  tho  dineaae, 
Ihaugli  ii  ta  plain,  from  the  dissection  uf  uasM  in  whieh  dwtta  took  place, 
In  Mirni!  at  leaai  the  anfa  of  Uie  aorta  was  diseased. 
I  Mr.  Ltmbvria,  quoted  Avm  tVardrop  on  Ancurifm. 
4  The  iaxt  aii>e  oiivrated  on  in  Loudou  was  under  the  care  of  Hz.  Ijtno. 
rb*  ofcration  was  uniuoMoafUl.  ■■  the  aaeurUim  burst  into  llio  lung. 
Joofmr'm  Hmrg.  Vict,  6th  ed.  IMl,  vol.  i.  p.  2ia. 


48ft 


DISEASES  OF  ARTERIES. 


almost  nil  flw  cases  pclatwl  in  Wr,  Wardrop's  bod;,  tbt  t 
vim  otiHpn-o:!  to  dimiiiixh  both  in  »i/.»  hiiiI  ifuUatioM  iiiUH 
nt\cr  til"  (){H'rntion  ;  a  result  which  cuiild  onl^r  have  bwn  dac 
rapid  incronso  in  »'xxo  of  tin*  bntnclKw  Iwlow  Um>  tiit(u)ur>  hy 
ilia  coiinvt  nf  tlio  Atroani  of  b1<Mxl  was  diverted  ftuni  the  atHn 

AiMMtrixms  of  tbi-  iimoniiiintv  artor^'  luit'o  kIm  bcoo  trn 
tlio  Biimo  way,  but,  as  far  as  I  can  disoovcr,  witboiii  ^uoccMk' 
can  tliis  bo  a  maltvr  of  Kiirprioo.  Tliu  plan  sdo]>Uii  Is,  to  tw  1 
brnnohes  of  the  artery,  the  common  carotid  and  subclavian, 
difToront  oiKTBtimw.  Now,  Uip  lipitHm  of  tUr  rif;ht  milM-la 
tlie  first  pmt  of  its  course  ia  only  Ices  ftirmidablc  and  doi 
than  that  of  thu  innominato  artery  itself;  and  it  con  hat 
expected  to  succeed  njioii  a  patient  who  has  abvady  been  * 
to  Bu  smore  an  oj>orati<.>n  as  tyjii^  tbo  common  carotid.  Oil 
there  is  no  meohatiicul  reason  why  the  treatment  shoahl  not 
cwfttul,  pruviJod  tlic  Siirj^ton  can  bo  tmro  that  hu  ti«s  tlio  uib 
between  ihn  ttinumr  and  the  origin  of  it«  great  brancJies,  Set 
tbo  mouth  of  so  large  an  art«ry  as  the  vertt^tbral,  tlnTotd  1 
internal  muniinnry  bt?  left  'ijM'i)in<;  mil  oflhe  tiimnur,  (lie  m 
probably  enlarge  to  such  an  extent  as  to  wurj-  on  tlw  oi« 
thimigU  the  anetirisni  aa  etTevtunlly  as  the  originul  Imnk. 
the  treatment  is  Iteeet  with  so  many  difKeidlicei  an^l  rb>)(»,  tli 
|icr»oni>  would  prefer  the  ehanoc  of  a  spontanoons  ctiri^  uitddt 
medical  and  dietetic  manngemeiit,  if  tlie  tuntonr  is  not  mi 
orbnretin^.  If  it  'm,  perhaps  iho  above  (^rativepUn  may 
mend  itself  to  some  Sui^eons ;   but  il  is  a  desperato  cxiHtlii-i 

There  is  indocd  a  ciiMit  in  whieh  both  arteries  (the  mill 
in  the  tliird  part  of  ita  course)  were  tiod,  tliotif;h  at  nn  inti 
two  years,  and  where  tbo  patient  is  said  (o  liav«  n.'oon'n 
both  ojterationB,  and  died  three  montlia  afier  ligature  uftlui 
vian,  of  pleurisy.  The  aneurism  was  tilled  with  ili'iiao  iiri 
eoagnlinii,  oxeept  a  channel  tl»e  ustuil  sixe  of  the  innominate 
ThiH,  however,  can  hardly  be  considcrad  a  satis&ctury  caw  0 

Old  optvation /or  rtirotid  atifurum.     The  trcsatmeiit  of  an 
nt  thu  root  of  tlto  nock,  at  lout  when  it  fbllowa  a  vroundi  hi 


•  I  ii)ioiil(lroir«rd  Wardrap'iMae  (op.  dLp.  M)u«nfn«t>n««<)1 
(and  only  ot  beticAt)  <l«r|vMl  ttvm  a  oombtnatlon  of  ^'>lnlva'«  tr 
with  tbu  lifmture  oftbe  thinl  p*n  nt  t)i«  aubolariaa.  Tb*  ranai  rem 
1  liave  lieuixl  of  necuired  tu  the  )>ni>:tic«  of  my  trieai  Sig.  OtitU*  of 
irho  ivlatrtl  it  to  me. 

t  K«ant.  Zioac**.  1S8IVT,  Tol.  i.  p.  199;  1689-8.  vol.  tip.  7l8:i 
TOl.  i.  p.  Ml. 


OLD  OPERATION  IN  THE  NECK. 


489 


elr  snccessfiilly  carried  out  by  Mr.  Sjme  on  tlie  old  inetliod,  by 
fiug  u\mai  Htv  tumour  an<l  i>(MU'<;limg  for  both  cnilx  of  tbo  vi'wwl. 
■bridged  account  of  Hus  daring  operation  in  apjieiideil  j  tlie 
Ut,  liowcvcr,  ciui  have  no  idoa  of  tJto  risks  and  difficulties  of 
toh  a  pnkc«txlii]g  witJiout  poruHing  iha  fuWiir  luiKOiiiit  in  the  ori- 
nol,  ami  rvcn  tbcn  bis  idea  will  bu  but  a  fuint  and  iniporfiift  one. 
Hio  operation  [jerfornied  l>y  Mr.  Synifl  may  Ufi  lluw  sununarily 
.■riUud.*  The  piitioiit  liad  been  stabbed  in  tho  rooC  of  tlio  nwk 
toot  two  moiiilis  bi^fore,  and  uti  atieuriitni  tuid  fni-inti),  oonncoted 
ith  t)w  lower  part  of  tliP  left  common  carotid.  Tliis  had  been 
.vaocing  rapidly,  under  oonipn-Mioii  applied  to  tlio  tumour,  80 
oi  it  wax  noccesary  to  do  something.  Mr.  Symo  made  a  email 
pctiiog  into  tli>o  pulsating  tumour  with  a  bi.ttoury,  and  then  pii»aed 
hi»  tingcr  mi  as  to  plug  tbo  puncturo,  and  felt  about  till  ho  ^^ 
ipon  the  spot  whcro  prcsaore  controlltx)  tbo  pulwiti'in,  and  where, 
',  tlic  opening  lay.  Keeping  this  point  firmly  compressed, 
llic  Aac  lively  o[icn,  and  Kponj^^nl  out  tbc  clut*.  A  Niiootb 
*nwriitarfaoe  was  exposed,  witb  no  trace  of  artery  or  vein.  The  skin 
^«lemal  portion  of  tlie  slomo-niaMoid  having;  now  IxTn  diviilod 
ttrutsrerse  incision  (prossnre  being  still  kept  npon  the  opening 
ihthe  Angur),  tho  edge  of  the  »Iit  in  the  art4sry  which  lay  under 
I  finger  was  caught  witli  catch-forcep?,  and  llie  veasel  drawn 
the  traelit-n;  it  wii*  llion  carefully  scratt-hwl  ivith  a  knife, 
tlie  arterial  coat  was  brought  into  view  on  tho  external  edge, 
WtbgHture  [Mutfed  nnmd  it  alxjve  tliL^  ap<-rttire.  Tlio  same  pro- 
wa«  repeated  below  tho  opening;  and  now  tlie  linger  could 
oilialrawn  without  tlift  treincndon*  gn»h  of  blood  which  had 
Wbw  followed  its  displadcraent. 

Jl  it  cltoir  that  such  an  operatiim  as  this  can  bo  tuccc^iiiftdly 
led  (that  is  to  say,  performed  without  inMant  deatb  result- 
by  a  Stirgcon  who  posw«i>cs  a  largo  share  of  that  fertility 
and  dexterity  in  operating  which  Mr.  Syme  showed  in 
peat  a  dcgn-i'  in  this  cwc     Uri  the  goneral  ((uustion,  aa  to 
'"Mfcer  a  ease  like  tlie  above  ought  to  bi>  treateil  im  Braador's 
or  as  Hr.  Syme  tixuiti-d  it,  it  would  bo  rash  to  affect  to  give 
itive  opinion ;  much  would  dejiend  ujion  the  confidence  of  ihe 
m  in  himself.      If  he  felt  able  to  carry  out  to  a  siieccMtnl 
n  90  difficult  an  oi}erauon,  ho  would  probably  imitate  Mr. 
■'»  practice;  if  not,  be  might  try  tbo  distal  ligature  c^  the 
id.     Shoidd  Bmsdor's  operation  fail  to  eheck  tho  progress  of 


*  Obitnation*  in  CltKieitl  Sargtrg,  p.  194. 


490 


DISEASES  OP  ARTEnms. 


Ut*)  tumour,  the  old  opration  might  be  tried,  and  eron  n  liin 
pruspi-crl  of  Itfu  might  rL-maiti  tu  tho  )<Rti<'tit  from  aa  attempt  madt 
to  secura  the  artery  after  tlie  aneurism  had  burst. 

The  abovo  n|>cr»tinn  indicate*  hu  cU^arly  tho  stops  that  chon 
be  taken  in  f/ecunag  the  (parotid  on  acoount  of  a  tvuuitd,  tliat  nt  J 
furthor  dcfuriiition  of  tliat  pruwcxiiug  is  n&xesary. 


Anedbimis  in  the  ui-PEii  Part  of  tuk  Neck,  tbk  Okbjt,  am 

TilE  CttAKtl'U. 

Aneurisms  above  the  root  of  llw  iitH^k  will  be  found  to  affcd 
cithor  tbi;  cjmnion  cjirotid  juHt  at  iU  bifurcation,  or  the  ortfric*  of 
the  orbit  or  pranium.  The  diagnoain  in  eitlier  of  tlie  tvft>  fonnuf 
situations  can  ji^-m-rally  hi^<  cKtabbslicd  satisfactorily;  but  fow  thing) 
are  do  tlith<nilt  m  to  djiitiii^uii^h  fruni  oacli  otlier  (he  varioiL>  <li»eaNd 
which  may  cause  pressure  on  porta  uf  tiio  brain,  or  disturbaooo 
of  the  cerebral  functions. 

Tlio  occurroiicc  of  dilatation  at  tho  UpjKT  end  of  tho  cornnjon 
carotid  artery  in  a  ttlight  degree  ici  iiat.uraJ ;  and  Liiia  iiiiturul  ii»- 
tation  IK  comparatively  often  so  fiur  incrcasod  that  an  am'urii 
reaultii.  It.  i:*  an  old  oliAervation,  that,  the  c-arotid  i»  the  only 
of  surgical  aneurism  wliich  is  tMjuaUy  frequent  iu  both  seizes,  if  it' 
be  not  even  more  common  in  women.  The  diagncwis  of  aneoriMi 
situated  in  any  part  of  tho  neck,  above  that  portion  of  the  carotid 
whicli  licH  in  till'  Iniiitediiiti'  vic^iuity  of  tin'  su1x:Iaviiui,  uaniiut  pI'^* 
sent  any  especial  difficulty  if  the  sac  is  formed  and  the  pulsslioO 
distinct.*  The  proximity  of  tlie  tnimmr  tu  (he  air-jiaMagcs  ud  0: 
tbe  nerves  which  supply  tlio  la^}^lI  may  causo  d>-spnae4, 
ne«H,  ur  even  loss  of  sjieeoh,  nausea,  niid  [H>rli»ps  impairmi-nt  n| 
appetite  There  will  also  bo  giddiness,  and  trouble  in  die  bvt^'- 
and  pi^rbaps  pain,  numbnenH,  or  otlicr  nervous  phcnomeiuL  o\^ 
the  bead  and  face.-f  Tliesc  symptoms  call  for  dociaive  and  efficii 
surgical  treatm«nt. 

Aneurisms  situated  witliin  the  orbit  are  usually  aup|)OAcd  to  1* 
of  tho  '  aiiiwtomotic'  variety ;  but  tlio  m-id«nc«  on  this  jwiiit  it  &f 
from  conclusive.  Mr.  Busk}  has  sliown  that  many,  at  any  rate, »" 
of  till?  ordinary  traumatic  variety ;  and  Jlr.  Mimnolcy,  tn  hispap-TO* 
tho  subject,  which  gives  the  result  of  the  most  extensive  oxperiiin* 


*  A  CAse  of  ruptured  arlPiy  i»  iiic niJuueJ  na  p.  ^i-i,  in  wbidli  mu^'li'' 
«ully  was  Rt  first  expi'iiutieed  in  furiiiinc;  n  diHKnosis. 

\  Sou  tho  account  of  Sir  A.  Ci)i>per*ii  cnsc,  Gug't  H<npi<al  Reporu.  vA-  *■ 
p.  08.        _  :  Mtd.Chir.  Tram*.  toI.  xkU.  -.  IKS. 


ORBITAL  ANEURISM.  491 


fmrtiimlar  \T}iich  has  fallen  to  any  individual,  sincp  no  Icsa 
atM-*  liiive  bi-eii  undtr  liiij  own  paro,  gi«e*  »o  lap  un  lo  <[uv»- 
(irtirely  Um>  correctness  of  the  common  opinion,  foundod  on  Mi-. 
wrs's  otuN> ;  and  bclk-vt-^  iliat  !i)l  the  ikni^irtHni.t  Imve  bot'ii  of  t.bo 
iponlaueous  or  traumatic  kind,  except  tlioso  which  have 
into  the  orbit  from  ii  iiiuvus  of  Uic  lact-.*  WlietJier  hII  tho 
en  so  or  not,  the  general  correctness  of  Mr.  Niumelev's 
to  N'  inipiipiod,  lliat  most  ol'  tliiw^  ciimw  (luid  pro- 
ly  Travcrs's  among  tJiera)  were  common  anourisro8.t  Both 
^inptont.4  und  tliv  hiMiirv  provo  Uii*.  Sir.  Niinin-k-y'it  arj^- 
Db  are  these :  aiteuriiini  by  uia&tomosiB  comes  on  gradually, 
erally  iii  early  life,  w  a  nwult  of  the  growth  of  a  oongcnibd 
rism  of  tlie  orbit  very  suddenly,  often  as  tlio  result  of  a 
imoNt  Hlwa\':<  in  advanwdlife: — aiimirinni  by  ikmuttotnoitift 
in  tlie  subcutaneous  tissiues ;  anouriim  of  tlie  orbit  gonorally 
(Wpt^t  [iiirt.  iif  the  cavity: — aneurism  by  iinn>>tomo.->itt  invotvcA 
)  neighbouring  vessels,  arteries  and  veins,  in  active  disease ; 
Bm  of  the  orbit  is  gnicrnlly  limited  to  a  singlo  [>art,  or  if  llio 
libouring  vessels  are  dilated,  tJjey  seem  only  enlarged  from  ob- 
— ligatiin-  of  the  trunk  of  a  ve-ssfcl  leading  to  an  uiidoubtvtd 
by  anastomosis  is  an  extremely  misucccssfid  operation ; 
nriittn  of  tl)c  nrhit,  n  vory  suocoestul  one : — finally, {  tho  ciuws 
have  turned  out  to  Ix)  common  mii>urism.§ 


a  (Sarg.  bueatnofthe  Eye.  Sd  eil,  l«ni.p,  TtO)  r*ilatM 

_  lumour  ijrotni(ling  tliu  oj  t".  iiinL  oituxing  sltKlil  (luUWion 

*iii  attcrikl  BoulUu  not  lif«rU  on  tlio  oihtr  side."  Crying  giojitly  in- 
ibe  |>ri>U-u«tuu.  auJ  Uii.-  vusL-ului'ity  uf  itie  coqjiinctlvii,  uLioli  was 
If*  Musldcmbk,  It  nun  diut;ii<»iuil  Iiy  llilnH(^1^  and  cntlongiios  to  bo 
iftfm  by  aiLSStuinOBiii.  Tttc  cuiviicl  wu.t  tk*(]  with  [lerrect  tiuocess. 
\  This  is  important,  sinou  the  ■tierms  of  Tmvem  in  tying  tLe  irarotid 
bean  used,  tiuder  the  a^suniption  that  Itb  fnnc  wni  acinuisiu  by  auAslo- 
it,  to  enforoe  tliu  reeoiDtnriidRtioit  nf  a  KJiniliir  ujierutioii  lu  oasvn  of 
kj«m  b;r  anaKtoniosia  on  tlio  scalp, — an  opcnuion  bjr  wliicli  a«v<ml 
hare  very  iirobablj-  hren  saciifiroil. 

!  Sm  Mr.  Nunnclcy's  no oiunt  of  the  iJIsxectlon  of  th«  ooljr  «ue  out  of 
Iaut  undi-r  bii  cun!  irliich  provnd  fstal,  in  Path.  8oe.  Tran*.  rul.  xi.  p.  0. 
rS  ob««rve.  tbat  Ibc  ivliolo  oi  Oip  opbtbnlnilo  artcr]r  und  its  biuiiubvs 
M^tctitcd  in  this  dnto'liig  a«  dilHt4<d.  wbicli  biings  the  anse  Homuwbat 
to  <inioi<l  ancnrivn.  I  da  not  understand  how  Mr.  Nunndcj'  aconunt* 
dilatatian  by  Myitig  tbat  it  is  the  result  of  obtttructiun.  Sudi 
miicht  ad  on  (he  art^rj-  behind,  but  suroly  not  iu  front  oi 
iriam.  Outlirie  {Operalite  Sutgfry  <•/ iht  Eyt.  p.  IBS),  in  n?fiMi-ins  to 
li«»««iloD  of  a  case,  m«r<'lj-  oafs  lUal  he  found  "  tru«  aueuriiim  of  tho 

\m\e  RrteiT  of  both  side»." 
it*d.Cliir.  Tra»*.  roL  xUi.  pp.  1934. 


493 


DISEASES  OF  ARTERlEa 


Tlio  dlngnwis  of  aruurtomotio  ancuriitm  in  Travm 
rjmple'a  ouea  reeled  on  tlie  preneooo  of  miA  cunprvMilib 
tumotm  in  \-srious  puis  oftlw  e^elidii,  whicli  presented  »  mo 
tinot  pnl&atioD  n-hen  pretitiuro  was  madu  on  Ibuni.  It  i«  moat 
jibk- 1  liat  llii-w  won>  iin'rely  c<ill«Gtion»  ofToiiu  enUrgcd  by  pn 
and  transmitting  pulsation  from  the  aneurism  lying  )jcn<-atli  I 

Ani'iirixtn  nuiy  uIho  iitTiH't  eitlicr  tlie  intomal  carotid  aiti 
its  bi>ny  oaiml  or  in  tlio  cavcmotis  sinuH,  or  one  of  the  tirtd 
tlio  brain.  Tlic  ^ymploni!*  of  uiiouriAiu  atfixitiiig  the  interna)  < 
in  tliQ  BtnuH  are  mainly  of  Uireo  lands:  (1)  tlw  syniptoois  of. 
ii>ni ;  { 2)  Uh<  Kyin])h>ni«  nf  prowuro  on  tlie  orbital  nenea ;  (3| 
of  disturban<>(!  of  the  oerebral  circulation. 

(1)  In  II  wijll-miirkiiil  ciiw  ihi'  HyinjitoiiL*  nf  uncurism  wil 
on  rapidly,  very  liki?ly  after  a  blow  or  otltcr  injuiy ;  t!i«nii  v 
]>erliapii,  ii  sliiirp  crnck  heard,  Ibllowod  by  n  wwing  or  nkHfuiig 
Tliia  sound  will  bo  jiercoi^ed  by  tlie  stcthoacopc  apfJiod  to  tl) 
or  nock,  nii^rv  plainly  on  tlic  iitlVctuI  tluui  tlic  mhukI  itniv,  m 
coase  at  once  on  making  preeeure  upon  tlie  common  cMrutid 
«ido  of  tlio  dtiM^itito.  If  the  diwusv  is  limited  lo  the  |iart  of  tW 
contaliial  in  the  Hinns,  no  tumour  will  be  percepliblo  exla 
nor  any  pulsation  or  lulnctM  in  the  ori>it.  (2)  Tivo  firM  vf\ 
of  pivMHtiK!  upon  thu  orbital  nvrt'e*  in  oitlior  int^mud  atnb 
from  paralysis  of  the  aixtli  nen-e;t  oe  ptosis,  with  external 
nnddtlntt>d  pupil,  from  pn!K»iiro  un  the  tliini  nor%-e;l  or  tow < 
sation  in  the  parts  supplied  liy  tlie  supra-orbital  norvo.S  Si 
tJlo  side  of  tliiH  diitcaw!  is  uMuilly  not  lUrc'utet) ;  M>mctimc9i,  bo 
oljeots  arc  seen  dnublo,  or  there  is  more  or  leas  iudistinru 
riKion,  tlio  ooiiMquonco,  probably,  of  tlw  dilaljitiun  of  tlie 
Tlieee  ^rmptoma  of  proasuro  on  the  orbital  i»en't.-«  may  ox 
to|^-tlu>r,  or  in  vnrioui'  vumbiiiiitions.  (3)  The  Hyniptuum  of  ct 
disturbance  do  not  seem  greater  in  a  moderately  oiu-ly  ouo 
nflection,  tlian  in  an  aueiiriKm  of  the  <»nimoti  carotid:  he* 
giddiness,  inability  to  stoop,  frijjhiful  dreams,  Ae.  TUcro 
prowure  on  tlic  brain,  »tnou  tlio  f^rowlh  of  tlto  tiiuour  i*  uj 
by  the  dura  mater.  It  seems  possible  thai  tlw  aneiirisdi 
grow  llirough  this  mombrano,  anil  cauao  oullening  iif  tlw  t 
llio  brain ;  but  I  have  not  met  with  such  a  Bose.  ^_ 

•  The  moat  ivpriit  niiil  complvto  infiinnAttoo  on  tliia  >iuli|jJw 
foimd  in  a  p«ppr  by  Mr.  Hart.  Lancrt,  Mnich  16,  l-*»i.  <m  a  f«»u  ..f 
TiMiousunuurikni  iii  Iho  urbiteiircdby  URadirwof  UiFciiinmui)  miMUi 

f  Alloc.  Journal,  I&aa,  n.  10B7.  J  Pttlk.  St*.  Triuu.  vol  U.  i 


ANEUBISM  OF  INTERNAL  CAROTID. 


493 


"ith  such  »  <sjrn()iii!Ui(>n  of  *j'iiij)tiftin*,  Ihon,  tlic  fiituj^wvets  of 
MKorism  may  reasonablj-  bo  made;  and  Uie  caso  maj- juatitiaWy, 
in  the  pnwcnt  xtntv  of  our  kiiowIcdf^D,  bo  IrociUMi  im  «uc1l  Such  n 
on  iraa  tlio  fallowing,  which  occurrixl  uiiclttr  the  care  of  Mr.  Coe 
rf  Bristol  and  Dr.  Swiiyntf. "  Th«  iiiiticiit  was  u  woman,  agrd 
fifty-five.  Tho  disdose  was  attributed  to  s  blow  five  moiilhti  befone, 
»ft'T  which  she  compUinwl  of  a  hiiz/inp  iind  I»ntrrii;  noim  in  the 
Iwrl,  which  at  the  time  of  the  account  she  liki^uod  Ui  i.he  piiiliiif; 
tf  a  Ktcam-eti^nc,  hvard  more  diMtiiictiy  with  tho  left  than  tho 
tigbt  ear,  aixl  aci>oni]ianied  by  a  continuous  sound,  Hke  low  lhun<h>r, 
•mtnnting  from  a  «i>ot  near  tlic  posterior  KujMTior  angle  of  t)ie 
'light  {larietal  bone.  She  could  not  tie  down  in  bed,  and  was 
ibled  with  friglitful  dreams  Tlivrc  wa«  no  Imiit  in  the  heart 
peat  vatMln,  but  a  mi^t  distinct  one  in  the  neck  and  ater  llie 
surface  of  t)i«  hcul,  cspocially  tho  left  petrous  (tone;  prte- 
MBQ  oa  Iho  right  cjirollrl  liad  no  induon<.-e  over  the  sound,  l>nl  on 
■b  loft  caroti<l  c:iasod  it  to  cease  iniuu'd lately.  On  aiisctultating 
'bright  cwrotid  i^arcAilly,  ila  puliation  could  be  wptirat^^l  from 
Ae  bruit,  which  was  also  loader  on  the  left  side.  Tito  left  eyo 
^nmted  a  lilil<!,  and  tdte  saw  donbic,  one  tiling  by  thu  fide  of  tlm 
Wbff.  No  tumour  could  bo  perceived  cxtomally,  Tlio  left  carotid 
*wticcl  on  DecL  11,  1**.'>1 ;  tin?  bruit  cvjlii>1;  a  gwntic  continuous 
ttnnmir  followed  (ascribed  by  Mr.  Coolo  tho  tlow  of  blooil  tlirough 
*^'  tqiiKKtr  fmm  tlw  aiiiHtiimosiog  bniiiohi.v«) ;  llii;«  ceased  in  about 
'^  hours,  and  all  tho  s\Tnptoms  subsided.  The  woman  was  cun-il, 
■BJ,  as  I  am  infrinni'"!  by  Mr.  Coi.^  n-inaiim  well  at  the  present 
taw.  But  a  c.Tse  which  oecurrod  recently  in  London,  under  Sir. 
Owinan's  <!arc,t  must  lio  kv]»t  in  mind,  as  showing  that  tho  dia- 
JDWJ  cannot  He  regarded  as  certain.  In  timt  caie  many  of  the 
"OTi)  symptoms  were  prewnt — severe  ]niin  in  tho  head,  after  an 
•Wdent,  aggravated  by  stooping;  distm-bed  sleep;  a  beating  noiito 
m  till-  head,  eoniparod  to  r  steam-engine ;  a  Innd  bniit,  synchronous 
*ilk  tik!  puLto ;  troubled  vision  ;  protrusion  of  tho  glolw  of  the  eye, 
"rf  [Milsatjon  in  Iho  orbit  strong  enough  visibly  to  lift  tho  fingers. 
0»  nirolid  artery  wa.s  tied,  and  t!ie  bniit  ceased,  but  recurred, 
"Migb  not  so  loud,  eight  daj's  afterwards.  Tlio  patient  died  of 
^Rimdan-  tueinorrhage,  when  it  wa.t  tuuiid  that  tho  artericA  were 
toil*)  healthy ;  and  the  only  dUeast^^l  a]i|><-3r:uico  was  in  tho  oph- 
IwBUc  v&o,  oavemous,  drcular,  traneiverse,  and  superior  petrosal 


*  Auot.  Jimnut.  iMn.  p.  1007. 

f  Slr«»lfli.-lil'»  Oj-hlhalmic  HrporU.  April  IgdQ. 


■  ■ --  —  n 


iU 


DISEASES  OF  ARTEKIES. 


sinuM*,  wlitcli  were  filled  vridi  coagiita.  The  prefisnre  on  ibe  mk- 
tid  artery  in  the  sinus  must  have  produced  tho  bruit,  tlic  oWmo- 
tioD  to  ttio  return  of  l)lood  by  tlio  voitia  oftlie  orbit,  tlio  protriuion 
of  the  eyeball,  and  tlie  coii^<eslioa  of  Hio  parts  around  it ;  wliilr>  the 
poltwtion  pOTWtptiblo  in  tho  orbit  \*  attribulod  liy  Mr,  Uutko,  tn 
whom  we  are  indebted  for  tho  report  of  the  caae,  to  tlio  same  canna 
"  Each  diastole  of  tho  o|ilil}ialrnio  nrtKry,"  lie  saya,  "  nm«t  kvi> 
been  attended  by  a  general  momentary  increase  of  the  wbolv  liium- 
tity  of  blood  in  tho  orbit,  1  wen ujw  it«  oxit  Ibrmigli  the  ophthaimji: 
vein  was  eut  off,  and  tlie  resisting  bony  walls  of  the  orbit  OTuld 
permit  a  dittonsion  in  front  only." 

Tlio  fljTnptoma  of  aneurism  of  one  of  tho  small  artcriia  at  the 
base  or  i?i  tlio  nuhstani.-o  of  tlio  brain,  arc  na  yet  tjuite  obscure. 
Physicians  and  physiologista  are  busily  endeavouring,  by  fX]»n- 
mtmt  and  tlio  »tiuly  of  caws,  to  dwldo  liow,  from  tlie  symptom*  tif 
liiiiitod  pressure  or  other  limited  lesion,  to  determine  the  prwiw 
part  of  tho  bniin  affwtt-d.  Even  if  thi^i  ji^nynt  ditRcully  were  pit 
over,  how  are  we  to  decide  whether  such  limited  injury  depciulij  on 
preMurc  by  an  uncuri!iin,  or  by  a  tumour  of  a  ilifivrent  kind,  "UJ 
a  aorofiilous  tubercle?*  The  rapidity  of  the  onset  of  tbo  sympiaiMit 
and  tlio  I'ariation  in  their  severity,  oecaitioncd  by  diffor«iii  slatwoi 
tho  oircnlation,  soein  tho  only  peouliarities  wliicb  point  to  wwur- 
Um,  and  they  are  cxccwively  doubtful  and  dcUuiive.  We  li!ii«! 
indeed,  no  means  at  prewent  of  diagnosing  cerebral  aneurism,  nu- 
lojss  a  bruit  could  bo  found ;  and  in  looking  over  a  nmiilxT  of  (»'*» 
I  do  not  tind  any  inontion  of  tins  syinptoin  having  been  lookud  y^ 
In  Dr.  Ogle's  case,  liowcvcr,  the  patient  was  herself  coiiwiou"  •i' 
"  a  nawing  ncii.-w"  in  tlio  ln;iid.  It  soeni*,  thereforo,  that  in  »imita 
oases  tlie  head  sliould  be  carefully  auscultatixl,  tliougli  i(  U  veif 
likoly  that  tbo  small  size  of  tlie  aiioiirisni  and  of  the  vessel  on  mW 
it  is  seated,  and  tlie  mass  of  soft,  ill-conducting  irarts  that  lie  ia'« 
it,  would  prevent  bruit  from  being  ho-ard. 

7>¥«?wenf  of  theM  aneitrimm.  Aneurisms  situafcl  in  tlictawtw 
triangle  of  tlio  nock  must  bt-  trojitwl  on  ordiiim-  )irii)ei])les,  Jip* 
pressure  on  the  trunk  of  tlie  vessel  being  oaed  in  cases  when  thr 
fiymjitoms  aro  not  very  urgent,  coinbinod,  porlinps,  with  moden'* 


»  Spo.  in  Alnl-Chir.  Tntit*.  voL  xliL  i>.  4«3.  a  pap«r  by  Dr.  Ogle,  in  •b'* 
he  ctuvfully  ontk&voiirs  to  point  out  Uow,  from  llie  ayniploms  pmtBl'' 
ia  thp  e.oMt'  thei-e  rplai«<l,  be  oiiglit  bare  diagaoseil  leaioa  Umitixl  to  A* 
pons  Varolii.  Even  hsd  be  Avwv  so,  Iiowevrjr.  Ii«  woulJ  have  rohrml  ^ 
lesion  to  piessui-e  bj-  n  soMrulouB  tuiuuur,  wliile  it  was  iu  rsali^  m  * 
eurism  of  the  auleiiur  oerebeilar  iu1«r}-. 


■^ 


J 


LIQATCRE  OF  COUfMON  CAROTID.  495 

over  tin*  tumour;  in  KtvcriT  cii.«c»,  or  on  tlic  fitiluro  of 
measures,  Uie  comntoii  carotid  artery  must  bo  lieii.  li*-siila^ 
onliitaiy  mtslical  and  divtetic  inoiuiH,  and  vixchidin^  a  very  few 
ID  which  tlie  8urg4^an  iiiiglit  be  tempted  to  try  the  etioct  of 
lnno-|>anct<ir<%  lliuru  arv  only  two  inctliod»  of  truatravnt  avait- 
for  aneuritira  within  tlio  craiiiuin  or  orbit,  t.  e.  pressure  on,  or 
itairu  of,  tlw  t-arotid  artery.  Thu  \i»v  of  digital  pn^tisurc  has  been 
mssful  in  aneuriHni  of  tho  orbit,  midor  the  care  of  f liojjjil  nnd 
nwUi  (pp.  323, 4) ;  and  thiTu  can  be  no  roiiHi>n  why  it  sliouid  not 
Meed  in  such  n  pa.*"  aa  iliat  of  Mr,  C'-oe's.  It  need  not  give  luiieli 
loyanco  to  tho  pnticnt,  and  can  Iw  carried  on  ni(  lonj;  as  tho  dis^ 
is  either  reewling,  or  even  not  mUaneing.  When  its  failure  in 
in,  tltc  common  carotid  artery  should  bo  «xr<ircd.  *  It  would  at 
light  apjiear  bttttur,  on  ihu  (lisea.4o  h  seated  upon  the  internal 
ntid,  to  secure  that  vessel :  but  it  docs  not  sccni  that  any  advaut- 
h  obtained  by  K-Jiving  the  Mtreani  of  blood  in  the  cxIcniHl 
MmI  anob>i|ructcd.  In  orbital  anouriHU,  tho  frtw  anastomosja 
tvprodii'ie  the  diwiuiu! ;  in  auouriMn  ut  tlio  base  of  tho  brain, 
dao^r  of  sof^ning  of  tlio  brain  is  as  great  aftor  ligature  of 
intomal  as*  of  tlio  common  carutid ;  while  no  harm  ever  comos 
(topping  the  circulation  tlirough  tlie  branches  of  tho  external 
So  tluit,  as  tho  ligaturo  of  tbo  oouimon  carotid  artcrj-  is 
and  saier  proceeding,  it  is  rightly  performed. 

Tit  Uffoture  of  l/if  eoimnon  carotid  in  an  ordinary  caste  of  anour- 

(Vbcro  tlic  patient  \*  not  very  stout,  the  aneurism  uot  sitoatod 

the  root  of  the  neck,  but  towards  tJie  angle  of  the  jaw, f  and 

I  porta  bcjilthy,  \»  gi'ncnJIy  an  ca.ty  ojtoration.     Tlic  artery  can 

>bk,  in  any  person  not  extrainely  stout,  pulsating  on  the  anterior 

of  tbo  iitcnio-miwtoid  mnwlc,  at  th<'  Icvol  of  the  cricoid  car- 

,  wliere  it  tirat  beroniea  superBcial,  after  haxing  been  crossed 

i  omohyoid  mtucic — the  apex  of  the  carotid  triangle.     This  b 

ngly  tiie  place  of  selection  for  the  ligature.    The  operation  i» 


la  Mr.  Hsrt'n  pnpcr  itc!  Kitril>ut<-a  to  llie  pi'iiriou^  usu  of  dlpul  pre» 

^•aj  oonuv|iU!iit  itilntjilion  of  lliu  cc>lliit<.-ml  ui'tcries,  Uiu  eotirc  unmu- 

InBi  all  nj-mptDinti  which  !ii>  piiliciit  ilispliiji-d  lifter  IJf^uluiv  of  the 

lid  u1rT7:  on  i  mm  unity  which  was  ccrtninly  rvmai'kuble. 

Tbti  obnerTBlion  of  coui'M!  npiilies  still  raorp  forcibly  tu  Uie  cimcii  In 

I  ibo  dtvpiuo  i*  «iciiatnil  la  the  orbit,  nnd  Uirr^foi*  quite  nwny  from 

>  fWU  operatc<l  on  ;  but  in  n  iwi>  where  Uriisdnr'n  tncthod  wan  nppttud, 

■  MMloK  fHni^iilcriiblfi  ditKciilty  experienced  by  Uwi  opcrai-ir  ftMtn 

BtUMa  tliat  Uio  »n>.Ty  hud  btcn  di>pku>«d  bockwuda  by  the 

t  of  Um  luBiour  at  the  root  of  the  ucck. 


49S 


DISEASES  OF  ARTEBIES. 


tliu)'  p«>rffimii><i :   If  tlin  nUrno-mastoid  tniiAcIo  ii 
incision  about  two  nitd  a  liiilf  iiioIm^  in  Iprj^i  { 
stout  adult)  it  to  lie  iiuulo  along  ibi  fliitcrinr  nlge^  tlie  crntiv  I 
Rpoiuling  to  tlie  Iwv]  of  the  cricoid  mrtiliigi< ;  and  aflvr  (lie  i^ 
fiuwia  Imx  bixni  dividc<l,  vrhicli  may  lie  done  freely,  as  ii»  iiupl 
part*  are  endangered,  tho  odgo  of  the  siomo-miwtoid  ougbll 
vxpoiuvl.     TliiH  having  Un^n  drawn  a  littln  nutwnrdH,  tiie  | 
sliuuld  bo  pajwed  into  the  wound,  to  fwl  for  tiw  tracbea,  wl|| 
artery  will  lie  felt  lying  Ixrtwcen  tlio  niUM-ic  and  the  wr*uit 
operator  must  now  carefully  Bepantte  tlie  oelitdar  tisMie 
•benth  wlucli  covctj*  tlio  art«ry,  and  ondmi'otir  to  nixc  Uto  < 
ing  branch  of  the  ninth  nerve,  whidi  generally  lies  o]Mn  iim  < 
Tlii»  iiiTvc,  wIh'H  cxjkh«xI,  i»  to  !«■  hcJd  ii»id<'  witli  »  Utui({ 
while  a  small  ojiening  is  made  in  tiw?  sliealh  of  the  artery ; 
Tuwel  Iiaving  bcc«  clt'snL'd  br  ttic  utual  maiiiiiiiUlions,  tho  ll 
is  to  he  ])BfiMed  around  it  from  witltout  inwar<t!i,  givat  caral 
taken  to  kucp  tlio  point  of  the  anvuri«in-n<i:iil<^  ijuito  ciotc 
arter^-,  ho  a.*  to  avoid  wounding  or  tjing  tlie  [ineumo-gaMiie 
The  operator  niiwt  romcmbor  that  tlie  dcsccndcn*  uoni  nnvo 
tinier  lii^H  williin,  in.-iCoiul  oriijMin,  tim  dheath  oftli^^  vewwln;  i 
when  it  has  not  been  met  with  after  a  enfticicnt  e«arcli,  the 
may  bo  tiod  witliout  sociiig  it ;  luit  in  thin  com  avva  man 
common  care  rIimuM  be  bestowed  in  esamiiiing  tlie  vmacJ  in 
upon  tbc^  uni-urimi-iRwlk',  in  order  to  make  euro  tluit  tliia  imQ 
not  been  included.     In  tho  coureo  of  the  dissection  atwat  bl 
mftj-  occur  from  the  stcmo-mastoid  artery,  wlitch  ta  bmM 
dcMiondirig  branch  of  the  Mi[>erior  tliyrnid,  ami  may  itntve  an 
to  the  ojicrntor  unh«s  tho  vi«iol  bo  tied. 

AVhcn  the  aneurism  lit  Nituatcd  lower  in  the  aeclt,  ihti  eif 
becomm  mon)  diDicidt,  since  it  is  itooossary  to  cut  tliroiigfa 
Hidci'able  mtua  of  niusele.     llie  artery  if  lirro  lultiiitivi  itoda 
of  the  sterna -niastoid  witlt  the  Btenio-hvotd  and  stenio-ttiyriNl 
ole«.    An  incision  muflt  be  made  idoiig  tl>e  conrM)  of  the  artiM 
thi'  lino  joining  tho  atemo-clavicular  articulation  witli  iJie  jwia 
way  betwii  II  tlio  an^  of  tin;  jaw  an<l  tlic  iiuiKloid  procttM,  u 
incision  may  be  joined  by  anuthur  mnnuig  outo-iurds.     Tb» 
or  sternal,  portion  of  ttiu  ftt<^^l<>'ma.•it«id  in  to  he  cut  acnMa,  ai 
being  tlrawi  onlwards  witb  a  broad  retractor,  it  will  Iw  ge 
pOHible  ^>  rlrnw  the  two  otlior  muM^'li.w  inwitnJii,  aUiorwiso  tliq 
be  di^idi'd.      The  sheath  of  tlio  vcewcU  will  now  be  cxposa 
tlicro  will  in  all  pi-obiibilily  bo  suvcnd  1iu;|l;u  vein«  lying  a 
which  dcHvud  from  the  thyroid  body,  and  ua  thv  loid  di 


LIGATURE  OF  COMMON  CAROTID.  497 

tfao  intonial  jugular  iteelf  inclines  consiclerahly  to  tlie  front  of 
artery  lovriii-dM  tin;  L]iuru\.  Tin;  woimd  also  i»  v«ry  <lc«i>,  and 
vvitscl  is  probably  roiidered  relatively  deeper  by  the  pi-ojeetion  of 
tuiuMir.  Ktill,  by  kwjiinf;  ibc  t-niirsc  of  tlio  vessel  slvadily  in 
',  aod  by  feeling  for  the  tr.tcliea  itilernally  iinil  the  Lran-tverso 
]irooo8!WA  of  tlw  vorU'hraj  boliiiid,  tlie  artttry  inu»t  bo  roiiched.  Grwit 
euro,  however,  is  nod^Asan^  in  opening  ilio  Hheatli  i«mt  oltHiriiuy  Ibo 
artcrj',  utiKv  the  vowel  itwit'can  luiixlty  Ixf  brought  fiiirly  iii  view. 
IW-  proximity  of  tlie  streani  ofbloo*!  in  the  innominate  ar«-ry  on 
the  riylil  side  If  a  K'*'^"t,  but  not  ii  fatal,  objodioii  to  this  oporation. 
PcnpT*  has  ti«i  the  right  c.iroliil  HutweitiifuUy  wJtliiii  half  an  inch  of 
Uie  bifiirciition  of  the  innominate. 

Hie  operation  of  Tying  tlie  common  carotid  artery  u»od  to  be 
btked  ii]>ou  a«  one  of  tlio  most  sDceoiufu]  in  Surgery ;  and  |>orliaps, 
if  We  regard  the  important  parta  whoMj  circulation  is  >nt«rfonil 
*itl).  Uuit  opinion  may  seem  rolntively  jnstifiod ;  but  absolutoly  tJie 
lionality  is  no«'  known  tii  l)u  vt-ry  «insi<I<'niblo. 

In  titv  paper  on  tlie  subject  by  Dr.  Norrls  above  I'efvn-Ltl  to,  tbo 
■OsuU  of  li'J  aiM>4  in  which  tlu-  citrotiil  waft  tieil  has  lieon  tnbiilal*,i|. 
Of  these,  54  died,  or  more  than  ono-ihird ;  an  amotmt  of  mortality 
imdi  exee^tling  lliat  of  any  of  the  commoner  operjitions  of  Sur- 

8«y-t 

The  diivf  CMiiwst  of  ileath  afler  ligatni'c  of  any  large  artery^ 
winding  those  aflcotions  which  depend  on  jirevious  dif>ea§e  and  tlie 
BVphaaionit  whi<'h  follow  on  anv  grave  Miirgicnl  oiH'nition,  aro 
***iiiiaiy  biemorrlmgo  and  gangrene.  The  former  is  eoniparati\eiy 
■•ciflcr  lignluro  of  the  oaixtlid,  In  conm^ipK-rKV  of  it»  long  coiir.ie 
*ilWt  branches.  Still  it  is  not  perhaps  so  uncommon  a«  is  gone- 
>4/ni|,jMK^xl,  »inco  among  th»T  fifty-fonr  Gitiil  vwv*  m  Dr.  IJorriw'a 
t>Ue,  h;Butorrltage  is  noted  as  the  cauae  of  death  in  fifteen  of  thorn, 


'  Sap.  ciu 

t  Dr.  Nonit's  paper.  Iiowcrrr.  incliidna  nil  olnssrx  of  rnscs.  tabulated  us, 

'  ^  Oftmlkins  for  aiifuriitiiii  (IIiiRti^iiiui) ;  II.  For  wdudUs  :   III.  In  ur  piiN 

)to  «xlliptilJoii  of  tunkoura  ;  IV.  Forctinrhmi  atTcctioiK ;  V.  Fur  i.'rcclile 

. .  ~J*n  of  tit*  orbit.  &(-al]>,  iK- ;  VI.  On  Itiaiilor's  niciliuil  for  iu)<.-uiiiniB. 

■*  Buy  foasiUvr  >it<|>ai-ali-ly  lb*  ciwcs  In  wliicli  tlie  urtcrj'  is  lii-d  (or  thv 

*»  (rfrt  iltBtfttte.  I>y  oxt'liiding  clw^»es  11.  aiiil  III.;  nmi  tlun  Dr.  Nonri*'* 

''He  (rv'jwiius  one  caais  iu  nliioli  it  is  iloubtfiil  wli<^ihcr  the  nrtciT,-  wii* 

,  IMtf  livil)  i^rra  us  exBoIlf  100  crbcs.  with  a  mortatity  of  S8.     Il  »ttai', 

l^fcnf,  fair  to  >>n>-.  tliul  tliu  uidiiinrv  li(:Hlui«  of  the  camniDn  avatld  for 

Abiilu  itiToWe*  a  Hik  uliivlj  niu)-  he  rt i)ri>«(;nt«i)  on  au  nrriimo  hy  a  mot- 

I  Uilf  ofonc-lhird.    Pcifinililv  wbcri-  tbi'  liiatraHe  is  r«mole,  ibe  diance  of  reoo- 

'itltmtCT.     In  Mr,  Elnit'ii  (npiT.  utjuve  i-efeii«d  to.  out  of  Iwontj-iMaM 

fcliere  tlw  mroUil  was  tied  for  oneurisni  iu  ibe  orliii,  onljr  tlin^c  die^ 

TOL.  tit  3.S. 


498 


DISEASES  OF  ABTEBIES. 


and  it  miiy  Imvc  bron  prc«ciit  im  u  »ymptcim  in  many  of  tliAM 
nwovcrt^il. 

Gan^onc  shovrs  iteulf  principnlly  in  tho  form  ofitnftoniiig  oftA 
bruin.     Tix!  cxtcrn:il  jiaru  of  the  Iicitil  nnil  tiock  ntv  nen'ur,  m  ^ 
aeems,  ai)(>cU><t  with  gungrono;  a  fact  nliicli  i^  n-tidily  iu«oai|,^' 
fgr  hy  tlio  (roa  aiiostomoticci  and  Itlx^nil  auji|ily  oftlw  vpjanb  of  iW 
faoR  and  nci^k.     The  aniiKtomoot^H  in  tlif  brain  itru  imluil  cwu  mm 
uhuniiiuit ;  but  tlicii  Lhi>  brain  iijijiuani  tit  ho  mure  in  want  ufa  voh 
etnnt  and  oqiiablv  Bii]>ply,  and  to  tolontto  badly  thu  witbdrainl  (g 
ovini  u  >lii>rl  N[iaf«  of  so  Iiir<r(-  »  ijimntity  nf  bl«<Kl  im  is  brDugiil  in  j| 
by  this  gront  artery.     Twolvo  of  Utc  tifly-four  futal  cam  in  Pc. 
Norris'!*  t«blii  nwin  to  have  <]to(t  fnun  #oni«  8ymi>lom»  ivfiTrahlc  M 
tho  brain,  which,  hovrcvor,  aro  very  variously  stated ; '  omtrnkitflt,' 
<  apoplexy,"  and  '  inflaminntton'  of  tbu  brsin,  boirtg  tlio  tnorooooara 
headings.     It  tnay  he  allowDd  us  to  doubt,  in  the  abwiiou  of  dm* 
OXMt  iufurmntjon,  whuthor  thiit  '  iiifloinniiition'  was  not,  in  mal 
ousB  at  any  rate,  atrophic  softening. 


^ 


Either  tlie  external  or  iiiti>rniil  oamlid  may  bn  lied  for  a  moll 
of  tb(<  vcMoI  itself  in  tho  curnticl  triangle,     Tlie  operation  dot*  tH 
eseeittJally  rlilT^r  from  tliat  on  the  eomtnon  carotid.     An  innmi 
made  in  the  same  line  hut  higher  up  will  Icwl  down  directly  opia 
tho  inlernid  cAmUil.     Tho  extomid  carotid  it>  nearer  tho  aUSh 
line,  and  would  be  reoognitiml  in  nn  ojaeration  by  tlie  edgenfllii 
digiiKtrie  niuK-lo  luid  the  hyjxigloMal  nerve  croMing  itH  oourM*, 
the  oircunislanees  which  wntdil  jiuilify  ligature  of  either  of 
ftrt«rie»,  cxtiqA  fur  wound,  muHt  be  very  rare.     In  anvuriini  afli 
iiig  tlie  internal  carotid  in  tlio  (■ruiiinin,  I  lui\'e  aln'nily  fUUfd 
roiuonK  w}it<.-h  would  lead  mo  to  prefer  tho  ligaturo  of  llio  eu\ 
carotid.    1  have  not  met  with  any  ncroount  ofeHMM  of  tnio  anoi 
of  till-  hranelk^  of  tlio  external  carotid,  exoept  traumatic  nomti 
uf  tlie  lenipoi'al  artery,  whieli  aro  iixu.illy  under  tlie  control  iifilii 
and  indir'vt  prcwurc,  othcrwiae  the  temporal  arterj'  itself  roiflit 
easily  tied  either  by  tlie  Huntiirian  or  tlut  old  nn'tlxML     Jtnl  dnai 
or  aiiuMlonioticr  aneurisms  of  the  bntnelies  of  lite  extental  onnitiil  m 
\-ery  common,  and,  u]»i>n  tlio  failure  of  otbiT  mi'thdiU,  it  taighl  U 
tliouglit  ndviiuible  to  tie  tlie  extenisl  carotid  arterT,-.    If  60,  it  wooU 
be  pei-hapn  lieller  Ut  «e<!uro  the  artericH  on  both  «idM  at  tlw  miM 
ojMTiition.    In  woun<li)  of  arteries  d«ri\-od  from  the  coinnion  carrtid, 
occurring  in  iimetx^fuible  ditiiationft,  tJw  common  carotid  arteri'  ittclf 
liu  usually  been  tied,  and  with  fre<jiK4it  sueocwt.     T1ii«  o|)emtit«s 
bat  ealJed  down  tlie  vdioment  oetuun!  of  Mr.  Guthrie  in  caM*  o' 


LIGATTRE  OF  LINGUAL  ARTERT. 


499 


ni  of  the  inlcmnl  wrotkl  from  iJie  fiiuoft* ;  biit  rlio  (>|Mratiitii  bv 

I  III?  proposed*  tn  secure  llie  two  cncls  of  tho  blceJiiig  int^mnt 

itiil,  iift«r  Iiavin^  liividiil  iiiiti  tiirmii  ii]>  ihi-  rinniiN  i)f  tliv  l«vr«r 

I,  lias  iiut  yd  been  demomtlrated  (a  bo  practicable  on  Uie  living 

i\;  uhI  it  tk'vnitt  Itanllv  wi>rtli  wbilu  tii  doscribo  lui  opcriilioii 

will  prolMibtv  iwvcr  be  put  in  praeti™,     Tlie  uAual  nictliod 

rHcun'nj;  the  outiimon  carotid  is  rKcninnioiulcil  iii  tho  essay  on 

.  OF  Tiu;  ViisHKLs,  vuL  J.  p.  GDL    lrV«  raaj',  IiowBvor,  allow 

,  eveiy  oxorlioti  sliould  bo  iiiikIi;  to  eocuru  tlio  blcuditig  artery 

i{  ill  any  oaw,  aixl  lliat  It  Ia  only  wbcrc  thikt  opci'stion  In  [ilitlnly 

siblo  that  it  is  Justiiiablc  to  resort  to  so  uncertain  a  moasuro 

I  (yiiij^  tlio  tntnk-vcskM-I. 

Any  of  the  bruicbos  of  tbo  external  carotid  which  ariso  in 

cmrotid   triiuij^lo   may   rotiuiro   U)   lie   tioi)   on   tu^^ount  tif  u. 

nd ;  but  DO  special  directions  api)ear  oecossary.     Tlic  diagnosis 

[iIm  ]>iu*ticu]ar  vt'Mi'l  iiijuivd  would  bo  imposnibli!  till  tbi!  [lurtK 

I  been  ex)M»<Kl,  when  the  bleeding  woidd  be  the  only  sure  guide 

I  ibo  niotith  of  iho  artciy.     But  the  lin^^uil  nrtcry  inity  require 

are  on  nocoiuit  of  diseiute.     Mr.   Mooi-e  has  lately  comniuni- 

pHpcr  to  the  Itfjyal  Mc<liud   and  Cbinirgical  •Sncioly,  in 

relates  Ik  case  whore  he  seeing  tliis  vessel  in  a  case  of 

I  of  the  tongue. 

operation  is  tliu*  pcrfanntil :  The  ]>ntient  being  in  Uie  ro- 
ut position,  witli  tho  head  drami  over  to  tho  sound  side,  and 
[pillow  undur  tlio  ncok,  an  incision  ii*  niadr  ()blii[iu'ly  dnwn- 
Mid  backwanlH,  about  two  and  a  half  niches  in  length,  its 
bt-ing  o()po»itv  tlitf  cud  of  tho  great  vomu  of  the  hyuid  bono; 
(a|K-rti<'iiit  purls  being  dividt-d,  the  pi)int  above  mentioned 
!)«  kept  in  view,  luid  the  lingual  nerve  cxpOiM'd.  Tho  arterj' 
I  dmiMT  tlian  the  nerve  to  gain  iJie  deep  surface  of  tlie  hyo- 
muscle,  and  mu«t  l>e  rareliilly  ftarelicil  for  in  the  ct^llu- 
6ieu<i.  Thin  vjx'ruciiin  is  more  dilVienlt  than  the  description 
ilil  toctu  to  imply,  file  n^uton  is,  that  as  tho  pnrt4  are  un«up- 
,  cxwjit  by  tlie  lenite  nod  soil  wall  of  the  pharynx,  tho  vessel 
lewstanlly  retreating  from  t]u^  op-riiUir,  who  iuukI  Im^  careful  in 
dueling  hh  di.->.-«ctition,  for  teiir  of  wounding  the  phar^'ux.  As 
tlBMel  is  tortiioHS,  it  is  ncceMaiy  to  keep  elose  u[Hin  tlie  end  uf 
ipni  ooniu  of  llie  hyoid  bone, — tlw  only  rare  guide  to  it.  In 
diawotioti,  a  large  vein,  tho  internal  Jugular  or  one  of  ilji 
,  nay  be  uxjuwed. 


Commmiarift,  p.  U&D. 


500 


DISEASES  OF  ARTERIES. 


REGIONAL  SURGERY  OF  AXEURISMS  IN  THE. 
ABDOMEN  AND  LOWER  EXTREMITY. 

TuK  Foot  and  Lrq. 

As  in  tlio  upper  oxtninity,  so  still  murn  in  tlw  lowur,  uirorii 
liitrdly  oviT  iifI'<i-U  Llie  nrti-niM  Maw  tlie  gr«nt  Iiin^-joint, «» 
ns  tile  result  of  accident.  S^nlanuoos  aneuriHin,  it  is  tnif,  it 
niiknuwn  in  tlio  \fg;  but  it  i*  oxtrctnoly  rare.  The  mtueam  «f 
George's  Hospital  contains  a  sjiecimi'ii  of  aneurism  of  the  po^M 
tibin]  artery  eiii-Oil  l>y  ligHtui-o  tif'lliv  fumnnd  ;  iind  oUmt  xatta 
ojcamples  oftlieHe  aneurisms  may  be  found  in  paUiolo^nl 
tiooK  TiwMi  iLnouri»iD«,  like  tluxw  in  the  fitnt-ann,  will  liunlly 
be  toxavl  origtnntiiig  !t|iuiitari«ously  exc«pt  in  subjects  aflTcvtn] « 
extcnttivo  dlHoiiw  of  tlio  lienrt  and  iirtcr>c» ;  atid  n]>|irojiriiiti>  jxeilil 
biuida^ng,  anil  dij^itiil  jirc^uro  on  the  lirst  aecessjble  arten'  abc 
the  tumour,  will  be  tlie  ajtpropnato  moans  of  ctiro  for  tbiwc, 
tliosG.  If  tliin  treiitnicnt  uliimld  fail,  it  will  Ix)  for  tlie  Surfjcot 
oon«i(lur  wliotlior  liis  pattont  has  sufficient  vital  power  to  rnirvf 
the  lij^tnro  of  tlio  femoral  artery,  uitd  whether  tlio  diiw.'AMi  ii  gn 
enough  to  justify  tbo  risks  by  whieli  that  operation  muat  be  atlrajl 

Prex«ure  aud  pni]>er  position  will,  in  all  proliabilttj-,  «t<ip 
ing  &om  any  vi^aacX  in  tlie  foot;  btit  it  is  piMMibli.-  that  a  im 
anourism  tn  the  foot  or  near  tho  ankle  may  neomsitato  tlie  ligrii 
of  one  or  otlier  of  tlie  tibial  urteriiw;  these  vewtels,  iHiworcr, 
much  more  otlcn  tied  on  aa?ount  of  wound.     Tlie  Uij-Uun  t^ 
antfrior  tiiriat  may  bo  tlinn  perfonntH],     If  ilio  venMi  nv]uim>  bi 
tied  above  the  middle  of  the  leg,  it  wilt  be  found  ver^'  deeply  j: 
on  the  interoiuteoua  mcnibrnno,  lx-tw«cn  tlie  thiek  niu.«e»Iar 
of  the  tibialis  anticus  on  the  one  side,  and  on  the  other  of 
nal  longua  digitonim  alxivo,  and  extttHsor  ]>ropriuM  [lollicu 
tightly  hound  down  by  the  fascia  of  the  leg.     In  order  to  naA 
on  the  living  subjeet  with  any  toIcnd>Ie  facility  ami  in  any  l<ili 
time,  tho  tntemiusculor  spaoo  must  be  hit,  and  tlie  vcoacjs 
withont  any  groping  about  among  (ho  munclcfl.    Tliis  caa 
done  un  the  dead  i-iibJGct,  but  on  the  living  the  ojwmtinn  mtal 
one  of  considerable  diUieulty.     An   incision,  pnijiortioned  to 
fatness  of  tlio  1<^  (about  four  inches  might  be  taken  m  a 
length),  is  lo  \»  mode  in  tho  line  Joining  the  head  of  the  lilntia 
tlie  middle  jioint  betwetMi  the  two  malleoli.     Tho  akin  and  iia[ 
fiotal  &soia  beiug  w\iaratod  from  the  deep  had^  a  whiter  U: 


LIOATUBE  OF  TJBIAL  ARTERIES. 


501 


tlie  latter  ivill  1>o  seen  marking  die  intemmscular 

is  to  l)C  slit  up  to  Uic  same  c.vt^-nt  iis  tJiu  origiiiui 

wtinnd,  and  tlic  uiuitcleR  dravm  forcibly  apurt  with  hroad  rctracttov^ 

txui  lim  aiiklo  fl«xcJ  in  order  to  relax  dicm.     Tlion,  at  tb«  Iwttom 

vf  tie  deep  iiiti^niil,  tJio  nerve  will  i-oiiu-  inlo  viow,  and  below  it  the 

Teftwif  will  be  found  inclining  to  its  inuor  tudc.     Even  in  the  (load 

<ui>i«H  difi'A  i.-4  oiU^n  conftidi'rablt^  diflii-iillj-  in  p-ttiiig  a  ligature 

totiiid  t)ie  anIeriiH'  tibi^  (ospociall}-  if  tliQ  operator  wi(ilK»  not  to 

iiicludt!  Ui(!  vt'inn,  wliit^i,  tuiwcvcr,  in  tliv  living  body  would  be  a 

laaltcr  of  indiftisrenco) ;  and  thi§  difficulty  would  be  much  inoroasod 

^    ill  pnu-liix)  by  the  ftct  tiint  llie  oiH-ratiou  would  proliubly  !•«  luidcr- 

^Wcqh  on  aocuunt  of  a  wound,  and   that  tiie  neighbouring  parts 

F'woaiil  lur  obi^-unod  by  thu  PxtrnviL-'iitwl  blixwl,  tlio  niuwlcw  |M;rliap« 

'sptTated,  and  the  cavity  in  which  tlie  vessel  lies  so  deep  that  tli« 

li^dinj;,  by  winch  ulonc  tlitf  artery  could  bo  rccognisvd,  would 

a]x,  constantly  obscure  and  hide  the  blci-ding  orifice.     Hence  in 

fuch  iuwc!  great  pains  sliuuld  be  tiikcn  to  endeavour  to  ro»triliu  the 

liliftling  by  graduated  compresses,  or  by  digitid  pressure  iu  the 

"mud,  bc&ro  resorting  to  an  oiMTation  which  may  fail,  and  if  it 

■Mm,  may  cost  tlie  putieut  his  limb.| 

In  tlw  lower  jiart  of  the  leg,  where  the  musdcs  liavo  ended  in 
vir  tcndon.<),  and  where  the  ve«sels  are  siipportisl  on  tJie  tibia, 
•■Btwill  bo  much  less  ditlieulty  ui  finding  the  artery;  but  the  lino 
*f  bciuon  is  tlio  same,  and  the  same  niu.'^cdc  (liblalin  aiiticus)  serves 
AgiUil^  ^  >^f  th'^  arter}-  lying  on  its  outer  side. 
Thi-  nmi&rk*  altove  made,  an  tu  the  prujiriety  of  endeavouring, 
.VfdMiblc,  to  a\-oid  operating  on  small  arteries  so  deeply  seated  as 
I'IbiKuf  Uh'!  up}>er  part  of  die  leg,  njiply  to  the  poaterior  tibial,  and 
^  tDor«  forcibly  to  the  peroneal,  whieh,  howevei",  has  been  suo- 
•*>WIy  tiwJ  on  aecount  of  whuikI  by  Mr,  Gutlirie  ;J  but  no  Mpceial 
VMnciions  are  needeil  for  this  operation,  which  eon.iitited  merely 
*  nuking  a  vary  long  iiicbiion  in  tiio  middle  line  of  the  calf  (iwven 
■Am  in  length,  with  its  centre  at  the  wutuid),  di^ncding  down 
^tnls  tbo  fibula,  Inniing  out  the  clots,  and  looking  for  thoblcuil- 
■^  point;  in  doing  which  it  was  iieconnary  tn  vmsA  tiiu  inuiitioa  by 


■  Gutfarte  rMommenJt  that  the  fooi  be  aiwmuely  Il«x«d  and  citeniJcd  • 
[**ltta|{  these  roaMloa  in  view  niuro  dlstLnollf . 

I     f  1  am  (afbnaed  by  Mr.  Moure,  ihal  iu  a  oitsc  ivli<^i«  li«  had  oooasioa 
'  I*  IM  Qit  anterior  tibial  Tor  a  uouiiJ,  ixv  fuuiid  mMi^h  actistance  to  dia- 
I  *«trkug  tli«  pONiliun  o(  liio  vi-nstfl  fi-oui  Iracins  '""J:  it*  I>r»aclic»,  nliicll 
\ti*  giT«n  off  in  conniilcnibli!  uumlivm  lo  tlio  mun^ln  arouad  it. 
l  Om  lt'«Mad<  aitd  Injurift  of  ArUria,  1S4B,  p.  3il. 


DISEASES  OF  ARTERIES. 


one  ninning  tmnards  tlw  fibnia,  so  as  to  tarn  down  two  littl 
ITio  Wwdiiig  pdiiit  having  I'oeii  wfli,  n  jiliarp  liook  was  Rtiu 
tlw!  tiMUi's  K'iow  it,  jiiiil  tlie  wliolo  vraa  tied  up  in  two  tij 
above  aud  bolow  tlw  pnrt  whonoo  lliu  blcvdmg  jkruMnntnL 
pnliciit  r<!C<)venil,  it  wiw,  uf  eoiirs*,  inii>o(.sibIo  to  afSrui  tl 
peroneal  was  renWy  the  arlitiy  wliirli  liud  hfvtt  tiod. 

I^ffiilure  o/f/w  jionlfrior  t3>utl  in  tho  iipfier  |Murt  of  its  i 
where  it  lioH  under  tlm  deep  faM?ia  wliii-Ii  MtfnntM  tbe  fl 
nuiHC-lct  forming  llitf  KU]>erlii'ial  Uyor  of  Uw  coif  from  thtwo 
ft>n«  the  deeper  layer,  can  be  effected  in  ono  of  two  wuyi 
first  of  tbft«c  coiisi]>!t»  in  milking  un  incisioii  »f  Miitable  lengl 
six  inches)  along  the  poHlerior  edpo  of  the  tibia,  and  having  i 
the  ioKeia,  pulling  tho  gastrocuiiiiiu!*  away,  cutting  tlie  soli 
Jhc  tibia  to  the  extent  t<:i  whieh  it  U  expomd,  aud  that  < 
down  upon  tho  d«'|i  fiiscia  which  ovent  tlic  artcrj,  aixl  w 
to  bo  divided  with  tlie  uitiiiil  precatitionA,  in  order  to  soarcfa 
I'OBsel  lying  bolow  it.  Tliis  way  of  making  I]m>  ineision,  w 
Uie  ohl  mclh<id  ofriMioliin^  the  veiM-1,  U  condi-nini'd  br  Mr.  G 
as  "  difficult,  tedious,  bloody,  and  dangeroos ;"  luid  be  prop 
AuK-'tilute  for  it  ii  vortieal  inoiNion  abmtj  tlw!  middle  lino  of  tfa 
over  the  position  of  the  veaaol,  through  11m>  gaKtrocncniii 
Mtlcnix  muscles.  Mr.  Gutbrio  h!niH.'lf  never  h:id  tho  (^>portw 
oiirrt'ing  out  thirt  snggi-iition ;  but  it  vn-i  put  io  pr»ctioo  i 
Aniott  in  a  cn«)  where  be  tied  tho  artery  for  .■»  woiintl.* 

Ill  titiit  e-uM',  ind^nxl,  the  {KMtition  dim)  direetioii  of  the  n 
wound  would  have  indicated  some  encli  c«uiv«;  but  Mr.  j 
buM  i>ut  on  reryin)  hi.-i  prcfi^Trvntv^  for  Mr,  Guthrie's  iDotbod 
acbises  tliat  it  should  be  followed  if  it  should  ever  bfoome  nao 
to  tie  iJio  piwtlerior  tihiul  on  aocuiuit  of  aiieuriMn  Hituittod  Imt 
leg;  a  necessity  which  does  not  seem  hitherto  to  have  ooa 
Ml'.  Aniott,  liowi'vcr,  remBrk"  about  hix  <^»irr«ilion  what  is  pn 
even  more  applicable  to  the  oW  procedure.  "  It  is  nal  oab 
should  l>o  uiiderlakcn  ineonsidonitely.  It  require*  good  ligl 
intelligent  assistants.  Tlie  case  which  has  been  deecribod  on 
in  tlte  daytime ;  and  from  what  wa«  tJicn  expcrienoc<d,  I  an 
posed  to  think  tliat  it  would  not  hav»  bocii  micceasfiilly  p<trii 
by  artiticiitt  light,  or  at  least  witli  gr«-atly  incrcosnl  dillicu 
Hie  difficulties  which  Mr.  Arnott  cxiNtricnc^t  were  <lepc]Mla 
Bays,  on  the  de]»tli  of  the  wound,  the  pain  and  emmp  on  pttcM 
tho  divided  muselea,  and  tbc  X'cnous  hnnnorrhagit  fnna  uonoM 


*  ittd'Chit.  IVccM.  wl.  nix. 


t  Ot>.  cil.  p.  U. 


tlGATimB  OP  POSTERIOB  TIBIAL. 


503 


l.qCtbv  venro  o»niitr#.    Of  IIicm  difficuItJM,  Mr.  Amott  rates 

I  the  leant,  and  the  laat  the  gri^tt-»t.     Tiio  m-coiiiI  would, 

'  cuurec,   in  tho  pn»ont  day  be  nvoidvtl  entirciy  by  anKetiimia ; 

Imt.  die  ibinl  must  ulways  be  anticijMtcd  in  operationH  li>r  wound 

nflhc  artoryj  sinct-  tlte  vonaj  coinitos  are  oloscly  connected  to  it. 

l*tanire  in  tlie  angle  of  the  wound  tram  wliioh  die  blctidiiig  comes 

must  W  ninliitainod  as  inucli  as  |Kwjybli:  during  the  ofwration  by  ibe 

finjcrofan  n.-wUluiit.     Tlio  trunk  of  die  ft-mwral  or  jHtjililcid  U  «f 

RHjne  «<xnirod  by  a  toamii]»vt.     Au  incision  is  to  be  made,  etx 

iBven  incbea  in  longtb,  down  tlio  middle  of  the  caH' uf  tlio  leg, 

tludin^  tbc  skin-wonnd  in  its  centre.     'II10  gasLrocnomius  and 

•Jini*  inusclt»  are  to  \m  frwly  divided  in  tlio  coursw*  of  thi-  wound, 

Lmd  luld  aside  by  broad  rctractoro.       Now  tlie   (^rator   kIiouH 

:  oarefully  for  tlit<  di^-ji  or  int4^nnu.'«(>llllt^  fast-ia,  iminiKliattdy 

'wneub  whicb    tfae    posterior    tibial   vessels   will  bo  tbund.      Tlio' 

^Mutiun  frrim  wliieli  tlio  bliitding  coino!*  will  [Hiiiit  out  wbotlier  it 

B  ihi'  tibial  or  peronoHl.      If  the  latter  be  llie  ai-tery  wounded,  most 

libK-  a  i;««i<l  |iiiri  of  till!  fli-x')r  longii.t  [HiUioiit  must  Ijo  M-ruiied 

tX  liiti  tibuUi  in  order  to  lind  it,  or  (as  Mr,  Guthrie  seems  to 

twn  done)  ail   tlii>  timui.-.t   ni'ouiid   tlio   blooding  point   mu^t  ha 

■clmlcd  in  tho  ligature.     If  it  be  the  tibial,  it  may  be  exposed 

[*itli  ntlior  ItMW  difijculty.     Still  it  is  n  most  tlifiicnlt  ui>cnition,  ai 

I  ht  wident  to  any  re-ider  of  Mr.  Arnott's  account,  although  in 

UM  the  wound  wiw  oidy  reoeiitly  intlict'i-d,  luid  Mr,  Arnott 

I  dile  assistance  at  hand.     In  cases  where  much  blood  lias  been 

Bted  into  tJio  teg,  obscuring  alt   tlio  noiglibouriiig  |i!irt«,  or 

'DOf  the  Surgeon  Is  not  very  much  versed  in  operations,  or  has 

■  triiitc  mainly  to  Ins  own  hands,  it  would  perhaps  1k'  tlio  liettcr 

to  amputate ;  but  I  may  be  excused  for  re|ioaling  that  pro- 

tl.V-applicid  and  carefully -graduntc-d  fompn-Met,  or  the  jn'oloiigt-d 

of  A  fingitr  in  tJie  wound,  enlarged  if  necessary,  would 

render  either  operation  unnecessiiry.     In  a  recent  tranuintJo 

Tisiii.  proliably  one  oi"  the  various  methods  of  applying  <Urect 

[•indirect  pressure  wotdd  succeed.    If  any  operation  bec^uiie  nwces- 

V,  mit*t  Surgeons  would  profer  to  tie  the  femoral  artery.    Somej 

,  (bat  they  would  bo  veri'  few),  might  treat  tho  ctuw,  liko  A 

jod  veMol,  by  the  old  opiTiition. 

If  tlte  posterior  tibial  arten,-  requires  a  ligature  in  tlie  lowor 

:  of  tho  li;g,  the  operation  i.'<  nion-  .tiinple,  on  account  of  the  leaa 

at  which  it  lies.      An   incision  is  to  bo  made,  about  three 

in  length,  parallel  to  ttie  inner  border  of  tlic  tendo  AohilliH, 

tlie  veaet  is  to  bo  sought  on  tho  outor  side  of  the  two  largo 


504 


DISEASES  OF  AUTERIES. 


Ictulons  which  pass  behind  the  inner  malleolus,  that  of  the  Amat 
Ioii)^i«  ili;;ib>ruin  hvinj'  thu  miurej't  to  UinveMetx.  Boliimi  rbcaddo 
thu  teii<lon  of  the  flexor  longus  polliois  is  on  the  opposite  (oxli-nDil) 
side  of  thu  ailvn,',  l>ul  in  onliiiarj'  Oiww  will  iiul  oiHinr  into  view, 

Tim  })Oj>i<U(il  artery  has  also  been  tied  on  account  of  subcutane- 
ous nipltii^-,  niiitUL-crwfiilly  tu  tnr  M  tlio  remit  of  thv  «ti»e  mrt, 
fiiiice  gangrene  set  in  on  tho  third  Aay,  followed  by  amputation  >nd 
death;  but  no  difficulty  wius  cxporiciioitl  in  Ui«  op«:Tation,*  whidiis* 
thus  described  by  the  openitorif  "  Mr.  Poland  made  an  incisicnar 
fnmn  tcvcn  to  ci^ht  incIio»  in  ItTiigtli  along  thu  vuiu^u  of  tin-  popU' 
teal  artery,  tuul  ol«>ared  out  uitich  coaguhim,  and  witliout  dit!i<.'nll>^ 
fennd  Iho  vnds  of  tho  rnptiin<d  artory  lying  un  inch  and  t  liiLs 
apart ;  thu  tipjier  en<I  aeeini-'d  tt>  bu  plu^od  by  coa^lum,  and  m\^^ 
secureil  by  ligatiiro  ;  the  lower  end  seemed  to  be  patvul,  and  "1^* 
Winibrly  Hffjituiiil.     Tlw  jtojilikid  vein  was    dJHtinrtly   ftoiii,  sncl 
ajipoarcd  to  bo   uninjured."     On   cxnminiug   the  parts   iitirr  il)*' 
ainpiitntion,  Mr.  Poland  found  thiit  the  knee-joint  ha«l  lieen  lnuiX 
open  by  an  estensive  laceration  of  the  poBterior  ligament,  a  v-im— 
plication  which  would  probably  hiire  prcohiditl  nnsivrrj- even  li^  ■■ 
gangrene  been  averted ;  and  as  tliis  same  complication  was  i)nwn*' 
in  tJiri'L-  eases  sucwissively  mhnitttil  int"  Guy's  Uinpit^l  (llie  fifs* 
tlircc  in  Mr.  Poland's  collection),  tho  point  ought  to  be  carcfiiilV" 
iuvostigftt«d  <luriiig  the  operation   for  ligiitiirc  of  tlwj  art<'ry. 
passing  the  finger  into  tlio  deo])  parts  of  tlie  wouml,  where  if  fill 
coiulylf  of  tiiu  femur  can  bo  fult  bare,  anipubttiou  sitould  bo  ^"i 
formeiL 

POPLITKAI,  AkKCBISM. 
Alfhongli  popliteal  aneurism  is  so  froqnently  cnrtihle  witk'nt 
operation,  yet  operations  for  its  ctirn  e<)nstitutc  the  great  miijofi'V 
of  tliose  perfoiTuod  for  aneurism.}     The  popHtetd  artwy  is  so  fr^^j 
quently  diseased  because  it  is  liable  U>  strain  both  in  tiesion  »i»' 
(though  to  a  mncli  less  degree)  In  frn-ced  extension  of  the  joinl!! 

*  In  the  only  two  oilieir  tttses,  lioivcyer,  rc|iorl<-'il  in  Mr.  PiVluid's  p«t*'' 
wliBi-u  lilt-  avlery  wns  sought  for.  llio  apcmlion  proved  impmrlicnbift  '''* 
(i.'Hi(inil  arWiy  lius  nisn  lieen  tit-d  on  nccgunt  of  llii»  injury  in  Ino  (•M**'J 
gHii^-veno  and  ik-iitli  foUon-ed  in  both.  Mr.  Polnnil  ii|icaks  in  teUDS  ** 
meriti'd  repTOlmlion  of  the  pmoticc. 

f  iluy'a  Hotpital  Hfportt,  3d  series,  »ol.  Vl. 

1  III  the  Slid.  jfimM  ami  Ons.  {supr,  cit)  s«vonty-fiv«  cases  of  ligs'"'' 
of  larB*!  nrteiies  arc  ifiporlcd.  of  which  fif^-on«  were  of  iha  f«DO»L'' 
almost  nil  tasi^s  foi'  pnjijileal  aneurism. 

5  Vyrv  lew  sedontuiy  pei-suns,  or  females,  sufTor  from  Uiia  dJscM*.  ^ 
Noma's  table,  out  of  105  jiatieuU,  five  only  wen  flBmales. 


POPLITEAL  AITEURISM. 


505 


I  I)««an««  it  is  tlie  end  of  a  large  tube,  convex  allpmately  for- 

ftud  borkwnriU,  wlitcli  diviili^-M  abruptly  into  much  smalliir 

and  U  au{){iortcd  only  by  fat,  wliilo  iu  bruncbi-j  ]iluiige 

^ma>  umoii^  iiuii>cl<v. 

Tbu  syin])toiiia  of  pnpliteal  luieuri.itii  nro  tiriimllr  <{iiiti>  cbnrac- 

Tlic  uttontioii  of  the  patit-tit  is  callml  to  tlic  part  by  tlie 

ar  or  by  pain  ond  .iiif!'riiii.i  of  ilif  limb,  i>r  by  t)i<.^  pidKntion,-^ 

'  oomtnonly  tbt^  latter ;  ;uid  on  examining  tlie  part  the  Sur^on 

^Iffl  in  no  rIotiU  «f  tin;  nutimt  of  tbi!  oi>ni))Ui]it.     Tlic  itncuriMna] 

b  twualiy  distinct,  tJiougli  nisea  are  .aometjincH  met  with  in 

bidi  it '»  aliwiit,     Tlu^  fooling  of  tlio  pulsiitiou  dilfcrs  wnncwliiit 

Jing  aa  the  atteurism  b  growing  townnb  or  nuny  from  the 

I;  liiat  a,  soconliiig  n»  it  is  oituatrd  on  tho  fi'ont  or  tlio  back  of 

inaeeL     Tlie  more  uauiil  position  np[)ount  to  bo  nt  tbt-  back  of 

I  may  towards  tbu  i>kin  of  tbo  liain ;  and  tlion  tbo  pnUation  is 

tdw  Qsnal  equable  beating  and  expuiiAivo  <-li»ni(ttcr.     Hut  wlion 

luwun«ni  is  growing  townixls  tho  joint,  and  the  artery  Uierefore 

Iniwd  npon  it«  posterior  Miriaw  toward!*  the  nkin,  the  pulnatiun 

I  Biitcli  morn  thrilling,  siid  a  ^listinct  line  of  gejKinito  jxdHfttion 

I  tuarkft  (lie  course  of  tlio  vct^iO.     Ilie  poHition  of  the  aiivnriMni 

1  nnlvrially  influences  tho  probability  of  compiicalions  involving 

joint.     A  largo  ttinintir  riijiidly  growing  on  to  the   posterior 

nt  of  tho  knee,  mutt  cauHo  ci>iiMiIerablt;  irritation  in  the  Joint; 

ijnmrial  inflamuuition  linam  tliiH  eaoeo  is  a  frequent  accom- 

nait  of  [Miplilt^al  aneurism.     IStill  further,  the  rc»iiitanoo  to  tht 

of  the  Hie  alfordod  by  such  firm  stmctures  aa  tlio  bones 

ligMoentM  of  tho  joint  »fx>n  IoikU  to  nlccrstion,  so  that  hucIi 

I  are  liable  to  bnrst  into  (be  knee-joint ;  the  ayin]>toina  and 

I  of  wliicli  L-venl  have  been  pointed  out  on  pp.  358,  411. 

Tbe  part  of  the  fuii'ry  allected  varie«;  but  the  amitritim  usually 

utn  in  tlM>  middle  of  the  pophta-al  Mpiiee,  and  hulge^  out  below 

'  luunsiring.     On  di.-w-etion,  tlie  opening  in  tho  artery  \»  most 

■intoidy  found  near  it«  lower  end. 

The  trentuient  of  |>opIiti-al  aneurism  Ik  nKimlly  mic- 

ahlOO  sueh  tuniotii-s  pnrtake    of  the   nature  of  the  milder 

of  tnunintic  niiouriitiii,  and  often  occur  in  cnniparutii.-ety 

hhy  jiersons.      Besides,  there  is  a  long  tract  of  artery  above  tlie 

ill  tlic  most  favourable  position  for  oomprvmion^  and  iho 


■  Fiuili«r  iibMrvatiuns  on  the  (liHgiioftia  uf  bursal  and  othrr  tumours 
lUie  hiuu  from  oncurinm  will  be  found  iu  the  e&nny  eu  Duomosi*  akd 
•loxiL  Scnor.KT. 


506 


DISEASES  OP  ARTERIES. 


1 


ftnastomotic  briiiicht:^  ciimc  <^i\'  in  tolerable  profuidoii  just  aba 
tumour,  and  enlarge  rtadily. 

Bcfure  rttln-r  »>!V«ror  mcai^urea  aro  tried,  jronufloxian  <iii(r|i{  un— 
doiibti^dly  to  bo  nttcmiitod.  If  U-ndini;  tlit-  ktipp  to  its  fidl  extdnfc 
Kt'iir!  itiv  [iiilwilioii  ill  tlio  lunioiir,  r.lie  Ix-.it  ]iO]iiv<  iii«v  bo  (-Tit<-T— 
tained  of  its  suffwes.  Tho  kind  of  unotirism  most  adapted  for  ifc 
apfH^iirs  to  bo  tlint  wltitth  i.i  H)tiiiilt\l  on  llio  butik  of  Lb*-  artery,  uid 
has  not  yet  ^t  very  near  tb<>  skin.  In  a  tutnour  nbich  ajtpean  on 
tJiv  point  of  burbling,  it  would  bo  imjirudi-nt  to  innint  on  iU  trial 
nor  would  it  bo  likely  to  siiceccd  if  tlm  pulsation  were  unalfw^ 
or  oven  (wliieh  sih-iiis  lIxtoi-tHicully  iiiwsibli)  Iikti-iimhI.  Pn.>*Mir». 
instrumental  or  digit4d,  on  the  femora!  artary  may  succeed  wl 
flexion  fails,  or  a  ooiiibination  of  llie  two  may  niipwir  more  iJHi 
ciouft,  and  ia  easily  arranged.  In  applying  pressure,  it  is  important 
to  romember  tbat  tli«  artery  4'hnn{^  iu  rt'lulion  to  the  bone  iai! 
ronrw  down  the  thigb,  and  tJmt  in  order  to  command  the  cirnils' 
tioii  witb  the  Ifust  poiwiiblc  force,  tlio  pad  onglit  to  be  dirrclpd 
tovrniil^  the  femur.  Tlie  method  of  applying  pressure  in  Uiis  linu- 
tion  has  been  dtKcussod  nlx>v(.i. 

JfundtT  llu!  use  of  pressure  tho  tumour  iit  making  visible  pro- 
gresB,  the  femoral  artt>ry  mnst  bo  tied  ;  and  this  becomes  still  iui«* 
iii'w-''Siiry  if  tlio  sai!  haie  burst ;  sinr^,  if  tbo  iipi-ratioi]  Ix-  dcUivJ) 
the  occurrenco  of  ganrrreue  will  probably  ncoessitato  amputation. 

Ampulntimi  aluo  becomes  neceMmury  ou  tlie  failuro  of  iln-  lig>- 
ture,  except  in  somo  raro  ciscs  of  recurrent  aneurism,  n  lion  llw 
femoral  can  be  tii-d  in  Huntcr'.i  ciniud  (*c«  mipr.  p.  409). 

I.iffatiirr  of  the  fnnoral  artiTt/.  Tbo  femoral  artery  may  Wnw 
at  tln-ee  parts  of  its  course :  (1 )  above  the  origin  of  th«»  |>r(ifuD^i 
(^)  at  tho  a|wx  or  lowest  point  of  Scitrpa's  triangle ;  (3)  in  tlio  (fiW* 
formed  by  tlie  tendinous  tibrejt  which  <;onnect  the  addutTtor  nia^V 
with  the  vastus  intvrmis.  Of  tliese,  tlio  last  proceeding,  that  on* 
ginaled  by  Hunter,  is  now  {JtHURed,  unless  for  eswplioniJ  »«*  " 
recurring  aneurism,  »ucli  as  Sir  A.  Cooper's,  above  quoted ;  soil  'i** 
seriond  ia  the  one  universally  «mploye<l  in  popliK>«l  anooriKin ;  l!)^ 
first  being  reserved  for  certain  cases  of  aneurism  in  the  thigh,  ^ 
as  a  preliminary  to  some  oj)orationH. 

Tlie  great  advantage  of  Scarpa's  operation,  for  securing  l'" 
artery  just  as  it  is  being  eroiweil  liy  tJie  oartoriu!'  muscle,  is  tJial  f^ 
vessel  is  exposed  at  a  point  where  it  is  superficia!,  and  iherefof 
easily  fonnd;  while  at  the  samo  timo  it  i«  lar  from  tli«  origin  of  **? 
large  braneli.     The  operation  in  a  natural  oondilioii  of  parts  and* 


LIGATURE  OF  SUPERFICIAL  FEMORAL.        507 


^Mtinit  not  \ery  stout  h  usuxliy  oasy.  If  tin-  milHito  "i'lhv  »Rr- 
lotrias  muscle  Ls  plainly  perceptible,  this  will  jwrlmjis  bo  Uie  eajiicAt 
tticl  Huroil  guide  OllmrvrUo  a  linu  drawn  from  lli«  wntre  of  tho 
fi»I*J  of  the  groin  to  touch  the  inner  border  of  tlie  patella  when  Uio 
txjt  iit  a  littlu  ithdiiotwi,  win  murk  tlm  (.-ourso  of  tht'  vessel.  An 
incision  thn'o  or  four  inches  long  having  been  made  in  this  di- 
leotioii  tliruugh  tlm  nlciii  luid  iiu)jcutan(>ouK  tissue  (in  which  it  will 
W>  iwell  to  avoid  any  largo  braneh  of  tbo  .in|)liena  vein),  tlie  fusciit 
Uta  will  Im*  n't^igniw.il,  and  shotild  bo  divided  on  a  dir«ctor  to  tho 
•*\\nh  extent  of  tbo  wound.  Tliis  .'•boiild  (-x|Ki&e  tho  i»iu?r  edge  of 
tL(«  sartortun,  wliieli  muKt  (itlu-rwiso  bo  sought  for  by  dividing  tho 
wUiiIar  tii^uo  oiirpfully  without  going  deejier  into  tlie  wound  ;  and 
vfhcn  tlic  iniisclo  is  rocogiii>ic<l,  but  not  before,  the  slioatb  of  tho 
itmuAs  is  ta  im  .sniiglit.  It  is  gonoraliy  iuiin<l  at  on<^e,  l)y  drawing 
li»>  Diuwio  slightly  outwards,  and  the  pidsation  is  felt.  A  nervo  IS 
wonily  seen  in  front  of  tlie  arlery,  anil  iiui.-'t  Im^  (•Jtoluded  from  the 
lignturc,  Tliis  may  bo  either  tiie  internal  saphenous  nerve  or  a 
•Mlw  bmn<;h  of  tbo  unlerlor  crurul."  A  small  ojiwung  ii*  lo  bo 
taJe  in  tbe  sbeatb,  and  enlarged  to  sucli  an  extent  that  the  artery 
*WTly  cxpoMxl;  and  tlien  tlio  vtwsel.  ebotdd  bu  so  tar  cleanu<I  as  to 
*""*  tile  ftnouriAm-nei-dlo  to  ho  jmssed  round  it  without  material 
rt*islauci'.  Ti]n:  great  dangi-r  at  this  slop  of  the  opirution  is  lest 
'*'<'  will  ^ould  be  injunHl,  or  should  he  included  in  the  ligature. 
'wiinjid  till'  first  mistake,  great  gentleness  is  required  in  cleaning 
"k' artery  and  in  paiwing  the  ncixUe  round  it;  wliilu  tlio  second 
•*Wia  iniptwsiblo  if  the  vessel  have  been  once  fairly  and  eleauly 
^p<«*d.  The  imiition  of  the  vein  must  he  un-urately  remembered  ; 
'^  li»  almost  direetly  beliind  tlio  arter^',  inolining  perhaps  a  litll« 
•it*  inner  sidi.i.  Hcnec  wo  lu-o  uhuhHv  reeomnieiuhsl  to  j>asa  tlm 
"■Be  from  within  outwards.  This  l>oiug  so,  if  tho  front  of  tlio 
"toy  have  hwii  once  cleanly  denu<led,  and  the  point  of  ihv  needle 
"•*  been  fairly  applied  to  it,  it  seems  irojiosftible  that  the  needle 
"0  be  llini^t  to  the  deeper  side  of  the  vein,  without  an  aniount  of 
•■feioe  which  is  never  uwnI  oh  the  living  subject;  nor  can  the 
""ofle  even  perforate  the  septum  whieh  separates  tlie  artery  fiom 


*  A  naatl  nerve  is  often  seen  on  the  troat  fit  lite  sbMtb,  bnt  Qi*  eapb^ 
^'^  Derrc  itself  docs  not  romc  into  connexion  with  tb«  aitmy  M  blgb  Up 
I  ^"^  ^"^  ""^  of  operation.  Hliorr  it  Is  in  rolnlion  wiifa  tlie  shesUi,  it 
1^  kUmt  sztcraal  to  Ibo  potttion  of  tlie  ttrivry,  ftiinl}'  bound  down  hy  m 
[  JjNit*  Uyer  af  bwLa,  which  spjieaxs  to  fonn  a  poi-liou  of  diu  kIiw^ 
[^Sfc.  if  tii«  sheath  la  opened  only  by  a  small  puncture  ovvr  tho  inner 
r^ofUte  T«a»el,  the  nerve  will  not  eome  iulo  sight. 


508 


DISEASES  OF  ARTERIES. 


tilt!  vein,  Ko  aa  to  wound  tlie  latter,  without  more  fiin^e  tlinn  in  _ 
tiiiblo.      If  tlic  ot^vunvDcv  uf  vonuuH  liarmckrrliagv  «l)(m-i>  lltut 
vein  liaH  Ikiui  |>iitiotiin>(I,*  the  bleeding  ougliL  tu  bo  CMDitutiitiliil  | 
])n»Mure,  which  is  not  diftiotilt,  and  tlio  operator  must  tnaJco  up  J 
mind  c-ithcr  to  uluiiiddii  tijo  ojioration  for  tlic  time,  aiid  m*k 
veAMJ  at  a  higher  part  of  it«  course  after  a  few  da^'s,  or  (wlitnbj 
pcrhapK  the  jn'i^fi -ruble  coiirHi>)  U>  cillarfrt^  tho  inciHiim  upnunU,! 
lie  tlie  artorj'  wiili  more  care,  about  an  inch  above  llie  spot 
ally  iM^li.w^'tiNl.   'i'liu  lignturu  lOiouId  on  no  noeount  be  tightMMH]  in  I 
jiart  whore  the  iietxlle  lias  fii-si  wounded  tlie  vein,  since  in  thii ' 
tliu  tlu^^ad  would  he  lc(l  in  tho  vein  to  act  a»  a  Roton,  and  ph 
coutd  hardly  &il  to  ensue,  and  would  in<Mt  likely  prove  fatal 
tho  needle  have  glided  round  tbo  vc«»vl  without  any  «neli 
the  next  ^■tep  ia  to  detomiiiie  tliat  tius  tiitsuc  euibrooud  by  it  it  i 
tlie  artery,  and  nothing  ol9)\     Tim  ia  WBJfy  osocrtaitwd  by  jn 
lif^htly  on  the  tituucw  ruiwd  I^  tho  neodlo,  awl  I'Muuininf;  ti»  \ 
with  tlio  Bngur.    The  pulsation  of  the  vemel  will  bt?  felt;  on  : 
IHVMiare,  the  beating  of  tlu;  ancuri»ni  will  ceuo  nt  om»  ;  wlifli^J 
any  donbt  exi§t6  on  tliat  point,  tlie  abwnoe  of  cougc»ti<>ii  nhtnn  I 
UiO  vein  in  not  iitL'lud>^-<l.     Nothing  tlien  remuinn  bo  Ixt  iIuik'  i 
to  tie  tlic  ligature  firmly,  and  olo»e  the  extcroaJ  wound  witJi  i 
ping  or  t«o  or  three  sutures. 

In  a  (tiw  of  ligaUiro  of  tlin  rcniomi  arti:Tj-  whicli  is  bo  <kp  < 
the  warmth  of  the  fool,  wliich  ia  maintained  by  wrapping  thn  1 
in  cotton  woi>l,  n'mninit  Mli;;!itlr  uljove  that  of  it«  fellow  for  a 
days;  the  (lattent  lying  ()ui<it  doos  not  notioe  the  numbncM 
partial  paraK>iK  wliich  would  no  donbt  niauifcfit  tlwoui'lvn  if| 
tried  to  move  about ;  aeuMition  i«  j)erli'ct ;  tlui  ligature  inijr  I 
cxjH-clol  to  fall  any  day  after  tho  first  wcck.f 

Tlie  oliief  danger  aller  llie  operation  It  from  gangrvmi    la  I 
Norris's  statistics,}  of  204  operations  {for  all  causes),  fifty  diitL 
of  tlioso  lifly,  tJie  cauAo  of  death  U  nut  Htat>il  in  f<Mir;  and  afi 


*  Slight  arhsriul  brnnorrho^  la  aomcUmn  obnervcd  ■■  Uic  n* 
ptMCd  ruutiil  till!  nricry,  and  atopa  wlien  the  Ugatun  i«  Ugliinii.'J.   I(| 
o«eds,  in  all  probtbUitf ,  fhtm  tlie  wound  of  n  iiiiiiut«  bnuMiti  a4«r  lU  < 
from  the  resael. 

t  The  oorlinil  period  at  wlUdi  the  Mparstiun  of  tli«  Uitaltmi 
Bot«U  ill  u  Bucccisful  cast.',  fnio  frora  bnni>iTlin);i'.  atiprKn  to  be  i 
duj- ;  but  il  inrvlj-  oomea  nwny  befnte  the  rlcrcuUi.    In  inm  cam  i 
anay  on  Uie  »ixUi  day,  but  bKunuirluipc  orciinvd.     In  Ul  oaaM 
it  H<;]Hiiuii.'d  boforo  the  twentioUi  dnj- ;  but  it  baa  botn  known  li>  mnakit 
tbo  vi-s*ul  up  to  the  tixtieth  day. 

I  Jm.  Jvum.  3Ied.  Se.,  OoL  IMU,  a.  a.  vol.  xvlti.  p.  9Vk 


LIGATURE  OF  SUPERFICIAL  FEMORAL.        509 


aiiiing  forty-*ix,  twcniy-dirwi,  exactly  one  balf,  (li«l  fixim  gaii- 

iie,  viialc  Ibi-iuoirliagc  proved  fatal  in  eigbt  cases  only;  tivu  of 

Lhv  ivmaining  doaths  aru  nttributwl  to  pliltfbitis,  one  to  Hloiighmg  of 

le  sac,  uxt  iho  re^t  to  acut(l«>nlal  (uiututs  oomiiioii  to  all  o{ienitions 

■tetanns,  fcvcr,  Iwctic,  pya^nita,  A:c 

Bieiiiurrbiij^',  bnwtiver,  ocounred  in  numerous  ciLtes  in  wliioti  it 
id  not  prove  fata!,  liaTinr^  been  atriwtod  by  pressure.  In  order  to 
){ily  ]in,-:iAun)  cfliK'tiudly  to  tlie  femoral  oi'U^y  wben  w^>iidiiry 
Kmorrbagfl  takes  place,  a  graduatod  compress  should  bo  fixed  rery 
uvfully  on  lli«  woiuiil  by  tiicinis  ot'a  preJisft-ttrttV*,  or  ilm  lii^-wIinjK 
vint  sbonld  bo  commanded  by  t)ie  lintel's  of  a  relay  of  ivclUin- 
metcd  a«si>ttaiit«.  iSIioiiM  rbive  uiciuih  fail  to  arrest  tbi-  bli-^cding, 
lo  est*mal  iliac  artery  must  be  tied,  or  tlie  limb  amputated,  unless 
lo  Surgeon  choose  to  cut  into  tli»  wutuiil,  and  tii-  up  iifptiti  the 
leediiig  portion  of  the  veesol.  Mr.  Ericlison  doclares  himself  in 
ivoiir  of  the  latter  mode  of  trcatnn!ut.  The  fiiTt  i»  the  course  most 
Baally  pn-seribed  in  our  surgical  works ;  but  it  has  always  (acconl- 
Ig  lo  Jlr.  Erichsoo)  been  follnwod  by  gaiij^'uc  T\w  ligature  of 
Ucislin;;  purlion  of  llie  artery  is  an  operation  which  hiw  never 
Won  carried  out,  as  far  a»  I  know,  luid  which  would  bo  most 
ly  extremely  difficult,  fi-om  the  infiammatory  olianges  and  extra- 
of  blood  which  bavo  gone  on  around  the  vessoL  It  could 
undertaken  as  ait  exploratory  measure,  preliminary  to  am- 
,  if  the  Iatb?r  measure  sliould  bo  found  necessary.  In  all 
of  M^'ore  Kecondai'y  bifmon'bitf^,  there  s<-cms  littlu  doubt  that 
ition  is  the  safc«t  measure  for  the  patient)  though  it  is  one  to 
no  Surgeon  would  willingly  resort. 
A  sligbt  amount  of  gangrene  is  not  always  IncoDsistent  with 
|tt«prcsu'rA'!»tion  of  the  limb;  while  of  the  eitws  of  more  exteiiHivo 
pogrene,  many  are  saved  by  secondary  amputation.  Six  cases  of 
ain]>utAliun  are  reeonltil  in  Nnrris's  Ijible. 
Peru's  statistics  give  somewhere  about  the  same  mortality*  na 
■(•e  of  Norris.  It  may  be  «u<i,  however,  tlial  these  »t«li!>tics  give 
view  of  the  mortality,  since  many  of  the  operations  were 
by  the  older  Surgeons  on  exploded  oiitl  im.tcieiitiliv  prio- 


*Il  would  be  nruii!,'  to  quit  the  subjuct  uf  tlie  inortality  after  ligaiui'^ 
IVIiw femanil  urtcrj*.  witiicmt  iiotic^iu);  tliH  ftiot  Uiat  Mr.  Syiiii;  tiud  tbe  lU'Ii'iy 
["'■ij'.lhrcc  tim«s  in  »aocpi»ton  iviUmul  any  uiifuvuurable  Byiuptooi  (i'rrn- 
[jW»^S«iprff-  IS''*-  V-  *"•)■  Still,  ill  ur-^itig  lliis  remiirkuWe  tnrt  us  nn 
BtiigiUOi>t  tit<!  uic  of  pi'oNKUra,  I  CHiiuol  hc'l])  tliiiikiiiu*  tluit  Uinl  dia- 

bed  Surgeon  hn*  bo«o  mUtrd  )>}'  ii  miccchs  nliich  miul  be  vxcupliouol 

tCbt  practice  of  anjr  opeintcrr,  howcwr  »kiIfuL 


510 


DISEASES  OP  ARTEItlES. 


cipIcA;  or  that  siicotwsfij]  opcntioDs  on  tlie  fL>moral  arterr 
ootnmon  Unit  tlwy  aro  not  (xn)!(itliMH<(l  wnrtli  piibli<ation.     Itut 
Midi  o1>jectiona  can  lie  ngaiiiiit  the  statisti(»  collected  bv  Mr.  Hut 
iiisoD*  of  the  discs  of  I]<^tiiro  of  this  «rt4,TT  in  motropoliUin 
IhK     Out  of  fifty  cnsps,  sixtflCT)  have  dipJ,  or,  in  roiiml  ntiml 
one-t]iird.    Mr.  Brvimt's  tahU'-x  of  nmpiitAlion  of  the  thi^h  al  linf 
HoHpit.-il  for  all  caiiscs,f  with  wliioh  diose  m>Uc«t(!(l  In*  Uw  fir 
writvr  from  8t.  Ucorf^u'n  HuN[>it«Jt  nfn'oe  in  iJl  c«M>ntial  psriic 
give  a  mortality  coiisidorahly  un<Ier  on«-th)ixl.     So  tJuit  lij^ltm< 
tho  fumoral  Art«-ry  ecomH  to  hnvu  provod  more  fata}  tlian  am|iiilatia 
of  the  thigh  iii  tJic  pmctJoe  of  IjoiuIwi  Kurgixtnii  during  the  lul  I 
years,  tiikiiig  &Ii  oaaca  of  cacli  operation  indi»criminatcly. 

If  it  bo  ncc««iiirj'  to  (io  tlie  artviy  in  HuntorV  canal,  whid 
however,  can  only  Iw  the  case  either  for  woumi  4)r  after  tlu-  faj 
of  the  oouimon  ogienition,  Uio  sumo  line  of  inciiuon  will  be 
but  lower  down;  and  it  will  be  neoetuuiry  to  divide  tlw 
freely.  Heneo  the  oporntjon  it)  more  procraciod  and  hlood_ri1 
DO  ini|>ortHnt  ]>arbi  are  endangered  in  oiltiur.  TIk'  priiieijicl  rift  i 
of  wounding  tlto  roiu,  or  of  including  it  or  the  sapfaeoOtts  MnreM 
ihe  ligature. 

Feuoral  Aiiei:ri!i». 

SpontaneotiR  femoral  aiieuriKm  ik  n^purdod,  witli  ronwHt, 
more  Horious  ufft-ctioii  tlinii  jKiph'leal,  ttineo  the  latter  uftm  il 
pornons  whose  va^eular  Ajiitem  is  in  nil  other  rcsfioctjt  ikmukI,  *!&' 
tlio  former  gives  much  reason  to  suspoet  a  generally  alhcrmiu 
eondidon  of  the  vcsseU,  in  whieh  eaw  tin'  csintcnw  of  organif  i 
onao  of  tlic  heart,  or  of  internal  aneorism,  n  exceedingly  prob 
Every  *uoh  cafte,  therefore,  ."hoiild  Iw  earrfully  ex.-ttntnii) 
reference  to  thcfic  poinU  before  the  treatment  is  flxt^d.  Tlir  lUf] 
gnosin  of  an  aneurism  in  the  tlitgh  can  hanlly  be  atteixlml  nih] 
difficulty.  It  is  conceivable  that  some  doubt  might  exJHt  u  to  ihl] 
vessel  upon  which  it  wa;*  Mmtt'd,  whi^lher  llie  MipeHJeiit  or  ilwy 
femoral ;  hut  I  am  not  anarc  tliat  such  an  nnibiguity  hiw  rrallylni'j 
met  with,  n<ir  would  the  doubt  have  nincli  etfect  upou  tivauoik.] 
In  traumatic  cnses,  tlie  diagnosis  between  H)nij>le  and  arliTn^-T 
aneurlHm  should  be  atteiiflod  to;  but  cnouiJih  1ia«  been  ahvailywij 
upon  that  [joint ;  what  folIo»vs  will  refer  eiitin-Iy  tn  tltu 
of  common  ujieuriMu  in  the  thigh.    licet,  witliout  any  spoaai  I 

•  Jtf*/.  ZVnwitnrfWiia.  vol.  iLlSSa,  p.  BIS,  i.  IBM,  jip.  li,3ft.fl4.MI,  ILT. 
t  i/*d  Chir.  Traiu.  xiis.  70.        ;  JJed.  Ttmc,  and  Om.  «.!.  L  IWI.p.  »>«^ 


M 


LIGATURE  OF  COMMON  FEMORAL. 


5U 


biu)  boftii  kimwii  in  load  to  the  ti}H>i)tMieoiis  cum  of  n  ftfinoral 

m ;"  but  it  woulil  not  be  good  practice  to  delay  tlie  coro- 

icnt  orinoro  activo  tn^iitnii^iit  boyoiid  (ho  day  <>r  two  which 

oaially  allowf^l  in  order  to  faiuiliariso  the  patient's  mind  and 

ekIj-  vfiUi  bis  iiiivol  trirciiiiistjiiu-i^,  iinlcjv  tbo  tummir  were  visibly 

nnuing  in  size.     In  all  oascH  in  which  the  sao  Iin^  not  buret, 

■npFCMion  oClbo  fonnjml  in  llio  f^oin  (>uf;ht  to  Iw  tritil,  and  will 

lodly  Bncoced,  especially  if  lliere  is  opjiortuiuty  for  the  earcfnl 

^lioitton  oi'difjilttl  ''"injinisnion.     Nor  if  tlic  sac  b;i»  burst  is  the 

Iwe  by  any  means  desperata     A  carefid  examination  will  sliow 

rlwluT  prownre  with  the  fiiipt-r  ci>ntn>!»  tlii?  fiirtlmr  proffrtas  of 

»  oxtravasntion ;  if  it  does,  compression  of  the  fomoml  may  bo 

■jid  lor  a  day  nr  two,  tho  case  being,  however,  very  earefiilly 

^^peil.     On  the  failure  of  procure,  recourse  is  to  bo  had  to  llie 

Mntcrian  operation,   wliich  ean   •;<"'<^''alJy  bo  iflV'cteil   below  the 

Km,  in  die  first  part  of  the  artery  ;  iiiit  in  cases  where  the  ttimotir 

■leads  higher  up,  tlie  ligature  mu»t  l>e  plaeed  on  tlic  D.ttemal  iliac. 

he  farmer  ojjeration  will  he  describixl  here,  the  other  being  »]>- 

coded  to  tlic  set^tioii  on  Inguinal  Aneurism. 

ligatHTt  of  the  common  fr-iiutral  arl&ry  is  an  operation  which  is 
^  generally  regarded  with  much  favour,  and  wlucli  is,  therefore, 
^le  practisAd  for  the  cure  nf  aneurism,  inasmuch  n^  tbo  operator 
nitrally  prefers  to  tie  tho  •>>:tcrnal  iliac.  Tbo  reason  of  tlie  sup- 
o»i  ihmp^r  of  the  ligature  of  ihe  artery  in  this  situalicni  iii,  tho 
Wedmily  of  the  ligature  to  largo  braueht*.  'file  epigastric  and  cir- 
■ttnflex  iliac  on  the  one  side,  mit^t  <'onie  ofl'  near  the  ligaturu  if  it  \» 
kod  close  to  tile  fold  of  tJie  gruiu  :  and  tlie  (irofuiida  on  tho  other, 
it  i«  pla»>d  lower  down.  Tlie  neighbourluHid  of  tliuw  largo 
Uuhes  would  certainly  appear  likely  n  priori  to  lead  to  secondary 
-liiigi-;  but  somo  doubt  is  ihi-owii  UjHJn  lliis  theoretical  con- 
hv  Uie  exporicncc  of  tlie  elder  and  younger  Porter,  tbo 
nf  wluini  rc[Mirta  three  cjum^s  '"'ly*  ■"><)  alludett  to  two  otbcn*, 
■  whieh  the  operation  was  porrornie<l  bv  him<soIf  and  bis  fatlier,  all 
vliieh  wore  Micoo:t!<fiil.f  But  tliis  o|>i!raliiin  lian  not.  as  yet  been 
BoffioientJy  often  to  allow  of  our  pronouncing  a  confident 
icnt ;  anti  it  mu»t  Iw  left  to  the  diM»«tion  of  the  operator  to 
the  proeeeduig  which  ho  may  think  best  ndculated  to  save 
pslient's  life.  Tho  ligature  of  tlie  femoral  is  cerl«inly  a  &r 
euj'  and  a  leas  formidable  oporatioii  primarily  than  that  of 


•  Luke,  ia  M*d.  Oat..  Muj'  U.  Mitt. 

t  Dubtia  Quarterly  Joum.  nf  Hot.  Se.,  Nov.  ISGO. 


5ii 


DISEASES  OF  ARTERIES. 


the  Uiac.  The  artery  can  asimlly  be  felt  pulsating;  and  noithin; 
HwcsTWin,'  «>x»50[)t  to  divide  tlio  »i»rt  [wirls  wvit  it  aircfuHv  vritii  a 
modoi'atc  inciiHion,  ho  as  to  apply  the  tigatiiro  (which  shonM  \k 
cnrrktl  frutn  within  outwanU)  witlioiit  any  cxix^uro  of  tliA 
or  othpr  parts,  Tlie  crural  branch  of  tlie  gfinito-orural  or  a 
brimcli  of'tliu  anterior  criirtJ  norvo  may  hv  foiuid  niuuing  doirni 
front  of  tlio  vessel,  but  can  be  flosily  avoiiled. 

Mr.  Kricliscii  swscrle.*  that  out  of  twelve  caifc*  in  which  tl* 
femoral  ha»  been  tieil,  only  llirei^  have  Huccoe<!e<l,  ilio  otiiers  liavin^ 
failed  in  cuiisoquoncv  of  secondary  luvuiorrliagv ;  and  tliinlu  ihA 
the  o])eration  should  be  luuiinbed  from  sur^ncal  practice. 

Anotiicr  objcL-I.ion  to  which  the  hjiaturc  of  tlic  oommon  Icnionl 
is  exposcil  i*  ihc  linbiiity  t^i  gangrene,  in  coRi*c<iuence  of  the  twkI 
being  blocked  up  above  the  origin  of  botli  of  the  groat  nutrient 
arteriett  ofrho  limb.  Tlie  superficial  femoral,  which  nourishm  liM 
lower  part  of  the  limb,  is  comparatively  easily  reinforced  aftor  tb» 
ligature  by  it«  fuv  nnmlumoKi*  with  llie  [irofumLi  artery;  bnl 
when  botll  these  channels  are  blocked  up,  tlio  coosoqueut  tum 
upon  the  coilatt-ral  circulation  i«  much  iiicrMwcd. 

In  Norris's  table,  above  referred  to,  the  femoral  artery  ww  tieJ 
twcntv-wvi'ii  finii-s  for  aneurism  in  Uic  thigh,  willi  tmlv  live  ilea^i 
a  smaller  proijortion  than  that  of  ligature  of  the  femoral  from  tH 
cauw».  Unfortunately,  it  is  not  tohl  us  in  bow  many  of  Uime  ooM 
the  artery  was  ox|M)sed  above  the  origin  of  the  profunda;  "In* 
must,  I  ])rc»uiuc,  have  been  the  case  in  suine  if  not  in  mofft  t^fllK* 
Tlie  omission  in  so  oareful  a  compilation  ia  doubtless  duo  to  iH 
inadcfpiacy  of  tlic  original  note*.  In  Porta'a  l«bl«,  eight  are  W* 
to  have  died  out  of  sixteen  ;  but  no  tlet^ila  are  given. 

Inguinal  Anbcrism. 

Pulsating  fnmoiirs  are  always  to  be  viewed  with  BOiBC  ai*- 
p'cion  when  tjicy  lie  in  close  proximity  to  any  Ijonc  possf*"'? 
u  copious  (liploc.  Hciioc  auch  aflcctions  about  any  part  oftbi 
pelvis  should  always  bo  very  carefidly  examined  before  ihey  »rti 
pniuouncc!  ancurinmnl.  Thft  rei'oids  of  Surgery  abound  i"  '"' 
stances  of  tmnonra  in  the  gluteal  and  abdoniiind  n^iona  iavo 
been  prunouncctl  to  be  aiHiiriitin  of  the  large  arteries  of  tliow  ptfN 
when  they  were  really  pulsating  cancers  of  the  bone;  sjkI  many 
the  cases  re(Mirted  by  the  older  Surgeons  were  obvioosly  of 
nature,  though  the  mistake  wns  never  discoi'crcfl,  and  tiier 

*  Op.cit.  ]).  UIT. 


LIGATURE  OF  EXTERNAL  ILL\C. 


613 


list  of  aneuriHiQA.  Rncli  a  mistake  is  Inm  likely  to 
thi-  fr"""'"*  "'=•"  n'wit  other  parts  of  tfic  pelvis;  Init  the 
■a  fi)ioul<l  be  on  liis  guitnl  lii>i*  also.  A  oinujiuriwiti  of  tlie 
in  the  chii'f  iirtvriw  of  th«  two  limbs  will  be  of  prcat  sorvico, 
k  it  is  uflitnlly  nlt^Ted  in  nnotimm  iuul  mil  in  tho  piilR-itile 
B«P;  im<l  lUe  other  |H>ints  of  the  <Iiii]tniosis  between  aiieuriBin 
fpvbatile  tumour  shouM  be  earafully  exniiiiitecL  (800  |i.  3>(3.) 
Slw  rlingiKwi*  haviiift  I>een  made,  tlio  ques^tinn  will  oceiir  whotbor 
iaie  U  a  fit  one  for  i^onipn-s.iion,  or  whether  tbi'  I(uiiTcri»n 
Mtion  must  bo  purlonntNL  CVinpreireion  on  the  external  iliiic, 
jmons  not  very  fill,  oun  bo  easily  ujiplieil  by  the  fiii^iT;  iind 
Itttnis  instances  of  the  sucecss  of  Uigita]  preti^uiv  in  thi«  region 

fcr^M  (see  pp.  A'22,  4)."  lu  llic  tact)  of  »uch  fiivttt,  110  Knr- 
mtd  be  doing  hix  duty  who  oxposed  his  patient  to  the  great 
p  of  an  o|H>mti<)ii  on  tho  extfrnnl  iliac  arler}',  willioitt  a  woll- 
lidoral  and  pen(o\'«ring  attempt  to  cure  the  difiwwe  by  pressure, 
(ligilal  or  itiAtninii^iital.  It  is  po»»ibli',  s]»n,  tbiit  direct 
;ro  npun  the  tumour  may  assist  in  the  cure,  as  it  seems  to 
tloiifi  in  Sir.  Litke'»  wise,  abovo  rt-ferrcit  to;  but  this  sibonld 
very  eantionsly,  if  at  all,  since  sloughing  of  tlie  coverings 
ttmiutir  would  most  seriously  eompIJeate  tlie  ease. 
ii^jatme  txf  the  extet-nal  Uiaf  artery.  The  operation  for  seenring 
lesbTDiil  iliac  artery  is  usually  regarded  as  a  very  suevessfiil 
jl  and  relatively  to  the  other  ojieriition*  on  large  tnmk  vessels, 
toy  U'  so  voiixidered ;  but  the  mortiility  is  slitl  very  great.  Of 
I  published  cases  taken  indi»Griiiiinatoly,  tliirtv-tJiree  died ;  a 
Rnlity  oxn>cding  that  of  amputation  of  the  thigh. 
[llie  o[icmlion  is  peHoniied  by  making  t\  .luftieient  incision 
In^ll  tJte  parietcs  of  the  lower  part  of  the  nbdomcn,  the  preciw 
^ion  of  which  U  not  a  ntiiiti-r  of  very  great  oonseijuence,  but 
|cfa  is  nstially  drann  from  a  litllo  above  the  eentro  of  Pouptirt'n 
It  outwardit  (so  aa  to  avoid  tlie  dtrcctioii  of  (he  epigastric 
)  to  a  little  internal  to  the  anterior  superior  s)iuio,  fix>in 
jioint  it  Ui  to  lie  c-urvtil  inwanU,  as  far  as  may  be  tliougbt 
y,  towurds  the  nmhilieus;  or  it  may  lie  directly  over  thfl 
of  dto  arterv.     Tlio  muselc-s  are  t<i  be  dii  ided  to  tlie  same 


Wlijle  tbnso  shwts  are  pacing  dironcli  the  press,  mi  anMirism  in  tlie 
I,  of  coDtii>lt>rnii>le  siao,  and  Hnothov  Tower  down  in  the  lliisli.have  been 
.J,  at  15l.  Gi'i'iriie's  tloajiilal,  by  tJie  use  of  niiKcd  digilnl  anij  mecbnnical 
limaion ;  aiiil  a  case  of  puplitt-ul  aiieiirisii^  tias  recently  l>eeii  eur« J  hj 
flexion  tTMtaieot,  after  thv  incfl'uoiual  uac  of  eomprcBaton  for  a  cou- 
lie  prriud. 

OL.  IlL  1. 1. 


614 


DISEASES  OF  ARTERIES. 


extent,  <!aro  being  taken  in  dividing  the  lowast  fttratu,  ujilil  the 
traiisvcM-caliit  fiweia  i*  rojifttit-d.  Thin  rtnit-turc  can  generafly  W 
rc«og«ispd  inimeiUatcJy  beneath  the  mwsdes,  and  t^hmild  Ik-  Jiviii^ 
in  tho  iliac  Wmm,  not  fur  fnun  tbo  nntcrior  BU)icrior  spin^,  u]'m  i 
director,  aft*r  a  Iiolo  has  been  cautiously  made  in  it.  Tiw  oj-mttif 
will  now  find  a  (-<-Uii]iir  itili;rval  lyin^  above  tite  poritoiueuin ;  tsd 
tlmt.  membrane,  with  tlio  intcstineft,  should  be  gently  mid  giadnl^ 
pushed  o^LT  tow^nN  the  uiiddlv  lino,  until  tho  vessels  aiv  iettt  or 
felt  The  vein,  it  should  be  remenjlieroil,  lies  inleniiil  tn  thcarl<*T 
and  the  genito-tfrural  iiiT^e,  or  lower  down  it«  genital  brandi,  lie 
on  the  nnti-rior  surface  of  the  ressel.  The  ligxturv  iniwt,  tJuw- 
fore,  be  pajisod  from  within  outwardft;  and  if  the  nene  Itara  bwt 
indiiilud  in  it,  eure  should  he  taken  to  slip  tlie  thread  awar  frM 
tmdcr  it  before  tho  knot  is  dod.  The  ligature  of  iJib  little  nerw 
nood  nut,  however,  lenil  to  any  biul  results.  'Hiu  aceidcnt  whii'Ii 
usually  happens  in  this  operation  is,  naturally,  tho  Ineenitian  li 
the  piTJtona'utn.  It  is  not  neciJssariiy  attended  «ith  fatal  orew 
serious  conse<]uenoeB  (see  voL  iu  p.  442) ;  bat  atill  it  t^oulJ  it 
most  carefidly  avoided." 

The  points  to  he  chiefly  guarded  against  in  the  ligature  of  ti* 
extcrim!  illiie  tirtory  are,  wound  of  the  epigastric  artery,  of  tliei« 
deferens,  or  otlior  constituents  of  tlie  spttrniatic  conl,  I»eeraUi»<< 
tho  pcritonieuui,  puncture  of  the  cxtciTia]  iliac  vein  or  oftlioti^ 


•  In  priiii^iplp.  the  varioua  operutiuns  deBeribed  on  ihe  iltae  irun" 
reduce  Ihrmsvlvva  to  two  methods,  in  one  of  which  Ibe  lutcTj  »  ttutd 
trom  beloiv.  wliili!  ill  Ibo  other  it  is  npproachrd  fii>in  witlioul  or  from  n'-'**^ 
Ba  dc3C  tilled  in  tlie  text.  The  lutlcr  mi-tliod  ix  caiicr  when  the  ant:'  • 
enci'oat'liKs  iition  I'lJiipnrt**  lignmcnt;  tho  former  when  tlic  tumour  ii  ••'■'■ 
ated  )oW''i'  down,  and  llie  whole  of  tlic  lUii-ry  may,  thcrcforp.,  fio  pij-rc" 
to  be  found  lieitltliy.  Tbi?i'e  in  little  difTerenco  bctwera  the  lwi>  pliuis>  <*' 
cept  tlial  the  opcmtlon  from  below  iTqniivs  a  snialli-r  iiii-isioo.  and  n 
diflioult  in  approprinto  cases;  but  if  ilio  ailcry  bo  pri-i^cii  hn-'k  into 
pelvi«  li.v  a  I.uiTioiir  extending  up  iiilo  th"  groin,  jt  bi^jewes  iuikIi  H" 
dillieuU.  it'  not  impi'ttclioablc,  from  ndlictiinn  b«tu-pen  th«  lumetir  tiid 
pmloiiiuuiii.  Sir  A.  Cooper,  iu  deHrribiits  the  opemtion  from  below,  ad'i 
tlmt  "  the  eeutre  of  the  iiiterinil  ublii)iie  arid  liauftveii-Mlii  inuaclet  ibui 
be  ruiaeil  fioiii  Poupnrl'e  lignnient.  The  opening  by  wiiieh  lh«  tiitnui* 
cord  quilB  the  abdomen  is  thut  exposed,  and  the  linger  pHSsed 
this  i|>uee  is  direetly  upplied  upon  lUu  iljua  artery."  The  rvnt  of  llie  oj 
lion  then  eoiisista  eliirtly  in  Bemlcliin);  the  faseia  off  the  lutety.  »eji 
the  lulter  from  the  vein,  and  passini,'  tlie  lifralure  ruand  it.  mliieb 
Cooper  ilii-eels  to  be  done  from  wilboul.  Mr.  OuUirie.  howeit-r. 
obseiTes,  tliiLt  ilia  vein  is  less  libely  to  be  ii|Jtu«d  if  th«  point  of  the  di 
be  first  iniiiuiiited  between  it  and  the  urtety,  and  the  ligatttre  carried 
wilbiu  ouliiiirds.     (Gutliiie'*  Oommentarin,  p,  208.) 


ibiwfti 


ABDOMINAL  ANEURISM. 


515 


1,  Ugalurft  of  the  f^'iiiio-oniral  ii<MTe,  and  n  loo  free 

oftho  subiifritont^al  n'llukr  tissue.     The  wound  of  the 

ric  nrtun-  U  only  [irobiiDu  n-heii  tlM>  opffratioti  i»  piiiotiwxl 

ibetovr.     The  vessel  can,  it  is  true,  bo  sccnrt-d.  but  tlic  blciHiing 

lluu  of  lime  sro  objiwiiutiiibli^ ;  imd  ullcr  it,  Ih  tii^d,  uii  Jnijiortiuit 

BIS  JB  stopped  up,  and  the  chanc«  of  gangrene  incrrcaiiccl. 

ITRK  d«frn'n*  uIho  i*  oniy  (-niUiijp'rril   in  Iriu'ing  the  arlcrv  up- 

A  knowledge  of  itx  positiou,  and  itjt  jtceuliar  eord-Iiko  feol- 

Kuffioo  to  make  the  ojKTator  avoid  it.     Tlio  laceration  of 

^toiueam  cannot  a]way§  bo  avoided.     (Jroat  gentleness  slionld 

mid  before  iIk-  oporiuion  tliw  putii^nt  iflii>ulcl  Imvc  boon 

:  porged,  in  order  to  obviate  any  distenaion  of  the  intestinea. 

cxpo«urc  of  tJic  urtory  is  tbc   bi^   Hnti.^<;uiu^  a^^iinitt 

ag  the  volii  or  inclmliiig  the  nerve.     Tlie  circumflex  iliac 

which  orosMs  the  end  of  the  artery  mni<t  bo  a^oidixl  iu  the 

utioii   from  below.     A  oan-ful   soleouon   of  the   method  matt 

riato  to  tliu  cose  beforv  liitn  will  enable  llie  o|K'rator  to  reach 

lattery  with  l)ie  iciml  [lOAsibte  diattu'hanoe  of  tlie  deep  »^lIiil]Lr 

It  M  .true  Uiat  it  may  beeotnv  absolutely  necussiiry  to  di»- 

>  ft  large  <>xt£nt  of  tlie  ]>eritonn>um  liv^m  Its  <M>llular  conncxioni^ ; 

(tliis  diould  alnays  bo  avoidi^^  us  far  an  possible,  siiioo  it  greatly 

the  riak  of  ilitiii.«i!  inttninniatiou  on  ono  or  the  other  »idti 

fim  serous  membrane. 

In  Niirrin's  tallo'  of  U  8  caws  of  ligat.nn>  of  thi*  artery  for  )dl 

thirtj'-Uicce  died ;   out  of  these  the  cause  of  death  is  not 

in  one,  and  in  two  was  un(.H>iuifet(^!d  with  tli«  opmition  j 

|lfa  remaining  thirty,  tliirteen  di«l  of  gangrene,  and  tlii-co  of 

ghiiig  of  Uw  Hue,  six  of  iia-morriiage,  two  of  |H^riloni^TK,  one  of 

fVK  inflammation,  two  of  prostration,  two  of  tetanus,  and  one  of 

itimn  IrrtiuMm.      ]n  wiecwsfiil  cjises,  tlic  ciu-liest  period  of  tlio 

ition  of  the  ligature  woa  the  t*iilh,  llie  latest  the  sixty-second 

In   forty-four  ra»cs  it  came  away  before  the  twoiitietli  diiy, 

I  io  twenty-four  others  beforo  tlie  tliirticlli. 


Abdominal  Axkubism. 

Hany  of  llto  pulsating  tumours  which  arc  found  in  the  fidse 
ar«  of  a  oiinit-nui.*  niituR- ;    many  of  tliow  wliieh    arc  nn- 
lly  aneurismal  are  sealed  upon  the  aorta,  too  high  for  jur- 
treatmeiit.     Tbn»,  both  the  dlaf^oiii))  and  treatment  of  satAt 
demands    the    moHt   careful    consideration.     I  can   wdd 


•  Am.  Jour.  ilnt.  Se.  vol.  xiij.  IMT,  p.  13. 


-I 


516 


DISEASES  OF  ARTEUIES. 


nothing  on  tlio  gi-nnml  question  of  tlio  diagno!ii»  bdwocn  snuon'aD 
nnd  ])iJsatile  tumour  of  bono  to  what  vnti  be  foimd  above;  ami 
will  licrc  nipn^iy  ri'niiirk  tliiil  tlii)  points  most  likclj  to  he  nurlnl 
HD  iliiiliiigii lulling  a  tiitiioiii*  of  tlic  os  inttomiitatiun  from  an 
ism  of  till'  iliac  or  ghitoul  nrtorv  vvoulil  l>c  Hk  [trawora  of  swei 
on  liotli  aiiles  of  tlu!  bone,  and  tlio  appearance  of  caitocr^wlU] 
tho  urine,  together  with  tho  u(]iiid  bc^at  of  tlio  pultw  on  tlio 
stdc^  It  wonid  nover  be  agreeable  or  adviHable  to  coiriix-ikv  ' 
operation  on  tlio  Uine  vo-«»fl«  without  having  plainly  heard 
imeuriitnial  bruit.  But  Mr.  Moore's  case  above  referred  to  (p. 
shon-H  tliat  o%-on  tliis  syntptout  may  bo  doceptivo. 

Am  (o  the  tnatro(»it  of  un  aneiiriun  in  tJie  belly,  tlirvc  pi) 
Euggc£t  themselves :  the  cinplo^'mcnt  of  compression  to  the ; 
8bf»vo,  the  n»o  of  modiml  nieana  only,  or  the  Hunt«riuii  opcrstio 
It  is  only  very  tliin  persons,  and  ihoso  of  a  %-erj-  plae'u!  temp 
ment,  who  could    heur  any   pivilon^i)  coni|)ru^ion   of  thir 
ajEainst  the  spinal  column.     But  in  sach  persons,  mauind  txtatf 
sion  of  tliat  nrtery  nmy  be,  nnil  oiiglit  to  iw,  tried.      In  eotne 
thin  persons,  Uie  pulsation  of  the  vessel  can  be  oontrollect  witi 
much  difHcidty  by  Uie  fiiif^r« ;  but  »  pod  vrould  generally  ho  i 
quired,  nnd  pressure  should  be  kept  up  for  a  short  tiuur  at  fnxju 
int«rvjil»,  a!<  long  as  thi?  tumour  appcarwl  not  to  be  increo^ngi 
necessary  medieal  treatment  Wing  at  the  same  tim«  viiiorood. 

TIk'  Hiiuk-rian  operation  for  abdominal  aneurism  may  1»| 
tised  im  tlie  eommoii  ilifti<  artery,  or  on  tlio  lowvr  [«rt  of  the  i 
In  eomo  caec«!  it  may  [wrhaps  bo  possjble  to  sectu-e  the  iip[«r| 
of  the  external  iliac  for  anourixm  xihinted  alravc  tiie  groiD ;  but  I 
operation  has  been  already  described. 

llie  opi^ratiomt  for  si^ouring  all  tlio  iliac  arteries  are  shnilari 
principle,  and  identical  in  most  of  tlieir  det.iiU,     The  tuuilc  inc 
aerves  to  rouoli  tlu-m  nll,^ — ^only  to  ixaioii  the  common  or  inie 
iliac  tlie  incision  must  extend  further  upwarda,  and  must  be  lii 
in  i-i)iiKO'|Ucnco  of  the  grt-attT  depth  at  which  tlio  inteniiil  iliaoli* 
and  tlio  higher  position  of  the  etunmon  iliiia     H<r«w  the  Sut] 
can  dirtenuino  during  the  opcmtiou  wliich  vessel   lie  will  scle 
according  to  the  extent  of  the  tumour  and  the  appearance  of  li 
artery  when  e.vposed.f 

In  applying  a  ligature  to  (he  cmnmon  iliac,  \\m  operator  mtt 


«  The  olrtm^thni)  hnjt  beea adopted  tiere  also:  but  its rasiiUa>  1 1 
have  bpcn,  imil  iv.mM  alivnvH  lie.  imirunuly  fiLlaL 
t  GutJirio,  CommrnfitrUt.  p.  263. 


LIGATUBE  OF  COMMON  ILUC. 


517 


(!»  situntion  of  tlir  hr^it  win*,  whii-h  run  with  the  artia-jr 
it  »do ;  aud  ho  must  bo  oarcful  to  look  out  for  die  ureter, 
ID  hviikI  mcliu[in<;  it  in  tlw  lifpiturc  (i>f  wliicli,  howuvvr,  tlioro 
c  risk),  aiid  to  avoii]  doing  it  any  otlier  damage. 
K  common  iliuc  may  also  be  tied  by  an  oporaliun  behind  tJu> 
lueum  simitar  to  tliat  which  ia  anad  in  cx}>eriniciital  operations 
t  lower  animals  for  tying  tlic  abdominal  aorta, 
r  P.  Cram]itoti*i)  case  in  well  known,  »iid  his  operntjon  in  a 
illuBtratioti  of  tile  metliod  of  reaching  tliu  artcrj'  firoiii  abuvo 
moar.     An  inoUion  v.ax  niitil'!  from  llio  en<!  of  the  last  rib 
cly  fomards  and   downwards  to   tho  crista   ilii,   and   thoa 
I  forwards  aln>vc  and  parallel  to  tJio  ci-ost  of  lIia  ilium,  terrain- 
at  tlio  antorior  superior  spines     Tlio  musclos  and  fiiscia  trans- 
Is  were  cut  tiiroiigb  at  thti  Wtlom  of  tliv  iiici.'<ioii  till  the  sub- 
oeal  inten'al  waa  reached,  ai]d  tlien  tlio  peritoosuni  being 
ack  by  the  front  of  tlui  fiii{p;r,  a  probc-poJntod  bistoiiri  was 
M»g  tha  baek  of  Uie  fing(-r,  «ii<l  so  by  repeated  sti-okcs  of  the 
(i  the  miiiicles  wero  divided  to  the   extent  of  ihc  cxttsmal 
I     Riitlictent  iXKim  wil«  thus  obtained  to  pas»  in  the  wliole 
ind  rai<ic  the  periMii^emn  and  intawtinet;  from  the  fascia  iliacd. 
krt!i  wen;  thou  ]ilain1y  vinihie,  and  tho  veanel  easily  iiecnred.* 
e  artery  may  also  be  reached  by  an  incision  through  tlio 
iQkl  cavity,  »imtliir  to  that  by  which  Sir  A.  OMi|ier  cut.  down 
be  abdominal  aorta  ;  but  this  oporanon  should  never  be  done 
!t  of  the  others  arc  practicable. 

B  etatistios  of  the  ligatnre  of  Uiis  great  vessel  are  most 
T)  the  recoveries  having  been  only  cxcqitlonal  In  the  Amf 
^iovnat  0/ }M!/-at  Science*  for  .July  1K(!0,  l>r.  Stephen  Smith 
Itoctod  all  tile  cases  known  to  have  occurred,  thirty-two  in 
r,t  of  whieli  only  seven  terminuted  in  ruuovery ;  and  in  one 


it  worth  while  to  quote  Sir  P.  Crsmplou's  fordblo  ilusoripUoii. 
i«rt«  were  unotiseimd  by  a  singla  drop  of  blood.  There  Iny  the 
iac  art<try,  n«arlv  aa  luig>!  as  my  linacr.  besting  au-fiiU}-.  nt  the  mt« 
a  a  mlnuto.  Its  yolluwisli-whiti-'  <!ont  c»iitritating  8tr»ii};ly  with  the 
IS  of  Uie  iliae  r«iii  which  lay  beside  it.  nnJ  sconmd  nenrly  doublu 

Tb*  ureter,  in  :t«  couno  to  tlie  hliulder.  lay  tiku  a  white  tape 
be  artery ;  but  in  llic  proeesa  of  HGpnrnling  tlis  pitriU>nii!um.  it  wns 
(iib  tlist  membruno.  to  whidi  it  remained  attachod."  J/nI.-(7Atr. 
ol.  xvi.  p.  lea, 

,  Smith  has  divided  Ills  mtcs  into  four  groups:  I,  for  amal  of 
huge  in  wounda.  or  in  sui'ttinil  opemliona,  oUvon  oasos,  only  one  of 
!i!OT«red:  i.  for  navuriicin.  fifteen  i-iiscs.  ton  d«ath8i  8.  for  puUnt- 
oar  miitakcu  for  luiciiriaiD,  four  cases,  ono  recovery ;  4.  to  obrlato 


518  DISEASES  OF  ARTERIES. 

cam  at  leiuH  Uin  patient  n|>pcai-!i  to  liavo  dtt-il  under  the  opt'rsitii 
The  causes  of  death  wcro  noted  in  ninL>tc«n  nuws;  aiid  it  t^  r<-mirk- 
ablo  that  gtu)gruiit>  wu.t  th«  ftll<^ged  caiin«  in  only  t]ire«  insteoca: 
the  others  wore, '  cxhanstjcm'  eight,  btcmorrhago  six,  and  ]icriioiutJ9 
twe.  In  MiieccMifitl  cft.t<»,  or  cwM  unoiiiplicat^d  b;  hxmorriuge, 
the  ligature  may  ho  expected  to  sejiarato  in  about  thrc«  week*. 

Ll^ture  of  the  a}ili»nma}  aorta.  Sir  A.  Coojier's  case,  the  first 
of  the  five  in  whicli  tlie  alxlominal  aorta  has  hw-n  ti«l,  is  well 
known.*  Tiio  )iiiti«nt  was  s-ufrt'rinp  from  niK-iirism,  which  tppcnB 
to  Iiave  involved  Uie  left  eomuaon  iliac  artery,  and  some  dixUura  of 
the  wffvX  \m\nv/  it.  It  hii<l  burst  through  tlw  sikin,  and  the  patient 
was  gi-eatly  reiluced  by  lia>morrhage.  Sir  A.  Cooper  ondcavourM, 
by  making  u  sinnll  pmu-turu  into  thi;  anvuriom  whieh  lie  could  [ilug 
witli  his  finger,  to  reach  the  opening  of  the  aiteri-,  with  *  view  (if 
(j-ing  it  on  both  sides  of  it«  comuiuiiii-ation  with  the  sac — the  op«- 
Wion  since  practised  by  Mr.  Syine.  But  as  he  could  not  reach ;!» 
vo(Wt'l  by  this  moans,  he  determined  to  give  the  piitient  the  'our 
hope  of  saffty'  which  rtMntilni'd  for  Inni,  hy  putting  a  ligataw 
round  the  artery  above  the  tumotir — the  aorta.  The  ojientK" 
was  aeeon)))lishod  by  an  incision  through  the  linea  alba,  tlnW 
inches  in  length,  its  centre  corresponding  to  lite  uinbiliciu;  w 
peritonniuui  wua  ojieiiod  to  about  the  i-xU'nt  of  tlio  skin-wound ;  1^ 
intestines,  which  were  completely  empty ,t  did  not  protrude ;  fl 
Kngi-r  was  paawd  down  between  llwir  convuhittons  on  In  the  spioC 
where  the  aorta  was  felt  lieatiiig  violently.  The  periton.Tum  ** 
then  scriitchod  through  with  the  finger-nail,  and  the  ]>()Uit  of* 
finger  was  uisinuatoil  below  the  vessel.  The  aneurism -ueoH-s  ** 
then  conveyed  round  the  aorta,  and  the  ligature  tiv-'l.  In  A^i 
this,  great  care  was  neoeaaary,  to  avoid  including  ^e  intwf* 
or  omentum.  Sir  A.  Cooper's  patient  »ur*ivod  forty  luiun;  Jn- 
Jiuiios's  died  the  same  evening.  These  cases,  to  say  noUiingofw 
numerous  Instimcos  in  which  tlio  artery  lia»  Ixmmi  suoecwfuUy  o» 


hreiDOiThage  in  on  operation  in  tma  cane,  and  in  au  aneurinn)  for  vt^ 
mosia  in  the  Ecconil,  tnn  oiiteii,  bolh  of  which  diet).  It  is  iH'rlu|»  hant 
pr>>sutnj>liiDiis  ti>  en;,  nflrr  thJa  cxiirriimri'  oftlic  opemtioit.  lluil  nl<M>" 
ibe  vftHOH  ought  never  1q  hnvo  boon  submitted  to  liculurc;  and  tJwl  llieDJt' 
raljoua  in  Iho  Hrsl  rlasfc  wnuM  nviw  bo  iinjiii.lifialil(;. 

•  Siiri/Unl  Eimnt.  by  Coojii'i'  and  Tiavnrs,  toI.  i.  p.  laS, 
t  Sit- A.  Cooper  adds  the  I'^iuM'k,  ihut  inihis  opcrniion  It  is  eueBtislH 
hnvo  the  tioift^ls  well  eiuplied  ;  and  the  tnilh  of  thin  nbaenatioa  ■•■  id 
nmplifieil  in  the  next  vmn  in  which  the  sriory  hm  ti«il,by  the  grMl  tnnU 
oxpitricncod  by  Ihe  operator  (Mr.  James)  in  conapquenc*  of  U(«  tywpuilj 
condition  of  the  int«i>tineit.    Med.'Chir.  Tram.  voL  xvl.  p.  I. 


LIGATURE  OF  THE  AORT^ 


519 


ilowpr  aoimnls,  certainly  sliow  the  po!»siI)ili(y  of  survival  after 
craUuii;  »nil  uvooriiiiigly  the  u[Htraticiii  lias  bouii  ropcated 
•eventi  tinn»,'  not,  however,  on  Astley  Cooper's  plau,  !>ut  by  an 
•^Miition  Htiiiiliir  ii)  morf  rc»pocte  to  Sir  P.  CrampMn's  mi  tlie 
annmon  iliac  artcrj-;  tliat  is  to  say,  by  a  free  incision  tlirough  the 
itxlontinal  wnllit,  »onii>wliat  far  IkicIc,  carried  down  to  tiiv  liutcia 
Suing  Uwm,  then  making  a  eaiitiotis  division  of  tliia  faseia  to  tlie 
^tttot  of  iJh!  wotnul,  gradually  jiusbiiig  over  tlic  poritona-uni  and 

■tines,  and  directing  the  tingei-s  towards  the  front  of  the  spine, 
die  piiUiition  of  tho  gn.'at  art^-ry  will  easily  bo  felt.  Uut 
«ngli  it  is  easy  to  leel  tlie  artery,  tliere  is  much  difiioulty  in 
puiii;;  iho  lin;^T  round  it,  and  in  acpamting  it  from  tlie  im' 
pviuit  |iaris  wliieh  lie  around. 

Many  mwt  interesting  questions  present  thcinsclvtw  in  considor- 
in^tiwjnstitiabih'ty  of  thirt  (biring  experiment  in  o]ierative  8nrgeiy. 
Our  ffM'v  will  not  allow  of  tlieir  adequate  discussion ;  but  the  main 
ooiuideracioii.i  nitisl  Ijc  Kuiuninnly  staK'd.  Fimt,  iw  lliere  really  any 
n&mt\  prwpcct  of  recovery?  One  of  tlio  patients  (Monlciro's) 
Wviveil  ten  iIhvh,  so  thnt  it  would  liO  runli  Ui  deny  lliiit  there  is. 
S*3l  wu  must  not  forget  that  such  an  operation  is  never  undertaken 
tJ»!|it  u|)on  H  patient  in  tho  extremity  of  a  (liseiuw)  probably  alfeot- 
■jt  iIh^  vholo  arterial  circulation,  one  in  a  very  differeiii  condition 
uWii  a  bi^^itby  uiiiinal,  or  even  n  henltliy  man.  •^ertnuili/,  allowing 
«» tliuoretical  posisibility  of  recovering,  is  the  practical  chance  of  it 
•"^wjoal  to  tluit  of  s])ontancou8  cure?  Sir  A.  (_'ooper'«  cyi«»  eer- 
mJv  was  one,  to  judge  by  his  description,  iji  which  such  a  euro 
*u  ini|iO!u>ible,  since  be  had  laid  opci]  the  tumour  in  kii  unKuoceds- 
fi«l  ilti-mpt  to  perform  the  old  ojieralion ;  and  batmorrbago  must 
•>«  bave  wctirrtHl,  and  could  bardly  bavo  failed  t«  prove  iiictantly 
™l,  so  that  some  ojwratioTi  was  inevitable.  But  tliinlli/.  Is  it  ever 
Ittmary  to  secure  the  aorta  itself?  Mr.  Guthrlo  beltcvos,  on  tho 
Omiraii-,  thai  wlien  any  ojionitton  is  |Mi*aibte,  the  eoDinion  iliac 
•"ftr  above  the  tumour  could  always  be  reached  by  making  ilio 

Kion  on  the  opptwit«  (tiound)  side,  oa  if  to  tie  the  common  iliac 

side,  and  then  passing  over  from  tbat  arter>',  wlieti  it  has 

(bond,  to  llie  one  on  tho  wde  of  the  diseaso.f    Tlie  old  opcra- 

I  might  be  attempted,  but  would  be  very  liiiUo  to  fail,  from  tho 

of  Uh!  sac  ]iamiiii;  into  the  p.'lvis,  and  so  perhaps  pressing  tlio 


By  Munrmjr,  M/J.  dm.  IMS*,  vol.  liv.  p.  88;    Muntuiro,  SehmWi 
1843 :  SoDtii.  iMHttt.  l(>ao.  vol.  ii.  p.  -iii, 
f  Cammmlanei,  p.  SM. 


520 


DISEASES  OP  AltTEUUiS. 


opcnin;;  of  tin;  nrtor}'  out  nfHight;  or  gulvano-pani- 
triml  in  a  case  whicli  bcciiimI  ituitablo  for  it.  In  mieli  iWjM-Tai 
cum^tjinvM  probRbly  uiiy  tii!Uti»<iit  would  be  miuvutlin);  tu  {ir 
lite ;  l>ut  tho  rUk  of  doing  liarm  by  any  truatmetit  w  ixrt  | 
Hrico  tho  \mlmil'»  Vil'v  will  nut  InM  iindt-r  any  pinrunurtancw 
tbiin  a  fokv  day^-  On  tbe  whole,  however,  tlii>  natural  repngi 
of  Siirywrn"  to  [ivrfurni  great  o]>entlion!t  which  titcy  ii«  not  w 
tu  HuceM-d  will  either  banish  lIiU  altogether  truni  prnvtieo^  or  ri 
it  to  a  v«ry  few  excei>tioual  case*. 


Gi.nTEAL  AxErHrsM. 


J 


Puliiatinp  luinoura  in  tlw  l>uttook,  of  tfi>ontanooiw  otigiq 
naually  found  to  bo  of  a  cancerouB  nature,  and  connoct4Ni  wU 
innoniinatu  bone ;  but  ancuriitin  of  tho  gluteul  or  MantK'  artny 
occur  uiioonnect«<l  with  wound.  Tiie  dtagno&is,  however,  rIviii 
Tery  olcarly  oalablislml  bcforo  the  extroini^y  «lan;;rrou]i  nun 
QOOCSMry  for  tho  tn^atmcnt  of  gluteal  aneurism  uro  rit'ummol 
The  pointfi  to  which  principal  attention  would  be  tlin-etwl  wmJ 
whether  niiy  tumour  in  prvdont  in  tlio  iliiio  fooM;  whotlMir  Uw. 
is  of  tlje  true  wieuriBmal  character ;  whotlier  any  bono  van  \m  i 
tlio  cnvolo]>o  of  the  tumour ;  wln-thor  ttii'  |iuL<«tioi)  roN'mblei  (| 
nneuriiim  (expansive)  or  tliat  of  |>uUiitile  tumour  (rapid  anil  I 
ing):  and,  finally,  whether  any  signs  of  constttutionni  atTnctia 
be  di^liiouai.  Mr,  Guthrie's  ease,*  however,  «how»  that  the  gn 
experience  in  anouriam  cannot  always  insure  against  errors  ol 
gi>o«i)t. 

If  tlio  osislenoe  of  sneurism  appears  eertain,  two  oourM 
opm  to  tlw  Surgeon;  viz.  to  perform  tJio  old  opvr«tK>ii  will 
preeautions  agaiiii^t  sudden  and  exceaaivo  luentorrhap.-  wlildl 
Sytnu  ailupt*,  or  to  tio  tho  internal  iliac  artery.  Th>>  fornnT  « 
cam  only  bo  reooinmcnded  when  the  auetu-ism  ia  of  traiinuitic  M 
•ineo  in  that  oxuo  tho  artery  will  bo  sound,  and  tho  wound  in  1 
be  witJiin  reach ;  while  in  a  Apontaneouii  uneurt§ni,  bcstdis  thi 
of  pullJng  the  hgaturo  round  an  onsooiid  artery  (which,  utidi 
cii'enmstanceii,  is  a  minor  consideration),  the  orifioo  of  corm 
oatjon  may  bo  within  the  ]ielvis,  and  tJie  iAil  ojioratkm  alxw 
imi>racttcable.  Mr,  Syino's  recoil  volumef  eiintains  an  exam 
eaoli  fonn  of  aneurism,  and  eadi  method  of  treatment, 


«  Mt4M)hir.  TniM.  vol.  sxvlU.  p.  808. 

\  Ob$.OH  Ctmietl  Snryerf,  \mi.  pp.  lOO-lTS. 


LIQATORE  OF  INTERNAL  ILUC. 


5S1 


sfiil  in  lx>th  intttaiiixts.  Ko  fiirlliwr  ilcscription  is  nccmisari- 
It.  Symo'3  Rietliod  (or  re\'ival  of  Aatley  Cooi*r'!*  iih-iIkhI) 
af  IwrfiirmEng  Uio  old  ujwradon,  as  it  has  boon  already  deecnbed  nn 
p.  A>^.  I  iihall,  iherefore,  proceed  to  describe  tlio  ligaturo  of  tlw 
JoAcmal  iliac  artvry. 

Tlw  internal  iliac  should  only  ho  tied  for  aneiin'sm  of  one  of  id* 
lr»jiclt«»,  or  for  a  wound  witJiin  tlio  pelvis  iu  which  prL-^suro  will 
not  stop  tJia  hl(«ding.  In  tliia  caso,  however,  the  operation,  which 
ii  OIK-  in  t(.M-!f  of  j^ruiit  dimgtT,  "tumid  Iw  ]>nidi*«<l  only  iiftcr  very 
»rx^ful  deliberation.  Tlie  arttry  has  Iwen  seonrKd  in  onliT  Ui  slop 
bieinorHiiigc  from  »  wound  in  the  buttock ;  but  tito  praclicv  has  bi-cn 
JBBtly  wnBured  by  Mr,  Oullirio," 

TW  otHrntiiiti  much  ri^sLiiibl(w  that  above  doscribod  for  placing 

lUgatnre  on  tlie  common  ilia<!  (see  p.  5Hi).     Having,  by  the  steps 

■We  prescribed,  arrived  at  tlio  lowivt  point,  or  bifumitiun,  of  tJio 

OBDmoa  iliac  artery,  tlio  operator  niUHt,  follow  down  tha  inteniul 

■iiw  into  the  pelvis,  his  fln^-r  being  laid  across  the  external  iliao 

rawli,  which  niiij',  if  it  bi>  pnicti<%ibli>,  lio  tthioldod  hy  n  curved 

>|*Uila  iiy>nt  all  ehaiiee  of  injury.      It  is  de&irable  to  place  tllo  liga- 

toe  at  a  dit<tanco  "f  iiUmt  ^-\  inch  bolow  tho  bifurc»tio».     Tlw 

Wio  lies  behind  iho  artery.     Tlio  spot  at  whieli  the  ligature  is  to 

W{ilawi|  lutving  Uvri  fixed,  the  Snrgoon  scrattjlios  ihe  artery  froe 

it*  e«nnexii>nB  with  his  finger-nail,  and  then  pi-owwla  to  paaa 

E^tiiru ;  in  doinfj  wliich  Mr.  tlHthrie  wiy.t  that  it  in  dosirablo 

■■potsibl«  to  see  llie  vessel,  and  for  this  purpose  directs  that  tlio 

"!•  i{  xIm  woinid  1k!  retracted.     Tin-  arti'ry,  however,  lion  nt  »a 

pwi  a  depth  that  it  can  only  bo  bronght  into  view  if  die  person 

I  "low.     Gr«at  care  acoonlingly  is  rtipiired  t-i  avoid  wounding 

I  ■•  fcritona-tim,  tlio  ureter,  and  tlie  vein  ivhieh  aocompanies  the 

'■•O)-,      Tlio  tiTmination  aliso  of  the  inferior  nn'-*enteric   vofwel* 

(^tfior  IiffimorrhoiiL-U)  may  bo  injured  in  operating  on  the  artery 

«f  lie  left  wdc 

Tbe  caitos  in  which  tins  opci-atjon  is  required  must  be  very  rai-e. 

"wtun  casra  contained  in  tlie  Jin^n'Mn  Joufwit  of  .\Mii-ul  Scumea 

\  ("•!■  Jciii.),  thrtji'  recovered,  ami  four  dietL     Mr.  Synio's  successful 

I  "^  i»  to  be  added  to  these ;  so  that  the  ojxM'iitiou  has  been  suffi- 

Wntljr  »u«ocs«ful  to  encourage  it*  rejwtition. 

T.  HOLMES. 


*  Commealana,  p.  STO. 


AFFECTIONS  OF  THE  MUSCULAR  8YSTK 


ALTHOUCiH   mti^dos  aro  so  much  exposed   to  nccidmts 
violence,  they  are  ii«t  rciulily  iujured;  ttor,  oonsiJi^Tiiig 
litgli  ur{;iiiii»Ht!oii,  nrv  they  frequently  die  nMtt  ofdiMaM.     Un 
may  Huflcr  from  contuiiiontt,  ctruinn,  rupture,  ami  wounds  of  i 
fwciit  kinil*.     Sfvcrc  contusions  arc  iV«|UL«ntly  fuUowivJ  by 
porary  loss  of  (wiwer  in  iho  iiniticle ;  lliiit,  together  willi  tlio  os 
]inin  in  iiny  attoinjit  to  move  tlio  part,  p)irl4<ni[iirly  in  tlie 
bourhoo<l  of  tlie  lai'gc  joinU,  »oiiu-liniM  lends  to  the  8UHpi»(«| 
more  HcrloiiH  injuries,  as  fracture  or  di»li>ealion.    StniiiiK  i^t'  mn 
are  ut\en  ToIIowmI,  esjx'dHlly  in  later  liio,  by  jKiins  of  a  Ustta 
troublesome   (-biirficter,  )Mirtak!iig  of  tlio  nature  of  rlwu 
MiL'iele  may  bo  riij)ture(l  i-ilbvr  from  cxtenuil   viob>ii«!  or 
the  too  energetic  action  of  ila  own  libr«» ;  this  latter  occur 
by  no  mean^t  a  common  one,  especially  tbat  tn  whioli  tli«1 
tQUHcIa  is  torn  «croM.     In  the  living  bojy,  muAole  offers  a 
rosistjince  to  »  force  tending  to  rend  it  than  oitlicr  tendon  nr  I 
and  when  it  does  give  way,  it  is  fur  tlie  moAt  part  at  its  point  | 
junction  u-itli   tbo  ti^^doii.      SetUIIol*   snyti,   that   in   twelitr^^ 
nascH  of  rupture  of  miLtcJeA,  tliirlui'ii  ut-ro  niptured  at  lliis  pMJ 
Tlie  power  of  reei»tjincx.'  In  a  sound  and  liealtliy  uinselv  in  a  otM j 
full  lonteity  is  cnoniKiUK ;  iind  ninny  inten^tinf^  eomparinon] . 
calculations  on  this  sulijcct  will  Lo  fuuiid  id  Bon'lli,  Of  Motu  \ 
mtiUum.     Percy  t  relnt«t  the  ease  of  a  person  with  very  neck,  < 
wn.t  Mi^pcmtiKl  by  tho  Iioad,  with  a  view  of  putting  tbo  tnusdil 
tlie  stretch ;  tlie  result  wnk  w>|i»nili<>n  of  tho  utuiicle  from  ita 
tion,  but  no  laecrntjon  of  its  fibres :  and  in  a  case  in  wliieh ' 
tiiumb  was  torn  off,  tlio  tcnilon.*  were  drawn  out,  but  tlM 
were  \vi\  uninjured,  except  at  the  point  of  junction  with  the  i 
We  are  all  familiar  with  tho  fact,  tluit  ihc  tendon  of  tbo 


•  Jl/^m.  lur  til  ttujtiurt  mHtaulain;  Uiat.  ot  PiLx  do  U  Soe.  dt  Uf£| 
Puri*.  I»I7.  p,  155. 

f  Journal  geitintt  dt  MAUmm,  toL  IxL 


f 


aUPTUHE  OF  MUSCLES.  523 

oris  and  the  tendo  Actullis  give  way  rather  than  tlw  61>refi  of 

tltutr  niKpccln-c  miuclce.      W!tti  tlio  Iom   uf  iUt  vital  contnurtilo 

povt-fff,  muacle  losoa  its  advantago  over  t«itdon,  and  ihe  ex]>erime»te 

ijtichcnuid  and  otlirnt  fully  VHtiiblii^h  tlio  fstc-l,  tliitt  uIUt  di.'ntli 

is  more  easily  ruptui-eil  llian  tendon.      IVe  observe  this 

ft  limb  is  forcibly  Htrnightcnud  from  tliu  hvnt  position  adar 

masdea  have  beoomo  unustmlly  rigid  from  oiniviilsions  before 

Lth;  Iivro  laceration  of  tbu   tnusclcs,  mid  not  of  tliu  tcndunit, 

Ukea  place. 

TIhiu]^1i  iniisclo  in  tlio  living  body  is  not  oiion  rupturud,  yot 

BWOS  of  rupture  occur  sufHcieiitly  ofti!:i  to  Imvo  given  niu^t  of  ud 

«ne  or  moro  opportunities  of  nitnossing  it.     SMillot  has  iweordod 

no   l»jt  thiiu  lw6tity-eighl   cmm  of  tnitiiD  or  iiiiitinl  Apoiitxuieoiui 

ni|>turc  of  muscles ;  but  he  obiterves,  titat  no  voluntary  act  can 

occasion  »  mpUi re  ot'rlu-ir  (iliivs,  liowi-vw  pdwwfnl  tlut  otfiirt  may 

b*,  and  this  for  two  reasons :  l«t,  because,  under  the  iufluoncc  of 

llie  will,  all  tlio  fibrt^s  of  ii  luuwli',  wid  the  muitelos  luwociatod  with 

il  U)  hs  action,  contraet  uniformly,  siraultanixmsly,  and  in  a  regular 

ffiw,  to  oviTOiinio  .1  re^ixtJince :  and  2dly,  bewuisc  ul  tlii)  moment 

tlat  \he  will  perceives  that  tlio  power  ojJiKmed  to  it  is  greater  than 

Us  vft'iirtA  can  overm)mo,  it  wti»o»  to  strive  further.      Rtiptiiro, 

flfivfore,  can  only  take  place  when,  in  ttome  itivoluiitury  or  in- 

wnc^ic  effort,  as  in  tlio  endoavour  to  roeovor  the  e4]uilibriuni  in  a 

«!»  step,  or  from  some  similar  cause,  tlje  wljolo  fi.rw*  is  thrown  in 

k*iolait  and  ancx[>octt-d  matnicr  upon  quo  or  two  muscles,  or  even 

o  a  few  Hhree.     Among  the  eases  oolleeloit  by  iS^-dillot,  ia  one  in 

(ho  rcctiu  feiDoris  was  rujitinod.     In  anotlier  ease,  tho  psoas 

us  muscle  was  found  ru]>liireil  atU^r  dojitti,  the  )>iitient  having 

from  inflammation  and  suj>puralion  following  tho  accidwit. 

coinplclo  ruptui-e  of  tho  bici'|H  iinisckyt  of  esieh  tliigli  (H-eurred 

■  •man  falling  from  a  height;  and  tho  two  recti  abdominis  wcru 
"Pwed  at  ihftir  u|iiK!r  [lart  in  a  young  man,  in  tlio  struggle  to 
^"f  &  trav  of  cement  as  he  was  falling  fi"om  &  platform. 

It  inoru  fre<ju>-ntly  iuijijii-'iin  I  lint  a  few  tihrts  only  of  a  muscle  are 

"flared,  and  tWs  usually  occnra  in  tho  gastrocnemius.*     Muscles 

.In  ntnelimc-!*  torn  across  in  violeni  j)iini\vsi:iN  of  inuseular  spsism, 

■  in  tetanus.  In  these  cases  tho  ouds  of  tlie  muscle,  from  the  vto- 
We  (if  tho  rc'lraction,  we  thrown  into  considerable  swellings.  In 
4  sue  of  aeutc  traumatic  tetanus,  under  I.arrey,  the  man  was  im- 

in  cold  bath's,  aft«r  oueli  of  which  tho  coiivuWions  and  mus- 


«  Wanltvp,  lItJ.-CUr.  Tnuu.  vol.  viL 


5U 


DISEASES  OF  MUSCLES. 


oulnr  contmrtions  were  most  sevon>.  nti'l  lio  <!io<l  (n  thiw- 
a  ewvlling,  liowcvcr,  Iia<l  boeii  pre^iousiv  obscned  Lelnw  l}ie 
bilicufl,  on  the  riglit  side.     On  a  jwst^mortoni  oxutninntJuii,  it 
found  tliat  tiiv  iuiiiniir  wn*  ocouuoned  !>>■  the  retracteil  Piut«  wfl 
rcctuH,  wliidi  wiw  oiilirolj'  torn  aaross.     Hie  spnco  I»«twwii  llm  \ 
ends  of  the  miuwilo  vnut  filled  witli  blood.     Mr.  Curling  dmnb 
A  oiwo  in  which  portions  of  both  recti  abflominw  were  rui-ruo-f? 
totanic  ci>nvn]»i<>iw  (i>nc  of  vh«  .(|Hviini-iis  in  in  t\w  inuwiiin  <if  t^ 
College  of  Surgeons).      Mr.  Gra_v  exliibitod,   at  tho  Piilb.J(i 
Society,  thi>  rt'Otiis  mu»c1o  of  ii  jiiitJiMit  who  hud  <iioil  of  I'-liuiiu,  ii 
whom  ali»o§t  <w[np1ote   traiisvortie  laceration  of  the  inu«>d« 
taken  place.     In  Mr.  Earlo's  com  oF  tcl»niui,  dMcribed  in 
Cfiir.   Traiu.  voL  vi.,  one  of  the  peotui  Din&rlce  wos  partialt^r  : 
ttirud.      Boyvr  ri>1atcfi  tlio   ciuo  of  u  Mtrong   man  idcntttfld 
La  Ctiaritt^  with  "bilioufl  fever;"  mi  irmetic  was  given  him, 
whilst  voniilint;,  ncuic  pnin  wsa  felt  »  little  below  Hip  niiddlc  oft 
left  rec4ii!>  iibiloiuiniN  iiuist-lo.     On  exniniiung  tlu>  J'lirt,  iIhto 
noitlier  tumefaction  nor  discoloration  of  tbo  akin,  but  on  ind 
lion,  into  which  tlio  fingont  could  he  ])lnc«>d,  wa*  folL     The 
died;  and  the  tnawJo  was  fband  completely  torn  a«9noM,  [he  i 
oiidw  l>cing  nil  iiii>h  a|)iirt,  and  tlw  spiiu*  botwvt-n  fillwl  with  hlooi 
Tlic  rtipttin>  of  II  muNcIo  in  aocumjuuiictl  by  (rxlrcmo  [iiitii,  i 
sombliitg  that  occmioiiod  by  a  smart  blow  Irom  r  whij)  or  ttiik,! 
wid  oHon  by  a  dijtlinct  found  like  th«  8Dn|»|Mng  of  a  cord;  « 
motion  of  the  part  is  oithor  im)M)ssible,  or  is  aocoinpank-d  W  MHh| 
»cvoro  pain,  uilh  Hpuumxlic  twitching,  A8  to  ouimi  lif-  imtiml  i 
desist     If  tJio  muscle  bo  a  Huperficial  one,  a  deep  indentation  mil 
be  found  nt  Uio  Kent  of  rupture,  produood  by  tlw  mtractimi  nf  in! 
divided  ends ;  and  oilen  a  considerable  swelling,  pruportiotM<d  to  A»| 
vigour  of  ll)o  contrnctjon  of  tbo  lorn  fibres,  a«  in  tetuniu ;  oaJ  i 
ihcro  is  alwai's  extravasation  of  blood,  much  discoloratiui  of  ifel 
skill  will  follow.     Tlio  indi-utation  and  extravasation  are  not  f^[ 
rent,  however,  in  ruiitun>s  of  iho  deep  innscIcA,  by  which  llieir| 
diagnosis  is  ronderod  lew  elcjir.     If  the  nijiture  l»c  dt8e<)>-crod  <iflt, ' 
and  judiciously  treated,  a  stillioiont  approximation  of  the  ilinM 
ends  will  result,  good  union  will  ibllow,  and  the  ttinctioo  of  lb 
muficiv  will  bo  restored.     If,  on  die  other  hand,  it  l>c  orcriookolw 
maltreated,  or  if  it  occur  in  a  [uirt  where  proper  measnrvt  OMMt 
bo  employed  to  approxiinutc  tlw  cn<U  of  tlio  muwh',  as  iii  khm 
parts  of  the  trunk,  In  niptures  of  tlio  deep  musolea  about  Om  bipi 
and  »huulder,  il^e.,  it  will  bo  found  that  a  widv  separation  axbt»,i 
tliat  tile  ends  of  tlio  uusde,  in-stcwl  of  uniting,  liare  become  alt 


INFLAMMATION  OP  MUSCLES. 


525 


tlic  pnrtif  ill  the  itnmcdiatc  noighbourltood,  aud  the  umi  of  Uiu 
l»H!wie  U  ooiiftemmiith'  lusl. 
■        Tile  ircutitK-nt  consists,  1st,  Ed  placing  aiid  retaining  tbc  part  in 
s   ixiiiiiuii  iiKMt  ravoiinihlo  for  rvlaxtti;;  iIk-  iiiil«c;1i.-h  ;  nnd,  id,  in 

■4jipn>xinialing  tliL*  separated  ends  to  one  another  hv  even  cotn|>r«(- 
lioii,  wkitil]  wc  know  ftxt^ciMiA  ho  givat  a  jwwur  in  wHilrolIing  luid 
I     laoilifYing  the  excess  of  contraclion  in  iho  nnicelos  in  traoturos,  Ac. 
I    A-s  rej^uil.i  tiifi  fintt,  tills  is  wuiily  !w;(!«nij>li»Ii(il  in  Uio  liiiiW:  ihit* 
Hfa  npture  of  the  rectus  fcmoriii  the  kneo  'k  straightened,  and  the 
liniL  U  mi»i-<l  to  an  ung,h  with  tho  IkmIj*.  as  in  fractured  jiatHU; 
l«t  where  the  mi>tiiro  occurs  in  the  Wiuik,  this  cannot  be  done  so 
Kndil)-;  yet  in  the  cum  nbovu  mmtloncxl,  in  which  bot}i  recti 
iMominis  were  rupturet),  a  good  union  wiw  efli-irtcil  by  keeping 
tto  puticnt  in  a  isitting  pcwturo,  tlic  body  being  buwud  furwaiil, 
logctlier  Vfitlt  proper  bandages.*    The  ^ccnd  i*  atrcomplislied  by  an 
evQD  bikI  uniform  conipn^ssion  of  Uio  musclcn  by  incuu)^  of  caru- 
^11y-»pplied  tiannel  l>iuidugi-x,  or  laced  Iwlta^  uded  in  some  cases 
''^  a  ftrip  of  k'athcr  or  gutta-percha.     At  tho  end  of  from  a  fhrt- 
<t'^hi  ro  three  weeks,  the  tiniini  i.i  gi>nera1[y  ix>in|itetc(L   Tlte  process 
<>failiMi  is  similar  to  that  of  other  structures;  tlio  effusctl  blood  id 
■fcserfaetl,  ]>hi«tlo  lynip}i  is  jmiirtxl  out,  wiiidi  iLvtiimcit  by  degrocn 
"*  firai  and  resisting  character  of  tendon,  muscular  fibre  itself 
Wng  never  n'pi-odiiced.      Whi-ii  a  niiisdi!,  with  Iho  intcguim-nl 
■ol  [arts  around,  U  divided,  it  retracts  to  a  greater  extent  than 
■awe  llw!  niiL-tcIo  alone  givw  wav,  from  bi;ing  doj)rivi;d  of  il*  coU 
■"ttBl  support.     Tliis,  in  conjuHction  with  an  ojien  wound,  reiidcnt 
*  «trwn«Iy   diliicutt   to   upproxiinaUi  the   retracted  ends  of  the 
■"Ode,  and  to  find  means  for  retaiiiiiig  tbeiii  in  a  proper  position ; 
''<We  it  will  be  fiiiiri<l  thnt  wouiiiU  extending  thriiwgb  iiiu.scie.i  arc 
"•wwed  by  nearly  (complete   Ioi«  of  their  use,    the  great  chasm 
■•♦tiston  tJieir  enili*  ln-ing  filled  up  by  granulntioii.     It  is  reoom- 
■■nAjd  to  endeavom-  to  bring  tlie  ends  together  by  sutures.   Theeo, 
*^ihu  position  favotu^blc  for  tho  tippro\iination  of  thu  endM,  lUid 
"•ch  encircling  snpfjorta  as  can  be  employed  wliere  a  wound  18 
l^neat,  may  do  much  towards  restoruig  thu  mu»clu  to  a  eertAiD 
"••aBt  of  uacfulncos. 


InjlinmttaHon  of  mtmrff.  Independently  of  rheum atj.im,  muades 
^^*iK  the  scjit  of  hiflainmatioii  from  variotu  causes,  both  nmpio 
''■I  tpedlic,  which  may  teriniiiate  in  ubitcess,  or  in  some  morbid 


•  Kiclicnuid,  yotugraphit  Ckir.  vol,  iL 


fil6 


DISEASES  OF  SnjSCLES. 


chnngys  ofstmetupe,  to  be  deeoribed  hereaftor.  Inllnnimntioii 
lowed  by  abifWM  ofcure  oefiicioimlly  in  tl)i.>  purictal  muscW  o 
hIkIoiikmi,  arising  either  from  Bonie  injurv  or  wiilioul  ap[ian!iit  cji 
It  apiMMirs  l)n>t  as  an  <-xtnMncly  painitil,  and  more  or  lesa  oi 
8cr)lM>(l  &we!Iing,  distinrtly  HAt  below  a  portion  of  die  muM.*ul 
plaiics :  after  n  time  obscure  ftiietuation  U  porceircd ;  pain  Is  now 
vfty  grenl,  especially  on  the  least  movcnient,  acooiiipatiinl  by  irri- 
tative fcwr.  On  laying  open  tbc  ab^ccw,  pus,  discoloured  and 
winiewliat  offenHiic,  etteapca,  Ibe  f«yin]>tuni9  ijiiickly  subside,  ntid 
the  cavity  rcadilv  fills  up  and  heals. 

I'liruleni  doiKjsits  in  the  j)eeUiral  miiAelfs,  extending  In  tin;  in 
costal  muscles  and  diaphragm,  occurred  in  a  case  described  by 
Uactiii  in  /'nlli.  Imrw.  viA.  v.  p.  329.     TIio  patient  lind  rig"r!<  ii 
otlicr  eymptoins  of  fever  fen  days  before  his  death,  with  gi-eat  pail 
in  ibit  right  hy[«ieliondriiio  region;  fiinnntion  of  matter  w»» 
pectcd.  and  pus  followed  the  intraduetion  of  a  needle.     There  wi 
no  pni-ulent  ilejiiwit.s  in  any  vi.ion.*. 

Secondary  dejioflit  of  puB  sometimes  takoa  place  in  muscle* 
well  lis  in  other  Ktructures.  A  ea!*e  i*  given  of  ph1«bitio  BUppurotion 
in  musele,  originating  in  what  he  lemis  puerperal  rheumatism,  by 
M.  CVavoilhi<T.' 

Inflammation  may  occur  in  muwles  as  a  sjinptom  nf  seeondiin', 
or  rather  tertisirj',  sypliilis.  In  a  pa])er  read  hefore  the  Hnyal  Ms- 
dieal  and  Chinirgieid  Mocirty  in  January  1^15, 1 1  deserilxtd  a  group 
of  three  cases,  two  of  which  wore  associated  with  other  symplcntf 
of  constitulionnl  syphili.i,  wliil.it  the  hisiory  of  thi-  lliinl  ease  f** 
obscure.  The  disease,  which  I  had  not  seen  dcscribod  befbrc,  *f 
penrcd  in  the  form  of  mnnilwl  enlargement.*  in  the  left  utenio-eW'" 
mastoid  muscle ;  there  were  tln-ee  swellings  in  two  of  the  case*,  "H" 
two  only  in  the  otlier ;  in  one  of  these  then!  wiw  ttl.«o  an  cidai^em^t 
in  the  tendinous  origin  of  the  musc-le;  the  tumours  were  e\-idcnlly 
fiinneil  in  the  sulHtitnei;  of  the  muscles,  and  wen.-  nearly  *>f  the  w* 
of  a  pigeon's  egg,  and  gave  a  singular  beaded  appearajice  lo  tb« 
muscles;  t.hert-  wns  ^tiffnetts,  with  much  tend" Tin •«•,  in  (Ih*  |inrt,ii» 
great  pain  when  the  muscle  was  in  action ;  tiie  skin  was  neitlierW' 
herent  nor  dist^^ilourcd ;  tho  diseoso  was  slow  in  itit  progrces,  «•» 
had  remained  iieaily  stationary  for  some  months.  All  the  ii*"* 
oecun'ed  in  fiinnles,  probably  from  tlie  neel:  being  more  o.\[K*« 
than  in  men;  in  each  case  tlie  effects  of  the  iodide  ofpouutsium  #**• 
manifest    Li  tlic  first  case  the  patient  obstinately  rofttsed  to  tJikt  tbf 


•  Path,  ilu  Carp  llamain,  fuse.  IT.         f  iMMttt,  Fidi.  I,  18W,  p.  138- 


SYPHILIS  IN  MUSCLES. 


527 


iodide  of  [mtaseitun,  m  coiisi>qui?iicc  of  wbich  mercury  and  rarioutt 

other  rvuMili^-?  wcrv  trivd  willi<mt  imy  ;j(>od  affviA.    After  mimf  time 

(lif  n>ii»ent<xl  to  take  the  itnliiic  of  [Mta-'siura ;  from  two  to  three 

gnins  vivTv  Uflminititvrcil  tlirici;  duily,  ami  tlio  ioiiiiit;  ointment  was 

tppliiMl  externally ;  tho  tumours  soon  began  to  diminiitli,  and  in  lew 

Hum  six  wt'clw  oi>ini>lcti'ly  disapin-uTXHl.     Tim  otliiw  two  canes  were 

I  nmilarly  treated,  with  complete  suceetts ;  l>ut  in  one  of  them  the 

l^ticni  was  obllfHil  t«  lay  wiitu  tlir  n-irusly  fur  a  tlnio,  during 

Iwhieb  it  wiw  remarktil  titat  llio  tumours  became  stationary  ;  on  her 

niiig  the  modicino,  howovor,  kII  remains  of  tlio  diaoonu  quickly 

her.     What  constituted  the  swellings  I  was  of  conrso  tiniit>1e  lo 

aill  from  tlicec  canc^ ;  hut  a  ante  occurrod  Sonio  time  after,  in 

*hieli  tltcfo  wn.<>  a  tiimour  in  the  middle  of  the  hieepa  muscle,  m 

hard  &iid  defintil  as  to  iiulupo  tho  Surgcuu  to  proceed  lo  it*  removal 

hy  opvmtion,  when,  on  cutting  into  the  fibi"es  of  the  muwli-,  no 

tntnour  was  visible,  bnt  the  muscle  in  that  part  was  conj^estod  and 

BfiUnt^l  with  a  grayish  kind  of  lymph,  great  ]iart  of  which  ooxed 

■way  with  much  blood,  all  the  sivnlHu^  mihsided,  and  tlie  wound 

lulled,  leaving  no  enlargement     Muoh  light  has  l>een  thrown  upon 

tw  nature  of  tlK>se  affections  of  the  inuseh«  and  the  eliangca  they 

Vnln^go  hy  M.  V.  lluiiissim  of  Mont|wIier,  nmh^j-  tho  tille  of  Tk- 

*on  ^pfiilitii/uft  dtg  Mnscleg.'     Acconling  to  him,  both  tendons 

*M  mtwdos  are  ihe  .icalH  of  syphilitic  tumours  and  oontraetions, 

liich  ucotur  in  oonjimction  with  other  symptoms  of  constitutional 

[  ^Q^ifc     Mo  hits  o)»er\-ed  tliese  timiount  in  the  glutieus  maximus, 

"Tjsti,  trapciiiis,  the  stcrno-eleido-inastoideus ;  also  iu  the  mus- 

*"'»  utmeturt.!  of  the  lungius  lijis,  and  pharynx.      With  re^ird  to 

*  Ireatnu'nt,  he  for  the  most  part  found  the  iotlido  of  potassium, 

S'***  intorttally,  with  the  cxti'rnal  um-  of  the  iodine  ointment,  very 

*«(ii«l  in  removing  the  tumours,  except  those  of  the  tongue  and 

NxiJ'nx,  which  were  very  nbstiniite;  in  these  ciwes  tlie  mtiriato  of 

^,  in  doftes  of  fiom  I'^th  to  tth  of  a  grain,  was  given  with  suc- 

*"k    M.  BouisNon  was  tbrtiinate  in  having  upporl unities  of  siK'ing 

"Ol  dneHMf  in  its  advanced  slages,  as  well  as  the  stage  above  de- 

^fiVd.     He  found  the  enlargement  continue  with  little  change, 

^«^t  under  the  treatment  of  the  iodide  of  potassium,  &c.,  for  a 

'^'laderable  period.     Sections  of  the  tunioiirs  preiwnlwl  an  iniiltra- 

"*i  snd  dejKjMit  between  tlie  fibres  ofa  gray  plastic  exudation;  many 

**  tW  muscular  fihrcii  were  nearlj'  eoloiirlvsa.     This  state  may  he 

'''^Dwcd  either  by  a  Minvniiig  of  the  eHiised  matter  and  it^  vonverMtoa 


Oattlte  Midie-jie  de  Parii,  Jul;r  190(1. 


538 


DISEASES  OF  MUSCLES. 


intn  •  kind  of  muGiluginouH  fluiil,  or  may  form  an  ahsrni»,  wTiicb, 
on  slowly  getting  to  a  Ii«i<l,  may  biu*!,  and  leavo  an  uiibealtliy  ulcer 
vrith  «louf:liy  fturfnoo  aiid  foul  difRhargo.  Sonio  of  tlw^i^o  vtilnrge* 
ments,  instead  of  suppiiniting,  Iiardun  and  booome  converted  inw 
caililnjfiiiotis  or  t'vcn  Umy  Hlnicture. 

A  caso  is  described  in  tlio  Goiftte  de*  17'ipitaiijr,  Jailliaiy  1 
1858,  of  H  UiRioiir  involving  iicjuly  the  wlioli;  l(>ngtli  of  tli«  stem 
deido-mastoidcuK  miisele.  When  tlio  musde  was  contra«ted, 
nwclljni;  wntt  iniiniiviiblo,  but  in  tlio  reUnwl  state  it  cvuld  be  wovei 
<>n  Uic  deep  piano  of  tibnw;  the  slcin,  though  not  adherent,  did  nol 
slido  ruailiiy  over  it  us  ii.-iliiml,  and  tliiMx;  wa«  u  itli^^ht  blu^Ii  on  >i: 
there  were  dull  pains  in  tlio  part,  which  oceorred  at  uncertain  inlcr- 
laU,  not  more  by  iiiglit  than  by  day;  neitlior  rcdpiratioii  nor  den- 
tition was  impeded.  Theiv  were  decided  traces  of  old  eoiislituikatl 
s\'])hi])s,  as  in  most  of  tlic  cases  roiMrlod.  The  pattont  was  about  t> 
undergo  a  course  of  iho  io<lido  of  potaaHiom. 

Sometimes  lht.«e  swellings  assume  tlie  form  still  moro  compk-ldr 
ofdoiinod  tumours.    M.  Kobfrt*  dcncribca  a  caAe  of  u  tumour  wbidi 
formt-d  in  iho  calf  of  the  right  leg  as  large  as  an  egg,  hiird,  nno<iiwL 
and   loliubileil  on    tlio  sririiic*',   somewhat  movublo,  tondcr  tii  iJi' 
touch,  but  not  painful,  which  was  completely  cured  by  the  iodidetf 
|ioljissiuin.     In  J'<ilh.  Tninn.  vol.  vii.  a  vtTv  iiit<-n.wtiri;i  iii.-c"tiii1  rf: 
tumour  is  given  by  Mr.  S.  Jones;  the  tuiHoiu-  was  renio\eii  by 
Soutli  from  a  (iiitie.nt  in  St.  TliomasV  HoK|iita],  NovemIxT  6, 1 
The  patient  had  had  syjthilis  eight  years  before,  wIkjh  ho  took  m*"' 
cury,  l>ut  liiid  no  cons ti  tut iuual  syniptoiiis.    He  liiid  rcccivi'd  a  l^** 
oo  the  left  shouldor  two  years  previonwly,  and  lost  for  some  tiK 
the  use  of  the  arm  ;  lie.  however,  firadualty  reeorcred  it  after  »>* 
moiitlm.    Ho  had  pains  in  the  sbouIcK-r,  which  w»»w  considerit!  rlnO" 
matic,  and  wore  treated  and  cured  by  the  iodido  of  potassium;  ut^ 
also  preseniiid  thenisohoa  at  (n.-vural  (MtinLt,  but  tlicy  diKi|>|iran^ 
Violent  pains  again  came  on  in  the  shoiUder,  which  were  fofltxw 
by  a  tumour  in  tlio  infra-Apinal  region  of  thn  Hcapula ;  this  incrtavJ 
rapidly   lu   size  ;    his  general    health  aiifferod   consider  ably,     TV* 
tumour  waH  well  di^ltnal,  niovinl  imly  with  rho  .'<eiipula,  did  iy* 
project  much  abovo  tlie  surface,  and  measured  6^  indiefl  in  on* 
diroction,  and  8  in  ntiothcr ;  it  was  removed  with  ii  large  |>orticn>  of 
tho  scapula.     On  examining  it,  it  w-is  found  to  be  formiil  ui  ihfl 
muscles,  but  princijiiLlly  in  tho  infriutpiiiatu",  tliongh  nodules  ww* 
founil  in  many  of  the  neighhom-ing  muscles.     The  lumoor 


•  VUnion  Mfilieale,  uo.  91,  mum  20, 183U. 


ATROPHY  OP  MUSCLE. 


5i9 


liard  and  dense,  slightly  olastii?.  of  a  dead  white  colour,  and 
homogeneous  or  .tlij^litly  rpticulatwd  Bti'iK-tHri.-  j  Ui«  surrounding 
lar  fibnui  wcro  <lit«>ctly  contuiuona  wilh  its  surfaoe,  and  rautt- 
fibrea  wore  pi'c^orit  in  great  ahnndauoo  in  many  parte  of  tlio 
tour.     Uany  of  tlio  fibres,  osaraiiied  by  the  mici-osoope,  liad  lost 
striated  cliiLractt<r,  and  had  bcoumo  gh«toning,  triuispamit, 
irtmctnrclcss.     The  spaoes  between  the  fibres  were  octrupicd 
aolclj'  by  («ll»t.     Sir.  South  Jiu*  mice  infomu-d  niv  that  tlio 
luud  hcalod  well,  and  there  liaa  been  no  sign  of  returning  disease 

Simple  eontraction,  or  shortening  of  o  muscle  witliout  apparent 
tenitinti  in  il«  structure  or  cliaiijE^  from  ibt  normal  conilition, 
WM  to  bo  an  owasioiial  erti-ct  of  the  iufinnimation  from  syr)hilitie 
ittOB  in  the  jiystfrn,  and  !»  usually  found  in  tlio  muRulos  uf  the 
Hot  fore-arm.  M.  Iticord  has  nolioixl  tliis  so  long  ago  as  1842." 
■  Xotta,  in  an  intcrtssting  paper  on  Syphilitii;  MiiscuUr  t'ontrao 
>ii*,t  gives  tJireo  cases,  the  features  of  which  wore  nmcli  tlie 
Ho;  imd  in  i-ach  tlio  biceps  waa  the-  scat  of  tlu!  contraction. 
Wlwas  no  Imrdnesa  or  rigidity  of  the  ninscle  when  not  in  action; 
M^ailifl  wen;  variable,  being  great  on  putting  the  iiiii»cli,*  on 
Itretch,  and  mostly  referred  to  its  insertion.  The  contraction 
slow,  an<l  graduiiily  reached  a  eertjiui  point,  cuuxing  lixod 
Kon  of  the  elbow.  The  iodide  of  potassium,  with  minute  doses  of 
t  proto-itHlidv,  api>car»  to  have  cured  every  ca«o.  The  Kaine 
ly  bo  said  of  tlie  cases  ciu>d  by  Uicoiilt  an<l  otliers,  in  which 
WM  ft  oortnin  change  of  structure  of  the  muscle,  iLwoeiatcd 
(h  oontracrtion.  As  a  gtrni-ral  rule,  merciirj'  has  done  no  good ; 
tct,  in  many  of  the  cases  the  disea*o  appcan-d  to  increase  while 
Bjatient  was  undergoing  a  course  of  nn-rcury. 

Muscle  is  occasionally  the  seat  of  atrophy,  with  or  without  fetty 
1  fibro-ci'llular  dogcnoratJon.$  Fatty  degencralJon  occuni  both 
tht  voluntary  rousclu:^  and  in  the  heart,  the  fibnii  of  which  boar 
lose  afliiiity  U>  diosc  of  iJio  muscles  of  animal  life,  piv*-iitiiig  lJ»e 
striated  appearance  of  their  elementary  fibres.  Fatty  trans- 
Balioii,  ft*  dc^cribod  by  Dr.  Quain,  on  Fatty  IJimiiics  of  tlie 
ltt,|  preeenta  two  diRtinct  forms;  viit.  tliat  in  wbidi  the  fiit  it 


•  Oai.  ilai  Hopitaux.  p.  W. 

f  Arekira  fiitrmle*  il<  MtJtdnt,  ear.  4,  vol.  xxir.  p.  413. 

;   Oat.  dft  Hopivmr.  ISIO.  p.  l. 

{  S««  Mr.  Paffct'ii  lectures.  Mrd.  Gat.,  1647.  pp.  MA.  aST. 

II  M«S.Ciur.  Tram.  vol.  xxxiii. 

VOL.  m.  u  u 


530 


DISEASES  OF  MUSCLES. 


iiituabid  on  the  surface  of  tli«  orf^i  nrnl  in  Uic  interstioes  of  ite 
fibrv»,  unil  wliicli  he  calls  *'  htty  grovrth ;"  and  tJtat  whcrv  It  i» 
found  widiin  tbe  mombranoofl  t<ib<!«  coiittiuiiiig  tl»o  muscular  c1^ 
mvnt  whicb  it  ultimately  aupenedes,  and  wliich  be  tonmi  "fiittr 
degeneration :"  tbe  first  lins  all  the  cbarRctcrs  of  adipoac  nuttttf 
I'lwwlmn- ;  ttie  otlior  is  composed  of  opaque   granules  of  great 
minuteness,  vv-itb  here  and  tliurc  ordinary  Bit-«lobuic«  of  Uie  twM^ 
kind.     Fatty  transformation  oranirs  in  tbe  voluntary  muscles,  fit^H 
various  causes ;  it  always  in  a  gn-atcr  or  lew  dcgroo  acoompaais. 
•trophy  of  the  muscles,  wbellier  from  paralysis  or  fi-om  any  ollw 
OBOM  wliicb,  by  iutcrfcKng  witli  tbu  uxorciw  of  tlieir  function  a 
oontraotility,  deprives  thom  of  iJiis  tboir  great  source  of  Iwallli  sod 
nutrition,  sMcIi   as  slifF  joints,  dist'irtions,  or  oliicr  aJlt'cttomia 
whicb  tliey  are  condemncHl  to  permanent  inaction.     Under  ihM 
oirruiiistfliicwi,  fatty  change  is  often  acPom[iiini"i  by  fibrif-wsllubr 
degeneration,  njid  tbe  progreaa  of  atntpby  is  rapid;  nbilsi  tlut  fiinn 
of  fatty  disooso  I  am  about  to  describe  (us  far  as  my  limited 
will  allow),  and  wiiioh  ic^nds  to  involve  the  entire  muscular  »y 
is  of  a  protracti^'d  nature,  and  sooner  or  later  tttrmtitatut  fat^fj 
either  troin  the  encroaclimenl  of  the  disease  npon  muscles  em; 
in  vital  offices,  or  from  c-nsual  attacks  of  fcrcr  or  of  iiiflammatii 
mostly  wiiliin  the  tliorax.      Tliese  attacks  are,  for  the  most  {: 
slight  in  tbvnisolvcs,  and  do  not  at  first  create  alarm ;  but  owin^  l> 
the  low  condition  of  the  vital  jwwei-s  always  associated  with  lii» 
diseiuc,  the  patient  sinks  almost  without  an  eifort  towanU  redbdwn. 
Let  mo  begin  the  description  of  this  disease  by  the  foDowb^  t^ 
connt  of  th«  apin-siraiictis  presenttsl  by  dissection  in  a  ease  ili>»crib« 
by  Mr.  C  J.  Ilallett,*  uixh-r  tho  hwid  of  Adipification  of  lIii«J»i 
or  Steattisis.     Tlic  case  is  that  of  a  man  aged  7t^,  who  died, 
was  said,  of  paraly.iis  (but  the  brain  had  been  removed  from 
bodj'  when  it  mmo  uodor  Mr.  Hallett's  notice).     Tlw  form 
development  of  the  muscles  were  as  nsual,  but  the  great  inajonl 
of  tliem  were  of  so  pale  a  colour  as  to  be  scarcity  distingiiv 
from  the  surrounding  tissues,  and  had  undergotte  in  inoet 
Comptet'f.'  triuiNfoniiatioii  into  tiit ;  sotoe  only  partially  so,  and  a 
ware  altogether  natural ;  fatty  matter  was  also  extensively 
in  ibn  \fM-l.     The  I li'gene ration  seomod  constantly  to  baxe  ooni' 
mmoed  on  tJie  surfaces  of  the  muscles,  ami  extc-u<)e'l  inwards  to 
their  centre ;  so  tii«t  many  wliich  apjH-arod  wholly  eonx'erted  i 
fat  exliibited  in  their  interior  musetilar  fibres  in  a  more  or 


*  Edin.  Mtd.  ami  Sur.  Jaum.,  April  ItiM. 


FATTY  DEGENTIRATION  OP  MUSCLES. 


631 


HmUiv  mndltion.    The  first  stage  of  tfao  change  consisted  in  tli«  obli- 

^entiou  of  iIhj  trniiiivi;r*(T  liuniii  on  tlu'  tilire,*.     Tiiu  fatly  matUx  in 

ihree  cases  appears  to  be  doposited  within  the  Barcolemoia,  mme- 

tinws  b<.>f;iiiniiifr  at  ontt  i^ml  i>f  a.  tilirn  nml  cxli-ndii)^  towitnU  Uiti 

otluT,  or  beginning  in  the  ccnti-o  and  extending  to  either  extremity; 

K  ipfxiArtHl  in  tin-  t'i>rm  of  miniitn  n{)W{iin  globulei*  or  onrjinsciiW  ar- 

tm^  in  a  linear  form,  with  occasional  ordinary  fat-globules,  which 

frttt  tlieir  greiili-r  si/i-  filliid  tlm  lin-udth  (/  lli«  Hdic,  or  eveii  caused 

it  to  btdge.     As  tlie  disease  advimce^,  the  fat-globulos  increase  at  the 

CipMue  of  the  o|mhiiii'  nioI<-cnli's.     Thfi  nan-olemnia  (;ivo«  way,  and 

th*  &t-gIobulefl  find  their  way  into  the  cellular  ti!>Kue  between  the 

filna.    Tbo  luyHtking  up  of  tlio  sorookinma,  and  liia  t^ivajiti  of  the 

isicibaies,  seems  to  have  the  efibct  of  destroying  all  appearance  of 

fim,  and  nothinjr  hut  •  mam  appenrs  loti  like  ftdi|>odro ;  yet  evoa 

We  the  element  of  muscle  or  myoUne  is  not  totally  lost. 

hi  vol.  XXXV.  of  Afat.-Cfiir.  Tnm*.,  I>r.  Meryon  Itns  givwi  a 
Wiy  interesting  account  of  a  case  of  '*  granular  a;id  fatty  degenera- 
In  of  vohiiitarx-  niu»clM ;"  and  Mr.  Leggutt  liaA  ditiicribnl  a  ca^a 
^  the  Bame  natiure  in  vol.  viiL  of  Path.  Tmns.  Li  both  papers 
toich  interesting  mattor  itt  oontained,  and  niaiiy  caso»  mid  tavis  are 
■fttred  to.  Tlio  case  described  by  Dr.  Mcrj'on  is  that  of  a  young 
iMn,  (Jirt  cIdeHt  of  four  sons,  who  died  at  the  age  of  sevmileon,  of 
tlie  liiwaiie  in  question.  lie  was  a  liiio  and  healthy  child  when 
hut  alnav!*  lity  hravlly  in  hiH  numo's  arms  ;  when  ho  inmld 
,  whit^h  was  late,  he  walked  without  vlw'ticity,  and  wns  unable 
•njnniji  off  the  gmund  ;  this  state  of  things  conlinuci!  until  li«  was 
«^  j-ears  old,  when  he  walked  more  bmivily,  inclined  to  trip,  and 
"•U  not  niiiko  an  ttffort  to  reexiver  himself.  At  the  ago  of  four- 
••fli,  wlien  Dr.  Merj-on  saw  him,  the  np|>er  oxtroniitics  were  fail- 
>g:  nill  Uit)  miL-u  of  the  miLscles  did  not  appear  to  diminish,  and 
•  *M  well-grown.  From  this  time  to  tho  period  of  his  death,  the 
*■  of  musculiir  fiower  increased,  tJie  body  and  limbft  became  at* 
fttnolod,  tJw  sjjine  was  cun'cd  forwani,  and  tlio  limbs  were  bent 
■*!  «iff.  He  <Ued  in  December  lS5t»,  of  a  low  fever,  with  no 
pBnuneat  symptoms,  oxc4>pt  indivjiuNtion  to  tako  food,  and  dif- 
™i!ly  in  (ieglulilion.  I  examined  tlie  boily  with  Dr.  Steryon.  It 
*«  much  wasted,  tlio  ^inc  was  ciir\-(.il,  the  chest  Hatteiicd,  and 
"» lindxi  rigifily  lient ;  the  viscera  were  healthy,  the  heart  entirely 
■m  6w»  fat,  but  the  voluntary  niuseic!*  thrr>Uf;liout  were  !itn>phiod, 
and  c«>lo«rf(*»,  as  ih^scriliot!  in  tho  former  case.  Tlte-se  and 
,&>  micraecopio  appearances  have  Iwen  well  described,  with  faitlifiit 
iiiDatioos,  by  Dr.  Mt'ryon.     Neither  the  brain  nor  spinal  cord, 


532 


DISE^VSES  OF  MUSCLEa 


?> 


nor  (ho  nerves  pmv<H.iliTig  from  tlie  Intter,  pTMeiited  any  ahnannal 
appeanutce,  Uiough  oacfa  uti(li>r«'cnt  a  tno«i  carcliil  scruliny.  more 
wpccislly  tlic  niitvrior  <.^>Iiiiiiii^,  with  thoir  iiervea.  A  ft^w  ycar^  latiT 
a  second  son  died,  aged  sixteen,  of  a  eimilnr  di»cit5c,  wlileli  liaii 
nin  tlift  Nniiie  proLntd<!d  course;  tlie  botlrwaii  not  exaniinM.  SbN 
then  a,  third  ison  1i:l«  fallen  a  viclim  to  this  diB(>aso,  at  thv  same  a^ 
altlioiigli  tiie  iniiiiL-diate  oaiiae  of  litH  death  was  aii  uttaok  of  piu^ 
monia,  which  liis  wt^kcncd  &amo  wa«  unL<qual  to  rosifL  Ifl 
fourth  iiinl  only  surviving  son,  aged  ton,  is  of  a  dighti-r  Conn, 
aiid  hiiH  hitiii^rto  »bowii  less  decided  s^pinptoins  of  tJie  compluiut, 
Uiey  cfirtninly  exist.  All  the  female  children,  six  in  number, 
on  the  wliolc,  healthy  ;  some  of  them  having,  however,  sliovrn 
few  striinKius  nytnj>tonii».  Mr.  Ijeggittt  in  hin  jiajwr  has  d««iW 
a  caso  of  a  youth  very  similar  to  those  abovo,  but  whieh  w«  wm- 
plicati^d  with  slight  sofletiing  of  Iho  sijiiia!  chord,  tlie  roota  of  lli> 
nerves  being  healthy.  The  first  ejnnjitoms  of  tlic  dUi-asc  »lii>w« 
themselves  when  he  was  about  eight  yoai's  old,  ami  he  died  (nHB 
an  attsek  of  pneumonia  at  eightt-eii.  All  tliewt  cases,  and  MvenI 
othorit  recorded  or  i-etorred  to  by  tHith  Dr.  Meryon  and  Mr.  Legg*<'i 
commenced  at  an  varly  period  of  life,  were  roctromoly  alow  in  their 
progress,  and  oiiotiiTcd  only  in  male  ohildron,*  and  oR«ii  in  fev«a 
in  tlic  »iitiie  tiiniily  ;  and  on  referring  to  tlio  tabular  sketch  iii  11'' 
Iieggatt*s  paper,  it  will  be  seen  Uiat  tlie  nervous  system  was  rarely 
alterwl  frcmi  the  Iioalthy  static  1  must  now  shortly  refer  !;>  tl* 
papers  of  M.  Aj-aii  and  M.  Crnvcilhier,  in  the  Archivti  ^ivimU* 
d«  Mtilerinr;  the  fonner  in  li*50,  tlie  latter  in  May  1853  aai 
JaiiUHTy  IHSfj.  M.  Aran  records,  under  the  name  ofa/roptiie 
culaire  proffir«tive,  eleven  eases  of  Jatty  degcuoration ;  tltcy 
diiefly  in  miJdle-aged  persona,  two  of  whom  were  females, 
most  of  thciwuises  a  limited  number  of  muscles  only  were  a: 
and  in  the  only  tliree  fatal  cases  two  belong  t«>  51.  CniveiUiii 
pajtcr,  and  will  be  »|K>kcn  of  shortly  ;  and  thv  remaining  eve 
not  examined.  The  syniptoms  ajipi^rir  to  have  be<!n  nimilar  to  lli 
above  deseribod,  namely,  wasting  of  tho  rauvolca,  hiit  not  of 
limb  generally,  giving  a  hollowed  appearanco  in  the  courts  of 
muHclcs.  8oine  cusos  iHrein  to  have  arisen  from  long-continm^ 
and  farigne  of  certain  muscl&s,  ihe  first  s^-mptoms  bt^ing  IvcUi 
inorenvtxl  by  fatigue  and  cold,  witli  crumps  and  subsaltus.     91. 


*  Pi-.  MfMyuii  tuts  ^iiii^e  iDfi)i-meil  lui.-  Ihiit  ho  lud  Iimmiiii*  a«>)UsinlM 
ivilh  tH-i>  cintiB  Unit  opcuni'il  in  Into  pbilcli*n.  a  broUipr  am)  uiitt^r;  lh«  UXUt 
rocnvorej,  aud  ivnsiiiiitc  well;  but  tli«farmcrdied,aA«rllie  usual  protntttJ 
courdo. 


FATTY  DEGENERATION  OF  MUSCLES. 


533 


gives  a  detailed  account  of  t.hro«  well-marked  cities  which 
aaiKtetl  fiitully  mid  wure  carc-t'ully  cxitiniiicd  »(Wi'  duitlh :  be 
ilbe  discnM  '^ paral^gie"  nui»culaire  airopiiiqttf  progrttstve,  Tho 
were  of  tlifl  i-t-spei'tivo  ages  of  oiyliteeii,  lliirty-lwo,  and 
the  hist  a  female.  Tlifl  disease  exlilbitcd  symptoms  simi- 
'to  tJM>.«i!  already  dencribed,  and  tlie  [lOKt-mortftiii  exarniiuitiona, 
appear  to  liavc  been  conduded  with  the  jcreatest  ear©, 
aired  I'xti^iisit't-  fatly  iIegt>iioralioii ;  aii<l  in  hvo  ■<ii.-u>!>  rJie  inu&- 
strneture  of  tlic  tongue  had  undergone  almost  complete  fatQr 
Teniou.  In  all,  tin;  brain  aud  Rpiiiul  c-oi'd  won-  found  j>cr« 
^HIt  healthy  ;  but  ui  two,  and  more  eHpeeially  in  one  of  them,  tha 
of  thu  anterior  iii>iiial  nervoA  liad  bfoome  atrogihitnL  The 
josaal  Qorvce  bad  also  wasted  in  the  two  casos  in  which  tho 
had  undergone  futty  cicj^-niiration.  t  i\ill  eonc-tude  this 
by  mentioning  tbe  ca£o  of  com|)!ete  fiitly  ttegeneration  do- 
riUtl  by  M.  Vin-liow.  Tin;  nnim-li-s  wore  pii-tty  generally  affected 
*itli  [he  disease.  Tlio  posterior  columns  of  tJie  spinal  cord  had 
one  great  change,  vix.  diitappearanoe  of  tiie  nen'oiis  tubas, 
only  hero  and  there,  and  distributed  moatly  in  pairs,  wide 
wtU)  n  grainilnr  eiti-uctiin-,  anil  here  luiil  tliero  aiiiyl-iceous 
din  between  tliem.  Tho  remainder  of  the  cord,  and  botli  the 
■  aud  poslfrior  nones  were  entirely  free  from  diw^jisii. 
I  is  a  dcetch  of  this  singular  disease,  the  symptoms  it  preseatfl, 
Itluj  appearimces  whieli  are  fuiind  aHer  deuth.  lti>  ciitittctt  are  ex< 
ncly  obsciue.  M.  Cruveilhier  considers  tho  disease  as  a  6|>ccics 
[uiiueular  paralysis,  the  cfftwt  of  atrophy  of  tbe  motor  tier*  ea,  by 
I  tbe  muscular  fibres  arc  deprived  of  tho  stimulus  to  contract 
ry  ti>  llieir  nutrition.  Xor  is  it  Aurpriiilng,  looking  at  tlte 
I  of  tho  po«t-mortem  examination  of  two  of  his  vaM»,  that  ho 
Itboae  engaged  wilJi  him  in  the  in(juir%-  shoulil  have  taken  this 
of  tlie  tliscaeo ;  but  further  observations  have  shown  that 
by  of  the  motor  nervett  is  a  nu^*  necompiniiinent  to  the  dis- 
»;  mod  JI.  Aran  and  others  consider  the  disease  to  be  purely  one 
Ilbe  musclctt  Uiemselvcs,  in  which  tlte  norvt>s  play  no  |>art,  and 
Hong  from  defective  assimilation  (see  two  interesting  pH]>erH  on 
tdiwussions  which  have  arist^n  on  Ihis  subject,  in  Nos.  14  and  16, 
MrdicaU  for  1853,  by  M.  J.  Guerin).  It  i«  ocrtain  tliat  in 
tbe  entire  nervous  ny»tein  is  fwrfeetly  normal,  as  in  the  case 
linnl  by  Dr.  Merv'on  and  myself  (this  is  omittj^l  in  Mr.  Leggatt'« 
e),  and  in  that  of  tlio  brother  who  died  recently,  anil  where  a 
:  careiiil  poHt-mortem  examination  wa«  conducted  by  Mr.  Skcy, 
^.  Utiryun,  and  otlicrs  (at  which  1  had  the  privilege  of  being  pre- 


diB^ase  must  He  sought  for  dspwhcra.  It  is  wd 
itmndi^  iifU:r  (i<!»tli,  when  ex|Kia«<]  to  moiiittire  l>i)t  ( 
air,  bccodicA  coDvcrtcd  into  ailipociro,  a  subntiiDoe 
tamo  imt.iiro  an  fiitty  <Jeg«nontio»  in  iu  comjilnlii  otat 
weakoiM  or  lowers  the  standard  of  tlm  vitjil  powers 
economy,  tend*  to  bring  ita  ooinponent  pmrtit  undvr 
of  tbosc  lan-8  which  govern  inorganic  matter.  Hei 
(loc  oit.)  (vtnHider*  that  ihn  jiroiww  of  fatty  wnvei 
of  s  pliVMcal  or  chemical  tlian  a  nul  nature ;  that  (1 
cffocta  of  nmny  <li'WA»c«  »liow  tlwrntu-lvi'it  by  fatly  di»gi 
in  the  tissues  aiid  in  librinoua  and  morbid  dejioisit;  t 
renuiiiborod  that  Htmma  in  it«  luuitl  forms  luid  d 
Diombors  of  the  family  of  most  of  those  who  were 
fatty  dogoiwrntion,  it  niiijlit  a|>{H>iir  prolmblu  that 
ing  influence  the  muscular  atrophy  is  diio.  It 
not  usually  loolc  in  miiw.^Iu  for  iadicataons  of  tlu'a  i 
until  comparatively  lately  waa  it  soppoaed  that ' 
turc  wiui  oiWii  tho  hoat  of  M%'philitic  changes, 

'J'reatma\t.  Muscle  that  has  undergone  fitt 
never  be  restored  ;  it  cuii  no  longer  bo  »ikl  to  bo 
body;  treatment  must,  therefore,  be  directed  to  u 
gruM,  or  jirei'fiit  the  InvnKion  of  tlio  diaoMO,  and  w 
of  a  ]>n>pliy lactic  than  a  cui'alive  nature.  Hitliertti 
all  di.-Jwri]>l4<iiiK  nttim  to  haw  failed  in  making  any 
tile  disease,  whether  mineral  or  vegetable  tonics,  i)U 
frictions,  &0.     (I  do  nut  know  if  the  iodide  of  potai 


-t—j;. 


■^  e~.  -«~  U»^v_~i  ^~.-~*  :-  •! ^- 


OSSIFICATION  OF  MUSCLES. 


535 


a  lengthened  com-so  of  tlie  intlide  of  potSBflicun,  t}to 
Jetelj  rctfovvi-wl  butli  llioir  sJzo  aiui  powent.  How 
tu  thi«  remedy  would  avail  wlien  the  diseaite  Bpringa  from  other 
I  Vwering  caaws,  I  cannot  wiV' — probably  not  at  all ;  ai«i  wo  liavo  yrt 
ta  look  for  a  retncdj  for  tliia  difienac  areording  to  t)ie  randition 
gning  rim  to  iL  In  tJie  gaho  of  the  fonnh  w^n  rvcordod  abo\-c,  I 
■Bitntand  that  lie  has  been  living  apart  from  his  family,  under  the 
fireetion  and  care  of «  liipbly  intvUigi^^nt  friend,  wbo  dcvotos  mach 
Inffli  and  car«  to  liim ;  that  he  resides  in  a  fine  and  bracing  atino> 
•[4«ej  ia  kvpl  in  oiiHtant  excrcinc  of  his  innticlo.*,  with  a  biKlily 
Mrittotis  diet ;  and  that  the  disease  has  but  slightlj  shown  itself 
ia  Mm.  M.  Anm  Unit  found  Homo  b<^^efit  follow  tlic  iikv  of  localiMcl 
tiettrioity :  possibly  his  cases  may  have  partiken  more  of  the  na- 
toeoftliOM!  rt'»nltin{;  from  defw;tiv«  oprvoiis  infliiftioo;  for  it  hiia 
leea  shown  by  Dr.  J.  Raid's  experimenta,"  that  the  irritability  and 
Mililiy  condition  of  miiwhw  niiiy  Ix^kcpt  up  by  tho  rtimnliwof  eitfo- 
nd^as  eftectiuiUy  as  by  that  of  tlie  nervous  centres  Uirough  tlieae 
■•ws;  and,  as  Mr.  Paget  fairly  conclndcs,  atrophy,  the  rovult  of 
^nlyas,  may  be  averted,  and  the  moaclos  sustained  in  a  oonditioa 
fcRmme  their  ftioclions,  should  ihr  iktvous  [wwcrx  be  rff»tor«d.t 
IhiTC  not  been  able  to  learn  if  any  benefit  has  been  obtained  from 
•Wtricily  in  iiitly  disi.-ajw  of  tJio  niiisflf*;  but  in  Mr.  [i".ij;gatt'8 caso 
■e  pUtcnt  derived  any  thing  but  benefit  from  it.  Friction,  moni- 
lidmiun,  and  pussivo  motion  wcro  of  sorvlcv  in  aomo  inKtanciM. 

Om/Koticn  of  mwKlt.  Tlio  conversion  of  muscle  into  (at  is  truly 
■  ^egcneratioD,  as  it  is  a  change  from  a  Iiighly  organised  ntructaro 
U>  ui  aincM^houa  mass  of  adipocire.  T)io  some  may  he  said  of 
AcK-callvd  bony  deposits  in  many  soil  pnrt»,  whidi  arc  not  tmo 
•*e  either  in  their  structure  or  their  chemical  composition  ;  while 
■tDMifio  growth  in  muBflc  pOfWcesoM  all  the  qualities  of  tniv  bono, 
M  is  merely  the  development  of  one  organic  titnicture  within 
MKlwr,  to  which  the  tonn  'degvneration'  would  ill  apply.  Mr. 
Qivkina,  in  a  clinical  lecture  to  which  I  shall  have  again  to  refer, 
i^rks  that  tlu;  os»ific  deposit  in  mitsclc  is  that  of  true  bone  with 
Vieelli,  compact  sliell,  ]>edosteum,  and  cartilage,  displaying  also 
Oder  the  microMopo  all  tho  signs  of  tmo  bono.  Mr.  QuckcU  liaa 
•adiy  abowu  me  Home  beautiful  microacopiool  preparations,  which 
I  )ht«  Ibo  tmo  bony  nature  of  these  doposits.  Ussific  growths  may 
take  place  over  a  Urge  extent  of  tlic  voluntary  mnscleo,  or  may  be 


*  PAyt.  Jaof.  ami  Surg.  Betmnk. 


f  Surg.  Path.  ToL  i.  p.  120. 


fnu  luuumni 


igrees  liiiving  been  watched  from  its  ooinmcnoi 
preaent  verj-  advanood  stato. 

Ill  Juno  1859,  G.  Brown,  n-t.  38,  pnwented 
Qeor^'a  Uo§pital  witli  extenuve  oHsificaUon  of  th 
gsUictr  wiUi  M^-vral  csuHtiwM  bt>Ui  un  (he  Hpin«  a 
greater  part  of  the  Intis^iniufl  doni  on  oitber  eide,  e 
free  «d^,  wm  omiliod  ;  largu  maiMM  of  booe  fillod 
on  either  side  of  the  lei-t^bral  s{kincB  from  tho  Bammi 
wilduriiig  ull  thf  bones  togntlicr  into  tm  inflc-xiblo  oolu 
were  likewise  inimovitble,  portlv  &oin  being  ankylow 
nn<l  partly  by  the  ossification  of  the  miucltf  oonned 
tJie  scapula  and  spine;  iH>  tJiat  resjiirntJunwasentirel; 
the  dia]>)iragm.  The  trapezius,  and,  apparontljr,  the « 
the  side  of  the  n(K>k,  cuiitainod  Inrgo  depoait*  of  bone 
■were  immovably  fixed  to  the  ribs,  prindpaliy  by  Uk 
the  aerratiiH  uiagniut  and  rhomboid  mtucleii.  bk  1 
grcitt  pectoral  muscles,  from  their  origins  to  their  i: 
almost  entirety  u-uifitxl,  prcuvnting  ridgca  taking  th 
fibre*,  and  forming  large  masses  at  the  fitjds  of  tl 
sterno-hyoid  and  thyroid  mtueloa  won  mtwh  o«ified ; 
getlicr  with  the  recent  appeanuwe  of  a  considerablo 
the  chin,  liad  been  accoinjianied  with  k>  much  diffi< 
tition  a?  to  alann  him  ;  he  therefore  came  to  the  boB| 
Hawkins,  uniier  wlioite  core  he  Iwd  bi-fore  been.  The 
upper  [lart  of  the  throat  was  not  hard,  but  verj-  toni 
to  a  second  application  of  a  blister  in  n  few  frcvl 
genio-  and  mylohyoid  muacles  could  be  distinctly  f 
tireir  ossifietL     The  man  had  been  a  i>atu!tit  untW  H 


OSSIFICATION  OF  MUSCXES. 


987 


Brown,  groom,  ict.  22,  waa  admitted  into  the  hoiapital,  Juno 
43,  witli  swellings  in  tlie  clor/^al  und  lumbar  ro^ons,  appa- 
iii  the  spinalis  and  rliomboid  niusoleri ;  tins  fi)iiuer  liard  tike 
tho  Uttor  not ;  commencing  a  week  befuro,  aftvr  much  ex- 
I  to  colli  and  wot,  with  severe  {inin  in  tlif  )mn!t  and  in  the 
snd  altouldi-rs,  like  riicumatism.  Up  to  tlio  end  of  Jaly 
t  other  enlargements  appeared,  some  hard,  »ome  etott,  iii 
ictoral,  latissimaB  dur^i,  and  »i!ict  muscles.  By  the  end  of 
It  all  tlie  swelling!*  hail  dtsappiun^d,  and  he  was  di.ioharged; 
u  again  admitted  at  tho  end  of  October,  the  tumourg  baring 
ed  more  numerous  and  {iiinnineiit  tliim  bi'fnrt^  He  bad 
uod  bis  medicines  under  wtiich  they  bad  disappcarod,  and 
ot  lua^t  any  freab  cold-  Several  osniBed  enlargements 
fnimd  in  the  nHen  of  tho  old  swclh'ngg,  cspocially  one  «xt«n(l- 
3m  the  ftpino  of  one  offJie  dorsal  vertebra*  to  the  base  of  tlie 
It  on  the  Icit  side.  An  tliis  bony  growth  was  last  incroasing, 
npeiling  ibe  million  of  the  shmdik-r,  it  was  di.-iHCcted  out  on 
liber  23  ;  it  lay  botwoon  tlio  trajiczius  snd  rhomboid  muscles, 
'■a  intimately  connected  witli  both  ;  fibrca  of  both  being  in- 
into  iu  One  end  of  this  bone  was  smooth,  frotn  playing  on 
i  of  tJie  scapula ;  the  oI.)it-r  was  lixed  to  the  opineji  of  tlii>  HJxtb 
reaUi dorsal  vertebra*;  its  Icngtli  was  tliree  inches,  contracted 
I  middle,  and  about  an  inch  broad  at  itj«  wii|<»tt  part;  the 
mass  reNmbtes  the  two  plialangcs  of  tbo  Uiumb.     Several 

Siels  were  divided,  and  secfindnry  Im'niorrbagi-  fullowuil  tho 
,  which  lowered  tho  patient  much  ;  the  woimd  boalcd  very 
.  TIius  monlli  alter  mniitJi  for  four  yejirs  fn-xh  lumoura 
t  in  dilfcront  muscles  of  tlio  trunk  and  neck,  being  at  first 
rowing  rajiidly,  then  becmiing  hard,  and  after  a  time  either 
oaring  altogether  under  the  remedies  given,  or  leaving  a 
leposit  behin<I.  The  new  hone  tliun  fiirnit-d  extended  slowly 
b  either  extremity  of  the  muscle,  in  ridges  corresponding  to 
W.  From  this  time  he  was  lost  sight  of,  until  be  apfieared 
in  last  Juno  as  above  mcntionod.  During  tliat  long  interval, 
1  tliat  he  bad  had  no  more  sw<-Hings  or  ]iain,  and  (hat  tlie 
^mbs  had  slowly  increased,  with  corresponding  stiffness  of 
ink  and  Hhouhter*. 

e  cause  of  osseous  growth  in  muscles  is  not,  I  imafpno^ 
«Eplain<-<l.  A  teiKlcncy  to  increased  bony  dc|ia»it  ii>  not  rcry 
mon,  and  shows  itself  in  exostosis  and  extension  of  bony 
1  into  the  tc-iiduii»  inM-rli.'d  into  the  bonc:t ;  but  in  ossifio 
I  in  muscle  it  is  a  distinct  fonnutlon,  and  in  no  way,  at 


538 


DISEASES  OF  UUSCLES. 


1 


first,  connected  with  Qxo«to»t».  It  is  of  inflammatoiy  on^ 
M  tho  [juiii  luid  swelling,  aiid  atao  the  efTecla  of  reotc<tie»,  votili 
indicate.  Mr.  Abernotliy  mcflitioiw  a  case*  of  a  lad  in  whoa 
eilluT  UI1  oxoNtosi.t  or  bony  growth  in  a  inaitole  in\iLri]ihly  Sdi. 
lowod  a  blow  on  the  part.  Mr.  Hawkiim  alludes  to  an  accooa 
of  ei};ht£i-n  cwtes  of  bony  grovrtha  in  muscles  among  tlio  recmita  ii 
thv  Pi'u»i«inn  !>«rvW  ;  tlicso  Wi-ro  said  to  luve  been  the  result  C 
intlauiniittioti  in  tlio  deltoi<l  and  {)ectoral  niu^cl««).  InfUmmoUon  s 
masclu  is  raro,  and  cxl-oss  of  bony  deposit  in  tho  system  is  not  Tcr 
common;  but  whtsn  tliev  both  occur  in  the  same  indivi<ltial,  dv 
cxu(hitivo  Ijnnph  in  tho  former  would  sram  to  bo  favoorable  i«r  i 
nidus  for  ossilio  dcpotut  As  regards  tlie  treatment,  no  local  mea- 
sures auswerod  so  woU  as  blisters,  tiDd«.-r  which,  with  tlio  exhibititf 
of  colcbicuni  iatemnlly,  voiinldKrable  dimhmtioii  of  tlio  swelliip 
and  relief  of  tho  pain  took  place.  Tlie  swellings  completely  <!)»■ 
apiM)ar«i  aftj^  a  eoiiMC  of  tJio  iodide  of  potiijisiiim,  at  first  five,  mJ 
then  seven,  grains  thrico  a  day  in  earsHparilla;  but  lliey  retumw 
again  shortly  ailer,  while  still  taking  tho  medieine.  On  tho  rap- 
pcaratiec  of  the  disease,  mercury  was  given,  two  grains  of  cakml 
and  a  (luarter  of  a  grain  of  ojiium  Iwioo  daily,  which  at  tliovnl  if 
throo  weeks  produced  soro  mouth ;  again,  all  the  swellinga  wti[ 
nearly  removed,  at  first  rapidly,  then  Jtlowly ;  but  a  largo  mtf 
of  bono  between  tho  scapula  and  §pine  was  removed,  as  ttstnli 
by  oprntion.  Atkr  tins,  from  ha-morrhngc  and  other  cauw^,  •» 
health  failed,  and  he  was  much  reduced,  and  spwifics  wore  luJ 
BJtide  lor  some  time.  Nnmcri^US  fr<!»li  tumoiu-s  having,  howi:'* 
formed,  he,  in  a  few  months,  began  the  phosphoric  acid,  first' 
liulf-drachin,  and  aficrwarrfa  in  draclim  doses  tlinw  times  i^Jn 
which  he  continued  from  April  tJth  to  May  2!st,  Tlw  sivelliiipj 
greatly  diminished  under  tlii.t  treatment,  and  with  the  Tcy^^  i 
application  of  blisters  their  recurrence  seems  to  have  been  an«uij 
Tlius  the  remedies  Bi>|>ear  bo  have  been  chosen  with  a  view  toA 
inflammatory  nature  of  the  complaint,  and  to  havo  Ijci-n  mo*t  (tf* 
ciouj* ;  yet  so  strong  was  tiic  tendoncy  to  relapse,  that  tho  sweliii# 
formed  again  and  again,  even  under  tlie  treatment  that  had  odm 
thorn  to  disappear.  Tlioy  were,  however,  finnlly  arrested,  tho  bla- 
teis  having  been  most  conducive  to  that  end. 


*  Suiy.  Leet.  vol.  iii.  p.  160. 


I  of  different  kinds  are  occaiiionalty  fonnd  in  masclo. 
wliioh  ftcourd  most  frequently  is  tlie  fibnmi*  tumonr, 
nous  hardnetrs,  and  often  growing  to  a  considcniblo 
nHjod  H,  wiw  iiniler  my  wiRt  in  St  (JiMH^-'f  Hospital 
^r  of  1860,  with  a  tumour  as  large  as  the  double  fi»t,  at 
'the  left  thigh,  abo  tit  its  middle;  it  wiw  exlremoly 
to  be  a  ehondroid  tumour  growing  from  tlio 
ely  did  it  aeem  to  be  attnelicd  to  it;  on  mWing  the 
rover,  by  bending  the  kneo,  It  admitted  of  a  certain 
ton  the  feiiHir.  I'liv  tumntu'  wti:*  roninvfMl,  but  not 
Kulty,  partly  from  ita  vicinity  to  iho  bone,  wliieli  it 
^SBp,  and  partly  tlmt  tlto  great  sciatic  ni^-rvo  was  im- 
\  and  was  only  freed  by  careful  dissoetion.  The  tmtiour 
i  have  had  its  origin  in  tint  M'niinii'nibnuiosas  muscle, 
rt  of  which  was  liealtliy,  but  the  part  above  tliv  tuntour 
(d  into  a  \ntli:  .itnict  iiro  similar  to  thi!  tumour,  but  leea 
etaining  the  form  of  the  muscle,  witli  a  slight  rvmsins 
^{M>araiKH;.  The  tumour  wiw  exln^mely  don-w,  of  a 
Wnt,  cartilaginous  as|)ect.  Some  of  tho  fibrc«  of  tJm 
t  spreail  over  the  tumour ;  otiicrs  dipped  into  it,  but 
H  in  its  substance. 

Mler  thU,  a  tumuur  of  a  siinilar  elianicter  v/m  removed 
hoid  muscle  of  a  young  man  by  Mr.  Johnson ;  it  was 
K  of  an  egg,  and  i^umiuiided  on  all  Kidtts  by  niuseular 
hy  of  the  fibres  entered,  and  could  be  traced  a  considur- 
p  tlie  den»o  tibro-i^trtilagtnuuii  maiw.* 
Irring  fibroid,  although  it  does  not  originate  in  muscular 
(lagreattemicneytoliorcprDiiiiociiin  it.  In  two  juitjeiits 
re  of  Mr,  Hawkins  in  St.  George's  Ilospilal,  each  of  whom 
tr  of  thiH  de^u-iptiuii  in  the  breast,  and  in  whom  tlie  tu- 
ned, and  were  removed  several  times,  it  was  observed 
b  Moorrence  took  place  ttie  pwt*)rnlis  major  was  the  part 
■mlved.     A  man  came  under  my  caro  about  two  j'cars 


ping  IPTCB  an  account  of  a  fibrous  Itimour  wltidi  lie  remove] 
■oeumiuu  muscle  of  a  girl,  ibl  0  :  ils  ciroumfcrciicu  ivas  iiot 

rLncd  from  Oxe  muscle,  so  thut  its  more  {irQUiiiii-nt  •:ciilntl 
tvmoved.  See  Palh.  Tram.  vol.  vi.  )>.  340.  Mr.  liirkrlt 
iBOur  A*om  tbo  itlinit  himil  of  Uie  biceps  flpxor  ciniriii.  of  a 
B  growth,  4}  \iy  H  ini7hc>i  in  slxe,  of  a.  gntj'iBli-pcftrl  tint,  Bud 
'n  stmcture :  tb«  coutre  wu  of  boaa.     IbiU.  vol.  ix.  p.  3QT. 


k 


ago,  from  w])om  it  tumour  of  tlie  above 
riijin  die  parotid  region,  und  AuWfiucD' 
from  over  1.)iv  huumjUt  inuHolo ;  four  moE 
mj  patient,  Iiaving  a  tumour  nboul  tiw  s 
tlio  noighbotii'lKitxl  oi'llie  second  cicatrix. 
tJiat  it  hud  formed  in  tliv  ii]>|ior  part  of  t1 
fihrcH  of  whicli  only  remained.  A  few  D 
came  undvr  my  cnru,  willi  two  titrn'-ars 
above  the  site  of  the  lost,  and  wliicli  p: 
out,  to  hav«  liad  tliuir  soat  in  tliv  tvm|>ori 
aeot  a  lady  under  my  care  from  wlio»e  bi 
a  tumour  of  iIk^  above  nature;  the  dtAWi 
pectoral  muscle,  in  which  it  is  making  ra; 
Cy»ta  of  various  kind^  are  occa»ioni 
short  time  ago  I  remo\e<l  n  oysl  from  tt 
young  woman,  agod  20.  Tlie  tumour,  w 
and  extremely  hard,  wa.i  di.itiiiolly  felt 
muecle,  movable  when  the  tnusde  waa  i 
movable  whon  oontrnctcd ;  it  was  of  a 
tbu  »yM  of  a  walnut.  Having  cut  down 
were  ftcpamted,  and  tlie  tumour  was  e 
appearance  it  looked  very  like  a  fibroun  ti 
tmed,  turni-d  out  to  be  a  cj'tit  containing 
ous  substance,  and  at  one  point  »  tunall  c 
explain  its  gn-at  tenderness).  On  pro 
oyet,  I  found  that,  though  thick  and  (lof 
its  outer  surface  wit3i  (lie  muscle,  that  to 
destruction  of  tlie  muscle  iiiudfl  I  llir 
nnticrior  face  of  the  cyst,  winch  was  prcti 
nexion,  and  having  scraped  out  tlio  om 
bottom  with  linl,  afti-r  wbicli  it  readily  fil 
of  these  c)'sl8  contain  hydatids.  Tlie  tri 
by  Mr.  Owen  an  an  eiitoxoon  wliich  infet 
In  the  two  caws  in  which  these  entox 
bad  died  aAer  long  and  wasting  disease 
minute  cysts,  eometiraes  singly  and  sain< 
were  found  disperwd  in  gnnt  nnml>ers 
Inntary  muscles;  they  were  of  an  I'llipti 
by  T*»th  in  diameter.  CyOs  containing 
are  oooa»ionally  foimd  in  miiKch-s ;  titry  ] 
of  liH-matoma  occurring  in  other  purls  a 
unabewrbcd  extravasntcd   blood,  wllicl)  I 


INJURJES  OF  TESDONS.  541 


¥ 


^B^mted  by  time,  Warrfiii  deaoribes  a  ftingulai'  tninrtor  of  som*- 
tliing  oTthis  nnturc  A  tumour  about  tho  nixv  of  an  v^  wus  re- 
moved tmm  tl>e  »iubHtanoo  of  rJie  roctiiA  feniari.4  nuisoto  of  a  worunn ; 
il  wj»  mid  to  be  of  only  five  or  wx  months'  growth ;  it  i;oii»i8t«cl  of 
a  hard  dark-ooloured  miiAouUr  suhatunco,  in  tlin  eeiilre  of  whicb 
vas  a  bony  sbell  an  itii-Ii  in  (liiimctcr,  conlainiiif;  a  daik-oolourod 
fluid,  which  htul  <iepoi9itcd  a  black  cmal  on  lius  bony  cynU. 

Sarrhn*  ecldom  orijiinates  in  muscle,  except  in  tho  tongue  and 
xibfiTanoe  uflbc!  lip.  Warron  iltfs<rr!b«>.t  a  oaao  of  n' but  bo  tormit 
winrlius  of  tbc  muscle,  wbicb  i-cECinbloa  more  the  account  given  of 
tbe  nphibtio  tumour  (la''crii)t^I  n.t  buviiig  bwn  romovi.Hl  from  llio 
iliO&ltUr  by  Mr.  t^outb.  Murtcles  readily  bocomc  implicated  in  tbo 
dittase  occurring  in  iK-igbixniriuf;  purls,  and  it  in  imt  unuMial  to 
End  t]ic  mnscica  for  a  conitidcrablo  distance  around  a  acin'bous 
btvttt  dotled  nitli  t)cii'rboi»  tuborcle.'*.  MolanottiH  must  Ih!  very 
Ire  in  musclc«.  Waircn  mentions  a  case  occurring  in  tho  mus- 
cular  »trueture  bi^wtion  the  liii.su  nf  lIim  .scapulu  and  tin;  npino;  tliis 
■nd  bwn  rrmor<xi,  but  a  second  tumour  appeared  in  Its  plnco  under 
Ihe cicatrix ;  it  wjw  frtun<i,  on  0[H'riitinjj  on  il,  to  Iw  MKitotl  in  tbft 
xibniuHw  of  tile  rhomboid  and  trapo^iius  muscles;  it  was  liaid  in 
■'ntctiire,  niid  the  int^^rior  coinpoM^l  of  black  mntt«r;  six  months 
>licr  tlii«.  the  ili«case  rcappoarod,  of  a  carcinomatous  appearance, 
•nd  proved  iittat. 

Knccpbaloid  tnmour»  no  doubt  originate  in  muHclos,  thongli 
•wj'grow  *o  rapidly,  and  involve  overy  structure  .lo  indi.scriminately, 
■■■akcs  it  difficult,  except  in  certain  organs,  to  define  their  origin, 
"•tren,  spcitkiiig  of  this  dineaAe  in  musclis,  dejcrilies  three  cases. 
•Vse,  however,  arc  not  clearly  proved  to  have  sprung  from  mnsclv, 
*U([it  tlic  la&t,  which  had  its  seal  in  tlie  lumbar  muacles. 


AFTKCTrosu  OF  Tekdons. 

hjtiriet  of  imdons.  It  has  been  already  observed  that  tendooB 
*'*  raptured  by  llio  action  of  tliuir  niusuira  moru  rvadily  tlum 
••  muscles  tliemselves;  tliey  may  also  be  nijitureil  by  direct 
■"oe,  9»  in  di.'<IiM-atioii,  luni  tlicv  arc  nflen  divjdi'il  juirtially  or 
•"•tirely  in  wouiids  and  by  eubouianeous  sections.  When  a  tcn- 
•"i  i»  ruptured,  or,  what  i.»  iicurly  Uic  some  thing,  divided  by 
^wutuieoas  operation,  tlic  part  which  is  attacbal  to  the  muBclc  is 
•WwH  nway  from  tli«  op|m.«il«  ond  for  about  an  inch;  tlii»  hitti.r 
0  liot  slightly  retracted  by  tlie  action  of  its  antagonists.     Blood  is 


M2 


DISEASES  OF  MUSCLES. 


poured  oat  1>ctwoon  the  ondft,  imt  much  lew  llum  in  rafttn  i 
inuH.-li-».     The  pain  b  said  to  bo  not  rciy  great ;  a 
shock,  howm'or,  a  fvit,  u»  fitim  a  blow  rvodvod  on  the  part, . 
{nnicd  by  imiiip  of  the  mosclt?,  and  a  perfect  inability  tn  ikw  I 
limb ;  and  in  ruptarv  of  tho  ttMido  Avliillis  a  fwlinf;  in  deMcrilrtj  i 
if  the  liool  were  sinking  into  a  bote  in  the  floor.     The  tondoiui 
freqaently  ruptiirod  uro  tin*  tuiido  Acliilliii,  and  Um  U'ndoninft! 
rootua  tV-Riorii)  and  tlio  tric4'])6  humeri.      If  tlie  sejiaration  nf  I 
ends  bo  not  too  great  cither  in  ruptnro  or  italwutsiii.'mu  divijii 
tbcy  luiite  wiOi  muc^h  rc«dineas,  tlte  new  material  soon 
gn-Jit  linnni^K ;  m>  riipidly  is  tho  prouM*  orn-{Hur  carried  on,  i 
<»atly  in  tlie  earlr  stage,  that,  ocoording  to  Ur.  Paget,  in  Iu» 
loctiiro  At  tlir  CVillv;^  of  Siirf^-onf,  a  H]>ooiincn  «ix  days  aftu-divieii 
(being  tlie  fi>urth  occupied  in  the  orguninn  of  the  new 
ooubl  Iwur  Ute  netj^lit  uf  twinity-five  poundit ;  in  another  me 
new  material  at  tbo  end  of  twenty-one  days  bore  a  weight  offift] 
fix  potinds.     Tltu  prrM^ss  of  re]>flir  is  briefly  Uiit,  according  to , 
Paget  (loc.  ciu).     For  tlio  first  forty-eight  boura  iufi 
mnttcr  i«  ]iourc<l  out,  and  infiltrattw  tlte  tuwucs  between  tho  < 
al\cr  tliis  there  ensues  infillmtion  of  a  material  of  the  diaracttf  i 
tlio  fibrin  of  tlie  blood  in  a  solid  state,  in  wlt»ch  are  enol'itnl 
unabsorbed  remains  of  tho  clot  of  vxtravajtat^vl  bUMxl,  and  the 
ends  of  tlio  divided  t4?ndon ;  this  by  <l<^rees  assumes  a  definiu  i 
like  form  :  but  even  in  five  or  mx  da^-s  it  shows  a  nttdeat^ol 
ttirc,  tending  to  the  production  of  tendinous  tissue.     On  the 
day,  tlic  material  beoomoa  paler  and  loss  vuHctihu-,  and 
disdnctly  61amcntary  form ;  and  in  about  tliree  wc«kfi  tbera  ii  j 
jiorreel  eurd,  of  tlie  nature  of  tvndon.     Ur.  Paget  further 
tliat  in  the  progress  of  the  process  the  cuds  of  the  tendon  9w<U  i 
flolteii  to  tbo  oontiittli.*iiot>  of  tJic  effiiwsl  matlm-,  •<>  tliat  tlwy 
ona  into  tlic  otlior,  assuming  thereby  a  oloser  adhesion.     lie 
remarks  that  the  repair  of  tlie  toudon  does  not  dojMnd  on  llie  i 
division  of  its  shenth,  as  has  been  supposed.     Should  thi<  inti 
between  the  two  eiid.4  of  a  divided  tendon  l>o  great,  a  vrry  a 
&ct  bond  of  union  will  be  established  Wtwceu  iIh-v),  as  tint  i 
become  attacliwl  to  tiio  neighbouring  liiwueji,  and  eitltor  a  | 
entiru  l«w  of  the  use  of  the  inuf^cle  will  result     Wlioro  tho  in 
inonts  and  siirrotiudiiig  parts  are  included  in  a  division  ofa  i 
there  U,  sm  in  muscle,  a  much  greater  rettaotion  than  wbiirv 
piirtn  remain  entire;  added  to  wlu'ch,  tJio  nuiterial  lor  the  repairi 
the  tendon  Iwing  here  common  to  all  the  other  tissDM  inclndocl  < 
tlio  wound,  tliey  all  bccomo  fuaod  in  a  oomnwa  eiualm,  so 


RDPTURE  OP  TENDOXS. 


513 


tlio  most  faroorable  circumstances  a  very  iinperfect  nnion 
limited  ii8e  of  ihe  musclu  enmo. 

Tbo  trpatmiMit  of  raptured  tendon  connsts,  as  in  mptare  of 

le,  in  a)i|)ni;timutiii<;  tiic  dJvul""!  i-iuIm,  ami  nstaiiiiiiji  tWm  in 

ition  until  tirm  uition  in  csiahlini\ed.     GIoeo  adaptation  caa- 

Itoped  for,  IjuI  still  n  pcrfptit  unitm  with  Riwivorj-  oftlic  netion 

miuclo  tuaally  takes  place.     The  seiored  ends  are  Itrouglit 

clojter  biwards  mn'  nnotlipr  by  flii'  ci>nl.ni».:titiii  of  the  new 

as  h  bcoomcA  perfected,  and  tJio  remaining  deficiency  is 

ipenaated  for  by  Uu)  notirtcnintxhitin;;  nature  of  tlio  niii»clix 

idon  of  tlio  trioops  bo  torn,  all  that  is  required  is  a  bandage 

^Kire  downvrartl,  with  a  splint  in  front  of  the  unn  to  keep  it 

and  KB  the  union  of  tendon  is  rapid,  passive  motion  may 

I  oaplojed  early.      Li  rupture  of  tliv  tunclciii  of  tho  (|UHdnocp« 
ir  cruris,  tlie  same  treatment  nearly  m.iv  1"    i  l<<[ited  as  for  a 

pat^lhu  Where  tho  timilo  Arhillis  'i*  Una  ;u'[m».->,  tlte  tnwt- 
rnsists  in  keeping  tlie  foot  extended  on  tho  leg,  and  the  leg 
tite  tiiigh;  a  )ii)^ili(>n  tiivnurahlo  Ui  tlii^  ri'liixiilion  of  tJio 
tnii  muscles.  For  this  ])urpoHe  a  bolt  is  plaoed  round  the 
igb  a  little  above  tho  knc<>,  tlu'  buck  of  which  is  )itt:u;hi.!(i  to  tho 
nI  4f  a  slipper  by  means  of  a  bolt  or  bar.  Before  applying  tlie  ia- 
mnent,  tho  calf  of  tlio  leg  should  be  bamlngiwi  from  above  dovm- 
■il,care  being  taken  not  to  approach  too  near  tlie  seat  ofrupttire, 

I I  great  dittpUomncnt  and  iK-rmaiicnt  defect  would  result  from 
I  tDds  of  tho  tendon  being  pressed  towanls  tlie  bones  of  the  leg ; 
inewhat  of  a  Minilar  incunvvnieitco  may  oociu-  from  a  loo  con- 
Wablc  or  a  too  long-continued  tilting  up  the  heel.  Desault,  to 
•id  iho  difptai^mcnt  of  llio  tendon  by  hiii  bamhigf!,  wliioh,  like 
•til'*,  extended  over  the  whole  limb,  recommends  comppessos  at 

uf  iJm!  tendon.     John  Hunter,  who  liirnMOf  biiil  a  niptura 

tcodo  Aekillis,  recommends  lh.it,  as  so  little  inconvenience 

a  Rinall  iic]>anition  of  tlic  tendon,  compurcd  to  the  great 

ieooe  and  ditHcultie^  attending  Uie  treatment  by  bandages 

the  parts  siiunld  be  iillowi'd  to  rcmHin  in  their  natural 

He  is,  however,  disposed  to  adopt  a  medium  between  tho 

gaggoM*  that  tho  hciol  should  he  elevHlt^^l  ihiring  walking, 

the  heel  of  the  nhoe,  that  a  bandage  should  be  kept 

[y  a{i|tlicid  to  tiie  call'  of  the  leg,  to  guard  ogaioKt  involuntai7 

of  the  mjisclea ;   and  thitl  at  night  tho  usual  slipper  ai>d 

night  be  applied.     When  the  int^-gumwits  anil  siirniuiiiiing 

are  included  in  Uic  division  of  a  tendon,  the  edges  of  the 

may  be  brought  together  by  adliewve  plaster,  or  perha[>s  by 

The  mode  of  bringing  the  divided  ead^  of  the  tendon  to- 


544 


DISEASES  OF  MUSCLES. 


gc4hor  by  naenno  of  sQtnre«  can  Bcanccly  be  recommended,  a«  thoy 
prodnco  irrilatiun,  kikI  k«e|i  Uio  vrouitd  open.  Banda^i  one  not 
w«ll  bornt) ;  khI,  therefore,  with  position,  must  mostly  be  tru&t«l 
to  for  tlio  caru. 


J 


/njf'itRmafHni  ofifnJoM.     TendofiR,  togotlicr  witli  (}i«!r  sliea 
both  lUii-iiu^  and  synovi&l,  are  not  ttnfrequontly  inflamed.     Ind^^ 
peodcntly  of  gout  and  rhciiinati«n,  the  mo«t  froiftivnt  cnuKO  >*^H 
Hpruin  or  wn^nch  in  tlio  neighbourhood  of  a  joint.     Tliese  injui^i^^ 
aro  occa»ioniilly  productive  of  kint;-ixnitiniiii(I  vn-ariiig  pain:;',  a»- 
Kaminj;  uiut^h  of  a  rheumatic  character,  and  yield  of^en  slowly  and 
unwillingly  to  tlio  remedies,  both  local  and  {jt^neral,  <;iiij)li>yc<l  in 
rtiouniatiun.     Sometimes  these  sprains  are  followed  by  inHamma- 
tioD,  with  (n^-at  vffiision  into  tlic  tihiath  iuul  vurruiinditig  oulliihtr 
tiitjiue  (e«peoially  in  the  region   of  the   foot  and   ankle),   which, 
either  rajildly  in  an  acute  fi>rni,  or  »lowly  in  a  ohronie  form,  may 
extend  to  the  ligaments  and  periostonm,  desti'oying  the  joints,  Bud 
producing  carit'K  of  the  bimc 

Under  iho  name  of  **t^nosynIte  or^pitante,"  the  French  de- 
scribe a  filiglit  degree  of  inflammation  of  tJic  slicath^  and  invcsHtient' 
of  tlie  muKeles  and  tendons :  it  folKiu-it  long-coittinued  and  fali^^aiuj 
muscuhir  exertion,  and  for  the  most  part  occur*  in  the  mu»cla*<rf 
the  foro-arin.  I  have  oI)M'r\eti  it  mostly  in  llie  extensor  musclotn 
the  thumb  sh  they  })!i»s  over  the  radius ;  it  is  usually  accompaniot 
by  considei'abte  pains  extending  up  and  down  the  limb,  and  a  *cn- 
nuurkod  crepitating  or  creaking  focling  can  be  frit  by  gras]Hn£  ll* 
part  while  the  niuscleti  niv  hi  action.  The  treatment  consists  in  eoB^ 
plolo  rest,  aud  stimulating  or  even  vesicating  applications,  in 
of  the  tiirms  of  whitliiw,  paroni/rhia  Irndisioin  of  Abenielhy,* 
tendons  and  their  sheaths  in  tho  finger  aud  hand  aro  the  scst  of* 
severe  and  oOen  most  destructive  I ntl animation,  which,  tliougkoftfl 
confined  to  one  finger,  not  unfrequently  extends  to  the  baud  uii 
arm,  attnoking  not  only  the  tendons  and  srjfter  partis,  hut  expmnS 
tho  bones  aJid  disorganising  tlie  joint*.  It  arises  from  the  *»»« 
causes  as  tlm  other  forins  of  piircinyehia,  flight  wouikIk.  prickfi 
with  or  without  uioculation  of  irritating  or  poisonous  matter,  wJ 
often  without  any  evident  oniise,  though  dotibtlcM  de]>c»dtng  nmdi 
on  tho  state  of  the  general  health.  It  begins  with  severe  and  (hrol** 
bing  pain  on  the  palmar  face  of  a  finger,  which  extend*  nlongOfl 
arm,  often  to  the  shoulder ;  it  is  aceompanied  by  redne«a  and  swell- 
ing, with  great  liiuvhioxs  aud  tension  :  if  not  cheeked,  tlic  influniBa- 


'4 


*  Lect.  38,  Laneet.  Apiil  Stf,  ISSIk 


INFLAMICATION  OP  TENDONS. 


MS 


^Kon  prootwiU  qiiii^klr  along  Uttt  front  of  Ute  tiiiger,  and  i»  «non 

^P&Uowed  by  stijtpumtioti  in   die  ehmth ;   this  at  first  ib  la  sniali 

KgtuuiUly,  nnd,  in  c-Dn.Ht^jiu'tira  ol'thu  f^-at  hardiices  H»d  swi^lling  of 

HOie  part,  cannot  be  detectod  by  the  toacb ;  if  no  relief  be  aSbrded^ 

tbo  Hujijitinilidii  iiHJcklv  |irtic:<HyIti  iilonjr  tli(>  hIiciiIIi,  tlii;  inHiinima- 

tioR  and  pain  aro  aggravated  by  the  density  and  unyielding  nature 

of  tho  |>artA,  nnd  nro  aocnnij»iniod  by  niiicli  von»lituttoiial  disturb- 

H^Dco ;  abwc^^scs  burst  externally  from  time  to  time  aa  tlw  disease 

V^li^n<i»  Hlong  1 1)1!  Hlicatb,  fruin  w}ii<-?i  (iingDiu  granulations  ttpring,  tba 

tendon  in  a  sloughy  state  lying  at  the  bcittom.     With  proper  treat- 

tnvnt,  and  in  a  fuvourublo  »t«t«  of  tlic  gcn'-rul  iK'sItli,  tlio  progroes 

may  be  arretted  with  a  greater  or  less  aniuintt  of  di>.Hti'uolion  of  the 

I  altairkcd,  and  a  {>ro]>ortionatu  dofonnity.    In  certain  unbcallh^ 

ateaoflbe  system,  however,  in  wliioJi  the  itifFti-se  or  erysipelutout 

^CirTn  of  inRanimntion  prvvaiU,  tlie  inflammation  and  Mipparatioo 

extend  into  Ute  pnlin  of  tho  hand,  behind  Uie  palnixr  ttuvM,  and  to 

the  n^ot  of  ttio  fingers.     Tlw  whole  band  now  presents  a  highly 

intlauied  a])pi-anin(N>,  of  an  eryHi|H'latitu.t  nature,  vi-itJi  grwal  xwelling 

and  timnon  ;  nor  doc«  the  mischief  end  here,  but,  passing  under  the 

tnnsyene  ligament  of  the  wrisi,  u.tceiidi*  Into  Iho  foi-tvnrni,  forming 

large  difliieo  abscesses  amongst  its  tendons  and  mnsclee ;  and  in 

ttu^  worn  ea.iOM  ti4>t  only  tJiu  joints  of  tlio  tingiir,  but  tliow  of  tlie 

earpus  and  wrist  are  dcetroyed,  aJid  the  Iionea  <leniidei)  and  no- 

cnwed.     'riu-  health  <lnriiig  this  time  sid!<T»  sewn'ly  from  iiTitativo 

fever,  with  gradual  prostration  of  the  bodily  powers. 

Trmlmrnl.     In  the   very   (larly   aUiffu   the   inflamniatiou  may 

often  be  arrested  by  leeches,  followed  by  hot  funientationa  to  soften 

and  relax  tW  hani  anil  tiiiyi<'liling  lt)">tie)*.     Tlio  hitiid  should  bo 

el<'\'ated,  and  an  active  purgative,  with  other  antijthlogistic  mea- 

lum*,  prwcribed  ;  if  rwliof  do  not  soon  follmv,  but,  on  lli«  eoiitraty, 

^Bhe  oontinuanee  of  pain  and  throbbing  with   increased  hardness 

Hnidicati;  Uw  o\tvnsion  of  the   inllanunutioii,  if  not  tho  formatioa 

^tf  pUK,  no  further  lime  mnst  bo  loist ;   a  free  incision  must  be 

nado  along  the  centre  of  the  finger,  and  though  llu'itt  may  1>0 

bat  very  little  or  no  piut  in   the  slieath,  yet  the  di^'i.tion  of  the 

lonsely  fttrangulutcd  stnicture,  and  the  esca[)o  of  blood  and  MVum^ 

aflonl  the  greaU-st  rt*lief.      IJy  these  moans  all  mischief  may  be 

iirrBsted,  and  tbo  finger  perfectly  restonxl.     On  tho  other  hand, 

intlnmmHtion  may  proeentl  along  the  shentli  in  spite  of  Uie 

ready  treatnieiit :  BU|)pumtion  may  have  cxtciidcd  under  tha 

Jmar  fasoia :  further  inciHiouN  must  llien  be  made ;  and  it  will 

sw  be  Jbund  proper  to  support  the  powers  of  tho  system  by  a 

VOL.  tlL  K  !1 


sure  witli  p»(U  of  lint  sonked  i 
iidiigo,  tho  pan«r«  Iwing  Hiipportoi 
good  diet,  iind  stimuli.  Where  tlie  suppiirution  « 
urni,  tho  rast-  w  more  scriouM;  and  if,  from  Uw^tatc 
taiioii  before  alKidud  to,  it  proi'cedii  tu  the  iiuluu7tmi 
tion  of  llio  Joints,  notliing  but  ampulAtion  remains,  i 
may  not  »iv»  litb.  I  liiivo  aDi|iutat4>d  the  forR-onn  > 
diMasv :  tile  first  case  was  in  «  gardener,  «  patient  al 
Hoapilnl;  lie  ncciticd  liuidttiy  ind  strong,  but  tlw  dif 
tion  vxk'iKk'd  rajiidiv  along  the  elicaths  to  tlie  ha 
dentiiiyinj;  the  joiiit«  nfilio  hand  mid  wrUl  in  »j»ilo 
dtnt'our  to  arrest  tlie  diseoae ;  mid  thougli  amputal 
formed  bofoiw  tJio  powers  wort-  lery  mncli  pMstmtci 
bj  constant  atteiitiun  and  active  treatment  Unit  oAe 
tho  man  recovcrtvl.  Tho  othor  caw  wtu  lliat  of 
St.  fif>v<(ivp,  whom  I  ntti^ndeil  with  the  bile  Mr.  R 
Mr.  11.  l*liillij»! :  hi-  WHS  of  u  bad  habit  of  boily,  |>nl 
with  a  weak  pulno ;  tli«  aiippiimlioii,  Iteginnitig  tit  llu 
HpiTtad  with  Mir[>ri»ing  rapidity  along  tho  slioatb,  qni 
Uto  otJier  flngi-nt,  then  thi?  limid  ami  ruro-arni,  (iMtroy 
in  its  course,  in  spito  of  free  incUions  atvd  wltatcvor  co 
u)  tho  wiiy  of  xnjijKirt.  Notlting  ])n>du(!Rt  tho  alig! 
llio  jinigrcHs  of  tho  inflammation,  nor  any  reaotion  ol 
it  wa&  tlierefttro  agreod  tlial  tJio  ami  slioukl  bo  i 
pcrrormod  tho  operation  unnsimlly  high  up  in  llio  (or 
view  to  cut  tlirmigli  i^uund  part^:  l>nt  ovon  hI  this  Iw 


TUMOURS  OF  TENDON& 


547 


m  a  miurltti.  Hv  a\*n  rclnhv  ii  ca.*u  of  nlnibisniui>  from  r  n-philUio 
tiDiKiur  o«.-iuTing  ill  the  tendon  of  one  of  tlie  miisoIeA  of  ttie  oye. 
%  I>tfnuic*  Mptnks  of  oortHin  tiwlc-liko  nwollings  on  tlio  ttnrfaoes 
gf  InvluiU',  which  he  csilla  "  nodoxit^H  blanelioa  dee  tendons." 
Srphiliiio  t'nlnr^-inviit^  of  tendons  do  not,  as  in  niuscloe,  rcadilj 
jM  to  the  mtcrnal  use  of  tlie  iodide  of  polansiuin;  they  rcqniro 
■  Ktiro  Io<.-kI  trcnlini-nt  tts  well,  such  as  iodido  and  mercurial  oiiit- 
noit,  or  blisit-ni  ke[>t  o{)cn  with  mcrauriAl  oiiiUnent.  Swt'Iliiiga 
ptllv  tcmJu  Adiillis  ucmsionally  oceur  without  a  eyplulitic  ori^n. 
I  We  found  ihnti  in  {n^r.innH  who  Imvit  talien  long  and  fuligu- 
iag  walkti,  not  having  boon  act-iistouied  to  much  exertion.  Tliese 
mitings  »ometim<4  occur  lui  a  nimplo  roiindod  ciilargiMnont  in  tlio 
tnlim,  and  sotnetimos  as  an  irregular  thickening;  they  are  tender 
vImv  handlnl,  and  are  lullioivntly  pninful  in  walking  to  niidco  tJio 
foticnt  limp.  These  tumours  are  oflon  troublesome  to  cure,  as 
tfey  lit)  not  niMlily  get  well  witliotit  Tt»t,  juid  IIr)  [itun  and  iuoon- 
WieiKw  are  not  ostully  sufficient  to  induce  the  jiatjont  to  lie  op ; 
lianior,  Itowcvvr,  to  euro  tlioni,  it  will  gencniUy  be  fonnd  ncccs- 
wy  for  llie  jiatient  to  lie  up,  or  at  all  evcnta  to  avoid  using  the 
and  In  apply  tJic  IocaI  uioatus  rvc-omincndcd  in  syphilitic 
,  as  UtBtem  kept  ojien  witli  mercurial  ointment,  or  tlie 
tnim  ammoniaci  cam  bydrarg^'ro,  &c. 

Ttmourt  of  Imtlons.     Malignant  tumours  do  not  often  spring 
itnidoD;  it  oRers,  onllic  contrary,  Hko  other  fibroiiN  stnielurcs, 
resistance  to  their  pi-ogross.     ^S'arren  gi\es  the  fol- 
Bocotinl  of  a  malignant  tumour  growing  in  the  subittance 
A  roiin<l  and  jiroininont  tiinioiir  npiienrod  above  the 
'Ibroc  inclics  in  extent,  without  mueb  pain  or  tH.iitiiIjilitr, 
caasing  lament'^;  it  hud  boi^i  growing  six  montluit.     On  out- 
down,  the  fibrcii  of  the  rectus  tendon,  wliicli  were  sh'etehod 
the    tuniotir,    wei-«    M^parati'd,    cxprisiiig    a   Mliiln   fiitigoiia 
firmer  than   the  ordinar^'  fungous  tumour,  but  breaking 
wliei)  bandied.     On  removal,  it  wim  found  to  bi-  mixed 
&ficieuli   of  tendinous   tibrc?.     It  showed  no  disposition 
lliii  tumour  rctunnil  after  tlm  healing  of  the  wouikI, 
WIS  again   removed,   when  it   presented   a   more    decidedly 
cJiarnctcr  witli  fewer  tendinous  fibren.     Tlie  ca»o  tennin- 
nl  EUnlly,  witli  the  formation  of  tumours  within  the  abdomen. 
"tarn  tumours  occasionally  arise  in  tendinous  structure,  as  in 


*  OiiittU  dm  Hifitaut,  af>.  ISU. 


MS 


DISEASES  OF  MUSCLES. 


tucSm,  oaA  otlicu*  jmrU  at  a  fihrmifl  nature.  SnuII  iMurti! 
«olargeroei)tH  are  ot^^n  found  in  tlio  <.-ours«i  of  tendoiui,  especudtj' 
Aow  of  the  liand  and  dwt;  they  tlo  not  grow  to  n  largo  aixc, 
seldom  protluce  any  inconvenience.  Small  growths,  described 
tft-niopliyK-M  !>y  Albcr*  dn  Hunn,*  uro  !s(>TiiirtinuMt  found  growing 
on  tiie  Aurfaoe  of  tendoiia  near  their  junction  with  tlieir  muscles ; 
tik'v  vary  in  diw!  from  a  pin'a  liwid  tf>  a  chorry ;  lln-y  arc  at  firtt 
altogKlitr  cartilagitmua,  but  as  they  increase  in  aizo  calcareoua 
mutter  ia  deposited  in  them,  a»  in  tbo  ilovolopm(;iit  of  buna. 


1  a«^ 


Aptkotioks  or  lUms.B  MccosJt. 

The  closod  syaovia!  bag*  called  burwn  raucosw  arc  of  two  kinds 
those  situated  in  the  subcutaneous  coUuIar  tiseme,  and  tlmw  voH' 
noutod  with  U-n<lijn.'!,  Tha  suboutarionus  bursa  is  fortnod  of  cellular 
membrane  that  has  been  exposed  to  friction  and  jii-essure,  by  which 
its  wlls  am  iiMiUrralini  and  ii  sint;I«  cavity  forniod;  it  retains,  in 
part,  the  form  of  its  ecltular  origin,  for  even  ufl*;r  great  di)(t<!iilioa 
till!  interior  oftiii  present.'*  a  sacculiit^d  or  multilocular  appearano 
Like  c«llidar  membrane,  it  has  niueli  of  tlie  cliar«i-tnr  of  scroi 
nKitnlinini',  in  il,*  unlinury  state  cxlinling  a  fluid  bttJe  denser 
Hemm,  but  assuming,  after  a  time,  niuuli  of  the  nature  of  ityiiovia. 
Tlitt  Kubeuttttivoti.-t  buma;  are  tiuiiicrous.f  and  are  cither  nonnal  or 
adventitious.  Ttie  normal  oeour  moAlIy  iHttwiH^n  tho  ^kiu  and  soma 
bony  prominoniij.  The  adventitious  bursas  are  formed  below  coma^ 
bimiouii,  or  other  aocidental  eallo^iti<>t4,  uk  lliosu  lu-isin^r  in  talipes 
on  tile  sides  or  buck  of  the  feet.  These  sacs  are  liable  to  bec(>nu> 
enlarged  from  various  causes,  mostly  local,  as  preasurt^,  friction,  or. 
blows,  though  occasionally  constitutional.  Tlie  bursa  in  front  ol 
the  putflla  is  most  fre<juently  tlio  wat  of  enlargement,  forming  al 
tumour  femiliarly  known  as  ihe  iioiwiiitiid'e  bute.  The  conti-nts  of, 
these  enliu-ged  cynta  vary  muclk ;  at  iirst  tlioy  arc  distendod  with  a 
fluid  little  more  douse  than  serum,  gi-adually  acquiring  more  and 
inure  tint  nature  of  .tynovia;  it  is  oftvii  mixed  with  blood,  eitJier 
recent  or  in  a  tfuck  grumoua  state;  somctiniea  there  i»  a  dark- 
bniwnisli  adhesive  fluid  containing  cholcstcrino ;  o»:'a;^ionally,  after 
long-continued  pressure,  fibrinous  matter  is  deposited  witliin  the 
sac,  .^oniolhing  aftjjr  the  manner  of  au  aneurism,  which  gradually 
fills  up  the  cavity,  forming  a  tumour  of  a  denae  flbroua  atructurcj 


•  Vidal,  Putlml.  txtern.  t<A.  ii,  p,  763, 


t  Iliid.  voL  i.  p.  5U. 


t:n*laiigki)  burs^. 


m 


» 


sometinwM  it  is  solid  throughout;  moro  frequently  there  is  a  contral 
nvitv  oMiit»ini>ij^  It  ^IntiiiouH  fluid;  !<omi'tinK'«  Oio  fluiil  in  uit  un- 
largol  bursa  contains  unmcrous  boilieo,  reaeiubliiig  inelou-socds  or 
parlx>ik><l  rice;  tlu!t>e  are  oi"  h.  clcnw:,  Hbriiioos  luilurv,  and  nppowr 
to  be  either  ilie  result  of  brokeii-n|)  deposit,  the  ])ortiona  becoming 
roiuKi  and  nmuutli  hy  motion  niid  uttritioii,  or  productions  from 
the  inner  sorfoco  of  tho  iibrous  deposit,  wliich  from  tlie  eifocto  of 
motion  and  friction  bvc-onio  fir»t  |K-duncalftted,  an<l  thi-u  being 
detAched  fall  loose  into  the  fluid  of  the  rao,  muefa  in  (he  same  waj 
as  occurs  in  tlie  fonnation  of  looso  cartilages  In  joints.  InOam- 
tnation,  terminating  ofli>n  in  Auppuriition,  sunitHimoa  taken  place  in 
ImnuD  muccnii' ;  we  sec  it  ooc-urriug  in  a  previously  boalthy  sUito  of 
the  part,  at^cr  a  severe  blow  or  a  wound,  esjfjcially  in  tho  bursa 
the  olecninon;  the  in  t)  am  mat!  on  runs  ver^-  high,  and  is  not 
to  die  tia<^  it^-lf,  but,  in  u  ditliisv  form,  extendn  often  over 
the  whole  ann,  with  much  swelling,  redness,  and  tension  ;  tho  pain 
it  great  and  tlie  coiiNtitntioiinl  diiliirbance  ciinnidorHbli>,  and  in  old 
people  there  is  iiomettines  much  danger.  Pus  forms  rapidly,  not 
only  in  th«  xac  but  also  in  tho  cellular  membrane,  if  not  rulievtxL 
Enlarged  burste  of  the  ])atella  are  frequently  attacked  by  inRam- 
mation  and  niii>|)u ration,  and  usually  thero  is  cxtunsivo  inltatnma- 
of  the  surrounding  cellular  structure;  and  sonietimea  Huoh  large 
of  pus  arc  found  in  tho  ncigliWurhood  of  tho  sac,  as  lud 

B>  Brodie  to  consider  that  tlie  ttuppurating  bursa  occasionally 
way,  and  allowed  its  contents  to  escape  into  tlio  cellular  mum- 

le.  Tlie  n^adinesit  with  which  tlie  neighbouring  <«llidar  mera- 
l>ranfl  is  involved  In  the  inHummation  of  subcutaneous  bursa-,  is 
probably  due  as  much  to  the  samciiMw  of  Uioir  nature  as  to  the 
continuity  of  their  tissue.  Troublosomo  and  burrowing  ulcers  somo- 
timm  remain  iitlcr  these  absccsHOa,  luid  somi'tinic-*  from  undue  pres- 
sure and  neglect  of  a  hardened  cyst  These  ulcerations  aro  sin- 
gularly ohfttinat*',  sometimes  witli  consiiioriiblc  fungous  growlha, 
the  skin  around  being  dark  and  uiihealtliy,  witli  deep  burrowings 
under  tbo  int^^^umonts  about  the  knee,  aud  a  foul  and  oBejisire 
discharge. 

TreatmenL  Wliatovcr  treatment  may  Iw  ndoptod,  it  sbojdd  be 
accompanied  by  complete  rest.  ^Vhen  the  bursa  over  the  patella 
is  affected,  a  well-fitting  ham-splint  may  be  applicnl,  and  all  mo- 
tk>ns  of  tlie  kneo-Joint  preiented.  8im{)le  enlargement,  if  recent, 
will  often  subside  under  rest  and  a  slightly  stimtdHting  lotion,  such 
Bs  ammonia^  hydrochlontt,  jj-,  m\\\x  ^v-,  aeoti  Jj-  M.  Some  merely 
Iniutfix  the  buna  with  a  needle,  aud  leave  it  to  itself.     If  the  en- 


WMnw  uinuneni  or  loe  unfinin  c 
tomonr,  amy  in  soiiw  awe*  sucot-isl,  L-sfitfciitlly  wli 
have  beeii  previoualy  evaauatod.  Mr.  Key*  recoi 
oomposod  of  11  fow  tlireads  of  silk,  to  tm  pauuwxl  tli 
giippuratioQ  is  thus  set  up,  an<l  the  pus  (.■scapes  by 
Uiroa'U  from  timo  tu  timo ;  «>i)i|in>Miiii  is  iiIm  «m 
of  a  pad  aiid  ailheslve  plaster,  the  openinj[s  bein 
tlia-tu  mi'atiK  tlio  discliargo  gradually  diitiiniRlioi, 
eootrantiuti  aiid  piu-Uy  by  granulation,  t)ie  cavity 
mtod.  Tho  French  Surgeons  often  treat  Uicso  c 
injectJonA,  like  liydroocle.  Wlion  there  ii  niu-k 
tho  sap,  Mr.  Key  stiti  fiods  tho  treatment  by  sotor 
ttial ;  for,  conoid ctriii;;  tliiit  tlic  indtirntion  is  kept  up 
of  the  cavity,  the  seton,  by  producing  inHammatK 
Hon,  would  cau>o  itii  oblit^Tnlion,  iin<I  the  abtiurbei 
the  indurated  walla.  When  tlio  tumour  has  b( 
([uite  a  solid,  gristly  mnsfi',  tliorc  i»  no  renioly  bat 
which  can  readily  be  done;  and  I  liavo  never  9« 
coquonc^'*  follow.  Whore  the  tumour  id  very  largo 
patella,  cai-e  should  be  taken  not  to  wound  the  apoi 
of  the  joint 

In  acute  inflammation  of  the  banw,  both  In 
Rntiphlogistio  measures  are  required ;  but  where  tfa 
flanimation  nround,  of  au  oiyttipohitous  tendency, 
derived  from  tho  sesquichloride  of  iron  )otion,t  w 
port.  If  siippumtioii  has  taken  place  in  tho  sue, 
laid  open  with  a  frra  incision,  or  ■  M^on  may  be 
it ;  tlie  former  would  bo  profentble  whore  then  k 


Kir  its  escape,  in  as  depending  a  position  an  pcuuiblo,  and  the  ^atam 
will  reqnirv  pincnil  ftijiport  and  stinjiili. 

'  Of  Uie  8cl%  entitiouB  bm-sie,  lliat  of  tlitt  litinion  is  tlio  most  aeri- 
tm.  Oiiu  of  the  efToeU  of  tight  suid  ill-tittlng  shoen  is  div  dinplaco- 
ment  of  Uie  toea  from  tlu-ir  natural  liirootioiiN ;  tin;  great  toe,  more 
•specially,  is  ilispUcixl  in  a  direction  outwardii,  forming  nn  obtuse 
luigle  with  iUt  nietatiirsal  Ikiiiu,  and  re^  eitlinr  on  or  below  the 
i>d  f«c,  usually  tbc  latttT.  In  coiisc(]uonco  of  tins  deformity  n 
lidcntblc  stiuiii  in  thiYiwti  ujion  ili^  iiiLcrniil  luU>ral  ligament  of 
'  the  joint,  under  which  it  gradually  yieldE;  a  kind  of  M.^miluxiitioa 
take:*  pliiOH,  and  a  conxtdendili;  |)i-omiiieiioe  i»  formed  by  the  pro- 
jecting base  of  the  fii^st  phalanx.  Upon  tltis  }>romiiivnt.-o  <■  liioiul 
mirfacu  of  homy  cuticle  i»  fonntid  l>y  pnwMire,  and  between  the 
skin  and  t}ic  ligament  a  bursa  is  formed.  Mr,  Key,*  in  ilc^icrihing 
a  bunion,  siiy»  thnl  tlie  protruding  jibiiliiiix  wH«  up  imtation  in  the 
UgamoDt;  tJiis,  m  conjunelion  with  pressure,  produces  a  svrit-s  of 
nnall  cjivitiai  or  oysis  bctwwn  the  Iuvot!*  of  tliw  ligament ;  these 
i^'«t»  come  forward  in  succession,  and,  hoooming  ohliterated  by  iu- 
flsmmatjon,  have  the  Hfeet  of  wanling  off  tho  consiK^ut-ncE^  of  prea- 
ore.  From  repeated  pressure  and  irritation,  inflammation  from 
time  to  time  tiikt»  pliici;  in  thu  burwi,  or  cyrt,  aeeonipanicil  hy  great 
pnin  and  redness,  witii  a  aeiiao  of  heat  and  dragging  of  the  part ; 
and  though  by  rc-it  and  treatment  tlxvio  uttiioks  readily  MilMidv,  yet 
tbt!  reiK-dtion  of  irritating  causes  occasions  a  permanent  tumour, 
which  usually  cwutaini'  only  the  ordinary  thin  bursal  fluid,  but  oc- 
casiotmlly,  an  has  been  obaerxed  by  Sir  IJ.  Urodiof  and  M.  Boycr,J 
is  filled  with  a  dense  erj'ftlidlinc  secretion.  Sometimes,  from  a  blow 
or  unii--<ual  pressure  and  irritation,  suppuration  takes  pbce  in  tho 
crat;  tiie  abscess  thus  formed  is  slow  in  its  progress,  oxti'Cintily 
painfnl,  and  usually  opens  after  a  time  in  tlie  centro  of  the  homy 
oalloeity  by  a  cireular  aperture  ;   after  which    tho    parts  hocome 

^_  quiot,  and  remain  so  until  renewed  vuust-s  Kt:t  up  tresli  abscesses. 

^■By  tliis  time  the  ligament  is  destroyed  by  ulceration,  tho  joint  i» 
Openi-<I,  an<l  a  prohi-  introduttKl  discovers  tli«  cartilages  eroded  or 
alltigirtber  gone,  and  tlie  hones  es|K>sod  and  carious.  Souu>t.imcM,  in 
ncgleetod  ciiMu*,  ubsceiLH^  burrow  nnnid  and  about  the  joint,  the 

^L  honca  become  necrosed,  anrl  the  neighbouring  ]>arts  greatly  thrck- 

H  ened  and  xwolkii,  with  so  much  paiu  aa  completely  to  prevent  all 

^M  locomotion. 

t 


•  Ony'i  Hotp.  Rep.  vo).  i.  )).  ilO,  1890, 
t  I^ct.  on  tiUk.  aad  Sur-j.  t8*6.  p,  MT. 


TraiU  lift  ifal.  Clir.  vol.  si. 


552 


DISEASES  OP  MUSCLES. 


blo_ 


Trtaltn^nt,    In  mere  painful  enlargement.  Sir  B.  Brodio  recom- 
inondH  n  lar;^  i^lioc  to  bu  worn,  and  a  coin]>rDS!(  of  throo  or  mora^ 
laviin  of  nniftiln<i,  iiprcwl  with  nnnp-plaater,  large  oiiough  to  ooven^ 
8omo  cxtiMit  of  earfac»,  and  cut  into  n  horseshoo  form.     Tho  bunion 
oootipj'ing  the  onij>tv  *paci>,  tti«  lior*e«lioG  form  of  ihe  i^onipreas 
pnivent§  tliat  bulging  of  tho  enclosed  part  wliivh  takes  place  in  a 
eircnlar  i>)H>nin^.     WI)iti-4>  tlio  hiirsu  i-t  largo  and  painful,  txilh  Sir 
B.  Brodio  and  31.  Bover  recommend  tlic  cTst  to  be  dcBtrovcd.    This 
tna^V  Im)  iloiti'i,  tifHt,  by  opening  it  either  by  iiici»ion  or  cauMio,  and 
sppIjHng  nitrate  of  silver  or  nitric  acid  to  tbo  inner  surface :  cnro 
matt  Ut  tftkon  ta  iu<c^irt»in  tlmt  tJiu  vysi  tlooH  not  commnnicjitit  with 
tho  joint,  in  which  case  the  latter  procoedings  would  be  biglily 
olijoctioiinhh-;  and  nniior  any  circumxtiuiciM  thw  nitric  aoid  slmiiM 
be  used  sparingly  and  witli  caution.     After  one  or  more  applies-^ 
\afm%,  the  Burtacw  gninul»t«3  and  the  euvity  clofieti.      In   iitflatn-ifl 
mation  of  a  bunion  it  may  be  proper  in   some   oases  to   apply 
leeches,  witii  fi)nientation  and  jwultico ;  whcrP  there  is  considerablo , 
surrounding  inflammation,  with  much  pain  and  dragging,  the  fot 
lowing  lotion  is  often  rery  useful :  Iiij.  pliimbi  diaciH.,  tinct.  o[»ij 
««  3J-i  mist,  campbor.  S'j-  M-  f^  K'tio.     lA'hon  abscess  liiLt  formnd) 
H  may  bo  ]>oTilticcd  and  opened.      Mr.  Key,  however,  preivrred 
leaving  the  aK^w-ss  to  burst  of  itfl(-lf,  as  being  less  likely  in  wtt  up 
tniscbicf  in  the  joint      Under  ull  eircuinstanoos,  great  benoftt  will 
arise  from   motoring  as  muoh  as  )ioa»iblQ  tho  too  to  ila  nntural 
direction  :  this  may  he  done  while  the  patient  is  lying  up,  by  keep- 
ing It  pad  lnHweon  tlie  first  and  scf'fiiid  tiH^K ;   but  whim  iJio  inlieni 
is  about,  both  the  slioe  and  stocking  should  be  made  ia  snch  a  Wi 
that.  tliiTe  wimUl  Im?  n  .soparnt^  eoinparlinenl  for  the  grenl  l'>e:  tllE 
tho  strain  upon  the  lateral  ligament  is  removed  or  diminished, ; 
K  ])rinciptil   mnu-co  of  mischief  taken   away.      Where,  &om  long 
n^Iect  or  other  causes,  extensive  disorgnnisation  of  tbo  joim  and 
part»  an>und  \\an  taken  place,  amputation  of  tlie  toe,  with  a  portion 
of  the  metalarsal  Iwne,  appears  the  only  resoitrce.     I  havo  dons 
this  in  a  few  eiiscs,  with  the  beet  results ;  nor  Iuls  tho  loss  of  the 
too  proved  sucli  sui  iinpe<Iiniont  i»  tho  iiutural  gait  us  might  bo 
expected.     Very  bad  cases  of  this  description,  however,  may 
restored   by  long  rest,  fixing  the  joint  witli  cnoutchouo  or  soc 
otlior  splint,  much  attention,  and  good  diet. 

The  biirsjp  of  t«iidiins  have  more  the  character  of  synoiial  meni.<4 
branes  than  tho  subcutaneous  bnrs.T?,  and  are  either  simple 
oontainiug  a  lubricating  fluid,  plaeetl  botwwtn  tendons  and  pro- 
minences of  boues,  as  that  between  tho  ligaiiionUini  patellie  and 


iwnt 
wajfl 

t]»4 


ENI.ARREI>  BURSJ?  OF  TE?a)ONS. 


553 


^ 


tnbrrclc  of  tlic  tibia,  or  cotnpf icatod  with  nntncrou^  prooc«e«  and 
[^ongationii,  as  in  tim  tiviioviui  nhciilkt  ^f  tlio  floxor  t«mIons  of  tlio 
liand  aixl  wrist.  Theec,  like  tlie  siibcutai)E<ou§  burKe,  ant  |ia)>l<!  to 
•iilurgeinont,  and  ofien  ntlaiii  n  ounficlcrutilo  size ;  b«t,  from  their 
deeper  eilimtionB,  tliey  are  less  exposed  to  injuries  from  wJtJiout, 
and  ooiineiiueiiilj-  do  not  ho  friv|iiiTt.!y  inHame  and  wipinirHt^  The 
bursa  between  tJie  liganientum  patellai  aiid  tibia  stometimea  enlar^s 
and  form*  iv  tuiwinr,  which,  by  filling  up  tlio  deprwi"i«ii  on  each 
side  of  the  ligament,  presentit  the  apiiearaiira  at  first  of  sjniovitis  of 
tho  kn<-e-j«int ;  but  tlio  abKenco  of  swelling  shove  and  around  tlie 
patella  renders  tlio  dinfrnnsis  ciwy.  Distention  (ifUie  bursa  above 
U>o  kiiee  UKtially  accompanies  s^-novitls,  bocniiso  thi«  bursa  aluiUHt 
tlwajs  oommiinieatuA  with  tlio  joint;  this,  however,  is  not  alwa^'s 
the  case,  and  I  liave  nt  this  time  a  patient  with  a  largo  barnil  tii- 
luour  under  the  viutti,  the  joint  bi'ing  ijniUt  lieiiltliy.  One  of  t]ie 
bane  of  tlio  hamstring  musdes  (usually  that  of  tlie  biceps)  occa- 
nonally  enlnr^!>,  and  ap[H-iirM  in  thi>  Imni  as  a  pnliatrng  ttimoiir, 
often  ofeonsiderabio  size;  it  is,  however,  too  little  like  an  aneurism 
to  be  mintaken  for  one  by  a  cnrcful  observer.  The  same  inny  ho 
nid  of  the  bursa  of  tlie  suhseapularis,  and  otJier  bursa!  about  tlio 
nbonlder-joiiit,  which  KoiDetinivs  fonTi  tunioiirs  in  the  axilla,  occa- 
uonally  pulsating  from  tlieir  vicinity  to  the  artery,  TIio  bursa 
between  the  psoaA  and  iltacus  Intemus  and  tlic  capsulo  of  tho  hip- 
joint  sometimes  form.*  a  tumour,  whitrh  from  tin  nituiition  may  be 
mistaken  either  for  an  inguinal  aneurism  or  for  a  psoas  abseesa ; 
t)ie  extrin.tio  ctinntoter  of  the  piil.'Uition  and  the  nlxtenve  of  all  other 
anearismal  sympt<ims  in  tho  one  case,  and  tlie  want  of  spinal  s^'mp- 
toms  and  of  Hucttintion  alxivu  )^eii[mrt's  ligintK-nt  in  thit  otlicr,  awist 
in  forming  a  right  diagnosis,  This  bursa  occiLsionally  communicates 
witJi  tlio  synovial  memhrane  of  the  joint,  nnd  when  inflammation 
occurs  in  tlie  former,  the  latter  will  most  likely  be  involved  in  it, 
and  wrioui*  niisehicf  may  follow,  nie  Imnwi  betwwn  the  ghitfl'un 
maximus  and  tuber  ischii,  that  between  tho  tendon  of  the  glutieus 
■ikI  tlio  trochanter,  and  that  between  the  lati.'^i'imus  dorsi  and 
Um  angle  of  the  sca]iula,  from  their  exposure  to  pressure  and  other 
■onroea  of  irritation  and  inflammation,  are  not  only  liable  to  in- 
Sam^f  but  even  to  su{>|mrate.  When,  from  frequently  recurring 
prearare  in  sitting,  tho  already  enlarged  ifiehio-glutcal  buna  inflanios 
and  MipjiurulVit,  it  incroaAos  in  Hixe,  becomes  painful,  and  renders 
bitting  on  tho  part  impossible,  and  even  motion  distressing ;  lying 
deep  under  tbo  m^*  of  muNcle,  iIa  fluctuation  Is  obscure,  and  the 
Wppuration  ia  usually  slow  in  coming  to  the  sur^ico,  and  aflor  it  is 


KS4 


DISEASES  OF  MUSCLES. 


0  m 


ovncualcti,  it  oft«i  Kmves  a  sinus  obi^tinatc  and  nlow  In  Iii^id,  from  if* 
depth  aiid  Uie  movements  of  tiie  imiMole.  Tlie  niiine  may  be  eaid  in 
most  rcjfpccbt  of  tlio  bnren  over  tlio  trocliaiitcr.  TiiL-  bur<a  lit  the 
angle  of  the  aonpiik  ottun  a('<^iiir«»  u  gruat  sixe,  and  wlien  it  sup- 
piiratps,  much  cotistitiitional  di»tui'ban<.'C  Is  ofttn  M-t  up.  Too  liui<;h 
caution  oiinnot  he  tuketi  in  (>[H:-ning  them  bin'siv,  vrhctlier  in  tboir 
amply  unkr^^ed  stato  or  in  tho  suppnratinjET  ^i«go,  as  an  nlarmiiig 
and  even  fal;il  train  of  HvinptoniH  iumi4>tiinoei  lolkiwit  the  uperatjon.* 
The  palmar  bursal  tumour  is  perhaps  the  most  obstinate  of 
any;  forming  u  Mvcilhig  niidtT  ihi-  pMliiiar  fuMcia,  it  exti^iiilH  unde 
tJio  trsiisvorsc  ligament  and  ascends  into  tho  foro-ami,  prcscntiup  i 
double  tumour,  tlift  coiilnietnl  piirt  ci)rre»j)Onding  ^vith  ihe  trar 
vcTso  ligament.  Tho  fingora  are  more  or  less  drai>n  into  the  pudm 
ol'tJifl  hand,  and  ciuiiiot  fw  utraigliUniitl.  'Jlic  Hiidniition  in  readily 
folt  by  attornato  pressure  above  and  below,  ajid  when,  wliicJi  is  often 
tho  oji-*o,  llie  mcloii-i't^'d  hwlie*  arc  pixwi-nt,  a  jiL-ciilinr  ereakiag  or 
gi-ating  sensation  is  eonintunicatcd  to  the  touch.  Tliese  bodies  ap^^ 
iiflon  extremely  nunieruuv ;  Diipuytrcn  bcliuvcd  tli«ni  to  be  )iy(lBtidij^P 
and  described  their  apjiearance  minutely,  |  Tlie&e  tumours,  after 
slight  attueks  of  inflimmintion,  often  cease  to  fluctutttv,  and  hvcome 
filled  with  BoUd,  unorganised  fibrin;  and  when  infianiination,  fol- 
lowod  by  .■■  II ]>|tn ration,  comes  on,  wlncli  it  usually  doe*  from  using 
tliQ  hand  in  tliis  state,  1  have  s(|uee*cd  onl  large  nuuwea  of  tlie  coagu- 
lated KuUttanco  tlirough  the  opening  made  to  let  out  tlie  piu ;  tli^^l 
lias  been  followed  by  the  gradual  subsidence  of  Uie  abscess,  and  the 
perfect  rcslomtion  of  tlie  usu  of  the  hand.  Sometimes,  however, 
the  ease  taken  an  nnfiivourable  conrM);  ditt'iise  «>ryai]>e)atouH  iiiflain- 
matton  is  set  up  instead  of  that  of  a  more  plastic  nature,  and  a  fatal 
result  will  iiccaitioniUly  ensue.  A  jxiticnt  wiia  udniitted  under  my 
care  into  St  George's  Hospital  with  disease  of  tills  bursa.  Ho  was  a 
publican,  about  filly  yours  of  age,  ofa  stout,  flabby  apjicuriuiov,  with 
failing  pulso ;  tho  bursa,  wliieli  bad  sujipurated,  hod  been  opened 
above  and  below  the  wrist,  oilil  was  tlisctiargiiig  large  qnuntitiiM  of 
pu8  mixed  with  the  rice-like  bodies  in  great  inmibei-s ;  tho  hand  was 
enormously  swelled,  and  the  whole  ann,  exteuding  aboM!  the  elbow, 
pulargetl,  tense,  and  ofa  deep-red  colour.  Tlie  case  in  many  rospecia 
resembled  that  (ifdJftuKO  thcciti.-*  formerly  described,  and,  Itku  it, 
proved  fatal,  in  spite  of  every  ine.niis  10  support  the  s>'stcm  that  I 
could  employ. 

•  Oil  iiiv  (liii^frsis  lietweeu  discaat^a  of  tLe  biu-aic  uiid  of  Uio  Joiuta,  M« 

DiBSABKB  or  TUK  JoIMS. 

t  Lr(iont  Oralu,  od.  1B8B,  vol.  U.  pp.  U8  ct  sqq. 


GANGLTOX. 


555 


I 
I 


A  modifination  of  lIms  bursa  is  found  «mnoi>twl  witli  tho  CKtcnxor 
toodoos  of  tho  fin^rs  and  toes ;  those  are  termed  ganglions ;  their 
fiavitieo  do  not  nfipoiir  to  niiiiiiiiiDiuito  nttli  the  »thcath«  of  tJic 
tendons,  but  are  forniod  in  tfie  dense  tUauo  investing  the  shcatlis  or 
tlioe:i|jsiili-  of  tlie  joint.'  Tik-y  form  wmatl  round,  movable  tumours, 
rarely  larger  tluin  a  filbert,  mostly  at  tho  biick  of  the  wrisl ;  ibey 
ore  M>ldoni  painful,  but  tlio  patioiit  UMtially  (K>m{>kin8  of  a  senso  of 
woaknoss  in  the  joint,  Tliey  ai'o  found  less  fi-efjuently  on  l.iie  <loi'sum 
of  tlio  iofit ;  licrc  ihi^y  [ia'-»oiit  a  mort'  t-omjircssixl  fonn,  and  are  less 
morablo  than  ii]  tho  haiid.  I  have  seen  lliem  on  tho  out«r  |mrt  of 
tlu!  <lnr)iuni  of  tlie  foot  mora  than  two  Inches  Jii  diaiiiot^'r,  broad  and 
Battened.  These  cysts  contain  altuoot  constantly  a  tirni  gelatinotia 
HubtttnJico,  nearly  iw  dviiRC  a«  the  crj'staUiiie  Ions  of  the  uyc,  Gan;;lia 
do  not,  like  subcmtaneons  bun4,T,  arise  fioni  pi-essuro ;  they  9om&> 
IJnaM  follow  n  sprain,  hut  uHually  apiicar  without  evident  causo; 
thejr  are  generally  slow  in  their  growlli,  but  now  and  then  appear 
qoito  raddiiily. 

Trtatmeni  of  enlarged  burgir  0/ tendons.  These  burssB  soraetjines 
I  rapidly,  iiiitler  wliiiOi  cin.-nin^littioc  tln-v  "ulisido  (piiekly  bv 
,  evaporating  lotions.  Tho  more  eonimou  and  chn)ni(!  form 
of  enlargement  requiros  a  moro  activu  raodo  of  troiitmont  Some- 
times a  blister  alone  may  be  sufHeient  to  cause  their  <U»ap|»earance  ; 
'  this  will  bo  more  ertVwtuid  if  the  vx^l  haj«  bcun  previously  cnijrtioj 
by  puncture;  and  it  may  be  advisable  to  keep  lite  blister  open. 
ComproH-^ioii  after  evuiaiation  of  tli(.^  eynt  niav  sucvocd  in  Momo 
cases.  If  thoy  prove  obstinate,  tliey  may  be  treated  like  a  bydrooelo, 
fay  injection  of  cfpinl  purttt  of  tincturv  of  iotlino  and  water;  tliis, 
lH>wever,  should  not  bo  done  in  tlioso  bunue  which  occasionally 
oa>innitiiiicat«  with  joints,  nor  perlmps  iu  the  burnt  between  tho 
btissimiiB  dorsi  and  scapula,  for  reasons  already  given.  A  seton 
oJWn  answers  well,  iw  in  Nul)cut(m<s>u*  bursa;,  Tho  jMilmar  bursa, 
when  enlarged,  as  well  as  that  at  tho  anglo  of  the  seapula,  requires 
tonus  coimidi'ralion  an  n^gani*  the  health,  power*,  and  condition  of 
the  patient  before  active  measures  are  adopted  for  curing  it ;  for  it 
must  iw  reiiiftiidHTCNl  that  th<uw  me!i.''imy  eH'ect  n  cure  by  )«>tliiig  up 
active  intlanimation  and  suppuration ;  and  it  has  been  already  seen 
how  prone  tlie  inflamnintion  i*  to  take  on  a  dilfuM!  an<l  ino«t  un- 
&vourabIe  form,  especially  where  tJie  burss  are  extensive.  Where 
tumour  is  not  of  long  standing,  it  may  oHen  bo  much  dimi- 


•  8m  Bojrer.  Trail.  Jet  Mai.  Chir.  vol.  tL 


556 


DISEASES  OF  MUSCLES. 


niithm],  if  not  CTired,  by  puncturing  it,  which  may  be  followed  1>1 
either  poniprcssion  or  blisKni.  In  a  patient  under  inv  caro  wit 
tnHnniiMl  tliccal  biirita  («  nurw  ui  llic  lioapital),  btist<-rs  were  kc 
open  (or  some  time;  afW  two  «■  tbroo  suceowive  puncturi-s  tin 
tinnrtiirs  wore  mncli  iliminisliiKl  tuid  felt  nolkl,  Uio  fry»t  oontaining" 
ovi<icntly  coagulated  fibrin  alone ;  she  was  now  enabled  to  ii»«  (lie 
h«»d  and  ntlciul  to  hor  dattcK.  At  the  end  of  a  few  montlis,  bow- 
©vor,  the  hand  beeume  painfiil  and  infiamod,  and  fluctuation  WM 
pore«[>lil>lo  both  abo^o  and  Iwlow  Ibo  trans^■«^•«;  Hgainviit ;  an  Dpen> 
ing  was  mado  in  each  part,  and  a  HUiall  quantity  of  pus  escapod, 
inixixl  with  frngmcnts  of  cirmKiilatcd  Hbnn.  Swing  tiii!',  I  enlarged 
the  o|>ening  and  stjtieened  out  a  large  quantity  of  verj-  firm  straw- 
coloiiruil  L-oa^i^iInnt ;  the  cy»t  boing  cmptiml,  a  jKiiiltic'O  wn*  apiilied, 
and  a  generous  dirt  ordered,  Onwiderjiblo  discharge  took  p1ac»  (or 
Koniu  days,  but  gradiutlly  diminisliod;  tliv  wounds  1k-»Um1,  and  no 
fiomplete  was  tlie  i-ecoveiy,  that  but  for  the  marks  of  the  in<nBion8)^P 
no  »ign»  of  prcnnous  diKpaso  fxisti-d.  It  han  Ihtpu  rueommundvd  to 
lay  opun  tlie  entire  sac,  dividing  the  transverse  ligament,  an<l  dread- 
ing the  wound  to  the  bottom  witli  lint.  Tliis  tn-atmttnt  ono  woidd 
hardly  recnninien<l,  tbnugli  where  the  rice-like  bodies  exist,  sicnpl* 
puncturf«  will  not  give  exit  to  them,  and  incisions  must  be  mad* 
for  the  purgmAC.  In  some  oa-^es  lH>lh  the  seton  and  iodiite  injoctioni 
may  Ik*  i;inp1oyod,  but  with  extreme  caution.  Tlie  gimglion  may  be 
trealed  in  varinus  wnys ;  it  is  apt,  liiiwever,  to  return,  li^  tJie  walls 
are  not  very  dense,  the  sac  may  bo  rupturotl  by  firmly  compressing 
it  with  tiie  two  thumb!',  or  it  may  l)i>  diviiii^l  xut)Culnii<!OiL''iy  with  a 
tenotomy  knife,  or  punctured  i^-iih  a  grooved  needle,  and  the  crys- 
talline contents  squc<')icd  out  Wliicbcvcr  plan  in  adopted,  tho 
swelling  will  probably  return,  unless  further  means  be  employed, 
audi  as  a  tirni  <xim]>rv«sion  witli  a  Kinail  utolid  body  tightly  bandaged 
over  the  part ;  or  a  blister  may  be  applied  over  the  part  with  a  good 
effect.  M.  Boycr  (loc.  cit,)  ban  dwicriijcd  a  case  of  very  extensive 
ganglion  conn<x;ted  witli  the  extensor  tendons  of  the  fingers,  which 
bo  dissected  out  and  drcsswl  to  the  bottom  witli  Hnt,  having  pre- 
viously failed  in  the  treatment  by  seton  and  compression.  Thft^— 
ro»ult  of  the  operation  wa»  very  favournblc^  Theso  cysts,  howovery^| 
cannot  be  entirely  removed  by  operation ;  the  attaclied  parta  cannot 
be  dit«i'rl«d  fmni  the  tendon  or  ligament ;  so  that  thoy  will 
onlosB  the  wound  be  kept  (>])cn  to  tJie  last. 

T.  TATUM. 


ORTHOPAEDIC   STTRGEET. 


I 


SINCE  the  Inboiira  of  8tnMnv}XT,  pabli»]iccl  in  1831,  nn  impor- 
tant rWs  of  affections,  ooiitraiiturcfl  Mid  dc-furniitieH,  Uil-  tn^ut- 
I  ment  of  w)ii<-h  IiaiI  prvvtoitsly,  for  tlic  tno«t  part,  been  pi-miiltcd  to 
remain  in  tho  bands  of  Uie  inHtruinent-tnaker,  lias  tlBHerveiilv  niti<!li 
eiigHj^t-J  llie  ntiviuion  of  tho  SurftuoiL  Styirpi*  in  1SU3,  Ji>rg,  180(!, 
Rwlolpki,  1823,  Delpech,  IttSi),  Dupnytren,  and  others,  had,  with- 
out niiu'h  iiimiudiatu  fruit,  ciideavourotl  to  rmnovi-  the  olwmritj 
in  which  this  class  of  atiuctionii  whs  iiiiolved.  Their  inquiries 
happily  M!r>-e<I  to  din^ct  tho  rcscarclics  of  Stromej'or  into  a  projwr 
L' direction. 

The  jathoIoKical  nature  of  tlic  affcsTtionn  rcHv^'ablo  bj-  ortho- 
Ifaedio  treatment,  »ftoii  by  division  of  tendons  (tcnoiomy),  is  various. 
'Shay  consist  of  alterations,  in  form  and  mownimt,  of  tlie  articu- 
lations, eapedally  of  those  belonging  to  the  lower  and  upjier  ex- 
tranitioa.     Tlioy  spruig 

1.  Fr»m  aocidentnl  injuries  of  arli('uliiti<'n!t;  undue  pressure  and 
Stnun ;  inHammntion  of  joints  or  coiiiiguoufl  parts,  particularly 
those  »!('<■»<'< Itxl  by  Huppuriitioii  and  iUt  cTinw^quencra. 

12.  From  derangement  of  the  cerebro-spiiial  system,  Ivadiiif;  to 
paralyAiA  or  i^innni  luxl  contraction. 
3.  From  congenitid  uiftuonces,  the  rarietjes  of  club-foot,  for 
Axamplc;  niulfurinuriiiii^. 
(MhopaHlic  Surgery  comprehends,  thcrofore,  a  multitude  of  ab- 
nnnnal  tiinii*  of  the  niusc-ulur,  ligunit'iitoiiH,  and  owii-otitt  Avsleuis,  of 
which  some  are  treated  elsewhere  ui  this  work.  On  the  patbolo^'  of 
dufbmiil'ivN  arising  from  disriites  of  the  joints,  the  reailiT  is  referred 
to  the  essav  on  thono  diseasea.  It.iL'lntic  dofomiitios  are  treated  of 
in  the  csHiay  on  tho  Sl'bgeky  or  CuiiJ>m>on ;  spinal  curvatures,  in 
that  on  DiSB.uiE»  of  thb  Juixts  ;  stmlHsmns,  at  vol  ii.  p.  889 ; 
mallonnations,  with  the  Surckkv  w  ('HiutHoon;  burn-ixintrac- 
tures,  above,  p.  IIW.  Tlie  afloclions  which  wo  have  tiore  (o  coii- 
Hdor  nn>  principally  thoso  wtucb  can  be  remedied  by  division  of 
len<lon«,  by  mechanical  extension,  or  by  both  of  these  meana  oom- 
luned. 


5» 


OBTHOP^DIC  SURGEKY. 


nl  aaa^^ 


B«*forc  proKMxIing  with  thu  description  of  tbo  inclirKlual  OOH' 
tracturcii  rolievablfs  bv  tenotoniv,  it  wiJI  be  well   to  consider  iImj 
circuni5tancf«  which  pi»X'  riso  to  t-on traction  and  dcforniJtj-f  snd  to 
itiijiiire  into  tlic  condition  of  the  muscloH  and  temloD.i  wlilch  rendera^_ 
tlieir  division  ncc«maiy.     It  a  now  a  wcll-andcretood  law  of  patbo^H 
1<^>  that  if  any  part  of  lite  liody,  into  tliti  conipusilion  of  which 
musclcH  enter,  be  maintained  in  a  state  of  absolute  repose,  or  bo 
haliititiilly  kept  in  oiio  position,  tm  tlmt  tJio  original  and  inner- 
tjons  of  particular  tnusflc«  art-  constantly  approx!iuatc<l.  whilst  tho 
points  of  origin  and  tn.ifti-tlon  of  otbor  iuiim,>I(!»  are  vi)nKis|UUR(ljr^_ 
proportionately   separated,   a   shortened,    contracted    condition   oi^| 
tbo  fintt  iwt  of  inn.'»!l<!H,  and  an  idon^^ttil,  wrMkciityl  Kt.-it*^  of  the 
second  set  of  muscles,  arc  produced.     This  is  illustraiod  by  wl 
occur*  duriiiB  a  Binijile  fracture  or  otliur  injury  of  an  extremity 
If  the  elbow,  for  osaniplo,  be  for  any  reason  retained  a  few  weeh 
in  the  bout  |H>nition,  the  nniKcivM  on  tho  tii^xwl  side  of  the  meml 
become  stiff  and  contracted,  and  are  only  ^adually  restonxl 
their  natural   mobility   by   afrtivc   unci   iKiJwive  cxerciw*  and  use," 
whilst  tbo  stretched  out  and  weakened  extensor  nitiAt-lcA  rwwver 
but  dowly  tlicir  full  power  of  extending  the  implinitod  articulation. 
Tlie  state  of  things  just  described  ia  aggmvatod  when  inflainina* 
tion,  exudation,  tupjiumtion,  loss   of  cutanooiiit  or  nioro  doeply- 
situatod  tissues,  and  conHe<juent   adhesions  and  cicatrices,   intoD^I 
poBO  pain  «n<l  jihy^iwd  obstruction  to  the  restoration  of  complete 
mobility.     Tho  greater  duration  of  the  diaonier  incrcMSCH  thti  pro- 
bability that  pcrwn'ering  or  active  remedial  means  will  bo  roqaired 
to  obviate  tlie  shortening  of  one  net  of  »tructiiri-s  and  ttie  iJougn- 
tion  and  weakening  of  tlie  ojipositc  set.     Tliis  shortening  and  oon» 
traction  occur  more  rajiidly  during  tlie  earlier  years  of  life. 

Tlio  influence  of  paralysis  in  producing  eontractnre  v»r\e 
cording  to  the  naturt)  and  i*\Ieul  of  the  si-ixure.      A  .^iiigk'  mi: 
as  tlio  sterno-cleido-masto ideas,  the  tibialis  autieus,  or  the  external 
rectus  of  the  eye,  may  be  mon'  or  l<\-w  Cftmplctely  f»araI_\'Mxl ;  and 
tlio  antagonist  stcnio-mastoid,  the  ga.itrocneinius,  the  pemnei,  of 
tlio  adductor  ocnii,  may  become  ci>ntraet«L     Or  several  muscles 
habitually  associated  in  their  actions  may  lose  their  ]>ower  of  vo- 
luntary i«in traction,  us  the  extenxors  of  tho  wrist  and  fin^-rs;  and 
tlie  opposing  muscles,  also  habitually  associated  in  their  actions,  %-ii 
tlie  flexors  of  the  wrist  ami  Angers,  bceonio  relati\-i'ly  shortened. 

The  demonstration  of  tlie  precise   amount  «»d  nnliire   of  ll 
chanfjes  which  oectu-  in    the    central    luid    iKTipheral  ])arts  of  tlie 
nervous  syi^tcm,  as  far  av  apparent  cause  and  morbid  anatomy 


ad  oon^^ 

rio^SH 
muscleU 


iml 

3 


PATHOLOGY  OF  DEFORMITIES. 


559 


'  IcAclt  US,  nnd  ilio  ilttt^miiiiutinn  of  what  pnrtitnilar  fitnoiionN  of 
^^llie  muscles  are  primarily  dUlurbcd,  belong  to  tlic  gpucial  patlio- 
^Wd^'  of  tW*  i)i>r^'i>a'«  fvNtt'rii,  wliich  nontl  not  liero  be  eiiten^l  iigioii. 
^HPew  paralyses  occur  without  some  degree  of  contraction  ou§iiing  as 
^»i  con»w|ii«nce,  cilhvr  tlirnctly  IVi>ni  the  inijiairnn'iit  of  liw;  biilaiiw 
I  of  innaoular  activity,  or  from  forced  repoae  or  maiiitcoanoo  of  the 
part  in  a  jiarticiiiai-  |)OHilToii. 

Tho  induction  by  abrupt  »pasm  of  a  more  or  less  rigid,  more  or 
tess  permiuioiiUy  conlrudixi  stoic  of  n  part,  in  obviouit  and  easily 
intctligihle ;  but  the   spasm  which  produces   many  pei-*i»teiit  di>- 
formitioi  is  not  always  of  that  iictivc,  |in)iiipt,  or  tonio  kind  which 
in  illiiMrated  by   cetlaiii  cases    of  non-congenital  wry-neck  and 
club-foot,  but  t»  ustiully  more  jilow  and   pro<;rc.'*»ivo,  ax  wicn   in 
miuiy  children's  cases  of  foot-deformity.     Tho  oitntraction  in  con- 
genital club-foot  and  in  the  majority  of  conf^cTtitn!  distortion*  can, 
YfO  believe,  be   assigned   only   to  a   pretj-rnaturidly  excitable   op 
spasmodic  condition  of  tho  mnscnlar  tibivsof  the  whortened  niUBclu>. 
In  niutiy  Rases,  even  when  the  nliortcned  nui^cle  ban  been  set  free 
^Kby  tenotomy,  the   morbidly    excitable  retractile  dispoiiition  of  tho 
^Biiiu:k.-!i;  oiii-n  itliown  it^idf  a^aiii  afUnr  reunimi  of  the  divi(h-d  jiart, 
^P;aiid  the  ccH^ttion  of  employment  of  the  meclianical  or  other  means 
^^"by  which  the  aliii^i<.\l  niUNcle  hiid  boon  ke|)t  in  an  elongated  dtatc. 

This   contraction   of  certain   inuscios  in  congenital   club-foot, 

vhicb,   fttr   want    of  any  otlicr  a])pr(i]>riHio  t«rm,   U  dosignatvd 

r^usmodie,  is  therefore  very  diSbrent   from   the   active   powerful 

tioii  which  iicrur*  in  <wrtAi»  wnnpitrativcly  midden  noii-win- 

cases,  and  in  which  the  will  of  ihe  individual  is  powerless 

Bt  nn  improved  condition  of  ttic  limb.     In  congenita!  dub- 

and  ill   analogous  gradual  non-congeni(al   lali[Ks9  in  whicli 

paralynts  <lu(u«  not  axlst,   if  thu  cliild   it   old  enough  to  exercise 

i volition,  the  affected  muscles  arc  to  a  certain  extent  snbsniTient  to 
tiic  will,  ulthongh  volition  i*  innipablc  of  witting  entire  ri-taxation 
of  tlie  contracted  mu-seles.  Thus  the  cuntractioti  in  tliia  non-con- 
genital non-paralytic  tali|H'i>,  tho  early  stage  of  which  wo  an-  able 
to  watch,  throM-s  light  on  tbe  congenital  affctttion,  tho  early  stage 
of  which  is  hidden  in  the  uteni)!.  In  noo-congonitid  ca«««  of 
moiitlin'  or  years"  duration,  induced  by  oerebro-spinnt  affection  or 
by  reflex  (?)  divordor,  the  vitid  abnormal  spastic  contraction  coexisto 
aftvr  a  time  with  secondary  structural  change.  We  sometimes, 
however,  before  structural  change  ha.<  taken  place,  have  an  op]x>r- 
tnnity  of  witne^ing  that,  although  the  patient  walks  with  the  heel, 
ifitr  example,  much  elevated,  yet  wLcii  bo  is  seated,  ov«q  with  tho 


560 


OBTHOP^DIC  SUROEKY. 


_rii_-^^ 


knee  eKtcndcuJ,  he  can  voluntarily  bend  tlio  ankle,— <!ontact  of  the 
solo  willi  ilie  ground  exciting  abooniial  contraction.  FutIIkt  light 
is  thrown  upon  tho  iiiituro  of  tlie  oonlraction  in  congenital  dub* 
foot  by  the  otfflervKtion  that,  during  sleep,  oven  !ii  very  young 
in&uts,  the  afToctMl  foot  vnn  bv  niuro  readily  Ktraiglitoned  ;  alito 
lliiit,  like  aa  in  certain  casos  of  adult  homlplogia,  whon  the  child 
yawns  aiid  istrctchos  ont  tlic  limliK,  the  invcroiiin  oi' the  foot  ofl«Q 
diHip{M>nr».  Tliis  obsenation  would  show,  tliat  whilst  in  the  or- 
dinary state  of  tho  infant'H  nawcnt  volition  tlic  iiddwi-tor  niiL'^-los 
(tlie  tibiales)  o\'oq>on'er  tho  abductors  (the  perouei)  and  uivcrt 
the  menilx-r,  the  net  t)f" yawning,  witJi  its  cinnplioit^Hl  ri-Hcx  itetivhy 
of  in8i>iratory  niusetes  and  of  associated  muscles  in  tho  extremities, 
neutralises  tho  peetiliar  diwtuibaneo  of  niuMjiiiur  atrl.ivity  on  vrtiidl 
talijJGS  varus  dejtends. 

It  Mcms  a«  if  in  congonibd  ehih-foot  and  anulngouit  diiiitorlionli. 
a  stimuluit  nr  irritant  were  jireaeiil  in  the  medulla  spinalis,  aeting 
upou  twrtain  gaiiglionie  eoUs  ihei-e,  which  kecj>s  tho  ut^^^e^ed  inusclo 
in  a  atato  of  tunic  contmoiion,  yet  not  suttident  to  neutralise  tlia 
BtiniuluK  of  tho  will  within  tlie  limits  of  movement  pormittod  by  ths 
gtnietund  shortening  of  tln^  nieinlier.  Many  no ti -congenital  sjioatia  \ 
eontractionii  ajtpear  allied  to  tlie  condition  which  pm'ails  in  some 
states  of  ehorea,  in  whi<rh,  when  tlio  will  would  |iermit  or  eaus«  non- 
traotion  or  ri'laxation  of  a  particular  muscle,  an  in^^olmitary  power 
of  exciting  contrimtJon  interfwcs  and  fi-u»tratea  tlio  vohintiiry  vtTort. 
In  more  intense  spasmodic  contractions  the  will  is  entirely  over- 
]io\vcitHl  beforo  rtructuiul  sliorh^iiing  supervenes  to  eft'wl  tJw  tamo 
end- 
To  resume,  then:— <'-linioa]  observation  of  n  on  •congenital  d»« 
formitios,  8])ringing  from  derangement  of  the  nervous  i«;^'st«n, 
teaches  tJiiit  then;  arc  aevural  modes  iu  wlueh  they  arc  prodacod. 
These  modes  are  as  follows :  i 

1.   Puralytio  distortions.  | 

a.  Certain  muRck-s  only  boing  partially  or  wholly  i>jindyiii^,i 
their  nntagonigta  slowly  contract  tlie  dependent  artiout 
lation.  I 

!'.  Tin:  muscles  of  the  part  in  general  being  partially  of 
wholly  paralysi>d,  tJie  vital  (H>ntractility  of  iIk?  grcJiK* 
miL*.*,  as  of  tJie  flexors  in  the  extremities,  slowly  ooit«j 
traete  the  de|»ciident  urticLdation.  I 

2.  Spastic  distortions.  I 

a.  Tho  contraction  is  suvoro  and  prompt,  the  wiU  bcinfl' 
quite  uverpowerod  or  absent  1 


I 


PATHOLOGY  OF  DEFOBMITIEa 


561 


i.  Hie  contraction  »  gr&dual,  u  in  tlie  mnjorilv  Apfnon- 
paralj-tic)  cases  of  non-congenital  talijM??s,  the  will  not 
being  neiitrnlisod  (tliUAO  reputed  from  Icctlitng,  for 
example),  but  restriotod  by  the  niari>id  innervation, 
ami  ill  t.iniA  hy  ittruvtural  »lii>rtoning. 
c  Tliv  contractjoa  is  gradual  bat  novere,  as  in  the  de- 
toniiitira  wliioh  wjiiiclitiivB  aecompaiiy  itnbvcility  in 
ciiildroii.  It  16  probable,  in  tliit>  tin-in,  tlial  llit;  con- 
traction if  intensified  by  the  oo-cxtstonoe  of  on  on- 
fecblod  condition  ol'gcwt>ral  voliLioii,  a  g«noral  inertia, 
favoiiriiii;  nriHuw  of  mi'Dibora,  and  a  greater  »ino»nt  of 
structural  change, 
Sivotnltuy  eJi/infffs.  From  whichever  of  tlio  above  causes  ft 
constaiiily  contra<!led  state  uf  an  articiihition  or  limb  may  have 
jmMxtxitHi,  the  titatc  of  thin^c:'*)  ctntsiHting  of  tho  inability  of  the 
individual  to  put  the  part,  by  tlio  action  of  tlio  nill,  Uirough  all  itfi 
jWTjpwr  nioveinoiitis,  Is  called  a  deformity.  But  if  tlio  patient  by 
means  of  liis  own  lundH,  or  if  the  8ui-gi'oii,  cnn  otercomc  the  con- 
tnctioii,  and  put  tho  affected  part  through  its  proper  movements,  no 
deformity  is  in  reality  socn  to  exist  Positive  dctifmiily  may  varly 
exi«t,  when  original  disease  of  the  joint  has,  bo^idcA  producing  con- 
traction, etid(>d  in  mon-  or  Icmm  considerable  uUcrntion  in  form  and 
structure  of  the  articubition.  But  alniont  ociually  si-ritms  (secondary) 
defonnity  inuy  tniunc  throii;ih  the  influence  of  tho  now  ill-regnlat4>d 
raosclcs  of  t)ie  Joint,  oHpei^inliy  whim  tlie^  act  njioii  tissuon  im- 
paired by  iliseaxr, — llie  production  of  sub-luxation,  for  oxaniplo. 
In  the  lower  cxti-emity.  tin-  efiVwln  of  tho  weight  of  tim  ImkIv  being 
bonte  iii«oii  tilt'  member  in  improper  directions  is  a  vcr>'  important 
causio  of  socomlary  deformity,  lulding  gnailly  to  the  obstacles  to 
rmtonilion.  'I'litw  u  ncit  JW%cro  caso  of  coiigciiit»I  club-foot,  re- 
ntniiablo  in  point  of  form  in  a  fi>w  wcukit  Ix^fore  walking  has 
commcnatl,  may  »iibwi|ucntly  rv<|uiro  treatment  of  months  or  of 
years ;  or,  from  the  deteriorating  cause  abfiw  niftiitioned,  be  ron- 
dvn<d  irrcmudiuble. 

We  may  no^v  pass  to  the  consideration  of  the  means  employed 
in  Orihopji'ilic  Snr<pTy  for  tho  rectification  of  dcformttiw.  This 
de|iarlmvnt  of  practice  avails  itself  of  much  lluil  is  common  ivilh 
goncrai  Slcdieine  and  >Surgery.*  Special  orthopiotlic  means  are, 
tbo  relioi'ing  uf  the  sbort4<ntKl  jmrts  hy  tJie  employment  of  mecliani- 


•  Conirtiluliona].  mtdidnal,  and  Jiutctic  licaunvnt,  «x«i^scs.  8}*iiuta8- 
lies,  lDniiclJ<iii».  to. 

VOL.  III.  0  0 


562 


ORTHOPEDIC  SUnOERY. 


(Mil  inntrnmont-s,  «r  mcclianical  power  i^xi'rtwl  hy  tl»o  luuid*  of  tlie 
Kurgi-oii  or  asBiMjinU,  itonictimeB  wiiii  tlie  aid  of  the  benumbing  ^ 
influPDci,-  of  oliloroform,  and  hy  diviitioi]  of  one  or  more  of  Uic  voii>i 
truoted  rauticlea,  loiidottii,  and  fasHH'. 

Tenotomy,  tni/otomy.  In  lliis  opcrutjoti  the  noccs*«rj'  n.-laxntioa| 
of  muM-ulftr  roHintaiKM}  and  of  aoconipnnying  xtructural  tihonening^ 
Is  pffei-lcd  bv  severing  the  musclo  at  it»  tmidinous  jiortioii.  Tl»« 
priiifiiih'S  laid  iluwii  by  l)i'l[>i-fii  fur  iho  [Ktrfiirmanoo  of  thi.i  ojiera-  i 
tion  are  followed  in  tli<'  [ k  -<  nt  day.  It  jfl  reinnrkablo  that  l>cl-^| 
[Mjch  nover  oiim'i-tl  out  iiis  nmi  ()rini-i|)lfls.*  Tlw  disi-overy  and  ^1 
applicAtioti  of  KiibcutajieoUB  tenotomy  hcloiigs  to  Stromeyer.  Many 
oltorutione  in  the  modv  of  npplying  ihcHO  ]>rineiplon  have  beoitj 
mad«  Binoe  tlie  original  labours  of  Delpeeb  and  Sn-omoyer.  Various.) 
knives  for  wveriiifj  tetiilons  (U-notoimw),  ami  ii  great  variety  of  tnei^i 
chanical  osteiision  apparatus,  have  been  devised.  In  this  place  onl^j 
the  means  in  most  goncral  use  in  this  eoniiti'v  will  be  dewribcd. 

In  describing  tlie  sevei-al  <liatortioiifl  in  the  treatment  of  which  , 
tenotomy  anil  meehanical  treatment  may  singly  or  ennjoinlly  bo^| 
requisite,  no  nosological  order  will  be  adopted.  We  will  commence  ^^ 
with  eiingrnitaldub-fbot  (talipes  %-am»  congenitus),  because  it  JsoiM) 
of  i)iemo»t  common  diHtnrtJons  whieh  the  Surgeon  Iiaa  lo  treat,  und| 
because  it  has  formed  the  basis  of  ex  ten  si  vo  pnthologieal  and  thtim-j 
pontioal  i-eweiireh.  The  eon»ideration  of  the  )tcienlili«  treuunenl  uf] 
club-foot  will,  therefore,  best  illustrate  the  principles  upon  which] 
tlio  moiiagnnient  of  uH  olhnr  distoHionpi  nlionld  be  condui-ted. 

No  otlier  deformity  exhibits  in  a  greater  degree  the  incidents 
orthopieilie  «sjM.'rii.'iiea. 


Conffmital  Club-foot  (^Talipes  varus  ccmgfnituii). 

It  is  niHlctiintblo  to  attempt  here  even  a  sketch  of  the  liisttny' 
of  the  acquaintance  of  our  profegaion  with  elub-fooL     It  will  suttioe 
to  niintioii  that  the  sidyect  engaged  the  attention  \yi  Hippocrates 
amongst  the  ancient*,  and  of  Scarpa  amongst  tJie  modeni.t.     Hut  it] 
was  not  until  tin-  genius  and  energy  of  StromeviT  were  conibinct 
with  a  sound  ac<|Uiiintance  with   the   prinelples  and   practiot)  of 
miHlern  Surgery,  that  the  complete  treatment  of  severe  club-fuotJ 
became  jtoariihic. 

Anatomy  of  chA-foot.    Former  opinions  on  the  aiiiitvmy  of  club- 


•  See  tlio  hisluiy  of  divisiuii  of  lendoos.  In  »  TrtMite  on  Club'/ool 
anahgaut  DiiCartiont,  by  tltu  AutJiur,  LoudoDi  1039. 


CONGENTTAL  CLUB-FOOT. 


tstud 


foot  mny  be  aJvatUagixm«!y  passe<l  over,"     In  1837,  nnd  8ubw- 

quently,  thc^i  autlior  Inid  down  the  otsetitial  cbaraiHers  oftbo  anatomy 

of  duh-lin)t. f    Till!  Kiibjwil,  iiiLs  f'lntM  Ihjuh  ciirufuliy  and  «ucuc«sJuUy 

iidied  by  Mr,  William  AdaniA.!     The  general  rcmilt  of  oli«ierv<t- 

'  tionii  of  lliis  iiiKflor  \%  tlw  ci>ntimi»tii>ii  uf  tlio  opinions  omittt^^l  by 

iIk)  author  in  l^Ii?  and  l».'Ji),5  that  club-foot  coiiHintit  of  a  lliroe- 

Ijnld  iiltonttion  of  liic  form  and  ponition  of  tlio  fnot,  the  lieol  being 

ttt«j,  the  toes  turned  in.  and  the  internal  margin  of  llie  foot 

from  the  fjroutid,  owinf{  Ui  ubiionrial  action  and  shortening  of 

principal,  if  not  of  at!  ihe  rauscIeH  of  die  inner  and  liiii-k  pcirt 

lof  tlic  log.     Prrhup^t,  also,  ta  at  loiut  the  iMivon-r  forms,  tbo!M>  in 

Ivhioh  the  sole  is  much  contracted,  the  plantar  miiHcle^  participate 

the  primur\'  afl'rction.     The  ligitminit^,  fiMcia?,  and  int^gutaonta 

'on  tJie  contracted  side  of  tbe  member  are  alao  ^lorlcned,  wktUt  the 

Rtmilar  timuos  on  tho  oppostto  Hido  arc  olongstiHl  and  woakcni^l 

These  passive  tissues  follow  llio  fortunes  of  the  active  organ* — tlia 

^■AuitcltiK,  on  which  they  arc  in  tho  main  dojicndout,  and  become 

^BBhu  aecondai'ily  allccU^L     Tlio  bones,  before  and  allur  os^ilicjition, 

^nnSer  in  proportion  to  tbu  intensity  of  tlio  museuUr  conti'uction, 

B^hm)  probably  in  projiortion  to  the  earliness  of  tJto  periiKl  of  uterine 

oxistvncc  at  which  the  distortion  cummcncod;  and  especially  in 

proportion  to  tbe  period  that  «I»|ino.<  utler  birth,  during  wbicli  tho 

pamvo  osseous  structures  remain  at  tlio  mercy  of  the  active  mus- 

enlor  agents.    The  boutK*  further  mffer  an  age  lulvunccs,  by  bearing 

the  weight  of  the  body  in  an  improper  direction. 

The  departure  from  the  nonniU  form  and  relation  of  bones  may 
be  diridcd  into — 

^l.   Primjiry. 
a,  Tho  cliangCB  specially  affecting  tlio  tibio-tarsal  joint. 
b.  Tito  change  of  n-lation  of  the  anterior  bones  of  llie  tar- 
BUS,  as  reganU  tbe  aatragaliis  ami  os  caleis. 
8.  Sooomiarj',  or  tln>«!  induced  after  birth,  by  Hpiinlaneous 
I  aggravation  of  the  deformity,  and  by  pressure  ui)o»  tho 

parts  through  walking  in  tin  improiwr  manner. 
Ute  anatomical  changes  of  bon«i  in  varus  of  practical  nionivnt 

*  S«e  Ok  th*  PisformUia  i-fiht  Human  FfotM,  by  W.  J.  LUMc,  Loud.  1053, 
pp.  STl  et  R«(|. 

f  Outaruitin  ituiuiruridU  dt  TaiipftU  Vitro,  IIorliD,  l^t?. 

\  Malieal  Tima  and  GiiseUf.  \Mi;  Tr,tn4arluin4  <lf  Pttk.  Soc,  IdOS. 

j  Trtalue  on  Clut^/oot  and  aaiiloguus  Dulorlwiu,  Loud.  1!4UU.  A  iarffi 
number  or  tifuiisi^i  oa  dub-fout  huvu  appeared  aiiiue  lt*3T,  (eve  of  wbioix 
eoatuiu  uuy  Aiuduueutttl  i-cioai'chua  ioto  tlic  tuiatutny  of  rams. 


M4 


ORTHOPEDIC  SURGERY. 


1 


an  duo  to  tlte  ataUt  of  cxtvtiMon  of  the  m  cali^iis  Ijihingiritb  it  ttifi 
sstngitlii^,  iliroiigh  whii-Ii  tlm  jiostt-rior  extremity  of  the  o»  cailcia 
IH  more  or  leas  closely  approxituntcd  to  the  posterior  xiufaoe  of  tho 


FM.L 


_..     I  atalt  attnOal  Vmt.  ttond  from  thr  frntil  and  Inilila^— a.  Ihrr  DM*,  f nl  dinra  In  «l4t 

Ifl  ■huv  thfl  rpuiivelj-  [ku«lflhor  ttlitHtW^rt  ntxha  flliiila:  h  Iho  rX'rn"!  ]ij»I1i'4>:ili;  f.  ihn  flt^rlA^  ^ 
Ih<p<ltl«rl«r«i1r']nliv  nf  Ehi>  burjiklh  iSnan  ■Irnoruinllf  liifhrilpL  c,  Mjir  fcrirKH*^'^*^  "nA'tl*  ynfUl- 
>aM«Ilht  dofBlhJO  4^f'lUi-  tfn-t\  /,  Ih^  it4T]riiUr  laonn  iii  cuaiACl  wltL  lbs  li>i»rifj  niUtrlilf-  |L^ 
Cilb^4,  Its  i>r^i»r  auixituj  turlncv  4]'p1led  to  thi«  gruunil.  ^^^^^^m 

ankle-joint;  mid  i\w  nnivnor  portiotiR  of  tlioartWIiitinp  Mirfaec^^^ 
tlie  trochlea  of  tlie  astragalus  aro  projcctt-d  from  the  ankle-joint  in 
front.  Owing  nljto  to  the  forced  inva'sjon  of  the  tnlirw  foot,  tlie 
externa]  malleolua  is  tlirown  hackwards  towards  tho  poslerior  inber- 
osity  of  tlie  OS  calci*.,  and  tho  aiitcriiff  exlremity  of  tiio  ai^tra^oliu 
slightly  inclines  towards  the  inner  margin  of  tho  foot.  The  forced 
elevation  of  tlic  posterior  jiiirt  of  the  foot  (caloaiu^imi  and  tiiitragahis) 
is  common  to  talipes  varus  and  to  talipes  equinus;  but  Uic  character- 
istic pceuliftrity  uf  varus  is  the  displacnnent  of  tlie  remuiiiin^  bones 
of  the  tnr.iuH  inwardly  to  the  cxleni  tliat  tlie  navicidar  Itonc  quits 
the  antrfigaluii,  ofiin  toufhhig  the  iiilernal  mHllcolus.  with  which  it 
fi-eqneiiily  awjulres  il  new  articulating  surface.  The  cnneifc»-in  and 
Pulioid  boncJ!  acwjiiipany  the  iiavifnla.  Morcovi-r,  in  severe  coses 
the  euneifuini,  cnbuid,  and  nic-tatArMils,  with  tlio  phahuigos,  are 
di-uwii  biiekwards,  limiting  tho  space  of  the  pluntRr  region. 

Tho  changes  of  bones  induced  by  improper  walking,  impr 
prea6uri>  .-uid  iK-aring  against  tho  ground,  by  whieb  aW  wmicttiM 
in  I!  animation  and  tdceration  of  sotl  porta  are  occasioned,  do  not 
propei'lj'  belong  to  simple  uucompUcated  club-fvoU      Oidy  whu 


«,  aw 
ctinH^B 


WGENTTAIi  CLUBFOOT, 


563 


■ 
t 

I 


injurieji  are  coiisiflerable  Jo  thoy  aftoct  the  refialta  of  Innt- 
sent. 

Th«  ftltnrtening  nf  Lh«  ligjunentf),  faMifc,  and  int«gumeiibi  on 
the  posterior  and  internal  aspocto  of  tlio  mcmbi-r  mtty  bo  obscrrcd 
irkt<«,  bt'forv  or  tiAor  ojx-rutJoii,  attempts  are  tnnd»  with  thn  baii<I 
to  rectify  ilie  deformity.  In  bcvcfg  cksch,  mucli  rcsistajioe  to  cure 
U  oflcrtxl  by  ibt;  ]>(>»turior  ligament  of  the  ankle,  the  doltoid,  tlio 
oalcaneo-Bcaphoid,  the  miperBciaJ  luid  d(N>p  plantar  ligaments.  The 
thsre  of  rmistancc  otforud  by  the  deltoid,  for  oxuniple,  is  well 
^own  when  disaectjng  severe  infantile  varus.  After  removal  of 
Ihw  Kuporfitiiiil  U'xlures  {intcgnineiiU,  fasfiiae,  musolos,  and  leiidonx), 
ititK'h  amelioration  of  stuipe  regulis  ;  but  the  ligaments  of  tJio  ankle 
bciug  intac-t,  it  i»  obiwrvuil  tliut  ilie  fnot  tttill  relain.i  u  variiK  form. 
But  when  the  deltoid  li^mcnt  ia  severed,  and  tJio  navicular  bone 
is  liberated,  a  miirkt-d  fiw^ility  of  rAplaoemeiit  1*  evincwL 

Tlie  general  direction  of  the  structures  involved  in  tlw  distor- 
tion i»  much  altered.  Thus,  iho  litg-bimw  ar«  iiiwar<liy  rotated 
from  the  knee-joint.  'Hie  Surgeon  sliould  not  expect  to  find  the 
t«ndons  occupying  tlicir  normnl  relations.  Those  passinj;  over  the 
front  of  tbo  niikl«-j<iint  are  deflected  inwardly,  whilst  the  posterior 
tilnal  tendon  appears  more  deeply  situatvd,  owing  to  tbo  incurva- 
tion, the  backwiu-d  dragging,  and  elevation  of  the  ant«rior  part  of 
tlie  foot. 

/itioloffj/  of  tvn{!*tiit^l  rlit!f/i)ot.  Tlie  primary  cause  of  talipes 
varus  oongcnitus  has  boon  aln>ady  touched  upon,  p.  659.  It 
oonsista  in  an  alteration  of  the  dynamic  properties  of  certain 
nnudea,  apt  to  bo  accompaiiiod  or  followed  by  structural  nliortvn- 
ing,"  and  by  fibnms  and  adijKi.*o  depiiicration  of  them.f  Until 
the  researches  of  Uudolphi,  it  was  hold  that  club-foot,  u  wdl  as 
other  tltHtortionii  and  in  nl  Ion  nations,  were  the  eonseqaence  of  sotne 
"  oooult  influences,"  lusua  nature,  maternal  imagination,  and 
intia-uU^inu  prowure.  An  noeiwional  effort  i*  niado  to  revive  tha 
last  of  those  theories,  that  of  intra-ntorine  pressure.  It  has  boon 
ckewkoro  sliowiij  tlmt  accidentiil  mcchanicid  i'aui»ea  do  sometimes 
set  npon  the  toetus,  giving  rise  to  easily  recognisable  conditions, 
[fc^.  iUsuras,  clotla,  iutra-utvrinc  fractiirc-s,  amputations  of  member) 
from  constriction  by  abnormal  bands  or  by  the  nmbilical  oonii 
and  sometimes  the  cooperation  of  ]in.'ssuro  by  Uio  uterine  walls 

pelvic  bon«!t  may  be  surmised. 

«  Iiul«.  too.  eil, 

f  Cruv^illner.  Annl.  Pathol. ;  W,  AJntns.  Patkol.  TntHt.  lot  ciL 

;  On  Dt/vrmitU*  t,/ the  Human  Frime,  pp.  2aS-314. 


566 


ORTHOPEDIC  SURGERY. 


ich 


TTio  arpiimcnts  in  favoar  oftlic  ixtlicf  that  ordinary  confronita 
cliib-fiiot  ix  causiil  !>y  ftnme  derangomeiit  of  the  oerobro-spiiial  wn-' 
tro8  and  dt-fwiniciit  iiorvc*,  as  oppowxl  to  tho  thourv  of  ild  lirpoiMl- 
eiiw  wjMJn  [in'flsm-e  of  tlie  walU  of  the  utems,  may  be  thus  Htatcd : 

Cliih-foot  ofk'ii  cot-xiBts  with  ovidont  derail K>'n]c lit  nf  ihv.  niTrvoua 
centres,  aa  in  awpIialotLi,  liemieephalous,  and  Hpiiia  bifida  subjects. 

Chib-foot  occ'a*ioiinlly  cocxistB  with  an  analogous  difitiirticui  ni 
the  iip)H'r  ■.•Atrcinity,  cliib-haiid,  in  whidi  Uio  iiiu8clt-H  contract 
aro  tho  anatomical  analogues  of  the  parts  contracted  in  the  lowt 
limbii.     Now,  if  it.  Im;  ndiiiitt-ed  that  thf  (•xlcrniil  cftnfi juration 
doable  club-foot  may  suggest  to  tlie  unpliysiological  and  unputho 
logica]  obswn-«r  tW  idea  «f  one  of  the  foot  having  overlapped  thq 
other  in  such  manner  that  tlie  uterus,  g»ppoiniiij  the  li<]Uor  nmtiii 
to  bo  deficient,  haif  wimprpsscd  the  two  fi.!i;t  into  tbn  ioriii  in  wliich^ 
wa  BGo  tliem,  thia  explanation  does  not  apply  to  the  club-iiandflj| 
which  iM'jir  no  niich  fi>rni  iw  can  Ik-  rcjw middy  altribntt-d  Ii*  )irt>ii- 
flmw  of  the  uterine  walls.     Moreover  club-foot  often  exists  in 
foot  only,  and  the  ntcrinc-prcwuro  tlicory  d»w»  not  explain  wh; 
one  foot  eseapea.     This  theory  is  still  less  applicable  lo  tho  ttighesf 
^adc  of  club-foot,  in  which  tho  gn^at  toe  is  more  a]>)>riixiniati.-d 
to  tlio  inside  of  tlie  leg  than  pressure  of  tlie  uterus  will  cxpIain^H 
whilst  the  opinion  ofundiic  (tipastic)  action  oftlic  miwck'-*  bcforft 
tJie  articulating  ends  of  bones  can  restriot  their  action,  atlbrds  an 
tntvlligiblo  explanation.  ^^ 

Club-foot  is  met  with  in  foetuses  Iwfhre   the   fourth   or   fifth^ 
montli  of  gestation,  at  which  period  tho  liijuor  aniuii  is  relatively 
80  larg«  n»  to  cxoludc  tlie  idoa  of  ut«riiio  pressure  eunsctjuent  u[ 
mpposeil  deficiency  of  tliat  fluid. 

Congenital  cluh-foot  van  often  be  traced  to  hereditary  iiiflnvr 
aomeiimes  on  the  father's  side,  sometimea   on   the  tnother's  aiii 
Wo  have  traecd  it  on  the  paternal  side  oven  tlirongh  four  gmora-' 
tioDH,  tho  mate  infant,  the  fsitlier,  tlio  grandfather,  and  the  great 
grandfather.     If  it  can  bo  plausibly   maintained  that  club-foot 
due  to  the  influence  of  uterine  pressure,  dolicioncy  of  liquor  aninii 
pressure   uf  jwlvic   bones,   and   its   rcjwtitiou   tlirougb   Hucccuiva] 
generations,  this  influencfi  nould  only  l>e  projiagated  through 
female  side     Wo   cannot  admit   utcriuo  influence   in   hcrcdit 
propagation  of  varus  ttntiugh  an  unintcrru]>t(-d  succession  ofi 
puvntt. 

A  comparison  of  club-foot  with   the  distortions   which  occnr' 
att<tT  birth,  unmistakably   from  diseases  of  the   nervous   n'stcm, 
tends  to  prove  that  congenital  aiid  non-congenital  dub-foot  Bi>nng 


ivcly 
upoifl 

uiieefl 
sidJ| 


d 


OONGENITAL  CLUB-FOOT. 


567 


from  niiiilosoHs  causes,  Pisiortiou  after  birtli,  from  altered  inoer- 
vatioii  ot"  iiitL^oli^  w  more  cuminon  in  tJi«  lower  oxtromiUi*,  ami 
opceixlK-  in  iJio  ft«t,  tlian  in  anv  other  part  of  the  frame.  Club- 
Jbot  ia  alua  t\w  ninKt  ctiinruon  tlLstortivn  hufurv  birtfu  Alter  birth, 
lulijwi  varus,  in  consequenoe  of  cerebro -spinal  afleotioii,  is  moi-e 
comraon  iJiuii  Uili)>i.-H  val^o;  bcfwrw  birth,  varus  if  uiorc  rammun 
tiian  valgup.  After  birtbj  fiwi-Jefdrmity,  from  (lidoaso  uf  tho  uervoua 
tPTStein,  allitinx  ol'u-iior  u  higher  grade  on  tlie  Ititl  thau  the  ri^ht  side. 
This  is  equally  the  case  witli  congenital  club-foot.  Some  oUier  iigerie^' 
tlian  ac<'uf<rtital  uti^rinc  or  pelvic  prc&suro  is  required  tu  account  for 
thct*}  analogies ;  thev  o-annol  be  regnrdeil  as  more  coincidences. 

Ora<ie»  of  mntf^nital  talipM  varus.  It  I*  convenient  for  (>rac- 
purposes  to  flivide  congciiilal  t-hib-fuot  into  tliree  (iqjrtwft  of 

erilA-:  the  slight^-«t,  that  in  nbich  the  ]M>eitiou  of  the  frout  of 
tJie  foot  when  inverted  ia  auch  that  the  angle  fonned  by  it  with 
tlio  iiinidc  <if  the  leg  i»  greater  tluin  a  right  angle,  and  in  which 
the  contraction  is  so  uimlcnite  tliat  thu  l«H.-»  can  easily  he  bronghf 
tcinpomrilv-  by  the  hand  of  the  Surgeon  into  a  straight  line  witli 
ti^H^St  Wd  the  hii'l  be  tl<t{irew<cd  to  llie  natural  [xMiliiin.  The 
nWrna  etan  includes  those  in  which  the  inversion  of  tlie  foot  and 
eleration  of  tlio  hcvl  a|)[>enr  the  sinttc  or  little  greater  tlian  in  lii»»o 
of  dio  first  clasH,  hut  in  which  no  reasonable  effort  of  tlie  Surgeon's 
huMls  will  triTi|>ciniriIy  extinguish  the  eontruetiun  and  delbnuity. 
The  tliird  class  comprises  tliose  in  which  tlie  contraction  of  soft 
parts  luid  displaw-iticut  of  hard  part*  roaches  the  highest  <legrc«,  ao 
tliat  the  inner  margin  of  the  foot  in  ailuated  at  an  acute  angle  with 
tlw  in^de  of  the  leg,  souietimes  is  evon  ahnost  in  oonluct  with  lb 

C-ases  of  the  first  and  socoml  grades  may  lie  respectively  con- 
verted into  the  "cennd  and  third  grades  by  delay  in  llie  applioalion 
of  remedies,  and  by  the  effects  of  improper  locomotion. 

Trexitment.  T)ie  indications  are  to  overcome  the  shortening  of 
the  muscles,  ligamenU,  fasei.-e,  mid  in  tegument',  on  the  contracted 
side  of  the  member ;  to  diroct  tlio  boneA  into  their  proper  position  ; 
to  ^vc  strength  to  the  muscles  and  ligaments  on  tJie  elongated  side 
of  the  incmbi-r,  and  to  combat  tlio  tendency  to  rol.-ipwc, 

A  few  slight,  cases  may  fiiim  tlie  day  of  birth  almost  bo  ro- 
linqui^heil  to  the  rubhingH  and  manipulntionit  of  the  lunvc;  Koiiie 
requin!  to  Ite  lightly  liiuidiigiHl  on  a  strip  of  tin  or  firmer  mela)^ 
bent  to  a  right  angle,  and  properly  padded ;  otiicrs  require  xupport 
not  only  beuenth  liic  fole,  and  against  llie  back  oiUte  leg,  as  when 
a  simple  bent  strip  of  metal  is  enii>loj-ed,  but  need  lateral  supftort 
or  pivssui'u  against  the  iiit«'mal  margin  of  tiic  foot,  u  by  the  ap- 


568 


OBTHOP^rHC  SUaOERY. 


plication  of  a  tin  splint  dei-isod  many  years  ago  by  the  atithor  ■ 
(»oo  Trtvtu'e  <m  DrjormitUn,  (t^.  113).  In  lliw  xae  of"  tliii*  and 
»i]~iiilar  contrivances  to  be  foond  at  the  different  surgical  iiutm- ' 
niont-inakori<f  tlio  nwontial  [Kiint  puiwixts  in  a)>|'l}*injj  tin-  ."mulinflt 
amonnt  of  prettsura  oompatible  wiib  maintaining  (lie  ajiparaius  on 
the  limb,  nut  »ndottvonriiig  at  otic-i-  villivr  to  furco  the  port  »tniiglit, 
or  even  to  make  the  tender  inliuitile  toot  accrwately  Kt  the  appa- 
ratus, but  raliicr,  if  the  npponitiu  svluctol  admits  of  aduptatiou,  to 
ndjtij't  it  to  tlte foot  in  a  ftomewluit  improved  poitilion.  I'liurtitjonera 
ODaoquaiiitod  with  the  tk-tallK  uf  ntans'^'tDunt  of  tlic»o  cat^  arc 
surprised  to  discover  how  unall  an  amount  of  prcioura  nufKces  in 
youn^  infanta  rapidly  to  improro  tlio  form  and  flexibility.  Tho 
splint  should  daily  once,  or  oOonor,  bt^  removtid  tu  aHci-rlain  tliat 
undue  preasure  has  not  been  used,  to  replace  it  when  loosened  "by 
the  movementa  of  the  child,  and  to  improve  tho  (losition  aa  often 
aa  practicable.  No  tmiieccsaary  loss  of  time  sboiild  be  pcrmittod 
duriij^  llii^  proccHH,  as  at  tirit  the  foot  rapidly  rclH|v<M  to  it»  moat 
distorted  condition. 

If  Hi  tlii»  oxplnition  of  tlio  fourth  viveV.  dintinot  contraction  oftlie 
tendons  remain  perceptible  in  spite  of  aasiduoua  edbn^  to  overooma 
the  dcforniity  by  muiiipiilntioiM,  frictionx,  and  steady  but  gentle 
employment  of  splint  and  bandage,  or  if  benefit  projiortionalo  to 
tlic  ntlention  btwtowwl  lie  not  n-alinwl,  or  if  the  cawi  micijui vocally 
belongs,  to  the  second  or  tliird  degrees  of  varnn,  tlie  aid  of  tcno< 
tomy  will  be  rc<]iiirc(I  t«  effect  rc»torntion.  If  tho  Sargcon  sbouM  ' 
entei'tuin  ikmbt  whether  tho  time  for  operation  ha;ii  arrived,  lio 
may  be  dclcrniin«<l  by  tlio  <ib»crvation  wlicther,  on  holding  the  foot 
in  the  normal  position,  it  springs  vigorously  buck  into  the  iibnormal 
one  as  soon  as  tin-  prmwurc  of  the  hands  is  removed.  In  unequivocal 
case»  of  the  second  and  thini  degrees  he  may,  in  most  ciwcs,  ilcci<lo 
affirmatively  at  the  moment  of  birth  on  the  absolute  necessity  ofl 
liitiiro  ujieration.  In  this  decision  he  must  not  he  guided  soldy  by 
tlio  external  eonfiguratioii,  biit  by  tlie  amount  of  firm  restsfanco 
opposed  In  restoration,  by  llie  depth  of  tlie  furrows  existing  in  the 
sole  and  lieliind  and  above  the  heel,  and  by  the  degi'ce  of  tension  of 
t.lie  inU'j:;ianei)tH  iilxiiit  the  internal  miiili.^>hiK.  The  deep  elcfta  or 
furrows  in  question  denote  intensity  of  contraction  of  muscles,  and 
claser  adhesion  tlmii  usual  of  integtmients  and  liixcia;  to  the  subja- 
cent soft  strttcturus  and  bones.  They  jtrobably  denote  also  that  the 
deformity  datea  from  an  eai-ly  ptTiod  of  uterine  existence.  Even 
atrophy,  tho  usual  concomitant  of  contractioua  of  long  duration,  is 
already  present  in  severe  club-fuut  of  uvw-horu  ubildniu,  and  is  a 


CONGENITAI<  CLFB-POOT.  569 

saro  of  the  Icnglli  of  time  the  muscW  hnvo  boon  contracicd  and 

rnmil  to  HUriictural  Hhortiiiinfr  niiil  [xifi'ibic  ili>gi>i)er»tion. 

iVd/tiMv  of  the  operation.  Tlio  esM>ntial  tliHi'actcr  of  cy>ngmiUJ 
talipoK  vnni*  being  n  ttt«t«  of  nbnormal  cU'vntinn  of  tlio  h«cl,  »xtA  in- 
veraion  of  tho  front  part  of  the  foot  \>y  undue  muscular  contraction, 
ti»o  operntivr  iiili'rftjivnci'  rt'i|iiin'il<i<mKi.-<(H  of  tlii' lUvLsicn  of  tlu^  ten- 
dons ofUiose  muftelos  which  are  mainly,  if  not  exclusively,  conoeraed 
in  the  [n^tiiK-tion  «f  tlic  deformity,  viz.  tJic  U^tnlo  Ac-hilliit  and  llio 
tendons  of  tho  anterior  and  |jo&terior  tibials.  In  average  casoA  ilioae 
thrc«  tvndoiu  inny  \»  divided  at  oiiv  operation.  In  M-ivror  ciiaea 
t]ie  opei-ation  may  he  advantageously  divided  into  two  parts,  tlie 
firtft  consistinR  of  thi'  swrtion  of  ihiw  I'lniiHiircx  whivh  (imtrihulc 
to  the  in*'ei'»ion — 'tlie  tihialea  tendons;  an<l  whore  the  sole  is  much 
contnictr<l  with  a  Htron^  prominent  hand  felt,  iit  tho  inner  wige  of 
the  phuitar  fasoia.  that  band  may  be  ineluded  in  this  portion  of 
the  operation.  The  lenHo  Achillis  may,  in  »ueh  cum:*,  U-  Mrvernl 
ID  three  or  four  weeks ;  in  adults,  two  or  four  montiia  later ;  the 
iDT«csioii  having,  in  tho  interval,  boon  overcome.  Tho  vahic  of 
thbi  procewliiif^,  tirst  reeiMiiraended  by  the  author,"  coniusta  in  tho 
08  cakns,  when  tho  tendo  Aehillis  is  leH  intaet,  offering  a  point 
d'nppui,  or  retiiitting  [>oint,  from  which  llie  Burfreoii,  during;  the 
meeluinical  atlcr- treatment,  is  cnahte<l  to  etreteh  out  and  unfold  the 
oontranttul  involuted  mi\i:.  If  thii*  divieiiou  of  the  ojH-i'ution  into  I  wo 
arts  is  not  obscn'ed  in  bad  cases,  incomplete  recovery  may  result, 
tho  aolo  reuiuiii  n>ntmeml,  and  the  individuid  wnlk  unilidy  on  tlie 
beel,  range  of  motion  of  tho  iwint  of  the  foot  being  deficient, — in 
ihort,  ■  iieoomlary  tnlipi*  cnleancus  be  pnxlucod.  Thin  wecoiidary 
deformity  is  always  overoomo  with  difficulty ;  sometimes  it  is  ir- 
removalilo. 

The  foUovring  is  the  mode  of  dividing  these  tendons,  and  the 
IttXlnimcntM  whieh  we  have  inlrtitluoitd  a-*  the  moit  appropriate  for 
the  purjjose,  Tho  operation  is  more  quickly  and  more  conveniently 
lone  by  falling  tho  tbreo  tendonii  in  tlie  f<dlowing  order,  vt:c.  tliepos* 
lerior  tibial,  the  anterior  tibial,  and  the  tendo  AchilliH.  Section  of 
tho  (wwlorior  tibial  in  Ixft  [K'rtonneil  by  pWIii};  the  child  on  a  table 
[if  oonvcnient  tieight,  on  its  back,  inclined  towards  the  limb  to  be 
>pcrated  on.  Tliin  >ilioidd  Iw  ihomughiy  rotattvl  oiiiwanlly,  renting 
ipoii  its  outer  side,  ivhiUt  a  competent  ntu-so  Itolds  the  child's  bands 
md  IIm  opposite  teg  out  of  tho  way  of  tho  Surgeon.  An  luwixlanl, 
laving  a  few  small  domils  of  lint,  a  bandage,  and  the  nooessaiy 

*  LmM.  M>r  2&,  1639. 


k 


570 


OBTHOP^DIC  SURGEUY. 


knivoa  wttllin  rMcIi,  Uikc»  Ins  {iliut)  by  Lh(<Md«  of  the  pationi 
holds  the  thigh  and  knee  of  the  limb  to  bo  operated  on  wit! 
imnrl,  beinp;  j>n!|iuiv<d  with  tho  othi-r  to  hold  Kniilj-  or  »tMiiint  tlia 
foot,  as  may  be  required.   The  oiwrator,  wlien  about  to  sever  the  l 
poslori(»r  tibia),  srnts  liimscif  in  front,  tiikft*  tlie  Cool  in  hiit  lull  hiin 
and  endeavours  to  feel  tlie  slight  proiniiioiico  of  the  posterior  tibi 
tondon  with  tho  Icfl  thiintb ;  during  tin?  time  h<!  cilliw  iilMlnrfit  i 
foot  witli  the  riglit  to  |mt  tlie  u-ndon  on  Uie  strcteh,  or  takes 
vanta^,  during  tlut  iipoiitniii.v>u!t  inovf^invnli!)  of  tho  infant,  tu  oIku:: 
where  Ihe  tendon  is  iJii-owii  into  palpable  relief. 

Wlk-n,  iiowovcr,  the  Surgeon  cnnnot  foul  the  tendon,  it  is  pnw* 
ticaUy  quite  safficient  to  nntke  out  the  inner  edge  of  tlie  tibia,  about 
»  finpiT**  brwidlh  above  the  lower  «nd  of  tho  inner  nialiiiilua ;  or 
ehould  then-  be  any  ditlioulty  in  defining  this  ridge  of  boue  in  oon-^ 
sequence  uf  tho  fatness  of  tlio  limb,  tlie  careful  insertion  of  tlic  kni 
txucttt/  mifljcay  hetwirn  ihr  antrmar  and  jHtM^riw  Imrdtrrt  of  fhf  U 
on  it*  inner  aspi-ct,  will  he  a  true  guide  to  tlio  position  of  tho  t«i 
don,  not  forgetting,  a»  anatomy  ttraeluM  n.*,  that  an  incision  made 
little  in  front  of  this  line  might  wound  the  internal  saphena  vein 
and  nerve ;  and  if  niuile  bvhintl  it,  would  run  lbt>  rink  ofdividi 
tlie  flexor  communis  digitorum  instead  of  the  tibialis  ]X)sttcus  i 
the  knife  ni)j;lit  i-ven  jiass  pusti-rior  tii  tbi>  fnnni-r  ti-ndon,  and, 
eaJTied  deep  ciiongh,  might  wound  the  artery  and  nerve  withoi 
touching  any  1«Miduu  what^-i-ur. 

Having  thus  detennined  the  exact  sitnation  of  the  posterii 
tibial  by  "iii!  or  all  uftlie^e  metbodH,  a  Hhar(>-pointe<l  knife  is 
through  the  skin  at  about  a  fijiger's  breadth  above  tJio  inner  m; 
lo()ln»,  aeijiirdinjj  to  the  ajjo  of  the  ehild.      It  mnift  bo  made 
penetrate  steadily  down,  jirrpntdirularli/  fo  ihn  mrfmv,  to  a  depi 
varj'ing  from  a  (jnurkT  to  half  of  an  inch.     In  doing  this,  it  is 
necessary  U>  be  quite  sure  of  suflioieiitly  opening  the  fascia  covering 
the  ]>ostvrijil  tibial  and  common  Dcsor  tondons;  othorwiso,  when  th« 
probe-pointed  knife  is  passed  in  (us  will  be  descrilMxl  in  tlto  ni 
»tu;^!oftJie  0|ierHtion),  it  may  cither  hitch  against  this  dense  u 
yielding  struetui'e,  or  glldo  over  ilt  surfatre  behind  tlie  <li-i'p  liiyiT 
inu-se1t!s,  innlj;a<l  of  passing  tlirough  tho  openin|;  in  front  of  them. 

In  oivier,  therefore,  to  aeoomjilish  \i\ajrrt  JicixUm  of  tliia  fn 
of  tlie  leg  close  to  its  insertion    into  the  edge  of  tho  tibia, 
likewise  the  projier  sheath  of  tho  piwt^^'rkir  tibial  tendon  tn>ni-ai 
the  sharp -pointed  knife  should  bo  passed  to  the  depth  above 
CfHiiiiietided ;  the  handle  must  ihi-n  In;  tilevated  so  as  (o  d«|i 
the  point  of  tliu  blade ;   that  ia  to  say,  tho  ui«trumvnl  should  bo 


i 


TEI 


TIBIALIS  POSTTCrff?. 


671 


awd  fts  a  delicate  kvor,  the  oentro  of  motion  being  iho  aJcin,  which 
mav  be  jyrifwiitl  hjhui  f^-iitly  by  the  t)JK-k  ol'tho  knife;  and  in  this 
w.iy  on  o[>eiuit^'  of  the  rorjuinitc  h'uq  can  l>e  nindo  in  tho  lii»oia 
«t  tiK;  bottom  of  Uic  wound,  williout  culurgiiig  the  externa]  aper- 
ture. 

Hnvin^  tiius  f:ir«ccoiiipl]i<'lied  tlio  operation,  the  sharp-pointed 

knife  ia  withdrawn,  and  a  probe-jioiiitMl  oik-  i»  to  hv  poMcd  into 

tho  puiicttiro  tlirou^h  th«  »kin,  superficial  fascia,  layer  of  adipose 

n     tJJwun,  deej)  fusd-Ay  and  liu«ti_v  tlio  proper  iiliiuith  of  tlit;  tcrndon,  and 

^fte  DOW  insort<xl  a  Httle  further  tn,  so  as  to  get  well  between  tlie 

^^o«t<^ior  tibial  and  tlio  tibisu     When  siitt.ttivd  from  tho  sensation 

comniuniciittHl  to  the  kiiit'i:'  t)int  tlic  boDo  is  on  one  side  and  the 

tendon  un  tlie  other,  all  that  remains  to  Ihi  done  is  to  turn  tlio  edf^ 

towards  the  tc^ndon,  giving  the  knife  a  slight  cutting  motion,  while 

Bt  IIm:  stuiii!  time  tho  assifitatit  tintily  abducln  and  di-|>rei>»e«  the  iinicr 

border  of  tho  foot. 

A  (liiitiiict  i<eni<ation  of  sr)nict}iiiij^  liaviiig  suddenly  yioldod  can 
be  perceived  at  tho  time'  of  the  division  of  the  tendon;  butif  tlie 
case  idw>n]d  lijivo  \veijn  pre\ic>a.ily  opcmted  on,  tliis  fwliiig  may  I>e 
Tery  slight,  in  consfqiienco  of  tlie  adhesions  existing  between  the 
original  wound  of  tho  t^tndon  and  tlio  niljiicent  parts, 
^ft     Aa  soon  as  tliis  peculiar  jerk  is  detei-ted  by  the  iiMiittaiit,  ha 
^^Jiould  ininii-iliiitoly  ridax  tlic  fix.t,  and  apply  a  dossil  of  lint  over  the 
wound,  holding  it  thoro  with  the  tore-finger  during  the  flivision  of 
[«ny  other  tvndons.     If  the  artery  is  sujtposod  to  bo  cut,  either  from 
iie  sudden  escape  of  Horid  blood  or  from  the  niHi-kod  liliiitehcd  ap- 
ranee  of  tho  fijol',  it  will  only  bo  ncceseaiy  to  apply  instantly  a 
luateil  compress,  and  to  roll  Bnnly  a  linndage  ti|H>n  tlie  fi>ot  and 
V^SStle.     This,  however,  may  require  to  bo  loosciic*!  if  tho  colour  of 
tlw  toot  sliows  any  indication  of  strangidatiun.     If  tlie  operator  is 
not  ambidexter,  ho  will  find,  in  the  operation  for  dividing  the  pos- 
terior tibial  tendon  of  the  right  limb,  that  lie  liiid  better  stand  on 
tfae  left  side  of  tho  patient  with  his  back  to  tho  patient's  face,  whilst 
the  ussistam  sitit  down  in  fnmt,  and  liohU  tho  thigli  with  one  hand 
while  he  sleiuUes  the  toes  with  the  other, 
^ft      Taking,  tlien,  tho  medial  lino  or  the  inner  aKjwet  of  tlio  \cg  at 
^■yMIDt  tiiroe -9  Darters  of  an  inch  alxjve  tlic  inner  malleolus  as  the 
^MhM  iKisition  of  the  li'iidoii,  the  Hharp-pointi^l  knife  is  to  be  iniierioil 
perjwiidicularly,  with  its  back  towards  tlio  sole  of  the  foot,     It  is 
thu»i  niiKlr  to  divide  thi>  nkin  and  dei-p  faseia  in  tlio  same  wuv  '^  wiut 
explained  when  cutting  tlio  let^  posterior  tibial  tendon.     Af^er  this 
initrumviit  is  withdrawn,  the  probe-pointed  knife  may  now  be  u^ 


572 


ORTHOPAEDIC  SUKOKIIY. 


to  finish  the  operation,  which  in  nil  otIi«r  rospecis  ogreeo  witli  the 
wction  orilii*  oorresi^nding  tendon  on  tho  opposite  tide  of  Uie  body. 
'File  long  tiexor  of  tlii?  Uh»,  owing  to  itit  pniximity,  JH  often  {ULTtially 
or  wholly  xevfirwl  at  tliis  operation  on  the  posterior  tibial 

Wcis  and  Vclpeau  divide  tlw?  [lortorior  tibial  t/TKlon  lit  it»  insor- 
lioii  into  tiui  navioular  bono,  the  knife  being  inunlct)  so  a&  meet  llio 
tendon  abont  an  inch  (in  the  adult)  bt-low  and  iu  front  of  llic  inner 
niailtfr>InM.  I'hin  plan  in  iiiii|)plicab1i]  to  infants.  In  adolescents  and 
adults  this  tendon  is  u^uutly  «o  promin<.iit  to  the  eye  and  tMich 
above  and  Wliind  thfi  ini<-niftl  malleolus,  tliat  it  is  an  easy  mailer 
to  sever  it  by  inserting  tlic  point  of  a  narrow  straight  s<»lpol  at  the 
luwterior  wlf^  of  the  ti>n<kin.  <lin^(rting  it  forwards  between  Umi  ten* 
don  and  tibia,  so  as  to  tliiide  it  without  ri«k  of  injury  to  tho  pos- 
terior tibial  art<Ty  or  the  iiiti-rrwl  !<H)>hcna  \'ein.  It  is  unnccetsoiy 
to  give  particular  directions  for  division  of  the  plantar  fascia  when 
nctiUil,  lho«i>  given  n-jiiMH-ting  o]H-nitioiiit  on  tendons  being  amply 
suHioient.  Tho  direction  of  tho  knife  shonid  be  from  without  in- 
wards, i.  f.  from  t!io  external  margin  of  the  fool  towards  tho  inter- 
nal margin. 

The  division  of  the  anterior  tibial  tvndon  in  talipes  vanw  should 
follow  the  section  of  the  ]»oaterior  tibial ;  the  patient  being  in  lliO 
same  position,  and  the  assistant  still  liolding  the  limb,  and  proseing 
liis  linger  upon  the  lint  covering  tho  punoluro  already  nitide  hXmw 
the  ankle.  The  operator  Hhinild  t'col  for  tlic  most  prominent  part  of 
the  ti^ndon  over  tin- joint,  soinewhut  nearer  the  mnllnnhui  than  in  tlM 
normal  foot,  and  insert  a  sharp-pointed  knife,  with  its  tlat  surface 
towanU  the  out«r  edge  of  the  tendon ;  and  having  jwtsicd  it  wcU 
beneath,  he  should  turn  the  >iharp  c<lgc  towards  tlic  tendon,  whilst 
till!  fon'-tingcr  of  tbu  lt;t>  hand  is  prisiiwi  gitnlly  over  llw;  [wrt,  to 
warn  him  of  the  approach  of  the  knife  to  tho  eur&co.  The  aasiat- 
KTit,  who  bus  iHvn  slj-adily  niKliieting  the  foot  during  tho  operation, 
gi-adually  relaxes  his  cndcavoiu-s  as  he  fcola  tho  tendon  yield ;  and 
so  Hooii  as  ho  pereeivi^s  tho  distinct  snap  which  is  tho  result  of  it« 
complete  division,  he  shonid  immediately  relax  his  hold,  and  apply 
a  small  dossil  of  lint  over  tin-  punt-ture. 

Division  of  tho  tendo  AcliiDis  is  accomplished  afVer  turning  the 
infant  over  on  Ibe  alHlomen.  ^\'liilst  an  aK«i>tant  eii<iea%'ourB  to 
Wnd  tho  ankle,  the  Surgeon  introduces  a  small  Mraigbt  tenotome 
through  the  inlegnments  from  behind  forwards  at  the  side  of  the 
tondoiu  As  soon  as  the  point  of  the  instrument  is  judged  lo  Itave 
reached  tlie  anterior  surface  of  tJie  tendon,  it  is  passed  in  front  of 
it;  tJie  cutting  cxlge  is  then  directed  to  the  tendon,  severing  the 


APPARATUS  FOR  CLUB-FOOT.  573 

tense  con!  by  on©  or  two  movcmont*  of  llie  blado  npiinst  it,  and 
vHJiout  wounding  the  integuroent^,  except  hy  the  jiimoiuro  of  entry. 
Ifae  anutunt  shmiW  can'fully  relax  tlw  i)rv!«ure  he  may  be  rxercising 
upon  the  foot  in  proportion  as  he  feeln  the  part  i»  ciit  through. 

TliesH)  ojK'rntion*,  when  properly  done,  oeeiipy  not  more  than  a 
few  9iX'ond§  eoch,  and  are  ttriually  absolutely  bloodli^**.  Much  has 
been  wrill«ii  eonccming  tbo  daiigor  of  wounding  the  poetcrior  tibial 
srto^'.  In  the  raotrt  experionced  liajids  lbi«  vessel  and  liio  posterior 
tibial  norve  may  be  injured.  I  liavc  only  onoe  witnessed  any  trouble 
from  the  cirouiiistanw,  Tliin  aecident  occurred  t"  n  former  coU 
lenj^C.  Lir^tura  of  the  vcwcl  on  account  «f  a  small  fiibori-sized 
Bneurtsm  was  re<|iiired  Ihe  ihinl  week  atler  the  op<jralion.  Li  that 
in»Unco  th«  wound  in  the  vessel  would  have  probably  lical«d  with- 
out aneurism  if  tlw  Stirgrxni  had  not  too  soon  aftwr  the  awitiwit 
incautiously  removed  the  bandage  and  «bduei*»l  the  foot.  Wlicn 
injury  of  tlio  \v.n*i-\  ii«  »iM[>eet4Hl  or  known  to  havo  occurred,  the 
removal  of  the  bandage  and  corameiiciemcnt  of  the  nieeliauital  after- 
treatment  8hoid<I  Iw  di.'lAyed  three  wectki*. 

Aj^ratut  re^uirid  a/Ur  operation.     Tlie  metal  spUnte  already 

PlO    J. 


ni<-  ih«  HUm  If  ihalKor^pnnii',*  d.  !»»  >inp>  ■hlcti  •tm  tmoi  vUbls  lb*  kidfpim  «  ika 
Miivr  iM-  of  111*  tool  BMr  Ihr  mlr  |<1-"'.  •"'!  in  lii'i-iklril  lu  iHaMiml  In  bBttWt  «■  iha  MMlIB 
■IdioriSf  Inrtninwnl.  •>t()isv>i'*-<**<'>i"l'1'"E  "'»  ■"•I'rtnriiHtaf  UialOM  llnnlf  aEdaillHM- 
■Uf  -•Mill-  ihiw,  vbUM  Ih*  •»■»•.  lod  *)i>-rt  •|itl«(  u  whirh  li  l>  uucb^  dn*  Ik*  IraMg^tb* 
totant'ntOly.    Tb*ManlmHnl  bu}  ukt  udrIh  la  Uii*  ■vfmiiu. 


A 


574 


ORTHOPEDIC  SURGERY. 


recommended  iitr  cnses  pfJievaMo  without  operation  are  i>qnany  ap- 
plicable after  diviaion  oi'len<ion*.  Tlirwi  <laj»  after  niK^ratioii,  one 
of  UitiM!  )i|i)int«,  not  much  M.i-ulglit«r  than  the  aHe«ied  foot,  sboukt 
ho  aeleclod,  or  If  a  ejiliiit  capable  of  bciDg  adjusted  by  a  screw  ba 
iisi.irl,  it  -tiioiiiil  \k  si-t  at  itii  nii^lu  ur  in  a  dinxiiioii  (liot  llie  cliild 
\vi!l  bear  without  eomplaint.  In  infanta  above  tiro  ago  of  two 
of  thni!  inonlliK,  n  inoiv!  clulxtnite  and  cflective  ujiparaluit  may  ba 
employed,  when  the  pectinian,'  eireumstaneos  of  the  parenu  perout 
it.  Tile  wooilcHt,  fig.  2,  reprewttiilA  tlie  lightest,  tJie  must  el^xitiro, 
ftnd  the  most  inoX[)eQ!(ive  of  the  more  elaborate  apparatos  oon- 
stnieted  for  the  iniriiow.  Tlio  i«!r[M!infieuIar  lever  niid  the  toe- 
spring  are  derived  IVom  Scarpa's  shoe ;  hut  as  Scarpa's  apparatos 
contain*  no  i-oiitriviinw  for  depn.'-*«infj  the  heol,  but  rolifis  "imply 
on  tlio  efteet  of  the  weight  of  the  body  acting  during  [ocomotion, 
the  author  ha«  introduevd  the  inuvablo  thumh-Mrren-,  capable  of 
being  inserted  into  any  required  hole  of  tlie  qua<lrant  shown  as 
above  ThiK  is  »ii  iinproienient  u]>on  the  male  and  fmiiik^  screw, 
and  the  double-aetiiig  rat<!het-sercws  often  used  for  the  porpoMk 
Tlw  simple  nrra]ig«?mcnl  of  a  movablo  thumb-screw  ha»,  in  addi- 
tion to  lightnoas,  the  advnntag»  of  permitting  mobility  of  the  ankle 
in  Uic  direction  of  bonding, — a  oircumstaucv  uf  much  importancie. 

Cajo^  of  the  Itmt  grade  of  infinitile  deformity  are  usually  roeti- 
fied  in  two  or  throe  weeks,  those  of  the  second  grade  in  about  four 
WifclcJi,  and  tliose  of  tlu'  hijjhost  grade,  tho  operation  and  the  me- 
clumical  treatment  having  been  divided  into  *'deus  temps,"  witfain 
two  or  tliree  monlh.s.  'Jliti  t-roiitmcnt  of  ailoIiMCOnts  and  aduJiS 
varies  fi\>m  two  to  twelve  months. 

Ifelapw  not  rarely  oiH.-uri  aiUir  tlio  mi>*t  eomplcle  flexion  and 
abduction  has  been  obtained.  It  takes  place  insensibly,  at  all  ages, 
espceially  when  growth  i»  most  rapid,  and  U  duo  to  too  early  discon- 
tinuanee  of  instrunient«,  and  to  neglect  of  manipulations  and  of  ]ns- 
•ive  and  actjve  exercises.  The  worst  no-called  relapses  n-siilt  from 
previous  ineomjileteness  of  oj)eration  or  of  restoration.  No  case 
ahoidd  be  considered  finally  Oiu'ed  utltil  the  mental  dovi-lopmcut 
of  tile  patient  b  sufh<riently  advanced  for  liiin  to  talce  an  intere.it  in 
his  cure,  and  to  bo  able  voluntarily  to  hold  the  [i»rt  iu  a  perfect 
position,  and  perform  the  natural  niovementjtofit.  In  relajiaed  cases 
repetition  of  tenotomy  is  not  commonly  required.  Often  Uie  tcndo 
Achillis  will  bo  found  of  anijilo  length;  itonietimes  tlic  diminutive 
belly  of  the  itiu.tde,  wasted  tlmiugh  want  of  tlic  stimulus  ofadoc|ttat« 
dteniate  flexion  and  extenAion,— t.  e.  pro(wr  exorcise, — being  alkort- 
ened  and  drawn  up  towards  t)ie  popliteal  region.     It  i»  Ion  euy  to 


Jl 


RELAPSED  CLUB-FOOT. 


575 


lino  whether  tlie  [K«terior  lihia)  rcfiiiirea  retlJTiBiofi ;  tJie  lon- 
foi'  iU  tviiiiuu,  tho  (lc{u;roe  of  relapse,  an<I  <w[iocially  iLc-  (lo^;rra 
'elevation  oftlio  inlt>ni.il  wlgeofthe  foot,  will  assist  tlio  judgment. 
CoiilmuMun  ^jiMitk-  re-nppliratlou  of  tho extending  a|)|iiirutufi,  aided, 
as  Boon  as  Hcxioit  to  iJii:^  riglil  nit^io  in  rcnolierl,  by  exoroiHA  with  a 
wedge  of  cork  liciioath  tlie  &oiU  of  t}ie  solo,  suffice  to  restore  tlieoo 
eues  usually  within  a  d-w  wi'(rk.«, — i.  f.  within  the  period  tlie  putiont 
vould  have  heon  rc-quii-ed  to  lie  up  if  tenotomy  liad  hoon  rcpcnie<l. 
It  is  satisfectory  to  be  ablo,  not  oidy  to  8parc  tlus  patient  and  trinids 
die  eoiirt-ni  incidwual  to  any  operation,  hut  to  bo  ablo  to  avert,  by 
meohanie.-il  moaim  only,  without  huf  iif  time,  t.ii6  dimjredit  which 
attacliCM  ti>  tlto  repetition  of  the  operation. 

In  the  treatment  of  relapKml  iidolesoents,  an  apparatus  tiut  iviU 


F.u.  S. 


Hr.  IMIU'i  •liiulJi.Aii'iial  l^rifht  .floi/vr  ■>»»  ri^iil  I'smt^  V>/°<<''  ~a,UiS  uiitlKliL  MnffdlM 
tsa^lHM.  uhlcti  ■lirn  •■■pllrri  lu  Ibt  ttt  idiiiMKHKMaBTilriirMoriliferinUr;  (,  niinlniicatTBd 
v&tvardlir,  vJkhcij  «Li.-iL  bnjiTEljr  iut'i  fuuUcE  vttli  tf  n.ii  be  Lli«it  ■tciirtd  Irj  mt^ntvf  ft  #i*ii*t<pliVdi 
44,  l>D  ■Inat  fur  JiuriKian  >ln:ll>r  In  ittip*  4.  In  lulllNunr;  i.  niDdfnllUK^Inpk  W  kt  Xeuml  •• 
/,  u  rv^ntrvd.  If  ihv  *ci  of  brLi]trii>K  11^^  ^^tnitf  A  luut  conut  wlih  «  abuuM  pemtkap  l»  fnovb 
Mimin.  i»D  Ht  I'aiiM'KA  nl  iiiiy  rr^uiii-i)  itliimr*  Qudi  *.  liy  luanm  •>(  •  upr.     hi  Ih*  Biipllmliin  of 

■4  lb*  A^il'A'itlua,  An^  tiiviEi  tuM'rijJ  ■itJiiKEiitiiitt  of  Uli  power  ■uijilUTetl.  Tbv  (ui>l^i]m  vf  lS<^  abiT^ 
thHiM  b«  wDptrljriippl^nJ  Effvni  Lhn  iiprl^lu  luTcr  i»  KGurcd.  Ttii  U]uUvnitiDif-*tnip  it  tLu  tut  Id 
btfuica«3. 


576  ORTHOPEDIC  SURGERY. 

bear  the  risks  of  walking  exercise,  and  at  the  same  time  favonr 
mobility  of  the  ankle-joint  in  tiie  required  direction,  is  afforded 
by  fig-  3. 

After  operation  for  club-foot,  even  in  infants,  continuoos  appli- 
cation of  apl!nt«  or  other  apparatos  is  required  for  four  or  five 
weeks ;  in  older  children,  for  two  or  three  months.  The  leas  severe 
Gie  case,  the  more  often  the  apparatus  may  be  removed  for  clean- 
liness, and  to  examine  lest  undue  pressure  is  employed.  It  is 
the  boast  of  successful  treatment  of  club-foot  to  be  able  to  accom- 
plish this  result  without  a  single  excoriation.  The  Surgeon  should 
watch  that,  in  his  efforts  to  depress  the  heel  and  abduct  the  foot,  the 
part  be  not  too  long  maintained  in  one  position,  to  the  extent  that 
the  power  of  lowering  the  toes  and  of  inverting  the  foot  is  lost ;  or, 
in  other  words,  a  valgus  be  engendered  in  exchange  for  the  varus. 
This  secondary  valgus  has  been  attributed  to  the  non-union  of  the 
severed  posterior  tibial  tendon.  It  is  really  due  to  too  long-con- 
tinued retention  of  the  foot  in  an  abducting  apparatus.  We  have  wit- 
nessed it  in  children  bom  with  varus,  who  had  been  treated  witliout 
operation,  It«  production  is  favoured  by  the  same  constitutional 
debility  which  produces  spurious  valgus,  or  flat-foot,  in  rapidly- 
grqwing  children,  who  have  previously  had  perfect  feet. 

Instrumental  treatment  is  further  required  during  at  least  a 
portion  of  each  twenty-four  hours,  until  the  individual  is  enabled 
to  plant  the  entire  sole  e\~enly  and  properly  upon  the  ground,  to 
thoroughly  flex  and  extend  the  part  at  will,  and  habitually,  when 
walking  properly,  to  evert  the  toes.  In  numerous  cases  a  child 
requires  no  apparatus  at^r  the  age  of  five  or  six  months;  but 
the  majority  need  some  instrumental  aid,  such  as  leg-irons  to  evert 
the  entire  extremity,  until  the  intelligence  is  sufSciently  awak- 
ened,— say,  until  the  age  of  three  years.  The  maintenance  of 
Uie  "  cure"  depends,  as  in  all  diseases,  greatly,  if  not  mainly, 
upon  the  individual  or  his  natnral  guardian.  We  have  had  cases 
nnder  observation  off  and  on  from  infancy  to  puberty,  owing  to 
successive  relapses,  which  have  more  commonly  occurred  abroad 
or  in  the  colonies.  We  have  witnessed  examples  of  adults  returning 
to  be  re-operated,  who  have  been  suceessfiilly  referred  to  their  own 
efforts,  with  a  few  instructions  as  to  mechanical  attention. 

After  tenotomy  no  replucement  of  tlie  part  should  be  attempted 
until  aft«r  the  pimcture  has  cicatrised.  Much  has  been  written 
respecting  the  propriety  of  immediate  replacements  It  is  unne- 
cessary in  slight  cases,  and  impossible  in  severe  ones.  In  slight 
cases,  notliing  is  gjiined  by  it ;    for  if  the  position  may  be  im- 


CONGENITAL  CLUB-FOOT. 


577 


^ 


I 


mediately  rectifit^d,  the  jmri  ciinnot  \u'.  imni«liat("ly  iLscd.  Tlic  Iiiiil> 
fhotihl  ihcrcforo  bo  gradually  replaced  wliila  the  tendon  is  eon- 
3oUdatii)g  itMilf. 

TlIic  influence,  in  interfmng  with  union,  of  too-oondderabla  and 
too-«arly  si'imnition  of  the  ends  of  a  scvt-red  t4.^idon,  «nd  ospocially 
of  fix)qucnt  ntotion,  as  in  walking,  in  incontcatablo.  Experltnttnt^ 
upon  uiiiiiial.i  iiacf  proved  tliat  coiisideroblc  len^^liM  of  tctidon  may 
bo  excised,  and  union  novnrriieleafl  ensue;  but  tJie  knowledge 
poaseiwod  «f  lh«  groat  estt-nt  of  tlio  power*  of  the  economy  is  an 
huufGdont  reason  for  nogU'ct  of  tliune  nites  of  caution  whi(-h  o\- 
yeruxnoe  diu(at««.  The  immcdiato  sofMiration  of  a  »e»eri'd  leiiclon  to 
too  great  an  extent  .-thould  bo  avoided.  Half  or  three-qimrlt'i's  of 
an  inch  may  bo  safely  borne,  alt]iour;h  as  a  ntle  gradual  scjiaratJou 
is  preferable  T\u^  eotxlition  of  a  sct<>re<l  It-ndon  approaebea  tliat  of 
•  fradurvd  bono ;  too  great  separation  of  tho  scn-ercd  ends,  dvpres- 
sion  of  tempenitiire  viitheient  (o  HUH|><!nd  active  arterial  cirrnlalion, 
loo-o«rly  movement  of  tlie  parts,  and  inherent  vice  of  couslitulioa, 
may  oauae  tendon,  like  bono,  to  remain  ununiled. 

Stromeyer  has  suggeatiMl,  that  previously  to  operation  the  patient 
should  Ih>  uo<::u!'tomed  to  woar  tlie  replacing  iiwtruini'iit.  Tliis  jtlaii 
is  deairablo  when  tho  practitioner  is  un&inlUar  with  the  treatment 
of  defonnilie*;  f<ir  he  thereby  becomes  vcrw-d  in  the  action  and 
mode  of  application  of  tlm  upparatuA,  and  i.4  rendered  certain  beforc- 
Iiand  of  tbe  apjiropn'ateness  of  tile  contrivance. 

^Vitli  rcferenci!  to  tho  oboico  of  tbe  ap[iaratua,  Stromoyer  liadi 
rightly  remarked,  that  every  practitioner  will  select  that  of  which 
be  best  nnileniiimils  tliv  action  and  iiindi:  of  application.  Tliis  saga- 
cious observation  explains  alto  one  cause  of  tliu  zeal  with  which  eac^ 
wnti>r  advociit('-s  lir.'s  jiurticiilar  nppHanoe. 

It  cannot  be  too  strongly  insisted  upon,  that  in  a  large  immbor 
of  d«fi>rmitio.4,  wimtlior  trcuUHJ  with  or  without  ojieratjon,  ex)>en&iv« 
instnimctits  are  unnecessary.  More  depends  n|»on  the  tact,  patience, 
and  p«'«i'viirance  of  the  priu.'tit  toner  tbaii  upon  the  ap[i.imtus  cm- 
ployed.  IJommon  ruUt-r  bandages,  tin,  wood,  or  giitta-perclia 
*pliiit«,  aided  by  manipulation)),  inny,  in  ingenious  hiiiuU,  supply 
tbe  place  of  the  must  elaliorate  contrivances. 

It  may  tKimctlines  happen  that  no  instrument  is  available,  aitd 
ibe  after-treiatnient  may  ri'i]uire  to  bo  conduct^'d  entirely  by  mani- 
imlations.  Thus  an  adolescent  case  of  double  congi-nitiil  \iiruii  wiw 
admitted  into  rbe  Ixinilon  Ho-ipituI,  under  the  care  of  Mr.  Crilchelt, 
which  had  been  rejcct«^  as  incurablo  from  anotlter  ho«j)itui  on  ao- 
oount  of  largtt  ulcers  witli  nooro«is  ou  the  dorBum  of  each  foot,  tn- 

VOl*  HI.  P  P 


^-  VOL 


578 


ORTHOPEDIC  SURGERY. 


duoed  by  presMiro  during  the  mechanica]  troattncnt  aft^r  icnrrfomy. 
As  tlie  uiihoniiliy  c-liaractcr  of  the  ulntnt  dc|Hn)i1<^tl  tijioii  w;iiit  of  air 
and  excTviM!,  ntxl  llie  iippUmlion  of  suiUible  instninients  was  impoe- 
sil>l«,  it  wns  <IetcTmined  not  to  wait  for  cicatri^ntion  of  the  iiln^n*, 
but  b»  n-|H-al  Iviioloiiiy,  ami  4^lllt4  fumblo  maiiijiulations  of  the 
membei-A.  CWoiwform  was  upon  ono  occasion  cmployod.  By  thew! 
mcanii  tliv  fi^  w«^n>  ^ri-intually  nrniiglilciuxl,  ciojirriHation  of  tlie 
idcers  was  tbopeby  fa\-our«l.  and  within  ttree  raoutlw  th«  lad  quitted 
tlw  hoHpitttI  irtitirctlr  re^torvd. 

After  oongenitai  varus,  as  aftsr  acquired  dofonnitie«.  nrleittiTO 
apparatus  may  Im?  m)tiir<!d ;  th<«c  f^r  tlio  iniwt  jwrt  coiuist  of  jointeil 
irontt  to  sapport  tbo  weak  arlioulations,  and  springs  to  assist  tlw 
action  of  tiio  dfbililalcxi  miLtcIo«. 

llie  TOinploteness  of  recovery  in  tlio  great  majority  of  tiie  «»» 
of  congenita)  varus  »Histitut«s  ono  of  thi>  triumph»of  mrgical  nrt. 

I>uring  childhood  congenital  varus  may  be  entirely  cured,  with- 
oat  otlicr  traoCK  of  ilrforniity  than  smalint-sM  of  the  iiicnilx-r,  grcaler 
nquareness  of  the  front  of  tlie  foot,  and  someliiwes  less  oomp)o4e 
mobility  of  tlic  ankle-joint,  tho  patipnt  n^^covcring  entire  volition. 
Wlien  the  case  ii^  unaltended  to  before  adult  age,  the  internal  mar- 
gin of  tlio  foot  may  never  bo  completely  nppliod  to  tlio  gronnd,  owing 
to  the  impoa.<iil)ility  in  sonip  east?;*  of  perfectly  unfolding  the  ob  cu- 
boidvs  from  its  infei'ior  and  rotatetl  [Hwition  in  tlic  tat^sus;  in  ulhcr 
instances,  owin;,'  probably  to  tlie  round  lic.nl  ninl  lui^k  of  die  astra- 
galus having  become  so  much  inverted  in  relation  to  tho  rcmaindw 
of  tlio  bone,  that  part  of  the  undiu'  convexity  of  ihe  twuH  mitwatds 
beeomcB  irremediable.  Every  year  reduces  the  number  of  adult 
coses  of  vanii*  requiring  trcatjiicTit,  t>ii  that,  tho  cfiiisidenilion  of  any 
means  of  meeting  tho  attendant  dilliculties  may  appear  superfluous. 
The  author  lian  uMially  fotmd  a  most  ctKc-ient  a;;ent  in  a  lirui  pad 
placed  in  the  sole  beneath  the  os  cuboiiles,  preAsore  being  at  the 
same  time  made  upon  the  upjior  surface  of  the  other  tarsal  bonci. 

Coiiifenilul  Talipft  ftptinuty  TalipfM  valffu*.  Talipes  e^uino-valfftUj  and 
Titipe*  caleaneo-ealffita. 

Tiy  talijics  i(]iii»ii,*  is  iMidi-r^tooil  morbid  contraction  of  tho 
muscles  of  tho  calf,  ajid  consequent  depression  of  the  toes,  the  »d- 
duotont  Iwiiig  imaffected.  Tliis  is  n  very  rare  amffotital  affection. 
Wo  liavo  met  with  two  cases  in  the  s-anio  family, — tlie  first  l>om  and 
the  last  child,  tho  eleventh.  When  it  has  not  been  treated  in  in- 
fenoy,  locomotion  is  effected  on  the  interior  extremities  of  tlie  incU- 
torsal  bonot  and  phalanges.     In  severe  cases  tlio  iDtemal  margin  of 


TALIPES  EQUINUS- 


57» 


t  fi>ot  is  slightJjr  incline<l  inwardly,  and  tiie  mfitatarsni)  i«  projocUHl 
fonvariU.    llioru  u  not,  lis  tit  vaniH,  iiny  tlittpoiiitiou  to  tread  cxdu- 

I  (ivcly  on  the  outside  of  itie  fifih  metataisa]  bone. 

Thvrxi^tpncc orconp>ntt}il  talipos  cqiiiniishnHboen  omphatically 

,  d«iiic«l.     It  U  a  ([iii^lion  olTnvt  nnd  oa[)ability  nf  di.-«Tiii)iiiatii>n.     It 

^m»y  he  eo^pcctcd  that  tlio  rare  i»i»us  ofvonffcnitttl  oquiniis  whioh  may 
\mvt>  fitHcn  under  Iho  ob^ert aticm  uftlioAOM'lui  have  ilnniod  its  vxiitt- 
enoe  hare  beeii  erroneously  classwl  as  varus.  In  congenital  contnuitioit 

'  ftf  (h«  muscles  of  th»f  calf,  owing  to  tli«  morbid  clovntion  ofthehool, 
the  narrow  portion  only  of  tho  troclilpa  of  tlic  astragalus  Is  retained 
witliin  tlii^  iii:illi'<ill,  and  tint  front  uftlii]  foot  fnWx  or  i»  drawn  rcndilv 
either  Inwardly  or  outwardly ;  tho  more  ready  or  usual  direction 
Winp  inwiinl ;  jiijrt  a*  wo  w*o  in  sound  vlukln'n  tlioro  is  a  propon- 
deranue  of  tho  ailductore  (tlbiales)  over  tlie  poronoij  and  tlie  feet  are 
consoqttcutly  obwrved  to  be  turned  in  tnorv  often  than  oaL  Con- 
■ei|Dent]y  iho  Surgeon,  who  nialiea  no  allowance  for  the  ordlnar}' 
t«i(lcn<y  of  tho  feet  to  itieline,  and  who  eotisidvrs  a  cjisc  to  bo  varus 
when  he  sees  tJie  foot  with  never  so  slight  an  inward  imdination, 
does  not  bclicvo  in  the  oxi»teiicv  ormngeuitHl  talijios  ec|umus. 

The  few  easea  of  unoporated  congenital  adult  iy|uinu.-t  whioh  wb 
hare  seen  have  mnainid  tjilipt^s  vqutnus  tliroughouL  Hie  patients 
Iiaii'e  continued  to  wulkon  thenietataraalextrcniUyoftlicgn-uttoc,  as 
w«II  as  on  t)ui  littlo  too.  Tlio  great  too  has  never  been  rai^iud  fmni 
the  ground,  as  it  is  in  cnngeniliil  varus.  No  original  or  secondary 
aG^tion  of  tbo  adductors  had  drawn  the  foot  in,  so  as  to  resemble 
eongOJiitui  variLt  nr  ei  en  U(iu-w>ngeuilul  etjui no- varus.  The  patJonl, 
we  repeat,  still  walked  on  tlie  great  too  and  tho  little  toe. 

If  I'lingitnital  iH|iiinus  l>e  rtyeeled  npon  the  ground  that  must  ho 
taken  by  those  who  deny  its  eustencc,  then  it  may  as  justly  he 
iwMTtvd  thiit  neither  does  non-congonitol  talijins  Cfiuinus  exist;  for 
tlicre  i*  no  non-eongenital  talipes  cquiniis  In  which  a  traoe  of  inver- 
non  or  of  eversion  cannot  he  diwiivi-nd,  wlik-h  when  vorj-  markpi) 
Is  termed  either  taJiiies  equino-varus  or  talipes  equino-^algtts. 

The  'iispulo  lis  U>  tho  i'xi>lencc  or  non-existeneo  of  oongenilal 

,  talipt>s  eriuinus  continues  for  tho  same  reason  that  discussion  is  end- 
in  every  depart ui cut  ofnatiiral  history,  rh  to  whether  a  given 

•iiil|}eot  belongH  to  one  spee.ies  or  forms  another  species ;  one  observer 
noagnMiug  a  radical  ditference,  which  another  observer  eitltur  over- 
looks or  explains  away  un  belonging  to  nnotlier  species. 

Tali)>es  valgus,  eqitino-valguM,  and  uideaneo-valgus,  are  the  terms 

'  appliiwl  t»  those  dixiordona  which  contrast  most  with  talipes  varus, 
or<adinar}'  club-foot.     Tlio  front  of  tlie  foot  is  more  or  lees  lorncd 


580 


ORTHOPAEDIC  SURGERY. 


out  in  each  of  tLcse  varieties,  instoad  of  being  itivprl«d  as  in  i 
In  ralgtts  tho  jieronci  um  thu  nm.*!'!)-*  niiiiiiiy  i-oiitrjicbtl ;  in  eqiiino- 
valgus  tho  toodo  Aohillis  U  itlso  tense,  and  tho  heel  elevatud,  tlio  toos 
at  the  siimi-  time  pointing  outwiirdly.     In  (yik'!iiK'o-viilyti»  the  hoel 
ia  dejiressed  throiigli  tho  iN^utrnoiIim  of  the  anterior  tibial,  and  tl*^^ 
toes  pointed  outwardly  from  tension  of  the  peron^.  ^H 

The  nilefl  alreatJy  laid  down  for  judging  of  the  necessity  fi^^ 
tenotomy  tii  varus  and  of  tlio  number  of  contradeil  U^ndons  to  Ims 
divided,  apply  to  eitoli  of  llio  dlstortionn  now  under  consideration. 
Tho  principles  whioh  shotdd  direct  tlic  mochani«d  treatment  are 
wjually  ujijilii^rjiMe.  Tito  vxiieriiyiee  of  iho  8nrgeon  and  the  in- 
genuity of  tho  mstrujnent-inaker  arc  required  to  adapt  tho  iii>para- 
tu.i  to  the  iritcuIiiiritiM  "f  each  <'jl«o. 

A  variety  of  oongeiihal  varus  occMionally  presents  itself,  in 
whioh  the  inner  margin  of  thu  foot  is  ohghlly  raiju^d,  tlie  i*olo  OMi- 
ti-actffd,  and  tho  dorsum  prominent  towards  tlie  outer  side  of  the  foot, 
hut  without  elevation  of  the  heel.  In  those  eade*  the  miiAoli-s  of  the 
ankle  are  uiiaffivett^.  AVe  have  deugnirted  this  aJleetion  calcaneo- 
lartis.  Tlio  treatment  consists  in  making  pressure  by  means  of  a  pad 
u])on  liie  prominent  dorsum,  and  in  suitable  R)Hni|)iilations.  A  heiie- 
ficial  result  IS  soon  obscr\'cd  ;  but  the  aifcctioii  is  prone  to  rotunt. 

Some  irregular  wingiaiital  fiwt-dislortioiis  are  mot  witL  In  a 
ftw  of  these  we  find  distinct  paralytic  loss  of  muscular  power:  in 
one  case  woll-mai'ked  jiaratytie  vai'us,  with  much  atrophy  of  tho  mft 
and  hard  parts;  in  unotlicr,  paralytic  contraction  of  the  hipe,  knee«, 
and  feet,  witli  implication  of  tho  upper  extremily-  Tiio  only  trvat- 
moiit  afii'lieahlc  is  to  rclie^T  contraction  by  tenotomy,  thus  offermg 
ft  chance  to  the  musc.le-4  which  remain  partially  un<ior  tlic  will,  to 
supi>ort  the  uidlvidual  in  attempts  to  effect  imperfect  locomotion. 
"SVe  ha\'o  w;il<'hiil  tliesn  cjwi>s  from  birtli  to  adolescence;  the  para- 
lysis lias  remained  uiidimiuislied. 

Bintorliong  oriffinatbirj  at  Ihc  moment  (if  Birth. 

We  have  seen  that  in  tho  earliest  times  of  the  study  of  congeni- 
tal distortions,  they  were  successively  attributed  to  tli«  nnprr  of  the 
Doily,  hisuA  natnno,  maijjosition  in,  and  pressure  of,  (ho  ntcma.  In 
tlio  present  day,  an  ciilarget]  ohwirvution  oC  iioii-oongwiital  as  w«^ 
as  congenital  distortions  leads  irrefragably  to  the  conclusion,  that  the 
numerous  causes  wliieli  are  found  to  0[M>rutv  in  Uie  pnHluetion  of 
distortion  afltu-  uterine  existence,  exercise  anatogonfl  if  not  identical 
offoot.s  whilst  the  ftctus  remains  witliin  tJi«  ut«na.  Thoao  causes 
luv,  hereditary  and  maternal  iniluenoes,  disturbance  of  the  nutritivt^ 


I 


DISTORTIONS  ABISI^fG 


» 


respiratory,  circulatory,  and  nervous  eyBtomx  of  tlio  fcctus  nnd  in* 
bat,  .ioci<loiit-->,  (iiitjiii^lomciit  liy  tii<^  runix  ami  tibnonnal  banda, 
intra-ut«rino  fractures,  mnlposition  and  preseuro,  fixed  rejMjsi;  in 
one  ]>n«itiun,  and  intlnimnation.  In  ordvr  to  illiixtmta  Uio  obnoxi- 
to  distoi-tifin  exifiting  at  every  epoob,  wo  shall  bore  describe 
of  dijst'>rtion»,  wbk'li  unt[U('stkii»ibiy  take  tlifir  origin  nl  Uie 
period  inlerTening  between  uterine  and  independent  life,  that  Id, 
during  IjirlJi.  Wu  Ix-liove  we  o«n  pariictiUriso  tbo  inoniont,  u»  tJmt 
moment  wliieli  eonnocts  plaocntal  with  pulraonart'  respiration.  When 
vrc  reHeet  upon  tlie  iinporUint  pbuiiotnona  in  tlio  ecunniiiy  »t  tli9 
moment  wben  it  sbould  adapt  itself  to  the  immense  obangcs  !n- 
voivwl  in  the  abrupt  transfer  of  tho  oxygriiatinf'  procesi  of  the 
blood  from  the  placental  to  the  pulmonary  cell -surfaces,  we  should 
anticipate  that  any  retardation,  interruption,  or  arrest  of  this  trana* 
fcr  of  the  nioat  iiii|>ortant  function  alioitUl  be  attended  with  the 
fn^!atost  evil  to  tin?  system  at  large,  and  especially  to  tho  ncn"oiis 
By»t«^ni,  the  inoAt  siLiceptihle  in  tbo  btxly. 

Wo  know  that  a  state  of  suspended  respiration  and  animutioii  J8 
titc  eonnnoii  Gon.«cHji](-n<i>  of  many  of  tlio  iicuidentj*  nttdndant  upon 
birth ;  and  we  might  infer,  from  tho  evils  often  wltnessod  utter 
reeovory  from  thu  itsphyxia  of  tlrownin|r  or  of  cliokc-dump,  what 
might  bo  tho  oonsequenees  of  the  asphyxia  of  new-bom  children. 
Some  of  thcoe  apjicar,  however,  Ui  have  escapcil  itotJw,  until  llie 
observations  piibli&lted  by  the  anUior  in  1H43,  The  lungs  suffer  in 
tlw  forin  of  atelwtjwis  ;  tho  heart  probably  in  dulnyed  or  deficient 
^osure  of  tlic  foramen  ovale,  and  possibly  in  straining  of  it»  wall* ; 

nenows  ccntrtwi  from  effuMons  and  apoplexy,  followed  by  im- 
peded developments,  atrophy  of  individual  parts,  impaired  Intolloct 
and  volition,  spiuunuilitt  ooiivulslons,  and  spa»ino<lic  eontractions. 

It  tA  scarcely  necessary  to  add,  that  difiieult  and  instrumental 
labonrit,  and  tlioso  In  which  the  cranial  bono  and  brain,  and  even 
tile  vertebriE  aiid  tlioir  contenta,  havo  suH'ered  mechanical  injury, 
arc  more  likoly  to  bo  followed,  if  not  by  death,  at  leant  by  9<erioiis 
derangi-ment  of  tJu-  nervous  ftyi*t4'ni,of  whioli  a  prominent  symptom 
is  "  internid"  or  snbdued  convulsions.* 

Tlje  eliu<*  of  affections  nwulting  from  injury  at  birth,  wlioUier 
Itanical  or  vital,  consists  of  diminution  of  volititm  with  Ionic 
idity,  '"  varying  degrees,  of  a  part  or  >>i'  tlio  whole  of  the  muscles 
of  the  body.  Both  lower  extremities  aro  moro  or  less  gcucmlly 
involved.     Often  one  limb  only  ia  ref^rnxl  ti>  by  the  parents;  bnt 


•  See  TraiuaeUotu  <if  th4  OlMeirietU  Soritif,  \HOti 


68K 


ORTHOPEDIC  SUBGERY. 


earvFul  cxuniiniitioii  umiatly  shows  a  sniallar  degree  of  ImpaimiMit 
ill  tJie  -limb  bii{>[)obc<1  to  bo  iiniifToctc'iI.     TIio  amount  of  ooiitmction 
jn  the  liijis,  kiu'i-s,  and  luikloii  is  often  ooiist<ii>rflblo,  and  tbo  Ican- 
iiosa  proportionate  to  the  eontrartion.    The  flexors  «iid  nd<lurtiirs  of 
*ho  tliigti.'",  tlw  Hoxor.i  of  the  kiiet>s,  and  the  j>osferior  inuseic*  of 
the  lege  preponderate.     The  lliighs  and  kncc«  cannut  tlien^fore  be 
coinplotvl/  t^xtt^nded,  or  ihe  hoiili<  1>(>  ^[tpliud  to  l]ie  ground.     TbftS 
npper  exiroinitiea  are  sometimes  held  down  by  tlie  pivjiond^rating" 
iictioit  of  tile  iwclonil^,  ten-H  major  unil  minor,  nnd  latJRsimus  dors! ; 
the  elbows  are  serai-flexod,  the  wriste  partially  flexed  and  jironated, 
tmii  Uie  fiijgcnt  incapnhlc  of  ]ierfec't  vuluntarv  diivelloii.     Participa- 
tion of  the  muHcles  of  the  trunk  is  ■omotimes  showni  by  tlio  idiort- 
■€n«l,  fiatkiiod  asfwctofthe  jiecloral  nnd  alHloinina!  i-urfaee,  as  com- 
pared with  the  nioi-e  e!ongat«},  rounded  form  of  the  back.     Tbn^ 
promiiioiiee  of  thu  back  partially  di^!i]>pe3ri(  on  ro(;timben<^ ;  but  th^H 
greater  vreukne-is  of  tlie  muw-les  on  tlie  domat  aspect  of  the  trunk 
i*  obvious  when  tlie  Individual  again  attempt?  t«  «t  upright.     Thu 
inability  and  indi^iMMilion  to  pxurt  the  abdominal  and  other  mmclcs 
•cotieci'ned  in  die  expulsive  proct^sses  may,  (KThapi,  suffieicntly  ex- 
plain the  tendency  butli  to  rare  nilt^turition  and  defecation,  vrhidi^ 
sometimes  exists.     The  muscles  of  speech  are  commonly  invoUtNlj^P 
Jlie  alTcction  viirjing  in  degree  front  iniiliility  eorreetly  to  uiter  one     ' 
or  more  letters  of  the  idphabct,  up  to  the  entire  loss  of  the  artieu- 
luting  power.    During  the  eurlieitt  months  of  life,  deglutition  is  often 
impaired.      Tlie  intellectual  fiinctions  may  wiffer  from  the  slightest 
impiiirnn'iit,  whieh  thr  fond  jmrvnt  unwillingly  aeknowMlgi*  or  faib 
to  perceive,  up  to  entire  imbecility  or  idiocj-.     Tlie  ftmctjons  of  i 
gallic  life  arc  nnaffeoteil,  rxivpt  perhnps  that  of  di-vfh)pment  of  i 
tone,  although  the  depi-ession  of  teniijerature  may  be  more  dejiend 
on  the  want  of  proper  cxcreisc.     The  appetitn  is  good;  the  frai 
generally,  in  average  cases,  in  well  neui-islied,  although  free  froB 
adijiose  deposit.     The  child  is  often  described  as  the  hcaltliicHt  of  th 
family,  escaping  ejiidemics,  or  liaving  these  disorders  leas  sererel; 
than  the  brothers  and  sisters.     Those  subjects  often  \twi  a  morif' 
preeariiiiis  exist^nee  ilui'ing  the  finst  weeks  alh.T  birth  ;  at  fir*l  even 
vegetative  life  languishes,  often  boeause  premature  birth  or  difficult 
labour,  by  impairing  tli«  niatenial  *u[>ply  of  nutriim-nt,  renders  mora 
difficult  the  infant's  recovei-y  from  the  shock  the  system  has  ro- 
ecived.     However,  in  tbo  majority  of  iustsnwti,  after  restoration  oi9^ 
the  vegetative  ftmetious,  a  gradual  amelioration  of  all  tlie  ftinetions 
-of  animal  life  is  perceptible. 

The  coatrootiooE  are  not  present,  or  are  not  obeen'od,  until 


d 


SPASTrC  COXTRACnONS. 


583 


^^^B  wcvkit  uft'Or  birtli.     Tliv  eliiUrs  linihit  are  !<im])ly  wenkor;  llie 

^^^Stjon  of  viability  aloiio  oompies  the  Ihoiighte  of  the  attendantft 

Before  llio  11^  <if' tlii'oc  or  four  mouths,  tliough  xomvUmv^  in  »liglil 

cucH  iiot  until  the  ordinary  time  fur  locomotion  has  arrived,  the 

H  nunc  pcn.<«ivi?it  tliut  ^^he  is  uiuibiv  progierly  to  separate  the  tlii^li*  or 

BluuxM  for  purjxiAGs  of  eloanlincMt ;  tliat  tlio  diil<I  nev(>r  thoroughly 

etraiglitvns  the  kncox ;  that  tic  cloc«  not  attcn)j)t  to  stand,  or  is  iiic'i4)- 

ulilu  of  standing  excf]>t  on  the  torn,  or  tlmt  llui  ftxL  are  <lif<pa«c<l  to 

cross  each  other.    E\  til  ohildrcn  slightly  affected  rarely  "  go  atonw" 

bcfom  tlie  age  of  tliii>o  or  futir  years;  many  are  unable  to  raise 

_  themK-lvc«  from  the  ground  at  ttmt  age,  and  otticnt  do  not  walk 

f  oven  iiitlilTonnttJy  at  jiuborty.    Ijoooniotivo  ability  necni.')  to  advance 

in  proportion  as  the  iiitollectual  powers  are  developed.     The  ex- 

temid  form  ofiliu  cranium  occuKionHily  (-.vhiblL-i  <lt'parturo  from  lira 

tionnnl  type — such  as  general  ^inalliicss  of  tho  skull,  depression  of 

tito  fronted  or  occjpitjd  ri-gJoii  only ;  $;r>nii.^timi.w  of  one  litttiiiil  half  of 

tlie  skull,  Bometimca  of  one  half  of  the  occiput  only.    In  slight  ca»os 

tito  liottd  has  been  well  develoiHHL     The  ensemble  of  plit^noinetia 

|K>inlA  to  injury  more  or  leas  extensive  of  Uie  cranial  contents,  and 

■  of  tltc  medulla  oblongata  and  spinalis. 
J»  all  eases,  even  with  gn-at  inertia  as  to  the  exorcise  ofvoli- 
tioOf  oomnion  sensibility  appears  littlo  if  at  all  detieienf.      On  tlic 
^^  contrary',  a  morbiil  M-nsibJIily  of  Uiv  orj^an  of  heariitj;;  and  of  die 
^Kcatancous  envelope  appears  to  exist,  evinced  by  "startling"  at  tJio 
»l!f;}ilt.'»t  iioisofi,  and  rxtrvino  »oii»ibilily  to  tont-li.    Tlii^i  morbid  sen- 

»sibility  may  bo  due  to  a  condition  of  spinal  cord  aualogou*  to  that 
prawnt  in  narcotized  frngt,  in  individual  under  tho  influence  of 
strychnine,  or  those  affected  by  tetanus.  It  may,  lioive^er,  be 
ap)Ktri!nl  only,  <Ii-]ieii(]i'nt  ujmjii  tlie  iiKlivIdual,  vheii  subjected  to 
common  noises,  being  leas  competent  quietly  and  promptly  to  iwason 
upon  tliem,  iind,  by  tlni.-'  reawurin-;  the  |>iriurlird  mind,  to  ewa|io 
from  the  exciting  intlucnee.  In  many  easw  tho  intellect  haw  been 
B  intncU  A  [n'cniiarity  of  these  ebildreu — an  uiio«>mmon  foar  of  fall- 
ing— is  often  obherverl  when  lliey  arc  seated  on  a  couch,  Ics*  when 
they  arc  on  the  floor,  and  not  observed  vrhvix  they  are  seated  in 
,  «n  arni-eliair ;  a  ciroimistiuice  clearly  due  to  conscious  inability  to 
'  balance  and  recover  the  position  of  the  body. 

SfMstie  CohtractiotiB /n/m  Cereftro-fpinal  Diteate  n  Infattey  and 

C/iildJwod. 

We  have  just  described  a  state  of  more  or  loss  general  spastic 
oontraction,  wbiuh  rosulti  from  dislurbanoe  of  the  corebru-spinal  con- 


fifti 


ORTHOPEDIC  SURGEHY. 


trea  at  (he  moinont  of  birth,  eitlicr  from  direct  iiijuri'  to  the  crantnni 
or  nock  wliilst  pushing  ihrwugli  tf  lO  inat*'riiiil  [iiirta,  or,  mori!  (irububly, 
from  aspIijTtia  consequent  upon  interruption  to  tho  8iib§t!tution  of 
pulmoiiiiry  for  piawnlJil  n»piruti'»n.  Sniin-limvn,  wilhotit  cilWr 
pi'ottiatiu'o  or  diflicuJt  labour  }iaviug  preceded,  convulsions  occor 
very  soon  afW  birtJi,  during  tlio  find  tioitrs,  Hay*,  or  wock»  of 
iiulejK'iuicnt  existence.  Conxniloions,  aa  is  well  kno»-n,  occur  more 
frequently  afUsT  dentition  lias  made  «omo  progn.--**,  wliilat  tlio  '1-^^ 
fuit  is  undergoing  another  transition,  that  of  passing  through  tlri^| 
er'mt  from  nourislmicut  by  tlio  mutlicT's  brtjust  to  fecilinji,  wlwn 
unfavonmhie  ounseqiiences  of  depriviilion  of  breast-nnlk  are  apt  to 
show  tbctniwlvvs.  Tlio  infant  may  be  of  previously  imcxccptionablo 
Iiifltory,  except  that  tho  pareiits  may  be  the  subjeda  of  diM>rderft 
of  Uic  nervous  system,  of  nervous  t<!mperamcnt,  have  ovcr-taakcd 
brains,  hav»  licen  pbtJiUicul,  or  ure  iiiti-niperuf'i^  I'hcHe  oonvulsion 
now  and  then  loave  the  RufTorer  im|jaireil  in  mental  power,  anij 
alfectx^d  with  fipastic  rigidity,  imdistingiiishable  fnmi  that  whiv 
8u<;ceed»  aspliysia  neonatonim.  It  is  scarcely  necessary  to  add 
the  previonH  rt^marks  on  spHSniodic  uixl  panilytie  (■o)itrm-tion!>  (hat 
ConvuIsioDH  and  other  cerebro-spiiia)  morbid  states  of  childhood 
may  bo  followed  by  Mpantio  eoiitraotiou,  or  purulysia  of  sin{;lo  mua 
elud  or  sols  of  ftssoeiated  muscles. 

Trmlmimt.  The  iiidicutruiis  for  either  tho  operative  «r 
ohanical  treatment  of  these  different  forms  of  spastic  and  paralytic 
cmitniction.'*,  and  tliw  mode  of  coiidueting  tlio  troatmeut,  »iro  tbo 
same  as  those  laid  down  in  sjK'aking  of  (wngenital  club-foot  (p.  5fi7), 
moditied  by  Uio  iiattu^i  of  iJic  cause  of  contraction.  In  contn- 
difltinclion  to  congenital  contTacLioitH,  wn  may  remark,  tliat  in  con> 
tractions  oceurring  during  tciothing,  the  occurrenco  of  struclural 
Bhorlening  may  generally  be  provenljid  by  thni'ly-nppliod  iiian!])U<^| 
lations,  frictiiiii*,  uicohanical  support  to  paralysed  parts,  or  assistance^ 
to  the  antagonists  in  tlio  case  of  sjiasl.ic  atti-ctions.  It  nhould  Iio  rv 
mcmbc-red  as  a  reason  for  avoiding  unnecessary  tenotomy,  that  ibo 
oonti'actfd  niiiHcJe  \»  often  ihu  hcaltJiinr  one,  and  that  in  Uie  cave  uf 
a  Bpusniodically  affected  muscle,  tenotomy  docs  not  "  euro"  tlw 
spiuni.  It  in  otleii  only  tumjiorarrly  beni-lteial,  and  Mimetime* 
transfers  the  preponderance  to  ajiotber  set  of  muscles,  merely  eob- 
stituting  oiift  e^il  for  another.  In  wiver(T  general  cpaslie  contnic- 
tion,  the  Surgeon  has  carefully  to  balance  tho  good 'and  evil, 
a^ust  the  other. 


infl 

hat™ 
hood 

nM>9 


FLAT-FOOT. 


585 


Flat-foot,  or  gpurlou*  Valffv*. 

i  common  ilfiforraity  pi-eseiita  esteraally  ninny  of  Uie  cliarao- 
I  of  ootigonttal  valgus,  imd  of  the  acquired  valgus  which  resulto 
pitmlvAiR  of  tlie  anterior  tibial  muscle.  Hut  the  rctwmtttanoe 
ia  only  snjwrficial.  The  person  trc;ul»  nndiily  on  tlic  inner  margin 
of  the  font,  the  toes  are  turned  outwardly,  and  tlio  nrnh  of  tho  fiMt 
is  diminished,  or,  in  severe  cnses,  may  be  obliterated;  honoe  the 
tenn  liiit-f<Hit.  Tnio  lalyus  sjirlnffs  from  oongi-nital  tiinlrnclii>n  of 
the  pcronei  niusclos  ;  spastic  n  on -congenital  vsdgiis  from  spasm  of 
the  pt'roiu'i;  piiralytic  valgus  from  piirtiiil  or  t<il,-d  iwinil\-»is  of  the 
anterior  tibial :  sometimes  combined  with  paralysis  of  tho  posterior 
tibial,  cunjiing  I'on tract! on  of  tlii'  [H'roni-i  owing  tii  thu  wjmt,  of  im- 
tagoiiistj^ ;  but  spurious  valgus  or  flat-foot  is  duo  to  general  want  of 
tono  in  the  fibrous  xlruiThinis  of  the  limlv, — displuytKl  in  liio  vii'tding 
of  one  of  the  parts  of  the  frame  most  exposed  to  strain,  tho  plantar 
musclvs  and  ligaments;  iicnco  sinking  of  ihw  arch,  t-wrsinn  oftlm 
toes,  and  secondary  contraction  of  tie  peronei.  After  a  time  the 
displaovmeut  of  tlie  tarsal  bniiea,  f(iiin«-l*«I  with  the  ninking  of  tho 
aroh,  leads  to  painful  or  <lit)ieult  locomotion  and  h~mit:ation  of  tlie 
mo%'«ment  of  tho  ankle-joint.  Finally,  tho  tjtreus  may  be  said  to  Ih; 
convex  interiorly,  concave  sujieriorly,  the  anterior  part  of  \ho  foot 
being  tlien  ilruwn  up  by  tho  conjoint  action  of  tho  anterior  tibial 
and  the  exten^rtt  of  tlie  toes,  and  tho  heol  held  lonttcly  npwarda 
by  the  inuMles  of  tho  calf.  Even  in  mo<lcrate  cases  contraelion  of 
tlie  peronei  is  diatinelly  felt ;  in  severe  ciLte»  shortening  of  tlie  ro- 
Iiuining  muscles  above  onumorated  is  a\fo  evident.  In  tho  worst 
fmftfii  soaroely  any  mobility  of  tlie  ankl<;-joint  nMnaina.  A  slight 
degree  of  flat-foot  is  common  in  girls,  especially  amongvt  thwu  of 
fine  organisation  in  tlie  up])er  and  middle  claiwoA  of  aooioty,  teas 
frpfjucnt  in  boys  ;  and  ia  curable  amongst  tliem  by  considerably  re- 
ducing tho  nntonnt  of  slaiidlng  and  walking  euTcise,  by  substituting 
honc-eicercisc  whero  practicable,  by  avoiding  fist  walking  in  tho 
company  of  mlults,  iiy  early  Imurs,  by  a\i»iding  competitive  over- 
Study,  by  generous  living,  fresh  air,  tonics,  attention  to  tho  state 
of  (he  prima!  viu',  embroralions,  and  nnmipulattona  directed  to  tlio 
promotion  of  inversion  of  tlio  foot  and  pretention  of  the  Utrcat- 
ciie<l  (.-rinlriurtion.  In  grcntx<r  rulaxatiim  nf  thii  parta  about  the 
inner  ankle,  actual  confinement  to  a  oouoh,  and  carriage  eserciso 
for  a  monlii  or  five  wooks,  or  thiit  time  upt^nt  on  the  tandi^  or 
boaoh  at  tho  sca-sido,  will  lay  the  foundation  for  cure.  Jjaced 
boots,  sujiportud  at  tho  sides  with  bllff  leather  or  thin  etoel  buoks, 


58« 


ORTUOPJEDIC  SURGERY. 


ar*i  «f  great  asaiatanco  in  walking.  An  clastic  Iioree-liair, 
nil>bor,  or  fdt  pad  bMii-atli  t\w  inner  inarghi  nfilie  foot  tendil 
»itp[K)r1  tlie  arch.  Iron  and  cork,  often  cniployo<I  for  Uils  purpcM^ 
are  harsh  anil  infffioiuiit.  Wc  niui«t  utti-rly  (xiniloinn  a  j>nieti<« 
wflKii  rertirtcii  to  in  oont«npt  of  the  pathology  of  the  atFection — tiiat 
of  Bevoriiip  tlio  ppronvi  and  t<?ndo  Adnllis  in  I'lK-h  raise*.  TI»o  re-  ^ 
oovorr  of  |iatii*ntfl  from  motli-rato  (lal-foot  whon  this  operation  lias^H 
bocn  jierfomicd,  »  duo  m»inlr  to  ihc  ahsoluto  rcpow  nf  lh«  limb^^ 
with  which  l)ie  ojxsration  i»  follovriHl,  and  to  the  mechanical  mca- 
sun.'S  concurrcntij'  fmjjloycd.  But  in  a  few  rare  cawrs  in  ])rivaW 
pmi'^ii;i>,  and  in  thott^  of  Imya  who  huvo  stmA  )>ivnia1tirety  boliind  ^J 
a  counter  twelve  or  fourteen  hours  daily,  and  amouf^t  the  Iowlt^^ 
elii^«c*  in  piihlie  inHtiiiitioiM  who  Ituvi;  snfien^d  from  prematura  ^ 
labour,  tlic  deformity  has  existed  so  great  a  length  of  time  Umt 
thv  ciiilraotcd  niiiNclox  luivo  iKTomo  .Nhorteni'd  nnd  rigid,  rendering 
tenotomy,  by  its  promptness  and  certainty  of  action,  a  uoc««Myi 
ndjunet  to  ihu  nii^eiiantcal  tix'ittiiK-nt, 

Flat-foot  often  exists  for  several  years  without  attaining  on 
an  intcnncliatc  frnulo  of  iw; verity,  when  all  at  once  a  purticularly 
long  walk,  a  leap,  or  initiation  into  a  standing  occupation,  beoomtw 
tlie  .".tartiiifT- point  of  u  considerable  and  rapid  aggrnratiott.     Some- 
times  evidence  of  chronic  inHammutlou  of  the  nalcaneo-scaphoid  liga- 
montr,  or  other  ])laiitar  struct iin.-"",  or  a  painfully  stretolw«l  conditio 
of  tJie  plantar  nerve,  exista.    Tliis  lant  aymptAm  ia  recognised  by 
osquisit",  unlicarablo,  cledrlc-likc,   painful,  tearing  wnsntinn  de-' 
neriljcd  by  the  patient  when  ho  takea  a  long  stride,  or  stan<iH  on  tho 
aSbcted  leg  nlonc     Wc  ehoidd  not  be  induced  to  opemt«  on  flal- 
foot  «ven  on  ni<oount  of  it«  long  ilurarion,  or  of  palpable  shortening 
of  the  tendons  before  enumerated,  since  even  rigid  contruetion  «f 
miiAcIcH,  heahliy  an  to  tlioir  innervation,  will  yield  in  a  few  weeks 
to  judicious  frictions,  manipulations,  disuse  of  tlic  part  (required  i 
this  deformity  owing  to  it*  Npecial  exposure  to  aggnivaitini  by  walk 
ing),  and   meebanica]   treatment.     Aa  an  argument  in  fiivour 
Bevcring  the  Aehilic*  and  other  t<.'ndons  in  sliglil  ouw,  wo  ha' 
Iwjard  the  question  put,  "  What  harm  does  the  eection  do?"     Ni 
although  tho    t«ndo  AelnJlis   is  very  tolerant   of  tli«   cver>: 
o[>erator'fl   scalpel,    it  cannot  he   pretended   tliat  an   onni 
o|>cralion  is  a  benefit.     A*,  in  extremely  seveiX!  ease*,  llic  act  of 
walking,  ntler  replacement  of  the  tiu-nal  bones,  tends  to  bear  down 
again  the  tarsal  arch,  the  aid  of  mechanical  appliauco*  ■*  mjba^ 
queiitly  needed  for  Heverul  months,  or  even  sometimes  for  two  OT 
tbree  yuan.     Itclief  ia  much  moro  readily  obtainable  in  the  child 


d 


L 


CONTRACnONS  OF  THE  UPPER  LIMB.         587 

tlinii  in  tilt;  ndiilt.  Tin-  apparntiu  available  in  Uiceo  cases  is  Uw 
Nuiiie  IIS  titiii  iinieil  fur  varuN,  but  with  tb»  action  of  tlie  springB, 
scrcnn,  or  hvw  reversed, 

Stt)icutiinc<>u.4  clivi.tioii  rift  ho  pnmncnn  Ioii^k  and  br(ivi.i  la  elf()ctc<l 
in  .1  m.uincr  similar  to  the  operation  of  severing  the  t«ndo  Acliillts. 
Thv  |iiilioitt  ithoiilfl  Ho  iivci-  on  th<^'  (>p[Ki«tt«  *i<lf,  nii  aKni^Hiit  hold- 
ing the  foot  Hiwanllj-,  so  as  to  maintain  extra  tension  of  iho  parts. 
Ttx!  t^Miotonie  8h(>iil(l  he  iittnjiiii <■>'(!  in  front  of  tLv  t4Midon»,  the 
section  proci-wling  from  before  backwanU. 

CoiUnKtuma  of  ihe  Upper  Extrcmilyfrom  Speum  and  Paralj/ris. 

T!ie  prinei]>lt>s  which  should  direct  the  applicntton  of  toitotomy 
to  spujiincKliu  a;ul  juiralytic-  contractions  of  tlic  upper  cxtroiutty  arc 
those  which  ore  applioiihle  to  other  purUi  of  the  bwiy,  <!xcept  in  no 
tiir  as  the  functions  of  tlio  individual  tnuBdosctf  ike  upper  extremity, 
eajtectully  those  of  tho  wrist  and  Ihigt'r*,  arc  more  doUcatiO,  \-ariod, 
and  compics  than,  for  example,  are  those  of  the  corresponding 
parts  of  itn'  lower  extremity.  We  jdioiild  ho  proimrcd  to  ex|K!et 
that  a  surgical  proceeding  which  aims  at  intercalating  a  piece  of 
new  tendon,  with  Uic  object  of  nvlucing  Uic  range  of  action,  and 
therefore  the  power  of  a  rehelliooa  Spastic  muscle,  or  for  tho  pur- 
[Kwe  of  thiTchy  wciikfning  a  lioalthy  musctc  so  a»  to  favour  a  jwir- 
tially  paralysed  antagonist  to  roco\-er  ita  activity,  would  ho  tesa 
Buceessfiil  than  in  the  lower  extremity,  the  aelions  and  movcmcntd 
in  which  .-u*  comparatively  simple.  Tho  «e(|uin>iin-nl  of  llie  jwwer 
of  prtiftn-sision,  c^■en  if  it  be  incom[)leie,  amply  compensate*  for  the 
sacrifices  tho  jiatitint  niiikes;  in  had  oiihcm  he  is  siitidticd  with  the 
p<ifWtf»,<ion  of  a  limited  Hexion  and  extension  of  tho  hip,  kne<T,  and 
ankle,  and  can  bo  aided  by  ineehaniciil  iippliunci-.i.  But  in  tho  case 
o(  tlio  wnst  aiirl  fingers  the  individual  derives  little  beneiit  firom 
thesfl  simple  moveinetiU,  ami  he  iwinot  he  mati-rially  tL-«i(iMed  by 
any  complicated  mcehanism  hitherto  invented.  We  bavo  dividod 
tho  hicc]>i<  at  tlio  bend  of  tho  cHmiw,  tin?  ri<;iil,  well-detiiUKt  pronator 
radii  teres  at  its  muscular  portion,  the  tendons  of  the  flexor  carpi 
radialiH  and  iilnortH  whore  moitt  prominent  cIomi  to  th«  wrist,  and 
have  found  tlie  resulting  benefit  proportioned  to  the  attention  suh- 
•ei|ui-i)ilv  h(s|i»v<Hl  upon  iiiaiii}iiiliilionH,  paniiivo  cxcrciM!!',  and 
painstaking  ednoation  of  the  enfeebled  non-contracted  oxtensofB. 
Ex«e])t  in  cases  of  many  years'  duration,  in  which  tliu  relractifd 
inuaeles  were  reduced  to  inexlensible  fibrous  Wnds,  it  has  seemed 
that  iw  mudi  nltiniatc  bcnoiit  was  obluinod  by  manipulutiuna  and 


588 


ORTHOPEDIC  SUBGERT. 


exerdMS  u  by  tho  employment  of  an  oporaUon,  and  at  no  f^raiti 
expenditure  of  time.     The  prognosU  must  be  based  on  the  amoimfc 
of  improvement  tliat  may  bo  expected  in  tho  affortcd  portion  of  thflii 
iiorvoiu  eentres.     Aa  an  encouragciiient  (o  treatment,  the  Surjreoni 
ehoold  reineifibor  that  eaws  oeeur  in  which  the  disorder  of  tJiol 
nervous  syst<?m  and  nerves  has  eeniml,  and  that  be  lia»  lo  deni  only 
with  eon KtH| licit eei^     Ttii»  obficrvatioa  applies  also  to  majiy  coo-J 
genital  oontractians. 

Di-formUg  from  Dinfanf.  aftlit  Palmar  Faena. 

A  not  unoonjinon  oontraetion  in  the  upper  extremity  con«i«f»  in 
n  ponnaiiwitly  flexed  conilition  of  one  or  more  fingerx,  with  visible 
and  palpable  thiekening  and  lij-jiertropliy  of  tJio  lascia  investing 
tlio  pahnar  surface  of  the  first  jthalurijc  of  iJie  affeeted  finfji-r  and , 
of  the  neighbouring  portion  of  the  palmar  fascia.     Sometimes  tbel 
whottt  of  tiie  tingert  and  thumb  are  implicated,  tbe  palm  ilM-If  i>] 
contracted,  and  tlio  use  of  tlie  niondier  as  a  |*ehenfiile,  and  even  asj 
a  tactile,  organ  almoet  destroyed.     Tlic  ring  ami  littlo  fingi^n*,  thai 
middle  finger,  index,  and  tinnnb,  are  usually  affected  in  frequency] 
wad  degree  in  the  order  in  which  we  liavc  j>laeetl  thimi.     Tlie  ar-I 
ticulations  are  commonly  unatfected,  altliough  oecasionally  that  at\ 
tho  tirKt  phidanx  with  the  second  phalanx,  or  tltis  willi  tho  ihir 
has  exhibite<l  slight   artliritio  enhu'gcment.     On  endeavouring 
straighten  the  fingers,  the  Surgeon  feols  that  a  general  resistance  il 
offered  by  the  tissues  of  tho  entire  pnhnar  surtaee  of  the  hajid  and! 
fingers,  and  ospeciuliy  by  the  indurated  palmar  fascia  itself.     Any] 
«xiiiiting  tension  of  the  iloxor  tendons  cannot  bo  felt  along  the 
fingers,  but  in  the  palm,  particularly  in  the  upper  part,  above  thol 
edge  of  the  nio^l  indiirutcd  purl,  of  tlu;  puhnar  fascia,  one  nr  mora] 
tendons  prominent  and  tense  may  be  felt    This  deformity  is  Dsually] 
attributed  to  injurj',  ollen  to  u  trilling  wound,  to  irritjilioii  by  lite  usal 
ofawhip  iji  driving,  of  a  walking-stick,  or  meehanieal  tool.     Tlieea] 
moehanieal  eau^wi,  or  local  irritants,  if  really  ojHirativc,  can  lie 
gardod  only  as  oecaaional  determining  or  exciting  causes.     Tlie  > 
mntjal  or  primary  cause  is  a  const itiilional  one,  allied  to  tl>e  gouty ' 
or  rheumatic  diathesiei.    We  may  not  venture,  however,  to  assert  that 
ilic  constitutional  cause  is  identical  with  tliat  of  gout  or  rlieumatismu 
as  tho  pei-sons  afiocted  liave  appeared  singularly  free  front  oihe 
nlanifi^Btati^ns  of  those  affections.    Tlic  disease  of  the  |>ahnar  fascis 
unlike  gout  or  rheumatism,  is  |iaiiilcsH.     Many  patients  affect 
with  oonsideriilily  contrsetcd  palmar  fascia  la  both  hands  present^ 
eimilar  induration  of  the  corresponding  fa-scia  of  tho  soles;  a  auffi* 


CONTRACTED  PAUiAR  FASCIA. 


689 


e proof  that  tlie  complaint  is  casentiany  indapendent  of  tlie  mo- 
uul  CHUi>iM  a«<igiiul  fur  it,' — unlem,  indMcl,  wo  nwumo  tliat 
the  act  of  walking  by  stretching  the  .'wle  can  aci  upon  tlie  pluilar 
£ucia  aflur  ihv  miinncr  of  «  mri'ltimicaJ  IrntAnt.  Tho  MtinniPtrical 
character  of  the  alfcotion,  the  precise  rcwmbhuice  of  iin«  case  milh 
anoUicr,  the  ucouMiuoal  cxist^-itco  of  hurcdiutrv  gnat  in  the  fnmilir, 
the  fre<)went  occiurence  of  tlio  .same  ilefunnity  in  fiitlicr  aiid  wm 
for  Bcvcnd  gt-ncrationn  (four),  as  well  as  the  aliovc  fiict*,  canfirm 
Kttie  opinion  of  iUi  con.stihitional  origin.  We  have  never  witncjwed 
~^  this  complaint  in  tbo  fomalt'.  Those  who  have  firoly  indulgod  in 
gtrwij:;  winiTS  and  npirito,  orlH!<>r,  am  tlio  friipiiMit  suhjects  of  it. 

iWo  rt'gard  it,  tlieii,  as  a  p!iiid(>R§  chronic  induratioa  of  the  fascia, 
leaitiTig  to  oomixilsory,  gruiiimlly-iiicrvtawing  diHiiitc  of  llie  fingcni 
ftml  hand.  Through  this  disease  tlio  tloxor  niiificlcs  and  tendons, 
vliit^h  arc  jirobalilj-  free  from  the  original  afi<x:tion,  assort  tlicir  pre- 
pondenuice  over  the  equally  idio  extensors,  and  hecom©  gradually 
Aifcctixl  with  swondary  ^Iwrtcniiig. 
Trt'itm^it.  Evou  in  tolerably  ailvancod  cases,  frictions,  nianipa- 
lationa  twice  or  ofloiier  daily,  tlic  apjdicatiim  of  u  ccRiw-adju^tmcnt 
splint,  or  straight  splints  of  wood,  tin.  or  gutla-pereha,  will,  if  snit- 
ably  and  ]Mrr!uveringly  Hi*cd,  rcdiico  the  eontractiim  and  deformity. 
^_  But  at  the  advanced  age  at  which  many  palient^  pr&ient  tJiemAelvco 
^Klbr  relief,  the  employment  of  mechanical  apparatiut  encounters  many 
ditficidties.  In  rigid  unyielding  oases  of  long  duration,  tenotomy  is 
remarkably  efficacious.  We  cannot  by  its  moans  alter  tho  oonstitn- 
tional  state,  or  direertly  remove  tbe  inditnitiutt  of  the  fiLtoia ;  hut  we 

■  wo  enabled  to  romovo  by  tenotomy  the  secondary  tenilinmis  con- 
traction, to  take  the  ease  entin'ly  out  of  tlie  inlluence  of  the  patient's 
will,  as  far  as  tlio  contracted  muscles  arc  concerned,  and  obtain  a 
starting-point  for  further  heiiofit  by  ini-chiiiiieal  trc^itment.  A  punc- 
ture half  a  line  in  width  suffices  for  the  passage  of  a  firm  tenotome 
heneath  the  tendon  in  the  jfalm.  The  tt^ndon  i:>  tints  divided  from 
below  upwards.  Ko  fuinhling  or  unnecessary  handling  of  tho  part 
after  tlie  operation,  hy  which  mnms  air  or  blond  might  be  di.-Ku^mi- 
■natod  amongst  tlio  palmar  tiasaet),  is  i)crmissiblfl.  The  operation, 
like  ni<wt  )m!"in  ipudti,*  ojN.Tationx,  is  blowIltMa.  \Vo  haw  in- 
variahly  seen  ilir  juiiiciuro  heal  witliin  forty-eight  hours.  Con- 
sidcmhle  yiolding  of  tho  coiitraetcd  finjpir,  the  t«ndon  of  which  haa 
been  sevenxl,  is  at  once  iwi-eeived.  ManipiiLitions  and  mechanical 
treatment  ei>niplet«!  the  cure.  We  have  fRi'(Uently  thus  ctfbctod 
entire  restoration  of  tlie  hand  and  fingers.  It  is  renmrknhle  tltat 
tbo  indurated  fascia  soiteus,  and  the  hard  rid^  and  ooircsponding 


b90 


ORTHOPEDIC  S0RGEKY. 


furrows  in  the  faaeia  tliMppcnr,  uiidttr  tltM  IreatitMint.  It  U  obvion 
lliat  ii)o  iitl1ii\  of  blood  to  the  part  excited  and  ntaJntained  I>y  the 
fifeqoent  niiLni|>ulHtion»,  frictions,  nnd  banda^^  ulters  Ux^  nntritian 
of  tlic  [MTi,  »i)d  reniov<»  the  previous  morbid  deposit  It  is  alao 
probabii':  ibnt  carv  w^  U>  diet  und  wine,  whilst  iindor  Hv  olw-rvuiiaa 
of  tlio  SurgooH,  assists  this  process  of  recovei^j-.  Tlie  canse«  bein, 
constitutional,  and  tho  attontitm  of  the  putimt  bein;;  liablo  to  sbtckra 
lifter  H  li-nytliened  recovflred  use  of  tlio  member,  tlie  complaint  ooea- 
uoiially  rt'tTiriis.  We  have  re-ojwratod  on  a  patient  thricw  in  winwiii; 
yc-iirs ;  the  individual  exprei^ng  himself  amply  oompensatcd  for 
oj>oratiun  by  nearly  as  many  years'  ^c^ood  om  of  Hk  p«rt. 
o|H.Talion  is  a  \'aluable  iUti^tmtiun  of  die  stuH^eets  of  subcutaneous ' 
tenotomy  ewmpared  with  Dupoytrcn's  painful  operation,  even  wbcn. 
|»erfiinticd  hy  m  jible  a  Siir^-oii  km  iht;  lal^-  Sir  A.  CV>oper.  Wi 
have  imd  under  observation  two  cases  in  which,  by  means  of  a  larj 
crucial  incision  of  Uio  gialtn,  the  indurated  fowia  had  been  dissect 
out  and  removed.  Tlio  operation  iiad  no  better  result  than  that 
of  cauwuf^  a  large  cantmoic^  cicatrix,  more  rigid  (hau  the  (brmec 
Btate  of  tJiuigs,  and  quito  irremediable. 

Torticollis,  or  wrj--nock,  is  a  not  v»Ty  nneommon  distortion 
the  ht'ad  and  neck,  originating,  like  cliib-fout,  front  a  variety  ol 
influence* ;  some  acting  through  Uie  muscles — cougeiiital,  spas-l 
modic,  iMiralylle ;   uUx^rs  acting  thrcMigh  the  ligumciitK  uiid  buneil 
— rheumatic  and  strumous,     Occasionally  the  point  of  departur 
ofac3H('i»  i^trnmoiis  affection  of  tin*  lyinph«ttc  inlands,  and  sour— j 
times  loss  of  textures  from  sluughiug  aft*;r  bums  or  a  gun-sho 
wound. 

Coiitfnilal  vry-tifft.     Tills   is  the  most  common  form  of  wtt«| 
neck,     it  is  perceived  a  few  utuntlis  or  more  alVr  birth,  nnd  wlicn' 
Butlt>red  to  proceed  unchecked  gradually  increases  during  diildbood, 
•dolcsecnee,  and  adult  life,  iintit  it  attains  tlie  proportions  of  a  fbr> 
niduble  iicfi)rmit.y.     Many  ciisin  of  wrj-iu-ck,  rejiutwl  to  be  con- 
genital, have  appeared  to  originate  from  accidents  at  birth,  in  cou- 
seijiienct)  nf  brii-cb  prciuintalion,  turning,  &C.      ^Ve  will  describflj 
an  ailnit  case,  in  wliich  the  right  sterno-eleido-mastoideus  is  tlifil 
head  and  front  of  the  ofiending,  for  it  is  prohublo  thai  other  muscle 
aro  always  either  primarily  or  secondarily  involved.     The  cnlir 
head  leans  to  the  right  nldc  nn<l  ^liglilly  ffii-wMixln,  llio  right  sida] 
of  Uw  nock  is  somewJmt  hollowed,  whilst  the  left  sjdo  is  uuiutturHlIj 
convex,  and  the  patient  not  unirctiucntly  coin]tla)ii3  of  pain  in  i 


WRY-NECK. 


591 


El.     Thttsp  dian;p>s  iii  tlic  form  of  the  neck  are  moro  j>rt>. 
„.,_ »t  tin;  tiiijiti-  part,  i.e.  »p[)OsiUs  lo  lltu  (wwo  of  tiip  cranium, 

thiit  Iwiiig  the  region  most  iiiflueiiced  by  tJie  oontractcd  iiiiiM!l<tt. 
Tlie  chin  is  drnwit  U>  our  »! Je,  aiiil  ap|)n>»<>)Kw  llio  left  tthoultler  ;  tlto 
rijjhl  WIT  is  op]>i'o\iniat«l  to  tlio  §ternal  extreiiiity  of  tlift  oinriclo. 
The  stern o-ck'id<»-iH list' )i4le II*  of  l.lio  nfIW;U'(I  Midc  (right)  has  lo§i  ita 
Byiimiulrv,  l>eing  reduced  to  a  coraparativoly  narrow,  hard,  tight 
^  tiord,  three  indies  in  k-ii^h,  Uio  nuui-Jo  of  tho  opposite  side  mea- 
^^L<nring  livo  and  a  half  inches.  This  prominent  i^ord  i.t  double  below, 
^^lepresenGnj;  the  doublw  origin  of  tin.-  init«c]c.  In  the  adult  a  marked 
I  upu'ard  bond  of  tlie  clavicle  ia  seen  whore  the  clavicular  portion  of 
the  contractoj  iimnclo  nris'-*,  induced  by  the  constant  abnormal 
traction  tio  wliicli  tlie  bone  tias  been  aubjoett^l,  and  iliu  iiiforior 
portion  of  the  muHclo  itself  appoam  of  cartilaguious  or  osseous  hard- 
^^k-jiew,  and  i>>  lust  in  a  large  hony  procetu  on  t)i'-  pn>titbcnint  vluviclc. 
^V]f  we  examine  the  neck  and  shoulders  posteriorly,  we  ohserw  thai 
I  tlio  cortical  vurtobrjo  hav«  yielded  to  the  dragging  of  the  contractod 
I  muscle ;  this  part  of  the  x'ortt'bral  cohunii  presenting  a  convi^xity  on 
I  tile  left  side,  which  is  comix-n-siiloil  tor  by  «  curvatura  in  the  oppo- 
I  mUs  direction  lower  down.  The  right  side  of  the  hoail,  neck,  au<l 
^K  light  sbouldor,  are  con*i<lcrably  smaller  than  the  pnrts  on  the  opposite 
^Fude ;  the  right  shoulder  and  scapula  being  luiduly  raisivd.  A  fingnlnr 
effect  ui>on  the  face  n.'nults  from  thiM  ditTorcnco  in  size,  combined 
with  the  impediment  to  the  function,  wliieh  the  abnormal  |>osition  of 
die  bead  involves.  In  the  adult  case  from  wliich  we  describe,  so 
great  i»  the  diilorence  in  sixe  between  ttie  two  ><idi.^  of  the  face,  that 
on  the  right  side  the  external  cantlius  of  tlio  eye  is  distant  from  tlie 
external  aiif;io  of  the  tiioulJi  thitx-  iiich(^i,  wliiUt  i>ii  the  IvA  tlie  dis- 
tance amounts  to  tlu-oe  and  a  half  inches.  The  hiclination  of  tlie 
liuad  to  tlitt  right  caiue»  llie  right  eyo  to  be  Imhitimlly  »ituatod  on 
a  still  lower  plane  than  would  bo  tlio  case  if  atrophy  of  the  affected 
side  w«>rc  alone  o|H>rativo.  1'he  ntn^iby  and  Hin  slight  bending  fi»w 
wanb>  of  the  heail  iiilerfbre  with  tlie  direction  and  use  of  the  right 
cj'o.  and  cause  a  jK-tMiliar  ex[>r<TK.'(ion  of  iin^^hncss  and  »enso  of  ditli- 
oul^  and  sufl'ering.  These  features  of  tlie  deformity  are,  as  already 
mentionnl,  prujuirtionully  less  iiiarkod  in  early  lile. 

.  The  princi]>al  muscles  o»  Uio  front  of  tlie  neck  are  probably 
involved,  the  trapezius  aiid  scali^ni,  a*  well  as  the  stemo-mastoid. 
In  Uii*  and  other  resjiecW  congenita!  wry-neck  oflers  much  ana- 
logy to  congenital  club-fout.  The  ])rincij>al  contraction  affects  in 
bolli  ca.-<es  muscles  whidi  pass  over  more  than  one  arti<tiihition,  the 
■tenio-clflido-mastoid  in  ono  case,  the  gastrocnemius  in  tlio  other ; 


593 


ORTHOPEDIC  SURGERY. 


Iipntv  in  tlir  twx'lt  tins  miseliief  of  morbid  contraotion  miiy  cffV'ct »" 
higher  degive  of  deformity  tlian  if  tli«  t-untractod  miuoto  intluenc 
OHO  articiiliitioii  only;  in  (lie  leg  tbo  ooiitractfid  gn.'it.rDcnuiiiius  da 
not  always  limit  ite  evil  influciic«  to  lli«  foot,  but  contracts  and  dJa-' 
torts  tln'  kiiw.     111  lioth  nry-ni'i;k  and  cltib-foot  otJier  muxcles  ; 
tioipate  m  tJio  defonnity ;  but  tbo  mngo  of  iii6a«nc«  of  iheite  bdnj 
less,  or  being  coiinttTucltyl  by  ntitagoniitt  povrcrt^  tbeir  contraction' 
ift  not  80  appai-eiit.     It  is  an  int«t«sting  question  of  pby»iiul<igi(!td 
pathology,  wbiHbcr  there  in  any  thing  Aj>ecial  in  ttio  anatomy  and 
fonotion  of  tlie  at<>rno-niii*toid  and  gastrocueinius,  that  tliey  xhciuld 
obtiun  tbo  dixtinction  of  vntiriug  into  m  large  a  [miiKirtion  of  cases 
of  congenital  and  acquired  dotormity.     Tbo  gaatrooncmiii»,  by  it*j 
great  ^^c^■eloJ>mcnt,  il»  grwitvr  nervous  i*H[>])ly,  and  ib*  rtlation  fo| 
tlio  upright  ataturc  and  locomotion  of  man,  is  certainly  cnlJtitil  ttti 
a  peculiar  and  elevated  rank  in  conipitrutivv  an<l  LuiiiaD  myology; 
sOf  when  wo  roflont  upon  the  size  of  the  stemo-cleido-mantoid,  it« 
n^Iation  to  the  Iarg«  vcwwls  of  Uie  bead  and  neck,  its  deriving  ita 
neiTe-powor  mainly  from  a  special  nerve  (s]>ina)  aeceworj),  and 
remember  tlie  influence  of  this  muscle  upon  tbe  aet  of  respiration, 
wo  cannot  deny  it  a  preUminent  function  iiniongHt  its  noighbouriug 
muvetes. 

We  bave  elsewhero  .ihown'  that  not  imfr&|Ui'nlly  "  ry-mi-k  ap- 
pears to  residt  from  straining  or  injury  to  the  neck  during  difiioult 
lahiiur,  from  traction  of  tlie  hcitd  bj'  itislrurnenl^  It  i:*  nuirtIIuous, 
after  what  wo  have  said  of  the  causes  of  congenital  club-foi»l,  p.  5(i.J, 
to  rcful*'  in  (ii^jiil  till'  tbwuy  which  would  attribute  wrj--nwk,  bko 
dub-foot,  to  accidental  uterine  or  pelvic  prct^ure.  Congcnilitl  wrj-* 
nock  dearly  originat^H  from  caiues  acting  tlm>ugb  iho  acrvoua 
syatem. 

Titat'inent.  It  Is  probable  Hint,  as  witb  slight  congenital  club-foot, 
90  alight  cases  of  congenital  wTy-ncek,  if  early  dct«cte<l,  nrc  remov-  , 
able  by  frictions,  manipulations,  and  subsequent  education ;  but  all  1 
the  cases  we  liavo  seen,  varying  in  ago  from  furir  lo  furty-fivoycarw, 
have  exhibited  so  much  contraction  and  proportional  secondary  de- 
formity, that  wc  liavo  in  no  ctiMi  detiivi^  division  of  tl»  stomo-  | 
cleido -mastoid.     It  bas  always  seemod  justifiable  to  gain  at  onee, 
by  means  of  tliiH  opcratii>u,  ii  large  meusure  of  relief;  lluii*  aflbnling 
an  encouraging  staxting-point  for  the  after  labours  of  the  attendant 
in  overcoming  Ihc  Bhortcning  of  ihr  iiitcginnvuts,  phitysnia  faseia', 
associated  muscles,  ligaments   on  the  hollow  side   of  the   neck), 


*  Tntnt.  OUM.  See.  iWM. 


DIVISION  OF  STERNO-MASTOID. 


593 


gradually  to  aot  upon  the  altorwl  relation  of  the  artJcttlsr  feoeta 

In-  itK-liiii-Hl  viirU-linc 

IHvmaa  of  the  eUmo^lfido-i»asfoi<Uiu  is  pErTornifld  subculane- 
ttfidy,  ii)K>n  tiio  prino^lvit  proctiMHl  l>y  •!;1roim-yor  in  divi«ion  uf 
Ab  bciido  Auliillis,  v)£.  eSMtin^  the  division  bv  the  mnallest  possible 
wound  in  tlio  intvf^mentv and  tlic  imnvxnoxt-  trad  tlirough  t)ie  sub- 
cutAiieouB  tissue,  and  avijidin^  any  cttema]  bleeding  or  extraram- 
turn  of  blood  into  tlK^  iirtoliir  ti'nuc,  or  adinimoii'  of  air  into  il. 
Nfiglect  of  tbese  precautions  would  be  ealnidated  to  exoite  suppu- 
ration and  pntvonl  iniin<^^liat«  boding  of  the  puncture,  and  dt-lay 
untowanlly  the  employment  of  tbe  neceswii^-  alU-i'-tn-ittment,  until, 
porhap*,  the  sercrLHl  tondon  might  bo  rounttod  and  implieatod  in  tiie 
fiun-ounding  adhetiions,  tlie  case  tliua  becoming  less  ainetiable  to  tlie 
iicci'swary  tnerlianical  treatment  than  bctbro  operation.  The  niwt 
ohoHen  for  liie  ojierution  should  he  tliat  at  which  Xhe  tendon  sprmgs 
ngidly  acroM  llw  important  subjacent  orgnni>,  and  nhuro  «on]!«- 
lly  mo^t  sfmce  is  ufTordiil  fur  introiliirtton  of  the  ti>notonin 
benaath  the  tendon  n-ithout  risk  to  thoae  organs.  In  wry-nock  tltii« 
•pot  will  Im  fonnci  lr(»n  ^  to  -^  at  an  inoh  abi>ve  the  elavielc.  It 
i»  also  more  easy  t<3  sever  the  muscle  entirely  by  keeping  at  this 
dirtnncv  fi-oni  the  hime.  In  Homo  eusrs  wu  have  fiiuiid  tho  !«lt>riml 
portion  only  developed  and  rigidly  eontraeled ;  a  few  weak  fibres 
Httn<!it<Til  to  Uic  elaviolo  Iwving,  buf(>re  the  knifv  renchecl  thein, 
yielded  to  the  tension  niHtniained  by  the  a^ist.-mt.  In  oases  in 
which  tlu!  clavti.-nhir  origin  of  the  miiHcIc  u  broud,  it  i»  safer  to 
divide  tlie  sternal  and  clavicular  portions  each  by  a  separate  pmic- 
lure,  rather  than  piiss  thv  knife  by  one  puncture  nindo  in  front  "f 
the  neck  as  far  back  as  may  be  neeossary  to  rojieh  the  whole  of  tlio 
duvicuhu-  |»ortiiiii.  Tbi.'  precaution  isjustifit^  by  t^io  nntin-ior  aiid 
posterior  edges  of  tlie  muscle  not  being  on  a  |>lane  surface;  for 
allhi'iigh  fhe  fascia-  of  the  lower  part  of  the  neck  may  uonally  bind 
down  suftieiently  the  vessels  and  nei-xes,  and  so  keej>  them  out  of 
dangi-r,  it  is  well  to  romcinlicr  tlie  liability  of  meeting  with  abnor- 
mal di»tribntion.  The  eomphu-  division  is  accompanied  by  a  very 
Hcnittblo  craol:,  and  the  head  at  onco  asiumex  a  much  improvod  coo- 
dition.  Wo  hnw  measnrwl  imniitliarely  arter  operation,  and  have 
fbmid  the  ditl'crcnco  in  length  between  the  sffcdcd  and  sound  ninsulo 
reduci'd  more  than  one-half  The  puncture  ^.liould  at  once  be  co- 
vcnid  with  a  compress  of  lint,  and  a  wmimon  baiidngo-  bo  applied. 
We  Imve  found  no  luinu  result  in  the  case  of  tlie  stemo-<'h.Mdo> 
mai^loid  in  allowing  the  ends  to  separate  as  lar  as  tboy  were  in- 
clined.    In  young  and  Hexibte  subjects,  we  hav«  fountl  adhesive 


594 


ORTHOPjEDIC  subgery. 


|iWtor  nni  a  cniuinoii  ri>IKT-biLiKlii^  an  amply  suiBoient  raechanioJ 
coiilri%-aiur*  to  aid  in  reciiti cation  of  iIk!  \uiaii.  Apfiy  a  long  strip 
of  mUmsivc  ]>lMt«>r  ftrouiiil  Uu!  forehead  and  occiput,  its  ituunteniince 
in  pmitiun  twing  better  eoeured  bv  a  bandagu  pomcd  ovor  tlic  vertex 
and  boiK'vtli  tla-  v\tm,  tlku  two  licin^  [>iiin«d  logetlior  wlwrv  tliu  one 
jiawuM  over  tbo  otber,  above  the  cant.  Next  attach  around  th«  wwst 
a  broader  buixl  of  odbi^i^'v  pliwtt^r,  not  mi  tigtil  an  lo  inb!rfirn'  with 
iJio  inovesacnts  of  tiie  ribs;  over  tliis  a  turn  or  two  of  calico  roller- 
bandago;  the  two  Kliouid  be  fiiiitvnod  toj^^hur  \iy  a  Mitch  lutre  aj>d 
thero.  The  Surgeon  has  now  two  circular  bandagea,  tlw  one  around 
the  Ibruliuul,  tile  ollu-r  iiiuuiid  tin.'  waiHt,  wliich  are  itot  llkvly  to  slip 
if  prt^ierly  applied.  He  sliould  thou  sow  a  atrip  of  ribbon  to  tl>e  head 
bandji|;c  dinti.Tliy  aUitt-  tin*  car  of  (lie  unairi^-tt-d  i>idc\  and  carrj'  it 
<U»gtiiialty  aoroi^  tike  trunk  to  tlie  oppuiite  Mile  of  tlie  waist  band* 
age,  and  thcrv  pin  it  By  this  tncaiu  tlic  IcH  ina«t«iid  pruoces  (we 
are  speaking  of  wry -neck  oatised  by  ountraction  of  tlie  right  atomo- 
niastuid)  will  ix.-  drawn  towardK  tlic  right  HUtmo-clavicular  articula- 
tion, tlie  original  wry-neck  be  removed,  and  the  chin  bruuglit  to  ihe 
modinn  line,  or  iti  youii^  »ud  fU^xIblc  subjects  ovun  across  it,  ton-srds 
tlie  afiected  eidc,  cou.->tiiuliiig  a  ti'uipurury  wry-neck  in  tlie  oppwita 
direction.  Tliu  circular  or  ovoid  form  of  the  cranium  renden  it 
difficult  to  act  upon  it  for  any  longtli  of  time  by  any  apparatni* 
hitherto  invpiitcd.  Tlie  appai'atus  will  shiil  ite  direction,  or  ratber 
tlie  Iiead  will  partially  ditteniiTigi!  itiielll  Hiiiue even  a  gn-jilcr  neces- 
sity for  inKtii|>iilati»ns  exists  in  wry-neck  tlian  in  other  defonuitiea. 
No  apparatus  eftecta  so  btHH'liiiial  uiid  lasting  an  iinpn-wtioii  upon 
the  distortiou  a*  the  luiuds  of  tlio  Surgeon  or  atlendauL  Whilal 
one  hold^  riowu  tliti  Hlioulclcr*,  tbu  otber,  standing  behind  tliP  patUnit 
seatod,  should  apply  finnly  hia  flat  hauda  to  the  sidea  of  the  Iiead, 
and  diruct  llie  <-liiii,  verlvx,  or  occiput  in  tbo  rc(|uirvd  dinvtions. 
Such  niatiipulatious  need  to  lie  doiio  with  duu  caution  and  tocliniuid 
akill.  It  i.4  not  iK-oc^iary  to  cause  juiiii  in  order  to  producv  much 
good.  Tlicy  should  bo  I'uiijloyod  tlin*  tiniea  a  day.  The  pUi.«t«-.r 
and  roller-lwiiliigi'  wliicrlj  wv  have  di:«(Tibod,is  most  convimiont  in 
rvfercncu  to  thc^e  luanipuii^ioiiH.  It  may  be  unpinned  in  a  rao- 
ineiit,  and  tm  (|uic)cly  readjusted.  Wo  luivc  cured  many  cases  by 
the  iQ<--uns  here  euumerateit,  in  |H>rio<bt  varying  fruin  one  to  thruo 
inontbii,  and  liiuu  ni>\vT  had  occasion  to  rc|K*at  tlio  operation.  Hani- 
pulatioDH  as  a  praeaution  agaiiktt  nrlapm^  nuiy  bo  longer  retorted 
to ;  but  the  patient's  vukiiitary  eftbru  ore  mora  employed  for  ob- 
vious reasoiiit,  and  are  more  Muv^CMd'ul,  than  in  xuine  otlier  oongum- 
lul  duformities.     An  aj>paratU3  similar  to  that  dc«ciibed  p.  69?,  for 


NOX-COXGENITAL  WKY-SECK. 


595 


rv«tili«t!on  of  the  position  of  the  heail  in  ileformih-  from  vertobnj 
diaeaae,  may  be  oniploycd  in  cases  of  adult  coiiguuitui  wry-tM.-ck 
during  some  portion  of  every  tvrenty-four  hount.  It  rcoulily  eflects 
re-poiiition  of  the  hitvr^  or  forward  iiiclinatioii  of  tho  hciitl,  but  is 
powerleea  to  alfeot  Uio  abnomuil  rotuUuu  of  tlie  head  round  llw 
liorisoiital  axuL 

At^iitrvd  or  ntm-mngmitid  rpwtmoiiii'  wty-neck.  We  liave  seen 
Mvural  cast's  of  active,  violent  spasm  of  the  sleriio-mastoid  in  un- 
married femaleti  of  middlu  and  Bdvimccd  a;^  oansing  severe  wry- 
Ttixk,  Tho  spasm  is  cuninioiily  jerking ,  irrofjular,  coni-nlsivo.  never 
ceasing  ealin^ly  whilst  tliu  putioiit  i^  awake.  Tliu  (ti^onler  hiui 
OHually  commenced  about  the  age  of  thirty  in  subjects  not  ohviously 
liysterical,  jK'nons  of  csct'Ilcnt  int^illoctnal  aiid  miciul  oharaeter, 
whow;  families  have  seenie<l  prone  to  other  cerohro-spinal  aflection«> 
We  haw  waU'iii-d  xovcral  of  Uibso  cn*e»  fur  many  ywir*.  The  spam 
and  <Ieformity  have  ni  every  cjiao  gradually  increased,  often  rendfflr- 
ing  tlie  piitii^ittV  existence  distn-Ksin;;  tbrou;^  in<ww>juil  motion  of 
the  head,  disturhaiice  of  ttleep,  and  [>ain  in  the  neck,  aj>paront]y  due 
to  ittraiii  ol'ligamenta  and  ncrvc-distnrbaii«r,  and  Mtmelinios  aocom- 
paniod  will)  pain  referred  to  ttie  upjier  part  of  the  spinal  cord  itself, 
OS  in  »onio  cases  of  "^inal  irritation."  Now  and  Uten  lite  s[>aHm 
is  so  considerable  riiat  the  ear  ol'  ilie  afiecteil  siile  is  drawn  down  by 
ft  iicri<»)  of  jerks  so  as  almost  to  touch  tho  clavieltt,  Thi;  patient's 
Tohintary  eltorta  to  iuTi<at  the  pulling  down  of  tlie  Itead  appear  to 
increase  tlio  disorder.  Such  patients),  bein^  compelled  to  i-ndea%'our 
to  steady  clio  Ix-ail  with  mw  hiuid,  !*i-]doni  ap]H^r  in  public.  Wa 
have  employed  mineral  and  vegetable  tonics,  galvanism,  and  elec- 
tricity, with  only  tiyinjiorary  bt>nefiL  However,  as  uii^lit  bo  ex- 
peeted,  guncrousdiet,  liygiene,  and  freed<)m  from  mental  (iisturbaiice, 
alleviate  tine  .tji-mittomx.  (loiujJete  n-Hef  i»  atibrded  by  subL-utaiieouv 
lenotoniy  of  Uic  aifccted  sterno-mastoid  ;  but  cvi.ii  thiM  nii-asure  is 
only  useful  for  a  tim« ;  f»r  aflor  two  or  tlu*i¥  niontlis,  or  as  soon  as 
rouuion  of  tlie  severed  part  is  complete,  tho  spasmotlic  nliortening 
and  jerkin;;  nlurii.  Stromi-yrr  hiul  »  patient  wIk>  submitted  to  tw<» 
ntfictitiuns  of  tenotomy  for  the  sake  of  the  tcm|>oniry  n-iief  afforded 
by  the  ojienitinn.  Tho  autiior  oiiee  opcnkted  on  an  elderly  temale 
who  had  sulferMi  from  spa-imndic  wr^-ueiJ:  upwanU  of  twenty-five 
years.  She  bad  been  unable  t<>r  miuiy  year«  to  sleep  in  the  recum- 
bent position,  hut  donc^  in  a  high-backed  nurse's  etuiir,  provided 
with  nidv-MipixirtH  for  the  head.  For  »  few  nights  after  the  opera- 
ration  she  slejit  soundly  in  hi<d.  Tlic  nudady,  liowvver,  returned, 
aiul  «ti«  ultimately  sank  cxhuui>l4Hl,  want  of  sleep  apjiearing  to  bu 


596 


ORTHOPEDIC  SURGERY. 


»princ!pal  cau«o  ofilic  fatal  rrKiiH.  Tho  oix;niti<ni  on  tlie  trtrmo- 
□laMtoid  iH  ill  sufficient  to  aifc>el  Uie  remaiDuig  iuu.hcI(»,  wJiieh  are 
sonictiines  involved. 

Pamt-fili'  trfj/->iiW(t  is  rare ;  w«  have  not  RSen  mora  (lian  three 
eases.  Tlio  h«ad  ls  drawn  to  ooo  sido  by  Ui«  healtliy  muiiclv,  wliidi 
18  dtiprivod  of  it*  aiitJiBonidt.  Si>nii>ti(nea  a  «R»e  onptir*  in  whidi, 
in  consequence  of  difficult  birtti,  the  head  falU  helplessly  to  ono 
side  more  thnii  \s  cominuii  tJ>  iniw-liDm  iiitimt.*,  jmiliiJily  t'nuii  n\t^ 
ehanical  injnn,-  to  some  of  tlie  Mrurtures  in  the  neck.  Such  cases 
rcBCinWc  wrv-nock  from  piiriilv^i",  bill  difii-r  liv  the  Iiislorv,  and  bv 
the  evil  being  less  confined  to  Uie  stenio- mastoid.  These  w«ik 
ncckft  fmni  injiirj-  at  birth,  ax  fur  b«  wo  have  had  tJic  o|)i>ortunity 
of  watching,  have  gradually  recovered.  In  paralytic  «Ty-n«rIt, 
wlwrn  thi^'  stsfp^"  for  wnliiiary  t.rcutini'nt  of  (ho  piininl  jKinilysin  has 
pasi^,  we  can  do  no  more  than  support  the  head  by  tlie  padded- 
Icnthcr  or  »twl-*])rinfr  cravat.  Excopt  when  the  unparaly*sl  st«mo- 
mustoid  is  structurally  degentrated  or  ver»-  rigiilly  contracted,  and 
i»  in)iii.icc|iltbl«  of  olonpiti on  by  munipnlntions  or  nioclinninil  treat- 
ment, it  would  he  as  irrational  to  employ  tenotomy  as  it  is  in  a 
CTiJte  iif  contfat-led  Kiistrotmoinini*  which  has  simply  lost  its  anta- 
gonist, and  which  can  be  relieved  by  a  auitabl«  intwbanionl  ftiipjKtrt 
without  npi-ration. 

(l'rr/-nrt/-./wrH  rfixmae  I'f  the  ivrvu-al  vtrlffmr,  i«  valued  by  «tm- 
niou«,  and  soniclinics  by  rho um at ico -strumous  disease  of  ono  or 
more  cervical  vcrtelira\  fi-oin  wliiirh  (bo  lu'ail  iiicHntyt  to  tli«  affw^tJ 
side.  The  chin  ie  directed  to  ono  aide,  although  this  feature  ts  leas 
nmrkeil  t.hsiii  l.lio  sidi-wiiril  fiilllnii  of  tin;  head.  In  bulging  of  tho 
opposite  side  of  the  neck,  and  in  general  ai>pearanee,  these  coxa 
much  n-M-uible  (>iin;^nit:i1  wry-nwk,  but  aro  distinguished  from  it 
by  tiioir  history,  the  jiain  on  motion,  tho  asfiect  of  strumouA  or 
COiislittitiunai  disorder,  by  bix-lic,  by  tho  itistiDcti\-«  aversion  of 
tho  patient  to  the  Surgeon's  handling  of  the  head,  and  oonvrimitoiit 
glandiiliii-  or  nther  fortiw  tif  ntj-iimous  disorder  in  tho  one  case, 
or  rheumatic  affection  in  the  other.  The  |iatlK>logi«ciI  ehai^M 
common  to  di«ert»e  of  the  vortebrn.'  in  each  region,  and  it*  peculiar 
dangers  when  situated  In  the  neck,  are  descnlied  in  a  .inli!^-qiient 
essay.  (JroJil  c-auti»n  i»  ni-oiswary  in  handling  these  cases,  lest 
tho  di^integrntJng  bones  give  way  suddeidy  to  the  prcwuro,  m 
tlie  reparative  pn)ce*»  which  rnny  bo  going  on  be  inierruptetl. 
Mueii  benefit  to  the  disease  itself,  and  graduiil  im|iriivcn)eii(  in 
the  position  of  the  hoad  and  neck,  may  bo  effected  by  a  well- 
adjust«4l  siip[iorting  and  rectifying  apparatus,  as  well  as  by  tbe 


I 


5 


KSOCK-KNEE. 


597 


recognised  moilicinal,  durtotic,  and  livgioiiic  trcatjiient  ofUio  coii- 
stituLionnl  malady,  Tlie  most  efhcicat  apparatus  cunnt.'<u  of  a 
pndded  luctitl  |iliit«,  socriircd  hy  strups  bviiuutli  the  asilk  iind 
around  tlio  chest  upon  tho  shoulder  of  the  side  to  which  Uui  liead 
inclines.  Fi-udi  tliis  KliouliUn'-pwl  aii  iron  upright  piooo  extendi 
upwards,  hy  the  side  of  the  neck,  to  tlic  pariotai  region.  The 
lower  end  of  tliis  u|)riglit  i*  attaohuil  to,  and  moves  upon,  tlio 
fihouldcr-platc  by  uieajis  of  an  endless  ratchet  screvr;  tlio  upper 
end  is  oi>niiuot«H)  with  a  pud  intended  to  Ikj  adjuntctl  «iid  prcssnd 
against  tho  parietal  region.  In  adults  and  very  severe  cnw.is,  this 
ap[).-uiitu»  may  lj«  uttac.hi.'d  to  a  common  ifpiiial  stipporl  for  tho  chest 
and  pelvis,  for  the  sake  of  greater  fixity  and  more  powerful  lever- 
age. SonielimcM  an  iron  stem  is  rc(|Utrx)d  to  extend  ujiwards  on 
one  or  both  sides  of  the  Iiead,  willi  connecting  straps  to  be  uppUed 
beneath  the  chin  and  ucei|iut,  so  as  to  receive  tlie  weight  of  tho 
hc^id.  Much  ojiportunity  for  the  ingenuity  of  the  in»truinciil> 
makers  is  nBordod  by  Uiose  cues.  In  llio  pn^i^ent  duy  we  do  not 
find  it  necessary  to  cm|)loy  tho  cumhrous  and  unsightly  inncliincs, 
COn:Usting  of  an  iron  seaifold  and  gibbet  for  suspension  of  the  head, 
to  which  Surgeons  re»ort«d  as  lutely  tut  the  (■oniniencemeut  of  the 
prewnt  century. 

KiiOfh-httf,  In-knee  {Genu  vafffHJn). 

Tliis  fny|uein.  deformity,  of  which  instiinocs  arc  met  with  nt  all 
ages,  eonsiiits  of  an  iiiwui^l  yielding  of  the  knce^joiuL,  in  eonsc- 
quonce  of  weakness  of  tlie  ligaments  and  muscles  which  re.-^ie(!tiv©ly 
connect  or  surround  the  artii-iiliir  extremities  of  tlie  femur  and 
tibia,  lu  causes  ai'c  identical  with  those  whiob  produce  iu-ankle, 
or  flat-foot  (talii>es  valgum  npiiriiis),  p.  585. 

Abnonnal  stati:^s  of  general  nutrition  in  children  and  adolea- 
OmtSf  dependent  upon  insufficiency  or  improp<'r  ijualily  of  food, 
aio  »  common  predisposing  cause  of  this  deformity.  Sonietimea 
it  appears  probable  that  tlio  constitutional  wcakut-ss,  or  laxity  of 
tissue,  has  been  engendered  U«s  by  unsniiable  supply  or  quality  of 
(bod  than  by  imperfect  assiniitnlion,  owing  to  defieient  al-ration  of 
tho  blood,  as  in  childi'cn  reared  in  exmlined  dwellings,  both  in  town 
and  eoniitry.  in  many  eiwe*,  the  abnormal  nutrition  proceeds  to 
tho  length  of  developing  an  unmistakable  rachitic  condition,  knuwn 
by  the  «o-exiHt«Mie«  of  tho  [HKruliar  cnrx'ntures  of  bones  which  elia- 
ractorise  that  disease.  Our  obaervatlon  of  tlic  numerotu  gradations 
of  knoek-knoc  met  witli  in  young  cliildn^n,  varying  in  outward 
api>cartitKO  from  tlie  uiusl  flourixhing  Iicaltli  to  tlie  most  miserable, 


598 


ORTHOPAEDIC  SURGERY. 


wiwtOfl,  «n<I  rlmHmJ  extreme  rickets,  haa  cnnviiuwd  us  thnt  evon 
in  the  uligliW  forms  of  knock-kn«i' a  <lcr;rco  of  impaired  assimilation 
of  fwx\  nnd  Kti  niinonnal  RUte  of  blood,  limitar  to  lluit  nretent  in 
raoliilis.  exists.  In  thcso  sliglitcr  casoa  of  knock-knoo,  trac«t  of 
rafhiti"  will  hv  t'lmnH  in  promiiiflnoc  an<I  detftmiity  of  tlio  tyirtilapvs 
of  the  ribs,  flattening  of  tli<>  sidw  of  tlio  chr»t,  and  sinking-in  of  tlie 
Stcmtim.  Oni!  «r  inon>  sovfn»  nttackn  of  broticliitiM,  or  br<nK'bo-j>non- 
monis,  have  fi-equently  been  witJi  justico  regarded  bv  the  frtendii  lui 
Oic  fonninncr  of  tln!  "wi-akm^ss  of  tlio  limU."  In  many  instanoM 
the  earliest  link  in  the  chain  of  «iUBation  has  been  an  erivir  in  thn 
infiuit's  diet;  namt'ly,  Ihr  xuK-ttitution,  for  an  in"iifficiiMit  mipjily  of 
braast-Tnilk,  of  farinaeea  boiled  in  reater,  witli  ilie  addition  of  little, 
if  any,  cow's  milk.  SonnHiinoH  wo  may  iwcend  a  (U-grcc  higher, 
and  distwver  an  hei-editary  pathogcnetical  influence,  Wa  tiavo  wrp- 
ral  timM  obtcrvod  knock-kncv  in  mnall,  dolicati*,  prcmnturely-born 
etiildirn  ;  the  limbii,  as  a  cons«inMice  of  general  weakness,  having 
yielded  tn  the  snprrincwmlient  weight  of  tlic  trunk.  Sueh  easea 
ahould  not  be  ennfounded  with  ttie  inivrt«i  flexed  and  contracted 
knccA  which  occur  in  childiTii  wlio,  in  eonw^qucnce.  of  premature 
birth,  luiv4>  <tn(r(!reil  fi-om  asphyxia  iioonatonim  (p.  ASl).  Kiiock- 
knco  oden  shows  itself  bcfuro  the  child  has  attempted  to  walk,  thia 
net  being  oeejisionally  (Jolayw!  by  it  as  mue-h  as  thn-e  or  four 
years.  When  the  deformity  attains  a  certain  grade,  it  may  iii> 
creitstt  rapidly  IWim  iho  ofl'ecta  of  walking,  or  it  irniy  iDcrcase  so 
grmtiuilly  as  not  to  excite  tlie  parent's  anxiety,  until  at  longtfa, 
alxmt  the  Hg«  of  «'vim,  ti>n,  nr  twclvo  yoAm,  the  chiVI  is  again 
"thrown  off  tho  feet,"  and  beeomes  ineapabto  of  walking  wiihntit 
crutclies  or  otlier  Bupport,  Tlii?  deformihr  often  takes  place  in 
tall,  raimlly-gmwing  lads  from  ttio  age  of  twebc  to  eighteen,  who 
may  have  exhibited  no  prcvioius  tendency  to  it.  Undne  exerdse,  and 
fatigui-  ill  Hinnding  and  walking,  with  litte  hours  and  the  [Kiii*oned 
atjnoBjjhere  of  ill-ventilaleil  places  of  business  and  dormilorieR, 
apiM-ar  in  wich  individtiaU  to  have  contributed  to  the  complaint. 
Undue  strain  upon  a  sound  limb,  in  eonaeqiience  of  some  other 
defect  in  the  opj>o»it«  limb  throwing  incrvasLyl  exertion  and  weight 
upon   it,  may  prwhiee  thin  deformity. 

Trfitlmetit  of  knock-kwe.  We  have  heard  it  maintained,  tliat, 
as  a  nde,  children  rtwover  ft}H>ntniieouNly  Irom  thii*  afleclion.  In 
a  smidi  piY'pnrtion  of  cases,  spontaneona  recovery  of  good  power  of 
walking  takes  place;  but  an  examination  of  such  iu»tanoo»  ha* 
shown  us  evident  traces  of  the  aft'ection  in  tho  persistent  enlarge- 
ment of  tite  intenml  condyles,  with  inability  to  take  long  walks  on 


KNOCI\-KXEE. 


59!) 


N 
N 


•evsrnl  mcpoHiivt*  <]•/•*  witliotit  woiikno^  jiihI  i«in  on  tlic  inside 
of  th»  kn<xi  Sliglit  ca«ea  will  recover  under  improved  diotctic 
aiui  hyfE:tc»ie  inflii«n«!«,  willj  tho  aid  of  siiiUblt'  tniiiiiiiuktions, 
and  tlio  discontinuance  of  premature  f/^at-liing  the  child  to  walk. 
8i*iii«CimeH  ««  ran,  in  niltlition,  adviint(if;iioiwily  njcmnun-iid  the 
jretrumbcnt  posture  <luring  certain  short  periodH  of  the  day,  and 
combine  with  thin  rcpow  tlio  placing;  a  wft  [nwl  Iwtvrneii  iHo 
coiulyli.'ff,  tho  limbs  being  ext^wled,  and  tJie  ankles  being  gently 
drawn  towards  «aeli  otlux  by  mwuis  of  a  aoft  banda-^n,  i4raj»,  or 
other  li^Utro.  In  carryinsr  out  Ihia  plan,  wo  require  to  watob 
tliat  tho  knoiw  be  not  too  fiilly  vxtontiod,  i  c.  bent  bsiekwards  be- 
yond the  horizontal  Iin<«  of  the  couch;  m  ctmdition  apt  to  ensue  M 
another  c<jn«ttjncnco  of  tiuduo  laxity  of  articular  lignmonto.  In 
woTwr  cases,  more  jjcmi.iient  meeliaiiinnl  means  are  requisite;  simpl? 
padded  wooden  splints,  a  short  one  applied  behind  the  ktioe  to  pre- 
vent flexion,  and  a  lonj;  one  reucliiiij:  fcmi  tho  trochanter  to  tlio 
malleolus  cxtenius.  not  too  tightly  bandagtil,  may  suffiec,  Miwliti- 
cations  of  such  Kplint.'',  ej)iistrni'te(l  of  mtttjil  or  wood,  articulated  at 
the  kno(>,  furninhed  with  u  ratehot-scrow  to  permit  adju^itnicnt  to  the 
inward  inollnntioii  of  tlit.'  knee,  and  MM'umt  by  Htrapti  and  buekle«, 
may  I>o  found  at  most  instrnmenl^nakers'.  On  tiio  whole,  even 
in  moderately  wvcre  caso*,  but  especially  in  aggraviited  oaaos,  no 
apjKiriitns  is  so  efheient  as  a  well-constinicted  iron  to  extend  from 
tlie  [lelvis,  on  the  outer  tidn  of  (ho  limb,  !u>iHi-tin)i>st  on  Ixith  sides 
of  the  limb,  to  the  bottom  of  tho  shoe,  tlu^  hip  and  anklo  joints 
being  left  free,  the  kn'V  /xni  in  a  luimcwhaf  improved  position ; 
which  may  bo  further  rectified  from  time  to  time,  as  tho  progrcwt  of 
tlio  i^anu  demands,  by  mcaiiit  of  tli«  ii<IJti*ting  scit'W  or  str.ipB.  The 
^>argcon  should  He4>  that  tlie  apparatus  is  eonstructed  with  duo  n^ 
gard  to  tlie  anatomico-pathological  and  the  mccbflnieai  want«  of  the 
caxe.  For  example,  irons,  to  be  promptly  effective,  need  to  take 
auilabte  [lointx  of  Mipport  againot  tho  upper  part  of  tho  ootnido  of 
tlio  thigh  and  the  lower  part  of  the  outride  of  tho  fibula. 

Severe  casus  require  tlio  knee  to  be  preiwiiled  from  bending 
when  standing,  during  a  jM'riod  varying  from  tlireo  to  sLx  montlis; 
tlien  freedom  of  motion  during  a  part  of  each  diiy  for  a  similar 
though  variable  [Mn-iml ;  and,  lastly,  perfect  freedom  yet  a  fow 
month*,  before  discontinuance  of  the  mpporc  Th«  total  average  dti- 
ration  of  U-eoiment  of  littd  i-iw^s  in  advanced  childhood  may  ocCiUpy 
two  years.  Core  s)ion]d  be  taken  to  employ  <liuly  friclioiw  and 
roanipiilalionit,  *o  ax  to  prevent  the  knee  becoming  stiff  in  an  ex- 
toudod  position.     We  were  fonnurly  accustomed,  in  sv^crc  ui-knc^- 


eoo 


ORTHOPEDIC  SURGERY. 


ofadolflfleento,  to  iikl  llir  nUK-lianifal  treatment  bv  preriotw  spriinn 
DfUie  cuter  iiamstring;  but  tlic  obsorvation  wftlic  U-iigth  of  tiin« 
uouupicd  in  t.hi>  thMtrntiit,  iiotwitlLilfliiding  the  tenotomy,  and  in<l<^ 
a <!on^k'tiou  forced  U|)on  us  tliat  the  opcratiou  did  not  njipreuiubly 
Bliortffii  lliv  liviiIiDciit,  Utvn  ciuiMil  ttH  for  many  yeiu^  fast  to  dU- 
rontinuo  recourse  to  it.  In  adoloacontx  tbc  most  scvt-re  com*  will  re- 
cover with  tbc  nil)  of  nifinigiiihitioiiM,  <^x<:^oi »<>!«,  und  ni«cbaiiica1  appa- 
mills,  without  oonfiiionieitl  Vj  tlie  couch  ;  but  until  a  straight  limb  is 
ol>tatDod,  rocuuiUitioy,  !>y  rwinoving  tjw  weight  of  the  trunk,  greatly 
aooelorates  ret^ivery.  We  arc  bound  cinplmtically  to  protect  ti^ninA 
tbc  ojtenition  of  roino^iil  of  a  wfd;;*'-sha])iil  plow)  of  bone  from  tlia 
upper  part  of  the  tibia,  performed  by  M.  Meyer  for  tlio  cum  of 
this  di:fi>nnity.  It  is  n  »uHiciviit  cinidoninatioii  of  ihiH  severe  opera- 
tion to  remind  the  reader  that  knock-knee  ib  not  di:|M'iidwit  «i>on 
curvatniv  or  ilcfonnity  of  tho  tiljia,  lint  upon  a  renw^able  displace- 
niont  of  the  relation  of  the  articular  extremities  whicli  enter  into 
Uio  kne<>-joint.  Consequently,  an  operation  of  the  kind  performed 
iiivay  from  tho  joint  is  at  best  a  clumsy  proceeding,  and  not  with- 
out danger.  DivinJon  of  tlie  external  lateral  ligaments,  another 
o_peration  reconinieniled  for  knoek-knee,  is  (dso  utmeceasar^'. 

.'hih/lotis  ofl/ie  Knee  aiid  olfier  Art'teuUiltoM. 

The  Roecciwiful  lolmun  of  ort.ho)xi>dic  praetitionent  have  coit-j 
tributed  to  iniproi'e  the  kn«wlodg«  of  tliB  real  eiin<Iition  of  joints 
atlcr  tlie  eeasation  of  various  forms  and  dogreoa  o(  inflammatioii 
and  degeneration.    The  erroneous  notion,  that  long-con tiiiuod  rvpow 
of  a  joint  alone  sufliced  to  induce  eucb  alterations  in  ita  articular 
(turfaoeH  as  to  lead  to  bony  union,  an<l  the  remarkable  rigidity  and  | 
immobility'  winch  result  Jivmi  the  agglutinated  or  contracted  extra- 1 
artleular  atructures — fa^ciar,   muscles,  ami   ligiunenls — ^e-*|iecialiy  I 
when  dense,  fibrous,  deeply-extending  cicatrices  co-exist,  favoured  I 
tho  supposition  of  the  common  prevalence  of  tnie  hony,    irromc- 1 
diabto  ankylosis.      We   now   know  tiiat  absolute  boiiy  union  of 
arlieulur   hhH'ucos   is  a  ^umjorativo  rarity,  cvcu   iu   pathological 
cabinets. 

For  practical  purposes  we  may  divide  the  eoiiditions  tn  whidtl 
joints  contracted  from  ditiea»e  ai'e  pn-jiienied  to  the  Surgeon,  with  J 
%  view  to  tho  restoration  of  form  and  motion,  into  tliroe  daasea. 
1st.  Tliose  in  which  the  resistimci^  to  motiftn  is  fnniished  solely  or 
mainly  by  the  extra- articular  tissues.     Sfd.  Tliose  in  which,  in  ad- . 
ditiuii,  inoro  or  less  oonnidornblo  cliangca  williin  the  articulation 
have  occurred,  viz.  transformation  of  the  synovial  aurikco,  vj 


ANKYLOSIS. 


eoi 


lioiiN,  fibrous  adKcstton!*,  ei-onion  of  <;nrli)it^  or  of  bono,  mineral 
DOny  clc[)wit«.  3il.  Absolute  oaseous  aiikvloaia. 
Tbo  fir^L  fllasit  of  <!atwA  in  ooniinoii.  \Vc  li«vv  uti-1  tvitli  niiincintis 
instaDOOs  of  kiieo  aiid  cllovr-joint  ooiitrw^tion,  indu(«cl  respoclivcly 
by  seirerp,  litwfjily-extoiuliiig  l)ura»,  by  phlcgmonoun  er\t<ijH'lii»,  by 
'*  Hwolli^  \pg"  ill  which  tlie  liistory  of  tlic  ease,  tlie  state  of  obviooa 
oonii-aotioii  aiul  .-iilli(>.-<)on  of  ibo  L'^tra-articuliir  tissuoi,  toprtliw  with 
tlif  absence  of  (l]s|)lncamoiit  or  doformity  of  ilic  articular  cxtremitiofl 
of  tJw  boHCH,  hi\  no  tlinibt  in  our  iniiiils  tbnlUiv  articular  xurfiiwn, 
nntwitlubiudiug  tho  paucity-  of  motion,  or  its  entire  ab&ence,  wero 
free  from  orgunio  oliati;^'.  In  tlicjw!  ca»ei(,  restoration  of  form,  aiwl 
ofton  an  almost  coaipletc  recovery  of  apontancouo,  i.  e.  voluntary, 
movement,  iiuiy  lio  e^tod  without  difficulty. 

Tl]o  Dccond  class  of  cases  includes  aoiui'  which  have  had  a  simi- 
hu"  orijrin  (o  tiuvn;  of  tli«  fir»t  cat«'gory,  bnt  in  wbicli  tlic  injury  or 
inKamniiition  lias  extended  to  tho  intt?rior  of  the  joint,  or  at  least 
b;iM  iiiviilvi.Kl  the  ciip«id8rligaincnt.  In  titosv  cases,  deep,  retrattt^d, 
indented  cieatricQ§,  and  batidti  of  uidiirated  luivetttitious  tiasne,  peoe- 
Iratiiig,  it  may  bo  prMuinti!,  into  tho  Injlloivs  and  Binnositiv-s  of  tho 
ends  of  the  l>on&'i,  even  if  all  biifi])i.-ii  l*i  Ij«  exityior  to  the  nrtieu- 
IftUon,  tell  of  cxiKwure  of  tlu?  synovia!  mombrano  so  near  to  the 
disease,  that  it  is  in)j)robable  tliat  it  will  have  I'w^nped.  Tbc^e  castca 
•dtuit  of  roctitication  of  j>osition,  and  eommonly  some  degroo  of 
Tolniitarv  motion  follown,  but  not  alwa^**  until  montli»  or  venra 
after  !\i.-tlM  nvilini,  I'lIIc  treatment  has  been  discontinued.  Tlie  bulk 
of  till!  M.r.ijii  I  l.i:.i  .(iiisi.st-t  of  easet  n>u!tin{;  from  Nlninni  us  syno- 
vitis (?)  and  diseases  of  the  artioular  extremities,  rheumatic  and 
gouly  oonti-atrlioiH,  mid  <li.4torlionK  from  aceidviitai  vioUmee. 

Tile  slnunous  distortions  of  the  knee  usoally  present  consider- 
able mobility  within  a  linul<.vi  range,  with  much  dctormity  and 
proni  ill  once  of  the  internal  condyle  fi-om  subluxation  and  Irom 
vaating  of  the  menilior  abovu  and  liclow  the  art Jouijil  ion.  Titer  are 
usually  straightened  without  ditlJeulQ-,  although  mueli  promuienoo 
of  tlie  cuiidyl(<s  and  subluxation  will  rcmiun.  Partial  mobility  is 
usually  recovered. 

The  rheumatic  cases  which  apply  for  orthopaptlic  relief  are  prin- 
cipally of  two  kiti<t.4,  tlia>e  in  whieh  "chronic  rheumatic  arthritis'* 
RulHtists,  and  those  rarer  instances  of  acute  articular  inflammation 
excited  by  expiinure  to  cold  during  goiiorrlm<a,  cJiihlbcd,  or  an  early 
I^H  ctsfro  of  lactation.  In  tlie  first  kind,  during  the  comparatircly  curly 
^^atago^^mucli  intra-articular  Huid  seci'ction  and  froo  mobility  within 
r        a  ocrtab  range  roimuo.     At  a  later  stage,  in  proportion  to  the 


I        1 

I        ' 
I        < 

1 

I     i 


603 


ORTDOP^DIC  StTBGERY. 


developmont  of  f^latiiioiu  niul  vnsoular  adUMioiiH  ant)  mineral  de- 
posit, the  movement  bocomcfl  ntoro  limited.  BtTforo  and  mbse- 
quentlj  to  Uio  a)))M^rniict!  of  Bonnet's  work,  'niMtpfntii/iu  tlitu  Ma- 
ladiet  Arlietilairfs,  no  linve  been  acvnstomiid  to  attempt,  bv  gentle 
nianiiiultttiiiii-'*  iukI  ^-iitli;  hut  Rrni  Rin|iloyin4>nt  ofmtK-Jianiail  contri- 
Tonoee,  to  rvstoro  these  limbs  to  grealpr  iiseiiilncBs  an  r^»i-ds  move- 
mtmt  anil  ■vinmi-trv.  \V©  have  itiiitcooilei]  in  obtaining  1b«  latter, 
but  not  tlie  fonner  de^idoratum.  In  feet,  as  might  be  inforred  from 
t'DiTPct  pHthciIogicii!  kn«wl«sl{fii,  l.ho  iH-nofit  ofortJiopnilio  trnitinvnt 
is  in  the  inverse  proportion  to  the  anatomical  degeneration  wbidi 
tlic  rheumatic  joint  lias  undergone. 

In  the  second  kind  of  rheumatic;  cases  c^  partial  ankykMiK,  thrae 
which  havu  comniL-nwxl  with  vciy  acute  affii^tion  of  oiio  joint, 
moat  often  the  knoo,  the  low  of  motion  oeetii'^  rapidly,  ant]  »  fre* 
qatrntly  eomploto.  It  ««cm8,  in  thc«c  raiM«,  that  an  acute  destruc- 
tion of  the  Mniona!  suHiicc,  witli  rapid  exudation  of  morliir-like 
plastic  material,  takos  pUco,  causing  tirm  agglutination  of  tlie  ends 
of  thft  Iwtios. 

Tact  In  the  examination  will  usoally  sliow  that  abBoIato  immo- 
bility of  the  knee,  i'mm  whiit«ver  ni»i*v  llio  nnkvloki*  \m»  pm- 
cecded,  doc*  not  exist.  Tlie  Surgeon  can  with  certainty  <leierraine 
tliat  lliu  jiiitil  i»  movable  if  an  oiiergclic  cflort  to  bend  or  Btraightm 
the  limb  produces  a  sharp  pain  through  it.  We  may  deduce  soma 
fiivounibli-  conctii-iionii  iw  to  tho  nl,itc  of  the  joint  if  we  find  the 
patella  movable.  This  bone  may  sometimes  be  mo\'ed  ujKm  il« 
[wqKrndindar  ajiis  when  no  motion  is  pcroeivod  upon  the  horizontal 
one,  and  when  no  flexion  or  exti>nsion  of  the  knra  can  be  eflbctcil  by 
ordinary  handling  of  the  joint. 

We  make  no  other  nii^ntion  of  HtitrncM  of  joint<<  from  common 
Hrtieolar  rheumatism,  acute  and  chronic,  than  to  observe,  that  as 
this  affeetion  nHually  liuivnt  thi>  synovia]  in<^inbrjtiie  intact,  ito  de- 
formity, as  a  rule,  remains,  the  exception  lieingin  the  ankle;  he«« 
the  weight  of  the  body  com i.i*  mon*  niischievnusly  into  play  than 
olicwlierc,  aud  sometimes  gives  rise  to  a  rheumatic  in-aiiklv  or 
tiat-fool. 

Mnny  rheumatic  contractions,  those  which  are  the  least  amen- 
able to  tri'iit  mi^int,  belong  to  the  jTcculiar  Ibrm  of  tlie  distMse  deno- 
minated "chronic  rheumatic  art]iriti»"  by  Adains  of  Dublin,  the 
'*  rliciniitiloid  arthritis"  of  Garrod. 

As  a  rule,  in  reference  to  ortbojiK'dio  trwitnicnt,  ft  correct  judg- 
ment of  the  cnntlition  of  a  joint  contracted  from  diaease  may  be 
formed  from  the  history  and  the  external  epjieanmce,  «id«d  by 


ANKYTX)SIS. 


«C\A 


carHiil  maimnl  oxnininatifin.  In  tlw  hip,  tlio  rlia/jTi"*'*  i*  sotnetimM 
mure  (littioiilt,  because  the  hiatorv  oommunii^atod  nia\'  he  liiilncious 
in  cttiitetjiiemie  of  tlie  ^renter  liubiiity  to  urron  in  iliMgno^it  during 
tiie  tint  Ktogc  of  (iisonlci-  in  and  around  tJiis  arcicuhitiun.  Tlius  wo 
have  aeeu  hip-i-oiiU-Actions  in  wliich  the  primary-  hi]>-altvction  hul 
bcon  originally  sciatica,  muscular  and  futcial  rheumatism  of  tho 
bulk  of  muscioM  of  the  iilp  and  loin,  one  of  the  li>rni»  of  rln»t mutism 
of  the  joint  iti^olf,  "  morbiia  c<)x;i',"  or  tlie  renult  of  accident.  To 
tbcao  cunsoH  of  hip-contnic-tioii,  whicli  are  not  always  diagnoMid,  we 
may  add  the  pocuharly  grave  iiilru-  and  extra-artiiiulav  exudation 
which  oM-jiHionslly  oecim  nt  the  cloeo  of  mah^ant  HCarUtina,  and 
tho  lent  seriotia  peraiatent  drawing  tip  of  tlie  Uii^iH  which  oocura 
(without  pywinia)  during  a  tedious  confinement  to  bed  frmn  fi'vtT» 
and  phh'giiiasiw,  cspt-ftially  in  |)*'rsoii*  whow-  growth  is  nol  complclo. 
We  ha\'e  «]»o  met  «ritli  severe  rigid  hip-contractjon,  with  pain 
and  vrasting.  whioh  hail  ci»mm(^ric<H|  during  pn^giiancy  from  uterine 
iiilliu>nO!S :  alfto  ailcr  childbirtii  from  puerperal  disturbance ;  and  in 
Dnimpregnat«d,  oa  well  us  in  unniinried  womm,  even  from  groat 
fieeal  accnmnlation  m  the  hitestines.  Whilst  reminding  tho  •Sur- 
geon of  tlie  vnrioivt  caiiftca  of  pt-ntirtcnt  hip-c«ntmo(ion,  we  may 
Gompietv  the  Krt  by  adding  oongenital  oontractions  and  hisations, 
para]\'ti(-  and  npaMiiodic  conti-afture^,  womo  of  th(!*«  lieing  hystt— 
rical,  Hnd  some  very  graie  atH-'cliona,  proceeding  from  disease  of 
the  brain  or  KpinnI  conl,  sometimes  co-pxinting  with  angiihir  apinal 
earvatuTP.  Vi'e  have  not  enumerated  iheAo  nunieroiw  caiu«s  of 
liip-c(intra(^'l.i<>n,  as  if  thoy  wcro  »o  many  pitfallo  to  tJio  Surgeon; 
but  in  order  tliat,  knowing  what  iniiy  ha\'e  prodnced  a  given  con- 
traction, the  young  Surgeon  may  he  forearmed  for  diagiiwi*  and 
suceew(l\il  treatment. 

Ttratmmt  of  partial  atid  eompitlf  anhfloeU.  Tho  Mveral  forms 
of  contracted  joints  of  thn  oxtr(*nutJe*  ahovo  enumerated  admit  of 
tliroe  niodm  of  trcabnent:  Int.  Mechanical  extension,  including 
tnanipnlatioDH  and  idiampooing.  2d.  Tenotomy,  succeeded  by  gentle 
gradual  mechanical  exteiiaion.  Hd.  Violent  extension  imdi^r  the 
Mueatbotic  intluenvo  of  <^oroform,  sometimes  proanled  by  teno- 
tomy. 

The  majority  of  joints  affected  with  incomplete  ankylosis,  even 
tho  knee,  elbow,  or  hip,  Htill  mon.'  t)ie  smaller  articuhit»oni>,  and  t^ren 
afier  three  urfotu*  years'  duration  of  the  conlnii^ion,  admit  of  as  full 
and  prompt  restoration  \>\  gnidual,  gentle  employment  of  meclui- 
nical  extension  as  by  cither  of  the  rvmaiuing  modes  of  treatment 
above  indicated,  with  tlio  advantage  of  the  treatment  being  conducted 


R(H 


OBTHOPiEDIC  SURGERY. 


without  pain,  Buffering  of  any  kind,  <>r  wnifinenieiit  to  tho  bou'*.  In 
severe  kiioc  (-ase.*  of  many  .Vf-ii"*'  tluralioii,  subcuiaiRHja*  iliviniim  of 
tliu  hamstrin;;  muscle*  may  tidvaata^^v^u^ly  ))r<K!C(le  tlie  m«cliauinl 
troatoient,  tiiu  Sijrgi>on  hparirig  in  mind  Uiat  here,  as  in  otiior  dis- 
tortions, »ucc«wi  di-'|H-nd*  mow  ujion  the  nmrnivr  in  which  tho  mtr- 
chatiioal  trciiMnent  h  coiidiicLeil  than  ujton  operatire  intcrfcreiioc 
Jn  a  small  pro]H)iiion  of  caisce,  thoso  in  which  ii]>p»ruiit  lotal  immo- 
bility cxiMii,  or  ill  whidi  it  in  obvious  that  partin)  calfarouu»  d«-)>o«it 
has  taken  place,  violent  extension,  with  tho  aid  of  ehlon>fofni  or 
etln-r,  ma^'  be  oniployed.  W'o  aIlllt^x  a  few  detailed  ohscrvationa 
on  tho  mode  of  conducting  each  of  tlicse  processes. 

Affvlumical  JCrUtmon  of  parluillif  Anb/lo«cd  Jolntt,  Long  ox- 
perieueo  in  the  use  of  mechanical  apparatus  sliowtt  how  tittle 
actual  appariMit  jiowcr  ts  reipiirvd  t«i  (ivcroonii;  the  moHt  rigid  oou- 
tractures  of  joints.  The  first  condition  of  success  is  tlie  ooment 
odaptntinii  of  Uic  nj)pro[>rifltt;  upparatii!<,  to  the  A\7.e  and  natural 
movements  of  the  part.  It  ia  of  much  importaiioe  also,  Uint,  ^vtnin 
praciicablr,  th«  H|)partttiiK  Khnuld  only  limit  thu  movement  of  the 
affected  joint  townj'ds  the  cfintraeted  side,  i.  e.  it  sliould  no!  im- 
movdhly  fi.x  tlio  part  in  every  direction,  but  should  leave  »omo  •  play' 
to  the  limb  ill  die  direction  which  it  is  wished  tho  part  should  take. 
No  eiirahle  aitkylnKi.*,  free  from  bony  union,  can  resist  graduxil 
gentle  pressure ;  we  only  resort  to  tenotomy,  in  addition  to  nicelmni- 
caJ  cxteiwiim,  for  (he  jiurjwsc  of  naviiig  time.  A  little  cjjii  side  ration 
will  exi>lain  how  a]>pareiitly  alight  eoiiljnued  presfliiro  can  oflect  to 
great  a  result  ns  the  strsiiglitening  of  a  knoo  contracted  for  twenty 
yt^ars  from  foraior  articular  diseast?  or  injury.  Tlie  uninitiated 
Surgeon  is  aceustoiiK^l  to  regard  such  ajoint  as  '  nearly  atikylowH] ;* 
perhaps  he  docs  not  reHcet  tliut,  if  bony  union  have  not  taken  plaoC) 
the  opposing  structures  aro  '  soft  parts,'  i.  e,  shortened  mii^des, 
liguincnls,  fusei)»,  cutjineoiis  textures,  and  oieatHoes,  all  liable  to 
yield  to  steady  pressure^  It  is  probable  that  as  soon  as  tliis  gentle 
pn>ssure  is  apjilii-d,  tlie  eoiitraetod  nnixcles,  shorleiioil  merely  froin 
position  and  repose,  not  (iriiiif  xftamiiodicuUi/  affn-ted-,  resist  elongation^ 
but  they  speedily  tire,  and  give  up  the  uuettual  struggle;  iImj  non- 
muscular  parts,  however  dense  iJiev  may  l>e,  probably  undergo  »om4 
ohange  of  vasi^ularity,  some  interstitial  cliange  in  their  nutrition  aa 
«  constHjuoneo  of  the  ^entU  riolfiiM  they  iiadei^,  titrougli  which 
their  meehaiiieal  ]M>wcr  of  rosislanco  ib  diminished.  An  iiivixiaiN)  of 
tem|ieratiu-o  and  of  bulk  of  the  part  iniilergoing  mechanical  exten- 
sioii  is  usually  jinrecived,  wliich  wc  believe  to  be  due  to  inerounei) 
flow  of  blood  consequent  u{>on  tlie  atinmluii  of  the  slato  of  tension  in 


MECHANICAL  EXTENSION  OF  JOINTS. 


605 


wlik'h  the  rcwisting  tissuoa  are  maintained.  This  aufrmcufod  flovr 
of  blood  1!^  uiiticooinfwniwl  by  iiiHmnmuUuii  or  ovnn  \>y  \>ahi  wUoii 
thu  pRTt  i»  Hi  rvst.  Sucli  appears  to  bo  the  procoea  in  tlio  stnietures 
on  tlie  (Mintnit^tctl  widv  of  the  Dii-ni)M;r.  The  In^nliiieitt  [Kxtbubty 
rceciit-s  aid  fi-om  the  miuoles  on  tha  uiieontraeled  side.  The  direc- 
tion (ifllio  dtntortion  wm  origiitalh-  ili'timniitod  hy  tho  stronger  set 
of  inuselc«,  or  by  ihcBte  most  ad*'aiil.igeously  liitiLatcd,  having  over- 
poweivd  tlio  wuaker  «;(.  Wlieii  tliv  coutnurtwl  nin-><;ii?t  vivid  in 
their  tnni  to  die  mechanical  instrument,  the  muscles  situated  on 
the  nucoiitniotpd  «ide  tend  to  rceovur  Uioir  lost  splivni  of  action, 

*ind  assist  rcpIai?onient. 
Tlift  knee-joint,  being  a  simple  hinge,  while  (he  thigh  iind  leg 
each  otftira  a  groat  lengtJi  of  loi-erage,  is  advantageously  formed  for 
SiicM»Mfut  orthopiedic  tre^tmeiit  by  moehanietd  extension ;  and  e«n- 
»«]uenfly  we  meet  with  no  pni'tiiilly  ankylofied  knee  which  cannot 
bfi  slraightetied  and  rendered  fit  for  u»c  without  the  aid  of  toiiotoiny 
or  chloroform  in  a  jioriod  varying  fifim  one  lo  three  montlts. 
^P  'J'lie  anatomieal  relations  of  the  hip-joint  render  it  hsn  favour- 
shlo  for  orthopu'die  tn^iitiniMit  thiiii  any  of  the  ginglymoid  articula- 
tioii*.  At  the  hip,  tiio  shorlness  of  the  lover  afforded  by  the  small 
deptJi  of  tltn  i>elviH,  and  tho  ditKoulty  uf  fixing  the  pttivis,  explains 
why,  when  power  is  applied  to  the  thigh  with  tlio  view  of  o\t«ndiiig 
the  aliuonniilly  tlt-.x(Nl  or  cuntnicliil  hip,  the  Iciwer  part  of  tiiD  vert<!- 
bral  eoiumn,  back,  and  loins,  yield  anteriorly,  eau&ing  an  extrenm 
hollow  ill  the  Ioin.4  (lordoMs).  In  faet  a  iMuaii  part  oidy  uf  tlie 
power  emploved  is  etteictive  on  the  contracted  hip-Joiiit,  the  greater 
port  being  e\|Kiidwl  in  drugging  forwards  the  Inwent  ilorsal  and  the 
lumbar  vertebra?.  Wo  may  mention,  in  illustration  of  the  eomparn- 
tive  ditlietdty  of  Ktraighteiiiiig  the  hip,  that  in  an  insliinoe  of  uni- 
fonn  iibrons  and  x-ascular  membranous  adhesion  of  the  head  of  tho 
femur  wiilmi  tJi«  acctnbuhim  after  death,  the  [inrlially  iinkyloaed 
peh'ls  and  thigh  having  been  removed  t'roni  the  body,  wc  were  un- 
^blihle  to  exti^id  tli«  hip  by  any  power  w«  eould  exert  with  our  hnn<U, 
^ranfil  the  capsuUr  ligament  and  some  of  tlie  adhesions  within  tho 
tlM(al>nlum  had  Wi>n  severed  with  thi<  kiiiti.-.  Thu  Miiite  kind  of 
adhesions  in  a  knee  would  have  yielded  to  tho  power  fruitlessly 

»0tD|>h>yod  at  the  hip. 
Great  ingeiuiily  has  been  displayed  in  tho  mannfactnro  of  the 
apparatus.  Ow.yi.*ionHlly  considerable  deinaiidit  upon  tlie  itkill  of  the 
mechanist  are  required.  Tlie  continued  attention  of  orthopatlic 
praetitionem  wh<),  during  tJie  la*t  five-and- twenty  yeunt,  have  trod- 
den in  the  footsteps  of  &iarpa  and  Stromoyer,  bringmg  pathologicsd 


6CM} 


ORTHOP.EDIC  SDRQERT. 


ami  iinatomipal  knowledge,  with  PJcpGrienco,  to  tlie  aid  of  the  in- 
fttrumLiit-niakrr,  Imx  rovolutioniMHlf  Hitnjililicd,  and  thus  fur  pvr- 
fvcb^l  ortliopa^io  appiiratuii.  An  a  general  rule,  eUbcH^te  instm- 
menta  should  l>c  avuiiictl.  Tlicy  arc  oft«ii  »trictl_v  artid(!»  of  InxMr^-, 
not  obuinuble  tor  (be  treatment  of  ihe  majority  of  caitcs  tiiat  [ireiwnt 
tbeDUwilvee  in  private,  and  CMp<H;ial]y  in  public,  practice  We  may 
itftirm  that  when  nathiiifftita^  be  otfceted  for  the  relief oTm  defor> 
miiy  witliout  a  cuinplieated  instrument,  very  little  «*n  bo  effoctod 
witli  it«  awtiftttuioe.  Yet  in  numeroum  iturtanoGA,  as  in  congenital 
dnb-foot  of  adolescents,  in  ronsiderable  kiiee-contraetions,  and  nub- 
luxation,  the  ne<-<'tui|y  <if  wtill  fixing  one  jiart  whilxt  iiiiother  io 
acted  upon,  or  tJie  complicated  character  of  the  doformity  itself, 
entailM  i^irrtr*|>(>ndiii^  ncinl  nfnn  elnlKiratA^  contrivaiice. 

Oillerent  nieoliaiiical  foroeii  are  eniployed — the  lever,  the  screw, 
and  the  Hjiriiij;;  thv  lawt  two  often  rcsolvalilo  into  the  lever,  acrewa 
and  &]>riiigs  being  emjtloyed  to  modify  the  actinii  of  the  lever.  The 
dii"i'iissi(>ii  fd'  llie  n-liilive  advantajic  of  the  drfleront  niodw  of  ap- 
plying these  forces  would  lead  us  away  from  oiu-  imDie<liate  object. 

It  ^hrxdd  Ijc  home  in  mind  during  the  employment  of  theM 
forces  in  ortliojiaedlo  a(>])»nitu»,  and  es[>eoially  in  ibe  use  of  tbo 
screw,  that  it  is  avitilahto  loss  as  a  moans  of  a)inip>tly  forcing  the 
deformed  partn  into  tliuJr  imtiirat  piuiition  Ulan  as  an  atljiisting  con- 
trivance, in  any  caw  in  which  tlic  scrow  is /orcil-lt/  employed, 
unless  for  a  very  hriel'  [leriod,  excoriation,  sloughing,  or  intolerable 
pain,  will  incv'itahly  result.  In  some  jiatu-nt  individuals,  vesication, 
and  even  Mi|H^rlicial  slouj^liit,  miiy  Im  iniitici'<l  over  pi-djiyiting  bones 
without  complaint  of  pain — an  urgent  reason  for  attxions  examina- 
tion of  a  [Mi-l  »nhjtvtcd  tii  pi-esi<iin\  e«|H«cinlly  by  the  iriex|ierienoed 
ortho|Kcdist.      Largo  sloughs  are  more  than  inexcusable. 

Evcr^-  iijipiirHtnK  xhoidd  be  paddetl,  mi  ai«  to  svoid  pnwsnre  upon 
prominent  points  of  the  bone,  and  adapted  to  each  individual 
naiiie.  TIio  orthopifdic  nppiiralii*,  like  that  for  a  fracturetl  limb, 
should  coiiipress  the  part  in  its  eitcinnferonoe  as  little  aa  |)o«stble, 
and  ueii'i-  li','htly  cncirck^  it.  It  shoidd  act  gradtmlly,  in  propor- 
tion as  t/it  (lefoniiifi/  if*elj'  chani/i-s  tin  f'orni.  We  Imve  endeavoured 
in  onr  pa'vionn  n^marks  t*.  show,  that  if  a  eontnict^-d  moinl»er,*  a 
knee  for  example,  is  evenly  secnred  in  a  suitJible  ap)>arat»s,  accu- 
rately adapted  to  the  degree  of  bending  of  tlie  joint,  the  proccsaes 


•  Tlie  pri'iiti-r  numhfr  of  c ontmctpii  joiiils,  ohcn  not  nflVirti?<l  with  bony 
snkylnsi*.  if  li-ft  to  ilipnitplvrfl,  nwiy  lii-  ivpHi-itoil  «»  roninirtJitit  jfiJntii;  ftT 
tbo  conliaciiiig  praec'se  i*  over  progtest-iiig  until  it  attain*  Om  masimuin. 


MECHANICAL  EXTENSION  OF  JOINTS.         607 

which  ensue  in  tho  joint  when  a  moderato  tonnion  is  impaned  soon 
fiitvour  t]iv  moviiig  ui'  lliv  joint  in  thu  <itrc(4it>n  (wntrary  to  Umt 
whidi  it  may  have  long  maintaiDed.  A  ooiitraoted  knee  resting 
upun  its  [KiHt«riur  lupoct  in  uti  n|)puratiw,  tends  by  it«  own  wuiglit 
to  regaui  a  slraij^htor  ]x)i>ition. 

At  liio  onbHit,  tliv  Surgeon  ttliould  be  ooDtcnt  i>tmp1y  to  apply 
tlie  iiiMrtiinenl  to  the  deformity,  ami  not  to  apply  tlio  defonniiy  lo 
the  instruin^-iit,  lis  it  too  otU^ti  attctnptttd  by  novtc-ra  in  orthoptic 
practice.  In  tJiis  gentle  manner  of  proceeding,  the  firHt  ilitficulty 
ill  the  treatinfnt  of  ovcry  case  of  di-forraity  Is  ovcrcoino, — tlie 
patient  Huffi;rs  pothing  from  the  attempt  to  Mi'aighten  llie  jiart ;  tJis 
simple  in<»nvonienco  of  wearing  an  a]>parHtus,  ttio  irksomencM 
attcodaut  upon  neees»ary  coiifmcnicnt  of  tJie  atlix-ied  [lart  in  an  iin* 
familisr  instrument,  !»  his  only  trouble,  and  one  winch  is  s]>oodily, 
in  a  day  or  two,  overcome.  Having  once  ajiplied  a  well-litting 
instrument,  the  screws  or  straps  by  which  it  is  adjiistod  to  the  now 
iiti]in»  itig  ntembcr  rociuirc  u>  tie  udvanced  or  tightened  ■»  o[^]or- 
Imuty  offers.  An  impatient  advance  of  the  pressure  will,  by  pro- 
duotion  of  pnin,  and  ncocnnity  for  relaxation  of  the  iiuU-ument, 
oooasion  loss  of  timt.  The  principle  of  action  in  the  progress  of 
moclinniod  treatmcut  »liould  be  tJiat  of  luivor  advanving  too  rapidly, 
»o  as  to  risk  the  nec^^ssity  of  receding.  By  gentle  meana,  and 
uniform  sti^udy  advuiiee,  the  piLt  item's  contidence,  so  et>wntia1  to 
prompt  recover}',  remains  un<liniinishM{.  By  sul)jecting  die  member 
to  «i)  greater  presxnre  than  can  be  eauily  borne,  no  teinptittion  to 
looM-ning  the  apparatus  U  atlbrded  to  the  titni<I,  and  no  rink  is 
iucttrnxl  of  occiugouing  cxmriatiun  or  inKammation  in  iiKiividu)i)« 
poeses»ing  greater  eiidunineo,  or  in  young  children,  wliose  cries 
inay  be  attribut<^^  to  other  causes.  In  this  niimuer,  in  wntabl« 
ca^es,  the  op|M»iilion  oH'ered  lo  ■'CHtomtJon  by  fascia?,  tendons,  IIga> 
nicnts,  and  ill  rlircction  of  articular  surfaces,  a]>|>areiitly  irmsistiblo, 
Uuy,  with  till'  t'urtlier  uid  of  nmnipnlulions,  be  i-emoved. 

In  tlic  choice  of  mechanical  ajtparatus  tlio  Surgeon  sbotdd  also 
ba  guided  by  that  princ-iple  whicJi  aelualtvi  him  in  the  selcetion  uf 
thempeutiu  agents  in  any  internal  or  cxti^'rnal  disease,  viz.  the  use 
of  that  nieiuiA  liie  uotion  of  which  he  be^t  luiderstaiids,  or  ui  tlie  u»e 
of  which  he  has  had  most  cxperienoc.  A  common  splint,  profwrly 
nppliod,  will  effect  mure  Ix-iiettt  tiuui  an  iiuitrument  of  greater  pn>> 
tousion  indifferently  managed. 

From  iill  these  considcralionK,  it  is  ap]Mir<nit  that  niuoli  harm 
will  rc«ult,  in  the  great  majoriir  of  deformities,  from  tl>e  habit 
aomeliuK-s  [tursuicd  of  kei-ping  a  deforiuvd  {Mut  many  weeks  in  iwo- 


L 


€08  ORTHOPEDIC  SURGERY. 

cession  in  an  apparatus  without  the  removal  so  necessary  for  ibe 
purpose  of  cleanliness,  manipulations,  and  readjustment.  Among 
the  evil  consequences  of  too  long  retention  of  instruments,  oftea 
combined  with  unsuspected  excessive  pressure,  the  author  has  wit- 
nessed the  production  of  an  opposite  kind  of  deformity,  as  the 
conversion  of  varus  into  valgus,  and  a  degree  of  ngidity  of  the 
part,  which  has  required  weeks  of  painful  numipulationa  and  stretch- 
ings before  the  natural  movements  have  been  possible, — sometimee^ 
indeed,  restoration  of  motion  of  an  articulation  has  been  rendered 
impossible. 

The  slighter  the  deformity,  the  more  necessary  is  freqnent 
removal  of  the  apparatus,  becaase  by  removal  and  appropriate 
manipulations  we  insure  retention  of  mobility.  In  severe  cases,  iu 
which  wo  expect  only  to  eScct  straightening,  and  do  not  antici- 
pate restoration  of  mobility,  frequent  removal  of  the  apparatus  is 
Qimecessary ;  for  too  freqaent  removal  may  be  hurtfiil,  by  allowing 
the  recently  elongated  tissues  to  recontract  during  the  time  the 
apparatus  is  removed  from  the  part. 

Dwuion  of  the  hamgtring  muscles.  We  have  shown  that  in  a 
limited  number  of  knee-contractures  from  disease  and  accident, 
eectioi)  of  the  hamstring  muscles  may  be  required  as  a  preliminary 
to  gradual  mechanical  extension,  or  to  abnipt  violent  extension 
under  chloroform.  In  att  cases  after  tenotomy,  extension,  whether 
gradual  or  abrupt,  should  be  delayed  until  the  healing  of  the  puno 
tures  in  the  integuments.  In  the  knee  this  healing  is  seldom  com- 
plete until  four  or  five  days  after  the  operation.  The  following  rules 
maybe  given  for  severing  the  hamstring  tendons:  Place  the  patient 
in  the  prone  position,  and  lot  an  assistant  make  finn  extension  upon 
the  joint,  or  desire  the  patient  to  endeavour  to  bend  the  knee,  by  either 
of  which  means  the  tendons  will  be  rendered  prominent.  In  general 
follow  the  directions  laid  down  for  division  of  the  tendo  Achillis 
(p.  572).  In  severing  the  tendon  of  the  biceps  femoris,  insert  the 
tenotome  in  the  adult  an  inch  above  tlie  apparent  point  of  contact  of 
tlie  tendon  with  the  fibula,  remembering  the  proximity  of  the  extomal 
popliteal  nerve,  and  keeping,  tlierefore,  the  tenotome  close  to  the 
tendon.  The  semi-tendinosus  being  very  superficial  is  readily  severed 
by  a  puncture,  where  it  ^rings  up  most  prominently ;  the  aemi-mera- 
branosua  being  more  bulky  and  fleshy,  as  well  as  more  deeply  seated, 
requires  a  larger  sweep  of  the  end  of  the  tenotome.  It  is  scarcely 
necessary  to  recommend  caution  as  to  the  impoi-tant  nervous,  arterial, 
and  venous  structures  of  the  jmpliteal  region.  Aft»r  section  of  the 
inner  hamstrings,  the  pressure  of  the  assistant's  hands  upos  the  limb 


DIVISION  OF  MUSCLES  OF  HIP. 


609 


g  oontinued,  baiwjB  offaflcia  ami  nerves  make  themiiclvea  pt*- 
mii>ont]y  full  in  tlio  tiam.  Tr<)ubli»Mjmv  iininbtifM  ui  tliu  calf,  and 
unuHtuI  pain  dorijig  estenaion^  has  followed  the  unnecessary  di> 
^-iwfin  of  tlifw)  structures.  It  is  (Iwiniblc  to  nj>plj'  protnplJy  a 
pI(!(I;^ol  of  lint  and  Auitnblo  preH-iiiro  by  u  bandagi?  ii\  er  lite  jmnc- 
turos,  to  provvnt  oosing  of  blood  into  the  areolar  tiB»uo  of  the  liatn, 
wliicli  ut!orilit  an  inconvenient  nidus  for  !iu|>)inratifln.  By  iirlopting 
this  imniwliatc  covcrin}"  atid  pressure  over  tlw  punciuroj  wo  liavo 
never  witne^i-d  delay  in  lioaliiig  beyond  four  or  live  djiyit,  in  ordi- 
nary tnodcrato  tomporaUirc.  Very  cold  weather  is  apt  to  cnuso 
tenotomy  jxiiirturt^  in  liniUt  of  weak  circulation  to  a[>pour,  at  the 
end  of  several  daj-s,  as  if  llicy  liad  hfon  vifbcted  an  lioor  pre- 
viously, no  attempt  at  iwlht'^ion  Ih)Iii<;  nmdo.  It  i»  itiercftirc  proper 
in  cold  weather  to  enveloji  tiit<  limb  in  flannel,  and  a«^t  tbo  repa- 
rative powers  of  tlio  )uitioiit  by  j^ncrous  diet 

TXeieion  <f  tniurles  in  tfit-  vicinili/  of  iKf  fiip^yoml.  Though  in 
bip-contraet tires  tlie  majority  of  the  muiioles  proceeding  from  the 
pelvis  on  tlie  I1exe<l  side  of  ilie  [lart  are  contracted,  exfierience 
teadics  that  few  require  o|)erutive  interference.  Wo  have  many 
times  severed  tlie  origins  of  tlie  adductor  lonjipis,  adduMor  brevis, 
and  ]K>ctiucus,  the  tensor  vaginic  femon's,  and  tJie  superior  origin 
of  ilie  reclux  femoris.  Rut  of  late  years  wo  have  i-oiunioiily  re- 
strictf^^  the  operation  to  the  tendon  of  t}io  adductor  longus,  for 
tlie  relief  of  U-ii.to  abnormal  upproximalion  of  the  tJiiglis,  iu  caRcs 
of  goDoral  &pastic  rigidity  of  the  lower  extrcmitiea.  The  adductor 
loiigus,  from  itn  position,  exerts  u  rebtively  greater  intluijn»-  in 
morbidly  addudlng  tlio  thiglis  tlian  other  musdes.  It*  division 
i*  a  iHiti.triictory  starting  point  for  :<iub:<.et]tieiit  bem^fit  from  manipu- 
lation and  use.  It  is  cflcctod  according  to  the  general  principles  of 
tenotomy,  and  rwpiin's  no  jxirtiiiilar  (Uwripliun. 

Section  of  the  tfiisnr  vagina.'  femoris  and  rectus  is  suggested  itt 
certain  WLses  of  piiralytio  contracture  of  tht?  liip,  in  which  atony  of 
the  adductors  of  the  thigh  exists,  a  state  of  things  opposite  to  the 
last-men tioiKtl  kind  of  caw.-.  Here  the  thigh  is  ilravrn  from  il»  fel- 
low, the  ti'uiik  tending  to  full  to  tlie  gi-ound,  as  it  were,  betweeji  tlie 
thighs.  Wliero  contraction  of  these  intwclcs  exist.-',  tho  ]>and\'si»  of 
the  adductors  and  otiier  iiiu.scles  of  the  hip  (pB04e  and  glutei)  is 
usually  so  considerable,  that  little  radii^  good  rvnultx  from  tliu 
(^ration.  It  should,  therefore,  as  a  rule,  bo  superseded  by  maui- 
ptdadooB,  frictions,  and  meehanleul  appliance*. 

Dtrvfon  of  the  jUxor  tatdom  of  the  Jinfftrt  and  tor*.     TI»o  pha- 
VOI~  111.  U  B 


610 


ORTHOP-^mC  SURGERY. 


laD|^,  when  contracted  from  articnlar  complaints,  rcqnirc  treat- 
nioiit  iiiuiilHT  to  tliHt  ul'  llio  Wgor  nrUculittiuiiH.  Coininnnlv  it  is 
the  flexor  t«ndon  wbidi  ia  implicated.  Enongb  lias  bran  stated 
conoomixg  llw  liirp'  ffinyly  nil  fill  urliuiiliitioiiM  Co  rvmlfir  mniiy 
datails  of  ti'eaiment  of  the**  Hniall  articulations  unnecessary.  In 
openitinj;  on  the  fin{;n«,  vrt^i  h»v«  to  ocmtiidcr  tx^forrbimcl  whe- 
ther tJie  articular  disease  lias  I«fl  the  joint  in  n  comliiion  to  resume 
its  lun<:ti«m  a»  to  movement ;  ft»r  if  wi>  may  not  ex|"cct  tti  nx-uvor 
mobility,  a  atrai^lened  finger  is  not  preferable  to  one  partly  bent. 
Wc  rcqniro  also  to  «iiculat«  the  duuicv  of  tbo  tondoii  whvn  ofvrutecl 
on  in  the  M)iin>(!  of  the  tlieca  becoming  agglutinated  to  the  thoea, 
and  the  finger  subset] ncntty  on  that  account  not  regaining  movn- 
menL  In  lli<*  ioot,  the  moitt  frequi^t  affections  of  the  toes  (or 
which  Surgeons  are  consulted  arc  tliose  re«iltjng  firom  improper 
iOiue»  worn  during  tluj  gmn-iug  jit-riot)  of  the  toot — in  childhood  and 
adolc«concc.  The  great  too  is  ol^n  thrust  inwardly,  and  overlape 
the  next  toe,  the  nu-tiitiirsii-phitliingitd  urlioulation  lieing  inflaiiMNi 
and  idtimately  deteriorated  as  to  the  normal  condition  of  tiie  arti- 
cular surface,  witli  cuiseqiicnt  imjminncnt  of  uiobtlity.  TIk'  joint 
is  inclined  to  sttflen  in  the  extended  position  af^er  subsidence  of  the 
irritation  or  iuflnmuiution,  the  individuiJ  Wng  pre^•en^od  standing 
tip-loc,  or  ascending  a  hill  witliout  pain  or  inconvenience.  This 
condition  of  things  may,  before  itnd  alwut  puNrrty,  bo  rximodied 
by  rest  and  suitable  tojiical  apjiheaTions,  followed  by  manipulalioni) ; 
the  inU,T{HH<iti(iu  of  a  parittion  betiv<Tii  the  ton*,  so  as  to  kc«p  llw 
groat  toe  in  a  projier  line  with  ibe  margin  of  the  foot;  an<l  the 
t«ii|»oniry  two  of  a  i^nitably  wide  sliiw. 

Another  common  troublesome  defect  in  the  tow,  similarly  pro* 
llueod,  though  sometimos  horeditary,  is  fixed  llcicion  of  the  second 
\oe.  In  children  under  the  age  of  ton  or  twelve  yeari*,  this  defect 
can  usually  be  rcmt'ditd  by  light  gentle  bandaging  (not  tight)  of 
the  part,  upon  a  padded  wluilcbone  splint,  night  and  day,  for  a  few 
weeks.  In  older  subjects,  and  in  peculiarly  rigid  cases,  section  of 
the  flexor  tendon,  opjumite  tliu  tirst  pliulnnx,  fotlowcil  by  bcuHlngiiig 
on  the  splint,  is  a  prompt  and  certain  means  of  cure. 

The  tittle  Uto  is  iit}eii  extcndod  upon  tlio  nietiiiamiN,  or  thrtot 
kteriilly  and  sufficiently  prominent  to  become  continually  a  sonrco 
of  pain  mid  irritation  from  the  slioe.  Iliii*  also  is  onen  a  eotigeniul 
AfTivlion.  Division  of  the  extonaor  tendon  and  bandaging  affords 
relief;  but  we  have  foimil  this  too  uiorv  obstinate  tiian  otlM^ni. 

The  toes,  ajid  particularly  the  great  toe,  are  often  contracted  in 
cases  of  vurii«,  congenital  and  acquired.      Thctie  contrnctious  nre 


rdieved  by  tbe  mecuiB  taken  to  «nro  the  (.-i1ii>t^^,  smd  Aometimes  by 
gradually  irajiroTing  tlteir  [xwition  with  nnitable  bandages. 

J-'oreilfU extfnwn.  Undw  th«  hiraii  iif  uumipiil'd'wm  ta\A «tretoh- 
iiigK,  tltc  Talaa  of  gattU  employment  of  preosai'e  and  inovvniiMit!! 
with  Uw  )uui<U  ([inA-tivft  (>j[OR-isf),  Imtb  u*  n  mmmfl  of  niriug  nlight 
deformities,  and  aa  an  unportant  atuiiliat^'  to  other  methoda  of  ln<nt- 
ment,  has  Imcn  hIwiwii.  If  a  Inrpwr  niwwurc  of  )>re»s«ro  or  fiirco  be 
UBod  with  the  hands,  the  treatment  be«»mes  that  denominated  vi<iftd 
exUnrioH.  Ht-re,  on  cl»i'wh<:ro,  it  is  <liflicult  to  draw  an  arliitrary 
line,  and  say  where  gentle  manipulation  ends,  and  violent  extension 
begins.  In  t.hu  practice  of  inanipnUtionx,  tlie  «onipot«nt  npemtor 
roar  frequently  avail  himself  of  the  timaller  d^ree  of  sensitironcM 
displnyuil  by  «omo  patients,  or  of  the  niomontarj-  HbitTiictimi  of  the 
patient's  volition  from  the  mu.4cle«  (n  oirmimstanee  instantly  felt  by 
the  hand  of  tho  operator),  and  apply  an  amount  of  fore*;  wliieh 
appro.vimat(>H  to,  or  may  be  onn.«idered  n«,  violent,  extension.  Bat 
ciotent  extension  with  the  hands  is  rarely  ctBeacJotw  in  tho  remo\'«I 
of  oonsiderable  eontnvetion  and  ileformity,  ospeoially  in  fuU-gmwn 
persons,  boeaose  either  the  pain  prodneed  is  intolerable,  or  the 
voluntary  r«ii«t;in(f  oH'erod  by  tlie  innsdes  of  the  patient  exeeeda 
that  at  the  eommand  of  tlie  operator ;  a  struggle  is  maintaine>l 
between  tli«  jintient's  muneles  and  the  Siirgi-on  or  ndibor,  in  whieJi 
the  latter  is  commonly  not  victorious. 

Through  the  inability  of  one  poinon  to  cffeet,  with  any  effi>rt  of 
hia  will,  an  extension  forcible  enough  to  ovMvonie  severe  oontrae- 
tiou,  violent  suddfii  oxteiisiuu,  by  means  of  tho  eonibined  stn:nglh 
of  sereral  asaistiuita,  or  by  nieani*  of  powerful  iwarews,  brought 
Mtddraly  into  action,  was  proposed  and  (tarried  out,  with  varying 
moeeen  and  nuHlorliine,  by  Lnuvrier,  Dielleoliaoh,  and  others.  In 
tho  IcKs  soToro  c»ea  of  deformity,  those  indeed  which  aro  curable 
by  gentler  m<nin«,  withuiK  Kiiiger  duration  of  trealinent,  the  |)ar1a 
wore  iwdtienlif  straightened  by  violent  extension,  without  ultimately 
miM^ievou!*  rcMiilta,  and  tlie  oxpectod  IwueHt  wax  obtiiined.  Rut  in 
aeveror  cases  of  deformity  of  many  years'  exisbenee,  in  winch  or- 
ganic changi-s  of  groaUT  magiiilude  liad  taken  place,  ha  in  Mnrere 
knee-ankylosis,  from  extensive  sopporation  about  tJie  articulation, 
with  necro^i^,  the  violent  M'|iamticjri  of  adhesioitt,  and  ttnappinf; 
uonder  of  bony  deposits  in  tlie  popliteal  space  and  olsowhero,  were 
accompanied  with  locenitiun  of  l)lortd-\eswI»  and  nervos,  fractures 
of  the  bones  themselves,  and  cou»e<(uent  inflammation,  suppuraiioit, 
and  evta  mortifieatinii,  of  the  niembur.  The  pLiui  wiu  doervudly 
denounced,  an<t  fell  into  di^uea 


L 


J 


512 


ORTHOPJSDIC  SUKGEBY. 


F'/reilAe  extaisioH  nnd«r  ehlor^orm.  Surgery  rocoivwl  un  in- 
vulunlilo  iid'Iitioii  t(i  it^  Ru>an»  of  ii3<:fuln«ss  by  tlie  tiboowry  of 
tlie  aassthetio  properties  of  oUior  and  chloroform ;  and  orthopoHlii^ 
practitionurs,  fi)ll()winf;  Urn  cx/imiilu  of  LangeiilMX-k,"  proiuptly 
availed  theiDselvos  of  the  aftiistaiict;  those  nicaiu  are  caloilated  to 
rondiT  in  the  cure  «f  defovpiitiea.  Hence  Uio  employuieMt  of  for- 
cible extension  with  the  aid  of  cUoi-oform  or  ctl>cr,  By  chloro- 
fbmiiwitjoii,  tile  two  groat  ol»tau1cM  u>  tlie  umplwyniont  of  furpo 
adequate  to  etraJgbteu  or  bond  a  contracted  limb,  namely,  pain  and 
voliuitarv  inoMtiilar  n-KiMtiinec,  «r«  r«iDO%-<ML  A»  oooii  iw  iIipho 
i 111) ie<l intents  disapjiear,  the  bands  of  the  single  operator,  and  his 
single  mind,  ajtplii.ti  to  the-  piirU,  cnniuiitcr  tliv  pb}'»icul  ixwintaiivo 
only  of  tJie  deformed  parts ;  oomparatively  gentle  man!j>ulations 
now  aoquiiinl  him  witJi  tliv  nature  and  amount  of  diDiculty;  \w 
can  feel  liiti  way  in  tlio  application  of  j^rflater  force ;  am  loel  and 
perccivo  tlio  rcsiKtnnco  of  parts  suoces^ivtly  overcome,  in  an  »ia- 
t4iiiiioal  ordoi-;  if  greater  ngidHy  atill  opjKise,  a  few  movements 
of  the  joint  backwards  and  forwards  prepare  the  way  for  a  moro 
extensive  yielding ;  and  oflen  the  prnctitioncr  has  tlio  satisfaction  of 
buing  able  tlnw  to  (tffoct  overy  Batural  movement  of  the  Joint. 

Chloroform isati on,  with  mnnij)u]iiLii>n.->,  iiiid  the  ntie  of  »  certain 
dcgrw!  of  (ort'o,  may  bo  of  service  as  a  moans  of  diagnosis.  By 
it  the  practitioner  is  enabled,  in  itonio  degree,  to  aAoertain  what 
proportion  of  itio  ilcfonnity  is  duo  to  shortening  of  soft  paits,  Iiow 
niiioh  miscliief  the  articular  itiirfuces  luive  luidcrgone,  and  wltal 
amount  of  restoration  is  j>racticablo. 

Aftur  utruightening  or  iH'.niling  Uio  limb,  as  tlio  case  may  have 
required,  by  means  of  this  forcible  procedure,  tlio  |Min  xliould  he 
lightly  secured  in  a  n-tenlrivc  iiixtrumont  or  upon  a  common  sfJint, 
ailjusled  so  a«  to  maintain  a  position  raoi-e  fitvoiirnbh-  lluin  ll»l  in 
which  till;  limb  wiw  before  llie  ofdTutJon,  though  not  so  as  to  keep 
it  in  the  now  position,  Le.  the  entirely  straight  or  Ixint  position  inio 
which  the  liitntLt  of  the  Surgeon  may  have  brougbi  it.  For  as  soon 
as  the  eft'ect  of  the  chloroform  disappears,  llie  pulivnt  arousn*  to  tlit^ 
conviction  of  the  violence  which  may  have  been  employed,  the  part 
may  be  acutely  painfiil,  and  incapable  of  tiii.Htuining  tliv  prcssnre  of 
a  tight  bandage  or  ligature. 

We  usually  content  ourselvea  witli  t)io  inercasod  knowledge 
obtained  of  the  nature  of  the  ca«o,  ^vith  the  satisfaction  of  know- 


*  Cnmtnenlalio  d«  OoHtntctura  *t  JnA^bn  6'«nu  lioMI  ^Mkoda 
tttuiiiiiu  ujit  tanandii,  IScroIiui,  X6A0, 


li 


FORCIBLE  EXTENSION  UNDER  CHLOROFORM.    613 


■ 


■ 


P 


inp  that  tlio  [lart  van  lie  impnivcil  in  fi>mi  nnd  function,  nn<I  as 
iJie  rcAistiiig  jKirU  Ijiivo  once  yielded,  iliat  (t«>y  wilt  aft^Twanlit 
oppoeo  loss  resi»taiioe  to  roplacemoiit;  wtiotlior  ttio  mpans  tmlwc- 
(|Uflntly  employ i^I  ahutild  bo  .Him[ile  iiiiuitpnkiiiin;^,  t)io  ii.<ie  ofintt- 
vluuiical  »|ii>arAtu]t,  or  repeated  ndmiDistralions  of  cliloroforin,  and 
fordblo  oxtenoion.  Tlia  Surgeon  who  &li<>uld  iiltMiipt  tlio  ior- 
cibtc  binding  down  of  a  long-deformed  limb  Immediatoly  nfier 
forciblo  oxteiinton,  would  bi^triij'  a  Innieiiitiblo  ignorant!  of  tlu) 
pathologiciil  condition  of  the  parts  in  tlio  immediate  vicinity  and 
wittiin  tixr  <Ii»L-a.'Hul  arli4;uliilt<rn.  Allliougli  tlio  iniiM-iiIiir  nti'uc- 
tures  may  linvc  yietdod  under  cbturoform.  and  iiiiluruttxl  fawite  and 
old  atlliettiuiiit  may  liavo  l}e«n  overcome  by  Htretehing  und  liuring,  it 
will  bo  romomberod  that  much  adaptation  on  tho  part  of  nerves, 
LlooiUveMuU,  and  ab^orbontK  to  ibo  altered  {K)i<tlii)n  of  liie  »Lrui> 
tures,  needs  to  be  aocompUshed.  We  find  that,  by  talcing  moderate 
meuiiit  of  retaining  as  much  iinjirovcmont  nf>tir  tlie  furciblo  «xt«i)- 
sioil  as  can  be  borne  by  the  stUlcrer.  by  tlio  unejuiring  use  of  lotions 
of  npirit  or  too,  and  by  tho  inlornal  iiM  of  morphia,  dangerous 
inflammation  of  joint*  Urns  straightened  has  boon  avertecL  By 
tiiuploying  aflcnvnnU  Uic  ordinary  uiwmJi  of  graihuil  vxlcni<!on,  wo 
have  straightened  join ta  wlueli  would  otliorwiso  have  reiiuired  many 
tnonths  of  ordinary  troatnicnt. 

It  is  perhaps  not  aujierflnoua  to  remark,  tJtat  the  use  of  for- 
cible extension  is  less  defensible  in  cuvtcH  of  recent  difcase  of  articn- 
latiuns  than  oven  other  active  attempts  to  restore  the  form  in  such 
caws.  In  a  diseased  jwnt  the  practitioner  has  to  note  not  only  tho 
local  <Ii«or<lcr,  but  also  the  general  condition,  of  which  the  local 
atfeclion  Is  but  one  manifestation.  A\'hen  the  Surgeon,  with  ability 
and  exjjericiiec,  liat  curi^!  tlie  local  ilinonler,  i.  r.  removed  the  in- 
Hammation,  hcnU<tl  the  idccratod  or  suppurating  part«,  or  effected 
snlwidonw  nf  pain,  heat,  and  Inmcfaetion,  tlic  conAoquenoca  of  tli» 
diseoaed  action,  contracture  and  rigidity,  only  remaining,  he  hax 
not  n(Wi^<arily  ciiriHl,  by  Int«)rniil  and  gi>noraI  tlierii|M^iiIte  mcusureti, 
Uio  morbid  conHtitutioual  state.  This  often  slumbers  aAer  suhsid- 
onoo  of  tho  local  lUxcaw;  and  lie  Hhonlil  piiiL^c  ore  ho  too  hiwtily 
iindertftkeA  the  restoration  of  form  and  movements  by  forcible  ex- 
tension under  chloroform,  or  by  other  active  nicasureii,  and  thus 
incantiousJy  evokes  a  renewal  of  local  disorder. 

These  views  were  enuuciatwt"  winii-  jtmrs  »go  by  the  author, 
perhapa  with  more  Icjuiing  (o  the  employment  of  forcible  extension; 


*  Tftaiue  OK  Drformitia  c/llu  //hdmh  Fram«,  IS08, 


614 


ORTHOPEDIC  StJRGERT. 


(utterly  Mr.  BrodhurBt  has  largely  employwl  and  advocated  this 
motliod.  It  will  l>o  fuiiiKl  Ui»t  violout  oxlcnMon  U  novt-jwiirj  in 
n  relalively  small  number  of  cases,  provided  gentkr  means  are 
suitaMy  carried  out.  Orlii<^i]t<ty  in  capublu  of  curing  all  tiwM 
eontra^ilionii  in  wbich  the  innervation  is  not  hop^Irasly  disturbed 
(severe  pnrulysis  and  Kpavin),  and  thvM'  in  wblch  tJie  synovial  Mtr- 
facctt,  i-arliUges,  and  articidar  extremities  of  the  bonea  are  not 
disorganised  froin  dimtiiw.  WIm-h  wo  cannot  bopo  to  do  more  than 
Htniijfhten  the  liuili,  as  in  lnng-stan<l)iig  hip  and  kiwe  t^ntrantiona 
from  urtictdar  dicoasoi':,  vioh-nt  i-xlonsion  under  chloroform  is  most 
op]>ftrtun«  as  a  means  of  obtaining  a  more  n^'ltil  poAttioit  of  the 
member. 

[n  a  fow  ca-ies  at  the  other  extremity  of  tlie  pnthologiml  scale, 
ID  which  the  will  alone,  or  timidity,  or  the  pocnUar  ahnormal  state 
of  the  Kvtcm  exiftjt  wliii.'h  ii<  im-t  n*illi  ueic-iLiionidIv  in  v<>ung  [ler- 
sons  of  both  sexes,  in  whom,  in  consetpienee  of  slight  injury,  a  limb 
rvinuinn  ntiff  in  tbn  ftruij^ht  or  iK'iit  itowitioii,  the  part  is  rehixed 
under  ehloroformisntion,  and  the  eontraetnre  is  promptly  and  pcr- 
mnuontly  enrwL  Tru«  hyKlcrical  contract.un.*  yield  witli  0(inal 
facility  during  the  ana'stlietie  state ;  but  they  usually  return  when 
the  offvci  of  tlio  cliifirofnrm  ha*  pMcoii  off. 

Mr.  Brodhurst*  has  lately  i-e-introdu^wd  section  of  the  femur 
tor  rigidly  luikyKmiuI  Inp,  in  tlio  hope  not  merely  of  straightening 
the  limb  but  also  sulwtittiting  a  new  nrtifieial  joint  for  tlio  ankylosed 
one.  Allbongh  ^ufHcient  time  Iihs  not  yet  olapscd  t"  ifhow  whether 
this  hope  ean  be  realised,  the  atten\[it  is  worthy  c^ imitation. 


W.  J.  UTTLE. 


ProiwJinj*  ft/"  thi  /loyal  iUiUcal  and  ChirurgiaU  Soctttji.  IMS. 


3)ISEASES  OF  THE  BONES. 


DISEASES  of  tlio  bonce  may  he  conveniently  divided  into  the 
tollciwiiig  eliL^os :  l-'irnf-,  iiitliuiiinn.ti<;i)  mid  iu  culiMX|ucnov9i ; 
under  wliich  lieud  it  is  proposed  to  include  the  varieties  of  the  in- 
flaiiiiiiatiiry  procfisf*,  \rliich  hnvo  rtuxiwd  the  n.iin<--9  of  p";rio»liti», 
ostitis,  and  osteomyelitis  ;  and,  aa  cousequeneos  of  tliese,  all  the 
numerous  coinlitiontt  which  have  b«cn  cuiifonrid'^d  tjif^uthor  under 
tile  common  but  vague  designation  of  caries,  the  various  forms  of 
suppuration  in  heme,  the  varieties  of  ncerosii!i,  itJ*  cftV-c-t-'*,  and  tliow 
prooeases  of  repair  which  result  in  ])eraianent  modification  of  the 
Stmctarc  aud  fitnn  of  the  organ.  Tbu  refoml  t-liiN^  will  ii>chide  tlio 
ipe«ifi«  diseases,  which  ooiMir  cd(hcr  as  modifications  of  the  inflam- 
matory procoM— syphilis,  scrofola,  and  rheumatism  in  bono— or  as 
eonsiitutional  oondiliona  leading  to  chjinj»eN  in  the  Uinj'  stntcture : 
audi  .an-,  m"lliti<'S  oitsium,  rickete,"  and  eancor.  The  Ihii'd  divi- 
uon  will  oompritw  a  description  of  ihtt  variant  new  fonnutioni*  found 
in  the  ohsoouh  syntirin,  and  which  are  not  dependent  on  any  of  tlie 
known  eonstilutionid  (-aehi-xia-.  Tbe/<'i(r/A  will  Iniat  of  iitfuphy  and 
byportrophy  properly  so  called,  i.  e,  tmcomplicaled  by  inflammation. 

SlUTLE  I>TLAUitAT10K  KST>  ITS  CoVSEQtrESCES. 

Inflammation  of  l>i>ne  differs  from  inflammation  of  soft  parts, 
not  in  its  exAentoal,  but  in  its  accidental,  fenturea;  tlie  inHam- 
matory  process  is  tlio  same,  but  tlio  conditions  or  circumstancoa 
are  ditli^mnt,  and  hence  arise  diveraiiifa  in  rate  of  progresa,  in 
external  appearance,  and  in  other  s>-mptoms ;  diversities  which, 
■Itbough  tlicy  are  not  really  eivcntiid,  yul  vaum-  striking  ditl'erenees 
to  ordinary  observation,  and  have  led  to  the  designation  of  tlte 
results  of  iiiHamtnation  in  bone  by  nnincK  ditfering  from  tboae 
which  are  used  for  the  same  eliangea  in  soft  parts.  This  differcuce 
in  mimonsluture,  tliougb  it  might  oriae  io  mistake,  at  a  lime  wlieo 


•  The  oibjectof  Rickets,  howcvnr.  irill  not  bo  foand  here,  as  It  baa  bwu 
thought  bettor  to  r«Ier  it  to  lh»  SoaoEar  or  Childhood. 


«ie  DISEASES  OF  THE  BOXEa 

necrosiff  was  dmigfat  to  be  Mnnetfamg  esMntuDr  different  from 
gangrene,  ami  caritn  a  duease  whidi  had  little  in  commtHi  nitli 
tdcerati'm,  is  yet  bardlr  to  be  r^netted,  since  the  di^ea^es  of  booe, 
thongh  jiatliotugically  identical,  are  practically  very  different  frmn 
thrMe  of  ifftt  laita ;  and  it  is  convenient  to  have  separate  names  fc^ 
tbinpt  which  rojuire  very  different  treatment,  and  mtail  a  veiy 
diffenrnt  amount  of  danger. 

If  tlie  reader  will  refer  to  the  essay  on  Ixflajoutiox  (voL  L), 
be  will  find  abundant  information  on  the  early  steps  of  that  process. 
These  affections  are  identical  in  bone  and  in  soft  parts;  in  fact,  they 
can  occur  only  in  the  soft  parts  of  bones,  since  the  mere  inorganic 
matter,  which,  involved  in  the  convolutions  of  a  cellolo-Bbroos 
and  vawnilar  network,  constitutes  a  bone,  can  itself  be  the  seat  of 
no  vital  actions,  but  must  obey  the  movements  impressed  npon  it 
by  the  li^  ing  textures  around. 

In  Von  Bibra's  "  Essay  on  the  Decomposition  of  Bone  I^ 
Caries"*  will  be  found  a  good  deal  of  interesting  information  on  the 
chemical  and  microscopical  characters  of  bone  in  inflammation;  and 
from  this  author's  researches  it  appears  clear,  that  the  changes  in 
the  inorganic  constituents  of  bone  are  often  limited  to  the  dissolu- 
tion of  that  connexion  which  pre^-ioosly  miited  them  to  the  organic 
matrix,  ro  as  to  form  one  system.  Tliis  connexion  having  been  se- 
vered, portions  of  the  salts  are  washed  away  in  the  discharges,  and 
they  may  be  found,  according  to  Von  Bibra's  account,  in  unaltered 
chemical  composition,  while  the  composition  of  the  organic  consti- 
tuents of  the  same  part  is  profoundly  changed,  principally  by  that 
£it^  degeneration  which  occ-urs  in  all  inflammations.  The  inor- 
ganic constituents  must,  however,  in  some  cases  of  inflammation, 
undergo  other  changes,  since  they  may  disappear  in  large  masses, 
without  any  discharge  having  been  present  Thus  in  caries  of  the 
spine,  or  in  inflammation  excited  by  the  pressure  of  tumours,  it  is 
not  rare  to  find  that  large  portions  of  the  vertebral  column  have 
been  removed,  sometimes  to  such  an  extent  as  to  expose  the  spinal 
.  canal ;  yet  no  abscess  has  formed.  The  older  pathologists  made  a 
distinction  between  these  cases  and  those  of  caries,  founded  on  the 
presence  of  pus  in  the  latter,  and  its  absence  in  the  former ;  but 
this  distinction,  though  of  great  practical  importance,  does  not 
indicate  any  pathological  difference.     Both  are  inflammatoiy  pro- 


1*  IMhig  und  Wohler'i  Annalen,  vol.  Ivii.  It  will  be  found  useful  to 
oonpsie  this  eaeay  with  thone  of  Mr.  Bsrtt-ell  and  Dr.  Bkclf,  i-efen«d  to 
Airtber  OS. 


TXTI.ASnirATIO^  AXn  TTS  C0N-SEQT;E>XE8.     fil7 


* 


h 


eofiKnt,  thoii;;li  of  ilitTimtnt  doi^roc^;  the  one,  ulceration  attoiidc^l  by 
snpfiiii'atioi) ;  tlii>  otlit>r,  iiIetT^tion  attendal  by  liqiie&otion  only. 
I<'n>i»  lUi*  tii<rt  uf  llio  (li>>fi  [>{>('»  run  CO  of  masses  of  haixl  tissuo,  vittH 
out  any  dianhai^  in  wlitcli  they  can  have  been  wnfliei]  nway,  it 
•MmH  dear  that  the  snxill  earthy  p!irticli>s  thus  loosod  Iroin  thvtr 
natural  oonnaxion  with  tJie  organic  matrix  may  iin<kTfjii  a  n'\i»rsal 
of  the  proct-M  by  which  they  wcro  dcpositpd  out  of  the  fluid  blood ; 
t.  e.  may  btwome  again  !w>lublo,  and  [lawt  into  th"  v<-niiii»  ciirri-iil, 

Tlic  carlittit  niicroKCopR-a!  chaiini'*  is  an  nntrsual  fiilness  and 
distinctness  of  all  the  viu>cular  cavities  of  lh«  bono;  the  Hnvcnian 
canals,  Ucinia?,  and  canalicidi  boin>;  all  more  )ili»rpty  marked  than 
in  the  natiinkl  KtatOL  Thin  Von  llibra  mnijuirr^  to  the  iiiji'ctcd 
condition  of  boH  parts.  Later  on,  the  Haversian  canals  and  la- 
oiin»  become  widened;  tlie  latter  dittap[tc»r  in  conMXpiviico  of  thd 
ooniinunication  of  neighbouring  cavities,  and  spaces  are  formed 
in  the  bone,  filled  witli  fat  and  earlliy  naltii,  tlic  detritus  «f  the 
doooni  posed  tissuei. 

The  carllvHt  eiinngo  in  the  coiiBiJ'tcnco  of  bono,  produced  if 
inflammation,  appears  to  bo  softening;  aa  a  consecjnenoe  of  the 
]vo»ciiin<;  and  absorption  of  iJic  mtii(,4riil  portion,  and  th«  liqucfiic- 
tion  and  convei-sion  into  fat  of  the  organic  matrix.  Mr.  Elarwell 
bus  recently  published  an  intwu'i'ting  cjwny  "on  Osteitis,"!  which 
affords,  perhaiia,  the  most  distinct  demonstration  of  the  eiilnr^ncnt 
of  tho  vii*cular  )ii)iu;cs  at  an  early  period  of  Inflammation.  In  (his 
eaaay,  Sir,  liarwell  teaches  tJ>at  tlw  cjirliwl  Ktagcs  of  iiifiiimmation 
are  accompanied  by  induration  ;  an  assertion  which  I  venture  to 
question,  Hince  it  ajjiieurs  to  mo  tiial  indnrntion  in  a  phenomenon 
subsequent  in  order  t«  tho  intlammatorj'  process  in  its  stridor 
aenae,  and  dun  to  one  of  ila  ri'unlts,  vix.  cfliiHiim.  The  i-eadcr  is 
referred  to  the  original  eway,  which  will  well  repay  perusal. 

^^U(;ll  are  the  earliest  chnnfreH  in  tlic  minute  »lniCturo  aiul  con- 
eistenco  of  inflamed  bone.  'Hie  changes  which  t.ake  place  in  its 
roU(;h  anatomy  may  be  thiin  di^criixHl.  If  a  }x»w  l)«  examined  at 
an  early  period  of  inflammation  (the  ordinary  and  most  accessible 
instance  in  llie  «tunip  of  the  botie  in  an  ainpiUation  fatal,  My, 
three  weeks  after  tlie  operation),}  the  poriosteura  will  be  found 


•  See  Von  Bibra.  op.  cit. 

f  JMt.  and  For.  Mrd.Chir.  Ittv  ,  April  1660.  pp.  400  «t  sqq. 

I  In  Kucb  a  8]>«oinieD  itae  iieHostmm  will  Kcnerally  be  fuund  stripped 
offfrom  A  stnall  rine  a'  tlii^  luwtT  citil  or  ih*  bone,  and  this  put  will  per- 
Im|>s  ha  diikd  or  alraut  to  itt« ;  but  aa  tJiU  feature  Is  aocidenlal,  it  will  not 
be  farUMr  notieed. 


C18 


DISEASES  OF  THE  BONES. 


somewluit  tliit^kennil,  viwctilnr,  and  not  m  ahiM'ly  connectod  to  the 
bone  aa  usual.  *  If  tlio  periosteum  bo  stripped  off,  titc  bona  is  seen 
to  bo  irrc'^ulnrly  vaHttular,  mudo  porl.inns  of  It  liuvtnjr  n  slij^litly  rod 
tint,  and  contrasting  with  tbo  lioaltliy  wliito  colour  of  tJie  rest  of 
lli«  bone,  'i'liix  nx!  tint  i*  ovidontiy  i.'«iwwi  bv  tlic  onlnrgomwnt  of 
tin  veesols  wbicli  pass  &oin  tho  perioetouni  uito  the  bone ;  and  if  a 
tIUigni^'iiig-;;Iius  hi)  mvi],  t!ic  inciTimxH)  »\/.i:  of  tiiv  vascular  a[Wr- 
tures  i»  eaaUy  proved,  %¥hi]e  if  pressure  be  made  on  tlie  surface  of 
tbc  bonu,  lb-ops  of  blood  wilt  frLH|unntIy  ooxc  fi'om  the  moutbs  of 
the  enlarged  veeseU,  ]>roving  their  increase  in  flii!«,  a»  wdl  as  tha 
Ios»  of  con»!»tfnco  in  tho  uutvr  bnni  wall  of  tha  bono.  At  tbo  t»m9 
time  tht-re  will  \ie  found,  in  all  probability,  on  cionifi  other  part  of 
tlto  Hurfucc,  more  or  less  doposit  of  otwoous  matter,  whicli,  with  the 
jntrtial  xcparutioii  of  the  perionteunt  abovti  intMitioiKHl,  U«tity  to 
tbe  fact  of  cf)iision  &-otn  the  vc«sels  of  tliat  membrane.  In  th«se 
aimple  cai>vn  of  injury  tlie  dot^por  pnrt^  of  llio  Ixme  ivill  iiroboiltly 
bo  unaflTcctml ;  but  should  tJiis  not  bo  the  caso,  i.  e,  should  inflain- 
nifttion  \\a.v(^  iiNo  tittiu-.kod  tin-  uiiimhniiit!  litiin;;  tlio  mtyluli«ry  cavity 
aitd  caiicelli,  that  membrane  will  be  fouud  in  a  condition  essen- 
tially aiiitlopiu.'t  in  that  of  tItA  ]>i>riu»tt!uni,  altliough  tJw  difforvnt 
situation  of  the  moduUarj-  membrane,  ajld  the  great  ((luuitity  of  fat 
and  other  loiJ-**i  ti.-wutw  anmiig  whicii  its  vessels  ran,  «ill  sonto- 
wbat  modify  the  ostcrnal  apjwarancos.  If,  however,  the«o  appeir- 
ancea  be  minutttly  invrstigiiUKl,  tlK^y  will  bo  reduced  to,  inercHAo  in 
the  Dumber  and  size  of  the  veedoU,  and  effusion  of  blootl,  lymph, 
or  pus,  aoxirdinf;  to  cireuui.'^tanues.  The  tliickening  botJ)  of  the 
periosteum  and  of  the  mwlullaiy  membrane  is  aomt-linici*  eonsider- 
able.  Tlio  former  mouibrauo  i»,  of  course,  more  frequently  found 
thickened  than  the  Inttor ;  but  prejiamtions  iihon-ing  lliv  participa- 
tion of  tho  medullary  membrane  in  inHammatiou  of  the  bone,  and 
the  identity  of  it«  appeanuiou  mlli  that  of  the  thivkcuvd  poriostcum, 
arc  not  wanting.f 

Tims  we  nee  that  wlien  indammntion  commences,  as  it  iwiudJy 
does,  on  Iho  snr&oe  of  a  bone,  whotbor  perioeiteal  or  endi^sieal,  its 
pnm;iry  symptom  is  increase  in  the  size  (and  porIui]»  numlwr)  of 
the  capillary  veeseb,  or  vascular  spaces,  and  eHiuion  of  blood  or 


*  Hunter  has  put  up  (Mus.  Coll.  of  Sui^.  no.  0A6)  "  A  pn^ration  of  a 
femur,  wliicli  wns  ampiitnted,  witli  the  porloBteura  separated  ;  io  aliow  bmr 
dcur  t!i<i  periosteum  sepiu'tLWs  from  the  bone  ia  inflammation  i  a  bet  al- 
most nlwn}'s  obacrvable  8ft«r  MUputatiou." 

f  One  of  the  moat  striking  prepnititiotiB  of  this  klucl  Is  b)  (he  muMun 
of  S'  Rartholomow'a  Hoapitdl, — a  buuierus,  eeri«s  1.  no.  WT. 


■ 


^ 


KFLAMMATION  AND  ITS  C0NSEQCESCE3.      619 

lyni|ih.  Tiie  primary  viTtxit  of  inflnminatiim  in  (ho  ctmtral  [nut*  of 
tbo  compact  ttMUo  are  similar  to  the  above ;  tliough  he-re,  from 
tlii«  difli^rviit  vtrcui(i«t»iicvN  in  which  tho  vci««cl«  nru  pla«Kl,  this 
siniilarity  has  l>ecii  less  distinctly  perceived ;  and  from  tlie  ttlownea.1 
nitii  which  xU  changca  go  ou  in  thu  compact  tissue,  opjiortumties 
rarely  occur  of  oompanng  the  diSTerent  juirto  of  tho  hiiiha  iMino 
witli  roeli  other.  Tho  first  ohan}:^  ih  thv  otihtrgomont  of  tho  vvssols 
which  rmi  in  the  Ua^er^an  canaU ;  hut  efhtsion  i«>  n  niiicli  Inter 
phtiiomonon,  and  is  {trcccdvd  by  tho  absorption  of  tlio  bony  tissno 
whicih  afljoina  Uie  cnlar^l  ve^scU ;  k>  that  in  niii^roanopii-ii]  (nwtions 
of  iofiamod  bone,  tlio  Uftvorsiau  s|>aceB  arc  sooQ  much  enlarged, 
irregular,  «rod«<l,  und  AometinicH  almn?it,  or  quite,  eoiiimunioatlng 
with  each  other.  The  liicniin.'  may  also  bo  noticed  to  bo  densely 
cntM'di-il  to;^tlit>r,  und  Hniiicliuics  the  gninidiir  inntrix  of  tht'  bono 
ap}x.<arH  more  coarse  tJian  uatural.  When  this  absorption  of  tho 
widl.i  of  tliij  Kiiveniiaii  uiuaU  iiccinKOs  viniWii  to  thi"  niikncl  vy»,  tho 
Brat  cliange  in  tlie  rongli  aii.ttoniy  of  intlamed  comi>aot  tissue  bc- 
comm  apprtrt'iid^Io — tliBt  ID  whioh  Mpitcc»  arv  mm.ii  in  it  ou  sitction 
like  tiioae  in  cancellous  tissue,  so  that  it  is  soraetimt's  said  to  be- 
come cjiiici^ilous.  Similar  i.-lmnfH'«  occtir  in  the  cancoliotw  tisnuo 
itself,  whereby  ita  c«llh  become  much  cnlarge^l,  and  Mtmetunen  the 
whole  bono  is  t-.ipandod  by  tin?  simultancoiu  yielding  of  its  wallt." 

Intf^t  die  s[>an(!A  thus  hollowed  out  in  the  i<u)>»t»rKW  of  ihe  bone, 
or  on  its  surikco,  by  tlio  romoval  of  the  oarthy  matter,  the  pro- 
ducts of  inflammation  aro  next  fMwrete<L  Thew  m;cn.TliunA  var^',  of 
cottrso,  according  to  numerous  preooding  circumstances,  f.^.  thu 
nature  of  llie  injury,  or  other  chum  of  inflammution,  tho  activity  of 
the  process,  tho  coustitutional  condition  of  tho  patient,  and  a  tlioa- 
•audolhftT«;  and  wo  tlio  product*  of  ostitis  arn  ilivi.tilile  into  two 
principal  varieties,  corresponding  to  the  plastic  and  aplastic  lymph 
nut  with  in  other  iKirt.*,  aii<l  IvMling,  Uio  fonnor  ti>  the  dt>]K>Nlion 
of  earthy  matter  and  the  formation  of  new  bone,  and  tho  lattvr 
to  mippunttion.  Tho  forini^r  rastdt  ttrminat^ti  in  luintviiing,  or 
Kteroeui,  an  it  ia  tenneil ;  tlie  latlor  in  a  variety  of  eonditiona :  when 
the  suppuration  is  Uniitod  within  a  cavity  in  the  aoncoUous  ti«mie, 
or  in  the  compact  tiasuo  roroticd  by  previous  intbunmatian,  circum- 
■oribed  abBOces  ia  produced;  wbeu  tiio  pus  oxtcnds  along  the  iimcr 


•  8oe  a  deaoription.  bj  the  author,  of  the  bones  of  the  lower  6xtr«inlty 
ten  montli^  ■fti-r  exobion  of  tile  kn«e.  wht're  iiie  supurfidit]  laininte  of  tho 
fenor  bad  bcru  no  sirpiLinti-d  fraro  e^\i  other  bj  iulliiiiLmulion  that  the  boue 
oncklcd  uudvr  thv  pmiMure  of  the  finger.  Path.  S<m.  Tr.  roL  xU.  p.  171. 


C20 


DISEASES  OF  THE  BOKES. 


surTace  of  tlw  tncmbrniic  litiin;:;  Uiv  modullaiy  cavitj*  and  c!in<.-olli, 
tiic  coiiililion  iil'lx.no  exists  wliicli  in  osuallv  itpoktin  of  by  Kii^lish 
»atliors  as  "  tliftuwd  Mi])]iurittioii,"  nnd  hy  did  Fn^ch  as  "  oaUXH 
myA'ith ;"  supimration  between  ilio  periosteum  niitl  l»onfi  formn 
periosteal  alwcf*«,  aciitv  or  cliroiiio ;  aiid  any  of  tJio^  forms  of 
811 1 ipii ration,  wluni  accompanied  by  the  iiiwm^iblo  oxfoliation  of  the 
bono  (or  its  dcatli,  and  removal  in  invisible  portions),  eonstJtntce 
ulcenition  i>l'  ilic  bone,  or  cariitif.  La.<<tly,  iiiHAiniiiiitinn  of  t}ii'  txinc 
sometimes  leads  to  tlio  death  of  larger  portions  of  its  tissoe,  which 
are  lli«n  roiiiovwl  by  the  proctiss  of  iiWrntioii,  )W  in  Hoft  jrarlA.  'Hiii* 
constitutes  ganKTcno  of  bone,  or  norwsw  ;  but  as  that  condition,  Ijko 
otlior  foi-mti  of  gangrene,  in  often  ]>r»(Uici^l  by  oilier  csiim>«  not 
inflanunatory,  the  whole  snl^oct  of  necrosis  must  be  treated  by 
itaclf. 

We  Iiave  now  to  eonsidor  separately  the  pauses,  symptoms,  and 
treatment  of  (,'aoli  of  tlnwr  [iSuisfs  of  tin;  iiiHaminat'iry  proww ;  tlio 
above  being  intended  only  as  a  kind  of  groun<l-plan,  to  mark  out 
tlu;  various  parts  of  a  ratliur  iiitrieatti  subject,  each  of  which  must 
be  studied  in  det^iiL 


Oall'is.  Inflammation  of  bones  is  oxcIIikI  usually  by  external 
violi'Tice,  or  exposure  to  eold,  acting  ujwn  A  constitution  prnlis- 
jHiseil  to  the  iliscdtte,  Tlw  jtn'(lU|M)«ing  cnuaes  are,  the  syphili- 
tic or  scrofulous  taint,  rlieumatism,  defective  nntrition,  Ac. ;  or 
tlicM!  may  tlicniselvi-tt  set  uji  iiitlnmuiation  in  any  Ikiiio,  without  a 
distinct  exciting  cause.  From  this  mode  of  causation  it  follows, 
that  tlic  Ixmi-jt  m<i.<t  lialilc  U>  inflamuiut.Ion  arc  ihnse  nioitt  exposed 
to  the  action  of  external  agents.  Hence  we  eeo  It  most  fi'equonlly 
in  the  tibia  among  the  long  Iwivit,  and  in  the  i«kull,  Menium,  and 
ribs  anu>iig  the  Hal  bones.  The  bones  of  tlie  foot  and  band  art!  also 
very  friiiucnlly  alTccUJ. 

Ostitis  is  a  very  common  affeotion,  aUhoogh  not  much  reoog- 
nisod ;  partly  because,  from  tho  little  attention  it  has  rocciied  fnim 
our  older  autliors,  ami  from  the  fact  that  most  swellinga  of  bono  are 
regarded  as  [periosteal,  wc  are  not  much  in  tho  liabit  of  looking  for 
it;  and  portly  bi-eaiisc  its  symptoms  are  at  first  obscure,  and  liable 
to  bo  ma^ki^d  by  those  of  the  injury  to  tlic  soft  parts  w  ith  wliidi 
it  IB  assoclatt.'d,  or  of  tlio  constitutional  affection  IVom  wbicb  it 
springs. 

Tlie  sym]ttomn  vary  acconling  to  the  stage  of  the  inflammation. 
In  tlid  first  stage,  that  in  which  the  size  of  tho  vessels  is  increaMtl, 
and  in  which  absorjitJun  is  being  pro<liiot^,  the  diseane  frc(|uunt]^ 


OSTITIS. 


621 


mnkcs considrralilt'  profiross without  approciable  Bjnnptonw.*  Soaoor 
or  lautr,  )iowt»v(-r,  tiia  occurrence  of  thoso  oiinruot^isliu  dull  jmitis 
in  Uio  IxMCB,  cxawrbalwd  by  changes  of  weatfaor,  hunxta«ng  in 
wverity  ilnrin^  ihn  nij;ht,  and  somtmliat  rrwftnililing  Iho  jwiinit  of 
rhminiatisin,  which  ai-o  dcscribctt  by  Fronch  writers  as  "  donleure 
oiit£oci>)><»,"  <]raw  tho  atti^utioii  of  tho  )i»tti»il  to  tlio  sunt  of  thv  <liK- 
KttOf  and  form  a  valuablo  ^ido  to  tho  Surgeon.  If  the  part  bo  now 
exiiniiiml,  tiiQ  pnibubility  in  tliut  eioine  Rvt<lt!nco  will  Ih>  found  of  in- 
flaramatjoD  In  the  tJBsues  surrounding  tbo  bono — rsdoma,  redness  of 
the  Bkin.  IfiidfrrrHtii  of  itio  aoiX  jmrUs  or  tlirfiili^iiing  aliHO-w.  Tho 
nbsoi'|ttion  of  tho  earthy  material,  which  aeconipanies  tin's  iiici'caHi^d 
va.4Ciihirity,  iiiuiiifiTntn  itit  etf*^ct{I  n|»on  llio  bgiio  by  u  diminntton  in 
itfl  eonsistenee,  and  tlien  the  bon«  becomes  at  the  Hiino  time  in- 
crmaed  iii  volunx!  luid  dimininhod  in  it:*  nuiMaiici-  Ui  pn^^fturu:.  Ttic 
fbnner  sytnptoia  is  indeed  eomowhal  delusive,  since  the  apparent 
inori-a«  in  otU;n  iluo  priiici)ia!ly  di  onlnr^wnvnt  of  fli"  soft  parts. 
Thus,  the  expansion  of  tho  joint-ends  of  bones,  which  freijuently 
Appnus  so  cunsideriiblt!  in  elironic  iitloctionH  of  tho  joints,  is  ofton 
reduced  to  a  Iiaivlly  appreciable  enlai'gement  on  disseetaon.  But 
tJie  swelling  of  iIk*  bgno  may  wmetiiiK*  I«!  niodo  out  very  clearly, 
and  is  then  a  valuable  indication  of  the  disense.  The  softening  ia 
not  goncrally  of  much  imiX)rtunoc  as  it  dia^^nofUc  symptom  ;  it  rarely 
affects  iJie  whole  thicknesa  of  a  bone,  so  as  to  lead  lo  a  cliniigi'  in  iUi 
form,  and,  when  limited  to  a  portion  of  tbo  surface,  cannot  be  ap- 
preeiutod  by  tho  toudi,  sinee  the  inflamed  and  trritntili!  condition 
of  the  soft  parts  renders  tho  patient  unablo  to  boar  tlie  nccLVsary 
presHurc. 

A  singular  change,  which  sometimt^  follows  inflammation  of 
a  lonfT  Imiik^,  '»  iti  oluu<;ation.  in  a.  puper,  I'tiefnrly  prejuMited  to 
the  Hoyal  Medical  and  Chirurgical  Soeietv,  Dr.  Humphry  has  laid 
nineli  stn-?>H  upon  tho  con»>oipieiio<'!<  of  <IiiM;QMHl  eonditiontt  of  tlie 
epi]>bysial  lines  near  tlie  ends  of  long  bones,  as  alfeeting  tlieir  sub- 
aecfiiont  (growth.  It  i-i  poMible  that,  inflaniinulion  of  ihiit  (i.-uiio  ptay 
have  led  to  the  elongation  of  the  bono  in  some  of  the  eases  :  as  in  a 
tihift  from  n  Ind  nut.  19,  prcsor^vd  in  iJio  nnusftim  of  St.  Bartliolo- 
mew's  Hospital,  in  wluoh  the  bone  has  become  lengthened,  and  is 
curvi.-d  in  onler  (o  adapt  its  length  tu  tJiat  uf  the  licnlthy  tibuliu 


*  Tills  is  tm«  nioro  Mpedollj  of  ibe  varlicr  stag<«.  bat  Is  occaakuallr 
observed  in  all  rtirms  of  JnilAmniatiaii  «f  bunc.  Thus  Urge  paoBs  abMNMses, 
euiirin.-U»l  Willi  rxl«nuv«  «ii»ii'ii  of  tlit^  vvrtclinv.  are  found  aomcliines  in 
IMtionts  not  ol  a  strnnions  hnbic.  and  wlu>  have  not  bccu  known  lo  (irOBeni 
aiijr  sfuiploius  of  «ucb  an  affoc^on. 


622 


DISEASES  OF  THE  B0NE3. 


To  the  Bta^  of  abeorptioo  and  rsrefiicdon  auooeeda  that  of 
effiuiun  uh]  dcpunit,  unlisA  tlie  jirooetw  be  aiTCitt«il,  and  resolution 
oocor.  The  varioua  oonficqoenoes  of  supparation  being  nwtn-ed 
for  sabMXjiH^it  Hctrtioiu,  wc  nvM  now  only  oonndcr  that  tcrtnination 
of  influtiination  of  bone  ii]  hartlening  or  scleroaaa,  which  oorn-Hponds 
to  the  intiiimmnbTy  Hnlidificutioii  of  |>arvncbyinab»UB  or^ns;  aiid 
whioh,  when  not  too  oxtonsive,  is  for  practieal  purjMWM^  liirli'  Iws 
desirable  thun  voinpl<tt«  rcnt'imtion  to  licaltli.  The  iiiterstioes  of 
tiie  oancoUona  tisBne  are  iillcd  op  at  finKt  with  lymph,  in  wlii<.4i 
OMific  matter  iit  aAcrvrardx  deposited ;  and  then  the  bono,  which, 
wliil«  actively  inflamed,  had  be«n  Iccm  dense  tlum  in  ila  iH-adthy 
condition,  boeomcti  hard,  hcaiy,  and  solid ;  the  in«dullaiy  canal  is 
narrowed  or  lilW  up,  and  the  ahaft,  tliiiikmied  by  deposit  from  the 
pcriostcnm.  Bonos  thus  alTectcd  abound  in  every  patholo^cal  coU 
]oc4ion ;  and  it  i»  «'a«y  t«  Irart^  iti  ihein  mniiv  of  the  a}>]>vanuiccfl  of 
which  an  explanation  has  been  attempted  above — tlie  large  siaie  of 
thu  ra»(uil(ir  n|MTliinsi,  tli«  im'{;uliir  dqiosit  of  bono,  both  in  the 
centre,  the  substance,  and  on  tl»e  surface  of  tlie  shaA,  the  oontnc- 
tion  of  iJie  medullar^'  cavity,  tiiid  usually  tlic  increase  in  size  of  the 
nntritious  loramina.  It  will  generally,  but  not  alway.4,  bu  noticed 
that  thi^^!  <.-lifing<;s  are  limited  t"  the  shaft  of  the  bone,  when  it  it 
tlie  jiart  first  alfcetcd,  and  Uiat  the  articular  mvU  mtM\!C,  Tlw  con- 
verse is  also  usually  the  case ;  though  perhaps  the  shaft  is,  more 
prone  to  becrnne  involved  in  the  morbid  wdiun^  of  the  joini-cnds 
than  the  joint-ends  arc  in  those  of  the  shaft.  Thus  inflammatory 
affitctiotia  may  long  go  on  in  the  shall  of  the  &mur,  yet  the  knee- 
joint  remain  unafFi^ctcd;  and,  on  the  other  hand,  in  most  disoawM  of 
the  joinCx,  the  alVtiction  ot  tlie  boiii-s  considered  by  itself  is  not  so 
extenuve  as  to  oootra-indicate  excision.  To  eaeh  uf  thcM  two 
^ncral  ndcs,  however,  numerous  exceptions  will,  unfortunately, 
be  met  with  in  practice. 

Inflammation  of  the  bone  is  almost  always  known,  in  oommon 
parlance  (wliett  it  Ih  n-cogniited  at  nil),  as  perioHUif;  l>ut,  in  tmth, 
periostitis  seldom  occurs  uncomplicated,  tmlcas  in  the  C!OU^^;  of 
secondary  syphilis;*  and  almiMt  ull  the  enM^  which  pan  under  that 
name  are  really  inflammations,  more  or  leas  extensive,  uf  thu  bont. 
That  this  ii>  so,  will  hardly  be  doubted  by  ajiy  one  who  oonsiden 
how  few  preparations  of  pure  periostitia  can  be  found  in  onr  ma- 
aenms,  and  how  seldom,  during  our  [xiet-mortem  examinations,  we 


*  I  «raulil  rvf«r  the  rvadnr  to  tho  »Mtlon  on  SyphlUt  In  B»ne  for  fanlur 
(ktoils  on  the  nubjcct  of  ehiiinic  pcrl«Hlitis. 


DIFFUSE  PERIOSTITIS. 


623 


moot  with  porioAlitiH  unattoiiilod  by  initiunmittory  ilcposit  in  the 
deeper  parts  of  the  bone  Tbo  sjnnptoms,  as  woll  oa  iJie  morlud 
lUUtAinj.*,  [if  ))utb  ai"e  i<li;nticiil,  imly  tlmt  in  pcrjortitis  tbc  tbicken- 
ing  and  vascularitv  involves  no  otJier  part  of  the  nutrient  membnuio 
uf  Uk>  buiw  t;x(^'i;pt  the  ]H)riostiMitn,  and  thtit  tJio  iDfliunnuitor}'  deposit 
19  cotdincd  to  the  surface  of  tlte  bone,  between  it  and  the  peri<Mt«uin. 
H<rrii)»titU  is  a  i]nickiT  pnwwui,  and  on«  nioro  under  the  influenoe 
of  remedies  Uian  tlio  other  forma  of  indammation  of  bono;  but  to 
ull  the  Mnw  fpMivrtd  oonrHO  of  tn.-atnKiit  ix  indicated,  viz.  the  in- 
ternal aibiiinistration  of  iodide  of  potassium,  and  b)«tl  a]>|iIiuttion 
uitlicr  of  iodine  ur  mcrcrurinl  ointment,  or  gwrliaps,  in  tliQ  early 
stage  of  die  disease,  ofUisters.  These  measurec  ahoukl  be  com- 
bined n-itb  prngH^r  pimitioii  of  the  uffoctod  member,  .and  as  much 
rest  aa  is  con^stent  with  attention  to  the  general  health.  Leeches 
or  ctippin;;  will  afford  relief  if  the  )>ain  bo  scv'cnn  When  there  is 
much  tension  o\er  the  Ixtne,  sontetimea  aocoropmnied  (ej<|iit-ia)ly  in 
the  crnninm)  willi  intolerable  pain,  nothing  gives  such  immediate 
and  decided  relief  aa  n  free  and  bold  ineiaiun  down  to  the  bono. 
Tl]c  disteiidii'd  perloeteimi  is  lliua  n<lax(-d :  and  in  oaaea  of  pnro 
poriiistitiM  nucii  a  nieit^nre  may  of  itself  altnoM.  kuIKou  tbr  the  cure 
of  the  disease ;  but  its  benoScial  effects  will  bo  decided,  though  Iciw 
strikin;;,  in  ciut-s  ofdi-cper-Miited  iiiHainmiitinn.  lu  eases  of  chronic 
intlaiiiinatioii  of  bone,  awwmpanied  by  deep-seated  and  woiwiiig 
pain,  an  upcnin};  made  witli  a  Ln-phino,  fi)r  tbe  evacnation  of  pus, 
haa  proved  benefieinl,  e^en  tliough  no  pus  was  found.* 

Whether  tlic  sclcriwis,  or  iiidtu'aLiun,  wliioh  \s  the  final  result  of 
ehronic  inflammation,  bo  amenable  to  any  remedial  me&aures  is 
doubtful,  since  it  usually  pivcs  Um  |iut4'(Mit  little  inconvenience,  and 
tluMrofure  ist  nut  made  tlte  suhjeet  of  treatment.  Tliickeniny  over  tlio 
bone  is  oflen  left  after  ostitis,  and  is  often  <lispersed  by  the  ordinary 
moAMireji,  such  as  friction  and  pressun- ;  biu  the  seat  of  thin  thielc- 
ening  is  very  generally  in  tJtv  soil  parts  around  tbo  bone,  and  not 
bcuoBlh  tlie  {feriostvum. 

Itifune  perioftitU.  Inflammation  of  the  bony  tiasne  itaolf  is 
rarely  aeute,  and  when  it  does  <H-cur  in  tlic  acute  form  pa^^es  rapidfy 
into  nccrosii",  under  which  head  it  will  bo  presently  sjiokcn  of;  but 
acute  InflanmiatJon  between  the  bone  and  periosteum,  diffitie  peri- 


*  See  a  cstte  reportnl  bv  Sir  B.  Brodie,  in  liU  /.teturtt  m  PiUktAoijf  and 
Eargrry.  )>.  4 10.  On  tbu  RDod  efflMits  of  a  fre«  inmJon  ot  infliuneil  perioi^ 
tciim.  wlicii  iniitItT  tiiciKiiiroH  bil.  see  Sir  P.  Cmaplom  on  Peiiwilitia,  DiMiit 
UoipUal  HeforU,  toL  L  p.  S31. 


624  DISEASES  OF  THE  BONEa 

<M(i(u,  tH  a  disease  of  nuhcr  fri>()nent  occurrence,  and  is  le<ta  noticed 
in  surgical  works  tliun  its  iin)>nrtancc  would  teem  to  rcjtiiro.  It  is 
sonn  winraonly  enough  in  pertwns  about  Ute  age  of  pubfitty ;  more 
fivquontly  in  Iwys  than  in  girb;  oHially  as  the  ixwtdt  of  some  in- 
jury, bikI  otutosl  always  in  one  of  ibe  long  boned.  It  is  so  dfM4ni<;- 
tivo  in  its  dfecte,  to  rapid  in  its  course,  and  is  eo  fa'ttle  rocogoised. 
that  we  liave  unfortunately  numerous  opportUJiities  gf  verifviiig  iLi 
tadskeaoB  after  the  tiuio  for  tr«itint-nt  has  passed  an'ay ;  yet  to  eariy 
luid  vijrorouii  irealiiient  it  is  tolcmbly  amenable,  at  least  u»  ninvfiable 
as  so  acute  a  disease  can  bo  expected  to  be. 

'Flic  [Killioliii^,-  of  die  disea.**!  apjx-arH  to  oun>n<«t  in  the  [lurtial  j!«\m- 
ration  of  the  poriosuiuin  from  the  bone,  by  effusion  on  the  surface 
of  tltc  latter  uf  lymph,  or  tilher  piiidwcts,*  kooh  giving  place  to  a 
co]>ious  formation  of  pus,  vhich  spreads  alon^  the  whole  bone,  and 
dissoctA  away  thr  jmrlontt-nm  tVoni  il,  oDcn  from  oiio  end  of  tlic  bono 
to  liie  oilter.  If  examined  at  an  early  period  of  the  disease,  the 
pnriostetun  do<»>  not  (»t  leaM  it  very  oflen  does  not)  dis)Jay  any 
disrinct  signs  of  inflammnlion,  eitlier  in  change  of  colour  or  of 
thickness ;  nor  is  the  xtirfiu-tt  of  iho  lionc  vixihiy  inflamed.  On  the 
contrary,  it  usually  looks  white,  and  inclined  to  gangrene,  a  con- 
summation whidi  rapiiliy  im|)i-ntU  over  such  eases.  Somctinioa, 
however,  the  surface  of  tlie  bone  may  Iks  found  slightiy  worm- 
eaton,  and  on  w^ueoziiig  it,  it^  supcrticial  layers  are  found  more 
readily  sepai-ahle  from  the  deeper  tissue  tiian  in  health ;  large  dnips 
of  blood  can  in  sueh  iiiHluntH^  hi'  i)rrs8cd  out  of  tlio  vessels  which 
fiMs  into  the  hone  from  the  ponosteum.  A  little  later,  aiul  nocroKis 
is  unmistakably  declared,  uikI  the  wholu  diaphysis  usually  perishes 
loariug  tlie  artiouJar  ends  unat}ect<»l,  and  llierefore  not  involving 


^ 


t 


■ 


*  The  discnse  Aors  not  commence  by  Um  fonna^on  of  «bBC«sa :  often 
wtiOD  till;  swcUinK  anil  inrtnnimatinn  nrc  conridmable,  no  pus  ivill  he  fouud, 
or  LhiN  fnpt  tlic  following  is  aii  iu«Uincp.  A  lad  was  fluIlVriug  from  ukiit 
was  i)\ip;ici8fld  to  lio  clilllisc  ■■cllular  iiirtHininstioit  anmiid  Ibir  uiikl«  0(1(7  a 
slight  injuiy.  As  it  was  ampFclcd  that  tlie  irillatnmHtiixi  was  ii-iil\}'  subpeii- 
osteal.  an  ItiL-ision  was  maJe  dowu  to  the  libiiL  No  |ius  folluneit.  Tnu  iia.ya 
iilVrwartls  Ihc  buy  presented  obvious  BvtiiplumB  i>f  cuiiltOMl  maltcr.  and 
now  b^  bivahlug  up  the  adhesions  of  tli«  nuiuid  a  copktis  evnctiatiou  i>f 
pus  was  obtained,  aud  the  surfuL*e  of  the  haait  mis  felt  rxposc^l.  A  few 
days  later,  svi'elliii);  aud  tcndenic^ss  wtre  fnunil  over  a  biglicr  port  of  thr 
tibia.  Tbe  Surgeon,  thiiikJiiij  tliiit  on  tho  former  occnaion  iic  miKhl  not 
liavo  dii'ided  lh«  puriontuuni  frcol,v  enough,  now  took  cnrn  to  pi***  Uic  r4g<! 
of  tbe  liiiifu  firialj'  npiiitst  tlie  bon«  for  somc<  diatiuicc.  Klnttfr*  wont  on 
exactly  hh  in  tlitj  farmer  wound.  No  pus  nns  ffund  nt  tlio  time,  but  on 
brcakini!  dou'ii  iidlic-niona.  tivo  dnys  later,  with  »  pmbc,  Ibo  pus  wm  dla-  j 
ohui'^tiii,  tuid  bund  full  uxpoicd. 


ACUTE  PERIOSTEAL  ABSCESS. 


635 


ntighbotiriiij;  jiiitit.  'riio  joint,  however,  (lw!»  not  nlways 
ewape.  A  boy  was  adniittcd  into  hoepital  several  days  after  an 
injurj',  with  crttnl  itwullinji  of  tbe  foK-ann,  ovi(]untl_T  dt-iionfling 
on  the  formation  of  matter.  A  gi-ating  sensation,  perceive*!  cm 
'^^  rotating  lliu  h.-in<!,  mgutliisr  with  tlio  liisturj'  of  tlic  at'ci<lont,  l«l  tv 
^1  the  belief  that  fracture  had  occurred.  He  died  of  pya-iuia;  and 
^^y^aa  it  wan  (liMvivcriMl  thitt  a  periosteal  ubnci!'!!*,  c-xtoiidin;;  fr'iin  tho 
^^S&ft  of  the  radiuH  into  the  ^vrist-joint,  hiid  ao  enxled  tho  articular 
^p  curtiliij^-H  wi  to  <3(HUk!«ti)n  the  »eiituition  of  crupitui. 

The  oourso  of  the  difieaao  is  usuallj  as  follows :  it  commences  in 
I       tho  fprvsit  insijority  of  chmk  with  an  iiyury  of  more  or  leas  severity, 

»oociirring  to  a  person  generally  of  the  strumouii  constilutioit,  at 
t^y  mte  a  wenkly  ])crson ;  the  symptoms  wbleh  imme<liately  fol- 
linr  the  injury  are  uaiuiUy  slight,  so  tliut  even  ibe  o(N.>urreiioe  of  the 
accJcbmb  is  pcrhnju  nearly  fi/rgottcn;  then,  afler  a  rart'ing  lupM 

I  of  time,  probably  four  or  five  da*"*,  syuii>toniA  oeour  ^vlii<'Ii  are 
almost  invariably  attributed  at  first  to  iliSitso  cellular  inRaniuiutiun, 
or  to  acute  rheumatism,  viz.  rigors,  pain  in  the  jiart,  and  an  i£<lo> 
Diatous  angr^'  swelling.  At  the  outset  the  diagnosis  is  not  easy; 
indeed,  before  suppuration  lias  oociurod,  ]>erlin[i8  no  etirlaiii  dia- 
gnosis can  be  made.  However,  as  n^spccts  diffuse  cellular  inflam- 
■  mntion,  the  age  of  the  patient,  tiio  eomporativo  remotena^a  of  the 
cause,  and  tlio  previous  immunity  of  the  superficial  parts,  will  lead 
to  a  Huspieion  of  llie  nntiiro  oftlie  enxc,  which  will  \k:  NtnTUgtliencd 
when  the  inflammation  is  seen  to  bo  limited  to  the  section  of  tho 
member  fimt  alfccleil,  iiift^wl  of  pu.t.4itig  ilu- joint,  idkI  .iprt^tiling  up 

Itho  limb,  as  an  erysipelatous  affoetion  woidd  in  all  likelilwod  do, 
luul  will  Ite  converted  into  certainty  by  the  discovtvy  of  deep-sealed 
'ttatter,  eitlier  by  fluctuation  or  on  punctiu*.  Fhiotnation  cannot 
•hnys  be  detecloil,  Hinoo  tlio  t^n^ion  of  tlio  mi'iiibruiioA  which  bind 

I  down  tbo  pus,  and  tho  tenderness  of  tho  sujwrficial  parts,  combine 
to  oppoetc  iUt  <iiiwovery.     Exi>lorat»rj-  ]>u»eturc!4,  however,  tihotdd 
never  be  neglected.     If  the  disease  be  merely  BU|>erficial,  tlioy  can 
do  no  linrm;  and  it  is  of  vital  importance  to  dinutwer  early,  and 
give  instant  exit  to,  tho  pus  before  it  has  dissected  off  large  (wrtions 
of  tlio  pcrioTitcinn,  and  involved  the   di-atli  of  a  {jniit  part  of  the 
bone.     The  diagnosis  between  a  case  of  this  sort  and  one  of  acute 
rheumatism  will  depend  upon  the  nature  and  history  of  tlie  di!<#aM, 
and  on  the  presence  or  absence  of  constitutional  symptoms  of  rhcu- 
^    matism,  or  rheumatic  aflW^ions  of  remote  parts.     At  the  nut»ct  of 
B  tbo  case  tile  diagnosis  may  not  bo  very  ooufideiit ;  but  tlu3  main 
point  to  r(-<^>Iluct  is,  tliat  any  |>erio6teal  affectioD,  if  acute,  is  liable 
VOL.  UL  8  8 


626 


DISEASES  OF  THE  BONES. 


to  run  earlr  into  Bnppnration,  and  that  in  such  <»»i<a,  whntm'er  vieirl 
may  be  lakoii  uf  the  orij^n  of  Uw  <li«aso,  wiw-itiar  it  is  to  be  oon-[ 
sidered  rheumatic  or  otberwise,  the  local  treatnumt  is  far  utoro 
■tnjwrttint  than  the  c-<>nntiliit!»iiitl.  Whsil  Sir  1*.  Cnunjiion  ea^j 
of  the  acute  porioatoal  wliitlow  applies  with  much  grcat4.T  furoti 
to  acut«  [leriiicti.'nl  nfiwtion*  of  the  larger  honeii :  "  thero  are  few 
diseases  where  art  can  do  bo  much  and  nature  so  little" 

If  tlio  (f iRBwo  be  olloweil  to  go  on  unehcckwl,  the  whole  circom- 
ference  of  the  limb  will  become  greatly  ewollon  and  ccd«niatous, 
UAuaiiy  willi  that  tonso  glUtvning  iwiia-t  whieh  tells  of  subjacent 
suppuration.  The  patient  mostly  complains  of  great  pain,  capcdaily 
icute  at  night ;  ho  lo»oa  uppotitti  and  flcvh  rspiiUy.  Pyitinia  is 
very  liable  to  occur,  and  many  of  these  piitients  die  of  it.  A  few 
die  exhuiistod  by  the  violeneo  of  the  action,  and  by  the  profim ' 
suppuration.  If  the  patient  survive,  and  the  absoass  do  not  obtain 
a  fi-eo  and  dcpcntling  oj>eniiig  by  timely  incJeions,  it  will  burrow 
among  the  miiseles,  and  ultimutety  numerous  openings  will  form, 
ux|M»iing  necrosed  bont-.  Tho  dead  bone  appears  to  scpaiatu  mudi 
sooner  than  iti  other  (onus  of  nucruKi.t,  and  tlio  repair  to  be  propor- 
tionally active.  Thus,  in  an  adtilt,  abnost  the  entire  length  uf  ill* 
shaft  of  the  ulna  wiw  tlirown  oiV  and  oMnovod  tliroo  inonlba  after 
tlio  injury  which  led  to  the  complamt;  and,  m-en  at  tliat  dat«,  tbo 
repair  aj)|>«irtrtHl  to  Iw  far  advanood.  In  IciW  acute  ea.*<»,  where 
only  a  portion  of  the  surface  of  a  bone  is  involved,  the  disease 
pursufjt  tho  onlinarj'  oourwof  necrnfii*. 

The  subjects  of  this  aHection  are  almost  always  young  persons,* 
in  whom  tlio  stnmxiiu  diatliusis  'i»  well  pronounced ;  but  it  occott 
more  rarely  in  lioatthy  subjects  about  tho  ago  of  puberty,  or  oven 
earlii^r ;  and  sotno  cases  are  observed  (as  tho  ono  to  winch  alluson 
has  just  been  made)  in  adults  of  impaired  eoustituljon  and  dissipated 
habit«. 

The  l>one  aflToctod  is,  in  the  great  rnajarity  of  com^s,  the  femur ; 
and  it  is  no  doubt  in  conscquenco  of  the  great  size  of  this  bone,  and 
lliu  severe  oftW-ts  wliJcli  always  attend  ii|M>n  a  large  abscc:>«  Nitaated 
at  so  great  a  doptli,  that  the  discaso  is  so  &taL     But  rofereooe  has 


I 


*  Cbsssnigiisc  BB}-B,  that  out  of  eleven  eases,  onJj-  one  liad  |i*8s«d  tlic 
sevcni^eiiib  year,  mxd  itas  bi'Iow  tnvttty-oni':  and  out!  wu  onljr  de 
uontlts  tild.     A  Gii<(nunstance  nhieh  seems  U>  tvetifjr  to  the  effect  of  a  i 
«litmiiiiial  {ireiIiB|>onilton  is  tnenttoneilbj  tile  same  autliar,  viz.  that  iii  i 
cAses  several  aeute  peiiosteal  abaeesse»  have  been  prcMOt  in  Um 
sulyeot.    Mem.  dt  la  Soe.  de  CKU.  nil.  iv.  pp.  :^80-7. 


ACUTE  PERIOSTEAL  ABSCBSa 


627 


already  been  imulo  to  two  cases  in  which  tlu;  bones  of  the  fore-arm 
Vfere  attackdil ;  aiiij  any  of  tJie  long  biines  may  be,  and  in  not  iin- 
frvt]uctit]y,  thv  ecat  o!  the  diooasc.  Tlio  i\ai  nmt  irregular  bonijs 
are  more  rareiy  afFecte<J ;  but  Sir  P.  CranipWii's  c«»e*  is  well 
known,  in  which  an  acuk>  abset'ss  fonned  bi-nvaUi  tho  periosteum  of 
Uie  biiiiAi  of  the  noiio  and  cranium  on  butli  ^He^. 

Tiwj  treatment  of  acato  periosteal  abscess  is  a  matter  of  t]io 
greatt^itt  inipurtancR,  lut  it  !»  only  by  vigoroos  meaAnrc-;*  lliat  »a 
rapid  and  dangerous  an  affection  eon  bo  ndieved.  Among  these 
mcaAure)!,  tho  fint  luid  ino»t  iitijHirtant  ia  to  make  UdmIv  and  Ruf- 
fioient  incisions  into  the  BwcUing.  If  doubt  exist  as  to  the  nature 
of  the  sweiliug,  or  an  to  the  mituation  of  tho  pu»,  tliey  will  be 
settled  by  tho  grooved  needle ;  but  even  if  no  pns  bo  found,  it  is 
botler  in  any  nwo  of  pcriostustl  ijiHaniniation,  where  llio  [>ain  i« 
great,  to  mako  an  inoision  down  to  tho  bone  in  the  jiart  to  which 
such  pain  is  referrtKl.  Li  cliildn-n,  it  will  be  advisabl«  to  wlininistia" 
(^oroform  before  commencing  the  examination}  when  the  aJfoctioD 
is  doep-xetited. 

Daring  iJie  aeute  atago  of  a  periosteal  aljaecss,  free  esit  having 
been  obtaiiiUMl  for  the  matter,  the  jiatient  must  be  troatetl  on  general 
principtefl ;  no  special  inloxnid  tr«iitnietit  U  tx^ceitaary  for  t}io  affec- 
tion of  the  bone.  Tho  indications  are,  to  allay  pain,  to  su]>port  the 
Htreitgth,  and  to  atolil,  if  {HKutlble,  Uio  const itutloitu)  nftoction  which 
leads  U>  pyarmia.  Tlie  last  is  tlie  most  important  of  all ;  patients  twl- 
dora  die  of  tlie  "sturgiual  firvcr,"  »o  called,  wliieh  is  UHiially  present ; 
they  seldom  die  of  the  exhaustion  of  the  discharge;  but  tliey  die  by 
pyiEmin  in  a  Urge  [HTccntagc  of  tiio  ciLtoH.  How  great  tlie  mor- 
toli^  is,  it  would  be  difficult  to  say,  suice  the  disesise  is  not  gene- 
nJIy  recognimMl  in  our  nomvndiiMire ;  but  out  of  a  comparatively 
small  noinber  of  cases  which  have  occurred  dui'ing  tlie  last  few  years 
in  llie  sin-gldU  ward*  of  St,  Owrgo'ii  Hospital,  a  very  large  propor- 
tion have  died  of  pya^mja.  Free  and  early  Inoisions  give  the  patient 
the  best  chance  of  escaping  this  iiitnl  complication.  No  fear  need 
be  entertained  of  duwinijHisition  of  tJie  pua  from  the  admission  of 
air.  In  fitct,  pus  whidi  is  cenHiM'd  over  a  bone,  in  an  acuto  in- 
flammabary  disoaae,  wtll  pmbubly  be  already  sut&ciently  putrid. 
The  0|H^ings  should  at  tirst  be  made  in  as  ilejtondiiig  a  pusilinu  sh 
possible,  and  lliey  ohould  h«  e.o  i'mv  as  to  preclude  all  risk  of  their 
do»ing  ogdo.  After  the  openutg  of  tho  abKtic««,  freo  stimulation  if 
gcneraJIy,  if  not  alwuvA,  neccssaiy.     The  patient  will,  pcrhagw,  be 


tfublin  JlotpiUil  Heportt,  loc.  ctt. 


628 


DISEASES  OF  THE  BONES. 


iiiial>lo  at  finit  to  take  solid  nonrUlnncnl,  sIdou  ttieeo  affections  are 
gfiieraliy  attcmlod  with  w;vore  fever;  but  as  soon  a.<)  llie  liviuniation 
of  tlw  matter  Iiaa  romovod  some  pmi  of  tlw  irrltatioQ,  bis  appetite 
will  probabljr  rclurii. 

In  ab»cca809  wbicb  are  at  oni^o  deeply  seated  and  ranall,  it  vomj 
eoiiK'tinu»  bit  lulvL-uible  to  uau  il  drainag(>-Uibe ;  but  in  most  cases 
llie  colk'ction  of  matter  is  loo  cxteniuvo  to  allow  of  this  treatmont 
boiiig  bcndicially  ndopt«l,  at  any  rate  till  «  latin-  [Kiriod  of  tlie 
case,  when  tlie  abscess  is  contrading  and  the  incisions  show  a 
twidwiijy  to  clwjie.  In  the  memoir  of  M.  ChutMugniu;,  already 
referred  to,  the  autlior  speaks  higlily  of  the  advantage  of  injeotiunt 
of  very  dihitv  iiytlnicliioric  acid,  wliioh  have  the  vffoct,  according 
to  him,  not  only  of  nleansiiig  the  suppurating  cavity,  bnl  also  of 
hantciiing  the  mnioval  of  supcrlicial  exioliatious  by  dissolving  the 
dead  Iwna 

If  tlii.1  patient  has  survived  the  acute  »tago  of  the  disease,  the 
absoeiis  may  long  remain  in  a  chronic  condition,  exposing  tho  bone, 
111  tlio  moro  favourable  cnsos,  tho  outer  shell  only  of  the  latter 
has  perished;  while  in  Uie  nioxt  severe,  the  entire  »liaA,  separated 
from  tbo  epiphyses,  may  come  away  in  u  mass ;  or  even  ttit!  «pi- 
physes  theniiK-lveA  miiy  nhare  in  tJie  destruRliuti,  though  tliat  is  very 
rare.  Tlie  treatment  of  those  sequela)  of  diSuso  periostitis  will  bo 
spoken  of  in  tJio  aoetiou  on  Nocrosia. 


Oi-tfomyf litis.  l>iRitso  inflammation,  and  suppuration,  in  the 
eancellous  liaauo,  an  iifffction  to  wliiuli  Freneh  piillioli>gi:=ta  havo 
given  tho  namo  of  "osteomyelitis,"  is  more  ii-cquently  recognised 
in  |xist-mortem  examiiiatjunft  tliim  »t  tiie  lic<Uide  of  tho  patienL 
It  is  eloscly  allied  to  pyieniia,  and  is  usually,  or  at  any  rale  voiy 
fre^^aently,  fullowed  hy  tliat  mode  of  death.  It  bears  tho  sanifi 
relation  to  the  medullary  tissue  as  tlie  complaint  just  ^wkon  of 
does  to  the  periuiiteum ;  but  the  ditltn-i>nci>  in  diameter  botwvon 
the  pr;riosleum  and  the  medullary  tissue,  the  latter  being  so  much 
more  ricJi  in  vessels,  o^jteciully  iu  liu-git  ]>atidou»>  venous  channels, 
give*  to  ristcomyolitis  a  gravity  ovou  beyond  tliat  of  diffu.w  jieri- 
ostitis.  It  is  WL'II  known  liow  ofleu  diflusc  xnppuration  is  found 
in  the  diploe  of  the  cranium  after  scalp-wonnds,  and  how  the 
"  puffy  tumour  of  Pott"  is  freiiuvntly  only  the  sign  of  such  supjtu- 
ration  !  and  fimhor,  in  what  a  large  percentage  of  such  wimw  evi- 
dent pyn.^niia  \n  found.  It  in  pruliai)Ie  that  in  all  tJiesc  eases  the 
external  tiiblo  of  the  bono  baa  been  wounded,  and  the  dijiloe  tlius 
cxposod;  in  fact,  the  only  known  cause  uf  ostoumyolitts  is  a  woiumI 


J 


OSTEOMYELITIS. 


629 


I 


which  exposes  the  oanoellona  intfirior,*  or  an  injury  to  tlie  interior 
of  tiu)  bono,  pitriiiijK*  unuocompatiiitl  hy  oxtertinl  wound,  us  in  fnu'- 
tursk  It  ia  a  frequent  cauiie  of  death  after  ainpiiUilionit  and  otlier 
Burf*ien]  o))criittons  in  which  bonL>  is  divided. 

When  a  bono  h  exiuniniHl  in  wliich  mUiomyoIitis  han  run  an 
Acuto  oourxc,  thi?  citncvlii  &rt>  found  loaded  wiili  pus,  and  the  me- 
dullary tiafiue  uHually  injtwti-il  itiid  oftmi  .*])  rink  Its!  with  ecohyinoses: 
tho  [wrioHtcuiii  also  is  ofen  in  tho  course  of  sepiirntion  from  tho 
bone;  but  tlie  bony  tissue  it.ti>if  iIoi'm  not  ^■nvrnily  ithow  luiy  appre- 
ciable clian]t|;v.  In  tho  larger  bones  the  disease  usually  torminates 
fatally  at  lliis  stage ;  but  ulionld  tho  jiitticnt  wirvivo,  the  piw  mny 
pc-nvtratc  into  neighbouring  parts,  most  probably  into  tho  nearest 
joint,  or  central  necrosis  may  r<wult.  •i^jweimL-iu  to  xluiw  either  uf 
tliuH!  terminations  are  not  wanting  in  our  pathological  collections. 
Thus,  in  l\xv  nniseuni  of  St,  Bartlioloinew's  Ho^pitjil  ttiero  U  a 
beautiful  specimonf  of  inDanicd  and  thickened  medullary  mcmbraiM) 
of  tho  IninitTtis,  which  uliow!?.,  an  a  con«fi[uonc«  of  tlie  inflamma- 
tion, a  portion  of  cancellous  tissue  exfoliated  and  lying  loose  in  tho 
mLthillary  cjukiL  A  long  fistula  loads  through  tho  tube  of  Uio 
bone  int^k  the  elbow-joint  The  Aiiine  miueum  poaaeaaca  another 
ti{XM.'Jmcti,t  in  uhich  »cut«  difiiisod  suppuration,  spreading  through 
tlio  tissue  of  many  of  die  long  bone»,  hart  caused  abscesi  in  tlic 
knee:!  and  ankles  on  botti  sides. 

TJie  synipcomii  of  tlii^t  grave  aHcction  are  exceedingly  obscure : 
it,  like  other  extensive  and  acute  aSeetions  of  bonce,  in  often  iu> 
conipanied  by  dillinte  intlamtnation  of  the  Koft  partu,  which  then 
niaski!  tlie  deeper  niTection.  The  only  known  special  symptom  ifl 
the  separation  or  roco>«wn  of  tlic  pcriiKt«jum  from  llie  bone,  accom- 
panying diffused  pain  in  the  bone,  and  not  caused  by  «ffu!«i"n  on 
the  external  Biirfiicc  of  the  latter.  After  am |>iita lions,  a  prominent 
fungous  mass  is  often  seen  projecting  from  tlie  end  of  tlio  bono,  and 
proves  tho  exi»tuuco  of  a  certain  extent  «f  inflammation  of  the 
medullary  tissue  ;  but  tliia  noixl  not  necessarily  have  affected  the 
bono  MO  exfciwively  us  to  desen-o  the  iiniiic^  of  owteomyeliliH  j  in 
&ct,  that  aifection  is  aeldom  recognised  before  death. 


*  TTnl^eo  tho  icfoction  of  conatltutioina]  eypbilu  ithautil  be  addod.    See 
infra,  pu  Syphilis  in  Bone. 
i  Seiics  L  DO.  30T. 

I  Ibid.  uo.  195.  Se«  also  do.  104.  a  pnpFiratioD  in  irhicli  tho  whol«  of 
th«  inner  poriioii  of  tho  us  culns  is  st pai-ating  fiom  ite  outer  wall, as  a  coo- 
vcquttaeo  of  diffua«(l  ouppuiatiou  tlin>u(jh  its  cauceUi. 


630 


DISEASES  OF  THE  BONES. 


Tn  olivintc  the  fonnickblo  duigeni,  and  the  exiennire  dis!ntcgrs-1 
tion  of  parts  conncctol  with  oetcomyvlitis,  it  is  ja«tifiitblc  in  tmy  I 
cnBC  wh«FO  pain  in  the  bone,  aoooniponied  with  the  ordinary  Hvmp- 
lana  of  acute  suppuration  (rig(»v,  fovor,  &c.),  bni  witliout  signa 
of  external  or  periooteal  niiscliief,  induoc»  a  reftMHiiihlo  Buspicittn  of  j 
this  affoction,  to  expom  tho  eurikoo  of  tlio  hone  by  a  free  incision. 
8hoiil<I  lh(!  penixitAum  be  found  separated,  or  even  »o]«irating, 
from  the  bono,  tho  diagnosis  of  diSViscd  suppuration  in  the  canoelli 
will  bo  rendcnnl  hij^hly  pmb.iblc.  ^VhclI  thiit  .wjianition  bn.i  pm- 
ocodcd  to  any  gwat  extent,  amputation  of  the  member,  ot  excision 
of  the  d>»osi»od  Iwiie,  is  cvrtninly  iiHlicat4.^<l ;  or,  if  tlio  Surgeon  bo 
unwilling  to  proceed  to  such  radical  measures,  it  may  ho  a  qucsiion 
whether  tbo  uiv.  of  the  trephine,  or  other  jH>rfo«itiiig  iii.><trutnciit, 
may  not  give  the  patient  a  better  chance  of  recovery.  Socb  opera- 
iion.%  lijive  lit  l'«5t  been  succwisfiil  in  relioviiig  the  Kyinptouw,  when 
undertaken  for  ihe  Mire  of  supposed  abscess  within  the  bone.  It 
Hhoiilc)  ho  remembered  that  the  disease  is  a  rapid  o»c,  tho  fatal 
complications  of  internnl  phlfliilis  am!  pya-inia  imminent;  and 
therefwro  Jw-sitniont,  to  be  etfoclual,  must  be  adopted  curiy.  Medi- 
cine, as  might  )x)  expectwd,  han  little  effect  on  the  disease ;  but  the 
finer  wliich  accomjianiw  it  should,  of  eounc,  be  treated  on  tho 
ordinaiy  prineiples.  Kiniilly,  in  (hx^iding  on  tlio  question  of  re- 
moving tlic  disease  (an  operation  whicJi  would  in  ordinaiy  cases  be 
held  to  be  cotuiter-indieate<l  if  pya-mia  Wl  set  in),  it  should  not 
be  forgotten  how  niueh  tlic  early  symptoms  of  sj-stemic  infecUen 
re«emhle  those  of  t^-plioid  fever;*  ko  that  it  may  Ite  j>m|Mir  in 
dotibtfiil  cases  to  give  the  patient  the  benetit  of  tho  doubt,  and 
attempt  to  relie%-c  him  from  thw  source  of  irritation. 


CJirank  <Akch*,  Limited  supporation,  or  nl^seoxs  in  tlw  oan- 
cclluus  tissue,  is  an  affection  whidi  is  fortunately  far  ntore  eatuly 
recognised,  and  far  moro  mider  the  control  of  Burger}',  than  osteo- 
myelitis. It  hardly  ncecU  to  be  said  tliat  tliis  condition  of  bone  wm 
first  discovered  and  described  by  Sir  Ji.  Brodio-t  Tbo  symptoms 
are  not  always  very  clear,  but  a  careful  study  of  the  ca.i<t  si^dom 
fails  to  establish  tlio  correct  diagnosis.  The  scat  of  the  disease  ia 
almost  always  the  articular  extieinity  of  the  hone^  which  form  one 
of  the  great  Joints — knee,  ankle,  or  olbow.  Tho  tibia  is  more  fre- 
quently alfectcd  tJian  any  other  bono,  and  usually  at  its  upper  end. 


*  See  ToL  i.  p.  MT. 

t  LioUtrt*  on  rathologg  and  Surggry,  ti.  1816,  p.  Stik 


CHRONIC  ABSCESS.  631 

Chronic  abaeem  niaj,  bowerer,  occur  in  any  sitiintlon.*  T)ie  aU^ccu 
is  almott  slwA^-8  situated  on  Uio  >>ti|K-rfiviul  unit:  of  tUv.  bono,  and  is 
probably  occa&ion«cl,  in  most  oases,  by  external  ^'iolenoe,  or  other 
CttDiKM,  acting  on  llml  Durlaott ;  but  tlio  litntory  is  uften  obscure,  in 
oniuequenoe  of  the  ohronie  nature  and  insiiliouH  progni^a  of  tlu) 
malady, 

Tbe  A^-mptoma  are,  a  duU  oeliing  pain  in  th»  part,  ofi«n  mnw 
at  nigbt  Utau  durtn/;  tlio  day,  lisblu  also  to  other  remisMcHis  and 
exuccrbatioiis,  and  iucreaiied  by  exeroJAe  or  prcw^uro.  In  nio»t  caso) 
the  bono  is  especially  tender  at  i>uo  particulnr  spot,  where  tlie  abHceai 
Ii^s  iidvaiioed  nearest  to  tlie  suHace,  mid  ihum  i.s  slif^lit  tumcfuctioa 
of  tire  soft  parts  over  it.  Sometimes,  but  not  always,  a  little  en- 
larjreiiient  of  the  ixmo  itci'lf  niHy  Iw  nmclo  nut-  Thuro  is  perhaps 
Dolhuig  very  characteristic  in  tliese  siTiiptonis  tAkon  80[>arat«-Iy,  or 
on  n  tint  iixiuniMutioii ;  init  the  pcrsioleiicij  of  the  wlmlu  asMrinblage 
of  tliem  for  a  consiiiefable  period  of  time,  and  in  spite  of  jtidioious 
treatnu^nt,  ilirccltMl  to  ntilxliitf  an  iiitlmiR-d  condition  of  tho  bone, 
will  be  reasonable  ground  for  tho  diagnosis  of  clironic  ab»ee«fl,  and 
more  LttjK'ciidly  if  the  nuiglilxturiiig  juint  Iw  unafluctcd.  The  local- 
ised, and  \ery  eireuniscribed,  tendemesa  is  perhaps,  when  well 
marked,  the  most  iiuiniv1«k»l>le  symptom. 

Tlie  condition  of  tlie  diseased  bone  testifies  very  elearly  to  the 
nature  of  the  morbid  process,  so  tliat  few  miiwuins  are  without 
iM>me  oflheM'  |in*pnralionx.  The  following  is  Sir  li.  Hnidi^t'i*  di>- 
scription  of  tho  first  preparation  which  lie  dissected  :|  "Tlio  lower 
end  of  the  tibia  is  enlarged,  and  the  surface  presents  marks  of  great 
vascularity.  Tho  bone  in  the  preparation  is  divicic<l  longitudinally, 
and  just  above  the  artitnilatitig  surface  tiiere  is  a  cavity  as  large  M 
a  small  chestnut.  This  cavity  was  tilled  with  dark-oolourixl  pus. 
The  inner  Hiirjit<^t>  of  it  is  smooth.  The  bono  immediately  surround- 
ing  it  is  harder  than  natiu^l."J 

If  tho  COM  be  allowed  to  proceed  beyond  tWi*  stage,  scriona,  and 
frc<]Uentlv  fatal,  miscbief  may  ensue  from  extension  of  the  absocsa 
into  tho  ncifjhbouring  joint.  Before  tliid  event  occurx,  however,  llie 
patient  may  bo  much  inconvenienced  by  re)>eatcd  attacks  of  swelling 
luid  pain  in  the  joint  when  be  attempts  to  use  tlie  limb,  the  eSvct« 


*  In  tho  mm&um  of  St-Thomns's  Hospital  tbcra  are  oznoDplw  In  Um 
body  of  a  rib,  in  tb«  cl«vlcl«v,  »nd  aUsmuiu.  hci'iph  C.  tios.  W.  Kl',  M. 

t  The  odgUial  propnration  is  in  the  miueuoi  of  St.  G«orge's  Hospital, 
series  ii.  30. 

:  Op.  oil.  p.  397. 


632 


DISEASES  OF  THE  BONES. 


orttligltt  H\iiaviiil  itifluninntinn  set  ut>  by  the  neighhonring 
I{«et  aittl  cold  application b  wiU  gcncnJIy  romovo  these  sytHptomK, 
bat  only  to  rwur  as  soon  as  the  patient  again  ntl^ni]it«  to  move  idiouL 
On  t]ia  euro  of  tlio  abaooM  tlioy  will  immediately  and  jM^rmancntly 
di-siipi'Ciir.  Whon  the  •bncens  hoA  bur^t  intii  flm  juinl.  tlio  affect 
don  of  the  bono  btoumcn  merged  is  the  more  serious  injury  to  tbo 
artii?tila(.ion. 

'i'rmtmenl.  In  all  casM,  as  soon  as  the  diogmosia  has  bocn  so 
hr  sellleJ  «*  to  tuitinfy  liw  Surj^wn  that  o|icrBl4ve  intcrieivnoc  ig 
justifiable,  he  ought  to  explain  the  nature  of  the  case  to  tJie  patient, 
Biid  oiuk'iivour  U»  obtain  hi"  coniH,ijt  to  the  iiimplo  o[)crnti<>n  which 
will  at  once  establish  the  diagnosis  and  cure  the  disease.  There  is 
not.  f;inR*rally  nuieh  diffieully  in  obtaining  tbc  cou^vnt  of  the  patient, 
whom  long-con tinuoil  suffering  and  enforced  inactivity  have  ren- 
dcrcil  ■jrtM.ily  of  any  ehaiic«  of  nrlicf.  (_ndi>njform  should  bo  ad- 
ministered, and  tlio  suspected  part  of  the  hone  well  exposed  by  a 
cnicial  incision.  Tlio  bono  shotdd  then  Ix;  perforated  to  a  coiiwder- 
ahle  clei>Lh  with  a  small  treptiiiie,  which  should  not  have  a.  nboulder. 
If  one  Mpot  on  the  siurface  of  the  bono  ap[icHrs  softer  than  another, 
this  should  be  selec-Ied  for  the  centre  of  tlie  o{)Oiiing.  Very  often 
piu  will  be  ween  welling  up  ui  the  groove,  as  soon  as  the  treplune 
has  penetrated  Ihc  cuiiijiacl  wall  of  tlie  bone.  The  instrument  may 
thti^i  be  withdrawn,  and  on  the  circlo  of  bone  being  raised  with  an 
elevator,  the  jius  will  be  e\iicua1e(L  1'he  cavity  cs[>osed  in  tiinxl 
with  a  thick  "pyogenic"  mombrane,  and  its  surface  ia  very 
Hcn.^itivc.  Tlie  ))uii  ia  only  in  small  (jniuitilj  (generally  about 
a  tea-spoonful) ;  but  it«  evacuation  suffices  at  onoo  to  relieve 
Uio  pHtittnt  of  his  wearing  piiin,  and  ho  is  soon  restored  to  per- 
fect health,  the  canty  being  filled  up  with  a  fibrous  material,  by 
which  in  all  prolmbility  the  excisod  piece  of  bono  is  ultimat4;ly  re- 
produced. 

Two  tbingn  may  interforo  with  the  complete  and  immediate  success 
of  this  operation, — the  diagnosis  may  have  been  corn'ot,  but  the  place 
selected  for  trephining  may  have  Ikvh  not  (juito  the  right  one;  or  the 
diagiiiisis  may  have  been  wrong,  and  the  symptoms  have  depended 
merely  on  chronic  ostitis.  In  the  latter  case,  as  may  bo  seen  by  Sir 
B.  Bnidti''s  [lutient  alK>ve  referral  to  (i>.  G23  note),  the  operation  will 
often  do  good,  will  relievo  the  pain  of  the  inflaimnatlon,  and  perha]>s 
prove  the  starting-point  of  aheulllner  action.  It  is  well,  however, 
KKncmbering  that  this  mistake  has  been  committed  by  the  bf^st  Sur- 
geons, to  prepare  tJie  jtatient  for  it,  so  that  ho  may  not  he  too  much 
disappointed  if  the  Sm'geoa  shall  afterwards  have  to  coofoss  that  do 


i 


CARIES.  633 


fmK  wa*  found.  If,  howcx-er,  tlie  trophirio  tlo  not  efuno  down  upon 
an  ab^ceHH,  i1  ntioulil  not  bf  tbrgr>tt4.-ii  tliat  this  ina^'  dqiciid  on  tlw 
ojiwiing  having  been  made  on  one  sJde  of  the  abscem,  whicli  may 
be  lying  close  to  tlie  trc])hi[i«  Iiok-,  biil  soparatod  from  it  by  a  Uiin 
Ix>ny  scpUiin."  It  is  advisable,  Uierefoi-o,  wIicd  tlio  ]>iw  h«Jt  been 
toisfled,  befom  faring  up  the  oporntjnii,  to  picroo  tho  walls  of  tlw 
tri'phinf-liole  in  several  direHionn  with  a  sliarp-pcnnted  inetrumcnl, 
in  onler  to  roinow  the  bono  freely  witli  a  cbuel  if  a  dlx^  of  piu 
fotiow  any  of  these  punctures.  ' 

Caries.  The  won!  cariori  will  Ih^  usmI  in  the  setjue]  as  otjiiivalenl 
to  tlio  torm  "  ulceration  of  bone."  It  is  true  that  »omi>  patliologista 
of  the  groatimt  authority  have  lii)iil(<<l  llie  w.«e  of  the  term  carii.'S  to 
semfulouH  ulcerallon,  and  otliers  have  sought  to  estMbli»l)  »  gonerio 
difference  hotwecn  caries  and  ulccmtion.  A*  to  Ihe  latter  pr>iut, 
however,  I  must  confess  that  a  earel'u]  perusal  of  worki«  in  wliieh 
caries  and  ulceration  are  treated  of  under  wpanitv  heads,  has  failed 
to  make  me  see  tlie  distinction  which  the  writers  wisliod  to  estAblbl); 
and  with  rt'feronoc  to  the  fonner,  although  tlicre  i*  as  much  dilfor- 
caico  between  strumdii*  ulcenition  and  simple  ulceration,  when 
occurring  in  a  bone,  as  there  is  between  tlio  same  pnicewwa  in  Boft 
pqufts,  I  cannot  see  ihiit  there  in  any  more  reason  to  attach  a  vpccial 
n«tnc  to  the  process  as  occorring  in  bones  than  in  other  tissues, 
while  confusion  in  oertiilnly  oecasionwl  by  the  use  of  a  special  tenn 
in  many  ca»c«  where  tlio  stnunoits  nature  of  the  procuwt  i»  only  a 
matter  of  infei-ence. 

SnjHTHcial  ulceration  is  distinguished  by  the  followi:ig  ciiaraeters. 
The  periosteum  is  Ioo»cnod  fi-orn  tho  suri'aw,  and,  if  the  disease  is 
Rd^1mced,  will  be  found  mucli  thickened,  and  convert(^l  into  a  vil- 
lous mass  of  u  pink  colour,  rOHcnibling  a  layer  of  granulations.  Tbik 
•dbetasco  adheres  very  loosely  to  Uie  surface  of  the  bono,  and,  when 
lifted  up  from  it,  is  found  to  fit  into  deprewiiims,  which  seem  to  have 
been  hollowed  out  of  the  bone  by  the  agency  of  tlie  granulations. 
The  lioiie  at  a  very  slight  depth  undemc^h  is  fijund,  in  most  cases 
of  hoalthr  inflammation,  of  tho  ordinary  oonsiatcnco  of  eiincellous 
tisHDo,  wliidi  it  rBsomblea  in  stnieturv  i^vcn  iti  those  parts  which 
ought  to  be  compact.     In  strumous  caries,  on  tlie  oontnuy,  tlM  os- 


*  A  preparation  in  St.  Oeorg«'s  Hospital  museum  illuatiiit««  this  neei- 
dent.  Tbv  uperotion  was  given  up.  After  tb«<  )iHiioiil's  il«atli.  it  was  found 
tlut  the  ftbnccu  \a.y  not  half  an  inch  tnm  tho  inck  of  the  tr«phb>o. 


6U 


DISEASES  OF  THE  BONES. 


ttcous  structure  vill  bo  found  ixtftcuod  iind  ntlicm-l'tc  nltenvt,  iw  wilt 
be  described  wben  treating  of  struma  in  bone ;  and  it  id  to  lhi»  com- 
biruition  ofstruinoiH  inltHnitDation  of  iho  bodv  ofn  boiio  witli  ulcer- 
atioD  of  itfl  6arfa(«,  tliat  the  old  deMnptiona  of  caries  appear  to  bo 
intviidi.'d  to  "{>)'l.y.  Tlie  oJccratod  mir&co  in  hvitilliy  inlliiiiiniatioD 
is  superJieially  excavat«d,  much  imftened,  and  easily  broken  dovn 
by  the  i>n>WHr«  of  a  probo,  Tlic  interior  of  canons  bono  u  sotttnuxl 
by  iiifiamnialion,  itA  caiioelli  enlarged,  and  tillixl  with  the  pi-oducta 
of  the  softening  and  dtsuite^n^tion  wbich  has  been  going  on  anmnd 
them.  These  produi^,  as  lias  bo^n  noti<!e(l  above,  are  principally 
oiUglobulus,  bloixi,  and  other  dt^bris  of  the  eofl  tissue*,  and  granular 
inorganic  materials,  l]a\'ing  iJio  same  chemical  composition  as  the 
salts  of  the  bone.  Tlie  iio<\  parts  ahnost  always  take  part  in  the 
morbid  actJons  wlilc)i  ItHid  to  c-uric*,  and  absocww  arc  fonned  which 
burst  externally,  and  leai-o  Binusea  communicating  rooro  or  lesw  di- 
rcetJy  with  tint  KoltoiiL-d  hnna,  and  through  wliich  some  part  of  it» 
expcwcd  surface  can  generally  be  felt  with  the  probe.  AbscesMS, 
liowevor,  fn>ipi<!nlly  form  in  the  neighbourhood  of  inflamed  bonea 
without  any  actual  communication  with  them.  This  ts,  perhaps, 
more  pi^nliai'ly  tin?  eiiae  in  cliiWliood,  and  near  tlie  joints. 

Stfmptoms.  The  symptoms  of  caries  are  merely  those  of  inflam- 
mation/i/tM  an  nbKvss  exjiosing  softened  bone;  hence  all  that  liaa 
been  said  about  tlie  frequent  obsenritj-  of  the  early  stages  of  tietitis 
will  apply  to  caries,  and  with  greater  foroe,  in»smticli  as  ttieie 
ulcerative  actions  are  more  prone  to  occur  in  tlio  course  of  low  in- 
flammations. Conittnnt  pain,  thon^  in  tho  neighbourliood  ofn  bone, 
with  swelling  and  more  or  lew  loss  of  tlie  function  of  the  part, 
followed  by  abscess  which  will  not  heal,  indicate  usually  that  tho 
abscess  procL-odH  from  ulceration  of  a  bone ;  and  this  presumptioD 
ie  much  strengthened  if  tlio  pus  have  a  putrefied,  oflonsive  odour, 
and  ft  prominent  nia^s  of  grunulntions  prujoct  trom  tlie  sinus,  and 
is  converted  into  certainty  if  tragments  of  bone  can  bo  found  in  the 
di:<cliai^,  or  if  tho  comnmnioation  wn'lh  tho  bou«  is  sutticiently 
direct  to  allow  of  its  being  struck  with  a  probe.  When  carious 
bone  is  toucbixl  by  tho  probe,  it  b  not  usually  found  {iiartJcularly 
sensitive,  perhaps  is  not  sensitive  at  all ;  it  bleeds  readily ;  its  sup- 
feco  is  irregular,  and  may  generally  bo  fclt  to  be  soft.  When  tlio 
openbg  is  sinuous  and  tho  bone  cannot  tlierefbre  be  struck,  the 
diagnosis  can  l)0,  of  cotu%c,  only  iniercntial,  and  found<^^  iiuiinly 
on  the  persistence  of  the  symptoms.  Clhemical  anal\'fiis  of  the  pus  I 
may  also  sometimes  assist  tlie  diagnosis,  since  tho  jntfl  from  di»-] 
eased  bone  coutains  more  phosphate  of  lime  than  that  from  soft 


CARIES. 


635 


I 


I 


part9^"  Romctimofl  the  patient's  ncnMtionH  ftflTnn)  vnlnftMo  ovi- 
dciicc,  more  particularly  in  caries  from  healthy  in6anun3tion,  where 
striking  liglitly  over  tlus  cariii(i.-<  piul  oftt<n  onut>a«  tbo  samu  kind  of 
sliarp  pain  as  is  felt  when  a  mrioiis  tooth  is  struek. 

Ciiri<>s<  i»  generally  nccomiiniiii^ti  by  itioro  or  I«b  of  pliutic  W 
organisable  cfEiuion  in  tlie  bone  in  tJie  neighbonrhood  of  tlio  nlcer- 
at*d  sjiot,  loading  to  eoiideiisntion  of  the  ilwp«r  [lartJi  i>f  the  bono, 
and  to  periosteal  depo§it  of  bone  on  the  surface.  Tltis,  however,  in 
tlie  c»*(!  only  in  tliono  indtiuict'*  where  the  iirocoss  guirlakes  of  tlio 
healthy  or  sthenic  character.  In  those  low  inflanimation-i  which 
wo  11 M 1  III  I  y  ad  Kid  otriinitinK,  whether  coiinoctwl  willi  ohvioiw  dqKmit 
of  tubercle  «r  not,  such  thickening,  or  porioatoal  deposit,  is  ollj-n 
nlutnit;  Init  tho  Ikbib  ih  sollemil  tlinmglKiut  all  thv  iiffrctiil  por- 
tion, the  liisintegration  hei'omirig  less  and  less  ponwptible  at  a 
diMtanoc  from  the  part  whcTo  the  lutw  of  vub^tAnco  exists.  TIio 
deposit  an>nnd  uleerated  hone  frequently  leads  to  aiikylosiii  of  the 
loM  movable  joinl« ;  an  occurrenco  which  is  extremely  common  in 
Uio  Umtitt. 

In  cases  of  superficial  ulceration  of  bono,  the  ^eota  for  it* 
removal  are  eitiier  rlie  jierioitteiini,  when  Lluit  mamfarane  mn&ina 
entire,  or  tlio  granulations  which  spring  fr«m  inflamed  surrounding 
partA  when  the  pt-rioAteum  liiis  Umi  reniovivht  Olhirr  vwira,  \iavt- 
ever,  of  nlccnttion  are  met  with,  in  wltieli  the  disease  is  more 
dcojily  wntwi,  and  connin-Tuxrs  in  iiiHninination  of  the  menibmne 
lining  the  cancolli  or  medullary  carity,  and  where,  therefore,  the 
agents  for  the  removal  of  the  Imnc  are  tti  Ijit  ttengbt  in  tlie  vesNoIn 
of  this  membrane.  Such  cases  as  these  are  ver\'  rare.  I  am  able 
to  r«fcr  to  pr<-piinition(t  showing  the  reality  of  the  utfe*ti()ri,t  but 
I  hare  no  knowledge  of  tlie  special  aym]>toms  which  it  presents, 
•  M  tlie  indications,  if  any,  which  it  fiirriishefl.  It  is  evident  timl, 
l^t  up  as  tlie  inflamed  parts  are  in  the  interior  of  the  bono,  the 
pn>ductjt  of  inilamination  can  find  no  exit,  and  the  disease  niufi 
Boon  become  merged  in  one  involving  more  extensive  destruction, 
i.e.  in  difiuNod  suppiu-atton  or  internal  necrosis. 

A  queeition  is  ver^'  ti-equently  asked  as  to  whether  caries  or 


•  ^mnthy  Cooper,  taetumOHSurgtrn:  Bn9M,<MDitKUtto/tht  JoimU. 
leoi.p.  ns. 

t  See  Piutur't  Malgaiffnf.  p.  106,  for  lie  appeurtncM  of  a  bone  iindcr- 
goioR  ■ti(i<>rptiuu  hj  gtunulntioa  foe  the  ruiuuval  of  a  Mtiuuvtrutn  after  com- 
pouiitl  fhU'lurt'. 

I  Sl  C«rlliulomew'a  Uoitp.  leriea  L  no.  163. 


636 


DISEASES  OF  THE  BONEa 


ntoeration  in  bono  bo  a  curable  ofFcction  or  noL  To  this  only  om 
nuHwcr  i-iLn  Iw  ^ven :  viz.  that  no  ulc«rauv<>,  L  «.  deMrucdre,  pro- 
cefs  is  i;vcr  (rarnblo,  in  tltc  trictc«t  senso  of  tbat  tmn,  ehux  soom 
defLict  will  ulwara  remain ;  but  Uiat  ulcersuon  in  bmio,  Uke  uleer- 
ation  in  soft  parts,  tuay  tenainato  in  cicatrtaUioD,  or  the  repro- 
(Inotioii  of  an  inli^rif^r  kind  of  Ixmh;  wktdi  i«  le«t  vawdlar,  aixl  Um 
smooth  and  woU  formed  than  Uw  portion  wUofa  h  radices.  This 
fortuiiuui  twrmiiiatiuii  become*  le«  prob^ile,  the  deeper  tlx;  dis- 
integration of  the  bone  exten<U.  and  tbe  mcao  profoand  is  tbe 
flonMituiioiinl  cachexia  with  which  it  w  aMoeiated.  In  exteonre 
BtnimouB  caries  it  is  hopeless. 

TIki  trteUmmt  of  bone  affoctcd  with  tltis  fimi  of  inflammation  i>  a 
matter  of  great  importance ;  since  upon  the  snecen  or  &ilare  of  sodi 
tnatmogt,  tbo  prcaorration  of  tlic  bono,  and  with  it  nometimes  of  tfas 
limb,  or  even  tlie  life  of  ilie  |>atient,  mmj  depend.  Ulceration  in 
bono  docs  not  dilfvr  materially  from  tbe  same  prooi?«s  in  soft  parte, 
except  in  lite  far  j^tv^t  leii|;tli  of  tJnie  which  it  tuually  occu]>iet.  In 
the  btme,  as  in  soft  partf,  tho  powers  of  nature  will  in  roost  cases  snf- 
fioe  for  curv,  wlit'ii  curv  iit  {fUNtihU:,  if  tlio  |Kirtt  be  put  in  a  »aitable 
position,  kept  at  rest,  and  pneser^-ed  clean  and  frw  from  tbe  accn- 
mulation  of  tito  diM-Iiar^^  But  often  tltc  patit-nt  cannot  wait  for  the 
oomplctioD  of  this  natural  proeoes,  and  calls  upon  the  Sorgeoo  to 
deliver  liim  from  the  chronic  malady  whidi  has  bcoomo  in«appor^ 
able.  Or,  sometimes  his  health  ^vcs  way  under  the  protracted 
di«charge ;  or,  after  on  interval  of  quicsccnott,  the  caries  again  make* 
prograss,  and  threatens  to  involve  neighbouring  bones,  and  to  im- 
pair the  ftinctions  of  the  whole  limb,  if  not  amwtcd.  This  is  more 
]M!culiarly  tlie  ca.te  in  the  tarsus,  and  other  "  irregular*'  bone^.  In 
the  ordinary  treatment,  then,  of  caries,  no  other  hxal  SK-asnrea 
are  reqiiinxl  tluui  to  [>n>vide  a  fre«  exit  for  tlte  diachar^nea,  and  to 
keep  the  exposed  sur&ce  of  bone  dean.  Tbe  sfipropriate  ooostitn- 
tional  treatment  will  complete  all  tlmt  art  «an  do  to  promote 
coverj',  and  more  active  surgical  interference  is  not  only  useless 
but  liortlul,  as  it  risks  duin<;  liami  witiiout  a  rea.-Ktiiitl>le  proHpoet 
of  doing  much  good.  Incisions,  however,  sbonld  not  be  i^tared  to 
Uiv  utmost  extent  neoessar}'  to  keep  tlw  discharf^  free,  or  pcrhapa 
even  somewhat  beyond  this  liiniL  In  Eiot,  in  all  tbe  aouter  eases  of 
oatitix,  much  benefit  appears  to  follow  tlic  mvxe  divittioti  of  thu  tcnae 
atmotnrea  over  the  bone.  When  the  surface  can  bo  felt  expoeed 
and  carious,  it  is  still  more  necessary  to  haw  a  free  dischai^; 
since  otherwise,  tbe  pus,  being  oonfiuod,  may  borrow  booealb  tbo 


le»^ 


CAniKS. 


637 


I 


periosteum,  and  cstend  tbo  miscbiof  to  tho  neighboonng  parts  of 
die  Ikhk".* 

OflcD  after  this  &oo  esposure  of  the  carioua  bone,  tbo  (lijM<iu<6 
nill  grudiiallv  Mubeidu;  Itut  wlicn  tLis  \*  iiot  the  caKO,  tho  question 
occurs,  wlioiher  it  will  bo  proper  to  attempt  (o  reniovfl  tJi«  carious 
tiiirt'ucc  and  fxjwso  a  more  i)i.-alt.}ir  one,  either  by  rasping  or  goug- 
ing the  bone,  or  by  t]ie  ajiplicAtion  of  tlie  actual  caut4>ry;  or  to 
modify  the  diseased  action  by  injections,  or  by  applications  to  the 
oanous  part.  Tlie  injectiona  wliich  are  in  use  are  Goni{iOM:^(l  cither 
of  iodine  or  dihitu  muriatic  acid.  Tho  hitter  a  Jntonded  to  unite 
with  the  base  of  the  jihosphatie  salt*  of  tlie  bone,  and  thus  to 
romoro  it»  surface  by  disintegrating  successive  portions  of  it.  It 
has  been  tried,  and  is  strongly  rficom mended  by  M.  OhaiWiiifjTiac  ;t 
ktid  no  okjectiuD  npgxtnrs  to  exist  to  its  employment  in  snilablo 
QAfea;  but  I  cannot  say  Uml  I  have  fonnd  timcli  benefit  from  its 
me,  Tho  injoction  of  tincture  of  iodine  in  tbo  trcatmont  of  abscess 
de|)ending  lui  dtseHse  of  iiiuccesrtihle  portions  of  Wne  (as  in  psoas 
and  lumbar  abscoBs),  has  been  warmly  extolled  by  M.  BoinetJ 
ThU  practice  does  not  seem  to  have  been  much  f<)I]owed  in  Kng- 
land,  notwithstanding  tlie  encouraging  results  of  M.  B<iiiii.-t's  ex- 
perience; but  M.  Itiilivrt,  wlm  liiw  tvst«^l  lliew;  rotmlls  by  uumeroos 
tmla,  pronounces  (what  indeed  theoretical  reasoning  would  li»vo 
lod  \in  to  expect)  that  M.  Boinet  "  ha»  singularly  ovor-cstimated 
tho  good  effects  of  iodine,"5  and  states  ids  belief  that  the  iodine  is 
quiti-  ineajinhle  of  modifying  the  diseawd  action  in  the  hone.  At 
tlio  same  time,  ho  allows  that  this  remedy  is  very  useful  in  large 
alinecNKe.t  dt-jH-nding  upon  carioHS  bone,  from  ita  effect  in  correcting 
the  fetidity  of  tlie  pus,  which  is  so  liable  to  occur,  and  >»hich  in  so 
detriment})!  to  tlic  patient's  healtli,  by  the  foul  atmo!!'i>herc  in  which 
it  compels  him  to  o\isL  The  iodine  has  also  the  effect  of  con- 
sotidaiiiif;  and  corrugsiting  tlie  walls  of  tho  abscess,  so  as  t**  prevent 
its  extension,  and  promote  its  convention  into  a  direct  sinus.  Tliis 
t*  u  considerable  advantage  in  such  cases.  From  tho  few  trials 
that  1  have  had  tlie  ojipurtunity  of  making,  I  believe  that  M.  Ko- 
bert's  cstlmatu  of  this  treatment  is  ven,'  near  the  truth.  Tlie  iodine 
may  bo  used  ditutt»l  at  first,  witli  one  or  two  parta  of  water;  and 


*  8mdo  authors  leni'li  tliat  pu^  exiTuises  a  Bulv«'nt  power  upon  the  bonr 
tUtltt,    This  (toclrine  a]riicnr«  ini8ti])portftl  by  dirVL't  «ciilence:  and  it 
'^HMM  Impittbuttlu  tlita  tiie  Cone  uau  bu  no  dtuuhed  while  it  reuins  its 
vludity. 

+  Al^m.  ih  la  SoeUle  dt  Chirart/u.  lac.  cit.  ^  Ibid.  toL  li.  p.  <1!U, 

{  ItulicU,  Gi/i\firmo>t  dt  tjliniqitt  Ckimrgiccle,  Paris,  I8CU,  p.  iO^ 


638 


DISEASES  OP  THE  BONES. 


afl«m'ftnb)  the  pwe  tinotiiro  (Lond.  Phar.)  may  bo  used.     It  iTl 
betwr  at  first  to  n-itlidraw  as  mucli  of  tlii.!  injcvtton  as  will  run  out^ 
and  covur  the  opening  with  a.  poultice.      ^Numerous  injections  will 
ba  neceesarr. 

In  caMa  of  auperflci&l  caries  of  bones  wbieh  can  bo  cxpoAed 
without  too  much  injury  to  the  soft  ports  (of  which  thts  tibia  and 
enlctuieum  are  tlie  nuiAt  faniilisu'  examplcii),  it  may  MiinolimL'^  bo 
advisablo  to  rasp  or  gougo  away  the  carious  surface  of  tbc  bone, 
«ji()  endeavour  to  arrenl  tlie  furtiier  pixigreie  of  tlie  <liMni.->o  by  tho 
application  of  the  actual  cautery  or  strong  nitric  aci<i  to  the  sur- 
face .so  expaiftl;  or,  if  lUv:  iliw-iuw  l»e  vnry  su)XH'ticiid,  Uio  liittcr 
measures  may  be  sufficient,  witliout  any  preliminary  removal  of 
bone.  Tlicse  ojH'rutioTts  ^'hotilil,  howevur,  only  bi;  pi^i-lormod  in 
cases  of  evident  necessity.  We  bare  only  too  frequent  instanoca  of 
tlic  dangers  of  all  oporntions  on  bone,  especially  of  tiuch  as  iuvoh'e 
the  exposure  of  large  surfaces  of  the  cancellous  tissue,  as  is  geno- 
rally  the  case  in  these  gouging  or  rasping  proecwUngs,  which  are 
extromoly  apt  to  be  followed  by  diiFused  iiiHaninmtion  of  the  tn- 
tcvior  of  tJie  bone  (osteomyelitis)  and  by  pya-niia.  Still,  if  the 
disease  be  accompanied  with  mui'h  pain  and  loss  uf  motion,  ami  iho 
wound  show  no  tendency  to  lical,  tho  patk-nt  is  often  compelled  to 
have  something  done  for  bis  ctihi,  as  otherwise  he  would  lose  Inn 
means  of  livi'liliixHl;  or  the  Surgeon  may  tJtink  it  right  to  inter- 
fere in  order  to  arrest  tlie  proj^retw  of  tlie  dii'cii.to  into  neighbouring 
organs.  The  di^-isron  of  such  questions  as  those  must,  of  coarse,  b© 
left  to  individual  judginent- 

Thc  application  of  tlie  actual  cautery  appears  to  be  less  duignr- 
OU9  tlian  the  eutting  oi»eniti(>n,  «nd  is  often  »uccus.tful  in  superficial 
caries.  It  seems  kaa  in  use  than  might  be  expected,  considering 
the  many  cii.ses  of  caries  Iiniit««l  to  one,  and  that  a  supertioial,  bone 
of  the  tarsus  and  metatarsus,  which  are  seen,  especially  tn  ditldren. 
Bore,  however,  and  in  all  situations  wlicre  a  bone  can  be  removed 
without  prejudice  to  the  function  of  tlie  part,  excision  [»  so  much 
more  8uti:>ractory  when  any  largo  part  of  tlic  bono  is  involved,  tli&t 
it  is,  perhaps,  not  wonderful  tliat  the  less  radical  meaaum  are  not  i 
much  in  use. 

M.  S(jdil!ot  has  lately  pmiwsed  a  more  extensive  nse  of  tlio  ope- 1 
ration  of  scooping  or  gouging  carious  hone,  as  a  substitute  fur  ox- 1 
cision  or  amputation.*  Hit  plan  eontem|)lales  the  removnl,  by  thai 
gouge,  of  the  whole  hone  except  a  shell  of  tho  outer  ItoaltJiy  parts,] 


Sue  Lanctt,  Dec.  10,  iSbH. 


im 


PHAGED.^aiIC  ULCERATION. 


639 


wni(it  is  left  to  effect  tlio  restoration  of  the  bonft.  With  all  due 
re»p«ct  for  tliti  autli^rity  of  M.  ti^tnlillut,  it  socins  iiiijHtssililo  to  allow 
Uiat  suoh  a  proposal  k  either  useful  or  safe.  There  are  few  cases  of 
extensive  and  ilocp-.^iMtiN)  onriuH  in  winch  tliv  liiuibi  of  thu  iU»uuc 
0011  bo  a-HCi^rtaiiieil,  and  a  partial  operation  is  oDen  worse  tlian  none 
at  alL  Bmid<»(,  cxtonitive  cxpomre  of  tho  iiitcnor  of  a  bone  is  a 
mOBt  ha;:ardoufl  proeeeding,  and  only  too  often  tenninates  iu  pyse- 
mia.  M.  Si-dillot,  howvvvr,  i»  s»!<l  to  lia\<i  pcrfurn)<.td  itiit  operation 
Uiirtoen  times  without  aoy  mstance  of  such  compUoation.  The 
further  coil «idi!mt ion  of  tliis  quostiou  wUI  occupy  a  portion  of  tlio 
ectsay  on  Hxciuio^s. 

Uloeration  in  bone  ia  not  always  of  this  ohronio  natnra.  Hr. 
Stanley  has  describi'd*  somu  cases  of  "  pliagcdnnio  ulceration"  of 
bone  which  Hecin.i  to  Iiave  been  coiiiii>Rt(N)  with  the  ooourrenco  of 
rodent  or  eaiieroid  uleorf  ui  tlio  soft  parts :  and  ill  diseases  uuao 
di.HtlniHly  ]iarltikin<r  orttii)  nature  of  oannsr  tJie  bonea  may  be  de- 
stroyed with  great  rapidity  ;  but  hero  tho  affection  ui  the  bones  ia 
only  a  jiart  uf  tito  ^cniTi-al  ditiniLv-,  an<I  iU  ire«itiii*Mit  must  depend 
on  tho  viL'W  whiuh  may  ho  taken  of  the  latter.  Cases  of  rapidly 
aproiiitiag  uloeration  do,  liowuver,  occur,  in  which  tho  bono  alone  is 
alTect^^d.  Two  veinarkahio  instances  havo  been  put  on  record  by 
Mr.  C:vNur  UiiwItiiiH  ;J  in  one  of  which  tluj  diE>c.a?e  was  oulv  part  of 
ft  general  strumous  affection,  but  pecuUar  on  account  of  ita  extreme 
rapidity  luid  gmat  fxtcnt.  The  otiutr  watt  »  vi>ry  remarkable  in- 
stance of  removal  of  givat  part  of  the  skull-cap,  and  protrusion  of 
the  brain  through  tlio  opening  ho  left ;  but  without  tlie  formation 
of  pus.  An  ab>tcess  was  found  in  tlie  brain,  but  tliis  was  connecl«d 
witli  violcnoe  done  to  the  protrudeil  portion  of  Ihat  organ,  and  not 
with  the  disease  in  the  bonee.  No  distinct  proof  of  the  presence 
of  any  constitutiiinal  cachexia  was  obtained,  nor  vrax  tho  exciting 
cause  of  tho  complaint  apparent.  Its  inHammatory  nature  waa 
ti.'ntififxl  by  distinct  mitrks  both  of  hiltamniatory  thickening  and 
of  iiitlammatory  oroaion  on  the  bone  in  the  neighbourhood.  There- 
fore tlic  old  definition  of  ulceration  as  "  iihsi)q>tion  from  intlam- 
mation"  would  strictly  apply  to  tliis  extraordinary  case;  and  wo 
have  ain-ady  seen  (see  p.  61li)  that  tlie  formation  of  pus,  though 
an  ordinary',  is  not  an  absolutoly  necossarv',  feature  in  ulcomtion  of 
bone ;  but  it  is  rarely  indeed  thut  ■m  large  a  ))ortion  of  bone  is  re- 


*  0»  DU»iia  of  ike  Bonft,  p.  ttn. 

;  Vtd.-Chif.  I'ftuu.  rol.  zxsix.  p.  SSi. 


t  &o«  ml.  1.  p.  no. 


6de  DISEASES  OF  THE  BO^'ES. 

moved  wit]>aut  the  fttrmadon  of  tJttaeeeSy  espeouUy  when  com] 
tissue  a  involved;   for  thv  'maitmoM  of  romova)  of  inflamed  bona' 
vHthout  su|>piiration,  Iiitherto  noted,  have  oocnrred  ulniost  exota- 
eively  in  tliick  caoccllotis  bone*,  sadi  as  tlio  vertobne  and  tarstu. 

ITeerom,  or  the  doatli  of  some  oonsiderabJe  pwtioD  of  a  bone, 
ocnurf)  a»  Itie  conMyjuencc  of  any  ciu»o  whicli  eulficiuntly  itti]: 
the  circulation  in  the  ncij^libourliood.     This  ia  preciselv  aiuilogonB^ 
to  wltat  taken  [>Iace  in  the  gangrene  of  soft  piirtM;  and  as  in  gan- 
grone  the  non-vascular  jiart*  are  most  easily  affected,  and  tlica 
Uio:)0  n-liich,  (hoiigli  vnaoiiUr,  are  ftii-tliCHt  from  Qk  cvntnt  of  the 
droolation,  and  in  which  tlie  veMcls  are  fewest  and  smallest,  m  the 
fre()Ut>nt  oociirrenoo  of  necnisi*  of  bono  id,  no  doubt,  dn©  to  tlio 
comparatively  small  quantity-  of  blood  which  circalate«  in  tliat  ti»-  j 
sue,  as  well  il>  to  tin:  inoxtt^fwilili^  nature  of  the  oncons  sah§uuic« , 
itself,  in  consoqiionco  of  which  any  extra\-3sation  or  product  of  in- 
flariitnution  cniim.'^  pn^s^uro  dire<:<ly  ujion  tlic  blood-vessels,  or  nar- 
rowing of  tlie  c)iannoU  for  the  conveyance  of  the  nutritivt*  plasms. 

It  is  <li.nii(Ml  by  some  antbort  of  r«[Kttation  on  this  subject  itiat 
necrosis  is  ever  a  consequence  of  inflammation  of  lione,"  and  they 
rofor  the  disojwe  hIwiivk  to  ](crio»tJtJs  or  ostcomyelids  as  its  oatiM', 
But  this  appears  an  error  in  two  senses.  In  tlie  tin>t  plnvc,  tlicrv  is 
no  csseiitini  diflvrenec  Ix^wvcn  periostitis,  or  ostoomrelitis,  and  in- 
flammation of  bone^  The  discuses  so  called  are  only  in  flam  mat  ions  in 
which  tlio  ])iul  of  bone  alone  aflbctotl,  or,  as  is  much  more  eouimon, 
the  part  mont  affected,  is  the  external  table  or  tliv  medullary  tissue. 
In  the  sccoti<l  )>lacc,  IIk'  <Iiseasi!  properly  called  ostitis  verv  freijiieiilly 
induces  n^icroiiis,  not  indeed  iL^ually  of  the  inftanied  jmrt,  but  of  the 
parts  in  its  nel^ghbourhood.  The  intlauied  part  itself  does  not  lutually 
j)ori»b,  1h'('«u!«!  the  final  canst-  of  m^crfwin  is  tlio  eto|>j>it<e;o  of  the  cir- 
culation by  the  obstruction  or  obliteration  of  the  vascular  cliannels, 
while  the  first  Hluct  of  inflammation  is  the  enlargement  of  thase 
rliiinnels.  When  the  ostitis  has  readied  the  stage  uf  exudation,  the 
dilaicd  voscidar  ehaunels  iH-odTiit!  «guin  narrowed;  but  the  prooess 
takes  places  slowly,  and  organisation,  whidi  involves  the  formation 
of  new  vessels,  takes  plai-e  in  the  cxiidcil  miiterial  as  it  is  prodnwxl. 
Still,  although  the  event  is  not  a  common  one,  triiees  of  tnilamniation 
are  fcon  on  sequeittra  suflieiviitly  oflca  to  show  that  the  inflamed 
part  does  somolimcB  die.  The  same  causes,  in  faet,  wliioli  phkIucb 
gangrene  in  sul).  pai'l^  will  occasion  the  death  of  a  bono;  and  among 


*  Ooi-tl.v.  Maladitt  da  Organet  <iu  MouvemeHl,  IMS.  p.  317. 


NECROSIS. 


641 


» 


Rtion  hol<]](  n  liigli  pUco,  loss  OD  acoonnt  of  its  direct 
tendency  to  produce  tho  diuth  of  tlio  port  iiifbinitHl, 
than  of  its  indiroct  consequences,  whereby  tlio  cireulntion  arotind 
tho  inflamed  pnit  is  obAtrucUHl,  and  80  luwtroAia  of  Uie  noighbouring 
parts  U  induced.  Hones  in  tho  course  of  an  cxteusivo  caries  the 
49roalation  of  Bonie  con!>idorablo  jiortion  of  tlio  ttoiie  h  apt  to  be  de> 
Bljoycd,  and  then  a  iiocrosed  or  loose  pi«oo  is  found  in  tho  middle 
of  ihe  ulcerated  part.  Such  conibinnticui  of  nocro.tis  with  vtrius 
was  called  by  the  old  writers  dry  carioe  or  hard  caries. 

Another  very  frL^iiieiit:,  if  it  i>o  not  the  most  common,  eauite  of 
superficial  necrosis  is  the  denudation  or  separation  of  the  poriostoum, 
which  occurs  a.*  a  oonMipieiic«  i-ither  of  direct  injury  or  of  etliittion 
between  it  and  the  bone.  It  is  true  that  large  separations,  and  oven 
oxl4:nAive  destruction,  of  tliojKiriwitoutn  may  occur  witliout  tlie  death 
of  any  portion  of  the  bone,  and  this  is  indeed  common  in  tlio  bones 
of  tlie  head  and  fno* ;  but  the  poeidiar  circulation  in  the  iVirmer,  and 
the  gi-eat  vasculai'ity  of  all  parts  in  tho  latter  region,  sufficiently  ex- 
plain tluK  fact.  In  other  piirt.s,  it  h  tho  nioru  general  nili)  that  when 
tho  periosteum  is  dosti-oyod  or  separated  over  any  considerable  por- 
tion of  a  bono,  the  superficiul  layers  of  tlio  latter  will  jwriMi.  'J'his 
ta  one  reason,  among  many,  why  it  is  important  to  adjust  tho  soft 
parts  over  a  Imiuo  denutie<l  by  violence,  in  order  that  tiiev  may 
rapidly  adhere  to  it,  and  tliat  so  fresh  vesaeU  may  connect  tlio  peri- 
osteum to  the  bone  before  the  Utter  has  undergone  an  irremediable 
change. 

Vi"lvnci>,  acting  directly  npon  tho  bono,  is  another  very  frctinent 
oauBO  of  necrosis,  as  is  frequently  seen  iji  compound  fracture,  whero 
both  the  |>eriontt:uiti  and  the  modnlliiry  tissue  arc  much  dainagi^l, 
and  the  bone  dies  witliuut  any  proof  of  previous  inihunmation  hav- 
ing exiittcd. 

The  action  of  cold  is  often  exhibltoil  on  the  Imnes  as  on  tho  soft 
parts,  and  the  subject  will  be  foutxl  trcAted  of  under  the  head  of 
F«0ST-WTE  (vol.  i.  p.  1!)1).  In  deep  bums  tlie  bonea  are  also  ooca- 
aioDsliy  charroii,  and  they  are  fretjnontly  involved  in  pingn-ne  of 
tbe  Bupedioial  tissue;*,  from  wiuitever  cauM>  it  arii^es.  Certain  caustic 
applications  arc  well  known  as  frequent  causes  of  nocrous,  of  which 
the  su|ierlii-ial  extelialtoii  produced  on  the  aurtaee  of  tiw  jaw  for  the 
Ctm>  of  epiilix  in  a  familiar  example  To  this  cutOficHry  belongs  aI»o 
the  necrosis  of  tlie  jaw  whidi  ia  produced  by  exposure  to  the  frmies 
of  phoiipbonis.'      Tlio  various  conotittitiona]  cachexia^  es]>ccia]ly 

*  TliU  nfiRRtiiHi  will  im  found  trcnuiil  of  in  th«  esnf  on  ScMicti- 
DisKABKii  or  TiiK  Texiu  Asa  Gsmb. 

TOL.  UL  T  T 


k 


643 


DISEASES  OF  THE  BOXES. 


ftVphUis  and  struma,  are  frequent  pauses  of  nocrcsis ;  Imt  Imjtc 
aflbciioii  of  tliu  bunOH  U  (Hily  a  varliHy  nf  the  inlluiiiTiuitDry  irnKt^i^i. 

Tlie  abuse,  and  oven  occasionally  tlie  moderate  use,  of  nicrcuiy 
id  aiioliicr  witwi;  of  iiu(T<km*i.  It  i«  quite  true  that  matiy  of  the  pre- 
parations and  cases  entitled  "  necrosis  from  the  abuse  of  mercoiy" 
nitiy  bo  explftined,  as  Imving  boon  <!ium»  of  ayphilitio  necrosis, 
whieh  mercurj-  bad  merely  failed  to  arrest  the  disease,  and  bad 
not.biiig  to  do  with  cauiting  it;  hut  1.ln-ro  are  tuo  nijuiy  instance* 
record  oftbo  occurrence  of  necrosis  of  the  jaw,  during  tJio  adminis- 
tration of  inenrury  for  siime  disoiisi!  wliieh  hiu  no  iuHueneo  U[xpii  tlio 
bones,  to  admit  of  a  doubt  that  Uio  atfection  was  dircetly  induced 
by  tlie  no-cailod  reiiiwly.  Tlum,  in  the  imiNciitn  of  Ouy'n  Uospitjil 
(no,  10£il)  is  a  sequostrum,  consisting  of  two-thirds  of  the  alveolar 
proo(sw  of  the  lower  jaw,  whi<'h  is  muil  U>  bo  "  necro»i»  iii<laoitl  by 
tlie  use  of  niercur)'  for  ovarian  dropsy."  Unfortunately  it  appears 
tlmt  wliiit  is  a  inotlerate  use  of  inereiiry  in  one  jjcnsoii  is  equivalent 
in  rai'o  cases  of  idiosj-ncrasy  to  an  excessive  abuse,  so  tliat  no  p: 
ti«d  mie  can  be  laid  tiown;  but  it  w  ut  any  rut«  piniwr  to  rcmem 
this  occasional  efteot  of  mercury,  pai'ticulariy  when  prescribing  tt 
for  caeheetiv  [icpwns.  In  the  museum  of  St.  llarthotomew's  Hos- 
pital is  a  preparation,  in  which  necrosis  of  tlio  jaw  is  attribute<l 
tlic  ndiuiniKlration  of  a  few  grains  of  mercury  during  a  fever;  bi 
in  some  fevors  necrosis  has  been  frequently  observed  as  a  oon»e>, 
queiici!  of  more  lowering,  lut  it  would  soom,  of  tlie  vital  povrei 
without  any  mercurial  eacbexia.* 

It  would  bo  idle  to  attempt  an  enumeration  of  all  the  causes 
which  may  leail  to  the  death  of  bona     Tim  iibovo  are  tlie  mi 
common,  and  will  be  found  sufficient  for  practico.     Tlic  sj-mpto: 
and  treatment  are  identical  ui  most  of  tltottc  forms.     Some  will 
quire  special  notice  hereafter. 

^Vhen  a  portion  of  bone  is  to  dio,t  the  first  phenomenon  is 
ooBsation  of  cii-cuhition  in  it.     This  leaves  it  hard,  white,  and  aoa- 
oroiiK  when  struck.     It  does  not  bleed  when  cxjkjsoI  or  cut  into^ 
and  is  insensible.     Occasionally,  when  the  dead  bone  is  ex 
to  tlis  air,  and  acted  on  by  the  prcseuee  of  putrid  pu«,  it«  oolo 
Ijccomefl  nearly  or  quite  black:  largo  surfaces  of  hard,  blaok,  nC' 
cro-'wd  bone  are  sometimes  left  exposed  by  the  sloughing  oftbo 


loa  V 


•  See,  in  the  nmseum  of  St.  George's  Hospitiil,  sevicn  ii.  noit.  fli,  08, 
prepnmtiona  in  wliinh  both  the  jiiiv  ant]  the  clnviolc  bcmino  necrosed  La 
the  satiie  piitient  (iuiiiig  tlic  couvse  of  n  fever. 

t  TliiB  dusci'iption  refei-s  to  the  process  ns  it  occurs  in  bono  pr«vioudjI 

hcHilliy. 


NECROSIS. 


6-13 


orer  the  tibia.  The  dead  bone  «t  first  retainR  its  connesioii  to  tho 
borif  around,  as  wc^ll  as  tu  tlic  jwriostcutn,  or  whatoviT  pait  of'tliu 
nubntiouH  inoiubmne  may  l>oIong  lo  it;  but  tho  j)rt>u,>i)ce  of  a  dead 
|IArt  i*  ntivcr  long  tolcral«d  by  tho  living  tissiios,  and  ncconlingly 
tile  }>roc«^40ii  which  aro  to  cliiiiinate  it  iwon  bci'oiiiu  ptircoptible  on 
butli  thoN!  structuree.  Tho  periostoum,  or  m^Hlullary  mombrane,  as 
the  caM>  may  he,  iteparat^a  from  the  dead  bono  mid  iH^ornnoH  in- 
flluniHl,  a  (tiumtity  of  o§sific  deposit  (moro  or  leas,  according  to  vari- 
I  ona  drouniAlatioea)  is  pouml  out  bntwocii  it  and  Uio  dmd  l>one, 
ari<I  OiiH  do{Kwit  soon  becomes  converted  into  new  bone,  forming  a 
shciath  over  tlie  dead  |Hjrli<iii,  by  wliicli  tJio  latter  in  unclonwi,  or 
invf^inated,  aa  the  technical  term  is.  Tho  dead  part  is  now  called  a 
tequetlmm,  a  name  only  [irojH^rly  applied  U>  it  when  ImiAO  and  in- 
vaginatfxl,  tliough  often  incorrectly  lisod  of  any  jiieoo  of  dead  bono. 
While  this  ahiMtli  \a  being  tbniied  fnini  <be  mvinbraiie  coating  the 
dead  bono,  changes  are  going  on  in  the  living  bone  to  which  it  was 
aitachcKl.  \\'!ica  tlio  latt*r  hiii»  bt-en  prcvioiwlv  (tiMiiisetl  (t.  e.  when 
tlio  nocrosis  has  been  of  inHammatory  origin),  the  hjflamniatory  do- 
posit  whii-h  Hiirrouiids  the  se<]ue«truin  sol\vn8,  pus  w  forinud,  and  a 
groove  of  ulceration  is  produced  at  tho  expense  of  tho  circle  of  in- 
Aaiiied  bmio  which  Ibnns  the  margin  oftJiu  seiinontrum.  If  the  Bor- 
ronnding  bono  have  been  previously  hoalthy,  the  sequestrum  acta  as 
ai)  irritimt  njion  it,  setting  up,  fir«t  inHummation  and  thickening  to 
It  variable  distance,  and  tlien  ulceration.  Thu»  a  gi'oovo  ia  traced 
around  the  :>ei]ueatruni ;  and  the  formation  of  this  groovu  i^  accom- 
panied by  suppuration,  as  has  been  described  above  (see  p.  OIH). 
The  ))n.t  formi'd  in  tho  noigli  hour  hood  of  tlio  dead  parti«  niidcoa  itit 
way  to  the  nearest  surface,  and  in  ao  doing  interrupts  tho  tbrmatJan 
of  tlie  {HTtiisti^al  Nhcath,  leaving  siniuwe,  or  doatti;  pfwsing  through 
this  slieath  from  the  sequestrum  to  the  surface  of  the  body,  or  somo- 
timen  int<i  a.  ncigliUmring  joint  or  serous  cavity.  Tho  |>rcHenoe  of 
such  sinuses,  leading  through  the  iihi^ll  of  bone  to  hard,  smootJi, 
sonorotifi  bone  at  tlio  bottom  of  tho  cavity,  ia  the  diiitingui&liing 
mark  of  necrosis. 

Tho  formation  of  tho  groove  between  tho  dead  and  living  bone 
is  a  very  slow  proiwsa  in  the  bonoH  of  the  limbs,  requiring  generally 
many  montlw  tor  it«  completion.  It  is  iniiwiwiblc  to  lay  down  any 
rule  as  to  the  time  at  which  a  se(|uestrum  may  bo  expected  to  be 
found  soparatod  &om  tho  n?«t  of  tho  \wna.  In  animalx,  ns  has  Ixvn 
provMl  by  oxperimenta,*  tlio  process  may  be  completed  in  a  tew 


Tnga.  Ik  notm/wn  Ouium  Begtneratioiit,  exp.  i. 


644 


DISEASES  OF  THE  BONES, 


dars.  In  cliildrvn  it  iwctns  to  go  on  somotimM  with  great  rapiditr-^ 
eepftcinlly  in  the  Imnes  oftiic!  fnca.  On  the  other  hand,  iii^t;uut4_ 
aro  not  wanting  in  which  half  a  Ufi^imo  may  havo  fllapeod,  and 
prooon  still  remain  untiniHlied.  One  of  these  hit»  Tuniiiihtid  a 
paration  in  tlic  muiipum  of  6t.  Bartholomew's  Hospital.'  it  is 
section  of  the  alinfk  of  a  femnr,  exhibiting  in  ita  intMrirar  a  snail 
fiatnlona  cavity,  with  nocroais  of  a  email  portion  of  the  inner  tayan 
of  ita  wall.  A  groove  cxtonds  Ut  nomc  <iq)lli  between  tlio  dead  and 
tho  contiguotu  living  bono.  Tbo  limb  was  romovod  by  amptitation. 
Tite  femur  had  been  fnidtiivd  tliiry-fivo  yeam  previous  to  the 
amputation :  tho  fracture  was  followed  hy  abscess  in  the  soft  parts, 
and  tJ)o  formation  of  a  fiHtuloiis  {nuHHiigc  lending  into  tho  interior  of 
tho  bono,  which  passage  remained  open  diu-ing  the  whole  periodi 
from  tho  fraelure  to  tlio  rciuovul  of  ih«  liiuli.  it  may,  liowwor, 
stated  generally,  tliat  tho  more  superficial  tlie  dead  portion  is, 
tho  moro  fi-titly  it  in  oxpi'scd,  siiiii  tin'  rnori!  viohmt  tho  action  of  1 
cause  has  been,  the  more  rapidly  will  it  separate  (see  p.  6ili). 

When  the  groove  in  complotiid,  tlio  dciul  bono  is  loose  in 
oavitj'  so  formed  for  it,  and  quite  free  from  any  vital  connexitni 
the  Ixxly.     Tlie  sequestrum,  tliercforo,  is  now  climinnti.^,  and  thit^^ 
may  bo  regarded  as  the  natural  process  of  cure,  siiiee  it  preventa 
tho  extension  of  t lie  necrosis  itirtlier  into  the  bone;  i>utastlie  socjnOB- 
tnun  is  still  lodged  in  its  cavity  in  the  interior  of  die  banc,  it  thna 
becomes  lui  abiding  soiireo  of  life-long  irritation,  whicjt  must 
all  means  bo  removed  as  s[>eedily  as  possible. 

Tho  iilxivc  is  iiitendwl  for  a  sketch  of  tho  procoM  of  necrosis  in 
one  of  its  most  frequent  seats,  viz.  tlio  out*>r  (subperioitteal)  Inyerv] 
of  tlic  compact  sh»ith  of  a  long  bona ;  but  it  may  occur  in  any] 
situation, — in  the  medullary  canal,  or  central  layers  of  tlie  compnoti 
tissue,  in  flat  or  irregular  bones,  or  tho  spongy  ends  of  long  bones ; 
or  agaui,  the  extent  of  the  necrosis,  or  tlie  aituation  of  tlio  (xurt^, 
may  modify  considerably  tlic  process  of  sqiaration,  t,e.  the  surgical] 
aspect  of  tho  case.     For  example,  even  when  necroMK  is  Kubjii 
osleid,  and  the  process  of  separation  nonual,  it  may  bo  iu  a  paii' 
from  which  extraction  is  imposaible,  as  on  the  inner  tniHiwo  of  thft 
sknll,  spine,  pehns,  tliomx,  &c.     The  stiIi  peri  osteal  sheath  is  oftaD 
wanting  in  the  bones  of  tlio  liinba  when  iJie  soil  partt*  liavo  bem, 
extensively  destroyed  over  tho  att'ecti-d  bone;  and  it  is  never  forme 
in  tho  skull,  where  necroais  ia  so  common,  nor  in  the  cancel] 
bones,  where,  though  less  common,  tliu  disease  lit  by  no  mcous  . 


'  Series  i.  no.  17%. 


NECROSIS. 


645 


I 


In  (rocli  caws,  wlien  tlio  <lc:iil  ln)ii«  ii*  Irrosfinwl  from  the  living,  )t 
comps  away  of  itM'lf,  or  can  be  at  once  removed.  Such  a  piece  of 
(leail  bniio,  not  oiitiiiuil  liy  ua  invti^jiiuiliii;;  xlicath  of  now  hone,  is 
called  aii  ex/oHation.  Again,  it  somL'tim(>B  bajipena  that  tbo  ne- 
cnw<!d  [lortion  involves  tlic  wliolo  lliickni.'.'>9  of  tin-  shaft  of  ii  long 
botte,  and  sometimea  the  whole  length  of  its  diaph^-^a ;  some  in- 
ovim  aru  vxliihJtod  in  ihu  tniiisvtuns  whvru  thu  opiphvtia  also 
shared  the  destruction,  though  this  ia  very  rare." 
Each  of  these  ounditions  is  acoompaniod  hy  noticeable  |)Gcu- 
liarities.  When  the  whole  thitrknoss  of  tho  shaft  is  involved,  cape- 
cially  in  n  txtne,  like  tho  liumoru^,  enjoying  &oe  and  rapid  motion, 
fracture  la  likely  to  follow  on  the  oompletion  of  the  groove,  allliough 
tliu  result  may  be  obviated  by  the  ^trrngtli  of  tho  coso  of  now  bono. 
When  the  whole  diapbviiia  is  iitvolvKJ,  t}ie  ease  assDines  a  graver 
sa]>e(rl,  fintx  tlio  oxt^nit  of  inflnm mutton  wluch  is  ncoi.-«Marj'  for  tho 
formation  of  the  new  abaft,  and  the  great  suppuration  tboreby  pro- 
duct^l,  sus[>cnd;«,  or  perhaps  permanently  abolishes,  tho  functions  of 
(he  limb.  The  mujtcles  become  matted  togetlier,  the  akin  a-dema- 
totis  and  (K^notratcd  by  numt'rotia  sinuses,  tho  parts  bolow  incapable 
of e\t<;iidi><l  motion  or  eiuirgt^ic  action;  caaeii  even  are  on  rvoort) 
wlicro  the  inflammation,  having  rcncli<xl  tho  great  vessels,  has  pro- 
duced coagulation  of  the  blood  in  lii>t]i  artury  luxl  win,  and  coiiso- 
qtumtdnr  gangrene  of  tlio  Iimb.f  In  other  cases  oiibor  the  ulcera- 
tion around  a  secjiiCAtnim,  or  other  dJAoaae  of  the  bono,  involves 
a  large  vessel,  or  tho  point  of  an  exfoliating  portion  of  bone  ia 
drii'en  into  the  artery  in  Aoine  movement  of  liic  liiiih;t  and  tlius 
oitltcr  a  direct  wound  of  tho  artery  is  produced  (when  the  sinus  of 
the  diseased  Utne  eninmnnientea  witli  the  hiceration  in  tlie  lulcry), 
or  if  no  oj>ening  exists  oxtornally,  a  oonsecutive  aneurism  may  poe- 
aib^'  he  eMlabli^hed.  In  any  caae  of  xiicli  injury  to  tlic  main  v<mm>J)i, 
when  tie  diagnous  can  bo  properly  c^iablisbcd,  amputation  would 

•  fluy'ii  UuspituI  >[uscuiu.  no.  116(i".  necroaia  of  the  condyles  and 
abaft  of  thu  fomur,  and  upper  end  of  iheUbin.  ScoalHono.  1100*",  refonvJ 
to  fiuibi-r  on. 

f  klusnum  of  SC  Bortholoiacv's  HospiUi],  seriM  i  no.  134. 

I   Mr.  Polnnd,  ia  bis  nssayoH  lluplurcoftlie  l'a[ililt«I  Artvry.quotetOD* 

)  of  >L]i<>iitiiiiRoiis  hn-iiKtrrliagc  fiviii  that  V0M«1  in  neoroiris  of  Uw  Getnur  (a 

"liati^ai  of  Dr.  Portor,  IfuMtn  Joum.  toI.  t.),  wkI  two  oUiun  wlit-po  ibe  iurte»y 

was  woiindol  bya»e)|nMtyaKidiirinRactiTcinur(.-iiimls  ofllii.-  limb  (Dr.  By- 

nn^  «aae,  .Vtd.-Ckir.  Um.  vol.  xxiv.  p.  ■ih^ ;  Dr.  Jacob's  Mm.  Mtd.-O-ir.  at 

^MMrJim.  Edta..  It<l-l),   I  harcieon  fatal bmn(>rriia([« from  tlioUngiulartpn- 

tndlaoasoof  Uiejaw.  and  from  ili« aorta  in  caiics  of  tbi- ipinc.    Mr.  Suiili-j- 

I        (op.  dl.  p.  Ill)  rtilutM  a  case  In  which  iho  (wpauln  of  the  kaiw^oiiil  wan 

K  {ODMntMd  by  the  poiaUd  end  oiHut  uccroicd  than  of  tha  iMDUr. 


646 


DISEASES  OF  THE  BONES. 


emnllvr  V 


bo  m(llrat(!(1  in  th(>  lower  limb.  In  tbo  apprr  limb  tho  mnin 
are  suiittratcil  from  the.  liniia  Uy  u  inasa  of  ttofl  parU ;  and 
veBsela  would  hardly  complicato  the  case,  as  thoy  might  bo  inchided 
in  tliu  inuisionit  mpiinHl  to  ftxjvoMo  Uio  <liHeA.4e(I  ttono.  In  other 
aitnatioRH  attompt*  must  be  made  to  tie  tUo  olceratod  vc**«d ;  ond 
if  tlioy  (ail,  n»  thoy  p)n«rally  will,  from  Uie  rottesi  condition  of  tbo 
parte,  the  trunk  leading  to  it  must  be  Bo«nm)d. 

In  t'liscs  of  nccrosii*  involvin;;  the  wliolis  Uiickneca  of  a  bone 
(^lolal  ntKVimfi),  when  the  seat  of  tho  disease  ia  a  largo  bono,  Bach 
as  tIl»^  fi-umr,  lifo  th  in  considcrablo  diiiifrtir;  and  as  tho  patients 
are  usually  persons  in  whom  some  constitutional  cachexia  is  pro- 
si>nt,  and  probably  in  au  advancod  stjigo,  they  frwjnoutJy  &uccuml).* 
Still  the  dangers  of  amputation  in  these  cases  arc  bo  gi'oat,  and  tho 
HclvantugCM  of  SHvins  the  Hiiib  »o  dt-cidcd,  that  they  nrc  usually  left 
to  tlio  reparative  powers  of  nature.  In  small  hones,  audi  as  tbe 
plmlanges,  nnipiitjition  is  indicated.  In  tho  u])por  limb  Inrgo  por- 
tions of  dio  ^\holo  thicknesN  of  tho  ahaSi  may  bo  removed  with 
entire  success,  and  prescnatioa  of  tho  motions  of  the  vxtromitr. 
In  a  sub^Gijuent  o-C'wy  tho  indJtuitiouK  for  excision  of  Uie  whole  or 
paits  of  bones  on  account  of  necrosis,  invohnng  their  whole  thick- 
tioss,  will  ho  liirtJicr  conaidonxt. 

Central  necrosis  is  usually  an  obscure  complaint,  and  is  hardly 
distinguinhublv  by  its  ayinptiimH  fmni  chronic  hIisci^hh  of  tho  bcino>. 
In  fact,  as  their  s_v-mptoms  are  the  same,  so  tlie  same  treatment  ia 
npplic'fthlc  to  each  of  tlipm.  Dci-p-soutcd  pain,  throbbing,  Uww  of 
rest,  general  debility,  perhaps  rigors  and  typhoid  fover,  with  slight 
puffinesa  over  tho  »<'nt  of  the  disi^asu,  and  a  little  pain  on  pressure ; 
these  symptoms  persisting  for  a  oonnidcrable  pei-iod  witliout  relief, 
notwithstanding  tiiat  thu  a])pro|)riatu  constitutional  and  local  re- 
medies have  lieon  employed,  indicate  thu  necessity  of  making  an 
exploratory  incision  at  tho  seat  of  the  inflammation,  and,  if  tha 
surface  bo  tbniid  healthy,  of  removing  it  with  tho  tn,-pliino  in  order 
to  soiuvh  for  an  abscess  or  swjuostnim  in  tho  centra. 

l)oep-80Hled  necrosis  often  loads  to  suppuration,  making  it*  way 
to  a  free  surface.  This  is  very  common  tn  tlio  long  bones,  and  is 
n  freijucnt  cause  of  abscess  anil  destructive  influnimntion  of  Uie 
joints.     Necrosis  may  also  attack  a  portion  of  tbe  articular  surface 


*  An  Int^reBting  caee  of  t«Ial  neurosis  of  ih«i  shaft  and  upper  part  of  iho 
fomur  in  a  jouiip  8ubje«t.  let,  13.  in  whom  miiputiitiou  wa»  aucocntfully  pcr- 
forraeJ  a  j'ear  and  half  nAvr  tlie  ooiiiiQt^uoi'iQV'ul  uf  tlie  discim.  i>  rcmrtlod 
by  Mr  Ki'rr  of  Aberili^eii  in  \iii!  Ed.  Mnl.  and  Surg.  Jour.  1B34.  vi>l.  xlii.  p.  09. 
U  is  worth  peniBiug,  as  sUowiag  tbo  aclivity  of  repair  at  ibat  early  age. 


NECROSia 


&I7 


I 
I 


of  one  of  the  great  joint»  of  tlm  boily,  altlioufih  tHi«  i»  nu*  except 
OK  a  complication  of  oxtonsivo  strumous  atloction  of  tiio  joint-ettr- 
Gm3&  Limiux]  Heterosis  of  Hrticulur  ends  ]»,  hvwc%-er,  occanoniLlly 
mot  with,  and,  like  the  preinoiw  affection,  will  set  np  abscess  in  tho 
joint.  Tliw  iliiigiic>.ii«  of  tlii;iMj  cauites  of  arlicrular  ab!««is»  must  U) 
«ouf;lit  in  the  essay  on  DiMBAHini  of  the  Joints,  and  the  indication 
for  oiienttiw  troiitirutot  in  tbiit  oti  Excisiox. 

In  the  flat  bones,  where  thej  are  formed  of  oompact  iasue, 
neoroHiit  is  ui  cxcittdinjjiy  cmnmon  dinctuo;  bat  hero,  ns  lias  been 
,bo£>ro  observed,  tho  dead  bone  will  usually  exfoliate  without  invagi- 
mtioii.  Tho  jiame  may  be  enid  of  tlw  iiwiTwcd  |<ort.ii>iw  of  irrOfjiilur 
;  tiODHi  whieh  oonsist  almost  entirely  of  cancellous  tissue  (such  as 
those  of  Iho  tarsus),  in  which  iii.'cro«is  is  by  no  mvanH  ruro.  Whole 
bono*,  or  largo  portions  of  entire  bones,  of  the  tarsus,  and  some- 
limc.t,  but  U»s  ofU-n,  of  tlie  aiqiii*,  are  found  quit«  scjiiinite  froui 
ail  their  attachments,  and  merely  retained  as  foreign  bodies  among 
tJi«  «otl  partn.  In  auch  C9UH»  there  is  sumctiuics  a  little  diihouitj'  in 
making  tlie  diagnosis;  since  the  dead  bone  has  not  tlie  hard  ringing 
M'liAation  u^ual  in  nvcroeii!  of  compact  tissno,  and  tho  largo  mm 
of  the  necrosed  p'livv  sonielimes  prevent*  it  from  moving  under  tlio 
probe,  Tlio  ca«c,  tJicroforv,  simulatca  one  uf  carioti.  This  diftictdly 
was  experienced  in  the  ease  of  a  little  child  under  the  writer's  care 
in  whom  a  siinis  cxisttMl  leading  down  upon  tho  on  culcis.  The 
proha  passed  down  to  soft  bune,  not  in  the  leant  movable,  and 
enunbly  to  tho  touch.  On  tlio  Hoft  parte,  however,  bmng  turned 
bttck,  it  was  found  tliat  the  patterior  part  of  the  oiileaneum,  iin'olv- 
ing  at  least  lialf  tho  bono,  wa«  dead  and  quite  separaf4,il  from  dm 
anterior  part.  This  having  been  removed,  the  child  made  a  rapid 
recover}'.  I  liavc  soon  similar  caiics  in  childhood  rU|XtiitO(lly,  and 
more  es|>eciidly  about  tlie  tantiis.  However,  though  tlie  cancellous 
tiMuo  is  sometimes  alToctod  witli  necrosis,  it  shotdd  bo  ruinvmbcred 
tiiat  thiii  is  i;xet'|>tioTiid,  and  that  necrosis  is  an  affection  more 
peculiarly  of  the  compact  tissue,  and  especially  of  the  denaoft  i)on««. 
Thus  tlio  (lOtrous  bono  is  l're<iuvntly  necrosed,  and  has  been  known 
to  Qxfoliat«  ahnost  entire.  * 

TmUnvnt.  Hitherto  wo  lia^-O  been  considering  the  usual  method 
of  separation ;  .'md  a^  this  is  a  long  and  tt^^lious  prucws,  noidom 
completed  under  many  months  in  tiie  case  of  a  large  sequestnun, 
and  often  dating  by  years,  it  is  not  surprising  that  oifort*  should 

•  Path.  Soc.  Tram.  vol.  vii.  p.  sail.  A  similar  cimo  occuitM  lately  at  St. 
Oaorge's  Hospital  under  Mr.  Pr«scoU  Ucwctl's  care ;  Miueuin,  &L  (ivoTgo't 
UospiUl,  Hries  ii  W. 


€48 


DISEASES  OF  THE  BONES. 


InvQ  boon  coiutaTitly  made  to  antioipato  tli«  jioriod  of  euro  by  tu> 
ceterating  tbo  separation  of  the  diseaaed  bono.  Xbcse,  liowever, 
have  rwtiiltvd  ui  dii«3[>iii)intnii?nt.  Tito  pruciMn  nitt«l  bo  kil)  U>  find 
ils  tutural  coniplelion  in  the  spontaneous  separation  of  the  dead 
IwDO  froin  tlio  living ;  and  way  ntt^^inpt  to  otli-ct  this  by  nrl,  i.  c.  to 
detxcb  the  nocrosed  portion,  and  to  cat  it  away  from  ttio  living 
piirtit,  only  vxtvudit  tliu  aira  of  the  dU<.>aKO,  and  endangcrt  tlw  pro- 
servation  oftlie  limb.  S)<ecia1  considerations,  applicable  to  Bome 
mgiona  oftlio  bo<Iy,  siicli  as  the  &kall,  may  tmlood  iiidii<x!  n  Sur- 
geon to  operate  on  necrosed  bono  before  it  is  loose,  for  the  relief  of 
mattor  jicmt  up  below  it :  »uch  upcnitionn,  however,  nru  not  under- 
taken with  a  view  of  curing  tbo  diseased  bone,  but  of  restoring  the 
function  of  organs  secondarily  aflcclud. 

Ritt  wlu^ii  the  M>(fiieALruni  has  separated  and  liea  loose  and  in> 
vaginat^xl  in  new  Ijonc,  surgical  ititorfercnco  is  most  necessary. 
There  is  jterlmps  no  jmrt  of  Surgery  in  which  the  improvements 
etFectod  in  conipitrativcly  modem  times  have  done  so  much  to  pre- 
serve life  and  linib,  and  to  oh\'iate  pain,  as  in  the  treatment  of 
necroiii!'.  The  iiiviiginated  portion  of  bone  can  never  get  out  by 
any  natural  proct'sa:  tlic  very  completenes!)  and  tSfiaoey  of  the 
efforts  which  nature  makes  to  preserve  tbo  continuity  of  tlio  bone, 
and  to  restore  its  strength,  etl'ectimlly  inipri.scri  tlio  deud  portion. 
Small  pieces  or  granules  of  dead  bono  constantly  exfoliate  &om  cari- 
oimsnrfaees;  bill  whoii  the  ■vtxpioi'tnim  isofany  coiisideralilesize,  tlio 
cloacH)  arc  never  so  large  as  to  admit  of  the  escape  of  the  sequestrum 
through  Llioni,  nithongh  Hmnetimcs  they  are  very  nearly  largo  enough. 
Thus,  in  the  museum  of  St.  Bartbolomevr's  Hospital,  there  is  a 
curious  S|Hv;iniuii,*  in  which  n  »mall  piece  of  loose  bono,  just  too 
large  to  get  out  of  any  of  the  numerous  cloacxe  which  have  formed 
ai-ound  it,  is  found  rattling  about  in  its  cavity  a«  if  in  a  dice-box. 

Tho  requisite  ojKjration  consists  in  cutting  down  on  the  dead 
I)onc,  and  exposing  it  sutKciciitly  to  remove  it  If  Uio  necnmis  bo 
superiieial,  nothing  Is  required  beyond  turning  back  tiro  soft  parts, 
which  liavo  no  ooiinv.xion  with  the  deud  bono,  elv\'atiug  tho  latter, 
and  pulling  it  out  with  a  pair  of  forceps.  But,  for  the  removal  of 
an  iiivafiiiiati'd  sequestrum,  it  i*  neco**ary  to  open  llio  shcatli  by  en- 
larging one  of  the  cloacic  with  the  trephine,  or  cutting  forceps,  until 
it  is  largoonough  to  admit  oftlie  extraction  of  tho  piucc.  Si>motimc«t, 
wbeu  tho  scquesiruni  involves  a  large  portion  of  tho  shafl  of  the  bone, 
it  amy  be  found  inipoissihlc  to  get  the  piV-ee  away  until  a  [mir  of  CUltiug 


SubscricB  «■  no.  01. 


NECROSIS.  M9 

forot^pa  hm  bocn  uitro<lui\<d  tlu-Dugli  tliQ  enlfirgcd  aportnre,  snd  tbe 
doncl  bono  (liviitocl.  In  the  neorn^iH  wliii>li  t<o  oiU^u  uii;i<;k>t  «tiintp« 
attcr  uriiputAtiuii,  n  riiig-liko  piece  tnny  separate  from  tho  eni  of  tbe 
divided  bone.  Its  cxtmiHion  !»  then  n  muttor  of  coiiKidernhle  difB- 
Ciilty ;  but  Htill,  la  there  is  a  free  opening  on  to  tho  pstiemity  of  the 
dead  bono,  it  tahy  )h!  tu>compli.->)iot!  witli  voino  littlo  Ij-ouhlc  If  k 
Biniilar  nt'ciiicstrum  shonld  form  on  one  of  the  long  bones,  involving 
a  fcnilo-liko  jiorlion  of  it*  niirfaee,  it*  romnvHl  would  Ixi  ntill  mitro 
InniMi'Nomo,  ixxiuinng  free  indsioos  on  botli  aides  of  the  limb:  but 
I  am  not  aware  that  nunh  c».'*<w  have  iHicn  notiu<!d  in  practice.  A 
prejiiiniticn  in  the  mnseiun  of  St.  George's  tlospital  (tun-iee  ii.  75) 
shons  a  strip  vt'  nfCTi«ic<[  bntie  winding  »pinUj-,  for  a  oonsiderable 
diMtanM,  round  tho  shaft  of  tho  tmmenis. 

It  has  sometimoM  Ihi^ii  nnulu  n  (juestion  whether  the  setjDMtta  of 
tie«roeed  bone  can  bo  removed  by  a  gradual  prooeea  of  disorganisa- 
tion and  moloctdar  dvoay.  If  tliin  question  \x  pro]x>«cd  ti»  an  essay 
in  scicntiBo  pathology,  tljero  is  no  donbt  of  its  great  interest ;  bat 
■viewed  a-t  a  pnictioti  coiisidoratioii  in  Snrgi^ry,  liardly  any  value 
attaches  to  it  Experiments  on  animals  certainly  appear  to  show 
the  posaibilily  of  tho  romovsU  of  umiill  piooi^st  of  osciwxl  l>onc  ro- 
imjtlaittod  in  the  esolsion-wound;*  and  it  is  possible  thai,  in  tho 
human  wibjix't,  Bonucstra  of  bone  mny  bo  to  Komc  extent  eaten 
away  by  a  proeeas  of  absorption  like  tliat  which  sometimes  removes 
the  ivory  |i«>g!t  <irtvni  into  bcmca  for  tlio  eiirc  of  ununited  fraeture;t 
bat  even  allowing  all  upon  this  head  which  any  one  oould  reason- 
ably deduce  from  sudi  facts  as  these,  wc  should  still  be  jiixlitiMi  in 
Baying  tliat  the  process  b  so  slow,  so  uncertain,  and  so  partial,  that 
no  ocooaut  ought  to  be  taken  of  it  in  Sargory.^ 


*  fldo*.  m  Ora/t  uml  U'nUlmr't  Jvurnal,  Dd.  xxiv.  p.  6i7,  quoted  by 
WsgDOT,  op.  infra  cit.  p.  HO. 

t  8m  Tol.  i.  p.  W)li. 

J  It  maj-  reaxonably  be  doubtod,  also,  whether  the  nlisATption  «dd  to 
bave  occumd  in  some  of  the  oxperimenta  above  n.'r(>iTed  to  did  rt^My  talio 
place,  er  ifhetber  the  whole  tliln^  whb  not  a  tniatoke  «n  tlie  pnit  of  the 
ex]>erim«nl«».  OuUirer'a  exp«riiii<niUi  iMtd.-Ckir.  Tmiu.  vol.  axi.)  show 
tlut  pui'tiuns  of  luose  bone,  tlm»t  iuto  Ui«  UnuM  of  living  aaimala,  tnay 
rcjuBin  Bu  iiidelitiite  tiiao  without  uxperienuingc  aajr  ab«i>r|itiou.  as  proved 
bj  curcful  weit:liin);  at  tin.'  bc^(;iuDing  aiid  eiid  oflbc  expeiimeiit.  Agmla, 
eases  aueh  ts  tlwt  quoted  »n  )).  flt4.  pruve  that  a  portion  «f  bone,  or  no 
cxtrnordinnix  nxe,  laay  rcoioiii  n<.i.*ruavd  during  a  fir^t  part  ef  a  lifetime, 
and  auiTur  no  perceptible  diminntiun  iu  sice,  even  wbuu  it«  niecJianiual 
connexion  with  the  i-c).t  nf  Uie  body  is  nut  oiilirclj  ilcstroj'od.  llul  auKly 
wlirn  looFe  nail  MpAiutcd  fTom  tile  bud}'  it  mual  bu  ntill  less  under  the 
inllu«nca  of  the  vital  action*. 


650 


DISEASES  OF  THE  BONES. 


It  ia  therefore  nccossarr,  in  every  caso  in  wliioh  a  soriuosbftEBH 
forms,  tliiil  a  Htn-pojil  (>|H-i-u1.iiiii  .ilutuld  lio  uiidertaken  for  its  ro'l 
raoi-al.  The  word  teipiegtrum  U  Iiore  used  in  its  Btrict  sense,  tol 
exprciis  A  jiortioti  ofdond  hmio  coittHUied  in  n  ciiiio  of  now  bone.  1 
An  enfolialim  portion  of  bono  may  sepai'ato  and  bo  tlirowii  ofl"  by  j 
tlie  naturnl  i>n>cw«(W,  Uiuugh  it  is  tuimlly  nccOMMiry  to  fuciilitate  iuJ 
removal  when  loofte  by  incisions.  1 

A  fjui^tioii  iif  sotiiotinics  raisetl,  whether  it  in  pnident  to  oijwnte 
as  soon  a&  the  operation  is  possible,  i.  a  as  soon  as  tho  bono  is  loose, 
or  whotlicT  a  tn^rtain  time  should  not  rntlier  lie  K'^on,  in  ordor  that  j 
the  newly-fomied  bone  may  become  consolidated,  and  tlio  limb  1 
Htiniciviitly  stronfi  to  pcrfonn  it»  funetiim*.     Tlic  ijiiestion,  Iiow- 
ever,  is  rather  faneiful  than  practical.      No  harm  appears  ever  to 
ro*uIt  froui  takiii;^  .iway  a  loowj  pieco  of  bonv,  but  much  niimhicf 
often  follows  on  its  being  allowed  to  remain.     If,  in  rare  cases,  tbe 
bono  is  left  too  weak  to  bear  tlio  weight  of  tho  IxKly  or  tho  motions  i 
of  tlie  limb,  it  in  pi-ohable  tliiit  this  is  n  eonscqiienco,  either  of  sach 
extensive  destruction  of  i)crioBtouin  aj»  finally  to  procludu  roproduo 
tion,  or  of  soino  constitntionid  fault,  or  other  prodifii»osing  causa   The  j 
inHaniination  excited  by  tho   preseneo  of  tho   soc|ue«tnim   in   tho  1 
noighbonring  bone  has  probably  not  |Mi.'L'«>d   the  stage  of  softon*  ' 
ing;  while,  fi-om  the  same  low  rato  of  tho  morbid  processes,  tha 
bony  depu.iit  tiiriii^hed  by  the  [ii^riostonm  ha.H  iicttn  small  in  <juantity 
and  loiv  in  organisation.      In  such  a  ease  as  tliis  it  would  appear 
that  the  best  chance  for  restoring  to  the  bono  its  proiKT  density  ■ 
would  be  aflbrdod  by  tho  operation  wluch  would  relievo  it  of  thai 
cause  of  the  iiiflamniation  whereby  iU  cohewve  jM>wer  iit  being  do-l 
stroyed.     It  would,  therefore,  be  far  more  rational  to  remove  ihe^ 
dead  bone,  and  put  the  Hiiib  at  rest,  thjui  to  leave  tho  ooorcc  of  irri- 
tatjon,  and  expect  a  cessation  of  the  effect  from  perpetuation  of  the 
cause.     It  iM  not  always  easy  to  determine  the  nuestitm,  whether 
the  bone  is  loose  or  not,  since  tho  growth  of  tho  periosteal  sheath, 
or  oven  the  wliaiHi  of  the  loose  jiortion,  and  tlie  arrangeiiieiit  of  iho 
parts  around  it,  may  prevent  it  fi-om  moving  under  the  probe.     Of 
this  fact  an  instanoo  has  been  given  above  (p.  647),  and  the  reader 
may  consult  a  ohnical  lecture  recently  published  by  Mr.  II.  Smith, 
Medwal  Timet  and  Gmette,  March  22d,  1862.      In  casw,  therefore, 
where  tha  disease  hoA  lasted  so  long  that  the  separation  may  be ! 
reasonably  expected  to  be  complete,  it  is  right  to  cn<ieavour  to  TO-  i 
move  the  bone,  even  although  the  pi-obe  haa  not  given  deciaivs 
vviduncc  tliat  the  oporation  can  be  carried  out. 

It  ia  necessary  hei%  to  say  sometliing  respecting  tho  agents,  and 


KECROSIS. 


651 


(be  nutnner,  of  rejieneration  of  bono  after  loss  of  BuTjetanee  from 
necrosis.  Ju  doiug  tliis,  iiowcvcr,  it  would  be  im]>ijLViil)!tr,  in  an 
eesAy  of  tliis  sort,  to  go  into  the  question  with  any  a]>proa<^  to 
ComplotcDCiw ;  Ittit  it  is  Iiop(xl  tliut  enuu^h  will  ho  foiiiul  in  tlio 
following  paragraphs  to  illustrate  tlio  jwints  necessary  for  practice. 
Tho  studtMit  who  wi«liOfl  to  Ivam  morv  shout  thu  mattvr  if  referred 
to  tli«»  ^vorkfl  of  Troja,  Weidmann,  Flourons,  Sjino,  and  Wagner. 

The  inott  iinjmrtant  agent  in  roproilucing  hone  lost  hy  nocTOMS 
is,  witliout  donht,  the  perioatfium  ;  and  tliis  membrane  is  soffioient 
of  itnolf  to  replace  all  tlio  ordinary  exfoliations  and  pitrtial  nccrowM 
whicli  follow  injuries,  ifec.  The  ostooj^iiic  pntporlaos  of  the  pei-i- 
0)tt«nm,  wliun  in  contact  with  tho  hone,  have  long  hi-vii  known,  in 
faot  njnat  have  been  apparent  when  the  tunotiou  of  tho  membrane 
was  fu«t  studiotl ;  and  that  [Hiriostoiim,  when  soparatvd  fruin  tho 
Hnrfacfl  of  the  hone,  will  still  generate  new  bone,  is  no  very  novel 
discovery,  sincv  John  Boll  seoms  to  hare  been  perfectly  acquainted 
with  tho  fai^t,  an<I  dtt^crilies  die  fonniition  of  a  bony  evnt  hy  secre- 
tion from  tho  dotaohed  porioeteum,  around  a  collection  of  blood 
which  hail  disrtoeted  otf  that  nienihrane  from  tlie  bone;*  and  tho 
experiments  of  Symo  and  Stanley  are  well  knon-n.  Lately  the 
a')teogeni«  poweni  of  [>ori<>stcuiii  Imvo  hvcn  placed  in  ■  very  Mrik- 
ing  light  by  tho  esperimenta  of  M.  Oilier  of  Lyona.t  He  has  shown 
that,  in  rabbits,  ]H)rtionit  of  pori<>Kt4;uni  may  bo  «ntiroly  di-tiu-lied 
from  tlio  bone,  and  pusliotl  into  the  cellular  tissue  of  tho  limb,  or 
even  grafU^l  int*>  rimmt*!  jiartu  of  tho  body,  or  into  tho  htxly  of 
snother  rabbit,  and  that  bone  would  he  generated  from  tho  frag- 
ment ol'  [X!rii)Mviini  in  tliJH  novel  position.  Ho  ha«  v\vn  nii(M?eeded 
in  pro<lucing  bone  hy  sucli  grafting  of  portious  of  periosteum  kept 
for  iHoro  tlian  lui  hour  out  <if  the  lK>dy. 

It  is  iar  from  certain,  nay,  it  is  most  impi-obablo,  that  any  snch 
nwiilu  oould  bo  produetxl  in  man,  since  tho  oonditiouH  of  all  re- 
productions, and  espoeially  of  reproduction  of  bono,  are  known  to 
difler  »o  niucb  in  nmn  luid  animals;  hut,  oven  if  Uic  vitidity  and 
osteog^iic  power  of  tho  periosteum  be  less  in  tlie  human  suhjeot 
than  in  tbu  lower  animals,  still  It  socnu  reAsonabte  to  infor,  from 


*  7^  Prindplti  of  Surgery,  by  John  Bell ;  a  new  citilion.  bjr  ClutriM 
Bell.  itiHa,  vol.  iv.  p.  100,  Tbe  puiholog)-  of  ih«  e&ee,  «s  related  bjr  the 
autlwir.  U  Builii'U'ritljr  obxcure ;  but  the  caw  mtj  be  used  to  show  Umt 
Bell  kDL'w  iliut  boti(>  (^uutd  be  furuiod  fh>m  the  detached  perioiileiim. 

t  Briluh  Mfdiml  Journal,  1800,  pp.  ;lt)f ,  438.  I  may  uirnttoii  tlut  some 
of  M.  OUicr'a  uspi^riuii^titii  have  bir«:i  repeated  aud  wrifiod  b;  uuuieroud 
M^aiawnten,  amongst  otheia  bjr  iuj'mLL 


«&a 


DISEASES  OF  THE  BONES. 


obscn-cd  phcnonionn,  that  tliut  powor  is  of  tlio  wimfr  nntiim;  so  thai 
tiicse  xlrikiiii;  ex|M>rimeiib»  may  serve  to  fis  moro  firmh'  on  tho 
atlentjon  of  Snrgoons  the  iin])ortaiii'c  of  prti««rvhig  ihe  )>cri(>:<.t<-um 
in  cases  whore  the  rejiroduetion  of  lost  bonw  is  in  qnestion.  Tlib 
property  of  porioHtctuu  may  also  Iiavc  some  iipjiltcatioii  in  P!«.*tte 
Surgery;  but  the  only  mich  n|>plirAtioii  with  which  I  am  aoqnainted 
Iiithorto  a  tho  proposal  by  Mr.  Jonlaii  for  the  cure  of  iinunititd 
fnwture  by  meantt  of  n  pln^ic  operation  beneatli  tlie  perii3»lcum 
(noticed  in  vol,  i.  p.  804),  the  suocess  of  tvhich  api)(.>ar!i  doubtful. 
Ill  nil  ca-Hi^i*,  thoii,  where  lotu  of  xtibMnnce  in  boni>  lioa  token  pl&ce, 
or  wlicjre  tho  bono  eeoins  deprived  of  life,  it  in  of  tin  gjviMt 
importjtiioo  tlmt  the  [tcrioKti^um  Hhould  be  preserved ;  so  that,  in 
excising  carious  or  necrosed  bones,  great  care  should  bo  taken  to 
miikc  t)io  iiK>i>ion«  w<.-ll  down  bo  the  bone  wliioli  is  to  be  riMnoved, 
and  to  keep  the  knife  close  to  it,  that  tie  pmoBt«ma  may,  if 
possible,  bi!  left  behind. 

It  lia»  fn?<juently  been  made  a  question,  on  what  this  power  of 
iwproduction  dopcuda,  whether  on  tho  action  of  the  fibn>u»  mem* 
brane  itself,  or  on  tlio  det-K-Iunent,  together  with  its  lower  strata,  of 
small  particloi!  fi-om  the  surfaco  of  the  bone,  whioli  serve  n^  nucld, 
around  wliich  new  bono  grows.  It  is  not  easy  to  prove  that  such 
nuclei  lire  not  <hitacliod  in  m'ery  case ;  but  there  is  no  evidence  that 
sneh  is  the  fact.  Bone  has  often  been  known  to  be  prodncod  from 
portions  of  iwrioMtciun  which  Iiad  licon  previously  curefiilly  es- 
oniined,  and  no  audi  particles  found;  while  in  other  cases  it  has 
ap{>carod  i>robable  that  tliu  |xTi(wtcum  hjul  curried  fragments  of 
bone  away  with  it.  M.  Otlior  consi<lers  tliat  a  "  subperiosteal  blas- 
tema" exists  natiu^Iy  between  tliu  periostuum  and  bono,  and  tJnt 
this  is  llie  source  of  the  dejioftit. 

Tho  periosteum,  however,  although  the  most  important,  is  not 
tho  sole  agent  in  tlie  reproihiction  nf  bone;  RO  that  it  may  be  con- 
fidently cxjjeeted  that  bone  will  bo  rej>roduced  in  healihy  »ubjoct«, 
oven  thoujjli  tho  ijeritiauniui  l)e  extensively  destroyed ;  but  tl>o  re- 
production will  not  be  HO  complete  as  if  that  membnuio  bad  been 
left.  Such  a  proooaa  of  repnxhietion  may  often  Iw  wuttrhod  in 
cases  whero  tho  soft;  parts  have  sloughed  afler  sealp-woiuids,  and 
have  left  the  cranium  expoociL*  Tlie  accident  will  often  be  fol- 
lowed by  exibliation  fi-om  tho  surjaooofthe  bone;  granulations  then 
shoot  up  from  tho  bony  surliioo  m  ex^Kisod,  and  Uiftte  are  joined  by 


•  See  Wilder  on  liqxtir  cffter  RrfeHioit  of  llunr*  (New  SjJ.Soc.).  Appen- 
dix, p.  241,  for  a  coso  in  which  this  foiiu  of  rt-iiroductiou  ia  vrelJ  deMril>ad. 


KECROSia  653 

I  wUcb  advance  from  the  soft  paru  in  the  ncigJibonrboDd :  a 
fibrous  cicatrix  h  forniod,  wliii^h  cua  hv  felt  gradually  ]i]irdt.'uiiig 
and  OHsi^ng.  If  an  opportanity  ocoora  for  examining  it  af^r  the 
Injiw  of^imio  (Viiiitidcnililc  tim«  (*ay  half  a  j-cnr),  it  will  W  foond 
tltat  the  fibrcms  tissue  of  tlic  cicatrix  is  o&sifyiiig  at  iw  dee^iest  part, 
and  :(cntt4n-o<l  f^iiuiidoii  of  bono  wiU  probably  bo  mot  witlt  st  various 
parts  of  the  cicatrix. 

This  pnici;^  may  go  on  ovon  when  tbo  bono  and  perioetemn 
hare  been  removed  by  operation,  as  in  the  wounds  of  resection," 
but  is  much  more  active  whon  previous  inflammation  has  bc«n 
excited  in  the  medidlary  tIf>auo  and  eiurrounding  soft  part*,  ilurJng 
th«  action  noccsMury  in  ordur  to  eject  a  piece  of  nocrost-d  bono. 
In  fact,  speaking  generally,  the  process  of  reproduction  after  ne- 
crosi:*  in  beyond  comparison  more  active  than  after  injury  or  opiTa- 
tion.  Thus,  whon  necrosis  has  preceded  the  operation,  whole  bones 
of  the  fbrc-orm  have  boon  removed,  and  yot  a  useful  limb  has  bouo 
prescri'ed.  In  a  cose  wliiiiti  1  hiul  lately  an  opportunity  of  seeing, 
in  which  Mr.  Savory  rcmovotl  tho  entire  shaft  of  tliu  radius  on 
account  of  necrosis,  leaving  tiie  nrliculnr  ends,f  the  bono  had  grown 
from  eaeli  of  tliesc  ends  to  so  j^reat  an  extent,  that  in  eight  montlis 
uA«r  tlio  operation  there  rentninod  an  inlcrval  of  only  an  inch  and 
a  half,  and  tliis  appcare<l  to  be  gradually,  though  slowly,  contract- 
ing. Tliis  and  several  i^imilur  caKCS  will  bo  found  ijuot^xl  in  ^Vng> 
ner's  treatise  above  referred  to,  and  may  servo  as  an  onceuragoment 
for  boldncM  in  our  atleinpU  to  nax'c  limbs  after  extcnaivc  necrosis. 

Tile  exfoliation  of  diseased  portions  of  bono,  sudi,  for  example, 
as  tnkoA  place  so  freciuenlly  ui  the  course  of  extensive  strumous 
disease,  whon  a  portion  of  the  ulcoratod  sorface  is  cut  off  from  the 
rett,  and  tlierefore  jierishes,  is  not  generally  accompanied  by  any  of 
that  reparative  eSbrt  which  forms  part  of  the  process  in  a  more 
healthy  condition.  The  mei'c  pra'tence  of  necrosis  in  such  affections 
is  of  comparatively  little  importance;  possibly  tlio  removal  of  tlie 
dfad  p»rt  inay  Ix!  advisable  (but  only  if  it  can  be  done  without 
maeh  violence),  but  the  operation  cannot  be  cjtpoctod  to  cure  tlio 
disoft.te,  since  the  necrosis  is  not  ilit  ca<i.w,  but  its  elfeot.  Nerer- 
tbeleM  consirierable  improvement  may,  in  appropriate  ca«»,  bo 
expected  to  follow  on  the  renuival  of  tlio  dead  {mrtion,  which  must 
always  act  as  on  irritant;  and  the  oxposuro  of  tJie  carious  snrfac*  is 
also  very  frcNiuontly  t)ie  st^irting-point  of  a  more  healthy  actioD. 
Henco,  when  bone  is  felt  exposed  and  dead,  it  is  nsaally  advisable 

•  S««  n'uguer,  op.  dt.  p.  latS.  f  IbiiJ.  p.  £13. 


694 


DISEASES  OF  THE  BONEa 


(o  Giidf-avour  io  remove  it,  even  altlioogh  the  aarfsoe  aroDnd 
kn<>wn  to  be  carious. 

The  above  d(>i)ca-i|)Uoii  eppliea  to  necro.tiH  in  its  more  muni  fDrir 
Bat  bosidus  tliis  coitituon  chronic  form  of  tho  disease,  an  affectioa] 
which  deiMirven  die  tinine  of  anitf  nrcniinM  \9  »nme^\mv»,  tluiitgh  not  J 
TOrj-  ofton,  mot  wiUl     Tho  destruction  of  all  tlie  soft  parts  Bur-| 
rounditig  a  i>innll  bone,  tts>  a  phalanx  in  a<^tito  neglc<rt<Hl  whitlow, 
urill  of  course  lead  to  tho  csioliation  of  tho  whole  of  it,  and  to  this 
nffection  tlie  name  of  acute  neoroKi*  Ih  iminotiuieft  j^iveii.     Thcro 
nothing,  howox-or,  in  the  pathology  or  treatment  of  such  a  diseaM  ' 
to  oall  H|M-cial  uM«i)tion  lo  the  bone.     Tiiu  rapid  and  len.'^ivu  inflnin- 
mation  threatens  other  parts  of  equal  imiwrtance, — tho  joint,  the] 
tendons,  nay  in  wim«  oaj^cs  oven  the  skin, — with  de«>truo(iou;  and 
tho  &ce  evacuation  of  tho  productit  of  tho  inflanunation  is  the  only 
mciu-uru  iyom  whicli  any  gtwid  can  rationally  l»e  cxjiectcd.     But! 
there  is  a  less-known  class  of  cases  in  which  larger  bones  are  in« ' 
Tolvcd  in  ra|)id  dcttnictioii,  without  known  cniLsi-,  or  from  causes  | 
apparently  quite  inadequate ;  and  such  cases  involve  not  merely  looal 
niisi'Iiiff,  but  very  grave  danger  to  lilt'.     Many  such  oi.«i'»  of  rapid  ' 
necrosis  are  the  iVMuIt  of  that  difliise  inflaninjation  of  the  ]H-*ri-  I 
OHtenin  which  lins  bewi  describoil  above;  but  in  otlicrs  which  I| 
havo  had  an  opportunity  of  seeing,  1  have  failed  to  detect  auoh  %  i 
cau.-u>  for  the  ilenth  nf  tlip  bone,  or  indeed  any  caiwo  to  which  so  i 
extensive  and  so  universal  an  action  could  reasonably  bo  asorilKsl. 
Such  a  case  was  tlio  following :   a  st^iblvnian  was  admitted  into 
St  George's  Hospital  on   account  of  disease  in  one  foot.     Tlw 
liistory  was  nfeciirtf,  but  it  scciiicd  certain  that  little  more  than 
tluHie  weeks  before  bis  death  the  foot  n-as  comparalivcly  well,  ai 
it  was  to  an  injury  ^ujiposcd  to  have  been  rMjcivcd  two  days  b&- 1 
fore  his  admission,  in   running  violently  down   the  stable-yard, 
that  the  <lt«casc  wa«  attributed.     Tlicrc  was  anlcnia,  swelling,  and 
pain  over  tlie  dornuni  of  tlie  foot ;  and  thiA  condition  waa  attri* 
butod  to  ditfti^o  c^-lhilar  inflammation,  and  treated  by  superficial 
incisions,  which  did  not  penetrate  the  periosteum.     The  man  diod, 
with  fymptoms  of  pyu'mia,  but  no  sueondary  abscoss,  twenty  days 
afler  his  admission.     On  examining  the  foot,  all  the  lanud  bones 
were  foiuid  looso,  and  grating  on  each  other  like  stones  in  a  bag ; 
the  oartilagea  between  them  had  almost  entirely  disap])eared.     On 
section,  tlio  bones  were  of  a  dark-gray  hue,  and  some  slight  traee 
of  pus  w.ia  seen  here  and  there  in  tlieir  interior,   but  no  sueh 
dintinet  indication  of  inflammation  of  tho  lining  mcmbranu  of  Uie 
oancelli  ad  to  deserve  the  iiautc  of  u9.tooniyelitiit ;  nor  was  the  perw 


I 

i 


ft 


SCROFCLA  IN  BONE. 


655 


6sf«um  thIcTioneil,  vaacrularj  or  separated  from  tlie  snrfnco  of  tliu 
bono  hy  citlur  lyinpli  or  pas  in  any  appiceiablo  qiiaiiti^-.  Tho 
surfaaos  of'tiio  bones  exposed  by  tho  removal  of  the  artlcitlitr  ciirti- 
lages  were  iilccrnlcd,  but  not  dooply.  Tho  bones  wore  of  their 
natural  conHitit<-iioe. 

]a  such  an  aSection  as  this  amcnablo  to  any  troatiDeut?    This 

iH  doubtful,  if  it  bo  coiiccdinl  lluit  vnscn  of  ii'^utu  ikktomix  rciUly 
it  in  wliifii  tho  aflcction  is  different  from  diffuse  periostitie.  In 
tJie  latter  ati(*iion  Uinoiy  incisions  may  Buocofti,  us  iius  Iwoti  already 
»aid,  in  checking  the  (^osion  and  rcHtoring  tlio  nutrition  of  die 
bone;   but  if  the  whole  bony  tissue    be   iiivolvod  ftt  etive,   wliut 

icy  <»n  bo  reasonably  expected  to  restore  it  to  health?  It  is 
clear  that  the  inniii  i]tie»tioii  in  such  u  case  i.i,  whether  the  patient's 
powers  will  vndiiro  tho  strain  of  tho  disoa^o,  so  that  the  bono  may 
be  cast  off,  and  he  iimy  Imve  tho  chiuioc  of  ita  reproduction,  or 
whether  amputation  niU  givo  him  a  bettor  prospect  of  liib.  But 
the  profi^iioHJ-i  of  an  ajnputntion  undertaken  under  such  circum- 
stances would  bo  in  tho  highest  degree  unfavourable,  since  tlte 
condition  of  iiystoni  in  wliieii  sudi  grave  result:*  can  follow  frnni 
such  trivial  injuries,  leaves  littJo  prospect  of  bearuig  up  against 
BO  seriouH  im  hijury  as  the  removal  of  a  limb;  wul  tlie  tendency 
to  pysemia  is  so  strong,  that  it  is  impossible  to  say  that  that  con- 
dition of  tho  svstcni  may  not  be  actnally  present,  tliough  latent, 
when  the  operation  is  done.  It  will,  therefore,  in  most  cases,  be 
judged  butter  to  support  the  [mlJcnt's  strength  by  u  liberal  allow- 
anoe  of  tonics  and  opiates  until  tho  graver  dangers  have  passed 
away ;  luid  then,  if  tb«  uscfulncw  of  tlie  limb  is  liO[»<jle-ssly  de- 
stroyed, to  remove  it  when  the  patient  has  rallied  from  tho  typhoid 
condition  tn  which  the  disease  coitimeiieus.  Incisions  may  not  hxve 
the  power  of  averting  tlie  deatli  of  tlio  bono,  but  they  ought  to  be 
made  to  an  extent  vuHidcnt  to  lilx-rut«  all  tension,  antl  that  tor  two 
principal  reasons — partly  in  order  to  avoid  sloughing  of  the  pcri- 
BJid  consequent  destruction  of  tlie  nidus  in  which  tJke  new 
rimieu  to  be  formed;  partly  to  provide  a  ready  way  for  the  pus, 
which  must  form,  to  escape,  and  for  tliu  examination  of  tlio  bone 

its  eventual  extraction. 


CoSSTITirnONAL  AlTECnOSB. 

Scrofula  in  hone.  There  ara  two  forma  in  which  scrofiiloas 
affections  of  bone  are  met  with ;  va,  cither  a  dcfwsit  of  tubercle, 
or  a  low  inflammation  of  the  o»scou4  »ubstanc«;  and  ttiero  is  good 


656 


DISEASES  OF  THE  BONES. 


I 


rciifton  for  considfTing  the  former  as  a  oonsoqnenoe,  or  ©ffoot, 
the  Utter.     [jcI  tii*,  t!i«n,  ^r^l  cDMsiilor  tha  i>oculiiir  or  distjnctivo 
diaraoters  of  scrofulous  inflammation  of  bone. 

A  scrofHiou*  Umo,  whrn  exiiniiiivcl  in  tlic  early  irtnge  of  tha 
Ai»iiiv,  is  soft,  liglit,  and  oily;  sometimes  more  highly  charged  with 
blood  than  niiliinil,  Mid  oecMionally  (though  only  ntruly)  prcMnt- 
ing  a  depoMt  of  tnborele  in  its  interior.  Bones  in  this  eonditjon 
are  co»i>tantly  met  witli  ulU-r  thv  removal  of  Kerofuloiu  joints :  the 
«i]l)&tanee  of  tho  bone  is  easily  cut  witli  a  knife,  and  the  canoelli 
are  large,  and  charged  tvilli  a  roi  jully-liku  mwt  of  d(;bri».  Tha  ^^ 
inflammation  readily  passes  into  ulceration,  or  cariea,  and  the  bona  ^M 
then  o\hiliits  on  its  sturfaoo  a  number  of  niiimte  pit«,  or  depres- 
*,  from  each  of  which  the  ulceration  extends,  so  as  to  oom- 


ikKma, 


municato  with  lliosc  artiii:i(l,  until  lui  oxtwiinive  worm-eateii  Miirfao» 
is  exposed,  soft  and  rotten  on  tta  exterior,  bleeding  readily,  and 
giving  exit  to  a  fouUxmelling  ichorous  pus,  in  wliich  piocm  of 
dceomjMsed  bone  can  be  felt,  as  gritty  partioles  nnder  the  fingers, 
Tiio  perionttnim  becomes  detached  and  thickened,  an<l  is  graduaUy 
converted  in  a  gelatinous  ma.ia  of  granulatioiia. 

The  minute  eluingcM  tn  the  ultimate  tissue  hnvo  bocu  nbly  d^ 
scribed  by  Dr.  Blaek,  in  a  series  of  reseanihes  to  wliieh  my  own 
obsor^ittionM  lead  me  U>  a«80iit.  The  cancolli  arc  dilated,  and  they, 
ns  well  as  the  lacume  and  canalieuli,  are  filled  with  exudation. 
Occa»ioniil!y,  iiiiniile  projw-tiww  of  bono  from  the  walls  of  tbc  ean- 
celli  indicate  an  attempt  at  the  t'ejirndiKition  of  Lnine,  and  tliat  heal- 
ing  by  »elcro»i9  wliicli  has  been  already  described  as  one  of  ttie 
UHual  events  of  hcaltliy  inflammation.  Tlio  li^iuling  fi-ature-t,  then, 
of  tbo  piithoiogioid  anatuiu}-  of  strumous  inflammation  are  the  same 
HA  those  of  ostitis  in  general ;  and  the  only  diittJnctivo  anatomical 
peculiar!^  connisls  in  tlio  iialuro  of  the  exudation,  which  chokes  up 
the  canals  of  the  hone.  Dr.  HlacJt  has  given  several  unalyinvi,  tend- 
ing  to  establish  these  four  conclusions :  tliat  tuberculosis  gives  rise 
(1)  to  a  con.iidcrable  inori^JiHO  of  fut  in  the  diw>a»od  Iwnc;  (3)  to 
a  largo  diminution  of  the  salts  of  lime ;  (3)  to  a  diminution  of 
tho  organic  matrix ;  (4)  to  un  increase  in  the  soluble  saltA,  Fi 
the  details  of  the  analyses,  the  re,-ider  must  \>e  referred  to  the  ori 
ginul  treatise,*  Tliey  serve  t»>  illu^tnilu  tho  fact,  tliat  stromoitt 
is  distinguished  from  common  uiflammation  by  the  Boftnosii,  light- 
netis,  and  oiliness  of  the  afleettnl  bone;  to  whIeJi  may  be  added, 
Uie  greater  extent  of  ilifftisioii  of  the  morbid  changoa. 


*  On  (A*  PatluiUigy  of  Tuhereuloiu  Some,  £diub.  IWB,  p.  8^. 


SCROFULOUS  AFFECTIONS. 


657 


I 


I 
I 


Tho  HtiporfictHl  cnrics,  during  tho  men  prOMiico  ofn^ich,  tho 
bone,  if  the  aRcction  be  not  veiy  extensive,  is  poftsibly  «lill  in  a 
curable  state,  epreails  gmtluslly  inwiinis,  euhI  thcii  tlio  con<Iitioii  of 
the  bone  passes  beyond  tho  poAsibitity  of  re)iair.  liargn  abnctioeH 
furm,  and  tho  wliolu  cjuicvIIoum  oxtroniity,  ov  iho  whole  bone  if  it 
be  <nio  of  iho  pubwiil  bones  of  the  tarsus  or  onrpus,  !i«  uimvertwl  into 
a  cavity  boiuidt-d  by  a  tliiii  sticU  of  osseous  matter,  and  containing 
buny  Mdt.«tani!o,  eitjicr  in  mere  <I^bnH,  or  so  soil  that  it  will  c-rnniblo 
away  in  maceration.  TIic«e  ab«c«8so«  aro  seldom  acconipitniM  by 
Lliat  thickoning  oftJieir  walls  from  periosteal  <!e|>oi4ii  nliidi  takes 
place  in  simple  ostitis ;  still,  at  some  distance  from  the  seat  of  pro- 
fuM)  ttupjjui'ntioii,  fretth  dopoiiit  is  sometimes  fonnd  lhi<-kcninf;  tho 
bone,  or  producing  ankylosis  in  joints  wliicli  enjoy  little  mol-ion. 
p<irtioiiJ>  of  largwr  or  smaller  size  are  often  found,  Imt  no 
soqueetra"  ni  the  proper  sonfle  of  tluit  term,  as  slgnifynig  necrosed 
purtioiui  in TH<;i tinted  by  new  bone. 

Such  are  the  anatomical  characters  of  scrofulous  inflammation 
of  bone.  Tlio  other  eominon  di-velopiiient  of  tJiiit  diatbesis  in  tlio 
osseous  system  eonsista  in  the  deposit  of  tubercle,  either  cirpum- 
scn'bod  or  ditlusod.  CircumMTibetl  tubercle  (mucb  tho  rarer  form) 
aeema  most  common  in  the  skull,  deposited  on  the  outi^ide  of  tlio 
bone  beneath  the  periosteun)  (tlic  stninious  node);  and  nest  to  tliis 
ita  fiii'ourite  locality  is  in  the  canoeUi  of  tlia  joint-end  of  some  bone, 
fMierally  tho  tibia.  No  inconvvnteiico  sooms  to  ba  produced  by 
moh  tiilwri;lutill  it  luiftens;  and  tben,  if  nituatcd  in  tlio  articuUrend 
of  a  bone,  it  usually  makes  a  passa^  into  tlui  neighbouring  joint 
an<t  'leHtroyit  it;  if  on  tlio  skull,  the  soAening  of  Hiioh  a  titlx-i-ele 
jbrm«  a  oacheetic  abscess  cbOicult  to  heal,  bordered  by  indurated 
eelhilor  tissue,  with  cold,  bluish  cdge-t,  and  loading  to  eKjHiHod  un<I 
loag^ened  bone,  wbieb,  however,  lias  not  tlie  pcLtdiar  feeling  of 
DftcnMiie,  and  is  not  at  nr»t  dead,  allliougli  it  i»  liable  to  become  so. 
The  deposit  of  diftused  tubercle  is  more  common  in  the  shafta  of 
the  long  bomes.  It  61is  up  tho  oancelH,  apjiearing  aK  a  nodulated, 
at  gnuinUr,  yellowish  mass  of  soft  consistenee,  and  extends  fre- 
qaently  along  t1i«  whole  leitgth  of  tho  kIihIU  Aly  own  improwion 
is.  tlmt  this  diffusal  tubercle  less  frequently  and  leas  ra)jid!y  softena 
than  tl>o  eircuniscribed ;  but  exact  infuniuitiun  on  tliis  point  is  want- 
ing. It  ahotild  be  remembei'ed  that  when  tlie  shatt  is  attacked  by 
tbis  or  any  other  form  of  diseaite,  the  extreuiitios  tisnally  cseape, 
nnd  viee  vorsit, — a  matter  of  great  importance  in  the  troaUneut  uf 
diseases  of  tile  jointd. 

It  liafl  occurred  to  me,  though  hitherto  only  on  two  occasions, 

VOL.  lu.  u  u 


«58 


DISEASES  OF  THE  BONE& 


to  meet  with  a  peculiar  fonn  of  uloeraUon,  whioh  was  in  one 
certjiinly,*  and  in  tlio   other   probaltly,   cr>nuect«d   wiUi  scrofula.! 
NamcTous  ]>it»  wcro  fouiul  on  the   articular  atirfnoc,  var^■i^g  in 
(leptli,  but  confined  to  tho  epiphysis,  with  sharp  edg<Bs,  and  curdy  ^ 
purulent   cx>nt«;nts.     Tlioir   ojionin^   into   the  cavity  of  Uio  joint 
wore  doanlj  punched  out  of  tho  cardiage,  and  all  the  cartihige 
around  was  quit's  htialthy.     A  few  Mniall  gTHUulcs  of  bono  woro 
mot  witli  among  the  ooRtonts  of  the  cavities.     In  one  of  the  cases, 
when  the  bones  wcro  vxaniinvd,  thoro  werv  found  eevornl  ^lots 
»r  vaiiciilnr  and  softened  tissue  beneath  tho  sur&ee  of  the  bones, 
ovidcntty  the  ooininencvinviit  of  similar  pit*.     There  was  no  trace  j 
of  tuborolc.     The  thigh  wa§  amputated,  and  the  patient  reeovwred 
for   a   time,   but   soon   <lio<l  of  phthiiti».     Li  the  other  ease,  tlis| 
patient,  a  hoy  tnider  tlte  care  of  Mr.  Thomas  Rraith,  rocovrml  after 
excision  oftlio  knoe,  and  reinninM  in  good  hcalUi.     I  believe  tbia 
jiittiug  or  sj)ott£'(l  uloerntion  of  the  articular  etnh  of  bones  to  be 
one  of  the  forms  of  scrofulous  disease,  and  to  be  indislingiiiahable 
from  it.s  otJier  forms  before  diRseetion.     It  pns«fnt»  a  very  iavonr-jj 
able  condition  for  resection,  from  tho  strict  limitation  of  the  disease  < 
to  a  vtTy  sliglit  di>|itti  below  the  surlWe. 

Syinproins.     Of  tho  sip'mptoins  of  scrofula  in  bone  hltle  nocd 
be  suid  licro.     The  general  aymptom.t  of  the  diathesis,   added  to  I 
an  indolent  swelling  of  soma  bone,  lead  to  a  diagnoniii  not  to  bo  I 
mistaken.     The  swelling  is  <x>mpoM><l  partly  of  tho  engorged  soft ' 
tiaauea,  and  partly  occasioned  by  real  enlargement  of  tho  Ikhiix    Tha , 
colour  is  usually  white  and  pasty,t  and  tho  swelling  indolent;  but  I 
sometimes,  when  tho  inJlamniation  is  higher  than  mtninon,  nnd 
suppuration  iramini-ut,  ru<ln<^sM  and  pain  may  be  present.     ^Iiea 
Huppumtion  has  been  effected,  the  j>ain  gt-nerolly  subsiile*,  and  tbsi 
finictions  of  the  jwirt  arc  more  or  less  completely  regained,  even  | 
when  tlic  Iwnc  is  destroyed  to  a  consideruhle  extent. 

TWattwnt.  Tho  treatment  of  scroiiila  in  bone  offers  little  that 
is  [H'ciillnr.  For  local  treatment,  [tcrhapa  the  most  iinportimt  in- 
dication is  to  keep  tlio  part  at  rest  during  the  prevalence  of"  inti^un- 
mation  by  splints  and  bandages.  Local  detilction  should  bo  can-  i 
tiously  used  while  tlicro  Is  pain,  tenderness,  and  sujx^rfieial  rwliicjw, 
or  the  pari,  may  he  envi-luped  in  a  large  warm  poultice  or  fonienla- 
tioD.     When  inflammation  is  not  apparent  in  tlio  soft  parts,  bat  i 

*  A  notice  of  ihis  cneu  tvill  bo  fuund  in  PalK.  Soc.  Tratu.  toI.  x.  p.  2lf.     , 
t  Tlie"whitc  swelling"  of  old  autliors  was  imiiied  bum  dtniniotis  discnso 
of  tlio  joints,  though  many  oUic-r  aXluuiiuna  cdtue  lo  bo  included  undor  th« 

ti-i'iii. 


SCROFULOUS  AFFECnOlfS. 


659 


ttM  Signs  of  its  pFowiKw  in  tlio  bono,  !t  vrill  bo  nocwary  to 

Fvse  oouncer-irritation  hj  caoatice  or  blisters;  or  in  less  severe  and 

morv  ctirom'c  ciuhm  by  moans  of  tho  tincture  of  iodinv,  or  other 

[stimulftting  a{i]>li (nation.     ^Vheii  in-ilation  has  nubsideti,  pre.<>9ure  by 

!  means  of  stmppiog  will  be  found  vor\-  Rurviccable,  both  in  injuring 

net  antl  in  promoting  absorption,  uid  the  loctd  action  of  mercuiy 

(Boott's  bandage)  may  be  conibined  U'ltli  tins.     By  tbese  sitnplo 

meosureit,  wilb  Judid<>ti!t  eimstitntioiial  Irojitniont,  most  of  the  caMS 

Bttf  stramoaB  inHammntion,  which  are  seen  before  tho  oocurronoe  of 

^UuppHration,  will  be  broii<r|it  to  a  tiivourablo  issue. 

H       When  suppuration  is  once  establislied,  it  is  hotter  to  prooore 

Htxit  tW  it  by  small  incisiouii,  and  t»  uoe  every  precaution  bu  jirevcnt 

tlie  denttdation  of  tresh  portions  of  bone.     The  qucetion,  however, 

of  Uie  mrly  or  klo  oiH-ning  of  abscesses  cnnneetwl  with  !>lrumoiu 

tbono  b  one  on  whioh  a  good  deal  of  difference  of  opinion  very 
SUtomliy  exists,  and  which  is  best  dctcnninod  in  each  individual 
owe.  If  auob  abseoaaes  are  allowed  to  go  on  increasing,  tlie  soft  parts 
nuiv  bo  cxt^'iisively  nndennincl,  the  disease  mav  extend  to  frcsh 

K bones,  and  an  ojiening  may  forui  in  a  diiiadvantageoua  aittuition.  If 
Dponvd  early,  the  caricy  may  bo  attacked  with  inRammation.  which, 
if  the  abaoeAti  be  largt^,  may  even  prove  fatal.  If,  however,  the 
■beooM  bo  near  an  iinjiortant  organ,  as  a  joint  or  soroiis  ca^-ity, 
tbera  oaii  be  no  doubt  that  no  time  »lii>uld  bo  lost  in  evucuKting  it. 
^ftXarge  openings  should  bo  avoided ;  but  tho  introduction  of  a  piece 
^of  Unlf  or  a  drHinafP'-tuhe,  will  kc<t[>  Uic  discharge  flowing;  or  tlie 


>  tnav  be  emptied  bv  means  of  a  trocar  from  time  to  time, 
B>«nd  the  iKwcKS  of  air  thus  clfiictually  prtM:Judcd.     When  tht^  bone  in 
^■€oq>OBod  through  the  opening  of  an  abscees,  its  condition  should  be 
tlioronghly  invwtigatod,  once  fiir  iJl,  with  the  pnilw,  in  order  to 
judge  of  the  necessity  for  operative  interference ;   but  notliing  ia 
taoro  uiscliicvous  tlian  repcxtod  meddling  with  diseast^l  bone.     'Hie 
gnienil  indications  for  ofierations  u})()ii  bunoH  affected  with  strumous 
OWiw,  and  Uio  form  of  operation  indicatod,  will  bo  the  xiimo  as  in 
^  caries  depending  upon  otlicr  oauseH ;  but  the  prognoaia  will  be  leas 
H  fiivotirablo  tluin  when  the  Mnstilntlon  is  mialfeclod,  and  tliercfure 
operations  .ihonld  be  uodertidten  with  more  caution.     OperaUons  on 
tlicsG  cnses  will  usiiaUy  suococd  or  fad  acoonUng  as  scrofula  has 
attacked  the  risc«fra  or  no,  and  acoorduig  to  tho  extent  of  its  dif- 
fusion through  the  system  ;  but  even  at^cr  a  succciwfiil  operation  the 
patient  ia  l)y  no  means  secure  against  a  relapse  in  some  otlicr  part. 
For  tho  general  treatment  the  reader  must  bo  rvfcrrod  to  tlie 
on  ScfiOFULA. 


660 


DISEASES  OF  THE  BOXES. 


Syphilitif  nfefit(m»  of  I/one.  The  chief  phenomena  «f  the  sj^ 
litio  aflections  of  bone  hnro  Wen  already  spoken  of  dutntnarUj 
undvr  tli»  bond  of  tertiary  s^'philts  (vol.  i.  p.  443) ;  it  will  tluircfor 
only  be  aeccfuary  hero  to  go  k  1itt]o  more  into  detail  us  to  the  ana 
tvmy  of  bono  xDbritMl  by  Byphilis,  ajid  tlie  menno  by  which 
disease  is  to  be  diagnosed.  As  the  general  treatment  of  ^rphilia 
liiw  boon  laid  down  in  Itlr.  Iiee'n  e»6ay,  only  tlin  local  treiitmvnt  uf 
it«  manifeslations  in  the  osHcotis  sjTstcm  will  bo  dwelt  on  here.         ^^ 

Sypiiilitio  iiHVidion.*  iira  tJioHo  in  whioli  tJio  exititcnoo  of  a  v)innii|j^| 
liniitod  inHaniination  of  the  periosteum  alone  is  nioet  etoai'Iy  proved^ 
if,  indeetl,  isiieb  iiitlniiiiiiHtioii  be  not  jiiKniliiir  to.tvpliili^     Stnmioiu 
nodes  (na  we  have  just  remarked,  p.  657)  are  formed  by  scrofulous 
matter  eonfiiied  between  the  eJirioiist  Ihiho  anil  its  piTJostenni,  and 
are  due  to  an  afieetion  of  the  bono ;  but  the  true  node,  that  wliieb 
follows  syphilis,  is  eau»ud  by  tho  olTuMOii  of  lymph  between  tbo 
bone  and  [jerioHteura,  and  is  duo  to  inHuminntion  of  a  liniilctl  |ior> 
tion  of  tho  dee|>er  layers  ("»ubpeno*teal  bWtenia")  oftlie  latter.^ 
Hcnco  it  is  of  a  different  aignilioation  from  that  of  a  stnimoat  ab 
seoss :  for  while  tho  latter  is  merely  a  cotise^uenco  of  diseased  bor 
and  iieeesHnrily  invotveii  eorresjionding  lo^i  of  aubstanoo  »n<t 
slow  processes  by  which  alone  an  ulcer  (and  more  especially  a 
fiLnimous  ulcer)  in  bone  can  be  heided,  the  ttyphilitiu  node  io  itM.^lf^H 
tlie  start ing-]x)int  of  the  diseobo  in  tJio  bone,  and  if  early  and  ]>ro-^^ 
perly  treated,  the  wlinto  organ  ojui  Ixf  r<»tjtreii  in  ii  nhort  time  t«  a 
state  of  health.     But  although  in  a  node  tlie  uiflammation  is  iisufllljr 
limited  to  the  |>i'rii)st<ii:m,  it  is  nut  alwtiys  w>.     JJuiiktoiim  prcpari-       , 
tjons  show  tliiokening  of  the  substance  of  the  bono  bene.itb  n(Kli>s,*^^| 
proving  the  implication  of  tlie  df-ejier  struetnre*,  and  then'fore  a  stata^^^ 
of  disease  which,  tliough  still  curable,  may  he  expeoted  to  be  moruob* 
stinate  thou  mere  periosteal  efRinion;  and  if  the  skull  l>e  examined! 
in  tJio  situation  of  a  nodo,  some  roughening  of  its  outer  talilo  may  [ 
generally,  |«!rhaiM  alwayit.  be  discovered.     Tho  i>rogrces  of  no<Ics, ' 
when  they  are  not  absorbed  under  ajipi'opriute  treatment,  in  in  oiioof 
two  directions :  cither  the  snbfKTiosteal  effusion  ossifies,  or  it  sofleDS^^ 
and  gives  rise  te  earies,  acoonipanii^l  usually  by  Huppuratiun.    Tht-^B 
fonner  event  is  commoner  on  the  tibia,  the  latter  on  tJie  skull.    The 
indisposition  of  the  [>erieranitun  to  loi'm  now  hone  in  a  very  wetl- 
known  fact  in  pathologT,',  nor  am  I  aware  that  the  formation  of  new 
bone  in  syphilitje  nodes  uf  tbo  skull  bits  over  boon  proved,  though 
new  bono  may  bo  sometimes  found  deposited  on  tho  outer  table  of 


iter.^ 


i 


St.  Thomas's  Huspiial  Museum,  series  c,  niK  61. 


SYPHILITIC  AFFECTIOXS. 


• 


the  eltTill  in  tho  noi^bourliood  of  largo  nicers;*  in  notlea  of  other 
flat  butii'^  aUi>,  i>!L«ilicntii>ii,  if  it  occurs,  in  rnro.  Many  node*  np- 
jifiir  si)  hard  as  to  be  pruiionnoi-d  oi«oi>iii* ;  but  thir  R-iding  is  often 
docnptivu,  sinou  tho  tvnso  and  tliicUoned  poriostouiu  rai«ud  by  wnii- 
fioli<l  otTiiaion  givea  a  soimation  hni-dly  to  be  diHtiii^iiiHiKMl  from  that 
of  a  bony  BWoIling,  Tliorcforo,  i»  a  Iiai-d  node  wliicli  is  of  no  long 
Htaiidirig,  tn>ntjtiont  foi'  it»  rom<»-al  may  lio  «oiiKdoiiiIy  nxviin- 
mended,  and  all  tlio  more  if  tlio  sw4>l]ing  bo  situated  on  a  tint  bone. 
On  tJii!  tibia*  nixlej*  are  iinino  Ut  ossify,  luid  ibnu  tbe  di'<*iicr  o.^^ilied 
part  roDiains  as  a  pennaiiont  irregulnrirj-  on  tho  siiHaoo  of  the  bono ; 
but  tlio  unoMMlKod  {tortion  inny  oftt-n  Iks  dU|>er»<>d  by  appropriat» 
measures.  When  a  nodo  suflons,  and  the  question  occurs  wliothor 
pus  liiui  fonnwi,  liio  <?!wti  ought  to  1n>  (.■nrfifiilly  v\ainin«d,  in  order 
if  possible  to  dotorniine  tho  point.  TIio  principal  indication  of  tho 
pre*«jijcw  of  pii*  is  th©  )ibinin<;,  tcnw,  and  tliinn<Hl  «oiidition  of 
the  skin.  It  is  important  to  obviate  more  destruction  of  tho  skin 
than  i»  incvitablu  on  tho  bumliiig  of  tho  abscess,  sintw  suclt  mrt» 
are  very  difticutt  to  heal,  and  in  some  eases  appear  inonrable.  The 
boet  way  is  to  make  a  very  small  puncture,  and  closo  it  after  tlrnw- 
ing  off  the  pus.  Frwiuontly,  under  the  projw^r  treatment,  the  soft 
parts  will  lulhcro  again  to  tho  bone  witli  ivrr  slight  or  no  oitfolia- 
tion.f  But  in  mast  cases  the  formation  of  pori(L'<t<*al  absoem  after 
a  node  is  followed  by  the  exfoliation  of  most  of  the  subjacent  bono. 
Syphiiilie  nodes  are  usually  precediHl,  and  always  uecntnjiaiiied,  by 
more  or  Icm  of  dull  nchJng  pain  in  tho  bono,  esjiecially  li.ible  to 
exaeerbations  at  night;  or  tliis  "xyphilitic  rbttiunittiHni/'  as  it  ia 
Bometiines  called  (tliu  dauleurs  ost^ocoprt  of  Frencli  authom),  may 
bo  the  only  symptom  n-ferred  to  ibo  fts^oous  sy«te!u  during  the 
progress  of  tho  secondary  affection.  Mr.  I'arkerJ  ix  iiiclinfii  to 
refer  the  juain  to  a  syphilitic  intluinmatjou  of  the  medullary  mem- 
brane. 

WIm^u  the  syphilitio  cachoxia  is  further  adruncod,  tho  whole  bone 
or  a  great  part  of  it  may  be  diseased  through  ite  entire  thiekne»«, 
leading  to  chnmio  ostitis  and  tennuiating  iu  wlenisi»,  or  what  is 
Bometimes  ciiUed  ■■  hyportiv>ijhy"  of  iJie  whole  tJuckuees  of  the  bone. 


*  Ev«n  here  it  is  h\  idorI  Mac*  itoublfiil  nbcthnr  tlio  dqfooil  hiui  born 

d  outnidc  till!  skuU.  or  wliolhcr  ihc  tliickcnintt  i»  net  potiluecd  bf 

dvptHHt  uitliiii  tho  diploc!  ■'xpiuidinn  tbo  outer  tablo;  fi>r  d«po>it  in  tha 

dlploc  U  cxocL'dinglj-  coiiiiann.    Sv^c  I'clow  on  tho  "  tubcroulated"  form  of 

^pbilitic  utccratiiin  in  honn. 

t  Sco  \'«Avt,  Modem  Trtatvwtt  o/SypMiOa  Dittam,  <lh  ed.  1800,  p.  SM. 


\  Loc.  du 


662 


DISEASES  OF  THE  BONES. 


1 

I 


I  am  not  awaro  of  any  diBtinctJon  which  could  bo  drawn  be 
such  iiiatiuKscit  orc^liroiiio  iiifiimiiiiatiun  and  tiiam  uriniit^  frxmi  iiod-1 
epecilic  causes,  excopt  that  which  w  fotinded  on  the  jiresetica  of 
concomitant  and  gircciHling  xy)))ii]itio  HymjrtomK  in  other  nr^ns. 

Still  more  gi'avo  and  more  obstinate  developraenta  of  tertiarjr 
8y(iliiliA  in  tlie  boiu's  oro  tlioso  mriouK  and  iiecmtic  afTcdionit  (ulvcr- 
ativo  or  gangrenous)  whipli  so  often  attack  the  skull,  the  bones  of 
iiic  taw),  nnif  tliu  mijieriinial  long  bones,  in  puriwin*  much  reduced  bf 
exceasas  or  by  tlie  injudicious  adiuinistnition  of  mercniy.     In  lor^l 
mor  timtw,  under  tlic  horriblu  syitom  which  prtivailfd  in  tiio  "  foul] 
wards"  of  the  great  hospitiiis,  where  ororj'  person  labouring  tuider 
any  diwuMV  supivoscd  to  bo  caused  by  promiscuous  intorcourso  was 
cotn[ielled  to  take  ineroury  to  salivation,  tlie  ravagi>a  of  a^^'philis  on 
tho  botiCH  wero  dreadful ;  and  it  is  to  this  ^stcm  that  wo  owe  many 
of  tlte  pregiariitions  of  sy]>hilitia  caries  and  necniitis  pfeaerv'ed  in  ouyl 
mutH.<unis.     But  thoro  seems  no  reasonable  doubt  that  such  aifectionsj 
do  ivlnii  iM'^iir  in  pcrwins  who  have  never  takiin  mi-rcurv,*  eapeciallyj 
when  tho  disoaee  has  been  allowed  to  go  on  unchecked,  and  tb 
oonnti  til  lion  is  at  tlie  same  time  cnfei^lilcd  by  allonintions  iif  de-l 
baucbery  and  hardship,  as  is  the  case  sometimes  witJt  sailors,  and 
more  freciueiitly  with  prostitutos. 

Tho  diagnosis  of  si.'philitic  affections  U  nsuaUy  easy  from  the* 
history  of  infcetion  aiui  the  proHcnee  of  other  symptoms ;  Iml  it  may 
in  some  cases  bo  obscured  by  tlio  patient's  unwillingness  or  inability 
to  rc\-eid  the  history  of  the  original  disease.     Tlius  the  puins  in  tlio 
bones  may  be  referred  to  rhcuniutiwn) ;  but  here  tlie  diagnosii^  can  in 
most  cases  bo  easily  established  by  obscr^-ing  that  rlii^nimatio  pains 
in  tlie  bonea  are  generally  aceompiinietl  by  affeetions  of  the  thick ^^ 
fibrous  structures  (muscles  or  fasciie)  and  of  tho  joints ;  or,  if  tli*^^ 
rheumatic  ntVi-otion  he  more  aciile,  tlie  urine  and  sweat  will  probably 
furnish  indications  of  the  nature  of  the  disease.      When  n<idcs  ha*'* 
made  their  appciu-ance,  the  diagniisiit  is  u.iuatly  easy,  the  only  <]ues> 
tion  lying  between  syphilis  and  struma,  since  rheumatic  periostitis 
i.«,  as  we  shall  see,  more  ditlViscd.  In  the  ahttenee  of  hixtory,  the  con-^^ 
comitant  symptoms  will  guide  us  while  the  skin  is  unbroken  ;  and^^ 
after  |ius  hn-s  made  it*  way  to  the  surface,  some  a.tstHtaiice  may  I>e 
derived  from  the  nature  of  the  secretion.     Sj-phihtic  caries  aniij 
necrosis  (as  has  been  observixl  in  the  essay  on  Rvphii.is)  are 
primary  affections  of  the  bonea,  but  are  tho  residt  and  termination 
of  nodes,  or  of  inflammation  of  tho  bones,  or  of  ulcerative  uffecCioi] 


*  See  Parker,  op.  lut.  p.  iH. 


SYPHILinC  ATPECTIONa 


688 


^ 


of  tlie  Boft  parts  around  the  bone,  ab  in  the  palate,  and  therefore 
h»vc  bven  pn^T^lvil  hy  a  long  uiursc  of  Bytn|>lon]e,  dtiriag  whiDfa 
tlw  diagnoeis  is  usually  eetablishcd.  If  not,  it  purely  prottenu  any 
difGcuIty,  sinco  the  traces  or  tha  {wenonoo  of  other  sytnptoma  of 
conatitutiona)  a^'pliilia  can  hardly  &il  to  ba  iwoognlMitl. 

An'  intonating  oompari»on  has  bc«n  made  between  the  forms  of 
BTphilitio  ulceration  in  bone  and  tlioso  of  nyjihilitio  eruption  on  thu 
skin.  Specimens  of  roundi'd  ulcere  may  sanietiincs  be  met  with, 
flspeoially  on  the  »kull-cjip,  which  bcjir  a  ittroiig  rcuoiiihiaiict-  to  the 
mpial  nloers  no  frcqui^nt  in  an  advanced  stage  of  oonstitutjona) 
Byjihiliii.*  A  sinidl  round  fpot  of  uli;orut.ion  i:^  soon,  wIh^ix!  Ihn  sur- 
face of  the  bono  is  trorm-catcn  from  the  preseiK^  of  numoroiu 
minute  depn>«i<ti()ri!<,  aiul  in  aonio  niiteA  llic  ln^no  iiroun<1  tliiH  worin- 
catcn  central  portion  is  marked  by  arborescent  grooves,  the  traces 
of  incrcaitcd  ^a.vularily.  Litfor  on,  it  eii-culur  tjvncb  is  niarkeil 
around  tbe  worm-eaten  spot ;  and  as  this  widens  and  deepens,  it 
uiuh>rniin«H  and  liiially  eliiMlit  out  tlic  ])icoe,  which  He]iiiratt.>9  a»  ft 
sequestrum,  and  then  the  bone  scars  over,  leaving  a  rounded  de- 
preaaioii,  much  larp.'^r  tlnm  the  original  spot,  the  nurtneo  of  whi<-)i 
is  rad>er  glazed  and  a  little  vasoular,  and  the  bone  below  it  a  good 
deal  hnnlfiied.  In  welt-mnrkcd  ^sjiecimcns,  Uieso  annular  tdeuis,  »» 
they  are  termed  by  Mr.  I*aget,t  look  very  ehiu-acteristio ;  but  in  less 
adraiiood  cok-.*,  espt^nally  before  the  surrooiiding  trench  has  tonnod, 
or  again  at  a  late  period  when  cicatrituitioii  ItaA  obliterated  some  of 
the  mure  distinctive  characters  of  tlic  tdcer,  it  seems  impossible  to 
diatinguiaii  it  from  a  aorofuloua  or  other  lealon.  The  other  cha- 
racteristic form  of  syphilitic  ulceration  is  the  (ubereulatfd,  which 
q>peiarB  to  commence  by  a  tulx'trt-ular  thickt-niu};  of  tlio  oxtemal 
wall  of  the  bono,  recalling  the  syphilitic  tubercle  so  common  on 
the  skin  of  ttit>  fixcc,  hf.,  and  dui>  nut  to  periosteal  deposit,  but  to 
chronic  infiammation  of  tlie  compact  tissue  itaeH  This  infliinied 
bone  soon  beiv)meii  dc»tl«d  over  with  iiuin«mn»  little  pita  or  depres- 
sions, which  coalcsoo  and  form  ulcers,  usually  oval  or  round,  [M-ne- 
trating  deeply  into  the  intt-rior  of  the  bone,  llesidiw  these,  Mr. 
Paget  has  described  a  third  form  of  syphilitic  ulceration,  (ho  »wi- 
mlatnl,  in  wliieli  tJie  disease'  apjieiirs  first  t"  show  itself  in  the  form 
of  a  network  of  periosteal  deposit,  which  is  liable  to  jmrforution  by 
uloem  subset] ueiilly  forming  and  a-vuming  the  annular  type,  of 


•  Unseunt  of  St.  Bartholomew'a  Hoapita],  •ul>«eriM  jt,  nos.  63, 109. 
t  In  lb*  Catalogue  of  tbe  Museum  of  St  Bartbideaew's  Iloipital  and 
In  that  of  tlio  Boj'al  College  of  SiufeoDB. 


664 


DISEASES  OF  THE  BONE& 


^ 


u'liidi  latter,  theroforo,  the  above  may  be  i-<^:ar<ied  as  a  yarietr.  Of 
the  two  kiiids  uf  ^-{iltilitic  ulcer,  tlio  iiniiiilar  ii[>j>i-uni  to  mo  tlic 
more  characteristio ;  but  I  do  not  helieve  tJtat  eidier  is  so  tli&linctive 
of  tho  diMoao  as  to  caiablo  u«,  with  any  thing  Kkv  w^rt^tiity,  to  iniiir 
tlie  previous  oonfitituUonal  afTcntion  front  exaniinalion  ol'tlie  atlected 
bone;  nay,  I  have  known  pntholo^ts  of  tliu  gruateitt  pxperienoO 
nifiiliHt  in  Hti('}i  nttoniptA  by  the  subHequent  diacovery  of  the  hJatory 
of  tlie  preparation. 

Any  of  tlioite  forms  of  xyphilitiff  ulceration  may  affc«t  the  bone 
fio  deeply  as  to  jtenctmto  its  whole  thickness.  Tlnis  in  the  intiseuin 
of  St,  lJiwtIir>!o mow's  HuH]>itaI  in  u  spoeiineii  (A  'M)  of  n  elavicie 
in  which  the  bone  has  gii'on  way  (probably  after  death)  in  conse- 
quence of  penetrating  ulceration  attributed  to  »yphiiiit.  Sjion- 
4ancous  fracture  of  a  loug  bono,  however,  from  penetration  by  a 
syphilitio  uIwT  is  cxtromttly  ruro;  while  [wnetralJun  of  ii  flat  bono, 
eapecJally  of  tho  cranium,  is  still  a  pretfy  6T3<iiieut  oireumstancej 
and  used  to  be  ua  ordiniirj'  residt  of  »y  phi  I  Is.  In  the  greiit«T  mini- 
ber  of  such  ea^ea  no  serious  mischief  follows ;  tlie  dura  mater  is 
cxposod  on  tlio  Hcparutiun  uf  tho  necrosed  centml  part  uf  llic  nicer, 
but  soon  gets  covered  over,  so  ttiat  Its  pulsations  are  no  longer 
vi»ibIo,  and  in  a  little  while  tho  gup  will  be  filled  up  by  fibrous 
tissue.  In  rare  eases,  however,  pn?sflun>  upon  tlio  brain  is  produced 
cither  by  matter  confined  between  the  skull  and  diu^  nintvr,  or  by 
uleei-ation  laying  open  a  branch  of  tlio  middle  meningeal  anery  and 
causing  bn;morrhago. 

Tmitjiutif.  Tho  treatment  of  cniiKtilutional  syphilis  has  been 
already  described,  and  it  has  becji  shown  that  at  one  period  or  otlicr 
of  the  disease  ii  pndongcd  and  sufKcictit  exhibition  of  mt-n^iry  will 
be  necessary  for  oura  To  this  general  rule  the  aliections  of  bone  form 
no  cxci^ption,  for  although  some  of  tliem  are  ustinlly  fount!  aoomi- 
panied  by  so  profounil  a  cnehexia,  so  complete  a  prostration  of  the 
whole  syiitem,  that  mercury  is  inadmissible,  tt  will  also  be  found  that 
such  afteetions  do  not  lulinil  of  eui'c.  Iodide  of  potassium  often  acts, 
however,  u|>un  tlic  earlier  affections  of  the  bone  and  periostenni  like 
a  charm,  and  tlio  aymploius  noon  disappear;  but  those  whoM  ex- 
periiMice  in  tlie  treatinent  of  syphilis  is  most  cxtcnsiive*  bcUcve  that 
the  improvemont  is  nut  (lermaneiit,  and  tliat  for  tho  entire  erndica* 
tion  of  tlie  constitutional  affection  a  mild  but  jinilongod  course  of 
mercury  (for  which  the  calomel  vnponr-bath  is  the  most  a)ipn>priato 
agent)  ought  to  bo  insisted  on.   The  local  treatment  of  bone  iiillainod 


•  I'ai'ker,  op.  cil.  p.  289. 


RHEUMATIC  AFFECTIOXS. 


64:5 


I 

\ 

I 
I 


from  S)-pliilis  prvsonto  w-wml  inUiredtiiif*  qiKtstions.  Nodes  wUl 
Uiiunlly  be  bcu^fitecl  bv  blislei's,  oi-,  if  the  bone  ecoin  to  be  more 
(liH'Iilv  uiloctod,  by  the  persevering  uw;  of  mereurinl  oiril.m«nt,  ulrnp- 
ping  with  tlie  empl  bvdr.  ciim  ammoniaco,  iodine  paint,  &c.  Bat 
wlicn  iJio  pain  in  the  tnf1ftmc<]  bone  is  eonsbint  aikI  vi^y  cliHtresjiing, 
it  is  quite  justifiable  to  <ltviil«  tho  )i)<noatoum  by  a  free  incision ;  and 
tiioii,  if  nothing  is  found  to  m^count  for  Uiv  tension  und  to  liol<l  out  n 
pro^ieot  of  it«  relief,  a  trojihine  niav  bo  aiijiIifHl  to  the  tione  it*i?]f,  and 
its  medullary  canal  laid  open.*  If  s\-inptoniH  of  eercbral  distiirbuiii;« 
tnnko  ibeir  appearaniM  in  tlie  eour.->o  of  ulceration  of  tlic  cranium,  tlie 
appli<Mition  of  the  trephine  has  sonietinies  been  fiuccestsfol  in  prusvrv- 
ing  life;  but,  on  (he  oIIut  band,  it  i»  not  to  be  di-nied  that  it  baa 
sometimes  producer)  or  hastened  death.  The  prorei'bial  otMCurity  of 
all  cranial  atfeetiont*  ought,  I  think,  to  nmki-  ui*  cuutlouain  adopting 
»o  extromo  a  measure  as  trepliining  the  skull,  imless  in  a  pntiont 
whose  »tat«  ia  othorwiso  evidently  hopideM.  EpiUiitie  convulsionB^ 
even  witli  slight  »\Tnptomft  of  paralysis,  are  hardly  a  suffieieiit  in- 
dication for  tho  O|!er«tion  ;  but  tho  oxjiorienco  of  Mr.  U.  Leef  has 
nhown  that  in  some  cases  the  removal  of  the  diseased  bone  has  been 
followed  by  tiio  hcniing  of  ideers  wlneh  had  |trevioujily  bwii  ot»ti- 
nato ;  and  it  seem^  that  tho  removal  of  the  ouiit  tjihlo  only,  when  it 
m  (tend,  and  a|)peurs  to  Iw  keopiiig  up  irritation,  is  a  safe  practico. 

The  treatment  of  Hssurea  and  defwts  of  tho  palate  from  syplii- 
litio  necrosis  will  Im  found  discussed  in  a  subsoqueiit  essay. 


I 


Hiteumaiic  and  gouty  affeetiont  of  bone.  It  is  extremely  diffioiltt 
to  be  certain  of  tho  (.•xiMonee  of  any  i'j)e<Tific  afli,>ctioii  of  hone  duo 
to  i\%{;  rheuniatie  diathesis.  Itokitansky,  in  his  *<  attempt  to  detci^ 
mine  tho  chiii-aiftitrit  of  tliv  constitutional  affections  of  bone,  particu- 
larly tlie  iiiHanimatious  and  caries,  by  reference  especially  to  tlw 
appearance  of  the  bono  after  maeoration,"J  doubts  "  whether  rheu- 
matistn  giios  rise  to  an  intlammati<}n  that  can  be  distinguishod  by 
■ny  definite  elinraeter  of  its  products,  or  to  any  partictdar  cwriea, 
Jtowcver  positively  assertion.^  be  made  on  tlio  point ;"  but  there  is 
no  doubt  that  common  ostitis  is  verj'  generally  j>roducod  by  exjMxiuro 
to  cold  and  wet,  and  otlier  oauM'S,  whi<!h  at  tlie  amne  time  generate 
rhciiiuati.ini ;  nor  is  there  any  roa«on  whatever  for  qm-xtioning  iJw 
universal  opinion  of  penoiiit  of  experience,  that  those  wlio  are  the 


*  Sue  vol.  i  p.  U3:  Parker,  op.  dt.  p.  9^. 

■t  Procwrfiny.  o/the  Mfd.Chir.  Soe.  VoL  iU.  p.  «M. 

X  Up.  cit.  voL  iiL  p.  itOa. 


€66 


DISEASES  OF  THE  BONEa 


J* 


sabjects  of  rlieunmtism  aro  a!ao  those  who  are  most  prono  to  inflant' 
mattoi)  of  tlic  6U)x;rliciaI  bonc«,  such  as  the  Kkull,  tibia,  &c.  ^^ 

The  disease  now  oommonly  called  "  chronic  rlioumatic  arthritis"^! 
is  refpuxJod  by  some  authors  of  credit  as  originally  a  (ii.-wawi  i>r  tlie  ^ 
bone.     In  tlittt  work,  li()\tev<-r,  it  i»  voniiiJvnHl  as  commenciog  in 
tlic  soft  tiwtKM  of  the  joint  (seo  DiismseH  or  Tli£  JoiMTs). 

I  would  not  be  undentixxJ,  howcvvr,  to  <)i>ny  the  existence 
an  aRl-ction  which  deserves  to  be  oalled  "  rheumatic  ostitis."  The 
condition  of  tlie  artictilnUnjj  ttxtrrmitics  of  tlic  bones  in  cases  of 
chronic  rheumatic  anjiritis  is  very  peonliar,  and  can  hardly  be 
explained  by  any  tb«ory  except  that  of  some  conslitutional  pe- 
culiarity in  the  dittense,  since  neither  the  age  of  tJie  patient  nor 
the  tnodu  of  ciiiisation  of  the  malady  offer  any  w>n!ttanl  foatnrea 
which  can  account  for  tlio  i»ingiilai-ity  of  the  afleciion  of  the  bone. 
That  which  is  most  cliaracteristic  in  all  those  cosos  wbicJi  appear 
to  be  rheumatic,  i«  tlieir  vory  cluw  counto,  ajid  the  great  Ictif^h  of 
time  during  which  uiHamniation  may  be  prcwnt  wilhout  citlter 
caries  or  necroHiit.  In  all  dioiimatio  allixHiond  of  tlio  joints,  and 
many  of  those  of  tlie  limbs,  altliough  it  may  ho  true  thut  tlio  con 
plaint  originates  in  tho  fihrouM  tii<Mi (.■.■>,  yet  tlie  hones  will  beooc 
involved  if  the  disease  lasts  long  enough  ;  and  in  that  c«uio 
principal  features  will  bv  in  ttic  sliad  of  a  long  bone,  estensivo' 
etalactitic  or  ibliacoous  laminated  de]>oait  from  the  poriostcmn,  iind 
BolerottiH  of  the  Hti|)orlicial  portions  of  the  bono;  the  roetlnllarj-  canal 
and  the  deep  c.incoUoiiii  tissue  being  usually,  if  not  always,  nnaf* 
fectvd.  In  tl)U  museum  of  tlio  Uoyal  CtJI^ge  of  Surgeonti,  Mr.  Paget 
haa  olaaaed  aome  specunens*  aa  "  rlieumatio  ulceration,"  in  which, 
along  with  these  appoaraiioes  on  the  shaft  of  the  Imnc,  ulceration  is 
seen  invailing  the  ncwly-formdl  |icrio»tcid  deposit;  but  whether  tins 
is  a  natural,  tliough  unusual,  result  of  the  constitutional  disoaM^  at 
an  accidental  coiiiplinitioi),  M>eui#  doubtful  In  any  case,  the  oc«ar- 
rcncc  of  nodes,  and  more  or  less  of  intlammatiou  of  tho  wall  of 
suporiicial  horiott  in  auu)*  of  rbutiniatism,  w  a  sufficiently  probaUe 
event;  but  it  is  a  complication  which  must  bo  treated  on  general 
principles,  'llio  nodcj"  do  nut  affect  the  liniit<Ki  extent  and  rouitdod 
outline  of  those  due  to  sy])hilis,  but  are  irregular  swellings  of  tho 
periosteum,  involving  a  considerable  extent  of  tho  surface,  nud  pTO^n 
hably  some  of  tlie  thickness  of  the  bone.  ^| 

Tlio  most  cbiimctcristic  effects  of  rhcumati.^m,  how;c\*cr,  are 
displayed  upon  the  articulating  extremities ;  but  as  this  disease  will 


•  Nos.  OSO,  037,  ««  4. 


MOLLITIES  OSSIUM. 


667 


» 


foiiinl  fiillj'  ilwwribod  in  (do  ««t»y  on  Diskjisks  of  the  Joints, 
it  will  not  bo  necessary  to  eay  much  about  it  here. 

Tlw  (ibidf  foflturiM  which  iiro  (ii*timTttvo  nf  rlivnmatic  inflam- 
mation of  the  bones  are,  the  exlensive  deposit  of  bono  in  tlie  fibroos 
HtnictitiTS  urntnid,  thu  condoivsation  nmt  thinning;  oftlio  shell  of  tliu 
bone,  the  rarefaction  aiid  partial  nb<iorptton  of  ita  interior,  and  the 
ouniHKiavnt  chnngv  of  sliapt-  wliJi-ti  jiartjs  containing  much  cun<.>cl- 
loos  tiaMUe,  8uoh  as  the  articular  hoath  and  iie^^kfl  of  long  bones, 
rafTor.  In  tlio  articular  disease  tho  now  bono  is  found,  to  »  p-ent 
extent,  in  t)ie  liganieiilA  and  otlu>r  tis-ines  distinct  from  the  peri- 
OBtinim,  and  tliuu  forms  what  Dr.  Adams  caHs  "  iidditAnioiitiuy 
bon^^a,"  wliiitli  have  l>een  !)o  oflon  miittnken  for  portions  Iractured 
off  the  iKjny  prominciicos  near  which  thoj-  may  bo  situated  and 
uiiunileiL  I  ahull  mldnott  fiomo  reu.'^onit  for  believing  that  many 
of  the  apodntona  in  which  portions  of  bone  have  boon  found  nvnr 
tlio  sliiiDx  of  long  hoDOH,  but  nioval)l«  upon  tliem,  and  wliioh  have 
been  thought  to  bo  instances  in  which  exoetoees  had  been  fractured 
at  tJieir  \m^,  may  be  of  the  same  natural 

As  to  the  treatment  of  the  rheumatie  affections  of  bone,  nothing 
need  be  >ini<l  hero,  since  nil  that  is  nPMUHmry  io  ailtl  to  tli©  gi'neral 
trvatmont  of  ostitis  will  be  found  in  tho  easay  ou  Diseases  oir  THB 
JODTTS. 

I  have  nothing  to  say  about  the  affections  of  the  bones  in  gout. 
The  deposit  of  lithnto  of  sodn  is  soinctimcH  found  in  tlie  interior  of 
tho  bones  in  inveterate  ease:),  as  well  as  on  tlieir  <!xterior ;  but  its 
iin]M>rtuneo  is  quite  seoondnry.  Strome^r'er*  sIUkIvs  to  a  aiw  in 
vrbioh  nearly  all  iJie  bones  of  one  siile  of  the  body  were  hypCT- 
trophiwl  in  a  patient  who  had  long  suffered  from  gout;  but  no 
opportunity  occurred  of  examining  (he  boncK  nflected. 


Me>USiif.i  oK'ium.  "Hie  {x'culinr  condition  of  the  Ixmea  whieh  is 
known  bv  the  name  of  niollities  ossinm,  or  nialacosteon,  is  one 
which  i«  very  rarely  met  with.  In  tho  female  pt'lvis,  as  a  canae  of 
diDiculty  in  parturition,  it  is  less  rare  than  under  other  ctrcum- 
stuiocs,  and  <l<'iriHiids  the  special  atl*^ntion  of  the  ol»letri<?  Snrgiwn, 
involving,  as  it  does,  some  of  the  gravest  questions  wliich  aro  to  bo 
aolvod  by  that  branch  of  our  art  Tliese  ipiostioii*,  however,  which 
hare  reference  to  the  altered  relations  between  the  deformed  bones 
of  tho  pcivis  and  their  contents  ((«[>ccially  the  gravid  ntenis  and 
fistus),  ore  not  within  the  scope  of  the  present  work.     We  haro 


*  Bandbvch  4.  ChinryU,  ToL  L  p.  US. 


668 


DISEASES  OP  THE  BONEa 


:  1.  A% 


only  to  consider  Uic  disooto  in  its  patliology  and  goncral  snrgic 
huaringti- 

The  pathdlogy  of  moIIiti<si  is  for  from  boiug  ratisfactorilv  cstab- 
lisiiod ;  and  Uiero  oiii  lie  little  doubt  that  tills  has  arisc-n,  in  f^reai 
part  at  any  rstw,  from  (ho  fact  timt  authors  haw  coiifinuidMl  stiver 
(li]l«riint  conditions  undor  tlie  sanio  name.     Some,  ind«od,  mako 
distjnctioii  Wtwct-n  mollidcs  and  fragUilaA  oMium ;  wtiilo  olhen 
regard  uiollitiea  as  an  afiWlion  allied  to,  if  not  identJeal  wiili,^^i 
rit^etfi.  ^M 

TIk-  (]i»i>iwi>  which  a!)i>"Virji  hc*t  in  do^orve  n  spparate  dosoription  ^* 
under  tho  name  of  iiiollilie.s,  is  marked  hy  the  following  chHr»i.Tti.Ti!*- 
tiM.     Sevoml  Iwiiw  Jirc  usuully  uHVx-tt'd  at  the  same  time.     The  por- 
tions of  bone  aitaoked  ai-o  uiiitbrmly  softonod  throughout  tho  whoto 
VxVuut  oflhti  diBiasc.      Tliir  dimvwu,  )i<iwovor,  dww  not  in  all  cases 
affect  either  tlie  wliole  length  or  the  whole  tliicknc**  of  the  borni,.! 
and  if  the  «poptin(;n  bo  examined  ut  an  osirly  |ii'riod,  the  outer  hJtell' 
is  often  found  to  retain  it*  natural  consistence.'     AVhcn  tlio  whole ' 
bone  i«  afli'otcd,  it  can  ho  roiulily  bent,  and  rv.'toinbleii,  iti  extrane'j 
cases,  as  Dr.  Orinei-odf  remarks,  rather  a  pfirtiou  of  fatty  matter 
eneltwod  in  n  case  of  ponowtciim  than  u  bono.     Ifllie  tiiuax^louA 
tissue  (in  which  tlio  disease  ap]>earB  to  originate)  be  atamined,  it  isl 
fiiund  that  (lie  toIU  aro  enlarged,  sonictimea  to  mich  an  vxtcut  tli 
tlie  whole  bone  is  expanded,  and  are  fi)li'<l  witli  a  peculiar  reddishj 
golatinifbnn  matter,  in  which,  ou  niicroscupieal  examination,  mt 
fat  and  oil  can  ho  disoovereil,  together  witJi  blood-discs.     Beside*^ 
tlieise  (t\  hicli  are  tlio  common  products  of  any  degenerative  cliange), 
certjiin  [ifouliiir  nuclenlatt^d  nuoleiir  Ixxlios  have  heen  disieriWd  by 
Mr.   Dali-yni])lc. }      luslancos  of  bones  affoetcd  with  niollitiva  do, 
however,  occur,  in  which  tlio  uniouiit  nf  fat  is  not  greatly  increasod. 
Tlius  in  a  specimen  iu  Guy's  Hospital  Musemn  (no.  1004''^),  taken 
(roni  u  case  reported  by  Mr.  Solly,  in  tho  27th  vol.  of  tlie  J/irf.- 
Chir,  Trans.,  it  is  said  that  the  diseased  tissue  ctmsisted  simiily  of 
iin  organic  matrix,  witlt  liltio  <tarthy  matter,  and  containing  Hltls 
fat.     Cases  like  these  show  that  it  is  impossible  to  describe  inollities 
as  simply  a  fiitty  degi-iieratlon,      Dcgcnoratioii  of  sonic  »ort  ts, 
howcxor,  always  present ;  and  as  this  advances,  it  involvM  the  com- 
pact walls  i>{  tlio  bone,  and  then  tjio  disease  l>t?ooini»  for  tho  fin* 
time  recognisable,  by  the  syniplonia  which  will  ho  immediately  de- 


•  As  in  Dahymplw'a  ease,  ivIV-rrL'tt  to  bolow. 

t  lirit.  AM,  Jaiirnat.  Kejil.  10,  1859. 

:  Dublin  Quarterly  Journal,  IMO,  p.  86;  see  also  PtOk-Soe.  Trant.  1M6-T, 

ue. 


4 


MOLLTTIES  OSSIUM. 


669 


scrifnyJ.  At  n  liilor  jwriini,  tlio  wliolo  bon«  i»  found  to  bo  involved, 
ajnl  beciiniCB  a  more  bag  of  soft  matter  endowed  iu  ifie  i>i>rio»tt>uin, 
which,  perhaps,  iiuiv  W  fioinovrhut  tlilclccnvd,  but  it  does  not  appear 
that  any  further  destnii?tioii  of  the  bone  iteelf  owiint.  It  i*  tnorcljr 
convcrfod  into  n  (w>ft,  generally  i)ily,  material,  which  crumbles  nway 
on  miioi^iitlioii,  but  which  seems  capable  of  roaisting  ab^Koriition  ibr 
an  unlimited  iierlod  durtnj;  ltfi.i. 

'J'h<)  jtyiiiploniH  of  inolltli«i  aro  sufficiently  striking  in  a  wdl- 
marked  caso  to  attract  inimodiato  notice,  howovor  obscure  may  be 
tliv  n^itl  iiutiire  of  tlie  constitutional  affoctioii.  Tlio  |iatieitt«  aro, 
it  is  said,  ii>-ually  fijiiinlcs,*  and  ji^ncraily  pust  tho  middle  period  of 
Hfo.  KAjicated  pregnancy  appears  to  act  as  an  exetting  ciiiiho  of 
the  disease,  and  may,  pcr)mi>s,  ncoount  for  the  groator  proportion 
of  fwnaiw. 

The  disease  appears  to  be,  in  somo  caws  at  least,  hereditary, 
TIius,  in  tho  history  <jf  l>r.  OrmenHl's  |intient,  referrwl  to  abo\'e, 
it  lit  stated  t)mt  both  tho  son  and  daughter  were  subjects  of  tho  same 
aflectioii.  8om<!timc!t  ]i»in  i.i  «oui]>lniiicd  of  in  tho  afTocti^d  bones 
for  some  time  before  the  nature  of  the  disease  beoomes  maiiifi'^t ; 
in  other  cjiww,  however,  this  deformity  inihici^l  by  gradual  soften- 
ing of  tho  hones  is  tho  tirst  symptom  noticed.  When  tliis  softening 
has  procoedwl  far  enougii,  the  hone  givos  way  griulually,  if  it  has 
been  ei|uiibly  and  thoroughly  softened,  so  as  to  yield  and  becomo 
merely  deformed  ;  but  if  the  wiftiming  han  been  confined  to  the 
intiTMiil  part  of  the  bone,  and  the  thin  outer  shell  has  been  left  solid, 
and  iJierefore  brittle,  siwnfwieout  fracture  (or,  more  oorroetly  speak- 
ing, fracture  from  very  slight  causes)  is  liable  to  occur.  The  former 
class  of  casee,  in  winch  the  bone  hi-n<Is  witliout  breaking,  are  those 
in  which  moHiti<»  U  most  characteristically  marked,  since  s]>on- 
tnneous  fractui*  preceded  by  jxiiu  in  the  bono  is  also  a  feature  of 
malignant  luid  other  diseases  of  the  osseous  sj-stcm.  In  xuch  ex- 
treme cases  of  mollitie«,  tho  linitw  become  distorte<l  in  the  strangest 
wav,  BO  that  the  tliighs  have  keen  known  to  twnd  till  one  of  tho 
feet  touchttl  tho  head;  and  from  tho  iwfU-ning  of  tho  vertebral 
column  and  bending  of  tho  limbs,  tlie  stature  is  very  consi<Ierably 
diminished.  The  constitutional  cachexia  is  often  not  very  sti-ongly 
narked,  and  patients  will  live  in  this  condition  for  an  in<Ielinito 
period,  bedridden  from  tho  wcakucjw  of  tlieir  limbs,  and  the  loss  of 


t 


•  I  do  not  ftnd  qalt«  M  graat  a  disproportion  betwMn  the  tnn  aa  la 
implieit  ill  tlte  d«soriptiim*  glvan  by  *oin*  antbon.  Of  l«a  «ues  ofuue 
tnoIUtiM  taken  at  randoia,  six  wnv  femolvi,  and  four  toalec 


670 


DISEASES  OF  THE  BONES. 


the  firm  points  from  aii<)  to  wliicli  tlio  mwH;Ii.4  net,  but  with  a 
(ucut  tnental  and  <H>nstitiitioiuJ  vigour.     The  wmse  of  dealli  iiji|Hvtrs 
generallj  to  bo  uniplc  vxhaiutlioii ;  or  liiilurv  of  vital  powers^  Ukd 
n'hut  tnkofl  placo  in  extreme  ol<l  age  (in  tact  some  of  tlie^e  j<«tjcnt»i 
do  not  die  till  the  cxtn-mc  of  lifv)  ;*  or  »oaii-tiin<«  lunctioriul  (Ii.i-| 
turb^iiou,  induced  hy  tlio  altered  relations  of  the  vLtcera,  and  tbo 
preasuro  to  n-liioli,  from  various  uiu»c»,  they  arc  subjected.      Soit 
unfrtMjiitMitly,  however,  the  patient  does  not  die  of  tlie  diitc«»tf  at  all,] 
but,  liaving  lived  under  its  inrtuenct  for  many  years,  is  carrie*!  off! 
by  i<«iiiu  tolully  ditliircnt  oonipkint.t 

With  these  symplomB  it  is  not  snrpriwng  that  lliis  diiteaM , 
sfaould  Imvu  hcen  clainie<l  as  uiorcly  u  rarvr  form  of  Miwral  better'^ 
known  aft'ections  of  bone,  to  all  of  whicli  it  bears  some  reaeniblunce, 
however  little  they  may  w-eni  to  U-nr  to  eiicli  otlif r.  Sumo  authorst  ' 
consider  molUtica  to  be  merely  &tty  degeneration,  or  atrii}iliy  "f^fl 
bone;  otbon  rt^trd  it  a»  riekvt«  ntttkt- king  tlio  adult;  while  many  ^^ 
class  it  with  eaucer.  Kow  eaeh  of  these  opinions  hact  a  bu»is  of 
probability,  and  it  it  very  pouiblu  llml  many  of  the  cases  of  so-i 
called  mollitiai  might  with  greater  propriety  liavo  been  ontitlod^ 
"  atro]>hy"  of  the  b<.)iie.  Of  thitt  Mr.  Curling'«  case  appears  to  hava  \ 
been  a  good  instance ;  and  the  ditticully  which  some  uuthon  havcj 
expressed  in  diMtinguishing  bctwcvu  moUities  and  fi-agilitas  o6&ium|  ■ 
appeal's  to  have  ariBen  from  their  having  cunipurcid  together  caaoa 
in  which  there  was  no  real  ditfcrcnco,  and  where  tlie  name  niollitiet^ 
had  been  given  to  sim]>le  alropliy. 

Tlio  connexion  bctwoon  rieki-ts  and  mollitiea  appears,  at  fir»t 
Bight,  a  very  close  one,  on  tunfouiit  of  llic  beiwllng  o£  the  bones,  and  I 
liabUity  to  iiacture  fi-om  slight  cau&es,  which  characteri»o  botb.1 
Some  patients,  also  atl<x'te<l  with  undoubted  ntoUitiee,  have  suftoredi 
in  tlicir  youth  from  ricket*.||     Still,  if  we  consider  the  question 
attviilively,  the  diftbrcneed  between   the  two  atfcctions  far  exceed 
tlicir  resemblances,     Itickets  is  an  atl'ection  of  curly  life,  doeely 
iillied  to  scrofula  in  it»  causation  and  in  its  core;  it  is  peculior^j 


»  See  tlie  cases  muotloued  iu  tlie  CaUJogue  of  Gu^'s  Uospitnl  Musouitti 
nos.  1044".  lOBe", 

t  TbuB  in  Dr.  R*insboUi«m"s  eurn  (Part.  Sott.  Timu.  1646-7.  p.  IM> 
patient  died  of  jitieumonia,  after  tiiHiiriiig  for  mora  Uiuii  aix  }*<Mr» 
■uollilies. 

I  Sue  Mr.  Ciirlinfi's  pnpi-r  in  Mrd.-Chir,  Trtitii.  toI.  x».  p.  3S0, 
ij  It  would  be  nvll  if  tlip  teiin  fl-R^IlM*  oasluni  weiv  allowed  to  booonia 

obaululv.  siiii'u  it  only  Jcsri'ib>->i  n  symptom  vooiiticiu  u>  oeTeial  aflccUon*. 

II  This  waa  Uie  enae  with  Dr.  Ormeroil'a  iiatieut,  aliovo  refviTcd  lo. 


JIOLLITIES  OSSIUM. 


fl71 


amcnnblc  to  troittiiictil;  nn<I  under  bvoiiniblo  c^rcnmstaoces  tbe 
ciiiinljtiitiona]  cacin'xia,  which  is  ite  eeaeiice,  rcatlilr  diBappean  wt 
tho  child  grows.  Itlollitttv  luirdly  ever  mukoa  its  firet  appoaranoe 
till  aih-r  middle  lifo  :  and,  even  in  tliose  catuM  where  Uie  piuent  Ita* 
been  rickety,  not  till  I'm;;  aftor  (liv  cavlioxia  of  Uiat  disoaso  has 
Mibsidod ;  it  sliown  no  alUanec  with  (wmlUlu,  and  Lh  not  aniiTnaMu 
either  to  Iho  rcDKHUoi  I'nr  that  disease,  ot,  as  far  as  is  known,  to  any 
otlu^r  reiniMlio),  but  puntueo  its  cai^er  steadily,  unatVt'UU<d  fur  good 
by  any  medical  trcatinc^nt. 

in  tlio  latter  particular,  at)  in  several  of  iU  other  fc-atnrrs,  it 

bears  a  &r  stronger  resemblance  to  cancer.     In  fact  there  can  be 

little  ht-sitati(>ii  in  ctnjwing  stonie  it))cciin(>iiH  preserved  in  niii.ii;tiiiis 

BS  mollities  under  the  bead  of  difl'uaed  cancer  ;  and,  conversely,  in 

[woonfcd  cujttia  of  eunispr,  xonio  of  thu  Ihiik'!*  Iiitvn  Ixion  found  in  n 

state  closely  resembling,  if  not  identical  with,  niollities.     Thns  in  a 

^m  caw  of  jietxindaiy  CMiiwr  in  tlic  *pinc  and  otJier  part.<,  aftiT  removal 

^fof  Bcirrlms  of  tlie  breast,  related  by  Mr.  C'jesar  tiawkins,*  it  is 

'      Botcd  tliat  "  ihv  ci-ntrc  of  tJio  nouk  flji[)uiirvd  »  littlt;  »mik  forward, 

M  if  die  upper  vertehnn  had  been  depresse<I  in  that  i>o3ition  ;"  and 

the  anatomy  of  the  affected  bono  is  tJiuit  dcscrilx-d  :  "The  body  of 

'  tlie  fifth  cervical  vertt>bra  was  very  in-egular  on  ita  Rm-f»c<!,  and 

L  wu  8oil«ned  throtijcliout,  wjtli  louch  unlarg«incnt  of  th«  colls  of  tho 

icelli,  which  were  iilh^  with  a  etanguineouH  pulpy  flui<l ;  tho  two 

Iwyoiniiig  vertebrsB  showed  a  lesser  tiegrcc   of  tlio  samo   morbid 

litructure." 

But,  allowing  that  many  of  the  recorded  cases  of  mollities  may 

IIm  rofcrrotl  to  Himpio  atrophy,  an<l  xontv  of  tlut  othiir!*  to  cancer, 

llhere  can  still  be  no  doubt  of  the  existence  of  an  independent  dis- 

[tmae  to  which  tluit  nain«  is  jwculiarly  appr(if>rinl«L    In  one  mich  case 

ulcd  by  Dr.  Bence  Jones, t  the  leading  feature  was  tbe  peca- 

'  ooudition  of  the  urine.     This  uttrnctwl  attvnl  ion,  tugether  with 

tbe  atate  of  the  patient'a  general  Iieatth,  long  before  any  alteration 

,  in  tho  buiivs  was  apparent;  in  tnet  no  alteration  in  tlivia  was  dt*- 


I 


Jlitd.-Chir.  Tmn$.  voL  xxiv.  p.  45.  Sec  also  a  caM  of  cancur  of  tbe 
lianca  after  ■oirrbuB  of  tlic  bi-cast,  di^scribcii  lij-  Uie  aulbor  iti  I'ath.  Sac. 
TVioat.  rot.  xi.  p.  i!10.  in  which  oonie  of  the  ribs  nvi-c  porftvtljr  flexible.  In 
'  vxmnininfi  a  oud  of  wcU-maikfrd  nanrrr  of  Uio  pitlvis.  I  hav*  found  ■  con- 
dition of  tho  innomiaata  bone  bearing  on  almost  «quaUy  cUiae  rcsomblaoca 
to  mullilifs. 

t  PkiL  Tnuu.  vol,  Ixvl.  p.  M,  Ttiis  is  the  same  efl*c  iw  Mr,  Dalryiople'*, 
alrvail}'  wfetToii  to, — the  paper  in  Uic  I'hilotnphiral  'ffmuattiout  wutaining 
,llic  aocouul  of  tlia  peculiar  *ub»UDce  fuund  in  the  niias. 


^K.llic  aocouu 


671 


DISEASES  OF  THE  BONES. 


n  t9 


COVakkI  Un  «ft«r  d^tb.  The  peculiar  substance  contalnod  tn 
urine  appoara  to  haw  booii  close!/  allied  to  albumvn.  Dr.  Bt-iice 
Jone«'»  oonclusiona  on  this  subject  may  be  quoted  hero:  *' 6ti'97 
parts  of  tliU  hvdratul  dvntuxkli;  of  iitl))im<>ii  woru  passing  out  of  Uw 
body  in  rverv  KKK)  parts  of  urine,  Honee,  thereforo,  liwtrc  was  as 
much  of  this  peculiar  itilMtminnn!*  ttiibntniiUD  in  t)io  urino  as  there 
is  of  onlinnrv  albunifin  in  lioaliby  blootL  tw  far,  tlioii,  lu  ihc  albu- 
men is  conoernod,  cac-h  (injico  of  urine  ]>»»«h1  was  L^juivsleni  u>  an 
ounce  of  Mooi)  U»t.  The  peculiar  characteristic  of  lhii<  hydrated 
dontoxido  of  albumea  was  its  iwUilnh'ty  in  Iwilin;;  w-at<?r,  and  the 
precipitate  with  nitric  aoid  being  dissolved  by  heat,  and  ru-furmed 
wheji  cfihl.  By  tliia  reaction  a  similar  substance  in  email  quantity 
may  bu  tletcct^-d  in  pus,  and  in  the  socretion  from  lh«  vcsieuhe 
»iMuinali>ii.  This  flubstance  must  be  n<B;ain  looked  fur  in  acute  ctwfti 
of  moUitics  ossiiim.  Tim  reddening  of  tlto  urine  on  the  addition 
of  nitric  acid  might  perhaps  lead  to  the  re-diseovorj-  of  it ;  wht'O 
found,  the  prescnoe  ofehlnrino  in  llie  urim\  of  which  there  wasa 
8U.->picion  in  tlie  above  caw,  should  be  a  special  subject  of  invi¥itifn>- 
tjon,  as  it  may  lead  not  only  to  the  explauaiion  of  tlio  formation  ef 
tliis  ittihi>tan<»,  but  to  tho  comprehensioa  of  tlie  uature  of  tlie  diMoow 
which  affects  tile  boiien." 

lln*©  ciLHwt,  then,  of  what  wo  may  call  true  mollitim,  are  dt»- 
tinguishcd  both  from  atrophy  aiul  from  caiioor  by  special  eharactera: 
from  atrophy  by  the  existence  of  vitiatod  secretion,  proving  the 
affcctiou  of  the  constitution,  and  by  th»  proscnoe  in  tlie  allt 
bono  of  special  morbid  t^lements ;  although  the  Latter  ilillierunco 
hardly  be  appreciated  during  life,  exct-pt  in  those  rare  imttanc 
where  tlic  boiKw  are  bwoUcii.  From  cancer  they  are  distinguisl 
by  the  ulrict  limitation  of  the  morbid  product  to  the  affected  Ixjii 
and  by  the  diU'crcnt  jiroj^Ji!*  of  the  conatitutionul  aft'oction  ;  siin 
tlic  patient,  if  he  dies  of  the  disease  at  all,  dies  of  the  e\hau!>li< 
produced  by  vitiated  secretion,  or  from  the  clfect*  of  mochauic 

in  extensive   fornialion  of 
lesi   from   traustcrence  of. 


inti.'rferenco  witli  the  viscera  ;    not,  as 
cancer,  from  pervertwl   iiittrilKHi,   null 


disonsu  to  remote  or^giana,  ^H 

Our  knowledge  of  the  true  pathology  of  tins  complaint  is  as  vet 
quite  defieii-nt,  and  so  it  follows  that  no  means  of  treating  it  are 
known.    Tlie  patient's  strciigtli  munt  be  mipported,  aiul  he  mtist  bqfl 
guanlod  from  all  exortion^  and  shocks.     If  bedridden,  liLi  |Ki.iition 
mu»t  be  accommodated  to  the  slmpo  of  his  limbs,  so  lu  to  correct,  if  _ 
possible,  the  existing  deformity  by  gra<Iual  traction,  and  to  prove 
any  greater  distortion.     Tlio  fractures  wliicli  occur  tu  thoeo 


CAXCER 


673 


iro  soDictiuios  cxvti3>ivvly  iiiiiiiciroiit^     l>r.  OiineroiI'D  patient  had 

'■  at  one  ami  iJie  aanic  iimo  no  fewer  titan  f/awn  i'vavUirtm  uf  tlifiej'* 

viit  I>oii(»>."     Vi-t  in  this  i-iuo  the  fractures  used  to  utiitc  iritli  llio 

rame  rcatUncwi  an  tliey  <lo  in  rJokdty  buiies. 
Msiiy  i)f  tht?  t-asos  arc  hardly  subjcctB  for  troatmout,  since  tlie 
(ItHcase  in  tlu^  lionet  uiid  the  (li.-<t»rlii)ii  ol'tlie  limbs  has  mh'ancxxl  to 

»nn  luiinanagcablo  oxtf^nt  before  the  patient  is  seen ;  and  it  would 
Lii  wju'wlj'  do-aii-ahle,  t-veii  if  it  wcro  ])WNiblc,  to  ]>rotract  tlic  course 
of  a  painleiui  but  inevitable  deoiv. 

^  Cancer  in  Ik»i^.  AU  tonus  of  itmlignaut  disease  are  met  widi 
in  the  bimi-«,  but  tlio  viicujdialoid,  or  mci biliary,  iis  by  far  the  most 
eommoii,*  Osteoid  caiioer  is  ahnost  oonfinoJ  to  the  bones  as  a 
(ii'imary  disoaw,  Hlthoiigh  a  v«ry  fiivt  castM  juv  on  record  in  wlitoli 
it  has  been  foiuid  in  the  s»ll  parts,  without  any  known  cancerous 
^Jitlectimi  'it'Lhu  l>oncs.t  Canwr  in  bone  may  b<i  i^itlicr  a  primaty 
lisease,  or  secondary  on  oaneer  iu  some  other,  and  u^matly  a  re- 
mote, organ.  As  the  gt^iieml  e<>nsitlorution«  a|>plicid*lo  to  inaJif;- 
Jiant  disease  have  been  describcMl  in  liie  essay  on  Cancek,  it  will 
uly  bo  noccMary  here  to  dwell  on  the  jx^uliaritJos  which  arc  found 
caiieor  when  dc\el()|)iHl  in  tho  bonos,  with  nrfei-enco  to  it»  wsit, 
lanncr  of  growth,  and  external  appeoranees,  and  to  ondeavouc  to 
[deduce  the  necessary  iiiti:roiiuc»  att  lo  diagnosis  luid  trcatincut 

AVith  respect  to  its  seat,  no  bone  is  cxt'uipt  from  tho  invasion 
if  tho  (litMuute,  but  iwmic  boiwn  are  far  iiioi-o  iiiibic  than  others ;  llio 
»ng  bones  of  tile  lower  extremity  taking  the  lead,  and  tho  femur 
'l>eing  of  all  others  immt  commonly  «tlackc<i.  Out  of  Ibrly  eases  of 
primary  cancer,  twelve  occurred  in  tho  femur,  eight  ui  tlie  bonos  of 
iho  leg,  five  ill  the  Hknll,  tliree  lu  tho  i>olvi«,  and  thre<.i  in  the  ftpine. 
Tile  others  were  single  cases  scattered  about  the  various  regions  of 
tho  body.     The  neiglibourhood  of  tho  kmr-joint  is  a  very  tiiMnii-ite 

rit  of  cancer;  so  tluit  a  sotl  tumour  springing  troui  the  lower 
^-—^--'  —  ^- 
*  In  tho  noMs  of  Ally  comw  of  mallsnant  dinciuu  uf  th»  bones,  nhldi  I 
liappeu  to  liuvo  by  mc.  lliirty-tlve  arc  rloisod  m  •.■nc«|)liiili>iil,  foQi- as  osteoid, 
four  nil  sriiTlius,  thi'oe  a>>  opiUielint.  onn  nn  ni'calur  or  colloid,  one  as  mela- 
noiiiii  of  thei  t'eriosteuui.  amlUiootlii^r  tivn  wcru  tuiaotm  of  iluubtfiil  nature 
atiil  lUiomaloas  struutuii-,  but  jn'obably  innliKDiuit.  Tlioio  notm.  liowcvtr, 
fwliich  oro  conijiosej  partly  of  I'sti-ncls  fi-om  booki.  partlj-  of  ciu«*  itot«il  on 
«oouut  of  iiiUri'aiin;;  fi-atur««.  ^niitAlit  too  kiftfl  n  pcrocnbige  of  mn  forms 
|of  disease.  TJiU  is  evident;  in  the  nutuhrr  of  rsac*  of  ortcoJd  cancer, 
t  See  I'ogct,  Surg.  Path.  VoL  d.  p.  490. 


674  DISEASES  OF  THE  BONES. 


'^ 


much  anxiety.  Out  of  tiio  alHrto-mentionod  twenty  ca«es  of  cancer 
of  tiio  long  hones  of  tlio  lo^vci-  liuib,  vlovun  iirc  iiotvtl  to  Iia\i.' 
grown  near  the  knee-joint. 

The  common  kind  of  cancer  in  bono  ]>rc»ontJt  itsolf  in  Uiro- 
principal  foi'nin,  \'iz.  periottteal,  interstitial,  and  infiltrstod.  Tbe 
last  is  by  far  tlio  least  common.  When  carriod  to  tto  cxtranv 
degree,  tliewbolo  bon«  ia  suni^iicd  liy  Hhi  ilist«(ision  of  ite  oelU  with 
tlio  mutci'ial  of  soft  cancer,  leading  to  pniiial  or  coniplcto  absorption 
of  tho  cancelli,  and  pmcral  diMintognttinn  of  the  bone.  In  ihia 
condition  it  forms  one  of  the  aifectious  of  bono  which  arc  inclutied 
under  ihe  name  "  mollitics  owiinn,"  nndi^r  wliieJi  liojul  it  has  been 
refeiTed  to  above.  The  periosteal  form  of  cancer  appears  to  bo  tliu 
moru  cuinmoii  in  ttie  loiijj  bone*,  while  tlie  int^irstilial  in  certainly 
the  one  more  usually  met  with  in  the  tiat  bonefl,  sucb  as  the  akuU 
and  pelvis,  and  in  tltc  joint-ends.  The  intcrsUtial  form  i»  found  in 
tlie  shape  of  nodules  of  various,  but  usHally  small,  size,  scattered 
about  the  ciuiccllous  tissue.  They  are  whitish  in  cwlotir  wlieii  stiudt 
and  reeently  depoAiteil,  and  generally  givo  out  a  creiuny  juice  under 
prensure,  exhibiting  tho  various  cell-forms  usually  met  with  in  the 
jnice  of  malignant  tuinotu's.  In  the  linrclor  kind  of  these  nodulea, 
following  Kcin'hous  ciinccr  in  the  breast  (and  to  which  the  designa- 
tion ••  acirrhiw  of  tho  bones,"  used  by  some  writew,  a[^ti«s, 
while  others  call  tlicni  '<  hard  cncejihatoid"),  I  have  somotimos  been 
unable  to  recognise  luiy  eanoer.jui(H',  or  any  ofill-su-iicturea  cha- 
racteristic of  cancel','  This  intei'stitlal  deposit  of  cancer  is  pro- 
ductive of  constant  and  wearing  puin  iji  tJio  part,  vory  frcqitfiiitly 
followed,  in  a  long  bone,  by  fraetnre  on  some  slight  injury-  or 
oven  ntiueiilar  exertion.  After  stinie  time,  during  wliioli,  if  frnc- 
turo  hiui  taken  place,  it  may  have  consolidated,  a  tumour  makes 
its  appcaruiiee,  Tim  disease,  having  overcome  tho  rc»i:<tunco  oftlM 
periosteum,  now  grows  rapidly.  On  dissection,  ft  large  niaas  of 
soft  cancer  is  tbiuid,  in  which  tiie  periosteal  onvcloijo  of  tlio  tumour 
may  or  may  not  be  recognisable,  mid  which  sjirings  from  tlie  bone 
by  a  narrtuvcr  base,  while  it  generally  extends  further  in  tJio  cnn- 
oellous  tissue,  or  to  a  still  greater  extent  in  tlio  medtillnry  canaL 
111  rarer  cases,  several  scfiarate  noilules  arc  found  scattci-od  aliout 
the  eancelloiis  tissue.  Tlio  hone  in  the  neigh boiu'hood  of  the  4nui- 
cerous  deposit  is  often  thickened,!  sometimes  to  an  extent  that  can 
bo  appreciated  by  external  examination. 


1 


'f  This  wna  so  in  a  esse  roporlod  In  Path.  Sof.  Tntn*.  vol.  xi.  p.  9tt. 
t  i'ugol.  Surg.  Path,  voL  ii.  p.  8C3 ;  Path.  Soc.  Tnuu,  vrf.  X.  p.  S4S. 


CA^XEB. 


675 


I    ofTi 

H  Stan 

I 


The  accidental  peotdiaritieet  of  slinjio  niul  nrrangenient  !u  the 
rarioua  »])ccimciii)  of  intentitial  deposit  of  cancer  Iiavo  given  ri»a  to 
(lilTorent  terms,  which  Iixving  now  taitt  »aran  of  tlieir  sjgnilicancc, 
ooght  to  Ix-,  and  havo  very  gCDwally  been,  allowed  to  bccoinn 
obsolete.  Thun,  ivIiimi  »ucIi  a  dejKwit.  in  ttio  ftrtic-ular  oik)  of  a  bono 
grows  into  a  number  of  flancelli  in  dift'erent  directions,  tlio  whole  of 
the  head  of  the  bone  becomes  cnlitrgccljfonninj^n  sort  of  innltilooH- 
Ur  tgrrt,  tho  spaces  of  which  «re  filled  with  the  tumoiii-,  and  Uio  sur- 
rounding part  of  the  bone  a  good  deal  consolidated.  S»i(j1i  a  »«'oll- 
ing  has  been  called  tho  vialitjnatil  ex^wloni*.  In  other  eases  the  soft 
tumour  vxpiuuls  tho  outer  layer  of  tho  bono  uniformly)  without 
producing  Iraoture,  and  tlius  it  ttwolting  h  formed,  the  wall  of  which 
cracklt^  under  tho  finger,     This  was  called  a  sptjui  ventoM. 

In  tho  pcriuAtoiil  form,  thu  tiiinoiir  iiiako:*  itn  iippeanuice  Hooner 
and  grows  moro  rapidly  than  in  the  interstitial.  The  subjacent  bone 
is  generally  (piilo  uniitt'iK-t"!,  and  a  nccti<)n  of  thr  di*oiwc  nhows  a  ring 
of  healthy  bono  surrounded  by  a  radiating  mass  of  malignant  sub- 
stance.    Tho  periosteum  a])j»ear8  in  some  case*  to  havo  degenerated 

bocomo  concerted  into  tlio  structure  of  tho  tumour ;  in  others, 
may  bo  traced  orer  tho  tumom',  which  then  seems  t«  grow 
l)Otwe«n  tho  bono  and  pcriosloum.*  In  this  form  of  tho  disease 
there  i«  u  strong  tendcney  to  ossitieatioii,  so  tliat,  after  niaecration, 
a  large  quantity  of  iri'ogtilar  liony  de))0)>it  ift  lofl  oit  the  surface  of 
the  bone,  fonning  very  often  a  coral-Uke  mass,  with  some  approach 
to  a  spiral  arraiigemont  of  its  Iniuina-.  Tht^n  sjtecinnTiis  were  often 
doHcribod  by  tlie  older  writers  as  periosteal  a^ostosos,  their  tni« 
nature  litring  overlooked  in  consc<i«cncc  of  tho  Iwno  not  having 
been  examtnod  till  afW  maceration. 

Cancer  in  bones  is  sometimes  said  to  bi!  a  le**  rapidly  fata!  dis- 
•asc  than  in  the  soft.  |«irts,  and  perhaps  if  wo  compare  it  (as  would 
aeem  most  correct)  with  tJic  average  duration  of  foft  cancer  in  the 
•oft  parts,  tbis  may  bo  so ;  but  tho  diHerenco  is  not  very  marked. 
In  twenty-eight  of  tho  eases  contained  in  my  notes  tho  di»onM)  waa 
followed  till  tho  jiaticnt's  death  from  its  commencement.  witJt  such 
ftjiprouch  to  accoracy  as  is  possiblo  in  thcso  circumstances.  In 
twelve  of  tliom  <Ieath  took  place  in  lext  tlian  a  year  (in  five  in  Iobs 
than  half  a  year)  after  tlio  first  s™ptoms  wore  noticed  by  tJie 
poitictil,  and  ten  of  tho  others  died  within  tlic  second  yew.  In  two 
only  of  the  remaining  cases  was  the  disease  protracted  mnofa  be- 
yond the  usual  period  of  duration  of  cancer,  but  tirathcr  were  caaea 


*  Ptah.8<x,  Tntaf.  ^-oL  i.  p.  820. 


676 


DISEASES  OF  THE  BOSE& 


of  cnccjilialf'id  cftiioer:  one,  ii  pjiso  of  railloid,  might  jwxwiWy  lie  vr- 
roiieously  classed  among  malignant  diseases.     The  tnio  oncephaloid 
cancvr,  thcnt,  in  tlte  botio»,  lut  in  other  piirta,  in  moro  ni])i<Uy  tntal 
than  sarrhlis,  although  its  progress  in  the  bone  may  he  somewhat 
leM  ntpitl  ihiui  clm'wlii-rc.     Hut  lK'!tiil(!A  thi^  riKiiplmloid,  nil  nther^^ 
forms  may  in  exooptional  eases  he  met  with.      Some  pathologists|^| 
ilMlocd,  deny  the  <*xi.i(oiioe  nf  wirrhiis  in   ihi!  Ixuh's,  jiri-ii-mng  to 
call  tho  small  hard  nodules  found  in  the  Bj)ine,  iikiilt,  juid  Icnj^— 
boncE»,  wjcondarily  allcr  scirrlius  of  the  hroust,  and  mi>n>  rarelj^^ 
after  scirrbus  ofotlier  parts,  as  "  hard  eneophaloiil."     Tho  differ-^i 
onoo  in  lumicnclature  i«  u  iiuittcr  of  no  iinjini-liiiice.     Hard  canoor, 
indeed,  when  deposite*!  in  the  hones,  cannot  of  coiu*se  draw  to  it^eb' 
the  iR'ighhoKriug  jwrts  and  thiw  re<f«oo  the  «>Ium«  of  tho  organ  in 
which  it  in  placed,  so  tliat  it  is  destitute  of  Uint  puckering  so  cltt- 
ractcrirtie  of  scirrhus  of  (ho  breast.     But  in  otlicr  re«pcct«  it  8eoni« 
identical.   Tlie  small  irregular  Iinnp,  creaking  under  the  knife,  emit- 
ting a  vt-ry  scanty  juioo,  and  presenting  luider  the  microscope,  bcsidoi 
n  good  deal  of  common  iibrous  tit«ue,  only  Hmnll  nudear  bodioii, 
those  pcrlm[ni  in  no  very  liirgo  proportion,  bears  a  sufficiently  cl' 
resemblance  tti  scirrhiipi  in  oilier  partA  tn  deserve  the  »«ine  nmati 
more  especially  when  only  another  product  of  the  scllsamc  disease 
Epithelial  cancer  attacks  hniies  usually  in  tlio  cotirsu  of  a  caiiecroa!' 
ulceration  of  (lie  soil  ])iu1.s  M*hic!i  cover  thorn,  hut  iK-attered  instances 
of  its  occurrence  as  a  jirimarj'  diw-aso  ore  on  record.     Thu«  in  the 
Patliolog.  Soc.  Tratifadions,  Ix.  358,  will  ho  found  a  description  of  this 
disease  in  tlic  haj^c  of  tJic  skull.     It  presented  tho  ujtjioarunoc  of 
a  mass  of  fibroid  tissue,  the  meshes  of  which  were  filled  with  a 
yellow  opfl(|uc  and  thick  inateriiU,  which  t-ould  be  »qucc»>fl  out  in 
tlio  form  of  eommetloncs,  and  consisted  of  a  mass  of  ejiithelial 
sciiles.     But  these  oiises  are  of  too  riuv  occurrence  to  have  much 
of  practical  importance ;  nor  in  tlio  few  seattercil  cases  of  colloid 
disca-sc  nfTecting  I>onc-s  with  wliicii  1  am  imiuaintcd,  is  thoro  any 
tiling  to  throw  light  oa  tlie  conti'overay  as  to  the  maUgnant  or  n' 
malignant  nature  of  that  afloction.     Mohuious  idfcctx  bones  v 
rai'ely,  and  probably  is  alwaj's  a  secondary  formation.*     The 
teoid  ciuiecr  has  bixru  sufficiently  doscribwl  cUcwhcro  in  this  work 
(vol.  i.  p.  533). 

lu  tlie  dia^ofU  of  cancer  of  tlie  bones  two  diffictdties  present 
themselves,— /)>jir,  to  distinguish  between  u  Hoft  tumour  and 


idai      I 


any 

1 


«  A  Tew  prapftratioiia  utny  be  foinid  iu  oui'  n)as«unii ;  *.f.  St.  Georgelj 
Ilospiul  museum,  ser.  ii.  234. 


DUGNOSIS  OF  CANCER 


677 


I 
I 
I 


rotJier  influiiimixton-  affl-etion;  luiil  second,  to  diMingtii»]t 
botveen  a  malignant  ami  an  innocoiit  tuniuur. 

Tbe  diagnoMs  butwri'ii  :t  tumour  and  aa  alisccss  U  somotituos 
very  difficult  Tho  question  txwura  only,  iw  tar  as  I  liave  seen,  in 
tlic  tioiglibuurhood  of  a  joint ;  vrhcro  also  tlie  question  somotimcs 
ift,  whether  the  aweHing  in  not  dun  to  tliickmitig  of  tho  aynovial 
uionibraiie.  Generally  speaking,  however,  the  soft  tumour  is  limited 
to  one  portion  of  the  circumforvnce  of  tlio  bono,  whiio  diniMio  of 
tJic  fiyuorial  mt-mhrane  would  involvo  tho  whole  ciroumference,  al- 
tlkough  not  ncccsHarily  ivjuaUy  [iromiiiont  over  the  nholo.  l**urlh('r, 
tho  clironic  thickening  of  Uie  synorial  meinbrauo  will  have  bcou 
pnKyxled  by  a  long  course  of  itympt»inK  of  discaiio  in  tlio  joint, 
and  these  symptoms  will  ])robabIy  have  boon  more  acute  at  some 
previoHS  time;  whik?  tlio  tumour  will  have  oommoucod  much  mor« 
rcewitly,  at  Brst  without  any  s^-mptoros,  and  the  symptoms  will 
have  been  ninro  mnrkvd  M  the  tumour  got  larger.  IJinttwl  ab- 
Dcessos,  also,  in  tho  thickness  of  the  swelling,  are  common  in  tijo 
chronic  synovial  di»eaHe,  while  abscess  ia  a  rare  complieation  tti 
the  coni-so  of  a  tumour,  and  then  forniii  e:tti.Tnal  to  it  and  singly. 
Tin-  following  inslanei?  of  the  occurrt-nefl  of  abscess  around  a  rapidly 
growing  timiour  will  illtistmto  the  ditticulW  of  tho  diagnosis  >n 
such  a  cv.'n\  A  young  woman  was  recently  admitted  into  St. 
George's  Unspital,  eonijilainhig  of  pain  near  the  ankle ;  no  diHcaaed 
appeanuice  tlien  existed.  Soon,  howovor,  a  soft  swelling  made  its 
apjit-amnce,  fluctuation  ivus  delected,  and  an  incision  behind  Uio 
internal  malleolus  gave  exit  to  pus  mixed  with  blood,  and  os]>osi'<l 
A  cavity  which  appeared  to  bo  thtit  of  au  ordinary  absCTJiw.  After  a 
few  days  arterial  Iia^morrbage  eamo  on,  and  soon  l>ecamo  uiicon- 
trollablc.  PtilHntion  aUn  bocanio  evident  in  tho  swolling.  Tho 
incision  wns  extended,  and  sovernl  pieces  of  soft,  broaklng-down 
tiMue  e»ca]M»l ;  tho  finger  pawed  into  a  mass  of  fuiigoiw  matter 
spruiging  from  the  o&  calcis.  After  ani]>uIation  ihe  disease  was 
secu  to  bo  a  Koft  tumour,  about  the  size  of  a  walnut,  cunnMtted  by 
n  broad  base  to  ihe  coleaneum,  and  ^un-oundiiig  the  posterior  tibial 
ve**eU.  The  artery  showed  a  small  pci-foration.  It  it  solilom, 
however,  that  such  diHiculty  i*  esperi<'need  at  in  ibis  case  in  form- 
ing tbo  diagnosis;  and  if  from  tho  ambiguity  of  tho  symptoms,  and 
llie  ihickneas  or  tension  of  tlio  soft  parts  over  tho  swelling,  doubt  is 
felt  as  to  tho  presence  of  a  soft  solid  or  a  eolloetiou  of  fluid,  tlic  ui- 
tjfoduetion  of  a  grooved  noeiUc  will  in  nio.-<t  eases  <lecido  the  question. 
Usually  tile  lobulated  surface  of  the  tumour,  and  tlie  healtliy  and  un- 
inflaniod  state  of  its  coverings,  .tuffiee  to  distinguisli  it  from  an  aliscesa. 


i 


!  678  DISEASES  OF  THE  BONES. 

The  diagnosis  between  malignant  and  innocent  tnmoors  is  oft 
,  veiy  difficult,  and  Bometimes  impossible.     It  is  of  most  important 

and  unfortunately  is  also  of  most  difficulty,  in  those  which  grc 
around  the  lower  end  of  the  femur.  Malignant  and  myeloid  t 
monrs  here  often  bear  the  strongest  resemblance  to  each  other, 
that  the  diagnosis  in  an  early  stage  of  the  cancerous  affection  a 
be  only  conjectural.  By  a  reference  to  the  essay  on  TunOB 
'  ;  (vol.  i.  p.  492)  the  reader  will  see  that  the  points  to  which  i 

t  Surgeon  is  to  direct  his  chief  attention  are  the  length  of  time  durii 

,  which  the  tumour  has  existed  without  constitutional  or  glandnl 

f  r  affection,  the  bulk  to  which  it  has  attained,  and  the  extent  of  i 

[ '  attachment  to  the  hone,  since  myeloid  disease  is  an  affection  oft] 

cancellous  ends,  while  encephaloid  often  surrounds  the  shaft,  to 
considerable  extent,  forming  a  long  oval  tumour,  like  a  great  ferul 
But  it  must  be  allowed  that  the  diagnosis  between  these  forms 
\  ■  disease  can  hardly  be  expected  to  be  accurate,  inasmuch  as  there 

strong  reason  for  believing  that  myeloid  tumours  are  occasional 
■     ■  malignant.     There  are  other  tumours  also  which  could  hardly  1 

distinguished  from  cancer  until  a  long  progress  had  proved  the 
innocence.     Such  are  the  fibro-cystic,  to  be  afterwards  mentione 
-  I  and  such  may  also  be  the  case  sometimes  with  encbondroma,  ai 

'  with  the  diffiised  osseous  tumour.     It  is  only,  however,  in  the  vei 

■'  early  period  of  osteoid  cancer  that  its  malignancy  is  not  a  prominei 

'f  feature.     It  grows  rapidly,  extends  far  along  the  bone,  and  sw 

'  1  affects  both  the  constitutional  powers  and  the  absorbent  system.' 

■  /  In  general,  malignant  tumours  of  bono  may  be  known  by  the 
'  f-                           large  size  and  rapid  growth,  their  soft;  consistence,  the  uneqa 

■  '  density  of  different  parts,  the  largo  veins  which  ramify  over  then 
i  .  the  extent  of  their  attachment  to  the  bone,  the  frequent  presence  ■ 
I  large  sanguineous  cysts,  the  amount  of  pain  by  which  their  growi 

is  attended  and  often  preceded,  and  the  rapid  destruction  of  boi 
which  they  occasion.     To  these  local  symptoms  the  general  symj 
i  toms  of  the  constitutional  affection  may  be  superadded. 


'  , '  *  Two  cases  of  osteoid  cancer  of  the  femur  have  been  in  the  surgic 

'  i  ;  wards  of  St.  George's  Hospital  within  the  last  few  j'ears.    In  one,  altbou; 

the  affection  n'as  not  of  long  standing  (lees  than  a  year,  I  believe),  tl 
inguinal  glands  presented  the  cbaracteiistic  bony  bardness.  In  the  othe 
the  tumour,  which  waa  mixed  with  encephaloid.  was  growing  rapidly,  an 
contained  a  large  cyat,  the  tension  of  which  occasioned  much  pain,  reticTc 
bj  drawing  off  the  fluid.  Amputation  at  the  hip  was  successfully  performs 
by  Mr.  Tatum ;  but  the  disease  recurred  in  the  lungs,  mad  proved  fotal  i 
about  half  a  year. 


'\ 


TREATMENT  OF  CANCER. 


679 


I 


Tho  irontmcnt  of  canoer  in  all  ]Kai6  of  tlw  hwiy  rcsolvwt  iUclf 
<{ncHtioii  of  lenving  it  nloiut,  or  or.iiJicatJiig  iL  flic  ouly 
itivlliod  of  vxlirpEitin;;  iiiuli-^nant  diwntw  of  any  bono  wliivli  is  at  uU 
oalJsfaolory  is  bv  excising  llio  tiiinottr  nloiig  wilh  the  whole  thick- 
ncss,  at  niiy  rate,  of  tbv  )>art  of  boim  from  which  it  it]>riiif;)'.  To 
remove  the  tumour  from  tlie  miriaco  of  n  boite,  in  tlie  wioertaia^ 
whicli  mu«l  ahva\-s  exist  nhftbcir  «inc-LT  hait  not  iilito  iiiIix:t<Ml  (Iiu 
interior,  would  bi^  highly  imiiriKluiit.  Nor  is  this  sufUdent ;  for 
if  tbo  disea&o  can  bo  dearly  mndo  out  to  bo  canccroius,  the  wliolo 
limb,  including  tlie  entin^  horn;  which  U  the  sent  of  the  disciise, 
on^t  to  be  sinjititatcd.  When  t)ic  tumour  ts  situated  in  tbo  leg, 
itds  is  a  matrer  ri><|uirii)g  eonijinratively  little  deliberation ;  tlie 
ehoiw  only  lies  between  amputation  of  the  leg  and  of  the  thigh, 
and  die  dillurenM!  iM^twccii  one  stum|>  and  niiotlier  in  of  slight 
moment,  compared  to  tli©  risk  of  a  rotttm  of  malignant  diHeasc. 
U«t  if  (lie  luimiur  nffw'^.,  an  it  »o  eommonly  does,  tlie  lower  end  of 
the  femur,  tJiL'  (juc'Btion  hoeomea  a  gi'ave  one;  since  amputation  at 
the  liip-joint  must  bo  porfurmi'd  if  the  dttoase  i»  olearly  tltngnosed 
as  being  cancerous.  No  other  general  rules  can  be  hiid  down.  If 
tlicre  ii*  a  rojisonablo  doubt  whether  tJie  tumour  bi'  soil  cjimwr  or 
myeloid,  or  whether  it  bo  hard  cancer  or  diffused  bony  tumour, 
luuIoubt^Hllr  the  wit(e«t  courw  is  to  give  Uic  patient  tlie  Iwncfit  of 
that  doubt,  and  to  remove  tlie  limb  at  tlie  lowe^it  level  at  \vliIoh  tlie 
ineisionit  can  bo  carried  dear  of  ttio  tumour.  Even  if  the  diM-jiM 
should  prove  to  be  caneer,  inx^tlbly  l}ie  reeiirring  disease  may  bo  in 
the  cicatrix,  and  ampntatioD  of  tho  stump  at  tho  liii>-joijit  may 
prolong  life.  But  so  many  com^s  are  on  reenni  in  which  what  has 
been  EU]>|)oscd  to  bo  malignant  discaik)  in  tlii«  part  (niid  whieli  in 
»U  the  KU»-»  wan  iiitLst  likely  myeliiid)  hof  been  »>iupletcly  arrested 
by  amputation  of  tbo  thigh,  that  it  is  only  right  to  tiy  the  mililcr 
operation  in  oaiies  not  evidently  cniiccrous."  In  the  foro-arm  the 
character  of  the  disease  is  usually  better  marked  (as  far  as  1  lia%'0 
teen),  or  ill  dnbions  etw.-' tho  nlltrrnativo  'i»  not  of  mucli  imjmrt^ince; 
nor  in  tlio  humerus  is  tho  removal  of  tho  limb  at  tho  shoulder-joint 
,'  any  iimiuN  »>o  formi<Iiible  iu  eom[)ari«oii  a»  in  the  lo\\er  limb, 
ica  in  the  upper  limb  tlie  rule  nhould  ho  the  reverse  of  that 
tbo  fiimitr,  vi/..  that  in  eases  of  doubt  tlie  eiilire  limb  ought  to  bo 
roinoTod. 

Wliat  is  tho  benetit  of  «ini>utat.ion  in  *ueh  cose*  as  tliew?    This 
is  a  question  very  dIfBcult  to  determine,  if  the  question  be  limited 


*  S«e  Mr.  Gmy'i  [•ajier  in  Mtd^Chir.  Trattt.  vol.  xxxix.  p.  litL 


6f(0 


DISEASES  OF  THE  BONES. 


m 

I 


t"  tin'  p,"([ipctiiti<>ii  nf  life.     SpaKwrod  pases  nro  met  with  here  and 
tlioro  in  nliiclt  :i  disease  apparently  mali;i^iant  litis  seeniotl  to 
chcekcil  aft<T  ampul  aliou  ;  nay,  whoiv  it  lia."  i-wriirred  aftiT  iitii[Ht- 
tatioi),  an<l  ihon  beon  cbwskcd  by  amputation  higher  up  :*  but  thes 
an?  riirn  cxwptiims.     nu;  di.-^^!ii.4o  may  'w  cxpitcttnl  to  rwnir,  andj 
to  prove  fatal ;  and  tlio  operation  mast  be  defimded  r-ither  on  it 
fjrminds  nt'  biuiiaTiity  tlmii  of  ncioiitifii!   iiuliciitiimi^  as  ofllinding 
relief  from  present  suft'eriiig,  and  tlie  clian^e  of  an  int<^n'al  of  somi* 
moiitlis,  pcrliaps  o\on  longer,  of  Iieuitli,  nithtT  than  as  lidding  out 
niuoli  jtrtis]>ect  of  a  radical  onre  of  the  (complaint. 

I'ulmtile  tuinour.     A  rcinnrknblc  featun-  in  mnlignnnt  tumours, 
of  bono  i.1  the  occasional  ooein-ronce  of  pulitation  in  tliein.     This , 
pulsation  t-nn  Sfimctimc*  be  with  difficulty  dirtiuguishwi  from  that 
of  ordinary  or  &apculate<i  anouriKm.     The  nwcmblanee  at^o  wlitoh 
thc§e  mulignitnt  tumours  of  bono  Kom(?timcs  bear  to  tho  aneuriHUs 
by  iiHii-itomosis  is  no  atrong  that  they  Iiave  been  defttTihi-d  nhniMt 
down  to  the  present  timo  as  *'  anom'istns  of  bonc,"t  and  liave  beeit  ^A 
believed   to  cousiitt.   merely  of  a   dilated  \esittA  or  \'cwteU  ia  tliO'^l 
int<irior  of  bu  otherwise  healthy  bone.      But  it  is  now  admitted)  tli.it  ^ 
the  great  majority,  at  luiy  ruto,  of  these  so-enlkil  "  wteo-oneurism*"  ^J 
were  really  pulsatile  malignant  tumours,  and  that  the  exiatence  (if^l 
liny  diseiisL-  in  the  eaiKflloiw  tiKsuc  of  bone  analogous  to  aneurism      -' 
by  anastomosis,  and  therefore  curable  by  local  incaaures,  ia  liighly 
rioiibtfiil,  if  not  absolutely  disproved,     Tlie  reserablaucK',  howevvr, 
is  in  the  highest  degree  peqilexing  >chi-n  iIk-  jmlsatile  tuntoitr  occu 
jiii'^  a  situation  whero  aneurism  by  anastomosis  is  common,  sucb  as- 
tlie  scalp. 

A  woman  iipplifd  a)  St.  George's  Hospital  some  years  ago  oit 
account  of  a  pulsating  tumour  on  iho  vertex  of  tlie  liend,  Mr.  ^j 
Pn>sCott  Hcniett,  under  whose  care  she  was  ])lflu-d,  came  to  tbe^^f 
conelnsion  that  the  disease  was  a  mnlignant  tumour  of  the  skull, 
niul  dissuaded  Iier  from  any  operation.  Being  anxious,  however,  (o- 
have  the  tumour  removeil,  she  consulle<l  anotlier  SurgtHm,  who  g»vo 
it  as  his  opinion  that  the  tuniom*  was  an  aneurism  by  amistnmosis. 
and  might  be  exiirjmted.  Mi-.  Fivseotl  Hewerl  aceonlingly  sought 
tho  advice  of  his  colleagues,  and  after  a  careful  esumination  Uiey 
confirmed  him  in  Iiis  uriginnl  opinion,  that  tlin  tumour  was  maltg- 


•  Path.  Sm.  Trani.  vol.  vi.  p.  aOl. 

+  Sfi'  .'"[leciiiUy  a  pn|iiT  by  Bi'cschot.  "■  Ohufnalhnt  ft  Itefl4:xiont  nr  Jri 
Tumfuri  mn'jainn  d^un  eoTactirt  tquinque.qxiipaTaitiatle'lre  daamitriimnit* 
artire*  ilt*  ot." 


I 


PULSATILE  TUMOUR.  f»Sl 

nnnt,  wm!  Icul  [lerforatoj  tlio  cranimn.  Hp  tlieivforp  declined  to 
ojKTitc;  imd  ilic  wonmn  w!w  jilneotl  in  jiiintJiCT  liongiitAl,  l»j-  Uo* 
ndvi«t  of  tlie  f^itloman  whom  slie  had  siihaoqiiently  roiisulted,  and 
who  thpii  ntU'ni]it(Hl  to  cxt-isf  ttic  TOiiiMMfd  vnwMiliir  tumour.  Ttw! 
original  diagnosiw,  liowover,  tuniwl  out  to  bo  t-orreot,  and  it  benunfl 
nooe*«iry  to  gW«  up  the  o[>crntiDii.  Suvh  cnw*  an  tiiw«o  xhnw  tlic 
difticiiUios  whiph  may  Ix"  exporii^nowl  in  diagnosing  the  nature  of 
isuch  a  ttimDiir  in  thi^  iscalp;  hut  it  tnoru  frctguvntiy  oc-viirt  tliat  tlio 
IMilftatilo  tnmour  of  liono  iit  situat^H)  on  tho  eoumo  of  iwnio  Uago 
iirtpr>',*  and  (■imnliitc"  an  ordinnrj'  anciiriiiin. 

The  aiuitoniy  of  theao  tumoura  is  a»  follows:  they  a|)ring  from 
the  cancellous  interior  of  tlio  bone,  oxpanding  and  eroding  iljt  coc- 
teniat  aholl,  imtil  thev  hiirst  out,  iVeijuently  on  both  ai<io«  of  the 
t)unc  at  onw,  forming  lobulatcd  masscH,  whtdi  sometimes  attain  a 
largo  si/e.  On  section  tliey  are  (tocn  to  \w  r«t\,  of  a  Acdhy  con- 
suttonco.  and  eontainuig  large  spaces  or  crlU  filled  with  hlood,  from 
tlio  pulwiltoTi  of  which  the  tumour  <Ii>rivi>H  its  movements,  and 
whidi  must  therefore  communieate  froely  witJi  tJio  main  arterios 
Around,  thi.ingli  thr  exiu't  nature  <>f  that  communication  has  not  yet 
been  demonstratoil,  Tlie  pulsation  appears  to  depend  on  tho  re- 
sistance of  the  periosteum,  which  i»  oflcn  thickened.  Hcnco,  when 
tlio  periosteum  is  penetrated,  the  pulsation  fre<]uently  diaappoan; 
US  that  of  an  anmirism  wilt  do  when  tho  sac  Iia^  given  way. 
Tile  mieroscopieal  ehametcrs  of  soft  cancer  can  ha  recognised  in  tha 
stmclnro  fonning  tho  walls  of  the  cells.  Spicnla  of  bono  are  often 
fomid  mixed  up  with  tlii?  malignant  matter,  llic  tumour  fre- 
qncntly  affects  the  large  veins  in  tho  neighbourhood,  projecting  into 
Uiem,  or  even  blockin^i  tlicni  up;  aiul  several  such  tumonrs  may 
exist  together,  or  malignant  disease  of  the  ordinary  enccplialoid 
I'aricly  may  lie  lonnd  in  Muno  otlicr  oi^ii  of  the  txHiy.  (See  the 
case  quoted  on  p.  384.) 

The  ilingniMiti  of  a  pulsatile  malignant  tumour  of  hone  is  very 
cosy  in  some  cases,  almost  impoiisible  in  otliers.  It  is  easy  when 
tho  tnntour  sjtring!!  from  u  en|H>rficiaI  Imne,  lie*  nway  from  tho 
course  of  any  largo  artery,  an<I  has  no  bruit;  and  still  more  so 
when  other  malignant  tumonrs  or  symptoUM  of  malignant  disMM 
nre  present ;  bat  where  tts  ooniioxion  with  tho  bono  is  obscure  by 


*  Sunfa  tamnun  may,  however,  (arm  in  Any  bone  ivitli  copioui  dtploJr. 
In  Iho  /■'iluiti.  M/il.  amd  Sury.  JoHrm.  Nov.  180O,  p.  453.  in  ■»  ac'wiiuil  of  ana 
which  impliraicrd  tlin  biuilar  prooesa  of  the  occipital  bone  and  lh«  first 
Ihrco  cervical  vciiirbnB. 


4 


€82  DISEASES  OF  THE  BONES. 

reason  of  the  depth  atwliicli  its  baJte  lies,  when  a  large  art«ry(wlu' 
is  generally  the  iliac  or  gluteal)  lies  near  its  situation,  when  i 
pulsation  is  accompanied  by  bruit,*  when  the  tumonr  is  solitary  ai 
the  general  health  unaffected, — it  becomes  a  matter  of  the  utmc 
difficulty.  Enough,  however,  has  been  said  above  on  this  subje 
(sec  p.  383). 

In  cases  where  other  tumours  exist,  or  where  the  Bymptoms 

constitutional  cancer  are  present,  no  doubt  can  be  felt  as  to  the  ii 

efficacy  of  local  treatment;  the  disease  declares  its  malignancy  I 

the  same  signs  as  cancer  in  otlier  parts  of  the  body,  and  its  pr 

V  li  gnosis  and  treatment  must  be  the  same.     But  are  there  any  pulsati 

tumours  of  bone  of  a  different  kind,  iu  which  tlie  Surgeon  can  ho 

out  a  hoi>o  that  tlie  cxcisiou  of  the  tumour,  or  its  consolidation  1 

chemical  agents,  or  by  ligature  of  the  artery  which  leads  to  it,  w 

offer  a  reasonable  hope  of  cure  ;  or  must  the  patient  be  senteno 

to  the  hard  alternative  of  death  or  amputation?     The  belief  th 

these  tumours  are  ever  local,  and  are  curable  by  local  measures, 

one  which  seems  to  become  less  strong  as  more  cases  are  seen  ai 

followed  to  their  termination.     Thus  Cruveilhier,  who  some  tin 

ago  shared  the  then  prevalent  opinion  as  to  tbe   local  nature 

the  "erectile  tumour  of  bone,"  expresses  himself  with  much  mo 

reserve  in  his  latest  work,t  regretting  that  all  the  cases  he  h 

'  himself  seen  have  turned  out  t«  be  encephaloid ;  and  such  seems  al 

I  to  be  Rokitansky's  opinion.}   If  we  mayjmlge  from  recorded  case 

)  ahnost  every  one  in  which  the  history  has  been  followed  out  h 

■   '.  run  the  usual  course  of  cancer,  and  the  osisfenco  of  what  used 

be  described  as  the  osteo-aneurism,  i.  e.  an  innocent  pulsating  ti 

mour  of  bone,  in  which  it  would  be  right  to  attempt  to  coagula 

'■  the  blood  by  injections,  or  to  produce  consolidation  by  hgature 

i  the  main  artery  of  the  limb,  is  quite  problematical,  although  mat 

such  attempts  have  been  made,  and  failed.     Lallemand's  caBe§  i 

j  ■■  it  is  true,  usually  quoted  as  a  success ;  but  this  conclusion  is  pr 

j  -  mature,  since  the  history  terminates  a  few  weeks  after  the  oper; 


.  I 


'i.  '■ 

i     ■ 


i. 


•  CruTeilhier  (AnatoniU  Pathohgiqut,  18B6,  vol.  ii,  p.  001)  i-elates  a  ve 
interesting  case  in  which  an  encephaloid  pulsatile  tumour,  springing  fro 
the  bones  of  the  skull,  presented  so  marked  a  thrill,  and  a  sound  so  exact 
resembling  that  of  arterio- venous  aneurism,  that  he  was  led  into  the  beli 
that  such  was  the  natui-e  of  the  tumour,  until  dissection  revealed  ita  tn 
character. 

+  Anatontie  Fathologiqiu,  1860,  vol.  iii.  p.  895, 

;  Op.  oit.  vol.  iii.  p.  183. 

§  Prefixed  to  Breschet's  paper  above  quoted. 


PULSATILE  TUMOUH. 


683 


» 


tion.  In  serera]  other  of  the  rwonled  eases,  a  toinjwriiry  im- 
provomcnt  lias  f bllownii  ligature  of  tlio  main  artery  in  ooiisequenoo 
of  tlifl  (liniiiiutioii  thita  oiii-asioiiod  in  tlio  bulk  of  tlra  (umour. 
LaUcmand's  caeo  kIiowk  rcnliy  no  more  than  this.  lit  Dr.  Kicol's 
case,*  tJ]cm  wait,  in  liku  ni;uinor,  ii  tiiuiiiorury  iliniinution  of  Uto 
balk  of  the  tnmour ;  though,  as  the  patient  died  of  setmndary 
hajuMnrhage  from  tlic  lied  artory,  lui  opportunity  cxi»tiN:l  to  prove 
bjr  diaseotion  that  the  disease  was  cancerous.  A  case  of  lliia  kind 
is  relutxxl  by  l>ni>uytn!n,f  in  wliioli  the  diK>4uu>,  whidi  was  situated 
in  the  tibia,  was  bclicvetl  lo  have  been  cured  by  ligature  of  the 
tinnoml  arttjry.  Tlio  liiniour,  however,  scorns  novcr  to  have  dis- 
appeared ;  And  when  die  patient  ^vas  agam  seen,  seven  years  after- 
wards,  it  prcscntixl  ail  t)io  ap|>caraiiccs  of  inuIiE^niint  dintasi-. 

If,  howcTp-er,  the  existenoe  of  ])nlsatiii<i;  tuiuoun*  in  the  bones 
formed  by  nivrc  enlargi>nieiit  of  the  vokscIs  inu)>t  be  allonx^ti  to  bo 
dcHibtruJ,  it  seems  that  ptiUation  ftus  boen  recognised  in  a  myeloid 
tumour  ;t  and,  as  those  tunioiirs  arc  u.«ually  innocent,  it  would 
follow  tliat  tlic  mere  preseiiM!  of  pulnation  in  a  sod  tumour  of  bone 
is  not  to  be  considered  as  a  decisive  proof  of  it.«  malignancy.  If, 
bowe\er,  we  allow  tliis  excojition  to  tlie  rule  that  pul.iating  luiiiotir^ 
of  bono  arc  malignant,  wo  ninst  still  admit  tliat  there  is  no  rcliablo 
wxount  of  any  such  tumour  eonnccltil  witli  llio  skull  oi"  [Hrlviti 
(Iboee  favomite  seats  of  the  disease)  which  was  otherwise  tJian  cun- 
oerouN. 

If  such  are  our  views  with  mpect  to  the  nature  of  tlie  pulsatile 
tumour  of  bono,  our  opinion.^  as  to  tlio  proper  coumc  of  trcJitinont 
cannot  be  doubtful.  To  tie  a  large  artery  is  so  very  grave  a  mca- 
VO,  that  it  can  only  be  justified  by  the  clear  prospiwt  of  im|>end. 

fetal  ha»iaorrhage,  or  by  the  presence  of  an  nneurismal  tnmour 
pressing  upon  inij>ort:Hit  organs.  In  tbcw  ptd«atiIo  tumours,  how- 
erver,  ha>morrbage  is  rare,  and  only  occurs  lale  in  llie  disc^tse ;  nor 
are  important  parts  often  pressixl  upon,  except  in  the  eranitmi.  If 
it  be  Aaid  iJiat  the  growtli  of  tlio  tumour  will  be  chocked  by  the 
ligatnrc  of  its  nutrient  vessel,  the  answer  is,  tliat  this  is  by  no  iiieuns 
borne  out  by  experience,  and  that  oven  if  its  growth  were  chedted, 
the  diseaso  would  not  therefore  bo  cured ;  wliilc  the  doubtful  good 
to  be  derived  from  a  very  uncertain  diminution  in  the  bulk  of  tlie 
bUDonr  is  as  nothing  when  comparc<l  to  the  frightful  risk  of  tying 


■  EJin.  MtJ.  and  Sarj.  Joirmtl,  toL  xlii.  p.  19. 

t  J>7»«  Orala.  Viait.  18aO.  vol.  ilL  p.  :!■-)». 

;  Gray  on  Myeloid  Ikimutt  t/fUtm,  UtJ.-CUr.  TVani.  vol.  xxxix.  p.  18S, 


6M 


DISEASES  OF  THE  BONES. 


a  larj?.'  nrtpry  in  a  subject  ]>robably  already  debilitated  by  the 
cerouB  Oiicliexia.     in  niaiiy  of  tlic  rt-cordrd  owws,  tho  ligature*' 
(ho  iiiniTi  artcr>-  niijienrs  »o  far  to  bavo  aiTectod  tlio  tumour  as 
Im%'fi  dii'ckeii  ila  pidsntion.     But  tliL-  pulsation,  though  a  formid-' 
ablo  symptom,  in  iiol  (in  csMdiiial,  and  may  not  even  Ix!  n  v»i).<lnnt, 
part  of  the  disease.     Thus  Profrs'^or  MiUer  relates*  a  case  of  pal- 
Militi>  mn1ifn>aiit  tniiiour  in  ibu  ham,  wliioh  ntuf  at  fii-»t  iniMtakcai 
for  aneurism.     The   pul&atiou  dis:ip(M?ai-cil   spontaneously,  but  re- 
turiiiKl  Hi\cr  an  csploratoiy  punoture  niado  in  (he  (uuiotir. 
^vard.-i  the  pidsation  \-ariod,   disappearing  oocasioually,   and  then] 
recurring. 

The  purport,  then,  of  all  that  has  been  noted  as  to  tlio  con 
and  nature  of  tlni«  di^i-asi-,  arnl  n*  t"  the  elfect  of  treabnont,  ap|>rar8,] 
lo  justify  the  following  conclusions ;  that  in  pulsatile  tumount  i-on-f 
noctod  with  tlic  bones  of  the  oxtrctnitics,  auiputatioii  diould  lie 
reoomracnded  thriiugh  or  above  the  nearest  joint,  except  in  lho«' 
t'onncctetl  with  the  lower  end  of  tho  femur,  where  it  may  ocea*ioii- 
ally  be  advisable  to  amputate  nnir  tlie  tumour ;  tliat  Uio  ligntmv 
of  tho  main  artcr\'  of  the  limb  is  unJuKtifinble,  esjjecinlly  as  all  tlic 
benefit  nliieh  could  he  derived  fnnii  that  iipi-riitlnn  ini^hl,  in  many 
case*,  bo  rcpmlly  well  obtained  by  compression  :f  tliat  in  pulsatilo 
tumours  connected  \>ith  the  heiiil,  ch»it^  or  jkiIvik,  no  loval  mea- 
sures ought  to  be  employed,  but  tho  disease  sliould  be  treaiUxl  as 
one  of  eaucer;  and  tinally,  thai  tin-  ])riigiiows  may  be  rendered 
fiomenliat  less  grave  by  remembering  that  pulsation  has  been  not 
in  n  myt-loid  tumour. 

Cuvceroun  tdeeralioii  is  usually  precede<l  by  a  known  and  <^vidc 
tumour,  probably  oi>itheliiU;  bnt  in  sonic  cases  tho  malignant 
posit  may  have  been  entirely  interstitial,  and  in  others  tlm  fnitivnt      . 
is  not  seen  imtil  extensive  idccration  titi^  destroyed  tuiy  tumour  tlu^H 
might  have  existi'd.    Such  eases  occm-  moat  usii.illy  alxiut,  tlie  bones^^ 
of  the  face ;  and  I  have  seen  death  produced  n  here  tho  loiver  jaw 
was  implicat4-i|  in  a  case  of  this  Idnil,  by  the  exton^ion  of  the  uloer- 
ation  into  the  lingual  artcri,-.     During  life  some  difficahy  may  bo 
experienced   in   distinguishing  this  cancerous   afTectioi)   from  tbo 
ro<lent  or  phagcdienic  ulceration,  spoken  of  at  p.  (1311;  but  it  is  a 
matter  of  little  j)racticfti  imjwrUinw,  since  amputation  or  eomplctOj 
excision  would  be  recommended  in  either  case,  if  tJio  paticnt'i 


ered 
otc^^ 

dciifl 
dc-^ 


•  EiUn.  Med.  and  Sm-y.  JmtnA  April  lf<60,  p.  9fl!l. 
t  Cmiipif«*io«  in  saoh  oaM*  ^oiilJ  be  digiial,  sine*  il  is  impoilwit  i 
to  iiitcifei-e.  if  it  can  be  lielped,  ivitli  ihe  vraous  ciretilatioii. 


ENCHONDROMA. 


685 


^ 


fp:'neri\t  condition  admitled  of  if.  The  Ixinoi  of  ihc  fiicc  arc  pc?cu- 
liarly  liable  to  cxioiisivo  destruction  in  cancroid  uJoer^itioii  niid  in 
tiipus,  lint  tJiA  (^lii'aiiiu  coiiriH.^  of  tlicao  uftix'tioiu  sufliciontly  tlietiii- 
guisIioH  tlicni  fi-oin  caiif*r. 

Ill  till.-  Ill II (■■■ni  1(1 1  bono,  niali;^iant  ulceration  ]inxluco8  cxtfliuuvo 
amf  irregular  dcttruction  Imlii  of  tin-  i?oin|Hii*t  and  cano^^llnna  tissue, 
witboiit  iiiiy  triici-  of  tin-  |M-ri(wli:iiI  siiid  otiicr  in flaminatory  deposit 
tliat  bounds  tlie  wore  hcaltliy  forms  uf  uloeraiioii. 


JfoN-MALIGNAST  TuMOCRS. 


^  Uiat  t» 

^^E  ^  TtimotniK  of  bono  arc  like  tliono  of  soil  purtA  in  itU  iin|M)rtfint 
^H^ipi-cbt.  Tiit-y  aro  innoociit  or  malignant ;  the  fonncr  being,  for 
^^rtit*  niiwt  Jinrt,  (•oin|Hi-w*d  of  .soinc  of  llii-  saiiii-  .•"Iniirtiiri'w  il<  fonti 

Ilbo  bone  itMcIf,   in   a  more  or    It'ss  ]H.'rfeet    statt*  <)f  development 
(lioRKilufTOUH   tiiniourH) ;   wliiU;   (bo   ninligtiant  tuinoufH  nw  coin- 
jioacd  of  otlier  structures,  to  wliicli   tlio  oswoiis   (issni'  in  a  state 
of  lutalUi  |>rt\HciiIti  no  nniJogufr*  (lict^'iMlogouK).     Tlio  |i»rts  wbioJi 
oom])oso  a  bono  aro  fibrous  membranes,  cai'tilsge,  the  projier  oaee- 
«iis  ti.-<f«ii'  or  jjrnnuliir  ba-w,  luui  blllcKl.^■c»!w;I*  ;  togetlicr  with  tlio 
n       spaces  or  ciineelli  filled  with  fat,  which  gi\i)  tlie  bono  tbi'  ntpii- 
^■Mit»  liglitnciW.     How  any  of  ihew  ck-mcnti*  ovcr-dcvciwjK-d  or  im- 
^^  perfectly  imitated  may  give  riso  ^^  a  tumour.     Tlie  imrni-owtli  of 
tlic  fibrous  ti.iNuo  ^ivcs  rix<?  to  the  Inio  fibr.iu*  tunKJiii-s;  its  inijiorfcct 
imitation  bjr  morbid  action  ]H-oduera  the  various  formA  of  fibroid  or 
6l>ru-])la.'<tic  tnniour;  excowlic  or  iiii>'i>lnceil  giMwtb  Vf  t-artilngw 

treoults  in  enchondroma ;  of  bono  in  oxostoeis.     Wlii-ther  tlie  vpssoIh 
of  bone  arc  cvtT  ftimpty  over-tlvveloix'*!,  without  any  otlier  inorbi<I 
produft,  MO  an  to  form  tho  "  owteo-.iiionrism"  sjmken  of  by  numerous 
Hiirgieal  patliologisl.s,  is  n  iiuestiuii  wliicli  liax  bocn  disiniiwcil  al>ov«. 
From  the  ovcr-distonsion  of  the  wlUJar  Bpaces  of  bones,  tionio  of 
their  cystic  tumouni  probably  ariso;  others  an'  foruK-d  by  a  jieciiliur 
itrrangtiincnt  of  tlie  eonnoctivo  ti.-MUo  in  tuinonrH  belonging  to  dif- 
^ft  fer«nt  clweeBj  aiid  some  of  the  gron-tliH,  nliich  txrv  eluKsificd  with 
^^  cy«t«f  »re  inwfly  iiiuwon  in  ihi-  caiici-lloii?  tissue.     Lastly,  onalo- 
iptm  to  tbo  fat  and  me<liil]ary  ti»suo  nbicli  Gllx  the  c.-ivitHW  of  tiio 
liones  wi'  bavo  a  ulav  oflnniount,  the  myeloid,  which,  nineu  Uicir 
^m  first  description  by  Mr.  Paget,  liavo  not  ceased  to  attract  mueli 
H  Att4>ntioii,  on  Bi.'count  of  llic  interf^tiu^  surgica]  and  palhologi<.-»l 
H  qtiesliotis  connected  witli  them. 


En^ondronM,     Cartihiginoui  and  bony  tumours  can  hardly  bo 


686 


I>ISEASES  OF  TEE  BONE& 


treated  of  separately,  for  altliontih  tlie  well-niarjiwl  ^jicctincns 
eitlKT  elawt  iiiwu-nt  litllit  i^imilHrity  nt  tii^  ^ig^il,  fioine  of  eaeli  azo* 
t>o  intiiimtcly  relnled,  tlmt  tbo  two  couM  not  wtthoat  votitbsion  be 
made  tlm  sabjccbt  of  M>|>arntv  st-ctiona. 

Ciu-lilitgiiious  tamooffi,  or  endioiidromata,  as  they  aro  «aUed, 
bftvo  been  already  de«.Til)wl  in  the  v*my  on  TPMOPRS  (vol,  i.  \>.  -tSfi), 
M>  tliut  it  now  only  remaiiiA  to  speak  of  tliem  as  they  affect  tbc 
bones. 

These  fonitationa  may  be  divided,  for  surpeal  purposes,  into  two 
classes:  viz.  tliow  wliidi  do,  and  tlK>i*i'  wliieli  do  iiwt,  "luiw  a  tviid- 
cucy  to  ossify.     The  latmr   usually  grow  as  exteuflive  infiltrations 
into  tbe  tissue  of  tlie  bone  ajitl  periosteum,  and  in  t)io  oonrae  ofS 
tinn-  sjuvad  slowly  over  the  wirfaeo  of  the  bono  (retaining  for  tl*e 
most  port  their  covering  of  periosteum),  and  fill  nil  the  E[Mices  er 
cavitit!!'  in  relation  with  thi>  boue.     It  \»  dltliinilt  to  det^^miino  ihcirfl 
precise  origin,  and  thus  to  initke  sure  wlietlier  they  arc  new  fonna-  " 
tionii,  in  »  strict  .4Ciise,  or  (iut-gn^wtli« ;   but  (ho    fomicr  ()j)i[uon 
seoms  more  generally  jirobabla     I  hai-o,  however,  met  witli  one  offl 
thrsi!  tumours,  in  the  phulunx  of  th<!  fingor  of  n  cbiUl,  witcrc  it 
seemed  iirobabic  that  tlio  origin  of  the  tumoiu-  was  tljo  epipbysa) 
cartiliigc.     Tliese  non-ossifying  uirtilaginouH  tumoiUK,  or  pure  en 
cliondroniflta,  are  little  untenable    to  surgical  treatment,  unleSB  io.' 
a  part  tiivoui-able  for  uinjiutatiun.     Tiicy  bave  bi-eu  Mi{>po0od  (0 
present  some  analogy  to  malignant  dii«ases,  lo  which,  indeed,  tbei 
vxtcnsivc  diQ'usiiiii  and  stearly  irresiiitililc  progress  do  offer  a  rcwun- 
btanoe.     Tliey  differ,  however,  from  tbc  true  cancers  at  any  mie 
in  ono  fuHturc,  wbifh  is  (piitc  characteristic,  vijt.  that  however  ot- 
tensivo  their  diffusion,  ihey  affect  tin-  surrounding  }<nrtf  only  by 
]ircssin'e  or  tths<irpli(ni,  not  by  contamination.     This  in  ibeir  utost 
distinctive  featmv ;  but  it  is  not  »o  nsi-ful  in  dingno«»  (linco  it  i* 
lc«5  easily  npprcciat<-d  during  life)  as  their  rate  of  growth,  which  b  h 
usually  stow.      To  tliis  mln  tliorc  arc,  kiwcitir,  rather  &e(iucnt| 
exceptions,  of  which  tlu-co  romarkable  instances  are  rclnted  by  Mr. 
Paget,*  in  one  of  which  llie  rapid  growth  of  tlio  tnmonr  lod  to  tlie 
erroneous  diagnosis  of  malignancy,  ami  so  deprii-cd  tlio  jioticiit  of 
the  cbatico  of  recovery  wliicb  amputation  would  have  given  lum.  M 
Hemembcriiig  these  and  similar  cases,  wo  imist  not  be  too  wmfident  ™ 
in  inferring  malignancy  in  the  case  of  a  tumour  of  bone  from  tJk> 
single  fact   of  nipiiUty  of  gmwlh,  although  that  is,  doubtless,  a 
most  suspicious  and  unfiivourablo  s}-mptoni.     In  many  cases,  these 


a) 

J 

torn 

I 


•  Lrctura  on  Surg.  Path,  vol  ii.  p.  181. 


EN'CHONDROMA. 


687 


I 


largo  oarlilaf^iiious  tiunouit^  romais  stationary  for  a  Ion;;  ixriiHl; 
and  this  aIiouIiI  hi-  iiikrii  tiiio  i.-uii»idi.'ratiuii  whun  consulting  oil 
tlwj  propricbf  of  aniputatian. 

Tiio  iitriictiiro  of  tlieso  tumours  vnrics ;  nsunlly  tlioy  aro  qnito 
solid ;  it)  other  cases  eysts,  filled  with  tliiid,  are  tbuiul  in  lliein. 
Tltcy  ftoinctimcs  comlM  cxclu«i^'cly  of  cartilage;  but  moro  com- 
inonly  fibrous  tissue  is  to  be  found,  in  sparing  quaiilityT  '"  *onie 
partis  oftbi'm.  Tbo  niicroscopiciil  appearances  will  bo  foiuid  de- 
scribed in  tlie  essftv  above  referred  to  (sec  vol.  i,  p.  \S9). 

Tlio  circuniscribctl  cartik^^oux  tumours  aro,  bowovor,  inueli 
more  fre<]iicnt,ly  met  witli,  and  are,  theivtiire,  more  tni]H>rtHiit  in 
pmc-tical  Surgoiy.  They  spnng  almost  exclusively  jrom  the  long 
bones,  tlio  plialaitfrcs  of  tlii*  linjrcrs  iind  toes  being  tiieir  m<Mt  fre- 
quent scat.  In  these  situations  they  are  often  found  in  great  num- 
bers at  the  same  time;  uiid  tin-  iipjK-nriiiice  tlmx  presentctl  i«  vety 
characteristic,  and  is  not,  as  far  as  I  know,  imitated  by  tumours  of 
any  otiier  kind.  Tbo  fingi-r*  are  ittud<k'd  over  with  ^MM!>c.■(  or  knobs, 
looking  something  hke  tlio  diy  gnarled  braiielics  of  an  old  tree.* 
Thin  utfection  m  suvn  gentjrally  about  the  ugv  of  puberty.  It  is,  of 
oouree,  quite  uiourabic,  except  by  amputation ;  but  that  measure 
should  n«%vr  bo  resortud  to  in  njiy  disease  of  the  banil  withont  mi- 
dent  necessity'.  In  ilie  foot  less  scruple  need  be  entertained,  since 
tlw  foot,  deprived  of  its  suitcriar  jiortion,  ts  still  a  very  useful  mem- 
ber; and  thei-e  would  bo  no  iiw^iwsily,  even  in  a  very  advanced  ease, 
for  going  fiu'lbor  than  Lisfranc's  or  Cliopart's  oitcration.  I  liavo 
>'er  seen  n  case  where  any  thing  more  was  requirod  tlum  to  rc- 
oiiB  or  two  toes.  In  tlie  hands,  these  multiple  cnchondromata, 
left  alone,  groiv  gcncnilly  virrir'  nlcjwly,  and  sometimes  not  at  all. 
are,  however,  on  record  where  tliey  »ocm  to  havo  increased 
ftlowly  during  tlio  whole  perioil  of  life,  and  to  have  attained  at  lengtJi 
a  truly  exQ-aordinai^-  development.  Of  this  tlio  specimen  figured 
by  !kliiller|  is  an  excellent  inxtanec;  and  a  ^-«ry  similar  case  iuw 
been  deseril>e(I  and  tigured  by  the  ViTitor,}  whore,  liowoi'or,  the 
cartilaginous  strnctiiro  was  less  distinct.  Such  tumonrs  usually 
originate  in  llio  interior  of  a  bone,  expanding  its  walls  into  a  thin 

^m       *  There  is  a  good  nioil^l  of  thin  alTection  (n  <*»t  uk«ii  from  life)  ia  Ike 

^Jatuseiim  of  St.  Georgo'B  Honpitul. 

H       t  C'Aef  dm  /fiiuni  Baa  unJ  iKt  Fonntn  drr  krimkl>it/Um  OacluriHttt.  Ber- 
lin, isa^.  ub.  iv.  fig,  1. 

;  PtUk.  Sot.  Tran:  voL  ix.  p.  3Sd.    Tlte  apeoimea  ia  ia  the  museum  of 
8t.  Ocoi^'s  Hospilai. 


Cases 


I 


688 


DISEASES  OP  THE  BONES. 


bony  oyat  or  shell,  vrlilch  U  liable  to  give  way  at  dilFcront  parts,  and' 
firm  prcKSure  will  llien  elK-it  u  feeling  of  crcpiiutJoii.  T1k.vhs  mul- 
tiple ondtondroinuta,  liko  tlie  ditFosud  eutilH^tioas  tumours  jast 
d<Mcribc<l,  .■•eftiii  to  hIiow  little  tciid«ncv  to  imil'y  in  the  Htrict  scns« 
of  tho  tena ;  tut  thoy  imdcrgo,  when  wry  old,  a  prooesa  of  cal- 
carooiiR  d«gt»iei'utiMii,  wliieli,  luMcil  itt  tJieir  {TDiiimd  incrcuM)  In  size, 
produces  ulceration  of  tlio  skin  over  tliem ;  and  so  a  c-ondiliuii  in 
brought  iihnul  not  unlike  tlmt  ofu  iiiiLts  of onormoiui  chalkstonea 
exposed.  More  rarely  the  tumours  spring  from  the  surfaoo  of  tl>e 
bones. 

Circumscribed  and  solitary  enchoiidi-ouiata  usiuiUy  grow  fnjni 
the  surfttce  of  a  bono,  and  most  of  tliem  «how  n  strong  tvndoDoy  to 
ossify,  tlie  process  commencing  generally  at  tlie  base.  Hence  tiie 
surgical  eonsidonitiona  ni)]>Iicablc  to  tlicni  ari;  identical  witli  those 
wliich  ap|»Iy  to  exostosis. 

Itiaffno/ij',  Tbo  tIi«giiosi»  of  iiiniKvnt  tumouri^  from  oacb  ollxir 
is  uncertain  and  obscure  ixi  all  partA  of  the  body,  and  [>Gr]ia[>«  awn 
w  when  they  aiv  connc'cliMi  with  tlio  bones,  on  account  of  tlie  gen^ 
rally  deep  jxisition  of  tlie  bitter.  If,  liowe\  or,  a  tumour  presenting 
tho  gcncrid  cbuniL-tcrs  of  innoccucy  can  be  dearly  made  out  to  be 
springing  frum  bone,  tlio  chaniits  are  very  great  in  favour  of  its 
Iwiiig  an  ciich<iudruntu  or  iin  exostosis.  If  very  lor^,  it  can  Iianlly 
Ijo  the  latter  without  displaying  cliaraotoriMic  litirdiici&  f^brou* 
and  fibroid  tumours  iiiny  be  found  of  large  size;  still  almost  all 
largo  tion- malignant  tunionr.i  of  bone  are  nirtilnglnuus.  Most,  also, 
of  the  smaller  tumours,  wluch  do  not  possess  tlie  hardness  of  ex* 
otttoKi.'*,  will  III!  found  to  be  e:u'lilagiiK>us.  Hueb  tumount  usually 
possess  a  certain  amount  of  resilience,  and  often  appear  ohHcnrcIy 
movable  en  the  bouc.  ThiH  .soiiHation,  howiwor,  it  often  deceptive, 
and  due,  apparently,  to  Ibo  motion  of  die  soft  parts  upon  lite 
tumotu*;  it  bus  been  noticed  in  tiunours,  tlio  ba»c  of  wluch  has  been 
fnmtd  to  be  completely  ossifim],  and  a  slight  amount  of  apptmot 
nuivemont  is  tlicn-fiirci  no  eoncbwive  roajmn  for  denying  tho  con- 
nexion of  a  tumour  with  the  bone.  Another  thing  whieli  ought  to 
hi'  taken  into  account  in  diagnosis  is,  tliat  tlio  cartila^nous,  e«|iuilly 
with  the  osseous,  tumours  ni.iy  have  n  biimu  oxer  tlietn.  This  will 
not  ofk'u  l)c  an  obstacle  in  the  nay  of  making  out  an  cxo«(to«ift, 
since  the  hardness  of  the  latter  in  L]'aiHniitte<t  thmugh  tlie  fluid,  but 
may  Kuuietiuios  cause  doubt  about  the  nature  of  .in  cnehontlronuL 
Tho  nodulattid  suriace  of  cntdiondroma,  though  <-haracler!Htic  to  a 
certain  extent,  is  far  from  distinctive  of  tho  disease ;  tlie  Mme 
proper^  may  belong  to  ci>1loid  disease,  fibrous  tumour,  and  other 


I 


I 
I 


EXOSTOSIS. 


689 


^Bwe11!nf;;B ;  in  Emt,  tlin  nuly  Kcnration  ulildi  ftfTords  a  reasonnUo 
ground  for  pronouncuig  a  tumotir  cartilapnouB  is  nwQionce  coni- 
binotl  with  Roliflity,  and  thi*  for  iloeii-seatcd  tumouni  i»  oflon  decop- 

'  tivo,  and  in  tho  many  enchondromata  enclosed  in  sholb  of  bone  is, 
of  oiwrw,  alKtcnt.  Oil  tin;  wliolc,  tlicroforo,  an  unchoiidroma  is  Iwwt 
linonii  by  its  being  an  innocent,  and  not  oaseous,  tumour ;  elastic 
when  firmly  pn-Mod,  fpiiornlly  growing  slowly,  and  not  uffooting 

»tbe  akin.  When  tlio  ))lialnngcg  are  the  float  of  tha  disonse,  the 
rtiagnoMi^i  is  miicli  more  nearly  cortain. 
Eroetosv,  Tbo  transition  fixim  cartilaginous  to  hoay  tumours 
is  a  natural  one,  sincfl  so  many  of  tho  former  m-e  merely  the  first 
stage  of  grwwtli  of  tbo  latter.  Tho  tonn  "  exostosis"  is  not  n  ^x-rr 
eaay  one  ta  define..     It  otiglit  to  l«t  nswl  oidy  to  signify  an  innocent 

»  tumour,  or  limited  out-growth,  formctl  exclusively  of  bone,  and  not 
tlie  result  of  inflnnnniitory  action ;  but,  on  tiie  one  band,  tlie  pro- 
ducts of  inflammation  secreted  by  tlie  periosteum  often  assiunc  the 
form  of  11  limited  oiit-gron'th  or  tumour ;  while,  on  the  other,  many 
comjtlex  malignant  tumom-s  possess  a  bony  framework,  and,  after 
iitaecriitiiin,  hear  »  gn.'at  rcseinblHiioo  to  exostosi:*.  In  the  latter 
case  tile  distinction,  though  occasionally  dilficult  after  the  bone  lias 
fcewn  m™eitrati;il,  is  etwy  during  life ;  »o  that  the  mere  faet  that  a 
malignant  tumour  posaeases  a  more  or  less  perfect  bony  framework 
is  of  little  moment  in  a  practicid  point  of  xnew.  Most  oftbogron-ths 
which  fall  under  tho  eategorj'  of  "  periosteal  exost^*!*"*  ai-e  exten- 
sive inflammatory  deposits  bencatli  tho  periosteum,  which  neither 
require  nor  ailmit  of  surgical  treatment.  Whether  limited,  pednn- 
culatod,  and  tlicreforc  romo\-sble,  tuinoors  over  occur  as  a  conso- 
qnencfi  of  inflammation  ia  as  yet  <loubtful ;  but  it  U  highly  probable 
'that  they  do,  both  from  the  analogj'  of  the  elongated  processes 
mietinicA  foinid  ]]rojecting  from  tlie  bono  in  tlie  neighbourhood  of 
finctnres  which  hax'o  been  eonsolidatcd  with  mom  than  tho  usual 
lunt  of  intlinnrniiti<)ii,t  and  aim  from  the  fullowing  coiiHidom- 
Exostoses  are  occasionally  found  attached  to  the  bono  only  by 
a  neck  composed  of  fibrous  tiMue.  Tlie  occurreneo  of  masse*  of  new 
bone  around  tbo  articular  ends  in  the  infljinimatory  disease  known  as 
*'  chroiiie  rheumatic  arthritis,"  and  llie  pnibiibiliiy  tlint  such  inaMcs 
beoomo  subneqaontly  blended  witli  the  original  bone,  ia  now  a  fa- 


I 


i 


*  S«c  Gerctf .  lialadiei  dei  Oryantt  du  Moavemeni.  p.  STj ;  Fano^s  edition 
of  Vidd  do  Catsis,  PatheUigu  KxUnic,  vul.  it.  p.  'i6\. 

t  See  a  pi«p«rntion  in  St.  Ocorse'9  Uoipttol  Aluscnm,  seriM  (.  no.  IM. 
VOU  lit.  Y  Y 


690 


DISEASES  OF  THE  BONES. 


miliar  fact  in  patholof^-.*  SpcrjiiK^tu  Imvo  b«»n  rxtiilutcd  in' 
it  wx'nicil  tliiit  iiiflaniinatory  apjKaranccs  could  he  ttanxi 
some  of  tlie  looso  cso»toiM>*  |nx'\'i<>U''iy  rofi'mxl  to;t  no  that  it  t*| 
sibio  t.liiit  sDKK'  i-x<»!»t«seH  may  to  developed,  ns  tho  nuuwfl  «f  I 
ore  nhioh  form  so  Htnkiiirr  a  fcatura  ufchmnic  rlionmatic 
ill  Ok-  "oH  >><nic-tin-<-.-<  m-iu*  tli<>  hatw,  as  a  n»iilt  of  inflammalioo,  nd 
may  afUrwards  ooalewc  with  tlic  on^^nal  lx>nc.  Tbo  great  tnajoriljr, 
liowovui',  of  tliuAi!  bony  liinioiim  which  arv  calloc),  in  Kurgionl  b»- 
gOBgey  exoBtoaos,  ori^nate  by  aii  out-growth  or  limitnl  hypprtrofih 
ofnimlii^iiK  ]inr1;i,Jii»t  ii.i  fntty,  fibrotH,  him]  other  iimooi'nt  timnon 
do,  quite  iudepcndeiit  of  any  inflammatory  ^mptoinfi.  Maair  »• 
thors,  CRjKtcially  tho  French  Surgviim,  ^M<iik  of  *'  buHotw  rxnatmoi,'' 
meaning  ajiiiaroiitly  by  this  term  tlioso  stielb  of  bone  which  «■»• 
tiuiOK  uTv  formed  by  thu  di^vclojnneiit  «f  a  tumour  (gonnraUy  aifr 
laginou.4)  in  tho  oi^ntm  of  tho  Hhai\.  Tho  diagnosis  and  tmtnol 
ofduoh  eases  will  be  found  dtiwribwl  elwwliere.  Anotlier  Itinj  1/ 
exoHtoaifl  in  tlint.  wliirh  iiriK'Xwd.'i  from  Ihn  oMifit^aticxi  of  Irmlogiy 
nr  from  the  oecmronco  tn  man  of  proi-cssrs  of  bono  natural  lo  At 
lower  nnimnlit.  Itutli  of  tJiesir  belong  mtlxir  to  tho  daw  ormumao 
eurioHties  than  of  subjects  of  practical  intermt.  Still,  if  th^  l»- 
oantu  obJevtA  of  treutmciit,  tlicy  would  |>robably  bu  indi«U))gitialiiUi 
from  exoHti)M!ii,  and  would  require  tho  wuno  opcmtiaa.  I'm  id» 
m'umK  are  without  a  npeciroon  of  owiBcation  of  lendona  ori  uth« 
fibrous  tiwiioH.  Some  ewws  oftliiH  kind  will  he  found  rr&tmlto 
on  )■■  535,  where  also  the  treatment  of  penoiH  preceotiiig  tbla  Ic^  , 
eney  !»  diwiiiMirl,  Such  casoa  e*  thorn  In  «^itcli  a  proeeM  fn^itk  ' 
troin  tile  hiuncrai  around  tluc  brachial  ailery,  when  tluu  ivd 
follows  tho  eiftirM'  UMial  in  tho  large  feline  aninuls,  in  whioh  ilii 
surrounded  by  a  ring  of  bono,  only  need  to  be  known  in  otdtf  It 
avoid  operative  interfcTcnee ;  and  in  any  operations  on  boiiy  uunm 
in  regions  where  sneh  anomalies)  ari!  known  to  exixl,  llie  tutan  l 
hiwtory  of  the  caw  ought  to  bo  first  carefully  investigated. 

Excluding  thuse  rarer  rarietieti,  the  cMf^  of  <rireutii!<Til)d  1 
fosiw  wliieli  Surgomu  ha^'o  to  tri-at  arvj  divided  into  two  1 
naneelluuK,  and  the  iTory ;  iho  fiinn<T  Uiing  a  reprodactiac  off 
tissue  of  tho  interior,  as  the  latter  u  of  tho  hard  osttTior  of  tlw  I 
TTiey  will  be  found  fully  di-seribcd  in  tho  «*«iy  on  Timotna  ( 
It  493). 

Trmtmait,     TIic  alow  rate  at  which  cxottoMw  proginM,  Wl 


*  On  tliislicod  I  imuld  «iip«ciaU}- rcfur  to  a  |ttprrby  Ur.W.AJMtM 
Pa4k.  800.  TntM,  vol.  iji.  p.  liB.  +  Gay.  in  P^iK.  Soe.  Tnu.  i».lU- 


EXOSTOSIS. 


691 


I 


■case  with  whtob  the  soft  parts  aMonunodatc  tlicnistlviw  to  tli6  gradnn] 
ikIvhuco  of  the  tunioiir,  rwiJ^T  it  f'nsiiiontly  umirtM-Koirj-  to  tncddio 
with  thorn ;  and  it  is  always  right  to  defer  the  oppmtion  until  it  is 
clciorly  seen  to  bo  iicwwary;  jiinco  thon?  i*  nlwaj-s  great  riik  in 
opei^atuig  on  any  deojj-soated  tumour,  and  still  groalei"  iji  laying 
o]WQ  the  CHnocUi  «f  botic,  iw  iniiKt  hu  dono  in  divi<Iiug  the  nock  of 
an  exoAtodfl.  DitFuae  8U|i]>unition  in  the  iiiterntnitculnr  ci|iiicc.'>,  ery- 
si[>L'lit*!,  and  pyiemia  are  very  liable  to  follow  xueh  a^ior.-itionH.  When 
the  exoatoiUii  is  of  tlie  ivorj'  viiriety,  and  situated  on  tbi>  Rrniiiuni,  tlid 
operation  is  mueh  more  dangerous.  Here,  indeed,  it  not  Uliire- 
qntiiiUy  hapjxtns  that  tho  tumour  U  so  hani  as  to  rcshl  all  tlto  t»olt 
which  can  bo  brought  to  bear  ujion  it,  so  that  it  i«  ]>br*iieally  ini]X)»- 
siblti  to  remove  it.  A  striking  ■■xmuplo  of  this  ot^f^urrcd  in  a  caM 
wliich  has  furnished  a  preparation  to  tlie  muiteum  of  St,  Gcorgo*a 
IIn'']>il;iI."  A  ninti,  i-ullVring  fnun  a  Miinlt  ivory  exosliisis  in  the 
frontal  region,  fell  under  the  care  of  tlio  lato  Sir.  Keate,  ono  of  tha 
boldest  and  most  skilful  oiicrators  of  hiit  daj-,  who  [wrseveringly, 
bat  vainly,  endeavoured,  by  the  use  of  trejihine,  raw,  ehisol,  and 
jnallvt,  dtu-ing  the  Mpuee  of  nearly  two  lioun,  to  cut  ofl'  l)ie  littto 
ip  of  hard  bone.  The  patient  was  fortunate  enough  to  reoorer 
from  thiw  jiroceedhig ;  and  Mr.  Keate,  eonviueed  of  the  u*»'Ie>»ne»s 
of  tiu'ther  ojicration,  determined  to  attemjtt  tlie  extirjiation  of  the 
tumour  by  the  freo  applieatJon  of  {Kftnssa  futa  and  nitric  acid  to  its 
d  basw.  This  was  Mifces-Hfiil,  The  eaa-'tics,  in  tha  course  of 
,  eat  their  way  through  tlie  base  of  the  tumour,  wliieh  dropiwd 
off.  Tlie  tumour  Atill  shows  the  di'wp  groove  worked  into  it  by  tbo 
trephine  at  the  time  of  the  o|K'ratio!i. 

U  would  )>o  ru.t]i  to  say  that  sueli  ojH^mtiona  are  imjustiliabtef 
sinoe  exostosis  in  tho  neighbourhood  of  tlio  orbit  may  grow  into 
tlial  cavity,  or  into  the  cranium,  mid  cauiie  death,  or  some  horrible 
iloformitj-  almost  worse  tlian  death,  by  displacement  of  tho  ej-os, 
ior  bones  of  the  fae«;t  but  tlw  ri*k«  of  openiting  on  tlic»e  small 
exostoses  about  tho  cranium  should  bo  maturely  weighed.  Some 
tuinount,  however,  which  present  on  ilic  wirface  llie  ehnnietcr  of 
tita  true  ivory  exostosis,  may  turn  out  on  section  to  be  hard  only  oa 
tbo  eoterior,  and  to  consist  of  a  soft  diploic  ti^uo  inu-nudly.  Tliis 
!•  tlw  case  uMially,  if  not  solely,  when  the  bone  from  which  tho 


^jnall 


•  Series  ii,  no.  180, 

t  Some  remnrkubte  siiccimcus  arv  iu  Iho  Mu6eum<i  of  St.  Bartholemon^ 
IToKpital,  nad  of  tbo  College  of  Suri;«on&.  ExostoHCB  uf  the  orbit  nro  not 
alwaj»  of  tbM  deaee  qiuUit}'.  Soc  a  caau  ia  Path.  Site.  TWiu.  vol-  xi.  p.  SU, 
wliert  the  tumour  nns  soft,  and  cuily  remored. 


[  Uur 

i 


692  DISEASES  OF  THE  BOXES. 

tumour  apnngtt  rcaemUcs  tho  oomposition  of  tlit-  vsttjlt  of  tlia  uuu>^ 
that  is  to  sny,  connsto  of  diplou  an-erocl  l>y  ii  tliin  tabic  of  compMCt 
tisBiie.     In  Lonnt  of  n-liiolt  the  shell  U  more  dense,   sucli  as  tfai^ 
knrerjan',  it  in  much  Dior*.^  prulmbli'  thiit  tlio  wliok-  ibickncss  of  tbv 
tumour  will  fw  of  eoin[inet  slructiiri".     The  exoswsos  whicli  com 
of  dtploc  internally,  covered  by  a  tliin  shell  of  hard  substanoo  (: 
whiflli  I  venture  U>  think  umre  ouniindii  than  (hoy  aro  uaiuilly 
to  be),  are,  of  eourse,  much  more  easily  i-cmoved  than  tlie  true  ivi 
oxo»twtC8  wliicfi  tlicfv  simulnto;   uiid  miother  uircHnwtnncw  whioh 
rtoiders  the  prospect  of  operations  on  large  exostoses,  wbetlicr  on 
tLo  «kull  or  other  ]«irtn,  rdtticr  more  i>romi.siiig  than  woubl  apfxiiar 
nt  firAt  sight,  in  tliat  the  tumour  when  exposed  is  sometimes  fomvl 
to  bo  conneetcd  to  tho  surface  of  tho  Ijono  by  n  very  narrow  nock, 
from  wliieh  it  can  he  oasJIy  broken  or  cut  off.*     It  i.*,  liowev-er^^ 
only  rarely  that  cither  tlio  Surgeon,  or  the  patient,  will  make  ^^| 
bii*  i}iin<l  to  till-  diingerous  and  doubtful  oxperiuiPtit  of  an  uporatic^^ 
on  an  ivory  exostosis,  especially  of  the  eraniuio;  wlicrciis  operations 
on  the  more  common  form*  of  exostxiiteH  whicli   spring   from 
shafts  of  tho  long  bones,  mid  present  the  cancellous,   or  mi 
cartillginotu  structure,  art!  of  daily  oocurrenec.     Their  moot 
mon  situation,  after  the  phalanges,  in  near  the  knee,  spHn^^ng 
tho  inner  unriiK-c  wf  tlm  fnnur,  a  Utile  alwrc  tlic  wndyle.     An^ 
\en-  eonimon  situation  is  beneath  tlie  deltoid  muscle. 

Tile  removal  of  »uch  an  cxoMlMii!  i*,  in  most  caee»,  easy, 
tho  base  i^  not  goiionilly  very  broad,  nor  the  os<(i(icatIon  very 
jmct.     Some  arc  even  »o  soft.  il<  to  be  divisible  with  a  strong  seal 
A  few  again  are  not  united  to  the  shaft  by  Imny  niatttT,  but  by  liga- 
mentous union. t     Tills  eon<litioii  i»  bigbly  favourable  for  oijeration, 
not  merely  beciHLao  the  tinnimr  «un  Iw  more  <iisily  exCTsed,  but  al»i 
Ijeeauso  the  vasenlar  spaces  of  tlie  bone  will  not  be  laid  ojien  in  tho 
oiieiiitioii. 


"  A  most  interesting  cnstr  of  a  tumour  of  this  kind,  f^TOwins  flrom  ! 
ciuniiun,  is  repiiited  in  llio  Path.  Sor.  Tram,  for  18S0.  p.  UO.  with  a  At 
inR.  nnd  has  been  coimuonto  J  on  by  Mr.  I'resoutt  H«n-i)U  in  hi«  T.r<ctD 
on  Discnaea  of  the  U(-aJ. 

t  The  ohaeTVAtiotis  uaile  on  p.  689,  nnd  tlie  «ftsc  of  Mr.  Gay'a  paticat 
thcra  i-efoi'i'od  to,  ivitl  rt'iidi-'r  it  jnvbuble  that  exostoses  aro  aonocUmei 
formed  in  the  soft  pnrts  Bruund  thu  bono.  Tiiesc.  of  course,  ara  conneeled 
\i>  the  boDC,  at  Ica^t  ongiiinlly.  by  liRRmcntous  tissue.  Afjain,  ossification 
«f  an  ptiehotidi'Oinii  may  prow-ei)  fium  without  iiiwniils.  iuslwit  of  iu  mon 
tiBunl  coui-so  fi-ORi  within  outwnrdK.  In  a  thinl  das«  of  cum.  exostoses 
inny  be  movable  on  tho  bnnc  M  lh»  r»iilt  of  fiuelure.  See  a  prvpanit 
in  ibe  Museum  of  St.  Unrtbolomew's  Hoi^jiitnl,  series  a,  no.  IM. 


EXOSTOSia 


6»3 


^! 


^ 


Jn  other  oaiws  the  tnraour  U  hroiuler,  aiid  mor(>  firmly  ossifiwl, 
'ml  its  biiM  tJian  in  luiy  otlicr  |)art ;  and  tlii-su  iuu  tlio  Icii^t  tavour- 
nblo  cases  for  operation,  siiiw  tliu  division  of  bo  largo  n  inuas  of 
lione  rv'tjiiin's  gix-sit  and  prolonged  violcnw,  iwciiliiirly  likely  to  Ijo 
fbUowed  by  tlio  coiii|ilicatioiin  aliovu  iiiiunttrat'^d.  Itnt  tho  ij|>vi'ution 
iH.'CVititHry  nlicii  tbt^  tiimotu'  is  gron-ing,  and  is  tlircatuniiig  Uiu 
fimotions  of  iinjiortant  |uii'ln ;  iiml  in  Kncli  ctwtt  lIk-  oi)tiralt>r  niiiiit 
bo  proparod  for  tlio  diHieuitiofi  wliicli  he  may  liavo  to  encounter,  and 
should  liave  n  HuKtcient  Mipply  of  inKlmnn^nttt  of  udi^cjualo  ntrvngtli 
At  hand,  sueh  hn  ^tont  bonc-nI])]>ci-s,  savm  of  variou;>  shnpe.«,  chisels, 
and  iniUleL  In  ull  on-v^t  rho  Uom;  of  tliu  tiunour  Hlinuld  !»•  diNirly 
«xt>o»cd,  and  wpai-jicd  with  eare  from  the  iiarta  around,  which  may 
re<juire  to  In*  IhKI  hm-lc  with  inrtrador^  Tin:  wjwirntiim  should  bo 
commoncoil  fi-ain  tho  side  ivJiero  any  danger  is  t(t  bo  appreliendod 
(e.ff.  in  c«it<<-(]iK'H(v;  of  tlio  pmxintity  of  a  vtiwl  or  joint),  in  order 
to  arald  implicating  any  iin[><irtiint  part;  and  then  any  amoimtof 
form  ncce-'wirj,'  inunt  in-  earefidly  hut  6rin!y  ajipliwl,  iho  bone  bnii^ 
steadied  by  aae-istajitK.' 

Tlio  "  builuUK  exont/jsls,"  or  et-ntrsd  cnclionilnniiu  i^ontiiiiKrd  in  it 
bony  <'yst,  UHtuilly  iv<)niri'.H  ainputatifui  oftlic  phalanx  ujwn  which 
it  ift  scAtod^t  It  may,  indeid,  bo  sometimes  |>0Mbl(;  to  i;iiualtfiitc 
the  growlli,  and  I  hare  svon  tliiH  donif  witli  sueoess ;  but  as  a  gene- 
ral nilo  it  is  hardly  worth  while  to  attempt  it;  isiitoo,  if  tJio  diiKUS) 
bo  seated  i»  iJio  hand,  the  nc&'itaiuy  disturbance  of  the  tendons 
would  i>robably  render  the  linger  nsclnts;  and  if  in  the  fuot,  the 
fiertatnty  of  it  s|itt(ly  im<l  tHtnipU-lo  n'coverj'  would  outweigh  tho 
adfantago  of  preseniiig  a  portion  of  one  of  tho  toc». 


Di^iued  bojy,  or  iiiiiocait  mteoui,  tumour,  Bcpide-s  thcwti  fonns 
of  limitetl  cxostwM.'s,  a  difluiH'd  bony  tumour  is  occasionally  met 
with,  hi  which  tlio  whole  tliiclaiess  of  tJie  bono  for  woine  dL-<tanc« 
t»  eon^x-rtwl  into  a  lubtdattnl  muss  of  K|M«igy  bone,  wliieh,  in  a 
section  of  such  a  lumonr  that  I  had  tlie  opimrtunity  of  examining 
juicnwcopicnlly,  jinwontod  tlio  usual  structure  of  bone,  but  with 


It  va.y  not.  perhaps,  ha  out  of  placo  to  ramsrtt,  that  in  ixiw  at  an 

'•txMitABia  ailual«(l  oear  die  kuee- joint,  theru  is  lbs  moi'O  t)nng«r  of  opening 

tbc  joint,  Hiiicu  tliiii  presL'iice  of  the  tumour  lias  probably  CJiumcd  Eiunii-rotL* 

nttaRkti  of  Hjiiuvitis.  Htiivli  Liave  left  tliu  poucli  of  synovial  meittbntic  ex 

tending  up  the  Uiif;h  ])oniianeiitly  (MiIargMl. 

I  I  linve  never  netxi  a  tumour  of  ihin  sort  cuiiuccted  with  ilio  lorRer 
boofs;  liut  tltu  suitcmriit  in  Uie  text  uoultl  apply  stiU  wore  fuivibly  to  audi 
a  htwour. 


694 


DISEASES  OF  THE  BONES. 


t'the    , 


Hiiiallor  cavitic^  and  an  iiKriva^cd  deposit  of  tlio  granular  biL-v. 
The  NiM-ciincii  (ill  th(!  JliLtcuni  of  St.  Qoorgc'a  Uos{)itiiI,  gi^ricM  ii. 
no.  185)  i»  larger  tliaii  a  man's  fist,  Mid  un-olves  one  sid*?  of  the 
lowtY  Jaw,  fruiii  Iho  oomlylo  to  new  thn  i^tnjihvMH.  Itt  initt 
nature  is  dearly  prov(.>d  by  tho  fact  that  it  bad  Ix-cn  growing 
fit'O  yinu-H  without  any  dt'triniont  t/>  tlio  gi^eral  lii^tii,  nnd 
be«n  [>artin))y  n-movod  on  a  previous  oeeafiion  without  aay  ill  con* 
Mqueiin-H  from  cutting  into  tlw  interior  of  tiic  tumour.  On  tho 
patient  coming  under  tJie  caro  of  Mr.  Tatura,  tbo  tumour  was  com- 
plet<'ly  ('xci.HCil,  and  with  i«iicoi-s«,  us  tLc  man  wiu*  nccn  in  perfect 
heaEtli  several  yeai^i  aftorwanls.* 

AnotlKT  Htill  more  remarkable  vofc  U  illustrated  by  a  series  of 
three  preparatiom  in  tlie  Museum  of  tlie  College  of  Surfji^fuw.  The 
history  w  so  mtcre^ling  tliat  a  condensed  report  of  it  must  be  intro- 
dnccd.  Tlie  thigh  waa  originally  nniputatcj  on  acconiit  of  a  lurJ 
and  heavj-  dry  osseous  substance,  surrounding  tJie  ends  of  the  femur 
will  liliia,  projecting  into  Urn  knw-jnint,  cxti-uding  far  tip  the  tliigh, 
and  implicating  tlie  [>o])titoal  artery,  \'cin,  and  nerve,  so  as  to  caueo 
oxlemu  imd  w»ere  piiin  (Pi-cp.  no,  .H2'14).  Tlio  patieut  remained 
well  for  five-  years;  ihon  anotlier  osteoid  tumour  finmed  ou 
atamp  of  tliw  frnmr,  ntTompanied  with  severe  pain.  Ampntati 
iras  jMii-fonned  higher  up,  Tlie  tumour  a])]M>ared  to  grow,  Dut  from 
tho  biJiio  il.M-lfHfi  much  as  from  the  jicrioMcum,  and  ooolosed  ti 
femoral  arteiy  (Prep.  no.  ii%iT)).  Tliore  wa*  again  an  interval 
health  (iir  two  years  ;  then  a  fresh  tumour  formed  about  the  stump, 
continued  to  increase  upwaiils,  out  of  reach  of  ojx'ration,  and  finally 
killed  liim,  from  iiiflammntion  and  sloughing  of  iti>i  sod  coverings, 
twmli/-Ji IV  i/rttrs  iii'U-r  ihc  fii-^t  njilx'arnnce  of  the  diseaBO.  Ho  tiad 
ijceu  in  good  general  health  (limiig  tho  wholo  timo  (Preii.  uk 
32-15,  A).t 

This  liistoiy  presents  a  reinarkahle  analogy  to  tliat  of  tlio 
cun-ent  fibroid,  or  filii-o-plii.Ktie,  timioui-s  of  uoft  jiartn.  There 
tlie  same  leading  features,  \\z.  tho  local  malignity  of  tlie  diseaas 
combiucd  with  iimoci'uec  eoii.ititutionally,  its  im]X'rfcct  imitatialt 
of  the  tissues  in  whieh  it  gi-ows,  its  eonstanl  reourri'nco  near  the 
Mtv  of  an  operation,  and,  fiiiully,  tlie  mixle  of  death — fixMO  exhaus- 
tion and  toughing  at^r  re[)eiite<l  operations,  not  &om  infection 
the  system. 


1      tl^l 

atifl^l 


»  PiUh.  Hoe.  Trans.  I"*?-",  p.  95. 

t  Aimilici-,  nnil  very  similar,  ciwe  inny  bo  Ibund  ia  Mr.  Pag«l'a 
on  Surgieal  Patltohgy,  vol,  ii.  p.  aOO. 


I 


I 


CYSTIC  TUMOURS. 


695 


C^«  in  hone  luie  of  two  kiniU;  vist.  wrotis  and  aan^uincon-i. 
TIk?  KtiroiiK,  or  iiiiicou»,  cysts  wfiit-h  occur  in  the  jawit  as  a  consc- 
(|Ut>nce  of  irregularity  of  tlio  {jriivrUi,  or  jMMitioii,  of  the  b^etli  will 
l>v  found  trpahnl  of  in  a  subiieqtient  vssay.  In  Huc-h  casc«  tho 
formntion  of  a  eytit  4>ontiiiii:n;r  clttnr  fhiid  i.i  Kuii«i^i)til>l<;  of  an  intcl- 
ligiblo  explanation  ;  but  it  is  difficult  to  hoc  how  tfimple  sorous  C}'stK 
can  be  tluvelojitxl  in  otlxT  bmicis,  anil  [irobtibly  tlx^  ivvr  cumm  wliidi 
aro  to  bo  found  in  bonks  re^t  ui>on  erroneous  dia^iof^iis '  But 
cnvitiea  containing  cK-ar  fluid  urc  fbrratsi  iu  bomw  by  thu  f^ron-tli 
of  hydatids  in  tlioir  interior ;  and  if  simple  cystj*  do  occur,  they 
would  Ih!  in<li.-<tin;ruis!iabli>  f'n>]ii  liyihitid  ryHtK  U^fort'  o{M>ralion,  and 
would  require  tlic  same  treatment. 

Blood-cy.its  Hit;  n<it  of  ct>iiiinon  Oftiurcuor.  nm-  in  it  usnially 
easy  to  dctennine  tlieir  patliolo^ieal  nature.  Many  of  tlic  ciimw 
re|)ortcd  unilor  t)ii:(  titlo  aj>})ear  to  havo  been  cxjunplm  of  rnali^iant 
tumour,  in  wliicli  a  eyst  has  been  (levehjj>ed,  nitieh  exceeding  in 
n'hitive  diuo  the  wbd  portion  of  iho  groirth-t  Tlio  niwt.  distinct, 
description  of  a  blotxl-cj'St  in  bom*  to  wiii<'li  I  can  refer  is  by 
'IVavor>i,  in  tho  Med.-CJdr,  Trang,  \'ol.  xxi.  Ho  oxcisod  tlio  greatei" 
part  of  tlte  cIa\'ii>lo,  on  noeount  of  n  lur;^  cynMc  tumotu*  of  about  a 
yonr'«  growth,  which  was  very  <'learly  connected  witli  a  biitory  of 
injui^'.  Tlio  Unuour  coiwirfod  of  an  arraiigcincut  <if  c<-!U  or  chitm- 
bcr^,  of  pretty  equal  dimensions,  filled  with  dark  solid  coagula  of 
blood,  wiib  Apiculit  of  bono  in  tlicJr  walls,  auil  invc.'^wl  by  a  ^ety 
stout  fibrous  membrane.  "Tlio  investing  niombvane  wa«  cvidwilly 
tim  con<len!W(I  JH^^i(lIt^lnlIn,  tJic  cells  were  llic  irrcgtiliwly -expanded 
eancclii,  and  the  calcai-eons  particles  were  the  debris  oftb"  iMiny 
l>Iules  and  walls."  'IVavcrs  is  uicliiied  to  attribute  tlie  disease  to 
expansion  of  the  bony  c:uioelli  from  blood  effused  into  Uiom  a»  llie 

lit  of  viokiicc.      If  this  explanation  bo  accept(H),  Uie  affection 

Id  be  identical  with  ili<;  bKHid-tiunonr,  or  hiematoma,  wliivh  i» 
illy  found  in  the  soft  parts  as  the  result  of  contusion  (seo 
vol.  i.  p.  574).  Sir.  Sliinloy  also  relntfs  a  oiu->i*t  in  which  In- 
funpuliitvl  the  thigh  succossfully  on  account  of  a  blood-cyst  origiu- 
•Ung  in  tlie  condyli^s  of  llic  femur,  and  wlu^n;  both  the  femur  uid 
the  tibia  prcscntixl  "an  eccbyniused  condition  ftom  miiiuto  effusions 


*  Mr.  Stanley  (np.  cit-  p.  lOl)  li^nic*  the  fomutton  of  nimple  cjsta  tu 
asj  other  boiiM  than  tboso  of  the  jaw. 

-f  See  a  ouo  reported  by  Mr.  Listen,  iindei'  th«  nuno  of  "ossified 
sn<MiH!im  of  tlu)  subscapular  oxitTy''  E4.  Mtd.  nuiI  Su^.  Jomn.  vol.  xn- 
pp.  11^  ^13. 

J  Op.  dt.  p.  18T. 


6!I6 


DISEASES  OF  THE  BONES. 


<}f  h1<KKl  thniiif^ii  titi'ir  ctmiiMU't  ri««uc."  Thia  condition  existwl  in 
tho  iemur  njt  to,  if  not  above,  tliti  k-vt-l  of  tlio  omputHtiuti ;  yet  tim 
(liiwofio  liiul  not  rtK-iirrocl  six  yc*ni  utli^rwiirOa.  Ur.  Stanley,  Itow- 
vviT,  in  his  desenption  of  tlii*  tumour,  In  ciirt'fiil  to  mciition  tlit-  fact 
tliut  t]icn?  yivTV  di^tiiiiTt  [Kiilloii.-t  of  suliil  niiitl'^r  ntUicIiod  to  tlw 
inaido  of  tlie  cyst,  and  would  o\-ident]y,  but  for  the  prugrcwt  of  tlie 
eofc,  have  Ixjuii  inclined  hi  ri-lcr  it  ti>  tin-  in<-i|Meait  aXtigo  of  <-ja*i-er.' 
Blood-i-ysts  oould  only  bo  distinguished  from  kofous  or  hydadd 
cysts  by  {lunfturc.  In  tho  grcnt  iiinjonty  of  ctiaet  thoy  would 
reqtiiro  wiini>lott-  roracrtal,  by  amputation  if  necessary.  If  tho  Sur- 
{{con  can  eatisly  himself  of  tbo  abwucc  uC  till  notl  Holid  inuttur 
nround  tlii^  ('vnt,  ho  iiiuy  in  rare  ai»es  be  justified  in  endcavoorii^ 
to  procure  its  obliteration  by  Inyin;;  it  ojnii  and  stuffing;  it  witli  lint; 
but  it  iiuiist  l>o  boniv  in  inind  tJuit  nuuh  mcasui^B  can  only  do  Itann 
if  there  he  any  thing  of  a  mahgnaiit  taint  about  tlic  (li»c«M.-.t 


4 


FiiTOfcs  and  fiiiro-cyttlc  tumour.  The  great  majoritj-  of  tlie  inno- 
cent tumoure  of  bono  wliicfa  arv  not  tBwwL*  will  be  found  to  be 
eartilaginonii  or  myeloid ;  but  a  smaller  number  present  tho  fibroiK 
ehanw^T  more  or  less  jierfcct.  Perfect  Kbn>uii  tuiiiuurH  ii)>jM-*r  M 
out-growtlin  from  the  jierioAteinn ;  and  tho  most  familiar  examples 
oftlicm  aru  the  fibrouN  polypus  of  the  now,  of  whii-h  nietitioti  has 
l)et-n  made  in  the  essay  on  Dihf^seb  of  tue  Nomk,  and  epolis, 
which  will  Im!  fbuiul  treiiti-d  of  among  tlic  Diseases  cosNca'En  wrra 
THE  Tketh.  As  in  citlier  dituatioiiH,  fibrous  tumour  could  liardly  bo 
ilistingnisbiHl  Irom  onelioiidroma  befon;  removal,  ami  tJic  diagnonK, 
evon  if  it  coultl  be  made,  woidd  Iw  i|uite  imimi>ortant.  We  neetl  not, 
therefore,  give  examples  of  tlie  dii^caw  occurring  in  otlicr  ])art«  of  tbo 
botly.  Scjittcred  S)H!cimfii!<  will  Ih>  tomid  in  moat  of  oiu*  largo  mu- 
seums, and  in  many  of  tliem  ossification  will  be  found  to  have  niado 
.wine  prtjgrcus.  In  simie  of  tliew!  (-ases  tins  iniiocftnt  nature  of  tlw 
disease  is  proved  by  tho  liistory,  In  others  it  is  an  Inference  (rom  the 
Htnioture  of  tht;  tmnour,  CalciHoation  oocur.i  in  tboHO  a»  ui  other 
fibrous  tmnours  (St,  George's  Hospital  Museum,  sor.  il.  no.  152). 

Fibm-cyslic  tumour  of  bone  is  a  diwiutc  whidi  is  little  kitonri 
and  may  therefore  possibly  be  of  veiy  tare  oooorrenoe.     It  is,  bow-j 


AT 


*  It  is  poxsibk  thftt  tliia  nnV>ntioii  may  hnvc  been,  u  Mr,  Pof^M  hints,  a 
myeloid  liimuiir.  in  wliicb  ili«  cy«t«,  nhich  ore  so  ccininon  in  tliat  iliiKmo. 
wei-o  developed  oin  of  proportion  to  the  solid  part  (sec  vol.  I.  p.  lUl). 

f  In  NcIiiton*a  Path.  Chir.  vol.  >i,  p.  49,  will  be  found  a  su-ikiu^  ic^ircwM- 
tation  of  a  Inigo  niultiloculor  cystic  tumour  dnvrlo]>ed  io  tliii  ((.■uiur,  aad 
contaiiiiiig  bloody  Duid.     Uafortuiiat«ly  there  is  no  history  ot  this  oum. 


E^JTOZOA. 


697 


I 


,  also  possible  Umt  tliix  a)i[)nn'iit  nirity  mny  lie  (!ih<  to  ibo  fuct 
that  ino*t  of  till-  c.\un]i>lci4  uf  thin  (Ii»ea8(<  have  been  (Xiiitouiiik^d  with 
iiuJignant  tunioiu^  A  vrry  InU^rcMing  lu^couiit  of  a  grovtli  of  tbifi 
sort  WiiiiocU-d  with  tlie  frimir,  in  which  tlie  limb  waif  romuvod  Ut 
the  hi[»-joint  by  Mr. .).  AthiniN,  will  In-  timini  in  J'at/i.  -Sot'.  Trans, 
vol.  V.  ]x  254,  aud,  appended  to  tho  ncouunt  of  tliis  case,  a.  report  hy 
Mr.  IVosoott  Hi'wrtl  on  (hii-CMiniinr  wi.sr.<,  in  uJl  nf  ivhii-h  tlw  fomm* 
was  the  "cat  of  tlie  discaw?,  and  in  all  of  wliich  tho  patient  roftn'iTcil 
aHer  ainpiiiatJoti,  and  n-tniiiiicd  well  (nr  iiituiy  yan  MlliTwiu'dB, 
There  W  therefore  the  r^trongci^t  ruiHon  to  bolievc  that  tho  diw-to^-  was 
not  cuinerouft.  It  oimnnvtioed,  in  oiii-h  of  tlir  four  in>tM])in-s  .-illudod 
to,  in  tlio  cniicelloiui  tissue  of  tlio  bone,  making  ilM  way  oiitwaitU, 
inlittmting  tho  shiift,  and  raiLting  N]K>ntan«ouK  friictnri^;  m  far, 
therefore,  exactly  resenibling  oanoor.  It  j*ave  tlio  sensation  of  an 
clastic  wMlwtiuico,  with  finid  licrc  and  there  in  wnitiiw.  Tln-ro  se^ma 
to  have  been  no  diagnofttic.  mark  bt-lwoou  it  itn<l  cancer  during  Utv, 
except  till'  negative  indications  to  bo  derived  from  the  abwiiiw  of 
glandular  or  eonstitulionul  oontiniii nation  during  a  somewhat  long 
<liseiL<i-,  the  duration  of  the  affection  Iwing,  in  tho  two  eaj(e-<  in  wliieii 
that  point  was  uototl,  tliii-n  and  fmir  vigors  nwjKMitively.  On  exami- 
lintioii  after  remova],  the  innocent  nature  of  tlic  di>iea»e  wai*  intem'd 
from  tlie  lnrgi>  ijuuntity  of  firm  glistening  fibrous  tiwiHo  of  which 
neiirly  (lie  whole  solid  jKinioii  of  tlio  tumour  was  formed,  the  pre- 
sence only  of  Niieli  celhilar  eicmentn  n»  are  fuluid  in  growing  libniun 
Btructttres,  and  the  absence  of  oancer-jui<'e,  or  imv  other  iudieation  of 
A  tendency  to  disintegrutioii  in  the  tumour,  or  infillnilion  of  ueigli- 
Iwtu-ing  tissues. 

Myeloid  tumoim,  the  only  other  form  of  iimocent  timioar  wbicb 
it  i»  nuccssaiy  to  partioalarise,  will  bo  found  sufficiently  described 
in  vol.  i.  p.  490. 

^lozoa  in  hone.  A  verj-  few  words  must  suffice  for  the  descrip- 
tion of  t!ie  ciises  of  entoxoa  in  (lie  interior  of  lione.  The  entoatoon 
apftcurs  to  baio  been  tho  ordinary  ochinococciis  in  all  owew  except 
€Hie  quoted  by  Mr.  Staidey,  in  which  tlio  v^-xltcercus  tela>  cclltdosm 
i»  jKtid  to  have  been  found  in  the  interior  of  one  of  the  phalange^. 
Tlio  suhjeiit  is  of  no  very  great  pmeticid  ini|>iirtaiice,  since  it  is 
seldom  possible  to  dtagnuao  tlie  nature  of  the  atfectiou  jirovioiu  to 
oi>Gratioii.  TIio  vaav*  an>  no  ran-,  that  in  tlie  great  work  of  Itoki- 
tatisky*  only  oight  are  referred  to,  as  tlie  total  number  wbieli  ha 


■  Syd.  8oe.  I'raM.  r«l.  iu.  ]>.  ItU. 


698 


DISEASES  OF  THE  BONES. 


suppose  to  Imvo  bocii  tJicn  iilis<Tnnl.  A  s<-ardi,  Iiowever,  tl 
the  vwitnLH  pathological  oolloetions  would  probably  discover 
in<a«  tiuui  tliesc."  It  its  noticed  by  KokitanHky^t  t^^t  ^'^  disease 
appears  oftirti  to  bo  dJroctly  induced  by  Eom(>  injury ;  but  it  is  dif- 
ficnit  to  beiievo  tliat  this  can  hv  odii-rwiw  lliaii  aocideDlal.  Ilii- 
diseaso  ruii»  n  pro4mvIed  course,  and  if  tho  eJuft  of  «  loug  boau  bt- 
the  part  nSect^,  frncturc,  sponlaiieoim  or  afeidt;«Inl,  in  \ery  pro- 
bably tho  fiml  tbing  noluvil.  Tbi;  f'ruc-tun^,  in  all  probability',  dots 
not  unito;  and  it  haa  eometimeB  happened  th&t  in  an  o]>cnuioii, 
undcrtnki^ti  for  tlm  piirpoiw  of  rvM'vtinfr  tJic  43id»  of  tho  firactnre, 
tho  hydatid  oavity  has  been  exposed  and  the  globular  aecpfaalocysb 
dii^bargod.t  Amputntion  in  tln'n  indJcati-d  in  ordinar}'  casee;  bat 
ono  ia  on  record,  in  which  tlie  hydatids  wero  scooped  out  of  tbc 
cavity  of  the  c^-st,  which  then  filled  np,  and  a  coinptote  cure  was  ob- 
tatned.§  In  other  vinm*,  the  seat  of  the  dii«eaHe  is  in  a  flat  bone,  M 
tlic  skull, II  nr  iliiini,1!  or  in  the  cx])anded  head  of  onu  or  moro  oftbe 
Jony  Ijoiies."  Tliew  aw*  im-  (|«ito  witliiii  tlie  reach  of  euro  when 
their  nature  is  discoieretl ;  and  in  some  rare  instances,  us  in  Mr. 
CouWu'h  and  Mr.  Stajiley's  cii«es,  the  discharge  of  hydatids  iJiroagh 
a  spontaneous  opening  or  a  punclure,  enables  tho  Sin-goon  to  deter- 
mine the  natiiiv  of  the  disease  beforehand.  Failing  this,  tho  symp- 
toms are  precisely  those  of  any  oilier  cyRlic  tumour  of  the  bone. 

The  treatment  ajijiears  to  be  usually  sncccssfnl.     The  cyst  is 
be  freely  laid  open,  with  the  trephine  or  bone-nippers  if  neoeeaaiy 
all  the  hydutids  removed,  and  some  eausticff  applied  to  the  wfaoJe 
intenor  of  the  cy-nt.     In  most  of  tlio  recorded  casea  this  has  been 
Hufiieient;  but  in  Mr.  Coulson's  case  tho  euro  was  not  com 


P- 


*  The  contiguuuij  Must^uing  oi'  Guj-'s  and  St.  TliomBs's  Hospitals  i 
lain  five  Bpeuimuua. 

t  1.01'.  dt.  Sl-c  uJso  the  histories  of  the  cases  wkicli  have  ftiraiah«d 
specimcuB  to  St.  'i'lionms's  Hospital  Mubcudi.  inorkeil  ocr.  c.  uos.  330, 2U. 

;  Uiipiiyti'vn.  Lr(.  Oralei,  I'ikr.  WiH,  vol.  L  p.  &S;  St.  Thomas'*  H 

MUBUURI.  SB]-.  O.  110.  230. 

(  Mr.  Wicklinm's  cnsc.  Lnitdon  Mnliral  and  Phyiieal  JouTnaL  vol. 

II  Keate.  in  Mid.-Chir.  Trout,  vol.  X,  St.  Thomas's  HoKp.  Museum,  c  8*. 
^  Slimiey.  op.  cit,  p,  19(1. 

*«  Coiilfann,  in  Mnl.-Ckif.  Trunt.  vol.  zli.    In  tho  specimons  in  SL  TliOi' 
iDu'fl  HoNpiul  Mtigeum,  c.  UdS-i,  hjiliitije  «'«re  found  ^multaneouslf  in 
the  lower  end  of  Oio  Temur  unJ  contiguoua  liead  of  the  tibia.    Otli«r 
are  noticed  in  the  boilk-H  of  tho  vertebra).  Dupujrtren,  loo.  cit.  Ouy's  Ho»- 
pitiil  Museum,  uo,  lOaS". 

ft  Nitnil«  of  Hilvi-r.  lint  impregnated  with  a  imtursi^d  aoIuUon  ofaul- 
phntD  of  copper  ("  blue  lint,"  as  it  is  called  at  St.  (i«orB«'B  Uokpital),  cMHia 
{lotasfa,  anil  the  actual  cauteiy.  linve  been  used. 


ospiuU 

WL    " 
0.8". 

Tti»B 
dysam 
eMM>^| 


HYPERTROPHY  AND  ATROPHY. 


699 


imtti  after  tlio  !ic|iaiiiliaii  of  a  smiill  piit-*-  of  lioiic  fram  the  floor  of 
tho  cavity,  which  on  pxainlnatiun  was  fouiul  tliickly  studded  on  boUi 
its  eiiHuccs  with  a  great  number  of  miuutc  hydatid» 


Htpkrteophy  and  Atiioi-bv  of  Bokk. 

OOnditioR  of  bone  uitually  known  by  tho  mime  of  hyper- 
is  vciy  gouorally  tho  coiiKotiuonw   of  chixmit  oBtitis,  and 

voiibi  i»erliaiia  be  more  oonvenieiitly  diwignatwi  by  somo  nanio 
exprtssivo  of  its  inflaminat«iy  origin.  T]iuh,  most  of  Uio  sjKxrimoiiH 
of  "  hyp'rtToiihiud  cranium"  not-ii  in  our  intiMOtintH  will  ba  found, 
if  the  hiiitory  ho  known,  to  bo  taken  from  casos  of  injuiy,  or  to  bo 
connvcloil  with  syphilis  or  scrotnla.  Tlio  ovt^  also  of  elongation 
and  Uiickening  of  tho  honen  of  tho  leg,  related  by  Mr.  Stanley* 
undtT  tho  bond  of  "  liypwrtropliy,"  up[)Ciu-  all  of  thciu  to  fall  more 
naturally  under  oonsidoration  witli  tho  soqnelni  of  inflanimation, 
vrtiicb  hav«  bocn  dowribod  ubovc.  It  uinx-iin*  tlint  tltis  thickening 
may  go  on  ibr  an  indefinite  period  after  tho  cessation  of  any  sj-mp- 
tobix,  and  tliat  tho  onlar^-mcnt  of  bulk  wltich  followN  from  it  i.t 
]ierinanent.  It  is  true  tliat  in  many  of  tliu  cases  of  tliickening, 
whether  of  tho  akuU  or  of  tho  long  boticH,  which  arc  prewrvod  ui 
pathi'logioal  colledions,  no  liiittory  of  injury  or  inlbiiiuiiilory  affec- 
tion has  been  obtained ;  hut  tho  exact  resemblance  of  tiie  itpccunciix 
to  those  in  which  Huch  a  hiittor)-  does  «xi»t,  leave*  no  doubt  tliat  moat 
of  them  are  sjicoiniens  of  cluv>nio  inflammation.  Cases  do,  however, 
occur,  though  so  rarely  as  to  bo  rather  matters  of  curionity  llian  pi-ac- 
tical  interest,  in  whicli  a  bone  (tho  skull,  for  the  most  part)  ha«  gono 
on  inctvn»iiig  in  mzo  withont  any  symptoniH  except  tlio:«o  produced 
by  itn  in<'reaite  in  bulk.  Such  waa  tho  well-known  in»tanoe  related 
by  Mr.  Prescott  Hcwett,  in  his  lectures  at  the  Roj'al  College  of  Sur- 
geons, in  which  it  man's  skull  conliiiuiHl  to  increase  in  aizo  from 
yvar  to  year,  with  no  i>)-niptonis  whatever,  to  that  lie  was  only  awarv 
of  the  tact  from  the  increasing  nizo  of  hi»  hat.  The  diKOtue,  liow> 
ercT,  in  this  ease  was  clearly  traced  to  an  injury.  As  no  symptoms 
can  bo  uttiii'iit^l  (ci  Mich  ciwcji,  no  treatment  is  known  U>  liavc  any 
influence  upon  them.    In  the  absence  of  any  constitutional  afTectioti, 

tho  jicrtu-'vering  u»o  of  couuter-irritjition,  by  iodine  or  blistering, 
woulil  ajtpoar  to  hold  out  mo&t  kopei>  of  checking  the  growili. 

jlfMpA^ofbone  is  a  more  IVeqitent  and  n  nioru  im|>ortant  dU> 


Op.  dt.  p.  ft. 


700 


DISEASES  OF  THE  BONES. 


caite  than  the  opposite  coiuliuoa  of  liyp<;nit>piij-,  Inilaminatim, 
tjitty  dofpncrfttiiui,  iJiMiM^,  aiiil  injury,  are  iVequciit  rauM'ii  of  aln>- 
|ihy;  and  there  is  also  a  BJmplo  atrophj-j  in  which  llio  com|x«idou 
»f  tUv  Ikuio  is  nnaltiTi-cl,  ami  in  ivliicli  no  ftliviotw  camm)  i*  [Hw- 
sent  (uiilp»i  it  may  be  tho  general  failure  of  nutritiau  in  advaaecd 
life),  nnil  when'  the  nmonnt.  of  Iiiiuy  tiiwue  Iwfvimw*  j^duolly  I's» 
and  loss,  until  the  bono  is  ho  longer  strong  enough  to  resist  slight 
violi-nw."  Ar  a  coiwcqucuco  of  suiiiic  chujij;i',  or  fatty  dL'gciwn- 
titHi,  atrophy  ia  one  of  the  moat  t-oniinon  causes  of  sponiancoos 
fmctun-.  It  may  also  occur  in  any  Iwnc,  to  mnuv  oxtrnt,  us  a  con- 
lUKjucnco  of  confinement  during  a  lingering  ilisease.f  Bixxlie  say»,t 
"All  bunt^  in  a  state  of  inaction  lose  a  ^^at  |uui  of  tbuir  phoejifaato 
of  limt*.  Afti-r  cumponnd  fnieturt!,  when  the  patient  has  bet^n  hmg 
confined,  the  bones  in  some  instaiiecs  becoiui;  ii;<  soft  us  a  scrofulotis 
bone,  HO  that  you  may  cut  them  witli  a  knife."  Hie  caMci  which 
arc  Hpokcn  of  under  the  name  of  "  frugtlitos  Oiwum"  cippcar  to 
bolong  for  tJii.>  most  piu-t  to  the  <!la.-wt  of  fat^'  or  senilo  Htropjiy. 
Iiyury  sustained  in  fi-aeturo  is  also  a  froquciit  cause  of  atrop)^. 
Of  tlii.4,  tlu>  most  i-jctriiiinliuury  iiisliuice  lA  that  quotod  liy  Ko[Tii>:,§ 
in  which,  after  two  fraetiuvs  occurrujg  at  the  same  point,  near  the 
middle  of  the  humeru.*,  tho  wliulo  boiiu  dic>ap[H-ared,  !<o  bh  to  l«iirc 
the  fore-arm  "  swinj^ng  hither  anil  thither  like  a  thong,"  and  the 
arm  shortencil  !»\  inches.  It  is  expressly  stiU«!<l,  in  lh<Miccoimt  of 
this  curious  case,  tJiat  there  wa*  no  open  sore,  and  that  tho  boiw*  di*. 
ttpixyu-wl  ■*  hy  tho  gi'ailual  aetiiin  <tf  tlio  uliKorbciit.*."  Mr.  Curlin{f| 
believes  that  the  cause  uf  atrophy  after  fi-aoturo  may  often,  if  not 
ulways,  be  found  in  injury  to  tho  mrdidlary  axtfrj'.  Ereii  allow- 
ing, tiowever,  that  thin  explanation  is  plausible  in  some  caiw*, 
there  are  others  (not  to  KpL^ak  of  extreme  instanccH  like  tlieone  jost 
cited)  where  it  cnmiot  apply.  Sucli  are  casea  of  atrojiby  of  both 
fragmciite,  or  of  tho  bone  in  the  neighhourhoo<l  of  the  Q-agments, 
while  the  latter  !iro  not  no  much  atrophittl.TI  Atrophy  from  inflam- 
mation is  a  condition  illiistrati.xl  by  many  morbid  pre[ianUioiu, 
tliough  it  duett  not  attract  niudi  attention  in  )iraetice.     It  is  merely 


1 
I 


\ 


*  Humpliiy  on  tilt  ShrUton.  p.  «. 

f  See  a  pi-eparattun,  uo.  S!44,  In  th«  Mutoum  of  the  Roj-al  College  of 
Sin'geons,  ivitti  its  liislorj'. 

I  Lfol.  on  Pathobigy,  p,  100. 

^  Atiwr.  Joitni.  of  Mai.  Sc.  Jan.  l&U,  p.  39.        |  ifed.-Ckir.  Tram.  nA.  xx. 

<[  S«o  a  prupimLtiun  tii  St.  Tlioinaa'ii  Hospital  Muoewn,  tiericB  c,  no.  S. 

Hei'o  tbe  ati'opliy  U  most  laarkt^U  in  tho  vjiper  pnrt  of  tliu  Kfaaft ;  and  tJM 

fi-agmeiits  included  li«tn*ccn  tlio  fi-artui-ci  (wlticli  were  tiiplc)  am  tbidur 

liiau  tilller  of  tlic  poilious  uf  ilie  shaft. 


SPONTANEOUS  FRACTURE. 


701 


lilt)  iKTStinU^nci!  of  that  (U'grtiprativo  rliangn  which  hadn  to  inflam- 
matory softening;  ajiil  i>rol)al)ly  many  of  thfi  eiLWi)  of  aUx^hy  after 
fracture  shimlii  lio  rffi-rrtid  to  this  head. 

Comiet!t*3il  with  atj'oj>hy  m  tlie  siiKpt-n.tinn  ofgrowtht  oooaaionally, 
though  rarclvj  mot  with,  in  wliicb  tlic  ep!pfa^-sca  rom^n  Mpnrnte 
from  tJie  shaft  of  tlit;  bunt^ ;  anil  it  tu-t'ni.t  jimliablit  that  injiirt'  U)  the 
epiphysal  cortila^,  in  separations  of  the  cpij>hr»is,  luay  occosion- 
iilly  ^ivo  rims  to  shorttminj;  oFtliQ  hoiiu  from  i^iiK]X^ii:ii(>n  of  growth 
between  the  shaft  anj  epipbj-sis.* 

Atrophy  of  hinii-  is  an  uflVcttoi)  which  dixm  not  iq)p«>r  to  ho 
marked  by  any  peculiar  sj-mpfoms,  or  to  admit  of  any  special  trcat- 
mviit.  AftiT  injiirv  I"  any  jiarj,  the  p'stnratinn  of  inotloratK  funo* 
tional  activity  as  soon  as  it  csui  prmluiitly  bo  rocommcndcd,  the 
avoidanoo  of  aiiy  cnuiw  of  prcusurc  on  tho  main  vcwU  or  thoM  of 
the  siirfaco,  and  the  choit-o  of  a  snitahh-  |iositiire,  with  attention  to 
tlic  poncral  hfiilth  »ihI  nutrition,  ar^•  (hi?  object*  of  a  jiidiciou.*  tn<at- 
ment,  uTcspectivo  of  die  condition  of  any  partictilar  part ;  and  tlieso 
racaMiri's  air  nil  that  could  ho  sug^fcstcti  to  avert  atroi>liy  of  the 
lioiie,  oven  if  it  were  known  to  be  iiiii>eii<ling. 

S/KntanfouKjracfuri' hstaheon  mi'iitiomxl  n-iK-atrtlly  in  the  pre- 
vioiu  pogoHj  ui  connexion  with  tcvcral  morbid  st;ito8,  wliich  may  bo 
thus  enumerated  in  tliu  orrlcr  of  tlioir  prvHumcMl  friMiuono}'  a»  uiiu>os 
of  fracture :  viz.  sciillt-  atrophy,  mnhgiiaiit  disease,  tnmotu's  of 
othta'  kinds,  ineludiu^  iiydatidA;  i.ho  tdi-c ration  wliicli  iici'oiii panics 
nQcrosiH,  and,  lastly,  other  kinds  of  ulceration,  But  besides  these, 
caaeti  of  H|>ontjui<i)iis  fracturo  tKvw  without  known  cjiiinc;  some- 
timcK  ill  making  a  violent  rouscuW  effort,  a"  in  throwing  a  stone, 
or  striking  a  blow  ;  at  other  time-*  in  tho  iniwt  ordinary  action,  m 
in  turning  in  bed,  quiet  walking,  &<•.  Those  which  are  caused  by 
violent  mum-uhu'  t;ll<irte  too  nwu-ly  rt-scniblo  tho  ordinary  ciwtw  of 

^ fracture  (particukrly  froetiu-et<  of  tho  patella)  to  call  for  any  remark 
here ;  and  tho  tivatinent  of  tlw  fnicturo  in  the  ca«!«  which  owar 
during  tlio  progress  of  known  disease  is  a  inatt«r  usually  of  »ub- 
jndinatti  ImiKirtanoe,  and  has  bci-n  already  sufKcicntly  diwwuod  in 
Beatuig  of  the  disease.  I  would  inendy  add,  that  when  tlto  long 
l>oiii'9  ivw  |H.Tfonited  by  tdecratlon  occurring  arotuid  a  wquewtnun, 
«  He.  Iluiclkinaon  lately  oxbibitod  at  a  i>i«ottDg|  of  tbo  Patlioloxidal 
8oal«ty  a  nuliuK  alioTtvnod  at  tb«  wrist  to  a  oonaidwabl*  exu^iit,  whilo 
th»  upper  part  of  the  bono  was  natural.  This  was  referrsd,  nith  great 
probability,  to  an  old  separation  of  the  cjiipbj'tiia.  !nw  Bpedmen  is  iu  the 
Museum  of  th*  Lomloo  Uosttilal. 


ro2 


DISEASES  OF  THE  BONES. 


llic  question  of  ampataling  tlic  limb,  or  uttcmjttiiij;  lo  savu  it,  will 
(lemaiid  much  t-are ;  uiid  tbitt,  aa  a  gewa^  rule,  amputation  will  not 
Ijc  roqiiirwl  in  the  upper  extremity,  ooc  ehonltl  it  bo  performed  ii 
tiie  epontanoouK  fmcture  whicii  rather  IV(H]itcntly  foUowH  ncuto  niy 
cnwiH  in  children,  unless  tlio  gvnend  lioultli  is  evidently  giving 
way ;  but  in  other  ciwe.*  of  nocro^i^  of  tlio  bonrs  of  tlie  l«wcr  limb, 
iuid  iu  nbiost  all  cases  of  uIe«rsition  not  due  to  tlie  separation  of  a 
torgo  ikxfuustrum,  umpututiun  nx  n  ;;i-iiiinil  ntlo  is  indii'attxL     What 
fracliLru  ootrurs  during  tlio  ordinary  muscular  exortimi  of  ovei7-<Uy 
life,*  and  iu  persons  not  known  to  labuur  luider  any  dinvaso,  vari- 
nv»  R^moto  ofluwM  have  been  imagined,  bat  none  have  boon  provad 
to  bo  really  effieient.    Tho  one  most  oummonly  admitted  is  sypii^i 
bat,  nut  to  dwi.'ll  on  tho  fjuit,  that  tho  accidont  lins  ocoorrod  in  many 
pCTHons  in  whom  tho  strongest  roa«on  oxistod  for  bclicring  that  no 
Buch  tuntr  wiut  prowMit,  ull  that  wo  know  of  the  action  of  Byj>hili!t  on 
the  bonas  tends  to  show  that  (ajiart  from  ulc€«»tion  und  tho  separa- 
tion of  noorosi'd  portions)  it  PMul<tr!«  them  not  more  but  IcM  brittle 
Tho  practioal  point  of  diiof  interest  eouneeted  with  sueh  cues  ia, 
that  thcru  is  no  reason  to  d(«pair  of  union,  and  that  tliey  should  1m 
treated  in  tho  ordinary  way,  with  perhajis  more  than  tlie  onlmarj' 
coiv  to  avoid  coiwtrictjon  of  tliu  sofl  pnrt«. 


Wounds  of  Bo^'B. 

It  is  not  neeossary  hero  to  dwell  upon  wonnds  of  bouy 
the  reader  will  find  all  that  is  practienlly  importaitt  in  the 
on  Fraoti;kks,  Gun-shot  Woijsns,  and  I>»vRtE3  of  Tiu  Hkad. 
Cases  of  ineisod  wounds  of  bone  witliout  fraeture  do,  it  i.s  U\Wf  oc< 
cibiioniiily  ciiiiio  under  tho  notict^  of  the  Stirg«ron.  Tho  ehiof  interest 
in  such  injuries  lies  in  the  probability  of  difiuse  Buppuration  (osleo- 
niyolitii*)  wiiwrvniiiig,  or  (if  tlie  sepnnitioii  of  tho  piTitwteum,  wlu'eli 
is  a  eonimon  event  in  suih  eases,  loading  to  neorosia.  A  reforenoo 
to  those  seetionn  will  ilhi.ttratv  snflieiently  the  prognosis  and  treot- 
mtmt. 


r.  HOLMES. 


I 


•  Some  intcrostiag  cages  ai-e  to  be  found  in  Itobvrt,  Con/.  lU  Cli»iqmOhtr. 
1)^01;  nnd  many  xre  itcuttercd  about  ia  vniioua  books  and  periodicato.  I 
rcmcmbcrscdnj-utSL.  George's  tlo'piul  n  Htoul,  florid  jroang  man  wbo  had 
friitrtiirml  his  tliigli  ill  Biinply  wnlkinfr  nciosi?  Ills  room,  u-ithout  catchins  Us 
foot  or  making  u  false  step.    It  healed  like  any  other  fiacture. 


DISEASES   OP  THE   JOINTS. 


I 


» 


PABT  I. 

DISEASES  COMMON  TO  ALL  TEE  JOINTS. 

IN  cstjraating  the  iintiim  am!  imjKirtaiiw  ofilifii'ii^eH  of  tlw  joinbt, 
wo  lijive  to  bear  iu  mind  that  we  liave  no  longer  to  deal  with 
xinffU  iiiviueut,  ns  in  tlio  casm  of  tbo  bonm,  tlio  inuticlo-i,  &x.f  but 
witli  varied  strtMrturoa,  distinct  in  their  formation,  their  funttioiw, 
iUid  their  ]mth<iliigy,  Iml  all  so  far  tiniCoil  f»i'  a  H[M;<;inl  |>urjH>4e 
that  distorbanco  of  aur  one  of  them  is  sufficient  to  derango  tiio 
hannoiiioiis  woi-kiiig  nf  the  wholo,  Tlio  study  of  iliiti'ii™--'  oflho 
joints,  therefore,  involves  to  a  gi-eater  or  lees  extent  tliat  of  the 
ufTcctioiis  of  the  oaeout  m/itan,  the  foondation,  «»  it  irero,  of  the 
articulations ;  of  cartHuge,  fibro-eartilo't^,  or  nitnAranf,  interposed 
bctwwn  tlio  buiios  to  |>lny  tlio  jiart  of  tho  buffer*  in  the  raiiway- 
tnitt ;  o(/ibrotu  titmu  or  ligament»y  the  coupling-cliaiua ;  of  lynorial 
nmfimmia  with  their  vipmviay  tlie  lubricating  boxMi  and  grea»e  by 
wfatd)  the  friction  ih  diminished ;  a.t  well  as  of  fOKnee^ee  and  adi- 
pote  tissMs,  which  scr\'e  as  packing  material  to  fill  up  tho  hollowa. 
Externa]  to  tlie  joints,  iimreiivtir,  but  slill  jilajinj;'  an  imixirfaiit 
part  in  tlicir  mechanism,  arc  \-arions  muscle*  with  tlieir  tendinis, 
M  well  as  synovial  burfue,  tho  pntliokigicnl  conditions  of  which 
ID  their  relation  to  tho  jobite  cannot  be  entirely  omitted  or  }>a!Hvd 
ov^- 

^Vhen  disease  has  advanced  to  a  certain  stage^  all  or  the  mujority 
these  Ktructmx'M  are  likely  to  bo  iii%-<)lvcd,  iwd  an  accurate  allot- 
of  tho  in'mptoms  to  their  respective  souivos  would  be  mwlcss, 
even  if  it  wero  pORKJble.  It  is  only,  however,  nineo  tho  investiga- 
tion  of  tho  dtseases  of  the  joints  haa  been  punoiod  ui  rolatioD  to  their 
I'O'UCtnral  origin,  that  any  precision  of  diagnosis  has  been  arrived  at, 
iutj  really  physiological  syatem  of  treatment  becu  adoptod.  Tho 
diMaw^K  of  tlio  jointji  aro  no  longer  lum]Nxl  together  under  the 
vague  denomination  of "  white  swelliug,"  but  referred,  with  more 
or  leMt  certainty,  to  tho  tissues  tn  which  they  commenced,  and 
connected  with  the  |»ithologieal  changes  which  those  tissues  are 


I        ov^- 


704 


DISEASES  OF  THE  JOINTS, 


1 


fomid  to  havo  un<]ci-^(>i]c.  For  tliU  great  iinprcn'am«nt  id  tlis 
SurgcQ'  of  ttio  nrlk-iilntionn  we.  an*  inuiiily  iiidcbled  to  tho  MdOtA 
int«II«<!t  will  philosophical  spirit  of  onr  illtistrioiu  ooimtiynum  Sir 
B.  Broiiic,  1'hi'i  liinil.s  luwi^i'*!  to  this*  ossay  are  evidenlJy  in«iir- 
flfjiciit  t«)  allow  of  any  complete  or  com])rclionMVO  study  of  theso 
>-ari(xt  dixuMMK  i  no  inoru  Uiati  a  Hki'to)i  caii  l>o  atU'iiipU^l ;  but 
that  ^ketdi,  it  is  hoped,  may  Ijp  found  sufficient  for  all  praptlcal 
purjHiwjs. 

Anatoniirally  all  Joints  are  not  aliko,  being  di\-ided  into  the 
com  ]>a rati vi'Iy  Hitn]>lv  tynarlfinxlml  aHictiliilioii.-t,  "r  tSiuM'^  ilc\-oid  of 
a  syiioviiil  membrane,  and  tlio  more  complicated  duirf/mxlial,  in 
wliiclt  u  syiiciviid  in<'mbrttn<!  itsiMtK.  Patliolopioally  a  similar  Atf- 
tinction  may  to  a  cei-tain  oxtpnt  bo  drawn,  and  the  affootions  of  the 
diarthrotiial  sirticiilatioiw  may  ronvciiiotitly  ho  xi'parati-d  froii\  tJlow 
of  tlw  synarthrodia!,  which  wil!  receive  sueb  notiee  aa  may  Imj  wn- 
siderod  nccc-x^ary  in  tlic  latter  part  ot*the  noaiy. 


Diseases  of  thk  Sykovial  Mkubkankx. 
Pltymohi^ical  Anatomif  of  Synorial  MemhranfS. 

The  s}*novi!il  ini'mbrauoH,  a.i  we  might  expert  from  a  e<»nxid<*ra- 
tion  of  llR'ir  function*  and  composition,  arc  tlic  most  prone  to  disea^i^ 
of  all  the  Htructiiit^  whiuh  coniiKiw?  a  joint,  and  e\en  if  not  orifji"- 
ally  the  Beat  of  tlio  iniscliief,  tlicy  nre  very  liable  to  become  involved 
In  its  [irogrefw;  it  is  with  thoir  affectionw,  tJion,  that  w«  nutiimlly 
commonce.  Tliough  usually  <Ie«cribecl  as  closed  bags,  tljo^'  may 
nitluT  lio  said  t'l  ponsi«t  of  slu)rt  but  wide  luU-s,  tJio  open  ends  of 
which  are  folded  in  upon  themselves  and  firmlj'  united,  but  with 
no  vei-y  distinct  marfiin,  to  Ihe  artienlar  eartila{;<!  near  it.-*  borKkr 
or  to  its  ixrichondriuni ;  ha^^^g  pre;'iously,  in  some  eases,  invested 
a  certain  extpnt  of  tlio  Iwne  itju-lf,  ami  contracted  eoimexiom  with 
its  periosteal  covering.  Delicate  in  tliemseK-es,  and  eoniiHxed  of  «n 
fpithdmm  at  well  a»  of  connfTftee  tissue,  in  whicJi  we  find  vo»f«U 
and  nerves,  in  many  articulatinna  they  are  in  dose  relation  oxtem- 
nlly  with  stnnig  fUnvins  coats,  wlneh  give  to  them  th«  appearance  of 
considerable  sb-cngtli. 

The  s^*navia1  inembranea  present  occasionally  large  adipmc 
masses  (plka  adipomr),  the  sn-oallud  "  IIiiM>rHiiin  glanils,"  whirJl 
consiNt  of  an  ae^umidatiou  of  fat-cells  lodged  in  vaacolar  folds  of  the 
membrane.  Thcso  arc  t>ccn  hoA  in  tlio  kni^e  and  hip-jointa,  and 
probiibly  tfervo  mainly  as  a  soft  packing  material  to  fill  up  spacn* 


J 


SYNOvma 


vlucli  would  othrnviso  cxut.     Connected  also  wiih  tho  iijiiurial 
mi>iiibrauoa,   ami    mtA   with   in  aliiioi't   ovi-ry   articiiLitioii,   «ro  its 

Ivatculitr  proctiges  {pluKe  vafCiiloMt).  presenting    sonn!  iv^^cmblanco 
in  tlte  aimiijroment  of  their  I>I(mm)-vi'.«u^I9(  to  Ltio  triioruid  plnxuius  of 
tlio  brain.     Thoy  form  flattened  Inlib.  and  lu'o  usually  Hihiatcd  nvor 
thii  |K>int  wh<^ro  tim  ^ynovinl  mcinlinitio  xn.  nnJti'd  U>  tho  artii^ulor 
caitJlagi^     Attached  to  the  edges  of  these  Tsn^ular  prooeascti  aro 
Kmsli  jjrojectjoiw  of  very  irn-j^lar  fonn,  fnijucntly  di-void  ofviMwUi, 
and  compi:>«>o:l  of  Rbrous  tissue  with  oce^onal  cartilage  cells,  and  on 
Khuiidiint  opitlii'ltitin.     The  vtuuruUr  [inHt-wM^n  in  (|ii<uiti(in  app'HT  to 
tbe  active  agent*  in  the  separation  of  tlic  synovia,  whilst  their  non- 
eular  prfijcctintii*  iirc  inli'rcstiiig  |i«tJni!i>;;icafly  froTii  llii'ir  sup- 
pi;>w<l  rilation  to  the  "  loose  cartilage*"  occasionally  met  with  in  tho 
<  arlJculnlioiiH.     Tin'  chcinicjil  ciiin|Hwili<>n  of  tJio  infnm'ia,  il  may  bd 
■ioentioncd,  was  found  by  Frericlis  to  consist  of  water,  94.8  ;  mucus 
and  opirhelium,  0.5 ;  tiit,  0.07 ;  albumen  uind  cKtmcUve  inalt4>r,  3.5; 

I  and  iudt«,  0.9. 
So  ooniititut^,  .tyiiovial  moinbninos  are  liablu  to  infl^immntion, 
forming  wliat  is  usually,  though  not  perhaps  veiy  correctJyj  termed 
tynovitia. 
SrsovTTie. 
Thci  inflammation  which  attacks  a  rmovial  membrane  may  be 
oftlie  onltnary  chftract^r,  or  it  maj-  Iw  modified  by  ccrttiin  consti- 
tution.il  ennditions.      Conitnon  s\iiovitifl  occurs,  in  many  csises,  as 
a  local  atli-cliiin  from  the  direct  irritution  of  mccliiiniml  injury,  or 
results  from  undue  exercise  and  exposnre  of  the  joint  to  atinosjihorio 
influ«nec--< ;  it  mny  nlwi  hr  indnccil  l.>v  diwiL-x-  wlii(-h  liiia  involved 
tho  adjoining  tissues.     This  form  of  inflammation  is  generally  con- 
fimxl  to  a  ttingle  urtieulution. 

Tlic  con^ititiitional  conditions  which  modifV  tho  elinractcr  of  iho 
i n flam m.^t ion  niiiv  be  in<irf  <•)•  liiw  [lennnncnt,  anil  even  luTcditary. 
8ometim<^w  we  Hnd  the  patient  presenting  endent  marks  of  ntt/uAt, 
and  tliii  local  diiwu«o  shurin<;  in  tin-  |H'cnliur!ti(»  of  that  affwrtion ; 
in  other  cases,  and  prinotpally  in  tin-  ]>oorer  classes,  who  are  til-clad 
and  uitdiily  ex|MiHcd  to  variations  of  t<in)iortitiirc,  tlie  rk^mnalic  dia- 
tbens  is  apt  to  prevail ;  whilst  in  those  who  live  liixurioitsly,  tlw 
local  inilanimntion  may  be  piiH-t-ded  or  necompanieit  by  various 
symptoms  of  disordered  digestion,  indtcating  tlic  preseneo  of  ati 
unuttual  rpianlily  (if  uric  m^td  in  tho  systcrm,  or  tlic  cxixtencn  of  the 

Iffouty  diathesis.    The  constitutional  modiflcatioiis,  on  tlie  otlicr  hand, 
may  rewili  from  causes  wliich  aw  obviously  tcmjioniry.    A  ptvuliar 
VOL.  UL  £  Z 


706 


DISEASES  OF  THE  JOINTS. 


form  of  xrnovift]  inAnmimilioii,  far  infttanw,  inaj  oociir  unexpt.'ctMllr 
aAi'T  jiHrtui'itlon,  or  tblluvriii^  sijitiio  0[>crutioD,  in  those  in  taut  wW 
aru  «ufti*-riii^  I'roin  what  iit  t4!nn«<l  j>)f(etnia ;  or  it  a\\\y  take  place 
flud(li>iily  <luriiig  tii«  progress  of  urvthral  (li»charge,  when  it  n 
ilistjii^ii-'^luil  liy  l\u\  iinine  ai  ^onorrhuMl  rhemnatum;  rir,  finally,  it 
may  dianltest  itself  during  the  oxirtoooe  of  nmoYU^  poisoning.  In 
all  tliuM'  iiiiKlitlftitionx  of  inflammation,  it  niav  l)o  roniorkcd,  tlutm 
ia  a  considerable  chance  of  the  topical  diiwast  niatiifcating  itwlf  in 
murv  lliaii  mw  iLHifuIiition. 

It  will  bo  oonvenient  to  commonco  With  a  <Ic«fription  of  tiie 
timpU  form  of  iiktluiuDiiiUoii  of  a  Hynovial  ■iii-iiibi'uiio,  oiid  its  oonse- 
quenoes,  and  afterwards  to  notice  briefly  tlie  peculiarities  [>rvst>iiIoi 
by  syimvilis  wlirn  tavfulow,  r/i^unaltc,  or  gvutg;  pyamky  gonor* 
rkceal,  or  gyphiiiiic. 

Afute  ^Hovili*.  Synovitia  may  be  acute  or  chronic.  Acute 
^Tloviti>,  urrsiiifi  in  the  inctnbraiio  itwif  fniTii  tlic  l-xums  alrcadt 
aliudMl  to,  occurs  more  frequently  in  adults  than  at  an  earlier 
jwriod  of  life,  ill  nialeH  tliuii  in  femaliw. 

Patholoffieal  analonti/.  Tiie  simplest  chants  nhioli  result  from 
iiifliiiriiiiiittiry  udicn  eiiiisist  In  iiioroti-'U'd  vftHciiiarilv  of  the  mem- 
brane, especially  of  it«  plica?  vbacuIorip,  followed  by  increase  in  the 
amount  of  the  aynnvia,  aiul  «umo  alteration  in  it»  liwJthy  compo- 
Bition.  A  little  later,  we  find  tlie  jnixluctn  of  inflninmation  nithei 
ell'iiM^d  iittii  Uic  ityiiuvial  uiirity,  mingling  with  and  umtrjiing  the 
place  of  the  nortual  soerotion,  or  lutuated  in  the  texture  of  thi 
meiiibnino  and  in  tlie  imm(sliiit''ly  onliguous  tiwun^  The  cfiiuiM 
into  Uio  joint-cavily  may  eontisi  of  Aerum,  mixed  with  nhnxb  of 
synovial  epitlielinni,  and  a  vuriablv  amount  of  or^aniMblc  lymph, 
giving  rifio  to  fiiLw  nionibraiieH  connected  with  the  walln  of  tltf 
cavity  or  floating  in  tln>  MH-retlon  ;  some  of  tlic  coluiiriiig  constitu- 
ents of  the  blood  may  also  bo  present.  In  a  large  number  of  cnhi 
tlie  iiiflunnnatjon  h  arrasttMl  before  mucli  miM-luef  optutb;  tfj^d 
vascularity  of  tlio  membrane  diniini»ilie&,  tlie  elfuitcd  fluid*  I^IV 
ahAorbivl  more  or  less  oompletvly,  and  the  joint  in  nvtored  to  ib 
original  condition ;  or  it  may  bt<  lefl  more  distended  than  iiatuml^ 
and  liiibli!  to  fre-tli  (!t!'iii<ion ;  or  a  certain  amount  of  tliicLcning  and 
loes  of  mobility  muy  i-emain  pennnnently. 

In  other  euBi's,  Iuiwi'\er,  fiirther  diaugc»  ooc«r  witJiiri  tho  joint; 
A  procc**  resembling  granulation  tnkea  place  on  tJie  curface,  es[)ecially 
in  the  more  loawly  attached  portions  of  thu  mombrute,  giving  rive 
to  villoiu  or  Iringod  prooeasos,  extending,  perhaps,  over  the  car- 


ACUTE  SYNOVITIS. 


707 


ttila^,  whiob  may  stiM  he  sound  Ixiicatb  Uwm.  At  tlio  Mine  time 
a  Aiinilar  adwn  takes  place  on  the  oater  nde  of  the  tnembnuie, 
incnwiing  i]w.  aiiiDiinl  of  diickcuing  uid  voniwlitlation  Dflho  cap- 
&uK  If  tho  iiillamiiintory  aotion  stjil  proceeds  uiioheckMl^lhe  Huid 
offuHod  into  the  Joint  bccoaioM  turbid,  (lot^iu-rativo  nc-tion  ^[oct!  on 
in  till'  c-lU  there  prewnt,  aiiil  pua  h  formed,  at  first  »(ia»tily,  but 
afterwiinls  in  liirj^r  <]imntiti«" ;  tho  oUkt  rtnmtiin's  (.■iitoriii^  into 

Itbo  oouiposition  of  the  joint  )i€coiiu>  involved  in  tlie  diseasod  action  ; 
tho  articular  t-nrtihi^^ts  are  affeotvd,  uIwhhik  tfxciiiatioiis  cxtcitd 
ilirou^li  their  subsiance,  ami  the  artioular  eAircniitie«  of  the  bones 
participate  to  it  ^reattT  or  loss  cxtunt  in  the  disor^iuiUini;  prooi-iM. 

I  Tin-  jHirt*  oulsido  tho  joint-cavity  nnilergo  simiUr  diangt's ;  d^y^ne- 
ration  takes  plua?  in  thuir  nvwly-toniu-d  nuitvrialK,  aiut  uIkhhmmm 
ar'tfuf  there,  ootnniunicatiRg  with  tlte  joint  by  ulceration  extcuding 
tJiroiigh  thti  cajvulo,  or  making  Uicir  way  to  tlic  »iirlaoo  by  uiciuis  of 
»iniiM»i.  Tho  UgaiucntouH  atructurea  became  thiokeued  or  softened, 
or  otlierwiMi  allvnil,  su  ae,  tn  soiov  ii]»tu>i(H'»,  to  bt!  no  longer 
eH|MhIi>  of  holding  together  Uk  bones,  whiuh  may  thuu  become 
completely  or  iucomplvtcly  dislocahxl. 
Sj/mptonu.  The  leading  H^mpbunis  tav  timno  of  infiamnuitioii 
g^Krally,  varying  in  degree  with  the  amount  of  synovitis  pn.wiit, 
with  the  canse  inducing  it,  wjth  tliu  particular  oonstituiional  condi- 

»tioQ,  and  with  Hm  individual  joint  afi'cotvtL  Tho  amount  of  inflani- 
tnatoiy  fever  de|>enda  u|Jon  thfi  eliaracier  and  extent  of  tlie  syito- 
vitift,  and  llio  inijiortjuice  of  tlio  nrtionlati^m,  U-ing  goiii-nilly  uMist 
marked  wlien  the  hi]>-joint  ia  the  seat  of  the  diwase.  Ixicatly,  we 
bavejMiin,  usually  *>f  cotLuderablo  amount,  incn'fiwnl  by  any  move- 
niflat  of  the  ]>art,  and  often  cliaraeterised  l>y  a  feeling  of  distension. 
U  may  ha  notici-d  also  tliut  tlio  p»in  in  luljtndiu-  inHiuimiationi»,  aa 
in  those  of  some  other  organs,  is  not  always  referred  to  thert-gion  in 
which  tho  dixuiuu  actually  exist*,  bi  di».^!L->i:d  hip,  for  instance,  the 
ni&ring  may  be  exjwrienoed  mninly  in  the  knee,  giving  rise  occu- 
•inuily  to  niUlukcs  on  tlic  part  of  tiie  uari'li-sn  obnurvor.  lliOTe  is 
awdHnff,  vaon-iiig  witli  tlie  amount  of  eftusion  into  and  around  tlui 
jointf  and  tjdung  tho  shape  not  of  the  jirticuiiu'  ■■xm-miitiu  of  the 
^_  tmiM)  hot  of  tlie  distended  synoviid  oajmule,  moditied  by  ttie  di-grco 
^■oT  reawtjtncu  attbrdixl  by  the  surrounding  9>lriM)tun4.  /VtidtMifintt 
^■■t  leaat  in  the  more  su^iertit'ial  joints,,  is  usually  di-vtinet,  becoming 
Vlesa  «a  if  tho  disc^iwo  is  prolonged  an<l  thu  intiiiniHiutoiy  products 
aoqmre  a  more  solid  character,  fttat  and  redtiese  are  more  or  Ium 
evident,  luiiirdltig  Uy  tile  situation  of  the  joint  Htrcetiil,  its  prox- 
imity to  thu  suilttcL-,  luid  thu  degree  in  which  thu  tissues  vi^tcriiul 


708 


DISEASES  OF  THE  JOINTS. 


ntoS 

}|IT 
1^ 


to  iJii*  synovia!  ra*?nibrade  are  involved.  Tho  posUiort  wliich  is 
nuoonsciously  assumi-d  in  Hotilo  urtivtilnr  iiiHiminiitliitti  in  oA«n 
oharooteristio  nf  the  afiei^tioii  and  of  the  jiorticular  joint  impliiated. 
To  idlo\'iatc  suflV.'ring,  thu  Itnib  \*  plai^txl  in  tliiit  (xi^ition  which  at 
oiioe  givt^a  to  tliQ  joint-cavity  it6  maximum  capacity,  and  rodu 
to  a  ntinimiun  Uio  tviision  of  tlio  capsule  M.  Bnnnct'  hns  sho 
exiH'vimi'nlally  tlic  ]>hy>ucal  etfocta  prodmed  after  doalh  by 
distension  of  the  nynovial  t'avitivs  witli  liquid  forciUy  inJLxittud  inh» 
them,  and  the  poHitions  so  aafluiued  would  probably  be  iinitatol 
vrbea  a  similar  diiftf^^Kimi  !«  pn>duc(Hl  rapiillii  hy  tWta-nt»y..  In  other 
etOdh,  however,  lliat  is,  when  tlie  elfuflion  lias  occurred  more  jdowly, 
or  when  it  can  escape  in  eonKociiivnot^  of  ntptun)  or  ulceration  of 
fiopaule,  the  position  of  ttie  limb  is  detennintxl,  to  a  great  oxt«nt, 
itM  weight,  and  thu  pn'iwure  exerted  on  it  by  surrounding  bodies 
by  the  neocecitty  of  fixing  the  jouit  aa  eteadily  as  possibU; ;  ■: 
ultJinati-ly,  by  tho  condition  of  contrnction  wbteh  the  notghbouring 
muschw  have  been  allowed  to  a»AUme.  It  may  often  hapjion  that  it 
is  difHcult  to  (Icteruiinc  the  uxact  amount  of  inRui^iev  dne  to  each 
or  any  of  these  causes ;  but  at  any  rate  the  (-ffect  produoi^l,  that  is, 
tlw  imwliou  avMuinnl  by  the  limb,  is  practiesiily  of  gri-at  imjtonanoe, 
for  it  is  capable  of  maintaining  or  aggravating  the  <limMu«  at  the 
b'me,  AA  wi-ll  AH  of  giving  rise  iiltiuiHt<.Jy  to  great  vmbarrafisment  in 
tJie  event  of  ankylofeiii  oc<-urring. 

In  the  majority  of  eH6<^-s  of  uneomplicAted  ftynovitis,  iSaxt  infiam- 
Rwtiou  speedily  subsides,  the  fluid  is  alMorU^,  and  the  part  rottinu 
t4)  it*  iiiii-m«!  eonilitiiin.  h\  otiient,  however,  tho  joint  reniainA  Minis- 
what  swollen,  tlie  syno\-ial  meinbraiie  is  lliiokeiipd,  and  tJio  mobilt 
of  the  part  diitiiiiij'hod,  whilst  tJie  patient  is  left  very  liable  to  rein] 
from  exposure  to  any  of  tlie  exciting  cjium's  of  rtyMi)viti8,  Or 
acute  syin|it*>m.-<  miiy  Hiinply  dtininiKb,  and  without  any  int^-ri-al 
restoration  to  health  the  disease  may  iiNHunio  tlio  chronic  form  to 
subsequently  described.  In  a  certain  number  of  cases,  uiifort  utiHi'-ly, 
tho  inllammation,  instead  of  suliKiding,  inereiLnw  in  wjverih,*,  and  the 
dijMaM-  is  no  longiT  eoiiliiied  to  tho  synovial  membrane,  tlie  cjtrtili^M 
and  other  stmcture.t  becoming  involviHl,  in  tlu!  miioner  to  be  more 
minutely  described  hereafter.  Such  extension  is  marked  by 
and  excrueiating  snli'ering,  by  )iaitifii]  *' jumping"  of  tho  tUnb, 
well  nx  by  erepitns  on  moving  tlie  joint,  as  tho  cartiUgeg 
destroyed,  and  is  followed  or  atl^uidcd  in  u  large  |)n>portioa  of 
by  su])purution. 

•  Traiti  <Um  MaUuIht  da  Artieulationi,  poi-  M.  A.  DonBet,  tooL  1. 1 


CHItOKIC  SYNOVniS. 


70d 


rittj^uraiien  in  a  joint,  however,  otvasionally  occim  alto  dinvllif 
oonaeqnence  of  anuU-  sjiiovitis.  So  long  ii»  tijc  |)U!4  is  ooiiiaiiwd 
vriuiin  the  Kvn<n'ial  cajMule,  the  fi}-inptom<)  are  by  no  itiviini*  im- 
(■qnivocal.     We  ra»v  tutpKi  tho  fonimtion  of  iniit.U'r,  if  the  inflam- 

iiiiiit.ion  (.■oittiiiuo  to  run  high :  if  one  or  more  rigors  occur,  foUowwl 
1)T  exaccrhation  of  th«  |uiin  luiil  f^ionJ  Miffiirintf;  mill  if  tlie  tume- 
fact.ion  iniTn-aiH^  ami  take  on  a  more  tlix'idedly  phloginonoii»  chHniv- 
ter  which  extWHis  to  (he  MiirfiMi".  'Dio  t-onMiUitioniil  liUlurhaiiw  will 
now  bp  K''wit,  thct  pulse  rajtid,  ami  the  character  of  tlio  fcvt-r  will  Imj 
altered,  asMiRiiitg  Homi'whut  of  n  ty]ih(>iil  fonn.  WliHi  »ii]if>unitioD 
liiM  occurred  within  the  joint,  and  the  vate  progressctf  unfit voiiniUly, 
tins  i>aiit  artjuod  Ikx-ohh-  !i|N^'<liIy  aRW-ttnl.     Almotswi'-'i  are  furmed 

I  in  tho  eurroiuiding  areolar  tiRAue  ^  at  6rst,  pCTha))8,  »e]>ar4it«i  IVoni, 
but  soon  communicating  witii,  the  arliciilnr  ravily.  The  fibroua 
ti'nuivt  beoonio  ^otleitcd  and  yield,  the  skin  gets  implicnbil,  and 
ojieninga  form  itunniunioatini;  with  tito  joint,  and  diwharging  a 
niort!  or  ktw  unlK-althy  piuv  When  much  disorganisation  luui  (ukoii 
place  within  tlie  joint,  Ihc  inont  fatunnihlc  \>mii:  to  wliich  wo  can 
look  forward  is  dixcharge  of  the  matter,  and  union  of  tliv  oppowd 
•rticutar  surfacie<).  TIic  hi'idt}i  may  now  iin]>rovc.  The  swelling 
8ulMd<»,  tlic  discharge  diinlnii^hes.  and  at  last  ceaM:«,  the  sinusfla 
hual  up,  the  joint-i-aivity  in  ohlitcrut*^,  l)t-iiig  fillod  with  uewly- 
formod  connoctivo  tiwuo,  and  tho  limb  is  sttfTciied  or  completely 
l()sefl.  If,  liowi'\<-r,  the  wnMtitutiinnil  powers  gi»'o  way,  tlic 
jcnt  may  he  worn  down  by  the  severity  of  the  pain  and  profuao 
discharge;  (he  imiiotid  of  tliv  iwuFco  of  irrilatiMi,  by  esdiuon  or 
aminitation,  becomes  neoeesary,  or  where  this  is  ini]>nK!ticahle,  life 
is  at  liuit  ex(inguii'hiyl. 

Chronic  /ynoriVu  may  be  simply  inflammatory  in  its  character, 
thoiigti  it  oiHnm  more  cMiinmonly  pcrliapx  im  u  nxNiiiioation  of  tlic 
inflaininntory  proeo««,  dependent  on  certain  constjiutjunal  cachexis, 
MkJi  an  Bcrofulii,  xypliiiiis  goMt,  or  rhciuniili.'>i».  In  many  c-mw  tlw 
dutinctii'o  characters  of  each  of  these  variotiea  are  cli^nr  loid  well 
dntiaed;  and  no  diHJeiilty  is  cx{K.Ticnccd  in  nmigning  the  afftvtiou 
to  it«  appropriate  place.  In  others,  however,  the  boundjtry-lino  U 
noCalwayii  drawn  with  prrx'tHion ;  and  tho  Surgeon  finds  in  (h(<M^ 
diaeaaee,  as  in  most  otliers,  tliat  llic  definiti^  deacriptioni)  ni-c<<esitatod 
in  book:i  an»  not  lUway*  liumo  out  in  pmctico.  Just  as  aoute  dii*rafle 
mdts  by  insensible  gradations  into  (Iw  Hironic,  ho  tlic  constitu- 
tjonid  mtxliti  cation  A  of  inflamnintion  are  ot^tm  ini|>orfectly  or  K-^uvcly 
marked.     At  tlio  bcdsidv  of  Uw  juUcnt,  tho  i^urguoii  must  work 


710  DISEASES  OF  THE  JOINTS. 

ont  for  hinnM-Jf  mmiT  (Idjiils ;  and  er^ry  eaae  will  siHI  offer  mme 
c|M>ci)il  eiR|Jo^iiH?iit  for  liis  inlt'lloctniil  iiivcnlij^atioii.  TIm-  antbc4- 
can  only  poiitt  out,  lut  it  wore,  tho  leading  tyjteti ;  bo  who  atwinpts 
more  bewilders  iii<>  I'cailtT  innlMuI  of  aiviittin^  lilui. 

Actitv  infliiitimHtidii  of  die  Hynovial  membrane,  imjiorfi^y 
t»Bted,Jiiay  by  degrwi  awumv  the  «-1irnnic  (nmi ;  or  oomDieonn^ 
vritVnit  niiy  ^n-iit.  tu;tivity  in  ilt*  fi>-in|iloinH,  the  inflammadan  tnty 
jmfls  into  a  chronic  condition ;  in  the  latlvr  nMc,  hovrvwr^  the  prfr- 
bnbilitHit  nn)  vi-ry-  mncti  in  tavwir  of  the  esi»teii<»  of  nrnw  ntiniiti- 
tutkmal  taint.  The  joint  is  wmirlinu-n  nitirli  diitt(^'ndi-<l  witli  floid ; 
and  th«'  Kynoviul  iiu!iiit>ratur  itdclf,  in  pn>tra«1cd  KttieH,  Uhm^  man 
or  l«w  of  iU)  natoral  fitnicturc,  U  over  vnMmlar,  and  permimeDdy 
tlitckvn<H),  or  voiniTtinl  into  a  firm  and  ^stly  «ul»1;inot'.  Tlic 
duMAW  may  griulually  yield,  or  it  may  remain  ntationan-  in  this 
oondilton  fur  a  conoid  ■•nil  >li'  time,  and  then,  iiniler  the  inflm-ncp  <)f 
fntih  inflammalion,  a  ww  deposit  of  organ!«ali1e  matcriai  may  taJoa 
place,  and  tliv  joint  idtimiiU'ly  U^wnm  totally  diAor^^aniMti 

Tlie  Byniptonts  are  maeli  the  same  as  in  the  acuto  form  of 
di*pa»o,  oidy  far  l<3w  M-vrre  in  ihiMr  duiracter.  Tho  oonntitittional 
di»turl)ance  ia  «>nii>aratively  little  folt.  Tliere  ih  swelling,  mine- 
time*  tu  a  cunnidf'ntliltf  exta^nt,  more  or  \enH  putn  ia  nciwmitcFd,  and 
the  movements  of  the  joint  are  often  very  greatly  impaired.  In 
Ktimo  iiiKlano*^  n  |Kxiiliiir  (■r«-]titu!«  or  crat'Iclinff  is  fi-lt,  or  a  aeiiMtHiii 
IB  communicated  to  the  hand  m  if  a  number  of  loose  bodies  exittlnl 
in  the  joint,  <Ii'|)cFidiiif;,  [«'rhni>«,  on  <*ffitsi(m  of  phiMio  materinl  into 
tilt'  cavity,  Himilnr  to  tliat  ivitiecd  in  iiiflnnimiition  of  the  bnnw  and 
timdinuuM  Klir^iitliK.  'Hie  shnjilo  form  of  climnie  Bynwitiif,  the  form, 
tJiut  is,  not  eciTinecteil  witli  any  conHtitutioiuil  taint,  nmiiilly  tpr* 
minato«  favoiimlfly  imless  ncjiletrtifl,  .il-«  in  oonLHiim.illy  t*rn  in  the 
labotirinjr  olawtes,  wlien  attack  after  iritaek  may  ocpnr  lilt  at  Ia.*t 
the  joint  i«  df-Mtmycd,  or  lit«  ilw-lf  ww!rificed.  In  oum,  too,  of  loi^ 
iilaiiding,  where  great  iudiiralion  of  the  mft  tiBsnes  haa  oomrrHl, 
complete  n-xtoration  toahttiltliy  condition  becnmce  at  best  difljcnlt, 
and  relapM>a  into  a  atate  of  Bab-a«ate  inflammatjon  are  of  fri-qncnt 
occiUT*'nce. 

Trfattnmt  of  antlf.  fyiwrili*.  The  treatment  to  he  a<ln[ited  ia  partly 
gpncral,  partly  local.  If  the  inflammation  naw  very  high,  ami  the 
patient  in  stn>ng  and  pletlioric,  it  iniiv  Iw  iH-d'asiiry  to  tnke  blood 
from  tho  arm ;  at  any  rs-U*,  a  brisk  mercurial  porgative,  fbllowKl 
by  HalinoK,  with  antimony,  and  |>crhn|iN  witli  t^ilohicum,  will  be  ad- 
visable, or  in  Dome  cases  it  may  be  expedient  to  placo  tho  systciii 


TBEATMKST  OF  SYNOVITIS. 


711 


npiclJy,  hut  fur  n  short  tiiiw,  midcrthc  influcnoo  wfmeivury.  Wlieiw 
tJie  patient  is  kfts  robudt,  any  blixKl-li'Ctiiig  liad  rwoursc  t"  shoald 
bo  local;  tatd  in  alt  csmm,  tJiough  it  M-ill  be  (It'-Nira1>l<'  to  keep  the 

I  liver  acting  by  CAnibining  urnxncum  witJi  llie  »illn«  tnediciiits,  op 
by  adiuini.tti-riu^  Qcca<Juiial]r  some  |»rf|iarjiti"n  of  mt-n'uiy,  ^Holoilt 
|)urpttivc9  should  bo  avoidtMl,  on  lu.-c'ouitt  of  the  disturbaucc  to  the 
limb  wiii<rh  tJiHv  nccciwitate. 
The  ]>riuittry  and  t-sw-ntiiil  noiuHtion  of  Oie  local  trentinent  ta 
eornplcu  rrpoff.  Where  the  infliiiiimHiioii  i»  of  nuiili-ruie  extent, 
taont  reet  in  b«l,  with  tlic  joint  !m|iiK:)rt(?d  by  a  |>artially-<iUti*nded 
I  air  or  wiititr  cushion,  will  Iw  »ufGciftil.  Where  thu  iriHanimatioii  is 
Bt-vcn.*,  and  danfjiT  of  jH^miaiteiil  iniscl»i*f  t]m?atcn»,  more  divided 
juoeliiiniml  »u(>]iort  ih  reijuircd.  The  jxiKitioii  to  b«  iu!i>|ited  variw 
■with  the  individual  joint,  but  ui  nil  oases  niiist  be  tliat  wliich  keopa 
no  li^uient,  and  no  |Mirt  of  the  wnovial  meiubnuxr,  on  the  stretch, 
and  which,  in  tJie  e\'CJit  of  Hnkylusrit  oa^urring,  will  allow  tlw  limb 
to  he  UAvI  to  the  (^'catest  advantage,  8u|)]HN'inK  tlio  nrticulatioo 
to  have  already  ibMunied  an  iinprojHT  [losition,  it  is  hotter  to  put  it 
^  tifiiii  at  once,  wen  if  tlie  existing  inflammation  i»  at^tt! ;  for  in 
Hnnitataral  positions  t)u>  ditfi>rent  (lartH  of  tli«  joint  are  kept  in  a  riato 
~  of  Hiuine  pR'Mure  or  of  undue  tenviori,  eitlwr  of  wliioh  interfere* 

■  witii  healthy  nutrition,  and  !«)  opjiCMt*  tlie  curative  proceM.  Undor 
Hk  influence  of  chloroform,  the  replaceinent  am,  at  tliii>  time,  be 
raadily  effi-cte<i.  'llw  splint  uwl  sliould  Iw  well  winpled  to  tlio 
Iiini>,  and  be  oftu^tnt  lemftA  ;  in  many  casee  it  'u  al}>tunlly  sliort, 
Jiving  no  real  rent  to  ihi^  joint,  and  nllnwitig  tluj  w«i|z:ht  of  the  parts 
below  to  drag  Ufwii  tlio  liganionts,  and  tend  to  pnxlucu  detormity. 
In  diMttMo  of  llii^  kniH'-joint,  fur  ini<l»nc<>,  tu  pve  effectual  Bupiiort, 
the  Bplint  should  cxt^-iid  very  &r  u]>  the  tJugh,  and  he  fumiiJied 
bcJow  with  n  f'mt-i>ii'0<',  to  pn'vi-nt  th"  tnnihiney  of  the  foot  to  fall 
outwards  or  inwards,  and  so  pitxluco  a  comwjtondinf;  IwiKt  of  the 
affected  urtiiMiliilion.  Ilio  |M>int»  hvrti  insisted  upon  are,  of  eourve^ 
applicable  not  merely  to  canes  of  synovitiit,  but  of  all  dtacaseti  of  the 
joints,  in  which  aUo'lutu  rvxt  i*  demand^il. 

Xoeol  depletion  wUl  prolably  be  roquircd  to  an  extent  determined 
hy  Um^  WMtonwt  of  the  inflammation  and  the  vigoiu-  of  the  patient 
If  leeclies  are  ap]ilie<),  it  miisl  be  renienibered  that  Ihej'  act  not 
merely  by  tlie  abstraction  of  blood  tliey  give  rise  to,  but  al«o  as 
derivativi-s,  in  o<lnM^quen<»  of  the  irritation  produoxl  by  the  bitoa. 
Ttxr  application  of  a  ;>vi  leeches  immi-dinlely  over  a  «i(p«i^<-ia/ joint 
may  tend,  ocHiMiqucntly,  tu  iiKreoM  tbc  inflammation  inatvud  of 


712 


DISEASES  OF  THE  JOINTS. 


dim! niching  it.  In  iiimti;  Kyiiovitis  of  sncli  a  joint  a.^  the  knei^ 
thrnli-n-,  it  is  better  to  api)!;'  leeches  freelj-,  if  at  all,  ancl  at  aame 
short  di0tan<H<  aiove  tliu  joint,  »o  as  to  vinpty  tl>c  di.-rt4-iidod  vcwclf 
twlow.  Tho  aamo  oliservatioos  would,  of  oourse,  &|^ily,  sbotdd 
cupping  Ijofinjikij'wl  iiwtruil  of  kvcJioit. 

AtW,  or  in  slight  casos  in  place  of,  the  looal  depletion,  varioos 
ODioUivnt  ii[tj>lioiition»  may  bo  ustil.  Aa  a  gcn<-ntl  mlc,  wann 
jbniontntiand  and  poultioea  are  the  most  sooceesful  in  relieving  pain. 
0»;a«ioiinlly,  Imwovur,  i^old  h  mom  grat*^  to  tW*  potivitt.  Whidi' 
ever  is  emjiloywl,  uniformity  of  temperature  is  much  to  bo  dosLRal ; 
the  joint  xliould  not  b(>  rxjxisiid  to  fW'qiifiit  changi^  imt  the  appU- 
cationii  should  bo  maintained  eonHtandy  at  or  near  the  saroe  stand- 
ard. It  is  OH  tlii*  print'ipk'  that  wrapping  tin'  joint  in  I'lrtton  wool, 
or  wivcriiig  it  wit]i  ointments  which  exclude  tlw  air,  is  often  of 
eervice.  If  cold  Uo  applieil,  it  may  ho  uM-d  a*  din-cU'd  by  Or. 
EmiBrdi,'  in  tlie  torui  of  ice  eontaimd  in  baga  of  vulcanised  india- 
rabber  (far  pivfvntblc  f^ir  many  n-awmK  to  bliiddvm),  tH.'p:irnted  trum 
tliv  limb  by  u  piece  of  lint.  If  tliis  prove  too  heavy,  a  aiuiplc  ap> 
paratu>^  may  be  contrived,  by  ifnx^icnding,  at  a  suitable  angle,  from 
tliv  crudli!  pliiccd  over  the  aA'<.^ed  limb,  a  boltle  containing  Mild 
water,  in  which  a  fuw  tliread;'  Rre  partially  inimcrstrd,  with  tJioir  ends 
hanging  out  of  the  mouth  uf  the  IxHtl'^;  theat-,  by  capillary  attraction, 
will  keep  up  a  cmslant  drip  ujkhi  a  j)iccc  of  lint  covering  the  ID- 
iJaiMitl  jiiJMl,  mid  tJie  supply  of  tluid  may  be  soregiilab'J,  by  var^'ing 
the  luuiiber  of  threads,  as  jtist  to  oompeiisato  for  the  loss  by  evapora- 
tioii,  nn<l  piweiil  the  rag  from  ever  getting  dry.  Such  an  arrange- 
ment I  ftv-qiiently  used  with  advantage  at  the  Hosjtital  for  Sick 
Children,  both  in  caw's  whortr  aoule  inlliimuislion  uln-aily  cxist«dt 
and  in  cithers  where  its  occurrence  might  be  anticipated  in  couM* 
quonce  of  o|ioratioiiK.  The  cH>!d  hIkiiiIiI  lie  mainljuni-d  without  inters 
mission,  as  long  as  auy  abnormal  increase  of  tcm]>erature  cxiNts, 
providetl  it  uppcju-»  grattiful  to  the  ft«;]ing  of  ifio  ]wtJ(MiL 

TrraitnftU  </ acute  absceti  q/'joinfe.  If  tJiei-e  is  reason  to  Kt^iovc 
that  acuttt  intlnmniution  of  tlie  synovial  mcmbrnne  hait  jiroceedml 
mpidly  to  suppuration,  the  fact  may  be  verified,  at  least  in  tliu  mnr« 
superficial  joint)',  by  tin-  tiitroiliietion  of  a  nceille-tnx-ar.  .Supposing 
mattt^r  to  he  fnujid,  if  letl  to  itself,  it  will  at  last,  afler  more  or  Iocs 
resistance  from  tlio  containing  cajmule,  find  its  way  tliroogh  tho 
muscles  and  tt-ndinous  structures  to  tlie  skin ;  in  dwng  so,  howtn'ur, 


•  Oittht  Ut$ef  Cold  M  SuTftry.  New  Sj-d.  Soo.  IfiSl. 


TREATMENT  OF  SYNOVITIS. 


713 


» 


will  (tiwed  up  Rn<I  alter  \ha  rclntion  of  tlic  part:*,  nnd  »n  diminish 
tliuir  HiilMcquent  ti^ndem-y  to  ooliore ;  whilM  tlie  long  wid  doviuiu 
BinuMit  which  an?  lolV  will  (>rovoiit  tho  articular  cavitj  ih«n  frwdy 
oontraoting  and  diwharging  its  contents.  It  is  better,  tberoforo, 
wboii  tlu!  ^iluutioll  of  tliv  joint  fidinita  of  it,  to  vvacuati:  tixr  mntter 
early  by  a  fret?  ineiffion  mitde  in  a  dejiending  poiution,  so  that  tlio 
tnattor  will  flow  out  with  tho  gixiitrrt  ctua.  Tho  opcmiii^;  in  wm'll 
ca«cs  !a  osually  attended  with  marked  relief;  but  frwJi  inei§ion3 
may  ani^rwiirdH  W  miulo  unhoitjiltngly,  or  tlio  ol<l  wound  wiiiirpxl, 
whonovcr  any  obstaole  to  tlie  exit  of  ptis  iihowB  itself.  l>uriHg  tiii* 
tiuio  till'  niiidt  porlvrt  n^  inuet  bo  obiwrvcd,  and  (ho  limb  niiiin- 
taitK-<l  nceurately  in  position  by  Hplinto  of  sufficient  longili,  moulded, 
if  netHJ.Houiry,  tii  the  rc<jiii«te  form.  Groat  at^'ntion  nuwl  idno  b© 
paid  to  tile  generul  healtli,  nnd  tlie  streugUi  supported  aa  the  acti^Hty 
of  the  iiiHMniniiitury  fovt-r  subsidt-s. 

If  the  matter  witJiin  tiio  joint  ibn'omfxutcs  without  escaping 
ftvely,  abwrplioit  of  mnio  of  !t«  pntrid  eonetitueiit»  may  ocvur, 
showing  itself  by  ilui  irril»tive  or  typlmid  <-!mr.irler  of  tlie  fever. 
In  aiwh  ctisi.ru,  si\rr  proWding  a»  lar  as  jwssibic  for  tlie  free  ovaoua- 
ffiun  of  the  jiuH,  weak  iiHline  iiijiN-tiona  luny  bo  userl,  not  merely  to 
{y  iJic  action  of  the  scereting  nienibrano,  but  also  to  im])rovo 
cliaractor  of  the  mutter  by  dei-umjHisiiig  ibo  (inKliK-is  of  jiuire- 
ion.  Witli  euro  and  attention  on  the  part  both  of  tlie  Sui^'on 
and  the  patient,  nciit<i  Hiippmiitlon  of  joinU  from  Hviiovitin  may 
filirly  1m'  oxjM.ftcil  to  terminate  favoarably,  especially  in  children  j 
Imt  as  more  or  loss  iititl'ntuw  uf  liiR  joint  mtiAt  Im  ex(iocteEi,  special 
itioii  nbould  be  paid  from  the  first  to  tho  fyosition  of  tbo  Itmb^ 
of  WiUting,  an  in  itoincliincM  done,  till  ankylms  has  taketi 
plltco,  to  rvuiody  tlio  deformity  which  has  boon  allowed  gradually 
to  arise. 

7'realmfnt  of  mb-aeftte  and  chnmic  gi^ioifUu,  Ini>tcad  of  giving 
to  tile  Ibmuiiioit  of  nlm^c-'oi,  tho  acute  iiiflMiiiiiiirtorv  symptoms 
ly  subside.  As  this  obango  ot'cum,  the  antipldogistio  treatment 
IDodiK<;<] ;  wmio  bliMxI  may  iitill  bo  absInuAcd  by  letK-lies  a{>|>lied 
dintctly  over  tho  pan,  and  cooling  apjilientions  may  bo  uwd,  or 
Count^!r>irr!tJiti<>ii  may  bo  Imd  rooour«-  to,  in  the  fimn  of  blisters,  to 
pTixluoe  a  discharge  of  senun  fr«>m  the  vessels  of  llie  skin.  Blistons 
may  be  niml  oiu-lior  in  inflammation  of  tlio  dix^jior-NeNled  joints  than 
wbcre  tho  supurtieial  articulations  are  implieaie<i;  for  in  tbo  1att«r 
titc  small  amount  of  intorveutng  tiiutuc-M  allows  the  irritating  action 
to  be  propagated  to  such  an  extent  aa  sensibly  to  affect  the  synovial 
torfiwe,  acutu  inflammation  of  wbicli  miiy  be  again  vxcited  under 


Pt^ 


714  DISEASES  OF  THE  JOINTS.' 

Ut»  i»f)amc«  of  too  wn-OTO  or  too  early  a  Btimnltu.  In  i>ynovits, 
theivfiire,  uf  tlw  »ii|MTtiotal  jotnis,  blUtera  ediould  not  lio  n[(j)lieil 
too  Itartily,  and  wlwn  used  may  be  placed  Mnu>  liHlo  dtabutw 
above  Ihi!  inflainod  !t|Hit ;  it  i.t  tx-cter  also  to  eniploy  a  ^iiiyiwioci 
of  **  flying"  blUtcTS  ratlier  tJuui  ktxjp  mie  opon  by  irritatiiig  applU 
catintiM.  Following  llie  blistt'ni,  itriii  jiliice  of  tfaom,  rariow  »limti- 
Uting  linimentH  inay  bo  oscd,  or  the  part  }Hiintrd  witli  roiicciitratcd 
linc-tiiro  of  i<Mliiii.-,  Ar  llm  inflaiinnator^'  Hymptama  DiilLHiiU',  ia 
those  rasoa  especially  where  some  tliickc^fiing  of  the  mcmlMWH 
has  oocuntKl,  v.v  eonibine  a  moderate  amount  of  ooni)in-M<ton  with 
oup  support  of  the  fart ;  this  may  bo  done  by  Bp|»lyinj;  alternate 
laycTV  of  bandiigi^  and  a'lhoJ<iv(!  pluirter  with  or  without  cnrnphonittd 
mercurial  cerate  next  tlie  i^kin  in  iho  way  described  a»  "  Scott'l 
bandage."  SninetiiiK-!t  the  Imiulap'  ia  Man-heel,  but  cjtre  alioiiU 
tlien  b»  takon,  if  any  fresh  outborat  of  inilanimation  opciir&,  that 
tiie  bamlnpi  can  be  promptly  mnovtvi,  if  iM><>c!Man-,  by  tli^  [latM-nL 
In  Bome  cases  it  is  nseflU  to  eni]>h»y  ^ints  made  of  cow-hide, 
soAonod  in  wonn  vine^^,  moiihlM)  to  tJie  form  of  the  joint,  and 
fastened  on  the  limb  ntV'r  having  been  lined  with  chamois  lesthcr. 
A  variety  of  Kiniiinr  contrivanot-s  will  probably  ouggMt  thcmtielvefl 
to  the  Surgeon's  mind. 

If  rc*t  bo  a  primary  neewMty  in  th«  aeut<T  stageit  of  iiHlam> 
matioii,  a  time  (-onii-s  at  lost  when  tliis  has  to  be  disoontinued,  and 
passive  motion  of  tlie  joint  substitut^^d  in  ibi  place.  Caro  ina«t  be 
taken  not  t<)  dt-fcr  the  i-hange  too  late,  nor  yet  to  ManmcDi-e  it  too 
early  ;  we  begin  to  employ  it  with  caution  when  wv  nn  longer  find 
tendenietiR  on  prcmure,  or  pain  produced  by  gentJe  movement.  Ib 
conjunction  with  the«o  pasxivc  movements,  friction  with  the  hand, 
eovenil  with  .itarvli,  may  bo  umvI  zealomJy,  though  still  cjiutioustr, 
for  gradually  lengthening  periods ;  or  we  may  employ  local  vai>onr- 
baUiA,  (!nnil>ine<l  or  not  with  shninpooiiip.  flT)en  the  distensitm  uf 
tlio  capstde  has  been  coiisiderable,  nml  the  joint  is  k-ft  relaxed,  it 
may  ho  nef>>itiian.'  to  w<nr  an  ol)i.-<lic  Imndage  far  a  ronsidcrahle 
period  after  8]>parent  reeovery.  When  tliickening  of  tlie  eapsnle 
hn.H  tiiken  plane,  and  the  wflV-etioii  Iinit  iKH'n  of  a  chmniii  chomctcr, 
time  and  gradunj  exercise  of  the  limb,  in  addition  to  tlio  mcoBoreB 
which  liavii  Iwn  alludttl  to,  will  do  much  townnin  restoration  of 
ftmetion,  for  in  tliese  easos  tlje  muscles  of  the  extremitj-  have  btH-oine 
weak  ritid  wiwtcd,  and  eiuinot  bo  used  freely  till  time  i»  aUnrded  for 
Uieir  renewed  nutrition. 

Tlio  treatment  sketched  otit  has  been  that  propoKtd  for  disease  of 
the  synovial  membrane  itself;  the  treatmoot  of  those  eases  in  whieli 


DROPSY  OF  JOINTS. 


715 


til?  Ixnipx  snd  oartilagoa  bpcom?  involved  will  be  alliid«]  to  snbso- 
qu«nti}-,  IP  tJift  MWtJou  treutiug  of  (liw.iiHea  gt'Uioao  tiMtacfi. 

Thopty  {^jobUi^  Wc  w««wnrmll_v  inert  with  cases  in  wliii-h  tlio 
J  ^'novial  mrmbnuies  are  very  graittv  tlisiondod  with  fluid,  whilrt 
f  few  or  no  othtir  symjitiiniii  of  influflimntiun  nro  {mtuml.  Thd  iifFtw- 
tliOTpforo,  has  been  Mtnipared  t«  dropsy  ol'ecnnB  mcnibraiK's, 
Jly  tlittt  of  Uk  tUTiion  viif;inali)i  teittiA  fonniiijr  liydrtK't'Ic,  »ii<) 
yha»  reooivod  tlie  Kjioeia]  niuno  of  AydncjM  articuH.  1  Iwve  placed 
it,  howe^er,  imniKdinti'iy  alU-r  ordinnry  synovitis,  Iwtwisi^  in  iilmurt 
all  the  casi'H  wlipre  lu]  ojipcotunitv  has  Uxm  ailbrded  of  examining 
th(!  Joint,  tlic  lining  niiiiiiirHnc!  lta>i  Im^n  Touiid  somcwliHt  tJii^-kcmrd 
and  iinusnally  viuiculiir,  especially  in  l}u>  situation  of  its  v-aseulur 
plVM'eaitei^.  Tim  fluid  diflrr*  i'mui  onltnan*  sviiuviji,  U'luj^  tninif- 
pMvnt  and  of  a  yellowish  colour,  but  presenting  no  appearance  of 
"  threaiU,"  llinuf*}!  il  (yHi^dntcs  on  tJio  npplicatioii  of  li<-:it ;  in  fact, 
,      it  closeh'  rescniblcu  the  fluid  tne4  with  in  aM-ites  or  in  hydrocele. 

*AII  sj'nf>\ial  nii-inbriini-s  an'  not  wtunlly  subjix-t  to  dn>psj-,  wbicJi 
dually  aflpcts  those  of  considerable  extent,  and  in  which  tlio  necro- 
tion  is  UHttindly  iihundant.  It  in  niwl  frwiuenlly  found  in  llu'  knee, 
sometimos  iu  tbc  elbow,  very  seldom  in  any  other  articulation. 
Hyilrojis  articufi  is  sfarocly  cv«t  a  primary  aftW-tion.  It  may  foUow 
an  acuto  attack  of  sjijovitis,  and  i»  apt  to  recur  in  jwrsoos  of 
iTfstk  and  irritjibln  constitutions,  especially  those  in  wluim  thi*  con- 
dition is  combined  with  lbi>  gouty  or  rheumatic  diathesis,  whea 
onra  tlio  tn<-iiibninii  lias  been  prctematiirally  dist^-ndcd.  In  «uch 
penvon*  the  immediate  ntlack  iiiuv  lie  induced  bv  expoenro  to  cold 
or  Tvry  slight  vjoImioo,  or  even  by  eoiae  les»  obviuiut  constitutional 
diBtortianco. 

The  eftuftion  takes  jiliiw  very  raj>iiny,  and  forms  a  tumonr,  whom 
Umtts  are  those  of  liie  sj-novial  cajiiule.  Iw  i-hw^acter  may  gener- 
«Uy  I)«  easily  nn-ogniscd  by  the  tihai>e  of  tho  swelling  and  il«  ready 
Ructoation.  There  may  Ixs  some  slight  symptoms  of  inflammation 
present ;  hut  ustmlly,  tboogti  tho  limb  is  somewhat  stiO',  it  may  !>« 
med  with  scarc^elv  any  pain,  v\«n  from  the  first,  and  the  parts  ex- 
ternal to  the  eaiwnic  show  no  traces  of  reilncw*  or  (pdniUL  From 
thickening  of  the  joint  due  to  effusion  of  jilastie  l)'mi)h,  hydropa 
articnli  is  distinguishetl  by  tho  fluetoation  which,  as  M.  Bonnet 
remark",  is  liest  nf-ognim-d  by  placing  une  liiind  above  and  the  other 
boli>w  tile  tiimotu' ;  if  they  are  placed  tnrnsvewely,  the  displacement 
of  the  musolw  or  tendons  may  be  mistaken  for  the  movement  of 
fluids.     From  aUweea  of  tlie  joint,  it  may  usually  bo  distinguished 


716 


DISEASES  OP  THE  JOINTS. 


\>y  tlie  oon<lition  of  iho  soft  pnrte  around  as  well  as  hy  the  Pon«tf+B- 
tioDaJ  »yui{>tiiiii«,  tJtoii^li  it  uci'iixioimlly  luipju'riH  liiut  iiit>  true  natufv 
uf  the  iHliiHioit  can  only  ho  determined  by  puncture  witli  a  ixtilie. 
^le  prognoHJx  in  llx'sr  t-iM-M  i^  nioHtly  Invoiinilili-;  ul  loiiAl,  llio  otlier 
MructunM  oftlui  j<jiQt  Eeldom  Iiecoine  involvty],  tliougti  (lio  dii«c!iMe 
itsdfinay  be  diOicult  of  curt!  uid  nrry  jtroiio  to  rdajinw,  (tniiccially 
in  awc8  of  eorae  xtandinj;:. 

TrMttitftit,  K  liny  in  flam  mil  tor}'  nyni|i1oin»  nm  pravn-iit,  tliesa 
miwt  first  bo  subdued  by  the  ordinary  constitutional  remedies; 
wliieh  inny  U'  miidifii'rl,  if  any  pnily  nr  Hioumnlic  li^nd.-ncy  f«n 
Ik!  di-lix-tc*!,  by  foocliL's  mid  lomenliitions,  or  by  cooliiijir  lotions, 
AVlien  ull  Inu'iv  nf  iiitliinunntioii  nn<  Mibdiu-<],  luid  itit*  attwitim  lata 
aiwiunittl  the  ehronin  form,  the  joint  mny  bo  blistered,  or  painted 
livc{tiinil]y  with  a  Htri>Ti^  iu>bitii>n  iif  tiMlino;  tiiin  iniiy  lir  fnllawcd 
by  ooinprG««on  by  means  of  itdhcsire  plasters  and  bandages,  «i>- 
oompnniixl  by  ntimnliitiiig  nnd  mi'miriid  iipplirjilioii.i  diriitrUy  to 
tbo  skin,  for  the  puriKxw  ofpramoiiiig  abfiorpdon.  If  the  ease  is 
recent,  under  t^aeU  tn-^iUm^ut  tho  cHuition  may  bv  oxpuctod  to  sub* 
sido;  but  it  will  utill  Ijp  neoesamy  to  support  the  relaxed  membrane 
and  pifitfct  llir  jdiiil  by  wearing  a  liu.-i.xl  or  i-luMliu  kiivf-uap  for  ut 
almoKt  indefinite  period. 

In  ol<l  and  m^jjK'ctcd  oases,  on  the  other  IiktuI,  the  affection 
n>ists  all  oivlinaiy  trealnit'iit,  luid  must  eiiJier  bfi  al>ftntiun(-d  as 
ifl<!nnibh-,  or  furtlicr  and  o(>crati\-e  meaxnrcs  had  rocvurso  to,  the 
must  ]jra<;ti<able  of  wliit-h  aiv  iotline  inji'irtion^,  cm(Joy<sl  as  tn 
cOM-it  of  onliiiitry  bydroeelo,  Sliould  It  bo  considvn-d  advisabUi 
to  have  reeoiirse  lo  this  plan,  and  liic  knee  b«  tho  joint  attW-tMl  (as 
in  niOMt  croniiuoiily  the  cose),  tlie  spot  selected  for  the  punetun*  i* 
that  part  of  tlio  nyiioviiil  menihi-uno  whi<'Ii  h  hituated  abiivi'  Hnd 
extoninl  to  thf  (Hitella;  the  limb  should  Iw  in  the  cxtende<l  jiosition, 
and  tho  opening  remlcrcil  viilvulnr  by  )iullinfr  aside  llio  skin  liefon 
tiit'Tiuliicin';  tho  trocar,  wliich  libould  be  only  of  moderate  size.  "Die 
fluid  injoctwi  may  tion«i»l  filJicr  of  a  spiriluoun  nr  an  nijiMniiu*  m>1u- 
tion  of  itxlino,  the  former  bciiip  preferred  by  Boinet,  who  uijet-ted 
aimplo  tincture  of  iiNline;  wbilitt  Scliiib,*  nho  has  em|iloyfd  tliia 
trcalmciit  xucecssfully  in  tliree  cases,  employed  one  port  of  tiDMurf 
of  iodine  lo  four  parlj*  of  wut<T.  Tlie  quantity  injtx-twl  mny  vij 
from  liiilf  an  oiuice  to  two  or  three  ounces,  the  latter  ijoantity  being 
tliat  used  by  t^'huh.  Ak  murU  as  jMnwiblo  of  tint  fliml  In  lUlowiiJ 
to  CMBpu,  alW  being  retained  in  tlie  joint  for  about  five  minutes, 


Him.  ZtiUoh.  N.  F.  voL  iii.  p.  0. 


SCROFULOUS  SYNOVITIS. 


717 


fiav}  rare  tAkcn  to  previ-nt  anr  admiaaion  of  air  to  tlic  artioulntion, 
'\\'Ii«n  tlto  trooir  in  widulrann,  tin-  (-tititiieMUA  wound  is  caalM  witJi 
I  oolKKiion.  Tli«  unmediatu  result  ut'  tJii!  injection  in  to  prodnoc  a 
oertnin  amount  of  in  Ham  million  ;  to  jin-veiit  thin  from  gwng  too  &r, 
I  or  from  ;;iving  riiw  to  t<U|t])urstioii,  the  litnb  tnn.'tt  be  nrtained  in  a 
^■Btale  of  immobility  alli^r  tiio  oiK^ration  by  iiieKiiH  of  a  pn>|R>riy  aH- 
^•opt^-d  K]>lint,  and  tlie  eaws  watt'hud  carpfully.  »«  tlmt  anti|ihI<igii<tio 
I  meanuros  may  do  hiid  n-iimrso  In  if  noctw^an'.  This  Uvauucnt 
^ft  would  only  l)v  adopted  wlioro  all  otht-r  moiitiK  liavc  failt-d,  and  much 
^H inconvenience  resuttii  to  diu  |iiitJi'nt  from  tlie  dii^teniled  capsule.  It 
^Pis  oniy  snitnbki  to  vaseti  of  simple  dropHV,  tliuw)  wliici)  aro  nnoom- 
plicated  with  disoatwHl  I'onditJotm  of  llw  bones  and  oaititageft;  bat 
in  pnipcr  cuws  it  may  produce  a  deoidod  iTn]>r«vcmciit  of  tlw  cou- 
[ditiou  of  the  juirt,  or  oveu  !iom(!tiin<.<a  a  eoni]tlete  cure. 

Scrafuiott*  ^n»pifu.     Thoro  is  a  pocnlinr  funn  of  xlow  infLuti^ 

UOD  of  the  »yno%-ial  membranes  occasionally  met  with  in  pcnons 

of  fttrumous  tuibit,  which  in  MumtiimM  di-f«iTiI>i-d  umler  tin-  name  of 

Iftlalitious  iltffeneration  of  tke  gi/noiiial  nte>rtbraiie,  but  wlueh  apjxtnrs 

|to  be  inilamraatiim  of  a  trlironic  charactor,  moditiod  by  the  ncrofiilouit 

[condition  of  tlic  system.     If  we  liave  nn  ojiportiiiiily  ofi^xaminiug 

the  joint  when  the  dii^aM  Iiili  lulvum-i'd  lo  a  (:(-r1;tiii  uxkiul,  tlie 

t  principal  points  which  attract  attention  are,  Uic  thickening  of  the 

aynorial  membrane,  anil  tbi;  j^t-liitinmi.'*  pwlpy  apixijiruiiei!  which  it 

iwxvwntj*.     The  vaseuiarity  of  tho  membrane  is  jncreawtl,  and  the 

us  of  its  Huh&tance  a]i|K!ars  to  bo  uouvurtisd  into  a  soft  yeJIowit^ 

for  lipht-bmwn  gelatinous  material.  iVnciuently  of  vcrj-  rinwid**niWo 

VlfaioknefiN.     The  articndur  cuvily  Ixvoimw  <liiiiiiiinlie(l  sia  the  tliickon- 

[Ig  i>xtond»  u|>on  the  mtfmal  surfaeo  of  the  menilimnc  ;  niid  a:(  tliiit 

sion  goos  on   muft  fruely  in  liu'  l»KM*e  syno\-iaI   folds  whicb 

oiuid    the  cartilages,  tlwse   arc   often    partially  or  c<>mph't«ly 

llmried  and  <'on(i'iUu(i  bcncalJi  tlu!  ni!W  formation.     A  somewhat 

proe(«s  occurs  at  tlic  same  time  in  tlio  nroolar  tiitMUR  at  tlie 

'  Htrfaco  of  the  incmbnini:-,  which  bci-iniies  tfondemsed  and  'm- 

liiltniled  with   a  corresponding  pulpy  su1»taaoe.     This  gdatinoiu 

material,   aoi'onliiig  to  Mr.   Itarwcll,*   tit  Iho  Ksult  of  Iho  samo 

pmci.'sw,  of  what  may  be  tenned  pramihtion,  a»  that  which  occurs  in 

(•ciit«  Rvnovitia;  but  in  Aea/My  inilanimation  the  growth  organism 

ititiOf  into  a  fibroux  or  areolnr  tissuo,  which  gnuhially  ix-owmw  iiwru 

and  muro  [icrfcct;  whilst  in  will-marked  tlrunuMi  iiiBaniiiuiduu  it 


*  On  DiKOtft  0j  tht  JomU,  p.  IH. 


718 


DISEA8BS  OF  THE  JOISTS. 


dooi  not  lulmnw  Iwyoml  tiio  lir^  fonn  of  rrudo  (>o11-Htnietiirft. 
Uany  gnuklions  of  coarse  exist  betwoea  tho  two  eondiiioiis,  wkidi 
■pprnximnto  or  divwrg^t  wiUi  <xim'«poii(ting  nJU'ruciotui  in  Uiv  pataent't 
oODsti  till  ion  al  powers. 

Thii  joint  m«v  rt^miiin  in  tJii*  ennclitioii  fw  «  conititlvnihU)  period, 
and  thon,  under  fsTouriiblo  cironiOBlannM,  «  process  of  rtstoniiioc 
OCCiUH,  tliH  iti'W  t!li!mi-i)ti>  rtltrink  iir  nnt  itlimirlN^I,  imd  the  Hrtu-iila- 
tion  is  restored  more  or  Icwi  perfectly  to  it«  former  condicioi).  Mt>r« 
firYH]u<mtly,  liowovcr,  lh«  dim^nw  mitkiTH  furilier  [mi^rns*:* ;  tJiu  gela- 
tinous thickening  of  tlie  e%-novial  membrane  extendi  furtlier  over  Ha 
<arUlaf|;c»,  wiiicli  Ixx-nnn-  l)R-itix>-lvea  Moondnrllj'  iit)ls-l*«l  in  t^pota; 
tliougli  these  spots  are  not,  newMsarily,  at  firfit,  in  d^i  relation  with 
the  nltitriid  ini'inlintni!.  Tlio  pn*i'iHi!  natiiru  uf  tlic*  rhoofrti  wiiirh 
occurs  in  cartilage  will  be  con^^idered  in  the  deecriptJou  of  tite  <lis- 
eoMM  whicli  nfCwi  thirt  wtrtiftUTO ;  it  iiw'd  only  Iw  said  Iwru  Uial  the 
cartilago  becomes  more  and  more  altered  and  deteriorated  at  tlie 
[KtintK  lint  uHiiitHi,  and  tliiit  itiUinatu  adlioitiun  men  takes  fJaoe 
between  the  gnmulatioii-tissue  which  these  points  present  aud  the 
COrr«tp<Hidi)ig  grywiJi  from  thr  cyimviul  iin'nibraiio.  Th»!  c.liangr  in 
the  cartilage  is  attcndi^i  or  foUoweil  bv  iiifliimmation  of  tlie  bone  on 
whinli  it  nwtt ;  tlic  iirticukr  Innidlit  givi-s  way  in  [Jius'i*,  »  commu- 
nication between  the  osseous  tisane  and  tlie  interior  of  the  joint  ia 
formed,  and  gnuiiihitioni<  ipritij;  up  fnim  the  inflami^d  membrane 
lining  the  cancelli,  whieh  join  witli  those  already  existing  within 
the  nrt.iculalioiu  bi  the  mi^n  time  mutter  lias  movt  jirobably  bot-a 
formed,  which  may  be  retained  within  the  articular  cavity,  or  may 
Dutkv  Hn  way  to  the  mirfiwc  by  mcjinx  of  ^iniiiwH. 

If  the  disease  still  makes  progit?§a,  the  gelatinous  grow^  con- 
tinnvx  Ui  cxtciiii  in  an  oulwiinl  ilinx^iwn,  iw  it  dogvncmtiw  in 
patches,  giving  rise  to  fresh  formations  of  matter  in  its  own  juib- 
stonou  or  in  the  articular  cavity  ;  the  conntitulioiial  jxiwers  now 
probably  fail,  the  tissue*  of  the  joint,  including  the  osseous,  are  still 
further  ilwitroyod,  and  ain|)utjitioii  or  cxcixiou  in  hail  rwunrso  ta, 
or  the  jiatient  dies  hectic.  Wlien,  on  tiie  otlior  band,  an  imjmne- 
mcnt  tiikc^  plucr,  the  now  gnm-tli  is  directed  inwitrds  towards  the 
articular  cavity,  whieh  it  tends  to  fill  up.  As  the  eonntittttionul 
powers  impn>vc,  the  gelatinous  materiid  becomes  firmer  and  more 
fibrous,  it  oontinues  to  «ontraet,  the  oavity  within  it  diminialnit  and 
U>  obliterated,  the  Iwncs  are  united  by  u  firm  and  solid  subetanee, 
and  the  joint  in  nnkyluMid. 

Symptoms.  In  a;>;signing  the  name  of  scrofhloits  synovitis  to  this 
form  of  disease,  we  arc  guided  in  tbo  first  pkce  hy  thu  constitutional 


SCROFULOUS  SYNOVITIS. 


7id 


ooodition  of  dt«>  piitieiil,  and  hj  hia  proMcntin^r  truvd  ofwliat  ix  vnin- 
mouly  UfiiMxl  Uif  scrofulous  diadicMH.  In  ooo  wt  of  ruiH.'s  tliU  b 
marked  hy  ovi^r-di-lii-jiny  "f  tin*  tiiwut-H,  giving  riw  U>  a  |H4culisr  iind 
Onuily  r<-or>j^iiM-d  L-haractor  of  beauty  ;  tlio  norvous  s\-»U'ni  in  hijilily 
developed,  liie  iiiinil  uiid  biHly  lu-t.ivo ;  btit  t)iem  i(t  an  ovidi^nt  wniit 
of  pn>portJotuit<>  vital  Btrongth.  Tlie  other  form  pn-iacnts  itwlf,  on 
the  contTiin',  with  a  ciuusi'  mid  niiiKTulmndimT.  condiiioii  of  ti.s-*iH<«, 
and  u  marki'd  by  the  thick  lip,  tlic  ehininy  liDibi!,  the  lieaiy  and 
letiiai^gto  a-igiei-t.  In  biitii  I'onditioiiH,  whit-li  mprv.HOiii  thi;  tiihfr- 
OtZtwuuid  the  «en>/iilosu  of  certain  authors,*  tho  nutrition  is  iui- 

'ect;  inflanimiition,  wlien  it  OMtim,  of  a  low,  b'diouN,  luid 
:labIo  character.  In  many  intttaii«w  ttit?  unnu'diute  attack 
Onn  be  trnnod  to  Hunie  slight  aoci<lent  or  ether  locitl  Miurov  of 
'irntntiuii ;  in  otliers  no  such  cause  can  bo  discowred,  the  attack 
■jipeariiig  U>  I'oinmi'iice,  lU  we  may  iwy,  i^jMuljuieoiLdy.  In  both, 
howc^cr,  it  is  characterised  by  a  want  of  aeuteness,  even  at  its 
contnionci^iiient ;  and  in  tlie  latter  coae  v-'<pK!iidly  (mid  thin  ntarks 
the  worst  form  of  tlie  disea^)  tho  swelling  may  for  some  time 
Ik!  almoHt  piiinli-.-<«.  'llie  ilisi'iiitc*  mt»k<«  its  apfwamnco  intwt  frc- 
[oeotly  in  early  life,  at  or  before  the  time  of  pabertr,  Uwmgh  no 
period  of  life  can  bo  maid  to  Iw  Hl>itoIuteiy  cxt>m]>t  fVoni  risk  of  its 

urrcnee, 

Tho  luittire  «f  tlie  affwtion  i*  inwt  elearly  rec(>gni«ed  in  those 
joints  which  are  the  most  superficial.  In  its  eai'ly  stages  it  !« 
cbamcteri.-K'd  by  .stiff'tii-sJi  of  thi'  joitit,  and  llm  pr^•«tll(K^  of  a  wft, 
elastic,  colourless  swelling,  oecnpring  the  whole  extent  of  the 
artii!uliili(ii).  The  aIiw.^noo  nf  ^luiiiKt  tlui-liiiilimi  hlxnild  prevent 
tho  disease  from  Iw-ing  mii^lakeo  for  dro]j«>-  or  abscess  of  the  joint ; 
.lizu  and  doiighy  foul  of  tho  flwHling<liHtingui.4h  it  fn>m  »im|}le 
ehronio  syuox-itiii ;  whilst  its  whitene!«  is  o[>poS€d  to  tho  <larkcr  tint 
hicli  '»  itKuailv  mtil  witli  in  iiudigiiaiit  diHi^«i»i>.  T)ie  enrly  stiigc-s 
cf  ihe  swelling  are  nsually  accompanied  with  comparatively  littls 
pain,  the  iliwanu  in  mtuiy  eOM^  being  vitv  insidious  in  its  jirogreM ; 
ID  this  respect,  as  well  as  in  tlie  shape  of  tlio  swelling,  which 
eaUmAti  equally  o%'vr  the  whole  joint,  in.->teail  of  being  H|<eeially 
nuifest  ii)  the  situation  of  one  of  the  bones,  differing  emeutiBlly 
from  strumom  di»ettsc  of  the  (wict^tlotw  Htnu-ture^.  If  tho  progreM 
of  the  ease  is  ton-ards  reeoverj-,  the  sweUuig  cease*  to  incroasBf 
solidiftoH  dowly,  aud  gradiudly  diniiiu«lie«  in  «i«,  H»e  [nun  at  the 


P 

■r 


tho 
■  whi 


I      *  9««  Dr.  Jenncr's  I,octun;ii,  in  tlie  Sittlkol  Timt*  itad  Omtttu,  18G0,  toL  i, 
p.  3M. 


720 


DLSEASES  OF  THE  JOINTS. 


nmo  time  yielding,  and  tlio  oonditioii  of  the  gonenl  tioalth  Ixieom* 
ing  modi  improved.  Rvm  if  iinxAti-<t  in  Uiiii  rur\y  Ht»j;!>',  a  ooo- 
MiU'nililc  aniotuit  of  ]obs  of  froo  ntoreoiont  of  ibp  joint  mtist  be 
ex]>pct«l,  and  firvM  cam  tukt'ti  ih&t  no  rcuurrviK-O  of  tlie  ttympUnu 
i»  (»nKluL-<od  bv  too  early  exwvisi^ 

Wlifii  (Ik-  ditx.'aiH.-  luhiuiww,  llio  wilarpi>nn>nt  aiid  s.tiffrw'jw  of  llie 
joint  in<^rease;  the  jiain,  which  was  previously  perhoi»  little  man 
tlian  n  twiiNv  of  ai.-liing  or  fii-lin^;  nf  lulncwi,  1K.-M>nii9t  more  marked 
■jul  altt?re*l  in  iu  character,  being  noiv  dospribed  aa  a  "  jamping," 
"gnawing,"  or  "  »tiirting"  pain,  and  fijit  witli  fptxdiU  ucut<>neM 
nt  iii^ht-time.  "niii^  ehiui^  m&y  bo  considered  as  «  sign  tliat  tlie 
discajw  i»  DO  longer  c(>ntiiic<l  l<i  tliu  oynovial  nitinhnuii!;  that  the 
caniluf^>3  ure  beoomiug  ulraralcd,  or  ratlier,  more  Htrictlr  s[)eaki]i^ 
that  tlie  bono  ou  wlueli  llioxo  eartiln^-^  re.«t  in  ifatdf  )MirLiei|iati[ig  ifl 
till;  inHiirnntaton'  aiHioii.  Another  H^inptom,  wbi«h  vroiild  indi<!ate 
a  considentblo  miiouiit  of  ileMtruvtion  of  (;nrliliigc,  i»  tlie  oxistcnoc 
of  er)?|iit»tion  on  any  moveni<5nt  of  the  joint  by  tlie  patient  Iiirondf 
or  by  the  Surjjewn.  Tlii:*  cre]>it«tiiin,  howcicr,  it  :'hiiiil<l  bo  rtoI- 
Ivct'tl,  may  disappear  oi'  be  masked  at  any  time  in  coniio<|uenec  of 
soft  and  extensive  granulutioiix  riving  from  the  bomit,  and  prevent- 
ing tiieir  aj-ticiiLir  tturfaceN  from  rubbing  on  each  other.  The  limb 
ia  now  in  danger  of  beeoming  rigidly  tL\eii  by  »pa«nvdte  contnactian 
of  the  muNcleH,  eauiung  it  to  atmume  portions  vanHng  in  tlie  lUffeivnt 
mrticulatiouH,  but  all  tending  to  produeo  future  vtnbnrraminent,  onloM 
wrvfully  wattdiod  and  guanl<'d  against.  ^i 

Before  tile  diseiwe  lias  advanced  to  Uiis  point,  in  the  majority  ^H 
Cflsi.-^  nil ppuniti  1)11  hiu  ooeurred,  eitJit-r  intiltrating  niun^  or  Uvf  ex- 
tonMvcly  [lie  gelatinous  maisH,  or  limited  so  an  to  fbmi  eiretunscri 
al>s0tf.4tH^  in  ita  Htilx'ttan<^>,  or  neeiiinulaled  in  the  rentuiiis 
synovial  cavity.  If  colleefetl  within  tliL>  joint,  tJiere  will  bo  a 
ineri^iL-ui  of  tlio  swelling,  with  tlii-ubiiing  |>iiiii,  aiid  |i<'rtiii|H  Huctustionf 
attended  by  febrile  disturbancv  to  a  greater  or  less  exteitt.  After  a 
time  tin-  iniittrr  iiiiikcH  ittt  way  tlirougb  tlw  noflcitiil  wnll*,  and 
'*  jKiiiitiiig"  takes  [ilueo  at  spots  detemiiiied  by  atuitoniiea)  peril- 
liarititM  n-forablo  to  the  iiuUvidiiid  Joint;  tlie  wnuito*  »o  fumicd 
presentuig  subsequently  lai'ge  and  Rabby  graiiulatioiis.  Vrlwn  thu 
altHeew  !.-•  situatinl  in  the  giilntiiuiu.H  uiuwi  ilM'lf,  tJje  inen-ancd  swi.'ll* 
ing,  instead  of  being  general,  takes  place  at  any  part  of  tlio  vaass 
whiijli  may  liu]i[>eii  to  Ijc  the  sent  of  the  d«^G;eneralion,  and  the  op«o- 
iug  fomiH  at  or  near  tliifi  point.  In  most  uim^-k,  howover,  (rven  wIku 
tlie  joint-ciivity  wiu*  originally  frue,  it  becomes  involved  mtbsequuntly 
in  tile  jiarictal  abscc§&. 


nscribe^^ 
snrM 


SCROFULOUS  SYNOVITIS. 


721 


In  proportion  to  l\w.  tlcUriorntioM  nf  tli«  (■iiiiHtituiJoD  will  bo  llio 
«xt«ntu<>ii  of  the  dotructivc  action.  The  ligainont«  and  nc'ighbuur- 
ing  part*  betHJino  S()tlt'ni>il  niiil  iliylifiywl,  liic  «lti'rc([  cxtiviiiittif  uf 
tli(!  boiK^*  lire  no  longer  firaJy  united  to  «i<?b  otlior,  and  in  this 

t«ondition  n  partial  iir  u)n))>lvtu  dixlouitioii  in  uc^'imioimUv  prrxlucftl 
nndvr  tliv  itiRuoiici?  of  Kiiasniodic  iniiaciilar  a<-tiofi ;  tliiit  diHiocatioii 
being  often   iittcndcd  witli   dcfi^liil   R-iii-f  U>   ttiw   m.-AX-rity  of  Uic 

^«yin|ib>m»^  If  the  oonstitutional  powere  improve,  it  is  ntill  jtoRgble 
for  a  procoiui  of  n-pajr  ttn<l  wvnvcry  to  oefwi'.  The  <Ii»cliarKi'  iti 
sack  ca«c8  dimiiuHhes,  the  o|jt-iiingH  ironira<'i  and  iiltiniaiuly  elow?, 

[tlie  iikin  r«>HUiniM  itx  uaturul  apiK'«ninw,wIiil«  tho  swelling  ikvixiastt-s 
and  btfomcs  niom  solid.  Tlie  diminution  in  size  of  ibe  joint  eon- 
tinueA  till  it  lii^tN>mL»  even  JinmlltT  tiinn  it  was  bi-foro  tlio  nltack, 
ami  tlic  skin  pre^jtitA  a  jteouliar  |>uckered  a]k|>earan(!o  arounti  Urn 
luticidatioii  anil  ut  tlio  »«it  of  tbf  i-icatrit-iif.  Tlio  nwtorntivc  pro- 
cctw  is  of  poursij  attended  witJi  juikvlosis,  fixing  t]ie  limb  in  tlie 

I  potution  it  may  Imvo  been  allowitl  to  assuine. 

TrtaUnaU.  In  onr  treatment  we  haie  to  bear  in  mind  that  we 
itre  (le-aliiig  witli  nn  sffcctloii  originating  in  uitlaiiunatiuii,  but  that 

I  inflammation  modified  and  nltered  by  the  strumouH  diatlieain.  Our 
efioiia  oonsctpicntly  havt-  8t*'adily  to  bo  dincftt-d  to  the  imjirove- 
uent  of  tho  const! tntional  condition ;  fuv  if  that  in  not  *-ffecti-il,  the 

f«lianou  <tf  material  benefit  to  the  Hmb  becomes  but  nnall.  Tlic 
general  treatment  of  i^-mfula  has  ain-iuly  Wn-n  desi-rilh-d  in  this 
work,  Kiid  nvKt\  not  be  now  repeated.      Good  air  and  pleiily  <if  it, 

[  varmth  ami  light,  attention  to  clemilinesa  and  pri)per  diet,  aro  in 
nl)  castw  elcjirly  inculcateth  Where  the  tendency  is  to  ncro/ulotif, 
tho  liver  and  bowels  lui'  iLMially  »hig^is]i,  and  ntjuiro  to  bo  etimu- 
lutvd  oc(ai.«ionally  by  tolerably  brisk  purges,  e«uibine<l  with  (juinin*-; 
whilst  in  tidji-miUaU,  piu-gulives  iiiiiat  bo  given  with  caution,  and  be 
of  liiu  mildest  character,  lu  botli  cases,  (oiiie»,  and  i>peciidly  cimI- 
liver  oil,  are  of  service;  tJioiigh  these  tonit-s  should  lie  administered 
with  judgment,  and  in  relation  to  tlie  presence  or  ab»i.'nco  uf  in- 

tflanmiaton,'  fe^er. 
.\n  cKsential  ]Mirt  of  the  local   treatment  consists  in  the  joint 
being  kept  in  a  state  of  |H-rfi;ct  rtiit,  by  mennA  of  splints,  whieli 
Bhutdd  bo  well  and  properly  made,  and  eoiislnictcd  so  as  camplctHy 
to  prevent  imy  motion  of  the  limb,  and  at  the  same  time  admit  of 
any  topical  applications  which  may  bo  deemed  advisable.     As  the 
chance  of  iinkyliuis  m-curriiig  is  more  eontoderuble  than  in  canes,  of 
onlinary  synovitis,  tlio  potition  of  tlie  limb  becomes  of  cicn  greater 
,iinport4uiee,  thougli  it  is  to  be  regtdateil  on  tliv  same  principles. 
VOt.  III.  3  A 


722 


DISEASES  OF  THE  JOINTS. 


Tbo  (iplints  may  be  matk-  «f  IcatlK-r  "f  of  im-tti-bDard,  or  conslniotc 
of  win^  ill  llio  mode  recomineiidod  by  Boimct  aiwl  by  Symc.  If 
Hindu  of  iron  win-,  a  strong  pii-tf?  ih  bent  t»  tlifl  shnjxs  of  the  limb, 
fstwidiiij;  rm  iMitli  sides  Biid  united  transversely  to  siicli  an  exUmi 
»fi  to  give  tbc  rDqiii«t«  dcgriH!  uf  strt'iij^li.  Tin;  !^>l!)it  w*  titniK^  i* 
carefully  IJnwl  vritli  soft  lonthcr,  or  fitted  wiili  a  kind  of  coshion,  nod 
wll  often  proro  highly  uitefid.  Tim  iiiufh  nttontion  oiiii  luirdlj'b"! 
piud  t'l  tlx'  sulix'tioii  and  adaptation  of  the  liplint  in  the  first  iiutanoe: 
If  inflammatory  M-mplonw  aro  pniwnt,  it  may  be  ncccoiVtry  to  em- 
ploy a  fi'W  leet-haH,  or  to  nsi-  ixxtliiig  or  wanii  appHeations,  as  may 
»ecm  cxjiodient.  Ah  tlie  ijiilammatory  tyniptoms  itubfidc,  couutcr- 
irritiints  may  be  bud  reeoiirfto  to ;  (bcw,  however,  sliotdd  be  enipluyed 
with  somo  dcgi'i*  of  hesitation,  and  with  the  cautions  previously 
|)Otnt4xl  out  HH  Kfiticiidly  a|>p!ii-n1>l<'  i»  their  ai-lion  on  tlie  Mi|i<.Tficiid 
joints.  At  the  Hospital  for  Sick  Cluldron  I  became  latterly  more 
spilring  in  my  nw  of  itnin.  Mi:  Barwi'll,"  liowovor,  rtrtMigly 
recommends  tlie  emijloyniieul  of  tlie  netual  eauterj'  in  these  cases^ 
when  tin-  first  symptom!*  of  inflnranialion  have  somewlmt  xubtudod, 
but  when  aome  sueh  a<'tion  ^till  continues,  and  enlargement  is  still 
going  oil.  The  ii-oii  in  to  Im  wliite  hot,  and  ctpplivd  in  liiiCK,  nlmtit 
an  eighth  of  an  inc^h  in  breadth  and  three  inches  in  length,  parallel 
to  tlie  axis  of  tin;  limb.  Four  sueh  line*  wm  rci-onuneiKU'ii  for  iho 
knee,  two  on  eaeh  side  of  tlto  jiatella,  at  least  aii  inch  aparl ;  dr\'  lint 
may  be  appliixl  iminediati-ly  iitler  Iho  cantor iiwti on.  Tlic  advantagn 
of  tliis  jJaii,  according  to  Mr.  Darwell,  conHiats  not  merely  In  its 
acting  as  a  counter-irritant,  but  also  in  the  2>rc»»iiTO  produced  sub- 
sequently on  tlie  subjacent  parts  by  tlie  oontraoting  eicatri«». 

\Micni  the  disease  is  coTifined  to  the  sjiiovial  mcmbnuic,  and 
has  assiuned  an  I'littti'ly  jjassivo  condition,  i>vidence*l  by  th«  j*wiil 
boing  swollen  and  pulpy,  but  with  entire  absence  of  pain  or  tender- 
ness on  pressure  of  tJie  part,  or  «^cn  on  moving  it,  niojistni's  may 
be  properly  adojitiil  to  pi-oducc  absorjition  of  the  indolent  gela- 
tinou.t  muss.  Sucli  racn.-'unx-i  wmiKl  obviously  consist  in  fiietim, 
patsife  viotion,  and  aecm'ately  ap]iliod  pretmr*  to  the  part  These 
means,  n.-*  pointinl  out  by  M,  Bonnet,  miij-  hv  finely  fldojitcd,  hut  still 
with  care  and  caution,  and  at  once  abandoned  if  symptoms  of 
renewed  ndivity  in  tbc  disease  show  tJicniselvc-*.  If  any  tuinipho- 
mtod  mennriai  a]>plication  is  iise<l  to  the  part,  with  the  pressare, 
in  the  way  de.-^criljeil  iw  "  Scott's  dressing,"  it  slioidt!  he  emptojT'i 
in  these  cases  very  sparingly,  and  in  a  very  dilnted  form ;   tlio 


*  On  DiteatetoftheJoinU.ebM^.x. 


KHEUMATIC  SYNOVITIS. 


723 


'  joint,  too,  Mhoiild  bit  exaniiiHil  tVi:>|iii'iitly,  to  miikc  wire  lliat  no  {ra^t 
attaak  of  itiBamtnatioit  ha,?  occurred.     As  the  case  jirogrrasai  to- 
wards recover^-,  friction  and  pnAinvu  motion  arc  mOK  frocly  UKod, 
and  tlic  treatment  assimilates  to  that  of  onlinarv  (■Iironi<'  siTioviiJH. 
iioulcl  !iii|i{)umtion  tnke  ]>lnc<;  witliiii  the  joints  tlic  matter  inunt  bo 
ciiatcid  by  free  incisions  made  in  depending  fxiitltiuiis,  followed 
"RtlMeqtwiitly  by  Kligbtly  Hl,iniuhitin|L;  lotions  to  tho  sinasos,  nnd 
I       moderate  pressuro  to  tho  joint,  wliioh  is  still  to  lie  itinintninod  in  a 
^p  Btato  of  [H'rfoct  wmI,  s.«  well  an  in  a  r'ttitahio  po»ition.     Wlicn  lhvn> 
is  stiirtinj;  of  tlio  limb,  or  otlicr  fivuli  i;  ■■    drir  i!m  (.--,-, n.  mid  ciirti- 
lagitious  ti*»m's  tiro  iiivolvwl,  isrtn.-  iii,i\    in    nin'n  ,    ir   tho  actual 

I  cautery  ajipliod  in  tlie  region  of  any  tender  s]>ot.  li'thv  iicnilh  ^vo 
way,  or  the  ttroTijith  npfioar  unequal  to  bear  a  loiig-eontinucd  dis- 
cbarge, and  tlio  I'ii'ciuHHtaiineit  of  tlio  cjixi  l>c  fucli  us  not  U>  mlmit 
of  a  prolonged  u»o  of  all  tho  constitutional  remedies  which  may  bo 
<l«sirabl«,  amj>uljition  of  iho  limb  or  exwHioii  of  tht'  joint  tvill  aficn 
IbecotDo  necessary.  Should  improTement,  on  the  otlier  han<],  take 
pUco,  and  euro  by  uikyloMH  bo  eSbotod,  wo  mati  be  curclul  to 
employ  passive  motion  in  dno  time  to  prei,'ent  ow>i6eation,  and 
tnuiiituiii  tlio  uniting  niatorial  in  ib  fibruiu  condition. 
Rhevmatte  tynovHu.  In  tho  dcmrription  of  tbo  ordinary  fbnn  of 
s^novitiB,  it  waa  statal  that  this  fre([uenl]y  arose  tVoni  expoBure  to 
H  cold,  or  in  connexion  wltli  other  causes  loosely  spoken  of  ax  rhou- 
raatio.  Tho  synovia!  momhrancw  am!  parts  uhout  tlie  joints  aro 
alw)  liable  to  suffer  in  a  special  condition  oftlic  system,  by  whiob 
the  inflainmntory  prooestt  in  mat«>rtally  mtMlIfiod,  and  which  coosti- 
ttitcs  "rheumatism"  properly  so  colled.  Li  acute  rbeumatii>m  or 
rlieamatio  fe^i'r,  iho  arlienhir  afltHrtion,  aitliough  it  may  be  severe 
and  tronblcsomo  enough,  is  evidently  dependent  on  const itutioiuil 
denuigement,  culmiuntinf;  in  a  kind  of  inHnmmutor}*  paroxysm  as- 
Bomed  to  bo  connected  wifJi  excess  of  lactic  acid.  Unlike  ordinani- 
tniiovilis,  the  oon.-<.titutioual  <Iii'turl>iuico  in  thin  niM!  in  ]>rimiUT  in- 
stead of  sccondar}' ;  and  though  a  joint,  wlien  attacked,  miay  di^ihiy 
•Qpw  of  iievvn  and  acuto  inflammation,  yet  tlicsm  Kigna  will  oft^i 
disappear  with  extraonlinary  rapidity,  whilst  other  articulatioiM  be- 
come as  Kuddcnly  affcelwl.  Acute  rhoumatism,  tiKrcfore,  being 
esHentially  a  constitutional  nudady,  falls  naturally  to  tbo  caro  of 
ll»e  plu'sician,  nnd  its  dcscrijition  ma*t  bo  ftougbt  for  In  work^  on 
inedicino. 


I 
I 


Chrmik  rttmmatic  »yiwrili« ;  thronic  rhntmatie  artkntu ;  rheu- 


7U 


DISEASES  OF  THE  JOmXS. 


matk  ffout.     Tlio  njiioviul  un>inl>nuic*,  iw  well  as  tlio  oUier  struc-- 
tarcfi  eaioring  iuto  (he  oompofition  of  a  joint,  ivrv  liahlo  to  it  t-limnic 
iilir<!<-lii)n,  H'liii-li  h:iii  long  hwn  luiiftk-allv  rwuynisotl,  though  vai^'- 
iiig  names  liave  hwn  aaaignnt  to  it  at  tUfffrciit  tiinc»,  or  nfcoixl- 
iiig  to  liiv  (^'tuM  of  jriiiit't  wlii^-h   it  hiijijKtii^  t<t  imjiUcat^.      Tlie 
tcmi  notloKitif  of  Ihf  Joinl-g  wan  tlio  one  propoMxl  hy  Dr.  Hnygartli, 
whoso  uthrntion  wa»  ultnu.*I«-«l  t*>  tlio  hniil  swellings  presented  by 
tbo  smaller  articulntions  of  tJie  hsuidi;  aiid  fe>et,  wliicJi  mt  the  pTc^tmt 
d«y  more  eonimunly  roccivo  th«  u{j))clluti<>ii  ofrfifumaiKffouL     Vt'hvo 
tlio  larger  jouits,  smti  an  tlio  sliouldor,  the  elbow,  or  tlio  kiu!>e,  arc 
iiii|)liciit(N),  tlic  diHcaKO  is  often  Irraied  c/irontc  r/uaimatiMi ;  wbilit 
»  »milar  alfeiHion  itl'  tlu>  liiji  has  been  described  by  aame  anihara 
(w   tJic  mo)1>\i»  «»jiT  seidUs.     l>r.  Adams  of  Dublin,  however,  in 
)i!d  valuikbli;  work  on  (lit-  stibjci-t,  has  arranged  and  da^dfied  tlie 
varieties  of  the  affection,  and  projxiwd  ihc  tenn  thronu:  Tftrtimatie 
orthritit;  u  name  wlii<-h  will,  no  doubt,  hencofortli  bo  generally 
udopti'iiL     It  will  be  seen  tluit  the  di»ca]^!  in)]>licntt.--$  uUivr  tJamot 
hesidos  tlie  itjiiovial  nkt-nihrikno;  and,  indeed,  the  changes  whidi 
ocpur  in  the  bones  in  these  eases  arc  hj  !s|>i'ciaily  ninrkod,  tJiiit  Mr. 
Bant'ell  oonsidi'1'91  tlio  morbid  action  to  bo  in  reality  a  rheumalic 
ostitis.     Hie  first  obvious  symptoms  dm-ing  life,  liunvvcr,  ure  those 
ill  relation  with  tJio  sj-no^-ial  tniHibnuic,  and  tlie  earliest  traces  of 
disease  after  death  Iiave  been  found  to  be  connceted  with  the  samo 
tiame.     Ci-uveilhier,  Dr.  Itol>ert  Adams,  mid  Sir  Benjamin  Brodie, 
enincide  in  tlic  opinion  tliat  a  ehroniL-  inftiimmation  of  the  synovial 
mi^mliriine  in  the  oiu'licHt  loeul  result  iis  fur  ns  tlie  ai'tii-nlittion  i« 
concerned;  and  I  have  therefore  thought  it  best  to  notice  tlie  aifee- 
tii)n  in  the  pn>!*ent  section. 

Clironie  rlieumatjsm  is  mot  with  in  two  distinct  conditions :  as 
a  ])»l]Hibly  eimstituUonal  iiffeetion,  impliuiling  a  mnltijilicity  of 
jointH,  and  either  snceo«ling  to  rheumatic  fever  or  following  ex- 
jMisiiix!  to  tbf  nwial  exciting  ci«ise«  of  rlieunuitisin ;  nn<l,  wcoudly, 
as  a  local  affc<rtion  attributed  to  over-exertion,  or  injury,  or  ariidng 
^'itliout  luiy  ji.wigiiablc  cause.  Ttie  two  wxcs  arc,  iXTliiipn,  newly 
equally  Uablo  to  be  attacked;  but  Dr.  Adams  is  of  opinion  tliat  the 
larger  joints,  eKiM-eially  the  hip,  arc  more  frequently  nficcted  in 
males,  whilst  females  are  more  suhjeet  to  die  disease  in  Uie  smaller] 
aiiieula lions,  such  lis  tlioso  of  tlie  fingers;  u  fact  which  wiw  origin-* 
ally  poinfe<l  out  by  Dr.  Hajgartli.  Though  usually  met  with  after 
middle  ag«',  ehnmie  rheumatism  is  by  no  means  confined  to  elderly 
people,  for  it  has  l>een  !<een  in  juitlents  under  tlie  ago  of  twenty, 
affeeting  simultaneously  a  conaiderablc  number  of  JMnte.     Nor  \»  it 


CHROXIC  IIHEUXUTIC  ARTHRITIS. 


^ 


725 


coiifincxl  tu  any  xppi-ial  rntik;  for  thougli  it  pre^'ails  oxfeiisivdy 
uraottg  the  lulKtiirin^  [luor,  it  in  uW  th^u«iitly  im't  vr'ith  iit  Uie 
wvflltlufr  c-Luw^,  in  tliuw  who  have  ktl  iiulolcnt  and  luxurious  liven, 
luid  in  uhotn  it  i»  »pt  to  aH-iunie  »  nion*  <1o<-iih!<lly  g»itty  cliiiraelcr. 
Though  C'hroiiii':  rlicuniati^m  materially  diminislios the  eom/ott,  it  docs 
not  n))|H>ni'  to  Httorton  tin-  lU't.Uiil  duniHon  of  lifi',  iit  Ifnst  in  tiiuM> 
whoBe  mcaiiit  ntlow  them  to  be  snp{)liod  with  all  reqiiiiul«  ii])pliancN>s ; 
^B0  vrry  jioor,  howfiver,  aiv  oxjmsod  to  arcidciilnl  or  <'xtniiivotiit 
maladic?)),  from  tlit-  hi'tj)k's«  condition  to  winch  they  aro  rediM^cd, 
and  3U>  witli  tliimi  tluT  I'himct-H  «riit'e  aro  nn(iuc-''ti(>ni(blv  d!inini>Jied. 
When  oQcti  tlic  disease  Itaii  become  cstabtiiiluxl,  its  tendency'  uu- 
d(Hibtc<lly  i»  ti)  |ini<;itwi,  ;Oowly  litiL  HUifly,  until  tli»  joint:*  iiir<)d4!d 
become  oltimattsly  disorganised  to  a  greater  or  le*s  extent ;  some- 
time* llio  iiffttrtion  reiniLinx  ijuioHccnt,  or  .^talioimry,  for  on  iiidofinit« 
period ;  but  vorv  seldom  indeed  pan  any  thing  like  a  cure  bo  nntiei- 
[mtcd,  and  tlu^ii  only  wIhtii  thi;  ta.ti^  lias  Im-i-ii  nwogiiiiwd  and  llio 
treatment  eommenoe<l  before  the  disease  has  made  much  progreos, 

Ak  ftir  as  tho  lixiit!  afit-ction  is  cwiiccniol,  if  we  iwvo  au  opinir- 
tunit^'  of  examining  tlie  joijjt  at  a  very  early  stage  of  llie  disease, 
wo  find  rtnlness  of  tlw  dynoiiul  nicmbrane,  whlcli  becomes  tliickoncd 
and  fibrous,  whilst  its  iriJige-like  proei>sses  are  much  (leM'hijied.  and 
more  viLscular  than  tisual,  the  internal  surface  of  tlie  eapisulo  |>rc- 
Honting  somewhat  of  the  appearance  of  a  villous  miiciinti  nu'nibrane. 
There  is  also  efTiiwoti  of  a  moderate  amount  of  flui<l  within  the  joint. 
At  a  Liter  perifxl,  tlie  fluid  is  aUiorbed;  hut  iho  li^iinn'iita,  wliieh 
bad  been  distended  by  tlwr  effusion,  recover  tliemsvlves  but  slowly, 
laying  the  foundation,  jierhnps,  of  tlie  piirtial  or  even  complete 
dbloeations  which  are  occaNonally  produced  subsequently  by  tlie 
qinamodifl  contractioat  of  the  onmcW  which  ait'-  apt  I1.1  occur  in  cer- 
tain stages  of  the  disease.  Tlie  capsules  become  very  considorabiy 
tbiolwned,  and  nonu-tinies  a  bony  dejNitfit  may  be  met  with  in  tlieir 
sobstaiico  [  in  tJio  interior  of  t3ic  joint,  too,  there  may  bo  found  onu 
or  inori!  of  tliiise  fon-ign  or  extruni'oiiH  bodies  which  ore  noticed 
He{>arately  in  this  essay  under  tlie  head  of  Loose  Cartilages.  Hm 
articular  carlilngi-s  by  this  time  are  probably  affected;  at  oertain 
points  tliey  assume  a  yellowUh  hue,  and  become  librous.  As  tlio 
disoaM  progn-i'W.t*,  Uwy  arc  destmyod  to  a  greater  or  Icttit  extent ; 
•ometimefi  prcBcnting  patdies  of  dense  bone,  which  are  smootli 
and  gCsteutng;  whilst  at  other  times  tlie  cortilaginotts  tiwtue  <li!i- 
apjK-itnt  entirety,  and  in  its  place  we  find  a  compact  ivory-likc  botiy 
mateirial,  which  soon  becomes  highly  polished  under  the  influcnco 
of  tlie  attrition  to  which  it  is  subjectetL     In  the  hinge-jointa  tho 


i 


-I 


j  726  DISEASES  OF  THE  JOENTS. 

porcelain -like  material  so  formed  preaents  linear  fiirrows,  resulti 
from  tlio  increased  wear  to  which  it  is  exposed  in  certain  situatio 
in  tho  movements  of  extension  and  fiexion ;  otiier  orticulatio 
show  analogous  markings  in  the  lines  of  greatest  pressure.  If  fibr 
cartilages  are  present  in  the  joint,  these  structures  do  not  escap 
where  the  disease  is  well-marked  and  of  long  standing,  the  fibr 
cartilages  disappear  completely,  or,  in  certain  exceptional  cases,  a 
converted  into  bono.  In  tlie  liip-joint,  too,  tlie  round  ligamec 
and  in  the  shoulder  the  tendon  of  tho  long  head  of  the  biceps,  i 
the  glenoid  ligament,  mil  often  be  removed  by  tlio  process  of  al 
sorption.  The  proper  osseous  structure  becomes  condensed  bencat 
the  articular  surfaces,  and  bony  vegetations  are  thrown  out  arooc 
them,  forming  buttresses  wliich  interfere  with  tlie  movements  i 
the  joints  by  their  mutual  apposition.  The  shape  of  the  articulj 
surfaces  is  altered ;  tho  globular  heads  of  the  femur  and  humeri 
are  flattened,  and,  as  it  were,  crushed,  their  neclcs  are  shortenet 
and  the  cavities  for  their  reception  exhibit  a  corresponding  changi 
resulting  in  varying  amounts  of  deformity'.  These  alterations  liav 
sometimes  been  mistaken  for  fractm^  of  the  neck  of  the  humeru! 
or  of  the  cervix  femoris,  in  which  bony  imion  had  taken  place.  1 
may  he  mentioned,  too^  tliat  the  abnormal  condition  is  not  alway 
confined  to  tlie  articular  extremities,  but  may  involve  the  shaft,  o 
even  the  entire  bone. 

The  general  symptomB  in  tliese  eases  present  no  very  spccin 
character.  In  some  instances,  as  Sir  Benjamin  Brodie  remarks,  th 
disease  appears  to  be  connected  witli  over-indulgence  in  animal  food 
and  the  patient  experiences  some  of  the  usual  effects  of  dyspopsit 
Buch  as  a  tendency  to  acidity  and  flatulence.  In  other  ca^s,  ani 
especially,  perhaps,  where  the  larger  joints  are  implicated  singly 
no  particular  constitutional  derangement  can  be  detected,  and,  in 
deed,  it  is  remarkable  to  how  sHght  an  extent  the  general  health  i 
affected  by  the  great  amount  of  topical  mischief  which  may  havi 
occurred. 

The  local  symptoms  are  the  most  characteristic,  and  consis 
I  essentially  of  pain,  enlargemad.  and  vltimate  (U/ormiit/  of  the  joint 

riffiditff  or  ali^nesi,  and  a  peculiar  crackling  ttoise.  The  pain  ex 
perienced  is  principally  felt  at  night-time,  or  when  the  joint  is  se 
in  motion  ailer  a  period  of  rest.  The  amount  of  p^,  which  i 
BHually  of  an  aching  character,  is  far  less  than  might  be  ex'pecfe* 
from  the  amount  of  structural  alteration  which  occurs,  and  icr; 
different  from  that  experienced  in  other  affections  of  the  articula 
ends  of  the  hone  implicating  the  joints.    When  only  a  single  ar 


t 


CHRONIC  RHEUMATIC  ARTHRITIS. 


7^7 


I 


ticiilntion  is  iinolvei],  ilw>  yi>nera]  &ufforiiig  Im  not  great,  and  Uie 
Iwtifiit'H  cxiiKlitioii  is  vi-rj'  twIvraMc;  cvcu  wlicn  i<cvi^nil  joinia  aro 
ntinc'ki.-(f,  tlicr  nmonnt  of  jhiui  oxpcrieiu^  may  be  tmly  tritliug, 
tliou^li  it  inuy  iMicoiiio  agjjravat«l,  cspcciiiUj-  uiidvr  tJic  iiifliieiu'c  of 
<i>l(I  MiJ  liuiniditr,  and  of  iiliiKi!>{ili(ri-i<-  t'lian-pw,  to  siii'Ji  an  oxUiit 
as  to  rt-nilcr  n-.^t  almost  iinpowible.  Tlio  culargcincnt  wliioh  oet'Hi* 
iK-jwinls  at  first  on  iut^reai>«i  t-tl'ti^iun  into  llic  i.-ioity  of  tlio  synOTiiil 
ineinlirain-;  ucwirdiiigly,  in  tlic  large- r  joint*,  at  any  rate,  llio  swtrll- 
ing  is  originally  sofi.  and  flticUiation  may  !«!  det«X'tod.  The  sjtio- 
vial  liiirNi!  ill  tlic  ncigliljourhood,  both  those  whicb  natundly  omii- 
municate  ivith  (Iio  joint  and  ibow?  whiirli  are  distinct  from  it,  arc 
[Mmi^tinif-s  utFcctctl,  and  by  thpir  di»<lcnuon  contribute  to  i)w  gcnonU 
fiolargcmcnt.  At  u  latter  [icriod  tbo  Hwellin^  becomes  bard,  and 
))»4(<oiis  jjrowihs  may  oRen  bo  fi.'U  connected  with  tbo  ]«'rio«leum 
jind  extl-emitii'M  of  llm  bimi-;*,  wliioli  load  lo  allci-ationA  in  tho  fonu 
of  llio  lulifutar  t^iu'faecs,  and  give  ri^  to  great  and  iKtinliar  de- 
Ibrnuty,  vaiyinj^  in  tljo  in<lividuid  joiiit--<,  but  cliaractcriaed  in  tho 
KmaJIiT  onos,  such  as  thoHo  of  tho  fingent,  by  tho  aplMViraiK-o  of 
irregular  knots ;  wlK-nM  iho  toj-m  noitarilff  of  l/ie  joinUf  ]iro[)oncd  hy 
Dr.  Haygartb.  Tlioso  nodcH  conttnuo  to  enlargo ;  tbo  th'rwtitHi  of 
tl]o  honca,  )i(-rtia|M,  is  att<-n'<l;  imd  wbcn  l)i'^  iliw.'n.so  a.HHumi.'!)  tlio 
constitutional  tbmi,  fri«li  joints  are  attatrked,  williout  .iny  rrbof  occur- 
ring to  those  originally  afilvk-d.  It  nniy  W  notiocd,  however,  tlrnt 
therv  is  littlo  or  no  tendunoy  to  supiiuratioi)  in  tiiwto  ca*cs  j  alwt-ss 
of  the  joint  rarely,  if  ever,  taking  jjacc.  Tlio  lunount  of  articnlar 
rigidity  wbicli  occurs  is  (wruliarly  striking,  rendering  tbo  nffi'i-leil 
joinU  iiraotically  "-■•(■li.'iw,  and  simulating  nukyloKin,  though  true  anky- 
loMs  rarely  occuta,  if  tnd<ted  it  ever  doi's.  In  llie  advant-cd  stages 
of  tlic  dineasc  vtiflritMS  or  oven  immobility-  <jf  tho  ai-tic-ulatioiis  may 
bo  present,  depending  on  the  deforniitj'  iihieli  has  occurrofi  in  the 
artic-ular  ^nriaei;:*,  and  on  the  bony  outgrowths  ivlneh  ha\e  formed ; 
and  where  many  joints  have  become  aftected,  the  imliappy  iiaticiit 
may  Ihj  oonfiiiod  to  bis  bed  in  a  Btate  of  utter  hel]>los»ni'K-.  T^"  ii;^h 
the  muscles  are  not  immediately  implicaU-d  iu  the  rhoumn  i  .  liv- 
tioii,  at  some  jtvriod  of  tlio  disease,  probably  when  tbu  bono  itadf 
begins  to  suffer,  ]i»infiil  i«puHni.t  aiv  apt  to  oeeur,  t-ontributing  mate- 
rially t»>  tlio  discomfort  of  tho  patient,  and  giving  ri.«o  in  wnne  easiM 
to  tho  partial  or  comjilvtc  luxations  which  are  oei-a^onally  met  uillk 
ttHieu  tho  joiiibt  have  become  rigid  and  praeticjdly  ilwIcm,  the 
inuselea  in  the  neighlwurhood  dogenerale  aixl  wtuito.  Tlio  itenwitiun 
of  decided  crackling  experienced  iu  the  movemcnbi  of  tltc  jtuiit  is 
«rident  both  to  the  ]>atieiit  and  to  the  Surgeon,  and  U  usually  moxt 


728 


DISEASES  OF  THE  JOINTS. 


marked  wlici]  the  nrti<.iilatK>n  U  fii>t  iiKctI  nftor  n-)mH) ;  it  is  ogpc- 
i-inllv  n<)tii-(il,  tlumrtiin-,  in  l)j(-  uinming.  It  dejK-jiilH  iij>on  tliv 
mutual  attrition  of  the  altorod  artk-ular  surfuofH,  and  may  be  dc- 
toctoil  in  iiKxil  of  till'  jiiiiil.H,  liiit  t>A|M>(-Iiilly  in  Iho  )ii|>,  Mill  onlv 
dlHBppcars  n-licii  complete  rigidity  hits  saiiervened. 

TrraimfTit.  Dr.  Hnygurlli,  tn  vrhoiii  wo  nre  initchNsl  for  oiir 
earlicrt  notinw  of  ttiis  disease,  lamented  the  scanty  nieams  of  trcal- 
■iiciit  wliicli  hi;  coidd  »ii^<^>-xt,  and  hujted,  when  tinu!  Iiud  been 
iifl'onloti  for  inveRtigation  by  the  profeasion,  that  freflh  and  mot« 
wiwri-nwliil  eiirafiii'  iiK'M»nn.v<  mifjlit  liv  ditKiwered.  Tliew  h()pn", 
however,  liave  a»  yet  been  only  jiartiaUy  reahsed ;  and  in  the  ad- 
vanced ittng«s  of  the  midiuly,  when  ilie  joint  has  bet-n  i^ssentiitlly 
disorgani§ed,  we  can  seai't'oly  aiilifipalo  iiiiieh  improvement.  Onr 
Uvatineni,  Ihcretiin',  to  Im;  ofrciil  wn-vioi',  nm^t  lie  adiipted  at  tlic 
commencement  of  tlio  affe<?tion  ;  at  a  later  period  we  ean  but  hope 
Ici  miti;;iite  the  wynijitom",  t"  relieve  the  I'liflVriiiL's,  and,  at  Ix-tit,  to 
retjird  the  iirogress  of  the  diseawe.  In  Uie  early  siage,  when  inflam- 
matory Kymptwmi*  are  prvjtcnt,  and  any  movonniit  of  (ho  joint  '» 
attended  with  aimte  |iain,  it  may  he  neeewoiy  to  employ  (-tipping 
or  livrlics,  to  keep  the  part  at  re»t,  and  support  it  by  means  of 
handageK  or  splints.  Care,  liowever,  nnist  be  taken  not  to  pro- 
long too  fur  the  |>nriod  of  immobility,  for  in  these  ease*  espeeially, 
want  of  exercise  of  tlie  joint  has  ere  long  a  deletoioiiit  inflix^nct'  on 
it*  iftruetun.'.  When  the  acutcr  s\'m)>tomt!  Bubiude,  therefore,  and 
ri(p(Kt?  increaftcft,  thi^  imlicnr  !>houId  bo  encouraged  to  use  tin- 
limb,  to  promote  polisliiiig  and  induration  of  the  artieulai"  surfacM. 
Wanntti  and  (Vietioii  to  tlin  [>art  »n>  nsunlly  grateful,  tlanncl 
choidd  be  worn;  imd  shampooing  maybe  employed,  or  loeal  douches 
or  hot-air  Imtli»  liiid  retrourse  to.  At  certain  stagex  of  Uie  affec-tJuu 
eounter-irritatJoii  may  bo  used  in  the  foi-m  of  blisters  or  of  painting 
withitHlino;  and  in  tho  iiodnMities  of  ilic  fiTigi^rH,  the  locid  appliea* 
tion  of  a  solution  of  iodide  of  potaasiuni  under  oilod  »i]k  is  some- 
times of  siTviei-;  or  c«d-li\cr  oil  may  be  iip]i)i«d  externally,  as 
recommended  by  Sir  Benjamin  Brodic. 

ITie  general  or  cunrtinittonjil  treiituient  must  l>o  lulaj^tcd  to  tJm 
indiridual  ease,  and  to  the  stage  at  ivhieh  the  disoitler  has  apri>e<L 
Wliero  any  gouty  eletnetit  exists,  when'  dysjwptic  -■'j-mploma  aiv 
]ire»cnt,  and  the  i^aso  appcorn  coiuieeU-il  witli  too  fiill  a  Irnbit,  grot 
attention  Xn  the  diet  heeomes  of  importance  ;  stimu[iint.-<  should  be 
ahst.titicd  from ;  sugar,  fruits,  and  raw  vegetables  avoided ;  and  a 
moderate  ijuaiitity  of  jKitash  or  mngncHia  be  a<Inii«i!'ter«>d  tlirt«  or 
four  Iiotms  after  eoeh  prineijial  ineiii.     In  other  cases,  however,  the 


GOUTY  SYNOVITIS. 

tsyHten)  appeals  impoverUbed  nitlior  Uum  ttto  rtill,  niul  hpitt  it  mar 
1)0  iicccwan-  to  <rniploy  a  bt-ttrr  iiiul  more  niitritit>ii«  dit-L  In  tlio 
I'lirlicr  sLogos  <»f  niiii-nciiti*  iiitlniimmt.inn,  it  may  Im  uili  iHabln  u»  give 

Ea  few  alti^nitivfl  (lo»eH  of  bliic-pill,  combinod,  pcrbap§,  with  avotons 
nxtnict  of  ■.■ololikrtiiii,  niid  to  iwiininistrr  Gii-gorjlo  [inwilor  nt  nigbt- 
titne,  nitb  nn  active  ajwriotit  at  regular  intcnnls.  Respiration 
xhotild  Ih!  ciii-oiiragixl,  too,  bv  tbo  uao  of  tho  bi>t-aii-  biitb,  or  bj 
talcing  Dover's  jiowder,  or  other  mwlicine*  to  net  upon  the  skin.  At 
n  Int^r  |M'ri(Hl,  when  rwmw  iiiiiciiiiit  of  ebiinge  hn.->  oreiirrcd  in  thw 
joint,  the  iodido  of  polafKiiun  niiiv  be  admitiintei'od  in  imiall  dosuH, 
un<l  <-()iili>nie<(  for  i^overa)  w('fk.-<  nt  a  tiiru',  if  it  ii[)[H-iir!i  to  nnit  ttut 
patient;  for  its  netioij  in  tliewi  vjufs  h  somewhat  iintertain.  Various 
stiniiduting  iiitcninl  ini^dicincs  iniiv  txy^'  ^»'  jZivon,  .ini'li  ils  tiirjientina 
or  giiiacuin  :  or  eod-liver  oil  may  be  adiuinistereil  iiitemally  an  well 
n.->  exii'i-nuliy;  opiates  also  are  uimally  of  norviiw  for  tlie  piiqiuM>  of 
procuring  rest.  Free  aetion  on  tlie  skui  is  still  benotieial ;  warm 
clothing  should  bo  u»od;  and,  where  eireuniHtanei---'  udmit,  rtvidenoo 
in  a  warai  climate  during  the  winter  nsonlbs  materially  incj«a«c« 
the  cfiniforf.  of  the  patient.  Warm  batlilng  i»  nnually  attmdod  with 
relief;  the  hot>air  or  Tiirktuli  bath  may  bo  employed  with  proper 
cantion ;  anil  if  practicable,  recourse  should  be  had  to  Iho  ininenil 
springs,  siwdi  as  (hti-e  of  Balh  or  Ihixtmi  in  this  r-ountr^',  Aix-la- 
Chapctle,  Vicliy,  Kuis,  Wiesbaden,  or  Carlsbad  on  the  Continent 


Goutff  m/novitui.  The  goiit>"  diathesis  present);  some  {Kiints  of  rc- 
aemblonce  with  tlio  rhnumntic ;  in  lact  tiic  elironi<-  form  of  alteration 
of  the  joints  jtL<t  described  is  often  termed  rhomnatie  gout.  The 
miociality  of  ihi'  gi>iity  inflammsifion,  liowcwr,  comiiids  in  the  tend- 
ency to  se])arate  from  the  blood  aji  inorganic  material, — the  nrute 
of  tioda, — till'  dciKwit  of  wliieli  in  and  around  the  joint  givca  rise  to 
more  or  loss  local  (listiirban<v.  flotity  inflammation  of  tho  joints 
occuiH  in  lUi  acute  or  in  a  more  ciironie  form,  llio  acute  form  of 
goat  reqtiires  no  dewrijition  here,  an  it  is  osHcntially  a  medical  com- 
|)Uint,  ami  If  well  and  lunply  treated  of  in  medical  works.  WHiere 
gout  has  assumed  a  chronic  form,  however,  tJie  local  affection  may 
predominate  oxtir  tho  constitutional,  and  cncii  e«!H,'w  may  at  times 
fiJI  under  the  eare  erf*  the  Surgeon  ;  they  require,  therefore,  to  1» 
briefly  inrtieod. 

When  gout  first  altaekn  n  patient,  tJie  joint  usually  recovore  ila 

'original  mobility  as  tho  "  fit''  j>as»e»  off;  but  when  n'l>Mit-e<l  atl«<Jw 

[bavo  oen'urrMl,  the  rc^limition  Iweonic-*  more  and  more  inipcrfeet, 

at  last  tho  articulation  loses  entirely  its  capacity  for  motion. 


1 

li    •  ■ 


730  DISEASES  OF  THE  JOINTS. 

0p]x»rhmitie9  of  examining  the  joint  at  an  early  stage  are 
common ;  but  Dr.  Garrod  is  of  opinion  tliat  gouty  inflamm 
is  invariably  accompanied  by  deposition  of  its  peculiar  salt, 
questionably,  as  the  disease  advances,  a  dcixisit  of  the  w 
chalky-looking  urate  of  soda  takes  i)lace,  in  the  aubataiice  o 
ligaments  and  in  tlie  surrounding  areolar  tissue,  as  well  as  ii 
neighbouring  muscles ;  or  it  may  occur  in  tlio  interior  of  the  j 
thickening  tlio  synovial  fluid,  and  studding  tlie  synovial  a 
branc  wiUi  small  n-liito  masses ;  or  in  tho  substance  of  tho 
cular  cartilages,  in  the  form  of  wliite  spots,  resulting  from  the 
sence  of  the  crystalline  salt  in  the  hyaline  structure ;  or,  fin 
the  urate  may  be  deposited  in  tlie  bone  and  in  tlie  periost' 
Resulting  from  this  de])Osit  we  may  expect  to  find,  sooner  or  1 
the  tissues  themselves  midergoing  clianges ;  the  synovial  meml 
will  be  tliiekened  and  vascular ;  tlio  ligaments  and  areolar  t 
condensed ;  and  tho  cartilages  subsequently  become  softened  ani 
1  /  removed,  so  that  the  articular  surfaces  of  the  bones  are  exposed 

alferetl. 

Whenever  a  joint  is  subjected  to  protracted  attacks  of  dii 
gout,  it  is  certain  to  be  permanently  injured,  either  by  becomii 
rigid  that  its  functions  are  practically  destroyed,  or  firom  the  foi 
tion  of  cludk-stones  around  it.  Chalk-stones, — or  tophi,  as  thej 
sometimes  termed,  from  a  Hebrew  word  signifying  concretion, — 
much  in  their  consistence ;  they  may  be  soft  and  semi-fluid,  or 
as  the  chalk  from  which  they  derive  tlteir  name.  Under  tlie  m: 
8coi)c  they  present  bunches  of  needle-like  crystals  of  urate  ofs 
and  chemically  they  are  composed  of  that  salt,  united  with  a 
tain  amount  of  animal  or  earthy  matter.  A  concretion  taken 
the  metacarpus  was  found  by  Lehmaun  to  contain — 

Urate  of  aodft    , 0212 

Urate  of  lime 1-23 

Chloride  of  aodium         ....  0'84 

Phosphate  of  lime.         ....  4-32 

Cellular  tiasae 3840 

Water,  loss,  Ao 3-98 

100-00 

Chalk-stones  are  generally  found  in  the  smaller  articulations  o 
hands  and  feet  They  form  protuberances,  distorting  and  crip] 
the  articulation,  which  approach  the  surface,  till  the  skin  over  i 
is  tliinncd,  and  allows  their  while  colour  to  become  visible. 
Watson  relates  the  case  of  a  gentleman  who  was  in  the  habit,  i 
at  cards,  of  scoring  the  game  on  the  table  with  Iiis  chalky  knuc 


GODTT  SYNOVITIS. 


781 


Timay  he  mfmiionoil,  a.*  iiomotiinKt  f;(c!l!tuting  oiir  diiipiosU,  iBat 
thcrv  in  aiiothor  ^litiution  in  wliioh  (le|)0!iite  of  urate  of  wxla  sro  <Tvca 
more  <wnit»>iily  x-iwble  than  in  connexion  with  tlic  joint*,  niunoly, 
in  die  cartilflgc  of  the  pxtema]  rar,  in  tlio  form  of  tiitle  [x'ai-l-Iiko 
bodie.t,  viirving  in  mx«  fix>m  ti  njilit-jica  to  si  mt-R-  white  i>i>iiit,  and 
iutuat«d  nsually  about  tlie  fold  of  tho  lielix.  Out  ofseycintecu  caiKS 
in  wliicli  1>P.  Gnrrwi  dcloftMl  gouty  concretions,  in  ep\-ni  tlw-y  t'xiwled 
in  tho  ears  alotu,  in  nino  in  the  enDt  at  writ  ru  nroun<l  th«  joints,  iuui 
vnly  in  one  uwo  were  they  fonnd  in  other  purts,  but  not  in  tJu  tar. 
The  gouty  (lc])0£iit,  whii'li  is  at  first  licjntd,  bi-i-onws  hmiW  in  time 
from  iibsorj>tion  of  ita  fliuil  part*,  and  nccuindatcs  in  many  o»jhv*  to 
aach  an  extent  a.i  to  render  tho  joint  coni[)K^titly  fixed,  wliilst  the 
n*'ishho)iring  stnictiu'cs  aro  also  JMCionx-ouioncod  by  tho  di^ioiwiiwi  tn 
whii-h  tJiey  iiro  siibjiH'ti'i!.  Tho  more  [inwi-'iico  of  th«  salt  in  con- 
nexion with  tlic  joint  docs  not  apjiear  UHiully  to  be  attcndod  widi 
uiDc-h  irritation ;  aftur  a  time,  howevor,  infliimmirtor)'  action,  pcr- 
hajifi  from  a  ii'osli  gouty  aitaok,  may  bo  mt  np,  tlio  iiitognnK-uts 
ldcei':ili>,  and  a  <liitchiu-gc,  pTV-xniling  tho  iirat<>  of  itKia  mixed  with 
blocKl-globulcs,  takes  place  throngli  ojjenings  whicll  are  often  most 
ironblosomo  to  henl.  Tlit'se  »hs<v».»i'*,  liow<rver,  it  may  bo  mentioned, 
appear  somttimcs  to  act  as  saft^-valves,  and  their  ciire  is  followed 
by  renewi^d  attacks  of  gont,  which  laid  b«in  nupendtxl  during  the 
time  th<-y  remained  ©iien.  The  diagnosis  between  ehroniu  gouty 
affection.-*  of  iht;  joiiitx  and  the  chronic  rhciunatlc  arthritis  ain-ady 
spoken  of,  is  ronderetl  easy  when  ulceration  of  tlio  soft  parts  ha« 
ocounvil,  niitl  tlirongh  tlio  Gstnlous  orifices  chalky  matter  exuded, 
which  can  be  determined  by  cIiomLstrj*  In  consirt  of  urate  of  Koda. 
At  an  ojiriicr  jxiriod  vomo  imoertain^  may  cxi*t;  though  the  ease 
may  be  eonsidored  gouty,  when  it  come*  on  after  repeated  and 
inH!iif«>f>t  attacks  of  gout,  and  when  tho  gouty  diathi-siw  is  j)lainly 
marked;  it  may  lio  provM  to  lio  »o,  if  a  pmu-turo  of  tlio  swelling 
with  a  neodlo  allows  of  tlio  escape  of  fluid  ui  wliIcIi  the  prew'flue  of 
caysials  of  tlio  urate  of  wtla  iH  ntvcuihil  by  tho  miiToseope:  for  tho 
cxi»t«nre  of  tbifl  salt  forms  tho  specifio  characteristic  of  iho  <iouttf 
affection,  nnrl  iit  never  met  witli  in  rheujnatiHni  or  in  chronic  rheu- 
matic arttu'itis. 

Trmttntid.  K»  ilie  di«caso  is  cjwentinlJy  a  i-oiislitntional  one, 
tlw  treatment  must  also  be  mainly  eonstitniional,  and  consist*  in 
iin]>eding  the  undue  formation  of  uric  acid,  w*  well  a^  in  getting  rid 
of  the  surplus  amount  of  the  acid  already  existing  in  tho  blood.  For 
the  fint  purpose  the  diet  has  to  bo  cnrclully  attended  to ;  the  dya- 
{icptic  «>inptom3  relieved  as  far  as  powiibie ;  the  !»ecTCtionf>,  «i]jccially 


782 


DISEASES  OF  THE  JOINTS. 


Uuit  of  the  Ih'cr,  ivgolatwl ;  luid  the  «tif  n^i  of  tho  pntiont  snp- 
{M>rtc<l  in  ihim^  wi?e»  wliint;  tJinn*  w  u  teiKleiwv  lo  Iom  of  tonv^  Tj 
free  tlio  blood,  we  may  adiniiitHtor  occiisionnlly  nnall  doses  ofcul- 
eliicuin,  wIk'ii  tlic  !4rfii;^li  ot'Un!  jniliout  iKliiiibi  of  it ;  bur  our  main 
eflftrbt  are  dirc<rU><)  to  int^reiiM-  tlic  aotioti  of  the  ktdiii-^'s  and  skin  hx 
mcniiK  of  .-wh'iK'!!  niul  iilkiilii-s.  The  s^iUnea,  to  be  of  »ervi<<ie  in  vhraw 
caMw  of  go«t,  rauHt  he  given  in  small  doses  ami  vcr>'  diluted  ;  tlKW 
Hhoiilil  ho  tiikoii  on  nil  vinpty  Ktoiitiicli  luut  fumit-  little  timi*  befim 
food.  The  uttture  of  the  saline  is  by  no  muuis  immaterial,  Mid 
mn»t  he  siut«d  to  the  indiviihiul  ciiw,  tnul  viiriwi  tM-cii.-*ii>iin)[y  o^ 
<»i'diiig  Ui  oiiVHrnsinnces,  Time,  loo,  constitutes  a  materiiil  element 
in  tlio  relief  of  thf  inaladr,  and  no  tiiL^ty  attempt  at  euro  is  Itfccljr 
to  be  of  siervicie.  From  the!«  (■(inMiderations,  it  is  o\-i<ient  that  tfcft 
muieral  watoni,  jtrnjwrly  (•cicttcd,  "(Ht  inmiy  iuK-antii<;c»  for  tb* 
adiiiiniiitj'atiun  of  tliiH  elnsx  of  medii^ines,  as  welt  from  tl>e  stale  <f 
dihition  in  whJrh  tJiey  are  fountl,  as  from  the  gn-iiter  clmncc  (if  Ae 
juitii-nt  e<inliiinin<r  to  tnke  tlieni  for  a  sufficient  time,  while  tlio  mind 
is  occupied  aiid  tlio  altontion  divcrlod  by  tlio  chnii}^  of  sccno  and 
1]0|>eliil  Htutcinentn  there  nOordei).  Tlie  external  nw  of  ttic  vniea 
can  also  he  conveniently  and  tisofiilly  adopteil.  TItc  njisi  to  bo  iC* 
leoted  innMt  dejwnd  to  a  great  extt^iit  ti|>on  the  special  cliaract^rs  of 
the  ;njivi<lua]  case.  In  stinio,  Ciirlshiid,  Wiesbaden,  or  even  Vichy, 
limy  ])i;  rinnniTifiideil ;  whll'^  in  fi^t^bler  <:aae^  Aix-la-Chiiix 
Te|)litz,  Wildbad,  and  Buxton  are  more  likely  to  bo  of 
Whcro  tli<'  ilfMhty  i»  •pvMf  or  after  a  conrji*  (if  otlwr  n-atcn 
l»een  taken,  llie  ferruginonH  springs  of  Sohwallwicli  or  of  PiiTmant 
aro  often  Ixuicticial.  For  tliuw  who  nru  pre\~ciiied  from  going  to  a 
grejit  (lislancre,  or  who  are  desirous  of  feeling  their  way  and  Mwin^ 
which  spring  is  likely  to  suit  them  bcM,  a  trial  of  iho  oaivfidly  pn> 
]inred  fa<-titiouH  mineral  waters  of  tlie  spa  at  Brighton  may  oftint  be 
deemed  advisable. 

It  IK,  liowo^'or,  for  the  local  niinchivf  that  tlie  Surp-on  may 
principally  o,\])eet  to  bo  consulted.  The  kiea!  treatment  will  vvrj 
aecoiilinj;  ili  it  is  direotrtl  simply  tn  relie\'e  llie  stiffm>s«  anil  rij 
of  the  joints,  oi'  to  allcTiate  anv  active  inflaininntory  action  whi 
mny  hav*!  Invn  w)  up,  with  or  without  llii>  fonnnlion  of  abscess  : 
production  of  ulooration.  To  relieve  the  stiSiics^,  one  toiiicat  app 
vutJon  ha«,  indoi-d,  Ixx^n  alrcndy  alliidetl  to,  in  ihc  form  of  batlis 
the  mineral  waters.  Where  tliewo  cannot  be  had  rocoimw  to, 
idkaliiit!  lotions,  with  iodide  of  ]>otassiuni,  may  be  agipHtMl 
joint  under  oiled  silk,  and  gentle  exereise  of  tlio  artieiilatinn, 
fthampooiiig,  fri(;tion,  &c.  employed  with  diycretton.     Wlien  a 


:hiiiieUfc 
s«rvieM 
iter*  haa^ 


I 
P 


PYEMIC  SYNOVITIS.  733 


I 


tain  amotuit  of  low  or  divonic  Inflamiuatorj'  artmn  is  going  on  in  t]i« 
I i;jaint-iilA  iiiul  nvDO^tal  laonibnini's,  small  ttjiiig  liIi»terK  an-  oRcu 
vseCuli  applied  only  for  a  sliort  time,  aiid  with  tiftwie-paiKT  between 
tlivin  tuid  llio  »kin ;  in  l.lii«  patiiciiliu-  cuiiditJoii,  tuo,  tbe  internal 
ailiuiiiistration  of  small  <losee  of  iiMlidt-  of  jiotiL^-^tmn  is  of\c]i  of  ufc. 
AV'hcn  aciitit  iiiHninmatJon  occtint,  a«  it  iiinv  do  wliun  n  iiinr  and 
severe  attack  of  gout  tnkoa  pluce  in  the  ^eat  of  a  ohalk-Htont!, 
tlic  unmuiit  t>r  »Wl.^lling  which  unsuvs  may  cntuo  rlic  ciitix  to  give 
way,  wbikt  tJie  cuticle  remains  entire.  It  i*  brtlor  in  tiicM-  eiiM-s 
to  avoid,  if  [HjKsibIc,  rnakuig  any  incinion ;  for  tho  salt  i;^  dcpositixl 
not  simply  in  die  eellular  tiiwuc  or  coll<;ctcd  a«  a  nia-ts,  but  ulno  in 
tlu.-  actual  Hiibslance  uf  tiut  artitMiliu*  cartilogi'H,  ajid  cannot,  tliere- 
fore,  be  exjjecleil  to  lie  cntin^Iy  or  fn)*'ly  evacuatMl.  Soothing  ap- 
plications are  of  most  service  ;  but  it  may  be  remarked,  tJiat  where 
Ml  o[ienhig  oofum  niitiindir,  or  is  niadt!  by  the  Siirgi^on,  llie  wn'ouK 
consequences  frequently  attendant  on  wounds  of  artic-tdatiotis  are  not 
to  Iw  «x[>eet«Hl,  |iiirtly  fri>in  tlie  diM>rgiiuiHut!(>n  which  Iuli  occurred, 
partly  also,  no  doubt,  from  the  unimportant  character  of  tlic  joint 
which  i.t  uHualiy  involvod.  SOTure  ojn-rative  mou-suru!*  arc  not  udlw] 
for  in  these  cases.  \Vhilo  tile  inftamniation  runs  Iiigh,  jjoultieea 
Mid  foin«ntations  aiv  of  most  wrvit-o ;  alU-rwanlH,  g<.-nllA  preMurv 
may  bo  emjJoycd,  a:id  tJie  fibunes  which  arc  left  shoidd  not  bo  irri- 
tated by  probing  or  by  Ktimulaiit  applications,  but  alluweil  graihially 
to  contract  and  ultimately  heal.  Aa  ah*a<]y  stated,  when  uleerfitjon 
lian  oiioi!  ^K'ciirn'd,  iho  easo  ia  almotit  invariably  tedtoiw,  and  may  be 
rendered  more  so  by  too  active  surgical  treatment. 

ic  synovitis.  Acute  synovitis,  frequently  loading  to  &up- 
in  tlio  Jotnbf,  {»  uot  a  vcr^'  uncommon  conM«iucncc  of 
or  systemic  infection,  and  is  met  witli  in  ])ldebitis,  afW 
Ofjcmtioiiit,  ajid  in  connexion  with  certain  pnci'i>end  conditionK,  na 
ireU  aa  in  the  progreaa  of  fcvere,  lie  For  tlie  description  of  the 
gonoral  condition  giving  ri»c  to  this  comjilication,  its  vyniptoms, 
and  ita  treatmeiii,  the  reailer  Ls  refem<<l  to  lite  etway  on  I'yxuia. 
It  tvccd  only  be  xtatixl  here,  that  when  tlus  pyajmic  condition  vxista, 
t  there  is  alwa_\'s  danger  of  thi>  joint-s,  lui  well  as  of  other  part^  of  the 
body,  Ix-coming  the  scat  of  the  local  disturbance.  Sometimes  the 
attack  is  marked  by  the  oociirrence  of  violent  jiaui,  accompanied  or 
foilowod  by  heat,  redness,  and  swelling,  afKiding  one  or  more  of  tlw 
Uticnladons,  wliicli  may  pros4-iit  distinct  HucUtalion,  provided  ihcy 
«ro  superficially  situated.  In  those  cases  more  or  less  tliin  aiid 
i(]ni(l  pus  m»y  be  found  in  tlie  interior  of  tlic  j<nnt,  or,  in  sunto 


;■  '  734  DISEASES  OP  THE  JOINTS. 


J 


i/ 


instances,  diffused  tliroughout  tlie  external  areolar  tissue.  In  ( 
cases,  however,  largo  aecumulations  of  pus  may  take  place  in 
joint,  suddenly  or  insidiously,  unaccompanied  by  pain,  and  per! 
unsuspected  during  life.  The  number  of  joints  affectod  may " 
considerably.  Only  one  may  be  attacked,  or  it  may  be  difficu 
find  a  single  articulation  which  does  not  present  pus  when  cat  i 
The  inflammatory  condition  may  rem^  confined  to  the  sj-nc 
membrane,  but  frequently  extends  to  the  otlier  Btmctnres,  wl 
become  more  or  less  disorganised.  In  a  case  of  suppuration  of 
knee,  following  thecal  abscess  of  the  finger,  Dr.  Handfield  J< 
found  increased  vascularity  of  tlie  synovial  membrane,  with  vil 
projections  from  its  sur&ce;  whilst  the  articular  cartilage 
ulcerated  in  places,  the  cartilage-corpuscles  containing  a  gro 
increased  number  of  eeiloid  masses  in  their  interior,  and  the 
tercellular  substance  being  fibrous,  and  deprived  ot  its  nat 
consistence. 

Tiio  treatment  in  these  cases  is  mainly  directed  to  the  relit 
the  constitutional  infection,  and  its  principles  have  been  liud  d 
in  the  essay  on  PviEMiA.  Locally,  when  we  have  reason  to  sup] 
that  a  joint  is  becoming  implicated,  it  should  be  maintained  i 
state  of  perfect  rest  upon  a  splint,  and  the  pain  relieved  by  sootl 
applications.  When  suppuration  has  indubitably  occurred  wi 
tlie  joint,  a  free  incision  for  tlie  purpose  of  evacuating  the  matb 
desirable,  and  tlie  local  treatment  already  recommended  for  abe 
in  tho  s)iioviaI  mombrano  becomes  applicable. 

Gcmorrfiaal  synovitia;  gonorrJujeal  rheamaiwn,  A  milder  f 
of  synovial  inflammation  is  occasionally  met  with  in  coniiexi<m  ' 
purulent  inflammation  of  tho  urethra,  or  even  with  purulent  opht 
mia.  This  complication  appears  to  have  been  first  described  by 
Benjamin  Brodie,  and  usually  passes  now  under  the  name  of  ^ 
rlusal  rheumatism,  tbotigh  it  differs  in  several  respects  honx  rheu 
tism,  and  is  not  necessarily  connected  with  gonorrhoea.  In  t 
cases,  during  tlie  existence  of  a  urethral  discharge,  which  : 
depend  on  gonorrhcea,  or  arise  af^r  the  passago  of  a  bougie,  infl 
mation  occurs  in  tlie  synovial  membranes  of  one  or  more  of 
joints,  more  particularly  in  the  knee.  Another  peculiarity,  wi 
was  pointed  out  by  Sir  Benjamin  Brodie,  is,  that  some  fom 
ophthalmia  very  commonly  accompanies  or  precedes  tho  artic 
affection,  or  may  alternate  with  it.  All  stages  of  gonorrhoea  : 
present  this  complication,  and  usually  no  material  change  in 
discharge  is  noticed,  though  sometimes  it  declines  a  little,  when 


[ 


GONORRHffiAL  SYKOVniS. 


735 


fviiovuJ  nffection  shows  itself.  Tlic  nrticiiliir  inflammation  may  tiirt 
for  n  ii>w  wifks,  or  iiiav  continu*  for  months  or  oven  wms.  I»  U 
vory  apt  to  involve  ono  Joitit  nftvr  unothtT,  niiil  (irej*entt*  n  (l(X>)ik><l 
(liH)inKittoii  to  irkpsc  Tho  rflWon  which  Idces  plnco  is  iisuaUj"  of 
scmm  ratlior  tliiui  of  K-iiiph,  niul  ttic-ru  ix  Itttio  or  no  Icntkiicy  to 
Kuppiiratioii ;  but  sometimes  it  leaves  tijo  s^-novial  merobrano  tliiok- 
cncd,  luul  tlio  mo\'em(dit.->  of  tJin  joint  ptmnanciitly  intcrlumc!  witli. 
In  wmc  fcw  instances  Uio  cartilages  bocomo  iuvolvoil,  and  permanent 
rigitlily  may  Ikj  tiio  rctHK. 

The  imniedialo  canso  of  tliia  affection  is  still  a  matter  of  dispute. 
I  By  Mimo  it  bus  bwn  coiwidcrwl  to  Iw  connoL-tt-d  witli  the  gouty 
hnbit  ;*  whilst  Mr.  Barwoll  ronniders  it  to  bo  "  in  ivality  a  slower 
form  tlian  onlinary  of  ]>urulctit  intcc^tion,  produced  l>y  infbimniittioii 
of  tho  prastatic  veins,"f  Ho  allow.4,  however,  that  he  bas  '*  no 
oafWH  of  dissection  to  prove  tliis  position ;"  for  thi»  affection  differn 
firom  tbo  oi-dinary  fonn  of  pyajmic  sniovitis  in  at  least  one  ira- 
[lortjint  rcsjiect,  namely,  tliat  patientA  do  not  seem  to  (He  of  it. 

TreaCmml.  Dm  local  In-jitnu'iit  in  iJiCJio  eases  ia  mnch  the  same 
08  ttmt  recommended  in  ordinary  synovitis.  So  lon^  tu  acute  in- 
flammatory symptoms  arc  i^ronent,  the  iixuni  antiplilogistio  m<!ainirGa 
miut  be  had  rccomxe  to;  tvbeu  eSitsion  remains,  frco  blistering 
alioidd  l>e  entployed,  and  "  Scott'n  bandage"  a]>j>lieil  in  tliosc  caj«a 
wbcro  tiioro  is  thickening  about  tJie  joint.  At  a  subsequent  period, 
friction,  sham]K>(>ing,  loeid  vapotu--bat)iit,  or  the  uw  of  i1m>  mineral 
waters  of  Buxton  or  of  Wiesbaden,  will  probably  bo  of  jK-n-ico. 
Tbo  fronoral  treatment  muiit  also  bo  conducted  on  tlie  ordinaiy 
plijiuotogi^-al  princij)les.  As  tlie  inflanmiatory  excitement  ]>»»■<■» 
off,  the  iodide  of  [K)ta**iim],  combined  with  colchictun  ami  o]>iuin, 
may  bo  administeretl,  along  witli  oewi-uonal  active  purgative*  j  to  be 
followed  «t  a  »till  later  ]»eriod  by  mild  tonics.  In  the  nioro  chronic 
fbnns  of  the  diseasii  the  greatest  InMiefit  will  be  derived  from  ebango 
of  t'lirnate,  including  a  residence  at  tbo  minond  spring!*  recomraendwl 
fijT  cbronii-  rbeumati.'iin,  with  the  iisti'  of  iho  waters  both  internally 
nnd  externally.  The  treatment  of  tliis  affwrtion  by  kcei>ing  liougles 
in  the  tuvthnt,  or  by  t)ie  aibiiiiiistratton  of  enbebs  and  copaiba,  as 
oneo  recommended,  is  hanlly  likely  to  be  often  had  recourse  to  in 
tluj  ptx!»ciit  day. 

Syphilitic  /••/nofUU.    TIio  charnetcr  of  ihft  M-novia!  inflammatioa 


•  JohnnoR  oil  lAf  <7i-nito-irruM/jr  Orfaut,  jx  Sll. 
t  On  liitfaM  of  th*  Jcriittt,  |^  101. 


'/ 


736  DISEASES  OF  THE  JOINTS. 

in  Bomo  caitcs  is  modified  by  the  cxistcuco  of  constitutional  syf 
Occaaionally,  as  Sir  Benjamin  Brodie  remarks,  the  synovial  i; 
branea  of  one  or  more  joints  assume  a  sluggish  fonn  of  inflamm 
in  the  early  stages  of  secondary  syphilis,  in  connexion  witli  pa] 
eruptions.  More  frequently,  perliaps,  tlie  joint-affoction  come 
at  a  more  advanced  stage  of  Byi)hilitic  infection,  in  connexion 
affections  ofthe  bones,  and  esjtecially  of  the  periosteum.  Tlie  inf 
mation  in  most  cases  is  any  tiling  but  rapid  in  its  progress  or  a 
in  Its  H^nnptums,  tliough  tlie  nocturnal  pains  may  be  severe ;  ai 
is  readily  distinguished  by  its  occurrence  during  the  existenc 
otlier  and  characteristic  symptoms  of  venereal  blood-poisoning, 
constitutional  origin  is  also  marked  by  its  tendency  to  affect  i 
tlian  one  joint.  The  general  treatment  is  naturally  directed  to 
cure  ofthe  syi>liilitic  infection.  Where  tlie  patient's  strength  ad 
of  tlie  administration  of  mercury,  this  is  tlie  most,  in  fact  the  < 
effectual  remedy,  and  it  may  bo  uaeJ  in  the  form  of  fumigationi 
conjunction  with  tlie  vapour-batli,  in  many  cases  where  it  cai 
safely  be  taken  internally.  If  mercury  cannot  be  given,  tlie  io 
of  potassium,  combined  with  sarsaparilla  or  other  medicinea 
tend  to  strengtlien  the  patient,  is  often  of  the  greatest  ben 
liocally  leeches  are  seldom  required,  or  indeed  admissible.  So 
ing  applications  may  be_  had  recourse  to  if  the  pain  is  severe, 
rest  of  the  limb  by  means  of  splints,  and  mild  counter-irritation, 
the  remedies  most  frequently  of  sen-ice. 

"  Loose  Cartilages"  in  Joints. 

We  occasionally  find  in  some  of  tho  articulations  small  mov; 
bodies,  which  may  be  quite  free  or  still  attached  to  the  walls  of 
joint  by  narrow  pedicles,  and  to  wliicli  the  name  of"  loose  cartila^ 
has  been  given.  These  bodies,  which  are  usually  met  with  in  ad 
radier  than  at  an  earlier  period  of  life,  vary  in  their  structure ;  s( 
are  comparatively  sof^  of  a  yellowish  colour,  and  resemble  ma; 
of  fibrin ;  in  other  cases,  they  are  liard  and  glistening,  rather  wl 
than  yellow,  and  evidently  comjwsed  of  cartilage  or  fibro-cartils 
both  on  tlie  sur&ce  and  in  their  interior ;  frequency,  too,  they 
partially,  or  sometimes  almost  completely,  converted  into  bone, 
many  cases  we  find  only  one  such  body  in  a  single  joint,  but  ii 
by  no  means  uncommon  for  two  or  three  to  be  present,  and  oc 
sionally  they  are  met  witli  in  much  higher  numbers;  Morga^ 
for  instance,  discovered  twenfy-five  smooth  and  ]>olished  globi 
bodies  in  tJio  left  knee  of  a  woman  who  died  of  apoplexy,     T 


LOOSE  CARTILAGES. 


73T 


vaiy  conadorabij'  in  ^inc,  Iwiiig  »omBtimtw  no  larger  lliati  a  b:irlcy- 

fiirii,  whilst  in  other  cases  they  ina>'  nearly  equal  (hi-  patella  iwelf 

in  tltoir  (limcnsioiuf.     Wlu>ii  mitall,  tlwy  art!  usually  rouutl  or  oral ; 

when  of  oonsiderahle  nlze,  they  may  be  elongated,  flattonoil,  or 

fuberoti».     Tile  most  itunmon  situation  for  these  "loose  cartilagt-s" 

H  iit  the  knM,  bat  they  are  not  eoniined  ta  tixat  joint ;  they  ha^'o  alftt^ 

^U^ean  discovered  in  the  other  articulations,  including  wen  the  lup, 

^Krhicli  wait  long  tiiip|Msixl  to  ho  exonijit  from  them.* 

H       *'  L006O  cartilages,"  in  many  cases  at  any  rule,  appear  to  tako 

tlictr  origin  from  the  small   invgular  projeelions  which  naturally 

exist  in  connexion  with  the  "vascular  processes"  of  tlic  sjtiovial 

momhranc.      Tlie»e   pnjjections  are   oAcii   of  extraordimiry  form, 

(devoid  of  vessels,  and  united  to  tlio  membrane  Ly  stalks  of  con- 
nective ti.ifmo.     An  ban  tNX'n  ulrt-iuly  elated,  tliey  eont^n  otx-ji^onal 
cartilage-cells  in  the  midst  of  their  fibrous  ti»sue,  and  are  fumitiivd 
with   an  r|iitlieliimi,   wbicb   iti  \'ory  tliiek  in  plaicoit.     In   certain 
abnormal  conditions  these  processes  increase  in  si^o  and  solidity, 
uni)  may  iiltim:it<-ly  Ixtemno  ilotaclii-d  tVom  tlieir  eonnexionit,  no  as 
_  to  form  sejiarate  botlics,  which  are  perfectly  free  in  the  joint,  or  tliey 
K^jnay  still  remain  (Hiimect^^l  wilJi  tlio  ]iiirieti>«  by  an  elongalMl  podiele. 
^U3iey  arc  compo^oil  of  "  cmneetivo  tissue  with  elongated  nuclei,  and 
^P«OBt«il  witJi  e]>ithelium,  and,  though  not  ulway:(,  vontjiin  n  vunabh; 
H  Dumber  of  scattered  fat-  and  true  cartilago-eells ;  and  tbey  are  not 
developed  externally  to  the  nyimviid  membnnie,  but  from  an  oiit- 

■  growth  of  that  membrane  itjiolf."t  Oeeasionally  we  find  imperfectly 
iormod  Ixine  in  the  MiliHlanee  of  t)ic  mM«*cj>,  derived  proWhly  from 
a  farther  stage  of  conversion  of  the  cartilage,  or  they  may  he  bony 
tliroughout.  Aeconfing  to  Dr.  R.  Ailams,  thc-ie  foreign  bodies, 
which  may  be  supposed  usually  to  take  their  origin  from  the  sj-no- 
vial  memhnuie,  vn  esjiecially  connectod  with  tlm  condition  <'onMi- 

•  tuting  ehrotae  tltewmaiie  arthritis,  thoogh  it  is  not  denied  that  they 
am  atvn  in  uticulaiiout  which  pn'went  no  tmoe  of  tliiit  diM>iL<e. 
It  is  probable,  however,  that  the  detnched  bodies  found  in  joint? 
may  hit^v  mure  ttuui  one  origin,  for  occasionally  tbey  have  been 
seen  witlioiit  any  evidence  of  organisation,  apponring  rather  as 
fibrinoui<c\u<lation:<,  or  a.«  solidific*!  precipitates  from  Ibe  syno\iii. 
Occasionally,  too,  jiorlions  of  bono  may  fin<l  their  way  into  the  joiut, 
which  havo  ci\Hdent]y  become  ddacliwl  from  the  articular  siirfuf'-*- 
,  We  also  find  occjL^ionMlly  in  jotntii  which  liavc  long  been  aSecttxt 


*  Sec  Arehita  t/eatraUt  de  MeJefiM.  ton),  xu.  ri840},  p.  3fl$. 

t  Sco  nnto  to  Kullikcr's  UoMiial  of  Hanutn  tiiUolofj}.  vol.  i.  p.  838. 

VOL.  lu.  3  k 


DISEASES  OF  THE  JOISTS. 


with  clirouio  rlicumiitic  anlintis  M'[i!irstc  ]iic«w  of  bono  doepcning 
and  49>tMi<Iuig  tiio  urliciilar  fa'cto;.  Dieso  luve  beeu  iemiix)  "  tutdi' 
Utmmlart/ boiu»"  by  Dr.  Adams,  who  look*  upon  thorn  as  duunct 
fonnitttnirs  rc^uUiii^  tVum  tlin  <»«ufi«ation  of  the  stnittturvs  in  the 
imtiiediato  vicinity  of  tho  joint 

A  "  loose  cnrliltip!"  may  oxist  in  tho  join!  for  a  hMiRth  of  time 
wiiliout  producing  sufficient  diBturbanco  to  attract  the  attention  of 
tjio  iiiiti(Mit,  or  to  makv  iiiiii  tliink  that  ho  it«  siibjoct  to  any  tliiiig 
tnore  serious  tluin  occasional  rheumatic  twinges.  At  last,  however, 
in  some  movcincnt  of  tlin  j"Tnt,  tJiif  foroijiii  l>ociy  i4i]»  between  tb> 
artioiiliir  endn  of  tlio  bonei*,  and  then  a  violent  and  suddi^n  pain  la 
cxpci'icnccd,  with  inability  to  um;  tlio  hinb,  wliich  rumains  fixed  m 
tlio  {iiMitiiiii  ^^}li(Ol  it  may  havo  liapjioned  to  a^iune  at  tlio  time 
Tho  pain  continues  until  tlii?  "  cartilagu"  is  dLtkxlgctl  hy  tarns 
meitn.t,  when  thti  inmiedlato  symptoms  at  once  8ubmdi>,  thoa|^ 
they  are  often  followed  by  hiftiunmatioii  of  tlic  synovial  membmie, 
ftoc^omjituiietl  with  clfaiuon.  Tlio  c-harocitcr  and  \-tuli^ico  of  llie 
snifering  in  tlieso  cases  is  peculiar,  being  often  siiliicient  to  mako 
tin;  patJont  tjdl,  or  cvon  t"  oocaiiion  (tyncoi>c.  T1m>  attention  of  Uw 
Surgeon  is  now  called  to  the  part,  and.  on  careful  examination,  1» 
may  ttucoecMl  in  diMCOvcring  a  firm  extranoons  body  in  the  joijrt, 
wlucli  elips  beneath  the  fiiigcr,  to  be  lost  beneath  tho  imtolla  or  tho 
tcndiiiotLt  [-tniclurcn  nbiivi;  or  below  that  \y>\v\  Vi\wn  the  symptom* 
described  havo  onco  wcurred,  they  may  be  rqieated  at  vai^-ii^ 
intcrvnlit ;  in  »i>mo  cane*  roctu^ng  on  th<>  flightntt  ino\'emont,  and 
even  during  sleep,  whilst  in  others  tliey  may  bo  kept  in  ch«<Ji  to  m 
to  give  ri»c  to  but  little  practical  inconvenience,  K  the  attacks  aru 
frequent,  however,  the  joint  suffers  sooner  or  later;  Hw  ligainmt! 
Wcomo  relaxed,  disciisc  extends  to  the  liardvT  tistntcB,  and  tba 
articulation  is  permanently  injured. 

Tho  trcatincut  to  he  adopted  may  be  citlicr  palliative  or  radic^ 
In  the  itrst  place,  however,  an)'  tnnanutiiition  wliieh  niny  )>o  jirvswnl 
must  be  subdued,  and  any  di'opsical  cfliision  got  rid  of  by  blisten 
or  other  approjaiate  remedies.  When  ttii.-t  lia«  been  done,  a  well- 
fitting  elastic  bandage,  or  a  laeed  knee-cap,  sllould  bo  couslainlv 
worn  to  limit  the  movements  of  tlie  joint  and  fix  tlic  loo»o  body,  if 
not  jiennaiiently,  at  least  to  such  an  extent  as  to  prc^'ent  it  finm 
slipping  bt'tweeii  the  bon<TS.  In  many  cii.*ftt  thijt  tn^ni.incnt  is  suf* 
ficient ;  but  tn  some  it  is  unsuoceHsfal,  and  inconvenienoo  ia  still 
exporienceil  t'j  .tudi  an  extent  a»  to  require  furllicr  0|>«>niti\-D  mea- 
sures to  be  hiitl  recourse  to.  Wliwi  such  is  tho  case,  tJic  cxtmneoiH 
substance  may  ho  rumovod  firom  the  cavity  of  the  joint,  cither  by 


3 


LOOSK  CAHTTLAGES. 


739 


I 


direct  or  by  raboutanooiw  iiici.«ion.  Bolli  llii^w  oper»tioti»,  lioiruvcr, 
arc  attended  witli  a  ccnain  ^inioiutt  of  risk,  and  fJiould  only  bo  [n-]'- 
fiirmcd  wlii^ii  llio  ])iLllijiti\i>  Irnitim-iit  Iiim  Iki-ii  ftilly  lv'w\  nmi/aiitdf 
and  tho  f<»reign  body  contuiuea  to  give  rise  to  afltive  miHcIiiof.  Tho 
ig»  Ijody,  too,  slioiild  !k'  cli.'iirly  niovKl)]i>,  and  capiiblu  of  being 
:ht  to  a  part  of  the  joint  in  which  it  la  easily  jw*«'>»it>l«.  Tins 
itiout  ithoidd  be  prcjiiLrvd  tor  tlio  ojwratioii,  botji  by  appro{m3ta 
diet  and  rogimen,  and  also  by  tho  limb  bping  ki>pt  ]Kiri'wliy  at  re<t 
for  a  it^vt  (liiy«.  Tlic  lousy  fsirtilafto  i«  tht'ii  guldod,  if  possible,  to 
the  outer  and  lower  part  of  the  joint,  where  it  is  most  snfHirticiul. 
TiiP  nest  jwint  i«  to  fix  the  body  securely,  so  that  it  may  not  «lip  out 
of  the  way  dnrinjj  tho  ojieration ;  if  tliis  cannot  bo  done  efTct-tually 
hy  tho  finger,  tlio  cartilage  mny  ho  tranaflxud  hy  a  noodle,  and  m 
Boenred.  If  tlto  dinvt  ojioration  is  tho  ono  adopted,  the  parta  over 
the  foreign  body  itro  now  divided,  :u)d  a  sufficient  ojKMung  mode  in 
tho  s\-novial  inembrano  to  allow  lijo  cartilage  to  Iw  prce^  out,  of 
tho  wound,  without  any  unnocoissary  mauipuLation  or  disturbance 
of  the  johit.  Tlic  odgM  are  llien  accurately  brought  togetlicr  by 
Rtrijffi  of  plaster,  and  tho  limb  kept  at  pcrfitct  rest  on  a  splint; 
<!onMant  cold  may  al*o  bo  a]kplied  to  tJie  joints  to  i>rcvonl,  if  (kw- 
lliblc,  the  ueetirrvneo  of  tiiflammatory  s^-mptoms.  Li  the  subctiia- 
fHUtM  ojieration,  liio  cartilage  Iiaviiig  booii  •ocurely  fix«d  iwlwtorc, 
tolerably  long  tonotoray-knifo  jh  introduced  through  tlie  akin,  at 
few  linos'  distance,  an<l  pnsseil  through  the  wUulsir  tiiwie  w 
to  make  a  subcutanoous  incision  into  tho  joint.  Great  earo  murt 
telcen  ill  diviiling  tlio  synovial  motnbrano,  tliat  the  foreign  bin\y 
not  slip  aside,  for  which  purpose  it  i»  better  for  tlio  operator  to 
it  hirnwlf  witJi  oni?  hand,  wlillflt  bo  makes  the  incision  with 
other.  Tho  loose  cartilago  is  tlien  prc-ised  tlu-ough  tho  wound 
in  tlie  K^-1lovial  capsule  into  tbo  twbcutaucou*  wUular  tissue,  and 
nllowed  to  remain  there,  at  any  rate  for  some  days,  at  tho  end  of 

tTrliicli  time  it  may,  if  eonitidenxl  necessary,  bo  removed  altogether. 
Sir  Benjamin  Bi-odio  states  in  hi*  Avork  on  tJio  joints,  that  his 
cspcricnco  does  not  enable  him  to  determine  wliieh  of  tliew*  oi»eru- 
tions  is  to  Ih*  preliTi-cd.  According  to  M.  Ijarrey,  who  refers  to 
107  pnblishctl  eaM-^  of  removal  of  loose  cartilages  by  optTati^ni, 
out  of  121  cases  in  which  the  old  or  dinvt  metlioil  was  employed, 

■  98  wore  sneee»»lul,  5  doubtful,  and  28  died ;  whilst  of  39  indirect 
O]>omtion»,  19  were  suce6«siul,  15  faik^d,  and  5  died.     From  this 
it  would   appear,  as  M.  Lan-ey  states,   that  extraction  by  either 
■     jnotiiod  it  HH4.^nde(l  with  decided  <laiigcr ;   but   that  in  tho  dirtri 
^kopcmiion,  tho  risk  to   life  is  greater   tlian   in  ilio  ntbmtaHfoite ; 


t 


740 


DTSEASER  OF  THE  JOINTS. 


while,  on  the  other  hiiii<I,  in  Lh«  Kal)cut«n«citui  operadcm  tlicrv  U 
i»cn.imMl  (tifliciiltVi  s'kI  <-'oiisor|uciit]_v  l<"-*t  fliftiicc  n(  unoaeit^.  On 
aocoont  «f  tlic  tlifficuUj'  wliic-ii  i*  f^xp^rienced  in  getting  the  parri- 
lagp  out  of  tlio  joint  into  the  ocllulor  dsHiio  witliont  sn  nn<l<wnihlo 
amount  of  uiJini]ni]Hli<in,  Mr.  Hyino  ivoominendB  another  motbod.  In 
whicli,  hfi  eays,  lie  generally  siict-cctls  without  risk.  Thin  wMiMJli 
in  '*  nuking  a  free  MulxnitaiiiKitui  incision  through  the  synovial 
mombrane  and  cartilage,  and  applying  a  hlistwr  over  ti«>  jmrt  whi-rc 
it  is  retained." 


DlBilASEg  OF  TIIB  AllTICCLAB  EXTRKMITIBS  OF  THK  BoNES. 

Tli«  ditM-iwes  of  the  joints  which  originate  in  the  articnlitr  i«tre- 
miticH  of  tlie  boniw  ajv  npxt  in  iin|i<irtJinw  mid  in  frctiiMmcy  to  tbcff 
whidi  eonitn«n<'o  in  i)h>  ^niovial  inombnine.  It  will  not  l>c  m-w*. 
aaiy,  however,  to  enter  mnch  into  dotnil  in  trt>uting  of  thorn  here^j 
tiio  morbid  prowtaes  hai-e  bo«i  aJready  described  in  tin-  csKty ' 
DiSKK&lOi  OF  TDK  BoNEs.  A  briof  notloL'  of  thc««  atTectioni 
their  relation  to  tho  jointa  will  therefore  be  eiifficienl. 

Simple  inflamijiotian  of  the  articular  enih  of  the  kon^,  and  i 
emufqMfncf*.  Tho  articrular  extreraities  of  bones  arc  liublo  to  atticlcfi 
of  aimple  inflammation,  which  may  result  fran  injnry,  or  tlqwnd 
on  other  ciin.-iiis.  It  may  hnp[K>n  in  tlin  long  Iwnos  t)i»t  the  diwoM 
has  sin-eatl  from  tho  ^aSi,  thougli  sucli  extension  is  by  no  mcaiu 
common,  for  inlbunniiition  of  l)on»  usiinlly  confines  itself  to  tba 
diaphysis,  or  to  tlie  extremities  in  wliieh  it  may  have  onmmi^onl 
The  ebanjpw  wliit-b  laki'  placi-  rtviembb'  \h<m!  wbieli  result  from 
!nfl»nitnation  of  other  tissues,  when  allowance  is  made  for  pfavsical 
dilForenecjt  of  M.nn-liirv'.  In  ravourulilii  casojii  restoration  to  a  hetdtliT 
coni^tion  o<'CurB,  or  the  inflaninmtoiy  prodnets  may  givo  ri»  ta 
deposition  of  iiifn^iL*«il  ossitic  inattirial,  kuuling  t<i  hardening  and 
inercHsed  weight  or  liizo  of  tlio  jiart  In  lese  favoumblo  CM» 
eujipuntt.ioTi  takes  jilni^o,  wliicli  may  Ijc  eirciinimrribcd,  forming  s 
/txw/  atitntm  in  tlie  articular  extremity,  or  diHiised  in  tJ»p  caneellouit 
tissue,  a»  in  oifeomt/dittf.  Local  abtcft*  of  lione  !«  nsually  found 
in  tlio  head  of  the  tibia,  and,  as  a  general  rale,  is  rocMignised  and 
romodiod  before  ibe  articulation  in  uffwtod.  If  not,  the  ayitm-iil 
mombrane  becomes  inflamed  from  lime  to  time ;  and  if  the  origiiuJ 
mischief  ik  xtill  allowed  to  rvmain,  tho  matter  may  at  last  mak«  its 
way  into  tlie  joint,  giving  rise  lo  Auppumrion  in  that  cavity.  F<W 
a  (letaiK^I  <Icscrj])tioii  of  tlic  symptoms  and  treatment  of  toral  atitctt* 
in  the  cancellous  Itftuff  i\n  well  an  of  osfftmiyeiilis  (which  may  in 


STRmiOUS  DISEASE. 


74t 


^ho 


like  umniittr  lead  Ion  liiwhiu-f^  ufpiis  iiito  tho  ncarciit  joinUraviLy), 
till-  rt-a<i(?r  is  referred  to  the  oettay  above  nicnltdtiotl. 

TfiL'  iiitliiintnf)t.ioii  nmy  load  Ui  tlio  death  of  the  whole  or  r  )uurt 
of  tilt)  artjcrular  cxtremi^,  coimtitutiiig  necrtMu.  It'  lIu>  (load  por- 
tion i»  lituitod  in  ito  vxk'nt  and  Mtnattxl  near  tiic  nirfu^-o,  the  arti* 
vitiation  iiiav  osr:a))«  witli  tillJo  or  no  diuiiu^>,  und  tln!  M.H|n»trum 
si'paratv,  or  hv  removed  Ity  o|>fration.  Somedme§  tlio  ue<;rwiU  is 
di^tp-Mutlfid,  prenonting  then  many  jxitnt^  of  refti^nblitiKv  witli  local 
aWesa  of  bono,  like  wlu'ch  it  may  lentl  to  destructive  inflammation 
of  tlie  Joint.  Tlit^ro  would  be  the  namo  diwp-HMttHl  guiin,  aceom- 
panie<I,  [wrhaps,  witli  ris^Tt  and  low  fever,  and  not  yielding  to  the 
ordinary'  miwinvs  of  relief  for  simple  inllammnliou.  lii  noinv  of 
these  canen  the  true  state  of  thiii]2«  is  otdy  recognised  when  death  or 
a  III  pi  ita  lit)  II  nllowN  die  parLt  to  tie  dLi«e(;U>(I ;  in  otliont,  liowcver,  u 
aimilar  oijeration  to  that  n-quired  for  local  absc«fH  can  bo  performed, 
tho  dead  bone  i.-"  ri-nio\wl,  tin-  jwnt-up  iiihHit  evaeimted,  aiid  ibu 
joint  ia  saved.  Sometimes  the  whole  or  iho  greater  part  of  tlie 
boad  of  tho  l)one  diwt,  giving  ri*>,  <if  c^ounu;,  to  rapid  iltrstruetion  of 
the  joint.     Except  in  some  of  tlie  dcep-ticatwl  articulations,  such  as 

liip,  the  intrixliirtion  of  a  probe  at  once  detvols  tlir  j>iim;iu.'(!  of 
bane  and  its  extent.  Aa  no  hoju  can  exi^  of  sa\-ing  tlie 
joint  ill  siKjh  c-iLHes,  it;*  renlo^■ld,  when  jiriieliad^le,  liccotnra  tJio 
(Hily  course  to  bo  pumied.  Iii  necrosis  afii3cting  the  very  small 
joints,  such  as  tlioMi  of  the  fingers  and  toof,  tlie  amount  of  eoiisti- 
tulioiial  disturbance  involved  is  so  slight  tliat  wo  may  wait,  if  we 
think  it  ox])etlioiit,  lor  the  natural  )»o])aration  of  tlio  juirtM.  In  t}|is 
a  HtiflieJently  useful  thtunb  or  great-too  inay  be  preserved,  the 
fieial  position  of  tlio  urtieulation  facilitating  tlic  n^noval  of  the 
bone. 

Finally,  insteail  of  deatli  ooeurring  in  obvious  masses,  tho  in- 

niation  inny  lead  to  a  mokctdar  destruction  and  removal  of  the 
tissue,  by  a  process  uudogotis  to  ulcc^rallon,  which  is  termed 
cariff,  Uiiries  of  bono  in  tho  vicini^-  v(  joints  may  arise  from 
tumple  iiiilnmmation ;  it  occurs,  however,  so  iniieli  more  eouuiioilly 
as  till!  result.  i>f  M-j'otulous  inflammation,  tliat  it  is  eonvetiient,  prao- 
tically,  to  defer  it»  consideration,  or  to  mcrgu  it  in  tlio  dciferiptiou  of 

Intt4>r  form  of  disoa.ic,  to  wliidi  we  now  proocod. 


^ 


neaa 
Bthej 


Scroftttotu  iitfiamtnatiim  of  tkt  artkular  rmU  ^  the  fionet.  Tbo 
Mmluloua  affection  of  bones  which  tends  to  implicate  tlio  joints 
consists  for  tlie  most  jtart  of  a  low  form  of  in  flam  iiia  lion  of  tlio 
ocwjous  substance,  differing  from  ordinary  inflammation  in  tho  na- 


rSEASES  OF  THE  JOIKTS. 


tnro  of  Uio  ezudatian  vrliieli   U  found  in  tho  bone-cnvities ;  foi 
tu1<i-roulo«s,  a<?ooRling  to  Dr.  Blatrk,  owasiong  an  incrcaso  in  tlia 
futtv  r<in>littiv»tH  mill  in  ttie  miUiIiIv  siiIIh,  irJtli  :i  ilitiiii>iitioii  in  lina 
limo-BoIbi  imd  in  the  organio  mntrix.     Souieiinie!<,  indeed,  there 
achial  <I<.-]]Ocdt  of  cdruiiniKcrilH'd  ttibcrclv  in  llio  iirtit-iilnr  cxtrumilitH 
of  die  bones  (eapcoialiy  in  the  tibia),  which  mar  uhiiimti^ly  bmk 
clown  and  find  ite  wny  into  tlic  nufjhboiiHng  artictdalion  ;  or  tfa» 
tQl>c)VidoiL<>  depo»*t  mnj  bo  dilftiMHl,  in  wliieh  mse  tlie  joints  nn*  nnt' 
m  tiabk  t<>  be  implicated.     Botli  the.w  forma  of  depoait  aro  not  im- 
])roI«diIy  thansclves  tlio  conwiimncvs,  or  the  result,  of  low  inflam- 
matorj'  aetiou.     Tho  patJlologic-d  Dlinnges  inrolvod  in  Uiib  aetion,  *a 
far  as  tlir  tH>no  in  c^inKreniHl,  am  ili-strWivi]  in  the  c^ay  on  Difkahb* 
or  TUB  Bosks  ;  tliey  nocd  not  be  rfKipitulatcd  \ktv.    Suffice  it  lo  mv, 
tliat  wo  find  tlie  nfHx.-twl  l«)no  more  vuAcubtr  than  nnlund  (at  ip»ft  itt 
first),  then  light  and  oily,  as  well  as  unusually  soft,  ho  as  to  aduu't  of 
being  cut  n-itli  a  knile,  the  <.-siwelli  lifting  ilihiti.'d  and  fjlltxt  nith  i 
jdly-like  nubstaiice.     Tliis  fomi  of  inflammation  is  niueh  disposed 
to  lead  to  earicM.     Caric!»,  when  iilfit-lin^'  the  ailicular  oxttYwiliis 
of  tlie  long  bones  or  iJio  euboi<l  boues,  sm-h  as  lliu»e  of  tJie  t«rsD* 
and  earj)us,  comnioncos  fivqucntly  in  si'jwrHlit  jtoiiit.s  of  the  ean- 
oellous  tissue,  whicli  gradually  extend,  and  bo  apjauaeh  the  iuir&o& 
At  last  tho  periosteum  it»eli'  i«  rcncht^^l,  ^uul  impHeatcd ;  it  bccamcs 
detached  from  tlio  osseous  auhstaneo  bemaili,  which  Ls  left  nag\t 
and  worm-eaten  on  tho  siu^aec,  bleeding  frciely,  and  giv-jiig  tail 
to  n  foul  di.->cliHrge,  in  u  Inch  are  coiitaine<l  partielcs  of  disintegrated 
bone.     Tbe  soft  port^  around  sliare  in  tho  diseiiHiil  action.     Senun 
and  hniiph  luv  etiiised  into  the  neighboiu-ing  areolar  tisinui,  giving 
rise  to  a  eliaracteristic  firm  and  elastic  swelliiip ;  at  a  later  period 
Kuppunttion  occui-s,  and  tho  tiiwueii  are  travei-sed  by  sinuiW)^ 

When  the  disease  is  situated  snflicicntly  near  a  joint,  tlie  arti- 
cular cartilages  in  the  iinniediato  \'ieinity  of  the  infliunod  bOB* 
become  affected ;  their  nntriont  Bup])ly,  as  far  as  tho  osteod  veaa^B 
aro  ooneomwl,  i;*  intorfored  witJi;  tlw-ir  adhesion  to  tlio  bono  i* 
inljlair<^(l,  and  tliey  become  fibrous  and  ulceratu,  the  chaiigv  eom- 
meudng  usually  on  tlieir  dtwiier  or  attached  surfeee ;  or  jmrtiotu  of 
them  may  become  dct-idied,  and  ultimately  be  found  loosi^  witlim 
tlio  joint  Tlic  MTio^'ial  mombnine  jiartJeipEttt-s  in  the  iiiflauimatian, 
whicli  may  either  spread  to  it  from  the  diseasml  rartilagea,  or  may 
affeirt  it  more  lUrcctly  by  cxtcuMon  from  the  jteriosieum  to  tliat  )tart 
of  the  synovial  eajir-ule  which  was  described  (p.  704)  as  in\'<»ting 
the  bono  to  u  ciiiain  extiiit  before  it  Ixrjiitie  iiiiitisi  witli  the  card- 
lago  and  ])crichoudrium.     It  may  bo  remarked  that  tlio  affection  (f 


6TBUM0US  DISEASE. 


743 


I 


le  articular  ends  of  die  bones  sometimes  nssinniMt  a  peculiar  f'omi, 
liicb  liiis  ixtxtivi'd  the  iiitniu  of '' fpotteil  ulceration,"  but  wliii-ti  l§ 
probably  a  variety  of  the  tttrtunoufl  clUeose.  AMit-n  tliis  ift  tliK  tww, 
MT^'vnd  j>iU  or  lii-pro'wiijii'',  contsiuiiig  a  ciuxly  tnatti^r,  are  found  in 
dio  anitnilai:'  hurtkt^'a,  tlie  cartHu^'ii  prf^ntiting  u  »Kr'w»  of  defined 
orificM,  t.'om»|>ondin^  to  thu  pits  in  tbo  bono,  tlicir  intervening 
fitrui'lui'e  n-maiiiinjj  frei]iieutly  unaltori-d.  Tli«  diMonKK)  nctiuii, 
wbicli  bas  Ix-L-n  sujipoHL-d  hitlu'rtu  to  be  contined  to  one  side  of  tbe 
joint,  now  benoineH  diltusocl;  tho  inflaintxl  nynovial  iiit-nibnuii]  ff)V* 
tluroiigh  tho  suricH  of  cbanjf^vi  w-Iuch  havo  already  been  described 
undiir  ilio  bead  of  ^ynovitia ;  the  nrticulur  c-ju'tiliigi^i  on  tlio  oi>|to- 
sito  sidu  of  tho  joint  bueome  alTectod,  Uicy  speedily  ulcerate,  and 
oimet^IIoui*  .*lnK'turt>  of  tin;  lione  on  wliii-h  tlii>v  nitt  U  i>xj)o»i>c!. 
diiietuo  gives  rise  to  tins  foruiution  of  matter  within  tlie  joint ; 
n|l)XuutJon,  it  bus  dlready  bcnii  t«t«t«d,  takes  jiliioo  lilunriae  in 
contiguous  8oft  parts.  As  tlic  ease  progresses,  tlio  matter  makes 
tin  wity  to  tlio  Niirfacf,  it  niuy  1h<  dintc-tly,  in  Ihu  iinin^diatt:  neigh- 
bourhood of  tlie  joint,  or  forming  tortuous  sinuses,  wbiob  open  at 
n  <s>ii.ii(kTabli'  dislimw,  and  give  I'xit  to  «  ]>rofn!u,'  di.*chttr||pr.  Wlifiii 
the  long  bonen  ai-e  aflecied,  partiiU  or  incomplete  tiixatjons  are  apt 
tw  lakt^  jiliicti  during  tlut  latvr  Klagc^  of  tlic  inidady.  llic  di.'Ruuk; 
ly  continue  to  progress  till  life  ceases  or  the  joint  is  removed  ;  but 
ivtiniv\4,  after  di.-dooatioii  biw  (Mn'iirred,  a  rcpanitive  process  takes 
ilaoe,  healthy  granulations  arise  in  the  bono,  tlte  synovial  mi-ra- 
ic  goes  thniiigli  tJio  changes  tending  to  n-eovery,  which  have 
already  been  described,  the  diseharge  iliiuijiiHlit-s  and  ceases,  anky- 
lovos  t»kvs  ])laiv,  and  llio  [tationt  is  left  wttJi  a  Umh  tho  utility  of 
hieJ]  varit>i)  nnich  in  different  on«CA. 
ScrofidouB  disoaso  of  thu  joints,  commencing  in  tli«  bone*,  if  not 
•o  common  ii«  synovitis,  is  fn.H|uonlly  met  with  in  children  of  stru- 
mous habit^  e»]xteia]ly  in  tbosowbo  have  nc\-er  thoroughly  reeiwcrcd 
from  tlie  depriMsitig  etfecta  of  ttonio  of  tlie  ailments  to  which  die)' 
are  subject.  At  tlic  Ho»j)ital  for  Sick  Cliildren  I  was  aUc,  in  n 
large  pi»i>nrtion  of  cJL'tes,  to  tnuM  llie  ntliu-k  to  the  weakened  state 
of  bcaltb  wliich  Imd  remained  after  scarlatina  or  measles.  In  curly 
lifu  tliij  dise^Hi'  may  nff'i'ct  iiidifrcreiiily  the  extr»-mitii-s  of  the  lotig 
bone»  or  the  cuboidal  bones ;  but  wbou  it  coiumcnccs  after  [lubcrty, 
wliieli  is  sometime  the  ease,  it  shows  a  decided  prufiawnco  fiar  the 
carpal  or  tarsal  bones.  Tlie  diseafio  is  verj-  insidioua  in  its  owlior 
stages,  oeeu»ioniiig  little  ]iain  or  inc>on\-euicncis  in  ehiidren,  (he 
thing  which  attracts  the  attention  of  tlie  parent  in  most  cases 
"  limping"  when  tho  joints  nffocted  uo  situated    in  tlte  lower 


DISEASES  OF  THE  JOIKTS. 


Wl 


cxtreinitj-,  or  unwillingness  to  nse  the  arm  wlicn  the  upper  Itmb  it 
iin[iIii.'Mt«(l.  It  iH  non'  notictx)  too,  {icrhajiA,  that  tlw  ehiM  M?ln:U 
that  position  whiwh  vfill  throw  least  atrcw  upon  Homo  partiftJar 
ji>iiit,  or  that  ho  fliiiolii.-t(  when  timt  joint  tit  movtoi  or  prL'«»c<l  u|xin; 
and  that  tlio  niglitA  ore  .lomevi-hat  restless.  At  this  time  little  or  no 
swelling  cnii  bo  dotoetnl ;  or  if  iiny  cxi>it->,  it.  i»  not  difl'usotl  over  ll)n 
whole  joint,  iM  iti  njiiovitis,  hut  situated  over  one  of  tl»e  boas 
which  enttjrs  into  its  compoKition.  A»  tJiu  diM'euu  udvancvs,  tiie 
joint  it««lf  iictionic^  mom  decidedly  implicated;  the  swelliiig  inoeosa, 
and  now  takes  more  the  flhapc  of  tlio  tiynotiid  memlinuiu,  thoti|;li 
not  so  d«^«i(l<Klly  nx  in  lho»c  vaaen  where  s^-novitis  oonstituted  the 
primaiy  <lisease ;  there  is  iisunlly  cfiusion  of  iicniin  and  lymph  into 
tlte  areolar  tissue  o^er  the  id^'iKtod  lx>ne,  diHtending  Uh;  xkin,  and 
|iroducing  a  "  white  swelling."  ITie  joint  is  obviously  etiffetwd, 
sovero  and  ]Hiinful  sturtinpt  of  the  limb  cJiow  themselves,  agj^valed 
at  ni{rlit-ti»ie,  ."uid  causing  ilie  nhild  to  cry  out  tn  his  sloep,  or  to 
wako  «j>  with  a  shriek  of  jwun,  Wlieii  tiiirt  occurs,  it  nhows  tbsil  tl» 
ulicTttor  Biirfai-e  of  the  hone  is  affected,  and  beginning  to  be  laid  ham 
to  tile  joint;  the  'startin;;'  heeinne.H  s>|i«Tiii]Iy  nuu'kcd,  too,  wbai 
inflammation  has  extended  to  tJio  opposite  bono,  and  when,  coast- 
<\acn{]y,  the  two  inflamed  luid  wnftitive  owcoiw  MU-fom.-^  arc  subjedsl 
to  mutual  preMure  by  spnsmoili<'  tontraction  of  the  rauauloa^  Hiis 
uinsiL-ulnr  ^jiastn  is  originally  indtiei^Ht  by  tliv  OKt«<al  discofio ;  e\*aitu- 
ally,  however,  it  reacts  upon  that  disease,  which  it  aggjenvaia  \f/ 
the  foreed  and  violent  a|ipositJon  in  whieh  it  muintainx  thu  inflanMd 
!«urfaw!t  Honcre  the  great  relief  to  suflering  so  (^en  <'X]H-nenoed 
when  displacement  of  tho  Iwncs  iakc»  place,  under  tho  inflnom 
oftlie  inorbiil  innwntiir  contraction,  after  the  ligament«  niwi  «0k» 
retaining  structures  have  bcconio  wesikenod.  When  this  occoiv, 
the  mtit  uid  pn.^wunn  of  tlio  inflamed  bone-stirfn4^e~s  ceases,  aJid  fiuM 
this  period  a  curative  process  is  often  dated.  Beforu  this  bappeoa, 
Lowever,  mutter  hiL-«  in  nil  jiifiliubilily  fiinnt^  iji  or  around  tin 
joint,  and  smnses  are  produced,  taking  various  directions  in  accord* 
ance  with  the  )iiiHtoiuie4d  iiriiuigomcnt  of  tho  pan.  If  a  probe  i> 
introduced,  carious  bone  ran  sometimes  be  felt,  but  not  always,  ik 
conxequeiico  of  the  irre^lAr  coume  whit-h  the  sintocA  often  take. 
The  integuments  around  tlie  wounds  arc  thin  and  disc<oh>iin.^l,  iW 
dUchurge  copious,  water}-,  aixl  iinlu^th^'.  The  general  health  by 
this  time  usually  shows  strong  signs  of  breaking  up,  t}»e  duU 
becomes  cmucint»>d,  Iiectio  nmnifiist*  it«oIf,  jn-oCu.-w  ni>;ht-sweau 
occur,  and,  unless  relief  is  afforded,  some  vital  organ  bciKiinc»  im- 
plicati^l,  leading  to  tho  dcatli  of  tlio  patient 


STRUMOUS  DISEASE. 


745 


I 


Prognotii.  Tho  proHjwct  ofa  jtiiwxawfiil  issue  to  tho  case  dcpcnrU 
KFCatly  on  Uic  tmalmi'iit  lx?iiig  (wmm^nocd  at  a  very  oarlv  i>oriod, 
before  tlie  joint  lia-s  Ixx-uiiii;  soriously  iiajJioatod.  It  is  most  dwir- 
ablvj  tlicrcforo,  whenever  a  tendency  to  Rtmma  exints,  that  any 
exJ^n^s^kl(l  uf  [win  nr  ti^ii(k'rii<\'>it  about  n  joint,  or  any  licxitntion 
in  iJie  niaiintr  in  which  it  in  use*!,  should  hct  at  oni-o  iilt<-ii(h^l  to, 
and  a  cuniliil  oxitininulion  mudu  by  it  (.-onifM-tent  Surgeon.  In  tiio 
wcaltliier  daasea  this  is  lumuUy  done,  aiid  die  iintgn-ss  of  tho  oaao 
at  tliijf  jienod  can  idmo.-'t  iiiviiriably  bo  iimwt<*d,  and  a  tolerably 
perfect  enre  iiiiiured.  Even  w]ieu  the  diHcaac  Iina  arrived  at  n  more 
ndvaiic^^l  !»(jigo,  wln-ii  rJu!  joint  hjw  Ixvotnc  iinpiicatcHl,  mid  jiiiji- 
puration  has  taJceii  pla**,  care  and  perseverajn-o  on  ibo  part  of 
Surg4Kin  and  {lativnt  will  u^iially  b«  rewarded  ultiinatt-Jy  by  i*u(ww«* ; 
ibr  theee  eases  occur  for  tlio  most  iiart  in  early  life,  and  *'  in 
children  tlio  piiftit-  jiowen*  of  imtiiru  aro  w>  gruat  that  rocovory 
may  take  plaee,  when  in  tJie  adult  any  suoh  hope  cau  scarcely 
exist,""  TIk'su  olwcrva lions,  however,  a]>pty  principally  to  the 
wealthier  classes ;  for  amongst  the  jjoor,  who  are  oCru^Iing  for 
tlioir  daily  bn.iid,  eiiriy  Hyinjitoins  arc  p^ierally  tuinotic^-d,  and  tiie 
disease  has  advanced  to  a  great  extent  before  surgical  iii<i  is  invoked. 
Even  if  luhnitiod  into  hospital,  tiiv  [Mtivnt  t^an  iN.ddom  be  kept  (hum 
long  enough  for  complete  recover}' ;  moreover,  tlie  general  bealtli  is 
i^it  tosutliii',  uAor  a  time,  from  the  ncceiwirily  impure  air  of  a  »ivk- 
ward,  and  so  tlio  patient  retiims  home,  to  be  again  oxjto^ed  to  ilio 
imjRTi'ect  nnlritioii,  the  coiifiiK-d  air,  and  tho  want  of  ncecssarj'  com- 
forts and  appliances,  which  originally  predis|HiMHl  to  tlie  disease  or 
acocleruted  iin  progrcN!;.  Sooner  or  later,  in  all  probability,  ho  again 
npplii^s  lo  tlio  same  or  some  other  litMpital,  in  a  still  more  advanced 
of  tile  malady,  irom  which  ho  nltimately  Hinkw,  or  has  to 
it  to  o])eration.  If  tiie  jirogiKmis,  iJiercfore,  in  the  affluent 
clfl«S(M  in  fiivotirnble,  it  is  far  lees  so  among  tlie  ]x)or  an<t  HOO(]y, 
Whei'e  eireiunstanccLi«  aiv.  Civourable,  nitd  tlie  treatment  eouunenceii 
at  an  early  jicriod,  a  few  weeks  may  suffice  for  recmery  with  a 
useful  luiil  movable  limb;  even  wlii-n  jHirtioiiit  nf  tlio  cartilage  havo 
been  destroyed,  the  liinctjons  of  the  joint  may  still  bo  pn»er^'ed, 
tiKiiigh  tlio  time  re<piirv<l  iKwmcs  oon-Mdcrahly  prolonged.  When 
the  disease  Iuls  advanced  to  snp]>uratioit,  and  suiiiscs  liave  formed 
commmiicatliig  witli  tlio  joint,  nvovvry  cJin  only  be  cx{Hx;tod  at 
the  expense  of  ankylosis,  and  after  the  la|ffo  of  many  moutlui  or 
even  Honio  yenr^ 


t/tttarfsm  (A«  >Sui^«ry  </C1UUhMH(,  by  Athol  Johnson. 


DISEASES  OP  THE  JOINTS. 


'5| 


7'reat.menl.  If  mfUunnixtioii  is  present,  we  hare  always  to  bear 
in  mind  tluit  it  is  of  a  lew  clmructtT,  ami  controlled  or  motiifiMl  b}' 
tliv  cunAtiliiiionul  iMiiilition :  it  U  to  the  relief,  therefon*,  of  ibe 
constitutional  i^oiiilitiuii  tlmt  oiir  tn-4itii)unt  ]\a^  to  be  maiiily  dircctiiL 
In  tliv  vKMir  <•>!  SuRoKtri-v,  mid  in  tho  section  devoted  to  Krof'i\ 
^noeUisy  tho  leading  (irinciplcs  of  tho  jL^'iiond  trt'ittmont  liaro 
deatcribiHl.  In  Uiis  afl«ction  of  tlie  bonos,  ns  iu  tlio  corroitponilinp 
disease  of  tlio  synuvifd  momhraiie,  vr<;  fiml  two  modifications  of  tbf 
8yt4£Rii<;  condition,  ivprosonting  ro^iccUvely  tuherculotia  mid  tcnf— 
Ums.  If  mcrcuriuls  aro  over  admi.sKiblo  in  th{-««  ca)>cH  (and  except 
for  Uic  ]mr[HiKi>  of  uiihiiidin^  die  liver  occasionally,  I  doubt  wliutlxr 
ibey  ever  circ),  it  is  in  iliv  form  of  gcrvfulosis,  with  its  singgilll 
teiidwicio!",  tlml.  till')'  may  ^»  givwi,  and  tlien  only  with  tliv  ^■aUM 
caution.  The  bowels  are  of  course  to  be  earcftdly  regulated,  and 
llic  staU;  of  (ho  fte<rrelifiiis  ntteii<le(l  to.  When  this  has  been  done, 
tonici,  especially  tlio  prepamtions  of  u-on,  form  our  8bect-an<'hor. 
In  tcro/ulosU,  tho  citnito  of  iron  may  bo  ailininUtcred,  iu  oombina- 
tion  with  alkalUg,  to  asHst  the  torpid  condition  of  tlio  liver  and  oiber 
wcretiiifj  jitiimlft.  la  tuberculoiu,  an  ai-iif  pn^piir-ition  of  steel,  such 
as  the  tincture  of  tho  sesqoJchloride,  is  often  of  more  aerviw,  by 
con-ecling  tlio  tendoncy  to  j>rufut<o  witfirotion.  In  neutral  cases,  or 
where  »  stimtdaiit  as  well  as  a  tonit;  is  required,  tlie  vinmn  fetri  i» 
a  UM;ftil  prcpaiittion.  I  t-niploycKl  occaMoiinlly,  at  tlio  Hospital  for 
Sick  Childi-oii,  a  sjTup  of  the  euper-phosphato  of  iron  with  lime, 
tuidouhtodly  with  lulvuntaf^-,  though  whether  the  bene6t  derived 
was  greater  tlian  that  which  would  have  been  proiluc-eil  by  otlxr 
prepnrutioiis  of  steel,  I  am  not  prcjinred  to  siiy.  Whero  there  is  los 
of  flesh  and  o\'ident  defect  of  imtrition,  cod-hver  oil  i.*  nioH  vahiablc^ 
slono  or  in  eonibiiiatiuu  n-itli  other  tonics.  If  iodine  is  given  (snd) 
without  going  so  far  as  Mr.  S^'me,  who  asi<erta  that  "iodine  anit 
mercury  are  preposterous  in  siieh  eajie*,"  I  think  that,  with  ibo 
exception  of  a  few  cases  of  »erofulo»'wy  it  in  innitinL-stibIc),  tlto  ^tuji 
of  tlio  iodido  of  iron  is  probably  tlio  most  advantageotis  forin  in 
which  it  can  bo  athntiuxtei-cd.  WImtovcr  form  of  tonic  may  be  se- 
lected, it  must  bo  given  for  a  great  length  of  time  to  be  of  N.T>-icA. 
As  Sir  Benjamin  lirodie  direct!*,  tliu  steel  may  ho  udminisjered 
for  three  or  fom-  weeks  at  a  time,  and  then  suspended  for  a  wcvk  cff 
ten  dnya;  oi-  numu  other  toinc  Kubstitutod  in  itn  place,  if  tlie  ficst 
should  have  ceased  to  agree.  Even  after  recovery  has  taken  [Jaeo, 
as  the  fi»n»i|itution  i»  in  iaidt,  it  is  ncccisaiy  to  jienievera  witli  tb* 
general  hygienic  ndes  prescribed  in  these  cases,  if  we  wii>b  to  prfr- 
vent  a  recurrence  of  thu  di«ea»c  in  the  same  or  some  other  |iarL 


I 


STBUMOUS  DISEASE. 


747 


TIio  local  trfofrntnt  i»  to  a  great  rxtont  iicKJith'4\  Tbo  iliscouc  in 
OFio  of  defective  power ;  local  (!c|iletioii,  therefore,  ohoold  bo  ANuiiinl, 
tlioQ^h  occaMoiiiilly  a.  very  frw  Icoclitii  may  bo  employed  to  rolicvo 
nij'rilly  niiy  outburst  of  lumia  ur  mib-acuto  iiitlanimation.  Cold  or 
irarm  applicatiuDM  can  Iw  u»cd  ut  Iheso  time«,  whjcboroi'  may  bo 
most  nj^nt-iibto  and  timtliii)^  to  thi)  [iitkii'ut.  Countcr-irritaiitK,  wlie- 
tiler  ill  tho  fomi  of  blisters,  isMUcs,  or  tlio  actual  cauterj',  iui!e*B 
ill  oxcfptiiinal  i-asow,  iiro  iima)  likoly  Ui  ilo  Iitirm  than  good,  by 
exhausting  the  patient.  They  are  also  objectionablo  for  another 
m:  these  caMM  UHunlly  ixx'ur  in  <-bil(ln->i,  a»<\  n'|>oiiU'd  iiaiiiful 
icadons,  with  tho  frequent  dres^ingn  subsequently  rcqulnxl,  ui- 
AvwM  fit*  of  [mMioii  or  of  »pi)n'lwnKi<m,  wbit-b  are  lowts-iHg  to  tho 
imtioRt  and  injurious  to  the  roalatiy.  In  fa^t,  iu  tho  treatment  of 
i-liildrfii,  it  is  of  great  moment  fur  tbe  Surgeon  to  tw^uire  their 
conftdeQce,  to  inajtire  thorn  vriih  a  feeling  ofr^iaixl  and  affeetion; 
and  tliii*  ean  never  be  done  if  bin  vi«t  becomes  (Vi'ijuwilly  a»»oc-iated 
in  iljeir  mind  with  [win  ami  suffering.  It  may  of  course  Iw  necoe- 
nt  IJmcK  to  liavo  rcconn>o  to  o|ionittvo  measurcB'^  or  tliorongh 
inationn  of  inflnnietl  and  sensitive  jnulji ;  but  if  practicable,  these 
d  \k-  doiKi  onre  for  n//,  ami  usually  under  t!ic  uifiueneo  of 
elilorofoni).  Is  uotbing,  tlien,  to  be  done  locally?  EfHpJcnt  reaf, 
with  tho  limb  iu  a  proper  fKwition,  here  as  In  !i}'no\-iti>',  is  of  tlio 
^-eatcst  moment.  Tbo  limb  »boiiId  bo  wrapiH^d  in  u  thick  layer  of 
oottoii-wool,  j)ro|N.Tly  soeuml,  pasteboard  or  other  splints  ada]>tcd 
|-to  tlie  form  of  the  joint  a|iplii-d,  and  the  whole  sfx-imil  by  jrumnied 
|or  starehc*!  biuidage"*,  which,  without  being  at  all  tight,  slionld 
extend  so  far  as  to  embrace  tho  joinUt  c^xnx  and  W<w,  as  well  aa  tho 
aetitul  one  which  is  discasMb  It  ia  nece^i-nary  tliat  the  limb  thoiild 
be  6xcd  to  tliid  exti-nt  in  onler  tlint  tlie  eontrnetion  of  tlxi^!  muarlea 
[■which  oriw  at  some  distance  from  the  nrttculniiou  may  bo  prt^cntodf 
mul  the  joint  kc]>t  ab!i4>lntely  in  a  Rtato  of  rest  Hup|>ort,  to  a  modi- 
fi«l  extent,  »hoidd  be  continued  to  tJie  j)art  ftw  some  time  after 
apparent  nn-overy.  It  i»  alw  desirable  tliat  tho  splints  slioiibl  bo  so 
adapted  w  to  allow  exercise  to  bo  taken,  wbiUt  immobility  of  tlio 
joint  is  niaiiituinciL 

When  ilio  case  comes  under  treatment  early,  tlie  Surgeon  haa 
only  Lu  nuiwtam  the  limb  in  a  proper  jKtsitlon ;  bnt  frw[U(aitly  it 
hap])cRH  tliat  the  limb  lia-t  iKt-n  idlciweil  to  iK-eome  distorted,  and 
mom  or  lorn  lixod  in  its  abnormal  direction.  In  such  a  caw  it  ia 
bettor  at  once  to  re<iton<  tlio  limb  to  it^  pmper  [MHitiAu,  ofcoorsfr 
nndiT  i^hloroform,  and,  If  nccoHtan'  for  this  purpose,  sulicutjmoous 
section  of  any  reai.iting  niu»glc»  may  ho  fiwiy  pcri'ormed.     Tho 


748 


DISEASES  OF  THE  JOINTS. 


limb  may  tliMi  I»  wrapiK-d  in  cotton-wwil,  luitl  tueciued  in 
po«itiuii  by  if]>t:iil.s  and  piiijniwl  bailtlagps  as  boforo.  Th 
en«%' of  tiiis  treatiiicnt  tlom-nilM  not  iHcrulv  on  Ulft  fact  tlutt  lUiLv 
IokU  i«  U>  Iw  oxpenkil  (»ii<l  for  recovery  by  ankyloeis  to  bo  dcwral 
tlio  limb  must  bo  dxtxl  in  a  pro]K>r  |>OMti(iii),  but  nUo  on  lu.'iMunI 
it.-*  iiiiiiiedintr  iiif1u>a](-t>  on  Hia  tiiHea-w.  Tlie  painful  startings 
ncc-Woitcd  by  prcssore  on  t}ic  iiiflaincd  boiie-Mu-iao(V!i ;  and  to  loi 
iL»  inv^itltu-  ]>rt^->urc  Ls  iiiiunluiiiiHl  by  the  muscles  in  a  state 
fipaiimodic  contraction,  pain  mti&t  be  cxpcricuoccl  natl  irritntiun  kit|< 
up.  Dr.  HiitK-r  lia-i  pni)H>iwcl  to  diviiio  the  tend(iti§  of  the  contract- 
ing nitiselcA  inde]M>ndont  of  any  malpottitioD,  ai*  3  mcAnit  of  rultvring 
tbo  Ktarting  pitinit;  ukI  siicii  it  plan  mijrht  not  unreasonably 
adopted  if  all  niildor  means  of  relief  sbould  prove  iimivuiliug. 
BcDJtuiiiti  Brwdie  lia*  pnfifcvstwi  tbo  tipj)liojition  of  a  mo(lt'J-nI«  bo* 
constant  extending  force.  For  this  piu^x>!io  bo  employed  a  weight 
ttttjiubwl  to  a  ittriiin,  iHUwiiig  nvor  »  pidley  fixtil  at  llie  boitxjiii  of  the 
Uidstea*!,  the  other  end  of  the  string  being  secimxi  to  tlie  limb, 
whilst  coil nt*^tr-px tension  wa»  kept  up  by  wtnipft,  ivliicli  |)r&veiiti«l 
the  body  from  slii)|)ing  down  in  bed.  A  better  ap)>lication  of  tlM 
tamo  principle,  adapted  to  tbo  lower  extremity,  lias  been  dvitcribed 
by  Ml-.  Banvell,'  in  tlie  form  of  a  long  splint,  fitt«d  with  puUm  at 
cacb  end,  over  which  strings  pass,  the  tipjicr  string  being  tUtadiad 
to  the  perineal  band,  fixing  tljii  tinib  ubovc,  [md  the  lower  one  (d  a 
baiidago  socurcd  round  the  ankle,  the  two  strings  being  nnitcd  in 
the  middle  to  a  strong  india-nibbt-r  spring,  which  by  itA  ebi§tie 
force  keeps  up  a  constant  tension  on  both  of  them. 

When  ulistH^MCs  uro  forming,  tlic  nplints  employed  murii  be  so 
eonti'ivod  as  to  admit  of  t}ie  application  of  jwultices  or  otbtf 
<bv3»Niiig!<.  Tliis  niu^-  be  done  with  tJic  gummed  bandagv  by  eul- 
ting  a  kind  of  trap-door  in  the  situation  required.  When 
absc-i'jis  approaches  tbo  wurfaw,  or  when  it  i*  preventwl  frogn 
doing  by  intervening  tascire,  it  is  advisable  to  make  an  o| 
provided,  of  course,  that  tbo  swelling  really  contiiiiiA  mattor,  ani 
not  serum.  When  an  incision  is  made,  it  should  be  a  free  otte, 
;i.-i  to  allow  nf  ready  c»caj>c  oftlio  pus  witliout  nnn(«u»sary  majiK' 
pnlatioii,  and,  if  practicable,  die  tiio»t  dojiending  position  Hbookl  be 
selected,  llial  the  matter  may  drain  out  a»  fast  us  it  form&  Hm 
sinuses  which  remain  sboiild  )k!  tn^ntnl  in  the  simplest  munner :  lite 
ap]ilicatiin]  to  them  of  irritating  substances,  and  the  frtHjueiit  intro* 


^ 


*  On  DImv***  <if  the  Joint*,  p.  206. 


STRUMOUS  DISEASE. 


dttction  af  probes,  are  not  merely  unn«ces8arr,  but  powdvelr  roio- 
chii^viiuR. 

If  tJio  case  progresses  favourably,  and  die  mnosea  contrart  and 
cloNc,  tlin  trontTiioiit  cointUtM  in  tlic  tuinio  l(X^  mNisurtM  mt  thow 
which  Imvo  already  boon  pointed  out  in  the  section  on  tfrnmoiis 
p/noeilU;  but  tlio  caw  may  nnt  prof^'.-'tt  favourably,  and  it  may 
then  become  a  question  of  re»ortin(t  to  operation.  It  has  olroady 
I>ocn  ittnt«<)  that  in  <yirly  lif«  (Jio  limb  may  gi'ncniUy  Iw  prcwr\'cd. 
With  the  eliildren  of  tlie  very  ]>oor,  however,  eHpecially  those  in 
large  towns,  ati<),  indeo<l,  a1  nil  [M-riodi*  of  lifu  amongst  those  who 
have  to  gain  their  livelihood  by  labour,  this  question  often  arises; 
Is  the  chance,  or  even  the  utmng  )>robiibility,  of  idtinmt4*  rcwvcrv- 
with  a  stifFone<l  limb,  after  many  months,  perhaps  years,  of  confine- 
ment and  forced  abstinenec  from  lalmnr,  pretl-rabhi  to  «  more  im- 
mediate reooveiy  with  the  loss  of  the  limb  or  joint,  but  with  all  the 
rinks  attendant  on  a  prave  o|ienitJon?  E\orv-  case  must  Iw  dccide<l 
on  its  ovra  jmrti<'ulai'  merits;  but  ha\Tng  this  consideration  in  view, 
it  is  ovidnit  that  n  Sur^i^'on  is  otlon  jti)itiGe<l  in  uNOg  the  knife  c^'On 
where  an  operation  ia  not  absohitely  neeowar^-.  When  health  is 
foiling  un<ler  tJic  protracted  continomcnt,  suffering,  and  exhausting 
discharge,  removal  of  tlie  part  often  becomes  advisable  to  pre*i'm- 
life;  for,  iw  hiw  Unjii  Hlrt'ady  stated,  where  death  takes  plaee,  it  is 
usually  itova  disease  oocurring  in  some  internal  organ.  Now  in 
seroluloiis  subjects,  any  tiling  which  lowers  tho  patient,  or  ofrc<ct» 
A  drain  u[)on  his  wj-stt^ni.  is  prone  (o  ii)rlu>>e  disease;  itie  removal 
of  the  sfjurcit  of  ininehief,  tliercftire,  often  saves  life  by  preventing 
more  important  structures  from  beeoming  nlfectecL  On  tlie  other 
.Juuul,  it  must  Ix-  borne  in  mind  th^it  ojwrations  En  stnimons  mi^ecto 
I  are,  in  some  eases,  rapidly  followeil  by  the  appenran<-e  of  serofulons 
aflbelJons  of  internal  organs,  which  did  not  provioiisly  exist,  or,  at 
any  rale,  had  failed  to  manifest  themselves.  In  deciding  the  point, 
tho  Surgeon  will  undoubtedly  be  influenced  by  tlic  ptmition  and 
importance  of  the  diseased  part,  anrl  the  (^nsequent  severi^  of  the 
operation  required.  To  expedite  the  patient's  recovcrj',  he  would 
pmmjilJ)'  n'ni<>\'e  one  or  several  of  tlie  tarsal  bones,  when  he  wotdtt 

Ihentato  about  amputating  the  thigh,  or  excising  tho  head  of  the 
fi»nur. 
The  comparative  m«its  of  amputation  ami  oxdson  will  be  dis- 
cussed hcn-after. 
: 


Tlio  articular  extremities  of  tho  bones  are  liablo  to  rkntmatie 
iiifiamjnatum.    In  tlio  essay  on  I>1SEASK3  of  the  Bonks,  tlie  subject 


750 


DISEASES  OF  THE  JOINTS. 


oSrhettmatic  osiUit  is  descrikctl;  and  its  relation  to  diseases  of  A 
joints  is  (tirihcr  ili.->cuK<>'4l  in  ilu^  Mtctinnjit  on  Chronic  RbcumatM 
S^-novitis  nnd  Chmuic  lUieimiatic  Arthritis  (p.  723),  to  which  iha 
reatlci"  i»  n-fitrnil. 

Tiie  joinu  may  also  Buffer  from  syphilitic  inflammation  oom- 
mcucing  in  or  extending  to  tlic  htpnos.  For  this  also  the  reader  it 
referred  to  the  essay  on  Diskakes  ok  the  Bokks  ;  and  soni«  furtliHr 
remarks  on  ttic  Kubjc-ct  will  bo  found  oudcr  the  head  of  Syphilltia 
Synovitis  {p.  735). 


fi 


Wtaeitic  affedunui  <^the  articttlar  ends  a/  tlu  hones.  Tlie  Ixhms 
are  matorially  slToctftd  in  tlio  vonstitntional  derangement 
rise  to  riokttttt.  Tliiit  condition,  whioli  is  Bomedmcs  Hujtposcd 
of  modem  origui,  tliough  the  lin<.<s  of  Martial*  would  »E<om  to 
ttmt  it  ootdd  not  luive  been  unknown  m  his  tiinn,  ia  <l(;s<rribnl  b 
another  part  of  tlii«  work,  f  It  is  only  ucoo«tary  to  remind  tiie  reader 
hen^,  tliiiL  tlKiiigti  thii  nltenilioriit  wiiioli  oot^iir  are  s|>ccia]ly  maoU 
festod  in  the  shafts  of  the  bones,  yet  the  artieulations  do  not  entirclT 
e(K.mj<o.  Ill  die  parly  Ktago  of  rivkvtt  tlio  "  knoti*"  or  swcUinpi 
wliich  take  jilato  in  tile  osseous  or  (cartilaginous  ends  of  tJio  Ikom* 
are  highly  ((linnurtoristie  of  the  nlfcction.  At  tlio  iintt-rior  ex- 
tremities of  the  ribs  these  enlar^innents  aiw  particidai-ly  obvious, 
aJFocting  Imth  the  hone  iiml  liio  wirtihige,  and  giving  rise  to  an 
angular  projection  of  the  costo-ehondral  ailieulations.  At  a  later 
period  those  urtdciilatiouH  become  mnch  weakened,  and  jjermancnl 
alteration  of  shape  ocrnirs.  Koiuetintes  the  rib  projeets,  and  the 
Cartila^  w  forc-od  inwards ;  more  frequently  it  is  tlio  rib  which  if 
driven  inwards,  and  Uio  eartilage  is  disloeatml  on  its  ext^M-naJ  Murfaoc, 
a  connexion  between  tlie  two  being  still  mainlined  by  ligunenteafc 
tiasae.  If  tlie  client  is  examined,  the  extremity  of  tlio  ribs 
found  ])re8entuig  a  row  of  nodosities,  tho  sides  of  tlie 
hollowed,  tlu^  tlioraeie  oapaeity  diniinishwl,  nnd  tht!  fi 
respiration  interfered  with  to  a  more  or  less  serious  extent.  In 
limbs  similar  noilo»itie8  are  met  with  in  the  ortieulftr  cxtnnnities  of 
the  boncB,  first  apjiearing  in  the  lower  ends  of  tlio  radius  mi<l 
as  wi>U  Hs  in  tlie  malleoli,  and  afterwards  afTcding  the  knees 
I'lbows.  As  tlio  iUscaso  advances,  tlio  sliafts  of  tho  bones  undi 
tho  alterations  described  el'^cn-here,   tlio  bonding  of  tlio  dinjihysoi 


*  Cum  sint  crura  tibi.  simiiknt  quv  i;omiia  liun. 
In  i-liylio  potiTit-H,  Pliicbc,  litrtuv  pedes. 

f  Soo  Scaassr  o»  Ckii.dhood, 


TUMOURS  NEAB  JOINTS. 


751 


(locurring  more  frequently,  as  well  a*  nt  an  cnrlior  ])criod,  in  Uio 

Iluwvrthan  in  tlu!  upi>(>r  «xtn^miite<i.  The  arlic.uliilion.4  juutiVijuilo 
more  or  less  in  die  jcfbrmity,  being  often  twi^ftcd  in  an  o)>p<Kite 
tlinx-tion  lo  tlie  ciirx'aturo  wliicli  tlio  limb  linn  assiinicil.  T)iv  lif^u- 
meots  yield,  and  incomplcic  dislocations  arc  aj)t  to  take  place.  At 
tbo  IciMC,  fiT  inatanfu>,  ilis]>l[u.'em«nt  iiiny  rH-ctn'  outwnrd.-*  nr  inn'nnU, 
resulting  fi'om  a  partial  yielding  of  tlic  articular  extremitiea  of  tlifl 
femur  and  tibiii,  itxctf  indui'ir<l  by  tlic  unM|Uul  di.-4ribtttion  of  tlie 
wciglit  of  the  body  on  tbo  surfneos  at  tbc  joint.* 

I  Till)  naluix!  of  tlio  affei-tion,  whi-n  ibo  joints  m\-  implivnt'.i!,  can 
waroely  Ciil  to  be  recognised,  in  consequence  of  the  rickety  condition 
iof  other  piirbt  of  tlie  oweona  cytttcni,  and  tlie  jioriod  i^f  life  ttt  wliicli 
lit  oeonrs.  Tbo  treatment  in  these  ea^^cs  is  mainly  constitutional,  to 
IWniedy,  if  )Hwiblo,  tJic  ^iH-eific  diatlifitJu.  IjOi-aHy,  it.  i*  mlvisiihlo 
iu  most  instaoccK,  when  the  articulations  are  disposed  to  yield  and 
to  becuino  liistortod,  Ui  ii|'ply  medmnioiJ  supjmrt  of  »w\i  u  mitnro 
as  to  counteract  tbo  tendency  to  displacement,  and  allow  of  exorcise 
being  freely  taken.  The  articular  deformity  in  this  way  iit  often 
relieved,  and  tbo  results  obfainod  aro  tolerably  satis^tctoiy. 

Tumoura  of  t/te  articular  ends  of  the  bouM.  In  the  essay  on 
[Diseases  of  thk  Honbs  on  mcwount  of  tbo  new  fitmuitionn  whieh 
J€)ccur  in  connexion  witii  the  osseous  system  will  bo  mi-t  witli. 
y^na  tiunount  in  question  may  bo  <lcrcloi>e<I  in  or  upon  the  nr- 
jticnbiting  extremities,  and,  indeed,  in  tlie  long  bones  tlio  ex- 
liicmitivs  asa  more  stibjeet  to  sueh  fonnation^t  than  Uie  !>)iaflj<.  If 
the  articuliu'  ends  are  involved,  tlic  joints  may  evidently  become 
aflvcteil  either  by  tlioir  inovutnent^  being  meebaiiiojiily  Jnti.Tferod 
with,  or,  in  the  case  of  cancer,  by  cxtt^nsioi]  of  tlie  <lisease  to  other 
ctures,  and  consequent  disorganisation  of  tliu  artieulation.  Tbo 
rsymptoms,  therefore,  produoed  by  thette  forniatioiis,  es{iectally  tlio 
<  maligninit,  ]>re«cut  certain  points  of  resemblance  with  t)io»c  of  otlior 
I  diseases  of  the  joints,  which  may  bo  briefly  noticed.  In  some  cases, 
the  nature  of  tiic  tiunour  for  various  reasons  is  obtnous  enough,  and 
no  difficolty  ari.Hcs  in  tlie  dla^^osis,  but  iliU  is  far  from  being  gene- 
rally, or  c\-eii  usually,  the  ease ;  the  rules,  however,  by  whieh  wc 
H  ore  to  1>o  guided  are  biid  down  in  the  essay  to  wbicb  the  reader 
■  has  already  been  referred.  Tlio  form  of  malignant  disca«i  most  fio- 
Hquently  mc-t  with  ix  thu  soft,  or  moduliury,  nrul  according  to  Iloki> 
Htenalgr  it  never  commences,  as  a  primary  disease,  within  or  upon  the 

L 


•  Seo  Boutior  ruT  te*  Miladie*  ekrtmipiM  de  tAppartU  lotoiMlMr. 


752 


DISEASES  OF  THE  JOISTS. 


Bjmovinl  nwmlimno ;  tlie  aanic  rcnmrk  applies  witli  increased 
hi  tho  cartilagee,  for  the  isirtilnginouii  ittnicttii-e^  are  aontetimi 
fennd  intjK-t  when  everi'  other  part  of  the  joint  has  been  destroyed* 
Whatever  may  V«  don<?  in  tho  cn«  of  iiinrnfiil  fonuution*,  in 
tnaligiiiint  iitTt^dtinna  die  only  chance  of  relief  consists  in  ampau- 
tion,  which  ithoald  bo  pcrformtyl,  if  posnblo,  m  m  to  romm-c  th4 
wIkiIi;  <if  l.ho  nffix-tod  bonfl,  Kven  when  this  is  done,  the  nfaaim 
of  ponaaneiit  !aii?cc-<i«  i«  Inr  from  gn^ut;  Init  lunpntatioii  invoKing 
tlio  retention  of  any  jmrtion  of  the  caiieerocu  bone  ts  next  to  bop- 
less.  Obviously,  thcrcforr,  it  i»  (i«»inilil«  to  axccrtHin  in  which  "f 
the  l>one*  tlie  diiteaso  I>ejjnn;  and  by  attending  to  the  point  where 
the  swelling  first  manifci^od  ib>(-lf,  lhi.-«  iiui  usually  he  dvienniaa]. 


Abnobmal  Conditions  of  the  Aeticui^k  Cartilages. 

Tlic  nrticiilftr  extremities  of  tJio  bonea  are  protcctod  by*  a  thin 
layer  of  nartila^,  one  surface  of  wliidi  in  firmly  connected  witi 
the  bone,  whilst  tlie  otiier  U  fi-eo  in  the  joint,  except  iioar  the  cir- 
cumference, where  it  is  eo^'oiTd  by  an  rxtonaon  of  tho  poriiistenm, 
forming  a  cjiocia!  i-oat — jjeru-Jiimdrium — which  gradually  tonuiDatc* 
on  tlio  cartilage,  without  any  wcU-dcfinctl  border.  It  is  to  Uii* 
pcrichondrinm  that  the  jmi-tiim  of  synovial  iTifiiibninc  which  ad- 
vajices  over  the  e<lge  of  tJic  cartilage  is  inseparably  unitcvL  Arti- 
cular cartilage  in  oumfiosMl  of  a  finely  granular  or  nearly  homo- 
goneons  -matrix,  in  which  are  imbedded  the  tliin-walled  carfiioffr- 
corpuacUs,  tlieinsclvcs  ooiitainlng  two  or  lltroe  smaller  or  secondly 
nncJentnl  (^e]IH.  These  corpnscles  are  numerons,  and  flattened  amr 
the  free  wirfaco  of  tJic  cartiiiigr,  jiiiriilli-I  to  which  thi'varo  ammgecl; 
in  tlio  centre  thej-  are  in-ogularly  disposed  and  more  scanty ;  wluL't 
thoy  assume  a  ])crpcndi«ul>ir  iliroctiou  towards  tlic  mir&co  of  tk 
bono  on  which  tJiey  rest,  and  hei-e  tlioy  become  cIongatwL  Tia 
surface  of  bono  to  which  the  cartibge  i"  immedintvly  attacrbed  it 
tormed  tlio  articular  iamella,  though  tliia,  perhaps,  miglit  bo  nxire 
properly  called  the  calcified  laniclla  of  articulu-  cartilage,  for  it 
coiiMnts  of  permanent  thick  -  walled  oartilagc-corpuwlcn,  nntli  tltf 
matrix  or  intcr-cclluIar  substance  calcified,  and  is  quite  distinct 
from  tlie  true  bone-strueturc  immediately  beneath,  ^o  aiticvlar 
lamella,  like  articular  cartilage  itself,  contains  no  blood-veseoU,  tad 
bomg  inlerpo-ied  betwwn  the  cartilage  end  tiw  raseular  bone-tiasiie 


See  Virchow,  C<fl.  Pathol.  LeeL  xix. 


DISEASES  OF  CARTILAGES. 


753 


■low,  w«  m»M  HiipimHC  !t  rapnbio  uf  trail Nnitting  tlio  dcmcnU  of 
iiuirilion  froiu  tho  lattvr  t<>  tlie  toniKT,  if  wo  luljnit  Uiat  cartUa^ 
van  ho  iKtunMlict)  by  tho  vowels  of  tho  bon«,  Mr.  BiirwcU  imagiiioil, 
accordingly,  tJuit  thi^  iirticiiliir  hiint^Ilii  *' wuhUU  nfn  series  of  very 
miimtv  (HmiUol  tube*,  which  niii  in  a  waiy  courw  from  thr  Immic  tu 
Uio  i-iirTilaginoiis  Hiirfiit-e."*  Thoiij^h  liiJR  ihi  jtrobiibly  not  tho  case, 
iinil  tlic  Ihiciir  arrangomeiit,  when  it  exitts,  is  only  tlio  rosult  of 
F^triiilioii  of  the  iiiiitrix  U-foiV  it  riih-ilied,  yt-t  tlicit'  (i;tii  l>o  little 
iloitlH  t]iat  tlio  articolar  lainella  is  suflieiently  jienneablo  by  Diiidit  to 
allow  reiiiiily  of  <IioAiiio»o. 

llic  artiL^ular  cartilages,  when  fully  (le^'clu|)otl,  contjiiii  ncitlicr 
nerves  nor  blwMl-ve»scU,  and  yot  tliey  are  living  tis*ues,  though 
niniplo  ill  tltclr  structni'o.  Nutrition  in  tliem,  as  in  tho  cumeo,  is 
not  eft'wt«Hl  <lircftiy  tlwough  the  int'UiiN  of  bluod-ifiwelti,  but  ivttults 
iroiu  tlic  eonveyaiiuo  of  the  nutrient  materials  taking  plnt-c  fixiin 
celt  to  ivJI.  Tho  tuulilagc-ceIN  retnin  their  jiowersi  of  n>produc- 
tion;  old  i-ell*  disii[ij>eiir  anil  iire  replaced  by  new  ones,  and  ifo  a 
round  of  nutritive  cbaiigvs  takes  jiln^xi  ndtipt(xl  to  servo  the  wunta 
and  maintain  tlie  integrity  of  the  ti.-wiie,  Tlie  nutrient  materials  aro 
ohlaiiKsI  fn)m  the  blood-vcsscls  of  tlio  s^nioviul  uicinbnuio  antl  of 
tlie  bone ;  in  both  <-aso«  tlu-n*  exiHtit  a  fiwe  vat*ulnr  supjJy  in  closo 
pmxiniity  to  thi;  oartilage,  nioiid  tho  circumfcmiw!  of  whicli  «re 
aminged  the  pHae  tiucuhtti:  of  the  K%*iiorial  monibrance ;  whilst 
we  liiid  in  llm  bones,  beneatll  the  cartilaginous  surface  (the  articular 
laitflla,  however,  intervening),  viun-ular  coiivolulion*,  dilatations, 
or  plexuses,  specially  ai:hi)>ted  for  tlio  i-eceplion  of  tho  blooil  ami 
sopiu-ation  of  its  plasma. 

Tlio  functions  of  articular  cartilage  are  comparatiwiy  ineeliani- 
cal,  intended  us  it  Lt  by  it"  »moot)uic«s  and  elasticity  to  diminish 
friction  imd  obviate  the  "jar''  or  Hhock  to  the  bones,  which  would 
otherwise  give  i't.Hi>  to  fntiuent  fractunit.  E»on  for  tlwiw  purposea, 
howevor,  it  is  necessary  that  a  certain  amotuit  of  vitality  or  nutri- 
tive jKtwer  shoultl  exist,  elsi?  the  (T»nilngo  woiil<l  gradually  wear 
away  in  pnijtortion  to  tlio  amount  of  fnetion  it  has  to  sustain,  and 
thnt  wo  know  is  not  tho  case ;  for  if  artieular  ciulilageM  are  aomo- 
wlmt  thinner  in  tho  old  than  in  tlie  young,  tlie  change  in  not  greater 
tJtan  tlial  which  in  known  tu  occur  in  other  tissues  of  tuiqucationabto 
vitality. 

^o  long  as  the  natural  processes  of  nutrition  and  secretion,  as 
well  .-IS  tho  disturbed  proctutscs  uf  iuflainniation,  were  uu-ibuted 


VOL.  Ut. 


*  BttrweU  on  Dittatn  ■>/  tht  JoinU,  p.  0; 


3c 


754 


DISEASES  OF  THE  JOINTS. 


vittirdy  to  fM>mi>  niVHteriotus  action  oii  tliP  jiurt  of  tlic  blood- 
tbe  ki'Altlij'  juid  rliM.*iiwNl  mncUtioiia  ot*  tfa«  non - vusf-ulKr  ti 
iteurovly  allciwoul  of  esplsnatton.  But  wliun  w«  iwlntit  the  nutri- 
ttro  |K>v.-(T  of  Uio  edl-  or  ;;ei'in-<:onMituent«  c^  tlie'  ti.'«iui>  itM^lf,  and 
conitidtT  the  veerala  as  bteixlod  to  hrin^  sup)>lict>  of  prepanxt  nutri- 
ment  into  nuffictcntlv  war  n-hnimi  to  them,  mucli  of  tho  (IifficnllT 
YimUhoH.  In  perfoptly  (lovelt^Ltl  orliculai'  cartilage  we  hav«  |)cr- 
ntaneiit  nucleated  ccll»  vontAined  in  tlivir  ui|ihu]i.w  nnd  inibodde«i  in 
Ml  iiitffr-irclluliu-  subHUuico;  nnd  if  we  have  no  vessels  in  tbu  cutilapi 
itwlf.  thoy  cxirt  in  nufficifiitly  i-Uvw  pnixiinity  to  th«  tissue  for  iho 
clenu-iit>  iht-y  oontuiii  to  \m:  within  rciich  of  the  more  <lin!ct  ugciiLt 
of  nntridon.  Such  an  arrangement  wonld  be  iiiHuilicieut  for  orgaas 
in  whieli  intciuo  action  ii»  goinj;  on  ;  but  fur  Uie  ii(isi*ivc  cartila^ 
the  blood-vesseds  of  the  bones  on  wliich  tbcy  rest,  and  of  the  syno- 
vial membranes  whieli  unrrouiid  their  circumference,  afford  n  snffi- 
cittnt  «u[i|>ly  of  nutritiie  material  for  tlie  eartilago-corjwuiulot  lo 
maintain  tlic  intcp'ity  of  l)ic  tJK^ue.  If  thin  supply  is  interfered 
wilh,  if  the  ciroulntinii  in  tho  bone  or  in  the  synovial  munibmue  in 
disturbed  beyond  a  cortuin  jKiint,  no  cim  luidcrstand  that  the  nutri- 
tion of  thi>  rar1il«j;i'  shiiiiUI  Iki  jn-ono  to  suffer,  and  mi  we  Sndtiu^ 
tissue  very  Uublo  to  bo  affected  secondarily  in  consequence  of  iiiflam- 
niution,  r-oninion  or  »i>*'eifie,  oeeiirriny  in  tlit-  synovial  mcnibrano  or 
in  the  ai'ticidar  extremity  of  the  bone.  Its  imtrition,  however,  may 
siito  become  ubiiurmul,  directly  or  primarily,  fr<mi  somo  disturbed 
aetion  in  it.«  own  elements,  and  we  have  disease  of  Hm  r.artila^^l 
altcnikvl  with  great  nlteration  of  Htructurc,  where  tho  neigbbooil^f 
tiHsut-s  4!3[liibit  tittle  or  no  sign  of  diwase. 

Artieiilar  cartilage  is  dcweribcd  even  at  tho  prt**iit  'lay,  by  au- 
thors of  high  standing,  as  not  being  suseoptible  of  int)iitiim:itio4i,  If 
tJiis  meaiiK  tliat  cEuiilago,  possoseing  naturally  no  resseht,  cannot 
present  d// the  s^nnptoma  which  charaoterisc  inflammation  of  ordi- 
nary tissue*  (amongst  wliieh  redness  &om  increased  capacity  of  tlw 
vessels  is  one  of  tlie  most  obvious),  the  Hlatement  i»  tnio  enongh, 
luid  cannot  be  denied.  But  if  we  look  upon  the  essential  cliarauter 
of  inflammution  iLt  vonMiMting  in  an  vxeuwivu  local  change  of  ma- 
teria], and  tliat  change  residting  at  once  in  iocreaaed  lot*  o/fA' 
Ma>u-«  and  increased  jyrodiK/ian  of  fni'fUiwv,  the  two  actions  goii^ 
on  at  tlie  same  time  though  in  ever-varj'ing  pro])ortion#,  it  is  diffi- 
cult to  axm'rt  tlien  that  articular  eartiUgo  is  not  subject  to  mch 
diwjrderwl  conditions  of  nutrition  «»  may  fairly  be  called  tn/feira- 
matoiy.  For  nrtieular  cartilage,  though  drawing  its  nutriunt  »aj>- 
plies  from  foreign  vei»eb  imttead  of  from  vc««cls  t^its  own,  is  » 


DEGENEEATION  OP  CARTILAGE. 


755 


fnr  ander  fbe  inflooiioo  oftho  lavr.4  wltittli  re<^iiliiio  vital  Iiwik;  oa  In 
buatonoo  ca]>abltfofmatDtainitigit«o^'U  status  <iuriiig  health,  undof 
undergoing  <-huig«8,  ninny  of  which  iim  aiuilognua  to  (Jmsc  termed 
inflammalon,',  in  a  Khilc  o(  disease.  Thus  cortilu^  will  maintain 
ir-'u-lfiii  iiti  usual  ounditiou  durinjr  a  tuiig  Ufv;  it  ina)' ho  )iy[M.!r> 
tropbiwl  or  atropliiixl ;  it  niav  degenerate,  may  oe«fy,  or  perish,  but 
it  may  alwi  uWrat«,  and  jirohahly  Mii|ipuruto.' 

llifperlrophy.  Artiuuliir  cartilugeR,  it  i.*  fsnid,  are  uL-c-asionally 
found  to  present  an  inercase  in  thoir  siibetaiice  without  any  obvious 
c-han;^  in  thoir  iK-ttial  twstiiro.  Siwdi  u  i.-uiiditioii,  however,  app«-aiv 
to  be  very  rare ;  for,  as  a  general  rule,  wlieii  the  cartilaga  is  tliiek^ 
than  natural,  the  tissue  in  snft  luiil  ''l>'>iig;',  with  a  tcndeiwy  to  break 
up  into  fibr<«,  oxhibiting,  in  fact,  obvious  marks  of  disease. 

Alrophii.  Sim])I(;  wiistinp  i>f  the  tissue  in  curtilage  necura  more 
iwrtkinly  Uian  nimple  hyiiortropliy.  In  advanced  life,  and  eapeoiatly 
in  those  joints  nliith  are  Kiibjoctcd  to  the  greatest  amount  of  proA- 
Huiv,  Hiti-h  as  thi-  hij),  we  find  the  oartilages  gradually  tliinnod,  tlieir 
structure  in  other  n.-»]>ecbt  rommning  hcalUiy.  Tlio  proccse  is,  of 
courM?,  a  .tloK,'  one,  ad^'aoeing  gradually  with  age,  and  ennxtituLing, 
Ul  fact,  little  moiv  tlian  a  sign  of  iiiituml  deeay.  True  atrophy,  in 
moiit  ea^tai,  aifeets  the  whole  aurfncu  of  tlie  uuiilagu ;  but  a  partial 
tiiiniiing  19  mot  with  in  comparatively  eai-ty  life,  aeeompanied  usually 
with  Hu ili (■!<'» 1 1y  marked  traoe*  of  provinuii  diMMme  to  dl»ttngiii.-Ji  it 
from  simple  wasting. 

Gontif  depoikt  in  cartUagt,  III  old  gouty  suhjeets  wo  somctimc« 
meet  witli  a  pcculim-  ehiuigo  in  tho  articular  eartilages,  n.-sulting 
from  tile  deposit  in  their  substance  of  orate  of  soda.  This  salt  is 
founil  not  iiKTi'ly  ou  the  siirfiice  of  tlic  cartilage,  but  aluo  in  tho 
inter-ccHular  substance,  through  which  it  is  diffused,  soroetimos  to 
nac.h  Ml  extent  m*  almoNt  tn  KU{x'rsvdv  the  projicr  eartilagiiioua  stntc- 
tinw.  which  tlion  pi>?«ent«  tlie  apjjearaiieo  of  a  elialky  maas.  The 
prcdilccliim  exhibiteil  by  fiic  gouty  nialeriat  for  this  tissue  is  for- 
tlier  sliown  by  tho  freqoenoy  with  which  it  ia  depoeited  in  tlte  oarti- 
lago  of  tlio  externa]  car  as  wdl  a*  in  tlic  articular  cartilages 

Fatig  dfgenfratiim  cf  rartilaffe.  In  ath-iincod  life,  ui  joints  wliioli 
hare  long  beeit  (h'nuMt),  and  under  otlicr  cireumMtunccii  unfavourable 


•  8e«  W«bPr  i>6*r  Jie  VfraiuUntngai  drr  Kmofftl  ia  OtU»kkranHnl*n, — 
Vlrclicw,  Anhit,  Junuur  ISM. 


736 


DISEASES  OF  THE  JOTKTS. 


to  liealihy  nati'ition,  nrti<;ular  «irtila^>K  mmirtimcs  ii>iclcr<^  u  pre- 
oC«8  «f  <Io^'»i*i'ati<)ii  I'orrosponcliiif;  to  tlio  analcgoua  affection  of  tV 
ciornea,  wliich  pu«K-s  by  tlu-  itamu  uf  arvtu  aemlu.  In  Mucii  vote* 
\ro  finil  tlio  wliulff  or  ])nrt  of  Ijia  nrtieulnr  Mirfaco  ]inwcnting  a  series 
of  Sbrcs,  ireo  at  one  «^'xtrpmity  wlicro  they  prujcet  Into  tlu>  artkula- 
tKHi,  iukI  attiirluHl  at  lliu  nilier  tii  the  ivniiiininfT  onrtiliiginouD  tissuet 
exhibiting;,  iiidewl,  somowhut  tlip  a]>|)paranoo  of  ^-elv^  The  carti- 
logo  i^  otU-n  thi<-k<-neil  iuxl  |'til|iv,  itiitt  inuc-h  Mjftcr  tluin  tuitiiral,  or 
it  inay  ajtitciir  raagli  and  filiroti'. 

In  tins  ilegoneration  the  cartilngc*  mny  Ijo  a«i<l  to  Iw  ulccmtol, 
and,  indocit,  tlils  itfToctioii  is  included  by  Dr.  Itediern  in  bis  incMt 
Vidiiitbk-  (iTiitJm-  (hi  llf  Anomutl  Ni^ritwii  of  CartiUtgr,  hikUt  ihe 
general  head  of  ulceration ;  for,  in  Initb,  t}ie  tendency  to  diahilD- 
;;nition,  dcgi-in'mtinii,  or  ib'slruHiwii,  which  foi'iun  <«hi  of  ttw  ch** 
raeterifltio-s  of  iiiflaini»ation  generally,  is  esjiecially  uiarkod  when 
tlio  cartilft^;v«  uru  tliv  ti««iios  afiVctud  ;  imd  ku  m'o  find  in  tin  caiti* 
lagee,  e\eii  when  Involveil  in  ai^iite  disease  of  the  joints,  the  soften- 
ing niut«nal  c\[iiljilitig  gt  plentiful  admixture  uf  ui1-<iTX>p«.  TIw 
<1egeneration  we  are  dew^ribing,  liowev»»r,  soemii  to  differ  as  weD  in 
tlie  iAaxn,  of  c^i.'^-'*  in  wliicii  it  occurs  ok  in  the  fxet  llutt,  while  tbe 
earcil3ge-coq>mi<-les  ajid  tJieir  oontcntN  ii)(>roftM>  in  .iixe,  inxtend  of  a 
uiiiltipIicatJon  uf  sticondsrv'  colls,  oil-  or  lat-glohiUcs  make  th«r  ap- 
[tearanee  in  the  interior  of  Hi«  cartilttgn-eoriniscIe.H,  inorca«ing  till 
they  occupy  the  whole  of  these  canities,  which  ihey  (Ustcivd,  and  i>» 
cinilribute  to  the  soft  or  pulpy  oiudition  i>f'  itio  tiiv^ue.  TIw  degene- 
ration extends  likewise  to  tlie  inter-eellular  substance,  wliit-h  beoonkc* 
8triiiti.Kl,  or  wparaUsa  into  fibn-^ 

Ofi'lficatioa  ofoartHagc.  Many  uirtilagiiiouK  stmetiu'Wi  have  a  na- 
tural tendency  to  ossify  as  ago  advances,  and  so  wo  find  the  ooMiil  car- 
tJliigcM  uvuidly,  and  tliu  thyroid  and  cricoid  ciirtitagM  occnsionaliy, 
undergoing  this  <d!ange,  which  rejiresents  in  tlicni  a  fomi  ofdti^De- 
rution  or  di.^;ity.  The  articular  cartiliigcx,  on  Uio  oUicr  Iiand,  arc  liT 
no  means  prone  to  such  a  transfonnation ;  for,  when  tho  d<»'elcq>- 
incnttil  OMsificution  is  completed,  any  furtlicr  tendency  in  this  dim;- 
tion  ap|>car»,  as  a  iide,  to  bo  ]>ennanently  arretted  in  tliie  cartitapi 
which  rciniiinM  beyond  the  articular  lamella.  Under  certain  ciroinn- 
stances,  however,  articuliu*  ciiiiilago  boconn.^  eonvertod  into  bow. 
Tliis  change,  occaxionally  met  witli  in  tlie  aged,  IS  obvious  enough  at 
times  during  llic  progress  n^  chronic  rfimmatic  arfkntu;  for  in  jointo 
suffering  from  that  affection,  the  place  of  the  entire  cartilage  may  \x 
occupied  by  ajwcuiiiu-Iy  Jcnw  kind  of  bone,  in  which  the  Ua^Drsiafl 


« 


ULCEIIATION  OF  CARTILAGE. 


757 


vanala  aro  fiUtMl  with  calcai-oous  matter ;  or  (jortions  of  die  cnrtiliifp" 
may  bo  ri.-|iliicmi  Ity  tliin  Imh-v  nr  {HiralluDoiix  nmtcriul,  wliit-h  rc- 
■itiiiris  on  a.  It^vcl  with  llio  remaining  uartilnginous  stru(;hire." 


Ulctratioii  offaHiUige.  It  has  been  ah-catly  stated,  in  aocorJanw 
Iwittl  the  opinion  oi' Wcbcr,t  Oiat  nrticiihir  cartilage,  like  t]ii>  eomea, 
i-t  vorv  liable  to  nil  ahurecl  condition  of  nutrition,  which  may  fairly 
bo  called  influmtnator)' ;  a  condition  whicli  sliows  il»etf  priiieijially 
'  in  tho  form  of  ulceration.  Tlie  reAearclieH  of  Ooo«lMr  and  Jtcdlbni, 
followetl  by  ihoso  of  still  nion-  recent  atitIioi^«,  have  shown  BatiMfac- 
torily  lliut  Uie  ehangi-s  in  ulceration  arise  iuiraediately  fiviu  a  vital 
altcradoR  occurring  in  tho  (.■iti-tilugiiious  Ktructiiro  ttwlf,  aaid  that 
the  iiifluenw  of  iln'  neighbouring  hlood-vesseti  is  oidy  indirect  or 
secondaiy.  When  the  diwas.-  \*  jicculiarly  active,  almoet  tlie  whole 
of  Uio  curtilago  may  dii^p]>ear,  a  f«w  isolated  patches,  which  an- 
usually  i-ocldcncd,  alone  remaining.  In  other  ea*ps,  tlio  eartilago  Is 
w)ftcnci;l  and  abniihsl ;  or  it  npiK-'or^  as  if  jHirtiunn  of  it  had  bocn 
ticooped  out,  leaving  smooth  pits  or  dcpretHioiia.  Ulceration  umially 
bogins  on  111"  fi"e«>  wirfftce  of  this  rartilago ;  it  niav  (M.irninciu.'o,  how- 
m'or,  on  itis  attached  surface,  or  oven  in  its  subbtanee. 

If  wo  cxaniino  lli«  «hango3  as  tliey  occur  on  tlio  free  surfiK'P 
iider  s^-novitis,  ivo  notico  that  tlw  colour  of  the  cartilage  is  altered 
in  s[>ot«,  which  eitlior  ra|)i<n\'  tw'comc  hole,  looking,  to  uso  Sir 
Doiijaniia  Brodie's  cxpreesion,  "  as  if  they  bad  been  cut  out  with  a 
kchiael}"  or  thu  I'l'ots  n>i*«mr  a  fibroiis  axpoct,  iK-^-nming  grailiially 
p-MCHCTited,  w>  n^  to  form  piu  or  depro^ions  with  fringed  margint^. 
Such  a  condition  may  Iw  found  tlc«troyu)g  tho  eartilago  cxt«iu(iv«ly, 
wul  cvon  laying  bore  the  bono,  without  the  prcwnoo  of  any  nwm- 
liraiio.  In  many  vans*,  however,  and  esjiocially  in  icrtduloiw  wj-no- 
vitis,  wo  find  a  tliickened  or  newly-formed  vnseidar  raembrano  ex- 
tending from  the  diseased  synovial  capsule  over  tho  ou-tilu^  Such 
an  extension,  indecii,  may  oeeur  uilliont  any  ulceration  resulting; 
or  even  when  tho  eartilago  is  afleetod,  tlio  oxoavations  aru  not  nt 
firft  nooesaarily  in  eonaosion  with  the  membrane,  for  they  may  bo 
found  in  situations  to  whicli  the  membrane  ba«  not  extcn<kHl.  A» 
tho  dittcft.'to  gocA  on,  howe\-er,  the  cartilage,  aoconling  to  Mr.  Bar- 
wellt  (in  bis  description  of  tho  changes  occurring  afW  stnunous 
synovitis),  iJowly  imdi:!rgo<-ji  a  transformation  into  a  form  of  granu- 


*  See  tlic  SL-cliou  oa  Cbnaio  Ithoaroatjc  Sfnoritis  ond  Artlii-ilia. 
t  See  Wcbi-i-'iipBpcriii  Virehow'*  j^reWsforJanuMy  ISM. 
\  liurvrcll  on  Diitatet  t^  tht  JmnU,  p.  Illl. 


758 


DISEASES  OP  THE  JOINTS. 


Iwt!on,  between  whioli  aiiJ  t\w  winiliir  iiuititrinl  fji-owiiuj  fnnji 
fi^-Bovial  inwnl>mn«  iwilwrsions  form,  resulting  at  la"*!  in  aliiioli 
Rontinui^.  If  Uio  olccmtinii  ■.■\t«iiil»  <lix']Jy,  tltc  bunc  bcnoatli  par- 
ttcipatut  it)  tiie  <liH<>r(ler,  its  ^aitcntarity  U  ini-n^aseit,  iind  .it  liL->t  iJu- 
uaUGellooa  tlnsue  beoomce  EiilLiiiicd.  'Div  iiiliciil.ir  Inntclla  cnun- 
blcw,  or  givott  way  in  nm9df«i,  oarrj'ing  witli  il  jxirtions  of  caitils^, 
wliie]i  may  Htill  be  eunipanitivcly  miind;  and  tbp  gratiiilutionB  vhleii 

"[■""a    'i^""    ''"^    t-X|M)!M-<)    <-llIICI-ll(>II.'<    tUsitM    Ullitl-    tvitll    ihllKI!    (>f   itu] 

tiynovial  mombranc  When  the  disease  originates  in  tlto  bone,  and 
t'xti-ndn  to  tJii^  i-jirtilii;:(r,  tti<^  i'ml  pmi'mut,  aowrdhi^  to  Mr.  BumfJ), 
ie  one  of  simpto  degeneration,  folloned  iisitalty  by  true  inflaniniatorv 
ulcomtJon.  A  }Mrtioii  ol'  thu  canil:ij^>,  liwliig  it«  nutrient  mpplv, 
degenerates  or  perishes,  and  is  detached  with  its  artieuUr  lanieUa 
from  lint  IiiAhiikhI  mrfnco  uf  rln-  buMc,  whilnt  iho  MUToundiog  jwr- 
tions  of  cartllago  tuidergo  the  changes  described  as  occuiring  in 
ijccrntion  nfb-r  Kjnmviti.-*.  [nflmunnifor)-  idcemtioii  of  the  tiartj- 
lages.  unaccompauied  witli  disease  of  any  otJier  joint-tisaiK-,  niny 
{KHwibly  lidco  plncf,  t]io;i;;)i  viukk  of  it  iirv  not  easily  met  with; 
degeneration,  ou  tlie  other  hand,  being  of  conipanilively  frcqacJit 
DC'purrcnci'. 

If  we  examine  tlie  minute  changes  which  have  occwrrod  in  tlie 
fiirtiliig"  during  this  process  of  nIc*Ttttion,  we  find  that  tlioy  eonast 
])riniarily  or  essentially  in  enlargement  iif  ihe  carlilagc-corpnscJw, 
with  greatly  iiitirciiscd  prodiictioii  of  the  ccli-stnieturea  ooiitiuiii'd 
witliiii  them;  and  this  is  att«nd<-d  or  followt-d  l>y  nitcmtions  aifcct- 
ing  tlie  intcr-ccIUdar  or  hyaline  substance.  In  pi-oporti<iii  ro  tin! 
at-tivily  witli  whicJi  llio  dix'UM  advances,  nn>  tlio  duuiges  which  tJw 
cartilage-corpuscles  present.  They  become  rapidly  (UhIcikImI,  tlw 
eell-HtnictiiroH  vrithiii  Uiom  augment  iind  undergo  dcvolopmrat; 
tlicir  walls  give  way,  and  their  contents  are  (Uschai^;;cd  into  cavities 
fornn'<i  in  the  ti.^iuo  ilftelf ;  or  tlicy  Imrst  tiiwn  tli«  frro  surface,  thoT 
ccll-eontents  mixing  witli  the  organic  subataiicesi  eontaineil  within 
till'  joint,  and  jirobsbly  tonning  ]in»,  while  the  emjiliod  eorpuselM 
give  rise  to  tlie  <leproesions  tliere  met  witli.  Tlio  nearer  to  tJic  Mid 
or  fociM  of  the  discaso,  the  greater  the  endogcnmiM  growth.  Instead 
of  two  or  three  micleateil  cclU,  tlie  corptincti*.*  may  conliiiu  an  almoDt 
indefinite  number  of  younger  cells,  or  structures  presenting  all  tho 
charaj-ters  of  pus-globiilc*.  Dr.  Rodlcrii  coiiniderwJ  tliat  "pus  bod 
never  been  shown  to  be  formoil  from  the  substance  of  diseased  aiti- 
cukr  cartilages,  nor  from  offuaiuus  into  tlicir  tcxliinr;"  but  Wobcr* 


«  VIrcliow's  Arfhiv,  Jto.  18*9. 


UI-CERATrON  OF 

uppcars  to  have  (t«inoi»trHtixl  rhiil  Hugifturation  really  doca  tnkn 
jilaco  in  luticular  cartilage.  As  tliia  auj^monted  action  fyuM  ou^ 
<Iwiy  and  (lo{;oi)criitioii  niKnitV-Ht  1  lii.iti'^flvoH,  aiitl  «>  w«  fiini  jK-riwIi- 
itig  G«U-structures  mixtxl  with  granulcia  and  drops  of  oil  in  the 
ulcer*.  TIio  intrcasc*!  productivity  of  the  cjirtilagc-corjui.'iclo''  i« 
attended  wiih  alteratitms  in  tito  inter-oolhilar  sulistanco.  Wlien  tlio 
|<liw^wa:-<l  nctiim  i*  vcrj-  nwito,  tlic  liyalino  mttt(^nal  is  ntj'idlv  dii*- 
iiilegratecl  an<!  dostmyrtl ;  wliiUt  in  more  oJironio  cases  it  is  s])lit 
itilo  ban<U  or  fibre.'*  of  varjing  wzcs,  ui  the  midst  of  wliicli  aro 
somcttnio.s  found  j^latinoua  niaaaea,  fiii[>i)oaed  by  Dr.  R«dfem  to  be 

^tliu  ehatiiced  cotitontH  of  tho  cartilaf;c-corpu«dei>. 
Wlicn  tJis  cjirtitagca  have  been  extensively  destroyed  and  die 
cancellous  bonc-tissne  on  each  ei<lc  of  tbo  joiiit  cx)K>scd,  repair,  if 
it  ocoirs,  tnki^  pluct!  by  ^nuiuliiLion-tiKKm-  uniting  tlie  op|K>siiig  sur- 
fiieca,  and  producing  ankylosis  in  tho  manner  already  doscribod.  Or 
tJie  ankylowis  may  be  incomplete,  jiortions  <tf  cartilage  still  remain- 
ing  onalteretl.  In  slighter  cases,  a  natural  euro  may  occur  after 
ulceration  has  gone  on  tor  some  tinio,  aiul  afi'ocdxl  the  cartilaga'  to 
a  i-onwidemble  deptli.  This  takes  place,  as  Dr.  Redfcra  jioinis  out, 
"  by  tho  formation  of  a  fibro-nucIeaV<l  membrane  fntin  tlie  Kub- 
stance  of  Uie  cartilage,  witliout  the  oceiinvnco  of  any  new  cxutla- 
tjon."  Oceiwionally  we  find  a  |Mitch  of  ivory  dcjxjsit  oeeupyiug  (he 
pJaee  of  some  portion  of  llie  cai-tilage,  or  there  may  Ix'  Mm|>ly  a  near 
left,  marking  tho  place  where  the  ulcer  bad  existed.  To  i«mpleto 
the  skeli-b  of  tlit>  cluuigcs  wbii-b  tliitt  tiwue  nii(l(*r):oe>,  it  may  be 
stilted  that  *'  in  cartilage  malignant  affections  aro  »o  mre,  that  it  is 
iU4unI)y  ii-«tinicd  to  be  altogether  inwiitceptibhi  of  them."*  For  Uiis 
in^uscoptibilitv  Virehow  gives  reasons,  founded  on  his  views  «f  tho 
truusicrencc  of  tbo  injection,  by  means  of  morbid  juices,  to  llio 
anastomosing  elements  in  tlie  neightwurhood. 

tft/mpfont".  Letious  of  cartiiago  may  occur  i>rimarily  or  second- 
arily. As  ]>riniary  atfections,  we  fi-equently  find  after  death  weH- 
marked  "ulceration"  where  no  symptoms  had  lieeii  iioticwl  ditrin^ 
life,  excepting  pertuijM,  ocensionaliy,  a  i-ertain  amount  of  "crack- 
ling" or  *'  grating"  in  tho  joints.  These  ca»c»  arc  of  course  chnmic 
in  their  cliaraoti^r,  and  tlic  affection  is*  of  tlie  nature  which  lias  been 
described  under  tho  head  of  degeneration.  Tnic  "  infiiimniiitory" 
nicoratiou  is  almost  invariably  set-iiiuiary,  the  wmiwquenee  ufinflani* 
madon,  conjmon  or  s(>eeifie,  occurrmg  originally  in  tho  sj-norial 
iiunnbnuio  or  in  the  Iwnc.     Tlii*  nficction  mnv  be  acute  or  chronic 


See  Cliaoce's  eililion  of  Vircliow's  CtUalar  PatMoff. 


DISEASES  OF  THE  JOINTS. 


in  ite  prcpiww.  Mr.  LawreHPc*  pplntos  the  case  of  n  |)nU<i>t  «1» 
iIimI  nft^r  Yeiicsoction,  in  wliotn,  m*  lie  l*oli«^'Vcd,  roiiil>lct«  dcstnu-- 
tion  of  tlic  urticlilui'  <-n]1Iln^>fl  of  the  Icniur  aiul  lihin  buik  ]iltii-c  in 
four  (lays.  Ill  mowt  cases,  however,  it  k  tniicli  »lo\ror  in  iia  jinf 
gresf ;  iiik)  in  soiiii*,  0!<|iccittllv  in  t>M  <lisi>ii<u.-.-<  of  riiftiimatic  origiit,  i 
may  l>e  extremely  clironic;  in  Ita  diaractor. 

l)cgcin;r«tJv«  iil<H>niti»ii  of  osirtiliifjf'  is  iittondiyl  «-illi  no  niark^i 
symptont,  gives  rise  to  no  pain.  Is  pain  produced  by  '•  iiiHtuuiiu- 
tory"  iili'cnition  ?  'iliu  (Ii-scrvtuHy  nivul  uiilhority  of  Sir  Ikiijniiiin 
finxlie  for  a  long  time  oonnertotl  witli  ulceration  of  tbo  vartila^ 
tlio.'H!  smen.'  ]Miin»  wliicli  arc  iiicr«iM,yl  iit.  »ij;lit-tini<!,  n^^fnivatod  Iff" 
niiy  motion,  and  attended  witli  iiivoluntarj'  Mnrtings  of  tin-  liinli 
TIk!  fact,  liowfvcr,  tlmt  1k>  n»'r\'0!«  wui  Ik;  disi-nvii-cfl  in  artioilxr 
cartilage,  even  witli  om*  present  improved  [wwers  of  inviwt!f>«tiiin, 
rwulcnt  Mticli  a  viwr  ulnioKt  iiiadini.viljlo,  uiilo**  wo  c-oncludo  that 
our  means  of  investigation  are  still  t«()  deteetivc  to  wamuit  our 
])liiciiig  trust  ill  them.  In  lus  hist  eilition,  however,  Str  Benjamin 
Brodie  avown  that  ho  is  "  inclined  to  tlio  opinion  that  the  incTwwfli 
miisiiiility  in  tlRW  t-asc*  i»  in  tln^  Imtij-  plato  iK'neiith  tlio  eartilage, 
ratlier  titan  in  tho  cartJIagft  itsi^lf;  and  that  tlio  pi-eeciu-o  of  xven 
paiiM,  with  involuntary  stortingit  of  the  limb,  is  always  to  be  r^ 
ganled  a«  a  sign  of  the  Ixme  [jartaking  of  the  tIi8oa.-*p,"  W«  may 
asHuiiic,  then,  that  di«iii^-  of  artiotdsr  eartthigri^  is  attended  with  oa 
distinctive  or  rliai-at-ttTistio  syinjrfoms  (if  we  exrept  tlie  "crnokling' 
on  innti'Di,  nu'cimiiieally  attendant  n|»>ii  a  loi^  of  smoothnes  o( 
their  siirtiicf).  In  cases  of  (liaeaw  (■i)nniu'n<'iiig  in  the  in'n<n'iai 
mciTibmno  when  )<tarting  pnins  eoino  on,  it  may  be  taken  indued  it 
eviileiice,  not  merely  tliat  ihi)  eartilagct  are  affocted,  Init  Uiat  111* 
disease  has  further  extendcti  to  tlie  bone.  When  the  disease,  ou  tin" 
otiier  liiind,  liiut  eonimenend  in  the  bono  and  iiivol\'ed  tliu  cartila{!Tv, 
the  joint  may  sjHxxlily  beconio  ojiened ;  and  the  Hippuratiuit  onl 
ahsofsK  which  occur  then'  lav  att<^ndcd  witli  the  nyiiiptoms  whtrb 
have  already  been  |>ointed  out.  The  treatment,  n*  well  aa  tbo  dia- 
gnosis of  ilisoaw.t  of  art.iculnr  cjirtilage,  so  far  il*  tJioy  eaii  be  aaccr- 
taiiiod,  will  he  foiuid  in  tlie  tlescription  of  the  afioctions  of  tliu 
Btnictiiros  of  the  joints. 


Diseases  or  other  TissrEs  is  and  abockd  the  Joints. 

We  have  seen  that  tlio  diifCasiM  of  tlio  joints,  wluub  I  havoj 
atteiiipti?d  to  describoj  are  prone  to  affect  in  tlidr  progress  tlio 


*  Lectures  on  Sur^ttiy.  Lancet.  I8IM0. 


OF  LIGAMENTS. 


761 


[  dtruiTtima  in  tlio  iiviglibuurhocxl.  Tlio  li^uviiU  bfcoiiw  it>Iiixe<l 
ROluL  m^entxl ;  die  Diuaeles  ooiitraetixl ;  Uio  iiit-olnr  tiMtuo  foruiH  thu 
"Hat'Of»b.-<C'i-sM,  or  is  tnivt-rm-d  l>_v  mihwh  ;  and  tlio  skin  iU"'lf  way 
bo  nlcontcd  or  destroyed.  Tlie  morbid  iiution,  on  Hv.  other  band, 
may  nrieiinati-  in  lliv  jHTi-ortii-ular  rtnictiirps,  and  eitluT  eiiiiulato 
ducafic'  of  the  joint  or  U>ail  dirc«tlj'  Ui  it  nm  varifty  of  thc**i 
leMoiiM  ii4  so  jrrt'Ht  tlint  it  in  inijHMWiblo,  witbiti  dio  limibt  of  Uiis 
ovmy,  to  ntit!iiij)t  a  detailod  f.xamination  tif  ibcni.  and  this  indwJ 
would  Im  mninci'»»urv,  sis  tlieir  df!«.Ti|ition  will  be  found  in  otiii-i- 
pgirts  of  tJiQ  work.  A  few  remarks,  howfl^er,  upon  tiio  relation  of 
«m;1i  of  those  striKlnrt-a  to  thw  jMitboloty  or  (tiugtioais  of  jointnliscuso 
may  not,  )H'rhajis,  be  I'onttitk-rLtl  out  of  plaeo. 

JJueae^s  aj'tiiitiif  I/m'  Liifamftttw  Strucfur^i. 

I       Tho  lifrHiiK^iKs  and  fibrous  strucliin.'H  urouud  the  jointa  arc  no 

uuubt  linblo  to  inflauimatioa,  amit«  or  chronic,  in  conaoquem-o  of 

tliij  injuries  whidi  tlivy  Mi»t»iii  from  M[>rttinn  or  otiirr  awitb'nw  (see 

tbn  cwa^-s  ou   injuries  of  the    different  repons).     It  is  [tfwbablu, 

liow(;v4-r,  tliiit  till'  li^^unu'iiliins  tisniKv*  tiro  bv  no  me-iuis  ])n>l)l^  to 

tliiwafie ;  for  they  aro  often  foiuid  unallerol  wlien  the  otiior  articular 

strutttiuw)  ha\'e  sutK^ri-d  to  n  jnn^iit  oxtcnt     Slow  to  inflaniv,  ttio 

lTC|jamtivo  j>roc'i'M  ajipears  to  be  stow  aW);  for  it  fi-oiuontly  hH|i|)en» 

at  the  movcnien1.4  of  ji  joint  are  hain|HTLil,  and  its  ust-  attvndi.-<l 

great  pain  fur  a  lon^  time,  after  a  ooinptu^lively  Hiiglit  injui^', 

pin  which  till!  lifrHUicnfous  or  t<-iulinous  tiwmes  alouo  havo  appnmitly 

,  been  injiu-etL     Opportunities  of  <-\aminiiig  tiie  pnrU  in  llicso  chro- 

\jnK  CNiw.«  havo  nut  often  Ikiii  iiffordod,  or  have  not,  at  lca»t,  been 

'  ofleii  made  uw  of;  but  oc<■a^t<^nldly  the  ligaments  ha*e  boon  found 

UitckniLil  and  pulpy,  indvpcndont  ofonyactuul  laceration  oftlicit' 

,  wibetaiice. 

Ill  the  Hkctcli  of  tlio  ajdvuKod  sIjikw  of  nrtieuliir  dis»>ase  wo  hiivo 
BOcn  the  li^'uuieiitn  td<>eratillg  or  yieldinj;,  and  so  p(niiiitliiig  llio  exit 
of  inuttor  fi-oi])  tlio  interior  »f  the  fniiotiid  inembmno,  or  allowinj; 
<»mi)lcte  or  partial  luxations  to  ocenr.  8onietimc<4,  on  the  contrar)', 
we  find  layers  of  a  tibivus  tisKw,  having  wmewhat  of  a  l:inl.io>roiLii 
appearaiH-e  and  oi-ciisionally  attainuig  a  very  eoiisiderablo  tliickne§s, 
(lavdiopvd  in  tho  li;;anionts  or  in  tho  areolar  liwue  nn>un<l  them, 
and  (brmiug  the  immediate  caiu^e  of  what  U  tenned  extrn-ca])sulai' 
fiilM)  ankyloMH.  Li  rbemnalii^  and  syjihilitie  nffcetions,  it  !»  ]m>- 
bablo  that  the  lij^omontoiis  sliiietures  t^hare  in,  or  tr\en  orij^natx, 
the  dim-jiMxl  action,  and  at  least  euutribute  to  tho  pain  wliiili  [>•  w 
xeven'ly  felL     In  f^viit  they  laay  fonii  llie  sunt  in  wliioli  the  tu^ntu 


762 


DISEASES  OF  XHK  JOINTS. 


of  soda  U  <lopo6itixL  In  elirDiuv  rliciimatic  arthritis  tlipy  imffbr  tt 
»  gniat  extent ;  tli<^  cnji^tiliii'  lijpuiuintH  niuy  bi»  jLTix-mly  iiicrtMoa)  la 
tbickiKnw,  or  jxirtions  of  bono  may  bo  Uovolopnl  in  tbcir  mibstuiiv; 
and  hi  the  hip  tli>;  iimiid  li^mii-nt  iiiiiy  oiiiitx-lv  dixii ))]>(.■« r,  or  in  Uk 
ahouJdvr  no  traix  of  the  glenoul  ligament  be  left. 

Ttic  lijBHmentj',  it  vian  luiid,  ant  linbl<!  lu  bvvonio  rolaxod  in  tL- 
pTTtgnwn  iif  ui1ii:ular  disease;  a  itimilar  looseness  of  tliem  is  somo- 
times  found  as  »  priuiury  affi-otion,  or  at  lu9i>t  dejxtidciit  4iiilr  njiB 
8oni«  t.>onHtitutional  condition.  In  persons  of  lax  fibres,  etipocnHT 
in  delieafe  or  liysterieid  yoiuig  woinrn,  a  pivl«'niatiiral  mobiiit7or 
liiK  joints  i*  not  luu-ominim,  so  that  extennion  of  the  lingers  or 
tliumb  may  bo  camod  nearly  lu  far  as  flexion,  iin<i  the  niuls  and  tU- 
buck  tif  ll)o  iiiuids  be  imula  to  meet.  In  many  fa»^  this  »UUe  U  iM 
attended  witli  any  |)iracti<-al  ineunvcnicnoo ;  Hnd  even  whore  paitid 
luxationK  o(;eiir,  tlie  lionos  n^turn  at  once  to  tlieir  normn]  [Wditiaa. 
Occasion  ally,  however,  it  ltaj)))en»,  pci'hapK  in  tlHuso  ])cr?sons  in  whoa 
the  undno  mobility  of  tlm  JoiiitJi  i^  not  iitten<)hl  with  a  <x>rn.-jip(ind- 
ing  relnxe<l  eondition  of  tho  mnwles,  that  eomploto  diHloeation  takc« 
place,  wliieli  may  not  be  reduced  niHintaneoii-ily,  but  nipiin.-  Mir^i'--d 
ii!aiAtaiu-e.  Inetanees  of  this  kind,  involving  an  miusnal  liability  tn 
Itixation,  arc  frequently  recorded.  A  t^imiliu'  oondttion  of  rdaxntkm 
of  tho  ligainenti,  involving  toss  <»f  [lower  of  tho  arttenlalion,  and 
leading  ocesuionally  to  luxation,  luuy  follow  ]ia]»y  of  n  limb,  and  is 
of)«ii  mot  with  us  a  result  of  infantile  parolyHis.  In  many  ehildrco 
it  is  neceMar}'  to  havo  rooourso  to  mcehauical  ex>iitrivances  to  obviali* 
this  weakne^K,  whilst  inean.i  are  boiiig  nilojiied  to  ineJ^-n.-«e  tlir  !»[■»• 
cidar  ])ower  by  which  tho  joint  may  be  moved  or  t]ic  limb  exercimL 
Tho  symptoms,  i»rogro»)i,  and  treatment  of  ai-tieular  diM>a»o,  a*  it 
iraplieates  tho  ligaments,  will  be  found  ineludod  in  tli<!  pr«<cediiig 
Fcetioiw. 

DiMotei  afectinff  llie  Maeela. 

Tlio  altered  eonditioii*  of  llio  nnL-«;I(^  ami  tlteir  tendoms  by  which 
the  joints  ai'e  forced  into  ceitain  positions,  or  retained  in  llu'  jkbj- 
tioiw  they  have  iu>Kiiniec],  may  V-  primary  m"  sceoiidaiy  in  tlieir  re- 
lation to  the  articulation.  In  the  latter  ease  disease  eommcnoM  in 
the  joint,  and  the  mnwlcs  arc  affected  wilwetiuontly,  contracting  ^as- 
modically,  or  bottoming  fixed  and  rigid,  so  aa  to  impede  funeiionn! 
exerc'i.Hp  of  the  joint  even  wlien  the  ori/^inul  artieidar  atTcction  a 
subdued.  Tlw  muscular  legion,  on  die  otJter  liand,  may  bo  primnrr, 
as  fai'  ut  leaMt  as  the  joint  is  conoenieil ;  from  xoinc  diittarbance  in 
the  neiTouH  »(y»tcm,  an  undnc  or  uubnlanoetl  contnction  of  certain 


AFFECTIONS  OP  MUSCLES. 


763 


miwclefi  occurs,  and  the  aniciilatioij  U  fixed  in  a  jiaitimilar  position, 
wliicti  bccwmw  [lermnnt^nt  if  tlio  inuKcidar  «itru«tnro  dejirncratw 
and  loses  its  |>mper  eoiitraclilo  niatoriul.  Sudi  a  condition  of  Hpas- 
tic  ri^'dity  k  N>nirtinic«  fuund  in  tliu  adult,  the  result  uttuilW  »i' 
serious  <ti!u?a.io  afiiv-ting  tiie  oorebra-HiiInal  axiA.  It  is  much  moro 
cuniniou  ill  i-arly  Itfc,  as  a  i^onsoquenoo  of  tlio  infantile  paralj'^itt 
which,  if  seldom  fittul,  is  frcijucntly  <|uit«  inuurublo.  lu  many  of 
tliceo  cases  tlic  amount  of  deformity  which  occurs  is  dcplui-ablc,  and 
the  maljux'tition  of  tlie  joint,  so  lon^r  its  il  lasts,  obviati^  any  hope 
of  rtimulnting  muscles  to  contract,  or  [jrcvcnts  that  cxorciso  of  tho 
iiuib  on  ivtiitrh  any  ))roit})ncL  of  improvetnent  dojx-nils. 

Rigidity  of  the  muscles,  terminating,  perhaps,  iu  atrophy  or 
on,  is  oAon  aeon  wh<-n  n  limb  liat  Ixi-n  maiiitain<Hl  for  too 
a  lime  in  one  position,  and  os|>cciaUy  wlicn  ]n'CB8uro  has  aW 
on  oxdviiiod  on  tlic  inu-tclcs  aud  tlieir  tendons,  nntl  tlii>ir  acU<»i 
itml  by  the  ap])lication  of  ti^t  bandages.  Tliis  condition  of 
ho  nukHclc*  may  alw)  be  acctitnpanied  by  gravu  nttschicr  within  tho 
joint  After  fi-actures  requiring  ])rolo»ged  immobility  of  the  limb, 
or  at  hra»t  in  wbicli  tho  limb  has  l>cc»  kv]>t  fixc<)  for  a  lotigtb  of 
time,  rigidity  of  die  parts  takes  ]>laoo  to  a  greater  or  loss  extent, 
and  in'  very  obstinate  in  it«  duration.  In  t«omo  of  these  ca»<^  and 
eqieoially  when  tlio  patient  is  aihanoed  in  life,  or  Uie  eonstitatioii 
i»  otliiTwiM)  ]inxliHpo»od  to  such  alterations,  wo  may  find,  a»  M. 
Tessier  has  }mintod  out,  effusion  of  iienim,  mixo<)  [wrbaps  witli 
bIo<Ml,  into  the  joint,  tlie  synovial  membrane  at  the  same  time  being 
injected  and  iU  va-i^tnlar  frinsc*  Knullcn.  In  otiior  cancs  the  mis- 
diicf  may  liaro  advanced  still  farther,  and  tho  articidar  cartilage 
linve  malerially  siiffcrc'tl,  br«oining  reddened  frtim  eontaet  witli  the 
effused  blood,  and  softened  in  their  structure,  or  prcocuting  actual 
loaa  of  substiuieo  on  their  «irf»ec.  Tlicw  chaugw,  it  may  be  remarked, 
are  not  confined  to  tho  articulation  in  tho  Immediate  neighbourhood 
of  the  fracture,  but  extend  to  olhiTr^  wbicli  liavc  Invn  maintained  in 
a  similar  state  of  fixedness.  Tho  imiKirtaiice  of  due  action  of  tlio 
muw.'hv<  need  scnri'ely,  tbi^rcfon.^,  be  inxisteil  on,  or  tlic  propriety  of 
having  recourse  to  passive  motion  at  the  earUest  j*eriod  ofwliieh 
tho  eonu  will  aihnit. 

Finally,  it  may  be  noticed  that  an  articulation  is  sometimes 
found  til  be  jx-rfi-etly  rigid,  from  muscular  (nnlraetioii,  in  that 
condition  of  tho  nervoun  system  which  we  term  hysterical  («» 
Articular  Neuralgia).  By  examining  the  limb,  hovrewr,  <luring 
itatural  sleep,  nr  in  tlie  insensibility  produced  by  ehlonrfomi,  tho 
relaxed  cuntlltion  into  which  tho  muscles  fall,  and  tho  free  move- 


I 


764  DISEASES  OF  THE  JOINTS. 

nu>ntf<  which  mn  Im-  iiiiprt-^'^Hl  tijwn  lite  joint,  leave  no  doubt  i 
Uw  tni(j  iiaturo  <»f  the  cast-. 

Tho  subject  of  tu)(lu<!  oi-  itii|>ain!<l  niii»«ulnr  ijontravtion,  ami  ki] 
imiulti^,  will  be  fovuid  treated  of  in  tho  essay  on  Obtikw-^dio  Sn-i 
GKity ;  biit  it  i>laj>  i*o  iiii})orlttiil  u  jmit  in  articwlnr  tliTH-ajW!,  lluii  itj 
was  iraims&iWe  to  avoid  aJI  notice  of  it  in  tliis  place. 


Dittsuet  ffffctwg  ihe  Ai'etJar  and  Adipote  TuMtea. 

Thu  areolar  tissue  around  th<*  articular  csli'PuiiticH  of  the 
or  ovei-  the  syniivial  nivinbrunc.'*,  eoininoidv  |iiirti('i|>nt<.-s  in 
easea  of  tlioso  Htrueturi>K,  and  in  eitluH*  Fiimply  cedeniatoua,  or,  vi 
w'vcr»i  oiwcs,  Ix'i'oiiU's  till)  dcst  of  abftcowi  ur  jM-TniMitod  by  Mna)«* 
At^utt!  iiitlaiiiniatioit,  on  the  other  hand,  not  uiifretjuoiilly  attada 
thn  areolar  tigsaa  in  tlio  ncighbotu'hood  of  joints,  as  tho  rcMilt  ■■( 
blowii  or  i^ontuBions,  of  woitmlA,  or  of  cnp-iipelas.  It  iktuts,  too, 
in  ninny  vaiv»  a*  a  scx-ondary  coiiwquonc-o  of  uiflamtnation  ofdi* 
Hvnovial  biinue.  Tlie  iiittainniuton'  a<rtion  frequently  rutu  M^, 
and  thcrv  h  much  conHtitutionnl  as  well  as  local  (ii&tiirbancc.  Tlxi 
Hwollinj^  i.4  confidcmblt',  tho  [wrt  i''  licit  and  tvudor,  the  !>kin  ivd- 
dcncd,  and  any  movement  of  tlje  part,  incUvding  tlio  nrticuktion,  in 
attciid<><l  with  jiiiin.  'Dicro  is  iiHiiiilly  iiiiich  tendonoy  to  suppnrati'i 
and  when  tho  Mnovial  burse  aiM  implioatoti,  matter  fomui  rapidly 
and  in  cfniNidiTabK:  (junntity,  prcjiciitin^  wine  rowjinblwiicc  to  »piH« 
abscess  of  tho  articidar  cavity.  Tlie  diagnosis,  however,  I)etw«ii 
tlii.<  iiflVftion  mid  dist'iisc  oriftinating within  Uic  joint,  is  not  (liffi<-ult. 
Tho  rapidity  witli  whieh  tlie  syinptfmis  have  come  on  dUtinguuJi  it 
IVom  disease  of  tlie  bones ;  whilst  the  jHjsittoii  of  tlio  i«welling,  whick 
esfonds  over  and  eonopalu  the  utt.'M'ouM  proniinenees,  prevent-t  it  (pom 
bein^  eotifuiindtxl  witli  synovitis.  By  carcfid  nianipnlntion,  too,  it 
will  be  found  that  the  joint  itrn'lf  may  be  handled  without  pitNliU'injI 
paiii,  providetl  tliat  no  prcssuro  or  tension  is  exfreisi'^l  ujioii  lia 
inflamed  parts  around.  Thii*  kind  of  inflaniniation  is  not  un(toniuii:ia 
iu  lU-lieatv  or  stnnnous  eliildrcn,  in  whom  it  i»  vcr)'  apt  to  invi^ta 
tlio  articulation,  unless  j^ixnit  <-aro  is  taken.  The  knee  tuid  tbo 
shonldcr  arc  tho  two  situations,  jierliaps,  in  wliicli  tlie  ofFoction  i^ 
moat  frequently  seen. 

Tlie  troatmont  in  those  oaacs  is  ftiifliciontly  obxnons.  Tlie  liinli 
must  be  kept  at  jn-rfcet  rest;  poultices  and  fomentiitions  appli«U 
anil  if  matter  forma,  eai'ly  anti  fi'eo  iiici»ona  should  bo  made  for  th* 
puqiose  of  evacuating  it,  leat  tlio  pus  shoidd  find  tW  way  into  die 
s^'iioviul  eaviU-,  and  ttio  vase  become  oue  of  serious  consequence,  { 


f  AFFECTIONS  OF  NEIGHBOCRrUG  PARTS.       765 

l\>ii<)Iving  itself,  in   tad,  into  acute  supjiurntlon  ot'n  joint.     The 

iucisinn^,  t]iough  frtK,  uliould  not,  of  c-r)ui:«c,  bo  so  ilwp  .-i»  to  opon 

llui  lutimlntion,  under  tli«  miittiken  Mim  HuA  ibU  is  iJrcitdy  iiii|ili- 

cated.    In  striunoun  cliildrcn  the  gciii^ral  livaltli  luu  to  be  Hedulotisly 

tlondtxl  to,  anit  onm  laki-u  iwit  Co  dc[i«-M  llie  ciiiiKtiUiliDiia]  [lowprs. 

^'  itii  rcepcct  to  the  atTc-ctiuiiH  of  tlio  n<t)po(M<  tissue,  tllcro  is  litde 

bo  said;  ac<.v>rdiiig  to  ItokitniL-^ky,  n  biiuicbing  growtli  »f  fat^ 

is  oc<asi(in:illy  mot  witli,  eliicfly  in  t]io  knee-joint,  in  tbu  fi-i-o 

<>r  ill  tJii.-  dnjiliciiiim'H  of  tlw.  synoviiil  incinbntiip,  (.■urTVK|K>udiiig 

to  tho  lipoma  artoroecens  of  J.  Miiller. 

J)!»eata  of  the  Synovial  Bursa, 

A  description  of  tlio  patbologieal  affections  to  which  the  synovial 
aro  liable  will  tio  found  in  tlio  f.-wiij'  on  Affkctioks  of  the 
[KiJHCUi^K  SrsTEM,  to  wliieh  tho  reader  is  referred.     Tlie  Hit»ati»n 
l«f  tho  Hubeiitancons  linr»«',  «t  Itywt  of  llionu  wliieh  lUx.'  most  liuble 
to  di.ioiw,  is  well  known,  and  tlicy  aro    at   oiieo  so  act?ea»il>lt!  t« 
[examination,  and  tli<-  ^^lll)>tonlii  att«iidanl  on  tlu'ir  n]«rbi<t  condi- 
tions  Mi  oliaracteriHtie,  that  mistakes  conoonung  them  aro  Irnnlly 
k<?Iy  to  ari!«\     111  tii«  W1.H0  of  tlio  dw|)-Hcat«<l  bursa',  howovor, 
bin  is  by  no  moans  so  eertain.     Their  diseaseH  simulate  to  a  much 
atcr  estpiit  diwiiw'  of  tho  jointu   in   tliwr  nci/;libourIiood,  and, 
indeed,  frequently  lead  diixx'tly  to  it ;  for  in  many  inMlaiiei's  tluuto 
l1)urRD  aro  enntinuoiw,  or  hava  somo  cuiiiioxion  with  the  artieular 
fcynovial  mombranos,  so  that  ilireet  exteiudon  of  ioHainniatioii  may 
■occur  from  one  to  tlic  other.     In   tlio  dcseriplJon,  thcR-fore,  of  tho 
Hpooiid  charai'tora  whi<-li  attach  to   tlio   diseases  of  the  individual 

C*  *  [j!,  I  hIiuII  hare  oce:wion  a^n  to  rcfi-r  to  the  dMp-scatcd  hnnae, 
to  tlie  nieaiu  of  distinguiidung  tlieir  affection:*  from  tltoso  of  llie 
eidatiolix. 
AiUred  CondUioits  of'tlif  liUfjumftdi  orounJ  the  Jomit, 
Tho  diarthrodial  joints  arc  intciidod  to  allovr  of  Irco  movo- 
itit  of  tlie  bonos  u-hicli  enter  into  their  composition.  If  these 
movements  aro  interfered  witli,  tlie  joint  i«  tndy  affwtcd,  whctiier 
the  M.>at  of  llie  ohi^tmction  itt  in  one  of  the  pro])er  articular  struc- 
tures, or  has  only  an  indirect  connexion  witli  thcra.  Whenever  tlio 
intcfuiineiit*  have  Ijccii  cxtcim^-cly  dwtroyod  anmnd  a  joint,  tlie 
resulting  cicatrix,  and  tlie  accompanying  indm^tion  of  tlie  Mibcu- 
tancoui*  areolar  titseiio,  may  cause  the  articulation  to  he  |nu1ially  or 


almost  wiiolty  rigid.  TIio  cook*  in  which  this  tunulljr  occors  a 
tJinso  resulting  from  extiiisivo  bums;  tuid  Iw-iw  too  wc  i>ft««li  Jutdl 
limb  ri'inlfivil  u»cle»),  and  hidpous  deformity  prwluood,  by  the  «* 
^inal  extent  of  the  injni^-,  or  by  tlw  want  of  proper  fonHliongI 
diiriti;:  the  heoliiig  prooesB.  In  the  eosaya  on  BoKKS  aud  on  PLAsn 
SuuuiiKT,  tho  importuioe  of  OMuidcring  tliv  jKHition  to  be  ebon 
l»r  tlitt  limb,  whra  tJio  bom  hui  invaded  tho  ctrcuiuforence  vf  ( 
artioidation,  bait  boon  pointed  out,  sa  wvll  m  t]io  best  means  to  i 
Hdi>|il>!d  fur  jiKrvi^iting  tiijorious  contraotion  at  tho  time,  or  k 
remedying  it  tf  it  ban  unfortunately  occuirod.  1  liavo  Uum^ 
rif^lit,  bowoi'or,  not  o.ntireIy  to  omit  in  thifi  essay  any  ulliniion  to  th 
fiict  lliat  a  natural  condition  of  tho  surrounding  intcguuienta  is 
iniporliuioc  to  the  integrity  of  tlie  joint. 


Akkylosis. 


I 


A  n-nnt  of  prociMon  nwa»ionidly  atta«heA  to  tlic  scfue  ia  whtd 
tlio  term  anlrtlosiA  is  nscd.  OriginsUy^  as  the  word  itself  iinpiie^ 
it  wa#  applied  kuIvIv  to  joints  which  Iiad  Uxmnio  fixed  in  an  to^iJa 
or  bont  position ;  rigidity  when  tlio  limb  was  straight  rweivui] 
another  desipiiilion  {op06icai\oy).  Tlio  jioution  wbtc-h  the  limb  hi 
iis8uined  is  no  longer  8|»ectally  designated,  but  wc  tt|icak  «t  tlrt 
]>i'e»cnt  day,  nimewhat  cltinfily  it  m  tnio,  of  ankylosia  as 
Init-  or  falif ;  tlie  latter,  at  m\y  rate,  having  a  somewhat 
signification  in  the  miii<U  of  many  luithurs.  By  trutt  anJcyli 
(i^((M(oni>)  igt  meant  actual  osseous  union  of  the  eontiguoiu 
Tliia  in)pli«8,  in  most  ctuas,  dndnivtion  of  tho  ontiro  joint, 
wiiirtiftitoH  ft  fnrther  or  final  stage  of  tJio  proce.'M  of  junction  by^ 
filiron-t  tissue,  wbicli  has  bocii  described  in  pm-lous  soetions,  tM 
wiiicli  form*  one  variety  of  feJso  ankylosia.  A  form  of  oaKOM 
ankylosis,  moreover,  is  sometimes  mot  with  in  wluch  tho  new  Ik'M 
is  placed  outside  tlie  artioidntiwii.  This  variety  i.t  wo#it  common  ia 
the  npine,  which  oocaaonally  presents  superficial  bridgo-likc  bony 
prooesses  extending  from  one  vertebra  to  anotlicr,  or  ovon  (onnii^ 
a  kind  of  owtcous  sheatli  enclosing  several  vortobra?. 

FaUe  ankifhm  may  bo  wtra-rapmlor,  when  Jt  signifies  a  junotim 
of  tlie  artintlor  8urfa«>a  of  tho  contiguous  bones  bv  a  com  para  tirply 
soft  or  membranooB  tissue  (the  joint-iwvity  In^iiig  partially  or  com- 
pletely dcKtroyed),  or  it  may  bo  extra-captular,  the  union  of  thfl 
bones  in  tliis  case  depending  on  adhonouH  annnxl  the  ardouladon, 
with  thickening  snd  ituhimtinn  of  tlte  capsidar  or  ligamentous  timna 
hi  that  situation.     Tli«  latter,  or  «xtra-cap«ulnr  taho  ankylosid,  ii^* 


ally  accompanies  tlio  fonner;  but  it  may  exist  alone,  aa  wns  8eiii 
ill  n  «W  rcliitwl  by  M.  Boiiiift,  wlicrc  dm  iirii dilution  was  rom- 
pletely  fixed  oven  when  swtioii  of  all  tlio  inuiwlL'!!  artunid  hsul  liw-ii 
pcrfunneil  nftcr  tlcatli,  whilst  tlie  interior  of  tb«  joint  was  iuund  to 
be  pt^rfectly  healthy,  thc>  ankylij*!*  ris*iiUin(i  frum  tliu  prt'jwaioo  uf  ut 
enwrmoiu  mnns  uf  fibrous  tbmie  in  th«  linm  tuiiting  tbo  fetnur  to 
tholibia.*  Imjiair^l  mobility  of  tliv  Joints  may  n-iiull,  nn  <loabt, 
from  other  oatLsos.  In  ifhronic  rlioumatic  arthritiit,  for  instanct',  tlie 
iili»|m  of  the  arCli-uIiir  siiHlu't'H  i--«  uituKxl,  or  bony  ve^rbitions  arc 
formed  around  thuni,  which  mechanically  impoclo  or  arrest  motinir. 
Tliv  jiiinl  may  Iw  cHpiiKiI  by  the  vontmction  of  eiealric>»  nflrr  iu- 
jiiriex  or  diBcases  affecting  the  integuments  and  contiguous  tissufw. 
Miiiuidiir  rvtriictioii,  too  {m  utlcii  prosiont  in  an<l  complicttttng 
ankyloHis),  may  alono  interfere  widi  freedom  of  movement.  TheaH 
faj«.'!<,  however,  may  be  termed  "articular  rigitlity,"  nitlier  than 
ank^'loain. 

Ankylosis  U  occaKionnlly  hccq  in  ad\'aiiccd  life  itllocting  nomo  of 
tlio  minor  joints  witliout  tho  «>xiM<>nc«  of  niucli  obvious  na1»^  b> 
Mcc-oiuit  for  its  ])re»enoe.  As  a  rule,  liowo%vr,  aitkylosis,  whotlier 
true  or  faUe,  n>siihn  from  influjm nation,  cnninion  or  Hpec!ifi<-,  which 
lian  nfii-ctml  a  joint,  and  jiroduccd  a.  certain  iimonnt  of  de»trnotioii 
of  ttio  [larts,  foUowifd  tiulh'4t><|itcntly  by  i-i'[uu'ati\'»  uetiun.  In  tho 
inajority  of  joints  there  is  little  difficulty  in  determining  the  fact, 
tlwt  motion  is  at  ImwI  impainvl,  if  not  iiltogrthcr  lost.  In  tJio  liiji 
and  slioulder,  however,  it  is  n(<cc^flsaly  to  h&  carefiil  that  increased 
mobiliiy  of  the  [x-lvis  (ctipcciaily  noticed  in  cliililren)  or  of  tho 
Bcspula  is  not  mistaken  for  action  of  tlic  articulation.  Tho  deter- 
mination of  llic  osact  caiiM!  of  the  rigidity  is  noi  always  oasj'.  In 
chronic  rheumatic  arthritis,  irregulai-  osseous  processes  may,  jwr- 
lin(M,  ho  fvit,  and  tlio  character  of  tho  (Iclbrmity  will  a.'tMxt  in  tliu 
diagnosis.  Wien  n>lra*rtioii  of  tho  niuscles  is  the  solo  or  principal 
catM)  of  tliu  impaire<l  mobility,  the  tcndonn  may  )>c  felt  rig«l 
beneath  the  akin.  If  Uic  areolar  tiitsun  around  the  entire  joint  or 
at  Olio  jiart  of  it  is  indurated,  ine\tcii»iblc,  and  tra%'<!r*cd  liy  Kinunn*, 
we  may  suspu-t  that  the  vxlra-capsultu'  form  of  fiilso  ankyloMS  n 
nut  entirely  absent  If  some  degree  of  motion,  liowcver  Hliglit,  can 
be  giwii  to  Uio  joint,  wo  know  that  true  or  osscoua  ankylosis  is  not 
prosont ;  altliough  the  converse  of  this  is  not  equally  ourtain,  for  in 
fiilac  ankyIo»i«  llio  firmness  uf  nnion  may  be  m  great  as  to  render  it 


*  Bounet  «ur  Itt  MaLiiliei  de»  AriKulations.  tout.  i.  p.  130. 


DISEASES  OK  THE  JOINTS. 


ililHntiU  to  detect  luiy  motion,  o^en  wlieii  iiui.<H>iilnr  i>]>p(MiUon 
removed  l)y  iiK-nns  of  chlorofonn. 

TrfiUtHfMt.    It  liii»  iHt'ii  iilready  o\']>lMiKtl  llnil  n  tiino  in«jr 
in  tlio  |>rogn>>*rt  of  articular  diwa^e  wlivn  it  U  necewiary  to  cxi 
tJio joint;  w)ton  ]>n»9Uvo  iiioltcm  iiiiiiit  be  luul  rcptnirftu  t<>, 
(ion  in   iw   varied   forms  n»<iduoiifi]y  oiiij>loy«l.     These 
conAtidile  wliat  niiiy  tx'  tfnii<-d  llm  [iniMiitiv*;  Iri'atinunl  of 
IomU.      Su|>)Hiniiij;  tliai  tlncy  luivo  not  hetsn  adopted,  or  iuLve 
luted  too  1at(^,  and  atikylnxiit  linx  nrtiiaily  tnk<ii  jiliKf.  tlto 
will  dv|X^Hl  {;rfut]y  on  tlio  [lOHition  in  wliicli  the  limli  Ijoh  hv 
or  iH  be<M)iuing,  rigid.     Ifthi^  |icuiiii(iii  i^  HiiiluMv  in  tnio  ai 
(»\Ti«i*to«!*),  Ko  ulif^lit  :m  lunoimt  of  further  improvcniont  cu 
hojKHl  for,  tlmt  no  intcrfcrc-ntii  ivill  pmlmlily  bi^  titternptixL     In 
or  librouH  aiikyloNi.s,  on  Uw  otlier  hand,  if  tho  i-asa  i*  itccn  st 
MifBciinilly  o-arly  period,  tlio  <Bpnend  plan  of  what  waa  termed 
vcnlivo  trratnii.'iit  iiiiiy  usually  ht>  i-»i]iloy<'d  willi  xnlHy  to 
wft  anion  fi-ora  becomiug  osseous,  and  alao  to  inerraM  aucit 
as  may  be  jircwiit,  by  nlwtching  the  soft  uniting  MnK-tnres, 
adding  to  tJie  uscfidness  of  the  hnib. 

Tiiv  joint  may  have  U<coin(!  lUikyloT^il  in  tiw  original  wnm 
iho  word,  or  at  least  in  a  faulty  jmsition,  for  the  sanu*  |M»4tioii 
not  of  otiual  u«o  in  all  articulutJonK,  or  v\vn  in  idl  olaases  ofj' 
suns ;  in  I'i-rlain  tnuh'ji,  for  iiutanee,  a  &]>ec'ial  position  ix  oAcD  <k 
«rabte.  Early  treatment,  tlicn,  is  ncei^wsuy,  if  tlio  limb  is  to  1 
reiuli^rcd  serviceable  iiutoid  of  becoinui^  simply  an  incnmbraiM 
Supfxiaing  the  case  to  bo  ono  of  faUj  aiikylo^tii^,  tho  first  thing 
bo  duno  iit,  to  plnve  tlie  limb  in  that  jxisition  in  which  it  may 
enijtluyed  to  tho  greatost  advantage,  and  6nl>«(M;uondy,  wlicn  inflaD 
miitiitn  lliL'^  HuliKidtx],  to  ini-n-aM!  the  inohiltly  of  iIki  joint,  if  U 
increase  is  eonsiderod  possiblo.  Tlio  moaiis  at  our  dis]xi<«i]  for  d 
pnrpom  of  i-vliuving  tho  dd'onnity  huw  hi^'ti  nag)ni'nu-<t  hy  inoda 
discoTeries :  by  the  eniploymeiit  of  cfdoroforai  we  aiiitihitiilv  pai 
ami  gc't  rill  nf  the  active  miweiilar  enntnu-tioii  whiuL  would  groal 
impede  our  etforis ;  and  by  means  of  subcutaneous  Sargen"  we  I 
fumixlieil  with  a--«d('  and  njady  mctlKHl  of  ov>Tv<iming  tho  paan 
or  permanently  rij^d  state  into  which  some  of  the  miiseloK  are  like 
to  Imvo  tUlIoii;  a  statu  whieh  adds  materially  to  tlie  recdslaD 
offered  by  the  joint 

Till!  r*^<pIaccmont  may  be  immodiato  or  gradual.  In  mort  uM 
where  tlio  required  aimmnt  of  ultcration  iit  ctauithmibte,  the  inun 
diafo  pi-oire-v*  i»  preferable,  tho  dread  of  mischief  arising  in  cflM 
qneiiec  of  the  sudden  change  from  o  jiositioii  which  may  have  laatt 


1 


ANKYLOSIS. 


769 


for  n  Iciipt.Ii  fif  timr,  not  bciiifj  jii.*iifi«"l  if  tlw;  oprratioii  is  j)ntj)cHy 
perfomiwi.  Indoixl,  it  is  minarkable  how  mueb  foiviblo  mauipula- 
tioii  may  Vm;  .'<ur(^lv  n)>|iliv'\l  to  a  rigi<I  niul  ili»t<>rto(l  ufticuluUcKi,  mvu 
wlioii  inilaiumntioii  is  still  in  |irogn».H,  In  many  instano«H,  liow> 
vvur,  the-  nittor.ttioii  of  ttiuipf  can  bu  vitbctcd  griiduiilly  or  twiiiilvttsU' 
by  simple  meclianical  ooiitri^amroA  cran>fii])y  adaptMl  tn  tlu>  indivi- 
dual joint,  and  in  utich  cases  thin  plan  of  trfatmcnt  may  properly  bo 
adopttxi.  (See  tho  aisay  on  OiiTHor^Pic  StrRUBRV.)  If  iniine- 
dialc  rcdtiL-tion  L*  dctcmiiiiixl  on,  it  w  di^irablo  tlutt  tlic  Surgeon 
flhtiidd  have  a  <-!c;ir  niition  of  what  he  h  afumt  to  do ;  that  Iio  should 
liavo  ilctoi'niiu<.il  tlio  position  to  )>l-  t^hown,  iind  <.-alFulutccl  the 
nb^tju-los  to  bo  overcome.  Tlie  key  to  siu>c«aa  in  the  proceutt  of 
initnodiato  ropIac«mont  oonsiat-s  in  tfio  previous  roonipalation. 
When  the  patient  ih  jilnced  under  ehlorofonn,  therefore,  the  move- 
monts  for  tlie  purpoito  of  bru.'dving  down  tho  adhcsioiu  which  have 
formed  ithould  ho  pn^[>orly  udaptett  to  ftdfit  their  pnqiose.  Instead 
of  applying  tlio  force  employed  simply  in  one  direction,  by  attempt- 
ing at  onrj;  to  I'tniishton  tlio  limb,  tlie  first  proeoM  U  to  move  the 
joint  in  every  sense  so  aa  to  render  it  aa  supple  as  possible.  Ac- 
cordiiigly  tho  limb  ii«  to  ho  altemntely  flexed  and  cxt«nd(Hl  (or,  it 
may  bo,  abducted  and  adductod  likewiao)  steadily  and  gradually 
with  somewhiit  inorunnutg  forw,  till  a.»  nuidi  «.■*  [HKV<ib!c  of  the 
natural  extent  of  motion  is  obtained.  Some  mintitea  may  elapse 
duriiij^  thi.s  manipulation  before  the  joint  appenra  to  yield;  at  length, 
porhapA,  a  eraid;ing  noise  is  heard,  wliieh  beeomes  more  and  more 
evident  as  the  movuiaente  arc  continued,  and  at  the  end,  it  may  be, 
of  half  an  hour  tlie  adhctuons  may  have  .so  far  ^ven  way  as  to  allow 
of  motion  in  all  directions  to  a  vory  conuderablo  extent,  in  u  joint 
wliieh  had  np[>cared  completely  ankylosed.  IrVhon  tlie  adhesiona 
aro  sufficiently  broken  down,  tho  Hmb  m.iy  then  bo  placed,  by  ap- 
propriate traction  and  pressure,  in  a  proper  position,  and  secured 
on  a  splint. 

Many  eases  of  atikylnsis,  it  wa*  Hlatt^J,  are  eomplicabed  by  tho 
existence  of  museuhu-  retraction,  wliioh  prevents  tho  ncccasaiy 
movement*  for  the  relief  of  the  ankylosis.  If  tlio  cxittcnco  of  this 
retraction  it  evi<Ieut,  the  muscles  may  bo  divided  subctitaneously  a 
few  days  beforo  tho  main  operation.  It  may  happen,  however,  that 
a  rotraoted  condition  of  one  or  moro  muscles  only  beoomea  mident 
during  the  manipahition  under  chlorofonu.  Ono  of  two  courses 
may  then  lie  adojitod.  Ha\-iug  restored  as  mnoh  motion  as  posaible 
to  the  joint,  tenotomy  may  be  practised  on  tho  opitosing  musdos, 
orul  tix)  nMoaindcr  of  the  operation  sus|imdod  till  tho  wouiidii  havo 

vol.  tit.  3  D 


770 


DISEASES  OP  THE  JOINTS. 


enUrcly  hcoilod.  Or,  as  Tkl.  BonnH  rec-ommendB,  after  sobcutanooin 
sectioQ  has  been  pracliMxl,  Uii;  movtxmcntK  may  1m  jiersuvcnxl  in 
till  ixtftnrution  of  the  articular  functioits  is  eflfectett  to  the  greatast 
pi'octicabto  osteiit.  If  thv  latter  plan  is  adopted,  n  vorr  lon^  bid 
fine  tciiuUtmy -knife  elioultl  be  employed,  and  the  integunieiila 
puncturad  at  a  considorable  distauoe  from  the  point  of  section  of 
tho  niiutulfl,  toAvoid  if  |i08iiih]e  tJic  mk  nttcndiuit  mii  tho  admutton 
of  air  to  the  out  surfaco  during  the  morcmonts  which  are  boiig 
peribnncd. 

As  the  effects  of  clilorofonu  pass  off,  the  pain  whlnh  is  cotpa^ 
coioud  may  bo  ox[)cdo<l  to  )>o  N^vcrv  (ur  Mino  liriun',  but  spoodfly 
Hubaidea,  without  tlie  dev<>Io]>inent,  usually,  of  any  very  severe  i»- 
fiammatoi^'  symptom*.  Constant  irnV^itiim  of  ilm  joint  may  W 
pntotiscd  for  tlie  first  day  "v  two  in  the  manner  described  in  a  pre- 
ceding soctioii,  tlie  limb  bcin^  Hccnivd  on  nn  opr4i  ^>lint  (tjic  plas 
I  it^natly  adopted  at  tlio  Hospital  far  Siek  Cliildren) ;  or  ilm  whule 
limb  may  bo  wrap|KM:i  In  cotton  wool,  sml  the  bamlago  at  nnai 
Rtaivhe<l,  as  rfloonimoiulcil  by  Bonnet.  When  the  projK-r  dirwtion 
has  boon  restored  to  tho  anlcylow^  limb,  and  any  iiiflammatoiy 
symptoms  pnxlutiod  by  the  fon^e  eniployetl  linve  subsided,  jt  is  tJuie, 
if  tho  ca«o  is  oue  which  allows  of  any  hojie  of  succom,  to  adopt  sncb 
nic«.«uri;s  un  may  tiMid  to  (K^velop  ix-nowod  mobility  of  the  jtMiitit 
For  tliis  ]iurix>se,  batlis  and  fi-ietion  may  bo  employed,  and  steady 
aJid  judiciouH  pojuivo  motion  had  rocourw  to,  whk^  may  be  }>er- 
tormed  by  the  hand  (usually  sufficient  in  the  child) ;  or  still  hMter, 
in  tbu  itiliilt,  by  variixiit  inoehanical  contrivanec^  wbieh  could  hanOy 
bo  understood  from  any  verbal  description. 

In  cstiiTiiiting  the  chance*  of  kucccm  from  these  proccedinj^  tlM 
age  of  tl>e  patunit  and  tlio  duration  of  tlie  lesion  are  inaiidy  to  b 
con^iderotb  bi  youth,  and  especially  in  ehildhood,  at  an  a^,  thai 
is,  under  sixteen,  the  results  are  usually  most  favourabla  In  nuddle 
life,  there  u  still  a  fair  hope  of  success  or  at  least  of  much  im- 
provementL  Beyond  tJiii^  jx^rioil,  however,  and  as  advanced  age  i> 
attained,  the  chancer  are  muc^b  diminished ;  and  if  the  lesion  is  ot 
old  Nljuulin^,  if  the  mthesion.t  liave  acquired  great  solidity,  or  if  tin 
ankylosis  is  conij)licated  wHth  otlier  local  mischief,  not  much  hope 
of  Iwnelit  can  iitiily  be  entertained. 

When  tho  ankylosis  is  oiseous,  the  means  alroady  spofcen  of  are 
obviouHly  inajijilieaide.  Sup{xiun;;  tJie  |K)s!ttoii  in  which  tlio  anky- 
losis has  o(rcurred  to  bo  inconvenient,  it  has  been  proposed  by  Mr. 
Barton  ol'  Philadelphia  to  remo%'o  a  wedge-*liapcd  portion  of  Iwn* 
fVom  tlto  projectbg  surtace  of  the  angle  formed  by  the  liinb ;  the 


ARTICULAR  NEURALGU. 


771 


r  i-xteiit.  "f  tJio  hroaiX  part  of  the  w«lgo  varj-ing,  of  courso,  widi  the 

amount  of  tJie  doforniiij'.     Wlu-n  tlii;*  o-iswhih  wiiI^o  [ihh  \nxn  re- 

itxirixl,  citlicr  from  the  aiikyloscil  part  itsi'ir,  or  a  little  abovo  or 

Im^ow  ihiit  )>oiiil,  1L4  mny  Ixi  (-oti«idi;iT(l  vx|io<lk'iit,  tUi;  roinniniiig 

tliickiiL-w  of  tlio  bone  is  IraotnriKl,  aiid  the  two  surfaces  brought 

bother  so  iw  to  n-ilrcwi*  tJn'  angiiliir  ilrformtty  prcvtoujilj'  cxixtinj;. 

H         Finally,  ca'«H  of  ankyloBJs  aro  som^^times  met  with  in  which  the 

^  limb  is  not.  mftrely  luicloi",  but  an  iricumbniiicf,  wliilut  tbc  tiontititi- 

anco  of  diseaso  in  the  bonps,  or  the  oxistoupc  of  other  com]>h<^ntiona 

^L  nfTccting  tlii"  «ni-riiiiruiirifj  strnotnrc*,  |>rw<rnt»  ru]dui-<^'msDt  from  liu- 

^K  ing  cffectwl.     It  may  tlien  beoomo  exjiedient  to  renjove  the  disea.-^rtl 

^■jotat,  or  even  ihc  ontiro  hmb.     Tho  jiropridy  of  such  ojioratioii* 

^P  muKt   ohvioaily  (Icjtenil  ii)>on  tlio  merits  or  pecuiiaritiea  of  each 

H  individtuJ  vom^. 


Akticul\k  I^euraloll 


We  fi-pfiuently  meot  with  ease*  wboro  iwiiiis  are  cxpcrionowl  in 

the  joint*  without  imy  iipprci-iable  maU^rin]  k^ion  to  aiwoiuit  for 

them.     In  many  instaj]ec«  these  are  termed,  and  no  doubt  comcotly, 

riicimiutlc  <')'  ;;outy  juiins,  for  th(!!((!  two  conditionit  nuiy  have  manj- 

fest»i  themsolvos  unqnestionably  in  other  artieulatjons,  or  may  nlti- 

in»t«?iy  JijiiK'iir  in  thow?  wliic-b   iiuvu  I)o<:n  tin;  i^jut  of  lli«  vrralic 

Ivnffering.    OwajsionaUy  |)ain  gives  a  brief  warning  of  mischief  about 

[■to  be  devclojKyI,  which  it  procodca  only  by  a  nhort  timo.     In  i}u> 

Ipysemici  oomUtioii,  for  inHtanoe,  a  iiharp  pain  may  ho  felt  in  »omo 

I  joint,  and  though  no  other  sign  of  diwawd  at-tion  if  pnwent,  wo  are 

Ihxl  to  oxjiei't  tiio  f'lmiation  of  matter  in  this  situation,  and  the  prtn- 

ew  of  CTcnts  commonly  jiii«tifiw  tmr  apjirehcnwon,'*. 

Tile  ]>ain  may  Itave  a  Wal  origin,  iudcpeodent  of  any  distni'h- 

toiico  in  tJitf  joint  in  wliieli  it  i*  ex|K'rIiii«xI.     Thn  pressure  of  a 

I  taniour  on  some  nervous  trunk  niay  give  rise  to  Huffering  refonrd 

[to  itn  articular  branvhc*;  and  all  8urgoonit  aro  fiimilinr  with  the 

.  that  pain  in  the  kiieo  is  one  s)-mptom  of  disease  within  tho  hip, 

'and  yet  this  sympathetic  aSV-clion  may  m  insMk  the  ririginal  ili.»i'jL«e, 

that  J  have  IVoqucntly  had  children  with  diseased  hip  brought  to 

Imc,  in  whom  blisters  or  other  local  remedies  had  InM-n  npj>li«(l  to 
tliu  knoe,  unclcr  thi;  iiW  tlial  it  was  tlie  seat  of  misehief. 
Unquestionably,  howei'er,  tI»o  majoritj-  of  thew;  cane*  arc  dept^n- 
ch^nt  on  that  abnormal  ondilioii  nf'tlic  nen'ous  fnntrtions  which  is 
termed  liysteno-al.  Tlio  eondition,  indeed,  is  not  absolutely  (^in- 
fined  to  Ihv  femalo  sox,  a;t  the  original  ngniticAtion  of  the  term 


IHSEASES  OF  THE  JOINTS. 


1 


wo[il<l  imply  (vwrepa,  wmiili),  for  it  niar  occasioiuilly  be  met  witli 

in  iiuilt-K,  Uioiigit  fiir  less  frequently  t]tiui  in  tJic  utlH^r  m-n.     Wbn 

tliin  <^xaltcil  or  cxeiUnl  cuiiililitui  (if  die  nennm  fiystoii)  |ire\'aiU,  a 

loc*)  (Liri'Rtion  in  oftim  given  to  tho  pcrviTlcd  eciiiubility,  by  tfmm 

aocidental  foii(?Mitration«ftJw!  "tiltmtioii"  on  the  pnrt.    Tlie  jiliyHo- 

logical  t.-tU><?t»  of"  uiiduo  "  attention"  on  or^;&n8  am  of  prcat  in 

luul  eerx'o  to  uxplatii  nixiiy  i-uriciin  {iluMuinumi  exhibtte*!  in 

disturbed  condiUons  of  the  iier^e-cenOr*,  wliidi  may  be  ini 

artificially,  h«  in  iiy]>nQti!<m,  or  ariiw  rnun   ie»»  obvious   internal 

cauKCH,  as  in  bypochondrio&is.     1  sm  unable  in  thin  essay  to  de\'ot» 

more  spacu  to  t\u»  suhjcet,  but  mu.tt  confine  mvM^lf  to  u  simple  notice 

of  llio  effects  u'hich  may  ho  produced  by  involuntar)'  or  autonuQc 

"  attention."     A  woman  is  hrouj^bt  into  dotto  rdution  with  some 

ono  vnllt^rin^  from  cancer  of  the  breast;  tho  attention  ia  direoted  id- 

ii-oluntarily  to  tlic  cornisponding  orpjiii  in  hi'Jiii'If ;  tlio  pai-t  bocoiiM 

painful,  swelling  even  o<rcuni,  and  what  is  termed  neuralgia  of  Uv 

breast  is  set  up.     A  case  is  relnttrd  of  u  geiitlcnuui  who  lost  an 

intimuto  frivnd  from  oancer  of  the  (Bsophngos:  the  sufferings  wludi 

he  witnessed  made  a  stjong  iuipreiwion  u]>on  liis  mind ;  he  bc^ 

hinuxOf  to  ■■x))cr!eiioi>  diihculty  of  swallowing,  and  ulltinutcly  died 

from  tho  offccta  of  spasmodic  dj'sphagis. 

In  livistcria,  wIhii  tho  ntti>nti(>ii  ha.*  been  fixed  on  nn  urticiila- 
lion  from  mental  or  from  emotional  cauikis,  or  in  consequence  of 
sonic  slight  iujiin.',  symptoms  which  might  bo  fiipi>oi«vd  to  indicate 
structural  disease  of  the  joint  are  apt  to  show  thcnisclven.  TIjcpb 
is  groat  paiti ;  pain  out  of  projHirtion  (o  tho  otitcr  »ytnptoine,  aal 
fmiuently  extending  over  a  largo  sarfac«,  bat  ofkai  auapended  t 
tlio  attention  is  divx-rtod,  and  coniplct<'!y  iibstriit  during  sleep,  whid 
iniiy  bu  prolonged  and  sound.  The  tendemeM  is  also  exiiggcralnl, 
and  usually  groator  in  tlio  integmiicnt^  tJiuii  in  tho  deeper  strno' 
turoH;  it  i»  Hltlo  felt,  too,  on  firm  pressure  on  the  articniiir  nnrisco 
oBbcted  &om  a  distance.  Tlicra  is  sometimes  a  slight  amouni  of 
sweUing,  which  is  diffused  in  the  external  areolar  tismio,  and  anM> 
from  a  turgid  condition  of  the  small  vcwcla,  or  from  increaaed  effii- 
sion  into  tlic  arcoliir  int4'rs]>acea.  On  handling  the  \>»ri,Jiruerfpi' 
lathn  ia  often  felt,  evidently  situated  near  the  sor&ioo,  and  diAijnn^ 
cnKcntially  from  tlie  grating  or  crackling  wliicli  may  be  attendant  on 
removal  of  tho  cai'tiiages.  Krcqucntly  convuhuv  or  s/XMnotlic  mfiem 
of  the  miucUt  is  indiicod  by  any  ntli^nijit.  to  bond  or  straighten  tbs 
joint ;  or  sometimea  there  is  a  more  permanent  rufiillitf^  by  whicb 
the  limb  is  fixed  in  Homo  impropiT  position.  \\'Iicn  lolition  is  sm- 
pcndcd,  liowevcr,  llie  rigidih*  and  tlio  spasm  ore  suspended  likewise. 


ARTTCULAH  NEUBALGI 


General  Kymptoms  indicating  hysteria  arc  otlnn  |ir<»ent;  in  iiuiiiy 

l^flUQl  titere  is  Iinbitiml  ooltlncu  of  t\i<i  vxtrcmitios,  with  oUtcr  ovi- 

FdniM  of  wt?ak  oirouktion ;   but  urticiilar  notii'iilgia  itt  8<inu!liin4>H 

•eon  in  nU>M  siitl  florid  girlti.     Somo  irregularity  of  tlietuonstrtuO 

fimctions  i§  wiiially  preetcnt 

Tito  iltagiiosis  in  tlicso  cases  U  gcnonilly  not  ditlicult,  for  it  ts 
commonly  oatiy  to  detect  tiyniptonut  wlildi  iinexjtiivoojtlly  vary  front 
l}iOK«  which  would  bo  induced  by  true  structural  disease.  It  may 
ho  iiientioncil,  liowcvrr,  thut  in  old  ciutcH  thft  jiaiiniit  may  linvo  iic- 
((uircd  so  much  information  regarding  tlio  §\'mptomB  which  ought 
to  bo  pro»ent,  that  h'-**  (■hancu  is  afionled  to  the  Siirgi-on  ol'<letcct- 
ing  any  palpable  iiiconHistoucy.  Whcro  any  doubt  exists  as  to  the 
true  diaruct^r  of  ilio  nllt-etiun,  time  Khiiuld  be  lakcii  before  a  potti- 
ti%e  opinion  is  pronounced;  a  cai-efiil  cxamuiation,  too,  sliotdd  be 
made,  to  detect  mid  remove  any  locjd  eaiwo  of  ncr\'oii!*  irrilation ; 
for  those  Hviiipatiiotio  paina  may  be  maintained  by  disturbaneo  of 
rfttru  witli  whicli  there  it  no  direct  norvoun  eominunication,  wkI 
llief  of  the  one  ivill  be  foUoivod  by  cessation  of  the  otiier. 
The  gtiiiural  principles  of  tlic  treatment  ha%'e  bwn  laid  ilowii  in 
r  tim  essay  on  lIvHTKitJA.  In  mo»t  casea  tonics  and  antiApasmodica 
I  are  kciiHicial.  Groat  attention  slionld  )w  paid  to  the  due  action  of 
tlio  »kiu  and  li\'cr;  and  where  a  tendency  to  jwriodicity  U  prenenf, 
qiiinino  is  of  marked  serviec  Change  of  air  and  occupation  aro 
benefieial,  especially  rividciico  at  the  »on-«ide,  where  .'*alt-water 
Iralliing,  general  or  local,  can  be  easily  enjoyed.  The  patient  slxHild 
be  urg«l  jincl  oneonraged  to  uso  the  arlicidation.  If  the  limb  is 
contracted,  and  any  attempt  at  restoring  the  joint  to  its  natural 
|H>tittion  i«  Wrongly  re*i>ttcd,  chloroTonn  may  I«  hail  n?coui'se  to, 
and  the  part  maintained  afterwards  for  a  »/iori  tinio  on  a  splint, 
witii  ftdvaiitago ;  but  exercise  of  the  joint  should  upeodily  Iw  on- 
librced.  Tlio  moral  treatment  to  be  adopted  is  of  material  import- 
twcc.  TJio  atUTution  mn«t  tfsi>ccially  bo  dinx-tisl  elucwliere,  and 
Jiy  oecupatiou  {pven,  if  possible,  to  tlio  monlal  aa  well  as  lo 
bodily  functions.  A  judicious  mixture  of  iinnnesw  wilJi  kind- 
ncA«  must  also  be  exhibited  iHitli  by  friends  aiid  Sm'gcon,  and  tho 
coiiGdcnco  of  tite  patient  acquired,  which  can  no'vr  bo  done  if 
any  form  of  dvcc]>tion  i#  had  ri'conrse  to,  aa  has  sometimes  bc«a 
reconunondcd. 


774 


5EASES  OF  TBE  JOINTS. 


Ikjcries  of  THF.  JoiSlT'. 

WmmeU  cf  Joint*. 

Tbo  jvints  nro  lUblo  In  ^ariotu*  luvl  Mvere  injuries.  Tlw l^a- 
inonU  nnd  utlii>r  Hoft  pnrttt  in  tlic  neigbbotirh'xMl  niny  bo  ftn)int«I  "r 
oUicrwiKf  ilninngiul ;  Ihw  Imiw-s  iiuiy  bp  mkIiIihiJv  fonHnil  a[iart,  mi 
tJieir  natural  relation  to  eacli  other  altorwl ;  or  a  (hurhire  may  erAmA 
into  aiul  ii»iilicnt«  bh  ntliiniliitiiui.  'Hu-si*  injuries,  Iw>wt-vM-,  hate 
already  been  described,  generally,  imder  the  licadN  of  DislocaTIOS 
Mid  I'iiACTDBE,  or,  as  they  nftoet  lire  indivklual  joints,  in  tiie  cmaTi 
whi<-h  treat  of  injurioft  in  the  different  regions.  The  subjcul  "f 
teoiinth  oj'thf  artindatwM  is  the  only  iine  tlijit  ivmains  tlu'iTfiire,  to 
lie  noticed  in  tliin  \Asu-e. 

In  treating  of  wouod*  of  the  joiiit.4,  I  dudl  confino  myself  to 
ihofe  whinh  actually  jH-netxate  the  synovial  membi-ane,  "Die  wound< 
may  Ijc  punetured,  inciswl,  or  contused.  Tlic  frravity  of  n  puneturti 
wound  is  infliienuctl  to  a  eortain  extent  by  tlie  eourse  wliicli  it  laics 
as  well  Of,  by  the  nature  of  the  instninicnt  wttii  which  it  is  inflicud. 
When  oliliqiu!  in  ic.-<  dirertlon,  of  nairew  dimon§ions,  aitd  iiiiidi*  with 
a  sliarp  clean  wea|)on,  it  «iiTe»|>ondi*  to  the  womids  protluced  ill 
oubrutaneouFt  Snr;;ery,  and  ii«»  comparatively  little  leiuic-iiey  1o  gire 
ri»o  to  Kujipuration  ;  a  dirc«t  wound,  on  tliv  other  hand,  even  of  the 
suRie  KiJio,  IN  more  prouo  to  3>roduoc  serious  misehicf,  c^jicdiiUy  if 
it  is  made  wit]i  a  blunt  or  jagged  instrument.  To  a  certain  ex- 
tent, (he  wnuc!  i)ljwrvatii»iii»  apply  to  mnfrd  woumiN,  but  flwr 
greater  dimensions  much  increase  tlio  chance  of  the  a<lniis^on  of 
air,  and  of  the  Mipervcntion  of  de«lructivo  intiiuiimjition,  whatin-cr 
tJio  direction  they  have  taken.  Co'itnuM  woumb  of  a  joint  may  be 
inflicted  from  within,  or  from  without.  Tlio  foniier  have  li«fl 
described  under  the  head  of  Compotmd  DiHloeation ;  llie  latter 
arc  produced  by  heavy  or  blunt  instruments,  and  arc  fonuidabfc 
from  the  injniy  of  tlio  soft  jinrts  they  involve,  and  tlie  c<)n.'<c4iuoiit 
chance  of  mortification,  as  well  as  from  the  inflammation  tliey  nugr 
he  expected  to  induce. 

Under  favourable  circiunstanoes,  tlio  Mlgcs  of  an  incitted  or 
puuciurtxl  wound,  if  muintaini^l  in  perfect  apponition,  may  muto 
i«iw*'ilily  by  tlio  processes  described  in  the  eway  on  WoiNns,  and 
the  articulation  Ix;  rc«lori?d  to  a  somid  and  heallhy  condition.  When 
tlie  wound  is  much  contused,  the  edges  gaping,  or  when  other  cip- 
cnnutances  nre  not  favounible,  h-i  ere  iiiflammBtion  li\\ityn  jtlace,  sii|>- 
piu^tion  rapi<lly  ensues,  and  destruction  of  tJie  joint  maybe  ex|(Ocifti 
to  occur.     Tlio  mischief  mnj-  not  fvcn  bo  confined  to  liio  articola- 


TVOUNDS  OP  JOINTS. 


775 


tJuR ;  pyicniia  mity  1x-  ostnblUhcci ;  or  thv  patient  may  sink,  oxhntistixl 
by  tJit'  profiise  didcliiirgv,  iiiid  tlie  ft-v<'r  i-xoitwi  by  ibc  Ificiil  irrila- 
tiiJii ;  tiicrti  is  also  a  risk  of  tetanus  making  ita  appearance. 

Tlu-  vnurntH  of  till:  grave  chiinwttT  of  tb««e  Ii'moua  are  not,  [ifr- 
I  Imji*,  diffionlt  of  comprelicnsioii.     When  early  union  does  not  take 
1  plaoi',  iiNit  n-pnir  liiw  lo  hv  viTitit^iX  by  wliat  is  called  llw  "  ftucou<! 
1  intention,"  sup|)uration  (jccuts  ;  but  tbo  ntnttcr  is  formed  not  nionily 
at  tliii  iliviilwl  Mtrfaoc'*,  n»  in  ordinary'  wounds,  but  extends  to,  and 
!  BCfiiumlates  in,  a  lai'j^e  and  ohen  intriciilo  njniovial  taivity,  wliii^h 
low  not  coininuniuite  fixH;Iy  witJi  tl)u  surfiico,  but  allows  of  burrow- 
ling  and  eonfineiucnt  of  tlio  pu^,  and  sn  fitvonrs  its  deoonipnuition, 
jwitii  tlio  consi.x| u cut  CO II stitutionnl  disturbances.     Tlio  structure  of 
fiome  of  the  tisAuca  wliich  (una  tlio  wall.t  of  tlio  cavity  in  also  most 
'  unfiivourablo  when  EU])piirntiou  has  veeurrcd  ;  instead  of  boiug  vas- 
cular and  full  of  lifr,  wtl  :uid  ittilu  to  npjiroximnto  and  oontraot,  the 
carliiaginous  surfaces  in  tlie  joints  an>  unyielding,  and  so  low  in 
|iliwr  viudity  as  to  bo  littU^  c«|iid>Ic  wf  otlbrts  ut  r»?pnniti»'o  iii^ion ; 
1  when  the  cartilages  disappear,  tlio  oeseous  atnictures  wfiieh  arc 
posed  arc  tlifmsi-lves  fur  less  adapted  for  the  proeosit  of  granu- 
[lation  tlian  Uie  softer  tissues,  and  obliteration  of  the  pii^fomiing 
I  CJivity  Ijwonitst  a  slow  and  tedious  process,  ofU-ii  iiit«rru|rted  by 
[local  or  constitutional  inishaptt.     Finally,  even  if  repair  dot^  take 
[|i]acc,  it  ha«  boeii  etlcctod  at  tlio  expense  of  tlto  funtrtlous  of  the 
IjNtrt;  for  union  of  tlie  opposing  surfaces  of  an  nrticnlalioii  involves 
*  ankylosis,  and  consequent  loss  of  mobility, — the  piuTMSc  for  wliidi 
'  tfao  joint  vim  vniiHtrnetcd. 

When  a  wound  exists  in  Ibo  neighbourhood  of  an  artJenliitJon, 
it  may  \to  of  such  a  »tz<>,  and  have  so  friH.-ly  t^xpuned  the  interior  of 
tbo  joint,  tltat  no  doubt  can  oxi&t  as  to  its  extent.  In  ceilaiii  caiwi», 
Llwwever,  il  is  not  always  easy  to  dcttinniiic  wlicther  tbo  Hx-novial 
membrane  has  been  injured  or  has  remained  intacU  Wo  arc  guided 
in  our  opinion  by  the  j^esilion  of  ttio  wound,  its  <lirccti«ii,  ilie  degree 
of  penetration,  and  the  form  of  Uie  weapon.  Our  diagnosis  may  he 
F  BaHSt«d  by  the  flow  of  synovial  fluid;  but  the  abscnoe  of  .tynona 
docs  not  prove  that  tlie  articulation  is  uninjured  (for  ita  escape  may 
bo  prevented  by  %'arioiu  circumstnnoce),  and  its  proscnoe  is  not  con> 
ciusixe  in  favour  of  injury,  for  tlie  fluid  may  loive  been  discharged 
from  a  H^-no^ial  bursa  or  &om  a  tendinous  sheath.  When  iiny 
doubt  exinta,  the  odvivo  uf  the  [wet,  ■' where  ignorance  is  bliss,  'tis 
foUy  to  bo  wise,"  may  safely  bo  token ;  at  any  rato  researches  with 
a  probe  had  better  Iw  avoided,  and  t!ic  ease  treated  at  lirxt  an  if 
penetration  bad  nudoubtcdiy  occurred. 


77C 


DISEASES  OF  THE  JOIKTS. 


1,  and^ 


The  (hiigcors  aitondaiit  on  a  wound  i.'\toti(lmg  into  an 
lion  arc  tni1tu,iit.>vd  hy  ne^oru]  circuiustiuioert.      In  early 
wounds  ju-e  usually  stteodcd  wiUi  Ices  teveniy  of  ^-mptonis  than  at 
a  more  advancL-il  :if^-,  hihI  a  <^iA  oii.itititlinti  h  mom  likely  to  {!o 
well  liutn  Olio  which  has  bocn  broken  down  by  prolonged  debsmcbcrF. 
A  KDinll  joint  will  (Mtcn]>e  witli  impunily  wlicn>  n  largo  one  wooU 
he  destroyed ;  and  even  if  the  ariitiilation  is  dcelroy«J,  the  gemT»! 
disturbance  may  bo  trifiiiig.  The  npjH-r  cxtmnity  i--*  nion;  invoiinJjh" 
.sitnated  than  tlio  lower,  as  far  aa  tJie  chance  of  recovery  b  con- 
«-nicd ;  iind  finally,  a  wotind  iiifliL-tcd  witli  A  xlinrp  iiwlrtimcnt  a 
more  likely  to  luitte  tlian  one  which  has  been  attended  with 
violcni-o  to  thu  soflor  tigsiu^s 

In  nkanaglng  u  woiiiul  of  a  joint,  it  becomes  evidently 
highest  importance  to  procure,  if  poMtble,  itninctliiitc   union 
pruvcnt  Uic  oceumHii.'e  or  check  the  spread  of  infliuumation.    Everr 
wound  involves  a  tendency  to  it1flaIn^lutor^'  action ;  but  tlto  smaller 
the  amount  which  i.-s  cxcik-ii,  and  the  more  complete  tlie  nbitonce  of  ^j 
infUnimntory  exudation,  the  better  the  form  of  healing  wliich  occun.^^ 
Tlio  fixe  of  the  woiuiil,  nnd  llie  di-grco  ofvitdenco  witJi  whScli  it^H 
was  iuilictetl,  are  elements  in  the  production  of  intlaniniation  oiiW 
which  wo  have  no  «Hitrot;   m  third  dentcnt  ia  the  duration 
amount  ofcx]>osure  to  the  ntjno^)here;  tliis  js  within  our  reaeb,,! 
and  the  itiiportaneo  whicli  lias  long  Ik<cu  attjichcd  to  the  j>rcvcntion 
of  access  of  air  to  a  wounded  joint  is  fully  justified  on  (heoretical  as 
well  ns  on  practjcjd  grounds. 

When  there  ha.i  liccn  luticli  laceration  and  eoiitu«on  oftliesoft 
parts,  little  or  no  chance  of  inimodiate  union  exists.  For  llis 
desoripf  ion  of  the  innniigeinent  of  tliin  class  of  wounds,  howevert; 
the  render  may  conveniently  bo  referred  to  tho  essays  which  treat 
of  Qtm-^hot  WouikIk  and  of  CoiDpoiiiid  Dislocations  ;  for  oontUied 
wounds  of  joints  usually  fall  within  one  or  other  of  tlR-sc  two  cate- 
goric*. In  punetiirtid  or  inei»i,'d  wouniU,  if  seen  at  a  Kutfieii'nUy  I 
early  period,  Uie  treatment  is  directed  to  procure  rapid  union,  and 
prcv'cnt  tlic  oceunviict^  of  inflammation,  or  rwlucc  it  to  a  minimum. 
For  tliia  purpose,  wo  retain  the  wouude<l  surfaces  in  close  appoitilion, 
luid  adopt  such  measures  as  will  insure  [wrfeet  immobiltly  ofthv 
joint,  whilst  wo  exclude  all  exposure  to  tlio  air.  If  any  foreign  or 
detached  body  is  present, — a  piece  of  glass,  for  in»ta»co, — it  is  care- 
fidly  removed,  and  the  wound,  having  been  gently  cleaned,  must 
tlien  be  cliiscd  tfl'cctually,  and  its  surfaces,  for  tlieir  ontiru  depth, 
kept  in  close  and  .-vteiuly  apposition.  Tlie  mode  of  cfTecting  thit 
nnist  varj-;  wliero  only  a  small  jmucturc  cxist&,  it  inay  bo  sufficient 


I 


rOUNDS  OF  JOINTS. 


I  ifpljr  n  piece  of  lint,  nOiicli  may  be  soaked  in  blood  or  covered 

fioUodioii;  iftho  wound  is  of  HOme  extent,  somctliing  inoro  is 

on  tliu  wliolc,  sitturc^M  arc  prtfi'mble  to  adhesive  plitstcrs, 

[^bwUible  to  be  iltRturlied,  and  Bdmittingof  tlie  »[iplicnUon  of 

ro  to  tho  part ;  the  twisted  suture  appears  to  bo  the  most  effi- 

t,  ii»  it  maintains  the  dlviihil  -lurfnceH  in  contiict  to  a  eoniridcniblo 

nic  limb  must  bo  carcfiillv  secured  on  a  splint,  or  otlierwise 

I  in  tliat  position  which  will  bo  nn>»t  iidvantngooiw  to  the  patii-nt 

rigi<iity  ultimately  occur.     As  jierfeot  iinniobili^  is  of  llio 

inijioi'tunoo,  tho  Kplint  must  be  cnrolully  solcctcd,  so  as 

ntUy  to  prevent  any  aiticidar  movement,     Tho  immediate  and 

ilinncd  apjilinitiim  of  cold  tu  tho  part,  In  tho  foi-m  of  in'igation 

[of  iced  water  in  ^uloaiiiaed  india-ruhher  hags,  i:*  usually  uttendwl 

bth  ^-at  a<Ivnutngo  in  preventing  or  subduing  inHammation.    Tho 

treatment,  at  an  early  period,  should  be  mnderalcly  nntl- 

tic,  withont  pomianeully  lowering  tlio  strength,  all  of  which 

'  required  sliould  evenii  take  an  unfuvourubli;  diivctiou.     If 

jlive  inflammation  occur,  it  will  be  expedient  to  endeavour  to 

it  at  the  very  cointiu-nccmeiit  by  ovcrj-  mean:*  in  our  ptiwor ; 

inflammation  in  this  case  imports  the  most  serious  mischief. 

i^tnatmvut,  thorufore,  bolli  general  and  locul,  adapted  fur  acuto 

Jon  may  now  bo  jironiptly  ad()]>te<l,  but  used  with  dis- 

and  not  persevered  in  imneocssarily  when  circumstances 

et  ojdl  for  it.     Care  should  bo  taken  not  hastily  to  diwtiu'h 

lint  op  tlio  BulurcB,  which  may  ho  left,  indeed,  with  advantage 

•  many  days,  iKTlmjis  a  week,  or  so  long  u^  tlioro  ia  any  hope  of 

,  being  obtained,  imlcss  their  removal  is  rec|uirod  to  give  exit 

*or. 

spite  of  the  measures  adopted,  or  in  consequence  of  the  c«ise 
too  Into  under  treatment,  intiiimmation  may  run  high  and 
Atioii  <jc<:ur.     When  matter  has  un<iuaitionalily  formed,  any 
opt  at  union  is  abandoned,  and  froo  exit  aflbrdol  to  tlio  pus, 
'  hy  enlarging  the  original  woimd,  or,  if  necessary,  by  making 
I  btoteions  in  a  more  dqwnding  |>ositiou.     Tlio  further  progroM 
\ike  CMC  docs  not  differ  materially  from  tlint  already  described 
'  the  hewt  of  Suppuration  in  Joints  (seo  p.  712),  to  which  tlto 
■  is  eonscquiTitly  referred. 


PART  II. 


DISEASES  OF  INDIVIDUAL  JOINTS. 

The  liinitoil  space  at  my  disposal  i-eqnires  Uiat  any  obsen-atuots  I 
have  to  offer  ns<j>octiiig  tJic  jnfiiliiii-ilii-*  jirL>^-iitc<l  by  UiKcaM  »s  il 
oSbots  individua]  joints  should  be  esti-cmcly  brief. 

DUea^fs  of  the  IHp. 

No  othor  articulatiuti  prcMiibt  tnich  (URicultMiA  in  iXMtpoct  to  tlie 
din^iioniK,  and  [tcHmpA  tJte  treatment,  of  its  lesiras  ae  the  hip,  owin^ 
to  tJio  de])t]i  »t  which  it  l»  situatt-d,  llio  mKM  of  soil  parts  whki 
tturroiiiiil  it,  uiul  tla-  little  leverage  afforded  by  its  upper  attaduiwat 
in  tlio  pelvis.  At  tlio  luimo  time,  unibrtuimtcly,  disease  of  tliK 
joint  \»  met  with  only  too  fn.-c|uc'ntly,  and  conHtJtntea  one  of  tfae 
most  troublosome  lesions  to  wiiieli  tii»  human  tramo  ix  liable. 

An  in  other  jointi*,  tlic  Htmdtnvs  in  which  diseaso  for  tlie  miet 
part  commences  are  the  sj-novijJ  menibrano  and  tho  articular  cx- 
tiuniilii^s  oi'tlio  Iwne^  Some  autliotv,  indeed,  liave  laid  i^twt  iiins» 
on  Uio  amount  of  miseliief  which  is  Eometimes  found  in  the  liga- 
incntnni  l<'iv.s  at  an  early  )xirJod  of  the  diiH^wtc,  nnd  liav«  contt-ired 
that  this  structure  is  oUcn  tlie  first  to  suffer ;  it  may  be,  howevis, 
tliat  tho  (.-oinplctt^  niamicr  in  w]uch  this  ligament  it.  surrounded  U' 
tlic  i<^iio%'ial  »iond>rano,  and  ilia  consequent  intimato  relation  ol*  Uie 
two,  lut)  conccniwUn  the  destruef ive  effects  of  artiotdar  disease  Dpoli 
il,  tiar  intvnitd  lifjiuiicnt.-*  niiplit  Imj  exjHXtixl  to  suffer  earlier  and  to 
a  greater  extent  than  those  wliicli  ai-o  iilacetl  external  to  the  joint 

Cvtmnon  /••fnwitU,  as  a  prtmarj'  ailin-tion,  is  k-ss  frM]uent  in  die 
hip  than  in  the  su]wrfieial  joints ;  though  when  it  occurs  its  sj-mp- 
toins  arc  usually  severe,  and  tlie  "ufferiiig  cxjiorienccicl  cousidcr- 
able. 

Strumous  aywcn-iVw  nnd  ostitU.  The  diwa-to  of  tlio  hip  whjeb  is 
most  common,  and  \vhi<!li  is  so  oilcn  met  witli  iu  ear^y  life,  is  »tni- 
inoiis  influnimatioii,  sometimes  eoinnieueing  in  tlie  syuovial  mom- 
braiie,  hui  Irequently,  also,  in  tlie  ai-ucnlar  extremitiea  of  tlio  lioiies. 
As  tills  di.^cosc  often  occurs  at  au  age  when  it  is  difficult  or  imjios- 
siblc  to  obtain  any  definite  infornialioii  from  tlto  juLtivnt,  we  are 
frequently  reduced  to  an  observation  of  tliosc  syiuptoma  wliieh  an; 
viable  to  the  eye.     Tho  special  points  in  llie  t^iptouts  whieh  most 


DISEASES  OF  TI 


i 


^i 


ittnict  iittciitioii  arc,  tliL-  poi>itioD  n-liicli  tho  limb  tuwuntcA,  I)ki  sent 
if  tliQ  piiin,  aiul  llie  louulitic:*  m  whk-ti  iLbt«ct>.<teit  may  niako  their 

appe^irancc. 

Ai\t<r  limping  Iihk  cxLittDl  for  it  viu-iabl«  tiin«!,  ami  iiiiin  haa  cvi- 

dflnUv  bocn  folt  on  excrciso,  some  alteration  will  usually  be  notjcvrl 

I  ill  tJic!  piwilioii  of"  tlitt  liinb ;  fin-  tiic  femur  itoart'cly  «vcr  prowrvos  lU 
ifoper  lUrection  in  tills  form  of  hip-<liiKuise.  Tho  thigix  is  bout  or 
Acxvtl  oil  tbc  jkIvih;  tlmt  \^,  tlio  daIk  of  tlio  tliijcb  <i»'l  timt  of  (ho 
pelvis  fonii  with  oiio  another  an  angle  opening  for>vaixla.  Combineil 
witJi  this  flexion,  wlii«li  in  very  wldoin  gSmpU,  an?  two  ]>i-in<^'i)>ul 
ileviations ;  in  the  one  case  we  find  inclination  and  rotation  mtlieai-Js^ 
atttiuk-d  witli  n]i[>arcnt  elon^rstioii  of  tbo  limb;  in  lliv  otbi.ir,  tliiro 
are  in<-liimtioii  and  ix>tation  vimirdi,  prndnring  ajtpnrent  slioilening. 
Xbu  CKU(H.«  of  tbesL-  apparent  altrratioiis  in  length  are  mwchHiiiettl ; 
i)np[MiHin^  the  femur  to  lie  bftnt  iil  an  art^le  on  tlic  |)olvi!*,  and  tlie 
foot  turned  out,  wlien  the  })atient  tries  to  stand  or  walk  tbo  wei^^bt 
of  the  limb  has  to  l>e  .'>U])jM>rte<!,  but  in  ortler  tliut  lint  fool  may  reai-b 
tiie  ground,  tliat  8ide  of  the  pelvis  it  <{eprei«od  an<t  advaiieed  tn 
fmnl  of  tho  other ;  in  tliis  nay  tho  lintb  appear*  to  Ixi  elongated. 

tlu  the  opposite  condition  of  flexion  combined  H~itb  adduction  and 
rotation  inwanl-*,  tbo  corri-»[«>n<iing  wide  of  (he  pelvis,  fi>r  a  similar 
reason,  is  raised  and  carried  backwards ;  a  poHition  which  involves 
sppjirent  xhortonin^  when  an  attempt  U  made  to  placu  the  limb" 
|)arallct  with  one  another,  Tlie  position  which  i«  recommended  as 
beal  Miibod  for  examination  is  that  in  which  the  trunk  and  tho 
Itnmd  limb  are  perfootly  straight ;  the  nature  of  tbc  ulteratioii,  as  it 
sfTocts  tho  diseased  side,  u  then  moro  oridcnt  than  if  tho  two  Uiigha 
^^  are  plaeed  parallel. 

^  The  fixed  and  altered  direction  of  the  affected  extremity  soon 
entails  secondary  deformity  in  other  part:*,  mjwcinlly  in  tho  apine. 
jHWIien  th"  thigh  is  fixed  at  an  angle  witli  the  pcbis,  in  order  ttial 
^■the  weight  of  the  extremity  may  bo  supportwl,  the  [x-lvi^  'umAC 
H  becomes  inclined  forwards ;  to  conipcnsato  for  this  inehnation  and 
maiiitjiiii  iJie  balanee  of  the  body,  the  vertebral  column  is  JtUrwiigly 

»  curved,  producing  a  deep  hollow  in  the  hmibar  region,  with  cor- 
re«[K>nding  projoetion  of  Uic  alxlomcn  anteriorly,  Tlio  exact  nature 
of  this  secondary"  dofoimity  is  readily  seen,  either  in  the  recumbent 
or  in  the  erv-et  posture,  on  Huj>[>orting  Die  affected  Umb  at  the  angle 
whidi  it  lias  assumctl,  when  tho  pelvis  and  a]>ine  may  caaily  be 
restored  to  their  natural  direction.  Lateral  deviation  oftlie  spine 
may  also  be  induced,  to  eompensato  for  tlie  lateral  incliiialion  or 
twisting  of  the  pelvis.    Tlio  pelvis,  it  will  be  noticed,  shifts  or  alters 


780 


DISEASES  OF  THE  J( 


its  poaiUon ;  and,  uidtwl,  iiK-r<oib<4^i  nioI)ilir; 
tioiu  oftvn  oocurii  to  an  oxtraordinai^'  « 
Rtagcs  of  Iiip-<li«;as«,  wlii^ii  ret'ovcrj-  in 
\<m»  (H-  rijridity  of  the  liip  itseIC     In  itucli 
Mnount  of  motion  whi(^il  boc-onioe  dcvclopo 
chondni«if  :m(l  ollior  n4^ighl)ourillg  joints  i 
naltiral  mobility  of  tlio  liip.  and  eauily  dpccr 

The  a>iidilioTi  of  niipiiTOnt  itliortoniiig  fr( 
aj^arcnt  longthcning,  though  it  may  oocac 
liiu  ovt-r  nittilifi'j»tcd  itwlf.      Is  ilicro  evor 
length?    Though  many  causes  have  been  j 
give  riso  to  actual  tlongation  of  tliti  Hmlj,  itj 
any  of  tJintto  lOiould  actually  oeour,  and  it! 
limgtlicning  k,  in  truth,  only  apparent,  d< 
position  of  llu>  jmlvitt.     In  most  <-Mfwa  the 
fjood  witli  respect  to  the  oppoaitn  eonditioii. 
liowevor,  a  certjiin  lunoiiiit  of  genuine  ^h 
place.     IV'hon  tlie  osseous  strueturcs  arc 
tho  spasniodii!  (■ontiiiettiiii  of  the  muscl«s 
siu-c  of  the  lit-ad  of  tlie  femur  on  flio  upper 
if  this  is  alreiKly  sofli'iHil,  and  the  carlili 
tho  bordor  or  edge  of  the  acPtabulum  jHeldal 
(!0nK«  dcrjily  idtiTated  and  (.•xeavaU.-d,  nm 
itself,  whidi  has  been  more  oi*  less  disintcj 
this  i;xi:nviition,  which  is  enlarged  to  roceln 
tbo  estorual  iliac  fossa.     This  oonilition  coo 
tcrmod  ipontaneow'  dUtocatiort  from  scTofulod 
evidently  from  ti-auniatlt^  ilisI<>cation,  in  w 
miir  dears  the  rim  of  the  acetabulum,  will 
tliis  false  or  incom]iI<?t«  luxation  has  occu 
real  dlmiuution  in  the  length  of  tho  limb 
ofcoiu^o,  If  the  hvud  of  tlio  fciiitir  is  de 
very  cscopdonat  cases,  too,  tJio  head  of  tho 
the  aoetaboluni,  m  a»  to  eittt'r  tho  jx-lvio 
theso  diangcs  may  bo  found  a  cci-tain  aniod 
luhioss  of  tlio  nates.     Tlicse  are  ofton  flatfl 
than  natural.     This  alteration  depends  pai 
gluteal  muscles  from  ivaut  of  use,  partly  idM 
duction,  on  tlie  twist  of  the  pelvis  and  con 
jirojoction  of  tlio  tuber  iscliii. 

Tlio  pain  whioh  is  exjipriencod,  and  ir 
H.Tmmation  of  other  joints,  is  usually  of  sJi, 


DISEASES 


I 


I 


Btagcx  of  tlio  discnjsu,  is  not  oolifincd  to  tlio  liip,  but  is  often  rcftured 
to  the  iiinor  aido  of  the  knoo.  Tho  oxtiol  onuse  of  thi.s  syiiiptttJii^tic 
piutt,  as  it  is  tomod,  is  not  always  cloar.  Any  pressure  in  tlio  i-egion 
of  the  liip  upon  tlie  trunkn  of  tiiow  nert'Ofl  wliioh  i^iijiply  Minitatioii 
to  tlio  knoe,  would  bo  attended  by  pain  in  tlio  latter  situation,  on 
tho  same  jrroiiiuU  lut  w«  find  puin  ofWii  rcfwrt'il  to  tlio  fiiigcrx  or 
toes  after  amputation  of  tho  extremi^-.  That  pressure  on  the  an- 
terior crund  norvo  will  pnKluixi  pniu  at  tlio  kiwc,  was  shown  bv  a 
case  related  by  Sir  E.  Brodio.  whero  pain  in  tho  knoo,  reseinbliiij^ 
that  cxporionoc<l  in  hip-joint  diM.-.ii.->i-,  ro.Milted  from  the  pressure  of 
a  femoral  aneurism  on  tho  anterior  crural  noi-ve,  and  ttubsidod  ok 
soon  as  llm  siiniurisiniil  enliu-^jwiioiit  wa-t  reliovcil  by  Ii<:^tnrv  of  tho 
arter)'.  We  can  easily  understand  tliat  similar  pi-easnre  on  tlie 
obturatijr  ncr\-o  woidd  bo  followod  by  a  liko  result.  Tlio  pnin  in 
the  kneu  ha«  also  been  referred  to  n  traii-sferenee  of  impressions  in 
the  spinal  cord,  to  B_\nnpathy  between  tho  oxtrcmitics  of  tlie  fcmtu*, 
or  tu  propufriitioii  of  the  inthiiiuuatioii  alon^  tho  interior  of  tlio 
bono.  From  whatever  cause  it  arises,  this  pain  is  somcdimos  the 
first  Nymptoin  whioh  uttrudit  iitteniion,  and  may  leud  to  niistukcs 
regarding  tho  real  soat  of  the  disoasc.  Tho  ohanco  of  error  ia  in- 
creased if  ]inffin<M»  over  tlio  knee  Rccoin)mnic!(  tho  poiii,  »»  it  doos 
HomotimoB ;  just  as  swelling  of  the  toBtiele  may  bo  produood  by  the 
passngi.*  of  a  enlciiliis  along  tlic  nrctor,  from  pressure  on  tlio  8[>cr- 
inntic  plexus,  and  consequent  nervoiLi  diMurhanoe  of  tlic  nutritive 
conditions  of  the  [)Eirt«  sup]iliod  by  its  )x*ripbcra]  brandies. 

When  absoc6sc«  furin,  they  may  )>oint  in  almost  any  part  of  the 
limb,  either  in  tlio  A-icinity  of  the  joint,  or  after  having  burrow«J 
among  tlio  mitiK>le>4  to  a  great  oxtont,  os^icicinlly  when  llio  eroei 
postmv  has  been  long  maintained.  If  tho  sinus  is  situated  tome 
distance  down  tho  lliigh,  near  tho  itiforior  attachment  of  tlic  tensor 
I'agin.'D  fi-mori*.  tho  probabilities  aro  in  favoui'oftho  femur  being 
th(^  neat  of  mischief.  When  the  aw'tabuluin  lia^  origimilcd  or  par- 
ticipated in  tho  disease,  and  matter  haa  formed  in  the  pelvis,  tlio 
t^WK'ff^  often  shows  itiidf  at  tlu!  outer  part  of  the  groin  in  lite  neiirh- 
boorbood  of  tlio  antcro-inferior  »i>ino  of  the  ilium ;  occasionally  it 
pastes  down  by  tlio  rcctnni,  into  whidi  it  may  burst,  or  it  may 
reach  tlic  surfneo  clo»e  to  the  anus. 

Tliore  an-  one  or  two  points  in  the  diagnosis  to  which  I  may 
briefly  direct  attention.  I  hate  twcn  oongenitui  dislocation  mis- 
taken for  hip-joint  disease,  and  tho  child  subjected  t"  touch  nn- 
neccfittary  oonrmciiicnt  and  siiObriDg.  A  little  attention  readily 
dtstinguishos  the  turo  afiections.     The  histocr  of  the  case,  and  tlie 


782 


DISEASES  OP  THE  .JOfNTS. 


(!xis4enGo  of  evident  limping  from  the  first  moment  wlioi)  any  w«igli 
was  nll(>w(>il  to  )-c»t  on  the  limb,  tlw  abscnco  of  jMin,  and  the  vxten 
of  roa]  slioitcniny,  nggnivatiMJ  wlien  tJic  limb  i«  i»roiu«xl  apmirili 
diniiniAbcd  when  extension  is  made,  aro  symptoms  of  eongenUi 
dislocation  wludi  difl'or  widely  from  liKxtc!  wliicli  woiiM  have  Iwci 
IMrcwnted  by  severe  disoase  of  the  joint.  Wo  occasionally  meet  witli 
caaoe  in  whtdt  a  diffcrcnuu  in  tho  Iciigtli  of  (he  two  lower  UnAi 
cxifttd,  rpiiulttng  in  some  instances  Jrom  congenital  malformaUon,  iq 
others  from  infantile  {uiralysis,  which  Iia«  lod  to  wasting  and  defBc 
live  growUi  of  one  extremity.  Sudi  a  cond!ti<Hi,  if  oxihting  to  an^ 
extent,  causes  limping  in  (he  set  of  wnlkin;;,  and  lends  to  seooiidaf; 
deformity  of  the  !>{)tiie,  in  tho  fcinit  of  lateral  enn'ature,  to  connter^ 
act  Uie  tendency  of  the  body  to  fall  towardti  the  affected  side.  Hit 
Htatc  nii^ht  oiLtily  lie  mistaken  for  di.-teased  hip,  sia  well  a.*  fur  di** 
eased  s]>ine,  until  a  careful  examination  of  the  whole  limb  is  insti- 
tuted, whwi  (ho  <yiU!W  of  tlio  Jtymptoms  is  readily  det<)ctod. 

Psoas  abseesH,  with  or  H-ithout  disease  of  tho  spine,  may  be  mis- 
taken for  hip-diHoa.*o.  Tho  limb  may  bo  flexed  <iii  tlic  pclviji,  and 
any  attempt  at  extension  give  rise  to  great  suffering.  It  will  be 
found,  however,  that,  provided  llio  p»ou.-«  niiucle  is  kc()t  relaxed  and 
no  traction  upon  it  be  allowed,  free  movement  of  tJio  joint  nay 
bo  cfiectt^d,  and  its  articular  surfaces  rotatixl  on  one  another  or 
pressed  together  with  mucli  force,  but  without  suffering.  Tlie  iiita- 
ation  of  the  nbsccs«  Kcrves  to  assist  in  the  diagnosis ;  pelvic  abscess, 
too,  depending  on  hip-joint  (li.tea.He,  is  almoHt  invariably  compli* 
eatod  with  sinuses  in  other  situations.  A  ease  of  this  kind,  whcr« 
the  psoiw  absee**  waa  eonnocttsd  with  cxtennive  tuljcrcidar  disous 
in  and  aromid  the  kidney,  came  under  my  earo  at  tho  Hospital  for 
Sick  Children,  which  hiuf  lieen  eon!*idcrtHl  and  treated  pro\-iou8ly  u 
disease  of  the  hip.  Inflammation  of  tlie  bursa  nnder  the  psoaa-iCaa 
may  simulate  hip-disease,  and  be  with  difficulty  dislinmiishod  from 
it.  •Sometimes,  indeed,  the  bursa  communicates  with  the  joint,  and 
disease  beginning  in  tho  one  Involves  tho  other  in  its  course.  If 
sneh  is  not  the  ease,  and  the  inflammittinn  is  eonfined  to  the  bursa, 
tiicTi:  will  bo  pain  and  teudemesii  on  prossnro  at  the  front  and  imicr 
part  of  ttie  joint,  witli,  it  may  W,  some  indistinet  swelling  in  that 
situation  ;  tlic  nia^s  of  muscles,  however,  obscnring  the  bursal  tu- 
mour. The  limb  is  usually  inittinctively  f1c:teil  on  iIk>  [lelvi.*,  a*  in 
liip-disoase,  and  any  attempt  to  extend  tlio  Innb,  or  any  movement 
which  iu\olvi«  tnietion  on  tin!  psoas  muwle,  is  ntl«nded  with  suffer- 
ing. Tho  diagnostic  marks  corresiiond  to  those  jnst  mentioned.  If 
care  is  taken  to  avoid  any  ]ircssuro  on  the  bursa,  or  action  of  the 


DISEASES  OF  THE  HIP. 


783 


-■,  tJie  joint  may  bo  frtjoly  Iiaiiillcd  witliout  suffering;  mciroo\'cr, 
toiidcm«A8  or  KWftiing  can  be  dotocted  bohind  tlic  trochanter. 

Thfl  trfiatment  of  struimiiiii  diwitse  oftJie  hipdoeo  not  diffur  from 
that  already  rccommondcd  for  strumous  inflammation  of  ihe  joints 
gcnendly-  Tlifi  iiibitiiit  of  sociiriiig  immoliility  of  llio  articulation, 
iwwever,  may  bo  briefly  noticed.  There  is  s  certain  amount  of 
m«chaiiteAl  difficulty  in  keeping  this  Joint  ut  rvst,  trhich  in  not 
experienced  in  otlier  articalstions,  for  the  reasons  already  nlhidod 
to.  Short  «plint8  applied  merely  to  the  hip  and  tliigli  are  of  little 
service,  for  they  do  not  entirely  obviate  motion  ;  the  only  way  of 
insuring  perfect  rest  is  by  the  u*c  of  tbu  long  Kplint,  »8  in  cases  of 
fracturi'd  thigh ;  to  this  splint  may  be  adapted  iron-gnuxe  at  its 
upper  part,  motddcd  upon  and  encircling  the  pelvis,  which  it  steadies 
more  tlinn  any  onliriary  ban<tage.  This  splint  not  merely  prei-ctits 
motion,  but  may  also  bo  made  to  effect  a  oertnin  amount  of  traction 
upon  the  muselex,  and  so  diminish  the  tipaHmodic  pressure  of  llio 
articular  surfaces  on  one  another.  For  tJiis  piu7>ose  clastic  bands 
may  !>c  ada])tcd,  if  necciwary,  to  th«  splint,  at  before  doMrihwl. 

When  suppiu-ation  has  occiirrod,  it  is  better  that  the  matter 
lould  not  1x1  alldweil  to  burrow  dci-pIy  among  tht-  muscles.  Dr. 
loer  recommends  an  opening  in  the  capsular  ligament  when  "  a 
idcrable  quantity  of  cffuwl  matcrittl"  Is  contained  within  it ; 
may  be  effected  with  a  pointetl  tenotoniy-knife  or  a  trocar  in- 
serted behind  tlm  joint  at  tlio  spot  where  fluctuation  is  most  mani- 
fest, usually  about  an  inch  liehintl  and  alioio  the  great  troeJianter. 
The  capsular  ligament  is  oijened,  and  tlic  limb  inverted  so  as  to 
Viroc  out  the  dtiid.  llie  woiuid  \*  then  t<>  bo  ouvfully  closed,  and 
tiio  limb  replaced  in  its  natural  position,  and  secured  on  its  *^>1int. 
Where  gn-iit  pain  exists,  fi-oiu  the  confinement  of  matter  in  the 
joint,  this  operation  may  in  some  eases  justifiably  bo  had  recourse  to. 

If  tlf«  caiio  lias  gone  on  unfavourably,  liio  hone  l»eoomo  ojuious, 
and  extensive  suppuration  taken  place,  resulting  in  sinuses,  tbe 
healtli  suffer*,  and  the  only  chance  of  recovery,  or  even  of  preserv- 
ing life,  may  consist  in  excision  of  the  head  of  the  femur,  or  removal 
of  tiie  di»ea»od  bone.  Such  iin  oiKiration,  in  childnrn  at  any  rate,  h 
more  formidable  in  imagination  than  in  reali^,  and  I  have  had  oc- 
coftion  to  ])crform  it  without  any  injurious  cunsoquenecs.  Tlie  unb- 
joct  of  cxcbcion,  howe^-er,  will  ha  treate<l  of  in  a  Hi-parate  essay. 

Iforbiu  fome  iemHa.      In  advanced  life  another  form  of  disease  is 

to  ocour  in  the  hip,  wliicb  i:*  known  by  tlie  name  of  tlie  niminia 

KnUu,  or  cAtohw  rhirumatic  arlfirilU.     Unlike   strumous  in- 

flnmination,  this  disease  seldom  occurs  under  tlic  age  of  lurty,  and 


784 


DISEASES  OF  THE  JOINTS. 


ollcn  n[>pear8  as  a  locnl  nflVcUdU,  witliout  uiiy  visible  imp: 
of  the  general  IicuIUl  la  chronio  arteritis  of  the  liiii, 
is  *Uff(U»«  of  the  Articulation,  mid  a  certain  amount  of  dull 
extflodinK  down  tlio  froftt  of  the  thigh;  the  pain,  liowc^-i-r,  thoi 
aupn<?nled  after  much  exercise,  dimiuishc!)  during  the  ni, 
if,  not  iucrcjuwd  ovou  Ity  rough  pressure  of  tho  orticultu- 
iguiuHt  oiH?  another.  Tlie  mobility  of  the  joint  ifl  much  iut 
witii,  snd  a  Imid  cruekhng  eon  ba  dUlin«[l_v  heart!  when  the 
ifl  exercised.  When  tho  disease  is  well  established,  the  foot  u 
everted,  the  uiites  are  flnttone<),  and  there  i»  apparrut  shi 
of  the  extremity  to  a  very  considerablo  oxUint,  in  ooii.44>ciucdm 
olovation  of  tbo  oorrc«pouding  «idc  of  the  ptJins;  a  certain  ami 
of  rrat  shortening  may  also  take  place  afW  a  time,  from  ttio  cl 
which  occur  in  the  femur,  the  heul  of  wliteli  may  bcoome 
in  Klia)>e,  and  flattened,  whilst  the  neek  may  assame  u  itorimni 
direction,  so  that  the  upper  extremity  of  tlie  bono  m.iy  he  pba 
bvlow  the  level  of  tho  Lroehanter  major.  At  this  stagn  of  Um)  da 
eftse,  too,  bony  protuboranoos  may  perhaps  be  fcit  around  tJie  artj 
cidtition.  Ilie  ehanicter!)  enumerated  are  so  di.4t)ii(H  from  tlioM « 
Btrunious  di^iLsc  of  tho  hip,  that  mistakes  between  the  two  an 
scarcely  urisi.!.  Front  sciatica  it  i»  distingaifthetl  by  tlm  chameta 
and  situation  of  the  pain,  as  well  as  by  tlie  presenoo  of  sliortenin 
of  tlio  limb,  nyil  <ir  njiiian-nt,  and  «ver«ion  of  the  foot,  Th 
appoarniices  presented  somewhat  resemble  tliose  of  fracture  ofth 
nock  of  tho  femur,  for  wliieh  it  might  powlbly  be  mistaken  if  an 
injorj'  or  accitlent  had  previously  <K«urred.  Tiie  hi*U>ry  of  llif 
ca>>e,  however,  and  the  slow  and  gradual  progrciw  of  tl>o  symptotm 
as  well  as  tlie  osseous  growths  which  are  apt  to  form,  ore  mfi 
cieiit  for  accurate  dia^osLs.  Whore  constitutional  sxtnpioms  ail 
present,  tlie  disease  extends  to  otlicr  and  lunaller  articiitatioDs,  an 
the  cbaractor  of  tlic  affoctiou  camiot  fail  to  bo  recognised.  Tb 
treatment  of  this  aH'ection  i-t  noticed  in  tbo  section  on  Chnxu 
Hhenmntic  Arthi-itis. 

Nettnthjia  nffliflap.  Tlii.i  joint  is  fVequoDtlytho  aMt  ofhyBterio 
pain,  closely  simidating  structural  disease.  "Iha  diagnostic  eharao' 
ters  of  Ibis  aftijction  have  already  been  jwinled  out  (sec  Artienlal 
Neuralgia).  It  may  be  remarked,  however,  that  apparent  shortening 
of  tlie  limb  may  bo  present  in  those  cascn,  owing  to  alteration  is 
the  direction  of  tho  pelvis  and  ita  relation  to  the  veitobnil  column, 
induced  by  lung  continuance  in  one  unnatural  posture.  Lateral 
curvature  oftJie  spine  also  is  froijueiitly  noticeable;  but  the 
arc  not  flattened,  and  abscesses  do  not  fonn. 


DISEASES  01 


rs. 


785 


JJutaiifi'  of  t/uf  Pulius  and  SaerO-iliac  Jmnla, 

pnhic  and  ancro-iliac  articulations,  in  oonseqnnnce  of  tlicir 
SBatontival  arruiifi^incnt,  and  (Ix^  o(>iu|)nrativ«  tin  importance  of  (beir 
avnovial  membranes  (the  place  of  which  is  supplttHi  lo  »  grcjit.  oxteiit 
bj  clastic  tissue  intervening  between  tlic  opposed  cartilaginous  sur- 
.),  nro  t(^>  e\{iuM^d  to  disease  tlian  the  pn>{iur  diartbrudial  joiate 
of  corresponding  siw, 

A»  u  <niiiso(]iiGiice  of  Iiip-diseafH),  e^ieciidly  in  early  life,  tbo 

Iric  articiilatioos  bocoino  unusually  movable;  to  sucli  an  extent 

iiKltvciI,  thill   rigidity,  or  even  complete  ank}-Iotiis,  of  Iho  diseased 

I  joint  may  bo  attended  with  but  littto  loss  of  mobility  of  the  limb. 
During  ]>rcf^i]niiry  iJie  union  between  tlie  jxdvic  bonis  i«  raid  to 
become  less  timi,  and  In  c>  rtuin  cases  tho  relaxed  condition  of  tlio 
encro-iliuc  joint  is  wi  con-iiderabli;  nd  to  givft  fiso  to  pain,  as  well 
:U  to  difficulty  in  standing  or  ivalking ;  during  exereJse,  too,  tJie 
patient  may  bo  (sen^'ihlit  of'u  coHHin  imioiint  of  motion  Ix-twcen  the 
sacral  and  iliao  bonce,  and  Bomotimes  a  distinct  "  crackliiiy"  can 
I  even  bo  heai'd.  In  most  oflihose  cntnf  tlic  ligaments  resume  by 
degrees  ihoir  normal  condition,  and  the  pain  and  limping  gradually 
subside.  Oeeanionally,  however,  tho  n.ila:Mxl  condition  va»y  last  for 
a  consideiahle  ])erio<l,  and  tho  limi>ing  may  eontinue  for  uiontlu  or 
j-ears,  or  even,  according  to  Lmlovie,  for  tlio  remainder  of  life. 
It  may  happen,  too,  thut  antual  intliimmation  of  the  joint  is  not 
the  pains  become  violent;  there  is  swelling  about  tlio  part; 
id  if  »uppursitioii  iakea,  place,  tbe  caJto  \»  muitt  likelv  to  terminate 
itallv.* 
Acute  inflammation  of  the  eacro-iliac  joint  may  reault  directly 
injury.  A  case  is  related  by  Louis  in  which  a  sack  of  com 
II  on  tliv  loins  of  a  man  who  wn«  sbioping  at  tliti  time.  Tlie  aoei- 
t  gave  rise  to  some  swelling  of  the  part,  followed  after  a  time  by 
violent  pain  and  much  fobrile  diitturlianoe,  and  ilentli  ensued  at  tho 
end  of  the  twentieth  day.  Ver)'  extensive  iuflammation,  attended 
with  suppiu"ation,  was  found  in  tlie  right  smoro-iliao  nrticiilation, 
and  the  bones  were  separated  to  a  certain  extent  from  one  another. 

Disease  of  tho  sacro-ilinc  joint  may  arise  from  ]f^  obvious 
causes.  8ir  It.  Hrodie  n>lat«s  tlie  ease  of  a  married  lady  who  was 
unable  to  walk  witliout  crutches,  nni)  who  experienoi-d  pain  after 
taking  exorci^o,  referred  to  llie  right  groin  as  well  aa  to  llie  right 

*  S«e  Dcaonncaux  mr  let  SMehemntt,  £cart4mtnU,  ite.  dt$  8j/mfhfta  ilm 

VOL.  m.  3  b 


786 


DISEASES  OF  THE  JOINTS. 


p[>ort  tin 


sacro-iliuc  nrticulation,  whcro  a  projection  o^i!^lc<I,  as  if  the 
liud  be«D  displucctl  wid  drawn  iipwanU ;  the  aflecUil  limli  w 
iuolicN  tltorler  than  tlio  aouud  one.  Pam»  resembling  sciatt 
beon  complained  of  for  many  yean,  hut  tlio  lir»t  dUtJncl  syinpton 
of  tho  iifUjction  a):^ared  to  be  referred  to  her  pregnancy,  four  jie«l 
lireviously,  Itocovury  tuuk  pliice,  tlioagh  Uiu  limb  rcIuainl^l  per- 
nuuii^iitly  »l]ort4mod. 

Mr.  Kiiclison,  wito  lias  [wid  much  lUUititioa  to  tho  itubjoct,  coo- 
Hiden  ehronic  i<acro-i)ino  diaeaao  to  be  usually  strutaous  in  its  ori^ 
It  Holdont,  if  over,  occurs,  however,  iq  diiklrun,  being  met  with  mot 
fixKiiiently  in  youii^  iiditltA.  The  H^inptoma,  according  to  Mi 
Erichsoii,' consist  of  pswii  and  swelling,  conliiied  to  tho  region  a 
thu  joint,  and  ntteudwt  wtlli  a  feeling  of  inability  to  iiup[M>rt  tin 
weight  of  tho  body,  and  consequent  limping  when  exorcise  ia 
Tlio  jMiin  i«  increasMi  by  [treasure,  or  by  any  motion  of  tJio 
joint;  but  if  care  ia  taken  to  keep  tlie  pelvis  quite  at  rest, 
may  be  moved  freely  in  any  direotion.  Tlw  foot  i»  usually 
but  the  limb  is  Raid  to  be  apparently  elon^ted,  and  the  ocHrre^Mnd 
ing  side  of  the  pelvis  is  partially  displaced,  becoming  t^vistcd  am 
rutnttHl  don-iiward.i  and  forwards.  When  suppuration  taken  pUioei 
and  In  most  cases  it  only  does  so  at  a  late  jwriod  of  tho  dtseaeo,  (In 
uialt«r  may  point  (^i.tu-rlorly  in  tho  immediate  ni^ghboiirhood  e 
the  articidation,  or  it  may  extend  outwards  to  the  great  trochanta*, 
or  upwanU  to  Uio  loin  ;  if,  on  iJie  otiier  hand,  the  matter  aveuoni> 
latea  in  iront  of  the  joint,  it  may  pass  into  tJie  porinfeatn  or  eni 
open  into  the  rcetuiii,  or  it  may  It-ave  tho  pelvis  by  the  great  *a»A 
notch  and  point  in  the  gluteal  region. 

Tho  prognosis  in  these  cases  is  always  nil  favourable,  but  becoiael 
spociiilly  flo  when  matter  has  once  begun  to  fonu. 

The  diseases  of  tlio  knee  have  lieeii  studied  willi  extfvme 
owing  to  the  fmiuoncy  of  their  oecurrcnco,  as  well  as  lo  tlw 
and  accessible  position  of  tlio  nrtieulittion.  Ilenoe  it  is  that 
affections  of  this  joint  are  oflen  taken  as  t^'plcsl  of  articular  diaiva 
generally.  Tlie  knee  is  liable  to  the  various  morbid  cliangee  wfaiol 
have  iM-en  described  in  tho  first  part  of  this  essay ;  lo  one  of  thiiUj 
indeed, — chronic  intliunmation  of  tlie  artiindar  extremities  of  thi 
bones, — it  is  specially  exposed,  for  local  obscen  is  more  common  il 
tho  bead  of  tint  tibia  than  In  any  other  situation;  and  nooroeb  oj 
the  lower  end  of  the  fenitir  is  oflen  met  witli,  at  fi»t  simulating,  bt4 
subsequently  inducing,  suppuration  of  tho  joint. 


i 


DISEASES  OP  THE  KNEE. 


7S7 


11)0  po^oa  which  iho  lunb  habitiudly  a»»iimc«  in  scvoro  di»oase 
of  this  ftrticuUtion,  whc>ther  fliniply  iiittammatorv  or  stnimoii!)  in 
ite  origin,  is  one  ul*  cunaiderable  flexion,  troqiii'iiUy  oombiiKcl  tvith 
ionion,  in  caiuM!quenc«>  of  ovcr»i<m  or  inversion  of  the  fooL  Iftliu 
ite  become  cxtf?Jtde<l  or  da<)troyed  in  the  progress  of  dif^afio, 

spiMtnodio  Miiit.rurlii>n  of  Uio  f\f.-xitr  muw:U'»  a^^M  ujwii  thu  Iw-ad 
tlte  tibia,  which  it  tends  to  dislocate  barlnvanla  into  tite  popliteal 
In  our  tiviitTti<;iit,  tln'rcfiiri',  wo  liavo  to  giiiird  against  tliis 
tendency ;  the  foot  must  lie  supported  to  prorent  torsion,  and  where 
any  n»k  of  jKTmanout  rigidity  cxistx  ihtt  limb  initnt  bo  inaiutainod  in 
A  nearly  sfrttiiifii  [>oe>itioii. 

In  chronic  rheumatic  arthriiU,  the  knM-joiiit  ioon  acquires  a 
ig  in<-]ination  iiueardx,  whitAt  tlio  tibia  is  usually  rotAted  ouU 
wards  and  the  foot  ovcrtcd.  At  a  nioro  advanced  period,  if  tbc 
limb  t>e^niiii-!i  rigid  in  a  seini-flexed  [KMUtion,  tlie  patella  is  oceasion- 
ally  found  resting  on  the  outer  condyle  of  tlio  femur,  or  even  oom- 
pleti'ly  lii.tl'iciiti.'d  outwarrfi*,  Tiic  uintiunt  of  synovial  effu-sion  is 
considerable  in  the  earlier  stages  of  the  disease,  and  the  swelling 
will  ofton  be  found  to  cxu-nd  ti»  \\\v  ])opIit«al  »paoe  in  the  direction 
■of  the  inner  head  of  the  gastrocnemiiia,  owing  to  distension  of  tho 
boiva  which  exists  in  this  situuliou,  »id  wlueli  frvKiuontly  cuniniuni- 
Cates  with  the  joint.  As  the  disease  advances,  the  patella  becomes 
incroasod  in  brcadtli,  and  osstfio  dopo«its  may  be  distinguishMl  at 
the  condyloid  margins  of  the  femur  and  on  the  head  of  Uie  tibia. 
Pendulous  oxcrcsconoos,  or  completely  detached  bodios  (loo«o  carti- 
Ittgt's),  ari'  fn^uontly  to  bo  found  in  tlie  interior  of  ilio  ai'lic-ulation. 

Tho  defonnitie^  o/  the  htee,  and  the  treatment  they  require,  are 
dltcuss(»l  ill  the  m»ay  on  OiiTROPADio  Subokrt. 

Iii/fainination  or  dropuleal  distfntian  t^variotu:  hnr»(s  in  tlie  neigh- 
boiu'hood  of  tli»  kii<H!-ji)int  may  utlcn  bo  met  witji.  I)eiii<les  tJw 
ffiiporBcial  bursa  over  the  patella,  which  gives  rise  in  its  diseased 
vondition  to  "  hoii^emaid'^  kimc,"  then)  w  k  dwjf-watotl  bur*a 
between  the  ligamentunt  pateltie  and  the  tibia,  which  may  also  be 
inflamed,  producing  pain  on  motion,  with  ilt-dcfincd  enlargement 
in  Uie  region  of  tlio  anterior  tuberosity  of  the  tibia.  Oecantonally 
that  part  of  the  s^'novial  menibraiiu  wluc-h  oxtonds  upwards  beneath 
the  extensor  niusclct  ia  replaced  by  a  bursa,  which  may  be  quite 
distinct  from  llie  knee-joint ;  or  an  imperfect  division  of  tlic  mvm- 
hrane  into  two  eavilti>i«  may  tixint  AVhttn  a  separate  bom  ii*  pro- 
sent,  it  may  be  inflamed  and  give  rise  to  a  painful  swelling,  which 
is  confined,  however,  to  the  region  above  the  iiatolla,  tJie  luiiculalinn 
below  remaining  unafieoted ;  this  diagnostic  mark  is  most  evident 


DISEASES  OF  THE  FOOT. 


789 


'  ankylosis,  is  that  in  whiob  tlie  foot  is  in  the  sanio  {ilnne  vritli  tho 
If  luui  fonnx  with  it  an  ■Mifflv  aiily  sliphtJy  cxcw^ling  a  right  one. 
may  ho  remarked,  that  (liaea.4e  of  thia  joint  is  moro  fiivourably 
it<?>l  for  n-tiovcry  than  (liKcnso  of  the  ttiigh  or  knee,  hci^aiiKe,  by 
!  einploj-mont  of  a  wooden  h'g,  wliilnl  ihts  luikle  itt  eru'ofwily  Alip- 
ed l)y  splints,  cxcrciso  may  be  taken,  and  the  general  heallJi 
quently  maintained. 
'Ckronic  rlifumatic  arthritis  seldom  affeotfl  tho  anklo,  but  when 
idoee,  tlto  taraal  jtiiMt.1  are  UMially  implioitMl  at  tho  eamo  timo. 
in  tho  brcadtli  between  tho  malleoli,  wliieh  are  preter- 
Jly  prominent,  omnbinwl  with  projc-clifin  inwards  of  the  sea- 
oid  and  depression  of  the  instep,  are  the  ap])earanees  oommonly 


DUfotea  of  the  other  Arliculation»  of  the  Fool, 

The  tAntsl  bones  ar»  m  Kmnll,  and  tlie  KrtieuIatioM  between 

eo  numerous  and  in  aneli  elose  proximity,  that  distinetiona 

en  the  morbid  eondilioiu  of  tlic  two  ojin  with  difficulty  bo 

■wn.     Bisease  in  the  tarauH,  in  the  majority  of  oasea,  arises  in 

B0U8  inlhiniination  of  tlio  bones,  which  soon  extends  to  the 

<  and  to  tlie  s^-novial  mombraneo.     Some  importance  must 

I  attached  to  the  original  seat  of  the  mischief,  in  conserjiience  of 

'f*'',vii>g  d<'gr»,'c.*  of  um|)lieity  of  llio  K_\-novial  in<nubr»Tii'S ;  of" 

e,  the  median,  or  /trnpho-cunei/orm,  is  by  far  tlie  most  eompli- 

i,  a«  it  oxietids  Iw-twivn  co  many  tArral  bones.     When  disease 

ohes  only  ilio  simpler  synovial  membranes,  or  is  eonfined  to 

bones  in  connexion  with  them,  tlie  probabilities  of  n  eao- 

issuo  are  comparatively  great ;  and  if  operative  measures 

iiy,  oxci»ioii  of  individual  bonos  may  be  had  recourse  to 

sutifl&otory  reaulta.     1  Itave  several  times  removed  tho  «al- 

1,  tlie  cuboid,  or  even  the  internal  etmoiform,  and  recoveiy 

oceiirrod  with  u  very  uM^ful  fool.      A^'lien  disenso  afToet*  tho 

ilns  OP  tho  scaphoid,  on  tho  other  hand,  and  tho  eontiguous 

nviid  membranes  are  inipliented,  the  elmnci*-«  of  locidiMn;:;  the 

chief  become  much  diminishctL    Tlie  middle  and  oxlenuil  cunei- 

lx>nes,  also,  are  unfHvonrably  Kitimted,  though  le»s  »o,  pcr- 

,  tluui  the  astragalus  or  Acaphoid.     It  may  be  remarked,  that 

I  repair  whieh  takes  place  afU-r  excinion  in  tbi:«e  eatos  is  usually 

complete,  for  a  large  portion  of  the  periosteum  is,  and  ought 

be,  left  behind  in  the  operation ;  reproduction  of  the  bono  con- 

fucnlly  occurs  to  a  greater  or  less  exlont,  giving  to  the  foot  all 

solidity  which  is  required.     After  removal  of  the  whole  of  tho 


M 


788 


DISEASES  OF  THE  JOINTS. 


1 


wlivn  tJie  pati«nt  is  in  tlio  erect  poshioii.  A  swelling  is  often  met 
with,  especially  in  cliililrcn,  M  the  inner  ^ido  of  ttio  popliteal  space, 
ooiifKctcd  vritJi  Uie  buriia  plnced  beneath  the  iiinor  httiul  of  Uie  ga»* 
trococtniu)'.  As  lliis  latti^r  Imnui  frcqiivjitly  tiotnmunicatca  with  tim 
synovial  membrane  of  the  joint,  inflammation  of  it  U  n  mntt«rff 
Bome  iin])ortai](w,  and  i-^n:  itiii«t  \n-  taken  in  our  surgical  treatnienu 
Inflainnmlion  may  also  take  j>laco  in  the  bursae  in  cooui^xion  with 
the  patte  iToU  tvndons  ut  tltv  inner  side  of  tlio  head  of  the  titna, 
leading  occaflionutly  to  moet  obstinate  and  prolonged  suppuration, 
and  interfering  with  tbo  moveineala  of  the  joint,  which  doea  not, 
however,  liircctl^  auil'i-r. 

It  may  bo  remarked,  that  lu  reoundf  of  the  tnee-joiut,  when  rap- 
puralion  occurs,  it  often  taki^  place  iniitdiouidy  in  the  areolar  ti»i», 
between  the  thigb-bono  and  the  muscles  which  surround  it,  nitha 
than  in  the  articidation  itself.  In  this  way  tlio  whole  tliigh  may  be 
inflamed  and  ewolleu,  and  tlie  appearances  eomewhat  cloMily  rcsen* 
ble  thoM!  of  acute  pK-riostitis  of  the  femur.  The  depth  at  which  ike 
matter  is  situated  provonta  it  from  coming  rapidly  to  tlic  rarface, 
and  i\w*  not  readily  alluvr  of  fluctuation  being  detected.  Macb 
constitutional  disturl>anoe  ia,  eonseiiuently,  usually  ])riywiit,  and  llie 
amount  of  pus  which  forms  before  an  outlet  is  obtaint-d  m  a&ea 
very  largo.  In  such  wises  eai-ly  and  deep  incisions  are  obviously 
culled  for ;  incisions  which  shall  extend  through  the  whole  miiwulif 
layers,  if  tlio  Mtiit  of  tliu  iiup|)uruli<in  ia  to  bo  roached,  and  tlu) 
symptoms  produced  by  tho  pent-up  matter  abated. 

Duttuet  of  the  Ankle. 

The  ankle-joint  is  liable  to  the  various  diseases  which  have 
alrcftily  dcJierilied,  and  i«  often  involvetl  in  the  progress  of 
affecting  tho  irregnlar  bones  of  the  tarsus.  "WTjen  disti-ntled  with 
fluid,  tin;  tumefaction  and  HueUuttion  are  most  eiidenl  Itctween  ih* 
two  malleoli,  on  either  side  of  the  estensor  tendons;  in  cxmine 
ca.-«cH,  tlio  elFuoion  is  [lerct^ptiblo  also  po(<teriorly,  at  tlic  inner  ami 
outer  boi-ders  of  the  tendo  Aohillis,  When  eappumttOD  oceurs,  the 
niatti.^r  may  make  its  way  to  tho  surface  in  the  immediate  ^'iei^iTy  of 
tlio  joint,  or  it  may  a»cend  tlie  leg,  or  deeoeiid  into  the  fiK)t  in  noi- 
nexion  with  tlie  tendinous  sheaths  around  the  ankle,  so  as  to  opfm 
at  a  considerable  diMance.  'Zlio  direction  nhieh  tlie  foot  is  pron* 
to  assume  in  disease  interfering  with  tbo  use  of  the  joint  is  that 
effluxion,  combined  generally  with  \-arvitig  amounts  of  invorBion  or 
cvorsion.  The  position  to  be  selected,  on  the  other  hand,  to  avoid 
present  stretching  of  (he  ligaments,  and  «»  most  useful  in  the  event 


I 


DISEASES  OF  THE  FOOT. 


789 


For  Mitcylottis,  ia  tliitl  in  wliicli  the  foot  is  iii  tliu  taxav  phmc  iritli  tho 
Meg,  and  forms  with  it  an  angle  only  sli^tly  exceeding  a  right  one. 
I  It  inuy  1)0  rciii»rkc<],  that  disoiuc  of  this  joint  is  more  iavourably 
iBitOAted  for  recovery  than  dUcase  of  the  thigli  or  knee,  be«autte,  by 
Itfifl  emplormpiit  of  a  woodi'n  ii'g,  whilst  tho  ankle  u  carefully  sirp- 
fported  by  spIintA,  exercise  may  bo  taken,  and  the  general  lieahh 
I  consequently  mnintniiiixl. 

I  Chronia  rheumatic  arfhrUU  sfildom  afTcclA  the  utkle,  but  when 
lit  docs,  tho  tarsal  joints  arc  usually  implivatod  at  tho  same  time, 
■bgveose  in  the  breadtli  between  tlie  malleoli,  whJoh  tim  jirclor- 
■Htnrally  prominent,  combined  with  projection  inwards  of  the  sca- 
Iphoid  and  depression  of  the  instep,  are  tlio  apjiearancca  commonly 
itioticcd. 

I  Dlteasta  of  the  other  Artieulatiotu  <^the  Foot. 

I        Tlic  tarsal  bones  arc  so  small,  and  tlie  articulations  between 

rtliein  so  niinierotis  and  in  sncli  close  proximity,  tliat  dititinrtiona 

between  the  morbid  conditions  of  the  two  can  witli  difliculty  bo 

,  drawn.     Diseast*  in  the  tarsus,  in  the  majority  of  eases,  arises  in 

BtnimouH  intlammation  of  tho  bones,  which  soon  extends  to  the 

tilages  an<l  to  the  s^'Uovial  memhrantis.     Some  im|>ortjine«  mn»t 

attschod  to  the  original  scat  of  tho  mischief,  in  conseqiiOTicc  of 

[ihe  vaiying  degrees  of  sim])lieity  of  the  nynovinl  niembnin*!!*;  of 

[tlicsc,  tho  median,  or  aeapho-euneiform,  i»  by  far  the  most  eonipli- 

1,  OS  it  extends  betwe4>n  w  munj-  tanal  bones.     ^^'h<^n  diMWse 

avdrea  only  the  simi^er  sniovial  membranes,  or  is  eonSnod  to 

[wngle  bones  in  connexion  with  them,  tlio  probubilitiea  of  a  aoo- 

cessful  issue  are  comparatively  great ;  and  if  operative  measures 

I  arc  necftwary,  cxciwou  of  individual  Ikiiioh  may  bo  had  niooiirw  to 
£vith  Batietaotory  results.  1  have  several  times  removed  the  eal- 
eaneum,  the  cuboid,  or  even  tho  intcrnai  nmeiform,  and  recovery 
lias  occurred  with  a  very  usefiil  foot.  Wlwn  disease  aSccts  the 
a8tzs<^Lliis  or  the  scaphoid,  on  the  other  hand,  aiii!  the  conttguoiu 
^■novial  membranes  are  implicated,  tho  chanc«a  of  localising  the 
miseliief  become  much  diniini^hcd.  The  middle  and  cxtenvnl  cunei- 
form bones,  also,  are  unfavourably  aitiuited,  though  less  so,  per- 
Itaps,  tlian  the  astragalus  or  scaphoid.  It  niiiy  be  remarked,  that 
the  repair  which  takes  ]>lace  atter  exeitiion  in  these  eases  is  usually 
B  most  complete,  for  a  largo  portion  of  the  perioetoimi  is,  and  ought 
^to  be,  left  behind  in  lli«  operation ;  reproduction  of  tho  bone  e<in- 
Beqnently  occurs  to  a  greater  or  less  extent,  giving  to  the  foot  all 
the  solidity  which  is  required.     After  removal  of  the  whole  of  the 


790 


DISEASES  OP  TEE  JOINTS. 


calcaneum,  I  have  found  the  liccl  perfectly  rigkl,  *nd  the  nmoan 
of  cIvK>nDily  vory  tj-ifiiiig." 

Infloiniiuition  oftlic  complicated  wn/^Ao-CTJirfl/'omi  ^rnoinal  mzan 
hnm  mwy  be  looked  upon,  a<»»rding  to  Mr.  Eriiihstin,  a&  a  duiuw 
affection  of  the  foot,  commencing;  itsually  ta  disease  of  tbo  scaphoid 
At  iint  tboro  is  piun  and  HTMiIUng  in  the  region  of  the  Jotat  b» 
tween  the  scaphoid  and  cuneifann  bones.  Tho  pain  in  increase 
by  bending  down  tbo  fuol,  luid  extiMidt  ucro»8  tliu  t^rsuit  to  it»  onM 
side,  as  tho  articuhttion  between  the  external  cancifaTra  and  thi 
(!iitH>i<l  licofiincM  invulvcd.  At  n  l«t«r  prriod  "  tbo  foot  amumai  I 
remarkable  bulbous  or  clubbed  appearance ;  the  synimotrj'  of  tb 
lu-ot  mid  tho  outline  of  the  auklo  are  unimpaired,  but  tho  lore 
Eind  di>rsum  of  tlifl  foot  arc  greatly  awollen,  glazed,  iui<l  po«si' 
jM-rt'cirultHl  by  sinuses  disobargbg  their  unhealthy  pu«."t 

Tlio  di.seaacA  of  Uie  metatarsal  and  phalangeal  nrriciilationH 
for  no  special  observations.  They  are  frequently  ffouttf  in  thea 
eharai?ter,  or,  in  wiino  cii««,  are  eximiplt«  of  rfuvnic  rheuma^ 
artliritit.  It  is  worthy  of  notice,  perhaps,  that  in  the  metatano- 
pfaalaogoal  nrliciilntiou  of  tlic  great  too,  tlio  dcfunnity  induced  hj 
tbo  latter  affection  has  been  mistaken  for  dislocation;  a  oondilM 
whioli  it  may  closely  resemble. 

Tlio  subject  of  hutiioH  is  oeiisiderod  in  the  esmy  on  ArFBontHj 

or  THK  MUSCUIAK  SySTEM. 

Disfoges  of  the  Stertw-clacieular  and  Aeromio-elaeicular  JairtU. 

A  certain  amount  of  enlargement  of  Ihc  ^tomo-clavieolar  tl 
well  aa  of  the  acromio-clat'icular  articulations  may  sometimes  bt 
seen  in  persfms  who  havo  long  boon  in  tho  habit  of  working  harf 
with  their  upper  extremities.  Acute  indammation  of  Uio  Htemo- 
clavicular  joint  is  also  met  with  occasionally.  Such  a  case  in  ai 
adult  came  under  my  can-,  in  wbif-li  KiipjumiUt^m  rapidly  took  placdi 
\vith  destruction  of  the  fibro-cartilagc,  inducing  spontaneous  dUlocfr- 
tion  of  tlie  inner  extremity  of  the  clavicle.  The  shoulder  and  arm 
having  boon  fixed,  and  the  dislocation  reduced  and  preventcil  fron 
recurring  by  appropriuto  ei>linti!,  recovery  took  place  with  a 
extremity. 

Chronic  rhmmatic  arthritis  of  these  articulations  may  also 


•  Bee  also  Pathohgu-iU  Trantaciitm*.  >t)L  xi.  p.  SIT,  for  an  aeoount  ■ 
the  oouditioo  of  the  purts  in  a  foot  from  wbicb  I  bad  remorod  two,  of  i 
tarsal  bones. 

t  Ericbsou's  Scienf*  ami  An  of  Siirsfiy,  Sd  cd.  p.  tl6. 


DISEASES  OF  THE  SHOULDER 


791 


produoing  enlar(>;eiiient  of  the  artioalar  exbnetnitics  of  tlto  clavicle, 
BtifTiivss  and  pain  uji  mo^'oincnt  of  tliu  juint«>,  n-s  wiill  oa  weakness  of 
Uw  appef  extremity. 

rl  Diifose*  of  tttf  Sliouhier, 

TIio  iihoulder-joint  rcacmhleei  tho  )iip  in  \i»  nnatoiniciJ  t^tomcten, 
but  is,  fortunately,  far  leas  subject  to  {jieease,  snd  when  disease 
oct-iirH  tlie  roHuhii  are  uHtinlly  mucli  Iukk  tun-ore,  tJie  |)<;rHt)>t«noe  of 
pain  and  the  produotion  of  rigidi^  oonstituting  tho  oonditioDs  most 
■Jo  1>«  uppK^henilod.     If  i> it p[iii ration  ttikos  plm-e,  wliicti  iH  M^Idom 
Hihe  case,  tho  matter  oft^u  fbllows  tlie  eourso  of  tho  long  tendon  of 
Btiio  ))ii!i.^{H>,  and  oj)enH   at  the  front  of  the  nnn  below  the  deltoid. 
Not  imfreqileritlv,  too,  it  passes  out  of  tlie  nrlJeulation  by  the  o|>cii- 
\ai^  wiiic.-li  exj.st.i  ill  iJie  xynovial  incnihninc  Iwiientli  the  Miiitioapu* 
laris,  and  follows  that  muscle,  arriving  at  tlie  surface  near  tho  back 
,ui'I  l»wei'  part  of  iJici  shoulder.     T)io  most  favound)le  po.4ttion  in 
I'hieh  a  disoasod  slioulder  can  be  placed   for  treatment,   is  thxt 
rhich  in  alino-tt  natiirallvndoptctl;  the  arm  slitnild  bo  ])anilloi  to  the 
t,  and  tho  olbow  slightly  separated  from  the  chest,  tlie  for&-arm 
jibcing  at  thti  same  time  HU])|>ortt'<i  by  appropriate  moclianictd  moan.*. 
The  condition  of  parts  induced  bj  ehronie  rhfumalie  arthriti*  of 
fthe  •Imiilclcr  lin-t,  no  doubt,  bfiii  f««()uontly  mistaten  for  tho  result 
'  injiu-y.     Ailer  the  stage  of  synovial  distennion  hiiii  iiaiwed,  wast- 
Bg  of  the  soft  parta  occurs ;  rigidity,  as  well  as  crepitation  oa 
movement,  are  met  wiiJi,  and  rlie  Iwad  of  tho  humcni"  apjiears  to 
[bo  olovatod  and  carried  forwards.      MTien  the  disease  is  of  long 
Iftanding,  tlie  deltoid  is  atrophied.    The  capsular  b'gament  is  usually 
Itliickoned,  and  lins  sometimes  osseous  partioica  in  its  substunce,  or 
lit  may  be  porfonit><(I  at  it^  a\i\ter  jiart.     Tlio  i>i,TK>vi>tl  membrane 
[flIiowH  marked  ugns  of  inflammation.     The  glenoid  foi<sa  lo^ei*  its 
tlignment  as  well  at  itii  enrtilago,  and  prowDts  the  characteristic 
rivorv-likc  material ;  occasionally,  too,  iTToguIar  osseous  growtlis  aro 
\  {bniid  around  iu  wlges,  incnwing  it*  capacity.     The  luider  surface 
lof  the  acromion,  and  even  of  the  acromial  end  of  ilw>  clavicle,  may 
M*  hollowed  out  by  prcitiire  of  tlie  humcms  upon  tlicm,  ainl  are 
often  covered  with  a  polished  porcelain-like  material.     Separation 

(of  tJie  acn>mion  is  iil.-»o  mot  with  someUmes.  The  head  of  the 
humerus  is  often  much  enlarged,  and  its  mirfiKHt  cburuated.  Tho 
tcndinoun  rtriiclui-eM  tiround  tlio  joint  may  appear  partially  <lis- 
intcgrated,  and  the  intra-articular  part  of  the  long  head  of  tlio 
bie«|i«  \i  usually  destroyed,  the  remmiiu  of  the  tendon  adhering  to 
H  tite  edg«e  of  tlte  bicipital  groove. 


7M 


DISEASES  OF  THE  JOINTa 


nienbi  on  the  fftretob,  and  favours  luxation  backwanls,  tli« 
form  of  »poutaneoRS  disIiH-ation  to  bu  Hiiju^iK-mled.  In  aciitv  ia- 
ftninmntion  of  tlie  wTist,  thopefore,  relief  may  oflen  be  nff'ord«d  by 
80  iidaf>ting  the  imi-liiiniail  Mi[>{)ort  »»  to  obviato  this  tendency  14 
pronation.  If  luxation  of  tlio  ulna  has  alroady  ocrurrect,  itiul  tbc 
trian^lnr  fibro-i-artilnf^  been  dvKtroycd,  tlw  hand  must  be  r(ecwti 
ill  ih«  jKifliiion  recomnifludt'd,  luid  iirewm-e  exeivUeil  on  the  bark  of 
tlio  ulna  to  reduce  i(^  ilislocation,  sikI  uiaintniii  tho  Imno  in  its 
normal  position.  As  KttHhesa  of  tho  lingiTs  is  very  «j>t  to  occur 
tmn  want  of  cscrcii«ii  in  case*  of  diseaKtd  wrist,  passive  motion  of 
tlkeir  nrtii-ulatioiis  niu.it  he  ha<\  rcot^unvt  to  aii  early  ah  [mMtiblo. 

Citronic  riteumatic  arthritis  of  tlio  wrist  is  most  common  in 
femnlt-n  hoyond  tho  itiiddlrt  ]>eriod  of  life,  ttiougb  it  in  init  witli 
occasionally  at  an  early  ago  in  both  sexes.  The  back  of  tiie  wrirt 
in  tliis  form  of  diwa!<t>  exhibit*  unnally  a  f)ceidiar  prtijwition  in  con- 
sequence of  enlargement  and  partial  luxation  hackwanU  of  tbe  nii% 
uid,  though  to  ii  iiiin-li  lii«  (U-jjrot',  of  tl»  nuliuE.  Tlio  fingM 
•re  fmjuentJy  distorted,  becoming  pennanently  flexed  tt»  well 
addactod  ;  tho  second  phnlimgi.<«,  however,  of  tlw  &ng«rs,  as  well  M 
of  tlie  tbunilj,  are  ustmlly  r^nniM,  giving  to  the  hand  a  pecntitf 
n])po!u'anfv  higldy  characteristic  of  the  disease  in  its  advanced  6\zgb. 
Enlargement  of  the  articular  exlremitimt  of  the  finger*  i*  reiy 
<»mmon,  representing  the  "  nodosities"  of  l>r.  Haygarth.  Partial 
or  complete  litxntions  of  them  may  alno  lie  pri?«i»iL 

Synovial  tumourg,  or  "ganglia,"'  about  the  wrist  am  treated  «f 
in  tho  vamy  on  ArFKcnoNs  of  the  Mpsccxah  Svsteil 

J)itm«es  oftlw,  Trmporo-marillary  Articulation. 

The  only  affection  of  thi^  joint  to  which  it  is  ne<!r!SiutTy  epedallj 
to  direct  attention  is  chronic  rheumatic  arthriti*.  Tins  disease  usually 
sltaulss  the  jaw  in  old  |)er!*onK,  though  it  butt  boon  seen  in  early  life; 
generally  speaking,  too,  it  is  constitutional  rather  than  loeal,  and 
sliows  n  markfil  di^iKicition  to  wym metrical  disturbunoe.  The  cMi- 
dyle  ajid  ramus  of  the  lower  jaw  are  nsually  enlarged  and  elongated; 
in  n  wise  relntiid  by  Cniwilliicr,  howcvt*r,  llie  condyle  was  found 
to  bo  entb-ely  absent.  Tlie  glenoid  cavity  is  more  or  less  altered, 
being  frequently  enlarged,  and  »ometimci^  funning  a  plane 
The  arlifmlar  cartilage  awi  fibro-cartilage  generally  disappear, 
Uic  porcelain  deposit  is  not  common,  and  ibrvign  bodies  are  rardy, 
if  ever,  jtrescnt.  Tho  minptoms  consist  principally  in  stiffm 
tJie  jaw,  and  inability  completely  to  open  tho  month,  with  a 
ling  noise  when  the  joint  is  used.     The  faoe  is  distorted;  ifuT 


db 


DISEASES  OF  THE  JAW.  795 

me  articulation  is  affected,  there  will  be  Bome  projection,  and  the 
(tee  is  turned  towards  the  opposite  side.  When  both  articulations 
lie  diseased,  the  whole  jaw  is  carried  forwards.  The  symptoms, 
however,  are  commonly  less  urgent  than  those  presented  by  the 
■me  disease  in  other  joints,*  bo  that  itd  existence  in  this  situation 
may  scarcely  be  noticed  when  many  parts  of  the  body  are  affected. 

ATHOL  A.  JOHNSON. 


*  Dr.  Hnmphiy,  however,  refers  to  a  case  in  which  this  disease  caused 
H  much  discomfort  snd  distortion  of  the  fsce,  that  he  was  led  to  excise  the 
condjrle  of  the  affected  joint,  aad  with  rery  good  result.  Humphrj  on  th» 
finuM  ShtUton,  p.  306. 


ON  EXCISION  OF  IJ02vES  AKD  JOIKTS.. 


-1 


EXCISIOXK  Df  GENXILU. 

THE  opcTtttions  which  ara  to  be  described  iii  ttic  (wqaci  ore  a 
of  modern  iiitroilitdioii  iiilo  [irartira;  for  although  scattcre 
pauagcs  aro  found  m  the  writinge  of  tho  tn<-dicul  authors  of  ml 
quitj  which  hntfl  boon  licid  to  prove  that  th«y  were  iux]uaiiite 
with  the  poirsibility  of  dissecting  oat  dincaiicd  or  ii\jim-d  Iranre, 
niuKt  hv  ulliiwtxl  tliiit  siich  pascoges  are  in  luiniy  reA]>o<>t»  dubioos 
and  it  is  at  any  rate  certain,  that  opemtioms  of  this  kind  w«t 
very  niro  in  cldvn  tinicji;  (Imt  no  nilcn  were  Uid  down  for  tJieiD  il 
ancient  Siu-gGr>-;  and  tliat  Uiey  had  altogether  passed  otit  of  notie 
before  tlio  jwivul  of  Surgery  as  an  art  founded  on  nitional  jiriii 
cipic'S,  When  tills  had  on«e  liappened,  an  attempt  to  pnveiT 
a  liiiili  by  n'Jiiuviiig  only  the  diseased  portions  of  bono  was  I 
reasonable,  that  it  waa  sure  to  be  made ;  nor  will  it  now  1 
denied  by  any  ono,  that  a  Urge  amount  of  sucocss  has  attcndo 
tliat  attempt.* 

I  propose  here,  as  well  as  my  limits  wfll  permit,  to  treat,  ^rdj 
of  the  goncral  indieations  for  exvi»ion  of  entire  boiieii  or  of  tbci 
articular  ends,  as  opposed  to  treatment  without  any  ojieration,  or  0 
orttio|iH-di<-  measure*,  or  to  anipatation ;  and,  wrondly,  to  dcscrib 
tho  operations  in  use  for  removing  certain  entire  bones,  and  ih 
jdiiilii  nhifii  are  «c<M;x$ibIo  to  ttuch  treatment. 

In  considering  the  question  between  excision  and  what  may  h 
termwl  (he  expectant  treatment,  it  may  be  laid  down  a»  a  gencn 
rule,  that  a  large  or  important  joint  ought  not  to  be  excised  nhil 
any  rojinoimble  prospect  exists  of  a  cure  without  operation ;  bo 
wlieii  bones  which  are  of  no  gre-at  t^ize,  and  removable  by  a  modi 
rulo  opcnttion,  nro  extensively  diseased,  tlie  Sorgvon  may  rec 
reasonably  propose  to  cut  vbort  tlio  cU^«a»e  by  excising  tJte  em 


*  I  have  nut  spaoe  iiere  to  ti'ace  the  hist«i7  of  eici»ioDR  from  tli« 
dilation  or  tliH  opvi-ulioii  br  Purk  uii J  tli«  Mor«sus ;  but  WOnlJ 
rondov  fi^r  tliis.  itnil  niwiy  oXber  poiuls  coiineoted  ultb  ttia  lilatoiT 
ti(Uc«  nTexcition.  to  u  vcr^- TulunWe  eswy  f*«ut!y  published  in  tliv  UdU 
Statu,  The  Extinou  i>f  JoiaU.  h\  Ridinrd  M,  Hodges,  MD.,  fio«ton.  iat1.| 


GENERAL  INDICATIOKS. 


797 


ana : 


bono,  while  yet  lie  nuy  allow  tliHt  cure  is  not  hopeless  shoulfl  tho 
[Mtieiit'a  circumBtancea  allow  of  hi§   olrfaining  prolonged  ukI  ju- 
dicious trud  tin  flit ;  for  Uio  ro--<ult  of  pra)ong«'l  troatment  la  always 
loubtfiil,  and  the  most  fortaoate  terrnination  n-liioh  <>ou1d  bo  ob- 
ned  by  many  niontfw  or  jwrlinp^  ycara  of  caro.  will  lenvo  t!io 
ttviit's  condition  little  better  than  t)i«  ojieration,  from  which  Ito 
I)  in  all  probability,  rveovor  in  a  fow  weeks  (see  p.  749).     I 
had  very  frequent  opportunities  of  noting  the  mccwa  of  opera- 
for  the  removal  uf  bonox  of  tho  tarsus  and  metataratia,  and 
sujieriorlty  of  sueh  treatment  to  that  of  waititig  for  a  curo^ 
lally  in  children,  wiio«c  rcstlosi<]ices  renders  eonfinement  lewt 
ly  to  bo  lH>rne.     In  tlie  hand  and  wri^t,  however,  «uc-h  opera- 
are  fat  less  applicable,  on  account  of  the  difficulty  of  perform- 
tbom  without  wounding  some  of  the  ten<Ii)ii.'«,  mid  »>  inducing 
of  motion ;  while  m  iJie  natural  cure  the  tendons  very  com- 
ly  escape. 

CoTinetited  with  this  part  of  tbe  sobjeot  U  tho  ijiieatJoi)  of  the 
<ta1  or  partial  cxtirj>ation  of  the  bono.  If  tho  function  of  tlie 
eaiicfl  bone  be  not  verj*  important,  it  is  always  better  to  removo 
the  whole  of  it,  since  it  i»  often  hanlly  posuble  in  au  operation  lo 
judge  of  tho  real  condition  of  tiie  bone;  and  if  Uio  i-iitiro  thick- 
ncda  of  tlio  bono  has  lo  bo  taken  away  for  any  considerable  extent, 
it  is  very  doubtful  whether  the  parts  left  behind  will  bv  of  any  use ; 
while  if  the  whole  bo  removed,  and  no  osseous  tissue  be  left  ex|K>«od 
the  wound,  Ihn  latter  will  heal  niiicli  more  readily  and  with  less 
igw  of  systemic  infection. 

But  the  qucition  wliii.-li  far  more  oltvii  perplexes  tlio  Surgeon 
Dot  that  l>etwoen  excision  and  tho  expectant  treatment,*  but 
een  excision  and  am]>utalion.  This  i^  90  oxtcuMvo  a  subject, 
id  so  much  dependent  on  the  ciiviumstances  of  each,  individual 
that  I  can  hanlly  hope  to  do  more  tliim  indicate  to  the  reader 
1c:ulingeon^derationa  which  apply  to  it.  Hiey  are  drawn  from 
lunieroua  circumstances,  wlueh  may  bo  thus  grouped:  1.  the  situ> 
ation  and  functions  of  the  bone  or  joint  to  be  excised ;  2,  tlte  state 
of  the  patient  as  to  general  hciiltb,  constitutional  affection,  and  age; 
3.  the  nattu-u  luitl  extent  of  tite  disease;  4.  various  extriineous  cir- 
cumstiuieuit.  I  will  proceed,  as  briefly  as  possible,  to  point  out  tlie 
moat  common  indications  for  one  o[>eration  or  the  other  under  each 
of  these  lieuds. 


*  Exc«pt,  perliapa,  In  eases  of  dtsoRM  of  tbe  hip  joint.    Roforotice  to 
is  subjuct  ultl  Irn  bttad  b«tow.  uniler  the  bMd  of  Esctxiou  of  the  Hif. 


798 


EXCISION  OF  BONES  AND  JOINTS. 


1.  As  to  tho  Hjuiation  aud  functions  of  the  bone  or  joint 
In  tbo  iippw  cxtremitr,  almost  nny  excuion  wturli  aBnixls  a  |ira 
ejteiH  of  prcsorvi'iig  to  tii»  [latiiiiit  the  motion  of  the  elbow,  of  til 
lund,  of  Uio  fingers,  or  portiapH  ovva  of  tho  tlmmb  onlj,  is  to  li 
preBsTed  to  ainputntion,  won  alt]K>ugh  tho  pittiont  may  not  H 
oav«r  aRL-fiil  motion  in  the  joint  operated  on,  nlicthcr  it  be  th 
nlioutder,  or  tho  elbow,  or  lli«  wrist.  TIwh!  i^,  hywovor,  ■  Ins 
to  the  s|>|iliaition  of  this  ruJe,  since  a  Umb  which  swings  oMlea 
like  a  flail,  may  provo  moro  of  on  aiuioyun<M  than  an  advantagi 
In  the  hip  no  queAtimi  of  ftin]>utatJon  for  dtseaMj  ever  ocean 
onder  ordinary  circumstaiioce,  in  any  caso  wln-nt  excision  ifli 
siblc:  and  in  ^uixUot.  injiiriai,  uhich  are  almost  tlie  only 
whioli  the  ojiorationB  arc  pitted  against  each  other,  tbo  nearly 
form  fatalitj'  of  primary  ampuutlion  hI  tlie  hip,  in  nio«lvrn  mili 
Surgery,  giv««  ibe  Snrgoon  a  decided  leaning  to  exciaioo. 
tlie  knee  the  question  i»  moro  difficult,  and  rliv  advantagn 
staff  limb,  letl  after  even  tlie  roost  stwoeeeful  excision,  over  tW 
fldal  substitute  (cepcdally  in  tlio  OMM  of  n  wealthy  person,  who 
aflbrd  U>  purijiuao  tiio  ingenious  artificial  limbs  now  maiiiifactand 
ore  not  so  great  as  to  balance,  in  the  minds  of  some  Siugeoo 
tho  inorea>ed  daiigor  to  life  wliicJi  (aa  I  fear  wo  cannot  help  ad 
mitting)  the  operation  entails,  combined  with  the  risk  of  failnr 
and  of  tho  uec<.^»»ity  for  coiiHocutivo  amputation.  Bat  there  seca 
very  reason  for  tltinking  that  excision  of  the  kn«e  will  soon  fa 
generally  adopted  in  ]>atient«  otherwiM  healthy,  wlicn  the  diseat 
is  only  of  limited  extent,  so  as  to  be  curable  by  tlie  removal  < 
tliin  slioes  of  tlio  affected  bones.  In  injurios  of  tho  knee,  exctfi 
has  not  a-t  yet  liceii  miic^h  praetised,  nor  lias  the  experience  o1 
of  it  been  very  satisfactory;  the  itytmcs  to  tho  knee  that  di 
oparation  in  civil  ])rftc(icc  ar«  generally  too  extensive  fur  cxcisii 
anil,  an  we  shall  see,  other  reasons  osually  preclude  it  in  mili' 
Surgery;  hut  in  limiU-d  injuries  it  will  occasioiwlly  bo  attei 
in  Itotli  civil  and  military  practice.  Below  the  knee,  tlie  cxei 
of  largo  portions  of  the  bonmoftlie  h-g  set^nu  much  p 
Ocrmuny ;  but  chiefly  in  nct-rosiH,  of  which  we  tOiall  have 
presently.  The  excision  of  the  anklo  is  an  operation  which  1  ha 
not  had  an  opportunity  of  pcrfoniting  or  Mictng.  It  apfMan 
have  oo<sa«ontdly  \-ieldcd  satisfactory  results  in  tlie  hands  of 
Hancock;'  but  amputation  at  tlie  unkle-joint  is  so  much  lees 
an  operation,  and  so  much  more  sure  of  success,  that  few  SurgMl 


*  Bai-u'i'U  on  thiJointi.  p.  403. 


GENERAL  INDICATIONS. 


799 


■|been 


to  attempt  excision.  In  cases  of  injury,  tlie  oomtninutod  pcr- 
of  bono  iiKiy  occasionally  Iki  rciiiov*Kl,  ami  a  u^c-ful  foo*  prc- 
Bon'od  !  but  no  rules  out  be  Liid  down  ou  this  point.  In  the  tarsus, 
.h«  removal  of  tlio  os  calns  wlion  much  diiH;a«od  or  oxtcnsivoly 
injunxl  is  a  very  suooedsful  ojMtrutioii,  aiid  ono  which  should  always 
Iw  prvlurrud  to  ampataUon.  Ttie  astra^Ius,  wlicn  dislucau^d^  hiu 
excised  without  much  iiniiainnetit  to  thu  uneruhuwi  of  the 
•t;  but  I  am  not  awaro  of  any  case  in  which  this  bono  alone 
baa  been  exciiiod  eiitiro  for  tliiieitm-,  nor  c-ould  thu  opiiortunity  ofWn 
TTio  bones  of  the  front  of  the  tarsus  are  fur  \em  fuvoimibly 
ituatad  for  cxciMuti,  ^incc  they  luv  all  viivclopinl  in  liio  fi.ilitii  of  a 
mon  sv-novial  niembrajie,  and  therefore  are  prone  to  participate 
in  eiu'h  other's  diiuMitcit ;  but  still,  in  tin-  cases,  wbicli  ait*  «>  c«m- 
tiUMi,  of  caries  attacking  the  cuneifonn  or  cuboid  bones,  an  attempt 
oagbt  always  bo  bo  made  to  save  tho  foot,  by  removing  tho  boiiot 
'ected,  whenever  tlie  diiieasn  has  not  apreaii  too  tar.  When  one 
two  metatarsal  bones  are  extonsivcly  (1ls<.'3si'<!,  they  should  bo 
ed  out,  the  toes  being  removed  at  llio  same  time,  if  lite  oper> 
■tor  thinks  fit.  I  havo  only  had  occasion  to  practiso  this  on  the 
first  metatai'ital  tmne,  which  I  have  stvveral  times  removed  with 
ty  good  results,  leaving  the  great  toe,  which  will  derive  so  mudi 
ipport  from  the  next  ton  as  to  become  extremely  niwful. 

2.  With  respect  to  tfae  sUtte  of  the  patient,  it  may  be  said,  in 
lerol  lerinft,  tlut  excision  of  Ur/^o  joints  is  only  to  bo  rocom- 

I'lnendcd  for  patients  in  good  licalth,  not  worn  out  by  previous 

ifteasc   or  confinement,   nor  deeply  aRvctcd  witli   cuiistJtutioDa] 

int  (rickets,  struma,  rheumatism,  or  syphilis);  nor  should  such 

:wi  operation  be  practised  on  patictita  past  tlio  middle  period  of  lifu^ 

In  the  lery  early  pi-riotl  also,  many  risks  may  be  run  with  a  view 

if  prei>«r\'ing  tlie  limb  entirely;  and,  alW  tho  failure  of  such  at- 

iipts,  tho  ca.se  hiL«  usually  p»s<*cd  beyond  the  reacli  of  excision, 

id  amputation  becomes  necessarj-. 

3.  As  to  the  diseoAO — exoLaion  is  never  to  be  recommended  for 
removal  of  malignant  disoases  of  the  joint-ond*  or  other  partjs 

bone.  It  i.t  tnie  that  Buch  operations  Iia^e  been  practised 
\hy  very  good  Surgeons ;"  bat  they  must  be  regarded  as  expori- 
Xoentnl  proceedings,  ja-?tifinb!e  in  the  early  |>criod  of  the  r^cration, 
T>«t  contra- indieatcfl  by  more  extensive  esperienec.  Nor  sliould 
excision  be  practised  on  account  of  acute  absocss  of  Uie  knoc-joiiitf 
and  only  with  much  caution  in  acute  diseases  of  any  joint.     It  is 


"  Paiit.  Sac.  Trmt.  vol.  iriii.  p.  3M. 


800 


EXCISION  OF  BONES  AND  JOIKT.S. 


■  dS 


muuli  t>ctt«r  Ui  endtiavour  hy  tree  incisions  aiv.1  ajtpropriatc  trot 
nifiiil  to  HUpport  ll»  paliftiit  HifohrIi  this  Hta^,  with  a  tisw  e 
removing  the  joint  (if  tho  extent  of  tlie  diiuiaiAe  n^ndcrs  it  prae 
tioalile)  at  a  later  period ;  but  Kliould  tl»  patient's  health  bo  girtsg 
way  under  tlio  irritation  of  anute  abacsie,  niiipiiutJou  is  indioat«i  in 
iJio  kneo  and  ankle,  and  l!ic  pnxtpcots  of  excision  in  otlter  jointa  an 
very  much  le**  favourable  tluui  in  <-lironi(-  <>iu>«s.  Tho  most  appro- 
priate cases  for  tli«  exciiuoii  of  jointo  are  those  of  chronic  disnav  of 
all  tliu  tisMiej)  (witite  swelling),  in  whivli  iho  bo»c«  are  probabir 
not  affected  to  any  groat  depth, — a  disease  due  in  most  ca»e»  to  ■ 
strumoiw  taint,  lint  in  w)iioh  tho  coiutlttiiioiial  afllbction  may  bare 
subuded  w  be  no  longer  active  For  excision  of  borioi>,  nocrwi* 
of  their  elmf1»  i»  the  itio«t  fnvutn-ablo  condition,  unoe  the  periosteal 
nlieiitli  vaay  be  relied  on  to  reproduce  the  bone  to  a  suffirtcnt 
to  resioro  the  fnnetion:*  of  the  tneinber.  in  uioh  conditions 
bonoA  of  the  upper  extremity  have  been  removed,  without  any 
ment  to  its  ultimate  wK^fuhKMi.  In  extensive  caries,  on  the  other 
hand,  amputnlion  is  clearly  indicated  in  the  lower  vxtrvmity  and 
vrrist;  while  even  in  tlx)  shoulder  and  elbow,  though  an  alti'nipt  to 
proser\'0  liie  limb  when  the  carious  diseaito  exu-iids  considerabi}' 
beyond  the  cpiphysal  ends  may  not  bo  unjustifiable,  it  miat  be 
allowed  to  bo  of  very  doubtful  Ijenefit- 

4.  Tlie  extraneous  oircumstanoes  which  may  deride  tlio  Surgeon 
to  perform  amputation,  in  a  caw  utlierwi^o  Rivourable  for  exciuoQ) 
refer  principally  to  the  lower  extremity,  and  d<?j>i>riii  on  llic  facilttici 
for  after  treatment.  Esci»ions  in  the  lower  limb  require,  in 
te  have  a  fair  prospect  of  euooess,  uninterrupted  care  and  na 
repose,  in  appropriate  pmnitioit,  from  the  moment  of  tlio  oj 
for  many  weeks  or  even  motiihs.  Hence  tl>e  gnait  rarity 
performanoo  of  excision  of  the  knco  in  military  practice,  and 
bad  success  which  has  attended  it.  Or  the  patJenl's  irritable  habiU 
and  impatience  of  conlinemcut  may  occasionally  lead  to  the  pre- 
ference of  aiiipiitntiuti. 

General  <.)l/uvrations  on  the  Operatimie  of  Ereuion. 

In  tlio  resection  of  any  large  joint,  except  the  hip  and  the 
shoulder,  it  is  of  importance  to  remove  the  wbtJa  articnlatini; 
surface.  Partial  exoiHions,  thoogh  they  ap[)car  to  8ttccec<l  well 
enough  in  the  two  great  ball  ajid  socket  joints,  are  repudLiled  b 
the  eano  of  the  large  ginglymoid  joints  by  all  Surgeons  who  have 
had  experience  of  such  operations;  ami  even  in  the  hip  rutd  slionldnr 
many  prefer  total  excision.   Hence  it  ib  ueceeeaiy,  in  the  Gnl  pbcV) 


Ha 


GENERAL  DIRECTIONS  FOR  OPERATION.       801 


■  out 

Vtu  iu 


tn  make  froo  iiicisJoitK  oxt«mnlIy,  in  order  to  be  able  to  turn  tbo  ends 

i^of  tbe  boiiea  out  of  tlie  wound,  and  apply  the  saw  above  the  artitnilar 

fa<.-c.     Tho  rcuiovnl  of  the  di-^i-jiM»l  bone  piocomctJ,  br  scooping 

[out  the  joint-ends,  ia  a  very  inferior  practice,  since  it  is  ao  difficult 

b>  Judgu  of  tJio  oonditioD  of  tliu  ]>art  left  behind,  and  the  union  is 

liable  to  be  very  irregular,  and  will  probably  be  delayed  by  the 

iBOparntion  of  numerous  small  nwlulvK  broken  awny  from  tho  bone, 

bat  not  removed.     IVIiereaa,  if  the  end  of  the  bone  lie  well  ex- 

1,  and  a  clean  section  made  with  tho  saw,  tho  condition  of  tbe 

left  behind  can  be  a»certained  with  almost  enlire  certainty, 

land  tho  ]>artH  are  placed  in  tlie  most  favourable  circumstances  for 

Itinion.      In  the  up))or  extremity,  where  freedom  of  motJon  after 

the  operation  is  sought  for,  it  is  desirable  to  present  too  extensive 

cicatri tuition,  and  enjioeinlly  tho  adln^n'nce  of  the  cioatrix  to  ibe 

B  bones.   Therefore,  when  t)ic  operation  is  completed,  the  parts  sboold 

Bbe  enrt-fiilly  rcut^ustc^l ;  Uiokc  piirts  of  tlie  wound   in  which  it  is 

H  wished  to  secure  speedy  union  without  puckering  should  be  brought 

^■togotlier  with  silviT  sutures,  while  free  exit  for  tlic  matter  in  otlwtr 

^Pparts  of  tlie  incision  ia  allowed.      It  must  not  bo  forgotten  tbai 

^kexcisions  art^  not,  under  onlinary  eireumittances,  [XTrformi'd  mitil 

^■the  joint  has  become  disintegrated  byehroniodisease,  ho  that  both  tbe 

Vpart-t  arotuid  the  joint  and  the  jmrts  which  form  it  varj'  vcrj-  much 

H  &om  their  natural  condition.      Around  tlie  joint,  tbe  thiekeniug 

^■produw^  by  old  inflammatjon,  and  tho  burrowing  of  abscesses  and 

sinuses,  tend  to  obscure  tlio  natural  ndalions  and  appearances  of 

tliepartji;  while  in  tho  joint,  okl  dislocation  and  partial  ankyloMS 

I  may  render  what  would  otherwise  1m>  an  eaiy  o]>eralion  inordinately 
difficult,  and  may  even  make  it  almost  impossible  to  recognise  tho 
parts  ex[)a4od.  Then  again,  the  contraction  of  llie  tendons,  which 
aometimcs  accompanies  long-continued  disease  of  the  joints,  may 
bare  reached  hucIi  h  point  that  the  limb  cannot  be  placed  in  the 
proper  position  without  the  aid  of  tenotomy.  In  conswiucnce  of 
ill  these  cireumntanoci',  tbo  knife  nnvit  bi^  kept  close  to  the  bones 
when  thcj-  are  reached,  in  order  to  avoid  any  part  which  it  may  bo 
desirable  to  Kpan',  but  which  the  morbid  condition  of  the  tiasuea 
prevents  the  operator  from  seeing ;  and  tbe  burgeon  must  be 
prepared  to  varj-  hi*  procot-ilings  glifihtly  with  Uie  varj-ing  con- 
tdition  of  the  articulating  ends  of  the  bones.  As  to  tl»  thickened 
t^iiovial  inrmbranc,  which  so  often  Iic«  aroand  the  diM<9»od  joint- 
ends,  it  is  well,  I  think,  to  cut  away  ajt  much  of  it  as  can  be 
removed  without  trouble  or  risk ;  but  I  have  not  obscrv-ed  any  burm 
from  leaving  small  portions  of  it  l>ehind.  Before  the  patient  baa 
roi_  m.  3  F 


^ 


802 


EXCISION  OF  BONES  AND  J0I^'T8. 


recovored  his  conscionsnoiw,  Utt'  limb  should,  in  all  csuws,  1 
fuUy  secar<xl  npuii  a  iijilini,  in  the  poeition  it  i&  intended  i 
tain  for  the  6rat  few  days  after  the  oporation.  This  poeitjon  nw 
not  necessiuilT  bo  the  one  ra»:<l  fiivnunihle  for  nnkviooiv,  «xcef 
where  bony  union  is  desired.  In  that  case  the  limb  ought  nen 
to  be  mox'ed,  if  it  can  be  uvoidcd,  out  of  the  position  in  which  it  i 
Lnt«ndei(I  ro  HiikyloHe ;  and  the  first  dresdng,  or  change  of  splin 
after  tho  operation  ought  txt  bo  delayed  as  Img  as  duo  attcotiii 
to  cleiajilInesM  allows. 

As  to  tho  instnunentft  roquircd  in  cxiusions,  little  nrod  be  sai 
Tliose  oiieraLionii  are  no  exception  to  the  general  rule,  Ijiul  difi 
culties  are  betiCT  overcome  by  Hie  dexterous  n»o  of  common  instn 
mcntM  tliun  by  iho  invtintion  of  ajiecial  and  often  coin[>lKBte 
apparatus.  Tlie  elaborate  instruments  described,  usually  in  Freiu 
surgical  works,  upi>car  to  be  really  intended  to  save  tliu  SurgM 
from  the  necessity  of  thoroughly  exposing  the  bones,  by  tnnuD 
down  proper  flaps,  and  tlni'>  to  enable  him  to  remove  the  bona 
piecemeal ;  and  if  so,  tlieir  principle  is  radically  had.  Tlie  cbaiii 
saw,  nlileh  scorns  to  be  much  used  in  France,  is  hardly  evfl 
employed  in  England,  though  it  may  he  useful  occasionally  in  deq> 
seate<l  parts.  Some  operators  like  to  steady  tho  bone,  and  guar 
the  pails  around,  by  pa^tslng  tnider  \l  a  large  director,  mounted  m 
a  handle ;  and  such  an  instrument  may  bo  very  oonrenient  wba 
the  bone  cannot  be  Uiniei)  out  of  tlie  wound.  The  stave  called  b 
tho  name  of  its  inventor,  Mr.  Butcher,  will  often  be  found  useful 
U  i«  itimilar  to  the  ordinary  metacarpal  saw,  exempt  that.  it«  Undl 
is  movable,  and  can  he  fixed  at  any  angle,  so  that  it  can  often  bt 
intmihiccd  and  worked  where  an  ordinary  amputating  saw  cannot, 
The  latter,  however,  is  much  better  for  sawing  offa  pieoe  of cleonlT- 
ex]>0Ke<l  bone;  as  Butcher's  »aw  is  rather  liable  to  bend,  and  thi 
blade  is  apt  to  get  loosa  The  large  bono  f<a%eps,  with  a  doubll 
jaw,  called  by  Mr.  Fergusson  "  the  I  ion -forceps,"  are  almost  indiii 
penaable  for  holding  firmly  the  piece  of  bone  which  is  to  be  Sam 
off.  These  instruments,  together  with  cutting-pliem,  a  koj'bolo- 
saw,  gouge,  oliisel,  trephine,  blunt  hone-forcejio,  aitd  curved  spatu- 
las, are  nil  the  special  apparatus  necesssiy. 

Tho  bones  to  be  removed  ought  alwnya  to  be  taken  away 
clean  an  possible,  and  if,  in  removing  entire  bones  or  portions 
their  shafts,  the  ]>eri»»teum  can  he  left  tiehind,  it  will  no  doul 
be  an  advantage,  as  tending  to  give  more  firmness  to  tlie  cicatris 
but  in  the  exoiiuon   of  largo  articulations   "  subperiosteal 
tion"  seems  neither  very  practicable  nor  of  any  undoubted  utility. 


EXCISION  OF  THE  SHOULDER. 


808 


tin  necrosis,  and  oci^aaionolly  in  the  nioHt  ndvancetl  t>tag«  or<?artes, 
pi-ricHttcuiii  will  bo  found  so  detaohod  from  the  bone,  tliat  by 
keeping  tlie  edge  of  tlio  knifv  cnix-fiilEy  tipon  tlie  Utter,  iu  in> 
vesting  mcmbraao  will  be  left  bcliind,  and  with  it  (at  least  in 
eases  of  iiecroftis),  in  all  probability,  the  gvmu  of  a  c«nsi<Ii;rable 
reproduction  of  the  bone ;  but  in  pasos  of  coniminuted  fracture, 
I  or  in  tliiisi*  nicwt  common  casPs  of  excision  of  joint«,  where  tlie 
Iwncs,  though  ulceratfd  on  tlieir  articular  surCace,  ami  somewhat 
Boftvuixl  tliiiiugliout,  retain  their  vitality,  the  oiwrator  could  only 
hope  by  the  expenditure  of  much  time  to  succeed  in  lea^  ing  in 
wound  romv  eerapK  of  liteoratcd  j)criosteum,  t!i<i  use  of  which 
rould  liardly  repay  tlio  trouble  spent  upon  them."     The  oommon- 
I  viflw  of  the  case  seems  to  bo,  that  disease  when  veiy  axtMlUW 
passeti  beyond  tlut  jiroviiioo  of  rcMiction,  unloAs  the  fimctJon 
of  tlie  whole  bone  can  be  dispensed  with;  except  in  nocrous,  when 

I  it  ha*  arrived  at  tho  ittago  of  Hxjnvtitratioii,  and  separation  of 
the  periosteum,  accompanied  by  tlie  formation  of  new  bono.  In 
such  a  ca»(i  tlio  operation  comes  much  nearer  (u  the  removal  of  m 
Bequestnim  than  to  excision  property  so  called.  Under  then 
circuiiiKtiinces,  sus  much  as  foorlcen  inches  of  bone  have  been  re- 
moved from  tlie  vicinity  of  the  olbow,  and  a  useful  arm  has  been 
preservwl.  Thcso  operations  for  extensive  necrosis  arc  indood 
triumplis  of  conservative  Surgery,  but  have  little  bearing  on  the 
question  of  subperiosteal  reflection,  unless  it>  could  he  shown  that  it 
is  really  possible  to  nccompliith  with  the  knifo  in  a  few  minutes 

I  that  which  nature  effects  in  months  or  years,  viz.  to  separate  the 
perioHt«uin  from  the  diseased  bone  along  with  the  blastema  which 
will  reproduce  the  part  removed. 
te 
XI 


ExaSIOKS  IN  PAKTICTLAB. 

EjKmon  of  the  thoaldtVy  a»  the  term  ia  ordinarily  osed,  is  in- 
I  tended  to  signify  merely  the  removal  of  the  hoad  of  the  humems. 
„Ibe   operation   is   pra«tisod   in   proferouoe  to   amputation   at   the 


*  Some  writers  spesk  of  subpfrioilcal  rotiectiona  of  Joinia  In  such  t«nas 
Uut  one  is  alinosl  iliipuHL-d  to  tliiiik  tliat  t)i«7  inittgiiie  the  pustiibillty  of 
diKnectiog  out  tb«  «nd  uf  lb«  Hliuft  of  a  large  bone,  likv  llie  f«iuur  or  ihe 

»  humerus,  ami  k-aving  behind  n  sk«ve  of  |ie(ioiitvuin,  wliiclt  is  to  r^pioduot) 
tlui  bono.  Siii^h  HD  idea  in  pivpontcrous.  TIm  ntliimpt  would  only  result 
in  leaving  som4>  IrreKiiliu-  shred*.  M.  Oilier'*  cxpurimenta  nbow  Uuit  meb 
shrods  will,  in  the  loner  animals,  produce  iircgular  nodulos  of  bone.  Pro- 
bably this  would  not  be  so  in  luan  ;  but  if  it  ii«t«.  cudi  nodulas  wxiuld  bo 
■tore  oft«n  in  the  way  than  otbervrU«. 


804 


EXCISION  OF  BONES  AND  JOINT& 


aboulder-joint  in  coh^s  of  gun<»liot  wotmd  or  coni|>oun<l  ituloci- 
tion,  when  titc  injury  is  not  too  extensive ;  and  is  the  o-aHy  opentioii 
a(liiiL««iblo  in  chronic  di«CRso  of  tLe  joint.  But  in  cwws  of  ra; 
growing  tumour  of  tJie  hend  of  tJic  bone,  unpiitalton  woold 
the  more  prudent  course ;  and  Btill  more  so,  if  the  tumour 
known  to  be  ojtiiovrou.t.  In  iinlcvl<"«is, — on  vflbction  which  is  nrv 
ill  tlie  shoulder, — no  operation  is  admi^isible. 

The  hcn<i  of  tho  bone  miiy  1n>  rewiovwl,  if  tltcrc  is  not  much 
thickening  over  tho  joint,  by  n  single  incision  running  downwards 
as  far  a»  m»y  hv  judgiil  necessary  from  tho  upper  part  of  ihi- 
acromion  process,  over  the  most  prominent  part  of  iJie  head,  where 
it  is  most  plainly  felt  bonoath  the  skin.  Tlitn  line  of  incision  con^ 
spouds  pretty  nearly  to  the  direction  of  the  long  tendon  of  the 
bic<;i>s  muscle.  In  motet  caNes,  however,  it  is  neceasary  to  ma^ 
a  flap  out  of  the  deltoid  muscle,  of  a  somewhat  triangular  fthsp, 
wit}i  its  base  upwards.  The  precise  position  of  the  incisions  whicb 
bound  ihiA  fla)>  Jh  a  matter  of  Hecondary  importAn<«,  and  is  nitunlly 
determined  bv  that  of  tho  sinuse«  or  wounds,  Tlie  head  of  the 
bone,  having  tbiiti  been  exjwwd,  ii>  to  he.  rotated  (when  the  shall  in 
cnt.irL')  first  outwards,  in  order  to  stretch  the  tendon  of  the  snb- 
Bcapularis,  then  iiiwanU,  Ut  niako  tense  thowo  attaclied  to  tho  greater 
tuberosity;  those  tendons  are  to  be  dinded,  and  the  capsule  thus 
freely  openeil,  and  then  tlio  head  of  the  bone  is  to  be  thrust  out  of 
the  wound,  and  sawn  off.  If  the  ease  is  one  of  injury,  and  the 
heiKl  of  tho  hone  i*  aevcnxl  from  the  shaft,  it  must  bo  seized  with 
tlie  lion-forceps,  and  dissected  out.  The  bleeding  is  iiKunlly  free, 
from  the  posterior  circumflex  artery  or  its  branches.  If  the  long 
tendon  of  the  biceps  can  t)e  distingtiished,  it  should  he  KpanxL  In 
botli  disease  and  injury,  tlic  glenoid  cavity  often  escaiies ;  but  if  it 
should  be  found  affected,  it  may  be  thought  ncccssnr^■  to  remove  it 
Tliis  is  best  done  with  bone-nippers,  or  the  gouge  may  be  used. 
The  parts  should  be  lightly  l)ut  together  hy  mosui.t  of  a  fow  suttuv*, 
and  the  iiaticnt  confined  to  bed  for  the  first  fijw  day*s,  until  the  ctm- 
seoutive  fever  has  passed  over.  He  may  then  Ixj  nllowod  to  more 
about,  the  etljow  being  carefiilly  supported.  The  tendency  of  tlie 
muscles,  whidi  form  the  finps  of  tho  axilln,  to  displace  the  bono 
may  be  countcractod  by  a  pad  in  the  armpit. 

The  amount  of  Imiie  which  may  Iw  rimiovcd  in  cases  of  iujarj, 
with  a  prospect  of  preserving  a  useful  limb,  appears  to  be  consider- 
able. Four  or  five  inches  of  tlio  bono  have  been  removed  witli 
good  result.*     But  no  doubt  tlie  less  that  can  be  taken  away  the 

*  Hiidgen,  op.  cit.  p.  io. 


^U 


EXCISION  OF  THE  SCAPULA. 


80$ 


otter.     In  coses  of  injury,  provided  all  the  conimiuuted  portion  is 

Etnoved,  fractures  or  tisiniret  numing  Jown  from  the  M(rf  w«t 
of  injur)'  may  be  disregarded.     In  rbronic  diseaso  of  the  joint,  the 

fevtion  in  uxtuilK-  limited  to  tho  Iicnd,  cixoept  in. crises  of  nocrosis; 
but  in  necrosis  it  is  more  usual  to  And  the  shaiV  only  diftoa.<)od,  and 

bo  joint  exODipt." 

The  amount  of  motion  obtained  after  the  most  »iiccc.s»ful  re- 
section of  the  ho»d  of  tlio  liuintTUs  does  not  seem  so  great  afl  that 
tvhioh  is  recovered  in  aome  caacH  oi'  ankylosis  uHvr  di.«oiLii\  The 
ami  can  never,  sui  it  scvmit,  be  elevated  beyond  the  horizontal  line; 
while  in  many  cases  it  hangs  down,  witliont  aiiy  jiowt^  whatever 
in  the  deltoid,  at  a  grvittcr  or  less  distance  £x>m  die  scapula.  But 
tbe  movements  of  flexion,  ext^naioni  and  adiluclion,  are  usually 
free ;  abduction  can  ofren  be  efTeetcd  to  the  extent  of  raising  tbe 
arm  con^iclorably  from  tb«  »ido;  and  there  is  usually  sufficient 
powsr  in  the  fore-arm  to  carry  heavy  weights,  and  perform  many  of 
the  ordinary  diimeslie  tiiKk.t.  The  ann  is  thon^^fore  a  vi-r*  useful 
one,  irrespective  of  the  vast  importance  of  jireserving  Uio  hand ; 
•lid  M>  tbo  patient  ia  enabled  to  follow  many  of  tbe  ordinary  trades. 
It  does  not  appear  that  any  advantage  in  gainwl  hy  removing  tlio 
glenoid  eavity ;  while,  ax  far  as  can  be  judged,!  the  opcriilion  i» 
rendered  more  severe  and  more  dangerous  to  lifr.  Hence,  unless 
dtMHue  is  clearly  present  in  tliat  part,  it  should  bo  let  alone.  "  The 
average  length  of  time,"  says  Dr.  Hodge*,  "  before  some  use  of  the 
litnb  was  commenced,  as  calculatul  from  thirty-one  of  tbe  csisca  in 
my  table,  was  over  four  months  ;  a  much  Umyer  period  than  this 
wait  riiquircd,  however,  to  elapse  before  t]ie  limb  coiiltl  be  said  to 
become  really  serviceable,"  The  table  iu  Dr.  Hodges's  treatise 
contains  fifty  cases,  cifjht  of  which  died,  and  iti  four  others  the 
Operation  was  uosucceasfuL 

Eiceuion  of  ihe  aeapula  and  clafu-U.  Kxci^on  of  tlie  scapula 
luu  been  oocasionalty  practised  on  account  of  necrosis,  or  llu>  bone 


*  In  tfa«  oelcbmud  esse  of  WluU  of  ManobMlvr.  usually  quoted  as  th« 
llitt  In  which  excision  of  tlie  shoulder  was  perforoMd.  a  iurge  AoiiiMiBUiiin 
irM  rsiDoved :  but  it  dooa  not  appear  Ibat  that  s«<]uestnun  iavolvfid  ilie 
Jnlnt;  in  fact,  lli«  pisie  in  Wliite'sCun  in  Surj/ery.  lig.  i.  p.  es.cUariy  tJiows 
UkM  the  sbtift  bad  aeiiamtvd  (luio  the  epipbyBJs.  nud  iLut  tlie  piul  raiaovtd 
was  the  oi-ciutit^d  up|i<^r  jjorlioa  of  the  diuptijain. 

t  tied  the  oa«i-H  quoted  by  lir.  Hoilf-ev,  up.  oiL  pi.  34.  Of  tlie  bt«l  ca>«B 
Ibere  rqwrted  {inslit  in  iiiiinbAr).  thrrv  nan  but  a  sinclo  iiuUnec  of  dvnih 
where  tbe  gtvnoid  coviij  liud  not  bcvu  intvrf'Tivd  villi. 


«06  EXCISION  OF  BONES  AND  JOINTS. 

liu  bent  removal,  together  with  a  tttmoor  groving  from  it :  d 
exotflion,  howerer,  in  the  latter  class  of  com*  has  usually  been  <io 
partial,  if.  only  the  portion  of  tlio  bone  implioated  in  tfae  tomoi 
has  been  removed.  Tbe  opcrstion  in  incli  coses  bas  nsnallj:  hct 
protrR<-t<vl  and  hWxly;'  anil  it  mny  bo  added,  cbat  in  mo-iioflli 
piibliHliini  c^aea  it  was  of  vcr^'  doubtful  benefit ;  the  tumour  bun: 
eithor  of  a  uulignant  nature,  and  returning  in  npite  of  Uie  operatioi 
vhioh  did  not  seem  to  prolong  life ;  or  olso  being  dependent  fl 
^rptiilis,  and  very  probubly  eiiniblti  without  any  ojMM-iilioii  at  alL 
These  conaideratiooa, — added  to  tbe  great  severity  of  tbe  opef«ti« 
in  caisM  of  rapidly  growing  tumour,  where  the  Inrgo  artvries  whil 
aurrottnd  the  scapula  oivall  sides  are  enlarged  for  the  supply  of  d 
new  growth,^-ought  to  make  the  Surgeon  vcr^-  cautious  in  reooa 
mending  such  operations.  The  operations  on  the  seapnla  R>r  iM 
erosis,  tike  all  other  operations  for  tliix  affpction,  liave  turned  <n 
much  more  satisfjiotorjly ;  but  tJiey  bear  more  reeemblance  to  tli 
usual  proceedings  for  the  extraction  of  eoquo^m  than  to  (bniiM 
operations  for  excision.  A  case  related  by  the  late  Mr.  Jones,  t 
Jersey,  in  the  42d  volmne  of  the  ^fedieo-Chirur^itxl^  Tratuadim 
will  illustrate  these  observations,  and  will  show  what  u-'«eful  mntia 
may  be  preserved  even  after  the  removal  of  a  aequoetrum  involvn 
almost  the  whole  scapula,  inclusive  of  itR  articular  miHium.'.}  S 
npecial  directions  are  needed  for  these  operations.  The  positioa  c 
the  sinuses  will  point  out  the  most  convenient  directions  for  til 
incieifiiis,  which  shoiikl  be  kept  ns  much  as  potoible  upon  Ute  limi 
of  the  bone,  in  order  to  avoid  as  many  of  the  large  vensels  as 
be  spared.  Tlie  bleeding,  liowe\'er,  in  tlwae  operations  for  ni 
seems  far  less  than  in  those  performed  for  the  remo\-aI  of  tumoun. 


*  See  tfaa  aceeunt  by  Mr.  Uatm  of  «u<ili  nn  opnntion  perfonucd  for 
tumour  whloh  he  regai-ilttd  as  an  OMiflrd  nn^inim  of  xba  mb»ca] 
ni'teiy  ;  but  whic.li  was  in  till  probabilllj  a  nrntignaiit  tuniour  of  tli* 
Edin.  Mtil.  iinii  Surg.  Journ.  vol.  Jtvi.  pp,  (10,  SIS. 

+  P/tth.  Soc.  Tran4.  vol.  vii.  p.  310. 

',  Mt.  Jones's  di'sc^iipliun  in  not  perfectly-  dear  on  thi«  point,  nor  U 
gUijoid  cavii.v  of  Lbe  ncapula  r«co(;ni!i!ibl«  in  his  drawing  of  tbe  large  plM 
of  boue  removud  ;  but  nx  lie  >pcaki  of  tlie  liead  of  tlie  humerus  as  oofcr* 
with  it!i  nuturnl  cartilnRn.  in  bis  dca«riptiun  of  iha  operatioa.  which  sli 
bo  nainea  " Dlsniticulntlon  of  the  icitpuln  from  the  hbou Id er joint.'  <* 
must  conc^ludc  ihnt  the  nocroRC^d  piece  itmludcd,  piaelioallf  HiK'tikiDe.  lb 
whole  bune.  and  that  the  shoulder-joint  was  dcBtrojred  in  ranoriug  it.  Hi 
Jonea  aonoriilngly  desoiibea  the  humorus,  aft«r  tfae  )»lient'a  recovox,  a 
"  moving  freely  in  il«  new  bed ;"  although  ho  doe*  not  aay  wbaro  that  nal 
bed  was  formed. 


EXCISION  OF  THE  CLAVICLE. 


ao7 


Almost  tho  same  giiicra!  obsen'stioDs  will  apply  to  the  removal 

of  tho  clavicle  as  to  lliut  of  tho  iica|)uia, — 'irilj-,  ilh  tjie  relations  of 

tiiv  clnviclo  arc  fkr  more  importitnt  tliaii  those  of  [he  scapula,  ao 

mst  even  greatnr  caution  bo  excroi»o(i  in  und«ruking  \i»  rcDDOval. 

It  i*  not  only  that  ven-  large  vcsscb  lie  in  the  neighbourhood, 

which  it  miiy  Iw  <lIfficiiH  U)  aviii*!  during  tlio  removal  of  n  larg« 

tumoui-  ]>aMing  into  the  root  of  the  neck,  and  perhaps  lapping  o\-er 

tJiem ;  but  «l»o  that  the  romoval  of  micb  a  ttiinoiir  from  below  tho 

(icop  iiiscia  of  tlie  neck, — for  that  fascia  must,  in  most  oase«,  be  cnt 

through, — involves  itlanning  ri«k  of  dcftth  from  JifFusc  inflamniation. 

The  benefit  to  be  derived  from  such  an  o]jeration  ought  therefore 

to  be  most  clwurly  proved  before-  it«  dangcrB  aro  cneounteiv<l.*     In 

operations  for  necrosis  the  proceeding  will  be  far  more  simple,  and 

H  is  likely  tt)  bu  far  more  kucuciwIuI.     Tlie  sMjucvtnim  will  prolnbly 

Hbe  sepoiiitod  from  llio  suij<-la\'i.i»  vein  anil  llio  deeper  parts  by  a 

HdepoBit  of  new  bono,  and  tho  pationt  will  havo  a  fair  cbancc  of  por- 

Brnanent  recovery.     In  operating  on  the  cluviclo  for  ■  tumour,  the 

f  incisions  should  bo  made  very  free,  one  over  tho  long  axis  of  tho 

bone,  Joined  by  othen  in  iip|)ro|>r!ulo  places  for  turning  down  such 

as  may  appear  nwessary,  and  the   parts  to  be  operated  on 

bid  bo  broiiglit  iiiirly  into  vi<w  bc-fona  iho  bone  i*  niwiillml  wiili. 

or  having  freely  divided  all  the  superticial  attachments  of  the 

one  iumI  tumour,  llio  next  .-itvp  is  to  divide  tlin  oiitur  end  of  the 

ivicle  from  the  scapula,  either  by  cutting  through  llic  joint,  or 

iby  severing  tlie  bono  with  a  small  i'aw  or  nip{)cr».     Thvn  tlie  [lart 

ifhich  is  to  bo  remmeil  can  be  raised,  and  must  be  separated  with 

^greut  caro  from  the  important  part*  which  Ho  below  i I,  so  as  to 

•  reach  tlie  Htcrnul  p;irt,  which  is  last  divided,  and  which  ser\-cH  dur- 

I  big  the  o|>eration  as  a  pivot  on  which  the  bone  can  be  moved  and 

^supported ;  or,  ui  otlier  cases,  it  may  be  fomid  more  convenient  to 

rilivide  Uu«  part  of  tho  bono  alxo  at  an  earlier  period  of  the  opcra- 

ption.f     It  appears  that  verj-  useful  motion  may  be  recovered  after 

lie  romoval  of  a  largo  part,  or  even  the  whole,  of  tJie  sliiill  of  the 

clavi(!lo. 

After  amputation  at  tho  shoulder-joint,  tho  scapula  luu>  been 
extirjialod  for  recurring  disease,  and  portions  of  tlie  clavicle  have 
been  simultaneouslv  removed.      One  case  is  on  record  in  which 


•  In  Mott's  cam  th«  opcrntion  U*tod  four  houn,  and  thirty  vmmIs  were 
U«il.  MottM?*,  "this  oprntion  far  »nrpHMd  la  (edlouencu,  diffleulty,  and 
danger,  anj  thing  which  I  hAT«  orcr  witnessed  or  |i«rfi>nned." 

f  8e«  TniT«VB,  in  JUfrf.-^Ur.  TViini,  vol.  xsi. 


80tt 
MtiK 


EXCISION  OF  BONES 


id  tu 


y,  of  Oincinnati,  is 
and  Bcapuiu  for  u  tumour  recurriog ; 
joint*     The  patient  survived  tiio  opratiu 
rec|uircd  fi>r  tho  iKirfurrnitiiw)  of  an  operat 
judged  adNisable  to  repeat  it)  must  vary 
tile  condition  of  tho  ymrUt  l«il  behind  att«r  ' 
oammeuoed  firom  the  inner  side,  bo  lu  to  i 
daviui  artery  oiirly  in  the  operntiun ;  an 
tbe  best  ooui'se  if  the  slate  of  parts  should 
io«t  hi*  piiti<^nt  from  tlio  ]ni*Aag«s  of  air 
As  th«  original  account  tenainKtes  immedij 
l<H»cunco  of  tho  patient,  and  no  RubaecjiMM 
been  publi»lied,  it  ia  impassible  to  say  w^ 
from  this  formidable  operation. 

Em^Kion  of  the  eUmc  for  discaso  may 
boneo  are  «xj><iHi>d  hy  »  frnti  vortical  inoi&iaj 
at  ths  external  condyle  of  tho  humcniis.  | 
peri>endi(!ii]tu-  tu  it  over  Uie  tip  of  the  4J 
bwards  far  enough  to  endanger  the  ulnar  i 
wanted,  it  may  ha  obtained  by  makiug  una 
B6  to  form  the  letter  H,  but  the  H  incisioj 
and  where  very  little  thickening;  osist*,  the 
oomplclcd  with  a  single  vertical  incision.  J 
in  found  dt.4louit«d  on  tho  buck  of  tho  ou| 
moD  condition  in  olironio  disea.se  of  this  join 
onco  with  the  bonc-nippcrs.  Tho  joint  tdufl 
by  dissecting  round  the  olecranon,  care  B 
edge  of  the  knife  close  against  its  toner  aij 
ulnar  nerve,  which  is  ununlly  hidden  from 
induru(«d  cellular  tissue.  The  end  of  tlie 
cleaned  and  turned  out  of  the  wound;  the  I 
ing  been  previously  cut  ofi',  if  the  latter  pil 
cult.  However  slight  tho  di.si'niw  in  tlio  | 
vnd  of  tho  humerus  just  above  the  condyld 
Afterward*  the  sigmoid  cavity  of  tho  ulni 
It  is  better,  when  it  can  be  done  without 
the  sections  of  the  two  bones  of  tliu  foi 
Tho  transverse  portion  of  tho  wound  shoi 
with  silver  sutures,  in  order  to  avoid,  i 


Aiiur.  Journ.  of  Mtd.  Se.  1 


EXCISION  OF  THE  ELBOW. 


809 


e,  whicJi  might  interfere  witli  motion.'     The  vertical  piut  inajr 

I  bnn^t  togothor  morv  liglitiy.     Tlir  Hnilj  »liou]d  tlicrn  be  lightly 

laged  on  an  angular  splint,  before  the  patient  is  reAtorod  to 

nseioiunem.f     If  troublesome  hGcmorrbago  occurs  from  the  arti- 

'oular  artories  at  the  beginning  of  tlie  opt^ration,  nn  a^ttijiUnt  niioiiM 

Ifiompresathe  brachial,  and  any  icssfl  which  continues  to  bleed  after 
tlio  reinoviil  of  tlio  l>oiiej4  ohould  bo  carefully  tied. 
The  extent  of  bone  which  may  bo  removed  in  an  *x<asion  of  the 
•Ibow  i»  (xiiisiilvnibio;  in  fjtet,  witliin  the  proper  limits,  it  jMwms 
BB  if  the  more  bono  is  removed,  the  boUor  i»  the  result.    If  only  tlie 
Qxtromc  ondx  of  tlii^  liun>---«  be  nawn  oft*.  ankyIo»is  will  moist  likely 
»take  place ;  while  if  the  amount  above  prescribed  (viz.  the  whole 
eundyloiil  extremity  of  the  humeniH  luid  all  the  sigmoid  cavity  of 
the  ulna  with  the  head  of  tlje  radius),  or  even  a  little  more  on  both 
siiU's,  hn  (liken  uway,  free  motion  may,  uiwier  fuvuitrable  circum- 
stances, be  expeeted.     An  exaggerated  idea,  bowerer,  appears  to 
cvnil,   of  tlte  amount  of  Itonc   which  inny  bo  cxciimkI   with  a 
spect  of  preserving  a  ufleflil  limh.     This  idea  has  originated 
om   conf\ising   opcratiomi   undertaken    for    necrosis  with   those 
injury  or  elinmic  dUease  (earie«>).     In  the  former,  tho  whole 
iiatl  of  a  bono  bus  oftoH  been  removed,  and  «  UMfttl  limb  letl.      In 
ho  latter,  where  the  ]ieri(Mteimi  must  he  removed  with  the  Iwnu, 
oly  a  limited  quaiiti^  of  bone  can  be  taken  away.     If  the  liniita 
ve  [winted  out  have  been  somewhat  excotxled,  and  still  jit  tho 
oint  of  section  tho  interior  of  the  bones  is  obviously  diaeafied,  it  is 
cr,  if  tho  disease  ia  not  in  a  very  ad\'ancfd  condition,  to  remove 
the  bone  which  is  quite  <lUintegniled,  preserving  wlmt  is  merely 
iitol,  and  t]iu8  give  tho  patient  a  chance  of  saving  his  limb; 
if  oomplele  diiiorganiAiition  cxtentU  thr  into  the  shafts  it  is  ad- 
i»  to  amputate.     The  position  of  tho  line  of  «octinn  in  relation 
be  junction  of  the  opiphyMin  is  a  matter  of  sabordimtte  import- 
ncB  in  thiM  joint,  since  it  is  of  much  moro  importjincu  to  obtain 
flexible  but  firm  miion,  no  as  to  allow  of  good  motion,  tlian  to 
ivoid  any  amount  of  shortening  of  tho  affected  arm. 

The  arm  .should  he  lefl  perfiitctJy  quiet  for  a  few  daya,  in  the 
sitJon  in  wliiclt  it  has  been  placed  after  tho  operation.     A  good 


fbciivt 


the 


•  Syme.  Obt.  in  CUnieal  Saryery,  1801,  p.  M. 

f  Some  KiuKcons. — Btiii  Hmuii;;  tli^in.  I  beltcv«,  Mr.  Sf  me  (see  liia  !■«*■ 
IJM  on  Krdtion  o/IHttfUrd  JoinU.  \fii\.  p.  TO),— merely  dex  UlO  ann,  «ii<t 
r  ft  roII<T ;  but  tho  mppoi't  a(A  sptiot  Dp|iciini  to  p**'  ounfidrncr,  and 
>  prevent  tipaamcHJic  mnvrmrntii :  it  nccil  not  he  Hp|>licd  at  any  particular 
[  aitglu,  but  morvly  to  sudi  a  poution  as  avoids  tension  on  the  siitiim. 


810 


EXCISION  OF  BONES  AND  JOINTS. 


deal  of  irritative  fever  often  rapcrronc*.     Wbcn  it  is  n 
clmngc  the  dressings  for  llio  sake  of  cLeBtilinofts,  u  groov 
abould  be  api>lirtl,  wliioh  will  lodge  tl»  arm  and  fore-arm, 
which  ID  jointed  tn  the  contrc  imd  movable  by  n  mck  and  pi 
with  this  apjiaratMs,  the  arm  may  easily  be  got  into  tuich  a 
M  will  «ftonvanU  bo  UM?ful,  by  griuhiiliy  changing   the 
Poaivo  motion,   liowever,  of  a  more  rigorous  kind  must 
nc^ected,  the  time  at  which  it  is  commenced  varying  with 
state  of  the  wound  and  tlio  <]iuuitity  of  the  bone  whiiJi  luu 
removed.     If  mncJi  has  been  taken  away,  ankylosis  is  little  t 
apprvlicndod ;  otliirwiw,  at  a  period  which  may  be  roughly  il 
at  about  tliree  weeks,  daily  passive  motion  ouglit  to  be  conunea 
In  the  most  farourablo  otwea  n  very  perfect  fahw  joint  saooea 
this  treatment ;  and  an  amount  of  motion  is  regained,  which 
practicfll  purposes  is  Httlo  iiifcrior  to  that  of  tlit-  urtj^iniJ  joint, 
tliifl  a  vn-y  interesdng  esample  is  recorded  by  Mr.  Syme,*  in  D 
he  had  the  opportunity  of  dtwcelinfi  tlio  iiftw  joint,  nine  years 
tho  openitioii,  whidi  had  been  performed  on  account  of  itgof 
tlie  man  having  in  the  intcr\-al  acted  ba  guard  on  a  railway,  svn 
ing  liiniHcIf  from  one  OArriago  to  another  while  tho  train  wil 
motion,  with  llie  iiijiirod  arm,  quite  as  easily  and  secarely  as 
tho  other,     Thti  tilrm  was  foiuui  nnitwl  to  iha  humcma  by 
mcnt ;  tho  end  of  tho  radius  was  polished  off,  and  played  M 
humerus  and  on   tho  ulna,  a  mntvria)   something    like   carl 
being  interposed.    Tho  ends  of  tlie  bones  of  tho  foro-arm  wcroli 
in  by  two  processes  projecting  downwards  from  tho  humerus, 
iitrong  lateral,  and  still  stronger  anterior  and  posterior,  ligail 
also  bound  tliera  to  the  latter  bonct.     Union  is,  however,  sddt 
perfect  as  thin,  and  the  bones  seem  to  be  united  m^.trely  by 
or  loss  extensible  ligament.t     In  tliese  coses,   it  is   aoid  b 
Kobcrtt  that  Hvxion  is  compo«o«l  of  two  movemont*;  the  for© 
being  first  drawn  up  to  tlie  humerus  by  the  triceps,  nml  then  I 
by  Uic  action  of  tho  biceps.     Oswous  ankylosU  ought  very  i 
to  occur.     I  f  the  ulnar  nerve  be  injured,  a  good  de«l  of  wasti! 
the  muscles  and  loss  of  motion  has  boon  obsorvod  to  follow ;  wb 
as  an  elfeet  of  tiic  injurt*  to  lite  nen'O,  may  be  doubted  ; 


•  />inwf,  vol. ).  p.  2St.  Iftftfi. 

t  Nolvs  of  tlie  ilisscRtiaDS  of  several  cnsea.  sA^r  succetisful  excid 

Iho  elboiv,  may  lie  found  in  WimneT  on  Hfpair  afltr  Rt$eetiom, I 

hy  the  writer  for  the  New  gydenhatn  Snciot}',  18S0. 

;  GiUftte  dtt  Hdji.  Nov.  20.  I9SP. 


EXnSION  OF  THE  ELBOW. 


811 


fact  sbonld  maku  tlio  operator  ctirctu)  to  «\-oid  the  non-e.     On  tlio 

\  other  hand,  cases  have  occurred  to  t!ie  moet  experienced  operators, 

in  which  thi?  ncn-c  vtm  woiindcd  ;  and  ono  is  ou  rvcord  in  which  it 

|re-utiiti^,  and  no  loim  of  motion  or  other  ill  conAcquenco  followed.* 

I  If  tile  patient  rocoi,tT,  but  with  disease  porsisling  or  recurring  in  tho 

i  end.H  III'  t)u>  lioncA,  tho  i^ueAtion  of  again  fxcising  the  di.'itia.'tied  jwr- 

[tions  will  occur.     If  necrosis  be  present,  no  doubt  can  exist  of  tJw 

propriety  nl' removing  the  dead  portions,  ithould  tJioy  bo  loo^e;  lint 

if  tlie  exposed  partA  of  tho  bone  bo  fixed,  or  if  the  disease  be  caries 

\ter  tlian  nocrosiH,  no  operation  tthould  bo  performed  while  tlm 

inctioiis  of  tho  member  appear  to  be  iniproring.     When  tliis  is 

[-jiot  till?  caso,  it  is  right  lo  ti-_v  onco  more  to  reniovit  the  diitciuMN] 

Vbone  before  sacrificiog  tbe  arm.     Even  a  third  such  attempt  lias 

[been  made,  and,  as  it  is  Hai<l,  with  good  rexults. 

Excision  of  tlie  elbow  is  usually  considered,  and  in  all  prob^ 
tnlity  correctly,  as  a  morv  formidable  opuration  in  nnpoet  of  mor- 
liality  than  amputation  of  the  ami;  but  no  data  exist,  as  far  as  1 
am  aware,  for  a  correct  comparison  botwwon  the  two.  In  Dr. 
[Bodgi'H'H  work  there  is  a  table  of  II!)  cases,  principally  from  the 
aals  and  other  published  i>onrco8  :  of  these,  15  died ;  and  in 
15  otliers  amputation  wa.'>  porfomied.  In  tho  great  majority  of  the 
I'Cases  which  siirtired,  tho  usefulness  of  tho  Hmb  was  proved  by  the 
(itiunt  being  able  lo  nvtunie  Iiin  ordinary  avocations ;  but  tho  dotaiU 
to  the  extent  and  kind  of  motions  left  are  not  exacL 
In  the  essays  on  iNJtmnts  or  thb  UprBii  Extremity  and  Gdn- 
BHOT  WoiiXDB  the  reader  will  find  the  indications  for  amputation, 
Kcision,  or  entire  prcscr\'ation  of  the  limb,  in  easts?  of  injury.  In 
of  ankylosis  of  tlie  elbow  excision  is  rarely  required,  although 
true  bony  ankylosis  has  occurred  in  a  bad  position,  excision 
aay  be  perfonned  if  the  [mtienl  wishes  it ;  but  in  bony  ankylooin 
tho  flexed  position,  and  in  all  cases  of  soft  ankylosis,  this  opera- 
tion is  inadmiHftible.  Tho  former  ought  to  be  let  alone;  (iie  latter 
under  tho  control  of  tho  methods  described  in  the  essay  on 
liTHOP.WDTr  SrnoKBT.  In  cascft  of  di^oase  of  tJie  (khic*  oftJie  elbow, 
excision  is  tbe  operation  ivhich  should  be  adopted,  except  onder 
cial  circumstances  necessitating  amputation,  such  as  unusual 
extent  of  implication  of  the  bones,  advanced  age.  great  debility,  or 
t constitutional  affection.  Bnt  tho  rarity  of  such  circumstances  is 
liown  by  tbe  tnet,  that  itr.  Bryant's  ooltection  of  300  amputationsf 


*  SjnM  M  tht  Bttinat  ttf  Ditmutd  JoinU,  1831.  caM  vUi.  pp.  88-M. 
1  MmL^Mr.  Tnuit.  voL  xliL 


« 


ISION  OF  BONES  AND  JOINTS. 


ovAy  inolucUa  10  in  wliidt  tlio  arm  was  nmpotated  for  dbeue  < 
all  ktDdft.     So  that  excisioa  of  llio  elbow  is  tJie  <q>eration 
univereaUy  nworbtl  to  in  oii3ea  of  inotiraUo  diaeaaa  of  thut  joint 

ExeinoN  of  the  icrUt.  The  operations  which  arc  doteribod 
CaceinKMiH  of  tlie  wrist  arc  verr  geoorally  excisions  of  several  of 
carpal  bones  only,  or  of  tlm  cnd«  of  the  bones  of  the  foro-ami  only 
»»in»tinies,  however,  more  or  less  of  tlie  carpus  is  exoiscxl  at  th 
same  time  with  tho  cncls  of  o»u  or  both  of  thu  long  boncK.  Th 
»{>oration  may  be  performed  by  means  of  longitudinal  inciinona  a 
cither  side  along  tho  suhculanoous  bordun  of  tiw  radius  and  nln 
continued  on  to  the  luuid  far  enough  to  enable  tlie  ojierutor  to  gi 
At  the  carpus ;  or,  as  is  more  usual,  by  u  transvcrMt  incision  acfoi 
tho  dorsum,  joini^l  by  6ueh  lateral  nitd  aa  may  i>oom  m 
The  advantage  intended  to  be  obtained  by  the  former  method ' 
prcscnation  of  the  tendons ;  bill  in  so  many  tsuKf  they  arc  citli 
previously  or  subsequently  matted  down  to  tho  bones  or  ciojitiix 
inflttmmation,  that  tho  U-nofit  rosidlins  bjw  not  been  proportii 
to  tlie  complexity  and  diflioul^'  of  the  operation ;  so  that  tlie 
plan  iit  in  more  frc^tient  use.  But  [RThaps  no  ibrmal  directii 
need  be  given  for  this  operation.  In  casea  of  limited  injury, 
as  a  gunshot  wound,  wlicrc  some  nf  tho  bones  of  the  carpus,  or 
ends  of  tlie  bonon  of  tlie  wriiit,  are  eomminul4»l,  but  witltout 
cicnt  destruction  of  soft  parts  to  neecssitatc  amputation,  or 
the  {>i'0!){>eot  of  savinjr  uno  or  more  flexiblo  di^l«,  it  is  proper 
enlarge  the  wound,  and  dissect  out  the  loose  portions  of 
when  tliis  oaii  be  done  without  further  mischief  to  the  a: 
tus  of  motion.  In  like  manner,  in  the  verj-  rare  event  of  limi 
di.wiise  cxi.^t.ing  in  this  jtart,  it  might  bo  proper,  after  bc»towiiig 
patient  trial  on  the  usual  means  of  eure,  to  enlarge  tlie  lunusea, 
gouge  out  the  aHocb^d  hones ;  but  no  operation  appears  ad 
when  the  whole  eaqms  h  involved  in  ohronie  disease.  Tho 
will  probably  rocovor  from  tho  disease  in  tho  course  of  time, 
the  etrumoiiH  cachexia  in  too  far  advimcod ;  while  if  it  Lt  no,  tw  w 
not  recover  from  tho  operation  any  more  than  fi-ora  tlte  disease.  X 
does  it  aeem  in  tlio  least  degree  probable  ihnt  he  will  liaro 
motiim  afler  the  operation  than  after  the  natural  cure,  C'oi 
tjuently  the  formal  excision  of  the  whole  wrist  for  uxtcnsive  dt 
(which  is  almost  always  strumous)  ia  an  operation  M'hich  in 
with  little  confidence  even  by  those  who  are  tlio  most  zoalous 
cates  for  oxcision  of  other  joints. 


dite 


EXCISION  OF  THE  HIP. 


813 


^r     Rtciitum  of  tingle  bouts  <^thf  fiaml.     Though  tho  oxciition  ofthi! 

Btmst-joint  is  an  operation  of  doubtful  benefit,  an<i  ono  wliich  caii 

HwUIom  bo  pcrformc<i,  on  siocount  of  the  wlrninoiis  cachexia  in  which 

the  diBea-SQ  origiiiatai,  and  tJie  probable  loas  of  all  usofiil  motion 

whidi  will  follow  Ihc  oporntioii,  tttill  tbo  excision  of  iunno  of  iW 

IboneH  of  tlio  hniul  may  '«'  praotised  with  advantage,  cspocislly  if 
tilt'  tendons  arc  unaffected  and  can  Iw  socurcil  from  injury  in  tlio 
Operation.  It  ia  of  csjMXiiul  injporlanco  to  preserve  the  thumb  by 
the  timely  excisioo  of  its  uietUL'arpnl  bono  »r  Hmt  phalanx  wlicn 
universally  discaw^l ;  and  tlio  liiMieHt  of  resecting  tlio  diseased  jmr- 
tion,  and  leaving  the  articulating  bead,  i*  of  courw  still  jjreaWr.  If 
the  perio^Unini  can  Im  spart!il,  there  will  be  in  all  probability  a  more 
firm  union  between  tho  severed  ends  of  the  old  bono,  in  C"ii»<;f|ucnco 
of  Uie  priHbiction  of  oiscoini  fpiinnle.*,  or  oven  larger  pieces  ofbone, 
(in  the  cicatrix ;  but  I  am  not  aware  of  any  facts  which  prove  that 
cxciswl  portions  art*  ever  really  niproducdl.  It  is  of  little  n*o 
I  remove  the  phalange.^  of  the  fingers  (except  those  of  the  terminal 
[row),  unless  ill  a  few  cases  whore  they  arc  nocniMKl  and  ItMuc,  for 
[the  formal  exi-isiim  «f  those  liones  would  almost  invariably  leave  a 
[useless  finger.  But  occasionally,  cspocially  wIhii  the  extensor  tcn- 
Idona  can  be  .ipnred,  Uie  metAcarpul  bones  ma_\'  be  niaile  tho  subjects 
of  opi'raUon ;  and  here,  as  well  as  in  tlie  thumb,  it  is  of  much 
importance,  if  tbo  extent  of  tho  disoaMj  allows  it,  not  to  open  cither 
jouit,  particularly  tho  phalangeal. 

I  No  [irt'cisc  iliroctions  are  nocessar}'  for  such  operations,  wluch 
consist  merely  in  exj>nsing  tho  disnaMxl  bone  on  its  dorsal  aspect, 
•craping  off  from  it  all  tho  soft  parts,  including  the  periosteum  if 
possible,  dividuig  the  bonewith  cutting  fiin^eps  (the  extensor  tendon 
being  bold  out  of  the  way),  then  seizing  the  divi<ie<l  end  with  the 
lion-forceps,  cleaning  tiie  bono  on  tlio  lower  surfiice,  witii  much  core 
tiol  to  dip  the  point  of  the  knife  into  the  palm,  and  finally,  when 
the.  limit  of  the  di.iease  !.<  rcacbo<U  nipping  off  the  bono.  If  the 
extensor  tendon  has  been  unavoidably  se\'orod,  tho  finger  must  be 
carefully  supporUvl  on  a  splint  till  ihi»  lia«  reunited.  In  case  of 
disease  of  the  two  middle  metacarpal  bones,  it  will  be  better  to 
remore  the  disenwd  portions  witli  a  small  chisel ;  and  tliis  plan  i« 
preftrred  by  many  Sorgeons  in  the  other  metacarpal  bones  also, 
)D  order  to  proservo  tho  ponostoum.  1  have  alrca<]y  given  my 
r«asona  for  preferring,  in  gonoral,  the  method  of  dissecUng  out, 
to  that  of  gouging  out,  carious  bones. 

EreiMon  ef  thf  htp  is  an  oporation,  of  the  value  of  which  the 


81-1 


EXCISION  OF  BONES  AKD  JOINTa 


most  vridely  diflering  eetimatcs  bavo  been  formed  by  difTerent 
geons.  Nor  is  tiiis  snrprwinf;,  vrlicn  it  t»  vuiisidcmi  tltat  thv  di: 
tar  wliich  it  is  osoally  tmderuken  ia  aooompauiied  by  exha: 
and  long-oontinacd  «u}i]ninitioti,  roiidoring  the  jirospPcts  of 
operation  utifiivourable;  while,  on  the  other  hand,  recovery  b  ao 
oommon  that  it  is  iin|)0Mtib1u  in  any  caAo  which  gets  well  after  ope- 
ration to  affirm  witli  wrtainty  that  Uie  niitunt)  euro  wa#  impca* 
niUe.  The  operation  is  performed  on  account  of  guOEhot  womt^ 
or  in  ndvaiiocd  ittrumouK  dinoHflc,  u(NXim)>anied  by  nb»ocs8,  when 
thff  patient  seems  in  danger  of  dying  of  hectic,  and  the  ulcerai 
th«  boni-  i»  judpsd  to  be  incnrablc.  The  hi])-jiiiiit  oii};lit  n< 
be  excised  on  aooount  of  deformity  from  ankylosis,  although  it  utay 
be  advisable  in  apjiroprinto  eue»  to  divide  the  txx^k  of  tlw  femur, 
or  fivon  lo  cut  a  wedge-sliaped  piece  out  of  it*  Tin*  operation  of 
esci&ing  tho  lup,  as  it  i«  conunoniy  npokau  of,  mi^ana  merely  tW 
n.-in<>\id  (if  l)ie  head  of  the  femur :  but  the  acetabuhin)  may  id:*o  b« 
removed,  if  it  bo  thougtit  nitijiwiiry.  TIio  operation  diftors  con- 
aiderably  in  (lifttotdt^',  according  as  the  head  of  tlie  bone  lit  or  is  not 
in  the  acctabuUim,  and  according  as  the  Surgeon  docs  or  does  not 
require  to  obmln  aeoitsii  to  tlmt  cavity  in  (inlt;r  to  remove  its  Aonr. 
In  most  cases  of  chronic  disease  the  licad  of  tlie  bone  has  andergone 
tliat  prows*  of  displacement  iisnidly,  though  not  very  accural*ly, 
spoken  of  as  ilijstoeation,—i.e.  tbo  lip  of  the  acetabulum  hail  beeu 
ulcerated  or  ab^iorbi^d,  and  the  head  of  tbs  bone  (also  altered  in 
ithape  from  ulceration)  lies  partly  on  the  dorsum  itii,  jiartly  on  the 
edge  of  the  expanded  acetabulum,  and  is  very  probably  covered 
few  ifany  muscular  tibrea,  since  thcae  have  become  atrophied 
disuse ;  the  ligamontx  also  have  in  a  great  measoro  disapi 
All  that  i»  necessary  in  tlie  operation  is  to  nudce  an  tncisJoa  <tCi 
sufficient  length  over  the  prominence  of  the  bone,  running 
what  iM'hind  the  trocliinitcr,  and,  having  exposed  the  head 
bone  anil  turned  it  out  of  its  cavity,  to  saw  it  off  at  such  a  lo' 
the  extent  of  Uic  <ItKca.'u>  M^-nis  to  indicate  When,  however,  Uia 
head  of  the  bono  remains  in  the  joint,  and  the  liganieuta  are  entire, 
as  is  the  civc  generally  in  excision  for  injury,  and  in  a  few  of  tlioM 
for  diHcaae,  the  operation  ia  not  quite  bo  simple ;  and  it  bcoomee 


*  Seo  p.  Bli,  I  once  saiw  n  cuse  in  wliU'ti  tlii?  bip  was  fixed  tn  ■euti 
flaxioii.  The  sjrmptoma  itiducvd  tlio  Stu'Sfun  in  charge  of  the  ensi!  to  per* 
form  an  exploratory  opcnitinn  :  but  on  outlini,'  doim,  tli«  joint  wns  found 
perfect.  The-  iK'c'k  of  ihn  fcTDUr  wan  nairn  tliroURh.  nnd  Ibu  Uilfih  placed 
on  a  Blrai^'ht  splint.  The  patient  (B  child}  reoorored,  with  a  itnight  and 
useful  Ijnib. 


EXCISION  OF  THE  HIP. 


SIS 


I  mom  difficult  if  thu  ti«ck  of  tito  bono  is  frncturcd,  ho  tliat  tho 
igean  faniK)t  gel  aiiy  [Hirchiwe  iii»>il  llio  liiijul  t«  turn  it  onl  of 
lie  ncctabalum.  In  suoh  coses  an  incision  must  be  made,  running 
ehind  taxd  )>iirnlli!l  to  tii«  jwstorior  border  of  the  trochiwitor,  ttnj 
ong  enough  to  admit  of  free  iu-ccah  to  the  joint.  The  length  will  of 
ooufM  vnry  nccnrdiiig  to  t!ic  »izo  of  tli<«  buttock,  bat  it  may  bo 
stated  in  general  terina  that  the  ineiiiion  shmild  commence  near 
B  Ifae  jiini^t.ion  of  tile  trochanter  and  tho  »linf\,  and  Hhould  <ntrt'i) 
^■(with  ita  eonvcxity  hat^kwardft)  round  lh«  jtromine^nt  u])pt>r  border 
^mf  tluit  prwesA.  By  cutting  now  along  the  nuck  of  tliu  fomur, 
^B^ie  situation  of  the  joint  may  be  accurately  aanei'tained,  if  it  has 
^pbc«n  hidden  by  HwelUng  from  disease  or  injury' ;  and,  Uiat  linving 
r^been  done,  tlio  jiarts  may  be  tlividod  from  wltliin  outwards  in  any 
direction  wliieh  mar  seem  couveniont  (according  to  tlio  [)ri.wn<.-o  of 
rotinds,  &c),  ho  n«  to  render  tho  external  inciwona  crucial  or  T- 
xl.  The  flaps  are  now  to  be  refleetod.  If  tlie  neck  of  tlio 
ar  is  fractiiriil,  tbu  fraotured  part  ii*  to  bo  seiw^d  witli  tlia 
iJon-foroeps,  and  cleared  up  to  tlie  head  and  round  it,  and  so 
iinovod.  8carch  should  then  bo  made  for  slioU,  foreign  iMxUet^ 
rngments  of  bone,  &o.  If,  on  llio  other  hand,  tho  neck  of  the 
ae  is  «iitire,  and  sufKuiontly  strong  to  bear  tho  rt^iuisito  force, 
it  may  bo  more  convenient  to  turn  out  the  head  of  tJie  bone,  and 
[divide  tlie  ligauivntx,  as  in  ordinary  oxarticulation ;  otlicrwiso  tlio 
Ineck  may  be  cut  tlirough  with  a  koj'Iuilc-saw.  This  instrument 
liMuld  alwa^'s  bo  at  hand,  together  with  a  trephine,  elevator,  gougo, 
lAc  for  removing  im}iacled  foreign  bodies,  or  for  clearing  tlie  ace- 
[tabuluin. 

Opinions  differ  as  to  (ho  expediency  of  preserving  tho  trochanter 
excisions  of  the  hip.     Most  Stu-geons  would  not  remove  tho  tro- 
chanter unless  it  waa  aiTected  with  di»eaM',aa  tlie  limb  wcKild  8p|>ear 
^uro  likely  to  enjoy  precision  and  frwdora  of  movement  if  tia 
Bumeroua  altachinentn  of  imjiorUint  itiuiieloji  around  llint  process 
rerc  left  undisturbed ;  besides  which,  tlie  amount  of  bone  roniox-od 
'in  t>xcising  the  linid  and  neck  of  tho  femur  is  alrojuly  consider- 
able ;  and  if  to  this  the  whole  extent  of  tlio  troebanter  be  added, 
a  serious   risk   of  a  Bnil-liko  union  is  ini-urred.      The  siipposiid 
advantage  of  removing  the  trochanter  is  to  avoid  tbe  risk  of  tbat 
proem  being  displaced  into,  and  so  intvrfcritig  with  thv  union  of, 
I  the  wound. 

Thus  far  we  have  spoken  Only  of  the  removal  or  decapitation  of 

|the  head  uf  the  femur ;  but  since  the  aoetabulom  is  freely  exposed 

this  operation,  it  is  possible  to  carry  it  fiirthor,  and  remove  |)art» 


816 


EXCISION  OF  BONES 


or  the  whole,  of  Uie  floor  of  Uiat  cavity  j| 
done  vfitli  sucoeHS.  In  Mr.  BarwcU's 
Joint*,  p.  444,  tJie  render  will  find  aii  int 
in  which  Mr.  Hancock  remo\'ed  the  whol 
buliuii,  togctliLT  witli  iiivi  li'^»d  of  Ui«  foint 
of  t]M>  patient,  nineteen  months  ailer  tJi 
ing  beoD  useful  in  tlic  inctiii  tlniP,  allhoti^I 
in  tiie  boneii),  an  ojiportimity  of  Jisseoiing^ 
Mr.  Erichson  rcmovwl  not  only  Uic  whoU 
but  also  the  rainua  of  tlie  piibeit  and  in 
tuberosity  of  tlio  iM.-hiiiin  and  a  [wrtion  I 
ri^>ort.'<  that  Iho  patient  had  a  u&eftd  liiRt>.*| 
The  statiBticB  of  tliis  operation  are  of  J 
thcyoftb«  i>Mnt!  importance  a»  in  thone  d 
tion  lies  between  the  removal  of  a  joint  al 
rate  of  niortnlity  \n  extminely  Iiigh;  no  H 
leotwl  by  Dr.  Hodges.f  in  which  the 
Tcrod  "  with  more  or  lea*  useful  limbs,* 
etfecta  of  the  operation  and  the  previ« 
mainiiig  two  awvn  iimjiutatioii  wa«  per 
sible  to  deduce  any  exact  conclnsion 
irinco,  without  »  pcnoniil  knowledge  of  oa 
the  probabiliQ'  of  recovery  wtllioiit  oper 
average  duration  of  treatment  in  tlioso  en 
noted  (Ai*  in  number)  was  230  days. 
Terj'  protracted  period  of  convalesceiiee  oe^ 
those  «cv«ro  OJLies  of  hip-di»ca»o  which  al 
operation,  the  patient's  prospects  are  not  q 
althongli  it  must  be  .nllriwcd  that  the  cod 
favoiu"  of  many  eminent  Surgeons,  who  haW 
of  watching  ite  eflecls,  justify  a  report  tq 
otherwise  hopeless.  The  immediate  effe( 
not  often  fatal,  and  it  is,  (o  say  the  leasu 
nhero  there  is  groat  and  exhausting  pj 
diseiucd  bones  on  one  another,  the  ojH'rd 
greatest  care,  however,  should  be  bestowed 
case  in  whieh  exci.sioTi  is  contemplated-  | 
of  advanced  hip-discaite  in  which  tJio  extdi 
is  not  more  or  less  involved ;  and  this  fad 


*  Soime*  and  An  o/Si 
t  Op.  ciL  p.  1 1«. 


fSurgfrg.  Sdj 


EXCISION  OF  THE  KNEE. 


817 


HSf 'pardj'  by  the  direction  of  sinuses,  partly  by  Uio  grating  ftcnsa- 
^■ion  wliciteil  by  pawtixu  motion  tind^^r  clituR>turm)  furni^s  no  instipcr- 
^bble  objection  to  the  proocecling;  but  abscess  aonimuiiioating  wiUi 
^■bl  intvriiir  of  tlic  pelvis  ni'»r  the  jciiit  (in  spih.-  of  tliu  cxk-iwiivo 
^H&iovaIb  tit'  bono  praotiscd  by  Mr.  niiiio<i<.'k  aJid  otliors),  und  Htill 
^pnoro  with  remoter  parts  of  iho  pulvis,  or  extensive  disooso  of  the 
^ni-inur,  or  thti  pres<'iico  of  oilier  ntnimouit  afroctiontt,  ought  to  be 
^ferogardcd  as  j'orbiddiiig  tlio  atti^'inpt. 

H  Tilt)  amount  of  motion  rocovt'ri-d  is  seldom  great.  On  this 
point,  again,  the  stati§tic8  fail  to  afford  any  roliable  information; 
Ijut  it  may  bo  safely  (wsi-rlod  tliat  liio  limb  i»  moro  likely  to  hv  iwe- 
^Lful  at\t>r  natural  i-coovcry  in  the  extended  position  tliaa  aftor  any 
operation.  So  tbat  excision  ought  never  to  be  atU'niplrtl  nnletut, 
with  diseswe  still  progrossing,  tlio  joint-surfaces  are  hopelessly  dis- 
pUcixl  (iL  very  raro  oocurrenco),  or  tlie  Surgeon,  on  n  mreful 
review  of  all  tlie  symptoms,  has  strong  reasons  for  concluding  that 
natural  recovery  it)  impossible.  Wbcii  tbc  opcrution  is  onee  dieidod 
upon,  it  should  not  bo  delayed  till  the  patient's  health  has  given 
limy,  but  should  bo  performoJ  at  once. 

Kxdgion  of  the  hue  has  been  iintctised  more  frcKjuontly  than  Unk 

sf  any  other  joint,  except  the  elbow ;  but  the  opinions  of  Surgoons 

by  no  means  so  unanimous  on  tJio  former  subject  as  Uiey  arc  on 

[the  latter ;  for  whereas  no  one  denies  that  ami>utulJon  of  the  arm 

liould  only  be  resorted  to  in  exceptional  cases  of  discaso  and  injury 

tof  tlio  elbow,  miuiy  {porhaps  I  might  say  wiUiout  inaccuracy  almost 

lall)  hospital  Sm'goons,  in  this  city  at  any  rate,  think  tliat  amputa- 

pion  in  iidvisablu  in  the  majority  of  the  afflictions  of  tho  knee ;  while 

>mc  have  never  yet  i>erformod  tlie  excision  of  that  joint     Thoro 

many  rwLsons  why  excision  slionkl  Ijo  Iww  sucfe.HsfuI  in  the  kneo 

in  the  elbow.     Firm  bony  ankylosis  is  required  in  the  lower 

Itxtminity;  llio  treatment  involves  many  weeks  of . strict  continement 

[to  one  position ;  tJie  surfaeoa  of  bone  sawn  t]m>ugh  are  \'er)'  large  ; 

tiu;  cavity  of  tlio  wound  is  badly  situated  for  union ;  iJio  epiphysu) 

lines  are  near,  and  if  trenched  upon  in  young  subjects,  the  growth  of 

tho  limb  may  bo  suspended ;  tlie  oin'ration  is  inon^  severu  than  rxci- 

sjon  of  the  olbow;  niid  finally,  the  advantage  of  preserving  the  foot, 

although  cousidorablc,  is  far  Ices  tliau  that  of  retaining  tho  hand. 

It  is  wot  likely,  llierclwro,  that  lliis  ojicnttion  will  ever  come  into 

Buch  favour  as  that  on  the  elbow ;  still,  thougti  it  has  been  velie- 

ineiilly  <Iccried,  and  tltough  lU  geiieriil  adoj)tion  bus  po^bly  been 

equally  retarded   by  its  having  been  vehemently  overpraised^  k 

VOL.  m.  3  a 


EXCISION  OP  BONES  AKD  JOINTS. 


aeetns  likoly  to  hoI<l  a  ponnaneitt  [>1aoo  among  tlio  reAonnies 
o|>cnttiro  Surgory  for  the  trratmenl  of  ajtpropriaUt  vaacs. 

Tbo  acocptancv  wliivl)  iIiIh  ojfin^lioii  liaa  Diet  vritli  is  not  doe 
ita  lower  mio  of  mortality.     It  has  beco  clrarly  ehow-n  by  Hk  AI' 
tistics  colIeotoJliy  Dr.  Hod;;*-!*,*  tlinl  in  gonoml  practice  tJia 
tjility  but  been  about  ono-tlunl;  a  farhiglicr  average  than  that 
amputation  at  tho  lower  Uiiixl  oft.hr  liiif;ii  for  dironic 
tlio  kiiet>;  aixl  from  what  1  can  Icani  of  the  statistics  of  ni 
hospital  practice,  I  kcliovo  tbv  »am«  rate  of  mortality  ha«  preva3ei 
Hut  rlti!t  only  imgxirfcctly  rcprasoiits  tite  ill-saooeps  of  the  operation 
for  if  to  thoso  who  liax'o  died  wo  add  tlweo  whoso  limbs  have  boa 
amputated,  or  luivo  remained  uselefw,  we  sliall  find  tlial  llie  tiiilnrai 
after  tlio  operation  at  least  o(|iial  the  sucocssck     In  epita  of  thi 
known  fiict,  however,  it  secnw  to  be  il»e  growing  conviction 
hospital  Surgeons  tliat  the  oporaljon  ongfat  to  be  introduced  inb 
practice.  J     Tliis  c(incIu«ton  nni!>t  re^t  upon  otlii^r  conaideratioU 
t3mo  thoso  of  the  more  mortality  after  amputaiioD  and  ex<d9M9i 
It  is  not  very  probable  tliut  oxdiuon  of  tlio  knou  will  over  be  l 
fat^l  tliiin  ai>i{iutalion.    Tliere  is  no  conceivable  reason  why  it  vhoti 
be  so.     It  is  sometimes  said  that  the  lucmorrhaf^  is  less ;  bttt 
am  far  from  eonvincivl  of  thin.     Hie  h1oo<l  ttint  in  an  amputatioa 
is  always  grcttcr  ih.tn  in  exctgion ;  the  blood  lo*t  is  fi-eqiiciitly  U«Sf 
for  in  a  well-iiianagixl  aiiipiiiatioti  the  Wood  which  gushes  out  b 
only  that  wliioh  waa  circalaUng  in  tlie  amputated  part,  and  lilllg 
else  i^  really  Io«t  to  the  system.     In  oxcinion  tho  operation  is  oftfiil 
a  bloody  one  (though  sometiaiea  not  so),  and  seconcbiry  haaiBf- 
rhagc  is  l^  no  means  rare     Then  it  is  said  Out  tho  wound 
Miinller  tlian  in  antput^itioii ;  but  though  the  tw/ar^  of  tho  vronm 
is  Mnaltcr,  itx  canty  (which  is  at  least  as  important)  is  larger.    Hx 
immediate  shook,  as  far  as  I  have  seen,  t»  gonersjlly  considcmblo 
quite  as  much  so  as  in  amputation.§     The  surfiioes  o(  bono  exjxue 


*  Op.  eit.  pp.  149-8,  t  S«e  Brit,  mtd  For.  Med.-C3iir.  B«c.,  July  l^C 
'  TI)os«  who  Judge  ojitj  from  Joumala  and  Iwoks  maj- iltink  tliat  1  ttgtiA 
tou  (Iubiuu9l,v  of  iJi«  support  aSi>rd«d  to  tbts  ui^mtioa ;  but  the  real  una 
niraity  of  ibu  profiUMOain  tlu)  mailer  maj  b«Ju(i!;«d  uf  from  Uii*  fact: 
to  tlic  end  of  IS61,  as  bras  I  (wn  tuam.  four  trxdniuns  of  tlie  kti(>nlud  Im 
pmctiscd  at  St.  Ilnrthnlomcw'ii  itnd  Guy  n  Ho\;iital.i.  nhilc  nearly  fifty  lis 
been  dona  nl  King's  Coll«><!«  mid  UnivRnity  CoIIfr^.  ConaidniiiR.  Uwrt 
furc,  t)ic!  n^liiUvo  »\xe  of  ihe  liotpltnlK.  the  oponttion  wax  mom  Utsn  1U)j 
times  ns  common  at  tho  lailer  as  »t  ihn  fonnri'  tnstitiiti<>n». 

>  1  itin  iafbrraed  by  Mr.  Hi'iiry  SmiOi  tlint  in  nioio  llinn  t>n«  Ulsi 
lit  Kiiic'h  College  Ho«piiaJ  dctili  bos  been  altrikuled  to  ibe  shock  i 
opcnition. 


\ 


EXCISION  OF  THE  KNEE. 


819 


nro  very  large,  and  tlic  union  of  this  great  cotnpoiind  fracture,  rikI 

tlio  tilling  up  of  tlie  Inrgi;  uivity  hH  \>y  t)io  ojieralion,  call  for  cs>n- 

sidcraUe  roparativo  powca',  auci  entail  dangei-s  from  wbicfa  ampu- 

tatii>n  is  wxcnipt.     Hut  wluit  litiw  ivaWy  brutiglil  fixciitiDn  of  tlie  kneo 

into  pi-actice,  and  has  compensated  for  iho  tiiilurca  induced  by  its 

iiuliH-riiniiiate  adoptiou  in  nil  kiniU  uf  ctiM^«,  is  it»  striking  Mccoie 

»  wliiirh  aro  fitted  fbr  it ;  and  it  is,  iliorefore,  to  tlie  discovery 

f 4f  roTw  wlicrciby  such  cases  ca:i  bu  liiugnoscd,  tlmt  the  clTorts  of 

JUkmo  who  wish  to  promote  this  ojwration  sliould  bo  directed.     ^0 

l:q>aco  which  an  adcqiinte  (h'sciission  of  this  matter  would  require  not 

ring  here  a.t  lay  comuiniul,  I  must  bo  cxcuHod  for  exprcoiiig  Mutn- 

I  marily  what  I  hclievc  to  bo  the  correct  indications  for  the  pcrfbrm- 

aiiCT)  of  ex<ri.''i(>n  rif  rJie  knee,  ii*  far  as  our  jin^ictit  experience  will 

enable  us  to  lav  thera  down. 

Excision  of  th«  knee  nliould  iiover  be  performed  in  elderly  per- 
hsoas.*     They  have  not  nsnally  the  requisite  reparative  power ;  and 
ktho  advantiigo  owe  niiiputation  is  not  Htillicicnt^  even  in  the  most 
I  fttvonmblo  eu.ie,  to  balance  the  increased  risk.    Tliere  are  many  rea- 
atso  agninst  performing  the  operation  in  very  young  children : 
■fih  a.<t  the  probability  of  reoovwy  without  ojiention,  if  tin'  Mippu- 
[  rating  joint  bo  kept  in  a  good  position  and  finely  opened :  the  risk 
I  of  olieckmg  the  growth  of  tho  limb  by  excision;   tho  grc«t  pro- 
I  Lability  that  tho  Joint-diseaso  is  but  a  symptom  of  eonslitutionul 
iniischiof,  in  which  case  incision  woidd  do  no  good.     No  excision 
of  the  knee  ought  to  be  midertakon  in  a  patient  in  whom  there  is 
any  gocxl  reuson  to  siLspcot,  far  less  any  evidence  of  the  exi>lenco 
of,  phtliisis  or  any  other  constitiitioiiitl  nflection.     H«d  Uiis  uraple 

idietHto  of  common  sense  been  more  strictly  ndltcrcd  to,  many  of  tlw 
deaths  which  now  give  m  gloiimy  ii  comploxioit  to  tlio  «latistical 
acports  of  excision  of  tlie  kneo  would  liavo  been  avoided.  ExcImou 
jbr  disease  should  ho  exolunivvly  (vmlined  to  e*»c»  in  which  tho 
disease  is  in  a  chronic  condition.  In  acute  absooas  tlie  operation  is 
imulmissihle.  In  all  c:»si-^  iviuro  «iniu4iw exist,  hmi^ng fiw  any  eon- 
siderahlo  distance.  ;.  i  '  nerally  whenever  U»  disease  is  of  very 
long  duraUon,  CM  i  I"  i  iH'iild  only  bo  nndcrtakcn  as  an  cx|>loratory 
measore,  and  every  thing  should  be  in  roadineaa  for  nmpnlatitMi,  if 
tlie  soUcned  condition  of  the  bones  should  render  the  latter  ujiera- 
tion  neccswtiry;  t»  will  ^ery  prohat>Iy  W  the  cn.'V,  even  if  no  jiait 
should  bo  found  absolutely  carious  or  necrosed.     In  deformity  the 

t*  Speaking  tftnenily,  and  wllh  due  allowance  fur  exccptienal  caaei,  I 
inmin  in  pcrauns  al>oro  the  age  of  fvr^-ftre. 


820 


EXCISION  OF  BONES  AND  JOINTS. 


rosaU  of  old  dUcasv,  if  tlin  tliticaM!  Iinvo  vntirflj  subsKlcd, 
piediis  ineji^iuroa  will  most  probably  succeed ;  but  if  the  case  ap] 
beyond  tholr  roacli,  no  gruvo  oporation  ought  to  bo  uudertakei 
except  nt  itie  oxpraoa  inf<tanoo  of  tbo  patiotit;  or,  if  a  child,  ( 
his  parctitH.  Th«  oporation  itself  has  its  oivu  poculiar  difiicoJtic 
nnd  dangers  in  hucIi  cas<^H ;  but,  as  ii  giMierul  rulv,  opfratm 
d«  compUtlfotice,  ns  tlic  Frcncli  call  thorn,  should  never  bo  presse 
on  tlio  pttt,ifiiiU  Excision  for  injiirv  is  vorj-  rarely  rcqtiirod,  4 
jostified,  in  civil  practice ;  einco  the  injuries  which  generally  Of 
cur  in  our  {Kt!']>itixlM, — kik-]]  »  suvero  fall»,  the  fate*ga  of  wbm 
over  the  limb,  crusliing  by  machinery,  ^—involve  eit^Mn-  rei 
cxtoniuvc  fracture  or  largo  laccratod  wounds.  But  cosoa  of  gunsbo 
wound  may,  however  rarely,  be  silmltted  into  civil  hospitals,  i 
which  a  bullet,  or  other  uiissilo,  hoK  lodged  in  the  articulating 
of  eitlit>r,  possibly  of  both,  bonea,  without  inHidiug  so  much 
upon  tho  neighbouring  part«  as  to  coutra-indicaie  excision 
in  some  very  raro  cases  of  fracture  it  may  bo  thought  p: 
excise  the  joint*  In  military  practice  (aa  stated  above,  vol  ii 
p.  84),  cxoi.«iou  is  rarely  fea«iblo.  Tho  little  c*  idcncc  that  we 
Beas  at  present  apjicars  to  show  that  tho  rink  is  aWut  a*  great  M 
that  of  primary'  amputation.  It  ought  not  to  be  andertaken  oxoep 
in  young  aubjocU,  and  not  in  tliem  c.vcept  in  lliosc  rare  caiwswhcn 
along  witli  an  amount  of  injury  to  tho  joint  whicli  renders  preeerra 
tion  of  the  limb  without  operation  hopole««,  tliero  U  at  tho  aun 
time  no  such  extensive  wound,  and  no  such  injiiry  to  tha 
vessels,  a>t  to  nc-ccAsilHto  am]>utntioii ;  imd  even  in  thoso  raro 
it  will  always  be  doubtlu]  whether  the  injury  to  the  boneti  is  limii 
to  tho  nciglibourbnod  of  the  wound,  and  thorcfoni  the  operation  i 
alw.ays  to  bo  regarded  as  an  exploratory  proceeding,  wltioh 
terminate  iu  amputation. 

TIio  conclusion  from  all  tJiis  api)ciirs  to  lie,  that  the  cbms 
ablo  for  excision  arc  thoso  of  incurable  injury  or  disease  of  the 
in  which  all  the  circuinst^inocs,  both  ooii«tituti»iinl  and  local, 
most  favourable ;    iu  wliich  the  patient  ia  in  tlio   prime  of 
and  free  from  visceritl  <lisetiso ;  imd  in  which  there  ts  roawa 
hoping  that  tbo  leeion  has  not  spread  bc}x>nd  tho  epiphysal  ends 
the  bones. 

The  operation  ia  thus  performed:  an  incision  should  bo 


•  Mr.  Canton  liss  latelj*  publish od  tan  cii*c»  in  iibickbeperfomiciiL 
Operation  bucci.^ssI^iIIj'  for  injury-;  or  pcrliBps,  moro  (Irictlr  spoaluag.  i 
abscess  following  injury. 


EXCISION  OF  THE  KN'EE. 


831 


I 


from  tliv  biti^k  part  of  one  condyle  to  the  back  part  of  tbo  otiicr, 
ling  acnwa  tlu^  front  of  tlio  ]iinl>  bclovr  tiw  piiU-IIn,  unit  ftljghlly 
'Wnvcx  (lownn-ards.  It  is  Hi>ld(>i»  necessary  to  niako  any  otliur 
incUion  into  thu  skin ;  but  if  tlicro  is  mucb  tltickiiiing  Hboiit  tbo 
Boft  parts,  pel-pond iciilar  inciAton^  may  be  ma(I(<  at  tJie  ends  of  tbls, 
S(i  a»  ill  foiiii  tln!  H-sliajJi'd  incision,  wbich  used  alwjiv»  lo  be  em- 
ployed in  thia  operation,  Tbo  ligamcntuu  patella!  is  to  bo  divided 
in  tbc  fir»t  inct«iuii ;  then  tlie  soft,  parts  arc  to  bo  thrown  bat'k  from 
tho  patella  and  tbo  end  «f  tho  femur,  and  the  paletla  ih  to  be 
rcmovfd."  Tho  joint  is  now  to  bo  frcoly  opened  by  cntting  at  tbo 
udeci  of  tbe  con<lylea,  ko  aa  to  sever  cnmiiletely  botli  lateral  liga- 
ments; and  tlwm  tbo  knife  is  to  bo  carritxl  round  the  posterior 
mrfaee  of  tlie  end  of  the  femur,  caro  being  taken  in  doing  tliia  to 
tbrost  tho  femur  out  of  the  wound  as  mudi  as  possible,  by  nn 
oMfttnnt  forcibly  flusiiiK  Uie  limb,  luid  to  kwji  tlio  edge  of  tJie  knife 
directed  towards  tho  bone  and  goided  by  tho  tinger,  so  as  to  at-oid 
till!  popliteal  artery,  wbicb  hero  is  sopunitcd  from  tlio  liono  only  by 
Bome  fat  and  loose  tissue ;  and,  in  sawing  the  bono,  it  may  bo 
iidvi«iible,  if  tho  finnnr  bavo  not  bwrn  *xry  conipIcltJy  cleanatl,  not 
to  pass  tbe  saw  entirely  through  tho  osseous  tissue,  but  ratlior  to 
break  Ibaii  to  cut  tho  outer  lamella  at  tbo  back,  by  using  tbo  saw 
■s  a  tever.  Tlie  end  of  tbo  femur  having  been  i-enioved,  the  bead 
of  tho  tibia  is  to  bo  cleaned  and  san-n  horizontally,  care  being  taken 
in  yonng  persons  to  keep  elusn  Ijelow  the  cartilnjriiiou.t  fturiaee,  so 
that  the  opipbysal  lino  bo  not  tronehed  upon.  In  cases  where  llierc 
liaa  been  no  diitloeation,  nor  much  alteration  in  the  shape  of  tho 
bouea  from  previous  disease,  there  is  now  usnally  no  impediment  to 
]>I(u;iiig  tbc  limb  in  a  Mraight  position,  with  tlie  iHincH  in  aeciiraie 
adjustment.  Otliemise  they  must  bo  adjusted  by  taking  off  shc- 
ce^wive  piix!os  from  tlie  end  of  the  femur  (if  [Kiiutiblo  without  going 
beyond  the  epiphysis);  and  in  cases  of  old  dislocation  it  is  often 
necessary  to  *evcr  some  of  tlie  hamstring  tendoii.-kt  The  parts 
should,  in  all  cases,  bo  adjusted  tit  perfect  position  upon  a  splmt, 
and  the  blindages  firmly  applied  before  tlie  i>3tient  is  inoveii  or 
allowed  to  reeoTOr  from  tlie  chiorefonn.     If  tJie  femur  appears  at 


*  I  bcliovc  no  dinVreiicc  of  nplniou  now  onLtts  as  to  tbe  iiscVmn-mi  of 
attempting  to  SHV<^  llio  patella  in  siij  caso. 

t  1  bolit'Vp.  nflcr  Itmiiig  bad  occasioD  to  do  it  in  botli  navs.  UiAt  this  la 
bett«r  d<:ia<s  from  tho  n-uuiiil  than  suLcutancuusly.  Tliere  Is  no  occaiiou  to 
make  a  )t»le  tliiv>ugli  tliu  puplitual  apacp,  ss  nurou  SurgMus  hare  recoia- 
mended.  U  tho  prineipnl  iiK-iHicm  hn»  licnn  made  Ikr  enengh  bai^k,  tb«ro 
will  be  snCGuiunt  cscspu  fur  lUc  matter. 


832 


EXCISION  OF  BONES  AND  JOINTS^ 


all  prominont,  n  short  splint  s1>ould  be  appltvd  in  front  in  onior  to 
counteract  the  tdidoncv  of  t,lio  log  tu  gravitate  baekwiml.'*  (wliidi 
is  nlM  ii»!tt!(li^  by  t)>o  action  of  tlio  flexor  tondons) ;  and  it  is  at  any 
rate  a  nsofid  precaution  to  opply  a  long  sidv-^jtlinl  to  the  outer  nile 
of  liio  limb,  whiolt  can  l>e  discarded  after  llw  iinit  few  days,  if  it 
appears  sujK-rllitonif.  I  have  found  much  comfort  to  the  patient 
from  Bus|>eRding  tl«s  whole  a]>pamtufl  in  a  "  Salter's  swing."  It 
wilt  of  ouursc  be  understood  tbitt  the  splints  are  interrupted  and 
bracketed  with  Iron  at  the  scat  of  o[>eration,  so  as  to  give  aeix^ 
to  the  wound.  It  ttt  an  essential  clement  in  tlio  success  of  Urn 
operation  not.  to  bn  fi)recd  to  diMurb  tlto  limb  at  idl  for  several 
days :  hcneo  the  dressings  should  be  most  carefully  applied  at  first. 
And  for  ilio  n;iiiic  rox'u^ri  all  bleeding  \'Cj(»oI:4  ^iiould  be  carefully 
aocurod,  so  as  to  avoid  socondai'y  haemorrhage.  The  bleeding  du^ 
iug  Iho  ofwration  is  oft«n  wvy  I'rcc,  fr<>m  ibo  eulargwi  articular 
vessels :  and  siHiondarj'  ha^norrhage  is  by  no  means  rare,  and  i»  a 
vary  unfavourable  oeonrronce.  The  operation,  especially  when  tt 
has  been  a  protractixl  one,  nhioh  in  cases  of  old  dislocntiunit  it  ofW 
is,  is  usually  followed  by  a  eontiidcrablc  amomit  of  fever,  subsiding 
witl)  the  eHt^hiUbnietit  of »  froe  suppuration;  and  then,  in  litvour- 
able  cases,  the  work  of  repair  commences  by  jci-aiiulation  and  oneow 
union,  as  in  (■i)m]iound  fracture.  In  unfuvouniblc  casc^,  tbo  bcd^^fl 
become  denuded  and  ulcerated  in  the  suppurating  oa^■ily,  the  uV 
charge  i»  ofTensi^x-,  the  wouud  tmhiMtltliy,  frc^th  alisoeascs  probably 
form,  and  the  patient's  health,  instead  of  improving  from  tho  removal 
of  tiio  disease,  shows  a  Icndencj*  to  decline.  Under  tliose  circtun- 
stAHOOS,  diloroform  tthnuld  \mi  administered  and  amputation  prf' 
formed,  if  on  examination  it  proves  necessary. 

The  proec,*s  of  reeovcry  is  u.-<nftlly  a  slow  one.  In  Dr.  Hodges'a 
tables,  already  referred  to,  die  duration  of  the  treatment  in  48  cases 
in  wliifth  tlio  patvlla  was  removed  i*  stated  to  have  been  22.')  days; 
and  in  38  cases  in  whieh  that  bono  is  believed  to  have  lnvn  left,  255 
days ;  or,  roughly'  s{>eaking,  the  average  duration  of  treatment  wu 
about  eight  months;  and  in  many  of  tlie  cases  which  afterwards  turn 
out  the  most  sueeessful,  sinuses  remain  open,  and  the  limb  is  in  a 
Btate  whii-h  eannot  but  caiiMe  anxiety  for  many  montJis  »ftcr  fonnal- 
trentmcnt  is  dtHcaiitinned.  *  In  some  e.\eeptiona]  eases,  indeed, 
nuittors  go  on  much  more  nipidly  tiiaii  tliis,  and  llw  recovery  i« 


*  In  u  acTtfx  of  Hgbt  suooeBSfuI  cases,  all  of  Uicm  in  chUdivn,  at  St. 
TboiDasD  HoEipitnl,  for  the  notes  of  which  1  am  lodclilcd  to  Mr.  Allingbam, 
the  average  dntntion  of  irx'aUnent  was  208  Jays. 


X 


EXCISION  OF  THE  KNEE.  823 

Don)])let>!d  m  soon  as  (iiidoixl,  it  may  bo  tliat  ono  or  two  luvo 
reoovenxl  soouer  than)  after  amputation  i  but^  as  a  general  role, 
til*!  limo  rvqiiiroii  fur  rccovorj'  aftc-r  i^xcisiou  may  ho  takt'ii  at  about 

Pur  liracfi  as  long  as  afliT  amputation.  In  fiu^t^  I  tJiink  wo  are 
king  a  view  vciy  favourable  to  fxcision,  if  wo  say.  tlwt  ovtiy 
oiilii  after  tlio  (iitei-alion  mlviuictut  tlie  euro  only  ast  fui-  a^  a  week 
ould  ailor  amputation.* 
What  is  the  valuo  of  the  limb  which  i*  obtained  by  lliis  operation, 
at  the  cost  of  such  increased  risk  and  m  muob  additional  suHrring? 
t/nliirtuniitcly,  this  i»  a  question,  the  answer  to  which  has  Ixieii  no 
idi§torted  by  the  rash  and  exaggerated  ^tatoDioDts  of  tho  iudiscrinii- 
ato  ailvocatcjt  of  the  operation,  that  no  impiu'tial  poi-Mon  aui  profess 
to  be  able  to  hoKo  iL  I  liave  seen,  in  a  few  caseo,  most  oxccllcut 
limbs  left  al^or  excision;  tar  superior  both  for  uppt^trimco  and  utility 
to  nny  iijiparutii.i  which  could  bn  m»iniracrured  after  ampDtati<Mi, 
and  still  more  lo  lh»  ordinary  wooden  leg :  and  it  is  on  iiccouut  of 
tlio  oocnrrcnco  of  such  cases  tliat  [  bcliovo  exciwon  ought  to  bo 
practised  upon  tlie  most  faronrable  oases  of  disease  of  tho  knee ;  but 
J  utterly  disbelieve  tlio  aecomits  whieh  have  boeii  puhlishwl,  resting 
upon  statements  in  ncws|>apcrs  and  periodicals,  of  cases,  many  of 
which  had  not  recovered  ftom  the  operation,  wliilc  in  a  prcs^  P"^ 
jKtrtion  tlie  siinisos  were  still  ojien,  sukI  tho  patient  in  about  an  equal 
chaneo  of  saving  his  limb  or  losing  it.  Ho  case  is  to  be  acx.-vpte<l  as 
a  i^ucocitsful  one  of  oxoision  oftliekiioe,  without />»WMrf  infonnation 
as  to  tho  following  facts :  ^VTiether  tho  wounds  were  idl  closed ; 
whellwT  the  imion  was  so  firm  as  no  longer  to  permit  any  motion ; 
wbetlier  tlie  patient  could  walk,  and  if  so,  witli  or  without  ap]>amtuft; 
and  what  wcro  the  rcsjioctive  uicasurcmeuU  of  the  limbo.  It  is  true, 
thai  to  have  wailed  long  enough  to  satisfy  these  queries  wciuUl  have 
Somewhat  delayed  tlio  appoaraiico  before  the  world  of  M>me  brilliant 
cases,  and  perhaps  have  condemned  many  of  tliem  to  peqiOtual  ob- 
scurity; but,  on  tho  otlior  hand,  it  would  have  made  the  information, 
when  it  did  appear,  useful  and  trustworthy,  insteatl  of,  as  at  proscnt, 
either  uscIchs  or  dvoeptive.  As  fiur  as  Dr.  HodgM  could  discover, 
from  llio  data  funiiKliod  hy  publi^liod  accounts,  out  of  IMS  cases  of 
excision,  103  failed  uttorly,  as  furoved  by  deatli  or  amputation;  and 
of  the  remaining  106,  (hi-rcwaji  n-ason  for  thinking  tlwt  in  Ii5  cases 
the  limb  was  useful,  and  in  1 4  |iartial]y  or  entirely  useless ;  27  being 

•  From  Um)  notes  ot  (W  tuocessAll  amputatlotis  of  tlui  thigh,  at  St. 
O*<orge'*  Hosptta],  1  Gud  lUst  Iba  artng/t  staj-  in  luinfiiul  wm  bs  duys. 
This  Include  patieuK  o(M  ag«a.  Cliildrco  aud  jrouni;  p<TS0BS,  stidi  lu  aro 
aloDc  the  aia^uet*  of  uxciiion,  rvuover  mon-  rapidlj'  tbui  iba  avtiagc. 


«24 


EXCISION  OF  BONES  AKD  JOINTS. 


'oodii 


left  quite  doubtful :  but  from  the  nntoro  of  socb  accounts  tlii»«>iidi 
Bion  uaiinot  bo  n  v«ry  (XMiHdeiit  uiio.  Out  of  19  (.tuMM  ocourrin^ 
Sl  TIioRiiL>'ft  Olid  ^  George's  UoH{>ita]ft  tngctlter,  of  which  I  Iiat 
trustworthy  and  Huffiviciit  details,  tlio  limb  was  uHiful  in  10  oum 
but  9  of  tliesc  were  children. 

Anothor  very  BCi'ioiiit  consideration  in  cases  wliicli  rocoror  wifl 
naefal  liinba  la,  whether  tliiit  tifwruhic^i  will  be  [>crmanoiit.  It 
liow  II  wvJl-ktiuwu  fnct,  titat  tho  utility  of  iho  linib  in  many  caa 
in  which  it  seemed  [lerlcct  at  first  han  been  destroyed  by  HulMcqaa 
chaiijlit'ji.  In  itdultfi,  tlio  union,  nhhough  it  has  appeared  quite  fim 
eomctimea  provoit  not  to  have  been  ho,  nnd  tlie  limb  I>giii1>  uiiJl 
coiintnnt  UM),  nnd  yields  to  the  power  of  the  flcx(«'  muscles,  uoti]  tl 
foot  no  1on^i-r  toiicbest  the  j;rotin<l,  nnd  llie  whole  oxtrcniity  beoooH 
an  incumbrance  instead  of  a  support  Sometimes  it  hows  om 
or  iiiwanh',  but  with  tli«  same  goneritl  result.  Oecasionnlly 
rccui-s,  after  a  shorter  or  longer  interval  of  api>arcnt  health, 
8j)ontniioously  uriLsaconxcqueuocof  »omo  accidental  ii^ury  orm' 
exertion.  In  children,  suspension  of  growtli  may  ensue  ns  a 
sequence,  in  most  cases,*  of  removal  of  tlic  entire  c^itphyeia, 
cncroaohtnent  on  tlie  shaft,  of  one  or  both  of  the  bones. 

If  the  limb  be  simply  bent  in  conse^iucnco  of  soft  niiion,  t 
only  treatment  re<[uired  is  to  straiphteii  it  under  chhirofurin,  am 
k<>ep  it  Ktraiglit  iii  a  carefiJly-fitted  splint  for  some  montJts,  wit 
duo  attention  to  the  ^ineral  health,  the  patient  being  put  iu  goo 
pure  air,  and  allowed  to  take  moderate  oxeroue  upon  orutdia 
AVlieii  disease  is  present  in  the  bones,  it  becomes  n  qnostion  whetlM 
the  diseased  hone  can  bo  removed,  or  whether  the  limb  should  fa 
antputatiil.  Some  Sur/^vms  have  even  proposed  the  complete  n 
excision  of  the  false  joint  by  an  operation  similar  to  the  origini 
one, — a  proposition  highly  worthy  of  consideration  if  the  patici 
lias  attained  his  fiiU  growth  and  is  in  good  health,  and  tbo  shorten 
ing  left.  Ijy  the  firrt  uponitioii  is  not  great.  Such  rvi^xdsion  m 
however,  alwaj-s  be  proposed  to  tlio  patient  as  an  explonitofy  oj 
ration,  wliicli  iu  many  cases  will  have  to  terminate  in  amputatioii. 

Ejvuion  o/  the  nnkif-joad  has  been  proposed  as  a  substitute  ft 
Amputation  of  the  foot  in  disease  of  tlie  ankle  ;t  and  it  catmot 


•  Siiii[>ons!oii  of  gruwLli  bos.  liowurer,  been  notici'd  in  one  nuc  al  Icaa 
under  Mr.Synie'acaiv,  where  Ilice])iiilij8a11me8spprar  to  hare  be«n  left  iaiM 

t  I  <l<5  iiol6|)enk  here  ofrcseetion  of  tbo  iirojeeling  c>iid»  of  tlwfaoai 
in  rompmiinl  fmuimu  or  iliilocntion.    This  is  treated  of  in  tJio  tWKj 

1bji;hie»  o\  the  Ljwcti  ExineuiTT. 


\ 


KXCISTON  OF  THE  AJHvLE. 


825 


lonied  tliat  some  siicccsstiil  oinT«ti<nis  bavo  been  porfbrmed,  al- 
Jioii^li  the  -p-oat  majority  swin  to  have  tenninntoil  in  disapp<niit- 
ncnt  Befori-  |iiTfiirmiiig  wr  projKisi'ng  tin*  opt^'nitinn,  the  diagnoaia 
»r<lt»i»iHo  Btridly  limited  to  thf>  aiikle-joiiit  fihoald  bo  mado;  and 
sin  is  not  »lwnyi<  oany  to  da  If  the  astragalus  lio  (iwj)I_v  iiitiwtfld, 
Btill  more  if  tlio  os  caloiei  I*  involved,  a*  jji-ovod  bv  tho  number  nnd 
lirewtion  of  tlio  sinuses,  it  would  bo  WToiig  to  attcmjit  oxdwon.  I 
io  not  mean  to  di-ny  ibi-  iiossihility  of  remo^nng  one  or  more  of  (ho 

rsiil  bfint^x  together  wit  !i  tho  ends  of  tlio  bones  of  th*-  log;"  but 
amputation  at  tlie  nnkIo>joiiit  Ih  prnfi-rable,  the  nortainty  and  the 
Sftlority  of  the  cure  far  outweighing  any  possible  advunt«go  from 
preserving  a  foot  »i>   inutilftt/!il.     K^'ori  in  diM»u«e  limited  to  tlio 

ikltf-joint,  I  have  hitlierto  only  practised  (or  seen  practised)  anipu- 

ation  through  tho  Ji^int ;  but  tboru  itcviii.'*  no  doubt  that  some  casca 

frf  Muvccsefiil  excision  have  occurred  at  Charing  Cross  Hospital  ;t  so 

it  1  cannot  do  better  than  quota  Mr.  BanvoH'!!  di^scription  of  llio 
operation  which  has  bi^cn  found  to  succeed.  "The  foot  is  fir«t 
lid  on  its  inside,  and  an  incli^lon  Is  made  over  tho  lower  three 
atiiCB  of  the  posterior  edge  of  the  fibula.  When  it  has  reached  tho 
>wor  viid  <)f  the  malleolus,  it  forms  an  angle,  and  runs  downwards 
ad  forwards  to  within  about  half  an  inch  of  the  base  of  tbo  outer 
aotjilar»inl  bout'.  Tlic  angular  flap  is  rofleeted  forwards ;  the  fibtda, 
^bout  two  inches  above  t)i«  malWIux,  lit  Nuflitiiently  cleared  of  soft 
to  allow  cutting  forceps  to  be  placed  over  it ;  and  tho  lH>iie  !« 
lien  nipped  in  two,  nnd  fju-cfiilly  disK-ctcd  out,  lonving  the  peronons 
>ngns  and  brovis  tendon  uncut     The  foot  is  now  to  be  turned 

cr,  A  itimilnr  incision  is  made  on  Uw  inner  side,  the  [jortion 
tbo  foot  terminating  over  tho  projection  of  tho  iniwr  cim«ifonn 

[>ne,     Tho  flap  is  to  be  turned  back,  ami  tJio  ohcallis  of  tho  flexor 

iigitoruin  and  posterior  tibial  tendons  diWded,  the  knife  being  kept 

elose  to  tho  hone,  avoiding  the  artcrj'  and  ner\e.     The  internal 

uteral  ligament  is  then  to  be  severed  carefnlly,  close  to  tho  bcitie ; 

Itnd  tiow  the  foot  is  tn-istcd  outwards,  and  tbo  astragalus  and  tibia 


•  In  one  ciuu  refwred  to  by  Dr.  Hodges,  lh»  ends  of  tlic  tibU  tuul 
[fibula.  Uio  nliolc  of  tliu  UBtngnlua,  ]wrt  of  Uie  os  calcis,  nnd  tlio  three  eunct- 
fona  boacn,  wrrc  remavvd :  in  niiotlier  thv  uud  of  the  tibia,  th«  utn^us, 
Licnphoid,  nnd  two  of  tbe  (nincifoira. 

t  lUrivell  on  IHnnun  ofjoinli,  p.  4(M.    In  monjr  oih«r  cosm  suooom  i> 

EelaiiDad;  but  in  by  far  tho  gTcatcr  nunilier  of  th«in.  it  is  clear  that  ihfi 

■innaen  were  unltetled.  and  irhoD  ihrj-  am  no,  Lbu  f<>ol  is  never  ssfc.    Mr. 

StaUwm's  case,  in  Die  ifeJifD-Chiturgieiil  TntmMttioiu.  is  an  example.    It  i» 

«port«d  aa  sucMsaful,  but  tlic  foot  was  oftemrards  ampulalAd. 


^M9$ 


EXCISION  OF  BONES  AND  JOINTS. 


will  presotit  at  tlio  inner  wound.  A  narrow-bla<Ieil  saw,  put  in  \ 
tween  the  teiidiins  into  the  innor  wound,  projects  Uimuglt  the  out 
The  lower  aid  of  \\iv  tibiii,  tlioii  tliv  lop  of  the  ustragulus,  tnny 
tavrii  (rfT  ill  n  proiwi-  direction.  The  ov\y  Tessel  that  may  reqn 
tyit^,  is  ono  of  tho  lower  branches  of  thu  pvroucad  arlcrj*. 

"  Tho  wound  may  W  closed  wiili  sutures,  «xn>pt  that  part  c 
posito  the  broach  of  osseous  matter ;  tlw  log  aud  foot  placed  oi 
tt])liut  with  a  fuot-bnard,  and  cold  water  applied.  No  sliuck  fbBiy 
tlio  operation.  Tlio  patients  get  well  very  quickly ;  a  fad  wiii 
may  l>c  in  jHUi  attributed  to  tliure  being  no  necessity  for  rigid  od 
finement,  aa  in  other  large  jomts  of  the  lower  pxtremitr. ' ' 

With  rcforonoo  to  tho  littt  statcinoiit  of  Atr.  Iliu~wcir»  doscri 
tion,  it  is  hardly  borne  oat  by  the  roconU  of  published  caacs. 
Dr.  Hodges'*  work  niuctocu  ca^os  will  bo  fooud  in  which  rccort 
i»  claimed,  aiul  tho  timo  of  treatment  given.  In  all  of  tbeu  I 
duration  of  treatment  oxcecdod  tlirce  mt>uth»,  aud  in  tlie  gn 
intyority  it  wiu  far  longer  than  thiH ;  reaching  in  one  ca»o  to  iJm 
t/eara.  In  all  tho  cases  in  which  tlio  report  is  given  at  an  ear] 
period  (one  month,  six  week*,  ten  iveck.*),  the  patient  is 


irsH 


to  be  "recovering."  In  a  case  alluded  to  in  Mr.  Barwell 
tho  patient  m  said  to  have  been  Me  to  witlk  several  miles  en 
<]ay  within  ton  montlis  after  the  operation.  It  is  to  be  regrelM 
howm'or,  llint  iti  this,  as  in  ahnost  wcry  otltcr  case,  the  proa 
condition  of  the  pai'U  U  left  ondescribed. 

Dr.  M.  Biichannnn  lias  also  described'  an  o^icratiou  for  excui 
the  ankle-joint,  )>^-  making  a  eurveil  ineiHiun  over  tlw  exteri 
malleolus,  removing  tins  process  with  the  bono  forceps,  ditiloeadi 
the  joint  hy  invwting  tins  mh  of  tho  font,  aii<l  thiw  obtaining  aca 
to  the  diseased  bones  witJiout  dividing  any  important  jt-u't^,  ( 
peronei  ton<luii»  being  the  only  Klructnrett  necessarily  divided  T 
proceeding  is  merely  a  jK>rtion,  as  it  were,  of  the  one  dewvibeil 
]\Ir.  BarweU.  It  ciuinot  gi^o  so  free  an  access  to  tho  bones  as 
obtained  by  the  former ;  bat  it  may  be  adopted  in  cams  where  I 
end  of  the  tibia  doc'*  not  rcfirirc  entire  removal  witli  tho  eaw. 
oiwration  may,  tJiei-eforo,  l»e  eonimcnood  by  making  mcrvly 
incision  on  the  outer  side;  and  th<»i,  if  it  be  foimd  neceesarj', 
on  the  inner  side  may  be  ad<lccL 

E.Tcision  of  th  loiK»  o/"  (A^  foot.  In  disease  of  the  tarsal 
metatarsal  bones  exci!«ion  is  otUn  very  sucoessfully  practised  w 
tho  disease  is  limited  to  tlie  os  calcis  bolund,  or  to  ainglo  boi 

»  Olui'jom  MttUwt  Journal,  ml.  U.  p.  ], 


EXCISIONS  IN  THE  TAR8DS. 


827 


Hie  mctiitanitLt  tii  Ti-otit ;  but  it  is  ofmoru  doubtful  utility  wIkmi  tlio 

wonos  which  aro  affected  are  those  coverod  by  the  large  <!onimon 

b)'i>uviut  nic-iiil>riiiii>  of  the  tanus.     These  honee^  both  troto  tlicir 

pmaU  size  and  &om  being  portionn  of  tlio  xamo  joint,  iu<e  vcr^ 

■bUo  to  bccumo  involved  in  the  same  aeb'on ;  and  thuH  it  froquailly 

H^)pen3  tliat  diiuMise  is  only  erodicutCHl  iil  i>ii<'  point  U>  »li<iw  itself 

■omc  wcekit  afU-rwards  at  anotbor,  and  tJio  attempt  to  save  the  toot 

K'jDiWn  unsuccc^ful.     But  in  favourable  o^ixos  it  ou<^lit  to  l)c  iiiadOf 

phce   the   ojicrat.ions   involve   littJo  danger,   and  no   continemeiit 

Dioyond  what   would  be  rendered   newttnu-y  by  tlie  di)u>a»o  itself. 

BLmy  SurpL'ons  prefer  goiigiiig  out  Uio  whole  carious  cavity,  leaving 

n  shell  tiiniKHl  of  buiuv  [nvntiniud  d^  be  hfnltliy,  itnd  of  tJio  wll  parte 

around ;  an  operation  souotimes  dignified  by  the  name  of  "  sub- 

poi-itxsti'ul  n>.i(vtion."     The  allcftfil  advaiitflfre*  of  tliin  proceeding 

are,  that  tlie  bone  niay  bo  reproduced,  and  that  tlie  pvat  tendons 

-will  be  loll  in  tWir  natural  attaebmc-nts.     I  do  not  attribute  vciy 

much   importance   to  either  of  theao   considerations.     No   direct 

evidence,  as  far  wi  I  ean  discover,  lias  Ixx^n  given  that  the  natural 

bone  will  bo  reproduced  after  auch  gou^ng.     I  mean   by  '*  tJie 

natuntl  bone,"  a  bone  which  will  (ill  u]>  the  place  of  the  original 

bone,  and  have  the  same  articulations  ;  and  by  "  direct  evidence," 

the  dL«M.-ction  of  a  foot  In  which  this  tias  taken  place.     Tlw  dis- 

advantagca  are  all  of  them  summed  up  in  iho  fact  of  the  diDieuIty 

of  being  iiiu*c  that  the  whole  of  the  diseased  bone  lias  been  removed. 

Whi-u  llic  whole  of  tJie  a«  culci.*,  or  of  the  fir<t  mettibirniil  bone,  has 

been  iniolved,  except  a  small  exterior  portion  of  dubiously  healthy 

bcinc,  1  hiivi-  not  »cru]>l«d  to  dissect  out  the  entire  lM>iie  without 

resjK-et  to  tlie  periosteum,  and  have  aeen  no  reason  to  repent  Imving 

done  so.     Tlio  foot  lui»  been  left  in  a  wry  sorviooahlo  condition; 

and  I  much  doubt  whether  the  addition  of  a  few  detaclicd  pieces  of 

bone  to  tlie  eicjitrix  (whicli  1  belioro  would  have  been  tlw;  entire 

result  if  the  periosteum  hatl  been  left  beltind)  would  liavc  affected 

the  ustffulncNt  of  the  foot  in  any  way. 

The  removal  of  the  os  calcis  is  an  operation  which  may  often  bo 
practised  with  great  ad\'antago.  Disease  of  the  tarsus  very  eora- 
monly  begins  in  the  joint  between  the  calcaneimi  and  astragalus, 
and  froqucntly  spreads  into  tho  former  bone  ;  tho  affection  of  tlkO 
latttT  iKriiig  .-io  su|)erl]cial  tliat  the  earious  .ijiot  can  bo  gouged  tnnj 
when  tliD  greater  mass  of  disease  has  been  remorod.  in  tluMo  caMS, 
tlie  central  i>art  of  the  cah>atu-imi  oflen  ]M.>ri»he(«,  leaving  a  largo  masa 
of  necrosis  enclosed  in  a  thin-walled  cavity  of  inflamed  and  softened 
bono,    li'now  the  whole  bone,  inclu<!iiig  tliis  shell  of  noftencd  boue^ 


828 


BXCrSIOX  OF  BONES  AN 


bo  rcmovixl,  ttw  patient  mitkcs  a  certain  aiiil  »po«iv  recovon* 
a  usu^ful  foot ;  wlitli!,  if  Uio  looRe  portion  ^>c  removoil,  an< 
siicll  wwoiK^ii,  lie  may,  it  is  true,  rcoo%Tr,  and  tlio  bcel  mny  |wa 
be  moiv  firm  ;  but  tho  rcccnciy  ift  oertnitily  more  doiibtfal,  a 
tbo  oourw  of  « tMllouB  oonxalcsceiKo  tlie  healt]i  may  give  way, 
diseaM  be  lighted  up,  itml  unipututioti  bocoiuv  noi-c«!iary. 

Excision  of  tlto  oh  ttalas  is  iIiuh  perfomiMl.  An  incisitm  i* 
m«ncod  at  tlio  Inner  edge  of  the  tnido  Aclitllii<,  and  drawn  bor 
tnlly  forwards  aluug  iho  (iuti>r  ^ide  of  the  fool,  AoinuwiiHt  in  fro 
the  calcanco-cuboid  jouit,  wliic-Ii  lies  midway  between  tho  i 
mnltcoIuH  a>»l  tlii*  end  of  tbe  tifUi  metatarsal  bone.  Tliis  ioi 
uhould  go  down  at  oiico  upon  tlio  bone,  so  that  llio  tendon  st 
Iw  fi'It  to  sn«]i  M  tlie  incision  is  coniiiicnocd.  It  should  be  as 
08  imssible  on  a  level  with  the  upper  border  of  the  <is  ealri 
jioiiit  which  tlio  Surgwn  ean  determine,  if  ihe  doi-ouin  of  tbo 
ia  in  a  natural  state,  by  feeling  the  pit  in  which  tlw  extensor  bi 
digitoruin  arise!*.  Arotbcr  incision  i»  then  t«  b«  dmn-n  vertJi 
across  the  sf>lo,  eonimcncing  near  ttie  anterior  end  of  tlio  fo( 
incision,  mid  tcrniiimting  si  the  outer  border  of  Iho  groova 
internal,  surfiiee  <if  tJie  os  oalcLt,  beyond  which  pmnt  i(  idioald 
extend,  for  frnr  of  wounding  tli«  |Hiatorior  tibial  vessels.  If 
riHjm  bo  reqnii-eil,  tliis  \-«rticnl  incision  may  !)«  prolonged  a 
upwards,  so  as  to  form  a  +.  Tho  bono  being  now  danuded, 
throwing  Imck  tho  Hnpn,  tbo  first  point  i»  to  find,  and  lay  open,' 
caleaneo-euboid  joint ;  and  tlicn  tJie  joints  widi  the  astragi 
Tltc  cIo»e  connexions  bctwoon  tlK«e  two  bones  constitute  the  p 
ci))al  ditHeulty  in  the  ojiomtion  on  tlio  dead  subject ;  but,  ai 
been  alri-ady  stated,  these  joints  will  ftw]ueiitly  be  found  to  1 
been  destrny»I  in  cases  of  disease.  The  calcancimi  having  1 
scpnratctl  thus  from  its  bony  connexions  by  tlio  free  use  of 
knife,  aide<(,  if  necessary,  by  the  lever,  lion-f<>rcep!«,  Ac,  tbv 
parts  arc  next  to  bo  cleaned  off  its  inner  side  with  caro,  in  <a6a 
avoid  the  vessels,  and  the  bono  wiU  then  eome  away.  "Bki  fl 
are  to  bo  closed  lightly,  with  one  or  two  points  of  wire-suture,  ( 
tlie  large  gap  left  by  the  cxei»ioii. 

This  plan  appears  more  convenient  and  loss  bloody  tJian 
rccomineiidiil  by  Mr.  Hancock  and  Mr.  Giilhric,  of  making  a 
from  tbo  heel  and  throwing  it  up,  as  is  done  in  Sonne's  ain{>utat 
Even  if  the  diagnosis  has  bccu  erroneous ;  if  disease  slioidd 
npiiarciit  in  the  astriigithifi  or  in  tJie  fore-jari  of  the  tarsus,  win 
bones  ait)  denuded,  and  so  the  Surgeon  shoidd  In-  led  to  amp' 
tlio  foot,  that  operation  could  be  easily  accompliahed  by 


EXCISIONS  IN  THE  TARSU& 


820 


of  thtf  inciBioiis  just  describod.  In  this  way  I  Im\-(?  rc- 
tamd  the  OS  calcin  iii  a  ufiiM  in  n  vi:ry  shurt  tiino,  aiid  wiiltout 
tiding  it  necessary  to  tie  a  single  arten-.  The  filling  up  of  so  largo 
cavity  itt  of  ounnfc  n  ratlior  tv<liou!t  bn^inoM ;  out  of  rtcverid  cases 
diildreti,  of  which  I  Itavo  notea,  I  find  iiono  in  which  it  was 
ipleted  in  luss  tJinn  thruu  months ;  and  probtibly  tlio  child  does 
lot  recover  tho  jiowor  of  putting  tli«  foot  lo  the  ground  for  another 
oontii  or  inoru.  I!ut  wlicu  it  in  soiuidly  ht^vd,  tbo  foot  i»  a  vory 
eiiil  one ;  aiid  I  have  seen  children  who  could  run,  danoe,  &a. 
Ay  newly  as  well  as  witli  the  natural  foot. 
No  formal  <lircctious  are  re'jiiired  fi>r  excUuig  the  other  tarsal 
[>nC8.  TIiv  si)tl  parts  am  to  bo  thrown  aside  by  crncial  incisions, 
idiating  from  tliti  i>iiiii.'<eH  wJiich  lanil  to  the  iliM>aM3d  bone,  and 
latt^T  n-movod  ;  caro  being  taken,  in  all  cases  where  it  is  [»)»- 
Bible,  to  (•x<;iii«  (lie  whole  bone  witll  the  iirticiitiiting  nurfiicea. 

Tbo  metatarsal  bono  of  tbe  great  too  is  very  often  discasoil ;  luid 
om  its  large  siite  disease  may  go  on  in  its  Niihstance  for  a  long 
riod  without  affecting  any  other  bono.     In  such  cases,  after  a 
liRoiently  patient  trial  of  the  appropriati!  constitutional  treatment, 
rith  rest,  it  is  proper  to  expose  tlto  disease ;  and  if  this  is  found  to 
Delude  tlio  greater  part  of  tlia  bono,  Uicii  tbo  bc«t  couno  is  to 
iio\c  tlio  whole,  witll  botii  its  articular  Hiu-fnoos.     This  may  bo 
eadily  done  by  making  an  incision  ovor  tbo  whole  length  of  tho 
Qne,  joined  by  shorter  perpendicular  cuts  in  front  and  behiiul,  and 
Inis  turning  buck  small  rectangular  flaps  including  tbo  whole  lengtli 
[of  the  hone.     It  U  better  tji  coninienco  by  severing  it  from  tho 
Liieifurm  bono,  ax  in  dividing  it  from  the  phalanx  the  plantar  arch 
rill  most  likely  l>e  woimded,  and  tlie  bleodinfr  may  prove  somewhat 
abarrussing ;  whereas  If  tlie  artery  be  not  divided  till  tlio  bono  is 
emoveil,  there  ia  no  difficulty  in  tying  it.     No  .ij>lint  is  required, 
lie:  groat  tijo  sinks  down  somoM-liat  towards  tho  tarsus,  but  the  foot 
Ijs  as  useful  in  progren-sion  as  before. 

Should  suiglc  metatarsal  bones  in  the  centre  of  tbo  foot  bo 
dietoased,  it  is  bettor  to  gouge  away  tbo  whole  of  tJio  diN<-:uc«l  part ; 
or  if  tlio  affection  seems  too  extensive,  to  amputate  the  loo,  and 
diuwet  out  Uio  mctutarMtl  bone  &om  tho  posterior  end  of  tbo  wMind. 

Tho  above  arc  all  tlio  operations  of  cxotsion,  which  it  bmmiu 
necoswiry  to  describe  ]«irticularly.  Dr.  Hmnpbry  lias  romovod  the 
condyle  of  the  jaw  (see  \k  795) ;  anil  the  sanie  Snrgeon  on  ono 
oeiuision  cxeiwd  a  iracturod  porfion  of  the  patella :  but  tho  ini|>cr- 
fictat  position  of  Uicm!  boneit,  and  the  rarity  of  the  oj>cnUion-i,  render 
Liny  formiil  description  sujxji-flnou* 


880 


EXCISION  OF  BONES  AND  JOINTS. 


The  opcraljoits  on  tlio  npi-er  and  lower  jaw  will  be  das 
ooniicxion  witli  tltc  enrgcry  of  tlml  jmrt  of  tlio  boly. 

Partial  rt»tcti<Ms  of  long  i)tmet.  When  Ww  cntirw  tlitckiK«n 
long  boQc  if)  di^ciiMxl,  it  may  sont^tinica  be  ad%'antag(M>iis  |i^  remo 
tbp  tliw-iiaed  portion  only.  In  this  way  portions  of  tlio  ribs  have  tn 
resectod  on  account,  of  i-airioft,  pmliably  in  orOer  to  a\ort  llic  oow 
rcncc  of  pleuritic  iiiflammHtion  from  tho  noigliboiirliood  of  Uh  i 
cosed  bono;  an  o[KTi»tioii  of  Mime  ri«k  utd  very  doiil^tfiil  utility, 
portions  of  tlie  shafts  of  the  ulna,  fading,  tibia,  or  (ibu)n,  liavc  been 
oat  with  a  view  of  pr(imotin!jih<!hi--iiliiig  of  ulcers  t  hilt  socined  otii 
wise  ineurable,  or  getting  rid  of  an  obstinate  ufToction  of  tlie  boi 
Many  operations  for  necnici.'*  aiv  uIm  erronormsly  entitled  roeectit 
of  the  shftflii  of  tho  bones,  when  diey  are  really  only  cxtraetioai 
f.eqnc«tra ;  but  in  a  fuw  case^  the  nocronxl  pluitl  has  been  rotnoi 
while  yirt  ennneotetl  to  the  living  bono.  Sncli  operations,  bon-cv 
whether  undertaken  on  aeeount  of  carie*  or  nwroeis,  too  often 
suit  in  fiiilure.  In  etae^  of  necrosin  of  u  portion  of  tho  lliicknow  a 
lone,  i-escction  should  very  rarely  be  ]>nietis«l — perba])LS  wo  mi 
r»y  never,  unless  for  tlio  iflicf  of  iiifl«niiiiatory  MTn]>lom!«  propags 
from  the  diseased  bono  to  neighbouring  organs.  Nor,  in  cam* 
ncerotif  of  the  whole  thiekneM  of  the  shall.,  is  it  usually  advin 
to  ojiorate  until  the  oitt  nlmft  has  separated  from  dio  in-w  bone, 
tho  latter  bus  acquinxl  Komc  volume  and  finnnCBs.  No  special  din 
tions  ai-e  needed  for  theae  operations.  The  ehief  point  lo  be  Rtteni) 
to  is  to  keep  ax  oloec  to  tho  bone  as  possible,  in  order  to  spare  i 
merely  the  tendons,  vo-ssols,  Jic,  which  may  lie  in  relation  witli 
diseased  bono,  but  also  the  periosteum ;  so  that  there  may  Iw 
good  a  ppospwt  a.*  possible  of  tJio  rcgmcralion  of  tho  part 
moved.  In  spite,  however,  of  what  has  been  said  as  to  tlie  ram 
of  subpcrifintcai  resection,  1  eimnol  discover  any  c^^denee  of  I 
restoration  of  the  continuity  of  a  long  bone  after  it*  intcmiplion 
thi;  resection  of  a  piece  of  its  shaft,  exC4.'j>t  in  cases  ofneeroeis 
Probably,  if  tho  piece  were  very  ftliort,  union  might  occur ;  but  t 
necessity  for  tlie  remould  of  such  a  piece  could  hardly  ever  aiiso. 

T.  HOLMES. 


*  See  Wagner  on  Rfpair  tffttr  Satetimt,  New  Syd.  Soc,  1S80,  np.  131 
and  33834 1. 


DISEASE  OF  THE  SPINE. 


THE  Hptnal  column  is  sulijoct  to  ti  morbid  proccAa  so  miicli  morv 
fbmudablo  and  &oqticnt  tlian  othant,  ihat  it  is  cmpbiticiilly 
Icallod  Disnii!«!  of  llii>  Spine.  Ttii.*  winsUUt  esHcntially  of  Ciurios  uf 
lecrtain  vertebra; ;  whence  tbat  tcmi  is  froqucntly  nsod.  From  the 
|dittU>rtioii,  Cinise<]  by  loss  of  shIwUhco  of  some  (mrtion  of  the  apino, 
[the  nawio  Angular  Deformity  is  also  applied.  la  foreign  works,  it 
lis  called  the  nialiuly  of  Pott, — from  the  fintt  standard  dcftcrijitioii  of 
;  given  by  our  oountryninn. 

Caries  of  the  spine  ia  properly  included  ainon^  diKeiiiiex  of  ilio 
iJointH.  The  morbid  action  hy  which  tlie  bodiea  of  tbo  vertebriB  and 
he  fibro-carttlagea  are  disorganised  is  id<Mitical  with  tliat  which 
decttrcivA  the  join t-»truetnrcH  of  the  carpoA,  tarsoii,  and  Hpoiigy  eiidn 
of  the  long  bones.  But  owing  to  the  spino  combining  tlio  appa- 
rently irrcoonciluhlu  oBiccs  of  being  a  flexible  pillsr,  and  the  gii»r> 
dian  of  the  spinal  oord,  various  special  characters  belong  to  its 
dt»euM.'», 

Of  Caries.  Tlie  morbid  process  thus  tomiod  exhibit*  itself, 
firrt,  by  eonsuming  the  portions  of  brine  lUid  fibroH?artaIage  at- 
tacked; swrondly,  by  pxeitiiig  a  discharge  of  pus.  Pathologists 
concur  in  rcgai'ding  tho  diseased  action  ns  the  same  in  bone,  tluit 
we  witness  in  uleerution  of  tho  aotl  structures.  Hence,  to  show 
thf^r  a}>|iIieution  of  the  terms,  it  woidd  be  wiid  that  the  bodies  of 
tijo  Tortcbi-.R  were  corrxHlcd  l)y  earics ;  that  tlie  fibro-cartilages 
H  were  destroyed  by  ulceration. 

^  A  (pia'ilion  ha»  olV-ii  been  diwnuMod,  whether  tho  disease  origin- 
ato  in  the  hard,  or  soil  textures.  But  as  yet  no  iiiati«faetor}-  answer 
hii4  been  driven.  It  suffices  to  know,  lliat  when  tho  process  \aa 
commenced,  all  tho  structurts  yield  indiscrimiuatciv  to  itn  destrnc- 
live  ngi'tiej'.  In  tho  child,  tomjwrarj'  cartilage  enters  into  tho 
com|ML4ition  of  tho  [Hirt^;  and  wo  find  tliat  osseous,  fibrous,  6bro- 
cartilaginous,  and  cartilaginous  tissues  are  all  dtsinltigratcd  and 
removtxl  in  lui  ajiparently  idnitical  mnnner. 

An  important  distinction  exists  as  to  tlio  ecgmont  of  t)i«  spino 


6S2 


DISEASE  OF  THE  SPI^JE. 


liable  to  Th  altAckod  by  caries.  Tlio  anterior,  toduduig  the  bo^ 
iut«rv«rtul>ral  sulwtanoc,  niid  a<^i;es.ti>ry  ligumvtitA,  ik  tJie  i^Mci 
teat  o(  spinal  (H.il-iim!.  Tbo  posterior,  consiBting  of  llie  pedide 
arcbo»,  tnuisNerao  and  spinous  jirocc-imefl,  tugoUwr  wiili  tiio  artia 
lations  of  Uv)  oliUcjiio  processes,  kas  no  similar  tendenoy.  It  U 
rcmarkKble  patJiolo^ical  fitct,  that  numerous  as  arc  tlio  small  joinl 
in  the  baok  of  Ute  vort«bral  column,  disoofio  in  tJiom  ia  M9UH 
cvL-r  witnessed.  ^Vnd  when  carli^  hiis  oxIiaiLsttxJ  its  d«6br^H 
agency  on  tho  Uxlies,  it  seldom  or  never  spreads  iiackwiird  to  inlil 
tlio  articulations  of  the  oblique  proccwe-s.  It  will  prosontly  be 
that  the  Btmetures  of  llio  puMlcrior  segment  exliibit  u  dU|>o»ition 
toko  on  u  reparative  action,  aiitagonifiUc  to  tbo  morbid  [iroceas 
front. 

Wlien  carioa  selects  a  part  of  tlw  spine  for  dostraction,  it  nu 
either  limit  itsvlf  to  eno  ur  two  bodies,  and  di»<>rgauiso  thcat  who] 
ur  [uirtiaUy,  witliout  much  injury  to  the  adjacent  bodies;  or  it  nu 
extend  along  the  Kurfacrs  of  numerous  contiguous  viTtcbne, 
corrode  a  great  many,  caoli  in  a  slight  degree.  In  pn>porti^^| 
the  ulceration  proceeds  deeply,  a  chasm,  more  or  less  widip 
rurnicd  lietwcen  tlie  romaining  sound  portions.  The  |mrt  of  tl 
column  whieh  has  been  thus  sap)>od  at  its  foundation  foils  fonran 
and  Angtibi-  DL-foniiity  in  tlio  ooiiHcquencc.  Again,  the  dc«lnN 
Ijon  of  the  bodies  aud  intervertelmJ  cartilages  is  accompanied  fa 
tin'  fonnation  nf  Ab»ct«st.«.  Lastly,  tho  spinal  cord  is  subject  t 
be  implicated  and  deprived  of  its  functions,  thereby  causing  Par^ 
plegia.  But  before  proceeding  to  treat  in  detail  of  any  of  tha 
grave  elfecta,  it  will  be  convenient  to  examine  tlio  sym 
epinal  disease,  iu  its  incipient  stage. 


InciptfTtt  Staffc  of  Cariet  of  Ifie  Spine. 

The  disease  is  generally  admitted  to  be  one  of  the  eiam 
iwTofnloiiN.     Yet  it  is  fmniciitly  met  with  in  patients  who  do 
olh<?rwiso  oxliibit  signs  of  that  diatliosis.     Its  origin  is  oflen 
butal  by  the  pationt  or  his  friends  to  an  accident — one  that 
bal)ly  oceurreil  a  long  tJmo  previously.     Tlio  evideitoo  is  scliku 
Katisfaetory.     tia>atcr  importanco  is  due  to  ti>e  unsound  oonditii 
of  the  oonntitution,  whicli  would  lead  wtiat  b)  common^*  a  slig 
injiirj- 1«  produce  audi  disproportionate  effects. 

Caries  of  iJie  spine  may  commence  at  any  [loriwl  of  lifo.  Pi 
the  middio  term  it  is  extremely  rare.  It  is  most  rife  from  cm 
childhood  to  adolescence.     It  occurs  oqaally  in  the  two  wxfls. 


SYMPTOMS.    ANGULAR  CURVATURE. 


833 


^M  Antpttnr prtgfdvm.  TTie  symptora  which  dosenes  earlieot  notico 
^Bs  tlic  appearance,  at  tlic  sout  of  tlu;  tsirk-s,  of  ii  pro[iiinen<.>c,  in  one 
Bor  more  of  the  (»i)inous  processes.  The  primaiy  canst;  of  tlio  pro- 
jection, or  (according  to  a  common  cxprossion  of  patlciita)  of  the 
"  growing  out"  of  llio  hack,  is  tlie  deslniction  of  a  ot.*rtaiii  portion 
of  the  front  of  tlio  spinal  column.  Tho  guporior  part  of  the  pillar 
fell.'t  forwanl,  from  having  hcen  undemiined,  nnii  forniH  aii  angle 

IiritJi  tJie  inferior.     The  spinous  process  of  tlic  particular  vert*?bra 
which  ha*  hid  the  deepest  excavation,  will  protmdo  tho  must,  aiid 
Iw  the  apex  of  the  angle. 
In  tho  odvaiicni  «t»ge  of  tlic  complaint,  no  syniptom  is  more 
easily  detected,  or  of  leas  doubtfltl  significance,  than  this  prominence 
of  tlic  spinous  processes.     Owing  tn  long  absence  of  motion  in  the 
affected  part,  the  muscles  in  each  trough  will  liave  become  atro- 
|pkie<i.     Consequently  tho  ridge  will  stiuid  out  conspicuously,  like  a 
jlceel,  with  a  rugged,  serrated  edge,  the  knob  of  each  process  Iwing 
[distinctly  visible.     LatcniHy,  also,  the  protrusion  of  tho  transverse 
lend  oblique  ])rooessca  will  be  distinguishable.     But  before  the  angle 
doddodly  formed,  and  n-liilc  tlii;  superjacent  struoturoa  arc  soimd, 
<  are  aourcos  of  obscurity  which  sometimes  moke  tho  diagnosis 
Scult. 

In  certain  regions  of  the  column  tlio  prominence  of  the  spinous 
jproccsscs  is  discernible  at  an  earlier  period  than  in  other*.     It  is 
Ithovm  in  tlie  dor»al  vertehne  sooner  than  in  the  lumbar ;  and  the 
iieason  is  obvioos.     In  tho  dorsal  region,  tlie  spine  hue  a  nattinU 
]  incurvation,  tlio  convexity  of  which  is  backward.     Hence  the  ridge 
[of  spinous  procosacs — although  eacli  is  pointed  downward  and  over- 
l.]aps  the  other — is  more  sn]>crfictal  than  obcwbere.      When  even 
la  email  part,  therefore,  of  tlie  .lubstance  of  ono  of  the  liodic.t  is  lost, 
incurvation  forward  becomes  at  once  conspicuous.     Hut  it  is 
lifferent  in  regard  to  the  lumbar  region.     Tho  normal  curvature 
lin  that  part  is  concave  posteriorly ;   accordingly,  altliough  each 
lipinous  process  i.t  {loiiitecl  bockwanl,   the  ridge  is  in  »  Iiollow, 
lisd  difficult  to  bo  felt.      Moreover,  the  bodies  and  uitervcrtebrftl 
eufilages,  being  of  largo  liize,  can  l>o  excavated  to  a  great  depth, 
witliout  perceptible  bending.     The  consequcnoo  is,  tliat  cariea  may 
exist  in  tlic  vertobnc  of  tlio  loin^,  fiir  a  long  time,  without  visible 
protiiborance  of  tho  spinous  processes,     llie  same  obscr>'atieu8, 
■witli  slight  modification,  apply  to  the  cervical  vertebne.    When 
caries  invades  tho  body  of  one  or  more  of  tticso  boue«,  tlio  effect  of 
tlio  less  of  substance  is,  that  the  head,  by  its  weight,  subsides  verti- 
cally ;  nnd  tho  consequence  is,  that  tlie  tfoco  between  tlM.*  occiput 
VOI_  IIL  3  H 


bL 


gn-i 


DISEASE  OF  THK  SPIKE. 


and  upper  part  of  tlie  ohest  i§  so  much  contracted,  thnt  tlic  R 
cannot  be  insetted  to  feci  tlic  epinous  [nx>c«ssoG  and  ascertain 
condition. 

But  in  refercDfc  to  the  nonnal  incurvations  adverted 
must  romembcr  thai  lltcy  arc  not  pcrfoctty  csUb1i»licd  tjll  a1 
poriod  of  [mberty.  Again,  the  spine  is  endowed  in  early  life 
Bttdi  great  flexibility,  that  it  bends,  vritli  reninrkablo 
tbroughont  ita  whole  length;  and  if  the  child  bo  debilitated 
any  illness,  the  eupplonoes  of  the  column  n-ill  bo  proportiont 
increased.  Now  when  tlie  npine  in  tlitu  ineun'atocl,  tho  ridg 
spinous  processes  may  stand  out  prominently,  even  where  not 
]>oot«(l,  aH  in  liio  lumWr  r«gion ;  and  the  np)>oamne«  mil  hx 
striking  resemblance  to  that  in  the  back  of  a  patient  affected  ^ 
caries  of  tiic  bodies  A  difliculty  of  dlngnoai^  hence  arises. 
only  means  of  becoming  satisfied  that  tberoia  an  absence  of  diM 
is  by  obscr^•ing  tliat  no  single  spinons  process  projects  decid 
furtlier  Uian  tlie  rest ;  and  tliat  on  laying  the  chiht  on  its  belly, 
elevating  t)io  hips,  tlic  convexity  of  the  incurvation  is  obliterate 

^irrllinrr.  Tiimcfiiction  i»  seldom  a  di*t.tn<-tly  mnrked  sympC 
rarely  amounting  to  more  than  a  diffused  thickening  and  indura 
of  tlio  structures  over  the  projecting  vertcbnc.  When  consideni 
it  indicates  an  actively  ])rogresaing  condition  of  the  umos. 
abiWiit,  aik!  titc  ]>oints  imd  surfiicos  of  tho  bones  are  eloarly  defi 
to  tho  toudi,  it  proves  that  tlie  disease  han  Kulnided,  and  ankj'l 
has  pn>b«bly  taken  place. 

Jlfut.    Ihiring  the  acute  stages  of  caries,  inovoM  of  tomperd 
may  bo  perceived  in  tho  affected  vertebr*. 

RiiiJtliiif  of  ffif:  .tpine.     If  the  hip-jotnt  bo  dnMMid,  an  « 
indication  is  impau-od  motion ;  and  a  similar  stifiheaa  character 
the  oommeuceuiorit  of  disease  in  other  articulations.     In  tike  n 
ner,  when  caries  invades  the  bodies  of  jiartienlar  vortctira, 
of  tlio  first  Higns  is  a  defect  in  tlie  natural  mobility  of  tbe  afla 
bones  and  those  adjoining.      For  <lotecting  the  incipient  stagi 
tho  diseajie,   this  symptom  is  of  great  value.      Owing  to  the 
treme  flexibility  of  the  s]>ine  in  i<litlilrr-n,  wo  may  not  alwayi 
able  to  avail  ourselves  of  it ;  in  patients  abo^-e  that  ago,  bowe< 
die  svnnptom  never  fiiiN.     Thi-ro  arc  %-arious  ways  by  which 
rigidity  can  bo  manifested.      Tlio  patient  may  be  made  to  st 
forw.-u-d,  or  lean  from  side  to  side ;   when  it  will   be  pen 
that  tint  four  or  five  vertebra*  where  the  disease  is  suppo: 
exist  do  not  partieipato  in  tho  general  flexion,  hot  move 
as  a  united,  compact  mass.     If  tJtc  Surgeon  pUnt  tho  palm 


SYMPTOMS.     PAIX. 


835 


linnil  flatly  nnti  broadly  o\-«r  n  soiinil  portion  of  llio  spinal  cotiiaiii, 
aiiil  direct  tlio  paticut  to  bond  and  extend  Iiia  baek  alternately,  ha 
Trill  be  iwiiitihle  of  the  scvoni!  prucM^mt  Euparating,  or  approncbing, 
kjn  reference  to  each  other,  in  con-espondence  to  the  diH'erent  move- 
nts.    Btit  if  iio  diift  his  hand,  and  plnco  it,  in  Uko  nuuiucr,  oiixr 
ltlu^  p»rt  where  tho  verlebRR  arc  snapecti^d  to  be  mrioiiH,  ho  will  not 
ive  the  samo  scnsntiuu  as  bcfbro :  the  distJiict  processes  will  retain 
BIT  relative  diAtaucc*  fi'i>ni  oacli  othi>r,  wliatcvor   may  bu   tlic 
leral  raovement     The  stiflTiiOfis  and  want  of  resilience  may  be 
accoimtj.'tci  for:  m  man  aa  the  procti-ts  of  enrics  i»  begun  in 
be  bodies  of  Uio  vertebra,  iuflaoiniatory  action  is  set  np  in  the 
joining  textures :  at  tlio  focua  of  tJio  di»o«M},  namely,  in  the  an- 
Iterior  segment,  the  aciion  is  of  tJie  suppurative  type ;  but  in  the 
IpoMk-rior  s^^'ginoiit  it  i»  adlicsivo  and  defensive:  accordingly,  at  llio 
laarae  time  that  the  front  of  tlie  csolumu  is  conRuinnl  by  uleeration, 
|«oa^iil.ibIe  lymph  is  dojiowtod  in  tho  lusaoa  which  connect  the  vcr- 
liohnt;  Uigi'tJuu- jxiKtiTiorly ;  and  in  proportion  «fl  that  aolidifles,  the 
linotion  between  tliem  is  an-ested. 

Pain.     Tills,  which  in  {jciicral  is  tlie  (iiitliftd  giiimlian  of  the 

I  textures  of  the  frame,  is  a  fallacious  monitor  in  regard  to  dieeaeea 

|jOf  the  npine.     It  foils  to  wani  whvn  <langcr  ix  imminent,  hikI  criw 

out  when  nothing  is  to  be  appi-ehendod.      Many  are  the  juitients 

with  coiitirniiMl  angular  deformity,  who  have  never  kept  their  bed, 

gn  account  of  pain,  for  a  single  day.     Again,  tlio  Surgeon  ia  eon- 

tintially   being    eon'^ultwl   concerning   otlicrs, — almost    inxiiriahly 

females, — who  have  sufliirod  kIuu'ii  ]iuin,  in  a  jiarlicular  spot  of  tJio 

[«olumn,  for  montlis  or  years;  and  who,  during  all  that  tim«,  way 

Inot  jierhiipH  have  ventured  onco  off  tltcir  cmicli,  froin  the  inipres- 

[  won  Uiat  such  di-eadftil  snffiiring  conJd  proceed  only  fi-om  fonnidablo 

SBC, — yet  having  all  tlic  whilo  every  vertebra  of  tbrar  ajiine 

erfectly  soand. 

2Ierarttielcs»,  in  cortaui  caw>«  pain  i»  a  leading  symptom  of 
ie».  It  ia  shown  by  tlio  patient's  inability  to  tat  op.  When 
Qg  in  bed,  the  act  of  turning  hiui  round  will  eause  great  agony, 
liii  nights  will  he  sleepless.  He  will  sometimes  complain  of  a 
I  of  constriction  about  tho  epigastrium.  Attacks  of  such  w^verv! 
•pain  do  not  eommonly  last  long,  hut  lliey  are  apt  to  recur.  The)- 
I  indicate  Kccoancms  of  aeute  morbid  action  at  the  sent  of  disease, 
^k  In  tlie  more  numerous  class  of  «um»,  in  wltich  pain  is  subor- 
^Bdinate  or  dormant,  particular  deviecA  are  necessary  to  make  it 
^Bocognisable.  ^Vhile  the  patient  is  upright,  a  sliock  may  Ik-  giveit 
^■to  the  spine  by  tlio  Surgeon  |)lan»g  his  IuukIs  on  both  shoulders, 


n  ti) 


836 


DISEASE  OF  THE  SPINE. 


and  suddenly  fleprossing  ihem ;  the  jerk  will  probably  canae 
at  the  affectwi  part.  Or  tht-  same  object  may  \>r  {gained  by  3»ki] 
tJie  patient  to  jump  from  n  low  stool  upon  the  floor.  Stroi^ 
pnswinj:  ii|Kin,  or  jwrcussing  each  spinous  process  in  snooesson, 
ftDOtlicr  iiiodc  of  fvolviiig  latent  jiuin.  Tbe  ])liin  of  cnrn-ing  a  h 
spongo  down  the  spine,  in  expectation  of  the  warmth  rendering  t 
pain  tiioro  sensible,  hait  not  niticli  to  rreoimncnd  it. 

Senralff'"  of  the  fjnne.  For  <IiagnosU,  it  is  necesaar^  to  adri 
in  this  place  to  the  painful  a9bctiou«  of  thv  itpino,  wluch  liarc  jl 
be<'ti  alluded  to,  as  frequently  causing  iinealled-for  alarm.  Aina 
tlieso  we  do  nut  include  pain«  in  tlie  baek  which  ariso  from  ihl 
matism,  dy»])C|Hiia,  diaeaaei)  of  the  kidnc^i),  or  of  t]io  utcnu  ■ 
ovaries.  The  alTection  to  which  the  term  *  ncural]cia'  propa 
applii^,  ix  of  t)u^  niiine  nutiire  a.'<  '  ela\'ii8  by»terieu.-<'  in  tlio  htt 
It  derives  its  principal  characters  from  the  statu  of  constitati 
known  an  tlic  '  hjTsterinil  diailiwi*.'  Pains  of  liko  kind  bcoot 
nettled  in  varioii§  parts  of  the  body,  especially  tlie  joints.  Ill 
wore  designated  by  Sir  B.  C  Brodio  ca»cs  of '  hysterical  ncnralgi 
When  the  spine  is  affected,  tljo  jiatient  (who  it  may  be  preniDt 
is  a  female)  will  complain  of  u  sJiarp  piercing  pain  fixed  in 
particular  spot,  situated,  aooording  to  her  sen»ition,  deeply  i 
ono  side  of  certain  vertebiic,  and  occupying  a  iqiaco  which  mar 
covered  with  tJic  point  of  the  finger.  AH  parts  of  ilie  eolimui  m? 
equally  subject  to  the  pain  j  but  it  commonly  continues,  in 
same  patient,  in  one  place,  Tlie  physical  suffering  to  wliieli 
l)ain  gix-tw  rise  is  undoubtedly  great.  B«t  its  worst  effect  is, 
hajiK,  that  producml  on  the  mind.  The  ]mtienl  becomes 
with  a  conviction  that  so  much  intenBe  pain  can  bo  produ' 
by  snme  friglilfid  ule<T;  sihe  fortliwilh  dev<>tc«  Iierself  to  its  trW 
ment,  as  if  she  had  disease  of  a  malignant  character,  corroding  ai 
destroying  her  spine.  Slic  i»  (won  furnished  with  an  invalid  Im 
Then  the  chances  are  in  favour  of  her  reniaijiing  a  prifloiicr  api 
her  buck,  not  fur  r'lx  montlis  or  a  tw<d\'emoiitb,  but  for  sevtl 
years  consecutively. 

Numerous  fact«  show  tJiat,  howc\'or  acute  and  persistent  tbe 
pains  may  be,  they  do  not  proceed  from  organic  legion.     On 
aniination,  the  j^aticnt  will  be  obscned  to  wince,  and  jerk  bcr  r 
every  time  she  Is  tonohud, — movcinentJ*  irreconcilable  with  tl: 
being  pofiitivc  disease.     Jt  will  bo  furtlier  remarke*!,  thai  alth 
tbo  supposed  ulceration  muKt,  aecnnliug  to  Iho  aewunt  of  the  d 
tioii  of  the  i)ain,  have  been  active  lor  a  long  jM-riod,  no  dcfom 
has  been  produced — not  even  rigidity — in  the  affected  rertebi 


DIAGNOSIS  FROM  NEUKALGU. 

I  writer  vtiimot  quuto  any  case  of  tlio  kind  referred  lo  in  which 

8]>me  haa  been  oxftmined  nfler  dc-atli,  to  aaccrtun  tin;  sustaaH 

lition  uf  tlio  boitos.      But  !u  analogous  oaaea  of  iieund^ia  in 

joints,  an  tlio  knoo,  lio  Inu  had  opportunities  of  observing 

hat,  even  when  Uio  pain  was  so  severe  that  the  pntientA  have  In^n 

i>niiiteil  to  nolioit  am jiu tuition  for  a  rcmwiy,  tlio  struc-tures  were 

Dond.     Ho  witnessed  two  cases,  both  under  tlie  iuinio  Surgixni,  io 

rhich  it  wa.-*  .*ui)i)0!«i^  that  tbo  si'voix;  pain,  rrforred  to  the  knee, 

raa  caused  by  uleoratioii  of  the  eartiJagee,  and  in  whieli   it  wom 

itd  neoewury  to  reniovn  tlic  linibi*.    On  iuvpcction  of  the  joints, 

I  cartilages  and  all  tlie  other  struoturea  were,  in  tiotli  case*,  tound 

ertl'Ctly  healtliy.*     Hence  it  may  Iw  Inferred  tliat  the  articulations 

and  hones  of  tlio  spine,  aifected  witli  similar  paiiu>,  wotd<l  also  bo 

,  found,  if  exiuiiined,  fm^  from  organic  disease 

I        If  Uie  nervous  jiain  hapjwn  to  be  aceomjiiuiiod  by  hyiitmcnl 

panipU';;ia,  a  eoinplicatioii   not    uncommon,  the  diagnosis  will   be 

.jrenderLtl  mort>  difhetilt.     And  if  l.lit-  jiatJi'iit  !<iuiul<l  liavu  heniJc^, 

rhat  is  frequent  in  fcmalex,  lateral  eurvature  of  tlie  s]>u)e,  a  new 

Jctnent  of  jicrijloxily  will  lie  addivl.     'llio  writer  hiid  under  liis  care 

ts  governess,  twouty-two  years  of  age,  in  whom  the  varioun  maladies 

Jrcferred  to  were  combined,  and  who  vrm  obliged  to  sacrifico  her 

llituatiou,  owing  to  the  Siu-geon  of  the  family  pronouneiiif;  hri"  ciwo 

l.to  be  one  of  caries,  reciuiring  a  lun^  period  of  rest  io  tlio  rvcumhvnt 


*  The  Biibsetim'ul  bintoiy  cjfoiiu  of  tlieae  putienta  nun  not  a  liul«  re- 
murkitblu.  Alilioiitth  tlio  iituinp  woa  u  porfectly  guod  oae,  it  soon  becamo 
the  sent  of  pitin.  oi]iiiil  to  wlmt  hud  been  fvit  la  the  kueu.  ThHi-eupoa  tli« 
Surgeon  repctttci)  Uio  amputation  liJKhcr  up.  Healthy  uicatrUaUon  took 
pluco ;  hut  ere  long  pain  as  bod  as  tlic  iirst  returned  tu  the  new  Btump. 

tThc  next  pri>c««ding  was  to  dsciac  n  I.irgc  portion  of  the  >iuenxciati«  uorv^ 
But  this  operation  bad  no  hotter  result  than  th«  prcocdinK.  NeiUur  Sor- 
goon  nor  patient,  howovor,  lost  h<^art.  A*  Ihnre  vtill  remained  a  portion  of 
Utiib  c'tpnlilc  of  itinioval.  amputation  Ht  the  hip-joint  wns  perfonned.  Thu 
Jargo  ivnunil  hritlcd  favourably.  Yot  the  pain  did  not  dcjmrt:  it  contiuucd 
In  the  cicatrix  as  great  as  over,  and  of  tlio  eanio  kind  a«  at  Qmt.  The  youni; 
woman  was  vventnaUy  sent  Io  the  sea-side.  Thf  r«  sho  becnmo  pTe;;unnt. 
lipui)  ber  r«lurii.  it  was  a«certaiued  that  as  soon  as  sha  f«lt  hi^riclf  in  tlic 

tbinily-wBy,  the  iiountlKia  oeascd.  Having  subftci)ueiill)'  boeoroo  tlto  motlicr 
of  a  Urg«  fumil.v,  slie  hiui  beni  trequciitly  se^ii  ou  acoouut  of  hor  cfaildron: 
and  aoeordiiift  to  her  xtuUimeut,  alia  hu  ami  oooasioaal  altaoks  ofllto  old 
pain  in  the  ilump. 

The  ivi-iter  ha»  bcpn  informed  of  a  ea*e  Himilar  to  ihc  above  that  oc- 
ourrcd  rcnnntl}':  In  which  tho  ifurgcon  waa  Indufud,  diielljr  by  the  tarucst 
•olicilations  of  the  patient,  a  woman  of  lij-stcrical  tvmponuneiit.  to  auipu- 
tat«  her  limb  for  supposed  nleoiution  of  the  cnrlilagt-!i  of  the  knee-joint. 
Tho  cti-uctures  w«id  all  found  poifectljr  heal^]'. 


838 


DISEASE  OF  THE  SPINE. 


]>mitioa.  Slic  hatl  n  [trotubiTaiion  of  tli«  s|>ii)c  on  tlic  convex  slie 
tl>e  liuiibnr  ctm'L>.  But  that  waA  caused  Miiiiily  hy  tlto  onlinai 
rotalioii  of  tlio  vtfrtubnc  on  thoir  long  axis  which  accompain 
Utenil  cun-alun.», — a  rotation  jirot!uo<.xl  by  <'xw*Jiiv«  ntMwrptHiii  i 
tlifl  articular  proccwK-*,  from  prcs»ure,  on  the  concave  nide.  H 
projoding  part  whs  tJie  seat  of  twvcre  liyrtcrical  [lain,  Sho  w 
also  unablo  to  walk  without  support ;  and  then  only  by  dragg^ 
tlie  1e^  It)  n  few  wcekii,  under  tn^atniciit  by  caUstltenics,  abowol 
hatliB,  tonics,  ix.f  she  perfectly  recovered.* 

Angfiii^  DfformUff. 

It  ia  easy  to  undei-etand  that,  if  the  substance  of  one  or  DM 
boclic*  of  the  vertebra;  bo  rcmovL-d  by  carivs,  the  supcr-itnpoM 
portion  of  tlm  column  will  fall  fonvaixl,  and  form  an  an;;lu  with  th 
below.  It  in  not,  however,  the  weight  alone  whlcli  itiHueucce  tl 
flexion.  When  a  patient  U  conftiii;d  atriclly  to  tlie  recumbent  poj 
tioii,  and  pressure  is  tiius  removed,  the  angle  nevcrtlioless  oontinw 
to  iiiorcnso  in  «rutuii(A<>t ;  wiiioh  Hbow.t  tbat  the  action  of  tlw  all 
dominal  muscles  shares  in  causbg  the  deformity. 

An  tlio  botli(M  aiitl  fibro-cartilagcs  occupy  tliu  racsinl  line  oTll 
hody,  it  fullowii  that,  upon  their  destrantion,  the  pillar  wiU  deacta 
anil  bond  in  the  inotlian  plane,  without  lateral  deviation.  Tlie  odI 
]inrts  at  which  it  is  apt  to  incline  to  one  side  are  tlie  lombar 
dorso-himbar  R-gionn,  wlicre  ft  has  greatest  latitude  of  in< 
The  writer  was  consulletl  in  the  caw;  of  a  girl  of  fifleen,  supj: 
to  have  lateral  cimatiirc  ;  proceeding  on  that  view,  the 
attondaiit  liad  previotL'^ly  i)Ut  lier  on  u  course  of  calislhenic 
for  strengthening  the  muscles  of  the  back:  tlicre  was  at  the  juni 
tion  of  till!  dorsal  and  hinibm-  vertebra,-,  an  atigidiir  deformilj^ 
modified  by  a  decided  iucunation  to  iJie  right  side,  witliout  an] 
scciiml  ctu'\e  alwvc.  Tliv  projection  posteriorly  was  rocoguiscd  ft 
result  from  caries,  by  tlie  directness  with  wliich  the  H]>inoua  pro- 
comes  stood  out,  and  pressed  against  the  skin.  In  lateral  curvatur0| 
owiny  U>  die  rotation  of  the  vertebra}  on  their  long  axiw,  the  spinom 
processes  always  (>oint  laterally,  and  are  ovcr-lapjicd  by  the  edge  o 
tile  l<iiigiss!nius  dorsl,  m  as  to  l>c  nearly  hidden. 

But  tlie  angular  deformity  caused  by  destructioa  of  Uio  bodioi 


•  See  tlio  ni-tirle  llvsmntA.  vol.  i.  p.  S63.     lipirlurcs  tm  LoimI  Norvo 
AITections,  hy  Sir  B.  C,  Itroiiio.     AUo  a  mnstcrlj  Kasny  on  Uic  mortl 
BtJtiitign  ill  femules  of  JiytiteHcnl  diathesis,  by  Dr.  Itobert  Frrgtison,  |ireB 
to  the  edit,  of  Dr.  Gooeh's  VVoiks,  publislicd  bj-tho  New  Sydenham  Socle^ 


ANGULAB  CURVATUBE. 


839 


W^  8 


Uie  vcrtobnc  at  n  particular  part  does  not  cooast  in  a  simple 
ing  farmurnl  of  ibe  UDilermitiecl  pcn-liun.     If  an  inBcxible  [ullar, 
tho  mut  oT  a  »>hi[>,  ircre  cut  tlirough, — to  sure  ttw  vesKl  fhmi 
liipwreck, — the  jiart  at  the  base  would  rcauun  perpeadicuhir,  tbo 
wotdd  fall  over,  and  aii  angle  more  or  less  acatv  would  be 
inod.     But  in  the  Iminan  Hgunt,  if  the  utpenor  part  were  to  pro- 
joct  forward,  while  the  inferior  was  npright,  the  eqnilibrinm  would 
dmtrvjod.     Ttiu  {nlioiit  mi  atlvnipting  to  widk  would  tuinblo 
long.     It  is  true  that  when  the  spine  has  just  recently  beoomo 
Wilt,  the  pCTKin  has  difficult}'  in  prcMerring  lits  balance ;  bat  by 
'ping  bodi  knees,  and  using  his  arms  for  supjMirta,  lie  mauagM 
got  about     Era  long,  liowovcr,  ho  succeeds  in  competing  tlic 
ineqiiali^  in  tlie  line  of  gravity :  and  tluit  lie  itceoinjilbJtc^  by  gra- 
dually throwing  the  whole  head  and  trunk  backward.    Accordingly, 
it  ia  aln-ayft  obncnod  that  tho  lower  part  of  the  column,  in-ntoitd 
of  being  uprighi,  is  directed  posteriorly  in  relation  to  the  aarmm, 
,nd  that  tliu  apex  of  tl>c  hump  projcctij  coiuidvrahly  backward  crnn- 
ared  to  the  hips.     At  the  same  time  the  pgili<-nl  ciutt^  biit  fiu!e 
uj),  and  tiirows  his  chest  forward,  with  an  apjuirent  air  of  pride. 
It  residts  that,  as  ilic  angular  projeution  [Kwteriorly  is  combiuod 
Willi  two  incun-ations,  one  above,  and  the  other  below,  in  contraiy 
direetions,  the  wlioln  fyiiiw  awtiuiics  im  appearance,  when  looked  at 
in  profile,  not  unlike  a  double  bracket  (} ).     And  it  id  of  vonie 
practical  u.i«  to  bo  actiuaintod  ivith  this  peculiariiy  of  the  mcurva- 
It  throws  light  oil  (ho  wity  in  which  tlio  quack  t^cctA  a 
iponu;j-  improvcmeut  in  the  figure,  aiicr  anl^losiB  has  taken 
place,  in  cast»  of  angular  deformity.     By  confining  the  patient,  on 
hilt  back,  and  employing  mechanical  means  to  stretch  tho  spiDC,  ho 
succeeds,  in  the  course  of  time,  in  stnughtvning  thoao  portions  of 
the  coluiim  which  are  above  and  below  the  scat  of  disease,  and  thus 
"hriiigiiig  tliom  more  nearly  to  n  ]vvc\  with  the  ankylosed  vortebne. 
Kiitice  tlie  "bump"  Is  rendered  less  prominent  and  conspicuous. 
But  as  tho  inclination  of  the  e^inc  nt  the  imglo  cannot  bo  got  rid 
of,  and  it  is  that  which  dcrangos  the  equililmum,  the  JBcurvatioEM 
are  sure  to  return,  and  be  m  bad  :ka  bt'furc.     And,  lu  will  1)0  seen 
proiwnt]y,  tho  treatment  is  attended  with  serious  daugere,* 

Wlien  the  lumb:ir  vertobiiv,  ur  tluaw  and  tlic  Mioniin  togiHher, 
aro  tm  oxtsiisively  dcstn)ycd  tliat  tho  column  sinks  trom  its  very 


*  Sec,  la  tlie  muaouin  of  tlie  Mcdiral  Collegv  nf  Middlesex  HMpitAt.  a 
Mr{«e  of  osste  tnkuu  from  patieuta  with  angular  deformity,  after  troatnirat 
by  extension. 


MO 


DISEASE  OF  THE  SPINE. 


base,  tlw  whole  bo<Jy  is  anavoidably  thrown  cUrecdy  forwa: 
tlte  jiaticnt  cannot  iiiukv  uso  vl'tliu  invuiis  d<>»cribcd  abow  to 
cover  hJH  ccjuilibi'ium.     AnkylodB.,  thorefore,  tjikea  plaoe  with  t 
epino  at  right  aii^lvn  tu  tli<;  |>eIvU,  and  tlio  patient  is   inuapR' 
of  Ikoltling  liiiibwlt'  tiprigJiU     A('<.x>nlingly,  if  Iw  attempt  to  wal 
be  can  do  ho  only  with  bis  body  directed  b(»iaoiitaUj.     He  is 
demnMl  to  mtopt  tlie  mwlc  of  progreMaon  of  qiinilru]>eil»,  on 
foun,  rtntre  a  terrf. 

Thorax,  Excavation  by  earivaofpartit  oftlic  bodies  of  tlic  doi 
vvrtd>nt),  and  angular  dcfonnity  thcnw  produced,  oauso  tJio  vriu 
cheflt  t<>  be  iiicludt'd  in  tlio  distortion.  Tito  grooter  tJio  acatcoQ 
of  tlie  angle,  the  more  tJie  ribs  will  be  displaced  and  compi 
Owing  to  tho  falling  forward  of  the  portion  of  tlw;  »piiio  abo' 
angle,  and  it^  t-ttirj'iiig  tlic  ribit  willi  it,  the  sternum  proj' 
front,  and  in  some  cases  is  even  bent  at  an  obtOM  angle ; 
forming,  as.  it  wore,  n  cou]it«T]M>t»o  to  tlie  posterior  protu^ 
1^0  general  dfeob  of  the  changes  of  confi>rmatioa  is, 
antcro-poAtcrior  diamotor  of  Uio  cavity  a  increased,  and  tho 
tical  dccroafiod.  The  shortening  of  the  trunk,  aa  a  whole,  Icadd 
tlie  ubdonioii  boiiig  what  is  termed  potbellied. 

Tho  viscera,  Iwtli  thoracic  and  abdominal,  have  a 
property  of  acoonimodating  thotr  various  forms  to  tiw  new 
assumed  liy  ihetr  raipective  cavities ;  and  in  tliis  adaptation  ncatlia 
their  Internal  structure  nor  their  functions  suSer  ap{a«ciable  danagil 
Tlie  longa,  heart,  liver,  stomach,  Ac.  prc»<Mil  deformiuea  of  a  not 
striking  nppoarance,  corresponding  to  tlioir  mode  of  being  ytda 
togetlier.  T}io  o:»opIuigii8  and  trachea  arc  simply  xlwrtcnod.  Th 
aorta,  following  tlie  coimto  of  llio  spine,  and  giving  off  its  intercoeti 
bnuichc«,  is  bent  at  tlio  site  of  tlic  angle. 

Caries  not  uii frequently  attuck^  two  <Iii)tincit  parts  of  tlic  fpiM 
at  n  distance  from  each  otlier;  either  simnltanooualy,  or,  more  con* 
monly,  at  diflcntnt  [wriods.  Tho  writer  ha;«  witneaaed  several  casa 
of  the  kind,  in  which  l]ie  patients  have  recovered  as  in  tlw  ordinar 
coiirso  of  till!  di.H-ase.  In  the  last,  tho  young  ]>ationt  hod  jntt  r» 
covprwl,  witJi  moderate  deformity,  from  c^cs  of  the  dorvo-liunbai 
vcrtebrii',  wlmu  ho  was  eoized  by  disease  in  the  ccrvioo-dona) 
gion,  lost  the  power  over  his  tegs,  and  died  in  a  lew  tnontha. 

Spinal  Abtccnet. 

Tlie  importance  of  the  subject  of  absccssies  connected  with  cari< 
of  the  vertebra?  will  be  appreciated  when  it  is  considered  ihnt  tbi 
arc  tlio  most  frt'quciit  causes  of  deutli,  in  tliis  disease     Deformity 


JV 


ABSCESS. 


841 


an  affliclion  for  which  tlio  xuficrcr  may  be  coinmisonitixl ;  pxm- 
iysie  of  both  iower  cstromities  claims  our  nympathj' ;  but  ic  ia  from 
I  cflix^ts  ul'  liu'gv  iibsctM.tON  lliat  |i»l!uiiU  inuj  Ix.!  4ix])Cctod  to  dio. 
It  has  bixn  snid  tJiat  caries  is  a  i)|K!ci«8  of  uloentUoit,  and  that 
I  corrosiou  of  tho  bono  und  fibro-cortiUigo  is  attended  witli  sup- 
puration. In  common  uJoera,  sititatcil  on  o[)en  sitrfaoc»,  as  llio  ttkin 
or  mucouK  incmbrano,  tho  pus  thus  secreted  is  cast  off  and  losL 
iSut  in  the  tilceratiun  of  -ipiiia]  diAciue,  llie  miittcr  «n  t)w  mirfacc  is 
nught  by  tho  looso  connecting  tissue ;  this  bocomcs  thickened  and 
andcnsi'd  iiit^  tlio  wiiUs  of  ii  eavily;  aiid  evontiuilly  il  ixt^tlariy 
built  abscess,  with  proper  pyogenic  membrane,  is  constructed. 
Wo  can  recognise,  in  all  aWeswiM,  a  principle  of  a«U<curo. 
'itii  the  net  of  producing  pus  there  are  associated. tlie  antaganistio 
oceaaes — of  absorption,  and  reparative  growtli.  Wlwn  the  ter- 
lination  u  by  "resolution,"  tiie  fluid  ia  remoi'ed  by  an  action 
lalogous  to  assimilation ;  thv-  pus-gtoltules  luidorgo  dijiiiilcgm- 
aon ;  tbcir  particles  mixed  with  tho  serum  are  absorbed  by  tho 
apillaries ;  a  process  of  new  growth  takes  place  simultaueoufly, 
and  the  eavily  of  the  abnoess  is  filled  up.  If  the  cure  be  by 
■"  poiutiug"  and  breaking,  the  proceeding  is  different.  The  olh- 
jeot  is  to  conduct  tlie  pus  to  iJio  exterior,  aiid  tlirow  it  ont  as 
R  foreign  body.  Tliis  end  is  aceomptished  by  tho  act  of  absorp- 
tion operating  wllh  principal  activity  near  Uio  surface ;  whib,  at 
tho  same  time,  the  process  of  new  growtli  is  carried  on  effectively 
at  the  bate  of  the  absents.  By  this  means  a  thinning  of  tJio  struc- 
tures intervenijig  between  tlio  superficial  part  of  tho  walls  of  the 
cavity  and  the  skin  takes  place ;  and,  paH  peu«u,  an  increase  of  sab- 
atauco  in  tlie  undemeatli  structures.  When  the  pus  has  thus  been 
protruilitl  (in  a  manner  analogous  to  thu  gron  tli  of  a  tootlt,  or 
eecape  of  necrosed  bone),  the  akin  at  last  breaks,  and  the  fluid  is 
discharged ;  or  if  tlic  skin  cannot  be  reached,  and  tho  lriK'lK>a, 
portion  of  bowel,  bladder,  or  other  outlet  of  the  body,  bo  in  tlw 
tvay,  tho  abscess  will  burst  into  cither  of  them.  Afler  tlie  pus  is 
m'scuated,  tlio  process  of  ropai'ation  continues;  and  the  cavity  is 
eventually  filled  up  by  a  growth  from  thu  bottom,  just  as  an  open 
wound  is  healed  by  granulation. 

If  we  apply  these  princi[^es  to  the  elucidation  of  absoMMs 
fi>rmed  in  consequence  of  caries  of  t)ie  ttpine,  tliey  will  assist  in 
explaining  the  <(iffcrent  eooraos  porsoed  by  them :  how,  iji  «onto 
eases^  tliey  may  be  romovcd  by  rcM>luUon ;  and,  in  others,  by  dis- 
cburgiiig  their  contctita,  at  a  distance,  outnardly. 

It  has  been  ahready  stated  (supra,  p.  832)  that  when  cai-ie«  at- 


843 


DISEASE  OP  THE  SPIKE. 


tncks  the  !»i>in«,  onp  aegmont  alono  is  affected  by  the  morbid 
that  tJws  bodies  of  Uio  vcrtobriu  and  fiijro-cartilagv:*  arc  Ow 
seait  of  the  (li»ca-4C ;  and  that  the  posterior  segment  is  exem 
f»11c>\r!t  fn>n)  this  distiiiutioii  that  the  inHuminutor}'  action, 
attendB  caries,  will  ussumo  tlic  *'  »ujipurative*'  t^'|x>,  lending 
furriintJon  of  absoeee,  in  front,  or  upon  tbo  bodies  aud  fib: 
)a^  i  but  that  it  will  be  of  the  "  adheaive"  or  re])«rative 
in  the  posterior  segment.      It  is  obvioos,  therefore,  that 
dcpoml  on  which  uf  Lbvau  two  forms  of  inflammation  jinxlouiil 
as  to  whether,  in  any  giron  case,  tho  abscess  will  be  larj 
burst  e.\tvniully,  or  bo  circuiiiitcribcd  in  it«  growtli,  uid 
by  resolution. 

It  will  be  preferable  to  eou«i[t>.T,  fSrM,  thomcaso*  in  whi 
patienta  havo  rc<;overed,  without  tlte  absoees  having  iidvau<] 
far  as  to  be  recoj^ised,  and  in  wlii«^4i  tho  only  momortal  ( 
diiiease  has  been  the  deformity ;  secondly,  those  in  which  sa| 
tion  has  obtained  tbo  mastery,  and  tho  nuttor  of  the  abaoe 
been  evuciintcd  tliroiigh  the  »kin. 

Termtnaiioii  o/alfsefsg  in  reaolutvm.  Of  patient*  defermeS 
caricH,  a  lurgi!  iiroportion  will  bo  found  to  liiivu  jui^svd  tbroo 
grades  of  the  disease,  to  have  hod  paraplegia,  and  to  have 
restored  Ui  liuiltli  mid  activity,  without  rigns  of  any  abscess  tit 
nexion  with  the  veitebriE  having  exhibited  tbemselvea.  Tber 
otJien  who,  in  like  circumstances,  have  continued  for  months, 
haps  years,  free  from  nny  i-xtcmal  nWi'^<>;  hut,  at  lastf  on 
beou  discovered ;  at  tir§t  concealed  and  ditHcult  of  doteotlOB 
latterly  buntting  forth  con.*|iicui(ii.''ly-  Again,  in  many  casM 
abscess  will  liave  apiwared  outwardly  at  an  early  period  o 
deformity,  diimhurgiKl,  and  brought  the  jtntJent  to  a  speedy 
'\iV'hcn  wo  meet,  tber^ore,  with  a  ease  in  which  there  has  bet 
manifestaljon  of  ab^ccT"',  wc  are  not  justified  in  concluding  tha 
has  not  existed.  Tho  inforenoc  ought  ratlii^r  to  be,  tliat  an  ah 
has  really  bocii  fonnod;  but  that  it  lias  been  kept  in  subjection 
prevented  from  developing  to  a  largo  size,  by  the  jiroocsaca  of 
lation,  wlticii  have  eventually  led  to  its  j>erfi3ct  romovaL 

It  ia  important  to  observe  how  tJiis  j>roco»s  of  absorption  < 
matter  c^ontained  in  an  abscess  is  favomwl  by  the  in6amm 
affecting  tho  pci»t*Tior  segment  of  tlio  column,  being  of  IIh-  I 
sive  tj'po.  As  uen^oned  before  (supra,  p.  885),  tlw  effect  < 
deposit  of  congulable  lymph  in  the  connecting  ^'(nicturus  b« 
js  to  consolidate  tlie  vertebras,  and  thereby  impede,  or  stop, 
between  them.     Tho  result  is,  therefore,  similar  to  what 


MS 

ttio  appltcatiui)  of  a  splint  to  a  diseased  jmnt,  or  tbe 

'  tlirowitip;  out  of  (uilluH  in  n  fnu^turiHl  bono.     'Die  Hiidni.it!s  »ro  kdjit 

at  rest,  and  protected  from  tlie  injury  to  wliicli  attrition  and  jar- 

wre  apt  to  give  rise.     OontN.'qucntty,  if  tlK^rc  be  «  dispo«ition 

the  morbid  action  to  subsida,  it  is  enconragod.     It  may,  nccord- 

iigly,  bo  iintivipatvd  Uiat  thi^  prixliiction  of  n«w  pas  in  the  abscess 

be  arrested,  and  that  airaorption  of  the  old  will  take  place. 

I  wails  will,  in  thnt  maimor,  lifcomv  c<in(.ntctvd  and  thickened^ 

;  &o  cavity  e^'entiially  bo  fiUod  up  and  obliterated, 

AnlylosU.     But  an  additionnl  process  will  be  tairriixl  on  Htnul- 

ricoujily  witli  those  jnst  mentioned ;  namely,  union  of  tlie  affected 

rcrt«bra'  by  bono,  or  "  ankylosis,"     When  rvparativo  action  takes 

plnoe  in  bone,  whetJter  in  the  case  of  fracture  or  ditioaae,  the  natural 

luct  is  oxsific  mattor.     Consequently,  in  proportion  as  tlic  nb- 

Bc^isM  <lin)iniBhea  by  absorption,  tlie  affected  vertebm'  will  boeomo 

lit  and  fusod  into  on«  another,  as  in  union  of  a  broken  femur. 

Spuriou*  anki/ltktU.  In  a  coin  muni  cation  mitilc  M>ino  yean*  ago 
■  the  writer  to  tho  Patliological  Society,  ho  bronght  forward  certain 
iaclK  to  hIiow  tJuit  aiikyl«»iit  commenced  in,  and  in  numy  cascH  was 
reatrictcd  to,  tlio  posterior  segment  Ho  exhibited  a  series  of  fivo 
specimens  of  Uic  npine  dcformi'd  from  caric-s,  in  which  the  boncK 
had  become  consolidated  and  immovable ;  and  in  all  of  tlit-m  a  con- 
tinuous line  of  os'fifio  union  could  bo  traced  along  tlio  whole  posterior 
aurface,  between  the  laminie,  and  between  tlio  articular  xiu-raccs  of 
the  oblicjuo  processes ;  while  on  the  fbrc-part,  open  spaces,  of  vari- 
ous degreea  of  u'i<[tli,  intervened  between  (he  rugged  surfaces  of 
the  corroded  bodies.  It  appeared  tliat,  owing  to  the  soli<lification 
of  tliii  spine  iiontcriorly,  tho  cohmin  liad  l)een  rendered  incapable  of 
bending,  and  forming  an  angle  sufficiently  acute  for  tho  confronting 
cnilx  of  the  bodies  to  coalesce,  and  oome  into  proper  coaptation, 
for  union  between  tliem  to  take  place.  * 

It  will  thus  be  jieroeivod  that,  in  «onie  cases,  wlien  tho  vertebra) 
have  become  fixed,  and  apparently  soundly  united  by  bone,  the 
junction  luu  been  only  partial;  flint  tho  [HMtorior  Rogineut  alone  lias 
been  coimected  by  oeeific  matter.  As  for  tho  bodies,  ttiey  are  held 
together  by  tlic  remains  of  ttie  walls  of  tho  abscess,  whicli  adlicre 
closely  to  Uieir  surfaces,  aiid  act  as  tigamenta.  An  amorphous,  fri- 
able substance,  not  unlike  putty,  and  which  may  bo  thu  d^-briii 
of  tlio  pua  formerly  contained  in  the  cavi^,  will  fill  Ute  interstioea- 
of  tho  partially  consumed  bodies. 


*  Sec  Path.  Soe.  TVwiu.,  Scsrion  1 847-16,  p.  338. 


844 


DISEASE  OF  THE  SPINE. 


Tnu  aniyforis.  Oii)>ocod  to  this  dc-ri-vtivc  ttiiion  ia  lltat  in 
the  vertebra;  are  joined  by  bony  aub^tjUico  through  th«ir  w1 
tliickneoii.  It  will  bo  found  that  notwithstanding  tJie  whoW 
of  one,  or  two  of  the  prinnijinlly  aifootoil  vertebrs,  together  wii 
portions,  of  greater  or  less  size,  of  the  bodies  of  tho  adjoining 
and  tliy  iiitorvort«;br(il  (■iu-tilng<-«  coiT<>|io»iiing  to  them,  lui\'B 
destroyed,  and  altogether  disap|»carod,  tmo  solid  oiikvlosis 
nevortholoNs  talct)  place  Tlitj  KuHiiccs  will  littve  coalesced,  o' 
the  spine  having  become  bent  at  a  very  acute  angle ;  and 
bo  a  Tttiion  tto  close,  tliiit  several  vcrtcbric  will  b«  f>i*<Kl  into  Of 
another,  and  the  distinction  between  tliem  effaced.  It  will  also  t 
observed,  that  every  trace  of  the  walls  of  tlio  absccAs,  whicli  moi 
have  previously  existed,  will  have  been  removed  by  absorption. 

The  distinction  between  those  two  modes  of  union,  it  is  ob^Honi 
is  of  much  practical  inipartanoo.  Owing  to  the  inaecnrity  of  tl 
jnnction,  in  tlio  "spurious"  form,  there  will  bo  continual  danna 
cither  of  tho  spinal  ounl  being  seriously  damaged,"  or  of  the  in 
perfectly  extinguished  diseaw  being  lighted  up  again,  &om  cam 
violence  to  tlie  Kpinc,  inflicted  in  the  ordinurj'  occupatiom 
active  life. 

If  it  be  now  asked,  how  we  may  discnininate,  in  any  partictili 
case,  between  ankylosis  that  Is  tnif,  or  .'«pui'ii>uA,  it  mnst  he  admilM 
Uuit  our  luiAwer  can  only  bo  conjocturah  In  both  oa«ee,  tbort  nu 
be  an  absence  of  any  outwanl  ap]iO!irance  of  ab«oc«a;  and  tlic  spin) 
BO  far  an  tlio  closest  examination  can  show,  may  be  perfectly  rigid, 
if  the  consolidation  nore  complete     'Hie  only  guide,  it  appears, 


•  A  young  womuti  had  caiics  of  tlic  upper  dorsnl  luid  lower  otnia 
vortebrie,  froro  ivhich  elie  iijoorcred,  so  tu  to  rosumo  bcr  oinplnj'raent.  Tl 
aDKular  dcfomiitjr  beiag  tuuBidenble.  slia  applt«d  lo  a  qitadt,  «bo  uDd< 
look  to  restore  the  liguro  to  iu  itatiual  shape.  The  ohiof  part  of  the  uet 
tnent  consisted  in  fardbl;  sUrt^luUing  the  Ddcli  bj'  nieuhaiiioal  lueaus.  VIm 
inarensing  tho  poiver.  otia  da-y,  tliei-e  was  au  audible  siiAp,  a'illi  mddcn  jnii 
and  the  pntient  was  iinmediittulf  found  to  be  pnriilysed  throughont  all  l) 
body  below  the  necit-  She  di<^d  ^ho^tJ7  dftvrwnids;  and  on  ■  post-moriOl 
exfLiniaalloo,  it  ivas  discovcrod  tlial  the  walls  of  nnenrlj-  obUtcraled  ■!■*«(■ 
ia  front  of  the  bodies  oflhc  eaiioUR  rcrtebrv,  hod  been  extt^naivul}-  torn  froi 
tholr  ooiiiiextuus  with  tho  bones.  Tho  mcdiiiht  was  didlueat.  The  inJl 
ence  dmwn  was,  hat  attliough  the  alTect^^d  vcrtnbiv  bad  beoa  ftnDlr  uniti 
hy  bone  in  iht^ir  posterior  Bet;ineDt,  ibcre  wn«  an  abemtce  of  ouifle  unii 
in  tbe  bodii-s:  that  the  iiiechaiuoal  force  employed  had  b«en  auffieten 
great  lo  niptare  tho  lignmeatouB  Hlruuium  cousiiiuted  of  the  reniaias 
tho  nbaeesBwnll.  wliicji  was  the  only  boud  of  Union  b«tn-e«i)  the  U>dJ« 
and  that  by  the  sudden  clongntiun  thus  produced  the  epinal  con!  luid  be 
iBeci'alcil. 


PSOAS  ABSCESS. 


nceti  of  tho  anguliir  projection ;  nnd,  it  may  bo  added,  in- 
flation regarding  the  [lerlod  of  life  at  which  tli6  diAea.w  xiilMtded. 
Tho  two  priiifijuil  obstaclve  to  tlio  aui*faccs  of  tlic  uppor  and  lower 
ja  of  tho  i)odi<>!i  oomitig  into  codptiition,  proliiiiiniry  to  their 
lion,  arc,  first,  the  natural  infloxibility  of  tho  spine;  secondly,  pre- 
tatiiro  iinicmoftJio  jiosterior  wginont  of  tlio  vcrtcbnc  Now  it  may 
inferred  that  in  early  childhood,  when  the  spine  is  most  flexible, 
will  bi'  fireattr  ])riil lability  of  a  oATcrnous  spmjo  in  thr  1«xiic« 
^of  the  vertebno  being  cffretualh-  closed  by  the  filing  together  of 
tlio  snrfiiwCfl,  mid  of  owitiii  >inion  Rupcncniiig,  than  nt  n  !at«r  period 
rof  life,  when  tho  spine  loses  its  flexibility.  It  may,  therefore,  bo 
[witicipat^Hl  that  tho  ooaleaocnoe  and  ankylosis  in  front  will  have 
place,  before  solidification  can  bave  been  accomplished  in  tbe 
urior  part,  to  inijHxle  tiie  flexion,  in  n  patient  nndwr  ten  or  twelve 
Ijearn  of  age ;  whereas  in  a  grown-up  person,  tho  normal  rigidi^ 
[will  keep  the  imriacen  apart.  It  coincides  witli  this  view  that  Kpinal 
lisoiLse,  although  a  frequent  malady  of  cliildron,  is  mncli  more  rarely 
in  thom  than  tn  adults ;  a  distinction  which  cannot  bo  accountod 
'  for,  Rimply  from  tho  greater  i>ower,  in  the  former,  of  repairing 
I  organic  lesion.  Accordingly,  as  tho  Surgeon  lias  no  means  of 
I  calculating  in  any  particular  case,  how  largo  and  deep  tbe  hollow 
in  the  spine  may  be,  and  is  aware  that,  to  obtain  perfect  imion 
between  the  opixwing  Hiirfiico»,  tbe  iti)in«  must  necessarily  be  I)cnt, 
even  at  an  acuto  angle,  he  abstains  from  emplo^nng  moasureB  that 
might  countenict  tht^  flexion.  On  tho  contrnr}',  he  look»  compla- 
cently  at  the  gradually  increasing  sharpness  of  tlie  angular  promi- 
ncncc  ;  satisfied  tliat,  liowovor  wo  may  regret  tlie  di)>figiiremi>nt,  it 
«    ii  not  an  immitigated  evil,  and  is  unavoidable.     The  friends  of  tho 

I  patient,  ignorant  of  the  proccs.*  of  cure,  or  of  tlio  fonniilahlo  coii»e- 
quenocs  to  be  apprehended  from  tlie  foilure  of  per^ct  ankj-laiis,  are 
novcrtheleits  a])t  to  express  dissatisfaction  at  tlie  apparent  neglect. 


Paoa*  jihtcem. 


Wo  now  arrive  at  tlic  consideration  of  those  spinal  abscesses 
I'Vhich^  inHlead  of  yielding  to  tlie  prooei(i*e!>  of  alxwrption,  enlai^go, 
overstep  tlieir  original  boundaries,  and  travel  great  distattces,  so 
UK  finally  to  cvacuato  tbeir  eontentii  oxtcninlly.  Tlierc  are  certain 
I'arieties  in  the  course  which  tliece  large  abBoc«9es  take.  Tho  nioHt 
fiTviiieiit  direction  is  in  the  line  of  tho  psoas  muscle.  Another  eoni- 
moii  ilircction  i.i  iKiekwnriUy  in  the  lumbar  region.  DiHiimH  nainct 
have  been  given  to  the  abscesses  according  to  tlio  roole  tliey  follow. 


SAC 


DISEASE  OF  THE  SPIKE. 


It  b(  proposed  to  adopt  tlic  "■  p«oa8  nbscoM"  as  the  hrptoal 
and  after  Itavtng  |>ointcd  out  its  pmicipal  diameters,  to  treat 
of  tiu!  voriotiee. 

Tlio  term,  pwas  fttxiocwi,  vtoA  first  aiijiltivl  iiixlvr  a  mi 
notion  that  the  collection  of  matter  wliicli  takes  the  course  of 
mosclc,  actually  originiLttid,  indviwiKlRntly  of  disc(t««  »f  the  ispi 
■0  its  interior.  But  it  is  now  generally  admitted  that  tlie  aouros 
tlio  abwcM  miiy  ulways  tiu  trncr<l  to  uu'ivs  iu  tln^  belies  of  ona 
more  Tertebne.  And  it  ia  frequently  found  that,  while  tlw  «oII 
lion  in  of  lar^je  dimonwms,  tlie  ]iortion  of»ijiiiu'  diseased  is  siu 
luid  apt  to  be  ovorlookod*  A^ain,  the  origin  of  tlio  nl)t<cvN»  ia  ] 
confined  to  rcrtobrip  with  which  tiio  inusclo  i»  in  rt?latJon :  tli 
tn  no  part  of  tho  .ipine,  from  the  upper  dontal  downward,  when 
it  may  not  start.  And  in  it«  dosctint  it  does  not  stoj)  wlierc 
muKctc  «;a»io» ;  it  j;eiierally  extonda  u|K»n  tlie  thigh,  and  itiay  boir 
to  tlio  ven-  knee. 

It  will  be  vonvtmieitt,  in  dMoribing  psoan  alitwo«K,  to  snppoai 
cose  in  whicli  the  diseased  vertebne  are  sitnated  sonicwliero  in 
donal  region. 

It  might  bo  eonoeived  tliat,  when  a  eolleotion  of  mnttor  i 
thns  gathcrod  behind  tJio  ])OHtcrior  inedia«tinum,  there  woukl 
danger  of  its  oomprt-saing  tlio  traelioa  or  msophiigm*,  and  thri* 
OBiuin^  difficnlty  of  breatlting  or  of  swallowing.     But  ^'fl'ix^ta  i 
that  kind  are  randy  ob«erx-0(l ;  and  tho  rciuton  is  obvious.     At  I 
name  time  that  tlie  abKiees  is  formed,  the  spine  (x'IkIs  rorwaid  at 
unglo  J  iwcordiiiRly  all  Ili«  structure*  in  l'n>nt  iH-conie  relaxed,  ill 
yield  readily  to  the  aeeumulated  fluid.     It  is  the  same  flexion  vrlii 
detennincs  the  pii.s  in  tliu  nbiMi^eiw  to  descend ;  for  not  only  are  I 
tissues  on  fJie  fore  part  loo-tonwl,  but  the  upper  part  of  iltc  sfiino, 
it  fuUs  down,  acts  in  pushing  the  contcmts  downward.     3Joreaf 
thfl  walla  of  the  eht^t  behind  are  an  impoiietntble  banior  agail 
the  pUK  travelling  bnekward.f 

In  eert^ii  ca^oH  Uio  abi^cesa,  as  i«oon  oi^  it  begins  to  onki 
downwardly,  bifiireates ;  and  one  collection  of  pus  travi'U  ak 
till;  IkkIios  of  Uio  vertebra;  on  one  side,  whilo  anotlier  ke<^ 


•  See  Brocli«  on  Ktratt*  of  ike  Joint*,  cd.  16&0,  p.  388. 

t  The  'n'rit«r  cnn  recollect  only  one  rnKC  in  which  the  nbcc^M  pSS 
and  bivko  poNtorlorty  between  the  ribs  ifijoininc  Iliu  nnRuJar  defcimii 
])iibbli?8  of  air  floated  on  the  jm*  nt  onrli  of  llm  two  otTAcv*  ;  nnd 
ivcvo  dinivii  inivaiJlj'  at  eath  jaspivation.  but  propelled  oatwnrdly  nt  e« 
cxpiratiiiQ. 


PSOAS  ABSCESS. 


ritti  it  on  tlio  opposite.    Both  i>omotim«fl  reach  tho  thigh  simullnne- 

ily.     It !«  mon*  ronimoii,  hfiwuver,  for  one  alono  to  (U«c<-ti(l. 

Perforation  of  th^  iliajtliroffm.     Tho  waits  of  an  abaoesa  formwl 

tlio  <l«r:tal  n'gion  are  covorpd  anu^riorly  by  tlio  parietal  pk-ara ; 

as  they  bun'ow  beneath  it  U>  iho  convex  floor  of  tlie  thorax, 

encounter  tlie  diaphra^^m.     This  obstaclo  tu  ite  prof^rcss  tho 

bsc^ss  overcomes  by  a  vital,  not  mechanical,  act.     The  Gmt  step  in 

process  con»tfits  in  tlie  walls  adiicriiig  hnaly  to  the  (nirfoce  of 

diaphi'ngni ;  tlio  next,  in  an  ojiening  being  niatlo  by  ab.<wjqtUon 

Ji  through  the  abscess  and  muscular  iwptum.     By  such  means 

pus  gains  iiccesi!i  to  the  abdominal  region  behind  Ute  jiarietal 

ritona?um ;  and  it  Is  obviouit  tliat,  owing  to  tlio  union  established 

ireen  the  ab^ceaa  and  septum  Iwfore  tlie  p<>rfonit!on  is  effect«I, 

danger   of  uxtravasation  of  tlio   fluid  during   tlic   pa»uigo   is 

Dided.  '^ 

33m  point  at  which  tho  opening  in  the  diaphra<nn  h  made,  is 
the  »itua(ion  of  the  lignnientum  arcuntnm.  It  is  oIao  Ui  bo 
ifcd,  tliat  from  that  ligament,  and  the  sides  of  tho  neighbouring 
rertebrtc,  tlio  pftoa-*  muKcIc  nri^tw  bj-  di^tinut  fa-scieuli.  It  rullows 
this  juiitapositiou  that,  according  as  tlio  absce&s  protrudes 
ntong  tl)0  jmrti*  immediately  behiw  tho  diaj>hriigm,  its  witU*  |x'ne- 
ats  between  the  difttinct  headu  of  tho  psoas  muscle,  and  to  a  cer- 
lin  degree  split  tiK-m  asunder.  In  this  manner  an  expansion  of 
lo  miinclo  in  prodnonl  by  llie  suoocH^ve  additions  of  pus,  and  an 
■I^mation  takes  plaee  bctwtN?n  its  fibres  and  the  walls  of  the 
Hence  the  puias  muscle  gradiiaily  bi^comes  hollowed  oat 
tho  centre,  and  dilated  in  its  sides,  till  converted  into  a  bag  of 
Oua.  Hern  it  may  bo  briefly  ti'iticinl  tliat,  after  tlio  perforation  of 
he  diaplmigm,  tho  most  depending  part  of  tho  abscess,  instead  of 
burrowing  along  tlie  ji^ous,  may  bn  deHocted  backwardly,  and  work 
passage  through  tho  abdominal  paiHetes  in  tho  <lin>ction  of  tlto 
linn.  Tlie  col!i>ction  of  pus  thii-*  pn-Acnting  it>telf  sujkcrfioiallv,  will 
E>htaln  the  name  "  lumbar"  abscess,  and  will  be  treated  of  distinctly 
llien'iiiler. 

The  dilatation  to  which  the  psoas  muscle  is  subjected  by  tba 
rudually  iiierca^'iiig  necmnulaliun  of  matter,  varies  according  to  tliO 
Jensity  of  the  oelluUr  shcatli  which  invests  it.  That  envelope  is 
Pfbnnod  by  tho  splitting  of  the  iliac  fascia  into  two  layers;  wltereof 
one  passes  in  front,  an<l  the  otlier  IiehiniL  Tlic  former  layer,  as  it 
ttu-ns  over  tlio  belly  of  the  muscle  to  tine  its  inside,  acquires  great 
strength,  and  is  united  rcr}-  finnly  to  the  edge  uf  thu  briui  of  ttw 


848 


DISEASE  OF  THE  SPINE. 


tmo  pelvia.      Otitwiirdlr,  on   the  votitnry,  tho  sheath    is 
Hencs  in  fifTcctunl  Fetiistanca  is  prceonled  to  the  enlarge 
the  abooeao  inwardiv ;  but  u  similar  opposition  U  not  offorcii 
on  the  otitflufi>.     It  ai?<!ordiug1y  follont),  that  in  proportion  k» 
pus  incrcaaes  in  quantity,  it  tfinds  to  hurst  forth  under 
&«ctn,  in  tho  direction  of  tlie  crcitt  of  tho  iliutn.     By  that 
hone  exteriorly,  and  tho  prominent  nnited  boUy  of  tho  psoas 
iltiwtu  inteniuN  imwclo.*  inU-nially,  tlte  lowest  or  most  dcpei 
part  of  tho  abscess  is  guided  in  a  groove  to  tho  level  of  Pou] 
ligamcnL 

Abscess  Khile  in  tite  il'tac  fw/iwi.  Daring  this  part  of  its 
namdy,  while  tho  nbM<es«  \»  utuatod  on  tlw  ventre  of  tho 
within  the  i>elvis,  it  ia  important  to  know  tliat  ita  presence  ean 
rvc>ogiitMxl,  oven  bcfiiro  it  ha«  attained  a  targe  size  The  cxami 
tion  is  to  be  conducted  hy  relaxing  the  ahdominaJ  miLtcleo,  i 
dirocUnr;  Hvi  fingcin  agtunst  the  iliac  rof^on.  By  carrring  til 
over  the  inner  edge  of  the  creat  of  the  ilium,  and  tliru^Ling  til 
deeply  and  inwardly  onward,  a  hard,  round,  well-defined  awoUi 
of  an  elongated  fonn,  and  occupyini;;  the  8i(e  of  (ho  p»ocui  l 
ih'acuft  intemuH  musclee,  may  be  fdt  and  snnnount«d  hf  tl 
pomta.  If  tracetl  downward,  the  iii\-elling  will  bo  found  abtitt 
against  tho  abdominni  parictes  above  Poupart's  ligament.  Pen) 
sion  will  iiH-ii^t  in  riintirming  i\\v  ili)ignoi<i8. 

When  an  ahst-oss  hns  reached  the  iliac  region,  it  ia  not  l 
common  fnr  it  to  \tv  arrfNt(<d  in  ittt  progress,  and  to  bi':  dcv«ta|| 
tliere  to  a  largo  size;  so  as  to  form  a  distinct  prominent  aweOi 
which  may  oitlitT  burst,  or  terminate  in  rosoluliou. 

I'assar/f  widrr  Poupart'n  lUjamfHl.     I'«oa.i  altaccsia  cxhihitit  gl 
conKtaTKy  in  tlie  point  of  its  cmergipncc  from  tlio  interior  of 
abdominal  walla.      Tliat  {turt  ia  n  narrow  space  under  Povpid 
ligament,  between  tho  unttod  bellioa  of  tlio  psoaa  and  Uiaous  i 
niia  muscles  and  the  inlerinr  anterior  spinous  proc«iss  of  the  ilr 
Boforc  the  transit  is  commenced,  there  ia  commonly  a  conaidei 
amount  of  general  awolling  in  the  inguinal  region.     It  has 
scon  that  iti  the  course  of  perforating  the  diaphragm,  adltceiofl 
place,  as  a  prcliminari'  step,  between  tho  absocss  and  tlio  part  Im 
pierced ;  so  it  is  in  the  passage  beneatli  Ponpart'a  ligament : 
walla  of  the  abscess  are  united  to  tho  abdominal  porioles,  alx»o] 
succeeds,  and  an  opening  is  thus  made  fur  tlic  pius  to  t?sca(ie  u 
tho  groin.     Wlien  the  most  dei>endiug  part  of  the  collection 
trudcs,  an  immediuto  thickening  and  eondcnsatioD  of  the 


PSOAS  ABSCES& 


849 


ti)wu<.'»  in  tlic  Dcighbourliood  takes  plaoo,  to  fcrm  new  and 
ng  walls  for  coiitiiiniiig  tlio  jmt<." 

Descent  oil  thigh.  When  a  pttoas  abscess  has  cinergod  on  Uie  groin, 
jw  llio  outer  tiiird  oC  Fo\i[iart'»  ligament,  it  may  either  culorgo 
B,  or,  beforo  incroasmg  much  in  sixe,  descend  on  tlie  thigh.  In 
[the  comiDunuMnunt  of  ittt  course,  it  abutjf  against  tlio  origins  of  tlio 
'  Bartoriua  and  t«nsor  vaginae  fenioris ;  tlicae  coiumonlv  arrest  its 
IjTogrcss  outwardly,  and  incline  it  inwardly.  Ueitco  the  most  fre- 
1  quent  direction  is  obliquely  across  the  thigli,  ui  the  line  of  tho 
rsartorius  muscle.  Uut  tlic  course  downward  is  »utijei>t  to  vaiiety; 
[SOmctimeH  tlie  abaoess  turns  abruptly  inwai'd,  at  the  groin;  occa- 
uonally  outwanl:  and  case*  arc  met  with  where  the  collection 
lividcs^  one  part  passing  straight  doivn,  and  another  quite  to  Uio 
Ipatitidc. 

^*  NefJ:"  of  ihf  abtei-M,     On  tlio  analogy  of  hernia,  tlie  part  of 
[tlio  cavi^  situated  between  the  upcaiug  in  tho  groin  under  Pou- 
l.{KUt'fl  ligament,  and  ilie  expaiiHiun  ou  tlie  tliigh,  tiuiy  bo  termed 
[tbo  "neck."     Tliis  [rartion  is  subject  to  considerable  vnriatJon  in 
>itit  width,  in   ditforent  ctLtos.       Directly  after  tlio  de-iicent  of  an 
abscess,  especially  of  a  rapidly  onlargmg  one,  it  may  bo  capacious 
end  cHiiily  i-ecogn!sc<l.     But    it   Imit  a  romurkulile  di-^pwdtion  to 
contract;   and  that  narrowing  often  takes  place,  wltliui  a  short 
time,  »o  eRecttiidly  that  idl  l-roee-s  of  tJie  coinmiinicjition  will  tw 
lost.     It  appears  as  if  tlio  pus  originally  pent  up  in  tlio  parent 
abscess,  having  burst  through  tho  eiiiof  harriers  to  its  progrws, 
the  diaphragm,  and  abdominal  pariote^,  had  found  fi-eo  scope  to 
'  flow  into  tho  comparatively  looao  and  yielding  sti'uctiiiWi  fif  tlws 
thigh ;  and  that  tlie  walls,  being  relieved  of  tlioir  former  tension, 
had  collapsed  and  become  contracted.     It  is  obvious  tliat  tlie  con- 
dition of  this  intermediate  chamiol  will  have  a  decided  influence, 
as  feeder  of  tho  lower  compartment  of  Uto  absccw,  on  tho  mto  of  its 


H        *  In  his  work  on  /Kmokw  <if  th*  JoinU  (p.  i61}.  Sir  B.  C.  Brodio  rcfora 

^Kto  en&cit  ia  wliicli  pui't  of  tb«  pus  of  a  paoas  iibsecM  liml  sot  ucnnss,  in  its 

B  passage  throii};!!  tlic  nbdoraianl  wnlls,  to  the  s})cnnatic  mnol.  and  appeared 

^■.mporfl daily  beyond  thr.  external  rinn,  liico  nit  in^iinal  hcmin.     Thn  writtrr 

^^witiMMed  onn  cftsn  of  n  simitar  kind,  in  which  tlio  lumoui-  reached  lh« 

Upp«r  part  of  llto  scrotum,  and  wh  associated  with  a  m«r«  gcurnJ  ttwelling 

abova  Pouijart'a  ligsmeut.    Tho  lumbar  Tortcbns  proved  to  bo  diseased. 

and  the  awoUiiii'  a  psoas  abscess,  from  the  olTeats  of  which  the  patiout  even- 

Inatlj  died.    But  owing  to  tho  absenoe  of  paiii  or  angular  deforiailjr  in  iho 

loins,  Uiu  iialuru  of  tho  vnaA  had  at  fimt  bitea  mistal:e»;  aiid  iii«  tumour 

was  auppoHtfci  to  be  a  nipture.    Tim  riiziditj  of  lb«  spiiw  at  the  itfft'et«d 

Eie  chief  diagnostic  sjrniptom  to  sliow  tlio  existence  of  caries, 
n.  3l 


850 


DISEASE  OF  THE  SPINE. 


otiltirgcnient :  facilitating  Uio  growth  if  cipncious,  am]  retarJing 
if  constricted.  Again,  wlicii  the  neck  is  so  greatly  redui 
dimensions  as  to  l>e  hid  from  obM>i'i,-atioii,  it  W(U  to  tl: 
pandvd  jiart  in  tho  thigh  appoaring  to  bo  an  inxulatod  »nd  dia^i 
ab.40S3S.  And  *o  di.-W[)tivo  1.5  this  dinractor,  that  tlm  S 
is  liable  to  mistake  tlie  soeminglj'  ciroumsoribed  swelling  for 
collection  of  pus  fornnil  directly  in  the  part — sui  a  chronic  al 
or  suppuration  oounoct«d  witli  diseft^ed  femur — and  to  ncglevt  look/ 
ing  to  the  spinu  for  its  source  When  he  comprosscs  it  with 
bands,  for  tlio  ]>uriK>.«fl  of  expelling  the  contents  back  along  llu 
spine,  he  nmy  find  that  the  canal  is  too  small  for  tho  floid  to  pas^ 
or  oven  for  it  U)  be  brought  into  view,  by  diKtcnniou.  But  io  otliui 
eoaes,  tho  swelling  will  diminish,  if  it  and  tlio  limb  be  firmlji 
bandaged  ;  and  it  will  recover  ita  former  *ho  hy  gravitation,  apoa 
the  roller  being  removed. 

EvaeiMtion  of  a  p»oa»  abmeig.  WhoTi  an  ahsecss  extends  from 
near  Uie  middle  of  the  ^ine,  a  considerable  di^^tunco  down  tht 
thigh,  and  the  walls  are  at  one  part  in  contact  with  carious  bonei, 
termination  by  rctwlution  can  scarcely  be  cxpectxxl.  Kxpcrienvfi 
proves  that  if  sudi  modo  of  core  is  ever  mot  with,  the  cases  ai» 
about  the  rarest  in  Surgery.  It  appears  inevitable  that  the  pnt 
must  bo  discharged.  And  tliat  may  bo  eScctod  either  hy  the 
nntunil  process  of  acimiinatlon  and  burvting;  or  by  the  interior- 
euoe  of  the  Surgeon. 

It  has  been  already  said  that  t  lien;  is  great  varie^  in  the  ra,pu 
with  which  psoas  abscess,  eittiatod  in  Uie  thigh,  enlarge.-!.  In 
cases  the  increase  is  ho  distinctly  marked  (hat  a  citange  will  bv' 
perceived  almost  daily;  in  others,  so  slow  (hat  it  will  be  diffii-alt 
to  discprn  any  ditlbroncc  even  in  weeks.  It  will  depend,  tJiert-fore, 
in  any  particular  ease,  u|»on  tlie  rate  of  growth  of  the  abscess,  as  ta 
the  period  when  it  will  bo  mature  for  giving  vent  to  tho  matter. 

When  tin?  Surgei^Hi  observes  n  inrgu  giilhi-nng  of  pus  advancuip 
and  progressively  undermining  new  structuras,  be  19  promjrfed  t» 
eiideiivour  to  limit  the  mischief  by  letting  out  tho  flnid.  AceonJ 
ingl'y!  it  is  the  common  practice,  when  obvious  ibat  the  ordinary 
loonl  applications  employed  for  subduing  inflammntion  and  promot- 
ing ahsorplion  have  l>een  ineflicaeions,  to  puncture  and  t-ineiiate 
the  mutter.  For  an  account  oftiio  dilTcrent  modes  in  which  ihi* 
ojicration  may  be  jn^rformcd,  the  reader  is  referred  to  tho  articla 
AUSCES»,' 


*  Vol  I.  p.  1«9. 


OPENING  PSOAS  ABSCESSES. 


^V  Afler  file  Kbsccs.t  litis  Ixnmi  cin])tiod,  it  is  usual  to  att«inpt  to 
^vprocurc  immediati?  union  of  the  wound  by  bringing  iho  lip*  togellier 
^ftvilli  luihcstivi;'  strapping.  It  i»  hopixl  that,  by  closing  tlio  orifico 
^■vheQ  tlte  n-alU  are  tliuit  rontroctod,  the  proixut*  of  abMjr[>tion  in«y 
^Bbe  caiTi<Kl  on  with  siioh  incrcnscd  nctivlty,  that  it  will  prevent 
^Hreaocumiilation  of  die  ptis,  anil  leud  t<>  the  oblitcratioit  of  tho  oitvity. 
^fiBut  disappointment  almost  invariably  awaits  tis.  It  is  found  that, 
^Hwe  a  few  daytt  have  {iaf»e(l,  tlie  »wolIing  ha.t  rctiimod ;  and  it  is 
^HMbeaxary  to  repeat  tho  puncture.  Tlio  same  thing  will  occur  many 
^Ktimes ;  and  at  length  tho  wound  bunt  niitile  will  refuse  to  unite, 
^■3^  result  ovontually  is,  that  an  orifice  is  established  for  the  oon- 
^ntont  dinchargo  of  pus  from  thu  abiiciiw*.  E^jH^riencc  of  tlicsc  nu- 
^■ZDeroos,  almost  constant,  failures  of  llio  attempt  to  disperse  such 
^^Hii^-sizod  ab»co-!ii<cs,  connected  witli  (liM.'a»ed  vertuhnv,  by  frcqticnt 
^^PoBOture  and  closure  of  the  wound,  lias  induced  other  Surgeons  to 
^ny;linqui»h  tlio  plan ;  and,  by  tniKting  mora  fully  in  nature's  pro- 
^■oeedinga,  to  let  tlie  pus  gradually  discharge  itself  by  pointing  and 

ulocration  of  the  skin. 
^^        Contet^lire  j'lVfr.    But  (hifl  question  of  the  local  mnnagomont  of 
^paoa«  abscess,  whetlicr  of  tho  aeuto  or  chronic  typo,  cannot  be  dis- 
cnsaed  ap»rt  from  that  of  the  constitutional  disturbanco  which  tboy 
are  prone  to  produce,  whenever  a  breach  is  made  in  their  walls. 
Notliing  i.t  more  xtrikin^  than  tho  oontnutt  in  tho  condition  of  a 
patient  who  has  long  carried  a  large  oollootion  of  pus  in  his  tiiigh, 
without  visible  injury  to  his  bculth,  and  his  state  when  that  abNCf^ 
has  either  burst  of  its  own  accord  or  been  emptied  by  the  trocar. 
The  time  varies  at  winch  tho  consceutivo  fo\-er  may  bo  fully  wttab- 
KIiKticd.      Sometimes  one  or  two   days  only  elapse;    at  others,  a 
Hiroek,  or  fortnight.    But  the  patient  si^ldom  cj«a{)cs  altogether.    Ho 
Hiia  ftcised  witli  a  fever,  in  which  high  action  prerallft  for  a  short 
^bime,  but  which  early  leads  to  dangerous  dt-pression.     At  the  com- 
V|mneem«nt  ho  has   thirst,  furred  tongue,   henilache,   cold   chills, 
rapid  feeble  pulse,  hot  skin,  want  of  appetite ;  followed  soon  by  pro- 
viso perspirations  and  diarrha>a;  then  luicoix^  a>dcaia  oFtfio  Ic^ 
and  extensive  bed-sores.     It  is  in  these  cases,  as  in  absceaaos  from 
diseased  hip,  &c,  Uiat  wc  so  frequently  Gnd  lli«  liver  cnlurr^  to 
immense. tllinonsions;  and  wlien  death  has  carried  the  patient  off, 
that  organ  Is  seen  converted  into  a  fatly  or  waxy  Etrueturc,  or  one 
which  conibin&i  tJicw  two  mari>id  conditions^ 

A  satisfactoty  explanation  has  not  hitherto  been  given  Iiow  Uie 
formidaUo  results  jnat  descTil>ed  should  follow  the  evacuation  of  u 
psoas  abscew,  or  other  Iiu'ge  coU«ctSon  of  pus.     Tho  theory  gene- 


85S 


DISEASE  OF  THE  SPINE. 


rally  adopted  m  to  tlio  rfTcci  ttuu,  when  a  breach  ii 
ntilU  of  an  abscess,  atmosplicric  air  ffci*  mhnittarux  into  Uio  i 
riov ;  that  a  chemical  change  takea  |>koo  tn  tlio  [>u)i  from  ihe 
mixture ;  that  the  fluid  i»  ritintcd  hy  tho  c-haiige ;  that  the  pus  tl 
rendered  Hiihi-althy  i*  ahsnrhfil ;  iin<l  that  tlie  ptviiliar  fever  whi 
»  HO  commonly  fatal  arises  from  Uie  poisoned  condition  of  I 
blood.  But  many  renwiiK  iiii;;Iit  Ix^  ur^^I  against  tliat  view.  Si 
fioc  it  to  say  that,  in  tlie  case  of  empyema  acoonipiuu«d  w 
pneumo-tlionix,  the  air,  csca]>od  from  tito  Itmg,  is  elaboniti 
utirred  up,  or  chiirnod  in  the  cavity  of  the  pleura,  by  tho  motil 
of  respiration,  with  tlic  pus ;  and  tliat  yet,  when  tLe  fluid  is  i 
aorlied,  wo  liiivo  no  !«ymi>toms  of  poi.4oning  of  tlio  blood,  or 
hectic  fever. 

It  is  an  iiit«re»Ung  fact  coniKvled  with  tliis  question,  that  il 
mediately  after  tlie  evacuation  of  a  large  abseesd,  lift  internal  lini 
incinbrnnc  begins  to  secrete  pus  more  copiously  tlian  before, 
oxaiR[>lo,  an  abftcess  may  linve  remained  iiUtionary,  pcrliapt, 
weeks,  showuig  that  it  could  not  have  received  additions  of  inatl 
for  that  time;  IxititniUWJmind  that,  about  tliencxt  day  after  il  ll 
been  opened,  a  rjuantity  of  pua,  equal  to  what  had  been  didchar^ 
at  first,  will  be  thrown  out;  and  tlinl  the  same  amount  wiD 
formed  every  twonty-fonr  hours  for  many  eonsecntive  tluyft ;  till, 
tlio  piiticitt  gets  weaker,  it  nill  gradually  decrease.  Now  it  is  d 
dent  that  tliia  increased  uetitity  in  tlie  scej^ion  must  be  tlto  om 
Hcijucnco  of  un  .icccssion  of  uiflammation  in  tho  pyogenic  membra 
of  the  abscotw. 

How  has  that  influmniatoi^-  action  been  excited?  Ifweooi 
trast  tlic  Htructurv  of  the  u-nlis  of  an  absccM  with  that  of  tbe  on 
of  any  of  the  liollow  viscera,  an  answer  will  pcrha[»  be  toai 
The  atomacli,  urliiaty  bladder,  &c,  aro  designed  to  expaitd  as 
owtenta  inerea^e,  and  to  contract  in  expelling  them.  A  [w: 
ney,  therefore,  be  drawn  between  them  and  an  absocsa.  In 
natural  ea\-itiea,  it  i»  known  ihat  the  mueoiu  membrane,  aniJi 
to  llie  jiyogeiiic,  is  attached  by  loose  connecting  tissne  to  the  mi 
oular  coat,  analoj^nus  to  (iic  buwmcnt  of  tlie  abscess ;  and  that 
object  of  this  inten'ening  tissue  is  to  allow  tlie  maoous  ooat  to 
either  ditttended  or  corrugated,  according  as  the  viscus  is  fuD 
6inpty,  without  injury  to  ita  blood-vcssel-t,  nerves,  or  own  i<tnic4ud 
Tlio  abscoHs,  howu\'or,  has  no  cellular  ooat  IDio  [tyogenic  mei 
bnuie  and  ba-seineiit  are  Kolidi}'  united  together.  No  provisid 
tliereiiire,  is  made  for  tJiat  dehcate,  soft,  thin,  and  vascular  ct 
being  tluxiwn  into  folds  during  contrnetion,  or  gently 


expand 


JAR  ABSCESS. 


Muring  dilatation,  irrcepcctivoly  of  the  ba^cmmt.  Howevnr  grcBtly 
Iraiposed  to  each  otbi-r  in  piiinl  of  iiticiie<).4  of  ntnicturo,  tbo  two 
narU  move  compactly  and  ctjnally.  Again,  whcrcns  tlic  »ti)inncl) 
■•ikI  bladder  nro  tireo  to  ox{>nnd  or  contract  in  u  common  cavity, 
wkfi  abdomen,  tbo  abecons  is  adherent  all  round  to  luiinelding  adja- 
mBtt  structure,  whicli  rcAlntiii  itt  iniiviTiiuiit.i  iriv^ulirly.  ^Vhon 
nhoAO  circumslancwi,  all  so  mifavoiirablo  for  tbo  altcmat©  dilatation 
land  closing  of  t1i<^  widl*  nf  tbo  nbiioi>st<,  are  eonxidero<l,  it  oiin  bo 
I  tiudcrstood  that  both  Irom  tlic  act  of  contraction,  when  the  pus  in 
tevaciiiitcd,  and  from  L)iat  of  cxpan.tioti,  when  tbo  fluid  ucctniiiilatcs 
lagain,  they  will  be  subject  to  much  internal  uijury, — that  in  tJie 
rono  co-Hc,  llio  pyoj^i^nio  mt^mbranc  will  bo  com  premised,  orvflhed, 
went,  and  cracked ;  and  in  tho  otboi",  ovcrsti-otclied  and  torn.  Such 
nxteiiMvo  damage,  it  is  rt'aMonablo  to  su]>po»c,  will  wt  up  intlan)nia- 
itory  action ;  from  whidi  constitutional  disturbance  of  tho  most  for- 
Ituidubto  kind  nun-  well  be  apprehended. 

I  VarkeUa:  I.wntiar  affcetr.  When  a  spinal  abscess  proscnts  in 
Itiio  Ioin:t,  it  f;otN  its  name,  witliout  regard  to  the  situation  of  tbo 
[  carious  vcrtcbrto  whero  it  conmiCMUHid,  from  tlie  locality  at  which  it 
Lboooiiic^  Nupcrfieial.  It  has  been  stated  aboro  (p.  847),  that  wheu 
u  collection  of  matter  deHceiiding  from  M>nic  of  tho  dorsal  verl^'Iiru 
)iAil  perforated  tho  diaphragm,  and  was  no  longer  restrained  by 
tli6  ribs  fimm  pa.4Min(r  posteriorly,  it  might  penetrate  baekwanl  and 
appear  upon  tho  loins,  instead  of  burrowuig  into  tlie  paoaa  muaolo. 
It  has  tiio  .<aiiu>  choice  if  the  cli^caso  be  in  tho  lombiir  vertebra*. 
:  Tho  pus  Dtakcs  iis  way  directly  to  tlie  back,  between  tbo  Uxt  rib 
I  »nd  ortst  of  tho  ihum,  chiefly  by  perforating  tiie  ijundratus  lum- 
rhonim  musele.  Tho  orifio*?  thu»  uiiicio  is  of  small  siiMi  eomparod 
Iwith  the  dimensions  of  tho  nwclling  when  it  reacliL-s  the  snrfaoi>. 
[Before  the  collection  arrives  at  iJic  back,  it  meets  with  opposition 
[from  various  dciiw  fa«ciit>  and  tendinous  ap<)n<rnr«se»,  which  d«fleot 
lit  in  diflereut  directions,  and  canae  il  to  assume  a  broad,  rounded 
r»p)>enrnncc,  with  »light  ole^ition.  The  boondnrics  of  tho  ubsocwi 
nsualiy  are. —  tho  lowest  rib  .in]jeriorly,  the  orest  of  tlio  ilium 
I  iijferiiirly,  tbo  sucro-himbalis  hitornally,  and  tbo  edge  of  the  ex- 
I  temid  abdominal  obliijuo  externally.  In  nil  osM>ntial  clioractera, 
'K  lumbar  may  he  regarded  as  a  modified  kind  of  pfoas  abH?c*s; 
-uid  it  \3  not  i-arc  to  find  both  on  the  same  side  in  ttio  samo  ]iattcnt. 
'  Sometimes  a  portion  of  the  proper  wall  of  a  lumbar  absceM  givcH 
[way  eloso  upou  the  outer  edge  of  tho  crctit  of  the  ilium,  so  lu  to 
1  allow  a  portion  of  its  eoutctita  to  dcnoGiul  over  the  pehis,  beneath 
tiho  fascia  of  tlie  glutteus  medlus,  causing  a  diffuse  swelling,  difii- 


&54 


DISEASE  OP  THE  SPINE. 


cult  of  recognition.  The  progress  of  the  atxtccsa  toward  pomta 
luiil  liiirHlitig  U  commonly  slow.  When  tfao  matter  has  been  di 
charged,  the  waIIm  cuIIujim!;  mid  owing  to  tli«  rdiitivdy  irniall  si 
of  Um  (icep  orilicc,  a  narrow-,  direct  diannel  Uirougl]  tho  abdoinii 
parietc&,  coramuiiicuting  vrittt  the  cavity  uf  tlic  abeccss  in  tlno  il 
tenor,  takm  the  place  of  the  former  external  abscess.  "OM  nn 
ia  not  proiio  to  c1o»c  up  and  hcnl,  but  g«n«ally  continites 
cliarge  puei,  which  varies  in  <]uiiiitily  according  to  Uie  oondii 
tbo  disease  within.  Ilio  patient  is  subject  to  tlie  same  oHistitatiaD 
fever  lifter  the  cvticiiatioii  of  the  ootiliftntt  as  in  pwiu  ttb«ov«s. 

Abscess  in  the  cervical  mjitni.  Disease  aifecting  tlie  two  uppa 
most  Tcrtcbrgu  of  Uio  iic«k,  the  atlas  and  axi«,  hna  certain  sped 
diaracters;  and  it  will  be  treated  of  scparuicly.  If  tW  t>odi<Bi 
any  of  the  othor  rvrtcbnt;  be  attacked  by  ciirit-s,  tiie  abscess  wUl  tan 
aa  elsewhere,  in  front.  It  might  be  tJiougfat  that  a  collcctten  i 
pus  in  that  situation  would  cause  obetruction  to  tho  breathing,  1 
compressing  the  Iniciieu;  or  difficulty  of  swallowing,  from  presm 
on  tlio  ozsophagUB.  But  owing  to  tlio  sptno  bonding  forward,  bol 
tlioHe  tube*  have  room  to  yield,  ami  c-*«i|ie  before  the  swdii 
and,  consequently,  neither  function  is  disturbed.  Moreover, 
tlio  alittecMti  Iios  a<tvanccd  a  sliort  distanoo  in  front,  it  changes  i 
direction :  expanding  laterally,  at  first,  and  tliej)  |Mst<Ti<irly. 
tlie  wflllM,  in  trnvtilling  obliquely  backward,  cncounier  the 
plexus  of  nerves,  the  patient  niiiy  be  found  eompluining  of  jniD 
weakness  in  tiic  upper  extremity,  while  all  other  parts  of  the 
are  free  from  stioh  symptoms. 

Ahst^Mte  which  discharge  their  content*  ly  the  litnfft,  intertme*,  ^ 
The  writer  w«*  conHullcil  in  llic  case  of  a  boy  affected  with  aognli 
deformity,  the  apex  being  formed  by  (ho  spinous  prooeaaes  of  tl 
fourth  and  6flh  dorsal  vertcbne^  Five  years  bcf(>rfl,  when  tl 
deformity  eommeneed,  ho  hatl  been  confined  to  bed ;  but  Iw  Im 
rccovcreii,  w>  ;ts  to  bo  fit  for  any  active  employment.  The  objei 
of  the  consultation  wa^n  to  asecrtain  whether  any  thing  oouki  t 
done  to  improve  tlic  figure.  In  tlie  interview,  he  showed 
pieccit  of  bone,  which  he  had  cotighi^d  up  together  with  a  1 
quantity  of  matter,  when  his  illness  was  at  the  worst.  Tliey  w«i 
of  an  irri'fpilnr  cube  ^hapc,  wttlt  rugged  surfaces,  and  the  sid4 
rnciinurcd  from  tliree  to  four  hues ;  their  general  stnieture  was  cai 
collated,  ninl  traoes  of  cortical  substance  wore  liere  and  tbero  di 
feelcil.  In  short  thoy  soemoil  nnquestionubly  portions  of  the  bodn 
of  vertchrit'  which  liad  been  in  a  state  of  caries.  It  a|^>e«red  i 
if  these  fragment*  hail  Iain  loosely  in  an  al»ceKs  connected  wit 


JSCESSES. 


855 


I  tlie  (liHoasGd  portion  of  spine ;  Uiat  tlio  walU  Imd  beoomo  adhcroat  to 
I  tliG  kings ;  tjiflt  by  tilcci-ation  the  pus  had  penetrated  into  tJie  auU- 
I  Ktnnw  of  ttio  lung,  "ii<l  louiul  sii  «x!t  by  oiiv  uf  tlie  bronclu ;  sad 
I  that,  as  tho  matter  flowed  from  the  abecesa  into  the  bronchial  lubc«, 
lihe  portiftiis  of  bono  hiid  Im'Cti  w,t-!ii"iI  out  and  cx|3Cctoratcd, 
I  Tlie  following  is  tlio  brief  iii)tiii  of  a  oaae  in  M'hicti  a  pAom 
l'ltb"CM»s  coimnunicatod  with  ii  fold  uf  intuslJnv;  and  in  which,  not 
lotdy  did  tha  matter  of  the  abscess  flow  into  the  bowel,  but  tho 
IcAiitonts  of  tliu  bond  pa.tscd  into  tho  abscowt.  Tlio  patient  was  a 
l^rl,  tliirf«en  yeai-a  of  age,  who  had  acute  angular  deformi^  in  tlii; 
Iccntro  of  tho  domal  region,  and  a  |)oom  abncow  of  Hovcral  montlis 
tdorntion,  on  the  lelt  side.  Tlie  external  oritiee  of  the  abscestt  wiu 
tAoar  tliv  knoo,  being  on  Iho  inner  eondylo  of  tlio  femur.  During 
i4}ie  writer's  visit,  tlio  patient  picked  out  with  lier  fingers,  from  ibo 
lopening,  the  skins  of  ooc  or  two  peas,  and  a  portion  of  undigested 
|et4dk  of  greens,  which  alie  had  been  lately  eating. 
I  Tlio  last  case  is  one  in  which  a  thoracic  spinal  abscess,  felt 
I  in  tlt«  iliac  rogiou,  above  I'oupart':*  tigunit^nt,  divelwrged  it«  con- 
[toits  into  tho  urinary  bladder.  Tho  patient,  an  undor-gardener, 
\  twenty-four  year*  of  age,  had  angular  ilefoniiity,  tlio  most  [iro- 
I  ininent  part  of  which  was  at  tho  seventh  dorsal  vertebra ;  but  he 
1  ootdd  not  tcU  at  what  ])enu<l  it  commenced.     He  linil  reliiet.-intly 

left  work  to  become  a  patient,  as  lie  alleged  that  tho  distortion 

did  not  incommode  lum.  On  examination,  however,  an  abecuss 
I  of  contiidoj'able  sixe  wan  discovered  in  tlie  iliac  region,  along  tho 
I  course  of  tho  iisoas  muscle.     After  submitting  to  treatment  for 

tn-o  montlis,  witJiout  perccjitible  eliange,  he  left  the  hospital.  Six 
1  mouths  subsequently,  ho  returned,  liaving  worked  nt  tho  sjiado 
[during  great  ]iart  uf  tlie  interval.  He  stated  that,  a  week  before, 
I  after  iliglit  embarrassment  in  micturition,  ho  had  suddenly  bt^imi 

to  past),  instetid  of  urine,  or  in  (^tmbination  with  it,  large  quantities 
j  <if  a  yellow  creamy  matter.  This  he  had  continued  to  do ;  but 
)  tlio  proportion  of  tJio  urine  to  the  mutter  had  grodiudly  inci-eai'od. 

"Wliile  resident  in  the  hospital,  tho  quantity  of  pus  at  each  making 
I  was  about  a  tliird  of  what  tJie  bladilcr  commonly  holds.  On  carefid 
i«[amination,  no  traooa  of  the  psoas  abscess,  which  had  been  often 
^ftlt  before,  could  be  <IiNCovcrixl.      In  a  fortnight  he  left  for  tho 

countrj',  and  was  not  heard  of  aftei-nards. 

In  tho  above  cases,  tho  process  by  which  tho  larf^  abeccssos, 
Qdering  in  Kiiureh  of  an  outlet,  had  emptied  thcDUelvQi  through 
win<lpi]>e,  intestines,  and  bladder,  was  llio  same  operation  that 
[is  |>criurmed  when  an  abscroM,  or  c^'St  containing  hydatids,  in  tho 


856 


DISEAfiE  OF  THE  SPINE. 


0  aiHUM 

ent  of  >U 


liwr,  ix  crapuatM]  tlimugh  the  lungB  or  bowels;  or  when  a 
fttone,  too  hrgo  to  jmh  the  duct,  a  espollcd.  It  is  similtr, 
deed,  to  tlu'  {in>ceKt  already  described  by  which  a  psoas 
in  its  dc«cent  from  the  dorsal  rrgioa,  perforates  tho  din 
and  tlui  ul>dflmiiiiil  parit^tes  before  reiu'hing  iho  thigh.  Fi 
agglutination  by  adhesive  U-tn{>h  'u>  first  cflcctcd  botwccQ  the  sui 
face  of  tli»  nlinecM  n»d  lliiit  of  thv  vLtciu  about  to  tw  pcnetn: 
that  is  followed  by  absorption  of  a  ecrtain  portion^  within  the  li 
of  the  adhering  dttriVicc!*,  of  tlw;  corobincii  walU;  mi  «ix'ning  id  tlii 
formed  from  the  abscess  into  the  now  channel ;  and,  owing 
tlie  Niirroimding  adhesion,  the  pii«  ciin  bo  diKchar^gMi  tlirougti  lii 
common  orifice  without  risk  of  any  escape  into  the  sorous  cavity. 

Dia^oriii  of  Spinal  AhsefM.  One  general  fourco  of  tUffionlly  ii 
distinguishing  abscosaes  connected  with  earios  of  the  vertebnp  froi 
KwdlingH  of  difiercnt  kinds  resembling  them,  is  tho  fad  that  th 
fiii-niei'  may  e.tist,  luid  even  attain  a  largi?  size,  at  a  remote  distUH 
from  tJie  «pinc,  while  tiio  dif«asc  is  so  limited  in  extent  as 
caiifie  deformity,  except,  [>orhapi»,  of  vei^-  doiiblfid  np] 
Were  angular  deformity  always  a  distinct  accompaniment 
aoQHBea  in  Uic  region  of  the  spine,  diagiiosi*  would  be  eonipnratii'el 

When  a  [woji*  nlweesa  hn»  dcsecndcd  to  the  thigh,  luid  fiwi 
the  channel  of  eammunication  between  it  and  tite  inlra-abdanuni 
part  contracting  and  blending  with  tho  adjacent  etmctiircs  it  bai 
become  apparently  cireumserihcd  and  in.sulated,  then?  will  be  diffi 
cttlty  in  distinguishing  it  from  a  locjd  abscess,  unless  tbo  prool 
of  disease  in  the  spine  be  dintinct  (hc«  p.  850). 

If  an  abscess  originate  from  caries  in  the  lowest  lambar  vi-i 
tebra>,  Involving,  it  may  be,  the  sacniin,  it  is  prone  to  extrtic!  bte; 
ally,  and  rise  above  tho  level  of  the  crest  of  the  Uiwn.     When  tl 
takes  place  on  the  riglit  side,  the  swelling  greatly  resemble*  a 
abscess;  and  the  obscurity  ia  increased  owing  to  tho  indisti: 
of  angular  deformity'  in  caries  when  sitnatcd  so  low  in  tlto  i^>i: 
Tlio  test  of  disease  in  the  vertebr«>  most  to  I>e  relied  on,  in  snob 
case,  is  the  ilcgrec  of  rigidity  at  the  baso  of  tho  column. 

Should  an  abscess  arising  in  tlio  part  J»8t  described,  instead 
coming  to  the  front' of  tho  iliac  region,  enlnrgo  posteriorly,  ii  ma; 
descend  w\  the  nate.*,  and  break  in  one  or  two  plao«»  new  iJh*  Iti 
80  as  to  embarrass  tho  motions  of  that  joint.  The  case  is  thorefi 
apt  to  bo  looked  on  a.«  one  of  morbus  coxip.  Tlic  writer  hitely  w 
a  boy,  twelve  ye.irs  of  age,  tlie  son  tjfn  medical  friend,  whose 
had  tlius  been  niidtakcii.     Tho  j>rincipal  cans©  of  deception  waa 


SPINAL  ABSCESa 

mdifitinctn&Hs  of  th«  angular  deformity  at  the  junction  of  Um  spine 
Lwitli  llio  poivi.*;  nn<l  tli«  rigidity  of  ttiv  part,  a]tlioa<^  a  strUcingly- 
ii'ked  sj-mptom,  had  been  overlooked. 

It  may  not  Ix)  common  to  conlbiintl  nortic  attciiriKin  witli  abaoOM 
im  diaeosoj  »]nne.  Vet,  wliPii  ii  tiinioiir  of  that  kind  protnidot 
>n  till;  back,  by  tbo  »ido  of  tbo  <'oluinn,  cspeciaUv  if  one  of  ttio 
Bpinous  pro<»\<utcA  at  tlic  |)art  be  prominent,  it  may  wwumu  tiw  np- 
raiiCG  of  a  t-oUcction  of  pus  foiiiieet<>d  with  carious  vort«bni?. 
writer  was  eoimultod  by  hl.i  milb-iigiio,  l>i-.  M.  Crawford,  in 
Ftlic  casu  of  a  man  who  had  a  tumour,  in  tlie  dorso-himbar  region 
[of  tlifl  lotl  dido,  (-orreaiionding  to  ibe  aWve  di-acription.  Frotii 
[observing  that,  combined  with  the  swoUiiig,  there  was  not  only  im- 
iobility  of  the  nH'eetcd  part  of  tbr  Npiiie,  but  dintinct  )irotiibemn(<e 
sf  a  Hpiiious  proL-css,  ho  concluded  that  the  ca^e  was  one  of  caries 
id  aorompaiiytng  ab.'«w.'«t.  But  tbo  post-mortem  examination  i-e- 
Jvealcd  an  anoiu'ismal  tiimoiu-  growuig  from  the  aorta,  as  it  paasod 
jthiiiii^h  the  iliupltrajipii.  Tho  vcrtcbnc  had  not  suffered  from  their 
^contiguity  to  tbe  tumour ;  and  tbo  eolumn  was  normally  utraigbt ; 
|T)iit  upon  inspecting  the  spino  [x>»tcriorly,  it  was  found  that  tbe 
|Bpinous  procestt  and  lamina',  forming  the  back  part  of  tbo  arch 
rof  the  eleventh  dorsal  vertebra,  was  a  soparato  piece  from  tbo  re»t ; 
I  and  Ibat,  at  tbo  roota  of  tbo  traiiRversfl  and  obliquo  pracciuteA,  it  was 
k«OUlicctnl  with  tlio  pedicles  by  Joint-structure ;  so  that  sligbt  motion 
Been  tliein  oonld  Ik*  )K,Teeiveil.  Thero  iva«  aW  a  g»«ieral  promi- 
facnco  and  oulargomCTit  of  the  back  of  the  vertebra,  compared  with 
'the  adjoining  Imnow.  The  condition  did  not  i>eein  the  result  of  in- 
ijury,  and  was  eonsidered  to  bo  a  congenital  malformation," 

If  an  enecpbaloid  tumour  prolrudo  backwiinl  from  tlie  side  of 
be  spine,  or  more  in  front  in  connexion  with  the  jielvis,  it  will  bo 
Uiabte  to  bo  niintaki-n  fur  a  lumbar  rir  |nH)nit  nliKccsii.  Every  dx- 
jporienocd  Surgeon  is  awaro  of  the  difliculty  that  sometimcM  cxisbi, 
Lin  otlier  regioiM  whero  ubst-ewscN  arc  Icsk  common,  of  distinguishing 
i  doeply-seat«d  collections  of  pus  from  cancerous  growths.  If  the 
^IiiBlignftut  diMHi»c  have  previfiusly  eonvcrtt-d  some  of  tbe  vertebra) 
kinto  its  own  strocture,  leading  tliem  to  bo  bent  as  if  from  caries, 
\  tiio  uncertainty  of  diagnosis  will  bo  incivased.  In  «  cuk;  lately 
attended  by  tho  writer,  the  obscurity  arose  fVom  the  spine  being 


•  Sen  a  dranlng  and  dncription  of  a  Eimllarlf  malf»nn«il  TiMt«Vr(t, 
from  a  cliMi«cting[n]Om  siibjvrt,  jn  Sir  0.  Boll's  Lirturft  ew  /itj^riu  </  rA* 
SpiiM  unit  of  the  J'AfyA-tonf,  plato  lU.  fig*,  b,  6. 


«58  DISEASE  OF  THE  SPINE. 

inctirv-atcd,  nimost  into  an  angle,  fttim  lat^rJ  diBfortion,  in 
iiiiinodiote  neiglibour!Ki<«l  of  the  cnce)>baloid  growth.  SSumo  lol 
of  the  tumour  resembled  the  acumination  oC«n  nbAoesfi  ao  graat 
tliitt  nioro  than  ooo  Surgeon,  cwksitltci  on  the  case,  \uA  boeo 
«eirod,  uiitil  i-onvincod  by  tho  oxplcuring  nocctlc 

Inchuion  of  th£  Spinal  Cord  in  the  Difttue. 

^Vben  wo  cotiHtder  tbo  delioacy  of  etnicturo  and  con^tatioD 
ihe  mttdulla  spinnlis,  xnd  lU  txintiguity  to  the  oentro  of  so  destn 
tive  *  morbid  action  as  caries,  we  may  be  nurpriacd  that  its  Sm 
tions  arc  not  loKt  in  a  greater  iiniiibei'  of  c<ut!!i  thnn  experii 
»howH  to  be  tbo  fact  Yet,  as  the  Sargooa  has  no  means  of  prt 
nosticating,  in  any  particular  pationt,  wliotlier  it  will  escape,  or 
aifectc<t,  be  ih  kept  in  constant  apprehension. 

Two  circumstances  may  be  mentioned  whidi  conduce  to  fl 
Ihc  cord  from  injur}'.     First,  in  proportion  as  the  apine 
ward,  and  forms  an  angle  at  the  scat  of  di&caeo,  Uic  al 
propelled  to  the  front,  and  the  chamn  Iwtwetsi  tlio  bodica  is 
behind,  so  as  to  prevent  the  pus  from  having  access  to  the  wi 
eimal.     Secondly,  it  is  wiiliui  tlic  posWrior  segment  of  the 
tliat  the  cord  is  contained ;  ami  it  has  been  formerly  shown 
whilo  (he  anterior  t>cgmcnt,  composed  of  the  bodies,  i»  the 
seat  of  carica,  ilie  [io.*tcriur  i.s  exempt  from  disease,  or 
reparative  action  canned  on  within  it. 

Deforo  dincus^ing  the  morbid  process  by  wliich  tlie  cord 
-deprived  of  its  functions,  it  may  be  intcrosttng  to  attend  sboi 
to  oertajn  changoe  of  structure  wJiicli  it  undergoes,  in  the 
fermity  consequent  on  the  disease,  without  tlicir  impairment 
diangc-H  n-fcrrcd  to  arc  those  which  occur  in  corrcsjiondcncc 
tlto  6oxion  of  the  vertebral  canal,  as  tlie  column  itself 
lient,  Wlion  tlio  IxkIics  of  the  vortcbne  have  been  largely 
vated,  and  the  surfiices  liavc  atlerwards  coalesced  and  united, 
the  formation  of  an  acuto  angle,  a  very  considerable  diminution 
tlie  area  of  th«  vertebral  c.iii.'il,  Citpccially  in  its  long  axis,  is 
inevitable  result.  That  alteration  of  capacity,  as  well  as  of 
implies  that,  to  bo  itcconimmlatcil  to  its  newly  allotted 
npinal  cord  must  have  undergone  important  interstitial 
throughiiiit  its  wlioie  substanoe.  And  tlicsMJ  miHlificnlionSr 
sixe  and  fonn,  will  be  wrought  to  an  unequal  oxtont  in  tlic 
columns  and  liods  of  cmcritious  matter  of  which  the  cord  eon; 
A  airailar  accommodutiun  is  witnessed  in  case^  of  hiteral 


I 


cli»- 


IMPLICATION  OF  THE  CORD. 

[«f  the  spine,  wliore  the  vertebral  column,  ami  connequently 

Hal  and  i^inal  oord,  arc  Bomcljroes  incurvated  and  contortod 

iKii  oxiromc  degree.      Now  Uu;  most  rtiniarkubln  circiimslaiKO 

hat  notwitltstiuulmg  thi^se  extensire  matorial  ch»ngeB,  Oio  medulla 

ontinucs  to  perform  its  fttnctioiiH  perfectly-     Tbo  c-xpinjinttcttt  in 

lj(>uiid(>(I  on  itti  being  a  law  in  ttui  [inllioiof^'  of  tlio  nervous  system, 

Rt  alterations  both  of  dimotisionB  and  form  in  the  brain  and  spinal 

^eord   can  be  cHectod  to  an  cxtmordinary  cxl<Mit,  without   intcr-^H 

ruptiou  to  their  functions,  on  condition  tliat  thoy  arc  made  »lowlj^ 

nd  gnxliially,  by  nonnnl,  att  distinct  from  morbid  jitocohmhi.     The 

imples  commonly  adduced  as  illustrations  of  the  law  aro  cases  of 

imoiint  of  frrcnt  mnKuitud«,  but  of  (■]««■  growtli,  which  stometimes 

[|brm  witliin  the  skull,  and  by  their  encroaobment  cauta  tlio  di»- 

Ippi'iiranoe  of  large  portions  of  tlic  substance  of  tbo  brain,  while 

atient  retains  his  powera  and  famltica  entire. 

I}i»organ\aation  of  the  Cord. — ParopUaia,     From  what  bait  ju) 
stated,  it  will  bo  peroeivnl  that  tlie  cbanjn*  of  fttrueturc  in 
Icord,  wbich  causes  paral)'siB  of  tho  lower  extremities,  Is  not  the 
|inero  alteration  of  it«  figure  or  nixo  which  the  angidiir  tleformity 
iuces.     It   consists   in   a  convereion  of  a  portion  of  it£  sub- 
ion  into  a  now  morbid  tiKsuc.     A  certain   part  of  tlio  orgwi, 
Fadjaccnt  to  the  seat  of  caries,  undergoes  a  proeesa  of  brenking- 
rn  of  its  texture ;   the   most  conspicuous   eflcct  of  which  is  a 
Lsoftenijig,  approai>bing  to  U^iuefaction,  of  il«   columns  and  gray 
matter.     If  the  diseaaod  part  be  tapped  with  the  fin;:cr,  it  will 
readily  yield  to  the  slighteat  prcwure;  if  a  Ktrciim  of  water  be 
I  Allowed  to  fall  gently  upon  it,  the  soft  sobstanoo  will  bo  wnidiod 
^away,  leaving  tlie  cfumecling  tiiwiii!.     "When  tbe  croiun-liko  matter 
cxamincil  in  the  microscope,  it  is  obsencd  to  be  made  up  of 
inumerablo  fi-ogmenta  of  nt^rvtstubt^,  gnmtdcs,  nil-globules,  and 
(mylacTOus  cells,  the  dt^bris  of  medullary  tubes  and  ganglion-cells. 
lA  tinge  of  yellow  pervades  the  sollened  and  neighbouring  pa 
Tiie  membranes  do  not  commonly  present  any  decided  aigna 
[baving  been  implicated,  nor  is  tho  vascularity  much  altered. 

It  will  depenil  on  the  dqitli  to  which  tlic  morbid  action  rcachc 
any  particular  case,  as  to  tho  functions  of  tlio  con)  whicli  will  bo 
shed.     We  owe  to  modem  discoveries  tho  kiiowlc<lgo  of  tho 
— ,  that  to  the  anterior  column,  from  which  tho  anterior  roots  cf  ^ 
lie  spinal  nerves  arise,  belongs  the  power  of  controlling  tlio  mu»^H 
Im  t  and  that  to  the  middle  lateral  oohnnn,  from  which  tlie  pos- 
llirior  roots  arise,  belongs  sensation.     Hence  if  tlio  disease  penetrate 
only  so  far  as  to  destroy  one  column,  leaving  tJie  otiior  sound,  we 


'Cells, 
na  d^l 
ichee^l 


J 


860 


DISEASE  OF  THE  SPINE. 


mny  nnticipato  t)i»t  tho  function  pertaltung  tu  Uw 
column  will  slono  bu  losL 

Now  extensive  expvrieneo  prorcs  tltat,  in  tlio  panpkp*  aoi 
by  diseafici  of  the  ^>ine,  one  of  tlie  two  proporliv*  mnfimvd  bjr  i 
con),  luunt-ly,  invtor  power,  i»  in  a  rcmwlcabte  degreo  man  I 
(jnonlly  detitroyed  than  sensation.  So  general  is  thi*  lact,  iImI 
nmy  be  regarded  x*  a  cwinparativdy  raro  went  for  both  tnntian  i 
sensation  to  \»  lost  .liiniLltaneoualy.  As  to  tJio  roveoe  UM 
abolition  of  scnwition  wbtic  motor  powor  in  retained— it  ia  iuH 
whether  such  a  oaae  was  e%'er  met  with. 

When  wo  oonsider  tbo  rolativo  potiitJon  of  lh«  diffinvnt  adu 
of  tho  ooni  to  the  centre  of  disease  in  the  spine,  tbo  caose  wifl 
nt  once  apparent  why  motion  tttioiiM  bn  tint  destroynL  Hw  i 
ttfior  oohmm,  tliat  on  which  [hiwoi-  over  the  miiBclm  cWpodi 
Mparalcd  from  tJw  bodies  of  the  vertahne  only  by  tbo  thuoi  n 
hn\i»  and  otbiT  ddicntv  nionibnne*  of  Un"  oord.  Heooe  «i 
thu  morbid  action  proceeds  backwitrd,  and  infrcts  tiio  idmIhIi, 
nay  anUcipato  that  tlw  column  of  motion  will  be  deprivod  li 
fiinetion  liefore  any  otli«r.  And  its  liability  to  be  m  involved ' 
be  increased  by  the  compression  to  which  it  if  |>Gcalbrly  m^ 
&om  tho  bmdiiig  ofllic  ^pine,  as  it  forms  an  acute  angta  at 
part. 

But  an  additional  reason  may  be  statcxi  why  motor  power  i1k 

thus  be  lo<tt  before  Dcmalion.     It  soomfl  capable  of  proof,  that 

projun-  Bcat  of  tho  latter  proper^  is  deep,  and  near  tho  centra  ol 

mediilln.     Tliat  opir)ion  is  siipporuil  by  olHM'n'ation  of  tba  • 

modes  in  which  tlw  two  roots  of  the  spinal  nerres  nre 

at  llieir  lerminatinnK  with  their  rrxjiretivo  cfilumn*.     Ifwal 

filament  of  an  anterior  root  to  ita  »ourcM>,  wo  shall  find 

abotit  to  join  tho  cord,  it  subdindv*  into  niimerutu  minutv  I 

and  tJwt  these  lose  llwni-'^olvos  nlmuHl  iuipereepiibly  ii» 

of  tlu-  onti-rior  column.     If,  on  the  other  hanil,  we  tnuv  a  ffioi 

of  a  posterior  root  to  its  dentinatton,  wo  sliall  observe  tliat  it  m 

trnti"  iti«elf  as  :i  finale,  entire   fibril,  nji   li>  tlic   c<ntd;   tliat  r, 

arrivnl  there,  it  (lipA  bodily,  witlxxit  ftuUliviTitMi  or  dnapv  ■ 

the  fisxttru  between  the  posterior  and  middle  latcia)  oidmaBij  t 

while  ill  the  fiAMin',  it  piimiifH  an  tinbn>kni  I'onnio  to  Uw  botU 

oihJ  tliat  its  actual  torminaiion  i^  in  tlio  deepest  jairt  oflhts 

viberc  tJte  ccntnd  cineritious  matter  is  Hitiutcd.     It  nppnn,  A0 

fkiTc,  from  UitH  anatomical  c\-idci»e«,  that  tlte  jiart  of  thf  mnli 

appit>j>riatcd  for  seimation  most  be  in  the  internal,  weD-pnta 

XMeaaes  of  the  or;izan ;  wlierv  H  ia  lea*  likely  to  be  rooebnl  l>y  i 


wan 
thalyi 
luteal 

I  thn  M 


PARAPLEGIA. 


861 


^faao  !iivn<liiig  tlio  exterior,  tlmn  tlw  column  of  motion,  situated 
'jriwro  BU|tprfiflia!lv.* 

It  will  depend  on  tJic  ]«irt  oftlw  »t(>Hitf  where  tlw:  Oiirics  exUtii, 
Ytvi  to  tim  pxtctil  (ifllio  body  llmt  will  be  jmralyscd.  If  tJic  coni  be 
['«f1iK^tcd  high  ill  tlip  eoliimn,  a  largo  portion,  ineludiiif;,  i>erha)H, 
rtJic  upjior  cxln-initiiw,  will  bti  dojiriviid  ol'  motion,  —  it  may  bo 
Imotion  and  sensation  conjointly  :  it"  low,  tJio  infci-ior  csin-intlivs 
lidono  will  liav«  jianijilc^iii.  t^luiuld  ttic  dUciisc  bo  »cnled  in  tlio 
lower  lumbar  vortebnp,  that  is  below  tlio  tt^riDiiiution  of  tho  voril, 
lllicro  may  he  an  ubximou  of  pftralywU:  tmloiiA,  as  ot-cjisionally  hap- 
|']>enfl,  tlieproiluots  of  inflammation  liavo  cxtcndwl  upward,  to  invulvo 
filta  medidia  nhovc.  In  n<it  a  f<-w  (.wwji,  one  lower  extrerai^  la 
lore  coniplcttfiy  deprive<l  of  motor  power  tliaii  tlio  oUiur,  indicat- 
\mn  tiiat  Ihr  c-orrcsiKindiii;;  side  of  tJio  cord  lia-i  been  more  exten- 
Bively  destroyed. 

Compnrinfj  tho  paraplc^a  resulting  from  di^-a-a'  wi(Ii  that  from 

iinjury,  it  is  remarkable  that  tlic  fonncj*  ia  M'ldom  accompanied  with 

I  of  command  over  tlic  bladder  or  rectum ;  and  tiiat  when  tbcAO 

"organs  are  [itiocti><l,  it  i»  conttnonly  to  a  juirtial  <le^'«.     'flic  [la- 

tieiit,  ri'tatnitig  fionsation,  may  have  an  urgent  desire  to  posH  water, 

[  but  will  1)6  nniibli)  lo  do  no,  )uu\  will  rwjuirc  Iho  HMiMtcincs  of  tho 

L'tor.      At-aiii,  tho  stools  may  pa.**  at  one  time  involuntarily, 

osiers  with  lii^  cdiLsciousnois*.     In  general,  tho  torpidity  of  tlio 

'  l>owels  renders  it  necessary  to  give  n|)crienttt  frequently. 

TIio  «!!«;«  luv  eomparativclj-  rare  in  whieh  tho  loss  of  power  ia 
the  limbs  leads  to  the  lorinatiou  of  hed-sorcn.     If  tlic  patient  be  tn 
l«dult,  and  lie  has  great  pain  at  the  Beat  of  disease,  making  it  dif- 


•  In  1631,  seT«i«l  yawn  HnbRequenUj  to  Lis  discovery  of  Uio  dUtini-t 
funotioDs  or  iho  roots  uf  ibv  Epinul  n«n'«e,  Sir  CharJea  Bi-U  was  broujifat 
b>  oODoIude  that  lh«  proper  orit;in  of  the  poiit«rior  roots,  and  tliereJbro  tli« 
tnH  teat  of  seoaation  in  tli«  cord,  was  tlie  raiddls  lateral  column,  and  not, 
jis  lis  had  previously  thought,  the  posterior.  He  was  Ird  to  the  obstrratioa 
hy  tludiiJ);  iu  till!  works  of  preceding  anat€>misU,  tliat  the  Isificr  gauglionio 
I  root  of  thi-'  fifth  nervit  uf  tlte  bmin,  whlcU  ho  hod  jtrovcd  lo  l>o  analogoiu 
in  fuDRtioti.  as  well  as  slmcturc.  to  the  posteiior  roots  of  the  spinal  ncrv<«, 
«!i>u[d  bo  traced  dawiiwnni  fioni  its  npiiaixtnt  orisin  tn  tho  pons  Vnrolil,  to 
the  top  of  the  vpinnl  rord.  v\a%ti  to  tlte  origins  of  Iho  posterior  roots.  Ho 
porooiyoi]  also  that,  in  Its  long  Irauslt,  It  kept  at  a  diaianoo  IVoni  ilia  poa- 
tsnor  eolumn  of  tli«  oord.  Not  long  aSUv  the  publicallon  of  this  view,  eases 
wci'o  recorded  ivhidi  coiifiriiiHd  it  so  far  sa  to  prove  that  feeosstiuu  did  not 
belong  to  tlie  pust«i'ior  eulumii.  Of  these,  the  most  iiilereBting  was  onu 
related  by  Mr.  Slmiky.  in  which  that  column,  in  a  grtat  part  of  its  exlvnt. 
was  thoroughly  diHor^anitied ;  aud  yet  the  sensation  of  ^i«  eoiTesponding 
■  part  of  the  body  was  uiiimpnircd.    Tnait.  Med.-Clur.  Soe.  vol.  xxiJi.  p.  SO. 


862 


DISEASE  OF  THE  SPINE. 


ficult  to  tarn  him,  so  as  to  hIhA  tlie  poftitioii  of  his  k^, 
dangoT  of  tliv  Ain  over  the  Hacriun  ulceratdng,  or  being  coii' 
into  u  dough.  But  ttic  nnk  i»  not  m  great  as  in  casm  of  fan 
plogia  from  fmcUirn  dP  the  tipiuo,  when  tJio  Geoea  and  urine 
invtJiintjirily,  and  tlio  hips  aiv  constantly  sodden  in  the  GltJiy  nioi* 
tare.  In  a  ynnii^  [kmnou,  i^n  tlu!  otlier  hand,  whow  bo'ly  is  ligfa^ 
awf  who,  from  posscssinjj  scnsntion,  can  feel  the  irksninenan 
lying  for  a  long  timv  in  the  aamv  paapan,  vrc  do  not  look  for  sami 
lio  LH  able  of  himself,  with  tho  uso  of  his  hands  or  elbows,  to  vfaangt 
tlto  pottttioii  of  h!H  li!|Ki,  Hiid  avoid  iIkt  bad  (tfTi^xHii  of  |irc«Kurc* 

Spanmodic  aclionf  of  t/te  paralysed  ii'jwt*.  ttlien  tlie  Iow<t  «• 
tromities  are  entirely  bereft  of  vohintar^'  |wwcr,  tJicy  are  snbjeft, 
neverllielfxw,  to  be  offocted  with  con^Tilsive  actions,  tlirough 
ohscoro  morbid  inBuonoc  acting  on  Ihi.^  distal  {loKion  of  the  spisal 
cord  cut  off  from  wnnoxion  with  the  brain.  Tlie  tipaRma  wliicJi  ar» 
met  with  in  paraplegia  consoquoat  on  caries  of  tho  vcrtfl)r:e,  am 
tho  same  tliitt  wo  witiif^t  when  the  cord  Itaa  been  dotroycd  by  rio- 
lenee,  or  by  the  encroachment  of  tumours,  ramoUissement,  4c- 

A  frequent  form  of  the  utiaok  consista  in  u  Mii<ldi.*i]  jactitatioa  rf 
one  or  botli  leg^  WUIe  the  patient  n  IjHng  quiet,  tJio  limbft  w3l 
sucldcnly,  ami  without  warning,  be  beitt  botli  at  tho  knees  and  hipe, 
— so  that  the  hivla  come  in  contict  witli  the  back  of  (hi-  thigh,  and 
the  ktiees  with  the  abdomen  : — the  flexor  muscles  will  tlieu  ndax, 
anil  the  Unib»>  will  fall  straight,  an  before.  In  such  coses  tlio  spasm* 
tiro  of  sliort  duration ;  hut  tliey  may  bo  repeated  with  great  &e- 
qui>n<ry,  Mi  a"  to  eaiLii!  cons  id  (Table  iliHtrefi^  to  the  patient. 

A  different  forra  conasts  in  the  l^s  being  drawn  up,  and  tlwa 


*  Bf  P>ro  any  othw  physiolu^ist.  at  homo  or  al>Tiwd,  Iui4  partidjMted 
with  Sir  Charles  Boll  in  in vooti eating  tlu>  diHiinct  functions  nrthenwHS 
by  expenioentiitg  on  Uietr  i-oots — Mr.  Jolin  Sk«w  3i*d  applied  the  diaoomj 
made  by  tlie  former,  that  tliu  aut«rior  rDota  ef  tlie  npinn)  ncrvea  bectow 
motor  power,  and  tliu  jiostcrior  sRnsation,  mmlinncil  by  the  oorrobontite 
obsorvntioiis  on  the  rooti  of  the  lit^li  nerve  imd  portio  dura  of  tbe  bnia, !» 
■olve  tb«  pnthnlogicft]  problem  trotted  of  in  tbe  text.  la  liiii  Paper  «a 
"Portinl  Pai'nlj«is."  the  folloiving  4)ii«stion  fomed  one  of  the  hnMl-iiilci: 
"  Why  Sifnuation  should  remain  entiro,  in  a  Limb,  wliea  alt  Volutttu;  Povtr 
over  ih<!  ftuiicins  of  its  Muscles  Is  lo4t;  or  why  Muscular  Poner  slioald 
rcmnin,  when  Feeling  is  gone."  Tlio  oxpliiiiatiuo  of  tlte  problem  wblcb 
Mr.  Rhftw  thi>a  gave,  and  the  aceount  of  tho  appropriate  fundJons  of  I 
anterior  and  posteiior  root»  of  tile  spinal  n^n'os  on  wlil^'h  it  was 
were  csspiitiuily  the  same  a*  those  presented  above,  Tliat  pajMr 
to  the  lloyal  Medii^nl  and  Cliiriirj;ienl  Society  in  April  1S8S.  It  was  not  till 
AiiRUHt  of  iliu  sarnc  year  that  M.  MiiRnndio  publiabod  hia  supposed  erigiial 
experiments  on  the  roots  of  tlie  spinal  nriYos. 


am 


\ 


APPECnONS  OF  THE  COUD. 


863 


remaining  henC  In  i\vym  <';wct,  (Iio  1imb«  and  body  will  bo  no 
rigidly  fixed,  that  the  (laticnt  vriit  be  inovtxl  abotit  iii  be<l,  in  ona 
taaie*,  like  H  log  of  wood. 

(Jases  will  bo  met  witli  in  whidt  both  tlio  above  forms  will  bo 
>rccicnto<l,  at  illQcrcnt  times,  in  the  samo  jHitieiiL  Tbo  spasmodic 
ioaf,  whether  olonie  or  touie,  are  apt  to  be  excited  by  certain 
ints.  Thus  tickling;  the  wjIo*  of  the  fct-t,  i>inching  or  pricking 
Hkin,  the  act  of  moving,  will  bring  on  tbo  sudden  !i>tartingM,  <]r 
II  aggravate  the  contractions  of  tlic  rigidly  bent  limbic.  Mictu- 
ilion  Mid  dtifiRcation  nomotimc^,  bat  rarely,  exeite  allaok*.  Yot 
(y  frcqucntJy  come  on  without  any  pcrt'C])tiblc  catixo  of  irritation. 
m  tfie  patient  is  drowsy  and  about  to  drop  aslee]>,  he  is  pecu- 
•ly  eubjoct  to  bo  woke  up  by  tlic  limb*  jiunjHiig. 
'rtie  |)ain  oecaaioned  by  the  spasmodic,  aifeetions  is  sometimes 
Ivo,  In  certain  cases  it  cqualx,  if  it  docs  not  surpaM,  Uio 
my  of  tctanns  in  iUt  worst  form ;  happily,  in  the  majority  of 
itleota  the  suffering  i»  modorato  and  cndorablv.  But  iudopen- 
itly  of  Uic  piiin  in  tlie  limbs,  thero  in  mi  indirect  e^'iL  When 
10  eonvulsions  are  strong,  they  shake  tiie  wliolo  body,  and  cum- 
iuiiiciiU>  a  jar  ulong  the  »pinc,  to  the  diseased  vertebne.  Again, 
the  patient  have  bed-eoros,  tho  concussion  produces  friirtion  of  tJio 
lilB"  ncsinst  tho  bedding,  and  tliut  iiggmviitwi  tJie  ulwtration  or 
loughing.  Owing  (o  the  elasticity  of  tlie  figure  in  young  [arsons, 
cSbctK  may  not  bo  perceived ;  but  in  adults  they  are  very 
larkM). 

When  it  is  attempted  to  subdue  the  *pa«inj*  by  upplying  s|ilintA 
to  the  limbs,  or  bandaging  tho  leg  that  is  aflect43d  to  the  one  that 
is  rjuict,  and  fastening  thorn,  when  tbrnt  ^otnired,  by  india-rubl»er 
tubing  to  iJie  bedposts,  tlie  ptaji  oommonly  fails ;  the  skin  is  h'ublc 
to  Ix^  iVtijxsl,  and  tho  pain  is  not  diminished.  There  in  no  jMurlitni- 
lar  medicine  that  can  bo  relied  on  for  overcoming  tbo  eonvulsions. 
SoiiK'  g<HMl  effect  may  bo  exju'ctwl  from  injix'tiiig  in»q>hiu  iin<)er 
10  skin. 
Diarfwmr.  As  intimated  bt^ore,  p4ira]>legui  eonocquent  on  earic* 
the  vertebra;  does  not  differ  materially  from  palsy  of  the  lower 
istremities  caused  by  morbid  affections  of  tlie  eonl,  of  \'arions  di»- 
let  kincK  IimIcxxI,  it  is  chiefly  owing  to  tlie  niedulla  being  mibjeci 
lose  its  functions  from  several  different  disease*,  and  lo  tlio  effects 
pnxinced  in  each  iwtng  uiuelt  alike,  Uuit  aoeuraey  of  diognofis  !« 
difficult. 

Hie  principal  diagnostic  kign  of  paralysis  in  H|>ina]  diseiiM)  is, 
doubtlessly,  Ibo  angular  deformity.     Extcnuvo  obser^'Stion  elmws^ 


ftfi-t 


DISEASE  OF  THE  SPTNE. 


Uiat  wIk-h  {Hiraplegta  in  eoniicctcd  wiUi  caries,  it  alwa^'i 
Ute  in  iho  diM>«u<o,  uftor  Uto  Liudii^i  liuvu  bvoii  tlM>|)Iy  <>x«^ 
Coit»ri|Ufnt]y,  if  tliere  bo  an  alisence  of  the  decided  proj«cti 
mw  or  moro  spimm*  iinx-ftwc",  or  rigKiity  of  tlic  vtwrUibra-, 
indicates  (It-Hirui'^tioii  of  the  ti:)[unin  liy  i-'aries,  it  may  bo 
that  ihn  pai-nplegia  do|H'iidH  on  Hoino  otlivr  morbid  nfiV.'ctioii.  A 
it  i»  geiicnilly  rbaracleristii'  of  pnUy  ai'ising  from  carica,  for 
power  to  bo  aboliftlicd  wbilo  iK-u^atioii  'i»  luiintpatrod.  It  is 
lliat  tliU  fijni  ift  not  (xjnotant,  and  tliat  in  i«evcral  otlier  affet 
of  tbe  cord  tho  Ktmc  |>ofuli!irih-  may  Iw  observed;  yet  it  18 
fri!(itiont  in  fOM-!!-  of  c.iriiM  tliitii  in  otlitTn.  If  tlu)  rovur^^t  be  ft 
namely,  lo&s  of  sensation  wltb  rotmtion  of  motor  power  (a 
ronciinx'nvc),  it  nmv  Ih:  iiittTivct  tlmt  tbo  cunt  i»  i^noruochod 
by  some  morbid  gi-owtb  iidviuuing  ti'oni  behimi  fonvard. 

Should  Cancer  attack  tlio  npino,  it  may  lend  to  a  dcftirmity 
unlike  anfiTiIar  curvature ;  also  to  paraplegia,  wbicli  may  be 
tended  with  painful  Kpa^ins,  aiid  ullicr  Kvvcro  and  fatal  c3i 
W)i<^n  treating  of  Abaceaa  (aee  p.  fio7),  it  was  Rtate<I  tliat  il 
enccj>haioid  cancer  protrudctl  by  tlio  ttido  of  tho  Kpiiial  oolouU 
miglit  t>o  mi»t-U<i'-n  for  a  eotleotion  of  pu».  Itut  tbi^i  uudig] 
di«oa»o,  (specially  of  tbe  scirrbous  kiml,  afiects  tho  bones  oF 
fipino  niori'  dirLX-lly  than  tliitt  deKoription  iinpllce^  To  nil  t 
vunant  with  the  puthologj-  of  Hcirrhus,  it  is  known  that  afbjr  it 
been  seated  in  u.  pnrilcnliir  4)rgmi,  m  tlie  mamma,  and  tho  w 
sj'gtciri  lias  become  infected,  tlie  peeidiar  morbid  product  of  cm 
ia  frrtjiiciitly  ilcjiosiU'd  in  tlic  intcrnul  irfructuro  of  tho  bones  gi 
rally.  Tlius  tlio  vortobrK  are  liable  to  bo  mfiltrated  througboii 
ihcir  inti-riur,  iiiclnding  i]od!c«,  arcbcit,  and  proecvM^ii,  with  can 
matter,  which  takcM  tliu  plaee  of  tlio  nonnnl  tlssiuw.  Comm  ax* 
wanting  in  which  tlio  discaeo  appears  to  have  attacked  the  bom 
the  spine  primarily.*  Dut  in  tlio  nmjority  offittMS  of  coruxtr  in 
vcrtobrul  L-oininn,  the  disease  is  only  a  part  of  an  cxtonsive  int** 
of  tJie  oBfieous  Kt.nietui'K;  and  it  i«  more  fnxpiently  ait^ooialcd  i 
scirrhuM  of  tho  female  breast,  than  with  any  other  form.  ASTieii 
vertebra;  ai-e  itiibjci,-1>»l  to  the  morbid  intVRttitiul  cluuigu,  so  that  t 
Bolid  material  is  given  up  for  the  soft  tissue  of  cancer,  they 
as  might  be  cxpectiHl,  to  tlie  pressure  of  tlic  Kuporiiicumbent  wei 
and  doformity  of  tho  i-olumn  ensues.     It  is  a  striking  feature 


•  l^fQ  n  i>nprr  on  "  Cancerous  Diaeosc  of  the  SpinnlColnntn" 
miiny  iTiEii-iiciiva  oaset,  by  Mr,  C«mr  Unvtkiua.—Tniiu.  a/  Mtd^ 
vol,  xxiv-.  p.  11(1. 


PROGNOSIS  IN  PARAPLEGIA. 


865 


affbction,  that  no  pnrt  of  thn  fipino  but  the  osacoua  is  iiicladcd  iu  tho 
icnorbid  clian^.  Accordingly,  when  tho  longitmliiud  Mcctioii  of  a 
I'Spine  so  traiiHtbnnod  it*  exmniiml,  n  remai'kxble  contrast  in  pro- 
»«iito<l  between  the  condition  of  tho  bodies  of  the  v«rtobrso,  and  that 
oft]ie  iiitervcniii'»  fibro-<."artiI:igi\'(.  Tho  UiitcT  reliiin  tho ir  natural 
tfiickncKS,  firmnoBS,  and  g)tHt<^niug  whiteness;  while  the  bodies 
are  not  only  converted  into  a  flc»hy,  polu,  uniorphoiis  8ub»>taiiuo, 
destitute  of  a  vestige  of  eaneoUatcd  bony  structure,  but  aro  oom- 
prowied  and  fltittcnwl,  m  a»  to  br,  in  somo  [i:ir(jt,  nciirly  oblitoratinL 
Ontgrowthfl  of  canoer  aro  apt  to  jirotnido  irregularly  into  the  ver- 
tel>ral  cana! ;  and  tlio  mvibdla  i*  dcprivwl  of  itn  function^,  either 
through  thorn,  or  tho  rapid  displacement  of  the  verbobno  in  relation 
to  thft  cJiual.  Oases  of  thi.<  kind  arc  readily  to  l»c  dintinguisbod,  in 
general,  from  those  of  caries,  by  other  parts  of  tjio  body  besides  tho 
spine  being  at  the  same  time  infested  by  cancer." 

ProfpxosU  in  parajtinfia.  Obsen'ation  proves  tJiat  restoration  of 
tho  power  of  the  limbs,  when  lost  from  the  effects  of  disi-aso  of  tlio 
fljHne,  is  much  nmn-  fitvpicnt  than  when  4;auscd  by  fracture  of  the 
ctJumn,  or  softening  of  tlie  cord,  &c     Tlic  explanation  ap]>eaTs  to 


*  In  the  eseny  on  Cavoer  (vol.  i.  p.  &Li),  a  caee  U  nfnred  to,  in  which 
lli«  paliciii.  a  fi'uiale,  foi't}'-ai\  yeum  of  ai;e.  uoder  Mr.  Moore's  care,  htid 
■vOtnccrous  tuiuuiuB  in  both  brirantii.  with  iufi-cUon  of  the  ftxilliuy  glaods : 
knd  iu  wlium  Uie  npioc.  in  common  trilli  tlio  ikull.  bccniuc  HL'coudiuiljr 
aObolud.  Ill  itii-  iloraol  rrjtioii  she  hnd  two  nnf^lnr  pun-ututes.  She  luiil 
also  lost  musi^iilui'  pon-vr  nml  s^nsntion  in  tiic  lown-  vxtrvmities.  Sinee 
llio  piiblicution  of  the  volume,  tlic  pitticiit  liiu  died.  The  foltowioi- is  a 
deaciiption  of  the  prrpnratton  of  the  spine  prcsci-vrd  in  the  nmseuni  of  Iliu 
Middlvncx  Ilniipilnl,  from  notes  fiiiiiishcd  by  Mr.  Motiru  :  Tho  npodmcD 
cshibitn  a  vcrtioiil  snction  mndo  tlirough  eight  loner  doraal  and  nil  the 
lumbur  vcrtcbi-m.  Canceivus  mUtor  has  been  deposited  in  tha  bones 
of  the  column,  uid  cxcluaivelj  in  them.  Tho  cfTccts  arc  most  distinctly 
visible  in  tho  bodies,  ivUich  have  become  subsfquontly  kbKorbcd.  The 
iBtorvcncbrnI  carliUgw  are  of  the  usual  thickness,  and  presoryo  ILslr 
nomifll  structure.  Some  of  the  vortebm  have  been  much  mar«  ^)aoi4>«d 
Iban  otJiers.  The  body  of  the  scrontli  has  been  reduced  to  half  an  fndi  In 
d«pth;  tliose  of  the  ninth  and  t«Dtli  to  about  an  eighth  «f  an  iueli  respe«- 
tively ;  of  the  tirclilli  to  haif  nil  inob ;  of  the  second  to  about  an  eighth  of 
ta  inch ;  Uic  body  of  tbi?  tliird  lumbur  T«rtebru  bus  bcuu  aliooBt  entirely 
absorbed,  so  tliat  the  inlcn-ertebnU  fibro-carli luges  above  aoJ  b«lo¥f  OOOM 
nearly  in  contact  with  one  aiiotlicr.    At  those  situation!  wberc  the  bodies 

Ifa«v<?  bt^co  most  ab«orbk^d.  th«  vcrtebnn  gt^nrmlty  have  been  eotnpi-ciscd, 
and  tlio  column  eorrcspondiogty  diminished  in  height.  On  tlie  left  side, 
llio  cunnerous  deposit  exlcnds  beyond  tiie  bodies  of  the  lower  dorMiI  vcrtc- 
bm,  and  baa  involved  and  compressed  the  spinal  Derres  at  Ibeir  exit  from 
the  intcrrci-lebral  foramina. 
VOL.  lit.  3  K 


866 


DISEASE  OF  THE  SPINE. 


be,  that  wlien  a  portion  nf  tlw  tiKnluIb.  hns  bc«n  <Iitoi 
deprived  of  itt  funrtioii  in  consequence  of  caries,  an  oppoi 
aSoixlcsl,  owiug  to  tlio  contintKtl  bending  <io\im  nf  the  eolni 
into  tin  Mtg^c,  lor  the  sound  purtA  abovo  and  below  to  come  u 
oontaet,  and  displace  tbo  di^tascd  part,  so  a«  to  unite  and  bo  able 
resume  tlirir  function.^  >>ue)i  a  reunion  of  (lie  upj>cr  imd  lowi 
portions,  it  is  obvious,  cannot  bo  effected  wlien  tlie  cord  bas  bei 
tndvliltly  cnuhod  for  it  «onfeiderol>lo  extent,  or  hn-s  U-eii  to) 
completely  asunder,  in  a  case  of  fracture  and  displacement  of  ll 
wrttibne.  And  ttie  imnic  remark  applies  to  destruction  of  tlw  mi 
dnlla  by  <!iiM>a.'u>,  wbcn  the  spine  is  straight;  for  there  will  be  i 
possibility,  sliould  tlio  morbid  action  cca»«,  of  llio  ends  aboro  an 
betdw  n]ii)roxiniiitiii;r  and  restoring  the  continuity' of  the  organ  I 
adhering :  and  it  is  not  probable  tliat  tlio  inlerti'ciun^  lost  part  will  1 
r^iicc<l  by  nowly-produoed  structjire.  Another  ground  for  cBtd 
taining  )io|>es  of  reooTory  in  eases  of  enrivs,  is  the  fact,  that  tbe  la 
of  Mtibstaneu  in  ti)0  cord  is  usually  confined  to  the  anterior  column 
it  is  reasonable  to  expect  tliat  from  tlio  port  that  has  been  dk 
organiwd  being  «>  small,  it  will  l>o  noplaecti  by  healthy  srtructuro. 

Should  the  spine  from  ankylosis  have  been  rendered  incapoU 
of  bending  sufficiently,  before  repiuative  action  in  tho  medulla  ca 
have  taken  plaeo,  tlio  ebanees  of  rocoveiy  will  bo  diminiidiiid. 

In  children,  tlie  prognosis  is  more  favourable  than  in  adolb 
Tliis  dilTcroncfl  wo  may  principally  attribute  to  tho  gjoator  fieri 
hility  of  the  spine,  in  early  life,  wliich  will  facilitate  proportionfltpl 
tliK  coule-tcenco  of  tlio  voutid  [lartii  of  tlio  t-ord.  Thti  writer  lia 
lately  under  his  car©  a  boy,  six  years  old,  with  angular  deformit 
in  tlio  dorsal  region.  Within  a  jicriod  of  two  years,  hi^  lower  limh 
were  twieo  completely  pai-alysed  :  die  first  time,  for  six  montlis;  th 
8(\und,  af^r  an  interval  of  eight  mouths,  for  four.  Ho  rocovore 
&om  the  parapli^a,  but  afterwards  died  from  tlio  effects  of  exlea 
avo  abMCKsc^. 

The  restoration  of  the  power  of  the  limbs,  in  some  ca-'tc*,  is  ootj 
parfial.  Certain  groups  of  muiwles  continue  paralywxl.  This  'at 
cfjualily  in  llic  condilion  of  tJio  muaelcjK  lead.4  to  particular  fo 
contntctions  and  deformities,  chiefly  in  tlw  ankles  and  toes. 


Dnusi  or  Atlas  ako  Axis. 

Disenso  affecting  tho  two  highest  vertobnD  of  the    spino 
certain  v**^'*'^'^itic8  which  entitle  it  to  sqiarato  consideration, 
twnc  aiUBc  viXucV  "Kva!s,c%  wi'aiKft'**  Vi  lj»»ft  bones  moro 


DISEASE  OF  ATLAS  AND  AXIS. 


66 


fluui  clscwliorc,*  renJi-ra  lucirbld  action  nwro  [H'rilomt.  TLo  por- 
'  tion  of  s]>inat  oonl  conlaiucd  witlu'n  tlie  rinj;  of  die  ntlas,  U  tlif. 
most  vital  in  tin*  lutnoiw  b^.^Iimh.  Hviico,  wliatf-vcr  toiicb*  to  weaken 
tho  joints  in  tJiai  part,  exposes  tho  putieni  to  tlio  luizttnl  of  fiiiildt^i 
(lentil,  or  puniplv^iii,  incliuliiig  tint  wlinlo  IkhIv  Im-Iow  tlio  licaJ, 

Both  alliis  and  axis,  fspei'ially  tlio  fommi',  liitliT  i'ntm  tlm  other 
VOrlebrsG  in  their  tuintomtoHl  Mtriictiirc.  Tlic  »tl(ui  is  iloficient  in  the 
]jiu-t  thttt  i-x>rres[ioiid9  to  a  body;  ainl  thero  is  no  fibro-cjirtihso 
eitlicr  between  the  iisii',  or  IIms  occipIUil  Ihiiic  niid  it.  Hoiico,  aa 
tlieito  ctriK^twrea  are  the  proper  scat  of  caries,  it  may  l>i>  i>x|K'c(«d 
that  the  morbid  ]>itKN.'.'*«  whi»;h  attiti-kH  the  two  bones  will  difler 
from  tile  oixliiiary  disease  of  tho  spine 

The  joints  particnlarly  subject  to  bo  affected  arc  those  between 
tlio  atliLi  an<t  axis.  And  a  reason  may  bo  assigned  for  tlivir 
hoing  pDculiarly  prone  to  diKcnso.  Tho  term  *  axis'  implies  that  tJio 
vcrtflbni  so  called  is  tJie  centre  of  llio  rotatory  tnovemenl.i  of  tlio 
head.  Kow  as  tho  spokes  in  a  earriago-wliccl  inserted  into  the  axle 
net  upon  that  central  point  with  great  levor  ]>owor,  an<I  when  a 
break-down  occurs  it  is  the  axlu  tliat  ^vos  way,  so  a  corresponding 
impulM!  is  diri->ctod  upon  tho  pivot  of  tho  uxi*,  by  sndden  violent 
rollings  or  twiatings  of  tlio  head.  Tlicse  shocks  and  sprainn,  often 
repeated,  predispotH*  tho  articulations,  in  iideliento  patient,  todisoasa 

The  morbid  action  thus  sot  up  m  the  atla>axial  johil^  iVMcinblcs 
a»  it  most  commonly  occunt  in  tho  wri»t,  elbow,  knoo,  Sic 
7!n>oee<ling  genei-ally  in  a  chronic  fonn,  it  gives  rise  graduidly  to 
a  Boftoniiig  and  i<']K>Dgy  thickonitig  of  the  :<>'novial  nnd  fibrotus 
tiiuiuea  that  connect  tlio  vortcbne;  and  to  ulccmtaon  of  llie  carti- 
Ijllges,  and  superfieia!  eorrosion  of  the  Iw'ny  .itriictunss.  The  di«- 
r<H^nUation  will  go  on  in  luost  («ses  to  an  extreme  dogroc,  without 
visible  signs  of  abseess. 

That  which  contributes  princi|)iilly,  as  intimated  I>eforc,  in  tho 
importance  of  disease  in  this  loeality,  is  the  danger  ttircatcne<l  to 
the  spinal  cord  at  its  most  vital  jturL.  Owing  to  tlio  heiul  being 
sustainci  >m  Uio  atlas,  and  the  ligaments  which  bind  the  latter  and 
Axis  tiigciher  being  unable  to  retain  tJiem  in  jionition,  the  weight  of 
the  head  is  liable  to  cause  tlio  atlas  to  gli<ic  forward  an<l  downward 
upon  tlie  axis.  This  movement  implies  that  not  only  am  llio  arti- 
cular surfaces  of  tlio  obliqno  processea  separated  from  each  other, 
but  tliat  the  oilontoid  procuw  of  tho  axis  is  detached  in  an  equal 
degree  from  tlie  surface  of  tlio  atlas  on  wh!>^h  it  turns.     Now  it  in 


•  Sw  IxioaiRs  or  iiik  Back,  vaL  ii.  jt.  Hi. 


86S 


DISEASE  OP  THE  SPINE. 


in  tim  laM-mentioned  rbango  more  than  anr  thlnfi  obo  that  the  I 
to  tho  s)>insil  «ml  cmisi.it*.     The  anterior  iin>li  nf  tin'  atim*  c«a 
bo  sejMrtlwl  from  tin."  oJontoid  process,  except  bv  Uie  stretoll 
and  elongation  of  tlx;  crnnitvrnw  li^^aiiMMrt  n-liich  rmbrticcis  tLo  ■ 
of  tJm  priiccwft,  and  of  tlio  actv^sory  restraining  hgani<>nt». 
oordingly,  if  tbu  woigli)  (hntrtctl  on  llm  mlan  I'bnnld  Ikj  suddi 
increjwod  wbilo  tii'm  exteu.tion  is  in  pro^rera,  and  die  ligament* 
caiTGS{Kiii<Tiii;;ly  »'cal>onrtl,  the  danger  if  imminent  of  tho  U 
being  nipltircd.      And  nhould   tliat  ir\'<nit  oceiir,  Hiora  would 
notliing  to  prrrcot  the  ntlas,  impcQod  by  the  weight  of  tlw  fai 
from  sliding  nbrii]>tly  forwaii!  on  tho  fnu-fiwo  of  tlio  JixiJi  to  ib 
most  reach.     Tho  consequciifo  of  tliis  <'on*ccutivo  dislocation  vra 
bo.  tltat  tho  pcniliariy  vital  portion  of  the  xpinal  cord,  c<nitai] 
witliin  tlie  ring  of  tl»  atlas,  would  be  sutl<lt>iily  {^rojtolled  by 
]>o»ti,Tiiir  arch  nf  that  bono  agniuM  tho  oiliintoi<l  pixtouss  in  fr( 
m  OS  to  bo  thorongbly  cmHh«)  between  tliem.     Its  funotiona  wo 
thus  bo  abolished  nt  once,  nnd  tlw  patirnt'.*  donth  be  instantaneM 
But,  happily,  thi>  termination  of  iheso  oasts  in  not  alvrnyR 
fbrmidabl(\     In  not  s  ii^w,  tho  transverse  and  rciitraiuing  liganu 
undergo  stivl<^hing  of  tbiir  fibres  witliont  Uting  nijrfurod. 
Gontinnc,  thcrrforr,  to  rt^tatn  a  hold  of  tlio  atlas;  and  to 
ch«-k  upon   it  as  it  glidcH  forwartl  ujion  tho  axi«.     Bceidcs, 
genoral   connecting  structures  around   tho  diseased  vert(>l>ne 
agglutinatt'il  tog<;th<T,  from  dojioMtioti  iiiiii  comleiDiation   of 
lablc  lympli.     Aerordingly,  the  shiBing  movement  procootlM 
and  gnidually.     Yci  the  dt«plavcnicnt  may  t.ikc  place  to  an  e: 
ordin.-irv  extent.     In  many  cases  tho  atlas  will  tic  traiufKirled  to 
Iront  to  such  a  distanci^  that  k-s«  than  ono-half  will  romain 
mi  iho  nxi.*,  thi-  anlftrior  part  protruding  uiiMupjxirtixl  bej-ond 
lercl.     When  (ho  dislocation  amoinit«  to  tJiat  degroe.  it  fiillon-H 
the  poKlerior  areh  of  th(>  Mthi.-<  will  eeasi-  tu  )h*  in  rulnlion  to  tliat 
tho  axis.      It  will  be  curried  so  far  forward  horixontidly  lliat  it 
<n-cn  bisect  (lie  vertubral  ojmal  into  oipiut  parbt.     Heneo  a! 
moiety  of  tho  area  a]>propriatcd  for  liohiing  tho  spinal  cwrd  will 
abiwliitcly  cut  off.     Now  it  luight  have  been  cxptvtcd  that  the 
of  material,  as  well  as  change  of  figure,  in  tho  part  «f  tliu  cord 
hod  to  accommodate  itself  lo  the  ennal  when  so  exteiuiirely  altc: 
would  hi?  iniTnmjialible  witli  its  pci-fonning  its  fnnotioii^     Nor 
Idsa  it  is  found  by  exiToricntro  tliat,  however  mtieli  eurtailiil  in 
proportions,  Ix-nt,  au<I  twisted,  tJie  pnrlion  cwresiwniling  to  tbo 
tortiid  and  contracted  canal  may  be,  the  whole  chango  in  tho 
may  \ie  cVXcwtoX,  \(v\Sm>\\V  \nccv$«i^ft.    V.  w  hIm  known  tliat  if 


DISEASE  OF  ATLAS  AND  AXIS. 


669 


I 


lysis,  induding  botJi  ui>jjer  and  lower  oxu-emities,  shoiiH  onsuo,  the 
paticrnt,  iiutwitiislaiidiug  tlio  iiltunttion  of  striictiuo,  niiiy  nx-jwvflr ; 
die  (liHloc^ated  vertobrao  vritl  !n>  suciirely  aukyloHed  ;  he  will  he  strong 
and  fit  for  any  occupntion ;  and  Ins  only  d«fo(;t  fvlll  bo  it  .■'tifl'  and 
(winewliat  contortt  d  ntvk.  Tht!  |iIienoni<>na  luv  to  be  ooiwunted  for 
according  to  tlio  patbologicid  jiriiiciplo  already  adverted  to  (p.  t*.'i9). 
'rite  dimiiiiit.iiiii  in  thn  Hiib.stumto  luid  dinligiin-nieiit  of  tint  cord 
gcnt'rally,  have  boon  i-onsoquciit  on  h  slow  process  of  intcmsUtisI 
«Iiangi';  inid  it  \inx  been  m-^h  tliat  deviations  fruin  llie  norniul  nixn 
and  shape,  of  tlio  most  sarprisin^ly  gwat  kind,  oan  bo  mado  in  tLo 
tipinal  vvrti,  an  \v<UI  il<  rlio  brain,  witliont  nacrilii^o  of  Uii^ir  ah- 
ilowinonts,  if  n-rouglit  in  tlmt  gradutil  mntitier.* 

A*  in  «[iiiml  di»c»&o  gencrully,  jR>rMin»  of  itt-rofnloiLi  liabit  nro 
prono  to  bo  affected  in  the  atio-axial  articulations.  Tho  last 
obMrvfxl  by  llie  writer  «-«■  in  ii  young  woman,  who,  juot  after 
recovering  from  disease  in  the&o  joints,  had  angular  deformity  from 
«iri<H(  in  tlic  duriuil  vcrtoijni!.  Tlic  nnwt  <:»mnion  ago  nt  whiuh  it 
ciimiiiencaa  is  near  puberty ;  but  neither  infantA  nor  adults  am 
vxompt. 

Symptom*.  A  general  swelling  around  tho  nape  oftbe  neok, 
nttondod  wi(li  stiffiietw,  and  pain  in  motion,  aro  tho  earliest  Endio- 
tioiiBof  tho  ditM^OAO  having  ftet  in.  The  patient  will  prefer  the  recum- 
bent position  to  being  erect ;  keeping  his  hoatl  sunk  in  a  soft  pillow. 
When  iipriglit  ho  will  iit«ady  his  heml  I>y  ploiHug  a  hand  on  each 


*  In  asjivduifn  of  conscRutive  dUIocAtion  of  ^eslla*  upon  t1i«  axis,  of 
wliidi  Mr.  Vaget  lias  givvn  nn  uccuiiitc  dcicriiition,  (lio  diipUratntnt  cx- 
COtdcd  wlial  hnn  liccn  stated  in  tbc  text.  Fully  twotliinli  of  the  ntU*  iiiUNt 
liaTO  been  entirely  lIiron*ii  oiT  tlic  (Urfiicu  of  tho  nxii,  leaving  oiic-tlilrd  niono 

I  snnl«d  Upon  Jl.  TiikinR  the  mcftsurcmcnl  of  the  part  of  the  vertebral  eiUiRl 
avftUuble  for  holding  tile  tpiiinl  cord,  it  wim  found  titflt  the  di«t«nco  ivM 
only  two  linen  from  tlio  odontoid  process,  and  thrco  liui>s,  M  the  most,  from 
tho  body  oftlic  >xii  lo  ilie  postorior  arch  of  Uie  atlas  (tliu  nortnal  ni«iuur«- 

I  incnl«  being  from  nine  to  clovoo  Udm).  In  lUo  it('t;k  uf  Uid  udoiiloid  pi'o- 
oetis  tlifrc  WM  &  <leop  ind«nt*tion,  which  proved  tUut  llie  tnuiiiversv  liga- 
roml  lia<l  retained  its  hold  of  (ho  atlna  to  the  liuit  iritliout  bdug  niiituivxl ; 

t«aii  tliiit  ihv  ilttplaoouieiit  had  Uiereforu  be«n  alow.  In  ftnotlier  tpteiiuea, 
ribed  by  tli^  wriltT  at  ^  «ei|uvl  to  Mr.  I'ugi-t'*.  the  diKloeation  mid  lur*- 
ireraeiita  oftlie  vurivliiui  uuiiiil  wvn-  ubuut  tin:  uim>'.  ItdilTcred  in  luiving 
a  llticUbooy  coiiiu-etinij  rod.  tivo-lliird.i  of  an  inrh  long,  formed  belmcen  tlio 
interior  ■arfaec  of  the  odontoid  pi-oeLVi.-i  And  thr  posterior  jmrfacc  of  tho 

'  anterior  areh  ofthoatbu;  tlittt  ».  liclwix^n  Uio  surfnocairliichbad  origiiinlty 
been  ni-ljciiktcd  with  caeli  otlier,  but  luul  hr»n  tliu«  widely  tepMuled  by 
tfae  ciTcets  of  tlio  diseate.  It  niuy  bo  infecrad  ihAl,  unl«M  lUe  ptroeen  of 
iliiplnonmeint had  been  slow,  a  beam  ofoiseoaB  structure  of  Ibni  doBCi^p- 

[ttou  eould  not  liavfl  boou  foriiwd.     Jlf^L-Chir.  Tnnti.\ci\.isai..^.'e^. 


870 


DISEASE  OF  THE  SPINE. 


fiide;  and  ifaskoil  to  rotnto  it.  tio  v>-ill  xUtTen  ]m  itcck,  anA 
Hw  wholn  body  round     The  nodding  motions  lie  will  be  able 
perform.     A  suddi-n  Jolt,  or  a  tap  with  tliv  htuid  on  the  cro' 
tho  Iimd,  will  give  pain.     An  (he  swelling  of  tlio  upper  part  of 
neok  mny  probubly  bo  niiKtiikcn,  at  first,  for  inflammation  of 
lympbatic-  glaiidii,  or  deeplj'  seated  abscess  arising  fix>m  some 
oaoiw,  the  most  certain  inuik^  of  dttciiliug  thu  qiic^lion  as  to  the 
nature  of  tlie  disoasi!,  is  to  observe  accurately  ibe  relative  \>on 
of  tbo  Mpiitoufi  process  of  the  axis  to  the  occiput.     Kotwithstandi 
it«  largo  six^*,  tliat  procct^H  is  not  readily  felt  in  tlie  normal  con<)itt 
it  lies  Buuk  in  a  hollow,  arched  over  by  tbo  lignmentum  nuel 
But  in  atlo-axial  diMUt-te  (lie  fpinuiis  proeeM  bix-oincK  ili»tii>ci, 
only  to  tbo  touch,  but  to  tlip  eye.     That  change,  however,  is 
coniwuiciit  on   the   axis   itsi-lf  protruding;    for  tliis   bono  is 
tionary.     The  spinous  process  apiwars  to  project,  mei-ely  because 
iitlas,  canying  the  skull  tqion  it',  glides  away  to  tlic  front,  there 
leaving  it  tnoni  exposed  and  deflne<l.    In  conformity  witli  llii.t  cxp 
nation,  it  will  be  porccivod  that  Iho  bead  droop»,  as  it  were,  upon  fl 
neck ;  that  f1i>'  chin  and  face  generally  iini  advancoi!  pn-lrrnntuiH 
forwanl  ill  comparison  witlt  the  throat ;  while  the  back  of  tho  M 
ia  deflcient  in  rotundity  and  fii!n4!«»  in  rcfcivnc«!  to  tlic  lino  of  a 
^ine.     It  may  hapjion  that  one  sidt>  of  the  atlas  will  mo^e  forwj 
norii  thiin  the  other  ;  when  thuro  will  be  luidtM]  a  littlo  obliqaily 
position  of  tho  head. 

Prognosis.  Many  patipiif/*  pass  through  all  stage*  of  tliis  oomplail 
till  it  ends  in  deformity  and  ankylii^j.s,  wititout  decided  i»dic.ad 
of  thc'spiiial  cord  being  aiFccted.  Yet  the  Surgeon  cannot  fiiil' 
be  in  eoni'fcnit  iijiproliciision,  and  to  watch  every  symptom  narrow 
Pains  darting  upward  to  the  back  of  tbo  Iicad,  and  siniultaneoa 
downward  over  tlie  siiouldor*  and  clavicles,  jx-riiapi*  givo  tlio  Si 
alarm.  Tlie  latter  sensations  are  somctimca  prolonged  to  the  fingi 
ends,  ui'companicd  with  slight  muscular  wcakncw.  Such  tt^-mptoi 
alono  might  be  explalneil  by  Mipposing  tliut  the  roots  and  trunks 
tbo  iicn-cs  given  off  from  tlie  cord  In  tho  notgliboDrliood  of  t 
disease,  had  heofiino  affected  by  tho  ]>roces«  of  displacement,  « 
lBOrhi<I  action  external  to  the  spine,  without  tho  medulla  itself  bcti 
involved.  But  prudence  will  not  allow  that  view  to  be  too  inn 
relieil  ujkiii,  Should  there  bo  added  any  symptom  of  tl»o  low 
estremities  becoming  paralyxod — na  a  tendency  to  triji  in  walkii 
or  a  sons*'  of  pricking  or  of  numbness  in  the  feet — the  comdua 
will  at  oijco  be  drawn  that  tho  morbid  action  has  ponctratod 
the  mcduAn.    \n  oeAiuxi  cuMA<^in  ^anJ.'^-KUi  of  tlio  lower  and  upf 


NECROSIS  OF  ATLAS. 


871 


STtromitiwi  will  bo  Imt,  iinperfootly  |iroiiouRi-R(l ;  and  it  will  poM  off, 

a  solitary  case  seen  hy  tho  writer,  tbc  mtiKilcs  bccuuid  uflbctod 

rith  tonic  fpoum  ;  tliu  wliolo  body  van  m  ngi<],  that  on  tomiiig  the 

>alieiit  in  bed,  she  rolled  with  tbo  atitfncsa  of  a  pcraoii  rcwiitly 

that  condition  lastul  for  a  niontJi;  it  gave  pliKW  gradually  to 

nary  paralysis, — from  which  she  eventually  recovered.     When 

Jic  paraplc'gia  is  complete,  tliv  pationt  is  in  u  »ingii1iir1y  helplesn 

ate,  being  dovoitl  of  voluntary  power  and  sensation  cither  in  tlio 

pper  or  lower  cxtromitics.      Yot,  notwttlistaiiditig  tlio  upjxirent 

tiopclowiKMu  of  these  casee,  oxperieuoe  proves  that  they  frequently 

nd  in  perfect  rocovcn,'.     Tho  ]>rognoeis  will  he,  of  coiii-!*',  more 

k-oiirublo  in  young  persons  than  in  tliose  above  tho  middle  period 

i>f  life.     Tlic  writer,  togotlicr  with  liis  collcagiio  l>r.  M.  Crawiord, 

jntleiidoil  a  man,  whose  age  was  forty-eight,  for  disease  in  tbc  ntlo- 

jaxial  artjoulations :  during  six  months  his  whole  body,  froin  tlio 

llifad  to  tlie  U^--->,  wti.«  [mmlysed ;  yvt  ho  eventually  rcco\'ored,  nitb 

jliis  neck  merely  stiS'and  distorted," 

A'ecjwM  ofcUlat.  Jieforc  quitting  the  snbjwt  of  dLieaacs  of  tlir 
flipper  vertebra?,  a  rare  afTeotion  of  the  highest  of  them  may  bo 
I  briefly  noticed.  Tliis  consirta  in  m%'ro»i«  and  oxfolintion  of  that 
[part  of  the  anterior  arch  of  tho  atlas  which  corresponds,  in  other 
Vi-rtcbra-,  to  the  body.  The  ilisenso  is  ooniwctod  with  ulocnilion  of 
the  bacJc  of  the  jibiit^-nx ;  and  it  has  b«en  commonly  observed  in 
Bvphilitic  patients.  In  the  roeordod  cases,  tho  wholo  tliickneos  of 
tlio  honi!  has  oomo  away,  a*  shown  by  the  artieiilar  surface  of  (he 
otloTiloitl  process  being  visible  on  its  jjosterior  aspect'.  From  the 
patient's  surviving,  it  cannot  l>o  doubttvi  thitt  tho  insortions  of  the 
transverse  ligament  had  been  prcfeencd  entire;  and  that  it  had 
retained  its  hold  of  tlio  process.  A  slfntghing  ulcer  in  tlws  pos- 
terior fauces,  with  occasional  attacks  of  difficult  deglutition  and 
breathing,  have  boon  tho  iiiorit  prominent  symptoms.  Wlion  the 
fragmi'iit  ha*  been  picked  away,  tho  sore  has  healed,  anil  (Jie  patient 
recovered.  It  need  seareely  hi-  said,  tliat  a  patient  who  lia.*  v.w\\  a 
threatening  disctuc,  in  a  situation  of  so  much  danger  Uj  lift!,  is  in  a 
critical  condition,  while  tho  dead  iHulion  <tf  bono  reinmns  as  a 
source  of  irritation :  and  that  tho  greatest  caution  is  <)cmanded  to 
protect  him  Groin  sudden  bonding  forward  of  the  boad.t 


•  S«e  the  jiBpct-  by  Mr.  Lawruoce,  "  On  IKsloaatious  of  tlie  Uppenoowt 
VerUbrtt  of  tlm  Ncok,"  in  MrJ.Chir.  Tiant.  vol.  riiL  Also.  '■  I.«ctmw  OO 
Fnin  and  Uio  ihvi-apeutic  InHucnM  of  Host,"  by  Mr.  Hilton,  Lanett,  Oct.  3D. 
,  JHO,  p.  361. 

f  Sv<!  case  nnmtcd  by  Mr.  Kcate,  In  th4>  IfrJkal  tiatelU,  vol.xvUl^^'. 


8TS 


DISEASE  OF  THE  SPINE. 


'i'jvaitiKid. 

The  f^nonil  course  of  treatmeiit  necesnrjr  for  Kjiinal 
the  same  that  is  rcqiiirod  fur  most  kinds  ofdtsvasos  of  tbejcifl 
9X  morliiw  vox^^,  ncrolulotLi  fivDoviUs  of  the  kno«-joiDt, 
the  ankle-joint,  &i:.  Tbo  remedies  mtut  be  directed  principally 
ttiutaiii  nnd  Ktrengthen  «  oonKtiluliun  originally  wi.-ak,  lutd  liabh 
be  Airtlicr  ckbilJtated  by  the  oflVicts  of  tbe  disease.  Hence,  all 
it  tntt>'  bo  noctuionally  nocc««ary  to  employ  depleting  meastins 
Hubduing  tcmporan'  aecDSiions  of  fever,  or  quelling  sliort  attiKh 
infill  I  rintntioii,  tln-y  an:  lulotitcd  willi  rt'Iiietaiiw,  mill  tbc  touic 
teim  in  otherwise  pursued  unintennijitedly. 

Of  local  remeiLiicfi,  '  rcift'  u  dcH-ni-diy  p)ac«d  at  tiio  head  of 
list.  Tito  oliji>ct  sou^lit  to  lie  gained  is  twofold.  First,  liv  fin 
tlto  dist^ucd  vertebra?,  wo  endeavour  to  prevent  jarring  and  a 
boiwi^n  the  ni^ii^red  opposing  surfaees  of  the  carious  bodies ; 
Ijy  removing  Uiat  soiuvo  of  irrilAtion,  to  vneourage  the 
tuition  to  ccnsc.  Sewndiy,  by  keeping  the  bones  at  porfcci  » 
we  afford  the  parts  the  most  favoiusblo  opportttnity  for  beooui 
eoiisdliiliitt'fl  liv  oNnific  union. 

TLo  most  effectual  method  of  arrvsting  motion  betw-oen  tJio 
eas(Hl  verteliiif,  in  nid  of  nature'*  effort*,  is  to  place  the  patient 
tJic  nxiumbcnt  position  on  liis  bade.  And  to  give  him  tJw  grtm 
udvantugi-Jt  wliili?  eonfiiunl,  it  vt  desirable  that  Itc  should  be 
nislied  witli  an  invalid-bed,  ]>rnvide(l  with  contrivaneea  for  cnabi 
liitn  to  lie  iiixin  it,  day  and  night,  witbout  rising.  Should  a 
of  that  kind  not  be  pi-ocurnl,  and  an  ordinary  cotiob  b<;  oaod, 
patient  will  lie  with  greaf*T  socurity  and  comfort  if  the  frame 
the  horseliair  inatlrais,  iiidlond  of  being  horizoiitiJ,  be  gently 
eliued  downward  from  tho  top  to  whore  tlio  hips  come;  and 
be  elevated  (but  to  a  sliglittT  dirgn^),  witli  ■  double  incline, 
the  kiiGcA  to  be  bent  over  tlie  angle.  A  Iwllow,  or  socket  fur 
reception  of  tiio  aiigid;u-  ]iroj(-ctiun  of  the  .ipino,  iuu»t  bo  toado 
tile  mattress.  Or  a  substitute  may  be  contrived  by  fillii^ 
india-rubber  pillow  with  xiuid,  or  Miilablv  grain  or  seeds,  : 
placing  it  midor  tlio  patient's  back,  protected  witli  bLmket  ; 
sheet.  In  young  persoux,  further  iwcurity  will  be  reqoired,  by 
closing  the  body  in  a  stiff  corset;  and,  perhaps,  by  .-itrupping  tbi 


"A  case  of  Exfuljuiion  of  tho  Anterior  ArtJi  of  llic  AiUh,"  by  Mr.  U.Wi 
Mcd.Uhir.  Tnint.  vol.  kxxji.  p,  KQ ;  Loctiira*  bjr  Mr.  Hilton,  Lamtel,  Uct. 

leeo.p.wa. 


TREATMENT, 


873 


ft 


raown  to  the  nouclt.     It  will  ittld  to  tlic  cotivftnicncQ  if  the  btxl-fi'aine 
[bo  portublc,  and  capable  of  hcing  oosily  tranfiforred  to  die  body  of 
Ian  invalid -carriage,  or  to  a  bciicli  in  tlio  •^nlvii,  witii  a  vi»w  to  tlie 
jiaticnt'i;  getting  frcsli  air. 

It  iR  iin  ImiHtrlant  duty  of  tho  Surgoun  to  cxcit  a  [wrvinptory 

authority  in  enfoi-ciog  conBncmont  in  tJie  retniinboRt  ponition.     Ho 

will  find  UiiN  tjisk,  a*  might  be  os|wcttHl,  more  difficidt  in  chiltlivn 

tliou  iu  adults ;  and  tlio  principal  cause  is  the  (latloiit's  being  iroo 

iVom  pain  in  tlic  innjofit)-of  caws.     No  doubt  can  be  ontortuinod 

{that,  however  luotlerato  may  bo  the  symptomB  with  whi(?Ii  the  di»- 

in  luhcred  in  at  first,  tlio  ini'ipi(^it  Kt<tge  i»  a  ptriod  duriiij; 

hiob  a  rigid  and  strict  obsetvanoo  of  perfect  rest  ought  to  bo 

inexorably  in^ii^tixl  upon.    And  the  time  over  wliieh  that  oure  sliould 

ixtond  cannot   be  estimated,   even  in  the  moat  favourable  cases, 

including  children,  uudor  six  or  ten  montbt.     In  [tatieiit^  ujijiruaeh- 

ing  adolescence,  the  eonfinemoiit  nuiy  be  longm-. 

If  tho  coAv  should  furtunately  proceed  without  puin  in  tho  baek, 
and  witliout  aboceaBes  proM^itiiig  tliemiiclveM,  for  tlio  number  of 
tils  mentioned  above,  tho  next  practical  question  will  bo  con- 
ing iJk!  jii-opriety  of  liberating  the  piitii-nl.  fnini  lii^  lung  durunc*'. 
That  is  eqitivalont  to  a«king,  how  it  can  be  ascorttuned  that  aailg-loeis 
shall  have  taken  place;  fur  it  ejiimot  he  of)ri>'ii)ered  safe  to  allow  llio 
paUont  to  get  into  the  upright  position  till  ilio  bones  have  become 
knit.  In  making  the  cxauiinutiun  of  tlie  angular  projection,  it  will 
be  carefully  observed  whetljcr  there  be  any  motion  between  tlic 
afToctud  bones ;  and  if  the  part  Ijc  (lorfbctly  stiff,  it  may  1r'  prt^uuicd 
that  they  are  united.  Should  tliere  bo,  at  the  saino  time,  atrophy 
of  the  muscles  in  each  trough  by  tho  side  of  the  protubei-ant  .tpinouK 
lii-fjoefiscM,  tliiit  will  confirm  the  opinion.  But  it  will  not  be  prudent 
to  n-Jy  on  tlio  solidity  of  tho  ankylosis  being  sufficiently  great  fur 
the  spine  to  support  tlie  body  unassisted.  Tho  patient  ooght  to  bo 
supplied  witli  artificial  nip|H>rts.  Space  duc»  not  allow  of  u  detailed 
description  being  given  of  tho  Wat  kuid  of  these  instnunents  to  bo 
used  ill  different  cases;  for,  of  course,  they  must  ^TUy,  not  only 
aceonling  to  tho  situation  of  tlie  disease,  but  tlie  age  of  tlio  jtaticnt. 
One  general  ivmark  may  bo  made,  that  tlio  corsets  ought  to  1>c  con- 
structed much  in  ttie  fiudiiflii  of  wotnen'it  sIavb,  so  as  to  embraco 
tho  body  above  and  below  equally  and  generally.  In  Mitfeiiing 
tlicm  with  steel  ribs,  as  prefemblo  to  wliiilelwne,  tlioy  ought  to  bo 
strengthened  as  much  to  the  front  as  practicable,  so  as  to  counteract 
tho  tendency  to  stooping  forwanl.  In  young,  feeble  children,  whoso 
K  bodies  are  soti  an<l  extremely  fle.\ibh;,  whilo   their  hips  are  too 


874 


DISEASE  OP  THE  SiTXE. 


ruuTow  for  l>cm{j  oectl  as  a  biiso  of  )(it]))>ort,  it  maj-  ho  found 
to  itnow*!  tlicm  in  separalfi  pienoa  of  j>ropj»red  lealJM-r,  mouMi 
ihe  body,  and  aftcrwardit  iiiscrtod  in  coracto ;  tlto  lateral  pi 
spiinbi  may  ^o  jn'oloit^I  (lownvran),  to  rest  on  tlio  smat  of 
chair,  jmd  brouglit  high  cnougli  to  rcaoh  the  arm-pits,  so  as  to 
iw  crntditHt  wliil«  »ittin^. 

Prone-awcJi.     A  mode  of  reclining  in  tho  prone  portion,  Jua 
of  on  iJto  Inok,  hm  been  rccDtiiinciidtil,  and  put  in  pructic& 
method  cousisu  in  making  tho  patient  lio  upon  tiis  cbeet  and 
doini-n,  on  lui  cloviiliyl  frame,  not  milikc  a  dfttk,  with  an  incli 
board  below,  U|»n  which  bin  legs  may  hnng  :  ho  is  prevented  fi 
sliding  by  pegs  at  the  top  roocaved  into  tin;  ann-pils.     Tlio  objoc 
the  position  is,  bv  fixing  the  upper  part  of  the  trunk,  an<l  allow 
tliP  hips  and  lege  to  glide  down  the  incliiio,  to  keep  tlic  spine  on 
stretch,  and  so  diminish  tho  aeiitencsa  of  the  angle  at  tbv  w-at 
disease.     But  such  a  design  is  ojipoecd  to  the  principles  that  hi 
been  advooatod  in  a  fonner  part  of  this  eway  (see  p.  845),  i 
about  which  the  highest  surgical  autlioritics  ooijioidc.     It  is  erU 
thiiL  if  tJii.^  angular  projoL-tion  bu  diminished,  it  oil  only  be  di 
by  separating  from  each  other  tiio  surfaces  of  tie  diseased  vortel 
which  oiiplit  to  c'oalcsf^ic,  thereby  i)ro\'cnting  ankylosis.     Moroo' 
as  tile   patiout  cannot  sleep,   and   cannot  empty  tho   bladder 
rectum  whilo  eonHncd  on  the  apparatus,  it  will  be  Di 
move  him  frequently,  to  the  great  injury  of  tlm  back. 

But  it  will,  perhaps,  bo  said,  diat  although  tho  eroploynii 
the  prone-couclt  bo  not  ndajitcd  to  cnriw  in  iw  iidivo  «big«,  it 
bo  advantageously  used,  to  improve  the  figure,  wlicn  ankykms 
been  effected.     That  de«iro  in  patients,  who  Iwn^o  made  a 
escape  from  a  disease  highly  dangerous  to  life,  at  the  price  of 
defornieil,  to  have  the  euro  made  pcricct  iiy  getting  rid  of  the 
on  tho  back,  is  a  very  natui'al  one ;  yet  it  not  unfroqucntly  li-ada 
tteir  running  into  new  daDgcrs,  in  the  hands  of  ignorant  and 
scrupulous  quacks.     In  a  fonner  part  of  the  article  (»eo  pp.  83 
844),  tlic  objections  to  scheme!)  which  Iiavc  for  their  object 
elongate  the  spine,  wiQi  tlio  view  of  rc*t«ring  tJie  khape,  have  b« 
stated ;  and  they  apply  to  this  plan  of  using  tho  prone-oouclt. 

Li  disease  of  the  ntlo-uxial  artieulationN,  tlie  danger  most  to 
apprehended  is,  that,  from  a  violent  falling  forwani  of  the  hca 
the  transverse  ligament,  in  its  stretched  and  attenuated  conditio 
abould  give  way;  and  tliat  the  utlus  should  tjiuii  be  permitted 
slide  forward,  and  compress  tho  spinal  cord  by  ita  posterior 
Specia\  caie  S&^  'Cl\«xe'i»««,tiii^anA  to  keep  tlic  head  and  seek 


.^^ 


TREATMENT. 


875 


pationt  in  a  state  of  perfect  rest  Accordingly,  oonatant  un- 
;uturni[iii'il  fimfiiu'inciiit  in  tlit?  rocuinbcnt  positiou  is  imtmrativcly 
Icuiandi-Hl.  Aiid  tlio  patiniit'ti  hend  oti^Iit  to  bo  Idtl  on  ouiihloita, 
iriiifli  will  prop  it  wjually  on  cvcrj'  side.  For  tliat  object,  tiie 
lia-rubber  )>illow,  stuffed  to  n  jinijKM-  d«groo  of  finiini-i»  witJi 
^ruiii,  H(i  tbat  it  tany  bo  easily  [ireased  into  a  hollow  wbidi  shall 
St  tlio  back  of  tlie  IuvaiI  and  nape  of  tlio  iivck,  in  to  bo  umkI.  Or  the 
jid-bags  recommended  by  Mr.  Hilton  will  be  more  easily  pro- 
A  baii<l  on^ht  also  to  I«;  ]tit.-wc<I  over  ihc  forehead,  from 
Jic  Bidt-s  of  tbo  pillow,  to  restrain  motion.  In  tbo  event  of  tho 
patient  boln;;  restless  and  liable  to  lifl  the  licnd  inudvertently,  ua 
luring  mcala  or  sleep,  it  is  a  useful  precaution  to  liave  a  shield 
noulded,  eitbi^r  in  {^ultA-pcrchn,  or  prcpimxl  loutber,  to  the  back 
of  the  neck;  this  ought  to  take  in  the  shoulders  below,  and  roach  to 
Itho  vortex  above,  so  that  it  may  be  socuRxl  by  bund*  both  to  tlie 
^'kbouldcrs  and  head,  to  arrest  movement 

Counter-irritants.     The  period  is  not  long  pa*t  when  i.tsues,  on 

■«ach  side  of  the  protuberant  nngl«,  were  almost  uni\'ersally  ordered 

I  ill  cases  of  defbnnity  from  caries,  whotlier  tlio  patients  were  young 

I  and  weak,  or  the  dincaae  a<'tilc  or  chi-onic,  or  llicro  woi-e  absoesaes 

I  or  paniplegiiL     The  use  of  them  was  attended  with  much  distre^n; 

and  tliey  hud  n  debilituting  effect  on  th«  const  it  ntion.     According 

'  to  tbc  practice  of  the  present  day,  iRsues  are  reaoned  for  subduing 

any  oiLinal  ucti.'?f»ion  of  tlio  morbid  action,  when  tbo  jiain  in  the 

diseased  verlobne  ia  greatly  incrciuted,  or  there  ia  a  tlircatcning  of 

j  poraiynis.     They  generally  oSbct  all  the  good  thoy  are  likely  to 

produce  within  a  short  time,  and  do  not  re<iuiro  to  bo  kcj>l  ojMn. 

^  JBIixtcrs  arc  attended  with  so  luucb  inconvenience  Eind  pain,  that 

an  seldom  liad  recourse  to.     Happily  the  introduction  of  tho 

roonipoDnd  tincture  of  iodine,  a«  a  kw»\  application,  1i:ih  supplied  us 

with  an  efficient  substitute  for  these  coarser  remedies.     As  in  cascft 

of  difica!M>«  of  the  joints  generally,  it  proves  itself  a  most  valuable 

agent  ill  caries  of  the  vertebnc.     Tlio  mode  of  its  use  nocd  not  be 

particularly  described. 

In  reference  to  the  treatment  of  abscefisos  connected  witli 
diseased  spine,  there  aro  no  special  instructions  to  bo  given.  They 
re([uiro  to  bo  dealt  with  ncconluig  to  tbo  general  prindplos  of 
managing  targe  collections  of  pus  that  oommunicato  witli  diseased 
[.jtMota. 

ALEX.  SlIAW. 


"DISEASES  OP  NERVES. 


Intboduwios. 

Two  dUimct  gronjiH  or  doAscs  of  symptoms  vaay  I>e  < 
lesion  of  a  uen-o  :  in  one  class  tio  «yini>U)ni»  aro  tlio  wflbc 
U)0  loM  of  function  «f  tlio  iicn~o ;  iti  the  otlier,  they  ore  due  to 
action  of  d)o  injured  aud  irritated  hctvc  In  tlio  tint  ciass,  ih 
toTVj  thu  K\*ni[>ti>nis  iirt^  duo  to  uitogctlwr  a  <)iftercnt  catuc  fi-oiu 
whio-h  exists  in  tlie  second  daas. 

Encli  of  tlii'sc  two  cliiHOs  of  Ky-inptomM  mny  b«  Mibji^'itied. 
tlicre  are  four  diflerent  kinds  of  nerves,  four  distinct  srmptoa 
loss  of  function  or  ccsiHttion  of  action  may  bo   olisn^'cd  aA 
lesion  of  u  nerve: 

Ifit.  There  may  be  a  paralysis  of  motion. 

2d.  'Hu-ie  niny  Iw  a  pitralyais  of  centripetal  ncn'cs  (mdi 
incito-motory,  &c.), 

3d.  Tliore  may  lie  a  paralyNK  of  tlie  vaso-motor  norve-fi 
in  consequence  of  which  the  blood-vcMcIs  may  be  distottded  and 
of  blood. 

4tii.  There  may  be  a  paralysis  of  the  vHtriline  uervo-i 
(crr«ii«iii*ly  called  inftibUori/),  in  coiL*oqu«ico  of  which  nutriti 
muclt  !e&8  aetive. 

It  is  not  my  purpuiK'  to  dwell  hero  upon  lhc««  ityni|: 
abaeDoa  of  action  caused  by  lesion.^  to  nerves.    I  will  iMnfine  m' 
to  tbo  study  of  some  of  tlic  olfects  of  in'it.ition  of  ncnos. 
efFect«  may  be  gnitiped  under  two  beatli*,— the  prri/iAfrie,  or  dii 
And   the   remote,   indirect,  or  re/iej;     Of  the   peripheric,   or 
efTectD,    I  will  ninijily  suiy  tlint  ibcy  give  ongin   to  lour  ki): 
symptoms ; 

1st.  Contraction  of  muBclc*. 

M.  IteforntI  sensations  (fonnieation,  prioking,  wroug  fi»t 
of  bent,  cold,  &c.). 

3d.  Diminution  in  tbo  ipiontJty  of  blood,  owing  to  tl>c  M>nl 
tion  of  bloud- vessels  in  the  ]iart  where  the  injured  nerve  distrib 
its  fibres. 

4  til.  Tlio  reverse  of  the  last  effect  when  the  irritated  ni 


REFLEX  EPILEPSY. 


877 


\iT(a  orfi  llic  nutriti\-c  (or  iiiliibitoiy),  willi  a  morbid  alteration  of 
otion  or  nuti'ition. 

Ofthcst!  four  kinds  of  sjrmptonu,  (Iirvo,  vix.  tbo  first,  third,  aod 
),  may  ol.so  \>o  catuiod  \>y  n  reflex  aetion.  I  jiropONO  in  tliia 
iole  to  treat  onlj-  of  theso  tliroc  kinds  of  rcfiox  Bj-tnptoma. 
Hanlly  in  tlicro  any  affection  that  cannot  bo  considered  m  bav- 
ig  soinctimea  been  produced  by  a  reflex  action,  cbo  oaUHO  of  which 
aji  injury,  a  diseiuc,  or,  ol  k^usl,  an  irritation  of  a  ncrvo.  If, 
istoad  of  confining  myself  to  the  lesions  of  trunks  and  brunclioa 
[»f  iicrveN,  I  intended  to  (b.'scribo  tin-  cfieot'*  tif  irritation  of  the 
|raniiflcatioii.4  of  nor\es  in  tlic  skin  <)r  in  the  mucous  menibraiies,  I 
[Oould  easily  prove  that  mttst  of  tlic  inllunniDition.'s  of  the  various 
oracic  or  abdominal  viscera  tako  place  through  a  reflex  aetion, 
1)0  Bliirting-iwint  of  which  Is  somo  irritation,  by  cold,  of  periphe- 
ric, sensitive,  or  centrijietal  norvc-fibrcs.  I  will  not  aay  more  liera 
iboiit  this  influence  of  cold,  as  m)-  piu-posc,  as  already  stated,  is  to 
wve  an  outline  of  tlio  rftHex  oflects  of  injuries  <)r  ilistejiMej*  of  oUivr 
I  of  nerves  tlian  the  network  of  their  terminal  ramiSeations. 
Of  tlio  various  reflex  cffw'ts  of  irritation  of  centripetal  norvcs, 
ho  following  are  the  principal,  of  which  1  propose  to  speak  sucoco- 
sively:  epilfp";/,  /rtoniw,  kt/strria,  eiuvra,  a,i\<\  olher  ftonvuhive  aj^ec- 
lions.  parali/iti»  a^tlane,  paralifgls  of  various  kinds  (hftniplfijia,  local 
paralij(v),  Ac),  amauro^,  amtvtliemaf  imanitfjf  deUrium^  ccftnOf  tiettr- 
aiffia,  and  other  pmn/ul  affeetionSy  in/tammalion,  atrophy,  tmd  other 
MOrHd  alterations  o/ ntitritmi  and  teeretion.  After  having  mentioned 
clear  and  ]K»^itive  faetit,  tdiowing  that  all  these  atfections  may  Ln 
Gaustxl  by  wi  iiyuiy  to,  or  a  disease  of,  a  nvn'c,  I  w^ill  briefly  give 

IUie  nilcs  concerning  the  diagnonis  aTid  treatinenl  of  injuries  and 
disuasoH  of  nerves.  This  essay  will  thcrefuro  eomiiftt  of  two  parts  : 
the  first,  relating  to  GicU  showing  tlio  reflex  effeciA  of  irritation  of 
centripetal  ncncs ;  tlio  second,  the  principal  fcMures  and  rules  of 
diagnosis  and  treatment  of  di.->ca.'«efl  and  injuricH  of  bmnolies  and 
tnmks  of  nerves. 
Part  I.    DiaE,vsKs  or  the  Neuvoijs  Cbmtrcs  asd  other  OanAvs, 

CAUSED  BY  AN  InJITRY  OK  A   DlREASB  OF  A  KeKVE. 

£piUpfy.     Of  all  tlic  nervous  complnintK  that  may  bo  duo  to  an 

Klarting  from  tlio  trunk,  branches,  or  ultimate  mmifica- 

of  ncnes,  none,  excepting  the  various  forms  of  paralysis,  'u 

[  more  frequent  than  epilepsy.     I>iiiea.4c»  of  the  inucous  membranes, 

tJicir  irritation  by  worms,  diseases  of  tlie  cerebral  meninges,  irritu- 


878 


DISEASES  OF  NERVES. 


tion  of  the  dental  ncn-e«,  &&,  aru  known  to  be  freqocnt  canua  i 
this  convttlxivo  afTecUon.  But  it  is  n<»t  so  well  known  tluit  a 
injury  or  a  disease  of  a  ncrrc  in  other  parts  than  its  terminal  rami 
6catioDH  not  nirely  prodnces  epilepsy.  Some  important  cases  ska 
that  no  doubt  can  be  ontertaincd  on  this  poiiiL  Sir  Bonjanii 
Brodie  m«iitiijii»  the  oa.se  of  »ii  offiorr  in  th«  army,  wlio  receivfd 
wound  from  a  muakot-ball  in  the  leg.  The  wound  IicsiImI,  but  th 
ball  rvmainud  lodged  in  the  fli^li,  in  Mimo  deep-geateJ  Aiiuiuini 
where  it  could  not  bo  fett  extenially,  uiid  giving;  tlio  patient  n 
inconvenience.  Af\(^r  xomc  time  the  ball  changed  it^  plaoe,  ho  tkd 
it  became  porceptiblo  to  tbo  touch ;  but  tltuii  H^nnptoms  appears 
which  had  never  existed  prcvioasly.  There  were  convuUive  tuit^ 
of  the  mnseW  oftlio  limb,  sometimes  followed  by  a  6t,  in  wtud 
there  w«re  general  oontnibionit,  as  in  epilepsy.  Tlie  ball  nii;,^ 
have  bcru  easily  extractijd,  but  the  opportunity  was  neglectod,  an 
the  bali  again  sliitkd  its  place.  "  Probably,"  !*ay»  Sir  BenjanuB 
"  it  wont  biiclf  to  the  xitnatiou  wliieli  it  had  ori^nally  occiiptod ;  i 
any  rate,  the  &]>nsms  of  the  muaeles  were  relieved,  and  there  wi 
no  recurrence  of  tlie  epilcptje  lite."*  It  ts  to  bo  I'e^cttod  tloU  t* 
more  details  have  been  given  as  to  the  symptoms  of  these  fita;  \m 
it  i«  not  probable  that  the  author  would  Iiave  called  thorn  r)>ilir{ili4r 
fits,  had  they  been  simple  reflex  eonvuUioiis,  without  loss  of  com 
sciouxnow  and  titc  other  features  of  epilepsy. 

A  similar  ease  is  rejiortfltl  by  a  very  able  practitioner  of  I'rovi- 
denco  (U.  8.),  Dr.  Parsona.  He  says :  "  I  have  recently  mot  witi 
tlic  case  of  ft  soldier  iu  our  Mexican  anny,  who  had  a  huUet-wounJ 
at  the  battle  of  Molino  del  Rey.  Tlie  bullet  lodged :  ton  montlu 
after  tlu»  ho  had  a  fit  of  epilepsy,  and  for  three  mi>uth.t  nfl«r  liad 
them  every  two  or  three  weeks.  Dr.  Kimball,  of  Lowell,  Massi- 
cinisctts,  cut  down  and  cstracted  the  ballet,  wbtcli  lay  near  to, 
not  in  contact  will),  the  sciatic  nerve,  close  to  the  iseliiatio  noli 
Up  to  three  months  after  the  operation,  when  Dr.  Kimball  repoi 
tJie  cii!«!,  no  fit  Iiiid  occurTed."t 

In  the  following  case,  recoi-ded  by  Dr.  W.  Ijaing  of  Aberdeen,  v 
is  <iuite  clear  (lint  epilepsy  was  caused  by  an  irritation  arising  froio 
wounded  norvos: — M.  D.,  xL  21,  hm!  tlie  left  (umd  lacerated  bj 
tnueiiincry.  She  went  on  well  till  tlie  night  of  tlie  6tli  of  Mnichi 
when  she  was  seized  with  convulsions;  and  after  a  day  or  two,  with 


♦  I^turft  UUutrativ*  <if  crrtain  ImmI  Jfrnont  4^«etion»,  London.  ISST 
p.  U. 

t  Pai'soDs,  in  the  Anurieaii  Journal  of  iMr  JM.  Swnea,  April  IHftl.  p 
itlS;  and  Kimbnll.  in  Jtotton  Mtd.  ami  Sarg.  JvuniJil,  Feb.  14,  I»«9. 


REFLEX  TETANDS. 


679 


Btrietnus  and  other  ttHanic  s^-mptom.*.  On  Ui6  7th  <i(  April  nlie  was 
fli^minHtKi,  aiTfii ;  but  on  tlic  24tli  of  Juno  bIio  returned  to  tlto 
hospital.      About  a  tbrtnlglit  a^i  ftlit)  Kuddeiily  foil  down  in  an 

|epilu[)tiu  fit;  nnd  since,  tlic  attacks  have  become  more  and  tnoro 
freqiiont,  rocurring  Gvo  or  oix  timos  a  day,  nnd  timting  about  five 
minutes,  after  which  she  romnined  a  conuderable  time  in  a  state  of 
stupor.  On  tli«  2Gtli  tlio  fits  wore  m  severe  tliat  xlio  was  put  in 
the  strait- waist  coat,  Wbcn  tlie  fits  wore  slight,  they  were  eon- 
fiiicd  eliii'fly  to  tlic  injured  arm.  On  touebtn;;  the  finpcns  smartly, 
I  the  ann  was  oonvulsively  withdrawn ;  and  wlien  tliis  was  done  while 
she  wax  lyin^  in  a  state  of  >tupor,  violent  conxnilHions  of  the  arm 
Ivero  produced.  Tlie  patient  often  felt  a  sensation  arising  from  tlio 
jinjurcd  hand,  previous  to  lier  fits.  As  tho  remainder  of  the  hand 
yKus  of  little  u.ie,  the  fore-arm  was  ainputatcl :  the  patient  never  had 
|ithc  slightest  appearance  of  epilepsy  after  the  operation,  and  was 
cured,  a  month  nfterwardi*.  Tlio  digital  branclie*  of  the 
Sisn  nerve,  and  a  branch  of  tho  ulnar,  were  found  enlarged  to 
iiar  or  five  times  their  ukuuI  si:ce,  and  tlieir  extremities  bidboits,  and 
Srmly  imbedded  in  a  bard  cicatrix.* 

Sir  Astlcy  Cooper  mentions  a  cnso  of  euro  by  excision  of  five- 
DighUis  of  an  ineh  of  tlio  radial  nerve,  f 

It  woald  be  easy  to  aecumulato  facta  showing  tliat  a  disease  or 

injury  to  a  nerve  may  cause  epilepsy,  and  tlint  by  the  section  of 

nerve,  or  by  some  other  a|>propnato  operation,  this  epilepsy 

fmny  be  cured.  J     I  have  seen  and  treateil  sueeewfully  siiveral  .tucb 

ases,  which  will  be  found  in  a  new  edition  of  my  work  on  Epilepsy, 

There  is  altio  no  doubt  whatever  that  various  alterations  of 

Inervcs,  not  only  of  the  limbs  but  of  the  trunk  and  of  the  internal 

Drgatis,^  may  cause  a  real  epilepsy,  absolutely  similar  to  tlie  idio- 

ntJiic  form  of  that  aflecUon. 

Tetamig,     As  objections  aro  daily  made  against  the  modem 

theory  of  tho  mode  of  production  of  traumatic  tetanus,  and  against 

itk  rational  treatment,  and  as  also  the  writer  of  tho  article  on 

Tbtakiis,  in  this  work,  Iia*  not  <iiscu!wcd  tho  importMit  ipiestions 

^-relating  to  tlie  nature  and  to  the  local  treatment  of  that  ad'cction, 

will  say  a  few  words  on  these  questions. 

No  one  can  doubt  thnt  it  is  owing  to  some  poouliar  infltienco 

•  Abenleon  luGriuar}'  R^iiuils.  in  lj>nd,  iltd.  GattUt  for  Dec.  20,  IMO. 
t  Locluws  iu  tlio  Lnnat.  Jlil  cci.,  IHifi,  vol.  ii.  p.  104. 
I   See  niy  Btacarclui  on  EpiUjiny.  lA*.,  Ih.VI,  |>a««)in. 
S  Cttppfi,  Da  Hitcii,  liiL'hUT,  Pui-tal,  BilloJ,  tx^  liaro  recorded  casM  of 
Icpilepny  du«  to  dineiucH  vf  ihe  phrenic.  pncUDK^gnatrtc,  snd  ajrmpaibetie 
crvc*. 


880 


DISEASES  OF  NERVES. 


1 


exerted  hy  Uw  irritation  of  some  centripetal  norve  tbnt  tetanus  is 
cauMxl  nflcT  a  surgical  l(!»iuii.      An  irritation  i^tarts  then  from  l 
iiervo,  reaches  the  itpinal  cord  and  medulla  oblongata,  is  refleote 
ajKiii  tlieao  veiy  contrcs  tlirottgh  tJieir  nutritivo  nen-os,    tbe  mt 
trition  of  tfac-iw  centrist  bocorae^  morbidly  increaitod  ju&t  n*  it  ■ 
nndor  tbe  influence  of  strychnine,  and  then  any  excitation  bring 
OB  reflex  spsutnis.     Hut  whether  thi*  iJioorv  is  the  inic  on<<  'ir  not, 
will  not  attempt  to  decide  here,  as  my  wish  now  is  siniply  to  shov 
thjU  this  convalsivo  affection  i»  tnily  depcnduiit  upon  tJio  irritotioi 
arising  fron>  injured  nenes,  and  what  the  trentmeut  should  \», 

The  relation  between  tlie  wound  and  tctouns  is  clearly  Bhown 
in  thoHO  caseii  in  which  tbe  musnleti  attacked  witli  spn^nis  are  oi) 
the  side  injured.  LepclletiL-r,  Sir  Gilbert  Blanc,  Sn-an,  Dapiiytno, 
and  Air.  Curiing,*  who  eili^  the  preceding  authors^  liavv  iiocn  taA 
cases.  My  friend  Dr.  O.  H.  B.  Uadeodf  relates  two  cases  of  bat 
tctaiiii«,  in  w)ii<-)i  tlie  tctanio  spaaintt  were  almost  entirely  limiloi 
to  ilie  aide  injured. 

It  may  seem  strange  that  tetannii  will  follow  tbe  sligklal 
wound,  that  it  will  come  at  any  period  of  inflammation  or  dcdri' 
saUon,  and  when  them  is  no  pain  nt  all  in  the  wound  or  its  neigh' 
bourhood.  But  thin  is  no  objection  to  the  view  that  it  talics  place 
by  a  retlcx  actinti,  as  wo  know  that  all  the  morbid  or  normal  reflec 
actions  may  take  plaee  witliout  any  semtalion,  or,  ut  any 
wttliout  pain. 

The  kind  of  lesion  that  moat  frequently  produces  tetanus, 
plies  that  there  is  a  great  irritation  of  nerves,  although  there  nay  be 
no  marked  piu'n.  In  u  tiible  ^ivt-n  by  Sir.  Poland  {in  this  work^ixl.  i. 
p.  607),  wc  find  that  out  of  1342  cases  ofmajor  and  minor  opviatiooi- 
at  Criiy'ii  Hospital,  thi^re  was  but  ono  case  of  tclanug ;  ivhilo  out  of 
39S  cascfi  of  compound  fractures  and  !)9i  cmmb  of  wouikIs  ofsO 
varieties,  there  were  18  rases  of  tetanus;  giving  a  proportion,  whra 
the  nerves  were  Hiroply  divi<led  by  a  sharp  kru'fe,  of  ono  caw  of 
tetanus  out  of  1364  patients ;  and  of  one  case  out  of  S5  patient^ 
after  wounds  and  frnetui'Cfl,  when  Uie  iiervtw  were  bruised  or  irri- 
tated hy  pressure. 

The  cnAo^  !<)iowin<r  that  tetanus  may  lie  cured  cither  by  im 
amputation  of  a  limb  or  by  section  of  a  nerve,  clearly  prove  Ih* 
dependence  of  ih'm  iilfeetion  un  an  irritation  slai'ting  from 


i 


•  A  Trfatue  nn  Ttlanu*.  r/OniJon,  IMO.  pp.  87,  174. 
t  Sue  hi*  excel  IcQt  work,  Hotnon  tht  Sargtry  t>f  Ike  War  in  the 
1868,  pp.  15.V10I. 


REFLEX  HYSTERIA. 


crii)lieri<'al  part  «f  n  iiftrvc.  Those  who  maint.-iin  lliat  totuini*, 
rboD  it  lins  fairly  bogiin.  and  attaclcod  itot  only  tho  lieud,  but  the 
ink  mill  Iiin1)«,  viLiiiiot  he  ritreil  by  thcKO  upi.'i'iitioit.'',  Iiuvo  nut 
■pad  t}io  dotailw  of  tbo  cases  of  core  wbicb  liavo  been  publisliod. 
io  doubt,  that  in  mfiny  «isi>!«  in  wbich  tlm  i<[>inul  (wrd  U  citlior 
Samed  or  rendered  extremely  excitable,  the  section  of  a  nervo  or 
lunputatioa  will  be  of  no  avail ;  no  iloulit,  nlto,  that  if  an  in- 
nmation  has  been  projiagatod  higli  up  in  tlie  trunk  of  a  iiorve, 
rard))  it«  rootH,  tliiwo  opcruLionR  will  be  uselons ;  but  it  ib,  nevor- 
tAetSf  most  important  to  ^vo  tbo  chanw  to  the  patient.  I  need 
lot  say  tliat  tbc  i^iuiplo  division  ofa  none  will  alway  be  proferrod 
lui  amputation,  unless  tlicro  ant  mme  special  reasons  for  Ihis  JaHt 
[Operation. 

JJ;f/iirria,     TIio  extreme  frequency  of  this  affection  i»  tromen 
endcre  it  difficult  to  prove  tliat  sometimes  an  irritation  of  a  ncrvo 
lite  cause.     However,  tlicre  arc  rases  in  which  it  seems ijiiito  clear 
bat  hysteria  is  due  to  a  wound,  or  cured  by  tlic  extirpation  of  a 
nour;   leaving   liardly  any  doubt  that  tliis  alfection,   liko  all 
(others,  may  be  the  result  of  an  irritation  of  a  nerve 

Two  \ery  inlurosting  «a»es  are  related  by  Dr.  Pursons;*  one 
!  obser^'ed  by  himself,  tlie  oilier  by  Dr.  S.  P.  HUdreth.  Tho  first  of 
[  tiiesc  cti.-«!!t  wiw  that  of  a  young  girl,  svt.  17,  who,  after  a  wound  of 
'the  lefl  tliumb,  was  attacked  with  pain  in  her  arm,  neck,  and  head, 
[and,  after  a  few  weeks,  of  a  hy^tcrieal,  biirking,  dn,-  coiif;b,  almu-tt 
ineessant  while  slie  was  awake.  After  tlie  i-eraoval  of  tho  cicatrix 
she  iuijiroved  gradually,  though  slowly.  Six  or  w^von  inoittlM  after, 
^ft  relapse  occurred,  when,  on  tbo  appantion  of  a  slough  on  the 
I  wounded  finger,  her  barking  mendtnl ;  and  after  the  separation  of 
I  the  slough  her  cough  c4kiehh1,  and  has  not  troubled  ber  since. 

Morgagni  mentions  the  easo  of  a  young  girl  who,  after  a  woiitxl 
I  to  a  finger  by  tbo  biting  of  a  sparrow,  was  attacked  with  fits  of 
I  trembling  and  screaming,  recurring  sixteen  or  eighteen  times  a  day.j 
Raynaud  relates  the  cafie  of  a  woman  who,  after  liaving  received 
[■a  blow  on  tho  breast,  had  a  first  attack  of  ht'steria.  Two  small 
,  tumours  soon  apjtoared  at  tho  injuri'd  plaei),  and  for  seven  years 
I  hysterical  attacks  occurred  several  times  every  day.  These  tumoun 
removed  by  Boyer,  and  iukini^liatol}-  nft<.T  tlic  ojH'ratioii  tho 
I  ceased,  and  did  not  rocur  agaiu.^ 


■  Ameriean  Joum.  ttfUit  Mtd.  Sdencet,  April'lSSl.  pp.  30T.  313. 

t  IM  StJibus  el  CauHi  Morbonm,  Lutetiu.  Wii.  rol.  vi.  p.  913,  qpist.  Ur. 

;  lUj^DKud,  in  Arekitr*  tit  3Mfeinf,  I8i9.  vol.  iii.  p.  434. 
TOL.  Ul.  8  L 


882 


DISEASES  OP  NEUVES. 


Tliroe  yean  ago,  in  n  pationt  of  mine  orn  liigbly  norvotu 
peroincmt,  but  who  never  had  had  any  marked  symptom  of  h 
oonvulsious  and  delirium,  with  some  degree  »f  liwk-jnw,  freq 
appeared,  and  ccaiwd  for  three  or  four  days,  aAer  a  slight  wound 
a  iiftodio  in  the  front  of  the  knee-joint,  just  below  tJic  pot^lUL  Th 
noedlt!  broktt  nt  tlio  timo  rpf  the  aceident,  and  a  smaU  part  of  i 
remained  under  the  skin.  As  soon  as  the  pain  ccii«od  in  tfao  UlA 
woun<l,  after  the  extirpation  of  the  point  of  the  needle,  the  padea 
got  well,  and  has  had  no  return  of  Iiysterics}  sj-mptoms  sim;*. 

Brachct  has  seen  a  temfxinil  neunilgin  produoe  hysterical  6t 
every  time  it  appeared,  and  for  all  the  time  it  lasted.* 

Sir  Benjiunin  BrocUe  montionn  several  ca»««  in  wbieli  a  wwini 
was  the  eause  of  hj'steria.  In  one  of  the  cases,  a  young  lady,  xt 
11  or  13,  pricked  a  finger  with  a  pair  of  scissors.  Tlio  arm  wa 
soon  convulsed,  and  by  dt'-grct^  the  other  limbs  were  also  aSecto 
with  violent  spasms.  Various  hysterical  symptoms  ap; 
recurred  nceiutionally  for  two  yiors-t  In  another  csutc,  hi 
was  brought  on  by  a  fracture,  and  continued  many  weeks, 
same  patient,  two  years  hofore,  bad  been  attat-kcd  with  h; 
sj'-mptoms  after  a  slight  injury  of  tlie  ankle.} 

In  eases  of  cure  of  hysteria  by  lui  np^mUon  (wImHIh^t  tbci 
comphiint  is  due  to  an  oxtomal  cause  or  not),  wo  must 
that  any  great  iiiipty>SMion  on  the  nervous  sy»t4Mn,  citiior 
physical,  niay,  as  has  been  well  shown  by  Sir  Benjamin  BrodJc^ 
euro  the  jmtient  at  once  Tli»t  hy8t<^'ria  will  sometimes  rotom  aflci 
an  operation  that  bad  seemed  to  bo  siic^^essful,  h  also  clearly  esM' 
blis)ie()  by  the  following  coso,  narrated  by  Sir  Benjamin:  A  young 
woman,  atlor  having  been  bled,  hiiil  piiiri  extending  fmm  tlwcic*- 
trix  along  tlic  arm,  and  on  tlio  side,  log,  and  foot  Tbo  arm 
cold  and  purple.  The  cicatrix  wa.s  exciaed,  and  Uiere  was  an  ioi' 
mediiite  relief.  Tho  wound  Eiaving  healod,  she  left  the  hospital  s> 
cured.  Two  montlis  afterwanls,  however,  similar  hysterical  symp" 
totmt  Hhowetl  themselves  in  otlier  parts  of  the  body.f 

It  results  from  the  above  facti*,  and  from  many  otJier  cases  ft* 
whicli  1  have  no  room,  that  hysteria,  like  epilepsy  and  leUnus, 
may  be  caused  by  an  irritation  of  a  nerve. 


*    ?Vai«Ar//y»tr>M,  IM7.  p.  SOS. 

t  I.feturtit  iUu»lraliv«  of  txTtaw  Local  JWrnnw  Affteiioiu,  1887,  p.  4ft.  In 
this  woik  Sii-  DcMJaniiii  does  not  say  how  loog  llm  p«tirnt  ivmatuo<l  hyt 
tci-ioal ;  but  he  ineuUouB  Ibis  point  m  the  LonAm  Mti.  Oat.,  IS30. 

I  Loc.  cit.  p.  46.  ^  Loo.  GiL  p.  89. 


CHOREA  AND  OTHER  CONVULSIVE  AFFECTIONS.  883 


Chorta.  £v«n  St.  Vitus's  cbuico  may  Iw  causwl  by  «ii  injury 
^to  n  nerve.  l>r.  BurclU,  of  Turin,  has  scut  U>  tJic  Park  Sock'U!  do 
Chirurgio  a  cjuo  of  cliorea,  CHUitcd  by  a  neuronm  of  Uio  loot,,  iu  ii 
chilti  13  years  old.  Tlio  convul§ivc  afli->ction  liad  lasted  five  or  sis 
nontJia,  and  was  at  once  diiniiiUliod,  and  iti  four  days  curod,  afUir 
be  cxtir[>ation  of  the  neuroma."  Prof.  Andi-al  mcotiona  a  case  of 
sliorea  <>aiii<«d  fiy  Uic  irrituttott  of  u  fingt-r  hy  >  n^iTOvcrtwi  pail,  f 

JSydropltohia.  No  clear,  positive  case  of  this  terrible  affection, 
v\\ffa  vauKod  by  the  bito  of  a  rabid  unintal,  lta.t  «\'or  been  curod, 
aitlter  by  the  section  of  a  nerve  or  by  any  otlicr  moans,  so  far  as  I 
Already  in  tlic  last  century,  liowcvi-r,  Mr.  0.  Hick.f  pro- 
sed the  division  of  nertos  as  a  moans  of  treatment  a^inst  hydro- 
phobin-t  Or.  Stokwt,  of  Dublin,  has  kindly  cominunieatod  to  ino 
most  im|>ortant  ca-se,  iihowiiig  that  tJicre  is  good  ground  to  hoi>e 
lint  liytlroi)hobia  miglit  sometimes  be  curod  by  tiiu  division  of  a 
nerve.  § 

7'rYmjilom  movements.     The  so-called  trfnxbling  pf^^t  wlueli  bo 
en  coDsista  simply  in  involtintary  In^inuloiis  moveuieiita,  witJiout 
(iiiy  ynUy,  may  bo  caused  hy  an  irritation  starting  from  a  nervo. 
IBabatierlJ  relates  the  cane  of  a  young  man  who,  after  a  woiinil  of 
sapliienous  nerve,  near  the  knee,  was  attacked  witJi  violent 
embting  of  the  log  and  tliiglt,  which  liuitcd  many  montiin.     In 
patient  sent  to  mc  by  Mr.  Ericliscn  an  injury  to  a  nitrve  of  the 
arm  Imit  pro<luccd  trembling  in  both  arms.     In  Home  cases  t]i» 

Dg  beooines  gaoerai.^ 

JtobUory  tOHBuUiens.     1  have   fooud    tliat   an  injury  to   (fa« 

hudhory  nerve  in  animolii  i»  at  onee  followed  by  rotatory  move- 

ncnts.     I  do  not  know  of  any  oa^  of  a  wound  of  that  uorve  iu 

nan  having  jtroducuil  tlio  naittc  symptoni.t;  but  several  easea  are  on 

ecord  in  which  these  movements  have  bocii  observed  in  man  wltcn 

I  auditory  nerve  was  irritated  by  an  inflammation  or  some  otbar 

(an  injection  of  cauatiu,  &n\).     I  would  refer  tW  thrao  eaeoa 

my  work  on  the  Central  Xtrvotu  System,  p.  195. 


*  OnsfUe  <Ut  Hipitnux.  1850,  p.  iM. 

+  Cuam  de  PiUhaloyU  iiiUrm,  vol.  iii.  p.  30i. 

;  fioait.  Mtd.  and  I'hyi.  Jaurtutl,  vi>l.  svii.  p,  Si7, 

^  The  case  aWvq  tneiitioncd,  and  tlii-  imioDs  I  hare  fijr  the  hope  I  hav* 

pressed,  will  be  toutti  In  th<i  Appendix  to  my  uork,  Ltrtunt  on  tk*  PA|^ 
nol.  rtn^i  Pathol.  •>/  tht  CTMral  N<Tiimt  Si/tUiK,  1800,  p.  2«1  et  »eq. 

II  Mtiledne  Opfratoirt.  vol,  i.  p.  't^i. 

^  Aa  Inquiry  amvfming  ConttUatwiutl  trritatum,  \)y  Boi^.  Travora,  IKJfl, 
p.  ]  I& ;  OLud  a  'I'mUiu  on  Dittattt  ami  Injuria  of  Ntnc*.  \>y  3.  Swau,  ltt94> 
|>.  124. 


884 


DISEASES  OF  NEEVE8, 


I  ncrr 
itifulti 


Rotiitory  movoments  arc  also  sometiincs  cattsed  hy  an  irritatii 
of  nnotlicr  Dono.  1  havo  tburKV  tliat  tying  tJic  ltlw>d-\'Vf«da  n 
nen-cR  of  quo  of  tfao  aupra-renal  capsules  sometimes  causes,  sfl 
eight  or  nine  houix,  rotatory  raoTrmcnbi  to  take  place ;  bat  I  i 
not  know  of  nny  case  in  whicli  Ihiti  s^TDptnm  lias  bc<en  obscm 
when  the  aupra-ronal  cajjsules  haro  boon  dLwasod. 

Jtffba  paraiym.     Every  fonn,  ^'cry  kind   of  pantlrxifi,  hi 
been  produced  by  a  reflex  action  caused  by  an  irritation  of  a  ncm 
In  children,  c»]iecially,  reflex  imralyiUH  is  very  froqueiiL     [n  tui 
tlu  muscles  of  the  eye  are  very  often  paralrBcd  by  a  reflex  action.  | 

I  would  refer  to  mr  woric  on  Parafgti*  (if  ifif  Ixncn-  LitiJn  i 
modo  of  production  of  refleix  paraplegia.     I  will  only  try  tol 
hero  that  a  wound  or  n  discaiw  of  a  itcrro  may  prodaoo  either 
lociJ  paralysis  or  a  hemiplegia. 

I  wilt  not  relate  individtuil  caK-N  to  prove  tluit  the  irifl  may  I 
paralysed  by  a  reflex  action.  A  neuralgia,  or  an  irritation  rf 
dental  norvo,  coming  when  tlic  [lain  conioif,  and  diminishing  < 
ceasing  witli  it,  are  so  oflen  the  causes  of  mydriasis,  tlint  it  is  n 
nccci«8ary  for  mo  to  mention  ca«!8  of  which  overy  nii>(llc«]  man  h 
seen  or  beard  of.  The  various  mnseles  of  tlie  eye,  tlio  recti,  si 
obiiciuv,  and  also  tlio  elevator  pnlpebne,  \\»\r>  been  found  paralyM 
cither  each  alone  or  »e\'<>ral  together,  in  cases  of  wouml  of  d 
infra-  or  supra-orbital  ner\-cs,  or  in  cases  of  neuralgia.  I  hal 
Been  sercT'al  cases  of  that  kind  of  paralysis  (caused  by  n  nonralgit 
and  all  charaetoriscd  by  tlioir  evident  rolntions  with  that  cause. 

In  a  case  of  rettcx  parulysi.'^  wliicli  I  liave  carefully  wateba 
a  oprain  of  one  arm  at  the  olbow-joint  soon  produced  a  paralyns " 
both  arms,  but  more  innrked  in  the  uninjunil  arm  than  in  the  oUifl 
Kverj-  change  in  the  dcgi'ee  of  pain  in  the  injtu'cd  elbow  wi 
accompanied  by  a  eorrCKpondJng  change  in  the  degrpo  of  tlio  [«« 
lysi« ;  and  up  to  the  time  I  wTife  tlicso  lines,  the  pain  having  cew 
for  several  years,  the  paratycis,  wbicli  cca«!d  with  it,  has  iwt  rwq 
pearcd,  and  the  two  arms  have  as  great  power  as  they  ever  In 
befoi-e  tlie  injuiy. 

Cases  of  hemipleglii  owing  to  a  neuralgia  arc  much  rarer  thai 
cases  of  loenl  paralysis  Hmited  to  a  part  of  a  limb,  to  thu  faee,  ill 
«ye,  Ac,  Dr.  Sbfiirninn  hiis  ptibliiJii'd  a  mosi  i»u-W'^ting  CB»  • 
hemiplegia  of  tlio  n'^ht  liiubs,  caused  by  tic  douloureux  of  the  rig 
inferior  maxiilnn-  ncrv«.  The  patient  was  cured  by  toniot  ai 
galvanism.' 


•  Protsnei-il  Med.  aaJ  S»r^.  Journal,  Mny  lA,  lUt. 


REFLEX  ANESTHESIA  AND  AMAUROSIS. 

I  Iiava  oolleoted  »eventooii  I'asca  in  wliich  there  waa  Iicmiplegia, 
duo  l^i  u  riiflox  iiiflupiiciC,  Htartiag  from  an  Irritation  of  eitkor  the 
L  trigemiaal  ntTve  near  its  urigiii,  or  of  ilie  c.rM  cvn-hciWi.     I  luv« 
[xhuwii  eU'wlicro  that  the  paralysis  in  those  caaea  is  a  refl«x  one." 

Sir  Aalloy  C«(»)x*r  inoiition.t  Uio  following  fwt :  "  Mr.  TnuUnin 

I  Bttcrnktl  a  lady  on  account  of  her  sutforing  severely  from  a  diseased 

,  iooUi,  and  rIio  ujtptnircd  also  to  be  afllicU(fl  uitli  lic'inijiIi^L     Mr. 

Toulinin  extraotcd  the  tooth,  and  in  a  short  time  the  pcu-aJytia 

affection  eiitiruly  Bul)»i(lijd."t 

Ano'sffi^tia.     A  reflex  ansestlicsia  is  not  rare  in  cases  of  neur- 
algia.    I  huvi^  i«<vn  wvend  cane^  of  luiiv-itlieitia  of  the  whole  oi'  one 
nde  of  tlie  fuf  e,  in  oases  of  ncuralgiii  of  one  [tart  of  the  tri^miiial 
ticrve  on  tlu!  hiuik-  itiilo.     I  have  mien  iil.o  ii  ojiao  of  ana^^lhoHia  of  a 
of  the  forehead  and  faee,  in  (ranscqueiico  of  the  irritation  of 
La  branoh  of  the  fitUi  pitir  on  the  cheek-bctiu^  by  a  brui.^e.     In  tlioae 
the  aiiajsthesia  subsided  when  its  eaiise  was  cured. 
Arwtunw.     Wardnifi  rflates  a  etufc,  in  which  (ho  sujira-orbitalii* 
InBrve  was  diviilefl  between  the  injured  sjwt  and  the  brain,  and  llio 
I  Ainiiui-oNi-1  enn\l  soon  aftcrwjuxU-t      Notlji,  in  iui  exwlh-nl  |ia|)iir,§ 
[states  ttiat  in  ton  <:ast:ii  of  ttniaurosis  caused  by  a  facia]  neuralgia 
(either  of  the  infra-  or  of  tho  cupra-orbitjil),  the  low  of  ^-i]>iun  was 
on  cured  after  tlie  cui-o  of  tlie  nouraJgijL     I  iiavo  seen  two  such 
Icosios.     In  oaswi  of  tlii;<  kind,  tlio  aniuiu'oi^is  inen-axoit  during  tho 
lutooka  of  neurol^a,  nnti  dt^roHMM  atU-rwanK     Dr.  Koyes,  of  Now 
York,  has  lately  oxamincii  wiUt  the  o[ilifhjilnio!M:'o|K)  thu  ntliiia  of  a 
patient  (a  niodiciil  iniui),  who,  atU^r  u  blow  on  Ills  forehead,  had 
become  amaurotic,     Tlie  only  alteration  obscrvod  was  a  diminution 
of  sine  of  the  t^enlml  Jii-liTy  of  thn  retina.  ||      In  an  importiuit  coso 
recorded  by  ilr.  J.  Hutchinson,  the  two  eyes  beeiunn  anuiuratie,  in 
oonsoquenco  of  an  injury   to  tho  supra-orbital  nervo  of  one  8i(I& 
Tiio  ophthahnoscope  showed  that  the  retina  and  optie  nerves  were 
atrophied.      The  accident  hmi  taken  jilaeo  ten  years  before  thia 
vxaniinution.^     1  eould,   if  necessary,   mention  niuny  otlier  fa^-ta 


I 


*  Ltct.  on  Oi*  PhgrhiUyy  ttR<l  PiUliohgy  of  Ui*  CtuUiii  Ktnoat  Syttem, 
pp.  SOI.  304. 

(  t«(,  on  tlie  PrittcipUi  rtnil  Pfuctie*  iff  Surgrry,  IPS*,  vol,  i.  p.  0.  Dr. 
Castlv.  uf  N«w  Vurk.  iq<;iiUodh  u  eiise  of  paraplegia  cuumhI  by  decaf  od  t*ctli 
quickly  euix-d  hy  the  exlu-pation  of  the  t«eU)  {Crutat,  Ittie,  toL  U.  p,  S4T). 

;  Med.-Vhir.  Trim*.  voL  xii. 

§  Archiva  gfu.  de  Mtd.Chir.  &o.,Juillct  ISH,  pp.  li-ti. 

II  Amtritan  Mfl.  TtniM,  Mnrnh  \f>.  1802. 

%  ittd.  rimM  aitd  Gaitiu.  May  7.  ISaS. 


im 


DISEASES  OF  NERVES. 


be  pfl 


iltuwing  llial  amaurosis  may  Iw  produced  by  s  ro6ex  infl 
au  irritation  »tar1ing  IVoin  a  centripetal  itcnc,  unci  ctipccull. 
trigtiniiiiil. 

Neural^.    Tho  fp«iuo«cy  oF  tk  doulomvttXf  caused  by  an 
tnliiiii  "1"  M  small  jiart  of  Uie  dent«l  nerves,  iit  such,  llmt  it  i* 
toinh'  nH'Icss  to  nicittioii  ca.'tois.     But  tiv  douloureux  mar  he  ca 
by  irrtl.itions  of  other  ncrvea,  while  also  an  irritAtion  oftlic  Da 
of  the  jaw  may  cause  a  iieuralgin  cWwhcre  than  in  tho  faec. 

Mr.   lliu-vey  hi<x  ticeit  a  cuac.  of  I'u-  (loril<Hirvux  caused  b 
tnmour  on  the  head ;  most  likely  pressing  upon  a  nerva     It 
owertaiiuxl  wcvond  timc!<,  tlint  pn-sniirt^  on  tlic  tmiitHir  hronglit 
severe  attack  of  tic.     Tlio  jjaticnt  was  cm-ed  by  tlie  nimo^' 
tuiiwnir,* 

In  the  case  of  a  patient  of  Mr.  Gay,  then-  vena  ii  in 
tho  ^rarious  ni.T\'c!«  nf  Uir  li'^,  r;ui>fil  by  a  i)eun>inn  of  the 
tibial  nonii  near  the  os  calcis.     Excepting  a  [>ain  remaining  in 
small  brancboK  of  tierv-cs,  the  nouralgtu  wa»  cured  at  once  after 
removal  of  the  neuroma, 'f 

An  injury  to  a  ncr^'o  in  one  side  of  tlic  body  may  even  (mdi 
a  neuralgia  in  tho  other  side.  A  girl  had  a  tu-uralgia  of  the 
temple  and  side  of  the  heatl,  caused  by  a  scvciv  cut  over  Ihf  r 
parietal  bone  A  blister  over  lliv  olriiirix  n-Iiovvd  tho  patient 
same  timet  I  have  seen,  with  Dr.  W.  T.  Gairdner,  a  ewe 
nuuralgia  of  one  arm  extending  ofUin  to  many  other  parts  of 
body,  and  caused  by  a  n-ound  of  the  hand. 

Two  caiws  of  notu-idgia  of  the  arm,  eau»c(l  bj-  an  tnitalMfl' 
the  dental  none  by  a  decayed  tooth,  are  ninnlionecl  by  Panonf^j 
an  excellent  piipcr  on  ncuriil^a.§  Botli  patients  were  euredl 
tho  extirpation  of  a  tooth.  ParMin.*  relat^^s  al>o  a  caKo  of  Deon 
of  tlio  lt}{\  ulnar  nerve,  following  a  ncimilgia  of  tlie  nibsrtpi 
nerve,  causal  by  a  l>oiL  After  the  tioaling  of  tlw  boil,  fttesB 
on  the  scar  would  cnusc  paitifid  and  strange  thrilling  srnsatii 
down  till'  idniirnervc.il 

Tavignot  mentions  oases  of  neiwslgia  of  the  ciliary  ncn-cs, 
ofttcverul  iitlii-r  bi'anchos  ofitio  trigeminal,  cunsed  bv  a  wounl 
tho  eomoa.l 


*  On  the  Naturt  and  Trtaimmt  of  tin  DoulomrtHT,  it,  by  Dr.  Heniy  H 
IH64,  p.  114. 

t  learnt,  1«10.  vol.  ii.  f,  Utt. 

;  A  TrcaUf  an  li'mmlffia.  hy  11.  Howlnnd,  ISSft.  p.  18. 

f  Amerima  Journal  o/ Med.  Science*.  OpI.  1*54.  p.  43S. 

J  I.OR.  eit.  lip,  1334,  H   Gtuttu  AftiUtaU  rf(  /'art*,  IMA,  p-  W 


REFLEX  NEURALGIA- 


887 


Dr.  Greene,  of  New  York,  haa  cured  u  victo  of  iiourmlgim  of  Uio 
tben  by  cxtirputiiig  a  (tmall  tumour  on  tlio  inferior  dental  ncn'c* 

The  following  case  a  ao  iniiM>rliiiit  tliul  J  glw  it  iilnnut  fully. 

.  A  woman,  aA  4«,  pricked  tho  foro-finger  of  her  right  hand  with  s 

thorn.     At  6n*t  gn>al  jiaiii,  swrlliii^,  and  rodncw,  (txtcn<iin{;  over 

1  the  wounded  finger  and  iKirt  of  tiic  middlo  one.    After  tliroo  months 

the  [lain  and  ttwclliiig  w«nt  ofi',  uxccut  that  of  the  tvro  tirrt  ]>ha- 

[luigcs  of  tlio  wounded  finger.     Nine  months  after  tiie  accident  tJie 

I  finger  wjw  excctfilingly  [luiiifiil   to  tho  touch,  idtliough  tiivru  v/u» 

only  a  h'ght-red  sjiot  on  the  »kin  at  tlio  point.     Two  or  throe  times 

,  •  day  tlu^ro  wcr«  attnokti,  during  which  the  pain  oxtentlcd  along  th« 

'  finger  to  tlie  back  of  tlie  hand,  and  between  the  two  bones  of  tlie 

fonj-iirin,  (hirted  tliroiigh  the  ell»ow-jointj  »trct«hfd  up  tlic  buck  of 

Uwi  ami  to  tho  neck  anJ  head,  producing  a  seniiation  at  the  roots  of 

the  huint  a»  if  they  had  bmumo  orcct.     To  these  feelings  mocec^lvd 

a  dimness  of  night,  and  tlio  pain  atlerwanb'  wt»it  suddenly  into  tlio 

stomach,  followed  by  eicknetM)  and  vomiting.    She  had  constantly  the 

fueling  of  u  lump  in  ht-r  ittomacli,  niid  iilwayi'  voniitod  after  taking 

food  or  drink.     The  finger  was  amputated  at  t]io  second  joint.     No 

sooner  had  i<>hi;  got  into  UhI  at\cr  the  oiivration,  than  the  Hcnnution 

of  a  liunp  in  tho  stomach  and  eiekneaa  immediately  subsided,  and 

in  liidf  an  hour  uftcrwanix  ithe  tiaid  tiiat  she  felt  for  tlio  firitt  timo 

as  well  as  tJie  had  done  previous  to  the  nccidcnl,  exeept  merely  a 

slight  pain  in  the  stump.     Her  general  health  was  twon  completely 

roi»tjiblisliod,  and  she  never  had  tlio  smallest  return  of  any  of  the 

non'ous  sym|>tomn,t 

Ak  a  uoiiBL-quitiiet)  of  a  blow  on  Uie  inferior  part  of  tho  orbits 
B  woman  was  attacked  with  an  abscess,  after  whieli  violent  [luins 
occurrcil  fthuoHl  con.itunlly,  radiating  alt  over  tlie  face  and  the  ante- 
rior, lateral,  and  superior  parts  of  ttie  head.  Tlu»  »t»(u  lasted 
Mvei'al  yearH.  Marshal  dividitd  tlie  infra-orbital  nerve;  and  at 
oncu  Uie  patient  wa»  free  from  pain.  Ttie  wound  healed  ;  however, 
tiu!  pains  reappeared.  Tho  nerve  waft  tlieii  destroyed  by  caustics, 
and  tho  patient  sermod  eure<l.  Ten  montlis  afterwards  tlioro  were 
new  HttaukH.  Tlie  eieatrix  was  tlicn  openi-d,  aad  kept  suppurating, 
and  tho  cure  was  defimtiro.} 

A  cam;  of  nciatiea,  and  another  of  fiving  jmins  in  one-half  of  the 


■  l/uhtin  J<mra.  of  Mrd.  Nb..  183rt.  vol,  xiU.  p.  63, 

t  Wardrop.  iu  TVwm.  ^  thi  Altd.Chirutf.  Soe.  r«1.  viu.  181T.  pp.  2U 
etwq. 

I  Caae  or  Maricbal.  cited  b;  Marcbal  dc  Oalrl,  In  AmnaUt  di  Ohimyit. 
1W4,  vol  iv.  p.  00. 


888 


DISEASES  OF  NERVES. 


IxhIj",  nrc  mcnti<nii>l  liy  Or.  Cawtk',  uf  New  York,*  as  having  I 
onred  ImmoiMtcIv  aApr  tho  removal  of  at^liliig  iveth. 

A  grvat  many  utLcr  catirw  of  neuralgia,  caused  by  an  injur 
It  norve,  migiit  l>o  mentioruKl.  I  will  refer  for  aovcra]  tmi>o« 
oases  to  u  i^jier  of  Marc-lial  du  Calvi}  attd  to  Bomberg4 

Delirium.  1  will  aimiJy  otontioM  hero  tlirce  eases  which 
i}tiito  dod.«i\cly  tliut  (lolirinm  may  bo  caused  by  an  tnjur)- 
uenc  A  Imy,  a-U  li>urhwu,  trod  on  a  jiicoo  uf  ^la«»  wliich  p 
tratvd  (hi!  big  too,  but  was  mnoved.  Poor  years  after,  lie  In 
suddrnly  to  (alk  in  u  t'i»y  i^tnuigc,  wild  way;  trim  delirium  so 
hikI  nol)iiii<r  »|i)x)aseJ  tlia  patient  Near  the  ball  of  Uiu  big 
a  small  reddish  clovution  was  found.  Tito  momcitt  prcfisore 
nutdc  upon  it,  tlte  aoiziire  returned  with  violence.  At)  tiicision 
made,  and  a  trilling  pi^-cc  uf  gluss  was  removed.  Much 
patient  had  mrat  during  the  <^>eration,  with  equal  sadd«iinc» 
all  the  symptoms  vanish  ;  and  ho  was  surprised  on  boing  totd 
the  aenaelotw  things  lie  had  utton!d.S 

I  have  published  a  case  very  similar  to  (his,  whicli  I  owi 
the  kitidncsH  of  3Ir.  Campbell  do  Morgan,  and  in  which  the  atb 
of  delirium  took  plaoo  every  time  pressure  was  made  on  a  vnt 
of  a  toe  containing  u  foreign  body.  Ax  noon  tu  the  ijrritated 
was  taken  away  by  a  cut  of  a  bit  of  skin,  the  patient  becaoie  nuiol 
and  remained  so  wlion  prc^isurc  wa»  made  on  tlie  wound.]) 

Mr.  Slierwin  hoi)  recorded  a  case  of  a  woman  who,  uAcr  Iiai 
been  blod,  was  attacked  with  pains  in  the  arm,  neck,  and  t*ace, 
M[ia»ms  in  (Iiom!  partA,  and  delirium.     Afler  the  symptoms  had 
tmuod  a  fortnight,  a  deep  incision  above  tJte  cicatrix  quite 
lier.1 

I  neod  not  speak  here  of  the  delirium  that  follows  ampnUI 
The  aiusc*  are  many  that  bring  on  delirium  aflcr  kuch  an  o[ 
Among  the  priocipul  caiiac^  I  will  point  out  a  gjreal  losa  of  bit 
and  the  anxiety  of  Uie  patient 

Inflammatioti.  Ca9<.-s  of  inflammation  of  tlio  eye  by  a  H 
action  ai-c  so  frequently  met  with,  that  1  nocd  not  stop  ben 


*  Lmett,  IMS.  vol.  11.  pp.  '206.  U6T. 

t  Annalf  de  Chirurstt,  Ion.  ciL  p.  7fr80. 

;  Lthrhach  der  i^ervrnkranihtitni.  Sil  ud.  to),  i.  pp.  334&. 

\  Joeid«iH.  w.\>.  llv/tlaiuti  Jcurual.  ml.  iv.  p.  S9T,  oiled  by  Dr." 
JPaj-ne  in  his  i/edical  and  PAgtiol.  Commtntitrim.  voL  i.  p.  43&. 

II  Courteo/leel.on  llie  PhgtioLaiut  P(Uli^o/lhfyfrr.Ceyit-,l&W.p.\ 
H  Dunoitii'ii  Medical  Vumment.,  vol.  iv.,  cited  by  Mr.  Ilauilton  in 
Journ.  qfMol.  Sntmx,  voL  aiii.  p.  51,  1839. 


REFLEX  INFLAMMATION. 


prove  Uieir  existence.  Any  one  who  will  read  tbe  facte  publiabed 
by  Ur.  W.  Mackciixiu,  in  liis  admirable  work  on  Uic  DLswiacs  of  the 
Eye,  by  Mr.  It  Taylor,"  aiid  by  l>r.  Brondoau,t  will  soon  bo  oon- 
j  vinccd  that  tui  inflnmiiuition  of  luiy  part  of  one  cyo  (tliu  rutiiia.  (Jio 
cornea,  the  conjunctiva,  &c.)  may  be  caused  by  a  wound  of  tlio 
othor  eye ;  and  that  if  tliu  iujtii-cd  or<;jiu  is  extirpated,  tlic  other  is 
noon  cured.  Ciises  of  ophtlialmia  of  an  eyo  owing  to  a  wound  or  a 
neuralgia  of  the  intra-  or  sti|ira-urbitJkl  iiorves  aro  alto  not  rarii. 

Dr.  Rowland  rolateti  several  facta  which  seem  to  prove  that  an 
indammation  in  one  eido  of  tin;  brain  may  be  viiuxcd  by  an  injur}' 
tato  a  iK^rve  in  tlie  otlior  aide  of  the  body.f  Tlie  intlamntution  of  tlie 
pinal  cord  evidently  caused  by  :ui  injury  to  a  nerve  in  nmny  ea«0!t 
'  of  tetajius,  leaves  no  <Ioubt  as  regards  tlie  posiiibility  of  the  production 
of  an  infiamtnation  of  a  part  of  the  ncrvouti  centres  as  a  con»e- 
quvneo  of  an  injury  to  a  nerve.  To  tliu  canat  of  inHaninialion  of 
tlie  brain  mentioned  by  Dr.  Rowland,  I  might  add  several  otlicn, 
amonj;  which  tlie  inoHt  i>i};niticant  have  l>een  recorded  by  Heiincn§ 
and  Meynier.  II 

Inflninniation  of  tlic  testicle  in  .-wnietiines  produced  by  a  reRc\ 
ai.-Lion  from  an  irritated  nerve,  as  in  cosea  by  Sir  Benjamin  Brodie,^ 
Barms,"  Man-otlCftt  and  other*.  Sir  A»tloy  CoopcrJt  tmyt  that  by 
irritatiou  morbid  actions  are  excited  in  dtntaiit  orjrana,  and  odds: 
**  tliuii  inflammation  is  produced  in  the  testicle  from  irritation  in 
tlie  urelJira.*' 

Inflammation  of  tlio  abdominal  or  thoracic  viscera  may  alxo  be 
'produced  by  a  reflex  action.  Proofs  of  lliis  iisaortioii  are  abund- 
antly furnished  iu  Lecture  X.  of  my  work  on  tlio  Central  Nervous 
SyMtcni.  A  n;flex  inflaniniutii>n  may  bi>  brought  on  to  such  a  de- 
gree as  to  cause  an  nicer,  which  tiotliing  can  heal  luittl  the  e4iu»e 
(viiE.  the  irritktioii  of  a  ucrvo)  is  removed.  Sir  Astley  Cooper 
mentions  several  ca«es  of  that  kind.$§ 


f       •  Mtdieal  Timet  and  Gaxttu.  i»Vt. 

f  Du  Affectiant  rifmpalh,  dt  Tim  drt  Veux.  Pniis,  18!i)^ 
:  On   Ou  Katart  and  Trtatmtal  qf  So/teniiig  <ij  ike  Brain,  p.  OT,  Ot  SS^. 
I.onclon.  IM\. 

S  MUitaiy  Surgtry.  p.  101. 
II  (liuttu  Mc'iicalt,  deceinbro  IS&O. 
%  lAcXura  oa  ImciU  Nrrtviu  Diuatt*.  1B37, 
>•  Cit«tt  hy  Niiltx,  ill  Archie,  dt  Med.  kit.,  p.  Ml,  Svpl.  18I>4. 
tt   L'Unioa  MedieaU.  p.  \b\  1851. 
k      ;;   Levturft  on  the  PrineipUe  and  Prattiee  o/  Surj/trg,  by  F.  TjnrcU,  toL  I. 
^p.  4.  1824. 

^  Loc  cil.  pp.  7,  e. 


k 


890 


DISEASES  OP  NERVES. 


Miucutar  titropiy.  ll  would  bo  very  easy  to  bIiow  by  nun 
fiicts  lluit  tliin  nlt(>ration  of  niuaoles  may  )>c  duo  to  a  redox  actio 
&om  an  irritatod  non'C.  1  ha^'o  seen  f«veral  sut-h  comm.  In  on 
of  thv  murt  (iocbtive,  a  man  was  attiutkcd  with  a  veiy  nptd  ntro]>]i 
of  the  musdefl  of  tivo  thumb  in  oonsc(|uen«o  of  ii  wound  (d  tbi 
uhiar  iicTvc  A  nouralgiti  uiten  {>roduces  atrophy  io  noigliboop 
ing  mmdes.*  Sovoral  of  the  cases  of  waMiiif;  palsy  rotated  a 
Dr.  Rohvrl^'  cxwilviit  work.f  ai-o  casoa  of  reflex  atrophy-.  1^ 
fiiend  and  pnpil  Dr.  C  Bomiefin}  has  seen  Tmetttn  casea  a 
atrophy  cauitcd  by  a  nouralgia. 

In  a  paso  rcoordeti  by  Vallor,  a  wound  of  tlio  tnfra-orbital  nem 
prwluccxi  im  atrophy  and  a  paralyais  of  the  fiine  on  Uio  same  sJda 
besides  conKldvnible  nlltiration^  in  the  oycj 

IJypfrtropliif.  This  alteration  mav  alao  be  caiwed  by  a  nBia 
untion  from  nil  irrilntion  of  a  nc-rvo.  Several  cases  of  ncuralgil 
followed  by  hypertrophy,  are  mentioned  by  Nirfta-p 

Eni)>tioM.  Itaycr,  G,  8tmon,  Didioux,  I^otta,  Romberg,  Huae) 
Parmt,  and  others,  haye  frequently  seen  various  kinds  of  onipdoa 
(ertftliema,  peinfJti^as,  urftraWa,  and  tspeciaily  tlie  different  fiiriltt 
h^^rjift)  piiidiioi«t  by  n  reflex  action  fi-oin  a  ncrro  attacked 
neuralgia.     I  liavo  also  soon  several  such  cases. 

Varioux  mwiiul  allfriitum*  o/mUritkm.  Two  cases  of  ivjfei- 
aftcr  the  wound  of  a  Dor*-e  are  recorded  by  Mr.  J.  Hamilton. 
There  arc  on  rooord  sewral  c-a«o«  o^  ^artgrfme,  in  which  it  was  i 
passible  to  understand  bow  the  mortifieatjon  tixik  ])luce,  if  it  ii 
not  through  a  cuntrnctioii  of  blood-vessels  by  a  reflex  actiotL 
one  of  these  i-»ai>s.  Dr.  Gublor  remarks  tliat  sciatic  pains  prec«di 
gangrGn(>  of  the  List  phalanx  of  one  of  the  toes  in  a  young 
in  whom  tliere  wax  no  appcar^ce  of  obstruction  to  the  arterial  cur 
culation,**  Morbii  secreliom,  or  ee»9at«m  of  a  aetretion,  arc  t^bm  Ih 
eft'eiH-H  <jf  11  noiintlgiit.  Oitaraet  is  iiomfttiini.T!  prodoccd  by  a  r«fla 
action  from  an  injury  to  a  nerve,  "ft  It  seems  probablo  also  thi 
fflauarma  may  bo  produced  in  Ihe  Komo  way.}} 


*  Sec  Notla's  pnpt^r  in  Atehir.  tic  Mid.  p.  5&T,  S«pt.  18(14. 
f  An  F.taag  on  Waiting  Palty.  Luuilon.  1^36. 
\  De  I'Atraph'n  munni/.  fonticuiire  a«x  Nivra^iu,  ParU,  1660. 
^  Qaxmt  iUed.  de  I'arU.  p.  C87,  IBlt, 
II  Piipi-r  in  Arehiv.  de  AUd.  pp.  3H,  818.  Aor.  1864. 
t  Diihtin  Joumiil  af  MtAiefil  Snence,  rol.  xiii.  pp.  40-13,  1838. 
••  CainpUi  rendm  dt  la  Sue.  dt  Bioltigi'.  pour  I8!)4.  p.  78. 
tt  See  GaifUe  dti  Hdpituux.  p.  I.  1818;   and  Oiunu  HM.  p.  130,  18 
and  De  Broiitioftii,  J.ic.  oU.  Ohi.  xxi.  xs".  xsiii.  x«r.  pp.  40^0, 
::  Tiiviguot,  in  Gui.  Mid.  di  Parit,  p.  MC,  IWft. 


5NERAL  FE> 


Fjibt  U.  Qekkilij.  Fkatukes  and  Rulks  uf  Tkcatment  of  the 

YABIOUS  AfFECTlOSiS  CAUSED  BY  AS  IRRITATION  OF  A  NMVE. 

The  following  features  cliaracteriso  cases  of  neuralgia,  paralj-sis, 
epilepsy,  uid  luost  oUkt  aSvcli^nis  depending  u|>oii  uii  irritation  of 
a  nerve. 

1st.  Previous  to  the  ujiiwaranoi'  of  tbe  rofles  affection,  tlio  pftttiiit 
has  suffered  from  a  neuralgia,  or  from  pressure  upon  a  nerve,  by 
oithcr  n  tumour,  «  diKiilottcd  Ixiuc,  or  n  foreign  body,  or  from  u 
wound  or  a  bum. 

2d.  An  incn-asfi  or  a  decreow  oftlio  Irrilution  of  tlio  iiltcrcd 
ner\'e  is  often  followed,  or  acoompanicd,  by  correeponding  changes, 
of  ibe  n^f\  iiffV-etiini". 

3d.  The  viirious  nioden  of  trcntraent  of  ner%'ous  and  oilier  affoe- 
tion»,  ])n.Kluce<l  by  a  rvflox  netion,  aro  generally  quite  uiuiucrcMfu], 
so  long  us  their  supjKised  cauae  (tlie  irritation  of  a  nerve)  pereints 
uniiliutwi. 

4th.  Tlic  various  aOeetions  [irndueod  by  a  reflex  ac^on  arc 
frequently  enred  or  relieved  at  oiiee,  or  very  soon  after  tJte  removal 
of  tlioir  eause,  viz.  tin-  irriUition  of  a  ner\e. 

I  may  add  other  c-haraeters  (more  or  [ew<  implied,  however,  in 
the  prew^linj;):  1st.  That  when  n-lles  affeetioiw  oeeur  by  fit*,  it  i* 
not  rare  to  wee  tlie  fit  suddenly  produced  (ii»mpietely  or  iuoom- 
pletoly)  when  tlie  injurwl  ncr\-e  k  irritatod  by  jiroiwHre,  or  other- 
wise (application  of  galvanism,  for  instance).  2d.  That  tiareotics, 
appiieil  to  the  injimsl  nene,  will  nhnoitt  invariably  dimininh,  ut  l«ii«t 
for  a  time,  tho  reflex  afioctioii,  nidcM)  it  oooMsts  in,  or  a  connected 
witli,  n  nutnhle  ulloration  of  nnlrltinn. 

Tlie  above  ohariicters  will  al!  servo  for  the  diagnosis  of  reflex 
affeetion.-i ;  but  tho  itrineipsil  eonsixt*  wrtainly  in  tlio  jircoxiittenco  of 
a  lesion  of  a  nen-e.  It  must  bo  remembered  thai  if  tho  trunk  of  a 
nervo  t»  iiiflaintil.  there  may  be  »!yin|itonu<  only  at  tlw  tcniiinal 
ruiniBcations  of  that  non'c;  and  tlie  only  way  to  o^ertatn  what  the 
stiiiiin^  [Hiitit  is,  eon^istit  in  the  exHrninatioii  by  pressure  of  tlio 
whole  length  of  tlio  nerve,  so  far  as  [>o)tsibIe,  from  tlu>  periphery  to 
the  brsiiii  or  spinal  eord.  If  tliis  nJc  had  been  applied  in  the  fol- 
lowing ea.<e,  it  would  not  liave  lieen  published  and  aooepied  a.H  a 
cww  of  reflcctod  influence  from  a  diwaso  of  tlie  nerves  of  tlie  tJiiimb 

upon  tJie  four  limbs.     Lady wa.«  attacked  Htidilenly  by  an  uiruto 

poiu,  soon  followed  by  redness  and  swelling  in  tho  left  tlmmb;  and 
the  other  fuigerv  gnuluiJly  were  aUso  attacked,  and  aftcm'artU  the 


Ilk 


892  DISEASES  OF  NERVES. 

forc-urni.  Tlii-rp  waa  wmtracturo  and  paralysis,  with  Ii^-pci 
'Dm  ntlior  arm  IxHTamv  uHoctctl  in  a  sinuliu'  way ;  mid  wtion 
Wtts  violent,  tliiH'o  wa.4  paraplegia.  No  benelii  waa  obtained  froi 
puworful  naircotic  applications  oii  tlie  left  tliuinb  imd  liaiid  ;  but  tb 
fntivnt  wiLs  curod  uflnr  iho  xtno  oi'n  vouiiter-irniaiil  oiatmcnl,  rubbo 
o%'er  tho  arm.*  In  tlus  cose  tlierc  liod  bcvii  iiu  injury  to  tlie  haod 
tllorc  WMA  no  noiinilj;iu ;  atxl  ihc  .-.yiiiptoms  olxi^rvod  iti  llic  fingofl 
and  (ho  forc-ann  ncro  tlioso  wo  fiud  in  cuftm  of  l<wu)  iiMrningitifi,  a 
inflannnution  i>f  t.Iio  nhvalh  <>f  nencii,  at  tJwir  exit  finom  the  spine 
I  Iiavo  mxn  two  similar  comos,  botli  of  whicli  wvru  uurod  by  ooiuitfir 
irritania  ui>pli(Kl  to  tiio  NpiiK'. 

The  wondcrfidly  powcrfhl  and  varit-d  iuflu«iK56  exerted  bv  u 
irritatiun  of  it  iK-rxo  i"  not  duo  lc>  pain,  but  tu  a  special  actiuii,  as  ii 
well  provod  bv  ibo  fai^t  that  we  seu  ovei^'  day  cuxutt  of  jiaiii  {ntn 
iitiuralgiii,  or  titJier  diwaWK  of  nvn'eii,  witliout  any  remote  rcAa 
affection.  In  few  cases  that  I  know  wa^  then;  ntieb  lui 
pain  OM  in  a  juUient,  in  whom  a  ball  Iiud  lodged  in  iho  trunk 
radial  n«rvc,  producing  for  many  days  tlio  most  excruciating 
dirprlving  iJie  putient  of  sleep,  and  ciuwing  a  continued  pCTspim 
from  Ids  faoo,  without  any  ulJier  marked  |-cBex  nclion  tlmn  a 
iniction  of  tlio  for«-«rm  upon  tlio  anii.t  In  somo  caaea  an 
tion,  [irodiieing  a  gmx'e  refle.v  affection,  may  start  fVom  a  itcrrd 
witiiuut  l)i-ing  fttlt-t 

It  may  seem  quite  surprising,  and  perlmpn  incrtsjiblc,  lliat  liia 
Mine  eauw,  vi*.  an  uritatjon  of  a  iiei-vc,  will  either  produoa  m 
effect  at  all,  or  produoo  audi  a  variety  of  affection*  ax  I  itttributc  t« 
jtiK-li  a  eanso.  But  those  who  will  take  tlie  trouble  of  studying  the 
variety  of  effi^ts  of  »  eli«ar  eanse  of  reflex  action,  sueJi  iw,  for  in- 
utancv,  tlio  e.\[iositioii  of  many  people  !*>  a  ooKl  wind  wlieii  thej 
come  out  pontpiring  from  a  very  woi-m  room,  will  undcnitaud  tiiat 
rvflex  effects  may  be  very  variouH,  although  rcartilting  from  the  juuiu 
cause. 

Treatment.  Of  the  various  means  of  treatment  of  the  remolu  oi 
reflex  cffi^cts  of  tin;  irritation  of  a  nerve,  the  most  important  may  bfl 
elassod  into  two  givjups — die  local  and  the  general  meana.  As  re- 
ganls  die  local  meun»,  tliey  consist  chiefly  in  apiilicatJon&  of  reind 


'  Caso  of  Pearson,  in  iled.-  Vhir.  Tram.  roL  viti.  pp.  'ih'i  ct  m<[.  PewSOl 
lines  not  spenlc  of  the  spine.  Hud  Iiu  eiftiainrd  it,  lie  ^ould  bare  fouiu 
great  ter)iloiiii;s3  between  llie  eliouldcra  tniil  ft  lilllc  ubov«. 

I  Case  orDL'Diijnrk,  in  Med~-Chir.  Tftmt.,  181!!,  vol.  iv.  p.  4S.  Tha  pfttienl 
vtts  curtiil  hy  the  ompiiution  of  the  aiia. 

J  Sue  oij-  lUieanhet  on  Kpiifi'ty,  p.  17. 


LOCAL  TREATiraiTT. 


893 


mvcB  or  swlativcs,  or  iii  an  amputation  or  division  of  a  nerve ; 
whilfl  t\w  jjiiutTHl  mcnn!)  consUl  clik-flv  in  tiw  iiw^  of  r('mivti<*s  tJuit 
will  diiDtuiisli  tho  rpfle."!  powor,  or  the  morbid  excitability  of  the 
inritAtcd  none. 

ImpgI  means  of  trwtmmf.  Of  tlieso  means,  tbe  best  tbeoretically 
ore  iilao  till'  Ixwt  nccunling  t4i  tlio  msL-w  of  fiicts  I  have  coUeoted. 
Tho  section  of  the  injured  or  irritated  ncrvt-  between  the  brain  or 
spinfti  conl.  iind  t!n>  part  nf  l.lii.'  nt-rvi-  wliicli  is  altfirod,  is  wrtainly 
the  most  importajit  local  moans.  I  hardly  nwtd  to  say,  that  if  thia 
operation  ix  to  l)C  |ii>rfi)i-niiKl,  tlu!  Mx>ncr  tlio  better,  in  caae^  of  hydro- 
phobia, epilepsy,  t«tanus,  roflox  neuralgia,  panilj-Bi*,  &c.  Of  course, 
if  tlu-ro  i*  any  diaiice  ofa  porstirtcm-);  of  tho  irritating  caiisu),  af\«r 
tho  timo  noccMarj-  for  the  reunion  of  the  parts  of  Uic  divided  ncn-e, 
an  exdiiion  of  an  inch  or  two,  which  will  riHard  reunion,  mu.tt  be 
made  instead  of  a  simple  division.  There  is  no  doubt  that  in  a 
tinmlK^r  of  nisc*  (wpeciidly  those  of  ionp  duration)  this  vpemtion 
will  not  sncceod  ;  and  there  are  many  discouraging  facts,  showing 
that  the  nltcrntioii  <if  nutrition  pivxhicoil  at  a  reuiote  distance  from 
tlie  irritated  nen-e  will  continue  after  the  division  of  the  nene, 
owiiifj  snmetimes  to  (lio  fact  tJiat  tiic  nene  i*  inflamed  in  a  great 
length  between  the  place  of  tlio  tteiTtion  and  the  ncn'ous  oentrea. 
Tt  would  III-  pnidi-nt  aiwaj's  to  excise  at  least  u  small  part  oftlio 
lengtli  of  tho  none,  to  ascertain,  by  a  niicroeropical  examination,  if 
it  in  indiimoil  at  the  place  of  tlic  operation ;  Of,  if  such  is  tho  cii».f, 
anotlier  division  4>nght  to  be  iwrtormod  much  higher  up,  aud  ovoii 
as  near  the  ncnous  centre  as  safbly  possible. 

Thoro  are  eiwos  in  which,  insttad  of  divi<Iing  a  nerro,  all  that  is 
necessury  i«  to  gain  a  few  days  to  allow  a  woun<I  lo  heal  up.  I 
proposed,  several  years  ago,  to  make  use,  in  those  eases,  ofa  iiimplo 
means,  consisting  in  laying  bare  thi?  nmo  nlmvv  tlie  wonml,  and 
in  dropping  sulphuriir  elher  u()oii  it  Tliis  operation,  especially  if 
rcpcattrd,  will  render  the  ncne,  for  many  dnj-s,  quite  unable  to 
transmit  any  irritation  from  tli«  original  wound. 

Ainpiitjition  ofa  limb  should  never  be  n-worled  to  with  tho  view 
of  curing  reflex  epilepsy,  Ictantt^,  Ac.,  uules;,  of  couthc,  llus  opera- 
tion haj>i>eiis  (o  be  nccessarj-  for  another  purjKisc. 

In  hyilrophobia,  li(^)d<-s  Mk-  Miction  of  tlje  nene  at  a  notable 
distance  fn>m  tiie  wound,  it  would  bo  pmdeiit  to  exeiiw  tho  whole 
length  of  tho  norvo  frotn  the  [tlucc  of  tlic  ftcction  to  tlw  place  of  tho 
original  wound  (('.*■.  tlie  bitten  part). 

Siibciitaui.'oiii'  injections  of  narcotics  junt  above  tlw  wouud,  or  on 
tho  irritated  ncn-e,  t<^hcr  with  applications  of  emollient  and  nar- 


DISEASES  OF  NKRVES. 


cotio  lotioTw,  or  [Xiiiltiiy^,  on  the  WAund  itself,  arc  nmon;;  tlio 
local  meant!  after  neurotomy.     1  havo  kocq  cases  of  cure  of  opil. 
chorea,  irrcgnlar  uUaclcit  of  oim>  iilsioiw,  itnd   rrfiecttd  ncn 
cttvuA  by  sulx!iitoneotifi  injoctioDB  of  narcotics  (half  a  grain  of 
phia  snd  onc^ixtictJi  ofn  gruin  of  iiUx>{iiii). 

I  Inve  derived  some  benefit  also  in  «isea  of  epilepsy  wi 
distinct  pvriphrric  aiini,  by  applications  of  tcmporar)'  circular 
Icn,  like  a  rin^,  aronnd  a  limb  or  a  finger. 

Applications  of  ie«,  or  even,  eomvlinios,  of  a  freezing  mix! 
on  the  spot  where  a  nerve  h  ivoiindnl  or  irritated,  might  b«  a 
<uont  to  prodncc  a  ect^ation  of  its  influcnoo  on  tho  nen-ous  centi 
niiotlier  organ.  Boforo  dividing  a  large  nerve,  thin  moans  6hi 
be  tried. 

A|iplIi.'at:ion«  of  the  nHual  cautery  (at  whito  ticat.)  may  alsi 
very  uscftil ;  and  ihcy  are  perhaps  the  best,  and  one  of  the  I 
painful  foiiiitcr-irritaiil  in<raiiK.  I 

I  need  not  say  that  foreign  bodies,  ttunours  (neuromntic  j 
others),  or  vicious  cicJit.ricc)',  &c,  ;^ving  riKC  to  rcRcx  aflcctiJ 
ahould  be  extirpated. 

(Jmeral  meant  oftreatmmt.  Tlic  must  poM'crftd  agents  to  aiili 
the  reflex  excitability  of  tlio  nervous  centrea  are  bntladonna.  In 
licinp,  aconite,  ergot  of  rye,  and  turpentine.  It  ought  to  bo  rem 
bcrcd  that  in  many  caaes  of  reflex  afl'ectJORa,  the  most  pow€ 
narcoticd,  especially  opium,  are  borne  in  lar^  doses  vritliout  I 
]x>iiionoui  efleet.  1  will  uot  nay  more  aH  regards  tlic  general  lr< 
mcnt,  as  the  roles  vary  according  to  the  kind  of  reflex  atfectio 
l)u  troatetl. 

a  E.  BKOWNSEQUAB 


NEUROMA. 


A  NEUROMA  is  a  fibrous  tiunour  on,  or  morp  raroly  betwoen, 
tiio  fuHoiviili  (>r  n  iicr\-<'.  Tlift  nint  of  tJuim  tiunount  varitn 
iinnioniiely.  In  one  oase,  tho  tnmoar  reached  the  size  of  a  Ini^ 
melon.  Almi).*t  nlwiijn  n<-iirc>niH.4  arc  piiri'lv  tibroii.*  hiraount," 
8i>ni(HlImG!i,  liowover,  together  with  purely  Bbroiin  dementi,  m^ur- 
oniaa  cotitain  thoM>  iiu<'1<n,  ami  lu.«itomi  or  ^itKlati;,  «r  stallat>> 
micloated  eells,  which  are  fonnd  in  granulations,  or  in  tho  fil>ro- 
cellular  tumourxt  Jii  m>iiio  caitci  nlHO  cyifl»,  [>rinvi]>ally  serous, 
nre  f'omid  in  neuromas, 

Ueiudiy,  thrri!  in  only  «no  tumoni" ;  fmt  in  itomc  caxm  Uioni  are 
many,  and  in  several  instances  almost  c^'ei^'  nerve  was  cov<ffed  with 
neuramntic  tumoiuv.  The  varioux  brancliPii  and  Uic  trunk  of  tlio 
great  sympathetio  neire  are  very  much  lesn  frequently  afta*^k*fd 
with  nooroma  than  the  cranial  or  Hpinal  iktacs. 

^Hm  nnul  fduipo  of  m  netu-oma  is  that  of  an  o1iv«,  t]i«  lon^r  dia- 
meter heinft  in  tlio  direction  of  tho  iicrrc.  Tlicre  is  no  adliesinn  of 
tliu  tumour  witJt  the  ncighbonring  ttttsuoa,  no  torltioui*  or  tlilati^d 
veins  round  it,  unless  it  is  extremely  large;  «id  the  tumour  is  gene- 
rally fina  and  elastic,  nni]  of  n  kIoiv  iJTDwth. 

Tho  nervc-tinsuc  is  not  dcstroyeid  by  the  development  of  a  neur- 
oma :  on  tho  oontniry,  it  i^jciua  that  somrtimos  n<iw  »^?^Vl^.fib^e!t 
are  formed  in  tlie  tumoiu".  As  a  general  mie,  ueiiromaa  develop 
themselves  on  one  Hide  of  a  nerve. 

Tlio  symptoms  of  a  neuroma  consist  in  attacks  of  pain,  darting 
I  almost  only  toward*  tho  |»eriphcry  of  tho  nervi-,  exeept  in  aiMW 
due  to  a  wound,  in  which  tJie  pain  very  often  radiates  upwards  and 
oxtenda  to  other  nerves  by  a  rvflcx  action.  GcncnJIy  tlio  pain 
recurs  by  paroxysms,  followed  either  by  its  complete  cessation,  or 
at  least  af^-at  tliminution  ofits  intensity.  Sometimes  there  is  no 
pain,  except  on  pressure  upon  tlie  mMiromt.  Aa  a  general  mU>, 
such  a  preraurc  causes  innoh  pain,  and  sometimfls  tho  least  ton<^ 


•  See  tho  deacriplIoD  of  flbroua  tumoim,  hy  Mr,  Paget,  in  ttiis  work, 
ToL  i.  p.  4^3, 

t  ragct,  loe.  oil,  p.  480,  Soreial  aaea  of  Uiii  kind  hnn;  reoMilly  been 
pubU«h«<t  by  Dr,  Hitchcofk.  Amerieaa  Journal  of  Mai.  SeUiifr*.  A|irii  1608, 
p.  330;  and  one  by  R.  Volkinann,  Orii.  and  Fortiyu  Mtd.-Cliir.  ICrt.,  April 
1M».  p.  513. 


896 


NBUBOHA. 


caniwt  be  tolcratwl.     In  otlior  ca.*«t,  iiltlioiigli  tliprts  Is  mu' 
more  or  kvw  i-onstaiitly  cuQi]>l3incid  of,  tborc  is  no  tender; 
prcMiiro  of  Uic  nuuroinn :  tho^e  tiro  wima  of  piirv  ucurnl^a. 
cvBtio  mkI  tlio  traumatic  ncuromii?  gx-norally  ciniiw  niuolt  mom 
tluui  the  idiu]>ut,liiR  an<I  purely  fibroti»  noiironms.      As  a  ^ 
ni]«,  miilli|ile  neuromas  do  not  <niuAo  pain.     Wlicn  an  «xnini 
of  a  tender  ncuroniivtio  tumour  is  to  be  niadc.  pressure  U|x>a 
discascil  norve  above  the  tumour  should  be  made,  to  destroy  a 
bility  in  Uic  partii  to  bo  oxamlned. 

TIkt  syiuptoras  prodtictKl  liy  the  iiiRtKriicc  of  a  ticurmna  apoi 
ncrv-tiUH  ccntri's  ami  other  orgajis  are  extrerocly  variuliti-.  C3i[ 
epilopsy,  hysterical  iivin]>toms,  tmmbling,  rcflvrtcd  ncundjcria,  ai 
tJiei^a  or  pHrulyxih,  and  many  ot}ier  affections,  havt^  bc<*n  (>1>wrrt 
effects  of  tho  irritation  of  a  iivr>*o  by  a  neuroma  as  well  as  by 
oUicr  letuon  of  n  iier>'e  (see  tlio  essay  on  DEBEAintiB  op  Nervk), 

As  regards  the  peri]>bLTic'  cffprts  of  a  ni-tirom.i,  it  is  ve: 
marknhle  thitt  tlii-n^  i^  not  ut)<-n  n  eoiiMJilerable  jmralyxiK  of 
bility  or  movement.  Generally  tJiorc  is  not  more  than  num 
(iiid  a  vorj-  wliglit  [>ani1}'iiie>. 

The  eanses  of  idiopatliic  uoumma  are  not  known,  I)r.  Ro 
W.  Smitli,  iu  Ilia  comploto  inoti(i^;raii}i  on  tlii»  iwbject,*  cfe 
shows  tliat  neither  iieuriljs  oar  rheumatism  are  onlinanr 
of  neuroma. 

^ere  is  no  otlier  treatment  for  netmuna  than  cxtirpatioi 
tbi!  t«muiir  or  amputation,  tf,  ns  in  a  cju«e  of  Cbolius,  die 
operation  is  not  possible.  At\er  extirpation,  the  paticjits  faa' 
greiit  rliancc  of  rt^eovcring  M.-ii»ibLlity  and  morcment  in  tho  [ 
which  roi'eive  brain^hps  of  the  exciwed  nerve,  in  conMrqtKrnce  ojf 
reunion  of  the  dividcHl  ends,  or  nitfaer  of  tlic  regeneration 
part  of  Uie  cxeioed  nerve.  Tliere  are  many  vases  showing, 
lifter  excixion  of  one  or  several  inches  of  tbo  ulnar,  mMiiin, 
posterior  tibial,  and  evttn  striatic  ni-rvt-w,  reunion  or  regcnen 
have  taken  place,  and  scnsibihty  and  movement  have  been  roco\- 
However,  when  posfiblo  (ami  it  is  not  nin-Iy  wi),  the  tumoirr  sbi 
be  diiwceled  itud  evtirjiated  witliout  dividing  iho  trunk  of  tlie  iM 
Except  in  eiises  of  fibro-plaNtie  or  fibro-cellitlHr  neuromas,  lh« 
no  dimgcr  of  the  reproduction  of  tho  tunioiu-  after  4^xtirpation. 

C.  E.  BBOWNSEQl ARI 


*  A  Trealue  on  tkt  Patholtm,  DiaptMit,  and  TteaimtM  ot  Si 
Dublin.  184n.  fglto. 


DISEASES   OF  THE  TONGUE. 


THE  tongue,  an  organ  of  wcU-known  form,  to  which  tho  sonso  of 
taste  is  chiefly  referrod,  ia  composed  of  muscular  and  of  gland- 
substance,  covered  by  mucous  membrane,  continuous  witli  that  of 
ihe  moutli  and  &uccs.  The  more  delicate  appreciation  of  ttusto  is 
limited  to  tlio  upper  surface,  where  tlio  papilla;  of  the  mucous  mem- 
Ijrano  are  remarkably  developed.  The  proper  muscular  structure 
is  striated,  and  arranged  in  two  horizontal  and  many  vertical 
layers ;  the  former,  immediately  subjacent  to  tho  mucous  membrane, 
are  to  be  found  on  the  upper  and  under  surfaces ;  tiio  latter  pass 
vertically  from  one  horizontal  layer  to  tho  otlier,  connecting  them, 
but  leaving  intervals,  which  are  occupied  by  gland-stnioturos,  sup- 
plied by  ducts  opening  on  tho  un<ler  surface,  and  secreting  a  fluid 
resembling  saliva.  In  the  posterior  tliird,  tho  muscular  prevails 
over  the  gland-structure,  wliich  ia  reduced  to  two  large  lateral 
bodies.  Abundantly  supplied  with  nerves  and  blood-vessels,  always 
in  movement,  and  exposed  to  many  souices  of  irritation  or  injury, 
this  organ  often  becomes  the  seat  of  disease. 

I  know  of  no  well  -  authenticated  instance  of  atrophy  of  tho 
tongue,  nor  of  congenital  tongue-tie,  so  as  seriously  to  interfere 
with  the  movement  of  tlie  organ.  Tlio  fnenum,  it  is  true,  extends 
in  some  cases  to  tho  tip  of  the  tongue,  when  its  division  may  be 
easily  accomplished ;  but  the  defect  usually  produces  little  or  no 
inconvenience,  and  tlie  difficulty  of  utterance  with  which  it  is  fre- 
quently itssociated  proceeds  from  causes  affecting  tho  Fensorium. 
Still  the  division  ofthoirtenum  linguEc  is  an  operation  somewhat 
popular,  and  may  be  jterfonned  without  detriment  to  tlte  patient 

Hypertrophif  and  etdargemenl  of  tlie  tongue  ("  lingua  vituli, 
lingua  propcndula,  macro-glossia,"  &c)  is  an  atlection  occasion- 
ally seen.  The  references  collected  by  Dr.  Humphry  on  tlio  sub- 
ject point  to  the  probably  congenital  nature  of  tliis  deformity. 
Zaccbias'  relates  that  he  saw  at  Komo,  in  1G2H,  a  mole  infant  well 


■  Quittt.  MedArg.  Ub.  vii.  UL  1.  qusat  ». 
vol.  lit.  3  K 


608  PISEASES  OF  THE  TONGUE. 

mode,  except  Utat  th«  tongue  pmjectetl  diree  fingon'  broaJUi 
the  inoiilh.  flie  child  could  stick,  luid  livod  to  the  age  of  four 
moiitliA,  wlicii  itdiod  without  <>bvi(iii>i  oiiu)ic.  BDrtliolia*  ment 
a  cam  of  "  lingnm  portcntoNi  magnitndo,"  rolaa>d  to  him  by 
[>u{)il  Ba^un :  u  iniilo  child,  born  with  tlw  ton^o  ont  of 
tDoutU  an  lai^  as  a  filbert.  As  the  child  grew,  IIm:  toiigui-  incro 
to  ibe  siBc  of  11  ailfs  Iwnrt  S.-»uva;jo«,  in  his  A'otoicffii,  speak 
onlor^gcnient  of  the  tongue  in  new-lmrn  uiIiuiIh.  Porcy  and  ] 
nmtt  spenk  of  two  cascM:  ono  a  woman,  in  whom  tlie  onlargeo 
wa.4  dated  from  birtli,  but  rapid  incrca-ne  took  plaoo  »t  llio  ag| 
throe.  The  other  was  tJiat  of  a  ho^,  aged  sixteen,  whoae  toiigue  h 
three  inohea  below  the  elun,  was  two  inclxtii  aiid  a  half  tliick, 
filled  the  month.  The  atfection  liad  existed  from  birth.  In  Mtral 
cn»fl,  tlio  man,  ageil  lliirty-fnur,  h;id  iiufreFcd  from  infancy;  so  I 
wise  in  that  related  by  M.  Manrant4  Iw  otliereasca  th«  enlnr^ca 
is  described  w  commencing  in  ibe  fiti't  or  :HKv>nd  j'ears,  ivben 
haps  the  better  expreesion  would  luive  been,  -'was  then  first  notice 
for  tho  tongue  is  nn  or^^nn  in  whicb  hypvrtrophy  ui  a  slight  de 
might  be  readily  overlooked,  especially  in  early  life,  and  bfl 
attempts  arc  iiiiulo  nt  arliculiition.  In  a  fuw  other  case*  One  be 
ning  of  the  swelling  in  adulta  has  bc«n  referred  to  salivation.  I 
in<rlint.'il,  tltoii,  to  tlie  Ijclicf  tliat  hyportropliy  of  the  tongtw  u  I 
in  infancy  is  congenital. 

Tlio  meiisiircment  of  the  tongue  in  the  case  of  a  child  of  ela 
under  tlie  care  of  Dr.  Humphry, 5  wa-i  a.t  fiillowx :  from  t]»e  nj 
lip  to  its  tip,  3',  tnclics;  from  tho  under  lip  to  its  tip,  l^  inch;  f 
the  iinglo  of  tlie  moutli  round  tlie  Nidc«  »n<f  tip  to  the  opposite  an 
6  J  inches.  The  circumference  of  the  widest  part,  which  was  al 
tho  middle  oftlm  piotruiU-d  jiortioii,  measured  6 J  ineheiA  ciixs 
measurement ;  immodiatety  witliin  tJie  lips,  5  indies.  When  dr 
into  the  mouth  (o  the  utmost  possible  extent,  the  tongue  mean 
from  the  upper  lip  to  its  tip  2  inches;.  Tl»  orgnn  was  sofi 
itiip[)le,  having  boon  kc]>t  habitually  cororcd  in  a  bag  hung  f 
t)ie  head.  Tho  pnpillic  were  greatly  enlarged,  and  separated 
<lecp  clefts,  giving  to  tho  exterior  of  tbc  mass  a  eoarttelv  gnuU 
or  warty  appearance.  The  colour  of  ttie  organ  was  natm^ 
oj)cning  of  the  mouth  was  large ;  the  lower  lip  «'\-ortcd,  and 
angliw  of  the  nniiith  de]>reasod,  so  as  to  clongutu  .-ind  give  a  p««( 
espression  to  the  face.     The  orifices  of  the  tiuhlingiial  duol^ 


•  JIUt.  Ctnlur.  iii.  p.  Hi.  f  Vkl.  lUt  Se.  UAl.  vol.  xxviL 

]  Journ.  dt  Mfd.  voL  xv.  %  MtdAlhir.  7Van«.  voL  xxx^-L  p.  Ui. 


HYPERTROPHY. 


S»9 


^ 


tmnsoal  sixe,  wcro  Kitii^iUiit  Jiii<l  in  front  ul'tlw  eclgn  »f  tli«  lip;  the 
saliva  was  «ontiaually  dribbling  lix>m  Uio  ond  of  tlio  tongue,  tlie 
qiumtity  tliiiK  lost  aiiiouiilii)g  during  tlio  diiy  to  inuro  thiiii  luiU'a 
pint.  Owing  to  tlio  constant  pressure  of  the  tongue  on  tho  mental 
portion  of  tlio  lower  jaw,  a  curvature  liad  takvn  plucv  in  thut  bone 
just  in  front  of  tJio  maitseter  niusctas,  in  such  a  manner  that  a  wido 
interval  always  existed  between  tho  incisors  and  hivus|)ids  of  tine 
two  jiiw».  Even  wlicn  tho  nioulti  was  closed,  that  i»  to  say,  when 
the  corresponding  molar  teeth  wor«  in  contact,  tliis  inter^-al  betwoi^n 
the  inci.Hom  iiiea.-iure(l  neurly  two  inches,  being  increased  by  tlie 
horizontal  dircetion  which  the  iuforior  iucisora  and  tlw  alvoohir 
prooeas  of  the  lower  jaw  bad  asBomed.  IlieHe  were  so  placed  as  to 
form  a  wide  channel,  in  wliich  the  tongue  rested. 

I>r.  Humphry  determined  to  remove  the  protruding  part  of  the 
tongue  by  excision,  altliough  he  was  aware  that  a  fatal  caso  had 
occurred  elacwhere  from  tliiK  practJoo.'  Hi^  juL-viud  »  »lraiglit  bis- 
toury from  below  upwards  through  the  organ  a  little  to  the  loft  of 
tlie  middle  line,  aiid  cutting  forwards  aii<l  (nitwartU  fornied  a  left 
lateral  flap.  He  then  secured  a  vessel  Kext  he  cut  across  tlio 
middle  of  tito  tonguo,  dividing  tho  ranino  arteries,  Uto  moremenls 
of  the  organ  being  still  controlled  by  means  of  the  prolapsing  por- 
tion, which  was  not  quite  severed.  Tho  operation  was  eompletud 
by  the  formation  of  an  oblique  lateral  flap  on  tlio  right  side,  corre- 
sponding with  tlint  on  the  left.  The  flaps  were  approximated  so  as 
to  form  a  tip,  and  muintJiinod  in  appoxition  by  two  sutures  passing 
JMply.  The  iia;morrhage  was  not  very  great,  and  the  bleeding 
veesela  were  tied  without  ilifGcuIty.  A  good  deal  of  swelling  of 
the  tongue  followed  tho  operation ;  but  under  frequent  washing  and 
fomontatiun  it  aoim  tixWuld,  and  the  wound  healed.  At  hnt  tho 
lips  cotd<t  not  be  approximated,  and  the  tliick  stump  of  a  tungtw 
was  always  visible,  tliough  novcr  protruding.  Ailor  a  few  days, 
however,  by  continued  action  of  the  orbicularis  mnsde,  the  mouth 
was  closed.  An  npjuiratits  was  ihon  conHtructwl  to  act  by  )>rGS«ure 
on  the  deformed  jaw,  and  ultimately  a  result  was  obtained  highly 
creditable  to  the  «|K>rator. 

Tlie  eSeot  of  continued  pressure  on  the  enlai^cd  tongue  i«  a 


*  A  Kirl,  aged  fourteon,  in  wtioea  the  enlarseil  toiif-ne  hunF;  oat  of  thq 
moiUb  IbrtM  iitclies.  wiis  undrr  Ibe  oare  of  Mr.  Sjriiii-,  wImi  n-tno-cJ  iho 
pralnpsing  pMrt  bj  obliiiiic  iix^iiinni  mooting  nt  an  aiigl«  in  tli«  rifiitru  ot 
tlio  tnnguo.  and  unitvd  in  llic  iiilddto  liini  bj- iiiturra.  Tbc  I'tiUil  died  a 
f^w  Hayi  n(t«r,  from  luHainuialioii  and  BwaUing  of  tho  tongue  aud  pMia 
about  ibc  larynix. 


DISEASES  OF  THB  TONGUE. 


mode  of  ireatmcnt  only  appliral)!*;  t«  early  cases,  and  ia  uncei 
in  its  rraulU.  In  a  «i*e  uiidt-r  tho  cai-e  of  the  lato  Mr.  Crosso, 
swrlling,  pftrtly  removed  hy  this  mctliod  of  treatment,  soon  rutiima 
nnd  tlto  relief  a|q)c«rs  to  liave  been  iiiijwrfcsit.  Sir  Astloy  Coo[i 
trantnl  wtcli  a  case  by  ligature ;  but  w  tliis  prooo«iiiig  an  objocti 
olTent  itself  in  tbo  fumiutinn  of  a^oiigh  noctipying  tJto  anterior  pa 
of  the  motitU,  and  in  tlic  immediate  proximity  of  l1k>  tiostrilx.  T 
fcnsetir  is  an  instnimoul  gciR-rally  utisuitml  to  operattona  ab< 
tlie  mouth,  faiiceH,  or  ton^o ;  but  may  be  advantageously  ua 
wltcnover  thero  is  fcnr  of  iinooiiti'ulUbIc  lucmorrbage. 

Acatf  utfianmtatKM  of  the  tonffng,  attended  witfa  sudden  eiilar^ 
ment,  in  a  disoiuta  oocaslonally  »een.  Mr.  8.  Coc^r  remarks  d 
it  may  ariso  spontaneously,  and  witliout  any  appai-rtnt  eaiiM; 
else  from  some  partioular  irritation,  jiueh  a*  that  of  mercury  ■ 
some  poisonous  substance.*  He  mentions  that,  in  the  middio 
the  8i:veiiU«i>tl)  oi*nlurv,  Schtegcl,  wli«  was  at  Paris,  saw  a  patie 
in  salivation,  whoso  tongue  became  so  enormously  onlar;^  th 
tho  miiul.lj  f<mld  nut  contain  it.  I*impn«iellc,  an  eminent  Sur^ 
oftlictimc,  was  sent  for,  and  amputated  one  bolfof  the  organ: 
measiu^  wliioli  Lonift  jiwtly  criticises  as  extremely  violent. 

The  disease  to  which  I  now  refer,  however,  proi-eiil-s  from  occo 
atmosplicric  caiwps*.  The  ^veiling  is  Kuddcn,  {>crhaps  ocuturri 
during  the  course  of  tlie  night,  and  it  produces  feelings  ofthreatcni 
sufFooTilioii,  having  been  pr«'e<lcd  by  loss  of  af^tite  and  a 
sensation  of  malttiMf  for  a  few  day*.  Tlie  first  cawj  witicb 
before  my  notice  was  that  of  a  gentleman  aged  sixty,  of  r%marku 
abstemious  habits,  living  chiefly  on  vegetable  diet;  tho  soeoiid,  ti 
of  a  young  married  lady,  residing  in  lodgbgs  in  a  licaltJiy  i>art  { 
London.  In  tiiis  latter  cuae  tlie  xwidling  of  the  tongue  waa  ■ 
great  tbat  tho  mouth  could  not  bo  closed;  the  teeth  bccamo  €oat« 
with  s<ffdes,  and  a  profuse  watery  and  biglil\'  f(eti<l  discbarge  flowe 
without  intermission  for  many  days.  Tlio  patient  feared  to  dot 
her  eyes  in  sleep ;  and  so  difficult  was  (ho  respiration,  tlint  at  oi 
time  the  question  presented  itaelf,  whether  it  mig)it  not  be  neeeasai 
to  make  d(V{»  iiiciitions  into  tho  swollen  organ,  or  even  to  open  tt 
trachea,  Howovei-,  by  consLint  attention  to  clcauUnesa  igul  gar 
gling,  Iiy  tlio  local  use  of  ice,  by  supporting  the  strength  wiili  w 
and  quinine,  and  the  administration  of  Dourisliment  by  enem 
during  u  short  time  when  deglutition  was  imposaiblo,  the  swelll 


Surn.  Did.,  ed.  1630,  p.  1102. 


ACUTE  GLOSSITIS. 


801 


I 


subsided,  and  the  patient  rocoverod.  For  some  weeks,  however, 
ijio  rcniaineil  in  an  eiifeolilw!  stnte,  I  saw  nboiit  tlie  wimc  tjmo  two 
other  cases  in  St.  Bartholomew's  Hospital.  In  l>oth  t!io  iliseaso  was 
rapid  in  itv  counw,  the  awN^ssion  Instinf;  but  a  few  liours,  dihI  tlic 
Bwelling  usiiaJIy  snbaiding  wiiliin  a  week. 

But  (Iiirin";  the  pcrioil  of  aculo  a-doiiia  of  tlic  tongue,  tlio  patient 
may  <lie  suftoeated ;  and  the  Surgeon  should  hear  In  mini!  thai  sneli 
an  accident  may  be  prevented  by  hiji  ninkin^  free  and  deep  longi- 
tudinal iiioixionn  into  tJie  swollen  organ,  **  I  have  seen  u  patient," 
observes  Mr.  Erichscn,  "  who  was  nearly  KiiHbcalo<l  by  tlie  immense 
nze  of  his  tongue,  relieved  at  once,  and  get  nearly  well  in  the 
course  of  a  few  hours,  by  such  incision*."*  Tliwe  incisions  s]iould 
bo  made  along  the  upper,  rather  than  the  under  surfaoe  of  the 
ton;;nc,  that  the  runine  urtery  hi^  not  wotmdod;  and  there  is  bat  one 
caution ;  the  cedemui  may  so  far  involve  only  one  side  of  tlie  tongue 
as  to  cauM>  the  lower  surfarc,  which  yields  the  more  readily,  to  bo 
turned  dirtetlif  wpxranh,  m  which  ea-so  tlie  inci.iion  made  above 
passes  in  trutli  into  the  tissues  normally  inferior.  Such  a  case 
happened  in  the  practice  of  Mr.  Worninld,  who  found  Utat,  iijion 
the  subsidence  of  the  swelling,  the  incision  made  above  gradually 
ueqiiircd  n  <Iinx!tly  inferior  potiition. 

1  have  not  known  tr.iehootomy  noceeaarj'  in  such  a  case, 
idthoiigh  thu  symptoms  might  poiwhty  bo  such  as  to  demand  it. 
The  oondition  of  tlio  month  prevents  tlie  administration  of  medi- 
cines during  the  aente  stage.  Afterwards  we  must  be  guided  in 
tlie  Mttection  of  remedies  by  tlie  state  of  l)ie  pulse.  Should  tliere 
bo  mueli  fever,  saline  and  diaphoretic  remedies  are  suitable.  But 
more  cunnnenly  the  indication  Is  U*  support  tJie  slrengtli,  by  the 
administration  of  tonics,  wine,  and  nutritious  diet.  For  tlio  mouth, 
a  gargle  containing  alum,  or  borax  and  honey,  or  (incturo  of 
myrrh,  may  bo  usod ;  and  tlio  Surgeon  may  give  mwch  relief  by 
oarcfulty  wiping  away  the  thick  visei<l  seerclion  fmin  tito  lectJi, 
and  by  touching  any  ulcerated  spots  with  a  weak  solution  of  nitrate 
of  silver. 

In  the  museum  of  Guy's  Hospital  there  is  a  preparation  of « 
portion  of  a  tongue,  weighing  two  onnovs  and  three  drachma,  nv 
movixi  by  ligature  by  the  late  Sir  Astley  Cooper,  in  consoquenoc  of 
enlargement  following  xidivation  produced  by  mcrcnrinl  medicines 
in  Uio  treatment  of  syphilis.  And  another  preparation  (lt>72)  illna- 
trates  the  extreme  effects  of  mercury,  namely,  modifieation  of  tho 


•  &tfli>r«  aad  AH  oj  Suryry,  Sd  ed.  p,  Ml. 


902 


■DISEASES  OF  THE  TONGUE. 


organ;  a  result  cxtrcmoly  nirr^,  and  due  to  tlw  itijtidiciouA 
contimrad  wlinliiistratioa  of  this  [wworftil  ag«nL 

Abtfrtt.  1  have  seen  vorj-  few  oasee  of  alwtoesa  of  Uto  ton 
One  case  n-as  that  of  a  ludy  of  middle  a^^  tinder  tlio  caro  of 
Stanley.  Sho  hail  a  fU-m  tumour,  che  siic  of  a  largt*  pea,  imba 
in  tile  sub&tanco  of  the  toii^c.  Considvring  the  paticnl*s  agr. 
tlie  Ryraptoinii  attttmiitig  tho  fonnatioit  of  the  tumour,  Mr.  Staj 
could  Tiot  dismiss  from  his  niind  Uta  idea  of  carcinoma,  Bol 
Mtuatioii  in  lh<-  nii(ldl«  of  tlu!  Htibstanoo  of  Uio  organ  militi 
against  tJint  idea.  Ho  made  3U  incision  uito  tlio  mass,  and  a  si 
quantity  of  h<.'aUhy  pxa  vmajtciL  1'ho  wound  cicatrisod,  and 
larfy  has  coiitinutKl  in  good  hcahh  for  many  years  since.  Mr.  Ei 
sen"  says,  "  ahsccus  of  tho  tofijnii!,  though  niro,  occasionally  oca 
A  boy  was  brought  to  me  some  time  ago  witli  an  daatio  fluctua 
tnmour  of  slow  growth  and  about  tho  sine  of  a  itmall  plum,  situi 
dooply  in  tho  ci>ntn>  of  tliu  tongue.  On  puncturing  it,  about  I 
an  ounce  of  healthy  pus  was  lot  out,  aftvr  which  the  cysi  speel 
cJowd."  OthiT  xiuiilar  cafios  are  mot  with  scattered  thiimgh  m<x 
literature,  and  ihey  show  that  the  gland-Eblliclctt  of  the  tongue 
liable  to  suppuration. 

Chronui  nlcfration,  "  Tho  inort  frequent  forms  of  dt^caso  in 
tongue,"  obeervea  Mr,  Ijawrenoe,t "  are,  ulceration,  generally  »aj 
fieini,  soinolimcs  more  deeply  seated :  swelling  and  tlnckenin, 
tile  muooiis  iiiembnuie ;  Kwelling  and  indnration  of  tlio  .«ii 
of  tJ)o  organ.  Ulecnttion  often  exists  in  conjunction  with  swe 
of  the  mucouii  membrane  and  with  induration  of  tJ>e  lingual 
fitnnfc.  Tlio  more  formidHble  diseases  of  the  tongno  are 
litio  or  cancerous ;  the  fonner  being  by  far  llie  most  nu 
Disonlcr  of  the  digestive  organs  is  sometimes  the  source  of 
mifldiief,  giving  rise  U>  nffeetiotitt  which  are  usually  superficial, 
somotunes  of  more  seriens  character.  "When  mauitained  by 
prudent  hidiihrvnce  in  drinking,  there  h  oflen  a  ."oro  sfnte  of 
organ,  the  epithelium  being  smooth,  roddcned,  or  white  and  upaq 
Wlicn  tlie  surface  is  sujicrfieially  nlecrated,  the  ulcerations 
generally  small,  eireular,  and  of  grayish  colour;  occasionally  til 
is  ihiokpiiing  of  tlio  mucous  membrane,  and  d(i'|)cr  ulcentiQ 
In  tlie  sanio  volume  of  the  AMuat  GazetU  (p.  8(H)),  Sir.  [jaw 


•  Saene*  and  Art  of  Saryery.  1863,  p.  073, 

f  Clinicnl  Luotuixi  repmteil  by  .Mr.  Coot*,  M*d.  OairlU,  1845,  p.  7ti 


CHRONIC  ULCERATION. 


903 


I 


rclflU^it  somo  cAsos  in  illw%tration  of  these  pointa.  A  hcaltliy-luoking 
geiitlemati,  butwwn  forty  and  fifty,  wlio  lind  alwayn  enjoyed  osctsl- 
lent  hcalUi,  but  wlio  hsu\  liied  freely,  lieo^nio  (he  sahjoct  uf  the 
following  i!Oiii)Itiuit  of  the  tonguo : — tiio  iiiucotw  mcmbpajie  over 
the  grcfltca*  part  of  the  organ  wntt  unnuturully  amootli,  luoro  or  Inw 
opaqtio  uiid  wliito,  hero  and  there  raw,  as  if  it  had  hoea  ulcerated. 
^  Jt  had  bcou  in  thi^  ntuti^,  gviivrally  cjiu.tin};  great  {Mtn,  for  four  or 
five  years.  Under  a  courae  of  mild  mercurial  modi<3iic»,  iho  era- 
ployment  of  tincture  of  myrrh  us  u  gargle,  and  alulmencc  fram 
sti»ng  <lrink,  tlio  pain  ceaHcd  in  a  week  ;  and  the  general  condition 
of  the  tougni^  wus  Improved,  although  tlw  isurfact.*  romained  auootli 
jmd  white,  but  otherwise  sound. 

A  hi<!y,  tiL-tw<,fn  fifty  an<l  cisty,  of  itnbcaUliy  ait|)caranco  and 
witli  a  red  pimply  face,  wlio  Imd  ofton  Huff^red  from  diwjnlvr  of  ihe 
digestive  organs,  consulted  Hw  same  Surgeon  for  a  disease  of  tbo 
toiiguo  of  formidfllfle  appearanee.  The  niiddle  and  upper  jiiirt  of 
the  organ  wait  swollen,  and  occupied  by  a  deep  nicer  of  irregular 
figure  and  foul  aspect.  It  wait  very  painful,  intinfering  with  ina.-'ti- 
eatiou  and  articidation.  The  digestive  organs  were  niindi  disturbed. 
Tlie  complaint  jioldeil  n^ieodlly  anil  iHTc-cttially  to  simple  measure*, 
regulfltioii  of  diet  and  tlie  digestive  organs,  small  doses  of  extract 
of  henbane,  and  Aootlilng  locutl  renitHliet,  8ouie  yi>ani  ago  a  patient, 
about  fifty  years  old,  cainc>  from  tho  countrj-  to  consult  Mr.  I^aw- 
rence.  The  man  was  of  xallow  nsjiect,  aud  Iia<i  lived  fi-cely.  On 
tho  upper  surface  of  tJie  tongue,  iu  a  space  about  an  inch  nn<l  a  Iialf 
long  by  an  inch  wide,  the  mucijus  inombrune  wiw  Uitekcncd,  indu- 
rated, and  raised  into  irregular  prtunlnoneos,  which  were  Rmooth 
and  not  ulccrat^nl.  The  ci>ni|)laint  had  cxi»(wl  some  months,  having 
become  so  painful  tJiat  lie  coidil  haj-dly  take  food;  wiLihes  and 
gurglcA  had  been  of  no  benefit.  There  was  no  cuitpioiim  of  sj-pbilb 
in  this  case;  and  liio  habit  of  drinking,  especiaUy  spirits,  sufB- 
ciently  accounted  for  the  disease.  Mr.  Lawroooo  piwcrihcd  tho 
compound  decoction  of  sarnapiirllla  with  compound  decoction  of  alocft 
three  times  a  day,  foiu*  grains  of  the  ei^tract  of  hyoscyamuM  at  night, 
an<l  a  strictly  regulated  <liet.  When  aguln  mXMi  at  Iho  end  of  a  fort- 
night, all  tlie  pain  had  ceased,  and  he  conld  masticate  any  tiling.  He 
considered  himself  well,  and  r«turncd  to  tho  country.  I  saw  a  tall, 
Sparc-looking  man,  age<l  wxty,  March  liilli,  1800,  in  whom  tlio 
gimiH  liftd  nlirunk  from  the  teeth,  Icavmg  the  rootn  denuded  to  tho 
Ivcolar  border,  and  ex]Hitting  iliem  to  an  accumulation  of  tartar. 
_  patient  had  Uvcd  freely,  having  been  a  publican.  The  wholo 
of  the  tongue  wai  swollen,  HmuuUi,  and  of  glistciung  red  hiio. 


904 


DISEASES  OF  THE  TONGUE. 


Unn 


L>fibe  papill? 


at  tlio  base,  win 


tnico  "t'ibe  papilla,  execpl 
papilla!  cirouun-allate  aj)pcaru<l  hvjwrtrophitHL 
where  tbo  of;f^n  rubbed  against  the  cxpawd  aa<\  niuglicned  bH 
the  inu»)u<i  nic-nibniDc  was  «v)iitv  nnil  Ihickpiicd,  and  seetaed 
surn>uiid  niinieixni.*  8innll  :iml  ui)1ic':tllhv -looking  iilccrtttWD*. 
directed  tJiis  gmtiont  to  liavv  tho  tooth  examined  mid  (-leaned 
»  foniju'tont  dciitUt;  iiii|KiMil  a  stridh  i-i*^il;i(eil  <Iitrt,  onkrt 
gargle  containing  alum,  and  occasional  aloctic  aj>ericnts,  CoRUf 
ublo  improven)i.-nl  took  plit>cti;  bul  nHur  a  lime  the  jnticnt  docli 
to  atteu<l  to  ihc  strict  regimen  whicli  was  consiilercd  ne<!e»sary. 

This  smooth  jjliwcd  coTi<Iition  of  tli«  linigiie  'iifftns  from  I 
eommonly  .seen  in  jHtriKina  HuRering  from  chronic  dj'spepiiin,  tboi 
habitually  abstemious.  In  tlic:><;  latlor  ctvfcv,  tin-  mucotu  membi 
has  a  red,  iiik^voii,  and  raw  aspect ;  it  in  deeply  ti»iui'eil,  ulccn 
in  spots ;  tho  piipillfv  may  be  nnivor»ully  or  juirtially  hyportroph 
or  purliunii  iniiy  n<i|iur<!  between  the  fissures  »  *'  knoblK-d"  a3|i 
It  is  im|>oriant  to  distinginsli  those  diHcretit  afFiKitions,  and  to  b 
the  morbid  clituij^  tn  lltcir  proper  oaiute.  Abo%'o  all,  it  is  n« 
sary  to  distjn^ish  them  at  tho  earliest  sta^  from  Uioae  m 
Bcriotu  nfToctions,  syphilis  or  ctuiccr.  Tlie  furinur  nppcara  t 
variety  of  forms,  and  under  drciimstanoes  perhaps  iiircxpcc 
Tlie  latter,  more  delinitc  in  its  sj-mptoms,  ii*,  however,  often  ro. 
at  its  commencement  by  eircnmslanoefl  ivl)i<:}i  will  <Iotiiand  ail 
Surgeon's  aeciiracy  of  diagnwis.  ludumtJon  of  (ho  tongtic  Li 
to  be  of  syphilitic  nature  when  it  oeeum  ui  the  cenlrx!  of  tlw  orj 
and  to  be  of  ciuictTous  nature  when  it  commence*  at  il>e 
And  thin  ih  generally  Iriie;  bul  yet  there  may  be  an  indarntod 
ditioti  of  tho  tongiio  neither  malignant  nor  syphilitic.  A  ha: 
agetl  sixty-one,  of  nnlinpuinxl  v(>n.HtItution,  who  liad  tiercr 
Mvphilin  since  the  .igo  of  eighteen,  found  tliat  whenever  he  had  b 
exposed  (o  the  fumes  ofwiric  secret  (wni position  usi-d  in  his  trs 
the  tongue  became  sore,  <?racked,  and  diy,  ami  remained  so  two 
three  days.  Kor  the  last  three  years  it  linil  swcllrti  and  beoome  p( 
till  during  the  winter  months,  but  returned  to  its  natural  slaw  w 
Ihe  api>r<iueh  of  wnrin  weather.  About  four  inonlhs  before  he  i 
tieon,  tJiebaeki^ai'tandleitaideoftlielongnesweDMlupinan  unus 
maimer,  and  became  luu'd.  Tliis  was  atlend<-d  with  a  didl  a<-}| 
pain.  The  surfiictf  was  iiiioten  and  tuberculated,  and  pnwnnlj 
BBvoral  suporfieial  ulcerations  not  attending  Iw^-ond  tho  ma« 
uiombrane.  The  hardness  resembled  that  of  scirrlius.  The  abaoi 
cmt  glands  under  the  jaw  were  not  alTectod.  loilido  of  potaasii 
was  tried  witliout  efliM^t.     A  courso  of  mercur^-  was  next  admiq 


m^ 


teroil,  uiidnr  whk-Ii  i\m  ^iim»  became  »orc,  Aiid  tlw  urgaii  rcxwrcrcd 
MO  mll(^ll  of  its  iiomml  clinracter  Uiat  tbo  jrationt  was  pragiouiiccd 


I 
I 


I 


Jfieeiu  of  tfui  tongtw.  On  March  lotli,  185U,  1  saw  a  private 
pAtient  ui](]cr  tho  caro  of  Mr.  Lnwrcnci;,  ."itfTi-ring  from  oongviiital 
venous  swelling  involving  tlio  right  border  of  tho  tongne.  Tlie 
part  hiu]  a  lind-bliio  roloiir,  with  n)uiid<!<I  an<l  irrcgulnr  twrfaoo, 
marked  by  largo  tortuous  veins.  Mr.  Lawrenpo  made  an  inciaion 
into  it,  and  ciacuattd  a  qtumtity  <if  Hiii<l  vonou.t  blotMl,  by  which 
tJio  bulk  of  tlie  tumour  entirely  disappeared.  A  ligature  was  then 
iipplicfl  to  arrcut  tho  Iin-morrhage,  when  tlioro  wiw  renewal  of  tho 
swelling  to  even  a  greater  e.xteut  than  before.  The  venous  trunks 
Htiil  eommiuiieatotl  one  witli  another.  Ultimately  tlie  cffiw  did  wcli. 
A  student  at  8t.  BHrttiolumew'.i  Hospital  showed  me  in  IK.^3,  on 
liiit  owni  person,  a  large  cangBnital  venous  naivus  of  the  tongwe, 
occupying  iU  right  lialf,  including  Iwtlt  upjttir  and  tnider  aurftiee. 
At  one  time  it  iiseil  to  bleed :  but  it  had  long  ecasod  to  caiUM  him 
inconvenience,  and  liad  boon  stationary  for  ninny  years,  luring 
in  mind  the  fact  that  nKvi  may  first  become  etationary  during 
the  growth  of  tlie  botly,  and  ultimately  diiuipixinr,  I  recommended 
thi*  gentleman  to  lol  the  disease  take  its  oourso;  ajjd  I  was  strength- 
ened in  thiit  opinion  by  the  remembmneo  of  an  examination  made 
of  a  similar  nspvus  remo\-ed  by  Mr.  Lawrenee  from  the  anterior 
part  of  tho  abdomen  of  a  young  gonUcman  of  about  twenty,  in 
whom  it  was  found  ttmt  the  venous  swellings  were  undergoing  a 
process  of  atheromatous  or  tatt^'  degeneration,  and  that  no  fttrlher 
enlargement  wa.*,  iiniler  rirdiniu-y  rir('Hm«lanees,  to  be  feaiixi. 

Tlierc  K  difficulty  in  the  U'eatment  of  such  an  niTcctJon  if  thu 
growtii  can  bo  neithtnr  tie<l  with  n  ligature  nor  extirpated  by  tlio 
knife.  An  organ  so  movable  and  highly  sensitive  as  the  tongue  does 
nfit  well  bear  llw  n])pliciition  of  jwwerfid  eau.-'tio-H  in  any  form ;  and 
proceedings  which  are  practicable  in  other  paarts  of  the  body  .tro 
here  eounter-indicatcd,  both  on  account  of  the  ailema  to  which 
tliey  may  give  rbe,  and  the  sabsefjnent  pain  an<I  difficulty  of  de- 
glutition. Fortunately,  luevi  of  the  tonj;ao  arc  uncommon,  and  do 
not  UMnally  ac({uire  great  magnitude.  Wlien  e.vtirpation  is  thought 
right,  tho  Surgeon  may  remember  that  the  hstnorrhage,  though 
profuse,  may  Im  genemlly  controllwl  by  iee.  When  tlie  ligature  is 
to  bo  a])plied,  it  is  usually  inirodncod  by  a  strong  curved  needio; 
tlic  twigue  being  drawn  forwanl  by  an  a-tNistant,  wlw  hi)ld!<  the 
organ,  eovered  at  the  front  part  by  a  towel,  between  the  thumb 


906 


DISEASES  OF  THE  TONGXJE. 


and  forc-fingor  of  ibo  right  hiknd.     No  instniment  can  pnw 
liotd  tlie  tunguo  wiUi  Uud  »mic  rnrtain^  as  the  liuman  lutiid. 

On  May  17lh,  1847,  Mr.  Lawmwc  removed  a  auiall  vase 
Uitnoitr  of  |]i«  Umguc  from  a  young  lady  aged  ID.  !^bu  liod 
vtously  had  removed  a  vaaculai-  tumour  from  Ui*  gum  of  Uie  h 
jaw  opiKwitc  tlic  in<u»or  lovlh,  uiio  of  which  had  been  extracted, 
microscopical  examination  of  the  extirpated  port;*,  1  found  thai 
pnfullffi  uf  the  toiiguc,  about  tlio  centre  of  tho  tumour,  were  hy 
trophied  and  agglutinated  into  a  proanincnt  and  flat-ituHaood 
of  whitish  colour.  It  was  compcK'^xl  of  white  fibi-ous  tisnu 
Etringy,  6brouii  matter,  and  of  an  immenso  quantity  of  mumu 
of  opitholial  cells.  It  scoiuod,  upon  Motion,  as  if  tho  foUi* 
portion  of  tiio  muctiii.-'  nioiubranti  was  mai^l  cJiIar;^-d  and  hjf 
trophi«d,  and  oovei-ed  by  altered  and  thickened  [Kijiilb-, 

Ml-.  Pa^  says,  "  In  the  museum  of  the  Middlottex  Hoe4)tt 
a  fatty  tumour,  on«  and  a  half  iuclnii  long,  which  was  rem 
fhim  beneath  tlio  tongue,  where  it  loofced  liku  a  nuiubi ;  and  i 
Colkgu  museum,  No.  190,  is  one  takeu  frum  tlie  substance  i 
tongue."     Tliis  Surgeon  also  statea  tltat  ho  removed  an  oval  hil 
tumour,  about  half  an  inch  in  diamclor,  froui   tho  tongue 
young  man,  from  llio  miWaiipo  of  which,  near  its  apox,  it  liad 
growing  for  three  years.     It  was  firmer  tluui   niottt  i)th<;Ri 
similar  kind,  yet  succulent,  tuid  fonuod  of  an  obscurely  til: 
tissue,  abnudantly  nucleated.' 


Hanula  ia  a  fluctuating,  aemitransparcnt,  Uvid-bluo  swvtl 
situated  under  the  tongue,  and  is  commonly  described  as  a 
tiun   of  tbo  duct  of  the  nubmaxillaiy  glcnd   (Wharton's 
Doubts  are  now  entertained  by  many  antbors  of  the  accu; 
tliis  description,  and  Mr.  Kriuhscn  questions  bow  so  small 
can  be  dilated  to  so  largo  a  size  as  is  ooeasioiially  attained  by 
tumours.     Tliis  doubt,  howuvor,  di^spiicare  when  one  rcSccis 
the  enormous  aize  wliich  the  muiute  ducts  of  tho  mammary 
niny  ultjiin  in  sorocystie  Siircoma.     Iji  ono  case  of  ranula  und' 
cai-e  of  Mr.  Lawrence,  tho  littio  finger  could  bo  inserted  for  a 
distjuico  into  a  cylindrical  tube,  pursm'ng  llio  normal  ooanel 
wards  tho  gland.     And  in  another  ease  under  my  care,  tlio 
a  domestic  servant,  preeented  herself  vriSii  a  luird  nwclliitg' 
Ihcoum  linguzp,  which  had  been  pronouncied  "  a  cauicer.' 


*  Sarg.  Path.  voL  it.  pjK  flS.  III). 


HANULA. 


907 


miimtJOD,  I  detected  in  'VS^la^Uln'8  duct  one  of  those  phofiphatic  con- 
cretions, about  tlio  size  of  a  pea,  common  te  tht;  diict»  of  tlw  naJivary 
glaii(l« ;  it  was  removed  with  eane,  a>id  tlio  patient  VL'oovcrod  in  a  f<?w 
days.  But  cyst*  may  form  lu  the  floor  of  the  moutli  frntn  iiny  of  the 
c»u»<.-«  which  lead  to  the  development  of  cjfts  in  otlicr  parti  of  (he 
body.  M»ny  years  ago  Mr.  LawroQCo  requested  mc  lo  give  him 
SMi«tanec  in  tlie  following  ojierution.  A  young  lady  had  a  swelling 
on  tho  flour  of  the  moutli.  It  waa  firmer  and  more  solid  iJian  tlie 
<M>mmon  rannlu.  Mr.  Lawrence  inuilu  an  incision  thi-ough  the 
niue/>us  iiicmbntno,  and  endeavoured  to  extirpate  the  oyst  entire ; 
but  finding  it  too  largo,  he  made  an  ineitiion  into  it,  and,  with  the 
handle  of  llic  sealpcl,  took  out  a  quantity  of  thick  matter,  tlio  eon- 
flistouco  of  putty.  He  then  removwl  the  entirn  cyst,  which  was  hut 
lr«isely  uttjivhcd  te  tlic  surrotmding  parts.  The  patient  rcooviMNxL 
Tlien  wo  meet  with  etiier  cn«cs  in  which  a  eyxt,  containing  a  fluid 
of  watery  consistonoo,  extends  from  the  floor  of  the  inoutli  wnder 
the  atei-no-miiMoid  muscle  to  tJic  middle  of  the  neck.  Such  a  tnnHiur 
can  scarcely  he  regarded  aa  an  enlargement  of  AVliarton's  duct 
Tlie  ]»ro[)cr  eonelnsion  seems  to  be,  that  cyirts  may  form  in  this 
situation  from  four  sources.  Fii-st,  dilatation  of  Wharton's  duct. 
Secondly,  dilatation  of  one  of  the  sublingual  ducts.  Thirdly,  dilata- 
tion of  a  mueous  follicle.  Fourthly,  dilatation  of  a  bursa  mucosa, 
fuiiii  tu  c^ist  on  the  outer  surface  of  the  goniohj'ogloc!»us  mttMjle. 
Tlic  contents  of  a  dilated  Wharton's  duct  are  a,  jwwfectly  clear  and 
thick  albuminous  fluid  of  the  conAistenoe  of  white-of-c^;  oocaaion- 
ally  wo  meet  with  phosplmtic  concretions.  An  enlarged  mucous 
fi^lliclo  is  filled  with  a  putty-like  suhstixnce  consisting  of  epitlieltal 
oellft  HlKil  with  granular  fiit.  An  enlarged  hnr*a,  wliieli  may  ex- 
tend down  the  nock,  contains  a  clear  florous  fluid,  in  which  bkwd- 
disca  may  !»  from  time  to  rime  detected  in  various  <)uantidea.  I 
have  no  information  respecting  ilihitation  of  the  sublingual  dacts. 

Tlio  mode  <jf  treatment  varies  in  these  ditrcrent  forma.  In  the 
first  case,  the  iQosC  prominent  part  should  be  seized  with  a  pair  of 
.'*harj>-[)ointcil  forceps,  and  cut  away  with  scissors.  Tlie  interior 
may  then  be  rubbed  with  nitrate  of  silver.  The  duct  will  contract 
to  itti  normal  size.  In  cases  of  cysts  oonlaining  putty-like  matter, 
the  cyst,  which  is  generally  hut  loovcly  attaclied,  shonid  he  di»- 
scrtcd  out  entire.  And  in  tlio  caa«  of  the  enlarged  bursa,  the 
fluid  may  bo  evacuated  by  a  trocar,  and  a  sohition  uf  iodine  then 
injected ;  or  tlie  cyst  may  bo  traversed  by  a  soton,  so  as  to  cxcJlo 
inflammation,  and  its  subsequent  obliteration.  Mr.  8key  cmj>]oys 
A  single  silken  tlircnd  passed  tlirougfa  tlw  floor  of  tlte  inoutli  to  the 


DISEASES  OF  THE  TONGUK. 


roofit  depending  part  of  tJw  cvst ;  and  I  have  scon  benefit 
from  tliis  trcuUncnI. 

TIm)  tonj^iv  tit  subject  to  injuries  of  various  kinds;  the  n 
common  of  nliicli  suv  ihoeo  inHictcd  bv  tlic  ti.-«>th  in  the  4'nnvnl] 
fit«  of  ti]>ile{i!'j'.  There  ofa  iii:itanm>!i  kno^vn  \vliere  a  portion  of 
organ  has  been  oom]>l«to1y  ecvcrc-d  by  th«  M[ia!imodic  closuro  of 
mouth ;  hut  iho  injury  i.<<  rurcly  of  a.  nature  to  i-oqaire  a  saU 
Wounds  heal  very  readily ;  and  n  foreign  body,  Iwwcvcr  sm 
ia  irritating  to  iho  inoulh.  But  a  Auturt>  may,  if  iiix^e^ary, 
applied,  In  the  tnnseum  of  Guy's  Hospital  tbcro  ih  a  sped. 
(Ili74)  showing  a  piece  of  tol>aee(i-|(i{>c  enibedilcd  in  tho  M)b«Lai 
of  tho  tongue ;  the  soft  parts  had  dosed  over  il^  so  tiiat  its 
was  nctl  readily  <Ioteetoil  fUiriiig  lift-.  Fnnjuent  iKvinorrh: 
sued:  and  the  case  proved  ultimately  fatal.  Fata!  luumorrh 
rarely  occur*  froni  a  simple  wound  of  the  tongnv.  T]>c  bleed 
generally  ceases  upon  the  application  of  ice, 

Ligature  of  the  lingual  artery  above  tho  gn-at  cornu  of  lb« 
hyoidea  in  Uie  neck,  for  tho  puqioao  of  controlling  lin^inoiTlfl 
from  the  ranuic  arim',  ts  recommended,  hut  is  rarely  required. 

SifpAiIitic  afffftinm  of  tho  tongue  are  muttly  ulivrndvo,  and  co 
bincd  with  secondary  sj-nii>tonis  in  otlicr  parts  of  tJio  Iwdy.  Tho  u 
eoinnmn  MXjvicnee  of  symptoms  i«  an  indurafod  primary'  chanc 
followed  by  gtanduhu*  enlargement  in  the  groin,  s^-]ih!Iitic  lop 
ulceration  of  the  tonsils,  soft  palate  and  tmigtie,  nivl  iritis.  But  i 
eeration  of  tJie  tongue,  ott  well  a.i  the  other  foims  of  oonntitntioi 
sypliiUs,  may  follow  any  variety  of  primniy  sore.  8j-philitio  indl 
ation  of  tho  tongue  may  occur  atone,  in  vthioli  m.-<e  it  \ui*  been  n 
taken  for  cancer.  But  the  following  rule  generally  liolds  good 
diagnoua  when  taken  with  other  pointii.  8yphililie  induration  co 
mences  in  the  middle,  cancerous  induration  on  the  border  or  o 
of  Ihe  tongue.  'Hie  diagnosis,  liowever,  is  not  nlwsiys  easy, 
female,  aged  thirty,  servant  in  a  &nu1y  of  rejipcctahility,  preaen 
herself  at  Ihe  bospilal,  with  a  foul  ulcer  ol'  the  tongue  on 
hard  base,  situated  betv^eeu  the  middle  line  and  Uto  cdgo  of 
organ,  midway  between  tho  base  and  the  njiex.  It  lukd  vxia 
tlu-oo  months;  there  were  no  other  symptoms.  Aft<T  dii<'  « 
udtM-ntion,  it  was  thought  that  the  discas<>  was  s}'philitie ;  and  i 
was  put  upon  the  projier  remedies,  namely,  two  grains  and  a  I 
of  meri'ury  and  elmlk  three  times  a  chiy,  when  the  ulcer  liealcd,  i 
the  iudoration  disiijiiKiui-ed.  We  tJieii  Icitmod  that  the  patient  I 
suffered  from  sypliilis,  tutder  peculiar  drcnmstancos,  which  il 


CANCEB. 


909 


hero  to  relate.  A  j^ntJcman,  set.  forty-fivo,  consnltcd 
vncn  with  nn  Jiiduratvd  knot  tlw  »izi>  of  n  mpence  on  tlie 
middlo  of  tlio  (loi'Kiim  of  tlif  tongue  It  had  rosistod  common 
treatment,  Imt  yiolilcil  to  ii  »li{;!it  incrctiriul  <;mir*«.  No  othor  o<mi- 
6titution:d  symptom  of  sypliiUi  was  present,  aiid  the  primary  sorw, 
whi<>ii  was  titl,li>  more  than  nn  oxcoriaUon,  ha<l  hajipcned  eiglil 
months  before.  From  tho  npper  sarfaco  of  the  tongue  tlicra  may 
[iTAJccL  It  miLtt*  of  liv[K?Hr'>j)Iii(»)  i^pithdiiim,  which,  liluiultHl  togi>- 
llicr,  constitutes  a  mass  analogous  to  tho  mucous  tubercle  oom- 
uionly  fcoii  ulioiit  th<^  HTotiiiii,  tlio  vulva,  or  anus.  For  ihu  ti-<^t- 
mcnt  of  these  syiihiiitic  aDcctions  the  reader  is  referred  to  tiw 
«May8  on  tlie  diMi^aitcs  of  t)io»(!  org-onit. 


CatioT,  OS  it  nflectA  the  lnngtK!,  usually  ots-urs  in  ono  of  two 
forms :  either  interstitial  deposit,  when  it  ia  called  Gcirrhus ;  or  more 
!<ii|icrfi<-ial  ihivi*]i)pTiioii(,  whni  it<  U  cnlli'd  cpitiic^iial  vaniv^r,  or  cpi- 
thelionia.  Both  forms  are  of  seriom  nature.  I  have  oot  hitherto 
known  any  wfel!-R'f<;if;ui''cd  caw*  in  which,  cvom  after  tho  most  com- 
))lcte  and  early  romoial.  the  cure  hat  boon  permanent.  In  both 
iii>itiuietii>  microscopic  irivcti^itioii  detect*  llic  wtunl  ck-tncnbt  of 
cancer,  namely,  nucleated  celU  and  connecting  tisauCk 

We  have  fintt  to  inquire  what  i«  tlic  cau»o  of  oaitc«r  of  the 
tongue.  Is  it  due  to  local  irritation,  auch  as  in  excited  by  an  irre- 
gular or  broken  tooth?  If  such  wore  the  case,  liow  infinit4Jy  inoro 
common  sliould  it  be  1  how  fni(|uently  should  we  notice  ita  i-avages 
in  tlio  mouth !  Many  cxijcrionccd  dental  Surgeons  deny  thai  ii-rc- 
gularities  in  tho  shajio  of  the  teeth  will  do  more  than  determine  the 
exact  Beat  of  development  of  cancer  in  constitutionx  ]»roviini»iy  so 
disposed ;  nn<l  the  same  may  l>o  Euiid  of  tlio  imtation  excited  in  other 
ways.  J<ct  us  take,  for  example,  tho  irritation  produced  by  a  clay- 
pipe.  How  many  are  there  who  .tmoke  unaJlectod  by  eancerons 
(liiieaNo  to  tJio  end  of  a  long  life !  Uow  often  liavc  wc  to  removo 
carcinomatous  or  canet^romt  gruwth.t  from  the  month!)  of  ]>eraons 
who  liavc  rarely  or  oven  never  smoked  at  all  t  1  lately  extirpated 
Huch  a  tumour  from  an  aged  man  of  Miventy.  lie  luul  lived  a  most 
sbst^tmiotLv  life,  and  had  rarely  indulged  in  any  luxmy,  however 
humble.  The  wound  of  tlic  tongno  eicatriiHxl ;  but  tlie  [Miticnt  <h'«t 
eight  montlis  afterwards  of  secondary  diseaM)  in  tho  glaudft  of  the 
neck.  Still  the  irritation  excited  by  the  eon»t(Uit  jireMnee  of  a 
tobacco-pipe  c«mnot  bo  ignored.  In  1848  I  examined  (he  body 
of  Miyor-Geu.  D.,  xi.  sixty-tltrco,  a  {uitivut  under  the  care  of  Mr. 
Lawreooe,  who  gave  inu  tlie  following  histor)'  of  the  caa&      Tliis 


910 


DISEASES  OF  THE  TONGXJB. 


officer  bad  been  above  thirty  years  in  India,  wliere  be  b 
freely.  He  whk  alwnya  in  th«  Imbil  uf  »mokitig  n  short  clay-pi| 
tbo  nnd  of  wliieh  be  kept  firmly  wedged  botween  tlie  floor  of 
inoutb  and  Un'  iiiwlnr  HiirliHrt'  of  tlir  toHjEuc.  Aboat  July  18( 
)h)  nolKed  a  sliglit  impediment  tii  8waIlowing;  th«  food,  M  lio  aa 
was  oaught  in  its  |)fijwiigu  tlironglt  tbo  fauccK.  A  physician  appli 
caiiHtio,  but  without  avail;  thi-  di^enso  incrauKxI,  ntnl  the  1«ft  s 
of  tite  tungtic  lx-i.^nti-  swelled  and  Iianl.  The  patient  diod  June  19 
1848,  without  particular  sulTering,  and  rnlluir  from  vxhatistion  tb 
from  Baflfocatiou.  Ou  examination  nfler  death,  a  deep  ulocr  m 
fotind,  the  size  of  a  iibilling,  with  nnl  mid  mii>«)l  itlgcs,  on  tbe  1 
side  of  tile  under  stiriacc  of  tlic  tongue.  It  perforated  tho  root  oft 
organ,  and  gipreftd  on  tlie  dontiini  Iiitii  an  uJccr  Uireo  incites  bra 
and  two  inches  from  beforo  backwards,  in  which  dirM>tiun  it  invoh* 
the  sof>.  piiliilo  and  tonailit,  ruid  hud  d^tittroyod  tlte  epiglottis  wid  I 
tu-yteno-epiglottidean  folds.  Tho  aperture  of  the  glotliK  was  oeai 
blocked  II]),  aitd  disease  spread  into  the  interior  of  tlm  laiyr 
There  had  been  little  or  no  hieinorrliagc  dtu-ing  life  There  wi 
six  or  soveii  sinnll  nbsorbont  glnnd^,  infiltrated  by  masses  ofopcui 
yellow ifth-white  matter.  Tlio  morbid  gruwUi  ocinsiMtod  of  epitbel 
cells,  and  xinulfir  bodies  were  imbedded  in  the  tongue  along 
course  of  tbe  penetrating  ulcer.  Tlti.-*  gentleman's  &tlier  had  li 
to  R  very  ndvanced  n^c. 

Hard  cancer  or  sein-hu.t  of  tlio  tongue  commences  ms  a 
and  incompressible  knob  oil  the  edge  of  the  orj^n,  ntaate 
oppatite  the  hist  m<diir  or  wiwloin  tooth ;  or  so  far  tovrurds 
root  that  it  Is  beyond  the  roach  of  surgical  interference, 
patii-tit  at  fttvi  euiiipliiins  tliut  the  tongue  is  sore,  nn<l  ho  oA| 
attributes  this  symptom  to  the  irritation  of  im  nnsound  tooth,  i 
the  luicouti-ollcd  niovcnicots  of  the  jaw  during  sleep.  Soon  the 
of  deglutition  becomes  painful;  the  patient  fcant  cither  to  cat 
drink :  a  whurp  pain  cxtt^nds  along  the  Eusta<>hlun  tube  toirar 
tho  ear;  the  saliva  flows  from  the  month  profusely.  The  symptxui 
bticome  aggravated  during  sleep ;  the  nights  arc  disturbed  by  tlj 
secrotiou  accumulating  in  the  throat  and  exciting  cougli.  Oiim 
Uie  patient  is  roused  by  a  painful  compression  of  the  tongi 
between  the  jaivs ;  and  a»  the  uloeration  extends,  h^morrhii;; 
ocfiuiiionally  supervene.  Sooner  or  later  tlio  Hnb-maxillan'  absoi 
bent  ghiiuh  become  enlarged  by  the  same  cancerous  deposit,  win 
first  a  eircumscribod  and  then  a  diHused  tumour  forms  in  Uw  ncc 
covered  by  thin  aud  rotldcncd  integument,  nlrieh,  ifbould  thepatt 
survive  a  sufTicient  longtli  of  time,  ulcerates,  leaving  a  foul 


CANCER. 


iHl 


I 


M>ri>,  (liitotiarging  u  thin  fa'tid  finki,  witli  occasional  lu^morrbagos, 
But  with  tJic  progresa  of  the  disease  emaciation  supervenes,  und  tho 
pditii'iit  ili<?A  with  tho  usual  cachcKctic  indifmtiouK  of  ciutmr. 

But  UiiH  in  not  tlie  only  form  of  miilij^nnnt  disease  ulfei-lliig 
tho  tongue.  In  1847,  Mr.  Cocly  of  Aylc-«bnry  rcmovod  from  the 
tongiit-  of  a  {naiiciit  a  wft,  friiihle,  and  imiguturly-lohulntod  mam 
of  reddish-brown  colour,  vnth  vascular  rod  points,  hut  without  any 
diM.inot  lu'nmgoinciit  of  vos.'tcltt,  compiled  of  cuudato  or  clul>-<«haped 
cells  with  large  nuclei,  blood-discs,  and  a  thickisli  matter  coagulablo 
in  aWhiil.  Tiio  tniniuir,  naitl  Mr.  Ooly,  when  examining  it  immo- 
dialely  before  its  removal,  protruded  from  tJio  mouth ;  the  tongue 
wax  llirusl  to  tlie  l<>fl  side,  and  vnut  «wriUen ;  tlie  lipa  were  cedo- 
matotis ;  the  surface  of  the  tumour  was  in  many  p)ae<i8  black,  and 
n  scro-'iumguineou.i  fluid  iiDzed  fi-om  iU  itpjwr  part.  By  retracting 
tho  angles  of  tJio  mouth,  and  directing  tho  patient  to  thrust  the 
tongno  forward,  ami  at  the  Sfimt;  time  niising  the  tnntour  over  ilio 
lower  lip,  it  was  brought  ho  far  forward  as  to  become  gin  roun<I 
it»  brood  base  by  the  whole  circnmfercnco  of  Ui<!  mouth,  whore  it 
remained  fixctl.  It  then  felt  quite  elastic,  and  measured  longitu- 
dinally five  inohe)>,  transrers^'ly  three  inches.  While  it  was  in  tlio 
above  situation,  I  placed  my  fingers,  continued  Mr.  Coety,  under 
the  tumour,  and  gently  raiding  it  from  the  base  1  peeled  it  otf, 
when  a  large  jagged  Hurfaco  was  left,  which  wiw  soon  eiiv(?rwl  witii 
Goagidn  from  bleeding  vessels.  The  biemorrbage  was  moderate,  and 
oanily  reprcMsed  wiili  tlio  matioo-k-af  in  ooanw  powder.  Tlie  |>or- 
tion  remove^l  very  mudt  resembled  recently  detached  ]>lneouta, 
though  pi^rliapit  Ic^s  6rm  ;  it  wait  a  "pongy,  granular  mass,  will) 
interstitial  fluid  blood;  it  had  none  of  the  shaggy'  filamentous 
apjHfaraiKW  of  cauliflower  excresocnoo  <ielai!lied  from  tbi*  utcrud. 
Tho  weight  of  the  mass  romovc<l  was  sevenloen  drachms  and  a  half. 
On  April  Sth,  It<W,  Mr.  CVIy  rcjKirtcd  tliat  the  nuin  wiu  ntill 
alive,  although  the  morbid  growth  was  reproduced  within  a  week. 

I  saw  near  to  Town,  in  1848,  a  patient  in  whom  there  was 
Bcareely  any  vestige  of  tongue  remaining,  the  whole  organ  having 
been  alloelod  with  n  similar  frialjlo  <!fgitnerMtiiiii,  TIm)  patient  coidd 
still  articulate,  and  suffered  less  than  might  have  been  expected. 

In  1860,  a  patient  under  the  carp  of  Mr,  Harle,  Surgtroii,  of 
Islington,  presented  himself  at  tlie  hospital,  in  whom  a  portion  of 
tho  upper  suHaeo  of  the  tongue,  tho  size  of  a  sixpcnny-pjcoo,  wait 
occupied  by  an  opaque  white  layer  or  mass,  consiitting  of  thickened 
cpitltolium,  ri»ing  above  the  Ie>'el  oftlio  surrounding  parts.  Under 
the  microM»i>c  Iho  substance  was  itcen  to  consist  of  opitliclial  soales,. 


912  DISEASES  OP  THE  TONGUE. 

driod  and  d<;f"rmi-<l,  and  rnntaining  but  fow  nucloi.  There 
Utrulency  to  indctiiiilo  propagatiun,  m  in  cancer,  nor  lo  any  A 
plication  of  tbo  ncightMiiring  lisMictt.  Tlio  fHi{>il]a!  iimW  tho  wh 
man  iccnicd  unJai^ced.  Tlioro  was  no  swelling  oftlioiteighbouri 
absoriKnt  glaniU.  'I'lio  (llHc».tiT  liud  vxixteil  twi:Iv«  ^njan  with< 
muttirial  change;  the  patioiit  was  a  liealtliy  woman  aged  for 
and  no  wirgicnl  intorrorcncr  veun  indimti'd.  Bwt  when  this  wh 
maaa  was  mined,  and  Uio  fitato  of  tho  |>spiUa>  seen  I>viK-sith, 
rtMcmbtanco  Ui  e]>ithulioma  wits  obrtoiis.  And  it  was  found, 
R)tcix>acopio  examination,  that  tlw  softer  cjiitliolial  coib 
out  thi»  resemblance  iiirthcr.  That  Hn:  lUfCueo  was  not  of 
ceronn  nature  was  jiroved  by  the  liistory ;  no  ooui'oe  of  local  in 
tation  was  discovered  by  the  most  oarcfid  examination;  aiwl 
vtuu!  servnl  to  illustrate  the  fact,  that  in  nialigiutnt  disease 
is  something  bejond  tlw  mere  incrxsase  of  tlio  epithelial 
It  wax  ill  all  pi-obabiltty  of  thia  tJiiu'acter  tluit  a  (nmoor, 
Bup])oso(I  epithelioma  of  tlic  tongue,  partook,  which  watt 
to  tlio  Palhological  Soaety,  December  Titli,  14)59.*  It  waa  lab 
frem  a  patient  aged  se\'enty-nitM ;  had  existed  sixteen  years,  ai 
had  been  nix  ^-ooni  under  obmrvation.  It  involved  Uie  tip,  I 
right  half  a]id  tlie  left  aide  of  the  tongue;  the  pbai:^iix  nnd  Urvi 
were  olrophiod.  AUn-  death,  an  examination  of  tlie  body  w 
made,  when  no  maligntuit  diaease  waa  found  elsewhere.  In  1857, 
saw  a  nimiliir  csm;  under  the.  care  of  Mr.  Ci-cly  of  Aylesbury.  1 
patient  was  a  sailor,  of  very  iittoniperate  habits;  and  about  tiAn 
years  ago  he  presented  himself  with  a  small  epithelial  j^wtli 
the  tongue  about  tlic  sizo  of  an  nhnond. 

A  cancerous  tumour  of  the  tongue  sliould  bo  cxtirTiatcd, 
|>ossible,  by  the  knife.     The  jiaUent  mn«t  sit  in  a  chair,  nil 
head  suppoi-tcd:  chloroform  Iiad  better  not  bo  given  in  simple 
beeauae  tlie  wneurrxince  of  tho  jHUtent  is  needed.      An 
grasps  tho  tip*  of  tho  tongue,  covered  with  a  towel,  betwi 
forc-fingor  and  ttniiid)  of  one  hand,  while  witli  the  otiier  Iw 
back  tho  check.      Tlio  Snrgeon  then  ttei7.c»  Ihe  tumour  exmipi 
witliin  tlie  blades  of  double-hooked  forceps,  and  wiUi  n  sharp  rou 
pointed  knife,  of  somewhat  large  nizc,  swocpK  away  tho  tmcli 
mass  in  a  lew  seconds.     The  whole  tnmour  must  be  grasped 
tlie  forceps,  that  none  bo  Icll  ln'Iiiiid.      Tlic  hsmorrlmge  rend 
any  subamjucnt  examination  troubleaonie.     Tho   knifo  sliould 
round-pointed,  that  none  of  llie  art".Ties  on  the  floor  of  the  m< 


•  PalK  £mt.  2>w».  to],  xi.  y.  StO. 


REMOVAL  OF  CANCER. 


I 


be  wouiultvl.  It  may  bv  curvnl  in  (liRVivnt  wnyx,  lufwrding  In  iliv 
&ncy  of  Um}  operator;  but  a  straigtit  knifo  is  always  Ute  best,  Tlifl 
hgemorrlinge  must  be  (ioiitn>llf<l  b_v  ic«.  An  iirlitrj'  whi<-ii  com- 
monly n«eds  a  ligature  is  tho  snblingual ;  and  this  can  only  be 
n-oiinded  by  the  Surf^iyin  w'mg  a  »tinq>-{ioiiitO()  knifi*.  No  liga- 
tures or  snturos  are  usually  (Ic«irablo  to  Iho  woonded  tongne ;  tfaej' 
irritate  tJiv  month,  and  uxdto  tJ>o  flow  ofitaliva.  Tlio  cut  sur&coi 
granulate  and  heal,  leaving  pcrliaps  an  elevation  of  the  eubatanoo 
of  tlif  umgue,  from  JU  being  |iu<tken><l  u|i  at  tliis  sejii.  of  operation. 
This,  however,  can  be  distingaislied  from  the  reproduction  of  dls- 
en»c  Ijy  the  abscntv  of  inihii'ution. 

The  <;oraficur  has  supimrters  as  a  proper  instrument  for  tlic  per- 
ftmiiancw  of  these  opiTalion*,  Whmi  Ijoth  liii;;ua!  nrti-rie!*  maybe 
divided,  it  is  to  be  preferred  to  the  knife.  But  I  cannot  recommend 
entirely  the  ])roi'oe<ling!i  of  M,  Chassaigruie.  TfiiB  Stirjjpon  ampu- 
tated tho  tongue  close  to  ita  ba^ic,  in  consec|uencc  of  cancer  of  tliat 
orgnii,  by  means  of  the  {cnuwur.  As  tho  di«ca«e  tlirealeiied  to  in- 
Toh-o  tho  entire  organ,  ita  complete  extirpation  waa  resolved  on. 
Tw<^  or  tlirce  da}-»  before  nndertaking  the  operation,  M.  OioMaignac 
pawMxl  a  drainage-tube  frnni  without  round  about  the  baw  of  tho 
tongue,  immediately  above  tho  groat  comti  of  the  os  Iiyoides,  The 
point  wliero  the  tube  wat  introduoed  wa»  a  little  lo  the  right  of  tho 
middle  line.  Ha\Hng  thus  prepared  a  passage  for  tho  chain  of  ilio 
i!cra*ienr,  the  tube  was  witlidrawn  a*  iwon  a!i  tlie  eliain  wa»  in 
position.  Tlicn  commenced  Urn  separation  of  tho  organ.  Two 
niinuU-s  were  allowed  to  elapse  between  eaeh  movement  of  the  in- 
strument ;  and  tho  transverse  division  of  the  organ  was  effected  in 
exactly  linlf  an  hour.  TIk?  ehnin  wan  llieii  piL'<iiiNl  b<thin(I  tho  blue 
-of  tho  separated  orgaji,  and  made  to  embrace  the  muscles  and 
tiKkues  attached  tx»  its  under  »urfHco.  In  tJiirty  minuti>M  more  tliiii 
second  part  of  tho  operation  was  completed,  so  that  the  entire  time 
oectipied  waH  exactly  one  hour.  Tho  quantity  of  blood  lost  was 
quite  insignificant,  and  the  poor  roan  did  not  evince  great  wiffering. 
On  t]io  cightli  <Iay  afVcr  the  operation  lie  was  going  on  woIL*  A 
subaequent  account  reports  the  paticnt^K  recovery.  A  y<^  mors 
serious  and  complicated  prooeoding  oonststH  in  the  introduction  of 
tlie  elmin  round  the  root  of  tlio  toiigao  by  means  of  an  ineiniini  into 
the  floor  of  tlio  mouth  from  twitJiout  A  second  chain  is  required 
to  free  tho  severed  tongue  from  the  muscles  and  mA  parts;  tlu» 
double  operation  takca  abont  one  hour  for  its  completion. 


*  litd.  Tiaui  and  Gat-,  Mv  !<.  ISM. 


TOt.  m. 


3m 


911 


DISEASES  OF  THE  TONGUE. 


When  the  cancerous  dcgi-iusnition  is  limited  to  the  aidi 
tongiK;,  no  niicli  proceeding  cjm  he  neeenary,  Sx  the  eevai 
arleri«a  are  but  hduiU.  But  when  the  operation  im-olves  iin  e 
tonaion  beyond  the  memai  line,  so  that  one  or  botli  raQino  i 
tertt»  must  ho  cut  ocrow,  and  that,  too,  towaixhi  Uio  ham  of  t 
(ir^n, — undi'r  »ucli  circumstanocai  tha  £cnuear  may  he  nwd  w 
ndvantage.  Witli  it  may  be  comhinod  the  iMnploym^mt  of  I 
ligature,  ns  in  tlic  fnllowing  ca#c.  In  1859  I  removed  by  Uic  ko 
A  conoeroua  maas  £i'om  tho  loH  side  of  the  tongue  of  a  man  ag 
forty-two.  The  hnimon-hago  -vraB  consideralJe,  the  nound  hoi 
\e.ry  deep ;  but  it  ceased  after  the  prnlongud  uxc  of  ice.  Tito  pal 
cicatrised  completely,  and  the  patient  left  the  ho!t|uttU  appann 
well.  In  ten  montlu  the  di»eatie  returned  in  the  cicatrix,  and  t 
patient  came  to  mo  vritli  the  request  that  I  would  again  romore  t 
hardened  parto,  in  order  to  give  him  even  temporary  relief  fi-om  pai 
As  the  induration  extended  quite  to  tlie  meaial  line,  and  the  rani 
arteriM  would  ofncot^wiily  bo  divided,  I  proceeded  as  fotlowti ; 

Chloroform  liaHug  been  adnuDtRtered  m>  as  to  prodnce  oompli 
ia'<»n«ibility,  tliv  t'niguo  wa»  dntwu  &Dm  the  mouth  by  an  aMistan 
the  chain  of  a  snmll  ^aseur,  armed  n-ith  a  needle,  was  then  foaa 
tliroiif^i  tlie  middle  of  tlio  tongue  beyond  the  base  of  Uic  tomoi 
and  made  to  cut  from  witliin  outwards,  so  as  to  M;vor  the  po«I«ri 
connexions.  Next  a  slight  incision  was  made  with  aci^sors  into  t 
point  of  the  longne,  so  as  to  guide  a  ligattiro  round  the  remainil 
nttncliment  of  tliu  partially  sov««d  moss.  A  strong  knot  vrta  tie 
die  p-ominetit  pari  cut  away,  and  the  patient  was  remo^-cd  to  htA 

In  Docemhcr  1861  Mi-.  Nunneley  described,  bofbrc  the  Media 
Cliirurgioal  Society  of  London,  the  particalars  of  an  opct 
lion  for  tlio  complete  cxtirjialion  of  tho  tongue,  in  which  it  9 
asserted  the  euro  had  been  permanent  for  some  montlw.  A  sm 
incision  was  made  anterior  lo  llic  os  hyoidos  through  the  iiitoi 
ment,  mylohyoid,  and  geniohyoid  musoles,  by  whi<4i  a  cur* 
needle,  to  wliieh  was  attached  the  chain  of  tho  ^crasenr,  was  inUi 
diieod  »o  as  to  carry  tho  cliain  completely  mun<l  the  base  of  1 
organ.  In  consofjuence  of  some  imperfection  in  the  chain,  it  n 
removed ;  strong  whipcord  was  aubatitulod,  nad  tied  with  all  I 
force  possible.  Ihiring  tin?  course  of  treatment  haMuorrhngo  snpe 
vencd,  but  it  was  easily  arrested  by  a  solution  of  tannin.  VH 
matoly  the  organ  camo  away,  and  the  wound  cicatrised.  Bob 
doubt,  however,  was  expressed  by  tho  society  as  to  the  Cfxact  naW 
of  the  disciise.* 

•  Med.  rnH«rt«w((3«*.,Dec3».160l,p.M8. 


DIVISION  OF  GUSTATORY  NERVE. 


915 


Tbo  tongue  lias  boon  oomplotclj-  cxtirpatul  by  Uic  knife.  R«g- 
noli  lias  removed  Inrge  porti<mB  by  nioking  an  ini^i.->tou  into  tlic 
floor  of  tlio  tnoutli  from  ono  niiglv  of  the  inferior  maxilla  to  the 
otlior.  But  Mr.  Syiiio  first,  and  siiVis«inondy  Sir.  I'"i4<ic«,"  have 
extirpated  the  entire  organ,  by  making  an  itiei&ion  through  the  lower 
Ii]>,  chin,  and  low«rjaw,  jiulliiig  aside  the  two  luilv<«  of  tho  bcMio, 
ajid  dissecting  the  diwtised  mass,  which  is  by  tlieee  means  fnlly  ex- 
po^^il,  fi-om  tilt!  OS  hyoido:^  Sir.  Fiildo*  jwinUi  out  tliu  imjiortancD 
of  securing  one  lingual  artery  before  tbo  other  is  di^nded.  He  hoa 
opcrat«>d  thus  twice,  iuid  spealw  well  of  the  nsmlte  of  iii.«  caxea. 
The  proceeding  baa  not,  however,  yet  found  favoui'  generally  witli 
modem  Surgeons. 

Now,  ill  c>uneor  of  tlie  tongue  the  groafost  distress  to  the  patient 
arises,  first,  from  ibo  pain  in  ever}'  ino^'cmeut  of  the  organ,  extend- 
ing to  the  &\r  luid  over  tlie  aidfe  of  tlio  head ;  and  Aeeondly, 
from  the  profuse  flow  of  saliva,  which  koopet  him  constantly  wot 
and  unable  to  arliculato  with  comfort.  Tlie  idea  of  diniini^bing 
the  sen&ibility  of  the  tongue,  and  of  chcckbg  the  excessive  secre- 
tion by  the  divi»iou  of  thu  gtiHtatorj'  nerve  aa  it  Iio«  clow)  to  llic 
ramus  of  tlio  jaw,  suggested  itself  many  years  ago  to  Mr.  Hil- 
ton;! <t"^  I^Ir.  Moore,  of  tlie  Middlesex  Hoitpiud,  has  recently 
repeated  tbo  operation.  By  tUvIding  the  gustatory  nerve,  he  re- 
marlu,  iK^twecn  tlio  disease  luid  Uie  brain,  all  the  conaequcnoes 
of  the  irritation  of  that  nen'o  are  necessarily  suspended.  No  aen- 
sntiun  from  the  tiunonr  van  In)  ei>nveycd  along  it;  no  reficdod 
irritation  can  reach  the  collateral  branches  of  tlie  fifth  none;  no 
stimulus  to  an  exaggerated  »ocri^ion  of  Nalim  cim  bo  given  to  the 
nalivary  glands.  A  patient  on  whom  this  operation  has  been  por- 
formod  should  speak  more  freely,  an<l  .*wall"w  with  lea  difiiculty ; 
should  bo  relieved  of  pain  in  the  tongue  and  jaw,  temple  and  crown 
of  the  head,  and  of  tlio  inec»aiit  aiiiioyanco  arj^iing  frx>in  tlie 
dribbling  of  .'^aliva;  he  sJiould  aloop  better,  anil  be  better  nonrisbed 
than  before. 

'Ilie  mode  of  performing  tJie  operation,  as  adopted  by  Mr. 
Moore,  differs  in  some  respects  from  tliat  adopted  by  Mr.  Hilton. 
The  latter  Surgeon  sought  for  tho  iion-e  in  the  floor  of  tlic  mouth, 
and  exposed  it  by  making  an  incision  along  tho  mncons  membrane 
clow  to  tlio  sublingual  gland.  Tbo  former  divi<leit  llie  nerve  just 
behind  tlie  last  molar  tooth,  as  it  escapes  frvm  the  cover  of  tho 


»  £Jin.  Mfd.  JottT..  Jun«  lAM. 

t  Ovf'i  Uorpilai  Btjiortt,  Tol.  vlL  p.  34S. 


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916  DISEASES  OP  THE  TONGUE. 

ptfiiygoidens  intemus  mnscle.  It  is  not  more  than  half  an  indk 
distant  from  the  too^,  and  is  covered  only  by  mucooB  membrane. 

The  guido  to  the  nervo  is  the  last  molar  tooth.  On  passing  the 
finger  into  the  mouth,  within  and  beyond  that  tooth,  the  b^ging 
alvcohir  ridge  can  bo  folt  narrowing  as  it  ascends  into  the  thin 
ramus.  Bcliind,  below,  and  parallel  with  the  ridge,  is  a  shallow 
groove  in  the  bone.  The  nerve  passes  along  tJiat  groove.  There- 
fore an  incision  three  qnartcrs  of  an  inch  in  length  made  within 
the  mouth  and  down  to  the  lower  jaw  behind  the  last  molar  tooti, 
and  in  a  direction  crossing  the  course  of  Uie  nerve,  must  di>-ide  it. 
It  is  advisable  to  operate  witli  a  curved  bistoury,  since  the  alveoUr 
ridge  might  shield  the  nerve. 

The  patients  have  expressed  themselves  reUcved;  tlie  tongue 
being  rendered  completely  numb. 

Mr.  Moore  has  combined  with  this  operation  ligature  of  the 
corresponding  lingual  artery,  bo  as  to  cut  off  as  much  as  possiblt 
the  supply  of  blood  to  the  affected  part.  The  results  are  Hufficientlj 
encouraging  to  merit  fiirther  trial. 

HOLMES  COOTE. 


END  OF  THE  THIRD  VOLUME. 


LomMxr 
FBUtTZD  BT  Linr,  aoBooK,  Axn  wuxkltv, 

OiMt  Mmr  EM«I  ud  ftVta  Ud*. 

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