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II. Members shall neither retain nor obtain books
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will be punishable by suspension.
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• refuse the loan of any volume.
THE
FIRST LINES
OF THE
THEORY AND PRACTICE
OF
SURGERY;
I
INCLUDING
THE PRINCIPAL OPERATIONS.
BY
SAMUEL COOPER,
SENIOR SURGEON TO UNIVERSITY COLLEGE HOSPITAL, AND PROFESSOR
OF SURGERY IN THE SAME COLLEGE, ETC.
LONDON:
PRINTED FOR
LONGMAN, ORME, AND CO.J WIIITTAKER AND CO. J S. HIGHLEYJ T. TEGG ;
SHERWOOD AND CO.J E. COX J SIMPK1N, MARSHALL, AND CO.J T. BUMPUS ;
HOULSTON AND STONEMAN J J. CHIDLEY ; B. FELLOWES J J. CHURCHILL;
H.RENSHAWJ C.DALY; J.BUTLER; J. MASTERS : A. AND C. BLACK ; STIRLING,
KENNEY, AND CO. ; AND MACLACHLAN AND CO. ; EDINBURGH : AND FANNIN
AND CO., DUBLIN.
1840.
LONDON :
Printed by A. SroTT.rc"»'oonE,
New- Street- Square.
T^EFACE
TO THE
SEVENTH EDITION.
THIS work was originally designed as an elementary treatise on
Surgery; and, in all the editions which it has passed through,
the same primary object has never been departed from. The
principal wish of the Author has been to offer such views of
scientific and practical surgery, as the student and young prac-
titioner may refer to with advantage. Above all things, he is
desirous, that the publication may serve as a text-book for the
Lectures, annually delivered by him to the Surgical Class of
University College; and, if the gentlemen, who compose that
class, shall be in any way benefited by the undertaking, or derive
from it a clearer comprehension of the doctrines, which they do
him the honour of listening to, the pleasure that he will expe-
rience in thus promoting their advancement, will be his highest
reward.
The reader, who compares this edition with the last, will
discover numerous corrections ; and, in almost every page, new
matter. All this seemed requisite to adapt the work to the
present state of surgery.
7. Woburn Place, Russell Square,
November 26. 1839.
A 2
CONTENTS.
SECTION I.
ELEMENTARY AND GENERAL SUBJECTS.
Page
1
- 32
- 36
- 37
- 42
- 46
- 50
- 74
- 76
- 91
Inflammation
Suppuration and Abscesses -
Qualities of Pus
Theory of Suppuration
Treatment of Abscesses
Hectic Fever
Mortification - -
Of Amputation for Mortification
Ulceration and Ulcers
Erysipelas -
Of Furuncular, Carbuncular, and
other Gangrenous Forms of In-
flammation - 99
Malignant Pustule - 102
Chemical and Mechanical Injuries - 103
Burns and Scalds - - - 104
Deformities brought on by Burns - 114
Effects of Cold - - - 115
Wounds - !' .Vi -125
Incised Wounds ~" '- • ' •'$•+*.. - 127
Hemorrhage - - - 129
Treatment of Wounds - - 146
Union by the First Intention - 148
The Nature of the Process - -^ 155
Punctured Wounds - - 158
Contused and Lacerated Wounds - 164
Granulation and Cicatrisation - 165
Reproduction of Lost Parts - 1 70
Gunshot Wounds - - - 171
Of Amputation for
Gunshot Wounds - - 181
Poisoned Wounds - - 183
Bites of Venomous Snakes - 184
Wounds in Dissection - - 186
Bite of a Rabid Animal - - 188
Of Particular Derangements of the
Muscular and Nervous Systems
from Wounds — Tetanus - - 1 96
Of Fractures in General - - 208
Process of Union - . --v--.: - 216
Ununited Fractures -. . -225
Page
Compound Fractures - - 228
Complication with Hemorrhage - 233
Of Dislocations in General - - 234
Compound Dislocations - - 245
Contusions - - - - 246
Sprains - - - 248
Diseases of the Bloodvessels - 249
Aneurism - - - 251
Diseases of Veins ' «* - - 267
Phlebitis - - : - V - 268
Varices - - - 272
Aneurismal Varix, or Venous Aneu-
rism - - - 275
Diseases of the Bones - -277
Inflammation and Suppuration of
Bones - - - 278
Caries - - - 28O
Necrosis - - - - 283
Mollities - - - 297
Fragilitas - - 298
Rickets - -A - 299
Exostoses - - 303
Medullary Tumours - - 307
Pulsatory Tumours - - ib.
Osteosarcoma - - 308
Diseases of the Joints - - 309
Inflammation of Synovial Membrane ib.
Extraneous Cartilaginous Substances
in Joints - - 311
Pulpy Thickening of Synovial Mem-
brane - 0 - - 313
Ulceration of Cartilages - - 314
Scrofulous Disease of Joints begin-
ning in the Bones - - - 3 1 8
Scrofulous Disease of the Hip - 3 1 9
Anchylosis - - 326
Injuries and Diseases of Tendons and
Bursa) - - 327
Growth of Tumours -333
Fatty Tumours — Adipose Sarcoma 338
Pancreatic Sarcoma - - - 339
VI
CONTENTS.
Page
Mammary Sarcoma - - 339
Tuberculated Sarcoma - - ib.
Cellular Tumour - - ib.
Fibro-cartilaginous Tumour - - 340
Painful Subcutaneous Tumour - ib.
Naevi - - 341
Polypi r - - - 344
Warts - - - ib.
Tage
Encysted Tumours
- 344
Scirrhus and Cancer -
- 347
Medullary Sarcoma, and
Fungus
Hasmatodes
- 358
Melanosis
- 360
Scrofula, or Struma
- 363
Of Lues Venerea — Syphilis
- 372
SECTION II.
INJURIES AND DISEASES OF , PARTICULAR ORGANS AND REGIONS.
/Injuries of the Head
Wounds of the Scalp
] Fractures of the Skull
x el Wounds of the Brain
I Compression of the Brain
, .. / Concussion of the Brain
1 1 Hernia Cerebri - -
i \Pungous Tumours of the Dura Mater
>- Diseases of the Eye and its Appen-
I f dages - - - -
,1 / Diseases of the Lachrymal Organs -
Y Encanthis - - -
Various Diseases formerly confounded
together under the Name of Fistula
Lachrymalis -
Diseases of the Eyelids
Calarrhal Inflammation
Ophthalmia Tarsi -
Hordeolum
Encysted Tumours - -
Ectropium -
Entropium - - -
Trichiasis ...
Ptosis - -
Paralysis of Orbicular Muscle
Granular Conjunctiva
Concretion of Eyelids
Diseases of the Eye itself
Inflammations of the Conjunctiva
Inflammation of External proper
Tunics - . _
Ophthalmitis - -
Rheumatic Ophthalmia, or Sclerotitis
Catarrho-rheumatic Ophthalmia
Scrofulous Corneitis
Iritis - -
Retinitis -
Glaucoma - - -
Onyx, or Abscess of the Cornea
Specks and Opacities of the Cornea -
Staphyloma - - -
Synechia -
Prolapsus of the Iris - -
Closure of the Pupil
Hydrophthalmia - -
Amaurosis, or Gutta Serena
emeralopia -
Nyctalopia
Cataract
Malignant Diseases of the Eye
iseases of the Ear
iseases about the Face
Lupus
Lipoma of the Nose
Polypi of the Nose
438 \ Salivary Fistula -
ib. i,} Diseases of the Antrum
440 ^ Harelip
Cancer of the Lip
Diseases of the Mouth
Wounds of the Tongue
447 AT Inflammation of the Tongue
ib. \ Ulcers, &c. of the Tongue
448 /Cancer of the Tongue
449 Division of the Fraenum
ib. Ranula
450 Diseases of the Tonsils
452 I Elongated Uvula -
453, \Diseases of the Gums
ibi:w Wounds of the Throat
Foreign Bodies in the OZsophagus -
Wry Neck -
'Bronchocele -
Wounds of the Chest
pEmphysema -
.Diseases of the Breast
464 / Nipples Deficient, or Supernumerary
ib. |-NExcoriations of Nipple
466 V Ulcerated Cracks of Nipple
467 /• Lacteal Swelling
468y * Inflammation and Abscess -
469N\ Hypertrophy of the Breast
472 ^ Hydatid Tumour
473 ( Chronic Mammary Tumour -
474 Scrofulous Swelling
475 Irritable Tumour
476 .^' Ecchymosis Discolouration
477 ^Wounds of the Belly -
478" ^ Lumbar Abscess
ib> Scrofulous Caries of the Spine
4«d'. Spina Bifida
481 "Hernia - - -
484
ib.
485
492
ib.
'194
ib.
497
ib.
499
500
501
503
504
ib.
ib.
ib.
505
ib.
506
ib.
507
ib.
508
512
514
516
518
5 20
522
ib.
ib.
523
ib.
525
527
ib.
528
ib.
ib.
529
ib.
54;;
£45
549
551
CONTEN
TS.
Vll
r Operation for Oblique Inguinal Her-
nia 561
- \ Operation for Direct Inguinal Hernia 565
Femoral Hernia
Congenital Inguinal Hernia
Hernia of the Coecum and Colon
Umbilical Hernia - \f5Z
Central Hernia
Cystocele
- ib.
- 573
- 575
- 576
- 577
- ib.
/~ Diseases of the Genital and Urinary
Organs - - 578
Acute Inflammation of the Testicle - 579
\ Atrophia Testis - - 581
\ Chronic Enlargement - - 582
> \ Granular Protrusion
J Irritable Testis — Neuralgia
] Scrofulous Testis
Cystic Sarcoma
Medullary Cancer
Scirrhus - - «-"i •
I Hydrocele - - ; -
Congenital Hydrocele
j Hydrocele of the Cord ••
Haematocele
Varicocele - - •
Diseases of the Scrotum «
Chimney Sweepers' Cancer
Cancer of the Penis
Diseases of the Prostate Gland
Strictures of the Urethra
Retention of Urine
• Catheters and their Use
Incontinence of Urine
Gonorrhrea
Chordee — Sympathetic Bubo — and
Inflammation extending to Bladder 633
\ Phimosis - - - ib.
\Paraphimosis - - 636
y-Diseases of the Anus and Rectum - 637
, / Abscesses — Fistula in Ano - ib.
Piles - - 640
Inflammation, or Strangulation of
\ Piles - - 643
Discharge of Mucus or Pus from the
J Rectum - - - 644
Prolapsus Ani - - 645
•.•
Page
Contracted Sphincter - 647
Ulcer of the Rectum - - ib.
;ricture of the Rectum - - 648
lignant Diseases of the Rectum - 649
articular Fractures - 65O
Fractures of the Ossa Nasi - - ib.
Cheek andUpperJaw
Bone - - 651
Lower Jaw - ib.
Spine
Sternum
Ribs
Clavicle
Scapula
Humerus -
Fore- arm
- 600
- 601 j
- 602 j
- 608
- 617
- 619
- 625
- 626
- 654
- 658
- 660
- 661
- 665
- 667
- 671
Carpus, Metacarpus,
and Phalanges of
Fingers - 674
Pelvis • - ib.
Thigh-bone - 675
Cervix - - 680
Fermir towards Knee 685
Patella ;, .. , - 686
Leg '.. ., - 688
Os Calcis - - 691
Particular Dislocations - - ib.
Dislocations of the Lower Jaw - ib.
Clavicle - - 693
Shoulder - ~ 695
Elbow - - 700
Wrist - - 703
Bones of Carpus
from one ano-
ther
Thumb -
Vertebra; .
Head -
Ribs
Hip
Patella
Knee -
Fibula
Ankle -
Astragalus
- 704
- ib.
- 706
- 707
- 708
- 709
- 714
- 715
- 716
- 717
- 718
SECTION III.
OPERATIONS.
General Maxims - - 720
Operation of Trephining - - 722
Extirpation of the Eye - - 726
Removal of the Superior Maxillary
Bone - - 728
Removal of the Lower Jaw Bone - 731
Bronchotomy - - 736
Tracheotomy - - 739
Laryngotomy - - 740
Paracentesis Thoracis - - 741
Removal of a Diseased Breast, and
Tumours in General - - 743
Paracentesis Abdominis - - 746
Removal of a Diseased Testis - 747
Amputation of the Penis - - 752
Puncturing the Bladder - - 758
Lithotomy - - 762
Composition of Calculi - - ib.
via
CONTENTS.
Page
Symptoms of Stone in the Bladder - 763
Sounding - 764
Lateral Operation - - 766
Dangers of Gorgets - - 772
Question — Whether the Prostate
Gland should be completely di-
vided - - - ib.
After-treatment ... 773
Wounds of the Rectum - - 774
Wounds of the Pudic Artery - ib.
Inflammation of Peritoneum, &c. - 775
Amputation - - 776
Circular Amputation of the Thigh - ib. -
Tourniquet - - - ib.
First Incision - - -111
Division of the Muscles - - 778
Use of the Retractor - - -781
Scraping the Bone - - ib.
Manner of Sawing the Bone - 782
Stopping the Hemorrhage - 783
Dressing the Stump - 784
Flap Amputation of the Thigh - 786
Amputation at the Hip Joint - 788
Lisfranc's Method - - ib.
Beclard's Method - - - 789
Amputation of the Leg - - 790
Flap Amputation of the Leg - - 791
Amputation of the Arm - - 792
Arm with lateral
Flaps - - 793
Fore-arm - 794
Flap Amputation of same part - ib.
Flap Amputation at the Wrist - 795
Amputation at the Shoulder - ib.
La Faye's Method - - ib.
Dupuytren's Method - - 796
Lisfranc's Method - - ib.
Larrey's oval Method - - 797
Circular Amputation at the Shoulder 798
Amputation of Parts of the Hand - ib.
Amputation of the two last Phalanges
of the Fingers - - 799
Amputation of a Finger at the Meta-
carpal Extremity - - 800
Amputation of all the Fingers toge-
ther from the Metacarpus - ib.
Amputation of the Thumb - - 801
Amputation of the Little Finger and
the Metacarpal Bone - - 802
Page
Amputation of Metacarpal Bones
alone - 803
Amputation of Parts of the Foot - ib.
1 . Of a single Toe - - - ib.
2. Of the five Toes - - ib.
3. Amputation of the First Mcta-
tarsal Bone - - 804
4. Amputation of other Metatarsal
Bones - 805
5. Amputation of the whole of the
Metatarsus - ib.
Amputation at the Middle of the Tarsus 807
Operations on Arteries - - 809
Ligature of the Common Carotid
Artery . - - ib.
Practical Remarks - - - ib.
Surgical Anatomy - ib.
Operation below the Omohyoideus » 810
Operation above the Omohyoideus - ib.
Ligature of the Arteria Innominata
or Brachio- Cephalic Trunk - 811
Ligature of the Subclavian Artery
where it passes over the First Rib - 812
Surgical Anatomy - - - ib.
Operation - 813
Ligature of the Subclavian Artery in
the Second Division of its Course - 814
Ligature of the Brachial Artery in the
Middle and Upper Parts of the Arm 815
Surgical Anatomy ... ib.
Operation - - » ib.
Ligature of the Brachial Artery at
the Bend of the Elbow - - 8l'6
Ligature of the external Iliac Artery ib.
Surgical Anatomy - - - ib.
Operation - - - - - ib.
Ligature of the Common Iliac Artery 818
Surgical Anatomy - - ib.
Operation - - - - - ib.
Ligature of the Internal Iliac Artery 819
Ligature of the Femoral Artery - ib.
Surgical Anatomy - ib.
Operation in the Upper Third of the
Thigh - - - 820
Operation in the Middle of the Thigh ib.
Ligature of the Popliteal Artery - ib.
Of its Lower Portion - 821
Of its Upper - - ib
Division of Tendons - - ib.
THE
FIRST LINES
OF THE
PRACTICE OF SURGERY.
SECTION I.
ELEMENTARY AND GENERAL SUBJECTS.
INFLAMMATION.
As soon as due proficiency has been made by the student in anatomy,
chemistry, the elements of natural philosophy, physiology, and other
branches of knowledge, constituting essential portions of the foundation
of medical science, he is qualified to commence with advantage the study
of disease ; the comprehension of which is to be derived, partly from the
most authentic descriptions of it, but chiefly from the personal observ-
ation of its extremely diversified forms, as they present themselves in the
field of experience.
No texture, possessing vessels and nerves, is beyond the reach of the
attack of inflammation, and consequently nearly every part of the body
is subject to it. In those animals which have no visible nerves, Dr. Mac-
artney believes that the phenomena of inflammation are not exhibited.
The nerves are regarded by him, and, I think, correctly, as essentially
engaged in the process. Many diseases owe their commencement to
it ; all mechanical injuries are followed by it ; and numerous disorders,
not associated with it in their beginning, become complicated and ma-
terially influenced by it in their more advanced stages. It is indeed
so closely connected with disease in general, either as a cause, an effect,
an accidental complication, or even -as a means of cure, that there is
much truth in the observation, that, when once a studenf has acquired
a knowledge of inflammation and its consequences, and has joined with
this information some good ideas of the nature of a few organic diseases,
he may be said to command a bird's-eye view of the whole field of
pathology.
Inflammation is not always to be regarded as a disease, but frequently
as a salutary process, absolutely necessary for the repair or removal of
the effects of various injuries and morbid alterations affecting the textures
of the animal body. Thus the disease, called hydrocele, is radically
2 INFLAMMATION.
cured by exciting inflammation within the tunica vaginalis ; and, in
wounds of the bowels, a fatal effusion of the intestinal matter can only
be prevented by the compact and close state of all the parts within the
peritoneum, followed up and cemented by the adhesive inflammation.*
Abscesses of the liver discharge themselves sometimes externally, some-
times inwardly into the colon, and occasionally they make their way into
the bronchi. In the first case, inflammation glues together the two con-
tiguous portions of the peritoneum, and by means of ulceration, a passage
is then safely formed for the matter through such adherent parts of the
membrane, and next through the more external textures. Thus, the
cavity of the abdomen is preserved from an effusion of pus, which would
immediately excite a fatal attack of peritonitis. In the second case, by
means of similar adhesions and ulceration, the contents of the abscess
are safely conveyed into the intestine. In the third, the two contiguous
peritoneal surfaces first, and then the two adjacent pleural surfaces, are
rendered adherent by inflammation; and lastly, the ulcerative process
opens a way for the pus through these adherent membranes, the
diaphragm, the cellular tissue, and through the sides of the bronchi,
whence the abscess is discharged by coughing.f
When any part of the animal body is red, swelled, and painful, its
temperature being at the same time raised, its natural secretions altered
or suspended, and- its functions disturbed, such state of it always receives
the name of inflammation. It is not, however, every form of inflamma-
tion that is characterised by a combination of redness, pain, heat, and*
swelling : in some cases, there is little or no redness ; in some, scarcely
any swelling ; in others, only a trivial uneasiness, tingling, or stiffness,
scarcely amounting to pain.
Inflammation is said to be acute when attended with redness, heat,
swelling, and pain, and when the quickness of its course is such, that it
either subsides in a few days, or brings on, in the same space of time,
suppuration, ulceration, mortification, or, when seated in important organs,
even the patient's dissolution.
Chronic inflammation is of a slower and less painful kind, frequently
beginning almost imperceptibly, and then lingering in parts for an indefi-
nite period. It may be attended with little heat or pain. Gradual and
insidious as its progress may be, it frequently leads in the end to struc-
tural changes and functional derangements of the most serious and irre-
mediable kind. Acute inflammation may terminate in it ; and many of
the slowly formed thickenings and indurations, of various tissues, appear
to be effects of it ; but the doctrine is far from being tenable, which
ascribes to it the origin of those multiform tumours presenting themselves
* In opposition to the commonly received doctrine of inflammation being often a
salutary process, essential to the repair of accidental and morbid lesions of textures
of the body (" the necessary condition, or means by which," as Dr. Carswell remarks,
"most injuries, and all solutions of continuity are repaired"), Dr. Macartney's invest-
igations lead him to conclude, " that the powers of reparation and of reproduction arc in
proportion to the indisposition, or incapacity for inflammation ;" and that " inflammation
is so far from being necessary to the reparation of parts, that, in proportion as it exists, the
latter is impeded, retarded, or prevented." " On Inflammation," p. 6. 8vo. Lond. 1838.
Many of Dr. Macartney's arguments, in support of this view, are derived from what
happens in some of the lower animals, which possess no visible nerves, or whose ner-
vous systems are exceedingly simple.
t See Dr. M. Hall's " Principles of Medicine," p. 28.
INFLAMMATION. 3
in the body as adventitious formations, or growths, superadded to the
primitive textures, and even sometimes annihilating them.
Inflammation is said to be healthy f, when uncombined with any deter-
minate disease in the part or constitution, capable of exercising an un-
favourable influence upon it, and particularly when established for the
accomplishment of some salutary purpose in the animal economy. Such
inflammation is also sometimes termed common or simple, and, if it be
near the surface of the body, forming a circumscribed swelling, attended
with heat, pain, throbbing, and redness, it often receives the name of
phlegmon or phlegmonous inflammation. This is sometimes defined to be
inflammation of the cellular tissue ; but, if we are disposed to adopt this
view, we must say, that it is healthy inflammation of that texture ; for
the cellular tissue is also the principal seat of some other kinds of inflam-
mation, as for instance those of carbuncle, malignant pustule, boils,
phlegmonous erysipelas, &c. Phlegmon is defined by Dr. Macartney to
be usually the consequence of some injury, or evident irritation, and
produced in constitutions, or parts of the body, which have been pre-
viously carrying on healthy functions. One of its most distinguishing
features is the deposition of fibrine in and around the inflamed part.
Unhealthy inflammation comprises those forms of it whose appearances,
progress, and termination, are under the influence of some definite or
indefinite disease in the part or the system at large : its varieties are,
therefore, as numberless as diseases themselves.
Specific inflammations, which always belong to the unhealthy class, are
so called when their appearances, effects, course, and termination, are
marked by striking differences from all ordinary cases ; such as a connec-
tion with, or a dependence upon, a particular diathesis ; the operation of
an animal poison ; the power of generating a contagious or infectious
principle, and of being thus propagated from one person to another.
Some specific inflammations, and their effects upon the system at large,
produce a permanent impression on the constitution, whereby the indi-
vidual is rendered insusceptible of a second attack of them. Particular
kinds of inflammation appear to be considered as specific, partly on ac-
count of the peculiarity of their nature, and partly because they require
treatment very different from that applied to the ordinary forms of in-
flammatory complaints. For one or another of these reasons, the inflam-
mation of syphilis, scrofula, small-pox, cow-pox, scarlet fever, and of a mul-
titude of cutaneous diseases, is specific : perhaps, indeed, the number of
inflammations entitled to this denomination is much greater than usually
calculated, and Rayer may be right in ascribing the peculiarities of
cutaneous diseases in general to the specific quality of the inflammation,
excited by various causes on the surface of the body.
Inflammation is said to be primary or idiopathic, when it is the original
affection ; secondary, or symptomatic, when the consequence of another
disorder. The sympathies existing between different parts of the body,
as that between the skin and mucous membranes, are jisually cited in
explanation of the origin of certain inflammations, which consequently
receive the name of sympathetic. Thus some cutaneous diseases are
frequently associated with chronic inflammation of the mucous membrane
of the digestive or respiratory organs ; while, in other instances, the
latter affection, or even ulceration of the mucous membrane of the bowels,
follows inflammation, injury, or disease of the cutaneous texture. This
fact is often exemplified in erysipelas and extensive scalds and burns.
The effects of phlebitis in bringing on inflammation and suppuration in
B 2.
4 INFLAMMATION.
various textures and organs, remote from the original disease or injury,
must not be confounded with sympathetic inflammations.
Amongst the most remarkable effects of inflammation are, the adhesion
of parts to one another; the filling up of the interstices of the cellular
texture with fibrine ; the deposit of the same substance upon free sur-
faces, in the form of one or several layers, having somewhat of the ap-
pearance of a membrane, and hence frequently called a pseudo-membrane ;
or around collections of purulent matter, or around a foreign body lodged
in the substance of parts, in which circumstance it is transformed into a
cyst, calculated to prevent such foreign body from irritating the neigh-
bouring textures ; or it is deposited between the surfaces of a recent
wound, which have been brought together, where it constitutes their
first bond of union. Now, all these curious effects and changes, result-
ing from the exudation of fibrine or coagulating lymph*, and its occa-
sionally becoming vascular and organised, as is frequently exemplified on
inflamed serous membranes and in wounds, led John Hunter to name the
kind of inflammation producing them the adhesive.
When the tendency of inflammation is to cause the production of a
peculiar fluid, termed pus, the epithet suppurative is employed to denote
this character of it. The expressions ulcerative and gangrenous signify
its disposition to occasion ulceration and mortification.
Whether inflammation is to be adhesive, suppurative, ulcerative, or
gangrenous, is chiefly determined by the kind of texture affected ; the
original quality of the inflammation itself; the nature of the exciting
cause ; or the previous state of the part, or constitution. In serous
membranes, adhesive inflammation is more readily excited than suppu-
rative ; and this is also the case in the cellular tissue in general, so far as
common inflammation is concerned. f On the other hand, a mucous
membrane is more prone to suppurative than adhesive inflammation, the
latter not taking place, unless the exciting cause act with violence, be of
long duration, or of a peculiar description. In inflammation of serous
membranes, and at a very early period, as Dr. Carswell has ex-
plained, the secreted fluid contains albumen ; afterwards, and as
the inflammation increases, fibrine is added, and generally an ad-
mixture of the colouring matter of the blood ; and lastly pus. The
same order of succession is also observed to take place in the fluid
products of inflamed mucous membranes. The mucous secretion, how-
ever, is, almost from the commencement of the inflammmation, re-
placed by a serous fluid, which is often very abundant ; this is suc-
ceeded by the presence of albumen and fibrine, and lastly of pus. The
different degrees of fluidity, viscidity, and coagulability of the secretions
generally of inflamed tissues, are derived from the presence of serum,
albumen, and fibrine, in various proportions. As illustrations of the
influence of the original quality of the inflammation, I may observe, that
such as attends boils and witlows is remarkable for its tendency to sup-
* The termjibrine is now frequently substituted for that of coagulating lymph ; but as
the latter contains albumen, there is, strictly speaking, a difference between them.
f Without the qualification here introduced, this doctrine, as taught by John Hunter,
would not be correct ; for " the cellular tissue is not only more frequently the seat of
mortification, but it is also more extensively and rapidly destroyed by it than any other
tissue of the body." See Dr. Cars well's " Illustrations of the Elementary Forms of
Disease," Fasciculus 7 ; one of the most interesting works on Pathology ever pub-
lished.
INFLAMMATION. 5
puration ; while that which is exhibited in carbuncles, malignant pustules,
phlegmonous erysipelas, and after the bites of venomous reptiles, is
notorious for its disposition to produce extensive gangrene of the cellular
tissue. Then some other kinds of inflammation, however severe, rarely
or never bring on either abscesses, ulceration, or gangrene, as we find to
be the case with gout, rheumatism, and the inflammation taking place
in the disease called mumps. The effect of the violence and peculiar
quality of inflammation, in giving to it the adhesive form in a part or tex-
ture not naturally disposed to it, is well exemplified on the mucous mem-
brane of the larynx and trachea in croup, where the interior of these
organs becomes the source of a copious and suffocating effusion of
coagulating lymph. The difference, made by the previously healthy or
morbid state of parts, on the effects of inflammation, is illustrated in the
perilous consequences of an attack of it on limbs already affected with
anasarca, or dropsical effusion. The same case likewise generally exem-
plifies the pernicious influence of an impaired constitution.
Parts remote from the source of the circulation, or having a circula-
tion particularly subject to considerable interruptions and retardations,
or to disturbance from inflammation, are more disposed to ulceration and
mortification than other parts and textures not under such disadvantages.
Hence the frequency of ulcers and sloughing in the lower extremi-
ties, of the mortification of tendons, surrounded by abscess, and of the
general inability of a cicatrix, a callus, warts, wens, and many other
adventitious formations, to bear inflammation, without being likely to
ulcerate or mortify. Mucous membranes, and the skin, which are tex-
tures of high vascularity, often ulcerate or slough, because peculiarly
liable to inflammation.
Generally speaking, inflamed fibrous tissues, as they are termed, in-
cluding tendon, ligament, fascia, aponeurosis, and periosteum, rarely sup-
purate or ulcerate. Or, perhaps, it may be more correct to say, they do
not do so from rheumatic or gouty inflammation ; for, in scrofulous
disease of the bones and joints, the ligaments and synovial membranes
are commonly more or less destroyed by the ulcerative process. Morti-
fication occurs more frequently in the skin, cellular tissue, mucous mem-
branes, and lungs, than in any other tissues or organs, as the immediate
effect of inflammation. Serous and fibrous textures never mortify, unless
the cellular tissue, from whose vessels their nutrition is derived,, has
previously been diseased. This, it is to be presumed, often happens when
abscesses are formed round tendons. In like manner, also, the death of
cartilage and bone is effected by previous disease of the perichondrium,
periosteum, and medullary membrane.*
The redness of inflamed parts seems to be principally owing to the
dilatation of small arteries, and possibly also of small veins, both which
orders of vessels become of sufficient size to admit the red globules ; and
they are not only increased in diameter,, but fully injected with blood, or
in the state termed by Andral hypercemia. Whether the*blood in the
minute veins of an inflamed part assumes the scarlet colour of arterial
blood, is a doctrine rather difficult to prove, because the exact line of
demarcation between the capillary arteries and the smallest veins does not
admit of demonstration. The redness has been partly ascribed to the
generation of new vessels ; but this doctrine is not tenable as a general
* Carswell, op. cit. Fasciculus 7.
B 3
O INFLAMMATION.
one, because redness is producible in a few seconds by friction, heat, and
other causes of irritation, — a space of time too short to be consistent
with such a view. Many textures, naturally colourless, may also be
reddened with fine anatomical injection, — a proof, that the distension of
those vessels which already exist, will account for a great deal of the
redness. Undoubtedly, inflammation renders vessels plainly visible in
certain textures, which cannot be made to manifest vascularity by means
of any sort of injection. However, this fact only proves, that it is the
nature of inflammation to dilate the minute vessels, and to make them
capable of receiving the red globules of the blood. Redness, though a
common effect of inflammation, is far from being one of its essential
characters ; for, notwithstanding the size of the minute arteries may be
altered, their dilatation is not invariably such as will enable them to receive
the red globules. This is exemplified in inflammation of the arachnoid
coat of the brain, and in slight inflammation of the delicate production of
the conjunctiva spread over the cornea.
The intensity of the redness varies in different examples : thus, some
dense fibrous tissues, like tendons and ligaments, exhibit, when inflamed,
but inferior degrees of redness ; while textures of higher vascularity
display a bright and florid red colour, as is often seen in cynanche maligna,
the pharynx and tonsils presenting almost a fiery redness. The species
of inflammation also modifies the colour of the inflamed part. The red-
ness of phlegmon is not of the same shade as that of erysipelas, and the
colour of a carbuncle is deeper, than that of the other inflammations
here adverted to.
In genuine erysipelas, " there is so little impediment to the passage
of the arterial blood into the veins, that it gives the skin a bright red or
scarlet colour. Several other inflammations of the skin, as scarlatina,
rose-rash, herpes, &c., are distinguished by their bright colour ; and, in-
deed, most inflammations of the skin, which do not involve the cellular
substance underneath, assume more or less the colour of arterial blood.
In other instances, where inflammation is attended with much tumefac-
tion or hardness, the colour is more or less purple, or that of venous
blood : because, under such circumstances, the circulation is impeded ;
and consequently the blood longer detained, and thereby rendered ve-
nous, although still moving in the arteries. The purple colour is very
remarkable in many scrofulous inflammations and tumours, in which the
circulation is languid." * Dr. Macartney also notices the fact of brown-
coloured inflammations being generally followed by a detachment of the
cuticle and rete mucosum.
Another effect of inflammation is, to deprive certain textures of their
natural transparency, a change noticed with remarkable frequency in
diseases of the eye. If a portion of inflamed arachnoid coat of the brain
be examined while extended over that organ, the loss of transparency is
particularly evident, where the membrane lies over the interspaces of the
convolutions.
* See Macartney " On Inflammation," p. 17. "That there may be no deception with
regard to the degree and nature of the red colour and vascularity of parts after death,
it is of great importance that they be examined immediately they are exposed to view, as,
under the influence of the air, those which are almost pale become reddened, or, if
slightly red, become much redder, in the course of a few hours." Thus also venous and
vascular congestion may put on the appearance of inflammation. See Carswell's
" Elementary Forms of Disease."
INFLAMMATION. 7
A common change, resulting from inflammation, is the thickening of
parts ; thus, a piece of inflamed pleura or peritoneum, is always found to
be so altered. Indeed, " an increase of bulky thickness, swelling, or tu-
mour, always accompanies acute inflammation."
Several of the above facts are finely illustrated in a preparation, pre-
served in the museum of the Royal College of Surgeons. John Hunter
froze the ear of a rabbit, and thawed it again : a considerable inflamma-
tion of it ensued. The animal was now killed, the vessels of the head
injected, and both ears removed and dried. The ear that was not in-
flamed, retains a clear transparent appearance, and its arteries are of the
natural size ; but the ear that suffered inflammation is opaque, and con-
siderably thickened, with its arteries much enlarged. Dr. Macartney
produced inflammation of a rabbit's ear by scalding it, and the only dif-
ference in the result was, that there was more dilatation of the
branches, and less thickening of the auricular artery, than after Hunter's
experiment.
The swelling and tension of inflamed parts arise partly from the dila-
tation and turgescence of the blood-vessels, partly from the extravasation
of fibrine, serum, and sometimes even of blood from the rupture of the
over-distended vessels ; partly from the thickening of tissues ; and partly
from the interruption of absorption. The degree of swelling depends in
a great measure on the violence of the inflammation, and the kind of
tissue affected. In some inflammations of the eye, and in all superficial
inflammations of mucous and serous tissues, there is little or no swelling ;
but, in inflammation of the testicle, phlegmonous inflammation in general,
phlegmonous erysipelas, and the state of the eye termed chemosis, the
swelling may be prodigious.
The interstitial effusion of limpid albumen, or serum, constitutes cedema,
and one of the early effects of inflammation. " It frequently remains in
the form of a pale and colourless swelling, after the vascular repletion
and the consequent redness have disappeared. In one case, inflammation
of the larynx, it is frequently the cause of death, obstructing the upper
orifice of the larynx, and suspending respiration." *
One important physical character of acute inflammation, correctly ex-
plained by Professor Carswell, is a diminution of consistence, or rather of
cohesion, of the organic elements of the inflamed part. " This change
commences in the first stage of inflammation, and may proceed to such
a degree in the second, as to render even the bones soft and fragile, and
convert all the tissues into a mere pulp. It appears to affect the uniting
cellular element, more than any other, of tissues and organs ; and to do
so in proportion to the degree of inflammation by which it has been
preceded."
An opposite condition, that of induration, is a frequent consequence
or accompaniment of chronic inflammation. " It differs from the solidifi-
cation of acute inflammation in this, that there is at the same time in-
creased cohesion of the anatomical elements of the affecte^l part." f
According to Mr. Hunter's experiments, the temperature of inflamed
parts, as indicated by the thermometer, is much lower than what might
be expected from the consideration of the patient's own feelings and re-
presentations. By artificial means, he excited inflammation in the chest
of a dog, and in the abdomen, rectum, and vagina of an ass, without being
* See Dr. M. Hall's « Principles of Medicine," p. 9.
f See Carswell's " Elementary Forms of Disease," Fasciculus 1.
B 4
8 INFLAMMATION.
able to detect with a thermometer any material rise in the temperature
of those parts. In one patient, however, on whom he operated for a hy-
drocele, the rise was more remarkable ; for the temperature within the
tunica vaginalis, which was only 92° directly after the operation, rose on
the following day to 98|. Later investigations prove, that the heat of
inflamed parts is sometimes as high as 107°.
It is not easily decided " how far the increased heat of inflamed parts
depends on the higher degree of sensibility, or on the state of circulation
and impeded secretion ; since we find, that the temperature is most aug-
mented, when inflammation affects those tissues which are the seat of
active circulation and secretion. The inflammation of bones, tendons,
and ligaments, which receive in a natural state few blood-vessels, and
which furnish no secretions, is attended with very little increase of tem-
perature ; while the skin and mucous membranes have their heat greatly
exalted during inflammation. It should nevertheless be considered, that
these surfaces are most richly supplied with nerves, as well as blood-
vessels." My friend Dr. Macartney, however, from whose writings I
have borrowed the foregoing passage, is disposed to ascribe the increased
heat of inflamed parts more to their state of local or organic sensibility,
than to the condition of their arteries, as regards circulation or secretion.
On the other hand, Dr. M. Hall inclines to the doctrine, that it is owing
to the augmented quantity of blood in the part. The varieties of pain
from inflammation depend partly on the character of the inflammation,
and partly on the texture of the inflamed parts.
The pain is throbbing in phlegmon, but of a tingling, burning kind in
erysipelas ; it is acute in parts largely provided with nerves, and this
more with reference to their number than their size. In parts of a dense,
unyielding texture, the pain is likewise extremely severe, though they
may not abound in nerves. This fact is exemplified in the generality of
fibrous textures. In bones, the pain is aching, and in ligaments it is of a
similar kind. In inflammation of parts bound down, or surrounded by a
dense, unyielding fascia, the pain is always great. Inflammations of se-
rous membranes a*re well known to be more acutely painful than those of
mucous ones.
Amongst the effects of inflammation are those produced in the secretions
of the inflamed part. When inflammation of mucous or serous surfaces
is slight, the secretions may be increased ; but, if it attain a somewhat
greater degree, they are not only more copious, but altered in their
quality, becoming of a thicker consistence, and assuming the appearance
of pus. " Thus 'the serum of blisters, when the skin is much irritated, is
found to be coagulated ; and the cutaneous secretions of the eyelids, ears,
and other parts of the skin, are changed into a glutinous adhesive fluid.
When parts are excessively inflamed, whether they are situated exter-
nally or internally, secretion of every kind is stopped. Even the secretion
of pus ceases, when. an abscess, an ulcer, or an issue, is suffering a severe
degree of inflammation." *
According to John Hunter, inflammation is not merely an action of the
smaller vessels of the part itself, but of the larger ones leading to it. In
a whitlow, the pain and swelling may be confined to the end of the
finger ; yet, the digital arteries may be plainly felt to throb through their
whole course with unusual force ; and, in severe cases, even the radial and
Macartney, op. cit. p. 21.
INFLAMMATION. 9
ulnar arteries participate in the same disturbance. These facts are some-
times regarded as proofs of the arteries contracting with increased force
in inflammation ; yet John Hunter, who first particularly adverted to
them, never ventured to draw such conclusion himself; but only that
the arterial system was dilating itself, and allowing a greater quantity of
blood to pass.
In all examples of common inflammation, its degree is greatest in the
direction towards the surface of the body. It seems as if it had a ten-
dency to spread outwards, and to avoid the deep-seated parts. Thus,
when the irritation of a bad tooth excites inflammation of the gums,
there is generally but little pain and swelling on the side of them towards
the tongue, but a great deal towards the cheek or lips. Mr. Hunter re-
garded this disposition of inflammation to extend towards the surface,
and not the interior of the body, as an established law or principle in the
animal economy, the usefulness of which in promoting the cure of many
diseases must be sufficiently obvious.
Every inflammation of much extent or violence, or affecting parts of
high importance, is attended with a general disturbance of the whole
constitution, called the sympathetic or symptomatic inflammatory fever, of
which the symptoms run as follows : — Pulse frequent, strong, and full :
many of the secretions changed, diminished, or suppressed : hence, dry-
ness and heat of the skin, a parched state of the mouth and fauces, and
oppressive thirst; urine scanty and high-coloured; and constipation.*
Nervous system disordered ; appetite lost ; patient anxious, restless, and
sleepless ; headach ; sometimes twitches of the muscles ; wandering and
confusion of the intellects ; or actual delirium. This fever furnishes an
illustration of what Mr. Hunter used to call an universal sympathy of the
body with the disturbed condition of a part of it. The symptoms are
always modified by the extent and violence of the inflammation and its
situation in common tissues, or organs of the first-rate importance to life.
When the latter are affected, the pulse is observed to be quicker and
weaker than when only skin, cellular or muscular tissue, or other ordinary
textures, are inflamed.
The symptoms are also modified by the nature of the constitution
itself; and hence, in naturally irritable subjects, they rise to a greater
height, and often assume a more alarming character, than in individuals
of better stamina. Females being generally more irritable and nervous
than men, are liable to experience from local injuries greater constitu-
tional disturbance than the latter, unless these happen to be of intem-
perate habits. Fat, corpulent persons, not in the custom of taking proper
exercise, bear local injuries and inflammation, as well as disease in gene-
ral, very badly ; and hence in them the sympathetic inflammatory fever
often prevails with extraordinary severity. But there is a particularly
irritable temperament, frequently accompanying a countenance in which
the cheeks exhibit a peculiar ruddiness, terminating very abruptly at the
circumference, and presenting the ramifications or streaks offminute ves-
sels, more plainly than in the fine complexion of youth, health, and a
* In the first stage of inflammation, " the temperature is variously and greatly in-
creased ; the function of secretion is also for a time augmented : in glandular organs,
however, only at the commencement ; in serous tissues, for a much longer period, and to
a much greater degree." In the second stage, the blood ceases to circulate, coagulates,
and assumes a dark colour ; the temperature sinks ; and secretion, absorption, and nu-
trition, are finally interrupted. See Carswell's " Elementary Forms of Disease," p. 1.
10 INFLAMMATION.
sound constitution. Individuals, with the ruddy kind of cheek here de-
scribed, do not undergo disease favourably — in them inflammation is
not disposed to be mild, nor the constitutional disturbance to be free
from severity.
Speaking of certain inflammations, and not of the healthy or phleg-
monous kind, the nature of the exciting cause has a powerful influence
on the character of the constitutional symptoms. This is manifest in cases
of poisoned wounds, whether received in dissection, or caused by the
bites of venomous animals. Here we have the most dangerous forms of
constitutional disturbance, though not always entirely corresponding to
the extent of the local inflammation, since the poison itself, when the
bites of snakes are concerned, has a chief influence in determining the
severity of the effects upon the whole economy.
Besides the common local and constitutional symptoms of inflammation,
there are particular ones depending upon disturbance of the functions of
the organs affected. Thus inflammation of the brain is attended with
delirium, vertigo, coma, convulsions, or paralysis. Inflammation of the
eye, with interruption or disorder of vision. Inflammation of the urethra,
or bladder, with pain and difficulty in making water. Inflammation of the
fauces, pharynx, or oesophagus, with pain or inconvenience in swallowing.
Many diseases are not restricted to the production of changes of texture,
or to derangement of functions : they seem often to bring about, and
even more or less to consist in, changes of the fluids, as well as the solids.
We know that the effects of inflammation extend to the blood itself; for,
when taken from the veins of a person labouring under an attack of in-
flammation, sufficiently severe to disturb the constitution, it coagulates
in the basin more firmly, and, according to John Hunter, more slowly, than
usual ; and a stratum of fibrine, of a yellowish buff or slightly greenish
colour, or very similar in appearance to size or glue, is left upon the sur-
face of the crassamentum, which often floats in an extraordinary quantity
of serum. The yellow substance is termed the inflammatory crust, or
buffy coat. Such blood is also called sizy, or cupped, &c. ; the surface of
the crassamentum being concave at the centre, but frequently contracted
and puckered up at the edges. The inflammatory crust varies in thick-
ness from a line to an inch or two, and consists of pure fibrine, deprived
of the colouring matter, and mixed with a proportion of serum, which is
found to contain nearly twice as much albumen as the serum in a healthy
state of the system. Great analogy, therefore, prevails, both in appear-
ance and in chemical composition, between the buffy coat of the blood,
and the coagulating lymph or fibrine that constitutes false membranes.
When the buffy coat is thick and compact, there is a proportional dimi-
nution in the firmness of the crassamentum. The cupped appearance,
however, and the firmness both of the buffy coat and the entire coagulum,
are usually proportionate to the strength of the patient and the severity
of the inflammation, and greater in the inflammation of certain textures,
such as serous membranes and fibrous tissues, than others ; being then
even more buffy than in inflammation of vital organs. The buffy coat
is not confined to venous blood, but formed also on arterial blood.
Thus, when in urgent inflammatory diseases, on account of the youth of
the patient, and the small size of his veins, it is considered necessary to
open the temporal artery, the blood exhibits a sizy appearance.*
* Dr. Davy is led by his experiments to think, that the coagulation of blood in
inflammation commences sooner, and is completed more quickly, than in health. Yet any
INFLAMMATION. 11
The buffy coat merits particular attention, because it is to a certain ex-
tent a criterion of the existence of inflammation, and a vindication of the
employment of means calculated to subdue it. Inflammation frequently
occurs in deep situations, completely out] of the reach of manual and
ocular examination ; and then the case may be obscure and doubtful,
while the life of the patient may entirely depend on the decision for or
against the use of the lancet. The doctrine of the buffy coat being a cri-
terion of the existence of inflammation, is to be received, however, with
limitation ; for, though the buffy coat generally occurs in blood taken
away from patients labouring under inflammation, it sometimes presents
itself when no inflammation exists. Blood taken from individuals labouring
under plethora, or such as are accustomed to be bled at particular periods
as a measure of precaution, is mostly buffy and cupped. Certain nervous
disorders, unconnected with inflammation, are attended with sizy blood.
In pregnancy, and in individuals who keep watch in the cold nocturnal
air, the blood exhibits the same appearance. Again, the buffy coat is some-
times absent, when inflammation is unequivocally present.* Sometimes
what is first drawn is not buffy, but what follows is so. In proportion as
the vessels are unloaded, the blood acquires more disposition to coagu-
late : thus, the blood, drawn in cases of acute internal inflammation, often
does not afford so firm a clot as that of subsequent bleedings, although
the inflammation may be lessened, t Some practitioners even dwell
more on the excavated concave surface of the blood than the buffy coat,
as evidence of the existence of inflammation. In establishing the diag-
nosis., then, we are to consider the buffy coat as not altogether sufficient
of itself to remove every kind of doubt or obscurity regarding the exist-
ence of inflammation, and are particularly to take into the account the
concomitant symptoms, the degree of fever present, the state of the pulse,
the situation and kind of pain experienced, and especially the nature of
the functional disturbance.
In obscure cases, we may take away a few ounces of blood at first for
examination, and by way of experiment. Sometimes great light is
thrown on the case by some of the common symptoms of inflammation
being accompanied by particular ones, or such as are often termed proper,
essential, and pathognomonic symptoms. Thus, severe pain in the loins
might arise either from rheumatism, or from an inflammation of the kid-
ney : but, if vomiting and retraction of the testicle were to be amongst
circumstances, occasioning an unusually rapid coagulation, will prevent the formation of
the buffy coat, such as a small opening in the vein, and the very slow escape of the blood
from the vessel : this will sometimes account for the first quantity not being buffy,
though what follows may liave this appearance. The receipt of the blood in a flat cold
plate, or letting the blood fall from a height into the basin, will also hinder the production
of the huffy coat. During the first stage of inflammation, "the vital properties of the
blood undergo a manifest increase. A greater quantity of fibrine is formed, the plastic
property of which is increased ; for, besides its rapid organisation, under favourable cir-
cumstances, it retains, when separated from the other constituents of the blood, its
fluidity for a longer period, and contracts more firmly, than in the natural state." See
CarswelPs " Elementary Forms of Disease," Fasciculus 1.
* In some inflammations of mucous membranes, such as bronchitis, the blood fre-
quently exhibits no buffiness, nor cupped appearance. When the blood is also greatly
impoverished, and the constitution seriously reduced, the blood, during inflammation,
instead of being buffy, will often present a dark red, jelly-like, and decomposed appear-
ance; as is often exemplified when inflammation proceeds rapidly to mortification, or is
attended with typhoid fever.
f See Macartney « On Inflammation," p. 1 45.
12 INFLAMMATION.
the other symptoms, with fever, £c., the inference would be, that the
case was one of nephritis.
The causes of inflammation are divided into predisposing, exciting, and
proximate. The human body is naturally susceptible of inflammation ;
and, if this were not the case, a recovery from many injuries and diseases
would be impossible. In this point of view, inflammation is to be regarded
as a salutary operation, the changes, which it brings about being abso-
lutely necessary for the restoration of the parts to the healthy and perfect
state again. Now, although there is in the animal economy a natural
susceptibility of inflammation, seemingly intended for beneficial purposes,
some constitutions are more prone to inflammation than others, and
sometimes acquire such a disposition to it as receives the technical ap-
pellation of a phlogistic or inflammatory diathesis. This unfortunate kind
of constitution may be innate or born with a person ; but it is much
more frequently produced by circumstances, which rank as predisposing
causes. One of the most powerful and common of these is plethora, or
a full habit, arising from taking immoderate quantities of food, or, in plain
terms, from eating and drinking beyond what nature requires, and can
well dispose of. This practice of living above par, and frequently at the
same time in a state of indolence, leads to a prodigious fulness of the
vessels, and a fibrinous state of the blood, which not only create a pre-
disposition to inflammation, but to the process being more severe and
difficult to repress whenever it does occur.
The extraordinary quantities of porter and other fermented beverages,
taken by certain classes of workmen in this metropolis, such as coal-
heavers, draymen, and others, make these strong-looking men notoriously
bad subjects for disease. I have attended great numbers of them, and
my experience justifies me in saying, that they frequently die of slight
injuries and diseases, from which less robust, but more temperate persons
would rapidly recover. When individuals are known to have followed
these habits, they are not in a favourable state to bear operations ; for
which they ought in general to be prepared by previous bleeding or purging,
low diet, and proper regimen. Unfortunately for them, circumstances
often give no time for preparation : they meet, perhaps, with bad com-
pound fractures, and their limbs must be amputated without delay.
A sedentary, studious life, joined with habitual indulgence at table,
invariably creates a strong predisposition to inflammation, and sometimes
either communicates a gouty diathesis, or, if such already exist from
hereditary causes, brings it into action, becoming then the exciting cause.
Among the predisposing causes, indeed, we should ever remember such
peculiarities of constitution, because they explain why some individuals
suffer from gouty inflammation ; some from scrofulous, and others from
rheumatic; though all of them may be living, perhaps, in nearly the same
manner.
I believe, with Dr. Macartney, that a local determination of blood, as it
is termed, is rather a predisposing, than a direct cause of inflammation.
When too much blood is sent to one part of the body, too little visits
some other ; the balance, therefore, may be disturbed by external cold
repelling the blood from one part, and causing its flow in undue quantity
elsewhere. Thus, cold applied to the skin of the abdomen, produces a
determination of blood to the peritoneum and alimentary canal. A de-
termination of blood to the head may be occasioned by circumstances
which have not a similar effect on other parts, as passion, mental ap-
plication, the exertion of the sight, and intoxication. A forced state of
INFLAMMATION. 13
the circulation in the head gives a predisposition to inflammation of the
membranes of the brain, the external parts of the nose, and the eyes.*
The exciting causes of inflammation are frequently mechanical injuries,
fractures, bruises, wounds, &c. ; stimulating applications, the contact of
fire or heated substances, friction, and pressure on parts ; the irritation of
extraneous substances lodged in the textures or cavities of the body, as
thorns, splinters of wood, bullets, fragments of bone, calculi, &c. One
of the most common exciting causes is cold. In some instances, this
seems to act directly on the part ; as in inflammation brought on by it in
the mucous membrane of the nose, larynx, trachea, and lungs. In other
examples, cold acts indirectly, so as not to bring on inflammation of the
part to which it has been applied, but of some distant organ. Thus,
exposure of the feet to wet and cold will occasion in one person an
inflammation of the throat, in another an inflammation of the chest, and
in a third an inflammation of the bowels. Exposure to wet and cold,
rubeola, &c., excite internal inflammation through the medium of the
nervous and vascular systems, f
If a part, that has been exposed to intense cold, be suddenly warmed,
the reaction is such as will bring on rapid and severe inflammation. In
this way chilblains are excited, and large portions of the body destroyed
by the quick advance of the inflammatory process to mortification. The
cold may here be considered as the predisposing causey and the sudden
exposure to a warmer temperature the exciting.
Fevers sometim.es operate as exciting causes of inflammation, which
comes on towards their close, and frequently produces abscesses, formerly
named critical, from their being supposed to have a share in bringing the
disease to a crisis. Constitutional causes likewise operate in producing
boils, some kinds of whitlow, the tendency of erysipelas to gangrene in
certain epidemics ; the carbuncle of plague, the malignant pustule, and
the gangrenous inflammations of the cheeks J and pudenda of infants. §
By the proximate cause of inflammation, is signified that state of the
part upon which the phenomena peculiar to inflammation immediately
depend ; that secret [process — that first essential action in the part,
which constitutes the very beginning of inflammation, attends all its
course, and is inseparably connected with its existence. The proximate
causes of Galen and Boerhaave — viz., particular states of the fluids,
viscosity and lentor of the blood, and the passage of the red globules
into vessels not designed to receive or transmit them— even if they were
facts, as indeed the latter one is, would not amount at all events to
proximate causes, but only to predisposing and exciting ones. Whatever
changes the blood may undergo in inflammation, they are now more
justly regarded as effects, or at most as a predisposing cause, and not
the proximate cause of inflammation. If the state of the whole mass
of the blood were the cause, why should inflammation be confined to
any particular part? Yet one fact here deserves to be particularly re-
membered, namely, that in plethora the blood is found to be bfcffy, which
state unquestionably forms a predisposing cause of inflammation, but
nothing more.
* Macartney " On Inflammation," p. 79.
f Dr. M. Hall's " Principles of Medicine," p. 6. 8vo. Lohd. 1837.
; Pearson's " Principles of Surgery," and Dr. M. Hall in " Edin. Med. and Surg.
Journ." vol. xv. p. 547.
§ Mr. Kinder Wood in "Med. Chir. Trans." vol. vi« p. 84.
14 INFLAMMATION.
A larger quantity of blood is determined to an inflamed part than is
sent to it in its natural state. If an incision be made in it, the blood
gushes out more profusely, thai**from a cut in a similar part free from
inflammation. If there be severe inflammation of the hand, and we
open a vein at the bend of the elbow, the blood flows out much more
rapidly than it would do from a vein of the other arm. This demon-
strates a greater velocity of circulation, a more forcible current of blood
towards the inflamed part, and also of the returning blood. Such facts
cannot be explained by any reference to the action of the heart, an
organ which drives the blood equally into the whole arterial system.
They must depend either upon an increase in the diameter of the arteries
of the part, or upon some power of the vessels themselves to transmit
blood into the seat of the disorder with increased impetuosity and in
larger quantity.
The capillary vessels are those by which the chief phenomena of in-
flammation are produced ; such as the increased redness and heat of the
part ; the effusion of fibrine and serum ; the formation of pus, when it
happens ; the swelling ; the deposit of new or additional matter in the
part ; the pouring out of fluids from its surface or into its texture, &c.
The researches of Mr. Hunter proved, that the arterial branches ac-
quire a greater power of contractility in proportion as they become smaller,
and that the arterial trunks are less contractile and more elastic. That
the minute ramifications of arteries are endowed with a high degree of
contractility, is proved by a variety of circumstances. The minute
arteries, like muscular tissues, retain the power of contracting after
breathing has ceased : hence the empty state of the arterial system after
death. When death is rapidly occasioned by lightning, or any violent
narcotic poison, the action of the arterial and muscular systems being
suddenly destroyed, the arteries are found filled with blood, as well as the
veins. It is by the capillary vessels that the functions of nutrition and
secretion are performed, and it is absolutely necessary for the uniform
and uninterrupted continuance of these varied and highly important func-
tions, that the vessels should have the power of controlling the motions
of the fluids circulating within them.*
Some pathologists espouse the doctrine, that the changes which the
vital fluid undergoes in its passage through the capillaries, whether these
changes be for nutrition or secretion, have an important influence on
its movement through them. However this may be, I would rather be
content with the inference, that the capillaries possess a distributive
power over the blood, so as at least to regulate the local circulation,
independently of the heart, according to the necessities of each part.
The relative momentum of the blood in different parts of the body, or
the quantity of the blood and its velocity, are perpetually varying, from
the influence of the external stimuli or internal causes ; facts, affording a
* Bichat, who did not attribute to the arteries any muscular power, assigned to them
another property, which he named insensible contractility. Dr. Macartney, who believes
in the positive and active extension and dilatation of arteries, and other tissues similarly
endowed, acknowledges, that, at present, we have no term applicable to the movements,
or spontaneous changes of form in non-muscular structure. " It has been called by
some," he observes, " tone, or tonicity, which, if applied both to the dilatation, or excited
state, and to the contraction, as the movement leading naturally to fixedness and qui-
escence, will be as suitable a term, perhaps, as any other that could be devised." In this
sense he speaks of the tone, or tonic action, of arteries.
INFLAMMATION. 15
decisive proof of the vital contractility of different portions of the arterial
system. In blushing, the minute vessels of the cheek assume an increased
activity, and admit more blood into them ; while under the influence of
depressing passions, such as fear, they are suddenly emptied, and the
countenance becomes pale.
That in inflammation the diameter of the small vessels is after a time
increased, so that red blood finds its way into many which naturally
admit only a colourless fluid, and therefore cannot be seen at ordinary
periods, is an undoubted fact. But, does the increased action in inflam-
mation, of which we hear so much, signify any thing more than the
action by which the diameter of the vessels becomes altered, a greater
quantity of blood is transmitted to the seat of inflammation, fibrine is
effused, redness, heat, and swelling are occasioned, fluids of various kinds
poured out, and new products formed ? Does it imply that the vessels
are alternately contracting and expanding themselves in an extraordinary
degree for the purpose of maintaining an accelerated flow of blood through
the parts affected ? Certainly not — with the naked eye we plainly see
vessels dilated, but undergoing no alternate motion of dilatation and
contraction. If, as Dr. Macartney rightly observes, the increased con-
traction were unremitting, it is the very state, to effect which is the
object of many of the remedies employed ; and, if it were alternated
momentarily with the dilatation of the vess'els, it would have more effect
in driving the blood backward upon the great trunks, than onward
through the minute termination of the arteries, unless the current were
supported behind by valves * ; neither, if we can credit microscopical
examinations, is the blood constantly pervading the smaller with increased
celerity. On the contrary, the experiments f of Dr. John Thompson,
Dr. Wilson Philip, Dr. Hastings, and Gendrin, all tend to prove that a
quickened circulation of the blood in an inflamed part is so far from
being an essential feature in the process, that when inflammation is esta-
blished, when a certain stage of it has arrived, the motion of the globules
in the minute vessels is retarded, or even stopped. Hence, Dr. Wilson
Philip was led to adopt the hypothesis, that inflammation actually consists
in a debilitated state of the capillary vessels, followed by an increased action
of the larger arteries.
It is curious to notice the very opposite conclusions to which different
parties are brought by the same facts : while the generality of medical
writers, ancient as well as modern, admit the doctrine of obstruction in the
minute vessels J of an inflamed part, some of them refer it, with Boer-
haave, to viscidity of the blood and error loci of the globules ; some, with
Cullen, to spasm of those vessels ; and others, with Dr. Wilson Philip, to
their debility.
With respect to increased alternate contractions and dilatations of the
arteries in inflammation, Mr. Hunter never meant any such hypothesis
* Macartney " On Inflammation," p. 126.
f With reference to such of these experiments as were made-on cold-blooded animals,
it is Dr. Macartney's belief, that, "in neither of the two classes of vertebrate animals
with cold blood, is it possible to produce the genuine effects of inflammation." This
doctrine, however, is disputed, and even vegetables are alleged to be liable to a state
corresponding with inflammation. See " British and Foreign Med. Review," vol. vii.
p. 429., and vol. viii. p. 188.
\ " It is probably by the partial obstruction to the circulation in the capillaries, that
the minute arteries become enlarged, according to the well-known law, that muscular
organs augment with obstacles to their functions." See Dr. M. Hall's " Principles of
Medicine," p. 17.
16 INFLAMMATION.
to enter into his doctrines ; for he distinctly says that " in inflammation
the muscular coat of the arteries does not contract."
Dr. Hastings takes the same view of inflammation as Dr. W. Philip,
and represents it as consisting " in a weakened action of the capillaries, by
ivhich the equilibrium between the larger and smaller vessels is destroyed,
and the latter become distended"
A simple enlargement of vessels, and a mere irregularity in the distri-
bution of the blood, will not constitute inflammation. We find that such
changes occur in the spermatic arteries of animals which copulate only
at particular periods of the year. We remark a similar change in the
carotids of the stag, during the growth of its horns. Yet, in such ex-
amples, there is no inflammation, no pain, no redness. A simple increased
determination of blood to parts may render their vessels preternaturally
full and turgid — may produce what is technically named congestion ; it
may even be a predisposing cause of inflammation, but it is not inflam-
mation itself.
The following is a summary of the principal changes occurring in the
inflammatory process.
First stage9 sometimes called active congestion * : — 1. Increased sensi-
bility of the part. The nerves are essentially concerned, I think, in the
first action of inflammation ; but there is good foundation for the doctrine,
that three elementary parts of the body have a constant share in the pro-
cess— namely, the nerves, the blood-vessels, and the blood itself.
Animals, which have no visible nerves, and those in which the nervous
system is very simple, exhibit, according to Professor Macartney, none of
the phenomena of inflammation. All the local causes of inflammation
seem to him to act by making such impressions on the sensibility of parts,
as dispose the arteries to assume the inflammatory state.f 2. Increased
action of the vessels — quickened circulation — increased influx of blood
— dilatation of the small vessels and capillaries — admission of red blood
into vessels previously colourless — turgescence — swelling — and then,
a slow embarrassed circulation in the immediate seat of the inflam-
mation.
If the inflammation continues, its second stage begins — it is no longer
merely active congestion. The contractility of the vessels is paralysed by
their over distension — the blood stagnates, and undergoes changes in its
composition — the coats of the blood-vessels suffer injury — many of
these vessels are ruptured — the action of others is changed ; hence, the
formation of new products — extravasation and effusion of blood —
fibrine and serous fluid — thickening, and other alterations of tissues.
The phenomena of inflammation, then, as Dr. Carswell justly observes,
cannot be explained by a reference to the exclusive doctrines of increased,
or diminished action, of the vessels. " It is obviously a compound of
both, and not merely of the vessels of the inflamed part, but primarily
* The term congestion would not be deemed by Dr. Macartney the best, because his
views lead him to regard congestion as belonging to the venous system, and actually
accompanied by a diminution in the size of the arteries. Op. cit. p. 139.
f Op. cit. p. 111. ; also p. 133., where Dr. Macartney endeavours to refute the ob-
jection to this view, derived from the fact of paralytic parts being liable to inflammation.
" The paralysis," he remarks, " consists in the interruption of the communication between
the central parts of the nervous system and those remotely situated, and not in the de-
struction of organic sensibility."
INFLAMMATION. 17
and essentially of the function of innervation also, of the vital properties of
the blood, and, consequently, of organic composition." *
One view entertained of this subject is, that t\\e first effect of a stimu-
lus, calculated to produce inflammation, is on the general organic proper-
ties of the part, and especially on its power of deriving from the blood
the materials of its assimilating or secreting processes ; and that the in-
fluence it exerts on the calibre of the vessels, and on the motion of the
blood through them, is altogether secondary to this. It is argued, that
the effect of a stimulus, which increases for a time the physiological or
normal actions of any part, is to accelerate the capillary circulation, whilst
the calibre of the vessels is diminished. The latter alteration, it is
thought, can scarcely be due to the direct application of the stimulus ;
but rather to the influence of the ganglionic nerves, which are unques-
tionably largely concerned in the subsequent processes. To the same in-
fluence the simultaneous dilatation of the arterial trunks leading to the
part is referred.f
The following considerations have been advanced against the doctrine
of the nerves being essentially concerned. " Is it true, that the impres-
sions, which produce inflammation, necessarily act through the nervous
system ? We think not. To prove this, it must first be shown, that the
normal changes, which constitute the organic functions, all of which
are due to the influence of external agents on the organism, depend upon
its influence. If a normal stimulus can produce a healthy change or
action without the intervention of the nervous agency, it is perfectly evi-
dent, that an abnormal stimulus may produce a morbid change inde-
pendently of it. The remark of Mr. Palmer upon this question strikes
us as peculiarly judicious. * The office of the nerves in inflammation
appears to hold precisely the same relation to this action that it does to
the other organic functions. It is regulative, but not essential/ " See
British and Foreign Med. Review, No. 15. p. 188. I briefly notice this
mode of reasoning, without adopting it.
In chronic inflammation, the vessels do not always exhibit the redness
and turgescence noticed in the acute forms of the disorder. Yet, some-
times, a good deal of redness is attendant even on chronic inflammation
of certain tissues ; but, more frequently, "^various shades of purple, brown,
or black ; " while the pain, the heat, the throbbing, the febrile disturbance,
usually accompanying acute inflammation, are not noticed. Besides, the
tumefaction resulting from the deposit of morbid products, when inflam-
mation is much prolonged, or often repeated, it causes an enlargement of
parts by exciting an exuberant action of the nutritive vessels, and a conse-
quent excessive nourishment, termed hypertrophy.
On the other hand, inflammation, by disturbing and interrupting the
functions of circulation and nutrition in parts, sometimes has the effect of
bringing on atrophy, or a wasted condition of them. These opposite
results of inflammation are sometimes observed in parts composed of
different structures : an exuberant nourishment of one tissue being
generally attended with a deficient nourishment of other tfssues of the
same organ. By inflammation, the function of nutrition in parts may also
be perverted, and then there may be transformations of texture — as into
bone, cartilage, fibrous membrane, ligament, &c. Acute inflammation
sometimes lessens the cohesion of tissues, and reduces them to a pulpy
* See Professor Carswell's " Elementary Forms of Disease," Fasciculus 1.
t See ''British and Foreign Med. Review," vol. viii. p. 191.
C
18 INFLAMMATION.
state, by a peculiar softening process. Chronic inflammation has a greater
tendency to cause parts to become indurated. There are, however, many
exceptions to these rules — and softening and induration are often com-
bined.
Inflammation has various terminations. More properly speaking, after
the process has continued a certain time, it either subsides entirely ; or
" new products are formed, or other diseased states are produced, as
softening, suppuration, ulceration, and mortification." It may end in the
adhesion of one inflamed surface, or texture, to another ; induce in the
vessels a disposition to form pus ; bring on ulceration ; or completely de-
stroy the vitality of the parts.
When inflammation is about to end in the first manner, termed reso-
lution, the pain becomes less, the swelling, tension, and throbbing subside ;
the redness fades away ; the fever and every other symptom gradually
abate ; and, at length, the part is restored to its natural size and colour.
There is no formation of pus, and no permanent injury of structure.
According to Kaltenbruenner, critical exudations take place through the
sides of the vessels, consisting of a thin serous or sanguineous fluid,
poured out on the surface, or in the cellular texture of the part. There
may be profuse exhalation of fluids on secreting surfaces. The small
coagula of blood, contained within the vessels, or deposited in the paren-
chyma, are softened, and removed either by the impetus of the current
of blood within the vessels, or by interstitial absorption. This termina-
tion, which may be rightly called so, is fortunately not only the most
favourable, but the most common.
A modification of it, characterised by a more sudden subsidence of
all the local symptoms, or by a rapid shrivelling and diminution of the
swelling, is described by French pathologists under the name of
delitescence.
Resolution is often preceded or accompanied by metastasis, or transla-
tion of the disease from one part to another. Thus, inflammation may
suddenly leave one tonsil, and attack the other. In mumps, the glandular
inflammation often suddenly recedes, and the testicle or breast is then
affected. In gout, the inflammation leaves the foot, and attacks the hand
or knee, or even the stomach or brain. Rheumatism, on quitting one
joint, causes inflammation in another. Sometimes it leaves the joints, and
fixes on the membranes of the brain, or the serous covering of the heart.
One frequent consequence of inflammation is suppuration, the vessels ac-
quiring the power of forming purulent matter, which either collects in the
substance of parts, so as to produce abscesses, or is poured out from their
surface in the form of discharges, as illustrated in wounds and ulcers, and
the inflammation of mucous membranes. Suppuration cannot be pro-
perly called a termination of inflammation, but only one of its effects or
consequences. It is rather a modification of the inflammatory action,
than a cessation of it. Indeed, when it occurs, the surrounding parts
are frequently in the stage of common adhesive inflammation ; and, so
far from the disorder having ended, the suppuration may be attended
with a severe degree of it.
Another termination, or rather consequence, of inflammation, is
ulceration.
Mortification of the parts affected is the most dangerous and severe
result ; but it only takes place in inflammations attended with unusual
violence, the debility of age or impaired constitution, or some spe-
cific peculiarity leading necessarily to the event, as is illustrated in car-
buncle ; and, upon a smaller scale, even in the common boil, in the
INFLAMMATION. 19
centre of which there is always a core, or slough of cellular tissue.
After acute inflammation has lasted a certain time, especially on a mucous
membrane, it frequently changes into chronic, the part then becoming
less painful, and the vessels generally less red, but seemingly relaxed,
and, one would here almost venture to say, with Dr. Wilson Philip,
debilitated.
T Dr. Macartney believes, that the only direct and genuine consequences of
inflammation are, the effusion of some of the fluid elements of the blood,
which cannot receive organisation ; the breaking down of some of the solid
textures of the body ; the formation of a new fluid, denominated pus ; and
the disorganisation, or the absolute death, of the inflamed parts. (Op. cit*
p. 36.) The effusion of coagulating lymph, and ulceration, are not admitted
by this gentleman to be the consequences of an inflammatory action,
(p. 37. &c.) While I agree with him, that coagulating lymph may be
thrown out by a natural and healthy action, as in the formation of the
decidua uteri, it seems to me impossible to adopt the doctrine, that in-
flammation has not among its effects or consequences the effusion of
that substance. With reference to ulceration, does not Dr. Macartney
accede to the commonly received doctrine, when he says, " there is every
reason to believe, that ulceration always takes place, because the vitality,
or the organisation of parts, have been impaired by inflammation, weak-
ness, pressure, or other external injuries ? " (p. 42.) The questions con-
cerning the salutary or pernicious results of such effusion, and whether
it may not happen in certain natural processes in the animal economy,
without inflammation, appear to me to relate to a different part of the
inquiry.
TREATMENT OF INFLAMMATION.
Although, in many cases, inflammation clearly appears to be a pro-
cess set up for beneficial purposes, and is to be regarded as salutary and
even necessary ; yet, more commonly, it happens, that, from its extent,
its situation, or its violence, it cannot be considered in this light ; and
being then more likely to injure or destroy, than to serve the patient, it
demands the prompt employment of every means calculated to check
and subdue it. Consequences, the most serious and fatal, frequently arise
from its attacks, when violent, of great extent, or situated in organs of
importance to life, or of great delicacy of texture, unless such attacks
be resisted by active measures. Enormous abscesses sometimes form ;
the functions of important organs are permanently impaired or destroyed ;
and, what is worse, the patient frequently dies from the amount of local
mischief and constitutional disturbance produced. If the bills of mor-
tality were correctly made out, the greater number of deaths would be
found to be caused by inflammation in some form or another. This is so
true, that the words of Milton, in relation to the forbidden fruit, might,
and indeed have been, applied to inflammation, as having
" Brought death into the world and all our woe."
But even when inflammation does not kill by its violence, its extent, or its
particular situation in parts of first-rate consequence to life, it frequently
gives rise to evils which can never afterwards be repaired. Thus it
renders transparent textures opaque ; it thickens, hardens, softens, or en-
larges the generality of parts affected by it ; it causes the effusion of a serous
fluid, which does not coagulate spontaneously, and also of fibrine, — one
c 2
20 INFLAMMATION.
character of which is its spontaneous coagulation, the latter sometimes
becoming vascular and organised, so as to produce lasting adhesions of
surfaces together which ought to move freely upon one another, or at
all events, not to be united. It also brings on ulceration and mortification.
Now, by producing these changes, it often completely destroys the
functions of organs, or so impairs them that they can only go on in a dis-
ordered, weakened, and imperfect manner. These facts are excellently
illustrated in inflammation of the eye, where, if the disorder be not suc-
cessfully resisted, we see opacities of the transparent textures produced ;
the pupil blocked up with coagulating lymph ; the iris thickened, and
rendered immoveable ; or the cornea in an ulcerated or sloughing state,
so as to occasion a discharge of all the humours, and a total collapse and
destruction of the organ. In other inflammations of the eye, adhesions
frequently take place between the iris and the inner surface of the cornea,
or between the iris and the capsule of the crystalline lens. In fact, in
the eye all the effects of inflammation are delineated in a manner that
can never be forgotten : transparent parts rendered opaque ; parts, which
ought to be moveable, fixed by adhesions ; textures surprisingly thickened
and swollen ; the white conjunctiva converted into one uniform vivid
redness by the dilatation of the vessels ; and even the retina paralysed,
and its functions irreparably destroyed. "The iris has its office destroyed
by being bound to the adjoining parts ; the actions of the heart are em-
barrassed by extensive adhesion between it and the pericardium ; and
(continues Dr. Macartney) I have known the general union of the
peritoneal surfaces of the intestines cause strangulation of the whole ali-
mentary canal, and death. It is also the agglutination by lymph, which is
the most frequent cause of hernia becoming irreducible, and, occasionally,
of the parts becoming strangulated. The effusion of lymph in the trachea
during croup causes as much danger as the inflammation. So, likewise,
when the bladder and urethra are blocked up with lymph." (p. 37.) Re-
specting the disadvantages, or the benefits, arising from adhesions in differ-
ent examples of inflammation, Dr. Macartney agrees with other pathologists.
But if parts not merely valuable from their functions, like the eye, but
absolutely essential to life, become attacked with inflammation, the ne-
cessity for active treatment is still more urgent. Thus, when the lungs,
the larynx, the brain, the stomach, or the intestines are inflamed, if
vigorous antiphlogistic measures be not speedily adopted, and the disorder
be suffered to make progress, the patient will generally perish.
The fact, then, being established, that inflammation, so far from being
always a salutary process, is sometimes an injurious and a fatal one, it
becomes the duty of the surgeon to adopt, in every severe example of it,
the most prompt and efficient means to oppose and subdue it.
" The nervous system of the human subject is so complicated, that
there is hardly a local affection with which the constitution does not sym-
pathise, nor any constitutional disturbance which may not become the
cause of local disease. The same susceptibility, however, communi-
cates a power to the means we may employ for preventing or abating
inflammatory action, which (power) does not belong to animals of an in-
ferior organisation ; and when by those means we are enabled to remove
the sense of injury sustained, or produce a state of insensibility inconsist-
ent with inflammation, the reparative processes (seem to Dr. Macartney
to) go on much in the same manner as in animals endowed with an
inferior degree of feeling."
Resolution being the most favourable termination of inflammation, is
INFLAMMATION. 21
what should always be aimed at, unless it be known from the peculiarity
and state of the disorder, that no chance of such termination remains.
According to Dr. Wilson Phillip's theory, inflammation is attended with
debility of the capillary vessels, and resolution is brought about by the
increased action of the larger arteries removing this condition of the
smaller ones. On the other hand, it might be argued, that such increased
action of the arteries leading to the seat of inflammation must have the
effect of gorging the minute vessels in a still greater degree, and that,
if the foregoing view were correct, the principal object in the treatment
would be to promote such increased action, which practice is inconsistent
with the dictates of general experience.
In the commencement, there are two principal indications. 1. To re-
move the exciting cause, if it be still present. 2. To lessen the deter-
mination of blood to the part.
With regard to the exciting cause, it may not admit of immediate re-
moval, or its operation may have already ceased. Thus, when inflamma-
tion is caused by a mechanical injury done in an instant, the exciting cause
continues not beyond the moment of its application, the instant of the
infliction of the wound, but the mischief remains to be repaired, and
this may be regarded as the exciting cause of the reaction which follows,
and constitutes inflammation ; it is manifest, however, that such mecha-
nical injury of textures cannot be immediately removed, and, indeed, that
it can only be gradually rectified by the inflammation itself. But, in many
examples, the exciting cause continues in operation,, as where sand or
other extraneous substances are lodged between the eyelids and the
front of the eye, or where a splinter of wood, a bullet, or fragment of
gravel, &c., are lodged in parts ; and, in such cases, it is absolutely neces-
sary to remove them as soon as possible ; for, until this be done, little or
no benefit, or, at all events, no perfect cure, will accrue from any mode of
treatment.
On the same principle, when pressure, friction, or the presence of
urine or irritating fluids in the cellular tissue, is concerned in kindling
inflammation and its consequences, the removal of such pressure, &c.,
and the making of a free outlet for the extravasated urine, are primary
objects.
The second indication is to diminish the flow of blood to the inflamed
part, by which means the surgeon removes, in a great measure, that by
which the disease may be said to be fed. The fact being once established,
that inflammation is kept up by an increased flow of blood to the part, this
indication presents itself as a matter of course, nor can it be affected by
any consideration of the exact state of the capillary vessels, or of the rate
of the blood's motion in them. Nay, were it right to be altogether in-
fluenced by the presumed debilitated condition of these vessels, I should
argue, that the indication of diminishing the flow of blood to them would
still be the most consonant to reason as well as experience. It is fulfilled
either by plans which act directly on the part affected, or by^others which
act indirectly upon it, that is to say, through the medium of the consti-
tution. There are also other means, which operate on a different prin-
ciple, viz., on that of the sympathy existing between different organs.
Counter-irritation is a remedy of this kind, which is often of essential
service when employed with due precaution. The first means, namely,
those which operate directly on the part affected, are denominated local or
topical ; and the second, or those which act indirectly, are called general
or constitutional. The local consist of bleeding, by means of cupping or
c 3
22 INFLAMMATION.
leeches, the application of cold lotions, emollient poultices, fomentations,
and, especially after depletion has been duly practised, blisters.
In all acute inflammations of any extent or violence, bleeding from a
large vein, or the temporal artery, should be practised, and in such a
quantity as to produce an effect upon the whole system. The taking away
of blood from the system is what the experience of many generations pro-
nounces to be the great antiphlogistic remedy, most entitled to reliance ;
and this is so strictly the fact, that the preservation of life often depends,
not only upon blood-letting being speedily and freely performed, but upon
its being repeated as frequently as circumstances may require. In inflam-
mation of the brain, lungs, larynx, pleura, peritonaeum, stomach, or bowels,
the patient must be bled, and this promptly, copiously, and sometimes
repeatedly, or life will be lost in a few hours ; indeed, to omit blood-
letting in such cases would be to leave the patient to the poor chance of
an accidental or spontaneous recovery. If there were no blood-vessels in
parts, or if there were no blood in the vessels, there could be no inflam-
mation ; and if to these truisms, a statement equally certain be taken into
the account, namely, that the continuance of inflammation depends on
fresh supplies of blood being sent to the part affected, the reason for les-
sening the mass of blood in the circulation must be manifest. By so
doing, the action of the heart and arteries is moderated, and in proportion
as the force and velocity of the whole circulation are reduced, the impetus
of the blood flowing to the seat of disorder is also diminished. Indeed, if
there were not thousands of other examples to convince us of the great
usefulness of blood-letting in the cure of inflammation, there is one case,
which of itself could never leave any doubt on this important point. If,
in severe inflammation of the eye, attended with great redness of the
tunica conjunctiva, blood-letting be practised, the redness visibly dimi-
nishes in proportion as the blood is abstracted ; the colour, which at first
was scarlet, a complete sheet of vivid redness, becomes a pale pink, the
vessels shrink, and their redness and turgescence are sometimes almost
removed by the time thirty or forty ounces have been taken away. When
we bleed, then, in ophthalmia, we have something like a demonstration of
the benefit of blood-letting. In wounds of the head, chest, or abdomen,
the chief danger, when the patient is not destroyed at once by internal
hemorrhage, is from the supervention of inflammation of vital organs ; and,
if the patient were not duly bled on the first signs of that disorder making
their appearance, he would soon die. In all such cases, the rule is to
bleed expeditiously, freely, and repeatedly, not to be content with taking
away scanty quantities of blood, and not be deterred by smallness of the
pulse, or other appearances of weakness.
Bleeding is not always necessary in slight inflammation of common
parts — I say of common parts, because in important parts, however slight
the inflammation may be, bleeding should not be omitted. It is neces-
sary also to consider the age, the strength, and the constitution of the in-
dividual. It must be evident, that an aged or weak person will not bear
depletion to the same extent as a young or robust individual ; yet, not-
withstanding the general truth of this proposition, when we are called
upon to check an inflammation of any important part, whether the patient
be old or young, weak or strong, the principal reliance must be upon
blood-letting. A small quantity, however, abstracted from weak aged
individuals, is equivalent to a larger quantity taken from the strong. The
fact of the usefulness of bleeding for the relief of inflammatory complaints
is so well established, that, in every severe instance, we are to employ,
INFLAMMATION. 23
not merely general bleeding, but also topical or local bleeding, by means of
cupping or leeches.
There are, however, some constitutions, not essentially joined with old
age or debility, but characterised by excessive nervous irritability, and
well known to be incapable of bearing bleeding to any considerable ex-
tent. This fact is particularly adverted to by Andral, who observes that
in individuals, who, during the course of an acute inflammation, have
already lost a considerable quantity of blood, or who, during a tedious
convalescence, have been kept for a long time on a low diet, and in others,
who, after a severe attack of acute inflammation, continue to be afflicted
with a lingering chronic form of it, the nervous system is apt to become
violently disturbed by the abstraction of even the slightest quantity of
blood. Hence the kind of constitution, and the previous history of the
case, are always to be taken into consideration, and measures adopted
accordingly. With respect to these nervous irritable temperaments, if
bleeding be useful at all in them, it is generally only in the beginning of
the inflammation, and, if this opportunity be lost, the practice will not
avail afterwards.
In the correctness of the following remark I fully concur. (f It is a
common practice to draw blood the moment an injury is received, long
before there is time for inflammation to set in. This (says Dr. Macartney)
appears to me to be worse than useless, as it deprives the practitioner of
the opportunity of acting with sufficient energy when the proper time
arrives." * Cases of accident, that of fractured ribs, for example, are
sometimes suspected not to bear loss of blood like those of inflammation.
According to Dr. M. Hall, different diseases induce in the constitution
different powers or susceptibilities,- in regard to the effects of loss of
blood. In cases in which it is doubtful, whether the pain, or other local
affection, be the effect of inflammation, or of irritation, " the question
is immediately determined by placing the patient upright, and looking
upwards, and bleeding to incipient syncope. In inflammation, much blood
flows ; in irritation, very little. The violence of the disease, the powers
of the system, and the due measure of the remedy, are determined at the
same time.*' In inflammation, we are to bleed fully ; in irritation, cau-
tiously : if much blood flows before syncope occurs, we may suspect in-
flammation ; if little, however similar the symptoms, Dr. Hall would sus-
pect the case to be of a different nature, perhaps irritation, or exhaustion.f
Exceptions to this mode of judging, however, are admitted, and every
experienced surgeon must have met with them.
I have already referred to the instruction to be derived from the
appearance of the blood taken away ; viz. from its buffy and cupped
surface ; but since these circumstances are not entirely to be depended
upon as a criterion of inflammation, and of the necessity for venesection,
the surgeon must reflect upon the state of the pulse, the type and degree of
fever present, the kind of pain experienced, and the nature of the function
disturbed. He should likewise pay attention to the character of the sym-
pathetic symptoms, as they are termed, such as pain in the*shoulder and
about the larynx in hepatitis, the vomiting and retraction of the testicle
in inflammation of the kidney, &c. From all these considerations taken
together, he will generally be able to judge of the existence, extent, violence,
and seat of inflammation, and form a correct opinion about the propriety
of taking away blood.
Op. cit. p. 152. f Principles of Medicine, p. 79.
r> A
24 INFLAMMATION.
^ In urgent cases, it is sometimes advisable to bleed the patient till he
faints, ad deliquium, as the phrase is ; because, when a person faints, all
operations in the system are immediately checked or suspended, and
among them the action or process of inflammation. Now, for the purpose
of inducing deliquium, it is frequently proper to make the opening in the
vein large, or even to puncture a vein in each arm, so that the blood may
flow away more suddenly ; for, on the quickness of the evacuation, the
success of the attempt will often depend. If the patient be not too ill, it
is also sometimes deemed advantageous, with a similar view, to bleed him
while he is standing or sitting up in bed, because in these postures half the
quantity requisite to make him faint while he is lying down will have the
effect. By attending to these directions, inflammation may often be reduced
at once, with a very inferior loss of blood to what would be required, if
this fluid were taken away in the first instance in a more gradual way.
The plan of bleeding from a large orifice, or from two veins, is only
to be adopted in urgent cases, and where the patient is in a state to
bear fainting without danger. After fainting commences, the surgeon
should always stop the further flow of blood, lest the prostration of
the vital power be carried to a dangerous extreme. When, from our
acquaintance with the patient's constitution, we know that the loss of an
ounce or two of blood will make him faint, we should bleed him in the
recumbent posture, and make an opening of moderate size in the vein.
Without these precautions, we might not be able to take away blood
enough to make any impression on some dangerous forms of inflammation.
Local or topical bleeding is employed in mild cases, and in the chronic
forms of inflammation, where the opening of a large vein is not deemed
necessary ; and it is likewise resorted to in inflammations which are
dangerous on account of their degree or situation, as an auxiliary to vene-
section, or arteriotomy ; but, in such instances, the use of the lancet
should never be omitted. So long as plethora has not been duly obviated
by general bleeding, topical bleeding will disappoint the expectations of
the practitioner ; and alone, it will mostly fail to stop the progress of any
important inflammation.
Topical bleeding will suffice where the symptoms are not severe enough
to require general bleeding, or where, on account of peculiar circum-
stances, the system will not bear much loss of blood from the arm, or
where doubts exist about the propriety of venesection, inasmuch as the
nature and state of the disorder may be questionable. Local bleeding, by
means of leeches and cupping, is also frequently of considerable service in
those inflammations which partake more of the chronic than the acute
form. To some parts, after the leeches have fallen off, a cupping-glass
may be applied, by which means the discharge of six or eight ounces
more blood may often be promptly obtained. In general, when plethora
has been obviated, the effect of topical bleeding will prove to be much
greater than could be expected from the simple consideration of the
moderate quantity of blood often thus taken away. Some pathologists
account for this fact by supposing the smallness of the evacuation compen-
sated by the nearness of the bleeding to the part affected, the effect being
concentrated, as it were, on that particular part.
By cupping freely, or applying a great number of leeches, however,
sufficient blood may be taken away to produce a vast effect upon the
system at large. These modes of bleeding may then indeed be regarded
in the same light as venesection, or general bleeding.
In some constitutions, leeches must be avoided, as invariably bringing
on an attack of erysipelas.
INFLAMMATION. 25
The symptomatic fever, which accompanies every severe attack of in-
flammation, always produces constipation. The removal of this confined
state of the bowels, then, is another indication. For this purpose, mild
saline purgatives, which act without much irritation, are sometimes pre-
ferred, as the sulphates of soda and magnesia, and the tartrates of potash
and soda. In many cases, however, more active purgatives become neces-
sary, such as colocynth with calomel, or calomel with jalap, James's
powder, &c. It may be proper also to assist the operation of these last
medicines with the infusion of senna, or the saline mixture, in which a
proportion of some of the neutral salts has been dissolved. In certain
instances, the aid of glysters is also requisite. Purgative medicines have
a considerable effect in lessening the strength and frequency of the pulse,
and in reducing the force of the circulation ; and, on this principle, they
must be of service in subduing inflammation ; they cause an extraordinary
secretion from the whole surface of the mucous membrane of the bowels ;
and when the immense extent of that surface, and the quantity of fluid,
thus abstracted from the circulation, are recollected, we must at once
recognise the manner in which purgatives become so beneficial as a means
of counteracting inflammation.
Amongst the remedies which act through the medium of the consti-
tution, is mercury, the powerful effect of which, in stopping the effusion
of coagulating lymph in inflammation, is a very important fact, made out
within the last thirty or forty years. The exhibition of calomel, joined
with opium, in the treatment of certain visceral inflammations, was first
particularly recommended to the notice of the profession, at an earlier
period, that is in 1783, by Dr. Robert Hamilton of Lyme Regis. The
effect of mercury in stopping the effusion of fibrine or coagulating lymph,
and promoting its absorption when already effused, was first brought into
great publicity by the late Mr. Saunders and Dr. Farre, whose statements
were deduced from the observation of the action of mercury on iritis.
Another illustration of the power of mercury in checking the progress of
inflammation, and especially in preventing that action of the vessels on
which the effusion of fibrine depends, is seen in inflammation of the
larynx, or croup. Here the chief reliance is on the lancet, and the free
exhibition of mercury ; for if the inflammation be not quickly stopped,
and its consequence, the effusion of lymph, be not rapidly checked, the
death of the patient will be inevitable : he will die partly from the ob-
struction of the air passages with fibrine, and partly from the glottis
becoming oadematous. •*
Mercury exerts a similar beneficial influence over inflammation of the
viscera and internal organs in general, and it has a peculiar power of
controlling the process, so as to prevent those changes from taking place
which are so destructive to the organisation of tissues in a state of inflam-
mation. The quantity, which is to be administered, must depend on the
violence of the inflammation, and on the nature of the 'parts affected.
Sometimes it is necessary to bring the system rapidly under its influence,
as for example, in inflammation of the iris, the retina, the larynx, or the
trachea. In such cases, immediately after general and local bleeding, we
may give two or three grains of calomel, or five of the hydrargyrum cum
creta, every alternate hour, till there be some decided affection of the
mouth, and amendment in the symptoms. Even larger doses are some-
times given. In the inflammatory diseases of hot climates, which run
their course with frightful speed, the rapid introduction of mercury after
venesection seems to be the only chance of saving life.
26 INFLAMMATION,
Though mercury has vast effect in arresting the progress of inflam-
mation, when exhibited alone directly after bleeding, it is often more
successful when combined with opium, especially if the pain is severe, and
there is a tendency to disturbance of the bowels. Here, sometimes, the
hydrargyrum cum creta, joined with the compound powder of ipecacuanha,
is the best formula. In active inflammation, however, neither mercury,
nor any other remedy, should be permitted to interfere with blood-letting,
which is the first and most powerful means of stopping inflammation, while
mercury, perhaps, deserves to rank as the second ; or, as Dr. Armstrong
used to say, bleeding is the right arm in the management of inflammation,
and mercury the left.
But, though mercury is useful in the treatment of inflammation situated
in various important organs and textures, it is by no means necessary to
put patients under its influence for the relief of every common case of
inflammation. This would be making the remedy worse than the disease.
There are likewise particular states of the health, brought on by the too
free or long employment of mercury, or other causes, in which any in-
flammation present will not take a favourable course until the state of the
constitution has been improved. Here the discontinuance of mercury,
instead of its further exhibition, may be the principal means of benefiting
the patient.
Tartarised antimony is useful in two ways; first, by lessening the
dryness of the skin and promoting perspiration ; and secondly, in freer
doses, by producing nausea, which at once renders perspiration more
abundant, and reduces the force of the pulse. No doubt considerable
benefit sometimes arises from its employment with these views, as well
as from its efficacy in promoting the alvine evacuations ; but if we were
to depend entirely upon it, if we were to lay the lancet aside for it, I
should say, that it would not generally be for the patient's good : the
Practice would not be less severe, and perhaps inferior in point of efficacy,
n Italy, the plan of giving very large doses of tartarised antimony for
the cure of inflammation has been common of late years. Thus, in pneu-
monia, Rasori, one of the advocates for this plan, gave, after blood-letting,
not less than eight or ten grains of this preparation in the twenty-four
hours. If the disease had made considerable progress in the lungs, he
began with twenty or thirty grains, increasing the dose daily till one or
several drachms had been taken in the course of the twenty -four hours.
Of 832 cases of pneumonia, treated in this manner, only 173 died.
Laennec, encouraged by these facts, also employed the same medicine
after bleeding., but, in the more moderate dose of one grain every four
hours, blended with about a drachm and a half of syrup of poppies.
Dr. Tweedie finds the irritation of the stomach, resulting from it, very
much allayed by giving it in the effervescing saline draught, with a few
drops of laudanum.
For many years past, surgeons have occasionally been in the habit of
treating violent inflammations of the eye and testicle by means of nau-
seating doses of tartarised antimony ; but partly in consequence of the
aversion of most patients to be sickened in this way, and partly from the
greater confidence now placed in mercury, the practice has of late con-
siderably declined.
Colchicum, as a diuretic, purgative, and nauseating medicine, is useful,
but chiefly in some specific inflammations, like those of gout, rheumatism,
and some forms of inflammation within the eye, connected with peculiar
states of the system.
INFLAMMATION. 27
Opium, being a stimulant and a constipating medicine, as well as a
narcotic,, has sometimes been deemed quite inapplicable to cases of in-
flammation. Yet, at all periods, it has had its advocates. In examples,
accompanied by excessive pain, some practitioners, after bleeding the
patient largely, give a full dose of opium, which is sometimes followed
by the most happy effects, especially in irritable constitutions. The
reaction, which often follows a large bleeding, may generally be pre-
vented by giving two grains of solid opium, or a draught containing one
grain of pure acetate or muriate of morphia, administered when the
faintness is disappearing. In many instances, one copious bleeding, a
full dose of opium, and a mild cathartic, will succeed in stopping inflam-
mation. The opium so tranqui-llises the nervous system, after the bleeding,
that the patient often falls into a refreshing sleep, from which he awakes
with a moist skin, and a freedom from pain. If, however, after an interval
of three or four hours, the skin should become hot and dry again, and
the pulse wiry, the blood-letting and opium, with three or four grains of
calomel, are to be repeated.
In the treatment of inflammation, the severity of the pain frequently
compels the surgeon to prescribe opium. When suppuration is taking
place in situations where the parts and the matter are bound down by
tense unyielding structures, the agony may be intolerable. After a sur-
gical operation, when the wounded parts continue inflamed, and more
blood cannot be taken away, the surgeon may sometimes give one grain
of opium and two of calomel every six or eight hours, with great
advantage.
Differences of opinion exist about the, general usefulness of giving
opium just before and immediately after surgical operations. When the
pain after an operation is exceedingly severe, the patient very restless
and nervous, with a disposition to spasms or subsultus tendinum, the
acetate or muriate of morphia may be prescribed. But the dose must
be a full one, that is to say, a grain ; for all surgeons of experience agree,
that small doses of any preparation of opium, after a surgical operation,
only render the patient more uncomfortable and feverish. If laudanum
be given, it should be in doses of fifty or sixty drops.
With bleeding, purging, antimonials, and sometimes mercury and opium,
are to be combined the advantages of a very low diet, from which all
animal food, spirits, wine, and fermented liquors in general, must be
strictly excluded ; often, indeed, only barley-water, or lemonade,, or tea,
with a bit of dry toast, ought to be allowed. Quietude of body and mind
is to be enjoined, and every thing avoided likely to stimulate the system,
accelerate the circulation, or disturb the nervous system, or the inflamed
part itself. The return of blood from the seat of inflammation may
sometimes be advantageously promoted by a judicious position of the
part. To borrow Dr. Macartney's language, where he is speaking of the
immersion of a wounded or inflamed part in warm or cold water, freedom
from the sense of restraint, pressure, and friction, an easy and elevated
position, and avoidance of all motion, are advantages acknowledged by
every body. The patient should be placed in a quiet apartment, in which
there ought to be no unnecessary conversation, nor any superfluous visitors.
The room is to be kept moderately cool, and the patient not heated with
heavy blankets. The several measures and plans, here mentioned, con-
stitute what is called the antiphlogistic treatment, which is applicable to the
relief not only of common, but of specific inflammations, though in these
latter cases other remedies are mostly required.
28 INFLAMMATION.
Local or topical remedies for inflammation. — One effect of this process,
in all its acute forms, is to produce a rise in the temperature of the
parts affected : not only does the patient experience in them a distressing
sensation of heat, but their temperature is actually proved by the ther-
mometer to rise several degrees above what it is in their quiet and
healthy state. Now, we should probably be inclined to adopt measures
for the relief of this symptom, if it were only for the purpose of freeing
the patient from the uncomfortable state in which he is placed by it ; but
there is another and a still more important reason for doing so. Heat
promotes every process going on in the system, and the process of in-
flammation amongst the rest ; therefore, inasmuch as we lower the tem-
perature of the inflamed parts by covering them with linen wetted with
cold water, or a cold evaporating lotion, we are doing what will have a
beneficial effect in checking inflammation. One drachm of the liquor
plumbi acetatis and a pint of water, with about two ounces of cam-
phorated spirit, make a very good lotion for ordinary .cases. In some
instances, the liquor ammoniae acetatis, diluted with water, to which a
little camphorated spirit is added, may be employed ; but whenever the
surface is excoriated or ulcerated, the more simple the lotion is the
better.
The great principle in view is to keep up evaporation from the surface
of the parts affected, whereby their temperature will be reduced, and the
inflammation checked ; but, in order to carry this principle fully into
practice, we must wet the linen frequently, and not let it become dry,
hard, and stiff, in which state it would have no effect as a means of carry-
ing off the heat, and be more likely to do harm than good.
For the purpose of maintaining the operation of cold and moisture
uninterruptedly, the French frequently have recourse to what is termed
irrigation. A bucket, containing cold water, is slung to the top of the
bed, and from a stop- cock the water falls in drops on the inflamed
part, which is left uncovered. The water is collected in a sheet of
oiled calico, and runs from it into another bucket placed near the patient's
bed. A more convenient plan is that of placing the limb in a trough,
and after some lint has been laid on the inflamed part, conducting the
water to it from a basin by means of a strip of woollen cloth, one end of
which is placed in the water, and the other cut into a pointed shape, put
on the lint, as recommended by Dr. Macartney. Irrigation is more
suitable for the hot months of summer than the winter season. In
many cases, however, cold applications fail to afford relief, and warm
moist applications prove more beneficial. Cold applications are useful on
the principle of evaporation, by which the heat of the inflamed part is
carried off; warmth and moisture may act by softening the inflamed
tissues, and thus lessening tension. It seems to me, that this explan-
ation may sometimes be correct ; that it brings with it an appearance of
probability, especially where the parts affected are near the surface. Be
the theory, however, correct or not, the fact that warm moist applications
frequently answer better than cold ones is perfectly ascertained. Numerous
cases of inflamed breast or testicle are much more benefited by warm
emollient poultices than cold lotions. I may also observe, that those
inflammations which arise during fevers, and the generality of whitlows,
boils, carbuncles, and inflammations about .the anus, receive greater
relief from warm moist applications than from cold lotions. The warm
applications in common use are poultices and fomentations. One of the
most convenient emollient poultices is that composed of linseed meal,
INFLAMMATION. 29
made by first putting the requisite quantity of warm water in a basin,
and then adding the linseed meal very gradually, at the same time that
they are blended together with a spoon. We proceed in this manner
until we have added as much linseed meal as makes the poultice of
the desirable consistence. After the poultice has been spread on linen
or tow, a little salad oil is sometimes put on it ; but, if the poultice be
changed at least twice a day, as ought always to be done, the oil may be
dispensed with.
The size of the poultice must generally depend upon the extent of the
inflammation, though there are cases in which the weight of a large thick
poultice cannot be endured. Then lint, or linen wetted with tepid water,
may be laid on the part, and covered with oiled silk to keep it from be-
coming dry.
Whenever we put a poultice upon an inflamed part, we ought to be sure
to let it be so placed that it will not slip about, a condition in which it
is not likely to afford any benefit.
In the most exquisitely tender kinds of inflammation, a poultice made
of bread and water, bread and milk, or bread first steeped in warm water,
and then medicated with the diluted liquor plumbi acetatis, or a watery
solution of the extract of opium, or hyosciamus, will generally agree
better than a linseed poultice. This is often exemplified where the parts
affected are not only highly inflamed and full of nerves, but in an irritable,
excoriated, or ulcerated state.
With regard to fomentations, they are frequently employed in the same
cases as emollient poultices, the opportunities of applying them being
the periods of changing the latter. A good fomenting liquor is made by
boiling half a pound of camomile flowers or poppy heads for twenty
minutes in a gallon and a half of water ; the liquor may then be strained,
and flannels or cloths wrung out of it, and put on the parts as warm as
can be conveniently borne.
When the inflamed part can be conveniently immersed in the foment-
ing liquor or warm water, this is often the best way of fomenting it, that
which is accomplished with the least disturbance of it. When inflam-
mation is situated about the anus or perinseum, the patient may sit over
a bidet filled with warm water, the steam of which will often afford great
relief.
For inflammation about the abdomen, the neck of the bladder, and
prostate gland, the slipper and hip baths are in common use.
With respect to the choice of cold or warm applications, there is
one rule, which we may always safely follow when any doubt exists
about the superiority of one plan to the other ; viz., that of letting
the patient's own feelings decide, for if he be rendered more easy and
comfortable by one application than the other, we shall never do wrong
in giving it the preference.
Another powerful means of checking and subduing inflammation is
counter-irritation, which seems to be useful on the principle of exciting
an inflammatory action in the shin, either in the vicinity of tne inflamed
part, or on some portion of the surface of the body with which the
inflamed part is known to sympathise. Here one inflammation is esta-
blished for the relief of another, and in proportion as the new is excited,
the original and more dangerous inflammation declines. It is an illus-
tration of what the old practitioners used to term derivation or revulsion,
or the turning of the blood or fluids away from the part affected to some
neighbouring or distant part. However, we should be upon our guard
30 INFLAMMATION.
against producing counter-irritation too near an inflamed part, more
especially while the inflammation is in the acute stage, because, if a
proper distance be not observed, the two inflammations are liable to
conjoin, and render the disease worse instead of better. Thus, when the
eye is inflamed, it is frequently more advantageous to blister the nape of
the neck than the temple, where the anterior part of the blistered
surface may approach too near the eyelids, and even make them inflame.
The nape of the neck is sometimes preferred also on another principle, as
being a part of the surface of the body, between which and the eyes a
strong sympathy is known to prevail.
But the means, employed to excite counter-irritation, frequently
operate at the same time on another principle. They do not merely
produce an irritation of parts in the vicinity of those which are inflamed,
or an irritation of parts at a distance from the latter, but connected with
them by sympathy ; they not only act in determining the blood away
from the parts affected on this principle ; but some of them, like blisters,
bring about a great deal of their good effects by occasioning a copious
discharge of serum from the vessels of the surface to which they are
applied. After the cuticle has been removed, a discharge of pus may
also be kept up from the surface of the cutis, if necessary, with savine
ointment.
We should not be too hasty in having recourse to counter-irritation ;
for if we do so in the treatment of acute inflammation, without having
first given the patient the benefit of bleeding and other means of deple-
tion, the practice will rarely be of service.
There are other plans for accomplishing the same things which are
aimed at with blisters ; namely, the production of counter-irritation, and
the maintenance of a discharge from the surface of the cutis, in order to
relieve inflammation in another situation. Thus the formation of issues
and setons, and the application of antimonial ointment, and the moxa, are
often resorted to, especially where the inflammation is of a chronic cha-
racter, or the most acute stage of it has been subdued by bleeding and
other means. The antimonial ointment is composed of one drachm of
tartrate of antimony blended with an ounce of lard, and, when rubbed
on the skin, it has the effect of bringing out pustules, and this sometimes,
not merely on the part to which the friction is applied, but in other
situations, and even on the genitals.
In inflammation, which is either originally chronic, or has become
so, after the cessation of its acute stage, I believe counter-irritation,
united with topical bleeding, is amongst the most efficient plans which
can be adopted.
When inflammation is situated in a mucous membrane, and assumes a
chronic form, attended with a morbid secretion, counter-irritation in the
neighbourhood of the original disease has frequently a most beneficial
effect. Then also the application of cold astringent, or even stimulating
lotions and ointments, to the surface from which the discharge comes,
will often rectify the wrong action of the vessels, and bring them into a
state in which they will be again qualified to produce only their healthy
secretion. This fact is exemplified in gonorrhoea and purulent ophthal-
mies.
Nitrate of silver has been of late used as an external application to the
skin for the relief of inflammation. For this practical fact, built upon
no hypothesis or theory, we are indebted to Mr. Higginbottom, of Not-
tingham. The method frequently succeeds in stopping inflammation of
INFLAMMATION. 31
the fingers, which would otherwise suppurate and form witlows ; also
in dispersing glandular inflammations, especially those brought on by
scrophula in the glands of the neck, groin, or armpit. In University
College Hospital, I have often adopted this plan very successfully, for
promoting the dispersion of chronic buboes. It answers likewise some-
times for checking erysipelas and the inflammation of absorbents. Duly
applied over and a little beyond the pustule of small-pox,[nitrate of silver
prevents the sloughing, which is the occasion of the pitting sometimes so
disfiguring a consequence of this disease.
Sometimes blackening the skin with the nitrate of silver will not only
prevent suppuration, but occasion the absorption of matter after it is
formed and can be plainly felt. In some cases, it is enough merely to
blacken the cuticle ; in others, vesication must be produced. The part is
first to be gently washed with soap and water, and dried, then moistened
with cold water, and the nitrate of silver lightly passed over it once,
twice, or thrice, in common cases ; but oftener, if vesication be necessary.
Afterwards the skin is to be exposed to the air and kept cool.
When inflammation is either originally chronic, or has become so after
the subsidence of its acute stages, one principal indication is to promote
the absorption of effused fluids, the coagulating lymph and other deposits,
by which the swelling of the parts is yet maintained) and the complete
restoration of their functions prevented. For this purpose, we may have
recourse to friction with mercurial, camphorated, or iodine liniments, or
to lotions containing a proportion of the muriate or acetate of ammonia,
with vinegar and camphorated spirit.
For the fulfilment of the same indication, a blister is also sometimes
the most efficient application, particularly where the synovial membranes
are affected with chronic inflammation, as a consequence of the acute
forms of it. In obstinate cases, a discharge should be kept up with
savine ointment, or the blister be renewed from time to time.
In the treatment of chronic inflammation in general, we shall find
counter-irritation, the occasional use of leeches, cold astringent ap-
plications, the external employment of nitrate of silver, friction with
iodine liniments, and sometimes the exhibition of mercury or iodine
internally, with purgatives, amongst the best and most efficient plans,
the choice of which must depend upon the particular circumstances of
each individual case.
The symptomatic fever, arising from inflammation, generally requires
only those curative means, which are calculated to subdue the inflamma-
tion itself. It is chiefly in nervous irritable constitutions that its
violence may be disproportionate to the extent, degree, or importance of
the inflammation, and then such treatment as offers the best chance of
tranquillising the nervous system, must be combined with antiphlogistic
measures ; but, bleeding is not to be adopted with unlimited freedom.
32 SUPPURATION AND ABSCESSES.
SUPPURATION AND ABSCESSES.
Suppuration is that process in the animal body, by which a fluid, termed
pus, or the matter of wounds, ulcers, abscesses, and of all purulent dis-
charges, is produced. It may occur in or upon any texture or surface
that is furnished with blood-vessels, and consequently may take place in
or upon any texture susceptible of inflammation, like which it is also
so connected with an infinite number of diseases and accidental iujuries,
as to form a very important elementary subject in pathology. It is some-
times described as one of the terminations of inflammation ; but this
language is not strictly correct, inasmuch as suppuration may be, and
frequently is, accompanied by a great deal of active inflammation. One
should rather say, that it is attended with some modification of the in-
flammatory process — some change in the symptoms, than that the in-
flammation ceases.
Suppuration may be a consequence of acute or chronic, of common
phlegmonous, or of unhealthy or specific inflammations, as those charac-
terising carbuncle, malignant pustule, phlegmonous erysipelas, syphilis,
scrofula, and numerous cutaneous diseases.
Suppuration, as brought on by acute inflammation, is illustrated in
every common abscess following healthy phlegmonous inflammation, all
the processes and effects of which are invariably quick, so that if resolu-
tion cannot be accomplished in four or five days, suppuration may be
apprehended. Specimens of abscess from acute inflammation are seen
in every common whitlow ; in the generality of milk abscesses ; and in
every abscess following gun-shot wounds, bad compound fractures, and
other mechanical injuries. Certain specific inflammations are likewise
productive of suppuration in the acute form, as the venereal bubo, the
first stage of purulent ophthalmia, gonorrhoea, &c.
Many specific inflammations lead, however, to suppuration in its
chronic shape. The generality of abscesses from s*crofula are chronic ;
and of this nature is the lumbar abscess. Exceptions to this statement,
however, are not uncommon in abscesses formed round scrofulous joints ;
for, though after a time they generally become chronic, they often com-
mence with every mark of acute inflammation.
The very gradual, quiet, and almost imperceptible manner in which
some chronic abscesses take place, justifies the suspicion entertained by
many, and especially by M. Andral, that suppuration sometimes occurs
quite unconnectedly with any inflammatory process.
Suppuration may be induced by a variety of circumstances : —
1. By the intensity and violence of inflammation. 2. By the very
nature and peculiarity of the inflammation, which, whether acute or
chronic, naturally leads to the formation of a puriform fluid. This is
mostly the case with whitlows, and always with purulent ophthalmia,
carbuncles, boils, gonorrhoea, and the indolent inflammation preceding
lumbar abscess. 3. By exposure of internal cavities and tissues, con-
tinued for a certain time ; as is illustrated in every wound the sides of
which have not been brought together, or which, after having been so
brought together, have not united. Also in every case, where the surgeon
lays open the tunica vaginalis, for the removal of a collection of blood
within it, forming the disease termed hccmatocele. 4-. Suppuration neces-
sarily attends, or at all events follows, ulceration. The fact is exemplified
in the origin and progress of every sore, whether of a healthy, unhealthy,
SUPPURATION AND ABSCESSES. S3
or specific character. 5. Ulceration is not, however, essential to suppu-
ration, which may be, and commonly is, brought on in mucous tissues by
a very slight degree of inflammation, unaccompanied by ulceration, or
any breach of surface. The much greater frequency of suppuration in
mucous, than serous tissues, is illustrated, not only in gonorrhoea and
purulent ophthalmia, but in the bronchial membrane, the lining of the
pelvis of the kidney, ; of the ureter, and bladder, of the frontal and
maxillary sinuses, and ethmoid cells. 6. Suppuration, though not
frequent in parts lined by a serous membrane, is possible, as is proved
in the disease termed empyema ; the very case which first led to the
discovery of the interesting pathological fact, that suppuration may
happen without ulceration, or any dissolution or loss of the solids. It
would seem, however, from modern investigations, that, when the surface
of a serous membrane is about to suppurate, it first becomes covered
with a layer of fibrine, in which many new vessels are developed, often
preparatory to the formation of granulations. Dr. Macartney not only
joins in this doctrine, but questions, whether, in any instance, the sur-
faces of the cellular, synovial, serous, and medullary membranes, the
pia mater, or periosteum, can furnish genuine pus, without the deposition
and organisation of some coagulable lymph. 7. Another frequent cause
of suppuration is a considerable injury of textures by the application of
great degrees of mechanical violence ; as seen in contusions, compound
fractures and dislocations, and in gun-shot and other wounds, attended
with a great deal of contusion and laceration. 8. Foreign bodies, or
extraneous substances, and irritating fluids lodged in the cellular tissue,
are very frequently exciting causes of suppuration. Diseased or dead
bone, or osseous fragments, quite detached, are to be viewed in the light
of foreign bodies.
An abscess strictly signifies a collection of purulent matter in the sub-
stance or tissue of an organ, or part of the body. Frequently the
matter of an abscess is contained in an orbicular cavity lined by a cyst ;
but sometimes it burrows into the adjacent textures, producing what are
termed sinuses, or long narrow channels, which, if they open through
the skin, or into a cavity lined by a mucous membrane, and continue
without any disposition to heal, are termed fistula. When the pus is
poured out from the surface of a wound, ulcer, or inflamed mucous
membrane, and the matter does not collect in the tissue of the part,
instead of saying there is an abscess, surgeons say there is a discharge,
or simply suppuration. Sometimes, from there being no cyst, pus is
infiltrated into the meshes of the cellular tissue, as the serum is in
redema or anasarca. This infiltration of pus is more commonly observed
in the lungs than a circumscribed abscess. Very often pus is diffused
over the surface upon which it is formed, as exemplified in peritonitis.
" But, even in this case, the space containing the pus is sometimes cir-
cumscribed by adhesions of adjacent portions of the peritoneum ; the
pus may at length point externally, or make its way into th# intestine or
the vagina. In the first case, the abscess may be opened without the
risk of exposing the general cavity of the peritoneum. This event (says
Dr. M. Hall) I have seen repeatedly after parturition and abortion."* A
collection of purulent matter in the cavity of the pleura is termed
empyema.
It is in the centre of the inflamed part that pus usually begins to be
* Principles of Medicine, p. 12.
D
34' SUPPURATION AND ABSCESSES.
deposited, the texture seeming first to become in some manner or another
softened, or, at all events, to be partially deprived of its power of cohe-
sion. The formation of an abscess is often preceded by chills, or one or
more fits of shivering, termed rigor. The probability of suppuration
may often be foreseen by the violence of the inflammation and the
quickness of its course ; and just before matter forms, the pain, throb-
bing, tension, swelling, and febrile disturbance (supposing the inflamma-
tion to be extensive or severe enough to excite fever) all undergo an
increase. As external inflammation of the acute kind advances to sup-
puration, the skin becomes of a deeper red colour, smooth, and glossy.
A sense of throbbing and weight in the part continues after the matter
is formed, and one portion of the swelling begins to rise or project beyond
the rest of it, in a conical form, presenting a paler appearance, or even a
light yellowish colour, with a gloss and even a degree of transparency
about it, permitting the purulent matter after a time to be plainly dis-
cerned. This conical projection, which is termed the pointing of the
abscess, is attended with a very thin state of the skin in the situation of
it, and at length the matter arrives immediately beneath the cuticle,
which breaks and permits the contents of the abscess to be discharged.
The pointing and bursting of abscesses occur with more or less quick-
ness, in porportion as the inflammation is more or less acute. A phlegm-
onous abscess will often point and burst in the course of a week, while
a chronic one may not do so till several months, or even a longer period,
have elapsed. In proportion as pus advances to the surface, the textures,
intervening between the cavity of the abscess and the cuticle, are
removed by absorption. In general, before an abscess points, a fluctuation
may be felt in the swelling, one of the surest signs that it contains pus,
inasmuch as a true fluctuation can only exist where fluid is present. In
many instances, it is distinguishable even when the purulent matter lies
at a considerable depth, covered by a great thickness of textures, and
unaccompanied by any pointing of the abscess.
Dr. Macartney is satisfied, that the alleviation of the pain of an abscess
after perfect suppuration has taken place, is not because the inflammation
has terminated, but arises entirely from the change effected in the struc-
ture of the part, by which the tension is relieved, the walls of the cavity
being rendered thinner by absorption, and thereby the pus better
accommodated.
The knowledge of the right manner of examining a tumour suspected
to contain matter, so as to have the best chance of distinguishing a fluc-
tuation, is of the highest importance in practice ; and here the skill does
not consist in pressing each side of the swelling alternately, but in placing
two or three fingers on one side of it, and while they are so applied,
in tapping briskly on the opposite side with the fingers of the other hand.
The fluctuation will be more or less distinct in proportion to the thin-
ness or thickness of the parts intervening between the abscess and the
surface. The thickness or thinness of the pus, too, will materially affect
the distinctness of the feel of fluid. When, in consequence of the thin
state of the skin, there is a manifest tendency in the abscess to point,
the fingers of one hand should be applied to this thinner part of the
integuments, while another part is gently tapped with the fingers of the
other hand. Thus, the fluctuation will assuredly be rendered perceptible ;
but the pointing alone, or even the inclination to it, is generally a suffi-
cient indication of the nature of the swelling.
Great mistakes are continually occurring from inattention to the proper
method of conducting the manual examination of tumours suspected to
SUPPURATION AND ABSCESSES. 35
contain pus or other fluids ; yet, it must be acknowledged, that some cases
are attended with such obscurity as perplexes the most skilful. There is
hardly any museum where specimens of medullary cancer are not to be
found, into which a trocar or lancet had been introduced on the supposition
of the tumours containing fluid. The softness and elasticity of that dis-
ease convey a sensation very like what arises from the presence of pus or
a serous fluid. In order to avoid mistake, the mere manual examination
of a tumour will not always be sufficient ; the history of the case must be
particularly investigated ; every symptom minutely weighed ; in what
respect the disease resembles others ; in what points it differs from them,
should be well considered ; and then the information, deduced from such
reflections, should be joined with that derived from a skilful manual exa-
mination of the part. Thus a correct diagnosis may generally be formed.
Deeply-seated abscesses, and those formed beneath unyielding fibrous
tissues, fasciae, aponeuroses, &c. do not readily point. However, even
under these circumstances, and when suppuration takes place still further
from the surface, so that we cannot feel a fluctuation, we shall have reason
to suspect what has happened, if, after a great deal of suffering and symp-
tomatic fever, a kind of crisis should be manifested by an attack of shiver-
ing, followed by a subsidence or a modification of the constitutional
disturbance, and a sense of weight and coldness in the part, or of uneasi-
ness and numbness, instead of the acute pain previously experienced.
This suspicion will be corroborated, if the patient afterwards have noc-
turnal sweats, emaciation , a small quick pulse, and other hectic symptoms,
nor referable to any other cause. Shiverings or rigors more frequently
precede deep-seated suppuration, than the formation of an abscess, near
the surface. An cedematous swelling of the integuments over a deep
abscess is another change affording light to the practitioner : and so, in
particular examples, is the mechanical effect of the pressure of the matter,
there being often an interruption of function from this cause, as must
happen whenever the collected matter makes pressure on the brain, neck
of the bladder, urethra, oesophagus, trachea, &c.
In many constitutions, especially those called scrofulous, a trivial in-
crease in the action of the vessels may be followed by the formation of
matter ; and the appearance of an abscess is sometimes the first indication
that such increased action must have existed, the patient having expe-
rienced but little, or even no previous uneasiness, or disturbance, in the
part. These slow and indolent formations of matter are very different
fTom others preceded by acute inflammation. The latter, just before they
occur, are always attended with an aggravation of all the symptoms, both
local and general, an augmentation of pain, excessive throbbing, heat, and
tension, &c., all which effects, however, undergo a modification as soon as
suppuration is completely established.
The pointing of abscesses, which arises from the approach of matter to
the surface, must be preceded by a gradual absorption of the^parts inter-
vening between the matter and the skin. In this direction, then, the
process is quite the reverse of that by which the boundary of the abscess
is determined in other directions, where the adhesive inflammation has
the effect of closing the cells of the cellular tissue, and consolidating the
textures around the purulent fluid.
After the pus has made its way through the cutis, its discharge may
for a time be prevented by thickness of the cuticle, which becomes sepa-
rated from the cutis by the purulent matter under it. This detachment
of the cuticle may proceed to a considerable extent ; but, at length, the
D 2
36 SUPPURATION AND ABSCESSES.
cuticle bursts, and then the matter escapes. The bursting of the abscess
and the partial discharge of the matter, resulting from a spontaneous
opening, give great relief, by diminishing the tension of the part, and
removing the pressure of the pus. As the matter continues to be secreted,
however, the discharge generally continues, and the opening itself may
become larger than at first. If the case proceed favourably, the cavity of
the abscess gradually diminishes ; the adhesive inflammation and the gra-
nulating process ensue ; and, as soon as the hollow is obliterated, suppu-
ration ceases, and the opening, being no longer necessary for the evacu-
ation of the pus, heals up.
If, however, from the nature of the disease, or the presence of dead or
diseased bone, the lodgment of foreign bodies, or from the disturbance of
the part caused by its situation or function, or from the difficulty with
which the matter escapes, suppuration is kept up for some considerable
time, the opening loses its disposition to close, and the passage, with which
it communicates, assuming a chronic state, is termed a fistula, or sinus,
though the term sinus is sometimes restricted to the passage, which the
matter, when it cannot readily get to the surface, burrows for itself in the
cellular tissue. We hear a great deal about fistula in ano : now the
reason of their frequent occurrence here is owing partly to the disturbance
of the disease by the action of the sphincter ani, and partly to the matter
not having a direct and sufficiently ready outlet, and only partially
escaping, at intervals, through a long, narrow, and often a tortuous course.
QUALITIES OF PUS.
The fluid, discharged from simple or phlegmonous abscesses, or from
common wounds or ulcers which are in a healing state, is termed healthy
or good pus, which is of a light yellowish colour, often presenting a tinge
of green in it, and being nearly of the same consistence as cream. Being
heavier than water, it sinks in this fluid; but, if they are shaken up to-
gether, the water retains a turbid appearance.- Examined with a micro-
scope, pus is found to consist of opaque, light yellow globules, and a clear
transparent albuminous fluid. The globules were believed by the late
Dr. Pearson to consist of those of the blood, deprived of their natural
colour from some change effected in them by the process of suppuration
itself, or that action by which they become separated from the circulation.
Dr. T. Young's investigations tended to strengthen this doctrine, for he
was led to the conclusion, that they really corresponded in size to those
of the blood, and were all of the same dimensions, a character which the
globules of milk and chyle are alleged not to possess. M. Gendrin
believed them to be the globules of the blood, somewhat enlarged,
and altered in shape ; but, Dr. Hodgkin is of opinion, that they have no
resemblance to the latter, inasmuch as they are irregular both in shape
and size.* Yet, in noticing the slower motion of the blood as it approaches
the dilated capillaries, and in describing the beginning of suppuration,
M. Gendrin states, that the globules of the blood gradually lose their
colour as they advance, and become globules of pus : and the blood thus
changed seemed to him to exude very slowly in the form of pus. Healthy
pus is a bland, opaque, inodorous fluid, without any acrid or corrosive
* According to Mr. Gulliver, the pus-globule is composed of central molecules, con-
nected together by a substance which surrounds them, and is analogous to fibrin. The
molecules themselves are found by him to differ from any part of the human blood-
corpuscle in their form, density, indisposition to putrefaction, and complete insolubility
in acetic acid.
SUPPURATION AND ABSCESSES. 37
properties. When pus is discharged,, however, from various ill-con-
ditioned sores,, abscesses, or diseased surfaces, or from certain varieties of
specific disease, or from parts where it is blended with urine or extrava-
sated blood, or when it issues from a part where a portion of dead or
carious bone is lodged, its smell is highly offensive, and \£s qualities acrid,
irritating, and even contagious. The presence of dead bone is often fore-
told by the peculiar smell of the discharge, with which is found to be
blended a quantity of phosphate and muriate of lime. The matter of
gonorrhoea has a smell unlike that of pus discharged from other diseases,
and that of cancer is so different, perhaps so much more disgusting, than
the discharge from any other ulcer, that the presence of a patient with
cancer is known to us as soon as we enter his ward. The fluid part of
pus is coagulable by heat and the muriate of ammonia, a point in which
it differs from the serum of the blood ; also by alcohol and acids. Tritu-
rated with potash or soda, it forms a soapy fluid, and with ammonia a
transparent jelly. When exposed to galvanism, it coagulates with rapidity,
and yields a substance like albumen.
Pus contains not only albumen, but fibrine, and it is partly upon these
two facts, and its globular appearance, that is founded the inference of
its derivation from the blood. In the transparent gelatinous fluid, poured
out upon the surface of a wound or an inflamed serous membrane, no glo-
bules can at first be seen ; but if the part be excluded from the air with
a glass, they begin to be perceptible in about a quarter of an hour.
The qualities of pus are diversified according to the nature of the dis-
ease that produces it. The matter of an irritable ulcer is thin, and adul-
terated with an admixture of blood, such kind of discharge being often
termed sanies or ichor. Its peculiarity is, that it contains more salts and
albumen in solution than ordinary pus, the clear part becoming turbid
when an acid is added, by which the soda, holding the excess of albumen
in solution, is neutralised. The matter of phlegmonous abscesses is not
like that of a cancerous sore ; and that of scrofulous abscesses is different
again. In the latter, flakes of fibrine and albumen are blended with a
limpid fluid, which contains a large proportion of soda and its muriate.
In some diseases of very different kinds, the mere appearance of pus
is nearly the same. The matter of a phlegmonous abscess and that of
a venereal bubo are not distinguishable from each other by their look, but
only by the differences of their effects on the animal ecpnomy. The
matter of gonorrhoea, that of the small pox pustule, and that of chicken
pox, may present exactly the same appearance to the eye ; yet, when
applied to a mucous membrane, or the skin, the very different and pe-
culiar effects, resulting from them, mark their extraordinary differences.
The former anxiety to discover a test between mucous and purulent
secretions has in a great measure subsided. The old pathologists looked
upon pus as a certain proof of ulceration, and consequently when it was
expectorated, the lungs were presumed to be in an ulcerat^i state, and
the patient's chance of recovery hopeless. It is now, however, perfectly
well known, that pus may be formed by the cutaneous, mucous, and
serous textures without any ulceration at all.
THEORY OF SUPPURATION.
This is a subject, on which different opinions are entertained by dif-
ferent pathologists ; some regarding suppuration as a process similar to
that of secretion ; one, in which the formation of pus is brought about by
a particular action of the capillary vessels ; while others seem equally
D 3
38 SUPPURATION AND ABSCESSES.
convinced, that pus is merely a transformation of coagulating lymph after
it has quitted the vessels, together with some change in the colour, and
perhaps in the size and shape of the globules of the blood, either in their
transit through the capillary system of the inflamed part, or subsequently
to their extravasation. It is observed by M. Gendrin, that all textures
are naturally pervaded by a very limpid fluid, which never coagulates
spontaneously, though coagulable by alcohol, heat, or weak acids ; and
that consequently such fluid, which is of an albuminous quality, is not
materially different from the serum of the blood. In the meshes of all
inflamed textures a similar fluid is deposited ; but as soon as the inflam-
mation has attained a certain degree, there is deposited, in addition to the
serous fluid, another fluid, which, on account of its fibrinous nature, has
the property of coagulating spontaneously. If the inflammation be in-
tense, this spontaneously coagulating substance is of a red colour, or even
blood itself; for, in the centre of the inflammation, there may be small
clots of blood, and around them a gelatinous and liquid serum.
In a texture that has been for some time inflamed, and is now suppu-
rating, the spontaneously coagulating fluid, fibrine, or lymph, is still
noticed at the limits of the inflammation, and with the microscope the
peculiar globules of pus may also be recognised in the interstices of the
inflamed texture. At the points also, where the infiltration of lymph be-
gins to assume a puriform appearance, true globules of pus may be seen,
mixed with those of the blood, which have been only in part deprived of
their colouring matter by stagnation,, and still present a reddish grey hue.*
In acute abscesses,, some of the small vessels seem, to Dr. Macartney,
always to give way in the first instance, and blood and serum to be poured
out into the surrounding tissue. " In order to separate the disorganised
from the healthy structure, lymph is shed, by which the extravasation of
blood and serum is restricted within certain limits. This lymph next ac-
quires regularity and organisation, and then, and not before, the secretion
of pus commences/' (p. 30.)
The formation of pus would seem to be a consequence of some modifi-
cation of the blood, as manifested by a change taking place in the colour,
transparency, and size of the globules, after its circulation has been
arrested in the minute vessels by inflammation. It would seem also that
this change usually takes place in the capillary vessels, and that these
conduct the globules to the exterior, where they appear to be combined
with the serum, under a peculiar liquid form called pus.
This is one mode in which pus is formed, a mode compared to the pro-
cess of secretion ; but, it is suspected, that pus may also be formed in the
blood, under circumstances in which the influence of the capillary system,
as exercising a function of secretion, can take no part. In phlebitis, the
conversion of blood into pus, independently of any action of the capillary
vessels, is manifest. First, there is a cord-like hardness of the vessel ;
and then a softness of it, from the coagulated blood having become pus.
Here the coagulated blood could not have passed into the circulation ;
and, as Professor Carswell notices, three remarkable circumstances are
constantly observed. 1. Cessation of circulation ; 2. Coagulation of the
blood ; 3. Conversion of the fibrine and globular part of the blood into
pus. Inflammation is the common origin of these changes.
* Gendrin, " Hist. Anat. des Inflammations." " In the first steps towards the form-
ation of an abscess, before the parts are made solid by coagulable lymph, blood is com-
monly extravasatcd." — Macartney, op. cit, p. 24.
SUPPURATION AND ABSCESSES. 39
If, also, pus is sometimes met with simply as a foreign body in the
blood, where inflammation can have had no share in its production, and
in various parts, unaccompanied by the usual characters of inflammation,
there can be no doubt of the propriety of adopting the distinction, sug-
gested by Professor Carswell, between the mere presence of pus and sup-
puration. This view will lead us to regard the production of pus as not
restricted to the effect of any process in the capillary vessels induced by
inflammation, and to the subsequent separation of the elements of this
fluid from the blood. As for suppuration itself, this may be essentially
dependent on inflammation.*
The hypothesis of the transformation of coagulating lymph or fibrine
into pus, independently of the action of the vessels, or of any vital
influence of the inflamed parts, would not apply to many examples. By
means of it, I think that it would be impossible to account for the great
varieties observed in the qualities of pus in the different forms of inflam-
mation, and especially for its specific properties in certain diseases. The
vital influence of the vessels, their particular mode of action, must un-
doubtedly be concerned. It seems to me also, that any attempt to explain
the formation of pus from mucous membranes, on this principle, would
completely fail. The mucous secretion appears, indeed, to be readily
changed into one of a purulent kind ; no lymph is separately and primarily
effused at all ; and generally, in certain stages of the inflammation, the
discharge is really a mixture of mucus and pus together.
Amongst the arguments, in support of the doctrine that pus is formed
by an action of tbe vessels analogous to that of the process of secretion,
the following merit particular consideration. Suppuration is influenced
by many circumstances, which are well known to affect the secretions in
general. An ulcer, while pouring out a white, thick, healthy matter
happens to become suddenly irritated and inflamed ; the discharge is
immediately diminished, and degenerates into a scanty, thin, reddish
ichor. This fact agrees with the effect of inflammation in lessening and
otherwise altering the natural secretions of all organs, which happen to be
the seat of it. Who does not know that the quantity and quality of the
discharge from a wound, ulcer, or abscess, are often suddenly changed by
mental emotion, by an attack of fever, by the state of the digestive
functions, and by the diminution or increase of other secretions ? Dr.
Macartney has seen the influence of fever exemplified on the process of
suppuration, in ulcers and in acute abscesses ; and, " on one occasion,"
says he, " I knew the discharge of gonorrhoea to be entirely suppressed
during the fever from measles, and afterwards to return when the fever
abated." What experienced surgeon is unaware that the nature of
purulent discharges is frequently changed by the influence of the nervous
actions in the system, by some organic or functional disorder in other parts
of the body, with which the suppurating parts have no direct connexion
either of function or structure ? Nor is this all the argument in favour
of suppuration being a process analogous to that of secretion ; for,
whether one kind of pus is to be produced or another, often seems to
depend upon the particular constitutions of individuals, — upon pecu-
liarities in their whole organisation. Thus, in scorbutic patients, the dis-
charge is always a thin, ichorous fluid, more or less blended with blood ;
* See Carswell's " Elementary Forms of Disease," Fasciculus 5.
D 4
40 SUPPURATION AND ABSCESSES.
in scrofulous subjects, liquid albumen, with clots of fibrine floating in it,
and an admixture of soda and its muriate.
The formation of pus from the surface of the cutis, or a mucous mem-
brane, free from ulceration, may be received as a satisfactory proof that
pus may be produced without any dissolution of the solids. This fact
attracted the notice of several eminent men about the middle of the last
century, especially of Dr. W. Hunter, La Peyronie, De Haen, Quesnay,
and Morgagni. In examining the chest of a person, who had died of
empyema, or an accumulation of purulent fluid in the cavity of the pleura,
Dr. Hunter observed, that every point of this serous membrane was
entirely free from ulceration ; and La Peyronie, on opening the head of a
person who had had a long and profuse discharge of pus from the cavity
of the skull previously to death, inferred, from the trivial proportion of
brain wanting, in comparison with the immense quantity of matter which
had been voided, that the pus must have been formed by the vessels,
and not by any dissolution of the solids. But, although this doctrine
prevails extensively at the present time, and seems to rest upon a good
foundation, the question whether a partial dissolution of textures ever
accompanies suppuration is another point. The microscopical researches
of Kaltenbrunner tend to prove, not only that the blood, which passes into
the inflamed texture, but also a portion of the solids, is converted into
pus. We know, that just before purulent matter is formed in the sub-
stance of parts, there is a softening, a loosened state of their textures,
more particularly in the situation where the pus is first produced, or about
the centre of the inflammation. Perhaps a portion of the softened tex-
tures may sometimes be blended with the matter ; but then it would only
be an accidental addition, and not by any means a constant and essential
occurrence in the process of suppuration. A few years ago, there was a
girl in St. Bartholomew's Hospital for an abscess of the hip. An open-
ing having been made, a mixture of well-formed pus and of an oily fluid
was discharged, followed by a considerable lump of adipous substance.
Here, no doubt, the fatty matter was only an accidental addition, and
not mixed with the purulent matter, as an essential part of it. The
matter discharged from some abscesses of the liver, is remarked to have
a brownish colour, and hence the suspicion, that portions of that organ
may be dissolved and blended with the pus; but whether this is the fact,
or whether the matter may derive its peculiar colour from the bile, are
points not at present determined.
The following is Dr. Macartney's view of this part of the subject.
" In some abscesses (he observes), as those of the liver, spleen, and
brain, we sometimes see with the naked eye the lacerated vessels ; and,
in the first, I have observed the biliary vessels also to be broken, and the
bile mixed with the blood, contained in the cavity of the abscess."
( Op. cit. p. 24-.)
Although there is no texture (if the cuticle, the nails, and the hair be
excepted) which does not occasionally become inflamed, yet an abscess,
strictly so named, cannot form in every tissue. For instance, it cannot
take place in the dense fabric of fibrous and cartilaginous textures, nor
in that of serous membranes. When pus is formed by these tissues, it is
effused either upon their surfaces or into the cavities which they invest;
but an abscess never forms in their proper substance. On a serous
membrane also, the formation of pus is preceded by an effusion of lymph,
and, I believe, also by the development of vessels in it, — another con-
sideration in support of the doctrine, that pus is not simply a transform-
SUPPURATION AND ABSCESSES. 4-1
ation of such lymph itself, but a fluid, in the production of which the
action of the vessels is concerned.
Pus has sometimes been found in the centre of clots of blood in the
heart, or large vessels. In the museum of University College is a heart,
the right ventricle of which contained a coagulum, within which pus was
observed. According to Andral's account, such facts have been noticed,
not only in cases where, before death, there had been suppuration going
on in other parts of the body, but likewise in other instances where no
such condition could be traced. The latter consideration has of course
been adduced as an argument in favour of the doctrine, that a coagulum
has the power of forming pus within itself. With reference to this part
of the subject, it deserves attention, however, that where pus has pre-
sented itself simply as a foreign body in the blood, Professor Carswell
has invariably found suppuration coexisting in some organ or texture ;
and, in the contrary cases, as referred by M. Andral, he suspects that
the fluid was not pure pus. If such be the origin of some puriform de-
posits in the blood, they come under the head of suppuration, the pus
having found its way into the blood from the part where the suppurative
process is going on. In such cases, the pus is mostly found in the veins ;
arteries do not contain it, and, except in uterine [phlebitis, Professor
Carswell has never seen pus to any great extent in the lymphatics.*
Although suppuration is commonly preceded by inflammation, yet
some collections of purulent matter are now and then met with in the
dead subject, the existence of which was never denoted by any symptom
of inflammation during life, while, in the dead body itself, there are no
vestiges of inflammation around the purulent deposit. The colour, con-
sistence, and thickness of the textures are unchanged. The pus, as
Andral states, is interposed between their constituent particles, and this
is all that can be discovered. On the other hand, Dr. Macartney concurs
with those pathologists wholbelieve, that some degree of inflammation is
always coexistent with the process of suppuration.
The interior of an abscess appears to be both a secreting and an
absorbing surface. Thus, when the pus has been discharged, the cavity
soon becomes filled with purulent matter again ; and sometimes abscesses,
the matter of which is very palpable, completely subside and are dis-
persed. Purulent fluid is sometimes detected in the absorbent vessels in
the vicinity of abscesses. The complete dispersion of buboes, by absorp-
tion, after the formation of matter in them, is a frequent occurrence ;
and the same fact is often exemplified in chronic abscesses. Dr.
Macartney has known this happen several times in psoas abscess un-
attended with disease of the vertebrae (p. S3.); and a similar result I
have also sometimes witnessed. Such facts can only be accounted for on
the principle of the lining of an abscess being both a secreting and an
absorbing surface. When, indeed, the abscess has existed some time,
the matter is contained in what deserves, on every account, Jo be called
a cyst, the consistence and texture of which give it very much the
character of a mucous membrane. Fistulse and sinuses are invested by a
similar structure.
Purulent matter, formed in the textures of the body, generally has a
tendency to make its way to the surface, and to be ultimately discharged
in this direction. John Hunter regarded this as an established principle
* See Carswell's " Elementary Forms of Disease," Fasciculus 5.
42 SUPPURATION AND ABSCESSES.
in the animal economy, the usefulness of which in promoting the cure of
many diseases is sufficiently manifest. Abscesses will make their way
through a considerable thickness of parts to reach the skin, and this even
when merely a delicate serous membrane intervenes between the purulent
matter and the cavity of the chest or belly. In fact, such membrane,
instead of giving way under these circumstances, usually becomes
thickened and strengthened.
There is one peculiarity in the course taken by pus, which may at
first seem rather at. variauce with the principle that abscesses have a
tendency to make their way to the surface : I allude to a certain disposi-
tion in some abscesses to burst into any neighbouring cavity, or duct,
lined by a mucous membrane. Thus abscesses near the urethra fre-
quently pass into that canal ; abscesses near the rectum commonly dis-
charge themselves into that intestine; and abscesses of the liver fre-
quently burst into the duodenum or colon. In these instances, I think,
we may discern the same kind of reason for the direction which the
matter takes, when so situated, as is plainly manifested when the pus
passes towards the external surface of the body ; namely, the pus, by
passing into a contiguous canal, passage, or bowel, lined by a mucous
membrane, is often taking in reality the most direct course to find an
outlet from the system.
Nothing forms a greater impediment to the passage of matter towards
the skin, than the interposition of a dense fascia. Then the pus is apt to
spread extensively under the fascia and between the muscles, causing
sinuses, and an extent of mischief seriously interfering with a prompt
cure.
TREATMENT OF ABSCESSES.
In every instance of abscess, attended with acute inflammation, one
plain indication presents itself, viz. that of lessening the inflammation
which has given rise to the formation of matter, and which is still going
on in the surrounding parts. Suppuration is not a termination of in-
flammation, but only a modification of it ; a change, in which the in-
creased action of the vessels is altered, not stopped. Indeed, that the
parts around the abscess are often severely inflamed, is a fact completely
manifest to the eye. Whether the swelling has suppurated or not, in-
flammation is still present ; its degree may differ in different cases ; but
the reality of its existence must not be overlooked in practice. A different
view, however, must be taken of an abscess which has existed some time,
which has perhaps been burst for several days, and which may be said to
have lost its acute character. In stating, then, that the tissues imme-
diately around an abscess are more or less inflamed, I am particularly
referring to the early stages of suppuration, as a consequence of acute
or phlegmonous inflammation.
After matter has been formed, it may not always indeed be necessary to
have recourse to measures which will seriously reduce the strength of the
system ; it may not always be right to bleed the patient again in the
arm, or to restrict him to quite so low a diet as that to which he may
previously have been confined ; yet other general means, calculated to
check inflammation, and in particular mild saline purgatives, and absti-
nence from all external and internal stimuli, and from every thing likely
to quicken the circulation, or to disturb the mind or body, or the sup-
purating part itself, must still be proper. Also, while the parts around
the abscess continue painful, red, tense, and hot, and the patient is not
SUPPURATION AND ABSCESSES. 4r3
too much reduced, the application, and even the repetition, of leeches
will be beneficial.
When no chance remains of acute inflammation ending in resolution,
it is a common and a good rule to discontinue cold applications, and sub-
stitute warm ones. These last will materially soothe the pain, abate the
violence of the inflammation, and accelerate the arrival of that stage, in
which the matter will either make its way out, or be in a fit state to be
discharged. Such applications, together with leeches, mild aperient me-
dicines, a lowish diet, opium, if the suffering be great, and keeping the
part at rest, will constitute the most useful practice. By conducting
the treatment of the early stage of phlegmonous or other acute abscesses
on the principles of a moderate antiphlogistic plan, matter already
deposited may sometimes be dispersed, when, without such practice, no
chance of this success would exist.
Another general indication is to remove all sources of irritation, — every
thing that is exciting or keeping up the inflammation and suppuration.
Thus, when abscesses in the perinaeum, or about the neck of the bladder,
originate from the effects of a stricture in the urethra, or when an abscess
is produced by the irritation of a foreign body — the presence of dead
bone, &c., the removal of the exciting cause is an essential part of the
surgeon's duty.
When an abscess is completely formed, and the accumulation of matter
in the part is denoted by the fluctuation, pointing, and other circum-
stances already explained, it is a common rule in surgery to free the part
without delay from the matter collected in it. After purulent matter
has been formed, and become confined in the part, its very pressure is a
cause of severe pain, if not of an aggravation of the inflammation itself.
I can conceive, that the discharge of the contents of the abscess not only
alleviates pain by removing pressure and tension, but is also importantly
useful in putting an end to these causes of inflammation. If an abscess
be small, and making quick progress to the surface, with pointing, and a
thin state of the skin, denoting that it will soon burst, whether a puncture
be made or not, is a consideration of little importance ; for here no risk
prevails of the patient's suffering being long protracted, or of the matter
accumulating or spreading to any extent. It is not often that abscesses
from acute inflammation are dispersed ; they generally come forward, arid
every attempt to prevent it, for the most part, only retards the cure.
Perhaps we might have prevented matter from forming at all by suitable
treatment in the earlier stage of inflammation ; but, the abscess being
already formed, its absorption is what cannot usually be expected.
However, certain abscesses, rapidly formed in a very reduced state of the
constitution, and without much inflammation, generally have a greater
tendency than others to be dispersed, because, under these circumstances,
the whole absorbent system is actively at work ; and then, if the kidneys,
the mucous membrane of the bronchial tubes, or the bowojs, or the
vessels of the skin, be excited to augment their respective secretions,
the pus collected in some other part, and especially that collected in or
about absorbent glands, will sometimes be dispersed. When patients are
using mercury, kept perfectly quiet, and the integuments touched with
the nitrate of silver, buboes, containing an ounce or two of matter,
occasionally subside. Perhaps these last cases furnish the most frequent
instances of the fact under consideration. The remains of large lumbar
abscesses are also sometimes dispersed by absorption ; and the effect of
the nitrate of silver on whitlows and on scrofulous abscesses about the
44 SUPPURATION AND ABSCESSES.
neck, is also an exemplification of the possibility of bringing about the
removal of pus by the action of the absorbents.
All surgeons agree about the propriety of opening abscesses under the
following circumstances, as soon as a fluctuation can be felt, or even
sooner, if there ; be other symptoms leaving no doubt of matter being
formed and confined.
1. Abscesses arising from the extravasation of stimulating fluids in the
cellular tissue, as urine or fecal matter.
2. Abscesses from acute inflammation, situated in parts abounding in
fat and loose cellular tissue, where sinuses are apt to follow the confine-
ment of the pus. Examples: abscesses about the anus and rectum, groin,
or armpit.
3. Abscesses under fibrous expansions, dense unyielding fasciae, or
within' the sheaths of tendons. Examples: abscesses under the fascia of
the thigh, leg, or fore-arm, or under the palmar or plantar fascia ; deep-
seated whitlows.
4. Abscesses from diseased or dead bone, or within the medullary
texture or natural cavities of bones. Examples : suppuration within the
antrum, diploe of the skull, or abscesses from necrosis.
5. Abscesses, attended with any risk of the matter making its way into
the chest or the abdomen.
6. Abscesses under the sterno-cleido mastoid muscle, in the cellular
tissue separating this muscle from the deeper parts.
7. Abscesses, whose contents produce urgent and dangerous functional
disturbance by the pressure on important organs, as illustrated in ab-
scesses near the urethra, neck of the bladder, or near the trachea, larynx,
oesophagus, or about the fauces, or on the dura mater. At the request
of Dr. Campbell, I visited a child in Welbeck Street, on the point of suf-
focation from the pressure of an abscess on the trachea, which had formed
with great rapidity around the thyroid gland. The discharge of the pus
afforded prompt relief.
8. Abscesses, where the matter lies close to a bone, should be opened
without delay. Periostitis with suppuration is a case requiring such
practice; also abscesses under the occipito-frontalis muscle.
9. The generality of chronic abscesses should be opened early, because
a long while elapses before they burst of themselves, and, in the mean
time, they continue to increase, and at length frequently become formid-
able on account of their magnitude.
Abscesses are commonly opened with a cutting instrument, which is
generally preferable to caustic, as letting out the matter more expedi-
tiously, and with less pain, occasioning no loss of substance, and con-
sequently a smaller cicatrix, and forming the outlet for the pus in the
most advantageous direction, and of the exact size required. Caustic is
now and then employed, however,, for opening buboes or abscesses in the
groin, in order to make a larger and more permanent opening,, than a mere
puncture, and to destroy a portion of the[diseased skin. By this means, it is
conceived that the formation of sinuses is more likely to be hindered, the
healing of the cavity from the bottom ensured, and an undermined state of
the integuments prevented. Generally speaking, caustic is not an eligible
means of opening abscesses ; for its action is tedious, painful, productive
of loss of substance, and disfigurement, and incapable of being regulated
with any precision, so that after all a cutting instrument must sometimes
be used. A seton is now and then introduced through a chronic abscess,
either where the surgeon wishes the matter to escape gradually, or to
excite a degree of irritation in the cavity, so as to make it granulate.
SUPPURATION AND ABSCESSES. 4-5
<k
When only a small puncture is needed, a common lancet, or a sharp-
pointed narrow straight bistoury, answers very well. When a larger
opening is necessary, an abscess lancet, a double-edged bistoury, or any
sharp-pointed scalpel, may be employed. By moving the edge of one of
these instruments forward after the part has been punctured, the opening
may be made of an advantageous size, with the greatest facility and
quickness. In opening abscesses, situated near important organs, the
surgeon may make the requisite enlargement of the first opening with a
curved bistoury, guided on a director.
The best place for the puncture is generally where the fluctuation is
most perceptible, or where the pointing takes place ; for, here the skin is
thinnest: this consideration, however, is not to make us unmindful of
the advantages of a depending opening, which lets the matter readily
escape, and often removes all occasion either for the enlargement of the
first opening, or for the formation of a second in another place. This
latter, which is termed a counter opening, becomes necessary when an
abscess bursts at a point from which the matter cannot escape with
sufficient readiness.
The size of the opening should be such as will allow the matter to
escape with facility. When the matter is thick, or contains flakes of
coagulated albumen, the opening should be a free one, to enable them
and the pus to pass through it.
Another maxim is to maintain the opening until the cavity of the abscess
is so far reduced, that another accumulation of matter is not likely to
occur from the spontaneous closure of the outlet. There is sometimes an
exception to this rule, with respect to large chronic abscesses, where
Abernethy thought it safer, after discharging the matter, to heal the
puncture at once, and afterwards repeat it when the matter had collected
again. In this way, he conceived, that inflammation of the cyst of the
abscess, and severe constitutional disturbance, were most likely to be
avoided.
Sinuses are produced by the matter not readily getting to the surface,
or not having an outlet made for it with due promptitude. Here the
principal indication is to make an opening in such a situation and of such
a size as will prevent all further lodgment of pus ; for this purpose, the
first opening may be enlarged, or sometimes a counter-opening made.
Fistula are disposed to occur whenever there is something at the
bottom of, or in the position of the abscess, keeping up suppuration a
long while, or preventing the ready escape of the matter that forms;
also where the abscess is subject to continual disturbance from the action
of muscles ; hence one cause of fistulcB in ano. Fistulae arise also from
the passage of the contents of certain bowels or receptacles through the
abscess, or from its having a communication with some excretory tube :
hence lachrymal, salivary, and perinaeal fistulse.
In the treatment of fistulaa, the indications are to make a freer and more
direct opening; to remove whatever is keeping up suppuration; to de-
stroy any stricture or obstruction of an excretory tube, causing the urine
or other fluid to pass through the fistula : and, in fistulas in ano, to divide
the sphincter, the action of which being then temporarily stopped, no
longer disturbs the part and impedes the cure.
In the treatment of abscesses attended with fistulae and sinuses, or a
backwardness to heal from the pus not passing out readily enough, a
position calculated to facilitate the escape of the matter from the open-
ing, or the skilful application of a compress and bandage over the place
46 HECTIC FEVER.
where the matter collects, frequently supersedes all occasion for fresh
incisions.
When fistulas and sinuses cannot be cured by attention to the foregoing
principles, and they have become perfectly indolent, their course should
be traced with a probe or director, and laid open with a curved bistoury.
Now and then, instead of this method, a seton, or a stimulating injection
is tried, but these measures are attended with uncertainty, and by no
means in favour with the most judicious surgeons.
The old painful plan of squeezing out every drop of pus from an abscess
that has been opened, and the practice of distending the cavity with lint,
are now exploded. In fisttilae in ano, which have been divided, a piece
of soft lint may be gently interposed between the sides of the wound,
directly after the operation, in order to prevent the superficial part of
the ^incision from healing sooner than the deeper part of it, the result
of which might be, another confinement of matter, and a return of the
fistula.
As a general rule, all acute abscesses require poultices and foment-
ations, not only during their formation, but for some time longer, that is,
until they have burst or been opened, the swelling and surrounding in-
flammation have abated, and the discharge has been considerably re-
duced. Such applications are then to be discontinued, and common
dressings and a bandage applied. In proportion as the inflammatory
action subsides, the patient's diet is to be improved : and, if the discharge
continue in large quantities, or repeated abscesses form, either from some
mechanical injury, or structural or organic disease, it will be necessary to
support the patient's strength, because a hectic state now comes on, one
prominent feature of which is debility.
HECTIC FEVER.
HECTIC FEVER is essentially characterised by a frequent weak pulse,
flushings in the face, the hands, or the feet, and either profuse night sweats,
or diarrhcea. The irritation of a local injury upon a healthy constitution
produces that disordered state of it, termed the symptomatic, or sym-
pathetic inflammatory fever. This is the immediate consequence of local
irritation. The system, fatigued and debilitated by the continuance of a
disease which it cannot subdue, at length loses the power of entering
into those strong actions, which characterise the preceding description of
fever. However, exhausted as it is, it still sympathises with the local
irritation. The exciting cause is almost always some local disease, and
generally a great, if not an incurable one ; so that this fever seems to be
a feeble and hopeless struggle of a constitution about to be overpowered,
without any apparent tendency to the removal of the cause. Hectic
fever, contrasted with the sympathetic inflammatory fever, is to be re-
garded as the remote consequence of local injury or disease.
The constitutional symptoms, which attend the formation of pus in
long-continued profuse suppurations, or which arise as effects of many
obstinate and incurable local diseases, even without any suppuration, are
generally comprehended under the name of hectic fever. However, some
writers still believe, that hectic fever is in every instance connected, if
HECTIC FEVER. 47
not with the absorption, at least, with the formation of pus.* My own
observations do not allow me to entertain such an opinion. How com-
monly do we see patients suffering considerably from hectic symptoms in
cases of white swelling, diseased hip-joints, tuberculated lungs, and cur-
vature of the spine, long before any suppuration has taken place ? I
should say, that the long-continued irritation of any severe local disease
upon the constitution, whether accompanied with suppuration, or not,
generally produces hectic symptoms. Dr. T. Young informs us, that,
when he was fifteen years of age, he had himself severe hectic, and every
other symptom, usually attending the formation of pulmonary tubercles,
though they never arrived at the period of suppuration. And, in an-
other place, he correctly remarks, there are cases in which a particular
change in the state of the fluids, secreted by diseased parts, seems to
bring on hectic symptoms, as when an abscess is opened, and the pus is
exposed to the air. But, says he, this state of the fluids is not the only
cause of hectic, for it often occurs, not only without an open abscess,
but without any abscess at all. And, on the other hand, in cancerous
cases, where there is a very unhealthy suppuration, with great pain,
there is often no material hectic to the last.f It is true, at the same
time, that hectic fever is most commonly preceded by suppuration ; but
the only reason of this fact probably is, that the greater number of local
diseases, which come under the care of the surgeon, are in their advanced
stages accompanied with ulceration or abscesses. We see that certain
local diseases, which cannot be called severe, though they secrete for a
long time a great deal of purulent matter, do not bring on hectic'symp-
toms. We may keep open an issue for a year, or the urethra may dis-
charge a good deal of pus daily for an immense length of time in tedious
cases of gonorrhoea, and yet hectic fever does not arise. Suppuration
alone, unless exceedingly profuse, in which circumstance it must always
be the effect of a severe form of local disease, is not to be regarded as
the essential cause of hectic.
Neither does the hypothesis, which ascribes the cause of this fever to
the absorption of pus, appear to have a better foundation. The inside
of every abscess is both a secreting and an absorbing surface, and, by
the combined action of the arteries and lymphatics, the matter is inces-
santly undergoing changes. If then the absorption of pus were a cause
of hectic symptoms, they would accompany every abscess, without
exception. Yet experience teaches us, that this is far from being
the case : and that abscesses continue for a very long time without
the patient becoming hectic. Nay, we observe that pus, even of the
worst quality, may be absorbed without producing a single hectic
symptom ; for we daily see the matter of phlegmonous abscesses, scrofu-
lous suppurations, and venereal buboes, manifestly and entirely removed
by the absorbents, and yet no hectic symptoms are the consequence.
Hectic fever comes on at very different periods after the cgmmence-
ment of any serious local disease. This is probably owing to peculiar-
ities of constitution, or the particular structure and functions of the part,
whose disease operates as a cause. The more delicate and feeble the
patient naturally is, and the more severe and incurable the local disease,
* Thomson on Inflammation, p. 326.
| A Practical and Historical Treatise on Consumptive Diseases, 8vo. 1815, p, 6. 10.
53.
48 HECTIC FEVER.
the sooner do the hectic symptoms generally begin, and the more rapid
is their progress. Disease of the lungs will bring on hectic fever sooner
than disease of a joint.
Sometimes the first accessions of this fever are almost imperceptible ;
a slight degree of emaciation, a pulse a little quicker than ordinary, with
a trivial increase of heat, particularly after meals, being the only early
symptoms. As the fever becomes more established, the symptoms are
generally of the following kind : a frequent small pulse, which quickens
towards evening, but is always ten or twenty strokes in a minute faster
than in health ; a moist skin ; pale copious urine, with sediment ; a good
deal of debility ; the tongue seldom so much furred as in most other
fevers, its edges being of a bright red colour, and the papillae swollen and
prominent; a florid, circumscribed suffusion of the cheeks; loss of appe-
tite ; sometimes an ejection of all food from the stomach ; a great readiness
to be thrown into sweats; profuse nocturnal perspirations; frequently a
constitutional purging; repeated chills and flushes of heat; derangement
of the nervous system ; loss of sleep ; indigestion ; heartburn ; flatulence.
When, however, the biliary system is undisturbed, the digestive powers
are little impaired, and the appetite remains good to the last. In an
advanced stage, the hair falls off, and the nails become bent.
Hectic fever is more or less remittent, but never wholly intermittent.
The pulse is generally from 100 to 140 in a minute ; seldom falling below
100, even in the time of a remission, and, in some cases, never being
under 120: while, in other constitutions, the pulse of health may be so
slow that ninety strokes in a minute would be enough to indicate an ex-
acerbation.
The principal exacerbations generally occur about five in the afternoon ;
and, an increase of the febrile symptoms always follows a full meal at any
time of the day. The exacerbations, which are mostly preceded by chills,
are marked by a sensation of burning heat in the palms of the hands,
which become red and mottled, and frequently in the soles of the feet.
A circumscribed redness is seen in the cheeks, the colour of which, in
persons of a florid and delicate complexion, has also, during the remission,
a more abrupt termination than in health. Whatever may be the form
of the exacerbations in the daytime, they are generally succeeded towards
the end of the night by copious sweats. When a diarrhoea supervenes
in the latter stages of "the disease, the sweats'commonly disappear. A
reddish sediment of uric acid is mostly observable in the urine after the
sweats ; but it is absent during the hot fit, when the urine is usually pale
and limpid.
Hectic fever is divided into two kinds ; viz. one, which arises from the
absolute incurability of the local complaint ; another, which depends
upon a disease that is curable, if the patient's constitution had powers
sufficient.*
TREATMENT OF HECTIC FEVER.
The exciting cause of every disease must be removed, ere a perfect
cure can be expected. If copious and long-continued suppuration give
rise to that affection of the constitution denominated hectic fever, how
can the febrile disturbance cease while the discharge of matter continues?
If the irritation of a scrofulous joint were to excite hectic fever, we should
See Hunter's Treatise on the Blood, Inflammation, &c., p. 497.
HECTIC FEVER. 49
in vain expect to put an end to the constitutional disorder, unless the
local cause were first removed. In short, as Dr. T. Young observes, the
radical cure of symptomatic hectic fever can only be attempted by reme-
dies calculated to remove the primary disease, on which it is dependent.
When the local complaint, connected with the fever, is totally incur-
able, the diseased part must, if possible, be removed by a manual oper-
ation. But when the local disease presents the prospect of being cured,
provided the state of the constitution were improved, the surgeon is to
endeavour to accomplish the latter object. Frequently, however, the
nicest judgment is requisite to determine, how long it is safe to exert the
power of medical surgery against the influence of an obstinate local
disease on the constitution ; for, although patients in an abject state of
weakness, arising from irremediable local disease, have often been
restored to health by the removal of the morbid part, yet many have been
suffered to sink so low that no future treatment could save them.
When an incurable disease in an extremity is removed by amputation,
the hectic fever immediately begins to abate. " I have known," says
John Hunter, " a hectic pulse at 120 sink to 90 in a few hours, upon the
removal of the hectic cause ; I have known persons sleep soundly the first
night, without an opiate, who had not slept tolerably for weeks before ; I
have known cold sweats stop immediately, as well as those called colli-
quative ; I have known a purging stop immediately upon the removal of
the hectic cause, and the urine drop its sediment."
But, though the radical cure of hectic can never be effected, unless the
primary disease be cured or removed, the severity of this fever may often
be palliated, and its progress retarded, by appropriate remedies. As
weakness is one of the principal features of hectic fever, blood-letting is
never admissible ; except, perhaps, in a very few examples, where the
disorder is attended with unequivocal marks of inflammation in some vital
organ. For the same reason, purging must be avoided.
I am afraid no medicine has the direct power of communicating strength
to the human constitution; and it is more than probable that bark itself
and quinine only prove serviceable in hectic fever, by sometimes improv-
ing the tone of the digestive organs. While the patient eats and digests
well, I believe, they are never of any service.
Bark was a medicine that filled the old practitioners with a blind sort
of confidence in the worst of cases. They saw dreadful forms of disease,
accompanied with hectic symptoms, sometimes get well while their
patients were taking bark ; but they forgot the vis medicatrix naturae,
whose efficacy often conferred an undeserved reputation on this, as well
as on many other articles of the materia medica. When first I entered
the profession, it was the fashion to prescribe bark to a very great ex-
tent ; patients were sometimes literally crammed with it ; they were
frequently purged, sickened, and weakened by it, instead of being
strengthened. Nature, however, occasionally overcame both the disease
and the supposed remedy ; and the ruling prejudices were Confirmed.
The best surgeons of the present day use bark much less frequently and
copiously than their predecessors. They sometimes give it in hectic
fever, with the view of improving the appetite, but never on the supposition
that it can directly strengthen the patient in proportion to the quantity
taken into the stomach. The infusion or decoction, and the sulphate of
quinine, are the most eligible preparations. When the hectic symptoms
have somewhat abated, and general debility remains, steel medicines
frequently prove the best tonics.
50 MORTIFICATION/
The patient is much more likely to be strengthened by nourishing
food, easy of digestion, than by bark, and it should be taken frequently,
and in small quantities at a time. Residing in a pure, salubrious air, is
also a matter of great importance. In these cases, wine, gentle cordials,
and aromatic draughts, are useful ; and opium is a valuable medicine, not
only for procuring sleep and alleviating pain, but, when joined with ipe-
cacuanha, for checking the diarrhoea which is so frequently present.
Digitalis has been praised for its beneficial effects in hectic fever ; but
Dr. John Thomson, who tried it, did not find this commendation well
founded. The frequency of the pulse, says Dr. Young, may, indeed,
often be reduced by it from 120 to 50 strokes in a minute ; but it is
extremely uncertain in its operation, and frequently violent and un-
manageable in its effects : nor is it either immediately or ultimately
beneficial in simple hectic affections. For checking the nocturnal sweats,
diluted sulphuric acid is generally considered the best remedy, when the
bowels will bear it.
When the local disease is curable, if the constitution could bear it long
enough, or the health were improved, medicine may be availing ; but the
utmost, which can be expected from it in all other instances, is a tempo-
rary palliation of the symptoms. These, however, will recur, and in the
end prove fatal, unless the diseased part, the cause of the febrile dis-
order, admit of removal by a surgical operation.
MORTIFICATION.
1. BY the term mortification is signified the death of 'a part of the body,
frequently of a considerable part of it, or the conversion of such part into
a dark-coloured, black, fetid, cold insensible mass, with which the general
nervous and vascular systems no longer have any organic connexion. In
the bones, the state, corresponding to mortification of the soft parts, is
called necrosis.
Dr. Cars well justly observes, that as the descriptive characters of mor-
tification were originally drawn from the appearances which it presents
in external parts of the body, they are also employed by the pathologist,
as the means of enabling him to detect it in internal organs after death.
" It may, however, be fairly questioned," he says, " whether the appli-
cation of the term mortification has not been too restricted ; and whe-
ther parts, deprived of their vitality and separated from the living tissues,
should not be designated by the same appellation as those which, similarly
situated, differ from them only in point of colour and, perhaps, smell.
Softening of the cerebral substance, of the mucous, and frequently of the
serous membranes, constitutes a state of positive death ; " though the
softened substance, in these instances, presents neither the peculiar
colour, nor the colour of external mortified parts.*
The entire and permanent cessation of every action and function in
the part is absolutely essential to what is understood by mortification ; for
sensibility, and power of motion may be annihilated, and yet the part
affected may continue to live, as is familiarly illustrated in paralysis.
The temperature of a palsied limb is generally diminished, and so pro-
* See Carswell's " Elementary Forms of Disease," Fasciculus 7.
MORTIFICATION. 51
bably is the momentum of the blood in it ; still, the fluids pursue their
usual course in it, nutrition and absorption are carried on, and the parts
retain for an indefinite period what may be considered as an inferior
degree of vitality.
We know that it is the property of living matter to resist putrefaction;
but no sooner is life withdrawn from any of the animal textures, than
they become subject to the action of chemical affinities ; they are decom-
posed, new combinations are formed, and various fluids and different
kinds of gas evolved. Hence putrefaction, and the disagreeable smell of
parts in the state of mortification. Heat, sensibility, motion, and arterial
pulsation, may be abolished in parts for several days, but afterwards gra-
dually return. We see this fact exemplified in the effects of cold, and
in the epidemic cholera, where from the interruption of circulation arid
secretion, and from the loss of temperature in parts, one might expect
that mortification would be common, yet it is exceedingly rare. Thus,
in three hundred cases of cholera, under Magendie, in the Hotel Dieu,
there was but a single example of mortification, and, in that solitary case,
portions of the fingers were in the state resembling the form of mortifi-
cation, which will be presently described under the name of gangrcena
senilis. In another hospital at Paris, that of St. Louis, only one instance
of mortification presented itself amongst the numerous cholera patients,
the extremity of the nose being attacked. Generally, however, in cholera
patients, if they recover, cold, insensible, and destitute of arterial puls-
ation as some parts of the system may have been, such state does not
bring on mortification, and consequently it is as different from true mor-
tification as suspended animation is from real death. An erroneous
judgment may generally be avoided by observing, that, when the part is
not truly mortified, the cuticle is not detached from the cutis, and no
fetid gas is evolved.
It is correctly observed by Professor Carswell, that mortification is
much more frequently observed in those organs in which the vascular
system predominates, or in which an inordinate accumulation of blood is
readily produced, on account of their greater sensibility, and their direct
exposure to the influence of the causes of inflammation. Hence its greater "
frequency in the skin and cellular tissue, mucous membranes, and lungs,
than in other textures; and hence its comparative rarity in serous and
fibrous textures. The latter, indeed, are stated never to be found mor-
tified, unless the cellular tissue from whose vessels they derived their
nutrition has previously been diseased. In all the deeper forms of mor-
tification, the cellular tissue is destroyed to a much greater extent than
the skin and muscles; a fact to be remembered in judging of questions
concerning amputation, and especially in deciding about the part of the .
limb to which the knife should be applied.
The most common form of mortification, namely, that which is called
humid, on account of the abundance of moisture noticed in the dead
parts, has two stages. To the early stage, while some marks ofvitality yet
remain in the disordered textures, the term gangrene is particularly applied.
Gangrene^ then, is the condition of parts where mortification is not
actually formed, but forming; it is the intermediate stage between the
height of inflammation and the complete death of the parts. The latter
event receives the technical name of sphacelus, in which state the parts
are of a dark brown or black colour, always devoid of circulation,
sensibility, and natural heat, forming what are called in the language of
surgery, sloughs. The best pathologists consider the state of parts,
E 2
52 MORTIFICATION.
denoted by the term gangrene, as not absolutely incapable of recovery,
the blood sometimes resuming its wonted course again, the natural tem-
perature returning, and the healthy characters and functions of the part
being restored.
Proper as it may be to have the distinctions of gangrene and spkacelus,
the two terms are often used synonymously.
Mortification, when considered generally, and in relation to the causes
by which it is produced, or the morbid conditions of the part in which it
occurs, admits of the arrangement of its several kinds under three heads,
as suggested by Dr. Carswell.
1 . Mortification from cessation of the circulation.
2. Mortification from the violent operation of mechanical, chemical,
and physical agents.
3. Mortification from the deleterious influence of certain poisons.
Cessation of the circulation in a part may be produced, 1st, by inflam-
mation ; 2dly, by mechanical causes, which obstruct the passage of the
blood ; 3dly, by local or general debility.*
That inflammation brings on mortification by occasioning a stoppage of
the circulation in the part affected, is a fact now well ascertained. Morti-
fication is not, however, a frequent effect of common or phlegmonous
inflammation in a sound constitution, except when the exciting causes are
unusually severe, or protracted in their operation. Thus, in severe burns,
bad gun-shot injuries, violently contused and lacerated wounds, compound
and comminuted fractures, and other injuries produced by great degrees
of mechanical violence, or by means acting chemically on the body, a
portion of the hurt parts is frequently destroyed at once, and must be
thrown off in the form of a slough ; while other parts of them, not actually
killed, are yet so injured that they are seized with violent inflammation,
which quickly terminates in gangrene and sphacelus. In some other
instances, the inflammation ends in mortification on another principle,
namely, because the action of the exciting cause is protracted beyond a
certain time, as when urine is effused in the cellular tissue, and suffered
to remain in it too long ; or when a portion of intestine in a hernia con-
tinues beyond a certain period in a state of strangulation.
When mortification follows an external injury, as a bad compound
fracture, or a severe and extensive laceration of the soft parts, it is in-
variably preceded by redness, swelling, and other marks of inflammation ;
the cuticle is raised in the shape of vesications, containing a dark bloody
serum; the texture of the skin is softened, and assumes, first a dark
purplish, greenish, or livid hue, and then a blackish colour ; the cellular
tissue is destroyed ; putrefactive changes commence ; air is generated in
the disordered parts, so as to give rise to an emphysema of them, a cre-
pitation being perceived on touching them ; the exhalations from them
are exceedingly fetid, and, about the textures destroyed, there is generally
more or less humidity; — hence the term humid gangrene, by which this
form of mortification is distinguished from another, characterised by the
disorganised parts being nearly destitute of moisture, and therefore called
dry gangrene. \
* See Carswell's " Elementary Forms of Disease," Fasciculus 7.
•f The following are some of Dr. Macartney's views of this part of the suhject : —
" When the disorganisation is produced by an unrestrained effusion of serum, and con-
sists of an unravelling of the structure of the parts, instead of an essential change in
the elements of the body, it is commonly distinguished by the name of moist gangrene.
"The other kind of disorganisation, which inflamed parts occasionally suffer, is not
MORTIFICATION. 53
Humid mortification is sometimes named acute, as contrasted with
other varieties of it, which originate with little or no preceding inflam-
mation, not from external violence, but from internal causes ; and, being
slow in their progress, are called chronic.
When the humid species of mortification follows bad gun-shot injuries,
severe compound fractures, and other mechanical violence, it is sometimes
named traumatic gangrene.
Besides these principal divisions of mortification, there is another
variety? which is often suspected to be of a contagious nature, and con-
sists in a rapid and very singular demolition of the parts attacked, which
are not converted into common sloughs, but into a whitish or ash-
coloured viscid or pulpy substance, studded here and there with specks
of blood. It is a disorder that may be said to be neither like ordinary
mortification, nor common ulceration, but something between the two ;
it has received the name of hospital gangrene.
The following are the principal causes by which mortification is pro-
duced, and its most, remarkable differences and peculiarities are de-
termined.
1. Inflammation, attended with violence. Whenever inflammation pro-
duces mortification, the stagnation of the blood in the vessels appears to
have a chief share in occasioning the death of the parts.
2. Inflammation, attended with weakness ; whether in the part itself,
as exemplified in certain modifications of texture ; or in the constitution,
as after fever, long courses of mercury, and great reduction of the powers
of the system by any cause whatsoever. Great impairment of the con-
stitution, whether brought on by previous disease, as in dropsical and
scorbutic persons, or by intemperance, or by a gradual decay of the vital
powers from old age.
3. Inflammation of a specific or malignant nature, like particular forms
of erysipelas, the carbuncle, small pox pustule, malignant pustule, and
pestilential bubo.
4. Stoppage, or serious interruption of the circulation and nervous
energy in parts from other causes. A mere diminution of the nervous
energy alone will not occasion mortification, because paralytic limbs live
for an indefinite period ; but that it facilitates the occurrence cannot be
doubted ; and hence the greater risk of mortification when the principal
artery of a limb is wounded, together with a large nervous trunk, than
when wounded by itself. There are two forms of mortification arising
from the cessation of arterial circulation ; the first, depending on a spon-
taneous rupture of the internal and middle coats of a large artery, and
the obstruction of it with coagulated blood, or fibrine*; the second, on the
obliteration both of the trunks and branches of the arteries of a limb by
fibrine, or by fibrous or osseous substances from some other cause, f
The blood may be prevented from arriving at, or returning from, a part
of the body by mere mechanical causes. In both cases, as Professor
Carswell remarks, mortification is the consequence of the ^ssation of
the function of nutrition, either from a deficiency of the arterial, or the
stagnation of the venous blood.
only attended with the death of the part, but a new and peculiar arrangement of the
animal substance, totally different from that, which takes by the death of a part, in con-
sequence of mechanic injury, or its being separated from the rest of the body." Op. cit.
p. 35.
* See Turner, in Edin. Med. Chir. Trans, vokiii.
f Carswell's " Elementary Forms of Disease," Fasciculus on mortification.
E 3
54 MORTIFICATION.
Dupuytren suspected, that the cause of gangraena senilis might depend
upon acute inflammation of the principal arteries of the parts affected
(arteritis), which arteries become red, the blood coagulating in them, fol-
lowed by their obliteration, and a complete stoppage of the circulation.
This doctrine has not, however, been confirmed in this country ; and
Professor Carswell considers some of the appearances described by
Dupuytren as evidence of arteritis, rather as indications of the worst
forms of phlebitis.
With regard to ossification of arteries, as a cause of mortification,
Dupuytren looks upon such condition of the arteries and the occurrence
of gangrene as a mere coincidence. A simple ossification of arteries, he
maintains, does not materially obstruct the flow of blood through them ;
and certainly it may exist without the circulation undergoing any percep-
tible check from it. How many bodies, says he, are dissected,, in which
all the arteries of a limb are found ossified, yet without having produced
gangraena senilis ? What surgeon, he asks, in operating for aneurism,
or in amputating, has not met with arteries completely ossified, and yet
the blood passed through such vessels as freely as if they had been quite
exempt from disease ? He argues, therefore, that the obliteration of arte-
ries, the stoppage of the flow of blood through them, are the real causes of
the disease. Dr. Carswell, as already noticed, does not regard arteritis
as the cause of gangraena senilis ; but he so far coincides with Dupuytren
as to state that, in every case of gangrsena senilis which he has examined
after death, the arteries of the limb were obliterated to such an extent as
to interrupt the circulation. In five or six cases, the obstructing cause
consisted of a fibrous tissue, formed either in the coats or cavities of
arteries, and which had converted these vessels into nearly solid cords of
ligamentous consistence. This state was traced from the toes nearly
half way up the leg ; it was always connected with ossification of the
larger branches and trunks of the thigh and other parts of the body. In
two other cases, the obstruction depended on extensive ossification of
the principal arteries of the limb ; and, in several others, on fibrine
formed round calcareous spiculaa projecting into the vessels. -
5. Another common exciting cause of mortification is irritation in a
thousand forms ; friction, stimulating applications, effused urine.
6. Severe degrees of mechanical injury from external violence.
7. Applications or agents which chemically destroy the parts, as high
degrees of heat, lightning, concentrated acids, and various caustic sub-
stances.
8. Intense cold, especially when followed by the sudden exposure of
the parts to a much higher terperature. Here, strictly speaking, the
cold is only a predisposing cause, and the parts would generally not mor-
tify, if the exciting cause, namely, the sudden exposure to warmth, were
not afterwards applied.
9. Organic disease of the heart, aorta, or their valves. This doctrine,
I observe, is admitted by Dupuytren, who states, that the generality of
individuals, affected with gangrene from arteritis, have either been ad-
dicted to intemperance, or are the subjects of chronic diseases of the
heart, or of the valves of the aorta, or of the great vessels.
10. Certain deleterious articles of food, as the ergot, or cockspur-rye,
or barley mixed with the raphanus.
11. Specific contagion, as exemplified in hospital gangrene.
When any considerable portion of the body is attacked with mortifi-
cation, the whole system is thrown into a state of alarming derangement,
accompanied by a sudden and remarkable depression of all its powers.
MORTIFICATION. 55
However, if the sloughing be preceded by violent inflammation, as is
generally the case where it is the result of mechanical injuries, the first
stages of the complaint are attended with inflammatory fever ; the strong
actions of which usually cease, either before, or as soon as, the parts are
in the state of sphacelus. But the degree and kind of constitutional dis-
turbance are not alike in all cases of mortification. Much will depend
upon the extent of the disorder, the nature of the parts affected, and the
acute or chronic form of the complaint. When the sloughing is confined
to a small portion of the skin, or cellular tissue, and has arisen from
acute inflammation, the common symptoms of inflammatory fever may be
little or not at all aggravated by what has happened ; but, if the mortifi-
cation be extensive, the countenance will quickly assume a wild cadaver-
ous look, the stomach often be severely disordered, vomiting generally
occur, and the diaphragm, being affected with an irresistible spasmodic
contraction, a frequent, loud, and distressing hiccough will be produced ;
at the same time the intestinal canal will be distended with a prodigious
quantity of gas, and the surface of the body covered with cold clammy
perspirations ; the pulse will be small, rapid, and irregular, ; subsultus
tendinum will occur, and the patient, especially in bad cases of traumatic
gangrene, be soon affected with delirium or coma. In such instances,
the utmost prostration of all the powers of life is generally manifested.
When things reach this stage, the patient soon dies.
In other cases, the course of the disease is slower, and the mortifica-
tion would stop, and perhaps life be saved, if the weakening effects of a
diarrhoea could be prevented, or the state of the stomach be improved.
The hiccough, which I have noticed as a symptom or effect of mortifi-
cation, deserves particular attention, because it is often one of the chief
circumstances by which we judge of the state of internal parts threatened
with mortification. Thus, it is a symptom which every experienced sur-
seon has a well-founded dread of in strangulated hernia, where it was
formerly regarded as a sure indication of gangrenous mischief within the
hernial sac. But this precept was carried beyond the limits of truth.
I have in several instances operated upon strangulated hernia, where
hiccough was one of the symptoms, though no portion of the protruded
bowels was in a mortified state.
In chronic mortification, or dry gangrene, the constitutional symptoms
are often of a slower character, and the patient may live several weeks,
with a pulse varying from 100 to 120, with his digestive functions toler-
ably well performed, and his intellects clear, until perhaps about a week
before the fatal result. Of this fact I saw a remarkable example in a
gentleman, whom I attended with Sir Astley Cooper and Mr. Hughes of
Holborn.
All mortifications from a mechanical obstacle to the venous circulation
present one common character, viz. an excessive accumulation of blood
in the venous trunks, branches, and capillaries of the affected part.
Owing, however, to the accumulation of serosity beneath the skin, as
Dr. Carswell observes, such venous congestion is not at first perceived in
that species of mortification of the legs which succeeds to disease of the
heart. Indeed, as this able pathologist notices, the first local sign that
an obstacle exists to the return of the venous blood from the inferior ex-
tremities, is manifested by slight oedema around the ankles, which increases
and spreads throughout the cellular tissue, and the skin assumes a smooth,
pale, and waxy appearance. At length, the subcutaneous veins gradually
increase in bulk and number, coalesce in several points, and communicate
56 MORTIFICATION.
a slightly mottled aspect to the skin, of a dull red or purple colour. On
one or more of these points, where the congestion is greatest, phlyctenae,
or large bullae are formed. When these burst, the skin underneath pre-
sents a dark red, or brown colour, and is soon converted into a dirty
yellow, or ash-grey slough. The separation of the slough is sometimes
preceded by an increase of redness in the surrounding skin, evidently
inflammatory; but, in other instances, the redness is very slight, and
plainly owing to mere venous congestion, occasioned not only by disease
of the heart, but also by the pressure of the serosity accumulated in the
cellular tissue of the limb.*
When a part, or limb, is seized with mortification, the blood coagulates
in the large vessels for some distance from the boundary of the dead parts.
It is on this account that the separation of sloughs is not commonly
attended with hemorrhage, which is afterwards prevented, not only by
the clots formed in the arteries, but also by the effects of the adhesive
inflammation.
The coagulum always extends within the vessel as far as the first
important collateral branch. This fact explains a circumstance sometimes
noticed in practice, viz. when the incisions in amputation are made within
a certain distance of mortified parts, there may be little or no bleeding
from the divided vessels.
Hemorrhage, on the detachment of a slough, is certainly not a common
circumstance : it is seen, however, now and then, when the disease is a
combination of phagedenic ulceration and sloughing, and sometimes as
a consequence of gun-shot wounds, implicating the side of a considerable
artery ; but not in ordinary cases.
The prognosis is much influenced by the consideration of the nature
of the exciting causes, and whether they admit of removal, or not. If
the disorder originate from organic disease of the heart, or from extensive
ossification of the arteries, combined with some other cause (for this
alone must not, I think, be set down as adequate to the production of
mortification), it may be regarded as incurable, because we have it not
in our power to remedy those particular states of the heart and arteries
which excite the disorder.
On the other hand, if mortification arise from the presence of any kind
of irritation, pressure, or friction, which can be effectually removed, we
may entertain the hope of stopping the extension of the complaint.
Thus, if sloughing of the cellular tissue of the perineeum and scrotum
arise from the irritation of effused urine, we may, by making free in-
cisions for the discharge of such fluid, and by passing a catheter or tube
to hinder the renewal of the effusion, remove the exciting cause, and thus
stop the gangrenous mischief. However, after urine is once effused,
so irritating is it to the cellular tissue, that more or less sloughing will
generally follow, even though ample and deep incisions for its escape be
made with the utmost promptitude. Still, however, the practice is useful
in preventing the extension of the mischief. In all cases of mortification,
the prognosis depends also very materially upon the age, strength, and
constitution of the patient ; the greater or lesser importance of the part
affected ; the rapid or slow progress of the disorder ; its extent ; and the
circumstance of its proceeding, or not, from internal causes.
* See CarswelPs "Elementary Forms of Disease." This work contains the best
description of mortification of the inferior extremities from disease of the heart, ever pub-
lished.
MORTIFICATION. 57
A mortification in what is familiarly called a bad habit of body, a
constitution ill suited to bear any disease favourably, may be set down as
exceedingly dangerous ; while a limited sloughing from external violence,
in a healthy person, may not be attended with any severe or perilous
symptoms whatsoever.
On the other hand, if mortification be not of too great extent, and arise
in a healthy person from the presence of any kind of irritation, pressure,
or constriction, which can be promptly and effectually removed, there is
the fairest prospect of bringing the case to a favourable termination. If
the part attacked by mortification, however, be one whose functions are of
high importance in the animal economy, the case is attended with great
peril, even though the individual may be of an excellent constitution, and
the portion of the organ destroyed but of small extent ; a fact frequently
illustrated in strangulated hernia, attended with mortification. The rapid
progress of traumatic gangrene, so quickly and often inducing coma,
delirium, and death ; the slower, but still more certainly destructive
course of gangrcena senilis, forbidding in its early stages an operation,
on account of its intimate association with internal causes ; and the well
known severity and disastrous consequences of hospital gangrene, must
always be remembered in giving our judgment concerning the issue of
this disorder. Great prostration of strength, a low, rapid, faltering
pulse ; a stomach which can retain neither food nor medicine ; and
an attack of diarrhoea, especially when joined with coma or delirium, are
symptoms leaving little or no hope of recovery.
In the treatment of every species of mortification, there are three
principal indications. 1. To endeavour to stop its progress. 2. To pro-
mote the separation of the mortified from the living parts. 3. To heal
the ulcer resulting from the loss of substance, or, where an operation has
been deemed necessary for the fulfilment of the second indication, to
cure the wound thus produced.
1. With respect [to the first of these indications, it naturally leads to
the object of ascertaining and removing the original cause of the dis-
order : I mean that cause which first gave rise to the intense inflamma-
tion of the parts, and which, perhaps, may still continue to operate. This
is a common principle, which should be observed here, as well as in all
other parts of surgery. Sometimes we have it in our power to remove
the exciting cause altogether ; as, when we let out by suitable incisions,
extravasated urine, and hinder its further effusion by the judicious em-
ployment of the catheter ; or when we discharge from the cellular tissue
the fluid, which occasions a prodigious distension of that texture in the
severe forms of phlegmonous erysipelas ; or when we take away extra-
neous substances, splinters of bone, and remove and diminish irritation
in a variety of forms. Frequently also sloughing is produced and kept
up by the employment of hurtful remedies, and then the change to a
better practice is the same thing as removing the cause of the disease in
other instances, and has an equally beneficial effect. In general, how-
ever, when gangrene arrises from intense inflammation, the exciting cause
is only momentary : it has already ceased ; but the injury, which the
parts have sustained from it, is of a more lasting nature, and must be
followed by a high degree of inflammation, and sloughing to a greater or
lesser extent.
There can be no doubt, that the extent of mortification may be con-
siderably influenced by the mode of treatment, adopted during its inci-
pient stage, termed gangrene. When the disorder is the effect of
58 MORTIFICATION.
inflammation, we are bound to believe, nay, we see, that the living
circumference is inflamed in the highest degree. Reason and observation,
therefore, seem both to concur with respect to the general propriety of
antiphlogistic measures in this state and species of mortification, especially
leeching, saline aperient medicines, and calomel with opium. The plan,
however, is to be pursued with moderation and caution : it is right, so
long as inflammatory fever and acute local inflammation are co-existent
with mortification ; but, even under these circumstances, evacuations
must not be resorted to with the same freedom and frequency, as in
examples of inflammation unaccompanied with mortification. In particu-
lar, venesection is to be ventured upon only in young, robust, plethoric
subjects. The necessity of this kind of circumspection depends upon the
fact, that, whenever a considerable portion of the body mortifies, the
constitution immediately feels the shock in every part of it. There is
hardly any interval between the genuine inflammatory fever, in which
the action of the sanguiferous seems to proceed even with preternatural
force, and another state of the constitution,, in which the predominating
symptoms are prostration of strength, and violent agitation of the whole
nervous system. In fact, more or less debility always rapidly supervenes ;
and if the patient be further lowered by the lancet, purgatives, and too
spare a regimen, his condition will be rendered hopeless.
Some years ago, the treatment of gangrene and sphacelus was often
conducted upon principles which had little foundation. It was presumed,
that cinchona had a specific virtue in stopping and resisting the progress
of the disorder. To this medicine, diluted sulphuric acid was added,
when a general tendency to putrefaction was suspected in the system ;
or cordials and aromatics, as wine, brandy, musk, ammonia, confectio
aromatica, &c., when there was great prostration of strength ; and opium,
when severe nervous symptoms, and extreme pain were experienced.
Musk and ammonia were recommended many years ago by Mr. White,
of Manchester, in examples attended with spasmodic twitches. My
friend, Dr. Gibson, Professor of Surgery in the University of Penn-
sylvania, gives his testimony in favour of the latter medicine., and also
speaks favourably of the effects in some cases of camphor, with or with-
out opium, small doses of the chloride of mercury, and of liquor ammonias
acetatis combined with laudanum.*
The opinion, respecting the specific power of bark for the stoppage of
mortification, is rejected by every modern surgeon of judgment and ex-
perience ; without the denial, however, that it is a medicine, which, in par-
ticular states of the disorder, may be administered with advantage. Even
then the benefit never arises from the specific power, which it was for-
merly supposed to have, of stopping mortification, but from its being an
eligible bitter, by which the tone of the digestive organs may sometimes
be improved. It is not long since it was the custom to prescribe it in
powder, or substance (as it was termed), and in as large quantities as the
patient could be prevailed upon to swallow. But no sooner was it
clearly ascertained that the utility of bark did not really depend upon its
specific virtue, than the plan of cramming patients with it was universally
abandoned ; and it is now only administered in such moderate and rea-
sonable doses, as are not likely to disorder the stomach and bowels, and
defeat the very purpose for which alone it can ever be justly recom-
* See " Institutes and Practice of Surgery," vol. i. p. 28. ed. 5. Philadelphia, 1838.
MORTIFICATION. 59
mehded. It is not, however, in the early stage of mortification, com-
bined with acute inflammation, that bark, prescribed in any way, can be
of service.
When mortification happens from an external local injury in a sound
constitution ; when it no .longer spreads, and the living margin appears
red for a small distance from the line of separation, bark is clearly un-
necessary.
Mortification, according to its particular "nature, causes, and circum-
stances, may be attended either with sympathetic inflammatory fever,
or with another fever, which is characterised by extreme debility, and is
either like typhus, or the disorder sometimes described under the name
of sympathetic irritative fever.
The first fever takes place when mortification arises from external
causes ^in a healthy constitution. Here bark is usually hurtful. The
other state of the system may undoubtedly require it, though, if the fever
be what is called irritative, [and great excitement of the nervous system,
delirium, picking of the bed-clothes, subsultus tendinum, &c., prevail,
anodynes, antispasmodics, blisters, and local treatment, will do a thousand
times more real good, if any chances of life still remain, than bark in any
dose or formula whatever.
In condemning this medicine, however, for certain states of mortifica-
tion, I am far from wishing the reader to suppose, that even in the pro-
gress of these very identical cases it may not sometimes become neces-
sary, although not at all indicated at an earlier period. Every experienced
surgeon knows, that the natural change of circumstances in the course of
numerous diseases renders the exhibition of some medicines absolutely
indispensable, which, had they been given at -first, would have had the
most pernicious effects. When the inflammation surrounding the spha-
celus has abated, the patient is low, the appetite bad, and the kind of
fever and state of the chylopoietic viscera are not such as to prohibit
bark, it should be administered with aromatic confection, wine, fer-
mented liquors, and a light nutritious diet. The sulphate of quinine
should also not be forgotten, as a very convenient preparation, which the
stomach and bowels will generally bear well. If delirium occur, cam-
phor or musk ought to be prescribed, and a blister applied to the head.
In many of these cases, also, the patients would be carried off by diarrhoea,
were not the surgeon particularly attentive to the diet, and prompt in the
judicious administration of opium, the mistura cretae, &c. Indeed, with
respect to opium, and the preparations of it, the muriate and acetate of
morphia, they are perhaps the most valuable of all the internal remedies,
employed in the treatment of mortification, and should be employed in
every stage and form of the complaint, attended either with severe pain,
or spasmodic or nervous symptoms, and they ought not to be given
merely at night, but every four or six hours, so as to keep the constitution
under their influence.
With regard to local applications, for cases of mortification, attended
with acute inflammation, experience appears to decide in favour of com-
mon emollient linseed poultices and fomentations. When the gangrenous
part is turned into a darkish, or black, fibrous, insensible mass, it is,
indeed, of little consequence what is applied to it, as the living circum-
ference claims almost exclusive attention. Both during the extension of
the disorder, and afterwards, when the sphacelation has stopped, a simple
linseed poultice, or one containing a proportion of finely powdered re-
cently burnt charcoal, is as good an application as can be employed.
60 MORTIFICATION.
Some surgeons are partial to fermenting poultices, and with these not
much fault can be found ; for, though perhaps no particular good can be
strictly imputed to their supposed antiseptic quality, the carbonic acid
gas produced by them is not stimulating enough, nor sufficiently in con-
tact with the living flesh, to counteract their good effects as emollient
applications. They have always appeared to me better calculated for
mortification, unattended with intense inflammation, than for the parti-
cular cases which we are here considering.
As I have repeatedly said, it matters not what is put upon such parts
as are actually dead, and, if the surgeon choose, he may lay upon them
turpentine, spirituous balsams, camphorated spirit, a solution of the
chloruret of soda, or lime, the pyroligneous acid, a lotion of creosote, or
any thing else which he may prefer, with the view of checking the fetor
and putrefaction. But, except in some instances of phagedaena gangra3nosa,
where it is necessary to destroy the textures directly connected with the
parts affected, it is of high importance that the living flesh around and
underneath a slough be not injured and irritated by any sort of applica-
tions. No one, who has sound ideas of the nature of the animal economy,
would talk of invigorating the parts with spirits and balsams, in order to
avert mortification. Yet, once so prevalent was this doctrine, that it was
a frequent practice to cut and scarify the parts for the express purpose
of letting such applications have free ingress to the subjacent living
textures.
Incisions and scarifications in gangrenous parts can do no good, if they
are merely made in the sloughs j and, if they extend through the dead to
the living flesh, they are not only likely to effect no rational purpose, but
must be productive of pain, hemorrhage, and frequently of fresh slough-
ing. When, however, a slough is large, and a part of it loose, the cutting
away such portion is commendable on the principle of lessening the fetor.
Were also much sanies to lodge under a slough, a careful incision through
the dead part might be useful in affording an exit to the matter. But
this proceeding can never be justifiable when the living parts are to be
irritated or wounded.
2. The second general indication is to promote the separation of the
mortified from the living parts.
Although a slough may be scratched, or cut, without pain or harm to
the patient, it cannot be pulled away immediately after its formation,
without pain, hemorrhage, and even a risk of renewing the spreading of
mortification. The dead part is yet adherent to the living flesh, and can-
not be prudently taken away before the absorbents have removed the
particles of matter, which compose the uniting medium. The separation
of dead from living parts is a vital process, not explicable on physical
principles, nor by the laws of dead matter. When it is about to take
place, a red line, varying in breadth in different cases, and said to be pro-
duced by the adhesive inflammation, usually appears on the living sur-
face, contiguous to the dead. The adhesive inflammation, in fact, seems
to be the means which nature employs for stopping the progress of mor-
tification, and preparing the living surface for the separation which is
about to be produced. By it, she fills the cavities of the cellular
tissue with coagulating lymph, assists in closing the extremities of the
blood-vessels, and establishes the commencement of those operations by
which granulations are to be formed, and the loss of substance repaired.
Soon after the formation of the red line of separation, slight solutions of
continuity may generally be seen, beginning at various points, and re-
MORTIFICATION. 61
sembling very minute ulcers, which, uniting together, form a hollow line,
or chink, which extends all round between the dead and living parts.
This loss of substance, which is at first superficial, generally proceeds
more and more deeply, till the separation of the sloughs is entirely
affected. In this process, which does not materially differ from that of
common ulceration, the absorbent vessels are actively engaged, and it is
by them that the particles which form the link between the dead and
living flesh are removed. From the moment that the separation com-
mences, a discharge, at first of a serous, and afterwards of a puriform ap-
pearance, begins to take place from the line of detachment, and it becomes
more and more abundant in proportion as the falling off of the slough
exposes the subjacent jaw granulating surface. In young subjects, and
in vigorous constitutions, the separation of the sloughs is accomplished
with much more celerity than in the old and feeble. The texture and
situation of the parts affected make also a considerable difference in this
respect, and, generally speaking, the harder and less vascular they are,
and the more remote from the source of the circulation, the longer they
are in throwing off their sloughs.
When a part, or limb, is seized with mortification, the blood coagulates
in the large vessels, for some distance from the line which bounds the
sphacelation. Hence, the separation of the sloughs is not usually attended
with hemorrhage, and the security is generally still further increased by
the effects of the adhesive inflammation already described. The cause
of the formation of the coagulum in the vessels, as Mr. Hodgson remarks,
is by no means evident, although it is probable that the condition of a
mortified vessel may interrupt the passage of the blood through it, and,
consequently, a coagulum is formed, extending to the next important
collateral branch. It is also the coagulation of the blood in the arteries,
near a sphacelated part, which accounts for there being sometimes no
hemorrhage of importance, nor any occasion for ligatures, when ampu-
tation is performed a little above the line of separation.*
With the exception of cases in which amputation of the limb is urgently
indicated, the separation of a slough should generally be left as much as
possible to nature. All that the surgeon can usefully do, is to take away
every portion of the slough as soon as it is entirely separated from the
living textures. An opposite line of conduct, as I have already stated,
would often excite unnecessary irritation, pain, and hemorrhage, and even
renew the spreading of the disorder. A trivial degree of violence will
sometimes bring on the latter evil, nor can we be surprised at it, when we
advert to the deranged state of the whole constitution, always resulting
from the effects of an extensive mortification. If it be at all practicable
to expedite the process by which a slough is thrown off, the good is to be
derived rather from general than from local treatment. By internal
medicines, a judicious regimen and diet, and especially by attention to
ventilation and cleanliness, the general health may be improved, and, in
this manner, the system enabled to throw off the sloughs, or <fead parts,
with greater expedition ; but until they are actually loose, we cannot in-
terfere for the purpose of taking them away. I know of no applications,
which have any particular virtue in quickening their detachment, and the
more simple they are the better. In fact, none are better than common
linseed poultices, with or without a proportion of powdered charcoal or
* See Petit in Mem. de 1'Acad. Royale des Sciences, an. 1732. Thomson's Lectures,
p. 552., and Hodgson on Diseases of Arteries and. Veins, p. 13. 8vo. Lond.1815.
62 MORTIFICATION.
some of the solution of the chloruret of soda : or, if the surgeon like, he
may have recourse to the fermenting cataplasm already specified. Much
stress has been laid upon the usefulness of antiseptics and tonics as local
applications ; as a solution of the chloruret of soda in water, or camphor
mixture, turpentine, camphorated spirit, &c. Bark in a variety of shapes
has also been used for covering the parts affected. So far as my ex-
perience goes, 1 should say, that the cases, in which the chlorides or
chlorurets of soda and lime, carrot and fermenting poultices, and various
acid or spirituous or other lotions, prove most useful, are those in which
mortification presents itself in the characters of phagedaena and hospital
gangrene. In these instances, concentrated nitric acid and the liquor
arsenicalis, mixed with an equal quantity of distilled water, have obtained
high repute. It is also in such cases that the actual cautery is still
sometimes made use of abroad*
3. The third general indication is to heal the ulcer, or, in the event of
amputation, the wound resulting from the loss of substance. But, on this
topic, I need not dwell at present, as the principles, on which this indi-
cation is to be fulfilled, are explained in the respective articles on wounds,
ulcers, and amputation.
GANGRJENA SENIUS.
This is generally an example of chronic mortification, and also of dry
gangrene, though, in respect to the rate of its progress, and the quantity
of fluid about the destroyed textures, there is considerable difference in
different cases. Thus some proceed to their fatal termination in a week,
as happened in an instance which I lately attended with Mr. Baker of
Staines ; while others do not terminate in this manner till several weeks
have elapsed, as was the case with a gentleman in Gray's Inn, whom I
attended with Mr. Hughes of Holborn. In Mrs. W. of Guildford Street,
who was a patient of mine, the disorder continued more than nine months
before she fell a victim to it, and then it had not destroyed the whole of
the foot. The disorder is always, however, completely different from
that which follows the ordinary forms of acute inflammation, coming on
more insidiously, and at first with less threatening symptoms, though, if
possible, tending with still greater certainty to a fatal result than any
other species of mortification. The first change usually noticed is a
dark red purple, or almost black, discolouration of the fleshy or under
portion of one of the toes, without, in general, any previous swelling, in-
crease of temperature, or sensibility of the part. I have known the
disorder begin on other parts of the foot : thus, in Mrs. W,, above referred
to, it commenced on the heel. Some few examples of its attacking the
upper extremity have come under my notice. At this present time, there
is an old woman in University College Hospital under my care, the ends
of several of whose fingers were attacked; the disorder has stopped, and
she is now recovering, with the loss of the third phalanx of one of the
fingers. I should mention, that she had also some sloughing of the inte-
guments of the foot. Dupuytren gives one instance of its commence-
ment in the fingers. In the winter of 1 834-35, a woman, aged seventy-five,
was in our hospital, one of whose arms perished nearly up to the axilla,
from this species of gangrene, and, nature having separated the dead from
the living parts down to the bone, this was divided with a saw, and the
woman recovered.
Frequently while the skin about the toes is of a deep purple colour, it
is of a lighter hue higher up the limb, and still higher up only mottled or
MORTIFICATION. 63
marbled. Here the parts begin to give a sensation to the hand of great
coldness, which increases the nearer the part examined is to the foot.
Still the patient retains the power of moving the ankle ; a circumstance,
explicable by the fact, that most of the muscles of the foot ascend nearly
as high as the knee, to which point the disease has not extended. If the
femoral artery be now examined with the fingers, its pulsations will be
felt to be very feeble, or the vessel converted into a hard, almost incom-
pressible cord.
Gangrsena senilis begins at the greatest distance from the source of the
circulation, almost always with a mere discolouration or spot on the side
or inferior part of one of the small toes, soon followed by an uneasi-
ness, numbness, and an extraordinary fall of temperature in the foot.
Although the disease is usually regarded as dry gangrene, the cuticle
rises up here and there in the form of vesications, filled with a dark very
fetid serosity, and on their bursting, the black mortified cutis may be seen
at the bottom of them. When the disease creeps up the limb very
slowly, the swelling of the parts about to perish may be very trivial ; but,
in other examples, there may be inflammatory redness, accompanied by
heat, pain, and tumefaction, and the upper part of the leg may be of
twice its natural size. According to Dr. Carswell, the bulk of the affected
parts depends chiefly on the situation and extent of the obstacle to the
circulation. If the obstacle be extensive, the quantity of blood admitted
to the foot is too small to give rise to congestion ; and this not taking
place, there is little or no effusion of serosity. Hence there is no increase
of bulk in mortification from this cause ; and, if the obstruction has been
effected slowly, the foot and leg may even be atrophiated, previously to
their being attacked with mortification, the dead parts being shrunk, dry,
and indurated.*
Sometimes the disease in its early stage is attended with great consti-
tutional disturbance, intolerable pain, constant restlessness, a small,
frequent, irregular pulse, hiccough, vomiting, twitches of the muscles,
and coma or delirium. Under such circumstances the patient usually
dies by the time the mortification has reached the ankle, or even earlier,
that is, in eight or ten days. In other examples, however, the patient at
first suffers but little constitutional derangement, and is surprised to hear
that a small discolouration of one of his toes, and a degree of uneasiness
in the foot, should be a case of considerable danger. This was singularly
illustrated in the gentleman in Gray's Inn, whom I attended in the sum-
mer of 1828, with Sir Astley Cooper and Mr. Hughes. The case was
also remarkable as presenting an instance of the disorder in both legs at
once. But notwithstanding this double attack, the constitutional dis-
turbance advanced so slowly, that the patient used to eat a mutton chop
for dinner every day, and to digest very well until within three days of
his death, which did not take place till nearly five weeks after the com-
mencement of the sloughing. The pulse, during the greater part of this time
was from 100 to 110, though occasionally it rose to 130, and tht intellects
were clear until the final stage. In this interesting case, two circumstances
were particularly remarked : — 1st. That the disease never spread, with-
out each extension of it being preceded by violent burning pain in the
part about to be destroyed, so that a correct judgment could always be
formed beforehand from the degree of suffering, whether the next ex-
tension of the disorder would be considerable or not. 2dly. That the
* See Dr. Carswell's « Illustrations of the Elementary Forms of Disease," Fasciculus 7.
64 MORTIFICATION.
process of mortification, and its appearances in one leg, were totally dif-
ferent from those presented in the other. In the left, the disorder began
on the inside of one of the little toes ; in the right, a general diminution
in the temperature of the foot and leg came on very gradually, with
scarcely any discolouration of the skin, any detachment of the cuticle, or
any particular change in the appearance of the toes. The coldness was
followed by a total loss of sensibility in the parts, and the cessation of the
circulation, and every other action in them. The skin was in this leg
shrunk, dried or mummified, but it was little changed in colour. In
University College Hospital, there is at this present time (June 1839), a
woman, aged about forty-five, both of whose feet have been destroyed by
gangraena senilis. In one limb, the parts are separating ; and, in the
other, the line of demarcation is beginning to show itself, but, from the
feeble state of the pulse, occasional delirium, and impairment of the func-
tions of the stomach, I judge that the patient cannot live many days.*
With respect to the loss of temperature in parts about to be destroyed
by gangraena senilis, Dupuytren states, that he has carefully noticed with
the thermometer, that such parts, before they perish, actually become
much colder than any of the surrounding media. It seerns to be well as-
certained, that this is a species of mortification arising from obstruction
in the arterial system. The results of Dr. Carswell's investigations con-
firm this view ; for, though he does not coincide with Dupuytren in re-
ferring the cause of such obstruction to arteritis, he has found the arteries
more or less blocked up with fibrine or other deposits. It is not perhaps
completely settled, how far an ossified state of the arteries should be set
down as a cause. In elderly persons, some of these vessels are always
ossified ; yet, in the parts to which they are distributed, nutrition appears
to go on tolerably well, and the textures usually escape gangrene. It
may be argued, therefore, that as one form of chronic mortification is
mostly met with in persons of advanced age, in whom there is generally
some ossification of the arterial system, whether mortification happen or
not, such ossification cannot be the cause of mortification, when this does
happen, but only an accidental complication or coincidence. I believe,
however, that it must be regarded at all events as a predisposing cause,
and that when joined with organic disease of the heart, an impaired con-
stitution or derangement of the health, it must promote the occurrence
of gangrene. One can hardly suppose that an artery, when converted
into a rigid bony tube, can be so well calculated for carrying on the cir-
culation, as it is in its naturally elastic and contractile state. Yet, with-
out some further cause of impediment to the blood's motion, no morti-
fication would arise.
Dupuytren believed, that this chronic form of mortification is owing
neither to debility nor impairment of constitution, nor to ossification of
arteries, but to arteritis, or an inflammation of the inner coat of the prin-
cipal arteries leading to the parts affected, whence follow coagulation of
* This prognosis was verified. In the post mortem examination, ossification and
thickening of the semilunar valves of the aorta were observed, and tubercular ulceration
of the ccecum and beginning of the colon. The femoral, tibial, and peroneal arteries,
and the dorsal artery of the foot, in each limb were slit up, but no obstruction of them
with any kind of substance existed. As no fine injection was thrown into the vessels,
it was impossible to offer an opinion respecting the actual state of the minute vessels,
which, according to Cruveilhier, are essentially blocked up and obstructed, whatever may
be the state of the arterial trunks, which he represents as an accidental circumstance,
and varying iu different cases.
MORTIFICATION. 65
the blood in them, and their obstruction with coagulating lymph, so that
if amputation be performed, no ligatures are required. Old age and
debility, he maintains, are not the cause, because he has seen the same
description of mortification in a child ten years of age, in a young woman
of twenty-two, and in a person of forty. At the same time, he acknow-
ledges that hard drinking, and disease of the valves of the heart, are
generally concerned as exciting causes of arteritis, and that sucli arteritis
may take place in the diseased arteries of old subjects, as well as in the
sound ones of young persons. With respect to these points, if they were
all admitted, they do not seem to me to invalidate the great truths, that
this species of mortification is rare in young individuals, and that it
occurs chiefly in persons above fifty, whose constitutions have been im-
paired by time and mode of living, and whose arterial system is in a state
demonstrating an obstructed circulation in the limb.
Dupuytren declares, that by means of venesection and opium, he has
saved two thirds, or even three fourths, of his patients ; whereas, the
disease, as it is commonly treated in this country, is generally fatal, the
number of persons living till its destructive process stops, and the dead
parts are separated by nature, or the amputating knife, not exceeding,
perhaps, one in twenty. Were Dupuytren's practice to be attended with
so much greater success than our own, doubtless it should be immediately
substituted for the latter, little as our confidence might be in his doctrine
of arteritis being the cause of the disease. I fear, however, that he has
either exaggerated his success, or frequently mistaken the kind of morti-
fication in which he employed the lancet with advantage. When we find
him describing this mortification as common in young persons, there
seems to be indeed some reason for the latter suspicion.
I have heard of the practice being tried in one or two examples in
London, but without success. Dr. Gibson, of Philadelphia, relates the
particulars of a case under Dr. Carmichael, of Virginia, in which both
feet were attacked with dry gangrene, and Dupuytren's plan was tried.
" The first bleeding to faintness afforded great relief from the pain, as it
did on every trial, which was repeated during the disease not less fre-
quently than eight or ten times. Purgatives assisted, as usual, in the
antiphlogistic treatment, and the most agreeable local adjuvant was snow
or iced water." The blood was buffy and cupped. Opium was sparingly
used. About the sixth week, Dr. Carmichael removed one of the legs
below the knee, and, upon inspection of the artery, it was found so filled
with granulated, albuminous, or fibrous matter, that no ligature was ap-
plied, or tourniquet used, nor was there the least hemorrhage. In the
tenth week, the other limb was amputated. The patient gradually im-
proved, and became convalescent, but died shortly afterwards.*
In gangrasna senilis, opium is a medicine of much greater value than
bark. This was a truth particularly insisted upon by Mr. Pott, who,
however, rather overrated the power of opium, which he represents
almost as a specific or sure means of stopping the extensfcm of the
disease. I believe it to be the most useful of all medicines in this ex-
ample of mortification, but by no means endued with so much power
over the complaint as Mr. Pott's statements might lead a young surgeon
to imagine. In fact, when we advert to the cause of the disorder, what
medicine can be expected to have great power over it ? Dr. Gibson has
tried opium both in small and very large doses, without finding the ex-
* See Gibson's « Institutes and Practice of Surgery," vol. i. p. 36. «*• 5.
G6 MORTIFICATION.
pectations held out by Pott realised in a single instance. In one
example, he began with moderate doses, and gradually increased them,
till the patient took 500 drops of laudanum every twelve hours; yet little
relief was experienced, and the case had a fatal termination. When
opium is prescribed, the patient should be kept continually under its in-
fluence, and the dose therefore be repeated every four or six hours,
either in the common forms, or those of the acetate or muriate of
morphia.
Besides opium, other medicines have been extensively tried — as sul-
phate'of quinine, diluted sulphuric acid, hyosciamus, camphor, musk,
aether, the subcarbonate of ammonia, wine, and various cordials.
The best topical applications are those which are not productive of
irritation ; hence, emollient poultices and fomentations are generally pre-
ferred. Surgeons often try the solution of the chloride of soda or lime ;
but, the application is merely commendable as a disinfecting agent, and not
on the ground of its having any specific virtue in stopping mortification.
The chlorides of soda and lime I have seen fairly and freely employed ;
but what experience revealed will only justify this report of them : they
lessen the disagreeable effluvia, but they neither check the mortification,
nor afford ease to the patient.
About a year and a half ago, an old man was under my care in Uni-
versity College Hospital, with gangreena senilis of one of the toes, in a
recent stage. I had then just learned from Sir Benjamin Brodie that in
Greenwich Hospital, where this disease is common amongst the aged
pensioners, the practice had been followed of covering the whole limb
with lamb's wool, in order to maintain its temperature, and this some-
times with a beneficial result. I tried the method in the case here re-
ferred to, and the man recovered, with the loss of part of the toe.
As this form of mortification proceeds from internal causes, it is one to
which the ancient rule applies, that amputation ought not to be under-
taken until the red line of demarcation is completely formed, and the
sloughing has decidedly stopped.
MORTIFICATION FROM DEBILITY.
Besides the foregoing species of mortification, there are others which
are preceded by a state of local and general debility, where (to use the
words of Professor Carswell) the physiological and physical properties
of the fluids and solids are so modified, that every function of the
economy is slowly, ineffectually, or imperfectly performed. Such is the
sloughing of the gums, cheeks, palate, and fauces, in persons whose
systems are universally deranged by the abuse of mercury, and such is
mortification coming on as the effect of scorbutus, typhoid fevers, and the
disease termed cancrum oris. In mortification from debility, a local ac-
cumulation of blood generally constitutes the first perceptible change in
the part. This may take place from the part being subjected to pres-
sure, slight friction, puncture, or other similar causes. " In some of
these cases the blood accumulates, partly from the influence of gravita-
tion and partly from compression of the veins."
The treatment of all these descriptions of mortification requires the
removal of the predisposing and exciting causes. The constitution must
be strengthened, and its derangement, whatever that may be, rectified,
and the pressure, friction, or other irritation, acting as the exciting cause
of mortification, removed if practicable.
MORTIFICATION. 67
MORTIFICATION FROM INJURY OF LARGE ARTERIES AND NERVES.
In the arrangement of the arterial system, nature seems as if she had
foreseen the danger that would arise from an interruption of the supply
of blood, and she has, therefore, so multiplied the reciprocal communi-
cations or inosculations, in all the different orders or branches of this
system of vessels, that the largest trunks are tied almost daily by the
enterprising hand of the modern surgeon, and yet, if there be not other
causes concerned, this single one is rarely followed by mortification. She
appears, however, not to have extended in an equal degree a similar
cautious and provident arrangement to the nerves. The destruction of a
principal trunk, in this latter system, is invariably followed by paralysis ;
and, when this circumstance is coupled with the division or ligature of
the principal artery of the same limb or part to which the branches of
that nerve are distributed, the chances of mortification are much in-
creased. There are, however, some facts recorded, which prove, that
the communications of some of the smaller nerves are sufficiently direct
to qualify them to become, in point of function, substitutes for each
other.
I have said, that the division or ligature of the main artery of a limb
and of the principal nerve, together, may occasion mortification. Cases
are related in which the consequences were only a paralysis and wasting
of the member ; but Delpech was not aware of any instances of this kind,
where the lower extremity was the part concerned ; and, with respect to
the arm, which is not supplied by a single nerve, hardly any sort of
accident can injure the whole of the brachial plexus ; the median being
the nerve, which is commonly wounded, or tied, with the artery. He
observes, however, that notwithstanding the advantage of several nerves,
it has almost always happened, that when the nerve accompanying the
axillary artery has been included in a ligature with it, .the limb has
mortified.*
It is true, that, in many of these cases, we are also to take into the
account the share which a large, extensive wound of the soft parts, or
their contusion, laceration, &c. have in the production of gangrene. We
rarely or never see a case, in which the injury simply consists in the
division or ligature of the main artery and one of the principal nerves
of a limb, unaccompanied either with great additional injury, much weak-
ness from the profuse and sudden hemorrhage, the irritation of a pre-
vious operation, the injection of the cellular tissue with blood, or a
diseased state of the member, any of which conditions may be such as
to have considerable influence in bringing on gangrene. On the whole,
perhaps, we are not yet authorised to infer, that the mere interruption of
the circulation through the main artery of a limb, and the simultaneous
stoppage of the nervous influence derived from one of the principal
nerves of the member, would generally occasion mortification, if there
were no other additional violence, nor injury, existing in the^art or con-
stitution.f Whatever may be the result of future experiments upon
* Precis des Maladies repute'es Chirurgicales, t. i. p. 98.
t Some years ago I was present with Mr. G. Young at an operation, in w"I£f
Mr. Lawrence divided by a circular incision, not only the principal arteries and nerve^
the finger, but every fibre of the part, with the exception of the tendons and bon^'Id onj*
contrary to all expectation, the blood still gushed profusely from vessels, wluci^o ^ fc
receive their supply of blood through the medium of such ramifications asp* •
F 2
68 MORTIFICATION.
this point, no doubt, I think, can be entertained of the fact, that when
the stoppage of the circulation through the main artery of a limb is con-
joined with loss of the nervous influence in the same member, there is
always a much greater risk of mortification, than if the case were simply
an interruption of the flow of blood through the vessel. Indeed, so
great is the success which now attends operations on aneurism, that I
might perhaps assert, with perfect accuracy, that gangrene never arises
solely from the ligature of an arterial trunk unless the patient be of ad-
vanced age; the circulation languid from previous debility; ma y of the
collateral branches destroyed or injured ; or some other important cause
co-operate in producing the evil.
When mortification follows the ligature, or division, of a principal
artery and nerve, the part is from the first cold, insensible, heavy,
benumbed, and motionless; its natural heat is permanently lost; the
pulsation of its arteries cannot be felt ; the cuticle separates ; the skin
becomes brown and shrivelled; and fetid exhalations soon leave no doubt
of the nature of the mischief. This species of gangrene is usually very
extensive, being a sphacelus affecting the whole of the limb. It is
somewhat less dangerous when it comes on later, and begins at the ex-
tremity of the limb ; under which circumstances, its progress is ordi-
narily slower, and its effects sometimes restricted to a partial destruction
of the member.
When once this kind of mortification has arisen, every means which it
is in the power of the surgeon to adopt will be found insufficient to stop
its progress. Hence, in tying the main artery of a limb, too much care
cannot be taken to exclude from the ligature the accompanying nerve.
WTe should also avoid every thing likely to obstruct the circulation
through the collateral branches and capillary system of vessels. After
operations for aneurism no compression should be employed, and the
limb kept moderately warm.
When the case is decidedly an extensive sphacelus, the only chance
of preservation depends upon the immediate performance of amputation,
high up ; and, if practicable, above the place where the artery has either
been divided, or tied. In certain examples, however, in which the first
appearance of mortification does not happen till some days after the
injury, when the sloughing occurs at the extremity of the limb, and is
slower in its advances, the disorder will sometimes terminate in a partial
destruction of the integuments of the hand, or foot, and the limb may be
saved. But here the surgeon must be most vigilant ; for if, in his anxiety
to avoid operating, he give the disease time to extend up the limb, the
patient will certainly lose his life.
MORTIFICATION FROM PRESSURE.
Somewhat related to the kind of mortification, which we have just
now described, is that which originates from pressure, whereby the cir-
culation in the smaller vessels, and the nervous influence in the parts, are
interrupted. However, the great extent of the capillary system, and the
the tendons and bone. It was equally curious, that though the principal arteries and
nerves were all fairly divided, and the cut carried entirely round the part, mortification
was not the consequence. The operation succeeded in checking the progress of an
aneurism by anastomosis, which had increased and become attended with many unplea-
sant symptoms, notwithstanding the radial and ulnar arteries had both been previously
taken up by Mr. Hodgson. Some account of this case is given in Medico-Chir. Trans,
vol. ix. part 1. p. 216.
MORTIFICATION. 69
prodigious number of its inosculations, make the circulation in it so free,
that it must be a powerful and long-continued pressure to stop this im-
portant function. The cause may act either upon a limited point of the
external surface of the body, or upon the whole circumference of a limb ;
and, in both instances, the effect may extend to a greater or lesser depth.
When the constitution is enfeebled, pressure much more readily brings
on mortification. Of this every surgeon of experience must have seen
repeated proofs in the mortification which attacks the integuments
covering the sacrum, os ilium, trochanter major, scapula?, heels, and
elbows of patients who have been long confined in bed by fevers, injuries
of the spine, bad fractures, &c. The constant pressure of such parts of
the skin, between the bedding and bony prominences, obstructs the
circulation through them at a period when the flow of blood is already
languid from general debility. They become soft, of a dull brown, or
purplish colour, red at the circumference, cedematous, and, at last, black
and senseless. The sloughing commences at the point where the
pressure is greatest ; thence spreads more or less widely, and terminates
in the formation of a foul, ill-conditioned, gangrenous ulcer. Some
cases present themselves, in which the skin is so extensively destroyed,
that, upon the separation of the slough, the sacrum and neighbouring
bones are denuded, and visible at the bottom of the ulcer, the discharge
and irritation from which prove rapidly fatal. Patients sometimes get
over severe fevers, bad fractures, &c., and ultimately fall sacrifices to this
secondary disease.
With respect to the treatment of this particular case, I need not re-
mind the practitioner, that he should always be apprehensive of this
species of sloughing in patients, who are weakened by disease and com-
pelled to lie for several weeks and months in bed. In cases of injury or
disease of the spine, of compound fractures of the lower extremity, of
fractures of the neck, of the thigh-bone, and in typhoid fevers, such
mortification is much disposed to occur. He ought, therefore, to prevent
the occurrence by now and then shifting the posture of the sick ; and,
especially, he should not forget to examine from time to time the state of
the parts most subject to attack. On the first appearance of any red-
ness, or discolouration in them, they may be bathed with the liquor
plumbi acetatis dilutus, and then covered with a piece of the emplastrum
plumbi, or, what is still better, the emplastrum saponis. The posture
should at the same time be so altered that the parts affected may not be
lain upon. The judicious arrangement of small pillows, or cushions,
under particular points, will often give the surgeon essential assistance in
the accomplishment of this highly important indication ; and of late
years the hydrostatic bed has been employed with considerable advan-
tage. When sloughing and ulceration have actually taken place, the
following applications are in common use : lint dipped in camphorated
spirit, or turpentine ; carrot or emollient poultices ; lint wetted with a
solution of -opium, or a solution of the chloruret of soda in me camphor
mixture or distilled water ; and common pledgets. This indetermination
concerning what is really the best kind of dressing, sufficiently proves
that not much is to be expected from the virtues of local applications.
Improving and strengthening the constitution ; changing the patient's pos-
ture ; the use of the hydrostatic bed ; and, above all things, the strictest
attention to keeping the parts affected clean, and to the avoidance <
whatever is irritating to them ; are the great leading principles by ^
the surgeon should be governed.
F 3
70 MORTIFICATION.
The circular compression of limbs by tourniquets and tight bandages,
if continued too long, will induce mortification. The smaller the extent
of the compression, the greater is the risk ; and bandages, which operate
equally upon every part of a limb, though they may be somewhat tenser,
can be borne with greater safety than a narrow band or ligature, which
acts only upon a very confined space. Yet, let it not be imagined, that
the danger of immoderate, long-continued compression is entirely obviated
by equalising the pressure, and increasing the extent of the compressed
surface. There are few surgeons, who have not beheld melancholy proofs
of the fatal consequences of tight bandages. The greater skill now gene-
rally evinced in equalising the pressure upon the whole limb, we must
admit, has much diminished the number of these unfortunate examples ;
but they do still sometimes happen. A surgeon, therefore, should never
forget, that, frequently when he is applying a roller, the nature of the
disease or injury will necessarily be followed by a great deal of swelling,
and for this due allowance should be made in first putting on the bandage.
For the same reason, the part should be from time to time carefully
examined, and if found to be too much constricted, it should be instantly
liberated. Compression is only safe, while it gives no uneasiness ; and,
when it appears to produce pain, the suspicions of the practitioner ought
to be immediately awakened to its dangers. In the practice of surgery, it
is sometimes proper to wet bandages with cold water, or particular lotions ;
but, whenever this is done, the fluid makes the linen shrink so consider-
ably, that, if the change be not guarded against, the constriction pro-
duced will often bring on a rapid mortification of the limb, and the death
of the patient. Let surgeons also continually bear in mind, that tourni-
quets are only designed as temporary means of suppressing hemorrhage,
and that if their application be long continued, they will surely have the
most disastrous consequences. The perils of immoderate circular com-
pression of limbs proceed, not only from the obstruction which it causes
in the circulation, both through the arteries and veins, especially the
latter, but also from the interruption of the nervous. influence and action
of the absorbents. It is a remark made by Professor Carswell, that
although the physical characters of mortification, produced by a mecha-
nical obstacle to the venous circulation, present considerable variety in
different organs, they present one common character, viz. an excessive
accumulation of blood in the venous system, trunks, branches, and
capillaries of the affected part. There is a great accumulation of
serosity in the cellular tissue, which by its pressure further retards the
return of blood, and has a chief share in bringing on mortification. It
is likewise this accumulation of serosity beneath the skin that at first
conceals the congestion of the venous system. Stagnation of the venous
circulation may depend on obliteration of veins by pressure, by acci-
dental products formed in their cellular sheath, by the presence of fibrine
or other solid substances within the veins, and, lastly, by diseases of the
heart greatly interfering with the return of the venous blood.*
With regard to the treatment, the indication in an early stage of the
mischief is very simple, viz. to remove the bandage, or tourniquet, and
have recourse to fomentations. When the disorder has advanced further,
and actually amounts to gangrene, the conduct of the surgeon must be
regulated by the extent of the mischief. If it be partial, let him, after
removing the compression, foment the parts and vigilantly observe the
* See Dr. Carswell's " Illustrations of the Elementary Forms of Disease," Faseic. 7.
MORTIFICATION. 71
changes which occur ; for it is the nature of this species of mortification
often to spread with incredible rapidity up to the very trunk, and thus in
a few hours destroy every possibility of saving either the patient's limb,
or his life. Whenever there is reason to apprehend that the case will be
of this serious description, if amputation be delayed, the operation should
be adopted as the only possible means of affording the patient any chance
of preservation.
MORTIFICATION FROM THE DELETERIOUS INFLUENCE OF CERTAIN
POISONS.
As illustrations of it, I may mention the mortification of the cellular
tissue consequent to the bites of venomous reptiles ; the disease called
hospital gangrene; the malignant pustule, and the form of mortification
arising from the use of unsound rye as an article of food. The subcu-
taneous gangrenous mischief, following the bites of snakes, will be de-
scribed under the head of poisoned wounds.
Hospital gangrene is very different from every other form of mortifica-
tion, not only with respect to its appearance, mode of occurrence, and the
peculiarity of its causes, but also with regard to its treatment. It is cha-
racterised by its contagious nature, its disposition to attack wounds and
ulcers in hospitals crowded with such cases, and by its conversion of the
soft parts into a putrid, glutinous, or pulpy substance, and not into a firm
distinct slough, like what is formed in other species of mortification. On
this account, it is sometimes classed with ulcers, and even named the
hospital sore ; and there is really some difficulty in deciding, whether it
should be arranged with mortification or with ulcers. Certainly, it has a
very strong resemblance to the worst forms of phagedenic ulceration.
True hospital gangrene is undoubtedly communicable by the application
of the discharge to an abraded or ulcerated surface in another person.
It must, however, have its first origin in some other way, and Dr. Carswell
considers it as affording an example of a septic agent being generated in
a morbid condition of the solids, and giving rise to a similar disease,
when communicated from one individual to another, by means of the
dressings, or other direct modes of transmission. Upon an abraded
surface, it begins in the form of one or more small vesicles at the edge of
the abrasion. These vesicles are very soon converted into greyish or
ash-coloured sloughs ; or if they happen to contain a dark-coloured fluid,
and to burst, they put on the appearance of a thin coagulum of a dirty
brown colour. At the same time, the part becomes acutely painful, and
a pulpy slough is rapidly formed over the whole sore. Hence, by Gerson,
the disease is actually named pulpy gangrene.
When this pulpy substance comes away, the subjacent surface presents
a healthy granulating appearance; but, this favourable look is only
transient, as the destructive process soon begins again.
When hospital gangrene attacks a wound or ulcer, the pajt becomes
painful, and a viscid light-coloured matter exudes from the granulations,
which lose their red colour, and exhibit spots of a greyish dirty white
hue, resembling aphthae. These spots, all uniting together, completely
change the look of the whole wound. The parts have also a much
greater disposition to bleed, than what is noticed in any other variety of
mortification.
A red purplish cedematous circle is next formed in the surrounding
skin. The edges of the ulcer become hardened and everted; *n<
72 MORTIFICATION.
sloughs, such as they are, put on the appearance of the foetal brain in a
putrid state.
Hospital gangrene spares hardly any textures. Amongst the severe
cases, seen by Mr. Blackadder in the military hospitals in Spain, there
was one, in which one half of the cranium was denuded, and as black as
charcoal. In another, the large arteries and nerves of both thighs were
exposed and dissected, the integuments and cellular tissue being en-
tirely removed, with the exception of a narrow strip of skin at the
external side of each of the limbs. In other instances, the cavities of
large joints were extensively laid open ; and, in one man, all the skin
and cellular tissue of the neck were completely destroyed. In the ad-
vanced staget hemorrhages come on ; the bleeding can rarely be stopped
by ligatures; no coagulum is produced in the vessels, nor does any
healing process take place in them. The pulse is rapid and feeble, and
the tongue covered with a brownish or black fur. At an earlier period,
the pulse is fuller and not so quick, and the tongue generally white. In
many examples, the lymphatic glands are affected with inflammation and
swelling.
As for the prognosis, this disease is universally admitted to be one of
the most dangerous complications to which wounds and ulcers are liable.
Slight cases may sometimes be cured, but the more severe ones generally
prove fatal, and this, in many instances, by a repetition of attacks.
The exciting cause of hospital gangrene is commonly believed to be
an infection generated in a crowded hospital, and especially one filled with
wounded persons. The situation of such hospital on low marshy ground,
and the hot season of the year, are generally considered to promote the
origin and extension of the disease.
Although the most experienced army surgeons concur in the belief, that
hospital gangrene spreads by contagion, little doubt can be entertained,
that the number of cases is also increased by the operation of the causes,
which give rise to the first examples of it in any particular hospital.
Unless we adopt this view, we should not be able to explain the com-
mencement of the disease in the patients first attacked.
In the early stage, bleeding is recommended by some, and condemned
by others, who also object to it on the ground, that there is risk of the
puncture becoming itself infected. Bark generally proves unavailing.
Emetics have been tried, and, though occasionally spoken of with appro-
bation, they are mostly represented as inferior to purgatives. In every
stage of the disease, unattended with diarrhoea, the citric and diluted
sulphuric acids have beneficial effects ; and, with respect to opium, the
agony of the disease is such as always to render its employment in some
form or another indispensable. However, on the whole, it may be stated,
that no internal remedies can be depended upon for stopping hospital
gangrene.
The patient, if possible, should be removed from the hospital, and put
into another well ventilated building ; and the linen, bedding, and floor
sprinkled or washed with a solution of the chloride of lime or soda.
During the last war, the French had a great deal of hospital gangrene
in their military establishments, and, at that time, their practice consisted
in applying the actual cautery to the parts affected. Now, however, they
seem to place great confidence in the solution of the chloride of lime or
soda ; such confidence, that Lisfranc has expressed a belief, that, by
these means, the disorder will be kept in future from committing the
kind of ravages formerly observed. The report of the effects of the
MORTIFICATION. 73
latter on the disorder, as it occurred amongst the wounded in the French
army at the siege of Antwerp, is also favourable.*
Mr. Blackadder recommends liquor arsenicalis, diluted with an equal
quantity of water, as an effectual application. He first washes the
diseased parts with a solution of the subcarbonate of potass, and then
dips lint in the arsenical lotion, and lays it on the parts, the lint being
renewed every quarter or half an hour. After the sloughs separate, the
surface is dressed with gently stimulating ointments. Mr. Welbank re-
gards gangrenous phagedaBna, especially that form of it met with in the
wards of hospitals appropriated to syphilitic patients, as the same disease
as hospital gangrene. In its treatment, he prefers applying to the parts
the undiluted nitrous acid, in the manner to be noticed when we come to
the subject of phagedenic ulcers. Delpech speaks very favourably of
the effects of hydrochloric acid as a local application.
MORTIFICATION FROM EATING UNSOUND GRAIN, ESPECIALLY SPURRED
RYE.
This, which is one of the worst forms of mortification, and generally
attacks the lower extremities, is sometimes accompanied, or preceded by
vertigo, drowsiness, and a malignant kind of fever, with a sensation of
numbness in the legs, which are painful, slightly swollen, but not in-
flamed. The skin is cold and livid, and the sphacelus commences in the
centre of the limb, not at first involving the skin. In a second series of
cases, the sphacelated parts are dry, livid, or black ; these appearances
commencing in the toes, and extending gradually upwards as far as the
thighs. In a third series of cases, the disease commences with lassitude,
and a sensation of insects creeping under the skin, but without any
febrile symptoms. Soon afterwards, the extremities become cold, pale,
wrinkled, and benumbed, and at last quite insensible and incapable of
motion, acute pain being next experienced in the centre of the limb.
There is now fever and headach, pain extending from the hands and feet
to the shoulders, legs, and thighs ; and next the affected parts become
dry, shrunk, and black, and drop off at the joints. Entire limbs are thus
separated without hemorrhage. Lastly, in other cases, the chief symptoms
are at first spasmodic contractions of the limbs, afterwards great mental
weakness, voracity of appetite, and fatuity, followed by sphacelus.f In
the treatment, the immediate discontinuance of the deleterious article of
food, the support of the constitution by tonics, and suitable diet, and the
promotion of the separation of the sphacelated parts, are the chief indi-
cations. It is an example of mortification unpreceded by inflammation,
and probably taking place, as Professor Carswell suggests, by the oper-
ation of the poisonous grain on the parts affected, through the medium of
the blood, or nervous system.
A remarkable instance has lately been recorded of dry gangrene in a
child., three years and seven months old, where there was no oossibility
of ascribing the attack to any particularity in diet. The left leg and both
arms were in an advanced state of destruction from dry gangrene. The
right forearm had been detached by nature at the elbow-joint ; but the
slough had extended above the joint, where a second attempt at separa-
tion was in progress. The left foot had been entirely detached with the
* H. Larrey, " Hist. Chir. du Sie"ge de la Citadelle d'Anvers," p. 55.
t See Professor Carswell's « Illustrations of the Elementary Forms of
Fasciculus 7.
74 MORTIFICATION.
epiphyses just above the ankle-joint, leaving the ends of the tibia and
fibula exposed. From the right foot, the phalanges of the second and
third toes had been removed.*
The forms of mortification exhibited in malignant pustule, carbuncle,
and phlegmonous erysipelas, and those occasioned by exposure of the
animal textures to high degrees of heat or to very low temperatures, will
be described in subsequent parts of this work.
OF AMPUTATION FOR MORTIFICATION,
In many accidental injuries, the operation should be performed without
any delay, so that mortification may have no time to begin. Numerous
gun-shot wounds of the extremities, badly lacerated and contused wounds,
and severe compound fractures, will inevitably be followed by gangrene,
and the patient's death, if an imprudent attempt be made to save the
part. Here amputation should be done immediately after the accident,
the wound of the operation being infinitely less hazardous, than an ex-
tensive and spreading sphacelus.
As a general rule, it is best to leave the separation of a slough chiefly
to nature. There are two exceptions to this maxim : the first is, when
one part of the slough is perfectly loose, while the rest of it continues
attached ; under these circumstances, the loose portion should be gently
cut away, and removed at once, so as to lessen the fetid effluvia, and
allow the healing processes to commence in the situation of the loosened
slough. The other exception is, when the whole thickness of a limb is
mortified ; but, unless the mortification be traumatic, the line of demarcation
must be awaited, as well as a favourable state of the constitution for ampu-
tation. However, even in this case, if the patient lived long enough,
nature would complete the separation. The soft parts would first se-
parate down to the bones ; the bony connexion itself would afterwards
be destroyed by a slow process, termed exfoliation; and the ulcer finally
heal. Yet, leaving the detachment of the whole thickness of a mortified
limb to be accomplished by nature is seldom advisable, because the patient
would not usually outlive the profuse discharge, the tedious confinement,
and the long continued irritation, which he would have to encounter.
Then another objection to the plan is, that, if he were to get through
these difficulties, and live till the dead portion of the limb had com-
pletely separated, and the parts healed, he would remain with an unser-
viceable stump, one not properly formed, not capable of bearing pressure,
and such as would never continue firmly healed.
In mortification, the precise time for the performance of amputation
is a consideration of the highest importance. Some years ago, the
common rule in surgery was, never to amputate until the progress of
the mortification had been stopped, and the red line of separation had been
formed. This maxim ought still to be observed in every instance of morti-
fication proceeding from internal or constitutional causes. Here, we have
a criterion, by which the question is at once easily settled. We must not
amputate in mortifications from internal causes, until the red line of
separation is distinctly formed ; that is, until the disorder has ceased to
spread, and has become bounded by the adhesive inflammation. In truth,
sometimes amputation may be advantageously deferred even beyond the
period of the first appearance of the line of separation, and of the stop-
* S. Solly, in "London Med. Gazette" for June 1839.
MORTIFICATION. 75
page of the mortification. Such delay would be proper, if the patient
were so reduced at the critical moment in question as to be likely to die
under the operation. Here some little time should be allowed, in order
to let the system rally, which it will sometimes do, with the aid of
opium, tonic medicines, a moderate quantity of wine, or brandy,
light nutritious food, and the admission of plenty of fresh air into the
patient's chamber. For the purpose also of lessening the disagreeable
effluvia, a solution of the chloride of soda, or lime, may be employed
with great advantage. The dead parts should be covered with linen wet
with it, and the floor be washed or freely sprinkled with it.
The next thing which I am anxious to explain is, that modern expe-
rience does not confirm the propriety of awaiting the formation of the red
line of separation, or, in other words, a decided stop of the disorder, in
every example of mortification before amputation is practised. The wis-
dom of the rule is acknowledged in mortifications from internal causes ;
but, if the maxim were extended to some other examples, the patients
would certainly go to their doom without having, what may be called, a
fair chance of being saved. They would die before the mortification had
stopped, or sink into a state, in which the performance of amputation
would be altogether hopeless. We are under great obligations to Baron
Larrey for many convincing facts and arguments in proof of the necessity
of deviating from the ancient rule in what he calls traumatic gangrene, or
the mortification arising from gun-shot wounds, compound fractures, and
other forms of external violence. In such cases, it would generally be
absurd to think of waiting for the mortification to stop, or for the appear-
ance of the red line of separation, because the patient would almost
always die of the extension of the disease, and its effects upon the whole
constitution, before such appearance presented itself — sometimes in the
short space of six hours.
Now, it is found, that if amputation be done early, and in, a sound part
of the limb, sufficiently distant from the sloughing, the stump will, gene-
rally, not be seized with mortification, and the patient will have by far the
best chance of recovery.
I have recommended this practice to be adopted in several cases, in
which I have been consulted ; and, in the army, I had many opportunities
of doing the operation myself, under the circumstances which have been
described, that is, where the mortification was spreading, and mostly with
success. A few years ago, I was consulted by a glazier, who had fallen
from a ladder, and met with a compound fracture of the lower end of the
humerus, in consequence of which the hand and forearm were seized with
a rapidly spreading mortification. In fact, when I was called in, the hand
and forearm were in the state of sphacelus, and the cellular tissue of the
upper arm was distended with serous fluid up to the shoulder. The
patient was at the same time beginning to be affected with stupor and
disorder of the intellectual faculties, and his pulse was weak, rapid, and
irregular. As there was no time to be lost, the limb was immediately
amputated at the shoulder joint. Every thing went on favourably after
the operation for five or six weeks — the stump healed, with the ex-
ception of a trifling fistulous opening; but, just at this period, when a
complete cure was expected, an extensive abscess formed over the sca-
pula, and ultimately proved fatal. However, as this patient would cer-
tainly not have lived twenty-four hours from the time of my first visit^if
the operation had not been done, I deem the case to be one strongly in
favour of the rule of amputating in traumatic gangrene, even while the
76 ULCERATION AND ULCERS.
disorder is yet in a spreading state. Some practitioners make one ex-
ception to prompt amputation in traumatic gangrene, viz. where it arises
in a bad habit of body from a slight mechanical injury. Here, under any
treatment, the prognosis must be unfavourable.
Mortification of the foot from injury of the femoral artery by a bullet, or
other mechanical means, is another instance in which the old maxim
should be abandoned. Here the only chance of saving the patient's life
depends upon the early performance of amputation, as high up at least as
the wound in the artery.
Mortification from obstruction of the circulation by aneurism) or after
the ligature of the artery for the cure of that disease, or for the stop-
page of hemorrhage, furnish additional exceptions to the rule of riot
amputating until the line of separation is formed between the dead and
living parts. Here the sloughing generally commences at the extremity
of the limb. I believe, indeed, that the mortification, following the liga-
ture of an artery for the cure of aneurism, is a case in which, whatever
may have been inculcated with regard to other forms of gangrene, the
early performance of amputation, at some distance from the dead part,
has always been recommended ; and the old surgeons themselves never
waited until the mortification had actually stopped. Before deciding to
amputate, however, we must be sure, that the mortification involves the
parts more deeply than the skin ; for a partial sloughing of the integu-
ments of the foot after aneurism sometimes takes place, the ulcer heals
up, and the limb is preserved.
In the seventeenth volume of the Med. Chir. Trans. I recorded the
particulars of an aneurism in the ham, which, in consequence of the sac
bursting under the upper part of the gastrocnemius, and the copious
effusion of blood in the cellular tissue of the leg, down to the very heel,
was followed by mortification. Tying the femoral artery had no effect
in checking ks progress, so that 1 was compelled to amputate just on a
line with the ligature on the femoral artery five days after the operation
for aneurism. Now, although the limb was amputated while the mor-
tification was spreading rapidly, a great part of the stump healed by the
first intention ; and the patient, an organ builder, now living in the
Waterloo Road, was soon able, with the assistance of a cork leg, to follow
his trade again.
ULCERATION AND ULCERS.
Ulceration is the process by which an ulcer or sore is produced ; an
operation, in which the absorbent vessels are usually supposed to be
more actively concerned than the arteries.
An ulcer or sore, previously to the stage in which it is filled up by
granulations, is a chasm formed on some external or internal surface of
the body by the removal of portions of the tissues back into the system,
the absorbents appearing as if they took away the old particles more
quickly, than substitutes for them are prepared and deposited by the
action of the secerning arteries.*
* " The term ulcer is indiscriminately applied to the vacancy that is caused by absorp-
tion, and to the same part, when filled up with granulations, secreting pus, and perhaps
ULCERATION AND ULCERS. 77
Morbid absorption of the solid parts, or that which takes place with-
out being accompanied by a corresponding deposit and repair, may ex-
tend to the whole machine, every part of which shall become smaller and
lighter; or it may be limited in its operation to some particular part,
organ, or region. Examples : 1. The wasting of the body in febrile dis-
eases, or of muscles in paralysis, and atrophy of the testicle from various
causes. This form of morbid absorption is termed interstitial, because it
takes place in the interstices of parts, which still remain entire.
2. Another form is that by which the solid parts, covering abscesses,
aneurisms, and deep-seated tumours, are thinned and removed. To this
Mr. Hunter applied the expression progressive absorption, apparently on
account of its being the means by which tumours and foreign bodies
make progress in any particular direction. The phrase has been cri-
ticised, because all absorption is really progressive, and in this objection
to it I fully concur.
3. A third modification of morbid absorption is denominated ulcer-
ative, in which not only a loss of substance, but a solution of continuity —
an ulcer is occasioned. Ulcerative absorption, therefore, is only a
synonyme of ulceration.
Ulceration is a process very different from erosion, or from any sort of
decomposition, or destruction of parts by chemical agents. It is not
produced by any imaginary corrosive properties of pus or the fluids of
the part affected. Healthy pus has no corrosive qualities : indeed, in
the early stages of ulceration, and while the uicerative process is ex-
tending with the greatest rapidity, hardly any of this fluid is formed ; yet
when the pus is abundant, and therefore most likely to produce corrosion,
if it had the power, the ulceration has stopped, and the sore is generally
healing.
Some writers offer what they call a physiological explanation of the
chief phaenomena of ulceration ; but what they say amounts to nothing
more than a statement in different terms of the circumstances I have ex-
plained. Thus, when we are told, that nutrition ceases in an ulcerating
part, while the destructive action of the absorbent system continues, we
are merely informed in other words, that the old particles of the textures
attacked by ulceration are taken away by the absorbents, without any
effectual attempt to replace them being made by the arterial system.
While ulceration is going on, the secerning arteries, those organs
which, in the natural and healthy state, bring and deposit the new mate-
rials of every part of the body in proportion as the old are removed, appear
to lose this power, and even they, as well as the rest of the organisation,
are taken away ; nay, after the process of ulceration has begun, the
absorbents themselves, which once existed in the situation of the chasm,
are no longer there ; they have disappeared, and not a vestige of them,
nor sometimes perhaps of any other part of the previous structure, remains.
It is commonly presumed, therefore, that so long as ulceration is spreading,
the unsparing action of these very busy organs, these minute vefsels, is
accomplishing their own destruction, as well as that of every other con-
stituent part of the textures affected.
There is a limit, beyond which nature will not allow us to pry into her
secret and mysterious operations ; and our knowledge of the theory of
ulceration is very confined.
^ .a
daily proceeding to be healed. An ulcer, in the state in vhkh it is commonlr-
the conjoint product of absorption, and of a new growth." (Macartney, op.
78 ULCERATION AND ULCERS.
When we express a difficulty in conceiving how a part of the body can
be removed by itself, we cannot get that difficulty obviated by our being
referred to some other inexplicable, but unquestionable operation or fact,
exemplified in the animal economy. Thus, when I am told,, that there is
not more difficulty in understanding how parts of the body can remove
themselves, than in comprehending how they can form themselves, the
position may be true, but it leaves me in the same uninformed state, re-
specting the minutiae of ulceration, in which 1 found myself previously to
this reference or comparison.
It is even uncertain whether in ulceration the veins may not have a
considerable share in the removal of the tissues ; for they are known to
be enlarged in the immediate vicinity of the seat of ulceration, while the
lymphatics themselves are alleged not to be so.
Whatever may be the agents of absorption on this occasion, whether
lymphatics, or veins, or both descriptions of vessels, and whatever may be
the exact manner in which these vessels are themselves removed in the
process of ulceration, we may conclude with John Hunter, that when it
becomes necessary that any of the substance of the body should be re-
moved by the actions of the system itself, nature must not only confer
new activity on the agents of absorption, but put the tissues about to be
absorbed into a state which yields to this operation.
All textures do not ulcerate with equal readiness. It is true, that every
organised part of the body seems liable to ulceration ; but we see this
process much more frequently in the cutaneous and mucous textures than
others. The synovial membranes are often the seat of ulceration, as we
see exemplified in the progress of inflammation of joints, and especially
scrofulous disease of them. Muscles, fascia?, and the trunks of nerves
and blood-vessels resist the ravages of ulceration for a considerable time,
far longer than skin, cellular membrane, or mucous tissues. The process of
ulceration is rare in serous membranes ; and, when it does occur in them,
their contiguous surfaces have generally contracted adhesions, through
which the ulceration proceeds.* Some of these facts are exemplified in
the progress of abscesses to the surface of the body, which do not usually
make their way through muscles by causing ulcerative absorption of any
portion of them, in order to reach the surface or nearest part of the skin,
but often take a very circuitous course, through the cellular tissue, to
the point where they present externally.
Ulceration seldom begins originally in muscle, tendon, fascia, a serous
texture, blood-vessels, absorbents, or nerves, though, in the progress of
disease, all these tissues and organs may be attacked. When a limb
mortifies, and the patient continues to live, the ulcerative process, by
which the dead parts are detached from the living, gradually extends
through all tissues.
Arteries of magnitude, situated in the midst of ulceration, do not rea-
dily ulcerate themselves, except in cancer, hospital gangrene, and certain
forms of phagedaena termed gangrenous. Even in the midst of phage-
denic ulceration and hospital gangrene, a large artery will often lie a con-
siderable time without giving way, and, when the bleeding commences, it
is mostly not from the trunk, but from the branches.
It would seem, from investigations made by Cruveilheir in France, and
Mr. Key, in this country, that, in the ulceration of some textures of
inferior vascularity, like tendons and cartilages, there is formed, previously
* See Dr. M. Hall's " Principles of Medicine," p. 27.
ULCERATION AND ULCERS.' 79
to the commencement of the ulcerative process, a vascular substance be-
tween the fibres of the tendon, or by the synovial membrane immediately
in contact with the cartilage, and that such new vascular substance
becomes the organ by which such tissues are removed. This view, how-
ever, which is not adopted by my friend Sir Benjamin Brodie in relation
to diseases of joints, requires further examination. Fasciae, tendons, and
ligaments are the tissues least subject to ulceration.
I have represented an ulcer to be a chasm, a solution of continuity,
produced in some internal or external surface of the body by the process of
absorption, and have stated that the absorbents, whether lymphatics or
veins, appear to be more actively concerned in the formation of such
chasm, than any other order of vessels.
That the vessels, which are the organs of absorption, are the principal
means by which the ulcer is produced, seems to be corroborated by the
fact, that, in particular states of the constitution, when old sores break
out afresh, the callus, or substance forming the bond of union between
the extremities of old fractures, is removed, and the bones, which perhaps
have been firmly united for many years, suddenly become flexible, and
the fractures are disunited again. Such occurrences were exemplified in
the crew of the Centurion, in Lord Anson's memorable voyage.
These facts prove the truth of one of Mr. Hunter's doctrines, viz. that
all parts not entering into the original structure of the body are weaker
than the rest of our organisation, and, on this account, more prone to
ulceration and mortification. A cicatrix is a substitute for the old and
original skin, but, it is inferior to it in vital power ; and the same is the
case with callus, as compared with the primitive osseous texture.
SYMPTOMS OF ULCERATION.
The formation of an ulcer is preceded by more or less pain, heat, red--
ness, a degree of swelling, and other marks of inflammation in the part.
The pain is mostly of a sharp pricking or lancinating kind, though it
varies in different textures, in the different kinds of disease productive of
ulceration, and according as the ulcerative absorption is quick or slow.
In numerous instances, the cuticle is loosened, and a little vesicle or
pustule is formed, and on its bursting, a breach is discovered in the sub-
jacent surface of the skin. Sometimes there is at first a single minute
excavation ; sometimes several ulcerated points contiguous to one another,
which quickly joining together, make a sore of some magnitude. On a
mucous membrane, ulceration often begins with small, round, ash-
coloured solutions of continuity, as familiarly exemplified in the mouth
and fauces.
The existence of inflammation as an attendant on ulceration is proved
not merely by the circumstances already specified, but by the regular
closure of the canals of the large blood-vessels, as the particles of the
tissues attacked are taken away. At all events, it is the modern doctrine,
that such closure is effected by means of the adhesive inflammaflon.
While no attempt at reparation is made, ulceration always presents an
excavation or chasm, the edges of which are red, sharp, and often jagged
and irregular. The surface of the exposed textures is of a dirty white
or yellowish colour, with an appearance of shreds upon it, as if every
atom of the parts destroyed had not been completely removed. The
surface is also generally covered with a thin discharge, or a kind r
sanies, or thin matter frequently tinged with blood. m ^ skin
While ulceration is extending itself, the margin of the adjoJv
80 ULCERATION AND ULCERS.
is hot, red, and painful; but directly a disposition to heal commences,
this state ceases. If not checked, ulceration may extend to any depth,
and affect any textures. In many instances, the ulcerative process ap-
pears to be diffused over a considerable extent of surface ; and in others
again, it is limited to a very narrow line, producing a chink or fissure,
an appearance similar to that which occurs in the separation of mortified
parts.
The progress of ulceration is extremely various in different textures,
and in the same texture in different individuals, according to the nature
of the inflammation, and no doubt also according to the particular con-
stitution of the person in whom it occurs. In some instances, it is ex-
ceedingly slow or chronic in its progress, the sores which it forms remain-
ing for a long while open, without any disposition to spread. In other
cases, ulceration advances with great rapidity, removing or destroying
considerable portions of the body in a few hours.
ULCERS.
If we restrict the definition of an ulcer, or sore, to a chasm or breach
in the solids, occasioned by the process of ulceration, we then have no
difficulty in determining what cases should be classed as ulcers ; but cer-
tain cases are frequently termed ulcers, which are not formed in this
manner. Thus, when a suppurating arid granulating surface is trie con-
sequence of a wound, that has continued for a long while unhealed, there
may be the appearance of a cavity from the simple retraction and separa-
tion of the parts ; but none of their substance may have been truly re-
moved, either by the accident itself, or by any subsequent action of the
absorbent system ; yet it is not uncommon to give the name of ulcer to a
case of this kind, which was originally a wound.
In mortification, both acute and chronic, the sloughs are loosened by a
process similar to common ulceration, by what Dr. John Thomson has
proposed to called disjunctive absorption. In these instances, therefore,
the surface, exposed by the detachment of the slough, will certainly
come within the definition of an ulcer.
The same must be the case with the solution of continuity, resulting
from every abscess that bursts of itself, because, after the skin has been
thinned to a certain extent by progressive absorption, ulcerative absorp-
tion takes place. If suppurating wounds, after a certain duration, are to
exchange their name for that of ulcers, then one common definition of an
ulcer will not be applicable ; viz. a solution of continuity in the solids, ac-
companied with loss of substance, and a discharge of purulent matter.
Nor would Callisen's definition answer, " a solution of continuity gra-
dually produced in organised parts? But, if the term ulcer be restricted
to the effects of the process of ulceration, then, of course, loss of sub.
stance, and the gradual manner in which the chasm is produced, are very
good criterions. With this understanding, Callisen's definition is the
best that I know of.
With respect to the causes of ulcers, the most frequent are inflamma-
tion and abscesses, which have burst ; the separation of sloughs ; pressure
on parts in a state of inflammation, as is too often exemplified in the
effects of chains on prisoners, of harness on horses, of badly padded splints
on broken limbs ; and of the long continuance of patients with fractures,
fevers, paralytic affections, and other tedious diseases, in the recumbent
P°Mtion. Ulcers are also produced by many kinds and forms of external
jn the iower extremities, a frequent cause of ulcers is a varicous
ULCERATION AND ULCERS. 81
state of the veins. The production of sores is frequently the consequence
of 'diseases, which begin in the bones, cartilages, or synovial membranes
of the joints, the ulcers in the soft parts being then generally preceded
by abscesses. In some diseases of the joints, ulceration of the cartilages
is one of the primary, or earliest changes.
But, ulcers frequently arise from constitutional diseases, several of
which are of a specific nature, as is illustrated in scrofula, lues venerea,
scurvy, cancer, and fungus haematodes. Hence, one of the best and
most practical divisions of ulcers, is into local and constitutional; but,
true and natural as it is, it should be adopted with a clear understanding,
that many sores, which at first depend entirely upon internal causes, and
are in the beginning of a specific nature, are often so materially changed,
long before cicatrization is completed, that, in their latter stages, they are
strictly local complaints.
On the other hand, many sores, which are at their commencement only
of a local nature, and quite unconnected with internal causes, are after-
wards changed, or influenced by some general affection of the system,
and become in every sense of the expression constitutional ulcers.
Ulcers continually vary in their nature and appearance with every fluc-
tuation in the constitution or change of health. Directly a patient, who
has a healthy ulcer on his leg, or some other part of his body, secreting
a due quantity of good pus from small granulations, of a florid vermilion
colour, such as are seen in the best conditioned sores, is attacked by
fever, a rapid change is noticed in the aspect of the sore, it will im-
mediately become pale, and cease to pour out any other discharge, than
a small quantity of thin ichor. Its surface then becomes dry, its'granula-
tions slough, or are absorbed, and the healing process is completely
stopped.
The state of ulcers likewise materially depends on the treatment of them.
Thus, by improper dressings, excesses in diet, and too much disturbance
of the part, an indolent sore may be converted into a very painful and
irritable one.
The prognosis generally depends, first, upon the nature of the predis-
posing and exciting causes, and the facility or difficulty of their removal ;
secondly, upon the kind of parts attacked, whether of great importance
or not in the animal economy; thirdly, upon the patient's age, constitution^
and mode of life ; fourthly, upon the extent of the ulcer; fifthly, upon
its peculiar nature; thus a venereal sore may generally be healed with
facility, because one medicine is well known to exert considerable power
over the venereal disease ; but, a scrofulous ulcer is commonly much
more difficult of cure, because we are in possession of no remedy so de-
cidedly efficacious in scrofula as mercury is in the venereal disease.
We know of nothing that will at once rectify that state of the system,
with which a scrofulous sore is intimately connected. As for a can-
cerous sore, I believe, that it can never be cured, without some process,
or operation, that has the effect of destroying, or extirpating Jhe can-
cerous tissue. With this understanding, then, it would not be correct, to
assert, that such a sore is absolutely incurable. I have known the whole
of a breast, affected with carcinomatous ulceration, to be destroyed by
sloughing, and the part afterwards heal. There was living very lately in
Great Ormond Yard, Queen Square, a woman, above eighty, who had
had cancer in both breasts, which, when I saw her, had entirely sloughed
away, and healed up, leaving only some induration, and a prodigious1
disfigured cicatrix.
82 ULCERATION AND ULCERS.
Ulcers on the trunk, or near the source of the circulation, generally
heal in less time than others farther from the heart, or on the limbs ; and
every surgeon is well aware, that sores on the arms commonly heal with
much greater expedition than such as occur on the legs. The depending
position of the leg retards the return of the venous blood, checks the
freedom of the circulation, and thus has a disadvantageous effect on the
healing processes.
The process, by which ulcers heal, is precisely the same as that which
brings about the cure of suppurating wounds. It includes the important
subjects of granulation and cicatrization, which will be noticed when the
treatment of such wounds as cannot be healed by the first intention come
under consideration. Therefore, I shall merely observe at present, that
when ulceration is checked, and the preternatural activity of the absorb-
ents of the part is reduced, the capillary secerning arteries regain their
power, and by their means a process of reparation is begun, by which the
cavity of the sore — the chasm produced by the absorbents — is filled up
with granulations, and the surrounding old skin gradually drawn a con-
siderable way over the part originally occupied by the ulcer, so that,
comparatively speaking, little new skin is required, which is rather diffi-
cult of formation, and never so strong and serviceable as the old.
In the treatment of ulcers, the chief indications are to remove and
diminish the causes which have given rise to their formation ; and to let the
patient have the advantage of a suitable diet and regimen, particularly
of rest, and a judicious position of the part, pure air, cleanliness, and
such internal medicines and dressings as the circumstances of the case
may demand.
With respect to the removal of the exciting cause, the necessity for it is
so manifest as scarcely to need any comment. Supposing an ulcer were
to originate from and be kept up by the presence of a dead portion of
bone directly under it, how could we expect it to heal the sore so long as
such piece of bone continued in the part ? If a sore were to arise from
scurvy, it would be in vain to attempt its cure, without removing that
peculiar derangement of the health with which the local complaint is in-
timately connected. I have mentioned the effect of scurvy in causing
the absorption of the substance composing a cicatrix, and of the uniting
medium of fractures termed callus. How then can we be surprised at
our inability to heal sores, while this disordered condition of the whole
animal economy remains unrectified ? In order to give some idea of the
universal derangement of the system resulting from scurvy in an aggra-
vated form, I may here refer to preparations in the Museum of University
College, London, demonstrating that, in advanced stages of this disease,
the muscular system is affected in a very singular manner, blood exuding
from the vessels, and becoming copiously deposited between the muscular
fibres.
Scrofula and syphilis, as exciting causes of ulcers, require the same
principle to be acted upon, and so does a stricture in the urethra, as the
cause of ulcers and fistulas in perinoso.
Some other sores, if they are not produced, are certainly kept from
healing, by disturbance of the digestive functions, the regulation and im-
provement of which then become essential indications.
However, I am far from meaning to assert, that every sore requires,
as a matter of course, the exhibition of medicines ; many sores will heal
nnder the use of simple dressings without a single dose of physic being
In all cases where the sore is healing well, and the constitution
ULCERATION AND ULCERS. 83
sound, the utmost that the surgeon is called upon to do with medicines is
to regulate the patient's bowels.
But constitutional ulcers, and especially those which are specific, irritable,
phagedenic, or in any other way ill-conditioned, may often be more be-
nefited by general than by local treatment. In the management of every
description of ulcers, one grand object is to keep the surrounding skin,
clean, and not to let the discharge accumulate and dry upon it. Were
this rule neglected, the skin would become irritated, and it will always be
found, that when any inflammation is excited in the integuments at the
circumference of an ulcer, it not only interrupts the healing process at
the edges of the sore, but is likely to be followed by a renewal and ex-
tension of the ulceration.
All ulcers may be arranged under three classes : healthy and unhealthy,
amongst which last are those termed specific. The first, or healthy ulcer,
can only be of one kind — the simple sore, the simple purulent ulcer as it
is sometimes termed — characterised by its freedom from all diseased
action, and its disposition to heal up in the most favourable manner.
The second, or unhealthy class of ulcers, comprises irritable, indolent,
and phagedenic ulcers ; those connected with varicous veins ; many
others depending upon disorder of the digestive functions, and various
definite or indefinite derangements of the health.
The third class, or specific, comprehends scrofulous, cancerous, vene-
real, scorbutic, &c. Many ulcers, proceeding from cutaneous diseases, are
specific. We need not here dwell upon the absurdity and confusion of
assigning the importance of distinct species of ulcers to those, which
happen to be attended merely by accidental changes, or complications, to
which all sores, without exception, are liable. Thusjistulous and sinuous
ulcer, inflamed ulcer, carious ulcer, sloughing ulcer, and fungous ulcer, are
expressions occasionally made use of to denote distinct species of sores,
whereas they ought, at most, only to signify certain states or complica-
tions incidentally conjoined with an ulcer, and which may occasionally
attend any kind of sore whatsoever.
Simple or healthy ulcers are known by the small size, florid colour,
firm consistence, and pointed shape of their granulations, which resemble
minute cones, and are less disposed, than some other kinds of granulations,
to rise higher than the level of the surrounding skin. The pus secreted
by them is white and thick, and not adherent to their surface. When
they have risen to the level of the neighbouring skin, those at the margin
of the ulcer become smooth and covered with a thin bluish semi-transpa-
rent film, which soon turns opaque, being converted into the new skin,
which is quickly covered by cuticle. Such is a healthy ulcer, or one in
which the process of cure is going on favourably in a person of sound
undisturbed constitution. The florid red, or vermilion colour of the
granulations, denotes a free and vigorous circulation in them. Their
colour is not, however, precisely the same in every position of die limb ;
for when the part is kept in the depending posture, the floria redness
frequently changes to a deeper, or purple colour, in consequence of the
retardation of the venous circulation. Under these circumstances, as
Mr. Hunter conceived, the blood in the minute arteries probably assumes
also the dark colour of that which fills the veins.
The treatment is simple, because the well-directed operations of nature
ought not to be too much interfered with. The surrounding skin shoujr1
be kept clean ; and soft lint having been applied to absorb the re
matter, it may be covered with a pledget of any mild un
G 2
84? ULCERATIOtf AND ULCERS.
ointment, like those of spermaceti, marsh-mallows, or calamine. In this
manner the evaporation of the thin fluid part of the pus, and the pro-
duction of a scab will be prevented. The lint ought never to be laid
over the edges of the ulcer, where the fine bluish pellicle lies. One
important part of the process of cicatrization is the extension of the
old skin over a considerable portion of the surface previously occupied
by the sore. Now this process would be much retarded if the granula-
tions, especially those near the edges of the ulcer, were suffered to
become too high. It may therefore become necessary to repress them
by touching them now and then with the nitrate of silver. In doing this,
the main skill consists in not applying it completely to the edge, so as to
disturb the semi-transparent film, or beginning of the new skin, but only
just so far towards it as the high appearance of the granulations may
require. Some practitioners use the sulphate of copper for this purpose;
but it is very inferior in its effects to the nitrate of silver, which I join
Delpech in thinking the best of all escharotics for sores, because it
appears to possess the greatest power of expediting the contraction and
absorption of the granulations, or the change established in them for the
purpose of making the old skin more effectually cover a considerable
portion of the ulcer.
The healing of sores on the lower extremity, even of those which rank
as simple ones, is seriously impeded by the patient's walking about, and
keeping the limb in the perpendicular position. The effect, which the
latter circumstance has in lessening the florid colour of the granulations,
I have already explained. Now when the patient will not confine himself
in the recumbent posture, or refrain from taking exercise, it will gene-
rally be found advisable to afford as steady a support to the limb as can
be obtained from the application of a roller, or laced stocking. In this
manner, the weight of the column of blood in the large veins is in a
great measure prevented from retarding the circulation, and the part is
placed in a state of comparative rest. A bandage is also useful on another
principle ; it keeps the granulations from rising up too much, and thus
renders the use of caustic less necessary. It also maintains a briskness
and vigour in the healing process. However, if a bandage is to do any
good, it must be applied skilfully, an4 with particular attention to let the
pressure act evenly and moderately upon the whole surface of the limb,
and not partially.
In University College Hospital, simple ulcers are seldom dressed with
ointments, but covered with the wafer dressing. A piece of fine soft
lint is wetted with cold or tepid water, laid over the ulcer, and covered
with oiled silk, to prevent evaporation. Dr. Macartney, who has taken
an active part in advocating this method, employs two, three, or four
layers of lint, and dispenses with a bandage. If the sore require gentle
stimulation, a weak solution of sulphate of zinc or copper may be em-
ployed, in the same way, instead of simple water ; and, if a stronger
application become necessary, the best is the nitrate of silver.
When the patient cannot avoid walking about, simple ulcers may be
cured by encircling the limb in the situation of the sores, and for a
little way above and below them, with long strips of adhesive plaster,
which should be long enough to reach all round the limb, and have two
or three inches to spare at each end. The middle of each strip is to
be applied to the side of the limb most remote from the sore, and the
v^o ends are then to be brought completely across it, one overlapping
the
TJLCERATION AND ULCERS. 85
Another class of ulcers comprises those named irritable. A sore will
always partake of the nature of the constitution, and, if this should be
what is termed an irritable one, the sore will generally be more or less
irritable. It will also be irritable, in various impaired states of the health,
in persons who may not naturally have what is called an irritable tem-
perament. In this point of view, I think, there is decidedly a difference
between an irritable and an inflamed ulcer.
These remarks receive some confirmation from a fact mentioned by
Sir Everard Home, namely, that an irritable ulcer cannot always be known
at once by its mere appearance, and its character is sometimes not mani-
fested till the surgeon ventures to use some slightly stimulating appli-
cation, or to make pressure. This would be explained, however, by some
practical surgeons in another way, viz. by their view of an irritable sore
being always attended with weakness and over-action. Yet, an irritable
sore is frequently marked by particular appearances. Thus the margin
of the surrounding skin is often jagged, sharp, and, as it were, under-
mined. Concavities of different sizes are seen at the bottom of the ulcer,
without any distinct formation of granulations. The discharge is mostly
thin and Woody, the disease attended with excessive pain, and a remark-
able tendency to hemorrhage, when its surface is slightly touched with a
probe. In many instances, some of the ulcerated surface is covered with
a dirty ash-coloured slough, on the separation of which new granulations
arise, but are soon absorbed again, or they slough directly after their
formation.
It seems as if local circumstances had influence in making an ulcer
irritable ; for, sores of this character are often met with in the skin
covering the lower end of the fibula, or in the integuments situated over
the shin, or the ligament of the patella.
In the treatment, complete quietude of the part, and the employment
of soothing applications, leeches, and aperients, are generally proper at
first. Bathing the part in a warm decoction of poppy heads, exposing it
to steam, and covering it with a warm soft bread poultice made with the
lotion of the acetate of lead, or with water to which a little of an aqueous
solution of opium or hyosciamus has been added, are very beneficial
plans. Dressing the ulcer with lint wetted with tepid water, and covered
with a piece of oiled silk to prevent the lint from becoming dry, will
sometimes agree with the sore better than any thing else. In private
practice, I have lately had several cases, with which no mode of treatment
agreed, excepting that now referred to. However, no success will attend
this, or any other practice, unless care be taken to keep the limb in an
elevated posture, and in a state of perfect repose.
Sometimes dressing an irritable ulcer with lint dipped in a solution of
opium (five grains to an ounce of water) or of the extract of hyosciamus,
answers well ; but a still better application, after a time, is found in many
instances to be a lotion containing from two to five drops of nitric acid to
one ounce of distilled water, with or without a proportion of oj^um in it.
The black wash or lotion, consisting of ten grains or a scruple of calomel
to one ounce of lime water, is sometimes employed. The pressure of a
bandage is invariably pernicious.
When the surrounding skin is red, swelled, and painful, and the patient
full of blood, general and topical bleeding are indicated; but the sore is
then rather an inflamed than 'merely an irritable one ; or partakes of
characters. ,
When the irritability of an ulcer seems to be connected with *'
G 3
86 ULCERAf ION AND ULCERS.
of the digestive functions, the blue pill or calomel with light tonics and
aperients may be prescribed ; or the compound infusion of gentian with
the sulphate of soda, the liquor potassae, or carbonate of soda, and leeches
to the epigastrium, according to circumstances.
In the generality of irritable sores, it is necessary to keep the patient
more or less under the influence of opium, or the preparations of morphia
or hyosciamus. Costiveness must always be obviated, and, when much
debility is present, the sulphate of quinine, or the infusion of cascarilla
with diluted sulphuric acid, will often prove valuable medicines.
Indolent ulcers constitute at least three fourths of the sores for which
surgical assistance is required, and are principally met with upon the
lower extremities. The edges of the skin, encompassing such an ulcer,
are generally thick, prominent, and rounded. The granulations are pale,
smooth, large, and flabby, with a peculiar gloss or semi-transparency
about them. They secrete an imperfect thin kind of pus, blended with
flakes of coagulating lymph, which adhere more or less to the surface of
the ulcer. The pale colour of the granulations denotes a want of brisk-
ness and vigour in their circulation. Indeed, such is the indolence of
some of these ulcers, that granulations are not formed at all ; but the
bottom of the sores represents a pale brown flat surface, and the disease
looks as if a portion of the skin had been taken away, and no attempt at
reparation made. For a considerable distance around the ulcer, the
parts are swollen and indurated : sometimes indeed the whole of the leg
is enlarged and cedematous ; yet the swelling is not soft and yielding
like common oedema, but firm and incompressible. In nine out of ten
cases, indolent ulcers form on the leg, and the nearer they are to the
ankle, the more difficult they are to cure. The patient is also generally
above the middle age. In the majority of cases, the pain is so trifling,
that the patient is scarcely conscious of having a sore at all.
The mode of dressing an ulcer may communicate this indolent cha-
racter to it ; thus, when fomentations, emollient poultices, or lint wetted
with tepid water, and covered with oiled silk, are continued too long, the
granulations become large, pale, and flabby, and the healing will not
proceed. But, if we could succeed in healing the sore with such appli-
cations,, and with the work of such granulations, the cicatrix would be
too weak to remain sound a long time ; and the part would soon break
out again into a fresh sore. On the other hand, if we take care to
stimulate these weak granulations by means of suitable dressings, they
undergo considerable improvement in their nature, becoming smaller,
more compact, redder, and free from their former gloss or semi-trans-
parency, and the cicatrix will be likely to prove lasting and serviceable.
With respect to applications to indolent ulcers, the following are in
common use : a solution of the nitrate of silver in the proportion of five
or ten grains to an ounce of distilled water ; the application of the nitrate
of silver in substance ; the diluted nitrous acid ; the ointment of the
nitrate of quicksilver, mixed with an equal quantity of spermaceti oint-
ment ; the compound tincture of benzoin; the yellow basilicon ointment,
with one drachm of red precipitate to each ounce of it.
When the surface of a chronic ulcer is foul, the discharge thin and
offensive, the chloruret of soda in a poultice, or lotion, will often produce
vast improvement. The strength of the application should be regulated;
but, from three to six parts of distilled water to one of the concentrated
Mution sold in the shops, will suffice for ordinary use. When a lotion is
us.ea> lint should be dipped in it, put on the ulcer, and covered either
with a common pledget, or piece of oiled silk, to prevent evaporation.
ULCERATION AND ULCERS. 87
Perhaps, however, nothing is more useful in the treatment of indolent
ulcers than well-regulated pressure, made with a common roller, a stock-
ing bandage, or strips of adhesive plaster, put on in Baynton's manner.
Pieces of soft linen are to be then laid over the part, and the whole leg
evenly covered with a calico roller. If the discharge be not very pro-
fuse, the plaster need not be changed oftener than every other day. In
summer, or when the parts are disposed to inflame, we cut the plasters
at the point opposite the sore, and keep the bandage and plasters wet
with cold spring water. Under this treatment, the swelling of the limb
subsides, the callous edges are levelled, the surface of the ulcer granu-
lates, assumes a healthier colour, begins to form good pus, and to heal
up. When common adhesive plaster is found to be too irritating to the
skin, we may employ either the emplastrum plumbi, or the brown soap
plaster and ordinary adhesive plaster blended together in equal quanti-
ties. We should be careful, however, not to extend this practice to
irritable ulcers.
Mr. Higginbottom treats indolent sores in the following way : he keeps
the patient in bed twenty-four hours, and puts a poultice on the part ;
he then applies the nitrate of silver, not merely to the ulcer, but to the
surrounding skin ; afterwards covering the sore with strips of adhesive
plaster, and a bandage.
When the ulcer is on the foot or lower part of the leg, the strips of
plaster may be applied as follows : they are to be fifteen inches long and
two wide ; the foot being placed at a right angle with the leg, one of the
strips is applied from the first bone of the great toe, along the inner
edge of the foot, round the os calcis, to the first bone of the little toe ;
the middle of another strip is placed under the heel, and its ends carried
perpendicularly up over each side of the leg ; the circular and perpen-
dicular strips are then continued alternately, and thus the foot and ankle
are entirely covered, the strips having a very neat appearance, and
not only making the requisite pressure, but keeping the ankle perfectly
quiet.
Phagedenic ulcers literally mean any sores which eat away the parts,
as it were, and truly their appearance conveys such an idea. Their sur-
face, which has a yellowish, or livid appearance, is so irregular, that one
might suppose it had been really produced in the manner referred to.
The matter secreted is only in small quantity, generally adherent to the
surface of the sore, and not unfrequently tinged with blood.
Phagedenic ulcers are frequently met with in syphilitic cases, but they
occur also under many other circumstances. Thus, cancrum oris, as it is
termed, is a true specimen of phagedenic ulceration of the mucous mem-
brane of the lips and cheeks ; and the gangrenous affection of the pudenda
in children, described by Mr. K. Wood, is another variety of the same
disease. We may also observe that, though scrofula generally produces
sores of an indolent character, it sometimes gives rise to phagedenic
ulceration of a very troublesome and inveterate description. Cut, when
phagedaena takes place in syphilis or scrofula, it is an accidental compli-
cation, and not any essential part of those specific complaints.
Phagedenic ulceration in its worst forms, as arising in syphilitic cases,
or perhaps, as we should rather say, those seen in the foul wards of
hospitals, and produced by the bad atmosphere of such places, the
noxious effect of mercury itself, and a constitution impaired by excesses
bears a considerable resemblance to hospital gangrene. It begins £ur-
some minute point of ulceration or abrasion, or as a small >• '
G 4
88 ULCERATION AND ULCERS.
rounded by a halo of dusky red inflammation. It is often met with in
the lowest class of filthy gin-drinking prostitutes ; and one variety of it
is well known at St. Thomas's and Guy's hospitals under the name of the
Siuan Alley sore, in consequence of the many young girls, who come
from that notorious place, being afflicted with it. Its most common situ-
ations are the cleft of the nates, the groin, or the upper part of the thigh.
I have seen it occupy the arm from the shoulder to the elbow, so as to
expose the brachial artery in the greater part of its track ; but much
more frequently in the groin, where, and in the thigh, its ravages were
such as to lay bare the femoral artery. The disease is attended with
severe darting pain, which is at first remittent, but afterwards incessant.
The exposed surface is covered with a straw-coloured flocculent substance,
and a viscid secretion. The surrounding edges are thickened, abrupt,
frequently everted, and always connected with a mass of swollen red-
dened integuments.
Hemorrhage soon occurs, and, returning from time to time, contributes
seriously to the reduction of the patient's strength. The fetidness of the
discharge is such, that no person can enter the ward without being conscious
of its peculiarity. A man of experience recognises it almost as a proof
of the nature of the disease. At length, the sore having become deep, a
copious quantity of foul matter, and shreds of a pulpy substance, are
taken away every time the dressings are changed.
The disease is often terrific, on account of the rapidity of its progress.
Its commencment is sometimes attended with little febrile disturbance,
but, in its advanced stages, the general indisposition is as alarming as it
was at first slight. The patient is sleepless from constant agony, the
appetite lost, the tongue covered with a white or brownish fur, the
epigastrium tender, together with severe headach, an accelerated pulse,
a sallow skin, and, when the disease spreads with great rapidity, bilious
vomiting, or diarrhoea. Delirium is rare.
Disease of this description sometimes attacks several patients in the
same ward, hospital, or district. Hence it is occasionally supposed to
be of the same nature as hospital gangrene, and to be, like it, contagious.
It is some corroboration of this opinion to remember, that here, as well
as in hospital gangrene, local remedies are at least as important as con-
stitutional ones. In the commencement of phagedaena, bleeding will
sometimes relieve the pain, and have other good effects, yet on account
of the natural tendency of this disease to hemorrhage, venesection
should not be carried to any great extent. Local bleeding is not ap-
proved of, however, because the leech-bites sometimes assume the same
morbid action, just as is seen in hospital gangrene. It does not appear
that bark, quinine, or the diluted acids, have any specific power over the
disorder, though, in the stages of debility, they may be prescribed, while
there is no diarrhoea. They should also be given with port wine, and a
nutritious but light diet. Opium, and especially the muriate or acetate
of morphia, are the best internal medicines, and the patient should be
kept constantly under their influence, with due attention to the regu-
lation of the bowels.
Mr. Welbank, who drew up an excellent history of gangrenous phage-
daBna, found the application of the undiluted nitric acid to the surface of
the disease the surest means of stopping it ravages. The surrounding
skin is first to be protected by a thick coating of cerate. Lint is then to
dipped in the acid, and pressed on the part. The surface, having
converted into a firm and dry mass, is next to be covered with
UICERATION AND ULCERS. 89
simple dressings, and an evaporating lotion. If any other sloughs form
after the separation of the first, the use of the nitric acid is to be re-
peated.
In France, a solution of the chloruret or chloride of sodium is much
employed as an application to phagedenic sores. The strength is one
part of the concentrated solution to eight or ten of distilled water. The
fluid may be blended with a poultice, or lint may be dipped in it.
Many phagedenic diseases arise from the patient's being in a bad
atmosphere, and then the best medicines and applications will be of little
use, unless the patient be removed from the pernicious influence of the
unwholesome air and effluvia to which he is exposed.
Pure air, free ventilation, cleanliness, fumigating 'the room or ward,
sprinkling it with the chloride of sodium or lime, are all proper measures
in the treatment of phagedenic ulcers. We are to employ purgatives
and venesection, when there is inflammation, &c. ; and when great de-
bility is present, bark, quinine, the diluted sulphuric or nitrous acid, with
a light nutritious diet, and wine. As for dressings, carrot poultices,
bread poultices, a watery solution of opium or hyosciamus, the liq. opii
sedativus, with a pledget or poultice over the lint ; a bread poultice made
up with a solution of the chloride of soda ; the nitrous acid lotion, or the
black or yellow wash, may be tried. In bad cases, amounting to gan-
grenous phagedaena, it is sometimes necessary to apply the liquor arsen.
diluted, or the concentrated nitric acid itself.
Dupuytren's powder, composed of four pavts of arsenical acid and
ninety-six of submuriate of mercury, has proved efficacious in curing
certain phagedenic ulcerations about the face ; but it must never be put
on any ulcerated surface to an extent beyond what a shilling would
cover.
Ulcers connected with varicous veins are peculiar to the lower extre-
mities, and mostly occur either on the inside of the leg, near the ankle,
or on the instep. A varicous state of the veins seems to produce vast
disorder in the capillary circulation, and a tendency to chronic inflam-
mation in the skin of the leg, often denoted by brown dusky discolour-
ations of the integuments, terminating in the formation of an ulcer.
The edges of the sore are generally indurated, raised, and callous, while
its colour and that of the neighbouring skin are brownish or livid. The
pain is considerable, but often more felt in the neighbourhood of the
sore, and in the course of the principal veins, than in the sore itself.
In the early stage of varicous ulcers, while inflammation is present,
leeches and simple dressings, with evaporating lotions, purgative medi-
cines, quietude in bed, and low diet, are the best means of relief. Some-
times, however, fomentations answer better than cold evaporating lotions ;
and frequently the best application to the ulcer at first is lint wetted with
tepid water, and covered with oiled silk. Afterwards, one of the prin-
cipal indications is to take off the weight of the column of blood in the
diseased veins, or to obliterate all direct communication between those
veins and the venous branches returning from the parts about the ulcer.
Hence, the practice of taking up the trunk of the vena saphena as it
passes behind the knee joint ; an operation now very properly abandoned,
on account of the dangerous consequences frequently arising from the
tying of large veins ; namely, those resulting from phlebitis.
Instead of this method, Sir Benjamin Brodie suggested another, which
consisted in passing a narrow convex-edged bistoury under the veij
with the flat side of the blade at first turned towards the "
90 ULCERATION AND ULCERS.
simply dividing it, without cutting the skin over it. There are some
other practitioners who attack varicous veins with caustic, applying it so
as to bring on a degree of inflammation in the dilated vein, near the part of
the skin on which it is put, just sufficient to produce an effusion of fibrine
within the vessel, and its subsequent obliteration. But, a better plan is
that of passing a long steel pin under each of the veins which it is wished
to obliterate, and then applying some thread, or silk, in the manner of
the twisted suture. The pin should be withdrawn on the third day, and
not be left to make its way out by ulceration. Except in cases attended
with remarkable obstinacy and severity, the patient should be content
with a well applied bandage, laced stocking, or the stocking roller, with
dressings adapted to the particular condition in which the ulcer and sur-
rounding skin may happen to be.* If inflamed, we should defer the
bandage, but keep the patient in bed, use leeches, simple dressings, and
evaporating lotions, or poultices, and fomentations, always keeping the
limb strictly quiet in the recumbent position, or rather with the foot and
leg raised above the level of the thigh. When the sore is foul, we may
employ poultices, or dress it with a solution of the chloruret of sodium.
When the inflammation has subsided, we may have recourse to equable
pressure, applied from the toes to the knee, with any dressing or appli-
cation which the appearance of the granulations may require.
With regard to specific ulcers, those produced by scrofula, the vene-
real disease, fungus heematodes, chimney sweeper's cancer, common
cancer, &c. will be considered in future parts of this volume.
Sir Everard Home has described, as a specific ulcer, a sore that some-
times occurs on the instep, or foot, attended with enormous thickening
of the integuments, something like that of elephantiasis. The disease is
met with in persons who have lived freely. The application, said by him
to agree best with this kind of sore, is the ointment of the nitrate of
quicksilver, with a proportion of camphor in it. He also describes a
fungated ulcer of the calf of the leg and sole, which he represents as
curable by the internal and external use of arsenic, unless attended by
disease of the lymphatic glands, when he always found it incurable. A
case, corresponding to the latter, was under my care in University Col-
lege Hospital in the year 1835, and the parts are preserved in the mu-
seum of the college. The disease, which implicated also the inguinal and
lumbar glands, presented a combination of medullary with scirrhous
cancer.
Hitherto the observations, delivered in this work, have chiefly related
to common inflammation, and its occasional consequences; but other
kinds of inflammation and their effects remain to be considered., without
some knowledge of which we should not be able to acquire even an ele-
mentary proficiency in surgery. The species of inflammation, which will
next be noticed, are erysipelas, diffuse inflammation of the cellular tissue,
and the inflammation accompanying boils, carbuncles, and the malignant
pustule. All these varieties are characterised by peculiarities not seen in
common inflammation, nor in the inflammation directly resulting from
certain specific diseases, as syphilis, scrofula, and cancer.
* Some additional remarks on this subject will be found in the section on " Diseases
of the Veins."
ERYSIPELAS. 91
ERYSIPELAS.
A peculiar inflammation of the skin, characterised in its simple and
genuine form by the bright red colour of the part affected ; by a propen-
sity to spread with remarkable rapidity ; by a diffused, not a circum-
scribed, swelling of the skin and cellular tissue under it ; and an indispo-
sition in the morbid action to be speedily checked by the establishment
of that process, which Mr. Hunter called the adhesive inflammation.
To define it merely as an inflammation of the skin, would not, how-
ever, be correct, because in one of its forms it affects the subcutaneous
cellular tissue even in a greater degree than the skin. Besides, in many
instances, the disorder is in reality a fever, beginning with constitutional
disturbance, which is followed by this peculiar inflammation of parts of the
surface of the body.
In popular language, the disorder is known under the name of St. An-
thony's Fire; and when the skin presents a light red hue, tinged with
yellow, it is sometimes called the rose.
No inflammation, except that of mumps, gout, or rheumatism, is so
subject to change its place suddenly as erysipelas. Neither is there any
inflammation in which the sudden resolution of inflammation, to which
the French pathologists apply the term delitescence, is so frequently
and so dangerously exemplified.
Of all cases of erysipelas, that of the head and face is most liable to
delitescence, preceded or followed by inflammation of the brain or its
membranes, and coma or delirium. If any parts suppurate, they are
generally the eyelids. The disorder may arise, not only from fever, but
local injuries — especially ^wounds, pricks, or contusions of the scalp. The
skin of the face and %head, indeed, are particularly liable to erysipelas
mi vervglight injuries.
Erysipelas is generally defined to be a peculiar inflammation of the skin,
characterised by a propensity to extend with great rapidity, though one
form of it certainly affects the cellular tissue in a greater degree than the
cutis, and, according to Baron Dupuytren, really commences in it. John
Hunter believed that erysipelas, when viewed as an inflammation, marked
by a great propensity to spread over an extensive surface, denoted the
existence of a peculiar state of the constitution, without which the patient
would have experienced from any local irritation, not erysipelas, but com-
mon inflammation. He also thought that the seat of erysipelas was not
necessarily restricted to the cutaneous texture, but that when that pecu-
liar state of the constitution prevailed to which I have alluded, all inflam-
mation, wheresoever situated, might partake of an erysipelatous character,
and have a tendency to spread in a greater degree, and with more rapidity,
than ordinary inflammation. But, although practitioners occasionally
speak of erysipelatous sore throat, and erysipelatous inflammation of the
conjunctiva, and although the extension of erysipelas from the face to the
interior of the mouth, the nassal fossae, the pharynx, and^ven the
cavity of the tympanum, is a fact recorded by Dupuytren and others*,
the view entertained by Hunter on this point, is far from being generally
entertained. Perhaps, the mere circumstance of an inflammation having
a remarkably great disposition to spread, — to run along a surface, as it
* Dr. Macartney, I observe, recognises mucous membrane as a texture liable to e*r
sipelas. Op.cit. p. 137.
92 ERYSIPELAS.
were, — is not an unequivocal proof of its character partaking of an
erysipelatous nature connected with peculiarity of constitution, because
sometimes the kind of texture affected communicates to the inflammation
that kind of disposition, as is well illustrated in the inflammation of every
serous membrane.
When the skin is merely affected with redness, is not perceptibly
swelled, has no vesications upon it, and is of its usual softness, the case is
termed erythema, which may or may not be the first degree of erysipelas,
according to the general state of the system, on which the latter essen-
tially depends. When the slight redness of the skin, called erythema,
is produced in a healthy subject from any stimulation of that texture, by
friction, heat, &c. it cannot be regarded, according to the foregoing doc-
trines, as a stage or degree of erysipelas.
Erysipelas is divided into simple or superficial, phlegmonous, and cede-
matous.
Some distinctions, occasionally specified, do rnot imply any peculiar
varieties of the disorder, and in this respect are superfluous : thus malig-
nant, or gangrenous erysipelas, is only a stage of phlegmonous erysipelas,
and erysipelas erraticum is merely a term applied to the disease when it
continues to spread from one part of the skin to another, to an unusual
extent, and for a longer period than common, thus visiting sometimes
nearly the whole surface of the trunk, limbs, &c., in succession.
In simple or superficial erysipelas, the skin is of a bright red colour,
smooth, and shining, the redness being in general more or less bounded
by a definite line, and not gradually fading away at the circumference of
the part affected, like the redness of phlegmonous inflammation. WThen
the part is pressed upon with the end of the finger, the redness disappears
in the place which has been touched, leaving a white spot visible for a
short time, but which is quickly obliterated again by the return of the
red colour. In simple erysipelas, the circulation is not impeded, and
hence the pressure of the finger on the skin removes the red colour,
which immediately returns when the pressure is discontinued. The same
fact accounts also for the bright red colour, the arterial blood being
readily transmitted into the capillary veins. Probably, as Dr. M. Hall
observes, it is by the stagnation of the blood in the capillaries, that
common inflammation differs from mere blushing, from eruptions, and,
in some degree from erysipelas.* There is no throbbing like what
attends phlegmonous inflammation ; and, if the skin alone be affected,
hardly any perceptible swelling, and no tension. Still, when the finger is
passed along the part, a trivial degree of stiffness, and a different feel
from that of the rest of the skin, are manifest. Except in slight cases,
however, there is always some fluid effused in the cellular tissue, and con-
sequently a softish swelling. The inflamed part is hot and painful, the sens-
ation at first experienced by the patient being that of an itching or pricking,
but this soon becomes a burning kind of pain, and, when the parts are
handled, extremely acute. The disease is frequently, but not always,
attended with vesications, a thin serous fluid being effused under the
cuticle, and raising it into small vesicles, or large bullce or blebs, like those
produced by a blister. Generally they contain a ^yellowish fluid, but
sometimes a gelatinous substance, and now and then a bloody liquid, or
pus. At length .they burst, and incrustations, or scabs, are formed,
Principles of Medicine, p. 17.
ERYSIPELAS. 93
which, in a few days, fall off, leaving the skin under them mostly sound,
but occasionally eroded by superficial ulcerations.
Simple erysipelas most commonly terminates in resolution, with des-
quamation, or a peeling off of the cuticle, though, if the disorder be
slight, there may be no desquamation at all. When the inflammation is
more severe at some points than others, limited suppurations in the cel-
lular tissue may take place ; but these only happen where the inflam-
mation extends more deeply than usual, and affects the cellular tissue
in certain situations with greater severity than in others. It is the nature
of simple erysipelas to extend rapidly, and hence it will frequently pass over
a large portion of the surface of the body in a short time. Another fea-
ture of the complaint is, its disposition to get well on one side, while it is
spreading in another direction. Hence it frequently presents itself in all
its different stages in one and the same person at the same period. In
one place, that which was first attacked, there is perhaps desquamation ;
in the part last invaded, there is redness and swelling ; at other points
vesications ; in other situations again, incrustations, or scabs ; and, in a
few places, if the disease has been severe, possibly a degree of suppu-
ration. As the inflammation declines, the redness fades, the part then
frequently exhibiting a yellowish tinge. One striking difference between
phlegmonous and erysipelatous inflammation is, that the former is circum-
scribed, whereas the latter has no precise limit ; for though the redness
is terminated by a more or less abrupt line, the swelling from the effusion
of serum in the cellular tissue is diffused, without any definite boundary.
In fact, erysipelas is attended with little or no adhesive inflammation
a'round it, and hence, partly, its uncircumscribed character, and the
extensive disorganisation of the cellular tissue, when suppuration takes
place in the worst, or phlegmonous variety of the disease. Simple erysi-
pelas is attended with restlessness, acceleration of the pulse, headach,
thirst, dryness of the skin, and other febrile symptoms. The most dan-
gerous example of it is that which attacks the head and face, preceded
by shiverings, headach, loss of appetite, and perhaps vomiting, and
afterwards accompanied not only by a frequent pulse and most of the
common symptoms of fever, but often by a lethargic drowsiness, or a
tendency to coma, or delirium. When the latter symptom comes on
early, the disorder is frequently fatal. The indisposition does not sub-
side on the breaking out of the cutaneous redness on the second or third
day, but continues till the local inflammation itself abates, which generally
happens, under successful treatment, about the tenth or eleventh day, fol-
lowed by copious evacuations from the skin and kidneys. If any parts
suppurate, they are usually the eyelids, the cellular texture of which is
abundant and loose. When erysipelas attacks the face, the swelling of the
eyelids, and indeed of every part of the countenance, is such as to pre-
vent the patient from being recognised by his most intimate acquaint-
ance ; the disfigurement is indeed prodigious. The loose cellular tissue
of the eyelids is vastly distended, and, as it were, oedematous f the eyes
are closed and watery ; the nose swollen ; the nostrils dry ; the lips puffed
up; the ears red and shining; the saliva often flows out in profusion ;
and the mouth is opened with difficulty. Erysipelas, in all its forms, is a
species of inflammation, the blood being cupped and buffy.
Phlegmonous erysipelas differs from simple erysipelas in the higher
degree and deeper extent of the inflammation, which not only affects the
skin and cellular tissue, but has a tendency, when severe, and especially
when situated in the lower extremities, to produce in the latter texture sup-
94? ERYSIPELAS.
puration and extensive gangrenous mischief. The skin itself, being more
highly organised, resists the effects of the disease longer, and when it
does slough, does not perish to the same extent as the cellular tissue.
Baron Dupuytren believes, that phlegmonous erysipelas does not affect
the skin originally, but the cellular tissue, the cutaneous texture being
attacked secondarily. This observation is true at all events, I believe,
with reference to that modification of phlegmonous erysipelas described
by Drs. Duncan, Scott, and others, under the name of diffuse inflamma-
tion of the cellular membrane. A few years ago, it was a common notion,
that phlegmonous erysipelas sometimes began in the fasciae ; but this is
never the case. Although, in severe instances, the fasciae may be de-
stroyed, they are attacked subsequently to the skin and cellular tissue,
and, in many post mortem examinations, they are found not to be at all
involved.
In phlegmonous erysipelas, the skin becomes more raised, and the
swelling harder, deeper, and of a darker colour, than in simple erysipelas.
At first, indeed, the part may be of a pale rose tint, with a smooth shining
appearance of the skin ; but, after a little while, the redness becomes
darker, sometimes assuming a brownish or deep, almost a livid tinge. In
many instances,, the discolouration is irregular, the skin exhibiting a mottled
or marbled appearance. At first a sensation of pricking and heat is expe-
rienced, which soon changes into a severe burning pain, and the swelling
becomes such that the limb is frequently of twice its natural thickness.
In the beginning, the swelling yields to the pressure of the finger, or pits,
in consequence of the copious effusion of serous fluid in the cellular tissue,
but afterwards the part becomes so firm, that if pressure be made on it,
no pitting is occasioned, because the cellular tissue has now become
hardened and thickened. In phlegmonous erysipelas, the white spot,
caused in the part when it is pressed with the end of the finger, is not so
quickly obliterated again as in simple erysipelas, neither does the. skin
rise up so promptly to its former level, after it has been made to pit.
As the disease advances, vesicles generally form, varying in size from that
of a pin's head to that of a bean, and very often they are still larger.
Their contents, which are at first a clear serum, frequently assume in a
little while the appearance of a purulent fluid, or of a reddish or turbid
serosity. If the case proceed favourably, the vesicles burst, incrustation
takes place, and the case ends in the separation of the scabs, and desquama-
tion. If the disease attain a more severe degree, the subcutaneous cellular
tissue sloughs, and, often about the fifth or sixth day, the skin itself assumes
a purple colour, loses its sensibility, softens, and becomes covered with
phlyctenas. There is now some sloughing of the skin, but a great deal
more of the subjacent cellular tissue, in which purulent matter is exten-
sively diffused. In fortunate cases, the sloughs separate, the gangrenous
cellular tissue comes out, and the ulcers heal ; but more frequently,
and especially without the aid of surgery, the patient falls a victim to
the constitutional disturbance.
The suppurative stage is not attended with additional swelling, eleva-
tion, and pointing, as in the suppuration that arises from common in-
flammation, but rather with a diminution of tension, a feel of softness,
and a trivial subsidence of the part. Hence, when the disease has arrived
at this stage, it may appear for three or four days as if it were stationary,
or even inclined to recede ; and an inexperienced surgeon may be in-
duced to defer the only measure likely to prevent gangrenous mischief.
In severe forms of phlegmonous erysipelas, there is always an exten-
ERYSIPELAS. 95
sive separation of the skin from the subjacent fascia, and of the muscles
from one another ; often attended with the formation of numerous sinuses
and sloughing of the fasciae and tendons themselves. In very bad cases,
inflammation, ulceration, or even gangrene of the synovial membranes, the
formation of matter in the joints, ulceration of cartilages, and sometimes
caries and necrosis, are the effects of this alarming disease. The con-
stitutional disturbance is often exceedingly severe. In the early stages
of the disorder, the pulse is frequent, strong, and full ; afterwards it in-
creases in number, but its strength and fulness decline. The urinary
and other secretions are suppressed, the alvine evacuations stopped, the
patient has no sleep, there is excessive agitation of the nervous system,
and frequently delirium. In the suppurative and gangrenous stage, the
tongue becomes brown or sometimes black ; at first it is moist, but after-
wards dry, with great foulness of the gums and teeth, and fetor of the
breath. The pulse is very quick (140) and small, and it is not un-
common for it to be irregular. If the disease assume a still more
aggravated form, a bilious vomiting, or a diarrhoea, with involuntary dis-
charge of very fetid dark-coloured matter from the bowels may ensue,
followed by coma or delirium, subsultus tendinum, and death.
In many cases, arising from local injuries, the febrile disturbance at
first closely resembles common inflammatory fever ; but afterwards, if
the disease lead to suppuration and gangrene of the cellular tissue,
or threaten those consequences, the pulse becomes very quick, weak,
and even irregular, with great derangement of the nervous system, and
imminent danger. In many instances, the fatal termination is preceded
by inflammation of the pleura, peritonaeum, or mucous membrane of the
bowels, or lungs.
Too often, when the patient recovers, after long and profuse discharge,
and the slow detachment of numerous deep-seated sloughs of cellular tissue
and other textures, the structure of the limb is so impaired, and the skin,
fascia, muscles, tendons, and bones, all so agglutinated together by
irregular adhesions, that the functions of the part are permanently
injured.
Phlegmonous erysipelas is sometimes the consequence of fever, but
more frequently of accidental injuries, especially of punctured or con-
tused wounds, compound fractures, burns, neglected or irritable ulcers,
the bites of venomous snakes, or punctures and cuts received in dissec-
tion. Sometimes it follows the prick of the lancet in venesection ; and
Dupuytren enters a caution against confounding phlegmonous erysipelas
from venesection with phlebitis ; for sometimes it is accompanied by
inflammation of the vein, and sometimes not. Phlegmonous erysipelas
is often attended with inflammation of the absorbent glands, and with
streaks of painful thickened inflamed lymphatics running up to them, as
is frequently exemplified in phlegmonous erysipelas of the leg and fore-
arm. The two affections, however, are very distinct, and not essentially
connected with one another. Phlegmonous erysipelas of the Ifgs has a
greater tendency to terminate in suppuration and a gangrenous destruc-
tion of the subcutaneous cellular tissue, than the same disease in most
other parts of the body. There the cellular tissue of the limb suppurates
as readily as that of the eyelids or the scrotum, and the pus is not col-
lected in one cavity, but diffused. The cellular tissue indeed is soon
converted into extensive sloughs, several inches in length. Then the
skin, thinned and deprived of its due supply of blood, turns of a livid
colour and also sloughs, more from defect of nutrition than from inflam-
96 ERYSIPELAS.
mation. This consecutive mortification of the skin is remarkably common
in the lower extremity, especially the leg, where the nutrient arteries,
the anterior and posterior tibial, and the peronaealare very deeply placed,
and only communicate with the cutaneous texture by small ramifications,
almost all of which are involved in the destruction affecting the cellular
tissue. On the contrary, phlegmonous erysipelas of the head rarely
brings on sloughing of the scalp or skin, because here the arrangement
of the arteries is very different; the temporal, frontal, and occipital
branches being situated directly under the skin, between it and the
aponeurosis of the occipito-frontalis, so that when the cellular tissue
under the latter part becomes gangrenous, the supply of blood to the
scalp is little interfered with ; the integuments do not mortify ; and if the
pericranium escape destruction, and the membranes of the brain remain
unaffected, the patient often survies. Dupuytren never saw but one in-
stance of sloughing of the skin in phlegmonous erysipelas of the head.
CEdematous erysipelas. Nothing is more common than to observe
cedema of the subcutaneous cellular tissue in the latter stages of simple
erysipelas, and in the first stages of phlegmonous erysipelas. It is indeed
a constant attendant on erysipelas of the eyelids and scrotum. But, by
the term cedematous erysipelas is particularly implied the case, in which the
swelling of the skin and subcutaneous cellular tissue comes on slowly and
progressively, communicating the feeling of oedema, instead of the firm
resistance of phlegmonous erysipelas. The skin, which is smooth and
glossy, pits when pressed upon, and the hollow thus produced is very
slowly effaced. Vesicles on the skin are less common in this, than the
other varieties of erysipelas. If they occur at all, it is usually between
the third and fifth day ; they are small, and on breaking are followed by
thin diminutive incrustations. The labia pudendi, the scrotum, the legs
of dropsical persons, on which scarifications have been practised, are fre-
quently the seats of cedematous erysipelas, often followed by sloughing of
the integuments, a feeble, quick, irregular pulse, vomiting, typhoid symp-
toms, low delirium, and death. CEdematous erysipelas is of a yellowish
brown, or dark red colour. It occurs chiefly in the parts specified, or, if
in others, only in broken anasarcous constitutions.
With respect to the causes of erysipelas, why should any local irritation
produce in one person this form of inflammation, and in another person
common inflammation ? Certainly, the fact is difficult of explanation,
unless we admit the existence of some peculiar condition of the consti-
tution, as a predisposing cause of the disease. Erysipelas is sometimes
prevalent in particular seasons of the year, and states of the atmosphere,
and occasionally endemic in certain districts and hospitals, where tem-
porary or local circumstances may be presumed to be exercising a per-
nicious influence on the system. Intemperance and errors of diet appear
to be frequently concerned in giving a tendency to erysipelas. Dr. Wells's
doctrine of erysipelas being now and then contagious, is one not settled
even at the present time. Fever, cold, and various accidental injuries,
and local irritations, are the usual exciting causes of erysipelas, where the
predisposition to it exists. It is not simple inflammation of the skin.
Simple erysipelas, not of great extent, and unattended with coma or
delirium, generally has a favourable termination in about ten days. I
have attended worse cases, which lasted six or eight weeks, leaving after
their termination a tendency to inflammatory affections of the mucous
membrane of the bowels, or lungs, or to the formation of large boils, and
very fetid abscesses in various parts of the body. One young woman,
ERYSIPELAS. 97
whom I attended, died soon after a severe attack of erysipelas, in conse-
quence of a large and suddenly formed abscess of the hip.
Erysipelas of the head, phlegmonous erysipelas of the leg, or affecting
the armpit and breast, and cedematous erysipelas in a broken or dropsical
constitution, are the most dangerous examples of the disease.
Mild cases of simple erysipelas yield to saline purgative medicines,
diaphoretics, and low diet. Dissolve one ounce of sulphate of magnesia
in five and a half ounces of mint water, and add to the mixture half an
ounce of antimonial wine. Two table spoonfuls of this may be given every
four hours ; or five grains of blue pill, or three of the submuriate of mer-
cury, may be administered every night, or every other night, or calomel
with James's powder, followed by a solution of sulphate of magnesia in
the common saline or effervescing saline mixture, which should be re-
peated at intervals.
More severe cases require venesection, and the free application of
leeches. This practice is particularly necessary where the patient is
young and plethoric, the pulse strong, hard, and frequent, and, in all cases,
where the head is the seat of the disease.
When simple erysipelas is accompanied by uneasiness about the sto-
mach, a foul tongue, headach, and fetid breath, an emetic, followed up
by a brisk calomel purgative, should be given. The old doctrine of
erysipelas being essentially dependent on debility is now much on the
decline. This is fortunate, because it led to the neglect of depletion in
the early stage, the period offering the best opportunity of keeping down
the disease. The idea also, respecting the specific power of bark, over
erysipelas, influences but few practitioners of the present day ; bark, the
sulphate of quinine, sulphuric acid, and other tonics being only useful
after the disease has been checked by bleeding and other antiphlogistic
measures. After this has been done, indeed, not only bark and quinine,
but cordials, wine, ammonia, and a light nutritious diet, may become
highly beneficial. Ventilation and cleanliness are of vast importance in
all stages of erysipelas.
When the disorder suddenly recedes, and internal organs are attacked
with inflammation, the part originally affected should be immediately
covered with a blister. When erysipelas is spreading up a limb, or from
the chest or arm towards the neck, its extension in such direction has
sometimes been effectually prevented by making a black line on the skin
with nitrate of silver, a little beyond the part affected. With regard
to local applications, fomenting the inflamed surface with decoction of
poppy heads, or simple warm water, or moistening it lightly with a feather
dipped in mucilage of quince seeds, are plans frequently adopted. When
simple erysipelas arises from a wound, or other local injury, cold evapo-
rating lotions are the best in the early stage of the disorder. Powdered
starch, flour, chalk, or calamine, applied for the purpose of absorbing the
fluid discharged from the vesicles, is not so frequently used at the present
day as formerly. The application of mercurial ointment is sometimes
commended, as having a specific power in stopping erysipelas ; Professor
Gibson speaks very highly of the plan* ; but, in this metropolis, it does
not retain many advocates. Rubbing the nitrate of silver on the inflamed
skin, and beyond it, or blackening the part with a strong solution of the
same caustic, I believe, with Dr. Macartney, to be more useful than either
* Institutes and Practice of Surgery, vol. i. p. 41. ed. 5.
H
98 ERYSIPELAS.
mercurial ointment, or blisters ; though not to be trusted for the relief of
phlegmonous erysipelas in a severe form.
In phlegmonous erysipelas more rigorous antiphlogistic treatment is
necessary than in simple erysipelas, and especially general and local
bleeding, and the administration of calomel, followed by saline purgatives
and tartarised antimony. In the very beginning, cold evaporating lotions
often prove more effectual than warm applications ; I have found this to
be the case, and Dupuytren's experience is in favour of the practice.
We are to persist in depletion, and employ cold or warm applications so
long as there is any chance of resolution. But immediately it is manifest
that, notwithstanding our utmost exertions, the cellular tissue is becoming
more and more gorged with fluid, and that suppuration and gangrene of
that texture would be likely to follow the continuance of such treatment,
then the indication, requiring prompt attention, is to make a sufficient
number of punctures or incisions, so as to discharge from the cellular
tissue the great quantity of fluid which distends it, and has a principal
share in bringing on mortification of it.
When matter has formed, or sloughs have occurred, all surgeons have
long concurred in the necessity of making free incisions ; but, in an earlier
stage, where fomentations, or cold sedative lotions, applied freely and
constantly, and rigorous antiphlogistic means, fail to check the disease,
punctures or incisions are now universally acknowledged to be the most
likely means of preventing gangrene of the cellular tissue/Jby discharging
the serous fluid with which it is gorged. For this improvement we are
indebted to Mr. Copland Hutchison.
The poultices or dressings are to be often changed, and the discharge
carefully sponged away. Out [of the openings we are to remove all
loose portions of disorganised cellular tissue, but to avoid pulling them
away before they are loose.
The lodgment of matter is to be carefully prevented by incisions, and
its re-accumulation by compresses and a bandage, as soon as the parts
are quiet enough to bear them. After a time, indeed, bandages become
of great service for removing the oedema and swelling.
Baron Dupuytren, in his mode of dressing abscesses and ulcers occa-
sioned by phlegmonous erysipelas, takes particular care not to let the
dressings confine the matter. After the discontinuance of the poultices,
he puts slips of old linen, spread with a mild astringent ointment over the
edges of the ulcers, and then lays over their centre a piece of soft old
linen, which has numerous apertures cut in it, and spread with the same
ointment. In order to expedite the healing, we may occasionally employ
a weak solution of nitrate of silver.
The tedious length of time which some of these cases occupy, the
protracted irritation, the profuse discharge, the number and extent of
textures injured, must be productive of dangerous degrees of weakness
and hectic fever. Hence tonics, wine, pure air, and light nourishing
articles of food, are frequently of great importance in enabling the con-
stitution to continue the struggle. But, sometimes nothing will give a
chance of saving life but amputation.
With respect to erysipelas of the scalp resisting venesection, leeches,
tartarised antimony, calomel, and other means of depletion, surgeons
have been many years in the habit of treating it by making a crucial
incision through the skin, cellular tissue, and aponeurosis of the occipito-
frontalis, so as to free the parts from tension. In twenty-four hours, the
FURUNCULAR INFLAMMATION. 99
patient is frequently relieved by such treatment, and the delirium and
other bad symptoms stopped.
Whenever erysipelas seems connected with gastro-intestinal inflam-
mation, leeches may be applied to the epigastrium.
In the treatment ofcedematous erysipelas, the constitution will not bear
loss of blood. Here aperient and tonic medicines, and sometimes iodine,
may be prescribed with advantage. The part may be fomented with
decoction of camomile flowers, to which may be added a proportion of
camphorated spirit. If sloughing occur, we are to use poultices. In this
form of erysipelas, the parts will not bear incisions without risk of gan-
grene. The quantity of fluid, however, sometimes renders punctures in-
dispensable, but they should be small, and made with the fine point of a
lancet. In the decline of the disease, a bandage is of great service.
Diffuse inflammation of the cellular texture differs from phlegmonous
erysipelas in the cutaneous inflammation itself being absent or trivial.
The skin, instead of being hot, as in phlegmonous erysipelas, is colder
than natural. In some cases, the inflammation runs its course, and ter-
minates in extensive suppuration and sloughing, without any redness ;
and, in all true cases, the inflammation of the skin, when it does occur,
is secondary.
The disease arises from external injury, sometimes from punctures
received in opening bodies, sometimes from the bites of venomous rep-
tiles, and frequently from fever. It often occupies the cellular tissue
of a whole limb, and proves fatal. In the cases related by Dr. Duncan,
when the cause of the disease had been applied to any part of the hand
or arm, the seat of the secondary inflammation was chiefly in the
axilla, extending towards the sternum, up the neck and down the side,
as far as the os ilium ; and, in Professor Dease's case, even to the thigh
of the affected side. The disorder sometimes shifts its place from one
side of the body to the other. It is mostly accompanied with excessive
constitutional irritation, fever of a typhoid character, extreme muscular
debility, and mental depression.
In the treatment of diffuse inflammation of the cellular tissue, the plan
will depend upon the nature of the exciting cause. Thus, the bites of
venomous reptiles, and of wounds received in dissection, may require
constitutional remedies not called for in other cases. For the most part,
leeches and cold applications are to be preferred in the early stage, but
afterwards fomentations. Blisters are beneficial by producing a copious
discharge of serum ; but, when much fluid is effused in the cellular
tissue, the best practice is to make free incisions for its discharge.
Notwithstanding the affection of the skin be only secondary, and that of
the cellular tissue primary, I see in this disorder a great resemblance
to phlegmonous erysipelas, of which, perhaps, it may be only a variety.
FURUNCULAR, CARBUNCULAR, AND OTHER GANGRENOUS
FORMS OF INFLAMMATION.
]. Furuncular inflammation is exemplified in the complaints called
boils and styes. If the investigations of Baron Dupuytren have been con-
ducted with accuracy, there are conical elongations of the subcutaneous
cellular tissue extending into the texture of the cutis, as coverings of the
vessels and nerves proceeding to its surface. Now, it is alleged, that it
H 2
100 CARBUNCULAR INFLAMMATION.
is the inflammation of one of these elongations of the cellular tissue which
constitutes a boil, just as a simultaneous and confluent inflammation of
several of these processes of cellular tissue takes place in carbuncle. Of
course, it is not meant that the inflammation is confined to the cellular
tissue ; for, the skin always participates in it. Whether the foregoing
statements be true or not, a boil may be described as a circumscribed,
prominent, hard, very painful tumour, of a conical shape, with a portion
of dead cellular tissue in it, its apex being above the level of the
surrounding skin, and its base below it. Its colour is a dusky red, often
inclining to purple. Between the fourth and the eighth day, the apex
turns white, softens, and bursts, giving issue to a small quantity of thin
bloody matter, and at the bottom of the little opening a part of the mor-
tified cellular tissue, termed the core, is perceptible. The generality of
boils do not become larger than a marble or walnut, though some few
attain the size of a pigeon's egg.
The conical prominent shape of a boil exposes it very much to friction
of the clothes and external injury; and considerable pain and annoyance
are common consequences of such a tumour. Between the tenth and
twelfth day, the core becomes loose, and, on its evacuation, a cylindrical
gaping cavity is left, reaching from the apex to the base of the swelling.
After this the pain ceases, the skin gradually resumes its proper level,
and the cavity granulates and heals.
Boils are most frequent in children and young plethoric individuals.
They are also common after acute febrile diseases, typhus, measles, small-
pox, attacks of erysipelas preceded by fever, and in persons who drink
ardent spirits.
Although Dr. Macartney believes, that if the water-dressing be resorted
to in the beginning, boils will seldom exceed the size of peas, and produce
no pain ; and although certain experiments made by Dumeril and Bre-
tonneau, and the observations of Mr. Higginbottom, on the use of nitrate
of silver, prove, that boils may sometimes be completely stopped and re-
pressed by touching them slightly with caustic at their very commence-
ment, the ordinary practice is to cover them with warm emollient appli-
cations. The core having formed and become loose, its evacuation is the
chief indication. For this purpose, the boil, when sufficiently mature,
should be opened. Should the patient be very timid, and the boil only
small, it may be covered with a piece of adhesive plaster, which will ex-
pedite the ulceration of its apex, and promote the discharge of the little
mass of disorganised cellular tissue. Few boils are severe enough to
require local bleeding ; but, if a boil occur in the perinacum, between the
scrotum and anus, it may bring on a difficulty of expelling the urine.
Here, or wherever a boil causes inflammation of the lymphatic glands, or
is of a large size, or there is more than one such tumour, antiphlogistic
treatment should not be neglected. In particular, when boils follow one
another for a long time in succession, a course of aperient and alterative
medicines is indicated. After a boil has been opened, a poultice may be
applied for a day or two, and then stimulating dressings.
ANTHRAX OR CARBUNCLE.
The term anthrax is sometimes not used synonymously with carbuncle,
or what the French call charbon, which Dupuytren, Kayer, and others,
restrict, to a gangrenous swelling that occurs as a symptom of the plague.
This is often named the pestilential carbuncle, in order to denote its dif-
ference from anthrax, or common carbuncle.
CARBUNCULAR INFLAMMATION. 101
Anthrax, or carbuncle, is a broad, flat, distinctly circumscribed, hard,
painful, inflammatory swelling, of a dark red, livid, or dull brown colour,
beginning in the subcutaneous cellular tissue, a considerable mass of
which is in a mortified state, while a bloody sanious matter occupies the
interior and base of the swelling. A carbuncle differs from a boil in the
greater flatness of its surface, the more violent nature of the inflammation,
the deeper and more extensive sloughing under the skin, the greater
breadth of the disease at its base, the more severe character of the con-
stitutional disturbance, and the kind of individuals in whom the disease
presents itself. It differs also from a boil in its greater size, in its being
almost always a single solitary tumour, which at length bursts, not by one
small opening, like that on the summit of a boil, but frequently by several
apertures, which give the skin a sievelike appearance. Like a boil,
however, the common carbuncle generally occurs on parts of the body
where the skin is thickest, and where the cells of the cellular tissue are
most fully developed, as in the nape of the neck, over or between the
scapulae, on the back, the sides of the chest, or about the nates. I have
seen several instances of carbuncle on the occiput, and although the dis-
ease is rare on the limbs, John Hunter mentions having seen it so placed.
When it occurs on a limb, the thigh is the part mostly affected. I had a
patient in University College Hospital, who had a large carbuncle on the
left side of the neck. While boils are never larger than a pigeon's egg,
carbuncles sometimes attain the diameter of a common dinner-plate ; and
they may become of this size in the course of a week or ten days. A
carbuncle begins as a little swelling, not more than a few lines in breadth,
with some resemblance, in this stage of it, to a boil, but sometimes pre-
senting upon its centre a little vesicle filled with bloody serosity. Occa-
sionally, however, a larger surface is affected in the very beginning. In
proportion as a carbuncle increases in size, it becomes more prominent,
but extends in a still greater degree in depth. At every point the
swelling retains a singular degree of hardness, a hardness often compared
to that of brawn, until the cellular tissue begins to slough ; then its
circumference continues hard, and its base to spread, while its centre
presents an obscure fluctuation. The deep purple colour of the skin
does not disappear under pressure ; and the sensation of heat, which is
from the first of a burning kind, only diminishes after one or several
apertures have been formed. The disease is also well known to be
attended with a sense of stiffness, tension, and weight in the part. If the
disease be suffered to go on, the skin, after assuming a deep purple, or
dull brown red colour, becomes thinned and softened, and at length bursts
at one or more points, from which flows a bloody discharge, mixed with
whitish flakes of mortified cellular tissue. Then additional perforations
of the skin follow, out of which may be extracted a white core, or gan-
grenous mass, all at once or piecemeal. The mortified cellular tissue
in carbuncles is never black, like an ordinary slough. The smell of the
discharge is exceedingly fetid, yet peculiar ; quite different fr*om that of
putrid animal matter. The white flakes of cellular tissue, and the white-
ness of all the sloughs, which come away with the matter, explain the
reason of Sir Astley Cooper's statement, that the matter of carbuncles
generally looks like a mixture of flour and water.
If nature herself prove adequate to the discharge of the mortified
cellular tissue, she is only capable of doing so slowly, and by an ulcerative
destruction of the skin, whereby all the sloughy cellular tissue is by
degrees voided, and a very deep ulcer left, at the bottom of which one
H 3
102 MALIGNANT PUSTULE.
may sometimes see the fascia, the tendons, the muscles, and in some in-
stances even the denuded cervical vertebrae.
Carbuncles are chiefly seen in persons above the middle age, whose
constitutions are broken and impaired. Hence the disturbance of the
general health, accompanying the disease, is mostly severe, and not un-
frequently the issue fatal. Intense headach, considerable disorder or
the stomach, great anxiety, and despondence, are usual symptoms ; and
in the progress of the disease in its severe forms, rigours, clammy sweats,
bilious vomiting, or diarrhoea, palpitations, faintings, extreme prostration
of strength, white tongue, followed by a dry brown appearance of that
organ, typhoid symptoms, coma, delirium, and death too often follow.
Carbuncles sometimes lead to phlebitis, and thus their fatal termination
is accelerated, as I have had occasion to see.
With respect to the prognosis, if, together with a carbuncle of large
size, there be great prostration of the vital power, a small, rapid, and
irregular pulse, frequent vomiting, and a tendency to coma or delirium,
the danger is urgent. The same is the case if matter form in the joints
or other organs, as effects of the complication with phlebitis.
A carbuncle on the head or neck, cceteris paribus, is more perilous than
in other situations.
As for the treatment, at the very commencement of the disease, leeches
and other antiphlogistic means may be useful, in proportion to the strength
of the patient and the intensity of the inflammation. In this country, the
applications, mostly preferred at first, are fomentations and poultices ;
but, in France, sometimes cold lotions. The best means of stopping both
the local and the constitutional disorder is to make one or two free in-
cisions, in the form of a cross, and carried deep enough to pass completely
through the dead cellular tissue. Some of this may now be pressed out,
and if a poultice of oatmeal and port wine, or the fermenting cataplasm
be used, the rest will soon follow piecemeal, leaving a deep ulcer, which,
as soon as the sloughs have come out, should be dressed with a mode-
rately stimulating ointment or a solution of the nitrate of silver. The ung.
resinae flavae with red precipitate or turpentine, or Peruvian balsam,
is also a dressing in great repute. Antiphlogistic measures can never be
long continued. The prostration of strength, and the typhoid character
of the constitutional disturbance, quickly call for a change of treatment.
Then tonics become necessary, especially the Peruvian bark, the sul-
phate of quinine, sulphuric acid, together with opium or the muriate or
acetate of morphia, to procure rest, and medicines for the regulation of
the bowels.
In some parts of the continent, and also in the United States, the plan
of destroying a portion of the skin over a carbuncle, with the potassa fusa,
as soon as openings form in the tumour, is not uncommonly adopted.*
MALIGNANT PUSTULE.
There are at least four diseases communicable from animals to man,
viz. cow-pox, hydrophobia, glanders, and malignant pustule. This last,
with the pestilential carbuncle, is treated of by liayer under the head of
gangrenous inflammations.
* Physick, in Philadelphia Journ. of the Med. and Physical Sciences, vol. ii. p. 172.
CHEMICAL AND MECHANICAL INJURIES. 103
The malignant pustule is a contagious and gangrenous inflamma-
tion of the skin and cellular tissue, exhibiting on its surface, in the
earliest stage of it, a vesicle not larger than a millet-seed, filled with a
bloody serous fluid, under which is a small induration, that soon becomes
surrounded by a redness like that of a flea-bite (puce maligne). The
indurated point is next attacked with gangrene, which spreads rapidly
from the central point towards the circumference, producing extensive
and fatal ravages,
In cases tending to a fatal termination, the pulse soon becomes small
and concentrated, with extreme restlessness, frequent syncopes, dry brown
tongue, cadaverous countenance, dryness of the skin, dull glassy look of
the cornea, great despondency, pain about the praecordia, and low de-
lirium, the forerunner of death.
The malignant pustule, instead of proceeding from internal causes, like
a carbuncle, usually arises from an external one, namely the direct
application of a specific contagion to the skin, produced in horned cattle,
which labour under or die of epidemic gangrenous diseases. Hence the
disorder is rarely seen except in butchers, slaughtermen, shepherds,
tanners, &c. It scarcely ever occurs in this country, and seldom at
Paris ; though it is not uncommon in Burgundy and some other parts of
the South of France, and in Italy.
Bayle and Rayer are authorities in favour of the possibility of its oc-
casional sporadic commencement in the human subject, a circumstance
not generally admitted. The eating of the flesh of cattle, killed when
affected with epidemic gangrenous diseases, is described by Larrey and
others as an exciting cause. Whether the disease can be communicated
from one human being to another is an unsettled point. Chelius believes,
that such transmission has never been proved.*
In the treatment, deep incisions, and the application of the most power-
ful caustics, as the liquid muriate of antimony, or caustic potassa, are
recommended. Even the excision of the pustule, while it is small, has
sometimes been performed^ and repeated when the gangrenous mischief
did not stop, followed by dressings of stimulating ointments or lotions,
caustic applications, or even the actual cautery. Tonics and stimulants,
bark, sulphate of quinine, the diluted sulphuric acid, wine, aether, ammo-
nia, opium, with aperients, and, if the stomach be much oppressed, an
emetic ; are the best internal means. Antiphlogistic msasures are uni-
versally disapproved of by those surgeons, who have had opportunities of
seeing this form of disease.
OF CHEMICAL AND MECHANICAL INJURIES.
The former comprise burns and scalds, and certain ill consequences
arising from the exposure of the body, or parts of it, to very low temper-
atures. The latter comprehend wounds, fractures, dislocations, sprains,
and contusions.
* Handbuch der Chirurgic, b. i. p. 22. Leipzig, 1826.
H 4
104
BURNS AND SCALDS.
A burn is the effect of the action of concentrated heat upon the living
tissues ; an injury combining in its nature inflammation, a lesion of
textures, and sometimes disorganisation of them. A moderate degree
of radiating heat thickens the cuticle, hardens the skin, blunts its sensi-
bility, and imparts to it a more or less deep brown colour. Such are its
effects upon persons, who are habitually exposed to the solar rays, or to
the heat radiating from powerful fires. Blacksmiths with their rough
horny palms and fingers can touch and hold with impunity pieces of iron
which are nearly red-hot.
A greater degree of radiating heat produces irregular marbled dis-
colourations of the skin, and chaps or cracks in the cuticle, not un fre-
quently followed by ulceration. Such effects are commonly seen on the
forepart of the legs of aged individuals, who sit almost continually close
to the fire. In a still higher degree, radiating heat will bring on redness,
vesication, and all the consequences usually noticed in the first and
second species of burn presently to be described.
A scald signifies an injury arising from the application of a hot, or
boiling fluid to the skin, or a mucous texture. The effect of the momen-
tary application of very hot water to the surface of the body is to pro-
duce pain and redness, followed by a degree of swelling. When the
scald is somewhat more severe, the cuticle is raised from the cutis in the
form of transparent vesicles, filled with a serous fluid. Here the same
change takes place, as follows the application of a blistering plaster, and
this with such quickness, that it has been proposed in some urgent disease
to employ hot water as an expeditious mode of forming a blister.
As water boils at 212° of Fahrenheit's thermometer, the degree of heat,
and consequently, so far as this is concerned, the severity of the injury
itself, attending a common scald, are kept within a certain limitation.
The mischief is therefore generally more superficial, than that resulting
from burns. But, even in this respect, something will depend upon the
length of time the hot or boiling fluid is applied, and the kind of fluid itself;
because oil, greasy soups, and some other liquids, with which these acci-
dents are frequently occasioned, not only take a higher temperature than
that of boiling water, but adhere longer to the parts.
Perhaps, the worst scalds happen to workmen, who fall into coppers of
boiling wort, or to firemen from the descent of boiling water from a
building in flames upon their thick clothes, from which they cannot
quickly extricate themselves. I have attended several children who
were most severely scalded in nurseries, by falling into tubs of hot water
carelessly left in their way ; and I have known many children die from
the accidental spilling of a basin of hot tea or coffee" over their breasts
and bodies.
In most of these examples, the injury, though necessarily severe on
account of its extent, is much and dangerously aggravated by the pro-
tracted duration of the contact of the hot fluid with the surface of the
body. Hence, there is not only an extensive scald, but one, which, if the
patient live long enough, will proceed to ulceration and even sloughing.
But, although scalds are mostly injuries of a more superficial kind than
burns, they are frequently perilous on another account — namely thdr
great extent, arising from the quantity of the hot fluid applied,, and the
rapidity with which it diffuses itself over the integuments.
BURNS AND SCALDS. 105
One case of scald is of a particular kind, inasmuch as it does not arise
from the application of any hot fluid to the skin, but to internal parts ;
and it involves questions respecting .the treatment, which do not present
themselves in other examples. Poor persons sometimes let their children
drink out of the spouts of kettles and teapots. NOSY this is often the cause
of fatal accidents ; for when such children are left by themselves, they
are disposed to drink out of the same vessels, which may now contain a
hot or boiling fluid. The consequences are not always, as might be sup-
posed, a priori, the symptoms of inflammation of the oesophagus and
stomach, but of inflammation of the glottis and larynx, resembling those
of croup, and, under , such circumstances, tracheotomy may become
indispensable to save the patient from impending suffocation. Dr. Mar-
shal Hall, who first drew attention to this subject, suspected, that the
hot or boiling fluid did not actually reach the stomach, or even the
oesophagus, but, that its course was arrested by a spasmodic action of
the muscles of the pharynx. By passing to the fauces, he supposed
that it only scalded the epiglottis and glottis, which became more
and more swollen, until at length the rima glottidis was completely
obstructed. This view is partly correct, that is to say, the larynx
inflames from the injury which it receives; but a case, and the post
mortem examination of it, recorded by Mr. Gillman, prove, that the hot
fluid sometimes passes much further than the foregoing account repre-
sents, the whole interior of the mouth, fauces, pharynx, and cesophagus,
nearly down to the cardiac orifice of the stomach, presenting the usual
appearances of a scald. The lining of the trachea, however, was found
considerably inflamed, with a layer of coagulating lymph adhering to it.
In another case, published by Mr. Stanley, the mucous membrane of the
pharynx, and upper part of the larynx, above the rima glottidis, were
slightly reddened, but that opening itself was pervious. The child died
twelve hours after the accident.
A burn denotes the inflammation and other consequences resulting
from the application of high degrees of heat to the body, in every other
manner than through the medium of water, or other fluids, which do not
admit of a temperature much above 212°. When solid substances undergo
rapid combustion, like phosphorus, sulphur, and resinous bodies, in gene-
ral they occasion deep burns; but, in the contrary case,. the intensity of
their effects is in a ratio to their degree of heat, the duration of their ap-
plication, and the tenderness of the parts. Cceteris paribus, a burn of
parts, habitually exposed to the external air, occasions an injury of less
depth than when it occurs on parts usually covered, and where, conse-
quently, the cuticle is thin and incapable of affording equal protection to
the cutis. Many individuals are severely burnt by the direct application
of the ignited substances themselves, or of the flames issuing from them,
to the uncovered parts of the body, as is exemplified in those who escape
out of buildings in which the flames already occupy a considerable part
of the interior. In other examples, the burn is caused by the clothes
taking fire, when the ascending flames often severely scorch the breast,
neck, and face. In consequence of the light combustible materials of
female dress, women more frequently receive bad and fatal burns in this
particular way than men. On the other hand, various employments, ex-
clusively followed by the male sex, as those of firemen and labourers in
brewhouses, gunpowder-mills, distilleries, laboratories, founderies, and
mines, particularly expose such classes to severe burns produced in other
manners. I have seen many instances, in which men employed to extm-
106 BURNS AND SCALDS.
guish fires, were not only dreadfully scalded by the fall of boiling water
upon them from the heated bricks, but severely and fatally injured either
by the descent of melted lead upon them from the gutters and pipes, or
by their falling into the midst of the flames, in consequence of their
having ventured upon walls or floors which gave way with them. Burns
in such persons are sometimes conjoined with fractures, and other bad
mechanical injuries.
Burns are divided into several kinds, the differences of which chiefly
depend upon the intensity and duration of the heat applied to the parts.
When the heat has not exceeded a certain degree, and its application has
been very transient, the skin may be only a little reddened and tender ; it
may present merely an erythema, an efflorescence, or a superficial phlo-
gosis of the skin, unaccompanied by vesicles. Such is tliejirst or slightest
degree of burn. In a few days, sometimes in a few hours, the redness,
heat, and pain go off, and the inflammation terminates with desquama-
tion. But however slight the burn may be, if it be extensive, the pulse
will become accelerated, the tongue red, and sympathetic irritation of
the mucous membrane of the alimentary canal may be excited. When
the head is the seat of injury, the irritation is liable to be propagated to
the brain, occasioning restlessness, delirium, convulsive twitches, coma,
and even death.
In the second degree of burn, serous fluid is effused under the cuticle,
and vesicles are formed, sometimes immediately, but more commonly
after a few hours.
In the third degree of burn more or less of the surface of the cutis is
destroyed ; a kind of mischief, indicated by grey, yellowish, or brownish
discolourations,, the parts so changed being thin, supple, and not painful,
unless roughly pressed upon. The vesicles, which frequently take place
over the points disorganised in this degree, are usually filled with a
brownish or milky fluid, or a red serosity. In this description of burn,
the pain, which usually subsides at the end of twenty-four or forty-eight
hours, soon returns again with severity, and inflammation comes on
around the eschars, which at length becoming detached, the sore heals,
and a pale cicatrix remains. Although the pain of all burns is acute, it
is much more severe when only the surface of the cutis is injured, than
when it is more deeply destroyed ; a fact, which Dupuytren justly regards
as important with reference to the prognosis.
In the fourth degree of burn, there is a total destruction of the whole
thickness of the cutis, together with a portion of the subcutaneous cel-
lular tissue. The parts are converted into a deep eschar, of a yellowish
or blackish colour, dry, insensible, and harder and tenser, in proportion
as its colour is darker. The sound skin around the eschar is wrinkled
and pinched up, as it were, the folds showing the degree in which the
burnt parts have shrunk and curled themselves up. At the end of three
or four days, the pain begins to be severe ; an inflammatory circle forms
round the eschar, which generally becomes detached about the fifteenth
or twentieth day ; the bottom of the sore then consists of the subcuta-
neous cellular tissue ; a copious suppuration ensues, but granulations soon
spring up with vigour.
Following Baron Dupuytren's classification, I may next observe, that
burns of the fifth degree only differ from the fourth, inasmuch as they
extend to parts more deeply situated. The eschars, composed of muscles,
fasciae, tendons, &c., sometimes include vessels and nerves which are not
yet completely destroyed. The eschars are black and brittle, and require
BURNS AND SCALDS. 10*7
a longer time to be detached than those of a more superficial description.
When they are produced by boiling liquids, however, they are soft, greyish,
and so insensible, that on being touched no pain is experienced. The
suppuration which ensues is profuse, and the subsequent cicatrix is full of
irregularities, the motions of the part being irreparably lost in conse-
quence of the locomotive organs being involved.
In the sixth degree of burn, implicating the whole thickness of a limb,
the surface of the part is completely charred, hard, insensible, and brittle.
Sanson refers to a young man, who put his foot into a gutter, just at the
moment when some fused iron was about to run along it ; the foot and
ankle were annihilated in a moment.
Each of the different degrees of burns, according as a small or great
extent of parts happens to be injured, may either be merely a local
affection, as it were, or the cause of such constitutional disturbance as
will endanger life. This general indisposition may be the immediate
effect of the irritation of the burn, the shock of the injury, or the second-
ary effect of the stages of inflammatory reaction, of suppuration, or of
hectic exhaustion, sometimes induced in the later stages of bad and
extensive burns. A burn may occasion immediate death ; but I believe
this is not altogether from the severity of the pain, as stated by Dupuy-
tren. In fact, he has himself noticed, that, in such examples, there is
generally extreme congestion of the viscera, and effusion in almost all the
large cavities. This quick fatality of burns, however, is more frequent
in children and nervous females than in adults or old persons. If the
patient be not killed in this sudden way, he may be seized with excessive
agitation,, restlessness, spasms, or convulsions, and his pulse may become
small, quick, and irregular. In other instances, a statQ of stupor and
prostration, or collapse, takes place, with a small hardly perceptible pulse,
cold pale skin, slow difficult respiration, and shiverings, the limbs being
motionless and relinquished to their own weight, and the patient either
giving no answers to questions put to him, or answering them reluctantly
and imperfectly. This condition will soon end in death, or be followed
by a general reaction ; a fever, which, when the burn is superficial, but
somewhat extensive, will resemble that febrile disturbance which accom-
panies erysipelas, the pulse being frequent, the skin hot, the digestive
organs disordered, and the tongue dry and red.
In many cases of deep burns, no particular constitutional disturbance
occurs in the interval between the receipt of the burn, and the beginning
of the detachment of the eschars. But, at this period, which (according
to Dupuytren) is usually about the fourth day, inflammation comes on,
attended with a great deal of severe pain. If extensive surfaces be burnt,
either considerable gastric irritation will be noticed, or great oppression
and difficulty of respiration, connected with determination of blood to
the bronchial membrane and lungs. But should the patient be fortunate
enough to get through all these dangers, he will yet have others to
encounter, namely, such as depend upon the extensive ulcers left after
the separation of the eschars, and upon the hectic symptoms brought on
by profuse suppuration.
Amongst the worst complications of burns are tetanus, and phlegmonous
erysipelas, which latter sometimes creates a necessity for amputation.
Another complication of burns of the sixth degree is necrosis, or the
death of bone.
Dupuytren enumerates four periods of danger, as arising from burns :
1. The stage of irritation, as it is termed by him, or, as we should
say, of the first shock of the injury on the system.
108 BURNS AND SCALDS.
2. The stage of inflammation.
3. The stage of suppuration.
4. The stage of debility and hectic exhaustion.
The same distinguished surgeon has the merit of having first well
explained, not only the complications of burns, but the post mortem
appearances in fatal cases.
When persons perish in the flames, or soon after being removed from
them, inflammation has not had time to invade the digestive canal, yet
marks of great congestion are noticed. Not only does the mucous mem-
brane exhibit red spots of greater or less extent, not only is it gorged
with blood, but the cavity of the intestine contains a copious quantity of
blood effused within it. The vessels of the brain are also fully injected
with blood ; the serosity in the ventricles has a red tint, which is likewise
noticed in the fluid in the cavities of the pleura, pericardium, and perito-
neeum. The bronchi also contain a bloody mucous secretion, and their
lining exhibits at various points a bright red colour, and different degrees
of capillary turgescence.
If the patients die between the third and eighth day, and are after-
wards opened, traces of inflammation are noticed in the alimentary canal,
brain, and lungs. If they die in the suppurative stage, ulceration of the
bowels and enlargement of the mesenteric glands may be observed.
In many burns, the parts are so violently injured, that though they are
not killed or decomposed at once, they undergo such inflammation as
soon terminates in their conversion into sloughs or eschars, as they are
here generally termed. When the eschars are deep or extensive, the
derangement of the whole system will be great, there will be collapse,
with pallid face, cold extremities, shiverings, vomiting, and frequently
hiccough.
The mortification from burns differs from that called traumatic, or such
as arises from mechanical injuries, in not having a disposition to spread
beyond the extent of the injury ; a fact of importance to be remembered
in the prognosis.
From the foregoing account of the division of burns and scalds into
several degrees, it must not be inferred, that each variety of them always
corresponds at every point to one of those degrees : frequently it is not
universally either a mere redness or efflorescence, or redness with vesi-
cation, or a burn with ulceration, or with the formation of eschars. In
bad burns and scalds, sometimes all these diversities of injury are exem-
plified in different parts of the burnt or scalded surface, according to the
intensity or duration of the heat, or the disposition of the parts to be
acted upon more or less quickly by it.
With regard to the prognosis: — 1. The degree of danger materially
depends upon the extent of the injured surface. A scald or burn of con-
siderable extent often proves fatal immediately, or in a few hours, without
the patient ever having rallied from the collapse. 2. The depth of the
injury is another consideration influencing the prognosis. The deeper
the effects of the burn extend, the greater the peril. 3. The situation of
burns is also to be taken into the account ; those of the head, neck, chest,
and abdomen, cceteris paribus, being more dangerous than such as affect
only the extremities. Scalds of the pharynx and larynx are remarkable
for their fatality. 4. The age of the patient makes also a vast difference ;
infants being often carried off by convulsions, and very nervous persons
sinking apparently from want of power in the system to bear the shock
inflicted upon it ; and delicate individuals, and others who lead irregular
lives, or are of a gross corpulent habit, being far less capable of bearing
BURNS AND SCALDS. 109
the consequences of severe burns, than strong healthy individuals more
careful in their mode of living. 5. In estimating the danger of burns,
however, a judgment is not to be formed abstractedly either from the
extent of a burn, or from its probable depth, but with reference to its ex-
tent and depth together,, joined with other circumstances already speci-
fied. In fact, a burn of the worst or sloughing kind, if it be of little
extent, and the patient's constitution good, may be attended with no
severe indisposition whatsoever, while the most superficial scald, if ex-
tensive, may prove fatal ; and the risk of this termination will be greater
in proportion as the patient's age, or previous state of health and mode of
living, may render him an unfavourable subject for the accident. 6. In
delivering a judgment respecting the degree of danger from a burn, we
are not to hold out too favourable a view on first inspection of the case,
because, when the eschars and sloughs come away, the mischief may be
deeper and more extensive, than first appearances might lead us to
expect. 7. In the process by which suppurating wounds and ulcers heal,
there is a principle in the animal economy exemplified, by which the
contraction and absorption of granulations are brought about during and
for some time after cicatrisation. It is in consequence of this contraction
of granulations, that the circumference of the ulcer is powerfully drawn
towards the centre, and the degree and force with which this happens are
perhaps greater in the sores produced by burns, than in those resulting
from any other cause. Hence the healing of ulcerated burns is liable to
be followed by hideous disfigurement and contraction of parts, and even
by a complete and permanent interruption of their functions. Thus, when
the forehead or eyebrow is burnt, the eyelids are likely to become
everted, ectropium may take place, and the eyeball, being deprived of its
natural screen, may have its functions considerably impaired, or even
destroyed, by repeated attacks of chronic inflammation, terminating in
opacity of the cornea. In burns of the neck, if the patient live, the con-
traction of the granulations frequently brings on a wry neck, and, in
worse cases, the chin is absolutely pulled down to the sternum, and fixed
in this position. When this happens, the integuments are thrown into
irregular folds, which, like so many cords or bands, seem to hold the chin
downwards. Sometimes the head is thus pulled towards the shoulder.
I have seen deformity of this kind carried to such a degree, that even the
lips were involved in it, and the mouth was horribly disfigured.
Sometimes the contractions^ following burns, will fix a joint in a per-
fectly useless position, drawing the thumb or fingers quite back against
the bones of the carpus, or holding the knee in a complete state of flexion,
or the whole hand may be bent and fixed against the forearm, or the foot
so twisted and deformed, as to be only a misshapen useless mass attached
to the leg. The lower eyelid is sometimes drawn down, and adherent to
the upper lip, or the lower lip is adherent to the chin. But, in order to
convey an idea of the force, with which the contraction of the cicatrix
takes place, I may quote a case recorded by Cruveilhier, where % burn
of the forearm occasioned such a contraction of the skin, that the carpus
was gradually dislocated from the radius. Dupuytren had a case, in
which the penis became drawn up and fixed to the skin covering the
linea alba ; and another, in which the thigh was fixed in the bent position,
the skin of the upper part of it being attached to that of the abdomen.
The patient had a hernia, and when an attempt was made to extend the
limb, thick longitudinal folds of the cicatrised parts projected, so as to
prevent the truss from being applied.
110 BURNS AND SCALDS.
These disfigurements and useless conditions of parts from burns are not
usually noticed alter burns on the posterior parts of the trunk, because
the movements of flexion, which are the most natural, oppose the con-
traction of the cicatrix ; and the same observation is generally applicable
to burns on the posterior surface of the limbs.
Now, although surgery has resources for the prevention and relief of
some of these severe disfigurements and mutilations, the risk of their
occurrence cannot be prudently overlooked in the prognosis.
Besides these ill consequences, frequently arising from the power with
which the granulations contract during and after the cicatrisation of
burns, serious deformities, and the loss of the use of parts, are often pro-
duced on another principle ; namely, by the growth and adhesion of
burnt parts to one another. Thus the eyelids sometimes grow together,
and the same thing may happen to the toes or fingers, or the ears may be
rendered adherent to the scalp. Sometimes the lachrymal puncta and
canals are obliterated; sometimes the nostrils. Deep burns of the fifth
degree usually lead to very serious consequences. From the destruction
of the muscles and tendons, the use of the limb often becomes perma-
nently lost ; from the copiousness of the suppuration, the patient is ren-
dered hectic, and likely to sink ; from the denudation of the bones, and
their long exposure to the air, they are in danger of being attacked with
necrosis ; from the synovial membranes being frequently injured, the
joints are likely to inflame ; and, when the large joints are thus involved,
the only chances of recovery are either b}' anchylosis or amputation.
Burns of the sixth degree on the limbs necessarily require amputation.
In burns, according to Baron Dupuytren's investigations, the patient's
recovery is frequently retarded for a long while by ulceration of the
mucous coat of the intestines.
With respect to the treatment of scalds or burns, when the injury is
superficial, the indication is to keep down the inflammation, and thus
prevent or limit the formation of vesicles; but, if the latter purpose
cannot be accomplished, we are to endeavour to prevent such vesicles
from becoming troublesome painful ulcers. For slight burns and scalds,
cold applications are frequently preferred. The injured part may be im-
mersed in very cold or iced water, or covered with linen wet with an
evaporating lotion, such as vinegar and water, the liquor plumbi acetatis
dilutus, with a small quantity of camphorated spirit in it ; or rose water,
with a drachm or two of diluted acetic acid, and two grains of the acetate
of lead to each ounce of it, or the diluted liq. ammon. acetatis. All these
applications, in common use amongst surgeons, and some others in favour
with the vulgar, like scraped potatoes, prove serviceable on the principle
of reducing the temperature of the burnt parts, and thus diminishing
and keeping off inflammation. In particular, they tend to check the
effusion of serum under the cuticle, and the formation of vesicles ; but,
for this purpose, they must be put on the part very soon, and, if possible,
immediately after the accident ; because vesicles sometimes make their
appearance almost directly after the receipt of the injury, and others
follow with more or less quickness. When there is a disposition to
shiverings, the pulse is feeble, the skin pale and cold, the patient faint,
and the burn extensive or situated on the trunk, cold applications are im-
proper. In such cases, we may either imitate Dupuytren, who applies
fomentations, or put the patient, if a child, into a warm bath, or use
what Sir Astley Cooper recommends, namely, spirit of turpentine, or a
BURNS AND SCALDS. Ill
liniment of turpentine, linseed oil, and lime water, in equal parts *, after-
wards resorting, however, on the reaction taking place, to antiphlogistic
treatment, that is to say, after the pulse has risen, the patient has rallied,
and a tendency to fever and inflammation has begun. Of late, the prac-
tice of dressing superficial burns with raw cotton, has been introduced
into this country from America.f The cotton is thinly spread out, or
carded and laid directly over the burn. This practice was at first pro-
posed chiefly for scalds and superficial burns ; but Dr. Anderson, of
Glasgow, represents it as advantageous for all kinds of burns, whether
superficial or deep, vesicated or sphacelated. One great principle in-
sisted upon by him, is that of not removing the cotton, unless compelled
by circumstances, until the cuticle is formed, and the parts are enabled
to bear exposure. The raw cotton is sometimes covered with a mode-
rately tight roller.
With respect to the suggestion of allowing the cotton to continue long
unchanged, it seems inconsistent with due attention to cleanliness, for the
discharge would in many instances convert the cotton into a fetid mass of
putridity, and, in hot weather, maggots would soon be deposited in it.
Another application to burns is common flour, plentifully sprinkled on
the injured surface with a flour dredger. This practice has gained re-
putation, and been introduced into the London hospitals. No doubt, the
exclusion of the air, the absorption of the discharge, and the idea of
protecting the burnt surface with a remarkably soft application, were the
considerations which first suggested this treatment. In its adoption,
nearly the same rules are followed as in the use of cotton, the parts being
kept constantly covered, and allowed to heal under the coating of flour
formed over them. For the purpose of loosening the masses of flour,
when they require to be taken away, poultices are applied.
The second class of burns, or those attended with vesication, may be
treated with refrigerant evaporating lotions, or with the lime water and
linseed oil liniment, or with carded cotton, or common flour.
But the question here occurs, what are we to do with the vesicles ?
Should we discharge the fluid from them, or leave it undisturbed?
Whatever be done, we cannot always prevent ulceration of the cutis from
taking place under them. I believe, the occurrence is not much affected
by the presence or discharge of the fluid from them, but depends rather
upon the degree of injury, which the surface of the skin has sustained
from the burn itself. In my own practice, when the vesicles are large, I
generally let out the fluid by making a fine puncture with the point of a
needle or lancet, a plan sanctioned also by the authority of Dupuytren.
When the cutis is exposed, we may apply the unguentum creasoti, or
liquor plumbi acetatis dilutus, with two grains of the sulphate of zinc
to each ounce of the lotion, as an application that seems to promote the
quick production of new cuticle.
The third and fourth degrees of burns, or those in which ike party are so
injured that eschars and ulceration are unavoidable, may also be treated
with the lime water and linseed oil liniment, emollient poultices, and
fomentations, flour, or the turpentine liniment, which is sometimes pre-
ferred as the dressing for every kind of burns.
* In superficial burns of the face, M. Velpeau is in favour of this common applica-
tion ; the parts being smeared with it four or five times daily with a feather. In five or
six days, large burns of the first, and some of the second degrees, have been cured
by it.
t Dallam, in Potter's " Medical Lyceum," p. 22.
112 BURNS AND SCALDS.
According to M. Velpeau, in a burn of the first degree, a compressing
bandage prevents the development of inflammation ; in one of the second
degree, it hinders the occurrence of blisters, or, if not employed early
enough to do this, causes the absorption of the effused serum. In a
burn of the third degree, it cannot prevent an eschar, but it lessens the
pain. M. Velpeau * generally prefers straps of diachylon plaster, or, in
other words, the plan adopted by Baynton for ulcers. He states, that
the first degree is constantly checked by surrounding the burn in such a
manner, that the strap may remain seven or eight days. In the second
and third degrees, the cuticle must be first removed, the surface cleaned,
and the strapping renewed every third, fourth, fifth, or sixth day. In
the fourth degree, it represses the surrounding inflammation, does not
hinder the separation of the sloughs, and, as they become detached, it
promotes cicatrisation. If suppuration be profuse, the straps are to be
changed every other day ; but, in ordinary cases, every third or fourth
day. In the fourth degree, before the eschars are detached, M. Velpeau
lets the straps remain five or six days. Very large burns are excepted
from this treatment, which of course is only adapted to those of the
limbs.
Suppuration is not the invariable consequence of vesicles, though it
frequently follows them. Sometimes purulent matter is formed from the
surface of the cutis, without any appearance of ulceration, and is at last
stopped by the production of new cuticle. In other instances, small
ulcerations occur on the surface or edges of the burn, and spread with
more or less rapidity into extensive sores.
Immediately the ulcers begin to secrete healthy pus, and to form gra-
nulations, the applications above specified should be discontinued, and a
mildly astringent ointment made use of, such as the calamine cerate,
ung. creasoti (L. P.), blended with an equal quantity of lard, or the zinc
and spermaceti ointments, mixed together in equal proportions.
Of all the sores which surgeons have to deal with, none are more
disposed than those of burns to produce high fungous granulations, which
seriously retard the healing process, and, if not repressed by suitable
treatment, often terminate in the formation of an ugly, protuberant, dense,
almost cartilaginous cicatrix. In Mr. Higginbottom's treatise on the
nitrate of silver, cases of this kind are reported, in which it was necessary
to apply this substance for the dispersion of the extraordinary mass of
projecting new matter collected in the place of the cicatrix.
For the prevention of this description of deformity, the best method is
to keep down the granulations by sprinkling them occasionally with
powder of myrrh and calamine in equal parts, or by touching them from
time to time with the nitrate of silver ; or, if the situation of the burn will
admit of the plan, by applying straps of adhesive plaster, or a bandage.
With regard to the treatment of burns, where the parts are reduced to
an eschar at the time of the accident, or are so injured that they after-
wards slough, we may either pursue the same practice which is applicable
to mortification in general, that is, we may either employ emollient ap-
plications, poultices, and fomentations, or use such local means as are
believed to have a specific virtue in the relief of sloughing burns.
Amongst the latter applications, the turpentine liniment deserves to be
particularly mentioned. Dr. Kentish, who first brought it into use, adopts
the principle, that the increased action in the parts near the eschars
* Sec Revue Med. Juin ct Juillet, 1835.
BURNS AND SCALDS. 113
should not be suddenly reduced, but supported until suppuration takes
place. With this view, he first bathes them with warm camphorated
spirit, or oil of turpentine, and then covers them with the turpentine
liniment, consisting of ung. resinae flavae, diluted and softened with tur-
pentine, and spread upon rag. When the secretion of pus commences,
he discontinues the turpentine liniment, and applies milder dressings,
such as the ceratum calamina3, or ceratum plumbi acetatis. For repressing
exuberant granulations, and absorbing the discharge, he uses powdered
chalk, which he also introduces into the cavities of separated eschars,
and into the furrows between sloughs, a pledget being then put on, and,
in tedious cases, a poultice.
With respect to the dressing of burns in general, all surgeons concur
respecting the advantages of keeping the injured parts well covered,
and not exposed to the air, which has a decidedly bad effect jupon them.
They also coincide in the usefulness of dressing a burn much less
frequently than was the practice in former days ; indeed, many practi-
tioners now make it a rule not to remove the first dressings until sup-
puration is established. On the same principle, when cold applications
are used, we should not frequently take off the rags, but merely sprinkle
them with the lotion as often as may be requisite to keep them wet.
For the purpose, also, of not keeping the burnt surface long uncovered,
we should not, when the burn is extensive, take off all the dressings at
once, but only a part of them. No doubt, it is partly on the principle
of keeping the burnt surface effectually excluded from the air, and partly
on the principle of avoiding the pain and irritation of the frequent removal
of dressings, that carded cotton, flour, and various liniments of turpen-
tine, linseed oil, and lime water, produce their beneficial effects. A
gentleman, who lately attended my lectures, informed me that, in the part
of the country which he came from, burns were successfully treated by
applying to them with a fine brush a solution of elastic gum in ether,
which formed a kind of varnish or coating upon them, preventing the ill
effects of their exposure to the air.
With regard to the internal treatment, when a scald or burn is of a
severe description, the first stage of danger, the danger from the shock on
the system, the period of irritation, as Dupuytren terms it, immediately
presents itself, sometimes accompanied by violent agitation of the nervous
system, but still more frequently by shiverings, paleness, stupor, coldness,
weak pulse, and collapse. Now opium, brandy, ammonia, or ether may
be given. Cold applications are to be avoided, bottles of hot water may
be put to the feet and epigastrium, and the patient kept covered. The
warm bath for children is in this stage particularly recommended by
Dupuytren. When the collapse goes off, and fever and inflammation
come on, we are to adopt antiphlogistic treatment, bleed young robust
subjects, and administer opium.
The second period of great suffering and danger is when the eschars
and sloughs are beginning to loosen : the stage of elimination, as it is
named by French surgeons. The constitutional disturbance now runs
high, and, when the patient is strong and young, bleeding may be neces-
sary, together with leeches, and opium. According to M. Velpeau, the
application of leeches around eschars prevents or lessens inflammation
and erysipelas.
The third stage of danger is that of suppuration, when the profuse
discharge may be such as the patient cannot safely bear : purgatives and
astringent lotions are now proper to check it, followed by bark, dil. sulph.
114« BURNS AND SCALDS.
acid, a moderate quantity of wine, and opium. For the diarrhoea, to which
burnt patients are subject in the suppurative stage, Dupuytren prefers
giving half a grain of opium, and one of sulphate of zinc, three or four
times a day.
The fourth stage of danger is when hectic symptoms have been in-
duced by the long duration of the effects of the injury, the irritation,
pain, discharge, &c. Here we must act according to the principles ex-
plained in the article on hectic fever, support the strength, give opium,
&c. The occasional complication of burns with phlegmonous erysipelas,
tetanus, or the determination of blood to internal organs, will of course
demand particular remedies.
OF DEFORMITIES BROUGHT ON BY BURNS.
Burns of the head and face are particularly liable to occasion more or
less deformity by the contraction of the cicatrix., because the tissues of
the face are remarkably moveable and extensible, and no position of the
head has any effect in counteracting the influence of such contraction.
Bandages, splints, and other mechanical contrivances, are here, also, totally
inapplicable and useless. Some trivial good may result, however, from
keeping the skin drawn in the opposite direction to that in which its
contraction would be disadvantageous, by means of straps of adhesive
plaster. We may also make free use of nitrate of silver to repress the
high granulations. When, however, the burn is on the neck or limbs, a
great deal may be effected by mechanical means, adapted to maintain
the head or limb in the opposite direction to that in which the con-
traction of the cicatrix would otherwise draw the part. Thus, supposing
the skin of the front of the arm to be in a state of ulceration from a
burn, if we maintain the limb extended, the cicatrix cannot diminish in
the long axis, but transversely, so that a permanent flexion of the arm
will be prevented. The plan is to be continued for at least two months
after the healing is complete, for, without such precaution, deformity will
still follow; but passive motion should be begun sooner. Fabricius
Hildanus notices the practice of cutting away the horny scars and indu-
rated substances left by burns ; a method revived by the late Mr. Earle,
who found that merely dividing the cicatrix and fraena would not suffice.
His plan consists in cutting away the whole of the indurated substance of
the cicatrix, and in then bringing the sides of the wound together trans-
versely by means of adhesive plaster. The aid of machinery and splints
is not to be neglected. On the other hand, Baron Dupuytren deems this
practice unnecessary, and declares, that the simple but complete division
of the cicatrix and its fraena at several points will answer every purpose,
if, by so doing, we can bring the limb or part again into its right position,
and the injury has not been such as to involve the muscles, or to have
caused anchylosis.
The limb is then to be kept extended by machinery, splints, or bandages.
When the part cannot be put into its proper position directly after the
division of the indurated cicatrix and fraena, a slow and gradual extension
is to be kept up : for this purpose, splints made with a screw, by which
they can be bent to any convenient angle, are of great service. After
the division of the cicatrix at several points, and the restoration of the
part to the desirable position, the treatment is to be conducted on the
same principles as are applicable to a burn, on the separation of the
eschars and the commencement of the granulations. If new fraena begin
to form again, they must be cut through without hesitation. When parts
EFFECTS OF COLD. 115
are merely adherent to one another, the following rules of practice are
laid down by Dupuytren: — 1. We are to divide them freely, and some-
what beyond their origin. 2. We are then to keep the divided surfaces
apart. 3. Next, we are to make methodical and constant pressure on the
point whence cicatrisation must proceed, viz. the angle of union.
When any natural opening is contracted or obliterated in consequence
of a burn, we are either to enlarge the contracted aperture, or to restore
the obliterated one by a perforation ; then a tent or ivory tube, of con-
siderably greater diameter than the natural opening, is to be inserted, and
worn, not only during the healing process, but for a long while after it.
EFFECTS OF COLD.
Of the general exciting or stimulant power of heat there can be no
doubt ; and, with regard to cold, the disputes concerning its operation
have been perpetuated only by logical illusion. In common language, we
are accustomed to speak of cold as a positive and active energy, while
philosophy can acknowledge it only as the expression of a relative decrease
of temperature ; for any degree of temperature designated by the appel-
lation of cold is still heat.* The very same temperature may be called
hot or cold, according as it is compared with a colder or a hotter tem-
perature. If we warm one of our hands at a fire, while we cool the other
by means of ice, and then plunge both of them into water of the common
temperature of the atmosphere, the water will feel cold to the hand which
has been heated, and warm to the other which has been cooled.
In a physical sense, every temperature of the air, or other surrounding
medium, below 98°, might be denominated cold, because this is the com-
mon heat of the human body ; but, with regard to the feelings and the
health, a degree much lower, namely, from 60° to 65°, is the most grate-
ful and invigorating. The external medium, at the temperature of about
62°, appears to abstract the heat of the body in the same proportion in
which it is generated, without any extraordinary exertion, of the system;
and, therefore, neither contributes to exhaust its powers, nor to excite
uneasy sensations. Hence, also, the denominations of temperate, warm,
hot, cool, and cold, are given to particular degrees of the thermometric
scale. The sensations of different men vary, however, according to the
power which their respective constitutions possess of evolving heat. This
depends much upon the original vigour of the system, especially of the
heart and arterial system. It is also much influenced by habit, or by a
person's being seasoned to the cold. Hence, people who, from vigour of
constitution or from habit> readily evolve a considerable quantity of heat,
especially during moderate exercise, can bear with pleasure and benefit to
their health the very same degree of cold, which to the weak and pnhabi-
tuated is a source of painful chilliness.
The first effect of certain degrees of cold, applied to the human body, is
to weaken the circulation through the small cutaneous vessels, more espe-
cially those which are situated in extreme parts, like the hands and feet ;
* Kellie, in Edinb. Med. and Surg. Journ. vol. i. p. 305. The latter part of the
above remark may be said to be generally true, with respect to any degree of cold of
which we ever speak, though rules for calculating the zero of heat have been given.
See Essays on Subjects chiefly Chemical, by W. Irvine, M. D. 8vo. Lond. 1809.
I 2
116 EFFECTS OF COLD.
or, in projecting part?, as the ears, nose, scrotum, £c. which expose a
larger surface to the atmosphere, or medium, by which their caloric is
abstracted. Hence the skin becomes pale, and, contracting round the
miliary glands and roots of the hair, exhibits a roughness which is com-
pared to the skin of an unfeathered goose, and is technically named the
cutis anserina. The action of the heart and arteries in general becomes
weakened ; and the blood being partially delayed in its course through
some of the cutaneous vessels, and not undergoing the change of colour
which the circulation through the lungs produces, it gives a bluish or livid
colour to the fingers, ears, and other projecting parts. If the cold be in-
tense, or the exposure long continued, the circulation in the extreme parts
becomes altogether interrupted, and, the power of evolving heat being
completely destroyed, mortification is the consequence. Parts killed in
this manner are said to be frost-bitten.
From the languor and weakness of the arterial system, produced by the
application of cold, other effects on the constitution necessarily accrue.
A free circulation of well-oxygenated blood seems essential to the perfect
execution of the functions of the brain and nervous system, and to the
support of sensibility. If the circulation is suspended for a few moments,
as in syncope, the sensibility is also suspended ; and, on the other hand,
when there is more than an ordinary supply of blood to any part, as in
inflammation, the sensibility is highly augmented. Hence, another imme-
diate effect of the agency of cold on the human body is a diminution of
the sensibility of parts. This is universally felt in the numbness of the
hands and fingers, which, under the impression of cold, are altogether
incapable of accurate discrimination of touch ; and the whole of the sur-
face of the skin partakes of the imperfect feeling. The tongue is also in-
capable of distinguishing the peculiar flavour of sapid bodies, if they be
extremely cold ; and the sense of smell is considerably enfeebled by cold.
If the cold be intense, or its application long continued, the powers of the
whole nervous system yield ; a torpor of the animal functions ensues ; the
action of the muscles becomes feeble, and scarcely obedient to the will ;
an unconquerable languor and indisposition to motion succeed ; and
drowsiness comes on, ending in sleep, from which the person, if not
speedily roused, frequently awakes no more.*
The strong propensity to sleep, following the anxiety and lassitude
experienced at an earlier period, is noticed by most writers as the precur-
sor of imminent danger -j- ; and it is certainly a symptom of usual occur-
rence. But, as an intelligent author remarks, it is doubtful how far the
state of sleep is the necessary consequence of simple exposure to cold ;
or, at least, what other circumstances besides cold are necessary for its
production, since this exposure may be made to an intense degree of cold,
for a considerable length of time, without sleep being induced. J The
case of Elizabeth Woodcock §, who lay buried under snow more than a
week without sleeping a great deal, and those of some shipwrecked sailors,
who were more or less immersed in water, in severe weather, for twenty-
* See a description of the effects of the cold at Terra del Fuego, on the persons who
landed there with Dr. Solandcr and Sir J. Banks, as detailed in Captain Cook's first
voyage.
f Richter, Anfangsgr. der Wundarzn. b. 1. p. 117. Larrey, Mem. de Chir. Mil. t. iv.
p. 10G. Callisen, Syst. Chir. Hod. pars i. p. 308.
| Thomson's Lect. on Inflammation, p. G24.
§ Reeve's Essay on Torpidity, p. 109.
EFFECTS OF COLD. 117
three hours, without being seized with drowsiness, are proofs that an irre-
sistible propensity to sleep is not constant.*
In describing the manner in which the French soldiers perished from
the severity of the cold in Russia, Larrey remarks that their death was
preceded by a paleness of the countenance, by a sort of idiotism, diffi-
culty of speech, weakness of sight, and even a total loss of these faculties.
In this state, some of the men continued to march, for a greater or lesser
time, led by their comrades. The action of the muscles gradually grew
weaker ; the men reeled about as if they were drunk ; and their debility
increased until they fell down — a certain sign of the total extinction of
life. The incessant and rapid march of the troops in close masses obliged
those, who could not bear it, to quit the centre to walk along the side of
the road. Separated from this compact column, and left to themselves,
they soon lost their equilibrium, and fell into the ditches of snow, from
which it was hardly possible for them to get out. Here they were imme-
diately seized with a painful numbness, followed by lethargic drowsiness,
and in a few minutes their miserable existence terminated. Frequently,
before death, there was an involuntary emission of urine, and sometimes
hemorrhage from the nose. Almost all the men who perished in this
manner were found lying with their faces downwards. The skin was
without alteration of colour, or any appearance of gangrene. In general,
death took place more or less rapidly, according as the subject had been
fasting a longer or shorter time, f
It has been a question, whether the human body, after being frozen,
can ever be restored to life. Richter asserts the possibility of recovery,
when the blood in the heart itself is not turned into ice; when this organ
and large bloodvessels still retain a degree of vitality; and there is no
extravasation in the brain to render the thing impracticable. And he de-
clares that persons, who have lain in a frozen state as long as four and
six days, have been restored to life. J After a full consideration of this
subject, I think there can be no doubt that Richter is in error ; and that
the cases of recovery to which he adverts were only instances of restor-
ation from a state in which suspension of sensation, voluntary motion, &c.
had been induced by cold, and not examples in which the whole body, or
even the greater part of it, had been frozen. In order to ascertain the
truth or falsity of an- assertion, that some animals, especially serpents and
fish, can recover their vitality after being frozen, Mr. John Hunter insti-
tuted a number of interesting experiments on the power of different
animals in resisting the agency of cold. Two carps were gradually frozen,
with the aid of a freezing mixture, and did not recover. It was with
great difficulty that he succeeded in freezing a dormouse, such were its
powers of evolving heat, and the non-conducting quality of its integu-
ments ; and it was not till the hair had been wetted that life was destroyed.
This animal, also, did not recover. When a toad was exposed to a similar
cold mixture, the water froze round the animal so as to enclosf it, but
without destroying life : yet, though not frozen, it hardly ever recovered
the use of its limbs. The conclusion drawn from these experiments was,
* Phil. Trans. 1792; and Currie's Med. Reports on the Effects of Water, 'vol. i-
chap. 15.
f Larrey, Memoires de Chir. Militaire, t. iv. pp. 127 — 129. His description, how-
ever, is rather that of people dying from the combined effects of cold, hunger, and
fatigue, than from cold alone.
t Richter, b. i. p. 119.
I 3
118 EFFECTS OF COLD.
that an animal must be deprived of life before it can be frozen* On the
other hand, Hearne says, that spiders, frozen so hard as to bound from
the floor like a pea, were revived by being brought to the fire. Leeches,
snails, grubs, and frogs, have been frozen to a certain degree by artificial
cold, and revived. Other experiments have also proved, that frogs would
revive even if the heart was frozen, but not if the brain congealed, after
which they could not be affected by the galvanic action, f Captain
Franklin, in his northern expedition, repeatedly saw fish, especially carp,
recover after having been congealed by cold into a solid mass of ice ; and
one carp recovered so far as to leap about with much vigour after it had
been frozen for thirty-six hours.J We learn from Professor Thomson,
however, that, in the year 1785, a variety of experiments were made at
the Royal Medical Society of Edinburgh, in order to discover some of
the effects which exposure to intense degrees of cold produces upon warm-
blooded animals. In these experiments it was uniformly observed, that
death took place long before the irritability of the heart and other internal
parts was destroyed, and at a time when the temperature of the blood,
circulating in the heart and larger blood-vessels, was but little, if at all,
reduced below 60° of Fahrenheit. § How far these various facts can be
reconciled by the different effects of artificial and natural freezing, or by
the less pernicious operation of severe cold upon similar classes of animals
in the polar regions than in milder climates, I cannot presume to con-
jecture ; but I have no doubt that, in whatever manner this physiological
question may be hereafter settled, with respect to the lower animals, the
truth of Mr. Hunter's inference, with regard to the human subject, will
remain unshaken. Whoever will advert to any of the most remarkable
examples on record, where persons have recovered after being exposed
for a length of time to extraordinary cold, will find that the particulars by
no means justify the conclusion, that such cases were instances in which
the whole body, or the greater part of it, had been frozen. We may be
sure that this did not happen in the case of Elizabeth Woodcock, who
lay buried six feet under the snow, and without food, from Saturday,
Feb. 2d to Sunday, Feb. 10th, 1799; for it is expressly related that she
was sensible the whole time ||; a state, which cannot be supposed to be
compatible with a general congelation of the blood and other fluids in the
system. The French peasant Boutillat was lost in a snow storm on the
Black Mountains, which separate France from Spain, and lay asleep under
the snow four days ; but on the fifth morning he awoke with a sensation
of thirst. How could this return of sense and intellect have happened,
had the whole mass of the blood been in a frozen state ? Or, if it be thought
that the fluid was in a state of congelation only while the man lay asleep
and senseless, by what alteration of circumstances is the thawing of the
blood to be accounted for, since he awoke buried under the snow, breath-
ing through a hollow cone, which, as in the instance of Elizabeth Wood-
cock, extended from his body to the surface of the snow ?^| Nor could
the circulating fluids have been frozen to a great extent in three other
individuals, whose remarkable case is upon record, since, in such con-
* See Philosoph. Trans, vols. Ixv. and Ixviii. ; and Hunter on certain Parts of the
Animal (Economy, pp. 100, 101.
f Quarterly Review, No. Ivi. p. 382.
j Franklin's Journey to the Shores of the Polar Sea, p. 248., 4to. 1823.
§ Thomson's Lect. on Inflammation, p. 642.
II Reeve's Essay on Torpidity, p. 109.
^ Pilhes, in Journ. de Medecine. Paris, 1 767, torn, xxvii.
EFFECTS OF COLD. HHW 119
dition, they would not have been in constant dread 'of being starved.*
The very existence of sensation and intelligence proves that, in none of
these cases, a completely frozen state of the body or of the blood could
have taken place. Had this last state been induced,' no doubt recovery
would have been out of all possibility, notwithstanding thej contrary sen-
timents which have been published on this point by Fabricius, Hildanus,
Richter, &c.f
TREATMENT OF PERSONS IN A STATE OF TORPOR OR SUSPENDED
ANIMATION FROM COLD.
One great principle, insisted upon by practical writers, is to let caloric
be communicated to the body in the most gradual manner. J From ob-
servations and experiments (says Mr. Hunter), it appears to be a law of
nature, in animal bodies, that the degree of external heat should bear a
proportion to the quantity of life. When life is weakened, this propor-
tion must be adjusted with great accuracy ; but, when the powers of life
are considerable, a greater latitude is allowable. if I was led (he ob-
serves) to make these observations by attending to persons who are frost-
bitten, the effect of cold in such cases being that of lessening the living
principle. The powers of action remain as perfect as ever, but weakened,
and heat is the only thing wanting to put these powers into action ; yet
that heat must at first be gradually applied, and proportioned to the
quantity of the living principle, which increasing, the degree of heat may
likewise be increased. If this method is not observed, and too great a
degree of heat is at first applied, the person, or part, loses entirely the
living principle, and mortification ensues. Such a process invariably
takes place with regard to men ; and the same thing, I am convinced,
happens to other animals. For, if an eel is exposed to a degree of cold,
sufficiently intense to benumb it till the remains of life are scarcely per-
ceptible, and still retained in a cold of about 40°, this small proportion of
living principle will continue for a considerable time, without diminution
or increase ; but, if the animal is afterwards placed in a heat about 60°,
after showing strong signs of returning life, it will die in a few minutes.
Nor is this circumstance peculiar to the diminution of life by cold. The
same phenomena take place in animals which have been very much
reduced by hunger. If a lizard or snake, when it goes to its autumnal
hiding-place, is not sufficiently fat, the living powers are, before the
season admits it to come out, very considerably weakened, perhaps so
much, as not to permit of the animal being again restored. If animals
in a torpid state are exposed to the sun's rays, or placed in any situation
which by its warmth would give vigour to those of the same kind, pos-
sessed of a larger share of life, they will immediately show signs of
increased life, but quickly sink under the experiment, and die; while
others reduced to the same degree of weakness, as far as appearances
can discover, will live for many weeks, if kept in a degree of cold pro-
portioned to the quantity of life they possess. " I observed, mafly years
ago (says Mr. Hunter), "in some of the colder parts of this island, that,
when intense cold had forced blackbirds or thrushes to take shelter in
* Narrative of three women saved, who were buried thirty-seven days under the snow,
in a stable at Bergemoletto, in Italy, by F. Soumis. 12mo. J739.
f For many judicious observations on this topic, consult Thomson's Lect. on In-
flammation, pp. 642 — 644.
v t Richter, Anfangsgr. b. i. p. 123. Callisen, Syst. Chir. Hodiern. t. i, p. 309.
J 4
120 EFFECTS OP COLD.
outhouses, such of them as had been caught, an ^ were, from an ill-
judged compassion, exposed to a considerable degree of warmth, died
very soon."*
I have deemed it advisable to cite these sentiments of Mr. Hunter,
with some of the facts upon which they are founded, in consequence of
my having read, in some modern works of high repute and extensive
circulation, that, in cases of suspended animation, or torpor from cold,
the patient may be safely brought into a warm but well ventilated room,
chafed with warm flannels, and his feet and legs immersed in warm
water.-)* Dr. Kellie does not think the same caution and reserve neces-
sary in the application of heat to a case of general torpor, as to benumbed
and frost-bitten limbs. In the latter occurrence, he admits, heat should
be very gradually communicated ; but (says he) surely we would not
commence the treatment of a case of general torpor, nearly approaching
to death, by applying snow to the body. He argues, that there does not
appear to be the same danger of violent reaction, or of destroying by
premature stimulation, an accumulated excitability % in general torpor,
where the sensorial functions have been all along suspended, as in a
partial affection, where, notwithstanding the injury done to the part, the
general powers of the system have remained excitable. Notwithstanding
the ingenuity of the reasoning which Dr. Kellie has adopted, I am far
from thinking the practical principles, to which the observations of Mr.
Hunter tend, are at all erroneous. The case, related by Dr. Kellie, was
not an example in which the vital powers were reduced altogether by
cold. The temperature, to which the individual had been exposed, was
not, indeed, depressed to a degree generally incompatible with activity
and life ; but he was reduced by fatigue and fasting, and the effects of
the atmospheric cold were increased by the drizzling rain which fell.
The blood which flowed from the arm was judged to be of its natural
temperature. This was, therefore, a case in which the temperature of
the patient could hardly have been low enough to afford any criterion of
the safety or danger of suddenly exposing a person to much warmth,
who has been subjected to the effects of intense cold. If the facts men-
tioned by Hunter had left this matter doubtful, we might still be con-
vinced of the truth of his observations by other events upon record.
The limbs of the peasant Boutillat, whose case I have already noticed,
were covered with warm linen, dipped in aromatic liquors : his feet mor-
tified, and he lost his life. These consequences, Dr. Pilhes thinks,
might have been avoided by the use of cold applications.^ The ample
experience of Larrey, who was an eye-witness of all the disasters of
Napoleon's campaign in Russia, appears also to confirm the truth of the
principle inculcated by Hunter, Richter, Callisen, &c. In describing the
sufferings of the French army from the rigour of the climate, Larrey ex-
claims, " Woe to the man benumbed with cold, whose animal functions
were nearly exhausted, and especially whose external sensibility was
destroyed, if he entered too suddenly into a warm room, or came too
near the fire of a bivouac I The prominent parts benumbed or frozen, at
a distance from the centre of the circulation, were seized with gangrene,
* Observations on certain Parts of the Animal (Economy, by J. Hunter. 4to.
p. 137. 2d edit. Lond. 1792.
f Kellie, in Edin. Med. and Surgical Journ. vol. i. p, 312. Rees's Cyclopaedia,
art. Cold.
\ Journ, de Medecine, torn, xxvii.
EFFECTS OP COLD. 121
which made its appearance at the very instant, and spread with such
rapidity, that its advances were perceptible by the eye, or the individual
was suddenly suffocated with a kind of turgescence, which appeared to
affect the brain and lungs : he perished as in asphyxia. Thus died the
chief apothecary of the guards. He had arrived at Kowno without any
accident, but his strength was much reduced by cold and abstinence.
An asylum was offered him in a warm apartment in the pharmacy of the
hospital. He had scarcely been a few hours in this atmosphere, so new
to him, when his limbs, in which he had lost all feeling, became consider-
ably swelled ; and he expired soon afterwards, in the arms of his son and
one of his colleagues, incapable of uttering a single word. We saw some
individuals fall down stiff-dead in the fires of the bivouacs," &c. *
In describing the treatment of a person in a state of torpor, or sus-
pended animation, from cold, Callisen and Richter rigorously adhere to
the principle, that caloric should be very gradually communicated to the
body. The former recommends long-continued frictions with snow, or
cloths wet with very cold water. This is to be done in a cold room ; and
he advises the surgeon not to let his endeavours cease too soon, as
patients, after lying without signs of life for several days, have yet been
snatched from the jaws of death. On the return of sense, motion, and
warmth, aromatic spirituous applications may be used ; the temperature
in which the body is placed may be raised, and cordials administered, f
When signs of vitality return, Richter directs strong volatiles and
sternutatories to be applied to the nostrils, air to be blown into the
lungs, and the fauces to be tickled with a feather. He also recommends
the introduction of tobacco-fumes up the rectum ; a practice, however,
the propriety of which is questionable in all cases of suspended animation,
on account of the debilitating, and even deleterious, effects of that plant.
It might be better to throw warm wine into the large intestines, or inject
it by means of a hollow bougie down the oesophagus. When the signs
of returning animation increase, the body is to rubbed with brandy,
and conveyed into a warmer situation. A diaphoretic drink is then to be
given ; and, as soon as the patient has been well dried, he is to be put to
bed, and remain there till he begins to sweat. J
Possibly, these eminent surgeons may have extended the principle too
far, in directing the body to be at first covered or rubbed with snow.
But, there is every reason to believe, that their method of allowing the
heat to be communicated only by degrees, is the most likely to be con-
ducive to recovery.
TREATMENT OF FROZEN PARTS.
As, in all the Experiments which Mr. Hunter made upon the freezing
of whole animals, he had never seen life return by thawing, he was
desirous of ascertaining how far parts were similar to the whole in this
respect. He froze the ears of rabbits, and the combs and w^tles of
cocks, till the parts were so stiff and hard that, when cut, they flew from
the blades of the scissors like a chip, and no pain nor bleeding ensued.
After being thawed, they inflamed considerably ; but, in the end, per-
fectly recovered. There was thus a material difference in the result of
his experiments, on the whole of some of the more perfect animals, and
Mem. de Chir. Mil. torn. iv. pp. 134, 135, f Callisen, t. i. p, 309.
Richter's Anfangsgr. b, i. p. 123,
122 ' EFFECTS OF COLD.
on parts of them. But, though it was [thus fully proved, that parts of
such animals might be frozen, and restored to their natural state, it was
not known whether this would happen in the more imperfect animals.
Mr. Hunter, therefore, froze the tails of a tench and two gold fishes,
and endeavoured to restore the vitality of the parts, by putting the fish
into cold water ; but the tails, when thawed, did not resume their original
appearance : the fish were suspended with their heads perpendicularly
downwards, and ultimately died. All his other trials to restore the life
of other cold-blooded animals, or of parts of them, after they had been
frozen, also entirely failed.* Spallanzani also found, that the irritability
of the muscles of frogs, toads, and lizards was not destroyed by keeping
these animals a good while in snow ; but that, if the cold was increased,
so as to freeze any part of them, the frozen part was invariably killed,
and rendered insensible to stimuli.f
The experiments, however, on warm-blooded animals corroborate what
has long been believed, that when a part of the human body is simply
frozen, without any impairment of its organisation, it may often be re-
covered by the gradual communication of caloric to it. What parts of
the human body admit of being frozen, without the destruction of life,
and how long they may remain in this state with impunity (as Dr. Thom-
son remarks), are points, which observation does not hitherto appear
accurately to have determined : but we know, that portions of the cheeks,
ears, and nose, have often been frozen by exposure to cold, and yet that,
by a proper management, the vital functions of these parts have been
restored. It seems probable, therefore, that a small part of the cutaneous
texture may be frozen for a short period, without the necessary destruc-
tion of its vitality. But Dr. Thomson considers the restoration of a
frozen limb a matter of impossibility ; and, in the course of his reading,
he has not met with a single unequivocal instance of such an event.J On
this point he differs from Callisen and Richter, quite as much as upon
the other question of the possibility of reviving the whole body, after it
has been frozen. Whatever doubts may have been suggested, concerning
the propriety of keeping patients out of a warm temperature, who are in
a state of torpor and insensibility from cold, none exist with respect to
the prudence of extending this principle to the treatment of very cold
or actually frozen parts of the human body. If a limb, that is not indeed
frozen but excessively cold, be suddenly warmed, chilblains, frost-bite,
and other more extensive forms of inflammation, are the result. The
part swells, turns livid, and becomes affected with insupportable darting
pain. And, when a part actually frozen is thus quickly warmed, the
same symptoms arise, but in an aggravated degree, and rapidly end in
mortification.}
I have already cited some facts ||, strongly illustrative of the danger
of exposing very cold or frozen parts to the fire ; but, perhaps, on no
occasion has the thing been more forcibly proved, than in the campaign
of the French army, about the period of the battle of Eylau. During
* Obs. on certain Parts of the Animal (Economy, pp. 124, 125.
f Opuscules de Physique, t. i. p. 118.
J Lectures on Inflammation, pp. 628. G42. " The fingers, toes, and nose may be
frozen^and perfectly recovered, if judicious means be employed ; whereas, if the whole
limb be frozen, it dies; and none of the higher animals can have the body congealed,
and escape death." — Macartney on Inflammation, p. 99.
§ Richter, Anfangsgr. der Wundarzneykunst, b. i. p. 120.
|| From Larrey's Mem. de Chir. Mil.'t. 4.
EFFECTS OF COLD. 123
the three or four severely cold days previous to this action, the mer-
cury had fallen to ten, eleven, twelve, thirteen, fourteen, and fifteen
degrees below the zero of Reaumur's thermometer, and yet, until the se-
cond day after the battle, not a single soldier complained of any accident
from the effect of the cold. " We had, however," says Larrey, " passed
these days, and a great part of the nights of the 5th, 6th, 7th, 8th, and
9th of February, in the snow, exposed to the most inclement frost." In
the night, however, between the 9th and 10th, the temperature suddenly
rose to three, four, and five degrees above zero, accompanied with sleet.
A thaw then commenced ; and, from this moment, numerous soldiers
began to complain of acute pain in their feet, numbness, sense of heavi-
ness, and annoying pricking pains in their limbs. The parts were but
little swelled, and of a dark red colour. In some individuals, a slight
redness was observed at the base of the toes, and upon the instep ; while,
in others, the toes had lost all power of motion, all sensation and warmth,
and become black and dried. These patients, without exception, de-
clared that they had felt no uneasiness while the severe cold lasted, and
that their complaints first began at the commencement of the thaw.
From these facts Larrey argues, that cold is not an exciting, but only
a predisposing, cause of inflammation and gangrene * ; a truth, which
Richter appears to have been well aware of, when he observes, that cold
alone, even the most intense, will never produce chilblains, f
In order to thaw a frozen part gradually, it is best to rub it with snow,
or ice and cold water, until sensibility and motion return. If the ear or
tip of the nose be the part concerned, care must be taken to avoid
breaking it. As soon as marks of sense and motion are discerned, the
friction may be made with brandy or camphorated spirit of wine. The
patient may then have some gently diaphoretic drink, such as a little
mulled wine, a basin of tea, &c. and be put to bed in a chamber where
there is a fire. Here he is to remain until he begins to perspire, when
a perfect recovery of whatever sensibility may have been lost generally
succeeds.
When a part is almost in the state of gangrene, in consequence of im-
proper exposure to sudden heat, sometimes its recovery may still be
accomplished by immersing it in water of a temperature nearly as low as
the freezing point. The part must be kept immersed until the swelling,
pain, and marks of discolouration begin to diminish, when frictions with
brandy, &c. may commence, and the warmth be gradually increased.
CHILBLAINS.
The inflammation attending chilblains is of a peculiar nature, irrit-
able, yet languid; and, from the state of the circulation in the parts
affected, the reparative power is low, and requires stimulation.^
A chilblain, in its mildest form, is attended with redness, heat, and
itching of the parts affected, which are generally either the toes, fceels, or
fingers, though sometimes the extremity of the nose, or ear, or parts about
the metacarpus. In the next degree of severity, the parts are more
swelled, redder, and so painful that the patient is deprived of the use of
them ; and, when the instep or back of the hand is the seat of the disease,
* Me"moire sur la Gangrene s£che causee par le Froid, &c. in op. cit. t. ii. p. 60.
t Richter, b. i. p. 124.
i See Macartney on Inflammation, p. 99.
EFFECTS OF COLD.
the subcutaneous cellular tissue is swelled to twice or thrice its na-
tural thickness, and the integuments are of a bluish or livid colour. In a
still more severe form chilblains produce vesication, or a rising of the
cuticle, in consequence of the accumulation of a dark bloody serum under
it. Beneath such vesications the surface of the cutis frequently ulcerates,
and the sores thus occasioned usually discharge a thin ichorous matter,
penetrate deeply, are excessively painful, and frequently very difficult to
heal. Their bottom presents a grayish and often a fungous appearance.
In the worst cases the inflammation ends in mortification, which is often
preceded by the formation of bloody vesicles.
The sudden warming of a cold part, and the sudden cooling of a heated
part, seem particularly conducive to chilblains : hence, parts most ex-
posed to the vicissitudes of heat and cold are most subject to the com-
plaint; as, for instance, the toes, fingers, nose, ears, and lips. When a
part is exposed to sudden cold, while it is in a state of perspiration, it is
more likely to be affected with chilblains, than when thus exposed while
simply warm. The most intense cold alone cannot produce true chil-
blains, though analogous complaints do remain in limbs which have been
frozen. The more irritable and tender the skin is, the more readily the
complaint arises. Children, especially those subject to scrofula, young
persons, females, and all who are brought up tenderly, who keep them-
selves warm, and unexposed to the air, and who perspire much in the
feet, are particularly liable to chilblains. Chilblains, as Dr. Macartney
justly states, occur with remarkable frequency in constitutions where the
circulation is languid in the extreme parts, with a predominance of venous
blood, indicated by a purple complexion, and the same colour in the skin
of the extremities appearing on exposure to cold.
One of the best applications to chilblains of the first and second sort is
ice-cold water : the part affected is to be immersed in it a few minutes,
two or three times a day, and then well dried and covered with a leather
sock. Ice-water, or snow, is not, however, eligible for patients disposed
to phthisis, or gout, nor for delicate females.* Astringent and stimulating
applications are in more common use ; such as the liquor plumbi acet.,
spir. vini. camph., tinct. myrrhaB, spirit of turpentine mixed with balsam
copaivae, linimentum camphorae, linimentum ammonia?, one part of tinc-
ture of cantharides diluted with six parts of soap liniment, or a mixture
of two parts of spir. vini. camph. and one part of liquor plumbi acet.
Ulcerated chilblains require stimulating dressings, as lint dipped in a
solution of the nitrate of silver, Peruvian balsam, a mixture of liquor
plumbi acet. and liquor calcis, or a lotion of the chloride of lime, as
recommended by Lisfranc. A salve, containing the superacetate of
copper, or the hydrarg. nitrico-oxydum, or touching the ulcers with the
nitrate of siver, is often beneficial. If a poultice be necessary in the first
instance, it may be made of oatmeal, with some port wine, or a propor-
tion of the solution of chloride of soda in it.
Gangrenous chilblains should be treated according to rules explained
in the remarks on mortification.
* See Gibson's Institutes, vol. i. p. 46. ed. 5.
125
WOUNDS.
By a wound, surgeons imply a recent suddenly formed breach in the
continuity of the soft parts, attended at first with hemorrhage, and gene-
rally produced by an external mechanical cause.
In a few instances, however, breaches of continuity, both in the soft
and hard parts, are suddenly caused by the violent action of the muscles,
which either tear themselves asunder, break the bones, or rupture the
tendons, with which they'are connected. Sometimes, also, the sharp point
of a broken bone wounds the integuments, and changes the case into a
compound fracture. Here we see, that the cause is mechanical, but not
of an external kind, as in ordinary examples.
Wounds are divided into several kinds, the distinctions being founded
either upon the sort of weapon with which the injury is inflicted, or upon
the circumstance of a venomous matter having been inserted in the part,
or, lastly, upon the particular situation of the wound, and the nature of
the wounded parts themselves. Thus, the first class of wounds, con-
sisting of cuts, incisions, or incised wounds, is produced by sharp-edged
instruments, and generally free from all contusion and laceration. The
fibres and texture of the wounded part have suffered no injury but their
mere division ; and there is, consequently, less tendency to inflammation,
suppuration, gangrene, and other bad consequences, than in the gene-
rality of other wounds. Incised wounds, also, may usually be healed with
greater quickness and facility than others which are more or less con-
tused or lacerated : the surgeon has only to prevent the solution of con-
tinuity from gaping, or, in other words, he has simply to bring the oppo-
site sides of the wound into contact, and to keep them in this state a few
hours, and they will grow together.
Another class of wounds is stabs, or punctured wounds, caused by the
thrust of pointed weapons, like bayonets, lances, swords, daggers, &c.,
and also by the accidental and forcible introduction of considerable thorns,
large nails, &c. into the flesh. These wounds frequently penetrate to a
great depth, so as to injure blood-vessels, nerves, viscera, and other
organs of importance ; and, as they are generally inflicted with much
force and violence, the parts suffer infinitely more injury than what would
result from their simple division. It should also be noticed, that a great
number of the weapons or instruments with which stabs are inflicted
increase materially in diameter from the point towards the other ex-
tremity ; and, consequently, when they penetrate far, they act like a
wedge in forcing the fibres asunder, and thus cause a serious degree of
stretching and contusion. It is on this account that bayonet wounds of
the ordinary soft parts are very often followed by violent inflammation,
extensive swelling, large abscesses, fever, delirium, and other unfavour-
able symptoms. The opening, which the point of such a weapon makes,
is quite inadequate for the passage of the thicker part of it, fwhich
can only enter by forcibly dilating, stretching, and otherwise injuring
the fibres.
A third description of wounds is contused and lacerated ones, which
strictly comprehend, together with a variety of cases produced by the
violent application of hard, blunt, obtuse bodies to the soft parts, all those
interesting and common injuries denominated gunshot wounds. Many
bites also rank as contused lacerated wounds. In short, every solution of
continuity, which is suddenly produced in the soft parts by a blunt in-
126 WOUNDS.
strument or weapon, that does 'not operate by means of a sharp edge or
point, must be a contused or lacerated wound.
Poisoned wounds are complicated with the introduction of a venomous
matter or fluid into the part. Thus the stings and bites of a variety of
insects afford us examples of poisoned wounds. But a more serious and
dangerous instance, which we meet with in this climate, is seen in the
cuts accidentally received in the dissection of dead bodies, or in handling
instruments infected with any irritating or venomous matter, as sometimes
happens to the surgeon in the performance of operations on gangrenous
limbs, and in dressing venereal and other infectious ulcers. The most
dangerous, however, of all the poisoned wounds which ever occur in this
kingdom, are those caused by the bite of the viper, and by that of several
rabid animals, especially the dog and cat.
Wounds are farther divided by surgical writers into those of particular
regions or parts of the body : thus, we haVe wounds of the head, face,
throat, chest, abdomen, limbs, arteries, veins, nerves, lungs, liver, fyc. fyc.
Wounds may likewise be universally referred to two other general
classes, viz. simple and complicated. A wound is called simple when it
occurs in a healthy subject, has been produced by a clean sharp-edged
instrument, is unattended with any serious symptoms, and the only
indication is to re-unite the fresh-cut surfaces. A wound, on the con-
trary, is said to be complicated, whenever the state"of the whole system,
or of the wounded part, or wound itself, is such as to make it necessary
for the surgeon to deviate from the plan of treatment requisite for a
common simple wound. The differences of complicated wounds, therefore,
must be numerous, as they depend upon many incidental circumstances,
the principal of which, however, are hemorrhage, nervous symptoms,
excessive pain, tetanus, a great degree of contusion, the discharge or
extravasation of certain fluids, indicating the injury of particular bowels
or vessels, the presence of foreign bodies, or of a poison or irritating
matter in the part, loss of substance, an attack of hospital gangrene,
phlegmonous erysipelas, &c.
All large or deep wounds are followed by more or less symptomatic
fever, which usually comes on at a period varying from sixteen to thirty-
six hours after the receipt of the injury, but sometimes much earlier.
Its occurrence is indicated by a greater warmth of the skin ; by an
increase in the frequency, and generally, also, in the strength, of the action
of the heart and arteries ; by anxiety, thirst, and a suppression of the
powers of digestion. The symptomatic fever from wounds is usually of
the inflammatory character ; and it even sometimes happens that a very
high degree of it takes place in debilitated constitutions, and in persons
who have lost a considerable quantity of blood. In these latter cases,
however, the frequency of the pulse is more remarkable than its strength,
and the fever puts on more of the asthenic than the truly inflammatory
type. It is of great consequence to attend to the character of this
fever ; for the loss of blood, which may be required and sustained with
impunity in one species of fever, may prove highly injurious, if not fatal,
in the other.*
The danger of wounds is proportioned to their size ; the degree of
violence done to the fibres in addition to their mere division ; the little
power which the part has of repairing its injuries ; its great importance
to the constitution; the size of the injured bloodvessels and nerves, and
the age of the patient, and the state of his constitution.
* See Thomson's Lect. on Inflammation, p. 292.
WOUNDS. 127
1. The removal of a large adipose tumour is often accomplished
without injuring any part of importance, and yet the magnitude of the
wound may occasion death.
2. A man cannot bear a large incised and lacerated wound equally
well ; because, in the latter case, the textures are not only divided, but
stretched, and otherwise injured. I have seen the integuments covering
the anterior surface of the tibia torn in a straight direction, from the
upper head of that bone nearly to the foot : a rapid mortification of the
limb took place, and the man died. Had this been a simple incision,
such fatal consequences would not, probably, have happened, since
the wound of amputation, even when a bulky thigh is removep!, is not
frequently the cause of death. All contused and gunshot wounds are,
for this reason, more perilous than if they were simple breaches of
continuity.
3. Joints seem to possess only an inferior power of repairing their
accidental injuries, which often induce a state of irremediable disease in
the part, or so violent a disturbance of the whole system, that the patient
loses his life. I here more especially allude to wounds of the large joints ;
for the smaller articulations generally bear severe injuries as well as most
other parts. Some organs are prevented from readily healing, owing to
the continual or frequent passage of fluids through them. This is the case
with all the ducts and outlets of secreting organs, the intestinal canal, the
arteries, &c.
4. The slightest wound of a part, the functions of which are intimately
connected with life, is often fatal : the brain, the cerebellum, the spinal
cord, stomach, the bowels, &c.
5. When large arteries are injured, the hemorrhage, if not immediately
stopped, will destroy life in a few seconds ; and, when the main artery
and nerve of a part are both divided, there is generally a considerable
risk of mortification, in addition to the first danger from the bleeding.
6. Wounds in young, strong, healthy subjects generally heal more
quickly and favourably, than in persons of advanced age, and -impaired
constitutions.
INCISED WOUNDS.
An effusion of blood from the divided vessels., pain arising from the
division and exposure of nerves, and a gaping of the wound, or separa-
tion of its edges from each other, are the immediate effects of a wound of
the skin, or flesh, with a sharp cutting instrument.
Almost every part of the body is furnished with a vast number of
bloodvessels, which, indeed, exist in such myriads that it is impossible
to prick the skin with the point of the finest needle, without opening one
or more ramifications of vessels containing blood, which instantly oozes
out. But this effect always happens in a greater and more remarkable
degree when there is an extensive cut in the skin or flesh ; and if tny of
the wounded vessels be above a certain magnitude, the hemorrhage may
be profuse, and even immediately fatal.
The same experiment, which demonstrates the presence of blood-
vessels in every situation, namely, the pricking of any part of the body
with a needle, proves, also, that filaments of nerves exist every where,
and at every point ; for, the slightest prick of the skin occasions pain ;
and pain cannot happen except where there are nerves. The pain of
wounds is observed to be more or less acute, according to the kind of
instrument with which they are inflicted ; the extent of the division ;
128 WOUNDS.
and, especially, according as the individual happens or not to be in
expectation of the receipt of the injury. A patient, on whom an operation
is to be performed, turns his whole attention to the effect which the use of
the knife will produce upon his feelings, and he suffers a great deal : but
if an incision be made when not expected, or when the mind is intent
on other things, the agony is more moderate. Thus, a soldier may be
wounded in the heat of battle, and not feel the hurt till the bleeding
attracts his notice.
When the skin or flesh is divided with a cutting instrument, the edges
of the wound separate from one another, and the injury presents a gaping
appearance. The instrument itself, acting like a wedge, must unavoidably
separate the parts between which it enters ; but, if this were the only
cause, the gaping would be very inconsiderable. We find, however, that
the opposite surfaces of many wounds are drawn away from one another
several inches ; and the principal causes, to which the phenomenon is to
be ascribed, are the natural elasticity of the skin, cellular tissue, fasciae,
&c., and the power of contraction inherent in the muscles.
The quality of elasticity which belongs to most animal substances, and
is inherent in them even after they have been deprived of life, does not
prevail in an equal degree in every texture. Hence, the degree of sepa-
ration, produced by this cause, varies considerably, according to the nature
of the wounded parts. The edges of an incision in the skin become
widely drawn asunder, because the integuments are endued with great
elasticity. The cellular tissue, when cut, gapes very little, because it is
less elastic. The extremities of a divided artery recede far from one
another ; the retraction being far greater than what happens in divided
veins, which possess a much smaller share of elasticity. The muscles,
also, are not remarkably elastic ; yet, -the sides of these wounds, especially
those of the transverse kind, are always considerably separated from one
another ; but, this is not altogether owing to elasticity, but chiefly to a
vital power of contraction inherent in muscular fibres.
The separation of the edges of a wound is also not always in proportion
to the elasticity of the parts, but depends in some measure upon the de-
gree of tension in which they happen to be at the moment of the injury.
A simple experiment proves the truth of this observation. If the skin
covering the knee be divided transversely in a dead subject, while the leg
is bent upon the thigh, and another similar incision be made in the knee,
while the leg is extended, the separation, which happens between the lips
of these wounds, will be found to be much greater in the first than the
second example.
[The prognosis of incised wounds varies according to the extent and
depth of the division, the nature of the injured parts, and several circum-
stances which rank as complications. Deep large wounds are more dan-
gerous and difficult to cure, than those which only interest the skin.
Wounds, accompanied with injury of large bloodvessels, or nerves, are
more or less dangerous, according to the magnitude and importance of
those vessels and nerves, and the possibility or impossibility of obtaining
speedy surgical assistance. Simple cuts, in which the only indication is
to bring the divided parts together, are the most favourable cases of all.
On the other hand, complicated incised wounds are more or less serious
and hazardous, according to the particular nature of the complication,
whether this be a wounded artery, a vein, or nerve of magnitude and im-
portance, a wounded excretory duct, a wounded bowel, a wounded
trachea, oesophagus, &c. The complications, also, of bad health, and very
HEMORRHAGE. 129
advanced age, are other considerations which should influence the prognosis.
Generally speaking, the most dangerous examples of incised wounds are
those of the throat, made by persons who attempt to destroy themselves.
Here there are so many large blood-vessels, nerves, and other organs of
importance, that deep incised wounds too often prove fatal, either imme-
diately, or in a short time. Sometimes the patient opens the carotid
artery, and perishes of hemorrhage on the spot, before any assistance can
be rendered. In other instances, he divides some of the principal branches
of the external carotid, and, after losing a great deal of blood, faints, in
which state the hemorrhage may cease for a little while. The fainting,
indeed, is often the very thing which saves his life, by checking the effusion
of blood until the surgeon arrives, who ties the vessels as soon as they
begin to bleed again. Incised wounds of the extremities, when such
arteries as the femoral and brachial are injured, may also suddenly destroy
the patient, by the great quantity of blood sometimes lost before the arrival
of surgical assistance.
In the treatment of incised wounds, there is frequently nothing to be
remedied, except the simple breach of continuity, the cut fibres not
having been stretched, contused, nor lacerated. When no artery of
importance is divided, and no extraneous bodies are lodged in the wound,
the duty of the surgeon consists in promoting the re-union of the divided
surfaces without delay. It often happens, however, that considerable
vessels are injured, and then the bleeding demands primary attention.
HEMORRHAGE.
According to the correct definition of it, laid down by Dr. Carswell,
hemorrhage consists in the extravasation of blood, or the escape of this
fluid during life, from the vessels in which it is contained and circulated,
into the substance or on the surface of organs, whether it be retained in
these situations, or conveyed to the external surface of the body. It
may take place from the heart, arteries, veins, and capillaries, as the
immediate consequence of a solution of continuity occasioned by incised
wounds, puncture, laceration, ulceration, and mortification ; or the san-
guineous discharge may proceed from the capillaries, which present
either no perceptible lesion of structure, or merely an increase of capacity,
whereby the red globules are enabled to pass along these vessels, with
the other constituents of this fluid, which is poured out after the manner
of extravasation.* Hemorrhage may be arterial or venous ; primary or
secondary ; active or passive. One of the best classifications of the
several forms of it is that adopted by Dr. Carswell, namely, —
1. Hemorrhages from Physical Lesions, comprising, 1st, those from
wounds, ulceration, and mortification ; 2dly, others, from a mechanical
obstacle to the circulation, situated in the heart, or the blood-vessels.
2. Hemorrhages from Vital Lesions, comprehending, 1st, those from a
modification of function of the capillaries, as exemplified in vicarious
hemorrhage, and that from erectile tissue ; 2dly, bleeding from a dReased
state of the blood, as illustrated in scorbutus, some forms of purpura, and
some of typhoid fever ; 3dly, hemorrhage from debility.
In every wound, the bleeding demands the earliest attention, because,
if loss of blood be not prevented without delay, the patient will frequently
die in the course of a few seconds or minutes. Every other consideration
may be deferred ; but, when large vessels are injured, they must be imme-
* See Dr. Carswell's Elementary Forms of Disease ; fasciculus on Hemorrhage.
K
130 HEMORRHAGE.
diately secured, or else the sudden death of the patient will leave the sur-
geon no opportunity of exhibiting his skill and usefulness in other mat-
ters connected with the treatment.
'} Previously to considering what surgical means are best calculated for
stopping hemorrhage, it seems right that I should advert to the nature of
the process by which the bleeding from wounded arteries is permanently
suppressed. As arteries are supplied, not only with small arteries and
veins (the vasa vasorum), but also with absorbents and nerves, and have,
in these respects, a similar organisation to the other soft parts of the
body, they must be susceptible of every change to which living parts are
subject in common ; and hence, when they are injured, they inflame,
and pour out coagulating lymph, by which the injury is sometimes re-
paired, or the tube permanently closed.* In short, the coats of arteries
inflame, and pass through all the stages of adhesion, suppuration, or gan-
grene, in the same manner as the skin, a gland, or a muscle.f
Surgeons formerly entertained various theories, concerning the process
by which the hemorrhage from divided arteries was suppressed ; but, as
none of these seemed altogether satisfactory, the late Dr. Jones was led
to undertake a series of interesting experiments, the results of which
enabled him to give a more correct view of the subject ; and from these
investigations it appears that, when an artery of considerable size is entirely
divided, the bleeding is stopped in the following manner : — An impetuous
flow of blood, a sudden and forcible retraction of the artery within its
sheath j:, and a slight contraction of its extremity, are the immediate and
almost simultaneous effects of its division. The natural impulse, however,
with which the blood is driven on, in some measure counteracts the re-
traction, and resists the contraction of the artery. The blood is effused
in the cellular tissue, between the artery and its sheath, and, passing
through that canal of the sheath which has been formed by the retraction
of the artery, flows freely outward, or is extravasated in the surround-
ing cellular tissue, in proportion to the open or confined state of the
external wound. The retracting artery leaves the internal surface of the
sheath uneven, by lacerating or stretching the cellular fibres which con-
nected them. These fibres entangle the blood as it flows; and thus the
foundation is laid for the formation of a coagulum at the mouth of the
artery, which is completed by the blood gradually adhering and coagu-
lating around its internal surface, till it completely fills it up from the
circumference to the centre.
The hemorrhage is checked by the effusion of blood into the surround-
ing cellular tissue, and between the artery and its sheath ; but, parti-
cularly, by the diminished velocity of the circulation, occasioned by the
bleeding, and by the quick manner in which the blood always coagulates,
when the action of the vascular system is much diminished.
Thus a clot over the mouth of the artery, within its sheath, called by
* See Jones on the Process employed by Nature in suppressing the Hemorrhage
from Divided and Punctured Arteries ; and on the Use of the Ligature ; with Obs. on
Secondary Hemorrhage, p. 5. 8vo. Lond. 1805.
\ Hodgson on the Diseases of Arteries and Veins, p. 1. 8vo. Lond. 1815.
i Arteries of the fourth and fifth orders, like those of the forearm and leg, are not
furnished with a distinct sheath, their external coat being immediately connected with
the surrounding cellular tissue. This accounts for the greater difficulty, invariably
experienced, in separating a small artery from its attachments than a large one. See
P. J. Manec, Traite Theorique ct Pratique de la Ligature des Arteres, p. 3. fol. Paris,
1832.
HEMORRHAGE. 131
Dr. Jones the external coagulum, presents the first complete barrier to the
effusion of blood.
The mouth of the artery being no longer pervious, and having no
collateral branch very near it, the blood, just within it, is at rest, coagu-
lates, and forms, in general, a slender conical coagulum, which neither
fills up the canal of the artery, nor adheres to its sides, except by a small
portion of the circumference of its base, which lies near the extremity
of the vessel. This coagulum is distinct from the former, and is named
by Dr. Jones the internal coagulum.
In the meantime, the cut extremity of the artery inflames, and the
vasa vasorum pour out fibrine, which is prevented from escaping by the
external coagnlum. This fibrine fills up the extremity of the artery, is
situated between the internal and external coagula of blood, is somewhat
intermingled with them, or adherent to them, and is firmly united all
round to the internal coat of the artery.
The permanent suppression of the hemorrhage chiefly depends on this
coagulum of fibrine ; but, while it is forming within, the extremity of
the artery is further secured by a gradual contraction, which it undergoes,
and by an effusion of fibrine between its tunics, and in the cellular tissue
surrounding it. Thus, these parts become thickened, and so completely
incorporated with each other, that one cannot be distinguished from the
other ; the canal and mouth of the artery becoming obliterated, and
blended with surrounding parts.
When the wound in the skin is not healed by the first intention, an
exudation of coagulating lymph, or fibrine, gives a covering to the end of
the vessel, and separates it from the cavity of the wound.
In the inferior portion of the divided artery, the orifice of the vessel is
generally more contracted, and the external coagulum is much smaller.*
The extremity of the artery, up to the first collateral branch, after-
wards gradually contracts, till at length its cavity is completely obliterated,
and its tunics assume a ligamentous appearance.
The external coagulum, which stopped the hemorrhage in the first in-
stance, is absorbed in a few days, and the thickening of the parts, from
the extravasation of fibrine, gradually diminishes.
If the end of the artery be examined, at a still later period, it will be
found to be reduced to a mere filamentous state, as high up as the origin of
its first branch, and the anastomosing branches are considerably enlarged.
Another fact made out by Dr. Jones is, that, when the division of an
artery has happened near a collateral branch, no internal coagulum is
formed.
When an artery is punctured or only partially divided, the blood is
effused in the cellular tissue, between the artery and its sheath, for some
distance both below and above the wounded part. On examination, a
short time after the hemorrhage has stopped, a stratum of coagulated
blood is found between the artery and its sheath, extending fr<Mn a few
inches below the wounded part, to two or three inches above it, and is
somewhat thicker, or more prominent, just over the wounded part, than
elsewhere. In consequence of the space between the artery and sheath
becoming filled with blood, and the latter part distended, the relative
* Mr. Guthrie differs from Dr. Jones, in believing the retraction and contraction of
the lower end of a divided artery not to be so complete, nor so permanent, as in the
upper. He states, also, that the internal coagulum is less perfectly formed. On the
Diseases, &c. of Arteries, p. 24 9.
K 2
132 HEMORRHAGE,
situations of the punctures in it and the artery are altered, and thus a
coagulum of blood becomes confined by the sheath over the puncture in
the vessel, and stops the hemorrhage. But this is only a temporary bar-
rier ; and the permanent stoppage of the bleeding is here also effected by
a process of reparation or obliteration.
If an artery be wounded only to a moderate extent, it is capable of
re-uniting, and of healing so completely, that, after a certain time, the
cicatrisation cannot be discovered, either on its internal or external sur-
face ; and even oblique and transverse wounds (which are attended with
more gaping than longitudinal ones), when they do not open the artery
to a greater extent than one fourth of its circumference, are also healed,
so as to occasion little or no obstruction in the canal of the artery. But,
as Petit observed, this can hardly ever happen, except when the aperture
in the vessel is of moderate size * ; and, as Professor Beclard's expe-
riments tend to prove, it can scarcely take place in an artery above a
certain magnitude, without the support afforded to the vessel by its
sheath. In larger wounds, the artery is rendered impervious by the effu-
sion and organisation of fibrine ; and, when the division is still more
extensive, the partially divided part of the vessel becomes either torn or
ulcerated through.f
SURGICAL MEANS FOR THE STOPPAGE OF BLEEDING.
The tourniquet consists of a band and buckle, a pad, and two brass
frames, the upper one of which is furnished with two small rollers, and
the lower with four, over all of which the band plays, so as to facilitate
the action of the screw. When the handle of this is turned to the right
or left, the band is tightened, or relaxed, in the exact degree which the
surgeon wishes. The piece of leather under the lower brass frame hin-
ders the skin from being hurt at this point by the pressure of the edges
of the hard metal. The buckle is prevented from having this effect by
its being commonly fastened over the pad. The band is first buckled
round the limb in such a manner, that the pad, which is attached to the
band, is placed exactly over the artery. The two brass frames, with their
respective rollers, over which the band proceeds, are then made to separate
from each other to the requisite distance by turning the screw, and thus
the due degree of pressure is produced.
The advantages of this instrument are considerable : the pressure may
be regulated with the utmost exactness, and it operates with the chief
force on th& point where the pad is placed, and under which the main
artery lies ; it does not require the aid of an assistant to keep it tense ;
it completely commands the flow of blood into a limb ; it may be relaxed
or tightened in a moment ; and, when there is reason to fear a sudden
renewal of bleeding, it may be left slackly round a limb, and, in case of
need, made tense in an instant.
Its operation, however, is limited to the limbs ; and, as the pressure,
necessary to impede the flow of blood through the principal artery, com-
pletely prevents the return of blood through the veins, its application
cannot be made long without inducing gangrene. Hence, it is only a
temporary expedient for the stoppage of bleeding, always discontinued
immediately the surgeon has had time to adopt other means of a more
permanent nature.
* Mem. dc 1'Acad. Royalc dcs Sciences, an. 1735.
f Jones, op. cit. chap. i. sect. 3. and chap. ii.
HEMORRHAGE 133
The tourniquet is unquestionably a meritorious invention, by which
the lives of wounded persons are frequently preserved, and a degree of
security given to several of the most important operations in surgery,
sometimes difficultly attainable without its assistance. Thus, when
surgeons are about to amputate a limb, they commonly apply the tour-
niquet, in order that the patient may not lose a dangerous quantity of
blood during the time requisite for the division of the soft parts and the
sawing of the bone. These proceedings having been completed, the
principal artery or arteries are looked for, the situations of which are
made known by anatomy. For instance, in the stump of an amputated
thigh, the operator searches for the open mouth of the divided femoral
artery near the sartorius muscle : he takes hold of it with a pair of
arterial forceps, and the assistant ties it. But, after having taken up the
main artery and such others as have determinate situations, and are large
and open-mouthed, so as to be readily perceived, the surgeon would not
be able to detect others of less size, requiring ligature, if the tourniquet
were not loosened for an instant, when the gush of blood from particular
points denotes where they lie. Directly the surgeon has gained this in-
formation, he tightens the tourniquet again, seizes the end of one of the
bleeding vessels with a tenaculum, and the ligature is applied.
Supposing a person were to meet with a wound of one of the principal
arteries of the upper or lower extremity, followed by profuse hemorrhage,
here the surgeon would immediately put on the tourniquet, and stop
further loss of blood, until he had had time to adopt the requisite mea-
sures for securing the wounded artery.
Important as the tourniquet certainly is, it is only applicable to the
limbs ; and even there its office may be partly executed by a steady as-
sistant making pressure on the main artery with his hand, or some other
compressing instrument. In University College Hospital, the tourniquet
is not usually employed in amputation ; the current of blood through the
main artery of the limb being commanded by pressure made with the fin-
gers of a trusty assistant. The objection made to the instrument in such
operation is, that it renders all the veins of the limb exceedingly turgid,
and that more blood is lost than when the pressure is made on the artery
alone with the fingers. The tourniquet is also, as I have stated, only a
temporary expedient, because its application beyond a certain time would
bring on mortification. Hence, it is absolutely necessary to employ other
means as soon as possible.
Ligature. With all the knowledge which we now possess about the right
principles of treating wounded arteries, and advantageous as the tourniquet
sometimes is, we could more conveniently dispense with its assistance
than with that of the means which I am next going to consider ; namely,
the ligature. A modern surgeon, possessing coolness and anatomical
knowledge, would know how to prevent the patient from being lost by
hemorrhage from any part of the body, to which that instrument is appli-
cable, even were he not provided with it. He would know how £<Rd where
to make pressure on the arterial trunk ; and, if the wound were so ample
as to let the orifice of the bleeding artery be seen, he would then have
recourse to the simple and effectual plan of placing his finger over it, until
he could get out his case of instruments and tie it. I have known practi-
tioners so confused as to let patients lose a fatal quantity of blood in
their presence, from the neglect of this obvious and simple proceeding.
It is not doubted at the present day, that the most important of the
means for the permanent stoppage of bleeding is the ligature, by which
K 3
HEMORRHAGE.
the most alarming bleedings may be restrained. With this the mouths
of the divided arteries are tied, and thus, not only an instantaneous stop
is put to further hemorrhage, but, long before the ligature becomes loose,
the opposite sides of the vessel have grown together, and all danger of the
renewal of the bleeding is over.
Several of the conclusions, drawn from Dr. Jones's experiments upon
the subject of hemorrhage, are of the highest importance in relation to
the practic of surgery, and, were they all of them universally admitted,
little doubt would remain about the most advantageous manner of making
and applying ligatures. That a ligature, especially a small one, when
applied round an artery with a certain degree of tightness, completely
divides the inner and middle coats of the vessel, is a fact well known to
all surgeons ; but, whether we should employ such ligatures as are ex-
pressly calculated to produce this effect, and whether we should aim at it
as a beneficial and useful, not to say an essential, object, are questions on
which there have been, and perhaps still are, differences of opinion. From
a variety of experiments Dr. Jones was led to infer, that the division of
the membranous and muscular coats of a tied artery by the ligature had
a principal share in bringing on the effusion of fibrine within the vessel,
or, in other words, the process of adhesive inflammation, by which the
permanent closure of the vessel was effected. He observes that, when a
ligature is properly applied, it cuts through the internal and middle coats
of the artery, keeps their cut surfaces in contact, and affords them an
opportunity of uniting and cicatrising, as other cut surfaces do, by the
adhesive inflammation. Nay, he extended the doctrine further, by re-
presenting the division of internal coats of the vessel by the ligature, not
merely as advantageous, but as absolutely indispensable ; for he remarks
that, if the ligature does not completely cut through the internal and
middle coats all round the artery, adhesion cannot take place between
its internal surfaces, and, therefore, secondary hemorrhage will take place,
as soon as the ligature has ulcerated through any part of the artery.*
That Dr. Jones erred, in describing the division of the inner coats of
the vessel as a thing without which the vessel could not be closed by the
process of adhesive inflammation, remains no longer questionable. The
assertion, as Sir Philip Cramptonf has observed, rested upon no other
foundation than several experiments made on the arteries of quadrupeds,
in all of which the internal and middle coats were ruptured by the appli-
cation of the ligature. No comparative experiments are related, in order
to show, that this operation of the ligature is essential to the process of
union, and that, under these circumstances only, the obliteration of the
artery can take place. Numerous instances are recorded of arteries being
obliterated by the pressure of tumours. The subclavian and carotid
have been found obliterated by the pressure of an aneurism of the arch
of the aorta.J In Mr. Freer's experiments, the pressure of a tourniquet
for four days was sufficient to effect the obliteration of the radial artery
in horses. § Mr. Hunter found, that the mere exposure of the tibial artery
of a dog to the air, for about an hour, excited such a degree of inflam-
mation and thickening of its coats as completely obstructed the canal. ||
* On Hemorrhage, pp. 166. and 170.
•f- Medico- Chir. Trans, vol. vii. p. 343.
\ Hodgson on the Diseases of Arteries and Veins, p. 110. A. Cooper, in Mod.
Chir. Trans, vol. i. p. 12.
§ Obs. on Aneurism, p. 14. || On the Blood, &c.t
HEMORRHAGE. 135
All the great arteries, the aorta inclusive, have been found obliterated, in
consequence of the effusion of fibrine from their internal coat, and this
independently of any injury which could produce the rupture of that
membrane. The cure of aneurism by compression (whether mediate or
immediate) affords an example of the obliteration of an artery without
any rupture of its internal coats.*
In the course of the interesting experiments undertaken by Dr. Jones,
he observed, that when a ligature had been tightly applied round a large
unwounded artery in a quadruped, so as to cut through the internal
coats, and it was immediately afterwards removed, the adhesive inflam-
mation took place at the part of the vessel embraced by the ligature,
and the canal of the artery became permanently obliterated for some
extent. This consequence happened, however, with increased certainty,
when two or more ligatures were thus applied near one another, and then
taken off.f
The promulgation of these observations at first excited hopes, that the
leaving of a ligature on arteries, tied for the cure of aneurisms, might be
dispensed with ; and what Dr. Jones had himself succeeded in accom-
plishing did not fail to convince him, still more firmly, that the division
of the inner coats of the artery was the main exciting cause of the adhe-
sive inflammation by which the canal qf the vessel was permanently
closed ; and that the obliteration could not happen unless those coats
were cut through by the ligature. But, as Mr. Travers has justly stated,
the result of these experiments neither warranted the conclusion that
the complete division of the internal coat was necessary to union, nor
that union was a necessary consequence of it. The history of the broad
tape or riband ligature proves, that contact without wound will sometimes
produce adhesion, and the frequent repetition of Dr. Jones's experiment
has proved that wound without contact will sometimes fail to produce
it. Mr. Dairy mple, of Norwich, repeated the second experiment, in
Dr. Jones's third chapter, not less than seven times on horses, and three
times on sheep, and, in every instance, failed in obtaining the same results.
Not only was no coagulum formed, but, even when the animal had been
suffered to live until the, thirteenth, fifteenth, or eighteenth day after the
operation, the canal of the artery was not found obliterated. Its calibre
was indeed contracted ; but the tube remained in some degree pervious,
and capable of transmitting a lessened column of blood. J The evi-
dence of another eminent writer also coincides precisely with that of Mr.
Dalrymple.J
Di% Jones's idea, that the division of the internal and middle coats was
essential to' the production of the requisite degree of adhesive inflammation
for the obliteration of the cavity of the artery, is completely refuted, not
only by the facts adverted to by the preceding authors, but by a variety
of other considerations. A ligature was put round^the carotid of a dog
without being drawn. It lay in contact with the artery, but did not press
upon it, nor interrupt the flow of blood through it. The result vq^s an ob-
literation of that part of the vessel which was irritated by the presence of
the ligature. The same experiment was made on the carotid of an ass
with a similar consequence. || Here, then, are further proofs, as unequi-
* Crampton, in Med. Chir. Trans, vol. vii. p. 345.
f Jones on Hemorrhage, p. 126, &c.
I Travers, in Med. Chir. Trans, vol. iv. p. 442.
§ Hodgson on Diseases of Arteries, £c. p. 128.
|| C. Bell, Surgical Obs. vol. i. p. 261.
K 4
136 HEMORRHAGE.
vocal as any of those previously cited from Sir Philip Crampton's valuable
paper, that the internal coat of an artery will effuse fibi'ine when any
cause of sufficient irritation exists on the outside of the vessel, and that
the division of its inner coats by a ligature is by no means essential to
the excitement of the adhesive inflammation within it.*
All serous membranes, including the inner coat of the arteries, when
kept in close contact, in sufficiently vigorous subjects, generally assume,
with surprising quickness, the adhesive inflammation in the seat of the
compression and around it, evincing a singular propensity to effuse
fibrine, and, though such membranes are inflamed, they remain free
from ulceration or breach of continuity. [This is daily seen between the
lungs arid pleura, between the peritoneum and the viscera of the ab-
domen, and between the tunica vaginalis and the testicle. And, in
order to assure ourselves that the same phenomenon also happens be-
twixt the two opposite sides of an artery, which are simply held in close
contact with each other, without any previous ulceration or rupture of
them, we need not have recourse to analogy in what takes place under
the same circumstances in other similar parts of the body, since there are
numerous instances of the quick union and perfect closure of an artery,
by means of the adhesive inflammation, under simple compression alone,
practised upon the artery while all its parts remain entire. Dubois f
effected this prompt adhesion by means of the serrenceud of Desault ;
Assalini J by compressing the artery with his forceps ; and Crampton
with a presse-artere resembling that of Deschamps. To these facts we
are to add numerous others of the closure of the artery, in consequence
of pressure made on the vessel by a neighbouring tumour, or an aneu-
rismal sac. If the ligature be preferable to compression in the treatment
of external aneurism, still it is certain that, by means of pressure applied
above the seat of the disease, several cures have been accomplished ; and
if the compressing apparatus does not always produce such good effects,
it is often because we have not the opportunity of making the pressure
with sufficient steadiness and force to obliterate the artery. Compression
(says Scarpa) generally answers very well when made upon an exposed
artery, behind which there is a point of resistance. Formy §, in a wound
of the brachial artery, laid bare the vessel, placed a cylinder of linen upon
it, and over this some graduated compresses, supported by means of a
suitable bandage ; and thus he effected the closure of the artery. ||
Guattani exposed the femoral artery as it passes under Poupart's liga-
ment, compressed it against the ramus of the os pubis with graduated
little bolsters and a bandage, and the vessel was speedily closed. Flajani^,
in similar cases, found the same method answer. Buzani * * also succeeded,
with graduated compresses, in healing a wound of the brachial artery
after bleeding ; and so did Garneri in two additional examples of the
* See, also, Crampton's experiments with a flat ligature, and piece of metal, on the
carotids of sheep, in Med. Chir. Trans, vol. vii. p. 346., and other experiments detailed
by Scarpa in his Memoria sulla Legatura dellc principal! Arterie degli Arti, &c. Fol.
1'avia, 1817. p. 34. et seq.
•f* Leveille, Nouvelle Doctrine Chir. t. iv. pp. 247 — 280.
\ | Manual e di Chirurgia.
§ Traite Chir. des Bandes Larges Emplatres, &c. Montpelier, 1652.
|| De Aneurysmate, Historia 15.
^ Collezione d'Osservasioni e Kiflessioni di Chirurgia, t. ii. p. 47, &c.
** Opere di Bertrandi. Trattato del Operaz. t. iii. p. 207. Gli editor!.
HEMORRHAGE. 137
same nature. Scarpa corroborates the purport of these observations by
a relation of some experiments, in which the arteries of sheep and other
quadrupeds were tied with a simple ligature, and also with a ligature
between which and the vessels a roll of waxed linen was placed, in order
to prevent the inner coats from being cut through. The main result
was, that in all these cases, the artery closed, but the ulceration ad-
vanced more quickly in the instances where the simple ligature was
used.* Four cases are likewise recorded, in which Scarpa's mode of
applying the ligature was successfully practised in operations for aneu-
rism.
The preceding facts cannot allow us to hesitate a moment about the
rejection of Dr. Jones's assertion, that a ligature will never be followed
by an efficient degree of adhesive inflammation within a tied artery,
unless the inner coats of the vessel be divided by the cord. Instead of
so sweeping an inference, this talented observer should merely have con-
cluded, that such inflammation may take place after the ligature has had
the effect described, and not that it cannot happen under any other cir-
cumstances. The determination of this question, however, is not at all
a decision of the other point, viz. whether such division of the inner coats
of an artery by the ligature be useful or detrimental in its effects upon the
process by which the vessel is to be obliterated. Dr. Jones, who consi-
dered it as the best means of promoting the effusion of coagulating lymph.,
or fibrine, within the vessel, and as the surest and most prompt mode of
bringing about the union and closure of the tied part of the arterial canal,
gave a decided preference to small ligatures, which always cut through
the inner coats of the vessel with the greatest certainty. He thinks that
ligatures should be round and very firm ; and he declares, that there is
no danger of their making the external coat of the artery ulcerate, by
their tightness, before the internal ones have adhered ; for the union of
the latter is found to be soon completed. He reprobates broad flat liga-
tures, because they cannot be tied smoothly round the artery, which
must become puckered, and, consequently, have an irregular bruised
wound made in its middle and internal coats. By covering a considerable
part of the external surface of the artery, they may also destroy the very
vessels which pass on it in their way to the cut surfaces of the internal
and middle coats, and thereby render these surfaces incapable of in-
flaming. But, says he, admitting that such a ligature makes a proper
wound, and that the wound unites, still it may cover that part of the ex-
ternal coat which is directly over the newly united part, and, consequently,
as soon as it has occasioned ulceration through the external coat, it will
produce the same effect on the newly united parts, and, of course, secon-
dary hemorrhage/ ' A ligature of an irregular form will not cut through
the inner coats of the artery equally at every point, which Dr. Jones en-
deavours to prove ought to be done, for the purpose of occasioning an
effusion of fibrine and adhesion. The first good explanation was likewise
given by him of the advantages of applying ligatures in as circulaf*a man-
ner as possible, not higher on one side of the vessel than the other.
Any deviation from a circle must be unfavourable to a steady appo"-
sition of the cut surfaces of the artery, and be conducive to secondary
hemorrhage.
Sir Philip Crampton, however, is far from admitting the utility of cut-
ting through the internal coats of the artery with the ligature, and is of
* Memoria sulla Legatura, &c. pp. 27. 34., &c.
138 HEMORRHAGE.
opinion that, in man, the division of these coats not tmfrequently prevents
the obliteration of the artery, and gives rise to secondary hemorrhage ;
two assertions which appear to me not to be very well proved. If it be
meant to draw a weighty argument from the weakening of the artery by this
effect of the ligature, and an apprehension of the vessel bursting, or becom-
ing dilated, how can we give such importance to this mode of reasoning,
when such inability of the remaining external coat to resist the impetus
of the circulation must be very rare ? Although the two middle coats
are divided by the ligature, in securing the vessels in the common way
after every operation, I have never seen an artery give way or become
dilated from this sort of cause. I have known the ligature slip from not
having been skilfully applied, or accidentally pulled off by a jerk of the
hand, and hemorrhage take place. An artery may also be in so diseased
a state as to give way at once under the application of the ligature ; or, if
it should not burst immediately, yet, from being incapable of the adhesive
inflammation, it may afterwards pour out its blood as soon as the ligature
has produced ulceration through the external coat. But, in this circum-
stance, it is evident, as Scarpa himself allows*, that no mode of tying
the vessel will answer. As we are not sufficiently acquainted with the
actual state of the vessels, the kind of ligatures employed, and some other
essential particulars, in the few cases cited by Sir Philip Crampton, with
the view of proving the risk of arteries giving way from their inner coats
being cut through by the cord, we cannot pronounce whether these were
really examples of this injurious operation of the ligature, or whether
they might not rather be specimens of some uncommon diseased state of
the arteries. For my own part, I cannot suppose any instance in which
the brachial artery, after being tied in amputation, would three times
form an aneurismal tumour above the ligatures f , if it were not in some
unusual state of disease, because I have seen many hundreds of ampu-
tations, but have never witnessed such an occurrence. Besides, if this
particular case prove any thing, it proves, at all events, that the largish
ligatures used in Warner's time, which ligatures probably never fairly
divided the inner coats of a sound artery, could not prevent the vessel in
question from giving way. Without extending these criticisms, however,
I may safely assert, that the advocates for the utility of cutting through
the inner coats of the vessel, and the employment of small fine ligatures,
will come off triumphantly, if they only encounter such objections as are
founded upon the danger of the artery at once giving way, or forming an
aneurismal tumour. It avails little to talk, as Scarpa has done, of the
arteries of some individuals being of preternaturally weak texture from
birth f; or to urge, with Sir Charles Bell, that, if a dead artery be tied
too tightly, it will burst at the tied part when distended with anatomical
injection. § The question can never be decided by such statements ;
and when we admit, with these writers, that an artery with three unbroken
coats is physically stronger than when two of these coats are broken or
torn, we still maintain, that the remaining external coat is strong enough
to resist the impetus of the circulation, so far as we can judge from the
# Memoria sulla Legatura delle Principal! Arterie, p. 7.
•j- See Warner's Cases in Surgery, p. 138. Probably the inner) coats of the artery
were in this case not divided, because the vessel was secured with a needle and ligature,
and of course an intervening portion of flesh included. Mr. Warner himself entitles the
case «' An Extraordinary Disease of the Humeral Artery."
J Memoria sulla Legatura delle Principali Arterie degli Arti, p. 25.
§ Surgical Obs. vol. i. p. 260.
HEMORRHAGE. 139
general result of the practice, in which it is the surgeon's particular aim
to cut through the inner coats of arteries in applying the ligature. It
matters not what happens in the injection of dead bodies ; what happens
in aneurismal and diseased arteries before the ligature is employed ; what
may have happened in very unusual cases, showing that ligatures may
sometimes fail : it must yet be proved, that the tying of arteries, on the
principles recommended by Dr. Jones, is generally less successful than
tfther plans.
Amongst the most distinguished surgeons who opposed the doctrines
and practice recommended by Dr. Jones, and so extensively approved of
in this country, was Scarpa, whose valuable observations on many parts
of anatomy and surgery rendered him the pride of the modern Italian
school. After briefly describing the process of obliteration, according to
Dr. Jones's account, and mentioning a few other things, to which I have
already adverted, he argues that, as cutting through the internal coats of
an artery must render the vessel weaker than when its coats are left
undivided, and we can never estimate the density of such a vessel in the
living subject, it is, caeteris paribus, better to tie the vessel in such a
way as will leave all its three coats uninjured. When the internal coat
is ulcerated from internal causes, and the adhesive inflammation does not
supervene quickly enough, he says, the blood is invariably effused through
the layers of the middle tunic, and extravasated on the outside of it,
first in the form of ecchymosis, and afterwards in that of an aneurismal
swelling. Now, if this can happen when only the inner coat is ulcerated,
it must still more easily take place when the middle coat is also divided,
and any cause retards the adhesive inflammation. He admits that, even
in this second case, if, directly after the division of the two internal coats,
the artery is affected with the requisite degree of adhesive inflammation,
as fortunately mostly happens, the union and closure of the vessel follow
as speedily and favourably as if the two inner coats had not been divided.
But he declares, that this fortunate issue is not constant, especially in
man, in whom the adhesive inflammation is not, as it is in brutes, suffi-
ciently quick to produce on the coats of the artery its beneficial effects
immediately after the application of a tight ligature. Yet, while the
adhesive inflammation is thus retarded, the ulcerative process, occasioned
by the pressure of the small ligature, rapidly attacks the external cellular
coat of the artery, eats more and more deeply into it, and penetrates
into the cavity of the vessel before this has been rendered impervious,
and certainly with greater celerity than if it had to make its way through
all the three tunics of which the artery is composed. The slow access
of the adhesive inflammation, whether from the general debility of the
patient, or from the particular state of the artery itself, is not followed
by a proportionate retardation of ulceration, which incessantly proceeds
till it gives rise to the worst effects. Besides, it is contended that, in
feeble subjects, the coagulating lymph effused in the cavity of the artery,
as well as the coagulum itself, sometimes does not acquire with'equal
celerity the degree of consistence necessary for firmly connecting to-
gether the opposite sides of the artery, which'are held in accurate contact.
These dangers, says Scarpa, are unquestionably avoided by keeping all the
three coats of the artery from being injured by the pressure of the ligature.*
But, after all this reasoning, we must return to experience; and, if Sir
Philip Crampton and Professor Scarpa have produced cases, exemplifying
* Memoria sulla Legatura delle Principal! Arterie, pp. 26~28.
140 HEMORRHAGE.
the possibility of effecting the obliteration of arteries without a division
of the inner coats of the vessels, as I admit has been fully proved, they
cannot subvert the fact, acknowledged by all the most experienced
surgeons in this metropolis, that since Dr. Jones's principles have been
acted upon in practice, and small ligatures been employed,, secondary
hemorrhage has become much less common. Those principles dictate
the use of a fine ligature, as first tried on the human subject by Dr.
Veitch, in the Naval Hospital at Plymouth, and prohibit all unnecessary
disturbance and irritation of the artery ; all needless separation of it from
its surrounding connections; and, in particular, forbid the introduction of
a larger quantity of extraneous substances into the wound than the indi-
cations positively require. If the increased success,, to which I have
alluded, be the truth, it is an answer to every argument used by the
opponents of Dr. Jones's doctrines. With respect to the danger of the
external coat being ulcerated through more quickly by a ligature, which
divides the other two coats, as this occurrence will enable the surgeon to
remove the extraneous substance sooner, it must be a great advantage,
if it be also a fact, as experience proves, that such division of the inner
coats expedites the adhesive inflammation, and insures the closure of the
vessel, before the ulceration has penetrated through the external tunic.
Dr. Jones refutes the idea of ligatures being forced off the vessels by
the impulse of the circulation ; a fear, which led to very hurtful practices,
with the view of mechanically fixing the ligature ; and he observes, that
a candid inquirer into the cause of it will find a much more rational
explanation, either in the clumsiness of the ligature, which prevented its
lying compactly and securely round the artery; or in its not having
been applied tight enough, lest it should cut through the coats of the
artery too soon ; or in its having that very insecure hold of the vessel,
which the deviation from the circular application must necessarily
occasion.
No other plan of preventing bleeding from large arteries is so safe as
the ligature, because no other makes such direct pressure on them, nor
acts with so little chance of being displaced. In the performance of
operations, large arteries are often wounded in situations where the tour-
niquet cannot be applied. The scientific surgeon now knows, that he
can tie such vessels immediately they are wounded, and then proceed
with his incisions, without that confusion and danger which would result
from the continuance of a profuse hemorrhage during the whole time
requisite for the completion of the operation.
It is a maxim in surgery always to tie arteries as separately as possible,
that is to say, without any nerve, vein, or portion of flesh being included
in the noose of the ligature. The tying of the flesh should constantly
be avoided when possible, because it produces immense pain, and causes
a larger part of the wound to remain disunited. Ligatures, thus
awkwardly applied, are likely to become loose, as soon as the substance
between them and the arteries sloughs ; or they may form a circular
furrow in the textures surrounding the vessels, and remain, a tedious
time, incapable of being removed. The intervention of any substance
between the ligature and the artery must also have a great tendency to
prevent the internal coats of the vessel from being cut through ; that very
event, on which the safety from secondary hemorrhage is found so much
to depend.
Bloodvessels partake of the same organisation as other parts. Hence
the healing of a wounded artery can only take place favourably, when
HEMORRHAGE. 141
that part of the vessel which is immediately contiguous' to the ligature
continues to receive a due supply of blood through its vasa vasorum. As
these vessels are derived from the surrounding ramifications, it is obvious
that the application of a ligature to a .divided artery at some distance
from where it is encompassed by flesh, must be very disadvantageous and
insecure. Thus, although it is quite improper to include much of the
adjacent soft parts with the artery in the ligature, it is highly judicious to
make the knot as closely as possible to that part of the vessel which lies
undisturbed among its natural connections. These observations, however,
only refer to vessels above a certain size ; for others are not sufficiently
visible to be tied in this manner.
The method of tying an artery is as follows : — The extremity of the
vessel is first to be taken hold of by the surgeon with a tenaculum, or
pair of artery forceps, which open by their own elasticity, and are some-
times so constructed as to admit of being kept closely shut with a double
button, that slides along a slit in each branch of the instrument. When
the vessel is large and obvious, the forceps should always be preferred.
A round firm ligature, and by no means too thick, is then to be put by an
assistant, in the form of a noose, round the artery, just below the end of
the instrument. The same assistant then tightens the noose ; and, in
order that it may not rise above the mouth of the artery, he draws the
ends of the ligature as horizontally as possible, which is most conveniently
done with the thumbs. A knot is next made. Assalini's double spring
tenaculum, which shuts in the manner of ^a pair of forceps, is now preferred,
by many of the best hospital surgeons in the country, to the common
tenaculum.
When the wounded artery is large, one ligature to the orifice nearest
the heart will not suffice ; for, as soon as this is tied, the blood finds its
way, through anastomosing branches, into the lower continuation of the
vessel, the further orifice of which from the heart then begins to bleed.
The lower or distal end of a divided artery is believed to be more
prone to secondary hemorrhage, than the upper ; and, according to Mr.
Guthrie, this is so much the case that, if the bleeding has been arrested
for four hours, and then returns, it is in all probability from the lower
end. " This," says he, " may always be known from the darker colour
of the blood, and from its flowing out in a continuous stream, in the
same manner as water rises from a spring, and not with any arterial
impulse."* When the anastomoses are very free, as in the lower part of
the forearm, the blood issues from the lower end of the artery directly
the upper one is secured ; or, more properly speaking, it never ceases to
pour out blood in small quantity, which is of a bright red, or vermillion
colour. On the contrary, when the blood has to pervade the capillaries, ere
it reaches the lower continuation of the artery, it flows out evenly, that is
to say, not per saltum, and presents a dark colour, and the appearance of
venous blood.f After a time, however, when the anastomosing communi-
cations between the upper and lower portions of the vessels have ifecome
more direct and free, the blood from the distal orifice, if secondary hemor-
rhage occurs, will exhibit the usual scarlet colour of arterial blood. In
hemorrhage from individuals who are in a state approaching to asphyxia,
the blood issuing even from the cardiac end of an artery will not retain
its characteristic redness.
* See Guthrie on the Diseases and Injuries of Arteries, p. 248.
f See L. J. Sanson des H&norrhagies Traumatiqucs, p. 82. 8vo. Paris, 1836.
14-2 HEMORRHAGE.
When a large artery is only punctured, and not completely cut
through, the vessel is to be first exposed by an incision, and a double
ligature put under it by means of an aneurism needle. One portion of
the ligature is then to be applied above the wound in the artery ;
the other, below it.^Thus, all danger of bleeding, from the passage of the
blood by the anastomoses into the lower part of the vessel, is effectually
removed.
Sometimes, when the punctured part of the artery cannot be prudent!}*
exposed by an incision, as in a bleeding from one of the deep-seated
arteries of the leg in a compound fracture, or from a wound that is highly
inflamed, and threatening gangrene, the surgeon should cut down to the
vessel in a situation nearer the heart, and be content with the application
of one ligature. On these principles it was, that in a gun-shot wound,
injuring the popliteal artery, I took up the femoral artery in 1814, and in
University College Hospital, in May 1835, I tied the popliteal artery,
on account of several returns of bleeding from the arteries of the leg ;
and, in both these cases, the plan answered very effectually ; yet the
safest general rule is, undoubtedly, to expose the wounded part of an
artery, and tie it above and below the aperture from which the blood
issues.
Since ligatures act as extraneous substances, and only one half of each
is necessary for withdrawing it when it becomes loose, the other half is
always to be cut off near the knot.
With the view of diminishing still further the quantity of extraneous
substance in the wound, the plan of cutting off both ends of the ligature
close to the knot was proposed by Mr. Lawrence ; but this method is
not generally followed, in consequence of the small portions of ligature
left in the part having sometimes occasioned a succession of troublesome
abscesses.* When, however, the Vound must suppurate, the practice
is free from objection, and the best ligatures for this purpose are very fine
ones, composed of dentists' silk, j-
Ligatures usually separate, even from the largest arteries ever tied, in
about a fortnight or three weeks, and from smaller ones in the course of
five or six days. When they continue attached beyond the usual period,
it is proper to draw or rather twist them gently every time the jwound
is dressed, so as to accelerate their separation.
Compression. When the blood does not issue from any distinct large
vessels, but from numerous small ones, compression is preferable to the
ligature, the employment of which would render it necessary to tie the
whole surface of the wound. In order to make effectual compression, the
opposite surfaces of the wound are to be brought into contact ; com-
presses are then to be placed over it, and a roller applied with moderate
tightness.
If compression can ever be safely adopted as a permanent plan for
bleedings from large arteries, it is when these vessels run in the vicinity
of a bone, against which they can be compressed ; as in bleeding from the
temporal artery. Compression is sometimes tried when the brachial
artery has been wounded in phlebotomy. Here it is occasionally tried
in -preference to the ligature, because the latter cannot be employed
* Guthrie on Gunshot Wounds of the Extremities, p. 93. See also Crosse's Obs.
in Lond. Med. Repository, vol. vii. p. 3G3., and Gibson's Institutes, £c., of Surgery,
vol. i. p. 72.
f Lawrence, in Medico- Chir. Trans, vol. viii. p. 490.
HEMORRHAGE. 143
without an operation to expose the artery. It is absurd to adopt com-
pression, in this instance, with an idea that it brings about the closure of
the wound in the vessel without obliterating the arterial canal ; and, con-
sequently, with less chance of mortification from a deficiency of blood in
the limb. Frequent dissections have proved that, whenever a large artery
has been wounded and healed by pressure, the canal of the vessel rarely
continues pervious; for, although Dr. Jones's experiments, as well as
those of Beclard, tend to show, that an artery, very partially divided, may
heal and remain pervious, the latter condition is not to be expected, when
much compression is employed.
When an artery of magnitude has received a small wound, and lies
favourably for the trial of pressure, either the ring-tourniquet or the
following plan may be tried : — I suppose the brachial artery at the bend
of the elbow to be the vessel. A tourniquet is to be applied, so as to
command the flow of blood into the vessel. The edges of the external
wound are next to be brought into contact. Then a compress, shaped
like a blunt cone, and formed of a series of compresses gradually increas-
ing in size, is to be placed with its apex exactly over the wound in the
artery. This graduated compress, as it is termed, is then to be bound on
the part with a roller. After relaxing the tourniquet, if no blood escape,
the surgeon should feel the pulse at the wrist, in order to ascertain that
the compression employed is not so powerful as entirely to prevent the
circulation. The arm is to be kept perfectly quiet in a^ sling ; and in
forty-eight hours, if no bleeding take place, there will be great reason to
expect that the case will end well. The plan would not, I think, be
likely to succeed, if there were much blood already effused in the cellular
tissue, because this would prevent the compress from acting efficiently on
the wounded part of the artery.
In a wound of the superficial palmar arch, the ends of the artery may
sometimes be tied at first without much difficulty, if the wound in the skin
and fascia be properly enlarged. Were the attempt to fail, or were the
wound itself a mere puncture, a graduated compress on the part, and cold
applications, might be resorted to with success, as I have seen in several
examples. Sir Astley Cooper informs me that, in some cases of puncture
of the superficial palmar arch, dividing the artery completely through, so
as to allow the ends to retract and contract, has effectually put a stop to
the bleeding. I have never seen a case in which the ligature of the
brachial artery was required for bleeding from the palmar arches ; but,
at least, half a dozen, where the radial or ulnar was taken up, and cold
and a graduated compress also resorted to. In every instance, the effect
of pressure on the radial and ulnar artery should be ascertained. When
hemorrhage takes place from the palmar arches, in gunshot injuries of
the hand, the bleeding orifices can rarely be secured by ligature. Here,
graduated compresses on the radial and ulnar arteries at the wrist, and
on the bleeding part itself, aided by a cold evaporating lotion, with which
the hand and forearm should be covered, will generally answer. When
the hemorrhage is secondary, and the hand in a state that will not bear
any degree even of regulated and limited pressure, the effect of a ring
tourniquet, in moderating or stopping the flow of blood through the
brachial artery, should be tried. The operation of tying the brachial ar-
tery,, or of mutilatingt he hand by removing one of the metarcarpal bones
to search for the deep palmar arch, I consideyinadvisable proceedings.
Compression can seldom be relied upon ; for the compresses frequently
slip off the artery, or the bandages become slack, so as to give room for
14-4? HEMORRHAGE*
fatal hemorrhage. When the plan is employed, a slack tourniquet may
be left on the limb, ready to be tightened in an instant by a vigilant
attendant left for that purpose. If the external wound heal, while the
aperture in the artery remains unclosed, an aneurism will be the conse-
quence. This is likely to happen when the pressure is not powerful
enough ; and, when it is too great, there will be risk of mortification.
When the mouth of a lar"ge artery, divided in amputation, or other free
and open wound, can be taken hold of with the finger and thumb, a slight
degree of compression made with them will stop the hemorrhage from it,
until some means of permanently suppressing it has been put in execution.
Or if the orifice of the artery, which may not project sufficiently for this
purpose, be yet close to the surface of the stump or wound, a very
moderate pressure, made perpendicularly on it with the end of a finger,
will prevent loss of blood, until the surgeon is ready to secure the vessel
with a ligature.
Many secondary hemorrhages may be restrained by moderate pressure,
and a ligature should only be had recourse to when pressure is inappli-
cable, or ineffectual.* Such pressure is sometimes required to be placed
directly on the bleeding vessels, but occasionally on the trunk from which
they originate, through the medium of a ring tourniquet, or compress
skilfully applied. By means of such a tourniquet applied to the femoral
artery, bleeding from the tibial arteries in compound fractures has often
been successfully commanded ; and the same instrument, as we learn
from Mr. Tyrrell, has proved very effectual in several instances, at
St. Thomas's Hospital, where the brachial artery had been wounded at
the bend of the elbow.
Sponge. In profuse hemorrhages after operations about the rectum,
or from the socket of a tooth, from the wound of lithotomy, or from the
nose, sponge is sometimes employed for the purpose of checking the loss
of blood. Its quality of expanding, when moistened, so as to distend and
press upon the sides of any cavity in which it is placed, renders it eligible
in these and a few other cases, where the bleeding vessels cannot be
easily commanded by ligatures.
Actual cautery. The application of a heated iron to a bleeding vessel
is one of the most ancient modes of suppressing hemorrhage ; but, at
present, almost in general disuse. It operates by producing a slough,
which covers and closes the mouth of the artery. In order that it may
not injure the circumjacent parts, it is applied through a cannula.
There are several objectionsjto its employment : one is, that it does not
regularly produce a permanent cessation of hemorrhage, as,, when the
eschar separates prematurely, the bleeding recurs.
In dangerous bleeding from the tongue f, and other parts within the
mouth ; and, perhaps, for the suppression of those' profuse_ hemorrhages
which sometimes arise from the bursting of varices, and aneurisms by
anastomosis, the employment of the actual cautery may be warrantable.
Dr. Elliotson recites a case, where the bleeding from the'Jbites of leeches
would have proved fatal, had they not been touched with the actual cau-
tery. I should say, however, that nothing, but urgent necessity, can
* See G. J. Outline on Diseases and Injuries of Arteries, p. 166.
f In Alibert's Nosologie Naturelle, torn, i., is described an amputation of the tongue,
where the bleeding from three large arteries was instantly and effectually stopped by
touching them with the cautery.
HEMORRHAGE. 145
justify its use, and that, if the bleeding could be stopped by any other
measures, they should be preferred.
Torsion of arteries. When limbs are torn off, or when wounds occur
with much contusion and laceration, the middle and internal coats of the
arteries are torn, and thrown into folds within the cellular tunic, which
remains entire. Under these circumstances, large arteries frequently do
not bleed, and then no ligatures are necessary. Probably, it was the re-
collection of this fact, which led MM. Amussat, Velpeau, and Thierry,
three French surgeons, to try the experiment of stopping hemorrhage by
twisting and stretching the extremities of the arteries, which they accom-
plished with forceps made expressly for the purpose.
Thierry simply twists the end of the artery with a pair of forceps,
five or six times, if the vessel be small ; and ten or twelve times, if it be
large. Amussat first seizes the artery with one pair of forceps, and
draws it out of the wound, with the view of separating it from the adjoining
veins and nerves. Then, with another pair of forceps, he takes hold of
the artery, below the grasp of the first forceps, pinching the vessel for-
cibly, so as to produce a solution of continuity in its internal and middle
coats. Having done this, he holds the first pair of forceps firmly, and
pushes the second ones, tightly closed, towards the undenuded part of the
artery. This latter movement has the effect of pushing in that direction
the inner coats, which are thrown into a fold, or duplicature, which
makes a sort of barrier against the stream of blood. Then holding the
second pair of forceps stationary, he twists the end of the artery, now
consisting of only the cellular coat, five or six times round with the first
pair of forceps.
The torsion of arteries has not yet gained many advocates in this
country. If we look over the cases published by Amussat himself, and
consider the experiments and reports on the subject collected by Manec,
we shall find, that the plan is not a security against hemorrhage at all
equal to the ligature, and that the accomplishment of it is more tedious
and painful than simply tying an artery. These reasons alone would induce
us to reject the practice, even if the wound sometimes healed more quickly
in consequence of there being seemingly no extraneous substance in it.
But, the fact is, what M. Manec has recorded, namely, the wound is
generally longer in healing, and suppurates more copiously ; and, as the
artery often sloughs, there is in reality an extraneous substance present,
namely, the slough itself. Hence, we cannot wonder, that Velpeau has
already renounced the method.
Potential cautery or caustic. The most common formerly used, was a
button of the sulphate of copper, of the size of a pea, rolled up in a piece
of linen, and placed on the aperture of the bleeding vessel. The opera-
tion of strong caustics is similar to that of heated irons. Caustics are
even worse than the actual cautery ; for their action is more tedious, less
effectual, and not confined to the vessel alone. In a case recorded by
Pelletan, inflammation of the dura mater and death were produced by
muriate of antimony applied to a bleeding tumour on the head.*
Styptics are alleged to have the property of producing a contraction
of the vessels, and, as is sometimes erroneously supposed, a quick
coagulation of the blood. Such are cold air, cold water, wine, brandy,
tincture of myrrh, spirits in general, diluted mineral acids, solutions of
alum, sulphate of copper, &c. These substances do, indeed, possess the
* Clinique Chirurgicale, torn. ii. p. 304.
L
146 TREATMENT OF WOUNDS
power of stopping a few hemorrhages from small vessels ; but, they ought
never to be trusted, when large arteries are concerned. The method of
applying fluid applications of this kind, is to dip lint in them, and place
it on the bleeding surface. Compression is generally adopted at the same
time. That cold air has a styptic effect, we have the most unequivocal
proofs. We frequently tie, on the surface of a wound, every artery that
betrays a disposition to bleed, so long as the wound continues exposed to
the air. We bring the opposite sides of the wound into contact, and put
the patient to bed. Not an hour elapses before the renewal of hemor-
rhage compels us to remove the dressings. The wound is again exposed
to the air, and again the bleeding ceases. I have repeatedly seen this
happen in the scrotum, after the removal of the testis. The proper con-
duct in such cases is not to open the wound unnecessarily, but to apply
cold wet linen to the part, and keep up a continual evaporation from its
surface, by which means its temperature will be reduced, and the bleed-
ing suppressed.
All styptics create great irritation in recent wounds, in which cases,
therefore, scientific surgeons never have recourse to them. They are,
however, judiciously used to suppress bleedings, from many diseased sur~
faces, where the vessels seem to have lost their natural disposition to
contract.
When an artery is partly cut through, it generally bleeds more pro-
fusely than when quite divided, because it can neither shrink under the
surrounding substance, nor contract itself sufficiently to become imper-
vious. Hence, when, in arteriotomy, the bleeding from the temporal
artery cannot be readily stopped by pressure, the surgeon sometimes sup-
presses the hemorrhage by cutting the vessel completely through.
Sympathetic inflammatory fever, attended with an increase in the
velocity of the circulating blood, and an augmented action of the heart
and arteries, is the consequence of all considerable wounds. Hence,
during its predominance, the patient is particularly exposed to the danger
of fresh hemorrhage.
If the vessels be small, and the patient plethoric, venesection is
sometimes recommended, the loss of venous blood being less prejudicial
to the constitution than that of arterial. The flow of blood into the
wounded limb is to be decreased by placing the part (if possible) in an
elevated posture ; and cold applications or compression tried. If, how-
ever, the arteries should be above a certain size, and the hemorrhage
still continue, they must be exposed, and tied.
Hemorrhages from external injuries seldom require internal means,
which, if they were needed, possess but questionable virtue. However,
keeping the patient in a cool situation, not covered with too many clothes,
enjoining him to avoid all motion and exertions, and allowing him only a
very low diet, are, undoubtedly, means well calculated to lessen the
chances of hemorrhage.
TREATMENT OF WOUNDS.
EXTRACTION OF FOREIGN BODIES FROM WOUNDS.
This is the second indication, the stoppage of hemorrhage being con-
sidered as the first. The removal of all extraneous substances from a
wound, is universally allowed to be an object of vast importance, because,
TREATMENT Off WOUNDS. 147
if it be not fulfilled, the wound may be brought together as nicely, as
accurately, and as skilfully as possible, and every thing look well at the
beginning ; yet, that desirable event, union by the first intention, will
not follow, but, instead of it, a severe degree of pain, considerable
swelling of the circumference of the injury, extensive redness, suppura-
tion, large abscesses, and even the worst consequence, sloughing. All
these aggravated effects frequently arise from the irritation of foreign
bodies in wounds ; and, as an incised wound can generally be examined,
at first, with the utmost facility, and properly cleaned, without putting the
patient to much pain, the neglect on the part of the surgeon becomes
the more blameable. In other deep, narrow, or lacerated wounds, and in
many gunshot injuries, it is often difficult at first to ascertain whether there
are extraneous substances present, or not ; or, when known to be there,
their exact situation cannot always be determined ; but, in open incised
wounds, no such difficulty and obscurity prevail, and the surgeon who
closes them, without having assured himself that they are perfectly free
from all extraneous matter, betrays either supine negligence, or an utter
ignorance of his professional duty. It is true, an incised wound, made
with a clean sharp instrument, which has not broken, can have no foreign
bodies in it ; but very considerable and dangerous cuts are often produced
by glass, china, &c., which break at the moment, and leave some of their
fragments in the flesh. Sometimes, also, the weapon with which the
wound is made is unclean ; and sometimes, dirt, gravel, &c., get into the
wound, in consequence of the patient falling upon the ground immediately
he receives the injury. I shall merely repeat, that, as extraneous bodies
create serious irritation in every kind of wound into which they happen
to be introduced, the surgeon should always direct his attention to their
removal as soon as the bleeding has been stopped.
Mr. Hunter believed that blood, retaining the living principle, and
lying on the surface of a wound, was rather useful than otherwise, in
promoting the reunion of the parts ; and it was his particular opinion,
that effused blood became hurtful to this process, only after being de-
prived of the living principle by long exposure, the effect of styptics,
&c. Yet, this is a doctrine which is by no means sanctioned by the best
modern surgeons, all of whom are perfectly convinced, that leaving any
blood upon the surface of a recent wound, when its opposite surfaces are
to be brought together, is highly disadvantageous, retarding the cure,
and rendering union by the first intention less certain. The presence of
blood must, indeed, have the effect of producing a greater or lesser
separation of the opposite surfaces, which strictly ought to touch one an-
other. Neither has it the tendency to become organised, when left on
the surface of a recent wound, which Mr. Hunter's doctrines would lead
us to suppose. We do not find organisation follow coagulation of the
blood, as it does the effusion of plastic lymph. At all events, this is not
usually the case with blood effused on wounds, or into cavities ; for^lood,
under certain conditions, may be organised after coagulation in its natural
cavities.*
* See Dr. G. Burrows on the Pathology of the Blood, in Med. Gaz. vol. xviii.
The investigations of Andral, Carswell, and others, support the Hunterian doctrine of
the possibility of effused coagulated blood becoming organised, forming adhesions, un-
dergoing various morbid transformations, &c. Yet, that it has less tendency than coagu-
lating lymph to become organised on the surface of a wound, and that its presence there
is generally hurtful, are facts which no practical surgeons now entertain any doubt of,
L 2
14-8 TREATMENT OF WOUNDS.
UNION BY THE FIRST INTENTION.
When the surgeon has stopped the bleeding, removed extraneous sub-
stances, and properly cleaned the wound, the next or third indication is
to bring the opposite sides of the injury evenly together, and keep them
quietly and steadily in this position, until they have united. Wounds
may be healed by two processes*, viz. by one, in which pus is produced,
and granulations and new skin are formed ; and by another, in which, if it
perfectly succeed at every point, no suppuration whatsoever takes place.
Surgeons have termed this way of healing wounds union by the first
intention, or adhesion, and Mr. Hunter named the process by which it,
together with many other analogous effects, is accomplished in the animal
body, the adhesive inflammation. This last expression, I know, was dis-
approved of by the late Mr. John Bell, and is objected to by Dr. Macart-
ney, who believes, that some wounds are promptly healed without any
heat, redness, tumour, pain, or disturbed vascular action. (P. 50.) But,
though these effects may occasionally be very slight, it appears to me,
that even a cut finger cannot rightly be said to be perfectly free from
one or more of them, short as their continuance may be rendered by the
quickness with which the union is sometimes completed. It is not because
the process is hindered by too high a degree of inflammation, that a low
degree cannot accompany it, and even be an essential part of it.
The great recommendations of union by the first intention are, celerity
of cure ; the hindrance of the pain and inflammation which would arise
from the exposure of raw surfaces ; freedom from the inconveniences of
suppuration ; the prevention of the deformity which would result from
a large irregular cicatrix ; and the greater permanency and soundness of
the cure, as the part is covered by the old original skin, which is invari-
ably stronger, and less disposed to ulceration, than what is new.
The strong tendency which divided parts of the animal body have to
grow together, when kept a certain time in contact with each other, is an
important fact, of which the moderns have taken much more advantage
than the ancients. In the treatment of ordinary injuries, the latter seem
to have availed themselves little, or not at all, of this readiness of raw
living surfaces to grow together; and, as we may see by referring to
Celsus, it was principally in making attempts to repair and improve the
appearance of deformed and mutilated parts, that they applied their
knowledge of the fact to practice. The moderns, however, (I speak more
particularly of our countrymen,) have shown their high sense of the good
purposes to which this tendency to adhesion in the animal body may be
converted, by recommending and practising the immediate closure of
every wound, for the keeping of which open there is not some very
particular and specific reason. There are even circumstances on record,
leaving no doubt of the fact, that it is not quite impossible for parts,
entirely detached from the rest of the body, to become united again, if
quickly replaced. One extraordinary case, generally quoted in confirm-
* Dr. Macartney describes four, adding to such as are usually admitted, and here spe-
cified, two others ; viz. 1. Immediate union, without the intervention of blood, or lymph.
2. Reorganisation, without any medium of lymph, or granulations, the cavity of the
wound becoming obliterated by a natural process of growth, which he terms the model-
ling process, and consists, according to his observations, in the growth of the surfaces of
the wound to the level of the skin, instead of the interval being filled up by any new-
formed substance, Op. cit. p. 48— G4, &c.
TREATMENT OF WOUNDS. 149
ation of this statement, is that mentioned by Garengeot, where a soldier's
nose was bit off, yet, on being immediately restored to its natural situation,
it acquired there a permanent union.* Two other examples of the re-
union of pieces of the nose, which were entirely cut off, are recorded by
Fioraventif, and BlegnyJ; and well authenticated cases of similar facts,
in relation to other parts, may be found in different publications. § The
celebrated experiments of Duhamel and Mr. Hunter furnish, also, a mass
of interesting evidence, completely displaying the possibility of reuniting
some parts, which have been recently severed from the rest of the body.
It was proved by Mr. Hunter, that the testicles of a cock, when intro-
duced into the abdomen of a hen, contracted a vascular connection with
the surface of the viscera, and lived ; and that a sound tooth might be
transplanted from its socket, and acquire an union in the alveolary pro-
cess of another person. Lastly, he repeated Duhamel's experiment : he
cut off the spurs of a young cock, and found that they might be made
to unite to its comb, or that of another cock, and grow even to a larger
size than natural, in such stiuations. The possibility of this species of
union shows how strong the disposition of the surfaces of a fresh wound
must be to grow together ; particularly when it is reflected, that, in the
foregoing instances, there can be, on one side, no assistance given to
the union, as the separated part is hardly able to do more than preserve
its own living principle, and (as Hunter expresses himself), accept of
the union. ||
But, although this evidence is too strong to permit us to doubt the
possibility of reuniting parts, which have been completely separated from
the animal system, and in which the circulation of the blood has neces-
sarily ceased for a time, it must not be dissembled, that attempts of this
nature have generally failed. They are very successful, however, when
the detached part still retains a partial and slight connection with the rest
of the body, by means of only a few fibres, or a little bit of skin : .a cir-
cumstance that makes a very material difference. As Dr. Thompson has
said^[, many cases are upon record, and many more have been observed,
in which parts have been reunited which were completely detached, with
the exception of a very small portion of cutis, a portion so small that it
is not easy to conceive that any effectual circulation could be carried on
through it ; and he quotes from Arcaeus an instance, in which the nose,
and most of the upper jaw, were so extensively separated, as to hang
down upon the chin, and yet were afterwards reunited. A remarkable
example of the same kind was published by Larrey**, one of whose
assistants was actually about to cut through the connection which was
left, when he was interrupted by the Baron, who happened to be on the
spot. The instances in which the fingers, toes, nose, and ears have
been entirely cut off, with the exception of a small bit of skin, and
afterwards saved by adhesion, are so generally known, and frequently
£ .
* Trait£ des Operations, t. iii. p. 55.
t Secret! Medicinali, 12mo. Venet. 1561.
\ Zodiacus Medico- Gallicus, Mars, 1680.
§ Bossu, in Journ. de Medecine, t. xxxiii.; Dr. W. Balfour's Obs. on Adhesion, with
two Cases demonstrative of the Powers of Nature to reunite Parts which have been by
Accident totally separated from the Animal System, 8vo. Edinb. 1814.
|| See Hunter on the Blood, &c. p. 208.; and Duhamel, in Me"m. de 1'Acad. des
Sciences, 1746.
f Lectures on Inflammation, p. 243.
** Mem. de Chir. Militaire, t. iv. p. 20. 8vo. Paris, 1817.
L 3
150 TREATMENT OF WOUNDS.
exemplified in practice, that it would be useless prolixity to dwell upon
them.
The knowledge of the preceding facts cannot but prove useful in re-
lation to surgery : it raises our confidence in the powers of nature, under
circumstances in which we should otherwise entirely despair ; and, with
the precedents before us, we shall be induced to attempt the union of
parts, and sometimes succeed, when the project would appear hopeless
and absurd to any one uninformed of what has already happened in other
similar cases.
In promoting union by the first intention, surgery is merely to officiate
as the handmaid of nature. There are only two indications : the first is,
to bring the edges of the wound accurately together, and keep them so ;
the other is, to endeavour to keep off violent inflammation, by which the
agglutination of the wound would certainly be prevented. The first
object is accomplished by a proper position of the wounded part, and by
the use of bandages, adhesive plaster, and sutures ; the second is fulfilled
by a strict observance of the antiphlogistic regimen, and particularly by
avoiding every kind of motion and disturbance of the wound. The rest
is the work of nature.
1. Position of the part is to be regulated on the principle of relaxing
the wounded integuments and muscles. If the extensor muscles are
injured, the joint which they move ought to be placed in an extended
posture ; if the flexor muscles are wounded, the limb is to be bent.
When the integuments alone are cut, the same posture which relaxes
the muscles, situated immediately beneath the wound, also serves, in
general, to relax the skin. In transverse wounds of muscular fibres, it is
astonishing what immense effect a proper posture has. This is never to
be neglected, whatever may be the other means adopted.
2. Bandages may frequently contribute very essentially to keep the
sides of the wounds duly in contact, as is strikingly illustrated in cases of
harelip, where the opposite edges of the fissure may be brought forward
so as to touch, and be maintained in this position by the simple use of
compresses and a bandage. Such was the mode of treatment actually
preferred by M.Louis ; and, were it not for the greater convenience and
certainty of the twisted suture, it is the plan to which surgeons would
yet have recourse.
The common uniting bandage can only be applied to wounds which
take a direction corresponding to the length of the body, or limbs, and
which are situated where a bandage can be used with convenience and
effect. It consists of a double-headed roller, with a slit between the two
heads, large enough to allow one head of the roller to pass through it
with facility. The proper dressings having been put on, the surgeon is
to take one head of the roller in each hand, and apply the bandage first
to that part of the limb which is opposite the wound. One head of the
roller is then to be brought round, so as to bring the slit precisely over
the breach of continuity. The other head is then to be brought round
in the opposite direction, and passed through the fissure. The bandage
is next to be drawn moderately tight, and, its two heads being carried
round the limb again, the same artifice is to be repeated. A sufficient
number of turns of the roller must be made to cover the whole length of
the wound. When the wound is deep, small longitudinal compresses are
sometimes put under the roller, at a little distance from the edge of the
wound.
As the uniting bandage can only be made use of for longitudinal
TREATMENT OF WOUNDS. 151
wounds, which never have a considerable tendency to gape, nothing can
be more absurd than the application of it with immoderate tightness. By
this cruel and injudicious practice many limbs"and lives have been lost ;
for, if the bandage be very tight on its first application, what a dangerous
constriction of the limb or part must follow, when the swelling, neces-
sarily arising from the wound, has come on. It is thus that insufferable
pain and gangrenous mischief have frequently been induced, when, if the
part had been simply dressed, and left unconfined, every thing would have
gone on most favourably. It is right to state, however, that modern sur-
geons are not partial to the uniting bandage, and I have no hesitation in
saying, that it is a means which may be advantageously banished from
practice. If it be true that it brings the sides of deep wounds together
better than adhesive plaster alone, and that it acts without the irritation
arising from the application of resinous substances to the skin, it still has
many inconveniences : its total concealment of the wound, its lying in
irregular folds, so as to create an uneven cicatrix, the difficulty of undoing
it, and some other serious objections, might be mentioned. These reasons
have rendered its employment much less frequent than in former times,
and, I may say, that its use in this country is now superseded by the
preference universally and justly given, either to a common roller, or an
eighteen-tailed bandage.
'3. Adhesive plaster is generally applied in strips, between every two of
which an interspace is recommended to be left, for the purpose of allow-
ing the discharge to escape, in the event of any part of the wound not
healing in the ready manner which is desirable. Therefore, to bring the
edges of the wound effectually together, and, at the same time, to leave
a little room for the exit of the discharge, are the leading objects to which
we ought to attend in using adhesive plaster. Hence, when the strips
are broad, it is not unfrequent to cut out an oval piece of each strip just
where it crosses the wound. When the plaster is about to be applied
to parts] where hair grows, they should first be shaved ; and, if wet, they
should be made dry.
Adhesive plaster is of great use, even in many wounds in which it is
impossible to bring their sides completely into contact ; for, by bringing
and retaining them nearer together than they would otherwise be, the
strips lessen the size of the wound, and ultimately, when the gradual
elongation of the old skin begins to take place, they succeed in bringing
the separated parts perfectly together.
A pledget of simple cerate is often applied over the plasters : it is fre-
quently preferable to dry lint, which sticks to them and the ligatures, and
is more troublesome to remove. Instead of common adhesive plaster,
Mr. Listen uses a solution of isinglass in brandy, smeared upon oil silk
or riband, as an excellent and less irritating means of keeping the sides of
wounds together. The application is sometimes not removed till the
wound is cured ; a plan which, when it can be followed, certainly saves
the patient from all the pain usually experienced at every removal of the
dressings.
4. Sutures. Of the numerous sutures used by the old surgeons, only
two are now ever employed in this country, viz. the interrupted and the
twisted. The latter will be spoken of in the observations upon harelip.
The interrupted suture is applied as follows : — When the bleeding has
been suppressed, and all extraneous substances have been removed, the
surgeon is to place the limb in such a posture as shall enable him to bring
the lips of the wound easily into contact. The needle, armed with a
152 TREATMENT OF WOUNDS.
ligature, and having a curvature that forms the segment of a circle, is
then to be introduced into the right lip of the wound, at a small distance
from its edge, and is to be directed across the wound, so as to come
through the left lip from within outward. It is now to be cut off, and the
ligature tied in a bow. These sutures should always be at least an inch
from each other. At the same time, strips of adhesive plaster, and a
bandage for the support of the part, are usually employed.
In the present schools of surgery, the use of sutures is less recom-
mended than in former days. By the combined operation of position, adhe-
sive plaster, and a bandage, the generality of wounds are capable of being
united as expeditiously and well as they could be were sutures employed.
In the treatment of harelip, wounds of the face, large wounds penetrating
the abdomen, wounds after castration, and operations for hernia, we must,
however, admit their utility. In wounds of the lips, the incessant and un-
avoidable motion of the parts, and in those of the abdomen, the distention
arising from the viscera, and the danger of their being protruded, are
reasons which, in these particular instances, may account for the advan-
tages of sutures. But, in general, the promotion of union by the first
intention cannot be set forth as a valid argument in favour of the practice.
Inflammation, above a very moderate pitch, always destroys every prospect
of this nature, and occasions the secretion of pus, instead of the exudation
of coagulating lymph. Sutures have fallen into disrepute, principally
because they tend to increase inflammation. The new wounds which
they make, their irritation as extraneous bodies, the forcible manner in
which they drag the living parts together, and their incapacity, in general,
to accomplish any useful purpose, which position, adhesive plaster, and
bandages cannot effect, are strong motives for reprobating their common
application. Extensive erysipelatous redness, uncommon pain, and severe
nervous symptoms, will often be found to originate from the irritation of
sutures. I believe, that they are still too much resorted to by the mecha-
nical class of surgeons.
Such are the principal means for keeping the opposite surfaces of
wounds in contact, until union has taken place. The first plasters and
dressings should continue on the part at least three or four days, unless
any disagreeable symptoms, as excessive pain, hemorrhage, &c. indicate
the contrary. The cause of the severity of the pain should always be
duly considered, and, if possible, removed : sometimes it is owing to the
sutures ; sometimes to the immoderate tightness of the roller ; and, occa-
sionally, to extraneous substances yet lodged in the wound.
When too much inflammation is apprehended, the bandage should never
be tight, and wetting it with cold water may be of use. Perfect quietude^
and an antiphlogistic regimen, should be observed. The old plan of
covering the dressings with thick woollen rollers, caps, and large masses
of tow, is entirely rejected in this metropolis, as being inconsistent with
those principles which are recognised by every scientific surgeon as best
calculated to avert and lessen inflammation.
When the first dressings are removed, the surgeon often finds union by
the first intention accomplished only at certain points of the injury ; and
the connexion even there still requiring further support. On the appli-
cation of the second dressings, however, it is generally unnecessary to put
on as many strips of adhesive plaster as were at first employed, and their
number may be gradually lessened at each future dressing. The sutures,
if there are any, should also be now withdrawn, as they can do no further
good, and their continuance may excite irritation, and do harm. Through-
TREATMENT OF WOUNDS. 153
out the rest of the treatment, also, the dressings should be light, simple,
and unirritating.
I shall conclude this part of the subject with a few useful rules in the
dressing and examination of wounds.
The first is, never to give the patient more pain from our modes of
procedure, or methods of dressing, than is absolutely necessary for his
present good or future security. For instance, we ought never to probe
a wound, where probing can be of no use ; and we should be contented
to remain ignorant of things, the knowledge of which would only gratify
an idle curiosity.
The second is, that any requisite examination of a wound should be
made as soon after the accident as possible ; for, at this period, inflam-
mation and swelling not having had time to come on, the patient suffers
much less pain from the introduction of the probe, or finger, into the
wound, and the surgeon more easily gains the information which he is in
search of, than in a later stage.
Another good rule is to let all the fresh dressings be perfectly ready
before the old ones are removed. A sponge and warm water, adhesive
plaster, lint, ointments, lotions, nitrate of silver, bandages, &c. should all
be at hand, and not left to be looked for at the very moment when they
are wanted.
As in many instances the removal of the dressings, and the application
of others, take up a considerable time, we ought carefully to reflect what
position would be most easy to the patient, and, at the same time, most
convenient to the surgeon.
When the bandage, adhesive plaster, and other dressings have become
hard and dry, and glued together, and to the surrounding skin, by blood,
or other discharge from the wound, the surgeon should soften and loosen
the applications by wetting them a sufficient length of time with warm
water, which is to be pressed out of a sponge upon them, a basin being
held below the part for the reception of the water as it falls off the
dressings. This duty is of much importance in saving the patient from
a great deal of agony, which the abrupt removal of the adherent dressings
would produce.
In removing the dressings which are under the bandage, we should be
careful that the ligatures are not entangled, and forcibly pulled away, so
as to give severe pain, and create a risk of hemorrhage.
The strips of adhesive plaster should be removed by taking hold of
their ends, each of which is to be drawn towards the wound. Were
the plasters pulled off in the contrary direction, the edges of the wound
would be liable to be torn asunder again, and the process of reunion,
at all events, disturbed ; neither should the plasters be pulled up, as by
this proceeding the edges of the wound would be torn from the sub-
jacent parts.
In large wounds, only a single strip, or at most two, should jpe off
at a time, and the part from which the plaster has been removed,
having been carefully wiped with a sponge, and dried, is then to be
supported with a fresh strip, before any more strips are taken off. As
Dr. Thomson well observes, it is from inattention to this rule, that
wounds are daily torn open again at each dressing, merely by the weight
of the parts.
The sides of the wound, particularly if it be large and deep, should
always be supported by an assistant at the time of changing the
dressings.
154* TREATMENT OF WOUNDS.
When there are several wounds, only one is to be opened and dressed
at a time, so that all unnecessary exposure of the parts may be avoided.
At each dressing, care must be taken to prevent lodgments of matter,
by placing the compresses and strips of plaster in the manner best calcu-
lated to press upon and obliterate any cavity in which the pus has a
tendency to accumulate.
The utmost attention should be paid to cleanliness, every thing filthy
and offensive being removed from the ward as quickly as possible.
Above all things, care must be taken not to let the matter touch the bed-
clothes. The custom of laying a piece of oilskin under suppurating
wounded parts, in order to keep the bed clean, is highly praiseworthy ;
for cleanliness is essential to the general health of the patients^ and the
favourable progress of all wounds.
The frequency of dressing must be regulated by the quantity and
quality of the discharge; by the situation of the injury; by the climate
and season of the year ; by the effect which the renewal of the dressing
seems to produce ; and by the feelings,, and sometimes the wishes, of the
patient,*
PROCESS BY WHICH THE WOUND IS UNITED.
When the opposite sides of an incised wound are maintained in contact,
they soon become permanently connected together. The vessels of the
wounded surface cease bleeding, and their extremities become impervious
to the blood itself, but not to the coagulating lymph, or fibrine, which forms
the general bond of union between living parts. This uniting medium is
the primitive and most simple connection that takes place between the
two sides of a wound. In many cases, where the wound is closed before
the hemorrhage has had time to cease, no doubt a quantity of blood must
be interposed between the opposite surfaces of the injury; but such
blood is now suspected, by many good pathologists, not to become itself the
first bond of union ; but, on coagulating lymph being effused, to be gene-
rally absorbed, as answering not only no useful purpose in the healing
process, but if too abundant, proving an impediment to the cure without
suppuration. Hence, the best practical surgeons always make the sur-
face of the wound as free from blood as possible, before its opposite sides
are brought together. I am quite sure, that union by the first intention
more certainly follows this mode of proceeding. Yet we are not to defer
bringing the sides of a wound together, until every little oozing of blood
is at an end ; for the long exposure of the wounded surface would be
hurtful, and tend to defeat the grand object in view, direct adhesion,
without suppuration. The doctrine of the occasional extension of vessels
into a clot of blood is considered, however, by Professors Carswell,
Macartney, and others, to admit sometimes of demonstration. Dr.
Macartney states, that he has seen vessels passing for a short way into a
clot of blood, covering the surface of an ulcer, &c. He also succeeded in
making injection pass into the coagula, formed in the cavities of the heart
after death, which injection presented the appearance of red elongated
lines. (P. 54-.) Clots of blood are often enveloped in fibrine, a substance
into which vessels are prone to extend themselves from those of the
nearest texture ; and this has sometimes been suspected to be the case in
certain preparations put up by John Hunter himself, to demonstrate the
vascularity of clots of blood, and preserved in the museum of the Royal
College of Surgeons, in London.
* See Thomson on Inflammation, p, 294, &c.
TREATMENT OF WOUNDS. 155
We have examples of the union of textures without suppuration, and, in
this respect, by a process similar to union by the first intention, in bones
which have been fractured ; in tendons which have been ruptured ; and
even sometimes in muscles, which have been wholly or partially torn
asunder, without any division having been produced in the skin which
covers such parts. In the sudden and violent division of these textures,
blood is always effused between the divided parts, and in to the surrounding
cellular tissue. When this extravasated blood is not very considerable in
quantity, and when the parts from which it has been effused are not too
severely injured, it is observed to be gradually absorbed, in proportion as
the process of union advances. If the divided surfaces be examined a
few hours after the accident, they will be found to be covered with coa-
gulating lymph. This substance, indeed, appears to be effused very
quickly after the injury. Professor Thomson found, that, in animals, a
distinct layer of it was effused over their wounds in less than four hours.*
But, says he, whatever may be the period at which it is first formed, it is
now well ascertained, that, in healthy subjects, when fractured, torn, or
ruptured surfaces, to which the external air has not been admitted, are
properly covered with this layer of coagulating lymph, and kept in con-
tact, they speedily coalesce, and that, by this fibrine becoming a living
intermedium, the continuity of the divided part is at length restored.
Appearances, precisely similar to such as happen in divisions without
communication with the external air, take place in simple incised wounds,
the edges of which have been brought together before, or soon after, the
bleeding has ceased. If a wound of this kind be torn open soon after its
reunion, the surfaces, which had been united, are seen covered with a
substance resembling jelly, which is the coagulating lymph, or fibrine of
the blood. By some it is supposed, as I have said, that this lymph is
poured out from the smaller vessels which have been cut; but Professor
Thomson inclines to the opinion, that it is chiefly, if not wholly, formed
by the secreting action of the capillary vessels of the divided surfaces.f
The simple agglutination of the sides of a wound together, is what may
be considered as taking place very shortly after they have been brought
into contact with one another. The next step, in the process of union
by the first intention, is the extension of vessels into the coagulating lymph,
and this is soon followed by an intercourse between the vessels of the two
sides of the wound. The manner in which the new vessels arise in the
uniting medium, as well as the way in which the inosculation of the
divided vessels happens, are at present only matters of conjecture.
Mr. Hunter once conceived that blood and coagulating lymph, so long as
they retained the living principle, possessed the faculty of generating
vessels within themselves, quite independently of any adjoining surfaces ;
and, in the growth of the chick, there are unquestionably some appear-
ances in favour of this opinion. This doctrine, however, he renounced
previously to his death, and adopted the belief, which is now dailf gain-
ing ground, that the new vessels are extensions from the old ones.
Professor Thomson delivers the following statement : the coagulating
lymph, or fibrine, soon after its exudation, becomes penetrated with blood-
vessels, which proceed from the divided surfaces, appear to join in the pro-
cess of reunion by open extremities, or, in other words, to inosculate with
one another. The blood now circulates freely through the new-formed
channels of communication established between the vessels, which pene-
* On Inflammation, p. 209. t °P- cit P' 21a
156 TREATMENT OF WOUNDS.
trate the lymph effused upon the surfaces formerly divided ; and the
vessels which shoot into the lymph often acquire, in the course of a few
hours, a size which renders them capable of being injected. The precise
manner, in which the vessels are extended into the coagulating lymph is
still unknown. It has not been positively settled, whether it is the divided
vessels which penetrate the lymph. The extremities of the larger
branches are closed with the effused lymph, and removed by means of it
and their natural elasticity to a distance from each other. Dr. Thomson
regards these circumstances as insurmountable bars to their immediate
inosculation ; and he remarks, that, if it be the closed vessels which are
prolonged into the lymph, each small artery must obviously have its cor-
responding vein. But, says he, the inosculation, or direct union of the
small bloodvessels from the opposite surfaces of the wound, however
difficult to conceive or explain, is a truth undeniably established.* He
then adverts to Duhamel's experiment, which fully proves, that, in the
reunion of parts which have been divided, the bloodvessels from the
opposite surfaces inosculate directly, and do not merely pass one another.
Duhamel broke the legs of six chickens, and, after the bones had re-
united, he cut through about one third of the soft parts, covering the
callus, or new bone. When the wound had healed up, he divided another
third part, and in the same manner the remaining third part, sparing
neither bloodvessel, tendon, nor nerve. Only one of the six chickens
survived these cruel operations ; but, upon injecting the artery at the
upper part of the thigh, the injection penetrated to the lowest part of the
leg. " I cannot say (Duhamel remarks) whether the large vessels, rilled
by the injection, were dilated capillary vessels, or the large vessels of the
leg, which had been reunited ; but the experiment proves irrefragably the
inosculation of the bloodvessels." Later observations than those of
Duhamel (says Professor Thomson) have shown, that it is by the small
vessels, and not by the larger trunks, that the inosculations are formed, by
which the divided parts of a limb are supplied with blood : nor does he
accede upon this point to the sentiment of Hunter, who conceived that
he had certainly succeeded in observing inosculation on the tunica con-
junctiva of the eye, the vessels of which are frequently divided by sur-
geons in cases of ophthalmy. He states, that the two ends of the cut
vessels are seen to shrink ; but, after a little while, they are perceived to
unite, and the circulation is carried on again. t
The celerity, with which the process of union by the first intention is
completed, is a circumstance that must excite the admiration of the phi-
losophical surgeon. In the short space of seventy- two hours, the wound,
produced by amputation of the thigh, is often securely united through its
whole extent, without any suppuration, except just where the ligatures
are situated. Incised wounds of a moderate size may, in general, be
completely healed by this method in forty- eight hours. How different,
then, is the surgery of the present day to that of half a century ago,
when the bigotted prejudices of our ancestors deterred them from doing,
not only what was most salutary, but most simple ! The complicated
business of accomplishing digestion, incarnation, and cicatrisation, is
now reduced to the easy duty of bringing the sides of a clean cut wound
together, and maintaining them so until they have grown together.
As John Bell has observed, " there is no wound in which we may not
try with perfect safety to procure this adhesion ; for nothing surely can
« P. 212. f On the Blood, p. 193.
TREATMENT OF WOUNDS. 157
be more kindly, when applied to a wounded surface, than the opposite
surface of the same wound: it has been but just separated from the
opposite surface : it may immediately adhere to it : though it do not
adhere, no harm is done ; still the wound will suppurate as kindly, as
freely, as if it had been dressed with dry lint, or some vulnerary balsam,
or acrid ointment. If only a part suppurate, while one half, perhaps,
adheres, then half our business is done : and, in short, this simple way of
immediately closing a wound is both natural and safe." * If I were to
instance any one circumstance, in which I think the excellence of English
surgery strikingly displayed, I should be inclined to cite our partiality to
the mode of curing wounds by the first intention. M. Rouxf, in his
criticisms upon this part of our practice, may convince his readers how
sincerely he believes what he says ; for he actually fancies, that we have
been, as it were, forced into the custom of healing up wounds as quickly
as we can, because, unfortunately, in this country, we have not, as he con-
ceives, a sufficiency of the requisite materials for dressing wounds, which
are to heal by suppuration ! But I doubt whether he will be joined by any
surgeons on this side of the Channel in the belief, that it would be better
to abandon the practice of adhesion altogether, than make it an exclusive
method of treatment. He particularly mentions the wound after castra-
tion as unfit for this plan, because the edges cannot be easily put into a
state of coaptation, unless a considerable piece of the scrotum be cut
away, and sutures be used ; and also because the closure of the wound is
attended with the risk of a collection of blood taking place in its cavity,
and nature is nearly as long in effecting a cure, when the sides of the
wound have been brought together, as when they have not. But, if the
principle were to be admitted, that the possibility of bleeding within a
wound is an adequate reason for filling it with charpie, and not attempt-
ing to heal it by the first intention, we ought to renounce this last bene-
ficial practice in every instance, where the surface of the wound is
extensive, and its cavity large, as after amputation, the removal of a
breast, the extirpation of tumours, &c. But, even supposing the scrotum
should sometimes become filled with coagulated blood, of which M. Roux
is so much afraid, it may then be inquired, which of two patients would
be the best circumstanced, one with the scrotum crammed with charpie,
or another with the same part distended with coagulated blood ? Which
would suffer least pain, have the most moderate suppuration, and get well
in the shortest time ? If the answer to these problems be so doubtful, as
not to admit of being readily delivered, surely we may be allowed to
argue thus : that if, when the evil complained of by M. Roux does really
occur, the patient is not decidedly worse off than when such disaster does
not happen, but the particular treatment recommended by that gentleman
is followed, how much better it must be to let the patient, at all events,
have the chance of a considerable portion of the wound uniting ; for when
this is accomplished (to use Mr. John Bell's phrase) half our business
is done. *
But if any wound require more strongly than others the approximation
of its edges, and to be healed, if possible, by adhesion, it seems to me,
that it is the incision made in the Hunterian operation for aneurism.
Here the wound should be closed to let the artery lie quietly amongst its
* Discourses on the Nature and Cure of Wounds, by John Bell, p. 14. edit. 3.
t Parallele de la Chirurgie Angloise avec la Chirurgie Franfoise, p. 117. et suiv. 8vo.
Paris, 1815.
158 TREATMENT OF WOUNDS.
natural connexions, undisturbed by the contact of any dressings, or other
extraneous substances, by which the adhesion of its sides might be pre-
vented, its ulceration induced, and secondary hemorrhage occasioned.
But, extraordinary as it may appear, this is another example of our
practice, selected by M. Roux to illustrate our blind predilection for
healing wounds by the first intention. The wonder ceases, however,
when we find that he considers ligatures of reserve (ligatures d'attente)
advisable means in operations for aneurism ; for they are undoubtedly
awkward things in a wound which ought to be healed as quickly as pos-
sible, and they put union by the first intention out of the question. But,
in London, where the inutility and dangers of these ligatures of reserve
are well understood, a practice, which tends to abolish their use, will be
welcomed as bringing with it another high recommendation.
PUNCTURED WOUNDS
Are not only dangerous on account of their frequently extending to a
considerable depth, and injuring large bloodvessels, nerves, viscera of
importance, and a great variety of textures, they are also dangerous,
inasmuch as they frequently give rise to violent and extensive degrees of
inflammation. It is not uncommon to see them followed by formidable
collections of matter, especially when the instrument, with which they
have been made, has penetrated deeply through an aponeurosis or fascia.
The extension of inflammation along the continuous textures from the
original seat of the puncture, and the formation of matter under the
fasciae, are two of the most remarkable local phenomena, which are par-
ticularly liable to arise from punctured wounds.* Stabs, and all other
punctures, are not siruple divisions of the fibres of the body : they are
attended with more or less contusion and laceration. Hence, there is not
the same readiness to unite, which we observe in wounds made with sharp
cutting instruments ; and, when the weapon has entered deeply through
tendinous expansions, the inflammation excited often spreads very
extensively, attended with most severe pain in the parts affected, great
tension, swelling, and abscesses running under the fasciaa to an alarming
extent. Violent symptomatic fever, and great agitation of the nervous
system, likewise often follow punctured wounds ; effects which used to be
erroneously attributed to the injury of tendons or nerves. This doctrine,
however, is now nearly exploded. Surgeons frequently see nerves of
considerable size and large tendons wounded, without the occurrence of
great constitutional disorder ; therefore, it cannot be the mere injury of
these parts which is the occasion of all the general indisposition.
More is to be feared, I think, from the frequent depth of a stab or
puncture, the roughness and violence with which the injury has been
done, and the many different textures pierced, than from the circumstance
of tendons or nerves happening to be wounded. Amongst the worst
kinds of general indisposition, more frequently following punctured, than
other descriptions of wounds, is tetanus ; a complication still oftener seen
in warm climates than our own.
Punctured wounds are generally more dangerous and difficult to cure
than cuts and sabre-wounds, though much depends upon the nature of
the parts injured. When great degrees of swelling and inflammation
ollow, when considerable abscesses form, when phlegmonous erysipelas
* Thomson's Obs. made in the Military Hospitals in Belgium, p. 29. 8vo. Edinb.
1816.
TREATMENT OF WOUNDS. 159
arises, or when a large artery or important viscus is wounded, and blood or
other fluid is extravasated, the case is undoubtedly of a serious and dan-
gerous nature. The same remark may be made when tetanus, or violent
symptomatic fever, and great agitation of the nervous system, complicate
the injury.
In the treatment of punctured wounds, mistaken doctrines were for-
merly the source of many serious abuses in practice. The unlimited
idea, that the severe consequences of most punctured wounds were in a
great measure owing to the narrowness of their orifices, induced numerous
surgeons to practise, indiscriminately, deep and extensive incisions, for
the purpose of rendering their external communication considerably
wider. To have in view the conversion of such injuries into simple
incised wounds, was always a maxim strongly insisted upon, and urged
as the reason for such treatment.
Certainly, if the notion were true, that an important punctured wound
such as the stab of a bayonet, could be actually changed into a wound
partaking of the milder nature of an incision, by the mere enlargement of
its orifice, the corresponding practice would be highly commendable,
however painful. But the fact is otherwise : the rough violence, done to
the fibres of the body by the generality of stabs, is little likely to be sud-
denly removed by an enlargement of the wound. Nor can the distance,
to which a punctured wound frequently penetrates, and the number and
nature of the parts injured by it, be at all altered by such a proceeding.
These, which are the grand causes of the collections of matter, which
often take place in the cases under consideration, must exist, whether the
orifice and track of the wound be enlarged or not. The time when inci-
sions are proper is when there are arteries to be secured, foreign bodies
to be removed, abscesses to be opened, or sinuses to be divided ; and to
make painful incisions sooner than they can answer any end is both inju-
dicious and hurtful. They are sometimes rendered quite unnecessary by
the union of the wound throughout its whole extent, without the least
suppuration.
It is true, that making a free incision, in the early stage of these cases,
seems a reasonable method of preventing the formation of sinuses, by
preventing the confinement of matter, and, were sinuses an inevitable
consequence of all punctured wounds, for which no incisions had been
practised at the moment of their occurrence, it would undoubtedly be un-
pardonable to omit them. To many this may seem a fair reason for
enlarging the mouth of a punctured wound. Fair, however, as it may
appear, it is only superficially plausible, and a small degree of reflection
soon discovers its want of real solidity. Under what circumstances do
sinuses form ? Do they not form only where there is some cause existing
to prevent the healing of an abscess ? This cause may either be the in-
direct way, in which the abscess communicates externally, so that the
pus does not readily escape ; or it may be the presence of some foreign
body, or dead portion of bone ; or, lastly, it may be an indisposition of the
inner surface of the abscess to form granulations, arising from its long du-
ration, but removable by laying the cyst completely open. Thus it becomes
manifest, that the occurrence of suppuration in punctured wounds is only
followed by sinuses when the surgeon neglects to procure a free issue for
the matter after its accumulation, or when he neglects to remove any ex-
traneous bodies. But, as dilating the wound at first, will only tend to
augment the inflammation, and render the suppuration more extensive,
it ought never to be practised in these cases, except for the direct objects
160 TREATMENT OF WOUNDS.
of giving free exit to matter already collected, of tying a wounded artery,
or of being able to remove extraneous bodies palpably lodged. I shall
once more repeat, that it is erroneous to suppose the narrowness of
punctured wounds so principal a cause of the bad symptoms, with which
they are often attended, that the treatment ought invariably to aim at its
removal.
Recent punctured wounds have absurdly had the same plan of treat-
ment applied to them as old and callous fistulas. Setons and stimulating
injections, which in the latter cases sometimes act beneficially by exciting
an inflammation, that is productive of the effusion of coagulating lymph,
and of the granulating process, can never prove serviceable when the
indication is to moderate an inflammation, disposed to rise too high.
The counter-opening, which must be formed, in adopting the use of a
seton, is also an objection ; and though French authors have given us
accounts of their having drawn setons across patients' chests, in cases of
stabs, they would find some difficulty in making the practice seem un-
attended with harm, much less productive of good. The candid and
judicious surgical reader should not always think a plan of treatment
right, because the patient gets well ; for, there is an essential difference
between a cure, promoted by really useful means, and an escape, not-
withstanding the employment of hurtful ones.
Why, however, should we mention the use of a seton ? What good
can possible arise from it? Will it promote the discharge of foreign
bodies, if any are present? By occupying the external openings of the
wound, will it not be more likely to prevent it? In fact, will it not itself
act with all the inconveniences, and irritation, of an extraneous substance
in the wound? Is it a likely means of diminishing the immoderate pain,
swelling, and extensive suppuration, so often attending punctured
wounds? It will undoubtedly prevent the external openings from
healing too soon ; but cannot this object be effected in a better way ? If
the surgeon observe to insinuate a piece of lint into the sinus, and pass a
probe through its track once a day, the danger of its closing too soon
will be removed.
The practice of enlarging punctured wounds by incisions, and of
introducing setons, is often forbidden by the particular situation of these
injuries.
I do not follow many surgical writers in recommending the indiscri-
minate dilatation of the orifices of punctured wounds ; nor the use of the
knife, for the purpose of preventing mischief only expected and appre-
hended but not certain of taking place. Whenever I have attended
bayonet or other punctured wounds, unattended with any particular
complication, I have always observed nearly the same principles as are
now so generally approved of in gunshot wounds. I have abstained
from dilating the orifice of the injury, except when it was necessary,
either to get at a bleeding artery in the first instance, or to relieve the
constriction of the parts, or to procure a freer outlet for the discharge
in a later stage of the case. I have given the preference to mild, simple,
unirritating, and superficial dressings. I have not placed any faith in
the utility of enveloping the parts in a tight bandage ; but, after applying
the first superficial dressings, have usually covered the limb or part with
linen wet with the lotio plumbi acetatis, or cold water. Whenever a
roller was used, in the beginning of a case, it was not with the view of
making pressure, but of retaining the dressings. The wound having
been dressed, I then put in practice all such means as are generally
TREATMENT OF WOUNDS. 161
deemed most efficient in preventing and diminishing inflammation ; such
as venesection,, the exhibition of aperient saline medicines, low diet, &c.
When the pain was severe, opiates were prescribed, and on the access of
much inflammation and swelling it was an invariable rule with me to be
sure that the bandage was slack. On the whole, I believe, that the ap-
plication of superficial dressings and cold washes is the best practice for
the first twenty-four hours after the receipt of a punctured wound. But
if, after this period, the pain should increase, and the swelling and tension
become more and more considerable, the surgeon may then remove the
linen and bandages, and apply leeches freely and repeatedly to the neigh-
bourhood of the wound. He may also substitute for the cold lotions
fomentations, and emollient poultices, under which is to be laid, over the
orifice of the wound, a small pledget of spermaceti cerate, or the tepid
water dressing may be employed. The poultices and fomentations are
to be renewed twice a day, and the leeches and venesection, if necessary,
repeated.
Sometimes, under this treatment, the surgeon is agreeably surprised to
find the consequent inflammation mild, and the wound united by the first
intention. More frequently, however, in cases of deep stabs, the pain is
intolerable ; the fever and disturbance of the nervous system severe ; and
the inflammatory symptoms run so high, as to leave no hope of avoiding
suppuration. In this condition, emollient poultices and fomentations are
the best applications ; and, when the matter is formed, its speedy and
effectual discharge is to be procured, either by dilating the original
wound, or by making one or more incisions in other places, as may seem
most advantageous. In short, the treatment must then conform to the
principles, already noticed in the remarks on suppuration and abscesses.
On the accession of the symptoms here adverted to, Professor Gibson
joins those practitioners who resort to dilatation of the wound, and mak-
ing a transverse division of the fascia, by which means, he states that the
urgent symptoms will cease almost immediately.*
CONTUSED AND LACERATED WOUNDS.
The instruments, which have the effect of producing what is termed a
contused wound, are either of an ordinary description, such as a cudgel,
stone, &c. ; or they consist of balls, bullets, and other metallic bodies,
which are driven into the living textures with immense velocity by the
explosion of gunpowder. Indeed, a forcible collision of any blunt, ob-
tuse, hard body against parts of the living body must contuse, and often
at the same time wound them. Gunshot wounds, strictly speaking, are
only examples of severe contused wounds, though surgeons find it expe-
dient generally to treat of them as distinct and peculiar cases: and when
it is recollected how many difficult, intricate, and momentous questions
the subject embraces, the necessity of considering it by itself must be
generally acknowledged. ^
The blunt weapons, or obtuse hard substances, which, being applied
with violence to any part of the living body, bruise, rupture, and other-
wise hurt the fibres and vessels, may produce two different species of
injury. First, they may more or less forcibly compress and crush the
parts upon which they act, so as to disorder the texture of those organs
which are situated under the integuments, without causing, however,
any breach of continuity in the skin itself. This is the case, which is
* Institutes, vol. i. p. 63. ed. 5.
M
162 TREATMENT OF WOUNDS.
familiarly called a bruise, or contusion, of which one of the worst ex-
amples is seen in the effects of cannon-balls,, which graze the surface of
the body, and crush the muscles and other deep-seated parts, while the
skin itself remains unbroken. Secondly, a hard blunt body, violently
striking against parts, may produce at once a solution of continuity, ex-
tending through the skin, and sometimes also through other textures : this
kind of accident is what surgeons name a contused wound. The latter
injury more commonly follows, when the surface of the contusing weapon
is not very broad. The cases, which rank as simple contusions, I shall
consider hereafter.
The majority of wounds are attended with some degree of contusion.
Those which are inflicted with the blunt edge of a sabre, or the obtuse
point and wedge-like end of a bayonet, are as much contused as punc-
tured ; and hence,, like other contused wounds, they do not often admit
of being united by the first intention. It must be confessed,, indeed, that
all our endeavours to reunite the sides of a contused wound, however
skilfully directed,, most frequently fail. An agglutination of the parts at
most only takes place at the bottom of the wound, in which situation the
flesh has suffered less coutusion, the violence having spent itself, as it
were, upon those parts upon which it first operated. Hence, suppuration
of the external portion of the wound is mostly unavoidable. Still, the
attempt at reunion ought to be made ; for, if only the bottom of the
wound heal by the first intention, it is a great advantage gained, more
especially, when the surface of a bone has been exposed, and uncovered
by the injury. In bringing the sides of contused wounds nearer toge-
ther, however, the surgeon is not to attempt to do it with the same
closeness and accuracy, as in the instance of an incised wound. The
injured parts would not bear the pressure, nor other means requisite for
this purpose ; and it may be laid down as an established rule, that
nothing is more hurtful to contused wounds than much pressure, either
from strips of adhesive plaster, or from rollers. In few of these cases,
also, are sutures admissible ; and I think that examples have fallen under
my notice, where the rash determination of the surgeon to close large
contused wounds with stitches, tight strips of plaster, and bandages, had
no inconsiderable share in bringing on the rapid and fatal gangrene
which carried off the patients. When I say, therefore, that a contused
wound ought to be closed, and that its opposite surfaces should be
brought nearer together, in order that the chance of some part of the
injury uniting by the first intention may be taken, I do not mean to re-
commend dragging the parts together by main force, or placing them in
a state of constriction. On the contrary, I think that they ought to be
left quite unconfined, the adhesive plaster being used very sparingly, and
so put on as rather to hold the loose parts nearer to one another, than to
press and draw them into contact. Nor should the wound be covered
with much plaster, as one or two strips will suffice for the object in view,
and a greater number would create irritation, besides hindering other
better dressings from touching the raw surfaces. Merely a strip or
two are to be applied to such points as seem most advantageous in
lessening the exposed surfaces, and all constriction should be most
carefully avoided. That the practice here advised may be followed by
a beneficial result is proved by daily experience ; and theory would lead
us to expect such good, when we remember that, by preventing the
wound from gaping in the manner it would otherwise do, we not only
afford an opportunity for parts of it to reunite, but at once diminish an
TREATMENT OF WOUNDS. 163
inevitable cause of inflammation and suppuration, viz. the continued
exposure of a raw surface.
Contused and lacerated wounds not only differ from incised wounds in
the circumstance of being more disposed to suppurate and slough, and
more difficult to heal by the first intention, they differ also in the particu-
larity of not usually bleeding much : sometimes, not even when the largest
arteries are lacerated, as must be the case when whole limbs are torn
away, in consequence of becoming entangled in different kinds of ma-
chinery. The circumstance, which hinders the bleeding from being
considerable in such cases was first correctly pointed out by Professor
Turner* ; namely, the middle and inner coats of the vessel are lacerated,
separated from the more elastic external coat, and thrown into irregular
folds within it, so as to constitute a barrier against the escape of the
blood, j- Here the very same change takes place as occurs when torsion
of arteries is practised. This indisposition to hemorrhage is not alto-
gether a favourable omen, because, though the patient runs less chance
of bleeding to death in these cases than in cut wounds, yet the very
circumstance of the large vessels not pouring out blood evinces, that the
violence, contusion, stretching, and other injury done to the parts, in
addition to the mere division of them, must have been excessively severe,
and that the danger of the subsequent inflammation, suppuration, and
sloughing of the parts, is more than a counterbalance to any advantage
proceeding from the absence of hemorrhage.
In the records of surgery, no facts are more extraordinary than those
which have been published, at different periods, on the subject of whole
limbs being torn away, not only without hemorrhage, but without any
fatal effects. The examples of this, related by Cheselden, La Motte,
Carmichael, Morand, and Gibson J, are some of the most remarkable.
All lacerated and contused wounds should be treated according to
common antiphlogistic principles. When the injury is extensive, and
attended with a great deal of contusion, venesection is to be practised,
and any moderate oozing of blood from the surface of the wound pro-
moted by the use of fomentations. With respect to dressings, they
should always be of a mild unirritating quality. After lessening by means
of a strip or two of adhesive plaster the exposed cavity of the wound, if
this be large, and the surrounding skin loose, or detached from the subja-
cent parts, the wound may be covered either with lint dipped in tepid water,
over which is put a piece of oiled silk, or with a pledget of unguentum
cetacei, over which should be laid an emollient poultice. The first
dressings should not be removed for at least two or three days. After-
wards, however, the dressings may be changed once or even twice in a
day ; for as soon as the sloughs begin to separate, and suppuration com-
mences, the necessity of renewing the dressings and poultices more fre-
quently is evident. In severe cases, fomentations may be used at the
periods of dressing, as nothing will be found more effectual jpr the relief
* See Edinb. Med. Chir. Trans.
f Speaking of the bleeding being sometimes profuse, directly after the receipt of a
gunshot wound, M. Larrey, jun. observes, " L'hemorrhagie est plus fort si une ai'tere
est divise*e partiellement, que si elle a £te totit-a-fait rompue, parceque, dans ce dernier
cas, le vaisseau eprouve une sorte de torsion et de refoulement par la force contondante
ou l'attrition ; sa tunique interne se dechire et se tortille en tire-bouchon, de maniere a
obliterer 1'orifice de 1'artere. " — Hist. Chir. du Sie'ge de la Citadelle d1 Anvers, p. 60.
8vo. Paris, 1833.
t Institutes of Surgery, vol. i. p. 66. ed. 5. Philadelphia, 1838.
M 2
164* TREATMENT OF WOUNDS.
of the pain. The employment of leeches, also, should not be forgotten,
as a valuable means of palliating inflammation. Professor Asalini *, of
Milan, has particularly recommended the application of cold washes to
contused wounds ; and,, I believe, the plan is decidedly useful in the first
instance, when it is a great object to check the increase of extravasated
fluids in the surrounding parts. I think cold applications are also highly
proper when contused wounds are disposed to bleed more than usual, and
yet no large vessel presents itself as the source of hemorrhage. But, in
other periods and states of these injuries, I prefer emollient dressings.
If, in lacerated and contused wounds, the surgeon is less frequently
called upon than in incised wounds to take measures for stopping bleed-
ing immediately after the accident, he finds greater occasion for attending
to another important duty imposed upon him in his professional attend-
ance upon wounded persons in general : I allude to the early removal of
all foreign bodies and extraneous substances. Cuts are usually made
with clean sharp instruments ; but contused and lacerated wounds often
occur in a manner, which renders them very likely to be complicated with
the lodgment of extraneous matter.
With regard to lacerated wounds, the same practical remarks apply to
them which have been offered on the subject of contused wounds. In
warm climates, tetanus is a frequent consequence of them. The stoppage
of bleeding, and the removal of foreign bodies having been effected, the
edges of the lacerated wound should be loosely drawn together, and
retained with a few strips of adhesive plaster, and here and there a suture
will sometimes be proper for keeping the flaps and angles duly fixed in
their places ; for, they ought not to be cut away. Although the union of
such a wound cannot be calculated upon to any extent, great benefit
results from keeping the parts as nearly as possible in their natural situ-
ation. Indeed, in some instances, union does take place through a consi-
derable part of the wound, and this even in severe cases, as exemplified
in the man who received a formidable bite from a shark, and the par-
ticulars of whom were recorded by Dr. Kennedy.-}- When a great deal
of inflammation ensues, it will generally be advisable to remove the
adhesive plaster and stitches, and apply a poultice or the water-dressing ;
and, if there be much fever, restlessness, or delirium, blood-letting, saline
purgatives, opium, and very low diet, with proper treatment of the wound
itself, are the most likely means to give relief.
Dr. Macartney remarks, " I have never seen an instance of tetanus
coming on, where wounds, however severe, and from their nature likely
to produce the disease, were healed under water- dressing." He adds,
that Dr. Bowyer, a gentleman in extensive practice in Demerara,
adopts this method after amputations and other operations ; that the
wounds are thus healed as favourably as the best treated cases in cold
climates ; and that, after fourteen amputations, not a single patient had
died of tetanus. J
When the surface of a contused or lacerated wound has thrown off its
sloughs, suppurated, become clean, and evinced a tendency to form gra-
nulations, the poultices are to be immediately discontinued, and simple
dressings employed. The quality of these is afterwards to be adapted to
the future appearances of the sore, agreeably to the directions already
* Manuale cli Chirurgia, 12mo. Milano, 1812.
t See Med, Chir. Trans, vol. ix. p. 240. f On Inflammation, p. 1 93.
GRANULATION. 165
given in the remarks on ulcers : at first, the tepid water-dressing com-
monly answers exceedingly well.
Some contused and lacerated wounds would be inevitably followed by
a rapid mortification of the limb, and the patient run the greatest risk of
losing his life, were amputation not performed immediately after the
receipt of the injury. These are generally examples, in which the soft
parts are extensively and deeply wounded, and large bloodvessels and
nerves injured. When mortification attacks patients so circumstanced, it
is the gangrene which Larry has called traumatic, and in which ampu-
tation may often be performed with success, though the sloughing has
not stopped. The treatment of lacerated and contused wounds, in a gan-
grenous or sloughing state, must be regulated according to the principles
mentioned in the observations on mortification.
OF GRANULATION AND CICATRISATION.
Process by which all Suppurating Wounds and Ulcers are cured. As
soon as ulceration ceases, and a sore evinces a disposition to heal, the
preponderating action of the lymphatics of the part (or, perhaps, of the
absorbent function of the veins) over the action of the nutrient arteries
terminates., and the power and functions of the latter vessels are resumed
with great activity. They have now something more than their ordinary
duty to perform ; for they have to fill up the chasm or excavation of the
ulcer, produced by the destructive process of ulceration ; and to accom-
plish certain changes, by which the part is brought as nearly as possible
into its original state.
This process of restoration is not confined, however, to the conse-
quences of ulceration, but is exemplified in the filling up and repair of
other chasms, or solutions of continuity, in the texture of parts, formed by
the separation of sloughs, or left after the bursting or opening of ab-
scesses. We find it, also, most usefully applied to the cure of wounds,
which, in consequence of loss of substance, severe contusion, laceration,
too much inflammation, an unfavourable state of the system, or other
causes, cannot be united by the first intention, and must unavoidably sup-
purate. In all these examples, the process of repair and restoration,
adopted by nature, is of one and the same description : she heals a sup-
purating wound exactly in the same manner, and by the same operations,
which she avails herself of in the cure of ulcers in general.
One of the principal means for this end is the production of granula-
tions ; the little conical, or more or less rounded, granular prominences,
of a softish new substance, which make their appearance on the surface
of suppurating wounds and ulcers, and serve not only for filling up the
chasm or cavity, but also for bringing its circumference or sides as much
towards a central point or line as the circumstances of the case will
allow. The manner in which this is accomplished, and its^isefulness,
which is much greater, than may at first be supposed, will be presently
considered.
The operation by which these new productions are formed, is called
the process of granulation : by the old surgeons, it was sometimes named
incarnation. It consists in the formation of numerous granular substances,
which originate from all points, and coalesce or meet, proceeding from
the circumference towards the centre, and from the bottom towards the
M 3
166 GRANULATION.
mouth of the wound. The result is a tissue of a peculiar character, a
fibro-cellular texture *, constituting the cicatrix.
Granulations consist of a deposit of animal matter, or fibrine, upon the
surface of an ulcer or open wound ; and into such fibrine blood is soon
conveyed. When a wound does not heal by the first intention, it begins
in a few hours to be painful, and attended with other symptoms of inflam-
mation. A thin serous discharge oozes out from it, and afterwards the
surface gradually acquires a uniform appearance, whatever be the tissues
of which it is composed ; for they all soon receive a thin covering of
coagulating lymph, which at the same time seals up the interstices of the
cellular tissue, and has been compared to a delicate pellicle, " some-
what similar to the almost invisible integument of the mucous mem-
brane."f A layer of coagulating lymph having been thus deposited by
the vessels of the wounded textures upon the surface of the wound, the
next part of the process consists in the growth or extension of minute
shoots from those vessels into the coagulating lymph. In fact, they soon
begin to enter it, and to deposit the new substance, which is to be con-
verted into granulations. These are likewise rendered exceedingly
vascular by the growth of young vessels into them. By Dr. Macartney
they are described as composed of a fine cellular membrane, into which
bloodvessels proceed from the subjacent tissue. Probably this state-
ment is only applicable to them in their completed state, and not intended
to controvert the commonly received doctrine of their formation com-
mencing with the effusion of fibrine.
At the same time that granulations arise, we notice the secretion of
pus. There seems, indeed, to be a close and intimate connexion between
the two processes ; and this is so much the case, that it is not an uncom-
mon belief, that an example of a granulating surface is never seen un-
attended by the secretion of pus. At all events, this view is generally
correct, the circumstances brought forward against it being few, as the
appearance of something like granulations between the ends of a fracture
examined by John Hunter.
Pus is not, however, secreted from ulcers of cartilages, or the cornea ;
«-, perhaps confirming the doctrine, that the morbid changes in the
' ^ous tissue depend upon the action of a vascular new substance
thtv • * ' v the synovial membrane.
The obser* ' ns, made by John Hunger ,on the process of granulation,
are remarkable tor their minuteness , 1 originality. He traced, with
derful pa, ovvth and vascularity of the new substance. He
lently noticed a vvhite «• .-.tter upon the surface of sores and wounds,
coagulating lymph: he left it undisturbed, and care-
he dressi. ••..-. were removed on the following
ound thj. ^cular, and that, when wiped
probe, it , "tained, by experiment,
take plat surface of an exposed bone : he
•t day, that a
i Wu:-- that the
Mch
d
srranulatu r , are
•
GRANULATION. 167
productions from the cellular tissue, but, after what has been already
stated, I cannot adopt this limited view. Undoubtedly, they may be
formed by any vascular texture capable of effusing coagulating lymph.
Every granulation has an artery, which is derived from those of the
subjacent original parts : after reaching what may be called the base of
the granulation, it divides into numerous ramifications, which then radiate
to its surface. However, from the account already given of ulcers in
general, we know, that the texture and appearance of granulations vary
according to the condition of the sore, and the state of the health. While
ulceration is going on, little excavations are perceptible on the surface of
the part affected ; but, directly the healing process is established, the
same surface becomes studded with innumerable small convex granula-
tions, which communicate to it a rough appearance; and the smaller and
more pointed these are, the more healthy is their nature. They then
generally exhibit a lively red colour ; their vascularity is considerable ;
the circulation in them brisk ; the secretion of healthy pus from them
carried on with freedom ; and the sore continues to heal without pain, or
inflammation.
When granulations vise much above the level of the neighbouring
skin, assume a pale colour, and a flabby spongy consistence, the circula-
tion in them is languid, they have not the power of forming healthy
pus, nor the new skin, requisite for the advancement of cicatrisation.
Neither have these large, high, spongy granulations any disposition to
unite with one another, and then contract and shrink, so as to draw the
old skin as much as possible over the part occupied by the cicatrix.
But when two surfaces, covered by healthy granulations, are brought
together, and kept in contact, they quickly unite, the granulations soon
join and inosculate, and the parts become permanently connected.
By the production of pus, granulations are proved to be secreting
organs. Their sensibility establishes the fact of their being provided
with nerves, and the development of nerves in them is quite as curious a
subject, as the growth, or extension, of vessels into them : they must,
indeed, be well supplied with nerves, for the slightest touch of them will
give pain.
It is said that, although granulations, which spring from parts endued
with great sensibility, are extremely sensitive, such as arise from bones,
tendons, and fascice, have little or no sensibility, unless these textures be
in an inflamed state.
Granulations not only have arteries, veins, and nerves, they are like-
wise furnished with absorbents. In fact, when unfavourable changes
occur in the state of the heath, and of the wound, or ulcer, the granu-
lations are frequently absorbed with considerable rapidity. It is in con-
sequence of the presence of absorbents in granulating surfaces, that
surgeons are obliged to be circumspect in the use of certain dressings
and applications. Cantharides put on an ulcer will affect the urinary
organs.
If arsenic, or the bichloride of mercury, be too freely applied to an
ulcer, or granulating wound, it will be absorbed, and the patient be as
truly destroyed by poisoning, as if he had taken those deleterious articles
into his stomach. Opium is also absorbed from the surfaces of sores,
and may thus produce constipation, headach, and lethargic symptoms.
I have known several instances of violent and unexpected salivation,
caused by the too free employment of salves containing the red precipi-
tate. The absorption of belladonna, when used as an application to
M 4
168 CICATRISATION.
irritable ulcers, has been known to bring on amaurosis, or loss of sight
from paralysis of the retina. The older an ulcer is, the greater is its
disposition to absorb whatever may be applied to the granulations.
How far the veins are concerned in this kind of absorption, and
whether they may not do what is usually ascribed to the lymphatics, are
points highly deserving of further investigation.
Cicatrisation is that part of the healing process which consists in the
formation of the cicatrix or substance composing the scar, which in ulcers
or wounds upon the surface of the body consists of the remains of the
granulations, a new tissue of a fibro-cellular kind, and the new skin and
cuticle covering them. Or, if Dr. Macartney's view be adopted, the
term cicatrisation is applied to " the last stage of reparation, in which
a wound, or an ulcer, assumes a covering resembling, in some degree,
the skin or other adjacent surfaces ; for, in no instance, does the cicatrix
perfectly possess the structure of the natural tissues." The cicatrix is
observed by this gentleman to differ most from the natural structure in
those instances where much lymph, or granulations,, have been organised,
and where these substances have not been sufficiently absorbed, but con-
tinue in a callous state, adhering to the neighbouring parts, and, proba-
bly, involving some palpable branches of nerves. Hence, the feeling in
the part is, sometimes, so unnatural, that various affections of the ner-
vous and muscular systems may be the consequence.* When the chasm
of an ulcer, or the cavity of a suppurating wound, has been filled up with
granulations, the next desirable change is the production of new skin, by
which they are to be covered. A fine, thin, smooth, bluish, pellicler
gradually extends from the circumference of the ulcer or wound, or from
the margin of the sound skin to the centre of the sore, until all the gra-
nulations are covered, when the secretion of pus immediately ceases.
The sore or wound is then healed; cicatrisation is complete.
The following explanation of this part of the subject by Dr. Macartney
seems to me interesting: " As a preparation for the final act of healing,
we observe, that the granulations on the edges of the sore are reduced
by absorption to a flat surface ; the vascularity of the edges about to
cicatrise declines ; and the thin pellicle, which covered the granulations,
becomes opaque and thicker. It is indispensable, also, that inflammation
should have ceased in the skin immediately surrounding the sore. The
bloodvessels, which previously ascended to the surface of the granula-
tions, now give place to vessels that are extended from the skin to the
surface of the cicatrix, in a radiated manner, as may be demonstrated
by the injection of the limb with a coloured fluid, in a case of recent
formation of a cicatrix. These vessels, which, at first, form but few
cross-communications with each other, ultimately acquire more of the
reticulated arrangement of the bloodvessels in the common skin." (P. 61.)
In almost all cases, the pellicle, which precedes the completion of the
new skin, is derived from the adjoining old skin, and,, consequently, is
seen only at the border of the sore or wound ; or, rather, it appears as if
the surrounding skin communicated a disposition to the nearest granu-
lations to form skin, just as bones give an ossifying disposition to granu-
lations formed upon them. In less common instances, new skin is also
produced on parts of the sore or wound situated away from the edges.
This may happen when the ulcer or surface of the wound has been very
large, and the disposition to form skin at the edges seems nearly ex-
* See Macartney on Inflammation, p. 59.
CICATRISATION. 169
hausted. Such was John Hunter's view of the subject ; but, according
to Sir Astley Cooper, an ulcer, or a suppurating granulating surface of a
wound, has no power of producing new skin at any point away from its
margin, unless some portion or portions of the original skin happen not
to have been completely destroyed in places away from the edges of the
sore. When cicatrisation takes place under a dry clot of blood, or a
scab, Dr. Macartney believes, that it does not proceed from the edges of
the wound, but over the whole surface at the same time ; the covering
being usually detached at once. In this mode of cure he observes, that
the cicatrix is pliant, and more nearly like the natural skin than in other
instances. He also adverts to certain specific sores, in which cicatrisa-
tion may begin, not only at their circumference, but at the same time in
other places. " In such cases," he observes, " the healing process is
very rapid, and the granulations acquire their proper integument, before
there is time for their being diminished by absorption, or by their having
assumed a plain surface." Under these circumstances, the cicatrix pos-
sesses a very irregular and puckered appearance. The whole of the
new substance, by which the chasm is filled up and covered over, pre-
senting a smooth surface and compact feel, is the cicatrix or scar. The
new-formed cutis is less supple, less moveable, and less elastic, than the
original skin, from which it also differs in being destitute of those lines
or furrows which the cutis naturally exhibits. At first, it is extremely
full of vessels ; but afterwards both it and the subjacent granulations
become less vascular, and the cicatrix, therefore, instead of being, as it
is in the beginning, somewhat redder than the rest of the skin, after-
wards turns even paler. The new-formed skin, however, always retains
a stretched, smooth, shining appearance. Hairs do not grow upon it,
and it seems not to be provided with sebaceous glands.
The formation of cuticle is a much easier and quicker process, than
the production of new skin; for, while this in general only grows at the
edges of the sore, that may be produced at once from every point of the
cutis, as is exemplified in the healing of a blister. It is doubted whether
the rete mucosum can be regenerated. Many surgeons consider the fact
to be established, because in negroes the cicatrix is at first of a pale red-
dish colour, but afterwards turns as black, or even blacker, than the rest
of the skin.
On this point, some valuable remarks were made by Dupuytren. It
appeared to him that, in certain burns, when the rete mucosum is
merely damaged, but not destroyed, its colouring matter generally be-
comes much darker than in the natural state : hence the yellow or brown
spots occasioned by the scars, and which time cannot efface. In the
negro the skin then becomes blacker than in the natural state. When
the rete mucosum has been destroyed in some parts, but not in others,
the cicatrix has an odd appearance, for the rete mucosum either being
not reproduced at all, or reproduced but imperfectly at the points where
it has been destroyed, the projections of the cicatrix present a white
colour, while the points of the skin, corresponding to the places in which
the rete mucosum has only been hurt, exhibit a brownish tinge.
While the formation of new skin is going on, the granulations undergo
absorption. The whole mass of them, united together as they are in the
progress of cicatrisation, is lessened in diameter, the effect of which is to
draw the original parts, with which they are connected, nearer together :
in particular, the old skin is thus drawn further over the part, and the
extent of the cicatrix materially lessened. This contraction of granula-
170 REPRODUCTION OF LOST PARTS.
tions not only takes place during cicatrisation, but for some time after
it : hence a scar, which may be at first three or four inches in diameter,
will finally be reduced to a half or one third of that breadth.
This process is not limited to ulcers and suppurating wounds ; it is
actively concerned in the obliteration of the cavities of abscesses, the
sides of which have thrown out granulations. They will not granulate,
however, unless they have burst or been opened.
The healing of wounds by means of suppuration, granulation, and
cicatrisation, is sometimes called union by the second intention, as con-
trasted with that named union by the first intention, which is chiefly
applicable to incised wounds. In the processes by which union by the
second intention is brought about, there is an increased action of the
vessels ; and, according to the investigations of Dr. John Thomson, the
thermometer applied to the neighbouring skin is two degrees higher, than
it is when applied to other parts of the integuments.
REPRODUCTION OF LOST PARTSi
One curious question, intimately connected with the foregoing subject,
is, whether lost parts, or textures, which have been destroyed, can be
reproduced ? In man, and the higher classes of animals, when an entire
part is lost, it cannot be reproduced, which fact is very different from
what occurs in some of the lower animals, in which whole limbs are
easily regenerated.
The skin and bones seem to be the two textures which manifest in the
human body the greatest power of reproduction. Considerable portions
of skin, perhaps even with the rete mucosum more or less complete,
may be reproduced, and few experienced surgeons have not met with
examples, in which the whole scrotum, after having been destroyed from
effusion of urine, has been followed by the formation of another. Then,
with respect to bones, the whole shaft of a long cylindrical bone, when
destroyed by necrosis, is frequently reproduced. Lost portions of the
brain and spinal marrow are never regenerated. Muscle is not regener-
ated; nor are fasciae. Muscular fibres are united by a substance,
different from muscular tissue, but such as restores to the muscle the
power of performing its functions. The same is the case with tendon.
The cartilages covering the ends of bones, when destroyed, are never
reproduced, which, as Dr. Macartney points out, is the more remarkable,
since, in what are called false joints, the ends of the bones, which rub
against one another, become covered with a sort of spurious cartilage.
The tissue of nerves is never reproduced, and, if a nervous trunk is
divided, the parts, to which its filaments are distributed, are irrecoverably
paralysed, notwithstanding the reunion of the divided nerve by means
of another kind of tissue. I know, however, that this is a disputed
point ; and that Mr. Abernethy, as well as Dr. Macartney and others,
espouse the doctrine of a true sentient substance being ultimately
regenerated in the connecting medium of nerves, which have been
divided.
With respect to ligaments, nature can also do a great deal, for, under
particular circumstances, she appears to be capable of forming new ones.
She has likewise the power of reproducing bursae mucosas, and of gener-
ating around abscesses and fistulae a texture nearly corresponding to
natural mucous membrane ; but, according to Dr. Macartney's investiga-
tions, she does not replace any portion of the mucous membrane removed
from the stomach or bowels.
GUNSHOT WOUNDS. 171
GUNSHOT WOUNDS,
So called from the manner in which they are produced, are generally
caused by hard obtuse metallic bodies, projected by the explosion of gun-
powder from cannons, muskets, pistols, or some other species of firearm.
Such bodies may be forced into, or even quite through, the injured
parts ; or, if the wound be made with a cannon-ball, either the limb may
be carried away, or, in other instances, the muscles contused and crushed,
the bones broken and comminuted, and the liver or other internal
organs torn, while the skin itself remains unbroken, over all this con-
cealed, and sometimes unsuspected, mischief.
With gunshot injuries, it is also customary to consider various severe,
and often fatal accidents, arising from the bursting of shells, or from the
violence with which splinters are thrown about, when a cannon-ball
strikes the hull of a ship.
When firearms were first employed for the purposes of war, the com-
ponent ingredients of gunpowder were not exactly known, and, as the
injuries occasioned by it had far more serious consequences than those
following common wounds, a suspicion was excited, that the peculiar
severity of gunshot wounds depended upon something of a poisonous
quality being conveyed into the part with the ball. Another notion was,
that the ball was intensely heated, and burnt the parts in its passage
through them; an idea that seemed to be confirmed by the observation,
that the generality of gunshot wounds threw off sloughs, or eschars, be-
fore the healing process commenced. These views are now known to be
entirely erroneous : there is nothing poisonous in the composition of
gunpowder; nor are the soft parts burnt by the ball.
All the usual severity of gunshot wounds is referable to other circum-
stances ; the principal of which are: —
First, the hard, obtuse kind of body, with which the injury is done.
Secondly, the immense force and velocity with which the ball strikes
against, penetrates, tears, bruises, or breaks the textures which happen
to be in its way.
And, thirdly, the nature of the parts injured, which, in consequence of
the depth and extent of gunshot wounds, frequently comprise organs of
first-rate importance in the animal economy.
Gunshot wounds are, in fact, constantly attended with contusion and
laceration, by which a part of the textures, immediately around the track
of the ball, is generally in such a state, that it must be thrown off in the
form of a slough. It is partly for this reason that gunshot wounds
scarcely ever admit of being cured by the adhesive inflammation, but
necessarily suppurate. In a few instances, however, especially where the
integuments of the face, or neck, or the lip, or scalp, are torn by a ball,
union may be obtained with the aid of a suture ; but this is ai»exception
to the usual character of gunshot wounds. Indeed, they not only throw
off a slough, and suppurate along the course of the ball, but extensive
abscesses are frequently occasioned in the neighbouring parts. Thus,
when a person is shot through the thigh, there will be suppuration in the
track of the ball, and not merely in this situation, but generally also
between the muscles and under the fascia.
Gunshot wounds, like other contused and lacerated wounds, com-
monly bleed less freely than incised ones ; yet, the hemorrhage is some-
times considerable, and even immediately fatal. When I was serving
172 GUNSHOT WOUNDS.
with the army near Antwerp, a soldier was brought to the Military
Hospital, who had received, about ten minutes previously, a musket-ball
in the lower part of the neck. He had not been more than two minutes
in the ward, when an enormous extravasation of blood, from an injury of
the right carotid, near its origin, produced instantaneous suffocation. Not
a drop of blood escaped from the wound.
It is computed, that a large proportion of the killed in every great
battle perish of internal hemorrhage. In Dupuytren's clinical lectures,
a young man is mentioned, who received a musket-ball in the upper part
of the thigh, and died of hemorrhage from the femoral artery, as he was
being conveyed from one of the streets of Paris into the Hotel Dieu.
In deeply penetrating gunshot wounds, a critical period comes on at
the end of a week, or ten or twelve days ; for, this is the time when the
sloughs begin to loosen. It is often impossible to know at first what parts
are injured : the extent and danger of the wound cannot be judged of,
perhaps, until the coats of some large artery, bowel, or other important
organ, touched by the ball in its passage, give way on the loosening of
the sloughs. The wound may now become far more complicated than
was expected, and profuse hemorrhage, or the effusion of the contents of
the bowels, or other viscera, may greatly change the circumstances on
which the prognosis is founded. Such bleeding may, indeed, destroy the
patient in a few seconds ; or the effusions give rise to fatal inflammation
within the abdomen or chest. Several days after the receipt of a gun-
shot wound, when all the dangers of the first inflammation are nearly
over, the separation of a slough may cause hemorrhage from a deep-
seated artery. In some cases, the blood accumulates in the abdomen,
or the chest ; and in others, the patient is carried off in another manner,
namely, by profuse discharges of blood from the bowels. The case of a
soldier of the 44th regiment, which came under my notice in Holland,
in the year 1814, affords a good illustration of the risk of hemorrhage,
about a week or ten days after the receipt of a gunshot wound, the pe-
riod when the sloughs begin to be loosened. This man had been shot
through the ham, and., one side of the popliteal artery having been in-
jured, it sloughed about eight days after the accident, and profuse he-
morrhage ensued. A tourniquet was immediately put on, and the femoral
artery secured about the middle of the thigh ; which operation proved
completely successful. The reason for deviating in this instance from
the common maxim of cutting down to the bleeding part of an artery,
and applying two ligatures to it, will be understood from the observations
already delivered on the subject of hemorrhage. The foregoing case is
instructive on another point : it teaches us why the separation of sloughs
in gunshot wounds often leads to copious and fatal hemorrhage ; a re-
markable difference from what is seen in common mortification, where
the arteries, being plugged up with coagulum, rarely bleed on the detach-
ment of the dead parts. In gunshot wounds, the ball sometimes touches
only a portion of the side of a large artery; the slough or ulceration of
the vessel is restricted to this situation ; and its cavity is neither filled up
with a clot, nor always completely occupied by coagulating lymph.
The foregoing remarks chiefly relate to bleedings from such gunshot
wounds as penetrate deeply, and are produced by bullets, musket-balls,
or grape-shot ; for the injury, arising from the blow of a cannon-ball, is
attended with such a degree of contusion and laceration, that a great
deal of bleeding rarely follows. We here observe the same thing as is
noticed when a limb is torn off by getting entangled in machinery ; a
GUNSHOT WOUNDS. 173
limb may be carried away by a cannon-ball, even as high as the shoulder,
or upper part of the thigh, without any bleeding of importance, or any
necessity for ligatures, either at the moment of the accident, or after-
wards, unless amputation be done. We had numerous proofs of this
fact during the last war. A soldier of the rifle brigade had his arm
shattered to pieces at the battle of Waterloo, as high as the shoulder ;
yet, there was no hemorrhage. A Dutch soldier was brought to the
Military Hospital, whose leg had been carried away a little way below
the knee, and whose thigh I was obliged to amputate : no hemorrhage
preceded the operation. Then, another remarkable case was brought
in the preceding year to the British Field Hospital, at Merxem, near
Antwerp : the greater part of the clavicle and scapula, with the whole
cushion of the shoulder, had been shot away by a cannon-ball from one
of the French batteries, yet no bleeding of importance occurred, and the
man ultimately recovered.
The peculiarities of gunshot wounds are numerous : one of them, occa-
sionally noticed, is a gradual loss of the pulse in the injured limb a few
days after the accident. One side of the main artery is hurt by the ball,
but, instead of sloughing, it inflames, and the vessel is rendered imper-
vious by a plug of coagulating lymph.
A gunshot wound may have one or two openings, according as the ball
has lodged in or passed quite through the part. When a musket or pistol
ball has entered a fleshy part, an aperture is seen rather smaller than the
bullet itself, with its circumference discoloured by ecchymosis, and its
edge forced somewhat inwards ; and, if the ball has passed quite through
the part, another larger opening, less contused than the former, is left at
the point of its exit, with an irregular and prominent margin.
The direction of a ball or bullet in motion, however quick its course,
is readily changed by the resistance it meets with, and the ball then
becomes reflected. It should also be recollected that a ball always has
two motions ; that of a paraboloid curve, and that of a rotation or spinning
of it on its own axis. If we had all the data for our calculations, the
seemingly extraordinary course which a ball sometimes takes would be
completely explicable by the laws of projectiles. In some cases, the
points of entrance and exit are precisely opposite one another ; but, in
others, their relative positions are very different. Dr. Hennen records an
instance, in which a musket-ball entered in front of the larynx, and passed
all round the neck, nearly to the point opposite that at which it first
pierced the skin. When balls strike the ribs obliqueJy, their course will
often be so changed, that they will run almost completely round the body.
A similar occurrence is sometimes noticed on the head, where a ball,
after having entered at the temple, may be so turned as to pass round the
cranium to the opposite side of the head. Facts of this kind aVe chiefly
owing to the great strength and elasticity of the skin. As a soldier was
climbing up a scaling ladder, with his arm extended upwards, 9 musket-
ball pierced the centre of the upper arm, passed over the back of the
chest, thence amongst the abdominal muscles, and, having pervaded the
gluteei, stopped about halfway down the opposite thigh, on the forepart
of which it presented itself.
Gunshot wounds are more frequently complicated with foreign bodies
than any other description of wound. These may consist of pieces of the
clothes,, of the ball itself, of fragments of bone, pieces of bomb-shells,
splinters of wood, &c.
When there is only one opening, we may infer, that the wound con-
174? GUNSHOT WOUNDS.
tains a foreign body. There is, however, one exception, which is, when
the ball carries along with it into the flesh a pouch of the clothes, which,
on being withdrawn, brings out the ball with it. A ball may also stop
close to the orifice, and be ejected by the elasticity of the ribs.
In 18 14, a French soldier, wounded under the walls of Paris, was
brought to the Hotel Dieu. On examining the upper part of the leg.
some pieces of the soldier's dress were observed to be lodged in the tibia.
By using force they were extracted. They consisted of a fragment of
the soldier's gaiter, which included a musket-ball. An analogous case
presented itself at the Hospital la Pitie, in July, 1830: a ball had pene-
trated the abdomen, carrying before it a piece of the torn shirt, which
served very usefully for its extraction.
The opening, made by a ball in the clothes, is always much narrower,
than that in the skin. It was the ignorance of this fact, which raised a
suspicion that Charles the Twelfth had been assassinated ; for the open-
ing, made in his hat by the ball, did not appear to correspond to that made
in the skin of the forehead.*
When two apertures are seen, and they have been caused by the
passage of one entire ball, it is manifest that this cannot be lodged ; yet
other articles may be so, such as portions of clothes and splinters of bone ;
and, occasionally, notwithstanding a ball may have produced two open-
ings, a part of it may remain behind, in consequence of its having struck
against the edge of a bone, so as to be split into two portions, one of
which passes out, while the other takes another course and continues
lodged. A ball, by striking against a bone, may undergo different changes
in its shape, be flattened, or split into fragments, so as to produce mis-
chief very difficult to account for. A ball enters the lower part of the
right leg, and strikes against the spine, or sharp edge of the tibia, whereby
it is cut into two fragments. These fragments, then diverging a little,
pass through the calf of the leg and lodge in the fleshy part of the
other leg, which happens at the moment to be behind the other limb.
Thus five openings may be caused by one and the same ball. Balls, by
striking against iron bars, may be split into fragments, which then enter
the body of the wounded person. Dupuytren saw many cases of this
kind at Paris, during the disturbances in July, 1832. f
It was once a disputed point, whether the cylindrical bones could be
fractured longitudinally. This question is now completely settled. I
saw several examples of this kind of injury, which were brought into the
hospital at Oudenbosch from Bergen-op-Zoom. They often extend the
greater part of the length of the thigh bone, or tibia, and sometimes run
into the knee, followed by inflammation of the synovial membrane, and
ulceration of the cartilages. Where such mischief does not ensue, it is
an exception to the general course of things. In University College
museum, there is one excellent specimen of a fracture of the tibia, extend-
ing into the knee, and united very well. The frequently considerable ex-
tent of longitudinal fissures in the cylindrical bones from gunshot violence
should be constantly recollected, when amputation is about to be per-
formed ; for, it may be necessary on this account to make the incision
and saw the bone several inches above the place where the ball entered
the limb. A case of longitudinal fracture of the femur, from the pas-
sage of a ball into the popliteal space, is recorded, in which the fissure
* See Dupuytren's Lefons Orales, &c. t. ii. p. 426.
t Lepons, &c. t. ii. p. 429.
GUNSHOT WOUNDS. 175
extended from the internal condyle to the upper third of the bone,
unattended with crepitus, and allowing the patient to stand up after the
injury. It proved fatal on the fifth day.*
Some of the worst compound and comminuted fractures, ever seen in
the practice of surgery, are those arising from gunshot violence. They
are not only frequently complicated with extensive laceration of the soft
parts, wounds of the nervous and arterial trunks, but with a degree of
comminution and splintering of the bones, rarely noticed in any common
examples of such injuries. It is also one peculiarity of gunshot injuries,
that they sometimes cause a compound fracture, and dreadful laceration
of the hip and shoulder joints, which are hardly capable of being so
injured by any other means. What in fact is likely to cause a compound
fracture of the head of the humerus, or femur, but a gunshot wound ?
In gunshot wounds, the prognosis depends chiefly upon the extent and
depth of the injury, and the nature of the wounded parts. Wounds of
the head, lungs, bowels, considerable arteries, and large joints, extensive
contusion and laceration of the soft parts, the dreadful degrees of con-
cealed mischief often resulting from what are erroneously termed wind
contusions, and all badly comminuted and compound fractures, may be
pronounced to be accidents of the most dangerous kind.
I have slightly alluded to the true manner, in which what are called
wind contusions are produced. A cannon-ball, especially when nearly
spent, frequently strikes the surface of the body, or a limb,. obliquely, and
is reflected without breaking the skin. A soldier may be killed in this
way without any appearance of external violence. His comrades sup-
pose, therefore, that he has been killed by the wind of the ball. But the
error of this opinion is immediately manifest, when it is remembered,
that cannon-balls often carry away parts of the dress, without doing any
harm to the person. I remember a case, where a cannon-ball passed
amongst the six legs of three officers walking together arm in arm ; yet
both legs of the officer in the middle escaped injury, while one leg of
each of the outside parties was so shattered as to require immediate
amputation. When a cannon-ball rolls, as it were, over the surface of
the body, or a limb, the toughness and elasticity of the skin keep it entire,
while the muscles and even the bones may be crushed to atoms, or the
viscera and internal vessels of the chest, or belly, fatally lacerated and
disorganised. Hence, when these wind-contusions do not immediately
kill, as they often do when the abdomen or thorax is implicated, they are,
at all events, to be regarded as examples of the most violent forms of gun-
shot injury.
In July 1830, at Paris, a woman's humerus was completely crushed
by a cannon-ball, though the skin remained entire; and, in 1814-, a
soldier was brought to the Hotel Dieu with his kidneys pressed to atoms,
though nothing particular was noticed in the loins but a considerable
swelling, the integuments being unbroken. Sloughing ensued ; and after
death the crushed state of the kidneys and posterior part of the spine
was detected.t
The violent contusion and laceration of parts, the several complications
of fractured bones, foreign bodies, wounded arteries, and lacerated
nervous trunks, are events fully accounting for the severity of the
consequences of many gunshot wounds, comprising dangerous degrees of
* See Alcock, in Lond. Med. Gaz. No, for June, 1839, p. 326.
t Dupuytren, op. cit. t. ii, p. 436.
176 GUNSHOT WOUNDS.
inflammation and sympathetic fever, enormous abscesses, mortification,
and the frequent loss of limb or life.
With respect to the immediate effects of a gunshot ivound on the system
at large, they vary in different subjects, even with the same kinds of
injury. Of course, the results of profuse bleedings will be nearly alike
in all individuals, and death be often suddenly produced by such as
occur from vessels of large size within the thorax or abdomen. Some
men will have their limbs carried away by a cannon-ball, without betray-
ing at first the slightest symptom of mental or corporeal agitation ; others
will be seized with faintness, vomiting, shiverings, a deadly paleness, and
syncope, from injuries of only a trivial kind. When this is the case, the
disturbance and depression of the system may generally be removed by
giving the patient a little wine or other cordial, or a few drops of lauda-
num, and by assuring him of his safety.
However, the long continuance of the foregoing class of symptoms
ought to raise suspicions of internal hemorrhage, effusion in one of the
great cavities of the body, injury of important viscera, or other serious
mischief.
After the subsidence of the alarm, frequently excited in the animal
economy by a gunshot wound on its first reception, a reaction follows, or
that state of the constitution, which is described under the name of sym-
pathetic inflammatory fever. This will afterwards abate as the effects of
the inflammation diminish ; or, if these should go on unfavourably, it may
change to hectic, so as either to destroy the patient, or render the removal
of the injured part necessary for his preservation.
TREATMENT OF GUNSHOT WOUNDS.
If the injury be in one of the limbs, the first thing is to decide whether
the wound is such as to require amputation, or whether an attempt can
prudently be made to save the part. The decision is generally one of
vast importance, because, if the injury be sufficiently bad to make the
chance of preserving the limb hopeless, the operation ought to be per-
formed without delay, and the opportunity of doing it, if now neglect-
ed, may never return. Violent inflammation, suppuration, and profuse
abscesses, phlegmonous erysipelas, and even a rapid mortification, at-
tended by the utmost disorder of the whole system, may come on, and
the patient be thereby placed in a condition, presenting little or no
prospect of recovery, whatever be attempted.
In many gunshot wounds, the stoppage of bleeding, and the removal of
foreign bodies, constitute the two earliest indications. With respect to
hemorrhage, the rule is also to be observed, which applies to wounded
arteries in general, viz. that of exposing the wounded part of the artery,
if circumstances admit of it, and putting one ligature on the upper, the
other on the lower, orifice or portion of the bleeding vessel. To instances
of profuse hemorrhage from the limbs, directly after the receipt of the
injury, this rule is strictly applicable ; but not so to many examples of
secondary bleeding, where the artery and neighbouring textures are in a
state of inflammation, suppuration, and sloughing ; the parts incapable of
bearing further disturbance ; and the artery indisposed to heal, if it were
tied, which, under these circumstances, is often a difficult, or imprac-
ticable, thing. Here the principles, laid down in the remarks on hemor-
rhage and compound fractures, are to be acted upon, and especially with
reference to secondary hemorrhage from the tibial arteries.
The application of a ligature to the brachial artery, for wounds of the
TREATMENT OF GUNSHOT WOUNDS. 177
radial and ulnar, often fails from the freedom of the anastomoses with the
recurrent arteries. An instance of such failure, on the third day after
the operation, is given by Mr. Alcock.
It was formerly the custom to dilate the orifices of all gunshot wounds
with a curved bistoury. This was done, first, to facilitate the extraction
of foreign bodies ; secondly, to lessen the tension and constriction of the
parts; thirdly, to diminish the inflammation b}' procuring an evacuation
of blood ; and, fourthly, to make a ready outlet for any purulent matter
which might be formed. The practice should not, however, be adopted
without discrimination.
John Hunter observed that, when an incision was made at the orifice
of a gunshot wound, it generally healed up in four or five days, leaving
the parts just in the same state as if the knife had not been employed at
all. Some gunshot wounds it would be highly inexpedient and danger-
ous to dilate, as, for instance, those of the abdomen, the doing of which
would occasion exposure and protrusion of the viscera.
In general, British surgeons only dilate the orifice of a gunshot wound
when some clear and determinate object can be accomplished by it ; as
when balls, splinters of bone, or other foreign bodies, are to be extracted,
a freer outlet is required for purulent matter, or sloughs ; or ligatures are
to be applied to a bleeding artery; or the inflamed parts are tightly com-
pressed by an unyielding fascia. Whenever a ball has entered a part
which is likely to get into this condition, the usefulness of dilatation in the
first instance is yet strongly insisted upon by some authorities.
1. In whatever region of the body a gunshot wound is to be dilated,
it is more frequently required for the opening by which the ball has
made its exit; because whatever extraneous substances have been
formed by the splintering of bones, or carried into the part by the ball,
are most likely to lie in this direction.
2. Another general rule is to dilate more freely the opening which, in
the patient's usual position, will be most depending.
No doubt can exist about the propriety of removing foreign bodies as
soon as it is practicable, without too much irritation of the parts ; and,
on this condition, not only is the plan right of making a dilatation of the
orifice of the wound, but even of practising other deeper incisions. In-
deed, as inflammation has not yet come on, the proceedings for the
purpose are much less painful immediately after the accident, than at a
subsequent period. But we should only resort to this method when the
foreign bodies can be found with certainty, and extracted with tolerable
facility. Their precise situation is frequently unknown ; and, on other
occasions, even when it is known, they may be so firmly fixed, or so deeply
lodged, that the measures, necessary for their removal, would be productive
of far greater mischief, than would result from their continuance.
The generality of British military surgeons make it a rule only to re-
move at first those foreign bodies which are near the external opening or
are superficial, and can be taken out without too much pain and irritation ;
or, if they meddle with others deeply placed, they do so only when com-
pelled to it by the urgency of symptoms excited by the pressure of such
foreign bodies on organs of importance. Thus a ball lodged under the
skull, upon the surface of the dura mater, may produce such compres-
sion of the brain as will justify any operation calculated to enable the
surgeon to extract the offending body. As for others deeply and firmly
lodged, but not attended with such urgency, they often become loosened
and get nearer the surface after suppuration has taken place, or the
N
178 TREATMENT OF GUNSHOT WOUNDS.
sloughs have been detached. Something, however, will depend upon the
kind of foreign body ; rough angular substances, broken and irregular
shaped masses of lead, loose splinters of bone, and portions of the clothes,
creating more irritation than a smooth leaden ball, and therefore more
urgently requiring to be extracted. Smooth, round, leaden balls some-
times lie in parts for an indefinite time without occasioning much incon-
venience. Adhesive inflammation forms a cyst for them, by which they
are separated from the neighbouring textures. Between such a cyst and
the foreign body, there is a small quantity of serous fluid.*
Balls do not, however, always remain thus stationary; sometimes, in
the early stage of the case, they change their place rapidly. Hence, it is
not warrantable to practise an incision for the extraction of a ball, whose
situation has not been made out directly before the operation. Balls
mostly travel towards the surface, less rarely towards the central parts of
the body.
No surgeons of the present time entertain any doubt, that Mr. Hunter
was too timid in his precepts relating to the extraction of balls from
gunshot wounds. This observation applies particularly to his advice,
" that, where the ball lies so remotely from the skin, that it can only
just be felt, and the skin itself is quite uninjured, no counter-opening
ought to be made." In opposition to this plan, the following maxim has
been inculcated: — If the ball 0an be felt, it matters not what depth of
muscular parts may intervene, it should be extracted, and the neces-
sary incisions made for the purpose. In one fatal case, where the ball
was lodged deeply under the muscles of the calf, where it could be felt
with a probe, Mr. Alcock regretted that he did not at once extract it by
a free incision carried directly through those muscles, down to the
foreign body.f He gives also another case, in which a ball lay imbedded
in osseous matter, between the radius and ulna. " This wound, after
many weeks' treatment, produced a permanent twisting downwards, and
contraction inwards, of the hand, so as to render it not only useless, but
exceedingly inconvenient; and, all measures failing to prevent or amend
it, the arm was amputated. But, says this gentleman, had the ball been
discovered and extracted in the first instance, I have little doubt, that a
useful hand might have been saved." Not knowing the exact state of the
limb, I can offer no opinion on what might have been the result of such a
proceeding in the subsequent stage of the case ; but it is clear to me, that
these and numerous other facts prove, that the practice of extracting
balls is more limited than it ought to be.
For the extraction of balls, bullet-drawers and forceps of particular
construction are sometimes employed; but the fingers and common
forceps are generally the best instruments. Balls sometimes pass nearly
through parts, and then lodge under the skin : here they should be cut
upon, and removedr
^ Dupuytren makes useful practical distinctions between the different
kinds of splinters ; and particularly notices such as still retain a con-
nexion, and may live and beneficially contribute to promote the repair of
the fracture ; and others, which are completely detached, either in the
first instance, or afterwards, and are to be regarded as foreign bodies.
On the same point, Mr. Alcock proposes two maxims: 1. S in ce frag-
ments, particularly long and irregular ones, generally in contact at one
* Dupuytren, Le9ons Orales de Clinique Chir. t, ii. p. 433.
f See Med. Gaz. New Series, No. 31.
TREATMENT Of GUNSHOT WOUNDS. 179
or more points, will not only unite in a firm and perfect manner, but
serve as a useful connecting link to the shafts ; since, moreover, such
fragments have extensive adhesions to muscular fibres, and, if deeply
placed, cannot be extracted without a good deal of dissection, and some
violence, this operation, under such circumstances, ought never to be
attempted. 2. A completely detached and short fragment should be
removed at once, if it can be done without much dissection or violence,
as it is likely in a few hours to become dead, and act as a foreign body.*
Military surgeons differ respecting one particular case, which is when a
ball penetrates and lodges in the spongy part of a bone. Baron Larrey
only sanctions the attempt at extraction when the ball is actually pro-
ducing dangerous effects : some other surgeons, on the contrary, deem it
right always to try to extract it without delay, apprehending that its pre-
sence will bring on necrosis, abscesses, sinuses, and that the diseased state
of the limb will be likely to continue for years. Much must depend upon
the precise situation of the ball with respect to the wound in the skin,
and whether it be deeply impacted, or only partially buried in the head
of the bone. If plainly perceptible, not too deeply buried in the cancel-
lous structure, and it could be got at without cutting through a great
thickness of soft parts, or injuring the synovial membrane of a consider-
able joint, the extraction of it would be the most advisable practice.
Such a case, attended with severe effects, and not admitting of ex-
traction of the ball, might justify the excision of the head of the humerus,
or the parts of some other bones, in which the ball had lodged.
Superficial, light, unirritating dressings are now generally preferred
as the first application to gunshot wounds. On the field of battle,
indeed, it would be well for many of the wounded if the surgeon, after
paying attention to hemorrhage and the removal of foreign bodies, were
to be content with applying simple pledgets, and covering the parts, if the
weather were not too severe, with handkerchiefs or linen wet with cold
water. The hasty and indiscriminate employment of tight straps of ad-
hesive plaster, and tense bandages, has cost thousands of soldiers their
limbs or lives. Dupuytren insists upon the usefulness of keeping gun-
shot wounds excluded from the air. He applies to them fine old linen,
with numerous apertures cut in it. This is covered with cerate, and put
on the part. Over the pledget is laid charpie, which is preferred by the
French to lint, as being more calculated to imbibe the discharge. In-
stead of a roller, the application and undoing of which cause great dis-
turbance, Dupuytren preferred long widish pieces of linen, which were
made to cross over the wound, and then pinned.
One of the most eligible applications for gunshot wounds is the common
tepid water-dressing, covered with a piece of oiled silk ; or pledgets of
simple ointment, poultices, and fomentations. In the suppurative stage,
poultices and fomentations are very generally employed. They are de-
cidedly the best applications when a slough is present, or matterfis form-
ing ; previously to which states, that is to say, during the first two or
three days, cold lotions are sometimes preferred. Cold evaporating
washes and cold water are not to be applied, however, when the temper-
ature of the part or limb is lower than natural, the. circulation in it languid,
the weather cold, and the patient particularly exposed to it. Such prac-
tice might bring on mortification.
The early stage of gunshot wounds generally requires antiphlogistic
* See Lond, Med, Gaz. New Series, No. 33. p, 240.
N 2
180 TREATMENT OF GUNSHOT WOUNDS.
treatment. As soon as inflammation comes on, venesection, leeches,
aperient medicines, and low diet are indicated. Wounded soldiers, being
subjects thrown from a state of full health into one of considerable dan-
ger, are sometimes conceived not to thrive so well under a system of
starvation as other individuals labouring under an equal degree of inflam-
mation. Whether this idea be correct, I cannot undertake to say ; but
in regulating the diet some allowance should be made for habit. The
wounded Cossacks, brought into the Hotel Dieu in 1814, were observed
by Dupuytren to eat with impunity ten times as much as a Spaniard in
health. In many cases, the free use of the lancet is the chief means of
saving life ; this fact is exemplified in wounds of the chest, attended with
injury of the lungs, in those of the abdomen, accompanied by injury of
the viscera, and in gunshot injuries of the head, where the effects extend
to the brain and its membranes.
In such examples, particularly, as well as in all others in which the
inflammation is likely to be severe and dangerous, on account of its
extent or situation, venesection, leeches, and the most powerful antiphlo-
gistic means must not be omitted. As for bleeding, both with the lancet
and leeches, it must be carried to the degree required by the urgency of
circumstances.
When the course of a ball is such as to create risk of secondary
hemorrhage, on the loosening of the sloughs, that is, between the sixth
and fourteenth days, the surgeon should be upon his guard, and direct
the patient to be at this time closely watched, and preparation made for
the immediate suppression of the bleeding.
The first dressings should not be removed before the fourth or fifth day,
unless tight bandages, stiffened with blood, cover and conceal the parts,
when, perhaps, the sooner they are removed the better. With this view,
they should be moistened with warm water, and cut off with as little dis-
turbance of the wound as possible. About the fourth or fifth day will
be quite early enough for the removal of the rest of the dressings, unless
excessive pain, or sudden hemorrhage, should render an earlier change
of them proper. Dupuytren used not to remove the first dressings before
the fifth, sixth, or seventh day; but, in order to prevent unpleasant effluvia,
he took away the outer pieces sooner, and wetted the remainder with a
solution of the chloride of soda.
When gunshot wounds suppurate or slough to any great extent, they
are to be treated according to the rules laid down with reference to
abscesses and mortification.
When complicated with hospital gangrene, we are to adopt those mea-
sures, which were advised in the observations delivered on that formid-
able disease. Baron Dupuytren's report of the effect of the chlorides
upon it does not agree with that of Lisfranc ; for he finds them ineffectual
in stopping it, and a solution of mercury in nitric acid is what he prefers.
When complicated with broken bones, gunshot wounds are to be treated
on principles applicable to compound fractures.
When complicated with tetanus, the practice should be regulated by
considerations which will be noticed hereafter.
Sometimes, after a bad gunshot wound, particularly one attended with
a shattered state of the bones, has suppurated, the case, instead of taking
a favourable course, proceeds from bad to worse ; large, extensive, and
repeated abscesses form ; the matter spreads, not only under the integu-
ments, but between the muscles and under the fascia. One collection of
matter is no sooner discharged, than another presents itself. Fragments
CASES DEMANDING IMMEDIATE AMPUTATION. 181
of bone keep up incessant irritation ; the fracture sometimes unites par-
tially, sometimes not at all ; the bone may be attacked by necrosis ; the
patient has hectic symptoms in an urgent shape, profuse night sweats, a
small quick pulse from 130 to 160; no appetite, little sleep, and great ema-
ciation, with perhaps frequent vomiting, or colliquative diarrhoea. Under
such circumstances, a further perseverance in the attempt to save the limb
would only terminate in the loss of the patient's life. On the contrary,
by removing the limb, the constitutional derangement may often be
checked, and the patient saved.
Amputation may also become indispensable, secondarily, in conse-
quence of traumatic gangrene, which so often . follows gunshot injuries,
complicated with fracture or a wound of an arterial trunk. Here the
practical rules are, not to defer the operation till the red line of demarca-
tion has been formed, and to make the incision in sound textures.
Amputation may also be required, secondarily, when a gunshot wound
of an alarming kind becomes complicated with secondary hemorrhage,
not admitting of suppression by the ligature of a principal artery at some
distance from the wound itself; for, besides the difficulty of finding the
bleeding part of the artery in the midst of the diseased textures, the
sloughs, matter, and blood around it, the ligature, if the vessel should
admit of being tied, would be of no avail, in consequence of the artery
itself being in a diseased state.
CASES DEMANDING AMPUTATION DIRECTLY, OR SOON AFTER THEIR
OCCURRENCE.
1. When a considerable portion of the whole thickness of a limb has
been carried away by a cannon-ball, or the explosion of a bomb. Ex-
ceptions occur where the ball has taken off the arm close to the shoulder
or at the joint itself, together with the acromion or coracoid process,
and spine of the scapula. Here no parts would be left, on which the
operation could be done. The same remark applies to other examples,
in which the thigh is torn off at the hip. In such cases, we should free
the wound from all extraneous substances, whether splinters of bone
or other things, and stop bleeding if it be going on, or, even if it be not,
we should imitate Dupuytren, and tie the exposed mouth of the principal
artery, in order to prevent it. Yet it is impossible to extricate the patient
from many serious dangers, as those of the shock of such an injury on
the system ; or, if he get over these first perils, he will still have to en-
counter all those of violent inflammation, and profuse suppuration ; the
difficulty of healing the stump ; and the risk of inflammation of internal
organs ; an event as formidable as it is common.
2. When bones are much shattered, and the soft parts severely con-
tused, lacerated, or torn away. If a bone were fractured only in one or
two places, the splinters not being numerous, the chief vessels and nerves
not being touched, and the soft parts not severely injured, ay attempt
ought to be made to save the limb ; but, in the contrary circumstances,
amputation should be performed without delay. These are, however, to
be received as general rules, founded on the average of the terminations
of numerous cases ; and not either upon the absolute impossibility of cure,
or the certainty of recovery of each description of injury in individual
examples. Many patients with wounded limbs, condemned to operation
by the nature of the injuries, refuse to submit to amputation, and yet
recover. Still, they frequently gain little advantage from such refusal ;
N 3
182 CASES DEMANDING IMMEDIATE AMPUTATION.
for, after having passed through all risks, long protracted hectic disorder,
and undergone innumerable painful operations for the discharge of ab-
scesses, and the extraction of broken or dead fragments of bone, they
usually remain with a broken constitution, a shortened mutilated limb,,
deep adherent cicatrices, and a member that is only an incumbrance.
3. When a cannon-ball tears away a great mass of the soft parts,
leaving the rest badly torn and contused, the principal artery or arteries
being at the same time wounded, though the bone itself may not be
broken, immediate amputation is necessary.
4. An injury of the femoral artery, with fracture of the thigh bone, is
another case for immediate amputation. However, Baron Dupuytren
does not admit the necessity for the operation when the femoral artery
is wounded, unless the fracture be a severe one. If secondary hemor-
rhage were to occur, this event, together with the diseased state of the
limb in such stage of the case, would generally call for amputation.
5. If the main artery and vein of a limb be both injured by gunshot,
the safest practice is to amputate without delay for the prevention of
mortification and its usual fatal result.
6. Fractures from grapeshot wounds, with laceration of the muscles,
and one or more of the principal nerves, without injury of the main
artery, is a case for prompt amputation, as is exemplified when a cannon
shot strikes the thigh, and carries away the muscles of the posterior part
of the limb, together with the great sciatic nerve. The mere division of
this nerve, however, without extensive laceration of the soft parts, would
not require amputation. Cases are recorded where a gunshot injury of
a nerve has led to the bulbous enlargement of the end of it, productive
of severe suffering on the slightest action of the muscles, or pressure,
and requiring the tumour to be removed. Mr. Alcock gives one example,
in which such change took place in the anterior tibial nerve, and where
relief was obtained by excision of the bulbous swelling.
7. Certain injuries, formerly termed wind contusions, where the muscles,
bones, vessels, and other textures are crushed, though concealed under
the skin which remains entire. Here an incision is first to be made for
the purpose of ascertaining the reality of the hidden mischief. When
the bones are comminuted, the muscles disorganised, and the large vessels
wounded, amputation is indispensable. But, if the vessels and bones
have escaped, and the muscles are the parts chiefly injured, amputation
may be deferred.
8. Gunshot wounds of the large joints, especially of the knee, are
universally recognised as producing the necessity for amputation. Ampu-
tation is necessary when a ball has passed through the spongy part of a
bone, near a large joint, or through the joint itself, especially when the
synovial membrane is extensively opened, and the comminution consider-
able. However, in fractures of the head and neck of the humerus,
with not too extensive injury of the soft parts, extraction of the broken
part of the bone is preferable to amputation.
9. Gunshot fractures of the two upper thirds of the thigh bone, or of
its neck, are generally deemed proper cases for immediate amputation,
or, more correctly speaking, as soon as the patient has rallied from the
faintness or depression often caused by the shock of such an accident.
Fractures of the lower third is a disputed case, unless much comminuted,
and the soft parts are severely lacerated.
10. A ball lodged in the articular head of the bone, or so placed in a
POISONED WOUNDS. 185
joint as not to admit of extraction. Perhaps, in some cases of the first
kind,, it would be better to remove the head of the bone. The excision
of the elbow joint, if much shattered, is a justifiable and often successful
proceeding, and, if adopted without delay, may be the means of saving
the limb. The excision of the knee, I regard, under any circumstances,
as an unwarrantable measure.
11. Fractures of the patella, unless accompanied by great comminu-
tion, or a large opening in the synovial membrane, will admit of delay.
12. Injuries of the forearm by a musket-ball, however severe, rarely
forbid the attempt to preserve the limb ; and, if amputation become
necessary, it may be performed after the chance of saving the limb has
been taken. These remarks apply even to badly comminuted fractures
of both radius and ulna.
13. Extensive denudation and concussion of a bone by a small cannon-
shot, or piece of bomb-shell. In this case, the medullary texture suffers
injury, and the muscles are contused and lacerated, the limb insensible,
the foot cold. Here mortification will be sure to follow, unless antici-
pated by the operation. This case is chiefly seen in the leg, where the
tibia is superficial.
14. When two limbs are injured in a severe and irrecoverable degree,
both ought to be amputated without delay. Convalescents from gunshot
wounds should return to a full diet, and the use of wine and beer, very
gradually. For some time after the cure, there is a strong tendency to
inflammation of internal organs. According to Dupuytren, this fact was
particularly exemplified a few years ago, at the Convalescent Hospital,
at St. Cloud, near Paris, where, in consequence of the wounded receiving
too liberal a supply of delicacies, wine, &c. from charitable and patriotic
individuals, many of them, after having got through the danger of severe
forms of gunshot violence, fell victims to inflammations of the viscera.
POISONED WOUNDS.
As poisoned weapons are not made use of by civilised nations, and
venomous animals are not numerous in this country, our opportunities of
seeing poisoned wounds are but limited. Still, the bites and stings of
insects, the pricks and cuts received in dissection, the bites of adders,
and those of rabid dogs, cats, foxes, and, on the continent, of wolves
also, form together a subject highly interesting.
With regard to the stings of wasps, bees, and hornets, they may bring
on severe consequences in unfavourable states of the constitution.
Professor Gibson gives the case of an elderly lady, who died in a quarter
of an hour from the indisposition occasioned by the sting of a wasp.
Although the sting of a single bee or wasp is not generally of much
consequence, fatal effects have often been known to result from an
attack of a swarm of them. A sting on the eye is also alleged to be
productive of a most violent form of ophthalmia. Inadvertently swallow-
ing a bee or wasp that happens to be in beer, or other fluid, may prove
fatal. Dr. Gibson has recorded an instance of death from a bee being
accidentally swallowed that happened to be in a piece of honeycomb.
The recovery of one person is mentioned in the Diet, des Sciences
He'd, who took directly after the accident a copious draught of common
salt and water.
"The bite of the mosquito sometimes leads to troublesome ulceration.
Dr. Dorsey records one example of fatal gangrene from such a cause.
Spiders have long been considered as venomous ; but the opinion, I
N 4
184? POISONED WOUNDS.
believe, is only correct in relation to some of them ; nor can any of
them be said to produce the severe effects formerly ascribed to them.
Even the bite of the tarantula, common about Naples, has not the
aggravated consequences often depicted. In Martinique, as we learn
from Moreau de Jonnes, there is an enormous spider that destroys small
birds and reptiles.
The scorpion is another venomous insect of warm climates. The
largest, the scorpio afer, inhabits India, Persia, and Africa. Its poison
is contained in a reservoir near the tail, and poured out of two minute
apertures at the extremity of the sting. The late Mr. Allan had oppor-
tunities of observing the effects of its bite on the crew of La Diane, a
French frigate, taken into our service, and abounding with scorpions,
which, though quiet and torpid in our climate, became very active and
troublesome on the vessel returning to a warm station. The sting was
always followed by violent and extensive inflammation, swelling, and
pain ; but Mr. Allan never knew any dangerous constitutional disturbance
excited.
The best application to the stings of bees and wasps, and the bites of
gnats and mosquitoes, are a solution of muriate of soda, the liq. ammon.
subcarbonatis, a solution of acetate of lead in rose water, or tincture of
opium. Were the stings numerous, bleeding, purging, and a strict anti-
phlogistic regimen would be necessary.
In Morocco, where scorpions are numerous, the favourite antidote is
olive oil. A ligature is first applied above the part : the sting is then cau-
terised and rubbed with the oil. If I were to meet with such a case,
I should be inclined to apply a cupping-glass ; for Sir David Barry's expe-
riments prove that, when the pressure of the atmosphere is thus removed,
absorption is immediately stopped.
Bites of venomous snakes. In Europe, the adder, or viper, is the most
venomous reptile. Its poison is lodged in capsules at the roots of two
moveable fangs in the upper jaw, which, when the animal bites, are directed
downwards, and the poison is then compressed out of the poison cysts,
and passes along grooves in the fangs into the wound. In this country,
the bite of an adder rarely proves fatal to an adult. According to
Fontana, the danger of the bite is generally in proportion to the smalness
of the animal bitten. Hence children suffer greater indisposition, and
more frequently die from the injury, than grown-up persons. The poison
of vipers operates also with unusual peril on animals already weakened
by disease. It is most active in hot weather, has greater effect when the
circulation is quick, or when the bite happens through a vein, or in a part
near the source of circulation.
Much will also depend upon the quantity of poison in the capsules, and
the depth to which the fangs have penetrated. The strength of the venom
is particularly great in the procreating season of the reptile.
The effects of the bites of all venomous snakes take place with great
rapidity. An acute pain and burning sensation are instantly caused by
the bite of a common adder, followed by rapid swelling, and a livid dis-
colouration of the part. These effects extend to a considerable distance,
indeed frequently to the whole limb, on which livid spots, or an appear-
ance of ecchymosis takes place. This rapid swelling is caused by the
effusion of serum into the cellular tissue, like what occurs in diffuse in-
flammation of that texture from other causes. The constitutional effects
are, giddiness, extreme prostration of strength, depression of spirits, faint-
ness, syncope, small quick irregular pulse, difficulty of respiration, profuse,
POISONED WOUNDS* 185
cold, clammy sweats, confusion of vision, headach, vomiting of bilious
matter, a general yellow tinge of skin, and vast pain about the navel.
When the case ends fatally, a rapid and extensive gangrenous affection of
the cellular tissue is usually noticed.
In the treatment of the bites of venomous makes, two indications present
themselves : —
1. To endeavour to prevent the passage of the poison into the
system.
2. To resist and lessen its operation on the constitution after it has
entered the circulation.
For fulfilling the first indication, the following means are proposed : —
1. Excision of the bitten part, or destroying it with caustic. The bite
of an adder, however, rarely produces effects severe enough to justify such
proceedings, and, unless the excision were to go beyond the depth of the
fang, it would be likely, as Sir D. Barry conceives, to do harm by expos-
ing the mouths of larger vessels to atmospheric pressure.
2. The application of a ligature or tourniquet.
3. Suction. In Sir D. Barry's experiments, several dogs and rabbits
were bitten by vipers. To the bites of some he applied cupping-glasses ;
to the bites of others he did nothing. Now, although the animals left to
their fate did not ultimately perish, yet they were invariably attacked
with convulsions and stupor, and the dogs with vomiting ; whereas, when
the cupping-glass was applied for half an hour to those which had been
bitten by one, or even two or three, vipers, they suffered no bad symp-
toms whatsoever, and exhibited no mark of constitutional poisoning.
Sir D. Barry is not an advocate for scarifications. The ligature, and
simple washing of the part, and exclusion of it from the air, are the only
measures which he approves of before the cupping-glass is applied ; and
even then only when suction, or the action of the cupping-glass cannot be
immediately obtained. When a cupping-glass has been applied an hour,
the contents of all the vessels will have taken a retrograde course ;
a stagnation of fluids will be the consequence, and the absorbent faculty
of the cupped surface suspended. Thus, according to Sir David Barry,
by letting the first cupping precede excision, we may remove some of the
poison, and lessen the chance of the remainder being taken into the
system.
4. The next proceeding is excision, which is to be followed by a second
cupping. It may not, indeed, be necessary to employ excision at all for
the bite of an adder. What I am now explaining relates rather to the
severer descriptions of poisoned wounds, and especially to the best
mode of preventing the fatal consequences of the bite of a rabid dog, cat,
or fox.
5. In such cases, the part having been cupped, cut out, and cupped
again, the cautery, or a powerful caustic, which will hermetically
close the mouths of the vessels, may be employed, as advised by Sir
David Barry.
6. Specific effects have been ascribed to certain local applications in
rendering the poison inert ; as, for instance, to olive oil, to the liq. ammo-
niae, and eau de luce. Their inefficacy was, however, completely demon-
strated in France, by Hunaud and Geoffroi.
With regard to constitutional treatment) ammonia and arsenic have the
strongest evidence in their favour as internal medicines. L'eau de luce,
once regarded as a specific, consists of ammonia with a small proportion
of amber, and therefore resembles the spir. ammon. succinatus. Ammonia
186 POISONED WOUNDS.
may act usefully in preventing syncope and depression of the vital powers,
but is not a specific. Persons under the influence of the poison of ser-
pents, or affected with hydrophobia, or tetanus, are capable of bearing
extraordinary doses of this and other powerful medicines, such as opium
and arsenic ; which last has, perhaps, more evidence in its favour, as an
antidote for the bites of snakes, than any other article. The doses of liq.
arsenicalis, given every half hour, by Mr. Ireland, to soldiers in the West
Indies, bitten by the coluber carinatus, contained one grain of arsenic.
He combined with this treatment purgative clysters, and as soon as
purging and griping commenced, the arsenic was discontinued.
In South America, the plant Mikania guaco has high reputation for its
virtues in these cases, though probably its power is exaggerated ; and, in
fact, there are many causes of deception. The bites of some snakes get
well without any particular medicines. The bites of serpents in general
are very unequal in their effects, according to the season of the year, the
temperature of the air, the empty or full state of the poison bags, and the
strength, health, and size of the animal bitten. Instances occur, both
among the Indians and the white people, who inhabit the mountainous
and thinly settled parts of the American states, of almost instantaneous
death from the bite of the rattlesnake. On the other hand, many others
undergo very trivial indisposition from a similar injury. The entrance of
a fang into a vein is stated to be inevitably and quickly fatal. There
was a man, a few years ago, in St. George's Hospital, who had been bitten
by a rattlesnake. He was not destroyed so quickly as some accounts of
the rattlesnake would lead us to suppose. There were two wounds on
the back of first phalanx of thumb, and another on the forefinger. The
hand soon began to swell, and, in ten or eleven hours, the whole limb,
armpit., and shoulder were very cold and enormously swollen. All the
surface of the body was indeed remarkably cold. At this period, the
mind was collected; but, immediately after the accident, there had been
some incoherence. From the armpit, the swelling extended down the
side, with extravasation of blood in the loins, giving them a mottled
appearance.
The temperature of the body now rose, repeated faintings ensued, vesi-
cations made their appearance in several places, a large abscess formed
on the outside of the elbow, and discharged half a pint of reddish matter.
Sloughing in the axilla, on the forefinger, and at a few other points, ensued ;
and death took place on the eighteenth day, when the original bites had
entirely healed. The body, on dissection, exhibited no remarkable morbid
changes, except the mischief in the arm.
Of punctures and cuts received in dissection. Whether the bad con-
sequences resulting from these injuries should be referred to the in-
sertion of a poisonous matter in the part, or to the effect of the simple
mechanical injury in particular states of the constitution, is a question yet
unsettled. The common belief is, that such consequences, at all events,
sometimes depend upon the introduction of a poisonous or deleterious
principle into the wounded part, and this view I am disposed to deem
correct, for the following reasons : —
1. If the severe effects, occasionally following cuts and punctures,
received in dissection, were referable to the mere mechanical injury, how
does it happen that they are noticed with such extraordinary frequency
when the ringers or hands are wounded, and this sometimes in the
slightest manner, in the examination of the bodies of persons who die
of peritonitis, and especially of puerperal peritonitis ? Why also should
POISONED WOUNDS. 187
such effects be more common after pricks or cuts, met with in the open-
ing of recent bodies, than of those which are more advanced in their
decomposition ? These circumstances are generally admitted to be
facts, and, as they are mentioned as such by those who dispute the doc-
trine of poison, it is rather extraordinary that their direct tendency to
prove the agency of a virus should have been overlooked by them in
all their reasoning upon the subject. <f Some dead animal substances,"
observes Dr. Macartney, " are more likely to communicate this dangerous
disease than others. The brain, in the recently dead state, is extremely
apt to produce it, even when no wound is received. The sero-purulent
fluid, found in the large cavities after death (if no means of prevention
be employed) seldom fails to infect persons, and the most dangerous
animal fluid is that contained in the cavity of the abdomen after puer-
peral peritonitis, or the serum found in parts which have suffered dif-
fused or gangrenous inflammation. The white cancer of the liver, and
the substance of medullary tumours, are found to be very irritating when
merely applied to the hands, without a breach of surface." (Op. cit.
p. 106.)
On the other hand, we sometimes see apparently the same conse-
quences brought on in particular constitutions by cuts, punctures, or
other slight mechanical injuries, which cannot possibly be complicated
with the lodgment or operation of any poisonous matter. It is also a
fact, that, notwithstanding the numerous pricks and scratches of the
hand, received in dissection, the production of any severe effects on the
part and constitution is restricted to a very reduced proportion of such
cases. It might also be urged, as an argument against the doctrine of
poison, that the general indisposition is always in proportion to the ex-
tent of the local mischief; and the disease does not exhibit any deter-
minate character, such as marks the effects arising from other poisons.
Dr. Macartney believes, that the spring season disposes persons to
this species of inflammation ; and that the state of the constitution gives
a strong tendency to be affected by inoculation with dead animal matter.
<f When the general health is injured by intemperance, anxiety, or
fatigue, even common wounds will be followed by consequences not very
dissimilar to those attending the introduction of dead animal fluids. From
observing this fact, some persons have been induced to deny, that a
poisonous quality exists in dead animal matter, and have ascribed the
consequences of wounds received in dissecting to the nature of the
wound itself, which is often punctured or lacerated. This opinion, Dr.
Macartney argues, is perfectly disproved by the same irritation being
communicated on an unbroken surface, and by the security derived from
using the solution of alum, even when there is no wound."
The bad consequences, occasionally following pricks or cuts received
in dissection, begin with uneasiness and festering of the wounded part ;
considerable pain and irritation in the course of the absorbents : swelling
and suppuration of the lymphatic glands at the inner side of the biceps
or in the axilla ; and more or less fever and constitutional disturbance.
In some instances, the pulse becomes greatly accelerated, but weak, and
a sense of unaccountable distress and anxiety is felt, and expressed in
the countenance. Often there is extreme prostration of strength, with a
furred tongue, and serious derangement of the functions of the stomach,
bowels, and liver. In vbad cases, the cellular tissue becomes immensely
distended with serum, and this not only in the limb, but from the axilla
over a large portion of the side of the chest, and even of the abdomen ;
188 POISONED WOUNDS.
the parts affected exhibiting the general appearance of phlegmonous
erysipelas, or the skin being paler and colder, like what happens in diffuse
inflammation of the cellular tissue. Sometimes, as Dr. Macartney has
correctly described, inflammations arise, one after another, in parts remote
from the original wound, and are unbounded by the effusion of fibrine. Pus
is not always formed in these tumours, and, if opened on the supposition
of their being abscesses, they are often found to contain only a bloody
serum. Yet, in a large proportion of the cases which I have attended,
purulent matter was formed and discharged. A very common place for
such collections of fluid is under the great pectoral muscle, and, as
Dr. Macartney remarks, out of the course of the absorbents leading from
the hand to the subclavian vein. In some instances, vesicles or pocks
arise in the neighbourhood of the original injury. If the patient escape
with his life, the health frequently continues in a shattered state, and
anomalous complaints recur from time to time for several months * ; and,
as I have known, for two or three years afterwards.
Practitioners differ widely about the right treatment. One party, be-
lieving in the presence of a virulent matter, advocate the plan of applying
nitrate of silver, caustic potash, liquor ammoniae, nitric acid, or liquid
muriate of antimony, to the puncture or cut, as soon as it begins to be
troublesome ; and, instead of antiphlogistic treatment, recommend a
generous diet, tonics, wine, and other cordials, the bowels being merely
regulated with aperient medicines.
Another party, doubting the existence and operation of any poison
in the part, confide principally in antiphlogistic treatment, discharging
the matter early, applying cold lotions, or poultices, to the part itself,
with numerous leeches, and employing copious and repeated venesection,
cold washes to the head, purgatives, and sometimes opium to tranquillise
the excitement of the system. The advice, which has usually been
offered by me to students, is, that the wound should be well sucked in
the first instance, the nitrate of silver then applied to it, the hand
covered with a cold evaporating lotion, and the limb kept quiet in a sling.
In the beginning, I believe, that antiphlogistic treatment should gener-
ally be preferred; but that when phlegmonous erysipelas, or diffuse
inflammation of the cellular tissue, or abscesses, come on, the case should
be treated according to rules explained in speaking of those disorders.
Dr. Macartney states, that, during the last fifteen years that he held
the professorship of anatomy in the Dublin university, no severe disease
occurred from wounds received in dissection, when the proper means of
prevention had been employed. These consisted in immediately washing
the wounded part, and afterwards keeping it wet for a few hours with a
solution of alum in water.
Bite of a rabid animal. (Rabies canina. Hydrophobia.) The bite of
a mad dog, or of certain other rabid animals, is the most dangerous kind
of poisoned wound met with in this country, because it is apt to be fol-
lowed by one of the most uncontrollable and rapidly fatal disorders to
which human nature is liable.
All examples of hydrophobia admit of being divided into two classes :
— first, those which cannot be ascribed to the bite of a rabid animal, or
to the application of its saliva to a wound or an abraded surface ; and,
secondly, all cases which are produced either by the insertion of the saliva
into a wound, or its application to an abraded surface.
* See Macartney on Inflammation, p. 105.
POISONED WOUNDS. 189
The first class of hydrophobia diseases is not strictly within my pro-
vince. I may mention, however, that it comprises symptomatic, and
idiophatic or spontaneous, cases ; the first division being merely a nervous
affection, accompanying certain inflammatory and febrile disorders, in
which a considerable dread of water is occasionally manifested by the
patient. As for the real existence of spontaneous or idiopathic hydro-
phobia, this is a subject of dispute, and I think there is ample room for
doubting the correctness of the doctrine, since the histories of most of
the persons, from whose cases the inference of the existence of such a
disease is drawn, cannot be depended upon. They were, in short, gener-
ally drunken irregular characters, and in the habit of lying about the
streets in the night-time. Now persons of this description might have
been bitten by rabid dogs, or some abraded part of the skin might have
been licked by dogs labouring under rabies, though not known to be
indisposed ; and hence no recollection of the circumstance might have
been retained. Dogs, in the early stages of rabies, are seldom prevented
from going about as usual, and are even domesticated in families, and
fondled by children and others, whose hands and faces they are permitted
to lick. Now, should there be a slight pimple, or abrasion of the skin,
this custom might lead to the communication of hydrophobia. But,
leaving the question about spontaneous hydrophobia to be settled by phy-
sicians, I proceed to the consideration of the form of the disorder, which
originates from the introduction of a specific poison into a wound, or its
application to an abraded part of the skin, which poison is contained in
the saliva of a rabid dog, cat, fox, or, as happens on the Continent, in that
of a rabid wolf.
It is sometimes asserted, that hydrophobia always originates in animals
of the dog kind, and in no other animals, and especially that it never
originates in animals' of the cat species, though communicable to them
by the bite of a rabid dog. But this is an obscure point, about which as
much dispute prevails as about the spontaneous origin of hydrophobia in
the human subject. The indisposition may, however, be certainly trans-
mitted from these animals, not only to the human subject, but to some
other quadrupeds, and, as is alleged, even to birds, as, for instance, to
the common fowl. Although animals of the dog and cat kind can com-
municate the disease to some other animals, it is not positively known,
whether the herbiverouS tribe can do so ; though one case is related, in
Ashburner's Essay on Hydrophobia, where a fowl became rabid after
having been inoculated with the saliva of a rabid ox ; but I do not know
whether this statement has received any confirmation from other quarters.
In Hufeland's journal, an instance of hydrophobia that was occasioned
by the bite of a badger, is recorded. Attempts have been made to ascer-
tain whether man can propagate the disease to other animals ; but no
instance of such transmission of it was ever completely made out, until,
the year 1813, when Magendie and Breschet took some of the saliva of
a man in the last stage of hydrophobia, and inoculated a dog with it,
which became rabid on the eighteenth day after the inoculation, and bit
two other dogs, one of which became rabid, and died in thirty days. This
seems to be a strong fact in support of the opinion, that man may com-
municate the disease to other animals. There has never been an example
of any human being in the hydrophobic state imparting the disorder to
another human being, though some persons in this disease, now and then,
become so unmanageable as to bite those who are near them. I remem-
ber an instance, in St. Bartholomew's Hospital, in which a medical man
190 POISONED WOUNDS.
was bit by a patient who was labouring under hydrophobia, but no ill
consequences ensued.
The wound, occasioned by the bite of a rabid animal, is not always
followed by hydrophobia : this fact deserves particular attention, because
attempts are frequently made to convince the world, that there are certain
specifics and nostrums for the prevention of hydrophobia. Of the num-
berless persons who are bitten by dogs undoubtedly rabid, only a very
limited number suffer from hydrophobia. Dr. John Hunter, who pub-
lished an excellent paper on this subject, gives a list of twenty persons
who were bitten by the same mad dog, yet only one of the whole twenty
was afterwards attacked by the disease. According to Dr. Hamilton's
computations, it appears, on an average, that not more than one out of
every sixteen or seventeen persons, bitten by animals certainly rabid,
becomes affected. Perhaps this calculation may be below the mark ; and
it undoubtedly is so, with regard to persons bitten by rabid wolves. On
one occasion, in France, twenty-three persons were bitten by a rabid
female wolf, and thirteen of them afterwards died of hydrophobia. In
another instance, nine out of ten had a similar fate ; and in a third exam-
ple, in which twenty-four individuals were bitten by a wolf near Rochelle,
eighteen died. It seems, then, that the bites of rabid wolves are ex-
tremely dangerous ; a fact fully accounted for, as I conceive, by the
circumstance of their teeth being larger, and penetrating more deeply,
than those of the generality of dogs. The depth, extent, and situation of
the bite are evidently circumstances which must materially influence
the chance of the system becoming affected. Thus, bites on the hands or
face, which are uncovered parts, are more dangerous than bites on other
parts, which are covered by the clothes ; because, in the latter examples,
the envenomed saliva is likely to be wiped off the teeth., before they pene-
trate the body, and hence there must be less chance of its being inserted
in the wound.
Dogs appear to be more susceptible of the disease than the human
species : one rabid dog bit four persons and twelve dogs ; none of the
former were attacked with hydrophobia, although they underwent no
particular treatment, and merely had recourse to common means, which
daily experience proves to be unentitled to any confidence ; but every
one of the dogs became rabid. The term hydrophobia is scarcely appli-
cable to the disease as it presents itself in dogs ; for they can generally
lap water without difficulty, and are sometimes very greedy of it, yet
their doing go is generally fancied to amount to a satisfactory proof,
that they are exempt from the disease. Now this is a serious mistake ;
for, as I have explained, they are for the most part fond of water, and
lap it very eagerly. As for rabid wolves, when they are pursued, they
will swim across wide and rapid rivers without the least hesitation or
dread of water. Nor should it be imagined, that dogs are furious in the
beginning of the disorder : at first they are merely somewhat irritable ;
afterwards they will bite other dogs, and even men, if they happen to be in
their way ; but they will not commonly turn out of their course to do so.
Under the influence of the disease, in its early stage, the habits of a dog
undergo a considerable change ; thus he becomes fond of picking up small
objects on the ground, and will even devour his own excrement ; his voice is
altered, the tone of lift* bark is quite different from what it is in the healthy
state, being affected, indeed, as much as the voice of a cholera patient.
The same circumstance is observed in other rabid animals, especially
sheep. As for the opinion, that dogs are more subject to hydrophobia
POISONED WOUNDS. 191
in warm weather than at other times, it is a completely erroneous sup-
position ; and this is so far from being the case, that heat has no concern
in it at all ; for, in Jamaica, in some parts of which the heat is sometimes
very great, not a single instance of a mad dog occurred during the long
space of forty years. Now, as rabid dogs are occasionally met with in
winter, other credulous persons suggested another hypothesis, which was,,
that dogs became rabid at this season of the year because they could not
always get water enough, in consequence of the frozen state of the ponds ;
but one fact is sufficient to refute these idle speculations : in France, a
list was kept of all the dogs which became rabid in a certain year ; and
it was found, that the smallest number occurred in January and August,
one the coldest, the other the hottest, month in the year. I think, then,
we can attach no value to any explanations of the cause of the origin of
rabies in dogs, founded upon the influence of either heat or cold.
In the human race, the interval between the bite and the supervention
of the disease is different in different examples. The majority of indi-
viduals are attacked at some period between the thirtieth and fortieth
days ; and the longer a person continues well after the latter period, the
less chance is there of his ever suffering from the disease at all. From a
list kept of a hundred and thirty-one cases, it appears that no person was
affected before the eleventh day after the bite, and only three before the
eighteenth. A few cases are reported by writers, where the interval be-
tween the period of the bite and the commencement of hydrophobia was
as long as ten, twelve, twenty, and even thirty years ; but these state-
ments do not gain much belief, and few cautious reasoners will venture
to give credit to any history, which represents the interval as having
exceeded a year and a half. The wound, inflicted by the bite of a rabid
animal, generally heals as readily as other common wounds do ; and,
indeed,, it is usually healed long before the hydrophobic symptoms com-
mence, which do not frequently come on in less than five or six weeks
after the bite. The wound will, of course, be mostly well before that
period. When, however, the constitutional symptoms do begin before
the wound is healed, the bitten part, instead of presenting healthy granu-
lations and secreting good pus, has an inflamed and sloughy appearance,
and the discharge, which is scanty, consists of an ill-conditioned thin
sanious matter. At some indefinite period after the receipt of the bite,
and occasionally long after it has healed, the patient feels a sharp pain in
the part which was bitten ; and such pain, if the wound should have been
in the hand, extends particularly to the trapezius muscle, or to the side
of the neck. In the meanwhile, the cicatrix, if the part should have
healed, swells, inflames, and sometimes suppurates, and discharges an
ichorous fluid ; but, in other instances, the part may not inflame at all,
and the indisposition may come on without the patient experiencing any
inconvenience in the situation of the previous bite. In different consti-
tutions, the other symptoms also vary: in the beginning of the Jndispo-
sition,, or the first stage, there is generally great depression of the spirits,
and an indescribable anxiety ; sometimes a chill or rigour is one of the
earliest occurrences ; frequently the sleep is disturbed by frightful dreams
or spasmodic twitches ; the pulse is more frequent and strong than in
health, and the nervous system more susceptible of impressions. In fact,
all the external senses become more acute ; the eyes, the pupils of which
are full and open, cannot endure the light ; the person courts the shade,
or even conceals himself in a dark place ; the most trivial noises agitate
him ; and in this first stage, though the thirst is increased, the appetite is
192 POISONED WOUNDS.
lost. In some patients, such is the augmentation of sensibility on the
surface of their bodies, that we cannot even touch their hair, without
producing a violent convulsive agitation of the system. This fact was
exemplified in one case seen by Magendie. The duration of the first
stage is sometimes very short, and the form of it such as not always to
raise a suspicion of the commencement of this terrible and fatal com-
plaint. Some patients are indisposed not more than a day or two, but
others five or six days, previously to the second stage, which commences
with a manifestation of a dread of liquids. The sight of water, or any
attempt to drink fluids, now brings on violent convulsive agitation of the
muscular system, and such a feeling of suffocation as those endued with
the greatest fortitude cannot endure. These paroxysms of violent con-
vulsive disturbance of the muscles, and the sense of suffocation, are cer-
tainly the most prominent effects of the attempt to swallow, or even look
at, liquids ; but they may also be excited in hydrophobic patients by other
causes, such as the opening or shutting of a window or door, a current of
air, a bright light, or the glare of a mirror. Some patients, though not able
to swallow liquids, will swallow juicy fruits, if their outer surface be made
quite dry before being offered to them. The influence of different sounds
on hydrophobic patients is very curious : some of these unfortunate indi-
viduals can bear a great deal of noise, without inconvenience ; but, if the
noise happen to be of avkind which is associated with the idea of fluids,
then excessive agitation is produced, and paroxysms of the greatest suf-
fering are brought on. Few hydrophobic patients can bear the noise of
a pump, or the clatter of cups and saucers, or the sound of earthenware.
When patients, by an extraordinary effort, do get any fluid down into
the stomach, it is soon ejected again, together with a copious quantity of
mucus and a greenish fluid. Another very distressing symptom is the
production of a thick ropy slime about the fauces and throat, which is so
tenacious as to be compared by the patient to birdlime: his constant en-
deavours to free his mouth and throat from this oppressive secretion keep
his jaws in continual motion, and, as soon as he gets rid of one portion of
it, another is formed, so that he has no respite from his sufferings. In
the latter stage of hydrophobia, the pulse is hurried, the respiration la-
borious, the countenance anxious, and the features horribly contorted.
Sometimes the patient is really furious and uncontrollable, though most
frequently it is otherwise. He may be so unruly as to bite himself and
others who are near him ; but mostly he is quite rational and governable.
A good deal of pain is generally felt in the epigastrium and chest j the
patient is always constipated ; but the urine is copious and high coloured.
With regard to the usual period of death from hydrophobia, this is a
point particularly deserving of attention, because the period of the dis-
order, at which death occurs, is one criterion between hydrophobia and
some other affections, which are occasionally confounded with it. The
patient seldom lives longer than four or six days from the commencement
of the hydrophobic stage, and then he is either carried off by a general
and violent convulsion, or dies quietly in a state of complete exhaustion.
The most common period of death is from two to three days from the
time when the dread of fluids is first decidedly manifested. I have
heard of a case that proved fatal in twenty-four hours : but the patient
was a child.
Between hydrophobia and tetanus, the following considerations will
serve as a criterion. Tetanus always begins with a spasm of the muscles of
the jaw, which remains firmly fixed ; in hydrophobia, on the contrary, the
POISONED WOUNDS. 193
jaw is constantly in motion, from the incessant efforts of the patient to
get rid of thatfropy viscid secretion to which I have already referred.
In hydrophobia, the muscles are not constantly rigid ; they are some-
times relaxed ; but, in tetanus, they are incessantly hard and rigid ; the
spasms may be, and indeed are, periodically increased in violence ; but
the muscles affected are never entirely relaxed.
In tetanus, though there may be difficulty of deglutition,, there is rarely
a positive aversion to fluids, or a dread of them, and the patient will
remain a long time in a bath without any inconvenience ; this is not the
case in hydrophobia, — the very idea of being put into a bath would ex-
cite such commotion in the patient, as might probably soon destroy him.
The paroxysms of tetanus are neither excited nor increased by light ;
neither are they affected by the noise or sight of water ; but those of
hydrophobia are violently increased by causes of this description.
Tetanus mostly comes on soon after the infliction of the wound, that is
to say, within a few days ; but hydrophobia does not usually begin until
a more considerable time has elapsed from the period of the bite.
Then, tetanus will come on after any kind of wound, — even after a
surgical operation ; but, as true hydrophobia can only be produced by
the application of the saliva of a rabid animal to an abrasion or wound,
it must have been preceded by the bite of such an animal, or by the ap-
plication of its saliva to an abraded portion of the surface of the body.
In the examination of persons who have died of hydrophobia, in-
flammation may generally be traced in some part of the alimentary
canal, in the mucous membrane of the pharynx, oesophagus, stomach, or
intestines; indeed, the mucous texture of these viscera may not only
exhibit traces of inflammation, but of what almost amounts to gangrene.
Marks of inflammation are also frequently discovered in the respiratory
organs, the mucous membrane of the larynx, trachea, or bronchi. In
some instances, there are appearances of inflammation about the medulla
spinalis, increased vascularity, a thickened state of its membranes, and an
enlarged tortuous state of the veins, running in the direction of the me-
dulla itself. In the museum of University College is the stomach
of a person who died of hydrophobia ; it has been turned inside out
and dried, and put into spirits ; an increase of vascularity is very per-
ceptible in it, and, about the lesser curvature, a cluster or chain of en-
larged glands.
The poison of hydrophobia is generally believed to be contained in
the saliva of a rabid animal ; but, in consequence of the salivary glands
not appearing to undergo any structural change, M. Trolliet, who wrote
a good account of the disease a few years ago, brought forward the
doctrine, that the secretion, with which the hydrophobic poison is really
blended, is the mucus of the respiratory organs. He argued, that, as
traces of inflammation existed in the lungs, and in the mucous membrane
of the air passages, and nothing wrong could be detected about the
salivary glands, his view must be correct. Trolliet's observations^)!! this
point, however, gained but few converts, and it was soon ascertained,
that vestiges of inflammation about the mucous membrane of the respi-
ratory organs in rabid animals was far from being a constant occur-
rence ; for M. Magendie dissected several rabid sheep, in which no
traces of inflammation in any part of the organs of respiration could be
perceived. In dispelling the error, which I have now been considering,
dissections have been useful ; but, I am sorry to be obliged to confess,
that, in other respects, they have not thrown any light either on the nature
194? POISONED WOUNDS.
or the treatment of hydrophobia ; in fact, though traces of inflammation
are frequently noticed in the above-mentioned organs, they are observed
only in a certain proportion of cases* In the bodies of persons destroyed
by hydrophobia, there is no regularity in the appearance of inflammation
in any particular situations or organs, so that, when it is met with, it
seems rather as an incidental than an essential occurrence. Sometimes
the lungs are emphysematous, vesicles being produced under the pleura
pulmonalis, as is occasionally thought, by the rupture of some of the
air-cells in the violent convulsive efforts of respiration in the course of
the disease.
As hydrophobia is still regarded as an incurable disease, it must
always be an object of the highest importance to prevent its attack, or
the commencement of the symptoms. Fortunately, this may generally
be accomplished, by removing the wounded parts as speedily as possible.
When, therefore, we are called to a person, who has been bitten by a
rabid animal, or by one suspected to be in this state, we should lose no
time, and, if the operation be practicable, have immediate recourse to
the complete excision of the bitten parts. Sometimes considerable per-
plexity arises from the situation, or number of the bites ; thus., we may
meet with cases, where the parts into which the animal's teeth have
entered, are very numerous ; we may also be consulted for persons, in
whom the teeth have penetrated among the small bones of the carpus, or
tarsus, or close to a large artery. I remember an instance, in which the
bite was situated close to the radial artery. In this circumstance, ampu-
tation has been proposed; but it might perhaps be a more justifiable
plan to perform the complete excision of the bitten parts, together with
the portion of the artery that happens to be in the way, and then secure
the ends of the vessel. The excision of the bitten part is a proceeding
which should be adopted early ; for it is unquestionably the most lik*ely
means of preventing an attack of hydrophobia ; but in order to answer
this purpose, the incision must be carried deep enough. Now, it fre-
quently happens, that there is an uncertainty about the possibility of
cutting out every part reached by the animal's teeth, and on this account,
before the operation is begun, I recommend a very simple, but obviously
prudent measure to be adopted, namely, washing the wounded part well ;
we may let a stream of water fall upon it from some height, out of the
spout of a tea-kettle, or throw warm water forcibly against the part with
a syringe. Thus we may possibly wash away any virus lodged upon the
surface of the wound, or near its orifice. I recommend the plan, which
Sir David Barry advised, next to be pursued : the ablution is to be
followed by the application of a cupping glass to the part ; thus, we shall
have a chance of removing another portion of the virus, and, at all
events, we shall suspend the action of the absorbents in the part, which
action, as Sir David Barry's interesting experiments prove, cannot go on
when the atmospheric pressure is removed. Having done these things,
we should perform excision in the most complete manner possible, and
then apply the cupping-glass again. Lastly, by way of still greater
security, we may cauterise the part. Such are the most effectual plans,
which I can suggest, for preventing the absorption of the hydrophobic
poison, and, no doubt, if performed in the order I have specified, they
would rarely fail. In examples of the bites of snakes, we have not the
same opportunity of preventing the influence of the poison on the system,
because the effects of the poison take place with surprising rapidity, and,
unless we were on the spot at the moment of the bite, the system would
POISONED WOUNDS. 195
be affected before we could put the preventive means in practice ; but, in
the kind of poisoned wounds now under consideration, the virus is
slower in its operation, and hence our plans for averting its action on the
system altogether will have a better prospect of success. The interval
between the bite and the constitutional disorder being long, and the ad-
mission of the virus tardy, the doctrine is often maintained, that if exci-
sion has not been performed at first, it is still called for so long as the
constitutional derangement has not actually commenced, provided that
not more than eight or ten weeks have elapsed from the period of the
bite ; for, after the sixth week, the chances of attack lessen from day to
day. Of course, the sooner we excise the, part, the better is the chance
of preventing hydrophobia. Caustic alone should never be depended
upon ; for many instances of its failure are upon record.
For the prevention of hydrophobia, some other plans have been pro-
posed. One medicine, formerly in great repute, was the Ormskirk medi-
cine, but its reputation, at the present day,jjhas declined. The same may
be said of submersion in the sea. Some years ago, a Russian physician,
Marochetti, extolled the practice of giving copious doses of the genista
tinctoria, or butcher's brooin, and of pricking with a lancet certain small
pustules, or vesicles, which, according to his statement, form under the
tongue, between the third and ninth day after the bite. These vesicles, or
pustules, it is alleged, form near the orifices of the ducts of the submax-
illary glands. Many endeavours have been made to discover them ; but,
I believe, they have never been observed in this country. In France,
M. Magistal is said to have noticed them in several instances, and to
have tried Marochetti's plan, which failed in his hands, and is not at pre-
sent a subject of much interest with us.
The importance of preventive treatment will be duly appreciated,
when it is recollected that, after the commencement of the constitutional
symptoms, the cure of hydrophobia is so rare, that the very circumstance
of a recovery generally creates doubt about the possibility of the illness
having been true hydrophobia.
In some other cases of poisoned wounds, especially those of the bites
of certain venomous snakes, the patients will bear immense doses of the
most powerful medicines, without danger of being poisoned. The liquor
arsenicalis has been given, every half hour, in doses containing not less
than one grain of arsenic, without any deleterious effects ; the same fact
is observed in hydrophobia and also in tetanus. M. Magendie dissolved
ten grains of opium in water, and threw the solution into the venous
system, without producing any narcotic effects, or derangement of the
animal economy by the experiment ; nay, the hydrocyanic acid itself is
alleged to have been injected into the veins without the usual deleterious
consequences. Such facts are adverse to the probability of any medicine
being ever discovered capable of curing hydrophobia.
Magendie having observed in some experiments on animals, that the
injection of water into the venous system seemed to have a tranq€illising
effect on the nerves, was induced to make trial of this plan in hydro-
phobia. In one patient he threw a considerable quantity of water into
the veins during the paroxysms, so as to cause an artificial plethora, at
first with some prospect of success, for the patient became tranquil, ap-
peared for a time to be soothed, and actually lived nine days, which was
a most uncommon event, as patients generally die in forty or fifty hours,
and very few indeed live beyond the sixth day. The particulars of this
case, therefore, were no sooner made public, than they raised expecta-
o 2
196 TETANUS.
tions that a very important discovery had been made ; but subsequent
trials of the plan have not established its value, and it is now deemed of
as little use as every other scheme for the cure of this disease.
Another plan, of which the most favourable report was received from
the East Indies, was that of bleeding a patient ad deliquium. Instances
of the success of this practice are given ; but the trials, made of it in
Europe, have not confirmed its efficacy. Indeed, I cannot mention any
mode of treatment entitled to much attention, except for the purpose of
stating that it has been tried unavailingly : thus, opium has been given
in immense doses without any good effect ; and so have the acetate of
morphia and pure ammonia. Belladonna has been given by the mouth,
and injected into the veins, without any useful result. Tobacco clysters
have been employed in vain. In other examples, the parts have been
washed with oxy muriatic acid, and the same medicine has been given
internally, in the quantity of a drachm in the course of twenty-four
hours, made into pills with crumb of bread. Galvanism has been tried,
with the same result; and amongst the extraordinary schemes ventured
upon, I may notice that of endeavouring to stop the action of the hydro-
phobic poison on the system by the influence of another powerful animal
poison, such as that of the viper. On this principle, vipers have been
purposely suffered to bite the patient ; but the plan, which was tried in
Italy, had no useful result. Arsenical preparations, and the Tanjore pill,
which was once so famous in India as a means of preventing the fatal
effects of the bites of snakes, the nitrate of mercury, turpentine, and thirty
or forty other things which might be enumerated, have all been amply
tried, and found to possess no real efficacy in hydrophobia.
OF PARTICULAR DERANGEMENTS OF THE MUSCULAR AND NERVOUS
SYSTEMS FROM WOUNDS.
I have already treated of the ordinary general effects of wounds, such
as inflammation, suppuration, abscesses, and fever ; but besides these
usual events, we observe, that wounds sometimes lead to such disorder of
the animal economy, as manifestly to affect the nervous and muscular
systems in an extraordinary manner and degree. Thus, in certain indi-
viduals, a very trivial local injury — one that involves no part of import-
ance— will give rise to violent disturbance of the nervous system. Some
persons always faint on receiving a mere scratch, or the prick of a needle,
while others are seized with convulsions and vomitings from equally slight
causes. In several instances, I have seen patients die before the comple-
tion of operations which would not have been at all dangerous to the
generality of persons, or those who had the advantage of better stamina.
I have seen individuals die on the operating table, though they had not
been at all debilitated, neither had they lost much blood during the ope-
ration. Now, if such idiosyncrasies were foreseen, it would be advisable,
I think, for the surgeon to direct a dose of opium, or some cordial, to be
given before the operation.
One of the most dangerous affections of the animal economy, occa-
sionally produced by a wound, is tetanus, a disease that occurs with much
less frequency in this country and other parts of the world having a tem-
perate climate than in hot countries, where it is disposed to originate
from slight injuries. Tetanus may be defined to be a spasmodic contrac-
tion, with rigidity of the voluntary muscles. In some examples, only the
muse es of i>ne or more regions arc affected ; in others, the disorder
TETANUS. 197
extends its influence to the voluntary muscles throughout the system.
Their extraordinary contraction, rigidity, and tension may be said to be
maintained without a complete relaxation at any time, in which respect
tetanus differs from hydrophobia, as well as from ordinary spasms and
convulsions. When the muscles behind the neck and down the back are
thus stiffened and contracted, and the body drawn backwards, the disease
is called opisthotonos ; but when the action of the abdominal muscles
preponderates, so as to bend it forwards, the disorder receives the name
of emprosthotonos. According to Baron Larrey, who had many opportu-
nities of seeing the disease when he was with the French army in Egypt,
it appears that, in that country, when the wound was in the back, tetanus
commonly assumed the form of opisthotonos ; but if the wound happened
to be in the anterior part of the trunk, and tetanus followed, it was ge-
nerally in the shape of emprosthotonos. The reality of emprosthotonos
has been doubted ; but if we refer to Larrey's Memoires de Chirurgie
Militaire, we shall find that, amongst the wounded of the French army
in Egypt, this was actually the most common form of tetanus. Sir
Gilbert Blane published two cases, which agree with the Baron's state-
ment ; for, in them, the side of the body, on which the local injury was
situated, became the seat of the tetanic affection ; another variety, termed
pleurosthotonos.
Tetanus is called complete when the muscles of the body at large are
affected ; that is, when the greater number of the voluntary muscles are
spasmodically and rigidly contracted. When this is the case, the muscles
antagonise and counteract one another, and the body is not drawn more
in one direction than another. When the disease is confined to the
muscles of deglutition, and to those of the lower jaw, it receives the name
of trismus or loched-jaw.
Now, although the muscles in tetanus are in" a state of incessant con-
traction, without complete relaxation, there are certainly periodical dimi-
nutions of their rigidity. In fact, inasmuch as the spasmodic action of
these organs usually has paroxysms of increased violence, there must
be periods or intervals during which they are less severely affected ;
yet they always continue rigid and hard — there is no complete relax-
ation of them ; and the jaws being permanently closed, there is often the
greatest difficulty in administering medicines, or getting food into the
stomach.
Tetanus is divided into the traumatic kind, or that which arises from
wounds ; and into the idiopathic, or that species of tetanus which origi-
nates from other causes. Another important division of tetanus is into
acute and chronic.
The acute is exceedingly dangerous, and often fatal ; but the chronic
may frequently be cured, and, at all events, it is curable in a much greater
proportion of cases, than the acute. Traumatic tetanus often comes on
and advances to its termination in a surprisingly rapid manner. Thus, a
case is recorded of a negro in the West Indies who died of tetanus in
a quarter of an hour, from a slight scratch of the thumb ; but, in
general, its course is more gradual. It was found by the surgeons of the
British army in Spain, who saw a great deal of tetanus, that if the dis-
ease did not commence on or before the twenty-second day from the
receipt of the wound, there was little chance of its coming on at a later
period. This is an important circumstance to be remembered. In Egypt,
Baron Larrey found, that the latest period of attack was the fifteenth day
from that on which the wound happened. Traumatic tetanus frequently
o 3
198 TETANUS.
proves fatal on the second, third, and fourth day from its commencement,
but sometimes even as late as the seventeenth. I had a soldier under
my care in one of the military hospitals in Holland, who lived five weeks
after the supervention of tetanic symptoms : this was a case of chronic
tetanus, following a gunshot wound and amputation of the thigh, at Ber-
gen-op-Zoom ; and certainly it was a horrible specimen of the effects of
tetanus, for the muscles were drawn entirely away from the bone, which
was left protruding far beyond the flesh, while enormous abscesses
formed in the hollow of the stump, and made their way so extensively as
absolutely to encompass nearly the whole of the pelvis.
With regard to the symptoms of tetanus, the first thing usually noticed
is a sensation of stiffness in the neck, gradually increasing, and at length
causing pain when the head is moved. This first symptom is followed by
an uneasy feeling at the root of the tongue, with a difficulty of mastica-
tion and swallowing. When the disease has made further progress, the
attempt at deglutition is attended with violent convulsive efforts ; in par-
ticular, when the patient attempts to swallow liquids, he experiences much
inconvenience, and in consequence of the pain and severe paroxysms of
spasm which then attack him, he will sometimes manifest a strong aver-
sion to fluids, and thus his disease may bear a resemblance to hydropho-
bia. It was on this account, that I particularly adverted to the charac-
teristic differences between the two diseases. The next symptom which
the patient complains of is pain about the ensiform cartilage, or a violent
shooting pain, directed from that part towards the spine in the course of
the diaphragm. This additional grievance brings on an increase in the
violence of the spasms ; and, in particular, the muscles of the lower jaw
now contract with great power, so that the jaws remain inseparably
applied to each other. As the disease continues, there is a marked
increase in the spasmodic contractions of the diaphragm, which come on
every ten or fifteen minutes, and are succeeded by extraordinary degrees
of spasm and rigidity of the muscles of the back, and also of those of the
lower extremities. At length, the abdominal muscles begin to be affected,
and the belly feels as hard as a table : so violent is their action, that the
recti abdominis have been known to be lacerated. The spasms next ex-
tend to the muscles of the lower extremities, and even to those of the
arms ; but the muscles of the fingers usually remain undisturbed to the
last. Nor are those 'of the tongue affected till a very late stage of the
disorder ; and when this happens, the patient cannot control the motions
of that organ, so that it is frequently thrust between the teeth and terribly
lacerated. These muscular contractions are attended with the most ex-
cruciating pain during their attacks ; the pulse is contracted, hurried, and
irregular ; the respiration quick and oppressed ; but, during the remis-
sions, neither the pulse, nor the breathing, may be seriously disturbed. In
the generality of cases, the heat of the body is not increased ; the urine
is voided in small quantities, and sometimes with difficulty ; and there is
invariably obstinate constipation. As for cerebral disturbance, the
patient remains free from it till the last stage ; and, when the patient
dies, it is generally in a paroxysm of violent convulsions. The blood has
been asserted not to exhibit in tetanus the inflammatory crust, and the
crassamentum is stated to be loose; but these are points which are
variously represented by different writers.*
* " In tetanus, and where death ensues from great muscular efforts, all the blood is
'found nearly as liquid as water." — Macartney _on Inflammation, p. 124.
TETANUS. 199
Baron Larrey had to treat a case of tetanus, produced by so trivial a
cause as the irritation of a small fish-bone lodged in the throat of a French
(soldier in Egypt. In cold countries tetanus is much less frequent ; and
when we see it in this country, it is generally as a consequence of wounds,
either peculiar in their situation or in their nature, namely, they are
usually lacerated, contused, or punctured wounds in tendinous parts ;
wounds of the thumb, toes, or fingers, or deep-punctured wounds in the
sole of the foot, compound fractures, or compound dislocations of gingly-
moid joints, and especially of the thumb. These are the most common
exciting causes of traumatic tetanus, when it occurs in this country. But,
although contused and lacerated wounds of tendinous parts are those most
likely to bring it on, any description of local injuries may excite the dis-
ease ; thus, we sometimes see it caused by simple wounds in common
parts ; sometimes by wounds in a healthy healing state ; sometimes by
sloughing wounds, and the most complicated forms of local injury. I have
known it follow amputation, castration, and the removal of a diseased
breast. It has been known to originate from a burn.
Dissection has thrown no light on the nature and treatment of this
formidable complaint. Sometimes the morbid appearances bear a close
resemblance to those observed in the examination of the bodies of
persons who have died of hydrophobia. We may meet with traces of
inflammation in the pharynx and oesophagus, and in the mucous mem-
brane of the intestinal canal. In one instance, Baron Larrey noticed a
layer of coagulating lymph on the lining of the pharynx and oesophagus,
which organs were contracted in an extraordinary degree. In another
case, he found scales of osseous matter deposited on the arachnoid cover-
ing of the medulla spinalis ; but it is hardly possible that these form-
ations could have been concerned in the production of the disease, because
they must have required more time for their completion, than the sudden
origin and rapid course of the disease would have admitted. In some
examples, the coverings of the medulla spinalis are found inflamed ; and,
in others, the substance of the medulla spinalis itself is changed. Thus
in one case, examined by Dupuytren, the coverings of the medulla
spinalis exhibited marks of inflammation ; and in another, examined by
Brera, the texture of the medulla itself was altered. None of these
morbid appearances, however, are sufficiently constant to justify the
opinion of their being essentially connected either with the origin, or the
symptoms of tetanus. When the arachnoid tunic of the medulla spinalis
is inflamed, it is said that the symptoms produced are those of opistho-
tonos, or that form of tetanus which consists in so forcible an extension
of the spine, that it is bent considerably backwards.
With respect to the proximate cause of tetanus, this is a subject in-
volved in considerable obscurity. Why should a wound in one individual
produce tetanus, while a similar wound in the same part in another
individual may be followed by no serious consequences whatsoever ?
From the frequency of tetanus in warm climates, it is natural to fuppose,
that the state of the constitution is concerned in the production of the
disease ; namely, that it acts as a predisposing cause : and of this fact, I
think, there can hardly be a doubt. Yet we must not altogether exclude
local circumstances from consideration, for they seem to have their share
in the production of tetanus. If this were not the fact, we should not
observe that certain descriptions of wounds, and wounds in particular
situations, more frequently give rise to tetanus than ordinary wounds.
We must, therefore, presume, that there is something in the state of the
200 TETANUS.
wounded parts tnemselves conducive to tetanus. If it were not so, we
should not find, that lacerated and contused wounds, and injuries of ten-
dinous parts, so frequently produce it. Then, another question arises,
whether the partial division of nerves is the exciting cause of tetanus ?
Baron Larrey relates some cases in support of this doctrine ; but whether
the opinion be true or not, the fact is, that tetanic patients cannot always
be cured by making a complete division of the nerve. Mr. Listen relates
an instance, in which the branch of the median nerve distributed to the
thumb was partially divided, and in which amputation was performed, in
the hope of curing the tetanic symptoms, but without success. When
the limb was examined, the extremity of the nerve was found inflamed
and thickened. Dupuytren records another case, in which tetanus arose
from the knot of the lash of a whip being detached from it, and forced
into the ulnar nerve.
It was noticed by Baron Larrey, that when tetanus comes on, the
secretion of pus from the surface of the wound ceases, or its quality is
considerably altered ; and hence he was led to suspect, that the origin of
the disease might be, in some degree, owing to the stoppage or disturb-
ance of the process of suppuration. This induced him to try what
would be the effect of endeavouring to renew the secretion of pus. But
this stoppage of suppuration appears to me to be rather the effect of
tetanus than the cause of it : indeed, I mentioned, when on the subject
of suppuration, that all great disturbances of the constitution had im-
mense influence on the process of suppuration, as well as on the secre-
tions in general ; and it is not at all surprising therefore, that in trau-
matic tetanus we should find suppuration stopped, or the pus converted
into a scanty, dark-coloured unhealthy secretion.
With regard to the prognosis in acute traumatic tetanus, I may remark.,
that the disease generally proves fatal. Dr. Parry thought, that one cri-
terion, respecting the probable issue of the case, might be derived from
a calculation of the velocity of the circulation ; and it was his belief, that
when the pulse was not more than 100 or 110 before the fifth day, a
favourable termination might be hoped for. Then, it is remarked by men
of great experience, that if the patient live beyond the ninth day, he will
have a much better chance of recovery than he had previously.
Idiopathic tetanus is well known to be less dangerous than the symp-
tomatic or traumatic form of the disease : many cases of the former end
favourably, but the traumatic species of tetanus — that which surgeons
have to deal with — is generally fatal. It is, indeed, a form of disease,
over which the resources of medicine and surgery have much less
control.
The treatment of traumatic tetanus comprises both local and constitu-
tional measures. Local treatment seems naturally to suggest itself,
because, the disease being brought on by a wound, we must suspect that
some irritation is existing in the part, or some peculiar operation is going
on in it, which is concerned, not only in producing the disease, but in
maintaining and aggravating its symptoms. The suspicion of the disease
being dependent upon the partial division of a nerve, led to the practice
of endeavouring to detach the wounded part from all nervous communi-
cation with the sensorium. This was attempted in two ways — first by
amputation of the wounded limb. Thus Baron Larrey proposes the
following question : whether in traumatic tetanus it would not be wiser
to amputate, without delay, than to make trial of other means, which ex-
perience proves to be almost constantly unavailing ? The same surgeon
TETANUS. 201
even published cases in support of the practice of amputation ; but, on
looking attentively over them, it seems that all those in which amputation
proved successful", were instances of chronic tetanus ; and we now know,
that the chronic variety of this disorder may frequently be cured without
amputation, and that it is generally more under the control of medical
and surgical treatment than the acute form of the complaint. Indeed,
Larrey himself admits, that amputation is of no use in acute tetanus,,
nor when the disease has made considerable progress. I believe he only
means amputation to be practised in the beginning of those cases, which
are likely to be slow in their progress, and for these I should say it is
unnecessary. Military surgeons generally disapprove of amputation, as
a means of stopping tetanus. In the hospitals of the British Legion in
Spain, the practice is also stated to have been fruitless.* Sir Astley
Cooper, Mr. Abernethy, and other distinguished surgeons, also join in
this opinion. I have already alluded to the case recorded by Mr. Liston,
in which he amputated the arm, in the hope of arresting the tetanic
symptoms, where there was a partial division, and an inflammation, of
the branch of the median nerve distributed to the thumb. The ampu-
tation seemed to stop the spasms for a moment, but they soon returned
with greater violence. In this instance one curious circumstance was
exemplified, namely, as soon as the operation was finished, Mr. Liston
wished to let the arteries bleed a little while before they were secured,
but he found that they had contracted so much, that scarcely any blood
could be obtained. In fact, no ligatures were necessary, for there was
no hemorrhage.
Another less severe local treatment has been proposed, one which acts,
however, on the same principle as amputation ; it is that of making a
deep incision in the wound, so as completely to divide the partially
injured nerve. This practice has occasionally answered; and I remember
one instance of tetanus, produced by an injury of the supra-orbitary
nerve, where a complete division of this nerve, performed by cutting
down to the bone, had the effect of stopping the disease. In the Medical
Gazette, No. 271, the particulars of a case are recorded, in which
Dr. Murray, of the East India Company's service, succeeded in arresting
an attack of tetanus by dividing the posterior tibial nerve behind the
inner malleolus, the disorder having been rapidly induced by the entrance
of a rusty nail into the sole of the foot. The relief was certainly very
remarkable, On the same principle, moxa, cautery, and caustic have
been used to destroy the seat of irritation, and cut off the nervous com-
munication of the part with the sensorium. In Baron Larrey 's history
of military surgery, there are instances where the median nerve had
been included in the ligature on the brachial artery, and also cases, in
which a ligature on the femoral artery had embraced the branches of the
crural nerve; here it was suspected that the tetanus, which ensued, might
have originated from the unskilful inclusion of the nerves, and the pro-
posal was made to cut down to the artery, and remove the ligature. In
one case, Larrey actually tried this plan ; he exposed the femoral artery,
and took away the ligature ; but the tetanus was only stopped for a short
time by this proceeding, and then it returned with increased violence.
Finding this expedient unavailing, he then cauterised the whole surface
of the stump, and administered opium. The patient ultimately recovered ;
See « Alcock's Med. Hist, of the Legion." 8vo. Lond. 1838.
202 TETANUS.
but it cannot be affirmed, that the cure was absolutely promoted by the
removal of the ligature. No doubt the practice was rational ; yet nerves
are so frequently tied without tetanus being brought on by it, that it is
difficult- to say what influence the tying of the nerve truly had in the
instance before us.
In consequence of the stoppage of suppuration in the wound at the
commencement of the tetanic symptoms, some surgeons endeavour to
renew the discharge by means of blisters ; but as the suppression of
suppuration seems to be rather an effect, than a cause of the disease, it
does not appear that much good is likely to be derived from this sugges-
tion ; indeed, I can trace but little evidence in favour of such treatment.
Another practice is that of stimulating the wound with tobacco
poultices, turpentine, laudanum, and other applications. This practice
was tried upon an extensive scale in our army in Spain, and in the French
army in Egypt; but the reports of it are not such as to justify the hope
of its proving useful. It is discouraging indeed to learn from Sir James
M'Grigor, that in several hundred cases, which happened amongst our
troops in Spain and Portugal, very few were benefited by any medicine
or plan whatsoever, after the disease had made any progress, and attained
the acute form.
In consequence of the blood being sometimes buflfy, and the pulse
being full and quick in the beginning, we might suppose, that blood-
letting would be beneficial, especially in strong robust persons ; but not-
withstanding such foundation for the practice, experience has produced
few facts in evidence of its usefulness. It is a treatment that has been
extensively tried, but without any decided good, so far as I am able to
judge; and some surgeons of vast experience positively declare, that
death is accelerated by it. I hardly dare venture, therefore, to recom-
mend venesection, especially as it has failed in every case, where I have
seen it tried myself. In Mr. Alcock's work is an abstract of seventeen
cases of traumatic tetanus, which occurred in the British legion in Spain.
The first six were treated by bleeding, opiates, and calomel, and all of
them proved fatal. Of the remaining eleven, one for which carbonate of
iron was administered recovered ; while of the other ten, in which bleed-
ing, acetate of morphia, calomel, and opium, and tartarised antimony,
were employed, only one got over the danger of tetanus, and this patient
afterwards fell a victim to irritative fever arising from injury of the knee-
joint. With regard to the question of taking away blood in tetanus, I
would abstain from venesection ; but if the patient were strong and ath-
letic, with a full quick pulse, I should not be afraid of having recourse to
local bleeding, 'of applying cupping-glasses near the spine, or leeches to
the throat and neck, as it is in those regions that inflammation, when it
does prevail, is mostly observed. The application of antimonial ointment,
or of a long strap of blistering plaster, or even of the actual cautery, to
the integuments over the spine, has been occasionally tried, and, as is
reported, with some degree of success.
Obstinate costiveness being invariably attendant on the disease, one
indication is to restore the functions of the intestines, and to procure
evacuations from them, which is sometimes difficult; for tetanic
patients are not easily affected by purgatives. Mr. Abernethy used to
prefer for this purpose calomel and jalap, mixed with treacle ; but we
have now a more convenient and certain medicine, namely, croton
oil. It is more sure in its effects than any other purgative that can be
administered ; we may give one or two drops of it mixed with mucilage
FRACTURES. 203
or gruel. By this dose a copious evacuation will generally be produced ;
a considerable advantage, because we are commonly exhibiting at the
same time another medicine, which has a contrary effect, namely, opium.
Now if we can keep the patient under the influence of opium, and also
succeed in maintaining the regular and proper action of his bowels, we
are doing almost as much for him, I believe, as it is in the power of
medicine to accomplish. The painful nature of the muscular contractions
led to the trial of narcotic medicines almost as a thing of course ; and,
accordingly, opium has been fairly and repeatedly tried. Other narcotics
have also not been forgotten ; in particular, hyoscyamus has been fre-
quently given, and found to relieve the patient's sufferings, though
inadequate to effect a cure. Patients in tetanus are not so easily acted
upon by medicines as in the generality of other diseases ; in fact, they
seem to require immense doses of medicines, and especially of opium.
It is not uncommon to give from half a drachm to one drachm of opium
every six hours, and from half a drachm to one drachm of the extract of
hyoscyamus. In tetanus we may certainly give medicines in large doses ;
but I would not recommend the immense quantities here specified as a
prudent plan to begin with. The safest maxim is to commence with
small doses, and gradually increase them. In some cases, the stomach
does not appear to digest the medicines put into it : thus, in one instance,
Mr. Abernethy opened a person who died of tetanus, and thirty drachms
of opium were found in the stomach.
Opium is sometimes administered in clysters ; and it is not unusual, in
trismus, to have recourse to frictions with opiate liniments about the neck
and jaws. For this purpose laudanum alone, or equal parts of laudanum
and soap liniment, are employed. Perhaps purgatives, with opium, or
the muriate, acetate, or sulphate of morphia, are the most valuable me-
dicines in tetanus. The warm bath has been occasionally tried, but no
confidence is now placed in it ; indeed, in the West Indies some individuals
died almost as soon as they were removed from it ; and as for the cold
bath, it has proved in traumatic tetanus decidedly injurious. Amongst
other things, mercurial frictions have been extensively tried : I have seen
them used in five or six cases, but invariably with ill success. What
confidence can be placed in them, when we hear, on the authority of
Sir James M'Grigor, that a soldier, in Spain, who happened to be using
mercurial ointment for the itch, was positively attacked with tetanus while
under the influence of mercury.
Dr. Elliotson conceived that there was some resemblance between
tetanus and paralysis agitans and chorea, in which the sesqui-oxide of
iron has been given with great success : he was therefore led to try the
same medicine in three cases of traumatic tetanus, two of which were
cured by it. He gave from two drachms to half an ounce every two
hours, obviating costiveness with castor oil and turpentine. The parti-
culars of several other successful cases have likewise been communicated
to him. I prescribed the sesqui-oxide of iron in one case of rfaumatic
tetanus, but without success. The disorder had advanced too far, I be-
lieve, when the medicine was begun.
FRACTURES.
A simple fracture is so called, when there is no external wound com-
municating with, or extending down to, the broken part of the bone. A
204- FRACTURES.
person may have a broken bone and a wound at the same time on the
limb; still the fracture may be a simple one ; because it is essential, that
the wound should communicate with the injury of the bone, to constitute
what is denominated a compound fracture. If I were to fall down and
break my thigh, and at the same time receive a cut, or laceration of the
soft parts of the thigh, quite unconnected with the fracture, the case
would not be of the sort, which, in surgical language, is distinguished by
the term compound. I may also observe, that the kind of wound, which
is essentially requisite to render a fracture compound, is generally pro-
duced by the protrusion of the broken bone itself: I say generally,
because, in compound fractures, the result of gunshot violence, the
wound is always occasioned by the ball, or bullet, that enters the limb.
When the bone is broken in several or many pieces, the fracture is said
to be comminuted, while complicated is the epithet applied to fractures
combined with a variety of circumstances, adding to the difficulty of the
treatment, or requiring especial attention. Thus, the combination of a
fracture with the wound of an artery, a dislocation, (for there may be
dislocation and fracture of the same bone together,) injury of viscera, or
of any organs, whose functions are highly important, will make the case
a complicated fracture. Thus the rami of the ischium and os pubis may
both be broken, and the fragments of bone may be so displaced as to
lacerate the urethra, and give rise to an extravasation of urine. In a
fracture of the ribs, the lungs may be wounded, in which case the addi-
tional complication of emphysema may be produced. Hemorrhage is
more frequently a complication of compound fractures of the legs than
of any other fractures, except such as implicate the anterior and lower
angle of the parietal bone, in which accidents the spinous artery of the
dura mater is usually ruptured, though the hemorrhage is then not exter-
nal, but takes place on the dura mater. I may state also, that whenever
there is extensive laceration of the soft parts, or whenever the fracture
runs far along the shaft of the bone into one of the large joints, as for
example into the knee, the accident ranks as a complicated fracture.
But, besides these distinctions, there are others derived from the direc-
tion of the fracture, as when it is transverse, oblique, or longitudinal,
particularities worth remembering, because they have considerable in-
fluence over the difficulty or the facility of effecting a cure. Thus, if
the thigh-bone be broken, and the fracture be oblique, the lower portion
of the shaft of the bone will be much more easily displaced, and more
difficult to keep reduced, than if the fracture were transverse. The reason
of this fact is sufficiently obvious, for, in consequence of the obliquity of
the surfaces of the fracture, the two ends of it are enabled to glide over
each other, and the muscles arising from the pelvis, and inserted into the
lemur, patella, and bones of the leg, draw the lower fragment towards
their origin, or more fixed point. But when the fracture is transverse,
the resistance of the upper end of it will tend to maintain the lower in
its proper situation, at least, so far as the preceding kind of displacement
is concerned. Next to the circumstance of a fracture being simple,
compound, or complicated, that of its direction is most important to be re-
membered.
The long cylindrical bones, which serve as pillars or arches of support
for the body, or as levers for the action of the muscles, are, by the nature
of their office, particularly exposed to fractures. Their shape, use, and
situation, are all so many circumstances rendering them extremely sub-
ject to be broken. On the other hand, the broad flat bones, such as the
FRACTURES. 205
scapula, sternum, and os ilium, though sometimes fractured, are much
less frequently so injured than the long cylindrical bones. The bones of
the skull, however, which are broad and flat, are exceptions to this ob-
servation ; but this is owing partly to their superficial situation, or their
not being covered by any great quantity of soft parts, and partly to the
force with which the head is generally struck by falls and blows. In
short, the head is a part remarkably exposed to external violence ; and I ,
may say, as a general rule, that the more superficial a bone is, and the
more exposed it is to the action of external violence, the more liable it is
to be broken.
It has been sometimes asserted, that the action of the muscles is
invariably concerned in the production of fractures ; but this doctrine
goes beyond the bounds of accuracy. We know that the patella is often
broken by the violent action of the muscles in front of the thigh ; that
the olecranon and part of the os calcis are sometimes torn off from a
similar cause ; and also that the humerus is occasionally broken by the
force of the muscles attached to it. I once attended a man, who broke
his arm by aiming a blow at another person, whom he did not succeed in
striking ; neither did he fall ; yet the humerus was broken. It is true,
that when a person falls down, he endeavours to save himself, and for this
purpose puts his muscles into violent action, which may therefore be sup-
posed to have some share in producing certain fractures; yet that
muscular action is always concerned in producing fractures must be an
incorrect hypothesis. When the cranium is fractured, can we possibly
suspect the action of the muscles, or, at any rate, of any muscles belong-
4flg to the patient himself?
Fractures then are produced, first by external violence, operating
directly on the part broken ; secondly, by external violence applied to
parts more or less remote from the seat of the fracture ; and thirdly, by
the action of muscles, as in ordinary fractures of the patella. When a
person alights on the ground from a great height, and fractures his thigh
or leg, the resistance of the ground and the weight of the trunk produce
the fracture ; there is no violence applied directly to the broken part, but
the extremities of the bone receive the force, and the middle portion of
the bone bends and breaks. This case is very different from one, in which
a man's leg is broken by the kick of a horse ; here the violence is applied
directly to the part which is fractured.
Fractures are more common at some ages than others. Particular
bones, too, are broken with remarkable frequency in young persons,
while certain other bones are more usually the subject of the accident in
aged individuals. In children, the femur, the humerus, and the clavicle
are often broken ; in adults, the bones of the leg and forearm, the femur,
humerus, clavicle, and ribs ; and in old persons, the neck of the thigh
bone suffers in numerous instances. The functions of some of the bones
render them very liable to fracture ; thus, the radius, which supports the
hand, and receives all the impulses communicated to this busy part of the
limb, is far more commonly broken than the ulna. The clavicle, which
keeps the shoulder in its right position, and supports, in the manner of a
pivot, all the motions of the upper extremity, is particularly liable to. be
broken. I have said, that fractures may occur at all ages ; but, as the
texture of the bones varies at different periods of our existence, some
differences in their liability to fracture will be created by this circum-
stance. The quantity of earthy matter in the bones of children is com-
paratively small ; but as man advances in years, the proportion of this
206 FRACTURES.
ingredient increases, while that of the animal matter diminishes ; the con-
sequence is, that they are rendered considerably more brittle than in the
early period of life. In children, the large proportion of animal matter
in the bones communicates to them a degree of elasticity and flexibility,
far exceeding what is noticed in the bones of older subjects. In children
the bones are also much protected by the quantities of adipose substance,
and the muscles are not yet sufficiently developed to act violently upon
them. The bones of children ought, therefore, to be rarely broken ; but
their venturesome tricks and carelessness in some measure counterbalance
the advantages which I have been noticing, and explain the reason why
the fractures of particular bones are tolerably frequent in the early pe-
riods of life. The bones of children, in bending, sometimes break only in
the convexity of the curve ; a peculiarity restricted to the early periods
of life. In adults, in whom the texture of the bones is actually strongest,
one might expect a corresponding diminution of the frequency of these
accidents ; but the protection of firmness of texture is counterbalanced
by the many dangerous employments in which a large class of society is
engaged, in the long interval between childhood and old age. In full
manhood, too, the muscular system has acquired its greatest force, and
hence fractures of the bones of adults are very common indeed. A pre-
disposition to fractures is known to be brought^on by certain diseases, as,
for instance, syphilis in its worst and most aggravated forms : a thigh-
bone, in the museum of University College, belonged to a person who
had been taking mercury a little while before his death, for venereal
complaints, — in fact, there is a node on the bone ; now, the femur of the
opposite side, contained also in the same museum, broke spontaneously,
that is to say, from the slight action of the muscles while the patient was
turning in bed. This is an instance of predisposition to fracture, arising
from the influence of impaired health in certain conditions of the venereal
disease. In the advanced stages of cancer, the bones are also frequently
broken by the slightest force or pressure, or the common and even very
weak action of the muscles. Kickets, fragilitas, and mollities ossium,
scurvy, scrofula, fungus haematoides, and certain diseases within the can-
cellated texture of the bones, are all well known to communicate a pre-
disposition to fractures. I may also remark, that, when a tumour presses
upon a bone in such a manner as to cause the absorption of the osseous
texture, of course a predisposition to fracture will be produced. At
University College are the remains of a thigh-bone, which is absolutely
reduced to a mere shell by the pressure of a tumour in the region of the
ham, and from the weakened appearance of it, it is manifest that the
slightest force would have been sufficient to occasion a fracture of it.
At the same institution is also the humerus of a boy, that was broken by
shampooing, tried for the relief of some scrofulous affection ; in fact, the
bone was broken twice : the first fracture united, but the second did not
do so. In this case, no doubt the texture of the bone had been weakened
by scrofulous disease. In the same collection is a preparation illustrating
the alteration, which any cancerous disease in the body may produce in
the bones : it is part of the skull of a woman, who _had cancer of the
breast; some of the texture of the bone is absorbed, and an animal matter,
which is sometimes described as a scirrhous substance, is deposited in its
place. If a similar change were to occur in one of the long cylindrical
bones, it would become so weakened as to be broken with a very slight
force. In the museum of St. Thomas's Hospital, there are or used to be
two thigh-bones, which were broken in consequence of their texture
FRACTURES. 207
being weakened'by the effect of cancer ; in the sternum of one of the pa-
tients, from whom they were taken, is a proportion of scirrhous matter,
occupying the place of the earthy matter which has been absorbed. All
pathologists know, that this effect of cancerous diseases in the body on
various parts of the skeleton is not an uncommon occurrence.
With respect to the general symptoms of fractures, some of them are
rather equivocal, because they may attend other cases. Of this descrip-
tion are pain, inability to use the limb, and more or less swelling : all
these symptoms may be noticed in other cases, as in contusions, in the
generality of dislocations, and in rheumatism ; they afford, therefore, no
positive information about the nature of the case. The symptoms, on
which greater dependence maybe placed,, are, first, the separation, which
often takes place between the two ends of the broken bone ; secondly,
the inequality or projection of the broken part of the bone, which, when
it is not covered with a great thickness of soft parts, is frequently
obvious ; thirdly, a change in the natural shape of the limb. Thus, an
angular deformity may be produced, the limb seeming to be bent, and
the axis of one fragment not corresponding to that of the other ; or there
may be a shortening and rotation of the limb" inwards or outwards, from
which position it may be more easily moved than in the case of a disloca-
tion ; the limb in the latter kind of accident being always more fixed.
j But of all the symptoms and signs of a fracture, none is of greater im-
portance, or affords a better proof of the nature of the injury, than the
crepitus, or grating noise or sensation, occasioned when one end of the
broken bone is moved upon the other. It is true, that, in some cases,
where the quality of the synovia is altered by disease, a grating may be
felt when a joint is moved ; but, generally, there is no risk of such a case
being mistaken for a fracture. Yet it should be known, that the absence
of crepitus is no proof, that a fracture may not exist; for, when a fracture
has continued some days, the ends of the bone become smooth, and there
will consequently be no crepitus or grating. The two ends of a broken
bone may also be so much displaced as not to be in contact, and then, of
course, no crepitus can happen. On other occasions, a portion of the
soft parts may be interposed between the fragments, as, for instance, a
portion of muscle : and here, likewise, no crepitus will be felt on moving
the part ; but whenever the grating noise or sensation can be distin-
guished, it is one of the surest signs of *,he existence of a fracture. The
grating may usually be perceived on pressing upon or trying to bend the
bone itself, or on bending, extending, .or rotating the nearest joint. One
symptom of a fracture is the loss of the use of the limb or part : this is,
no doubt, a common effect of most fractures, the functions of the limb or
part being more or less impeded ; but no positive conclusion can be drawn
from this circumstance, because it is one that accompanies other injuries
and diseases, and does not invariably attend a fracture. When the por-
tion of the limb, in which the fracture takes place, has only one bone on
which its inflexibility and firmness depend, then the loss of its ufe will
immediately result from its being broken. Thus, when the humerus or
femur is broken, the patient immediately loses the power of using the
limb ; but if only one bone happens to be broken in a part of a limb
in which there are two bones, the patient may then retain some use of
the member. For instance, if the ulna alone be broken, considerable
power of using the hand and forearm will remain ; but, if both the radius
and ulna be broken, then the circumstances will be different, and the
functions of the part will be more or less completely interrupted. Some-
208 FRACTURES.
times even when there is only one bone in a limb, and that is broken, a
degree of power of employing the limb will be retained, that is to say, the
use of it will not be so entirely destroyed as to render the nature of the
case at once manifest. Thus, in a fracture of the neck of the thigh-bone,
if one fragment be wedged and entangled in the other, there will be no
separation of them, nor any retraction of the limb ; and patients in this
condition have actually been able to walk some distance after the acci-
dent. This circumstance might cause the real nature of the injury to
remain unsuspected ; but it is very rare. When the injured part of a limb
contains two long bones, and only one of them is broken, the other sup-
ports the fractured one, and generally prevents retraction, or much dis-
placement of the lower fragment ; in fact, the perfect bone acts as a splint
in keeping the broken bone steady, and hindering deformity ; and, under
these circumstances, great attention may be requisite to detect the nature
of the accident.
With regard to swelling^ which is one of the symptoms of a fracture, it
may be produced either by extravasated blood, by the increased fulness
of particular muscles in consequence of the shortening of the limb, and
the approximation of their origins arid insertions to one another, or by
the prominence or projection of the broken bone itself. By any or all
of these causes, there may be an immediate swelling produced. The
muscular swelling is exemplified in fractures of the thigh-bone, in which
the middle portions of the ^triceps, the rectus, and the other extensors of
the leg give a preternatural convexity and fulness to the forepart of the
thigh. A similar effect may be observed in the arm, when the humerus
is fractured above its middle : then it is the coraco-brachialis and biceps
which chiefly produce the muscular prominence. Besides the immediate
swelling, to which so many causes may contribute, a still greater degree
of tumefaction follows at a later period, and is the result of inflamma-
tion. This kind of swelling of course requires some time for its pro-
duction ; and hence, when a bone has been some hours unset, the swelling,
from all the various circumstances which I have mentioned, may be con-
siderable, and such as may render the true condition of the bone obscure.
When, therefore, a limb is suspected to be broken, it should always be
carefully examined in the first instance, because then the examination
may be made with less pain to the patient, and the nature of the injury
can be made out with less difficulty than at a later period, when the in-
flammation and swelling have attained a considerable degree.
The displacement attending fractures is a subject, to which too much
attention cannot be paid. Surgeons should certainly have precise
ideas about the particular kinds of displacement to which the various
kinds of fractures are liable ; because the displacement is necessarily
accompanied by deformity, or deviation of the part from its natural
shape; and the grand object in the treatment is unquestionably the pre-
vention of such deformity by every possible means. We should therefore
study and inquire into the causes of the displacement of the ends of a
broken bone, and of the several varieties of it, which may occur in dif-
ferent cases. In fact, without this knowledge, we should not be qualified
to practise this part of surgery with reputation to ourselves and advan-
tage to the public. First, then, I may observe, that a fracture may be
without any displacement at all, as when the tibia is broken transversely
a little way below the knee-joint : the bone is there so thick, that the
fracture will scarcely admit of any displacement. Also, when the upper
and thick part of the ulna is broken, and the radius is perfect, there is
FRACTURES. 209
usually no material degree of displacement. The same fact is often
exemplified when the upper portion of the fibula is fractured, while the
tibia continues entire. The displacement may either be immediate or
secondary. When immediate, it is produced by the same violence as
produced the fracture : thus, the wheel of a heavy carriage may pass
over a person's leg, and break it, and at once produce a displacement of
the broken ends of the bone. A musket ball may have the same effect.
Here the displacement is immediate. Secondary displacement may arise
from two or three causes, the principal of which is the action of the
muscles ; but the weight of the limb will also be concerned in its produc-
tion, if the injured part be not properly supported, or carefully carried.
There are several kinds of displacement, in regard to the direction in
which it may take place ; first, it may happen in the direction of the
diameter of the bone, as seen in a transverse fracture. In such a case, the
two ends of the fracture may be either partially in contact, or not at all :
in the latter case, the displacement in the direction of the diameter of
the bone must obviously be very considerable. In some cases, the dis-
placement is longitudinal, as is most frequently noticed in oblique frac-
tures, where the surfaces of the broken bones slip or glide over each
other, the lower portion being generally drawn upwards, and the limb
consequently shortened. But the displacement may take place in relation
to the axis of the bone, the two fragments forming an angle, so that the
axis of one portion of the bone does not correspond to the axis of the
other fragment. This is termed the angular displacement. A fourth
description of displacement is the rotatory, in which the lower fragment
of bone is twisted inwards or outwards. Thus, in fractures of the thigh-
bone, the lower portion of it will generally be twisted or rotated outwards
by the action of the muscles and the weight of the foot. A fifth descrip-
tion of displacement is not seen in the generality of fractures, but only
in particular ones ; and consists in the upper detached portion of a frac-
tured bone being drawn away from the lower part of it by the muscles
attached to it. Examples of this displacement are seen in fractures of
the olecranon and patella, in which the muscles draw up the upper frag-
ment away from the rest of the bone.
With regard to the causes of these several forms of displacement, they
are of various kinds: a bone is often broken by a fall; but sometimes by
blows or kicks ; the fall following the fracture and aggravating any
displacement, which the injury, producing the fracture, may already have
caused. In some instances, the weight of the limb may displace the
fracture in the direction of the axis of the bone. Thus, in a fracture of
both bones of the leg, if the limb be laid upon its outer side, and the
lower part of it be not duly supported, there will be an inclination of the
inferior part of the tibia too much outwards. But, of all the causes of
displacement, the action of the muscles is by far the most common, the
most powerful, and the most difficult to counteract. Its usual effect is to
draw the lower portion of the fractured bone upwards, or to make it, as
the phrase is, ride over the upper fragment. The muscles, principally
concerned in causing the displacement, are those, whose insertions are
below the fracture. Thus, when the humerus is fractured between its
head and the insertion of the pectoralis major, this muscle, together with
the latissimus dorsi and teres major, will draw the lower portion inwards.
The fibres of the deltoid, it is true, may have some tendency to pull the
upper fragment outwards ; but it is the muscles specified which have the
greatest share in occasioning the displacement. The same principle lets
210 FRACTURES.
us understand, why it is so troublesome to maintain the lower end of the
fracture in its right place, when the thigh is broken ; for the muscles of
this part of the body are remarkably strong and numerous. Arising
from the pelvis, which they make their fixed point, they are inserted into
the femur below the fracture, and also into the patella and bones of the
leg, which parts are their more moveable attachments, and consequently
disposed to be drawn up by them more or less towards the pelvis. In
fractures of the leg, the gastrocnemius, the soleus, and the peronei mus-
cles, all tend to draw the lower portions of the fractured bones to the
outer and posterior side of the upper fragments.
Prognosis. Those broken bones which have the greatest number of
muscles attached to them are usually the most difficult to repair without
deformity, because the muscles are the principal cause of the ends of
the fracture being displaced ; and when the muscles are numerous, or
particularly strong, more difficulty is experienced in counteracting their
influence.
Fractures of the long cylindrical bones, near large joints, are generally
more serious accidents than other fractures situated in the middle portion
of such bones, because in these no risk of inflammation of the synovial
membrane, of abscesses, or anchylosis is induced, one or more of which
consequences are exceedingly apt to supervene, if the fracture extend
into or near a joint. Compound are more dangerous than simple frac-
tures; for, the inflammation is more violent, the constitutional symptoms
more severe, and, if the wound in the skin cannot be united by the first
intention, large abscesses may ensue, and the case will sometimes take
so bad a course, as to render amputation necessary. Indeed, when bad
compound fractures are cured, it is frequently not until after long con-
finement in bed, repeated abscesses, or even sloughing, many exfoliations,
and severe and protracted hectic disturbance of the system. In com-
pound fractures near the ankle, an anchylosis of the tibia and fibula to
the tarsus, and of the bones of the tarsus to one another, may follow.
However,, anchylosis is not the invariable consequence of a fracture
close to a joint. A comminuted fracture, and also one in which the bone
is broken, not exactly into a great number of fragments, but only in two
or three places, are more serious than if it had only been broken at one
part. A similar remark applies to the case, in which there is a fracture
in two different portions of the same limb, as, for instance, in the leg
and thigh together ; here it would be exceedingly difficult to effect a
cure without deformity, far more difficult than if there were only one
fracture in the leg or thigh. In oblique fractures, as the lower fragment
has a tendency to glide over the upper one, the chance of deformity is
more serious. Longitudinal fractures of the cylindrical bones are gene-
rally severe cases, because they rarely occur, except from the effects of
gunshot wounds, and are liable to extend into joints. At one time, so
few specimens of this sort of fracture had been preserved, that the
reality of it was a matter of dispute ; but it is now known by military
surgeons that it frequently takes place, and Cloquet has given an account
of some fractures of this kind, which occurred in individuals who had been
crushed and buried in the ruins of a building. Complicated fractures,
or those accompanied with a wound of a considerable artery, a disloca-
tion, previous disease of the bones, or an insane and unmanageable state
of the patient, or with various other perplexing circumstances, are ren-
dered more difficult of cure by these complications. In the museum of
the University College, is a preparation, exhibiting a fracture of both
FRACTURES. 211
bones of the leg irf two places, which accident was complicated with
hemorrhage ; the treatment tried was pressure, which, I think, afforded
little prospect of success in preventing hemorrhage, either from the
anterior or the posterior tibial artery. At all events, the result was
mortification ; indeed, injured in the degree in which the limb was, it
was certainly in the worst possible condition for bearing pressure, which,
besides being injurious to the soft parts, could have had little operation
on either of the arteries specified, whichever it might be, that was the
source of the bleeding. Here, if taking up the femoral artery were
unadvisable, and cold applications would not have answered, it might
have been better to have amputated at once, according to the rule which
I mentioned when speaking of gunshot wounds, namely, that very bad
compound fractures, accompanied by the injury of a considerable artery,
are cases for immediate amputation. In this case, not only was the limb
not saved, but the patient lost his life. Fractures of the lower extremities
are generally more serious than fractures of the upper ones, for they are
more difficult to reduce, and keep reduced, and complete union requires
a longer period of time for its accomplishment. Fractures in debilitated
and aged persons do not get well so soon as in healthy and young people :
in infants and children it is really surprising with what quickness and
facility fractures are repaired, and this notwithstanding the impossibility
of keeping such patients duly quiet and in the right position. Fractures
of the neck of the thigh-bone, entirely ivithin the capsular ligaments, occur
most frequently in old persons. Now, partly from the patient's age,
partly from the difficulty of maintaining the surfaces of the fracture in
co-aptation, and partly from the scanty supply of blood to the pelvic
fragment of the femur (the only supply of which is through the medium
of the vessels of the round ligament), it is exceedingly difficult to bring
about bony union, so difficult, indeed, that it was at one period often sup-
posed to be impossible to effect it. When fractures are accompanied by
certain diseases, as syphilis, scrofula, scurvy, rickets, &c., the prognosis
should always be guarded ; the friends of the patient should be apprised
that the unfavourable condition of his health may have disadvantageous
effects on the process by which nature brings about the union of a broken
bone. I have, however, attended many ricketty children for fractures,
and generally found that their bones unite again with tolerable readiness.
In such individuals, the bones are more easily broken it is true, but I
have not met with any very great difficulty in bringing about the reunion
of them.
The danger of fractures depends more on the injury done to the soft
parts, or on the state in which they are placed by the accident, than on
the affection of the bone itself. The injury of the bone, abstractedly
considered, is not dangerous; and whatever bad consequences follow,
will mainly depend either upon the degree of mischief done to the soft
parts, or upon the inflammation of such parts, excited by the saflie vio-
lence that broke the bone ; or upon the irritation of them by the spiculss
and sharp projections of the fracture. In short, the principal evils to be
apprehended, will depend on the condition of the soft parts, produced
by the manner in which they are affected by the fracture, or else by the
same force that occasioned the injury of the* bone. This is illustrated by
what takes place in a fracture of the sternum, ribs, cranium, or spine ;
here the peril manifestly arises from the injury done to the important
organs, which those parts of the skeleton are designed to protect. A
fracture of the cranium is in itself an occurrence not likely to cause a
p 2
FRACTURES.
single bad symptom ; but, if we take into the account the injury which
may have been done to the brain, we shall see where the real danger lies ;
and, in the same manner, if we reflect, that when the ribs are broken,
the lungs may be injured, or that when the vertebrae are fractured, the
medulla spinalis is likely to be wounded or compressed, we discern at
once that the danger depends not so much upon the state of the bones,
as upon the effects of the accident upon other organs.
In the treatment of Fractures, several minute circumstances present
themselves, which some persons may think of little importance, but which,
as Dupuytren observes, being neglected, may lead to serious consequences.
Thus, the precautions to be taken in stripping the patient of his clothes,
and in transferring him from one place to another, so as to avoid subjecting
him to cruel sufferings, and the aggravation of injuries already done to the
soft parts ; the situation, in which the patient should be placed ; the form
and degree of hardness or softness proper for his bed during the treat-
ment; the manner in which the surgeon should proceed to dress his
patient ; the means of ascertaining the consolidation of the callus ; and
the advice to be given in this stage, are all so many points, which expe-
rience pronounces as needing great attention. If the case be a fracture
of the leg, the patient's boots and stockings ought to be slit up, and not
drawn off. If he be carried on a litter, or on a door, as the celebrated
Pott was, the surgeon need not be in a hurry to remove him from it,
until his clothes have been taken off, the bed well arranged, and the requi-
site apparatus has been prepared. In lifting the patient to the bed, an
assistant must take the patient round the body, another by the two lower
extremities; while the surgeon, or some other careful person, must take
charge of the fractured limb. In fractures of the lower extremities, the
patient should lie upon a firmish, unyielding bed, and his pillow is not to
be large and high, which would cause him to slip downwards, and alter
his position.
The first indication is the reduction or setting of the fracture, by which
is meant, the bringing of the fragments into their proper situation, in re-
lation to one another. Technically speaking, it is performed by extension,
counter-extension, and coaptation. Extension, means pulling the limb in
the direction away from the trunk, in order to obviate the retraction of
the lower fragment. Now, it must be evident that, if extension alone
were employed, the whole limb and the body too would yield, and be
drawn in the same direction, and the patient would perhaps be pulled off
his bed ; it is necessary to prevent this inconvenience, by what is called
counter-extension, that is, by pulling the upper part of the broken limb in
the opposite direction. I need scarcely say, that some cases will not re-
quire extension and counter-extension at all ; there may be no displace-
ment, and then such proceedings would only be putting the patient to
useless pain. Extension, counter-extension, and coaptation, when they
are necessary, should always be performed with the greatest possible gen-
tleness, no more force being exerted than is absolutely indispensable.
Whenever there is displacement, they are manifestly proper ; but, under
other circumstances, that is, when a bone is broken, and the ends of the
fracture are not at all out of their right position, the attempt to make
better what is already right, is too absurd to require any comment.
Modern experience teaches us also, that not one quarter of the force is
necessary for the purpose of reducing broken bones, that was formerly
resorted to, because surgeons of the present day avail themselves of the
advantages, derived from the relaxation of those muscles which have the
FRACTURES. 213
chief power of displacing the fragments. Thus, in a fracture of the
bones of the leg, the powerful muscles of the calf are relaxed by bending
the knee, by which means the displacement may be obviated with little
difficulty, and with the employment of less force, than would otherwise
be necessary. The same thing is illustrated in the case of a broken
thigh ; but here the exact position, which, in Pott's opinion, has the
greatest effect in relaxing the principal muscles capable of disturbing the
fracture, is unfortunately not that in which the most effectual mechanical
means for maintaining the reduction can be employed. The principle of
relaxing the muscles, therefore, I think, should not completely prepon-
derate over all other influential circumstances. It was noticed by Desault,
that what is gained by the relaxation of one set of muscles, is lost by the
increased tension of others : this is another fact, which should not be for-
gotten, and, at all events, in whatever position the limb is placed, there is
an abundance of muscular fibres capable of producing a considerable and
very troublesome displacement of the fracture. This circumstance de-
serves particular attention, because it enables us to understand, that we
must not depend entirely upon position for effecting the end we have in
view, but that we should bring to our assistance every other means
within reach. As in oblique fractures of the long bones, there is mostly
considerable displacement, greater extension will be demanded, than in
the case of a transverse fracture. The latter kind of accident generally
requires but little extension, merely just what is sufficient to lessen the
friction and pressure of the surfaces of the fracture against one another
at the period of coaptation ; indeed, in such a case, there is seldom any
retraction, and whatever displacement exists is of other descriptions.
When extension and counter-extension are practised to obviate the
retraction, or shortening of the limb, no unnecessary force should be
exerted ; the bone should be pulled steadily and gently in the natural di-
rection of its axis, until it resumes its proper length, and then the two
ends of the fracture are to be adjusted, or, in technical language, coap-
tation is to be performed. From an early coaptation of the ends of a
fractured bone, the patient will experience much less pain than from the
operation at any subsequent period, because inflammation has not yet
had time to commence. Severe spasms' are noticed by Dr. Houston,
as sure to be the consequence of extending a fractured limb, that has lain
for any time in the flexed position. " Yet," says he, " even with the
certainty of giving rise to temporary suffering of this kind, I would not be
deterred from the operation, having often found, even after spasms, pain,
and high inflammation had set in, by bringing the broken fragments pro-
perly together, and placing them so that no motion could take place be-
tween them, that a check has been given to the cramps of the muscles,
and relief from pain procured. The momentary suffering, caused by such
a procedure, will be amply repaid by the subsequent ease, and good final
result."* The maxim of always setting a broken bone as soon after the
accident as possible, and that of not allowing the displacement to continue,
though inflammation may have come on, receive the approbation of all sur-
geons of judgment and experience. In certain cases, a good deal of trouble
arises from continual spasms of the muscles; and, if the patients be
strong and athletic, it will be advantageous to bleed them freely, and put
them under the influence of opium or morphia, and then the reduction
will be more easily accomplished and maintained.
* See " Dublin Journ. of Med. Science," vol. viii. p. 490.
p 3
214? FRACTURES.
Dr. Houston has published some interesting cases and remarks in favour
of treating fractures of the lower extremity in the straight position.
This position, he maintains, is the best for stopping the spasms, which,
in many cases, prove a source of considerable suffering and perplexity.
He argues, that the spasmodic contractions of the muscles surrounding a
broken bone, appear to be wholly the result of the unusual condition into
which these organs are thrown by the loss of the customary support of
the bone, and aggravated, perhaps, in some instances, by the irritation of
pointed fragments. In fractures of broad portions of bones near joints,
as of the condyles of the femur, head of the tibia, or lower end of the
humerus, and in fractures of one of the bones of the leg, or forearm, he
finds, that patients scarcely ever complain of startings in the injured
limb, because, in such examples, notwithstanding the fracture, the mus-
cles enjoy a mechanical support, which keeps their origins and insertions
at fixed distances apart. Taking a completely opposite view to that of
Pott, Dr. Houston believes, that the primary cause of spasms of the
muscles in fractures is the loosening of one or other of their fixed points
of attachment, and that, by leaving them in a loosened state, or giving one
set of muscles a greater degree of relaxation than another, such as is
communicated to the flexors, by bending the limb, a check to their move-
ments is not likely to be produced. Dr. Houston considers it well proved,
that no degree of injury, unless accompanied by fracture, is followed by
spasms of the kind here alluded to ; that no fractures, except those of the
limbs, give rise to those spasms ; and that, even in the latter examples, if
the ends of the fracture are so circumstanced as not to admit of derange-
ment from the action of the muscles, there will be no spasmodic affection
of the limb. Hence, he makes the following inference, that, for the
prevention and relief of this harassing symptom, the fragments should be
restored to their original places, and immoveably retained in them, all
hurtful pressure being avoided.*
The second indication consists in preventing the return of the displace-
ment ; or, in other words, in heeping the ends of the broken part of the
bone steadily in contact, so that nature may have a favourable opportunity
of uniting them. This indication is so plain as hardly to require explana-
tion: the ends of the fracture must be kept motionless; for, if this rule
were neglected, they would not be united by osseous matter, but an arti-
ficial or false joint be produced by the ends of the fracture becoming smooth ,
and joined together by a soft ligamentous substance. With the view
of promoting this motionless state of the fracture, and keeping the mus-
cles quiet, Pott and his numerous followers prefer maintaining the limb in
fractures of the thigh and leg in the bent position ; while others, as Dr.
Houston, decide against this method, and insist upon it as a fact, that re-
laxation of the muscles, having a tendency to spasmodic contraction,
excites and promotes such contraction ; whilst, on the other hand, exten-
sion of them is declared to be the most likely way of preventing or
subduing the spasmodic action. Instead of adopting this explanation, I
feel assured, by long experience, that the straight position is generally the
most advantageous for a broken thigh, not for the reasons given by
Houston, but because it admits of a more efficient apparatus being ap-
plied than can be used in the bent position, and especially in the posture
so erroneously advocated by Pott. In the extended position, Dr. Houston
observes, the patient sooner becomes reconciled to the bed than in the bent
* See Houston's " Obs. in Dublin Journ. of Mcd. Science," vol. viii. p. 477. ctscq.
I
FRACTURES. 215
one ; he can be shifted more readily, so as to vary the points of contact
between his body and the bed, and thus save himself from excoriations,
or sloughing ; he can assume the sitting posture, and maintain it with less
fatigue, for a considerable time. A better judgment may also be formed
of the length and shape of the broken limb, by its admitting of a com-
parison with the sound one. The limb can be kept more steady ; and
extension, if necessary, can be more readily and effectually practised.*
These observations, I think, apply more properly to fractures of the thigh,
than to those of the leg, which seem to me to be treated with the greatest
possible success in a slightly bent position of the knee on M'Intyre's
apparatus.
For the purpose of keeping a broken bone motionless, we have recourse
to various mechanical means, consisting, generally, of long thin portions
of wood, tin, or pasteboard, termed splints; together with pads, com-
presses, cushions, and bandages. Instead of splints, the use of plaster of
Paris casts, and of what the French term I'appareil immobile, is sometimes
advocated as the best means of fulfilling this second indication, especialiy
in the treatment of fractures of the leg; but, for reasons which need not
here be considered, this plan cannot be said to gain much ground. At
the same time, the principle is universally acknowledged, that when once
a fracture is properly set, the less the apparatus is meddled with the
better, unless particular circumstances occur to render an examination of
the part necessary, or some alteration of the limb, or the applications to
it indispensable. These contrivances form what is called the apparatus
for fractures. According to Desault, the moderate pressure of a bandage
on the surface of a fractured limb assists in preventing cramps of the
muscles of a broken limb ; and this principle, which is also commended by
Dr. Houston, is commonly acted upon in practice, except when the degree
of inflammation present renders such pressure unadvisable. In order to
prevent the hard splints from hurting the skin, we interpose between
them and the integuments some kind of soft materials, such as pads filled
with tow, wool, or chaff of oats, which is preferred in France. In frac-
tures of the shoulder, and of the bones of the upper extremity, a sling is
another contrivance of great service; for it not only supports the limb in
the most desirable position, but keeps it as quiet as the leg would be by
confining the patient in bed. In other words, a sling is as useful for
fractures of the upper extremities, in keeping the parts quiet, as the re-
cumbent position is for fractures of the lower limbs, with this additional
advantage, that, as the patient is not confined in bed, he can take exerr
cise, and his health is less likely to suffer. The sling should never be
omitted, when the clavicle, scapula, humerus, bones of the forearm, or
those of the metacarpus and fingers, are broken.
Sometimes almost every thing is effected by the relaxation of certain
muscles, or by position, without splints, which could not act either di-
rectly or effectually on the fracture. For instance, in fractures ^bout
the shoulder, affecting the scapula or clavicle, the treatment is conducted
altogether without splints. Then, in certain other cases, splints are in-
deed used, not as a temporary substitute for the bone, nor as a means of
giving support and steadiness to the part for a time, but for the sake of
keeping the limb in a particular position. Thus, in fractures of the neck
of the thigh-bone, splints are used, not to support that particular part of
* See Houston's « Obs. in Dublin Journ. of Med. Science," vol. viii. p. 489.
p 4
216 FRACTURES.
the bone, but to maintain the limb quiet in a determinate posture. In frac-
tures of the patella and olecranon, the same fact is illustrated : in these
cases, splints are not employed on the principle of affording lateral sup-
port, as in a common fracture of the thigh or leg, but to retain the limb
in a particular posture. Here splints could have no direct action on the
fractured part.
Besides bandages, pads, compresses, and loops of tape, other con-
trivances form parts of the apparatus for fractures, as, for instance, what
is called the double oblique plane, on which the lower extremity may have
the advantage of the bent position, though the patient lies on his back : it
is often used for fractures of the leg, and of the neck of the femur, and for
oblique, and other fractures of the shaft of that bone. The foot-board is
an essential part of the double oblique plane, as without it the limb would
receive but indifferent support. In general, the foot-boards of the best
double oblique planes are so constructed, that their situation and the
angle of them can be altered and regulated according to circumstances.
fracture-beds, or beds invented expressly for the accommodation of
patients with bad fractures, fracture-boxes, and contrivances to keep off
the weight of the bed-clothes, called fracture-cradles, are other mecha-
nical aids sometimes resorted to. Thus, in fractures, when much inflam-
mation exists, the patient frequently cannot bear the weight of the bed-
clothes ; and then the cradle is found^convenient. Common beds, intended
for the reception of patients with fractures, should be furnished with
hard unyielding mattresses, and not soft feather beds, which soon sink in
the centre, and not only have an unfavourable effect on the patient's
posture, but render his condition very uncomfortable. Fracture-beds are
now brought to great perfection ; and when the patient is likely to be
confined for a long time with a severe compound fracture, or a fracture
of the spine or pelvis, I would recommend him to procure, if possible, a
fracture-bed, which will enable him to obey the calls of nature without
any disturbance of his body or limbs, and which, if necessary, may be
converted into a double oblique plane. It also allows the head or chest
to be raised or lowered without the slightest disturbance of the fracture,
or any effort of the patient himself, who may even be inclined to either
side, if such posture be required, in an equally quiet manner. What is
termed a fracture-box is intended to hold the limb securely and steadily,
with the assistance of cushions and pads ; it consists of a bottom-piece,
two sides, and a foot-board ; a soft cushion, or pad, is laid along the
bottom of it, and the lateral pieces, which have hinges, and are fastened
with straps, are also kept from hurting the integuments with soft cushions
or pads, calculated to fill up the interspace between them and the limb.
A fracture-box is of great service in the treatment of some bad compound
fractures, requiring to be dressed every day ; but in University College
Hospital, it is not employed, because M'Intyre's apparatus, there preferred,
answers every purpose.
Process by which broken bones unite. A solution of continuity in the
soft parts unites with wonderful quickness, the cure by adhesion taking
place in a few hours. The process of union in bones is slower and more
complicated, nature requiring a longer time for the reparation of a frac-
ture than for the union of a wound, and the process not being, in the
first case, so simple, clear, and manifest. Even at the present day, with
all the assistance of experiment and actual dissection, different statements
and theories are advanced by different authorities. A few years ago,
lecturers on surgery got over this subject very easily, and those teachers,
FRACTURES. 217
whom I happened to attend, explained the matter in a concise and sum-
mary way, by stating, that the only difference between the union of bone
and that of soft parts, was, that the coagulating lymph, effused between
the ends of a fracture, gradually acquired the consistence of cartilage,
earthy matter was deposited in it, and thus the bone was united, and
acquired its former strength, the only particularity being in fact the
deposit of phosphate of lime in the uniting medium. But, even before
the time alluded to, considerable progress had been made in the investiga-
tion of the process by which broken bones unite, and great merit is due
to Du Hamel for the success with which he examined this part of sur-
gical pathology. After making numerous experiments to ascertain the
steps adopted by nature in uniting broken bones, he inferred that the
periosteum and the medullary membrane were the sources of the new
bony matter, or callus, as it is called, or of the substance which was the
means of union. The periosteum and the medullary membrane he con-
sidered as the exclusive organs of ossification. He maintained that, in
the process by which a broken bone is united, the periosteum, covering
the end of one fragment, grows to that of the other, and then swells and
forms a rising round the fracture. In the swelled portion of the perios-
teum, he described vessels as becoming developed, and depositing specks
of osseous matter, which formed a kind of osseous ferule, or hoop,
directly round the fracture. Now this explanation partly agrees with
later observations, and especially with those made with so much care
by Baron Dupuytren. Besides the changes leading to the production
of the external callus, Du Hamel found, that the medullary membrane
was not inactive, but contributed its share to the promotion of union
in nearly the same degree as the periosteum. One error in Du Hamel's
theory, however, was the supposition, that the bony ferule would
permanently remain, as the bond of union. It is occasionally asserted,
that the periosteum is exclusively the organ of ossification. Without
entering into a minute consideration of the objections to the latter
opinion, be it sufficient to say, that callus, or new bony matter, is often
produced in parts where the periosteum is totally destroyed ; and it is
well known, that the patella may be united by bone, although it is not
furnished with a periosteum at all ; it is true, that it rarely unites by
osseous matter, when broken transversely, but when it is fractured by
external violence, or in the longitudinal direction, osseous union is not an
uncommon result.
Bordenaave, having had an opportunity of examining a bone that
had been formerly broken, and long united, and, finding no bony
ferule in the situation of the previous fracture, conceived that Du Hamel
had been mistaken, and he therefore espoused the doctrine, that union
is accomplished by the vessels of the bone itself, and that they
effuse coagulating lymph between the ends of the fragments, which
lymph is first converted into cartilage, and finally into an osseous con-
sistence. Baron Larrey also rejects the theory, that the periosteum is
the organ of ossification, and he adverts to examples, where, although
portions of the cranium had been removed, and the pericranium had been
destroyed to a considerable extent, nature made considerable efforts to
repair the loss. In young subjects, especially, such efforts may indeed
accomplish a great deal, and, I think, we must acknowledge, that
the facts and arguments, brought forward by Larrey, amount to a
refutation of the opinion, that the periosteum is exclusively the
organ of ossification. The experiments of Dupuytren, Villerme, and
218 FRACTURES.
Breschet prove, that all the doctrines to which I have adverted are too
limited ; for, whenever a bone is broken, the soft parts around the injury
are more or less contused and torn, and it is alleged, that not only the
periosteum and medullary membrane, but also the soft parts around the
fracture, the cellular tissue, and muscles, or rather their vessels, are con-
cerned in repairing the injury of the bone. It was found,, that when the
ends of the fragments were kept steadily together, they became surrounded
by a swelling and a subsequent ossification of the soft parts, and that, in
this manner, a kind of external case was formed to include and support
the ends of the bone. This first production corresponds with Du
Hamel's bony ferule ; for, as I have said, he noticed that a sort of bony
hoop is produced around the fracture. Dupuytren calls this hoop or
ferule the provisional callus, because it is only a temporary production,
and is absorbed as soon as it has fulfilled the purpose for which it is de-
signed, namely, that of acting as a splint, or means of support to the
broken part of the bone, until nature has had time to bring about a more
complete and direct union of the ends of the bone themselves.
In the first stage, then, of the union of a fractured bone, comprising a
period of about ten days, there is merely a swelling of the soft parts
around the fracture; and, on examination of the limb in the dead subject,
the swelling appears to consist of a reddish substance, as would seem from
the quantity of blood effused. The swelling is greatest or thickest op-
posite to the fracture, and gradually diminishes above and below the
injury, till it is completely lost in each of these directions. About the
tenth day the redness 'has disappeared, the blood being now absorbed,
and coagulating lymph effused. At this time, a reddish vascular spongy
substance is formed between the ends of the bone, which substance is not
itself of an osseous nature; but in the swelling, around the fracture,
specks of bone now begin to be deposited, a change, or new action, cha-
racterising the beginning of the second stage, which extends from the tenth
until the twenty-fifth day. During this second stage, then, the effused
lymph on the ouside of the fracture becomes ossified ; it first assumes a
fibrous structure ; it then becomes cartilaginous ; and, by degrees, cal-
careous matter is deposited in it. In the meanwhile, similar changes are
going on in the medullary membrane, so that, in the process of union,
nature is labouring without and within the bone to give it a temporary
means of support, and'steadiness, while the principal and permanent work
of ossification is as yet only preparing for commencement.
The bone is still capable of partial flexion ; the ends of the fracture
not being yet consolidated.
In the third stage, extending from the twenty-fifth day to the end of the
sixth or eighth week, the external swelling becomes completely ossified
and firm ; the internal medullary membrane undergoes the same change ;
but the ends of the fracture are not united, and the bone is only strong
from the support received from the external and internal osseous form-
ations. The ends of the fracture^ themselves are not yet consolidated
directly together, and the bone may still be broken again, or bent, by any
violence or weight applied to it in a careless way.
The fourth stage extends from the sixth or eighth week to the end of
the fifth or sixth month, during which time the external or provisional
callus has become completely ossified, and even covered with periosteum.
The ossification of the medullary membrane is also perfected ; and the
ends of the bones themselves being now truly united to one another by
bony matter, the former solution of continuity is hardly distinguishable.
FRACTURES. 219
The fifth stage reaches from the fifth or sixth month to the twelfth.
During this period, the external provisional callus is absorbed and re-
moved, and "the direct union of the fragments is so strong, that it would
be as difficult to break the bone in the situation of the former fracture as
in any other place. For a certain time after the injury, the medullary
cavity is filled up by a kind of internal provisional callus, obliterating, as
it were, the cavity of the bone. These final changes take place in the
interval between the sixth and the twelfth months : then all irregularities
are removed ; the external callus is absorbed, and the medullary canal
restored.
In the museum of the College of Surgeons, there is a bone which is
united in such a way, that a portion of the medullary cavity is turned
outwards, instead of inwards, a large * splinter having been entirely de-
tached : yet union took place. Long splinters and fragments frequently
unite, but they sometimes perish, and fall into the state of necrosis.
The source of the external provisional callus is not then exclusively in
the vessels of the periosteum ; the surrounding cellular tissue and muscles
having a share in the production of it, and this, in a still greater degree,
when the ends of the fracture are considerably displaced. The formation
of the definitive, or permanent callus, which follows that of the temporary
one, is not completed till the eighth, ninth, or even the tenth month
after the accident; but as, when_it is finished, the provisional callus be-
comes unnecessary, nature then takes away, not only the external provi-
sional callus, but also that which is formed in the medullary cavity, and
this becomes restored to its original state. All these changes, however,
are not brought about until long after the occurrence of the fracture,
much longer than was formerly supposed.
The provisional differs from the definitive callus, not only in its situ-
ation and duration, but also in its lesser consistence and solidity. When
it is finished, it only possesses the strength necessary to resist the action
of the muscles, and the weight of the part ; nay, there are cases in which,
on the removal of the splints, it will yield to these two forces,, especially
in oblique fractures ; and it is of consequence for the surgeon to recollect
this fact, namely, that the limb may be straight so long as the Splints
remain applied, but that from the too great weight on the limb, or the
too powerful action of the muscles, after the removal of those supports,
deformity may still ensue. If the splints are removed too soon, or the
part be used too roughly and boldly, while the strength of the fractured
bone depends entirely on the external and internal provisional calli in a
certain stage of their formation, it is possible that a degree of deformity
may yet follow. Sometimes the strength of the provisional callus will be
overcome by a shock or blow, or some other form of external violence,
and sometimes by the effects of constitutional disease. I have seen
patients with bad fractures, whose limbs had proceeded a certain way in
the process of cure, when they were attacked with fever, and the pro-
visional callus was so weakened, that it admitted of being *bent with
facility, though it had previously been quite inflexible. This fact proves
that the provisional callus is weaker than the definitive one ; and the
knowledge of it is useful ; for, supposing a limb to be badly set, if the
provisional callus has only advanced to a certain stage, an attempt may
.yet be made to improve the shape of the limb. This has been done in
France, with success ; yet, it must be manifest, that the older the pro-
visional callus is, the more difficult will it be to amend the shape of the
bone, for the callus becomes firmer and more unyielding in proportion
220 FRACTURES.
as its ossification is more advanced. The definitive callus, though less
bulky than the provisional one, is harder, stronger, and more compact,
being indeed, when it is perfectly finished, stronger than the rest of the
bone ; and, if the bone be broken again, the fracture will not be in the
situation of the definitive callus. Leaving out of present consideration
the effects of scurvy, I may say, that the definitive callus is never de-
stroyed by disease : in this respect also, it is stronger than the provisional
callus, and whatever deformity may exist in the limb after the definitive
callus is formed, cannot be lessened.
Hitherto I have been considering chiefly the process of union in simple
fractures of the long cylindrical bones, which have been properly set.
When the two ends of a fracture are in apposition only at one point of
each of their surfaces, it can only be at this point that there can be any
definitive callus of the ordinary kind ; but, as a compensation for this dis-
advantage, the external callus is never entirely absorbed, but remains as
a substitute for what would be the definitive one under common circum-
stances. When the two surfaces of the fracture are not at all in contact,
but the ends of the bones touch one another laterally, strictly speaking,
there is no provisional callus. In such a case, not only the periosteum,
but the vessels of the adjacent cellular tissue and muscles, assist in
the work of producing new bone, by which the two fragments are to be
connected. The side of one fragment here becomes soldered by osseous
matter to the side of the other, and whatever new bone is formed for this
purpose, remains permanent, or, in other words, is a definitive callus.
Lastly, in compound fractures, attended with suppuration, the bones
remain disunited for several weeks, and then union takes place in a dif-
ferent manner from what I have been explaining. In this instance, no
provisional callus is produced ; but at the end of several weeks, the ends
of the bone soften and granulate, and in proportion as the secretion of
pus subsides, the granulations of the surface of the fracture deposit osseous
matter, or, as the French pathologists say, they are themselves converted
into bone. It appears then, that the process of union in compound frac-
tures is different from what it is in simple ones ; and it will generally be
found, that the greater the degree of displacement of the fracture, and
the greater the injury done to the surrounding soft parts, the less will the
work of producing the external provisional callus be confined to the
periosteum.
Broken cartilages do not unite by cartilage but by bone; osseous
matter is deposited around the part, forming a kind of hoop or ferule,
which is alleged to be formed by the vessels of the perichondrium. This
mode of union is exemplified in fractures of the cartilages of the
ribs. Fractures of the patella, olecranon, condyles of the humerus. and
coronoid process of the ulna, generally unite by means of a fibrous liga-
mentous substance, and the acromion, when fractured, may also unite in
the same manner.
Different bones require different lengths of time for the union of their
fractures. In the upper extremities, fractures are sooner cured than in
the lower ones ; the ribs and clavicle are generally united with tolerable
firmness in about a month, and even sooner in young subjects. Fractures
of the humerus require about six weeks for their reparation ; but those of
the tibia and femur are not firmly united before the eighth week. When
I speak of bones being Jirmly united at particular periods, I allude only
to that firmness which is derived from the provisional callus, and do not
mean that the definitive callus has been produced. The latter work,
FRACTURES. 221
which may be regarded as the completion of the cure, is one that is riot
accomplished till a much later period.
The time required for the union of a broken bone will also be much
influenced by the age of the patient, his state of health, the kind of
fracture, and the efficiency or inefficiency of the treatment. A com-
pound fracture, and a very oblique fracture, are longer in uniting than a
simple one, which is either transverse, or of less obliquity. In infants, a
broken bone will make as much progress towards a cure in a week or ten
days as it would in a month in an adult. When the bones of infants
happen to be broken during parturition, they are generally united with
considerable firmness in a week or ten days. The tendency to quick
union is strongly evinced during the development of the skeleton, that is,
while the individual is growing ; and, I may say, that it is most consider-
able while this development is taking place with the greatest vigour.
Hence the impossibility of keeping children quiet does not seem to inter-
rupt the process by which a fracture unites ; and however much they
may move and toss themselves about, the injury is generally repaired with
wonderful expedition. This is a circumstance which should always be
remembered in the treatment of fractures in children; for, if these acci-
dents are not vigilantly attended to during the first ten days, and the
position of the broken bone is neglected, we may afterwards find the
process of union too far advanced to admit of the shape of the limb being
rendered better again. Circumstances are different in the adult, in whom
the ossific process does not actually commence till after the tenth day ;
a fact which led Sir Stephen Love Hammick, and some other surgeons
to defer the application of splints during such space of time, and merely
to employ cold lotions, with the view of keeping down inflammation.
This practice would not be advisable in children ; for, after the ten days
had elapsed, we should most frequently have to regret the omission of
splints, by means of which, in the early stage of the accident, we might
have had effectual command over the shape and direction of the limb, but
which would now perhaps be irremediably deformed.
As a general rule, Dupuytren recommended the apparatus to be kept
on for twenty-eight, or thirty days, in children ; forty in adults ; and a
much longer time in aged persons. It ought not to be removed until we
have ascertained that the consolidation is complete. In order to be sure
of this, the surgeon lays hold of the two fragments, and cautiously tries
if he can produce any motion between them. If the callus yield, the
apparatus must be reapplied immediately ; if it do not, the splints may
be discontinued, and the part merely supported on each side with a piece
of thick pasteboard. At this period, it will not be safe to let the patient
walk immediately; for the callus may give way under the weight of the
body, or the action of the muscles. He must be kept quiet in bed for
ten days, or a fortnight longer. He may then sit up in his bed, or in an
arm-chair, with his limb rolled, and on a pillow. Crutches ma^ next be
given him, and they should be tipped with cloth to prevent them from
slipping on the floor. If possible, the patient should not attempt to go
up and down stairs, nor to walk in slippery or uneven places. /
The process 'of union is retarded by old age, and by every temporary j£jt,-$.fc
disturbance of the system: such as an attack of fever or erysipelas. The
union then proceeds more slowly, or may even be completely suspended. tx/i£
The process is retarded also by several of those diseases which sometimes ^
operate as predisposing causes of fractures ; as, for instance, certain dis- Jc^^
eases which weaken the texture of the whole skeleton, or that of particular '
222 FRACTURES.
bones, the chief of which are rickets, fragilitas, and mollities ossium, can-
cer, scrofula, and, as some allege, the venereal disease in its advanced
stages ; but, with regard to this last disease, I must observe, that it is
disputed whether the condition of the bones may not be brought on rather
by the mercury which is given for the cure of the disease, than by the
disease itself. Pregnancy is generally set down as one of the causes
impeding bony union, and it is even asserted, that fractured bones in
pregnant women will not unite until after delivery ; but this is not always
the case, for I once attended a woman, who lived in the neighbourhood
of St. Paul's, who fractured both bones of her leg in the fifth or sixth
month of pregnancy; yet I found that the fracture united favourably, and
in about the usual time.
Another circumstance, sometimes retarding the union of a fracture, is
the lodgment of a dead portion of bone between the ends of the two frag-
ments. In the museum of University College are several preparations
exhibiting this fact.
In the writings of Schmucker, an interesting case is related, in which a
portion of dead bone was lodged between the fragments of a broken tibia,
and retarded the uniting process for eight months ; at the end of which
time an incision was made and the sequestrum taken out, after which the
union took place in three or four weeks.
The continuance of a fracture in a disunited state depends sometimes
on constitutional causes, and sometimes on circumstances directly affect-
ing the broken bone itself. Among the latter causes, I may specify a
total want of apposition between the two ends of the fracture. If the
bones do not touch at all, there will probably be no union, or more time
will be required for it.
Another circumstance, contributing to prevent union, is moving the
fractured limb too frequently, or even continually, by which the ends of
the bone are prevented from being in steady apposition. We shall find a
remarkable proof of this recorded by Baron Larrey. When the French
army was retreating from Syria, there were among the wounded a great
number of soldiers with compound fractures, whom it was necessary to
place on the backs of dromedaries and camels, in order that they might
travel with the rest of the army : for if they had been left behind they
would have been murdered by the Turks and Arabs. They were obliged
to continue their retreat day and night for several weeks, jolted very
roughly in this mode of travelling; the consequence of which was, that
many of these fractures did not unite by osseous matter, and were sent to
Marseilles, a year after the period of the retreat from Syria, still uncured.
Too much motion of a broken limb is, then, one of the circumstances
impeding the favourable union of fractures, and occasions what is called
a false joint ; indeed, one of the principal indications in the treatment of
fractures is to prevent all motion of a fractured part.
One occurrence, sometimes impeding the union of fractures, and first
pointed out, I believe, in my writings, is the interposition of a portion of
muscle between the ends of the broken part of the bone. I have been
present at one or two dissections, in which the want of union was ascer-
tained to be produced by this cause. In one of these instances, in which
the humerus had been fractured obliquely, the lower fragment, the end
of which was sharp, had been drawn up into the biceps muscle ; conse-
quently, there was no apposition of the ends of the fracture, as a quantity
of muscle intervened between them.
The greater number of fractures, not uniting by bone, are either in the
FRACTURES. 223
patella, neck of the thigh bone, or shaft of the humerus. With regard to
the humerus, I may observe, that most of those fractures, which do not
unite by bone, take place just below the insertion of the deltoid : here
the upper fragment is pulled outwards by this muscle, while the lower
one is drawn inwards by the coraco-brachialis. The failure of union,
therefore, seems to depend upon the non-apposition of the ends of the
fracture ; and, perhaps, upon the disturbance by the action of the muscles
in question.
Besides these cases, false joints or union by ligament may also happen
in other bones, or other parts of bones ; thus sometimes a fracture of the
shaft of the femur will either not unite by bone at all, or very tardily;
fractures of the lower jaw may fail to be reunited by osseous matter, or
the process may be very late in its completion. A few years ago,
there was a man in the Queen's Bench with a fractured radius, which
had been in that state a long while, and there was not the slightest degree
of bony union. A fractured tibia, too, will sometimes riot unite in the
regular way. I have seen two cases which did not unite by bone for
nearly two years, though they were both simple fractures.
From these general observations on the first and second indications in
the treatment of fractures, and on the nature of the process by which
broken bones are reunited, I now proceed to the consideration of the
third common indication. After the broken bone has been reduced, or
set, and means have been taken for retaining the ends of the fragments
in apposition (for these are the objects aimed at in the two first indica-
tions), it is necessary, in the next place, to attend to any unpleasant
symptoms or circumstances likely to arise, or which may have already
followed ; for example, there may be an unusual degree of pain from
various causes, swelling from effused blood, a severe degree of inflamma-
tion, erysipelas, the formation of abscesses, &c. Now any or all of these
circumstances may follow the setting of a fractured limb. When pain
occurs, we ought to ascertain, that it does not arise from the immoderate
pressure of bandages, or badly padded splints. In either of these cases,
the mode of relief is manifest enough ; we are to undo the bandages, and
either leave them off for the present, or put them on again in a more
skilful manner. For the prevention of inflammation, the chief means is
undoubtedly quietude of the part, which the favourable progress of the
cure requires on another account, namely, for the purpose of preventing
the displacement of the ends of the fragments ; but, while quietude is
enforced, other measures should not be neglected ; as, for instance, low
diet, which, however, can only be continued for a few days, because its
effects will be to retard the formation of the callus, in the same manner
as too much bleeding, or any other weakening plan, is known to do. For
fractures, abstractedly considered, bleeding is never requisite; but we bleed
when the injury of a bone is attended with much contusion of the soft
parts, a description of mischief generally greatest when the frJbture has
been produced by direct violence, as by a blow, or a kick. Hence, con-
siderable swelling, and sometimes laceration of the skin and muscles, are
often produced by the same violence which breaks the bone. Under
these circumstances, the bandages and splints should never be tightly
applied at first; and sometimes it is most advisable to refrain from
making any kind of pressure with them till the inflammation has subsided,
and have recourse to cold evaporating lotions, and bleeding, in a degree
proportioned to the patient's age, strength, and constitution, or to the
violence of the contusion. Under such circumstances, many good sur-
224' FRACTURES.
geons do not think it right to apply splints at all for some days, but
endeavour to keep off and subdue inflammation by means of cold
evaporating lotions, bleeding, and leeches ; they put the limb or part in
an eligible position, and, applying no bandages, merely lay a piece of
linen on the part wetted with the cold lotion. The practice of omitting
the use of splints in the early part of the treatment is not generally com-
mendable, though the inflammation and swelling may occasionally render
it indispensable. As the common maxim, I should say, that the sooner
the splints are put on the better ; but they must not be applied too
tightly at first. As for bandages, they had better not be put on when
much inflammation and swelling prevail ; folded linen, wetted with a cold
lotion, will be much more useful, and not attended with risk of doing
harm. Costiveness should be obviated; but as fractures of the lower ex-
tremities are liable to a hurtful degree of disturbance from frequent
purgation, it is not advisable to carry the practice thus far. Leeches
and cold lotions are the best topical remedies for the inflammation
in the early stages of fractures ; after a time, if there be any disposition
to the formation of abscesses, fomentations and even poultices may be
applied, but leeches and cold lotions are often preferable in the com-
mencement of the case. We must not, however, allow too much dis-
turbance of the limb to be produced by the employment of these, or any
other applications ; and if they cannot be put in practice, without this dis-
advantage, they had better be dispensed with. The best way of using cold
lotions will be to squeeze them out of a sponge upon the eighteen-tailed
bandage, roller, or folded linen, which may be upon the limb, so that the
fluid may pass between the splints, and wet the bandage or linen without
the splints being taken off at all. When the limb is well set, its position
right, and the bandages and splints skilfully applied, the less it is moved the
better ; this may be set down as an axiom in surgery, and it is a principle,
which is so much valued by Baron Larrey, that after reducing the frac-
ture, and putting it into the proper posture, he then makes use of an
apparatus, which is not taken off till the bone has united. This practice
is followed even in compound fractures. The apparatus is soft and
flexible at first, and being wetted with a solution of acetate of lead, to
which is added a little camphorated spirit and white of egg, it is after-
wards converted into a stiff firm case, precisely corresponding to the shape
of the limb, and consequently well adapted to keep up equable pressure
upon it, without chafing or hurting the skin. Baron Larrey was led to
adopt this mode of practice, in consequence of the necessity he was fre-
quently under of moving patients in the army from place to place with
bad compound fractures ; for, by means of the apparatus here referred to,
they could be moved any distance with the greatest security ; and I may
state, that his son, who has published a treatise on fractures, and in re-
commendation of the same principles, gives an account of several indi-
viduals who were moved, with severe compound fractures, great distances
without injury : one individual had been brought to Paris from a place a
hundred miles distant, the day after the accident.
If no pain is produced by the splints and other parts of the apparatus,
and the fracture is well set, the less frequently they are taken off the
better. However, with the ordinary plans pursued in this country, it
would be unsafe not to examine the limb now and then, and, more
especially, between the tenth and twenty-fifth days ; for, if the process of
ossification in the provisional callus were allowed to go on beyond this
period, the fracture might unite in a bad position, and such deformity be
UNUN1TED FRACTURES. 225
the result as would not afterwards be remediable. On the other hand, if
the state of the limb be vigilantly attended to till the bone has knitted, as
the expression is, less caution will afterwards be necessary, as the risk of
the ends of the fracture changing their respective situations will now be
considerably lessened.
UNUNITED FRACTURES.
Sometimes fractures continue for a long time without evincing any
disposition to unite; and, in other instances, they lose all tendency to be
consolidated by osseous matter, the ends of the bone becoming rounded
and smoothed, and connected only by a fibrous ligamentous substance.
Now, when this mode of union takes place, the case is said to terminate
in the formation of an artificial joint. A main point in the treatment of
such fractures as have continued a long time without osseous union, is
to ascertain the cause of the deviation from what is the usual course of
things ; for here, as well as in every other part of surgical practice, the
cause of what is wrong should be investigated, because, as soon as it is
removed, the effects will probably cease. Thus, if the continuance of a
fracture in a disunited state were to depend on general indisposition or
bad health, which could be removed, the cure of the injury of the bone
would then, perhaps, admit of being accomplished ; but sometimes the
cause of want of union in the fracture, depends on a constitutional disease
which is totally incurable. Thus, when no callus forms in a patient with
cancer, there is little prospect of bringing about the union of the bone
by osseous matter, because no means are known by which the original
disease can be cured, or the patient's state of health materially im-
proved. The same may be said of mollities and fragilitas ossium, and
of some other constitutional affections, in which we have no means
capable of leading to the re-establishment of a sound state of the con-
stitution. However, many diseases, causing this backwardness in frac-
tured bones to unite by osseous matter, do admit of cure ; such are
rickets, scurvy, and lues venerea in its advanced stages. In these in-
stances we may hope, by proper treatment, to bring about such an
improvement in the health as will be followed by a deposit of bony
matter for the union of the fracture. It is certain, however, that dis-
eased bones will sometimes unite. Sir Benjamin Brodie had a syphilitic
patient, with an enlarged clavicle, which broke from some exertion of the
arm, the fracture extending through the diseased part ; yet this fracture
united in the ordinary time. With regard to rickets, I have attended
many children in this state with fractured limbs, and in all these ex-
amples, there was no remarkable indisposition of the broken bones to
undergo bony union. Also with respect to a pregnant woman, whom I
attended with a fracture of both bones of the leg, the bones united very
well in about the usual time. I remember a woman in University Col-
lege Hospital, who had cancer of the breast, and such fragility of her
bones, that she had met with several fractures from slight causes.* Twice
she came into the hospital for such accidents, which ended favourably.
Cases are met with, in which the formation of callus is kept back by
illness excited by the state of the soft parts around the fracture, or
occurring as an accidental complication. Thus there will sometimes be
an attack of fever or erysipelas, in which events the formation of callus
will be retarded as long as the general indisposition continues. Sir
Benjamin Brodie has seen two cases where fractures did not unite, in
consequence of the constitution having been impaired by a kind of
226 UNUNITED FRACTURES.
voluntary starvation, to reduce the embonpoint of the individuals : he
also suspects, that too tight a bandage may sometimes impede the pro-
cess of union.
Dr. Houston regards the doctrine as not being well established, which
ascribes the imperfection in the formation of callus to the want of inflam-
matory action. In illustration of this point, he recites the case of an old
woman who broke her thigh, and after she had continued in the hospital
several months, without complaining of much suffering, the limb was
surrounded with adhesive plaster, and she was able to walk about on
crutches. " She did not, however, long survive her convalescence, and
upon examination of the limb after death, it was discovered that, in
addition to a transverse fracture of the middle of the thigh, a perpen-
dicular one, four inches in length, ran up to the trochanter. The trans-
verse lesion exhibited a perfect false joint, with fibrous capsule and
synovial membrane, whilst the portion detached by the perpendicular
fracture had become firmly and universally united to the original bone.
The explanation usually given of the cause of such a failure, want of
sufficient action, will not hold good in this case, as the action was fully
competent to the reparation of the lateral fracture, though it failed in
the transverse one. Want of proper apposition, and the frequent occur-
rence of motion between the two main pieces of the bones, were more
probably the causes of non-union at this part."* Dr. Houston also adverts
to an instance of a middle-aged man, in whom almost every long bone in
the body had been broken at one time or another, from trifling causes ;
but notwithstanding great weakness of constitution, all these accidents
were repaired with very little suffering, and in a moderate time. Un-
questionably, there is sometimes great difficulty in explaining the cause of
the failure of our endeavours to unite a broken bone; but generally some
of the circumstances, to which I have referred, will account for it.
When the want of union is owing to the fragments not being properly
in contact, or to the fracture not being well set, or to its being moved
about too much, then the indication will be obvious — the bone must be
better set — the fragments must be put in a state of more accurate
coaptation, and such an apparatus employed, and such quietude of the
limb observed, as will more effectually and steadily maintain the re-
duction. However, these means will only answer when an artificial joint
is not completely formed ; for, after this has happened,, no improvement
of the general health, nor any means calculated to render the limb more
motionless, will be attended with success.
If there were interposition of any soft parts, such as portions of muscle,
between the ends of the broken bone, and we were sure that such com-
plication was the cause of want of union, and could not get the ends of
the fracture together by freely extending the limb, and altering the posi-
tion of the bones, we should then be justified in making an incision, and
dividing the muscle interposed between the ends of the bone; but, I
believe, the diagnosis would never be clear enough to vindicate such
operation. In the same manner, if a portion of dead bone, a sequestrum,
as it is termed, were to intervene between the ends of the fracture, and
to prevent union, or retard it for a great length of time, the indication
would be obvious enough ; we should be required to make such an inci-
sion as would enable us to remove the sequestrum. Some fractures do
not unite by bone, or do not readily admit of osseous union, in consequence
* Dublin Journ. of Med. Science, vol. viii. p. 493.
UNUNJTED FRACTURES. 22?
of anatomical circumstances. These are believed to have some con-
siderable share in making it difficult to unite certain fractures of the neck
of the thighbone by osseous matter. Fissures of the cranium are very
slow in uniting.
When a fracture has remained a considerable time without union, and
common measures have been found unavailing, various methods for ex-
pediting the process of osseous union have been proposed by surgeons.
The most ancient is that of moving the ends of the broken bone freely
upon one another, so as to excite a degree of inflammation in the parts
about the injury ; this plan has occasionally led to the establishment of
the, requisite process for the formation of callus. When John Hunter
had occasion to treat patients in this condition, he sometimes made them
get up and walk about with the splints on : I have seen this method tried
at St. Bartholomew's Hospital, where it was not uncommonly resorted to
at the period of my apprenticeship there. However, if an artificial joint
be already formed, this plan will not have the desired effect, and other
expedients will be necessary. One of these, first suggested by Mr. Charles
White of Manchester, consists in making an incision down to the frac-
ture, and dividing the ligamentous connexion, then turning out the two
ends of the bone, and sawing them off; the limb being next carefully put
up in splints, as in a case of recent fracture, and care taken that the two
ends of the fracture are as correctly in contact as possible, and steadily
thus maintained.
The first operation of this kind, performed by Mr. White, was attended
with the most encouraging success : the case was one of a broken
humerus, that had remained for a long time without bony union. The
proceeding has been repeated by other surgeons, and with various results;
sometimes the plan has had the desired effect, and sometimes it has not
answered ; nay, in certain instances, it has not only failed in procuring
union of the bone, but occasioned loss of life. Richerand and Larrey
mention cases which had this unfortunate termination. I remember a
man in St. Bartholomew's Hospital, who broke his humerus, and the
fracture, instead of uniting, led to the production of an artificial joint.
In this example, Mr. Long cut down to the fracture and sawed off the
ends of the bone ; but, although this was most completely done, and
the greatest care afterwards taken to keep the ends of the bone steadily
in contact, no bony union followed. Of late years, therefore, surgeons
have been more shy of resorting to White's operation, and not solely on
account of its results having sometimes been so unfortunate, but also
because another method has been proposed, which is, at all events,
milder, if not more successful. The method, to which I allude, consists
in introducing a seton between the ends of the disunited bone, in order
to excite such inflammation in the situation of the fracture as may be
followed by the formation of callus. Dr. Physic, of New York, proposed
the seton, which he tried with success, first in a case of fractur* of the
lower jaw-bone, and afterwards in an instance of a broken thigh that had
remained a long time without union. Experience has since proved,
however, that the seton fails in a certain proportion of cases : I have seen
two in which it did not answer, although it had had the fairest trial. The
success of the seton is then very uncertain ; but, as this latter plan is less
severe than that of cutting down to the fracture and sawing off the ends
of the bone, it seems to me to merit the preference. It may not answer;
but its danger is not equal to that of the operation requisite to turn out
Q 2
228 COMPOUND FRACTURES.
the ends of the bone and saw them off. In some instances, however, the
ends of the fracture were not sawn off, but merely scraped.
Instead of these methods, Mr. Amesbury thinks that another practice,
which is still milder than that of the seton, will generally answer ; namely,
pressing the ends of the fracture methodically and strongly together ;
thus, when the humerus is broken, and the fracture is transverse, the
pressure is made in the longitudinal direction, which is effected by means
of a short sling, and an apparatus expressly calculated to fulfil the indica-
tion ; but when the fracture is oblique, the pressure is made in the trans-
verse direction, and with the requisite degree of force. This treatment
has proved successful in several cases, and, as it is a mild and simple
plan, I think that it ought always to be tried before the other more severe
methods are resorted to. But, if an artificial joint were already com-
pletely formed, I should not expect that this mode of treatment would be
effectual. When a fracture of long standing, and not united by bone, is
dissected, the union is generally ligamentous, though the uniting sub-
stance differs from common ligament in not having a distinctly fibrous
structure. In other cases, there is absolutely a false joint produced ;
the rounded ends of the bones are covered by a thin ligamentous sub-
stance, and the inner surface of the capsule is lined by a smooth mem-
brane, like the synovial membrane, and, as Sir Benjamin Brodie observes,
capable of secreting the synovia. It is only where the want of osseous
union causes loss of the use of a limb, or other serious grievance, that
any severe operation for the purpose of exciting ossification would be
justifiable. A disunited fracture of the rib would not demand it; nor
would some other cases promise any benefit from it.
COMPOUND FRACTURES.
When a fracture is attended with a wound of the integuments and
other soft parts, which wound leads down to, and communicates with, the
interspace between the two ends of the broken bone, the accident is of a
far more serious nature, and more apt to be followed by severe and dan-
gerous consequences, than when no such wound is present : the case being
termed a compound fracture.
In a compound fracture, the wound is generally occasioned by the pro-
trusion of one extremity of the fracture, except in gunshot fractures,
and some others produced by direct violence. In gunshot fractures, the
external wound is produced by the ball itself, or other substance, which
breaks the bone ; and, in some other instances, it may be caused by the
same violence that breaks the bone, as when the accident is the result of
the passage of the wheel of a heavy cart over the limb, or by the limb
getting entangled in machinery. Under such circumstances, the same
cause which fractures the bone may tear and mangle the soft parts, so as
to occasion a wound communicating with the fracture. When the bone
is broken obliquely, the extremities being sharp, one of them is very
likely to be forced through the skin, particularly if the individual be in-
toxicated at the time of receiving the injury, and moves himself roughly
and carelessly ; also, if he be carried unskilfully by others, without the
limb being duly supported, a protrusion of the bone will be likely to
happen. In fact, many simple fractures are converted into compound
ones, by the awkward manner in which the patient is carried after he has
received the injury ; and Mr. Pott, who met with a compound fracture
of one of his legs, by his horse falling as he was riding through a crowded
part of the Borough, v/as so impressed with the danger frequently pro-
COMPOUND FRACTURES. 229
duced by the manner in which patients are carried after accidents of this
kind, that, as soon as his misfortune occurred, which was in the most
populous street and greatest thoroughfare near London Bridge, he begged
the by-standers, who surrounded him in great numbers, not to touch him
until a door or some contrivance had been brought, on which he might
be carried home without further harm.
When a surgeon is called to a bad compound fracture, the first question
which he has to decide, is the same as that which must always be deter-
mined in the early stage of bad gunshot wounds, namely, whether the case
will safely and judiciously admit of an attempt being made to save the
limb? In all bad accidental injuries affecting the limbs, and caused by
external violence, the principles of treatment are the same. Therefore,
what has already been stated with regard to this question, in relation to
gunshot wounds, is also perfectly applicable to bad compound fractures.
If, then, from the first, there seems no probability that the limb can be
saved, it will be the surgeon's duty to amputate without delay. In fact,
he will never afterwards have so good an opportunity of doing the oper-
ation with the prospect of saving the patient, because the constitution is
now tranquil in comparison with what it will soon be when inflammation
and fever have commenced. This principle I inculcated with regard to
gunshot wounds, and it applies to compound fractures, as well as to all
other bad injuries of the limbs from outward mechanical violence. If
the present opportunity be neglected, there may never be another ; be-
cause inflammation will come on, followed by fever, and sometimes by a
rapidly spreading mortification ; and, even if the patient were to live be-
yond the first stages and dangers of inflammation, he would yet have to
encounter a series of profuse abscesses of great extent, and hectic dis-
turbance of the most alarming kind. During the suppurative stage, when
the patient had passed through the first dangers, there might be, indeed,
an opportunity of performing amputation, but one not so advantageous as
what presented itself before the system had become universally deranged
by the effects of inflammation, great suffering, and severe hectic disturb-
ance. At all events, if the surgeon do not amputate immediately, he
must not do it until suppuration is established, unless mortification happen
to come on, in which event the case would be one of traumatic gangrene,
where the practical rule is not to wait for the red line of separation. If
an exception to the common maxim were not here made, the patient
would generally die in twenty-four or forty-eight hours, without any line
of demarcation having presented itself. But if an attempt has been made
to save the limb, and it is frustrated by the formation of enormous
abscesses, tedious and extensive exfoliations, frequent returns of inflam-
mation, or attacks of erysipelas, or by extreme prostration of strength,
and all the urgent symptoms which I have, on a former occasion, de-
scribed as constituting hectic fever, tending to the 'patient's dissolution,
the surgeon should then seize the best opportunity he can get •f ampu-
tating the limb, because if he does not remove the cause of the hectic
symptoms, the result will necessarily be fatal. How long he can rightly
persevere in the endeavour to save a limb with bad compound fracture
will, of course, depend partly on the state of the limb itself, and partly
on the condition of the patient's health, the strength which he may retain,
or the degree of hectic present.
I should not recommend amputation for compound fractures in the first
instance, unless they were of the worst description ; at this early period,
the operation is only necessary when the bone is very badly shattered, and
Q 3
230 COMPOUND FRACTURES.
the soft parts extensively torn., or when a large joint happens to be seriously
involved in the mischief. The superior skill with which compound frac-
tures are treated at the present day, is productive of a remarkable degree
of success, many limbs being now saved which formerly would have been
taken off without delay. In fact, with all the advantages of private
practice, and the judicious principles which prevail in this part of surgery,
it is only the worst descriptions of compound fractures that call either for
primary or secondary amputation.
Supposing it is decided to attempt the preservation of the limb, the
first indication, after the reduction, is to endeavour to close the com-
munication of the fracture with the atmosphere, and unite the wound by
the first intention. In this object we sometimes succeed, but on other
occasions fail, because the parts are more or less torn and bruised, and
not simply divided. Sir Astley Cooper's plan is to cover the external
wound with lint dipped in the blood, a mode of dressing which effectually
excludes the air, and disposes the wound to unite favourably ; but this
method, unobjectionable as it may be, is not exactly the common practice,
and most surgeons bring the sides of the wound together with strips of
adhesive plaster, just as is done for the union of ordinary incised wounds.
In University College Hospital, lint, wetted with tepid water, is frequently
preferred. If we succeed in uniting the wound, then all danger is re-
moved, the compound fracture being, as it were, at once converted into
a simple one. In certain instances, the wound only unites partially, and
the rest suppurates ; yet, if inflammation be kept within moderate bounds,
the case will generally go on favourably. In other instances, no union
takes place at all, the wound sloughs, and large abscesses form ; there
will then be a great deal of constitutional disturbance, and the case will
not be free from danger.
The reduction of compound fractures is conducted on the same prin-
ciples as those which are observed in the reduction of simple ones, regard
being paid to the relaxation of the muscles, and to bring about the co-
aptation in the gentlest manner possible. Sometimes one of the ends of
the fractured bone protrudes through the skin, and cannot be got back
without a great deal of violence being done to the soft parts. In such a
case, the projecting portion of bone should be sawn off, or the external
wound enlarged, so as to allow the bone to be restored to its proper situ-
ation, without any further injury of the integuments.
When the fracture is both comminuted and compound, the first indica-
tion is to remove such spiculae of bone as are perfectly loose, detached,
and near the surface, and thus a considerable source of irritation will be
removed. Of course, under such circumstances, there is little chance of
union by the first intention ; yet, the sooner the spiculae are removed the
better, as it will put the wound into a more favourable condition for heal-
ing without the formation of abscesses.
Reduction having been accomplished, the next object is to close the
wound accurately, either with strips of adhesive plaster or by covering it
with lint dipped in tepid water, or in the blood flowing from the part, as
recommended by Sir Astley Cooper. In the warm season of the year,
the bandage may be kept wetted in a cold evaporating lotion, in order
to keep down inflammation. The best plan of proceeding, if it be a
compound fracture of the leg, and we intend to put the limb on its side
in the bent posture, is to place the inferior splint with its padding and
the eighteen-tailed bandage under the fibular side of the limb. Then
we should effect the reduction of the fracture, and having done this, and
COMPOUND FRACTURES. 231
put the limb into the right position, next dress the wound itself, and lay
down the tails of the bandage. It is a great advantage to have the splint
arranged under the leg before we attend to the coaptation of the frac-
ture, for thus the limb lies steadily upon a convenient surface of support,
and the rest of the necessary measures are completed without the ends of
the fracture being again disturbed. It is not my intention to say, how-
ever, that this is the most eligible position for the limb, but as the
practice of Pott still finds a few advocates, the exact method of putting
on the apparatus adapted to this plan, has appeared to me to deserve a
brief notice.
The most advantageous position for a compound fracture of the leg I
find to be that in which the patient lies on his back, with the knee
slightly flexed, and the limb supported on a double-inclined plane, or
M'Intyre's apparatus. When the latter kind of splint is employed, it
should have an excavation, or aperture, in the situation where the heel
is placed, as directed by Mr. Listen, so that all hurtful pressure on this
part of the limb may, with the aid of soft padding, be effectually pre-
vented. With this apparatus, common rollers answer better than the
many-tailed bandage, as they may be applied so as to include the limb
and apparatus together, and at the same time to admit of those circles
being taken off without the slightest disturbance of the wound or fracture
which cover the place of the injury. Thus, the position of the fragments
may be ascertained, the wound dressed, leeches applied, &c., in the most
advantageous manner, as often as may be judged advisable.
In all leading points, the treatment of compound fractures resembles
that of simple ones, with the exception of the measures called for by the
wound itself; and also of those plans, which may be rendered necessary
by the greater risk of inflammation, abscesses, and severe constitutional
disturbance. Thus, the presence of a wound, if attended with suppura-
tion, will make it necessary to undo the splints and bandages more fre-
quently than would otherwise be the case. Here cleanliness is an essential
point; and it is frequently advisable to put under the limb a piece of
oilsilk, so as to keep the bedding from being soiled with the discharge ;
and, in the hot season, the parts may be bathed with a weak solution of
the chloride of soda. When the discharge is profuse, it is sometimes a
good plan to cover the pads themselves with oilskin ; for then they can
be washed every day, and kept perfectly clean with a sponge. While the
inflammation is considerable, we should not put up a compound fracture
too closely and tightly, because, in this state of things, the pressure of the
bandages and splints will do more harm to the soft parts than good to the
fracture. At the same time, I am of opinion, that those surgeons who
do not put on splints at all, so long as the inflammation lasts, are not the
best practitioners ; and that, as a general rule, the sooner splints are ap-
plied the better. Still there are many cases in which they cannot be put
on tight, and a few others in which they should be dispensed \\#h for a
short time, particularly as exemplified in fractures of the elbow, attended
with much inflammation and swelling of the joint.
In compound fractures of the lower extremity, a fracture-box is some-
times a better apparatus than common splints ; for it affords great accom-
modation and convenience, having a foot-board whose place and position
can be altered, and whose two sides can also be let down at pleasure.
The bottom, sides, and foot-board of this machine are duly lined and
covered with cushions. Now, when the sides are thus properly lined with
soft materials, or well-contrived cushions or pads, the limb often feels
Q 4
232 COMPOUND FRACTURES.
much easier than with splints ; and if there should be occasion to apply
leeches, or any particular dressings, one of the sides may be let down,
and the business accomplished without any disturbance of the limb.
Sometimes both sides of the machine are let down at once ; and thus the
limb may be examined, and any necessary dressings applied, without
subjecting the parts to any kind of motion. Before double oblique planes
and M'Intyre's apparatus began to be employed, the fracture-box was
even of greater importance, and more frequently used than at present.
In University College Hospital it is not employed at all, because here
M 'In tyre's apparatus supersedes all occasion for it.
For the prevention and diminution of inflammation, we must have re-
course to common antiphlogistic plans ; but it is not an unusual belief,
that patients with compound fractures, especially in London, will not bear
venesection. Although this doctrine has been carried too far, it is never-
theless true, that if a patient were to be too much reduced by bleeding,
he would not be able to bear all the profuse discharge, long confinement,
and constitutional disturbance which he would have to encounter. Hence
circumspection with respect to venesection is necessary ; but leeches,
cold applications, and aperient medicines, not urged to such an extent as
to disturb the limb too frequently, should never be neglected.
When the wound does not heal by the first intention, considerable in-
flammation of the limb and a more or less severe attack of inflammatory
fever, are likely to follow. Then, if large abscesses form, hectic symptoms
will soon take the place of those characterising the first description of
fever. The treatment must now be regulated by those principles which
were explained in the observations on hectic fever. The sulphate of
quinine and the diluted sulphuric acid should be given to check the night
sweats ; opium to procure rest ; chalk mixture to relieve diarrhoea, and
other medicines, according to particular symptoms. With respect to
abscesses, a most useful part of the treatment will consist in preventing
the lodgment of matter ; and generally, in these cases, many abscesses
form in succession ; first one forms, and as soon as it is discharged,
another takes place ; and so the case may go on for several weeks, with
a repetition of fresh inflammation and suppuration. I believe, that, in
compound fractures, the discharge of pus is sometimes kept up longer
than it would otherwise be, by continuing the use of relaxing applications
too long. If there be reason to suspect this circumstance, we should dis-
continue them, and substitute for them astringent lotions, made with the
sulphate of zinc or of copper. Many practitioners are partial to the plan
of making pressure on the situation of the matter with compresses ; but,
in general, the best plan is to form an adequate outlet for it, and employ
bandages directly the inflammation subsides. If there be not a sufficient
outlet, I should say, that pressure cannot be of any service.
Another indication is to remove all loose portions of exfoliated bone.
Some patients do not recover until long, very long, after the occurrence
of the accident ; and one frequent cause of the difficulty of cure, is the
presence of a portion of dead bone in the part. The lodgment of a se-
questrum will often retard the union of the bones for an extraordinary
length of time. Hence, the dead bone should be removed as soon as
practicable ; and this, even though it may be more or less entangled in
the callus.
With respect to the question of amputation, when hectic is present, the
severity of the constitutional symptoms, and also the particular state of
the fracture itself, must be considered ; we are to be guided by the com-
FRACTURES. 233
bined consideration of these two circumstances ; and when we see that
perseverance in the attempt to save the limb will most likely end in the
patient's destruction, we should seize the best opportunity which circum-
stances afford of performing amputation.
One other circumstance it maybe right to mention, namely, that many
patients with bad compound fractures die, not from the bad effects of the
injury of the bone itself, nor of any mischief resulting from it to the limb ;
but in consequence of sloughing of the soft parts over the sacrum or the
trochanter, or over some other prominences of bone, where the skin par-
ticularly suffers pressure in the usual position of the patient. Such mis-
chief is seen to arise, not only from long confinement to bed by compound
fractures, but from such confinement rendered indispensable by injuries
of the spine, and various tedious diseases. In these examples, there is
such languor of the system, such a weakness of circulation, and diminution
of nervous influence, that the parts, most exposed to pressure, will fre-
quently slough. The principles, applicable to the treatment of this kind
of mortification, have been already noticed.
COMPLICATION OF FRACTURES WITH HEMORRHAGE FROM LARGE
ARTERIES.
The museum of University College contains a specimen of a compound
fracture of the leg, which was amputated for gangrene, that followed
pressure tried for the stoppage of bleeding from one of the tibial arteries.
Any considerable degree of pressure, under such circumstances, will
never be endured with impunity; and, even if it could, I should say, that
the plan would be inefficient in relation to the hemorrhage from vessels
of this size and so deeply situated. On account of the great ill success,
usually attending compound fractures of the leg, complicated with hemor-
rhage from one of the principal arteries, amputaton has been the common
practice. In fact, the broken part of the limb will neither bear pressure,
nor a tedious operation for securing the artery ; for, the cellular tissue is
mostly gorged with blood, and if we were to pursue either of these me-
thods, mortification would generally ensue.
All surgeons should make up their minds about the treatment of such
a case, because it is an urgent one, leaving little time for consultation.
If the fracture were not one requiring amputation on other accounts, I
would neither have recourse to that operation in the first instance, nor to
strong pressure ; nor to the expedient of tying the wounded artery itself,
unless it happened to be the anterior tibial in the lower and superficial
part of its course, where it could be taken up without any serious addi-
tional disturbance and irritation of the injured part of the limb ; but if
cold applications and a gentle degree of compression failed, and there
was no doubt about one of the tibial arteries being wounded, I would
either try the effect of the pressure of a ring tourniquet on the femoral
artery, or imitate Dupuytren, whose experience in some casts of this
description demonstrated what course ought to be pursued. Thus, in one
female patient, fifty-five years of age, who met with a fracture of both
bones of the leg, complicated with laceration of the posterior tibial artery,
he took up the femoral artery, and having thus succeeded in checking the
hemorrhage, he treated the fracture by ordinary means, and the patient's
life and limb were saved. In another case, a bullet had passed through
the upper spongy head of the tibia, and wounded the popliteal artery.
The ligature of the femoral artery was here also attended with success.
Delpech adopted the same practice, and the results were equally favour-
234? DISLOCATIONS.
able. Hence, if a fracture of the leg were not such as to require imme-
diate amputation on other accounts, hemorrhage alone, I think, would
not be a justification of it.
It is true, that here the valuable maxim of always securing a wounded
artery with two ligatures, one above, the other below the opening in it, is
deviated from ; but were we to perform such an operation on the injured
part of the limb itself, loaded as it is with extravasated blood, and perhaps
already much swollen and inflamed, gangrene would scarcely be avoid-
able. There would be no difficulty in proving its ill success, by reference
to several cases reported to have occurred in the London hospitals.
OF DISLOCATIONS OR LUXATIONS IN GENERAL.
When the head, or articular surface, of a bone, is thrown out of its
proper place, with respect to the corresponding articular cavity, or sur-
face, of another bone, in or upon which it is naturally situated, the
accident is termed a dislocation or luxation.
In some dislocations, the head of the bone is thrown at once into the
situation in which the surgeon finds it ; in others, a further displacement
is produced by the action of the muscles ; hence, the distinctions of
primary and secondary dislocations, or, as it ought rather to be ex-
pressed, of primary and secondary displacements, resulting from these
accidents.
Dislocations are either simple or compound ; simple, when there is no
external wound penetrating the synovial membrane and communicating
with the cavity of the joint ; compound, when the injury is attended with
a wound of this description.
Another difference in dislocations arises from the circumstance of their
being complete or incomplete ; according as the articular surfaces are en-
tirely separated, or not. Dislocations are also divided into old and recent
ones ; the former not admitting, after a certain period, of successful treat-
ment ; while the latter may be generally rectified with greater facility in
proportion to their recency, or the shortness of time that has transpired
since their occurrence. When a dislocation arises from disease of the
bones, or from elongation or any other morbid change of the ligaments of
a joint, it is termed spontaneous.
Those dislocations of the hip, which are termed by Dupuytren original,
or, as others would name them, congenital, are not the consequence
either of disease or accidental violence, but of original imperfection, or
malformation of the acetabulum. Dupuytren had seen about twenty-six
cases in the course of twenty years ; and all, excepting three or four,
were in females. These congenital dislocations were first noticed by
Paletta, and afterwards by Dupuytren and Delpech ; and the subject has
since been followed up, with reference to such dislocations of the elbow
by Mr. Adams, in the ninth part of Todd's Cyclopaedia ; and, with refer-
ence to others of the shoulder, by R. W. Smith, in Vol. XV. of the
Dublin Journal of Medical Science.
The most important differences of dislocations, depend, 1. Upon the
hind of joint in which the accident happens.
2. Upon the extent of the dislocation.
3. Upon the direction in which the bone is displaced.
4. Upon the length of time which the displacement has continued.
DISLOCATIONS. 235
5. Upon the absence or presence of such a wound as makes the dislo-
cation compound.
6. Upon the complication of the case with a fracture.
7. Upon the causes by which the articular surfaces are separated from
each other.
1. Now with respect to the hind of joint, we do not always estimate the
seriousness of a dislocation by the size of the articulation, as we do with
respect to fractures, and diseases of the joints in general. In a simple
dislocation, this is not always the criterion of the difficulty of reduction ;
and it is only when the accident is attended with a wound, communicat-
ing with the cavity of the joint, that the size of the articulation then
becomes a consideration of primary importance. In fact, some dislo-
cations of the thumb are infinitely more difficult to rectify, than luxations
of the head of the thigh bone, or shoulder.
Every kind of joint is not equally liable to dislocation. In the verte-
bral column, if we except such dislocations as happen between the atlas
and dentata, they are hardly possible. The pieces of the spine are articu-
lated together by extensive and numerous surfaces, so diversified in their
form and direction, and so powerfully bound together by ligamentous and
elastic substances, that the motion between any two vertebrae, is very
trivial. At all events, we cannot have dislocation without fracture except
in the cervical portion of the spine. The strength of the articulations
of the bones of the pelvis hardly ever yields so as to allow of the occur-
rence of a dislocation, or separation of the articular surfaces, unless the
force applied be of that irresistible kind, which causes also at the same
time a fracture of this strong and thick part of the skeleton ; at once
strengthened by its shape and structure, and protected by large masses
of muscle arranged over a considerable portion of its exterior surface.
Those joints, which are contrived for the performance of extensive and
very diversified motions, are generally the most exposed to dislocations.
Hence the orbicular ones furnish by far the most numerous examples of
dislocations.
The ginglymoid joints perform motions resembling those of a hinge ;
while the orbicular admit of motion in every direction, for which pur-
pose the bones entering into their formation have the ball and socket
construction. Their ligaments must also necessarily be loose, in order to
permit this free range of motion. Hence their dislocations are more fre-
quent than those of ginglymoid joints, which move only in two directions,
and are strengthened both by their more numerous ligaments and the
conformation of the bones themselves. In fact, in consequence of the
great breadth of the articular surfaces of several of the ginglymoid joints,
the mutual correspondence of their eminences and depressions, and the
number and strength of the ligaments by which they are bound together,
they cannot be so easily dislocated as the orbicular ones ; and, when the
accident does take place, the articular surfaces are in general not wholly
separated ; the case being what is termed an incomplete dislocation.
In the orbicular joints, or those of the ball and socket kind, a disloca-
tion is not only more frequent than in the ginglymoid ones, but it presents
another difference, which is, that it is almost always complete.
With the exception of partial or incomplete dislocations of the astra-
galus from the os naviculare, two bones of the tarsus, and a rare partial
displacement of the head of the humerus, we scarcely ever meet with
incomplete luxations in any other joints, than the ginglymoid. In the
ankle, knee, and elbow, however, examples of incomplete dislocation are
236 DISLOCATIONS.
common enough. For instance, in the ankle, the lower end of the tibia
is sometimes partially dislocated, one portion of it continuing on the
astragalus, but a larger portion of it resting upon the os naviculare.
While dislocations of the orbicular joints are generally produced by
force applied to another part of the limb, those of the ginglymoid ones
are often, but not invariably, caused by direct violence, applied to the
joints which suffer dislocation. Hence, luxations of the hinge-like arti-
culations are frequently attended with severe contusion, and followed
by a great deal of inflammation and swelling of the soft parts, by which
much obscurity in the nature of the case is sometimes occasioned, espe-
cially to a person who has not a correct knowledge of the anatomy of
the particular joint that is injured.
2. With respect to the extent of the dislocation. The extent of the dis-
placement, as I have said, makes the case complete or incomplete; the
latter expression signifying that the articular surfaces are partially in
contact. On this part of the subject I have little to add. Though the
dislocations of orbicular joints are almost always complete, and those of
ginglymoid ones incomplete, we have the exceptions which I have already
specified. The head of the humerus sometimes rests upon the edge of
the glenoid cavity, from which position it readily slips back again into its
proper situation ; and sometimes the astragalus is partially dislocated
from the navicular bone. What have been described as partial disloca-
tions of the head of the humerus, I may here take the opportunity of
stating, are considered by Mr. R. W. Smith to have been in many in-
stances congenital dislocations of the shoulder, from imperfect formation
of the glenoid cavity of the scapula.*
The lower jaw is subject to what is sometimes termed a partial or
incomplete luxation, in a different sense from that usually conveyed by
this expression, namely, to a dislocation of one of its condyles, while the
other remains in its right place.
3. Direction in which the heads of the bones are displaced. In the
orbicular joints, the head of the bone may be dislocated at any point of
their circumference ; and the dislocation is named accordingly upwards,
downwards, forwards or backwards. In the ginglymoid joints, a dislo-
cation may take place to either side, or backwards or forwards.
4. The time that has transpired since the accident makes the case, as I
have explained, either a recent or an old dislocation ; an important con-
sideration with respect to the prognosis. In general, recent simple dislo-
cations may be easily reduced ; but, when the head of a bone has been
out of its place several days, the reduction becomes difficult, and, in
older cases, very often impossible. The muscles have now adapted them-
selves to the altered length of the limb and changed position of the bone,
the head of the bone is fixed in its new situation, and the cavity, originally
destined for its reception, becomes more or less obliterated.
5. The absence or presence of such a wound as makes the case simple or
compound. The degree of danger is much altered by the accident being
simple or compound. Simple dislocations, when recent, may generally be
reduced with facility and cured without danger ; but compound disloca-
tions of the large joints are frequently a source of severe and extensive
inflammation and suppuration of the parts, and of such constitutional
disturbance as may endanger life. The degree of risk, however, will
depend very much upon the size of the joint, the extent of the laceration
* See Dublin Journ. of Med. Science, vol. xv. p. 257.
DISLOCATIONS. 23?
•
in the synovial membrane, the direct and free or the indirect and limited
exposure of the articular cavity ; the degree of contusion, .laceration, or
other mischief done to the soft parts; the great or little chance of healing
the wound by the first intention ; the patient's state of health, kind of
constitution, and his youth or advanced age.
The same nicety of judgment is required in deciding about the attempt
to save the limb in bad compound dislocations, as in bad compound
fractures.
6. Complication of dislocation with fracture. That a dislocation must
be rendered a more severe and even a dangerous accident by this com-
plication, is self-evident. We often meet with cases of this kind in the
elbow and ankle, and sometimes in the hip.*
A dislocation of the humerus, or femur, may be complicated with
fracture, in consequence of a fall directly after the bone is out of its
place ; there may also be a complication with fracture of another limb.
Generally speaking, however, dislocations joined with fracture terminate
favourably, except, when in addition to the fracture, the soft parts are
violently contused and torn, and there is a wound rendering the accident
compound as well as complicated. Even then, many cases end well.
In luxations of the hip, the acetabulum may be fractured ; in those of
the ankle, the fibula is mostly broken ; and in dislocations of the upper
part of the ulna, the coronoid process of that bone is often fractured.
Other complications are oedema and paralysis of the limb from pressure
of the head of the bone on the veins and absorbents, and on the axillary
plexus of nerves.
7. Causes of dislocations. The natural predisposing causes are the
great latitude of motion which a joint admits of; the small extent of the
articular surfaces; the looseness and fewness of the ligaments ; the shallow-
ness of the articular cavity, as of the glenoid one of the scapula; the
action of the muscles in particular positions of the joints ; and lastly,
the great length of the lever represented by the cylindrical bones of
the limbs.
But, besides these natural predisposing causes, there are other circum-
stances, which facilitate the occurrence of these accidents, and consist of
deviations from what is to be regarded as healthy and natural.
Thus paralysis of the muscles of a joint, and an extraordinary looseness
of the ligaments, may become predisposing causes. Now, to understand
why this state of the muscles should have the effect here mentioned, we
are to recollect, that the strength of some orbicular joints depends very
little either upon ligaments, or the conformation of the bones ; but prin-
cipally upon the support which they derive from the muscles and tendons
which pass over them. This is exemplified in the shoulder. Here if we
except the muscles, we find little to strengthen the joint, or hinder dis-
location. The capsular ligament is too loose and yielding ; the glenoid
cavity too shallow to form much resistance to the displacement down-
wards and in some other directions. Hence, when the deltoid is affected
with palsy, the mere weight of the arm will sometimes cause such a
lengthening of the synovial membrane, that the head of the humerus
descends two or three inches below the glenoid cavity.
Sir Astley Cooper mentions the case of a young naval officer, whose
foot had been placed on a small projection of the deck of a ship, while
* See Thornhill's case of dislocation of the femur into the ischiatic notch, with frac-
ture, reduced after six weeks j reported in London Med. Gaz, for July 1839.
238 DISLOCATIONS.
his arm was kept extended for an hour with a rope fastened to the yard-
arm. Whenever this person afterwards raised his arm to his head, a dis-
location was produced. The muscles of the shoulder were wasted and
weakened, so that they could neither prevent the luxation, nor resist the
reduction, which was perfectly easy. The same tendency to dislocation
is illustrated also by Sir Astley Cooper in a case of paralysis of one side
from dentition, where a young gentleman had the power of throwing the
head of the humerus over the posterior edge of the glenoid cavity, but it
could be most easily replaced again.
When the ligaments are preternaturally loose, dislocations will arise
from very slight causes. Hence, some persons cannot yawn, or laugh,
without the risk of a dislocation of the jaw. Sir Astley Cooper speaks
of a young girl, brought up to tumbling, whose patella used to be brought
flat against the outside of the external condyle, whenever the rectus
muscle was put in action. Collections of fluid in the knee, by causing an
elongation of the ligaments of the patella, give a tendency to dislocation
of that bone. Whenever a bone has once been dislocated, the production
of the displacement again is more readily effected, than in the first in-
stance.
Such diseases as destroy the cartilages, ligaments, and more or less of
the articular surfaces, often cause dislocations, which, as I have stated,
then receive the name of spontaneous or consecutive ones. We meet with
them frequently in the hip, and sometimes in the knee. There used to
be a specimen in the museum at St. Thomas's, in which the bones of the
leg were so displaced from the knee by disease, that the leg formed a
right angle, directly forwards from the condyles of the femur. I have
also seen the head of the tibia drawn quite up into the ham from disease
of the knee-joint ; also another case in which the tibia could be moved,
and this, even when the limb was extended, very far towards either side.
Bones are sometimes dislocated by the effects of the growth and pressure
of tumours on the ligaments, and parts of the articular surfaces ; also,
by the contraction of burnt parts, of which there is a remarkable example
described by Cruveilhier, where the carpus was thus displaced from the
radius. The change in the shape of the bones, produced by rickets,
will sometimes cause a dislocation. The clavicle has been dislocated
inwards at its sternal end, in consequence of disease and deformity of the
spine. Dislocations, however, are most commonly occasioned by external
violence.
In the ginglymoid joints a dislocation is usually produced altogether
by external violence ; but, in the enarthrosis, or orbicular joints, the action
of the muscles may have a share in promoting the accident. We have
one ginglymoid joint, however, in which a dislocation is commonly the
result of the action of muscles, viz. the articulation of the lower jaw.
When a person falls on his elbow, while the arm is separated from the
side, the force thus applied tends to throw the head of the humerus
down into the axilla; but the dislocation is much promoted by the action
of the pectoralis major, teres major, and latissimus dorsi, which, during the
alarm, contract, and pull the head of the bone downwards, and inwards.
When the articular surfaces are in particular positions, with respect
to each other, a dislocation may arise entirely from the action of the
muscles, as is exemplified in the jaw, also in the enarthrosis joints, when
the axis of the bone is oblique, with respect to the surface, with which it
is articulated.
With respect to the injury done to the parts about dislocated joints,
DISLOCATIONS. 239
such ligaments are torn as naturally keep the heads of the bones from
being thrown in the particular directions, in which we find them displaced
in the various examples of the accident. Even tendons in the vicinity
of the joint are frequently lacerated. The capsular ligament and synovial
membrane are torn ; in the hip the ligamentum teres is ruptured ; in the
shoulder the tendon of the biceps is occasionally, but not generally,
broken ; Sir A. Cooper in his dissections never having noticed it. When
the head of the bone is thrown into the axilla, the tendon of the sub-
scapularis is ruptured. Even the muscles themselves are sometimes
lacerated, as the pectineus, and adductor brevis in luxations of the thigh :
and while some muscles are stretched, others are shortened. From this
account, it must be manifest, that a dislocation in its most simple form is
rather a complicated injury.
General symptoms of dislocations. Pain in the joint, and great difficulty
or absolute impossibility of moving it. These are equivocal, belonging to
other cases,, as a bruise, a fracture or a sprain.
We may say, however, that the symptoms generally consist of an
interruption of the functions of the joint. The head of the bone can
often be felt in an unnatural situation, and amongst parts which it com-
presses and renders painful. Hence, there is a diminution or loss of
motion in the joint, the limb or part is either shortened, lengthened, or
distorted, according to the kind of dislocation. When there is an elong-
ation of the limb, it removes all suspicion of fracture, and this view is
confirmed by the circumstance of there being no crepitus. The axis of
the dislocated bone is changed, the shape of the joint is altered, the
natural prominences of bone either disappear or become less conspicuous,
as the trochanter does in dislocations of the hip, or the reverse may
occur, as is the case with the olecranon in dislocations of the elbow,
and the acromion in dislocations of the shoulder, these processes project-
ing more than usual. In many cases the head of the bone may be
plainly felt in its new situation, and then the nature of the accident is
readily detected by rotating the limb, as the head of the bone then also
rotates.
The pressure of the head of the bone on the surrounding parts causes
severe pain, which is much increased when the limb is moved. When a
large nerve is thus compressed and injured, an obstinate, and even an
incurable palsy may be the result. Nay, the pressure of a dislocated
bone upon important organs may endanger life, as has happened from
the pressure of the dislocated sternal end of the clavicle upon the
oesophagus.
In subjects who are not too fat, and in whom inflammation and
swelling have not had time to come on, the head of the dislocated bone
may sometimes be distinctly felt, forming a preternatural tumour or
projection ; while, in the situation of the articular surface, there is an
unusual depression, or a want of fulness. 9
A dislocated bone cannot be so easily moved about as a fractured one,
yet, for a short time after the accident, a considerable degree of mobility
sometimes remains. In one case, the head of the thigh-bone was thrown
upon the obturator foramen, the femur could at first be moved about with
freedom; but, in less than three hours, the head of the bone became
firmly fixed by the contraction of the muscles.
Dislocations are generally followed by swelling, which comes on quickly
and to a considerable extent, when the violence has been great — the joint
is a ginglymoid one — and blood extravasated. Such swelling often con-
240 DISLOCATIONS.
ceals the displacement of the bones, and hides the change in the relative
situations of certain processes of bone, so that it becomes less easy to
make out the nature of the accident.
In simple dislocations which have been reduced, the ensuing inflamma-
tion rarely terminates in suppuration, though two fatal instances of it,
after the reduction of dislocations of the hip, are recorded by Sir Astley
Cooper.
The prognosis depends upon several considerations. The increased
trouble and danger of compound and complicated dislocations I have
already mentioned. Old luxations can hardly ever be reduced after a
certain time, for not only the muscles become permanently shortened, and
the articular cavity more or less obliterated, but the head of the dislocated
bone acquires adhesions to the parts in its new situation, and is sometimes
confined by a new bony socket, which must be broken ere the head of
the bone can change its situation again.
When a dislocation of an orbicular joint is left unreduced, nature will
sometimes make vast efforts to restore to the limb some degree of the
power which it has lost. She does this occasionally by forming a kind of
new joint, and, as I have said, even sometimes a new socket, for the dis-
placed head of the bone. In the generality of cases, if the head suffer
pressure, it undergoes a change in its shape, and becomes lessened. New
ligaments are sometimes produced, calculated for holding the head of the
bone in the best situation which circumstances will allow, with a view
to the restoration of some use in the limb. Thus, when the head of the
humerus has continued long unreduced, the cup of the scapula becomes
filled up, a new cavity may be formed on the concave surface of the scapula
for the head of the humerus, and new ligaments produced, adapted to
this substitute for the original joint.
In the hip, a new cavity is sometimes formed for the head of the femur
near the anterior and superior spinous process of the ilium, or the head of
the bone may lie upon the dorsum of the ilium, or upon the foramen
ovale, and there have a new kind of joint with a socket and ligaments
produced around it.
In the ginglymoid joints, however, nature has much less power of
lessening the evils of a neglected and unreduced dislocation. The shape
and breadth of the articular surfaces readily explain why this should be
the case. Circumstances are very different from those of an enarthrosis
joint, where the displaced head of the bone is more or less globular, a
configuration which qualifies it admirably for motion in every direction.
In fact, in the ginglymoid joints, the dislocations of which we know are
generally incomplete, the neglect to reduce the displacement is often fol-
lowed by anchylosis. By referring, however, to Cruveilhier's great work
on Pathological Anatomy, we may find cases and engravings illustrative
of the efforts which nature sometimes makes, even in an unreduced dis-
location of the elbow, to form new articular cavities for the displaced
ends of the humerus and radius. Many years ago, I saw a case, in which
a lad about sixteen years of age dislocated the upper head of the ulna
into the place of the radius, so as to displace the head of the latter bone
from the lesser articular surface of the humerus. The accident had not
happened more than between three and four weeks, yet two of the late
surgeons of St. Bartholomew's, namely, Mr. Abernethy and Mr. Ramsden,
with every means they could devise, were not able to reduce the ulna
into its right place again.
Notwithstanding the partial improvement in the state of the limb, ac-
,
' TREATMENT OF DISLOCATIONS. 24-1
complished by nature, in unreduced luxations of the ball and socket
joints, it may be observed generally, that she can never of herself rectify
these accidents ; and the patient, if his case be mistaken or neglected,
will be for ever afterwards a cripple — a monument of surgical ignorance —
the disgrace of the practitioner originally consulted.
With respect to the question, what ought to be done for old unreduced
dislocations ? the answer is, that after a certain time nothing can be done.
Attempts to reduce the shoulder after it has been dislocated three months
have rarely succeeded in this country ; and if conducted with too much
violence, they may cause serious mischief, rupture of the axillary
artery, paralysis from injury of the axillary plexus of nerves, laceration
of the soft parts, gangrene, and death. If the head of the bone should
have formed an accidental connexion with the axillary artery, the rupture
of this vessel may happen in the attempts to reduce the bone, as exem-
plified in two cases under Professor Gibson.*
On the other hand, Baron Dupuytren, some time ago, had reduced
twenty- three dislocations of the hip and shoulder, which had remained
unreduced from fifteen to eighty-two days. In all old cases, if an attempt
is to be made to reduce the bone, the patient's muscles should be first
weakened by means of the warm bath and bleeding ; plans which Dupuy-
tren always practised. As for the emollient and oily applications to the
parts, employed by Dupuytren, I cannot suppose that they could have had
any real effect on the nature of the resistances which were encountered.
Pulleys were not employed, but gradual extension was made by the assist-
ants, while the patient was engaged, as much as possible, by conversation,
and his mind diverted from the case.
The dislocations, named by Dupuytren original, or congenital, depend-
ing upon the imperfect formation of the acetabulum, are of course in-
curable. The same remark applies to other congenital dislocations.
TREATMENT OF DISLOCATIONS.
1. The first indication is to reduce, or replace the head of the bone, or
articular surface that has been removed from its natural situation.
2. The second is to prevent all movements of the limb, or part likely to
bring on a return of the displacement, or a disturbance of the torn synovial
membrane, ligaments, muscles, and tendons.
3. The third is to endeavour to render the inflammation following the
accident as moderate as possible.
1. Reduction. In order to be able to judge of the principles by which
we should be guided in the fulfilment of this first indication, we should
consider what are the resistances likely to be encountered.
The chief impediment to the reduction generally arises from the resist-
ance of the muscles, and becomes greater and greater in proportion to the
length of time which the bone remains unreduced. The business of the
surgeon is to counteract this resistance. If the attempt at reduction be
made immediately after the accident, the resistance of the muscles is
then more easily overcome than afterwards ; and, very often, if the ope-
ration be deferred for only a few days, the utmost difficulty is expe-
rienced.
That the action of the muscles forms the principal impediment to
reduction is proved, first, by the facility of replacing the head of a dislo-
* See Gibson's Institutes of Surgery, vol. i. p. 324. eel. 5. Philadelphia, 1838.
R
24?2 TREATMENT OF DISLOCATIONS.
cated bone when the muscles are paralytic : secondly, by the same facility
which occurs when the patient happens to faint, or to be debilitated by
bleeding, sickness, intoxication, or any other cause.
Another proof of the muscles being the powers resisting the surgeon's
endeavours to reduce the bone, is the ease with which a luxation may
often be reduced when the attempt is suddenly made while the patient's
mind is directed to another subject, and the muscles are unprepared for
resistance. These facts furnish useful suggestions in practice ; teaching
us, not only how to avail ourselves of any accidental swoon, or syncope,
as an advantageous moment for the reduction ; but also, how, in cases
attended with difficulty, to adopt means for the express purpose of in-
ducing faintness, great temporary debility, and universal muscular relax-
ation. The means alluded to are, bleeding from a large orifice, nauseating
doses of the tartrate of antimony, the warm bath, and the exhibition of
opium.
I do not mean, however, that such means should be employed in every
case of dislocation ; — certainly not ; only in those where great resistance
is to be overcome owing to the strength' of the muscles, or to the time
the bone has been out of its place.
The reduction of a dislocated bone requires, of course, the employ-
ment of mechanical force in some way or another, to bring the head of
such bone back into its proper situation again.
It is chiefly the orbicular joints, whose dislocations are liable to the
primary and secondary displacement already referred to. The luxations
of ginglymoid joints are generally incomplete ; and no secondary dis-
placement from muscular action usually follows the first immediately
occasioned by the violence itself.
In fulfilling the first indication, we are to consider what course the head
of the bone has taken to reach its present situation, and make it return, as
nearly as possible, by the same track. If it be the upper head of the hu-
merus, or of the thigh-bone, that is dislocated, and it should appear to
have undergone secondary displacement, by the action of the muscles,
we are then to direct our first interference to the removal of this second-
ary displacement. In short, extension is first to be made for the purpose
of dislodging the head of the bone from the situation into which it
has been retracted by the muscles. It is therefore generally made in
the direction, which the dislocated bone has assumed. Now, in many
cases, no sooner has this been done, and the head of the bone been a
little inclined towards its articular cavity, by giving the bone a particular
direction, than it is drawn into its place again by the muscles themselves,
a snap being heard at the moment of its gliding into the socket.
If, however, we were merely to make extension, we should not gene-
rally reduce the dislocation, but pull the patient off his chair or bed.
The extension must therefore be accompanied with some plan for fixing
the bone or bones with which the luxated one is naturally connected : it
must be combined with counter -extension. In the reduction of disloca-
tions of the hip and shoulder, counter-extension is usually made by means
of a girth, or sheet, with which the pelvis or chest is fixed. The girth,
or sheet, may be held by the assistants, or be fixed to a post, or iron ring
screwed into the wall, or floor.
On the Continent, many surgeons apply both the extension and counter-
extension, as far from the dislocated joint as they can. In dislocations of
the hip, they make extension at the ankle, and counter-extension by
fixing the pelvis ; in dislocations of the shoulder, they make extension at
TREATMENT OF DISLOCATIONS. 243
the wrist, and counter-extension by fixing the scapula and chest. Tn dis-
locations of the forearm, instead of making counter-extension at the
humerus, as is done in England, Baron Dupuytren makes it by fixing the
chest and shoulder just as we do for the reduction of the head of a dislo-
cated humerus. The necessity of fixing the scapula and chest in disloca-
tions of the shoulder, and the pelvis in dislocations of the hip, is so
obvious as to require no comment.
In this country, in compliance with Pott's advice, extension is most
commonly made by applying the force to the lower part of the dislocated
bone itself, and counter-extension by fixing or applying the counter-ex-
tending force to the bone or part with which the dislocated one is natu-
rally articulated. In dislocations of the shoulder and hip, the French
plan affords the advantage of a longer lever, whereby additional power is
gained, not merely in the extension itself, but at the important period
when, by making use of such a lever, as a means of inclining the head of
the bone towards its socket, we give the muscles the opportunity of
drawing it back into its right place again.
The principle of using the dislocated bone, or even the whole limb, as a
kind of lever for the accomplishment of the reduction, is one of the highest
importance, perhaps of as much practical utility as that of relaxing the
muscles concerned in making the greatest resistance to the completion of
this first indication.
In certain dislocations, the reduction cannot be accomplished merely
by extension and counter-extension. When the head of the thigh-bone is
thrown upon the obturator foramen, these means are useful when carried
to a moderate extent ; or, in other words, when practised just so far as
to dislodge the head of the bone from that situation ; but the limb not
being shortened, nor the bone truly retracted, further extension will do
no good. The object is now to incline the head of the bone outwards
towards the acetabulum, by carrying the knee and leg inwards ; while a
kind of fulcrum for the lever, which the femur now represents, is some-
times formed by placing a band or piece of cloth upon the inside of the
thigh a little way below the groin, and drawing it outwards at the mo-
ment that the lower part of the bone and limb is moved inwards.
This principle of using the dislocated bone as a lever for the reduction
of its displaced head, or articular surface, is illustrated in the treatment
not only of luxations of the hip, but in those of the shoulder, jaw, and
other parts.
In the hip, indeed, it is necessary on another account, viz. the acetabu-
lum is surrounded by a high ridge, which makes it necessary that the
head of the bone should be lifted over it. Nothing has a greater effect
in facilitating the reduction, than attention to this principle.
The relaxation of the muscles was insisted upon by Pott as much in the
treatment of dislocations as in that of fractures, and when it can be
practised with due attention to other principles, it cannot be to^ much
commended ; but, in the reduction of some dislocations, the position of
the limb must occasionally be regulated by other considerations, as, for
instance, the advantage of making the first extension in the direction calcu-
lated to remove the secondary displacement ; in other words, for dislodging
the head of the bone from the situation into which it has been drawn by
the muscles subsequently to its first displacement. Neither is the advan-
tage of the lever to be sacrificed altogether to the plan of relaxing the
most powerful muscles.
In a dislocation of the lower end of the tibia from the astragalus, relax-
R 2
24-4? TREATMENT OF DISLOCATIONS.
ing the powerful muscles of the calf of the leg has very great effect in
facilitating the reduction.
The extending force may be made either with towels, sheets, a table-
cloth, or any other piece of strong linen, folded and applied round the
limb, and drawn by assistants, or else with a multiplied pulley; while the
counter-extension is made with a girth or cloth, by which the shoulder or
pelvis is fixed.
In dislocations of ginglymoid joints, however, it is seldom requisite to
use any folded sheets or cloths either for the extension or the counter-
extension, as both can be effectually performed with the hands of the
surgeon and his assistants.
In France it is customary, for the purpose of preventing the soft parts
from being chafed and hurt by the pressure of the extending means, to
cover the part of the limb to which they are applied with a piece of linen
smeared with ointment. In this country, we frequently apply a wet roller
round the part, which not only protects the skin, but will not slip, like
any greasy application. Flannel or buskin has likewise been occasionally
employed.
It is a rule always to let the extension be made unremittingly and
increased very gradually. Sudden violent efforts will be resisted by the
muscles, and are more likely to cause laceration of the soft parts than
the return of the bone into its place. Moderate extension, slowly in-
creased and incessantly maintained, will soon tire the strongest muscles.
When the resisting muscles are very powerful, or there is additional
difficulty on account of the length of time which the dislocation has con-
tinued, we may let the attempts at reduction be preceded by means cal-
culated to bring on temporary weakness or fainting.
The return of the bone into its right place is indicated by the snap heard
at the instant of its slipping into the socket, by the restoration of the
proper shape of the joint, and by the recovery of its original motions.
No "snap is audible, however, if the patient be very faint, or weakened by
intoxication ; for then the muscles do not generally act with sufficient
vigour to occasion a sudden return of the bone into its socket. That
part of the process of reduction, which consists in putting the head of the
bone in its place, is termed coaptation. In the orbicular joints, when ex-
tension and counter- extension are made, the muscles sometimes replace
the head of the bone by their own action, without the surgeon troubling
himself much about coaptation ; but, in dislocations of the ginglymoid
joints, the coaptation, or pressure of the head of the bone towards its
right place, is frequently even more essential than extension and counter-
extension, of which a very moderate degree is sufficient.
2. The second indication is to prevent all movements of the part or
limb likely to produce disturbance of it, or to bring on a return of the
displacement. The rupture of the ligaments, and sometimes of tendons,
which naturally strengthen the joint, render this precaution necessary.
The reduction having been accomplished, our next object is to confine
the part or limb in a posture in which the luxation cannot return. For
instance, the head of the thigh-bone cannot be thrown out of the aceta-
bulum while the limb is in the state of adduction, with the knee close to
its fellow. Hence, after the reduction of such a dislocation, the knees
are to be confined together with a slack roller. The shoulder cannot be
dislocated while the humerus is kept near the side : after the reduction,
therefore, we confine the elbow in that posture with a sling, aided some-
times by a roller. The lower jaw cannot be dislocated unless the mouth
COMPOUND DISLOCATIONS. 245
be widely opened. After the replacement of the condyles, therefore, we
put on the four-tailed bandage, by means of which we keep the bone
quiet, and hinder the mouth from being opened.
This prevention of motion of the dislocated bone, and confinement of
it for a few days in a particular position, determined on the foregoing
principle, are also useful in promoting the union of the torn ligaments,
tendons, and muscles. It is one of the best things likewise with the view
of preventing the inflammation from attaining a severe degree.
The third indication, or the prevention and removal of tfie inflammation
and its effects, sometimes requires, besides quietude of the part, other
antiphlogistic means, such as cold evaporating lotions, leeches, and pur-
gative medicines, and, in severe cases, venesection, fomentations, and
poultices. One might expect, that the consequences of the inflammation
would be more serious after a dislocation, where ligaments, muscles, and
tendons, are actually torn, than after sprains, where they are only violently
stretched. But experience proves the contrary, and that, if the reduction
be skilfully performed, the inflammation and swelling commonly subside
in the most favourable manner.
COMPOUND DISLOCATIONS.
Here the severity and danger depend upon various circumstances : —
1. The size of the joint.
2. The extent of the laceration in the synovial membrane, and of the
injury of the ligaments and tendons.
3. The degree of contusion and laceration in the soft parts.
4. Several complications, as fracture and comminution of the bone,
rupture of large blood-vessels, considerable effusion of blood in the
cellular tissue, paralysis, &c., bad health, extreme old age, and general
debility.
The ankle-joint is perhaps more exposed to compound dislocations,
than any other joint in the body, which are also, for the most part, com-
plicated with a fracture of the fibula. Compound dislocations of the
thumb are remarked to be followed by tetanus with extraordinary fre-
quency ; and hence some writers, but not good practitioners, as I suspect,
advise, in these cases, amputation, as a preventive of that fatal disorder.
Compound dislocations are to be treated very much on the same prin-
ciples as compound fractures. The first thing for decision is, whether
the circumstances of the accident justify the attempt to save the limb.
If the joint be the knee, the laceration in the capsular ligament exten-
sive, several other ligaments torn, and the integuments and soft parts
considerably injured, amputation should be performed without delay.
In compound dislocations of the elbow, wrist, and ankle, amputation is
less frequently performed at the present day than formerly. After the
reduction, appearances are much changed for the better ; and these acci-
dents, unless accompanied by an extraordinary degree of laceration and
contusion of the soft parts, and complicated also with fracture, generally
terminate well.
When an attempt is made to save the limb, the bone or bones are first
to be reduced. The next object is to heal the wound, if possible, by the
first intention, so as to convert the case, as it were, from a compound
into a simple dislocation.
If the head of the bone should protrude, and much difficulty be expe-
rienced in the reduction, some practitioners would adopt the plan of
sawing it, off ; but, if it can be returned into its proper place again, this
R 3
246 CONTUSIONS,
seems to me to be the best practice. The cases published by Mr. Hey,
of Leeds, are certainly but little in support of the other suggestion,
though intended to convey the most favourable view of it. The edges of
the wound, having been brought together with sticking plaster, the joint
may be covered with linen, wet with a cold evaporating lotion, and kept
steady and motionless by means of splints duly applied, and lined with
soft pads.
In the early stage, venesection, leeches, purging, low diet, and other
antiphlogistic means will be requisite.
At present, limbs are not so frequently amputated for compound dislo-
cations as they used to be thirty or forty years ago ; the right principles
of treatment being now better understood. Cases, which have an alarm-
ing appearance, while the bones protrude, and the external wound is un-
closed, look very differently after the reduction of the bones, and the
dressing of the wound.
However, examples do occur, in which the propriety of amputation is
unquestionable, and it must be judged of by reference to some of the
considerations already mentioned.
When from the first no chance presents itself of ultimately saving the
limb, the knife should be employed without delay. If we lose time, we
only give an opportunity for inflammation, suppuration, and even gan-
grene, to arise, attended with such disturbance of the whole constitution
as may neither admit of being controlled, nor afford another period suffi-
ciently tranquil for the successful performance of the operation. All
the considerations already specified in this work, with regard to severe
gunshot-wounds of the limbs, and the worst kinds of compound frac-
tures, are equally applicable to bad compound dislocations.
CONTUSIONS.
A contusion or bruise is a mechanical injury of the soft parts,
produced by the blow of some obtuse body or weapon, or the collision of
a hard blunt substance against them, without, however, any breach taking
place in the integuments, which, technically speaking, would make the
accident rank as a contused wound, and not a simple bruise. A contusion
varies in degree, from a very trivial injury of the parts which have re-
ceived the blow, to their complete disorganisation, as exemplified in those
dreadful forms of mechanical violence, erroneously termed wind-con-
tusions. In all severe contusions, besides the sudden forcible compres-
sion of the parts, besides the inflammation necessarily following the
injury of various textures, there is a rupture of an infinite number of
minute blood-vessels, and the knowledge of this fact will account for
the rapidity with which the swelling frequently comes on. It also
explains to us the cause of the black and blue, or livid, discolouration
following ordinary bruises, and well known amongst surgeons under the
name of ecchymosis. Of this effect of a contusion, what is called a black
eye is a familiar example. An ecchymosis depends then upon the escape
of blood from the minute vessels into the cellular tissue. Numerous
small arteries and veins are burst by the violence of the blow, and blood
and serum are immediately effused into this texture. However, the
reason of the various shades of red, purple, green, and yellow, which
present themselves in the different degrees and periods of an ecchymosis,
is not entirely ascribable to the extravasation of blood, but to other
changes, the nature of which has, perhaps, not been made out. Dr.
Macartney's explanation of it is, that the absorbents first take up the
CONTUSIONS. 24/7
colouring matter ; and hence, says he, the colour of bruised parts is, in
the beginning, a dark purple, or black colour, because the effused blood
soon acquires the venous character, and, as the colouring matter is ab-
sorbed, the part becomes yellow.
When the skin is unbroken, the extravasated blood may accumulate in
considerable quantity ; and it is a remark made by Dr. Macartney, that,
unless it be wanted for reparation, as in fractures, it usually does not
coagulate, and is removed by the absorbents.
Contusions sometimes produce the rupture of more considerable ves-
sels, and then the hemorrhage, in particular situations, may have fatal
consequences. Thus, when a contusion of the head occasions the rupture
of one of the arteries of the brain, or of the dura mater, the pressure of the
effused blood upon that important organ will give rise to the most urgent
danger. Here the peril is not from the quantity of blood abstracted
from the circulation, but from its pressure on a certain part, whose func-
tions cannot bear it without life being endangered. In other instances,
however, we find enormous collections of blood, vast extravasations
arising from contusions, but not attended with any serious degree of
danger, though productive of an immense degree of swelling, and much
disfigurement. Thus, a contusion of the head, instead of rupturing one
of the arteries of the brain, or dura mater, may only burst a considerable
arterial branch under the scalp. In this circumstance, the scalp will some-
times be raised up from the skull several inches ; and were the degree of
danger to be estimated by the degree of swelling and deformity, a very
erroneous prognosis might be delivered. In fact, experience proves,
that most of these collections of blood in the cellular tissue from con-
tusions admit of being dispersed by proper treatment, and this generally
without making any opening for the discharge of such blood. The ab-
sorbents are for the most part competent to bring about its removal.
The severity of a contusion depends, not simply upon the violence with
which it is occasioned, but upon the nature of the parts affected by it.
Thus contusions of the skull, on account of the mischief, likely to be pro-
duced by them within the head, are always perilous accidents. A con-
tusion on the hypogastric region, at a period when the bladder is distended
with urine, will easily rupture that organ ; a contusion on the abdomen,
when the bowels are distended, will sometimes burst them, and cause a
fatal effusion of their contents in the cavity of the peritonaeum. A con-
tusion of the integuments, situated directly over the hard surface of a
bone, will often cause them to slough, whereas similar violence applied to
the skin, not so situated, would not lead to equal mischief.
Contusions are sometimes dangerous, from the effect they have on
parts more or less remote from those on which the violence has immedi-
ately acted. This effect is termed by the French a contrecoup: Pott
mentions an illustration of it in a man, who fell with great force on the
tuberosities of the ischium without striking any other part of the body ;
yet the result was a concussion of the brain.
In the treatment of contusions, the first indication is to prevent and
dimmish the inflammation likely to follow the accident. For this purpose,
rest, fomentations, or cold evaporating lotions, and, in severe cases, vene-
section, purgative medicines, leeches, and antiphlogistic treatment in
general are proper. Bruised muscles are to be relaxed. Cold applica-
tions have a useful effect in checking the further effusion of blood into
the cellular tissue.
The second indication is to promote the absorption of the extravasated
248 SPRAINS.
blood and serum by employing (after the tendency to inflammation has
subsided) means calculated to quicken the action of the absorbent vessels ;
lotions containing hydrochlorate of ammonia, diluted acetic acid, and cam-
phorated spirit of wine ; and, when the case is chronic, camphorated
liniments, and the pressure of bandages.
The third indication is to restore the tone of the parts, and remove any
disposition to redema. This object requires more stimulating liniments,
containing iodine, or iodide of potass, or a good proportion of camphor
or ammonia ; pumping cold water on the parts, champooing, passive
motion, and a bandage.
When, notwithstanding the means here recommended, the absorbents
appear incapable of dispersing the swelling caused by a copious effusion
of blood, and matter forms, it becomes indispensable to make an opening,
remove as much of the blood as possible, and treat the case like a com-
mon abscess.
SPRAINS.
When a joint is forcibly moved, or twisted, in any direction further
than the natural conformation of the bones 'and arrangement of the
ligaments will properly allow, yet without the degree of displacement
amounting to a dislocation, the accident is termed a sprain. In every
sprain, then, the ligaments are violently stretched, and no doubt, sometimes,
partially torn. This is not, however, all the mischief attending such an
accident. The violent wrench, or twist of the joint, extends its action to
all the surrounding soft parts ; the tendons and their thecas, the integu-
ments, and even the muscles themselves, through the medium of their
tendons. All these parts are sometimes stretched with a degree of vio-
lence, that must involve them in the consequences. The ginglymoid
joints chiefly suffer from sprains, especially the ankle, the wrist, and
articulations of the fingers and thumbs. A ginglymoid joint is more
liable to a sprain than an orbicular one, because its movements are natu-
rally very much restricted to two directions, so that any accidental twist,
or forced movement of it in another direction, cannot happen without
the ill consequences being produced to which I have adverted. If it
could move in every direction, like an orbicular, or ball and socket joint,
then it would suffer a sprain only when the movement were forced in any
direction beyond a certain point ; but the movement, if not carried too
far, might be made in any direction without mischief. The observation,
that an orbicular joint cannot be sprained, does not appear to be al-
together correct ; for the shoulder is sometimes sprained by the arm
being carried too far behind the trunk, and, as Sanson remarks, the hip
may be sprained by the extreme abduction of the femur. As for the
general symptoms of a sprain, they consist of pain, faintness, or even
sickness, inability to use the joint, more or less swelling, and a degree of
ecchymosis. The effects of sprains in elderly persons are often tedious,
disabling such persons for weeks and months. These accidents, indeed,
frequently require a longer time to be cured, than the complicated
injury left in the textures about a joint after the reduction of a dislo-
cation.
The fast indication is to keep the sprained joint perfectly quiet, and
adopt measures to prevent inflammation. At first, we may apply cold
evaporating lotions, or fomentations, and have recourse to leeches, pur-
gatives, and in severe cases to venesection. Fomentations often give
more relief than cold applications.
DISEASES OF THE BLOOD-VESSELS, 249
When all disposition to inflammation is past, and merely a degree of
'stiffness and a tendency to oedema remain, the 'second indication is to aim
at the removal of these consequences, by means of liniments, bandages,
the pumping of cold water on the joint, straps of soap and adhesive
plaster applied circularly and perpendicularly in an alternate manner, so
as to form an efficient support for the joint and neighbouring parts,
champooing, &c. In scrofulous persons, sprains frequently lead to
disease of the joints ; and whenever there is reason to suspect, from the
tediousness of the case and the general appearance of the patient, that
any danger of this kind is present, the part ought to be blistered without
further delay.
DISEASES OF THE BLOOD-VESSELS.
The diseases of arteries and veins constitute one of the most interest-
ing departments of surgery. In the remarks on hemorrhage, and on the
principles which should guide us in the choice of means for its stoppage,
I have indeed already touched upon the subject ; but various parts of it
still remain to be explained.
1. Diseases of arteries. The participation of arteries in the general
organisation of all other living parts of the body must render them sus-
ceptible of inflammation, suppuration, ulceration, and sphacelus. They
are also liable to a deposit of earthy matter between their internal and
middle coats; to a steatomatous thickening ; to dilatation; to obliteration; and
to several other deviations from their healthy condition.
The two great arterial trunks, the aorta and pulmonary artery, differ
remarkably in two respects. The branches of the aorta unite and
anastomose freely with other branches derived from that vessel or
its continuations ; but the branches of the pulmonary artery remain
separate and unconnected from their origin to their very termination.
A thin transparent pellicle is found to line the interior of a large
aortic artery. Externally to this is a dense hard brittle tissue, which
can be separated only in scales, forming in reality a distinct tunic com-
posed of several layers, situated between the fibrous and serous coats.
This structure, which Malgaigne has named the sclerous coat, is that
which renders the aortic branches stronger than those of the pulmonary
artery ; so that if branches of equal diameter be cut through, that from
the aorta will present an almost circular opening, while that from the
pulmonary artery will be evidently collapsed. When any species of con-
cretion, or any point of ossification, occurs in the aorta, it is almost
always in this tunic ; and it is remarkable that, in the pulmonary artery,
where this coat is not found, no well-attested case of ossification is on
record.
The coats of the aorta are often the seat of disease, find the
branches arising from many of the trunks which it gives off frequently
wounded; while those of the pulmonary artery rarely undergo any
morbid change, are seldom wounded, and, when they are so, admit of
little being done. Hence, with reference to surgery, the aortic system
of arteries is by far the most interesting.
The internal coat of an artery is more subject to inflammation, than
either its middle or its external coat. This is proved by the frequent and
copious effusion of lymph upon the inner surface of an artery, in conse-
250 DISEASES OF THE BLOOD-VESSELS.
quence of the inflammation of contiguous parts, the application of a
ligature, the effect of a wound, the pressure of tumours, or any irrita-
tion in the vicinity of the artery affected. Sometimes the inflammation
thus excited spreads to a great distance from the point at which it
commences, even up to the heart itself. Such a case receives the
name of arteritis ; a formidable complaint, rapidly producing great irrita-
tive fever, an extremely quick pulse, collapse, low delirium, and generally
death.
Chronic inflammation of the arteries is frequently met with, especially
as a cause or effect of calcareous deposit. An appearance, similar to that
produced by inflammation, often presents itself upon the internal surface
of arteries ; viz. a vivid redness or scarlet tinge. This is not, however,
always the result of inflammation ; for it may not be accompanied by an
effusion of fibrine, or any thickening of the vessel. Arteries exposed in
the dissecting room to the air for a few days, and in which a degree of
putrefaction has taken place, invariably assume the same colour.
Although large arteries resist ulceration fora long while, they are some-
times involved in it. When healthy, and not placed under circumstances
peculiarly unfavourable to their own nutrition, they seem to be capable
of resisting its destructive effects more powerfully, than when their
external surface has been separated from its surrounding connections, or
their coats are the seats of previous morbid alterations.
Considerable arteries not only pervade the generality of diseased struc-
tures for a long while without being attacked by ulceration, but preserve
themselves in the midst of the worst tubercular and cancerous affections.
This indisposition of arteries to suffer from the ravages of surrounding
diseases, is strikingly illustrated in the extensive cavities sometimes
formed towards the roots of the lungs in tubercular phthisis ; all those
frsena or bands, extending across such cavities, being only arterial
branches, which have escaped the work of disorganization. Sometimes,
however, the arteries are attacked by ulceration, in consequence of
certain forms of disease around them. We know that this frequently
happens in phagedenic ulceration, cancer, and hospital gangrene.
The internal coat of the arteries may also be attacked by ulceration,
primarily beginning in it. The ulceration s are generally of a roundish
shape ; sometimes only one exists in the whole arterial system ; some-
times the aorta is studded with them. In proof of the arteries being
liable to suppuration, I may mention, that Andral once found the lining
of the aorta raised up by six abscesses, each of which was as large as a
nut, and situated between the internal and middle coats. Pus is also
occasionally noticed within certain arteries, either blended with the
blood, or contained alone within the vessels. The same pathologist has
seen most of the branches of the pulmonary artery in this remarkable
condition.
Pus is not, however, so often found between the internal and middle
coats of arteries, as a peculiar matter, that is not precisely like any other
production in the animal economy, and has long been described under
the name of a pultaceous or an atheromatous substance. Blended with it,
are frequently noticed particles of earthy matter, which feel like sand.
When they are abundant, they form, within the texture of the vessel, a
sort of concretions more like mortar in their appearance than bony form-
ations. These calcareous deposits are so common in elderly persons, that
they are calculated to exist in seven tenths of all individuals whose ages
exceed sixty. This was the observation of Bichat, which agrees with that
DISEASES OF THE BLOOD-VESSELS. 251
of Dr. Baillie, who represents the change as being more frequently seen
in old persons, than the natural or perfect state of the arteries.
However, young subjects are not completely exempt from such ossifica-
tions. The temporal artery has been found ossified in a child only fifteen
months old ; and the late Mr. Wilson met with an ossification of the
aorta in a subject aged only three years. In one girl, eight years old,
and in four or five other young persons between eighteen and twenty-
four years of age, Andral saw the aorta studded with calcareous deposits ;
and in another person under forty, there was a considerable ossification
of the superior mesenteric artery.
Strictly speaking, the internal coat is never the seat of these earthy
deposits, though it is frequently raised up by them, thinned, and even
cracked, or more or less absorbed, so that they are then actually in im-
mediate contact with the blood itself.
While these earthy deposits are forming in the arterial texture, the
middle or fibrous coat undergoes a morbid change, sometimes becoming
thickened, and in other instances wasted, and its place occupied by the
calcareous matter. An analysis of these earthy concretions of the
arteries proves their usual composition to be phosphate of lime, and
animal matter, in the proportion of about sixty-five of the former to
thirty-five of the latter. Such concretions are 'nowhere more frequent
than in the aorta, and they rhave been met with in every one of its
branches. In its abdominal branches, there is some diversity in this
respect ; for, while the splenic artery is frequently ossified, the hepatic and
coronary stomachic are rarely found in this condition. The arteries of
the limbs are well known to be often affected in this manner ; and every
man of experience in the habit of feeling the pulse, must have occasion-
ally perceived the radial artery to be ossified. However, the coats of the
arteries of the upper extremity are much more rarely the seat of any dis-
eased alteration, than those of the arteries of the lower limbs.
Sometimes an artery is completely incrusted with earthy matter, so as
to form an entire rigid cylinder ; and, in other instances, the phosphate of
lime is blended with an atheromatous substance. This condition of an
artery often lays the foundation for the disease, called aneurism. It also
sometimes makes an artery incapable of bearing a ligature, which either
breaks through the vessel at once, or causes ulceration of it without
adhesion. In the Med. Chir. Trans, of London, is a case by Mr. LangstafF,
illustrating the inefficiency of the ligature on the ossified arteries of a
stump ; with another by Mr. Lawrence, proving that an ossified artery
may sometimes be tied with success.
Aneurism is defined to be a tumour formed by arterial blood, and
communicating with an artery ; or it may be said to be generally a pul-
sating tumour, arising from a dilated, ruptured, or wounded artery, and
filled with blood, which, while the disease is recent, and of trivial size,
is in a fluid state, but afterwards, when the swelling is largei^and has
existed a considerable time, is found partly arranged in the form of solid
concentric layers upon the inner surface of the cavity or sac. Some
forms of aneurism arise either from an alteration of structure, and a
consequent dilatation of all the coats of the affected part of the artery,
or from a dilatation of the external coat alone, the inner coats having pre-
viously given way in consequence of disease or violence.
So long as the boundary of the tumour is formed by all the dilated
coats of the vessel, the disease is termed a true aneurism; but, when the
coats of the artery are wounded, or some or all of them have given way,
252 ANEURISM.
in consequence of disease, the tumour receives the name of false or spu-
rious aneurism. When all the coats of the artery have given way, the
blood may be injected extensively into the cellular tissue, so as to make
a diffused false aneurism; or collecting in one mass, it may soon become
bounded by a kind of cyst formed around it by the adhesive inflam-
mation, so as to constitute, what is termed, a circumscribed false
aneurism. *
Another rare variety of aneurism is that where, in consequence of the
destruction of the outer coats of the aorta by disease, the internal coat
yields to the impulse of the blood, and becomes dilated into an aneurismal
pouch.
This form of aneurism has hitherto been noticed only in the aorta, the
lining of which is more loose and elastic than that of the rest of the
arterial system. Some unequivocal specimens of it were collected by
Dubois and Dupuytren, and an excellent illustration of it is contained
in Mr. Liston's museum. What is termed the aneurismal varix, or
venous aneurism, is a dilatation of part of a vein, from the gush of blood
into it from a neighbouring artery. Of course, the existence of such a
disease implies a preternatural communication between the two vessels.
The aneurism by anastomosis, as it was called by Mr. John Bell, ought
not properly to be arranged with aneurisms, as it is of a totally different
nature, being the growth of a new tissue, which is compared to what the
French term the erectile tissue, abounds in blood, and, when wounded,
pours it out so profusely from every point, and even from its smallest ves-
sels, which seem to have no disposition to close, that the hemorrhage is
truly alarming.
We are then to understand, that aneurism may be produced either by
the rupture, or the dilatation of the coats of an artery, or by a combin-
ation of both these circumstances, the dilatation having preceded the
rupture. The truth of the doctrine of aneurism by dilatation of all the
arterial coats, unattended with ulceration, or laceration of the middle
and internal ones, was disputed by Scarpa ; but, the correctness of that
view, as first taken by Morgagni, and subsequently confirmed by the
valuable researches of Mr. Hodgson and others, is now universally admit-
ted. The dilatation of all the coats of an artery may then precede the
rupture of the vessel, as is often illustrated in the aorta, where the coats
of the vessel can sometimes be traced throughout the whole extent of the
expansion, while the inner surface of the sac at the same time presents
appearances peculiar to the coats of arteries. But the state of dilatation,
preceding rupture, is not confined to the aorta ; it has been noticed by
Mr. Hodgson at the bifurcation of the carotid and iliac arteries, and also
in those of the extremities. In the cases to which I refer, all the coats
were dilated and extended over the aneurismal swelling, and not merely
the external coat.
Notwithstanding these facts, the most common form of aneurism un-
doubtedly corresponds to Scarpa's description, and is attended with a
disease and giving way of the internal coats of the artery, followed by the
* M. Lisfranc recognizesj>ut two forms of the disease, the traumatic and the spontaneous.
Des differens Methodes el dcs different Proccdes pour V Obliteration dcs Artercs, &c. 8vo.
Paris, 1834. Rejecting from aneurismal diseases mere extravasations of blood, usually
described as diffuse false aneurisms, he confines the name of traumatic aneurism to a
tumour produced by blood escaping from an opening in an artery, and forming for itself
a sac at the expense of the surrounding tissues. These views seem correct.
ANEURISM. 253
dilatation of the outer tunic, which, after a time, may also burst, and
allow the blood to be effused.
When the disease consists of dilatation only, without any rupture, or
ulcerationof the inner tunics of the vessel, the swelling is generally of an
oval shape ; but when the internal coats have given way, a lateral promi-
nence is formed, which gradually increases in size. Scarpa considers the
morbid dilatation of an artery, unattended with rupture of its coats,, as a
disease totally distinct and different in many particulars from aneurism.
He represents the root of an aneurism of the aorta as never including
the whole circumference of the tube of the artery, but as occupying
only one side of the vessel, from which the aneurismal sac rises in the form
of a tuberosity appended to it, and of various size and extent, according
to its situation, and the stage of the disease.
On the other hand, he describes the dilatation of the artery, as con-
stantly affecting the whole circumference of the tube ; the blood is yet
within the proper cavity of the vessel ; no layers of coagulated blood are
ever found in the cavity of the dilated portion of the artery, as in aneu-
rism ; and, so long as the continuity of the proper coats of the vessel re-
mains entire, the circulation is not perceptibly affected. In aneurism, as
defined by Scarpa, the blood passes into a cavity, which is, as it were, out
of the track of the circulation ; there its motion is necessarily retarded,
and there it invariably deposits lamellated coagula, and sometimes in such
quantity as entirely to fill the cyst. If any solutions of continuity happen
upon the inner surface of a morbid dilatation, it is only within the cavities
and inequalities of such parts that lamellated coagula are deposited, and
all the rest of the inner surface of the disease is entirely free from them.
These solutions of continuity are looked upon by Scarpa as the beginning
of aneurism, formed subsequently to the simple dilatation. These facts
are worth recollecting, whatever view we may be inclined to take of the
usefulness of discriminating the mere dilatation from aneurism.
Whether an aneurism begin with dilatation, or not, a rupture, or ul-
ceration of all the coats of the artery, usually follows in a more advanced
stage of the disease. In most instances, the aneurism is formed by a
destruction of the internal and middle coats of the vessel, and the
expansion of the external one into a sac, which at last, giving way, the
sheath of the artery, and the surrounding parts, whatever they may be,
form the boundary of the tumour. The rupture, or ulceration of the
internal and middle coats, is not, however, always followed by aneurism
of the kind just now described. Laennec met with a case, in which the
internal and middle coats had been divided by a narrow transverse fissure,
extending over two- thirds of the circumference of the artery; and the
blood, instead of distending the external coat into a sac, had insinuated
itself between it and the middle fibrous coat, and dissected them from
each other, through more than half the circumference of the artery, from
the arch of the aorta down to the common iliacs. Fissures of .the kind
described result from cracks, or lacerations occasioned by calcareous de-
posits ; but the case reported by Laennec, and another by Mr. Guthrie,
are the only instances on record, where such a fissure was followed by
more than a circumscribed effusion of blood around it.
In the Dublin Hospital Reports (vol. iii.) is the history of another new
kind of aneurism related by Mr. Shekelton : the blood had forced its way
through the internal and middle coats, dissected the middle from the ex-
ternal one, to the extent of four inches, and then burst again through the
internal and middle coats into the canal of the artery ; thus forming a
ANEURISM.
new channel, which eventually superseded the old one, the latter having
become obliterated by the pressure of the tumour.
The sac, formed by the dilatation of the arterial coats, as it increases
in size, acquires firm adhesions to the parts in its immediate vicinity, so
that when the external coat gives way, the effusion of blood is often still
restrained by these adhesions, and the extent of the aneurismal cavity
then goes on increasing only gradually. Sometimes, however, the aneu-
rismal sac bursts, or rather is lacerated, so suddenly that there is not time
for the adhesive inflammation to circumscribe the blood, and an aneurism
with extravasation in the cellular tissue is the consequence, generally ac-
companied by a great increase of danger.
Aneurisms are divided into external and internal; the former taking
place in the arteries of the neck, head, or limbs ; the latter in the aorta,
or some of its branches within the chest or belly.
Symptoms of true aneurism. A true aneurism, when not situated
within the chest or abdomen, commonly begins in the form of a small
pulsating tumour, which subsides under pressure, and immediately be-
comes prominent again, when the pressure is discontinued. It also dimi-
nishes, becomes less prominent, and beats feebly or not at all, when the
artery, leading to it from the heart, is compressed ; but directly the com-
pression is removed, the swelling becomes as full and conspicuous as ever
again, and pulsates with its original force. At first, there is not much
pain ; and as in this stage the blood in the tumour is all fluid, and no
lamellated coagula are deposited on the inside of the sac, the swelling
throbs distinctly and forcibly.
In a more advanced stage, the tumour is larger and more solid, and
the sac cannot be completely emptied by pressure. A part of the blood
in it is now in a solid state, and the sac and the adjoining cellular tissue
are much thickened. The size of the swelling and its pressure on the
surrounding parts next begin to give pain, and obstruct the circulation.
The pulsation, however, though not so strong as at first, is yet distinct.
In a still later stage, the size and solidity of the aneurism are more
increased, and the pulsation is so weak that it can only be felt at that
part of the swelling which is directly opposite to the communication
between the artery and the sac. The sac is now almost full of lamellated
coagula, and contains but a small quantity of fluid blood. If the case be
a popliteal aneurism, the pressure on the posterior tibial nerve causes
severe pain in the foot and toes ; and the nerve itself may at length be-
come as flat as a riband, and its texture scarcely recognizable. The
pressure may also obstruct, or even obliterate, the popliteal vein ; and
these effects, and the pressure on the lymphatics, will account for the
cedematous swelling of the leg in the advanced stage of the disease. As
soon as the tumour has filled up the popliteal space, the patient cannot
completely extend the leg, nor place his heel on the ground. In the
diagnosis it is important to remember, that pulsation is by no means a
certain proof of a disease being aneurism, and also that a tumour may
be an aneurism, though it may be destitute of pulsation. I was once
sent for to Egham to give my opinion on an enormous tumour in the
epigastric region, attended with pulsations as strong as those of the
aorta itself. The patient, under the care of Mr. Gilbertson, was a young
man about twenty, and one protuberant part of the swelling was on the
point of giving way. Now, a correct judgment was formed of the
nature of the case, which was only a large chronic abscess, by the con-
sideration that, if the disease had been an aneurism of this magnitude,
ANEURISM. 255
the patient would have suffered not only excruciating pain from its
pressure, and the action of the diaphragm would have been more
obstructed, but the functions of the stomach and bowels would have
been seriously interfered with. In fact, the swelling had formed in the
quiet and insidious manner that many chronic abscesses do arise, and
had attained a large size before it attracted notice. Some useful light
was also thrown on the case by the fact of the patient having had, when
a boy, a scrofulous abscess of the hip.
I once had an opportunity of seeing another considerable abscess
between the quadratus lumborum muscle and the peritoneum, where the
tumour was so affected by the pulsations of the aorta that the tumour,
which was of immense size, throbbed with surprising force, so as to
assume very much the external character of an aneurism of that vessel.
The discharge of the contents of the tumour by puncture manifested the
true character of the disease.
Pulsating tumours, not of the aneurismal kind, may sometimes be known
by their not pulsating equally in all directions as aneurisms usually do.
The two abscesses, which I have mentioned, could not, however, be dis-
criminated by this criterion. Every part of them within the reach of
examination throbbed with equal force. Besides, we know that, in
aneurisms attended with much deposit of lamellated blood in the sac, the
pulsation is often much more distinct at one point than another.
Another better criterion, if the tumour be moveable and admit of par-
tial displacement, is to press it to one side, or raise it from the artery
near it, when, if it be not an aneurism, it will be found to possess no
pulsation. If it be an aneurism, its pulsation will not be lessened by any
change in its position.
We have also one valuable source of information in the stethoscope ;
for, if the case be an aneurism, we may, with the assistance of this in-
strument, and sometimes without it, if the ear be applied close to the
swelling, be able to hear distinctly the passage of blood into the sac,
causing a sound compared to that of the working of a pair of bellows.
If it be a fact, as it certainly is, that many pulsating tumours are not
aneurismal, it is quite as well established that a swelling may be of this
nature, though unattended with any kind of throbbing whatsoever. When
aneurisms change from the circumscribed to the diffused state, and the
blood rushes from an aperture in the sac extensively into the cellular
tissue, the pulsation generally undergoes a considerable diminution, or
even a total cessation.
The same things often happen when an aneurism attains a large size,
for then the sac is thickened, and much or even the whole of the sac may
be occupied by considerable masses of pale-coloured firm coagula, ar-
ranged in concentric layers.
The absence of pulsation may lead to serious and fatal mistakes in
practice : aneurisms have often been mistaken for abscesses and ^opened,
and the patients destroyed by hemorrhage. I once saw a case, where a
popliteal aneurism, which was undergoing a spontaneous cure by the
deposit of firm layers of coagulated blood in the sac, was amputated
under the idea that the swelling, which had no pulsation in it, was re-
markably hard, and extended far forwards over each side of the knee,
was an osteo-sarcoma, or some other anomalous incurable swelling. A
puncture was first made in it ; but, as the contents of the sac were solid,
the hemorrhage was not such as it would have been in a less advanced
period of the disease.
256 ANEURISNf.
Symptoms of diffused false aneurism. In this case, the pulsations are
generally feeble and indistinct ; the part or limb is cold ; and, in conse-
quence of the extensive injection of the cellular tissue with blood, the
skin is more discoloured than in a circumscribed true^aneurism, unattended
with inflammation.
The form of aneurism, produced by the bursting of the sac of a true
one under the skin, or even more deeply from the surface, is termed a
secondary false one. When this happens, the patient is sometimes con-
scious of a laceration or giving way of something within the limb ; the
tumour frequently undergoes a great and sudden change in its shape, and
there is a rapid increase in its size ; it spreads all at once over a greater
extent of the limb or part, or becomes diffused. At the moment when
these changes commence, the temperature of the limb falls, and there is
a material decrease in the force of the pulsations, which in two or three
days are entirely lost. Some time ago, I had a patient, in whom several
of these facts were illustrated ; but a degree of ambiguity was created by
the circumstance of no particular change in the shape of the limb having
followed the bursting of the sac. This was owing to its having given
way in a very deep situation at the back of the head of the tibia, whence
the blood escaped into the cellular tissue under the gastrocnemius muscle
down to the tendon of Achilles; and, as the cedema had been previously
considerable, if any sudden increase of the swelling did occur, it was con-
cealed. Doubts were therefore entertained whether the reduction and
stoppage of the pulsation arose from the deposit of lamellated blood in
the sac, or from the change of the aneurism from the circumscribed into
the diffused state. I then held a consultation with Mr. Lawrence ; and
the latter gentleman thought he could distinguish the bellows sound,
proving that there was yet a jet of blood into the sac, and that the
communication between it and the artery could not be entirely closed.
The sudden diminution or cessation of pulsation, and an equally
sudden change in the shape and extent of the tumour, accompanied by
a rapid fall in the temperature of the limb, and more or less disco-
louration of some part of it, resembling that of ecchymosis, seem to be
the circumstances indicating the change of the aneurism from the cir-
cumscribed to the diffused state. This occurrence, instead of lessening
the danger, always greatly increases it, by bringing on a disposition to
mortification.
When all the coats of an artery have given way, and the arterial
sheath contributes to the formation of the aneurismal sac, it becomes
thickened, partly by a condensation of the surrounding cellular tissue,
and partly by the deposit of fibrine upon its inner surface.
The lamellated blood, within an aneurismal sac, is always arranged in
concentric layers, the furthest of which from the centre of the swelling
acquire surprising firmness, and are so adherent to the inside of the
tumour, that they seem as if they were confounded and blended with the
parietes of the sac itself.
The commencement of the deposit of fibrine upon the internal sur-
face of an aneurismal sac, soon follows the origin of the disease,
and seems designed by nature as some protection against hemorrhage,
and as a means of strengthening the boundary of the aneurism, and
resisting the impulse of the blood against it. Sometimes, by filling up
the whole cavity of the sac, it becomes, indeed, the means of a spon-
taneous cure.
This deposit of fibrine takes place, as I have explained, in successive
ANEURISM. 257
concentric layers, which have a different aspect according to the date of
their formation. The most central consist simply of blood more or less
firmly coagulated, and sometimes probably formed after death. A little
farther from the centre, the coagulum is drier, paler, and evidently
composed of a large proportion of fibrine. Lastly, in contact with the
cyst, are layers of the same substance, but completely opaque, of a
somewhat friable consistence, and very closely resembling meat deprived
of its red colour by boiling. The most recent layers adhere to one
another but slightly ; the old ones very firmly.
It appears, then, that these lamellated coagula are formed by succes-
sive deposits of the fibrine of the blood ; and their production seems to
be owing, in a great measure, to the retarded motion of the blood in the
sac. Hence, they are more readily produced in false than true aneurisms,
because, in the former cases, the communication between the canal of
the artery and the sac of the aneurism is narrower. This deposit of
lamellated blood is not vascular and organised, and the pus sometimes
found within it, is, according to Cruveilhier, secreted by the inner surface
of the sac, and then insinuates itself between the concentric layers.
While these changes are going on within the sac, its outside becomes
connected to all the adjacent parts by the adhesive inflammation. Nor
do those parts themselves remain unaffected. Sometimes they are sim-
ply displaced, or compressed by the aneurismal swelling; sometimes
they are more or less absorbed and destroyed from the effect of its
throbbing and pressure. In certain cases, ulceration is produced; in
others, sloughing.
Thus, in aneurism of the aorta, large portions of the ribs and sternum
are destroyed, and the tumour protrudes externally. If the swelling
should make its way through the ribs in the direction backward, it may
then come in contact with the scapula, and occasion a remarkable dis-
placement of that bone, as occurred in a patient some time ago at the
Bloomsbury Dispensary. Frequently the bodies of the vertebraB suffer,
and the aneurism may even penetrate the spinal canal, so as to press upon
the medulla, and occasion a sudden paralysis. This last effect of aneu-
rism, however, is exceedingly rare. It is curious to observe, that, while
the bodies of the vertebrae are thus more or less destroyed by absorption,
the intervertebral substance itself frequently remains perfect.
Sometimes an aneurism of the aorta produces serious effects upon the
organs contained in the thorax, or abdomen; compressing, or even
making its way by ulceration into the pulmonary artery, or right auricle
of the heart, or by a kind of lacerated fissure into the pericardium ; by
ulceration, into the [oesophagus, the trachea, the bronchi, the lungs,
stomach, or some part of the intestinal canal. The vena cava, the sub-
clavian vein, and even the thoracic duct, may be obliterated by the pres-
sure of aortic aneurisms. In one case of aortic aneurism in the abdomen,
paralysis was brought on by the pressure of the swelling on the ^icrves
of the lower extremity, and not by the effect of the disease of the spine
itself and spinal cord.
The tumour may also burst either into the pleura, or the peritoneum.
Just in the same manner as the lungs may be compressed, and altered in
their shape by the pressure of an aneurism within the chest, the kidneys,
and other viscera may be similarly affected by the pressure of an aneu-
rism of the abdominal portion of the aorta.
In the vicinity of certain aneurisms, we not only often find the veins
obstructed, or obliterated, but the large nerves converted into flat expan-
s
258 ANEURISM.
sions like ribands, the muscles singularly wasted, and the bones either
deprived of their periosteum and carious, or else that membrane thick-
ened, and osseous matter so profusely thrown out, that it extends more
or less around the aneurismal swelling. Sometimes the sternal end of
the clavicle is dislocated by aneurismal tumours. The absorption of bone,
produced by the pressure of aneurisms, is different from ordinary caries in
not being accompanied by the formation of pus ; and experience proves,
that, if the aneurism be cured, the state of the bones rarely gives any
future trouble.
An aneurism, having made its way through all the coats and the cellular
sheath of the vessel, becomes bounded by whatever parts or textures hap-
pen to lie near it. Thus, in aneurisms of the aorta, a portion of the cyst
maybe composed of the side of the oesophagus, the trachea, the sub-
stance of the lungs, or even the bodies of the vertebrae deprived of their
periosteum.
When an aneurism is about to burst externally, a conical inflamed pro-
minence forms on the swelling, and here a small slough is produced, on
the loosening of which the effusion of blood takes place, which destroys
the patient either in a few seconds, or by repeated returns of hemorrhage.
The process by which such an aneurism gives way, then, is neither lace-
ration nor ulceration, but the production of a slough, which becomes
loose, and the fatal bleeding ensues.
When an aneurism extends into a cavity lined by a mucous membrane,
as the oesophagus, intestines, or bladder, the process by which it bursts
may be similar, namely, a small slough may be formed on the mucous
membrane ; but generally the rupture takes place by ulceration. When,
however, the tumour makes its way into a cavity lined by a serous
membrane, the process is different ; for a crack or fissure is then produced
in the latter texture after it has been rendered very thin by the effect of
distention, and the blood is discharged into the cavity of the pericar-
dium, pleura, or peritonaeum, according to the circumstances of the case.
An aneurism of very moderate size, situated at the root of the aorta, within
the pericardium, will frequently give way, and prove immediately fatal.
Sometimes aneurisms prove fatal by their pressure on important organs,
and the patient is destroyed neither by internal, nor by external hemor-
rhage. A patient, from whom one of Cruveilhier's engravings was taken,
was destroyed by the compression of the trachea. What is remarkable,
also, is the total disorganisation, produced in a portion of the pneumo-
gastric nerve, by the pressure of one of the aneurismal swellings. It was
flattened and converted into a fibrous substance for some extent, without
any vestiges of nervous tissue. The patient had had continual vomitings,
rigors, swoons of considerable duration, general coldness of the body, and
inability to keep any solid food on his stomach.
Causes of aneurism. If we exclude from consideration those cases,
in which an aneurism arises from the wound of an artery by a sharp or
pointed instrument, the spicula of a fractured bone, or the laceration of
the axillary artery by the employment of great force in the attempt to
reduce dislocations of the shoulder, we rarely meet with aneurisms, which
can be positively referred to external violence, unless the artery affected
should have been previously in a diseased state. Thus, if the popliteal
artery be in a healthy state, no forced extension of the leg will produce a
laceration of its coats. To have such an effect, the leg must be extended
in a degree that would first rupture the ligaments of the knee-joint.
A predisposition to aneurism seems to depend upon : 1. The large
size of certain arteries. 2. The force with which the blood is propelled
ANEURISM. 259
into them, and against certain parts of them. All these facts are
illustrated in the frequency of aneurism of the arch of the aorta. From
what has been already stated, the reason why aneurism appears to be
frequently combined with hypertrophy of the left ventricle of the heart,
must be manifest. 3. Such a situation of an artery that it is left very
much unsupported by muscles, and exposed to continual motion and dis-
turbance in the exercise of the part, as exemplified in the popliteal
arteries of post-chaise drivers and others.
The atheromatous and calcareous deposits which occur between the in-
ternal and middle coats of the arteries, or in the sclerous tunic of Mal-
gaigne, and are often the forerunners of aneurism, sometimes pervade a
considerable extent of the aortic system. Pelletan met with sixty-three
aneurismal swellings, from the size of a nut to that of an egg, in one
subject, from such disease of the arterial coats.
If an artery be sound, mechanically weakening it either by stripping off
the outer tunics, or by cutting through the inner ones, by the application
of a ligature, and then immediately removing it, so as to let the blood
flow through the vessel as usual, will not lead to the formation of
aneurism. Spontaneous aneurisms are almost exclusively confined to the
aortic system ; for, of three hundred cases referred to by M. Lisfranc,
only two or three were in the pulmonary artery, and these not free from
ambiguity.
Aneurisms of the brachial artery and its branches are rarely com-
bined with disease of the coats of those vessels ; but arise from wounds,
while axillary, aortic, popliteal, and most other aneurisms are gene-
rally preceded and accompanied by a morbid change of the arterial
coats.*
Men are more frequently the subjects of aneurism than women ; ac-
cording to Mr. Hodgson's calculation, in the proportion of fifty-six to
seven ; and according to Lisfranc's estimate, founded on a list of one
hundred and fifty-four cases, in the proportion of one hundred and forty-
one men to thirteen women.
The period of life between thirty and fifty is most liable to aneurism ;
and, before twenty and after sixty, the disease is very rare. Sir Astley
Cooper has known it arise in one person who was eighty, and in a boy of
eleven. Lisfranc refers to an aneurismal patient, only thirteen years old,
and to three between seventy and eighty, in a list of one hundred and
twenty cases. Popliteal aneurism is rare in females, who, when they be-
come the subjects of the complaint, mostly have it either at the bend of
the arm from a wound, or in the ascending aorta, or the carotid artery
from disease.
Prognosis. An aneurism, left to take its own course, would generally
destroy the patient either by hemorrhage, gangrene, or the interruption of
the functions of the viscera by the pressure of the tumour. For the
most part, internal aneurisms either gradually make their way outwards
through the parietes of the chest, or abdomen, and at length prove fatal
by external hemorrhage, or else they burst in the cavity of the chest, or
abdomen, or within various organs with which the swelling happens to
become connected, as the pericardium, esophagus, trachea, intes-
tines, &c.
On account of the impossibility of practising any surgical operation
* One aneurism of the brachial artery, from disease of the arterial coats, is recorded by
Pelletan, and another by Mr. Hodgson, but the occurrence is rare.
S 2
260 ANEURISM.
for the cure of various internal aneurisms, and also because such diseases
affect vessels into which the blood is propelled by the heart with extra-
ordinary force, the prognosis is infinitely more unfavourable, than in
external aneurisms. The danger is often likewise seriously increased by
the mechanical effect of the swelling upon important organs. Thus
the pressure of aneurisms of the aorta upon the oesophagus, trachea,
lungs, pneumo-gastric nerve, and other parts, whose functions are highly
important to life, adds considerably to the risk, and sometimes has such
an effect upon the health, that the patient even dies before the aneuris-
mal tumour bursts. This happened in the case recorded by Cruveilhier.
The prognosis will be much more unfavourable, when the patient has
more aneurisms than one, a circumstance showing a tendency to disease in
the arterial system at large. Sometimes, in such cases, soon after an
operation has been performed for the cure of an external aneurism, the
patient dies of the rupture of an internal one of the aorta. Indeed, it
is always a requisite precaution to ascertain, if possible, whether an aneu-
rism on which we are about to operate, be the only one. If there be any
internal aneurism, besides another situated in one of the limbs, we should
not be justified in operating upon the latter. In one case of this de-
scription, operated upon by Sir Astley Cooper, no sooner had the first
incision been made, than the patient fell back, and died in a few mi-
nutes. On examination of the body, the pericardium was found dis-
tended with blood, which had escaped from an opening in an aneurism,
seated at the beginning of the aorta, immediately above the semilunar
valves.
Supposing there were two aneurisms on the same limb, for instance, one
of the femoral and another of the popliteal artery, but unattended with
any signs of internal aneurism, we ought to tie the artery in the groin, or
the external iliac, by which means we might accomplish a cure of both
aneurisms at once.
The prognosis in aneurism depends also in some measure upon the
size, as well as the situation of the tumour. Generally speaking, the
larger the aneurism is, the more tedious and uncertain is the cure. The
magnitude of the swelling materially prevents the establishment of a col-
lateral circulation, for its pressure may have obliterated the principal
anastomosing branches. It not only has this effect, but it produces a total
change in the large nerves, flattening them into the shape of ribands, and
rendering the great veins impervious. In addition to such mischief, which
necessarily creates a tendency to gangrene, the pressure causes vast dis-
organisation of all the other neighbouring textures, muscles, bones, and
joints.
If a popliteal aneurism be suffered to attain an enormous size, under
the erroneous notion of affording time for the anastomosing vessels to
enlarge, we not only incur the risk of the aneurismal sac bursting
under the skin, and of the aneurism changing from the circumscribed
into the diffused state, a serious change indeed for the worse ; but such
disease of the head of the tibia, condyles of the femur, and all the
adjacent parts may take place, as will render the patient for a long time,
or even permanently, a cripple, notwithstanding the cure of the aneurism
itself.
In the case of a diffused aneurism, following a circumscribed one of
immense size, and accompanied by enormous extravasation of blood in
the cellular tissue, mortification will frequently follow, whether the
ANEURISM. 261
artery be now tied or not, and if the patient be then saved, it is only by
amputation of the limb.
In the case of a single aneurism so situated, that the artery leading
directly to it can be readily secured, and occurring in a person otherwise
healthy, and not too far advanced in years, the prognosis is favourable,
provided the operation be done according to the right principles.
An oval dilatation, extending to the whole circumference of an artery,
is set down by Scarpa, as incurable. At the same time, this form of
disease may remain stationary for a great number of years, and often has
no decided influence in shortening life.
Spontaneous cure of aneurism. Aneurisms, even when not submitted
to surgical treatment, do not always terminate fatally, but in a small pro-
portion of cases undergo a spontaneous cure, which may be brought about
in various ways.
1. The most common mode of cure is such an increase in the quantity
of lamellated blood in the aneurismal sac, that its cavity becomes filled
up, and then of course the circulating blood no longer passes through the
aneurism, but is conveyed to the parts beyond the disease through the
collateral vessels. The pulsation of the tumour ceases, the sac is gradually
diminished, the solid layers of fibrine are in time absorbed, and the whole
of the tumour is, by degrees, nearly or entirely obliterated.
Not only is the sac filled up by successive deposits of laminated blood,
but the artery itself becomes blocked up with the same substance, both
upwards and downwards, to the places where the next large collateral
branches are given off above and below the tumour.
Now this desirable accumulation of laminated blood in the sac, is de-
noted by the cessation of the bellows' sound ; by the tumour becoming
more solid, and its pulsation being stopped, without any sudden increase
of its size, or fall in the temperature of the limb, circumstances attending
that stoppage or reduction of the pulsation of an aneurism, brought on
by the change of the disease from the circumscribed to the diffused state.
2. Another mode of spontaneous cure is that in which the aneurismal
tumour presses upon the portion of artery leading directly to it, so as to
produce inflammation of the vessel, followed by an impervious state of it.
Here the accidental shape, position, and direction of the tumour, do
nearly the same thing, as is accomplished by the most approved surgical
treatment.
3. A third manner, in which a spontaneous cure happens, is when the
whole aneurismal swelling inflames, and sloughs away, attended with such
an effusion of fibrine in the adjoining portion of the aneurismal artery as
renders it completely impervious. When the sac inflames deeply, and
abscesses form in an aneurism, the same consequences ensue. But, when
the inflammation and sloughing do not reach to a sufficient depth, the
communication between the artery and aneurismal sac may not be ob-
literated with fibrine, and the patient may then die of hemorrhage on the
detachment or loosening of the sloughs.
4. A fourth mode of spontaneous cure happens when the pressure of
one aneurism extends its effects to the artery leading to another, so as to
cause an obliteration of such vessel. Of this variety of spontaneous cure,
Mr. Liston mentions one remarkable instance : the patient had an aneu-
rism of the subclavian artery which had attained a considerable size, but
afterwards gradually subsided and disappeared. When the patient died,
the cause of death was found to be the rupture of an aneurism of the
arteria innorninata, which had made such pressure on the subclavian
s 3
262 ANEURISM.
artery as to have obliterated it, and produced a cure of the aneurism in
the axilla.
In whatever manner the cure is effected, the artery is almost con-
stantly transformed into a kind of dense impervious chord in the situation
of the disease. Scarpa lays down this as an invariable and essential cir-
cumstance, without which an aneurism cannot be cured. Perhaps, the
only exceptions to this statement are some examples of aortic aneurism,
where the sac is of moderate size, and completely filled with the fibrinous
part of the blood, at the same time that the canal of the aorta remains
perfectly unobstructed. Some cases of this description are recorded in
Hodgson's Treatise on the Diseases of Arteries.
Treatment of aneurism. As the enlargement of every aneurism and its
ultimate rupture, depend upon the force with which the blood is thrown
into the swelling, the most important principle in the treatment must
necessarily consist in lessening the impetus of the circulation, or even
in preventing the entrance of the main current of blood into the aneu-
rismal sac altogether. The latter of these plans is the only one, upon
which much dependence can be placed. Unfortunately, however, it is
quite inapplicable to certain aneurisms, the situation of which renders it
totally impracticable to adopt the necessary proceedings for the accom-
plishment of the principle in question. Under these circumstances, we
are obliged to be consent with the employment of means calculated to
reduce the general impetus of the circulation, and to maintain it in as
quiet a state as possible.
In aneurisms of the aorta, a low diet, abstinence from animal food,
occasional venesection, the exhibition of digitalis, and the avoidance of
much exercise and of all laborious pursuits, are the means commonly
recommended ; rather in the hope of retarding the progress of the dis-
ease, than of bringing about its cure. By means of such treatment, how-
ever, the suggestion of which originated with Valsalva, who also applied
ice and other cold applications, when there was an external tumour, the
success has sometimes exceeded the expectations formed of it ; and if
we are to believe the histories of some cases recorded by Pelletan in his
Clinique Chirurgicale, and by other writers, aneurisms of the aorta, so
large that they protruded through the absorbed ribs and sternum, have
thus been reduced and cured. I saw a case, in which the external swel-
ling subsided in consequence of the aneurism bursting into the oesophagus,
and a profuse bleeding taking place, which brought on syncope, and
then stopped. The patient lived a quarter of a year after this first
rupture of the aneurism, and then fell a victim to the return of hemorrhage.
One caution is necessary, with respect to bleeding in cases of aneurism
of the aorta, namely, to avoid producing syncope, as it is attended with
considerable risk of the circulation not being restored again. Hence, the
blood should be taken away slowly from a small orifice in the vein, while
the patient is in the recumbent position, and only in the quantity of a few
ounces at a time.
Sometimes also the attempt to cure external aneurisms on the principle
of lessening the impetus of the circulation has been made, though not
with much success. In Pelletan's Clinical Surgery, may be found one or
two instances of a cure of subclavian aneurism, on Valsalva's plan, but
they are very rare ; and as they sometimes happen from other causes,
some doubts may be entertained, respecting the share which the treatment
had in bringing about the desirable event. I have seen one example of
spontaneous cure of an axillary aneurism.
ANEURISM. 263
We have, however, one means which can be tried in cases of external
aneurism, which is not applicable to internal ones ; namely, pressure,
which operates on the principle of checking the impetus of the blood in
two ways. Thus, when a bandage is applied with the nicest equality over
the whole limb and tumour, as advised by Scarpa, it can only do good by
retarding the circulation in the limb generally, and thus promoting the
coagulation of the blood in the sac. The plan does not appear to con-
template the interruption of the main stream of blood to the aneurism, as
is aimed at when the surgeon tries pressure in another way, and directs
it against the portion of artery near the swelling, and through which the
blood is conveyed into the sac.
Whenever pressure is tried, whether in one manner or in the other, the
plan should be combined with Valsalva's treatment, especially a low
regimen, perfect quietude, occasional venesection, the administration of
digitalis, and the application of ice, or cold evaporating lotions to the
tumour.
Pressure made on the artery, with the view of obstructing the passage
of blood into the sac, rarely answers. Few patients can bear the pain
which arises from it, and it is exceedingly difficult to make it operate
effectually.
There is indeed but one method, on which a reliance can be placed as a
means of fulfilling the great principle of cure, namely, that of preventing
altogether the continuation of a powerful stream of blood into the aneurismal
sac. The method alluded to consists in cutting down to the principal
artery, by which that fluid is conveyed into the aneurismal sac, and then
applying a tight ligature round it, by which means we not only immediately
stop the main current of blood to the aneurism, but excite such changes
in the tied portion of the vessel as lead to its permanent obliteration.
The pulsation of the swelling directly ceases ; what fluid blood may be
in the sac being now in a more or less stagnant condition, gradually
assumes a solid state ; the portion of the artery between the sac and the
ligature becomes filled with coagulum, and a gradual obliteration of the
aneurismal swelling is the result ; the artery itself is converted into an
impervious cord ; the lamellated and coagulated blood in the sac is by
degrees absorbed ; and at length the tumour dwindles entirely away, or
is quietly reduced to one, the size of which is so inconsiderable as to
create no inconvenience. The artery is generally rendered impervious,
not only for some way above the tumour, but also for some way below
the sac down to the giving off of the first large collateral branches.
There are cases, however, in which a diminished circulation in the sac
goes on after the operation, and even a degree of pulsation may either
continue or return, in consequence of the blood finding its way by ana-
stomoses into the portion of the artery immediately above the tumour,
which, for some time at least, remains pervious.
The old method of operating consisted in opening the turno*, taking
out the lamellated blood, finding out the communication between the sac
and the artery, and applying a ligature above and below it, the cavity
being then filled with lint, and left to suppurate. Instead of this practice,
modern surgeons avoid opening the tumour, and content themselves with
the more simple and better plan of exposing the artery at some conve-
nient point of its course toward the aneurism by an incision, from two to
three inches in length, and then tying the vessel with a smallish but
strong ligature, calculated to divide the inner coats of the vessel, and to
bring about its closure by the adhesive inflammation.
261' ANEURISM.
In the observations, delivered on the subject of hemorrhage, I have
explained the principles to be observed in the choice and application of
ligatures. A few maxims require particular attention in operations for
aneurism. 1. We should always make a sufficient incision in the skin ;
for, if it be too small, all the rest of the operation will be tedious and
difficult ; the artery will not be found and tied without a good deal of
handling of the parts, and the patient, instead of being saved from pain,
will suffer much more, than if the external wound had been made of
proper size. 2. Avoid the inclusion of any large nerve or vein in the
ligature. 3. In order to avoid more certainly the inclusion of the vein, or
the wound of it, the point of the needle is generally introduced between the
artery and vein, and brought up on the side of the former, away from the
latter vessel. 4. A free external opening in the integuments would be
useless if not followed by a free incision in the fascia. I am glad to find
Dupuytren joining in this doctrine, which I have always inculcated.
" The external incision (says he) must be sufficiently large to admit of
free manipulation, with respect to the vessel, and the aponeuroses must be
more extensively divided, than the skin." 5. Never tie the arterial sheath, as
such practice would not only render the ligature less likely to produce a
proper effect on the artery itself, but make the completion of its detach-
ment tedious and protracted. The sheath ought to have a very limited
opening made in it, for all that is required is room for the passage of the
needle round the artery ; and a larger division of the sheath than is ne-
cessary for this purpose, will only lead to disturbance of the artery, or
even a detachment of a larger portion of it, than is advisable, from its
cellular and vascular connexion with the interior of the sheath. At all
events, the artery should be fairly tied by itself, without any unnecessary
separation of it, or of its sheath, from their surrounding connexions.
Hence, the practice of insulating the artery for some extent, so as to be
able to put the finger under it, deserves reprobation. All we have to do
is to pass a small ligature, by means of an aneurismal needle under the
vessel, and this may be done, after the arterial sheath is opened, without
any rough handling of the vessel, or any material separation of it from its
natural connexions. If we were to separate the artery from those con-
nexions, which supply its vasa vasorum with blood, how could we expect
any healing process to take place in it ? Ulceration or sloughing would
certainly occur, instead of the adhesive inflammation, and, after a short
time, profuse and fatal secondary hemorrhage, instead of the cure of the
aneurism.
The knowledge of the value of the principle, which dictates the
avoidance of the detachment of the portion of artery which we are about
to tie, from its natural connexions — which points out at the same time
the prudence of not disturbing such portion of artery any more than can
be avoided — will enable us immediately to make a due estimate of various
ingenious, but unsafe contrivances, intended to render the obliteration of
the artery more certain, but which have in reality quite a contrary
effect. Another frequent cause of hemorrhage, in former times, was the
employment of thick clumsy ligatures, which also were not applied with
due tightness, lest they should injure the coats of the artery.
As a guard against secondary hemorrhage, the old surgeons sometimes
had recourse to ligatures of reserve ; one or more ligatures were put
loosely round the vessel above that which was tightened, so that if tJio
latter failed, the others might be immediately tightened.
But it is manifest, that these ligatures of reserve were the very things
ANEURISM. 265
likely to produce a risk of hemorrhage. They were objectionable as extra-
neous irritating substances in contact with the artery ; they were objec-
tionable as requiring for their application a more extensive denudation and
a considerable disturbance of the vessel. In short, their employment was
entirely repugnant to those wise maxims in the treatment of wounded
and aneurismal arteries, which should ever be our guide. The fear of
tying the arteries with proper firmness, and the use of irregularly shaped
broad clumsy ligatures, sometimes occasioned bleeding in another way,
namely, by the noose changing its position, and becoming loose. Thus
bleeding came on, almost as soon as, and even sometimes before, the
patient had been put to bed. Hence arose the absurd scheme of passing
the ends of such a ligature, through the artery, directly below the noose,
in order to keep it from slipping.
This suggestion was intended as an improvement of Mr. Abernethy's
plan of applying two ligatures, one to the upper part of the exposed
portion of the artery and the other to the lower, and then dividing the
vessel at the mid-point between them.
With respect to this latter plan, it was founded upon the ingenious
comparison of the state of the ends of the arteries thus treated in aneu-
rism, with the condition of the extremities of the arteries upon the face
of a stump after amputation. Hemorrhage was formerly found to be
much less frequent after amputation, than after an artery had been tied
for the cure of aneurism. Mr. Abernethy conceived, that as the ligatures,
when this plan was followed, were put on the artery close to the points,
where it lay amongst its natural connexions, it would be less likely to
ulcerate, and that, by dividing the artery in the interspace between them,
its ends would retract, and lie still more perfectly protected by the sur-
rounding parts.
No doubt if, in the operation, a large portion of the artery were detached
from its connexions, this practice of applying two ligatures, and dividing
the intervening portion of the artery, would be the best, as it would
enable us to avoid tying the vessel in the middle of its separated and
disturbed part, which is the point most likely to ulcerate or slough, and
to apply the ligatures at two points close to where the artery retains the
advantages of its natural connexions. But in all other cases, the simple
application of a single ligature, with due attention to the rule of making
no unnecessary detachment of the artery from its surrounding connexions,
is the practice, that now receives the general approbation of all the best
modern surgeons.
Having secured the artery with a ligature of proper construction, for
instance, with one made of thread, or strong dentist's silk, passed under the
artery with an aneurism needle, the point or edges of which should not be so
sharp as to endanger the vessel or neighbouring vein, nor yet so blunt as
to be incapable of going round the artery without the employment of too
much force ; we are then to cut off one half of the ligature, on tjae prin-
ciple of lessening the quantity of extraneous matter in the wound. The
other end of the ligature is then to be brought out and fixed at the
nearest part of either side of the wound, which is to be closed with ad-
hesive plaster, so that it may have the best opportunity of uniting by the
first intention.
The limb or part is then to be kept perfectly quiet, and every thing
avoided, calculated to retard the circulation through the collateral vessels,
or reduce the temperature of the limb. With respect to the proposals of
cutting off both ends of the ligature, of taking away the ligature after
266 ANEURISM,
it has remained a given time, and of endeavouring to obliterate the
artery by the graduated pressure of particular kinds of forceps, and other
inventions, after the exposure of the vessel by an incision ; I shall merely
mention them in this work, as liable to objections, which prevent them
from receiving general approbation.
When an artery is tied for the cure of an aneurism, according to the
principles which have been recommended, hemorrhage after the ope-
ration is a rare event, unless the artery happen to be diseased where the
ligature is applied to it, or some considerable branch arise close above
the point at which such ligature embraces the vessel, in which case, we
know, that the formation of.a clot within it is likely to be prevented.
When hemorrhage does follow an operation for aneurism, it is not
always necessary to cut down to the artery and tie it again, as a matter
of course, because experience proves, that in a certain number of these
cases, the hemorrhage either stops of itself after six or eight ounces of
blood have been lost, or else is readily suppressed by the employment of
cold and moderate compression. No doubt, the partial closure of the
end of the vessel, sometimes effected, will suggest an explanation of
these circumstances. However, if the bleeding were not to be easily
controlled, the tying of the vessel higher up would be indispensably
requisite to save the patient's life.
In some examples, the aneurismal swelling, instead of being quietly
and gradually removed by the absorbents after the successful obliteration
of the artery by the ligature, is attacked with inflammation, and a con-
siderable abscess forms, attended with severe constitutional disturbance.
No sooner is an opening made, than a copious discharge of fetid matter
takes place, blended with coagulated blood. Various cases prove, that
under these circumstances, there is generally no bleeding from the open-
ing in the sac. For besides the security, arising from the obliteration of
the artery by the ligature, there is the additional security resulting from
the changes produced in the sac itself by inflammation, which, if they
had occurred sooner, would probably have led to a spontaneous cure, and
rendered the use of the ligature needless.
In the St. Marylebone Infirmary, however, Mr. Perry had a case, in
which, after the rupture of the aneurismal sac in the state of suppuration,
subsequent to the ligature of the femoral artery, the patient fell a victim
to returns of profuse hemorrhage.
Of Brasdors method of operating upon certain aneurisms. W'hen a
carotid, femoral, or subclavian aneurism leaves no room for the safe ap-
plication of a ligature between the tumour and the heart, Brasdor con-
ceived, that if the artery were tied on the other side of the swelling, a
cure of the disease might be the result, because, though the sac would
probably become even more distended for a time than it was previously,
yet the transmission of blood through it being more or less impeded, and
its motion stopped or retarded, its coagulation would be promoted. The ex-
periment was first imperfectly and unsuccessfully attempted by Deschamps.
It was completely executed, perhaps for the first time, by Sir Astley Cooper,
who took up the femoral artery below the groin, in another case of inguinal
aneurism ; but the patient died some time afterwards of the bursting of
the tumour. To Mr. Wardrop belongs the merit of having brought the
value of this practice to the test of careful examination, and he reports
several cases in which the operation proved successful. The examples
alluded to were chiefly aneurisms of the carotid artery, situated very low
down. Some instances, however, of aneurism of the arteria innominata are
* DISEASES OF VEINS. 267
reported to have been cured by the application of a ligature to the subcla-
vian. Dr. Mott's case, which is amongst them, is free from all ambiguity,
and the occasional success of the practice is on the whole satisfactorily
established.
But, with respect to the value of this method, it cannot be precisely
estimated without additional cases. One would expect the plan to be
more suited to carotid aneurism, situated very low down, than to any
other forms of this disease, because one advantageous circumstance would
be the current of blood through the aneurism thus being completely
stopped, which object the ligature would effect in few instances, except
carotid aneurism, owing to the origin of arterial branches between the
ligature and the sac. But as the common carotid gives off no such
branches, it seems to be well suited for this operation. In axillary and
inguinal aneurisms circumstances are very different ; for, with respect to
inguinal cases, unless we could tie the femoral artery above the profunda,
the circulation through the sac would go on so freely, that any favourable
change in the disease would certainly be much less likely to result from
the operation, than in the instance of a carotid aneurism. And, as for
axillary aneurism, several large branches arise so near the tumour, that
a ligature could not be placed between them and the distal side of the
swelling, and through them so free a circulation of blood would be main-
tained in the sac, that the prospect of success from the operation must
be less encouraging than in a similar operation on the carotid. Further
experience must, however, decide the question of the fitness of the
method for various cases. The fact, that the ligature of the subclavian
has already cured aneurism of the arteria innominata certainly proves,
that sometimes a reduction of the motion of the blood, far inferior to its
complete stagnation, will have the desired effect. We know that, in the
generality of popliteal aneurisms, a retarded passage of blood through the
sac continues for a certain time after the operation, and that even a
degree of pulsation will occasionally return ; but that these circumstances
do not usually prevent the progressive increase in the quantity of coagu-
lum from terminating in a cure.
The operation may be calculated for one case, and not for another ;
whether it will ever be the means of curing an inguinal or a subclavian
aneurism, remains to be proved. One interesting case was under the
care of Mr. Lawrence, where the pressure of a femoral aneurism obliter-
ated the artery below the swelling, yet such change had not the effect
of curing the disease. The same thing was here accomplished as is
aimed at in the operation, but without any useful result.
Of the anastomoses after operations for aneurism. It might be sup-
posed that the anastomosing vessels would become more numerous and
conspicuous, in proportion to the length of time from the operation. But
the researches of Sir Astley Cooper prove, that the reverse of this is the
fact ; for, at first, a great many vessels convey the blood originally con-
ducted by the principal artery, and, after a time, their number diminishes,
only a few vessels, conveniently situated for carrying on the new circula-
tion, and adequate to this purpose, remaining in an enlarged state. The
method of taking up particular arteries will be noticed in the third section
of this publication.
DISEASES OF VEINS.
The difference of texture between veins and arteries ; the more mo-
derate impetus of the blood in the former vessels ; the presence of valves
268 DISEASES OF VEINS.
in many of them ; their greater tendency to inflammation ; and the
higher degree of danger attending that inflammation ; are circumstances
at once apprising us, that the diseases of the venous system cannot cor-
respond in every respect to those of the arterial system. Thus the veins
are not liable to aneurism, in the common acceptation of this term, or
the formation of a tumour upon them produced by the impetus of their
own blood, and preceded either by a wound, or a morbid alteration of
their coats. The so-called venous aneurism^ is indeed a swelling of a
vein, filled with blood, and accompanied by pulsation, but it is occasioned
not by the force of the venous, but of the arterial blood, which, in con-
sequence of an accidental communication existing between a large vein
and a neighbouring artery, gushes into the vein, and causes a pulsatory
swelling of it.
In or between the coats of arteries, calcareous deposits are parti-
cularly common, more especially in elderly persons ; but in the veins
they are very unusual. Indeed, in every part of the sanguiferous system
where black blood circulates, the same fact is exemplified. Thus, in the
pulmonary artery, and in the right cavities of the heart, ossifications are
far more rarely met with than in the aorta and left cavities of the heart.
Small bodies, termed phlebolites, and composed of phosphate and car-
bonate of lime, are occasionally met with in the veins of the uterus,
bladder, or testes, varying in size from a millet seed to a pea, and in
number from two to twelve. They are situated in dilatations of the
veins, and loose enough to let the blood pass between them and the in-
terior of those vessels.
The veins are more frequently blocked up with coagulated Hood and
lymph than the arteries.
Pus is also more frequently met with in veins than arteries, a fact
which Andral refers to its being sometimes conveyed into veins from
other parts by absorption, and sometimes to its being formed in them ;
whereas, in arteries, pus has only one mode of production, namely, it
must be formed within these vessels themselves. The greater disposition
of veins to inflammation, must here also be taken into the account.
While the wounds of large arteries give rise to hemorrhage, which is
often either directly fatal, or cannot be suppressed without the ligature,
those of veins are followed by bleeding, which is of a much more con-
trollable kind. We purposely open veins of considerable size, in order
to take blood from the system; yet we seldom find any difficulty in
stopping the bleeding, which ceases of itself as soon as the removal of
the fillet allows the stream of blood within the vessel to pursue its
course towards the heart. But even when venous hemorrhage is more
troublesome, it may almost always be suppressed by means of moderate
pressure ; and, I believe, that when a vein is so situated that it will
conveniently admit of compression, a wound of it need not produce
any alarm, so far as hemorrhage is concerned, which may thus be readily
commanded.
In general, the right method of suppressing venous hemorrhage is
pressure ; and, as tying a large vein is now known to be frequently fol-
lowed by a dangerous, extensive, and often fatal inflammation of such
vessel, and other parts of the venous system, it certainly ought never to
be done, except under circumstances which render the other plan inap-
plicable or ineffectual.
Of inflammation of veins-) or phlebitis. Phlebitis is regarded by
Cruveilhier as intimately connected with the whole^ range of pathology.
PHLEBITIS. 269
Surgeons should always be apprehensive of it after operations, and
physicians in every organic disease that reaches the stage of softening, or
that of ulceration. Sometimes phlebitis is restricted to the great veins
and their principal branches ; this is ordinary phlebitis ; in other in-
stances, it is seated in the capillary veins, when it is termed capillary
phlebitis, which seems to Cruveilhier to constitute one' essential part of
the process of inflammation. Occasionally it affects both the capillary veins
and the ramifications connected with them.*
The veins are particularly prone to inflammation, which frequently
spreads with considerable rapidity along their internal surface, and this
so far as to extend from the point where the affection first commences
up to the very heart itself, bringing on a train of formidable and often
fatal consequences. We are not, however, to consider the mere red-
ness of the lining of these vessels, often met with in the dead subject, as
a proof of their having been inflamed during life : for, after a body has
been kept a few days, the inner coat of a vein imbibes and becomes dyed
with the red particles of the blood, even more readily than the lining of
an artery. The inflammation of a vein is always disposed to extend
itself in the course of the circulating blood, but frequently also in the
opposite direction. Sometimes it produces an effusion of fibrine, by
which the tube may be obliterated, and a more or less extensive portion
of it converted into a solid chord. In phlebitis, the great source of dan-
ger is the formation of pus within the vessel : in this event, the matter is
either mixed with the circulating blood, or the inflammation having pro-
duced adhesions, at certain intervals, boundaries are formed for the
collections of pus, which then represent a single abscess, or a chain of
abscesses in the course of the vessel. If phlebitis advance not beyond
the effusion of fibrine, it is termed adhesive, which is not productive of
the serious risk always resulting from the suppurative.
When phlebitis is of trivial extent, and in the adhesive stage, its
symptoms merelyVesemble those of any other common local inflammation
of equal extent ; but, when it ascends into the principal venous trunks,
and pus begins to be formed and circulated with the blood, the disorder
is accompanied by violent constitutional disturbance, a quick, small, irre-
gular pulse, hurried respiration, a white dry tongue, which afterwards
turns brown ; thirst, nausea, sometimes bilious vomiting, pain, and severe
oppression about the region of the heart, and a countenance indicative
of the utmost distress and suffering. In this aggravated form of phlebitis,
the depression of spirits, and prostration of strength, are extreme. Low
delirium generally follows, and death in the short space of from three to
six or seven days.
The inflamed veins are exceedingly hard, and painful when pressed
upon, or kept in an extended state. The skin over them is often of a
dark red colour, and sometimes the whole limb becomes cedematous and
prodigiously swelled, this state being followed by the formation *f un-
healthy matter diffused in the cellular tissue, or lodged in numerous
small collections in the muscular tissue, and attended with sloughing
of the cellular and ether textures. When inflammation stops at any
point within the vein, the line of its boundary is often determined
by the entrance of a branch of the vessel, or the junction of two veins
together.
What is the principal cause of the dangerous effects of phlebitis ?
* See Cruveilhier, Anat. Pathologique, liv, H.
270 DISEASES OP VEINS.
Experience proves, that inflammation of a vein is often followed by the
rapid formation of pus in some other part of the body, external or inter-
nal, and more or less remote from the inflamed vessel. Thus in phlebitis
of the arm it is not unusual for an abscess to be suddenly formed in the
axilla of the opposite side of the body ; and when the femoral vein in-
flames after amputation, the patient is often affected with symptoms of
disease in the chest, and on examination after death, abscesses are dis-
covered in the substance of the lungs. Sometimes there is a deposit of
sero-purulent fluid in the pericardium ; sometimes in the pleura ; some-
times in the liver or other abdominal viscera ; and occasionally in the
synovial membranes of the joints, No doubt, these secondary effects of
phlebitis, the causes of which have, until lately, baffled every "attempt to
explain them, are principally concerned in bringing on the fatal termina-
tion of the disease. The deposits of pus in remote parts seem to arise
from the passage of pus from the inflamed vein into the circulation, as is
argued by Breschet, Andral, Dupuytren, and Cruveilhier.
Any extraneous substance in nature, introduced into the venous system,
when it cannot escape from it by some of the emunctories,is apt to bring
on visceral abscesses, completely like those which follow wounds, or sur-
gical operations, and these abscesses are the result of capillary phlebitis
in these same viscera.
If ink, or any stimulating substance, be injected into the femoral vein
of a dog, in the direction from the heart toward the extremity of the limb,
and the collateral veins should not convey the ink into the general circu-
lation, so as to prove at once fatal, the limb in thirty-six hours swells,
and if the animal be killed, small collections of effused blood are found
in the cellular tissue and the substance of the muscles. The large veins
are distended with solid adherent blood ; and the venous ramifications
connected with the effusions of blood are also similarly filled, while the
rest of the veins in the healthy parts are free from such coagula. Cru-
veilhier introduced a thin long piece of wood into the femoral vein of
a dog down to the ham, and another piece upwards into the vena cava.
Death followed on the sixth day. All the veins and venous branches of the
lower extremities were filled with pus, and here and there were small ab-
scesses. It is estimated by Cruveilhier, that the majority of persons who
die of wounds, are destroyed by these internal deposits of pus. Velpeau,
Marechal, and Cruveilhier, found pus, not merely in the inflamed veins,
but in the right cavities of the heart, and in the centre of coagula of blood.
Cruveilhier observed it in the lungs, liver, brain, spleen, muscles, and
synovial cavities, without any manifest appearance of a general previous
inflammation of those organs. The lymphatic vessels and heart were also
similarly circumstanced-
Pus, circulating with the blood, is stopped in different parts of the
capillary system : wherever this happens it gives rise to capillary phlebitis,
or circumscribed inflammations, which rapidly lead to abscesses. The
pus, like mercury, is most frequently stopped in the lungs ; then in the
liver or spleen ; or it may produce circumscribed inflammations in any
part of the body.
Why do not these multiplied abscesses of the viscera follow extensive
abscesses of the common kind ? why should it be a suppurating wound,
that is generally necessary to bring on capillary phlebitis of the viscera ?
is there absorption of pus in the latter, and not in the former cases ?
The difference seems to be explained by the pus in one instance being
acted upon and changed by absorption ; while in the other it is formed in
PHLEBITIS. 271
the veins, and is already in the circulation unmodified and unprepared by
any previous influence of absorption on -it. In France, phlebitis of the
medullary texture of bones is found to take place with remarkable fre-
quency after amputation, and to give rise to visceral abscesses.
Phlebitis is mostly occasioned by accidental wounds, or by those of
venesection, amputation, and other surgical operations. A prick of the
femoral vein in the operation for the cure of popliteal aneurism, has been
known to bring on inflammation and suppuration within that vessel, ex-
tending thence to the external and common iliac vein and vena cava, so
as to destroy the patient. The application of a ligature to the femoral
vein in amputation, has also been followed by a fatal inflammation of that
vessel, and of the external iliac vein, with traces of diffused inflammation
up to the right auricle. It is true that the same consequences sometimes
arise from amputation, when the femoral vein is not tied ; but though the
wound alone may excite the mischief, a wound and the ligature together,
are much more likely to do so ; and, on this account, all good practical
surgeons make it a rule to abstain, as much as possible, from applying
ligatures to veins. Numerous patients have died of phlebitis, brought on
by the ligature of the vena saphaena major for the cure of varicous veins
of the leg.
What Cruveilhier calls the adhesive stage of phlebitis is less dangerous
than its other forms ; the inconveniences of it are entirely local, merely
those of obstruction of the vessel ; and hence this pathologist regards
uterine phlebitis in its early stage, as more curable than has generally
been represented.
The peculiar, cedematous, painful enlargement of the lower extremity,
called phlegmasia dolens^ sometimes occurring in women two or three
weeks after parturition, frequently depends upon obstruction of the iliac
veins, in consequence of the effects of inflammation. This fact was
satisfactorily proved by Dr. Davis, of University College, In several
women who had been afflicted with phlegmasia dolens, Velpeau also
found the iliac and femoral veins full of pus. Sometimes, in women, who
die shortly after childbirth, the veins of the uterus, ovaries, and the iliac
veins, are the only ones containing pus ; but sometimes, besides abscesses,
in these vessels, there are others in the lungs, spleen, liver, muscles,
synovial membranes, and various cavities lined by a serous membrane.
Puerperal fever itself is only the constitutional disturbance attending
uterine phlebitis.
A coloured engraving in Cruveilhier's great work on pathological anatomy
gives a correct view of various circumstances characteristic of phlebitis.
The patient from whom it was taken died of the consequences of that disease
on the fifth day from its origin, after a gunshot injury of the biceps muscle,
received about five weeks before the fatal result. The cephalic, basilic, ul-
nar, median, and radial veins, and their ramifications, are large, cylindrical,
tense, and knobby, giving an appearance as if they had been injected with
wax. Fig. 2. represents the veins opened : their coats are as thick as those
of arteries. The cephalic vein is full of pus, as well as the median and radial
veins. On the contrary, the basilic vein exhibits all the stages of phlebitis:
thus its lower part contains pus ; and its middle, a coagulum, in the centre
of which is pus ; while its upper portion is entirely filled with coagulum.
In the substance of the deltoid muscle, may be remarked numerous
small abscesses ; some consisting of veins distended with matter, and
others of pus effused around the ruptured veins. Two considerable
abscesses were formed, one under the deltoid, and the other in the
272 DISEASES OF VEINS.
shoulder joint, which was completely full of purulent matter: both quite
distinct, and without communication. As the original injury was in the
centre of the biceps, this case proves the extension of phlebitis both up-
wards and downwards.
With respect to the treatment of phlebitis, in the early stage, leeches
may be freely applied over the inflamed vein. Owing to the quickness with
which the symptoms assume a typhoid character, venesection is not
generally considered advantageous : it may however, sometimes, be tried
at the commencement of the case. The limb is to be kept in a perfectly
quiet state ; and purgatives and antimonials may be prescribed. Foment-
ations relieve the pain ; but, whether they are more effectual than cold
applications in checking the inflammation is questionable. I should rely
chiefly on calomel and opium, with local bleeding and fomentations.
When the vein becomes much distended, and pus is manifestly confined
in it, the case should be treated as a common abscess, the matter let out,
and a poultice applied. We know that, in such a case, the matter is
bounded by the adhesive inflammation. Whatever treatment is chosen
should be actively pursued in the beginning of the disease ; for, after the
formation of matter in remote organs, and after the commencement of
the serious indisposition, resulting from such collections of pus, all pros-
pect of recovery has vanished. Cruveilhier considers, that the treatment
can only be successful in the stage of the coagulation of the blood, and
that, when once pus has formed and entered the circulation, every plan
fails.
Varicous veins, or varices. A varix is usually described as a dilatation
and thickening of a vein, which becomes at the same time elongated,
tortuous, and knotty. It occurs chiefly where the blood has usually to
ascend against its gravity. Thus the veins of the lower extremities are
often the seat of varicous enlargements, with chronic thickening of their
coats, and a tortuous knotty appearance. If every enlargement of a vein,
whether attended with thickening of its coats or not, be regarded as a
varix, then we shall have several varieties of the disease, as pointed out
by Andral.
1. One is a simple dilatation of the veins, without any other particular
change in them, but a lengthening and tortuosity, and may accompany
the chronic inflammation of any organ. What Cruveilhier denominates
hypertrophy of veins, differs from varices, inasmuch as these vessels are
only enlarged, not diseased, nor imperfect ; so that the blood flows well
through them ; but, in varices, the coats of the veins are diseased, and
their channel more or less obstructed. They are dilated into little cells,
in which the blood coagulates, fibrine is deposited, and in the centre of the
clots there is sometimes osseous matter. Hypertrophy of veins is noticed
wherever the regular or morbid nutrition of a part takes place, with in-
creased energy,, as is exemplified in the uterine veins during pregnancy,
and in the growth of considerable tumours, fibrous, medullary, &c., in
that organ. One cause of hypertrophy is an impediment to the return
of blood.
2. Another dilatation of veins is attended with a thinner state of their
coats, than natural, and it may be either an uniform or an irregular dila-
tation.
3. The third variety is dilatation, with thickening of the vessel, pro-
jections of certain points of it in the form of knobs, and a tortuous ap-
pearance of it.
4. In a fourth variety, septa or partitions are produced in the vein,
VARICOUS VEINS. 273
whereby its cavity is divided into small cells, in which the blood accumu-
lates and coagulates.
5. In the last form of dilated veins, besides these septa, there are
irregular perforations in the veins, so that these vessels communicate
with the surrounding cellular tissue, which is generally more or less
diseased. This state is frequently exemplified in varicous veins about
the anus, which receive the name of piles or hemorrhoids. Some hemor-
rhoids seem to be the smaller branches of the hemorrhoidal veins dilated,
and forming tumours covered by the mucous membrane, skin, or the in-
termediate cellular tissue. Others resemble dense cysts, containing a
coagulum of blood, with lymph around it.
Some of the forms of varices here described, when situated in super-
ficial veins, must necessarily render their valves inefficient ; and, no
doubt, these are frequently in a diseased state, and more or less de-
stroyed, or impaired. In this state, they may even be concerned in pro-
ducing an impediment to the return of the venous blood, and operate as
a cause of the varicous dilatation. Frequently varicous veins seriously
affect the capillary circulation in the lower limbs, so as to give rise to a
tendency to chronic inflammation, followed by ulcers, which are incor-
rectly named varicous, and very difficult to heal. Varicous veins also
frequently occasion a great deal of weakness and pain, the latter of which
symptoms generally extends over a great part of the leg, and is remark-
ably severe. The diseased vein itself is also particularly subject to
chronic inflammation, ulceration, and the consequent production of copi-
ous hemorrhage. It would be therefore incorrect to say, that varices are
unattended with danger. Chaussier records an instance in which a preg-
nant woman died of hemorrhage from a varicous vein. Murat gives a
similar case in a washerwoman. Velpeau, in 1819, saw a countryman
die of the loss of blood, twenty-four hours after the rupture of a varix.
The veins, most liable to become varicous, are the great saphcenal and
its branches, the spermatic, and the hemorrhoidal. The disease rarely
occurs in the veins of the lower extremities of very young persons ; but,
in the other veins, which have been specified, it often comes on at an
early period of life.
Tall stature, and the large size and long perpendicular course of the
veins, predispose to the disease, the commencement of which is often
dependent upon constipation and a loaded state of the bowels, the
pressure of the gravid uterus on the iliac veins, and sedentary occupa-
tions, and certain employments, in which the standing posture is long
maintained without exercise Any mechanical impediment to the return
of the blood will bring on the disease. Hard drinkers are well known
to be often the subjects of varicous veins.
In the treatment of varicous veins, one principal indication is to remove
the exciting cause. Thus, in pregnancy, little effectual amendment can
take place till after delivery. In every case, remove constipation*; and
when the disease is situated in the leg, a bandage, elastic-gum roller, or
laced stocking, should be worn, and the limb kept as much as possible in
the horizontal position.
When varicous veins are inflamed, leeches, fomentations, cold lotions,
mild purgatives, quietude in the horizontal posture, and a temporary
discontinuance of the bandage, until the inflammation ceases, and the
patient can safely get up again, form the right practice. The inflam-
mation of a vein, arising from a varix, is not commonly of that rapidly-
spreading, and fatal kind, which I have described under the name of
T
DISEASES OF VEINS.
phlebitis. It extends rather to the skin, than to any considerable portion
of the vessel.
When a varix bursts, and much bleeding comes on, cold applications,
and, if necessary, pressure, are the best means of relief. When varicous
veins of the leg are not relieved by pressure, rest, &c. and the severity
of the case justifies the practice, the surgeon may try to obliterate some
of the principal and most conspicuous of the diseased veins. The danger
of the ligature, or even simple division, of the vena saphsena is now generally
acknowledged. The division of its branches is not, however, so likely to
be followed by such danger; a fact, adverted to by Sir Benjamin Brodie.
Many individuals who come to hospitals with wounds in the leg must
have varicous veins, yet such wounds rarely bring on phlebitis. Neither
does the excision of varicous veins, forming piles, induce this perilous
consequence. When all the veins of the leg are in a state of morbid
dilatation, and the distress is not restricted to any point, uniform pres-
sure should be tried. When an ulcer was irritable, and difficult to heal,
on account of its connexion with varicous veins, or when, without any
ulcer, there was a painful varix, disposed to bleed, while the other veins
were not the source of particular uneasiness, Sir Benjamin Brodie
formerly applied potassa fusa, so as to make a slough of the skin and veins
beneath it ; but he found the practice objectionable, as leading to a
tedious ulcer. The method is still, however, pursued, with some modi-
fication, by Mr. Mayo, who aims not at producing a slough of the vein,
but only such a degree of inflammation in the portion of it adjoining the
part of the skin, touched with caustic, as shall be followed by its obliter-
ation with fibrine. In other cases, Sir Benjamin Brodie made an incision
through the varix and skin, a method less painful than caustic, and the
cut sooner healed than the ulcer left by the slough. Abandoning all these
methods, he next tried the plan of dividing varicous veins, and leaving the
skin over them entire. Having ascertained the precise situation of the
vein, or cluster of veins, he introduced the point of a bistoury through the
skin on one side of the varix, and pushed it on between the skin and vein
with one flat surface turned forwards, the other backwards. The cutting
edge was then turned backwards, and the vessel divided by withdrawing
the instrument. Moderate pressure was then made with a compress and
bandage to stop the bleeding, and the patient kept in bed four or five
days. Although this practice was not found so liable to excite phlebitis, as
the division of a varicous vein and the integuments together, or the ligature
of the trunk of the vessel, Sir Benjamin Brodie informs me, that he now
rarely or never resorts to it, as he finds that rest, bandaging, and other
proper means obviate the necessity for it. In University College Hospital,
the twisted suture has of late been tried in numerous instances as a means
of curing bad varices of the lower extremity, and the ulcers connected with
them. A steel pin, about three inches long, is thrust under each of the
venous trunks adjoining clusters of the varices, until the point protrudes
through the skin on the other side of the vein. Silk or thread is then
tightly twisted round the projecting ends of the pin, and thus the vessel
is constricted. The point of the pin is next removed with a pair of
cutting forceps. Sometimes pins are thrust under the veins in this
manner in several places, including the trunk of the great saphenal vein.
I have known severe pain, abscesses, and erysipelas follow in some cases ;
and, in one of my patients, there was a fatal attack of phlebitis. I there-
fore recommend this practice not to be adopted, without some previous
consideration of the kind of constitution which the surgeon has to deal
with. Perhaps, also, the plan of introducing more than one or two
ANEURISMAL VARIX. 275
pins at a time ought to be renounced, and care taken to withdraw all of
them directly any unusual suffering begins to be experienced. The
method also of removing them, as soon as ulceration commences, and
not leaving them to make their own way out through the ulcerative pro-
cess, seems entitled to commendation.
The varicous enlargement of the spermatic veins, called cirsocele, and
that of the veins of the rectum, constituting piles or hemorrhoids, will be
noticed in our second section.
Venous aneurism, aneurismal varix, or varicous aneurism. This is a
pulsatory swelling of a vein, arising from a preternatural communication,
formed between such vessel and a neighbouring artery. The situation,
in which this peculiar disease ordinarily presents itself, is the bend of the
arm, where it is produced by the unskilful performance of venesection,
the lancet completely transfixing the median basilic vein, and piercing
the subjacent artery.
The venous aneurism may occur, however, in any situation, where a
large artery and vein lie near one another. Hence, examples of it are
recorded by Larrey and others, in which the disease took place in the
ham, thigh, and upper part of the arm, in consequence of gunshot and
other wounds. When it arises from venesection, or a punctured wound,
there are two wounds in the vein, and one in the artery, besides the
puncture in the fascia. The external opening in the vein heals up, but
the internal remains permanently open ; thus allowing the blood to gush
directly from the artery into the vein, which becomes dilated sometimes
to the size of a pigeon's egg ; the two vessels and intervening fascia
becoming connected by the adhesive inflammation. However, instead
of the artery, fascia, and vein, being always thus connected by the
adhesive inflammation, so as to afford a direct passage for the blood out
of the artery into the vein, an interspace is sometimes produced between,
the vessels by a part of the blood being effused in the cellular tissue,
under the fascia, where a sac is formed ; and this being placed between
the two vessels, the blood is first discharged from the artery into it, and
afterwards into the vein. It is to the latter form of the disease that
Mr. Hodgson restricts the term varicous aneurism, while the case in which
the blood flows directly into the vein, he calls aneurismal varix.
These modifications of the disease certainly appear to me sufficiently
different to require different appellations ; because one is really a false
aneurism conjoined with a venous dilatation ; and what proves the truth
of this observation is, that the communication between the sac and vein
may close, and then the aneurism of the artery take its usual course.
In the museum of University College is a specimen of a varicous aneu-
rism, with a bifurcation of the brachial artery high up the arm : it was
taken from a subject, in whom the radial division was punctured in bleed-
ing. It was a double aneurism, one being formed under the fascia, with
a communication kept up between the arterial aneurism and the vein,
through an opening in the fascia. The anastomosing brpich, between
the radial and ulnar arteries, is as large as either of them.
When an aneurismal varix arises from a gunshot wound, in which the
ball has passed between a large artery and vein, so as to open a direct
communication between them, there is of course only one opening in the
vein, and not two, as after venesection. A few years ago, I knew but of
a single example of the spontaneous production of an aneurismal varix ;
and the case, which is related by Mr. Syme *, is a very remarkable one,
* Edinb. Med. and Surgical Journal, vol. xxxvi.
T 2
276 DISEASES OF VEINS.
for the aorta and vena cava communicated by a large aperture, a little
above their bifurcation into the iliac vessels. Since then several other
instances of the same form of disease have been recorded : one by Mr.
Robinson, where an aneurism of the abdominal aorta communicated by
two openings with the vena cava. The same gentleman, also, briefly
alludes to an aneurism of the arch of the aorta, which was in St. Bartho-
lomew's Hospital, and opened into the vena cava.* Another, by Mr.
Perry, which I saw in the St. Marylebone Infirmary, arising from an
opening formed between the femoral artery and vein ; "or rather, I should
state, that at the spot in the thigh, where the communication had been
presumed to exist between the artery and the vein, there was an aneurismal
sac, about as large as half a walnut, firmly ossified within, which, by the
pressure that it had exerted upon the vein, had caused the absorption of
the coats of the latter, so as to form a circular opening about two lines in
diameter, into which the aneurism had burst ; thus producing a free and
permanent communication between the vessels. The ligature was applied
to the artery, but the patient died of hemorrhage on the sixth day after
the operation. One circumstance, particularly explained byM. Breschet,
as common in varicous aneurism, was noticed in this case, namely, the
remarkable thinness of the coats of the artery, which were scarcely
thicker than those of a vein.f Dr. J. Proud Johnson, of Belmont,
Shrewsbury, lately favoured me with some account of a varicous
aneurism in the leg, where "the internal malleolar branch of the ante-
rior tibial artery was the chief cause of the venous sac anastomosing with
the posterior tibial/' If I understand Dr. Johnson's communication cor-
rectly, this example is unique, inasmuch as I know of no spontaneous
aneurismal varix, arising from a communication between so small an artery
as the internal malleolar branch of the anterior tibial, and a neighbouring
vein, which, in this instance, is stated to have been the internal sa-
phcenal. Without having seen the parts, however, I can offer no positive
opinion on the nature of the disease. At the same time, I trust that Dr.
Johnson will take an early opportunity of publishing the particulars of
the case, and a description of the disease, as it appeared on dissection. It
was a case of spontaneous formation. The patient was afflicted with scrofula
and epilepsy. The limb was amputated. The patient has recovered from
the operation, the fits have left him, and his general health has improved.
In the common form of the aneurismal varix, a communication is
established between the median basilic vein and the brachial artery. The
consequence is, that the vein becomes large and tortuous. The tumour
gives a jarring thrilling sensation to the hand which examines it, and a
peculiar hissing sound is heard, when the ear is applied to the part.
After the swelling has attained the size of a pigeon's egg, it usually
becomes stationary. If the artery be compressed above the swelling, the
latter becomes flaccid, and the blood may be pressed from it. In general,
a slight weakness of the arm is the worst effect of the disease. Some-
times, however, it becomes cold from the want of its usual supply of
arterial blood, a great part of which, instead of proceeding to the fore-
arm, flows at once into the vein, and is carried back to the heart again.
Hence, there is only a weak pulse at the wrist : but the brachial artery,
above the tumour, is larger than natural, and pulsates with uncommon
force. The observations of Breschet prove, that some of the venous
blood passes into the artery, the coats of which gradually undergo sucli
a change, that they are more like those of a vein than of an artery.
* Lond. Med, Gazette, vol. xiv. p, 462. f Terry, in Mecl. Chir. Trans, vol. xx.
DISEASES OF BONES, 277
A case of this description was brought to my house a few..years ago.
The patient was a washerwoman, who had imprudently allowed some un-
professional person to bleed her. The hissing noise, thrilling sensation
in the tumour, and vibratory motion in the adjoining veins were well
exemplified. As the case was recent, I recommended pressure, and as
the woman did not continue her attendance long, I conclude that she
was either cured, or so far relieved, that the inconveniences of the tumour
were not very great to her. In general, the aneurismal varix requires
no operation, as it becomes stationary, and does not produce any severe
annoyance. But if it were to be conjoined with an aneurismal sac be-
tween the two vessels, so as to constitute what Mr. Hodgson proposes to
call the venous aneurism, then an operation might become necessary in
the event of the sac showing a disposition to enlarge and become trouble-
some. Here, the right practice is to tie the artery above and below the
opening in it; for Dupuytren refers to no less than three examples, in
which the application of one ligature did not cure the disease. We should
not, however, resort to the operation without a real necessity for it, be-
cause in one instance, the particulars of which were given me by Mr.
Atkinson of York, it proved fatal, the limb having mortified; and such
was also the result of the case from which a preparation at University
College was taken. The ligature of the femoral artery in Mr. Perry's
case, as already stated, was followed by hemorrhage on the sixth day after
the operation : whether the alteration in the texture of the artery in this
disease would generally create an increased risk of this event, future
experience must determine.
In the early stage, pressure, by means of a graduated compress, is the
right treatment, or else with an instrument calculated to compress the
swelling, as was once successfully employed by Sir Astley Cooper, in the
case of a young lady who had this affection. In the museum of the
University College, is a specimen of varicous aneurism presented to it by
Mr. Oldknow. Pressure was made on it with an instrument ; the tube of
the vein obliterated ; and the puncture in the artery closed : the remains
of a sac between them is evident.
DISEASES OF BONES.
In noticing the question how far lost substances, or portions of the
human body can be reproduced, I explained, that the osseous texture is
one of those in which the greatest power of regeneration is exhibited.
In all general circumstances, the texture of bones resembles that of other
organised parts of the body, being supplied with arteries, veins, absorbents,
and nerves. Its chief peculiarity is that of containing the phosphate of
lime, which communicates to it that rigidity, strength, and solidity, so
essential to the purposes and uses of the various parts of ^he skeleton.
The changes which the bones undergo in the commencement, progress,
and decline of their diseases, are generally marked by a slowness of cha-
racter, much more remarkable than what attends the processes of disease
in the soft parts. We have seen an analogous circumstance in relation to
the cure of fractures, as compared with the cure of wounds. No doubt,
these facts are connected with the introduction into the osseous tissue of
the lifeless inorganic calcareous matter, which I have specified, and per-
haps, also, with the inferior supply of nervous energy in the bones at
large. Under such circumstances, we should not have expected, that
T 3
278 DISEASES OF BONES.
the bones would be endued with even a greater power of repairing the
losses and injuries which they suffer from disease, or accidental violence,
than is manifested in any other texture of the body. For this purpose,
however, it is their nature to require^time, — frequently a considerable
One remarkable circumstance, ascribed to the peculiar vital properties
of bone, is that its injuries and diseases generally affect the constitution
much less than those of soft parts * : we know, that the severe effects of
certain fractures truly depend, not on the injury of the bone, but on the
manner in which they are combined with other mischief, done to the
soft parts, or the important organs, which the bones support and protect.
Inflammation of bone, termed ostitis, may be either acute or chronic ;
simple or specific ; either produced in a single bone through some local
impression, or in several as the result of a general disposition to inflam-
matory enlargement in the osseous system. Pathologists distinguish in-
flammation of the periosteum and medullary membrane from that of the
proper osseous tissue ; for each of these membranes is liable to be at-
tacked with inflammation independently of the bone ; though it is true,
that it sometimes extends to them from the osseous tissue itself, when
this is primarily affected.
It has been well explained by Mr. Stanley, that a constant corre-
spondence may be remarked between inflammation of the medullary
membrane, and of the periosteum, and of the substance of the bone itself,
so that it is difficult on looking at a bone, in which there has been for
some time a diseased process carried on, to determine in which tissue the
affection first commenced, and the order in which it has supervened in the
others. For instance, if an abscess form in the medullary tissue, the
irritation is speedily propagated to the corresponding part of the perios-
teum, in which ulceration may occur, or suppuration take place between
it and the bone* So, also, venereal nodes, beginning with inflammation
of the periosteum, soon produce irritation of the bone itself, causing in-
creased thickness and density of its walls, and sometimes even obliteration
of its medullary cavity, f
In chronic cases, the enlargement or swelling comes on with remark-
able slowness, and the hardness is quite incompressible. The pain is
also subject to variety ; for, when the case arises from an accidental blow,
the pain may be inconsiderable, and unaccompanied by any constitu-
tional disturbance ; but when a bone inflames, in consequence of syphilis,
the abuse of mercury, and other causes extending their influence through-
out the system, the pain is often remarkable for its severity, and its
periodical exacerbations, which usually come on in the night.
Inflammation of a bone sometimes produces an enlargement of it, by
what is termed interstitial deposit, or by the deposit of an extraordinary
quantity of the phosphate of lime in its texture. Frequently, however,
instead of having the latter effect, it produces an absorption of the calca-
reous matter, so that at the same time that the bone is enlarged, it be-
comes porous and lighter than natural ; its surface presenting numerous
foramina, occasionally described as apertures through which the vessels
of the inflamed bone took their course.
Scrofulous inflammation of a bone does not make it more solid or
heavier, but the reverse. On the contrary, in syphilis, the enlargement
of bones may be attended with increased weight of them.
* E. Stanley, in Med. Gaz. vol. xx. p. 421. -j- id.
DISEASES OF BONES. 279
Inflammation of bones often renders their surface rough ; we see this
effect produced both by syphilis and scrofula, though with a diversity in
the appearances.
The following are described by Mr. Mayo, as the different appearances,
found on making sections of inflamed cylindrical bones : — 1. A growth
of porous bone, superimposed upon the cortex. 2. A growth of compact
bone in the same situation. 3. An expansion of the cortex through its
conversion into porous bone. 4. An expansion of the cortex through its
apparent separation into an outer and an inner layer, with porous or can-
cellous structure between them ; or the expansion consists of an outer
part, compact ; an inner part, porous. 5. Expansion of the cortex, with
compactness of texture throughout. 6. The medullary cavity more or
less diminished, either by the encroachment of the cortex inwards, or
through the solidification of the cancellous structure.*
While either a slow enlargement, with increased weight and solidity,
or a porous alteration of structure and caries, attended with greater light-
ness, and a loss of the phosphate of lime, are not unfrequent consequences
of chronic inflammation of bones, suppuration in the medullary texture^
and mortification, or necrosis, are more commonly the effects of acute
inflammation of the osseous texture, or injury of the medullary part of the
bone. This statement is liable, however, to exceptions ; for, in persons of
a scrofulous constitution, a slight disturbance in the nutrient processes of
a bone by a trivial blow, or exposure to the influence of a damp cold atmo-
sphere, will bring on suppuration in the cancellous texture.
It is only the cancellous texture, or medullary cavity of a bone, that
is liable to suppuration ; or, at all events, suppuration cannot take place
in the solid parts of a bone, unless their tissue be previously expanded
and loosened by the effect of chronic inflammation. Whenever a bone
suppurates, there is generally more or less absorption of it ; and sometimes
while the interior texture is removed by the absorbents, so as to leave a
considerable cavity, the external shell is expanded, constituting the case
technically named spina ventosa. Many inflammations of bone, followed
by caries, or necrosis, and by separation of the periosteum originate from
inflammation, disease, or injury of the medullary membrane. At length,
the matter makes its way under the skin, by causing the absorption of
parts of the most superficial side of the bony cavity ; then a soft swelling
and fluctuation occur ; and the abscess in time bursts, attended with great
diminution of suffering.
A collection of pus may continue, however, for a surprising length of
time, within the texture of a bone, and keep up very perplexing symp-
toms. In one of the volumes of the London Med. Chir. Trans-, there is
a paper by Sir Benjamin Brodie, on small abscesses in the cancellous
structure of the tibia, attended with enlargement of the bone, which
continued for many years to distress the patient, until the matter was
discharged with the trephine. In the Writings of the late Mr. Hey, are
some other cases of this kind, which were treated in £ similar way.
When a cavity, or cyst in a bone is full of purulent matter, the making
of a prompt and free outlet for it is generally the principal indication ;
but, this rule is not always applicable, where the matter is the product
of a specific disease, as such operation would often render the patient's
condition worse.
With respect to the osseous cysts, termed by the older surgeons,
* Mayo's Pathology, p. 23.
T 4*
280 DISEASES OF BONES.
spines ventosce, their formation, perhaps, cannot always be referred to the
mechanical expansion of the bone ; or, at all events, while absorption is
going on inwardly, increased deposit^ is taking place outwardly. Hence,
as Mr. Stanley observes, the bone is sometimes increased in size. In
some instances the walls of the cyst are not thicker than paper ; in
others, they are fully an inch in thickness. In the former case, the
tumour may present a sensation to the touch, compared to the crackling
of parchment ; in the latter, the feel of a solid bony swelling, or exostosis.
The contents also vary, being either a serous or purulent fluid, or the
products of specific disease, as scrofulous, or medullary matter.
Acute inflammation of bone, taking place as an effect of idiopathic perios-
titis, requires leeches, fomentations, poultices, calomel, and opium, saline
purgatives, and other antiphlogistic naeans, including quietude and low diet.
When the inflammation is chronic, the treatment must be chiefly regu-
lated by the consideration of its cause, whether syphilitic, scrofulous,
or the joint effect of mercury, cold, excesses, and irregularity of diet and
regimen, and an impaired constitution. I believe, that we do not fre-
quently meet with nodes in syphilitic patients, unless these individuals
have been' using mercury in an injudicious manner, that is to say, irre-
gularly or immoderately, and without keeping themselves in a proper
uniform temperature at home, during the mercurial course. Under such
neglect, the united influence of the original disease, and the mercury
itself on the constitution, thus unfairly dealt with, seems to produce a
considerable tendency to inflammation of the periosteum, or even of the
osseous texture itself. Hence nodes, caries, and necrosis, as complica-
tions of the venereal disease.
Simple absorption, or removal of bone, unattended with any formation
of pus, or ichorous matter, should be discriminated from caries, as it is
completely a local affection, caused by the pressure of aneurisms, and
other swellings on the osseous texture. It is sometimes accompanied
with an effort, on the part of nature, to repair the injury of texture ; for
which purpose, she throws out new bony matter near the chasm that
has been produced.
Caries or ulceration of bones. Some years ago, caries and necrosis
were not duly discriminated from one another, though the former is as
different from the latter, as ulceration of the soft parts is from mortifi-
cation. While caries is one of the consequences of an inflamed or irri-
tated state of a bone, some of whose texture becomes absorbed, so that a
chasm is produced in it, without its vitality being destroyed ; necrosis is
another condition, involving the complete or partial death of the original
bone, and often followed by the formation of a new one, or by the more
or less complete repair of the part that has been destroyed.
The points of resemblance between caries of bones and ulceration of
soft parts are striking. Each affection is preceded by inflammation;
each is attended with the formation of matter ; each may be followed by
the production of granulations ; each may arise from local or constitu-
tional causes ; and each may be combined with the total extinction of
vitality in certain points of the textures affected. Thus, precisely in the
same way, as we often see ulceration and sloughing exhibited together
in the soft parts, we also frequently find caries and necrosis prevailing
together in the bones. Some portions of the osseous texture seem to
perish, and to be detached from the living parts of the bone, while, in
other places, caries is making its attack and producing its usual effects.
The venereal disease is sometimes a cause of caries, but more fre-
quently of necrosis ; and very often of both affections together. On other
CARIES. 281
occasions, it leads to the production of nodes and other changes in the
osseous system hereafter to be considered.
The bones are all liable to caries, though the soft or spongy portions
of them are most commonly the seat of it, especially the bodies of the
vertebrae, the sternum, the upper heads of the femur and tibia, and the
bones of the pelvis, tarsus, and carpus.
Sometimes the disease may be traced to the effect of local injuries,
followed by considerable inflammation and abscess ; but it is still more
commonly seen as the consequence of scrofula and syphilis. In whatever
manner occasioned, it is at first attended with some pain in the bone, and
inflammation and swelling of the neighbouring soft parts. Generally, an
abscess of a more or less chronic nature is formed over the diseased bone,
breaking and discharging a thin ichorous bloody matter, of a peculiarly
offensive smell. The integuments around the opening, assume a dark,
unhealthy livid tinge. If a probe be introduced, the surface of the bone
will be felt to be rough and bare, and if the disease be seated in the head
of a bone, a probe will sometimes pass into the cancellous texture, with-
out any material resistance. There is a softening and partial absorption
of the bony texture, some of which crumbles away on the slightest touch.
The disease is accompanied by the production of pale fungous granu-
lations, and the discharge of a thin, foetid, dark coloured, or bloody mat-
ter, which blackens a silver probe. The aperture, formed in the skin,
does not heal, but becomes what is termed a fistula, through which the
matter, and sometimes little particles of the diseased bone, find their way
outwards.
The worm-eaten cariest as it is called, which perforates a bone at innu-
merable points, and in an infinite number of directions, and which used
formerly to be so common in syphilis, as then treated, would appear to
begin with disease and suppuration in the diploe, the worm-eaten appear-
ance being afterwards caused by the pus causing numerous apertures to
be formed in the skull for its escape.
Around the carious part of a bone, from scrofula, may frequently be
noticed new bony deposits, in the form of spiculse, or tubercles and pro-
jections, sometimes extending to a considerable distance from the diseased
joint. These productions may be the result of periostitis. As Mr. Stan-
ley observes, generally around an ulcer in bone, there is found a heaping
up of osseous matter, proportioned to the activity of the process, and
analogous to the thickening, which occurs around an ulcer in soft
parts. This fact is well represented in one of Weidmann's excellent
plates. Its presence Mr. Stanley considers to be characteristic of
the inflammation by which the ulcer was formed ; for a similar thicken-
ing and increased density is believed by him not to exist around bone,
which has been progressively absorbed in consequence of the pressure of
a tumour ; nor around some specific ulcers of bone, as those occurring in
scrofula, syphilis, and lupus. With respect to scrofulous disease of bones,
however, nothing is more common than the rough deposits in its vicinity,
which I have described, and of which there are several fine specimens in
the Museum of University College. The bone in the immediate vicinity
of a carious part of it, if injected, appears to be exceedingly vascular.
Caries may occur at any period of life ; but is most frequent in young
subjects. This fact may admit of explanation by the consideration, that
scrofula, which is one of the most common causes of caries, principally
affects children and young persons. Syphilitic caries, and caries from
the effects of external injuries, are met with in individuals of every age.
282 DISEASES OF BONES.
"' The treatment of caries is to be regulated by the view entertained of
its causes. If the disease should have arisen from a local injury, and have
followed the inflammation and suppuration resulting from the violence,
without being accompanied by any marks of general disorder of the
system, any traces of syphilis, scrofula, or scurvy, we should then be
justified in regarding the affection of the bone as completely local. In
the early stage, we could only employ such treatment as the state of the
soft parts might require ; generally antiphlogistic treatment until the in-
flammation had subsided. Afterwards, we should aim either at removing
the carious portion of bone, or at stopping the morbid action, in which
caries consists, and exciting such a change in the bone, as will lead to a
cure. Mr. Stanley lays it down as a remarkable fact, however, that, after
ulceration of the osseous tissue, or caries, as it is termed, the lost bone
is never reproduced. The utmost reparation, he finds, is the cicatrization
of the parts around it. In ulceration penetrating the shaft of the tibia,
however, he has seen the vacancy filled up by a gristly substance, with
osseous points scattered through it, but never sufficiently to render it a
mass of bone. In the cure of caries of the vertebrae, the deficiency is not
filled up with new bone, but the surfaces, above and below, approximate
and unite.
With respect to the removal of carious portions of bone, the practice
is sanctioned by some surgeons of eminence, who think that more good
may be done in a few minutes by cutting instruments, than will generally
be accomplished in as many years by nature, even when aided by medi-
cines and local applications. This is sometimes true ; for, even when the
disease arises from constitutional causes, and requires internal remedies,
accordingly, such remedies may stop the progress of caries, but are fre-
quently quite inadequate to bring about a new healthy action in the part,
sufficient to lead to a cure : this, however, is not always the case. The
caries produced by syphilis, and scurvy, may be completely stopped,
and cured by remedies adapted to those particular states of the constitu-
tion. And even the caries arising from scrofula, though less under the
control of internal medicines, may sometimes be checked by counter-
irritation, and the administration of iodine, iodide of potassium, the sul-
phate of quinine, steel, and other medicines required to amend the state
of the constitution.
Caries, resulting from local causes, accidental injury, &c. may also get
well, without any occasion for the excision of the diseased portion of bone.
But when caries presents no reasonable prospect of cure by any internal
plan of treatment, and the part is so situated as to admit of removal, the
indication is clear. The requisite denudation of the diseased part of the
bone is to be made, and the disease either cut or scraped away. Some-
times, however, instead of this practice, we may try the plan of exciting
a new action in the carious part by dressing it with a strong solution of
nitrate of silver, or the diluted nitrous acid. Setons, issues, or blisters,
near carious bone, are frequently of great service.
Necrosis is the death of a portion of bone, sometimes of the greater
part of it ; for, not unfrequently, the whole shaft of one of the long
cylindrical bones is destroyed. Generally, however, the head of the
bone escapes ; the articular parts are spared ; and, when the new shaft
is formed, the original portions left, which are commonly the ends of the
bone, become grafted, as it were, on the new osseous case.
After a portion of a bone has perished, or fallen into the condition of
necrosis, its detachment and removal become as necessary, for the pro-
NECROSIS. 283
cess of reparation and the cure of the patient, as the taking away of any
other extraneous substance lodged in the body, and keeping up irritation,
suppuration, and other effects; indeed, the dead bone is to be now re-
garded as an extraneous substance, and its removal from the part, either
by the action of the absorbents*, or some other natural process, or by sur-
gical proceedings, is absolutely necessary. It matters not, so far as the
nature of the disease is concerned, whether merely one layer of the bone
is affected with necrosis, or the whole substance of it — the disease is still
essentially of the same kind ; and the various circumstances of depth and
extent, to which the disease may have proceeded, relate only to its
severity. In this point of view, they certainly are of great importance in
respect to the prognosis, the prospect of cure, and the length of time
which will necessarily elapse before this desirable event can be accom-
plished.
While caries mostly affects the spongy parts of bones, and those bones
which are of a light texture, necrosis is found to attack principally the
harder parts of bones, and those bones which naturally contain the
greatest quantity of phosphate of lime, and are of a firm compact texture ;
and this is so much the case, that those circumstances, which would pro-
duce necrosis in the harder parts of bones, seem mostly to cause caries
when they exert their operation on the softer spongy parts of the skeleton.
Among the bones most frequently attacked by necrosis, I may mention,
first, the tibia, then the femur, the lower jaw, the clavicle, the radius, and
the ulna. The bones of the cranium are also frequently the seat of
necrosis. Of all the bones, none so frequently suffers from necrosis as the
tibia. The disease is one to which both sexes are liable, and this at any
period of life ; yet we find, that the disease is more common in children and
young persons, and especially in those of scrofulous constitutions, than in
other individuals. But this observation must be received with one qualifica-
tion, namely, that all persons who are exposed to dangerous and laborious
employments, or whose pursuits render them liable to suffer from accidental
external violence, are frequently the subjects of necrosis, and this, what-
ever may be their age or the nature of their constitutions.
Although the most extensive forms or degrees of necrosis are chiefly
seen in the long cylindrical bones, we do also sometimes meet with them
in the flat ones ; and even the short thick bones are occasionally quite
destroyed. I have, indeed, already explained, that the bones of the cra-
nium are not unfrequently the seat of the disease, and that the lower jaw
is often affected. In the records of surgery, many instances are given in
which the scapula was attacked. Cases do sometimes happen, but they
are uncommon, in which the articular parts of bones are destroyed, or
involved in the mischief of necrosis ; and, then, as the shaft is more or
* In cases of necrosis, " the whole of the old bone, provided it be not exposed, is carried
off by the absorbents, into the system," &c. — Macartney on Inflammation, p. 41. This
is the common doctrine. On the other hand, Mr. Gulliver is led to believe, that " if a
piece of bone, truly dead, be inclosed within a new osseous cylinder, then it is indeed a
bad case of necrosis, which the patient will carry to the grave with him, unless relieved
of the sequestrum otherwise than by absorption." (See Med. Chir. Trans, vol. xxi. p. 6.)
The experiments and preparations, on which this inference is founded, are admitted,
however, by Mr. Gulliver himself, not to amount to a peremptory proof of the impossi-
bility of the absorption of dead bone. (Op.cit. p. 18.) I have attended so many
patients, in whom the sequestrum has ultimately disappeared, that either its absorption,
or dissolution, seems to me a fact admitting of no dispute, difficult and slow as the
change frequently is.
284? DISEASES OF BONES.
less destroyed at the same time, the prognosis is generally unfavourable,
and amputation of the limb can scarcely be avoided.
Every thing affecting the periosteum, the substance of the bone, or the
medulla in such a way as to interrupt the nutrition of the bone, may con-
duce to the origin of necrosis. The causes, therefore, of necrosis, may
be divided into external and internal. The external causes are principally
severe contusions, bad compound fractures, the pressure and irritation of
foreign bodies in the substance of the bone itself, or in its cancellous
structure, (the lodgment of a musket-ball there, for example, may produce
necrosis,) the long-continued exposure of the surface of a bone deprived
of its periosteum to the air ; or the irritation of it with acid or caustic
applications will produce a similar effect. Thus sometimes the free use
of strong concentrated acids in the treatment of sloughing ulcers on the
shin will, if care be not taken, produce necrosis of the tibia. In Univer-
sity College Museum is a necrosis of part of the cranium from a burn.
As a general rule, when the walls of a cylindrical bone perish in their
whole extent, the medullary texture suffers with them ; but, Mr. Stanley
refers to a remarkable exception, in which, in consequence of the appli-
cation of nitric acid to a phagedenic ulcer, the whole of the periosteum,
covering the tibia, became inflamed ; the walls of the bone perished ; but
the medullary texture escaped.*
Whenever the old surgeons saw a portion of bone exposed to the
atmosphere, and deprived of its periosteum, they concluded that a cure
was impossible without exfoliation of the part of the bone thus uncovered ;
they fancied that it would of necessity become attacked with necrosis,
and thrown off from the living part of the bone before a cure could be
accomplished. But this was taking an erroneous view : it does not follow,
that a bone must die and exfoliate under these circumstances. It is true,
that if the bone has suffered much contusion, if the patient is old, feeble,
and unhealthy, and, especially, if the exposure has been long continued,
necrosis will most probably take place. But former practitioners were
confirmed in their erroneous opinion by invariably committing two errors
in the treatment of these cases ; in the first place, they did not take care
to cover the exposed portion of bone as quickly as possible with the soft
parts, which had been detached from them, and thrown back in the
form of a flap ; and, in the second place, they commonly dressed the
wound with irritating applications, and with what they conceived was
calculated to promote exfoliation. Such practice would of course tend
to confirm the view which they had taken of the case ; for, under the
kind of treatment referred to, necrosis would be almost certain to follow :
whereas, if they had promptly covered the exposed bone with the soft
parts, and had then resorted to proper dressings, they would soon have
discovered, that the simple exposure of the surface of a bone is not neces-
sarily followed by necrosis ; and that exfoliation is not always to be ap-
prehended as a matter of certainty. We know that the osseous texture
does not depend entirely on the arteries of the periosteum for its nutrition ;
and that those of the^medullary membrane are materially concerned in
this function ; hence, it does not follow, that a bone must perish, because
it is deprived of its periosteum. On the contrary, if the patient be
young, and his constitution sound ; if the bone be not too much contused,
and not kept exposed too long to the atmosphere, or dressed with impro-
per drying, astringent, spirituous applications ; the production of necrosis
* Med. Gaz. vol. xx. p. 498
NECROSIS. 285
may generally be avoided. All this implies, however, that the violence
which has given rise to the accident, has not operated too much on the
medullary texture. When a limb has suffered such a degree of injury,
that the periosteum is detached from the surface of the bone, along with
the soft parts, an injudicious method of proceeding will of course bring on
necrosis of the exposed bone ; but, if the loosened flap of soft parts be
immediately laid down again ; and no stimulant applications be used,
there may be no necrosis at all, and, of course, no exfoliation ; granu-
lations will spring up from the surface of the bone ; these will unite to
those arising from the soft parts, and a complete cure will often follow
with extraordinary expedition, particularly in young and healthy sub-
jects.
But necrosis, and the worst forms of it, may proceed from internal
causes, or from such as affect the bone, through the medium of the con-
stitution. Experience proves that necrosis may follow that deranged and
debilitated state of the system remaining after various kinds of febrile
disturbance. The origin of some of the worst cases of necrosis may
be attributed to the debilitating effects of typhus fever, small-pox,
or measles. Scrofula, lues venerea, scurvy, and the prejudicial influence
of a badly conducted course of mercury,, have all been known, under par-
ticular circumstances, to excite necrosis. When mercury gives rise to
this affection, it is generally when that medicine is administered for the
cure of syphilis, and the patient does not, during such mercurial course,
take proper care of himself, being exposed to the vicissitudes of the
weather, or incautious in his diet. In many instances, the mischief is
brought on by the mercury being given in excess, or by small quantities
acting with unusual violence. The bones which most frequently suffer
under these circumstances, are the lower jaw, and part of the alveolar
processes of the upper jaw. Necrosis and abscesses are frequently com-
bined together ; we sometimes find matter on the surface of a bone, part
of which has perished ; but the latter circumstance is usually in conse-
quence of the very inflammation which gave rise to the abscess, having
extended its effects to the bone itself; die bone, therefore, suffers from
the same causes as produced the suppuration. It is, however, possible to
conceive that an abscess may produce necrosis, when its pressure ope-
rates upon the bone in an extraordinary degree ; then, indeed, it is pos-
sible, that necrosis may be occasioned by an abscess, but certainly not by
any corrosive qualities of pus.
The symptoms of necrosis vary in different cases, according to the
extent of the disease and the nature of its cause. When it is of
limited extent, that is, when it is merely superficial, not extending
deeply into the bone, and arises in consequence of external violence,
the symptoms will not be very different from those of a common
phlegmonous abscess. Suppuration occurs in the soft parts, and, as soon
as the matter is discharged, if a probe is introduced, the bare bone is
felt. In such a case, unless there be an extensive and 'violent in-
flammation of the soft parts, there may be little or no constitutional
disturbance ; but when the necrosis is more considerable, and the
soft parts are more extensively implicated either primarily or second-
arily, in the disorder, then there will be a greater, and sometimes
a violent derangement of the system. But there is a form of necrosis
— one, in which the patient is generally young and of a scrofulous
habit of body, and in which the bones of the carpus, or tarsus, or the
phalanges of the fingers, suffer. In such cases, an indolent swelling first
286 DISEASES OP BONES.
forms, unattended with much pain or disturbance of the system; at
length a fluid collects in the part, which bursts and pours out an ichorous
matter. In this stage, if a probe be introduced, we may feel the bone
to be bare and rough — in fact, it is already in the state of necrosis. It
is chiefly in individuals, thus predisposed to the disease, that we also meet
with those formidable examples of necrosis, in which the whole shaft of a
long cylindrical bone perishes. In scrofulous or syphilitic persons, on the
application of some exciting cause, the death of the whole shaft of a
long bone, or a considerable portion of some other bone, frequently
occurs. When the disease arises in individuals, whose state of constitu-
tion promotes the origin and wide spread of disease in the osseous sys-
tem, necrosis generally begins with a deep-seated and excruciating pain
in the limb, followed by a general swelling, involving the whole of that
part of the member, and mostly including also the two nearest joints.
It is, however, much greater about the centre of the limb than elsewhere ;
and one of its characters is, that it seems to have no definite boundary,
presenting every where a remarkably firm unyielding feel. The patient
experiences no alleviation of his sufferings till matter forms and the ab-
scess bursts, and then there is generally some diminution of the pain ;
but it is found that, on the escape of the matter, the tumour does not
subside in the degree usually remarked in a common abscess under simi-
lar circumstances ; there still remains an immense swelling, which is of a
firm, unyielding kind, depending upon the great quantity of coagulating
lymph effused around the dead bone, the thickened state of the perios-
teum, and the cedematous state of the cellular tissue. These circum-
stances explain why there is but little subsidence of the swelling
immediately after the matter has been let out, or found an outlet for itself.
If a probe be introduced after the bursting of the abscess, it passes on-
wards till it is stopped by the bone, a portion of which may often be felt to
be bare and rough. In all these cases, we should let out the matter early,
for the sooner this is done, the sooner will the patient experience a dimi-
nution of the agony attending the confinement of deep-seated matter.
After the abscess has made its way out, or been discharged by puncture,
the opening or openings (for there are sometimes more than one) will
not heal up very speedily ; in fact, they are converted into fistulae,
and losing all disposition to cicatrize, they emit fungous granulations
around their orifices. The indisposition of these fistulae to heal, however,
does not usually depend upon any other impediment than the presence of
the dead bone in the limb, the sequestrum, which, in the manner of an
extraneous body, keeps up irritation and suppuration. Hence, nature
seems to maintain the fistulous apertures, in order that whatever pus is
formed may flow out, and sometimes, as experience proves, for the passage
of the dead bone itself. In consequence of the presence of the seques-
trum and the long-continued suppuration thereby produced, the sympa-
thetic inflammatory fever, which attends the first stages of an extensive
necrosis, is soon converted into a febrile disturbance of the hectic type ;
indeed, the disease generally goes on so long, and the discharge some-
times continues for such an indefinite length of time, that the constitu-
tion may be reduced to the lowest state of weakness ; and, in addition to
the hectic, there are occasional attacks of irritative fever, by which the
patient is brought into great danger, such danger as admits of no means
for its removal, except an operation for the extraction of the sequestrum,
the cause of all this suffering and peril ; or if the disease be not in a
state for such proceeding, we may be called upon to perform amputation
NECROSIS. 28?
of the limb, in order to save the patient's life. Before we can say posi-
tively that necrosis exists, it is necessary to introduce a probe, for until
we can touch a portion of dead bone, we cannot be certain that the
disease has occurred. Sometimes, however, when the dead portion of
bone lies superficially, we may actually see a part of it within the fistula,
or at the bottom of an ulcerated chasm.
The colour of a sequestrum is not always the same ; it is often per-
fectly white ; and when a portion of bone is whiter than natural, we may
be sure that it is in the state of necrosis. Generally when the dead bone
has been exposed for some time to the air, it becomes brown or black,
and every body knows, that a bone with this appearance has perished. In
particular instances, where the whiteness is not much increased, there
may be doubt ; but if a brown tinge be seen upon the exposed bone, we
may conclude that it is dead. Excessive whiteness, or a darker colour
than natural, is a sure indication of necrosis. When a sequestrum lies
deeply, and is not exposed to the air, it is generally white, or of a light
brown colour ; but when it has been exposed for some time to the atmo-
sphere, or remained long at the bottom of an open ulcer, it assumes a
darkish, or even a black hue.
The process of exfoliation, or that process by which the dead portion
of bone is separated from the living portion, has a considerable resem-
blance to the process by which sloughs of the soft parts are thrown off;
especially this will seem the case, if we make due allowance for the
greater slowness with which all changes in the bones are carried on. In
making an issue, the first step is to kill a portion of the skin. Very soon
increased vascularity of the adjacent skin is noticed, and a red line forms
immediately around the eschar. And so it is with bone ; the parts, sur-
rounding the dead portion, directly become preternaturally vascular, or
(to use Hunter's expression) inflamed.* A groove is next formed all
round the sequestrum, which is generally believed to be produced by the
action of the absorbents of the adjoining living bone, or, as Mr. Hunter
first demonstrated, the groove is formed by the absorption of that part
of the living bone which is contiguous to the dead ; its earthy matter
being first taken away, and then its animal part. The groove begins on the
surface, and extends gradually more and more deeply, until the dead por-
tion is completely undermined and detached ; in this respect, we recog-
nise also a correspondence to what happens in the separation of sloughs.
As the groove deepens, it is occupied by granulations arising from the
living bone ; and hence, as Mr. Stanley observes, on removing the seques-
trum, we see next to it, not the surface of the living bone, but a layer of
vascular granulations. And, in correspondence with the granulations
that have sprung up from the living bone, there is the well-known rough
surface of the dead, with its multitude of prominences and excavations,
fitted to the granulations, which, as it were, push out the dead bone from
the cavity in which it is lodged. In the course of time, a sequestrum may
be reduced to an inconsiderable size, compared with what it w%s originally,
the greater part being removed, and unless the portion that is lost undergo
some unexplained kind of dissolution, as suspected by M. Velpeau and
others, or come away in minute particles with the discharge, I know of
no agents for the production of this change, but the absorbents. At all
events, whatever may be the inability of the absorbents to remove a loose
and perfectly separated piece of dead bone, experience furnishes very con-
* E. Stanley, Med. Gaz. vol.xx. p. 498.
288 DISEASES OF BONES.
vincing proofs, that dead bone may be absorbed while retaining its con-
nexion with the living bone.* In University College hospital, I have
repeatedly noticed the disappearance of portions of dead bone, which
had been plainly felt in wounds and ulcers for several weeks, and inter-
fered with the healing process.
In the earlier stages of the necrosis of the shaft of a long cylindrical
bone, the periosteum (if spared), in the neighbourhood of the portion of
bone about to be destroyed, always becomes thickened and more vascular
than natural, and continues in this state during the formation of the
substitute for the old bone ; but as soon as this process is finished, and
particularly after the detachment of the sequestrum, the periosteum
returns to its natural condition, and loses its increased vascularity ; its
inner surface has no longer the pulpy, granular, highly vascular texture
which it had in the early stages of the case, when the office of producing
the new bony formation round the sequestrum devolved upon it. After
the sequestrum has been completely loosened, it still remains at the
bottom of the abscess or ulcer, or within the new bony case, and would
sometimes continue there a considerable time, keeping up pain, irritation,
and discharge, were we not to introduce forceps and remove it, and even
to make such incisions for the purpose, and such removal of a part of the
new deposit of bone as may be requisite. Occasionally the sequestrum
is not only perfectly loose, but so superficial and exposed, that it can be
taken away without any occasion for the knife, trephine, or saw. When
an abscess, ulcer, or fistula is complicated with dead bone, it is a rule in
surgery always to remove the sequestrum as soon as possible, that is,
directly it is loose, and for this purpose to practise such operations as
may be necessary. But not only is the sequestrum often loosened and
thrown off from the living bone by spontaneous or natural processes, (and
I have seen several cases in which considerable portions of the shafts of
the humerus and femur have been thus detached, coming out through
the integuments without the aid of any formal surgical operation,) not
only does nature effect all this, but, when the entire shaft of a bone has
been destroyed, she makes wonderful, and generally most successful
efforts to form a new bone, that answers almost as well as the original
one. When the shafts of the tibia, humerus, femur, or other long cylin-
drical bones are destroyed, and nothing of the original bone remains
alive, except the articular extremities, even when the destruction has
proceeded to this extent, nature will form a new bone, and the uses of
the part or limb will be restored. In the sides of the new bony form-
ation are openings, termed the cloaca, which serve for the escape of the
matter secreted in the interior of the new bone, so long as the seques-
trum keeps up irritation there. The cloacae, in many instances, take an
oblique course, and do not pass straight and direct into the cavity of the
osseous tube. They mostly have an oval or a round shape. Sometimes,
however, they do pass direct into the cavity of the new bone, a fact not
agreeing exactly with Weidmann's description. No doubt, the straight
direct course of some cloacas is an exception to the general rule.
The flat, as well as the cylindrical bones, when attacked with necrosis,
possess the power of reproduction : there are several cases on record, in
which the scapula was reproduced, after having been destroyed by ne-
crosis ; and it is known, that portions of the cranium, under particular
circumstances, may also be regenerated. Instances are related, where
* E. Stanley, Op. ct vol. cit, p. 49J>
NECROSIS.
nearly the whole of a parietal bone was reproduced. Considering the
little reparation which losses of portions of the skull from the trephine,
or external violence, generally undergo, this is what we should not a priori
expect ; yet, in the Museum of University College, there is a remark-
able preparation, the skull of a person who had been trephined forty years
before his death, and where a considerable portion of bone was taken
away, which has been in a great measure restored. Generally, the repro-
duction of bone after trephining does not happen to any great extent ;
the pericranium being destroyed, and both the tables of the skull being
removed, the reparation is very partial. It appears, therefore, that the
dura mater does not possess a power of reproducing bone at all equal to
that of the pericranium, or periosteum of the bones in general; how-
ever, if only the outer table be removed, the diploe and the dura mater
together will effect the reproduction of the lost portion ; but, in other
instances, we rarely find that any very successful attempt is made by
nature for the restoration of the two destroyed tables. Even fractures
of the skull unite with difficulty and slowness. The preparation just
now referred to, I regard as a particularly interesting one : in all pro-
bability, at the time of the operation, the patient was young, perhaps a
child ; this I infer from the circumstance of his having been trephined
forty years before his death ; and, in young growing subjects, the power
of reproduction in bones is always considerably greater than in older
p ersons.
Though the long cylindrical and flat bones may be regenerated, the
short cuboid bones cannot be reproduced. When once destroyed, there
can be no restoration of them ; this fact is one which all men of ex-
perience are fully aware of. In the early periods of life, and in healthy
subjects, the power of reproduction in bones is always greater than in old
or debilitated persons. It is also seriously diminished in particular states
of the constitution, and especially when the individual is under the
influence of the worst forms of lues verierea, or of cancer, scurvy, or
rickets. However, some of these constitutional diseases do not abso-
lutely prevent the reproduction of bone in every instance ; and exceptions
are met with, in which broken bones unite more or less completely in
spite of them.
The next subject, respecting necrosis, is a curious and interesting one ;
I allude to the means adopted by nature to bring about the reproduction
of bone. Of this part of the inquiry different pathologists give different
accounts, proving that further investigations into certain points would be
desirable. The questions are, whether nature accomplishes her purpose
by means of the vessels of the periosteum ? by means of those of the
medullary membrane ? or in another manner, in which it is supposed,
that, when the whole shaft of a bone has been reproduced, the inner
portion of the bone alone has perished, and that the outer one has been
saved and transformed into the new shaft ? This last opinion is main-
tained by some men of considerable eminence. They assort, that in
necrosis, the whole of the bone does not really perish, that the outer
portion is preserved ; and that, when the whole shaft seems to have been
reproduced, it is in consequence of the external layers separating from
the inner ones, which alone are truly destroyed. That the latter repre-
sentation is not applicable to a great number of instances, I consider per-
fectly certain ; but whether it is ever the case, is another question.
Dr. Macdonald, who investigated this subject with considerable talent,
found, that the new bone actually began to be formed previously to the
u
290 DISEASES OF BONES.
complete death of the old one. Both he and Professor Russell observed,
that during the formation of the new bone, they could inject the vessels
of the old one.* These circumstances, so far as they go, would strengthen
the doctrine, that the old bone is the source of the new one. The sup-
porters of this doctrine have recourse likewise to another circumstance,
as an argument in favour of their view ; they take advantage of the fact,
that in all, or almost all cases, where new long cylindrical bones are
formed, the articular heads are saved, so that, these preserved portions
must be regarded as contributing also to the formation of the new bone.
But this doctrine certainly cannot apply to other instances, in which the
whole shaft of the bone is known to have been destroyed through its
entire thickness. Cases are continually presenting themselves, in which
from the thickness of the sequestrum, there can be no doubt of the whole
substance and diameter of the original bone having perished. Then, how
would the suggested theory explain the reproduction of portions of the
whole thickness of the tibia sawn away, or lost by the effect of external
violence ? Indeed, the careful observation and correct examination of
the different stages of the process of reproduction, tend to prove that, at
all events, in some cases the periosteum has a principal share in the
formation of the new osseous matter ; for it is found to become thickened
and more vascular than natural, to [assume a pulpy, granular texture
internally, a new kind of organisation, fitting it for its increased duty ;
the cellular tissue external to it also becoming swoln. In the museum of
St. Bartholomew's Hospital, are some valuable preparations put up by
Dr. Macartney of Dublin, clearly exhibiting these facts. The periosteum
then separates from the portion of bone which is about to perish, and
becomes covered internally with a vascular pulpy substance, destined
for the secretion of the new bone, the nidus for which is, no doubt, at
first coagulating lymph. Such are the processes which usually take place
when the whole shaft of a bone perishes. They seem to happen also
very early ; for, in one instance, which Dr. Macartney had an oppor-
tunity of examining in an incipient stage, the separation of the periosteum
had taken place, though there was only a small abscess formed in the
medullary membrane. These facts admit of demonstration, and com-
pletely refute the doctrine, which maintains exclusively, that the old bone
is invariably the organ by which all the new shaft is produced. I do not
mean to say, that there may not be cases in which the internal portion
perishes and the outer portion lives, any more than that there may not
be instances in which the destruction is confined to the outer lamina ;
we know that these last cases are common enough, in relation to the
destruction of a certain extent of almost any bone. Experiments have
been made on animals, which tend also to prove the fact of the perios-
teum being fully capable of, and often actively concerned in, the repro-
duction of bone : every part of a bone has been removed, all the medullary
membrane, and the whole of the osseous texture have been taken away,
in order to ascertain whether the periosteum was adequate to restoration
of the lost substance ; these experiments demonstrated, that the peri-
osteum possessed such power in a wonderful degree. Some of them
were made by Troja, and others by Koehler. Several have been repeated
* In the museum of St. Bartholomew's Hospital, according to Mr. Gulliver, there is
the tibia of a dog incased in a shell of new bone, and partly detached ; " but the in-
jection has run pretty freely into the old bone." — (Med. Cliir. Trans, vol. xxi. p. 6.)
Mr. Stanley, however, considers this to be doubtful.
NECROSIS. 291
by Mr. Stanley, who sets down this membrane as the most important
agent in the reproduction of bone.
If the surface of a bone has perished to a limited extent, producing a
superficial necrosis, the dead bone will exfoliate, or be absorbed, but no
reproduction of bone will ensue, the vacancy becoming filled up only with
a dense fibrous tissue.
If, from peculiar circumstances, the shaft of a bone die, while the
medullary texture is left perfect, and the periosteum is entire, then there
may be a complete reproduction effected by the vessels of the peri-
osteum.
In all common instances, however, where necrosis attacks the whole
thickness of a bone, the walls and medullary texture both perish. Under
these circumstances, the shaft of the bone may be reproduced from three
sources. 1. The articular ends of the bone, which are very rarely im-
plicated in necrosis. 2. The periosteum, which invested the dead bone.
3. The soft parts indifferently, whatever their nature may be, which sur-
round the periosteum, supposing this to have been destroyed either
simultaneously, or subsequently to the death of the bone.*
Some of Dr. Macartney's views of this subject have been more particularly
noticed in his last publication. " The mode (says he) in which the dead
bone is removed, and a new one formed, is perfectly consistent with the
general laws for the reparation of bone. A vascular substance is created,
resembling granulations in structure and offices, for the purposes both of
absorption and reproduction, which I have called the vascular investment.
This new organ will grow upon whatever tissue lies next the dead bone ;
and as the periosteum is usually in that situation, the mistake has arisen
of attributing to that membrane the offices of absorption and reproduction ;
functions, which it would be quite incompetent to perform in its natural
state." Dr. Macartney does not agree with those who suppose, that the pe-
riosteum, as such, is the proper structure for reproducing the new bone.
" The granulation-structure," he observes, " is that which is employed
for the separation of different substances that are not fit to remain in
contact with the living body. Hence, we find it constitute the organ for
this purpose in necrosis ; in the process of exfoliating bone that is dead;
in detaching sloughs ; in drawing the line of demarcation in a mortified
limb; and in the removal of deciduous teeth.
" When the principal part of the shaft of a bone is necrosed, the peri-
osteum becomes detached from the bone ; and from the number of red
vessels it now receives, it is rendered soft, pulpy, and perfectly red on
the surface next the bone; and, as soon as the work of absorption begins,
this surface acquires the form of granulations. As this vascular invest-
ment proceeds inwards, devouring the dead bone, the shell of the new bone
is deposited in the back of the granulation- structure, which undergoes the
preparatory change into a gelatinous, or cartilaginous tissue, previously to
its ossification. The shell is at first of course thin, and w^h numerous
holes in it, for the transmission of red vessels to the vascular structure,
and for the exit of a fluid, which hardly deserves the name of pus, in the
first instance, if the inflammation be kept down ; and as the process ad-
vances inwards, the new formed bone becomes thicker and firmer, until
at length, when the dead bone is all removed, the regenerated one becomes
solid throughout. This description applies to those cases, in which the
whole of the middle of a long bone dies and is reproduced ; but, when
* E. Stanley, op. et vol. cit. p. 577.
u 2
292 DISEASES OF BONES.
the skin ulcerates, and a certain portion of the sequestrum or dead bone
becomes exposed, that portion is separated by the granulations of the
ulcer, by the process of exfoliation, if it be not removed by an oper-
ation." *
If in a living animal, a portion of one side of the walls of a bone be
removed, without much injury to the medullary texture, the lost bone
will be reproduced by the vessels of the medullary membrane. If, in a
living animal, a portion of the whole thickness of a long bone, with its
periosteum, be removed, reproduction is not to be expected. But, in man,
in consequence of the quietude in which the limb may be maintained, union
will take place between the ends of a long bone after such experiment.
Here the new osseous matter, which fills the vacant space, is produced at
once by the vessels of the medullary membrane, by those of the surround-
ing cellular tissue, and by those of the walls of the bone. These all pro-
duce granulations, which are converted first into fibro-cartilage, and at
last into bone.f These facts, and others noticed in the description of the
process by which fractures unite, place in a conspicuous view the error of
supposing the periosteum to be the sole organ for the reproduction of the
osseous tissue.
The sequestrum, when long retained, gradually undergoes a change in
its shape and size ; but this change is one of considerable slowness ; in-
deed, the total absorption of the sequestrum would sometimes require so
long a period, that the patient would hardly live till the completion of
the process. In children it goes on more quickly and with greater suc-
cess. The absorption of the sequestrum is probably effected by the
absorbents of the vascular substance between the sequestrum and the
new bony tube. In the living subject, the dead portion of bone is not so
loose within the new case as it is in preparations; in fact, the space
between the old and new bone is completely occupied by the pulpy vas-
cular substance. As the new osseous formation is produced before the
removal of the old bone, and is external to it, of course it must be larger
and more clumsy than the original one. The old bone appears, then, to
serve as a kind of model for the new one, and in time, after the seques-
trum has been entirely removed, the irregularities on the surface of the
new bone are gradually smoothed down, and its thickness diminishes, so
that it becomes as nearly as possible of the size and shape of the original
bone. The medullary structure is also formed in the new bone. Dr.
Macartney had a preparation in which the disease commenced thirteen
years before the death of the patient, and, in this case, the interior was
becoming cellular, preparatory to the formation of the medullary struc-
ture. He had seen a tibia, in which the medullary reticulated texture
had been reproduced, although the medullary cells were irregular.
During the whole of the processes by which an original bone is de-
stroyed and regenerated, it rarely happens, that any want of firmness in
the limb is experienced ; it is not flexible ; there is no shortening of it ;
and, what is equally remarkable, the attachments of all the muscles are
preserved as in their original state. In a few examples, however, the
new bone is not thrown out fast enough to prevent shortening of the
limb. There was an instance at St. Bartholomew's Hospital, a few years
ago, of the femur being destroyed by necrosis, and the new bone not
being secreted with sufficient quickness and perfection to prevent retrac-
* See Macartney on Inflammation, p. 73.
f Stanley, in ]Mc-d. Gaz. vol. xx p. 501.
NECROSIS. 293
tion and deformity of the limb. In that case, amputation was deemed
necessary. A poor chimney-sweeper had necrosis of the femur with ex-
tensive abscess. This went on very well, however, and a large tumour
of new bone was felt around the ends of the dead piece ; one near the
knee-joint, the other about half way up the thigh. An attack of erysipelas
came on, and caused the entire absorption of the new bone, with con-
siderable increase in the extent of the dead portion ; so that the next
time the prominences, formed by the new bone at the ends of the dead
piece, were distinguishable, the upper was nearly as high as the tro-
chanters, and the lower one very near the knee. In another case of
necrosis of the femur, the patient, in consequence of the limb being at-
tacked with erysipelas, had one or two ill-conditioned abscesses in the
leg, and, what was worse, an abscess of the knee-joint, with ulceration of
its cartilages. Such complication, added to the disease in the thigh,
rendered amputation indispensable.*
In Weidmann's excellent work on necrosis, are representations of
several of the most interesting circumstances which take place in this
disease. One engraving shows the protrusion of the dead shaft of a hu-
merus through the skin, in such a way that it admitted of being taken
out with the fingers, and exhibits the appearance of the sequestrum
after its removal. It is curious to notice, that the lower portion of the
dead bone is generally more angular and irregular than the upper. In
some of these fine and accurate plates, the drawings for which were all
taken from nature, are views of the cloacce, or apertures, forming out-
lets for the matter collected between the sequestrum and new bone.
There are also several plates, representing necrosis of the articular ex-
tremities of bones, and amongst them is a very remarkable one, in which
there are not less than three sequestra, one in the upper head of the
fibula, and two in that of the tibia. One of the plates represents a re-
generation of the lower jaw ; the case was a necrosis of that bone, and
we see the degree of reparation effected by nature, the appearances of the
new bony formation, and how well it is calculated to be a substitute for
the original bone.
In the treatment of necrosis, it is necessary to consider, that the
disease presents itself in three different stages. The first is attended with
inflammation, and is that in which the disease is forming. In the second
stage, the sequestrum, or dead bone, has been produced, but it is still fixed,
and firmly connected to the living parts of the bone. In the third, the se-
questrum is not only formed, but loose. Now such varieties in the con-
dition of the disease have a considerable influence on the choice of plans,
with the view of promoting the cure.
In the first stage, supposing the disease to be extensive, and to be
accompanied by severe inflammation of the soft parts, while the seques-
trum is only forming, we can do little more than endeavour to check and
moderate the inflammation of the soft parts. In this stage, recourse may
be had to antiphlogistic treatment, especially leeches, fomentations, and
poultices ; and sometimes we may cup the part with a better effect, than
what is obtained from the other form of local bleeding. It is evident
from the very nature of the disease, namely, from the circumstance of its
unavoidable and speedy complication with a portion of bone, entirely de-
prived of all vital action in it, which dead piece of bone must then be
regarded as^an extraneous substance, that the utmost we can do in this
* Caesar Hawkins, in Lond. Med. Gaz. vol. xii. p. 749.
u 3
294 DISEASES OF BONES.
stage, is to lessen the inflammation and appease the patient's sufferings ;
the sequestrum will inevitably be produced, and must be got rid of before
a cure can be accomplished. In the early stage of the disease, another
principal indication is to make free openings for the discharge of abscesses
as soon as a fluctuation can be felt.
In the second stage, or that in which the sequestrum is completely formed,
yet firmly attached to the living part of the bone, we are generally obliged
to wait, till nature has more or less detached it, before any useful steps
can be taken for its removal : we know of no medicines that would cer-
tainly have the effect of quickening the process of exfoliation ; and even
when the whole shaft of a bone is in the state of necrosis, it is by the
same process that its separation from the living extremities of it is to be
effected.
We may usually recognise this second stage of the disease, by ob-
serving the presence of fistulae, through which some part of the seques-
trum may be felt with a probe. Many years ago, the proposal was made
to apply diluted nitrous acid to exposed sequestra, for the purpose of
dissolving the earthy part of them, and thus getting rid of them with
expedition. The fear, however, of injuring the sound part of the bone
prevented this practice from being extensively tried. This suggestion
merits notice, however, because a report was presented to the Royal
Academy of Medicine at Paris, in the year 1835, giving highly favourable
accounts of a similar practice followed by Delpech, who employed for the
dissolution of the earthy part of the sequestrum, the diluted sulphuric
acid. This was applied to the exposed dead bone four or five times in
the course of the day, and soon afterwards the animal part of the de-
stroyed bone admitted of being taken away with forceps. I have tried
this plan in University College Hospital : the acid of course dissolves the
sequestrum, but the subjacent bone seems to be acted upon, and more or
less destroyed.
The process of exfoliation, or that by which the dead portion of bone is
loosened and separated from the rest of it, is a particularly slow one,
sometimes requiring months and even years for its completion. Though
the process is analogous to that by which sloughs are detached, it differs
from it in requiring a much greater time ; and, unfortunately, we have
few means by which we can influence it in this respect. Some surgeons
try counter-irritation ; they apply blisters and keep them open with
savine ointment, for the purpose of expediting the process of exfoliation ;
this plan was strongly recommended by the late Mr. Crowther, in a good
practical work, which he wrote on the subject of necrosis and diseases
of joints, and, at one time, such treatment was extensively adopted in some
of the London Hospitals. I believe, that counter-irritation, with blisters,
or issues, setons, and the exhibition of tonics, or of the ioduretted solution
of the hydriodate of potash, according to circumstances, may tend in
some degree to quicken the process of exfoliation. At all events, a
blister, seton, or issue, is often beneficial in lessening the disposition to
repeated attacks of inflammation in the deeper parts of the limb, the re-
currence of painful and profuse abscesses, and all the severe constitutional
disturbance which is so liable to arise from these states of the disease.
In necrosis, the health suffers, not merely from the discharge which is so
copious and long kept up, but from the repeated recurrence of fresh in-
flammation, and renewed formations of matter after other abscesses have
been nearly, or quite cured. Sometimes we may essentially serve the
patient by supporting his strength ; for, when he is languid and debili-
.NECROSIS. 295
tated, or much reduced by hectic complaints, the process of exfoliation
will not go on so well, as it would do if the actions and functions of the
system at large were carried on with more vigour and less disturbance.
We know that exfoliation naturally proceeds more quickly in young per-
sons than old ones, which may be regarded as fortunate, because a large
proportion of the worst forms of necrosis happen in young subjects. As
Mr. Stanley has observed, in some cases* and these in whatever circum-
stances the death of the bone has taken place, whether from constitutional
or local causes, from external violence, or otherwise, the sequestrum will
still retain its connexion with the living bone* and no exfoliation ensue.
This gentleman had seen cases, where, many years after the death of a
portion of bone, it was found to have undergone no change whatever ; nor
had any separation of it from the living bone taken place. " In many cases,
the causes of this failure of separation seem obscure : in some it may arise
from simple debility, or a peculiar derangement of the system ; or it may
be the effect of a diseased condition of the soft parts surrounding the dead
bone. This is perhaps capable of illustration by those cases, in which
necrosis takes place from the influence of the venereal disease. In these,
a portion of the front of the tibia, for example, having perished, and the
skin covering it ulcerated, dead bone is exposed, and becomes perfectly
black ; but it undergoes no further change. At length, after it has re-
mained in this condition for some months, a suspicion begins to be enter-
tained of its syphilitic nature, and mercury is administered : when, as
soon as this remedy commences to affect the system, the sore assumes
a healthy character, and the process of the separation of the dead bone
commences. It may be, however, that the mercury excites the absorbents
to action, independently of its influence on the constitutional affection." *
Instead of mercury, which often has very pernicious effects on the gene-
ral health, where necrosis exists in a syphilitic patient, I usually prefer
giving the iodide of potassium*
Notwithstanding all that can be done, by means of tonics, iodine, blis-
ters, &c., assisted with an eligible diet, notwithstanding the most judicious
support and regulation of the general health, a complete cure of necrosis,
in its second stage, by natural processes, that is, by the absorption, or
annihilation of the sequestrum, and the subsequent healing up of the fis-
tulous openings, is not frequently accomplished. I have attended several
young subjects, however, in whom a necrosis of the upper portion of the
humerus terminated in this favourable manner. In the generality of in-
stances, active and sometimes remarkably bold measures become neces-
sary ; but these can seldom be adopted with any success during the
second stage of the disease. Sometimes, however, in this stage, we are
absolutely compelled to amputate the limb ; for if the health should be
so dangerously reduced and deranged by the pain and irritation, and pro-
fuse discharge, that a further perseverance in attempts to save the limb
would be more likely to lead to the patient's death than tlje cure of the
necrosis, we should then be called upon to amputate the limb. This
necessity occurred in a case, from which one of Weidmann's engravings
was taken ; there was a necrosis of the condyles of the femur and of the
head of the tibia ; and the health being so seriously reduced as to render
further attempts to save the limb improper, amputation was performed by
Siebold. In Mr. Listen's collection is a fine specimen, in which the
bones of the knee are not only involved in the ravages of necrosis, but
* Op. et vol. cit. p. 579.
U 4
296 DISEASES OF BONES.
also dislocated. Whenever necrosis involves a large joint, the patient
cannot be expected to recover without amputation. Sometimes, patients
with necrosis are attacked with erysipelas ; and abscess of the knee-joint,
with ulceration of the cartilages, is added, perhaps, to necrosis of the
shaft of the femur, or tibia : this is a case for amputation, as illustrated in
that recorded by Mr. C.Hawkins. When the case is a necrosis of the femur,
and the new bone gives way, followed by irremediable deformity of the
limb, and profuse abscesses, amputation may be called for. The possibi-
lity of such an unfavourable change dictates the propriety of affording, in
some instances, the support of a splint, or other mechanical apparatus,
for a certain time after the removal of a considerable sequestrum.
In a necrosis of the femur, the sharp point of a sequestrum has been
known to open the popliteal artery, and give rise to an aneurism ; and
the patient, who refused to submit to amputation, died of mortification
and hemorrhage.*
In the third stage of necrosis., or that in which the sequestrum is loose,
the dead bone can only be regarded as an extraneous body, keeping up
more or less irritation and suppuration. Its removal, therefore, either by
natural processes, or by the interference of the surgeon, is now necessary
for the cure. Sometimes one end of the sequestrum will actually make
its way through the skin, and will protrude, and then it may be easily taken
away ; but, in other instances, where it is completely surrounded by a
new bony tube, an operation will mostly be required, sooner or later, for the
purpose of extracting it. In young subjects, the dead portion of bone, even
though thus circumstanced, is sometimes removed by natural processes.
In general, however, we are obliged to cut away a portion of the new
osseous deposit that confines it. When we find the health good, the dis-
charge lessening, and the fistulous openings inclined to heal, there is no
urgency for an operation. But when the health is suffering, the discharge
copious, and the sequestrum known to be loose, that is, can be felt to be so,
it becomes an object to remove the dead bone from within the osseous tube,
which is frequently so hard as to require the cutting pliers, saw, or tre-
phine. Suppose the sequestrum to be surrounded by a bony tube, we
should make an incision over that part of the new osseous formation,
under which we have ascertained with a probe, that the loose dead
bone is situated. Having done this, we may generally see the cloacae,
through which we make another examination of the sequestrum with a
probe. Then, by cutting the interspaces, or bridges, between two of
these apertures, or enlarging one of them with the cutting pliers, we make
sufficient room for the extraction of the sequestrum. At all events, as
much of the bony case as will enable us to get at and remove the dead
bone within it, must be cut or sawn away. After the dead bone has been
exposed to a sufficient extent, it should be cut in half with a pair of cut-
ting pliers, or one of Hey's saws : an elevator is then to be used to force
the end of one of the fragments outwards, which being drawn out greatly
facilitates the extraction of the other half. We should avoid making
several openings in different parts of the new bony case, because it
would destroy too much of the new bone, and injure the soft parts to too
great an extent. When the new bone is very thick and hard, the appli-
cation of a small trephine may become necessary.
In many instances, the sequestrum does not extend through the whole
length of the tube, only certain portions of the original bone being de-
* W. H, Porter, in Dublin Journal of Med. Science, vol. v. p. 190, ,
MOLL1TIES. 297
stroyed, and consequently, the new bony formations are then only at par-
ticular points.
In unfavourable and extensive cases of necrosis, amputation sometimes
becomes indispensable, because the patient's constitution cannot bear the
repetition of the operative proceedings necessary to get away every part
of the dead bone ; for it frequently happens that we cannot remove all
the sequestrum at once, and then several operations become necessary.
In the course of the treatment, tonic medicines, bark, sulphate of quin-
ine, chalybeates, the carbonate of soda and rhubarb, or the salts of
iodine, will usually be needed. Sometimes, however, we are compelled
to return to antiphlogistic means. In the course of a year, there may
be from eight to sixteen attacks of severe inflammation of the soft
parts, followed by new abscesses on each occasion, and under these cir-
cumstances, reluctant as we may be to do any thing to weaken the
patient further, we are obliged to employ local bleeding and other anti-
phlogistic remedies in moderation. Then, if we consider the unavoidable
irritation and drain upon the system, produced by the long continuance
,of the disease, we shall not be surprised that, in many instances, the
patient should be reduced so low by hectic fever, that amputation is the
only chance of preservation remaining for him. We must not, however,
take off the limb unnecessarily, but remember that nature will do a great
deal for the patient in this disease ; and, as I have explained, it is in the
osseous texture that she possesses, perhaps, a greater power of repair
and reproduction, than in any other tissue of the body.
Mollities ossium is a very rare affection, and one that is sometimes er-
roneously confounded with rickets. In mollities, the bones become preter-
naturally soft and flexible ; those of the lower extremities may indeed, in
some instances, be bent in such a degree that the outer ankle can be
brought against the temple without the femur being fractured. In the
natural state, the bones contain more than half their weight of earthy
matter, and I believe that, in some instances, the proportion of it
amounts to nearly two-thirds of their whole weight. But, in the mor-
bidly softened state of the bones to which I am referring, the earthy
matter is only in the proportion of one-fifth part to four of the animal
matter in their composition, and sometimes even less. There are several
striking differences between mollities ossium and rickets. The former is
a particularly rare disease, whereas rickets is one that is seen daily.
Mollities ossium hardly ever takes place except in females, and in those
who are above the middle period of life ; whereas rickets chiefly attacks
children, or, at all events, those who are under puberty. Another dis-
tinction is, that in rickets, the earthy matter is originally deficient ; the
bones have never been properly developed from birth ; but, in mollities
ossium, the bones attain their full growth ; their texture is perfect ; and
their proportion of earthy matter is quite right, until about the middle
period of life, when those peculiar changes in the texture of the osseous
system take place, which constitute the disease under consideration.
Mollities ossium, appears to arise from some defect in the nutrition of
the bones ; but the exact cause of it is not understood. Some writers
confound mollities with fragilitas ossium; but the two diseases seem to
be the reverse of one another. Thus, when the thigh-bone is so soft,
that the outer ankle can be placed against the temple, this must be a dif-
ferent case from fragility, in which the bone cannot be bent at all with-
out breaking. Sometimes in mollities ossium, nearly the whole of the
natural texture of the bone is absorbed. A bone in this state is found to
298 DISEASES OF BONES.
contain cells, filled with a brown or livid substance, and having communi-
cations with the cells on the outside of the bone, or, in other words, with
the cellular tissue. When the osseous system is thus affected, of
course it is disqualified for its functions, as it can no longer support the
limbs ; nor will the bones, thus altered, serve as levers for the muscles to
act upon ; neither can they afford that protection to certain important
parts which they are designed by nature to give. Hence, in the worst
forms of mollities ossium, the stature is so much altered, that persons
afflicted with this disease, who were originally five or six feet in height,
become not more than two : — thus Madame Supiot, whose case is the
most remarkable one on record, 'was, at the period of her death, only
twenty-three inches in height. In her case, there was also such a change
in the shape of the bones, that the compression of the thoracic viscera
was probably the circumstance which mainly contributed to put an end
to her miserable existence. Her limbs could be bent in the extraordi-
nary manner I have explained, without breaking. Mollities ossium, so
far as all our present information reaches, is invariably a fatal disease ;
for there is no instance of it on record in which a cure was effected.
It is accompanied by immense disturbance of the constitution ; in par-
ticular, constant and profuse perspiration ; a very copious deposit of
phosphate of lime in the urine; and a great deal of fever. Here is an-
other great difference from rickets ; in which there is not necessarily any
severe degree of constitutional disturbance ; the disorder of the bones
not being the cause of any fever or pain. But, in mollities ossium, the
patient's sufferings are truly deplorable, and the health is universally
and totally deranged. In rickets, there are no profuse sweats — no copious
deposit of phosphate of lime in the urine. It is not my meaning, that
rickets may not be combined with very bad health ; but, when this is the
case, the complication is only an accidental and not an essential one.
There may be marasmus and great constitutional disorder with rickets,
or not. In the treatment of mollities ossium, the phosphate of lime has
been given, on the supposition that there is a deficiency of that earth in
the system. Though an unusual quantity of phosphate of lime seems to
be thrown out of the system by the kidneys, it does not follow as a mat-
ter of course, that there must be any want of it in the constitution. The
fault lies, probably, in some inexplicable derangement in the nutrition of
the osseous system, either interfering with the regular deposit of that
substance, or causing its too rapid absorption and conveyance out of the
system. Acids and tonics have been tried ; but every thing has proved
inefficient.
Fragilitas ossium^ consists in an unnaturally brittle state of the
bones. In the advanced stages of syphilis, cancer, fungus haematodes,
scrofula, and scurvy, so great a weakness and fragility of the texture
of the skeleton are sometimes occasioned, that fractures take place from
trivial causes, and are therefore termed spontaneous. In the museum
of University College, is a thigh.-bone, which broke as the patient
was merely turning himself in bed, and the accident happened while
he was taking mercury for nodes on the opposite thigh-bone, which
is also in the same museum. In the same collection, is another specimen,
in which the humerus was broken by champooing ; the patient had scro-
fula, and while the limb was undergoing the champooing process, the
bone broke ; this first fracture united ; but a second fracture happening
afterwards in another place, a false joint formed in the situation of the
injury. The bone was so brittle, that when the surgeon was dissecting
it after death, it broke in a third place.
RICKETS. 299
In old age, there is always a degree of fragilitas ossium, and this is
generally explained by the circumstance, that, in the bones of old persons,
there is a large proportion of calcareous matter to the animal and vascular
matter in them. However, they contain likewise a great quantity of greasy
matter ; and on this account can never be well cleaned so as to make white
good-looking skeletons. The other varieties of fragilitas ossium are at-
tended with a diminution in the quantity of phosphate of lime ; and when
there is really an increase in its quantity, it is, I believe, only in that form
of fragilitas ossium which comes on as the natural effect of old age. In all
the other forms of this disease, the bones are generally lighter than natu-
ral. The fragilitas ossium of old age is of course incurable. In other
examples of it, arising from different diseases of the constitution, the cure
will entirely depend on the possibility of curing the original disease ; if
this can be cured, there will be a chance of the proper texture of the
skeleton being restored ; but, under other circumstances, no hope of a
cure can be entertained.
I was called some time ago to a patient, whose thigh-bone broke as he
was turning in bed ; it appeared that he had a cancerous disease of the
bladder, for after death a large fungous tumour was found in that organ,
situated upon so hard a cartilaginous base, that when felt through the
Wadder, it was at first supposed to be a stone. One of the ribs was also
broken, and both this fracture and that of the femur were surrounded by
a mass of scirrhous matter.
In sotne individuals, not beyond the middle period of life, or even con-
siderably below it, the bones are extraordinarily brittle, without any
assignable cause. As a stout man, a patient in the Middlesex Hospital,
was cutting a slice of bread, the humerus broke. I have heard of young
and apparently healthy persons, whose bones were so brittle, that they
were continually breaking from very trivial causes. It is remarkable,
that in almost all such cases, the fractures unite just as Well as in others.*
Rickets or Rachitis, principally affects children, and mostly between the
ages of eight months and three years. Besides the differences from mol-
lities ossium already specified, there is not in this last disorder the same
thickness of the cranium, which is commonly observed in rickets ; some-
times, indeed, the thickness is immense. As Mr. Shaw has observed, the
derangement of the minute textures is exhibited in the skull in a remark-
able manner, some parts of the calvarium having an extraordinary thick-
ness, while other parts of it are reduced to the thinness of paper, and the
divisions of the tables are lost. Sometimes the parietal bones become
seven-eighths of an inch in thickness ; while, in the situation of the fon-
tanelle and sutures, the cranium is surprisingly thin. Hunauld presented
to the Academy of Sciences a skull-cap, taken from a child, between
three and four years old, where the bones were in some places seven or
eight lines in thickness, and when squeezed, blood and serum issued from
their interstices. Bones, affected with true mollities, never recover their
natural texture, and, sooner or later, the disease proves ratal ; but, in
rickets the bones often acquire a better shape, and a greater degree of
firmness, as the child grows ; indeed, they often acquire such a degree of
firmness as fits them perfectly for the performance of their functions ; and
some rickety children grow up to be remarkably athletic subjects. When
the disease, however, is in an aggravated form, the deficiency of phosphate
See Mayo's Pathology, p. 18.
300 DISEASES OF BONES.
of lime is sometimes so great, that nothing but the shell of the bone is
left, the internal part being filled with cells containing a red sanious fluid.
Although there is in this circumstance a degree of resemblance between
rickets and mollities ossium, it is to be recollected, that the bones in the
former disease cannot be bent as they can in the latter. With respect to
the change in the bones, it does not merely consist in a deficiency of
the secretion of phosphate of lime ; in addition to the loss of firmness
from that cause, there is a disorganisation of the minute textures of the
bones — and this is so much the case, that, in aggravated cases, the walls
of the long cylindrical bones may be entirely removed, and the whole
interior preserves, according to Bichat, a homogeneous appearance, and
consists of cellular texture throughout. Perhaps, however, some examples
of this description, referred to by writers, might have been true cases of
mollities.
In rickets,, nature makes great efforts to obviate the effects liable to
occur from the weakness of the bones. In a bone, bent by the disease,
in proportion as the walls of the larger curvature are thinned, the walls
of the lesser one are thickened and strengthened. The reason of this is,
that the lesser curvature has all the weight of the body to support, and,
if there were not this provision made, the bone would be incapable of
supporting any weight. For some valuable observations on this subject,
we are indebted to Mr. Stanley.
One effect of rickets is to flatten the long cylindrical bones, and the
greater diameter of the bone, when thus flattened, is always from the
forepart of the curvature backwards ; thus the same result is produced
as what arises from the wall of the lesser curvature being thickened — the
bone is strengthened by it. When the cylindrical bones are affected with
rickets in an extreme degree, even the medullary canal is sometimes obli-
terated, in consequence of one side of the wall of the bone acquiring an
immense thickness. Sometimes in rickets the bones bend laterally, and
the convexity of the curve may be on either side of the limb.
It has been supposed, that the heads of rickety bones expand ; but this
is not usually the case ; the joints seem large in this disease ; yet this is
proved by dissection to depend principally upon the emaciation of the
soft parts. Bichat has adverted to a thickening of the periosteum in
rickets ; but this is not commonly observed.
As it is principally the weight, which the bones have to support, that
makes them bend, it follows that those of the lower limbs must be more
liable to deformity than the bones of the upper extremities. There is,
however, in the museum of University College, a humerus, that has
been twisted by the action of the muscles, in consequence of which the
ulna has been moved partly into the place of the radius, and the radius
displaced. The upper head of the latter bone, no longer having the
humerus to play upon, is elongated, and altered in its shape. In the same
collection is likewise a skeleton, in which is seen an extraordinary de-
formity of each humerus produced by the pressure of crutches. The
skeleton is that of a boy, about ten or twelve years old, and it shows
various other interesting circumstances connected with rickets ; for ex-
ample, it exemplifies the slow development of the teeth, and the imper-
fect formation of the alveolar processes, occasionally noticed in rickety
children. The preparation is interesting on another account; for, here
rickets was complicated with a scrofulous caries of the vertebrae.
Many writers incline to the belief, that rickets is essentially connected
with scrofula ; but this is an erroneous opinion. It is true that scrofula
RICKETS. 301
may be accidentally joined with rickets, as in this instance, but we fre-
quently meet with rickets where there is no scrofula in the system. The
skull of this subject is also surprisingly thick, more than an inch, I be-
lieve, in some places ; and many of the bones and their processes are
but very incompletely developed. This is certainly the case with the
vertebrae.
It was an observation, made by the late Mr. Shaw, that in whatever
state of distortion the spine and ribs may be, the bones of the pelvis will
not be found distorted, unless there be at the same time marks of rickets
in some of the long and solid bones ; and it is argued by his brother, that
as neither the bones of the upper, nor those of the lower extremities
become incurvated, when the distortion commences near the age of puberty ,
it follows, that a cause, totally different from rickets, gives rise to it, and
that the pelvis incurs no danger of being implicated in this deformity.
Mr. Alexander Shaw, therefore, considers those skeletons only as true
specimens of rickets, in which the distortion is exhibited throughout all
the osseous system together — in the skull, the cylindrical bones of the
extremities, and the large bones of the pelvis, as well as in the spinal
column and the thorax. The figure of a rickety skeleton is distinguished
by the head, the thorax, and the arms being preponderating and large,
while the pelvis and lower extremities are, in a relative degree, diminutive
and short. In the skeletons examined by Mr. A. Shaw, all the bones
were to a certain degree deficient in size ; but such want of development
was much more considerable in the lower half of the skeleton, for the
vertebral column and arms wanted scarcely one-fifteenth of their natural
length, while, in the bones of the lower extremity, one-third of it was
deficient. In the pelvis, the bones were nearly a quarter under their
natural size. Hence, when the pelvis is deformed by rickets, it is not
only those diameters, which are contracted by the thrusting inwards of
the bones that are smaller than usual, but all the diameters are less than
natural ; whereas in the deformity of the pelvis from mollities ossium, in
proportion as one diameter is lessened, the other is elongated.
I have stated, that the common period of the commencement of rickets
is between the ages of eight months and three years ; but the disease
may begin in the foetus, of which fact we have an example in the museum
of University College.
There is a deformity of the spine arising in young persons who are
growing with great rapidity, especially in females, which does not depend
on any disorder of the bones analogous to rickets., but on the circum-
stance of such individuals not exercising their muscles equally, or on
their being prevented from taking the free and unconstrained positions
and exercises most agreeable to nature. Under such disadvantages, the
spine becomes deformed, without any imperfection in the texture or
development of the bones, and consequently there is no rickety disease
of them. When the curvature of the spine, arising from such causes, is
not too considerable, and the growth of the individual not yet completed,
the deformity may be removed by letting all the muscles of the trunk be
daily exercised in a free, regular, and uniform manner, so as not to suffer
one set to be put more into action than another. It is on these principles
that gymnastic feats and manoeuvres become exceedingly useful in the
treatment of those deformities of the spine, which are so common in girls
during their growth. However, if the deformity has been of long stand-
ing, it will be impossible to remove it in this or any other way ; for the
disease then approaches in its nature to that kind of deformity of the
302 DISEASES OF BONES.
skeleton, which results from old age. When a rickety curvature is in the
dorsal vertebrae, the upper part of the spine is usually inclined to the right
side, and the consequence of this is, that there is such an alteration in
the position of the ribs, that a great convexity of them is produced on
the right side, and a flattening of them on the left. Then the scapula is
made to project backwards, and the right shoulder is thrown forward.
In consequence of the flattening of the left side of the thorax, there is
hardly room enough in it for the proper action of the heart and the due
expansion of the lungs. In many instances the spinal column is not
merely curved, but twisted spirally. In the museum of University
College is a preparation affording a fine illustration of such deformity :
there is not only a curvature of the spine, but a complete twist of it, in-
somuch, that, in one part, the spinous processes of the vertebra? are
brought nearly round to where their bodies ought to be situated.
In some of these cases, the clavicle may be displaced, in consequence
of the alteration in the position of the shoulder, that is, the sternal end
of that bone may be thrown inwards so as to press upon the oesophagus.
An instance of such displacement of the sternal end of the clavicle is
mentioned in Sir Astley Cooper's work on dislocations, and the pres-
sure on the resophagus was such, that the surgeon, under whose care
the patient was placed, was obliged to remove a portion of the clavicle
in order to prevent the fatal consequences which would have arisen from
the impediment to deglutition. Amongst the preparations in Uni-
versity museum are some showing the alterations in the form of the
female pelvis occasioned by rickets. Frequently the sacrum is displaced ;
and the ossa innominata are thrown inwards, so as to give the pelvis
a triangular shape. In rickety females, the bones of the pelvis are
not properly developed, and the pelvis is surprisingly small.
When there is a bend of the spine in one direction, there will fre-
quently be another in exactly the opposite direction to counterbalance it,
and sometimes there will be even a third curvature, so that the spine will
represent an italic S9 as is illustrated in an excellent specimen in the
above-mentioned collection.
Treatment. With respect to the causes of rickets, the subject is very
obscure. Perhaps the observation of Mr. Stanley is correct, that it is
not an affection peculiar to, that is, restricted to the osseous system.
The muscles, surrounding the soft rickety bone, are pale and flabby, and
probably contain less than their natural quantity of fibrine. It is likely,
also, that the deficiency of phosphate of lime, one of the characteristics
of a rickety bone, is the result, not of peculiar local action, but of a
general and constitutional deficiency of assimilation and nutrition, by
which the peculiar character of the muscular tissue is coincidently pro-
duced.* As the disease consists either in a congenital defect in the
organisation of the bones, or in such defect arising in infancy, it is
to be expected that nature must be more confided in than any medi-
cines, or other means, for the removal of the imperfection, which the
deformity and bending the bones are only an effect of. We know of
nothing that has the direct power of so altering the texture of the
osseous system, as to communicate to it a due consistence, to rectify
the derangement of its nutrition, and promote its full development.
While the bones are under the influence of these imperfections in their
texture and nutrition, they gradually yield under the pressure of the
* E. Stanley, in Med. Gaz. vol.xx. p. G41.
RICKETS. 303
parts above them, and to the action of the muscles connected with them ;
and hence they bend, and deformity ensues. Now, the question is, how
can we counteract these two causes of deformity ? One would say, of
course, by keeping the muscles from acting, and taking off the weight
of the parts most liable to affect the bones by their pressure on them.
But considerable difficulty is experienced in putting these principles into
execution ; for, if the individual be confined long in the recumbent posi-
tion without being allowed to use his muscles, his constitution soon
begins to suffer — he loses his strength — and his health gets into a state
in which no improvement in the texture and development of the bones
can take place. Again, if we attempt to take off the weight of particular
parts by the use of machinery, the pressure will only be transferred to
other parts ; thus, in the application of machinery to take off the weight
of the head, chest, and upper Hmbs5 from the spine, we should be obliged
to use the pelvis as a fulcrum, and thus deformity of the bones of the
pelvis might be produced. I have mentioned a skeleton, in which the
humeri have been vastly deformed by the pressure of the crutches on
which the individual supported himself. However, it is not my intention
to say, that the use of machinery in rickets should be entirely relin-
quished ; perhaps, in some cases, it is preferable to a rigorous observance
of the recumbent position, in which the patient always loses his health.
Whatever tends to strengthen the constitution, has a decided tendency
to promote the removal of the rickety disorganisation of bones ; and, as
the individual grows and acquires strength, those parts of the osseous
system which the disease has deformed, will assume greater strength,
and a better shape. In the treatment, therefore, it is always an im-
portant object to rectify any manifest disorder in the health, and in
particular to keep up the child's strength. Many rickety patients are
more or less debilitated, emaciated, or big-bellied, and some of them
plainly scrofulous. To these sea-bathing will prove eminently service-
able, care being taken to promote the cutaneous circulation by the use
of the flesh brush, or friction with napkins. Tonics, and particularly
steel medicines, will also be beneficial. When the curvature of the
lower extremities is considerable, machinery maybe applied, and when the
deformity is conjoined with an inversion of the feet, a great deal may be
accomplished by means of mechanical contrivances sold in the shops.
But I think that, where machinery is employed, the patient should be
allowed to exercise his muscles for a certain period of the day. I have
already remarked, that many deformities arising from rickets may be
cured entirely on gymnastic principles ; that is, the patient is obliged to
follow up a certain train of exercises, which put all his muscles into
regular and equal action ; and one principle is to put into action the
antagonists of those muscles, whose preponderating activity and strength
have led to the deformity, as well as those muscles themselves. Thus,
when the spine is drawn to one side, by the right arm and shoulder
being used more than the left, the object is to put the mus€les of the
left side into regular exercise, in order to counteract the effect of the
muscles of the opposite side. The imperfection in the organisation of
bones, depending upon rickets, may be removed, and yet such bones
never recover their proper shape. They acquire strength, but continue
deformed. It is well known, in fact, that in some persons, whose bones
are restored to their right texture, though yet bent and disfigured, the
muscles acquire remarkable power, and some individuals, so circum-
stanced, have been distinguished for feats of strength and agility.
An exostosis signifies a tumour of a bony nature growing upon and
DISEASES OF BONES.
arising from a bone, or an enlargement or hypertrophy of it. Sir Astley
Cooper describes exostosis as having two seats ; by periosteal exostosis,
he means that form of the disease, in which bony matter is deposited
between the periosteum and the surface of the bone ; but, by medullary
exostosis, he implies a growth from the medullary texture, by which the
bone is expanded and ultimately absorbed and destroyed, so that the
tumour protrudes externally. Now, this latter kind of tumour does not
consist entirely of bone, and some forms of it are of a malignant cha-
racter, partaking of the nature of fungus hsematodes, or medullary cancer.
Sir Astley Cooper has also divided exostoses into cartilaginous and
fungous, the former being preceded by a cartilaginous deposit, into which
osseous matter is afterwards secreted, while the latter seems to be really
fungus haamatodes, or medullary cancer of the bones.
An exostosis may arise from the periosteum, or from the surface of a
bone, or from its cancellous texture. When originating from the first of
these situations, it may, in the early stage, be readily separable from the
bone, but afterwards become united to it by osseous, cartilaginous, or
dense fibrous tissue. At first, it receives an immediate covering from the
periosteum, but this soon becomes absorbed, and then a dense cellular
tissue forms its investment. And, lastly, when it arises from the can-
cellous texture, it will gradually extend, and make its way through the
walls of the bone and the periosteum.*
The largest true exostoses are chiefly met with on the long bones, and
if considerable ones are sometimes met with on other bones, they are
generally not of the true kind ; thus, in the cartilaginous exostosis of the
medullary membrane, described by Sir Astley Cooper, the shell of the
bone is extremely thin, and, within it, there is an elastic, firm, and fibrous
substance. In other instances, a medullary substance presents itself,
which is known to have the character of fungus haematodes ; whereas,
the fibrous growth is not of a malignant nature. It is universally ad-
mitted, that the blending of so many different diseases together, under
the name of exostosis, creates a vast impediment to a clear view of the sub-
ject ; and it would be much better, if the term exostosis were limited to a
bony tumour, growing out of a bone and forming a projection on its sur-
face, or an enlargement of a part of the bone itself, and not consisting in
the growth of a soft substance in the interior of the bone, followed by an
expansion of its walls, and afterwards of a protrusion of the fungous or
fibrous mass itself.
With respect to the physical characters of a true exostosis, it may
have the whiteness and density of ivory ; or it may be dark coloured, and
of a cancellous texture throughout ; or it may be made up of a mixture
of two such tissues ; and again, there may be some cartilaginous matter
in it, which may be deposited interstitially with the bone, or may be
limited by a well defined line to one part of the tumour, and this is
usually the base, which may be movable on the bone from which it has
arisen. This diversity of texture has no relation to the size or duration
of the tumour.f
Various terms are applied to true exostoses, according to the textures
which they exhibit ; some are lamellated, there being distinct layers ob-
servable in their texture ; others are cellular ,- while others are so solid
and hard, that they resemble ivory, and hence are called ivory exostoses.
Some are so irregular and angular, that they receive the name of stalac-
titic or spinous exostoses. A most extraordinary specimen of this form of
E. Stanley, in Med. Gaz, vol. xx. p. 643. f Id.
EXOSTOSES. 305
exostosis is described in the Philosophical Transactions ; for the whole
skeleton was affected; and the bony formations had all the fantastic
shapes of coral. One extended from the os coccygis to the femur; and
hardly a joint was left, whose motions were not stopped by the bones
being connected together with those spinous productions.
A true exostosis is always completely fixed and immoveable, and, at
first, unattended with any pain or inconvenience ; it generally comes
on in a very slow and indolent manner, and sometimes remains, for several
years, nearly in a stationary condition. Indeed, it is generally some years
before it produces much inconvenience, and then it may cause severe
agony, and occasion dangerous functional disturbance by its pressure on
particular parts. An exostosis of magnitude, situated behind the knee-
joint, has been known to interfere with the action of the flexor muscles.
The growth of an exostosis from the os pubis has by its pressure rendered
the urethra impervious. An exostosis of the thigh-bone, though of small
size., has been known, on account of its projecting angular shape, to
obliterate the femoral artery; an instance of which occurred in the prac-
tice of Dupuytren. An exostosis of the orbit has frequently produced
a displacement of the eye. An exostosis of one of the lower cervical
vertebrae has been known to press upon and obliterate the subclavian
artery. An exostosis, extending backwards from the lower jaw, has pro-
duced a fatal impediment to respiration, by its pressure on the larynx.
Fixed pain in the head and epilepsy have been produced by the growth
of exostoses from the inner table of the cranium. We have, then, numer-
ous examples of the dangerous consequences of exostoses in particular
situations ; indeed, the prognosis in this disease materially depends on
the situation of the tumour, and the possibility of removing it, with due
regard to the parts amongst which it is placed. I am here speaking of
true exostoses ; because others, of a medullary character, are entirely
different diseases, the cure of which involves the question, how far it is
possible to cure, or effectually remove, fungus haematodes by operation.
Exostoses are frequent on the femur, tibia, humerus, and lower jaw ;
and not uncommon on the sternum, clavicle, and bones of the head and
face. There are no bones on which they may not be produced. The
upper part of the humerus and tibia, and the lower part of the femur,
especially near the insertion of the adductor magnus, are their ordinary
situations upon these bones. I was lately consulted for a girl, about
thirteen years of age, who has an exostosis connected with the outer
condyle of the femur, and interfering with the free action of the biceps.
Sometimes an exostosis forms at the insertion of the psoas and iliacus.
The causes of exostoses are involved in considerable obscurity. True
exostoses occur most frequently in young persons, but less usually
before, than after the age of ten or twelve years. It would appear
as if there existed in some individuals a predisposition to the disease,
exostoses forming, in such persons, from very slight and trivial exciting
causes. A little while before I began my professional stiidies at St.
Bartholomew's Hospital, a youth had been sent into it from Cornwall,
the particulars of whose case were always mentioned by Mr. Abernethy
in his lectures. In this individual, a trifling blow on any part of
his body would invariably lead to the production of an exostosis ; and
this disposition to form bony tumours was not confined entirely to the
skeleton ; for, after a blow on the muscles, a sort of osseous deposit
would take place in them ; in fact, the margins of the axillae had be-
come ossified ; the great pectoral muscle and the latissimus dorsi were
306 DISEASES OF BONES.
both turned into bone at their edges, so that the patient was com-
pletely pinioned. In a preparation in King's College Museum, the femur
is immoveably fixed in the acetabulum by ossification of the front of the
capsular ligament, and of part of the iliacus internus. Mr. Langstaff has
a beautiful specimen of ossification, which appears to have spread from
the femur, and involves the vastus internus,, the structure of which is
converted into bone. * The alliance between ossification of ligament,
muscle,, tendon, and exostosis, or the origin of the former, from the bones,
is well exemplified in Jeff's skeleton in the museum of the Royal College
of Surgeons in London. Local irritation of the periosteum, by an external
injury, would appear sometimes to act as a cause. In certain examples,
where exostoses form numerously and almost without any assignable reason,
the state of the constitution is to be suspected ; and, as Mr. Stanley has
noticed, the disposition to exostoses appears occasionally to be hereditary,
as in the instance of a man in St. Bartholomew's Hospital, who had many
exostoses, and whose father and children had been similarly afflicted.
When pressure is made upon a bone for a considerable time by any kind
of mechanical apparatus, a bony swelling is sometimes thrown out. In
young persons, whose growth is rapid, nothing is more common than
an irregular development, or an hypertrophy of the clavicle, ribs, or
sternum.
Treatment. — Excluding from present consideration venereal nodes,
perhaps we possess no means of checking the growth, or preventing the
increase, of a true exostosis. I have been sometimes consulted by patients
for exostoses, and have tried, as a matter of form, blistering, mercury,
and iodine preparations, but have rarely or never seen a case that was
materially benefited by them. Sometimes, however, an exostosis leads to
inflammation of the soft parts, and then of course we should employ com-
mon antiphlogistic plans, viz. local bleeding, cold evaporating lotions,
aperient medicines, and perhaps the blue pill, or calomel with opium.
The inflammation may be relieved in this manner ; but, as for dispersing
the tumour by medicine, there is not the slightest chance of it. Yet, in
many instances, surgery may be of essential service ; for, though we
cannot disperse an exostosis by external or internal medicines, we may,
when it is producing dangerous effects by its pressure on neighbouring
organs, remove it, or cut it away with Key's saws, trephines, cutting forceps,
or saws capable of working by machinery in deep confined spaces. Of
course I mean, that an operation is to be performed only when it can be
done without danger to the neighbouring organs. In the operation, the
first object is to make such a division of the soft parts as will enable us
to get at the base of the tumour without difficulty. There will be much
difference in the facility of removing the tumour in different instances :
its shape is one circumstance that will have influence : when its base
is broad the operation will generally be difficult ; but sometimes the
base of an exostosis is narrower than its body, and then its removal may
be easily accomplished with a saw or pliers. Even when we are not able
to remove the whole of a true exostosis, we may sometimes do essential
good by taking away a part of it ; for this kind of bony tumour is not
attended with any malignity, and meddling with it will not turn it into
any dangerous variety of disease. In some instances, when it was
not practicable to saw away the tumour, attempts were made to get rid
f it by purposely exciting necrosis of it, by removing the periosteum
* See Mayo's Pathology, p. 15.
EXOSTOSES. 307
from its surface. A few years ago, I was consulted by a woman who had
an immense bony swelling on the face. As several medical practitioners
suspected that it arose from a fungus in the antrum, a point on which I
had doubts, I sent her to Mr. Lawrence for his opinion, who coincided
with me, that it was an exostosis of the upper jaw-bone. Now. in this
example, after vast suffering, and repeated inflammation, and abscesses of
the soft parts, the bony tumour came away spontaneously : it was attacked
with necrosis, and exfoliated. The tumour, which was very large, came
away by considerable pieces at a time, and the woman is cured, I believe,
with the exception of a good deal of disfigurement of the face. After having
been removed by operation, exostoses do not generally form again. Ex-
ceptions, however, are occasionally met with. A young woman had an
exostosis of the humerus, which was sawn off. In a year another exos-
tosis grew, nearly in the same place ; but, on a rubefacient plaster being
applied, an abscess formed, and the new bone was absorbed.* This proves
that suppuration excited contiguously to an exostosis may lead to its
absorption ; but success of this kind is not common.
An exostosis may be so situated that we cannot prudently attempt any
operation upon it; for instance, it may be so near a large joint, that any
attempt to remove it would not only endanger the limb, but the patient's
life. The exostoses, or abnormal enlargements of the clavicle, sternum,
&c. so common during the rapid growth of the body, require no treatment.
As Mr. Mayo observes, they are almost sure to disappear after a year or
two ; either the rest of the bone grows up to the enlarged surface, or the
superfluous part is absorbed.
Medullary tumours, sometimes injudiciously classed as exostoses, are
of the same nature as fungus haematodes. The disease is of frequent
occurrence, usually begins in the cancellous texture, and, in the majority
of instances, is not accompanied by a similar morbid deposit in other
organs. Mr. Stanley has never seen a case, in which the disease seemed
to have originated in the compact texture, or the periosteum. It gene-
rally, though not always, occurs before the age of forty ; and its most
frequent seat is the head of the tibia, or the lower part of the femur.
Mr. Stanley knows of only a single instance, in which it had occurred
coincidently in more than one bone ; and, in a large proportion of the cases
in which amputation had been performed for it, there had been no return
of the disease in the stump, or other part of the body. The general result
of post mortem examinations has been such as to indicate a similar localis-
ation of the disease. The few exceptions to this remark, at all events,
do not materially affect the conclusion, that medullary "disease, beginning
in bone, is less apt to occur coincidently in other organs than when it
originates in the softer parts, and that consequently its removal by
amputation may generally be undertaken, with a fair probability of per-
manent benefit.f This last observation seems not to be applicable,
however, to medullary tumours of the upper and lower jaw-bones, few
experienced surgeons now venturing to undertake an operaffon for them
in these situations, well knowing that a return of the disease would
almost certainly ensue.
In relation to exostosis, I may here mention a case, that is sometimes
met with, where a considerable swelling of a bone arises from the form-
ation of hydatids in the cancellous texture. In the Medico-Chirurgical
Transactions of London, are the particulars of an interesting example of
* Mayo, Op. cit. p. 13. f E. Stanley, Med. Gaz. vol. xx. p. 644.
X 2
SOS DISEASES OF BONES.
this disease. The tumour, which was in St. George's Hospital, under
Mr. Keate, was situated on the cranium, and occupied the greater part
of the os frontis. At the time of attempting its removal, its exact nature
was not known ; but, in performing the operation, a collection of hydatids
was discovered between the tables of the skull, and before they were
completely extirpated, and the patient cured, repeated operations, and
the application of the strongest caustics were necessary.
Pulsatory tumours. In my Dictionary the earliest notice was taken
of cases in which tumours occur in bones attended with throbbing,
and even followed by a spontaneous fracture of the osseous texture. The
subject has been particularly considered by Dupuytren and Breschet,
both of whom describe such swellings as consisting in the growth of a
morbid erectile tissue, like what composes certain naevi, or aneurisms by
anastomosis. Dupuytren remarks, however, that the tumour may be
partly formed of other substances, especially the encephaloid, or medul-
lary. Sometimes it is rather a slight thrill that is felt in the tumour, than
a distinct pulsation ; but in other instances, the throbbing is so strong, as
to lead surgeons to mistake the disease for aneurism, and even to tie the
great artery of the limb. The investigations of Mr. Stanley prove that
pulsation occurs in tumours of varied character. The majority of those,
which he has himself examined, consisted of medullary matter; but one
which originated in the humerus, and pulsated strongly, was composed of
firm gelatinous matter, which formed the walls of a cyst, about half an
inch thick, and containing serous fluid. In one, recorded by Dupuytren,
growing from the tibia, the morbid structure consisted of cells containing
a gelatinous matter. In some of those related by Dupuytren and Scarpa,
the pulsating tumour consisted of a sac, filled with coagulated blood and
layers of fibrine ; and in the sides of the sac were numerous dilated arte-
ries, presenting open orifices upon its internal surface. In these instances
it was supposed that the current of blood from these arteries into the sac
might have produced the pulsation ; but, in the greater number of pul-
sating tumours, growing from bones, no such change in the arteries can be
found to account for this symptom. In all the specimens which Mr. Stanley
had examined, the walls of the bone were absorbed between the tumour
and the contiguous large artery, so that, on the outer surface of the tu-
mour, there were either no remains of the bone, or so thin a layer of it
that the impulse communicated by the artery to the tumour could be felt
at every point of its surface. One variety, recognised by Mr. Stanley in
four cases, consists chiefly in an enlargement of the arteries of the medul-
lary membrane, accompanied by absorption of the interior of the bone, and
simultaneous deposit of bone externally, so that the tumour is covered by
a thin, more or less complete osseous shell. This is the disease regarded
by Dupuytren and Breschet as corresponding to growths of morbid erec-
tile tissue, and sometimes curable by ligature of the main artery, provided
the operation be done before much destruction of bone has occurred. In
one case, tying the femoral artery was followed by a permanent cure ;
in another, the same practice was successful for only seven years, at
the end of which the tumour returned.
Osteo-sarcoma is a term frequently employed, though rather vaguely ;
it is found to be a convenient name, because it suits any tumour, which
consists partly of bone, and partly of a soft or fleshy substance : thus,
medullary tumours of bones, when surrounded by, or interspersed with,
osseous matter, have been sometimes described under the appellation of
ostco-sarcoma ; and so have fibrous, and fatty lardaceous tumours blended
INFLAMMATION OF THE SYNOVIAL MEMBRANES. 309
with osseous matter, or the remains of the original shell of the diseased
bone.
Scrofulous caries of the spine, scrofulous disease of the heads of
bones, anchylosis, and spina bifida, will be noticed in subsequent parts of
this work.
DISEASES OF THE JOINTS.
Some diseases of the joints begin in the synovial membranes ; some in
the cartilages ; and others in the heads of bones. The commencement
of disease in the ligaments appears to be a rare occurrence : Sir Benjamin
Brodie states, that he has never known it proved by dissection. Mr.
Aston Key refers to some instances, in which the ligamentum teres was
implicated in a very early stage of the morbus coxarius; though here the
disease probably began in the synovial membrane. Some syphilitic pains
in the joints are suspected to arise from an affection of the ligaments ;
and it is believed, that the obstinate effects of many severe sprains depend
upon a slow inflammation of the ligaments, the consequence of their
having been ruptured, or over-stretched.*
INFLAMMATION OF THE SYNOVIAL MEMBRANES.
This may arise as an effect of phlebitis, gout, rheumatism, derangement
of the constitution by mercury, or by the poison of syphilis. With the
exception of the case originating from phlebitis, we must agree with Sir
Benjamin Brodie, that inflammation of the synovial membrane from con-
stitutional causes is generally less severe than other forms of it ; for,
though it produces an increased secretion of synovia, there is usually no
effusion of fibrine, nor any material thickening of the synovial membrane
itself. Sometimes it attacks several joints together, and even extends to
the bursse mucosae and sheaths of the tendons ; while, in other instances,
it attacks different joints one after another. Frequently inflammation of
the synovial membranes is entirely a local disease, excited by mechanical
injuries of the joints, as sprains, contusions, wounds, dislocations, or
fractures of the heads of the bones. The danger of a wound of the
synovial membrane, depends, first, on the size of the joint ; secondly, on
the extent of the laceration or rent in the synovial membrane and integu-
ments together ; for where the former alone is torn, as in a simple dislo-
cation, or where the opening in it is speedily covered by the integuments,
the danger of severe consequences is infinitely less, than in the opposite
circumstances ; thirdly, on the degree of contusion and laceration of the
synovial membrane, in addition to the mere solution of continuity in it,
forming a communication between the cavity of the joint and the external
wound. Wounds of the knee-joint from gunshot are sure to be followed
by so dangerous a degree of inflammation of the synovial me^nbrane, and
such constitutional derangement, that the rule of practice in such a case,
is to perform amputation without delay, before inflammation and its con-
sequences on the part and the system at large have had time to come on.
But a clean incised wound, or even a fine puncture gently made with a
lancet, or couching needle, and so as to admit of being immediately
* See Sir Benj. Brodie's Pathological and Surgical Obs. on Diseases of Joints. 3d ed.
p. 5. 8vo, Lond. 1834.
x 3
310 DISEASES OF THE JOINTS.
afterwards covered with the integuments, may not be followed by any
bad symptom whatever, more especially if care be taken to keep the joint
quiet," and to employ antiphlogistic means. It is the knowledge of this
fact, which encourages surgeons sometimes to cut into the knee-joint,
either for the purpose of discharging fluid, or of extracting loose cartila-
ginous bodies, which, acting as extraneous substances, excite frequent
attacks of pain, swelling, and lameness.
Exposure to cold is the most frequent cause of inflammation of the
synovial membrane, and the knee, as being less covered by muscles, is
more subject to the effect of atmospheric influence, than the hip or
shoulder. Sir Benjamin Brodie observes, that the disease seldom attacks
young children, becomes less rare as they approach the age of puberty,
and is most frequent in adult persons. The disease begins with pain in
the joint, which is generally most severe at one point, and attains its
greatest height in a week or ten days. In a day or two after the com-
mencement of the pain, the joint becomes swollen. At first the swelling
arises altogether from a collection of fluid, which in the superficial joints
may be felt to undulate. In time, however, the fluctuation is less mani-
fest, because the synovial membrane is now thickened, or lymph is effused
from its inner or outer surface. As the swelling in the early stage arises
principally from the distension of the synovial membrane, its shape is
very much regulated by the situation of the ligaments and tendons, which
resist it in certain directions and allow it to take place in others. Thus,
as Sir Benjamin Brodie has explained, in the knee, the swelling is chiefly
on the anterior and lower part of the thigh, under the extensor muscles,
where there is only a yielding cellular structure between these muscles
and the bone. It is also considerable in the spaces between the ligament
of the patella and the lateral ligaments. In the elbow, the main swelling
is above the olecranon.
When, after the absorption of the fluid, and the subsidence of the
principal swelling, the synovial membrane continues thickened, it some-
times happens, as Sir Benjamin Brodie observes, not only that a certain
degree of inflammation lingers in the part, but ulceration may take place
in the cartilages, suppuration ensue, and the articulating surfaces be
completely destroyed.
The following statement from the same authority deserves attention :
in syphilitic cases, it seldom happens that more than one or two joints
are affected at the same time. In the early stage of syphilis, the inflam-
mation is usually an accompaniment of a papular eruption or lichen ;
there is then but little pain ; fluid is effused only in small quantity, and
when this has been absorbed, the joint is restored as nearly as possible to
its original condition. In the more advanced stages of syphilis, we find
inflammation of the synovial membrane existing in combination with
nodes ; and then it is productive of much greater inconvenience, and is
more difficult to cure ; and the synovial membrane is left thickened, and
the joint larger than natural, after the fluid has been dispersed. On the
other hand, in rheumatism, several joints are mostly affected, either at
the same time, or in succession ; and the bursse mucosae and sheaths of
tendons are often involved. There is usually a good deal of pain and
swelling, and the joints are frequently left stiff and enlarged after the
attack. When the inflammation is connected with gout, the pain is
generally excessive, compared with the other symptoms.
The treatment of inflammation of the synovial membrane, varies ac-
cording as it may be acute, or chronic, a local, or a constitutional affection.
EXTRANEOUS, CARTILAGINOUS, OR OSSEOUS SUBSTANCES. 311
In the acute and local form of the complaint, perfect quietude, leeches,
venesection, repeated according to circumstances, saline purgatives, and dia-
phoretics, are required. If the skin be very tense, fomentations and poul-
tices will be the best applications ; but, otherwise, cold evaporating lotions.
In chronic cases, the taking away of blood from the part, by means of
leeches, or cupping, quietude of the joint, and cold evaporating lotions,
are the best early measures. Afterwards, when the inflammation has
been in a great measure subdued, blisters become useful, either applied
in succession, or kept open with savine cerate. In a still later stage,
stimulating liniments, as the ointment of tartarized antimony, that of the
hydriodate of potash, or camphorated mercurial ointment.
When patients are so far recovered, that they cannot be prevented
from moving about, though the joint will not yet bear much exercise with
impunity, its motions should be moderated by the application of circular
straps of adhesive or soap-plaster, and a bandage, or it may be covered
with a kind of cap made of leather, or other elastic materials, and laced,
or buckled on the joint.
Amongst the means employed for the removal of the stiffness, and
thickening of the soft parts, left after synovial inflammation, friction
made by the hand with hair powder ; the pumping of water, cold or
warm, from a height of several feet ; the vapour bath ; and champooing ;
deserve to be mentioned.
When inflammation of the synovial membrane arises from rheumatism,
and especially when several joints are attacked, local or general bleeding,
followed by the exhibition of purgatives, pulv. ipec. comp., or the wine,
or acetous extract of colchicum, will be the most successful means. When
the inflammation affects only one or two joints, calomel combined with
opium is the best medicine. There is also a case, which begins with acute
inflammation of the periosteum of the femur, then involves the synovial
membrane of the knee, and may advance to ulceration of the cartilages :
this is an example, particularly pointed out as one demanding the exhi-
bition of one or two grains of calomel, with a quarter, or half a grain of
opium every six hours, to which also two grains of antimonial powder may
sometimes be added.* In other cases, arising from syphilis, a well-regulated
course of mercury is necessary ; and when the disease has been excited
by the abuse of that mineral, or is conjoined with disease of the bones and
periosteum, the iodide of potassium with sarsaparilla may be prescribed.
EXTRANEOUS, CARTILAGINOUS, OR OSSEOUS SUBSTANCES IN JOINTS,
Are more frequent in the knee than any other joint, but they occa-
sionally present themselves in the elbow, ankle, and articulations of the
lower jaw. It is only in the knee that they become objects of surgical
attention. Sometimes they are quite detached from the synovial mem-
brane ; sometimes connected with it by a narrow pedicle. They have a
glistening pearly lustre, and mostly consist of a cartilaginous substance,
with osseous matter in its centre, and a firm capsule investing their outer
surface. Sometimes the joint contains only one body of this description ;
sometimes as many as twenty or thirty. They are usually convex on one
side, and concave on another, and more or less oblong. Sometimes they
are not larger than a pea ; in other instances, nearly equal in size to the
knee-pan itself.
So long as these cartilaginous formations retain an attachment to some
* Csesar Hawkins, in Med. Gaz. vol. xii. p. 652. ;
x 4?
312 DISEASES OF THE JOINTS.
point of the articular cavity, and are thus kept in one situation, they give
no inconvenience ; nor even when loose, do they cause any annoyance,
unless they happen to be pinched between the articular surfaces of the
bones. When this occurs, the patient is suddenly seized with excru-
ciating pain,, and is immediately deprived of the use of the limb. These
attacks are frequently followed by more or less inflammation of the
synovial membrane, and effusion of fluid in the joint. The patient is
then obliged to confine himself to his bed for a few days, till the tender-
ness and swelling subside, after which he returns to his usual occupa-
tions ; but his knee remains weak, and attacks of the same kind returning
from time to time, he finds it necessary to consult a surgeon.
With respect to the manner in which these moveable cartilages are
produced, one explanation of it is, that they derive their origin from the
synovial membrane, which, in consequence of inflammation, throws out
fibrine, and this becoming organized, is at length converted into cartilage
or bone. By degrees, however, it is more or less loosened by the move-
ments of the joint, and often completely detached. When this has hap-
pened, the new cartilaginous formation never afterwards increases in
size ; but, by changing its situation, and getting between the condyles of
the femur, and head of the tibia, in the motions of the joint, it causes
severe pain and lameness. In France, an opinion prevails, that the new
substance is first formed in the cellular tissue on the outside of the syno-
vial membrane, or else between the fibres of the synovial membrane itself;
that, in the former circumstance, this membrane is pushed inwards, and
that a part of it constitutes the pedicle, which at length gives way, and
leaves the new formation quite loose in the cavity of the joint. It is pos-
sible, however, as Cruveilhier thinks, that they may not always form in
one manner ; for, in one case, he found one loosely attached to the tibia,
and under the synovial membrane. It is also generally admitted, that
portions of the natural articular cartilages may sometimes be broken oft*.
In the majority of cases, met with by Sir Benjamin Brodie, no symp-
toms of inflammation preceded their formation, and hence, he believes,
they are often generated like other tumours. " They appear (says he) to
be situated originally either on the external surface, or in the substance of
the synovial membrane, since, before they are detached, a thin layer of
it may be traced upon them. He met with two cases, in which, from
some morbid action, a bony ridge was formed, like an exostosis, round
the margin of the cartilaginous surface of the joint, portions of which
ridge broke off in the motions of the joint over them.
Treatment. Whether these substances should be taken out, or not,
depends on two circumstances ; first, on the degree of annoyance suffered
by the patient ; and, secondly, on his willingness to encounter an opera-
tion^ when the risk of it has been fairly and correctly explained to him ;
for, it must not be dissembled, that some individuals who have submitted
to the operation, have had severe inflammation of the joint brought on by
it, and have lost their lives. They therefore sacrificed themselves to an
experiment, made in the hope of being relieved from what is commonly
a very endurable complaint. But, supposing a person were to be pre-
vented from getting his bread by this disease, and were not only willing,
but desirous to submit to the operation, after its danger had been rightly
explained to him, and a bandage or laced knee-cap had failed to give
him relief, then I should say, that the operation ought to be per-
formed. I once attended a gentleman, who had a large cartilaginous
substance loose in the cavity of the knee-joint, which prevented him from
PULPY THICKENING OF THE SYNOVIAL MEMBRANE. 313
following his affairs ; he used to be attacked with inflammation of the
synovial membrane every two or three weeks. I explained to him the
risk attending the operation, but he chose to encounter it, and fortunately
he got well without a single bad symptom. The cartilaginous formation
was half as large as the patella, with one side convex, the other concave.
In the operation, it is a good plan not to make the incisions through the
skin and the synovial membrane exactly opposite one another. The in-
teguments should be drawn to one side, and then cut through ; and thus,
when the integuments, with the synovial membrane, resume their natural
place, the aperture in the latter texture will be closed. The situation,
often considered most convenient for the operation, is over the internal
condyle ; here we may try to fix the foreign body, and after having ex-
posed it, we are to take hold of it directly with a tenaculum, lest it
slip away into another part of the joint, whence we may not be able to
remove it so as to bring it out of the wound. As there is a risk of in-
flammation after the operation, it is always prudent, for two or three days
before it is undertaken, to keep the patient in bed, or perfectly quiet in
his room, to restrict him to a low diet, and to give him an aperient mixture.
Above all things, we should never operate while the joint is at all hot,
painful, or disposed to inflammation. If inflammation come on after the
operation, we must trust to copious and repeated bleeding, leeches,
mercury, purgatives, and cold applications. Supposing the cartilaginous
substance were rather large, we ought not to force it through an insuffi-
cient opening in the synovial membrane ; for this would be far more
likely to bring on inflammation, than if we were to enlarge the wound.
This should not, however, be made any larger than actually necessary, as
the danger of wounds of the knee is in a great measure in proportion to
their size.
PULPY THICKENING OF THE SYNOVIAL MEMBRANE.
Another disease of the synovial membrane, called the pulpy thickening
of it, is a disease generally reputed to be of a scrofulous nature. Not
many years ago, many very different complaints were all confounded
together under the name of ivhite swelling ; thus, chronic inflammation
of the synovial membrane ; a disease beginning with ulceration of the
cartilages ; a scrofulous disease, commencing in the heads of the bones ;
and this pulpy disease of the synovial membrane, were all jumbled
together under the head of white swelling. The disease, which I now
wish to describe, occurs chiefly in young persons, or individuals between
the ages of sixteen and twenty- two or twenty-five ; and is mostly met
with only in the knee. At first, the pain is inconsiderable,, merely amount-
ing to a stiffness, accompanied by a slight swelling and rigidity. The
disease, therefore, comes on slowly and insidiously. By degrees the
swelling increases, and, on touching it with the finger, we find that it
communicates a sensation as if it contained a fluid, there being con-
siderable softness and elasticity about it. In time the jomt is nearly
destroyed. Yet the pain is not very severe ; indeed, it occasions no
great suffering till abscesses form in the synovial membrane, or on the
outside of it. The disease may go on for several years without rendering
amputation necessary ; it is one. of those tedious diseases, in which the
patient lingers a long time without getting well, and yet without being
reduced to such a state as absolutely to be obliged to submit to ampu-
tation. At last, however, the hectic symptoms become aggravated, and
amputation is unavoidable. According to Sir Benjamin Brodie, who
314 DISEASES OP THE JOINTS.
first discriminated this case from other forms of disease classed as white
swellings, it is incurable, inasmuch as it consists in a total disorganisation
of the synovial membrane, which is converted into a brownish or lightish
brown pulpy substance, varying from a quarter to half an inch or more
in thickness. It is then an organic disease, and white lines may be
seen crossing the pulpy substance in various directions. In its advanced
stages, the cartilages, ligaments,, and bones of the joint become diseased,
or destroyed. Generally, the whole synovial membrane is changed in
the manner described : but in a few instances only a portion of it is
attacked. In the majority of cases, we may recognise this disease by
the very gradual progress of the enlargement of the joint, the stiffness
without pain, and the soft elastic feel of the tumour : — such are the cha-
racteristic marks of the pulpy thickening of the synovia! membrane.
Treatment. Mr. Syme, who considers the disease not totally incurable,
recommends quietude of the joint, which is to be maintained with the
assistance of pasteboard or splints. This principle applies to all chronic
diseases of the joints. He also puts the patient on a regimen calculated
to improve his general health. If there be inflammation in the part, he
attacks it by means of leeches, cupping, &c., and with the view of pro-
moting the absorption of the pulpy substance into which the synovial
membrane is converted, he recommends blistering the part, and the ap-
plication of iodine preparations, or iodine with mercury, and the ointment
of iodide of potassium.
Mr. Scott adopts a particular mode of dressing diseased joints : he sur-
rounds the joint first with soap plaster, blended with mercurial ointment ,
over this he applies straps of emplastrum plumbi, and then common
soap-plaster spread on thick leather. Whatever efficacy this method
may possess is owing, I conceive, not to the mercury, nor to the particu-
larity with which the dressings are put on, but to their effect in keeping
the joint motionless. No doubt, the keeping of the joint motionless is
one of the most important means in the treatment of the disease, and
whether we adopt Mr. Scott's method, or use common splints, either
plan will answer the same purpose. When there are abscesses, paste-
boards or splints seem preferable to a mass of materials, which are to be
removed only once a week, and under which a great deal of filthy dis*
charge would accumulate.
ULCERATION OF THE CARTILAGES.
Some diseases of the joints are alleged to begin in the cartilages.
Ulceration of the cartilages is more commonly noticed in adults, than
the pulpy thickening of the synovial membrane. It is not very easy to
discriminate the incipient stage of ulceration of the cartilages from chro-
nic thickening of the synovial membrane. In the early stage, there is
generally no enlargement of the joint, but, after the disease has made
some progress, the synovial membrane begins to be inflamed, and the
case is then accompanied by swelling. Generally, however, for the first
few weeks, there is little or no swelling ; nor is any serious degree of pain
experienced in the beginning of the complaint, unless the joint be exer-
cised. Certain other forms of disease in joints are seen, in which there
is constant pain, whether the limb be moved or not. At night, however,
some pain usually accompanies the present affection ; and, after a time,
the synovial membrane becomes affected, and then, in addition to the
ulceration of the cartilages, there is an effusion of fluid in the joint, which
adds considerably to the swelling, and occasions a fluctuation. The latter
ULCERATION OP THE CARTILAGES. 315
circumstance may therefore be considered as sometimes constituting one
of the symptoms of the disease. Almost all the surgical diseases of the
joints have a tendency to terminate in suppuration and abscesses both
within and without the synovial membrane, followed by fistulas and
sinuses, as well as caries of the bones ; so that, unless we examine the
disease in an early stage, we may not always be able to pronounce exactly
in which texture it has commenced. When abscesses form in the disease
now under our consideration, the matter collects in the synovial mem-
brane, and also ultimately in the cellular tissue on the outside of the joint,
frequently spreading to a great extent under the thickened integuments,
and at length making its way out by one or several fistulous ulcerations.
Professor Cruveilhier * and Mr. Key believe, that inflammation of the
synovial membrane is the most frequent cause of ulceration of the carti-
lages. Some of the cases to which the latter refers, prove the existence
of a long-continued synovial affection, before any ulceration of the carti-
laginous surface could have taken place ; for, in them the cartilage was
quite sound, with the exception of a slight loss of substance at the edge
of the bone, where the synovial membrane was reflected from it, though
the symptoms of diseased joint had existed for many months, with pain
over a large part of the synovial surface, and general swelling of the joint.
According to Mr. Key's investigations, the inner part of the knee-joint
usually exhibits the most extensive ulceration, on account of the oblique
bearing of the femur, and its unequal pressure on the inner part of the
head of the tibia. Hence the inner semilunar cartilage is oftener de-
stroyed than the outer one, and there is a corresponding destruction of
the cartilage covering the inner condyle of the femur and inner part of
the head of the tibia. The patella and extremity of the femur are stated
by Mr. Key to be the parts on which the ulcerative process can be best
traced, on account of the disease being less advanced in them. In the
former bone, the part which first commonly ulcerates, is the margin of
the cartilage where the synovial membrane is reflected from it. At this
point, Mr. Key describes grooves of different depths as being formed,
which cannot be always distinguished, until the thickened edge of the
synovial membrane is raised. The ulcerated surface sometimes exhibits
parallel vascular lines, verging towards the centre, and having their
origin from the synovial membrane, which, if the vessels are well filled
with fine injection, appears highly vascular and fringed, or villous, like a
mucous membrane. This highly vascular fringe of membrane, described
also by Cruveilhier, is a newly organised, and, as Mr. Key conceives,
sometimes a superadded structure for the purpose of producing ulceration
of the contiguous cartilage. When recently formed, some parts of it may
be raised from the synovial membrane, but it adheres very slightly to that
part of the cartilage where ulceration is going on : indeed, according to
Mr. Key, this adhesion will not be perceived, unless the joint be opened
with care. It seems, therefore, from these interesting researches, that
the process, by which the ulceration of cartilage is here effected, is ana-
logous to that by which the sequestrum of the cylindrical bones in necro-
sis takes place. The cartilage, indisposed to ulceration from the low
degree of its organisation, is acted upon by the newly organised synovial
surface, which is rendered highly vascular, and forms a groove in the
edge of the cartilage, by means of its villous processes. We also learn
from Mr. Key's investigations, that the granulations which sometimes
* Anatomic Pathologique, fol. livraison 6.
316 DISEASES OF THE JOINTS.
arise from the surface of the exposed bone, assist the membrane in the
work of absorption. The formation of the vascular membrane frequently
takes place without suppuration, as may be seen in strumous joints that
have been the subject of chronic inflammation for years, without abscess
having formed; and the inflammation is sometimes confined to one side
of the joint.
The second mode, adverted to by Mr. Key, in which nature effects the
ulceration of cartilage, without the agency of its own vessels, is exem-
plified, where suppuration follows acute inflammation, from a wound of
the synovial membrane, which then undergoes a change, enabling it to
perform its new function. Its surface becomes highly vascular, and, in
most parts, covered with a new deposit of adhesive matter which is in
many parts villous, or furnished with vascular fringed projections. In a
joint, thus far advanced in disease, Mr. Key considers that the only mode
of arresting the disorder, or of repairing the mischief, occasioned by
inflammation, consists in the production of anchylosis. To this end, the
removal of the cartilage is an essential step; and it would appear, that
the office of removing it devolves on the inflamed synovial membrane.
The absence of all action in the cartilage, and a total want of vascularity
in those parts, where ulceration appears to be most active, were the cir-
cumstances which first led Mr. Key to look for some agent in the work of
ulceration. The ulceration, as he explains,, evidently begins on the sur-
face of the cartilage, and not on that side next to the bone. It presents
merely an eroded surface ; there is no disorganisation of its texture in
the parts where absorption is about to take place. The grooves are
formed only in those parts of the cartilage, which happen to be opposed
to the fringed and vascular synovial membrane. The removal of the
cartilage, which is an impediment to anchylosis in many diseased con-
ditions of joints, is what nature commonly aims at. In the most chronic
form of strumous ulceration, the removal of the cartilage is accomplished,
according to Mr. Key's researches, by the gradual development and
organisation of the synovial membrane, where it is reflected from the
edge of the cartilage. Where the process is required to be more rapid,
a false membrane is effused from the edge of the synovial membrane, that
gradually diffuses itself over the whole surface of the cartilage, and, by
means of its increased vascularity, ulcerates the cartilage even to the
bone, anastomosing often with the granulations of the exposed cancellous
structure.
Another case, is where'ulceration begins on the surface of cartilage
attached to the bone. In examples of chronic disease in the cancellated
structure, Mr. Key finds, that, when the cartilage begins to give way,
vessels can be seen shooting towards it, and accumulating in sufficient
number to form a vascular tissue, covering the attached surface of the
cartilage. Afterwards, when the ulceration has proceeded through the
cartilage, or nearly so, into the joint, the synovial membrane inflames,
and the ulceration is then forwarded by a similar process, commencing
at the edge of the cartilage, by means of the synovial membrane, and a
newly developed vascular structure. In acute inflammation, attacking
the spongy extremities of bones, the osseous substance is said by
Mr. Key not to be softened, but to retain its firmness of texture, and
exhibit no marks of disease, except at one part of the cancelli. Here a
cavity is found, containing one or more portions of detached bone, sur-
rounded with pus. This cavity communicates with the joint by a fis-
tulous opening of small size. The process of ulceration evidently begins
ULCERATION OF THE CARTILAGES. 317
on the outside of the joint, for the cartilage seems undermined, and its
articular surface perfectly sound, while the synovial membrane itself is
acutely inflamed, and its cavity has communications with one or more ex-
tensive collections of pus above and below the joint. These pathological
researches, undertaken by Mr. Key, harmonising as [they do with those
of Cruveilheir on the same subject, seem to me to be well deserving of
attention, and calculated to throw light on the difficult and obscure sub-
ject,, of the theory of ulceration in general. From Sir Benjamin Brodie's
work, I find that he was aware, many years ago, of some facts relative
to this doctrine, which, however, he does not adopt.
The cartilage, covering the articular surface of a bone, being once de-
stroyed, is reproduced with great difficulty : indeed, when cartilages are
destroyed, and caries has attacked the subjacent bone, the disease must
either terminate in anchylosis, which is, under such circumstances, the
most favourable termination that can take place, or in a porcelainous or
ivory-like deposit on the surface of the part from which the cartilage has
been removed. In many instances, when the disease is in the knee, ankle,
or elbow, hectic symptoms may begin even before suppuration com-
mences, and especially when the disease is in the knee, though it rarely
happens, that amputation is rendered necessary by the constitutional dis-
turbance under such circumstances.
In the treatment of this form of disease of the joints, one obviously
essential plan is, to keep them as quiet as possible; for every movement
occasions a disturbance of the textures affeeted ; and when the cartilages
are ulcerated, friction of them must be particularly injurious. The treat-
ment, then, consists in keeping the joint quiet, not only by making the
patient observe the recumbent position, but also by the use of splints, or
pasteboard, or by the method of strapping and bandages recommended
by Mr. Scott. Another indication is, to endeavour to stop the morbid
process, which, through the agency of the synovial membrane, and the
new vascular substance developed from it, is occasioning the ulceration
of the cartilage. For this purpose, experience has not furnished us with
any means more effectual than counter-irritation by means of blisters,
issues, moxa, or antimonial ointment. However, this observation is to
be received with some degree of limitation ; for in this, as well as in other
diseases of the joints, there is often at first acute inflammation present, the
part being painful and hotter than usual, from not having been kept quiet.
Under these circumstances, it will be proper to employ common antiphlo-
gistic means, previously to counter-irritation. On the Continent, and also
in the surgical schools at Edinburgh, the cautery is sometimes recom-
mended, as a means of producing counter-irritation, in the treatment of
diseased joints ; but in England surgeons rarely or never resort to it.
Here we dislike heated irons as implements of surgery, which may be
looked upon, perhaps, as mere prejudice, because no doubt is entertained
of their frequent efficacy. They are, what the French term, heroic
remedies. After the morbid action has been in some degree Stopped, we
may try other plans, such as pumping cold or warm water on the part
from a height, as practised at some of the watering places. If the disease
be arrested in time, the cure may take place without any material loss of
cartilage, or consequent anchylosis, and after a period has been put to
the disease, if there should still remain some uneasiness and weakness in
the joint, we may try pumping water on the part from a height, or cham-
pooing, or mere friction with the hand or with hair-powder. Anchylosis,
however, is the common termination of this disease, and with this view it
318 DISEASES OF THE JOINTS.
is, that nature takes away the cartilage. The application of steam to the
part is a beneficial plan, where anchylosis can be avoided, for it
promotes the restoration of the functions of the joint, and tends to ob-
viate the stiffness, which is apt to continue a long while after the disease
has stopped. Dr. O'Beirne has published several interesting cases, in
order to prove the great usefulness of mercury in ulceration of the carti-
lages of joints. To scrofulous patients, labouring under this disease, he
administers the infusion of sarsaparilla in lime-water, as the best medicine
for preventing the injurious effects of mercury on their constitutions.*
SCROFULOUS DISEASE OF JOINTS, BEGINNING IN THE BONES.
Another form of disease of the joints, is that in which the affection
begins in the cancellous texture of the heads of the bones, often set down
as scrofulous. All the joints are more or less liable to it ; but the ankle,
knee, and elbov* , are those in which it occurs with particular frequency.
When the knee is the part affected, there is considerable pain about the
head of the tibia, or in the centre of the joint, followed by a general en-
largement of it. In consequence of the swelling of the part, and a degree
of emaciation, which takes place in/the limb above and below the joint,
it seems as if the heads of the bon'gs were enlarged ; but experience has
proved that such is not really the case, and that the appearance depends
on the emaciation of the leg and thigh, and the thickening of the synovial
membrane and parts external to it. This scrofulous disease of joints is
remarkable for the great length of time, during which the skin retains its
natural colour ; hence, indeed, the term white swelling. Ultimately,
however, the skin becomes tense and shining, and streaked with dilated
tortuous veins. In this stage, the joint will also generally be noticed to
be above its natural temperature. Frequently before the disease has
advanced to suppuration, the joint cannot be bent and extended, but be-
comes permanently fixed in one position. Thus, when the knee is affected,
it becomes generally more or less bent, and cannot be straightened ; fre-
quently it is quite bent, and the patient has no power to change its
position. In time, matter forms in the cavity of the joint, and makes its
way by ulceration through the synovial membrane, or abscesses sometimes
form on the ouside of the joint. Then the cartilages are destroyed, and
several fistulous apertures take place about the knee, through which the
matter is discharged. Sometimes sinuses occur, and run to a considerable
distance from the joint under the fascia or between it and the skin.
When a joint in this state is examined after amputation, besides ulceration
of the cartilages, and inflammation and thickening of the synovial mem-
brane and of the cellular tissue external to it, we find the heads of
the bones softened and weakened in their texture, in which is deposited a
soft substance, of a caseous yellow appearance, seemingly in the very
tissue of the bone, the phosphate of lime being partly absorbed, and this
new softer substance secreted in lieu of it. In many scrofulous bones, a
considerble deposit of bony matter takes place on their outside, in very
irregular forms, and sometimes in the shape of spiculse or icicles. When-
ever we amputate scrofulous joints, we mostly see these irregular bony
deposits. They are, as I have said, sometimes very much like icicles, or
stalactical processes, and very sharp.
This scrofulous affection of the heads of the bones is, perhaps, more
* See Dublin Journ. of Med. Science, vol. v. p. 159.
SCROFULOUS DISEASE OP THE JOINTS. 319
difficult to cure than the generality of diseases of the joints, excepting the
organic change, or pulpy thickening of the synovial membrane. The
disorder, indeed, is connected with a scrofulous constitution, the recti-
fying of which is no easy task. However, this must be attempted by
means, which will be described when I come to the subject of scrofula.
In the treatment of scrofulous disease of the joint, commencing in the
heads of the bones, we are to keep the part perfectly motionless : this
principle applies, as I have before observed, to all diseases of joints. The
object is effected either by means of long straps of plaster, by Mr. Scott's
plan, or by the use of splints. When there is a tendency in the limb to
assume a posture, which would let it be of little use to the patient in case
of anchylosis, we should endeavour to counteract such tendency with the
aid of splints. In addition to these means, blisters should be applied to
the joint, and kept open with savine ointment. Or we may employ the
antimonial ointment, issues, moxa, and other counter-irritants, which
form the common mode of practice. But whenever the joint is affected
with a degree of acute inflammation, we should defer or discontinue the
counter-irritants, and trust chiefly to quietude and antiphlogistic measures
till the inflammation has subsided. When the diseased process has been
arrested by the above methods judiciously put in practice, champooing
may be had recourse to, or water allowed to fall upon the part in a column
from a considerable height, which plan is to be persevered in for a certain
time every day. It is always a rule in the treatment of this disease to
open abscesses early, and when anchylosis is likely to take place, the joint
should invariably be placed in the posture most likely to let the limb be
of the greatest service to the patient.
COXALGIA, OR SCROFULOUS DISEASE OF THE HIP JOINT,
Is generally supposed to commence in the cartilages ; but this is, per-
haps, rendered doubtful by the tenor of Mr. Key's investigations, whence
it would seem that cartilage is not susceptible of any primary morbid
change itself. Sir Benjamin Brodie's observations tend to prove, that in
many cases, the cartilages are, at all events, affected in a very early stage.
Mr. Key's dissections lead him to believe, that the ulceration of the car-
tilage is preceded by inflammation of the ligamentum teres. In one case,
the ligamentum teres was found much thicker and more pulpy than usual
from interstitial effusion ; and the vessels upon its investing synovial mem-
brane were distinct and large. At the root of the ligament, where it is
attached to the head of the femur, a spot of ulceration of the cartilage
was seen, commencing, as it does in other joints, by an extension of the
vessels in the form of a membrane from the root of the vascular ligament.
The same process was also taking place in the acetabulum, where the
ligamentum teres is attached. That the synovial membrane of the hip-
joint, and not the cartilage, is often primarily engaged in this disease,
appears to Mr. Coulson deducible from one of the first symptoms which
marks its commencement, viz., a fulness of the groin, depending, in all
probability, upon the increased secretion into the joint, similar to what is
known to take place in synovitis of the knee.* It is not to be supposed,
however, that Sir Benjamin Brodie is unaware of the fact, that ulceration
of the cartilages of joints is often preceded by synovial inflammation ; on
the contrary, he distinctly states, that he has known many cases in which
* W. Coulson, on Disease of the Hip- Joint, p. 32. 4to. Lond. 1837.
320 DISEASES OF THE JOINTS.
there was evident destruction of the cartilages of a joint by ulceration,
manifestly arising from neglected inflammation of the synovial membrane.
" When inflammation attacks the synovial membrane of the hip, there is
(says he) an evident fulness of the groin, and, in some instances, of the
nates also. The pain is aggravated when the patient stands erect, and
allows the limb to hang without the foot resting on the ground. It is
also increased by motion, but not by pressing the articular surfaces against
each other, so that it does not prevent the weight of the body from being
borne by the affected limb." Coxalgia is most commonly met with in
children between the ages of seven and fourteen ; though occasionally at
an earlier, and also at a much later period of life. One of the first symp-
toms is pain about the knee-joint, and sometimes there is more uneasiness
felt there, than in the hip-joint itself. The pain generally shoots down-
wards along the inside of the leg, as far as the instep. The pain is so
much complained of in the knee, that nurses and careless practitioners
often apply poultices to that joint, without even suspecting that the hip
is the true seat of disease. If, however, the surgeon press upon the
joint, anteriorly, or posteriorly, or grasp the foot and rotate the head of
the femur against the acetabulum, the pain, thus excited, soon apprises
him, that the real seat of disease is the hip. The next thing usually
noticed is, that the patient feels weakness and stiffness in the joint, and
cannot walk his usual distances without great fatigue, and uneasiness in
the limb ; in fact, he is soon observed to limp, and the limb to shrink and
dwindle away. One remarkable symptom is, that the glutaeus maximus
muscle on the diseased side is much flattened, and its lower margin less
prominent, than that of the corresponding muscle on the opposite side.
Hence, when any doubt exists about the nature of the case, we should
never omit to examine the posterior appearance of the pelvis and muscles
attached to it ; and then, if the disease be coxalgia, we shall observe that
difference between .the glutaei muscles which I have described, viz., the
gluteeus maximus on the diseased side will be flattened, and its lower
margin, instead of being prominent and conspicuous, will be almost effaced.
In the early stage, the patient inclines his thigh forwards, and, when in
the same stage of the disorder, we examine the patient as he lies on his
back, it appears as if the affected limb were longer than the other. If
the patient stand up, we observe that he does not rest equally on both
feet. The sound limb is extended, while the affected one is bent, the
knee being lower than that of the opposite side, and the foot generally
everted, though it is occasionally turned inwards.* At the present day,
most surgeons ascribe the lengthened appearance of the limb to the po-
sition of the pelvis being altered ; for, in order to save the limb as much
as possible, the patient keeps it suspended, and the weight of it has the
effect of drawing that side of the pelvis lower down than the opposite
side. Therefore, when we examine the two limbs, in the recumbent po-
sition of the patient, the diseased limb appears the longest, because the
acetabulum is lower than natural, and the posture of the pelvis oblique.
This alteration in the position of the pelvis even affects the spinal column
more or less ; and, we find, that it is also more or less distorted by the
efforts made to counterbalance the weight of the suspended limb. In
addition to the change in the position of the pelvis, Mr. Coulson con-
ceives, that the limb is really a little lengthened, or rather the trochanter
major is slightly protruded. However, there is one resistance to such
* Coukon, Op. cit. p. 51.
SCROFULOUS DISEASE OF THE JOINTS. 321
protrusion, that has been adverted to only within a recent period. Weber
proved by experiments, that it was not simply the muscles and ligaments,
as was formerly supposed, which preserved the head of the femur in contact
with the acetabulum ; but that the acetabulum being closed by the head
of the bone in an air-tight manner, the femur was held suspended by the
atmospheric pressure. Hence, all the muscles and ligaments about the
joint may be cut through without the weight of the leg causing the head
of the femur to recede in the slightest degree from the acetabulum ;
whilst, on the contrary, when all the muscles and ligaments are left en-
tire, the head of the bone will sink from three to four lines out of the
acetabulum, if the atmospheric pressure be permitted to act on the upper
surface of the head of the femur, through a hole bored from the inside of
the pelvis into the joint. By careful measurement of the space between
the anterior superior spine of the ilium and the external malleolus, Fricke
ascertained, that in apparent elongation of the limb, there was always real
shortening, which amounted to nearly the same extent as the apparent
elongation.* In a few instances, the affected limb, even in the early
stage, does not appear to £>e longer, but shorter than the other. The
cause (as Sir Charles Bell remarks) is the same in both examples : the
patient seeks the position of ease. " If the patient be taken due care of,
and be put to bed early in the disease, the leg will be shorter; but, if the
disease be of a more chronic nature, so that the person is permitted to go
about, the leg will be longer ; for, in walking with an inflamed hip, the
weight of the body must be thrown on the other hip, in order to relieve
the affected joint ; and the patient dare not bring the diseased hip
exactly under the centre of the body, but he pushes it forward, whilst he
bears on the other limb. This gives rise to a curve in the spine ; and
the limb is longer, owing to the position of the pelvis, which is poised
differently ; the diseased side being depressed, instead of being elevated,
as in the other case."f As the disease advances, pain begins to be felt
about the trochanter major, and also in the groin, and the suffering is
greatly increased by eversion or abduction of the limb, a fact, which Mr.
Key dwells upon, as corroborating his belief, that the disease begins with
inflammation of the ligamentum teres ; for those movements cannot be
endured in the early stage, though flexion and slight inversion cause no
complaint. He also deems the pain, felt on pressing the head of the
femur against the acetabulum, another proof of the disease beginning with
inflammation of the ligamentum teres. In some cases, the disease does
not advance to suppuration ; the morbid changes cease ; and a cure takes
place, without the formation of any abscesses. Sometimes the disease
terminates in anchylosis, also without suppuration. In other instances,
abscesses form, and then the matter generally passes down behind and
below the trochanter major, and often spreads to a great extent down the
limb. Sometimes the abscess spreads upwards above the great tro-
chanter, and around the pelvis. Such abscesses may burst in various
places, and frequently there are several ulcerated openings, fading by
fistulae to the diseased hip. Sometimes the matter escapes by h'stulous
openings on the nates, or thigh ; but, now and then, the acetabulum, be-
coming carious, an opening takes place through it, the matter thus finds
its way into the pelvis, and, descending by the side of the rectum, bursts
* Many other ingenious remarks on this subject have been published by Dr. Gadechens,
of Hamburgh ; a translation of whose paper by Dr. Bigger is ^inserted in the Dublin
Journ. of Med. Science, vol. xii. p. 409.
f Sir Charles Bell, in Med. Gaz. vol. xiv. p. 302.
Y
322 DISEASES OF THE JOINTS.
near the anus. One memorable case is recorded by Sir Charles Bell, in
which not only were the acetabulum and the head of the femur injured
by the effects of caries, as usually happens, but, after the disease had
advanced to a certain extent, the remains of the head and neck of the
thigh-bone passed through the carious acetabulum into the pelvis. In
two specimens in the museum of University College, a portion of the
head of the femur projects into the pelvis, in consequence of the injured
state of the acetabulum. In the second stage of this disease, the aceta-
bulum is either widened, or parts of its brim destroyed, while the head of
the femur is more or less diminished, and both the ligamentum teres and
the synovial membrane are sometimes nearly annihilated. Hence, the most
frequent cause of the shortening of the limb, in the second stage of the
disease, a shortening, not dependent upon actual dislocation, which, how-
ever, sometimes occurs, as was the case in a patient under my care last
spring (1839) in University College Hospital, and the specimen taken
from whom is now preserved in the museum of the same college.* The
head of the bone then is sometimes truly dislocated by the action of the
muscles on the dorsum of the ilium. In rarer cases, the upper end of the
femur is drawn downwards and inwards on the foramen ovale. In still
less usual instances, the head of the femur is displaced forwards, and
rests on the pubes. Sir B. Brodie, in one case, found the head of the bone
out of the acetabulum, yet within the capsular ligament. Dislocation
may take place very suddenly, the limb becoming, all at once, three or
four inches shorter than natural, with the toes turned most frequently
outwards, but sometimes inwards. The examples, in which the foot and
knee are everted, are those in which the head of the femur is totally
destroyed, or separated from the rest of the bone, and the shaft drawn
upwards ; but, when the head remains, and is not totally destroyed or
separated, the toes are turned inwards, unless the dislocation be forwards.
Mr. Wickham gives an instance, in which both hip-joints had been dis-
eased, and in which the toes of each limb were turned out. This position
he also regards as the invariable one, when a dislocation really happens ;
for in those cases, where the limb is inverted, he conceives that it is
merely drawn across the other.f The view, which I have given, corre-
sponds to that entertained by Sir Benjamin Brodie. In the advanced
stage, attended with dislocation, the limb is not only sometimes shortened
and turned either outwards, or inwards, but the thigh is considerably bent
upon the pelvis. During these changes, the constitution suffers severely
from hectic fever, and not unfrequently a fatal termination is the result.
Carious disease of the hip-joint, attended with suppuration in the adult,
is seldom cured. In a grown-up person, the prognosis is almost always
unfavourable if abscesses take place ; but children sometimes get through
the disease, though suppuration be present. The degree of danger in
these cases depends on several circumstances. First, on the extent of the
disease in the bone ; in some instances, which I have dissected, a consi-
derable portion of the ossa innominata (and not merely the acetabulum
and head of the thigh-bone) was diseased and carious. I have seen the
os ilium extensively diseased ; so that a great deal must depend on the
question, how far the disease of the bones has reached. Secondly, much
will depend on the size of the abscesses ; when there is no suppuration,
the danger is less considerable, and then even an adult may recover. It
* See London Med. Gaz. vol. ii. p. 255. New Series.
f On Diseases of (he Joints, p. 100. 8vo. Winchester 1853.
SCROFULOUS DISEASE OF THE JOINTS. 323
is curious to find, that sometimes the case will advance to the stage of
dislocation, though no abscesses have occurred. This happened in the
remarkable case, which I have quoted from Mr. Wickham's publication.
Thirdly, the degree of hectic disturbance influences the prognosis ; and
so does the age of the patient : because, if he be an adult, and abscesses
take place, he will have but little chance of recovery. Many children
who die of this disease, have pulmonary tubercles : I attended, with
Sir Astley Cooper, a young lady at Walthamstow, who died with disease
of the hip, and, on opening her chest, numerous tubercles were found in
the lungs. Another patient of mine had a vast accumulation of serous
fluid in the abdomen before death.
Dissection reveals appearances of the following kind: The synovial
membrane and capsular ligament exhibit the effects of inflammation,
being thickened, and occasionally perforated at various points. Fre-
quently the synovial membrane is lined with fibrine, or filled with thick
purulent matter. Sometimes it is converted into a gristly substance. In
the progress of the disease, it is often completely destroyed. The liga-
mentum teres is ulcerated; but, in advanced cases, not a vestige of it
may remain. The cartilages are abraded in some parts ; and absorbed
in others. et Sometimes that of the acetabulum is first affected ; some-
times that of the femur ; and sometimes ulceration begins in both at the
same time. As the disease proceeds, these cartilages are completely de-
stroyed, and occasionally replaced by an ivory, or almost vitreous deposit.
Loose floating portions of cartilage are occasionally found in the joint
after death. Cruveilhier relates a case, in which he found fifteen loose
fragments of cartilage in the hip-joint. The cotyloid and transverse
ligaments are generally destroyed.
" The socket is widened, and rendered shallow by this process ; the
bare surfaces of the bone become carious ; and the head, and even the
neck, of the femur is lessened. In scrofulous inflammation of bone,
the earthy matter becomes absorbed, and the bone consequently soft-
ened ; whilst the cancelli are filled with a yellow carious matter, or a
transparent yellow fluid. But (according to Mr. Coulson), the striking
feature in this kind of inflammation is the absence of all secretion, or
deposit of bone ; whereas, in simple inflammation, uninfluenced by the
scrofulous diathesis, bone is secreted in abundance. Bony anchylosis
in a scrofulous subject is very rare," &c. The head of the bone in
scrofulous subjects is much softened.* In the museum of University
College, however, we have several fine specimens of anchylosis, and also
of bony deposit, after scrofulous disease of joints.
The matter of abscesses, formed in this disease, has frequently to take
along course to reach the surface; and hence sinuses of considerable ex-
tent are produced, leading to fistulous openings in the skin. Mr. Listen
has a preparation, in which a sinus leads through the foramen ovale,
and it was found to terminate in the rectum. Abscesses, produced within
the joint, sometimes extend through the carious acetabulum into the cel-
lular tissue of the pelvis. In one case, examined last winter in University
College Hospital, this had happened ; so that not only was the pelvis
greatly occupied by pus, but some of the matter had descended into the
upper part of the thigh, under the crural arch.
In the last stage, the acetabulum is sometimes filled up with a whitish
organized substance, all distinction between synovial membrane, capsular
* See Coulson, Op. cit, p. 37 — 39.
Y 2
324< DISEASES OF THE JOINTS.
ligament, cellular tissue, and this new substance, being lost : all being
confounded together, and even the muscles altered in structure. In the
acetabulum of the patient last referred to *, a fine specimen of a mass of
organized fibrine was found : the preparation is now in the museum of
University College. In some cases., the os innominatum is more exten-
sively carious, than the head of the thigh-bone itself.
Sometimes, when the disease stops, anchylosis takes place between the
femur and os innominatum, or the os ilium. In a few instances, a new
joint is formed, and some degree of motion is allowed. In the museum
of University College is the unique specimen of a new joint, formed by a
globular or convex mass of new bone, thrown out at the side of the os
ilium, and adapted to a cavity produced for its reception, at the inner
side of the upper portion of the femur, all the head and neck of which
are annihilated. The woman, from whom it was taken by one of my
dressers^ had a scrofulous abscess within the pelvis. This and various
other facts lead me not to join in the doctrine, that scrofulous disease of
bone cannot be attended with deposit of new bone.
The most essential part of the treatment consists in keeping the joint
perfectly quiet : this principle is insisted on by all good practical sur-
geons. If the joint be moved, abscesses will form, and the disease take
an unfavourable course. In the early stage, we may have recourse to
cupping or leeches, poultices, and fomentations ; and if the patient be a
strong subject, or of rheumatic constitution, we may, after having cleared
out the bowels, prescribe two grains of calomel with half a grain of
opium, which are to be taken every night, until the mouth is slightly
affected. But if these medicines prove of no service, the vinum col-
chici may be exhibited in doses of 5ss. When the inflammation has been
moderated, a blister may be applied, and kept open, or several blisters
repeated in succession ; and, as soon as the disease has become still more
chronic, the joint may be rubbed with iodine liniments, the ung. potassii
iodidi, ung. hydrarg. fort, with 3J of the iodide of potassium to each jj of
the ointment, or with camphorated liniment, strengthened with 3ij of the
tinct. canthar. to each ounce of it. With respect to an issue, seton, or
the moxa, although these means are not so much confided in as they
were formerly, I know from long experience, that when employed with
judgment and discrimination, they often realise every expectation which
can be reasonably entertained of the benefit, capable of being derived
from counter-irritation, and the maintenance of a discharge from the
neighbourhood of the affected joint. They are not, however, to be con-
tinued for an immoderate length of time, nor resorted to in very reduced
states of the health, nor where abscesses have already formed, or fistulae,
from which a more or less profuse discharge is daily taking place. I have
already insisted upon the great importance of keeping diseased joints in
general strictly at rest. Here, as soon as the patient can bear mecha-
nical contrivances for this purpose, we are to avail ourselves of them, and
endeavour at the same time by their means to get the limb into as straight
a position as can be done without occasioning pain. Mr. Scott's plan
consists in cleansing the surface of the joint with a sponge, soft brown
soap, and warm water, and then thoroughly drying it. The part is then
rubbed with a sponge soaked in camphorated spirit of wine, and after-
wards covered with cerate, made with equal parts of ceratum saponis
and the ung. hydr. fort. c. camphora. This is thickly spread on large
* See London Med. Gaz. loco cit.
SCROFULOUS DISEASE OP THE JOINTS. 325
square pieces of lint, applied entirely round the joint, and supported with
broad strips of the emplastrum plumbi. Over these strips is placed an
additional covering of emplastrum saponis, spread on thick leather, and cut
into four broad pieces, one for each side of the joint. Lastly, the whole
is secured with a calico bandage,, which is not to be applied so as to
cause any uneasiness from pressure. If abscesses have formed, it does
not appear that this method has the power of promoting the absorption
of the pus ; but, if fistulas are present, the support of the above applica-
tions is alleged to prove beneficial.* The frequency of changing the
dressings will depend upon the quantity of discharge. The principles
of keeping the joint perfectly motionless, and the limb from inclining for-
wards, may be enforced by various mechanical contrivances, which consist
either of leather splints, or cases of leather, or other materials, adapted
correctly to the contour of the hip, nates, and thigh, and made to reach
below the outer side of the knee, so as to maintain that joint also at rest.
In University College Hospital slips of patent lint, dipped in a solution
of gum arabic, are sometimes employed by Mr. Listen, and laid upon the
parts, which are first greased. Several layers of dry lint are added, and
the whole is confined with a bandage. When the composition dries, a firm
case is formed, which may be made to embrace the parts from the knee
up to the false ribs. I have tried this plan with advantage ; but, when
the patient can afford to purchase an apparatus, I recommend one made
of leather, as best adapted to private practice. In scrofulous subjects,
mercurial alteratives, with the extract of conium, chalybeate medicines,
with the iodide of potassium, sarsaparilla, or for children rhubarb and
carbonate of soda, with tonics, are the best medicines. The diet is to be
light, but nutritious, with or without wine or beer, according to circum-
stances. If abscesses have formed and burst, and the appetite is bad, a
little wine or porter will often prove of great service.
After the disease has been checked, the patient should be taken out
in a spring carriage or boat, for the benefit of the air ; and, if possible,
he should try what good may be derived from the sea-air, and warm
salt-water bath. In the advanced stage of bad cases, the constitution
becomes completely hectic ; and, before death, there is often general ana-
sarca. Differences of opinion exist on the question, whether abscesses,
proceeding from a diseased hip, should be opened early or not : Sir Astley
Cooper prefers not making an opening, until the matter has extended
to some distance from the joint, where, he believes, that it may then be
made, without being followed by so much irritation as at an earlier period.
This advice merits consideration, as the more common plan is to open
all abscesses near joints without delay.
After the disease of the hip seems cured, the patient should be very
cautious; for I have attended some cases, where children, who had re-
turned to school apparently well, on receiving a blow, or fall on the hip in
play, were brought home again with a recurrence of the disease in -an
aggravated and fatal form.
Antiphlogistic measures, in the beginning, appear to be called for by
Mr. Key's view of the probable commencement of the disease with inflam-
mation of the ligamentum teres. Afterwards, when the inflammatory symp~
toms have been subdued, nothing is more beneficial, than the application of
some mechanical contrivance for the purpose of preventing all motion of the
hip-joint, and keeping the thigh from inclining forwards, which last object is
* See Coulson on Diseases of the Hip, p. 84. 4to. Lond. 1837.
Y 3
326 DISEASES OF THE JOINTS.
often very difficult of execution, on account of the pain which the attempt
is apt to produce. Generally, the aim can be accomplished only in a gentle
and gradual manner. One of the best contrivances for hindering all mo-
tion of the hip is, as I have stated, a leather apparatus, lined with soft
materials, provided with straps and buckles, accurately fitted to the nates
and thigh. It should also be made long enough to keep the knee-joint
in a perfectly quiet state. Together with this, or some other mechanical
contrivance, for the foregoing purposes, counter-irritation may be tried,
either by means of a blister, an issue, the antimonial ointment, or a seton.
In the course of the disease, it sometimes happens that portions of dead
bone exfoliate ; but more frequently nothing of this kind takes place. A
good situation for issues is just behind and below the trochanter major :
here they are less inconvenient to the patient than elsewhere ; the peas
can be kept in well ; and the discharge and counter-irritation, whether
kept up by peas, or the occasional use of antimonial ointment or caustic,
will have the best effect. The skin, immediately in front of the joint, has
sometimes been selected for the situation of issues or setons ; but the
other is preferred by the generality of practitioners.
ANCHYLOSIS
Is of two kinds, complete and incomplete ; or, as it is sometimes expressed,
true and false.
Complete or true anchylosis is that, in which the articular surfaces of
the bones become firmly and inseparably connected together by osseous
matter. When the cartilages of a joint are destroyed by ulceration, and
the surfaces of the bones are carious, if we succeed in stopping the
disease, the mobility of the joint will not generally be preserved, nor will
the cartilages be reproduced ; but the heads of the bones will be united
together by osseous matter. True anchylosis, then, is, under such cir-
cumstances, scarcely to be regarded as a disease, but rather as the mode
in which another disease terminates. The functions of the joint are per-
manently interrupted by it; but its completion denotes the cessation of
all further morbid action. In coxalgia, if the cartilages and ligaments be
destroyed in diseased joints, generally if attended with ulceration of car-
tilages" and carious bones, and in scrofulous caries of the spine in parti-
cular, anchylosis is one of the most favourable terminations which can
be hoped for. Now and then, however, coxalgia ends in the formation of
a new joint, as already explained; and, occasionally, after the absorption
of the cartilage, a substitute is obtained for it in the production of a
substance, termed, on account of its hardness and smoothness, the ivory,
or porcellainous deposit. In caries of the spine, the disease is never
stopped till a complete and true anchylosis is established. This is the
only mode of cure.
Whenever tiue anchylosis is expected to take place, or considered
possible, the limb should be kept in that position which will afterwards be
most useful.
True anchylosis is a consequence, however, very much to be appre-
hended from fractures near or extending into joints, or from other me-
chanical injuries bringing on inflammation and suppuration of the joints.
Here the right principles, with the view to its prevention, are, in the first
stage, to employ every thing calculated to lessen inflammation of the joint,
as bleeding, leeches, calomel, cold evaporating lotions, and quietude of the
part ; and, in the second stage, after having thus kept down the inflamma-
tion a certain time, to let passive motion be gently resorted to every day.
DISEASES OF TENDONS. 327
In all mechanical injuries of, or near, the large joints, these principles
are never to be neglected.
In the records of surgery, examples are described, in which all the
joints of the body were anchylosed ; and in the Hist, de 1' Acad. des
Sciences for 1716, is the case of a child, twenty-three months old, which
was afflicted with universal anchylosis.
Generally speaking, there is a natural tendency to anchylosis in the
joints of persons far advanced in age, in whom the vertebrae and heads
and tubercles of the ribs are frequently all joined by osseous matter.
False anchylosis denotes any loss of, or vast interruption of, the motion
of a joint from any causes short of ossification^ or the connexion of the
articular surfaces by firm bony deposit. Thus the swelling and thickening
of the synovial membrane,, and of other soft parts, after bruises, fractures,
and sprains, and weakness and loss of tone in the muscles, may produce
a degree of stiffness about a joint, amounting to what is termed an incom-
plete or false anchylosis. Here gentle passive motion, friction, champoo-
ing, the exposure of the joint to the vapour of hot water, the aspersion of
the part with warm or cold water thrown upon it from a height, the use
of stimulating or iodine liniments, and the support of a bandage, are the
best means of relief.
Though anchylosis of the lower jaw is of rare occurrence, instances of
it have been met with ; one is mentioned by Eustachius, and another
came under the notice of Cruveilhier. He has given an engraving of
the skull ; the anchylosis was in the right articulation of the lower jaw.
The subject of it, an old woman, was not more than eight or nine years of
age when the anchylosis formed, which happened from a blow on the side
of the face. The s'ection of the joint which is exhibited, shows that there
was not merely a deposit of bony matter external to the joint, but
that the condyle of the jaw and glenoid cavity of the temporal bone
were actually consolidated into one solid mass. Notwithstanding the
anchylosis, the patient contrived to masticate with tolerable facility, by
pressing the food against the alveolary processes with her tongue. As
for her speech, it was perfect ; so that she managed to live to the age of
eighty-nine with a great deal of comfort.
INJURIES AND DISEASES OF TENDONS AND BURS^E MUCOS^E.
Some notice of these subjects will appropriately follow the account,
that has now been given of the diseases of joints.
We know little about the pathological changes in tendons; but, it
would appear from Mr. Key's investigations, that the reticular tissue,
interposed between the tendinous fibres, is the medium by which the in-
creased vascularity is produced in tendons which inflame and are about
to ulcerate : or rather, I should say, a new vascular substance is deve-
loped, which becomes the organ by which the phenomena of ulceration
are supposed to be chiefly effected.
The right principles in the treatment of divided tendons are well illus-
trated in the instance of ruptured tendo Achittis, an accident which takes
place every now and then, in dancing, leaping, and other exercises, in
which the muscles of the calf are put into violent action. It occurs
chiefly in the male sex — seldom in females ; and even when it happens
in men, they are generally athletic and muscular subjects. At the mo-
Y 4?
328 DISEASES OF TENDONS.
merit of the tendon giving way, the patient feels a sensation as if he had
been struck on the heel with the lash of a whip ; and a noise is /sometimes
heard both by himself and the bystanders, as if a nut had been cracked
under the heel of his shoe, or like the smack of a whip. If the part be
now examined, a depression will be found in the situation where the
tendon has given way, and the power of extending the foot will be con-
siderably diminished, but not entirely lost ; for the long flexors of the
toes, the peroncei, and the tibialis posticus, yet enable the patient to ex-
tend his foot in a weak and imperfect degree. In the treatment, the first
and most essential principle is to relax the mass of muscles forming the
calf of the leg, and attached to the tendon. The gastrocnemius and
soleus are relaxed by bending the leg upon the thigh, and extending the
foot : this is the proper position ; but it cannot be maintained without the
aid of bandages or some kind of machinery. The apparatus invented by
Monro, primus, whose tendo Achillis was inadvertently ruptured, consists
of a slipper, to the heel of which is affixed a strap, which is buckled to
another strap put round the limb a little below the knee, and the heel is
kept drawn up towards the ham. This contrivance, which has the re-
commendation of great simplicity, completely answers, so far as the foot
is concerned ; but it is a thousand to one against our being provided with,
or able to procure, such an apparatus when we are called in to a case of
ruptured tendo Achillis ; therefore we ought to be prepared to do what
may be requisite, without any ready-made mechanical contrivance. Under
such circumstances, after bending the knee and extending the foot, we
may apply a longitudinal compress on each side the tendon, and then
surround the ankle and tendon with a roller, applied in the form of the
figure 8 ; next put a few turns of another roller below the knee, and let
this bandage and that on the heel be connected together with a band placed
along the back of the leg, by means of which band the foot is kept duly
extended. In this manner, we shall experience no difficulty in keeping
up the heel, and we need not use any particular contrivance for keeping
the leg bent. If the patient be in bed, as he ought always to be for a few
days at first, we direct him to keep the leg in the state of flexion ; and
when he gets up, we desire him to provide himself with a high- heeled
shoe. The tendo Achillis generally unites firmly in from four to six
weeks. Instances are on record (and Mr. Hunter's own case was one), in
which the cure was effected without confinement at all, merely by keeping
the foot extended, and letting the patient wear a high -heeled shoe.
With respect to ganglions, they are tumours connected with tendinous
structures ; and having very much the appearance of encysted swellings.
They are filled with a fluid resembling white of egg, or calf's-foot jeily,
their cysts being fibrous, and lined by a smooth membrane. On pres-
sure, a ganglion feels remarkably hard, and destitute of elasticity. The
tumour is generally fixed either to a tendon or to the fibrous sheath, or
theca of a tendon; but sometimes what are called ganglions are actually
collections of a glairy fluid within the fibrous sheaths themselves. Com-
mon ganglions are round, or globular ; but sometimes oblong, which is
chiefly exemplified when the collection of fluid is within the sheath.
Some of these swellings about the wrist are so oblong, that apart of them
may be felt on the palmar side of the annular ligament, and the rest
higher up the limb on the wrist. Such ganglions form within the loose
synovial membranes of the tendons. Ganglions are not usually attended
with pain : they form slowly ; and, in most cases, the only inconvenience
experienced is a slight weakness of the muscles, or joint, whose action is
DISEASES OF TENDONS. 329
interfered with. The patient may have a slight weakness of the fingers,
or of the wrist; but, although most ganglions form on the hand, or wrist,
others occasionally present themselves on the instep. I have seen several
examples of ganglions on the foot ; and I lately had a patient in the hos-
pital who had one upon the inner head of the gastrocnemius. Certain
subjects appear to be very liable to them, especially after bruises or
sprains ; but, in common instances, no such causes can be assigned for
their formation. I attended a girl, who had three of them, two of which
formed during the treatment of the first. It is a disputed point, whether
any ganglions are truly parts of new formation, that is, whether they are
actually new productions or growths. I believe many of them are only
collections of fluid in the fibrous sheaths of tendons, which are natural
and original parts ; but whether others of a more globular, prominent,
circumscribed figure, are of the same character, merely enlargements
of original parts, is undetermined. Mr. Key looks upon them as new
structures, formed upon tendons, and capable of being produced by
pressure,, friction, or undue exercise of a part.* Instances occur, in which
ganglions at the wrist are attended with pulsation, and the occasion
of severe pain. In the Dictionary of Surgery, ed. 7«, I have referred
to one case of this kind, the particulars of which are detailed in the
Edinburgh Medical and Surgical Journal. The wife of a prisoner in the
Queen's Bench, who was under Mr. Callaway, consulted me for a pulsatory
swelling at the wrist, which was found to be a ganglion, with the radial
artery passing over it. On pressing even slightly on the tumour, violent
pain in the arm was excited, followed by fainting. The reason of this
will be quite intelligible from the following account of another case,
communicated to me by Mr. Morton, of University College Hospital,
who saw the above-mentioned woman with me : —
"January, 18<38. — When dissecting the upper extremity of an old
woman, we found a small elastic swelling under the skin, a little above
the wrist, upon the front of the forearm, near to its radial border. The
cyst was of the size of a common hazel nut. Upon its surface several of
the filaments from the radial nerve were expanded, so as to form a mesh
upon the swelling. The sac lay over, and received the radial artery into
its posterior surface. When it was opened a quantity of glairy fluid,
of a light straw-colour, escaped. The posterior, or deep-seated surface of
the sac, was very irregular in its outline ; but it was not connected with
the sheaths of the tendons.
" The only difference in the two cases, it appears to me, is, that in the
woman, at the Queen's Bench, the radial artery lies upon the tumour,
which has grown up from behind it; whereas in the instance above-
mentioned, the vessel lay behind the sac."
Although ganglions usually produce little **pain or inconvenience,
patients are generally very desirous to get rid of them ; and few persons
behold with indifference any disfigurement, infirmity, or imperfection,
about their hands or feet. Ganglions may occasionally be dispersed by
blistering, or rubbing them with liniments containing ammonia, iodine,
camphor, or the tincture of cantharides. Many of them will also yield to
firm pressure, made on them with a piece of lead and a roller. But after
being lessened, they often return, and on this account, instead of the plans
which I have specified, it has been proposed to rupture them ; that is, to
employ such pressure as will burst them, and squeeze the fluid into the
* Guy's Hospital Reports, vol. i. p.415. _
330 DISEASES OF TENDONS.
surrounding cellular tissue. When we can succeed in effecting this,
either by striking the tumour with some obtuse body, such as the back
of a book, or by compressing it against a bone with the thumbs, if it ad-
mits of it, the disease will generally be cured ; for, after it is ruptured, if
the pressure on it with lead or other compress be continued, the obliter-
ation of the cavity, in which the fluid was collected, will be obliterated.
Occasionally we cannot succeed in rupturing it at all, so strong is the
texture of the fibrous cyst. Under these circumstances, we may puncture
the cyst with a lancet or couching needle, introduced obliquely through
the skin and the cyst, so as to let out the glairy fluid, or jelly-like sub-
stance, which it contains, after which steady and firm pressure is to be
kept upon the part. I have treated many ganglions in this way with
perfect success ; and having seen no ill consequences from it, now com-
monly follow it. For the small tumours at the base of the palmar side of
the fingers, Mr. Key deems the puncture the only remedy. This gentle-
man once punctured a ganglion, situated over the tendon of the trochlearis
muscle, and the swelling did not return. In the writings of Mr. Abernethy,
we find instances, in which tumours, supposed to have been ganglions,
were converted by the irritation of setons into malignant and fatal
diseases. Ganglions have been removed with the knife ; but I think
this practice would only be right when the swelling resisted all other
means, was occasioning much greater annoyance than is commonly ex-
perienced, and had a shape and conformation that adapted it to such
treatment.
Bursce mucosce are parts very liable to disease. They are mem-
branous sacs, placed under tendons, or parts of the skin exposed to
much pressure ; and their use is to secrete a synovial fluid, which renders
the surfaces, on which the tendons or integuments move, smooth and
well qualified to facilitate the action of the muscles, and obviate the
effects of friction. Sometimes, in consequence of sprains, bruises, pres-
sure, or accidental inflammation, the cavity of a bursa becomes distended
with a greater quantity of secretion than usual ; it is therefore enlarged ;
and, in this state, a considerable degree of pain is experienced in the
part ; though, in many instances, the inflammation is of a more chronic
character. This disease is often seen in the bursa, situated between the
patella and the skin ; but sometimes it takes place in the flexor tendons
of the fingers, in that which is placed over the olecranon, or in that of
the ball of the great toe. A curious case is related by Sir Benjamin
Brodie, in which the bursa, situated between the latissimus dorsi and the
lower angle of the scapula, was enlarged to the size of a man's head, in
consequence of the disease now under consideration. The sacs of bursae
mucosse, when inflamed, become considerably thickened ; the fluid within
them is sometimes clear, but, in other instances, turbid or even purulent;
and occasionally it contains numerous granular bodies, which are compared
to melon-seeds, both in respect to size and shape. Substances of this
kind, however, are met with only when the disease has been of long
standing. These swellings are very common on the patella, particularly
in housemaids, who are employed a good deal in scouring rooms, in which
occupation the pressure of the bursa against the floor has the effect of
bringing on inflammation : hence the disease is sometimes called the
housemaid's knee.
Treatment. — In the first stage of the disease, while acute inflammation
prevails, and there is great tenderness, antiphlogistic measures should be
employed, especially leeches, or even bleeding, cold applications, quietude
BURS-E MUCOS^E. 331
of the limb, and brisk aperient medicines. Afterwards, when the disease
has become more chronic, we may try discutient lotions, particularly those
which contain the muriate of ammonia, vinegar, and a proportion of
alcohol ; and in a still later stage, blisters, or liniments containing iodine,
or the camphorated mercurial ointment. Sometimes the disease cannot
be dispersed by the above plans, and this is especially the case when the
tumour contains those small granular bodies, like melon-seeds, to which
I have adverted. There is always considerable difficulty in getting rid of
them when they are of long standing, and the parietes of the bursa are
much thickened ; under these circumstances, it is necessary to open the
bursa, for the purpose of discharging the granular substances, and after-
wards to excite such an inflammation in the cavity of the bursa as shall
lead to its suppuration, granulation, and obliteration. If these processes
can thus be brought on, without exciting too much inflammation in the
surrounding textures, the disease will soon have a favourable conclusion.
But, sometimes, though we open the bursa and discharge its contents,
the necessary degree of inflammation does not ensue; the bursa con-
tinuing to discharge a glairy fluid, and the integuments to be from time
to time attacked with troublesome and painful degrees of inflammation,
sometimes of the erysipelatous kind. I had a case, in which I opened the
bursa over the patella ; but the disease continued to annoy the patient for
a considerable time after the operation, so that I found it necessary to in-
ject a solution of the nitrate of silver into the sac, in order to excite the
requisite inflammation for its obliteration : this measure succeeded, and
the patient soon got well. Some surgeons recommend the introduction
of a tent or seton for this purpose. I should mention, that we ought not
to open bursae mucosse without a real necessity for it; for we occasionally
hear of cases in which patients lose their lives in consequence of the limb
being attacked with phlegmonous erysipelas. There are examples in
which it is even necessary to cut away a diseased bursa, it being converted
into such an indurated mass that no common plans will cure it ; and its
size seriously interfering with the action of the joint. In University
College Hospital (this summer, 1839) I cut away one from the front of
a woman's knee, which was as large as an orange, and every where solid,
excepting a small central point, at which there were a few cells filled
with a synovial fluid. The preparation is in the museum of University
College. The tumour was so intimately attached behind to the ligamen-
tum patellae, that some care was necessary to avoid wounding the joint.
In some of these cases, Mr. Key finds a seton capable of dispersing the
swelling.
There is a common and very painful swelling, familiarly called a bunnion,
situated on the ball of the great toe, and ordinarily supposed to arise from
a thickening of the bursa placed at the junction of the first phalanx of
the great toe with the metatarsal bone ; though from the statements of
Mr. Key, which will be presently noticed, this does not appear to be in
every instance the nature of the disease. The surrounding cenular tissue
is much indurated, and, in some cases, the bones of the joint are involved;
at all events, the disease is frequently conjoined -with a distortion of the
bones of the toe, which seem partially luxated. In consequence of the
projection of the tumour, it is greatly exposed to irritation from the
pressure of the patient's shoe, and from this cause it becomes the seat of
repeated attacks of inflammation ; indeed, few complaints are more dis-
tressing than an inflamed bunnion. We rarely find persons whose tarsal
arch is flattened, that have the great toe in a line with the foot ; and thus
332 BUNNIONS.
the inner part of the joint forms an angular projection. It is this kind of
deformity in the arch of the foot, and in the bearing of the great toe, that
predisposes to bunnion. For the prevention of this consequence, Mr. Key
adopts the following contrivance : — " The offending toe is placed in a
separate compartment of the stocking, like the finger of a glove : this
again is enclosed in a separate part of the shoe, which is contrived by
fixing a piece of firm cow-leather in the sole of the shoe, so as to form a
separate apartment for the toe. By these means, it is kept in a straight
line with the foot, or parallel to its fellows ; and the pressure against the
inner side of the joint being removed, the joint acquires a sufficient degree
of strength to enable it, in a few months, to dispense with the artificial
support." Four or five years ago, Weedon of Hart Street made for a
young lady, under my care in Bedford Place, an instrument, which ful-
filled the above objects exceedingly well. The principles of treatment
consist in the removal of pressure from the part, and, when inflammation
is present, in keeping the foot perfectly quiet, with the limb in the
horizontal posture, and in employing leeches, poultices, fomentations,
and cathartic medicines. Warm applications generally answer better
than cold ones ; but if the former fail to afford ease, the latter may be
tried.
One common plan is to cover a painful bunnion with soap plaster,
spread on thick soft leather. The application, by keeping the skin in a
pliant state, and protecting the part in some measure from the pressure
of the shoe, gives partial relief; but, as Mr. Key observes, the plan does
not reach the root of the evil. With this view, the inclination of the great
toe must be corrected by mechanical means, made on the principles
already explained.
In the dissection of a bunnion, the first effect of the pressure made
by the edge of the base of the phalanx, is found by Mr. Key to be that
of irritating the lateral ligament : if inflammation follows, it becomes
thickened and painful, forming the bunnion. If inflammation is not ex-
cited, a series of small cavities or cysts are formed, in a manner analogous
to ganglia, between the layers of the ligament. As soon as one of these
cavities is obliterated, by inflammation, another is formed ; and thus, by
their successive formation, the effects of pressure are warded off. In
some instances, the irritation extends as far as the bone, and a fungous
growth takes place from the cartilage. So long as these cysts remain in
the state here represented, but little inconvenience is experienced. The
pressure of the shoe, however, is frequently followed by paroxysms of
suffering, the part becoming the seat of inflammation, and unable to bear
the slightest pressure, either from without or from the base of the pha-
lanx, in progression ; sometimes an abscess occurs on the most prominent
point, and, as the matter is slow in discharging itself, the surgeon gene-
rally makes an opening. This proceeding is condemned by Mr. Key as
likely to be followed by an extension of the inflammation into the joint
and disease of the bone. He has known gangrene and death ensue from
opening an inflamed and suppurating bunnion ; and three or four instances
of the same results have come under my own observation. I concur
with Mr. Key, therefore, in the advice to let nature bring about the
discharge of the abscess, after which the ulcer will often heal up, and the
part lose its extreme sensibility.*
* See Mr. Aston Key's Obs. in Guy's Hospital Reports, vol. i.
833
TUMOURS.
What is a tumour ? This at first view, as Dr. Warren justly observes,
seems an easy question to answer ; but, on a little reflection, there is
some difficulty in giving the reply. The most simple idea of a tumour is,
that it is an unnatural enlargement in some part of the body. But, is
this enlargement an increase of a natural part, or a new formation ? John
Hunter's definition represents a tumour to be " a circumscribed substance,
produced by disease, and different in its nature and consistence from the
surrounding parts."
I believe it to be most convenient to limit the surgical meaning of the
word tumour to a swelling, that is strictly a new production^ an adventi-
tious growth, a substance that did not constitute any portion of the original
structure of the body.
In proceeding through the subject of diseases of the bones, I described
certain morbid formations which are comprised under the preceding de-
finition, as, for instance, exostoses, and fibrous and medullary growths from
the medullary membrane. In the account of cancer, fungus haematodes,
and melanosis, I shall have also to notice tumours, which, at least in some
of their forms, are regarded as new productions in the system, and not
merely as changes of structure, or as augmentations in the bulk of original
tissues, for they comprehend several of those formations which are deno-
minated heterologous> and which a distinguished professor of morbid
anatomy describes as consisting " in the presence of a solid or fluid sub-
stance, different from any of the solids or fluids which enter into the
healthy composition of the body." Professor Carswell's definition will
include, however, calculous and purulent deposits, which, though they are
heterologous formations, it is advantageous not to arrange under the head
of tumours. While some of the growths, which I regard as tumours, cor-
respond to the foregoing definition in not being like any of the original
tissues of the body, others bear more or less resemblance to some of its
primitive structures. Tubercle, scirrhus, and melanosis, are examples of
the first ; adipous and cartilaginous swellings, of the second. In fact, as
Andral says, with reference to such of these deposits as become organ-
ised, when once vessels are developed in the morbid product, or sangui-
neous currents are established in it, the amorphous mass begins to lose its
homogeneous nature, and to assume some definite kind of texture. The
anatomical elements may now take the arrangement of fibres, layers, coats,
or of a net-work ; and they may put on the appearance of any of the
normal structures, excepting two — the muscular and nervous.
Our profession is under many obligations to the late Mr. Abernethy,
for drawing its attention very particularly to the great difference between
tumours of the above nature, and other swellings, which are merely alter-
ations of natural structure, or sometimes only the consequence of the
accumulation of blood, pus, or other fluid in parts, and which last cases in
particular have no claim to be considered as tumours, under the'principle
of classification here suggested. This was, unquestionably, making a bold
step out of all the confusion, in which this part of the pathology of surgery
used formerly to be involved. Nobody can doubt that the distinction
here laid down is a good one, and that all swellings of original parts, to
which no new morbid tissue has been added, and which consist rather of
alterations of natural structures, or of the accumulation of pus, blood, or
other fluids in them, than of the growth of any adventitious substance,
should not be confounded with tumours, in which the latter circumstance
334? TUMOURS,
is exemplified. The swellings of arteries, termed aneurisms the knotty
enlargements of veins, called varices, and all tumours arising from accu-
mulations of blood, pus, or serum, in natural cavities and tissues, as well
as a multitude of other examples, in which the tumour or swelling does
not strictly consist of a new formation, growing upon or amongst, or added
to, the original parts and tissues of the body, should not be comprised in
the classification.
If there were not some limitation assigned to the surgical meaning of
the word tumour, every disease, whatever might be its nature, if accom-
panied by increased fulness, or enlargement of parts, would be arranged
under this head, whether an aneurism, a phlegmon, a boil, a carbuncle, an
abscess, or a dropsy. In truth, such is the miscellany,, adopted in old
works, and which should not be called an arrangement, but a chaos.
As, however, we find the new matter deposited not merely upon free
surfaces, like those of serous or mucous membranes, or within the cells of
the cellular tissue, but likewise in the molecular structure of organs, after
the manner of nutrition, it is manifest, that, when original parts become
enlarged in the latter way, the disease ought to rank as a tumour, accord-
ing to the principle of an adventitious substance being added to their
primitive tissues.
In practice, the discrimination of the different kinds of tumours from
one another is frequently a difficult task. As an excellent surgeon ob-
serves, the difficulties arise from a number of causes ; from the great
variety of these diseases, which is such that the most experienced surgeon
is often meeting with species that he has never before seen ; from the
resemblance, in external appearance, between tumours whose character is
quite different ; and from the want of an arrangement, which will enable
him to view them in groups., instead of being compelled to consider them,
as often happens, merely as individuals.*
Tumours, in general, have been divided into sarcomatous OY fleshy, osse-
ous, osteosarcomatous, and encysted ; many of the latter being familiarly
termed wens, and consisting generally of a more or less fluid or fatty sub-
stance in a globular cyst. By a sarcomatous tumour is meant one that is
chiefly or entirely composed of a fatty, fibrous, medullary, fungous, or
other substance of inferior hardness to bone, with, or without a cyst,
which, when it exists, is merely condensed cellular tissue, not globular,
like that of true encysted swelling, and of a different texture. The term
sarcomatous, or fleshy, as applied to tumours generally having no resem-
blance to flesh, is objectionable ; and perhaps its use will gradually cease,
especially now that the subject is beginning to have important additional
light thrown upon it by the meritorious labours of several pathologists
of the present day.
An encysted tumour is composed of a regular cyst, or sac, filled with
matters of very different kinds in different examples, which matters are
commonly secreted by the cyst into its cavity. The contents are not
always fluid, being sometimes of a pultaceous consistence, sometimes like
horn or bone, and, in other instances, like adipous substance. Frequently
the cysts are filled with a fluid resembling honey or white of egg; and
* Surgical Obs.'on Tumours, with Cases and Operations, by John C. Warren, M.D.,
Professor of Anatomy and Surgery in Harvard University, and Surgeon of the Massa-
chusetts General Hospital. 8vo. Lond. 1838. This work, for the present of a copy
of which I beg here to return my best thanks to Dr. Warren, is replete with valuable
cases, and practical remarks^
TUMOURS. 335
occasionally they contain melanotic matter, and even hair, or teeth.
We also frequently meet with cysts, which serve as lodgments for
hydatids.
Some sarcomatous tumours are encompassed likewise by a kind of
cyst, by a dense cellular tissue, which yields, and becomes thicker and
thicker as the tumour increases in size, and appears to form a sort of
barrier between the new morbid formation and the healthy parts, so as to
protect the latter in some degree from the extension of the diseased ac-
tion to them.
Some sarcomatous tumours have no such limit, but extend in the direc-
tion in which there is the least resistance, and soon transmit their morbid
action amongst the surrounding parts. Others have no tendency to com-
municate any diseased action to the rest of the body ; but only become
dangerous or annoying by their bulk and pressure. Some tumours grow
rapidly, and prove troublesome in a few weeks or months ; others remain
for years without much change or inconvenience. Medullary tumours
are often remarkable for the rapidity of their growth, particularly when
they meet with little resistance from the neighbouring textures. The
texture of some tumours bears more or less resemblance to that of the
neighbouring parts ; thus, fatty swellings frequently grow in situations
where they are surrounded by the natural adipous tissue. Cartilaginous
tumours are often produced within joints, where they become detached
from the articular cartilages, and a cause of pain and lameness ; and
tumours of a cellular structure internally, and covered by a mucous tissue,
frequently grow from the surface of mucous membranes. But, we are
not to consider the resemblance of the substance of a tumour to the near-
est tissues as an invariable principle ; for many swellings not only have
a different structure and appearance from those of the adjacent parts,
from whose vessels they derive their supply of blood, but from every
other healthy and natural tissue in the body ; and, as I have mentioned,
Hunter defined a tumour to consist of a substance different in its nature
and consistence from the surrounding parts.
Mr. Abernethy not only proposed the restriction of the meaning of
tumour to what is truly a new and adventitious formation, and not
simply a change or enlargement of an original tissue, but he suggested
the plan of naming every tumour according to its anatomical structure.
Thus he first applied the term medullary sarcoma to what is also called
soft cancer, fungus hcematodes, or the encephaloid tumour. That, and
some other names which he selected, may be appropriate enough, but
fault may be found with others; and his nomenclature, however inge-
nious, has the defect of not being altogether consistent. Thus, as it was
designed to be one founded upon the anatomical structure of tumours,
the term cancerous sarcoma is not admissible. I should say, also, that as
many kinds of tumours have vessels, the phrase vascular sarcoma is not
well chosen to express only one species of the disease. ^
One fact, perfectly established, is, that some kinds of sarcoma are
merely new formations, unconnected with any malignant tendency, or any
thing particularly wrong in the constitution. Thus common adipous
swellings only become troublesome by their size, weight, and pressure ;
but a scirrhus, a fungus haematodes, and, perhaps, a melanotic tumour,
though this may be doubted, are malignant diseases. Certainly each
and all of them, inclusive of melanosis, are associated with constitutional
derangement or peculiarity, the precise nature of which may not indeed
be known, but of the existence of which not a doubt can be entertained.
336 TUMOURS.
The distinction between innocent and malignant tumours, important as it
is with reference to practice, and especially with reference to the pro-
priety of operations, and the mode of performing them, is yet a subject
involved in the greatest obscurity. Tumours, which in their regular
progress destroy life, by the changes produced in the affected part, such
as ulceration, bleeding, and sloughing, or by causing similar productions
in other parts of the body, more particularly in important internal organs,
or by both together, are considered to be malignant ; and the occurrence
of serious local and general symptoms, the development of new growths
in other parts, and such constitutional suffering as leads to the suspicion
that organs of consequence are involved in the affection, are generally
set down as decided proofs of malignant character, and as insuperable
objections to an operation. Yet, much caution is required in giving an
opinion'on the malignancy of some tumours. The tuberculated sarcoma, as
it was called by Mr. Abernethy, is represented by him as a very malig-
nant disease ; yet, in one example of it, recorded by Mr. Lawrence,
where the original tumour had a most threatening aspect, where several
similar tumours presented themselves in other parts, and where the
patient had been brought to the brink of the grave by constitutional
disturbance, life was prolonged for many years by amputation.
Some of the new formations or deposits, constituting tumours, are
organised and vascular ; others are completely free from organisation,
and are furnished with neither vessels nor nerves. They seem to be
merely morbid products from the blood, only deposits produced in the
manner of secretion, and frequently from a serous surface.
With respect to the origin of vascular tumours, we have little inform-
ation that can be supported by demonstration, or even by arguments
unexposed to disputation. It is a subject that was lately considered by
Mr. Lawrence, in a paper read to the Medical and Chirurgical Society,
in which he inquires into the mode wherein tumours originate and
increase, and adverts to the three explanations usually offered of the
phenomena : — 1- By the effusion of blood, and its coagulation, and the
subsequent organisation of the coagulum. 2. By the effusion and organ-
isation of coagulating lymph. 3. By chronic inflammation. Now, if
these explanations were true, we should expect, with Mr. Lawrence, that
tumours ought to pass through successive stages, and to present different
appearances at different periods of their development. For instance, we
ought to find them at first as masses of coagulated blood, or coagulating
lymph, and then to observe various degrees of transition from those sub-
stances to the textures, which characterise the perfect growth. Ob-
servations, however, disclose nothing of this kind : tumours, in their
earliest state and smallest size, have their peculiar structure as well
marked as in their subsequent progress and full development. An
adipous tumour, not exceeding the bulk of a pea, differs only in size from
one as large as the head. Effusions of blood into the cellular texture, from
external violence, are of daily occurrence ; if they could become organised,
and then form tumours, few persons would be without these productions,
which would also be, from the first, as large as the extravasation. We
see, however, that blood thus poured out, disappears by absorption, or
irritates the surrounding parts, and causes suppuration, by which it is
expelled.
The hypothesis of the formation of tumours by the effusion and
organisation of blood, seems, indeed, to have little foundation ; and, I
think, we must agree with Mr. Lawrence, that no satisfactory proof exists
TUMOURS. 337
of blood becoming organised, when effused in wounds, bruises, or serous
cavities, or aneurismal sacs.
The preparations in the College of Surgeons, put up by John Hunter
himself to prove the extension of vessels into coagulated blood, are con-
sidered by many good judges as insufficient for that purpose ; because
coagulated blood, when effused, soon becomes surrounded by fibrine or
coagulating lymph, into which vessels may shoot from those of the sur-
face, out of which such fibrine has been effused. Thus, the coagulum
and fibrine being blended together, the former may give a deceptive look
of being itself vascular and organised.
The interstitial effusion of coagulating lymph in inflammation, is a
thing noticed every day ; the substance thus poured out is not formed
into tumours, but is absorbed as the inflammation subsides, or its partial
organisation causes the enlargement, or condensation, of the affected
structure. Then none of the phenomena characteristic of inflammation
commonly precede the formation of tumours, which arise insensibly, and
often attain some size before the patient is aware of their existence.
Besides, as is well observed by Mr. Lawrence, if the accounts given of
the origin and growth of tumours were correct, the attempts to check
their production by leeches, cold applications, and antiphlogistic treat-
ment, would generally have more effect than we find to be the case.
Such treatment has no influence over accidental productions, though
sometimes employed with advantage in lessening swellings caused by
changes of structure.
From all that is at present known respecting morbid growths in the
animal body, it seems to me, that they generally commence at a point as
it were, and that directly the nucleus of them has been produced, how-
ever small, they have a power of attaining afterwards a magnitude, only
limited by their particular nature and character. The vessels, which
first extended into their substance, or their cysts from the original
vessels of the neighbouring parts, continue to deposit or secrete additional
matter, and, as the tumour enlarges, the vessels also enlarge, and shoot
into it wherever an increased quantity of an organised substance is about
to form. How this process begins, however, and from what cause it
originates, we do not know.
The best pathologists are then in a state of ignorance, respecting the
circumstances which determine the production of tumours in general, or
of any particular variety of them. No more is known about these aber-
rations of nutrition, than of the mode in which this function is accom-
plished in its natural or normal state. In order to arrive at as correct a
diagnosis as practicable, we should follow Dr. Warren's advice, and begin
with acquiring the history of the origin and progress of a tumour, its
influence on the part where it is situated, and on the whole system. Then
the figure of the tumour should be well considered. Certain species of
tumour assume particular forms : the steatoma, for example, is com-
monly rounded, and encysted tumours always have this fornj. Bony
tumours, and those of the complicated glands, are often irregular ; and
so is a medullary tumour, after it has attained a certain size. The con-
nexions of a tumour — its extent — its moveable or fixed character, are all
important points to be attended to ; and, as Dr. Warren observes, the
extent of the part, beyond the reach of the senses of touch and vision,
may implicate the most important structures and cause the greatest
embarrassment. The consistence is another source of information ; for
it often apprises us of a tumour being malignant, either a schirrus, or a
z
338 TUMOURS.
medullary disease, or some other kind. The colour in certain tumours
conveys also information. The purple colour of tumours, composed of a
substance compared to erectile tissue, is universally known. The darkish
red colour assumed by medullary tumours, or fungus haematodes, in an
advanced stage, is well known to every surgeon ; and so is the brownish
red discolouration of the integuments often covering a scirrhous tumour.
Sometimes, however, a tumour quite free from malignancy, presents a red
or purplish appearance from an accidental inflammation of the skin that
covers it.
Pulsation, vibration, and undulation are other characters, affording valu-
able instruction.* The first two indicate that the tumour is either
affected by the pulsation of a contiguous artery, or that it is an aneurism,
or else a tumour consisting of vascular erectile tissue, or of the nature of
certain swellings spoken of in the remarks on "Diseases of Bones."
Undulation informs us, of course, that the tumour contains at all
events a quantity of fluid, though the rest of it may be more or less
solid.
Adipous sarcoma, or the fatty tumour, is the most common of all
these new formations. In its appearance and structure, it has a near
resemblance to the subcutaneous fat, but is of a somewhat deeper yellow
colour, less granular, and more compact. It is always covered by a
thin capsule, formed by the simple condensation of the surrounding
cellular tissue, and having a close attachment to the mass itself, by means
of small vessels; though, unless the swelling has been Inflamed, the
connexion to external parts is but slight. It is in consequence of these
circumstances, that adipous tumours admit of removal with considerable
facility, and, after a sufficient division of the skin, and other textures
covering them, the diseased mass may be readily detached from the
surrounding parts, sometimes with the fingers, and always without any
troublesome dissection.
We frequently observe these fatty growths in persons, in whose
constitutions no particular defect can be discovered ; and sometimes
they occur, not merely in one situation, but in several, though the
individual may be in other respects perfectly healthy. They are gene-
rally attended with little or no uneasiness, and are characterised by a
soft doughy feel, or one as if they were filled with wool. They have less
disposition than many other tumours to become dangerous by changing
into any malignant form of disease ; and whatever pain and incon-
venience they may produce, are the result of their weight, pressure, and
magnitude ; for adipous sarcoma is generally inclined to grow to a larger
size, than any other solid kind of tumour met with in the human body.
I have seen one or two examples which weighed nearly fifty pounds, and
larger ones are upon record. In some persons, they are caused by pres-
sure. I have removed several from the upper part of the deltoid muscle
in females, occasioned by the pressure of their dress ; a case also noticed
by Professor Warren.
They are sometimes the seat of uneasy sensations, and they occasion-
ally interfere more or less with the free action of the neighbouring
muscles ; but, they are rarely the nidus of any scirrhous or medullary
deposit ; one or two such occurrences are alluded to by Sir Benjamin
Brodie : they are exceedingly uncommon.
Now, when it is recollected, that the operation for the removal of an
* See Warren on Tumours, p. 9.
TUMOURS. 339
adipous swelling of immense size may prove fatal from the unavoidable
extent of the wound ; when we also remember, that we have no means
of dispersing a fatty swelling, which,' if left to itself, is sure to acquire
considerable magnitude ; arid that when of immoderate size it is apt to
become closely adherent to fasciaB, and even to the capsular ligaments of
important joints, so as to render its complete removal difficult, — we must
see the prudence of always taking away an adipous sarcoma, while it is
small and but loosely attached to the surrounding parts. An adipous
swelling does not, like a malignant tumour, require the free removal of
the adjacent textures.
Pancreatic sarcoma, so named by Mr. Abernethy, from a degree of re-
semblance in its structure to that of the pancreas, is rather an uncommon
disease, and scarcely any unequivocal specimen of it has been preserved
in the museums of the metropolis. One was exhibited a few winters ago
to the Medical and Chirurgical Society, as a rarity, and even that was
considered by some gentlemen present as having much the appearance
of ordinary scirrhus. Mr. Abernethy represents pancreatic sarcoma as
occurring sometimes near the nipple, and sometimes in the lymphatic
glands on the mylo-hyoideus muscle, and as an irritable and excessively
painful affection.
It has also been met with close to the parotid gland, or under the jaw
close to the sub-maxillary gland. Pancreatic sarcoma is loosely connected
with the surrounding parts, and therefore very moveable ; a character in
which it is said to differ from scirrhus, though we know that scirrhus, in
its early stage, is frequently as moveable as any other kind of swelling.
In some cases, recorded by Mr. Lawrence, the disease was free from pain
and malignancy, and effectually cured by operation. The pancreatic
sarcoma, which Professor Carswell arranges in his Illustrations of the
Elementary Forms of Disease as a species of cancer, does not at all cor-
respond to the disease noticed by Mr. Lawrence ; and, as a foundation
for classing the disease with cancer, he refers to its disposition to termi-
nate in the gradual destruction, or transformation of the tissues affected,
its tendency to affect several organs in the same individual, and its repro-
ductive character.
Another species of sarcoma, described by Mr. Abernethy, is the mam-
mary, from the likeness of its structure to that of the mammary gland.
It appears to be malignant, communicating to the surrounding parts a
disposition to disease, and requiring the same free removal of them in an
operation, as a scirrhus, of which I suspect that it is only a modification.
In corroboration of this opinion, I may observe, that Professor Carswell,
in his invaluable Illustrations of the Elementary Forms of Disease, actu-
ally arranges mammary sarcoma as a species of cancer.
The tuberculated sarcoma, consisting of numerous firm globular swell-
ings of various sizes and colours, connected together by cellular tissue,
advances to ulceration, is a malignant disease, and ultimately proves
fatal. It is questionable, I think, whether this form of sarcom^fis essen-
tially different from scirrhus, which, we know, has its varieties.
A species of sarcoma, with which surgeons have long been familiar, is
described under the name of cellular tumour, consisting of a fleshy mass,
elastic, and almost fluctuating to the touch ; tough, fibrous, and chiefly
composed of condensed cellular tissue free from fat, the fluid in the cells
being like that of the common cellular membrane.
"Between the cellular tumour and the enormous swelling, in which the
z 2 <
340 TUMOURS.
male organs of generation are sometimes involved, Mr. Lawrence con-
ceives that there is this distinction, — the former is a new production, the
latter merely an enlargement of the cellular and cutaneous tissues by
interstitial deposit, and curable by extirpation.
1\\z fibro-cartilaginous tumour is another variety of sarcoma, not un-
frequently met with about the head, neck, and axilla ; and sometimes
near the mammary or parotid gland. It differs from scirrhus in having
nothing malignant in its nature ; the only inconvenience is what results
from its pressure and size.
I removed a fibro-cartilaginous swelling from the occiput of a black-
smith at Halliford, which had been stationary and free from pain for many
years, but at length began to enlarge and cause severe annoyance. It
was as large as an orange; and the patient was induced to have it re-
moved, in consequence of his suspicion that a difficulty of swallowing,
which he laboured under,, was dependent upon it. The latter affection
ultimately proved fatal, and, on opening him, a stricture of the oesophagus
was found, with two considerable sacs extending from the tube above the
obstruction, in one of which were two orange pips.
The painful subcutaneous tumour or tubercle, although of small size, and
free from malignant action, is attended with most excruciating pain, and
generally situated in the subcutaneous cellular tissue, but sometimes in
that which is between muscles. One tumour of this kind, removed by
Mr. Liston, lay so deeply, that it was in contact with the posterior tibial
nerve. The tumour is usually of the size of a pea, and seldom larger
than a cherry. Ordinarily, it does not cause any external tumour, or any
rising of the skin, unless situated on a superficial bone ; the skin is loose
and moveable over it, and its structure is almost like cartilage. The
reason of its causing the extraordinary degree of pain by which it is
characterised, has been ascribed by some pathologists, amongst whom is
the celebrated Camper, to its connexion with the twigs of the subcuta-
neous nerves. One preparation in Mr. Listen's collection clearly exhibits
such an arrangement, which, however, is contrary to what Sir Astley
Cooper and Baron Dupuytren have noticed in their dissections.
Camper's opinion that the tumour depends upon a diseased enlarge-
ment of a portion of a subcutaneous nerve, is that to which Mr. Wood him-
self inclines, though he thinks it very desirable that additional minute
and accurate examinations of the tubercles and surrounding parts should
be made, with the view of ascertaining, if possible, whether the diseased
alteration of structure takes place on the neurilema or within it, or
whether it may have originated in the contiguous textures, and become
afterwards connected with the nerve. In those painful tubercles which
he had an opportunity of examining, he found only a firm, whitish, homo-
geneous body, of a fibro-cartilaginous appearance, without being able to
say whether it was included between the nervous fibrils or not, or whether
it was even positively connected with them.
The pain comes on periodically, and shoots extensively through the
limb. The slightest pressure causes the most excruciating torment; and
such is the agony sometimes excited by the action of the muscles, that the
use of the limb is entirely lost. The disease is more common in the
limbs, particularly the lower one's, than other parts. I have never seen
an instance, in which a painful subcutaneous tubercle suppurated ; but,
according to Dr. Warren, it may, after a time, inflame, the skin over it
ulcerate, and a foul acrid discharge take place. Then, the lymphatic
glands between it and the trunk become swollen, constitutional disturb-
TUMOURS. 34-1
ance ensues, and the disease may prove fatal.* There is only one right
and effectual treatment, namely, excision.
Ncevi, and tumours termed aneurisms by anastomosis. Certain natural
textures in the body are, in the ordinary state, flaccid, but admit of
being rendered turgid and firm at particular periods, when injected
with blood. This kind of structure is exemplified in the penis, clitoris,
and nipple ; and by anatomists it is termed the erectile tissue. Baron
Dupuytren compares the tumours, which usually go under the name of
ncevi, to a morbid erectile tissue ; and, so far as I can judge, there is a
sufficient resemblance between the natural tissues of this kind, and the
structure of nsevi, to justify the comparison.
Under the head of morbid erectile tissues may be arranged,
1. The superficial naevus,
2. The subcutaneous naevus, and aneurism by anastomosis.
Superficial ncevi, or ncevi materni, as they are called, signifying those
congenital tumours, spots, or imperfections and peculiarities in the ap-
pearance and texture of parts of the skin, which are vulgarly supposed to
arise from some influence of the mother's mind upon the foetus, as when
during her pregnancy she longs for various delicacies and fruits, which she
is not able to procure, or, at all events, which she cannot obtain so quickly
as she desires ; or when, perhaps, during her pregnancy, she is terribly
frightened at the sight of a spider, mouse, or some other animal. Under
these circumstances, whatever cutaneous mark the infant is born with, is
imputed to such disaster. As a proof of the truth of the connexion of
naavi with such longings or frights, a strong resemblance is often fancied
between these maternal spots and the objects of desire or alarm. Thus
some nsevi with a granular surface are compared to strawberries, mul-
berries, or raspberries, and are supposed to become particularly red and
conspicuous when those fruits are in season. Others have a reticulated
appearance, produced by the ramifications of minute vessels on their sur-
face, and being thought to resemble a cobweb, are named spiders ncevi;
then other congenital blemishes of the skin, on account of their peculiar
red colour, are called claret marks. Another form of nsevus is familiarly
known, receiving the name of a mole, in consequence of its brown colour,
and the long hairs growing upon it. Objects of this kind always present
an opportunity for a flight of the imagination, and for the invention of
comparisons and names.
These superficial nsevi frequently continue stationary during life, and
neither increase in size, nor cause any inconvenience ; but sometimes, in
consequence of their happening to be situated on the face or neck, they
cause considerable disfigurement, and, with the view of removing or
lessening it, the excision or removal of the blemish with caustic, or vaccine
lymph, may be undertaken, if desired.
Examples do occur, however, in which these maternal spots assume,
after birth, a disposition to grow, and even to acquire considerable size.
In this circumstance it is prudent to recommend their extirrlltion with
the knife, the nitrate of silver, ligature, or caustic potash, according to
circumstances. Very superficial ones are easily cured with nitrate of
silver and pressure ; or by inserting vaccine lymph in them, or touching
them with nitric acid or a strong solution of nitrate of silver, or rubbing
them with this substance.
Of subcutaneous ncevi, and aneurism by anastomosis. With respect to
* See Warren on Tumours, p. 60.
z 3
34*2 TUMOURS.
these tumours, probably they differ from the more superficial kinds of
cutaneous naevi in being new formations, and not merely changes of struc-
ture. Between aneurisms by anastomosis and subcutaneous naevi, I can
discern no essential difference. Their nature and texture are alike ; and,
though the subcutaneous naevus communicates no pulsatory feel, while
the aneurism by anastomosis does,, this is to be referred to the latter often
forming an external tumour; a projection above the level of the skin —
while the subcutaneous naevus is more flat and concealed. As for the
proposed distinction, between aneurism b}'- anastomosis and neevus,
founded upon the supposition, that the former disease consists of an en-
largement and growth of the small arteries, and the latter of similar
changes in the venous capillaries, it must be abandoned ; first, because
there is no proof of the alleged circumstances, and secondly, because the
blood, which gushes so profusely from naevi, when they are wounded,, is
of a bright scarlet colour, and manifestly arterial. The aneurism by
anastomosis, which is more or less raised above the level of the skin, is in
fact a morbid growth — a new production. Its colour is generally bluish,
or livid, and, on careful examination, a pulsatory motion, corresponding
to the action of the heart, or, at all events, a vibration, may be felt in it.
Sometimes, the skin retains its natural colour. I once made an explor-
atory puncture in a tumour of this kind on a child's back at Sunbury,
the integuments being quite free from discolouration, and no vibratory
feel being perceptible until the child felt the pain of the incision : the
rapid bleeding immediately apprised me of the nature of the disease, and
I immediately closed the wound, which healed by the first intention.
When compressed, it becomes smaller; but any thing, that quickens
the circulation, always makes it more prominent and turgid. Frequently
it is a congenital disease, being small and hardly perceptible at the time
of birth, and remaining stationary until puberty, when it may begin to
enlarge with rapidity. It has been known to follow external violence,
and Professor Warren relates one case, where the disease followed a cut,
which had been caused by the blow of a stone on the right side of the
occipital region. After it has acquired a certain size, it sometimes bursts,
and bleeds dangerously. In females, the discharge of blood is most dis-
posed to happen at the menstrual periods, and even to supply the place of
the uterine evacuation.
The parts of the body, in which the disease, improperly named aneu-
rism by anastomosis, is most frequently seen, are the scalp, face, upper
part of the trunk, and sometimes the hands and feet.
John Bell has described it as a tumour, consisting of a congeries of
active vessels, and he states, that the cellular tissue, through which these
vessels are distributed, resembles the cellular structure of the penis, the
gills of a turkey-cock, or the substance of the placenta, spleen, or womb.
In short, his comparison is nearly the same as that made by Dupuytren,
namely, to the erectile tissues. The aneurism by anastomosis, and the
larger subcutaneous naevi, are occasionally represented as containing cells,
which are filled with blood, and have a direct communication with the
blood-vessels. This is yet an unsettled point ; for what appears to some
persons to be cells, is thought by others to be the orifices of blood-vessels,
who, of course, regard the disease as an aggregation of such vessels, rami-
fying and combining into a tumour. At all events, it is an adventitious
growth, — a new formation — full of vessels — abounding in blood — and,
when cut, exhibiting such a disposition to bleed profusely and ungovern-
ably, as is perhaps not seen in an equal degree in any other disease that
TUMOURS. 343
can be specified. The erectile tumour, or structure, is sometimes blended
with medullary or scirrhous cancer.
Whatever plan of treatment be selected for subcutaneous naevi and
aneurism by anastomosis, should be regulated by the principle of not en-
dangering life by hemorrhage.
Supposing therefore it is decided to perform the excision of a naevus,
we ought to adhere to the rule laid down by Mr. John Bell, " not to cut
into the tumour but to cut it out." If we were to cut into the disease, we
should sometimes have so profuse a bleeding, that the patient would die
under our hands. The blood might gush out in such a torrent, as would
destroy a child in two or three minutes. Besides, as it is absolutely ne-
cessary to cut the whole of the diseased texture away, without leaving
any part of it behind, we should gain no advantage by opening the swell-
ing. The whole must be taken away, or what is left will continue to
grow. Hence it is a rule in practice, to make the incisions for the
removal of a nsevus in the surrounding healthy parts, at some little dis-
tance from the circumference of the disease, and then to cut deeply under
its base. But, when a neevus is large, excision, even performed with these
precautions, is not free from danger, on the score of hemorrhage. Several
cases are recorded, in which the operation led to so sudden and profuse a
gush of blood, that life was extinct in a few minutes. Such an accident
happened in Mr. Wardrop's practice, who with his usual candour has
recorded the fact himself. The patient was a child, and the nasvus large.
On examination, a vessel equal in diameter to a quill, was found to have
been divided. Indeed we may form some conception of the disposition
to hemorrhage attending this disease, when I state, that I have seen
Mr. Lawrence, with the view of curing a growing nsevus on one of the
fingers, divide every part of the finger, except the periosteum and bone,
and yet the vessels on the distal side of the cut bled most profusely; and
this notwithstanding the radial and ulnar arteries had both been previously
tied by my friend Mr. Hodgson.
Instead of the knife, therefore, other means of curing naevi have been
suggested. One of these consists in passing two double ligatures through
the centre of the base of the swelling, at right angles with one another,
and tying the part by quarters, as it were, so as to include the whole base
in the eight threads. For the purpose of making the action of the liga-
tures extend more widely, so as to embrace tumours having a broad base,
long pins are sometimes passed under the swelling, and the ligatures
then twisted round their ends, as originally practised, I believe, by my
friend Mr. Keate. Sometimes, with the view of lessening the disfigure-
ment, and rendering the action of the ligatures more effectual, Mr. Liston
first raises the skin from the surface of the swelling, in order to preserve
it, and then applies the long pins and ligatures.
Another plan consists in taking up the principal artery, or arteries
leading to the disease. This plan sometimes answers; but more fre-
quently it produces only partial, or temporary relief. The Jigafbre of the
carotid for aneurism by anastomosis situated in the orbit, or other parts
of the face and head, answered completely in the practice of Travers,
Dalrymple, and Warren : in that of Dupuytren, it did not cure the disease,
though it put a stop to its increase.
A fourth plan consists in destroying the tumour with caustic potassa.
And a fifth is founded on the principle of producing a total change in
the texture of the swelling by exciting inflammation in it with pressure,
z 4
344 TUMOURS.
caustic, or stimulating applications, or by the introduction of a small
quantity of the nitrate of silver solution into the morbid tissue. Vacci-
nation is useful for superficial naevi on the same principle. Breaking up
their texture with a fine couching needle, or exciting the adhesive inflam-
mation in it by transfixion with pins, has also been done with success.
Professor Gibson mentions an example of spontaneous cure, brought on
by an accidental inflammation consequent to fever.
Polypi constitute another class of tumours, growing from mucous
membranes, or, if not growing from them, at all events covered by them.
In this place it is only necessary to notice their general characters, and
the principles of treatment. They are of two kinds, viz. the soft gelatinous
polypus, and thefashy, or fibrous polypus. As for what are termed ma-
lignant polypi, they should not be regarded as polypi at all, because they
partake in reality of the nature of medullary cancer, and sometimes,
perhaps, of scirrhous cancer.
The ordinary soft polypus, such as most frequently grows from the
mucous membrane of the nose, is of a light yellowish, or grey colour,
not disposed to bleed profusely when injured, and not very sensible. It
has no tendency to become malignant, and whatever inconvenience
attends it, arises from its pressure and size. It generally has a narrow
neck, and often a pyriform shape, though when the swelling is large, its
figure is chiefly determined by that of the cavity in which it grows.
Fleshy polypi, which are firmer than the preceding, and of a fibrous
structure, more commonly grow under the lining of or in the substance of
the uterus, than from the mucous membrane of the nose.
The treatment of soft and fleshy polypi consists in extracting them
with forceps, as is usually done for those of the nose ; or by tying their
neck with a ligature, or dividing it with scissors, as is more frequently
practised for those which grow from the uterus. Malignant polypi admit
of no operation.
Warts are excrescences growing from the cutis, and sometimes covered
by the cuticle. They usually assume an expanded shape, or radiate from
their basis to their surface, which in general has a granular appearance.
After they have risen above the level of the skin, their base often remains
stationary, but the higher part of them continues to expand, and to become
rougher and rougher. Their substance is compact and firm, and some-
times very sensible, and disposed to bleed freely when cut. In this respect,
however, warts are not always alike, some appearing to be unorganised,
and insensible.
When much stimulated, they generally become smaller, and disappear
or drop off. For this purpose, the most eligible applications are, nitrate
of silver, acetic acid, tinct. ferri sesquichloridi, or a powder composed of
subacetate of copper and savine in equal parts. When the neck of the
wart is narrow, the best practice is to divide it.
The thin integuments, situated near the anus, often produce excres-
cences, which are of an intermediate nature between polypi and warts.
They are of all sizes from that of a pea to that of an egg, or orange.
In consistence and vascularity, they hold a middle space between warts
and polypi. When small, they may be cured by local stimulants ; when
large, the most expeditious plan is to remove them with a knife.
Encysted tumours, or wens, are composed of cysts, whose texture,
thickness, and contents, are subject to a great deal of variety. The cysts
themselves are organised ; but their contents unorganised. They are
generally of a globular form, and unattended with pain. They are divided
ENCYSTED TUMOURS, OR WENS. 345
into three principal kinds, named according to the nature of the sub-
stance with which the cysts are filled. When it is fluid, and more or less
like honey, the tumour receives the name of meliceris ; when it is of a
pappy or pultaceous consistence, the tumour is called atheroma ; and
when the contents are fatty, sfeatoma. Atheromatous swellings on the
head and back of the trunk, usually have thick dense cysts ; while the
cysts of similar tumours on the face are generally thin. Sometimes the
cysts are ossified. In ordinary cases, the cyst has only one cavity ; but,
occasionally, there are partitions in it, dividing its interior into separate
cells of various sizes. The internal surface of the cyst is mostly smooth,
presenting an appearance somewhat like that of fine cuticle. In some
instances, the cyst is loosely connected to the surrounding parts ; in
others, it is firmly attached to them, and immoveable. Certain descrip-
tions of encysted tumours attain a considerable, I may say an enormous,
size; but common ones, known by the name of wens, are from the size of
a pea to that of a walnut or orange. Those which contain fat, sometimes
become as large as a cocoa nut ; but the swellings,, known under the appel-
lation of liydatid cysts, and ovarial cysts, are frequently of enormous mag-
nitude.
The terms meliceris, atheroma, and steatoma, as expressive of three kinds
of encysted tumour, are then by no means sufficient to convey an idea
of the nature of many encysted swellings. The cyst may secrete
matters of very different consistence and appearance : thus, some are
filled with a thin fetid brown fluid, mixed with flakes of the fibrinous
part of the blood ; some contain a serous fluid ; some a matter of gelati-
nous consistence; some, a calcareous matter; some, a melanotic liquid;
and others, hair, teeth, hydatids, or various depositions of more or less
firm substances disposed in concentric layers.
The greater number of common encysted tumours are situated im-
mediately under the skin ; but there are few textures, parts, or situations,
in which they may not be produced.
It appears from the investigations of Sir Astley Cooper, that, in the
early stage of a common wen, a dark-coloured spot may often be seen on
the skin in the centre of the tumour, and such spot, he says, is caused by
the obstruction of the orifice of one of the sebaceous glands of the skin.
He therefore adopts the opinion, which is now universally admitted to be
correct, that some encysted tumours are only enlargements of the cuta-
neous follicles, in consequence of such obstruction of their orifices. Of
course, this explanation would not apply to many cysts in deep situations,
and which are unquestionably parts deserving to be considered altogether
as adventitious growths.
Children are sometimes born with encysted tumours. When formed
near the eyebrow, they generally adhere to the bone, and are covered
by the orbicularis palpebrarum, or occipito-frontalis muscle.
In some persons a remarkable disposition to encysted swellings is ob-
served, and this in such a degree, that more than twenty have be^n noticed
in different parts of the body. One of the most remarkable instances
of this kind was a woman, who presented herself, about four years ago, at
University Hospital, with seventy or eighty encysted tumours on different
parts of her body. As some of them obstructed the meatus auditorius,
they rendered her deaf in one ear. The largest of them did not exceed
a walnut in size, and most of them were not larger than peas. She had
had forty or fifty extirpated before she came to the hospital, but they
continued to grow in such numbers, that she would not submit to any
34*6 TUMOURS.
further attempts to free her from them. I was informed that, at the
menstrual periods, these tumours always became more prominent and
turgid, and rather painful ; a character more usually exemplified in nsevi,
than wens.
Perhaps the common species of encysted tumours are more frequently
formed on the head than in any other situation, and, when they occur
here in adult subjects, they are mostly of the atheromatous kind. In
children, atheroma is also very common on the face. Many encysted
tumours about the eyelids are likewise atheromatous.
In encysted tumours of the steatomatous sort, hair is sometimes blended
with the fatty matter, and it differs from the hair naturally growing on the
surface of the body in having no canal nor bulb.
Some cysts not only have the power of forming hair, but of producing
a horny substance. This sometimes happens when the swelling ulcerates,
so as to let out its contents, and expose the interior of the cyst to the air.
Then the cavity becomes dry, and a substance of a cuticular or horny
quality, continuing to be secreted, gradually protrudes. One in the
British Museum is remarkable for its resemblance to a ram's horn. A
few years ago, I removed a horn of this nature from the nates of an
elderly medical gentleman in my neighbourhood. Occasionally cysts are
met with containing teeth. One instance of this kind fell under the
notice of Mr. Barnes of Exeter.
Those smallj cutaneous encysted tumours, which have a black point
on their centre, will sometimes allow the obstructed aperture to be
cleared and their contents pressed out ; and in this manner, they may be
kept stationary and free from inconvenience for a long time.
Encysted tumours are seldom dispersed, though this event occasionally
happens, in consequence of changes brought about in them by accidental
blows, or by inflammation excited in their cysts. On this principle, they
are sometimes, but not often, cured by the application of local stimulants,
as a solution of common salt, or lotions, containing the muriate of am-
monia.
The plan of puncturing common encysted tumours, squeezing out
their contents, and applying stimulants or caustic to their cysts, not only
frequently fails to produce a perfect cure, but is attended with some risk
of giving rise to the formation of fungous growths, which are ten times
worse than the original disease.
Sometimes encysted tumours occur in parts, from which they cannot
be wholly removed,, and then, if the cyst be thin, a puncture may lead to
a cure. In this way, encysted tumours, placed deeply in the orbit, are
sometimes cured. An encysted tumour will sometimes inflame, and the
most superficial part of it having given way by ulceration or sloughing,
the contents escape, and the cyst itself sloughs away, leaving an ulcer
which heals, and a cure is the result. I have more than once been called
to atheromatous swellings, the skin over which was inflamed, and per-
forated by a small ulcerated opening, within which the white sour-smell-
ing pappy matter could be discerned. Instead of practising excision, I
have sometimes merely pressed out the atheromatous substance, and
applied a small poultice, after which the cyst has gradually been separated
in fragments, and the cure accomplished. Not long ago, I attended a
lady with Sir Astley Cooper, and the swelling being severely inflamed,
an incision was made, and the contents of the tumour pressed out: the
cyst afterwards followed, and the part healed in a few days.
There are two methods of removing common encysted tumours : one
SCIRRHUS AND CANCER. 34?7
is to divide the skin and fat over the cyst, and having separated the latter
from the surrounding textures, it is to be seized with a small hook, and
dissected out entire. In some situations, the dissection may be completed
without the hook, which, if the contents of the cyst be very fluid, lets
them partially escape, so that cyst collapses, and is less easily taken
out perfect. The other method is to cut the cyst at once into two halves,
and then to extract each half of it separately, as practised by Sir Astley
Cooper. No part of the cyst must be left behind. If not removed, the
patient may continue to be annoyed with a discharge of matter from a
fistulous opening, or a painful troublesome fungus may arise, requiring
another more painful operation than the first to be cured.
Congenital cysts near the eyebrow adhere closely to the bone, and re-
quire a free incision, so that every portion of them may be taken out.
SCIRRHUS AND CANCER.
THE specific and malignant disease, known by the name of cancer, may
begin either as a molecular deposit in the tissue affected, from a derange-
ment of its nutrition, or as a deposit of the cancerous substance upon what
Professor Carswell terms a free surface; as, for instance, that of a serous
membrane : here it is, then, in the form of a secreted matter. It gene-
rally has two stages, namely, that of induration, or scirrhus, as it is termed,
the first shape in which the disease usually presents itself; and that of
ulceration, which is a later condition of it.
The disease, in the stage of scirrhus, is sometimes denominated occult
cancer ; and, in the ulcerated stage, open cancer, or carcinoma. I think,
that when the latter word is employed, the generality of surgeons now
signify more particularly the ulcerated form of the disease. There is no
uniform custom, however, about this point ; and sometimes carcinoma is
only synonymous with cancer.
In Professor Carswell's Elementary Forms of Disease, Fasciculi 2.
and 3., the term carcinoma includes cancer and medullary sarcoma, as
two species, under the names of scirrhoma and cephaloma, each of which
presents varieties, determined chiefly by the relative quantity of the
morbid deposit, the manner of its distribution, and the difference in its
colour and consistence.
Scirrhus, at its commencement, occupies a minute and limited space ;
thus it maybe confined to one of the acini of the liver, as Professor Cars-
well has ascertained. In the breast, it is commonly of a globular form,
and irregular and craggy, as it were, on its surface. It afterwards enlarges,
though rarely in the degree or with the quickness exemplified in many
tumours of a different nature ; it also continues to be moveable for a
certain time, but has a tendency to become fixed by attachments to the
neighbouring textures, at an earlier period, than what is observed with
respect to most other swellings.
Scirrhus is likewise remarkable for its excessive firmness, its cartila-
ginous, or, as it is sometimes expressed, its stony hardness. The sub-
stance of it, however, is not one uniform, homogeneous mass, but it is
intersected by septa, or bands, the interstices of which are filled with a
yellow, grey, or light blue semi-transparent inorganic substance. These
bands, or septa, often diverge, as they proceed from the centre of the
disease, sometimes radiating, as pathologists are fond of expressing them-
348 SCIRRHUS AND CANCER.
selves, a considerable way into the surrounding textures, so as to extend
the same morbid action to them. The septa, now described, have a tough
consistence, and are very much like a ligamentous tissue.
When a section is made of a scirrhus, a central point, or nucleus, may
be observed, from which these dense ligamentous bands proceed towards
the circumference. Sometimes the larger bands subdivide into smaller
ones, which follow a course similar to that of their trunk, and ramify very
regularly, or the bands may pursue from the first an irregular and intricate
course, often uniting with and crossing one another, so as truly to present,
when minutely inspected, a retiform appearance.
Frequently the greyish or bluish matter, interposed between the firm
tough septa, appears broken down or removed, its place being occupied
by a glairy or a turbid fluid, by a very soft, pulpy, semi-liquid substance,
or blood itself.*
It was a remark first made by Laennec, that scirrhus and medullary
sarcoma (la matiere cerebriform) as well as other adventitious productions,
which have nothing analogous to them in the tissues of the animal body,
present in their progress two different states ; the first named by him the
state of crudity ; the second, that of softening. This view does not, how-
ever, appear to be correct ; for, according to Dr. Carswell's researches,
the degree of consistence of cancerous formations is not an invariable
character of a particular stage of their development ; for they may, when
first perceivable, be as hard as cartilage, soft as brain, or fluid as cream ;
or they may become soft or fluid, after having remained for a greater or
less time in a state of hardness.
Scirrhous cancer most commonly begins in glandular or secreting or-
gans,— as the female breast, the skin, the mucous tissues, the tongue,
the cardiac and pyloric portions of the stomach, the cervix uteri, the
rectum, the lips, especially the lower one, and the glans penis. The
testicle and ovaries are also liable to cancerous disease. The parts which
I have specified, are some of the principal ones on which cancerous disease
makes its primary attack; but many other textures and organs may be-
come the seat of it secondarily; as, for instance, the lymphatic glands,
the lungs, the liver, and even the bones. It is not to be supposed,
however, that lymphatic glands are not sometimes the primary seat of
cancer. In fact, sometimes the scirrhous cancer, and in other instances
the fungoid or medullary cancer, commences in them.f Mr. II. W. Smith,
in some interesting remarks, annexed to a case of this description, ex-
presses his belief, that when carcinoma begins in the axillary glands, and
the breast is only affected secondarily, the cases are more rapid in their
progress, and more fatal in their termination, than those in which the
disease of the lymphatic glands follows that of the breast. In persons,
who have long suffered from carcinoma, portions of the natural structure
of their bones are frequently absorbed, and a scirrhous substance is
deposited in their place. This fact is sometimes exemplified in the ribs
and sternum ; and we have in the museum of University College the
upper part of a cranium, taken from a person who died of cancer of the
breast, and illustrating the secondary effects of the disease on the parietal
* The varicous state of the capillaries, alleged to be connected with the production of
cancer, in some of its forms, is a subject which I do not enter into at present, because
it yet awaits further elucidation.
f For cases, see Warren on Tumours, p. 168. Also, R. W. Smith, in Dublin Journ.
of Med. Science, vol. xii. p. 65.
SCIRRHUS AND CANCER. 349
bones. Probably, if the viscera of the same individual had been carefully
examined, the cancerous texture might also have been traced in several
of them. I attended a gentleman's coachman in Montague Street, Russell
Square, for carcinoma of the bladder, and the effects of this disease on
the skeleton were such, that one of the ribs and the left thigh-bone
underwent spontaneous fractures previously to the patient's death. The
rib and the thigh-bone I have placed in the same museum. As secondary
effects of cancer, scirrhous formations have been noticed in the walls of
the heart itself. A case, illustrative of this fact, occurred in St. Bar-
tholomew's Hospital, and the particulars of it were inserted in the Me-
dical Gazette, by Mr. W. M. Coates. In this example, the primary
cancerous affection was situated in the lower lip ; a form of the disease
not unfrequently regarded as entirely local.
When cancer is considered as a genus, comprehending in its species
scirrhus, common vascular sarcoma, pancreatic, medullary, and mammary
sarcoma, and fungus haematodes (the view adopted by Professor Cars-
well), many other parts may be set down as very liable to carcinoma,
besides those now enumerated by me. Those diseases he considers to
be of the same family ; 1st, because they often present in the early
periods of their formation certain characters common to all of them, how-
ever much they may differ from each other in their subsequent periods.
2dly, because they all terminate in the gradual destruction, or transform-
ation of the tissues they affect. 3dly, because they all have a tendency
to affect several organs in the same individual. 4-thly, because they all
possess, though in various degrees, the same reproductive character.
Dr. Carswell describes two states of the new adventitious deposit, of which
these diseases consist ; in one it has little or no tendency to become
organised, its form and arrangement appearing to be determined chiefly
by external circumstances, and its formation and subsequent increase
being entirely dependent on the nutritive function of the organ in which
it is contained. In the second state, this deposit exhibits, on the contrary,
a greater or less tendency to become organised ; it possesses within itself
properties, by means of which its subsequent arrangement and develop-
ment are effected, independently of the nutritive function of the organ
in which it is formed, except in so far as the materials of its growth may
be derived from this source. The first example Professor Carswell calls
scirrhoma, the second cephaloma. Here, however, when I speak of scirrhus
and cancer, only those forms of disease are signified, to which these terms
are ordinarily applied ; the others will be considered hereafter. There
are many interesting observations in Dr. Carswell's Illustrations of the
Elementary Forms of Disease, relative to cancer and fungus haematodes,
which bring the subject completely into a new light. Thus, one circum-
stance which he observes, and which is new, I believe, to the generality of
pathologists of this country, is, that numerous examples might be given
of scirrhus, medullary sarcoma, and fungus haematodes, as they are com-
monly called, originating in the same morbid state, and pacing suc-
cessively from the one into the other, in the order now enumerated.
Indeed, he says, that we often meet with all the varieties of what he
terms scirrhoma and cephaloma, not only in different organs of the same
individual, but even in a single organ. And of so much importance has
it appeared to Professor Carswell to establish this fact, that the coloured
representations in his second fasciculus are chiefly devoted to its illus-
tration. Sir Astley Cooper once informed me, that he removed a lady's
breast, and the tumour, on examination, proved to be a true scirrhus, but
350 SCIRRHUS AND CANCER.
a relapse took place, and the second disease in the same part was medul-
lary sarcoma. In University College Hospital I have had several patients,
in whom, after death, the two forms of cancer were found, either in dif-
ferent parts of the body, or blended together in the same part.
Scirrhous cancer rarely occurs in subjects under thirty years of age, and
not often in any individuals under forty or forty-five. The late Sir Eve-
rard Home, however, met with an instance of a true cancerous formation
in the breast of a young woman under twenty. This was a rare occur-
rence, with reference to the breast, or scirrhus in general ; yet I may
state, that it is not very uncommon for scirrhus of the uterus to be met
with in patients under thirty. We have had some melancholy instances
of this fact amongst the patients of the Bloomsbury Dispensary.
In consequence of the female breast and the uterus being particularly
often the seats of scirrhous cancer, the disease more frequently afflicts
women than men ; and I may remark, that there is another circumstance,
affording an additional reason for females being more liable to this in-
tractable disorder; namely, the change that occurs in their constitutions
about the period of life when the menses cease. Hence, between the
ages of forty and fifty, they often begin to suffer from scirrhous and can-
cerous affections.
It is generally believed, that various common tumours, ulcers, and
pimples may change into malignant ones, and assume the cancerous
action, under the influence of particular states of the constitution. Thus,
when a female has a tumour in the breast, not originally of a malignant
nature, another morbid action may be excited in the part about the period
of life when the menses stop, and the disease may then assume the cha-
racter of scirrhus or carcinoma. Nay, a tumour of the breast, brought
on by a blow, and beginning to all appearances with common inflamma-
tion, in a seemingly healthy woman, long before this critical period of
life, will sometimes leave a hardness behind that will then change into
scirrhus and cancer. I suspect, however, that common adipous tumours
less frequently degenerate into cancer than any other swellings; yet, the
possibility of such a change is attested by Sir Benjamin Brodie.
Swelling is frequently considered not to be an essential feature of
scirrhus and cancer. On this point, I think Sir Charles Bell has delivered
one of the most accurate statements. In cancerous diseases of the breast,
there is not always an increase in the dimensions of the whole breast, but
often an actual diminution of its total bulk. But what is true of the
breast, or mamma, is not true of the disease, more generally considered ;
for the proper structure of the mammary gland frequently either shrinks,
or is compressed by the scirrhous deposit ; and sometimes the quantity of
surrounding fat is lessened by absorption ; and the consequences are, that
the whole mass is less than the natural breast, or than what the breast
was previously to the commencement of the disease. Still it is a fact, that
the disease is properly a tumour — it is, indeed, a preternatural growth —
a new formation.
The difference in the feel of scirrhi materially depends upon the quan-
tity of fat around them ; if much of the adipous substance be absorbed,
the irregular knotty form of the disease will be felt ; but when a good
deal of fat remains, the breast seems large, full and smooth, streaked
perhaps with blue dilated veins, and having sometimes an ulcerated aper-
ture in its centre.
However, after a scirrhus of the breast has existed a certain time,
its character is generally denoted by the puckered state, and dull leaden
SCIRRHUS AND CANCER. 351
or brownish colour of the integuments, the knotty and uneven feel of the
disease, the occasional sharp darting pains in the part, its fixed attach-
ment to the skin above, and to the pectoral muscle underneath it, and
the early retraction of the nipple, a circumstance produced by the ex-
tension of some of the scirrhous bands between the lactiferous ducts,
whereby its spongy texture is destroyed.
A true scirrhous tumour of the breast, one disposed to be attacked by
cancerous ulceration, is often known to a man of experience by its re-
markable hardness ; its great weight in proportion to its size, which is
seldom considerable ; the lancinating pains occasionally felt in it, and its
close connexion with the gland of the breast ; so that, when moved, this
gland moves along with it. The diagnosis will also be much assisted by
reference to the patient's age. With the exception of medullary cancer,
few other diseases so completely involve in their ravages every kind of
tissue, skin, muscle, mucous membrane, cellular substance, lymphatic
glands, &c. In ordinary tumours, the skin does not usually become
affected till they have attained a considerable size ; but, in true scirrhus,
near the surface of the body, the skin generally soon becomes adherent
to the morbid mass, and both discoloured and puckered.
Although a scirrhus of the breast may remain for months, and even for
years, in a quiet state, without advancing to ulceration, the disease mostly
ulcerates before the new formation has acquired great bulk. A large
chasm is then commonly produced, partly by a sloughing, and partly by
an ulcerative, process ; and an excoriating peculiarly fetid ichor is dis-
charged, often in such abundance as to excite surprise in a person not
accustomed to the view of this fatal disease. Its smell is also so different,
so much more offensive than any other kind of discharge, that, when
once acquainted with it, a surgeon never forgets it; and would after-
wards recognise the presence of a patient with cancer, though out of his
sight.
When the sloughs have been detached, partial but ineffectual attempts
at reparation are made. Even granulations form, but they are greyish,
hard, warty, and endowed with but little vitality; never covering the
whole surface, but rising only at certain points, and soon changing into
fungous growths of extraordinary hardness. However, sometimes can-
cerous ulceration really stops, cicatrisation even occurs at particular
points, and a degree of mitigation is experienced ; but the part never
heals to any great extent, never becomes healthy. The margins of the
sore become indurated, irregular, and twisted in various ways; in some
places everted, in others inverted, or turned downwards and inwards.
The disease extends to other parts, and often to remote situations ; the
absorbent glands especially become affected. The disease is propagated
from one gland to another, so that, after all the axillary glands are
affected, those which lie under the clavicle, in the neck, or in the upper
part of the chest, or under the sternum, in the course of the internal
mammary vessels, become diseased.
The absorbent glands are indeed frequently affected in an early stage,
becoming much indurated, and having almost the density of cartilage ;
but sometimes becoming softened and broken down at several points,
and containing a purulent or bloody fluid. The lymphatic vessels, enter-
ing or leaving the glands, also sometimes feel hard and wiry. In the
advanced stage of cancer of the breast, so seriously is the function of the
absorbents and veins of the nearest arm sometimes impeded, that the
limb is in a constant state of painful oedema, and rendered completely
352 SCIRRHUS AND CANCER.
useless. In ulcerated cancer, frequent hemorrhages take place from the
fungous granulations ; and these repeated losses of blood, joined with the
constant pain and irritation of the disease, the want of sleep, and the pro-
gressive extension of the disorder to other parts of the system, soon bring
the patient into the lowest state of debility. Nausea and disturbance of
digestion now come on, followed by a distressing and incessant cough.
Pains in the chest and oppression of the breathing increase from day to
day ; the patient becomes wan, sallow, and emaciated ; the pulse rapid
and faltering ; and death at length puts an end to this scene of misery,
often preceded by anasarca.
One deplorable effect of cancer in its inveterate form is an extraordi-
nary fragility of the bones, which are apt to be broken by the most trivial
causes, and even by the ordinary action of the muscles attached to them.
In some of these cases, masses of scirrhous matter are deposited in the
vertebrae, cranium, sternum, or long cylindrical bones, in lieu of their
proper texture.
When cancer attacks the skin or a mucous membrane, an induration
or warty lump is first produced, which afterwards ulcerates, and the sore
has a particularly hard base. The ulceration gradually assumes the
appearance of cancer, and soon cannot be distinguished from a sore that
has been the result of scirrhus in other textures.
With regard to the causes of cancer, one important question is, whether
the disease is a local or a constitutional one ? Its origin is frequently
ascribed to blows, pressure, and external injuries; but, I believe, the
whole history of cancer tends to prove, that, although it may follow a
slight contusion, the scratch or irritation of a little wart or excrescence,
that has been stationary and harmless for years, or a common inflamma-
tion or abscess of the breast, these circumstances can only be regarded as
exciting causes, which would not have brought on the disease, had there
not been a certain state of the constitution qualifying it for the production
of the specific structure of a cancerous tumour, and the peculiar morbid
actions by which the nature of cancer is distinguished.
I do not adopt the views of some surgeons, who get rid of this question
by saying, that cancer is at first a local, and afterwards a constitutional,
disease. If cancer were not always dependent upon constitutional causes,
why should it be so rare in persons under thirty years of age ? Why
should it be so common in women at the critical change which affects
their system about the age of forty-five ? Why also should the disease
be so frequent in particular families, as to excite the suspicion of its being
hereditary ? At all events, we must believe, that the disease is the effect
of a specific action in the part, preceded by some peculiar state of the
constitution, without which such specific action would not have taken
place. It is true, that we occasionally, though rarely, meet with the
true cancerous texture in young persons, and that we are not alwaj'S
able to trace any defect in their constitutions ; but because we cannot
discover it, we are not to presume that it certainly does not exist; and,
so far as we can reason from other examples of the disease, we must
infer, that when a scirrhous or cancerous disease forms either in a young
or old person, there must be peculiarities in the constitution, without
which such a complaint would not have been produced. As Professor
Carswell justly observes, hundreds and thousands of individuals are daily
affected with inflammation, without this local disease being followed by
any other than its usual effects ; a fact, placing in the clearest light the
n ecessity of a previously existing modification of the economy, as the
SCIRRHUS AND CANCER. 353
immediate and essential condition of the speciality of the adventitious
formations, when they occur in conjunction with inflammation.
The same distinguished pathologist, in his highly valuable Illustrations
of the Elementary Forms of Disease, refers to another very interesting
fact relating to this part of the subject: I allude to the formation of car-
cinoma in the blood. According to his views, cancer is divided into
scirrhoma and cephaloma, of each of which there are varieties, to which
the terms vascular, pancreatic, medullary sarcoma, fungus hcematodes, £c.
are usually applied. He states, that the heterologous substance, which
constitutes the two species of carcinoma, is present in the vessels which
ramify in carcinomatous tumours, or their immediate vicinity ; and that
it can be traced from the trunks into the branches or capillaries ; also, that
it is found in vessels having no direct communication with a cancerous
part, as when it is confined to a small extent of the vena portae ; and,
lastly, in blood that has been effused into the cellular tissue, and on the
surface of organs. He observes, that the divisions of the vascular system,
in which the carcinomatous substance has been found, are the venous
and the capillary. The formation of carcinoma in the blood, he says,
cannot remain a matter of doubt ; and he adopts the belief, that the pre-
sence of an organised product in the blood can have no other source but
the blood itself, and cannot be introduced into this fluid by absorption.
From this view of the origin of carcinoma, says Professor Carswell, its
formation in the intimate structure, and on the free surface of organs,
follows as a matter of course. The material element of the disease is
separated from the blood, and deposited under a variety of circumstances,
which modify, in a greater or less degree, the form, bulk, colour, and
consistence, which it afterwards presents in the several periods of its
development. Dr. Carswell, therefore, does not agree with several
pathologists, who limit the seat of cancer to any one tissue, nor does he
ascribe its origin to any modification of structure, or special organisation.
Here, however, we are to remember, that Dr. Carswell's views of car-
cinoma comprise, as varieties of this disease, several cases which have
usually been separated from it.
Scirrhous cancer is common at all ages between thirty and seventy.
Sir Everard Home met with a single instance of the true scirrhous texture
in a person only fifteen years of age ; and Sir Astley Cooper, in all his
long and extensive experience, never saw cancer in more than two indi-
viduals, who were less than thirty. The most common period for its
commencement is the age of forty-five or fifty. Another fact, which is
curious, in relation to the influence of age on cancer, is, that when the
disease occurs in persons of very great age, it is slow in its progress, and
does not, in general, materially shorten their lives.
Cancer is known to all the world to be one of the most intractable dis-
eases to which the human body is liable. When we consider it as a new
formation — as an adventitious deposit, accompanied by the peculiar tex-
ture and organisation, which I have described, accompanied alsofby some
peculiarity of constitution, or modification of the economy, — we must
see, that the power of medicine can have little or no influence over the
disease. Yet, we may not be justified in asserting, that scirrhus and
cancer are absolutely incurable. I formerly attended a young woman,
under thirty, in Great Ormond-yard, Queen-square, who died of scirrhous
cancer of the womb, as ascertained by dissection, the parts having
been removed, and preserved by Dr. Miller. Her mother, who was
living in the same house, and far advanced in years, had had both her
A A
354 SCIRRHUS AND CANCER.
breasts entirely destroyed by cancerous disease, which had termi-
nated in extensive sloughing. Here, no doubt, the whole scirrhous
mass in each breast had been separated by the process established by
nature for the detachment of the sloughs, and with them, I presume, the
scirrhous bands, radiating from the tumour into the contiguous parts,
were also thrown off, after which the ulcers healed like any common sores.
The front of the chest on each side presents a most irregular mutilated
appearance ; the woman cannot now be less than eighty years of age.
As however this mode of termination of cancer is on the principle of
extirpation, accidentally brought about by nature herself, strictly speak-
ing, it may not affect the truth of the general observation, that cancer,
whether in the state of scirrhus or carcinomatous ulceration, is positively
incurable by any means, except such as are calculated to remove or
destroy the whole of the parts affected. And, even when this is done,
owing to the continued influence of constitutional causes, a recurrence of
the disease, either in the same part or others, will always follow in a cer-
tain proportion of cases thus treated.
One circumstance, proving the connexion of cancer with constitutional
causes, is the greater frequency of the disease in women, who bear no
children, than in others who have families. This is a fact universally
known and admitted ; yet a female may have children, and even many,
without being safe from an attack of the disease. One woman is men-
tioned by Sir Astley Cooper as falling a victim to cancer, though she
had been pregnant not less than seventeen times. I have attended
several women, who died of cancer uteri, notwithstanding they were
mothers.
Another fact, in support of the opinion, that cancer is a constitutional
disease, is the presence of the cancerous substance in the blood, either in the
vessels, which ramify in a carcinomatous tumour, or its immediate vicinity ;
or in the vessels of a portion, or of the whole of an organ, to the former of
which this substance is exclusively confined, and can be traced from the
trunks into the branches and capillaries, or in vessels having no direct
communication with an organ affected with the same disease.*
With reference to the prognosis and treatment of scirrhus and cancer,
I may observe, that they are amongst the most intractable and fatal forms
of organic disease to which the human body is liable. When we consider
scirrhus as a new formation, as an adventitious growth or deposit, accom-
panied by the peculiar texture, which I have endeavoured to describe,
we must naturally suspect, that it is not a case over which medical sur-
gery can have much power. Indeed, it is the belief of the most ex-
perienced and careful observers, that cancer, whether in the form of scir-
rhus, or carcinomatous ulceration, is absolutely incurable by any means
except those plans, which bring about the total removal or absolute
destruction of the parts affected. And even when this is done, a recur-
rence of the disease, either in the neighbouring tissues, or in remote parts
and organs, will follow in a considerable proportion of the cases thus
treated : another fact, confirming the truth of the doctrine, that cancer
is a disease dependent on constitutional causes. When a scirrhous cancer
is so situated as to admit of being entirely removed with the knife, no
time, I think, should be lost in attempting to disperse the induration, or
cure the ulcer, by other means. It is only while doubts prevail about the
true character of the complaint, or while it is in a very early stage, that
* See Dr. CarswelPs Illustrations of the Elementary Forms of Disease ; Fasciculus 2.
SCIRRHUS AND CANCER. 355
it is generally advisable to try plans which have in view the dispersion of
the hardness, or the healing of the sore by external or internal remedies.
The ground, on which I offer this advice, is, that all the medicines
and applications, described in every pharmacopoeia in the world, have
already been tried for the relief and cure of cancer in thousands of in-
stances, without the slightest advantage ; and in innumerable cases, the
time employed in the trial of them has afforded an opportunity for the
disease to extend from the part originally attacked, and which might
easily have been taken away at first, to other parts not admitting of re-
moval, and the patients have died, without having had that chance of
being saved, which a timely operation would have given them.
We occasionally hear and read of cancerous affections being cured by
various medicines and applications. But the question is, whether they
were diseases, really attended with the true scirrhous formation and struc-
ture, or genuine carcinomatous ulceration? Numerous swellings, indura-
tions, and ulcers, have more or less resemblance in their outward charac-
ters to scirrhus and cancer ; and such are sometimes dispersed, or
healed; but that a disease, accompanied by the genuine scirrhous texture,
the heterologous substance that distinguishes it, can be cured by medi-
cine, or any local means, not acting so as to destroy the part affected like
caustic, is a proposition, against which the voice of experience is loudly
raised.
Believing in this fact myself, I shall be brief in the enumeration of a
few of the principal medicines, which have been repeatedly praised for
their efficacy in scirrhous and cancerous cases ; for, according to the
view which I have taken of the subject, they have been extolled without
good foundation, and, in the trial of them, other diseases have been gene-
rally mistaken for those now engaging our attention. Conium maculatum,
or hemlock, was at one time praised up to the skies as a remedy both for
cancer and scrofula. It is yet confided in by Recamier, who combines
with it an allowance of only one third of the patient's ordinary quantity
of food, and makes him take as ordinary beverage a weak infusion of
bark. The extract of belladonna is a medicine that can only be given
in very small doses, the effect of which is not to cure or stop scirrhus, or
cancer, but to diminish the pain of the complaint. As for arsenic, in the
form of the liquor arsenicalis, I have frequently given it the fairest trial
in scirrhus and cancer; and am sure, that it has no power over them;
though certain troublesome and inveterate ulcerations and tubercular
diseases about the nose, lips, and other parts of the face, and on the
tongue, will sometimes yield to it. Certain malignant-looking sores on
the face, reputed to be of a cancerous nature, were cured, under Mr.
Carmichael, by the sesqui-oxide or phosphate of iron, with the occasional
use of purgative medicines. The dose of these preparations of iron
varies from a scruple to a drachm twice a day. They are now generally
acknowledged to possess no specific virtues against true scirrhus^and can-
cer. As for mercury ', though it has the power of promoting the absorption
of various indurations, and of curing different forms of the most obstinate
ulceration, no modern surgeon has any confidence in its usefulness as a
medicine for cancer. When the digestive organs are disordered in a
patient labouring under a scirrhous affection, small doses of the blue pill,
or compound calomel pill, with leeches on the epigastrium, or hypochon-
drium, and aperient medicines occasionally, will sometimes improve the
general health, and put the patient into a better state for an operation ;
but neither this nor any other medical plan, will serve to disperse a true
A A 2
356 SCIRRHUS AND CANCER.
scirrhus. The muriate ofbarytes has been tried, but it is now given up,
as entitled to no confidence. Living altogether on a milk, or vegetable
diet, or a diet just sufficient to keep the body and soul together, some-
thing very nearly approaching to starvation, is one of the schemes which
have3 been resorted to. In the periodical works of the day, we read of
cancerous diseases yielding to iodine. 1 have frequently tried it for such
complaints in the breast, uterus, and lips, but without success.
Amongst the favourite topical applications, are the liquor arsenicalis
properly diluted, and Dupuytren's powder, consisting of ninety-six parts
of calomel, and four of oxide of arsenic. Strong arsenical pastes are dan-
gerous applications. I remember a patient being poisoned with them ;
he had a cancerous ulcer of the face ; the surgeon covered it with the
paste ; and he died in a few hours from the absorption of the arsenic, and
its deleterious effects on the system. If any surgeons are yet bold enough
to attack cancerous diseases with caustic (which I am not), let them ab-
stain at all events from arsenic, and employ pure potash, though, I think,
they will often kill the patient even with this.
Narcotics, in the form of plasters, are sometimes employed, particularly
opium, conium, hyoscyamus, and belladonna blended in various propor-
tions with the ordinary brown soap plaster. The watery solution of opium,
and the liquor opii sedativus. are common applications for all kinds of
malignant ulcerations. In addition to these articles, I will merely refer
to carrot poultices, fermenting poultices, a solution of one ounce of the
sulphate of iron in one pound of distilled ivater ; a paste composed of
sesqui-oxide of iron blended with water, or sprinkling the ulcer with the
powder ; the solutions of the chloride of lime and soda ; and covering the
scirrhous part with a piece of hareskin, or fleecy hosiery, so as to protect
the disease from the influence of vicissitudes of temperature, and the
injurious effects of accidental blows.
Pressure was recommended by Young, as a means of curing cancer,
but the trials made of it in the Middlesex Hospital, and the report of
Breschet, are decidedly unfavourable to the practice. I have tried it in
two or three examples, without success. In France, however, Recamier
is still an advocate for it. According to Dr. Carswell, the influence of
pressure in favouring or retarding the development of carcinomatous
tumours, is conspicuously seen in those situated near the surface of the
body.
As none of these plans and medicines will cure cancer, we are to con-
sider what benefit may be obtained by extirpating the diseased part.
If the operation be done early, and performed on the principle of re-
moving, not merely what is obviously diseased, but a good deal of the
substance around the scirrhus or cancer, the result will frequently be a
permanent cure, so far as that part is concerned. But the cure is not a
certain thing. Indeed, after a cancerous tumour has been extirpated,
whether the disease be indolent, or painful, small, or recent, there is no
certainty that the disease will not return. On the other hand, it is not
certain that the disease will return, even when it has made considerable
progress previously to the operation. Yet, it is an undoubted fact, that
the more recent the disease is, the less are the chances of relapse.
Hence, as we have no medicine that will cure scirrhus and cancer,
we should recommend an operation for their removal as soon as no doubt
exists about their nature.
When it is impracticable to remove the whole of the diseased parts, it
is a rule in surgery not to undertake an operation at all. The partial
SCIRRHUS AND CANCER. 357
extirpation of a true scirrhus, whether by caustic or the knife, is sure to
convert the disease into a fatal painful carcinomatous ulcer.
Another maxim in surgery is, never to perform the operation for the
removal of a cancerous tumour when there is reason to believe, that the
disease is not confined to the part, but has already extended itself to
internal glands and other textures, more or less remote from the original
seat of the disease. My experience teaches me, that, if an operation be
performed, where the integuments/ covering a scirrhous breast, are
thickly studded with hard pale tubercles, the patient will be almost sure to
have a return of the disease in the skin, though every part of it visibly
diseased may have been removed.
What good can arise from cutting away a cancerous breast, when, per-
haps, all the absorbent glands about the axilla, neck, and within the
sternum, are similarly affected ? Where can be the prudence of cutting
away an external scirrhus when there are cancerous deposits in the lungs,
liver, bones, or other deep-seated textures?
Surgeons do not decline to operate when the axillary glands are
diseased together with the breast ; and provided the whole disease in each
situation can be thus removed, the practice may be right ; but, certainly,
the extension of the disease to those glands very materially lessens the
chance of a permanent cure. It shows that the diseased action has
passed to organs more or less remote from the original affection, and that
the system may be inveterately under its influence. Camper believed,
that a sure sign of the incurability of a cancerous breast consisted in a
shooting pain between the second and third ribs. He was convinced,
that such pain denoted the extension of the disease to the lymphatic
glands under the sternum.
Is it right to operate when the disease is in the ulcerated state ? The
answer must depend upon circumstances. If the whole of the diseased
parts can be removed, if the viscera of the chest and abdomen appear
not to have suffered, and the lymphatic glands are not extensively affected,
the operation is justifiable, though its chances of success are much less
than those where the case is only a scirrhus, under similar conditions.
The lips, however, have been removed in the ulcerative stage, without
the disease afterwards extending itself to the submaxillary glands, or any
relapse taking place. The same fact has been exemplified after the ex-
tirpation of portions of cancerous tongues.
When the opportunity for operating has passed away, palliative treat-
ment is all that can be attempted. Appeasing the pain by the application
of the watery solution of opium, or dressing the ulcer with the liquor
opii sedativus, or with an ointment containing one drachm of the powder
of opium in every ounce of lard, are rational methods. I had lately one
patient with a dreadful carcinomatous ulceration of the breast, who found
no dressing afford her so much ease as the common spermaceti ointment.
The fcetor may be lessened by applying the chloride solutions ; but they
give not the ease derived from other dressings. To a scirrhm which it is
not judged advisable to remove, we may apply soap plaster, containing a
proportion of the extract of belladonna or hyoscyamus ; or we may sim-
ply cover the part with a piece of soap plaster or soft fur. On account of
the pain, the acetate or hydrochlorate of morphia may also be prescribed.
This practice is most particularly called for in examples of ulcerated
cancer. Where the agony is great, and the disease incapable of removal
by the knife, all that can be done is to render the patients journey to the
grave more free from misery.
A A 3
358 MEDULLARY CANCER, ENCEPHALOID TUMOUR,
The success of an operation will materially depend upon the whole dis-
ease in the part — every atom of it — being completely extirpated.
Hence, we should always make a free removal of the skin and cellular
tissue around a scirrhous tumour, as the fibrous bands frequently extend
a considerable distance round the perceptible induration and swelling.
In a certain number of instances, however, a relapse will unfortunately
take place, whatever be the precautions taken in the performance of the
operation. Still the prospects of a radical and permanent cure are more
promising when the operation has been properly performed, and strict
attention is afterwards paid to the patient's general health. Hence, when
we take away a scirrhus, we ought not to think that we have fulfilled the
whole of our duty to the patient ; but prescribe such medicines, and re-
gimen, as will be likely to produce a beneficially alterative effect on the
constitution.
When the disease extends only to one or two of the axillary glands,
and the patient seems to be free from organic disease in the chest and
abdomen, we may perform the operation ; but the diseased gland or
glands should be removed with the knife, directly after the scirrhous
breast has been extirpated.
MEDULLARY CANCER, ENCEPHALOID TUMOUR, OR FUNGUS H^EMA-
TODES.
The latter name was adopted by Hey, in consequence of its tendency
to throw out, with great rapidity, a large bleeding substance, after ulcer-
ation of the skin has taken place. It is sometimes called soft cancer;
and, by Abernethy, was named medullary sarcoma, from its resemblance
to the medullary substance of the brain. It is, in fact, very similar to
the substance of the brain in all chemical and physical properties. Most
commonly it presents itself in masses, contained in fine membranous par-
titions : but it has three varieties, as originally pointed out by Laennec.
The first is the encysted, which varies from the size of a filbert to that of
an apple. The unencysted, which may be very small, but, in other in-
stances, obtains the magnitude of a child's head. Its exterior is not so
irregular as that of the encysted, though divided into lobules, with fissures
between them. The infiltrated or diffused, consists of masses, which are
not circumscribed, and the medullary substance presents a diversified
appearance, in consequence of its being blended in various proportions
with the tissues amongst which it is produced. It is generally of the
same consistence as the cerebral medulla ; but sometimes much softer.
It varies also in colour : in some instances, it is quite white ; in others
light red ; and it has occasionally been found to be of a deep red colour.
A section of the tumour exhibits numerous bloody points. A vascular
organisation is conspicuous in it, and as the coats of its vessels are remark-
ably delicate, the circulation of the blood through them is readily inter-
rupted ; haemorrhage from congestive rupture takes place ; and the
effused blood is mixed with the brain-like matter.* When superficial,
medullary cancer begins as a colourless swelling, soft and elastic to the
touch, unless bound down by a fascia, in which case it has a firm tense
feel. When immediately subcutaneous, it is elastic, and hence liable to
be mistaken for a tumour containing fluid. When it occurs in the tes-
ticle, it is frequently supposed at first to be hydrocele.
* See Carswell's Illustrations of the Elem. Forms of Disease; Fasc. 2.
OR FUNGUS EL3EMATODES. 359
Like cancer, it has a tendency to spread to the absorbent glands, which
become converted into a similar substance. In every sense of the ex-
pression, it is a new formation, an adventitious growth, whether situated
in the cellular membrane, in the tissue of the muscles, in that of the vis-
cera, or within the orbit, or in any cavity or on any surface of the body.
When it occurs in deep-seated parts, it has an invariable tendency to make
its way to the surface, and when this happens, a considerable swelling
arises, the skin at length becomes thin and discoloured, and from being
at first smooth, now projects irregularly ; openings are formed in these
projections, and a medullary growth springs up, which sometimes bleeds
profusely. It is only at this period of the disease that the name of fungus
haematodes is at all applicable ; and even now it is not very correct, as
the mass is not a fungus, but a substance of medullary consistence.
Medullary cancer seems to be a constitutional disease, and rarely confined
to one organ. It has been observed in the eye, the brain, the lungs, the
heart, the liver, the spleen, the kidneys, the bladder, the uterus, the
ovaries, the mammae, the mesenteric glands, the dura mater, the bones,
and the thyroid gland, of which there is a fine specimen in Mr. Langstaff's
museum. It may commence in almost every texture, or upon any sur-
face. Sometimes it originates in the antrum, from which it may extend
to the brain, through the orbit, or outwards through the cheek, or into
the mouth, or nose.
An early symptom of this terrible and unfortunately common disease,
is a wan, pale complexion, such as is remarkably indicative of what may be
termed a fatal organic disease. The patient generally dies hectic. One of
its differences from scirrhous cancer is, that it contains within its substance
no ligamentous bands, nor central hard nucleus, but consists of a soft
pulpy matter contained within septa, composed of a fine delicate mem-
brane. In order to be able to see its structure well, we should subject it
to maceration or the action of alkalies. A scirrhous tumour is generally
firm, hard, and incompressible from the very first ; whereas there is a
softness and elasticity about fungus haematodes, at once constituting quite
a different character. The parts in this latter disease are not destroyed
by ulceration, as in cancer ; but, after the skin has ulcerated, a medullary
bleeding substance protrudes. While the new deposit in schirrous cancer,
also, has little or no tendency to become organised, that of medullary
cancer exhibits a greater or lesser disposition to become so. Fungus
haematodes frequently attacks the liver, the spleen, the kidneys, and lungs,
primarily; whereas it is alleged by some pathologists, that scirrhous can-
cer only attacks these organs secondarily ; a point, however, deserving of
further investigation. Medullary cancer is not uncommon in young
subjects, and persons below the middle age ; whereas cancer chiefly at-
tacks individuals between the ages of forty-five and fifty, or older persons.
With regard to the treatment, we know of no medicine that will correct
the state of the constitution upon which this disease depends. The only
chance of curing it, is by the removal of the tumour at an earl)» period of
its formation, before the lymphatic glands and other parts have become
affected. Thus, if the disease has extended up the spermatic cord, or to
the lumbar glands, castration will be of no avail. I am of opinion, that
the viscera generally become diseased much sooner in medullary tumours
externally situated, than is generally supposed. I am now speaking of
that form of them, which comes under the care of surgeons, where the
surface of the body, or the limbs,, are the seats of the disease. This fact
A A 4?
360 MELANOSIS.
accounts for the general failure of operations ; and induces many judicious
surgeons to condemn them altogether.
Notwithstanding there is every reason for believing medullary cancer
to be a constitutional disease, and we find, that after an operation, there
is usually even a greater disposition to relapse, than is manifested in
examples of scirrhus and cancer, experience occasionally brings forward
cases forming exceptions to this statement. I removed a testicle affected
with fungus haamatodes from a man in Newton Street, Holborn, who re-
covered, and continued well a long while afterwards ; and we sometimes
hear of the same disease in the eyes, breast, and limbs, being effectually
extirpated by operation, without being followed by any return of the com-
plaint. Unfortunately, the contrary more generally happens, so that the
prognosis should be qualified by a reference to this important fact.
MELANOSIS.
The black cancer of Dupuytren, the melanoma of Professor Carswell, is
characterised by the formation of a brownish, deep blue or black inorganic
matter in various textures and cavities of the body, especially those lined
by a serous membrane. The shades of its colour vary in different ex-
amples, sometimes presenting only a yellowish or light brown, sometimes
a dark brown, and frequently the deepest black.
The scientific arrangement of melanotic diseases, partly suggested by
Bayle and Laennec, but improved by the labours of Breschet and Cars-
well, seems to me to convey the most correct idea of their principal varie-
ties. Thus, melanosis is divided by the latter pathologist into true and
spurious; the first comprising those cases, in which the formations or
products depend on a change taking place in that process of secretion,
whence the natural colour of certain parts of the body is derived ; the
second comprehending cases, in which either a carbonaceous matter has
been introduced from without, or in which the appearances are owing to
the action of chemical agents on the blood, or to the mere stagnation of
the latter fluid. According to Professor Carswell, the most frequent seat
of true melanosis is the serous tissue, more especially where this consti-
tutes the cellular element of organs. Here the melanotic matter is
formed after the manner of secretion, accumulates in the cells, of which
the serous tissue is composed, and gradually acquires the form of tumours
of various sizes. A similar mode of formation of this matter takes place
much more conspicuously in loose cellular tissue, and particularly on
extensive serous surfaces, like those of the pleura and peritoneum.*
Another mode of formation is pointed out by Dr. Carswell, where the
melanotic matter is deposited in the substance, or molecular structure of
organs, after the manner of nutrition ; arid, lastly, as he has further ex-
plained, the melanotic matter, like that of cancer, or medullary sarcoma,
is sometimes formed in the blood, chiefly in the venous capillaries, and
under circumstances which show that it must have been formed in these
vessels. There are not less than four modifications of true melanosis.
1. Punctiform melanosis, the melanose infiltree of Laennec, in which the
black colouring matter appears in the shape of minute points, or dots,
either grouped together in a small space, or scattered irregularly over a
considerable extent of surface. These appearances are most frequently
exhibited in the liver, and, when a section is made of it, the surface seems
as if it had been sprinkled with soot or coal dust.
* See Dr. Carswell's Illustrations of the Elementary Forms of Disease ; Fasciculus 3.
MELANOSIS. 361
2. Tuberiform melanosis, which is by far the most common, answers
to the concretions mdlaniques of French pathologists. Sometimes the
tumour is not larger than a millet seed, but occasionally it is equal
in bulk to a child's head, or even of more considerable dimensions.
Of this size, however, it is chiefly seen in the horse ; for, in the human
subject, we rarely meet with an instance of its exceeding the size of an
egg or an orange, and commonly it is much smaller. It is in the loose
cellular and adipous tissues that melanotic tumours are disposed to attain
extraordinary magnitude. Their great size seems to depend upon the
agglomeration of numerous small tumours. According to Professor
Carswell, when the tumour is single, it is always of a globular or ovoid
shape, but, in the contrary circumstance, lobulated. In compound tis-
sues, he has observed it to be most frequently a single tumour, but in the
cellular and adipous tissues aggregated. In the liver, single melanotic
tumours of large size are more common than in any other organ of com-
pound structure. Melanotic tumours may be either encysted or without a
cyst ; the encysted being chiefly met with in the cellular and adipous
tissues. The tuberiform melanosis of Professor Carswell, however, is not
confined to the cellular and adipous tissues, or parts abounding in them,
but may occur on the surface of the peritoneum, or that of the pleura.
3. Stratiform melanosis, the melanose membraniforme of Laennec, occurs
only on the surface of serous membranes. In its first stage, the part
seems merely stained with the melanotic matter ; in the second, a distinct
layer of this substance is deposited on the surface of the serous membrane.
Its consistence is generally that of jelly, and, as it is enclosed either in a
soft spongy cellular tissue, or fine transparent serous membrane of new
formation ; it has a pulpy feel, but is not removed by the finger or scalpel
passed over it, unless some force is employed. In certain cases, it forms
a black coating, in appearance very much like what is produced by
Indian ink.
4t. Liquiform melanosis, the last of Dr. Cars well's species of true mela-
nosis, the melanose liquide of Breschet, may occur in natural or accidental
cavities, and also within a melanotic tumour itself, in consequence of what
French pathologists describe as the softening process in the centre. The
cavities of the pleura and peritoneum are the chief natural cavities, in
which the liquiform melanosis presents itself, and here only in small
quantity. What has been described as this form of melanosis in mucous
cavities, seems to Dr. Carswell to be owing to the changed colour of the
blood, either effused in such cavities, or contained in its proper vessels,
and acted upon by some external chemical agent, consequently they are
spurious cases. Ovarial cysts furnish the best examples of accidental cavi-
ties, in which liquiform melanosis is sometimes seen. The consistence of
melanosis is exceedingly diversified. In the large cavities, it is never
solid ; in the cellular and adipous tissues one or two cells may contain
liquid black matter ; but, in the dense texture of the cutis, the smallest
tumour may be as hard as cartilage. 0
The spurious forms of melanosis depend either upon the introduction
of carbonaceous matter into the pulmonary tissue in the process of respi-
ration, or upon the action of acids or other chemical agents on the blood,
situated in, or upon parts, or, lastly, upon the simple stagnation of this
fluid.
Melanosis frequently originates in the subcutaneous cellular tissue, or
in the cellular and adipous tissue, behind the peritoneum.
The most striking example of its circumscribed existence in adipous
362 MELANOSIS.
tissue is specified by Dr. Carswell to be that, in which the disease occurs
in the appendiculce epiploicce, which are sometimes converted by it into a
homogeneous solid mass of melanotic matter.
Melanosis may take place in various parts of the same individual, as the
eye, the skin, the liver, the lungs, the heart, the pancreas, and the perito-
neal covering of the viscera. From this fact, one may infer its connexion
with a constitutional cause.
The bones are not often the seat of melanosis. In one example de-
scribed by Dr. Alison, the whole of the sternum, the anterior portion of
the ribs, and a great part of the parietal and occipital bones were black,
more brittle, and of a softer consistence, than natural ; but without en-
largement, or caries. The periosteum was but little changed ; but the
dura mater was stained black, and the pleura studded with very dark
coloured tubercles.
One interesting fact, explained by Professor Carswell, is, that the fluid
of melanosis may be found in natural or artificial cavities, without its
being the ^product of their secretion. This happens, when melanotic
tumours perforate the sides of those cavities, and pour their fluid contents
into them. This has been observed in the thorax and abdomen ; and, in
one case, a melanotic tumour had perforated the right lateral ventricle of
the brain, in which was found a considerable quantity of black fluid, some
of which had passed into the third and fourth ventricles, and thence into
the theca vertebralis.
Melanosis of the brain is rare. In the museum of University College
is a specimen of a small melanotic formation on the cerebellum of a child,
that lived only three days from its birth. No doubt, therefore, in this
instance, the disease must have commenced in the foetus.
The matter of true melanosis has no smell — a circumstance, by which
the disease may always be known from the effects of gangrene.
With respect to the symptoms of melanosis in the living subject, the
disease may at first produce little or no pain ; but a sallow complexion,
excessive debility, and anasarca frequently come on before its termina-
tion. In some instances, however, great general indisposition, and most
severe pain in various parts of the body, are experienced from the first ;
and, occasionally, the patient is rapidly destroyed in the short space of
three or four weeks. In common examples, I believe, it does not cause
a vast deal of suffering, except when nerves are involved in it, or com-
pressed by it.
The matter of melanosis is completely insensible — it is only an inor-
ganic secretion, or deposit — sometimes produced in textures, or upon
surfaces otherwise apparently healthy and natural — sometimes formed
in parts, affected with chronic inflammation — and sometimes co-existent
in the same mass, either with scirrhus, cancer, or medullary deposit ; a
point, in which the researches of Professor Carswell agree with those of
the late Dr. Armstrong. These facts explain why melanosis is sometimes
described as a malignant disease, and sometimes as having this cha-
racter but very rarely.*
Melanosis is a more common disease in horses, than the human sub-
ject ; but it is principally met with in those of a white, or grey colour ; a
fact, corroborating the doctrine of its origin from constitutional peculi-
arity. As Professor Carswell remarks, the circumstance is also favourable
to the theory, which ascribes the origin of melanosis to the accumulation
* See Warren on Tumours, p. 25,
SCROFULA, OR STRUMA. 363
in the blood of the carbon, naturally employed to colour different parts
of the body, as the hair, rete mucosum, and choroid coat of the eye.
From chemical analysis, it would seem, that the substance of melanosis
consists of fibrine, a black colouring matter, a small quantity of albumen,
chloruret of sodium, oxide of iron, water, subphosphate of lime, and a few
other salts in small proportions ; and it is the general opinion, that the
melanotic matter is essentially composed of the constituent elements of
the blood. The colouring matter seems also to be a highly carbonised
principle.
No remedy is known of for melanosis. Its causes are as obscure as those
of cancer, fungus haBmatodes, tubercles, and other new and adventitious
formations. The only chance of benefit depends upon the early removal
of the disease by operation, when the situation of the part affected will
admit of it. An eye, affected with melanosis, has been extirpated, with-
out any relapse having followed the operation at the end of two or three
years ; so have melanotic tumours of the skin and cellular tissue. Mela-
notic formations under the tails of horses have likewise been frequently
cut away with permanent success. These facts prove, that malanosis in
some situations has more chance of effectual relief by operation, than
medullary cancer.
SCROFULA, OR STRUMA,
Commonly called the king's evil, from the superstitious notion formerly
entertained, that it was curable by the royal touch, frequently presents
itself in the form of glandular enlargements under the skin — swellings
whose progress is in general remarkably indolent, — which soften very
slowly, — and at length frequently suppurate and burst, after which they
remain a greater or lesser time as ulcers, and, after healing (which they
do very tediously), often leave behind them callous irregular scars, which
can never be effaced.
Sometimes the disease occurs in the substance of the cutaneous texture,
which it disfigures and alters in a most disgusting manner ; and very
often it attacks the ears, the eyes, the eylids, the nostrils, and the lips,
which it thickens and deforms in an extraordinary degree. In other
examples, we find it fixing upon organs more deeply situated, as the
bones and joints ; or obstructing the organs for the conveyance of the
lymph and chyle ; or giving rise in the lungs, the peritoneum, and other
parts, to those tubercular diseases,, which, in this climate at least, are one
of the greatest causes of mortality.
Scrofula will not admit of a short and satisfactory definition, and this,
notwithstanding our familiar acquaintance with its usual seats, and its
ordinary ravages and course. I may observe, however, that it is charac*
terised by a remarkable propensity to chronic inflammation of the lymphatic
and mesenteric glands. The absorbent glands of the neck, and others
under the jaw, are more frequently attacked by scrofula than those of any
other region in the body; and perhaps their being more exjlbsed to
vicissitudes of temperature, and to the irritation of diseases of the scalp,
which are so common in children,, may afford some explanation of this
fact. Next, perhaps, the mesenteric glands are most frequently disor-
ganised by it ; and it is not unusual to find it affecting the glands in the
groin, and even those in the axilla, and other situations. Indeed, the
absorbent glands of every part of the body are liable to scrofulous
disease.
Scrofula always produces in the system a tendency to the formation of
364 SCROFULA OR STRUMA.
chronic abscesses, not merely in and about the absorbent glands, but in
the general cellular tissue of the body.
As already mentioned,, it likewise creates a disposition to the origin of
tubercles in the lungs, liver, brain, spleen, and other internal organs.
The most frequent seats of scrofulous tubercles in adults are, first, the
lungs, and then the small intestines ; but, in children, the bronchial
glands, the mesenteric glands, the spleen, the kidneys, and the intestines,
in the order here enumerated.
If we regard tubercular phthisis as a scrofulous disease, it will make a
material difference in the comparative estimate of the frequency of scro-
fula in children and grown up persons.
Scrofula is accompanied by a tendency to certain morbid changes in
the spongy and cancellous texture of the bones, and also in the synovial
membranes.
In the common language of surgery, we frequently say, that a person
is scrofulous, though he may not have any visible disease about him ;
but merely certain appearances, usually regarded as emblems of a scro-
fulous constitution, or of a predisposition to scrofula. Thus a fair com-
plexion, light-coloured hair, a fine thin delicate skin, exhibiting the
minute ramifications of vessels, full sized, rather dilated pupils, and a re-
markable whiteness of the albuginea of the eye, a tenderness of the
edges of the eyelids, a swelling of the upper lip, with some thickening of
the alae and tip of the nose, are known to denote a scrofulous constitu-
tion. In many instances, the ends of the fingers are broad and clubbed,
as the expression is, and the belly protuberant. Perhaps the doctrine of
a fair complexion and light hair being indications of a predisposition to
scrofula, may have been carried too far, and certainly I should have been
inclined to suspect, that it had arisen merely from the accidental cir-
cumstance of the greater number of children in this country being fair,
and having light-coloured hair, had I not found it noticed by Alibert and
other French pathologists, that scrofula is most frequently seen in France
in the same description of children, where we know that dark complexions
and dark eyes predominate. It is not, however, to be supposed, that a
dark complexion is an absolute protection, for many scrofulous persons
have dark skin and hair ; and every surgeon of experience knows how
subject the negro and other individuals of the dark races are to scrofula,
when brought to this damp, cold, and variable climate.
It is frequently difficult, perhaps sometimes impossible, to draw with
precision the line between scrofulous and some other diseases, because
there is an insensible transition or gradation from one to the other. Yet
certain forms of diseases present themselves daily, in which there can be
no hesitation in pronouncing them to be scrofulous. Such are particular
indolent swellings and abscesses of the lymphatic glands of the neck, cer-
tain diseases of the joints and spinal column, and various tubercular
affections.
Children are more liable to scrofula than grown up persons, the period
of life most exposed to its attack being from infancy to puberty. Nay, if
tubercles are to be regarded as unequivocal effects of scrofula, as many of
the best pathologists believe, the disease may commence in the foetus ;
and there are in my friend Mr. Langstaff's museum portions of lung,
taken from a foetal subject, and evidently containing completely-formed
tubercles.
As puberty approaches, the disposition to every form of scrofula,
except that of pulmonary tubercles, lessens, and those who have suffered
SCROFULA OR STRUMA. 365
from it in their childhood, sometimes become free from it, and bid defiance
to its further annoyance. Females are generally considered to be rather
more subject to scrofula than males. The disease is well known to be
neither infectious nor contagious ; not being communicable from one
person to another by inoculation, nor through the atmosphere. The idea
that scrofulous nurses may impart the disorder to children, is one that is
at present universally renounced.
It appears, then, that scrofula may make its appearance in almost any
texture of the body, and is not, as is sometimes conceived, peculiar to the
lymphatic glands, though they are perhaps more susceptible of it than
any other parts. The glands of the neck and those of the mesentery un-
doubtedly come within this remark ; and next to these organs I may say,
that the skin, the lungs, the eyes, the ears, and the spongy parts of the
bones, are most frequently the seats of scrofulous disease.
Scrofulous inflammation is generally remarkable for the slowness and
indolence of its character. Its attack is always more insidious, and its
progress much slower, than the invasion and advance of phlegmonous
inflammation. The acute pain, the throbbing, the firm circumscribed
swelling, the bright red colour, and the quickness of the changes, which
attend all simple healthy inflammations, may be said to be absent from
scrofulous inflammation as it most usually presents itself. Neither does
scrofulous inflammation, when situated in a lymphatic gland, or any
ordinary texture, commonly produce at first any febrile disturbance ; yet,
when scrofula makes progress, or attacks organs of great importance in
the animal economy, or extends its ravages to the large joints, the degree
of constitutional derangement and of hectic is often such as to form a
state of considerable and urgent danger.
Scrofulous inflammation near the surface of the body, often begins
with a soft swelling of the part affected, which is frequently one of the
lymphatic glands. The covering of the gland becomes slightly thickened,
and the gland itself has a doughy feel. As the swelling increases, it
becomes more elastic, or even communicates the sense of a fluctuation ;
and, in this stage, a degree of induration is generally noticed under and
around the tumour, with a more or less red or livid colour of the skin. If
a puncture be now made in the swelling, a thin fluid is discharged, mixed
with flakes of a curdy substance, composed of albumen, but only in trivial
quantity, and rarely in the shape of good pus. The edges of the puncture
next inflame, and the opening becoming larger, in consequence of the
ulcerative process, a dark yellow or brown sloughy-looking substance
may be seen within it : and betwixt this substance and the skin a probe
may be passed freely all round the sore. Indeed, it is one of the charac-
ters of scrofulous abscesses, when formed near the surface of the body,
always to detach the skin extensively from the subjacent parts. If the
disease be allowed to take its own course, without being punctured, a
part of the skin at length becomes very thin, and of a light purple red
colour ; afterwards bursting and discharging a thin fluid-like wljey, with
which flakes of albumen, and occasionally pus, are also blended. The red-
ness continues, the surrounding hardness remains, the ulcerative process
advances, and the disease is now converted into a scrofulous ulcer, which
is generally not much disposed to heal. The cavity and sides of many
deep ulcers and abscesses, resulting from scrofula, are noticed by
Mr. Wardrop to be covered with a tough yellow fibrinous incrustation,
that produces an impediment to the formation of granulations ; and he
accounts for the usefulness of laying open scrofulous abscesses partly
366 SCROFULA OR STRUMA. '
on the principle of its promoting the separation of this extraneous incrus-
tation within them.
Scrofulous ulcers originate either from glandular swellings, which
inflame and break; or else the skin spontaneously inflames in various
places, and ulcerates. In general they are not very painful ; their edges
are hard, irregular, and undermined. Their circumference, and indeed
the ulcers themselves, are of a pale red, or purple colour ; their bottom
is here and there covered with a yellow curd-like substance ; and the
matter secreted by them is thin. Although it is not the most usual dis-
position of a scrofulous ulcer to be very painful, it is occasionally met
with in this latter state, and particularly when scrofula is excited by a
course of mercury, or the ulcer is complicated, with dead or carious bone.
The cicatrix of a scrofulous sore generally exhibits a very puckered ap-
pearance, with small portions of projecting skin, and even complete
bridges of it, allowing a probe to pass under them. The healing of a
scrofulous sore is often followed by the advance of other tumours to sup-
puration, or the formation of new ones. Thus one train of evils succeeds
another, till the discharge and irritation together seriously weaken the
patient ; or the disease fixes on some organ of high importance in the
economy, followed by hectic derangement, extreme debility, loss of sleep
and appetite, colliquative perspirations, diarrhoea, and a state of more or
less urgent danger.
One of the common effects of scrofula is a remarkable tendency to the
formation of chronic abscesses. Their frequent occurrence in the absorbent
glands I have already noticed. The same disposition to suppuration is
also exemplified in discharges from the ears, nose, vagina, and lachrymal
passages, so common in scrofulous children. A similar tendency is like-
wise often manifested in the cellular tissue of different regions. The
cases, termed psoas, or lumbar abscesses, have long been veiy correctly
regarded as scrofulous : in fact, many patients, afflicted with them, have,
or have had scrofula in other forms. Most of those indolent collections
of pus, which are termed by the French abcesfroids, are true scrofulous
diseases ; and in many instances originate from the irritation of a dis-
eased bone, or joint near them. It is indeed of great practical importance
to remember, that many scrofulous abscesses do not begin with disease of
the soft parts, but with morbid changes in the synovial membranes, carti-
lages, or spongy parts of the bones. Lumbar abscesses are generally
connected with disease of the vertebrae ; and scrofulous suppurations in
the hand or foot are mostly a secondary effect of disease of the phalanges
of the fingers or toes, or of the carpal or metacarpal, or of the tarsal or
metatarsal bones. Many abscesses of the ear in scrofulous children are
likewise complicated with necrosis of the meatus auditorius, or even of
the ossicula within the tympanum. While the lymphatic and mesenteric
glands, the skin, the eyes, the ears, and joints are particularly liable to
scrofula in children and young subjects, the lungs become after the ar-
rival of puberty equally prone to tubercles, which are now set down by
the greater number of pathologists as a form of scrofulous disease.
Those who doubt the accuracy of this doctrine, observe, that the time
of life for scrofula is from childhood to puberty, while tubercular phthisis
does not usually show itself before the latter period, and prevails most
extensively between the ages of twenty-five and thirty-five ; that is, in
the very stage of life when the tendency to scrofula appears to terminate.
They remark that individuals often reach the worst stages of scrofula,
without exhibiting any symptoms of tubercular formations ; while, on the
SCROFULA OR STRUMA. 367
other hand, these latter very frequently take place unaccompanied by
any scrofulous affection. It is declared, that in Scotland, Belgium,
Dauphiny, Le Valais, Lower Brittany, and some other parts of the world,
there is less phthisis than in other countries, where scrofula is much less
common. These arguments, plausible as they may seem, do not appear
to me to carry great weight ; because tubercles, regarded as a form of
scrofula, are admitted to be influenced in their production by the age of
the individual, and, no doubt, also under particular circumstances, by the
climate and country in which he resides. Hence the tubercular varieties
of scrofula may bear a larger proportion to other forms of this disease in
one place than another, and always do so between the ages of twenty-five
and thirty-five. Thus we know, that tubercles and other scrofulous
diseases more frequently exist together than is sometimes imagined.
Tubercles or tubercular formations consist of a greyish semi-trans-
parent caseous, inorganic substance, and in their smallest size are not
larger than a millet seed ; but by agglomeration often produce much
larger masses. In time, they become softened, and this change is fol-
lowed by suppuration. As they are often extensively disseminated in
the lungs, they destroy the original texture of these organs, which become
disqualified for the efficient performance of respiration. The matter
formed in the situation of tubercles, termed vomicaB, making its way into
the ramifications of the bronchi, is coughed up from the trachea, occa-
sionally mixed with blood. Pulmonary phthisis is thus really a scrofulous
disease. But the lungs are not the only viscera, in which scrofulous tu-
bercles frequently occur, for they are met with in the spleen, peritoneum,
intestines, brain, and liver.
Tubercles, as I have already stated, are at present mostly regarded as
effects of scrofula, and though Dr. Abercrombie detected some differences
between the constituent parts of scrofulous glands and pulmonary tuber-
cles, Professor Carswell tells us, in his Illustrations of the Elementary
Forms of Disease, that he detected the tubercular deposit in abundance
both in the lymphatic glands, and in those of the mesentery, when the
seat of scrofulous disease. It may exist in the tissues in an infiltrated
state, as in the bones and around the joints ; and although the character
of the affection does not change, the name of tubercle is here no longer
assigned to it.*
The lymphatic glands are frequently attacked by scrofula in a secon-
dary way. Thus, in children afflicted with porrigo, the glands under the
ear and lower jaw after a time inflame, and, if the constitution be scrofu-
lous, they will become the seat of strumous disease. They may also
swell from the irritation of catarrh and sore throat. When the glands
of the mesentery become diseased, it is often in consequence of a diseased
state of the mucous membrane of the bowels. The glands in the groin
and armpit frequently swell, as the consequence of disease in the adjoin-
ing limb, and where a tendency to scrofula prevails, such swelling will
be so influenced by this condition of the system, as to become af tedious
scrofulous abscess or ulcer.
That some peculiarity of constitution, original or acquired, must be a
predisposing cause of scrofula, is now generally acknowledged, difficult
as it is to define precisely what the nature of such peculiarity may be.
According to some pathologists, there is an undue preponderance of the
white over the red tissues, or, as Portal supposed, a deficiency of red
* Eager in Dublt Journ. of Med. Science, vol. v, p. 345.
368 SCROFULA OR STRUMA.
blood in relation to the great quantity of colourless fluid in the vessels.
Baudeloque ascribed the disease to some imperfection in the original
preparation of the blood; Bordeu to derangement in the nutrition of the
different textures of the body. An individual, originally free from a
scrofulous diathesis, but afterwards exposed to certain noxious influences,
may become the subject of scrofula ; indeed, under certain circumstances,
scrofula may perhaps affect any kind of constitution.
What is called a scrofulous constitution, is not invariably accompanied
by the same appearances. Some individuals have a pallid countenance,
a deficient proportion of vessels filled with red blood,, and a redundance
of white tissues, the abdomen is tumid, the muscles are loose and flabby,
the circulation is languid, and there is a want of vigour both in the mind
and body. Other subjects of scrofulous diathesis have a great deal of
colour, an accelerated circulation, and a precocious development of the
mental and corporeal powers. In such persons, it cannot be said, that
there is any deficiency of vessels containing red blood. With regard
to the scrofulous diathesis, which often seems to be congenital, though it
may undoubtedly be acquired after birth from the influence of various
detrimental circumstances on the system, it appears to be referrible to
the fact adverted to by Mr. Lawrence, that each individual has some-
thing peculiar to himself in his bodily organisation ; that there are infinite
varieties of natural organisations in the human species, and that, in indi-
viduals, distinguished by some of them, there is a greater or less sus-
ceptibility of particular forms of disease. This view would not, however,
lead me to doubt the fact, that a constitution, originally perfect, may be
so changed by various influences as to become at a subsequent period
prone to scrofulous disease. Still those constitutions, which are con-
genitally disposed to scrofula, will have the disease brought into action
by causes which will not invariably excite it in other temperaments.
Amongst the exciting causes of scrofula are usually specified various cir-
cumstances tending to produce debility, or, at all events, to leave the
system in a seriously disordered state, as fevers from contagions of a
specific kind, like measles, scarlet fever, and small-pox. Hence, pre-
viously to the introduction of vaccination, scrofula prevailed even to a
greater extent than at the present time.
Of late years, scrofula, and many other diseases, have been ascribed
to disorder of the digestive functions, little trouble being taken to con-
sider fairly whether such disorder may not be rather the common effect,
or accompaniment of such diseases, than the cause of them. To say
that, in scrofula, there is always more or less disorder of digestion, and
primarily of no other important function, is an hypothesis that cannot
be reconciled with the fact of the occasional existence of scrofulous
disease in the foetus. Impure air, unwholesome diet, unhealthy employ-
ments, uncleanliness, and exposure to a damp cold atmosphere, are
undoubtedly frequent exciting causes of scrofula, and sometimes com-
municate a disposition to the disease, even where none originally pre-
vail,ed. Yet these noxious influences will operate to this extent only in
a limited proportion of individuals ; for we find, that in a given number
of children, all living together under the same roof, breathing the same
atmosphere, feeding and sleeping together, and clothed exactly alike, only
two or three become scrofulous. Here then we must return to predis-
position, and original kind of constitution, organisation, or susceptibility,
as an explanation of the difference.
Of all the exciting causes of scrofula, the operation of climate is the
SCROFULA OR STRUMA. 369
most powerful ; for scrofula prevails in the greatest degree in countries
which are remarkable for their damp, cold, and variable atmosphere.
Individuals, living in warm regions, are more rarely affected ; but no
sooner do they come to a damp cold changeable climate, than they are
even more liable to scrofula than other persons. This is exemplified
in the great frequency with which children, brought from the East and
West Indies to this country, suffer from the disease. The same thing
is also seen in African Blacks, and the natives of the South Sea Islands,
many of whom are destroyed by tubercular phthisis. The monkey also,
a native of warm regions, is in the same case.
Notwithstanding the general truth of the preceding statements, re-
specting the comparative rarity of scrofula in hot, and also, I believe, in
extremely cold countries, it is certain that the disease, and this even in
its worst or tubercular form, is a source of considerable mortality in
Italy, Spain, Minorca, Malta, and several other countries, whose shores
are washed by the Mediterranean Sea.
It is probably in consequence of the influence of damp and cold in
promoting scrofula, that patients generally suffer more from it in one
season of the year than another ; their complaints being worse in winter
and spring, and better in the mild dry weather of summer and autumn.
Besides atmospheric influence, various other influences deserve to be
regarded as promoting the occurrence of scrofula, especially where the
organisation of the individual renders him, as it were, predisposed to the
disease, and he is residing in a climate favourable to its origin. Im-
proper or insufficient diet, neglect of regular exercise, bad nursing, insuf-
ficient clothing, inattention to cleanliness, and the residence of children
in badly-ventilated crowded dwellings. Hence the frequency of scrofula
amongst children who work for many hours daily, crowded together in
the unwholesome atmosphere of cotton factories, often badly fed, and, at
all events, deprived of that beneficial influence, which due exercise in the
open air would have upon their digestive, cutaneous, nervous, sangui-
ferous, and muscular systems. Period of life has considerable influence,
not only in facilitating the attack of scrofula, or in making the individual
less susceptible of the disease, but in determining the organs and textures
in which it will be most likely to take place, if it is to come on. The
period of life, between the termination of suckling and the arrival of
puberty, is that in which the greatest tendency to scrofula prevails. In
many individuals, as Mr. Lawrence observes, the whole of this period is
occupied by a succession of attacks of scrofulous disease in the absorbent
glands, the skin, and the joints, and very often it exists in several of
these parts at one and the same time. In individuals who have had
scrofula in these various shapes, extending over the whole of the body,
and who have been for several years the subjects of the most serious
forms of disease up to the time of puberty, it is by no means uncommon
to find the attacks then decline, and such persons to become healthy
and vigorous. At the time, however, that this particular chang^ takes
place, and the succession of disease in the eyes, glands, ears, joints, and
skin is stopped, it not uncommonly happens, that the disease is de-
veloped in other more important parts, as the lungs, the mammary
gland, or the testicle. Sex also makes some difference ; for, according
to a calculation of M. Louis, the proportion of scrofulous males to
females is only as seventy to ninety-two, or according to the estimate
of Lepelletier, as three to five. This fact is ascribed by M. Jolly,
B B
370 TREATMENT OF SCROFULA.
Dr. Stokes, &c. to the greater abundance of white tissues in the latter
than the former.
Scrofula is not contagious. Kortum, Pinel, Alibert, Dupuytren, Lepel-
letier, and others, tried in vain to communicate the disease, either by
making healthy children sleep with scrofulous ones, or rubbing the skin
of a healthy child with scrofulous matter, or by inserting it under the
cuticle, or introducing in into the veins or stomach. With respect to the
power of a scrofulous nurse to impart scrofula to the child at her breast,
it is sometimes suspected that, as her milk is imperfect and not well
adapted to nutrition, she may communicate to such child a predisposition
to the disease ; but the notion of her doing this by the action of any
contagious principle, or virus, is now universally rejected. Even the
suspicion adverted to is far from being unequivocally well founded.
According to M.Lepelletier, privation of solar light has considerable in-
fluence in giving a tendency to scrofula ; but, though it certainly occasions
a pale complexion, a flaxidity of fibre, and a general bloated appearance,
these changes may not amount exactly to the state implied by the term
scrofula. Independently of the redundance of white tissues and fluids,
conjectured to form one of the chief attributes of a scrofulous consti-
tution, and at the same time one of the chief anatomical characters of
scrofula, there is no doubt that the composition of the fluids of scrofulous
individuals is more or less altered ; especially that some of them contain
an extraordinary proportion of the phosphate and carbonate of lime and
the chloruret of soda ; and that these same principles enter copiously into
scrofulous tubercles. M.Labillardiere, a chemist at the Veterinary School
of Alfort, has ascertained that the milk of a cow, affected with tubercles,
contains seven times as much phosphate of lime as the milk of a healthy
cow.
The vascular system of scrofulous persons appears to Dr. Macartney
to be weak, the vessels small, the blood deficient in quantity, and not
possessing the full power of generating coagulating lymph. The secre-
tions, which indicate strength, seem to him to be deficient ; the fat of
the soft parts, and the marrow of the bones, to want the genuine oily
composition ; the earth of the bones not to be formed in proper quantity;
the unctuous secretions of the skin to be deficient ; the sebaceous secre-
tion to be albuminous and inodorous, and liable to dry and produce irri-
tation of the parts it ought to protect. The mucous and serous secretions
appear to Dr. Macartney to be the only ones perfectly formed; and he
describes the brain as pale, and not having the usual quantity of red
blood. *
TREATMENT OF SCROFULA.
On this subject I shall here make only a few general observations,
because the practice, applicable to particular forms of the disease, is more
conveniently considered in other parts of this work.
A scrofulous constitution will generally derive infinitely greater benefit
from regimen, diet, pure air, proper exercise, &c. than from medicines,
which are not, however, to be neglected. The cure of some forms of
scrofula will mainly depend on improvement of the system at large, as
may be said to be the case with scrofulous ulcers. But there are other
examples, in which the local treatment is more efficacious than the inter-
* On Inflammation, p. 82.
TREATMENT OF SCROFULA. 371
nal ; and such is scrofulous disease of the bones and joints, as well as one
variety of lupus, a tubercular affection of the skin of the nose, now fre-
quently regarded as scrofulous.
When we remember the circumstances which operate as exciting causes
of scrofula, we must immediately see, that one of the chief means of ob-
viating that morbid condition of the system, which accompanies scrofula,
is the removal of the patient from the reach of various detrimental influ-
ences. If he be residing in a damp, cold, badly ventilated, crowded
place, he should be immediately taken from it. If his diet be faulty in
point either of quality or quantity, it should be rectified. If his clothing
be insufficient to protect him effectually from the influence of damp and
of sudden changes of the atmosphere, it should be made warmer. If the
patient be a child, kept in a sedentary state, working in some crowded
factory for a great part of the twenty-four hours, it should be taken from
such employ and place, and allowed to have the benefit of a salubrious
air and healthy exercise.
The doctrines of the late Mr. Abernethy make the principal indication
in the treatment of scrofula to consist in the improvement of the state of
the digestive functions. While I do not admit the truth of the theory,
that the origin of scrofula is essentially dependent on disorder of the
digestive organs, I fully concur in the advice, that we should always
endeavour to restore the natural and healthy functions of those important
viscera when in any respect deranged. This indication, in fact, has
not been neglected by practitioners who lived half a century ago. Who-
ever compares the practice of Mr. Charles White, in giving small doses
of calomel, occasional purgatives, and the simple or compound decoc-
tion of sarsaparilla, with the blue pill, sarsaparilla, and laxative treatment
of Mr. Abernethy, will see no very material difference between them,
especially when the stress, which White laid upon attention to diet,
clothing, the avoidance of damp and cold, and the usefulness of good air
and regular exercise, is taken into the account. Mr. Abernethy's prac-
tice consisted in giving five grains of the blue pill every night, half a
pint of the compound decoction of sarsaparilla twice a day, and, if the
bowels did not act by a certain hour every day, some aperient medicine
was administered. The plan was followed up until the bowels became
regular ; and then, with the view of preventing a relapse, five grains of
the compound calomel pill were given every night for an indefinite time.
When acidity prevailed, small doses of the carbonate of soda were pre-
scribed ; and when the stomach was weak and the appetite bad, bark,
steel, and the mineral acids were recommended.
A light nutritious diet is generally found to agree best with scrofulous
patients ; but it should not include wine and porter, unless the forms of
disease are attended with profuse suppuration and hectic debility. When
the tongue is foul, the breath bad, and the belly tumid, it is advisable to
let the treatment commence with brisk purgatives, as jalap and scam-
mony, or the compound powder of scammony, or the antimonifrl powder
and calomel. Such medicines may be given in proper doses at night,
and their operation promoted by giving the senna mixture, or castor oil,
on the following morning.
The bowels, having thus been well opened, we may next employ milder
medicines of the aperient and alterative kinds, as rhubarb and the sub-
carbonate of soda, to which a small quantity of mercury with chalk may
be added. Then, with such treatment may be combined, after a short
time, the employment of tonic medicines, as the infusion of cascarilla, the
B B 2
372 THE VENEREAL DISEASE.
sulphate of quinine, and other preparations of bark, or the infusion of
calumba, with or without the vinum ferri, or we may give either the
compound infusion of gentian, with the subcarbonate of soda ; or else
the compound decoction of sarsaparilla, with the diluted nitric or sul-
phuric acid. Those who believe in debility, as essentially conducive to
the origin of scrofula, place their chief dependence on tonics, and espe-
cially bark, quinine, steel medicines, and cold sea-bathing, or the shower
bath, and flesh-brush. If the skin be dry, antimonials are used. Mercury
has sometimes been decried as decidedly injurious to scrofulous patients;
but this is only a prejudice, apparently derived from the notions about
debility, or from the fact of scrofula often following a course of mercury,
instituted for the cure of syphilis. Mercury in small alterative doses is
often beneficial; and, in scrofulous ophthalmy, even the freer use of it one
of the best means of removing the opaque matter sometimes effused in
the cornea.
The fear of prescribing mercury for scrofulous patients has now,
however, nearly subsided; and surgeons frequently order, besides the
preparations I have mentioned, the bichloride, one grain of which is
dissolved in an ounce of the tincture of bark, and given in the dose of a
teaspoonful, three or four times a day. All the foregoing plans are
founded upon the aim of improving the health in general, and do not
embrace the idea of combating scrofula with any specific. Amongst the
medicines, which have attracted celebrity for their supposed specific
virtues against scrofula, I have to mention conium or hemlock, the chlo-
ride of lime, the chloride of barytes, the sesquicarbonate of soda, and
preparations of iodine. As for hemlock, it has now lost the reputation of
being a specific, though sometimes prescribed in equal proportion with the
compound calomel pill as an useful alterative. The chlorides of lime
and barytes, I believe, are completely out of favour. The sesquicar-
bonate of soda is undoubtedly a useful medicine ; but not entitled to be
regarded as possessing any specific power over the disease. It is often
joined with rhubarb and a few grains of the hydrargyrum cum creta, or
with rhubarb and cascarilla; which formula are sometimes beneficial as
alterative medicines, but nothing more. With respect to iodine, it is at
present in considerable repute, and as prescribed by Dr. Lugol for internal
use, in small doses, varying from half a grain to two grains in the twenty-
four hours, dissolved in distilled water, with double its proportion of
iodide of potassium, seems to possess considerable power over some forms
of scrofula. Dr. Lugol also employs iodine in baths and lotions to a much
greater extent than is done in this country. His baths contain about two
grains of iodine in each pint of water, and' his lotions for ulcers, &c.
about one grain and a half, dissolved with iodide of potassium.
OF THE VENEREAL DISEASE.
LUES VENEREA SYPHILIS.
By the " venereal disease " are usually signified certain morbid changes,
produced in various textures of the human body by the action of a specific
morbid poison. Some writers, however, extend the meaning of the ex-
pression further ; for they make it comprehend not only syphilis, or the
true venereal disease, but also clap, or gonorrhoea, sores of different descrip-
THE VENEREAL DISEASE. 373
tions on the genitals, and numerous effects or accompaniments of the
latter complaints. Such writers do not speak of the venereal disease in
the singular, but in the plural number, and offer a description not of one
disorder, but of several, under the appellation of venereal diseases, the
varieties of which are sometimes ascribed to the existence of different
kinds of venereal poison, each capable of producing distinct and peculiar
effects on the part and constitution.
Now, if it be inquired what we know about any venereal poison, and
what proof we have of its existence, the answer is, that it has never been
detected in a separate form, and nothing is known respecting its appear-
ance, colour, consistence, or any of its general or chemical qualities.
Venereal pus, considered in all its relations, may present globules more
or less similar to those of other kinds of pus ; it may, according to
situation, be mixed with other secretions, normal or morbid, especially
with mucus ; but its most distinguishing property is that of being capable
of inoculation,, the results of which are characteristic and specific.*
The only further explanation that can be given of it, is perhaps what
Mr. Lawrence has suggested, namely, that it is that state of the secretion
of a sore, which renders it capable of producing the disease in another
person, or that state of the blood in the mother which renders it capable
of communicating the disease to the foetus in utero; but what that par-
ticular state is we are unable to describe ; we are only able to observe
its effects, and judge from them that a virus or poison is concerned.
A chancre, or primary venereal sore, produces pus of the specific kind,
however only in a certain stage of it ; and, as M. Ricord believes, it is
from inattention to this simple fact, that the results of inoculation with
the matter of venereal sores have been disputed or involved in uncer-
tainty. It is plain that a primary syphilitic ulcer cannot be the same in
all its stages, and that it could never heal up, did it not at length change
into a simple sore. If we are to believe M. Ricord, it is during the
progress or the stationary state of a chancre, while no work of cicatrisation
is going on in it, that it secretes the venereal virus, which is not at all
dependent upon the greater or lesser degree of inflammation accom-
panying the chancre.f On the other hand, Dr. Wallace inferred, that a
bubo was rarely or never formed, i. e. the poison was never absorbed so
as to affect the glands in the groin, until some part of the ulcer had
produced granulations, by which such absorption was effected. If this
view be correct, and the granulating process be a part of the work of
cicatrisation, the two foregoing doctrines are at variance with one
another ; but I am not sure that M. Ricord extends his meaning to the •
stage of granulation, for a chancre that has granulated may become
stationary.
It would not appear to be the nature of the venereal poison always and
inevitably to excite inflammation, ulceration, or disease of the part to
which it is applied in any shape; it cannot therefore be a very active and
quickly penetrating agent ; and though the proportion of case^, in which
the poison takes effect, is considerable, experience proves, that many
individuals, exposing themselves to the risk, come off with impunity.
When the contrary happens, the poison, after the expiration of a variable
space of time, which appears to be requisite for it to make an impression,
* See Ph. Ricord, Traite Pratique des Maladies V£neriennes, p. 55. 8vo. Paris,
1836.
t Op. cit, p. 85.
B B 3
374> THE VENEREAL DISEASE.
produces changes, not only in the part to which it is immediately applied,
but, at a subsequent period, in a giverv number of examples, disease in
other situations, in consequence of its absorption into the system.
Syphilis cannot be propagated from individual to individual through the
medium of the breath, nor of the atmosphere, nor apparently through the
medium of any of the ordinary natural secretions, and certainly never by
one person merely touching the sound part of the skin of another indi-
vidual labouring under the disorder, as was at one time believed.* With
the exception of what may happen between a syphilitic pregnant female
and the child in her womb, only one way is positively known in which
the disease can be communicated, and that is through the medium of the
specific poison, blended at the time of its application with pus, or some
other morbid secretion. Such infectious matter begins its action by
exciting inflammation, followed by a pimple, or pustule, which is gradually
converted into an ulcer. Of course, such ulcer is almost always on the
parts of generation ; but, if a person accidentally prick himself with a
lancet infected with venereal matter, or if such matter happen to come
in contact with any abraded part of the skin, syphilis may then com-
mence in other situations.
The symptoms or effects of the venereal disease are divided into the
primary and secondary. The primary are those which arise from the
direct application of the poison to the part, namely, ulceration of that
part, often followed by a swelling of the absorbent glands, to which the
lymphatics of the ulcerated texture first direct their course ; the sore
receiving the name of chancre, and the glandular swelling that of bubo.
The latter is deemed one of the primary etfects, because excited not really
by the poison after its entrance into the circulation (as all the secondary
symptoms are believed to be), but by its directly irritating the gland or
glands, as it is passing through this portion of the absorbent system into
the blood.
The application of the poison does not invariably cause a chancre. It
seems as if some individuals were less susceptible of the venereal disease
than others, and, no doubt, those who are attentive to ablution, after a
suspicious connexion, much oftener avoid being infected, than other
parties who neglect this precaution. Nor does the poison, when it gives
rise to a primary ulcer, or chancre, constantly lead to the formation of a
bubo. I may say, that in the majority of cases, the latter swelling is not
produced, and this sometimes even when secondary symptoms follow, and
the poison has found its way into the constitution.
The secondary symptoms are all those effects of the disease which take
place from the introduction of the poison into the circulation, whether ul-
ceration of the throat, cutaneous eruptions, ulcers, or excrescences on the
surface of the body, inflammation of the iris, various affections of the nose,
ears, testicles, larynx, or joints ; and, in the osseous system, severe pains,
nodes, caries, or necrosis. These secondary symptoms, which make the
constitutional form of the disease, do not occur, however, with any regu-
larity. In many cases, they never show themselves at all ; while in others,
they take place with great severity, though there may be no remarkable
differences in the appearance of the primary ulcers, or the kind of treat-
ment, to account for this diversity of consequences. In a given number
* While such doctrines prevailed, medical writers did not deem it at all indelicate to
publish the venereal cases, met with in virtuous princes, holy abbots, and pious prelates.
See Ph. Kicord, op. cit. p. 94.
THE VENEREAL DISEASE. 375
of cases of primary symptoms, under any plan of treatment, secondary
symptoms will occur only in a limited proportion of the patients.
M. Ricord, by means of inoculations with venereal matter, practised
repeatedly and extensively, has the merit of having, perhaps, settled some
points, relative to syphilis, which have until lately been a source of end-
less dispute. Amongst other things, his experiments prove, that the ces-
sation or the continuance of the primary complaint, whatever may be the
period of its duration, does not make the patient incapable of contracting
others ; and his investigations, verified by Fricke, Lallemand, Ruef, and
Blandin, fully establish the doctrine, originally promulgated by Hunter,
that the number of secondary symptoms is not at all in relation to that
of the primary ones ; and that no more constitutional effects will follow
two, three, four, or five chancres contracted at the same time, than if
there were only one chancre.*
In this work, I shall not dwell upon the facts and arguments against
the opinion, that the venereal disease began in Europe towards the close
of the fifteenth century, having been either brought to this quarter of the
world from St. Domingo by the followers of Columbus, or having broken
out from unknown causes in the French army then besieging Naples.
Every consideration that I have been able to give to the subject leads
me to believe, that the venereal disease has existed from time imme-
morial ; that it always has existed, and always will exist, in every popu-
lous country, where promiscuous sexual intercourse takes place. Those,
who ascribe the origin of syphilis to the latter part of the fifteenth cen-
tury, are much influenced by one fact, which is, that down to that period
no description of any disease, corresponding exactly to what we call
syphilis, had been given by medical writers ; and although ulcerations on
the genitals, and buboes, had been commonly treated of, no mention was
made of the secondary symptoms, no connexion was ever traced, or even
suspected, between the primary effects, as they are called, and the sore
throat, cutaneous affections, and the pain and swellings of the bones,
which we denominate secondary ones. Perhaps, however, it is scarcely
allowable to infer, that because no notice is taken of the secondary symp-
toms of the venereal disease in the old works on medicine and surgery,
that such complaints were not in existence previously to the close of the
fifteenth century. The relation of the primary and secondary symptoms
to one another might have been overlooked ; it might never have been
suspected when there had been a chancre on the penis, that the sore
throat, cutaneous affection, or node, which came on subsequently, had
any connexion with the sore. Certainly this will not seem incredible
when it is recollected, that it was not until a recent date that some par-
ticular effects of the venereal disease were made out ; and that, even at
the present day, with all the advantages of a better system of pathology,
our knowledge of many circumstances, relative to this extraordinary
disease, is very obscure and uncertain. Thus, two or three hundred
years hence, when it shall be recorded to posterity, that, at as Ifte a period
as the year 1800, no account had been given of syphilitic iritis, and that
the true character of gonorrhceal ophthalmia had not been described, I
think it would not be correct to infer, that those affections had no exist-
ence until the time when they began to be discussed in works on surgery.
Their not having prevailed, and their not having been described, are two
different things.
* Ricord, op. cit. p. 84.
B B 4
376 THE VENEREAL DISEASE.
Not only are diseases of the genitals acknowledged to have existed
from time immemorial, but we have every ground for believing, that they
were of a contagious nature. This seems proved by the precautions
adopted by various governments, to prevent the extension of such dis-
orders among the population. Thus, in the borough of Southwark, prior
to the time sometimes fixed upon for the origin of syphilis, there were
places called stews, where prostitutes were confined, and received the
benefit of surgical assistance. They were taken up and put into these
establishments, whether agreeable to them or not, by virtue of certain
decrees, made expressly to protect the rest of the community from the
risk of catching their complaints. At the same time, or even earlier,
similar establishments were formed in Paris, Edinburgh, Avignon, and
even in the holy city of Rome, under the Pope's nose, under the walls of
the Vatican itself, with an abbess at the head of it.
In relation to the origin of syphilis, one interesting question pre-
sents itself, namely, are we to fancy that the disease never had but one
primary source ? and that it is to the mysterious concoction of the
specific virus by one couple of individuals, that all quarters of the
world, and all generations, are under obligations for the gift of the vene-
real disease. No doubt, syphilis must have had a beginning, like every
thing else ; but probably it has had numerous beginnings. Various con-
siderations would lead us to expect (what is indeed the fact), that in
every country where the population is numerous, and promiscuous sexual
intercourse exists, the venereal disease would be prevalent. Mr. Travers
expresses his conviction, that if all the syphilis in the world were now
to be annihilated, a never-failing source of the disease would still remain
in the action of the matter of superficial or gonorrhceal ulcers of the
penis on the human constitution. If I have a correct comprehension of
this gentleman's views, however, he looks upon the poison of syphilis and
that of gonorrhoea as identical, and the suggestion which I have quoted
from his interesting remarks on the pathology of the venereal disease,
perhaps, necessarily involves that conclusion ; but this is a disputed point,
and the greater number of professional men do not now take the same
view of it as John Hunter did. The experiments of M. Ricord are as-
serted, indeed, to furnish complete and ocular proof, that whenever
inoculation with what is called gonorrhceal matter communicates the
venereal disease, chancres exist in the passage, which is the source of the
matter of the supposed gonorrhoea. Some persons, as Dr. Macartney
notices, are subject to inflammation of the glans penis and prepuce, after
copulation with healthy women. Sometimes a female will suffer after mar-
riage an extensive inflammation of the internal labia and vagina, attended
with a purulent discharge, although no venereal disease has been com-
municated. Dr. Macartney conceives it possible, that the transmission
of pus, generated in this way, and mixed with other secretions, might
have given origin to true venereal inflammation.*
I have explained, that the venereal disease is commonly believed to be
communicable only through the medium of pus. The late Mr. Hey, of
Leeds, was induced, however, to regard this doctrine as incorrect ; and,
from some cases which came under his observation, he suspected that
the disease might sometimes be communicated, not only after all ulcera-
tion and suppuration had ceased, but even when the person giving it to
another was to all appearance in perfect health ; but whoever reads the
* See Macartney on Inflammation, p. 103.
THE VENEREAL DISEASE. 377
cases, on which Mr. Hey founded this extraordinary inference, will per-
ceive how great was the possibility of his being deceived by the patients,
who gave him the histories of their cases. Some particulars involved the
honour of the individuals themselves, and therefore they might have
been ashamed of disclosing every secret relative to their cases. It is
more rational, I think, to suppose that Mr. Hey had been deceived by
the patients themselves, than that any such mysterious sources of infec-
tion existed, as those implied by his view of their cases. The idea that
syphilis can be communicated by a person so healthy, that he has no
venereal matter formed upon any part of the surface of his body, or in-
deed any visible or palpable complaint whatsoever, is a problem, that
every thing yet ascertained about the nature of syphilis tends to refute.
As the venereal disease may be transmitted from the mother to the foetus
through the medium of her blood, many surgeons have been inclined to
suspect that it may be also communicated through the medium of the
natural secretions, such as the saliva, the semen, the milk, &c. With
respect to the foetus we may infer, that it receives the infection by means
of the circulating blood, in the same manner as the mother herself receives
her secondary symptoms ; but with regard to the saliva, semen, and milk
there is no clear evidence that these natural secretions will serve for the
transmission of the disease. I believe with Mr. Travers, that none of the
common natural secretions of a contaminated individual can communicate
the disease to other persons. The following statement in this gentleman's
work is interesting : a man who has syphilis in the secondary form, pro-
vided he be free from all affections of the genitals, will communicate no
taint to his progeny, any more than to his wife; but a healthy wet nurse,
getting a sore nipple in consequence of suckling a pocky child, and having
secondary symptoms, will communicate the disease to the foetus of which
she may become pregnant. Now this is agreeable to the usually received
opinions, that the blood will contaminate the embryo, though all genital
sores may be absent, and though the party cohabiting with the woman,
is beyond the sphere of the influence of the disease in her. So far., then,
as the present state of our knowledge reaches, we may conclude, that the
disease is only communicable through the medium of purulent fluid, and
not an ordinary natural secretion, with the exception of the mode of its
transmission to the foetus, which receives the infection through the circu-
lation, and may be regarded as under the same circumstances, with respect
to the secondary effects of the disorder, as the mother herself. There may
also be an exception to the general principle in what happens between
the pocky child and its nurse, provided the disease in the former is to be
regarded as the constitutional modification of it, transmitted through the
blood of the mother.*
The effects of the venereal disease are different in different individuals ;
two men may have connexion with the same woman ; both may catch
the disease, but one will have it severely, and the other only in a slight
and mild form. One man has been known to give the disease to different
women ; some of whom have had it in a lenient shape, while the others
have suffered most severely. Sometimes the same individual will have
* Certain descriptions would tend to prove, however, that the ordinary secretions of
the female organs are sometimes the medium or vehicle of infection. M. Ricord joins
in the belief, that the disease may be communicated through the medium of common
secretions, mucus, milk, &c. " If," says he, " the mouth of a child may infect its
nurse, the breast of the nurse may infect the child." Op. cit. p. 95.
378 THE VENEREAL DISEASE.
two or more sores of different kinds at the same time. In some examples,
sores of the Hunterian character are seen on the glans penis, while sores
of other descriptions are close by them. One of the most curious cir-
cumstances in the venereal disease is not unfrequently exemplified in the
army : soldiers are sometimes gregarious in their amours : a party of six-
or eight will have connexion, one after another, with the same woman.
In this manner, several men contract disease from the same source, and
on one and the same occasion ; yet they do not all suffer in the same
manner. Some have sores of one kind ; some of another ; and some,
various sorts of ulcers; while others will contract a discharge from the
urethra. That discharge, however, according to the experiments of
M. Ricord, if capable of communicating a chancre by inoculation, has
always for its source some venereal ulceration in the part from which it
proceeds. It is not, however, every gonorrhoea, or discharge from the
urethra, that has this property.
" Ever since I have employed the speculum uteri in the investigation
of venereal complaints (says M. Ricord), many perplexities about them,
previously inexplicable, have been reduced to the most ordinary and
simple facts. With this instrument I have ascertained, that a woman may
be simultaneously affected with blennorrhagia and deep-seated chancres in
the vagina and uterus, so that, though considered only to be labouring
under blennorrhagia, she might well communicate chancres and blennor-
rhagia together, or merely one of these affections." M. Ricord further
declares, as the result of numerous observations, that whenever he has
had the opportunity of examining women who had communicated disease,
he had never found that a chancre had originated from a discharge, un-
attended with ulceration in the genital organs of the female from whom the
complaint was contracted. Inoculation afterwards confirmed what the
observations made with the speculum had established. It is not, however,
according to M. Ricord, every state of ulceration in the vagina or womb,
keeping up a discharge, that will admit of a chancre being produced by
inoculation with such discharge ; for, if it be in the granulating stage, it
is no longer adapted to this purpose. On this point, however, M. Ricord
leaves us in some difficulty; for, in another part of his work (p. 137.) he
admits, that what he terms the specific ulcerative period is indefinite, and
that he has inoculated with pus derived from sores of eighteen months'
continuance.
Supposing it to be clearly proved, continues M. Ricord, that " the
muco-purulent secretion, taken from the female genital organs, can never
produce a chancre, when the speculum demonstrates that no ulcerations of
this nature exist in those parts, it is allowable by the most rigorous analogy
and the closest logic to conclude, as I have done, that whenever a discharge
from the male urethra has communicated a chancre to a woman, there must
have been something more than gonorrhoea about the man, and the urethra,
at some point of its extent, must have been the seat of a chancre."
As for the Hunterian hypothesis, which supposes the cause of gonorrhoea
and syphilis to be identical, and the difference of effect to depend upon
the textures affected, the poison when applied to a non-secreting sur-
face being supposed to give rise to chancre, and applied to a mucous one
being fancied to occasion gonorrhoea, M. Ricord argues, that, if this were
true, the muco-purulent discharge from the urethra ought, when put on
the skin, to cause a chancre ; and the pus of a chancre, applied to mucous
membranes, ought to cause gonorrhoea. But M. Ricord asserts it as a
well-known fact, that gonorrhceal matter never produces chancre on the
THE VENEREAL DISEASE. 379
skin, and that when it is applied to any raucous membrane, and has effect,
it gives rise only to a discharge. He further observes, that the matter
from the urethra, applied to the mucous membrane of the eye, has never
caused chancres in that texture, or the eyelids ; nor, on the other hand,
says he, has the muco-purulent secretion ofgonorrhceal ophthalmia ever given
rise to chancres by inoculation, or otherwise, although the eyelids are ca-
pable of being the seat of such ulcers. When a bubo has originated from
gonorrhoea, and suppurated, M. Ricord has constantly found, that no dis-
ease can be imparted by inoculation with the matter. The same fact he
has repeatedly made out in relation of the matter of abscesses, now and
then following inflammation of the testicle from clap.
Many of the circumstances, which have been noticed, are adverse to
the opinion, that syphilis is owing to a plurality of poisons ; for here
are many different effects, apparently produced from the same source.
Facts of this nature, however, create considerable difficulty in the investi-
gation of syphilis, — a difficulty that cannot be solved by reference to pe-
culiarities of constitution or states of health ; for certainly no explana-
tion on these principles will account for two or three different kinds of
sores occurring in the same individual on the same part, and all at the
same time. Neither can the circumstances be ascribed to the differences
of texture between the prepuce, glands, and corona glandis. No doubt,
the kind of texture often modifies the appearances of sores ; but this will
not explain the peculiarities I have mentioned, because sores of different
kinds are met with on one and the same texture ; as, for instance, on the
prepuce, or on other parts of the skin of the penis. The researches and
experiments of M. Ricord, however, if established beyond all doubt, would
throw considerable light on some points here noticed. I would also re-
mark, that before any inference can be drawn from the circumstances
mentioned with respect to profligate soldiers, a minute investigation
into their cases would be essential ; for it is hardly to be credited, that
such individuals would not be in the custom of cohabiting with a great
number of women in a short space of time, and not merely with the one
who received them in a gregarious way.
That the effects of the venereal disease are modified by climate, mode
of life, and state of the general health, is universally acknowledged.
Hence syphilitic affections get well with greater facility in warm cli-
mates, and the symptoms are much milder there than in cold countries.
The observations, made by Dr. Ferguson on the venereal disease in
Portugal and the West Indies, leave no doubt on these points. When
the British army was in Portugal, our soldiers suffered severely from
this disease ; yet the natives, from whom they caught it, had it in an
exceedingly mild form ; so that, while amongst our troops it made
terriblfc ravages, occasioning in many of them the worst of mutilations,
the natives suffered but very slightly, and got well under what would
here be regarded as inert treatment. Attempts have indeed been made
to explain these facts by the greater excesses which our soWiers were
guilty of, and their habit of drinking more spirits and wine than the
Portuguese ; and no doubt, these circumstances must have had some
share in rendering the disease worse in them, than in the more abste-
mious natives. Another question is, whether the greater mildness of
the symptoms of the venereal disease in warm than in other countries,
is to be ascribed to any modifications or changes in the nature of the
poison, produced by the temperature or atmospheric causes ? I think
what has already been stated will refute this notion; for it appears
380 THE VENEREAL DISEASE.
that in Portugal the British soldiers suffered severely from the dis-
ease ; consequently, the virus must have possessed sufficient activity,
provided the ravages alluded to were truly occasioned by the operation
of the virus, and not by phagedenic diseases, independent of such a
cause. Another question is, whether the greater mildness of the dis-
ease in warm countries is owing to the effects of the atmosphere in
rendering the individual less susceptible of the influence of the disease ;
or whether it maintains the system in such a state as makes the dis-
ease yield more readily to the remedies employed. All these points
are still disputed ones. The opinion, that the disease is continually
getting milder and milder, and will in the end cease altogether, has
been entertained almost from the earliest periods ; at all events, nearly
from the time of its supposed origin, towards the close of the fifteenth
century ; but, instead of adopting this conjecture, a more rational
way of explaining its greater mildness at the present day will naturally
suggest itself to every man of judgment and reflection ; viz., by the
consideration of its treatment being now conducted with much greater
skill and discrimination, than it was forty or fifty years ago. Many,
who incline to the opinion that the disease originated towards the
close of the fifteenth century, lean also to the belief, that the disease is
continually changing its nature, and becoming milder ; for if they did
not shape their conclusions in this manner, they would be obliged to re-
nounce tlie other doctrine, respecting the time of the first origin of
syphilis : because the venereal disease of the present time is totally
different from the rapidly fatal and infectious disorder which broke out
in the French army before Naples. As a matter of course, therefore,
they must think, that syphilis has changed its nature, and assumed milder
forms. Within my recollection, the disease was more severe than it is
now ; but the cause of this fact I should account for on a different prin-
ciple; in fact, when I was a student at St. Bartholomew's Hospital, the
treatment of this disease was what would now be considered injurious in
the extreme, for it consisted in the administration of mercury in the most
unmerciful and indiscriminate manner. The practice in those days was
founded, indeed, on a doctrine now exploded, viz., that it is the invariable
character of syphilis to proceed from bad to worse, unless checked by
the power of mercury. This was undoubtedly a most pernicious error —
one that led to the death of many unfortunate persons. When Mr.
Abernethy was making investigations into the nature of the venereal
disease, he went to all the most experienced hospital surgeons in London,
and put these questions to them — whether the venereal disease is
capable of spontaneous cure, and whether the primary symptoms can be
removed and the disease be permanently cured without the aid of
mercury ? and from all these men of eminence he received the answer,
that a spontaneous cure, or even one without mercury, was totally im-
possible. In those days, then, the opinion prevailed universally, that
the disease would be sure to extend itself, and could not possibly admit
of a salutary change, unless the patient were put under the influence
of mercury. However, in the year 1813, in one of the early editions
of this work, I happened to take into consideration some observations,
inserted by the late Mr. Pearson in his Treatise on the effects of certain
Articles of the Materia Medica in the Cure of Lues Venerea, and from
which it clearly appeared to me, that what he stated was absolutely
equivalent to an admission, that syphilis would sometimes, at least, get
well under the administration of the most inert medicines. Although
THE VENEREAL DISEASE. 381
this gentleman, whose experience at the Lock Hospital was unbounded,
may be said to have added the weight of his authority to the mainte-
nance of all the principal Hunterian doctrines relative to syphilis, any
impartial man who studied his book could not fail to discern the clear
admission in it, that a beneficial change was often brought about, in
syphilitic cases, without the exhibition of mercury. Since the year
1813, the correctness of the view, which I then took, has been fully con-
firmed by subsequent experiments and observations. Amongst the in-
vestigations to which I allude, those made in the hospital of the Cold-
stream Guards by the late Mr. Rose are the most important. The great
question, as to the spontaneous curability of syphilis, was by him com-
pletely settled. It was proved, that the venereal disease might be cured,
not only without mercury, but without any medicines whatever. As for
the cure without mercury, that indeed may be said not to have been a new
discovery : the spontaneous cure was the great point made out. Many
practitioners of the sixteenth and seventeenth centuries treated the vene-
real disease with considerable success without mercury, that is to say,
by means of guaiacum, sarsaparilla, and antimony, occasionally aided by
venesection and purgatives. If it had been the character of the venereal
disease always to grow progressively worse without mercury, no patient
could ever have recovered prior to the epoch when that medicine began
to be exhibited, which is contradicted by abundant evidence.
Mr. Rose had vast opportunities of bringing the question to a decision ;
for he could not only put his patients under particular treatment, but he
had it in his power to enforce its strict adoption, and to watch his patients
for the requisite period of time. Now, he cured without mercury all the
ulcers on the parts of generation, sores of every kind, which he met
with in the course of between two and three years in a regiment of
soldiers, together with all the constitutional symptoms that followed them.
It is not to be understood, that none of those, who were cured of the
primary sores without mercury, had no secondary symptoms ; a certain
proportion of the men, so treated, had them ; but, be it noticed, that
Mr. Rose cured both the primary and the secondary symptoms too on
the same plan. Some of these cases were probably not truly venereal ;
yet others must be admitted to have been venereal ; for it cannot be
imagined, that there were not many cases of true syphilis in a regiment
of twelve or fifteen hundred men, who were continually having intercourse
with the lowest prostitutes of the metropolis. In the treatment pursued
by Mr. Rose, all ideas of specific remedies were renounced ; his general
practice was to confine the patient in bed ; various local applications were
used according to circumstances ; aperient medicines, antimonials, bark,
diluted sulphuric acid, and occasionally sarsaparilla, were administered ;
these were the chief means resorted to. From these, and other accounts
corroborating them, there can be no doubt, that the venereal disease,
both in its primary and secondary forms, may be cured without mercury ;
but this is not settling the question whether such practice isjthe right
method or not? And I have only mentioned the circumstance to prove,
that the old notions about the progressive nature of the venereal disease,
till stopped by the imaginary specific effects of mercury, were completely
erroneous. The facts, established by Mr. Rose, are chiefly valuable on
two accounts ; first, as leading to more correct views of the diagnosis of
the disease, inasmuch as they abolish the false doctrine, that all sores,
healed without mercury, are necessarily not venereal, a maxim usually
taught when I was a student ; and, secondly, Mr. Rose's facts are import-
382 THE VENEREAL DISEASE.
ant, as encouraging us to withhold mercury when the patient's health is
not in a safe or favourable state for its exhibition. Thirty or forty years
ago, surgeons were actually frightened into the use of mercury, lest the
disease should get progressively worse and worse, and the mischief
advance till the patient had been destroyed.
The venereal disease presents itself in a great variety of shapes, and is
attended by apparently the most capricious irregularities, and this in rela-
tion both to the primary and the secondary symptoms : thus, we find,
that some persons will have only superficial ulcers without, induration
around and below them, but with elevated or raised margins ; while others
will have sores, characterised by a hard circumference, an indurated base,
an indisposition to granulate, and, in a word, all the features belonging
to, what is called, the Hunterian chancre. Again, others will have
phagedenic sores, entirely different from either of the other kinds now
described ; and while one individual will have only one sore of one of the
descriptions here pointed out, another will have not merely a sore, cor-
responding to one of those varieties, but also a bubo ; and a third will
have gonorrhoea, in addition to the chancre and bubo. With respect to
the secondary symptoms, these also exhibit the most perplexing diversities :
the primary symptoms are frequently followed by secondary ones, as
varied as the former, and even more so ; thus, with regard to the
cutaneous eruption, the spots on the skin may either be a scaly eruption,
a papular eruption, a pustular eruption, or a tubercular eruption. The
sore throat also, which is a common secondary symptom, presents itself
in a variety of forms : there may be a deep excavated ulcer on the tonsils,
or only a superficial ulceration of them ; or there may be an ulceration,
extending to the upper part of the pharynx and soft palate, without
affecting the tonsils. Then, in the affections of the osseous system, we
notice the same indisposition in the disease to confine itself to any deter-
minate shape : there may be only periostitis — a mere swelling or inflam-
mation of the periosteum ; or there may be true nodes, or a real enlarge-
ment of the osseous texture itself — an increased deposition of bony
matter ; or there may be merely pains in the bones, or swellings and pains
of the joints. Thus, we see in the outline of this singular disease,
nothing but variety and irregularity, which it is difficult to solve by
reference to any principles yet suggested by the many able men who
have exerted their talents in the investigation of this Protean disorder.
Mr. Carmichael attempted to explain some of the varieties of the
venereal disease, by supposing a plurality of poisons ; by the consider-
ation that it is in truth not one, but several diseases, each depending on a
specific poison of its own. His doctrine is, that, except in a few anomalous
cases, every primary sore has its corresponding eruption ; so that we may
foretell by the appearance of the former what the latter will be, provided
it come out at all ; or if we see only the eruption, we may be able to pro-
nounce from it what has been the character of the primary sore. When
these views were first made known, they raised the most lively hopes,
that a great step had been made in the knowledge of venereal complaints.
But the disease in London is not found to have the same regularity and
constancy in the relations between its primary and secondary symptoms,
as Mr. Carmichael thought that he had noticed in Dublin. A primary
sore of a determinate character will frequently communicate a sore of a
different kind, and, what is still more inexplicable, frequently several
sores, each of different kinds. Certain facts, recorded by Mr. Evans,
prove, that a connexion with a common prostitute, in whom there are
THE VENEREAL DISEASE. 383
no ulcers at all, will sometimes give rise to venereal complaints, and then
the disease seems indeed to have been communicated through the medium
of the ordinary secretions of the genital organs, with which the poison
was commixed. So far as the doctrine of Mr. Carmichael goes, which
ascribes the origin of phagedenic ulcers to a particular venereal poison,
the idea does not seem at all tenable. We have seen that the phagedenic
character may occur as a complication of any kind of ulcers, whatever
may have been their original nature, and that such unfavourable change
often depends on constitutional causes, bad health, injudicious treatment,
intemperance, disturbance of the part, and other very definite and manifest
circumstances. It is true, that we see in hospital gangrene and phagedenic
diseases from syphilis, which are believed to be analogous to, or identical
with, hospital gangrene, disorders certainly capable of propagation by
contagion ; but this refers to the accidental application of the matter, by
means of a sponge, &c., to the abraded surface in another person. With-
out such abrasion there would have been no evil consequences. Then,
how unlikely, how impossible I might say, it would be for a person
afflicted with a phagedenic disease of the genitals to have sexual inter-
course, so as to give the complaint to another person. On the contrary,
we have reason to believe, that some of the worst forms of phagedenic
ulcers are communicated by women, who have but trivial complaints
themselves. Every body has heard of the captivating Lisbon opera dancer,
whose charms attracted so many of the officers of the British army into
her embraces. If we are to credit the reports, many hundreds of our
countrymen had connexion with her, no doubt civil also as well as mili-
tary ; and great numbers of them received, as a reward for their adora-
tion of this irresistible goddess, the present of something more than a
trifling clap. Many who had an acquaintance with this lady, contracted
venereal complaints of a particularly obstinate and afflicting kind, such
as are comprised under what is sometimes facetiously denominated the
black lion, a phagedenic, rapidly spreading, almost uncontrollable ulcer-
ation of the penis, yet this lady continued to dance every night for months
and months together, as if she were right in every respect herself, whilst
her unfortunate friends were suffering all the pains and penalties inflicted
upon them through the power of so fascinating a goddess, whose poison,
like that of the serpent, hurt not herself. Now it cannot be imagined
that she had phagedenic ulceration of the genitals, while she was dis-
charging her duties so well, which consisted of dancing in the early part
of the night, and of another sort of amusement in the latter part of it. It
is impossible then to suppose, that these phagedenic sores could have
arisen from a particular kind of poison, the product of any phagedenic
sore. Mr. Carmichael's description of the venereal disease is excellent,
so far as the symptoms are concerned ; we daily recognise in practice the
very forms and shapes of the disorder which he has described so well ;
yet .we see various circumstances, which prevent us from coming to his
conclusion respecting the diversities of venereal diseases. Vfe cannot
trace any uniform and mutual correspondence between the primary and the
secondary symptoms ; for the different effects, which he refers to different
poisons, are found by us to be frequently too much blended together,
One series of complaints is not so separate, so restricted to particular
cases, as Mr. Carmichael's views would induce us to expect ; for instance,
we often meet with the scaly and pustular eruptions in the same patient.
His account of the causes of phagedaena is totally incompatible with the
facts revealed to us by experience. No doubt the Lisbon opera dancer
384? THE VENEREAL DISEASE.
had not any thing very serious the matter with her ; probably her natural
secretions were somewhat changed, or she might have had at most some
gleety affection. Then we must recollect another fact, which agrees with
my inference from the opera dancer's case ; in the large towns in France,
it is customary for the Cyprian corps to be inspected once a week by
medical officers ; this was the established plan when I was abroad. Mr.
Evans, who was stationed in Valenciennes, attended several of these re-
views, made under the direction of the police. The British garrison at
Valenciennes, at that time, consisted of four or five thousand men, and
many of them suffered severely from venereal complaints ; there was at
least the usual number of venereal cases among them : yet Mr. Evans
informs us, that in the inspections referred to, where some hundreds of
concubines were carefully examined, very little disease was found.
M. Ricord, whose researches lead him to recognise only one kind of
venereal poison, after noticing the influence of situation and texture,
describes the varieties and particular forms of chancre as being developed
after, and under the influence of, conditions which have nothing to do
with the specific cause; as., for instance, peculiarity of constitution, pre-
ceding or concomitant diseases, hygiene, and the general or local treat-
ment pursued. " Hence," he remarks, " we see patients with phagedenic
chancres, who have contracted their disease from persons that had ap-
parently only slight sores."*
Mr. Travers suggests one peculiar mode by which the venereal disease
may be communicated ; he supposes that a woman may, in some instances,
be the passive medium of infection, that is, when she has had connexion
with an infected person, and immediately afterwards has connexion with
another man who is sound, the last person may be contaminated, though
she may escape the disease. This seems possible ; but whether it fre-
quently happens or not, it is difficult to say. " It is incontestable," says
M. Ricord, " that women who have had intercourse with infected men,
and who have afterwards cohabited with healthy ones, have infected the
latter, though not themselves diseased, but only the vehicle of the
infectious matter. Such cases I have had an opportunity of verifying,
and if they were not common, might create a belief in the spontaneous
origin of the venereal disease amongst healthy persons." f At all events,
it appears as if the natural secretions of the female organs were sometimes
pregnant with infection, though no ulceration exist in the genitals.
Mercury often facilitates the cure of venereal complaints : this is a
truth unequivocally settled ; yet, generally speaking, the disease may also
be brought to a conclusion without the influence of mercury. In this
last sentence are contained the sum and substance of all the valuable in-
quiries made in modern times, respecting the possibility of dispensing
with mercury in the cure of venereal complaints.
But the question, about the necessity of using mercury, is not settled
by our being told, that such medicine is not essentially and absolutely
necessary for the cure. The decision for or against its employment
must rest on other grounds ; and first it should be considered, not only
whether the non-mercurial method is the most expeditious mode of cure,
but whether it succeeds most effectually in removing the primary symp-
toms, and also in preventing or curing the secondary ones? This'view
changes the question altogether. It has been fully proved, that all the
primary and secondary symptoms of syphilis may be cured without
* Op. cit. p. 13G. | Id. p. 98.
THE VENEREAL DISEASE. 385
mercury ; but we are to inquire, is this the quickest way of doing it,^and
does this practice render the secondary symptoms less frequent ? When
we look over some of the evidence on these points, we might be induced
to suppose, that mercury ought not to be given at all ; but when the
comparatively greater quickness of the cure of the primary eruptions,
often exemplified when mercury is not given, is found to be counter-
balanced by the comparatively greater frequency of the secondary
symptoms, when mercury is not given, our first impressions receive
a check. It appears from valuable * and important documents deposited
in the Army Medical Board Office, that out of 1940 cases of venereal
primary sores cured without mercury, the average time required for the
cure when buboes did not exist, was only twenty-one days ; when there
were buboes, forty-five days. On the other hand, when mercury was
employed, out of 2827 chancres, treated with that medicine, the average
time for a cure when there was no bubo, was thirty-three days, and with
a bubo fifty ; so that here things are in favour of the non-mercurial treat-
ment, so far as the primary symptoms are concerned, and without refer-
ence to secondary ones ; and this corresponds with the results of similar
investigations made in the venereal hospital at Paris, and which proved
that the non-mercurial removed the primary symptoms sooner, than the
mercurial treatment. But as we are not compelled to restrict ourselves
to either one method or the other, I think that the entire rejection of
mercury, even in relation to the treatment of primary symptoms, (and
abstractedly in this point of view,) is not rendered justifiable by any
views, which have yet been brought before the public. This must be
manifest, when it is acknowledged, that a certain number of cases of
primary symptoms, cured without mercury (not perhaps a consider-
able number), are very tedious ones. The calculations I have men-
tioned were the average of the whole number of cases, throwing out of
view cases in which the cure was particularly tedious ; therefore with
reference to them, a determination to abstain from mercury was, strictly
speaking, decidedly wrong. A consideration, which ought to influence
us more powerfully, than the slowness or quickness of the cure of the
primary symptoms, is the question, whether the secondary symptoms are
more frequent after the non-mercurial, than after the mercurial treatment.
On this interesting point we receive different information from different
quarters ; one computation makes the proportion of cases, in which
secondary symptoms followed the non-mercurial treatment, to be one in
three ; a second, one in ten ; a third, one in twelve ; a fourth, one in
five ; and a fifth, only one in twenty ; but the cases of secondary symp-
toms, where mercury had been given, were only one in fifty-five. This
fact, if it were to agree with general experience, would be a most im-
portant consideration in favour of the use of mercury. Its power in
preventing the secondary symptoms from coming on would then be fully
proved to be greater than that of the other plans of treatment here
specified (excluding the effects of the salts of iodine, which had not then
been tried). It would indeed be proved, that secondary symptoms more
frequently come on when mercury is not used, than when it is. But it
does not follow from this, as a matter of course, that we are to give mer-
cury. The state of a chancre may be such as to be more likely to be
exasperated by mercury, than to be benefited by it. The condition of
the patient's health may be a prohibition to its employment. Then a
circumstance, that ought to have some weight, is the well-known fact,
that when secondary symptoms do follow the non-mercurial treatment,
c c
386 THE VENEREAL DISEASE.
they are for the most part milder, and more easily curable, than those
which take place after the use of mercury. All the experience that I
have had in the hospital and elsewhere attests this fact. I am not sur-
prised, therefore, that mercury is nearly abandoned, not only in several
hospitals on the continent, but, as I am informed, in one of the principal
hospitals in the United States.
Whenever mercury is given, the wisest plan is to give it in moderation,
and, above all things, to avoid the pernicious custom of putting the pa-
tient under a course, in which the mercury is given rapidly and profusely,
and continued for ai£ immoderate length of time. Experience has fully
convinced me, that in no variety of chancre, nor in any other stage of the
venereal disease, is it proper to give mercury so unmercifully, and for so
long a period as was formerly done. At all events, violent and long
salivations should be given up. This practice, as I can state from my
own observation in the foul wards of St. Bartholomew's Hospital, during
a period of twelve years, instead of being more successful than the pre-
sent methods, often led to the most dreadful of mutilations, and the
number of those who lost their palates and noses, was infinitely greater
than what is now observed. I should guess, that for every such instance
in the present day, there were then twenty. When these facts are con-
sidered, and joined with the treatment employed thirty or forty years
ago, we cannot avoid concluding, that a great deal of those ravages must
have been produced not by the disease itself, but by the manner of
treating it. At present, the practice of subjecting patients to long and
immoderate courses of mercury is given up by all experienced and
judicious surgeons. Common ulcerations are also more carefully discrimi-
nated from venereal ones ; and when mercury is given, it is so adminis-
tered as merely to produce a moderate affection of the gums and salivary
glands, and not to occasion a total derangement of the whole economy.
Surgeons are also now no longer blinded by the pernicious fear, that
unless mercury be given, the disease will continue to grow worse and
worse till the patient is ultimately destroyed. In former days, directly a
patient was brought to a hospital, however bad his health might be at the
time, it was immediately considered necessary to cram him with mercury.
But we are now aware, that the notion by which the old surgeons were
terrified into such practice, was a mere ghost, nothing but a bugbear.
When the patient's health is seriously impaired, I advise, as a general
rule, the postponement of mercury till an amelioration in that respect
has taken place. Even those practitioners, who place the greatest reliance
on mercury as a specific, and still maintain that it ought to be called so,
qualify their assertions by admitting, that it ought not to be given under
every condition of the system ; they candidly allow, that neither the
condition of the parts, nor that of the constitution, is at all times such
as will let mercury be given with impunity ; they confess that its rash
and unscientific employment will aggravate the symptoms; and they
specify two cases in which its use is generally erroneous, namely, during
excessive weakness of the system, and while the disease is complicated
with excessive inflammation. Under these two conditions, the greatest
advocates of mercury commonly admit, that its employment should be
postponed. But these are not the only states, in which it should usually
be prohibited ; it should not be given during any great derangement of
the system from diarrhoea, or fever, or from what is termed erythismus, a
peculiar state of constitution, in which the patient labours under exces-
sive irritability, weakness, palpitation of the heart, and other evils from
THE VENEREAL DISEASE. 387
the mercury already given. There are some constitutions, in which this
condition is liable also to be induced by a very slight quantity of mer-
cury, and when it is present, the patient may die suddenly on making
any trivial exertion.
Although mercury may not be absolutely essential to the cure of the
venereal disease, yet so long as it shall continue to be looked upon by
many surgeons as a remedy of greater power for the prevention of se-
condary symptoms, than any other known medicine, with the exception,
perhaps, of the salts of iodine, its employment is not likely to be dis-
continued. It is used either topically, that is, as ^direct application to
sores, nodes, and other affections, or constitutionally, being introduced
into the system, either through the medium of the stomach or the skin.
Amongst topical mercurial preparations, the black wash is in very com-
mon use for venereal sores, both primary and secondary. It should vary
in strength according to circumstances : when I was a student the pro-
portion of the ingredients was a drachm of calomel to a pint of lime
water ; but now it is frequently made stronger, and sometimes as much
as ten or fifteen grains of calomel are put into each ounce of lime water.
With regard to the manner of using it : — if the sore or sores are on the
outside of the prepuce, a piece of lint is dipped in the lotion and applied
to them ; but if the sores are under the prepuce, the introduction of lint
into that situation would create too much irritation, and the lotion may
therefore be occasionally injected under the prepuce with a small syringe.
The yellow wash, used in the same manner, contains two grains of the
bichloride of mercury in each ounce of lime water.
In general, ointments are not good applications for primary venereal
sores of any description. Now and then the unguentum hydrargyri ni-
tratis, blended with the unguentum cetacei, or with zinc ointment, in
various proportions, is employed ; and, of late, the unguentum hydrargyri
iodidi, in the proportion of twenty grains of the iodide to one and a half
ounce of lard, has been commended as a dressing for inveterate venereal
ulcers. I cannot make any report of its real utility from my own expe-
rience.
Another manner of using mercury topically is that of fumigation. For
this purpose, an apparatus is made use of, furnished with an iron heater,
and a copper tube, by which the fumes can be conveniently directed to
the part affected ; and, in order to be able to do this better, we have both
a straight tube and a curved one, the latter being particularly convenient
for ulcers in the throat. The mercurial fumigating preparation in general
use is cinnabar, or the red sulphuret of mercury, from which, when placed
on the heater, a subtile grey powder is sublimed, which, lodging on the
sore, is found in many instances to produce a very beneficial effect upon
it. 1 have seen sore throats,, chancres, and other ulcerations, which had
resisted for weeks and months every plan that could be devised, assume
a healthy appearance, and heal up rapidly, after fumigation had been
tried a few times. To know this truth is important ; much nfore so than
to be able to say exactly, how far the specific power of mercury was here
concerned in the production of the good. The fumigation of a sore of
moderate size is not likely to have much or any effect on the constitution ;
and I should suppose, that the method cannot generally operate on this
principle. Perhaps, with the exception of fumigation,! may say, as a general
remark, that topical mercurial applications are not usually considered at
all more useful than others which contain no mercury. The black, or
calomel wash, is frequently made use of; but I do not know that it pos-
c c 2
388 THE VENEREAL DISEASE.
sesses more efficacy, than several other astringent lotions, which have not
a particle of mercury in them.
With respect to the introduction of mercury into the system from the
surface of the body, this can be accomplished either by rubbing mercurial
ointment into the skin, or by mercurial fumigation of an extensive por-
tion of the surface of the body. Friction with the ointment, the ordinary
method, the most generally adopted, as requiring no machine for the
purpose, is practised by the patient himself, who rubs some part of his
body, which is frequently the inside of the thigh, for a quarter of an hour
or twenty minutes before the fire, sometimes once a day and sometimes
twice, with half a drachm or a drachm of the ointment. The quantity of
ointment employed, however, varies in different cases, according to cir-
cumstances. Sometimes a scruple, sometimes half a drachm, and, in other
instances, double this quantity, or even more, may be employed at a time.
This is termed rubbing i?i, because a portion of the ointment seems as if
it had been made to enter the pores of the skin by the friction ; but,
except where the patient is very easily affected, what remains on the sur-
face of the skin should not be wiped away, the patient putting on a pair
of flannel or other drawers over it. I ought to mention, however, that
sometimes friction and the rancidity of the ointment together (for we
seldom meet with mercurial ointment perfectly free from rancidity), will
bring out numerous pimples, and even erysipelatous inflammation, and
then the patient should be directed to repeat the friction on another part,
and not to leave any of the ointment on the skin. A few years ago,
friction with mercurial ointment was commonly preferred in this country
to all other plans of treating the venereal disease ; first, because it was
conceived to be the most efficient mode of treatment, and the mercury in
the ointment being combined with a very small proportion of oxygen, was
usually given as one reason for the alleged fact ; secondly, because it
occasions less risk of disturbing the stomach and bowels than internal
preparations ; thirdly, because it is frequently considered to be the only
certain way of getting a sufficient quantity of mercury into the system.
Preparations of mercury, given by the mouth, sometimes disorder the
stomach and bring on diarrhoea. I have long suspected, that^the latter
was the principal cause of mercurial friction being formerly so favourite
a practice ; for, while the doctrine prevailed, that it was necessary for the
cure of syphilis to fill the patient with mercury, to saturate him with it
from head to foot, and to salivate him unmercifully, the stomach and
bowels often revolted against the scheme, which absolutely could not be
carried into execution in every instance by preparations, designed for in-
ternal administration. It was then chiefly by means of mercurial friction
that the old fiercely salivating practitioners were enabled to get into the
system as much mercury as they wished; not that they did not also give
internal preparations so far as they could. I believe that the doctrine of
the superior efficacy of mercurial friction is founded on prejudice, and
that, unless the stomach and bowels be disordered, and the constitution
cannot be affected with moderate doses of the blue pill, it is seldom in-
dispensably necessary to have recourse to this uncleanly practice. In cer-
tain cases, we are indeed obliged to direct mercurial frictions, as when
the stomach and bowels will not bear even a small quantity of mercury,
which occasionally happens, or when it is necessary to resort to more
plans than one, in order to bring the system under the influence of the
mineral. Under these, and perhaps a few other circumstances, we may
be called upon to prescribe frictions, as well as internal preparations.
THE VENEREAL DISEASE. 389
Fumigating the surface of the body is not at present deemed so neces-
sary and eligible a method of putting a patient under the influence of
mercury, as some of its admirers once endeavoured to instil into the
minds of the profession. It is attended with considerable trouble and
inconvenience ; it requires a particular machine, somewhat resembling a
sedan-chair, in which the patient sits naked with his head out of an open-
ing at the top of it. At the bottom of the machine is an iron heater, on
which a preparation of mercury is thrown, which is sublimed and covers
all the surface of the patient's body. The preparation of mercury em-
ployed for this purpose is the grey-oxide. Another mercurial powder,
that was recommended and used by Mr. Abernethy, was calomel that had
been put into liquor ammonise, and then dried. After having undergone
the process, the patient puts on his shirt or flannel waistcoat, and goes to
bed. The reasons formerly urged in favour of the practice were, that it
is less fatiguing to a debilitated person than mercurial frictions, and that
the system can be more quickly brought under the influence of mercury
than in any other way whatsoever. This seems to have been Mr. Aber-
nethy's opinion, who was once an advocate for fumigations ; but afterwards
relinquished them. With regard to the reasons given for the use of
fumigations, that mercury may thus be employed, when the patient is in
the weakest state, and that he may be mercurialised without the fatigue
of friction, or the risk of disordering his stomach and bowels with internal
preparations, the argument, though plausible, has not really much weight;
because, when the health is seriously impaired, we are seldom justified in
giving mercury at all ; and, at all events, it should then never be intro-
duced so rapidly into the system. But, if the plan deserves adoption in
any particular instance, it may be useful to know, that it is not necessary
for the patient to go into the machine at all; he may turn his flannel
waistcoat and drawers inside out ; and put them into the machine to be
fumigated. They will become covered with the fine powder sublimed
from the heater, and, on being worn afterwards, will salivate the patient
as well as if he had gone into the machine himself.
Of the internal preparations ', the pilula hydrargyri, or common blue pill,
has the greatest reputation in this country ; it is one of the mildest of all
the internal preparations; the common dose of it is five grains; but fre-
quently we are called upon to give a larger dose, and sometimes a smaller;
from three to ten grains may be stated to be the ordinary average quantity
proper to be given in the twenty-four hours. We may join it with other
medicines, according to circumstances, as with the sulphate of quinine,
the iodide of potassium, extract of conium, and various other medicines.
Jt is often combined with a small quantity of opium, in order to lessen its
tendency to affect the bowels.
The chloride of mercury, or calomel, is not extensively employed in
England for syphilitic complaints, though it is a favourite medicine for
this purpose abroad, especially in Germany. Even in England, for one
effect of the venereal disease, calomel is usually preferred, v ft. syphilitic
iritis. This preparation, like the blue pill, may be joined with other me-
dicines, as with guaiacum and the sulphuret of antimony, as in the pit.
hydrarg. chlorid. comp., which is not unfrequently prescribed in venereal
affections, but especially in those requiring merely slight alterative treat-
ment.
The bichloride of mercury, or corrosive sublimate, is a very powerful
medicine, and, if it be incautiously given, it may readily poison the indi-
vidual. The dose is small, the average quantity, usually given, is one
c c 3
390 THE VENEREAL DISEASE.
eighth of a grain, twice or thrice a day. When mixed with distilled water,
it dissolves more readily if a small proportion of the chloride of ammonia
be added. There are instances, in which from half a grain to three quarters
of a grain may be prescribed in divided doses to be taken in a day.
When it is wished to give it with bark, we may dissolve one grain of it
in an ounce of the tinctura cinchonae, of which a teaspoonful is the
proper dose. The biniodide of mercury (L. P.) in the form of an alcoholic
solution, is sometimes deemed useful in obstinate forms of syphilis, occa-
sionally met with in very scrofulous subjects. The proportions are, alco-
hol at 36° 1£ ounce; deuto-ioduret of mercury 20 grains. The dose 10,
15, or 20 drops in a glass of distilled water.
The hydrargyrum cum cretd is the mildest preparation of mercury ever
employed in this country, and, on this account, is preferred where we
wish to exert a slight mercurial influence on the constitution. It
is deemed the best preparation of mercury for infants labouring under
syphilis.
One caution is necessary in the employment of mercury ; namely, to
watch its effects very attentively ; for it will act differently on different
individuals. Some will be violently salivated by a few grains of blue pill,
or a scruple of blue ointment ; while others will use from one to three
drachms of it daily for months together, with no manifest effect on the
function of the salivary glands, bowels, or other organs. The doses of
mercurial preparations must then be regulated by circumstances ; indeed
it is wholly impossible to give any precise rules on this head, on account
of the different effects of the mineral on different individuals. I may say,
however, that the safest plan is always to begin with small quantities
of mercury, watching the effects of the medicine, and being guided by
them.
The action of mercury on the animal economy is very powerful; the
nervous, the absorbent, and the sanguiferous systems are all considerably
affected by it ; an universal irritability is excited ; there is a quickness of
the pulse, and a feverish state of the whole constitution brought on by
it ; the secretions are all increased, especially those of the skin, kidneys,
and salivary glands. Salivation, or an increased secretion of saliva, and a
soreness and swelling of the gums and mouth, are the effects, which sur-
geons have long been accustomed to observe with attention ; for these
are usually regarded as tests of the remedy having a sufficient influence
on the system effectually to cure the complaint, -for which it is given ; not
merely to cure the primary symptoms, but give the patient the best pos-
sible chance of escaping the secondary ones. In fact this is the main
object of giving mercury ; we know that we can cure the primary symp-
toms without mercury ; and were these alone abstractedly considered,
perhaps, we should seldom be justified in salivating the patient at all.
But the great argument for the mercurial practice is, that, without it, the
patients will be more likely to be attacked by secondary symptoms.
However, even on this point, I doubt whether secondary symptoms are
more frequent after the treatment of primary sores with the iodide of potass
and sarsaparilla, than after mercurial treatment, and, at all events, many
gentlemen who watch the results of the first mode of practice commonly
adopted in University College Hospital, know that the secondary symp-
toms, when they do follow it, which is not very frequently, are but slight
compared with cases brought to this hospital from others, where the God
Mercury is more rigorously worshipped.
The first change perceived is a copper taste in the mouth ; the breath
THE VENEREAL DISEASE. 391
acquires a peculiar foetid smell ; sometimes letting out a secret which the
individual may not always wish to be known, namely, that he is under a
mercurial course ; his watch and the money in his pocket will also, in
consequence of the transpiration of the mercury from the surface of the
body, become coated with mercury, so as to let out the same information.
When mercury is given in ordinary doses, a swelling and sponginess of
the gums are generally brought on — an inflammation and tenderness of
them ; an uneasiness, pain, and looseness of the teeth, and more or less
inflammation of the mucous membrane of the mouth. When the consti-
tution is remarkably susceptible of the action of mercury, a very small
quantity of it will sometimes throw the patient into a violent salivation,
attended with ulceration and even sloughing of the parts in the mouth.
The gums and mucous membrane of the mouth will ulcerate ; the edges
of the tongue will be in the same condition ; and the tongue itself may
swell to an enormous size, and be pressed against the teeth ; in conse-
quence of which deep ulcerated indentations will be formed in it. I have
frequently seen the ulceration so severe as to extend through the cheek,
and even produce extensive mortification of the parts, with necrosis of
the jaw. It is this risk, which should always induce us to begin with
small doses of mercury, and to watch their effects. The quantity of
saliva, discharged from a patient in a complete salivation, is sometimes
very copious — from three to four pints may be poured out in the twenty-
four hours. I never look upon a patient, in a state of violent salivation,
without a feeling of disgust, for I know that it is a practice completely
unnecessary — nay, it is highly prejudicial ; and I should therefore say,
it is a cruel mode of administering mercury, by no means justified by
anything, which is made out respecting the true character of the venereal
disease. I am happy to say, however, that such practice is not now
common in London ; but whoever had the opportunity of seeing the mer-
curial courses, pursued in the foul wards of hospitals a few years ago, will
never forget the horrid scenes there displayed. At that period, an im-
mense number of deaths were actually produced by the abuse of mercury.
If it be introduced too quickly or copiously into the system, we may not
be able to stop the salivation for a considerable time. Thus, a poor
woman, whom I lately attended, was at first under a physician, who gave
her ten grains of blue pill in divided doses : this quantity produced a most
violent salivation, with loss of all the teeth., and ulceration, and sloughing.
Here no blame could attach to the practitioner ; there must have been an
idiosyncrasy concerned, or an extraordinary susceptibility of the action
of mercury, such as could hardly have been contemplated. But even in
common constitutions, these severe effects will sometimes come on before
we are able to check the mercurial action ; and, I may say, that we know
of no means that will check a violent salivation so quickly, as mercury will
sometimes bring it on. The usual plans, resorted to for this object, are
exposure to cold air, the exhibition of saline purgative medicines, and
the use of gargles, especially those containing the chloriae of soda.
When there is ulceration, the same gargle, or one of hydrochloric acid,
may be used.
There are one or two interesting questions connected with this part of
the subject : one is, how far salivation is a right criterion of the influence
of mercury on the constitution ? and another is, how far it is a means of
judging whether that influence is such as affords the patient the best
chance of secondary symptoms being prevented, and the primary affec-
tion cured in the most expeditious and favourable manner ? Perhaps I
c c 4-
392 THE VENEREAL DISEASE.
may state as a general fact, that salivation is a good test for these pur-
poses : but the remark is liable to exceptions ; for some individuals cannot
be salivated by any quantity of mercury, and yet their venereal com-
plaints will get well with tolerable facility ; while others may be salivated
by a few grains of blue pill, and therefore long before any adequate mer-
curial impression can have been made on their disorder. But supposing
salivation to be generally a good test of the proper influence of mercury
on the system, then the question arises — to what degree are we to under-
stand that salivation is to be carried ? Certainly not so far as purposely
to bring on ulceration and sloughing of the mouth, or even to produce so
profuse a discharge of saliva as to make it run out of the mouth in streams :
this is not at all requisite as a test of the adequate influence of mercury.
I should say, that a moderate swelling and tenderness of the gums, a dis-
tinct copper taste in the mouth, and a gentle increase in the secretion of
saliva, are the three conditions which we should aim at bringing about ;
a more violent mercurialisation is not only generally unnecessary, but
decidedly injurious. Neither are we to imagine, that mercury should
be given in the same quantity during the whole time that the medicine
may be proper ; sometimes it may be necessary to suspend the use of the
medicine in consequence of the gums getting too tender : and, under-
other circumstances, where the constitution is difficult to affect with mer-
cury, we may be required to increase the quantity of it. Indeed, there
is only one general rule which I can offer, and which was laid down by
Mr. Hunter, namely, that we must be guided, in the administration of
mercury, partly by its influence on the disease, and partly by its influence
on the constitution.
As for the length of time that the salivation should be kept up, it is
difficult, also, to lay down any precise rules on this point ; sometimes all
the specific characters of the ulcer are removed long before it is healed,
and sometimes a chancre heals so rapidly, that we have little opportunity
to give mercury before it is well. When the complaint yields in this
rapid manner, it is usual to continue the employment of mercury for ten
days or a fortnight, and this is done to diminish the risk of secondary
symptoms. In other instances, where the sore heals very tardily, perhaps
when a bubo is also present, the disease will not get well for months,
though all the specific characters of venereal ulceration may be removed ;
then, of course, we should not think of continuing mercury till cicatrisa-
tion had taken place.
The diet and regimen to be observed during a mercurial course is a
subject of importance, because if we give a patient mercury, and allow
him to continue his usual diet, and to follow his common occupations,
we shall generally be disappointed in the results of our treatment. If
we allow a patient to take wine and a full diet, to walk about the streets,
to expose himself to all weathers, and even to ride on horseback, as some
are disposed to do, I think it will be found that secondary symptoms are
more likely to come on, and even affections of the periosteum and bones
will be more frequently produced. I always recommend patients to
clothe themselves more warmly than usual, and to confine themselves at
home ; but there are many who will not submit to this : they say they are
obliged to go to their offices, or counting-houses, and that they have no
choice ; I then tell them that, if this be the case, any unfavourable circum-
stances which may occur must be imputed, not to my having omitted to
give them good advice, but to their not following it.
As mercury produces a quickness of the pulse, and a feverish state of
THE VENEREAL DISEASE. 393
the system, it is advisable not to let the patient have a full meat diet ; it
is better for him to live on light farinaceous food, such as milk, sago,
arrow-root, &c. This practice is consistent with medical science on
another account ; for, in many venereal cases, there is a good deal of
inflammation present; perhaps in the groin there may be severe in-
flammation, or a similar state of the throat may exist. Under these cir-
cumstances, letting the patient have a full diet would be contrary to all the
rules which influence both physicians and surgeons in their treatment of
disease in general. When the patient is in so reduced and weak a state,
that it is necessary to let him have plenty of animal food, I should say,
that mercury can then rarely do him any good. It is especially neces-
sary, also, during a mercurial course, to recommend abstinence from all
acid drinks and acid fruits ; for mercury has often a tendency to produce
diarrhoea, and mercurial friction will sometimes act more on the bowels
than on the salivary glands. When diarrhcea has been induced by the
use of mercury, the condition of the patient is much the same as if he
had dysentery : a slimy matter is discharged from his bowels, and fre-
quently blood. Under such circumstances, we must discontinue mercury,
for the further administration of it would not only do no good to the
venereal complaint, but put the patient's health into a most dangerous
state. The mercury should be left off, and recourse had to opium and
rhubarb, or the chalk mixture.
Sometimes mercury has a peculiar effect on the skin, causing a specific
eruption, named the mercurial erythema, or eczema. It is generally
preceded by an increased heat of the surface, accelerated pulse, difficulty
of respiration, and more or less fever. On the first or second day after
the feverish attack, the ery thematic affection makes its appearance, some-
times bearing a considerable resemblance to urticaria, or nettle-rash, and
when it assumes this form, the disorder will always prove very slight;
but, in other instances, large red patches appear on the surface, crowded
with vesicles, which, uniting altogether, may cover the greater part of the
body. After a time they burst, and form incrustations on the skin, and
the patient, from the extent of surface affected, is really in a very distress-
ing condition. Under wrong treatment, this is actually a dangerous
complaint ; and, in former times, when the disease was supposed to be
syphilitic, the quantity of mercury used to be increased, and the patient
destroyed.
Former practitioners were confirmed in their suspicions, that this was
a syphilitic eruption, by the fact, that eruptions are rarely the consequence
of mercury, but very frequently the consequence of the venereal disease ;
therefore the cutaneous affection was ascribed to the latter disorder, and
treated as such by pushing the mercury in greater quantities, according
to old maxims and firmly rooted prejudices. As the mercurial erythema
sometimes comes on, when only a small quantity of mercury has been
exhibited, it is supposed that it can occur only when there is a particular
idiosyncrasy in the individual : it is asserted that it never taltes place,
except when the patient has been exposing himself to cold damp air.
Here, then, is another reason, why the kind of regimen, which I have
recommended, should be attended to. Sometimes the eruption begins on
the part where the patient has been rubbing in mercury, as on the thigh
or leg; but, in many instances, it comes on, though the mercury has
been given only internally ; so that the friction is not essential to its pro-
duction. The treatment consists in fomenting the parts well with a de-
coction of poppy-heads or chamomile flowers, discontinuing the mercury,
394 THE VENEREAL DISEASE.
as a matter of course, and administering small doses of antimonial powder
and saline purgatives, or castor oil. When the inflammation has abated,
and there is merely a discharge from the surface, sarsaparilla may be
given, or bark with diluted sulphuric acid, and a light nutritious diet.
The warm bath will also afford great relief. If the part be excoriated, it
will be necessary to apply the zinc ointment.
Mercury acts upon some individuals like a poison : they are seized with
palpitations of the heart, tremblings of the limbs, oppression of the
breathing, and irregular pulse. When such indisposition takes place in
a person employing mercury, we may conclude, that this mineral is actually
producing a deleterious impression on the system. It was noticed by
the late Mr. Pearson that every year, when it was the custom to salivate
freely, a certain number of individuals, thus treated, died suddenly, in the
Lock Hospital ; they were first affected as I have described, and, on
attempting to make the slightest effort, they dropped down dead. Mr.
Pearson learned from experience, that these deaths arose from the dele-
terious action of mercury on the constitution, and the derangement of the
system, thus excited, he proposed to call the mercurial erythismus. I
need hardly say, that the treatment consists in suspending the use of
mercury altogether, letting the patient be exposed to a pure, cool, dry
air, administering tonics, especially sarsaparilla, or, as some practitioners
prefer, ammonia in camphor mixture.
With regard to other medicines, often given in some stage or another
of venereal complaints, we should, in estimating their anti-syphilitic
power, never forget the important truth, that mercury is not absolutely
necessary for the cure of the generality of venereal complaints ; for, so
far as Mr. Rose's inquiry went, he never met with a case which he could
not cure without mercury. Mercury is frequently useful in accelerating
the cure, and, perhaps, with the exception of the iodide of potass,
still more importantly serviceable than any other ^known medicine, in
lessening the frequency, though, I believe, not the severity, of se-
condary symptoms. Yet, let not these advantages render us blind
to the fact, that mercury is not absolutely necessary for the cure of
syphilis ; and, in estimating the anti-syphilitic power of any medicine,
this truth must never be lost sight of. Sometimes, indeed, mercury,
so far from being indispensable to the cure, may have the effect, in
particular states of the health, of retarding, or even preventing alto-
gether, the patient's recovery. Frequently the general health becomes
bad before a venereal complaint is cured, and then, on the mercury being
discontinued, the health improves, and a cure of the syphilitic affection
follows. This frequently occurs, and gives a kind of false credit to any
medicine which may have been prescribed after the discontinuance of
mercury. It is, perhaps, in this manner, that sarsaparilla has acquired
the reputation of having anti-venereal qualities : — the patient is taking
mercury, and his health suffers ; the mercury is left off, and then a favour-
able change takes place in the constitution, and chancres, buboes, second-
ary ulcers, &c., yield, whether sarsaparilla be given or not. Yet, I by no
means wish to insinuate, that sarsaparilla is completely useless ; probably it
has some good effect in accelerating the cure, independently of the benefit
derived from our stopping or moderating the mercurial course. Nothing
can be more various, than the opinions about the real efficacy of sarsapa-
rilla : — Dr. Cullen believed that it has no power at all ; and it is found,
that if we give it to a person in health, it makes no sensible impression
on the constitution ; it does not affect the pulse ; neither does it mate-
rially increase any of the secretions. Hence it has been presumed, that
THE VENEREAL DISEASE. 395
it possesses little or no power. Fordyce thought it useful in certain com-
plaints that would not yield to mercury ; and the late Mr. Pearson came
to the conclusion that though sarsaparilla was, in a certain degree, useful
in venereal complaints, it could not cure them without mercury. The
latter part of this opinion we now know is erroneous. He also says,
that sarsaparilla is particularly valuable as a means of obviating the per-
nicious effects produced on the system by a mercurial course ; and, in
his day, when mercury was given copiously, and its action maintained
for a considerable time, these effects were often of a severe description.
At the'present day, sarsaparilla is commonly given at the end of a mer-
curial course ; and, so far as I can judge, the practice is attended with
beneficial effects, restoring the patient to health much sooner than if he
did not take the medicine. It is also used as an alterative in various
complaints Deputed to be venereal, though not exactly possessing the
characters of the disease insisted upon by Hunter, or those of the scaly
venereal disease, as described by Mr. Carmichael. Many affections,
arranged with venereal ones, undoubtedly yield to sarsaparilla, and alter-
ative plans of treatment, even better than to a full mercurial course.
We often find this benefit accrue from sarsaparilla, given either with
small doses of bichloride of mercury, with nitric acid, with iodide of
potass, or antimonial medicines ; and numerous cases present themselves
which are more served in the beginning, by this method of treatment,
than by mercury ; though, in a later stage, mercury may be administered
with surprising effect. In University College Hospital, at least two
thirds of the venereal cases are readily cured without mercury, small
doses of the iodide of potassium with sarsaparilla being substituted for it ;
and it is well known that our cases are far from being often followed by
secondary symptoms ; which, when they do occur, are for the most part
exceedingly mild and easily cured. Instead of having recourse to mer-
curial frictions, and violent salivation, I also, sometimes, adopt the practice
of giving a few grains of the blue pill daily, in conjunction with the iodide
of potassium ; and the efficiency and mildness of this method, where mer-
cury is called for, give me a favourable opinion of it. With respect to the
compound decoction of sarsaparilla, and the mineral acids, they are all
useful in particular stages of the disease, where the health is not in a
favourable state for the action of mercury ; but whether any of them
really possess what is sometimes understood by an anti-syphilitic power
is a question that resolves itself very much into the consideration, how
far syphilis is capable of getting well without mercury, and how far it ad-
mits of a spontaneous cure. Certainly it is quite conceivable, that,
although the cure of the disease may sometimes be promoted by the
discontinuance of mercury, it may still admit of being expedited in a
greater degree, when, with this change in the treatment, we join the ad-
ministration of sarsaparilla, or other alterative medicines. Another
circumstance, never to be forgotten, is, that venereal complaints are
frequently complicated with common as well as with specific inflammation,
and, consequently, that they often call for antiphlogistic treatment. The
whole of the inflammation attending the effects of the venereal disease is
not specific : a good deal of it is merely common inflammation, and may
be benefited by the same means as are usually resorted to for checking
inflammation in general, — bleeding,, leeches, cold applications, poultices,
low diet, quietude, &c.
From these general observations on the venereal disease and its treat-
ment, I now proceed to consider more particularly each of the primary
and secondary symptoms.
396 THE VENEREAL DISEASE.
CHANCRES.
It is not strictly because a sore lias been contracted in a suspicious
sexual intercourse ; nor on account of its situation ; the greater or lesser
induration at its base ; its colour ; its excavated surface ; its undermined
callous edges ; or its deep red margin, that it must necessarily be con-
cluded that it is always a chancre ; but the inference, according to
M. Ricord, is rather to be deduced from the kind of pus which it secretes,
and the contamination which such pus is capable of imparting. All the
other conditions may vary, the secretion alone, and its general consecu-
tive effects remaining the same.
The term chancre, as conveying the idea of an ulcer that has a cor-
roded appearance, is not exactly what ought to be employed ; perhaps
the expression primary sore is preferable. It is not every sore, arising
from sexual intercourse, that is to be considered a chancre ; there are
many which are supposed to be produced by the irritating action of the
secretions of the genital organs more or less changed. Sores, produced
in this way, are not uncommonly classed with venereal ones, though not
having the aspect which the meaning of the word chancre would convey ;
and for this and other reasons, the term primary sore seems preferable.
Primary sores are most frequently situated on the external parts of the
organs of generation, and especially on those parts of them, which are
covered by a thin delicate membrane, as on the inside rof the prepuce,
and on the glans penis, or corona glandis, in the male subject, and on the
labia, nymphee, &c., in the female. They are also sometimes met with
in other situations about the genital organs, as on the common integu-
ments of the penis, or on the skin of the labia, and sometimes, as all
surgeons now admit, actually within the orifice of the urethra or vagina,
though less frequently in these situations, than in the others which have
been specified. The formation of chancres on the outside of the labia,
in the perinseum, and on the common skin of the penis, seems to prove,
that the venereal matter may produce ulceration even in situations
where a thick cuticle intervenes between it and the cutis, so far as those
parts are concerned. I am not aware, that there is any clear proof on
record of a venereal primary sore having been produced on any common
part of the general surface of the body, away from the genital organs,
unless there had been a wound, ulcer, pimple, or some kind of breach
existing in that situation at the period when the matter was applied.
The period of the commencement of venereal ulceration, after the
application of the virus, is extremely irregular. Mr. Hunter met with
chancres which began within twenty-four hours after exposure to con-
tamination ; but knew of other cases, in which the sores did not make
their appearance till six or eight weeks after coition. Perhaps, a true
primary venereal ulcer does not often form earlier than six or seven days
after the application of the virus. On an average, says Dr. Wallace, of a
number of cases of primary syphilis, produced by artificial inoculation,
notes of which are now before me, the phlogosis, or redness, commenced
on the second day : the stage of ulceration occupied seven days ; that of
granulation ten days ; and cicatrisation six days ; making the whole period
from the insertion of the virus to the healing of the ulcer twenty-five
days.*
* Wallace on the Ven, Dis. p. 71.
THE VENEREAL DISEASE. 397
Primary venereal sores are of several kinds. The most remarkable
is that which was so well described by Mr. Hunter, and is called,
accordingly, the Hunterian chancre. It is characterised by a tendency to
assume a circular form, its excavated surface, the tenacious and adherent
quality of the matter produced on it, and by its hard cartilaginous base
and margin. It generally begins as a pimple, or minute vesicle, which
enlarges, and soon breaks and ulcerates. Generally speaking, venereal
ulceration does not extend itself with great rapidity ; neither is it the
common character of the Hunterian chancre to make quick progress.
Nevertheless, exceptions to this statement do occur, and these seem to
depend on the state of the health : for when this is in an unfavourable
condition, or certain forms of constitutional disturbance and irritability
prevail, the ulceration will spread with greater quickness than usual. When
the sore is situated on the prepuce, or the freenum, there is usually more
inflammation present than when it is situated on the glans. When the
ulcer is on the glans, it is less painful, but more disposed to give rise to
haemorrhage. Wrhat is termed pliymosis, is an inflammation, a thickening,
and a contraction of the extremity of the prepuce, rendering it impos-
sible to draw it back so as to uncover the glans : this case is less frequently
a consequence of the Hunterian chancre, than of some other primary
sores on the penis. My own experience does not incline me to adopt the
opinion, that the hard cartilaginous base of the Hunterian chancre is
essential to a sore, that is capable of imparting to the system such effects,
or secondary symptoms, as are exclusively regarded as syphilitic. Neither
does it lead me to join in the statement of M. Ricord, that the indu-
rated chancre is more frequently than others followed by secondary
symptoms.* All surgeons know, that the Hunterian chancre may, and
often does, give rise to secondary symptoms ; but there are other kinds of
primary sores, which will produce similar complaints, so similar that they
cannot be discriminated. It is curious to find, that the frequency of the
Hunterian chancre is much lessened in London, though still very common
in Paris, as I learn from my friend, Mr. Morton, of University College,
who has spent the last two summers in attending the Parisian Hospitals.
Another kind of primary sore is that which is generally called the su-
perficial ulcer with raised edges ; it is not accompanied by induration,
but its margin is very high ; it is often seen on the outside of the pre-
puce ; and frequently is not a single sore, but is accompanied by others
of the same nature, sometimes by two, three, four, or more. In many
instances, we see them surrounding the orifice of the prepuce, producing
a thickening of it and phymosis, which may continue long after the cure
of the sores. Sometimes we notice some of these superficial ulcers on
the corona glandis, and others under the prepuce, or around its orifice,
or just on the outside of it. They are frequently very obstinate, and it
may be long before any impression can be made upon them, whether
mercury be given in full quantities, or merely in alterative doses. Some-
times, in five or six weeks, there will be very little change in trfbm what-
ever is done, and what change does take place, may be for the worse. I
have seen thousands of them in my lifetime ; but, I have observed, that,
after five or six weeks, they generally yield to common treatment, to
mild alterative plans, namely, to small doses of iodide of potass or mercury,
aperient medicines, and antimonials, and sometimes to bark, sarsaparilla,
and the mineral acids. At first, the surgeon will be discouraged by finding
* Op. cit. p. 93.
398 THE VENEREAL DISEASE.
them resist all plans of treatment. One common situation for such a
sore is just at the side of the frsenum, which is generally soon destroyed.
The black or yellow wash, the nitrate of silver, or lotions of the sulphate
of copper, or zinc, are the best applications.
Another description of primary sore is \\\Q phagedenic, as it is termed,—
a corroding ulcer without granulations, corresponding to the description
of phagedenic sores in general. It' is destitute of any remarkable degree
of surrounding induration, but its circumference is of a livid-red colour.
It is invariably rendered worse by mercury, a fact, which I deem to be
as well established as anything yet made out, with regard to the treatment
of venereal complaints. In this form of the disease, when the treatment
is injudiciously conducted, the whole of the penis is frequently destroyed
in a very short time. Sometimes considerable haemorrhage takes place,
and a useful hint is afforded by it ; for we commonly observe, that, after
loss of blood, the extension of the ravages of the disease stops, or is sus-
pended for a time ; and hence we may infer, that venesection will fre-
quently be useful in the early stages of the disease, a truth fully confirmed
by experience.
Another is the sloughing ulcer. It appears first as a black spot, which
increases, and is thrown off, leaving exposed to view a corroded or pha-
gedenic surface. After the slough has separated, an ulcer may remain
of a painful character, with a dark blue, or livid crimson margin. In this
manner, the disease will go on alternately sloughing and ulcerating, some-
times till nearly all the external parts of generation are destroyed. With
respect to the hypothesis, that phagedenic primary sores derive their origin
from a specific poison, various considerations oppose its adoption. The
sore is not always phagedenic from the beginning, which we should na-
turally suppose would be the case, if it arose from a specific poison. The
causes of phagedenic ulceration may frequently be traced very unequivo-
cally to the condition of the individual's health ; to his having neglected
to restrict himself to proper regimen ; to his having been guilty of excess ;
or to his having neglected some other kind of primary sore in its com-
mencement. The opinions I have delivered on primary phagedenic sores,
derive considerable support from the observations of Mr. Travers. Nu-
merous phagedenic venereal ulcers, of a particularly severe character, are
brought into St. Thomas's Hospital from a particular district of the town,
namely, Swan Alley, near St. Katharine's Docks, in consequence of which
the disease is familiarly known in the Borough hospitals by the name of
the Swan Alley Sore. I have seen the same disease in St. Bartholomew's,
brought, I believe, from other alleys. The genuine form of it, however,
as described by my friend Mr. Travers, is usually seen in very young girls,
who reside near St. Katharine's Docks, and have frequent connection
with sailors, Lascars, and other men of colour. It usually shows itself in
the cleft of the nates, in the groin, or on one of the labia towards the pe-
rinaeum, and as it enlarges, the surrounding skin puts on a crimson colour ;
its surface is generally covered with a deep ash-coloured slough ; it often
extends with alarming rapidity, producing great constitutional disturb-
ance and intense pain ; the appetite is lost, and extreme prostration of
strength attends the disease throughout the greater part of its course.
This kind of sore is rarely or never followed by secondary symptoms; a
fact, confirming the view I have taken, that this sore does not depend on
a specific poison, but is in a great measure accounted for by the state of
the health at the time it is contracted. We learn from Mr. Travers's
statements, that most of the young creatures, who are brought from that
THE VENEREAL DISEASE. 399
genteel place, Swan Alley, afflicted with phagedenic ulceration, have had
very little wholesome food ; they are generally kept by Jews and Jewesses,
who give them plenty of gin, though but little proper nourishment. They
are half starved, and more or less in a continual state of excitement and
intoxication, having connection with Lascars, and other dirty foreign sea-
men, as many times in the day as there are hours. In this manner, their
constitutions must soon get into a very disadvantageous state for the
favourable progress of any disease whatever, and we cannot wonder, that
their impaired, imperfectly developed frames, their course of life,, and
uncleanliness, should promote phagedenic ulceration, and give it an un-
usually severe character.
If proper treatment be not delayed too long, however, we shall gene-
rally be able to stop the progress of the disease ; but if the case be
neglected, or wrongly treated at first, the ulceration will often make such
havoc, as to destroy all the soft parts, closing the lower aperture of the
pelvis. I have seen cases, whose severity was even to this extent, and
then of course the result was fatal. Although I have given it as my
opinion, that phagedenic ulceration does not necessarily depend on a
specific poison, I would not wish it to be imagined, that sores, originally
excited by the venereal virus, are not convertible into phagedenic ones :
on the contrary, I believe, that any sore may assume the phagedenic
character in particular states of the health, or in consequence of bad
treatment ; but that, in the greater number of phagedenic sores, there is
no specific poison concerned at all in their production, and never essen-
tially as a cause of them.
Dr. Wallace has attempted to form a classification of phagedenic and
sloughing chancres. One of his principal divisions is into phagedenic
chancres without slough; phagedenic chancres with white slough; and
phagedenic chancres with black slough. For these last, he does not recom-
mend mercury ; but, when the slough is white, and also when the case is
phagedenic without any slough, he frequently resorts to that mineral.
But, whoever carefully reflects upon the bad effects, admitted to arise
from the free use of mercury in phagedenic cases, will not find great
reason to imitate the practice.
With respect to primary venereal sores, we should be careful not to
confound with them several common complaints which cannot even be
suspected to be connected with, or to originate from, any kind of virus,
as,^for example, the disease called herpes preputii, which begins with heat
and itching of the foreskin, and, in one or two days, is followed by red
patches as large as a silver penny, on each of which may be remarked
five or six small vesicles, which lose their transparency in a few days,
and become filled with pus. They then burst, and the fluid oozing out
of them, and drying, forms scabs. Excoriations of the corona glandis too,
and of the prepuce, are common in individuals who are not cleanly, and
who neglect to wash these parts occasionally. Under such circumstances,
troublesome excoriations will be likely to be produced by the^lodgment
of the natural mucus, and its becoming acrid and irritating. These
cases merely require cleanliness for their cure. Patients with such ex-
coriations often ask our advice, and if we give them mercury we give
it unnecessarily; nothing is required but a weak solution of the sul-
phate of zinc, or a lotion of rose water and subcarbonate of potash.
There are also cases, in which there is a scaly appearance of the pre-
puce, a kind of psoriasis, which must not be mistaken for a venereal com-
plaint.
400 THE VENEREAL DISEASE.
The old practitioners sometimes cut chancres completely away ; in
other instances, they destroyed them by means of caustic. The latter
practice is often followed at the present day, when the sore is recent and
of small size, in order to lessen the chance of secondary symptoms. The
late Dr. Wallace particularly insisted upon the usefulness of this practice,
on the ground, that if its surface can be destroyed in the early stage,
before granulations form, the risk of secondary symptoms from absorption
will be greatly diminished.* " If, by any means," says Dr. Wallace, u the
poisonous quality of an ulcer, produced by the direct application of the
venereal virus, can be destroyed before the process of ulceration has
ceased in any point of the ulcer, the contamination of the system will be
prevented." The same practice is urged by M. Ricord ; the secondary
symptoms, he remarks, which can only take place after a chancre, do not
occur in all cases, and, when they do follow, do not present themselves
till after a certain period. To be convinced of this important point, the
real beginning of a chancre must be discriminated from the supposed
one ; that is to say, the calculation is not to be made from the day when
the patient first perceived the sore, but from the day when he actually
contracted it. It will then be found, says M. Ricord, that if the ulcer-
ation be completely destroyed by caustic, or other means within three,
four, or five days after the application of the cause, such ulceration will
not be attended with risk of secondary inflammation. " It is only about
the fifth day," he continues, " that the induration of a chancre commences,
and it is ordinarily the indurated chancre that is followed by secondary
symptoms." Such induration seems to M. Ricord, then, to denote, that
the principle (that is, the active principle of the disease) has penetrated
further into the system. While it is absent, he considers it allowable to
suppose, that the disease is yet superficial. Dr. Wallace, I think, offered
a better explanation in the fact, that absorption does not usually take
place till granulations are formed on some part of the ulcer. During the
two or three days spent by Dr. Wallace in the application of the nitrate
of silver, he prepared his patient by a purgative, and by regularity in his
mode of living, for subsequent constitutional treatment. In the mean-
while, lint dipped in the liq. plumbi acet., and covered with oiled silk,
was applied to the sore. As soon as ulceration had ceased, and the pro-
cess of reparation begun, he had recourse to mercury " to hasten the
process of healing, and to diminish the chance of secondary symptoms."
Although I do not concur with Dr. Wallace in so free a use of mercury,
as he advocates, or in the use of it at all in some cases for which he
recommends it, I am perfectly convinced of the usefulness of the maxim
inculcated by him, as well as by M. Ricord, " that the sooner a primary
sore is healed, the sooner the risk of several serious consequences, both
local and constitutional, will be removed." f I have already stated, that
all chancres are not to be treated alike. In phagedenic ulceration mer-
cury is improper ; the right plan at first is the soothing one ; antiphlo-
gistic treatment will be proper ; and, if the patient be not too far reduced,
and manifest traces of inflammation be present, venesection, saline
antimonial medicines, sarsaparilla with mineral acids, and anodynes, such
as conium, hyoscyamus, or the acetate or muriate of morphia, with low
diet, and plenty of ventilation, and strict cleanliness, will form the best
plan of treatment. Then to the ulcer itself it will be useful to apply
* W. Wallace on the Venereal Disease, p. 53., £c. 8vo. Lond. 1833.
f Op, cit. p. 113.
THE VENEREAL DISEASE, 4-01
lotions, containing opium or hyoscyamus, with a proportion of nitric acid.
Quietude in the recumbent position is of course an essential thing. But
in the worst kind of phagedenic ulceration, which I have adverted to,
and which is accompanied by great debility, the diet must not be too
low. We begin with putting the patient on a diet of eggs and milk, and
when the stomach has acquired more power, the patient may be allowed
a mutton chop every day, and from ten to twelve ounces of wine.
Sometimes the undiluted nitric acid may be applied ; in other instances,
a lotion, consisting of a pint of distilled water, three drachms of the
chloride of sodium, and one drachm of caustic potass, will produce a
clean surface, and promote the formation of healthy granulations.
The treatment of phagedenic venereal ulcers by compression has been
recommended, but I cannot speak of it from my own experience.
Sloughing chancres are believed to be less frequently than others fol-
lowed by secondary symptoms. " If from the violence of the inflam-
mation," says Dr. Wallace, " a process of sloughing commences in a
chancre, before the action of ulceration has ceased upon any portion of
its surface, and if this process involves the structure of the part beyond
the point of contamination, it may form, not only a natural cure of the
local disease, but may also prevent contamination of the system." Hence,
he accounts for the escape of many patients from the attack of secondary
symptoms, whose chancres slough in the early stage. It would be errd-
neous to suppose, however, that no patients who have sloughing chancres
experience secondary symptoms. In University College Hospital, the
contrary fact is occasionally seen ; but, under the treatment there adopted,
the secondary symptoms have always been free from severity, and readily
cured.
With respect to the treatment of the primary sore, characterised
by a cartilaginous hard base and margin, the Hunterian chancre, as
it is called, the employment of mercury is the common practice ; but,
there are differences of opinion as to the extent to which it should be
carried. Some of those surgeons, who are decidedly against the free
exhibition of mercury in other primary venereal sores, are strong advo-
cates for it in the example now under consideration. Mr. Carmichael is
one of this number ; and, though he cannot be said to be generally an
admirer of the copious administration of mercury, he recommends a full
cours'e^of mercury for the Hunterian chancre. Frequently we hear it
asserted; that thus the disease is cured sooner, and the chance of
secondary symptoms more effectually lessened, than by any other known
plan. This doctrine would find, however, but little support in the facts
brought forward by Mr. Rose ; and, in University College Hospital, I
have treated the Hunterian chancre, as successfully as other chancres,
with the hydriodate of potassium and sarsaparilla, no mercury being
exhibited. If mercury be preferred, it should be given so as to affect
the gums, and produce a mild degree of salivation ; but I would avoid
bringing on a more violent action of it on the system, such qe would
occasion severe derangement of the health, by which the cure would be
more likely to be retarded than quickened. At all events, I advise, in
the first place, a trial of what the moderate action of mercury will do,
aided by a proper regimen, before the patient is subjected to a severe and
profuse salivation.
When a sore is situated under the prepuce, and the latter is so swollen
that it cannot be drawn back, and the sore examined, we should always
be careful to wash the matter away which collects under the foreskin.
D D
402 THE VENEREAL DISEASE.
For this purpose, we should first use warm water, and then a solution of
the acetate of lead or sulphate of zinc. Here, by attending to clean-
liness, we are doing a great deal towards the cure. Now that the plan
of giving mercury in moderate quantities is generally preferred to a
violent and profuse salivation, we should do no material harm by fol-
lowing this method, even though the concealed situation of the sore
might not let us judge of its exact character. In such a case, if the
iodide of potassium were objected to, I should consider the exhibition of
mercury, on the moderate plan specified, perfectly justifiable. Formerly,
when the ulcer could not be seen, and when it was the custom to salivate
the patient profusely, the question, as to whether mercury should be
given or not, was a very serious one — it was virtually, whether the
patient should or should not undergo a long and violent salivation ?
whether his constitution should be subjected to severe impairment or
not ? But now the decision does not involve a consideration of this
importance.
If a chancre heal up quickly under the influence of mercury, the
general rule is to continue the medicine for ten days or a fortnight after
the sore has been cured. Another general rule is, that of not dis-
continuing mercury until the hardness of the base, upon which the
chancre was situated, has been dispersed, for this is not uncommonly
looked upon as the criterion of all diseased action having ceased in the
part. Exceptions occur, however, where a chancre leaves a callous
cicatrix, which will not yield to mercury ; and, consequently, a perse-
verance in it beyond a certain period would do more harm than good.
One kind of chancre, situated on the lining of the prepuce, where it is
reflected over the corona glandis, sometimes leads to an accumulation of
pus between the skin of the dorsum penis and the corpora cavernosa.
If an outlet be not made for the pus collected in this situation, it will
sometimes spread up to the pubes, and a good deal of the skin of the
penis be destroyed. Occasionally, several small openings take place, but
they are insufficient to prevent the mischief. Here the best practice is
either to make a free opening, or to slit open the prepuce from its orifice
up to the corona glandis.
Dr. Wallace frequently demonstrated to the pupils of his hospital
the remarkable influence of the nitrate of silver in stopping the progress
of a chancre on the fraenum. The tendency, which a chancre has in this
situation to perforate the fraenum, is universally known, and it is also
usually believed,, that, when such perforation has taken place, the
ulcer cannot be healed until the whole fraenum has been destroyed,
and hence it is common to divide the perforated part with a bistoury.
Now, Dr. Wallace affirms, that, in nineteen cases out of twenty, if the
patient apply before the ulcer has perforated the fraenum, its perforation
may be prevented, by the application of the nitrate of silver ; and that, if
the fraenum be already perforated, the remaining portion of it may yet be
saved by the same practice.*
Many surgeons do not place implicit reliance on the doctrine of the
possibility of knowing whether a primary sore is venereal or not, by its
mere appearance ; and when there is doubt, it may be the wisest maxim
always to give mercury, or the iodide of potassium, in moderate quan-
tities. The successful treatment of primary sores materially depends on
the kind of regimen observed by the patient ; for if he neglect to keep
* See Wallace on the Ven. Dis. p. 95.
THE VENEREAL DISEASE. 403
himself quiet — if he expose himself to all weather, and be guilty of
excesses, he will be liable to more severe consequences, than other
patients with similar complaints, who conduct themselves more prudently.
With respect to dressings, astringent lotions, and especially the black and
yellow washes, usually answer better than greasy applications ; and, when
there is much inflammation, we should enjoin the recumbent position,
which, indeed, has a great effect in promoting the cure of sores on the
genitals, whatever be their character.
I will conclude these observations on chancres with a statement made
by Dr. Wallace, which, as coming from a gentleman strongly attached to
the mercurial treatment, merits great attention. " In dispensary prac-
tice, and among the lower ranks of society, says he, the internal admin-
istration of mercury, particularly at inclement seasons of the year, can
seldom with safety be recommended. In such persons, and under such
circumstances, topical applications (nitrate of silver and mercurial lotions)
are of infinite value. In cases of this kind, I generally confine my
treatment to them, in conjunction with the internal use of nitrous acid ;
and, by these means, I succeed, for the most part, in healing the disease
with rapidity. Cases, treated in this way, are also very seldom followed by
secondary symptoms" *
BUBOES.
The venereal matter or poison, in its passage through the inguinal
glands, frequently gives rise to inflammation and enlargement of them,
which, in many instances, is followed by suppuration and ulceration.
The swelling, abscess, or sore, thus produced, is termed a bubo, a name
derived from a Greek word signifying the groin; though, if the patient
happened to have a primary venereal sore on one of his fingers, he
might have a bubo just above the elbow, near the inner edge of the
biceps, or in the axilla ; so that a bubo does not always signify a disease
in the groin, as the etymology of the word would imply. But the poison
of syphilis may make its way into the system, without exciting any
inflammation in the absorbent glands of the groin, or other region of
the body ; no bubo at all may intervene between the occurrence of the
primary sore and the commencement of secondary symptoms. In other
terms, the latter are not invariably preceded by a bubo. On the whole,
buboes form more frequently after a chancre on the prepuce, than after
one on the glans ; yet every inflammation of the glands of the groin
must not be set down as venereal, for these parts are subject to various
enlargements from other causes. Should a bubo occur in consequence
of a chancre, before the ulcerating process of that chancre has ceased,
Dr. Wallace deems it more likely that such a bubo has been produced
by irritation than by absorption of the virus. This fact he considers to
be tacitly admitted by those who have had most experience in venereal
complaints ; for, it is allowed, that buboes are most apt to occur after a
lapse of some time from the formation of a chancre, and that,fhe longer
a chancre has continued, the more likely is such bubo to be the fore-
runner of constitutional symptoms. Mr. Hunter observed, that, when the
venereal poison affected one of the absorbent glands, the gland that in-
flamed was one of the nearest to the primary ulcer. Such, indeed, is
the fact ; and we never find that the absorbent glands, situated in the
* Op. cit. p. 113.
D D 2
404< THE VENEREAL DISEASE*
course of the aorta or iliac vessels,, are inflamed, and brought into the state
of suppuration by the absorption of venereal matter. The glands of the
groin, then, may inflame, suppurate, and ulcerate, but not those within
the trunk. Mr. Hunter entertained a suspicion, that another criterion of
a venereal bubo was the circumstance of its involving only one gland ;
but, at the present day, this test is not entirely relied on. Frequently,
in venereal cases, several glands inflame ; and sometimes, in glandular
swellings from irritation, only one gland is concerned. Also, in a bubo
arising from scrofula, there may be only one gland affected at first;
so that the distinction suggested by Mr. Hunter cannot, I believe, be
depended upon. However, Wallace, Ricord, and others incline so far
to the doctrine of Hunter on this point, as to represent the venereal bubo
as most frequently seated in a single gland. " When absorption takes place
from a chancre of the genital organs," observes M. Ricord, " the bubo
only takes place in the superficial glands, and most commonly only in one
of them at a time ; though several may inflame and swell, both superficial
and deep, so that one gland may actually have all the characters of a
virulent bubo, while others near it, in which the inflammation may
also advance to suppuration, as well as the surrounding cellular tissue,
may present only one of a simple kind, quite free from virulence." *
Another character, assigned by Mr. Hunter to a venereal bubo, is the
quickness with which it generally proceeds to suppuration, and the
shortness of time which the matter requires to make its way to the
surface. I am afraid that this test, also, is not of much practical
importance; for there is great variety in venereal buboes in this
respect, some being much more indolent than others. It is far from
being the invariable character of venereal buboes to proceed rapidly to
suppuration ; for while some of them are very acute, corresponding more
or less to Mr. Hunter's description, others are of a chronic character, and
this frequently cannot be accounted for, either by the influence of
scrofula or mercury, the two circumstances which Mr. Hunter believed
would generally explain it.
The venereal poison excites inflammation and abscess in the- lymphatic
glands much more frequently than in the lymphatic vessels.
Such buboes as are supposed to arise from the venereal poison, but
have not been preceded by any chancre, are sometimes called primary
buboes, and by the French bubons demblee. But, when a bubo follows a
chancre, it is occasionally termed a consecutive bubo. If the bubo has made
its first appearance in the stage of the constitutional symptoms, M. Ricord
names it a secondary bubo. A sympathetic bubo means one not proceed-
ing from the action of the venereal poison, but irritation in the urethra,
lower extremity, or other part. Buboes are also divided into acute and
chronic ; inflammatory and indolent ; suppurating and ulcerated.
The pus, formed by a venereal bubo, is well known to be capable of
communicating the disease by inoculation ; though, for reasons readily un-
derstood, if what has been stated by M. Ricord be correct, the matter
secreted by the surrounding cellular tissue, or other glands simply in-
flamed at the same time, will not be infectious, and, consequently, if it
happen to be employed, the inoculation will not communicate the venereal
disease.
The generality of buboes, not truly venereal, are preceded and accom-
panied by more or less disorder of the health ; and under such circum-
* Ilicord, Mai, Vcn. p. 40.
THE VENEREAL DISEASE. 405
stances, if there were no chancre to account for the bubo, we should
have reason for suspecting, that the state of the health had brought on
the glandular enlargement. It is one good rule when the patient will
not admit that he has had a chancre, or we cannot discover any traces of
one, always to inquire into the state of the nearest lower extremity, and
to ascertain whether there is any inflammation, wound, boil, or sore,
about the foot, leg, thigh, or nates ; any bunion on the great toe, or any
inflamed bursa, or painful corn ; for the inguinal glands are liable to in-
flammation and enlargement, in consequence of any of these causes.
Buboes, which arise unpreceded by chancre (bubons d'emblee) or any
other cause to which they can be ascribed, except a suspicious inter-
course, M. Ricord observes, mostly affect the deep-seated glands ; their
progress is generally chronic; they have little tendency to suppuration;
and, what is especially worthy of notice, the pus which they form never
communicates the venereal disease by inoculation. M. Ricord further as-
serts, that he has never known constitutional symptoms follow a bubo of
this description.*
In the treatment of a bubo, if it be a venereal one, we ought to be
guided by the same principles as in the treatment of primary sores.
The doctrine, that venereal primary sores may be cured without mer-
cury, applies also to venereal primary abscesses and buboes. Although Mr.
Hunter referred the efficacy of mercury to a specific action excited by
it in the constitution, which action is represented as capable of subduing
the venereal complaints ; yet he entertained a particular opinion, with
respect to the modus operandi of this mineral, in the case of a syphilitic
bubo. For instance, he had a high opinion of the usefulness of getting
the mercury to pass through the diseased gland, which usefulness, real
or imaginary, must have been ascribed in part, at all events, to the direct
influence of the mercury on the gland, in its passage through it : he be-
lieved, that in this way buboes were sooner cured than when mercury
was differently exhibited; and it was therefore a great object with him
to rub the mercury upon a surface, from which the absorbents proceeded
to the gland affected. This practice is, perhaps, not deemed so essential
at the present day ; and some very good surgeons even think, that the
irritation of the mercury will sometimes actually bring on swellings offyhe
absorbent glands, or aggravate them if they exist. At all events, I may
state, that the plan is not universally approved, especially when there is
acute inflammation about the glands affected. "When, however, the
swelling is of a more indolent or chronic nature, the practice of making
the mercury pass through, or to the gland, or even of applying it to the
groin itself, is frequently adopted ; and there can be no doubt, that such
method has an influence in dispersing the swelling. On the contrary, if
the gland should be much inflamed, and highly painful, the value of the
practice is extremely questionable.
How long the use of mercury ought to be continued in the treatment
of buboes, and what is the quantity requisite to be given, ar£ questions
to which different replies would be made in different schools. I consider
myself to be of that party which, while it admits the possibility of curing
all the forms of syphilis without mercury, fully admits the general useful-
ness of this mineral as a means of checking and eradicating the disorder;
that it divides with 'the salts of iodine the repute of being the best
means of lessening^the risk of secondary symptoms, and of quickening the
* Ricord, Mai. Verier, p. 149.
D P 3
406 THE VENEREAL DISEASE.
cure of many forms of the disease. But, for this purpose, I should say,
that long- continued and full courses of mercury are hardly ever requisite.
In former times, when buboes yielded with tolerable celerity, it was the
common rule to continue the mercury for about six weeks, at the end of
which time it was entirely left off, and bark, sarsaparilla, and other tonics,
given. Such was the general plan, when buboes yielded in a moderate
time. On the other hand, if they subsided very rapidly, then the mer-
cury was given for at least three weeks or a month after the healing of
the bubo. But, we often find that buboes will not heal after mercury has
been persevered in for a long time, and more especially when the health
is much disordered by it. Here the discontinuance of the mercury is
necessary, and such other medicines ought to be given as are likely to
produce an improvement of the general health. Too long a perseverance
with mercury will often retard the cure of a bubo, — nay, will sometimes
so derange the constitution, that the ulceration will spread from this
cause alone, and assume a most dangerous condition.
In scrofulous constitutions, either the influence of the mercury, or the
derangement of the system, arising from the united effects of this mineral
and of the disease together, will frequently give rise to scrofulous gland-
ular enlargements. When mercury is so employed for primary venereal
sores, as to occasion a full saturation of the system, if there be a tend-
ency to scrofula, this abuse of mercury will frequently act as an exciting
cause of the latter disease, and its continuance be sure to render the
patient's condition worse. Here the discontinuance of mercury is a sine
qua non in any plan likely to be attended with benefit ; and, instead of
looking up to mercury for a cure, we should confide in remedies of an-
other description, namely, bark, quinine, sarsaparilla, the diluted nitric or
sulphuric acids, and narcotics, such as hyoscyamus, conium, opium, the
acetate or muriate of morphia, &c. In some cases, also, it will be neces-
sary to use such medicines as are considered to have a peculiar influence
over scrofula, namely, iodine, or the carbonate of soda, and to let the
patient have the benefit of a change of air.
It is a good rule not to be in too great a hurry to open a suppurated
bubo, unless the matter is above a certain quantity, or has a tendency to
spread, and then the sooner the swelling is opened the better. The
matter is not always within the glands themselves, but often in the sur-
rounding cellular tissue. In common examples, the skin should be suf-
fered to become thinnish before an opening is made, and then a puncture
may be made with a lancet or bistoury ; but if the skin should be much
undermined, and separated from the subjacent parts, some surgeons
would prefer opening the abscess with caustic. In this manner a portion
of the diseased skin may be destroyed, and a free opening made, well
calculated for the ready outlet of the matter, and for obviating all risk of
the formation of fistula? and sinuses. One consideration, in favour of not
opening buboes prematurely, is, that, after matter has collected within
them, it may be absorbed again from the influence of mercury, or the
iodide of potassium, aided by the effect of blackening the skin with the
nitrate of silver, and then no opening at all will be required.
When a venereal bubo is much inflamed, antiphlogistic treatment will
be necessary, as well as mercury, or the iodide of potassium ; for specific
inflammations, as well as common, are not out of the control of ordinary
antiphlogistic remedies. We ought to apply leeches, and cold evapora-
ting lotions, as in common inflammations ; or, if cold applications will not
answer, warm emollient ones, as poultices and fomentations, are to be
THE VENEREAL DISEASE. 407
tried. When a bubo becomes a sore, the local treatment must be regu-
lated by the appearances, character, and condition, which the ulcer may
exhibit. In relation to this subject, I have already given general di-
rections in treating of ulcers. When all specific action has ceased in the
bubo, the disease is of course only a common sore, or a sore of %ne of the
characters explained in the part of this volume, to which I have just now
alluded.
When a bubo is in the form of a deep phagedenic ulcer, the application
of a solution of opium, with a proportion of nitric acid in it, will often
cause a rapid improvement of it. Even the undiluted nitric acid, applied
in the manner adopted for hospital gangrene, will sometimes prove the
best application. Dr. Colles, in such cases, brushes the edges of the
ulcer with the strong muriate of antimony ; and he assures us that, how-
ever large the surface, " it will begin to heal, even if the edges alone be
touched."*
Sometimes, after a bubo'has burst, one of the enlarged glands will pro-
trude above the level of the skin, and retard the healing process. In ge-
neral, such prominent gland will recede again under the use of mercury,
as Dr. Colles represents ; but I have seen other cases, in which this has
not happened, and the disease became so tedious, that it was judged ad-
visable to cut off the highest part of the glandular protuberance, or to
destroy it with caustic. I had such a case in University College Hospital
last spring (1839). I do not mean such practice, however, to be adopted,
unless the prominent gland should not be reduced under milder plans.
A bubo occasionally leads to the formation of a sinus, commencing at
the pubic corner of the ulcer, and descending in the angle between the
scrotum and the thigh. If the sinus cannot be cured by pressure, or
does not heal under the influence of treatment adapted to improve the
general health, we should either lay the sinus open throughout its whole
extent, or make a counter-opening in a depending situation, and wash it
daily with some stimulating injection, as advised by Dr. Colles. Another
troublesome consequence of bubo, described by this last gentleman, is a
superficial ulceration, spreading along the inside of the thigh, sometimes
even to the anus, or upwards on the abdomen. One edge of this ulcer is
deeply and slowly increasing, while the other is thin and may be healing.
This has occasionally been named the horse-shoe ulcer. Mercury is gene-
rally useless or hurtful. The black wash is a good application ; and, if
mercury be tried, it should be in small doses.f
When the patient has been taking a great quantity of mercury, a bubo,
after having burst, may leave the skin in an undermined state, with cal-
lous and irregular edges. These are mostly obstinate cases, and will
sometimes remain unhealed for months. So difficult is it to bring such
ulcers into a favourable condition by common means, that it may be re-
quisite to cut away the hard callous edges, as a measure that at once
removes a principal impediment to cicatrisation. Instead of this plan, a
strong solution of the nitrate of silver, or a caustic solution of iHdine, the
undiluted nitrous acid, the nitrate of silver, or the potassa fusa., is some-
times applied to the callous edges of the ulcer. In general, under such
treatment, their hardness will gradually subside and disappear ; but, in
the event of the case resisting this mode of treatment, the hardened and
diseased edges of the ulcer should undoubtedly be removed with the knife.
In this condition of a bubo, the liquor arsenicalis, sarsaparilla in lime
* Abr. Colles, M.D., on the Ven. Disease, p. 102. f Ibid. p. 103.
D D 4
408 THE VENEREAL DISEASE.
water, or cascarilla with hydriodate of potash, or bark with the nitric or
sulphuric acid, given internally, change of air, and sea-bathing, will fre-
quently be of essential service.
What treatment ought to be adopted when a bubo arises unpreceded
by any chancre ? The statements of M. Ricord, already noticed, would
of course incline us not to fyave recourse, at all events, to mercury ; yet,
if we listen to other authorities, mercurial treatment ought not to be
omitted. Thus, Dr. Wallace informs us, — "I have treated certain cases
of bubo, which were neither accompanied nor preceded by primary symp-
toms, but which had followed suspicious intercourse, as if they had been
caused by the absorption of the venereal poison ; and I have never had
occasion to regret the practice. On the other hand, I have known buboes,
which were not preceded by primary symptoms, to be followed by
secondary symptoms when mercury had not been used in their treatment."
Here we observe a positive disagreement between M. Ricord and
Dr. Wallace on the question, whether secondary symptoms ever follow
bubons d'emblee 9 The former states, that they never do, and, also, that
inoculation with the matter of such a bubo cannot communicate syphilis
by inoculation. In University College Hospital, we should never think of
subjecting a patient to salivation for a bubo of this description, but adopt
simple means for its dispersion, and, if this plan failed, try some other,
according to the condition of the bubo, and the constitution. If the
swelling suppurate, I recommend it to be treated as a common abscess ;
and either small doses of iodide of potassium with sarsaparilla to be pre-
scribed ; or, if there be any febrile disorder, saline antimonial medicines,
with five grains of the pil. hydr. chlorid. comp. every night, or every other
night, according to circumstances. If the swelling remain chronic, the
skin covering it may be blistered, rubbed with the ung. potass, iodidi, or
camphorated mercurial ointment, or blackened with the nitrate of silver.
In some cases, compression is useful. With this treatment we may com-
bine the internal exhibition of four or five grains of extractum cicutac once
or twice daily, and from ten to fifteen drops of the alcoholic solution of
biniodide of mercury (L. P.) once, twice, or thrice a day.
SECONDARY SYMPTOMS.
Previously to the occurrence of secondary symptoms, the constitution
may generally be observed to be somewhat disordered ; there is more or
less fever present, with accelerated pulse, headach, loss of appetite, pains
in the limbs, and inability to sleep. Indeed almost all patients are parti-
cularly restless for two or three days before the appearance of any se-
condary symptoms ; that is, before they complain of a sore throat, or
perceive any traces of cutaneous disease about them. When secondary
symptoms take place, which does not always happen under any mode of
treatment, and is not invariably prevented by any yet tried, they are
more disposed to occur in some parts than others. On this account,
Mr. Hunter divides the parts affected into two orders : the first order
consisting of those, in which the secondary symptoms usually first show
themselves ; namely, the throat and skin, with which parts the iris and
perhaps the joints are also to be arranged :the second, including parts
in which the disease produces its influence at a later period, as the
periosteum and the bones, to which may be added the nose, in which
an ulceration of the mucous membrane, the ozcena syphilitica, with/or
without disease of the bones, is very common. In the second order of
parts are likewise to be included the ear, the larynx, and the testicle, to
THE VENEREAL DISEASE. 409
which, however, the effects of syphilis less frequently extend than to the
other parts here specified. I believe that Mr. Hunter's statement, re-
specting the throat and skin, agrees pretty well with general expe-
rience, and modern surgeons are inclined to accede to his doctrine in
relation to them ; though pains in the bones and joints sometimes pre-
cede the sore throat and cutaneous eruption. I have seen nodes follow
a primary sore as the first secondary symptom, and this has also been
noticed by others. I once attended a medical gentleman, who had no
sore throat, and no cutaneous eruption ; yet he had nodes. It is gene-
rally considered, that the interval between the primary and the secondary
symptoms is, on an average, from six to twelve weeks ; but it may extend
to several months, or, according to some reports, to one or two years.
The earliest secondary symptoms generally commence within three months
from the cure of the primary sore ; but they may come on much more
quickly, or even before the primary sore is healed. Almost every sur-
geon has had opportunities of seeing cases, in which there were at the
same time an uncured chancre, an unhealed bubo, a sore throat, an iritis,
and so forth, all existing together. According to the observations of
Dr. Colles, when the primary symptoms have been treated on the mercu-
rial plan, the secondary symptoms are generally later in making their
appearance, and are also preceded by less disturbance of the system ; but
when mercury has been used only for a short time, or has been discon-
tinued as soon as the chancre has healed, the Appearance of secondary
symptoms will be more early. He adds, that the same will be the case, if
febrile action be excited by ordinary causes.*
AFFECTIONS OF THE SKIN.
The eruption presents considerable varieties. A few years ago, it was
considered that no eruption was venereal, unless it had a copper-coloured
appearance, and was scaly. Mr. Hunter represents the skin as at first
becoming mottled, and tells us that such appearance will come out and
fade away again repeatedly. Now, this observation must have been over-
looked by former surgeons, who endeavoured to prove that, without mer-
cury, syphilitic symptoms invariably proceed from bad to worse ; for here
we find it stated, by their own great authority, that the eruption sponta-
neously disappears and then returns ; that the disease fluctuates ; yet the
doctrine that Mr. Abernethy collected by his inquiries from all the most
experienced surgeons in London was, that the symptoms of syphilis are
continually progressive ; and that when there is a true venereal sore, or
eruption, it would always continue to get worse till mercury had been given.
One form of syphilitic eruption is characterised by being scaly, and of a
copper or reddish-brown colour ; small copper-coloured spots first show-
ing themselves, and the cuticle then peeling off. Some of these blotches
conjoin, so as to form extensive patches ; but others of the same colour,
and decidedly syphilitic, are, on account of their diminutive siz» and par-
ticular figure, sometimes termed the lenticular syphilitic lepra. The
venereal eruption, according to Mr. Hunter, consists of copper-coloured
spots on the skin, accompanied by desquamation, which leaves the subja-
cent cuticle thicker and thicker as this process goes on, and of the same
colour as the cuticle which peels off. If the disease advance further,
scabs will form, suppuration will take place under them, and the result
* Practical Obs, on the Ven. Disease, p. 120.
410 THE VENEREAL DISEASE.
be a secondary venereal ulcer, which, when thus produced, affects princi-
pally such parts of the skin as are in contact with other portions of the
cutis, like the fold of the nates, the angle between the scrotum and thigh,
or the armpit. In these situations, the eruption has a raised surface,
from which a whitish matter frequently oozes. These copper-coloured
scaly blotches generally first appear on the face, hands, and wrist, and
afterwards on the breast and the extremities, where they are particularly
numerous, and assume the form of lepra or psoriasis. Another circum-
stance deserving of attention is, that when the palm of the hand or the
sole of the foot, where the cuticle is very thick, is affected, an appearance
is produced, constituting what is often termed the syphilitic lepra, and
psoriasis of the hands and feet. Mr. Carmichael, like Mr. Hunter, re-
garded the scaly copper-coloured eruption as characteristic of true
syphilis ; and though, says he, there are other eruptions which are vene-
real, or the consequence of venereal complaints, yet they are not truly
syphilitic. He notices pustular, tubercular, and papular eruptions ; but
he does not consider these as consequences of a true Hunterian chancre,
but refers them to primary sores of other descriptions. The syphilitic
eruption seems to him always to consist of scaly blotches, in the form
either of lepra or psoriasis, and unattended with fever ; or, I should rather
say, there is not so much fever present with these eruptions as with
either of the others, namely, the papular, the tubercular, or pustular. As
already noticed, Mr. Carmichael attaches so much importance to the
form of the eruption, that he believes it possible to tell, by the inspection
of the cutaneous disease, what has been the character of the primary
sore. In short, he divides the venereal disease into four species or varie-
ties. The first of these is the scaly venereal disease, or that which is
correspondent to the Hunterian description, the chancre having a har-
dened edge and base ; and when the bones are affected, their shafts and
harder parts chiefly suffering, the nodes being true ones, and the eruption
scaly, in the form either of psoriasis or lepra. The second is the papular,
so called from the character of its eruption, which consists of inflamed
pimples, and may follow gonorrhoea, and what some surgeons call the
gonorrhceal ulcer of the prepuce and corona glandis. The third is named
the tubercular, as being attended with an eruption of this character ; and
the fourth is the pustular variety of the venereal disease, so called also
from the appearance of the cutaneous affection. The projecting incrust-
ations, which are conical, or in the form of limpet-shells, constitute the
appearance known by the name of the venereal rupia, which may follow
an eruption, originally either tubercular or pustular. One important fact
to be remembered is, that papular and pustular eruptions, when they have
reached a certain stage, may be attended with a scaly appearance, which
is, therefore, not exclusively the feature of lepra and psoriasis. This cir-
cumstance may, perhaps, explain some cases, in which the eruption seems
to consist of scaly spots, and pustules and pimples, more or less mixed
together.
Secondary venereal ulceration of the skin is often preceded by an erup-
tion, some part of which, after repeated desquamation and scabbing, is
converted into sores ; but, in other instances, chronic inflammation takes
place, independently of any eruption, and ulceration follows; and occa-
sionally inflammation, suppuration, and secondary venereal ulceration,
will occur over nodes. Secondary venereal ulcers have not any regular
and constant appearance ; they are frequently of a round shape, more or
less chronic, and with an irregular, foul, ash-coloured surface ; while others
THE VENEREAL DISEASE. 411
evince the peculiarity of healing in the centre and extending at the cir-
cumference, the unhealed part being of a tawny colour, with sharp edges,
and a foul bottom. No sooner does an experienced surgeon cast his eyes
upon an ulcer of this kind, than he is led to suspect its venereal character ;
its tawny appearance, its shape, and its situation, will induce him to en-
tertain a suspicion, that it has been preceded by other venereal complaints.
But we should never conclude, from the mere look of a sore, that it is
certainly venereal ; but always take into consideration the history of the
case, before a positive opinion is delivered.
Besides these secondary symptoms, presenting themselves as affections
of the skin, I must not omit to specify the ragged ulcerated fissures and
clefts seen on the nates, or about the anus (rhagades ani), and especially
in the fold at the lower part of the nates, and between the perineum and
the thigh, or sometimes even about the roots of the finger or toe nails.
In the latter event, matter forms under the nail, which becomes detached,
and the discharge is remarkable for its strong, fetid, and peculiarly disagree-
able smell. Such is the venereal whitlow, as it is sometimes named.
Some excrescences in venereal patients, taking place especially about the
genitals, perineum, and anus, receive different names, according to their
various shape and consistence ; as warts, condylomata, fai, &c. They are
frequently accompanied with ulceration, or purulent discharge from the
urethra or vagina ; and they often grow from parts which have been
ulcerated, though now healed. They are not essentially connected with
syphilis ; for we see precisely the same kind of growths in persons, who
appear never to have had the venereal disease. In women they are very
common, and some of them do not appear to me to be materially different
from particular kinds of hemorrhoidal excrescences. Formerly it was the
practice to salivate patients for the cure of these excrescences, and this
sometimes more profusely than for a sore throat or a chancre ; and it must
be acknowledged, that, when the system was thus brought and kept a long
while under the influence of mercury, such growths generally dwindled
away, and ultimately disappeared. The fact, however, that these excres-
cences could be as permanently and certainly cured with the knife, liga-
ture, escharotics, and stimulating applications, as by mercury, was well
known to some intelligent practitioners nearly half a century ago ; and,
what is still more to the point, it was known that the cure was radical.
On what principle, then, could the severe measure of a long and profuse
salivation be vindicated ?
SORE THROAT.
One of the most common secondary symptoms is ulceration of the
fauces, tonsils, and soft palate, — in other words, a sore throat. What has
generally been considered as the most unequivocal specimen of syphilitic
ulceration of the throat, is remarked to come on without much previous
inflammation, to begin on the surface of the part affected, and to extend
more and more deeply ; so that, when situated on the tonsils, aft appear-
ance is produced, as if a portion of them had been scooped away. The
sore has a sharp prominent margin, and its excavated surface is covered
with yellow adhesive matter, that cannot readily be separated from it.
It is not uncommonly believed, that a sore throat, corresponding to this
description, is peculiar to true syphilis, or the scaly form of the venereal
disease — that disease, all of whose symptoms are sometimes thought more
particularly to require larger quantities of mercury for their cure, than
other varieties of the venereal disease. On this point, however, I may
412 THE VENEREAL DISEASE.
observe, that the doctrine, to which allusion has here been made, is not
so much insisted upon at the present clay as it was some years ago. In
fact, this kind of sore throat has frequently been cured with sarsaparilla ;
and it sometimes follows sores, which have no kind of resemblance to the
chancre with an indurated base and circumference. At the same time,
the belief prevails, that whenever this kind of sore throat is accompanied
by a scaly eruption, or by pains in the shafts of the long bones, or by
true nodes, it will be more benefited by mercury than any other medicine.
I sometimes employ small doses of the blue pill, joined with iodide of
potassium and sarsaparilla. In University College Hospital we do not find
it necessary,1 however, to keep up mercurial action for eight or ten weeks,
as sometimes recommended even at the present day.
Besides this description of sore throat, there is another, consisting in
superficial but foul and wide-spreading ulcerations of the tonsils, velum
pendulum palati, and upper portion of the pharynx, accompanied by con-
siderable pain, restlessness, and fever. On account of its appearance, it
is frequently called the ulcerous excoriation of the throat. Mr. Carmichael
thought he had traced it to be an effect of what he terms the papular
venereal disease, or that which he conceived to arise from the simple
primary sore, patches of excoriation on the prepuce, or gonorrhoea
virulenta.
Sometimes a patient complains of experiencing severe pain whenever
he attempts to swallow ; yet the surgeon, on first inspecting the fauces,
detects no ulcer, nor appearance of inflammation. In many such cases,
there is an ulcer at the back of the pharynx, concealed by the interposi-
tion of the velum palati. " We should, therefore (as Dr. Colles directs),
desire the patient to inspire as fully as he can ; in attempting this, he
raises the velum, and, if we then look into the pharynx, we shall gene-
rally discover the lower part of an ulcer ;" and, to bring this more per-
fectly into view, the tongue must be depressed and the velum raised with
a curved probe. The ulcer has a circular form, sinks deeply into the
substance of the pharynx, has rather a foul but not a sloughy surface,
and the surrounding inflammation extends only a very short distance
from its margin.
An ulcer low down in the pharynx generally presents a foul, and
sometimes a sloughy surface ; and, according to Dr. Colles, the lower
edge of it is very deep, while the upper part of it is superficial.
Another position, in which a sore is sometimes formed, is close to the
insertion of the anterior palatine arch into the tongue. The ulcer, so
placed, is deep and foul ; but not sloughy.
In a few instances, we observe that the voice is rendered very nasal ;
the patient feels pain in swallowing ; frequent desire to draw down the
mucus from the back of the nares; and this,, when coughed out, is often
found slightly tinged with blood. The case is generally accompanied by
fever. Under these circumstances, the ulcer is situated behind the velum,
high up in the angle, between the upper and back part of the pharynx,
or at the junction of its occipital and vertebral portions.*
Certain ulcers of the throat have a truly phagedenic character, and are
disposed, under improper treatment, to destroy the whole of the soft
palate, and to extend their ravages to the pharynx, and even sometimes
to the larynx, causing necrosis of its cartilages, and endangering life.
With this form of sore throat, when the constitution is in an unfavourable
» Abr. Colles, Op. cit. p, 124—126.
THE VENEREAL DISEASE. 413
state, from the injudicious use of mercury, there is a tendency to the
production of caries and necrosis in the bones of the palate, and even in
the upper jaw-bone and the ossa spongiosa ; but, if the disease be pro-
perly treated, and the employment of too great a quantity of mercury be
avoided, the patient will generally escape all this serious mischief. Acci-
dental inflammations of the throat from cold, common abscesses, and
chronic scrofulous enlargements of the tonsils, must be discriminated
from venereal sore throats.
IRITIS.
One species of iritis, or inflammation of the iris, is an affection ranking
as a secondary symptom of syphilis. After the appearance of disease of
the skin, or sore throat, the iris sometimes inflames ; this affection, which
may follow, or accompany, various kinds of syphilitic eruptions, particu-
larly the papular, and is usually attended with pains in the limbs and
joints, I shall notice with other diseases of the eye.
VENEREAL AFFECTIONS OF THE MOUTH.
The tongue is sometimes the seat of venereal ulceration, which may
occur at its base, apex, or edges, or on its dorsum. The characters of
the sore are described by Dr. Colles as not being constant. Sometimes
the point of the tongue, when this is the place of the disease, is broad and
truncated, the surface of the ulcer covered with a thin and rather a soft
slough, and the end of the tongue much swollen and indurated. In other
instances there may be the same degree of swelling and hardness, but the
surface of the sore, though foul, may not be sloughy. An ulcer of the
side of the tongue is attended with induration, but less swelling. Occa-
sionally a venereal ulcer of the tongue is attended with an enlargement of
one of the lymphatic glands under the jaw. Ulcers on the dorsum of the
tongue are generally of a circular form, and as large as a fourpenny piece,
with the same characters as are seen in a secondary venereal ulcer of the
skin.
The hardness attending a cancerous ulcer of the tongue, is what is
termed stony, and, in this' respect, is believed by Dr. Colles to differ from
the kind of induration attending many venereal ulcers of that organ. But,
says he, if a slightly elevated narrow ring, of considerable hardness, in-
clude an ulcer, whose surface is so clean as at first view to resemble a sore
that is about to granulate, we may unequivocally declare it to be cancer-
ous. In all doubtful cases, the patient is to try the effects of a slight
ptyalism.
The greater number of ulcers of the tongue, occurring in venereal
cases, arise, according to my experience, from the action of mercury
itself; but, on this subject, I need not enlarge, as, in the second section
of this work, ulcers of the tongue are further considered.
VENEREAL AFFECTIONS OF THE NOSE. ^
Ulcers of the alae nasi may begin in the angle between the nose and
cheek ; and I fully agree with Dr. Colles, that whenever an ulcer, so situ-
ated, shows a tendency to phagedaena, or sloughing, it should be treated
with some active caustic. The distinguishing characters of a venereal
ulcer in the nose are, perhaps, not known ; and are rather to be deduced
from the history of the case. A scrofulous ozcena may be mistaken for
an effect of syphilis. Dr. Colles refers to cases, as not being venereal, in
which an ulcerated opening is formed in. the septum nasi, about a quarter
THE VENEREAL DISEASE.
of an inch from its anterior extremity. He describes it as continuing for
years precisely in the same state. Numerous ulcers of the septum nasi
I find to be most successfully treated by applying the nitrate of silver, or
a strong lotion of creosote, or chloride of lime to them, and giving from
3 to 5 grs. of the iodide of potassium in the decoct, sarsae. thrice a day.
VENEREAL AFFECTIONS OF THE BONES AND JOINTS.
If the swelling has come on suddenly, seems to be chiefly seated in the
periosteum, and the pain is not remarkably aggravated at night, we may
generally conclude that the case is not venereal. True syphilitic nodes
are more indolent in their progress than the swellings to which I have
now referred ; and the pain of them is always more severe at night than
in the day. They are particularly disposed to occur on the central
portions of the long cylindrical bones, and on such parts of the bones as
are not covered by any great thickness of soft parts. Hence, the front
surface of the tibia, the superficial part of the ulna, the sternum, the
clavicle, and the cranium, are often the seat of nodes. The swellings,
most likely to be mistaken for venereal nodes, are inflammations of the
periosteum, and not of the bone itself, attended with pain in their very
commencement, and even with redness of the skin ; they arise suddenly,
and frequently disappear in a short time, without the use of mercury.
They have, therefore, more of the inflammatory character about them,
than usually belongs to venereal nodes. The best plan, in all doubtful
cases, is to inquire particularly into their history; we should consider the
other symptoms which may have previously existed ; the order in which
they have occurred ; and the effect of any treatment that has been
tried ; and we must form our conclusion by connecting the present symp-
toms with all the other information that can be collected.
I believe that true nodes are rarely produced in syphilis, unless the
patient has been using mercury. From this remark I exclude simple
periostitis, which has certainly occurred in venereal patients, treated by
me in University College Hospital without mercury. The late Dr. Hennen,
ajman of considerable observation and great experience, affirms that he had
never seen more than two cases of nodes in patients who had not taken
mercury. I know that some surgeons maintain that the fact is otherwise ;
but it seems to me, that there is a great deal of truth in Dr. Hennen's ob-
servation, and that we seldom meet with patients who have nodes, unless
they have been taking mercury. But here the question arises, how far
the mercury is concerned in producing these nodes ? In considering
this question, we should recollect that, though we do not often see nodes
in syphilitic patients, unless mercury has been given ; yet in liver com-
plaints, for which mercury is often given in considerable quantities, and
for an immense length of time, nodes are never produced. On the other
hand, if no mercury be given in the treatment of syphilis, nodes will
seldom be produced. It seems, then, as if the action of mercury, and the
influence of syphilis, together, had a share in bringing on these osseous
swellings. At all events, it appears to me, that the venereal disease must
be mainly concerned in the production of nodes. Still, there undoubtedly
is foundation for the opinion that, unless mercury be given in some quan-
tity or another, great or small, for the cure of that disease, nodes and
other affections of the osseous system will rarely be excited. A node,
once formed, will often remain for a long while unchanged ; no increase
of size, no discolouration, and no fluctuation being discoverable. In other
instances, however, a node will slowly suppurate ; which is observed to
THE VENEREAL DISEASE. 415
happen more frequently on the skull and tibia than other bones. If the
bone be exposed by ulceration, or an incision, a thickish plate of it will
sometimes get into the state of necrosis, and the ulcer will not heal till
exfoliation has taken place. In other instances, the surface of the bone
granulates, and the ulcer heals up, without any perceptible exfoliation
having occurred.* I entertain not the slightest doubt, also, that there
is some truth in the opinion that caries and necrosis are not so much the
consequence of the venereal disease itself, as of the baneful influence of
mercury, when it is rapidly and unskilfully thrown into the system, at a
period when the patient is exposing himself to the weather, not confining
himself at home, and committing the most imprudent excesses in diet. I
believe that, under such circumstances, an individual is far more likely to
have his osseous system affected, than one who observes a more prudent
regimen during a mercurial course; and it is my firm conviction, grounded
on remarks which I have made in practice, that caries and necrosis of
the bones of the nose would very rarely occur, if mercury were not given
in immoderate quantities, and the patients took due care of themselves
while using that medicine. Syphilis much more frequently extends^ its
effects to the bones in cold, than warm countries.
The researches of M. Ricord fully confirm the Hunterian doctrine,
that none of the secondary symptoms are capable of transmitting the
venereal disease by inoculation. He accedes also to the proposition, that
none of the secretions, either normal or abnormal, of individuals affected
with constitutional syphilis, will serve for the communication of any
venereal complaints by inoculation. •)-
TREATMENT OF SECONDARY SYMPTOMS OF SYPHILIS.
Here the same general rules and principles, respecting the use of
mercury, are necessary to be attended to as in the treatment of the pri-
mary complaints. I may say, then, that mercury will frequently expedite
the cure of the secondary symptoms ; but that, in some states of the con-
stitution, even when true syphilitic affections are present, or when ulcers,
which were originally of this nature, have assumed the phagedenic or
sloughing character, and are accompanied by considerable inflammation,
or much derangement of the health, mercury is the most pernicious
medicine that can be employed. Mercury is also improper when any
extraordinary degree of inflammation is present with a secondary sore.
No surgeon will ever treat either the secondary symptoms, or any other
forms of the venereal disease, with judgment and discrimination, unless
he recollect various facts connected with this subject ; and one of these
is, that mercury will generally benefit not only the ordinary forms of the
venereal disease, but many other complaints ; it will cure not only syphilis,
but many other diseases which resemble it, and many also which are to-
tally different from it. He should likewise recollect that many diseases,
which are successfully treated with mercury, iodide of potassium, sarsa-
parilla, guaiacum, antimonials, mineral acids, the nitro-muriatk; bath,
creosote, &c., would generally get well of themselves, in the ena, if the
constitution could bear the requisite struggle. And, with respect to
mercury, or any other powerful medicines, be it also remembered that, if
they are not administered in such doses as totally to derange the whole
economy, if only moderate quantities of them are exhibited, they will not
commonly prevent any disease from taking a favourable course, if it be so
* See Colles, Op. cit. p. 184. f Ricord, Op. cit. p; 161—165.
416 THE VENEREAL DISEASE.
disposed. Such reflections will render the fact very intelligible how, in
forming an opinion of the nature of syphilis, and of the effects of mercury
upon the disease, so much deception has frequently occurred. A patient
takes mercury in moderation, and his disease gets well, and then the
practitioner is confirmed in his idea, that the disease was venereal, and
has yielded to the specific remedy. But it will be sufficient to recollect
the facts, here specified, to be convinced that mercury is by no means
a test of the venereal character of a disease. In the treatment of second-
ary symptoms, generally, when mercury is given, it is preferable to give
it in moderate doses. In particular instances, it may be necessary to
push the mercury beyond what may be denominated a mild mercurial
course ; but such examples are less common than sometimes represented.
As a general piece of advice, therefore, I recommend the maxim of not
aiming to excite a profuse and violent salivation.
With respect to secondary symptoms, it is a common remark, that
when mercury is useful in this stage of syphilis, it generally shows its
efficacy with even greater promptitude, than in the first stage, or in the
treatment of the primary sores and buboes.
When the cutaneous eruption consists of scaly copper-coloured
blotches, presenting the character of either psoriasis or lepra, and not
attended with much febrile disturbance of the system, and perhaps asso-
ciated with that affection of the tonsils, which is sometimes thought to
be the greatest test of true syphilitic ulceration in the throat, namely,
the deep excavated ulceration, frequently accompanied by pains in the
shafts of the long bones, the majority of surgeons agree, that mercury
should be prescribed, and employed according to the principles I have
explained ; namely, in moderate doses, and not so as to excite a profuse
and violent salivation, or to bring on severe derangement of the health.
But, if the patient's health be much deranged, or he be considerably
reduced and debilitated, I never give mercury, but commence the treat-
ment with light tonics, as sarsaparilla, or cascarilla, and small doses of
the iodide of potassium ; or, if the latter disagree, the dilute nitric acid
may be prescribed in lieu of it. Afterwards, when the patient's health
is improved, mercury may be employed, if necessary ; but, in University
College Hospital, the greater number of venereal eruptions are easily
cured without mercury, or with small quantities of it, joined with the
iodides and other means. The fact has been so often witnessed there, by
the numerous body of students always attending that institution, as not to
admit of dispute.
Foul or phagedenic ulcers in the throat may be fumigated with the red
sulphuret or with the grey oxide of mercury, or washed with a solution
of the chloride of soda, the black wash, or gargles containing muriatic
acid, or any other detergent gargle. Secondary ulcers in other situations
may also be fumigated with benefit, and either poulticed till they granu-
late, or dressed with various applications, as with the water dressing,
watery solution of opium, or henbane, when they are painful, or with the
black or the yellow wash ; or, if they are of a more indolent character,
they may be dressed with the ointment of the nitrate of quicksilver, or
with the red precipitate ointment, or touched with the nitrate of silver.
I have known a lotion, composed of from four to eight drops of creosote in
an ounce of distilled water, make obstinate secondary venereal ulcers of
the skin heal, when other applications seemed to fail. The more I see
of venereal sore throats, the more I am impressed with the value of the
nitrate of silver as an application to them, and this even when the sore is
THE VENEREAL DISEASE*
attended with surrounding redness. In general, foul phagedenic ulcers of
the throat are greatly benefited by it ; but, if they resist its influence,
the nitric acid, or the strong liquid muriate of antimony, may be used.
They may be applied with a small camel-hair brush, or a bit of lint well
secured to the end of an eye-probe.
When the eruption is papular, and has been preceded by a great deal
of fever, and considerable disturbance of the system, and when such erup-
tion ends in desquamation, we may employ bloodletting in the commence-
ment, with the compound calomel pill and saline aperient medicines.
The same practice should be pursued if there be pain and swelling of the
large joints, accompanied by a diffused redness, and .swelling of the
tonsils and glands of the neck. Here it is to be suspected, that some
particular state of the constitution has had a share in thus modifying the
disease, rather than that the modification depends on some other poison
different from that of true syphilis ; but these still remain questionable
points. After continuing the treatment that I have mentioned for a time,
it is to be changed for small doses of James's powder, or antimonial
powder, with decoction of sarsaparilla. Mr. Carmichael, who is a good
practical surgeon, entirely disapproves of the use of mercury in the com-
mencement of the treatment of the papular form of the venereal disease ;
he does not even give the compound calomel pill, which contains but a
small quantity of mercury ; in short, he expressly avoids administering
mercury till the eruption desquamates, and then he admits that such
medicine in moderate doses will be superiorly useful. With respect to
that form of iritis which is met with in syphilis, often accompanying the
papular eruption, mercury is highly necessary, and should be given freely,
for reasons that will be explained when we come to the consideration of
diseases of the eye. The papular eruption will often readily yield to
iodide of potassium, in the dose of three grains, made up into pills, with
one or two grains of the pil. hydrarg., and given once, twice, or thrice a
day. In our hospital, this combination is often employed with great effect,
and less injury of the health, than from the old custom of profuse saliva-
tions.
When the secondary symptoms are associated with a pustular eruption,
we should begin the treatment with alterative medicines, especially anti-
monials, sarsaparilla, and iodide of potassium. After these medicines have
been continued a certain time, we may prescribe bark, and the nitric or
sulphuric acid. What is called the sulphurous bath is also frequently
highly beneficial, and so are the nitro-muriatic acid bath and lotions
of the sulphuret of potash. Mr. Carmichael does not give mercury in
the pustular form of syphilis, unless the pustules change into scaly
blotches ; but he chiefly trusts to sarsaparilla and guaiacum, with small
doses of James's powder, or of the compound powder of ipecacuanha.
When white aphthous ulcers of the mouth accompany syphilis,
they may be touched with a solution of the nitrate of silver, or with
diluted muriatic acid : some surgeons particularly recommend ^he oxy-
mel aeruginis, and others the black wash, or a strong solution of the chlo-
ride of soda.
It would appear from Mr. Carmichaers researches, that these forms of
syphilis, comprising such as are termed papular, pustular, and I might add
tubercular, do not require any mercury in their early stages ; though it is
admitted that, in all of them, after they have lasted a certain time, mer-
cury will come in beneficially, bring the patient completely out of danger,
and do what it would not have done, if given in an earlier stage of such
E E
THE VENEREAL DISEASE.
diseases. In University College Hospital, we find, that most of these
eruptions readily yield to the decoct, sarsae., and small doses of the iodide
of potassium ; but, when they resist, I combine the latter with two or
three grains of the blue pill, rarely giving a greater quantity in the course
of the day ; and few cases cannot thus be overcome, unless there be some
manifest derangement of the health, preventive of the usual efficacy of
these medicines. Then such derangement, whatever it may be, will re-
quire attention.
One observation, made by Mr. Carmichael, agrees with what I have
seen ; namely, that when the knee joint is enlarged and swollen from any
cause connected with venereal complaints, mercury will never do any
good, but, on the contrary, render the case decidedly worse.
With respect to the treatment of the phagedenic ulcers, which occur in
the advanced stages of syphilis, and generally accompany or follow either
the tubercular or the pustular eruption, they are rarely or never bene-
fited by mercury in their early stages. On some tubercles or pustules
scabs form, which assume a conical shape. In Mr. Carmichael's book
there is a drawing of one of these conical scabs projecting from the fore-
head, and so long as to resemble a horn. I believe that, in this form of
disease, termed the venereal rupia, mercury is injurious ; and that one
reason, why the osseous system is so often affected, is the exhibition of
mercury in the commencement of phagedenic venereal ulceration. In
the early stages, bloodletting should not be omitted, unless there be some
peculiar symptom or condition of the health prohibiting it. Antimonials,
saline purgatives, and small doses of the compound powder of ipecacuanha,
may also be employed with advantage. In all cases of phagedenic vene-
real ulceration, opium and its different preparations are truly beneficial.
Sometimes opium may be combined with conium or hyoscyamus. Bark
and the mineral acids are also frequently of particular service in the pha-
gedenic varieties of syphilis ; and the nitric acid has long enjoyed great
celebrity. Besides these medicines, we have now another powerful aux-
iliary in the iodide of potassium, which, in the hospital of University Col-
lege, has completely answered in the cure of phagedenic venereal ulcers,
when aided by proper local treatment. How many bad cases have been
brought to this hospital from workhouses and other places — cases at-
tended with extreme emaciation, the utmost debility, loss of rest, and
urgent hectic symptoms; yet, under the use of small doses of the iodide
of potassium, decoct, sarsae., an opiate at night, and a light nutritious diet,
have soon terminated in a perfect cure.
When phagedaena affects the throat, the same general treatment will be
of advantage ; and, as for applications to the ulceration itself, we may
use fumigations with the red sulphuret of mercury, or apply the black or
yellow wash as a gargle, or touch the parts affected with the nitrate of
silver. Another good plan is to touch the sore with diluted nitrous acid,
applied by means of a camel-hair brush. * The solution of the chloride of
soda is another application which is now very much in favour. Some-
times phagedenic ulceration of the throat extends to the mucous mem-
brane of the larynx, and even necrosis and exfoliation of the cartilages may
be produced. When we have reason to suspect this sort of mischief to be
going on, we should apply a blister over the larynx, or rub the neighbour-
ing skin with antimonial ointment, so as to produce counter-irritation.
In the treatment of the secondary symptoms attending the phagedenic
form of the venereal disease, we should always try alterative medicines,
as antimonials, guaiacum, sarsaparilla, conium, the nitrous acid, or nitro-
THE VENEREAL DISEASE. 419
muriatic bath, &c., before having recourse to mercury ; for, under such
treatment, the health will get into a more favourable state for the recep-
tion of mercury ; and though at first we cannot advantageously give this
medicine, yet, when the health has been improved, it may become of im-
portant service, if prescribed with moderation.
The treatment of nodes, and of swellings of the periosteum, is to be re-
gulated by the history of the case, and by attending to various circum-
stances already specified. When the pain or inflammation in a joint or
bone seems to be more acute than belongs to the character of syphilis
and true nodes, the best plan is to employ leeches and fomentations
and poultices, with aperient and antimonial medicines, or small doses
of the compound powder of ipecacuanha, followed up by the iodide of
potassium, and some light tonic. Such treatment will mostly give con-
siderable relief. After the affection has been rendered more chronic,
if it be still obstinate, we may try blisters, which should sometimes be
kept open for two or three weeks. In some cases, pus will form under
the periosteum, and then nothing will afford relief but making an incision,
and forming an outlet for the matter.
True nodes require either a course of mercury, or of the iodide of
potassium, or the latter medicine joined with very small quantities of the
blue pill ; but it is erroneous to think of continuing mercury till the bones
are reduced to their natural level. If, after mercury has been employed
to a certain extent, the nodes become stationary, all pain has ceased, and
all appearance of specific action is at an end, the practice should be
changed. Of course, at this period, the patient's health is generally a
good deal reduced, and therefore we are called upon to endeavour to
rectify whatever derangement of the constitution may be obvious. Such
derangement is partly, perhaps, the effect of syphilis, but certainly, in
many instances, more the effect of the mercury that has been given. We
may, therefore, give the compound decoction of sarsaparilla, bark, or the
sulphate of quinine, with or without the mineral acids ; but, with respect
to the nodes, we must now trust chiefly to local treatment, and, with this
view, we may try frictions with mercurial ointment over the part, or with
an ointment composed of Jj. of mercurial ointment and 5j. of the hydrio-
date of potass, or 5j- of the tincture of iodine, blended with an ounce
of soap liniment. Many practitioners are in the custom of covering
nodes with the empl. ammoniaci cum hydrargyro. Nodes, which lead
to suppuration and ulceration over them, may be followed by caries, or
necrosis of the enlarged portion of the bone, and even of a more
extensive part of it; and occasionally matter forms in the medullary
cavity.
ENLARGEMENT OF THE TESTICLE FROM SYPHILIS.
This disease occurs in the more advanced stages of constitutional lues,
being mostly chronic, and coming on without much pain. Th^ enlarge-
ment is at first confined to one testicle ; but afterwards both are some-
times implicated. There is, however, as Mr. Cusack * has described, an
acute form of the disease, accompanying venereal hectic, pains in the
bones, and scaly or other eruptions. I attended one horrible case with
Mr. Doughty of Kensington, formerly one of my pupils, in which, after a
most inveterate phagedenic ulceration and sloughing of the penis, both
testes enlarged, suppurated, and at length sloughed away, with a con-
* See Dublin Journ. of Med. Science, vol. viii, p. 306.
EE 2
420 THE VENEREAL DISEASE.
siderable portion of the scrotum. The case had been under the care of
an eminent surgeon at Brighton. This patient ultimately diecj. Mer-
cury will not be of any service in the form of disease here adverted to;
but, were I to meet a similar case, I would prescribe the iodide of potas-
sium, with opium and tonics. The common venereal sarcocele yields to
calomel and opium, and other means noticed in the observations on diseases
of the testicle in our second section.
DISEASE OF THE LARYNX FROM SYPHILIS.
In the advanced stages of syphilis, and especially where phagedenic
ulceration of the throat has continued some time, and has been wrongly
or inefficiently treated, the larynx becomes involved in the ravages of the
disease. Its lining becomes thickened and ulcerates, and sometimes the
cartilages are attacked with necrosis. This state is usually attended with
great emaciation, extreme weakness, loss of rest and appetite, night
sweats, frequent cough and expectoration of matter, loss of the voice, and
paroxysms of difficulty of breathing, sometimes ending in asphyxia. So
far as I have seen, mercury is more hurtful, than useful in cases of this
description. Tonic medicines, as bark and quinine, with the mineral
acids, or sarsaparilla, with the iodide of potassium, are to be preferred,
opium being given at night if required. A blister, or seton, may also be
put in front of the larynx ; and a discharge of matter kept up. In some
instances, the prevention of immediate suffocation would justify trache-
otomy. Portions of the cartilages have been known to exfoliate, and to
be removed from an external abscess.
SYPHILIS IN INFANTS.
Syphilis is occasionally communicated to the foetus in utero, through
the medium of the blood of the mother. The effects of the syphilitic
poison, thus developed in infants, may be said, therefore, to be secondary
ones, as they arise from the introduction of the poison into the circu-
lation of the foetus, such poison not having been applied directly to the
parts affected; — of course, then, the foetus must receive the infection
through the medium of the blood. Whether the child is ever primarily
affected, that is, whether at the time of birth it ever contracts syphilis,
in consequence of the direct application of the virus of a chancre with
which the mother happens to be affected, is a questionable point. When
the infant is actually born with the disease, the latter mode of communi-
cation is, of course, out of the question. I have already observed, that,
in adults, with the exception of the parts of generation and of the mu-
cous texture of the eyeball and eyelids, the venereal virus will not operate
upon the general surface of the body, unless there has been some excori-
ation or wound at the period of its application. But if it be the fact, that
an mfant may contract a primary sore on any part of the general surface
of its body, by such part coming in contact with venereal matter in the
birth, then the remark which I have made, however true in relation to
adults, cannot be extended to infants. But I believe, that few or no un-
equivocal cases, illustrative of this mode of communication from the adult
to the child, are on record. On this point, however, Dr. Wallace declares,
that there is no doubt that the child may be contaminated by the mother
both in utero, and at the moment of parturition.*
The symptoms of syphilis in the new-born child, or soon after birth,
* See Wallace on the Venereal Disease, p, 125. <
THE VENEREAL DISEASE. 421
are mostly a universal desquamation of tlue cuticle, which peels off very
extensively and freely; copper-coloured blotches and scaly eruptions over
a considerable part of the body ; various rednesses and superficial ulcer-
ations about the anus and nates, and sometimes about the parts of ge-
neration ; also ulcerations and fissures at the corners of the mouth, and
in the mucous membrane of the fauces, and sometimes on the eyelids.
Besides these symptoms, there is frequently an obstruction of the nostrils,
with a thick yellow secretion, so that the child cannot breathe freely, and
the respiration is attended with a snuffling noise. There is also an extra-
ordinary degree of emaciation, the infant continuing to lose flesh daily ;
and, if not speedily relieved, it soon perishes. Abroad it is usual, in these
cases, to give mercury to the mother, so as to affect the infant through
her ; but in this country, the cure of the disease is accomplished with such
facility by certain preparations of mercury given to the child, that the
latter plan is commonly adopted. We find that the disease readily yields
to calomel, in half-grain doses, or to five-grain doses of the hydrargyrum
cum creta. The latter, as the milder preparation, is perhaps the better
medicine of the two ; it hardly ever fails.
On the subject of the influence of syphilis, an interesting question
arises, whether the child, that has received the infection from its mother
in the womb, is capable of communicating the disease to others ? We
find many cases on record of wet nurses having contracted venereal sores
on their nipples, by suckling pocky children : and, if the statements be
correct, the fact is curious ; for syphilis exists in such infants, as it were,
in the secondary form, and the occurrence would therefore prove that, in
them syphilis, even in that form, is capable of propagating itself, which is
at variance with the Hunterian doctrines, and with what is commonly be-
lieved with reference to its nature in adult subjects.
When a pregnant female has chancres, she should be put under the
mild influence of mercury, which will not only cure her, but save the
child from contamination, or, if it be already infected, cure it also. Vio-
lent salivation, however, as likely to cause abortion, is to be condemned.
END OF SECTION I.
EE 3
THE
FIRST LINES
OF THE
PRACTICE OF SURGERY.
SECTION II.
INJURIES AND DISEASES OF PARTICULAR ORGANS AND REGIONS.
INJURIES OF THE HEAD AND THEIR CONSEQUENCES.
THIS important subject will here be considered, as it relates,
1st, To superficial injuries^ i. e. wounds and contusions of the scalp ;
2dly, To fractures of the skull;
3dly, To wounds of the brain ;
4-thly, To compression of this organ ;
5thly, To concussion of it;
Gthly. And to inflammation of the brain and its membranes from ex-
ternal violence.
SUPERFICIAL INJURIES.
In consequence of the free intercourse, subsisting between the vessels
of the pericranium and those of the dura mater, through the medium of
the diploe of the skull, inflammation on the outside of the cranium is apt
to be propagated to the dura mater. This is one reason why injuries of
the scalp, especially contusions and contused or lacerated wounds of it,
are generally more serious than similar injuries merely affecting the
common integuments of other parts of the body. Indeed, it is a maxim
in surgery, that no wound of the head is so trivial as not to require the
strictest attention.
The scalp is often the seat of erysipelas, which, in certain constitu-
tions, will be brought on by a very slight cut or contusion ; the inflam-
mation spreading rapidly, and soon involving not only the scalp, but the
forehead, eyelids, and greater part of the face. Too'often also, notwith-
standing the most judicious treatment, delirium, or coma, comes on, and
the case has a fatal termination. I know of several instances, in which
the removal of very small encysted tumours from the head led to the
production of phlegmonous erysipelas, in so violent a form that the loss
of life was the result.
Contusions of the head frequently give rise to an effusion of blood
under the aponeurosis of the occipito-frontalis. The swelling is gene-
SUPERFICIAL INJURIES. 423
rally soft in the centre, and hard at its circumference ; hence the feel of
it may lead an inexperienced surgeon to suspect, that the accident is a
fracture of the skull, with depression of the bone. In other instances,
the extravasated blood may lie immediately under the scalp, and cover
all the upper part of the head, raising up the soft parts in a manner that
creates an alarming degree of disfigurement. In general, however, these
accumulations of blood under the scalp, from blows on the head, subside
very favourably under the use of a few brisk purgatives, and the appli-
cation of lotions, containing a proportion of the muriate of ammonia,
diluted acetic acid, and camphorated spirit. If, however, inflamma-
tion and abscess were not to admit of being prevented, fomentations,
poultices, free openings, and washing out all the matter and putrid blood
with a syringe and tepid water, would be the proper treatment.
When the scalp is wounded, or severely contused, the hair should
always be cut off immediately ; and, in many cases, it is a matter of
prudence to shave the whole scalp, not merely that the wound may be
rightly and conveniently dressed, but that every part of the oustide of the
head may be seen and duly examined, and every mark of external violence
detected. Haemorrhage is, of course, to be stopped, and the wound freed
from extraneous substances, and clots of blood ; rules applicable to
wounds in general.
Frequently the scalp is not merely wounded, but lacerated, bruised, and
more or less extensively separated from the subjacent parts. In many in-
stances, not only is the scalp thus torn and detached, but a portion of
the skull completely denuded, the aponeurosis of the occipito-frontalis
muscle and the pericranium being torn up together with the scalp. Here
the raised portion, or flap, of the scalp, however torn and irregular it
may be, should never be cut away, but be immediately replaced, and
laid down upon the exposed portion of the cranium. The scalp is ex.
ceedingly vascular, and nature is more successful in repairing its injuries,
than circumstances would sometimes lead us to anticipate. At all events,
the chance of its preservation and reunion should be taken; for, if we
succeed, we materially lessen the risk of necrosis of one or both tables
of the skull. We thus expedite the patient's cure, and obviate the de-
formity which would ensue, either from cutting the flap away, or leaving
it more or less displaced from the parts with which it was naturally
connected. If slips of adhesive plaster and a bandage be not sufficient
to maintain such flap in the proper position, we ought to avail ourselves
of the assistance of the interrupted suture, making as few stitches as
possible, because they are a source of irritation, and, in this situation,
likely to promote the occurrence of erysipelas. For the same reason,
when they have been employed, they should be cut and withdrawn at an
early period, that is to say, on the removal of the first dressings.
When erysipelas follows wounds of the head, it is to be treated ac-
cording to the rules delivered in the first section of this b<M)k. Cold
washes ought to be applied to the head, copious venesection practised,
the free use of leeches not omitted, and the exhibition of calomel,
James's powder, and saline aperient medicines, actively followed up in
the early stages of the case. When abscesses seem likely to form under
the tendon of the occipito-frontalis muscle, and to bring on sloughing of
that aponeurosis, a free incision down to the bone should be made with-
out delay. It is an observation made by Dupuytren, that, in phlegmonous
erysipelas of the head, the integuments hardly ever mortify, like the skin
of the leg from the same disorder ; and the reason which he ascribes for
E E 4
424 INJURIES OF THE HEAD.
the difference is an anatomical fact ; namely, that in the leg the inte-
guments receive blood only by ramifications from the tibial and fibular
arteries, which lie very deep, while the skin of the head has the occipital,
temporal, and frontal arteries directly under it ; consequently, it is not
so easily destroyed by the mischief produced under the aponeurosis of
the occipito-frontalis muscle, as the skin of the leg is by similar mischief
between it and the fascia.
In the treatment of suppurating wounds of the scalp, one object con-
stantly requires our vigilance ; namely, that of preventing the matter
form spreading widely in the cellular tissue under the scalp, or in that
under the tendon of the occipito-frontalis muscle. We must, therefore,
be careful to make with promptitude the free openings, which may be
required for this purpose, and to apply pressure, with the view of pre-
venting fresh accumulations.
Frequently, when a portion of the scalp has been separated from the
subjacent parts, and replaced, it will unite at every point ; but in other
instances, the union may not be general, and collections of matter may
form in certain places. Here one principal indication is, to procure a
ready outlet for the matter ; for if we neglect to do so, it will not only
destroy whatever union may have taken place, but diffuse itself to a great
extent, and lead to a vast increase of mischief and danger. The loose
cellular tissue, connecting the tendon of the occipito-frontalis to the peri-
cranium, may also be the seat of extensive abscess, and that aponeurosis
itself mortify ; though the scalp itself will not generally slough, for rea-
sons already stated.
FRACTURES OF THE SKULL.
When the solution of continuity is very fine, it is termed a capillary
fissure ; when more open, a fracture. The broken portion of bone may
either continue on a level with the rest of the cranium, or be beaten in,
or, as we say in the language of surgery, depressed. The inner table,
being more brittle than the outer one, is usually more extensively broken
than the latter ; and occasionally, violence, applied to the head, will
fracture the inner table, and actually cause a depression of it, though the
outer table may not be at all broken.
The most important distinctions are those of depressed and undepressed
fractures, comminuted fractures, and. fractures of the inner table alone.
In young subjects, depressions of the skull without fracture sometimes
happen ; a circumstance owing to the softness and elasticity of the bones
of the cranium in the early periods of life ; and now and then cases pre-
sent themselves, in which the bones of the cranium are separated from
one another at the sutures.
When violence is applied to the skull, the fracture may not happen to
the part which is immediately struck, but in some other situation more
or less remote from it : this kind of accident is termed a counter fracture,
or, more commonly, a counter fissure. Fractures of the base of the skull
are sometimes produced in this way, but not always ; for a blow on the
occiput or temporal bone may cause a fracture extending from the part
actually struck to the base of the cranium.
It was formerly the custom to inquire of candidates for a surgical
diploma the symptoms of a fracture of the skull ; and I have no doubt
that, in the times to which allusion is now made, certain replies of the
most erroneous kind were expected and given ; for vertigo, paralysis,
stupor, loss of sense — circumstances specified by writers and lecturers,
FRACTURES OF THE SKULL. 425
about thirty years ago, as symptoms of fractured skull — really denote
injury of the brain, or disturbance of its functions, and not a fracture of
the skull. The simple solution of continuity in the bone, were it not ac-
companied by other mischief, would not be attended with any particular
circumstances denoting its existence ; and, in fact, every experienced
surgeon knows, that many fractures of the skull are, on this account,
completely overlooked — never discovered; and the patients get well
without a single bad symptom. A mere crack in one of the bones of the
cranium, abstractedly considered, is not more likely to produce any serious
complaints, than a simple fissure in any other bone ; and if symptoms of
consequence do frequently attend the accident, they proceed either from
the bone being beaten inwards, so as to press upon the brain, or from
the mischief done to the parts within the skull by the same force that
broke the bone itself. The same violence which breaks the cranium,
may occasion a concussion of the brain, an extravasation of the blood
in or upon it, or subsequent inflammation of that organ and its usual con-
sequences.
In Klein's Chirurgische Bemerkungen (p. 161.), we find a remarkable
proof of the truth of these observations. A man's skull was so badly
broken, that, after death, the left half of it could with very little trouble
have been separated from the right ; yet, after the patient had recovered
from the first stunning, which lasted an hour, he remained twenty-four
hours without a single bad symptom.
A fracture without depression, then, is not, in itself, productive of any
dangerous effects, or of any symptoms peculiar to it, or by which its
existence may be known. Hence, if the scalp be free from wound, the
accident is not likely to be detected at all ; but the want of precise in-
formation on this matter, I should say, ought to be of no importance in
practice, because the treatment should be regulated by other consider-
ations. Thus, if the symptoms indicate concussion or compression of
the brain, or a tendency to inflammation of this organ, we are to act ac-
cordingly, whether the bone be broken or not. We are led to adopt
rigorous antiphlogistic treatment, or to examine the bone, with the view
of making a perforation of it, by entirely different reasons than the ex-
istence of a simple undepressed fissure or fracture. However, when the
symptoms indicate pressure on the brain, and the part struck is denoted
by a wound, or ecchymosis of the scalp, we are then called upon to make
an incision, for the purpose of ascertaining whether any fracture with
depression exists ; and, if this should not be the case, such incision may
still be useful, because, if the symptoms call for the trephine, the part
that has been struck is generally the proper one for its application, as
being the most likely situation for any effusion of blood, and for any
splintering or depression of the inner table. However, when we trephine
under these circumstances, in the expectation of finding blood extra-
vasated under the part to which the violence has been directly applied,
we sometimes learn that this is not the case, and that the pressure is
neither produced by an effusion of blood on the dura mater in this situ-
ation, nor by any fracture and depression of the internal table. Experi-
ence proves, that blood is frequently effused in or upon the brain, in
situations more or less remote from the part of the head which received
the blow.
We are not to suppose, then, that fractures without depression are not
often accompanied by bad symptoms, but only that the mere injury of
the bone itself is not the cause of them. The same violence which
426 INJURIES OP THE HEAD.
breaks the bone may cause a concussion of the brain, an extravasation
of blood in or upon it, or a subsequent inflammation of it or its mem-
branes. But fractures with depression are a very frequent cause indeed
of dangerous symptoms, because necessarily attended with compression of
the brain. Yet, it is a curious fact, that the symptoms do not appear to
be constantly in a ratio to the degree and extent of the depression of the
bone. Sometimes fractures with a manifest and visible depression of the
skull are not accompanied with any bad symptoms, or any of those
effects known usually to arise from pressure on the brain. I was once
called to a hackney coachman, a patient under the care of Mr. Hooper,
of the London Road, in one of whose parietal bones a depression as
large as a crown-piece had been occasioned ; yet he had no urgent
symptoms of pressure on the brain, and ultimately got well without an
operation. We are not, therefore, to employ the trephine in every ex-
ample of fracture with depression, but only in those cases which are
made urgently dangerous by the existence of such pressure on the brain
as this organ cannot quietly endure. I believe it to be an excellent
general rule in surgery, never to trephine a patient for a fracture of the
skull, unless he be actually labouring under coma, paralysis, and other symp-
toms of compression in an urgent and dangerous degree, excited either di-
rectly by the pressure of the bone itself, or by blood effused under it, or by
suppuration under it, the consequence of a subsequent inflammation of the
dura mater. One exception to the foregoing rule, sometimes specified, is
a depressed fracture, occasioned by a pointed weapon, or a punctured
fracture, as the injury is often termed ; and the reasons assigned for such
practice are, first, that this kind of injury of the bone is always attended
with a splintered state of the inner table ; and, secondly, that the patient
will have the best chance of recovery, if the bone be removed before in-
flammation and suppuration of the dura mater have had time to take place,
Fractures of the base of the skull are cases of so perilous a nature, that
they are generally regarded as inevitably fatal. Whether the opinion be
true to this extent, is not an easy point to determine, because we never
know positively, while the patient lives, whether the fracture has been
of this kind or not ; and if he recover, we have no opportunity of ascer-
taining the point by examination. Fractures of the base of the skull are
mostly produced by the application of great violence to the lateral parts
of the head, or to the vertex and base through the spinal column. If a
person fall from a great height, and the top of the head come to the
ground, the skull is operated upon by two forces — the resistance of the
ground, and the pressure of the body upon the base of the cranium : the
bones are seldom displaced to any extent ; the dura mater is generally
lacerated ; the substance of the lower surface of the brain itself wounded ;
and blood, consequently, effused at the base of the brain. Indeed, such
has been the degree of violence, that we generally find blood effused,
not merely in this situation, but in others. I have opened many persons
who died with fractures of the base of the skull, and the mischief noticed
within their heads corresponded in every respect to what has now been
described.
Bleeding from the nose, mouth, or ears, when attended with other cir-
cumstances, evincing the receipt of a violent injury of the head, and much
consequent disturbance of the functions of the brain, has been frequently
insisted upon as denoting a fracture of the base of the skull. Sir Benja-
min Brodie relates one example of such a fracture, which was attended
.with haemorrhage from the ear, and where the source of the blood was
FRACTURES OF THE SKULL. 4-27
found, after death, to be the lacerated cavernous sinus. Perhaps, how-
ever, no great degree of importance can generally be attached to this
symptom ; for such bleeding sometimes comes on from slight injuries, not
at all affecting the cranium or its contents ; while other cases are met
with, where, on dissection, extensive fractures are found of the petrous
portion of the temporal bone, and of the sphenoid and ethmoid bones,
though no bleeding at all had occurred from the ears, nose, or mouth.
Treatment of Fractures of the Skull. — If the fracture be unattended
with depression, or with symptoms of a dangerous degree of pressure,
either from this cause, or from extravasation of blood, we must direct
our views to the prevention of another source of peril, namely, inflam-
mation of the brain, which may, perhaps, sometimes, be caused by the
mechanical irritation of the inequalities of the fracture, but generally by
the same violence which broke the bone itself. When the broken bone
is not depressed, we can scarcely venture to trephine on the supposition
that the inflammation of the dura mater and brain, which often follows
such an injury, is owing to the mechanical irritation of the irregularities
of the fracture ; and, if this should not be the cause of the inflammation,
as I believe it seldom is, then the infliction of additional mechanical
injury by the operation would be the least rational and advisable mea-
sure that could possibly be adopted. Here, it appears to me far more
prudent to be content with antiphlogistic treatment, such as cold washes
to the head, venesection, arteriotomy, leeches, the free exhibition of
calomel, with tartarised antimony, saline purgative medicine, and barley
water or tea for sustenance. Nor should the antiphlogistic regimen be
altogether discontinued till three or four weeks have elapsed ; for the
records of surgery prove, that a disposition to inflammation of the brain
and its membranes lasts a considerable time after the application of ex-
ternal violence to the head ; and such disorder has attacked and proved
fatal to many who, supposing all risk over, have returned, prematurely,
to their usual mode of living.
Some very interesting cases, illustrating this fact, are contained in
Pott's works, and Klein's Chirurgische Bemerkungen (12mo, Stutgard,
1801, p. 113., &c.). In some of these examples, the patients remained
well and sensible more than a month after the receipt of a blow on the
head, and were then seized with fever, shivering, convulsions, paralysis,
&c., which soon destroyed them. What is particularly worthy of notice
is, that, in some of the cases, though the symptoms began thus late, and
perhaps proved fatal in two or three days, a large portion of the brain and
its membranes was inundated with matter ; parts of it destroyed ; its
membranes considerably thickened, and even broken. We must here sup-
pose, either that such disease was going on for a time, without producing
any particular bad symptoms, or that its progress was most rapid after it
had once begun.
A doctrine has arisen, that fractures of the cranium, attended with a
wound of the scalp directly over the injury of the bone, are accompanied
by much greater danger than other fractures of the skull, uncom-
bined with such a wound. In short, it is alleged, that there is the same
difference in this respect as prevails between simple and compound
fractures of the bones of the extremities. This is the belief entertained
by that highly respected surgeon Sir Astley Cooper, whose views of
every part of surgery have great experience for their foundation. The
point is important, because the doctrine might deter us from examining
the state of the .skull by an incision, and applying the trephine, when
428 INJURIES OF THE HEAD,
the patient's safety, perhaps, depended very essentially upon such mea-
sures not being postponed. Surgeons, who subscribe to this view of the
.subject, will naturally be as much afraid of cutting down to a fracture of
the cranium when there is no wound,, as of cutting into a simple frac-
ture of the leg, and making it compound. They will be inclined to
avoid this proceeding, and, of course, to refrain from trephining, when-
ever the fracture is not accompanied by a wound ; while, if the fracture
happen to be already exposed by the accident, they would probably
apply the trephine for precisely the same symptoms as they con-
ceive would not justify it when no wound of the scalp exists. If I
feel certain of any thing in surgery, it is that the decision for the opera-
tion of trephining should depend upon the symptoms of pressure on the
brain being urgent, dangerous, and unequivocally manifested; and, I
believe, whether there be a wound of the scalp or not conjoined with
a fracture of the skull, it is our duty, under those circumstances, always
to examine the state of the bone, and not to let our conduct be at all
influenced by any analogy, whether true or not, between these cases and
simple and compound fractures of the limbs. If the doctrine be true,
however, which I am by no means prepared to deny, it should certainly
teach us not to use the knife without any real occasion for an inspection
of the bone.
In the time of the French Academy of surgery, it was customary to
employ the trephine, or rather the trepan, in almost all cases of fractured
skull, not merely for the removal of any urgent symptoms present, but
with the view of preventing their occurrence at all. The absurdity of the
latter doctrine received a complete exposure from the facts and observa-
tions published by the late Mr. Abernethy, whose investigations into this
difficult part of surgery contributed very essentially, as I think, to its im-
provement, more especially by showing in what cases the application of
the trephine might do good, and in what instances the operation should
not be undertaken. Even at the present day, his advice is sometimes
neglected ; for I am continually hearing of persons being trephined under
circumstances in which, according to the principles established by his re-
searches, they cannot possibly be benefited by the removal of any part
of the cranium. Here, so far as I can judge, the nature of the symptoms
actually existing should be the guide ; and, instead of admitting the
wisdom of the old rule of trephining, in anticipation of bad symptoms
which are only apprehended, but may never occur, I should say that the
plan is altogether contrary to the dictates of reason and experience. As
Mr. Abernethy observed, if the brain will, in the first instance, bear a
certain degree of pressure without ill consequences, whether from fracture
or effusion, — if it will, at first, bear it without the production of urgent
symptoms, or irritation of the dura mater by the inequality of a fracture,
— why should it not continue to do so subsequently ? Dupuy tren records
the case of a banker at Paris, who was lately living in perfect health with
a considerable depression of the cranium, though the accident took place
many years ago. Yet Velpeau's observation on this and other similar facts
is, that, for one patient who gets well under such treatment, ten would die.
It is also not to be denied that, in some instances, the leaving of the bone
depressed has been followed, at a subsequent period of life, by severe,
and even fatal, affections of the brain and nervous system. It may be
asked, then, why do I not approve of trephining every fracture with de-
pression, whether attended at first with urgent symptoms or not ? My
answer is, that I cannot recommend this plan, partly for the reasons
FRACTURES OF THE SKULL. 4-29
stated by Abernethy, and partly because I doubt whether the cases of
subsequent inconveniences, or dangers, from the continuance of the bone
below its proper level, when the depression caused no bad symptoms at
first, are numerous and common enough to be a foundation for what
ought to be the general plan. Supposing the scalp were wounded, and
the fracture of the skull comminuted, we ought to extract all the loose
fragments ; for they are already detached, and might cause irritation of
the dura mater. This practice would be conformable to the general
rules relative to the treatment of all wounds, wherever situated. But, if
the pieces of bone were not completely detached, so that they could not
be removed without an operation, and no bad symptoms existed, I should
be inclined to join those surgeons, who do not recommend an operation
under these circumstances.
One consideration which influences me in defending the principle, that
the trephine should not be used in injuries of the head, unless bad symp-
toms actually exist, and are of that description which may be relieved by
this measure, is, that the operation itself, viz., the removal of a portion of
the skull, and the exposure of the dura mater, are proceedings attended
with some considerable risk of bringing on bad, and even fatal, conse-
quences. The late Mr. Ramsden was rather fond of operating ; and I
remember very well two cases, in which he tried what the trephine would
do for the relief of a long-continued fixed pain at one part of the head.
A piece of bone was sawn out in each case ; inflammation of the dura
mater ensued ; and, in two or three days, each patient fell a victim to the
experiment. The removal of a portion of the cranium is also followed,
in a certain number of examples, by a gradual protrusion of the brain
through the aperture — a hernia cerebri, which generally has a fatal
termination.
WOUNDS OF THE BRAIN.
Many fractures with depression produce a laceration of the mem-
branes, and even of the substance, of the brain. This organ, important
as are its functions, is frequently wounded without the event being im-
mediately productive of those perilous symptoms which might be ex-
pected ; but there is a difference in this respect, the reason of which is
not at present satisfactorily understood: in some cases, a comparatively
slight wound of the brain gives rise to severe and rapidly fatal conse-
quences ; while, in others, the same degree of injury, so far as can be
ascertained, occasions no serious symptoms. In the Memoirs of the
French Academy of Surgery are detailed various recoveries from most
serious injuries of the brain ; such cases as would a priori have been
regarded as completely hopeless. If we look over the annals of surgery,
we find numerous cases in which the patients were cured, notwithstanding
the brain had not merely been wounded, but portions of it torn away, or
separated. In one of the volumes of the Medical and Chirurgical Trans-
actions of London are the particulars of a boy, through whose frontal
bone the linch-pin of a gun was driven with such violence that it lodged
in the anterior lobe of the brain. Directly after the injury, he walked
several hundred yards, and then fell down, and was seized with convul-
sions. No suspicion was at first entertained of the passage of a foreign
body into the brain. Venesection and other antiphlogistic measures
were put in practice ; and, on the following day, the urgent symptoms
had abated. The boy was treated on this system until the 27th day,
when a piece of iron was noticed at the bottom of the wound, and ex-
430 INJURIES OF THE HEAD.
tracted. It proved to be the linch-pin of a fowling-piece, a substance of
considerable size and weight. A cure ensued, with the exception of an
amaurosis of one eye. A French soldier was wounded at the battle of
Waterloo : a musket-ball entered at the anterior portion of the squamous
suture, lodged in the substance of the brain ; and on the fifth day, after
an enlargement of the wound, and the removal of several fragments of
bone, it was extracted from the posterior lobe of the right hemisphere
of the brain, where it had rested upon the tentorium. Headach and
partial deafness of the right ear were the only bad symptoms. A re-
covery took place. However, I believe the history of this part of sur-
gery will warrant me in representing wounds of the brain as generally
attended with vast danger ; and that, even if no bad symptoms occur
directly after the accident, they mostly come on and prove fatal after-
wards. Paroisse gives an account of twenty-two French soldiers, from
whose skulls portions of bone, with the scalp and slices of the upper part
of the brain, had been separated by sabre wounds.. All these men
ultimately died; but at first they had no bad symptoms, and actually
performed a journey of ninety miles after the receipt of their wounds,
one half of which distance they travelled on foot.
Surgeons maybe called upon to perforate the cranium for the removal
of balls lodged within its cavity. Larrey relates some extraordinary
examples of this practice; and it was he who first suggested the necessity
of sometimes making a counter-opening in the bone for the accomplish-
ment of this purpose, when the ball had passed to some point of the
surface of the brain remote from the opening by which it had entered.
He introduces an elastic gum catheter along the track of the ball, and
makes a perforation with a trephine over the part where he feels that it
is lodged. Now, one of these histories is very curious ; for, after having
removed a portion of the skull with the trepan, he took out an iron ball,
that weighed seven French ounces, which was lodged upon the anterior
lobe of the right hemisphere and against the orbitar process and spine of
the os frontis. The patient suffered a painful sense of weight in his
head ; and whenever he inclined it backward he was seized with syncope.
Here, also, the case ended in the recovery of tl)e patient.
In the treatment of injuries of the head, attended with a wound of the
dura mater or substance of the brain itself, if no particular symptoms or
circumstances immediately demand the trephine, our chief reliance
should be upon rigorous antiphlogistic treatment ; the same plan as
already advised for fractures unattended with urgent symptoms of com-
pression. The external wound itself is to be treated on common prin-
ciples ; it is to be made clean ; foreign bodies, or fragments of bone, are
to be taken out, and its sides brought together. Such cases commonly
end fatally ; but we must not absolutely despair of them, for the injury,
and even a considerable loss of substance in the upper part of the
hemispheres, may occur, as we find in the cases which I have quoted,
without being necessarily fatal, or even productive of very alarming
symptoms.
Wounds of the dura mater and brain are sometimes followed by hernia
cerebri, which then often appears to have a considerable share in occa-
sioning the patient's death.
COMPRESSION OF THE BRAIN
May arise from fracture with depression, from an extravasation of blood
within the cranium, or from a collection of matter in the substance of the
COMPRESSION OF THE BRAIN. 431
brain, or between the inner table and the dura mater, in consequence of
previous inflammation, the symptoms of which must then precede those
which usually accompany the injurious effect of pressure on the brain.
Compression of *he brain may also be produced by the lodgment of balls
within the cranium, or by the formation and growth of tumours. When
such pressure ^exists, it cannot be expected that the symptoms will be
alike in all e£ses, because the pressure not only differs in respect to its
cause, its degree, and its situation, but it differs also in another important
point of view, namely, that relating to the kind and quantity of other in-
jury, or mischief, with which such pressure may be conjoined. For we
find in practice, that every case of pressure, following external violence, is
not so clear as many writers would lead us to suppose ; and that we do
not always have mere pressure to deal with, but often pressure combined
with concussion, with inflammation, or with a wound or laceration of the
membranes or substance of the brain. In short, we frequently have to
exercise our judgment on what may be called mixed, or complicated, cases,
in which the symptoms do not correspond altogether to those either of
compression, concussion, or inflammation singly. Yet, if we understand
the general character of the symptoms resulting from each of these states,
we shall be in a great measure qualified to judge of the effects likely to
be the result of their happening to be coexistent.
It may be thought that apoplexy will give us the best illustration of
the symptoms of simple compression of the brain ; yet this is perhaps not
precisely the case, because apoplexy is often preceded by disease of the
brain ; and, at all events, as good an illustration of them is afforded by
certain cases, in which, after the receipt of a blow on the head, the
patients recover from their stunned state, immediately following the
blow, and shortly afterwards begin to labour under the effects of an
effusion of blood, gradually going on within the head.
The symptoms of compression of the brain are headach, stupor, and
drowsiness ; and, while the quantity of effused blood is small, they may
be the chief symptoms. Afterwards, when it increases, and the pressure
on the brain is greater, there will be a loss of all sensibility, and of all
power over the voluntary muscles. The eyes will remain half open, the
retina will be perfectly insensible, the pupils will generally be dilated, and
the iris quite motionless, even when a candle is brought close to the
eye. The patient may be pinched or pricked, but he is perfectly uncon-
scious of it: the bladder, being paralytic, cannot empty itself; or its
sphincter and that of the anus being in this state, the urine and faeces
come away involuntarily. The pulse is slow, and respiration carried on
with difficulty and a stertorous noise.
The observations, already delivered respecting mixed or complicated
cases, enable us at once to perceive that, even when compression of the
brain exists, and this in an unequivocal manner, the symptoms may be
modified by the particular complications attending it. Thus, frequently,
one pupil may be contracted, and the other be dilated ; or th€ patient
may be paralytic on one side, and convulsed on the other. My expe-
rience teaches me, that convulsive twitches of the muscles are rather
a symptom of laceration of the brain, than of simple compression. They
often attend fractures with depression.
In compression, there is usually no sickness and no vomiting. This
fact is well exemplified by cases, in which the patient is free from these
symptoms until he has been trephined, and then the removal of the
pressure is sometimes immediately followed by the rejection of the con-
tents of the stomach.
432 INJURIES OF THE HEAD.
Another fact which deserves notice is, that, when pressure exists
only on one side of the head, the paralysis generally manifests itself in
parts on the opposite side of the body. Complete hemiplegia, however,
is much more rarely the consequence of accidental injuries of the head,
than of apoplexy ; a difference, perhaps, referable in these cases to the
difference in the situation of the effused blood.
With respect to paralysis, though it is a common symptom of pressure,
various facts prove, that it may also arise from concussion.
Too much attention cannot be paid to one circumstance, frequently
throwing considerable light on these cases. I allude to the patient some-
times recovering his senses, after having been stunned by the blow, and
then relapsing into a drowsy condition, which is soon followed by all those
symptoms already specified as denoting compression of the brain. That
these symptoms cannot depend upon concussion is manifest ; for then
the patient would not have regained his senses for a time, a fact proving
that the stunned condition of the patient,, or the immediate effect of the
concussion, had subsided. That the symptoms cannot depend upon a de-
pressed fracture is equally manifest, because the patient would have been
senseless from the fast, and have continued so ivithout remission. That the
same symptoms cannot depend upon the lodgment of matter beneath the
skull is certain, because there has not been time enough for inflammation and
suppuration to occur. The real cause of the return of the loss of sense,
then, under these circumstances, becomes tolerably evident, and is ac-
counted for by the extravasation continuing slowly to increase, and to
produce more and more pressure, and its usual consequences, notwith-
standing it had not advanced sufficiently at first to prevent the return of
the mental faculties, on the subsidence of the immediate effects of the
concussion which the brain had sustained.
When no interval of sense takes place, but the patient lies insensible
and motionless from the first, then we can only form a judgment of the
cause of this state of the system by the consideration of other symp-
toms. Frequently cases of this kind are particularly unfavourable, as
being complicated ones, combining concussion and compression together;
and not only these evils, but a wound or laceration of the brain, and even
a fracture at the base of the skull or elsewhere.
Extravasations of blood between the dura mater and base of the cranium
are mostly fatal. When the blood lies between the dura mater and the
tunica arachnoides, it is often widely diffused, so as not to admit of being
effectually discharged. When situated on one of the hemispheres, between
the cranium and the dura mater, however, it is often circumscribed, and
may be discharged by a perforation of the bone.
There is frequently extreme difficulty in forming an opinion about the
precise situation of extravasated blood, even when symptoms indicate
such extravasation. Generally we know not whether the blood lies on
the dura mater or in a deeper situation, or under what part of the cranium.
Now, if the symptoms be urgent, the rule is, that we are to be guided in
the choice of a place for the application of the trephine by any mark of
violence on the scalp, or any wound or fracture showing the part on which
the violence has acted; for it is directly under it that the extravasation is
frequently, though not constantly, situated. We should also consider on
which side of the body the paralytic effects show themselves, as the pro-
bability is, that the pressure is on the hemisphere of the brain of the
opposite side. But, supposing there were twitches, or spasmodic action,
of the muscles of the arm or leg of the opposite side, with paralysis of
COMPRESSION OF THE BRAIN. 433
the limbs on the same side, as the mark of violence, the surgeon should
not trephine in the expectation of the blood being effused under that part
of the skull which received the blow. In University College Hospital, I
have had several cases, confirming the correctness of this advice.
Sometimes there is no mark of external violence on the head, no
wound to guide us, no restriction of paralysis to one side of the body,
no interval of sense. Here circumstances are desperate, and we have
no choice, but either that of trusting to means calculated to stop the
further effusion of blood in the head, viz., cold washes and venesection,
or that of perforating the cranium without any kind of clue to the
situation of the effused blood.
Under these circumstances, the generality of practitioners would be
content with bleeding and antiphlogistic treatment ; while others, knowing
that when a considerable quantity of blood is effused on the surface of
the dura mater, it is generally poured out from the middle meningeal
artery, might feel disposed to trephine in the track of that vessel. Were
there any guide to the side of the head on which the extravasation lay,
this bold measure might be warranted ; but many surgeons would rather
confide in antiphlogistic treatment, and it is not for me to pronounce such
decision erroneous. Often the blood is on both sides, or at the base of
the skull likewise; and sometimes not only so, but not under the part
struck.
When dangerous compression of the brain arises from a fracture with de-
pression, the indication is to elevate or remove the portion of bone forced
below the level of the rest of the cranium. For this purpose, we are to
adopt certain modes of proceeding, which will be explained when I de-
scribe the operation of trephining.
Also when suppuration occurs on the surface of the dura mater, and pro-
duces urgent symptoms of pressure, the same operation is indispensable ;
but this case is generally not one of simple compression, — it has been
preceded, and is usually still accompanied, by inflammation under the
cranium, affecting not merely the dura mater, perhaps, but the brain
itself. In the museum of University College is a cranium in which
a small exfoliation has commenced, in consequence of suppuration on
the dura mater. It is one of Pott's cases, as they are called, in conse-
quence of his having particularly described them. In this instance, the
trephine was applied, and the dura mater found red and spongy. But
the case was not one of simple pressure ;' for besides the disease of the
dura mater, another preparation, taken from the same patient, exhibits a
deeply-seated abscess in the brain, about an inch below that part of the
skull which is undergoing exfoliation.
The patient, before exhibiting the symptoms of pressure, must have
had those of meningeal inflammation, — he must have had^jsevere pains in
the head, shiverings, an accelerated pulse, and disturbance of the intel-
lects, followed by coma, and loss of sense, and generally a puffy circum-
scribed tumour of the scalp, and detachment of the pericraniufh, corre-
sponding to the extent of the abscess between the inner table and the
dura mater. Or, if there were an external wound, its lips would have
lost their vermilion colour, become pale, flabby, and swollen, and the dis-
charge changed to a scanty foetid ichor.
Such a case calls for the immediate perforation of the bone, and
rigorous antiphlogistic treatment, copious bleedings, leeches, the repeated
exhibition of calomel and James's powder, and saline purgatives, with
abstinence and quietude.
F F
434? INJURIES OF THE HEAD.
CONCUSSION OF THE BRAIN
Has many degrees, as may readily be conceived, when the great dif-
ference which exists between its two extremes is recollected, — ^the slight
transient stunned condition of the patient, the sudden effect of a mo-
derate blow on the head, and that complete disorganisation which, at the
moment of the injury, permanently annihilates all the powers of life.
When the concussion is slight, the patient may be stunned only for
a few seconds, or minutes, and a degree of headach, followed by acceler-
ation of the pulse, vertigo, and sickness, may take place ; but, in general,
none of these effects continue long if depletion be employed. How-
ever, in some examples, a very slight blow on the head will bring on
inflammation of the dura mater, and this sometimes long after the acci-
dent, when all apprehension of danger has ceased.
When the violence applied to the head is greater, the patient is im-
mediately stunned : his extremities become cold ; his pulse is feeble,
slow, and intermitting; his respiration difficult, but generally without
stertor ; and his sensibility and power of motion are entirely abolished.
This is the first stage of concussion, or the first effects produced by
severe degrees of it. Such a state cannot last long, for the patient either
dies in a very short time, or the effects which I have been describing
gradually subside, and are succeeded by others, which may be said to
constitute the second stage of concussion.
In this the pulse and respiration improve, and, though not regularly
performed, are sufficient to maintain life, and to diffuse warmth over the
extreme parts of the body. The nervous influence is also now so far re-
vived, that if the skin be pinched the patient is conscious of the injury ;
and in many cases the contents of his stomach are thrown up; but
he lies in a dull stupid state, quite inattentive to slight external impres-
sions. In proportion as the first effects of the concussion subside a little
more, he becomes capable of replying to questions put to him in a loud
tone of voice. So long, however, as the stupor remains, the inflamma-
tion of the brain is moderate ; but as the former abates, the latter seldom
fails to increase, so as to bring on the third or inflammatory stage of con-
cussion.
In this third stage, if the eyelids be opened, the patient will shut them
again in a peevish manner ; the pupils are contracted, and a strong light
is very offensive. The patient is sleepless ; talks much and incoherently ;
and, if not restrained, will get out of bed, and act with frantic absurdity.
As the delirium increases the pulse becomes small, very quick, and even
rapid ; and, if the inflammation of the brain be not checked, suppuration,
or effusion, will occur within the head, preceded by rigors, and the fore-
going symptoms change into others, arising from the pressure of the fluid
on the brain.
The dangers, then, of concussion depend upon its original violence,
which may be such as to kill the patient at once, or upon the inflamma-
tion of the brain and its consequences often following the injury.
With respect to the sickness and vomiting, they are generally early
symptoms, and seldom continue after the patient has recovered from the
first shock of the accident.
Concussion and compression, we know, are often combined ; and this
fact will explain why the symptoms frequently have not the simplicity
we might expect from some descriptions given of them.
Patients, who recover from severe degrees of concussion, sometimes
CONCUSSION OP THE BRAIN. 435
remain variously and curiously affected by the accident during the re-
mainder of their lives. Imbecility, loss of memory, and a marked change
in the character are sometimes the permanent consequences. The patient
may have loss of hearing, or partial paralysis. In consequence of an
accidental concussion of the brain, a patient, previously a lunatic, has
been known to recover his reason. In other instances, the patient, at
first, can only remember circumstances with which the mind had been
lately impressed, but afterwards recollects nothing but what happened
in his childhood. Sometimes one effect is the total forgetfulness of a
language, with which the patient was previously familiar. Mr. Liston
attended a woman, who recovered her hearing entirely from the acci-
dental effects of a concussion of the brain. I lately attended a lady in
the Regent's Park, who met with a concussion of the brain from her
horses taking fright and galloping away with the carriage till it came in
contact with some iron railings : in this example, the patient has not the
slightest recollection of having met with any accident in the Park ; nor
does she remember the circumstance of the horses galloping away with
her, or the fall of her coachman from the box. During my attendance
on her, with the late Dr. Pinckard, she never adverted to the injury of
her head, but repeatedly to a slight burn of her neck, which she had met
with two or three days before the other more serious injury.
I believe there is great practical utility in dividing concussion of the
brain into the three stages which I have described, because the treat-
ment should be regulated accordingly. In the first stage, the taking away
of blood must be improper and dangerous, the powers of life being already
reduced to the lowest ebb ; and, consequently, an attempt to reduce them
further would be contrary to the dictates both of reason and experience.
The patient, in fact, is already in danger of dying, without any reaction
taking place in the system, and nothing would be more likely than bleed-
ing to render the risk of this termination still greater. On the contrary*,
the indication is to endeavour to rally the depressed state of the system,
for which purpose warmth should be applied to the surface of the body,
and especially to the epigastrium and extremities, and stimulants to the
nostrils. These I consider safer means than the internal administration
of cordials and spirituous medicines, which, after the revival of the
patient, always begin to have the most pernicious effects. However,
some practitioners venture to give ammonia or ardent spirits by the
mouth, or even to throw up turpentine clysters. From these plans I
should always abstain myself, and be content with external stimulants,
which can be discontinued directly they are no longer needed, without
any hurtful prolongation of their action.
In the second stage, in which the freedom of the circulation has been
restored, and a disposition to inflammation of the brain commences, all
sources of excitement should be removed. The patient should be kept
perfectly quiet in a darkish room, the head should be shaved and Covered
with cold applications, blood be taken away, the bowels freely opened
with calomel and antimonial powder, and the functions of the bowels and
skin promoted with saline aperient draughts. When the circulation rises
a little more, the pulse quickens, and the fever and cerebral excitement
have taken place, the lancet, assisted with leeches, small repeated doses
of tartarised antimony, and cold washes to the head, may be said to be
the sheet-anchor. At this period, we should bleed fearlessly, as often as
the pulse rises above a certain point ; for if we do not check the disturb-
ance of the circulation, the inflammation in the head will certainly in-
F F 2
4-36 INJURIES OF THE HEAD.
crease, and the patient die. It is in cases of this description that arteri-
otomy is frequently practised.
The third stage is that of complete phrenitis, requiring quietude, bleed-
ing, purgatives, calomel, tartarised antimony, and cold evaporating lotions
on the head, and, after a time, blisters on the scalp, or the application of
the antimonial ointment to it. When bleeding can no longer be con-
tinued, and there is risk of effusion upon the brain, we should give
calomel freely, or employ mercurial frictions, so as to excite a salivation.
When all risk of arterial excitement is over, and certain imperfections
and infirmities of the intellectual and muscular systems remain, seem-
ingly as consequences of effusion, or some other permanent changes in
the brain, the patient should be put under the influence of mercury, and
the scalp blistered, or rubbed with the ointment of the iodide of potas-
sium.
HERNIA CEREBRI, OR ENCEPHALOCELE.
As a subject intimately connected with the consideration of injuries of
the skull, I will now make a few observations on hernia cerebri, or ence-
phalocele, as it is sometimes called, which signifies a gradual protrusion
of a portion of the brain through a preternatural opening formed in the
skull, either by the trephine, or by the exfoliation of a portion of bone
in the state of necrosis. In children, indeed, the protrusion has been
known to happen through an opening in the skull, left by its incomplete
ossification. When hernia cerebri follows the application of the trephine,
or the loss or removal of bone from other causes, some days generally
elapse before the brain begins to protrude through the aperture ; and this
occurrence is preceded by ulceration, or sloughing, of the dura matter,
without which circumstance probably there would be no protrusion at all
in ordinary cases ; I mean such as follows the removal of bone by the
trephine. The tumour soon attains the size of a pigeon's egg, and its
circumference is pressed upon by the edges of the opening. There is
great tendency to haemorrhage from the surface of the protruded mass,
and consequently the tumour is usually covered with layers of coagulated
blood. In some few cases, the patients do not lose their senses ; though
in by far the greater number of examples they lie in a comatose state ;
and if coma does not exhibit itself at first, it always comes on in the
advanced stage of the disease. The immediate cause of hernia cerebri
is obscure and unsettled, no completely satisfactory explanation of it
having yet been given by any pathologist. It is said to arise in conse-
quence of the removal of bone ; but this is not the only cause, for if it
were so, the protrusion would always follow such loss of bone, which is
contradicted by experience. The ulceration of the dura mater, and
other changes, appear to be concerned. The cortical and medullary
portions are often distinctly visible in the protruded mass, and the pia
mater is seen dipping down into the sulci, and enveloping the convolu-
tions. Occasionally the tumour ceases to enlarge, acquires a brownish
colour, pours out a fcetid matter, and breaks into several pieces, which
afterwards separate, and are thrown off; and then granulations will some-
times arise, and the patient recover. This favourable termination, how-
ever, is rare ; and I have seen so few patients get well who had hernia
cerebri, that the prognosis seems to me very unfavourable, more espe-
cially when our ignorance of its proximate cause is taken into the account.
In France, it used to be the practice to dress the swelling with a pledget
dipped in wine. Such an application, one .would suppose, could not pro-
TUMOURS OF DURA MATER. 437
raise" to be very serviceable ; yet Larrey and others prefer it. In this
country, pressure in moderation has sometimes been tried, and even the
bolder method of slicing off the protruded part of the cerebral mass. As
a linen compress cannot be so exactly applied as a plate of metal, I should
conceive that when the surgeon means to resist the return of the protru-
sion, the latter should be preferred. In removing a hernia cerebri with
the knife, there is frequently profuse haemorrhage ; but though copious
at first, certain cases on record prove, that it stops after a short time,
and is not itself productive of danger. The liberties taken with the pro-
truded portion of brain, without any apparent ill consequences, are truly
surprising : the facts demonstrate, at all events, that the superficial parts
of the hemispheres will bear a great deal of injury and mutilation, without
life being destroyed or recovery prevented. We cannot wonder that this
disease should be so often fatal, when we remember, that, in most cases,
it is complicated with extensive and deep-seated injury of the brain.
Dissection shows, that there is generally blackness and sloughing of the
dura mater for some extent around the tumour ; and that, in many cases,
the substance of the brain has a softened and broken-down appearance.
A foetid dark-coloured fluid is also found between the dura mater and
arachnoid membrane, which latter part is often thickened and opaque.
FUNGOUS TUMOURS OF THE DURA MATER.
Fungous tumours sometimes grow from the external surface of the
dura mater, and, after destroying the superincumbent portion of the cra-
nium, make their appearance in the form of an external swelling under
the scalp. They are generally preceded by a blow, or fall on the head,
and occur at the part to which the violence was applied. As the fungus
grows larger, its pressure against the skull, and particularly its pulsatory
motion derived from that of the brain, occasion a slow and gradual absorp-
tion of the bone, just in the same way as an aneurismal tumour destroys
any part of a bone against which it happens to press. The portion of
the cranium immediately over the swelling^being absorbed, the fungous
excrescence meets with less resistance ; it quickly protrudes through the
opening in the skull ; forms a prominent tumour under the scalp ; and
enlarges with increased rapidity. The severe pains in the head, which
precede the external appearance of the disease, become still more violent
as soon as the fungus protrudes through the opening in the bone, and is
irritated by the sharp inequalities of its edge. The swelling has a mani-
fest pulsation, corresponding to that of the arteries ; and when com-
pressed, it either returns entirely within the cranium, or is considerably
lessened. The pain then subsides, the tumour being no longer irritated
by the irregular circumference of the opening in the skull. If the size
of the fungus be large, no relief can be thus obtained; for, when an
endeavour is made to reduce the tumour, all the alarming symptoms of
pressure on the brain are immediately excited.
Fungous tumours of the dura mater constitute a very dangerous form
of disease, and mostly prove fatal.
Before a fungus of this description has made its way through the cra-
nium, and projected under the scalp, so that its nature and existence can
be ascertained, the practitioner has no opportunity of attacking the dis-
ease with any effectual means. The ordinary treatment of the severe
pain occurring in certain parts of the head, after blows or falls on the
cranium, and before the fungus protrudes, has consisted of bleeding and
evacuations. But when the disease has manifested itself in the form of
FF 3
438 DISEASES OF THE LACHRYMAL ORGANS..
an outward swelling, the nature of which is recognised from previous cir-
cumstances, as well as from the pain which attends it, and subsides on
its reduction, and its pulsatory motion, the head should be shaved, a
crucial incision made in the scalp covering the fungus, the angles dis-
sected up, and the whole of the tumour and the margin of the opening
through which it protrudes fairly exposed. But, as it is impossible to get
at the entire root of the fungus, while it is closely embraced by the cra-
nium, it becomes necessary to saw away the surrounding bone. This
object can be best accomplished with one of Key's saws. The root of
the fungus being thus exposed, the next business is to cut it away from
the dura mater. Fungous tumours of the dura mater have occasionally
been extirpated with a ligature. The first operation which I ever saw in
St. Bartholomew's Hospital, was the excision of two or three of such tu-
mours, which was performed by the late Mr. Ramsden. The patient did
not recover.
DISEASES OF THE EYE AND ITS APPENDAGES.
This part of surgery being now cultivated with minute care, no sur-
geon, who values his own reputation, will neglect the study of it. Were
it not a subject disfigured by too many harsh and barbarous terms, I
should say, that it is one of the most inviting departments of surgical
pathology and practice — one, in which we may often actually see the
changes of disease exactly as they occur, and estimate their nature and
character with wonderful precision.
For the sake of method, 1 will divide it into three parts ; the first com-
prising diseases of the lachrymal organs, the second those of the eyelids,
and the third the diseases of the eye itself.
DISEASES OF THE LACHRYMAL ORGANS.
The lachrymal gland is not itself very liable to disease. In scrofulous
children, it is occasionally the seat of inflammation and suppuration ; but
such a case is uncommon. The proper treatment would be leeches, pur-
gative medicines, a cold evaporating lotion, and other antiphlogistic
remedies. If suppuration could not be prevented, the cold lotion should
be exchanged for poultices and fomentations ; and, as soon as matter had
formed, a puncture ought to be made, if possible, through the conjunc-
tiva, under the outer portion of the upper eyelid ; or, if this were imprac-
ticable, through the skin.
Another disease is an indolent scrofulous enlargement of the lachrymal
gland. When I speak of any disease of the lachrymal gland, the case,
whatever it may be, must be an uncommon one ; and this we shall be
convinced of when we hear, that the Reports of the London Ophthalmic
Infirmary, for twelve successive years, contain no example of any disease
of the lachrymal gland. If we were to meet with an indolent enlargement
of it, we ought to treat it with the general remedies recommended for
other scrofulous diseases, especially the repeated use of leeches, the
compound calomel pill at night, and aperient medicine in the morning ;
or, what might be still more advisable, we should have recourse to fric-
tion with iodine ointment, prepared according to Lugol's formula, the
patient taking at the same time the iodine solution, made according to
his directions.
Scirrhus of the lachrymal gland is mentioned by most surgical writers ;
but doubts are sometimes entertained, whether a certain chronic indura-
tion of the lachrymal gland, generally described as scirrhous, be truly of
DISEASES OF THE LACHRYMAL ORGANS. 439
this nature ; for the disease is remarked not to affect the lymphatic
system; never to undergo malignant or cancerous ulceration, independ-
ently of that of the eyelids or conjunctiva ; not to be followed by relapse
after extirpation ; and that the lachrymal gland is not very prone to as-
sume any malignant change, may be inferred from the fact, that when
the globe of the eye and the other contents of the orbit are extensively
diseased, the lachrymal gland usually remains unaffected. The same fact
is commonly noticed in cases of medullary disease of the retina, even
when it has advanced to that degree which makes the removal of the eye
necessary. The gland may be rendered as large as, or even larger than,
a walnut ; but when removed, its texture, though hardened, does not
always exhibit the peculiarities of the scirrhous structure. However,
the best authorities differ on this subject ; for some of them contend, that
the lachrymal gland, conjunctiva, and eyelids are the parts about the eye
peculiarly liable to cancer ; and there is no doubt, that the lachrymal
gland is sometimes involved when these other parts are attacked. A
truly scirrhous affection of the lachrymal gland alone is undoubtedly a
rare disease. In the examples, recorded by Mr. Todd and Dr. O'Beirne,
the structure of the diseased gland seems to have corresponded to that
ordinarily described as characteristic of scirrhus.
What is reputed to be scirrhus of the lachrymal gland, is not attended
with that preternatural dryness of the eye which has frequently been
supposed to be an unavoidable consequence of such a disease ; for in the
cases of it, recorded by Mr. Todd and Dr. O'Beirne, in the 3d vol. of the
Dublin Hospital Reports, there was actually an increased secretion of
tears ; an epiphora, as it is technically called. The symptoms character-
ising it are, lancinating pain in the external and upper part of the orbit ;
enlargement of the gland, till it forms a prominent, hard, lobulated, tu-
mour, quite perceptible under the tense skin of the upper eyelid, and
displacing the eye-ball in a greater or less degree, downwards, inwards,
and forwards ; dulness of the cornea ; dimness of sight ; double vision ;
dilatation of pupil ; and at length complete blindness. In the worst
stages, the temporal side of the orbit is dilated, or the eye so pressed upon
as to be destroyed by ulceration and the evacuation of its humours.
As for the treatment, with the view of reducing and dispersing what is
termed scirrhus of the lachrymal gland, the means proposed are leeches,
followed by a succession of blisters, alternately to the neighbouring part
of the forehead and temple ; or friction with Lugol's iodine ointment, as-
sisted by the internal exhibition of the iodine solution.
Were these plans to prove ineffectual, and the tumour to become a
source of considerable annoyance to the patient, or of mischief to the
eye, it would be necessary to remove the diseased gland. The operation
cannot be easily done from beneath the upper eyelid, as it is sometimes
recommended, unless an incision be made through the outer commissure,
so as to let that eyelid be turned completely up, and the conjunctiva be
sufficiently exposed. Hence surgeons, who have occasion to remove the
lachrymal gland, have generally preferred cutting directly down to the
tumour, making a crucial incision over it, raising the angles of the wound,
and then taking hold of it with a tenaculum, and dissecting it out.
The return of vision, and of the eye into its place again, does not
always take place immediately ; and the sight may, indeed, never be re-
covered. In one case, reported by Dr. O'Beirne, the eye resumed its
proper position, and vision was restored. In another instance, the parti-
culars of which are given by Mr. Todd, though the protrusion of the eye
f y 4
440 DISEASES OF THE LACHRYMAL ORGANS.
was gradually rectified after the operation, the blindness continued. In
one or two examples, which were under Mr. Lawrence, the operation was
followed by a considerable improvement of the sight.
Diseases of the Caruncula Lachrymalis. — The caruncula lachrymalis
and semilunar fold of the conjunctiva are liable to inflammation, and
sometimes matter collects in the substance of the former. The treatment
consists in the removal of the cause, which may be the pressure and
irritation of the eyelashes, or the presence of some extraneous substance ;
but the most common cause is exposure to cold. The caruncula is to be
frequently bathed with tepid water, and opening medicines administered.
In the early stage of a severe case, a leech might be put on the caruncula ;
and, in the event of suppuration, a bread and water poultice, included in
a little muslin bag. The abscess should be opened early ; and if fungous
granulations arise, they are to be repressed with the nitrate of silver.
Encanthis signifies a chronic enlargement of the caruncula lachrymalis.
Two forms of it are usually described ; one, a simple indolent swelling of
the part ; the other, a scirrhous affection of it, disposed to degenerate into
cancerous ulceration, but, fortunately, so rare that some surgeons, who
have had the greatest opportunities of seeing this department of surgery,
have not met with a single example of it. The inconveniences neces-
sarily resulting from an encanthis, are considerable ; as chronic ophthalmy,
an impediment to the complete closure of the eye, and an interruption
of the passage of the tears into the nose by the compression and dis-
placement of the puncta lachrymalia. Hence the tears are continually
dropping over the cheek, so as to produce the complaint technically named
stillicidium lachrymarum, which is not to be confounded with epiphora :
for while this last consists in so profuse a secretion from the lachrymal
gland that the tears cannot wholly pass down into the nose, the stillicidium
is a dropping of the tears over the cheek, in consequence of an impedi-
ment to their passage from the eye into the lachrymal sac. From the
various causes, which I have explained as accompanying encanthis, the
eyesight itself must be considerably weakened and disturbed.
When an encanthis cannot be reduced by applying to it the vinous
tincture of opium, or a solution of the nitrate of silver, and especially
when, from its great pain and disposition to bleed, it evinces a cancerous
tendency, or, at all events, a propensity to become a very painful and
troublesome disease, it should be removed without further delay. Some
operators pass a ligature through it, by means of which they draw it
out, while they perform the requisite incisions with a small scalpel ; but
taking hold of it with a tenaculum will enable us to cut it away with
facility.
In the encanthis of the large inveterate kind, an elongation of it upon
the inside of each eyelid may be seen, requiring to be separated with
the knife in the commencement of the operation, before the main part of
the tumour is separated. The surgeon should be careful not to encroach
upon the conjunctiva, and, if possible, he should save a small portion of
the caruncula, sufficient to prevent a perpetual dribbling of the tears over
the cheek, after the cure of the disease. The eye is to be bathed with
tepid water, and afterwards mild ointments, and astringent collyria, &c.,
are to be employed. If the granulations rise too much, the nitrate of
silver is to be applied.
Of various Diseases of the Lachrymal Organs, formerly confounded
together under the Name of Fistula Lachrymalis. — It is only within a few
years, that any discrimination has been introduced into the views taken
DISEASES OF THE LACHRYMAL ORGANS. 44-1
by surgeons of the diseases of the lachrymal organs. Nearly all these
complaints were supposed to be essentially connected with obstruction
of the nasal duct ; and hence its removal was generally the principal
thing contemplated in the treatment. It was too much looked upon as a
cause, and not as an accidental accompaniment or consequence, of certain
affections of the lachrymal parts of the eye. The truth is, obstruction of
the nasal duct is sometimes merely the temporary effect of inflammation;
and, I might say, that in the greater number of diseases affecting these
parts, such obstruction either does not really exist, or, at all events, has
no share in the original production of the inconveniences which the
patient is experiencing. Thus, if the disease be simply a morbid change
in the secretion of the mucous lining of the lachrymal sac, the blennor-
rhcea sacculi lachrymalis, as it is termed, — or if the case be merely an
extreme relaxation of the part, the hernia^ of it, as it is sometimes called,
the absurdity of opening the sac with a knife, and thrusting a probe,
bougie, or style down into the nose, must be obvious.
Inflammation of the lachrymal sac may extend, more or less, down it
into the nasal duct. The affection may be acute or chronic; the latter being
more common than the former. In the acute, a swelling, shaped like a
horse-bean, and attended with a degree of redness, presents itself just
below the tendon of the orbicularis palpebrarum muscle. The swelling
of the skin is at first confined to the part over the lachrymal sac, but
afterwards spreads to the eyelids, which present an cedematous appear-
ance. Now, in consequence of the lining of the sac and nasal duct
becoming thickened, the passage for the tears into the nose is obstructed ;
so that, partly from this cause, and partly from the shrunk contracted
state of the puncta lachrymalia, usually noticed at the same time, the
tears do not descend into the nose, but fall over the cheek ; consequently
there exists what is termed a stillicidium lachrymarum. However in-
flamed the skin may be, we may always distinctly feel the swelling of the
lachrymal sac beneath it. In healthy individuals, this kind of inflam-
mation of the lachrymal sac rarely leads to the permanent obliteration of
the nasal duct by the effusion of fibrine, though in scrofulous subjects such
a result is possible.
The pain attending acute inflammation of the lachrymal sac and lining
of the nasal duct, is more severe than might be expected from the small
extent of the part affected. The headach is excruciating, and the fever
considerable. Frequently the case advances to suppuration. The sac,
and the parts by which it is covered, being incapable of any further dis-
tention, sometimes slough ; but, more commonly, in the middle of the
swelling a yellowish soft point is observed, which soon gives way. Then,
the collection of pus and mucus within the sac makes its way through the
orbicularis palpebrarum and the integuments ; but, by this opening, merely
the thinner parts of the matter are discharged, and the tumour is for a
time somewhat lessened. Soon afterwards, when pressure is^made upon
the superior part of the sac, not only pus and mucus are discharged
from the opening, but occasionally a quantity of pure tears ; a proof, at
all events, that the conveyance of the tears into the sac is now re-esta-
blished. In other words, the action of the lachrymal puncta and canals
has again commenced. This is always a favourable circumstance, as it
denotes that now the only question relates to the state of the nasal duct.
For some time after the discontinuance of suppuration, a morbid secre-
tion, somewhat like pus, is kept up from the mucous membrane of the
sac j but this also ceases in its turn, and healthy mucus is again formed
442 DISEASES OF THE LACHRYMAL ORGANS.
in the natural quantity. Sometimes the opening in the sac now heals up
either spontaneously or by the aid of common surgical treatment. Most
frequently it contracts at first to a very minute size, through which, if
the nasal duct should not have become duly pervious again, the tears and
mucus will occasionally be discharged. Should this minute opening close,
and the nasal duct still remain impervious, the patient is obliged several
times in the day to press upon the sac, in order that the mucus and tears
collected in it maybe discharged through the lachrymal puncta and canals.
In other instances, the swelling of the lining of the sac and duct lessens
with the inflammation ; the passage for the tears is restored ; and a com-
plete cure is the result.
From what has been stated, it is manifest, that it is not every inflam-
mation of the lachrymal sac that terminates in the production of an exter-
nal opening indisposed to heal, or a, fistula lachrymalis, as it is termed.
Whether such an opening form or not, and whether, when formed, it will
become fistulous or not, will materially depend upon the treatment.
If, when the lachrymal sac is violently inflamed, the case be neglected
or wrongly managed, a complete or partial closure of the nasal duct by
the adhesive inflammation is likely to be the consequence. There may
also be produced an obliteration of the lachrymal canals, in which event,
the absorption of the tears, and their conveyance from the eye into the
sac, may be for ever impeded, and the patient remain during the rest of
his life afflicted with a stillicidium lachrymarum.
In the first stage, the plain indication is to endeavour to subdue the
inflammation ; and it is by combating this affection, and not by attacking
one, or even several of the symptoms, or effects, that we shall have the
greatest success in curing the patient. For instance, what would here
be more absurd than the scheme of dilatation, by the introduction of
probes through the lachrymal canals into the sac, or even through the
nasal duct into the nose ? This would only be subjecting the inflamed
parts to a new cause of irritation, and increasing the risk of greater mis-
chief than is actually impending. Hence, instead of trying to insinuate
instruments from one of the puncta lachrymalia down into the nasal duct,
— a method, as I think, never advisable as a common practice, on account
of its injurious effect upon the delicate organization of the lachrymal
puncta and canals ; and, as Dr. Mackenzie attests, rarely successful in
any cases ; we should have immediate recourse to antiphlogistic treat-
ment ; applying leeches freely and repeatedly to the inflamed part and
its vicinity, covering it either with a cold evaporating lotion, or applying
poultices and fomentations, and prescribing saline aperient medicines,
followed by the exhibition of calomel, and antimonial powder. A very
low diet will always be requisite ; and, when the pain is severe, vene-
section.
Two principles I wish particularly to inculcate : 1st, that it is not every
inflammation and temporary obstruction of the lachrymal sac and duct,
which require the introduction of instruments down the duct into the
nose : 2d, that when the obstruction is permanent, we should puncture
the sac, and attack the obstruction in this manner. This is much better
than throwing lotions into the sac through the lachrymal puncta and
canals, whereby we should be more likely to destroy the right action of
these delicate organs, than remove the stoppage of the flow of the con-
tents of the sac into the nose.
In the second stage, when resolution is no longer practicable, the cold
lotion may be laid aside for emollient applications ; and when the sac is
DISEASES OF THE LACHRYMAL ORGANS. 443
so distended with mucus and pus that the centre of the swelling begins
to soften, and a fluctuation to be perceptible, a puncture should be made
large enough for the ready discharge of the contents of the sac. Having
made an opening, I would merely inject tepid water with Anel's syringe
down the nasal duct; a plan, which may be repeated every day, if the
fluid can be made to pass into the nose. If it cannot, the obstruction
should be removed with a probe.
When, by means of antiphlogistic treatment, the inflammation of the
membrane of the sac has subsided, and by this and other measures the
mucous secretion from it has been brought into a healthy state, and all
the induration has disappeared, we may then think of adopting some plan
for the re-establishment of the passage through the nasal duct, if it
should not have already become free again under the treatment here
recommended.
What I have now said principally relates to acute inflammation of the
lachrymal sac ; but this part is still more liable to chronic inflammation.
Sometimes, and especially in scrofulous subjects, the lachrymal sac be-
comes distended with mucus, without any previous active inflammation
in it. This is the stage which Dupuytren calls the lachrymal tumour,
and which begins almost imperceptibly, the swelling being at first scarcely
distinguishable, and situated under the inner canthus, and below the ten-
don of the orbicular muscle. It is circumscribed, and at first unattended
with pain, or any change of colour in the skin. The inconvenience, first
noticed, is a weakness of the eye, from the tears collecting at the internal
canthus. Whenever the patient looks at minute objects, he finds a tear
ready to drop over the cheek ; and, to relieve himself from this annoy-
ance, he is obliged to press upon the sac, so as to expel its contents,
which either regurgitate through the puncta, or, what is less common,
pass down into the nose. In this case, the nostril is generally drier than
in the natural or healthy state of the lachrymal organs. Things go on in
this way a considerable time, until at length the tears cannot any longer
be made to descend by pressing upon the tumour in the corner of the
eye ; but, instead of doing so, they regurgitate entirely by the puncta
lachrymalia, mixed with pus and mucus, and the whole of the lachrymal
secretion falls over the cheek. The mucous membrane of the sac is the
chief seat of this chronic inflammation. Sometimes the lachrymal canals,
the sac, and the nasal duct are all affected together ; and occasionally the
lachrymal canals alone. After a certain period, the effects of the inflam-
mation generally extend, more or less, to the mucous membrane of the
eyelids, and even to the eye itself. The edges of the former are swollen,
and adhere together in the morning ; and the vessels of the conjunctiva
are always more injected with blood than in the healthy state of the eye.
In many individuals, the complaint disappears during summer, but returns
at the commencement of cold or wet weather.
The complaint may continue in the above state for a long time ; but,
at last, a period arrives, when the parietes of the tumour become very
thin, when the swelling can no longer be emptied by pressure, and the
skin over the sore is red, hot, and painful. Frequently the inflammation
extends to the eyelids, cheek, nose, and forehead. A fluctuation is now
felt in the tumour, which points and bursts ; and the opening, if neglected,
is converted into a true fistula lachrymalis. In most patients, the stilli-
cidium lachrymarum is now materially lessened, in consequence of the
tears finding an outlet through the new opening, which the nasal duct did
444 DISEASES OF THE LACHRYMAL ORGANS.
not previously afford them. The discharge from the sac is a mixture of
tears, mucus, and pus.
The treatment of chronic inflammation of the lachrymal sac consists in
endeavouring to remove the inflammation ; and, if we succeed in this
purpose early enough, we prevent suppuration and ulceration of the sac,
the formation ofajfistula lachrymalis, as it is called ; the nasal duct will
not be permanently obstructed ; and the tears and mucus will gradually
resume their proper course into the nostril.
If, after the cure of the inflammation, the passage should not be free,
and the sac remain distended, we may endeavour to press the fluid, with
which it is filled, down into the nostril, placing the finger for this purpose
between the puncta and the sac, and pressing from the puncta towards
the nose. We may also instil into the corner of the eye, every day or
every second day, a few drops of a lotion containing 2 grs. of the nitrate
of silver, or from 2 to 4 grs. of the sulphate of zinc, to an ounce of dis-
tilled water ; and in order that such fluid may be absorbed by the lachry-
mal puncta, the patient should lie upon his back, and continue quietly in
this position during, and for a short time after, the operation.
When the conjunctiva of the eyelids and the Meibomian glands are
affected, we may employ salves, the best of which are the ointment of the
nitrate of quicksilver, in the proportion of one third of it to two thirds
of spermaceti ointment ; the red or white precipitate of mercury ointment
in the proportion of one scruple of the powder to an ounce of lard ; or
the nitrate of silver ointment, from five to ten grains to an ounce. Un-
doubtedly, when suppuration cannot be prevented, emollient poultices and
fomentations are advisable ; and, as soon as the abscess is distinctly
formed, a puncture should be made in it.
On examining the nasal duct, we now generally find it contracted at
one or several points ; and, for the removal of the obstruction, we are
next to introduce a probe, and then employ a nail-headed style, in order
to remove the disposition of the passage to close again. This instrument
may be worn for an unlimited time without any material annoyance. The
eyelids being drawn outwards, so as to put the orbicularis palpebrarum
on the stretch, we are to make a puncture in the sac with a lancet, or a
narrow sharp-pointed bistoury, along the surface of whose blade the style
will pass into the sac, as on a director ; a convenient method, which, I
observe, was practised by Dupuytren, with his cannula, and which I have
seen Mr. Liston adopt, in University College Hospital, with great skill,
as soon as the puncture had been made. It is the method to which I
usually give the preference. Before making the puncture, we ascertain
the precise situation of the nasal edge of the orbit, and of the tendon of
the orbicular muscle ; for it is between these points that the knife should
be introduced, carefully avoiding to go below the margin of the orbit,
where the sac will not be found : a large quantity of mucus and
puriform matter will be immediately discharged. A common silver
probe is then to be passed into the sac, and thence down the nasal
duct into the nostril, so as to clear away the obstruction. It should be
introduced horizontally, till it touches the nasal side of the sac ; it should
then be raised into a vertical position, and its point directed downwards
and a little backwards. If it meet with an obstruction, we must not
immediately conclude, that there is an obliteration of the duct ; but should
press the probe down a little more strongly, turning it round between
the fingers, and giving it different directions. In this way, the obstacle
DISEASES OF THE LACHRYMAL ORGANS. 445
may frequently be overcome, and the probe will suddenly descend. The
probe is then to be withdrawn, and a little tepid water injected ; after which
the style is to be introduced sufficiently far to bring its head in contact
with the skin. I see no utility in making a formal extensive incision :
all that is required is a puncture to let out the matter, and to allow the
style to be introduced, which is to be withdrawn, once or twice a week,
and tepid water, or some slightly astringent lotion, injected through the
nasal duct.
After the style has been worn a little time, the blennorrhcea of the sac,
as it is termed, disappears almost entirely. The tears and mucus, ab-
sorbed by the lachrymal canals, would seem to be conveyed along its sur-
face through the nasal duct; and thus the functions of the parts being
restored, the inflammation and discharge quickly subside. The curious
fact of the fluid taking its natural course, when a solid style is thus kept
in the nasal duct, seems to Mr. Lawrence to be explained by what hap-
pens in the urethra; namely, by the enlargement of that canal round a
catheter, which is left in it.
Sometimes, after the style has been worn one, two, or three months, it
is discontinued, and the opening heals up ; but a relapse takes place, and
it is necessary to introduce the style again, and to continue it for some
weeks longer. What proves how little inconvenience is commonly felt
from its presence is, that the patient will often express a preference to
wearing it a very long time, rather than subject himself to the slightest
chance of a return of the disorder.
When the head of the style is covered with black sealing wax it causes
little or no disfigurement. The instrument must occasionally be taken
out and cleaned. After the parts have become habituated to it, I find
that taking it out once a-week is quite sufficient. If left in too long,
without being cleaned, it would be corroded, and likely to break in the
part.
When the style, on being first used, creates much irritation, it is better
to withdraw it, and after clearing away all obstruction in the nasal duct
once more with a probe, we are to be content with injecting tepid water
through the nasal duct by means of Anel's syringe, using at the same
time leeches, emollient applications, and aperient medicines. Instead of
a style, a tube made of gold, or silver, is employed by some practitioners.
Baron Dupuytren prefers a tube of this kind, which is introduced into
the nasal duct by means of a steel stilet, bent at a right angle at the por-
tion beyond the bend corresponding to the cavity of the tube. The
latter must be fairly lodged in the duct, with its upper or expanded por-
tion occupying the lower part of the sac. The puncture soon heals, and
the tube serves as an artificial channel for the tears. It is calculated,
that Dupuytren treated 3000 cases in this way, and that, in nine out of
every ten, the cure was accomplished, without any inconvenience from
the continuance of the tube in the duct. In some instances, however, it
became displaced, rising too high, or sinking into the nostril, rfirough the
lower opening of the duct. The first occurrence brings on inflamma-
tion, ulceration, and abscess, which render the extraction of the tube
necessary. The second inflames and irritates the mucous membrane of
the nostrils, and sometimes excites ulceration and sloughing of it, and the
end of the tube may even perforate the roof of the mouth. Dupuytren
has suggested very good plans for extracting the tube in each of these
events ; but as the style, preferred in this country, is not liable to the
44-6 DISEASES OF THE LACHRYMAL ORGANS.
inconvenient consequences here specified, I need not enter into any
further details.
When a probe cannot be got through the obstruction in the nasal duct
at the first trial, a piece of catgut, or bougie, may be left in the passage,
and the attempt to overcome the stoppage daily repeated. If the obli-
terated portion of the nasal duct should still prevent success, perhaps the
right practice would be that of rendering the nasal duct pervious again,
by means of a small triangular perforator. This, I think, would be bet-
ter than drilling a hole in the os unguis, and removing any portion of
this bone with forceps, or destroying it with the cautery. If the perfor-
ated part of the duct should not admit of being kept open after the style
has been worn a long time, the patient must continue to wear either it or
a silver or gold tube. Caries of the os unguis, so frequent formerly, is
now rarely met with, a proof that it was generally occasioned by wrong
treatment. In the Le9ons Orales of Baron Dupuytren is an instance,
however, where such caries took place, even before the lachrymal tumour
had burst, or any fistula had been formed.
With respect to general treatment. — In scrofulous cases, chronic in-
flammation of the lining of the sac and nasal duct will sometimes not
yield, unless an attempt be made to improve the state of the constitution,
by alteratives, tonics, especially the sulphate of quinine, and iodine medi-
cines. We may also usefully combine with such treatment blisters
behind the ears, or a seton in the nape of the neck, and iodine lotions,
according to the formulae given by Dr. Lugol.
Obstruction of the Puncta Lachrymalia and Lachrymal Canals. — The
puncta lachrymalia are sometimes congenitally deficient ; such a case is
hopeless. Sometimes the puncta and canals are constricted, but pervious ;
and occasionally they become blocked up with calcareous matter depo-
sited from the tears. The most frequent cause of their obstruction is a
thickening of the membrane lining them, a consequence of previous in-
flammation.
When calcareous matter is present, it must be removed, as soon as its
presence has been detected, by means of Anel's probes, made expressly
for the purpose of examining the lachrymal puncta and ducts, and for
removing any slight obstruction in them. When they are stopped up
with mucus, they may, with these instruments, easily be made pervious
again. In examining the superior punctum and lachrymal duct, we are
to introduce the point of the probe first from below upwards, till it reaches
the angle of the canal. It is then to be directed circularly downwards
and inwards. In examining the inferior duct, we are to direct the point
of the probe first from above downwards, and then horizontally towards
the sac.
When, with these instruments, we cannot decidedly make out whether
there is an obstruction in the puncta or not, we may put into the lacus
lachrymarum a drop of an aqueous solution of saffron, while the patient
lies upon his back. If the canals execute their office, this coloured fluid
will disappear, without falling over the cheek.
When the puncta and canals are completely obliterated, the case is
irremediable ; for, were we to think of forming new puncta and ducts,
we could not give them the organisation essential to make them of any
use.
Sometimes cases present themselves, in which a stillicidium lachryma-
rum arises from atony and relaxation of the lachrymal puncta and canals,
in consequence of previous inflammation, or the too frequent irritation of
DISEASES OP THE EYELIDS. 447
them with probes and syringes. The puncta are seen to be widely open,
and incapable of contraction.
For the cure of this form of disease, an astringent colly rium, made of
distilled water and a small proportion of the sulphate of iron, and cam-
phorated spirit, or the tinct. opii, is to be dropped out of a pen, or di-
rector, into the inner angle, frequently in the course of the day ; the pa-
tient being kept for some time on his back after each application.
In old persons, this kind of stillicidium is attended with more or less
separation of the lower eyelid from the eye. It may be somewhat relieved
by astringent collyria ; but never admits of a perfect cure.
DISEASES OF THE EYELIDS.
Inflammation of the eyelids is not so disposed to involve the eyeball, as
external inflammation of the latter is to extend itself to the former. How-
ever, if the inflammation of the eye be restricted to its internal textures,
then the eyelids are not affected. When abscesses form in the cellular
tissue of the eyelids, an early opening should be made in them, as the
most likely means of preventing the extension of the disease, and subse-
quent eversion of the part. Passing over wounds, phlegmonous and ery-
sipelatous inflammation of the eyelids, the treatment of which is regulated
by general principles, I shall first consider —
CATARRHAL INFLAMMATION OF THE EYELIDS,
Which affects their mucous membrane and the glands of Meibomius,
and begins near the margins of the eyelids, which become sore, and are
affected with heat and dryness. Their lining assumes a red, thickened,
and villous appearance, and, if everted, looks like a piece of scarlet velvet.
When the eyelids are moved, the pain is severe, because then the in-
flamed surface rubs against the globe of the eye ; and hence, in every
severe case, the patient keeps the eye more or less shut, and the eyelids
motionless. In the beginning of the attack, the natural mucous secre-
tion is suppressed, and a sensation of dryness and stiffness is experienced ;
but, after a little while, this feeling subsides, because now the secretion
of mucus recommences, and is even more abundant than natural, though
altered in quality, and somewhat like pus. The secretion from the
Meibomian glands is also changed, so that it has a share in making the
eyelids stick together in the night, and in the morning the patient cannot
open his eye.
Catarrhal inflammation of the eyelids is mostly produced by atmospheric
causes, and such as usually bring on inflammation of other mucous mem-
branes. But inflammation of the lining of these parts is sometimes owing
to its being habitually exposed to the irritation of smoke, or of an atmo-
sphere impregnated with gas or vapour of a stimulating kind, mimite par-
ticles of lime, &c. The influence of any of these causes will be rendered
more powerful, if the patient be uncleanly or intemperate.
In the early stage, during which the inflammation is always more or
less acute, antiphlogistic remedies are proper, as leeches, tepid lotions, and
the unguentum cetacei, to the edges of the eyelids, in order to keep them
from becoming adherent in the night time. The bowels are to be kept
well open ; and, at first, some brisk purgative medicine should be given.
These means, if the case be one of sufficient severity, are to be followed
448 DISEASES OF THE EYELIDS.
up by a blister on the nape of the neck. When the acute form of the
complaint has been subdued, we are to employ astringent lotions, and
stimulating applications, especially the vinum opii, and the ung. hydrarg.
nitratis, which latter is to be melted, and put on the edges of the eyelids
with a camel-hair pencil. At first, it ought to be weakened with an equal
quantity of the ung. cetacei.
OPHTHALMIA TARSI, OR PSOROPHTHALMIA,
Is merely a chronic inflammation of the lining of the eyelids, or rather
of their margins, occasioning their adhesion together in the night, a de-
gree of soreness and itching in the parts, and a falling off of the eyelashes.
The Meibomian glands are considerably implicated. When the lining of
the eyelids has been frequently in the state of chronic inflammation,
especially in old subjects, not only are the eyelashes lost, but the edges
of the lids, instead of being angular, become rounded, and present an
habitually raw and red appearance, which is technically named lippitudo,
or blearedness.
When ophthalmia tarsi has continued for a long while, or been neg-
lected, the orifices of the ducts of the Meibomian glands, placed along the
inner margin of one or both eyelids, may be partially or totally obliterated ;
and it is chiefly in such examples that the eyelashes are lost, and the
edges of the lids are rounded off. Sometimes an eversion of the lower
eyelid takes place, from a contraction of the frequently excoriated parts
of the adjoining skin of the cheek, or an inversion of the part, from
the effect of previous ulcerations on the inside of it.
When a person is troubled with ophthalmia tarsi, or psorophthalmy, he
should never attempt to open his eyes in the morning, till the glutinous
matter, which makes the eyelids and eyelashes adhere together, has been
properly softened and dissolved, so that it may be done without pain.
For this purpose, the margins of the eyelids and the eyelashes should be
anointed with a small quantity of spermaceti cerate. Then a piece of
soft sponge, wrung out of hot water, is to be held over the eyelids for a
few minutes, after which the eye may be opened without pain. All the
gummy matter should be tenderly removed, because, so long as it remains,
no eye- water nor salve can be brought in contact with the principal seats
of the complaint.
The first indication, or that of diminishing inflammation, may be further
promoted by fomenting the eyelids with a decoction of camomile flowers,
applying leeches to the eyelids, and giving aperient medicines.
In bad cases, the eyelids may be covered at night with a bread and
water poultice, included in a bag of fine muslin, the margins of the eye-
lids being first smeared with a little spermaceti ointment.
The second indication, or that of healing the ulcerated and excoriated
parts of the lid, is fulfilled by applying to them the unguentum hydrar-
gyri nitratis, more or less weakened at first with a proportion of lard ; or
salves containing the red or white precipitate of mercury, in the propor-
tion of 10 or 12 grains of the former, or 30 grains of the latter, to an
ounce of lard.
When small ulcerations are noticed along the margins of the eyelids,
they are to be touched with the nitrate of silver, or a strong solution of
it ; and, in bad cases, it is best before using the caustic, to extract the
eyelashes, for if their bulbs are suffered to be destroyed by the ulceration,
they will not be reproduced.
The third indication, or that of improving the general health, requires
ENCYSTED TUMOURS OF THE EYELIDS. 449
the employment of tonic and alterative medicines, sea bathing, pure air,
and regular exercise.
THE HORDEOLUM, OR STYE,
Is generally compared to a little boil, of about the size of a barleycorn,
projecting from the eyelid. It is of a deep red colour, attended at first
with itching, and afterwards with a considerable tenderness, and even
more pain than might be expected from so trivial a swelling. Sometimes
the irritation is such that the conjunctiva is partially inflamed, and the
motion of the eyelid productive of great annoyance. It is the nature of
a stye to suppurate very slowly ; but at length it does suppurate, points,
and bursts ; and after discharging a minute quantity of curdy matter and
disorganised cellular membrane, it usually subsides and disappears. But
if any of the sloughy matter remain within it, the disease is apt to return,
or to degenerate into a hard, white, chronic tumour, that is very slow in
undergoing any change, and is technically named grando, from having
been compared to a hailstone. Young persons are often annoyed for
several weeks by a succession of styes, one forming as soon as another is
cured.
In the beginning, cold applications, as the lotio plumbi acetatis, or a
cold bread poultice, made with the same, or iced water, may be tried,
though we rarely succeed in dispersing the swelling altogether in this
way. However, we may first try what cold applications and aperient
medicines will do ; and when suppuration is obviously taking place, ex-
change them for warm poultices and fomentations. As soon as we see a
white speck on the apex of the little tumour, provided the tumour is slow
in bursting of itself, we may make a small puncture in it ; but this should
not be done unnecessarily, or prematurely, as it would only increase
the inflammation, without obtaining any discharge of the contents of
the stye. The pus and sloughy cellular substance are then to be pressed
out, and a poultice applied again. When the sloughy cellular membrane
is very slow in coming out, the cavity may be touched with lunar caustic,
or with the end of a probe dipped in sulphuric acid.
The best way of treating the tumour, termed grando or chalazion, is
to open it, press out its contents, and touch the interior of the cyst with
lunar caustic, scraped to a point.
ENCYSTED TUMOURS OF THE EYELIDS
Are not unfrequent, their seat being generally in the cellular tissue,
connecting the integuments of the lid with the orbicular muscle ; but
they may be more deeply placed, so as to be covered not only by the
orbicularis, but by the levator muscle. The more fluid kinds sometimes
grow to the size of a pigeon's egg; but the steatomatous ones rarely be-
come larger than a filbert. They often contain, besides the ordinary
matter of encysted swellings, small short hairs, entirely destitute of
bulbs and tubes.
The encysted swellings, not closely connected with the tarsal cartilage,
are to be treated precisely on the same principles which apply to ordi-
nary swellings of a similar character in other situations ; but if they
should be intimately connected with that cartilage, a formal dissection of
them out would be difficult without cutting a portion of the cartilage away.
Such operation may be rendered unnecessary, by everting the eyelid,
and making at the point where it appears to be thin and most closely
connected with the base of the swelling a free puncture through the car-
G G
450 DISEASES OF THE EYELIDS.
tilage, by which the contents of the swelling, if fluid, will be discharged,
but if found not to be fluid, a second cut may be made across the first
and the four angular flaps snipped off with scissors.
ECTROPIUM, OR EVERSION OF THE EYELIDS,
Is a case productive of vast annoyance and considerable disfigurement.
The lower eyelid is most frequently affected, its edge falling downwards
and forwards away from the eyeball, which is no longer duly covered and
protected. This exposure of the lower portion of the eye, and of the
conjunctiva of the eyelid, produces in these parts a degree of inflam-
mation, attended with constant pain and redness, and thickening of the
membrane, which is at length converted into a hard callous substance,
lying just under the eyeball. As the flow of tears, towards the inner
angle, and through the puncta lachrymalia, is also obstructed, they fall
over the cheek, which is apt to become excoriated.
Ectropium may arise from various causes, which considerably influence
the treatment ; for it may be either a permanent or only a temporary
deformity, which will subside of itself on the abatement of the inflam-
mation that has given rise to it. Thus we meet with ectropium from
acute inflammation of the conjunctiva. When it affects the upper lid, it
is in some degree accidental. A child, for example, is labouring under
acute purulent ophthalmy, and the surgeon, in order to examine the eye,
or remove the copious discharge, everts the upper eyelid ; the child
begins to cry violently, and all attempts to reduce the lid to its natural
position are found to be ineffectual. It soon becomes greatly distended
with blood ; and even if it admit of being replaced, it is generally
everted again as soon as the child begins to cry. When this variety of
ectropium affects the lower eyelid, it is not produced in this accidental
way, but by the swelling and protrusion of the inflamed conjunctiva.
The treatment of ectropium from acute inflammation of the conjunctiva
requires, 1st, scarification of the everted conjunctiva; 2d, after the swell-
ing of the eyelids has been lessened by the discharge of blood, the part
may generally be reduced ; 3d, if the inflammation be not very acute,
the lid is to be kept from quitting its natural position by means of a com-
press and roller. In the contrary case, every thing must be avoided
likely to make the child cry ; and the attendants are to be instructed
how to replace the eyelid, if it should happen to become everted again.
A collyrium containing alum, the nitrate of silver, or sulphate of copper,
must be applied frequently, for the purpose of checking the purulent
discharge.
When scarifications fail to remove or prevent the eversion, we may
cut away a portion of the swollen conjunctiva. The bleeding which
follows will prove of great service. Afterwards strips of plaster passed
from the upper to the lower lid, and a compress and bandage, will pre-
vent the return of the displacement.
Ectropium of the lower eyelid from relaxation is most frequent in
elderly persons, as a consequence of chronic inflammation of the con-
junctiva and Meibomian glands. From constant exposure, the inside of
the everted lid becomes red, firm, and almost insensible, and the lower
punctum lachrymale displaced forwards. These various circumstances
are necessarily productive of a weeping of the eye, a stillicidium lachry-
marum, and of various degrees of inflammation of the eyeball itself.
The treatment of ectropium of the lower eyelid from relaxation, consists,
first, in removing the inflamed state of the eyelids and conjunctiva, and
ECTROPIUM, OR EVERSTON OP THE EYELIDS. 451
then in applying escharotics to the exposed conjunctiva, for the purpose
of obviating the tendency to a return of the displacement. After having
scarified the inflamed conjunctiva, we may apply the sulphate of copper,
or nitrate of silver, and a compress and roller. In inveterate cases, a
portion of the thickened and relaxed conjunctiva is to be removed.
Ectropium of the lower eyelid, consequent to excoriation of it and the
cheek, resulting from long-continued ophthalmia tarsi or lippitudo, is one
of the most common forms of the disease. The palpebral conjunctiva
becomes thickened by long-continued and repeated inflammations ; while
the skin excoriated, or even ulcerated, shrinks, becomes shortened, and
thus draws the edge of the lid outwards. In this case, the edges of the
lid are rounded off, the orifices of the Meibomian glands partially or
completely obliterated, the eyelashes destroyed, and a considerable por-
tion of inflamed conjunctiva exposed to view. The ophthalmia tarsi is
to be removed by the means already explained. For the removal of the
chronic lippitudo, Mr. Lawrence finds that no application answers better
than the red precipitate ointment, which may be freely applied to the
thickened and everted surface, as well as to the ciliary margin of the lid.
It reduces the swelling of the conjunctiva, and rectifies the secretion of
the tarsal glands. Ectropium, even when accompanied with much
thickening of the conjunctiva, may be remedied in this manner. In
more obstinate cases, the skin of the everted lid is to be smeared with
zinc ointment, and the exposed conjunctiva scarified and touched with
nitrate of silver. Should these means not prove effectual, a portion of
the conjunctiva must be removed. In bad cases, resisting this treatment,
the practice of cutting out a portion of the cartilage of the shape of the
letter V is sometimes adopted.
Ectropium of the lower eyelid from disunion of it from the upper one at
the temporal angle is seldom seen, except in old persons who have been
long afflicted with inflammation of the margins of the eyelids, and have
had a succession of ulcers near the outer commissure. The treatment
requires an operation similar in principle to that performed for the cure
of harelip, namely, — the edges of the disunited commissure are to
be cut off, and the parts then brought together by means of a suture.
The diseased state of the eyelids, however, should be first previously
removed.
Ectropium from the contraction of a cicatrix. — The deformity is not
an unfrequent consequence of a wound, an abscess, an ulcer, or a burn.
In slight cases, the simple operation of removing a fold of the con-
junctiva may be sufficient ; but some examples are met with, in which
the degree of eversion is very great, the length of the eyelid in the
transverse direction much increased, and its outer surface fixed by ad-
hesions. Here the cicatrix must first be divided, in order to loosen the
lid from its unnatural position, and then a portion of the conjunctiva is to
be removed ; but, for the purpose of counteracting the morbid •longation
of the lid from one canthus to the other, it is sometimes necessary to
remove a portion of the whole thickness of the tarsal cartilage, shaped
like the letter V, and then to bring the edges of the wound together
with a suture. Or, in some examples, we might imitate Jaeger in
completely detaching the everted eyelid from the cheek, or superciliary
ridge, leaving it connected at the angles only. The details of this
operation may be found in Mr. Lawrence's " Treatise on Diseases of the
Eye/' p. 350.
GG 2
4:52 DISEASES OF THE EYELIDS,
ENTROPIUM.
Amongst the numerous diseases of the eyelids, I have next to explain
one which is exactly the reverse of the preceding; namely, entropium,
or inversion of the eyelids, which is mostly seen in old subjects, in whom
the skin of these parts is loose and redundant, destitute of a proper
degree of elasticity, and thrown into folds. When the upper eyelid is
inverted in the slightest degree, a considerable irritation of the eye is
produced ; but when a large portion of it is so displaced, the case
becomes truly afflicting. The friction of the eyelashes against the eye
is incessant, attended with immense suffering ; the eye itself inflames,
the cornea ulcerates, or becomes opaque, and the eyesight is ultimately
destroyed.
The inversion may be either temporary or permanent, the former
chiefly affecting the lower lid, and occurring in chronic external oph-
thalmia, or sometimes even more acute cases. The ciliary margin be-
comes contracted from repeated inflammation ; a spasmodic action of the
orbicular muscle is produced, and the eyelid being thus forced inwards,
retains its unnatural position. The temporary inversion may be gene-
rally remedied by putting a small compress against the lower portion of
the eyelid, and fixing it there with adhesive plaster, placed transversely
over it. If this plan be continued for twelve or twenty-four hours, the
inversion will not return.
Permanent entropium may be mostly cured by cutting away a fold of
the integuments near the edge of the tarsus. We first take up a portion
of them with the entropium forceps, and observe whether what we hold
is sufficient to bring the eyelid into its right position ; if so, we cut it off
with a small pair of curved scissors, and unite the edges of the wound
with one or two sutures, which may be withdrawn the next day, as the
wound will then have united.
Another mode of cure is that of producing a contraction of the skin of
the eyelid, by cautiously applying across its central part a little sulphuric
acid, by means of a thin bit of wood dipped in it, and rubbed upon an
oval space a little longer than the extent of the inversion, and from
three to six lines in breadth. Three or four applications will generally
suffice.
But more difficult cases sometimes arise from an alteration in the
shape of the cartilage of the eyelid. For these, the common plans will
not answer, and we must try others. One consists in making two per-
pendicular incisions in the broad margin of the tarsus, at the sides of the
inverted part, and then making a transverse cut through the lining of the
eyelid, from the extremity of one of the first wounds to that of the other.
The inverted portion of cartilage, thus comprised within the incisions,
is then to be put into its'right position, and retained in it with sticking
plaster.
When the vicious shape of the tarsal cartilage makes the adaptation
of it to the eye impracticable, its total excision has been occasionally
performed.
Sometimes it seems as if entropium depended upon the cartilage being
too short ; for if a cut be made through the outer commissure, the eyelid
no longer presses against the eye. Another operation, adopted by Jaeger,
of Vienna, consists in paring away the edge of the inverted tarsus.
PARALYSIS OF THE ORBICULAR MUSCLE. 4-53
TRICHIASIS
Signifies the growth of the eyelashes in such a direction, that they rub
against and irritate the eyeball.
We seldom find all the eyelashes turned towards the eyeball, except
when trichiasis is really accompanied by an inversion of the eyelid itself.
The inconveniences of the complaint are severe ; for the friction of the
eyelashes against the eye brings on inflammation of that organ, and, in
time, and under neglect, opacity of the cornea and blindness. The
wrong direction of one, or more of the eyelashes is often overlooked, and
the effect, the inflammation, only attended to : but here, as in every other
part of surgery, we should search for the cause of the disease, and not
disregard it in the treatment ; for its removal will alone frequently suffice
to bring about a cure.
One plan of treatment consists in removing, one after the other, all
the inverted cilia by means of forceps. Each eyelash is to be laid hold
of as close as possible to the skin, and pulled out quickly in a straight
direction ; but, in general, the result is only a temporary relief, as the
hairs grow again. Hence, I believe, the best way is to pare off as much
of the ciliary margin of the eyelid as will include the bulbs of the in-
verted eyelashes.
When trichiasis is merely an effect of entropium, the eyelashes need
not be extracted, as the cure is brought about by the measures applicable
to the entropium.
Distichiasis means a double row of eyelashes ; but, in fact, the super-
numerary cilia are never arranged in this regular order ; nor do they
usually extend the whole length of the eyelid, but are scattered at
different points, between the natural place of the eyelashes and the
orifices of the Meibomiau glands. Cases also sometimes present them-
selves, in which strong hairs grow from the inner concave surface of the
eyelids.
The only effectual mode of treatment is to extract the hairs and their
bulbs.
PTOSIS.
An inability to raise the upper eyelid, which hangs loose and pendu-
lous over the globe of the eye. In some examples, this depends upon
excessive distension and inflammation ; but what is more commonly un-
derstood by ptosis is that form of it, which is accompanied by paralysis
of the levator palpebra? superioris. If the eyelid be lifted from the eye,
it gradually sinks down again by its own gravity, being often slightly
cedematous, the eye looking dull, the iris being less irritable than natural,
the pupil dilated, and the eye frequently amaurotic.
Ptosis is generally symptomatic of disease of the brain, and the treat-
ment must be regulated accordingly. With due attention to the cause,
however, there is no objection to rubbing the eyelid with camphorated
mercurial ointment, or with liniments containing ammonia or camphor,
or to blistering the neighbouring part of the forehead.
PARALYSIS OF THE ORBICULAR MUSCLE
Sometimes follows operations performed near the lower extremity of the
parotid gland, and producing injury of the branches of the portio dura of
the seventh pair of nerves. So far as the eye is concerned, the conse-
quences are not usually serious, and the inconvenience is that of not
G G 3
454 DISEASES OF THE EYELIDS.
being able completely to shut the eye ; a state, to which the term lagoph-
thalmos is applied, whether arising from palsy of the orbicular muscle, or
a shortening or retraction of the upper eyelid itself. However, lagoph-
thalmos, when it exists in a considerable degree, may bring on inflam-
mation of the conjunctiva, opacity of the cornea, and even staphyloma.
GRANULAR CONJUNCTIVA
Is mostly an effect of severe purulent ophthalmy, and consists of a rough,
hard, granulated state of the lining of the eyelid, attended with a thin or
purifbrm discharge, a varicose affection of the vessels of the sclerotic
conjunctiva, an increased vascularity arid opaque appearance of the cor-
nea, great tenderness of the eye, and an incessant epiphora, or copious
effusion of tears. The mechanical friction of the granulations against the
cornea, has the effect of changing the texture of the delicate layer of the
conjunctiva extended over it. In recent cases, leeches may be applied
near the eye, and other means adopted to lessen inflammation of the
organ. Then the granular surface of the eyelid is to be smeared with the
melted ung. hydr. nitratis, or a strong solution of the nitrate of silver,
twenty or thirty grains to one ounce of water, by means of a camel-hair
pencil, or rubbed with the sulphate of copper, or nitrate of silver. For
this purpose, the eyelid should always be completely everted, as there is
sometimes a semilunar fringed excrescence at the angle where the con-
junctiva passes from the globe to the eyelid, which might otherwise
escape attention. After caustic has been used, the eyelid must be bathed
with tepid water before it is returned into its natural position again.
Sometimes, when the granular productions are remarkably hard, callous,
and pendulous, excision is preferred.
CONCRETION OF THE EYELIDS.
Two varieties are met with : in one, the inside of one or both eyelids is
adherent to the eyeball (symblepharon) ; in the other, the edges of the
two eyelids are connected together (anchyloblepharon). This last case
is sometimes, though rarely, a congenital malformation ; and, when it
occurs, it is mostly as the result of violent inflammation or burns. The
treatment consists in dividing the adhesions with a knife, guided along a
director, so as not to injure the eye itself, and keeping the edges of the
wound asunder, if the cornea be known to be opaque, such an operation
is useless.
As for adhesions of the eyelids to the eyeball, it is only when they are
loose and of limited extent, and not situated over the cornea, that the
division of them can be of any service.
DISEASES OF THE EYE.
I now proceed to consider diseases of the eye itself; and first, inflam-
mation of it, termed ophthalmia, the most frequent of all its disorders,
and that, indeed, which may likewise be connected with any other com-
plaint of the eye, either as a cause or an effect. It is only of late years
that the various inflammatory affections of the eye have been well dis-
criminated ; for ophthalmia used to be a term applied to every inflam-
mation of the eye, or parts appertaining to it, whether the eyelids, the
conjunctiva, the sclerotica, the iris, or the retina, were the structure
DISEASES OF THE EYE. 455
chiefly concerned ; and although the epithets mild and severe, dry and
humid, external and internal, were in common use, the more valuable dis-
tinctions, deducible from the structure principally affected in different
examples, the characteristic symptoms of each variety, and its most ap-
propriate treatment, were altogether overlooked. In whatever parts in-
flammation occurs, we know, that its effects are always modified by the
structure affected. Now the eye, small as it is, contains a great variety
of textures, each possessing both physical and vital properties peculiar to
itself, and consequently exhibiting, under the process of inflammation,
phenomena which are peculiar to it. The modifications of inflammation,
arising from differences of texture, are often beautifully displayed in the
eye ; and this in so distinct a manner, that its appearances and changes
under inflammation are commonly cited by the pathologists of every
school, as presenting, perhaps, the very best illustration that can be found
of several most important points, relative to the nature of this interesting
process.
One thing, which I conceive it is very useful to understand, is, that in-
flammation of the eye generally commences in one structure, to which it
is at first restricted, and beyond which, if it be rightly treated, it may
not materially extend. But if it be neglected, or wrongly treated, it
soon exceeds its original limits, and perhaps ultimately invades every
part of the organ. The conjunctiva, the sclerotica, the cornea, the iris,
the crystalline capsule, and the retina, all severally exhibit a series of the
modifications of inflammation, dependent upon peculiarity of texture.
The mucous tissue of the conjunctiva secreting a profuse quantity of
purulent matter, as in the ophthalmia of new-born infants ; the fibrous
sclerotica, affected for months with rheumatic inflammation ; the trans,
parent fibro-cartilaginous cornea becoming opaque, or being destroyed,
layer after layer, by ulceration ; the erectile iris losing all power of execut-
ing its motions of expansion and contraction ; the crystalline capsule
pouring out coagulable lymph from its serous surface, and this lymph
forming the medium of morbid adhesions ; the nervous retina, too deeply
seated to be immediately observed, but, in a few hours, losing its incon-
ceivably delicate and specific sensibility, are all so many circumstances
illustrating the modifications of inflammatory action, and the various con-
sequences of it in different textures of the eye.
Inflammations of the eye, besides being modified by differences of
texture, are also much influenced by peculiarities of constitution, consti-
tutional diseases, and certain artificial states of the constitution ; and they
are subject to innumerable variations from the influence of those inscrut-
able connections called sympathies. Scrofula, syphilis, gout, disorder of
the digestive organs, and that deranged state of the system which is
sometimes termed mercurialism, are each of them either capable of ex-
citing inflammation in different parts of the eye, or, at least, of communi-
cating to an inflammation, excited by other causes, such differences in
character as shall often render the recognition of the diseafe difficult,
though we may be perfectly familiar with it in its more simple form.
With respect to the treatment of inflammation of the eye in general,
I may observe that, if the disorder be not speedily checked by efficient
and active means, it will soon extend from the texture originally attacked
to others, and that its continuance beyond a certain period will perma-
nently impair the delicate structures of the organ, or even cause a total
annihilation of its functions. Hence the necessity of adopting very active
treatment ; and this, not on account of any danger to life, or any extraordi-
G G 4?
456 DISEASES OF THE EYE.
nary suffering, great as this may be, but to prevent those changes of
structure which would weaken or destroy the eyesight. Hence we are
frequently called upon to take away as much blood from the system for
an inflammation of the eye, as for an inflammation of the pleura or lungs,
stomach, or brain, or any other most important internal organ. If prompt
and vigorous treatment be not adopted in the early stage of inflammatory
affections of the eye, we frequently find lymph effused, or opaque matter
deposited in the transparent parts of the eye ; or the retina more or less
impaired in texture and sensibility ; the pupil rendered irregular, the
motions of the iris prevented by adhesions; or the complaint degene-
rated into a chronic form, sometimes difficult of cure, and always lessen-
ing the chance of such a recovery as leaves behind it no defect or weak-
ness of the eye, either with reference to its moveable, its transparent, or
its nervous textures.
External inflammation of the eye. may be seated in the conjunctiva only,
or in the sclerotica and cornea. Simple inflammation of the conjunctiva
is a much less serious complaint than that of the sclerotica. Yet,, specific
inflammations of the conjunctiva are exceedingly urgent cases, as, for
instance, violent purulent and gonorrhoea! ophthalmies, which, if unsuc-
cessfully treated, soon involve the organ in incurable mischief. In scle-
rotic inflammation, the implication of the cornea, and the ready transition
of the inflammation to the iris, always expose the organ to considerable
danger.
From these preliminary remarks, I proceed to the consideration of the
chief varieties of ophthalmy, beginning with —
INFLAMMATION OF THE CONJUNCTIVA,
Divided into the following kinds : —
1. Simple or catarrhal.
2. Purulent, or Egyptian.
3. Leucorrhceal, or the ophthalmy of new-born infants.
4. Gonorrhceal.
5. Scrofulous.
1 . Simple inflammation of the conjunctiva. — Catarrhal ophthalmy , as
it is often called, generally commences with stiffness and smarting of the
eyelids, or a sensation as if sand had got under them, an increased
secretion from the lachrymal gland, giving a watery appearance to the
eye, with some degree of redness and uneasiness upon exposure of the
organ to the light. When fully developed, the disease is characterised
by considerable redness, and the increased lachrymal discharge is ex-
changed for one of a thin whitish mucus ; but the pain is generally
slight, and now there is no intolerance of light. The redness is super-
ficial, and the tint a bright scarlet, forming a striking contrast to the rose
or pink colour which belongs to inflammation seated in the sclerotica.
The distended vessels form a network, and the redness is in patches ;
though, in the fullest development of the affection, the whole surface of
the conjunctiva becomes of a bright red, the redness first showing itself
at the circumference of the eyeball, and gradually advancing towards
the cornea. In severe cases, small ecchymoses, or effusions of blood,
may be noticed in the conjunctiva ; and sometimes little vesicles, filled
with a serous fluid, arise upon it, near the margin of the cornea.
The conjunctiva is seldom considerably swollen, and never in the de-
gree exemplified in what is termed chemosis, or that remarkable elevation
of the conjunctiva, which is sometimes caused in other ophthalmies by
INFLAMMATION OF THE CONJUNCTIVA. 457
effusion of lymph underneath it. There is, however, a certain quantity
of serum poured out under it, whereby it is somewhat raised up from the
sclerotica.
As soon as the lachrymal discharge, observed in the very commence-
ment, stops, its place is supplied by an increased secretion of mucus, which
is at first thin, but becomes thicker, as the inflamed conjunctiva goes
through certain stages, assuming a whitish or yellowish appearance, and
even that of pus. It is this altered secretion which, drying on the eye-
lashes in the night-time, makes the eyelids adhere together, so that the
patient has a difficulty in opening them in the morning.
In every well-marked case of catarrhal ophthalmy, the eyelids partici-
pate in the affection ; and whenever the attack is severe, other mucous
membranes suffer. Hence pain and sense of weight about the frontal
sinuses and antrum, disordered stomach, foul tongue, chills, succeeded by
heat, and other febrile complaints.
Simple inflammation of the conjunctiva is distinguished from common
inflammation of the external tunics by its catarrhal origin ; the diurnal
remission and nocturnal exacerbation of the symptoms ; the absence of
pain and of intolerance of light, even when there is great general red-
ness ; the bright scarlet colour of the membrane ; the distended state,
and areolar arrangement of its vessels ; and the altered mucous secretion
from the lining of the eyelids. From purulent ophthalmy it is distin-
guished by its milder nature ; its indisposition to do mischief to the
cornea, or the deeper textures of the eye ; its not being infectious or
contagious ; its having no tendency to cause chemosis ; and its freedom
from all the severe sufferings which attend bad forms of purulent oph-
thalmia.
The origin of this complaint is generally ascribed to atmospheric
causes — exposure to draughts of air or cold winds — sudden changes from
heat to cold. Frequently it prevails as an epidemic in certain towns and
districts, owing to particular states of the air, not precisely ascertained ;
or shows itself extensively in schools. For its relief, mild antiphlogistic
treatment will generally suffice ; and it is not necessary to reduce the
patient so much as in some other inflammatory affections of the eye;
unless the patient be of a full habit, or both eyes be severely attacked.
We need not therefore always have recourse to venesection. In ordinary
cases, cupping and leeches will answer the purpose. The bowels, how-
ever, should be freely opened ; and if the tongue be foul, an emetic
ought to follow the loss of blood. Saline and sudorific medicines, as a
solution of the sulphate of magnesia, with a proportion of tartarised an-
timony in it, may then be given repeatedly, and the feet put into warm
water at night. In a case of severity, we might, after depletion, put the
patient, in the evening, into a warm bath, and, directly he is taken out of
it, give him a full dose of the pulv. ipecac, comp.
\ As local applications, we may foment the eye with a decoction of
poppy-heads ; but afterwards, when the inflammation is on the wane, as-
tringent lotions, containing three or four grains of the nitrate of silver
or sulphate of copper, in 3 iv. of distilled water, will be beneficial. These,
with blisters on the nape of the neck, or behind the ear, will generally
soon complete the cure : if not, the remains of the disorder may be got
rid of by introducing into the eye, once a day, a drop of the vinum opii,
or of the liq. plumbi acetatis. To prevent the agglutination of the eye-
lids in the night, their edges may be smeared at bedtime with spermaceti
ointment.
458 DISEASES OF THE EYE.
2. Purulent, or Egyptian ophthalmy, reputed to be contagious^ is one of
the most violent forms of ophthalmia. The first stage, that in which no
pus is secreted, never surpasses thirty-six hours, and is often of shorter
duration. At the end of this time, purulent matter is always found on
some portion of the conjunctiva. Frequently the patient makes no com-
plaint, till he finds that his eyelids adhere together in the morning, or
till the sensation of some extraneous substance in the eye becomes dis-
tressing. In some cases, a sudden attack of darting pain in the eye-ball
or forehead is the first thing experienced; while, on other occasions, the
increased vascularity of the conjunctiva first excites notice. The right
eye is more frequently attacked than the left. It is also in general more
severely affected, and the sight of it oftener lost. In some instances,
only one eye suffers, but more commonly both ; although there is often
an interval of several days before the second becomes inflamed. A con-
siderable itching is first felt in the evening, or a sensation as if there were
dust in the eye, which becomes watery. This is succeeded by a stick-
ing together and stiffness of the eyelids in the morning, which parts
appear more swelled than natural. Their internal surface is inflamed,
tumid, and highly vascular ; and the caruncula lychrymalis enlarged and
reddened. Generally, in about twenty-four or thirty-six hours, the dis-
charge from each eyelid is already considerable. It is at first thin, but
soon becomes viscid and opaque, and lodges particularly about the in-
ternal angle. There is also a frequent gush of tears, an epiphora, espe-
cially when the eye is exposed to a current of air. The patient always
complains of a sensation as if the eye were full of sand, but seems to ex-
perience, comparatively speaking, little uneasiness from the light.
In the second stage, the discharge becomes truly purulent, and, in
many cases, so abundant, that, on the patient opening his eyes, the mat-
ter instantly flows over the cheek, irritating and excoriating it. The
quantity of discharge sometimes amounts to several ounces in the day.
The whole texture of the conjunctiva may be seen to be swollen and
thickened; its vascularity is increased; and its colour an intensely
bright red. Its mucous surface is rendered villous, pulpy, and granular,
like the villous surface of the foetal stomach, and from the secreting sur-
face, thus produced, the puriform discharge flows. If not checked by
effectual treatment, this species of ophthalmy soon attacks the layer of the
conjunctiva, extended over the cornea, thickening it, and rendering it
more or less opaque. By these changes vision is much diminished, and
very frequently the opacity and consequent diminution of vision continue
after all the acute symptoms have ceased. But the change in the cornea
is not confined to this affection of the delicate layer of the conjunctiva
covering its surface; there is often an interstitial deposition between its
layers, producing a still worse kind of opacity ; and frequently its texture
sloughs or ulcerates ; the anterior chamber being opened, and a discharge
of the humours, and a prolapsus of the iris, being the too frequent con-
sequences. In this manner, both the function and form of the eye may
be destroyed.
In some cases, the inflammatory process is still more severe ; extend-
ing even to the internal textures of the eye, accompanied by a deep
throbbing pain in the eye, coming on in paroxysms ; but, occasionally,
without any remission till the cornea gives way, The duration of the
paroxysms of pain, and their recurrence, are irregular. They come on,
however, most frequently from ten to twelve at night, with an increased
INFLAMMATION OF THE CONJUNCTIVA. ' 459
secretion from the lachrymal gland, and a diminution of purulent dis-
charge.
Sometimes the swelling of the conjunctiva is such that the upper eye-
lid cannot be raised, and projects so enormously that the lower eyelid
is entirely concealed by it, attended with a great deal of redness of the
integuments, extending even to the cheeks and forehead.
In many instances, the conjunctiva forms a prominent red swelling all
round the cornea, so as to give the appearance of a thick ridge of flesh
encircling the latter membrane, which seems as if it were sunk in the
eye, with only a very small portion of its centre discernible. This state
is technically named chemosis. If the purulent matter be allowed to lie
some time upon the cornea, it may acquire a thick consistence, and so
resemble sloughy membrane that an inexperienced surgeon may suppose
the cornea has been destroyed.
Whether the infection can be propagated from one person to another,
through miasmata in the air, arising from the diseased eye, is a contested
point ; but that it can be transmitted by direct application of the dis-
charge from a diseased to a sound eye, is tolerably certain. In the
Royal Military Asylum, and some other public establishments, the mat-
ter of purulent ophthalmia has occasionally been applied inadvertently to
the eye of another person, and the disease been excited. Yet it is
curious, that the surgeons of the French army in Egypt never suspected
its contagious nature. In Egypt, and some other countries, in which it
prevails to a great extent, the origin of it is usually ascribed to the com-
bined effect of exposure of the eye to vivid light and heat, reflected in the
daytime from a sandy soil, followed by exposure of the organ to the
damp, cold, nocturnal air.
The constitutional symptoms are, generally speaking, influenced by
the degree of pain and inflammation, and are a frequent but soft pulse,
not much heat of the skin, the tongue white, not much thirst, the appetite
good, the bowels torpid. On the whole, the constitution suffers less than
might be expected.
The following are some of the differences of this disease from catarrhal
ophthalmia: — 1st. The peculiar change of structure in the lining of
the eyelids ; 2d. The frequently long continuance of the complaint ; 3d.
The disposition to relapses; 4th. The tendency to chemosis; 5th. The
greater swelling of the eyelids; 6th. The great increased vascularity and
redness of the conjunctiva; 7th. The copious purulent discharge.
The treatment is strictly antiphlogistic — beginning with bleeding,
which, in young, strong persons, may be carried at once to the extent of
thirty or forty ounces. This is absolutely necessary if chemosis already
exist ; leeches should also be applied about two hours after venesection,
which is to be repeated according to circumstances, the renewal of in-
flammatory action, and the state of the pulse. So long as there is a
throbbing pain in the eyeball and orbit, the repetition of bleeding is gene-
rally proper. Mr. Tyrrell has published an account of " a successful
plan of arresting the destruction of the transparent cornea from acute
purulent inflammation." * The cornea appears to him to mortify from the
strangulation of its blood-vessels by the chemosis, or the elevation and
tension of the conjunctiva, which covers the sclerotica. Hence, he was
led to try what benefit might be obtained by some means, which would
immediately relieve the tension of the conjunctiva arising from the che-
* F. Tyrrell, in Med. Chir. Tr. vol. xxi. p. 414.
460 DISEASES OF THE EYE.
mosis. A free division of it, practised with due regard to the course of
its principal vessels, was what seemed to him worthy of trial. The me-
thod consists in raising and securing the upper eyelid, and then making
free incisions in the sclerotic conjunctiva, and the subjacent loaded cel-
lular tissue, without injury to any other textures of the eye. It is essen-
tial, that the incisions extend close to the margin of the cornea, where
the tension and pressure are greatest, and that the direction of the wounds
correspond to the intervals between the insertions of the recti muscles, so
that the principal vessels of the conjunctiva may not be injured. The
old plan of scarifying the conjunctiva, which never proved very success-
ful, differed from the latter, inasmuch as the incisions were made circu-
larly, in the direction of the margin of the cornea.
Purgatives are to be given ; as a dose of jalap and calomel, followed by
a solution of sulphate of magnesia, containing in each dose one fourth of
a grain of tartrate of antimony. When severe nocturnal pain is ex-
perienced in the orbit, much benefit has resulted from giving every night
two grains of calomel and one of opium, until the mouth is sore ; but,
under other circumstances, the free use of mercury is of no service in
purulent ophthalmia. In the chronic stage, when the patient is much
debilitated, and the discharge profuse, bark and other tonics are sometimes
prescribed. When the cornea is threatened with sloughing, the same
medicine is occasionally given.
The local treatment is fully as important 'as the constitutional. The
first thing is completely and frequently, in the course of the twenty-four
hours, to clean away the puriform discharge from the eyes. This is to
be done partly with a bit of sponge, and partly with a small syringe, and
a weak alum lotion ^ ss. to half a pint, or with a tepid solution of one
grain of the bichloride of mercury in eight ounces of distilled water.
The best astringent application for checking the secretion is now gene-
rally allowed to be a solution of the nitrate of silver — from four or six
grains to an ounce of distilled water, and applied once, or at most twice,
in the twenty-four hours. Dr. Ridgway even ventured upon twelve grains
to an ounce of water, and published a report in favour of this strength ;
while Mr. Guthrie gives the preference to an ointment containing ten
grains of it to 5j. of lard. In the early stage, relief will also be derived
from anodyne fomentations, the compound powder of ipecacuanha at
night, and a mild ointment to prevent adhesion of the eyelids.
3. Purulent ophthalmia of new-born infants is often believed to arise
from the eyes coming in contact with leucorrhceal discharge in the birth.
In a great proportion of cases, the mother has vaginal discharge : excep-
tions are met with, however ; and then the influences of draughts of cold
air, or of exposure of the young eye to vivid light, usually fall under
suspicion. Mr. Hugh Carmichael, who has commented on the little found-
ation there is for the opinions, prevailing about the causes of the disease,
observes, that the bowels are always more or less deranged, and that this
may possibly operate as a cause.*
In general, the eyelids are first remarked to be glued together about
the third day after birth, but sometimes much later. On opening them
a drop of thick white matter is discharged, and their inner surface is
found to be swollen and vascular. If the disease be not checked, the
swelling of the conjunctiva rapidly increases, and the inflammation ex-
tends from the conjunctiva of the eyelids to that of the eyeball. The
* See Dublin Journ. of Med. Science, vol. xv. p, 210.
INFLAMMATION OF THE CONJUNCTIVA. 461
purulent discharge becomes copious, and the skin of the eyelids assumes
a dark red colour. Light is now exceedingly painful ; the child turns its
head from it, and resists every attempt to open the eye. In this state,
the eyes may continue about a week, without any affection of their trans-
parent parts, except a slight haziness of the cornea. About the twelfth
day, however, suppuration generally takes place between the layers of
the cornea, its texture becomes destroyed, it ulcerates, the humours are
discharged, and the iris protrudes.
If the disease be seen before the cornea has suffered, the prognosis is
favourable. If the cornea has sloughed or ulcerated, the loss of sight is
inevitable.
In the third stage, there is a gradual abatement of all the symptoms ;
the redness, swelling, and discharge are diminished ; the light can be
endured ; and the eye is more easily examined.
Treatment. — One or two leeches may be put on the swollen upper
eyelid. The bleeding from the bites will often seriously reduce an infant,
and perhaps, in ordinary cases, ic is best to be content with a single leech.
The discharge is to be washed away with a tepid weak solution of alum,
or bichloride of mercury. The lids are to be gently opened, and the dis-
charge removed with a small bit of sponge. The upper lid has a tendency
to remain everted, but it may usually be replaced, if the swollen con-
junctiva be first pushed back with a probe into its right situation. For
checking the discharge, we may use a solution of the sulphate of copper,
or nitrate of silver ; four grains of the latter, or six grains of the former,
to an ounce of water, applying it once or twice a day, with a large camel-
hair brush, to the whole surface of the inflamed conjunctiva. Mr. Hugh
Carmichael prefers, however, weaker collyria, such as one grain of the
nitrate of silver, or two or three grains of alum, to the ounce of distilled
water. Neither must we forget to apply the ung. cetacei, to keep the
eyelids from sticking together in the night. If there be a tendency to
chemosis, one or two leeches are never to be omitted ; the bowels are to
be opened with castor oil ; and a blister put behind the ear. In tedious
cases, I usually give small doses of calomel. The vinum opii is one of
the best things for removing the relaxation of the conjunctiva, left after
the cessation of the discharge. Sometimes the disease has been success-
fully attacked with the nitrate of silver ointment, ten grains to one ounce
of lard. The granular state of the conjunctiva generally yields to astrin-
gents, or the nitrate of silver, or sulphate of copper.
From the connection existing between this inflammation of the eye and
the state of the bowels, Mr. Hugh Carmichael recommends giving the
hydrargyrum cum creta, in grain or half-grain doses, twice or thrice
a day. In obstinate cases, he also advises the nurse to be changed,
because her milk may be keeping up the bowel derangement. He objects
to pap composed of bread and milk, as likely to become sour. The bread
should be of the best quality, and first washed; and the milk be blended
with equal, or two parts of water, and sometimes a little calcined fhagnesia,
mixed with it. Four grains of calomel and four drops of tinct. opii,
divided into four or six papers, one of which is taken every night, he
commends, as often the source of much benefit.
Blisters are mostly disapproved of for infants of tender age; but if two
or three threads of worsted be greased with the blistering ointment, and
placed in close behind the ears, the practice is found by Mr. Hugh Car-
michael to be safe, and productive of great benefit. When the cornea
suppurates, Mr. H. Carmichael relies on leeches, potassio-tartrate of an-
4-62 DISEASES OF THE EYE.
timony in doses of one sixth or one eighth of a grain three times a day,
the application of blistering ointment in the way described, the alum wash,
or alum curd. If the cornea has sloughed, he joins Mr. Saunders in praise
of the extract of bark, given to the extent of sixteen or eighteen grains
a day, mixed with pap.
4. Gonorrhceal ophthalmia in its acute forms is a violent inflammation of
the mucous membrane of the eyeball and lids, attended with profuse
discharge of matter, closely resembling in all its sensible properties that
which issues from the inflamed urethra in clap, and occurring in some
kind of connection with the latter complaint.
It is the most severe and rapidly destructive inflammation to which the
eye is subject, but fortunately one of the most rare. It is not the con-
sequence of the sudden suppression of gonorrhoea ; for, in a great ma-
jority of examples, the gonorrhceal discharge is not stopped, though, when
the affection of the eye begins, the clap may be on the decline. As go-
norrhoea is so common, and this species of ophthalmy so rare, doubts have
often been raised about its connection with gonorrhoea at all. Indeed,
the mode of infection has not often been unequivocally traced; but that
the discharge from the urethra of one individual, applied to the eye of
another person, will bring on the disease, seems well proved by facts col-
lected by Mr. Lawrence ; and even that the matter of clap, applied to the
patient's own eye, will bring on this destructive ophthalmia, is exempli-
fied in the consequence of the vulgar custom of attempting to cure sore
eyes by washing them with the patient's own urine ; for, if he happen
to have gonorrhoea on him, the matter is then applied directly to the
eye, and a destructive purulent ophthalmia is the result, as related in
Mr. Lawrence's work " On the Venereal Diseases of the Eye/' The symp-
toms are those of purulent ophthalmy in the severest form, intense red-
ness, extensive swelling, chemosis, and profuse discharge of thick yellow
fluid, quickly followed by ulceration, sloughing, or opacity of cornea.
The treatment is not essentially different from that of other severe puru-
lent ophthalmies. The boldest antiphlogistic measures are called for; as
copious venesection, cupping on the temples, numerous leeches, &c.; fol-
lowed by blisters, and warm or cold collyria, according to the patient's
feelings. A strong solution of nitrate of silver, ten grains to an ounce, or
the strong ointment of the same, has sometimes had the effect of check-
ing the disease.
When the cornea sloughs, and the patient is reduced, we may prescribe
bark. In gonorrhceal ophthalmy, the structure of the palpebral con-
junctiva is not changed ; that is, it does not become granular ; one eye is
often affected ; and the disease may begin on the sclerotic conjunctiva.
These characters are all different from such as are usually noticed in or-
dinary purulent ophthalmy of adults.
SCROFULOUS INFLAMMATION OF THE CONJUNCTIVA.
The symptoms characterising it are slight redness, great intolerance of
light, and pimples or small pustules on the conjunctiva. It seldom at-
tacks infants at the breast, but children at some period between weaning
and the eighth year. At the commencement of the disease, the redness
of the conjunctiva is very slight, and in patches or clusters of vessels ;
but, afterwards, it increases, and becomes more uniform, and the sclero-
tica appears to participate in the inflammation. At the apex of each of
the clusters of blood-vessels, one or more minute pustules arise ; some-
times a single elevated point, of an opaque white colour, near the centre
SCROFULOUS INFLAMMATION OF THE CONJUNCTIVA. 463
of the cornea ; and sometimes numerous pustules, scattered over different
parts of the conjunctiva. In some cases, they are small, and filled with
a thin colourless fluid, when they are termed phlyctenulce ; in others, they
are larger, and contain fluid more like pus. It is not known whether
there is any specific difference between the phlyctenular and the pustular
cases ; but it has been observed by Dr. M'Kenzie, of Glasgow, that the
pustular cases are in general attended with less intolerance of light. The
phlyctenulae and pustules may be absorbed, and then, if situated on the
cornea, they leave behind a white opaque speck — the effect of that effu-
sion of lymph which surrounds every circumscribed abscess, but which
in time generally disappears. Sometimes, however, a vascular speck is
left, which is more difficult of removal.
Quite as frequently these pimples burst, and are converted into ulcers,
sometimes superficial and considerable in extent, more commonly deep
and funnel-shaped. If they happen to penetrate the cornea, the aqueous
humour is discharged, and a small piece of the iris protrudes, and unites
to the sides of the aperture, which is closed by an opaque indelible cica-
trix, partially or entirely obstructing vision ; but the cicatrix of a super-
ficial ulcer may leave no permanent opacity.
The excessive intolerance of light, attending scrofulous ophthalmy, is one
of the most distressing symptoms. The child is quite unable to open its
eyes in ordinary daylight ; and every attempt to look up instantaneously
brings on a strong spasmodic contraction of the eyelids. The pain from
the light is most severe in the morning ; for, in the afternoon, the intole-
rance of it is sometimes so far lessened that the eye can be opened.
Notwithstanding the violent suffering produced by light, there is fre-
quently an insignificant degree of redness, and the cornea often remains
perfectly transparent, or with merely one minute opaque speck upon it,
and a few red vessels running over the sclerotica. The intolerance of light
is always attended with epiphora, a gush of tears following every attempt
to open the eye. Hence, the eyelids and cheeks are sometimes excoriated
and swelled. Occasionally the disease is conjoined with iritis ; but more
frequently with ophthalmia tarsi, and other scrofulous complaints.
In the treatment, powerful antiphlogistic remedies are less necessary,
than in some other inflammations of the eye. In the first stage, which is
short, we may apply a few leeches, followed by a blister behind the ears,
or on the nape of the neck. The secretions of the skin and alimentary
canal are to be restored ; for which purpose we may prescribe the liq.
ammon. acetatis, combined with the vinum antimonii, and a small quan-
tity of the syrup of poppies. Or we may give rhubarb and carbonate of
soda, in equal parts, with or without a little of the hydr. c. creta. For
the ulcerations on the cornea, the solution of nitrate of silver is the best
application. The eye should be protected ftom the light with a green
shade, or by darkening the room. If the cornea be opaque, calomel, or
the blue pill, should be given, so as slightly to affect the systenn After
the first inflammatory stage is over, tonics are generally found beneficial,
especially the sulphate of quinine, with light nutritious diet.
The best applications to the eye itself are slightly astringent lotions,
used tepid ; as the decoction of poppy-heads, with a small quantity of
spirit of wine in it ; or a weak solution of the acetate of ammonia, or a
solution of one grain of the bichloride of mercury in eight ounces of
distilled water. In France, the collyria for scrofulous affections of the
eye frequently consist of a weak solution of iodine in distilled water, with
a small quantity of hydriodate of potash.
464 DISEASES OF THE EYE.
INFLAMMATION OF THE EXTERNAL PROPER TUNICS
Is characterised by a great deal of external redness, pain, and intolerance
of light, soon followed by increased lachrymal discharge and febrile dis-
turbance. The redness begins on the front of the globe, immediately
round the cornea, where it forms a red zone, to which numerous vessels
proceed from the back of the eyeball. In inflammation of the con-
junctiva, the redness begins at the circumference of the organ, its
anterior part being at first free from it, and the sclerotica retaining its
natural white appearance : the discharge is also of a mucous or puri-
form kind.
The redness is quite different in the two cases : in inflammation of the
sclerotic coat, the vessels seen through the conjunctiva exhibit a pink
colour, or a lively carmine appearance, which forms a striking contrast to
the bright scarlet tint of the vessels in conjunctival inflammation. The
vessels of the sclerotica always follow the motion of the eye, while those
of the conjunctiva are capable of being moved, independently of the eye-
ball. The distended vessels of the inflamed sclerotica run in straight
lines forwards to the edge of the cornea ; but those of the inflamed con-
junctiva have no such distribution, as they are reticulated. However,
the conjunctiva soon participates in the inflammation of the external
proper coats, and the cornea looks dull. The eye feels dry and stiff,
with a burning or aching pain, and feeling of tension, pressure, or as if
sand were lodged in the eye. As the disorder increases, the pain grows
more severe, and extends to the back of the head and nearest temple.
Intolerance of light is a strongly-marked symptom of inflammation of the
sclerotica, another feature in which it particularly differs from conjunctival
inflammation.
Although the eye may be at first dry and stiff, the lachrymal secretion
is soon restored, and even increased, so that whenever the eye is opened
there is a considerable effusion of tears. In unfavourable examples,
attended with chemosis, the cornea first turns greyish, then white and
cloudy, and lastly yellow, as if pus were deposited in its texture. The
yellow matter, however, is not fluid ; neither does it make its way to the
surface, like pus ; but the cornea ulcerates, and the deposited matter is
removed by ulceration. A similar deposit may take place in the anterior
chamber, producing what is termed hypopium. When the whole cornea
is thus affected, the ulceration may penetrate the anterior chamber at
several points, the aqueous humour escape, and the iris either protrude
or become adherent to the inflamed cornea.
The degree of danger will depend on the state of the cornea : when
this is only slightly affected, there is no danger ; when chemosis is present,
and the cornea is grey or white, or when a yellow deposit takes place in
its texture, followed by ulceration and escape of the aqueous humour,
sight will be impaired, and perhaps totally lost.
Before speaking of the treatment, I may as well describe
Inflammation of the entire eyeball, or ophthalmitis, for the practice in
each of these cases is founded on the same principles, Common inflam-
mation, seated both in the external and internal structures of the eye,
when fully developed, is characterised by considerable pain, increased
external redness, more or less swelling of the organ ; at first dryness of
the eye, but afterwards augmented secretion from the lachrymal gland ;
and redness and swelling of the upper eyelid. The pain is not confined
to the fore part of the eye, but is deep-seated, and extends to the eye-
INFLAMMATION OP THE EXTERNAL PROPER TUNICS. 465
brow, cheek, temple, and back 'of the head. At first, the redness is in-
considerable, and chiefly in the vessels of the sclerotic coat ; but the
conjunctiva very quickly participates in the inflammation, and the dis-
tention of its vessels produces the bright scarlet colour, which conceals
the fainter pink or carmine tint of the sclerotica. The conjunctiva then
begins to swell, and a deposit of coagulating lymph takes place, not only
in the texture of that membrane, but in the loose cellular tissue uniting
it to the sclerotica. This red circular projection of the conjunctiva round
the cornea, giving the latter membrane a sunk appearance, and even ma-
terially concealing it, receives the name of chemosis.
Light is very offensive, so that the pupil contracts to exclude it, and
the eyelids are spasmodically closed. In a more advanced stage, the
colour of the iris is altered, its brilliancy disappears, and its usual mo-
tions in the different degrees of light are interrupted ; the pupil diminish-
ing and losing its clear black colour. The cornea becomes more or less
opaque, and vision is lost, sometimes from this cause and the closure
of the pupil, sometimes from injury of the retina, as when the sight is
destroyed, though the cornea and pupil do not completely obstruct the
light, and frequently from all these circumstances together. Sometimes
the thickened eyelids protrude, an ectropium of the lower one taking
place, and a portion of the conjunctiva projecting in the form of a piece
of red flesh.
So violent an affection of a vascular and sensible organ, situated in the
immediate vicinity of the brain, necessarily produces a great deal of
sympathetic inflammatory fever. If the disorder be not checked, sup-
puration of the eye occurs, preceded by severe throbbing and rigors ;
then no relief is experienced till the cornea bursts, and the matter is dis-
charged, the vitreous humour and crystalline lens usually passing out at
the same time. The eye next shrinks into the orbit ; its form is com-
pletely destroyed, and its functions annihilated. When the disease does
not proceed quite so far, the patient escapes, perhaps, with opacity of
the cornea, a closure of the pupil, or injury of the retina.
With respect to the prognosis, if chemosis be formed, the cornea
cloudy, the colour of the iris changed, and the pupil contracted, the eye-
sight is in considerable danger.
The causes of inflammation of the proper coats of the eye may be
wounds ; the irritation of extraneous substances lodged under the eye-
lids ; exposure of the eye to a draught of cold air; immoderate exertion
of the organ, particularly in the examination of minute shining objects,
and in hard study by candle-light; and certain states of the atmo-
sphere. As predisposing circumstances, I may mention a full habit, or
plethora ; a disordered state of the digestive organs ; intemperance ; and
costiveness.
Treatment of Inflammation of the External Proper Coats of the Eye,
and of Ophthalmitis, or General Inflammation of the Eyeball. — 1 . The
first indication is to remove, if possible, the cause; as, for example, extra-
neous substances. The eye should be examined in a good light ; and, if
nothing be discovered on it, the lower eyelid should be depressed, and
the inferior portion of the globe brought into view by the patient looking
upwards. If no particle of extraneous substance can be detected in this
way, the patient should turn the eyeball downwards, and the upper eyelid
be raised, so that the upper portion of the globe may be seen. In most
cases, the extraneous body lodges in the concavity of the upper eyelid,
which must then be everted, The eyelashes are first to be taken hold of,
H H
466 DISEASES OF THE EYE.
and the eyelid drawn downwards ; a nd while steady pressure is mae
against its upper part, by placing a probe across it, its ciliary margin is
to be carried upwards and backwards.
When small particles of metal stick in the cornea, they should be re-
moved with the point of a cataract needle.
Next to the removal of the exciting cause, bleeding is the chief means
of subduing these forms of ophthalmic inflammation. Venesection is to
be practised, and from twenty to forty ounces should be drawn ; and,
after two or three hours, if the pain return, we should take away from
twelve to fifteen ounces more without delay. The blood may also be
taken from the temple or nape of the neck, by cupping, or from the tem-
poral arteries. The eye is to be guarded from the light with a green
shade, or the room darkened.
Neither must we omit the repeated application of leeches, which are
to be put on the temple, eyebrow, or just below the inner angle. We
should also prescribe purgatives, with saline antimonial medicines ; and,
after depletion, have recourse to calomel and blisters.
With respect to topical applications, if the case be attended with
violent headach, the decoction of poppy-heads may be used as a fomenta-
tion. In other instances, we may bathe the eye, in an eye-cup rilled with
tepid water, or with a warm collyrium, containing five grains of the sul-
phate of zinc, or acetate of lead, dissolved in four or six ounces of rose-
water. In proportion as the irritability of the eye lessens, the application
may be used colder.
When the acute stage has completely subsided, we may introduce
between the eye and eyelids, once or twice a day, two or three drops of
the vinous tincture of opium ; but, while much tenderness and aversion
to light continue, its use must be deferred, and depletion repeated.
When there is risk of effusion, or opacity, I always give calomel and
opium freely, and keep open a blister. Two grains of calomel, with half
a grain of opium, four times a day, may be administered, until the mouth
becomes sore.
For the cure of any remains of chronic inflammation, astringent ap-
plications, blisters, the occasional use of leeches, and the free exposure
of the eye to the open air and daylight, are generally the right measures.
RHEUMATIC OPHTHALMIA. SCLEROTITIS.
There are two remarkable forms of inflammation of the eye, most
frequently arising in adults from atmospheric influences, viz. — the ca-
tarrhal and the rheumatic. The catarrhal is an affection of the con-
junctiva; the rheumatic, of the albuginea and sclerotica, occasionally
extending to the iris. In the catarrhal, the red vessels give a reticular
appearance ; in the rheumatic they are radiated, or in the form of a
zone, and seated under the conjunctiva. Catarrhal ophthalmy is an in-
flammation of a mucous membrane, and attended with an increased secre-
tion from it ; rheumatic ophthalmy attacks the fibrous membranes of the
eye, and is not accompanied by any morbid secretion from its surface.
The pain in catarrhal ophthalmy is like that of sand under the eyelid,
does not extend to the head, and is felt chiefly in the morning, or when
the eyes begin to be moved. The pain in rheumatic ophthalmy is throbbing
and deep-seated, not in the eye chiefly, but round the orbit, and is se-
verely aggravated from sunset to sunrise, In catarrhal ophthalmy, there
is little intolerance of light ; in sclerotitis, a great deal.
Rheumatic inflammation is by no means a good name for the complaint,
CATARRHO-RHEUMATIC OPHTHALMIA. 467
as it is not connected with a rheumatic constitution ; it is a primary
affection, and not the result of any transfer of rheumatism from other
parts to the eye. Sclerotitis may be a better term. At all events, this
inflammation only resembles rheumatism in its exciting causes, its accom-
panying pain, its exacerbations, and its treatment.
In sclerotitis, the fasciculi of distended vessels advance in radii towards
the edge of the cornea, and sometimes even a little beyond it. They are
of a bright red colour, and the degree of inflammation in the conjunctiva
itself is never such as to conceal them. In general, there is no tendency
to chemosis, nor do the eyelids take part in the disease ; but there is a
haziness of the cornea and pupil, attended with a slightly contracted state
of the latter opening, and a sluggishness in the movements of the iris.
The iris may even become a little discoloured, and lymph be effused
from it; but a severe degree of iritis seldom attends rheumatic sclero-
titis. Suppuration and ulceration also rarely or never follow this affection
of the eye ; but there is a considerable degree of symptomatic fever, in-
creasing with the nocturnal paroxysms of pain. The digestive organs are
deranged, the bowels confined, and the excretions morbid.
Treatment. — Blood is to be taken from the arm, and leeches afterwards
applied to the forehead and temples. Calomel and opium are effectual
in lessening the severe pain in and around the orbit. Two grains of
calomel and one of opium may be given every evening till the gums are
affected, when the calomel may be omitted, and ten grains of the com-
pound powder of ipecacuanha administered in lieu of it. The forehead
and temple may be rubbed with a mixture of olive oil and extract of
opium, or with warm laudanum ; and, in chronic cases, with equal parts
of laudanum and tincture of cantharides. Blisters are likewise to be put
behind the ear, or on the temple, or nape of the neck. Great benefit
will be derived from mild purgatives and the warm foot-bath at night,
with sudorifics.
I believe that, in rheumatic sclerotitis, the iris should be kept mo-
derately under the influence of belladonna, either by smearing the moist-
ened extract upon the eyebrow and eyelids every evening at bedtime,
or by infusing 5 j. of the extract in each ounce of the laudanum used for
rubbing the forehead, eyelid, and temple.
In chronic cases, we may give small doses of sulphate of quinine ; and,
in old mismanaged ones, from three to ten drops of the liquor arsenicalis,
three times a day.
Local applications have little effect. The lunar caustic solution, which
is almost a specific for catarrhal ophthalmy, is decidedly injurious in
rheumatic sclerotitis; but, when all painful and febrile symptoms are
gone, and little more than chronic redness and weakness of the eye
remains, the vinum opii may be dropped once or twice a day into the
eye.
CATARRHO-RHEUMATIC OPHTHALMIA
Affects both the conjunctiva and the sclerotica. The feeling of rough-
ness, or sand, between the eyelids and eyeball, and the secretion of a
puriform fluid, indicate the participation of the conjunctiva in the dis-
order ; while the nocturnal accession of racking pain in and around the
orbit marks the affection of the sclerotica. In this case, chemosis is by
no means uncommon, and the eyelids generally adhere together in the
morning, from the thickened state of the Meibomian secretion. There
is also considerable intolerance of light, with epiphora.
H H 2
468 DISEASES OF THE EYE.
The cornea frequently ulcerates, or pus is effused between its layers,
constituting what is termed onyx. In bad cases, the ulceration makes its
way into the anterior chamber, the aqueous humour escapes, and the
iris protrudes. There is also commonly, just before this state of things,
an effusion of fibrine in the pupil ; the iris changes in colour, and the
pupil is often obliterated. The pulse is generally quick and sharp, the
tongue white, and the nocturnal pain prevents sleep.
Treatment. — 1st. Venesection — from ten to thirty ounces, and re-
peated.
2d. Leeches to the temple.
3d. Scarifications are sometimes advised for the chemosis, and if
practised, should be so in the way noticed in the remarks on purulent
ophthalmy.
4th. Calomel and opium every night.
5th. Opiate frictions about an hour before the expected attack of pain
in the orbit.
6th. Pupil to be kept dilated with belladonna.
7th. Blisters behind the ear.
8th. Purgatives ; a brisk dose of calomel and jalap at first, and after-
wards mild laxatives.
9th. Sudorifics ; liq. ammon. acet., warm diluent drinks, and the pedi-
luvium.
10th. In the chronic stage, the sulphate of quinine and mineral acids.
llth. Local applications: the solution of from two to four grains of
the nitrate of silver in an ounce of distilled water, dropped upon the
conjunctiva once a day, relieves the painful feeling of sand, and speedily
removes the other symptoms of conjunctivitis.
The eye is to be bathed three or four times a day with a tepid solution
of the bichloride of mercury, one grain to eight ounces of distilled water.
The edges of the eyelids are to be smeared with the ung. hydr. nitratis,
weakened. If onyx take place, it is not to be punctured, as such prac-
tice would be followed by protrusion of the iris and opacity.
SCROFULOUS CORNE1TIS
Is a slow disease, occupying weeks and months, and sometimes years.
The conjunctival covering of the cornea, and substance immediately
under it, are chiefly affected. The redness of the sclerotica is not con-
siderable; the vessels are minute, and arranged in a zone round the
cornea. Not unfrequently, there is a reddish ring at the circumference
of the cornea, with red vessels extending to the centre of this membrane.
In some cases the conjunctival covering is thickened, and reddened, so
as to look like a piece of red cloth, whence the term pannus. The cornea
is more .or less opaque and rough; sometimes only hazy, sometimes
marked with white streaks or specks, sometimes uniformly white. Occa-
sionally its convexity is increased ; the pupil is not unfrequently dilated,
with a tendency to amaurosis ; there is not much intolerance of light — a
striking contrast of this form of scrofulous inflammation of the eye to
what is noticed in the pustular variety. In a few cases, however, the
patient cannot endure the light, and there is epiphora. The pain is not
very severe, and the complaint soon becomes chronic, especially after the
cornea has become opaque. The pulse is especially quick, the patient
restless at night, and the skin harsh and dry. The disease is most com-
mon in subjects about puberty, and often accompanied by symptoms of
struma.
IRITIS. 469
Treatment. — Leeches are to be applied and repeated ; but not so as
o weaken the patient. We may also try small doses of tartarised anti-
mony, and then the sulphate of quinine, and Dover's powder at bedtime.
Calomel, combined with opium, so as to affect the mouth, after the acute
symptoms have ceased, has great effect in clearing the cornea. Colchi-
cum, sarsaparilla, and elm bark,, are useful as alteratives in scrofulous
corneitis, but not generally equal to sulphate of quinine.
The local applications are fomentations with poppy decoction, and the
steam of hot water,* with a little laudanum in it. Blisters are productive
of great benefit. The best stimulating applications, after all acute in-
flammation is over, are the vinum opii, a collyrium of the nitrate of silver,
or a weak solution of iodine in distilled water, according to Lugol's for-
mula. When there is any tendency to iritis, the pupil is to be kept
dilated with belladonna. When the cornea is very convex, denoting an
unusual accumulation of the aqueous humour, the discharge of this fluid
is sometimes recommended, but rarely adopted.
IRITIS.
When we recollect, that the iris receives its supply of blood by the
two long ciliary arteries, the external and internal, which are but little
connected with the arteries of the other textures of the eye, we may
readily conceive that inflammation of this organ is likely sometimes to
exist without much inflammation in other parts of the eye. The danger
of iritis chiefly depends upon its partaking of the nature of the adhesive
inflammation, by which the pupil is apt to become, under the least
neglect, completely and irremediably obliterated by the effusion of co-
agulating lymph. ^Iritis is, indeed, attended with a degree of inflammation
in the sclerotic coat, the front layer of the capsule of the crystalline lens,
and too often with inflammatory action in the choroid coat and retina ;
yet the iris is plainly the focus of diseased action, the affection com-
mencing on its pupillary margin, and other parts becoming subsequently
affected.
Iritis is divided into idiopathic and symptomatic, acute and chronic, and
into several specific varieties. Some common symptoms, however, cha-
racterise iritis, from whatever cause it may originate.
1. In the early stage we discern minute red vessels, running in radii in
the sclerotica to the edge of the cornea, where they form a red zone,
while the rest of the sclerotica retains nearly its natural paleness, its
vessels under [the conjunctiva only presenting a pale pink colour, which
increases, however, as the iritis makes progress. The vessels of the con-
junctiva in the anterior part of the eye soon enlarge ; and, in violent
cases, there is a uniform redness. Together with change of colour, the
iris loses its natural brilliancy ; it becomes of a dull appearance ; and the
beautiful fibrous arrangement, so characteristic of it in the healthy state,
is either confused or entirely lost. These changes begin in the f upillary
margin.
2. Then, another symptom, common to every iritis, is a change of
colour in the iris : if naturally blue, it turns greenish ; if dark-coloured,
it changes to a reddish brown. This is owing to the deposit of fibrine
in its texture, and to the effusion of the same plastic substance upon its
surface. Hence we frequently notice irregular tubercles, or masses,
formed either_at the edge of the pupil, or upon the iris itself.
3. Another symptom, noticed in every iritis, is a tendency to contrac-
tion, irregularity, and immobility of the pupil.
H H 3
4>70 DISEASES OF THE EYE.
4. We also frequently remark an effusion of fibrine into the pupil and
posterior chamber, and sometimes into the anterior. In rheumatic iritis,
however, fibrine is more sparingly effused than in venereal iritis.
5. Considerable intolerance of light, accompanied by increased lachry-
mal discharge, is another effect of iritis in general ; but much greater in
rheumatic than syphilitic iritis.
6. In every iritis, there is a disposition to the production of adhesions
between the pupillary margin of the iris and the capsule of the lens ;
and sometimes between the iris and cornea, or even between the poste-
rior part of the iris and the ciliary processes. Such adhesions are
usually of a dark colour, like that of the edge of the uvea.
7. Together with these common effects of iritis, the patient has dim-
ness of sight, and sometimes total blindness.
8. Pain in the eye, the orbit, and forehead, are likewise invariable
attendants on iritis, and often subject to nocturnal exacerbations.
Notwithstanding what has now been stated, iritis, if combined with
amaurosis, may be accompanied by a dilated pupil.
Exposure to atmospheric changes, very strong light, syphilitic disease,
scrofula, gout, rheumatism, wounds of the eye, may each be a cause of
iritis, which may be acute or chronic. When acute, the inflammation,
beginning on the pupillary margin of the iris, quickly extends over its
whole surface, and affects the external as well as internal tunics. In
chronic iritis, the inflammation sometimes begins at the ciliary margin of
the iris, whence it may be slowly propagated to other internal textures.
Chronic iritis, however, sometimes produces effusion of fibrine, and ad-
hesion of the edge of the iris to the capsule of the lens, without any
perceptible inflammation of other textures of the eye. Between this
slowly creeping chronic iritis, and the most acute form of it, we meet
with numerous other cases, in which every gradation of the inflammatory
process is exhibited.
The constitutional disturbance is different in different cases. Acute
iritis is generally attended with headach, restlessness, a full and strong
pulse, white tongue, thirst, loss of appetite, and costiveness. At the
same time, it must be confessed, that, in some cases, which would be
regarded as acute, such symptoms prevail only in a slight degree.
The prognosis is favourable, when the affection is recent and confined
to the iris, without too close a contraction of the pupil, or organisation of
the effused fibrine ; or extension of the inflammation to the retina, and
other textures behind the iris.
Syphilitic iritis is frequently, but not invariably, accompanied with effu-
sions of fibrine, in the form of tubercles of a reddish or yellowish brown
colour ; it is also characterised by a reddish brown discolouration of the
inner circle of the iris, the remarkable nocturnal exacerbations of pain*, the
previous occurrence of syphilis, and, in most instances, the concomitant
existence of other syphilitic symptoms. There is an angular disfigurement
of the pupil, which, according to Beer, is usually drawn towards the root of
the nose ; but, according to Mr. Guthrie, not more frequently in this direc-
tion than others. The form and situation of the pupil seem to Mr. Law-
rence to depend upon the effusions of fibrine. With regard to the opinion,
that mercury is the cause of iritis, Mr. Lawrence's observations are
strongly against its correctness; in nine cases, related in his "Treatise on
Venereal Diseases of the Eye," iritis came on where no mercury had been
* See Lawrence's Treatise on the Diseases of the Eye, p. 317.
IRITIS. 471
taken previously to its appearance. In some cases of syphilis, treated by
Rose and Thompson, without mercury, iritis also occurred.
In idiopathic iritis, there is either no distinct deposit upon the iris, or
it presents itself as a bright yellow elevation from the texture of the
part, increasing to a certain size, and then breaking, so as to allow the
escape of a yellow matter, which sinks to the bottom of the anterior
chamber. Such yellow little abscesses are not observed in syphilitic
iritis.
In arthritic iritis, or that connected with a gouty constitution, fibrine is
effused from the margin of the pupil, but not deposited in a distinct form,
and the adhesions are generally white. Both in the idiopathic and arthri-
tic iritis, the pupil is contracted; but generally retains its circular figure
and central position in the iris. In gouty and rheumatic iritis, a white
zone is distinguishable between the red one and the margin of the cornea ;
but frequently it is incomplete, being only noticed on each side of the
boundaries of the cornea.
In the treatment of iritis, there are three principal indications : —
1. That of putting a stop to the inflammation.
2. That of preventing the effusion of fibrine, and promoting its absorp-
tion, if it has been already poured out.
3. That of preventing the contraction of the pupil, and the formation
of adhesions between the margin of the iris and the capsule of the lens.
The first indication, or that of arresting the inflammation, is ac-
complished by antiphlogistic measures ; bleeding, saline aperients, and
tartarised antimony. If the inflammation is not checked, it will soon
.extend to the choroid coat and retina, and sight be endangered. We
should have recourse, therefore, to venesection, or cupping from the
temple, or nape of the neck. Sometimes bleeding and the exhibition of
sulphate of magnesia, and tartrate of antimony, with other antiphlogistic
means, will accomplish the cure of iritis, if duly followed up ; but more
frequently additional plans are requisite. Antiphlogistic treatment re-
lieves the congestion of the blood in the eye, lessens the redness, and
diminishes the fever ; but it does not always succeed in preventing the
effusion of fibrine, or in bringing about the absorption of what has been
poured out.
This makes it necessary to consider how the second indication, or that
of preventing the effusion of fibrine, and promoting its absorption when
deposited, is to be fulfilled. Experience proves that the grand remedy
for this purpose is mercury, employed quickly and freely, so as to affect
the system. It must be used immediately after bleeding and other means
of depletion have been practised. The effect of it is so to change this
action of the vessels of the iris, that they lose their disposition to effuse
plastic substance ; and that which has been already effused becomes
absorbed : the natural colour of the iris is restored, the cornea becomes
clear again, the red zone round it fades away, and the power of vision
returns. All this improvement is rapidly effected when the ^system is
expeditiously put under the influence of mercury ; and here it is advis-
able to let that influence be stronger, than what is usually deemed neces-
sary in other cases of ordinary disease. Two grains of calomel with one
third of a grain of opium, are to be given every four or six hours. In
cases of long standing, it is sometimes necessary to keep the patient under
the influence of mercury several weeks.
The third indication, or that of keeping the pupil dilated, requires the
application of belladonna. Other narcotics will produce the same effect,
H U 4?
DISEASES OP THE EYE.
particularly stramonium and hyoscyamus ; but belladonna is most effec-
tual. One scruple of the extract should be dissolved in 3 j. of distilled
water, and filtrated. This preparation is to be dropped, once or twice
a day, into the eye. But, if the inflammation be acute, it is better to
smear the upper eyelid, forehead, and eyebrow with the extract itself, a
little moistened. The other, however, is the most prompt method, if the
inflamed state of the eye will bear it, which is not always the case. This
use of belladonna is very important ; not only as tending to prevent the
closure of the pupil, but as keeping its edges away from the capsule of
the lens, and even making the iris so withdraw itself from the lens that, if
adhesions be already formed, and the fibrine soft, they will give way, and
the pupil still recover its natural size and mobility. This beneficial change
is materially promoted by the simultaneous use of mercury. While the
iris is highly inflamed, and the disease not checked, belladonna will not
dilate the pupil ; yet, if applied only to the skin, and not to the eye itself,
Mr. Lawrence is of opinion that it will do no harm, and perhaps may even
prevent further contraction of that opening. Other local applications are
of secondary importance ; poppy fomentations generally give most relief,
but cold applications may be used, if preferred. Blisters are not advis-
able until the disease becomes chronic ; or, not until bleeding has been
freely practised, and mercury exhibited.
When there is severe nocturnal pain about the orbit, the forehead
and temple should be rubbed with mercurial ointment combined with
opium, in the proportion of four grains of the latter to one scruple of the
former.
In arthritic, or gouty iritis, mercury is less necessary than in the idio-
pathic and syphilitic forms of the complaint. Colchicum and magnesia,
and, in the chronic stage, blisters, carbonate of iron, and quinine, are
means on which some practitioners place their chief dependence. We
should not imbibe the notion, that syphilitic iritis absolutely cannot be
cured without mercury. Sometimes it may be cured by antiphlogistic
treatment alone ; and Mr. Hugh Carmichael, of Dublin, has published a
series of well-marked examples of syphilitic iritis, which were cured by
giving 5j. doses of turpentine in the almond emulsion, three times a day.
Yet he only resorted to this practice when mercury was inadmissible, in
consequence of its injurious effect on the health.
CHOROIDITIS AND RETINITIS.
The internal inflammations of the eye may sometimes arise in one tex-
ture, and, at other times, in another ; in one case, the retina may be first
affected ; in another, the choroid coat ; and, in a third,, the iris. From
these individual textures, the inflammation may afterwards extend to
every part of the eye.
Retinitis is occasionally excited by long- continued immoderate ex-
ertion of the sight in the examination of minute microscopical objects,
under a strong, and, perhaps, a reflected light. Such cases, however,
are generally preceded by determination of blood to the head, or the eye.
The same consequence may follow the effect of vivid flashes of lightning,
or the sudden exposure of the eyes of persons to the light, who have long
been confined in dark dungeons. Chronic retinitis is often regarded as
weakness of sight, characterised by a morbid sensibility to light, and
slight obscurity of vision, followed, after a time, by a gradual contraction
of the pupil, immobility of the iris, and amaurosis.
GLAUCOMA. 473
The treatment of acute retinitis consists in keeping the eyes perfectly
at rest, with the benefit of darkness, abstinence, and active depletion,
followed by the quick introduction of mercury into the system, belladonna
being also applied, as in iritis. The treatment, indeed, is essentially the
same in both cases.
Having now finished the consideration of the principal inflammations of
the eye, I proceed to notice some other affections which are consequences
of an inflammatory process in that organ.
GLAUCOMA
Is so called from the greenish colour reflected from the pupil, the iris be-
coming of a dull leaden or dirty green colour, the pupil dilated, the eye
painful, its vessels distended, and vision generally destroyed. In the
early stage, the green reflection seems as if it came from the very bottom
of the eye ; but, as the disease advances, the apparent opacity, which is
always of a greenish colour, and often sea-green, looks as if it were situ-
ated in the centre of the vitreous humour, and at last appears to be im-
mediately behind the lens. The opacity and green reflection are not the
result of any change in the crystalline lens, but are more deeply seated.
The change cannot be seen when the eye is inspected laterally, but only
when we look directly towards the bottom of the eye.
Scarpa ascribes the glaucomatous state of the eye to inflammation and
thickening of the retina ; Beer to similar alterations of the vitreous
humour ; and other surgeons to morbid changes in both these textures.
Dr. M'Kenzie, in dissecting some glaucomatous eyes, found the choroid
coat, and especially the portion of it in contact with the retina, of a light
brown colour, without any appearance of pigmentum nigrum. The
vitreous humour was in a fluid state, perfectly colourless, or slightly
yellow, without any trace of hyaloid membrane. The lens was of a
yellow or amber colour, firm and transparent. In the retina, no trace of
the foramen centrale and limbus luteus was distinguishable. No other
change was noticed in the retina ; for it was not thickened, nor changed
in colour ; neither was the vitreous humour thickened, or opaque, but
perfectly fluid and transparent.
Glaucoma is always attended with a limited and sluggish motion of
the pupil and other amaurotic symptoms. Ultimately, indeed, the pupil
is greatly dilated, and the retina becomes insensible to light. The loss
of sight, however, is generally gradual ; and the want of pigmentum
nigrum has been suspected to be capable of affording some explanation of
the weakness of sight, which accompanies the early stages. This, how-
ever, may not seem satisfactory to every pathologist ; nor are we sure,
that a deficiency of pigmentum nigrum is an essential occurrence in every
glaucoma.
Inflammation, leading to a destruction of the hyaloid membrane, may
perhaps be set down as the proximate cause of glaucoma. The disease
is much more common in old than young subjects, and is occasionally
believed to come on chiefly in consequence of slow inflammation of the
interior textures of the eye in gouty constitutions. Surgeons must be
careful not to mistake glaucoma for cataract ; the mere colour of the eye
is sufficient to prove that, at all events, the case is not one of simple len-
ticular cataract, for opacity of the lens alone is never green. Also, when
the pupil is dilated with belladonna, the green appearance seems to be
further^ behind the pupil, and uniform, not streaked, nor spotted like a
cataract.
4/74 DISEASES OF THE EYE.
When glaucoma has commenced in one eye, we generally find it take
place also in the other, the disease being often seen in different stages
in the two eyes.
Complete glaucoma may be set down as absolutely incurable, though
it is possible that, in the early stage of the disorder, its progress may
be arrested, and even vision improved. I should say, however, that the
prognosis is always peculiarly unfavourable. Mild antiphlogistic treat-
ment, with calomel and opium, may be tried, or iodine given ; but the
prospect of benefit is very slight indeed.
Instead of mercury, Dr. M'Kenzie, of Glasgow, suggests the trial of
carbonate, or sesqui-oxide, of iron and sulphate of quinine, directly after
depletion, but I know of no fact in support of the practice. Dilatation
of the pupil with the aqueous solution of belladonna will sometimes
temporarily improve the sight.
ONYX, OR ABSCESS OF THE CORNEA,
Signifies a collection of matter between its lamella?., and so called from its
being of a semilunar shape, like the white mark at the root of one of the
finger-nails. It is generally situated at the lower edge of the cornea, and,
even when more extensive, may be readily distinguished from a collec-
tion of matter in the anterior chamber, called hypopium, by its form and
situation remaining unchanged, whatever may be the position of the
patient's head.
The treatment consists chiefly in the employment of remedies called
for by the kind of ophthalmy, of which the onyx is an effect. As a
general rule, it is the best practice not to open any collections of matter
in the texture of the cornea, as we thus rather increase, than lessen, the
risk of opacity of that membrane, and prolapsus of the iris. When, how-
ever, the onyx has a tendency to spread over the cornea without burst-
ing, it becomes necessary to make an opening with a cataract knife.
HYPOPIUM
Is a collection of matter in the chambers of the aqueous humour, espe-
cially the anterior. The matter is always first noticed at the bottom of
that chamber ; and it may increase gradually, till it not only covers the
pupil, but fills the chamber, and even the pupil. Sometimes it shifts its
position with every motion of the head ; and, in other examples, its thick
glutinous properties fix it in one place. If the case be neglected, the
prominence of the cornea increases, and, at last, after most agonising
pain, that membrane gives way : the suffering now ceases, and the iris
falls forwards, protrudes, and becomes adherent to the cornea.
In the treatment, the principal indication is to lessen the inflammation,
from which the hypopium has originated, whether of the cornea or the
iris ; for, if we succeed in doing this promptly, and then give mercury,
absorption will often proceed so quickly in the anterior chamber, that the
matter will soon be removed. The best general rule is to abstain from
making an opening ; for, in fact, the matter is a viscid kind of lymph,
which will not flow out if a puncture be made.
If the eyeball were to suppurate extensively, things would be different,
and then an opening for the discharge of the abscess would unquestionably
be required.
Ulcers of the cornea are frequently the consequence of the rupture of
an onyx or small abscess. In purulent ophthalmy, however, the ulcera-
OPACITIES AND SPECKS OP THE CORNEA. 475
tion generally begins externally, and penetrates more and more deeply,
until it reaches into the anterior chamber. Sometimes ulcers of the cor-
nea are produced by the irritation of extraneous substances on the eye,
as quicklime, or pieces of glass. The ulcer is of a pale ash colour ;
its edges high and irregular; its margin surrounded by a slight halo
of lymph, or a cloudy appearance of the cornea ; it gives acute pain, dis-
charges a thin lymph, and is disposed to spread. To the deposit of lymph
around the sore, a fasciculus of vessels proceeds from the sclerotic con-
junctiva.
When the ulceration extends superficially, the transparency of the
cornea may be destroyed ; and when it penetrates the anterior chamber,
the aqueous humour escapes, and a prolapsus of the iris takes place.
If the opening be large, even the vitreous humour and lens may be
discharged, and the eye destroyed. Then, if less mischief occur, the
cicatrix frequently produces indelible opacity of the cornea, and more or
less injury of vision.
Treatment. — Our first endeavour should be to stop the ulcerative pro-
cess by means calculated to lessen the inflammation, which is the cause
of it. Local bleeding is proper, so long as there is an appearance of
active inflammation, and much pain is felt in the eye. The bowels are
to be kept open, and opium administered. In strumous cases, we may
give the sulphate of quinine, and wash the eye with a collyrium contain-
ing iodine, according to the formula of Lugol. In the chronic superficial
ulcer, we may prescribe calomel. In almost all cases, counter-irritation
is useful. When the ulcer is kept from healing by the irritation of the
motion of the eyelids, and it protracts the inflamed state of the eye, lunar
caustic is the grand means of relief.
OPACITIES AND SPECKS OF THE CORNEA
Receive different names according to their degree and mode of forma-
tion. The slightest degree of opacity is termed nebula^ in which the
cornea presents a diffused cloudiness, a hazy or milky appearance, that has
no distinct boundary, but is gradually lost in the surrounding transparent
portion of that membrane. It is often accompanied by an enlarged and
reddened state of the vessels of the conjunctiva, some ramifications of
which extend into the delicate layer of this membrane, spread over the
cornea.
Opacities of a more circumscribed and complete kind are exemplified
in Albugo and Leucoma, which consist of a deep extravasation of dense
lymph in the substance of the cornea. They are of a clear white or
pearl colour, and only differ in one respect ; namely, that the albugo is
the consequence of some description of ophthalmy, or of an abscess, or
ulceration of the cornea, while the leucoma is the opaque speck or mark
occasioned by a wound of that texture. For some time after the comple-
tion of the healing process, the opacity continues to diminish ; but this
improvement can only take place in a certain degree, and an indelible
speck will yet remain, though considerably smaller than the original
wound which was the cause of it.
Numerous red vessels are sometimes observed running into an albugo
from the conjunctiva ; and, when this is the case, the opacity is apt to
spread, and is somewhat raised above the level of the cornea, the delicate
layer of the conjunctiva spread over this membrane being much thick-
ened. This variety of albugo is occasionally seen in scrofulous adults,
and sometimes in children.
4-76 DISEASES OF THE EYE.
The remedies, calculated to do good to specks of the cornea, in their
early stage, are those which have the effect of removing the inflammation
that has given rise to them. At the same time, there are both general
and local means peculiarly adapted for hastening the absorption of opaque
deposits in the cornea ; such are mercury and iodine. We have likewise
various applications for quickening the action of the absorbents in the
removal of specks, if employed at the proper time. If we commence
their use too soon, that is, before the cause of the opacity is removed,
we shall do more harm than good. For instance, if in an albugo, arising
from scrofulous corneitis, and still attended by considerable vascularity,
we were directly to attack the opacity of the cornea with stimulating
powders and strong solutions of nitrate of silver, oxymuriate of mercury,
or iodine, we should not only fail in accomplishing the object in view, but
create a great risk of rendering the patient totally blind. But, if we be-
gin with attacking the strumous inflammation, which still lingers in the
eye, and that chiefly with constitutional remedies, we shall not only dis-
perse the redness, but often find the cornea begin to get clearer from day
to day, and the eyesight to be proportionally improved.
The best local means for dispersing opacities of the cornea are, a solu-
tion of the nitrate of silver, from two to five grains, in an ounce of dis-
tilled water ; a solution of one or two grains of oxymuriate of mercury
in an ounce of distilled water ; the vinum opii ; the ung. hydr. nitratis ;
or a finely levigated powder, consisting of 5j. of red precipitate and one
ounce of white sugar. The latter is generally blown on the speck through
a quill. The useful effect of iodine colly ria must also not be forgotten.
The vascular forms of albugo sometimes require the trunks of the ves-
sels distributed to them to be divided, and mercury or iodine to be
exhibited.
STAPHYLOMA
Is a term applied to various protrusions or projections on the front of
the eye, in consequence of their fancied resemblance to a grape, staphyle
being the Greek word for that fruit. Thus, a protrusion of a portion of
the iris through an ulcer, or wound of the cornea, used to be called sta-
phyloma racemosum, but now more properly prolapsus of the iris. At the
present time, the term staphyloma is usually restricted to protuberances
of the cornea and sclerotica. Staphylomatous affections of the sclerotica,
however, are so rare, in comparison with those of the cornea, that it is
only the latter which need detain us. When the cornea becomes staphy-
lomatous, it looses its natural transparency, rises above its proper level,
and even projects between the eyelids, in the form of a whitish, pearl-
coloured, or bluish tumour, attended, when the whole cornea is affected,
with loss of sight. To this grievance are added, in bad cases, all the
evils which unavoidably result from the projection of the cornea :
inability of closing the eyelids ; exposure of the eyeball to the air and
extraneous matter suspended in it ; irritation and inflammation from this
cause and the friction of the eyelashes ; and soreness and excoriation of
the lower eyelid and cheek from the constant stillicidium lachrymarum.
Even the other eye is often sympathetically affected, becoming tender,
and sometimes truly inflamed.
Staphyloma of the cornea is either partial or total. Although the
most evident symptoms are opacity and projection of the cornea, a com-
mon effect of the disease is adhesion of the iris to the diseased cornea,
SYNECHIA. 477
and consequently a diminution or total obliteration of the anterior
chamber.
Where a partial staphyloma neither covers nor involves the pupil, the
patient may be able to see objects placed above him or on a level with
his eye ; but he is generally affected with epiphora and painful sensibility
of the organ. In more unfortunate cases, all the margin of the pupil is
adherent to the opaque and projecting portion of the cornea; and it is
only by the formation of a lateral artificial pupil, that any degree of vision
can be recovered.
Partial staphyloma is sometimes confounded with leucoma ; but it is to
be recollected, that in general the iris is firmly adherent to the whole ex-
tent of a partial staphyloma, but either quite unconnected with a leu-
coma, or connected to it by a mere point. In partial staphyloma, the
whole cornea inclines to a conical form, the apex of which is the centre
of the staphyloma ; whereas, in leucoma, the general spherical form of
the cornea remains unaltered.
If either from closure of the pupil, or from the partial staphyloma being
situated over it, no vision exists, we should try to lessen the staphyloma
itself, and then consider whether, by an operation for artificial pupil, the
eyesight can be restored.
Now, the safest plan of reducing a partial staphyloma is to apply to its
apex the muriate of antimony with a camel-hair pencil, while the eyelids
are kept widely separated. Then, before the eye is shut, the surface of
the staphyloma should be washed with a large camel-hair pencil dipped
in tepid water or milk. The caustic is not to be repeated till the slough
has come away, and the inflammation, caused by the former application,
subsided.
In one form of total staphyloma, the tumour is spherical; in the other,
it has the shape of a blunt cone.
As there is no possibility of restoring sight to a patient afflicted with
total staphyloma, even in cases where the lens, vitreous humour, and re-
tina are sound, the only thing we can usefully do is to lessen the protu-
berance of the cornea, which is not only a great disfigurement, but a cause
of the serious annoyances already specified. This is done by an oper-
ation, which consists, first, in the formation of a flap with the cataract
knife : and, secondly, in completing the circular excision of the most pro-
minent portion of the tumour with a pair of curved scissors. The lens
and vitreous humour escape ; the eye shrinks into the orbit ; and, though
the organ is destroyed, the patient is freed from a disease, which, besides
being attended with total loss of sight, was a source of great misery and
suffering.
SYNECHIA
Is a term employed to signify a morbid adhesion of the iris. When the
adhesion is to the cornea, the case is called synechia anterior ^ when to
the capsule of the crystalline lens, synechia posterior. The former is
often the consequence of a wound, or ulcer of the cornea, attended with
escape of the aqueous humour ; the latter is more frequently brought on
by iritis.
Partial and recent adhesions of the iris to the capsule of the lens may
sometimes be separated by the use of belladonna and mercury. In some
instances of partial synechia anterior, and even of complete synechia pos-
terior, which is mostly attended with closure of the pupil, vision may be
restored by the formation of an artificial pupil.
4/78 DISEASES OF THE EYE.
The adhesion of the iris to the cornea produces a change in the size,
position, and shape of the pupil; and when the result of inflammation, or
of a prolapsus of the iris, the cornea mostly becomes opaque.
PROLAPSUS OF THE IRIS,
Sometimes termed staphyloma racemosum, is a protusion of the iris
through a wound or ulcerated opening in the cornea. It is necessarily
of the same colour as the iris, brown or greyish, and its size varies from
that of a pin's head to that of a small pea. As the cornea is rarely per-
forated at more than one point, the prolapsus is usually single, and its
base is generally surrounded by an opaque circle of the cornea.
The inconveniences of a prolapsus of the iris are, pricking pain in the
eye, inflammation of the organ, intolerance of light, a deviation of the
pupil towards the seat of the prolapsus, and a lessening of its diameter.
In cases of long standing, the protruded portion of the iris becomes less
sensible, and the distress experienced less acute.
When the prolapsus is quite recent, and the consequence of a wound,
no doubt can exist about the propriety of reducing the iris into its right
situation again. In other examples this is impracticable, and then the
inconveniences of the projection of the iris are to be relieved by touching
the tumour repeatedly with the nitrate of silver, until it is sufficiently
levelled and the ulcer healed; while the obstruction of vision itself, caused
by the displacement and ulceration of the pupil, and the partial opacity
of the cornea, may sometimes be removed by the formation of an artifi-
cial pupil. When the protruded piece of the iris is large, it may be ne-
cessary to snip off a part of it with scissors, before the nitrate of silver is
applied.
i
CLOSURE OF THE PUPIL, AND FORMATION OF AN ARTIFICIAL PUPIL.
A permanent contraction, or a closure of the pupil, is most frequently a
consequence of inflammation of the iris; but sometimes it follows operations
for the removal of cataracts, coming on slowly and insidiously at some
indeterminate period afterwards, without any marked inflammation in the
eye. The iris becomes motionless, assumes a radiated wrinkled appearance,
and, when the lens is free from opacity, a small black point is seen in its
centre. Under these circumstances, if the retina be sound, the patient
may sometimes regain a considerable power of vision by the formation of
an artificial pupil. The pupil may also be obstructed by the effusion and
organisation of coagulating lymph from inflammation ; or there may be
such a displacement of the iris from prolapsus as causes an alteration in
the shape and position of the pupil, attended with serious obstruction of
vision.
The several varieties of operation for the formation of an artificial pupil
may all be referred to three principal methods ; the first is a simple cut
through the iris, without the removal of any portion of it, termed coretomia.
The second is an incision in the iris, and the removal of a part of it — corec-
tomia. The third consists in separating some of its external margin from
the corpus ciliare — coredialysis.
It is manifest that none of these operations can be performed with a
reasonable prospect of success, except when the changes in the condition
of the pupil are the only defect in the eye. Thus, unless the retina were
sensible, it would be doing no good to make a new opening in the iris.
The patient should always be capable of discerning the difference between
CLOSURE OP THE PUPIL. 4-79
light and darkness ; and, if he had not this power, the operation would
hold out little prospect of success. This state, however, does not amount
to an absolute prohibition of it, because sometimes the iris is so thickened,
the posterior chamber so full of dense lymph, and the transparency of the
lens so affected, that the power in question may be annihilated, yet the
retina itself not be incapable of resuming its functions. The experiment,
though unpromising, may be made.
An artificial pupil should never be formed in one eye, so long as the
patient is able to see with the other. Nor ought the operation to be at-
tempted if the eye be affected with inflammation, preternatural hardness,
dropsy, or atrophy.
When a part of the cornea is opaque, the place for the artificial pupil
must, of course, be determined by the situation of the transparent portion
of that membrane; and if the operator has the choice of placing it behind
either the nasal or the temporal edge of the cornea, the former situation
is to be preferred, as affording a more useful degree of vision.
Whenever the lens and capsule are transparent, one chief caution in
the operation is to leave those parts completely undisturbed.
As an artificial pupil possesses no power of contraction and dilatation,
care must be taken to make it neither too large nor too small. Too small
an opening would not be very serviceable : and if it were too ample, the
quantity of light admitted into the eye would dazzle vision, and the new
aperture be comparatively useless.
The limits of this work
prevent me from describing all the modifica-
tions of operations, rendered necessary by the infinite variety of circum-
stances attending a closure of the pupil. The state of the pupil itself;
its being filled or not by opaque fibrine ; the condition of the cornea ; the
state of the lens ; and the disease being complicated or not with prolapsus
and adhesion of the iris, are several principal considerations materially
influencing the particular mode of operating.
Coretomia, or the simple division of the iris, may be performed with an
iris-knife, or couching-needle, that has a sharp edge only on one side ; or
else with a minute pair of scissors, one blade of which has a sharp point,
the other an end, like that of a small probe. The iris-knife, which is but
little larger than a common couching-needle, is introduced through the
sclerotica, about a line and a half from the cornea ; and, after perforat-
ing the iris on the side towards the temple, its point is conveyed across
the anterior chamber nearly as far as the ciliary margin of the iris to-
wards the nose. Then the sharp edge is to be turned backwards, and
pressed against the iris as it is withdrawn, so as to make a transverse cut
in the iris.
Another plan of dividing of the iris is performed by making an incision
near the side of the cornea, and introducing small scissors, one of the
blades of which has a sharp point, the other a probe point. The sharp
point is then passed through the iris, near its ciliary margin ; while the
probe point is passed under the cornea, the requisite distance, when the
blades are to be shut, and the necessary division of the iris executed.
These methods of operating are proper when the iris has a tense ap-
pearance, when the cornea is transparent, and there is no crystalline lens,
or when the closure of the pupil has followed extraction of the cataract.
The excision of a portion of the iris, termed corectomia, is another me-
thod. It is performed in different ways. Thus, we may puncture the
cornea, draw out a piece of the iris by means of a minute hook, made for
the purpose, and snip it off. This was Professor Beer's way, which ap-
480 DISEASES OF THE EYE.
pears quite as good as that adopted by the late Mr. Gibson, who made an
incision in the cornea, so as to let out the aqueous humour, after which
he made a piece of the iris protrude by means of gentle pressure, and cut
it off. The iris then receded into the eye with the new circular opening
formed in it.
These last plans are proper when the centre of the cornea is densely
opaque, but the whole, or a portion of its circumference, transparent, and
the lens and its capsule sound.
The operation of separating a portion of the outer margin of the iris
from the corpus ciliare, coredialysis^ was first done by Scarpa, on the side
towards the nose ; but, as the opening did not continue to be permanent,
this plan was abandoned in favour of Reisinger's method, which is exe-
cuted by means of a very fine double-hook forceps, capable of being put
into the form of a single hook by slight pressure. A small puncture is
made in the cornea near its margin, the double-hook forceps introduced,
and conveyed, with the points turned downwards, as far as the place
where the iris is to be separated, but always as near as possible to the
ciliary edge. The points are then to be slightly opened, and made to
enter the iris. The blades are now to be shut, and the instrument slowly
drawn outwards, by which means a sufficient piece of the iris will be de-
tached, which, having been disengaged from the instrument, is to be left
strangulated in the wound of the cornea. In fact, this operation is a com-
bination of coredialysis with corectomia. In this country, coredialysis is
not much in favour, surgeons generally preferring either coretomia or
corectomia.
HYDROPHTHALMIA, OR DROPSY OF THE EYE,
Seems to be generally a local disease, or, at all events, is never connected
with, or dependent upon, ascites, anasarca, or other dropsical affections ;
and, if it depend upon constitutional causes, their nature has not yet been
made out. There may be dropsy of the chambers of the eye, that is, an
increase in the quantity of the aqueous humour ; or there may be a pre-
ternatural accumulation of the vitreous humour ; or, lastly, there may be
a collection of serous fluid between the sclerotic and choroid tunics.
The symptoms of dropsy of the anterior and posterior chambers are a
greater prominence of the cornea than natural, and an increase in its dia-
meter, attended in the advanced stages with loss of its transparency.
The iris is soon rendered motionless, and of a darker colour than usual.
At first, the eye is far-sighted, but afterwards the power of seeing be-
comes considerably impaired, or lost. When this variety of hydroph-
thalmia follows injuries of the eye, it may be combined with a tremulous
state of the iris, and partial amaurosis.
In the treatment, we may try blisters on the temple, or behind the
ear ; mercury, iodine, and purgatives. In inveterate cases, paracentesis
oculi has sometimes been practised. If this plan be adopted, the best
instrument is a grooved needle. I had a case in University College Hos-
pital, in which I punctured the eye seven or eight times at intervals with
such a needle, so as to discharge the fluid, and at^length to diminish the
size of the organ, and relieve the patient from the severe pain previously
experienced.
If the existence of subsclerotic dropsy could be made out, the discharge
of the fluid by puncture would be indicated.
Dropsy of the vitreous humour is attended with enlargement of the pos-
terior part of the eyeball, a conical projection of the cornea forwards,
AMAUROSIS, OR GUTTA SERENA. 481
advance of the iris towards the cornea, deep blue colour of the sclerotica,
and shortsightedness, followed by complete amaurosis, the eyeball becom-
ing hard and motionless.
As the eyesight is totally lost, all that the surgeon can do is to relieve
those inconveniences which arise from the distended state of the eye, and
its pressure. If puncture with the needle were insufficient, a piece of
the cornea might be cut off, and the humours discharged.
AMAUROSIS, OR GUTTA SERENA,
Is an obscurity or loss of vision, arising from a more or less insensible
state of the retina. Either the retina, the optic nerve, or the brain, may
be the part first and principally affected. The expression gutta serena is
only applied to cases of total blindness, plainly derived from the circum-
stance of the pupil having no opacity in it, and being apparently clear,
though the patient is blind.
The symptoms of amaurosis are of two kinds : first, those which the
surgeon notices in the form, colour, texture, consistence, vascularity, and
motions of the different parts of the organ, or in the general condition of
the patient ; secondly, those which the patient himself experiences, as
impaired or deranged vision, headach, vertigo, peculiar sensations in the
eye, &c.
The first symptom, and one that never fails to be present, is the pa-
tient's want of a proper control over the eye affected, the pupils of the
two eyes not being directed harmoniously to the objects looked at ; and
hence, there is a kind of staring and vacancy in the countenance. This
symptom may exist at first only in a very slight degree ; but, in some
cases, it amounts to an actual squinting, or strabismus ; while, in others,
such is the want of control over the eye, that it is either affected with
oscillation or stands quite motionless in the orbit. The motions of the
eyelids, as well as those of the eyes, are likewise not unfrequently inter-
rupted ; sometimes the levator of the upper eyelid being palsied, and
sometimes the orbicularis palpebrarum.
The eye may also form a greater prominence than the other, or be
otherwise changed in its shape. Its colour is seldom that exhibited in
the healthy state, the sclerotica being yellowish, bluish, or ash-coloured,
and often streaked with varicose vessels ; while no symptom of amaurosis
is more to be depended upon, than an increase or diminution in the na-
tural firmness of the eyeball.
Another usual symptom is a sluggish and limited motion of the iris,
generally attended with dilatation of the pupil, but occasionally with con-
traction. The early and incomplete stages of amaurosis are, indeed, rarely
accompanied by a widely dilated pupil ; but, after the perception of light
has become further weakened or extinct, the opening is commonly ex-
panded and quite motionless. Yet, cases sometimes present themselves,
in which the pupil of a completely amaurotic eye will move briskly, accord-
ing to the degree of light acting upon the opposite or sound eye? though,
if the amaurotic eye alone were exposed to its influence, the pupil of
it would remain perfectly motionless and greatly dilated. Hence, it is a
rule in surgery, always to close and cover the sound eye during the ex-
amination of the state of the iris and pupil of an eye suspected to be
amaurotic. Other examples still more curious occur, in which, though
the patient is totally blind, both pupils vary in diameter, according to the
changing degrees of light, exactly as they do in the perfect state of the
eyes.
i I
482 DISEASES OF THE EYE.
Besides the motions of the iris, which must be examined in each eye
separately, and with the opposite eye excluded from the light, the shape
and situation of the pupil should be noticed, and the inclination of the
iris considered ; for sometimes the pupil is irregularly dilated, and some-
times moved towards a particular point of the circumference of the iris,
while this membrane itself may either bulge out towards the cornea, or
sink back, so as to present a concave appearance.
When amaurosis is an effect of hydrocephalus in a young subject,
the pupil may exhibit its naturally black hue ; but in elderly subjects,
amaurosis is almost constantly accompanied either by some degree of
glaucoma, or a dull glassy, or horny appearance in the pupil.
As for the symptoms or effects, of which the patient alone is conscious,
there is, first, impaired vision, the progress and degree of which vary in
different cases ; for, in some instances, the patient becomes suddenly and
permanently blind, while, in others, the sight diminishes in a very slow
and gradual manner, without ever terminating in total blindness.
Hence, the distinctions of complete and incomplete amaurosis. Fre-
quently, in the commencement of the disease, the failure of sight is only
occasional, or for a short time, or periodical, assuming the form of night
blindness or day blindness, or coming on after any great exertion of the
eyes. A few lines of a printed book may perhaps be read, after which
the letters appear completely confused. The failure of sight may extend
to the whole field of vision, or only to a part of it. Thus more or less of
the page of a book may not be visible (visus interruptus), or only the half
of objects maybe seen (hemiopia). Sometimes objects can be seen only
when placed exactly in one particular direction (visus obliquus). To
some amaurotic patients all objects seem disfigured, crooked, enlarged,
diminished, or even inverted (visus defiguratus).
Then another common sign of amaurosis, which the patient perceives,
is what are termed ocular spectra, as sensations of flashes of light in the
eye (photopsia), or of insects or cobwebs flying about before the eye
(muscae volitantes) ; or of colours which are not before the eye. Double
vision is also another frequent effect of the disease in its early stage. As
the complaint advances, however, vision is obscured by one uniform cloud
or network.
In the early periods, the patient has sometimes an unwonted sensibility
to light, which even gives him pain ; while, in other more usual cases, he
always courts it from the very beginning. Pain in the eyes, head, and
face, is another important symptom in amaurosis, denoting the probability
of the existence of a slow inflammation of the retina, or of organic disease
within the cranium itself. In fact, several of the incurable forms of
amaurosis depend on causes, which act on the nervous structure of the
eye from within the skull. Such are collections of fluid in the ventricles
of the brain ; disease or tumours of this organ, situated near that part of
it where the optic nerve is connected with its base ; while other swellings
or diseases may affect the optic nerve in its course either within the
cranium, or in the orbit.
Loss of sensibility in the retina, and a complete annihilation of its func-
tions, may be the effect or accompaniment of other diseases of the eye ;
as, for instance, of the severe varieties of ophthalmy affecting the interior
texture of the eye, glaucoma, hydrophthalmy, melanosis, and fungus
haematodes. These examples, in which the retina suffers, in common
with other textures, are named according to the primary disease, or to
their most prominent symptoms ; and when we use the term amaurosis.
AMAUROSIS. 483
we commonly understand a case, in which the retina, or nervous apparatus
of sight, is the part of the eye first affected.
Immoderate exertion of the eye, more especially on small objects, and
in persons either of plethoric constitution, or intemperate habits, pro-
ducing a determination of blood to the head, may be set down as frequent
causes of a slow inflammation of the retina, ending in an alteration of its
texture, and in impairment or abolition of its functions. Hence printers,
watchmakers, engravers, tailors, and other classes of workmen, whose eyes
are employed on minute objects and needlework, are frequently afflicted
with amaurosis.
Amaurosis is sometimes divided into functional and organic, the first
implying the interruption of the functions of the retina, independently of
any organic disease. Whether such case really occurs has sometimes been
disputed; but if we admit that amaurosis may arise from sympathy of the
eyes with disease or irritation in distant parts, we must, I believe, admit
the doctrine of functional amaurosis. Thus amaurosis may arise from
gastric disorder, the presence of worms in the bowels, the irritation of
dentition, or that of a carious tooth. The disease may also be excited
by a wound of the scalp, caries of the skull, disease of the antrum, ab-
scesses about the face, the suppression of the menses, or the effect of
particular aliments in persons of peculiar idiosyncrasies.
With respect to the prognosis, the functional amaurosis must leave a
greater hope of cure than the organic. A suddenly formed amaurosis is
generally less unfavourable, than one that has developed itself slowly.
Complete inveterate amaurosis, attended with organic change of the
retina, or optic nerve, may be deemed incurable. The distorted appear-
ance of objects in the early stage is always a bad omen, because indicative
of disease in the brain.
Amaurosis may be combined with glaucoma, or with cataract. The cha-
racteristic differences between the latter and amaurosis will be explained
under the head of Cataract.
Treatment. — No doubt much of the difficulty of curing amaurosis arises
from our being frequently ignorant of its causes ; to their being in many
instances various, complicated, and incapable of removal ; or, if removable,
to the impossibility of obviating their effects on the retina.
When amaurosis is attended by signs of determination of blood to the
head, such as headach, vertigo, flushed countenance, and arterial throb-
bings of the temples ; when the pulse is full, and the subject young and
plethoric ; general and local blood-letting, purgatives, and low diet, are
indicated. If the case be altogether dependent upon vascular distension,
these means, conjoined with rest of the organ, will probably effect a cure.
If, along with vascular fulness, there be effusion, depletion will also be the
most likely means of relief, and the best preparation of the patient for
other remedies, more especially for the use of mercury.
When functional amaurosis depends upon disorder of the chj^opoietic
viscera, habitual costiveness, and an increased flow of blood to the head,
purgatives, assisted by bleeding, are found to answer better in this country
than nauseating doses of tartrate of antimony, so highly praised by Richter
and Scarpa. We may give the blue pill at night, and a mild saline ape-
rient mixture in the morning ; and, after having continued this treatment
for some time, tonics may be prescribed with advantage, as sulphuric acid,
bark, and steel medicines.
Many examples of amaurosis depend upon the effects of chronic
inflammation on the retina, or upon a slow and gradually-produced depo-
i i 2
DISEASES OF THE EYE.
sition of lymph in various situations affecting the immediate organ of
vision. Now, for the diminution and removal of such effects, we know
of no medicine that is at all equal to mercury. I fully agree with Mr.
Lawrence, that the right treatment of most cases of amaurosis turns upon
two points, viz. — the employment of ordinary antiphlogistic means, and
letting these be quickly conjoined with, or followed up by, the use of
mercury. Here it acts in the same way as it does in iritis ; and, in
order to give it a fair trial, the system must be kept under its influence
for a month or six weeks. The influence should also be such as is indi-
cated by a moderate degree of salivation. Perhaps, I may say, with re-
spect to nine out of every ten cases of amaurosis, that if they will not yield
to a combination of antiphlogistic and mercurial treatment, they will
yield to nothing that has yet been discovered.
We ought, indeed, to modify such treatment according to circum-
stances. Thus, if the patient were of weak frame, and apparently
affected with more gastric than cerebal disorder, we should employ,
perhaps, local bleeding, rather than venesection ; and moderate doses of
the blue pill, or compound calomel pill, with saline medicines, in prefer-
ence to the active exhibition of calomel, or the free use of mercurial
ointment.
In some cases, we may apply a blister, or seton, to the nape of the
neck or temple.
The plan of treating amaurotic eyes with electricity, or stimulating
applications, and tonics, is found to be generally unsuccessful. The idea
of amaurosis being essentially connected with debility is erroneous. The
only exception to this remark may be the amaurosis from suckling, and
from profuse loss of blood. However, galvanism has now and then been
applied to the frontal nerve with advantage. If a delicate female were to
lose, first, her health, and then become amaurotic from suckling a hearty
child, of course the best plan would be to wean it, and give her tonics
and a light nutritious diet, with a small quantity of wine daily. In some
instances, applying from half a grain to two grains of strychnia, to a blis-
tered part of the skin behind the ear, or over the frontal nerve, has been
productive of decided benefit.
HEMERALOPIA, OR NIGHT BLINDNESS,
Is an incomplete and periodical amaurosis, exemplifying, according to my
judgment, the reality of functional cases. The patient enjoys good vision
all the day ; but after twilight he becomes blind. No sooner, however,
does the sun arise, than the affection of the optic nerve and retina goes
off, and the patient then sees very well again. It is only in the tropics
that hemeralopia is likely to be met with : in this climate, examples of it
are rare, and, when they do occur, are generally relapses in persons who
have been previously affected in hot countries. The disorder is easily
cured by blistering the temples, and mild antiphlogistic treatment.
NYCTALOPIA,
Signifying blindness during the day and vision by night, is described by
writers, but is so rare, that few surgeons have ever seen an example of it.
Larrey records a case of it in an old man, one of the galley-slaves at
Brest, who had been shut up in a dark subterraneous dungeon for thirty-
three years. When released, he could only see in the shade of night, and
was completely blind during the day. Ramazzini also mentions an epi-
demic day blindness, which, in his time, attacked boys in Italy, about ten
CATARACT. 485
years of age. But, though we do not meet with nyctalopia in England
as an original disease, we know that great intolerance of daylight is one
of the common effects of scrofulous ophthalmy. The photophobia, or
aversion to light, exemplified in the albino, is familiarly known. Day-
blindness is also noticed as a symptom of mydriasis, or a simple preter-
natural dilatation of the pupil. Patients, who have] incipient cataracts,
see very little in the brightness of day, but much better in the evening,
when the light is diminished and the pupil expanded.
CATARACT
Is usually defined to be a weakness or interruption of sight, produced by
opacity either of the crystalline lens, its capsule, or the fluid of Mor-
gagni. Occasionally, however, the term is used in a more comprehensive
sense, implying every perceptible obstacle to vision, situated between the
vitreous humour and the uvea and pupil.
When the disease is seated in the lens, its capsule, or the fluid of
Morgagni, it is called a true cataract; but, when it consists of opaque
matter deposited in front of the lens, it is denominated a false cataract.
The terms, lenticular, capsular, and capsulo-lenticular cataracts, express
some of the distinctions referred to. The Morgagnian may be dismissed
from present consideration, its separate existence not being generally
credited.
Cataracts are also distinguished into idiopathic, or such as arise from
internal, but generally unknown causes, — and into accidental, which
originate from external violence, or active inflammation. In general, the
idiopathic, sooner or later, affect both eyes ; but an accidental cataract
is frequently restricted to one eye.
The symptoms of a cataract are of the following description : — 1st.
All objects, especially white ones, seem to the patient as if covered with
a mist, a circumstance that generally precedes any visible opacity behind
the pupil. 2d. The decline of vision bears an exact proportion to
the degree of opacity. 3d. The opacity is almost always first noticed in
the centre of the pupil, the examples, in which it first presents itself
at the circumference, being much less frequent. 4th. When the iris
is light-coloured, the more opaque the cataract is, the more plainly a
blackish ring is seen at the edge of the pupil ; and such a ring is
particularly conspicuous when the cataract is soft and large, as it then
propels the margin of the uvea forwards. 5th. As a cataract generally
begins at the central point behind the pupil, objects placed directly
in front of the eye are most difficultly seen, even in the early stage
of the disease ; but those, which are on one side, may yet be discerned,
particularly if the light be not strong, which would make the pupil too
diminutive to let the rays pass through the thinner transparent edge of
the lens. 6th. What I have just observed likewise explains why patients,
having an opacity in the centre of the lens, are sometimes completely
blind in a strong light, though they may enjoy a useful degree of vision
in the shade, or in moderately dark places. 7th. The eyesight of patients,
affected with incipient cataract, may be materially assisted with convex
glasses, because objects are magnified by them. 8th. To patients in this
state, the flame of a candle seems to be obscured in a white misty
halo, which always becomes broader the further the patient is from the
light. When the cataract is more advanced, the flame cannot be dis-
cerned, but merely the place of the light. 9th. The action of the iris is
not affected.
i i 3
486 DISEASES OF THE EYE.
In amaurosis, the horn-like or glaucomatous appearance is more deeply
seated in the eye than the opacity of a cataract, and is somewhat con-
cave. It is frequently of a greenish colour, while the opacity of cataract
is usually greyish, white, or amber-coloured. The decline of vision,
also, is not in a ratio to the opacity, and the patient may be entirely
blind, with little appearance of defect in the eye. The pupil is likewise
generally dilated and motionless, with its pupillary margin somewhat
irregular. The temporary increase or decrease of blindness, a circum-
stance so common in patients with incomplete amaurosis, depends upon
circumstances which depress or excite the system, and not, as in cases of
cataract, upon the degree of light, and the corresponding alterations in
the size of the pupil.
The misty halo, seen by amaurotic patients round the flame of a
candle, is not like a whitish cloud, as in cases of cataract, but exhibits all
the colours of the rainbow. To amaurotic patients spectacles are of no
service ; and objects situated on one side are not better seen by such
persons, than those which are directly in front of the eye. Neither is
there any temporary increase of the power of vision obtained by the use
of belladonna, as in cataract.
Whiteness .denotes either a dissolved lens or a capsular cataract ; a
grey colour, a lenticular cataract ; an amber colour or dark grey, a firm
lens ; and light grey, a soft one. If the whole extent of the pupil is
uniformly opaque, the cataract is probably one of the lens; if the opacity
is streaked or speckled, it is likely to be one of the capsule. If the
opaque streaks radiate from a centre, the posterior layer of the capsule
is probably affected. If the form of the opacity is convex, either the an-
terior capsule or the lens is the seat of it ; if concave, the posterior part
of the capsule. With the light concentrated on the pupil by means of a
double convex glass, all these particulars maybe ascertained. I believe,
that the size of a cataract is a better criterion of its consistence than its
colour is ; and, at all events, that the smaller the lens is, and the darker
its colour, the more solid its substance will generally be ; while the
larger and more protuberant it is against the iris, the greater is the pro-
bability of its being soft.
A cataract of the lens itself, as I have already explained, is termed a
lenticular cataract, which may vary much in its consistence. Thus, such
a cataract may be hard, as it is often found to be in elderly persons,
with an amber colour, the tint being deeper in proportion as the cata-
ract is firmer.
A lenticular cataract may be soft, that is to say, of a cheesy, gelati-
nous, or even milky consistence. Soft cataracts are more bulky than
hard ones, so that they project nearly into the pupil. Hence, sight is
more considerably interrupted than when the cataract is hard, and the
power of distinguishing colours frequently quite abolished. The capsu-
lar cataract has a smooth and glistening surface, with streaks upon it,
and it lies close to the edge of the pupil.
When the lens is present, a capsular cataract is rarely unaccompanied
by a lenticular one ; but an opaque lens may be removed or taken away
by absorption, and a capsular cataract may be left. In this case, as the
opacity is merely a thin layer of the capsule, the cataract makes no pro-
jection against the iris, and the anterior chamber is not lessened by the
advance of the iris towards the cornea.
In children, cataracts are never hard: but in adults, we meet with
both hard and soft ones.
CATARACT. 487
Cataracts may occur in any period of life, and are sometimes conge-
nital. They are most frequent in elderly persons, and mostly arise
without any manifest cause, or any thing wrong in the rest of the eye,
or the constitution at large. The capsulo-lenticular cataract is alleged to
form very commonly under circumstances denoting a determination of
blood to the head and the eye, accompanied by uneasy sensations in
those parts ; but generally we cannot refer the origin of a cataract to any
particular causes. There is an exception, with respect to cataracts fol-
lowing a wound ^of the lens, or its capsule. Experience proves that
the slightest prick of these parts will lead to their opacity, or rather,
I should say, that the capsule inflames, and becomes opaque, and the
lens itself is afterwards absorbed ; so that the result is, in fact, a capsular
cataract. ,
A cataract is termed simple when accompanied by no other disease of
the eye likely to impair its functions, or with no particular constitutional
disease ; complicated, when joined with other diseases of the eye, as
adhesion of the crystalline capsule to the iris, amaurosis, glaucoma, or a
gouty, rheumatic, or syphilitic state of the system. The circumstances
denoting glaucoma have already been explained. If, in addition to a
sluggish or immoveable iris, the patient is totally incapable of distin-
guishing the least glimpse of light, the cataract is combined with amau-
rosis.
When a cataract is free from every complication ; when it is not
attended with frequent headach, nor pains in the eye ; when the pupil re-
tains its regular circular shape ; when the iris possesses its natural power of
motion in the different degrees of light ; and when the patient can readily
discern the difference between light and darkness, and even perceive
bright colours, and the outlines of objects, in shady places where the
pupil naturally expands — the prognosis is favourable.
There are no medicines, nor applications, capable of dispersing an
opacity of the lens, or its capsule. The cases, injudiciously blended with
the subject of cataract, under the name of false cataracts, which are only
obstructions of the pupil with fibrine, effused in consequence of inflam-
mation, may indeed sometimes be benefited, or even cured, by the means
recommended for the cure of iritis ; but no real analogy exists between
such cases and opacity of the lens and its capsule. In all examples of
true cataract, it is only by an operation that sight can be restored.
Whether an operation should be performed when the cataract is single,
and the other eye in the enjoyment of good vision, is a question on which
some difference of opinion is entertained. Diversity in the refracting
powers of the eyes after the removal of the lens from one of them, and
the apprehension of confused vision, as the result, are the reasons usually
urged against the practice, which has, however, to a certain extent,
proved successful ; while the continuance of a cataract in one eye not
only gives a disposition to the origin of the same kind of opacity in the
other, but permanently impairs the sensibility of the retina itselHbr want
of exercise.
It is a general rule, and I believe an excellent one, never to operate
upon both eyes at the same time. In particular, when extraction is to
be done, this maxim universally prevails. It is also a maxim to let the
patient have the benefit of preparatory treatment before he undergoes the
operation. His diet should be lowered and his bowels emptied.
In cases of congenital cataract, ought the operation to be delayed till
the patient has attained the age of docility and reason ? Or ought it to
i i 4
488 DISEASES OF THE EYE.
be practised in early infancy ? Every consideration seems, I think, to
be in favour of an early performance of it. If it be postponed, the eyes,
having no distinct perception of external objects, acquire such an in-
veterate habit of rolling, that for a long time after the pupil has been
cleared by an operation no voluntary effort can control this irregular
motion. The retina, too, by a law common to all structures of an animal
body, for want of being exercised, becomes more or less deprived of
power. From the age of eighteen months to that of two years is deemed
an advantageous period for operating on congenital cataracts.
Persons blind from congenital and other cataracts of long duration, and
habituated to live with four senses, are generally confused and perplexed
on the restoration of vision. They have a difficulty in combining the
action of the eye with that of the other senses. Hence Dupuytren has
often found it necessary to deprive them, for a time, of the use of one or
two of the other senses, in order to enable them to use the organ of
vision. He has applied this principle to infants, by closing their ears, as
it was noticed that they suffered themselves to be guided by sound, and
by impressions received by the hands, which they thrust out before their
bodies like tentacula.
There are three kinds of operation for cataract. 1st. The method
formerly termed couching^ and which is simply the removal of the cata-
ract out of the axis of the vision, leaving it still in the eye. It is now
frequently called displacement; and has two varieties, depression and
reclination. 2d. Surgeons practice extraction of tlie cataract ; that is, they
take the opaque lens completely out of the eye. 3d. Another method
often adopted consists in the division of the cataract into fragments^
which, being exposed to the aqueous humour, become absorbed.
By depression and reclination, we change the situation of the cataract.
In depression, the lens is pushed directly below the level of the pupil.
In reclination, the lens is made to turn over into the middle, and towards
the bottom of the vitreous humour ; so that the surface of the lens, which
was previously directed forwards, is now placed upwards, and what was the
upper edge is turned backwards. Over the lens, displaced in this man-
ner, the vitreous humour will close much more completely than over the
simply depressed lens, so that its ascent behind the pupil again will be
less likely to happen. Nor will the retina be so liable to be pressed upon
by the cataract as after depression ; yet, reclination unavoidably does
more extensive injury to the hyaloid membrane of the vitreous humour.
Extraction is the complete removal of the cataract out of the eye
through an opening made in the cornea. The incision for this purpose
must form the segment of a regular circle, be smooth, and, at the same
time, of sufficient size to permit the easy passage of the cataract through
it. Both in this first period of the operation, and in the subsequent one
of opening the capsule, the iris should remain entirely free from injury.
One of the chief dangers of extraction is that of loss of the vitreous
humour, which, if due care be not taken, is apt to be suddenly forced out
of the eye along with the cataract.
Another risk is that of the iris being wounded. Sometimes the opera-
tion is followed by a prolapsus of this organ, and occasionally by a
closure of the pupil from the inflammation excited in the iris by injury
of its texture.
The division, or breaking of a cataract piecemeal, may be done with a
needle, either through the sclerotica or the cornea. It has the recom-
mendation of being the most easy, but sometimes needs repetition.
CATARACT. 489
Opaque portions of the capsule, however, frequently resist absorption,
and must, after all, either be extracted or displaced. The division of a
cataract, when performed by passing the needle through the cornea and
pupil, is termed keratonyxis.
No method of operating for the cure of cataract should be exclusively
preferred ; each having its advantages in particular cases.
Depression and declination through the Sclerotica. — Each of these
operations has three stages: —
In thejirst, the needle is introduced through the coats of the eye into
the vitreous humour.
; In the second, the instrument enters the posterior chamber, and is
applied to the cataract.
In the third, the displacement is effected.
It is only in the third stage that reclination differs from depression.
The patient is generally seated on a low stool, with his head sup-
ported on the breast of an assistant, who stands behind him ; and, if the
operation be about to be done on the left eye, he puts his right hand
under the patient's chin, while with the index and middle fingers of the
left hand, applied to the margin of the upper eyelid, he keeps it raised
against the superciliary ridge of ^the frontal bone, without making any
pressure upon the eyeball itself. In all operations on the eye, performed
with the needle, the pupil should be first dilated with belladonna, because
the more expanded this opening is, the better the surgeon can see what
he is doing. The pupil should also generally be kept dilated for some
time after the operation, in order to let the aqueous humour have free
access to the lens, and to prevent the pupillary margin of the iris from
contracting adhesions.
The operator sits in front of the patient, on a seat of such height that
the patient's head is opposite to his breast. If it be the left eye which is
to be operated upon, he takes the needle in his right hand, while, with
the left fore-finger, he depresses the lower eyelid, and at the same time
puts the end of the middle finger just below the caruncula lachrymalis,
so as to prevent the eye from rolling inwards.
First Stage. — With the little finger resting on the patient's cheek, the
surgeon introduces the needle one eighth of an inch behind the temporal
edge of the cornea, so as to avoid the ciliary processes, and one line below
the transverse diameter of the pupil, so as to avoid wounding the long
ciliary artery. For the purpose of avoiding the lens and ciliary processes
more surely, the needle should be directed towards the centre of the
vitreous homour, but only to the depth of one fifth of an inch, as it
would be wrong to injure the vitreous humour to an unnecessary extent.
Second Stage. — One flat surface of the needle is now to be turned
forwards, the other backwards, and its handle inclined towards the
temple, so as to bring its point between the ciliary processes and the
circumference of the lens. ^
The instrument is next to be carefully introduced between triese parts
into the posterior chamber, across which its point is to be conveyed, till
it arrives behind the nasal portion of the iris.
Third Stage. — When depression is the method chosen, the flat side
of the end of the needle is now to be placed upon the upper part of the
lens, the handle gradually elevated, and the point carried downwards,
and a little outwards and backwards, the proper direction in which the
lens should be depressed, but no further than is necessary to remove it
from the axis of vision. The needle should be kept for a minute or two
490 DISEASES OF THE EYE.
on the lens, and, before it is withdrawn, we should observe whether the
cataract rises again.
Some operators turn the point towards the pupil, and move it freely
in it, in order to be sure that the capsule, if left behind, will be so lace-
rated that it will give no further trouble.
When reclination is preferred, the surgeon alters the plan of proceeding
in the third stage ; and then, instead of placing the end of the needle on
the vertex of the cataract, he applies the instrument to its front surface,
a little above its centre, and makes pressure on it downwards and a little
outwards, by which manoeuvre it is made to fall backwards, as it were,
into the vitreous humour.
If displacement be attempted on a soft fluid cataract, no sooner is the
capsule opened with the needle, than its contents mix with the aqueous
humour. In a day or two, however, this fluid will become clear again;
but, unless we break the anterior portion of the capsule, before we with-
draw the needle, vision will still be interrupted by the capsular part of
the cataract.
After the operation, the eyes are to be shaded by means of a slight
compress, pinned to the nightcap. The room is to be kept moderately
dark, and a low diet and quietude strictly enjoined. After three or four
days, a green shade may be put on ; but the eyes are not to be used at
least for a fortnight.
Extraction of the cataract through an incision in the cornea is divided
into three stages: —
In they?rs£, the cornea is opened with a knife;
In the second, the anterior layer of the capsule is divided ;
In the third) the cataract is taken out of the eye, or extracted.
The eye is to be fixed, as already explained ; unless the surgeon choose
to place the patient in the recumbent position, with the intention of
dividing the upper segment of the cornea, while he fixes the upper eyelid
himself; a plan which has its advantages, and the merit of first practising
which belongs, I believe, to Mr. Alexander.
First Stage. — 1. The point of the knife is to enter the cornea very
near the sclerotica, and a little above the horizontal diameter of the
cornea.
2. It is first to be directed rather towards the iris, until it reaches the
aqueous humour, so that there may be no risk of its gliding between the
layers of the cornea, and not entering the anterior chamber at all.
3. As soon as the point is in the anterior chamber, the handle is to be
inclined backward, and the point directed towards the place at which it
is intended to make it pierce the cornea on the side towards the nose.
This place should be rather above than below the horizontal middle
diameter of the pupil, and very near the edge of the cornea.
4. Having performed the punctuation and counter -punctuation of the
cornea, as they are termed, the eye is completely under our control. At
this particular period all pressure is to be removed, and therefore the
finger, placed on the caruncula lachrymalis, shifted to the lower eyelid.
Just before the section is finished, the upper eyelid is to be allowed to
fall, the room rather darkened, and nothing more done till the patient
has had a short time given him to become composed again.
Second Stage. — For opening and lacerating the anterior layer of the
crystalline capsule, a lance-shaped, sharp, double-edged needle, is the
best instrument. The assistant is cautiously to raise the upper eyelid,
without touching the eye in the least. The operator draws down the
CATARACT. 491
lower eyelid, and presses it very gently against the eyeball, so as to make
the cataract advance a little, and the pupil expand, but not so forcibly as
to burst the hyaloid membrane. The needle is then to be introduced
under the flap of the cornea, and through the pupil to the anterior layer
of the capsule, which is to be freely cut and torn in various directions ;
then the needle is to be withdrawn, and the eye again closed.
Third Stage. — If the pressure made on the lower part of the eyeball in
the second stage were continued, the lens would come out of the eye on
withdrawing the needle ; and many surgeons allow this to happen. Others
let the pressure cease for a minute or two, and close the eye again after
having divided the capsule. They then take the curette in the hand
which held the needle ; and having opened the eye, and renewed the
pressure, they see the whole lens pass into the anterior chamber, and
then through the incision in the cornea. The curette is only used, if
necessary, to facilitate its passage through the wound.
The patient is now to close his eye again, and the operator, having re-
ceived the lens on his finger nail, examines whether it is entire.
After having once more opened the eyelid, and ascertained that the
sides of the incision in the cornea are accurately in contact, and the pupil
clear and circular, the eyes are to be shut, and a light fold of linen is to
hang down from the cap, to which it is to be pinned.
The patient should afterwards be kept perfectly quiet, in a room
somewhat darkened, with a nurse to watch him, so that he may not rub
the eye with his hand during sleep. The incision may be looked at on
the third day, and on the fourth the patient may be allowed to sit up.
On the fifth a shade may be put on ; but the eye should not be used for
at least ten days, and then only on large objects. The bowels are not
to be disturbed for a day or two after the operation, but the patient
should be restricted to low diet for eight or ten days. If pain and
inflammation follow the operation, we are to bleed the patient freely, and
give calomel. Many surgeons always bleed the patient before and after
the operation.
The kind of operation to be preferred must depend upon the species
of cataract, and the sort of eye which is to be dealt with. I put out of
present consideration the difference of skill in different operators. No
doubt, extraction is the right method, when the cataract is hard, and
the practice not contra-indicated by the cornea being remarkably flat,
the iris too convex, the eyeball small, and sunk in the orbit, or the space
between the eyelids very narrow. When there are adhesions between
the cornea and iris, or between the iris and the crystalline capsule, ex-
traction should not be attempted. A very small pupil, not admitting of
being much dilated even with belladonna, would be another reason
against extraction.
The operation of division is most applicable to caseous or fluid cata-
racts, and especially to such as occur in children. If the cataract were
hard, but not proper for extraction, owing to the general form or state of
the eye, depression should be practised.
The loss of the crystalline lens necessarily produces a considerable
diminution in the refracting power of the eye, and in its faculty of
adapting itself to the different distances of objects. These defects are
palliated by the use of convex glasses of different foci. Their use, how-
ever, must not commence too soon after the operation, and never while
vision continues to be improving without them.
492 DISEASES OF THE EAR.
MALIGNANT DISEASES OF THE EYE
Are three ; namely, Cancer, Melanosis, and Fungus Hcematodes or Medul-
lary Cancer.
Cancer frequently begins in the conjunctiva, whence it afterwards ex-
tends to the eyelids, caruncula lachrymalis, and the eye itself. The
lachrymal gland, I believe, is not so often implicated as was once sup-
posed ; though it is prudent to remove it with the rest of the contents of
the orbit, when the eye is extirpated on account of cancer.
As cancer commences on the external parts of the eye, and, therefore,
in its early stage, may admit of effectual removal, it is a less formidable
disease than fungus hcematodes, which first attacks the optic nerve and
retina, the pupil becoming dilated, of a dark amber or greenish hue, the
iris motionless, and the sight seriously impaired or destroyed from the
very first. Jn an early stage of the disease, a white shining substance,
compared to burnished iron, may be seen through the pupil, at the back
part of the eye. As the disease advances, this substance is found gradu-
ally to extend more and more forwards, and to be of a solid nature. It
is, indeed, a medullary mass, occupying the whole of the interior of the
eye behind the iris, and presenting an amber or brown appearance. Next,
the form of the eyeball begins to deviate from what is natural ; the
sclerotica becomes of a dark blue or livid colour ; and the medullary mass
gets into the anterior chamber. Lastly, the cornea or the sclerotica
ulcerates ; so that, in the former event, the medullary substance pro-
trudes; and, in the latter, it forms a tumour covered by the conjunctiva.
It is generally rapid in its growth, often attains a considerable size, is of a
dark red or purple colour, and is frequently attended with haemorrhage
and sloughing of its most prominent part. The absorbent glands about
the parotid and under the jaw are also frequently involved. The disease,
which begins in the optic nerve and retina, and corresponds in its un-
governable and fatal nature to fungus haematodes, or medullary cancer in
other situations, is very much restricted to children.
With few exceptions, the operation of extirpating the eye for this dis-
ease has been of no avail.
With respect to melanosis, or the deposition into the eye of a peculiar
black substance, attended with total disorganisation of it, if it be confined
to the eyeball, and the optic nerve is not implicated, the eye may, per-
haps, be removed with some little more prospect of success, than for
medullary cancer. The prognosis, however, would be bad.
DISEASES OF THE EAR.
What is called earache frequently proceeds from inflammation of the
meatus auditorius, or the tympanum itself. The pain is often remarkably
severe ; a circumstance observed to attend inflammation of all textures,
whose nature and situation prevent them from readily yielding to the
swelling, which is commonly the result of that affection. Inflammation
within the ear may proceed to suppuration, the abscess make its way out
through the meatus auditorius externus, the Eustachian tube, or the
membrana tympani, or even behind the ear, with or without having per-
vaded the cells of the mastoid process, and occasioned caries of the bone.
According to my experience, the worst suppurations of the ear occur in
DISEASES OF THE EAR. 493
scrofulous children, in whom they are frequently accompanied by partial
destruction of the membrana tympani, and disease of the bony parts of
the organ, followed in some instances by necrosis and separation of the
ossicula. But inflammation and suppuration, within the ear, may not
only cause these consequences, and more or less complete deafness, but
extend their effects to the dura mater, and destroy the patient. When
exfoliations occur, they most commonly consist of the meatus externus,
or of the outer laminae of the mastoid process.
Acute inflammation of the ear demands rigorous antiphlogistic treat-
ment. In adults, copious venesection should be resorted to ; and, in
children, leeches. With these means, fomentations and purgatives are
proper, which should be followed up by blisters.
If, after the reduction of the inflammation, the discharge of matter
should continue, and the patient appear to be scrofulous, alterative me-
dicines, as iodine internally and iodine lotions, or an injection of a weak
solution of the nitrate of silver, may be employed. When diseased bone
is present, of course the discharge will not cease till exfoliation is
completed.
The meatus auditorius is frequently blocked up, and the external side of
the membrana tympani covered with hard dry masses of cerumen, so as to
render the patient entirely deaf. Such hardened pellets of wax, if ne-
glected, may ultimately cause a great deal of irritation, followed by in-
flammation and ulceration of the membrana tympani and lining of the
passage, and they always give rise to a sensation of false confused sounds
in the ear, which are truly distressing.
The cure consists in washing out the meatus auditorius by means of a
syringe, capable of holding at least four or six ounces of warm water.
This should be thrown into the passage, so as to make it regurgitate with
considerable rapidity. We generally have to do this several times, before
the pellets are loose enough to be washed out.
The meatus auditorius is occasionally the seat of polypi and oilier ex-
crescences. When situated near the orifice, they may be taken hold of
with a hook, and cut away ; but, in other cases, it is best to extract them
with forceps, and apply the nitrate of silver, or tinctura ferri muriatis, to
the part to which they were attached.
Extraneous Substances in the Meatus Auditorius Externus. — When
insects get into the ear, if they can be seen, the best plan is to take them
out at once with a pair of forceps. If not, we employ a piece of lint,
dipped in honey or oil, and put on the end of a probe ; these, on account
of their adhesiveness, will entangle any small insect, and bring it out.
Then the passage is to be washed out with a syringe. Syringing the ear
I deem the best method of all, not only for insects, but for the removal
of peas, small pebbles, &c. The regurgitation quickly brings them out,
when all other means fail. One day, when I was visiting the Fleet
Prison Infirmary, a child was brought to me with a pebble in each of its
ears, that had been there a twelvemonth, and had now excitetl violent
pain and inflammation, attended with total deafness. Various surgeons
had failed in their attempts to get these foreign bodies out. I immedi-
ately tried what could be done with a large syringe, and had the satisfac-
tion of soon bringing the pebbles so near the external orifice, that they
admitted of being hooked out with a bent probe. In some instances, it
has been judged necessary to divide the soft parts of the meatus; but a
real necessity for this proceeding must rarely occur.
Almond or sweet oil, dropped into the ear, soon destroys any insect
lodged in it.
494- DISEASES ABOUT THE FACE.
Deafness from, more internal causes than those which I have specified,
forms too long and complicated a subject for consideration in a work like
the present. It may arise from obstruction of the Eustachian tube by
mucus, as happens in severe catarrh ; by the pressure of a tumour, as is
sometimes exemplified in cases of polypi, or swelled tonsils, or in the
effects of syphilitic ulceration, or sloughing sore throats.
For the removal of deafness, caused by permanent obstruction of the
Eustachian tube, Sir Astley Cooper suggested the practice of making a
small puncture in the anterior and inferior part of the membrana tym-
pani ; a method that has been attended with a degree of success, but
which should not be undertaken without mature consideration, and a
proper discrimination of the cases, to which alone it is applicable.
Diseases of the labyrinth, or of the complicated apparatus composing
the internal ear, are the cases which, generally speaking, completely
baffle the art and science of surgery. We scarcely ever have any clue to
their cause, or even to the precise parts affected, so that no surprise
ought to be entertained at the little success with which such kinds of
deafness are treated.
~ Amongst the varieties of disease to which the labyrinth is liable, I may
mention, —
1. Disease of the fenestra ovalis and fenestra rotunda, as ulceration
and thickening.
2. Malformation of these apertures.
3. Inflammation of the nervous membrane lining the labyrinth.
4. Malformation of the labyrinth, especially of the semicircular canals.
In two cases, examined by Mr. Cocks, the extremities of the semicircular
canals, opening into the vestibule, were perfect, but the central portions
were impervious, or rather did not exist at all. See Med. Chir. Trans,
vol. xix.
5. Alteration or deficiency of the liquor of Cotunni.
6. Affections of the nerve of hearing, analogous to amaurotic diseases
of the eye.
When one eye is diseased, the other is disposed to fall into the same
condition ; but a similar fact does not prevail with respect to the ears.
Numerous persons are more or less deaf on one side, but the other ear
usually continues its functions very well, and even as long as if the other
ear had no defect.
Every kind of deafness from malformation of the labyrinth is incurable.
Nervous deafness ought perhaps to be treated on principles analogous
to those adopted for the cure of amaurosis. Inveterate cases of long
standing must, of course, be hopeless.
DISEASES ABOUT THE FACE.
LUPUS, OR NOLI ME TANGERE,
Begins with a tubercular induration in the tissue of the true skin, or mu-
cous membrane, or, perhaps, in the subcutaneous, or submucous cellular
tissue. A single tubercle may be formed, or several appear together.
While the tubercular induration is making slow progress to the surface,
the skin assumes a livid colour, which extends itself in proportion as the
tubercular affection spreads, and is almost always followed by ulceration.
After a time, the cuticle cracks, and a coarse laminated scab is produced,
LUPUS, OR NOLI ME TANGERE. 495
from beneath which ichorous matter exudes. The scab, which is very
closely adherent to the tubercle, continues to enlarge, occasionally falling
off, and exposing a very foul inveterate ulceration, which is found to be
larger at each successive detachment of the crust, the limits of which it
even sometimes exceeds. Dr. Houghton, who has drawn up an excellent
description of lupus, chiefly founded on the observations of M. Biett*,
notices three varieties : 1. Lupus, in which the ulcerative process de-
stroys principally in depth. 2. That in which the destruction and cica-
trisation do not produce any open ulceration, but are accompanied by
hypertrophy of the skin. 3. Lupus, which spreads chiefly superficially.
The first, or the deep erosive lupus, is more particularly that of the nose.
In many cases, the ulceration is accompanied by a constant discharge of
thin fetid matter from the nostril of the side affected. The disease some-
times, indeed, commences in the mucous membrane, though more com-
monly upon one of the alae, or the tip of the nose. It may even cause a
great deal of internal mischief, without the skin itself being implicated ;
but, as it extends itself from within outwards, at length it approaches the
skin, which then assumes a livid colour. But, whether it be in the cuta-
neous or mucous tissue that the disease begins, its progress after a short
time is the same. The subjacent cellular tissue and the muscles are de-
stroyed by ulceration ; the cartilages, in their turn, share the same fate ;
and frequently also the bones. The destruction is generally complete in
one of the alae, or the point of the nose, before it spreads further on its
surface ; but, sooner or later, the disease extends so as to embrace both
sides ; and wherever it advances, it is by the same kind of tubercular de-
posit with which it began. Sometimes, after having destroyed the tip of
the nose, or one of the alae, it forms a puckered cicatrix, and seems to be
nearly healed up ; but it rarely stops in this manner, and more generally,
after a time, new tubercles are developed in the midst of the cicatrix
itself, which ulcerate and destroy with all their original virulence. In
general, while the mischief is spreading externally, the internal parts are
not spared, the inner surface of the alae, and especially the septum narium,
being attacked. In such cases, the discharge is constant, and the crusts
which collect on the septum and turbinated bones nearly block up the
nostrils. In the end, if the disease be not checked, all the soft parts of
the nose are destroyed, and the septum broken up, leaving only a square
aperture in place of the nose, partially divided by a partition. Nor is this
all the possible mischief; for it is not uncommon for the ossa nasi to
suffer, and, in some instances, the superior maxillary bones.
All the varieties of lupus are rare after the age of forty. The disease
is more common between the ages of six and sixteen than at earlier or
later periods. The female sex is more subject to it than the male. The
superficial lupus is frequently considered as a scrofulous disease.
In the treatment, general as well as local means are, for the most part,
proper. If the patient be manifestly scrofulous, and the lupus superficial,
the medicines and regimen in repute for this state of the systenf should
be employed. In such cases, the use of iodine lotions, made in the man-
ner directed by Lugol, were found by Dr. Houghton to produce striking
amendment. The proto-ioduret of iodine, in the dose of one quarter of
a grain twice a day, is one of the best preparations for internal use.
* Abrege" Pratique des Maladies de la Peau, d'apres les Auteurs les plus estime's, et
surtout d'apres les Documens pris dans la Clinique, de M. le Dr. Biett, par MM. Caze-
nave et Schedel.
496 DISEASES ABOUT THE FACE.,
Iodine, however, is only useful in the superficial variety of lupus. The
chloride of barytes, which was believed by Bateman to have influence in
dispersing the tubercular formation, is not at present so frequently pre-
scribed as the chloride of lime, which agrees better with the stomach.
The tinctura ferri sesqui-chloridi, and the sesqui-oxide of iron were
formerly praised as useful medicines in cases ot lupus ; but I am not
aware of their possessing any specific power over this disease.
Arsenic has considerable influence in checking the progress of the
tubercles, and altering the character of the ulcerated surface. Small
doses of the liq. arsenicalis may be prescribed, beginning with not more
than two or three drops thrice a day ; but gradually increasing the dose
to ten, if no deleterious effects are produced.
Another medicine in repute is the bichloride of mercury, prescribed in
minute doses, so as gently to affect the gums.
External applications constitute the most important means of cure.
Sometimes the progress of the lupoid tubercle may be arrested, and ulcer-
ation prevented by the application of leeches to the inflamed skin round
its base, followed by evaporating lotions, and alterative doses of calomel.
Thus the disease may often be reduced to a chronic state, in which fric-
tion with ointment of the ioduret of zinc, or mercury, may be employed to
promote its absorption. Biett uses the ioduret of sulphur, made into an
ointment, in the proportion of fifteen grains to an ounce of simple ointment.
In the hypertrophic lupus, these resolvent ointments are particularly indi-
cated. When the tubercles are once ulcerated, the ung.hydrarg. nitratis,or
the liquor arsenicalis, is often used ; but generally escharotics now become
necessary, and arsenic is the substance frequently preferred. Sir Astley
Cooper uses an ointment composed of 3 j. of spermaceti cerate, 5j- of sul-
phur, and 5 j. of white arsenic. When the action of arsenic is impeded
by the thickness of the cuticle over indolent tubercles, a small 'blister is
sometimes first put on the part, or the following ointment applied:
R ung. cetacei 353., oxydi arsenici 5 j«> empl. cantharidis 5iij. ; M. ft. ung.
Sometimes an arsenical paste is applied. That of Frere Come is made
by moistening arsenic, cinnabar, and burnt leather. Being a very power-
ful application, this paste demands particular caution not to let it act on
more than a small area, lest the patient be poisoned by it. Indeed, no
arsenical dressing should be allowed to come in contact with a surface of
greater extent than a shilling. The above paste is apt to bring on ery-
sipelas of the face. A milder, safer, and better arsenical paste, is that
recommended by Dupuytren, composed of calomel and oxyde of arsenic,
moistened with mucilage in the proportion of from six to twelve parts of
arsenic in every 100. The same eminent surgeon also used an arsenical
powder, made of ninety-six parts of calomel and four of arsenic. These
applications, however, he applied but to a small surface at a time. The
nitrate of silver, sulphate of copper, and muriate of antimony, are like-
wise escharotics in great repute ; and so is the concentrated nitric acid
for cases where the ulceration invades the deep layers of the skin and
the cellular tissue. At the Hopital St. Louis, a solution of 5j. of the pro-
tonitrate of mercury in an ounce of nitric acid is employed with great
success, by Richerand and Cloquet.
I have known lupus cured by excision of the diseased part of the skin.
When the nose has been destroyed, a new one has often been success-
fully formed from the skin of the forehead.*
* See Dr. Houghton's article on " Noli me Tangcre," in the Cycloptvdia of Practical
Medicine,
POLYPI OF THE NOSE. 497
LIPOMA OF THE NOSE.
The integuments of the apex and alae of the nose are sometimes enor-
mously thickened by interstitial deposit, so that a true hypertrophy of
them is occasioned, forming, as Mr. Liston correctly states, a lobulated
reddish-blue mass, intersected by fissures.* The sebaceous follicles are
so expanded, that they will admit the point of a quill. The ramifications
of many turgid superficial veins are seen on the part. The disease, be-
sides being productive of vast deformity, may attain such magnitude that
vision, the passage of air through the nostrils, and the introduction of food
into the mouth, are more or less obstructed.
The only mode of relief is that of removing the hypertrophied skin.
If both sides of the nose are affected, the nostrils may be distended with
lint, and then a perpendicular incision made through the morbid skin, in
the mesial line of the nose. The edge of the divided integument may
then be taken hold of with a pair of forceps, and the diseased structure
carefully cut away. The bleeding is generally copious : some of the ves-
sels will require ligature ; the others will cease to bleed on pressure being
applied.
POLYPI OF THE NOSE
Are swellings arising from the mucous membrane of the nose, and gene-
rally consisting of a soft substance easily torn, streaked with a few vessels,
and of a light yellowish or grey colour, and not endued with much
sensibility. The disease is most common in persons between forty and
fifty, though occasionally met with in younger subjects. The polypi,
which have the character now enumerated, are not of a malignant nature ;
and whatever inconvenience may be produced by them is caused by their
obstructing the nostril, and by their pressure on the adjacent parts. They
are commonly of a pyriform shape, though, if they are large, their figure
is in a great measure determined by that of the cavity in which they
grow ; but whatever may be their shape, they are invariably connected
to the mucous membrane by a narrow stalk or pedicle, sometimes termed
their root. They rarely or never grow from the septum nasi, but usually
from a point at or near the upper os spongiosum.
The polypi, whose texture corresponds to what I have mentioned, are
those mostly met with, and often named soft or gelatinous polypi ; or
occasionally mucous polypi, from their structure bearing a considerable
resemblance to the mucous membrane from which they originate ; or benign
polypi, in consequence of their having no disposition to assume a danger-
ous morbid action. Sometimes they are of a firmer consistence and
fibrous texture, when they are termed fleshy polypi ; but these are more
frequently noticed in the uterus than in the cavity of the nose, and grow
not from the lining of the uterus, but under it, in, or connected with, the
substance of the womb itself. Another kind of disease is improperly
called the malignant polypus, because it is not truly a polypous excres-
cence at all, but a tumour, partaking in every respect of the nature of
medullary cancer.
In many cases, several polypi of different sizes occur in one or both
nostrils. Sometimes we meet with only one ; and, in particular examples,
the nostrils are filled with a peculiar kind of polypi, consisting of cysts or
vesicles, filled with a colourless fluid : these are vesicular or hydatid polypi,
* Elements of Surgery, partii. p. 179.
K K
4-98 DISEASES ABOUT THE FACE.
as they are termed, and are not uncommon in children and very young
persons.
Truly cancerous polypi are said, occasionally, to take place in elderly
persons ; but the malignant polypi, which I have seen, were evidently spe-
cimens of medullary sarcoma.
The common pendulous soft benign kind of polypus generally grows from
the external side of the cavity of the nose, and, in many examples, from
the mucous membrane covering the ossa spongiosa. The growth of a
polypus from the septum narium, if it ever occur at all, is so uncommon,
that some surgeons of the most extensive practice have never seen an in-
stance of it. The commencement of the disease is attended with a feeling
of obstruction in the nose, like what is usually felt in an ordinary ca-
tarrh, the obstruction being more considerable in wet, than dry weather.
These polypi, when under a certain size, maybe made to advance or recede
by the force of the breath in inspiration and expiration. The sound of the
voice is nasal, and there is generally some uneasiness felt about the frontal
sinuses.
Sometimes, when a polypus becomes large, it passes towards the velum
pendulum palati, over which a part of it hangs towards the pharynx ; or
if it originate towards the back of the nares, it may take the same direc-
tion, instead of towards the nostril. In certain examples, potypi project
in both directions.
Common polypi cannot be cured by local applications ; caustic only acts
upon their surface, and cannot get to their root. They grow indeed faster
than any caustic can destroy them.
Extraction, excision, and the ligature are the three means of curing'nasal
polypi. Extraction is the method usually preferred in this country, and
is accomplished with forceps made for the purpose, and of different shapes
and sizes. Some are slightly curved, and formed with oval excavations
on the inside of the ends of the blades, and also with an aperture in each
of them. Others are straight, and the inner surfaces of the blades
furnished with projections, or teeth. Some are constructed with ser-
rated blades, which, when shut, meet in the manner of a suture of the
cranium.
The patient being seated opposite a strong light, the surgeon first ex-
amines the extent and situation of the polypus with a probe, endeavour-
ing in particular to make out the point of its attachment and the place of
the pedicle. This cannot always be done ; but we know that the os spon-
giosum superius, and the outer and upper side of the nostril, are the com-
mon situations for the attachment of the polypus. We therefore convey
the forceps in that direction, and endeavour to seize the pedicle. If we
succeed thus far, the best plan is not to pull it directly outwards by a jerk,
but to twist the tumour from its connection. The haemorrhage from soft
benign polypi is never dangerous, though it may be copious. Some-
times, a layer of bone comes away with the polypus, a circumstance often
regarded as favourable, inasmuch as the root of the tumour will then have
been taken away. After the operation, the nostril and nares should be
washed occasionally with an astringent lotion, containing alum, or the
muriate of ammonia.
When a polypus projects backward, towards the throat, it is sometimes
taken hold of with a pair of curved forceps, introduced from the mouth,
and extracted. But frequently another part extends forwards, which we
may begin with. In this manner, the pedicle is sometimes broken, and
both portions may then be readily extracted. Much of the operation is
SALIVARY FISTULA. 499
necessarily performed, as it were, in the dark; for, after the bleeding be-
gins, nothing can be seen. Supposing only a fragment of the polypus to
be at first taken out, we should not stop, but try to extract the rest, either
piecemeal or in one mass, just as may be practicable.
Excision is a plan occasionally applied to large polypi extending back
towards the throat, and having a pedicle, the situation of which can be
felt and reached with a pair of long probe-pointed scissors. The bleeding
need not be feared ; but, so far as my experience goes, we seldom know
the precise situation of the pedicle, or can reach it sufficiently well with
scissors to make this method advisable.
The ligature has also been applied to similar polypi extending towards
the throat. The noose of a ligature, or piece of wire, is introduced
through the nostril to the back of the throat, where it is put over the
tumour with the aid of a pair of forceps. The ends of the ligature, or
wire, hanging out of the nostril, are then passed through a double cannula
and twisted. It is a practice rarely adopted in this country. The best
instruments for this operation are those of Graefe, which may be pro-
cured of Weiss.
Vesicular or hydatid polypi generally grow again. We may clear the
nostril from them, but they return. One plan, to which they will some-
times yield, is that of applying strong astringent lotions to them. They
should first be removed, and the lotion then applied by means of lint.
With respect to the malignant kinds of polypi, they are out of the
power of surgery ; all that can be done is to lessen the patient's sufferings
by narcotic medicines, opium, hyoscyamus, or hemlock, and to diminish
the foetor of the discharge by means of lotions, containing the chloride
of soda, or lime, or a proportion of creosote.
SALIVARY FISTULA.
An opening in the cheek, from which the saliva escapes, arising from a
wound, ulceration, or phagedenic disease, involving the parotid gland or
duct, is called a salivary fistula. The duct has also been burst by
violent blows. We sometimes meet with cases, in which the parotid
duct becomes obstructed by a calculous formation within it, just in the
same way as the salivary ducts under the tongue become occasionally
blocked up with calculous matter. Calculi in the parotid duct, if not
removed, may, of course, enlarge, and excite inflammation and an abscess
in the cheek. This bursts, and the flow of saliva from the opening
immediately draws the surgeon's attention to the state of the parotid
duct ; a probe is introduced, and the calculus felt. Here the first indi-
cation is to extract the extraneous substance, and then endeavour to heal
the ulcerated opening in the cheek.
If the parotid duct is recently wounded, the sides of the wound should
be brought together, and pressure applied. Thus a salivary fistula may
often be prevented altogether : either the divided ends of the duct
re-uniting, and the saliva resuming its original course, or, whatais more
probable, the wound in the face healing at every part, with the exception
of a small fistulous track, which serves as a continuation of the duct into
the cavity of the mouth. This is supposing the wound to have extended
quite through the cheek.
When a salivary fistula is already formed, it may be cured by passing a
seton from the fistulous opening into the mouth, keeping it there a certain
time, and, after withdrawing it, applying the nitrate of silver to heal the
outer opening. The caustic alone will frequently succeed. Another in-
K K 2
500 DISEASES ABOUT THE FACE.
genious plan is that of Beclard, who passed a leaden style into the orifice
of the portion of parotid duct connected with the gland, and then united
the outer wound with the twisted suture. This is a quicker mode of cure
than the seton, and more sure than simply closing a recent wound and
applying pressure.
DISEASES OF THE ANTRUM.
The antrum, or rather its mucous lining, is subject to inflammation
and suppuration. A darting pain is felt in the side of the face, usually
supposed to Jbe the toothach, and, indeed, mostly connected with a
carious state of the neighbouring teeth. If an abscess form, and the
matter be prevented from passing into the nose by accidental obstruc-
tion, it may produce an expansion and attenuation of the sides of the
antrum ; and at length discharge itself either through the cheek, or, what
is more common, into the mouth.
The indications are, to lessen inflammation and pain by antiphlogistic
soothing means ; to provide a speedy outlet for the matter, when an ab-
scess forms ; to check the discharge, and maintain cleanliness by the use
of tepid slightly astringent injections; and, if there should be any dead
bone or carious teeth present, to remove them as soon as circumstances
will allow ; the teeth as soon as the inflammation has somewhat abated,
and the dead bone when exfoliation is sufficiently advanced.
When there is a carious tooth below the antrum, its extraction, and
the perforation of the socket, are sometimes considered the best mode of
making an outlet for the matter. In other cases, the third or fourth grinder
may be drawn and the socket perforated. Another method is that of
detaching the cheek from the front surface of the antrum, and applying
a small trephine, or other perforating instrument, to the bone. The
cheek is to be raised up so as to expose the membrane covering the gum
on the side of the face, and a transverse incision made down to the bone.
The instrument, preferred by Sir Benjamin Brodie for the perforation of
the bone, is a pair of sharp-pointed strong scissors. This plan is applicable
to cases in which the socket is filled up with bone.
In one case of inflammation of the antrum, recorded by Sir Benjamin
Brodie, where the severity of the symptoms made him suspect the pre-
sence of matter in that cavity, he made a perforation, but no pus was
met with. Two grains of calomel and half a grain of opium were then
given three times a day, and, on the gums becoming sore, a cure speedily
ensued.
COLLECTION OF MUCUS IN THE ANTRUM
Is more rare than one of puriform fluid. The cause of such an accu-
mulation is probably an accidental obstruction of the natural com-
munication of the antrum with the nostril, between the two turbinated
bones. The manifest indication is, to make an outlet for the confined
fluid, which is producing the swelling and pain of this part of the face.
In one interesting case, related by Sir B. Brodie, he made an opening
with a knife in the swelling above the gum, which opening continued ten
years afterwards, the patient wearing a plug in it.
MEDULLARY DISEASE OF THE ANTRUM
Produces a gradual expansion of it, and then such pressure on other parts
as leads to an immense degree of suffering, and often fatal consequences.
Thus, the pressure may render the eye amaurotic, or even displace it
from the socket ; it may force out all the neighbouring teeth ; make its
HARE-LIP.^ 501
way through the palate and alveolary process into the mouth ; fill up the
nostril ; protrude through the integuments of the face in a frightful form ;
or through the cribriform plate of the ethmoid bone, or the orbital process
of the frontal bone into the cranium itself, when the patient soon dies in
a comatose state. I have seen one case, however, in which the patient
did not die, or even become senseless, till the mass of the tumour in the
cranium had attained the size of an orange.
When the character of the disease is known beforehand, and especially
when the soft parts are implicated, an operation is not likely to be of any
service, the disease almost always returning. However, if the new growth
were entirely restricted to the antrum, and the patient, after a candid
explanation of the nature of the disease, and the bad chance of benefit
from an operation, were anxious to take that chance, the surgeon would
be justified in performing the excision of the upper jaw. This is to be
preferred to the plan of opening the antrum, and attacking the disease in
that situation, as Desault appears sometimes to have done. I do not, at
the present time, recollect how far the cases published b}' Desault amount
to a satisfactory proof of the permanency of the cures ; but, in one ex-
ample recorded by Dr. Anderson of Glasgow, no recurrence of disease in
the antrum had taken place five years and a half after the operation, as
was ascertained by a post mortem examination. The actual cautery had
been employed after the knife had done its duty ; a measure very essential
for the prevention of a relapse. However, I should be sorry to advocate
the removal of medullary tumours from the antrum. No doubt, the dis-
ease in this situation presents little chance of benefit from such or any
other proceeding ; but fibrous tumours hold forth more prospect of per-
manent success.
HARE-LIP
Is for the most part a congenital malformation ; but it is now and then
produced by accidental wounds. It is mostly met with in the upper
lip, and very seldom in the lower. Sometimes there is only one fissure ;
on other occasions two, the hare-lip being then termed a double one.
In some cases, the fissure only extends partly towards the nostril ; in
others, it reaches into that aperture, which is then much expanded. The
fissure is of course to one side of the mesial line ; and its edges, which
are covered by a continuation of the prolabium, are rounded off below.
Besides the fissure in the lip, there is frequently so large a cleft in the
upper jaw and palate bones, as to convert the mouth and nose, as it were,
into one cavity. A double hare-lip is particularly often accompanied by
a fissure in the bones of the palate. Sometimes, but not usually, there is
a fissure in the soft palate. In certain examples the jaw-bone, or teeth,
project forward into the cleft of the lip.
A hare-lip, besides being a great deformity, is attended with a defect
in the speech ; and when the fissure extends through the palate^there is
more or less impediment to sucking and swallowing.
In ordinary cases, the cure is easy ; the surgeon pares off the margin
of the fissure, brings the fresh cut surfaces into contact, and keeps them
in this position until they have grown together.
As infants are very subject to convulsions after operations, many
surgeons think it best to defer the cure of a hare-lip till the child is
about two years of age, or even rather older. The youngest subject on
which I ever operated, was only five months old, but the case was per-
fectly successful.
K K 3
502 DISEASES ABOUT THE FACE.
In the operation, the wound should be as clean and regular a cut as
possible, in order that it may the more certainly unite by adhesion, and
of such a shape that the cicatrix may form one narrow line. The margins
of the fissure, therefore, ought not to be cut off with common scissors,
which always produce some degree of contusion ; though what are called
knife-scissors, which are employed by some operators, are said to answer
well.
Sometimes a bit of pasteboard is placed under the lip ; and while this
is supported and fixed upon it, the edge of the fissure is cut off with a
sharp bistoury. Or the lip may be held with a pair of hare-lip forceps,
in such a manner that as much of the edge of the fissure, as is to be re-
moved, is situated at the side of the upper blade of the forceps, so that it
can be cut off with one sweep of the knife, which will be guided along
the instrument, as along a ruler. This is to be done on each side of the
cleft, the two incisions meeting at an angle above, thus A, in order that
the whole of the wound may admit of being brought together, and united
by the first intention. Particular care should be taken to remove com-
pletely the rounded corners at the lower part of the fissure ; for if this be
not done, an unseemly notch is left in the prolabium. Mr. Liston's mode of
operating I commonly prefer to any other, as being the neatest, quickest,
and most easily accomplished: it consists in passing a straight bistoury
from without inwards, so as to penetrate the membrane of the mouth,
above the angle of the fissure. The part is stretched by the fingers of
an assistant, whilst the instrument is carried downwards, so as to detach
the edge and rounded corner of the fissure. A similar proceeding is then
adopted on the other side. Hemorrhage is prevented by the assistant
making gentle pressure whilst the surgeon stitches the lip.
As the lips are exceedingly moveable, and it is essential to heal the
wound by adhesion, the twisted suture is generally employed for keeping
its surfaces in contact. Two steel pins, or silver pins made with steel
points, are introduced through its edges, and a piece of thread is then
repeatedly twisted round the edge of the pins, from one side of the
division to the other, first transversely, then obliquely, from the right or
left end of one pin above, to the end of the lower on the opposite side, &c.
Thus the thread, being made to cross as many points of the wound as
possible, maintains the edges in contact. If silver pins are used, the
points, which are made to slide on or off the instruments, are now re-
moved; or if steel pins are employed, the points are taken off with a
small pair of cutting forceps. A great deal of exactness is requisite in
the introduction of the pins, in order that the edges of the incision may
afterwards meet correctly : and, as it is of great consequence to make
the red parts of the lip correspond precisely, this object is secured by
introducing the lower pin first. The pins ought never to extend more
deeply than about two-thirds through the substance of the lip ; and they
should be removed in three or four days, the support of sticking plaster
being then sufficient.
When the case is a double hare-lip, and the intervening portion of
skin is sufficiently broad and long, it should be preserved in the ope-
ration ; but if narrow and short, it should be cut away. In the latter
event, the rest of the operation is the same as for the single hare-lip.
But, when the middle piece of skin is to be saved, a union between^ it
and the lip on one side is first to be accomplished by an operation like
that for the single hare-lip, and then, in a few weeks, a second operation
of the same description is to be performed on the opposite side.
CANCER OF THE LIPS. 503
Hare-lips are frequently complicated with a fissure in the roof of the
mouth. When it is confined to the upper maxillary bones, it generally
closes, by slow degrees, after the operation ; but when it reaches along
the palate bones and velum pendulum palati, its entire closure rarely 01
never takes place. Sometimes one upper maxillary bone exceeds the
level of the other. When the hare-lip is double, a distinct part of the
jaw may push forward the middle portion of skin. In certain cases,
one of the maxillary bones inclines backwards, and its alveolary process
juts out. In other examples, an impediment to the union of the hare-lip
arises from the projection of a tooth, which must then be extracted.
When the jaw itself projects,, the common preliminary step to the
operation for the hare-lip consists in cutting away the bony prominence.
But, according to Desault, this measure is seldom proper ; for when the
original congenital deformity is removed, a disfigurement of the face yet
follows, from the upper lip having no proper support. The diameter of
the upper jaw is also liable to diminish so considerably, in proportion
as the two maxillary bones coalesce, that the upper and lower jaws
no longer correspond, and the same kind of inconvenient mastication
is produced, which is often noticed in old people. Hence, Desault pre-
ferred reducing the projection of the jaw, by means of the pressure
of a tight bandage ; for, as there is a fissure in the roof of the mouth,
the bony prominence has little support, and readily yields. In one
instance, I made the necessary pressure with a small spring truss, which
in a few weeks reduced the bony projection sufficiently to let the ope-
ration be undertaken. In another instance lately brought to me from the
country, I advised the same plan to be tried.
CANCER OF THE LIPS.
The lips are frequently the seat of troublesome and obstinate ulcer-
ations, sometimes connected with disorder of the general health, but
more commonly prevented from healing by the constant motion and
friction to which they are subjected.
U Some ulcers of the lip having a foul, and even a malignant appear-
ance, will yield to liquor arsenicalis, iodine, the iodide of potassium, the
extract of hemlock, the compound decoct, sarsap., or the compound
calomel pill, with occasional purgatives. The most eligible dressings are
generally the ointment of the nitrate of mercury, or that of the nitrate
of silver, 10 grs. to an ounce. In one case in University College Hos-
pital, I tried both the carbonate of iron and Dupuytren's arsenical powder,
and found the latter answer better than the former.
When cancer takes place, it is almost always in the lower lip ; and it is
not an uncommon opinion, that the pressure and irritation of tobacco
pipes give a disposition to the disease, which usually commences as a
small tumour in the cellular tissue between the mucous membrane and
the skin. The swelling and induration make the disease obvious before
the villous surface of the lip cracks transversely, and a thin flbid oozes
out. The part then ulcerates and scabs by turns, and the disease ulti-
mately penetrates more deeply, and throws out a fungus. The patient
is generally a male subject, above the middle age, and, as I have said,
accustomed to smoking. The skin, mucous membrane, and labial glands
now form a close compact mass, and the submaxillary lymphatic glands
become affected.
Whenever any malignant disease of the lip resists alterative plans,
it should be extirpated with the knife, before its effects extend to the
K K 4?
504- DISEASES ABOUT THE FACE.
lymphatic glands. The disease may be removed by an operation resemb-
ling that for the cure of hare-lip, or by a semi-lunar incision through the
lower lip, as practised by Dupuytren, by which a freer removal of the
part may be made than can be effected in the other way. The com-
missures of the lips, however, should always be spared. A moderate
breadth of the lip may thus be taken away with much less deformity
than might be apprehended.
DISEASES OF FARTS IN THE MOUTH.
Wounds of the tongue are generally transverse, and caused by the
violent and spasmodic closure of the teeth, while the tongue is out of
the mouth, as sometimes happens in epilepsy, and falls on the chin.
Wounds of the tongue, thus produced, may give rise to profuse hemor-
rhage ; such as would prove fatal if not soon suppressed. As for taking
up one of the lingual arteries for this purpose, it would not generally
answer, because the wound almost always affects the branches of both.
Sometimes, in order to stop the hemorrhage, the surgeon has been com-
pelled to apply the actual cautery,, or even to pass a double ligature
through the centre of the tongue, behind the wound, and then tie each
side of that organ. With the aid of a tenaculum forceps, however, the
tongue may be kept steady, and drawn sufficiently forwards to facilitate
the application of a ligature to any bleeding vessel. This plan is always
the most eligible, when practicable.
INFLAMMATION AND PRODIGIOUS SWELLING OF THE TONGUE.
The tongue, when in the state of inflammation, may swell so enor-
mously as entirely to fill the cavity of the mouth, protrude between the
teeth, and obstruct deglutition and respiration in a most dangerous
degree. I remember a soldier's wife at Brussels, whose life was in
urgent danger from such an affection of the tongue, brought on by the
use of mercury.
Common antiphlogistic treatment will not afford sufficiently prompt
relief. The right practice consists in making two or three longitudinal
incisions in the dorsum of the tongue. The copious bleeding, which
ensues, soon reduces the swelling. In bad cases, all medicines and food
ought to be given through an elastic gum tube, introduced down the
pharynx from the nostril.
ULCERS AND INDURATIONS OF THE TONGUE.
Putting out of consideration the effect of mercury, the irritation of
carious teeth, with points and inequalities, is one of the most frequent
causes of ulceration of the tongue. Here, it is clear enough, that the
right treatment consists in extracting such teeth, or filing away their
sharp projections.
Hard tubercles sometimes grow on the dorsum of the tongue, having a
narrow pedicle, and a broad mushroom-like head. These may be snipped
off with a pair of scissors, or tied, and the parts afterwards touched with
the nitrate of silver.
I have seen the whole surface of the tongue covered with hard tu-
bercles, some of them in a state of ulceration. On this form of disease,
I find that mercury has considerable effect. Some inveterate ulcerations
of the tongue may be cured by the same alterative plans, as I have ad-
vised for similar sores on the lips. Venereal ones I have noticed with the
subject of syphilis. •
DISEASES OF PARTS IN THE MOUTH. 505
CANCER OF THE TONGUE
Commonly begins as an irregular, rugged, unyielding knob, generally
situated in the anterior third of this organ, midway between its raphe
and its edge, the mucous surface being puckered and rigid, and the patient
experiencing severe pains in the part, which shoot towards the ear. Some-
times the knob acquires considerable size before ulceration commences.
Persons, about the age of forty, are most subject to cancerous disease
of the tongue. The glands of the neck after a time become swollen
and indurated, and profuse bleedings are disposed to take place from
time to time, whereby the patient becomes extremely weakened and
reduced.
There are two methods of extirpating cancerous portions of the tongue :
one by the knife ; the other by a double ligature passed through the
centre of the part by means of a sharp-pointed curved needle fixed in a
handle, one portion of the ligature being firmly tied over one side of the
organ, and the other portion over the other side. In this operation, some
surgeons first take hold of the tongue with a pair of hook forceps, so as
to fix it. The objection to the knife is the hemorrhage, which, if profuse,
and not capable of being stopped by the methods noticed in the remarks
on wounds of the tongue, would require some extraordinary means for
its suppression, such as the application of the actual cautery, or even
securing the lingual artery as it passes over the cornu of the os hyoides.
When the extirpation of a cancerous induration can be accomplished by
removing a piece of this organ in the shape of the letter V, the best mode
of stopping the bleeding is to bring the sides of the wound closely together
with a suture. The tongue may also be removed by an incision, made
under the jaw, between its symphysis and the hyoid bone. If the portion
to be removed be drawn out through the wound, and the rest held with a
tenaculum, the requisite incision maybe performed, and the arteries tied.
In this way, also, the extirpation with a ligature may be performed further
back, than in the common mode.*
Relapses are frequent after operations on cancerous tongues; a fact
that should make us cautious in the judgment we give, respecting the
chances of a cure.
OF DIVIDING THE FR-ffiNUM OF THE TONGUE.
Children are not so frequently tongue-tied as nurses and mothers ima-
gine ; and we may be sure, that when once an infant has been able to
suck properly, whatever may be its present inability to do so, it does not
proceed from the confinement of the tongue by the frsenum, but probably
from the large size of the nipple, excoriation of the lips, or other causes,
which should be investigated.
When the fraenum really ties the tongue too closely to the bottom of
the mouth, the surgeon will find, that he cannot raise the tongue to the
palate with his fingers. Sometimes, however, the fraBnum is feally so
short that it interferes with the requisite movements of that organ in suck-
ing, deglutition, and the articulation of words. The surgeon is then called
upon to divide it, which may be done with a pair of blunt-pointed scis-
sors, care being taken to direct the incision downwards, so as not to in-
jure the raninal vessels.
An immoderate cut gives rise to two dangers : one is, that of hemor-
rhage ; the other, that of the tongue being left so unfixed, that it may
* Aniott, Med. Chir. Trans, vol. xxii. p. 20.
506 DISEASES ABOUT THE FACE.
be thrown back into the pharynx in the act of deglutition, and cause
suffocation. A similar danger has been exemplified after the operation of
removing the lower jaw.
With respect to hemorrhage, children are constantly disposed to suck
and swallow whatever comes into their mouths, and hence they sometimes
die with their stomachs full of blood, even when only the branches of the
raninal artery are wounded, and not the trunk itself. Nay, it is alleged,
that the veins have sometimes yielded a dangerous quantity of blood,
which has been swallowed.
RANULA
Is a tumour situated under the tongue, and commonly believed to arise
from a dilatation of the duct of the submaxillary salivary gland. The
swelling is usually situated on one side of the fraenum, and, when large,
extends forwards, under the apex of the tongue. Its contents are gene-
rally a glairy fluid, resembling white of egg ; but if the tumour has been
of long standing, their consistence may be much thicker, and even blended
with calcareous matter. Neglected ranulaB may attain a considerable
size, and not only obstruct the movement of the tongue, but even produce
serious annoyance and mischief to the teeth and lower jawbone by their
pressure. In general, however, when they have become as large as a
walnut, they burst ; the opening heals up ; and then they fill and burst
again.
Some ranulae arise from obstruction of the duct, the orifice of which,
therefore, should be examined ; and if a piece of calculus can be felt with
a probe, it should be removed : this alone would lead to a cure. In ordi-
nary cases, the disease may be cured by opening the swelling and snip-
ping off a portion of the sac, so as to prevent the part from closing again.
Merely opening the cyst, without the excision of a portion of it, will not
always suffice. It is also a good plan to apply a bit of lint, dipped in a weak
solution of lunar caustic, to its inner surface. I lately attended a young lady
for a ranula, that would not yield to any ordinary modes of treatment.
I opened it, and removed a considerable piece of the c}rst, filling the cavity
with lint ; but this plan failed. I then cut away a second piece of the
cyst, and dressed the cavity with lint dipped in a solution of nitrate of
silver : this also was followed by a relapse. I then passed a seton through
the ranula, and kept it applied for two or three weeks in vain. Lastly,
I made a small opening, and put into it a little silver tube, which was
worn about five or six weeks, and the disease never returned. The latter
treatment of ranula by puncturing it, and placing in the opening a small
tube not quite half an inch long, and made with a rim, by which it is re-
tained in the part, was frequently adopted by Dupuytren.
DISEASES OF THE TONSILS.
When the tonsils are so considerably swollen from an attack of acute
inflammation that deglutition and respiration are seriously obstructed, they
should be freely scarified ; after which, the bleeding from them, assisted
by venesection, leeches, and other antiphlogistic means, will in general
quickly bring down the enlargement.
If the same inconvenience should arise from the formation of matter,
the abscess should be opened with the long narrow sharp-pointed bistoury,
the blade of which may be partly covered with lint to keep the edge from
wounding the tongue.
The tonsils are also liable to chronic enlargement, more especially in
scrofulous subjects. It is a mere hypertrophy, without any tendency to
DISEASES OP PARTS IN THE MOUTH. 507
cancerous or malignant action. The tonsils may, indeed, swell to such
a magnitude as to close the aperture between the mouth and pharynx,
and create a total impediment to swallowing, and much difficulty of
breathing.
If these enlargements resist the internal use of iodine, or small doses of
the bichloride of mercury, with tinct. rhei, or tinct. cinchon, and the appli-
cation of lunar caustic, or nitric acid, the tonsils, or rather the redundant
portion of them, should be extirpated by means of a ligature or cutting
instrument. Cheselden's plan of passing a ligature through a diseased
tonsil, by means of a crooked needle fixed in a handle, and with an eye
near its point, is not a bad method. Graefe has also invented a most
ingenious instrument for the purpose. Excision of part of the tonsil,
however, is a better practice, and may be safely performed with a hook
and straight probe-pointed bistoury, for the hemorrhage will never be
serious, if the knife be directed downwards and inwards away from the
carotid artery.
ELONGATION OF THE UVULA.
The uvula is sometimes thickened and considerably elongated, pro-
ducing great uneasiness about the throat, and irritation of the epiglottis.
If the disease cannot be remedied by astringent gargles, or touching the
uvula with the tincture of the sesquichloride of iron, the best plan is to
snip off the superfluous length of the part with a pair of long blunt-pointed
scissors. I once attended a gentleman with a phagedenic venereal sore
throat, whose uvula was so deeply attacked at its root with the same kind
of ulceration, that it remained attached only by a few fibres, so as to hang
down, and irritate the epiglottis in a most distressing manner. Under
these circumstances, as it could not be saved, I immediately cut it off, to
the great relief of the patient.
DISEASES OF THE GUMS.
The gums in the natural and healthy state are not very sensible : they
may be divided with a lancet without much pain ; and the pressure of
hard substances against them in mastication is not productive of any in-
jury. When, however, they become inflamed, in consequence of decayed
teeth, a cold, or any other cause, they cannot be touched or pressed
upon, in the slightest degree, without the patient being put to a great
deal of suffering. Some diseases of the gums originate from those of the
teeth ; while others have no connection with this cause.
THE GUM-BOIL, OR PARULIS,
Is merely an abscess of the gums, generally arising from the irritation of
a diseased tooth, though sometimes from disease of the alveolary process,
or from splinters of this part left after the extraction of a decayed tooth.
These abscesses are to be treated on common principles, and opened with
a lancet as soon as matter is formed : afterwards, when the part has be-
come quiet, the decayed tooth, if there be one, should be taken^out.
If the gum-boil become fistulous, it must be freely laid open, and a
solution of lunar caustic applied.
EPULIS, OR EXCRESCENCE FROM THE GUMS.
The fibro-vascular texture of the gums is much disposed to produce
fungous and other excrescences. Any kind of irritation, as that of bad
teeth, or a severe blow, will sometimes lead to the growth of considerable
tumours from the gums ; and occasionally they arise without any mani-
fest exciting cause.
508 WOUNDS OP THE THROAT.
The texture of an epulis is generally soft, spongy, and vascular; but
sometimes hard, fibrous, incompressible ; and not endued with much vas-
cularity.
A soft vascular epulis mostly originates from the gum itself; while that
which has a fibrous orfibro-cartilaginous structure frequently grows from
the alveolary process. When the excrescence first makes its appearance
between sound teeth, which it afterwards loosens and forces out, it may
be concluded, that the disease originates from the periosteum and interior
of the socket.
As tumours of the epulis kind have no disposition to recede, and, when
they originate from the periosteum or bone, are disposed to assume a
malignant character, I cannot too strongly insist upon the necessity of an
early operation for their complete removal. The knife is the best means
for the purpose. Any teeth in the way should be first extracted ; the
whole substance of the swelling removed; the bone and periosteum
scraped; and even a portion of the jaw (if diseased) removed with Key's
saw, or a pair of cutting forceps. After the removal of a cancerous
epulis, many foreign surgeons apply the cautery.
The manner of removing the diseased portion of alveolary process is,
to make a perpendicular cut through the bone on each side of the tumour
with a fine saw, after which its separation may be completed with a strong
pair of forceps. The bleeding is profuse, but may be stopped by pressing
into the wound a dossil of lint dipped in the tincture of sesquichloride of
iron; the application of which, or of a solution of lunar caustic, may be
repeated, if necessary, at each succeeding dressing.
WOUNDS OF THE THROAT
Are cases of frequent occurrence in persons who attempt to commit sui-
cide. Some merely penetrate the integuments, and are not of any par-
ticular importance. Others extend more deeply, and divide some of the
primary branches of the external carotid, especially the lingual, and
superior thyroid arteries. Others make an opening into the mouth by
separating the os hyoides and tongue from the thyroid cartilage ; while
others are situated lower down, so as to penetrate the thyroid car-
tilage, or betwixt that cartilage and the cricoid, and sometimes through
these into the oesophagus. Surgeons meet with more wounds of these
parts, than of the trachea itself; for persons, who aim at suicide, gene-
rally make the wound high up in the neck, and, unless they cut with great
determination and violence, they do not reach the carotid, or internal
jugular vein, because they hold their heads back at the time, and thus
render the larynx and trachea prominent. Some individuals, however,
in a desperate state, reach these vessels, even high up in the neck, divid-
ing nearly every thing down to the vertebrae. Under these circumstances,
they are, of course, immediately destroyed by hemorrhage.
A simple incised wound of the trachea, unaccompanied by injury of
other important parts, provided all hemorrhage has ceased, or can be
controlled, is generally much less dangerous than a wound of the larynx
— especially one that penetrates the thyroid cartilage, so as to approach the
vocal cords and edges of the glottis, which may be involved to such a
degree in the subsequent inflammation, as to put a stop to respiration.
Mr. Ryland, whose work contains the best observations on the present
subject with which I am acquainted, divides wounds of the larynx and
WOUNDS OF THE THROAT. 509
trachea, 1st, into those which interest that part of the larynx which is
situated above the attachment of the vocal cords to the thyroid cartilage ;
and 2d, into others, which penetrate the cavity of the larynx or trachea.
Wounds in the former situation are comparatively free from danger, be-
cause, unless very deep, they do not reach the track through which the air
passes in respiration, and therefore the risk of hemorrhage into the trachea
is absent. The effusion of blood into the air-tubes is generally the im-
mediate source of danger in wounds of the larynx, or trachea, and life
is more frequently lost by this occurrence than by external bleeding.*
In ordinary cases, when there is much bleeding, it is from the lingual,
or superior thyroid artery. Then also the patient, if not promptly assisted,
may die from loss of blood, but more frequently he faints, and this is fol-
lowed by a temporary stoppage of the hemorrhage ; and time is thus
afforded for a surgeon to be sent for.
I have known a patient die in about twenty minutes after cutting his
throat, though no artery of any size was wounded, and the hemorrhage on
the whole was very trifling. Thus, a prisoner in the Queen's Bench cut his
throat, dividing the trachea and the external jugular vein. As he did this
when he was alone in his room, the occurrence was not known to any
other person for nearly twenty minutes after it had taken place, and when
the gentleman who assists me in the duty arrived, the patient was at his
last gasp. On examination after death, it was found that no large artery
had been cut, but the stream of blood from the external jugular vein had
passed into the trachea, and caused suffocation. Bleeding even from
some of the numerous veins in front of the trachea, below the thyroid
gland, might have the same fatal consequence.
I had another patient in the same place, who, after the nurse had re-
tired to rest, took out his razor and cut his throat. A girl accidentally
entered the infirmary directly afterwards, and seeing the stream of blood
which went as far as the middle of the room, she gave the alarm, and a
surgeon in the prison immediately secured the superior thyroid artery that
had been divided. In all cases of this kind, the bleeding vessels are to be
secured by ligature ; and the edges of the wound are not to be immedi-
ately brought together, because, as Mr. Ryland justly remarks, " when
the immediate danger from bleeding into the windpipe has past away, se-
condary hemorrhage may occur, either on the establishment of reaction,
or from the effects of ulceration ; and this is more likely to be attended
with fatal results, when the edges of the wound have been brought toge-
ther, and no outlet is left for the escape of the blood."
Wounds between the hyoid bone and the thyroid cartilage may injure
the epiglottis, the anterior wall of the pharynx, or the lips of the glottis,
and the arytenoid cartilages. The epiglottis may be severed from the
tongue and hyoid bone by a division of the hyo-thyroid membrane, and
by then falling over the rima glottidis cause danger of immediate suffoca-
tion. Such a case is recorded by Dr. Houston, who extricated the patient,
from this first danger by raising up the epiglottis, bringing it over fhe edge
of the thyroid cartilage, and fixing it there with a single stitch.-j- Loose
portions of the mucous membrane, I have known cause similar distress.
Certain cases recorded by Larrey prove, that the destruction of the
epiglottis seriously injures the voice ; that immediately after its occur-
rence, the power of swallowing is lost; but that, in time, the lips of the
* Frederick Ryland on Diseases and Injuries of the Larynx and Trachea. 8vo.
Lond. 1837. p. 234. A work of great merit,
f Dublin Hospital Reports, vol. v. p. 315.
510 WOUNDS OF THE THROAT.
glottis are able to prevent solid food from penetrating into the larynx,
though liquids will still produce much inconvenience.
Wounds between the hyoid bone and thyroid cartilage may prove fatal
by exciting inflammation of the glottis, and consequently serous infiltra-
tion of the submucous cellular tissue of the epiglottis and superior aper-
ture of the larynx.
When the knife or razor penetrates deeply into the hyo-thyroid space,
the anterior wall of the pharynx will be opened ; an occurrence soon
manifested by the passage of liquids, taken by the mouth, through the
external wound. If the opening in the pharynx be large, so as to be fol-
lowed by a frequent escape of the alimentary matters through the wound;
or if deglutition be attended with difficulty, an elastic gum tube should be
introduced into the oesophagus from the nostril, or mouth, and food injected
through it into the stomach.
I have seen cases, in which the epiglottis, and also the arytenoid carti-
lages and vocal chords, were injured. In one example, recorded by Sir
Charles Bell, the divided arytenoid cartilage, suspended merely by a
membranous connection, slipped into the rima glottidis, and caused suf-
focation.* A man who commited suicide, and died in University College
Hospital, made an oblique incision in the thyroid cartilage, extending
upwards with such force, that the os hyoides was cut in half.
Wounds penetrating the air-tube cannot be attended with obstructed
respiration so long as the external wound remains open; but in others only
interesting parts above the rima glottidis, death may be occasioned by
this circumstance in a few hours. At the same time, as Mr. Ryland ex-
plains, there can be no doubt, that wounds which penetrate either the
larynx or the trachea are attended with much greater risk to life, than
those which merely injure the epiglottis, the anterior wall of the pharynx,
or the hyo-thyroid membrane. In the former cases, death may ensue
from hemorrhage into the trachea ; from suffocation, caused by excessive
granulations; or from a chronic thickening of the mucous membrane, as
happened some weeks after the accident in one of my patients in Univer-
sity College Hospital, when the outer wound and that in the air- tube had
been perfectly healed ; or from extension of the inflammation around the
wound to the lungs and pleura.
With respect to wounds of the trachea or larynx, complicated with a
wound of the pharynx or oesophagus, it is remarked, that, upon the whole,
the pharynx is less frequently wounded than the oesophagus, because it is
so protected by the larynx, that it cannot be reached unless the thyroid
or cricoid cartilage be cut through. When the trachea is completely cut
across, the resophagus is generally injured.
Certain cases, quoted by Mr. Ryland, show that the escape of fluids
taken by the mouth, through a wound in the trachea or larynx, is not an
absolute proof that the pharynx or oesophagus is injured. He conceives
that the circumstance is to be ascribed to some defective action in the
epiglottis from the injury.
In the treatment, the tirst indication is to stop the bleeding by tying the
divided vessels, if large enough to require it, whether arteries or veins.
Until this has been done, no wound communicating with the trachea
or larynx is to be closed ; because, if the hemorrhage continue, the blood,
not being able to pass outwards, will flow into those tubes, and death
be likely to be produced by suffocation.
As soon, however, as all risk from bleeding is over, the wound may be
* Surgical Obs. vol. i. p. 44.
WOUNDS OF THE THROAT. 511
closed by position, sutures, plaster, or bandage. The edges of wounds in
the hyo- thyroid space may generally be brought together by means of
position alone. The patient is to lie on his back, and the chin is to be
approximated to the sternum with a bandage, the upper ends of which
are to be fastened to each side of the back part of a night-cap, while the
lower are attached to a band placed round the chest. High pillows are
also to be placed under the head. Adhesive plaster, or water dressing,
may be applied to the external wound.
In wounds of the hyo-thyroid space, penetrating the pharynx, the
patient is to lie upon his back, in order to lessen the flow of saliva and
mucus towards the wound, and an elastic gum tube should be passed
from the mouth or nostril, for the injection of nourishment and medicines
into the stomach.
If urgent difficulty of respiration should come on within a few days
after the infliction of a wound in the hyo-thyroid space, and this apparently
from extension of the inflammation of the injured parts to the lips of the
glottis, bleeding and calomel should be immediately resorted to, and if
not promptly effectual, bronchotomy should be practised.
Wounds of the larynx require very similar treatment to that recom-
mended for those of the hyo-thyroid space. I have rarely employed sutures,
though Mr. Ryland considers them necessary, if the thyroid cartilage be
cut in more places than one, and the pieces separated.
When the wound is made in the space between the thyroid and cricoid
cartilages, the pharynx is more likely to be reached, than when the knife
first meets with the thyroid cartilage. Here the use of an cesophageal
tube is required. With respect to sutures, if, in this case, the gaping of
the wound in the larynx be considerable, one or two stitches will be ad-
vantageous, on condition that they be taken out immediately any obstruc-
tion of respiration occurs. In wounds of the trachea, if the whole of its
circumference be not divided, no sutures are necessary ; the head is to
be kept forwards ; and adhesive plaster, or the water dressing, applied.
When the division of the trachea is complete, position may not suffice to
bring the separated parts together, and then one or two sutures will be
indispensable.
If the oesophagus be wounded, the cesophageal tube should be intro-
duced.
The danger of closing the external wound before the oozing of blood
has entirely ceased, and the risk of its passing into the trachea is over,
has been already insisted upon. So has the necessity of having quick re-
course to bleeding, and calomel, when difficulty of breathing follows a
wound of the air-tube, and depends upon obstruction of the rima glot-
tidis from inflammation and thickening, or oedema, of the lining of the
larynx ; quickly followed up, if relief be not speedily obtained, by the per-
formance of tracheotomy.
All patients with wounds of the throat, inflicted for the purpose of
suicide, should be closely watched, lest they repeat the attemptf They
should be kept perfectly quiet, and their minds soothed by good advice.
In many instances, we find great depression of the system, especially
where the loss of blood has been considerable, or the individual is under
the influence of some deplorable domestic calamity. On this account,
and also that air of too low a temperature may not pass direct into the
trachea through the wound, the chamber should be kept at a moderate
temperature. In other instances, where much reaction supervenes, bleed-
ing and other antiphlogistic means may be called for.
During my service in the army, I had opportunities of seeing many ex-
512 WOUNDS OF THE THROAT.
traordinary wounds of the throat and neck. Thus, after the battle of
Waterloo, one man was brought into the military hospital, who had re-
ceived the thrust of a lance in the throat, by which the mouth was laid
open, the tongue dreadfully lacerated, and several of the primary branches
of the external carotid were wounded ; consequently it became necessary
to tie the common carotid artery. This operation, performed by Mr.
Collier, suppressed the bleeding, and the patient recovered. After the
attack on Bergen-op-Zoom, I saw a soldier, the whole of whose lower jaw,
with the soft parts attached to it, had been carried away by a grape-shot.
This poor fellow recovered, and was much indebted for this favourable
result to the aid derived from elastic gum catheters. In another example,
a musket ball had injured the carotid, in the lower part of the neck, which
gave way about ten minutes after the soldier had been placed in the hos-
pital. No blood escaped outwardly, but the man died of the pressure of
the effused blood on the trachea, so suddenly, that there was no time to
make any attempt to save him.
FOREIGN BODIES IN THE (ESOPHAGUS,
Requiring extraction, are such as might create bad symptoms, if pushed
down into the stomach, in consequence of their hardness, indissolubility,
pointed shape, or other hurtful qualities. On the other hand, those which
are not likely to produce harm, and are capable of being digested, may
be at once pushed down into the stomach. They most frequently lodge
about the upper or lower orifice of the cesophagus ; seldom in its middle
portion. When low down, the surgeon is often compelled to force them
into the stomach, though their quality is such as would render their ex-
traction desirable. In many instances, they are situated in the pharynx.
Hence, it is an important rule, always to press down the tongue, and ex-
amine the back of the throat, before any thing else is attempted. Thus,
they may frequently be discovered, and extracted with the fingers or for^
ceps, when, from the patient's account, one would conjecture that they
had descended much further.
When a foreign body is situated about the upper orifice of the resopha-
gus, it may often be felt with the surgeon's finger, and if incapable of
being removed with it, it may sometimes be easily extracted with a pair
of forceps, provided the patient extend his head as far back as possible,
so as to bring the mouth and pharynx nearly into the same line. In this
position, with a pair of long-bladed forceps, like those invented by Dr. Bond
of the United States, foreign bodies, nearly down to the cardiac orifice of
the stomach, may be taken hold of, and extracted. A common instrument
for the removal of foreign bodies from the cesophagus is a kind of hook,
constructed of flexible wire, doubled and twisted together, and the bent
end forming a noose. In general, small bodies, like needles, fish-bones,
&c., are more easily extracted with a piece of sponge, introduced be-
yond them. The art of employing compressed sponge in the most
advantageous manner, consists in taking a piece about the size of a chest-
nut, and introducing a strong ligature through it. The ends of the
ligature are then to be passed through a flexible catheter, and fastened
to that end of it which the surgeon holds. The sponge is then to be in-
troduced down the cesophagus beyond the foreign body, and water is to be
injected down the tube, in order to wet the sponge and make it expand.
The ligature is then to be firmly drawn, for the purpose of pressing the
sponge against the extremity of the tube, and making it spread itself out
in a still greater degree. The tube is now to be withdrawn, together with
FOREIGN BODIES IN THE OlSOPHAGUS. 513
the sponge, the instrument being twisted to the right and left in thi
part of the operation.
When the foreign substance cannot be extracted with this instrument,
a probang may be tried, to the end of which a bunch of thread is fastened,
doubled so as to make an immense number of nooses. In this way, fish-
bones, and other substances, frequently admit of being entangled, and
extracted, after other modes have failed.
Some practitioners are in the habit of giving emetics ; but this method
must be improper when the foreign body is pointed, and is seldom of
much use in any case, as patients usually make efforts to vomit of their
own accord.
When foreign bodies produce urgent symptoms, and cannot be ex-
tracted, it becomes necessary to push them into the stomach, whatever
may be their nature or quality ; and here it should be mentioned, that
substances which one would imagine likely to produce alarming symp-
toms by being put into the stomach, frequently occasion, after they
are in that organ, no dangerous symptoms, and even not the smallest
inconvenience. A whalebone probang is the instrument for this pur-
pose.
When foreign bodies can neither be extracted, nor pushed down, the
consequences are not invariably dangerous. When the extraneous sub-
stance is small and pointed, it frequently excites suppuration, becomes
loose, and is either carried into the stomach,, or ejected from the mouth.
Sometimes it makes its way to the surface of the neck, occasioning there
an abscess, out of which it is extracted.
In some instances, foreign bodies, especially needles and pins, after
making their way through the oesophagus, travel a great way about the
body, and, at length, arrive under the skin of remote parts, behind the
ears, at the shoulders, feet, &c., where they produce an abscess, that
leads to their discovery and extraction. Surgical authors mention a
variety of examples, in which pins and needles, after being swallowed,
continued in the body many years. In one instance, recorded by M. Hevin,
in the Memoirs of the French Academy of Surgery, a needle that had
been swallowed, remained in the body eighteen years before it made its
appearance under the skin, during all which time not the slightest incon-
venience was experienced.
When the foreign body is large, impedes deglutition, dangerously
obstructs respiration, and can neither be pushed down into the stomach
nor extracted by the mouth, the only means of saving the patient's life is
cesophagotomy, which is directed by Lisfranc to be done as follows : the
patient's head having been inclined backwards, an incision is to be com-
menced at the inner edge of the left sterno-mastoid muscle, opposite the
superior edge of the thyroid cartilage, and continued down to the lower
edge of the cricoid. An assistant is now to draw the carotid sheath
towards the outer side of the wound, while the operator cautiously dis-
sects through the cellular tissue close to the trachea, until tne ceso-
phagus is exposed, where it inclines to the left side of the windpipe. A
long, slightly-curved cannula, with a grooved stilet, is now to be intro-
duced from the mouth down the oesophagus, and its point, being inclined
to the left, may readily be felt in the wound. The stilet is then to be
pushed forwards through the oesophagus ; the operator ascertains, by
passing his finger along the concave end of the instrument, that no
arterial branch lies over it, and then puts a bistoury into the groove,
under the guidance of which the oesophagus is opened. The foreign
L L,
514? WOUNDS OF THE THROAT.
body, lodged in this canal, is now to be extracted with a pair of forceps.
The only example of cesophagotomy in this country, within my recol-
lection, was performed by Mr. Arnott. The operation was perfectly well
executed, but did not ultimately save the patient, who was a child of
tender age.
WRY-NECK. CAPUT OBSTIPUM.
In this complaint, the head is drawn towards one of the shoulders. In
general, the face is turned towards the opposite side ; but, occasionally,
towards that to which the head inclines. The affection, when in a high
degree, renders the head quite immoveable, so that neither the patient,
nor any other person, can place it in its proper position. Hence, when
the patient wishes to look in any direction, except immediately before him,
he is necessitated to turn his whole body. Sometimes the head can be
moved, but not brought into a straight posture. In other instances, the
patient, with exertion, can manage to keep his head straight for a short
time ; but it soon becomes inclined again towards the shoulder. The dis-
order mostly arises from irregular action in the muscles of the neck,
especially the sterno-cleido-mastoideus, or else from the contraction of a
cicatrix, or from deformity of the cervical vertebrae.
When the cause is irregular action of the sterno-cleido-mastoideus,
this muscle, on the side to which the head is drawn, has a hard,
tense, unyielding feel ; every attempt to bring the head into its right
position exciting the muscle to make greater resistance, and to assume a
more stretched appearance. Frequently the sterno-cleido-mastoid muscle
of one side is paralytic, and the wry-neck is then occasioned by the
healthy ordinary action of its antagonist. It may be inferred, that the
cause of the deformity lies in an alteration of the vertebras, when the
muscles are free from the above-mentioned appearances, the patient
is scrofulous and ricketty, and the head more moveable than in the
preceding case.
The prognosis depends on the cause and duration of the deformity.
In young subjects, if the cause lie in the muscles, the prognosis is fa-
vourable. When, however, the case has existed a long while, and par-
ticularly when it began in early childhood, and continued during growth,
the cervical vertebra? are sometimes distorted, altered in shape, and
even anchylosed ; in which circumstances, the disease is incurable. This
participation of the vertebrae in the disorder does not constantly exist, at
all events in an irremediable degree, even though the disorder may have
begun at an early period of life, and prevailed a considerable time.
Richter and Chelius refer to several instances in which wry-necks of
the most unpromising description were cured ; cases, in which the head
had been quite immoveable, the disease of twelve and sixteen years'
duration, and its origin had taken place in infancy.*
When the deformity follows the contraction of a cicatrix, the cure is
by no means easy. A transverse incision is made through the integu-
ments, and the head is afterwards kept in a straight posture by some
mechanical contrivance, until a certain period after the wound is per-
fectly healed. The apparatus being left off, the distorted position of the
head is generally disposed to return. It was on this account, that
Mr. Earle proposed the removal of the whole of the cicatrix, and having
* Ansfangr. de Wundarzn. b. iv. p. 276. M. J. Chelius, IJandbuch der Chirurgie,
b. i. p. 796, 8vo. Leipzig. 1826.
WRY-NECK. 515
recourse to treatment already noticed in the observations on burns. In
some instances, however, where the chin was nearly in contact with the
breast, in consequence of the effect of severe burns, I have known con-
siderable amendment follow the division of the longitudinal folds in the
cicatrized parts, and the long continued use of mechanical means for
preserving the head in an even position.
In common examples, depending chiefly upon a loss of equilibrium
between the muscles of the opposite sides of the neck, and especially
upon a rigid contraction of one of the sterno-cleido-mastoidei, the means
of relief, usually tried, are camphorated mercurial frictions over the rigid
muscle, even till salivation occurs; the application of the nitrate of silver
to the skin ; the internal exhibition of opium, together with mercurial
frictions ; electricity ; stimulating embrocations ; the shower-bath ; blis-
ters ; issues, &c. These remedies should be assisted with mechanical
contrivances, for gradually bringing the head into a straight position.
The best apparatus which I know of for this purpose, is that invented by
Professor Jorg.* It consists of a pair of leather stays, and of a band or
fillet, which goes round the head. On the centre of the forepart of the
stays is a kind of pulley, or grooved wheel, which can be turned round
with a key in one direction, but not in the other, as it becomes fixed by
means of a spring. From this pulley, or wheel, a band proceeds up the
neck to the fillet on the patient's head, to which it is fastened directly
behind the ear, close to the mastoid process. The band lies in the same
direction as the lengthened sterno-cleido-mastoideus muscle, and, when
drawn towards the breast by means of the wheel, it produces the same
effect as would arise from an increase in the action of that muscle. In
short, it pulls the mastoid process downwards and forwards towards the
sternum, counteracts the opposite muscle of the same name, and rectifies
the position of the head. The apparatus is to be constantly worn.
When, by perseverance in the use of this simple invention, and other
means, the position of the neck has been improved, the head is generally
found to have a disposition to incline too much forwards ; an effect which
the contracted sterno-cleido-mastoideus, and its antagonist, the band,
both tend to promote. In order to hinder this, Professor Jorg removes
the end of the band from the breast, carries it under the arm, and
through a ring at the side of the corsets, or stays, and thence to the
fillet, on the head, where it is fastened close to the mastoid process. The
ring hinders the band from chafing the axilla, and following the motions
of the shoulder.
If, when the disease originates from irregular action of one of the
sterno-cleido-mastoidei, Sharp's operation of dividing the muscle be de-
termined upon, it will generally be prudent at first only to cut through
the clavicular portion of it. A transverse incision having been made
over this part of the muscle, the operation is completed by passing a di-
rector, and blunt-pointed curved bistoury, under the place where the
division is intended to be made. In one example, Dupuytren*passed a
bistoury behind the muscle, and divided it by cutting forwards, leaving the
skin uncut, in order that the patient, who was a female, might not have
the disfigurement of a scar in the neck. The position of the head was
then regulated by a bandage ; and the result was successful.
When a wry-neck depends upon paralysis, or weakness of one sterno-
cleido-mastoideus, while the other retains its natural power, electricity,
* Ueber die Verkriinamungtm des Menschlichen Korpers. 4to. Leipzig. 1816,
L L 2
516 WOUNDS OP THE THROAT.
the application of a grain or two of strychnia to the skin which has been
blistered, setons, blisters, liniments, the cold bath, and tonics, are indi-
cated. The state of the bowels and digestive organs should also be care-
fully regulated. During the trial of these remedies, the head should be
kept in a straight position, as paralytic muscles are more likely to recover
their tone in a tense, than a relaxed state. When such treatment fails,
a partial division of the healthy sterno-cleido-mastoideus has been
suggested, as a means of restoring the equilibrium of the head. At the
present day, we rarely hear of operations of this kind.
BRONCHOCELE,
Signifies an indolent enlargement of the thyroid gland ; the tumour,
when not accidentally inflamed, is free from pain; and in its incipient
state, has a soft, elastic consistence. When it has existed some time,
the gland loses its natural figure, assumes a firm fleshy feel, being firmer,
however, in some places, than in others, spreading towards the sides of
the neck, and sometimes attaining a prodigious magnitude. When the
adjacent cellular tissue, and lymphatic glands, participate in the disease,
the base of the swelling may extend from one side of the neck to the
other. In a few instances, only one lobe is affected.
Bronchocele is endemic in several mountainous countries ; as, for in-
stance, Switzerland, Savoy, the Tyrol, Derbyshire, £c. ; and is most fre-
quent in young females. The disease is sometimes a mere hypertrophy
of the thyroid gland ; sometimes an excessively indurated, or even a partly
ossified condition of it; and, in other instances, the swelling consists of
many cysts of different sizes, filled with transparent viscid fluid, or matter
of various kinds. The tumour sometimes creates no particular inconve-
nience, and is merely a deformity. When large, however, it is frequently
attended with considerable obstruction of the speech, respiration, and
deglutition. It has little tendency to become malignant, that is to say,
cancerous, and is not very liable to inflammation and its consequences,
though these changes sometimes happen. In Mr. Langstaff's museum
is a fine specimen of fungus hrematodes of the thyroid gland, which had
been mistaken for bronchocele.
The causes of bronchocele are involved in great obscurity. At one
time, it was conjectured, that drinking water, obtained from melted ice
or snow, frequently gave rise to the disorder. The disease, however, is
frequent in Sumatra, where ice and snow are never seen ; while it is en-
tirely unknown in Thibet, where the rivers are exclusively supplied by
the melting of the mountain's snow. Bronchocele has been regarded as
a scrofulous complaint; but this doctrine is denied by Prosser*, who
argues, that the disease is often seen in persons entirely free from every
mark of scrofula ; and that, while boys are as subject to scrofulous diseases
as girls, bronchocele seldom occurs, except in young females.
Formerly, the medicine commonly given for the cure of bronchocele,
was burnt sponge, in the dose of a scruple, two or three times a day, either
made into an electuary with syrup, or prescribed in the form of a lozenge,
the efficacy of which was thought to be greatest when it was placed under
the tongue, and allowed gradually to dissolve there. A mercurial purg-
ative was usually given about once a fortnight. The good effects of
burnt sponge are now well known to depend upon the iodine which it
* An Account and Method of Cure of the Bronchocele, or Derby-neck, 3 edit. p. 5.
4lo, Lond. 1782.
BRONCHOCELE. 517
contains, and, consequently, at the present day, iodine itself is commonly
prescribed. Its efficacy is promoted by the previous application of leeches
to the swelling, and a low regimen.
With such treatment, external means are to be combined ; as repeated
frictions of the swelling with strong camphorated or ammonia liniment,
or, what is still better, the ointment of the iodide of potassium, with or
without a proportion of mercurial ointment blended with it.
From the foregoing description of the very different conditions of the
thyroid gland in different instances, it is manifest, however, that iodine
will not cure every form of it.
Accident has sometimes furnished useful suggestions in the practice
of surgery : bronchoceles have occasionally festered, or ulcerated, and the
result sometimes been the dispersion of most of the swelling. Hence,
the plans of forming issues and setons, as a mode of cure. Valuable in-
formation, respecting the effects of setons, may be collected from a paper
by Dr. Somerville, describing the practice of Quadri at Naples, and in-
serted in the Med. Chir. Trans, vol. 10. ; and from another paper in the
eleventh volume, drawn up by Mr. Copland Hutchison. The seton was
often employed by Dupuytren. It should never be made, except when
iodine has decidedly tailed, and the complaint is beginning to be very
oppressive. If a seton be passed through the thyroid gland, the hemor-
rhage is always profuse, and might prove dangerous, were it not checked
by cold applications, and pressure. In general, the seton must be kept in
several months, before the swelling is completely reduced. It will not
cure the hardest forms of bronchocele ; but it will cure hypertrophy, cysts,
and hydatid formations, which iodine and other specifics frequently fail
to disperse.
If this latter measure, or the formation of an issue, should not be deemed
advisable, and the patient's life be rendered miserable, or seriously endan-
gered by the pressure of the swelling on the trachea, oesophagus, and
veins returning the blood from the head, it will be for the practitioner to
consider, whether he will imitate Blizard, Walther, Wedemyer, Graefe,
Coates, Brodie, &c. in tying one or both of the superior thyroid arteries,
or follow the example set by Gooch, Desault, Theden, Vogel, and He-
denus, who ventured to extirpate the enlarged thyroid gland. The latter
surgeon has performed this bold operation, at least six times, with com-
plete success. The most essential rule in the operation would be to se-
cure every large artery directly it was cut, so that the patient might not
be lost by haemorrhage, ere the complete detachment of the swelling had
been effected. The ligature of the superior thyroid arteries is generally
followed by some diminution of the tumour, but this amendment has not
always been permanent. In some of the cases on record, the patients
died either of inflammation and its consequences, or of secondary hemor-
rhage.
In one example that occurred in University College Hospital, Mr. Listen
exposed a large prominent portion of the tumour, and after Carrying the
dissection1 as far as he deemed safe, passed a double ligature through its
base, and thus effected its destruction.
L L 3
518
WOUNDS OF THE CHEST
Are divided into superficial, and penetrating. The former do not mate-
rially differ from common wounds of the skin and muscles in other situ-
ations, and therefore do not here require particular notice.
When we consider the important organs contained in the chest, we
should hardly suppose it possible for a bullet or a sword to pass across it
without inflicting a mortal wound. Yet, recoveries from such injuries
are frequent, and this notwithstanding they may be complicated with a
wou-nd of the lungs. Nay, facts are recorded, which leave no doubt, that
even wounds of the heart itself are not always fatal, balls having been
found encysted in its substance, after death from other causes, long after
the receipt of the wound.
When, in respiration, the air passes alternately into and out of a wound
in the parietes of the chest, we know that the weapon must have pene-
trated beyond the pleura costalis. In the expansion of the thorax by the
muscles of inspiration, the air enters the wound ; in its contraction by the
muscles of expiration, the air is pressed out in a more or less forcible cur-
rent. When the communication between the cavity of the pleura and
the atmospheric air is free and ample, the lung generally collapses, unless
prevented by adhesions ; and the knowledge of this circumstance led to
the belief, that if direct openings were made simultaneously into both
cavities of the pleura, the patient would inevitably die of asphyxia pro-
duced by the collapse of both lungs. Experience proves, however, that
this is not the fact, and that recoveries may follow wounds penetrating the
two sides of the chest, even where the admission of air to the cavities of
the pleura is free and direct. Three chief sources of danger present them-
selves in all penetrating wounds of the chest.
1. The risk of profuse internal hemorrhage, by which the patient is
sometimes destroyed at once; or by which he is more slowly cut off,
generally in consequence of the extravasation in the pleura producing too
much pressure on the lungs, or becoming combined with inflammation of
those organs.
2. Other patients fall victims to inflammation within the chest, without
any effusion of blood, though sometimes the inflammation is followed by
abscess, or, as it is here called, empyema.
3. Another cause of danger, when the lungs are wounded, is emphy-
sema, or the inflation of the cellular tissue, sometimes of the greater part
of it throughout the body.
, The symptoms of a wound of the lungs are, bloody expectoration im-
mediately after the receipt of the injury, frequent coughing, great diffi-
culty of breathing, a feeling of suffocation, and a sudden alteration of the
countenance, which exhibits paleness and marks of great anxiety. Here
the immediate danger is either from the quantity of bl'ood withdrawn from
the circulation by internal hemorrhage ; or from the passage of that fluid
into the bronchi and air-cells of the lungs; or into the cavity of the
pleura, so as to cause suffocation. Hence wounds of the root or upper part
of the lungs, where the vessels are large, are always the most dangerous.
With regard to the treatment, it is a general rule to close all such
wounds without delay. We ought, however, to extract any splinters of
a broken rib, a ball, a portion of the clothes, or any other extraneous
substances which lie near the surface, and can be easily reached without
too much irritation. With respect to a wounded intercostal artery, all the
best modern practitioners disapprove of the introduction of various in-
WOUNDS OF THE CHEST. 519
struments and contrivances into the wound or chest for the suppression
of the bleeding. Dr. Hennen had heard of examples, in which the inter-
costal artery was taken up with a tenaculum. But supposing this were
not practicable, I believe, that less danger would arise from closing the
wound and applying a compress over it, than from the introduction of
extraneous substances round or within the rib. I attended, with Mr.
Frogley of Hounslow and Mr. Broxholm of Sunbury, a young gentleman,
one of whose intercostal arteries was wounded by a small knife. The
result was a prodigious effusion of blood under the muscles of the back,
followed by large collections of matter, and very urgent danger ; but, in
the end, the patient recovered. No attempt was made to secure the
vessel. About eight ounces of blood flowed out of the orifice of the
wound directly after the accident ; the outward hemorrhage then ceased ;
but the blood accumulated in the cellular tissue ; great swelling ensued,
and, in about eight days, such a quantity of matter and putrid blood was
suddenly discharged from the external wound, that the patient lay in a
kind of pond, extending from his feet to his neck. Incisions were occa-
sionally practised to facilitate the exit of the matter. It was some months
before the discharge ceased, and the wound closed. In the early inflam-
matory stage, leeches and venesection were freely employed.
In all penetrating wounds of the chest, and especially those extending
into the lungs, the free use of the lancet is the only thing that can be
depended upon in the beginning. It is by this means that internal he-
morrhage is to be checked ; and inflammation of the lungs prevented or
subdued. Here, as in certain injuries of the head, moderate bleeding
will not suffice. We may perhaps be required to bleed the patient more
than once a day for six or eight days in succession. The first bleeding
should be copious ; and, if the patient faints, we should not give him
cordials, but allow him to revive gradually without them.
When the oppression of breathing returns, and the pulse rises, accom-
panied by pain in the chest, and spitting of blood, venesection should be per-
formed again ; and thus the lancet is to be used as often as the state of the
circulation, the pain, and oppression of breathing, or other circumstances
call for it. If we neglect this rule, we are certain of losing the patient.
When the paroxysms of pain, the sense of suffocation, and the internal
hemorrhage are lessened, but the cough is severe, we may prescribe
digitalis or hyoscyamus, with small doses of the acetate or muriate of
morphia, and saline medicines.
When much cough and pain in the chest continue, after bleeding has
been carried as far as practicable, a blister may often be applied to the
chest with great benefit ; and, sometimes, leeches or cupping may yet be
ventured upon, though venesection itself is not any longer admissible.
When matter forms in the cavity of the pleura, after a wound of the
chest, constituting empyema> or when the extravasation of blood in the
chest causes urgent danger by its pressure, the indication is to make an
outlet for the discharge of such fluids ; but, if the wound should not be
closed, we ought to avail ourselves of the opening already existing for
this purpose ; and, with this view, direct the patient to lie in a posture
that will render the wound depending.
In former days, when blood was extravasated in the chest, surgeons used
to make themselves particularly officious about its evacuation, sometimes
using tubes and syringes for the purpose. But, at present, we never hear
of such schemes being put in execution. This part of surgery, however,
is sometimes attended with a great deal of perplexity ; for we have two
L L 4
520 WOUNDS OF THE CHEST.
dangers to contend against, — one is that of letting the patient die of
suffocation from the pressure of the blood on the lungs and diaphragm,
if no opening be made for its discharge ; the other is that of seeing him
fall a victim to continued hemorrhage if such opening be made. I be-
lieve, however, that the experience of army surgeons, who are the best
and most experienced judges of this subject, will justify me in saying,
that we shall generally act with most prudence if we do not hastily adopt
schemes and contrivances for discharging blood from the chest, but rely
upon rigorous antiphlogistic treatment. The diagnosis also is rarely so
clear, with regard to an extravasation of blood, as to justify the performance
of an operation for its evacuation. At all events, we should not be in too
great a hurry to make an opening in the chest ; but give nature an oppor-
tunity of doing her best, under the assistance of the treatment which I
have advised.
Sometimes wounds of the chest are complicated with protrusion of a
portion of the lungs : one such case was brought to me at Brussels after
the battle of Waterloo. The protruded piece of lung was of a long, nar-
row, tongue-like form, and severely contused. The wound had been
made with a lance. I thought at first of cutting the protrusion off, but
the bleeding made the inclusion of it in a ligature necessary. The
patient, I believe, did not ultimately recover.
EMPHYSEMA,
Or the inflation of the general cellular tissue, is frequent in cases of frac-
tured ribs with wounded lungs, because the air has no outlet, the skin
being entire. It seldom occurs as a complication of a free and direct
wound, but chiefly of those, whose orifices are narrow, and whose direc-
tion is oblique, as is the case with punctured wounds in general. It is
not uncommon in cases of gunshot wounds of the chest, their orifices be-
ing blocked up by the swelling around the wound, and the sloughs within
it. Emphysema is not confined to examples of penetrating wounds of
the chest, or of broken ribs, but may take place in any situation in the
vicinity of the organs and apparatus of respiration. Hence, emphysema
of the eyelids from fractures of the os ethmoides, os unguis, or frontal
sinus, or from a laceration of the mucous membrane of the nose.*
The symptoms of emphysema are, great oppression of the breathing,
inability to lie down, or a preference to an upright or sitting posture ; a
colourless, elastic, crackling tumour, beginning near the wound or frac-
tured rib, and often extending with great rapidity, so as to cause some-
times an enormous distension of the cellular tissue of every part and re-
gion. The cfrief cause of danger, however, is not this diffusion of air in
the subcutaneous cellular tissue,, but its insinuation into the interlobu-
lar cellular tissue of the lungs, and its accumulation in the cavity of the
pleura, — two circumstances causing a perilous obstruction of the function
of respiration. Emphysema is also frequently combined with the danger
depending upon inflammation, effusion "of blood, or lodgment of foreign
bodies in the chest.
Experience proves, that when emphysema is restricted to a moderate
space, and only a few cubic inches of air are within that space, it is rea-
dily absorbed again. But circumstances are different, when it has passed,
not only into the whole of the cellular tissue under the skin, and between
the muscles, but into that of the viscera of the thorax, and even of the
* See Dupuytren, Legons Orales, t. i. p. 123. A footman, in the service of the
Duke of Sussex, was lately under my care in University College Hospital, with a frac-
ture near the inner side of the right orbit, accompanied by emphysema,
EMPHYSEMA. 521
abdomen ; and likewise into the great cavities lined by serous membranes.
The mechanism, by which the air is impelled into the cellular tissue, is an
interesting part of the subject. When, in consequence of previous in-
flammation of the chest, there exist organised adhesions between the two
pleurae, and a continuity of tissues is thus formed between the surface of
the lung and the parietes of the chest, emphysema is very easy of com-
prehension. The air then passes from the interior of the lungs into the
interstices of the new organisation, and afterwards, gradually making its
way through the parietes of the chest, gets into the submuscular and sub-
cutaneous cellular tissue. Here we are supposing the weapon, or point
of a fractured rib, to have pierced the lung precisely in the seat of such
adhesions. But, when there are no adhesions, the air, which is inspired,
partly escapes from the breach in the surface of the lung, and passes at
first into the surrounding tissues and cavity of the pleura. Thence it is
next forced by the influence of the contraction of the chest in respiration.
The expansion, or act of inspiration, draws the air first from the breach
in the lung into the cavity of the pleura, and thence it is propelled into
the cellular tissue adjoining the wound in the side, by the diminution
in the capacity of the chest in each expiration. In other words, each in-
spiration draws it out of the rent in the lung into the cavity of the
pleura, and each expiration pumps or compresses it out of that cavity
into the cellular tissue, for it cannot return into the air-cells, on account
of their being already full of air themselves. Its progress over the body
is also, no doubt, facilitated by its own elasticity. The quantity of it, thus
diffused, is sometimes enormous, filling not only the parietes of the thorax
and abdomen, the upper and lower extremities, the loose cellular texture
of the scrotum, the neck and head, but also the pleurae, the mediastina,
the pericardium, ^and even the interlobular cellular tissue of the lungs.
The treatment varies according to the degree of emphysema, and the
urgency of the symptoms arising from it. In cases of only moderate ex-
tent, attended with broken ribs, a compress may be applied over the
swelling, and then a bandage round the chest, followed up by venesection
and opening medicines. The object of the bandage is to suspend the
action of the intercostal muscles, and to make the patient breathe en-
tirely by the diaphragm, so as to promote, on the one hand, the union of
the fractured rib, and, on the other, to resist, as much as possible, the
causes of emphysema. In emphysema of great extent, as I have ex-
plained, one principal risk proceeds from the accumulation of air in the
cavity of the pleura, — a state indicated by a metallic tinkling sound,
compared to the dropping of shot into a porcelain basin ; and, therefore,
when scarifications do not give relief, and there is reason to believe, tbat
air is confined in the chest, we should make a deeper and freer incision
over the broken part of the rib, or enlarge the original wound, and punc-
ture the pleura costalis.
Slight scarifications and a bandage round the chest will tend to pre-
vent the increase of emphysema in the common cellular tissue c^andmay,
indeed, be of important utility in hindering its extension into this tex-
ture so far as to reach the interlobular cellular substance of the lungs.
Yet, in more aggravated cases, I believe with Baron Dupuytren, that they
are inefficient means, and also that the pressure of the bandage would
really make the state of the breathing worse. In urgent or rapidly in-
creasing cases, therefore, perhaps, the most prudent plan is to make an
incision, and then cautiously puncture the pleura costalis. However,
nothing will answer, if the cellular tissue of internal organs is already
much inflated.
522 DISEASES OF THE BREAST.
The place for the incision and puncture is determined by the fracture,
or original wound, where the air first escapes from the chest ; but, when
the intention is to let out blood, water, or purulent matter, we are to
divide the integuments over the space between the sixth and seventh
ribs, where the indigitations of the serratus magnus meet those of the
obliquus externus, and, having cut through the intercostal muscles,
cautiously puncture the pleura.
The incision through the intercostal muscles should be made away from
the lower edge of the rib, where the chief branch of the intercostal
artery runs.
DISEASES OF THE BREAST.
The classification of diseases of the breast, adopted by Sir Astley
Cooper, is,
First, into diseases, the result of common inflammation, whether acute,
or chronic.
Secondly, into diseases accompanied by peculiar o? specific action, but
which are not malignant, and do not contaminate other structures.
Thirdly, into others, which not only consist in local, malignant, and spe-
cific actions, but are connected with a peculiar and unhealthy state of the
constitution, and affect with similar disease, besides the part originally
attacked, others in the neighbourhood, and even sometimes remote
parts.
The first class of diseases comprehends : 1. Acute inflammation of the
breast, and the milk abscess. 2. Chronic inflammation, terminating at
length in suppuration. 3. The lacteal tumour, so called by Sir Astley
Cooper, on account of its arising from obstruction of one of the lactiferous
tubes, as an effect of chronic inflammation. To this arrangement I shall
confine myself, after noticing a few diseases of the nipple.
DEFICIENCY OF THE NIPPLES, OR THEIR NUMBER GREATER THAN
USUAL.
'- Sometimes there is congenital absence of the nipple ; sometimes, it is
acidentally obliterated by wounds, pressure, a burn, venereal, or other
forms of ulceration. Under any of these circumstiinces, there is an im-
pediment to the excretion of the milk, which can only be determined
from the breast, as much as possible, by the action of purgatives.
The nipples may exceed their usual number ; for instance, there may be
two on each breast, or even as many as five.* The removal of the super-
fluous nipples is evidently the proper measure ; but, as there is a risk of
mistaking the natural nipple itself for the abnormal ones, Boyer may be
right in advising the operation to be deferred until after the birth of the
first child, when the true nipple will be ascertained.
Sometimes the nipple is imperforate from birth. This condition may
not become known until after the subject of it has been delivered of her
first child. Such a case is generally incurable.
EXCORIATIONS.
The greater number of women who suckle for the first time, experi-
ence, more or less, tenderness of the nipple. But, frequently, in conse-
* Acta Havniens, vol. iii. Obs 98.
THE LACTEAL SWELLING. 523
quence of being incessantly irritated by the child's mouth and the lodg-
ment of milk upon it, it inflames, and becomes excoriated.
•. Various plans of relief are adopted for excoriations of the nipple. One
consists in not letting the infant suck only at longish intervals, and keep-
ing the part covered with a piece of fine soft linen. If this should not
answer, the nipple may be bathed several times a day with the lotio
plumbi acetatis, or the linimentum calcis. Sir Astley Cooper prefers an
application, composed of 5j. of borax, §ss. of alcohol, and 3j. of water.
M. Velpeau, if simple ointments fail, employs a weak solution of the nitrate
of silver, or sulphate of zinc, or an ointment containing white preci-
pitate.
But it is always to be recollected, that the child's suction is the exciting
cause of the complaint, and that several of the applications above specified,
would be productive of inconveniences, if allowed to remain on the nipple
when the infant sucks. Hence, under such circumstances, an artificial
nipple, made to fit accurately, is sometimes deemed one of the best means
of relief. With the aid of this, and cleanliness, and some of the applications
enumerated, a cure is generally accomplished in a few days.* In some
cases, the child should take milk chiefly from the opposite breast.
ULCERATED FISSURES, OR CRACKS IN THE NIPPLE,
Which arise from the same causes as excoriations, may occur on different
points of the areola, or on the nipple itself. In consequence of being
stretched and irritated whenever the infant sucks, they extend more and
more deeply, and cause acute suffering. Sometimes they become so
large and deep, that, whenever disturbed by the child, they bleed pro-
fusely ; and, occasionally, they penetrate the base of the nipple so far,
that the latter part is in danger of being completely detached. Hence,
from the severity of the inflammation the secretion of milk and suckling
are sometimes quite interfered with.f
The treatment should be like that of excoriations ; artificial nipples &
being here even more necessary. The applications in common use are,'
the calomel and lime water lotion ; zinc ointment ; or the nitrate of silver i
with which all the surface of the fissures should be carefully rubbed at
intervals. I concur with M. Velpeau in thinking lotions of the bichloride/
of mercury improper, as likely to poison the infant.
In women, who have long ceased to suckle, the nipple is sometimes
attacked with a combination of chronic eczema and psoriasis. In two
cases, recorded by M. Velpeau, the disease had continued for several
years, attended with itching, and thick greenish, or yellow scabs, but no
inflammation. He ascribes its commencement to the friction of the corsets
against the breast. One patient was cured by the use of an ointment,
containing white precipitate ; the other submitted to the excision of the
diseased nipple.
THE LACTEAL SWELLING
Is confined to the nipple, and consists of a large collection of milk, partly
fluid, and partly coagulated, often mixed with pus, in one of the lactiferous
tubes, the aperture of which has been stopped up by chronic inflamma-
tion. It is a disease analogous to ranula. The swelling presents a dis-
tinct fluctuation ; the cutaneous veins are large ; but the colour of the
* See Velpeau, Mai. du Sein. p. 4. 8vo. Paris. 1838.
j- See Velpeau, Op. cit. p. 6.
524° DISEASES OF THE BREAST.
skin is not changed. If a slight puncture be made, it soon heals, and an-
other accumulation takes place ; or, if a small ulcerated opening form, a
little way from the nipple, it continues during the period of suckling, and
the milk, instead of passing into the child's mouth, is lost.
The origin of the lacteal tumour is referred by M. Velpeau to sudden
exposure of the breast to cold; too abundant a secretion of milk; and too
long retention of it. Rough suction of the nipple, and the free use of
cordials, will also promote its occurrence.
A puncture of moderate size will suffice, if the child is weaned ; if not,
a larger opening must be made, so as to let the milk escape while the
child is sucking, until the secretion of milk ceases, or the child is weaned
This is the advice given by Sir Astley Cooper.
If a small lacteal fistula were to be left after the puncture, or to follow
an abscess communicating with one of the lactiferous ducts, M. Velpeau is
in favour of touching it at intervals with the nitrate of silver, and applying
astringents. This practice he finds almost always successful. If it should
not be so, he recommends injecting, twice a day, a weak solution of nitrate
of silver, or alum, or lotions containing tincture of iodine, or red wine.
Were this plan not to succeed, he would dilate the orifice in the skin,
and apply the nitrate of silver freely to the inside of fistula. By one or the
other of these methods, M. Velpeau has never met with a lacteal fistula that
was not cured. If the patient were not obliged to suckle, these means would
cure the fistula still more quickly. Compression, and internal medicines
might also be employed.* Dupuytren gives an account of cysts filled
with a milky or buttery matter, which he had found in the breastf ; and
which contained a milky substance either in a liquid, half-liquid, or im-
perfectly curdled state ; but M. Velpeau is not aware that solid tumours,
really formed by the milk have been hitherto described. Certain irri-
tations of the texture of the breast, he conceives, may lead to infiltration of
the milk out of the lobules or excretory ducts of the mammary gland, so as to
form abnormal collections of it, just as blood is extravasated from its vessels
as a consequence of blows. M. Velpeau, in 1838, attended a woman, whose
breast was transformed into a spongy, highly-sensible mass ; an explora-
tory puncture was made in it, and a quantity of milky fluid was dis-
charged, which manifestly issued from the cellular tissue. But he is of
opinion that the actual escape of milk from its proper vessels is not
essential to the production of true accumulations of it. The lactiferous
tubes may be dilated, and transformed into cysts of considerable size.
M. Velpeau believes, that milk effused in the breast may, like extravasated
blood, remain a long while, and be the cause of much pain ; or, that it
may be decomposed, and lead to the formation of a cyst filled with se-
rum, if the curd is first absorbed, or filled with semi-fluid matter, if the
serum is first taken away. In other cases, the effusion of milk may cause
inflammation and milk abscess ; or, again, in others, being once coagu-
lated in the lactiferous tubes, or interlobular tissues, it may become
blended with the fibro-cellular element, concrete, and harden more and
more, and thus produce what M. Velpeau terms a buttery or caseous tumour
of the breast. It is less necessary for us to adopt the foregoing theoretical
explanation, than to remember the fact, that the breast is liable to tu-
mours of this nature, which sometimes attain a large size. It is curious
to learn also, that, in the case recited by M. Velpeau, tumours of the same
kind were developed secondarily, as medullary masses in the axilla, and
* Op, cit. p, 48, f Poillard, Journ. Hebdom. 1829.
ACUTE INFLAMMATION AND MILK ABSCESS. 525
under the clavicle. The tumour of the breast itself, after being com-
pletely removed, was reproduced.* These latter particulars lead me to
suppose that, whatever might have been the first state, or cause of the
formation of this tumour, it was afterwards of the nature of medullary
cancer ; a disease, which, in some of its varieties, we know is as liquid as
cream or milk ; though in others of the encephaloid consistence or even
much firmer, as exemplified in Abernethy's mammary sarcoma, f The
great size which the swelling of the axillary glands attained, viz., that of
a child's head, and its lobulated shape, tend to confirm the view to which
I incline. However, caseous matter is described as issuing from ulcerated
parts of the tumour ; and M. Donne, who, in one instance, examined the
substance compared to cheese, or butter somewhat altered, found in it
numerous globules, which, in the microscope, resembled those of milk,
and, like them, were found also to be soluble in ether, and alcohol, and
insoluble in ammonia. They were likewise blended with mucous globules,
and the minute granular bodies, characteristic of colostrum.
In the treatment of solid milk tumours of the breast in the early stage,
and where the milk appears to be diffused in the breast by infiltration,
M. Velpeau recommends leeches, or even venesection, and active purga-
tives, followed by liniments of camphor or ammonia. But, if distinct
lobulated prominences present themselves, quite concrete, and the disease
is of long standing, he deems the extirpation of the tumour the only
chance of saving the patient. I apprehend, however, notwithstanding
some particulars calculated to support his view, that my friendly corre-
spondent, M. Velpeau, may have mistaken a variety of medullary cancer
for a tumour composed at first of effused, and afterwards of curded,
milk.
ACUTE INFLAMMATION AND MILK ABSCESS.
Inflammation and abscesses of the breast admit very well of the divi-
sion adopted by M. Velpeau, into the subcutaneous, the deep, or submam-
mary, and those of the mammary gland itself.
Women, during the period of suckling, are particularly liable to inflam-
mation and suppuration of the breast : hence, the term milk abscess. The
inflammation is of the phlegmonous kind, exhibiting all it usual characters ;
but, on account of the sensitive nature of the part, and the envelopment
of it in a dense cellular or fascial covering, not readily yielding to inflam~
matory swelling, the suffering is uncommonly severe. A solid swelling is
produced, succeeded by a blush of inflammation on its surface, and at
length a prominence and smoothness in one particular situation, where the
fluctuation of matter may be felt.
The most frequent cause of milk abscess is the great determination of
blood to the breast each time the child is about to suck, by nurses called
the draught, combined with the mechanical irritation, to which the part
is continually subjected. The origin of such abscesses is sometimes pro-
moted by the child not being put to the breast soon enough aft§r birth ;
consequently the breast becomes too full ; and this state, influenced by
the stimulating diet often pressed upon mothers by nurses, soon ends in
acute inflammation.
In the early stage, we may sometimes bring about resolution by employ-
ing cold evaporating lotions, leeches, and purgative medicines. All action
* Velpeau, Op. cit. p. 83.
t See Carswell's Elementary Forms of Disease.
526 DISEASES OF THE BREAST.
of the great pectoral muscle should be prevented by keeping the arm in a
sling ; and the patient, when in bed, should lie on the opposite side. If
the breast be very large, some practitioners keep it supported with a
bandage ; a method, which I do not usually follow. Amongst the causes
of this complaint, I have mentioned the mechanical irritation and disturb-
ance of the breast in suckling. Hence, I always advise the mother not
to allow the child to suck the inflamed breast ; and, if it be necessary
to draw the milk from it, recommend the use of a glass tube made for
the purpose.
When an abscess cannot be prevented from forming, cold applications
are to be discontinued, and emollient poultices and poppy head foment-
ations substituted for them.
With respect to the question of opening the abscess, I may observe, that
if the collection of matter be superficial, not attended with extreme pain,
and quick in its progress to the surface, it is not of great consequence,
whether the abscess be opened, or allowed to burst of itself; but when
the abscess is deep, its progress tedious, and the pain severe, and
accompanied by fever, the matter should be let out. But, even with
regard to the most superficial abscesses, some practitioners prefer opening
them at once, so as to obviate all risk of the skin becoming undermined by
them. I see no objection to the practice, for otherwise sinuses may form,
and the cure be rendered more difficult and tedious. " Abscesses in
cellular and fatty texture of the breast," says M. Velpeau, " should be
opened, and this very freely as soon as a fluctuation can be plainly felt.
I will add, that making a puncture in the centre of such abscesses, even
before they are completely mature, appears to me to check their progress,
and promote their dispersion." The puncture should be made in a de-
pending situation, and if the skin be extensively thinned, or sinuses exist,
incisions should be made at different points.*
Some cases are exceedingly obstinate, in consequence of several ab-
scesses following one another in succession. Here the administration of
opium and the sulphate of quinine will be found beneficial ; and when a
deep-seated abscess, in consequence of not being opened freely or soon
enough, leads to the formation of sinuses in various directions, which
continue to discharge matter for a long time, if they cannot be healed by
pressure, we may follow Sir Astley Cooper's plan, which is, to inject into
them a lotion of rose water, with every ounce of which two or three
drops of concentrated sulphuric acid are blended, and apply the same
lotion to the surface, and sometimes a bandage. Mr. Hey, of Leeds, was
an advocate for laying open all sinuses of this kind ; and M. Velpeau
strongly insists upon the advantages of such practice, with the condition,
that it be restricted to cases, where the fistulae have existed several
weeks or months, and ordinary incisions and other means have failed.
While M. Velpeau gives his testimony in favour of opening superficial,
subcutaneous, and submammary abscesses of the breast early, he recom-
mends not opening those of the mammary gland itself, until a fluctuation
is very distinct. In the latter cases, also, he finds, with M. Donne, that
the milk secreted contains numerous globules of pus ; and hence, he ob-
jects to the child being put to the breast in this state. t
Chronic abscesses of the breast occur chiefly in scrofulous constitutions,
and are much less frequent than acute or milk abscesses. The matter
ought to be let out, and an attempt made to improve the general health,
* Op. cit. p. 26. f Id. p. 39.
HYDATID TUMOURS. 527
by some of the plans mentioned in the general observations upon scrofula.
The state of the uterine functions, in particular, should always be inquired
into ; for they are often disordered, and then aloetic and steel medicines
are indicated.
With regard to diseases of the breast, arising from peculiar or specific
action, but not malignant, I will first notice
HYPERTROPHY OF THE BREAST,
Especially that, which M. Velpeau names glandular, is more frequently
met with in the Indies, America, England, and Germany, than France.
The principal cause of hypertrophy of the breast is ascribed by Sir Astley
Cooper to celibacy ; and, according to his observations, it occurs princi-
pally between the ages of thirty and thirty-five. He mentions a girl,
only fifteen years old, whose breast, of a pyriform shape, and extending
over the abdomen, was twenty-three inches and a half in circumference.
One case is also recorded, in which the breast descended to the knees,
and weighed thirty pounds. Others deem the age of puberty that in
which this hypertrophy is chiefly noticed. As the swelling is not at first
attended with pain, nor with any serious functional disturbance, its com-
mencement does not excite much attention. The menses, however, are
lessened in quantity, or are irregular, or even suppressed. The voice is
also affected, and patients seem hoarse.
As the state of the mammae is intimately dependent upon that of the
womb, M. Velpeau regards marriage and pregnancy as the most likely
mode of checking hypertrophy of the breast. The internal exhibition of
iodine is also recommended, with iodine baths, and then rubbing the
breast with an ointment, containing either the ioduret of lead, the iodide
of potassium, or mercury. A vegetable diet is preferable to animal food,
and a suspensory and compression are not to be neglected.
HYDATID TUMOURS
Were so named by Sir Astley Cooper, who has described several forms
of them. Since the expression hydatid would lead us to suppose, that
the disease always consisted, not of adherent cysts, but of detached glo-
bular ones, endued with separate vitality, independent of the texture in
which they are formed, many surgeons prefer the term cysts of the
breast.
The tumour is characterised by a tendency to increase to a considerable
size ; but it is not prone to malignant change ; nor does it occasion any
inconvenience, except what proceeds from its bulk. At first, it feels en-
tirely solid, but after a time a fluctuation can be distinguished at certain
points. The tumour is very moveable and pendulous. Sometimes the
cysts ulcerate, discharge a serous fluid, and then heal, or even become
obliterated. No local applications are of any service. If there be only
one large cyst, and it be punctured, sometimes it will not fill aga^jn. The
only reason for removing this kind of disease, when it becomes large, is
to relieve the patient from the annoyance produced by its bulk. All the
swollen and indurated parts must be taken away, for if any small cysts
remain behind, the disease will recur. The glands in the axilla are either
free from disease, or only enlarged from irritation. M. Velpeau doubts
whether the extirpation of a serous cyst of the breast is ever indispens-
ably necessary. He would prefer making a puncture with a small trocar,
emptying the cyst, and then injecting a lotion consisting of 5ij. of the
528 DISEASES OF THE BREAST.
tincture of iodine in each ounce of water. He has tried the plan, how-
ever, only in one case, but with complete success.*
As for swellings of the breast consisting of globular kydatids, an incision
should be made in them, and the bag extracted, after which the part will
heal. The disease is characterised by a central fluctuation, a solid circum-
ference, and freedom from tenderness on pressure. The disease is of an
innocent nature. Dr. Warren describes one case, in which the tumour
weighed twelve or thirteen pounds.f
CHRONIC MAMMARY TUMOUR.
The substance of the female breast is liable to a slow kind of induration,
— a swelling that grows from its surface rather than from its interior, and
therefore seems to be superficial, except when it grows from the posterior
surface of the breast. It is exceedingly moveable ; not buried in the mam-
mary gland, but only connected to its surface ; not generally painful, nor
tender when touched; its growth is slow ; and its weight seldom more than
from one to four ounces. It is not malignant, and often remains stationary
for years, and then disperses. The disease seldom occurs in persons after
the age of thirty.
The tumour, when taken out and examined, is lobulated, and at first
view something like the mammary gland itself: it is contained in a cyst.
The cause of the chronic mammary tumour is generally sympathy of the
breast with the uterus, producing great determination of blood to the part ;
but blows and the pressure of stays may likewise excite it.
When the digestive functions are deranged, we may try the com pound
calomel pill at night, with the infusion of calumba and rhubarb and car-
bonate of soda twice a day. When the uterine functions are disordered,
we may prescribe small doses of the blue pill, with extract of colocynth
and steel medicines.
Sometimes the tumour yields to the internal and external use of iodine.
The emplastrum ammoniaci cum hydrargyro is a common application.
The disease does not require to be extirpated, nor, as Sir Astley Cooper
observes, is it any impediment to matrimony; for, in fact, pregnancy and
suckling rarely fail to make it disappear.
SCROFULOUS SWELLINGS OF THE BREAST
Are occasionally seen in young women, who have enlarged lymphatic
glands under the jaw. In general, there is only one tumour, and it is
exceedingly indolent. There is no disposition to malignancy, and, of
course, it would be improper to have recourse to extirpation. The treat-
ment is like that of scrofulous diseases in general.
IRRITABLE TUMOUR OF THE BREAST.
The breast is sometimes the seat of severe pain, without any distinct
or perceptible swelling. Such an affection might be called neuralgia of
the breast ; but occasionally, besides excessive pain in the part,, there is
also a tumour, composed of a structure unlike that of the gland itself, and
which therefore appears to be a specific growth. When the glandular
structure is the seat of it, one or more of its lobes become exquisitely
tender; and, if handled, the pain will sometimes continue for several
hours, extending to the shoulder, axilla, down the arm, and even to the
* Op. cit. p. 70. f Warren on Tumours, p. 20C.
WOUNDS OF THE BELLY. 529
side of the body. When the pain is most severe, which is often the case
prior to menstruation, the stomach frequently sympathises, and the patient
is troubled with vomiting. The irritable tumour is most common between
the ages of 16 and 30.
Sometimes a distinct circumscribed tumour is noticed, highly sensitive
to the touch, acutely painful at intervals, more especially just before men-
struation, very moveable, often not larger than a pea, and rarely exceed-
ing the size of a marble. Although the disease may continue for years,
it varies but little in size, hardly ever suppurating, but occasionally
disappearing of itself. In the general account of tumours, I have al-
ready noticed this disease, under the name of painful tubercle^ as affecting
other parts. The tumour, when taken out and examined, is found to be
composed of a solid semi-transparent substance, with fibres interwoven
with it; but, according to Sir A. Cooper, no large filaments of a nerve
can be traced into it.
Equal parts of soap cerate and extract of belladonna may be applied ;
or a bread poultice made with a solution of the same extract. Or the
part may be protected with a piece of oil-skin or hare-skin. Leeches are
proper during the violence of the pain.
As internal remedies, we may try calomel with opium, and hemlock
with purgatives. If the menstrual secretion be interrupted, the mistura
ferri comp., combined with aloes, may be prescribed.
The breast is also liable to the greater number, if not all the varieties,
of tumours noticed in our first section.
THE ECCHYMOSE DISCOLOURATION OF THE BREAST
Is a morbid change, sometimes occurring in young women at the time of
menstruation, preceded by severe pain in the breast and arm. Velpeau
notices its occurrence also sometimes in women arrived at the critical
age. The extravasation of blood makes its appearance as a large spot,
with smaller and less conspicuous ones in other places. In general,
it gradually disappears after menstruation. According to Sir Astley
Cooper's views, the indications are, 1st, to render the menstrual discharge
more regular, by means of steel medicines ; and, 2d, to support the
strength by means of sulphate of quinine, given with infus. rosae comp.
The best local application is the liq. ammon. acet. with spirit of wine, five
ounces of the former to one of the latter. M. Velpeau does not consider
any active treatment usually requisite, as the discolouration and pain
almost always subside of themselves in a fortnight or month ; but, if a
contrary case presented itself, he would try one general bleeding, leeches
to the breast, a discutient lotion, and purgatives and emmenagogues.
With respect to the third class of diseases of the breast, or the malig-
nant, it comprises scirrhous and medullary cancer, the nature of which
has been treated of in the first section of this work.
WOUNDS OF THE BELLY
Are divided into two principal classes : in one, the solution of continuity
is confined to the integuments, muscles, &c. exterior to the peritoneum ;
in the other, this membrane is penetrated, and frequently some of the
viscera. Wounds, which do not extend through the peritoneum, are not
materially different from those of ordinary textures, and are to be treated
U M
530 WOUNDS OF THE BELLY.
on principles applicable to wounds in general. However, if the injury
penetrate more deeply than the integuments, the parietes of the abdomen
generally remain weakened at the part ; and, firm as the cicatrix may
appear, if it be not supported with a bandage, it is liable to become the
seat of ahernial protrusion.* Severe contusions of the skin and muscles
of the belly are also sometimes followed by such an incapacity of resist-
ance in them, that they yield to the pressure of the contained parts, and
a particular kind of hernial tumour is the consequence.
A spent ball, striking the belly, may rupture the rectus muscle and
aponeuroses of the abdominal muscles, so as to produce at once a pro-
trusion of the viscera ; while the integuments, on account of their greater
elasticity, continue unbroken.f In other examples, the ball, in its rota-
tion over the circumference of the abdomen, not coming against any hard
projecting part, depresses the parietes of the belly, and produces deeper
mischief amongst the viscera, succeeded by inflammation, a copious
effusion of bloody serum in the cavity of the peritoneum, and other fatal
effects.:); In a case that had a favourable issue, a cannon ball carried
away the integuments, a piece of the left os ilium, and the attachments
of the broad muscles of the belly, exposing a part of the sigmoid flexure
of the colon. §
Sometimes, in consequence of punctured wounds, or violent blows,
matter forms in the tendinous sheath of the rectus muscle ; and when the
abscess bursts, or is opened, several pints of pus are unexpectedly dis-
charged. The nature of this case should be remembered, as there is
frequently no change of appearance in the integuments, denoting either
the suppuration, or its extent. Such an abscess ought always to be opened
early, and in a depending situation. The same practice is advisable, when
purulent matter collects between the layers of abdominal muscles, or be-
tween these muscles and the fascia transversalis, and the peritoneum.
Except when a wound of the belly is free and direct, attended with
protrusion of the bowels, or the escape of feces, chyle, fetid air, bile, &c.,
the fact of its having penetrated the cavity of the abdomen is generally
somewhat obscure. Authors do, indeed, advise us to compare the direc-
tion of the stab with the ordinary thickness of the abdominal parietes at
the wounded part, and the breadth of the wound with that of the weapon
with which the injury has been inflicted. When the instrument has en-
tered perpendicularly at a place where the parietes are thin, and when,
notwithstanding the narrowness of the end of the weapon, the division is
rather broad, it is inferred that the wound is of the penetrating kind.
This mode of judging, however, must generally be fallacious, on account
of the frequent impossibility of learning the exact direction of the thrust,
or of obtaining a sight of the instrument. Also when a probe will pass
perpendicularly into the wound for a certain distance, it is concluded,
that the injury extends into the abdominal cavity. But it must not be
positively inferred, that the wound does not penetrate because a probe
* Richerand, Nosogropbie Chir. t. iii. p. 322. ed. 2. Sclunucker relates a case, which
followed puncturing an abscess of the abdomen with a lancet, Vermischte Chirurgische
Schriften, band. i. p. 197. See also a case by Wardrop, in Sir A. Cooper's work on
Crural and Umbilical Hernia, p. 60.
f Larrey, Mem. de Chir. Mil. t. iii. p. 882.
J Op. et vol. cit. p.. 334.
§ See in Hennen's Mil. Surgery, p. 452., a case, in which nearly all the anterior
parietes of the belly were torn away, leaving the lacerated peritoneum exposed. The
injury was not immediately fatal.
WOUNDS OF THE BELLY. 531
cannot be thus introduced ; for its passage may be stopped by the several
layers of muscles not having exactly the same situation with respect to
each other which they had at the moment of the injury. In short, unless
the wound be straight, a probe can hardly be made to follow its course.
The local symptoms, then, of a simple penetrating wound are frequently
not to be depended upon, and the employment of probes and injections
for ascertaining the point is more likely to do serious harm than real good.
Nor can certain information always be deduced from a consideration of
what may be called the general symptoms ; a small, feeble, contracted
pulse ; pallid countenance ; cold extremities ; great and sudden debility ;
hiccough ; vomiting ; and spasms. Several of these effects frequently
take place in irritable, timid, nervous subjects, without any parts being
injured in addition to the skin and muscles ; and they are frequently ab-
sent when the weapon has actually entered the peritoneum. I am far
from meaning to say, however, that such indisposition is to be disregarded ;
on the contrary, it seems to me, that particular attention ought to be
paid to the symptoms in question ; because, if they do not soon subside,
there are then strong grounds for suspecting something more than the
effects of a common superficial wound on an irritable, timid subject. But,
in the beginning, unless the wound be large, or a protrusion of the vis-
cera, or a discharge of bile, chyle, or feces, take place, there is generally
a degree of uncertainty with respect to the depth of the injury. At the
same time, it is not to be concluded that the wound does not penetrate
because no protrusion nor extravasation happens ; for a narrow stab may
extend into the abdomen, even amongst the viscera, without giving rise
to either of these accidents.
There is in these cases a class of symptoms which Richter* and
other writers denominate particular, from their evincing what bowels are
wounded ; as, for instance, bloody urine, when the kidneys and urinary
bladder are injured ; vomiting of blood, when the stomach is pierced ;
discharge of blood with the feces, when the large intestines are wounded.
Symptoms like these must of course throw considerable light on the
nature of the accident.
With regard to our not being always able to pronounce whether a wound
penetrates the cavity of the belly or riot, the want of precise information
on this point is of little practical importance ; for, if the case be not
complicated with any urgent symptoms, the treatment should obviously
resemble that of a simple wound.
The principal dangers of penetrating wounds of the belly partly arise
from internal haemorrhage, or extravasation of the contents of the viscera;
but, in a still greater degree, from the strong disposition of the peritoneum
to inflammation. With the exception of persons who die instantly, or in
a few hours, from internal bleeding, &c., nine tenths of those who die
from penetrating wounds of the belly, are cut off by peritonitis. They
who perish with extravasation of the contents of the bowels, also die in
fact from peritonitis, which is generally excited partly by the mjury, and
partly by the irritation of the effused matter. Many authors represent
the danger of a penetrating wound of the belly, as principally arising
rrom the entrance of air into the cavity of the peritoneum. But,
According to my ideas, it is the wound itself that excites the peritonitis,
by which the patient is destroyed; and the same fatal inflammation
would come on with equal frequency, were the wound entirely excluded
* Anfangsgr, der Wundarzn, b. v. p. 7.
M M 2
532 WOUNDS OF THE BELLY.
from the air. The cavity of the belly is always so completely occupied
by the viscera, that the whole inner surface of the peritoneum is con-
stantly in close contact with them, and, therefore, the air cannot so
easily enter within that membrane as some writers seem disposed to
believe.
WOUNDS IN WHICH THE VISCERA PROTRUDE, BUT ARE UNINJURED.
When a portion of intestine or omentum protrudes, the sooner it is
returned, the more effectually will the irritation, arising from its exposure
and constriction be prevented. Fomenting the protruded bowels, as is
sometimes recommended, would be absurd ; for what application can be
so congenial to them, as the natural warmth and moisture of that cavity
into which they ought to be immediately reduced ? And is it possible
to suppose, that the efficacy of any artificial fomentation will make amends
for the harm, resulting from continuance of the bowels in a state of ex-
posure and constriction ? In order to promote the reduction, the muscles
of the abdomen should be relaxed ; but, whether we ought to waste any
time in giving clysters to empty the large intestines, previously to at-
tempting to return the parts, is a question, on which I entertain the same
sentiments as those delivered on the subject of fomentations. The me-
sentery is always to be returned before the intestine ; and the intestine
before the omentum ; but the last protruded portion of each of these
parts ought to be first reduced. In the reduction, care must be taken
that the bowels are completely returned into the abdomen, and are not
pressed between the layers of the abdominal muscles, or into the sheath
of the rectus muscle.
When the distension of the protruded intestine with air or feces creates
a difficulty of reduction, its contents may frequently be gradually pressed
into that portion of the intestinal canal which is within the abdomen,
and the gut may then be returned. But, if this plan were attended with
difficulty, I should prefer dilating the wound to much handling of the
bowel.
When the protruded bowel is distended with air, Pare and others re-
commended making small punctures in it with a needle, so that the air
may escape, and the intestine collapse. This proposal is justly rejected
from modern surgery, both on the grounds of danger and inefficacy.
The small apertures made with a round needle will not discharge the air ;
for they are closed by the mucous coat*, and the making of larger punc-
tures, as suggested by Desaultf , would be far more dangerous than di-
lating the wound. When it is absolutely necessary to enlarge the wound,
the dilatation should be made in a direction which will not endanger the
epigastric artery ; and, if possible, parallel to the muscular fibres.
When the protruded intestine is already inflamed, its immediate reduc-
tion is, beyond all dispute, the right practice. Even when the inflamma-
tion is severe, the reduction of the part without delay, and the employ-
ment of antiphlogistic means, will often prevent gangrene. The dull,
brown, dark-red colour of the protruded intestine, may induce the prac-
titioner to suppose, either that it is already gangrenous, or that gangrene
is inevitable, and, consequently, he may delay returning it into its
natural situation. But, notwithstanding this suspicious colour of the in-
testine, its firmness will evince that it is not in the state of gangrene,
* See Travers on Injuries of Intestines, &c. p. 176.
f Traite des Maladies Chirurg. toui. ii. p. 135. ,
WOUNDS OF THE BELLY. 533
and, therefore, its immediate reduction ought to be put in practice.
The recovery of a portion of intestine, so circumstanced, is always a
matter of uncertainty ; but the propriety of speedily replacing it in its
natural situation is a thing most certain. In case it should mortify,, after
being reduced, all hopes of the preservation of life are not to be aban-
doned.
When the omentum protrudes, and is strangulated by the narrowness
of the opening, it soon contracts adhesions. Richerand has recommended
us to cut off all this membrane which exceeds the level of the integu-
ments, and not to trouble ourselves about the remainder, which, he
asserts, will act like a stopper, and hinder a future hernia. If adhesions
had already been formed, this practice would, perhaps, be the best, but
under other circumstances, if the omentum were sound and free from
constriction, it should unquestionably be reduced without delay. In cases
where this membrane, besides protruding, is in a gangrenous state, cer-
tain writers authorise the excision of the dead part, and the reduction
of the rest, each of the bleeding vessels having been first tied with a
small silk ligature. It will be found, however, that whenever the omentum
has been out so long as to slough, adhesions within the wound have had
time to form ; an event which would embarrass the operator, and con-
stitute a decided prohibition to the attempt. The reduction having been
effected, the patient is to be laid upon his back, with the thighs some-
what raised or bent, and he must strictly avoid making any exertion,
lest he bring on another protrusion. The wound is then to be closed with
adhesive plaster, the uniting bandage, or a suture. Sewing up wounds
of the belly made a long subject, in all the old works on surgery, under
the appellation of gastroraphe, which was nothing more than a quill-suture,
practised by introducing the needle through both lips of the wound from
within outwards, in order to avoid all risk of pricking the bowels. In
Pibrac's* dissertation on the abuse of sutures, cases are related which
satisfactorily prove, that the majority of penetrating wounds of the belly
may be healed very well without it ; and if we wish for still more decisive
proofs of the fact, we may find them in accounts of the CaBsarean opera-
tion, the extensive wound of which has frequently been healed by com-
mon means. But, though sutures are not necessary for all wounds of the
belly, they may be useful under particular circumstances : for instance,
were the wound of a certain size, they might be indispensable to pre-
vent the protrusion or exposure of the bowels.
CASES WITH INJURY AND PROTRUSION OF THE VISCERA.
Penetrating wounds, attended with protrusion of the intestines or
omentum, are always to be regarded as dangerous cases ; but the danger
is much more serious, when a portion of the intestine not only protrudes,
but is wounded. Under such circumstances, we have the authority of
numerous writers on surgery, as a sanction of the practice of sewing
together the edges of the wound in the bowel; the true utility of which
practice, however, is now a disputed point. Even the advocates of
sutures here differ exceedingly, both as to the precise object in view, and
the way of making the stitches. Some advise only one stitch to be made
(frequently only through the mesentery) ; and they employ the ligature
* See Mem. de 1'Acad. de Chir. torn. iii. 4to. Other cases of similar success may
be perused in numerous works; Journal de Medecine, torn. Ixxi. ; Duncan's Medical
Commentaries, vol. x. ; Philosophical Transactions, vol. xvi. &c«
M M 3
534- WOUNDS OF THE BELLY.
chiefly with the view of confining the injured bowel near the external
wound, so that, in the event of any effusion, the matter may readily find
its way outward. Other writers wish to remove the possibility of ex-
travasation by applying numerous stitches, and attach little importance to
the plan of using the ligature principally for the purpose of keeping the
intestine near the external wound.
When the wound of a bowel is so small, that it is closed by the protru-
sion of the villous coat, the application of a suture must evidently be
needless. Supposing the breach in the intestine, however, to be some-
what larger, so as to be capable of letting the feces escape, what prac-
tice ought we to follow ? — As Sir Astley Cooper was operating upon a
strangulated hernia, an aperture, giving issue to the intestinal contents,
was discovered in a portion of sound bowel, just when the part was
about to be reduced. The operator, including the aperture in his
forceps, caused a fine silk ligature to be carried beneath the point of the
instrument, firmly tied upon the gut, and the ends cut off close to
the intestine. The part was then replaced, and the patient recovered.
Mr. Travers, who has related this fact, approves of the plan of cutting
away the extremities of the ligature, instead of leaving them hanging
out of the external wound ; for the remnant always finds its way into
the intestine, and is discharged by stool, without the slightest incon-
venience.*
We are next to consider the case, in which the protruded bowel is still
more extensively, or even totally, divided. Here the admirers of the
needle have found ample scope for their ingenuity ; and since very few
of them have met with cases exactly of this description in the human
subject, they have made a variety of experiments on animals, in order to
determine the right mode of treatment. Some of these reports are fa-
vourable to the practice of sewing up the wounded bowel. Ramdhor
is stated to have actually cut off a large part of a mortified intestine in
the human subject, and to have joined the sound ends together, by insert-
ing the upper within the lower one, and fixing them in this position with
a suture ; the ligature being also employed to keep them near the ex-
ternal wound. The patient recovered, and the feces afterwards passed
entirely the natural way.f About a year after the operation the patient
died, when the anatomical preparation of the parts was sent to Heister.
They were preserved in spirit of wine, and exhibited, according to this
last author, a union of the two ends of the bowel, and their consolida-
tion with a part of the abdomen. Now, it has been reasonably questioned,
whether the union here spoken of ever really happened. When the
upper end of the bowel is introduced into the lower, the external surface
of the former is put in contact with the inner one of the latter ; a serous
membrane is placed in contact with a mucous one. These heterogeneous
structures are not disposed to unite. The mucous membrane, when
inflamed, more readily secretes a kind of mucus, which must be an invin-
cible obstacle to adhesion. In the case related by Heister, the in vagi-
nation was probably maintained by the union of the intestine with the
corresponding part of the abdominal parietes. Several experiments on
living animals tend to prove, that the mucous membrane will not unite
with the external peritoneal coat. If this be a fact, it is of course a
* Inquiry into the Process of Nature in repairing Injuries of the Intestines, £c
pp. 112, 113.
f Haller, Disput. Anat. vol. vi. ; Obs. Mccl. Miscull. 18.
WOUNDS OF THE BELLY. 535
strong argument against repeating Ramdhor's practice. Another objec-
tion is, that the upper end of the bowel cannot be put into the lower one,
unless it be separated from a part of the mesentery, and a division of the
mesenteric arteries would cause a dangerous bleeding. In vain did Boyer
tie seven or eight of these vessels ; his patient died with an extravasation
in the abdomen.* The difficulties encountered by Moebius and Dr.
Smith in their attempts to repeat this experiment on animals, are related
in my Dictionary, and I need not, therefore, expatiate upon them. In
short, experience is decidedly adverse to Ramdhor's practice, either in its
original form, or modified by the ingenious introduction of cylinders of
isinglass, pasteboard, &c. Flajani tried the artifice on several patients
under his care in the hospital at Rome, but death was invariably
the consequence. f I am of opinion that Mr. Travers deserves the
thanks of the profession, for the attention and talent with which he has
investigated the subject before us ; but, with respect to the question of
sutures, I apprehend that he has gone too far, when he declares that, in
order to avoid abdominal effusion, the suture employed should be such as
will secure the absolute contact of the everted surfaces of the divided
intestine.^
When the intestine has been completely divided with a cutting instru-
ment, Scarpa§ is decidedly of opinion, that Ramdhor's operation cannot
be undertaken with any probability of success. But, setting out of the
question this bold method, at once so amusing and captivating to the in-
experienced student, this eminent professor offers a variety of arguments
against sewing the intestines at all, and asserts that in all cases of pe-
netrating wounds of the abdomen, attended with injury of the intestine,
ivhether the canal be opened longitudinally or transversely, a suture is
always not merely useless, but even dangerous and fatal. In whatever
manner it is practised, says he, one cannot avoid the evils which must
originate from the punctures, however few, and from the passage of the
ligatures through the coats of the intestine; a part endued with exquisite
sensibility, and whose external tunic is much disposed to inflame, and
rapidly to communicate the inflammation to all the other abdominal
viscera. It has (says Scarpa) been unfortunately proved, by the expe-
rience of several ages, that, in most of the cases in which the intestine
has been stitched in penetrating wounds of the belly, the patients have
died in the greatest agony. If a few escaped the dangers of this opera-
tion, it was only because in them the stitches soon cut their way out,
and were voided with the feces, which continued to escape from the
wound until it was entirely healed.
All surgeons of experience, and particularly those of large hospitals,
have often seen wounds of the right or left iliac region accompanied with
injury of the great intestine. They may also have noticed in these ex-
amples, that, after the subsidence of the local and general inflammatory
symptoms, the wound still continues to discharge feces for a certain time ;
but that afterwards it contracts, and the excrement resume^ its usual
course. These wounds almost always heal || completely: first, because
* Richerand, Nosogr. Chir. t. Hi. p. 345. &c., edit. 4.
f Collezione d'Osservazioni, &c. di Chirurgia, tomo iii. p. 60. 8vo. Roma, 1802.
j Inquiry into the Process of Nature in repairing Injuries of the Intestines, p. 121.
and p. 134.
§ Sull' Ernie Memorie Anatomico-Chirurgiche ; mem. iv. fol. Milano, 1809.
|| See Larrey's Mem. de Chir, Mil. t. ii. p. 161.
M M 4
536 WOUNDS OF THE BELLY.
the adhesion of the large intestine to the parietes of the abdomen pre-
vents the feces from being extravasated in the cavity of the perito-
neum ; and, secondly, because the ample capacity of the same bowel
always presents a ready passage for the feces, notwithstanding the pro-
gressive, and sometimes quick, closure of the external opening.
If, in the instance of a penetrating wound of the belly, attended with
injury of the small intestines, it were in the surgeon's power (as indeed
it is) to return the bowel into the abdomen, so that the opening in it may
exactly correspond to the wound in the abdominal parietes, there could
not be a doubt of its quickly acquiring adhesions to the peritoneum,
which lines the part around the internal orifice of the external wound.
Hence, the feces would readily escape from the outer wound, and at
length the artificial anus would close, and the feces resume their natural
course, just like what happens in wounds of the large intestines. The
narrow diameter of the small intestines would not make an insurmount-
able obstacle to the passage of the feces, if these were, as they usually
are, in this part of the alimentary canal, in a sufficiently fluid state ; and
besides (as Scarpa observes), is it not proved by experience, that they
resume their natural course, after the cure of an artificial anus, even when
a considerable noose of the small intestines has been destroyed by gan-
frene, and when the two ends form by their reunion a very acute angle ?
carpa then feels no hesitation in admitting the possibility of curing
wounds of the small intestines, without having recourse to a suture. It
would not, he says, be difficult to quote examples of such cures ; and one
is related, which fell under his own observation. He afterwards describes
the incessant pressure made by the abdominal muscles and diaphragm
upon all the viscera, as the cause which makes the wounded intestine
enter the external wound, and soon adhere to its edges, instead of
quitting it. When these adhesions are formed, all danger of extravasa-
tion is over. He observes, that one should neglect no remedies, internal
as well as external, which may be of use in moderating the patient's
sufferings, diminishing the impetus of the circulation, and bringing the in-
flammation down to the degree suited to the formation of adhesions. He
recommends keeping the external wound open, with the same precau-
tions, and according to the same indications, which are to be attended to
in the treatment of an artificial anus. The principal object of these pre-
cautions is to let the treatment be such, that the external wound may
only diminish in proportion as the evacuation from the lower part of the
intestinal canal increases.
The very nature of the process, by which the reparation of wounds of
the bowels is effected, is a weighty argument against the employment of
a suture. In their cicatrisation, they follow quite a different course from
that of simple wounds of the skin, muscles, or any other parts of the body.
Their edges never become immediately applied to each other, and there-
fore, strictly speaking, they do not reunite. Their cure is altogether
completed through the medium of the surrounding parts ; that is to say,
by the adhesions which the intestines contract with the great sac of the
peritoneum lining the cavity of the abdomen, or with the productions of
this membrane, which compose the external covering of the greater part
of the viscera.*
Even from the description which Mr. Travers has given of the process
of reparation, in the cases where sutures are employed, we may conclude,
* See case recorded by Littre in Acad. Royale des Sciences, an. 1705.
4
WOUNDS OF THE BELLY. 53?
that the stitches can be of little service; for, says he, " the action of the
longitudinal fibres being opposed to the artificial connection, the sectioJis
mutually recede as the sutures loosen by the process of ulcerative absorp-
tion." * Unless, therefore, it be allowable to suppose, not only that the
divided portions of bowel can be sewed together so closely and accurately
at every point as to remove all possibility of effusion of its contents, but
that this can also be done without risk of exciting inflammation of the
bowel, thus handled, dragged, and stitched, I must fully agree with
Scarpa, respecting the impropriety of thus boldly sewing up wounds of
the bowels with as little scruple as a hole in a glove.
In some former editions, I have said, that if a case were to present
itself, in which a protruded intestine were extensively cut, or its whole
diameter completely divided, I should venture to make a single stitch
with a small needle and piece of fine silk. But subsequent reflection and
information make me doubt whether this limited employment of the
needle would be necessary ; and if not necessary, it would undoubtedly
be improper. The following case, which, as well as Ramdhor's memorable
experiment, is at variance with another statement, that wounds amount-
ing to a direct division of the canal are irreparable, and therefore invari-
ably fatal •]-, furnishes an unequivocal proof, not only that an intestine may
be completely cut through, and the injury not always be fatal, but that
the cure may be effected without any stitching whatever of the bowel.
At the assault of Cairo, in 1799, M.N was struck by a ball, which
divided the muscular parietes of the abdomen, and a portion of the ileum.
The two ends of the bowel protruded, were separated from each other,
and very much distended. The upper end was everted, its contracted
edge strangulating the intestinal tube, as the prepuce does the penis in
paraphymosis. The progress of the contents of the bowel being thus
obstructed, they accumulated above the constriction. Larrey began with
making four small incisions in the constricted part of the intestine ; he
then passed a ligature through the portion of mesentery corresponding
to the two ends of the bowel ; reduced them as far as the edge of the
opening, which he took care previously to enlarge; and, having dressed
the wound, he awaited events. Without detailing the subsequent par-
ticulars of the case, suffice it to say, that in a few months it ended in a
perfect recovery .J
It is curious that Flajani, who has so decidedly reprobated Ramdhor's
practice, and mentioned facts against it from his own experience, should
recommend stitching a wounded and protruded bowel in any manner ; for,
with the exception of his unfortunate trials of inserting one end of the
bowel into the other, in the cases which occurred in the hospital at Rome,
he records only two instances in which he stitched the intestine, and, in
both these, the bowel became gangrenous, and the patients lost their
lives. § We may therefore infer, with Mr. John Bell, " that if there be a
work of supererogation in surgery, as 1 believe there are but too many,
surely this of sewing an intestine is one." || 9
Every reflection, then, which I can make on this subject leads me to
* Inquiry into the Process of Nature in repairing Injuries of the Intestines, p. 28.
f Op. cit. p. 133.
{ Larrey, M£m. de Chir. Militaire, t. ii. pp. 160, 161.
§ Collezione d'Osservazioni, &c. di Chirurgia, t. iii. p. 35 — 41. In one case, the
protruded bowel was a portion of jejunum ; in the other, a piece of colon.
|| Discourses on the Nature and Cure of Wounds, edit. 3d, p. 320.
538 WOUNDS OF THE BELLY.
adopt Scarpa's sentiments in relation to sutures, and the indications,
which should be fulfilled. The chief indication, and that on which the
patient's safety mainly depends, consists in keeping the external wound
open, in order that the feces may find a ready outlet. The wounded
bowel soon contracts adhesions to the inner lips of the wound of the belly,
and then we have nothing to fear from an extravasation of intestinal
matter in the cavity of the peritoneum. .Afterwards, in proportion as the
feces resume their natural course, the external wound is to be allowed to
diminish, and entirely heal up.*
In every instance of a penetrating wound of the abdomen, attended with
injury and protrusion of a portion of the intestinal canal, if the patient be
not already in a hopeless or dying state, from internal hemorrhage and
other lesions, the displaced part is to be reduced, whatever we may
choose to do in respect to the free or limited employment of stitches, or
their absolute rejection. The reduction should be performed as speedily
as possible, before the bowel has suffered much from exposure, con-
striction, &c., and also before any adhesions have formed at the inner
orifice of the external wound; adhesions which would make the reduction
of the protruded part impracticable. Of course, when the wound is so
small, that the reduction cannot be effected without handling and bruising
the bowel immoderately, it ought to be carefully enlarged with a curved
bistoury, guided on a director. Indeed, according to Scarpa's principles,
one would suppose that the wound, if not free, should always be dilated,
as by this means the ready escape of any extravasated matter would be
insured. The rest of the treatment consists in antiphlogistic measures,
more especially copious and repeated venesection, with the view of
counteracting the danger of peritoneal inflammation. With respect to
the dressings, they cannot be too light, simple, and superficial, except
when the stoppage of evacuation in the natural way, and the issue of the
intestinal contents from the breach in the bowel, are such as to lead us
to adopt particular means for hindering a premature closure of the
external wound. The tepid water dressing is one of the best.
The pressure of the elastic bowels, and of the diaphragm, and abdo-
minal muscles, not only frequently presents an obstacle to the wide dif-
fusion of extravasated matter, but often propels it towards the external
wound.f We can conceive no power capable of overcoming the resist-
ance so produced, to the extensive dispersion of extravasated fluids in the
cavity of the abdomen. Numerous cases are on record of persons being
stabbed, or shot through the body, without any effusion in the abdomen,
or other very serious consequences. In some few of these instances, the
bowels, perhaps, might have eluded the ball, or point of the weapon; yet
it is highly probable that, in most of them, the bowels were injured, and
that an extravasation of the intestinal matter was impeded by the pressure
to which I have referred. In many of the cases, the intestines were
known to be wounded.;}:
* Scarpa sull' Ernie Memorie Anatomico-Chirurgiche; mem. 4.
•j- On this subject, I would particularly recommend the reader to consult two essays
by M. Petit le Fils, one entitled " Essai sur les Epanchemens et en particulier sur les
Epanchemens de Sang;" the other, " Suite de 1'Essai sur les Epanchemens," in Mem.
de 1'Acad. de Chir. torn. ii. and iv. 12mo.
{ Recoveries are recorded in Wiseman's Surgery, p. 371. (Euvres de Pare, liv. x.
chap. 3,5. ; La Motte, Traite Complet de Chir. Albucasis, lib. ii. cap. 2C. j Ravaton,
Traite des Plaves d'Armes-a-Feu, ch.ip. 6., &c. &c.
WOUNDS OP THE BELLY. 539
PENETRATING WOUNDS, ATTENDED WITH INJURY OF THE VISCERA,
BUT NO PROTRUSION.
A wound of the intestines is indicated by the discharge of blood with
the stools, and sometimes by the escape of fetid air, or of intestinal
matter from the external wound. Such an injury, however, when the
wounded bowels lie concealed in the belly, does not always admit of being
immediately known with certainty. In the majority of examples, there
is at first no escape either of air, or of the contents of the bowels, from
the external wound ; the quantity of blood voided per anum may be in-
considerable ; and however this may be, none at all will generally be
discharged downwards, until a certain time after the accident. Wounds
of the small intestines, especially of the duodenum and jejunum, are
indeed usually followed by great anxiety, paleness of the countenance,
syncope, cold perspirations, and a small, intermitting, tremulous pulse ;
but these symptoms are far from being unequivocal, and they cannot be
said to furnish any positive information, because a superficial cut, or
unimportant stab, frequently causes similar indisposition in subjects of
nervous, irritable, or timid habits. Our inability, however, to say posi-
tively in every case, whether the bowels are injured or not, is of no
practical importance ; because, when the nature of the accident is not
clearly manifested by some peculiarity or severity of the symptoms, the
case ought to be treated on common antiphlogistic principles; and^also,
when circumstances leave not the smallest doubt of the intestines being
hurt, the same treatment is the only rational plan. Wounds of the small
intestines are more dangerous than those of the large, and the nearer the
injury is to the pylorus, the greater is the risk. Such cases are also
much more frequently than injuries of the large intestines the cause
of extravasation. In the latter examples, the symptoms are generally
milder, and either the passage of the intestinal contents outward through
the wound more easy and certain, on account of the bowel being more
fixed than the rest of the intestines ; or their passage towards the anus
more ready, by reason of the greater capacity of the ccecum, colon,
and rectum.
There are several other facts, highly interesting, and absolutely neces-
sary to be remembered in relation to wounds of the bowels : my limits,
however, oblige me to pass over the rest of this subject with as much
brevity as possible ; for which, the fuller account in my dictionary will
also afford a just excuse. Were it not for these considerations,, I should
have felt myself obliged to enter into explanations of the particular ap-
pearances presented, as well by punctured wounds, as by transverse and
longitudinal cuts in the intestinal canal ; and to comment on the circum-
stance of small punctures being obliterated by the protrusion of the
villous coat. I should also have had to point out the results of Mr.
Travers's experiments on dogs, proving that, in these animals, a division
of the small intestine as far as the mesentery is always fatal ; tlpt gene-
rally in wounds of the intestinal canal, the retraction, immediately follow-
ing the injury, is a chief obstacle to its reparation ; and that longitudinal
wounds of the bowels are more easily repaired than such as are trans*
verse. This tendency of the two portions of a divided bowel to recede
from each other, tends to show, that the only mode of spontaneous re-
paration consists in the formation of an adventitious canal, by the
encircling bowels and their appendages.
In the preceding remarks, I have adduced many arguments, casting
540 WOUNDS OF THE BELLY.
doubt on the propriety of sewing up a wound in a protruded bowel ; but,
when the injured intestine lies in the cavity of the belly, the rashest sur-
geon, the greatest admirer of needles, would never think of ripping open
his patient for the sake of performing so cruel and fatal an experiment.
In fact, as I have already stated, we rarely know at first that the bowel
is injured ; for extravasation, as will be presently related, is not the most
usual consequence of a wound of an intestine : when it happens, the ex-
travasated matter does not always flow out of the external wound, and
indicate the nature of the accident ; and, if an extravasation should be-
come manifest in a later stage of the case, it would then be impossible
to get at the wound of the bowel, on account of the adhesions, which
generally form with surprising rapidity. Even if the wound of the intes-
tine were known to exist directly after the receipt of the injury, and a
suture were not objectionable, on grounds already detailed, it could not
be applied without enlarging the external wound, searching for the
wounded bowel, and drawing it out of the cavity of the abdomen. By
these steps, a wound, not at first essentially fatal, might be so altered for
the worse, as to leave no possibility of recovery. When an intestine is
first found to be wounded, from the occurrence of extravasation, a day or
two after the injury, a suture is entirely out of the question, as by this
time the part is entirely fixed in its situation by the adhesive inflamma-
tion, — that salutary process, which also circumscribes the effusion, and
throws out an effectual partition between the extravasated fluid and the
general cavity of the peritoneum.
When the wound of the intestinal canal is situated in the abdomen,
closely behind the external wound, a suture is also unnecessary, because,
if care be taken to keep that opening from closing too soon, the contents
of the gut will be discharged outwardly, and there will be no reason to
fear their diffusion among the viscera. Nor is the wounded bowel at all
likely to slip away from the outer wound^ if the patient be kept duly quiet
for a few hours, after which the adhesions render a change in the situation
of the bowel quite impossible.
In a penetrating wound of the abdomen, caused either by gunshot or a
pointed instrument, if no protrusion of intestine take place, the lancet,
abstinence, and quietude, should be our chief dependence. In short, as
the main danger is inflammation of the peritoneum and bowels, the rigo-
rous adoption of antiphlogistic treatment is indispensable. Pain and
tension must be relieved by leeches, fomentations, and the warm bath ;
and if any purgative medicine be given (which, however, I think should
never be done before time has been afforded for the formation of adhe-
sions), it should be of the mildest description possible. Castor oil is
perhaps the safest which can be employed. In these cases, indeed, clys-
ters are generally to be preferred to any other means of emptying the
bowels. By the simple observance of an antiphlogistic plan, wounds, in
which several folds of the bowels were hurt, have been happily cured.
Authors abound with instances of this kind. One related by Littre, I
have already referred to in this chapter. Garengeot and La Motte record
others ; and Dr. Hennen has seen several : one was the recovery of a
soldier, who had been shot through the abdomen with a ramrod at the
siege of Badajos, in 1812. The instrument entered the front of the ab-
domen, and actually stuck in the vertebrae, from which it could not be
disengaged without force.*
* Obs. on Military Surgery, p. 436, 437.
WOUNDS OF THE BELLY. 54-1
Patients, who have recovered from wounds of the bowels, should after-
wards be extremely temperate in their diet, and, above all things, avoid
taking any kind of flatulent, stimulating, indigestible food. They must
also be very careful to keep their bowels regular.
In all cases of penetrating wounds of the belly, the dressings should be
light, simple, and superficial. If excrementitious matter be discharged
from the opening, the utmost attention must be paid to cleanliness. We
should also recollect the precept inculcated by Scarpa, viz. that the ex-
ternal wound should only be allowed to close, in proportion as the feces
resume their natural course, with ease and regularity.
Sometimes the intestinal matter continues to be discharged for a con-
siderable time from the wound, and even during the rest of the patient's
life, either through a fistula, or an artificial anus. In general, however,
this affliction gradually ceases. In almost every collection of cases, we
may find examples fully proving, not only that simple stabs of the bowels
in the end get well, without leaving a permanent annoyance of this kind,
but that large portions of the bowels may even be destroyed by gangrene,
and yet the continuity of the intestinal tube be completely re-established.
From the facts quoted in this chapter, it would also appear, that a com-
plete division of a bowel is neither certainly fatal, nor necessarily followed
by an irremediable artificial anus.
Balls, shot into the abdomen, are occasionally discharged with the
stools.
EXTRAVASATION.
An occasional consequence of a penetrating wound of the abdomen is
an extravasation in the cavity of the peritoneum. The extravasated mat-
ter may be undigested food, chyle, the succus pancreaticus, feces, bile,
urine, blood, &c., according to the nature of the injured parts. Fortu-
nately, this kind of accident is far less frequent than an inexperienced
surgeon would apprehend, or than our hearing so much of the cavity of
the abdomen would lead us to expect. Strictly speaking, no empty space
exists within the animal body ; and all the parts, contained in the abdo-
men, are in close contact with one another, and with the inner surface of
the peritoneum. Hence, except under particular circumstances, though
the bowels may be wounded, extravasation is generally prevented alto-
gether ; or when it does happen, the effused matter may all lie in one
mass, and become circumscribed by the adhesive inflammation.
If, immediately after a wound of the belly, and of its contents, it be the
compact state of the contained and containing parts, which at first hinders
extravasation, it is that salutary process, the adhesive inflammation, which
afterwards renders the occurrence quite impossible; or bounds or circum-
scribes the effusion, if it should have already taken place. In fact, all the
surfaces in contact with each other, and surrounding the track of the
wound, become generally so intimately connected together, by the ad-
hesive inflammation, that the wound forms a sort of canal, entirelyflestitute
of all communication with the cavity of the peritoneum ; and the rapidity
with which such adhesions occur is very great.
According to the investigations of Mr. Travers, the following are the
only circumstances, in which an effusion of the intestinal contents can
happen. If the gut be full, and the wound extensive, the surrounding
pressure is overcome by the natural action of the bowel tending to the
expulsion of its contents. But, in defect of either of these states, effusion
cannot follow. When, however, air has escaped from the bowel, or blood
54-2 WOUNDS OF THE BELLY.
has been extravasated in quantity within the abdomen, at the time of the
injury, the resistance made to effusion will be less effectual, although the
pressure of the sides of the abdomen is the same, as such fluids will yield
more readily than the solids naturally in contact with each other. Effu-
sions more generally follow ruptures of the bowels by blows or falls
upon the belly, than ordinary penetrating wounds.*
When an extravasation is perceived, in the first instance, a part of the
wound is to be left open, and the posture of the patient is to be so regu-
lated, that the wound may be as depending as possible, and the effused
fluid readily escape. If the extravasation should not be perceived till
after the wound has been dressed, we are directed to remove the means
employed to close a part of it, and to place the patient in a proper pos-
ture, with a bandage applied round his body. When internal hemorrhage
is suspected, and the state of the pulse will admit of it, venesection is
proper.
When symptoms of irritation exist, attended with local inflammation,
pain, and a fluctuating tumour, denoting the seat of the extravasation,
the effused fluid is to be let out by a puncture.f In the Memoirs of the
Academy of Surgery may be found observations, recorded by Petit and
Le Vacher, illustrating the advantages of such treatment.
When there are no symptoms denoting the exact seat of the extravasa-
tion, the treatment should be restricted to the prevention, or diminution,
of inflammation. Venesection is to be resorted to, or not, according to
the state of the pulse ; the belly fomented two or three times a day ;
and only liquid aliment allowed, sometimes merely barley water. In
some cases, a bandage is applied round the body, as a means of promot-
ing that compact state of all the parts in the abdomen by which the ill
consequences of extravasations are so materially diminished.
Musket balls may pierce and lodge in the bladder, in which circum-
stances a surgical operation, resembling lithotomy, will become neces-
sary, as soon as the dangers of the first injury are past, f In wounds of
the bladder, a great deal of difference in the degree of danger will depend
upon whether this organ happens to be full of urine at the time of the
accident, and whether the injured part of it is one over which the peri-
toneum is reflected. In all cases, however, the principal danger depends
upon the chance of the urine becoming effused, and exciting inflammation
and gangrene of the peritoneum, bowels, cellular tissue, and, in short, of
every part with which it comes into contact. The obvious indications
are to make a free and depending outlet for any urine already effused ;
to prevent a further extravasation by the continual use of an elastic gum
catheter ; to keep down and diminish inflammation by copious bleeding
and low diet; and to avoid every sort of dressing at all likely to irritate
or obstruct the wound itself. The best applications, indeed, are light,
simple pledgets, or lint kept soft with tepid water, the strictest attention
to cleanliness being paid. The cases are now numerous, in which
considerable wounds of the bladder terminated favourably under such
treatment. §
* See an Inquiry into the Process of Nature in repairing Injuries of the Intestines,
&c., p. 25— 3<J.
f Richter's Anfansgr. der Wundarzneykunst, band. v. p. 38.
j See Larrey's Mem. de Cliir. Mil. t. iv., and Hennen's Mil. Surgery.
§ Such facts are abundant in Larrey's excellent work, especially the 4th vol. Flajuni
relates another case, in which the means were restricted to antiphlogistic remedies.
Collez. d'Osservazioni, t. iii. p. 39- Thomson saw fourteen examples of wounded
adder recovering. See Obs, in the Military Hospitals in Belgium, p. 108. &c.
543
THE PSOAS, OR LUMBAR ABSCESS,
Is a collection of matter, formed in the cellular tissue of the loins, behind
the peritoneum, and mostly descending in the course of the psoas muscle,
until it produces a swelling below or above Poupart's ligament, or glides
under the fascia of the thigh. In a few cases, it descends into the pelvis,
whence it passes through the sacro-ischiatic foramen, and forms a swell-
ing near the anus. Sometimes it passes backwards on the outer edge of
the quadratus lumborum, and sacro-lumbalis muscles, so as to cause a
swelling on one side of the loins ; and, in some rare cases, it takes the
course of the spermatic chord, and forms a tumour projecting through
the abdominal ring, such as superficial observers might easily mistake for
a hernia. The disease furnishes one of the best illustrations of the nature
of large chronic abscesses, and especially of those usually regarded as
scrofulous. It begins with slight uneasiness in the loins, and a weakness
in walking ; but no acute pain may have been experienced, though the
matter be already copious enough to produce an external swelling. By
degrees, however, the quantity of matter becomes considerable, produc-
ing a sense of tension and weight about the loins, pains shooting down
the lower extremity, and some degree of hectic disturbance of the system.
As the disease advances, the lower extremity of the same side becomes
more and more weakened, and the thigh inclines forwards. In a girl,
who was under my care in University College Hospital, with a double
lumbar abscess, both thighs were drawn close up to the abdomen.
Lumbar abscess may or may not be combined with caries of the ver-
tebrae ; and the disease of the bone may be either the cause or the acci-
dental accompaniment of the collection of matter. At the same time I
ought to mention, that my friend Sir Benjamin Brodie is led by his ex-
perience to believe, that lumbar abscess is rarely the primary disease, but
commonly originates from caries of the vertebrae. When a psoas abscess
is joined with disease of the lumbar vertebra?, there is no paralysis, a pe-
culiarity referred by Sir Benjamin Brodie to the greater magnitude of
the bodies of the lumbar as compared with those of the cervical or dorsal
vertebrae, in consequence of which the former are not destroyed by the
same degree of caries which would be sufficient for the destruction of
the latter. In the lower part of the spine, the disease seldom reaches
the theca vertebralis. It is the disposition of lumbar and other chronic
abscesses to begin very slowly and insidiously, and to increase in the
same way, until, from containing a few ounces of matter, they include at
last several quarts. The matter of a lumbar abscess frequently presents
flakes of a curdy substance, like those seen in other scrofulous abscesses ;
and the whole cavity, in which it collects, is lined by a membrane called
the cyst of the abscess, which has somewhat the appearance of a mucous
membrane, and is the organ by which, after the disease is established,
the matter continues to be incessantly undergoing secretion an<f absorp-
tion. The extent of the surface of such a cyst may well be conceived,
when it is recollected that a lumbar abscess sometimes contains a gallon
of matter. Until the quantity of matter is enough to>produce an exter-
nal swelling and fluctuation, we rarely have any positive knowledge of
the existence of the disease, which is often mistaken for rheumatism.
I have seen several lumbar abscesses, the swelling of which in the bend
of the groin more or less resembled that of a hernia, and was attended
with impulse when the patient coughed. One case was brought to my
544 PSOAS ABSCESS-.
house: there was a small soft prominent tumour, with impulse, near the
groin, but rather more towards the ilium than the place of a hernia, and
accompanied by a larger swelling, — evidently an abscess behind the os
ihnominatum. I recommended the tumour behind to be opened, when,
if it had a communication with that in the thigh, the latter would subside,
and indicate, at all events, the nature of the case. Another surgeon of
great experience advised the introduction of a needle into the femoral
tumour, in order to learn the quality of its contents.
Attempts have been made to disperse lumbar abscesses by exciting
the action of the absorbents, by emetics, blistering the surface of the
swelling, and the employment of purgatives. The plan has been attended
with little success. Now, as it is the nature of lumbar and all chronic
abscesses to become larger and larger, and sometimes to attain vast mag-
nitude before they burst, it is, I think, a good general rule to open them
as soon as a fluctuation can be plainly distinguished. It is found, how-
ever, that the plan of opening a considerable lumbar abscess is frequently
followed by a violent and even fatal attack of irritative fever ; and hence,
some caution is requisite if the tumour be large. In fact, when we
puncture the abscess, discharge its contents, and leave the opening un-
closed, the cyst often inflames over its whole extent, and the patient now
suffers that violent derangement of the system, excited by any fresh
irritation operating upon a hectical constitution, which is well known by
the name of irritative fever.
The knowledge of this fact made surgeons fearful of following this
practice, when the cyst was of considerable size. Hence arose the method
of introducing a seton across the tumour, and letting the matter escape
gradually ; and Mr. Abernethy's more successful way of letting out the
matter by a puncture, and then closing it with adhesive plaster, and
healing it by the first intention. The skin is to be drawn to one side, the
lancet introduced, and the matter having been discharged, the skin is
allowed to resume its natural place again. Thus the openings in the
skin and the fascia and cyst do not afterwards correspond, and the ad-
mission of air is more likely to be excluded. The cyst remains for some
time undistended — it has an opportunity of contracting — and, as soon
as a certain quantity of matter accumulates again, the same proceedings
are repeated.
With such treatment should be combined the administration of tonic
and alterative medicines, and especially bark, preparations of steel, the
iodide of potassium, and such as are found to be the best for scrofulous
constitutions in a state of hectic. After the abscess has been consider-
ably lessened, blistering the skin, or rubbing the skin freely with ung.
iodidi comp. will sometimes promote the dispersion of the remains of it.
If the vertebrae be diseased, counter-irritation will be advisable; especi-
ally an issue or blister kept open. The fact established by Sir Benjamin
Brodie, that a psoas abscess is almost constantly attended with caries of
the vertebras, must have a very unfavourable influence on the prognosis,
on account of the greater difficulty of curing any abscess combined with
disease of the spine, than an abscess free from so serious a complication.
The double lumbar abscess in University College, above referred to, was
opened, and terminated in the girl's recovery.
545
SCROFULOUS CARTES OF THE SPINE.
Perhaps I may not be altogether justified in calling this affection a
caries of the vertebrae, because it is alleged that one variety of it begins,
not with a morbid alteration of the cancellous structure of any of those
bones, but with ulceration of the intervertebral substance. But as the
disease, in whatever texture it begins, generally leads to caries of the
spine, I think the name sufficiently appropriate. By adding the epithet
scrofulous, we also distinguish this caries from other forms of it, as well
as from necrosis, and simple absorption of parts of the vertebral column,
the effect of aneurism, or other tumours, not usually productive of any
paralytic affection of the lower extremities.
In whatever manner the disease commences, if it be not checked in
its progress, it occasions a destruction of the bodies of the vertebrae and
intervertebral substance, leaving, as Sir Benjamin Brodie correctly says,
the posterior parts of the vertebrae unaffected by it ; the necessary conse-
quence of which is an incurvation of the spine forward, and a projection
of the spinous processes posteriorly. The same pathologist adverts also
to the frequent and early complication of the disease with chronic inflam-
mation of the membranes of the spinal cord, and even of the latter organ
itself, which in consequence of the curvature, and, as I have reason to
believe, still oftener in consequence of the disease around the spine, quite
independently of the mechanical effect of the curvature itself, becomes
disqualified for the performance of its highly important function. This
observation is founded on the fact of many cases being upon record, in
which the most surprising degrees of curvature, from destruction of the
bodies of the vertebrae, were not accompanied by paralysis. In the mu-
seum of University College is a preparation, illustrating the earliest
change perceptible in the most common form of the disease, — that
which begins in the bones. In the cancellous structure of the cervical
vertebrae, small cells are seen, which are produced by the removal of a
portion of the natural texture.
Frequently in caries of the spine, and especially in scrofulous cases
beginning in the bones, suppuration occurs at a very early period of the
disease, and, in other examples, not until a late stage of it.
I have explained, in the first section of this treatise, the changes in the
shape of the spine produced by rickets ; where the curvature is lateral,
and the spine twisted, not from any carious affection of the vertebrae, but
from their being only imperfectly developed, and not calculated to resist
the preponderating influence of the muscles and the weight of the parts,
which the column has to sustain. However great such ricketty curva-
ture and deformity may be, no paralysis is induced. I have also made
some remarks upon that kind of absorption of the bones, which arises
from the pressure of aneurism and other tumours upon them, and which
has peculiarities marking it very completely as a different affection from
what is denominated caries; for, in no situation, does it lead t§ the form-
ation of abscesses ; and, in the spine, it is particularly remarked by all
pathologists that it does not give rise to paralysis. Not, however, that
the thing is absolutely impossible; for, in the museum of University
College, is a specimen of aortic aneurism, which had occasioned such
an absorption of the lateral part of the spine, that the medulla spinalis
was exposed ; though even in that case, I believe, there was no paralytic
affection of the lower limbs. It is conceivable, however, that the mis-
chief might have gone on, till palsy had been excited by its effects upon
N N
516 SCROFULOUS CARIES OF THE SPINE.
the medulla spinalis ; and I have certainly read of a case or two, in which
the pressure of an aneurismal tumour in the abdomen was the cause of
paralysis. Such an occurrence, however, is at all events rare.
The greater number of individuals, afflicted with scrofulous caries of the
spine, are infants or children ; yet many adults also suffer from it, espe-
cially after having been weakened by fever, or a long mercurial course.
It is very uncommon for it to begin after the age of forty-five.
It may be asked, how are we to distinguish scrofulous cases, commenc-
ing in the bodies of the vertebra?, from others, which begin in the inter-
vertebral substance? Now, the only information that I can deliver, in
reply to this question, is a remark made by Sir Benjamin Brodie, that
where the disease is of a scrofulous origin, affecting the cancellous
structure, he suspects, that it is more immediately followed by suppura-
tion, than where it commences in the intervertebral cartilages ; and that,
in the latter cases, the pain and tenderness in the carious part of the
spine are more considerable than in scrofulous examples.
With regard to the general symptoms of caries of the spine, I may
remark, that, in the early stage, the patient has pain and tenderness in
that portion of the spine which is the seat of disease ; and, as I have
stated, perhaps these symptoms will be most strongly manifested in those
cases in which the disease begins in the intervertebral substance. If the
patient be old enough to describe his complaints, he will tell us, that he
is annoyed with a feeling of tightness of the chest, uneasy sensations at
the pit of the stomach, a torpid sluggish state of the intestinal canal, per-
haps some disturbance in the functions of the urinary bladder, and weak-
ness, aching, numbness and cramps in the muscles of the lower extremities.
Now, it is scarcely necessary for me to say, that very similar symptoms
may proceed from other causes ; and even some of the information re-
specting the symptoms now enumerated, as appertaining to the early
stage, cannot always be obtained, because the patient may be an infant.
Hence, until some inequality or projection becomes perceptible on the
spine itself, and until the want of control over the muscles of the lower
limbs and the paralysis are more established, the diagnosis is generally
obscure. The muscles and parts affected with paralysis must, of course,
be those, which derive their nerves from the portion of the medulla spi-
nalis below the seat of the disease. Generally there is impairment of
motion and sensibility together ; but sometimes one limb will retain more
or less sensibility, yet be deprived of the faculty of motion.
In different cases, the symptoms differ considerably. Sometimes there
is great pain in the part affected ; sometimes none. In many instances,
the paralysis comes on early, and often even before there is any material
curvature forwards; but, in some cases, we see the spinous processes
making a considerable angle posteriorly, in consequence of the bend of
the spine forwards, and the destruction of the bodies of the diseased
vertebrae, yet without any paralysis having taken place. The true cause
of most of the symptoms is a morbid state of the spine and parts con-
nected with it, attended with irritation and disease, and perhaps some-
times with compression of the medulla spinalis itself. The morbid state
of the spine always precedes the deformity observable in the vertebral
column itself. Indeed, the curvature forward, in such a degree as to pro-
duce the angular projection of the spinous processes posteriorly, cannot
happen until the bodies of the diseased vertebra) have been seriously in-
jured by caries. The deformity is of a peculiar kind, and such as nothing
can produce, except the destruction of one or more of the corpora ver-
tebrarum, the spine being bent forwards, as I have already explained, so
SCROFULOUS CARIES OF THE SPINE. 547
as to form an angle backwards. The body of one, and sometimes the
bodies of several vertebrae may be completely absorbed, permitting those
below and above the deficiency to join, and be united by anchylosis.
The spinous processes may also be soldered together ; and the sides of
the thorax pressed downwards and backwards, so as to lessen, in a very
serious manner, the dimensions of the hypochondriac region. In this
disease, the bones are large and well developed, which is very different
from what is noticed in rickets. In curvatures from other causes, there
is not an angular projection of the spinous processes ; but the bend forms
the segment of a circle, generally affecting a great extent of the spine,
and often assuming the lateral inclination or spiral figure, with a very
conspicuous leaning above, towards the right side.
In most cases of scrofulous spine, paralysis of the lower extremities,
and even a more extensive paralysis, will come on sooner or later ; but, in
rickets, where the spine may be said to be deformed, rather from an im
perfect development of the bones, than from disease of them, palsy of the
legs is not produced, however great the lateral or spiral curvature of the
back. Professor Cruveilhier, in the 4-th Livraison of his Anatomic Patho-
logique, gives us the particulars of a case, which proves how very far even
scrofulous disease of the vertebrae will sometimes advance, without caus-
ing paralysis, though this is a deviation from what is most common. In
Cruveilhier's case, no paraplegia existed, though not less than five of the
bodies of the dorsal vertebrae had been totally annihilated ; and the alter-
ation in the shape of the vertebral column was such, that the upper half
formed with the lower an extremely acute angle, which would have been
still more acute, if it had not been prevented by the eleventh and fifth
actually touching one another. The intervertebral foramina were all pre-
served, though more or less deformed, contracted, or displaced backwards.
In those which were most diminished, the corresponding intercostal nerves
must have been compressed, and consequently the action of 'the intercostal
muscles impaired, explaining partly the cause of the asthmatic disorder,
with which the patient was troubled. The engraving in the above work
shows how nature contrived to maintain the integrity of the vertebral
canal, and to keep the spinal cord from being compressed, in the midst of
such a surprising deviation of the vertebral column from its natural con-
figuration. Although the bodies of five vertebrae were demolished, an-
chylosis took place, and the medulla suffered no pressure or irritation
adequate to paralyse the lower extremities. A beautiful specimen,
illustrative, I think, of an equally extensive destruction of the bodies
of the vertebrae, and of as sudden a bend of the spine, will attract the
attention of every pathologist who visits the museum of University Col-
lege. Cruveilhier also gives the particulars of a child, ten years old,
brought to the dissecting room, in which only a few vestiges of the bodies
of the third, fourth, fifth, sixth, seventh, eighth; ninth, tenth, and eleventh
dorsal vertebrae were left. According to this pathologist, diseases of the
vertebral column, like those of every other part of the osseous system, are
seated, not in the osseous tissue itself, but in the cellular or medullary
tissue occupying its interstices. When this cellular tissue inflames, some-
times it pours out pus in abundance, constituting an abscess, but sometimes
in a more scanty quantity so as to admit of absorption. The cells of the
osseous tissue, being distended by the development of the cellular tissue,
and deprived of the materials of nutrition, may be entirely absorbed; and
thus Cruveilhier accounts for the total disappearance of the texture of
bone, without a vestige of it being left. In fact, his doctrine is, that all
N N 2
SCROFULOUS CARIES OF THE SPINE.
disease is seated in the cellular tissue of organs, the other tissues being,
according to his views, only liable to simple atrophy or hypertrophy.
The view, now taken of this subject, must render it manifest, that the
removal of the deformity of the spine, even when we succeed in curing
the disease, must be altogether impracticable. There must always remain
an angular projection backward, which will be greater or less, according
to the part of the spine affected, and the extent of the destruction of the
bodies of the vertebrae.
Nevertheless, we are not to conclude, that every bend of the spine for-
ward is from scrofulous disease. We have the authority of Sir Benjamin
Brodie for the observation, that a curvature of the spine in this direction
may arise from other causes, as a weak condition of the muscles, or a
ricketty affection of the bones. Generally, he says, in such cases, the
curvature occupies the whole spine, which assumes the form of a segment
of a circle. Occasionally, however, the bend occupies only a portion of
the spine, usually that composed of the superior lumbar and inferior dorsal
vertebrae, the curvature being always gradual, not angular, a circumstance
in which it particularly differs from the curvature resulting from caries.
One common effect of scrofulous caries of the spine is the production
of an abscess around the diseased bone. Yet, it frequently happens, that
the caries will go on to a vast extent, and even so as to demolish the bodies
of several vertebrae, without any abscess being produced. Disease of the
spine may continue for years without suppuration ; but abscesses some-
times lie upon the diseased bone, and are not detected till after death,
when the body is examined.
With respect to scrofulous disease of the upper cervical vertebrae, and
of the articulations between the atlas and the condyles of the os occipitis,
I may remind the reader of an observation made by Sir Benjamin Brodie,
which is, that the pain is greater in such cases, than in others, where the
disease is in the dorsal or lumbar vertebrae. When abscesses form from
disease of the cervical vertebrae, the matter generally collects amongst the
muscles of the neck, or behind the pharynx, into which it may pass. As
the disease advances, the arms become paralytic : and this while the
muscles, which derive their influence from the spinal cord below the neck,
remain under the control of the will. Afterwards, however, the paralysis
extends to the muscles of the trunk and lower extremities, in the case
of a girl, eight years old, with disease of the spino-occipital articulation,
as recorded by Mr. T. It. Blackley, " the countenance was peculiarly ex-
pressive of caution, and was florid and full, if not bloated ; the chin was
advanced preternaturally beyond the chest; the mouth slightly opened;
and she kept the arms parted from the side, as if to poise herself. On
looking laterally, she strained her eyes in the direction of the object, and,
failing in this, turned her entire body for the purpose. The effect pro-
duced, when she attempted to observe any thing placed near her feet,
was yet more remarkable ; for this purpose, she generally put her hand
to her forehead, as if fearful of undue weight in the head, and bent her
body, thus avoiding the least motion between the first and second ver-
tebrae. In getting up from bed also, or in lying down, she invariably
supported the head with the hand." During the last four days of her
life, the right arm was powerless.* The post mortem appearances, which
are interesting, my limits compel me to omit.
The most approved plan of treating scrofulous caries of the spine con-
sists in employing, in the early stage, cupping or leeches over the part,
* See Dublin Journ. of Med. Science, vol. xii. p. 62.
SPINA BIFIDA. 54*9
followed by the application of blisters, caustic issues, aseton, or the moxa.
With the local abstraction of blood, are of course to be joined other mild
antiphlogistic remedies, especially aperient medicines, composed of rhu-
barb, and the carbonate of soda, castor oil, or the sulphate of magnesia.
After beginning with these means, counter-irritation, or issues, setons, a
perpetual blister, or the moxa, may be tried; and these remedies maybe
assisted with the medicines and regimen usually recommended for other
scrofulous diseases, particularly bark, chalybeates, and iodine, with the
benefit of a light nutritious diet, and pure country air, if it can be con-
veniently had. One thing is quite essential, namely, the diseased spine
should be kept as quiet as possible, and therefore the patient ought to
remain very much in the recumbent position. When the disease has
existed a considerable time, and a conspicuous angular curvature is formed,
I think Sir B. Brodie's advice should be followed, which is, to let the pa-
tient recline on his side, instead of on his back ; or if this posture be dis-
agreeable, he should not lie on an absolutely flat surface, but be supported
with pillows, so that his position may have no tendency to restore the
spine to its original figure, which would only have the pernicious effect of
disturbing the completion of the anchylosis, by which alone the cure can
be accomplished.
Of late years, issues and blisters, from having been employed in these
cases for immoderate periods of time, and without discrimination, have
become objects of abuse by certain practitioners. Yet, that they fre-
quently produce great benefit, I am convinced by repeated experience.
We often find paralysis suddenly cease, or diminish, on the application of
a blister. At the same time, I am of opinion with Sir B. Brodie, that
issues are chiefly useful in the early stage of the disease, with the view
of preventing suppuration, and that they are of no service after an abscess
has actually formed. He likewise suspects, that issues are of little or no
service where scrofulous disease of the cancellous texture precedes ulcer-
ation of the cartilages. If this be true, we see, then, the reason why so
many cases are not benefited by this plan ; but it is a point for further
investigation, and one on which, I cannot say, that my experience agrees
with what has now been suggested.
I may next observe, that the medulla and its coverings are liable to
chronic inflammation and its effects, as a consequence of external violence.
Cases are likewise sometimes met with, where scrofulous tubercles form
in the medulla itself. Any of these changes may of course impair the
functions of this important organ, and bring on paralytic affections. The
treatment must be regulated by principles applicable to diseases of joints,
and comprise very much the same means which have been advised for
scrofulous disease of the bodies of the vertebrae ; local bleeding, counter-
irritation, quietude in the recumbent position, and medicines and regimen
for the improvement of the health in general.
SPINA BIFIDA, HYDRO-RACHITIS, OR THE CLOVEN
Is a congenital malformation, consisting in a deficiency of one or more of
the spinous processes and arches of the vertebra, which, indeed, are some-
times deficient throughout the whole extent of the vertebral column. In
consequence of the deficiency of the back part of the spinal canal, the
theca vertebralis protrudes, and forms a kind of pouch filled with a limpid
fluid. The swelling is of different sizes in different cases, according to
the extent of the malformation in the bones, and the age of the individual.
The most common situation of it is on the lumbar vertebrae ; but it may
N N 3
550 SPINA BIFIDA.
take place on the dorsal or cervical ones, and even the sacrum. In
some cases, an aperture is left in the bodies of the vertebra, in addition
to the absence of the spinous processes. All the processes are occasion-
ally deficient, and the vertebrae small, and not properly developed. The
swelling is soft, and attended with fluctuation, and sometimes a degree
of transparency. It generally subsides when compressed, but returns as
soon as the pressure is removed. The skin retains its natural colour, and
there is no pain in the part, unless it be compressed.
Children born with spina bifida seldom live more than a year. They
are generally weakly and emaciated ; and very often afflicted with para-
lysis of the lower limbs, and of the sphincters of the bladder and rectum.
However, I have seen children with spina bifida, who had a healthy ap-
pearance and suffered no paralytic complaints. Sometimes, also, instead
of dying in infancy, they live to the adult age, as was the case with a
young woman, whom I saw many years ago under the care of Mr. Cop-
land Hutchison. The urine and feces passed involuntarily. The tumour
was of such enormous size, that it measured in the vertical diameter
thirty inches.
With very few exceptions, spina bifida proves fatal ; and this, in the
greater number of instances, within the first year from the period of
birth. Some children thrive for a few years, and appear to suffer little
or no inconvenience ; but no sooner does the tumour burst, or is it punc-
tured, than convulsions usually come on, and the little patient suddenly
dies. This was the final result of a case, in which I saw a little boy,
about two years old, that was in perfectly good health, and with the free
use of his legs, though he had a spina bifida on the sacrum nearly as
large as his head.
Gentle pressure on the tumour was suggested as worthy of trial by
the late Mr. Abernethy, with the view of producing an absorption of the
fluid ; and, if that object could not be accomplished, he deemed the ex-
periment of letting out the fluid by a small puncture, and then closing
the opening with sticking plaster, quite warranted by the commonly fatal
course of the disease. This was done in one example, the puncture being
repeated every fourth day for six weeks, and regularly healed ; but,
at length, one of the punctures failed to unite, the sac inflamed, pus was
formed, and the result was fatal.
Sir Astley Cooper tried the effect of puncturing spinae bifidae with a
fine needle. In one case, the fluid was discharged, and the cavity obliter-
ated by the adhesive inflammation, so as to produce a radical cure. This
gentleman, however, besides the radical treatment, if it can be so called,
as it is only supported by one or two instances of success, has a palliative
method, which consists in treating the protrusion on the principle of a
hernia, and applying a compress and bandage to it.*
Spina bifida, when joined with hydrocephalus, paralysis of the lower
extremities, and involuntary discharge of the urine and feces, is entirely
a hopeless case. The same observation applies to examples, in which the
spinal cord itself is deficient.
In mgny children, the bodies of the vertebras are not perfectly de-
veloped, the ossification of the cranium is not complete, and the disease
is associated with other deformities, such as club feet. All these circum-
stances were illustrated in a case, from which a preparation in the museum
of University College was taken. The child lived only three days.
* Two patients, treated in their infancy on these plans, and now grown up to be
strong men, I have lately examined by the favour of Sir Astley Cooper, under whose care
hey were about twenty years ago, or more.
551
HERNIA.
The term hernia is applied to a protrusion of parts from any of the
greater cavities of the body : thus, there may be herniae of the brain,
lungs, or abdominal viscera. The expression rupture, employed synony-
mously with hernia, signifies, however, only the abdominal form of the
disease, and came into use from an erroneous notion, that the parts,
through which the protrusion happened, were constantly burst or torn.
When any of the viscera of the abdomen protrude, they almost always
push out, along with them, a portion of the peritoneum, which forms a
kind of pouch in which they are contained, and is called the hernial sac.
Of this the narrow part is termed the neck, and the more expanded part
the body.
But hernia is attended with infinite variety, so that it will not always
admit of being defined to be a protrusion of the viscera, included in a
peritoneal sac ; for the parts may not protrude at all ; the displaced or
entangled bowels may form no external swelling ; they may be entangled
in some unusual aperture in the mesentery, or be compressed by adhe-
sions formed within the abdomen ; or, if they do protrude, they may not
be entirely covered by a peritoneal sac. The total or partial absence of
a sac, however, is the peculiarity of but few cases, as when a hernia
follows the cicatrisation of a penetrating wound of the abdomen, or when
the sac is rendered imperfect by ulceration or absorption, or is torn by
accidental violence directly applied to the tumour. The bladder and
ccecum are not contained in the peritoneum, and hence, when they form
herniae, they have not a complete hernial sac ; they do not push out the
peritoneum before them, but draw after them the portion of that mem-
brane with which they are naturally connected. Thus a kind of sac may
follow them, without covering them, and into such sac other bowels
may fall.
The most common situations for hernise are the abdominal ring, the
navel, and a limited point below Poupart's ligament, just at the inner side
of the femoral vein. They are also met with at every point of the linea
alba, and, in less common instances, at the foramen ovale, at the ischiatic
notch, in the perinseum, or the vagina. Hernial protrusions are also
possible through the diaphragm into the chest, sometimes through a
lacerated opening in that muscle, sometimes through a natural aperture
in it, or one from congenital malformation. The contents of a hernia are
mostly either intestine or omentum, or both together. The small in-
testine, being more moveable than the large, is more frequently pro-
truded, especially that portion of it named the ileum, which lies very near
the ring and the space below Poupart's ligament. Sometimes the pro-
trusion will comprise merely a part of the diameter of the intestine ; and
sometimes several inches or feet of it may be contained in the sac. In
rarer forms of hernia, other parts are met with, as portions of the stomach,
or liver, the spleen, uterus, ovaries, or bladder.
From the two circumstances of situation and contents, are derived nearly
all the various names of hernia?. Thus, when the tumour contains intes-
tine alone, it is called enterocele; when omentum alone, epiplocele; and,
when its contents consist of both parts, enter o- epiplocele. We hear also
of hernice of the stomach, bladder, &c. With respect to names derived from
situation, when the protrusion is at the abdominal ring, or even merely
within the inguinal canal, the case is termed a bubonocele or an inguinal
N N 4?
552 HERNIA.
hernia; but if the parts come out of the same aperture, and descend fur-
ther, so as to get into the scrotum, such form of the disease is termed
oschcocele, or a scrotal hernia. The protrusion below Poupart's ligament,
just on the inner side of the femoral vein, receives the name of crural or
femoral hernia. A protrusion at the navel is termed an exomphalos, or an
umbilical hernia ; and, at any other point of the front of the abdomen not
yet specified, a ventral hernia. Protrusions by the side of the vagina, at
the foramen ovale, in the perinaeum, through the diaphragm, or the ischi-
atic notch, are named accordingly, kernice of the vagina, foramen ovate,
&c. One kind of hernia, named from the circumstance of children being
born with it, or having it very soon after birth, is called congenital, which
is likewise singular in another respect, viz., that of having the tunica va-
ginalis for the hernial sac.
When the protruded viscera create no disturbance, and readily admit
of being put back into the abdomen, the hernia is said to be reducible;
but when they cannot be put back, owing to adhesions, or their large size
in relation to the opening, through which they would have to return, the
hernia is called irreducible, or incarcerated. If the parts be not only diffi-
cult of reduction, but subjected to such pressure, or constriction, as
impedes or deranges their functions, stopping the passage of the intestinal
matter towards the anus, causing frequent sickness, with inflammation or
worse consequences in the constricted parts, the case is well known among
surgeons as a strangulated hernia.
The causes of hernia are divisible into the predisposing and exciting.
With respect to the first, I may remark, that a natural deficiency of resist-
ance in any part of the boundaries of the abdomen, and a loose, very
moveable state of certain viscera, must be regarded as the common pre-
disposing causes. According to the observations of Sir Astley Cooper,
debility predisposes to hernia by occasioning a relaxation of fibre, and a
dilatation of the aperture through which the spermatic vessels pass. If
a person, debilitated by fever, return to habits of violent exertion before
his strength is fully re-established, a hernial swelling will frequently take
place. It is on the principle of general relaxation, that the same dis-
tinguished surgeon explains the remarkable frequency of the disease in
old persons, especially those who work hard. Hot climates, by producing
relaxation, and all circumstances which tend to bring on a sudden absorp-
tion of fat, are well known to give a tendency to the formation of hernial
swellings. Many facts also support the doctrine, that hernise are some-
times particularly prevalent in certain families, so as to be called heredi-
tary, and no doubt this depends upon a weaker conformation of the parts
where the tumcurs form, than is exemplified in the generality of indi-
viduals.
The exciting causes may all be referred to the powerful action of the
abdominal muscles and diaphragm on the viscera ; and this is the reason
of the great frequency of the disease in the labouring classes, in dancers,
in the inhabitants of mountainous countries, in the cavalry, in persons
who ride hard, &c. ; persons who lift heavy weights, who suffer from
asthma, or from long-continued cough, or who habitually exert their lungs
in any kind of manner, are principally subject to hernia. Costiveness
likewise creates a risk of hernia, which usually comes on when the person
is straining at stool. Strictures of the urethra also promote the forma-
tion of hernia, the abdominal muscles being required to act with unusual
force in order to empty the bladder. Cases are recorded, in which se-
veral hernial tumours were thus occasioned in the same individual. The
REDUCIBLE HERNIA. 553
same causes, which first produced the complaint, are constantly tending
to promote its increase. The tumour becomes larger, in proportion as
the pressure against the hernial sac is stronger and more frequent. Hence
the great size which it often attains in persons following laborious occu-
pations. Its increase will also be in proportion to the less considerable
resistance of the parts in which it is situated; hence the magnitude of
scrotal ruptures, and the generally small size of a femoral hernia. Sir
Astley Cooper adverts to one condition conducive to hernia, through an
altered state of the viscera, the abdominal muscles being nearly passive ;
this is when the viscera become, as it were, too large for the belly, from
extreme obesity, the fat accumulating in extraordinary quantities in the
omentum and mesentery. The enlargement of the uterus in pregnancy, as
every surgeon knows, gives a great tendency to the occurrence of umbilical
and ventral hernise, by over-distension of the abdominal parietes.
At the first moment of the occurrence of a suddenly formed hernia,
the protruded peritoneum must be unconnected with the parts amongst
which it lies ; but, in a very short time, it becomes firmly bound to them
by the adhesive inflammation, which then prevents the return of the sac
into the abdomen on the viscera being reduced.
The great apparent increase in the thickness of the sac is mostly owing,
not to such change in the peritoneal sac itself, but to that of the more
external coverings of the tumour, as the fasciae, cremaster, and cellular
tissue. However, there are exceptions, in which the hernial sac is
really much thicker than the rest of the peritoneum ; especially when the
tumour, after having been long reduced, protrudes again, and is not kept
up ; when it has been repeatedly affected with inflammation ; or there
are extensive adhesions between the sac and its contents.
REDUCIBLE HERNIA.
The general symptoms of a reducible hernia are an indolent tumour,
situated at one of the points of the abdomen, already specified as the
places for hernia ; sometimes originating gradually, sometimes suddenly,
and subject to change of size, being smaller when the patient lies down
on his back, and larger when he stands up or holds his breath. Frequently
it diminishes when compressed, and grows large again when the pressure
is removed. Its size and tension often increase after a meal, or when the
patient is flatulent. In many cases, colic, constipation, and vomiting oc-
casionally take place, seemingly from the bowels being out of their natural
situation, and less capable of their usual action on their contents; but, in
others, the functions of the bowels go on quietly and regularly.
When the sac contains only a piece of intestine, forming what is termed
an enterocele, the tumour is characterised by elasticity and uniform
smoothness. No pain attends the handling of it ; and, on the patient's
coughing, while the surgeon's hand is applied to the part, a forcible im-
pulse is felt, as if air were blown into the swelling. The bowel gene-
rally returns into the abdomen with great facility, a guggling ^oise being
frequently heard at the moment.
If the sac contain only omentum, constituting epiplocele, the tumour
has a more flabby and unequal feel ; is more inclined to be oblong than
round ; and if the quantity of protruded omentum be considerable, the
disease is in some degree indicated by its weight, which is greater than
that of an enterocele. Here, also, an impulse is felt in the tumour when
the patient coughs. In very young subjects, the contents of a hernia are
generally intestine, and seldom omentum.
554< HERNIA.
With respect to the signs of an entero-epiplocele, or hernial tumour,
containing both omentum and intestine, if a part of the contents slip up
suddenly and with a guggling noise, leaving behind something which is
less easily reduced, the disease is an entero-epiplocele.
The general treatment of a reducible hernia is perfectly obvious. The
protruded viscera are to be returned into the cavity of the belly, and a
truss applied for the purpose of preventing their descent again. The
manual proceedings, by which the contents of a hernia are reduced,
without the use of the knife, are termed the taxis, the manner of per-
forming which varies according to the situation of the tumour.
If no means be employed for reducing the parts, and keeping them re-
duced, there will be a constant risk of the hernia becoming strangulated
by an additional protrusion of more bowel or omentum into the sac. But,
besides this danger, and the loss of all chances of a radical cure, when a
reducible hernia is neglected, other considerations should be pressed upon
the patient, to make him understand the necessity of regularly keeping
up the parts with a truss. It should be represented to him, that, if he
neglect this precaution, the hernia will increase in size, so as not only to
prevent all active exertion, but, if a bubonocele, to impair the genital
function by involving the integuments of the penis, and sometimes also,
by the pressure, causing a wasting of the testicle. In particular, as the
early period of life is that in which the opening has the greatest disposi-
tion to close, infants and children should never be suffered to be without
a proper truss ; and it is now perfectly ascertained, that they can wear
trusses with steel springs just as well as adult subjects.
Though such are the doctrines which 1 have to offer in relation to the
general treatment of reducible hernia, cases sometimes present themselves
in which the contents of the hernia are so bulky that, though reducible,
they cause, after their return into the belly, so much pain and indisposi-
tion, that it becomes necessary to let them continue in the sac, which
should then be supported with a suspensory bandage.
IRREDUCIBLE HERNIJE FREE FROM INFLAMMATION, AND TROUBLESOME
OR DANGEROUS SYMPTOMS.
The usual causes, preventive of reduction in such cases, are, first, the
bulk of the protruded parts, in relation to the opening through which
they would have to return; secondly, alterations in their form and tex-
ture ; thirdly, adhesions to one another, or to the inside of the sac ;
fourthly, transverse membranous bands within the sac, or the neck of it ;
fifthly, some herniaB are rendered irreducible, because the viscera are
bound down by their natural cellular connections, though in a state of dis-
placement. The bladder is generally incapable of being completely re-
turned ; and the hernial sac, where the ccecum protrudes,, is deficient
behind and at the outer side of the tumour, where the bowel has only its
usual cellular attachment.
The course of the intestinal matter is always more or less obstructed
in that portion of the bowels which is included in the hernia; and hence,
patients with irreducible enterocele are frequently subject to complaints
of the digestive organs, colic pains, or even a total stoppage of evacuations
per anum ; not the result of any constriction of the protruded bowel, but
of the difficulty with which its contents pass through it.
Persons with irreducible ruptures should avoid rough exercise, support
the tumour with a bandage, and keep it out of the way of all harm from
STRANGULATED HERNIA. 555
pressure or bruises. They should also be careful to avoid costiveness, and
irregularity of diet.
An irreducible omental hernia, free from constriction and inflam-
mation, may not be the cause of much present inconvenience ; but, when
affected with inflammation from any accidental cause, or when a portion
of bowel slips into the sac with it, severe and fatal consequences may
ensue.
GENERAL SYMPTOMS OF A STRANGULATED HERNIA.
The first symptoms are a tumour in the situation of the hernial protru-
sion, attended with pain, not only in the part, but about the diaphragm,
followed by eructations, sickness, inclination to vomit, suppression of
stools, and acceleration of the pulse. The suppression of stools is often
as complete and as irremoveable by purgative medicines, when only a
small portion of the diameter of the bowel is strangulated, as when an
entire fold of it is pinched. The action of a clyster on the bowels below
the stricture often produces a stool after strangulation has taken place ;
but when they have once been emptied, the most irritating clysters have
no effect. If the reduction be delayed, the bowels are distended with
air ; the belly is tense and swollen from this cause ; the vomiting and
eructations become more frequent, — all the contents of the stomach, and
afterwards those of the bowels down to the stricture, being rejected.
Afterwards, the pulse, which was previously about 90, and, perhaps, strong
and hard, becomes much quicker and weaker, and the belly is very sore
on pressure. Peritonitis has now come on. There is great anxiety and
restlessness, with a small, quick, hard pulse, and generally cold extremities.
After a time, hiccough occurs, the pulse sinks, and the whole body be-
comes covered with a cold clammy perspiration. Mortification next takes
place, beginning in the protruded viscera and extending to the containing
and neighbouring parts. The patient may now experience a sudden feel-
ing of relief but this is only temporary. The tumour becomes emphy-
sematous, a sure sign of the gangrenous mischief within it. In this
state, the gut either goes up spontaneously or is returned with the
smallest degree of pressure ; but, the hiccough and cold sweats continu-
ing, the pulse becomes more and more rapid and irregular, and death
soon follows.
When the body is examined, the whole surface of the peritoneum is
found inflamed, the intestines participating in the disorder, particularly
those above the stricture, which are considerably distended with air.
From the strangulated part downwards, the intestine is generally smaller
than usual, and sometimes not inflamed. The convolutions are also fre-
quently connected together by recently formed adhesions ; a turbid
puriform fluid is effused in the abdomen ; and, not unfrequently, spots of
gangrene are seen on the intestines.
The symptoms of a strangulated epiplocele are less severe and rapid,
and stools may generally be procured by purgatives and clysters ; but this
is sometimes attended with great difficulty, and the sickness and vomiting
are, for the most part, truly distressing. In the museum of University
College is a preparation, exhibiting the production of a permanent stric-
ture of the inner coat of a portion of bowel that had suffered strangula-
tion : an exceedingly rare occurrence.
General Treatment of a Strangulated Hernia. — Surgeons should always
remember the necessity of not losing too much time in the trial of means
not to be depended upon for procuring the reduction of the parts ; for the
556 HERNIA.
rapidity with which gangrenous mischief sometimes takes place in the
hernia, attended by a dangerous and fatal degree of inflammation within
the abdomen, is very remarkable. The greater number of patients, who
die after operations for strangulated hernias, do not die of those opera-
tions abstractedly considered, but rather of the effects of the disease ; and
if the knife were used more promptly, life would more frequently be
saved. I fully coincide in the opinion entertained by many surgeons, that
we should save many more lives by operating on strangulated hernia
much sooner than is generally done. I would recommend a fair and
prompt trial of those means which are the most likely to promote the re-
duction of the hernia; and if they failed, and the symptoms were urgent,
it seems to me, that time ought not to be wasted in the useless repetition
of them, or the employment of others known to be less efficient.
The taxis, or an attempt to reduce the parts with the hand, is, of course,
the first proceeding for adoption. For this purpose, the abdominal mus-
cles and femoral fascia should be relaxed by inclining the chest forwards,
and bending the thigh and rotating it inwards. In the external in-
guinal hernia, the pressure should be directed upwards and outwards,
along the course of the spermatic cord ; but, as the femoral hernia passes
first downwards and then forwards and upwards, the pressure in this case
must be directed first downwards and then backwards. In umbilical and
ventral hernia?, it is to be made directly backwards. No violence ought to
be used, as it can be of no service*, and must increase the inflammation of
the bowels. The intestine may even be burst by too much force, or the
sac forced into the abdomen, with the viscera strangulated by its neck.
While the tumour is grasped with one hand, and moderate pressure on it
steadily kept up, the ringers of the other hand are to be employed in the
endeavour to get up any portion of the contents of the hernial sac, and to
keep it reduced, until followed by another portion. If air be felt to
return, this will be encouraging. Dr.O'Beirne's plan of lessening the con-
tents of the abdomen, and thereby some of the resistance to the reduc-
tion, by discharging the air from the large intestines with an elastic gum
tube, appears to me to deserve greater attention than it has yet received
from the profession. If the first trial of the taxis should fail, we may
put the patient into a warm bath, if it can be prepared without too much
loss of time ; and while he is in it, take blood from his arm. If the warm
bath should require much time for its preparation, I would advise it to be
dispensed with, and blood taken from the arm.
The object of the warm bath and bleeding is to render the patient weak
and faint, to bring on a kind of general collapse, during which the taxis
may often be practised with success. If the patient should fall into
this state, therefore, the opportunity of trying the taxis again is to be
taken.
Supposing, however, we were not yet able to succeed, what ought to
be done ? If the patient were not a very old or debilitated subject, I
should next try the united effect of cold or ice applications to the swell-
ing, and of an infusion of tobacco thrown up the rectum : 5 j- of tobacco
is to be infused for ten minutes in a pint of boiling water poured upon it ;
the liquor is then to be strained, and one-half of it injected first ; and if,
in about a quarter of an hour, this produce not too violent effects, the
other half is to be thrown up. When the patient is under the influence
of the tobacco, and the tumour has been subjected to the cold ap-
plications some little time, the hernia will sometimes return of itself, or
with the slightest assistance. If it should not, the taxis is to be tried for
ANATOMY OF INGUINAL HERNIA. 557
the last time ; and, if it now fail, and the symptoms be urgent, and peri-
tonitis present, the operation ought to be performed without further delay.
Although I would not generally employ the tobacco enema in old weak
subjects, one exception deserves notice ; and this is, when such an indi-
vidual absolutely refuses to submit to an operation. One, or two cases
of this kind have been attended by me in University College Hospital,
and the practice was so successful, that, as soon as the patients came
under the influence of the tobacco, the contents of the hernial sac re--
turned into the abdomen, almost without the aid of any manual proceed-
ings.
I have little faith in purgatives and opium, except in cases of stran-
gulated epiplocele, or where there is reason to believe that a part of the
contents of the tumour has been reduced. We are sometimes called to
cases in which so much time has been lost, that we only just have an
opportunity of trying the effect of tobacco and cold, or even not of them.
ANATOMY OF INGUINAL HERNIA, OR BUBONOCELE.
It will be impossible to understand the subject of inguinal hernia, un-
less we are acquainted with the anatomy of the passage through which
the spermatic cord naturally proceeds, in order to reach the scrotum, and
through which the most common form of inguinal hernia takes place. We
must also understand the coverings of the spermatic cord, because they
are also the coverings of inguinal hernia; and, in addition to these matters,
we should have a clear idea of the situation of this hernia, in relation both
to the spermatic vessels and the epigastric artery.
The abdominal ring, or triangular opening in the tendon of the external
oblique muscle, the base of which corresponds to the crista of the os pubis,
is the external termination or outlet of the canal through which the sper-
matic cord passes. The upper, inner, and weaker pillar of this opening
is inserted into the symphysis of the os pubis, and its lower, outer, and
stronger pillar into the angle and crista of that bone. In the living sub-
ject, it is not an unclosed aperture ; for, besides being occupied by the
cord, it has the intercolumnar fascia extended over it. The inner opening
or commencement of the passage, designed for the spermatic cord, — the
very place, in fact, where the viscera first protrude in the most common
kind of inguinal hernia, — is not situated directly behind the abdominal
ring, but about an inch and a half from it, in the direction towards the
anterior superior spinous process of the ilium. Or, I may say, that the
inguinal canal, as it is generally named, is about an inch and a half in
length ; the internal ring being situated very nearly midway between the
symphysis of the pubes and the anterior superior spinous process of the
ilium.
From this description, it is manifest, that the direction of the inguinal
canal must be oblique, extending downwards, inwards, and forwards.
But the student will naturally ask, what parts form the inguinal canal ?
In order to understand this part of the subject, it should be renfembered,
that a thin fascia, termed the fascia transversalis, first accurately described
by Sir Astley Cooper, is extended from the inner margin of Poupart's
ligament, over the posterior surface of the transverse muscle, thus form-
ing a kind of partition between the abdominal ring and the peritoneum,
and also forming, with a portion of the united fibres of the transverse and
internal oblique muscles near the crista of the os pubis, the posterior
boundary of the inguinal canal, the anterior side of which is formed, to the
extent of its first third from the inner ring, by the transversalis and internal
558 HERNIA.
oblique muscles, and, in the remainder of its continuation, by the aponeu-
rosis of the external oblique.
The precise point, at which the most common forms of inguinal hernia
begin, corresponds, in the adult, to the passage of the spermatic cord under
the edge of the transverse muscle. In the sound state, this part of the
peritoneum has a small funnel-shaped depression in it ; and it is this small
digital kind of pouch, whose progressive enlargement constitutes the her-
riial sac, the hernia in its course always following the direction of the
spermatic cord, in front of the vessels of which it is situated.
In point of fact, the opening which constitutes the internal ring, or
commencement of the inguinal canal, is the aperture in the fascia trans-
versalis, designed for the passage of the spermatic cord into that canal.
Now the cord, in passing through this opening, carries along with it a
covering derived from the margin of such aperture in the fascia transver-
sal is, which covering is termed the funnel-shaped process of the fascia
transversalis. It is the least important of the investments of the hernia ;
for, after it has descended a little way, it is lost in the cellular tissue, be-
tween the peritoneal hernial sac and the cremaster.
The spermatic cord, invested by the funnel- shaped process, then passes
under the lower edge of the transverse and internal oblique muscles, and
here it receives its second covering from the cremaster muscle.
The abdominal ring is closed by the intercolumnar fascia, and from this
the cord also derives a third investment, termed the spermatic or inter-
columnar fascia ; and, in addition to these several coverings, namely,—
t\\e funnel-shaped process of the fascia transversalis, the expansion of the
cremaster, and the spermatic or intercolumnar fascia, — the cord is also co-
vered by the superficial fascia, placed immediately under the integuments.
These investments of the cord are also the coverings of the common
bubonocele, or oblique inguinal hernia, which descends through the in-
guinal canal. The hernial sac has between its external surface and the
inner surface of the cremaster the funnel-shaped process, or investment
derived from the margin of the aperture in the fascia transversalis, and
named in some schools the internal spermatic fascia. On the outside of
the cremaster, the sac has the covering derived from the intercolumnar ;
and, external to this_, the fascia superficialis, which is immediately under
the common integuments.
Sir Astley Cooper believes the inguinal canal to be endowed with mus-
cular contraction, which, under the action of the abdominal muscles, serves
to close it, and lessen the propensity to hernia. He observes, that the
lower edge of the transverse muscle begins to be attached to Poupart's
ligament almost immediately below the commencement of the internal
ring, and that it continues to be inserted behind the spermatic cord into
Poupart's ligament as far as the attachment of the rectus. Sometimes,
he has found a portion of muscle descending from the tendon of the trans-
versalis, in the course of the linea semilunaris, to be inserted into the
fascia transversalis, behind the cord, and into Poupart's ligament, and a
preparation exhibiting this conformation he was so obliging as to show me
some time ago. Sir Astley believes, that this encircling of the internal
ring and upper part of the inguinal canal by muscular fibres, may be a
cause of strangulation in the external bubonocele. However, the ana-
tomical facts, on which this doctrine is founded, are sometimes considered
to be only deviations from what may be regarded as the normal, or most
usual, conformation of the parts. Although we may not be disposed to
explain the supposed spasmodic nature of some kinds of strangulation by
SITUATION AND COURSE OF THE SPERMATIC VESSELS. 559
the cause referred to by Sir AstleyCooper,we ought to feel obliged to him
for his original explanation of the internal ring being occasionally sur-
rounded by muscular fibres derived from the transversalis. His greatest
discoveries on the subject of this hernia, however, appear to me to be
those relating to the first correct description of the internal ring, and of
the fascia transversalis.
OF THE SITUATION AND COURSE OF THE SPERMATIC VESSELS AND
EPIGASTRIC ARTERY, IN RELATION TO INGUINAL HERNIA.
As the epigastric artery naturally runs first behind the spermatic cord,
and then about a quarter of an inch from the pubic margin of the internal
ring, and as the viscera protrude through this aperture, and follow the
course of the cord, they must be situated on the outer side of that artery,
which passes first behind the neck of the sac, and then at its inner side,
in its way to the inner surface of the rectus muscle. Hence, the inner
margin of the neck of the sac is encircled, as it were, by the track of the
vessel.
In recent bubonoceles, the internal and external opening of the ring
are at some distance from each other, the first being situated obliquely
upwards and outwards in relation to the former ; but the pressure of the
protruded viscera gradually forces the internal opening more towards the
pubes, and nearer to the abdominal ring, so as to render the posterior side
of the neck of the hernial sac and of the inguinal canal very short. Thus,
in an oblique inguinal hernia of long standing, the opening into the ab-
domen is almost direct, and the epigastric artery becomes situated nearer
the pubes than in the natural state.
But, though in the most frequent form of bubonecele the protrusion
begins at the point which I have described, and follows the course of the
spermatic cord, passing all through the inguinal canal, and having the
epigastric artery behind and at the inner margin of the neck of the sac,
circumstances are very different in another less common variety of bubo-
nocele, where the viscera, instead of beginning to protrude at the internal
and upper opening of the inguinal canal, and descending through that
canal by following the course of the spermatic cord, are thrust out at the
point directly behind the abdominal ring, together with the portion of the
fascia transversalis, forming, with the conjoined fibres of the internal
oblique and transverse muscles, the posterior boundary of the inguinal
canal, immediately behind the abdominal ring, out of which the viscera
then protrude in a direct manner. Here the hernial sac, instead of passing
over the spermatic cord, as in the most frequent form of bubonocele, lies
on its inner or pubic side ; and the epigastric artery now pursues its course
in front of the neck of the sac, at the usual distance from the upper and
outer angle of the abdominal ring.
As in the most common inguinal hernia, the protrusion is on the out-
side of the epigastric artery, which winds under and round the inner
margin of the neck of the sac, the case is sometimes termed tl^ external
bubonocele; while the less frequent one, in which the protrusion takes
place immediately behind the abdominal ring, out of which the viscera
pass without having descended through the rest of the inguinal canal, is
named the internal bubonocele ; a case, most particularly claiming recol-
lection, as the protrusion is at the inner or pubic side of the epigastric
artery. One case is also called the oblique inguinal hernia; and the
other the direct or ventro-inguinaL
In this internal direct inguinal hernia, the sac pushes out with it the
560 HERNIA.
fascia transversalis, situated immediately behind the ring, and must either
lacerate or displace the united fibres of the internal oblique and transverse
muscles at this point. As the hernia does not follow the spermatic cord
through the inguinal canal, in general the cremaster only covers it near
the abdominal ring. With this exception, the coverings of the hernia are
the same as in the external bubonocele.
The explanation of the very different situation of the epigastric artery,
in relation to the neck of the sac of an internal bubonocele, from what
prevails in the external one, immediately shows how important it is to dis-
tinguish one case from the other in practice. In fact, if we were to divide
the stricture in the same way in each case, we should often wound the
epigastric artery. The discrimination of one case from the other is also
important, with reference to the manner of performing the taxis, and the
kind of truss that should be selected.
In scrotal hernia? of large size, the spermatic vessels, instead of forming
a cord, may be disjoined by the pressure of the swelling, the vas deferens
being situated on one side of the sac, and the spermatic artery and veins
on the other. In general, towards the upper part and neck of the sac,
the cord is not much unravelled : but, as its component vessels proceed
downwards, they diverge more and more, and spread themselves over the
sides, or even over the front of the sac.
The close adhesions, which a hernial sac soon contracts to the cellular
substance on the outside of it, make its reduction a rare occurrence. Such
an event, however, sometimes happens, especially in the femoral and in-
ternal bubonocele ; for, in the external one, the prompt and intimate man-
ner in which the sac becomes connected to the spermatic cord, makes it
much less likely to take place.
Bubonoceles are most common in the male sex ; but are occasionally
met with in women, and then the round ligament of the uterus bears the
same relation to the tumour as the spermatic cord does in males. Of
course, in such a case, the hernia has not the covering which, in the male
subject, it derives from the cremaster. There are also rare examples in
which the direct bubonocele occurs in women. I operated upon a
Mrs. Smith for a strangulated hernia of this description, a tailor's wife, in
Cumberland Street, Middlesex Hospital. As she had had no stools for
three or four days when I went to her, and the symptoms were urgent, I
performed the operation at once, without trying any previous means but
the taxis, and, in about a week, she was perfectly well.
DIFFERENCE IN THE SYMPTOMS OF OBLIQUE, AND DIRECT INGUINAL
HERNI^E.
In the oblique inguinal hernia, there is an oblong swelling, extending
obliquely inwards and downwards ; in the direct hernia, the parts pass
from behind straight forwards, and form, on the outside of the abdominal
ring, a circular globular swelling, in general suddenly occasioned by some
violent effort. If any obliquity occur in the direct inguinal hernia, it is
in a course towards the linea alba, and not towards the anterior superior
spinous process of the ilium. Then, in the oblique inguinal hernia, the
spermatic cord is situated behind or under the sac ; but, in the direct
bubonocele, it lies to the outer side, or upon the external half of the front
of the neck of the hernial sac. In the direct inguinal hernia, where the sac
adheres to the cord, the testicle is not situated exactly under the fundus
of the sac, as in the oblique inguinal hernia, but either at the forepart, or
on the outer side of it.
OPERATION FOR OBLIQUE INGUINAL HERNIA. 561
Iii the direct bubonocele, the epigastric artery ascends obliquely in-
wards at the outer side of the neck of the hernial sac, though Hesselbach
found an exception to this in one rare case, where that artery proceeded
from the obturatrix. This hernia occurs where the tendon of the trans-
versalis is unnaturally weak, or from malformation does not exist at all,
or from violence has been broken. Sometimes the fascia transversal is
protrudes before the peritoneum, and there may be between the two mem-
branes a stratum of fat. In certain instances, the hernia neither dis-
tends nor lacerates the conjoined tendon, but the protrusion takes place
under the edge of the transversalis, and then through the lower opening of
the inguinal canal. Sometimes this hernia consists of two protrusions,
divided from each other by strong tendinous fibres.
In other instances, the fascia transversalis is lacerated, not dilated.
In general the sac is not covered by the cremaster ; but all the best
authorities concur in the statement, that this investment is not unfre-
quently met with. A direct inguinal hernia is now and then accompanied
by an oblique one.
From the previous description it is sufficiently clear, why, in the
oblique hernia, the pad of a truss should always press, not merely upon
the abdominal ring, but upon the track of the inguinal canal ; and why,
in the direct hernia, the pad should only act upon the abdominal ring.
In the taxis, the direction of the pressure should be different ; for, in the
oblique bubonocele, the viscera should be pushed upwards, backwards,
and outwards; in the internal, upwards and backwards. Then, in the
operation on strangulated cases, a still more important thing to be re-
membered is the different directions which should be given to the incision
for the division of the stricture : in the oblique case, we may cut upwards
and outwards, with perfect safety to the epigastric artery, but not in-
wards or towards the linea alba ; whereas, in the direct hernia, the cut
must not be made outwards, but inwards, the epigastric not being dis-
placed from its natural situation. In order to avoid doing mischief by
mistaking one sort of hernia for another, Sir Astley Cooper recommends
the incision always to be made directly upwards.
OPERATION FOR OBLIQUE INGUINAL HERNIA.
The hair having been removed from the parts which will be in the
track of the knife, and the bladder emptied, the first incision should com-
mence an inch above the external angle of the abdominal ring, and ex-
tend obliquely downwards, and inwards over the middle of the tumour
to its lower part, except when the hernia is very large. This incision
divides the skin and the superficial fascia, and sometimes the upper
branch of the external pudic artery, as it crosses the tumour near the
abdominal ring. By directing the incision obliquely downwards and in-
wards, we lessen the chance of injuring the spermatic vessels, should
they happen to be situated towards the front of the sac. The division
of the integuments, subcutaneous fat, and the fascia superHcialis, ex-
poses the fascia derived from the intercolumnar, at the abdominal ring,
and generally forming one of the thickest coverings of the hernia. We
should then make a small opening through this covering derived from
the intercolumnar fascia, which may be safely done by taking hold of a
small portion of it with a pair of forceps, and then dividing it cautiously
close to the point of the forceps, with the edge of the knife turned hori-
zontally. Having made an opening, we introduce a director, and, with a
probe-pointed curved bistoury, divide the fascia upwards and downwards
o o
562 HERNIA.
as far as the external incision reaches. Thus the next covering of the
hernial sac is brought into view, namely, the expansion formed by the
cremaster, which must be opened and divided in the same manner as
the fascia. Having done this, we come to the funnel-shaped process, or
the continuation of the fascia transversalis between the upper portion of
the cremaster and the hernial sac, but which is so thin and so soon lost
in the cellular tissue between the sac and the cremaster, that it is not
recognised by some of the best writers on hernia. Now the cellular
tissue on the outside of the sac will be brought into view ; and, after
having carefully divided it, we arrive at the hernial sac itself; a little
piece of the anterior and lower portion of which is to be lifted up
between the thumb and fore-finger, and carefully examined to learn
whether the fold thus raised includes any portion of bowel. If it does
not, we take hold of it with a pair of forceps, and cautiously open it
with the edge of the knife directly horizontally. Surgeons choose to
open the hernial sac at its anterior and lower part, because if there be
any fluid in it, it will gravitate to this part, and be a kind of protection
to the intestine from the edge of the knife. Sometimes much perplexity
is evinced in distinguishing the sac itself from the intestine. However,
the circular arrangement of the vessels of a piece of intestine, and its
smooth polished surface, sufficiently characterise it from the hernial sac,
which has a rough cellular surface, bloodvessels pursuing an arborescent
course, and is closely connected to the surrounding parts. Having made
an opening into the hernial sac, we are to introduce a director, and, with a
probe-pointed bistoury, lay it open to the extent of the other incisions.
The next thing is to divide the stricture, which may be situated either
at the abdominal ring, and be formed by the margins of this opening ;
or else, what is more frequent, within the inguinal canal, where it is pro-
duced by the lower edge of the internal oblique and transverse muscles ;
or, lastly, at the internal ring itself, about an inch and a half from the ex-
ternal ring, in the direction towards the anterior superior spinous process
of the ilium.
If the case require it, we may now introduce a director, or the end of
the left fore-finger, into the neck of the sac, within the abdominal ring,
and, with a probe-pointed bistoury, cut the stricture upwards and out-
wards, or if it be preferred, directly upwards; the recommendation of
which last plan, suggested as a general one by Sir Astley Cooper, is,
that we shall not endanger the epigastric artery by it, whether the case
be an external or an internal bubonocele* Were we completely sure,
however, that the case were a direct bubonocele, we might safely di-
vide the stricture upwards and inwards, the epigastric artery lying on
the outer side of the neck of the sac, the reverse of what happens in
the oblique, or most common form of bubonocele.
When the stricture is at the upper opening of the inguinal canal, the
abdominal ring itself should not be cut, unless it prevent the operator
from reaching the more deeply-seated strangulation.
The next business is to return the protruded parts, if sound, and free
from adhesions ; and this will be considerably facilitated by bending the
thigh, and rotating the limb inwards. Sometimes, it is true, there is a
good deal of difficulty in separating adhesions, which may even be such
as to prevent the reduction of the protruded parts altogether ; but this is
unusual. In such a dilemma, by dividing the stricture, we render as
much service as surgery can accomplish ; and the patient will not always
be lost, though we may be obliged to leave some of the bowels pro-
OPERATION FOR OBLIQUE INGUINAL HERNIA. 563
truding. The intestine, if possible, should always be reduced, unless it be
found in a state of actual mortification. The appearance of dark-brown
chocolate discolourations is no objection ; and they should be discriminated
from the black or purple spots, which indicate mortification.
With respect to adhesions, the intestines are not often firmly adherent
to one another. In general, the strongest adhesions are those between
the omentum and the inside of the sac. Slight adhesions of the intes-
tine to the inside of the sac may be gently broken with the fingers. If
such connection should require the use of the knife, the safest plan is not
to cut too near the bowel, but to remove the adherent parts of the sac,
and return them with the intestine into the abdomen. But, if the adhe-
sions should be within the neck of the sac, the inguinal canal should be
more freely laid open, so as to bring them into view.
One important rule, after the reduction, is, to introduce the finger
tenderly, and ascertain that the parts are all fairly and freely returned, and
not suffering any degree of constriction, either from the margin of the in-
ternal oblique and transverse muscles, or the inner opening of the inguinal
canal, or other causes, and not confined by any adhesive bands, formed
across the mouth of the hernial sac.
Treatment of Omentum. — In entero-epiplocele, the omentum, if
healthy, is to be reduced after the intestine. If much enlarged and in-
durated, or gangrenous, diseased, or mortified, the unsound portion is to
be cut off, and the arteries taken up with a tenaculum, and secured with
fine thread or silk. One half of each thread is to be cut off close to the knot.
I do not return the portion of omentum, that lies in the upper part of the
sac; by which means all risk of bleeding into the abdomen is avoided.
Treatment of Mortified Intestine. — In many cases, when the intestine
mortifies in a hernial sac, the latter part, its coverings, and the integu-
ments, also become gangrenous. If the patient continue to live, the in-
testine bursts, and the feces at length find an outlet, either through the
wound made by the surgeon, or an opening formed by the separation of
the sloughs. Of course, before the bowel mortifies, the neighbouring
inflamed part of it becomes adherent to the neck of the sac. After this
the final result may be of three kinds: either the death of the patient ;
his recovery, with the loathsome annoyance of an artificial anus ; or the
gradual diversion of the feces from the wound to their natural course
again, the cicatrisation of the part, and a complete cure.
The principal thing, on which the re-establishment of the continuous
state of the intestinal canal depends, is the adhesion which the living
portion of bowel, adjoining the mortified part, contracts with the perito-
neum all round. In this manner, the escape of the contents of the bowel
into the cavity of the abdomen is in general completely prevented. The
two ends of the sound portion, after the sloughs have been thrown off,
become connected together through the medium of a membranous cavity,
which previously constituted a portion of the peritoneal sac. The gra^
dual contraction of the wound closes the membranous cavity externally,
and thus the continuity of the canal is restored. The two ends, however,
are not joined, so as to form an uninterrupted cylindrical tube, like that
of the natural gut ; but they are united at an angle more or less acute ;
and the matter, which goes from one to the other, describes a half circle
in the membranous cavity, while the two ends of the bowel always lie in
a more or less parallel manner by the side of each other; the upper with
its orifice directed towards the external wound by the feces, so long as
they take that direction. The lower is less capacious than the upper.
oo2
HERNIA.
This account renders it plain, that there must be a considerable pro-
jection,- or jutting angle, between the orifices of the bowel, directly oppo-
site the communication between the cavity of the intestine and that of
the semicircular funnel-shaped membrane, as it is termed by Scarpa.
Now, it is this projecting ridge, or angle, that forms a material obstacle
to the direct passage of the feces from the upper into the lower portion
of the intestinal tube. It constitutes one of the chief hinderances to the
cure of an artificial anus ; and it is by destroying it with the pressure of a
pair of forceps constructed for the purpose, that Baron Dupuytren's plan
often succeeds in curing this loathsome affliction. One of the blades of the
instrument, which is blunt, being one line in breadth, is received into a
groove in the other, so that the jutting angle, or Feperon, as it is termed by
the French surgeons, is crushed, not suddenly divided, which would
afford no opportunity for the adhesive inflammation. The first blade is
passed into the upper part of the bowel, the second into the lower, and
the instrument is then firmly shut by means of a screw, which connects
the handles, and by which the degree of pressure can be regulated. The
adjoining portions of the peritoneum unite by the adhesive inflam-
mation ; the jutting angle included between the blades sloughs ; the
cavity of the peritoneum is saved from an effusion of intestinal matter
into it; and the canal of the bowel remains free and perfect. Much of
the danger of an artificial anus will depend upon its degree of nearness
to the stomach. Thus, if the opening be in the jejunum, there will be so
small an extent of surface for the absorption of chyle, that the patient
will die of inanition.
If mortification of the bowel be first detected on opening the sac, and
there should be only one or two spots, we are to divide the stricture ;
and, if the gut be not adherent, it is to be reduced.
When the chief part, or the whole diameter, of the bowel is mortified,
the indication is to make an outlet for the intestinal matter, by a free
incision through the sloughs, and by cutting the stricture if it should still
exist. Here, of course, all idea of reduction of the parts is out of the
question.
In operating upon very large hernia of long standing, the proper plan is
to divide the stricture, if possible, without laying open the hernial sac.
The plan will answer, if the stricture be at the abdominal ring. When
the sac must be opened, it should be so only towards the latter opening,
and Hot more extensively than circumstances demand. The free exposure
of the cavity of a bulky hernia is itself a frequent source of fatal mischief.
In operating upon hernia within the inguinal canal, but not protruding
through the ring, we should make the incision in the direction of that
canal. In such a case, the stricture will be found at the internal ring.
After the operation, the wound is to be closed with a suture or two, and
lightly dressed. Evacuations from the bowels are to be promoted by
means of small doses of sulphate of magnesia, dissolved in peppermint
water, or by clysters. The patient must not, however, be allowed to sit
upon the night-stool, as doing so would be likely to bring on a protrusion
of the bowels again. It is safer to put a bed-pan under him. If tender-
ness and tension of the belly, with costiveness and febrile symptoms,
come on again, in the course of a day or two, we must have recourse to
local and general bleeding, poppy-head fomentations, and castor oil. If
the stomach be much disturbed after the operation, the sulphate of mag-
nesia may be given in the effervescing saline draught, with or without a
few minims of the tincture of opium or hyoscyamus.
THE FEMORAL OR CRURAL HERNIA. 565
Before the patient leaves his bed, a truss is to be applied.
When the bowel has been much discoloured, it will sometimes give
way two or three days after the patient has appeared to be going on
well ; and the patient is destroyed by peritonitis, resulting from effusion
of the contents of the bowels into the cavity of the peritoneum.
OPERATION FOR DIRECT INGUINAL HERNIA.
In this case, the coverings of the sac are the skin and superficial fascia,
the intercolumnar fascia, the fascia transversalis, and sometimes the ten-
dinous fibres of the internal oblique and transverse muscles, if not torn or
burst. It is only in the vicinity of the abdominal ring, that this hernia
commonly has any fibres of the cremaster spread over it. The several
investments, here specified, are to be divided much in the same way as
those of the oblique bubonocele, and the stricture cut, either upwards and
inwards, or directly upwards, as preferred by Sir Astley Cooper, for a
reason already explained.
THE FEMORAL OR CRURAL HERNIA
Is so called, when the hernial sac and its contents protrude under
Poupart's ligament at the inner side of the femoral vein, so as to be
situated in the bend of the groin, upon the pectinalis muscle, between
the gracilis and sartorius. The protrusion takes place, in fact, through
the crural or femoral ring into that compartment of the crural sheath
which is destined for the passage of the absorbent vessels of the lower
extremity. When once the sac has descended as low as the saphenous
opening in the fascia lata, the hernia has more room to extend itself for-
wards, and to each side, and the integuments now become raised into an
oval swelling, the greatest diameter of which is nearly transverse.
The femoral hernia is frequent in women * who have had children ; but
rare in young girls. In men, a hernia more readily forms through the
inguinal canal, by following the course of the spermatic vessels, than
under Poupart's ligament ; but the latter case is far from being so uncom-
mon in them as sometimes represented.
The tumour, produced by a femoral hernia, may be mistaken for an
enlarged gland. A gland can only become enlarged by the gradual
effects of inflammation ; the swelling of a femoral hernia comes on sud-
denly, and, when strangulated, occasions the train of symptoms already
described, which an enlarged gland could never occasion. As my friend,
Mr. Morton, also correctly observes, in consequence of the extensible and
yielding nature of the deep lamella of the superficial femoral fascia,
glandular swellings are readily moved upon their bases by lateral pressure,
and even allow the tips of the fingers to be pressed underneath them, so
as to lift them up, as it were, from the fascia of the thigh. On the other
hand, the neck of the tumour, formed by a femoral hernia, is deeper and
more fixed.
When the expanded part of a femoral hernia lies over Poupart's liga-
ment, it may be mistaken, for a bubonocele ; but, the true nature of
the case may always be made out by observing, that the neck of a femo-
ral hernia has Poupart's ligament above it. In the bubonocele, the spine
* A large proportion of the patients, on whom I have operated, were old women. One,
on whom I operated towards the end of October, 1839, in University College Hospital,
was eighty-seven, and is at this date (Nov. 2. 1839) nearly well. I remcmher no instance
where the operation was performed on a subject of this very advanced age.
o o 3
566 HERNIA.
of the pubes is below and behind the neck of the sac ; but in the femoral
hernia, it is on the same horizontal level, and a little on the inside of it.
When a femoral hernia expands in the bend of the thigh, its shape is
oval, and its greatest diameter is placed transversely ; but, whatever may
be the size of an oblique inguinal hernia, it has an oblong pyramidal
shape, with its fundus not inclined towards the ilium, but in the direction
of the spermatic cord towards the scrotum.
Besides the symptoms, common to all hernial swellings, the femoral
hernia, when of a certain size, has some which are peculiar to it, as stupor,
and sense of weight in the thigh, and sometimes oadema of the leg and
foot : circumstances, accounted for by the pressure of the hernia on the
bloodvessels, lymphatics, and nerves, which pass out of the pelt is in its
vicinity.
SURGICAL ANATOMY OF FEMORAL HERNIA.*
The crural arch is a term applied to the lower margin of Poupart's liga-
ment, the space intervening between which and the ilium and os pubis
is. in a great measure, closed on the side towards the abdominal cavity by
the union of the iliac and transverse fascice at Poupart's ligament, which
fasciae, in fact, shut up all that space which is between the anterior supe-
rior spinous process of the ilium and the femoral vessels. Hence, a her-
nial protrusion scarcely ever happens in the space below the crural arch
to the outside of the femoral artery and vein. The occurrence is pre-
vented not only by the junction of the iliac and transverse fasciae within,
but also by the fascia lata without, which, in this situation, is strong and
closely attached to the subjacent parts. The femoral hernia takes place
through the crural ring, a small oval aperture, which is situated under
the crural arch, more towards the pubes ; in fact, between the thin pos-
terior border of the crural arch, termed Gimbernat's ligament, and the
septum at the inner side of the femoral vein.
As the protrusion does not take place through a simple aperture, but
follows a course of some trivial length, the expression crural canal is em-
ployed by Scarpa and Cloquet. It is at all events the superior or poste-
rior aperture of the crural canal which is implied by the crural ring, the
canal itself extending obliquely downwards and forwards for a half or
three quarters of an inch, and terminating below at the oval depression
for the vena saphena major ; or, in the words of Mr. Morton, the crural
canal, is the short passage which extends between the saphenous opening
of the fascia lata and the crural ring. It is formed by the innermost of
the compartments into which the funnel-shaped sheath of the femoral
vessels is subdivided.
The viscera descend at first nearly in a perpendicular direction, and
come into the hollow in front of the pectinalis, but the hernia then turns
forwards, and directs itself rather towards the ilium, the fundus of the
sac sometimes inclining over the crural arch.
As the protrusion descends over the pectineal line, or close attachment
of the pectinalis muscle to the pubes, it must be situated over the pubic
portion of the fascia lata. Gimbernat's ligament, which is a part of so
much importance in the anatomy of femoral hernia, I think, will be best
* An excellent description of this subject, which I recommend to all students, is
contained in " Morton's Surgical Anatomy of the Groin, the Femoral and Popliteal
Regions." 8vo. Lond. 1839. The lithographic plates and wood engravings are
superiorly executed from original drawings ; and the book is replete with valuable surgical
remarks.
SURGICAL ANATOMY OF FEMORAL HERNIA. 567
understood by considering it as a prolongation or extension of Poupart's
ligament, which, when it approaches the os pubis, becomes suddenly
broader, and is attached by this broad portion to the angle and crista of
that bone, and ileo-pectineal line. The posterior edge of Gimbernat's
ligament is concave, thin, and sharp, the ligament itself about three
quarters of an inch in breadth, but broader in the male than the female
subject. In the erect position of the body, it is nearly horizontal.
The crural ring, through which the absorbents of the thigh ascend to
the lymphatic glands situated upon the inner border of the psoas muscle,
is formed by this posterior edge, or, as it is sometimes termed, the base of
Gimbernat's ligament, directed towards the crural vein ; externally by
the femoral vein, or rather by a production of fascia, or a kind of septum
placed between that vessel and the compartment of the femoral sheath,
through which ascend the great lymphatics of the thigh ^ anteriorly by
the thin posterior edge of the crural arch, or Poupart's ligament ; and
posteriorly by the horizontal branch of the os pubis. But into the crural
ring productions both of the fascia transversalis and fascia iliaca always
descend, so as to form at once a part of the tubular or funnel-shaped sheath
for the femoral vessels, and a lining for the crural canal, the front half being
formed by the fascia transversalis — the back by the fascia iliaca ; and, as
Sir Astley Cooper has clearly explained, it is through the inner side of
the sheath, next to the pubes, that the femoral absorbent vessels pass
into the abdomen, the openings for which give a cribriform appearance
to this portion of the tubular sheath. The femoral sheath is wider above
than below : its external side, which is straight, being closely applied to
the femoral artery ; while its inner margin extends downwards and out-
wards from Gimbernat's ligament to the femoral vein, just on the inner
side of which vessel is an oval aperture, frequently occupied by a lym-
phatic gland, and some absorbents and loose cellular tissue (the septum
crurale of J. Cloquet), through which opening the hernia, in its descent,
passes towards the point of the fascia lata, at which the vena saphena
major gets to the femoral vein, which point is included within what is
called the falciform process. It should then be clearly understood, that
the tubular or funnel-shaped sheath of the'femoral vessels is subdivided
into three distinct compartments by the membranous septa, which are
situated on each side of the femoral vein, and connect the anterior and
posterior parietes of the sheath more firmly together. The most exter-
nal of these subdivisions contains the common femoral artery, the second,
or middle, the great femoral vein, while the third, or that which is near-
est the tuberosity of the os pubis, corresponds with the crural ring, and
is closed in the natural condition of the parts by some loose cellular tissue,
and lymphatic vessels, an absorbent gland also occasionally lying within
it.* Into this last compartment, the viscera protrude in a femoral hernia.
The very lucid and original explanations of the anatomy of femoral
hernia by Sir Astley Cooper reflect the highest honour on himself, on
his profession, and, I would also say, on his country. We fcnew little
about various points in the minute anatomy of femoral hernia until he
demonstrated them, and published a clear description of them. If we
turn to this source of information, or, what is better, if we dissect and
open the tubular sheath, we find that it contains two membranous par-
titions, or septa, one passing between the artery and vein, and another be-
tween the vein and the absorbents. The artery and vein completely fill
* See Th. Morton, Op. cit. p. 90.
o o 4?
568 HERNIA.
up the spaces in the sheath allotted to them ; but the absorbents, being
but loosely connected by cellular tissue, do not always afford sufficient
resistance to prevent the descent of the viscera in this situation, and the
formation of a crural hernia. It is this opening, then, in the inner part
of the sheath, which is really the aperture by which the bowels descend,
and which is situated, as already stated, between the thin crescentic edge
of the base of Gimbernat's ligament and the femoral vein, or rather the
septum. Or I may say, that the hernia protrudes into the division of the
tubular sheath, designed for the transmission of the principal trunks of
the absorbents from the lower extremity, scrotum, and superficial parts of
the hypogastric region into the pelvis.
'The falciform process is easily comprehended when we remember, that
the fascia lata has two origins, one from the lower border of Poupart's
ligament, all the way from the anterior superior spinous process of the
ilium, to the tuberosity of the os pubis. This, which is the thickest and
strongest, is called the iliac portion, and it covers the psoas, iliacus, sar-
torius, and rectus muscles, the femoral artery and vein, and the anterior
crural nerve, its breadth in the adult subject being from four to five
inches. The inner or pubic portion of the fascia lata arises from the
pubes in front of the origin of the pectinalis muscle, which muscle it
covers, together with the adductor longus, and the gracilis, and after-
wards unites with the iliac portion of the fascia lata, under the great
saphena vein. Of course, it lies behind or under the femoral vessels,
while the iliac portion is in front of them ; and above, it is continuous
with the iliac fascia. From this description, it is manifest that, where
the pubic portion of the fascia lata joins the iliac portion under the vena
saphena major, there must be an aperture left for the passage of that
vessel. This opening is termed the saphenous opening, the concave
external margin of which consists of part of l\\e falciform process, first
correctly described by Mr. Allan Burns.*
Scarpa represents the iliac portion of the fascia lata as connected with
Gimbernat's ligament ; and Mr. Lawrence describes the upper end of the
falciform process, not merely as passing in front of the femoral vessels,
just as they emerge from behind the crural arch, but as bending under
Poupart's ligament, so as to unite with the thin border of the arch called
Gimbernat's ligament.
The great saphaenal vein passes over the inferior sharp edge or lower
horn of the falciform process, and there joins the femoral vein. Then,
between the parts just described and the skin, is the fascia superficialis^
quite distinct from the fascia lata, and consisting of two layers, between
which lie some adipose matter and the superficial inguinal glands.
Where it covers the saphenous opening, it has several apertures in it,
and this portion of it, or rather of the deep layer of it, is sometimes
termed the cribriform fascia, -\-
* " It is in a great measure owing to the connection that exists between the margin of
the saphcnous opening and the sheath of the vessels, that the fundns of the sac of a
complete femoral hernia is usually prevented from descending anv further downwards,
but is rather turned, or tilted forwards and up wards, so as to rest upon the falciform pro-
cess and the lower part of the aponcurosis of the external oblique muscle." Morton,
Op. cit. p. 1 10.
•j- " The fascia cribriformis adheres pretty closely to the margins of the saphenous
aperture of the fascia lata ; it is covered externally by the cutaneous vessels and super-
ficial absorbent glands; while its internal surface is in apposition with the anterior part
of the funnel-shaped sheath of the vessels, where it is formed by the fascia transversalis."
Morton, Op. cit. p. 103.
SURGICAL ANATOMY OF FEMORAL HERNIA. 569
The anterior wall of the crural canal is formed by the fascia trans-
versalis, covered by the falciform process of the iliac portion of the
fascia lata. The posterior wall is formed by the fascia iliaca, supported
on the pubic portion of the fascia lata, which here covers the pectineus.
The external wall is formed by the septum at the inner side of the
femoral vein, and the internal by the transverse and iliac fasciaa, where
they unite to complete the inner side of the funnel-shaped sheath.
In femoral hernia, the viscera descend through the crural ring, pushing
before them the peritoneum. They then pass into the internal com-
partment of the tubular sheath of the femoral vessels, that designed
for the transmission of the lymphatics, and afterwards turn forwards, and
even upwards, through the saphenous opening in the fascia lata, so as to
lie over the iliac portion of the fascia lata.*
The coverings of the femoral hernia are the integuments, the fascia
superficialiS) and the fascia propria, or tubular sheath of the femoral
vessels, besides the peritoneal hernial sac. The epigastric artery passes
obliquely upwards and inwards, about half an inch from the external side
of the neck of the sac. When the obturatrix artery arises from the epi-
gastric, it may go either near the outer or inner side of the neck of the
sac to the obturator foramen. When the common trunk of these vessels,
so originating, is long, and the place where the obturatrix goes off from
it is high up, the latter vessel may descend near the upper and inner
border of the crural ring. But, when it arises from the epigastric lower
down, it will then pursue its course downwards near the external margin
of the neck of the sac. On this point, Mr. Morton makes the following
remark : — " When the obturator artery is given off from the epigastric
(a variety that occurs about once in three subjects), it most frequently
descends upon the pubal side of the external iliac vein to reach the thyroid
foramen ; and, when it does so, will always be placed upon the iliac, or
external side of the crural ring, and therefore altogether removed from
the edge of the knife, as commonly directed in the operation for femoral
hernia." Sometimes, however, it runs, for a short distance, along the
superior margin of the crural ring, and then descends behind the lunated
border of Gimbernat's ligament, in its way to the thyroid foramen. When
this latter arrangement prevails, the neck of the*hernial sac is surrounded
for at least three fourths of its circumference, by large and important
vessels. The spermatic cord, or, in women, the round ligament, as it lies
within the inguinal canal, passes directly over the superior part of the
hernia ; or, in other terms, is situated close above the anterior margin of
the crural ring. All these are essential things to be considered in oper-
ating on a femoral hernia.
The peritoneum, as it descends before the hernial protrusion, pushes
before it the subserous cellular tissue, and the septum crurale. So long
as the hernia is lodged within the crural canal, and does not project
through the lower opening of it, the case is termed an incomplete femoral
hernia. On account of the tumour being small, and bound ddtvn by the
falciform process, its detection, as Mr. Morton justly observes, requires
much attention, especially in corpulent subjects.
When thefundus of the sac protrudes through the saphenous opening,
the case is a complete femoral hernia.
* In a few instances, where the septum on the. inner side of the femoral vein is defec-
tive, the hernia, instead of protruding at the saphenous opening, descends further into the
sheath of the femoral vessel, and then, of course, it lies under the fascia lata.
570 HERNIA.
OPERATION FOR STRANGULATED FEMORAL HERNIA.
The bladder should first be emptied ; for, a wound of it has been known
to occur in the operation. This is not always performed in one way,
different surgeons having different modes of proceeding, according to
their view of the parts chiefly concerned in forming the stricture, and of
the safest place for the incision, with reference to the epigastric artery
and spermatic vessels ; for the round ligament in the female ought not to
have much influence on the question, a wound of it being of little im-
portance. At St. Bartholomew's, the school where I was brought up,
the surgeons usually began the operation by making an incision, which
commenced about an inch above the crural ring, or pubic portion of
Poupart's ligament, and extended obliquely downwards and outwards
over the centre of the swelling. This plan answered very well where
the intention was to divide Gimbernat's ligament near the pubes, in order
to free the protruded parts from strangulation in the crural ring itself,
and to be able to reduce them. Sir A. Cooper and Baron Dupuytren
make two incisions through the integuments, in the form of the letter T
reversed. The transverse cut, extending over the middle of the tumour,
is safely made by pinching the skin into a fold in the direction of the
femoral vessels, and then cutting it across. The second incision is then
to descend from a little above Poupart's ligament to the central part of
the transverse incision, after which the angles or flaps are to be carefully
dissected up. The first transverse cut is likely to wound the superficial
epigastric artery : but this is a matter of no importance. The division
of the integuments exposes the superficial fascia, which is here generally
thicker than what lies over an inguinal hernia, though, in thin persons
and recent cases, it may be so delicate as to escape notice. It also
includes between its layers the superficial absorbent glands. Sometimes,
when we have made the incision through the skin, we find the hernia
concealed by dense fat and enlarged absorbent glands ; but we are not to
be perplexed by the circumstance, provided we are clear and certain
respecting the existence of hernia. I remember being sent for to a poor
woman in St. Giles's, one twelfth-night, for a strangulated femoral
hernia, when, as the symptoms were urgent, and I had not much time to
spare on account of a private engagement, I proceeded to the operation
directly after the taxis had failed. Now, on making the incision
through the integuments, I came to such a mass of diseased fat and
glands, that I was a little staggered, and led to consider for a minute or
two whether I might not have been in too great a hurry to operate, and
mistaken a case of enlarged glands for a hernia. But a little reflection
convinced me, that the patient's symptoms could not depend upon the
latter cause ; and, on dissecting more deeply, I came to the fascia pro-
pria of a small hernial tumour. The patient recovered, as, I think, most
patients do, in whose cases the operation is not deferred till too much
inflammation and other mischief have had time to take place. After the
division of the superficial fascia, we come to the tubular sheath of the
femoral vessels, or fascia propria. Our next object is to lay open the
fascia propria, first lifting up a piece of it with the forceps, and then
making a small opening in it with the edge of the knife directed hori-
zontally. A director is then to be introduced into the aperture so made,
and the fascia propria divided upwards and downwards to the neck and
fundus of the sac. After having laid open the fascia propria, we may
meet with a quantity of fat, which, in consequence of the long pressure
OPERATION FOR STRANGULATED FEMORAL HERNIA. 571
of trusses, sometimes presents a thickened dense feel, and assumes very
much the appearance of indurated omentum, so as to cause an erroneous
suspicion of the hernial sac having been already divided, followed by
pernicious efforts to push back the parts into the abdomen. This is a
subject, on which excellent practical information is contained in Key's
edition of Sir Astley Cooper's work on Hernia, who has given a plate
exhibiting an unopened sac pushed back into the abdomen, with the
strangulated bowel in it. In University College Hospital, I operated last
winter (1838-39) on a woman of sixty, for a strangulated femoral hernia
of long standing. On opening the fascia propria, a portion of a cyst,
imbedded in fat, and filled with fluid, presented itself, looking very
much like a fold of intestine. On dissecting more deeply, another cyst
of the same kind was met with, before the hernial sac was exposed.*
Circumstances of this kind, if the surgeon be not aware of their pos-
sibility, create much embarrassment in the operation. The hernial sac,
having- been exposed, is now to be cautiously opened, in which step of
the operation we are to nip up a small portion of the fundus of the sac,
and feel that no portion of the contents of the hernia is directly within it.
Then we are to take hold of it with the forceps, and make a small open-
ing in it with the edge of the knife directed horizontally, and kept close
to the extremity of the forceps. On this being done, a certain quantity
of clear or turbid serum mostly gushes out, but not invariably. The
director is now to be introduced, and the sac laid open upwards and
downwards to the crural sheath and fundus of the sac itself.
Having proceeded thus far, we may sometimes easily return the con-
tents of the hernia without the further use of the knife ; but, unless this
be practicable without any squeezing and bruising of the parts, the
stricture ought to be cut. In this important stage of the operation, I have
generally divided Gimbernat's ligament, and with it the neck of the
hernial sac, and the contiguous part of the fascia transversalis. A director
is introduced along the inner side of the protruded viscera into the crural
ring, with the groove turned towards the pubes. Then with a narrow
probe-pointed bistoury, or with Sir Astley Cooper's hernial bistoury,
which has but a limited cutting edge, and none at all towards the handle,
in order to occasion less risk of wounding the bowel, we are to cut the base
or deep-expanded part of Gimbernat's ligament in the direction inwards,
or inwards and upwards. In this part of the operation, the bowel is con-
tinually exposed to injury, on account of the small space in which we
have to act ; and I recommend all surgeons, therefore, not only to use
the kind of bistoury suggested by Sir Astley Cooper for the division of
the stricture, but to be particular in keeping the intestine out of the way
of the instrument with the left fore-finger, or with the hand of an assist-
ant. Of late, I have sometimes cut the posterior edge of Poupart's liga-
ment upwards and inwards either with a common probe-pointed bistoury,
or Sir Astley's knife, passed along the nail of the fore-finger of the left
hand, which is sometimes safer than a director. " The tip of the finger
nail (as Mr. Morton. observes) should be insinuated underneath the band
which forms the stricture, and the blunt extremity of the probe-pointed
bistoury (placed flat upon the finger) guided just within the sharp margin
of the stricture; after which the edge of the knife is to be turned up-
* See Clinical Lecture in Lond. Med. Gaz. for March, 1839. Cysts of this descrip-
tion I find noticed in the last edition of Lawrence's Treatise on Hernia ; also by Sir
Charles Bell, in his Illustrations of the Great Operations of Surgery, p. 41.
572 HERNIA.
wards, and the handle being raised, the tendinous band, which resists the
return of the bowel, will be easily divided." The stricture having been
divided, the thigh should be fixed, and rotated inwards, in order to relax
still further the crural ring, and facilitate the reduction.
When the bowel has been strangulated beyond a certain time, it be-
comes dark-coloured ; and, though not actually gangrenous at the period
of the operation, it will sometimes give way afterwards. This happened
in a case, where I operated rather too late on the sister of the celebrated
harlequin, Bologna. She was a dancer, a profession particularly exposed
to the risk of hernia. After the operation, her sufferings ceased, she had
several motions, and her pulse came down to 80 ; but, all on a sudden,
forty-eight hours after the operation, she was seized with excruciating
agony in the abdomen, faintings, quick faltering pulse, and cold sweats,
with which symptoms she soon died ; and, on opening her, it was found
that a small point of the ileum had given way, that the contents of the
bowel had become effused, and that a rapidly fatal inflammation of the
peritoneum had been the consequence.
It would not be safe to cut the crural ring upwards in a male subject ;
because we should wound the spermatic cord. In a female, however, in
whom we find that this hernia is most common, I do not know, that the
round ligament ought to deter us from cutting in this direction, if we
had any reason for selecting it. We could not cut upwards and out-
wards, because we should injure the epigastric artery; and we could
not turn the edge of the knife precisely outwards, or in the direction
away from the pubes, because we should wound the femoral vein. The
safest plan, therefore, seems to be generally that of making the requi-
site division of the crural ring by cutting inwards, or inwards and a little
upwards.
The only case, in which the division of the deeper part of the stricture,
in the direction inwards, would be attended with danger, is that in which
the obturatrix artery arises from the epigastric, high up, and, in its way
into the pelvis, descends round the inner margin of the crural ring. This
position of the obturatrix artery, however, in relation to the neck of the
sac and the crural ring, is computed not to occur more frequently than
once in about eighty cases of femoral hernia. The division of Gimbernat's
ligament inwards has not the sanction of some surgeons, for whom I en-
tertain the highest respect; and though it is the method which I have
frequently adopted, and found answer, let not the reader suppose that I
do not see reasons for sometimes following other plans. Sir Astley
Cooper cuts the anterior part of the crural canal, by carrying the knife
as far as the front margin of the crural arch, in the direction upwards and
inwards. When this is not sufficient, he next cuts the thin posterior
border of Poupart's ligament in the same direction. There ought, indeed,
to be some variety in the method of operating, according to the circum-
stances of each individual case: and the valuable investigations of that
eminent surgeon tend to prove, that the seat of strangulation in femoral
hernia is not always in the same place, but may be either in the crural
sheath, where the stricture is occasioned by the semilunar edge of the
fascia lata, or the saphencus opening, or at the posterior edge of the
crural arch ; or, lastly, at the mouth of the hcrnial sac, in the fascia
which surrounds it.*
* On this interesting part of tlic subject, the following is Mr. Morton's statement.
In by far the greater number of instances, the constriction is relieved by the division
CONGENITAL INGUINAL HERNIA. 573
Having laid open the hernial sac, Sir Astley Cooper introduces his
probe-pointed bistoury, which does not cut near the point, into the crural
sheath, at the anterior part of the sac, and divides with it the sheath as far
as the front edge of the crural arch. This cut, which does not exceed half
an inch, is sufficient for the reduction of small hernice. But if the bowel
cannot now be returned by gentle pressure, he passes in his finger about
half an inch higher, and divides the posterior edge of the crural arch and
fascia transversalis immediately next to it. As these two incisions are
made from within the sac, they will of course remove any stricture
formed by the sac itself. The direction of an incision for the division of
the stricture, which he deems most eligible, is upwards, with a slight
obliquity towards the umbilicus.
Baron Dupuytren, in operating on femoral hernia, used to divide the
same parts as Sir Astley Cooper ; but employed a curved probe-pointed
bistoury, which cuts on its convexity ; it is introduced into the hernial
sac flat on the left fore-finger, and its edge is then turned upwards and
outwards, and the upper extremity of the falciform process divided as far
as the front margin of the crural arch. Hesselbach also regards an inci-
sion through the front side of the crural canal safer than one through
Gimbernat's ligament. Although Dupuytren directed the knife towards
the spermatic cord, he did no injury to it ; because he took care not to
cut far enough to endanger it. He also avoided the epigastric artery by
making a very limited cut.
CONGENITAL INGUINAL HERNIA.
The great peculiarity of this case is, that the protruded viscera lie in
the tunica vaginalis, which serves as the hernial sac. The bowel, or
omentum, is therefore in contact with the testicle.
The congenital inguinal hernia arises in the following manner: — In the
foetus, the testes are situated immediately below the kidneys, on the fore-
part of the psoas muscles, with their anterior and lateral surfaces covered
by reflected peritoneum, and their posterior surfaces connected to the
psoas muscles by means of cellular tissue. About a month or six weeks
before birth, but sometimes subsequently to this event, the testes de-
scend through the abdominal ring into the scrotum, where there is a
production of the peritoneum already formed for their reception, and
afterwards constituting the tunica vaginalis. The testes in their descent
do not fall loose into the tunica vaginalis, but carry with them the peri-
toneum immediately adherent to them. Soon after the testes have got
into the scrotum, the upper part of the tunica vaginalis is closed, by which
change all communication between the cavity of that membrane and the
belly is shut. Sometimes, however, this closure is delayed, and then, if
any of the bowels insinuate themselves into the passage, they become of
course, so long as they continue unreduced, an impediment to its further
obliteration ; and the case is a congenital inguinal hernia, which differs
from all common herniae in having no hernial sac produced bj*a protru-
sion of the peritoneum with the bowels themselves.
No doubt, one of the most frequent predisposing causes of congenital
hernia is the occasional delay in the descent of the testicle, which cir-
upwards and inwards of the falciform process of the fascia lata, and the lunated edge of
Gimbernat's ligament, where they join with each other. In some instances, it will be
the fibres of the deep crescentic arch ; in others again, the neck of the sac itself," within
the circumference of the crural ring.
574 HERNIA.
cumstance has the effect of retarding the closure of the passage between
the belly and the scrotum. The disease is not generally produced by
the insinuation of the bowel into the tunica vaginalis at the same time as
the testicle itself. Before birth, the small intestines are but little dis-
tended ; and, in the absence of respiration, they can suffer no compression
from the diaphragm and abdominal muscles. Hence, notwithstanding the
expression congenital, the disease is hardly ever noticed in infants directly
they are born, but makes its first appearance afterwards. One acci-
dental circumstance, however,, may really make the hernia strictly con-
genital, namely, — the intestine or omentum may become adherent to the
testicle previously to its leaving the abdomen, and consequently descend
with it into the scrotum before birth.
The formation of such adhesions between the bowels and testicle before
birth may also sometimes prevent, or retard, the descent of the latter
organ.
Surgeons are frequently consulted for congenital hernia, where the tes-
ticle has not yet descended through the ring.
The congenital inguinal hernia must always necessarily be external, or
oblique ; because the neck of the tunica vaginalis invariably corresponds
to the point, at which the spermatic cord passes under the border of the
transversalis muscle. Also, as the tunica vaginalis enters the inguinal
canal beyond the point at which the spermatic cord crosses the epigastric
artery, it must have this artery on the internal side of the inner ring.
In young children, the congenital hernia more frequently contains in-
testine than omentum, because in them the latter part is very short.
The impossibility of feeling the testicle, while the bowels are down, is
the most important criterion between this hernia and a common bubo-
nocele, where we can always feel the testicle at the lower and back part
of the swelling. Then a suspicion of the nature of the case may be en-
tertained, if the hernia has existed from early childhood ; not that infants
may not be occasionally the subjects of common bubonoceles.
The viscera, included in a congenital hernia, but more especially the
omentum, are frequently adherent to the testicle ; a complication at-
tended with serious inconvenience, unless removed, as it prohibits the
reduction of the protruded parts, and the use of a truss. The bowel
and omentum may also adhere to the sac, and sometimes to the sac and
testis at the same time.
A congenital inguinal hernia is to be treated on the same general prin-
ciples which apply to other hernias. If the bowels admit of reduction,
the patient be young, and a proper truss constantly worn, the communica-
tion between the abdomen and scrotum will frequently become obliter-
ated, and a radical cure be the result. The chances of this desirable
event diminish, however, as the individual grows older, and, after the
adult age, a truss can hardly ever be safely dispensed with. Unfortu-
nately, we cannot always apply a truss, as when a piece of intestine or
omentum is in the sac, while the testicle is in the groin, or even within
the abdomen; for, in the first case, it would press upon and inflame the
testicle, and, in the second, prevent its descent. However, if the patient
should be beyond the age, when any chance of the descent of the testicle
exists, I would recommend the hernia to be reduced, and a truss applied.
In young subjects, in whom no congenital hernia exists, but one or
both testicles have not yet passed the ring, their descent should be
watched, and, as soon as they are low enough, a truss should be worn,
constructed so as not to make any hurtful pressure on them.
HERNIA OF THE CCECUM AND COLON. 575
A congenital hernia is remarkable for the thinness of its sac ; a fact
dictating caution in the first steps of the operation. The sac is, indeed,
frequently not thicker than the natural peritoneum. This hernia is also
well known to be particularly often strangulated at the inner opening of
the ring, or by a contraction of the neck of the sac within the inguinal
canal. It has also another peculiarity, which is, that it sometimes becomes
strangulated by constrictions in the body of the sac itself.
As the epigastric artery is always on the inner side of the neck of the
sac, the division of the stricture may be safely made upwards and out-
wards.
Great care should be taken not to handle, wound, or, in any manner
injure the testicle in the operation.
A peculiar case is sometimes met with, consisting of a protrusion of the
viscera, together with a peritoneal hernial sac, into the cavity of the tu-
nica vaginalis. It is formed after the recent obliteration of the communi-
cation between the abdomen and the tunica vaginalis. Were we not
aware of the possibility of such a case, we might be considerably per-
plexed on meeting with it. In the museum of University College is a
preparation of a double kind of hernia: first, a congenital one, with omen-
turn in it ; and, secondly, another hernial sac pushed down into the tunica
vaginalis.
HERNIA OF THE CO2CUM AND COLON.
Scrotal herniee of the right side, formed by the ccecum, the appendix
vermiformis, and commencement of the colon, draw after them into the
scrotum that portion of the great bag of the peritoneum by which those
viscera are naturally fixed in the right ileo-lumbar region ; and, on
opening the sac, we find the crecum and colon connected to this part of
the peritoneum, just as they were in the abdomen previously to the dis-
placement. The same kind of natural adhesion of the large intestines to
the hernial sac may also take place in a scrotal hernia of the left side,
when the protrusion consists of that part of the colon which is naturally
fixed in the left ileo-lumbar region by duplicatures of the peritoneum.
Another peculiarity of these herniae arises from the ccecum and begin-
ning of the colon being partly situated out of the peritoneum : hence
they can only be partially surrounded by a hernial sac, a portion of their
external side being in immediate contact with the adjacent cellular tissue.
In such a case, were the surgeon to cut too much towards the outside of
the tumour, he would find the ccecum and colon immediately under the
cremaster and infundibular process of the fascia transversalis.
From what has been stated, we discern the cause of another peculi-
arity of herniae of the ccecum and fixed portion of the colon, namely, the
impossibility of their reduction. The appendix vermiformis may be re-
turned, but the ccecum itself cannot be reduced, unless the sac itself ad-
mit of being replaced.
These circumstances render it a matter of importance to discriminate
a hernia of the ccecum and beginning of the colon from others. Now,
such a case can only form gradually ; the displacement of the coecum and
colon, fixed as they are in their natural situation, must be a slow process.
Herniae of sudden formation, therefore, cannot be of this kind. The tu-
mour will also generally be of large size, of long standing, and of an irre-
gular knobby shape.
In this species of hernia, as well as in all others of large size, the symp-
toms of strangulation are seldom violent, on account of the width of the
576 HERNIA.
opening through which the protrusion takes place. We should in such
cases be cautious not to mistake the colic and irritation, to which the
viscera in the tumour are liable, for the symptoms of strangulation. When
a large old scrotal hernia is really strangulated, the evacuations from
the bowels are soon totally suppressed, the swelling is painful, and the
patient is affected with vomiting, eructations, and fever. On the contrary,
in the colic from irritation, resembling strangulation, the discharge of air
and feces from the rectum is never entirely suppressed ; and the evacu-
ations are increased when mild purgatives and clysters are given. If
nausea and tendency to vomiting occur, it is at long intervals ; there is
not much fever ; and the swelling, though tense and bulky, is not painful
on being handled. Under such circumstances, mild saline purgatives,
clysters, and cold applications, may frequently be employed with success,
and we should not be in haste to perform an operation.
But, if a large hernia of the ccecum were to be truly strangulated, we
should remember, that the bowels will not admit of being completely re-
turned, on account of their particular and natural adhesions to the sac;
and in this, as well as in all scrotal herniae of large size, the neck of the
hernial sac is not the seat of strangulation. Here, perhaps, the best plan
would be merely to expose the abdominal ring, and make a division of it,
upwards and outwards, without opening the hernial sac at all, and then to
try to reduce the viscera as far as practicable.
THE EXOMPHALOS, OR UMBILICAL HERNIA,
Is a protrusion of the viscera through the navel, or in the neighbouring
part of the linea alba. The first case, whether met with in the infant or
adult, has a circular neck, at the circumference of which the tendinous
margin of the umbilical ring can be felt. Whatever may be the size of
the tumour, its body always retains nearly a spherical shape ; nor can any
wrinkle of the skin, nor any thing at all resembling the cicatrix of the
navel, be seen upon the convexity or the sides of the swelling. On the
contrary, in a hernia of the linea alba, the neck of the swelling is of an
oval shape, like the fissure through which the protrusion has taken place ;
and, if the hernia be very near the navel, the umbilical cicatrix may be
seen on one of the sides of the swelling — a sure proof that the viscera do
not protrude through the umbilicus itself.
In a true exomphalos, the tumour in a thin person is free and pendu-
lous ; in a fat subject, broad at its base, less prominent, and hence sphe-
rical. The protruded parts will naturally tend downwards, so that the
opening into the abdomen is from the upper part and not from the middle
of the swelling.
The umbilical hernia is not only furnished with a true peritoneal sac,
but with a superficial investment of condensed cellular substance. The
coverings of this hernia, however, are frequently very thin, and, in old
cases, portions of the sac are sometimes absorbed. Nay, the viscera may
be adherent to the integuments, and strangulated by the opening in the
sac,, through which they have protruded, and which has been occasioned
by its partial absorption.
An umbilical rupture in an adult rarely contains intestine unaccompa-
nied by omentum. The disease happens with much greater frequency in
women than men ; a fact explicable by the consideration that pregnancy
has more influence than any other cause in bringing on the complaint.
Dropsical and corpulent subjects, however, of both sexes are particularly
liable to it.
CYSTOCELE, OR HERNIA OP THE BLADDER. 5?7
HERNIA IN THE LINEA ALBA, OR VENTRAL
Are much slower in their progress than a true exomphalos. On account
of their small size, they are frequently unobserved, especially in corpu-
lent subjects, or when situated on one side of the ensiform cartilage.
However, they bring on complaints of the stomach and habitual colics,
and are more liable to simple obstruction, than strangulation with inflam-
mation and tendency to gangrene. But when this state unfortunately
does occur, the symptoms are more intense, and the accession of mor-
tification more rapid, than in any other species of hernia. Even when
merely the omentum is strangulated, the symptoms are particularly vio-
lent, a circumstance ascribed to the proximity of the stomach.
When practicable, the exomphalos and ventral hernia? should be re-
duced, and a truss worn. In Hey's Surgery is a description of an excel-
lent truss for umbilical hernia. In young subjects, the pressure of a truss
will often radically cure the disease ; and the plan is much more com-
mendable, than that of reducing the viscera, and then extirpating the
integuments and sac with a ligature.
When, in adult subjects, an operation is unavoidable, the sac should
be laid open with the greatest caution, and the umbilical ring divided
either directly upwards or downwards. When the hernia is very large,
but not attended with gangrene, we should be content with cutting the
umbilicus, without opening the sac at all, or as little of it as possible.
The division of the stricture in ventral hernia may also be made up-
wards or downwards, due regard being paid to the epigastric artery which
crosses the linea semilunaris.
CYSTOCELE, OR HERNIA OF THE BLADDER.
The protrusion is most frequently through the abdominal ring ; and
generally in male subjects who have been repeatedly afflicted with re-
tention of urine. Cystocele has been noticed, however, in children, from
the irritation of stone, and even in women from the effects of dropsy and
pregnancy.
Only the fundus and a part of the posterior surface of the bladder,
down to the insertions of the ureters, are covered by peritoneum. Now,
as it is usually the anterior and lateral part of the bladder which first
passes through the ring into the scrotum, the peritoneum will not pro-
trude at the same time, and the displaced part of the bladder will not be
covered by a hernial sac; but, as more of it descends, its fundus at
length passes into the scrotum, drawing after it the peritoneum naturally
attached to it. Thus the bladder first protrudes, and a hernial sac fol-
lows, into which a portion of the omentum or intestine may glide. Here
the bladder is invariably excluded from the other hernia, and situated at
its posterior and inner side. Sometimes the case is reversed, and the
cystocele is the consequence of an ordinary hernia.
The symptoms of cystocele are a fluctuation in the tumour, Hie swell-
ing becomes large and tense when the patient holds his water, and
diminishes when the urine is discharged. If the scrotum be compressed,
an inclination to make water is experienced. Sometimes, the muscular
coat of the bladder being paralytic, the patient cannot expel the urine
from the swelling, unless he raise and compress the scrotum ; indeed, as
the bladder is always drawn to one side, the patient invariably has more
or less difficulty in making water, and is sometimes afflicted with a total
retention.
p P
578 DISEASES OF THE GENITAL ORGANS.
The disease has been mistaken for hydrocele, though the marks of
difference are great. Thus, the tumour produced by the bladder always
extends into the ring, the testicle is plainly perceptible below the swell-
ing, and the tumour diminishes when the patient voids his urine.
Cystocele may occur also under the crural arch, in the perinaeum, or
the vagina.
The reduction of a cystocele is soon rendered totally impossible by ad-
hesions ; and all that can be done is to apply a suspensory bandage. If
a total retention of urine were to attend it, caused by the displaced con-
dition of the organ, and not to admit of a catheter being passed, the
swelling should be punctured. If a calculus were to form in the pro-
truded bladder, an incision might be practised for its extraction.
This is all the information which I can offer on the subject of hernia
in this treatise. Some forms of the disease, like hernias at the foramen
ovale, or ischiatic notch, in the vagina, or perinseum, or through the
diaphragm, are rare ; though I would advise all surgeons to remember
them, and be prepared for them. They will be still more likely, I think,
to meet with cases, in which the bowels within the abdomen become
strangulated by accidental displacements., bands of adhesion, or various
other causes.
DISEASES OF THE GENITAL ORGANS.
The testicle is particularly often the seat of inflammation and disease,
owing, perhaps, to circumstances adverted to by Sir Astley Cooper,
namely, the slow manner in which the blood returns from it against its
own gravity ; the occasional immoderate distension of the seminiferous
tubes ; its exposure to injury from blows or pressure ; its sympathy with
morbid conditions of the urethra and prostate gland ; and the changes,
which it almost naturally undergoes in old subjects.
The classification of the diseases of the testicle, adopted by this able
pathologist, is, first, into those which are the result of common inflamma-
tion, acute, or chronic ; secondly, into those which are of a specific nature,
but not malignant; and thirdly, others, which are both specific and
malignant.
The first division comprises acute and chronic inflammation, and atrophy
of the testicle. The second, embracing diseases, attended with specific,
but not malignant action, comprehends what Sir Astley Cooper names
the hydatid or encysted disease of the testicle ; the irritable testicle, or neur-
algia testis ; the swelling of this organ frequently occurring in the disorder
of the system termed mumps ; ossific changes in the part ; solid tumours
of the epidydimis, or the testis ; the scrofulous testicle ; and what has been
occasionally denominated the venereal sarcocele. The third division of
the classification, including specific and malignant affections, comprises
medullary cancer, or fungus hcematodes, and scirrhus. But, besides the
numerous varieties of disease now referred to, there are several diseases
of the coats of the testicle and spermatic cord, for which the advice of a
surgeon is often requested. Now, if attention be not paid to the subject,
the ignorant practitioner will be likely to get into serious scrapes, by con-
founding one disease with another; mistaking diseases of the body of the
testicle either for hernial swellings or hydroceles ; or these again for en-
largements of the testicle itself; and varicous swellings of the spermatic
ACUTE INFLAMMATION OF THE TESTICLE. 579
veins for hernias, or hernise for varicoceles. I am continually meeting with
patients who either have hernise, and, not being aware of the nature
of their cases, do not wear trusses, or who are wearing trusses on the
supposition of their having herniae, when, in truth, they have no such
complaint.
ACUTE INFLAMMATION OF THE TESTICLE,
When it arises from gonorrhoea, or some other kind of irritation in the
urethra, is frequently, though absurdly, termed hernia humoralis. It is
often excited by strictures, and still more commonly by the means
ordinarily employed for their cure, namely, bougies, the irritation of
which becomes the cause of the affection of the testicle. When inflam-
mation of the latter organ is thus excited by disease in the urethra, it
is preceded by soreness or irritation about the membranous and pros-
tatic portions of that canal ; the spermatic cord becomes swollen and
tender, and in particular the vas deferens, which seems much thick-
ened, and, on being touched, is extremely painful. When the case is
still further advanced, the swelling extends to the whole of the tes-
ticle, the hardest part of it being jjhe epidydimis. In general, so con-
siderable is the enlargement of the organ in every severe case, that
the, scrotum is exceedingly distended, and its rugae being effaced, its
surface is completely smooth. Painful as the inflamed testicle is itself,
a still greater degree of suffering is often experienced in the lumbar
and inguinal regions, with great uneasiness about the hip and thigh.
Sometimes the agony in the part affected seems to have paroxysms of
increased severity, which are alleged to depend upon spasmodic con-
tractions of the fibres of the cremaster. The scrotum, besides losing its
naturally corrugated appearance, is also reddened. These symptoms are
accompanied by an acceleration of the pulse, constipation, restlessness,
thirst, heat, and dryness of the skin, and other symptoms of inflammatory
fever. The blood taken away from the patient is also found to be buffy.
Sometimes the stomach is disordered sympathetically, and nausea, and
even repeated vomitting may occur. I once attended a man for an acute
inflammation of the testicle, who laboured under so obstinate a sup-
pression of the stools, and such a repetition of vomiting, that a suspicion
of strangulated hernia was created for a short time, but quickly abandoned
on a careful examination of the swelling. In fact, a general enlarge-
ment of the testicle, like that from acute inflammation of the organ, is
not at all likely to be mistaken for any kind of hernia, excepting the con-
genital ; because in bubonocele the testis may always be felt at some
point or another below the hernial tumour.
Inflammation of the testicle may be the consequence of external
violence ; and it is often purposely produced by various surgical proceed-
ings, employed for the radical cure of hydrocele. Sometimes it is brought
on by the pressure of badly constructed trusses ; sometimes as one of the
effects of the disorder of the system, well known by the appellation of
mumps.
When the testicle inflames and swells in gonorrhoea, the pain in making
water and the discharge of matter are almost always suddenly diminished,
or even suspended ; a circumstance ascribed by some pathologists to me-
tastasis ; and by others to sympathy between the urethra and the testicle.
All that I can say upon this point is, that we seem to know little more
than the fact itself, which is exemplified, I think, with remarkable
frequency in patients, who, while they have a clap, take rough exercise,
p p 2
580 DISEASES OF THE GENITAL ORGANS.
indulge in wine, and live altogether too freely. One thing here merits
attention, and it is perhaps what would not have been expected, namely,
the swelling of the testicle does not always come on exactly at the period
when the inflammation in the urethra is worst, but requently when it is
on the decline, or even nearly cured. Occasionally, also, the inflammation
of the testicle is not followed by any diminution or stoppage of the dis-
charge ; a fact clearly overturning the doctrine of metastasis. A suspicion
is entertained, that the inflammation is sometimes propagated to the
testicle from the mouth of the vas deferens. Mr. Hunter did not, how-
ever, adopt this view, because he found a swelling of the testicle to be as
frequent in gonorrhoea, where the inflammation did not extend further
than an inch or so from the orifice of the urethra, as where it reached to
the neck of the bladder. Another idea is, that a swelling of the testicle
is particularly disposed to come on when gonorrhoea is suddenly checked
by the employment of copaiba, cubebs, or astringent injections ; but, the
correctness of this opinion may be doubted ; for, many experienced sur-
geons believe, that they have seen an inflammation of the testicle arise
as frequently under other modes of treatment as that now alluded to.
At the same time, I feel it right to mention, that Sir Astley Cooper in-
clines to the belief, that injections really have a tendency to bring on
hernia humoralis, especially when they are made to pass far into the
urethra. Notwithstanding Mr. Hunter's view, I am disposed to think,
that inflammation may sometimes extend to the testicle from the urethra,
by the course of the vas deferens ; and Sir Astley Cooper describes cer-
tain appearances, noticed in the dissection of the urethra of a criminal,
who had been executed, which confirm the possibility of this occurrence.
The man had a gonorrhoea at the time of his death; and when his urethra
was cut open, although the inflammation was greatest in the first three
inches of the canal, yet it extended also to the membranous portion of it,
and even blood had been extravasated under the mucous membrane.
Under such circumstances, the verumontanum, and the terminations of
the common ducts of the vesiculse seminales and vasa deferentia in the
urethra, participate in the inflammation, which may then be propagated
along the vas deferens to the cord, epidydimis, and testicle.
One fact, relative to this subject, is certain ; which is, that inflamma-
tion of the testicle rarely or never comes on in the early stage of gonor-
rhoea, but usually between the tenth day and the end of the third week.
When the pain and swelling begin to abate, the discharge from the
urethra very commonly returns. Within the tunica vaginalis there is
generally a quantity of serum effused, which, after the inflammation has
subsided, is absorbed again. We find likewise that fibrine is thrown out
within the same membrane, and in the interstices of the glandular part of
the testicle, occasioning considerable hardness, the remains of which will
often continue a long time,
The treatment of acute inflammation of the testicle must, of course,
be antiphlogistic, comprehending quietude, and even the horizontal pos-
ture in bed, if the case be severe. When the patient is young and robust,
the swelling considerable, and the pain in the lumbar region violent, we
should have recourse to venesection, and this pretty freely ; and in all
cases, leeches, saline purgatives, and low diet, are absolutely necessary.
If leeches cannot be procured, the veins of the scrotum may be punc-
tured, whereby a copious and beneficial discharge of blood may gene-
rally be obtained. With respect to local applications, we may employ
cold evaporating lotions ; or, if the patient seem to derive great relief
ATROPHY OF THE TESTICLE. 581
from emollient poultices and fomentations, these may be used. Perhaps,
in very severe cases, the latter ought always to be preferred. But,
nothing will lessen the patient's sufferings more effectually, than the plan
of taking off the weight of the testicle from the spermatic cord with a
bag-truss or suspensory bandage ; it has, indeed, the greatest effect in
diminishing the pain experienced in the back and inguinal region, parti-
cularly when assisted by bleeding, saline purgative medicines, and the
occasional exhibition of eight or ten grains of the compound powder of
ipecacuanha. When the disease has arisen from the irritation of bougies,
their employment must, of course, be suspended. One plan that has
sometimes proved expeditious in stopping the inflammation, and bring-
ing down the swelling, is that of prescribing tartarised antimony, so
as to keep up a degree of the nausea ; but the practice is not com-
monly adopted, because patients more readily submit to other means
of relief.
In general, a considerable hardness of the testicle, and especially of
the epidydimis, remains after the inflammation has been completely re-
moved : sometimes during the rest of the patient's life. Mr. Hunter
even suspected that, in some cases of this description, the canal of the
epidydimis was impervious, and the function of the testicle annihilated.
However, this suspicion does not coincide with the examinations insti-
tuted by Sir Astley Cooper, who says, that, when the swelling is at the
lower part of the epidydimis, it is seated in the cellular tissue of the vas
deferens, ; where it forms its first convolutions, and is not an effusion
within the cavity of the duct. The induration, according to his re-
searches, frequently affects merely the tunics ; and when situated in the
upper part of the globus major, it arises either from fibrine effused in the
cellular substance between the coni vasculosi, or else from a sac filled
with a viscid fluid.
For promoting the dispersion of the chronic induration, remaining
after all acute inflammation is over, we may employ camphorated mercu-
rial ointment, with or without two scruples or a drachm of the hydrio-
date of potash in each ounce of it. Or we may try poultices of vinegar
and oatmeal, or the hydrochlorate of ammonia lotion, where friction cannot
be borne. In some cases, good seems to be produced by internal alter-
ative medicines, as the compound calomel pill, and sarsaparilla, or the
tincture of iodine.
Acute inflammation of the testicle, when a consequence of gonorrhoea,
or irritation in the urethra, rarely suppurates ; but when produced by
external violence, the chance of an abscess is greater.
ATROPHY OF THE TESTICLE,
Or a more or less complete wasting away or absorption of this organ, may
follow the subsidence of acute inflammation of it; but it more frequently
takes place when such inflammation has been brought on by external
violence, than when it originates as a consequence of gonorrhoea. No
doubt, under these circumstances, the structure of the testicle has been
irreparably damaged by the inflammatory process ; and probably in some
instances, the atrophy may depend upon an obliteration of the vas defer-
ens ; for, in the museum of St. Thomas's Hospital, there used to be a
testicle in this condition, the vas deferens of which could only be filled
with quicksilver for about half an inch of its extent from the abdominal
ring towards the testicle itself. This fact is reported in Sir Astley
Cooper's work. An atrophy of the testicle sometimes takes place with-
p p 3
582 DISEASES OF THE GENITAL ORGANS.
out any previous inflammation of it : the pressure of a truss on the sper-
matic cord will produce it ; and many curious cases are recorded by
Larrey, where sabre wounds about the occiput and nape of the neck
were followed by it.
CHRONIC ENLARGEMENT, OR CHRONIC INFLAMMATION OF THE
TESTICLE,
Usually commences with hardness and swelling of the epidydimis, at
first attended with but moderate uneasiness, scarcely amounting to pain ;
at length the glandular part of the organ becomes involved, and the tes-
ticle seems rather larger and more tender than that of the other side. If
the disease arise from a blow, then it may begin in the body of the tes-
ticle, which may present a globular, instead of its naturally oval form, and
sometimes, though enlarged and altered in shape, it has no inequalities
upon its surface. In other instances, however, it is at first unequal, so
that knobs can be felt upon it ; and this, according to Sir Benjamin 13rodie,
is usually the case in the beginning ; a general uniform enlargement,
without any knobs, being the more advanced state of the disease.
The case is rarely so painful as to compel the patient to keep himself
quiet, and refrain altogether from labour and exercise. In some cases, a
clear transparent serum is effused in the tunica vaginalis, constituting
one of the forms of disease, to which the term hydro- sarcocele is vaguely
applied. In ordinary cases,, the spermatic cord is not hardened, but its
veins are somewhat enlarged ; and when the disease has existed some
considerable time, and has attained magnitude, the patient complains of
pain and a sense of weight in the loins and thigh.
This chronic inflammation of the testicle, the sarcocele tulerculeux of
Cruveilhier, which has been well described by Sir Benjamin Brodie, leads
to the production of a yellow tubercular substance in the texture of that
organ ; an unorganised yellow matter, collected at first in small masses, but
afterwards in larger ones at certain parts of the testicle ; while, in other
places, the glandular structure is quite healthy. In a later stage, the yellow
matter, which is secreted within the tubuli testis and epidydimis, assumes
a harder consistence, and is generally laminated. This disease is met with in
various unhealthy states of the constitution, whether connected with rheu-
matism, syphilis, or other causes. It often presents itself in persons who
have been scrofulous in their youth, or whose constitutions have been
broken by the long use of mercury. What has been termed the venereal
sarcocele is only a variety of it. In this latter case, according to Cruveil-
hier, the tubercular deposit always takes place first in the epidydimis.
He describes one remarkable instance, in which the tubercular substance
was deposited not only in the epidydimis and body of the testicle, but
in the vas deferens, the vesiculae seminales, seminal ducts, and the pro-
state gland.*
According to Sir Astley Cooper, when a solid effusion has taken place
in the seminiferous tubes, or even in the substance of the testicle, or
epidydimis, the disease may be cured by the strict observance of the re-
cumbent posture, and the exhibition of three grains of calomel and one of
opium, night and morning, so as to keep the gums affected for a month at
least. A black dose and fifteen or twenty minims of the liquor antim.tart.
are to be given every fourth morning. The topical treatment should consist
of leeches twice a week, and a lotion composed of the liq. ammon. acet. 5 v.
* Cruvcilliier, Anat. Pathol. liv. ix. p. 2.
THE IRRITABLE TESTICLE, OR NEURALGIA TESTIS. 583
and one ounce of spirit of wine. Cruveilhier supports the same view,
observing that a deposit of tubercular matter in the epidydimis, or even
the body of the testicle, is not an adequate reason for castration.
GRANULAR PROTRUSIONS, OR FUNGOUS GROWTHS FROM THE
TESTICLE,
May follow the formation and bursting of an abscess in the part; or they
may occur in the advanced stages of chronic inflammation of it. At one
point, the testicle adheres to the skin, inflames, and ulcerates; and then,
through the ulcerated opening, a fungus of small size at first projects,
but, gradually acquiring greater bulk, makes its way through openings,
not only in the tunica vaginalis, but in all the investments of he scrotum.
Now, according to Sir Benjamin Brodie's investigations, we may trace
on the surface of this fungus the same kind of yellow matter, found in
the glandular portion of the testicle, which glandular texture itself like-
wise protrudes, until no part of the testicle is left within the scrotum,
and the spermatic cord can be distinctly traced into the centre of the
fungus. In a still more wasted condition of the glandular structure, the
cord terminates in a small tubercular mass, the only remains of the organ.
The height to which the fungous or granular protrusion rises, prevents
the skin from healing over it ; but it may generally be reduced by the
pressure of a dossil of lint, fixed on it with adhesive plaster, or it may be
got rid of with escharotic applications. However, the surest mode of
cure is that of cutting away the protruding mass on a level with the inner
reflexion of the tunica vaginalis, making two semicircular incisions, and
afterwards bringing their edges together. This plan is not, however, ap-
proved of by Sir Benjamin Brodie, because in doing it we actually slice
away the tubuli testis ; and hence, he prefers sprinkling the fungus with
red precipitate, and giving mercury. Then, as soon as healthy granu-
lations form, he dresses the sore with a solution of the sulphate of copper
in camphor mixture. I believe it to be a very good practice, when ab-
scesses of the testicle leave deep and fistulous openings, to prescribe
calomel and opium in the manner directed by Sir Astley Cooper, and to
inject into the fistulee a lotion of the sulphate of copper, or bichloride of
mercury.
THE IRRITABLE TESTICLE, OR NEURALGIA TESTIS,
Is a case analogous to tic douloureux, or neuralgia in other parts. It is a
highly sensitive and painful state of the organ, often without any very
obvious cause, the suffering produced by it being frequently of the most
excruciating kind, and of long duration, though subject to occasional re-
missions. The part is but little, if at all, swollen ; and, on dissection, no
change of structure can be detected. One example, however, of this
affection in a medical student, in which I was lately consulted, and in
which Sir Astley Cooper was also kind enough to give his advice, had
been attended with repeated swelling of the testis, though it mostly re-
mained with scarcely any perceptible change of size. The most success-
ful treatment consists in giving large doses of the sulphate of quinine or
carbonate of iron ; or, when the disease assumes an intermittent type, the
liquor arsenicalis. Opium, the acetate or hydrochlorate of morphia, the
extract of conium, hyoscyamus, and other narcotics, with calomel, may
also be given. If the secretions of the skin and liver be defective, calomel,
opium, and antimony may be tried in combination.
p p 4<
584 DISEASES OF THE GENITAL ORGANS.
As local applications, I may recommend leeches, ice, or a plaster com-
posed of one third of the extract of belladonna and two thirds of soap
cerate. This is a disease, in which the ointment of veratria may deserve
trial. In one instance, Professor Gibson dissected down to the spermatic
nerves, and divided them ; a difficult operation, but alleged to have
answered.*
No doubt, neuralgia testis frequently depends upon some disorder of
the system at large, the removal of which is an essential thing in the
cure. That severe pain in the testicle may arise from sympathy between
this organ and other parts, without any alteration of its structure, is
illustrated in cases, where great agony in the testis is experienced on the
descent of a calculus from the kidney into the ureter. In particular
instances, however, a degree of swelling of the part, a varicose fulness
of the spermatic veins, or even some hardness or prominence about the
epidydimis, may be observed.
OF THE SCROFULOUS TESTICLE.
The secreting glands are rarely affected with scrofula ; but this organ
forms an exception. Even in young children, it may become enlarged
and hardened, without pain, and remain in this indolent state for many
weeks, months, or years ; and then, as the health improves, gets well.
More frequently, the disease occurs towards puberty, preceded or accom-
panied by some other marks of scrofula, and sometimes it affects both
testicles. Scrofulous disease of the testicle is remarkable for its indolent
character, and the little pain attending it; we perceive a trivial swelling
of some part of the organ, mostly the epidydimis; and, afterwards a small
superficial lump at another point. These little tumours increase, and by
degrees create greater uneasiness in the part. The skin becomes ad-
herent to them; they suppurate ; the abscesses burst, but discharge only a
scanty quantity of matter ; and the openings, having little tendency to
heal, remain fistulous. At length, the testis sometimes diminishes and
wastes away, until but a small portion of it is left ; but, more commonly,
the organ is not entirely destroyed, and a considerable part of the glan-
dular structure remains.
The treatment is to be conducted on the same principles as are appli-
cable to other forms of scrofulous disease. We may prescribe rhubarb
and carbonate of soda in equal proportions (ten grains of each) to be
taken once or twice a day ; liquor potassee ; preparations of iodine, or
tonics of various kinds, according to the circumstances of the case, and
the effects which are produced by such means on the part and the whole
system. With respect to iodine, I prefer the way in which it is pre-
scribed by Lugol, to the less diversified mode in which we employ it.
CYSTIC SARCOMA. — HYDATID DISEASE OF THE TESTICLE.
This latter term is objected to, as conveying the erroneous notion, that
hydatids exist in the part. The morbid mass, into which the organ is
converted, is partly composed of a solid structure, and partly of cysts,
varying in size from that of a large pin's head to that of a small marble ;
some of them containing a thin, transparent, yellow serum, and others a
more turbid fluid. The disease occurs chiefly between the ages of thirty
and thirty-five, and is sometimes mistaken for hydrocele; though the shape
* Gibson's Institutes, &c. of Surgery, vol. ii. p. 179., cd. 5. Philadelphia. 8vo.
1838.
MEDULLARY CANCER OF THE TESTICLE. 585
of the tumour ought to serve as a criterion, since it is oval, not pyriform,
like that occasioned by a collection of fluid in the tunica vaginalis. The
particular character, however, of enlargement of the testicle with cysts
cannot always be known with certainty previously to the examination of
the part after its removal by operation. It is not malignant, for it never
extends to other parts : it may however be conjoined with medullary can-
cer, which is itself malignant No treatment is of any use, because the
disease is truly an organic one, accompanied by a total disorganisation of
the testicle, and changes of structure, leaving no possibility of a return of
the part to its healthy state again. The pain, caused by the weight of
the tumour on the spermatic cord, and the annoyance of its bulk, fre-
quently compel the patient to submit to castration.
What we call cystic sarcoma of the testicle, is termed by Cruveilhier,
Cancer Alveolaire, of which he has given an excellent representation in
pi. 1. liv. 5. of his Anatomic Pathologique. In the dissection of the spe-
cimen from which the engraving was taken, he ascertained, that the pro-
per substance of the testicle did not participate in the morbid change, but
was pressed by the new formation towards the surface of the tumour,
where it formed a thinnish stratum of a grey semi-transparent appear-
ance. " The further," says he, " we advance in the study of morbid alter-
ations, the more we shall be convinced of the truth (which, I believe,
was first announced by me), that our textures are unalterable, and that
what are called morbid lesions, are new productions, endued with an in-
dependent life of their own, and that our tissues are only susceptible of
hypertrophy and atrophy. Here the atrophy is admirably explained by
the compression which the substance of the testicle had undergone/'
MEDULLARY CANCER OF THE TESTICLE
Is a malignant disease, that has received a variety of names ; by some it
is called the pulpy testicle ; by some it is denominated medullary sarcoma;
by others fungus hcematodcs ; a term that is only warranted in an ad-
vanced stage of the disease, when a mass, which, from its look, is mistaken
for a fungus, occasionally, though not often, protrudes through the scro-
tum. It is the soft cancer of the testicle, as it is denominated by some
writers, on account of its malignancy ; that is to say, its having a tend-
ency to extend itself in the course of the absorbents ; its disposition to
attack other textures ; its incurable nature ; its general character to show
itself again in the same, or other parts, after removal by operation ; and its
connection with some undefined, but highly unfavourable condition of the
system. By Cruveilhier it is named sarcocele areolaire encephaloide.
The disease begins in the body of the testicle, which it enlarges, the
swelling extending to the whole of this part of the organ in the course of
three or four months. Afterwards the epidydimis becomes involved.
While confined to the body of the testicle, the swelling is of an oval
figure ; one circumstance, by which the case may be known not to be a
hydrocele : but as soon as the epidjdimis is diseased, the tumour may
assume a somewhat pyramidal shape, and be not unlikely to be mistaken
for a hydrocele, more especially as the disease is attended with a softness
and elasticity, which often lead the practitioner to think, that he feels a
fluctuation in the part. Indeed, there is sometimes a small quantity of
fluid in the tunica vaginalis. I should say, however, that, with due atten-
tion, a medullary tumour of the testicle may almost always be discri-
minated from hydrocele, by the tumour presenting a more decidedly oval
form than the latter disease; by its greater weight; its having^no trans-
586 DISEASES OF THE GENITAL ORGANS.
parency ; its being harder in some parts than others ; its not being, after
a time, so uniformly smooth as a hydrocele; and its being accompanied
by a sallow, unhealthy look, such as is usually indicative of a malignant
organic disease of an important part. At first, the swelling is not at-
tended with pain ; but, after a little while, the patient begins to expe-
rience shooting, darting sensations from the testicle, up the spermatic
cord to the lumbar region and the groin ; and the part will not bear much
handling, without a great deal of tenderness being produced in it. The
period of life in which medullary sarcoma of the testicle is most frequent,
is that between puberty and the age of 35 or 36 ; but Mr. Earle has re-
corded a rare instance of its occurrence in a very young child. These
circumstances deserve attention ; because, though medullary disease of
the testicle is seldom met with in children, the same disease of the eye
is chiefly confined to them.
The swelling consists of a mass of medullary very albuminous matter,
or of a pulpy substance, firmer than the medullary matter of the brain,
included in the interstices of a thin, delicate, transparent membranous
texture. It would not be correct to say, that the organ is always con-
verted into this kind of substance; for, in many cases, the medullary sub-
stance is not a molecular deposit, after the manner of nutrition, but an
adventitious formation, an additional growth, which by its pressure seems
to cause the removal of the original tissues. Sometimes the glandular
portion of the testicle remains unaltered, while a medullary tumour lies
beneath the tunica albuginea, or grows from the superficial part of the
testicle, and fills the cavity of the tunica vaginalis, of which Sir Benjamin
Brodie relates one instance, and Cruveilhier another. At last, however,
the substance of tbe testicle always suffers atrophy from the compression
of the new and extraneous substance, whether this be first formed within
the testicle, or on its surface.
In the latter stage of the disease, the tumour becomes adherent to the
scrotum ; the spermatic cord becomes knotty and unequal ; at length
ulceration of the scrotum may take place, and a large mass of the me-
dullary substance protrude, from which copious hemorrhage every now
and then occurs. The protrusion of such a mass, however, I believe, is
much less frequent in medullary disease of the testicle than in the same
disease of the breast, eye, and limbs. Sometimes, when the scrotum is
implicated, the inguinal glands become affected ; but it is the lumbar,
which are so liable to be involved in the disease.
This malignant disease of the testicle has a tendency to extend itself
in the course of the absorbents, and to attack many different parts and
tissues in the same person. As the absorbents of the testicle pass to the
lumbar glands, these are frequently involved, and sometimes are trans-
formed into an immense mass, equal in size to a child's head, readily per-
ceptible when the abdominal are relaxed, and causing, by their pressure
on neighbouring organs, various functional disturbance. Such may be
the case, even when the spermatic cord itself is sound. Too frequently,
indeed, the testicle is only one of numerous parts which are implicated ;
and soon after this organ has been removed, the patient may die, and on
his being opened, we may trace various other medullary tumours in the
organs or membranes of the cranium, chest, or abdomen. Cruveilhier
gives the particulars of one case, in which the ascending vena cava was
rilled with medullary matter. In another, in University College Hos-
pital, after I had removed the testicle, the medullary growth of one
of the lumbar glands made its way into the pelvis of the kidney. Even
MEDULLARY CANCER OF THE TESTICLE. 587
the beginning of the thoracic duct has been obliterated by the pres-
sure of the diseased mass. Some surgeons of great experience, who
have removed many testicles, affected with medullary cancer, have
not known one instance of a permanent cure being effected by such
operations. This fact, at all events, is a lesson to us in delivering a pro-
gnosis ; we should candidly explain the chances of a return of the disease,
and let it not be said, that we have persuaded the patient to submit to
the operation as a certain means of cure. In the museum of University
College is a fine specimen of a medullary cancer of the testicle, one of
considerable size, which I removed from a young man about thirty years
of age, who had a remarkably sallow unhealthy look. The case illustrates
several interesting circumstances. The patient came from Oxford, where
a surgeon had introduced a trocar into the swelling, on the supposition,
no doubt, that the case might be a hydrocele. Another practitioner had
been led to do the same thing. The punctures, however, healed up very
well, without any subsequent inflammation, or any protrusion of the
morbid substance ; a circumstance, which I had an opportunity of no-
ticing ; for, not being aware of these fruitless operations, and fancying
one morning that a fluctuation was perceptible, I also passed in a trocar,
but no material harm resulted from the experiment, only a very slight
degree of pain, the wound healing up completely in two or three days. I
showed the case to Sir Astley Cooper, who advised castration, which I
performed, and thqn sent the diseased testicle to him, which he injected
and carefully dissected. One section of it, with the spermatic vessels,
he retains himself; the other he was so obliging as to send to me as a
present. In the examination of the cord, minute extraneous substances,
some of them less than pins' heads, were noticed in the cellular tissue,
which were suspected by Sir Astley Cooper to be of a medullary character.
This was a very discouraging circumstance, one that fully prepared me
to expect a return of the disease; yet, contrary to my expectation, the
wound, caused by the operation, healed up favourably, the man's health
improved, and he continued well more than three years from the period
when the testicle was removed. We learn from this case, that the intro-
duction of a trocar into the swelling is not attended with any serious con-
sequences ; and that even when the patient has a very unhealthy, sallow
look, and the cord is not entirely sound, there may not be a return of the
disease. We must not, however, anticipate success as a common occur-
rence under these unfavourable circumstances, and we should always be
guarded in our prognosis, though the case may present much less dis-
couragement than the one which I have mentioned. Here, also, the
best chance of benefiting the patient permanently can only be obtained
before the disease has extended itself to other parts ; and, if they are
already involved when we are first consulted, it will be too late for us to
recommend an operation ; for the case is of a hopeless description. But,
operate when we will, we shall find that, in a large majority of cases, the
disease will show itself again in some part of the body or another, and
bring on fatal consequences. Thus, in one case, where Mr. dine had
removed the testicle for medullary disease, another tumour of a similar
nature formed in the lumbar region*, and by its pressure destroyed
the bodies of the vertebra? near it, so as to injure the medulla spinalis,
occasioning paralysis and fatal consequences. This case is recorded by
Sir Benjamin Brodie. As, however, we have no medicines, nor appli-
* See also Cruveilhier> Anat. Pathol. liv. v. p. 4.
588 DISEASES OF THE GENITAL ORGANS.
cations that have the power of stopping this malignant form of disease,
the knife is the only means that can be resorted to, with any prospect of
success, and this, as I have explained, is very uncertain. In some cases,
medullary disease and cystic sarcoma, appear to be blended together
in the testicle, as well as in the absorbent glands, which happen to be-
come affected. This modification of the disease is as bad, and difficult to
control, as where no cysts are present, and the morbid mass is simply a
medullary substance.
The rule of operating early, if an operation is to be performed at all
for medullary disease of the testicle, is inculcated by every surgeon,
whose judgment is worth having. It is only at this period, that there is
any hope of other parts of the system not participating in the disease.
Possibly, in some few instances, the disorder may be at first strictly local,
and afterwards become a constitutional one, by reason of the absorption
of the medullary matter into the system. In a former part of this work,
however, I have described the common characters of this terrible disease,
and mentioned the situation and organs in which the medullary matter is
found. Sometimes the absorbent vessels, leading from the disease, have
been found full of a cerebriform substance ; a fact, which Sir Benjamin
Brodie regards as giving some probability to the hypothesis, that the
disease may thus, from being at first local, become more widely diffused,
and extend from one to several organs in the body. We may therefore
operate early, though we are sure that the case is a medullary tumour. But
if we have doubts, we should first try the plans that were recommended
for the cure of chronic inflammation, or enlargement of the organ, — in par-
ticular, the free use of mercury, iodine, and other alteratives. If these fail,
and we are certain that it is not a hydrocele which we are dealing with,
we may conclude that the testicle is disorganised, and that, in all proba-
bility, the disease is medullary. If there be any suspicion of fluid in the
tunica vaginalis, we should introduce a trocar before we resort to cas-
tration ; for the puncture will do no harm to the testicle, if it be already
disorganised by medullary disease ; and if the case be a hydrocele, with
a thick tunica vaginalis, the light thrown on the nature of the complaint
will save the patient from a dreadful mutilation.
SCIRRHUS OF THE TESTICLE,
Exhibiting precisely the same morbid structure as in the breast, is ac-
counted by some of the best pathologists a very rare disease, if it exist
at all. Sir Astley Cooper doubts whether a hard swelling of the testicle,
intersected by a net-work of strong fibres or bands, has any existence.
However, we meet with solid, heavy, particularly indurated, almost carti-
laginous enlargements of the testicle, with a tuberculated feel, severe
pains in the part, the cord, and the lumbar region ; some fluid in the tunica
vaginalis ; and, at length, followed by anasarca of the lower extremities.
The patient's countenance is sallow, he becomes surprisingly emaciated, and
at length he sinks under impaired digestion, constant suffering, diarrhrea,
and loss of rest. This is the kind of disease, which the late Dr. Baillie
described as scirrhus of the testicle. Certainly, though, in texture, the
part affected may not correspond to other examples of scirrhus, it does
so in malignancy and incurableness. Here, the early extirpation of the
diseased organ is as strongly indicated as in fungus haematodes. Jf the
case should be too far advanced for an operation, and the part be ulcer-
ated, all we can usefully do, is to palliate the patient's misery with opium,
hyoscyamus, morphia, and other narcotics, at the same time applying
HYDROCELE. 589
the nitric acid lotion, the liquor opii sedativus, the chloride of soda
wash, or the carrot or fermenting poultice ; or one made with bread and
water, with a proportion of the extract of hemlock, or henbane mixed
with it.
HYDROCELE.
The common hydrocele is a collection of serous fluid in the tunica
vaginalis, producing a pyriform, fluctuating, and, generally, a more or
less transparent swelling in the scrotum. I have seen it in persons of
all ages, but less frequently in boys than adult subjects. The swelling
commences opposite the lower part of the testicle, unattended with pain ;
at all events, the cases in which pain is felt at the beginning of the com-
plaint, are not the most common. At first, the tumour is soft, and
readily allows the testicle to be felt through the fluid ; but, by degrees, it
becomes tense, and then the testicle can no longer be perceived. The
largest part of this pyriform swelling is below, its diameter lessening
gradually as it approaches the abdominal ring. It is only after it has at-
tained a certain magnitude, that its weight and tension cause uneasy
sensations in the lower part of the back.
In a dark room, if a lighted wax taper be held close behind one side
of the scrotum, and the swelling be viewed from the opposite side, while
the surgeon's hand is placed over the external portion of the tumour, the
transparency will generally be very manifest. It will always be so if the
fluid be clear, and the tunica vaginalis, cremaster, and other coverings, be
not too much thickened. This thickening is found to prevail chiefly in
large hydroceles ; but, as Sir Benjamin Brodie has noticed, sometimes it
occurs where the tumour is but of diminutive size ; and then, if we have
an opportunity of examining the parts after death, we find the inner sur-
face of the tunica vaginalis exhibiting a slightly honeycomb appearance,
which is suspected by the latter gentleman to denote, that the hydrocele
began with inflammation.
Another symptom of hydrocele is the fluctuation, which on the surgeon
grasping the scrotum,' and propelling the fluid forwards, may be very
plainly distinguished, except when the tunica vaginalis is of considerable
thickness. When the tumour is of some size, the testicle is commonly
placed about two thirds of the way down the posterior part of the cavity,
a circumstance deserving recollection when we are about to introduce a
trocar for the discharge of the fluid.
Sometimes hydroceles take place on both sides of the scrotum.
Although a hydrocele is mostly of a pyriform shape, with the thicker
part of the tumour downwards, it may assume other shapes. Thus, if
much pressed upon by tight small-clothes, or any thing else, the form of
the swelling may be altered by that cricumsrance. Perhaps, however, a
deviation of the disease from its common shape may not always be re-
ferrible to a cause that we can trace. In the museum of University
College is a preparation, in which, in addition to the principal cavity of
the hydrocele, there is another pouch freely communicating with it.
Sometimes the hydrocele forms two swellings, with the hour-glass con-
traction between them. If we puncture the lower compartment of such
a hydrocele, we may discharge the fluid from both, which proves that
they communicate. Such is the usual state of the case : but it some-
times happens that the two compartments do not communicate, a perfect
septum being interposed between them. We are to believe, however,
that the communication is open for a time at the contracted part, but
590 DISEASES OF THE GENITAL ORGANS.
that, in consequence of the adhesive inflammation, or other causes, the
constricted part is at length entirely shut. Sir Benjamin Brodie records
an interesting case, proving that a hydrocele is sometimes divided in this
manner into two portions, perfectly distinct from each other. In the
case alluded to, the first time the hydrocele was punctured, the trocar
was passed into the lower cavity, which emptied both this and the upper
one. About a year afterwards, the same method was repeated; but the
upper swelling could no longer be emptied in this manner, the incom-
plete contraction having become a complete one in the course of twelve
months.
Some hydroceles communicate with the cavity of the abdomen, in
consequence of the upper part of the tunica vaginalis continuing unclosed.
This case, which is termed congenital hydrocele, is seen principally in
children, but occasionally in adults likewise. The quantity of fluid in
hydroceles, which have existed some time, is mostly about eight or ten
ounces ; but Gibbon, the historian, who was attended by the late Mr.
Cline, had a hydrocele, from which six quarts of fluid were drawn ; and
many instances are recorded of the tumour reaching down to the knees.
Such an occurrence can only be the result of great neglect.
The fluid is also subject to variety in its quality as well as quantity.
Sometimes it contains flakes of fibrinous matter, the product of inflam-
mation. The fluid is generally very transparent, and of an amber or
pale straw colour : it is also coagulable by heat, acids, and alcohol, and
resembles the serum of the blood, except in having less albumen in it.
Sometimes, however, it is of a much higher colour, and even reddish,
particularly when the case has originated with a degree of inflammation
about the parts. We also meet with certain cases, in which loose carti-
laginous or osseous substances are contained in the fluid. Occasional!}^,
small, shining, greasy particles are observed in it, which are probably
adipocire. In particular instances, the fluid, instead of being clear, is
quite turbid and opaque, a circumstance generally proving, that the inner
surface of the tunica vaginalis has been previously the seat of an inflam-
matory process.
When a hydrocele is complicated with a loose cartilaginous body in the
tunica vaginalis, Sir Benjamin Brodie believes, that the loose cartilage is
the original disease, and that it is the irritation of it which keeps up the
increased secretion of fluid within that membrane. If the extraneous
substance could be felt, and secured in one place directly after the dis-
charge of the fluid, we should cut upon it and take it out. This proceed-
ing would, no doubt, bring about the radical cure of the hydrocele. both
by removing its cause, and by exciting a degree of inflammation. Sir
Benjamin Brodie relates the following case : — A patient with hydrocele,
whom he used to see occasionally for some years, always experienced vast
suffering whenever the fluid was let out. On those occasions, the patient
invariably threw himself on the floor, and groaned dismally for a quarter
of an hour. After his death, it was ascertained, that the tunica vaginalis
contained a cartilaginous body, which, whenever the fluid had been
voided, appeared to have been the cause of the patient's agony.
In hydroceles of long standing, the tunica vaginalis, the cremaster, and
the cellular tissue, are often excessively thickened. Examples also occur,
in which that membrane has ossifications upon it.
The testicle itself is usually healthy; sometimes, however, trivially in-
creased in size ; sometimes rather lessened. The testicle may also be
diseased, constituting what is termed hydrosarcocele.
HYDROCELE. 591
Among the best diagnostic signs of a hydrocele, I would specify its
transparency, its fluctuation, its commencement at the lower part of the
tunica vaginalis, its gradual extension upwards, its pyriform shape, and
the circumstance of a portion of the spermatic cord between the abdomi-
nal ring and the upper part of the swelling remaining free and unsur-
rounded by the fluid.
We are able to discriminate a hydrocele from a sarcocele, or diseased
testicle, by the latter being much heavier, more globular or oval, and
flatter at the sides than a hydrocele ; by its being also more solid, and
productive of a peculiarly sickening pain when compressed; by its being
attended with a greater degree of pain in the loins, and very frequently
with an unhealthy sallow look, which is not by any means a characteristic
of a hydrocele, which is often seen in very healthy persons.
Then a hydrocele may generally be known from a hernia, by the pre-
sent or previous possibility of reducing the latter, the impulse in it on
the patient's coughing, the direction in which the tumour has passed, its
course from the abdominal ring downwards into the scrotum and not
upwards to the ring, its lying over the upper part of the cord, and, if the
case be a bubonocele, and not a congenital hernia, by the possibility of
feeling the testicle below the swelling.
But sometimes a hydrocele is conjoined with a hernia. Under these
circumstances, we generally find, that the hydrocele lies in front of the
hernia, and if we should be called upon to operate for the latter disease
in a state of strangulation, it would obviously be the safest mode of pro-
ceeding first to lay open the hydrocele.
A hydrocele, though not a very painful disease in its ordinary states,
is a considerable annoyance ; for it interferes with all active pursuits,
and the tumour is much exposed to the effects of external violence.
When large, it draws over it likewise a great part of the integuments of
the penis, which appears buried, as it were, in the swelling, so that the
disease is certainly a serious obstacle to coition.
I have seen a few cases, in which hydroceles were accidentally burst
by falls or blows. The result is various ; sometimes one of the veins of
the tunina vaginalis being ruptured, hemorrhage takes place into the
cavity of that membrane, and the hydrocele is converted into what is
termed hcematocele. In other instances, the tunica vaginalis is rather
more extensively torn, and the fluid of the hydrocele passes into the cel-
lular tissue of the scrotum, the original tumour subsiding for a time, but
almost always returning after the opening in the tunica vaginalis has closed
again. However, if much inflammation were to ensue, the hydrocele
might be radically cured by the accident ; but the termination will com-
monly not be so fortunate.
Hydrocele of the tunica vaginalis, I mean the common form of it in
adult subjects, that which comes on without pain, very seldom undergoes
a spontaneous cure. Sir Benjamin Brodie gives one example, however,
of such an occurrence. Probably, whenever a spontaneous disappearance
of a hydrocele takes place, the event is owing to some previous accidental
inflammation of the parts, or the effusion has happened as the effect of
inflammation, on the subsidence of which the fluid is absorbed again, and
the vessels resume their proper action.
Treatment. — In children the disease, when not attended with a com-
munication between the cavity of the abdomen and that of the tunica
vaginalis, may generally be cured by lotions containing the liquor ammon.
acet., the hydrochlorate of ammonia, or other ingredients calculated to
592 DISEASES OF THE GENITAL ORGANS.
excite the absorbents. Iodine ointments rubbed into the scrotum, friction
with soap liniment, strengthened with the tinct. cantharidum, or blistering
the scrotum, as practised by Dupuytren, will also frequently succeed.
The common hydrocele of adults will rarely yield to such plans, and
we are obliged to resort to other measures. Now the nature of our pro-
ceedings should be chiefly regulated by the consideration, whether the
patient is desirous of temporary or permanent relief; in other terms,
whether he is willing to submit to what is called the palliative, or the ra-
dical treatment) which latter is necessarily attended with more pain. The
palliative treatment simply consists in discharging the fluid by means of
a small trocar and cannula. We are to grasp the back portion of the
swelling with the left hand, and puncture it in the central line,, about
two thirds of the way downwards from its uppermost part, taking care to
incline the point of the instrument a little upwards. In choosing a trocar,
we are to be careful that it is well adapted to the cannula, and, in par-
ticular, that the extremity of the latter does not form too great a circular
projection on the trocar by being too wide or too thick ; for when this is
the case, the entrance of the trocar into the tunica vaginalis will be very
likely to be stopped by the circular prominence of the cannula, and
then we shall either not get the cannula into the hydrocele at all, or
succeed only by forcible and repeated trials, which give the patient con-
siderable pain, and form a display of awkwardness not likely to keep us
in favour with the party operated upon. Attention to minute things in
the practice of surgery, such as the make of a trocar, is often of great
importance to a man who values his professional reputation ; and I have
known serious mischief done by inattention to the construction of this
instrument. Having withdrawn the trocar, and let out the fluid, during
the flow of which we must keep the cannula well introduced (for if it
slip out of the tunica vaginalis we shall not be able to put it in again),
we may place a bit of plaster over the puncture, and apply a suspensory
bandage, which latter, however, is not essential, and is often dispensed
with.
If any accidental circumstance bring on inflammation after the ope-
ration, it may lead to a complete cure ; but this only happens in a small
proportion of cases, and hence the method, now described, is called by
surgeons the palliative treatment.
The radical consists in discharging the fluid, and then adopting some
measure calculated to excite inflammation of the testicle, or rather of
the inner surface of the tunica vaginalis. We may fulfil these indications
by different proceedings. About half a century ago, surgeons sometimes
applied caustic to the scrotum, which produced a slough, the separation
of which was followed by the issue of the fluid, and the requisite inflam-
mation of the tunica vaginalis. This plan was at length renounced as
unnecessarily severe, and uncertain of success. At the same period,
the practice also prevailed of passing tents and setons into the tunica
vaginalis for the cure of this disease. The seton was in favour for a long
time, and even now, though not used for the present form of hydrocele,
is sometimes employed in another variety of it. Then, another plan of
cure consisted in making a free incision 'into the swelling, so as at once
to let out the fluid, and make such an exposure of the cavity of the hydro-
cele as was followed by inflammation, suppuration, granulation, and the
obliteration of it. This last mode of treatment is still advisable under
particular circumstances. But, in general, the best practice, arid that to
which all the most experienced surgeons in this country give the pre-
HYDROCELE. 593
ference, is to discharge the fluid, and immediately afterwards to throw
some stimulating fluid into the cavity of the tunica vaginalis, for the pur-
pose of bringing on the necessary degree of inflammation. This ope-
ration requires a simple but well-made apparatus, composed of a trocar
and cannula, and either a syringe with a pipe adapted to the cannula, or
else an elastic gum bottle with a brass neck, furnished with a stopcock,
and of a size exactly adapted to the mouth of the cannula, Some sur-
geons use an injection containing sulphate of zinc ; others, employ a solu-
tion of alum, or brandy and water. Port wine and warm water in equal
proportions, were preferred by the late Sir .James Earle. Of late, an
injection, composed of 5ij. of tinct. iodinii, and 5vj. of tepid water, has
been used, on the ground, that the cure is sooner accomplished by means
of it than other injections, a larger quantity of which is also stated to be
necessary, so that the passage of some of it into the cellular tissue is
more likely to happen. The port wine and zinc injections are the only
ones, which I have hitherto employed. The wine injection should be
made stronger than what is above specified ; if two thirds of it be wine,
it will not be too stimulating. I have also frequently put 5iss. of the
sulphate of zinc into a pint of warm water, and believe that the chance
of a failure of the operation is thereby lessened. The fluid of the hydro-
cele having been discharged, and the elastic bottle filled with the lotion,
we push the end of the stopcock into the mouth of the cannula, and
throw the injection into the tunica vaginalis. Before we do this, how-
ever, we are to be sure, that the internal end of the cannula has not
receded from the cavity of that membrane ; for if it has done so, the in-
jection will pass, not into that cavity, but into the cellular tissue of the
scrotum, and bring on extensive abscesses, or even a dangerous sloughing
of the parts. I remember once assisting a surgeon in this operation, and
telling him to be on his guard against this accident, the risk of which he
seemed to think very trivial. He told me that he had tapped numerous
hydroceles without the occurrence ; and yet, from not paying attention
to keep the cannula well in during the discharge of the fluid, and the
shrinking of the tunica vaginalis, the very thing now happened which he
considered to be impossible under his management. Abscesses and some
gangrenous mischief followed ; but I believe the hydrocele was radically
cured, which might not have been the result. On the average, the
injection may be kept in from five to ten minutes. In young persons,
three minutes will suffice. The quantity of injection should not be quite
equal to the quantity of fluid discharged, because if we distend the tunica
vaginalis too much, some of the injection is apt to flow out by the side of
the cannula into the cellular tissue, and occasion suppuration, or even
sloughing. If the testicle should be affected with chronic enlargement,
this circumstance ought not always to deter us from employing the in-
jection, which, in such a case, has often brought about a cure. After
the operation, we are to put a piece of adhesive or soap plaster over the
puncture, and when inflammation has come on, apply a poultite. At
one time, it was supposed, that this method could not produce a cure,
except by obliterating the cavity of the tunica vaginalis, or by exciting
the adhesive inflammation in it, followed by the union of the loose tunica
vaginalis to the portion of it reflected over the testicle ; and that, unless
such union took place, the hydrocele would return. But it is now well
ascertained, that a hydrocele is often cured without the cavity of the
tunica vaginalis being obliterated, and on another principle, namely, the
injection excites inflammation of the interior of that membrane, followed
Q Q
.094- DISEASES OF THE GENITAL ORGANS.
by some permanent change in the state and action of the vessels of the
part, whereby they are prevented from continuing to secrete a redun-
dant quantity of fluid ; and there seems to be a restoration of the due
equilibrium between secretion and absorption.
With regard to the variety of hydrocele, in which its cavity is divided
into distinct bags or cells, one circumstance merits notice, namely, that we
cannot treat it efficiently, or. indeed, with the slightest prospect of a cure,
by injection ; and the proper plan is that of making a free incision into
the tumour, and discharging the fluid from the several pouches in which
it is confined. Thus a radical cure may be accomplished with tolerable
certainty. In some cases, where a hydrocele is found to have two dis-
tinct cavities, this peculiarity depends upon a hydrocele of the tunica
vaginalis being combined with an encysted hydrocele of the spermatic
cord.
In all ordinary cases, the treatment by injection should be preferred,
as the mildest and surest. Where, however, the hydrocele contains se-
veral different cavities, not communicating together, where likewise the
nature of the disease is doubtful, or the case is variously complicated with
a hernia, or the presence of a hernial sac, or the method of injection has
already failed, it may be the most prudent course to practise an incision,
in preference to a puncture, and this, under some of these circumstances,
even with extreme caution. When, however, the doubt is, whether the
disease is hydrocele or a medullary tumour, a puncture with a small trocar
seems to be followed by no ill consequences ; and it is, I think, preferable
to an incision, which, in the event of the case being hydrocele, would be
an unnecessarily severe mode of cure. When an injection has not an-
swered, the seton may be employed, if the surgeon prefer it, as a milder
practice than the treatment by incision. In a few such cases, I have tried
acupuncture with success ; but in others without it. In two or three ex-
amples, I have resorted to acupuncture after a partial return of hydrocele,
and completed the cure. If acupuncture be tried, pressure may be com-
bined with it.
We should never proceed to puncture a hydrocele of the tunica vagi-
nalis, without having examined it most carefully ; for various cases are
recorded, in which the testicle, instead of having the fluid in front of it,
has been adherent to the front of the interior surface of the tunica vaginalis,
and actually been wounded with the trocar, none of the fluid collected
at the sides of this body being discharged. One of the best ways of avoid-
ing this serious error is to examine every hydrocele with a wax taper, in
the manner already specified ; for if the forepart of the tumour seem
opaque, and, when compressed, occasion the sickening pain always arising
from compression of the testicle, we may infer, that this body is adherent
to the front of the cavity of the hydrocele, and would be wounded by the
introduction of the trocar in the usual place.
CONGENITAL HYDROCELE
Signifies a collection of water in the tunica vaginalis, attended with a
narrow communication between the cavity of the latter membrane and
the interior of the peritoneum. In the foetus, the testicle is contained in
the abdomen, whence it descends into the scrotum, generally a little
while before birth, but sometimes not till after this event. The produc-
tion of the peritoneum, by which it is accompanied, and which is to con-
stitute the future tunica vaginalis, usually closes soon after the descent of
the testicle is completed. But before this happens, fluid may pass into
HYDROCELE OF THE SPERMATIC CORD. 595
it from the cavity of the peritoneum, and a peculiar form of hydrocele,
termed congenital, be the result. This case has one symptom that does
not characterise other hydroceles ; namely, pressure makes the swelling
disappear by forcing the fluid up into the cavity of the peritoneum. In
this respect, then, we see a similarity to hernia. The hydrocele, how-
ever, is a transparent, soft, pyriform swelling, in which a fluctuation can
be plainly felt. A congenital hydrocele not only diminishes or disappears
under pressure, but also when the patient lies on his back ; resuming its
ordinary shape and dimensions as soon as he puts himself in the erect
posture again. It may take place either when the testicle has descended
properly into the scrotum, or when it has not descended, and is not even
perceptible ; or it may occur while the testicle is somewhere in the in-
guinal canal, or can be felt just at the abdominal ring. In these latter
cases, the tunica vaginalis is elongated and extended from the place where
the testicle is lodged down into the scrotum. These are circumstances
very necessary to be remembered, because they influence the treatment.
This must be manifest, because we cannot prudently attempt any thing
for the cure of the hydrocele that would interfere with the descent of the
testicle, or be likely to injure it.
The best mode of treating congenital hydrocele, when not complicated
with a retarded descent of the testicle, is to apply a truss ; for thus we at
once remove the danger of a protrusion of the bowels, and promote the
closure of the passage between the scrotum and the belly. No sooner
has the obliteration of the opening been accomplished, than a further
supply of fluid from the cavity of the peritoneum is cut off, and what is
contained in the tunica vaginalis is absorbed. This practice is more
advisable than the old method of cure by means of a stimulating lotion
thrown into the tunica vaginalis, while an assistant made pressure at the
ring, in order to keep a portion of the fluid from entering the cavity of
the peritoneum. I deem the treatment by means of a truss more advisable ;
first, because unattended with any risk of bringing on peritonitis ; and
secondly, because it is adapted to expedite the closure of the communica-
tion between the scrotum and the belly, — a desideratum which is entirely
out of view -in the treatment with injections.
HYDROCELE OF THE SPERMATIC CORD
Is much less frequently met with than hydrocele of the tunica vaginalis,
and is commonly described as an accumulation of fluid in a thin mem-
branous cyst within the sheath of the cord. Sir Benjamin Brodie, indeed,
regards this encysted hydrocele as corresponding to a cyst filled with
fluid, produced in any other organ of the body, and takes notice of its
loose connection to the surrounding parts. While, however, Sir Astley
Cooper admits this mode of formation, he conceives that, in certain ex-
amples, the production of the disease is owing to the adhesion between
the peritoneal investments of the cord happening to be imperfect in one
place, so as to leave a cavity between them. This is also Sc^-pa's ex-
planation, who published, many years ago, an interesting memoir on the
present complaint. The swelling is generally oblong, or globular ; and,
if it be so placed as to admit of being grasped and pushed forwards, it
will often present a light blue colour, with a degree of transparency about
it, and considerable tension. Few specimens of it attain much magnitude,
its ordinary size not exceeding that of a pigeon's egg, and pain is not one
of its characters. We now and then hear, or read, however, of a large
one, including several ounces of fluid. When situated in that part of the
QQ 2
596 DISEASES OF THE GENITAL ORGANS.
cord which is within the inguinal canal, the tumour is liable to be mistaken
for hernia, though I may observe, that it is free from pain, as well as from
the guggling sound or feel perceptible in intestinal hernias, and that the
functions of the alimentary canal are not in the least disturbed or inter-
rupted. Though such a tumour may be forced a little way up the in-
guinal canal, we cannot bring about its perfect reduction. When the
tumour is on the outside of the abdominal ring, we recognise its nature
by various circumstances. We advert to its transparency, its fluctuation,
its giving no sudden impulse to the finger when the patient coughs, and
to its being unconnected with any of the organs in the abdomen, even
though it may admit of being pushed into the ring. Under these or any
other circumstances, it can never be put completely up into the belly, and,
when left to itself, it soon descends into its usual place, above which the
cord is free.
The fluid of a hydrocele of the spermatic cord is generally paler and
more limpid, than that of a common hydrocele, and contains less albumen.
One of the best modes of treating this disease is, to make an incision
in it, and then fill the cavity with lint. In the case of a lad in Univer-
sity College Hospital, I removed a slip of the front of the cyst, and the
disease was soon cured. Another eligible plan of treatment consists in
passing a seton of two or three threads or silks through the swelling.
These may be introduced in the way recommended by Sir Astley Cooper,
with a common curved needle. The latter method deserves the praise
of mildness, and I believe is tolerably certain of answering, though, per-
haps, less so than the treatment by incision. If we fill the cavity with
lint, after laying it open, there will be no occasion for the removal of any
portion of the cyst, in which proceeding there is some risk of doing
injury to the vessels of the cord. The cavity will suppurate, granulate,
and soon be obliterated.
Hydrocele of the spermatic cord, when small, produces little or no in-
convenience ; and, on this account, some practitioners scarcely consider
it as a case requiring the performance of any operation. If, however, the
patient's mind is rendered continually uneasy by the tumour, or the
tumour should be in any way a source of inconvenience, or show a dispo-
sition to enlarge, it is right to attempt its cure. Injections have so often
failed in the treatment of this form of hydrocele, that they are now aban-
doned in this metropolis.
Besides this kind of encysted hydrocele, there are other varieties, situ-
ated on the epidydimis, or the testicle. The former lies, as Sir Benjamin
Brodie has explained, between the epidydimis and the inner layer of the
tunica vaginalis; the latter between this membrane and the tunica albu-
ginea.
II^MATOCELE,
Which, etymologically speaking, means simply a tumour composed of
blood, at the present day always denotes a collection of blood in the
tunica vaginalis. The swelling is of a pyriform shape, like hydrocele,
from which it may be distinguished by its want of transparency, its
greater weight, its obscure fluctuation, and the manner of its production ;
the cause being usually a blow on the scrotum, or a wound of an artery,
or vein of the loose portion of the tunica vaginalis, or an injury of the
testicle itself. Sometimes, I suspect, an enlarged or diseased vein gives
way spontaneously, after the water has been discharged from the tunica
vaginalis, and, continuing to bleed into the cavity of this membrane, leads
HAEMATOCELE. 597
to the formation of hacmatocele. We know, however, in many instances,
that a largish vessel has been wounded, for the fluid of the hydrocele, as
it flows out, is more or less mixed and tinged with blood. If a lancet
be used for this purpose, the risk of haematocele is increased. Some persons
have become the subjects of haematocele in consequence of a blow on the
testicle from the pummel of the saddle, in riding on horseback ; and, in
such cases, probably the bleeding is often from the vessels of the testicle
itself.
Some time ago, I visited with Mr. B. Cooper a gentleman, who had a
large hydrocele on each side of the scrotum, and one of these he had con-
verted into a hsematocele by a trial of his own ingenuity. Perceiving
that all that a surgeon did, when he let out the fluid, was to make an
opening in the swelling, he fancied that he could invent an instrument
that would make the attendance of a surgeon unnecessary. After a little
study, he contrived an instrument, very much like what is used by far-
riers for bleeding horses, only it was on a larger scale ; the blade, which
darted out on touching a spring, being something like a dagger. With
this weapon he perforated the swelling, indeed, and let out the water, but
wounded some of the blood-vessels, so that in a few hours the tumour
was as large as ever, and a great deal more painful. In short, the cavity
of the tunica vaginalis had become distended with blood. The blood soon
began to putrefy, the parts inflamed, considerable fever ensued, and,
partly from the constitutional disturbance and the approach of gangrenous
mischief, the patient's life was in danger. If a prompt and free incision
had not been made, I fully believe his condition would soon have been
hopeless. By this operation a considerable quantity of putrid blood,
matter, and a most offensive gas, sulphuretted hydrogen, having been
discharged, the patient recovered very favourably.
One hydrocele was radically cured by this proceeding ; but, notwith-
standing the inflammation was considerable, it had not the effect of curing
the other hydrocele.
Haematocele is only painful when complicated with inflammation, or
with mechanical injury of the testicle. Some cases, therefore, are painful,
and others not so. In certain examples, a haematocele is combined with
hydrocele ; this may take place when a person, who has a hydrocele, re-
ceives a severe contusion of the scrotum, and one or more blood-vessels
of the tunica vaginalis are ruptured by the violence, and the blood, which
flows from them, is added to the fluid already in the tumour. The state
of the case may be known by the previous accident, the sudden increase
of the swelling following the injury, and the dark opaque appearance of
the tumour, which no longer exhibits its former transparency, when a
lighted taper is placed behind it.
The treatment of haematocele varies according to circumstances. When
the quantity of blood is inconsiderable, we should not interfere with it by
any operation, but endeavour to promote its absorption by means of brisk
purgatives and lotions containing vinegar, spirit, and hydrochl<»-ate of am-
monia. The absorption of a more copious effusion of blood in the tunica
vaginalis is not likely to be accomplished ; for we hear of cases in which
the blood continued nearly twenty years unremoved, though changed in its
appearance, and turned into a pale brown lamellated substance, very much
like what is met with in an old aneurism. Sir Astley Cooper gives one
instance, in which he cut into a haematocele that had existed seventeen
years, and in which the blood, originally effused, still remained, though in
an altered condition. When haematocele arises from a blow, antiphlo-
Q u 3
598 DISEASES OF THE GENITAL ORGANS.
gistic treatment at first is the most prudent ; we are to keep the
patient quiet in the recumbent posture, and try what benefit can be ob-
tained from purgatives, leeches, venesection, low regimen, and cold eva-
porating lotions. In a later stage, if the swelling should continue of any
material size, or threaten to bring on suppuration, sloughing, and other
troublesome or urgent consequences, we should of course make a free
incision into the tunica vaginalis, discharge the blood collected in it, and
then apply emollient poultices, unless there was a tendency to a renewal
of bleeding, in which circumstance linen, wetted with cold water, or the
Saturnine lotion, would be better than warm applications.
If the disease were combined with hydrocele, or to follow the puncture
of the latter kind of swelling, I should lay open the tunica vaginalis, take
out the blood, and then apply warm or cold applications, according as
there might or might not be a disposition to a return of bleeding. In
almost all cases of haematocele, requiring an operation, antiphlogistic
means are indispensable at first ; and I have seen several cases in which
it has been necessary, on account of the inflammation and constitutional
disturbance, to employ the lancet and other means of depletion very
freely. In cases, where the effusion of blood follows the puncture of a
hydrocele, that is, where there is a communication formed between the
cavity of the tunica vaginalis and the external air, the blood soon putre-
fies, and becomes a source of considerable irritation ; matter forms ; a
tendency to sloughing is produced; sulphuretted hydrogen gas is generated
in the swelling ; and the patient gets into an urgent state of danger, from
which the formation of a free and immediate opening into the disease is
the only means of extricating him.
VARICOCELE, OR CIRCOCELE,
Consists of a varicous enlargement of the spermatic veins ; the disease
being more common on the left side than the right, in consequence, as
Morgagni believed, of the termination of the left spermatic in the renal
vein, the current of the blood in which is not in the direction of the left
spermatic vein, as the course of the blood in the vena cava is, with refer-
ence to that of the right spermatic vein. In former days, the first of these
terms was generally restricted to a mere varicous dilatation of the veins of
the scrotum, an affection requiring no particular notice ; while the ex-
pression circocele was used to denote more particularly a varix of the
spermatic veins themselves, a case more deserving of consideration, be-
cause surgeons are often consulted for it, and it occasions a swelling that
has frequently been mistaken for hernia. In the present day, these two
terms are mostly employed synonymously ; and when we hear of a
modern surgeon speaking of varicocele, he is almost invariably alluding
to a morbid enlargement of the spermatic veins, and not of those of the
scrotum. When the veins of the cord are thus altered, they assume a
tortuous course, their coats are considerably thickened, and the vessels
have a knotty feel, attended with a greater fulness below the ring on the
diseased side than the other, and with more or less uneasiness, sense of
weight, and occasionally a severe pain in the testicle, inguinal canal, and
loins. The swelling is sometimes large, and of a pyramidal shape, with
the base just above the testicle. When we examine a varicocele with the
hand, we feel the cluster of dilated veins, which are commonly described
as communicating a sensation, as if we were taking hold of a bundle of
earth worms. We may distinguish varicocele from a hernia, by placing
the patient in the recumbent posture, and pressing the blood of the large
DISEASES OF THE SC11OTUM. 599
veins upwards, or returning the protruded viscera, so as to reduce the
swelling; we then cover the abdominal ring with our fingers, and desire
the patient to rise while we keep the fingers thus steadily over the ring.
Now, if the case be a varicocele, the spermatic veins fill again, and
assume their former distended condition directly the patient is in the
erect position, notwithstanding the abdominal ring is covered and com-
pressed ; but if the case be a hernia, no protrusion can happen, while we
keep our fingers on the ring, and consequently, so long as they are thus
applied, there can be no return of the swelling, though the patient change
his posture from the recumbent to the erect. The swelling of varicocele,
when it returns, makes its appearance also in a more gradual manner than
a protrusion of the abdominal viscera.
In the generality of cases, varicocele is not a very painful disease, and
the patient finds any uneasiness from it relieved by supporting the testicle
with a suspensory bandage or a silk net, by bathing the scrotum and
groin with cooling lotions, and keeping his bowels regular. If there be
greater annoyance, or any severe degree of pain, he should, in addition
to the foregoing measures, observe the recumbent posture, and apply
leeches. In a few rare instances, the sufferings produced by varicocele
have been such as to induce the patient to submit to castration ; but, in
the present state of surgery, I am reluctant to believe that such pro-
ceeding is justifiable. Another experiment has consisted in putting a
ligature round the largest of the varicous veins ; but by this we should
expose the patient to the risk of phlebitis: and one of the late Sir
Everard Home's patients nearly lost his life after such an operation.
Some practitioners have had recourse to another plan ; after dividing
the integuments, they have compressed the most distended veins be-
tween the blades of forceps constructed for the purpose, and thus oblite-
rated their cavity. Fricke's method consists in passing a seton of three
or four threads through the bundle of varicous veins. One of the most
serious occasional consequences of the disease, and also of treatment of
it with the forceps, is atrophy of the testicle.
DISEASES OF THE SCROTUM.
The scrotum is liable to anasarca and ecchymosis, which, however, are
here attended with no peculiarity, no circumstances different from those
accompanying such affections in other common textures of the body.
It is also occasionally the seat of phlegmonous erysipelas,, and then, from
its abundance of loose cellular tissue, which becomes distended with a
serous fluid, is productive of a considerable degree of swelling, often
extending to the very end of the prepuce, and causing there a phymosis.
On first sight of such a case, where the swelling is equal in size to a
child's head, the suspicion at first raised is, that the urethra has given
way, and that the urine has been effused. Whether this has really
happened or not, free incisions should be made ; and, if any doubt exist
about the state of the urethra, a catheter ought to be introduced^and kept
in, as it can do no harm, even if the urethra should be sound, and, in the
opposite case, will be of essential service in preventing the further escape
of urine into the cellular tissue of the perineum and scrotum. The scrotum
is sometimes the situation of tumours ; and I remember one case in St.
Bartholomew's, where an excrescence in the shape of a horn, and of a
horny consistence, was formed on it. In warm climates, the scrotum is
often converted into an enormous mass of adventitious or hypertrophied
cellular tissue, often amounting to half a hundred-weight or more, and
Q Q 4
600 DISEASES OV THE GENITAL ORGANS.
not only burying, as it were, the penis and testicles, but absolutely dis-
qualifying the patient for exercise or any kind of employment requiring
locomotion or muscular exertion. Now and then a similar distressing
disease has been seen in Europeans ; Delpech operated upon some
remarkable cases of this kind, in one of which the swelling weighed
seventy or eighty pounds. In Mr. Listen 's collection is another tumour
of this nature, which he removed, and the weight of which must be very
great. It is generally, however, in warm climates that the disease is met
with. Larrey relates the particulars of several cases which he saw in
Egypt, and facts of the same kind abound in the records of surgery.
The case of a native of China, who died under the operation attempted
for his relief in Guy's Hospital, must be fresh in the memory of all
surgeons in London. Many successful removals of the diseased mass,
however, have been performed, especially by Clot Bey, in Egypt,; and it
is the only expedient that can afford relief, where the patient's life is
rendered a burden by the magnitude of the adventitious formation. In
practising these operations, there are three principal points to be attended
to : first, we are to take care to secure every large artery as soon as di-
vided, so that the patient may not die of hemorrhage before the operation
is finished; secondly, we are to avoid injuring the testicles and urethra;
thirdly, we are to give the patient a cordial draught, or a little brandy
with a proportion of laudanum in it, before the operation, so that his
nervous system may be better enabled to bear the long and unavoidable
agony, or the shock, of the operation.
CHIMNEY-SWEEPERS' CANCER
May be strictly denominated a disease of the scrotum ; for the instances,
in which it has been known to commence in other parts are very unusual.
It seems to arise from the lodgment and irritation of soot in the rugae
of the scrotum; and, perhaps, if other parts of the integuments were as
well adapted for the reception and detention of this substance, we should
more frequently notice the disease in them. A few cases, in fact, are re-
lated, in which the disease occurred on the face and limbs, and this even
in persons who were not chimney-sweepers ; but then it is to be observed
they were gardeners, or labourers in some other way, requiring them to
handle soot. The disease commonly begins in the form of a smallish
wart or induration upon the scrotum, such wart or induration soon
presenting a broken surface, from which a particularly foetid matter is
poured out, but, drying, is converted into a kind of scab, or incrustation.
From time to time this is rubbed off and followed by a more and more
copious effusion of very offensive bloody ichor. At length, an ulcer of
some extent is produced under the scab, with hardened, everted, or con-
torted margins. In time, the ulcer reaches the tunica vaginalis and the
testicle, and the absorbent glands in the groin swell, burst, and some-
times change into similar malignant ulcers. I have known a chimney-
sweeper's cancer commit such ravages that the artery in the groin was
laid bare by it. In some cases, indeed, the patient dies of profuse bleed-
ing ; but more usually he dies hectic, exhausted by irritation, long suffer-
ing, profuse discharge, and extension of the disease to the lymphatic
glands in the loins.
This is a malignant disease, over which internal medicines and exter-
nal applications possess little or no control. If, therefore, we meet with
the disease in its early stage, before the testicle, the spermatic cord, or
the lymphatic glands are involved, we ought to lose no time in trying
CANCER OF THE PENIS. 601
useless medicines and dressings, but at once take away the disease with
a knife. Even then the result will be uncertain ; and, in the course of
my time, I recollect more instances, in which the operation was followed
by a relapse, than a permanent cure. I attended, at the Bloomsbury
Dispensary, a chimney-sweeper afflicted with the disease in the state of
ulceration, with one or two glands in the groin enlarged, which seemed
to me a prohibition to the operation. He went into one of the hospitals,
where the diseased portion of the scrotum was removed ; but, I am in-
formed, he soon died of a return of the disease higher up in the body. By
these remarks, I would not wish it to be supposed, that the operation will
never succeed when the inguinal glands are swollen. I am sure it will
not answer, if those glands participate in the morbid action ; but, if they
be merely enlarged from irritation, then a cure may be the result, the
glandular enlargement gradually subsiding after the disease has been re-
moved. About two years ago, I operated under these circumstances on a
chimney-sweeper in University College Hospital ; and, though the in-
guinal glands afterwards suppurated, the man was perfectly cured in a
few weeks. The same thing, it is well known, is occasionally noticed
after the removal of a scirrhous breast.
One remarkable difference between chimney-sweeper's cancer and
common cancer is this : in the former case, if the whole of the diseased
parts be taken away, there will be no relapse ; in the latter, the same
practice will not secure the patient from a return of the disease in the
same or other parts.
CANCER OF THE PENIS
May commence on the glans, or the prepuce, and afterwards not only
involve both these parts, but extend its ravages much further, so as to
cause excessive induration even in the corpora cavernosa themselves, and
sometimes to destroy the greater portion of the penis, by a process of
malignant ulceration as high up as the pubes. In the museum of Uni-
versity College is a fine specimen of scirrhus of the penis, in which
the corpora cavernosa and septum penis are involved ; it was taken from
an old man, who was under my care as a patient of the Bloomsbury Dis-
pensary, and whose water I used to draw off daily for some time before
he died. At certain times, he suffered acute pain in the organ, which
was much enlarged, and the hardness of which was very remarkable. His
great age, the state of his prostate gland, and the diseased condition of
his bladder, prevented me from proposing the removal of the penis. He
died, indeed, from a complication of diseases, and not exactly from scir-
rhus of the latter organ. In many instances, the disease originates in
the form of a warty induration, either on the inner surface of the pre-
puce or on the glans, and it may continue in this state'many years, with-
out much change, though more generally it is soon followed by ulceration,
the discharge of a thin peculiarly offensive ichor, and the formation of a
malignant sore, with hard everted, or contorted, edges. In th* case of
the old man to which I have alluded, the disease had existed a very con-
siderable time, without getting into the ulcerated stage. The late
Mr. Hey, of Leeds, took particular notice, that, in many instances of can-
cer of the penis, the patients had a natural phymosis ; for, in eight out of
ten examples, which he attended, this was the case. The observation
was corroborated by the reports of M. Roux, of Paris. Mr. Travers has
never known a Jew to be the subject of cancer of the penis ; but he
operated on a man, who had been cut for phymosis ten years previously,
602 DISEASES OF THE GENITAL AND URINARY ORGANS.
in whom a pimple on the side of the fraenum ulcerated, and assumed the
form of cauliflower fungus, completely surrounding the glans, while the
latter continued, sound. Perhaps, the following consideration may ex-
plain why many cases are combined with phymosis, which may not in
every instance be natural, or congenital, or have preceded the other
disease : when a cancerous affection begins on the inner surface of the
prepuce, or when a cauliflower induration exists either there or on the
glans, the irritation of the prepuce, arising from such a cause, may lead
to a swelling, thickening, and enlargement of that part, just as we know
that common warts, in the same situation, frequently do. Yet, I believe,
that congenital phymosis does predispose to cancer of the penis, as
Mr. Hey suspected ; for, undoubtedly, those who have a long prepuce,
and neglect cleanliness, are more liable to disease within that part than
others, whose foreskin is short. Sooner or later, after scirrhus or cancer
has begun in the penis, the glands in the groin enlarge, and the ravages
of the disease may gradually extend from the extremity of the penis to
the pubes, and have a fatal termination. Other ill-conditioned, or fun-
gous diseases of the penis, however, must be carefully discriminated from
cancer. I should say, with Mr. Travers, that whenever the disease begins
as an irritable pimple of the glans, or prepuce, and this breaks into a
spreading ulcer, with an indurated base, and a disposition to throw out a
fungus, the case must be viewed with great suspicion, whether the glands
in the groin be affected or not, particularly if the patient has passed the
age of fifty.
The only chance of freeing a patient from a cancerous disease of the
penis depends upon the timely removal of the affected portion of the
organ with the knife. The earlier this is done, the greater the prospect
of success ; for, when the inguinal glands are involved, the operation is
too late. Trivial sympathetic swellings of those glands, however, are not
accounted by every surgeon a just prohibition of the operation, though
the discrimination of such enlargement from one of a truly scirrhous kind
is by no means easy. One thing has been fully proved by repeated ex-
perience, namely, that the patient is not certain of not having a return of
the disease, though the operation be done at a period when no glandular
enlargement exists. When the disease returns, it may either reappear
upon the stump, or in the shape of cancerous buboes in the groin, which,
after a time, often bleed profusely, so as to bring the patient very quickly
to his doom.
DISEASES OF THE PROSTATE GLAND.
A swelling of the prostate gland may be of different kinds, and de-
pend upon a variety of causes : thus it may originate from common in-
flammation of the part, abscesses, calculi within its substance, a varicous
enlargement of the veins in its vicinity, or a chronic alteration of its tex-
ture, by which its shape, size, and consistence are materially affected.
This latter case, though attended with great induration of the part, and
often termed scirrhus, is different from any cancerous affection, not be-
traying any disposition to affect the lymphatic glands, or to communicate
a truly scirrhous form of disease to other textures and organs. The
gland itself, when examined, does not present the texture of scirrhus,
but is a dense, compact, nearly homogeneous substance. Whatever danger
attends it (and great danger does frequently accompany it) proceeds
from the difficulty of passing the urine, and its injurious effects on the
bladder and kidneys, to which such state of the prostate gland, when far
DISEASES OF THE PROSTATE GLAND. 603
advanced, inevitably leads. The prostate gland, besides being liable to
the several affections which I have mentioned, is also subject to scro-
fulous disease and abscess; and perhaps, when a chronic enlargement of
it takes place in a young person, — one under the age of thirty, for in-
stance,— there is reason to suspect the affection to be scrofulous ; for the
other chronic enlargement, to which I have adverted, rarely happens in
persons much under fifty.
With respect to acute abscesses, I believe they are generally formed
around, or in the vicinity of, the prostate gland, and not in its substance.
They may occur, however, in the cellular 'tissue, between its lobes.
Most of the examples which I have seen, followed suddenly suppressed
gonorrhoea, or were produced by the irritation of strictures in the urethra.
They interfered seriously and urgently with the evacuation of the urine ;
and consequently required free and prompt incisions for the discharge of
the matter. Sometimes they burst into the urethra, or make their way
out in the perinseum. All inflammatory complaints about the neck of
the bladder and the prostate gland generally cause more or less difficulty
in passing the urine ; and such is the ordinary effect of abscesses in this
situation. In the 'early stage, we should employ every means in our
power, calculated to prevent the inflammation from advancing to sup-
puration ; and, for this purpose, we should apply leeches freely to the
perinaeum, bleed from the arm, administer calomel and brisk purgative
draughts, and employ fomentations, or even the warm bath. But, directly
matter has formed, the sooner an incision is made the better.
With regard to prostatic calculi, they are composed of phosphate of
lime, their size varying from that of a pin's head to that of a nut. Some-
times they pass into the urethra, and are discharged. When they cause
much annoyance, and can be felt from within the rectum on the finger
being introduced into this bowel, they should be removed by making a
suitable incision into the gland with the aid of a staff. When they pro-
ject into the urethra, a similar operation will be required. If possible,
they should always be extracted without actually cutting into the bladder
itself.
The disease of the prostate gland, most interesting to the practical
surgeon, is a slow enlargement of it, by which its bulk is sometimes
enormously increased, from that of a chestnut, its natural size, to that of
a large orange, or even a melon ; for it has been known to attain the
magnitude of fifteen times its natural size. The museum of Univer-
sity College is particularly rich in specimens of diseased prostate gland,
bladder, and urethra. One preparation exhibits the bladder with the
prostate gland, not only much enlarged, but torn or fissured by the
repeated attempts of the surgeon to get the instrument into the bladder.
Small calculi are lodged in the bladder in the depression behind the
prostate ; and we learn from the history of the case, that an abscess had
formed between the bladder and rectum, which burst by an opening,
which is still discernible, into the former of these organs. 9
Chronic enlargement of the prostate gland is most common in the de-
cline of life, at which period there is a natural tendency to it, such that,
in persons of advanced age, this part is always increased in size. The
alteration of the prostate gland does not usually render the contiguous
portion of the urethra narrower, in the manner of a stricture, but com-
presses the sides of that canal together, and either bends it more sud-
denly upwards, pushes it to one side, or turns it in spiral or other
diversified modes. These facts enable us at once to understand why this
604- DISEASES OF THE GENITAL AND URINARY ORGANS.
disease of the prostate gland should render the patient liable to retentions
of urine, and why lie should have symptoms and complaints very similar
to those of stone.
The urethra has been known to be widened. Thus. Sir Benjamin Brodie
has recorded a case of diseased prostate gland, where the urethra was
dilated into a sinus, capable of holding two or three ounces of urine. The
urethra, however, is generally more or less compressed and distorted, at
the same time that it bends more suddenly up into the bladder. In conse-
quence also of the prostate gland acquiring an increased magnitude, the
prostatic portion of the urethra must necessarily be lengthened; and this
may happen in such a degree, as to make the urethra two or three inches
longer than natural. Frequently the gland is more enlarged on one side
than the other ; a circumstance that gives more or less obliquity to it.
As the principal part of the prostate gland naturally lies below the
urethra, the greatest part of the swelling occupies the same place. In
many of these cases, there is a swelling of a portion of the gland just
behind the vesical orifice of the urethra. Such a swelling may act like a
valve at the neck of the bladder, and, in many preparations, it is actually
seen constituting a large prominence in the bladder, attended with the
effect of mechanically forcing the urethra forwards towards the pubes, and
of obstructing the passage of instruments, or of preventing the surgeon
from readily touching with a sound a calculus situated behind and below
it. In one specimen in University College, the prostate gland is ir-
regularly enlarged, and one part of it projects into the bladder, so that
it was wounded in the attempts to introduce the catheter. Small calculi
are also adherent to the inner surface of the bladder. In many of these
•cases of enlarged prostate, there are calculi in the bladder : in another
preparation in the same museum, several calculi form a very serious com-
plication of the other disease.
This chronic enlargement of the prostate gland comes on slowly and
insidiously, not indeed exciting attention until the size of that organ ge-
nerally, or of the third, lobe in particular, begins to bring on first a fre-
quent desire to make water, and occasional tenesmus, or uneasiness about
the rectum, followed, after a time, by more or less difficulty of voiding the
urine. There is not only pain in making water, but a desire and straining
to discharge more, after the bladder has been emptied as far as it can be.
The muscular coat of the bladder, being obliged to exert itself very fre-
quently, and having a mechanical obstacle, as it were, to overcome, be-
comes of course considerably thickened. In fact, in an early stage of the
disorder, the patient finds that he is obliged to make a greater effort
than usual to get the urine to flow ; he is compelled to strain a good deal
ere it will begin to escape ; but when once the first difficulty is surmounted,
the contents of the bladder pass out tolerably well. However, in propor-
tion as the diseased gland continues to increase in size, the difficulty of
passing the water also increases ; more straining is always required, and
at times there is a complete or incomplete retention. No doubt, in a
great number of instances, the projection of the third lobe, as it is some-
times termed, just behind the vesical orifice, has a mechanical effect in
obstructing the discharge of urine ; and probably it is when such promi-
nence begins, that the inability to empty the bladder with perfect facility
is first experienced. In one preparation in the museum of University
College, the projection resembles a nipple in shape ; in another it repre-
sents a complete ridge. Sometimes, when the third and one of the lateral
lobes project considerably into the bladder, their surface has an irregular
DISEASES OF THE PROSTATE GLAND. 605
ulcerated appearance, and on this account the patient suffers aggravated
pain in expelling the last drops of urine, as well as distressing attacks of
spasm at the neck of the bladder, symptoms also noticed in cases of stone.
An ulcerated state of the projecting portion of the gland will also explain
the great disposition to hemorrhage, exemplified in some of these cases
on the introduction of a catheter.
In all advanced cases, the patient is annoyed with distressing irritation
about the rectum, tenesmus, and flatulence ; and a desire to go to stool
often takes place so suddenly and irresistibly, that it is with great diffi-
culty he can reach the proper place for relieving himself, j
Generally, the patient voids large quantities of a viscid ropy mucus from
the urethra, which was supposed by the late Sir Everard Home to be
derived from the prostate gland itself. No doubt, a great deal of it is
secreted by the inner coat of the bladder, which sometimes becomes the
seat of inflammation.
In a considerable proportion of these cases, after a certain period, not
only is the muscular coat of the bladder much thickened, but the inner
coat protrudes between the muscular fasciculi in the form of cysts, or
little sacs. A sacculated bladder, as it is termed, is a frequent compli-
cation of enlargement of the prostate gland. Now, these cysts may also
include calculi, and instances have been known in which they were filled
with pus. But this is not all the mischief resulting from disease of the
prostate gland ; for, amongst other bad consequences, the complaint, by
deranging the functions of the urinary organs, may bring on, and fre-
quently does bring on, a morbid enlargement of the ureters, and fatal
disease of the kidneys.
Several of the symptoms of diseased prostate gland are like those of
stone in the bladder; but, in the former case, the patient is able to bear
exercise and the motion of a carriage much better than in the latter dis-
order. In a case of stone, there is also less tendency to retention of
urine, but a greater disposition to paroxysms of violent pain in the hypo-
gastric region, and to the discharge of blood with the urine after exercise.
I occasionally visit an old gentleman, who has long had a considerable
swelling of the prostate gland, yet, except at periods when he is laid up
with retention of urine, he is able to walk into the city daily. In all
doubtful cases, the state of the prostate gland should be examined from
the rectum, and the patient sounded.
The museum of University College contains one specimen in which,
besides the enlargement of this organ, a considerable thickening of the
muscles of the ureters is seen, and likewise sacs formed by a protrusion of
the inner coat between the fasciculi of the detrusor urinaB, from one of
which sacs a calculus had been extracted. In another specimen, the
prostate is very much increased in size, while the muscles of the ureters
form a ridge adapted to give lodgment to calculi. Another preparation
is the bladder of an old man, who died of retention of urine. The pro-
state is vastly enlarged, its lateral portions rising up, and its naturally
posterior part projecting forwards ; whereby the course of the urethra
was so altered, that no instrument could have been introduced, unless it
had been forced through the substance of the gland.
An enlarged prostate is an awkward complication of a case of stone,
not only because it sometimes carries up the neck of the bladder almost
above the pubes, and removes the cavity of that viscus very far from the
perinaeum, but because it may create impediment to the passage of a staff,
and certainly will render the operation more difficult and protracted.
606 DISEASES OF THE GENITAL AND URINARY ORGANS.
Another instructive preparation is a bladder with diseased prostate gland,
and four calculi in the former viscus. The third lobe is enlarged. In
trying to introduce the catheter, the surgeon forced it between the blad-
der and rectum ; abscesses followed ; and the patient died.
I do not know whether disease of the prostate usually produces a ten-
dency to disease of the rectum ; I suspect that it does, more especially
hemorrhoids. In the above museum is a diseased prostate, complicated
not only with a thickened sacculated bladder, but with stricture of the
rectum.
One occasional effect of disease of the prostate is a vast dilatation of the
ureters. In the above-mentioned collection is a tuberculated enlarge-
ment of the prostate gland, with the mouths of the ureters remarkably
widened.
In another specimen of diseased prostate, taken from a patient who
died of retention of urine, there is a fungous mass projecting from it into
the bladder. The preparation also affords a specimen of the anatomical
lusus of three ureters.
In the treatment of chronic enlargement of the prostate gland, occur-
ring in persons above the middle period of life, we are to remember, that
it is an organic disease, for the removal and complete cure of which no
surgeon possesses any effectual means. Yet, notwithstanding this dis-
agreeable truth, it is some consolation to know, that surgical assistance
is often of essential service ; and this not merely by obviating some
consequences, which would be likely to abridge the patient's life, and
even cut him off very abruptly, but by rendering the usual inconveniences
of the complaint much more bearable than they would otherwise be. By
the due regulation of the stomach and bowels with alterative and aperient
medicines ; by directing the patient to avoid sitting long at table after
dinner, and not to expose himself to wet, cold weather, the stoppages of
urine are rendered much less frequent, and the annoyance from tenesmus,
flatulence, &c., ordinarily experienced by patients labouring under the
disease, materially diminished. Setons and issues in the nearest part of
the perinaeum to the prostate gland have been tried ; but I have never
seen any good from them ; and the same observation applies to various
internal medicines, with respect to their power of reducing the swelling
of the gland, especially iodine, mercury, and hemlock.
A retention of urine, arising from this disease of the prostate gland,
will not often yield to the warm bath, opium,, or hyoscyamus ; and the
reason of this fact seems to be explained by the consideration, that the
obstruction is less of a spasmodic nature than of a mechanical descrip-
tion. Local bleeding is occasionally serviceable, and, as a degree of
spasm may, and probably does contribute, with the mechanical effects of
the disease on the urethra, to prevent the discharge of urine, I conceive
that, when a catheter cannot be immediately introduced, the surgeon
ought not entirely to neglect the trial of the warm bath and opium in the
form of an enema, though he should not place much confidence in them,
nor defer the use of the catheter. In fact, it is always best to resort to
the catheter at once, because a prompt discharge of the urine is the only
method of preventing the ill effects of a forcible distension of the bladder.
The bladder itself rarely or never bursts in these cases, even if the water
be not discharged ; but the constitutional disturbance increases, the action
of the kidneys is interrupted, the inner coat of the bladder inflames, and
the patient dies comatose. I have seen examples, in which, when the
water was drawn off, it had a completely purulent appearance, and no re-
DISEASES OF THE PROSTATE GLAND. GOT
covery followed ; and Mr. Travers has seen two cases of long retention
of urine from disease of the prostate gland, where the mucous membrane
lay like a slough, loose in the bladder.
The catheter used in these cases ought generally to be of full size,
greater length than common ones, and rather more bent upwards towards
its beak. Some cases require the catheter to be thirteen or fourteen inches
in length, as a shorter one will not reach the bladder. The late Sir
Everard Home, who had considerable experience in the treatment of
disease of the prostate gland, preferred elastic gum catheters, so con-
structed, that they retained a particular curve, even when the stilet or
wire was withdrawn from them. These he sometimes left in the urethra
several days ; for they were calculated to bear warmth and moisture
better than other common ones of the elastic kind. For the purpose
of retaining them in the passage more surely and conveniently, a ca-
theter bracelet was employed. A flexible catheter should be preferred to
a silver one, when it is deemed most advantageous to keep the instru-
ment any time in the passage ; for it will remain there with much less
annoyance than a metallic one. But, on the other hand, we are some-
times able to pass a silver catheter, when we cannot succeed with one
made of elastic gum, which, unless the wire be of unusual thickness, has
not always sufficient firmness to overcome the impediment arising from
the compressed state of the urethra, or the alteration of its course. In
these cases, whatever catheter be employed, it generally passes to the
anterior portion of the prostate with perfect facility, and here its beak is
stopped, sometimes partly by the compressed state of the urethra, but
chiefly by the new curvature of the passage, which we cannot always get
an instrument to follow. In fact, there are few instances of considerable
enlargement of the prostate gland, without the urethra included in it
being propelled forwards and upwards, or to one side, or twisted in
various ways. Perhaps, where the passage is tortuous, an elastic catheter
of moderate size is the most likely to find its way ; and this instrument has
one advantage over a silver one, deserving to be well remembered in
practice, namely, by withdrawing the wire at the period when we are
trying to make the instrument pass the obstruction, we are able suddenly
to increase its curvature, and thus often succeed in getting it into the
bladder when no silver catheter could be introduced.
Generally it is necessary either to leave the catheter in the urethra,
or to draw off the water once or twice a day, according to circumstances,
removing it directly after each evacuation. These plans are to be con-
tinued, until the patient regains the power of expelling the urine himself.
When the case is such, that the introduction of the catheter is always
difficult, the wisest plan, after getting the instrument into the bladder, is
to keep it introduced for a few days, and, as soon as the patient can
empty the bladder by his own power, it may be withdrawn. An elastic
gum catheter, if it can be passed, should here be preferred. A surgeon
should always be provided with catheters of various kinds, c|jameters,
lengths, and curves ; and one improvement, made by Sir Benjamin
Brodie, I consider entitled to commendation, namely, that of having the
handles of the wires of elastic catheters made large like the handle of a
staff; for thus we acquire a greater command over the instrument, and
can guide its beak with greater precision and delicacy. I approve also
of the wires being thicker than those in common use, and of the plan of
keeping some catheters prepared, so that they will retain their curvature
after the wire is taken out of them.
608 DISEASES OF THE GENITAL AND URINARY ORGANS.
The gum catheters which Sir Benjamin Brodie prefers, are mounted,
not on small flexible wires, but on strong iron stilets, having the curve
of a silver catheter. The stilets of the larger ones have flat iron handles
resembling those of common sounds. Gum catheters should be kept thus
prepared for a considerable time before they are used ; they will then
have the proper curvature. Sir Benjamin Brodie tries first to pass the
gum catheter without the stilet ; if he fails, he then tries the instru-
ment with the stilet. In the present disease, large catheters are more
easy of introduction than small ones ; and the stilets of elastic catheters
ought to be considerably curved. In passing them, it is now a common
plan to keep the handle, at first, close to the left groin, introduce them
as far as possible in this position, then bring the handle forwards nearly
to a right angle with the pubes, and the handle is then to be depressed
slowly and gently by placing one finger on it. When this is^done, the
point generally glides into the bladder, though sometimes this does not
happen till the stilet is withdrawn. In particular examples, it is necessary
to bend the point forward by means of a finger within the rectum, or on
the perinaeum.
If no catheter can be introduced, we must either puncture the bladder
above the pubes, or form a passage through the diseased mass of the
prostate. At the same time, I may observe, that we can almost always
succeed with a catheter, and that puncturing the bladder is rarely
called for.
STRICTURES OF THE URETHRA.
A stricture of the urethra may be defined to be such a contraction or
alteration of a part of the passage, that here it becomes considerably
narrower than what it is by nature, or even entirely obstructed. With
the subject of strictures, however, it is usual to consider several states of
the urethra : as first, the irritable urethra) as it is termed ; secondly,
spasmodic strictures; and, thirdly, permanent strictures. Respecting the
irritable urethra, I believe the term is rather employed for its convenience
than its precision ; and, generally, what is said upon this reputed irrita-
bility of the urethra, is vague and of little value. Frequent desire to
make water, and more or less uneasiness in passing it, are commonly
specified as symptoms of an irritable urethra: occasionally attended also
with a discharge. Now, these effects may result from so many various
causes, that really it is difficult to admit the propriety of taking them as
proofs of an irritable urethra. Any inflammation in the urethra will cause
the symptoms ; so will an incipient stricture in certain constitutions.
Now, nothing shows more clearly the unsettled notions, attached to
the subject of irritable urethra, than the widely opposite modes of treat-
ment adopted for its relief by different practitioners. Thus, some sur-
geons treat it by prescribing, three times a day, one eighth of a grain of
the bichloride of mercury, and 5J. of nitrous spirit of aether ; some, re-
ferring it to disorder of the digestive organs, prescribe the blue pill and
sarsaparilla ; some, viewing it as connected with the inflammatory state
of the canal, employ leeches to the perinaeum, and take blood from the
loins by cupping ; some, judging that it is the same thing as the alleged
spasmodic stricture, give hyoscyamus or compound powder of ipecacu-
anha ; while others, regarding it merely as too sensitive a state of the
passage, endeavour to blunt its extraordinary tenderness by the occasional
introduction of bougies.
The division of strictures into spasmodic and permanent is not satis-
STRICTURES OF THE URETHRA. 609
factory to all surgeons, some of whom have a difficulty in believing, that
the lining of the urethra is endued with muscularity. The observations
of John Hunter maintain the latter doctrine, in favour of which several
facts are usually adduced. Thus, a man, if otherwise healthy, voids his
urine one day in a full stream ; on the following day, he exposes himself
to damp and cold, or takes punch, or acidulous wine ; and next morning
he cannot void his urine ; but is relieved by going to bed, taking a dose
of compound powder of ipecacuanha, and, after having had the bowels
emptied by medicine, he passes his water as well as usual. Then the
effect of large bougies, or nitrate of silver, in enabling another patient to
make water in a considerable stream, is also adduced as an argument on
the same side of the question. The difficulty of passing water in such
cases comes on suddenly, and ceases suddenly ; the cause is temporary
— not a permanent disease. The canal of the urethra certainly varies in
its diameter at different periods, and cold appears to have great effect in
rendering it narrower. In practice, it has always appeared to me, that
bougies and other instruments will enter the urethra much more easily in
the same patient at some periods than others ; and that opium, hyoscyamus,
and other narcotics, often facilitate the passage of such instruments.
But then it is maintained that the resistance, when it occurs, is not an-
terior to that portion of the canal which may be conceived to be affected
by the action of muscles in the perinaeum. Abroad, the doctrine of the
muscularity of the membrane of the urethra, and of spasmodic strictures,
has gained, I believe, no advocates. There, the formation of strictures is
invariably ascribed to the effect of inflammation in thickening parts of the
canal ; and the same view is adopted'by Sir C. Bell and many other prac-
titioners in this country, who explain various circumstances, which have
been referred to spasm of the urethra itself, b}' the action of muscles in
its vicinity. A permanent stricture is attended with a conversion of the
contracted part of the lining of the urethra into a substance of the con-
sistence of ligament, but without its fibrous texture. The contracted
part has, it must be confessed, no resemblance to muscular tissue.
One of the earliest symptoms of a stricture is the retention of a few
drops of urine in the urethra after the patient has made water, which drops
soon escape, and slightly wet the linen ; while another small quantity, col-
lected between the neck of the bladder and the stricture, may be expelled
by pressure below the urethra. The next thing noticed is, that the pa-
tient cannot retain his water as long as usual, but is obliged to empty the
bladder once, twice, or oftener in the course of the night. As the dis-
ease increases the stream of urine becomes forked, spiral, or scattered ;
and in a still more advanced stage, the water is voided only by drops, or
altogether stopped, especially when the urethra is under the influence of
cold, irritation, or the effects of intemperance. In addition to these
symptoms, the patient has pain about the glans penis, and there is com-
monly a thin gleety discharge from the passage, a circumstance, which
often leads to the serious mistake of treating the case as if it wev merely
a gonorrhoaa or gleet.
In consequence of the natural sympathy between the urethra and tes-
ticles, one of the latter organs is liable to be attacked with inflammation,
more especially, however, during the use of bougies. Whether a stric-
ture be at first merely spasmodic, and capable of relaxation, as the Hun-
terian doctrines teach, is a disputed point ; but it is universally admitted
that, after a time, the part of the urethra, which is the seat of stricture,
is thickened, as well as contracted ; that the diminution of this portion of
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610 DISEASES OF THE GENITAL AND URINARY ORGANS.
the canal is not a temporary or periodical affection : in other words, that
the stricture is permanent.
In old and aggravated cases of stricture, the bladder usually becomes
considerably thickened, and does not admit of its usual degree of expan-
sion. Frequently it inflames, and pours out a viscid kind of secretion
like pus. And, when the obstruction in the urethra attains a certain
stage, ulceration takes place between the bladder and the first and prin-
cipal stricture ; abscesses form on the outside of the canal, and, bursting,
produce channels for the escape of the urine, called, on account of their
situation and their usual indisposition to heal, so long as the obstruction
in the urethra is not removed, fistula in perinceo.
Strictures in the urethra sometimes give rise to paroxysms of inter-
mittent fever. I have seen many examples of this fact, and, in some of
them, the ague had been treated without any suspicion having been en-
tertained of its real cause.
A stricture, when examined in the dead subject, is often found not to
occupy a great extent of the passage, the contraction being sometimes not
broader, than what would originate from a piece of packthread drawn
tight round the urethra. In some cases, however, a stricture does not
correspond to this description ; but the urethra is contracted along a con-
siderable portion of its course, in which event its inner surface is ex-
ceedingly irregular, and sometimes as indurated and tough as cartilage.
In particular instances, the contraction or diminution of the tube is only
on one side of it ; while, in others, it amounts to a complete circular
constriction of the passage.
The most frequent place for a stricture is just behind the bulb of the
urethra, or about six and a half or seven inches from the orifice, in the
anterior part of the membranous portion of the canal. Perhaps the situ-
ation, next in order of frequency, is about four and a half inches from the
extremity of the penis ; then three and a half; and sometimes close to
the opening in the glans. Strictures anterior to the bulb are less liable
to be influenced by spasm, if they can be so affected at all, than other
strictures placed more backward in the canal. It was the doctrine of
Sir Everard Home, that, in the generality of cases, where only one stric-
ture exists, it is just behind the bulb ; and that if others are found
more forward, we are almost sure of meeting with one in the former
situation.
In the advanced stages of stricture, there is frequently a remarkable
dilatation of the passage behind the stricture. In one case, under the
care of Sir Benjamin Brodie, whenever the patient attempted to make
water, a tumour, as large as an orange, was formed in the perineum.
When strictures have continued a long time, and increased to a certain
degree, the bladder is required to make greater efforts than natural to
expel the urine, and the result is a great thickening of its muscular coat.
The same change is commonly seen likewise in persons, whose discharge
of urine is not so free as it ought to be ; and who suffer occasional re-
tentions of it in consequence of the effects of disease of the prostate
gland, or the portion of the urethra pervading this body. In cases of
stricture, when the patient has repeatedly suffered from retention of urine,
it is no uncommon thing to find, after death, the ureters themselves
vastly dilated. I have known them to assume the appearance of two
glass tubes, three quarters of an inch in diameter, distended with trans-
parent urine.
Amongst the bad consequences of stricture, is the unfortunate and too
^ STRICTURES OF THE URETHRA. 611
often fatal occurrence of a rupture of the bladder or urethra, arising from
unrelieved retention of urine. The bladder itself sometimes gives way ;
but far more frequently a portion of the urethra behind the stricture ul-
cerates, or sloughs, and the urine becomes effused.
It is not an uncommon opinion, that strictures promote the origin and
increase of disease of the prostate gland. They certainly do so, inas-
much as inflammation and abscesses about it are concerned ; but I do not
believe that they have any share in bringing on the indolent enlargement
of that gland, so common in elderly persons. Bad strictures unquestion-
ably keep up a disposition to chronic inflammation of the mucous coat of
the bladder, and hence it may be thickened, as well as the muscular
fasciculi of the detrusor.
An irritable bladder is a frequent complication or effect of strictures.
Then another change, resulting from strictures, is the formation of sacs or
cysts in the bladder ; a sacculated state of this organ, which we know is
also a frequent complication of diseased prostate gland.
If strictures are suffered to reach a certain stage, abscesses form
about the neck of the bladder, the prostate gland, or in the perinaeum.
I have opened a good number of individuals, who died from the effects of
very bad strictures ; and, in a large proportion of these cases, I found not
only extensive abscesses in the cellular membrane of the pelvis, but
disease and suppuration in the kidneys.
In studying diseases in general, we should always make ourselves ac-
quainted, if possible, with their causes. Now, with regard to strictures
of the urethra, it is a common belief, that gonorrhrea is the most frequent
cause of them ; a view, however, that was rejected by John Hunter, on
the ground that most of the ducts and passages in the human body, lined
by mucous membrane, are subject to stricture. Then, another idea is,
that though gonorrhoea may not have this effect, the astringent injections,
employed for its cure, may bring on strictures. This is a point on which
the highest authorities differ. A long residence in the East or West
Indies, and the mode of life there pursued, give a disposition to strictures.
At all events, in the better classes of society, strictures are particularly
frequent among those individuals who have passed a considerable portion
of their lives in a tropical climate.
The treatment of permanent strictures is conducted on various prin-
ciples : —
1st. On the principle of mechanically dilating the contracted part of
the urethra with common bougies, catgut bougies, elastic gum bougies,
metallic instruments, or sounds, or elastic gum catheters retained in the
passage.
f 2d. On the principle of producing a destruction of the stricture by
making it ulcerate with the pressure of bougies or metallic instruments,
or slough from the effect of escharotic applications to it.
3d. On the principal of perforating the obstruction with a conical
sound ; a plan, however, only sanctioned in bad cases, not yielding to
milder methods.
4th. On the principle of piercing the stricture with a sharp instrument,
introduced down to it through a tube.
5th. By cutting down to the stricture, removing the obstruction
with a knife, and then introducing a catheter, and healing the wound
over it.
The Cure by Dilatation may be regarded as that which, on the whole,
retains the greatest share of approbation, though particular circumstances
R R 2
612 DISEASES OF THE GENITAL AND URINARY ORGANS.
may sometimes call for some of the other methods. The cure by dilatation
is accomplished by common bougies, flexible metallic bougies, and some-
times by means of steel sounds and silver catheters of various sizes. They
are all intended to act upon the principle of a wedge, and thus to dilate the
contracted part of the canal. However, the action of such instruments
is different from what it would be on inanimate matter; and the living
parts, pressed upon and distended by them, undergo certain changes,
which are the result of processes depending upon life. Thus, the parts
either adapt themselves to the pressure, or recede by ulceration.
Strong as the symptoms of stricture may be, which have been enume-
rated, we require a more unequivocal proof of its existence ; and we wish
also to know what part of the urethra is contracted, and in what degree.
For this purpose, we first carefully examine the urethra with a well-oiled
bougie of nearly full size ; for, if too small a one be employed, it may
pass through a moderate stricture without any stoppage, or it may de-
ceive us by its point becoming entangled in one of the lacunaa of the
mucous membrane. All bougies above a certain size should be cylindri-
cal,, or not too conical, which shape would immoderately distend the
orifice of the urethra. The stoppage of the instrument, together with
well-marked symptoms of impediment to the free escape of the urine,
may be regarded as a proof of stricture. If doubts exist, we should pass
a metallic sound, or silver catheter warmed, and try whether more posi-
tive information can thus be obtained.
Supposing a stricture to be ascertained, the next object is to get as
large a bougie through it as it will admit; but often only a small one will
pass ; and, if we can succeed thus far, we then know that the dilatation
of such stricture is in our power; for, after leaving this small bougie in
the passage a few minutes, we find the constricted part of the canal still
more capable of receiving this bougie again, or even another bougie of
rather larger size, on the next trial, which should be made in a day or
two. This is next to be withdrawn, and one of still larger size introduced.
In this manner, we proceed gradually from small to full-sized bougies,
with which the cure is to be completed.
With respect to the questions — how often a bougie should be intro-
duced, and how long kept in the stricture, there is no invariable rule to be
followed ; but much must depend upon the patient's capability of bearing
the bougie without too much irritation. With this qualification, 1 may
observe, that generally the bougie may be employed every other day,
and be worn for twenty minutes, half an hour, or an hour, if the patient
has favourable opportunities for it. The principle is to increase the size
of the bougie, as fast as the yielding of the stricture will allow.
Of late years, metallic bougies and conical sounds of different sizes and
curvatures, have been extensively employed. Sometimes they pass more
readily along the passage, with their point directed to either side ; an
advantage which does not belong to common flexible bougies. The latter
also, in consequence of their bending or cracking, are not so well calcu-
lated for those strictures, in which an instrument must be used with some
degree of force. To common and flexible metallic bougies we can give
any curvature deemed proper; but, with respect to steel and silver
sounds and catheters, they are always constructed with determinate
curves, adapted to the urethra? of different individuals.
The advantages of a waxen bougie are, that one of much smaller size,
than any metallic instrument, can be safely employed ; because metallic
instruments, if constructed of similar slenderness, would be liable to break,
STRICTURES OF THE URETHRA. 613
I scarcely need observe, that the minute diameter of some bougies is an
important advantage, when the stricture is close, and will not admit a
larger instrument.
Small sounds are usually made of silver; the large, of steel plated.
I believe it is best to have them but slightly curved, and not more than
eight or nine inches long. In using them, too much violence must not
be exerted, which would make a false passage ; and we shall more cer-
tainly avoid this risk, if we take care to make the beak glide along the
upper surface of the urethra. After having passed one of the sounds, we
may repeat the introduction of it again in two or three days. In many
cases it is best to begin with small bougies, and then to go on with sounds,
in the manner recommended by Sir Benjamin Brodie. The latter instru-
ments are frequently advantageous for old gristly strictures, and cases
complicated with a false passage.
It may be asked, to what size should we carry bougies, sounds, and
other instruments used for the removal of strictures ? In answer to this
question I may remark, that some practitioners gradually proceed to
bougies which are thicker than the little finger ; but I never follow their
example, finding that instruments of more moderate diameter answer every
purpose. Bougies act, as Mr. Hunter has observed, on the living parts,
constituting the obstruction or contraction : and these parts recede, or, in
other words, are absorbed under the application of the instrument, so as
not to require the passage to be distended in any extraordinary degree.
In common strictures, the most successful practice is conducted on the
principles of gentleness and skill ; and those surgeons, who employ great
force and rough manual proceedings, not only put the patient to a great
deal of unnecessary pain, but expose him to the danger of abscesses in
the perinaeum, profuse hemorrhages from the urethra, and the formation
of a false passage.
It is well known to all men of experience, that strictures of the urethra
are very liable to return : when, therefore, we have dilated the contracted
part or parts of the passage, so far as is considered advisable, we should
recommend the patient still to use a large bougie occasionally. In my
opinion, it is much better for a man to pass the instrument himself once
a fortnight, or once a month, for some considerable time after the end of
the treatment, than to run the risk of having a relapse.
The method of curing strictures with elastic gum catheters has been
preferred by several eminent surgeons abroad to all others as a general
one. If we resort to this method, and succeed in getting the catheter
through the stricture, it is a good rule to do what Sir Benjamin Brodie
recommends ; viz. to let the instrument be kept in the passage day and
night, for three or four days ; then taken out, and one of larger size
passed, and allowed to remain. This mode of treatment is deemed by
Sir Benjamin Brodie advantageous, 1. When the patient's time is of high
value ; because the stricture can thus be more quickly removed, than by
any other means. 2. Where the stricture is dense and cartilaginous.
3. Where the urethra is irregular, or a false passage has been made.
4. Where rigors follow the use of the common bougies: for it is an
observation made by Sir Benjamin Brodie, that such rigors are most dis-
posed to take place when the urine first comes in contact with a part of
the urethra that has just been dilated ; which contact is prevented by
the catheter, through which the bladder should always be emptied.
In very close strictures, we sometimes cannot succeed in getting any
bougie immediately through them. In this circumstance, we must either
R R 3
611- DISEASES OF THE GENITAL AND URINARY ORGANS.
endeavour to make way through them by exciting ulceration, — that is to
say, by pressing the end of the bougie with some force against the ob-
struction daily until the part ulcerates, — or try some of the other methods
to which 1 have alluded. Now, it was the difficulty of getting through
some strictures, which led to the employment of escharotics for their de-
struction. Another reason was also urged in favour of this practice,
namely, that it produced a radical cure ; whereas the treatment, on the
principle of dilatation, was alleged only to relieve the patient temporarily,
as the stricture generally returned some time after the discontinuance of
the bougie. I believe that, in this respect, one method is not better than
the other ; and, whether we use common or caustic bougies, the patient
will sometimes have a relapse.
So long ago as the time of Wiseman, red precipitate was conveyed on
the end of a bougie down to strictures; but it was not till the period of
John Hunter, that a more skilful way of applying caustic to them was
suggested. This was by passing a piece of the nitrate of silver through
a cannula, by means of a piece of wire down to the stricture. Afterwards
a still better method was introduced by Sir Everard Home, who caused
a portion of the nitrate of silver to be fixed within the extremity of a
common bougie ; which, thus completed, was called an armed bougie.
A full-sized common bougie is first introduced down to the stricture,
and a mark made with the finger-nail on the instrument close to the orifice
of the urethra. Thus we have the measure of the distance of the stricture
from that orifice. We withdraw this first bougie, and taking the armed
one, which should be of the same size as the common one previously
introduced, we make a mark upon it precisely at the same distance from
its point, as that already made on the bougie employed for the first mea-
surement of the distance of the stricture from the orifice of the urethra.
We then oil it, and pass it quickly along the urethra, until the arrival of
the mark at the orifice of the urethra denotes that the caustic has reached
the stricture. The caustic is then to be steadily applied for a minute or
two against the stricture, and the bougie immediately afterwards with-
drawn. This plan is followed up three or four times a week, and each
stricture attacked in succession, until the urethra is free.*
By some judicious and experienced surgeons it is still maintained, that
this treatment is advisable for spasmodic strictures, for old strictures with
spasm, and for peculiarly irritable strictures. The following objections,
however, are urged against the practice by others, viz. hemorrhage —
severe constitutional disturbance — the risk of making a false passage —
the bringing on of inflammation of the passage, and retention of urine —
swelled testicle, or abscess in the perinaeum.
The late Mr. Whately brought forward another mode of treating stric-
tures with caustic. In short, he boasted of the wonderful effects of minute
atoms of pure caustic potassa, weighing only one-seventeenth of a grain.
They were taken out of a bottle at the moment when they were wanted,
and pressed into a depression at the end of the bougie, and smeared over
with cerate. No doubt Mr. Whately cured strictures, but he did not cure
them in the way he supposed ; his bougie, armed with this soapy mixture
of fat and one-seventeenth of a grain of potash, would have no caustic
effect, but operated merely on the principles of pressure and dilatation,
* A superior contrivance for the lateral application of the nitrate of silver to stric-
tures was invented, a few years ago, by M. Ducamp : it can be procured of Weiss and
Son's, Strand.
STRICTURES OJF THE URETHRA. 615
For my own part, I ascribe much of the action of other armed bougies
to the same principles.
The employment of caustic has, for some time, been going gradually
out of fashion in this country ; and, in France, the practice was never
adopted to any great extent. Ordinary cases do not require armed
bougies ; and bad cartilaginous strictures, attended with induration, and
more or less extensive contraction and thickening of the mucous mem-
brane, are manifestly examples, which the nitrate of silver would never
relieve. At the same time, I believe, that where a stricture is peculiarly
irritable, such irritability may sometimes be more quickly removed with
the nitrate of silver bougie, than any other instrument.
Now, what is to be done where all common plans completely fail ?
Ought we to cut down to the stricture, after having passed an instrument
into the urethra, as far as the commencement of the obstruction, endea-
vouring next to cut through the diseased portion of the passage, so as to
find the continuation of it between the stricture and the bladder, and
then to convey the catheter into that organ ? I have seen this operation
sometimes done with success ; but more frequently the operator failed to
find the continuation of the urethra. The difficulty proceeds from the
great change and thickening of the urethra ; and not only of that canal
itself, but of the cellular membrane and more external parts. We have
to cut into a mass likely to cause much perplexity. At the same time,
the point of the staff, or catheter, is an important guide ; and it is to be
remembered, that, in the generality of these cases, the membranous portion
of the urethra behind the stricture is considerably dilated ; a circumstance
that ought to facilitate the detection of it. I believe the danger of the
operation is overrated, though not its occasional difficulty and frequent
failure.
Then another method consists in perforating the stricture with a stilet,
adapted to a kind of catheter, or tube, out of which it is made to project
after the instrument has been passed down to the stricture ; an old prac-
tice, revived in modern times. In 1795 it was introduced again by Dr.
Physic, of the United States, who found it very successful. Of late years
it has been practised in England by Mr. Stafford and others. The objec-
tions, commonly urged against this method, are the risk of hemorrhage, and
the chance of not making the perforation in the right direction. But, in
obstinate cases, some risks must, I believe, be encountered ; and this will
happen whether we cut down to a cartilaginous stricture, perforate it
through a cannula, or force a conical sound through it. Mr. Stafford's
cases, many of which he has published, seem to prove, that the danger of
bleeding has been exaggerated. With regard to the forcible passage of
a conical sound through the stricture under urgent circumstances, I en-
tertain an unfavourable opinion of the practice, and should be exceedingly
reluctant to adopt so uncouth and unscientific a method, which must
always be attended with great danger of producing a false passage.
A false passage, as it is termed, is one caused by the laceration of the
mucous membrane of the urethra by the forcible and unskilfur'introduc-
tion of a bougie, sound, or catheter in a wrong direction. One conse-
quence of such an injury is, that when an instrument is afterwards intro-
duced, the end of it goes into the new passage, and cannot be made to act
upon the stricture, or find its way into the bladder. It scarcely admits of
a doubt, I think, that a false passage is sometimes made, and heals up
without any inconvenience, except a degree of hemorrhage at the time
of the accident. Indeed, if we were to suspect the occurrence directly
R R 4?
616 DISEASES OF THE GENITAL AND URINARY ORGANS.
after it had happened, we should, perhaps, give the patient the best
chance of the laceration healing up without trouble, by directing him to
retain his water a few hours, and then to pass a catheter of larger size,
and more curved, than that which produced the false passage, so that its
beak might be kept close against the upper surface of the urethra. I
suspect, with Sir Benjamin Brodie, that a false passage is generally made
by letting the end of the instrument press too much against the lower
surface of the membranous portion of the urethra ; though the forcible
propulsion of this part of the canal to one side or the other may lead to
similar mischief. However, by endeavouring to make the beak of the
catheter glide along the upper surface of the passage, we elude the lacuna
magna, the sinus of the bulb, the orifices of the prostatic ducts and the
sinus pocularis ; all points in which the end of the instrument may be
entangled, and all situated on the lower surface of the canal.
When a false passage had been produced in the treatment of a stricture,
Mr. Hunter used to introduce a staff as far as it would go, which he cal-
culated would generally be to the bottom of the new passage, and of
course beyond the stricture. The end of the instrument was then felt
for outwardly, and cut upon. The new passage was next slit open to its
junction with the urethra, at a point beyond the stricture ; a probe or
director was now passed in the direction towards the glans penis, and
necessarily towards the stricture. On its further introduction being im-
peded by the stricture itself, this was cut through ; and the operation was
finished by withdrawing the probe, and introducing two cannulse, one
through the wound, and the other through the urethra, until they came
together, when they were held securely, a perforatar pushed through
them, so as to divide the obstruction, and then a bougie, after which the
tubes were removed. The operation is now simplified by passing a ca-
theter directly the stricture is divided, which part of the operation can
also be now more conveniently done with Mr. Stafford's instrument.
Sometimes profuse hemorrhage follows the introduction of bougies or
catheters ; in such cases, the effect of cold lotions on the perinaeum, or,
what is still better, the cold bath itself, may be tried. If the patient be a
strong, robust subject, we may also have recourse to venesection. In one
instance, under the care of Sir Astley Cooper, the hemorrhage was so
profuse, that it was judged necessary to divide the artery of the bulb ; a
measure which had the desired effect.
Fistula in Perinceo are ulcerated openings in the perinaeum, which are
not unfrequently formed in examples of bad strictures, as outlets for the
urine, the urethra ulcerating behind the obstruction. When they are
about to form, the patient generally experiences an increased difficulty of
making water ; perhaps he is attacked with shivering, followed by other
febrile indisposition, and then considerable tenderness begins to be felt in
the perinaeum, — a hard tumour, with some degree of cedema, presenting
itself in that part, or its vicinity. The skin next inflames, and a fluctua-
tion is felt. The abscess bursts, or is opened, and fetid pus discharged,
sometimes blended with urine from the first, and, in other instances,
no urine coming out of the aperture till two or three days have elapsed.
The discharge of pus then diminishes ; but the urine flows out of the
new passage in larger quantities, and whenever the patient makes water,
a part of it escapes through the natural channel, and the rest through
the orifice of the abscess. Sometimes instead of one, there are several
external openings produced.
In consequence of the urine continuing to flow through the cavity of
RETENTION OF URINE. 617
the abscess, the track of the purulent matter becomes lined with a texture
closely resembling that of mucous membrane, and the adjoining parts
assume a hard and callous consistence. Fistulae of the same nature may
form in the scrotum, in the groin, or even on the penis near the pubes.
When fistulee in perinaeo are established, the patient is no longer liable to
attacks of retention of urine. Some time ago, I had a patient in the
Queen's Bench Infirmary who was in a curious state ; for, in consequence
of the whole of his urine having passed for several years through fistulse
in the perineum, all the urethra anterior to their communication with it
appeared to have been completely obliterated.
Jn a few cases, urinary fistulae form a communication between the
rectum and the portion of the urethra behind the stricture ; a complica-
tion, the possibility of which ought to be recollected. I may lay it down
as a general principle, that abcesses in the perinseum, or near the pro-
state and neck of the bladder, should be opened early. The cure of
fistulae in perinseo must obviously depend upon that of the strictures them-
selves ; for, in proportion as these give way, the urine resumes its natural
course, and the fistulous openings heal. If they should not do so, how-
ever, we may pass a gum catheter into the bladder, and confine the patient
for a few days to bed. Sometimes, however, when the communication
with the urethra is unusually large ; or when the urine flows too freely by
the side of the urethra ; or when the catheter excites a great deal of
suppuration in the passage ; the foregoing plan will not answer. Under
these circumstances, let the patient be taught to pass the catheter him-
self, and let him for some time never make water without having first
introduced it, as advised by Sir Benjamin Brodie. We should also do
another thing which he particularly recommends, namely, stimulate the
bottom of the fistula with nitrate of silver, while we retard the healing
of its orifice by touching it once a week, or once a fortnight, with the
potassa fusa.
RETENTION OF URINE
Should not be confounded with svppression, which properly means an
interruption of the secretion of that fluid, none being discharged, because
little or none is formed by the kidneys. Examples of the latter disorder
were commonly noticed in the late epidemic cholera.
In retention, the urine is poured into the bladder by the ureters, but,
either owing to the want of power in the bladder, or to an obstruction in
the urethra, it is not properly discharged. Of course, there is a disten-
sion of the bladder — very perceptible in the hypogastric region, — the
swelling, indeed, often reaching as high as the navel ; attended with a
distinct fluctuation that can be felt through the parietes of the abdomen,
as well as within the rectum. The patient suffers great torture ; there is
a hot, dry skin ; thirst ; an accelerated pulse ; and other marks of febrile
disturbance.
The bladder often continues distended with urine, notwithstanding, the
patient may void it at periods in a stream, and even pass, in trfe twenty-
four hours, the quantity usually discharged by a person in health. But,
then, he discharges merely the overflowings of the bladder, as it were ;
and though the water may dribble away, or even occasionally flow out in
a stream, that receptacle is never truly emptied, but remains with an ac-
mulation of urine. This is the retention par regorgement, as it is termed by
French surgeons. In cases of this description, serious mistakes are apt
to be made in practice. A certain quantity of urine is discharged from
618 DISEASES OF THE GENITAL AND URINARY ORGANS.
time to time; a retention is not suspected; and the patient, of course,
does not receive the benefit of proper treatment. All surgeons, there-
fore, should remember well these retentions par regorgement, and, in
doubtful cases, examine the hypogastric region, and introduce a cathe-
ter. This last proceeding can never do harm ; it is fraught with no
peril, not even with severity ; and I can affirm, from repeated observ-
ation, that it will often be the means, and the only means, of saving the
patient's life.
The division of retentions of urine into complete and incomplete, or total
and partial) appears to me truly practical — a valuable and well-founded
distinction, well calculated to put us upon our guard against taking a
wrong view of particular cases. I believe, that if we examine the hypo-
gastric region, and connect the fulness perceptible in that situation with
other symptoms, we shall rarely be deceived, whether the patient dis-
charge a part of his urine or not. If corpulency should conceal the hard
circumscribed swelling of the bladder, so manifest in thinner persons, we
ought of course to follow the manifestly prudent rule, which I have laid
down for doubtful cases, and immediately pass a catheter. In fat sub-
jects, I would also recommend the introduction of a finger into the rec-
tum, where we may plainly feel the prominence of the distended bladder,
and also a fluctuation, if, while the finger is applied to the prominence
within the rectum, we tap briskly on the hypogastric region with the
fingers of the other hand. This method, I should say, is particularly
useful when the bladder is so thickened and contracted, that it does not
rise above the pubes.
I constantly inculcate the maxim of letting the treatment of diseases
be always guided, as much as possible, by the consideration of their par-
ticular causes, the removal of which must of course be a principal object
in view. Now, retention of urine may depend upon a variety of causes,
the nature of which entirely influences the prognosis and treatment ; nor
is it possible to form any just opinions, with regard to the treatment of
this urgent disorder, without a constant recollection of the different cir-
cumstances concerned in its production.
The general indications are, first, to bring about, if possible, the dis-
charge of urine through the natural passage ; which object is sometimes
accomplished by means of the warm bath, fomentations applied to the
hypogastric region and perinaeum, bleeding, opium, hyoscyamus, &c., and
sometimes by the removal of mechanical obstacles to the flow of urine ;
but still more frequently by the skilful use of catheters. 2dly, When
all these means fail, it becomes necessary to have recourse to some ope-
ration by which an outlet is made for the urine.
CATHETERS.
Some are of course designed for the male urethra, and others for the
meatus urinarius. Another general division of them is into flexible and
inflexible ones. The former, or elastic gum catheters, as they are usually
named, are now brought to great perfection, being made of many different
sizes, to each of which a number is assigned. Some of them are of such
a construction, that they will retain their curvature permanently; while
another advantage is their being composed of materials calculated to re-
sist, for a long while, the warmth and moisture of the urethra. It is only
the best sorts, however, that are superior in this respect. They are pro-
vided with stilets and wires, which give them the requisite degree of
firmness, and the particular curvature needed at the period when they
RETENTION OF UK1NE. 619
are about to be introduced into the urethra. Those employed by Sir
Benjamin Brodie are furnished with firm iron stilets, and flat, broad
handles like those of common sounds, by which means the surgeon ac-
quires a greater command over the direction and management of the beak.
Elastic gum catheters are frequently the only means by which the lives
of patients, labouring under retention of urine from different causes, can
be saved ; and they render this important service by accommodating
themselves to the displaced and contracted state of the urethra, and
admitting of being passed through a very small channel. While those
of diminutive diameter are frequently the most advantageous for stric-
tures, the larger ones answer best for the retention of urine arising from
disease of the prostate gland. Generally speaking, when other circum-
stances are not opposed to it, a large catheter is preferable to one of
small size, as it distends the parietes of the urethra, and is much Jess
likely to be obstructed by any of the irregularities, which the internal
surface of the canal presents at different points of it.* Elastic gum
catheters may be introduced either with or without the stilet, or, when
partly introduced, their curvature may be suddenly increased by with-
drawing the stilet at the same time that they are pushed further into the
passage. All instruments about to be introduced into the urethra, should
be smeared with sweet oil or lard.
Inflexible or silver catheters are introduced in the same way as a sound
or staff, either with the convexity at first towards the pubes, succeeded
by the tour de maitre, or with the concavity of the instrument always up-
wards, that is to say, towards the pubes, or else with the handle kept in
the first instance inclined towards the patient's left groin ; a plan which
Sir Benjamin Brodie follows, and which I often find advantageous,
Whichever mode is followed, the catheter gets into the same position
after its beak has reached the perinaeum, and the tour de maitre has been
practised in the first manner of proceeding. We have now to direct its
beak through that point of the urethra encircled by the margin of the
opening in the deep perineal fascia ; and, as soon as this is cleared, we
should bring the handle of the catheter gently forwards and downwards,
by which manoeuvre the beak will be made to ascend through the mem-
branous and prostatic portions of the urethra into the bladder. In this
part of the operation, we should particularly aim at keeping the beak of
the catheter against the upper surface of the urethra, so as to avoid
the risk of making a false passage. If the instrument were forcibly and
rudely pushed towards the bladder, without its handle being depressed
at the proper moment, the canal would certainly be ruptured.
Sometimes the catheter is passed while the patient is standing with his
back against a bedpost or the wall. If he be in bed, he should lie evenly,
with his knees somewhat raised and separated. Mr. Morton's description
of the mode of introducing the catheter is perfectly correct. " The
operator, standing upon the left side of the bed, takes hold of the penis
with the thumb and fore finger of the left hand, and raises it gently, so
as to efface the curve, or angle, which the penis forms, where it bends
down in front of the scrotum. Holding the catheter in his right hand,
lightly poised between the thumb and two first fingers, the surgeon in-
troduces its point into the orifice of the urethra, and continues to pass
the instrument onwards, until the point reaches the bulb, which is about
an inch below the arch of the pubes. During this time, the concavity of
* See Th. Morton, on the Surgical Anatomy of the Perinseum, p. 62. 8vo. Lond. 1838.
620 DISEASES OF THE GENITAL AND URINARY ORGANS.
the catheter is directed towards the symphysis pubis, while the straight
portion is held parallel with the front of the abdomen. The point of the
catheter having reached the bulb, the position of its handle is now to
be changed from the horizontal direction, in which it has hitherto been
held, until it has been brought into a perpendicular position, and thus
forms a right angle with the axis of the patient's body. This movement
of the handle of the catheter will cause its point to rise out of the sinus
of the bulb, after which it may be safely pushed onwards through the
opening in the triangular ligament, and thus enter the membranous
portion of the canal. By gradually depressing at this time the handle of
the catheter, a little more between the thighs of the patient, it will glide
smoothly onwards through the remaining portion of the urethra into the
bladder!" *
The same well-informed surgeon delivers the following valuable re-
marks on this subject : — " The natural obstacles, which most frequently
oppose themselves to the passage of the catheter are, first, the lacunas
of the urethra, and the sinus of the bulb ; after which comes the opening
in the triangular ligament. When these are passed, the anterior border
of the prostate gland, the orifices of its ducts, and the sinus pocularis,
may all serve to obstruct the introduction of a small catheter by en-
tangling its point ; and, lastly, the elevated ridge, which marks the
commencement of the neck of the bladder. It will be observed, that
all these natural obstacles to the easy introduction of a catheter are
situated upon the inferior surface of the urethra, and therefore they
will be best avoided by keeping the point of the catheter gently directed
against its superior wall. The margins of the opening in the trian-
gular ligament will not give any trouble, if the situation of the circular
aperture that transmits the urethra is accurately understood : it is
nearly one inch below the arch of the pubes, and equidistant from the
descending branches of the same bones. When the point of the catheter
is arrested in either the membranous or the prostatic portions of the
urethra, it will be found of considerable advantage to introduce the left
forefinger into the rectum, which will frequently enable the operator to
distinguish the situation, as likewise the cause of the difficulty, and also
to direct the instrument with greater certainty into the bladder." Mr.
Morton very properly cautions surgeons against grasping the catheter
too firmly, instead of holding it lightly, like a pen ; and explains, that if
the end of the catheter be kept too strictly against the upper side of the
urethra, it will be stopped by the superior margin of the opening in the
triangular ligament, or, if it pass that, by the edge of the prostate gland.
W7omen are much less subject than the male sex to retention of urine,
the meatus urinarius being short and capacious ; not liable to stricture ;
nor to those consequences, which originate in the other sex from disease
of the prostate gland, and from abscesses situated near, and pressing
upon, the urethra.f Neither does the inflammation, accompanying severe
gonorrhoea in females, lead, as it frequently does in men, to retention of
urine. Yet women are now and then afflicted with retention of urine,
from causes very different from those which bring it on in the male sex.
Polypi of the uterus, or vagina, ovarial dropsy, cancer uteri, displace-
ments of the womb, especially that termed retroversion, and inflamma-
tion about the neck of the bladder after parturition, are the usual causes
of the disorder in women.
* See Morton's Surgical Anatomy of the Perinanim, p. G2.
•\ I have known, however, great difficulty of voiding the urine, and severe pain, arise
from an abscess of one of the lacunas of the meatus urinarius.
RETENTION OF URINE. 621
The catheter for females is shorter than that for the male subject, and
has but a slight curve. It should be passed without subjecting the patient
to exposure : we should hold the catheter in the right hand, and pass the
left forefinger between the nymphse, and on the smooth surface between
them, about three quarters of an inch below the clitoris, we shall readily
feel the papilla denoting the orifice of the meatus urinarius, into which
we are to direct the instrument upwards with its concavity kept forwards.
Here we have none of the difficulties which are met with in the male
sex from the length and curvature of the passage, the resistance of the
deep perineal fascia, the yielding of the membranous part of the urethra,
the impediment formed by the prostate gland, the hitching of the end of
a small catheter in the orifice of an enlarged prostatic duct, or in the
sinus pocularis of the verumontanum, the stoppage of the beak of the
instrument in the sinus of the bulb, or by spasm of muscles in the
perinaeum.
Men advanced in years are particularly liable to retention of urine.
This is partly explained by their being remarkably subject to disease of
the prostate gland, and partly by the bladder, after a certain period of
life, losing some of its irritability and contractile power, so that it no
longer retains the capability \ of lessening its cavity beyond a certain
point. Hence the expulsion of urine in old persons is never complete, a
portion of it always remaining in the bladder after each evacuation. At
length, the infirmity increasing, the quantity of urine voided each time
lessens ; the desire to empty the bladder becomes more and more frequent ;
and, in the end, the urine only comes away by drops, or in a dribbling
stream.
In this state, the sufferings are not very great ; the tumour, formed by
the bladder above the pubes, is indolent, and, if compressed, a certain
quantity of urine will sometimes flow out of the urethra. In short, this
is a case of incomplete retention ; frequently as much urine being dis-
charged in the twenty-four hours as is natural, but the bladder is never
emptied. However, the symptoms are generally less urgent than in other
examples ; because this form of the complaint does not, like others, lead
to a positive interruption or total suppression of the urinary secretion, nor
to a rupture of the bladder.
The weakened state of the bladder from age can never be removed ;
but when there is a greater tendency than usual to an accumulation of
water, the use of the catheter should never be omitted, as it will afford
immediate relief to the patient's uneasiness, and also prevent that degree
of distension, which would terminate in incurable disease and total
paralysis of the bladder, if not in a rupture of it, and fatal effusion of
urine.
Retention of urine often proceeds from injuries and diseases of the spine
and pelvis, by which the bladder is rendered paralytic ; cases remark-
able, on account of the strongly ammoniacal quality of the urine soon
produced under such circumstances, and the propensity in the coa^s of the
bladder to become softened and ulcerated. In such cases, the treatment
should consist in the regular use of the catheter, in cupping the injured
part of the back, or bleeding the patient in the early stage of the case,
followed up by purgatives and counter-irritation, as blisters, the moxa, or
an issue. Fractures of the spine or pelvis, however, would call for par-
ticular treatment, one essential thing in which would be to keep the in-
jured bones as quiet as possible.
Another retention of urine, accompanied also by a paralytic state of the
622 DISEASES OF THE GENITAL AND URINARY ORGANS.
bladder, does not depend upon any injury of the spine or pelvis, but alto-
gether upon the detrusor urinse muscle having suffered long and immo-
derate distension, in consequence of a previous accumulation of urine in
the bladder from some other cause. Here, whatever benefit can be
rendered, must be derived from the catheter, tonics, cold bathing, the
exhibition of the tincture of cantharides, or the tinctura ferri sesqui-
chloridi, and the application of blisters to the region of the sacrum.
Retention of urine from inflammation in or near the urethra is often
exemplified in severe gonorrhoea, and in acute inflammations about the
prostate gland and lower portion of the rectum. In all probability, when
some practitioners describe a retention of urine, as arising from spasm or
irritation, they would be speaking more correctly if they were to refer
the disorder principally to the effect of inflammation somewhere about
the urethra or the neck of the bladder.
When retention of urine proceeds from inflammation in the urethra or
neighbouring parts, we should first try the effect of soothing antiphlo-
gistic treatment, antimonial purgative medicines, bleeding, leeches to the
perinseum, the warm bath, fomentations on the hypogastric region, and
the effect of hyosciamus or acetate of morphia. If these means prove
unavailing, the use of the catheter is not to be deferred.
Retention of urine is sometimes caused by the pressure of collections of
matter on the urethra. Here the first indication is to discharge the
abscess, and draw off the urine. Afterwards, with the assistance of
antiphlogistic treatment, hyoscyamus, or opium, and the warm bath, or
fomentations, the patient will soon begin to be able to discharge his
water himself. I once visited a case with Mr. Holt, which was attended
with a complete and obstinate retention of urine, arising from the
pressure of an extraordinary mass of coagulable lymph effused in the
corpus spongiosum, about two inches from the orifice of the urethra.
The original complaint was a virulent gonorrhrea, accompanied by chordee.
Here bleeding, the warm bath, narcotics, the tinctura ferri sesqui-chloridi,
and leeches to the perinseum, did not supersede the necessity for the
catheter.
Another retention arises from fungous and carcinomatous diseases of the
bladder. Cancer is sometimes propagated to the bladder from the rectum
or uterus. Here the treatment can only be palliative, and the catheter
is not to be neglected.
Amongst the varieties of retention is that depending upon foreign bodies
in the bladder, whether hydatids, coagulated blood, worms, or calculi,
which may obstruct the passage of urine from the bladder into the
urethra, or through the latter tube. Here the cure depends upon the
removal of the substances causing the obstruction. Worms, hydatids,
and coagulated blood would require the bladder to be washed out with
a syringe and catheter of the largest size. In cases of worms in the
bladder, turpentine has great power in promoting their discharge ; and,
what is remarkable, gets into the bladder, in a few seconds after it is
swallowed.* Calculi, either in the urethra or bladder, not above a certain
* Mr. Law, of Penrith, Cumberland, was kind enough to send me some specimens
of what were supposed to be taenize, voided from the bladder of a young woman under
his care; but, if Mr. Owen's report be correct, the patient must be guilty of deception,
as the specimens, which I presented to the College of Surgeons, were found by him only
to be imitations of taniiae, made from the intestines of some small bird. From a kind
of monomania, she seems to have introduced some thousands of pieces of these sham
taenice into her bladder.
RETENTION OF URINE. 623
size, may be removed with the urethral forceps, sometimes without an
incision in this canal, sometimes with it.
In children, one kind of retention is produced by the diminutive size of
the orifice of the prepuce, or a congenital phymosis, as it is termed. In
such a case, the prepuce is sometimes distended by the urine into a large
pouch, from which it escapes slowly and difficultly. Instances of urgent
danger from such a cause are given by Petit.
In retention of urine from stricture in the urethra, a difference of
opinion exists about the right principle of treatment. Many surgeons
begin with an antiphlogistic soothing plan, and try the effect of the warm
bath, bleeding, leeches, aperient medicines, or opium, given by the mouth
or in clysters. This plan may be the best, if the retention is quite
recent, and the patient is not in much agony. In the opposite case, it
is proper to resort to the catheter at once. Thus, instead of the method
adverted to, Sir Benjamin Brodie takes one of the smallest gum catheters,
which has been kept for a considerable time on a curved iron wire, and
which consequently will retain its curved form after the wire is with-
drawn. He introduces it without the wire, and keeps the concavity of
the catheter towards the pubes, elongating the penis at the same time.
The instrument will then be likely to pass the stricture and enter the
bladder, the urine to flow out in a fine stream, and the patient to be
instantly relieved.
If this plan fail, we may try a small catgut bougie. We are to intro-
duce it as far as we can, and then elongate the urethra by drawing the
penis forwards, when the bougie will often pass. Certainly, as Sir Benja-
min Brodie has justly observed, it is not always necessary that it should
pass into the bladder ; if it enter the stricture, that is sufficient, — we
should then let it remain there, until a violent effort to make water occurs,
when it is to be taken out, and the urine will frequently follow it.
If this expedient should not answer, we may take another small cat-
gut bougie, and bend its point upwards before it is introduced, by which
means we shall be enabled to keep its point against the upper surface of
the urethra, and to avoid the lower, where the obstruction is mostly, if
not always, the greatest.
When a catgut bougie will not succeed, a silver or an elastic gum
catheter t mounted on a firm iron stilet, will sometimes pass. When the
stricture is recent, the catheter should be of nearly the full size of the
urethra ; but, if the stricture is of long standing, the instrument should
be considerably smaller. Sir Benjamin Brodie prefers one that is shorter
and less curved than usual ; and if it is made of silver, he advises the
tube to be fixed in a wooden handle, which will enable us to direct its
point more delicately and with greater effect. If we use an elastic gum
catheter, the iron stilet should have a handle, like that of a common
sound. The rules and advice, given by Sir Benjamin Brodie on these
matters, appear to me particularly valuable. We are to pass the instru-
ment as far as the obstruction, and then, having withdrawn it fpr about
half an inch, we are to pass it on again towards the bladder, keeping the
point against the upper part of the urethra. No violence is to be em-
ployed ; for, if we tear the urethra, we cannot succeed. I recommend
steady and moderate pressure against the stricture, to be maintained for
a little while, and then perhaps the obstruction will begin to relax or
yield, and the instrument enter it. If a gum catheter has been used, we
should leave it in the urethra for a day or two, which will have a great
effect in curing the stricture. Even if we do not succeed in getting an
DISEASES OF THE GENITAL AND URINARY ORGANS.
instrument into the bladder, the pressure employed may still do good, by
bringing about a relaxation or yielding of the stricture, and on the in-
strument being withdrawn, a stream of urine may follow it. Experience
confirms the frequency of such occurrences, and, if they can be brought
about, the patient is extricated from an urgent state of danger, as well
as from the torture to which a retention of urine from this cause neces-
sarily subjects him.
Now, supposing we were not able, in a case of complete retention of
urine, to relieve the patient by the catheter, and he were strong and
full of blood, he may, in the first instance, be bled, and put into the
warm bath, and then the catheter tried again ; or, what is still more
applicable to all cases, an enema should be injected, composed of 5j. of
tincture of opium, and ^ij. of mucilage of starch, or gruel — not more, as
it would not be retained. As soon as the influence of the opium begins
to be felt, if the hypogastric region be kept well fomented, sometimes the
urine will begin to flow, and, at all events, there will now be a greater
chance of success with the catheter.
If all the measures specified were to fail, and the bladder were to
continue distended beyond a certain time, either that organ, or a
portion of the urethra behind the obstruction in it would give way, and
the urine be extravasated in the cellular tissue of the perinaeum and
scrotum. Thus either a rapid and fatal inflammation, involving the
peritoneum, would be excited, or more or less extensive abscesses and
gangrene of the cellular tissue of the scrotum, perinaeum, and interior
of the pelvis be the consequences. In such unfortunate cases, the
urine does not gravitate to the thigh or nates, but spreads over the
scrotum, penis, the groins, and even higher up towards the navel and
loins. The reason why it does not pass towards the nates is, that it is
stopped by the connection of the deep perineal fascia, with the super-
ficial, and the rami of the ischium and ossa pubis. When the urethra
gives way, there is generally at first a small induration in the perinaeum,
which is sometimes rapidly converted into a dark, livid, extensive, and
quickly spreading tumour of the scrotum, groins, and parts in the
perinaeum. Nay, sometimes the effusion of urine ascends, as I have said,
far above Poupart's ligament. Now, wherever the urine passes, it is sure
to produce suppuration or gangrene, and sometimes the whole scrotum
sloughs away, leaving the testes hanging by the spermatic cords, totally
destitute of their natural coverings. The only way of preventing such
evils, — I mean those of effusion of urine, — is to procure, in some way or
another, an outlet for the urine from the bladder previous to its rupture,
or that of the urethra.
In stricture, this may frequently be accomplished by making an incision
in the membranous portion of the urethra behind the stricture, which part
of the canal is generally dilated into a sort of tumour, by being distended
with the urine, forced thus far by the bladder.
In diseases of the prostate gland, attended with urgent circumstances,
we must either convey the catheter into the bladder, through the tumour,
by a combination of skill and well-directed force, or puncture the bladder
above the pubes ; which last proceeding, however, is rarely necessary.
I had occasion, however, to adopt it in one instance in University College
Hospital, as will be mentioned more particularly when the methods of
puncturing the bladder are described.
But, if urine be already effused, the surgeon must never forget to make
free and deep incisions for its escape ; and, if possible, a catheter should
INCONTINENCE OF URINE. 625
be introduced, so that the urine may have a ready outlet, and no more of
it pass into the cellular tissue.
INCONTINENCE OF URINE.
An inability to retain the urine in the bladder is of three kinds : in
one, the water continually dribbles away, without any inclination to void
it, or any sensation of its being voided. In other instances, the patient
can hold his urine in a certain degree; but the propensity to evacuate
it comes on so frequently, suddenly, and irresistibly, that he is compelled
to discharge it. The third kind of incontinence only occurs when the
patient is asleep.
The first case depends on a weakness, or total paralysis, of the sphinc-
ter muscle of the bladder. As the neck of this organ is constantly open,
every drop of urine escapes into the urethra, immediately it has de-
scended from the ureters, and does not lodge in the bladder at all.
Sometimes the weakness, or paralysis, of the sphincter is quite a local
disorder; but, most frequently, it is symptomatic of some other affection.
In the first case, it is often the consequence of a difficult labour, in which
the neck of the bladder has been a long while compressed ; or of the
formation of fistulous communications between the vagina and the bladder.
Sometimes, incontinence of urine depends on a malformation of the
urinary passages, and exists from the time of birth. The complaint is
often an effect of apoplexy, injuries and diseases of the spine, &c.
It is not dangerous, though exceedingly annoying, in consequence of
its continually wetting the clothes, causing a disagreeable smell, and
even excoriating the parts over which the urine flows.
When the complaint is local, tonics and astringents are indicated ;
and the principal remedies are, cold bathing, bark, blistering the sacrum
or perinaeum, the tinctura cantharidum, the shower-bath, electricity, and
rubbing the spine and sacrum with stimulating liniments.
When incontinence of urine is merely the effect of another disorder,
the latter claims the principal attention.
The second species of incontinence of urine is of a spasmodic nature,
and commonly depends on some irritation operating on the bladder.
Hence, the indication is to find out the irritation, and if possible to
remove it. Hemorrhoidal complaints, suppressed menses, a stone in the
bladder, a fistula in ano, &c., may cause the affection. When the parti-
cular irritation cannot be discovered, general soothing and antispasmodic
remedies, such as bleeding, opium, the warm bath, fomentations, &c.,
should be prescribed. The uva ursi is sometimes useful, of which a
scruple, or half a drachm, may be given three times a day.
This kind of incontinence of urine is frequently only a symptom of
epilepsy, or hysteria. Sometimes it originates from pressure made upon
the bladder ; and hence, it may be a symptom of polypi of the uterus, a
prolapsus of this viscus, or difficult parturition.*
9
* Retention of urine, from paralysis of the bladder, is a case attended with an invo-
luntary dribbling away of this fluid, if the catheter be not properly employed, and is a
disorder that has frequently been mistaken for an incontinence of urine. As soon as
the bladder is distended to a certain degree, the urethra being unobstructed, the con-
tinued secretion from the kidneys, instead of causing the bladder to give way, passes off
through the natural channel. The discharge of urine leads the unwary surgeon never
to suspect the real nature of the disease ; but if a catheter chance to be introduced, the
quantity of urine drawn off immediately throws light upon the true character of the
disorder.
S S
626 DISEASES OF THE GENITAL AND URINARY ORGANS.
The last case is. that, in which the urine is involuntarily discharged in
the night-time, when the patient is asleep. The infirmity is mostly met
with in young boys and girls ; and, for the most part, spontaneously goes
off as they approach the adult state. They should avoid drinking any fluid
just before going to bed, and empty the bladder before they go to sleep.
When, in adult persons, the complaint does not yield to the above pre-
cautions, one fourth of a grain of the powder of cantharides, given with
milk of almonds, every evening, has been known to be of service. The
effect of exhibiting a grain of opium, or two grains of ipecacuanha, every
night, a little before bedtime, may also be tried. The best apparatus for
catching the urine, where no cure can be accomplished, which I have ever
seen, consists of a long tube, made of elastic gum, or other flexible water-
proof material, and capable of holding about a pint and a half of fluid. It
causes little inconvenience, and, as it is so narrow as to be concealed by
the trowsers, it occasions no disfigurement.
There is a particular incontinence of urine, arising from the formation
of a preternatural communication between the bladder and vagina. It is
usually the consequence of a slough, and sometimes follows difficult la-
bours. The continual dribbling of the urine through the opening, gene-
rally prevents it from healing ; but by making the patient lie a good deal
on her abdomen, the water is hindered from constantly escaping, and the
aperture will sometimes heal. The fistulous opening may occasionally be
made to heal up, by scarifying its edges, and keeping them afterwards in
contact with the twisted suture ; the patient being made to lie on her
abdomen, as much as possible, for two or three days. In the worst cases
which admit of any chance of relief, perhaps, the actual cautery, applied
with great caution and moderation, is what ought to be employed. Many
cases on record attest its frequent efficacy.
GONORRHOEA,
Or Clap, may be defined to be an inflammation of the mucous membrane
of the urethra, attended with a discharge of puriform matter, which is
frequently believed to be of a specific quality, and which is well known
to possess infectious properties. In women, the discharge takes place
from the mucous membrane of the vagina, labia, nymphae, and clitoris,
as well as from the lining of the meatus urinarius, and, according to
M. Ricord, sometimes also from the lining of the uterus itself.
A gonorrhoea is found to begin at an earlier period after infection than
a chancre, generally within a week or ten days. However, some indi-
viduals are attacked in two or three days ; and others experience no in-
convenience, perhaps, for two or three weeks. The earliest symptom is
an itching at the orifice of the urethra, sometimes extending over the
whole of the glans penis, which, with the mouth of that canal, has a fuller
and redder appearance than usual. The glans being reddened and
smoothed by distention, is sometimes compared to a ripe cherry. The
natural secretion of the mucous membrane of the urethra first loses its
viscid quality, and becomes thinner, but soon assumes a thicker consist-
ence, turning white, yellow, or greenish, so as to have the common ap-
pearances of pus.
r About the period when the discharge begins, heat and pain are expe-
rienced in the passage, more especially at the time of making water. The
urine gasses with a scalding sensation, and sometimes with considerable
difficulty, either in a very diminished, broken stream, or merely by drops.
Occasionally, the irritation is such, that a complete retention is brought
GONORRHCEA. 627
on. In ordinary cases, the inflammation does not extend further along
the urethra than an inch and a half, or two inches, from the orifice —
the specific extent, as it was termed by Mr. Hunter ; but, in severe
examples, the inflammation passes through the whole course of the
urethra, and even affects the mucous membrane of the bladder. When
this happens, the patient's sufferings are considerably aggravated, the
pain about the hypogastric region, perinaeum, and hips, being particularly
distressing. In such cases, small indurations, consisting of enlarged
glands, may often be felt in the course of the urethra, and sometimes
these, and Cowper's glands inflame and suppurate.
In general a common clap increases, or, at all events, maintains itself
in an unabated degree, for ten days or a fortnight: the discharge then
frequently begins to lessen ; the pain and scalding sensation in making
water to subside; and in a month or six weeks, none of the symptoms
may remain. In this manner, gonorrhoea may undergo a spontaneous
cure. Sometimes, however, the acute symptoms go off, especially the
pain and heat in making water ; the quantity of discharge is also re-
duced ; but the urethra, instead of resuming its natural healthy mucous
secretion, pours out a thin, colourless, or light green matter, which may
continue for a long time 10 ooze from the passage, constituting what is
called a gleet.
It was one of the opinions of John Hunter, that a gleet is essentially
different from a gonorrhoea, in not being infectious, and in consisting of a
discharge composed of globules, blended with the mucous secretion of
the part ; while the matter of gonorrhoea is made up of globules blended
with a serous fluid. Gonorrhoea in its worst forms is truly a distressing
disorder. Not only may the inflammation run along the urethra to the
bladder itself, as already described, but fibrine may be effused in the
corpus spongiosum urethra?, so that, when an erection takes place, one
side of the penis being less yielding than the others, the part assumes a
distorted or bent appearance, termed chordee, and attended with great
suffering. The irritation, accompanying gonorrhoea, gives a tendency to
erections ; which are perhaps a source of far greater suffering, especially
when combined with chordee, than the ardor urinae, or even the irritable
state of the bladder itself.
Frequently, the inflammation extends to the prepuce, which becomes
thickened, swollen, and redematous, so that the glans cannot be un-
covered ; a state termed phimosis.
Sometimes other parts are affected, as the glands in the groin, and
the testicle, which are attacked by acute inflammation. Hence sym-
pathetic buboes, and the inflammatory painful enlargement of the testicle,
absurdly called hernia humoralis. I may say, that tenderness of the glands
in the groin, and of the testicles, is an ordinary attendant on clap, so that
even when one of the latter organs does not actually inflame, it is often in
a state in which the use of a suspensory bandage affords much comfort.
Several curious and interesting questions necessarily present them-
selves to our notice in the consideration of gonorrhrea.
The first is, whether a clap depends upon a specific virus ? All sur-
geons know that simple irritation of the mucous membrane of the
urethra will increase the quantity, and alter the quality, of its natural
secretion, or will change the mucous secretion into one of pus, so as to
bring on a discharge. Some practitioners denominate a case of this
description a simple or benign gonorrhoea, reserving the epithet virulent or
venereal for the case which is conceived to depend upon a specific poiso
s s 2
628 DISEASES OF THE GENITAL AND URINARY ORGANS.
A discharge of matter from the urethra may result from any kind of
irritation affecting it, as that of the employment of bougies, or of the
application of various acrid and unhealthy secretions to its orifice in the
act of coition. Such altered secretions may be formed from the mucous
surfaces of the female parts of generation, totally unconnected with the
poison of syphilis. What experienced surgeon does not know, that when
female children are violated, a discharge generally follows, in consequence
of the injury done to the parts, even though there may be no actual
laceration of them ? And hence the offender is frequently alleged to
have been in a state of disease when he perpetrated the crime, though
this inference is far from being warranted, merely because the female is
attacked with a discharge.
But, besides these gonorrhoeas from simple irritation, it is contended
that there are others, arising from the influence of a specific poison, and,
as some surgeons maintain, from the identical poison that is concerned
in producing the venereal disease.
As we know not what the poison of gonorrhoea is, nor what the syphi-
litic poison itself is in a separate state ; nor even whether there may not
be, as Mr. Carmichael conceives, several varieties of venereal poison, the
determination of this question is particularly difficult. If we were to
judge of the nature of the venereal and gonorrhocal poisons by their
general effects, and consequences of each of them, we should be led to
the inference that they are certainly not identical. We see in gonorrhoea,
generally speaking, only a discharge from the mucous membrane of the
urethra without ulceration, going through a certain course, and usually
terminating of itself in three, or four, or five weeks, without any eruption,
sore throat, or affections of the bones. In syphilis we see a disease that
begins with ulceration of another texture, generally lasts considerably
longer than a clap, and is disposed to bring on a train of secondary
symptoms, denoting its influence over the constitution at large, and
often lasting for several months.
The arguments, in support of the identity of the two poisons, are of the
following kind : —
1st. The supposed conveyance of the venereal disease from a country
where it was known to be prevalent, to a very distant one, in which it then
commenced for the first time. Now, Mr. Hunter supposed that it could
only have been conveyed, during a voyage of several months, in the form
of gonorrhoea, as he thought that a chancre on the penis would in this
time have destroyed the organ.
2d. The occurrence of secondary symptoms after gonorrhoea. Mr.
Hunter mentions a gentleman who had gonorrhoea three times, which
was treated without mercury : about two months after each infection, he
had secondary symptoms, which consisted of ulcers in the throat, and
blotches on the skin.
3d. The result of an inoculation with gonorrhceal matter, as performed
by Mr. Hunter himself; followed by bubo, ulcer on the tonsils, and
blotches on the skin ; all ultimately cured by mercury.
If the particulars of this case be closely attended to, it will be perceived
that Mr. Hunter deviates from some of his common doctrines about the
venereal disease. In the first place, the primary sores, resulting from the
inoculations, he says, healed up without mercury ; then the sore throat,
after having been made to heal by mercury, broke out afresh, and required
this medicine again. Now, if Mr. Hunter had not been intent on proving
the identity of the gonorrhceal and syphilitic poisons, he probably would
GONORRHOEA. 629
not have admitted, that a primary sore could have healed without mercury,
or that a secondary one, after being healed, could have broken out again,
without a new stock of infection ; for these are the principles which he
insists upon in other parts of his work, though, inasmuch as they are not
correct, they do not really affect the inference deduced from the present
case by Mr. Hunter, except by proving that this great man had no settled
rules for deciding whether a complaint was venereal or not.
4-th. The frequent production of secondary symptoms, when gonorrhoea
leads to ulceration at the orifice of, or within, the urethra. According to
the researches of M. Ricord with the speculum vaginae, and his experi-
ments with inoculation, ulceration or a true chancre in the vagina, or
other concealed situation, is a much more common accompaniment of
gonorrhoea in women than usually supposed; and he declares that syphilis is
only inoculable with the discharge, and secondary symptoms liable to fol-
low gonorrhoea, when such ulceration exists. As this is asserted by him
to be the fact, with respect to women, he deems the inference warrant-
able, that the same combination of a discharge from the male urethra with
a true chancre in that passage, is also not uncommon, and will serve to
account for the very opposite doctrines frequently entertained respecting
the dependence of gonorrhoea and syphilis upon the same poison. The
fossa navicularis in men is found by M. Ricord to be the part of the
urethra in which a primary venereal ulcer is oftener found, than any other
portion of the urethra. Every experienced surgeon must have seen
chancres occupying the very mouth of this canal.
If these facts be admitted, the plain inference from them is, not that
the poisons of gonorrhoea and syphilis are identical, but that the former is
a decidedly different disease, arid that, unless a chancre exist in the
urethra, no discharge from this passage, no mere gonorrhoea, can be the
source of secondary symptoms.
While some surgeons observe no particular differences between these
comparatively rare secondary symptoms of gonorrhoea and the more fre-
quent ones of syphilis, other practitioners have attempted minutely to
define such differences, more especially Mr. Carmichael, who, as we know,
attributes to gonorrhoea papular eruptions, soreness of the fauces, pains
in the larger joints, iritis, and inflammatory swellings over the superficial
bones.
Sometimes, though the doctrine of gonorrhoea originating from any
specific poison is rejected, it is conceived, that the disease may arise
from the operation of any mechanical or chemical stimulus, and that, in
this way, infectious matter may be generated, which will even propagate,
under certain circumstances, syphilitic as well as gonorrhceal complaints.
This view seems to combine two things, namely, a denial of the existence
of a specific gonorrhceal virus, and the admission that gonorrhoea may, if
it lead to ulceration, give rise to syphilis itself. It is sometimes imagined
that this hypothesis rather coincides with many of the anomalies in the
history of the venereal disease, especially the probability of thf infinite
multiplicity of its origin in every country where promiscuous sexual inter-
course prevails to a great extent ; and that it tends to reconcile some of
those extraordinary relations, in which soldiers, having intercourse with
the same woman in quick succession, severally contract gonorrhoea, chan-
cre, or primary sores of various characters, all from the same source of
infection, a subject already discussed in the observations on syphilis.
For my own part, I feel less difficulty in adopting the conclusions to
s s 3
630 DISEASES OF THE GENITAL AND URINARY ORGANS.
which M. Ricord has been brought by his experiments with inoculation
and the speculum.
The arguments against the identity of the gonorrhceal and venereal
poisons are : —
1st. The rarity of secondary symptoms after gonorrhoea, and the fre-
quency of them after a primary venereal sore.
2d. The differences between the secondary symptoms of each disease,
when such symptoms do occur.
3d, If the poison were the same in each case, why should the matter
of gonorrhoea not commonly produce chancres on the glans and prepuce,
with which parts it is so much and so long in contact ?
4th. Why should it be a disease completely beyond the control and
influence of mercury ?
5th. If the application of the poison to a secreting or mucous surface
be specified in explanation of the difference of effect, why does the syphi-
litic poison frequently produce chancres on the secreting surface of the
corona glandis, and, occasionally, notwithstanding all assertion to the
contrary, within the urethra itself? and why should women ever have
chancre at all, as the poison in them must generally be applied to a
mucous surface ?
It is not an uncommon belief, that the various degrees of severity,
which a gonorrhoea assumes, indicate only the stage and extent of the
inflammation, which, wherever the natural susceptibility exists, is excited
by the introduction of any irritating secretion.
It may here be remarked, that all this is true : yet, we find that per-
sons have chancres secreting pus close to the orifice of the urethra, with-
out gonorrhoea being brought on by it. This is certainly another fact,
and what does it tend to prove ? Not, that the two diseases depend upon
the same virus, but, merely that the matter of chancre will not commonly
irritate the urethra of the individual having such a sore upon the penis.
Neither does it generally cause ulceration and chancre on the neighbour-
ing part of the penis. So far as the fact proves any thing on this ques-
tion, it is, I think, decidedly against the conclusion, that these two
diseases depend upon the same kind of virus.
TREATMENT OF GONORRHOZA.
Notwithstanding our ample experience in the treatment of clap, we are
quite ignorant of any specific remedy for it, The disease, however,
though characterised by a disposition to go on for three or four weeks
(whatever be done), is capable of being rendered much milder by proper
treatment, and also of being prevented from continuing for many weeks,
and even months, in the form of gleet. The benefit, therefore, which a
patient with gonorrhoea may derive from surgery is not unimportant.
Gonorrhoea is manifestly attended with inflammation of the mucous
membrane of the urethra, as indicated by the heat, pain, and swelling,
and often by the effusion of fibrine in the corpus spongiosum, and other
effects. Its first stage should, therefore, be treated on antiphlogistic
principles ; the penis should be covered with linen wet with cold water
or the lead lotion ; — or, as preferred by M. Ricord, the penis, scrotum,
and perinaeum may be fomented with a decoction of poppy- heads, to
which, when the pain is severe, laudanum may be added. Or the same
parts may be fomented with a decoction of the leaves of belladonna. The
patient should abstain from violent exercise, wine, full diet, and high-
seasoned dishes, and take purgative medicine every second or third day.
GONORRHOEA. 631
When the discharge is quite incipient, M. Ricord finds the application of
from twenty to forty leeches on the perinseum, according to the strength
of the patient, and the exhibition of copaiba, or cubebs, the most success-
ful mode of checking the complaint. But, he considers the latter medi-
cines, after a gonorrhea is completely developed, as inefficient, and
calculated to render the digestive organs averse to their exhibition in a
later stage, when they may become necessary.* The urine is to be rendered
less stimulant, by giving mucilaginous diluent drink, as barley water,
linseed tea, or a solution of gum arabic, with a proportion of nitrate of
potash and a little syrup of poppies in it. The liquor potassae may be
given in doses of ten drops, repeated eight or ten times in the course of
the day; for it has the effect of rendering the urine less irritating.
Medicines, calculated to promote the secretions in general, to keep the
bowels open and the skin moist, are generally approved of in the early
stage ; as mixtures containing the liquor ammon. acet. and nitrate of
potash, or powders composed of the nitrate of potash, and a small pro-
portion of pulv. ipec. comp. The decoct, hordei comp., with nitrate of
potash, and tinct. hyosciami, is a medicine very commonly prescribed.
When, from the violence of the pain about the bladder and perinaeum,
there is reason to believe, that the inflammation extends further than usual,
or when the urine cannot be voided without the utmost difficulty, or is
even retained altogether, the treatment must be still more active : leeches
should then invariably be applied to the perinaeum, venesection practised,
the slipper-bath employed, the bowels freely and repeatedly opened, and
the patient kept under the moderate influence of opium, or hyosciamus,
with the view of lessening the spasm at the neck of the bladder. If com-
plete retention come on, a clyster, made with two or three ounces of the
mucilage of starch and from forty to sixty minims of laudanum, should
follow bleeding and the warm bath.
After the inflammatory stage is over, and the discharge and some un-
easiness about the passage are the chief inconveniences left, the indication
is to employ means calculated to bring the secretion of the mucous mem-
brane into its natural state again. For this purpose, we may direct the
patient to take certain medicines, which act upon the membrane of the
urethra by altering the qualities of the urine, as the balsam of copaiba, or
cubebs : twenty drops of the copaiba balsam may be taken three times a
day, in a glass of milk or peppermint-water, or it may be made into draughts
with the mucilage of gum arabic and a little of the aqua pimento. The
cubebs, or Java pepper, is to be given in doses of 5j. or 5ij. twice or thrice a
day; or we may employ injections, which may either be of an astringent or
stimulating kind. The former generally consist of a solution of the sul-
phate of zinc, or of the acetate of lead in water, or rose-water, in the
proportion often or twelve grains to six ounces of the fluid. The stimu-
lating injections usually contain the bichloride of mercury, or nitrate of
silver. Two grains of the bichloride in six ounces of distilled water make
a strong injection, and about five grains of the nitrate of silver : though
this has been of late sometimes used in the proportion of ten grains to an
ounce for the stoppage of the discharge in the chronic stage. When the
first periods of a gonorrhoea are attended with pain, I think with M. Ricord,
that, though astringent, stimulating, or other injections sometimes stop the
discharge, they mostly fail, and do more harm than good. But, should
the discharge commence without pain, or other sign of inflammation, the
* Ph. Ricord, jMaladies Vener. p. 707 — 712.
S S 4
632 DISEASES OF THE GENITAL AND URINARY ORGANS.
balsam of copaiba, or the powder of cubebs, might be tried, with the view
of putting a sudden stop to the complaint ; but all bleeding is unnecessary.
With the same object, M. Ricord has a good opinion of the efficacy of
drastic purges ; and joins many other surgeons in commending the trial
of nitrate of silver injections; but, instead of beginning with one composed
often grains to each ounce of water, as recommended by some modern
surgeons, he prefers commencing with only a quarter of a grain to that
quantity of water, and augmenting the strength of the injection by degrees.*
1 believe with M. Ricord, and many others, that, so long as there is a good
deal of inflammation, it is best not to employ any kind of injection.
The erections, which occur in the acute stage of gonorrhrea, are the
cause of great suffering. The best means for their prevention, or relief,
consist in not letting the patient have too many blankets on his bed, or be
in too warm a chamber ; in applying cold water, or evaporating lotions to
the parts ; and in prescribing the tinct. hyosciami, vinum colchici, or,
what M. Ricord joins in the praise of, camphor combined with opium,
and given either in the form of pills, or that of an enema.
For the stoppage of profuse bleeding from the urethra, caused by
laceration of the urethra during an erection, the following plans are re-
commended : — ice-cold water to the penis, inner side of the thighs, peri-
neeum, and hypogastric region ; acidulated beverages, not however taken
too freely ; an elevated position of the pelvis ; not heating the patient
with too many coverings on his bed ; a towel rolled up, and kept firmly
pressed on the perinaeum with a T bandage ; or circular compression of
the corpus spongiosum. If these means prove unavailing, M. Ricord in-
troduces a catheter, so as to compress the urethra from within outwards
for a day or two, combining with it sometimes very moderate external
pressure.f When gonorrhoea is productive of dysury, leeches should be
put on the perinaeum, blood taken from the arm, the warm bath used, and,
as M. Ricord directs, the extract of belladonna rubbed on the perinaeum.
But, when urgent retention of urine prevails, a catheter is to be introduced,
No. 8. or 10., which will pass more readily than a smaller. In France, the
instrument is sometimes smeared with an ointment containing a proportion
of the extract of belladonna J; a method which may be more deserving
of attention than it has yet been deemed in this country.
TREATMENT OF GLEET.
We may try injections of bichloride of mercury, or nitrate of silver, or
the internal exhibition of balsamum copaibae, cubebs, the tinct. ferri ses-
qui-chloridi, or tinct. of cantharides, in doses of ten or fifteen drops thrice
a day ; and in particularly obstinate cases, the cold bath, sea-bathing, rough
horse exercise, a blister under the urethra, bark, sulphate of quinine, and
steel medicines.
Many gleets cannot be cured by any of the preceding measures, because
the disease may not be simply a wrong action of the secreting vessels of
the urethra, but dependent upon other diseases of that canal, or parts con-
nected with it, as is exemplified in stricture and disease of the prostate
gland. Hence, when a person applies to me for a gleet, and says that
he has had it a long time, I generally make it a rule to pass a bougie, in
order to ascertain whether there is any other disease of the passage.
Op. cit. p. 711. + Op. cit. p. 716.
Ricord, Mai. Ven^r. p. 718
GONORRHCEA. 633
CHORDEE
Takes place when the inflammation is not confined merely to the surface
of the urethra and its glands, but affects the corpus spongiosum : in this
circumstance, an extravasation of fibrine occurs in that texture, which
becomes incapable of yielding in the same degree as the corpora cavernosa.
Hence, during erections, there is a curvature of the penis — it is bent, as
it were, with the concavity mostly at the lower side of that organ. The
patient may suffer severely from erections, conjoined with the state of
the penis termed chordee ; for the irritation of gonorrhoea keeps up a
determination of blood to the part, and it is difficult altogether to prevent
them.
When much inflammation is present, wfe may bleed the patient from
the arm, and, in all cases, apply leeches, cold lotions, or use cold bread-
and-water poultices, with which may be blended the extract of bella-
donna.
The bowels are to be kept open, and the tincture of hyosciamus, or
what is still more efficient, the vinum colchici, the acetate of morphia, or
some other preparation of opium, administered, with the view of lessening
the disposition to erections.
After the inflammation has subsided, the remaining hardness may be
dispersed by frictions with ointment of hydriodate of potassium, or cam-
phorated mercurial ointment.
SYMPATHETIC BUBO,
One of the occasional consequences of gonorrhoea, arises from mere irri-
tation, and not from the absorption of any virulent matter. It is a simple
inflammation of one or more of the inguinal glands, much less frequently
advancing to suppuration than a venereal bubo.
Treatment. — Antiphlogistic, with cold evaporating lotions, or fomenta-
tions and poultices, leeches, aperient medicines, and quietude.
INFLAMMATION EXTENDING TO THE MUCOUS MEMBRANE OF THE
BLADDER
Is another occasional effect of severe claps ; it is attended with extreme
suffering and annoyance. In this state, the bladder is so irritable, that
it cannot contain the smallest quantity of urine, without the patient being
put to intolerable pain ; and when this affection is joined, as it frequently
is, with a difficulty of discharging that fluid, and even with retention^ the
patient's agony may well be conceived. This state of the bladder demands
prompt and vigorous measures : venesection, brisk purgatives, leeches to
the hypogastric region and perineum, the warm slipper-bath, fomentations,
and draughts of the camphor mixture, with ten minims of the tinct. of
opium and fifteen of that of henbane, every three or four hours ; or an
injection of the mucilage of starch with forty drops of opium into the rec-
tum. The uva ursi is another medicine frequently prescribed* in these
cases, in the quantity of 3j. or 5ss. every six hours.
PHIMOSIS
Is either a congenital smalness of the opening of the prepuce ; or else
an accidental narrowness of the same orifice preventing the glans from
being uncovered, and arising from any circumstance that produces a
swelling of the prepuce, whether inflammation, or an infiltration of the
cellular tissue of the part with urine, or a serous fluid. It may arise from
631- DISEASES OF THE GENITAL AND URINARY ORGANS.
simple excoriations caused by the confinement and acrid quality of the
sebaceous matter secreted round the corona glandis ; primary venereal
sores, particularly those which are formed on the inner surface of the
prepuce, or which take place in clusters near its orifice. Phimosis is
also sometimes induced by sores on the glans, especially such as are on or
near the corona glandis, or on one side of the fraenum. Occasionally, the
pressure of warts against the prepuce will bring on phimosis. Sometimes
the inflammation of the prepuce partakes of the erysipelatous character,
and, whether it be of this kind or of the phlegmonous, the part frequently
has an cedematous or anasarcous appearance behind the glans. When
chancres occur, phimosis sometimes leads to serious evils ; for the glans,
being then situated between the sores and the orifice of the prepuce, the
pus may be prevented from escaping. The result is an accumulation of
matter round the corona glandis : ulceration begins within the prepuce ;
makes its way through it ; and the glans protruding through the new
opening, the whole prepuce seems thrown in the opposite direction. In
certain instances, the swelling and thickening of the prepuce cause such
compression of ulcers on the glans, that unless a timely division of the
prepuce be made, the whole of the glans is destroyed by sloughing.
Sometimes, phimosis produces obstruction of the passage of the urine
through the orifice of the prepuce, and this fluid may then insinuate
itself into the cellular tissue of the part; while in other examples, the
retention may lead to ulceration of the urethra, and extravasation of
urine around it.
Phimosis is not then itself essentially a venereal complaint : for it may
arise from any kind of irritation producing inflammation of the prepuce,
whether a gonorrhoea, a chancre, simple excoriations, the pressure and
irritation of warts, or an accidental injury of the part. When it arises
from a true venereal sore, it is itself only an example of the common
inflammation usually produced in the vicinity of the specific disease.
The phimosis, from simple excoriation, and from the irritation of acrid
secretions lodged under the prepuce, requires that tepid water, or the
diluted liquor plumbi acetatis, should be frequently injected between the
prepuce and the glans, so as to keep the parts clean. The penis may
also be covered with linen wet with the lotion, the patient be kept in bed,
or, at all events, from walking about, and purgative medicines and a low
diet prescribed. When the inflammation is more severe, leeches or
scarifications will be useful, and the bleeding should be promoted by
bathing the penis in warm water.
The phimosis, originating from severe gonorrhoeas, chancres, or other
sores, may require, in addition to local and even general bleeding, warm
emollient poultices, or the steam of hot water. The sores are to be kept
clean by freely throwing between the glans and the prepuce a weak
solution of the sulphate of zinc, the black wash, or a lotion composed of
two grains of the bichloride of mercury, 9j. of the extract of opium, and
six ounces of distilled water; or, when the inflammation is considerable,
we may simply inject under the prepuce a tepid solution of gum arable,
with which the extract of opium is blended, in the proportion of ten
grains to six ounces.
When a chancre is complicated with violent inflammation of the pre-
puce and phimosis,, I believe, that the best practice is to suspend the use
of mercury, and direct our endeavours to the reduction of the swelling
and inflammation of the part. When these effects subside, mercury may
be more advantageously continued.
GONOIIRIICEA. 635
The following are the circumstances, which, in cases of phimosis, some-
times render the division of the prepuce necessary : —
1st. An accummulation of matter under the orepuce, secreted by sores
in that situation, and not admitting of being readily washed out by means
of a syringe. Here, if we neglect to divide the prepuce, an ulcerative
process takes place upon its inner surface, and forms an opening through
which the glans will protrude with a very great degree of deformity.
But this is not the only evil ; for the chancres, under these circumstances,
always continue to enlarge, and sometimes the glans and prepuce both
become involved in gangrenous mischief.
If the glans had already protruded through an ulcerated opening in the
side of the prepuce, the best plan would be to put a director from the
natural opening through the new one, and divide the intervening portion
of skin. In order to stop the progress of ulceration from within, and to
prevent the protrusion of the glans, Mr. Hunter did not divide the pre-
puce completely, but merely punctured it, so as to let out the matter, as
he would have done in any other common abscess.
In cases of permanent phimosis, combined with chancre, M. Ricord
concurs with such practitioners as recommend the operation to be de-
ferred, unless there is an urgency for it, until the chancres are healed,
and thus all risk of the wound becoming inoculated will be avoided. If
circumcision, which he prefers, be performed, while a chancre is present,
he advises the sore to be taken away if possible, together with the por-
tion of the prepuce ; a method, which I have sometimes followed. But,
if the chancre be left, M. Ricord immediately rubs it with caustic.
2d. Sometimes we meet with cases in which the compression of the
swollen prepuce acts injuriously upon sores of the glans; and when there
is reason to suppose that this cause is likely seriously to retard their
cure, and even bring on sloughing, we are justified in dividing the pre-
puce.
3d. Phimosis, arising from the puckered and contracted state of the
orifice of the prepuce after chancres are healed.
4th. Phimosis from the pressure and irritation of large warty ex-
crescences.
5th. Examples of congenital phimosis producing impediments to the
discharge of urine in infants, or even leading to the formation of cal-
culous substances under the foreskin ; and, in adults, creating an obstacle
to sexual intercourse, and, in old persons, causing a predisposition to
cancer of the organ.
There are several methods of operating. One consists in passing a
director under the middle of the upper part of the prepuce as far as the
corona glandis, and then, with a pointed curved bistoury, slitting the
prepuce up to the point to which the director extends. We push the
bistoury with its back in the groove of the director gently along this in-
strument, until the point reaches nearly to the corona glandis, when by
raising the point and bringing the edge towards us, the division is made
in an instant.
2d. Instead of this mode of dividing the prepuce, Cloquet and Wallace
prefer making an incision, parallel to the fraenum, at the under part of the
prepuce ; because the line of the incision, thus formed, is found to be, as
soon as the prepuce is drawn backwards, transverse in place of oblique,
or parallel to the axis of the penis, and those angular flaps of skin are
avoided, which cause great deformity when the operation is performed at
636 DISEASES OF THE GENITAL AND URINARY ORGANS.
the upper part of the prepuce. This plan I sometimes adopt. M. Ricord
objects to it, as leaving a deformity very similar to that of hypospadias.
3d. A third method consists in the performance of circumcision : the pre-
puce is drawn forward, and taken hold of with a pair of forceps; as much
of the extremity of it being left out of their grasp as needs removal :
with one stroke of a common scalpel, guided along the forceps, as a pen-
cil is along a ruler, a complete circle of the prepuce is cut away. In
applying the forceps, as the upper part of the prepuce is quite uncon-
nected to the glans, and longer than the lower portion, which is also
united to the fraenum, of course, a more considerable piece of the prepuce
above should be left in front of the blades of the instrument than below.
After circumcision has been performed, the inner membrane of the
prepuce and the outer skin are seen with their edges more or less sepa-
rated from one another. If the inner membrane should still seem tight,
it is to be slit up, or cut with scissors. Then, in order to keep the edges
of the outer and inner skin of the prepuce together, a small suture may
be passed through them. If the artery of the froenum bleed copiously,
it must be tied, or twisted. For the prevention of inflammation and
erection, cold water is to be applied, and camphor and opium, or the
acetic extract, or the tincture, of colchicum prescribed.
PARAPHIMOSIS
Is the case, in which the prepuce is drawn behind the glans penis, and
cannot be brought forward again. If the opening in the prepuce be
narrow, as is often the case when the part is in an inflamed state, it
will, when drawn behind the glans, produce such a constriction of the
penis, as is not only followed by considerable swelling of the glans, but
by the greatest difficulty, or even impossibility, of getting the glans back
again through the narrow part of the prepuce. The glans is uncovered
and of a livid colour, its corona being overlapped by a tumid ring, formed
by the cedematous lining of the prepuce. Behind this tumid circle is the
seat of stricture or compression, produced by the "contracted orifice of
the prepuce. The extent of the swelling backwards is various in dif-
ferent instances. Neglected cases sometimes terminate in sloughing
either of the glans, or the prepuce, or both parts together.
From what has been said, we may readily understand why a phimosis
should frequently change into a paraphimosis, when the prepuce is im-
prudently drawn too far back.
In the treatment, if the case be recent, the inflammation considerable,
and the patient a strong subject, venesection should be practised. The
indication is to reduce the glans to as small a size as we can, by the
application of cold lotions, or snow, or ice-water, and then compressing it
equally, and unremittingly, for a few minutes, between the ends of the
fingers and thumbs of both hands ; and when we have pressed as much
blood out of it as is practicable, and reduced it to the smallest size, we
are then to press it back with the thumbs through the constriction of the
prepuce, while the fingers are used at the same time for bringing the
prepuce forwards over the glans.
When the attempt does not succeed, we may have recourse to leeches,
purgatives, punctures in the anasarcous part of the swelling, and cold
applications; but if we cannot succeed, notwithstanding these means and
the manual proceedings which I have described, and the constriction be
such as to threaten to produce sloughing, the portion of the prepuce
forming the constriction must be divided with a sharp-pointed narrow
DISEASES OF THE ANUS AND RECTUM. 637
bistoury. The operator will always find the stricture behind the corona
glandis, and separated from it by a tumid ring, consisting of the cedema-
tous lining of the prepuce. It is therefore in a kind of depression, or
groove. Into this, the point of the knife is to be passed, deeply enough
to go under the stricture, which may then be divided by cutting upwards.
No preliminary incision is necessary.
Even when the stricture has been cut, the adhesive inflammation may
prevent us from immediately bringing the prepuce forwards ; but as the
constriction has been removed, no sooner does the inflammation abate,
than the parts resume their natural state.
DISEASES OF THE ANUS AND RECTUM.
ABSCESSES. FISTULA IN ANO.
THIS last term is applied to almost every abscess which breaks in the
vicinity of the anus; but very improperly; for, the idea of there being
a fistula naturally leads to the adoption of measures totally different from
those usually required for the cure of abscesses in general. Sometimes,
the complaint makes its attack in the form of phlegmonous inflammation,
attended with a frequent, full pulse, and heat and jlryness of the skin.
The formation of matter is often preceded by a fit of shivering. A part
of the buttock near the anus is considerably swelled, and presents a large
circumscribed hardness, the middle of which soon becomes very red, and
matter forms in its centre. On other occasions, suppuration is preceded
by erysipelatous inflammation, without any of the circumscribed hardness
which characterises the foregoing tumour. The redness spreads more
extensively ; the disease is more superficial ; the quantity of matter
small ; and the cellular tissue sloughy to a considerable extent. Some-
times the complaint begins somewhat like a carbuncle. The skin is of
a dusky red, or purple colour, and, although harder than in the natural
state, not nearly so tense as in phlegmonous or erysipelatous inflamma-
tion. At first, the pulse is full and hard; but, if no relief be obtained, it
soon becomes unequal, low, and faltering; and the strength and spirits
are greatly dejected. The matter, formed under the skin, is small in
quantity, and bad in quality, and the cellular tissue is deeply gangrenous.
This species of the disease affects persons, whose habit is either naturally
bad, or has been rendered so by intemperance.
These different affections often influence parts in the neighbourhood of
the disease. Hence retention of urine, strangury, prolapsus ani, tenes-
mus, piles, diarrhoea, or obstinate costiveness.
Sometimes the abscess begins as an induration of the skin near the
anus ; but without pain, and alteration of colour ; the hardness gradually
softening and suppurating.
The matter may either point in the nates, at a distance frora the anus ;
or near the latter part ; or in the perineum. The matter may escape
from one opening, or from several. Sometimes there is not only an ex-
ternal aperture, but another internal one, communicating with the cavity
of the intestine. In other instances, there is only one external or internal
opening.
The matter may be formed at a considerable distance from the rectum,
which is not even laid bare by it ; in other cases it is laid bare, but not
perforated ; sometimes it is both denuded and pierced.
638 DISEASES OF THE ANUS AND RECTUM.
Many abscesses about the anus are connected with a bad state of the
health. When quite local diseases, they generally arise from obstinate
costiveness, and the irritation of the mucous membrane and cellular
tissue of the rectum by the passage of indurated faeces. Individuals, who
have long suffered from piles, are particularly liable to abscesses near the
extremity of the rectum. Severe diarrhoea, accompanied with tenesmus
and great determination of blood to the rectum, has also been known to
bring on the complaint. Sir Astley Cooper is of opinion, that the most
common cause is disease of the liver, which, preventing the free return of
blood from the intestines, and influencing their secretions, leads to inflam-
mation near the rectum.* In a few instances, abscesses at the side of the
rectum appear to have arisen from the penetration of the mucous mem-
brane, and sphincter muscles, by fishbones, or other irritating extraneous
substances in the bowel, one or two interesting examples of which are
recorded by Sir Benjamin Brodie.
When the inflammation is phlegmonous, Pott advocates the doctrine,
that the thinner the skin is suffered to become, before the abscess is
opened, the better ; but the generality of modern surgeons make it a
rule to open every abscess near the rectum as soon as a fluctuation can
be felt. This affords the best chance of preventing a fistula and sinuses
extending far up. If the patient be of a full, sanguine habit, venesection,
leeches, and mild purgatives, are proper in the early stage. The con-
fectio sennae with sulphur is one of the most eligible aperient medicines.
An emollient poultice is the best application ; and if the pain be severe,
leeches and fomentations should be employed.
When the attack is of an erysipelatous kind, and there is a sloughy
state of the cellular tissue, the sooner the part is opened the better. If
we wait for the matter to point, we shall wait for what will not happen, at
least not till after a considerable length of time, during which the disease
will extend itself, and the cavity of the abscess be greatly increased.
When the fistula in ano commences with that kind of inflammation
which a carbuncle exhibits, calomel, with opium, and mild aperient medi-
cines, may be prescribed in the early stage ; but the patient will not bear
much depletion ; and very soon tonics, with ammonia, or wine, will be
required. The part should be opened early by a very free incision.
All suppurations in the vicinity of the anus do not necessarily interest
the rectum ; sometimes the matter is so distant from the intestine, that
the surgeon has no more to do with this part than if it did not exist, and
the abscess is to be treated upon general principles. Under simple treat-
ment, the necessity of meddling with the rectum will often be removed.
But it more frequently happens, that the intestine, although not pierced
by the matter, has yet been so denuded, that the fistula will not heal,
without laying the cavity of the abscess and that of the intestine into
one. The difficulty of healing many abscesses near the rectum depends
upon their being influenced by the action of the sphincter and levator ani
muscles, which have a constant tendency to prevent the union of the
granulations and coalescence of the sinus.
The operation consists in dividing the rectum, from the top of the
hollow, in which the matter is lodged, down to the anus. Thus the fis-
tula is converted into an open wound. The course and extent of the
fistula is to be first ascertained. The patient may kneel on his bed, and
at the same time lean forwards on his elbows, while the knees are kept
* Lectures, vol. ii. pp. 327, 328.
FISTULA IN ANO. 639
close together; or he may get 'up, lean forwards on the back of a chair,
and place his knees together. The forefinger of the most convenient
hand, according to the side on which the fistula is situated, having been
oiled and passed into the rectum, the surgeon introduces a narrow curved
probe-pointed bistoury into the fistula, with its edge turned towards the
rectum, until it has traversed the fistula, and the probe-point is felt press-
ing against the extremity of the finger within the bowel. Then, by mak-
ing a little pressure with the knife, held in a particular manner, the
rectum will be pierced, and the probe-point having come in contact with
the end of the finger, the latter is steadily withdrawn ; and as the knife
rests upon and is made to follow it, the edge divides all the parts inter-
vening between it and the anus, including the external sphincter. When
a silver director is bent, it will sometimes pass through the whole track
of the fistula into the rectum : then the division of all the parts, inter-
posed between it and the anus, should be performed under the guidance
of this instrument. Or the director may be employed when the course
of the fistula is tortuous. Then the director, if used, is to be withdrawn,
and the operation is to be completed, by bringing the knife out, with its
point applied to the finger, within the intestine. In this manner, all that
is between the edge of the knife and the anus must obviously be
divided. The sphincter muscle being included in the cut, not only is
there a free and ready escape of the matter, but the action of the muscle,
which creates such a disturbance of the part, and prevents its healing, is
for a time suspended.
Immediately after the operation, a soft dossil of fine lint should be in-
troduced, from the rectum, between the lips of the incision. This first
dressing should remain till loosened by suppuration. Afterwards, lint
dipped in sweet oil or tepid water, is one of the best applications. A
T bandage is usually employed.
We have now to consider fistulas in ano, in the state, in which they are
after having spontaneously burst.
When the matter has made its escape only through an external opening,
the case is termed a blind external fistula. Sir Astley Cooper has several
times known a fistula form on each side of the anus, and communicate
round the rectum. He examined the body of a man, who died of a dis-
charge from a fistulous opening in the groin, and who had a fistula in ano :
the fistula passed under Poupart's ligament, took the course of the vas-
deferens, and descended into the fistula in ano. Sometimes the fistula
only just reaches the sphincter, and is extremely small, appearing at first
merely as a suppuration of one of the follicles of the anus. Sometimes
it reaches four inches up the side of the rectum.* When there is an
opening in the intestine, and none in the skin, the fistula is called a blind
internal fistula. Fistula?, having an opening both in the skin and gut,
are termed complete. The first and last cases are the most common. A
probe is to be introduced to ascertain their nature, and the operation,
already described, is the proper one for obtaining a cure. W^en there
are several openings, and corresponding sinuses, they are all to be divided
with a curved bistoury, so as to make one cavity of the whole.
In cases of blind internal fistula, if the bursting and discharge of the
matter should not produce a cure, which they sometimes do, though very
seldom, an external opening is to be made, and then the same operation,
as has been already described for other cases, is to be put in exe-
* Sir Astley Cooper's Lectures, vol. ii. pp. 326, 327.
64-0 DISEASES OF THE ANUS AND RECTUM.
cution. The place for the opening is always sufficiently denoted by the
induration.
Sometimes the health will require to be improved before a cure can be
accomplished, and many patients, who cannot recover in hospitals, do so
on removing into a better air. The medical treatment of fistula in ano,
connected with disease, consists in restoring the secretions of the liver,
and intestinal tube, by giving the chloride of mercury, or the pil.
hydrargyri at night, and the compound infusion of gentian, with soda and
rhubarb, twice in the day,*
If any organic or visceral disease exist ; such as disease of the liver or
lungs, or carcinoma or stricture of the rectum, the operation ought not
to be performed ; for, under these circumstances, the fistula, though laid
open, will not heal, or, if it should, the viscereal disease will advance with
a quicker pace.f
Besides the foregoing kinds of abscess near the anus, piles sometimes
suppurate, and matter forms in their centre, as will be presently ex-
plained. Occasionally, also, abscesses form in the front of the vertebrae,
descend into the pelvis behind the peritonaeum, and bursting somewhere
near the terminaton of the rectum, become fistulous. The operation in
such a case would be entirely useless.
PILES, OR HEMORRHOIDS.
In their texture, piles are subject to a great deal of variety. Some-
times they are merely dilated veins, or varices, situated near the anus, or
lower portion of the rectum, forming prominences covered by its mucous
membrane, or the delicate skin near the anus, and from which a bleed-
ing takes place, whenever there is a great determination of blood to the
parts.
In other still more frequent cases, the texture of hemorrhoidal tumours
is more complicated ; many of them being characterised by an areolar,
soft, spongy structure, filled with blood. At periods, when these are in a
quiet state, free from irritation, and without any particular determination
of blood to them, they are small and shrivelled ; but in the contrary cir-
cumstances, they swell, become firmer, undergo, as it were, a kind of
erection, and blood is voided from their surface. Hence, their texture is
compared by French pathologists to the erectile tissues. Numerous
arterial branches are distributed to them. Chaussier found, that if an
incision be made in them, and a coloured fluid thrown into the hemor-
rhoidal arteries, it will issue from numberless small apertures within the
swellings.
Other hemorrhoidal tumours consist of one or more cysts, or cells,
smooth internally, more or less vascular, retaining the blood for variable
periods, but every now and then bursting, and occasioning hemorrhage.
Lastly, some hemorrhoids, originally having cavities, or cells, are gra-
dually converted into solid swellings by the effects of repeated attacks of
inflammation, and the effusion and organization of fibrine.
Hemorrhoids are divided into internal and external, according to their
situation, either above the sphincter muscle, and in the inferior part of
the rectum, or below the sphincter, near the verge of the anus, under the
delicate thin integuments by which this part is covered. But, as an in-
ternal pile may protrude below the external sphincter, the best criterion
* Vol. cit. p. 328.
f Sir 13. C, Brodie, Lond. Med. Gaz. Oct. 1835. p. 29.
PILES. 641
is its texture ; for it is always covered by the mucous membrane of the
bowel; while an external pile is invested by the delicate skin near the
anus. Those internal ones, which resemble varices, lie under the mucous
membrane, which is often adherent to their surface, and so thin, that
their bluish colour can be plainly distinguished through it. Varicous piles
make their appearance, chiefly when the parts are in a state of conges-
tion, in the form of dark blue, elastic knobby swellings, not attended
with much pain, yielding to pressure, but returning immediately it is
discontinued. These venous dilatations under the skin, or under the
mucous membrane of the rectum, are generally only a small part of those
which exist around the bowel. M. Begin has sometimes found the
lower portion of the rectum involved in a plexus of enlarged veins, com-
posing a thick vascular zone around it, and so gorged with blood, that if
it had been cut in the living subject, a very dangerous hemorrhage must
have been the consequence.
Internal hemorrhoids of the spongy and cellular kinds are always
situated between the fleshy fibres and the mucous coat of the bowel,
under which they project. They are of different sizes, from that of a
pea to that of a nut, walnut, or even a small egg. Their number is equally
various; sometimes only one or two ; but occasionally so many, that the
affected part of the bowel is filled and distended with them. Sometimes
only a small portion of them projects into the bowel, the greater part of
their mass being lodged in its cellular tissue ; but, in other instances, the
whole or greater portion of the swelling directs itself towards the interior
of the bowel, and being gradually detached by the repeated passage of
the feces from its original connection, at length hangs by a kind of pedicle
into the cavity of the rectum.
External hemorrhoids of this kind also sometimes form slight promi-
nences under the thin delicate skin near the anus ; but in other examples,
considerable and permanent tumours, which were often termed mariscce
by the old surgeons, from their shape and appearance.
Various circumstances may tend to bring on a determination of blood
to the rectum, followed by hemorrhage from the mucous membrane, and,
in many instances, by the tumours called piles. Plethoric individuals,
and others in whom the circulation in the branches of the vena portaB is
obstructed, are particularly liable to them. They are seldom met with
in very young persons, being scarcely ever produced till the body is com-
pletely developed in breadth as well as height. An age between thirty
and forty is the most common period for them to begin ; and if in a full
habit, they mostly continue during life. In the male subject, the occa-
sional bleeding from piles is frequently regarded, and not without reason,
as a salutary evacuation.
In the other sex, menstruation seems to render this other spontaneous
kind of depletion unnecessary ; but, on the natural discontinuance of the
menses, piles are disposed to form, and, in full plethoric womenv the
bleeding from them may then become a substitute for the uterirffe evacua-
tion. Also during pregnancy andxafter delivery, many women are troubled
with piles. In these cases the enlargement of the'hemorrhoidal vessels
depends upon the suspension of the menstrual discharge, the compression
of the veins by the gravid uterus, and the efforts and local irritation ac-
companying parturition.
Whatever tends to bring on plethora creates a disposition to hemor-
rhoids ; as taking more food than nature can properly dispose of, eating
high-seasoned dishes, and drinking too much wine and other fermented
T T
DISEASES OF THE ANUS AND RECTUM.
liquors. Such excesses, combined with an indolent or sedentary life,
will be still more likely to induce the disease. A similar effect may also
proceed from any other circumstances occasioning a great determination
of blood to the rectum ; as the abuse of aloetic purgatives, and stimu-
lating glysters ; habitual constipation ; the irritation of the bowel by the
passage of indurated feces ; and excesses in venery, whereby a larger
quantity of blood is made to pass into the vessels of the lower part of the
rectum, as well as into those of the genital organs.
By the expression hemorrhoids, some of the old writers signified
bleedings from the rectum, whether attended with piles or not. In fact,
a congestion of the hemorrhoidal vessels is sometimes terminated by a
copious discharge of blood from the mucous membrane ; but repeated
congestions will not always end in this way, but often in inflammation,
and the change in the size of the veins, or the formation of the tumours
already described.
Few diseases are more painful than piles in the state of inflammation.
About the fundament, there is an excessively painful feeling of tension,
burning heat, and weight, extending from the anus, through the pelvis,
and to the neck of the bladder in the male, and to the womb in the
female. The pulse is hard, quick, and contracted. The patient is con-
tinually wanting to go to stool, and the efforts made for this purpose
generally have no other effect than that of subjecting him to severe
torture. Sometimes the evacuation of the urine is attended with diffi-
culty. The anus and surrounding parts are red, gorged with blood, and
the seat of prominent, tense, elastic swellings, which are of a purple or
deep brown colour, and extremely painful on being touched. The suf-
ferings are still greater, when the inflamed mucous coat of the rectum is
propelled down, so as to form a circular projection, which is strangulated
by the sphincter muscle. A corresponding increase of suffering results
from a similar constriction of inflamed hemorrhoids by the fibres of the
same organ, the action of which not only prevents the reduction of the
protruded swellings into the bowel, but interferes with the return of the
blood from them, and thus their tension and size become still further
increased. Under these circumstances, it may be impossible for the pa-
tient to empty the bowel, and he may be attacked with the same symp-
toms as are noticed in cases of strangulated hernia.
When the irritation of the rectum, resulting from piles, is less intense,
but protracted, a frequent consequence is a morbid secretion of mucus
from its interior. In other instances, the effects are a thickening of its
coats, a contracted state of the anus, and great induration of the adjoining
cellular tissue. Piles, which have been repeatedly inflamed, sometimes
occasion a permanent spasmodic action of the sphincter, or numerous deep
fissures at the margin of the anus, rendering the evacuation of the feces
exceedingly painful. Lastly, abscesses and fistulae may become compli-
cations of hemorrhoidal swellings. Inflamed piles occasionally suppurate
in their centre ; and the matter, which forms within them, may long con-
tinue to be imperfectly discharged from them through a fistulous open-
ing on their surface.
When persons experience little inconvenience from the tumours, or the
hemorrhoidal flux, as it is termed, takes place from time to time in a ple-
thoric subject, there is in the first case no real occasion for the removal of
such piles ; and in the second, the stoppage of the periodical bleeding
may create a risk of bringing on some other more serious disease like
apoplexy, which the discharges of blood from the rectum tend to keep off.
INFLAMMATION AND STRANGULATION OP PILES. 643
It is on this account, that piles are sometimes regarded as safety-valves
for the constitution. The prevention of constipation by the mildest lax-
atives is here the chief indication. The lenitive electuary, with sulphur,
or small doses of castor oil, are commonly preferred. Even when the
evacuation of blood from the anus is rather profuse, it is not always proper
to check it. So long as the pulse is strong, the colour of the face natural,
the muscular system vigorous, and the patient feels relief from the deple-
tion, it is best not to interrupt it. But, if the countenance be pale, the
debility considerable, and the pulse much reduced, the patient should be
kept in the recumbent posture, cold acidulous injections be thrown up
the rectum, cold lotions applied to the anus, and all his beverages be of
a low temperature, and acidulated with citric or sulphuric acid. If there
were pain about the rectum, and the pulse not too much reduced, vene-
section might also be proper, as calculated at once to relieve the irritation
of the part, and to stop the determination of blood to it.
When the hemorrhage recurs very frequently from an internal pile, or
the tumour often descends, and inflames from constriction by the external
sphincter, the tumour should be extirpated. By the patient sitting over
a pan of warm water, and making efforts as if at stool, the tumour may
almost always be made to present itself at the anus, and then can be
easily taken hold of with a tenaculum forceps, and tied. On account of
the profuse hemorrhage, liable to follow the excision of internal piles, the
removal of them by ligature is now almost constantly preferred by the
London surgeons. If the pile cannot be made to descend in this way, a
pint or two of warm water may be thrown up the rectum, and on its dis-
charge taking place, the tumour will often present itself.
When an internal pile is above a certain size, it should be trans-
fixed with a needle and strong double ligature, 'one half of which is
to be firmly tied over each side of the neck of the tumour. The
surgeon, after having secured each pile in this way, may cut off its
convex portion, and snip off both ends of each ligature close to the
knot, returning the remains of the pile and rest of the ligatures into
the rectum. On the day before the operation, the bowels should be
emptied by means of a dose of rhubarb, so that there may be no neces-
sity for another evacuation for two or three days. After the ligatures
have been detached, which usually happens in a week, and a little time
has been afforded for the healing of the sores left after their separation,
the patient should take some lenitive electuary and sulphur every night,
and use a lavement of cold water every morning. Thus he will prevent
a recurrence of the disease.* External piles may be safely removed with
a cutting instrument.
INFLAMMATION AND STRANGULATION OF PILES.
Another inconvenience from piles, and, in some cases, not less serious
than that resulting from their magnitude, or the bleeding from them, is
their inflammation, which, in its very beginning, is usually conjoined with
a protrusion, either of the hemorrhoidal swellings, or of a circular promi-
nence of the mucous membrane of the rectum, in a state of great tur-
gescence. Nothing can exceed the sensibility which these parts acquire
from distension, and the pressure made on their base by the sphincter
muscle. Violent nervous symptoms, extreme restlessness, severe febrile
* Sir B. Brodie, Lond. Med. Gaz. 1834-35, p, 844.
T T 2
DISEASES OF THE ANUS AND RECTUM.
disturbance, and even subsultus tendinum, may arise from the inflamed
and strangulated state of hemorrhoidal swellings.
Here the first indication is to push up the tumours completely beyond
the grasp of the sphincter muscle. The patient is directed to rest on his
knees and elbows, and the swellings, having been smeared with a little
spemaceti ointment, are to be gradually pushed up by one of the sur-
geon's fingers, with the intervention of a fine napkin. Then, in order to
prevent the protrusion from taking place again, a thick compress is to be
applied to the anus, supported by the T bandage. At the same time, the
patient is to be kept strictly quiet in bed, lying on his back, and restricted
to a very low diet. Cold water is now and then to be thrown up the rec-
tum, and, in the greater number of cases, local and general bleeding is
indicated. When inflamed and strangulated piles cannot be returned into
the rectum, antiphlogistic treatment is to be employed, especially venesec-
tion, leeches, and either cold or warm emollient applications, frequently
I have at once relieved the patient by cutting off inflamed piles, which
did not admit of immediate reduction. In other examples, where the
anus is surrounded by a circular prominence of protruded, turgid, inflamed
mucous membrane, attended with excessive pain, a few deep incisions
made in it will frequently give prompt relief, and bring about such a dimi-
nution of the part, that it may be returned.
What happens when the foregoing methods fail to accomplish the
reduction of constricted hemorrhoids ? If the inflammation has not risen
above a certain pitch, the irritation generally begins to abate in the course
of four or five days, or a week, accompanied by a discharge of blood, mu-
cus, or pus from the surface of the tumours, which, becoming diminished,
gradually return into the rectum. These desirable changes are to be
promoted with emollient applications, leeches, and other means already
specified.
In a worse description of cases, hemorrhoids, whether in the shape of
tumours, or a prominent thick ring of the mucous coat, are so forcibly
strangulated that they mortify. I have seen several instances, in which
this has terminated in a cure. Gangrene of strangulated piles, however,
may extend beyond the tumours, thus involving the lower part of the
rectum in the mischief, and bringing on likewise phlegmon ous erysipelas
and gangrene of the cellular tissue, not only around that bowel, but in the
parts external to the anus.
External piles, inflamed, but not strangulated, may often be rendered
less painful by anointing them with a cerate containing powder of galls
and a little of the extract of opium, or belladonna ; then applying a cold
lotion to them, and, if requisite, leeches ; care being taken to keep
the patient in the recumbent posture, and on a strict antiphlogistic
regimen.
MUCOUS AND PURULENT DISCHARGES FROM THE RECTUM,
Arising from piles, require different modes of treatment according to
circumstances. Thus, when piles suppurate in their centre, and become
fistulous, the extirpation of the hemorrhoidal tumours accomplishes like-
wise the cure of the abscess. When, however, piles are attended with a
chronic mucous discharge, this may be checked, or even completely cured,
by cold astringent injections, the balsam of copaiba mixture, the sesqui-
oxide of iron, a blister kept open over the sacrum, the cold bath, sea
bathing, and exercise in the pure open air.
PROLAPSUS ANI. 64-5
PROLAPSUS ANI,
Though generally described as a descent either of the mucous membrane
alone, or of the mucous and muscular coats together, seems to Sir Ben-
jamin Brodie to be always of the latter description, the other case being
merely internal piles, which we know are only covered by the mucous
membrane. He admits, however, that protrusions of elongated portions
of mucous membrane take place, but they are arranged by him under the
head of excrescences and polypi. On the other hand, Mr. Salmon* re-
presents prolapsus of the rectum to be always a descent of the mucous
membrane, which is detached from the external coat ; so that he differs
from Sir B. Brodie in even a greater degree than the generality of other
writers, who describe two forms of prolapsus, one with descent of the
mucous coat alone, the other with prolapsus of both.
Prolapsus ani is more common in infancy and old age, than any other
period of life. It is particularly frequent in children with large tumid
bellies, and confined bowels, where the whole mass of intestines becomes
too large for the abdominal cavity. In children also the prostate gland,
urethra, and vesiculae seminales are not so much developed, and the at-
tachment of the rectum to the surrounding parts does not extend so high
up as in the adult. In grown-up persons, prolapsus ani sometimes occurs
as a consequence of piles. In this case, the piles are seen at the upper
part of the prolapsus, close to the anus, forming a zone round the gut ;
and the colour and appearance of the mucous membrane, covering the
protruded piles, is altogether different from that of the membrane invest-
ing the rest of the bowel.f
Treatment. — Except when prolapsus ani takes place in a child from the
irritation of calculus in the bladder, when of course the cure will depend
on the removal of the stone, relief may generally be derived from Sir
Benjamin Brodie's plan : it consists in prescribing occasionally calomel
and rhubarb, directing that the child may not eat much vegetable food, and
injecting into the rectum every morning two or three ounces of a lotion
composed of tinct. ferri chloridi 5j-> aq. purae fbj. When, in an adult,
prolapsus ani is a consequence of piles, the first indication is to extirpate
the latter.
The prolapsus consists, as I have stated, in a descent of the mucous
and muscular tunics of the rectum, the upper portion of which passes
down in the manner of an intus-susception, within the lower as far as the
anus, or even further, so as to protrude to the extent of from one to
several inches. In general, the prolapsus occurs whenever the patier.t
goes to stool ; but, in some individuals, whenever they continue long in
the standing position.
This state of the rectum is often combined with hemorrhoidal complaints,
and a feeble, relaxed constitution. In certain chronic cases, where the
prolapsus has existed a long while, the mucous coat becomes thickened
and almost insensible ; but, in most instances, the part is liable 60 attacks
of inflammation, followed by ulceration. The disease is frequently at-
tended with discharge of blood, mucus, or even pus. In the treatment
of other examples, presenting themselves in the adult, the reduction of
the bowel is the first thing to which the surgeon naturally directs his
attention. In some cases, this is easily accomplished; but in others
* F. Salmon, on Prolapsus of the Rectum, p. 6, &c.
f Sir B. Brodie, Loud. Med. Gaz. 1834-35, p. 845.
TT 3
64-6 DISEASES OF THE ANUS AND RECTUM.
difficulty is experienced, in consequence of the swelling of the parts, and
the sphincter strangulating the bowel. In fact, the protruded portion of
bowel may be twice or thrice its natural size, of a deep purple red colour,
marked with ecchymosis, and sometimes in great danger of mortifying.
Under these circumstances, the immediate reduction of the bowel is
urgently indicated. The patient may lie on his face, as Dupuytren
directs, with a pillow placed under the pelvis ; or he may support himself
on his knees and elbows in bed, with the nates towards the surgeon.
The protruded part having been covered with wet linen, and a compress
laid over its extremity, pressure is to be gently made on its base, so as to
diminish its bulk, while the same part is gradually pushed within the
sphincter muscle. Thus the reduction commences with the return of
the portion of bowel last protruded. If this plan should not succeed, the
effect of scarifications and leeches on the part is sometimes tried, though
such practice is condemned by Dupuytren. Followed up by cold appli-
cations, however, it answers in a few examples.
Even when the reduction is accomplished, the condition of the parts
producing the tendency to prolapsus yet remains, and, consequently, the
relief is only temporary.
Cold astringent lotions and the cold bath are frequently employed, for
the purpose of giving strength and tone to the sphincter, which may
then make greater resistance to the descent of the bowel. This practice
occasionally proves effectual, but not till it has been persevered in for a
great length of time. Where the disease has begun in early life, and con-
tinued to the adult age, the horizontal posture, the use of a bed-pan, an
astringent injection daily, and a course of Ward's paste, are the means
recommended by Sir Benjamin Brodie, though he acknowledges that they
will not always succeed. Astringent lotions, and compression, made
with a piece of sponge, covered with fine linen, and supported with a T
bandage, sometimes answer in children, but mostly fail in adults and old
persons.
Under such circumstances, the excision of the whole circle of the
protrusion, or of a part of it, or of any hemorrhoids on the mucous mem-
brane, is advised. The risk of dangerous, and even fatal, hemorrhage is
the objection urged against these proceedings by Dupuytren. If, says
he, the cautery be used to stop the hemorrhage, the agony, and chance
of a perilous degree of inflammation being extended to the upper part of
the rectum and neck of the bladder, will yet form a prohibition to the
practice. The extirpation of the protruded part, either with the knife
or the ligature, must always be out of the question, so long as the bowel
admits of being reduced.
Instead of these measures, I should prefer the less severe expedient,
originally suggested and practised by Hey, and adopted by Dupuytren ;
it consists in raising up two, three, or more of the radiating folds of skin
close to the anus with a pair of forceps, furnished with broadish ex-
tremities, and removing them with curved scissors. Afterwards, on
cicatrisation taking place, the anus becomes lessened in diameter, and
the relaxed state of the skin removed. The excision should extend up
close to the anus, and even half an inch within it, if the relaxation be
considerable. The number of folds to be taken away is also to be greater
in proportion to the degree of looseness of the skin near the anus. Not-
withstanding the remark made by M. Velpeau *, that the description of
* Nouveaux Elera. de Mcd. Operatoire, t. iii. p. 1002.
ULCER WITHIN THE RECTUM. 64<7
Hey's practice, in the Dictionary of Practical Surgery, is so imperfect,
that this improvement in surgery would have fallen into oblivion, even
in England, if it had not been for Dupuytren ; the fact is, that there are
few British surgeons, of any experience, who have not been in the habit
of performing Hey's operation for the last thirty years. I have practised
it in several instances with complete success. Besides, if the Dictionary
were not in existence, English surgeons possess Hey's Practical Ob-
servations in Surgery, containing his own explanations. At the same
time, I fully admit the merit of Dupuytren's more particular account of
the subject. Mr. Salmon's plan of removing a triangular portion of the
sphincter seems to be a modification of Hey's or Dupuytren's method.
Many years ago, I performed this operation on a Jew, carrying on the
trade of a furrier in Holborn ; and last year (1838), I adopted it in
University College Hospital, for a little boy, about four years old, who
had suffered from a prolapsus ani almost from birth, and for which the plan
advised by Sir Benjamin Brodie, after a long and strict trial, was found
unavailing. The removal of two slips of integument was followed by a
complete cure.
PRETERNATURAL CONTRACTION OF THE SPHINCTER ANI.
When the sphincter has been long in a state of spasmodic contraction,
it undergoes considerable enlargement, and acts with a proportionable
increase of power. The disease is chiefly met with in women, especially
those who are disposed to hysteria ; but sometimes also in men. In
emptying the rectum, the patient is obliged to strain very much, par-
ticularly when the feces are hard, or even solid. Mr. Salmon even con-
ceives, that this condition sometimes leads to prolapsus of the rectum ;
though a close state of the sphincter appears, I think, more likely to
be an obstacle to any descent of that bowel. There is pain not only
while the feces are passing, but for a long time afterwards. Frequently
the disease is complicated with a small, but exceedingly sensitive, ulcer
of the mucous membrane, or with irregular cracks or fissures, which
M. Velpeau suspects may often be the cause of the spasmodic affection
of the sphincter.
Treatment. — Relief may be derived from aperients, which will keep
the feces from being of a hard or solid consistence. A suppository of
extract of belladonna has been tried by Sir Benjamin Brodie ; but as it is
apt to produce deleterious effects on the brain, he does not at present
frequently resort to it. Another plan adverted to by him, and also by
Mr. Salmon, is that of always dilating the anus with a bougie before the
patient goes to the water-closet ; a plan that must be attended with
extreme annoyance. In obstinate cases, it is necessary to divide one
side of the sphincter muscle. The pressure of the finger, or a plug of
lint, will command the hemorrhage. An active purgative should be
given the day before the operation, and opium afterwards to keep the
bowels constipated for two or three days, so that the wound ipay not be
disturbed. It is to be dressed with lint, and generally heals in about
three weeks. If the surgeon avoid dividing the sphincter muscle in the
female forwards, no inconvenience results from the operation, the patient
retaining the feces after it as well as ever.
ULCER WITHIN THE RECTUM.
The ulcer, which sometimes accompanies a spasmodic contraction of
the sphincter, may take place independently of it, on the posterior part
T T 4>
648 DISEASES OF THE ANUS AND RECTUM.
of the rectum, opposite to the point of the os coccygis. It occurs prin-
cipally in costive individuals, is difficult to heal, disposed to enlarge,, and
creates a great deal of pain during and after each passage of the feces.
In some instances, it bleeds copiously.
Treatment. — Mr. Copeland's practice is to divide the mucous membrane
longitudinally, so as to comprise the ulcer in the incision. According to
Sir Benjamin Brodie, a cure may always be accomplished by dividing the
sphincter muscle, and very often without an operation of any kind, if the
confect. pip. comp., or Ward's paste, be given internally, and the bowels
kept gently open with lenitive electuary and sulphur. Ward's paste,
blended with soap, he has also introduced into the rectum, as a sup-
pository, twice a day, with advantage.
STRICTURE OF THE RECTUM
Consists in a thickening and induration of the mucous and muscular tex-
tures, and no doubt also in similar changes of the intervening cellular
tissue.* Sometimes the contraction extends three or four inches up the
bowel ; but, in other instances, the constriction is limited to a very nar-
row circle. Very often the gut is of its natural diameter close to the
anus ; but, about an inch and a half, or two inches above it, there is a
circular contraction, while higher up the bowel is again of its natural
diameter. Now, although the stricture is thus confined to a certain ex-
tent of the rectum, the mucous membrane is in an unhealthy state both
above and below the contraction.*
The disease occurs in both sexes, but in adults more frequently than
children, and comes on very gradually. At first, the patient experiences
some slight difficulty in emptying the bowel, and is obliged to strain a
good deal, especially if the feces be hard, which, when discharged, are
found to be of small diameter. At length, the constricted portion of the
bowel inflames, and the pain then becomes much more severe, attended
with a discharge, not only of mucus, but of blood and purulent matter.
If the disease proceed further, inflammation takes place in the cellular
tissue round the rectum, and putrid abscesses form, which burst in vari-
ous places near the anus, and occasionally into the urethra in men, or
vagina in women. I lately attended a gentleman, from whom nearly a
pint of matter issued from the rectum daily for some time before he died,
and there was pus under the glutsei muscles. In some instances, the
patient dies with symptoms like those of strangulated hernia, in conse-
quence of the stricture becoming completely blocked up by indurated
feces. Great pain in the abdomen, vomiting, and a tympanitic distension
of the belly, are here amongst the most prominent symptoms. As SirB.
Brodie has explained, the bougie and injections may remove this kind of
obstruction, once or twice, and thus save the patient ; but another attack
coming on, the treatment may not be equally successful. In the ad-
vanced stage of the disease, patients generally become completely hectic,
but often linger many years.
Most of the strictures of the rectum met with by Mr. Salmon, he says,
were situated between five and six inches from the anus ; but many other
surgeons, amongst whom is Sir Benjamin Brodie, represent the lower part
of the rectum as their common situation. At all events, they occur high
up, in a certain proportion of cases, and even in the sigmoid flexure of
the colon.
* Sir B. Brodie, in Lond. Med. Gaz 1834-35, p. 28.
MALIGNANT DISEASES OF THE RECTUM. 64$
The treatment consists in the occasional employment of mild aperient
medicines and injections ; sometimes in the introduction of a suppository
of opium, or hyosciamus, and in dilating the stricture with bougies.
The exact place and degree of the stricture should first be ascertained,
if possible, with the finger; and if the disease be not in too irritable a
state, the use of the bougie may commence at once. The instrument
should be kept in ten minutes, a quarter of an hour, or longer, every
day, or every other day, according as the patient may be able to bear
it without too much inconvenience. Mr. Salmon considers that it is
better to pass the bougie less frequently than usually recommended, and
at intervals of from three to five days. In some cases, Sir B. Brodie
divides the stricture in two or three places with a bistoire cache, so ad-
justed that the blade may be opened to about one sixth or one fourth of
an inch. The incisions having been made, the larger bougie can be at
once introduced.
Frequently this disease is attended with such irritation of the bowel,
that bougies cannot be resorted to, unless this condition be first obviated
by other means. A suppository of opium, or hyosciamus, at night,
followed by a mild aperient in the morning, will sometimes enable the
patient to bear the use of the bougie. In other instances, a draught,
composed of half a drachm of balsam of copaiba, fifteen minims of liquor
potassae, three drachms of mucilage of gum arabic, and nine drachms of
carraway water, taken thrice a day, has answered the purpose.* When
the feces accumulate above the stricture, and cause considerable irritation
by distending the bowel, an elastic gum catheter should be introduced
through the stricture, and tepid soap and water injected, followed by
warm water. By persevering in this plan every day, or every other day,
the whole collection will soon be cleared away.
If the disease be much advanced, the mucous membrane ulcerated., and
abscesses have formed, the case will rarely admit of complete cure.
I fully concur with Sir Benjamin Brodie, that bougies are scarcely
ever, perhaps never, safe for strictures of the rectum, except when the
obstruction is within reach of the finger.
MALIGNANT DISEASES OF THE RECTUM
Rarely occur till after the middle period of life. At first, the patient
experiences some slight uneasiness about the bowel, followed after a
time by difficulty of expelling the feces, which gradually increases, and
becomes attended with acute lancinating pains, extending through the
pelvis to the back, nates, hips, and thighs. Frequently, these pains are
followed by a sudden gush of a fetid bloody discharge from the bowel, in
consequence of ulceration having taken place. At length, the stomach
gets out of order, and the general health declines. The patient has a
sallow look, denoting the existence of a severe organic disease ; and fre-
quently the scirrhous or medullary affection of the rectum is accompanied
by other visceral disease. Sometimes, but not commonly, if the ad-
vanced stage, there is copious hemorrhage from the bowel ; and abscesses
form around the part, and burst externally. In females, they burst into
the vagina ; and the ulcerated communication between this tube and the
gut may be so free, that a large quantity of feces may be discharged
through the former passage. In the male sex, the ulceration frequently
makes a communication between the rectum and bladder, or the rectum
» Sir B. Brodie, Op. cit. p, 29,
650 PARTICULAR FRACTURES.
and the urethra, and then the patient expels not only air, but feces, with
the urine. Retention of urine is another frequent complication of the
present disease. The patient, after lingering a considerable time in
severe agony, is at last exhausted. In some instances, the diseased mass
completely obstructs the passage of the feces, and symptoms, resembling
those of strangulated hernia, come on ; or the bowel ulcerates immedi-
ately above the obstruction, and the feces, escaping into the cavity of the
peritoneum, excite a fatal attack of peritonitis.*
Whether the disease partake of the character of carcinoma, or of
medullary disease, it consists in the growth of a new substance, whose
pressure seems to produce an absorption of the mucous and muscular
coats of the bowel, -f The cases, in which the mass projects into the
bladder, or vagina, are, no doubt, examples of medullary cancer, or
fungus haematodes. In some examples, the texture of the morbid parts
is such, that it appears like a combination of scirrhus and fungus hsema-
todes, some portions of it being of a soft medullary consistence, and others
hard.
Attempts have been made to remove malignant disease of the lower
part of the rectum with the knife. If ever such an operation be justifi-
able, as Sir Benjamin Brodie observes, it must be where the disease is
very low down, and quite in its earliest stage. Under other circum-
stances, there would be no probability of the whole of the diseased tex-
tures being taken away.
Bougies render the disease worse. Opiate clysters, and injections of
linseed oil, with or without lime water, sometimes allay the pain and irri-
tation. Sir Benjamin Brodie speaks favourably of the liquor potassas and
balsam of copaiba, as internal medicines. The sufferings of the patient
always make the exhibition of anodynes indispensable, and the best are
the acetate and muriate of morphia.
PARTICULAR FRACTURES.
FRACTURES OF THE OSSA NASI
Are by no means unfrequent, a circumstance accounted for by the pro-
minence which these bones form, and their being so little protected by
the soft parts. The injury can only happen from direct external violence,
as blows, or falls on the face. Besides being accompanied by evident
marks of contusion, there is bleeding from the nose ; and in consequence
of the moveable state of the pieces of bone, a crepitus can be felt. In
some instances, the fragments are not at all displaced ; but in others,
where the force applied has been greater, the ossa nasi are driven inwards
towards the nasal fossa3, and, if there has been time for much swelling of
the soft parts to come on, the injury and depression of the bone is to be
ascertained by manual examination; for the tumefaction will conceal
from the eye the nature of the accident. Sometimes, the fracture extends
through the nasal process of the upper jaw-bone I, and across the nasal
* Sir B. Brodie, in Loncl. Med. Gaz. 1834-35, p. 238.
f F. Salmon, on Stricture of the Rectum, p. 6f5.
j: Such a case was under the care of my friend, Mr. Hooper, about three years ago.
The injury was produced by a scrubbing-brush being thrown in the patient's face witli
immense force. There was likewise injury of the brain, The case soon ended fatally.
FRACTURES OF THE LOWER JAW-BONE. 651
duct, attended with a great deal of ecchymosis, a regurgitation of blood
from the lachrymal puncta, and an impediment to the passage of the tears
into the nose. Lastly, the violence may be transmitted through the per-
pendicular plate of the ethmoid bone to its cribriform plate, which may
also break, and symptoms of pressure, or injury of the brain, be excited.
In other instances, there may be no fracture of the cribriform plate, yet
the brain suffer concussion.
When a fracture of the nasal bones is not attended with displacement,
all that is requisite to be done is to apply the cold evaporating lotion ;
but, if the fragments are beaten inwards, they should be restored to
their proper situation, by introducing a director up the nostril, and
adjusting the pieces of bone with the aid of the fingers applied exter-
nally.
Generally, when the fragments are replaced, they have no disposition
to quit their situation again ; but, cases are mentioned, in which it was
judged necessary to afford them some support, by means of lint passed
up the nostril. When the soft parts are much swollen, bleeding, leeches,
and other antiphlogistic means are indicated.
FRACTURES OF THE MALAR AND SUPERIOR MAXILLARY BONES
Are rarely met with, except as the effect of gunshot violence, or other
great mechanical force applied directly to the face. Thus, the cheek-bone
is sometimes fractured by the kick of a horse, or the blow of a hammer ;
under these circumstances, there must be more or less splintering of the
bone, and contusion, or even laceration of the soft parts.
Individuals sometimes attempt suicide by firing a pistol into the mouth,
In such cases, the alveolary processes, with the teeth, are often forced
away, together with the palatine processes of the upper maxillary bones,
the palate bones, the lower turbinated bones, the vomer, and lateral por-
tions of the ethmoid bone. The antrum is of course laid open. In one
case, recorded by Dupuytren, the patient lived till the fortieth day ; and
after death, the cribriform plate of the ethmoid bone was found fractured,
and a bullet lodged in one of the anterior lobes of the brain.
All action of the muscles about the throat is to be suspended, and only
liquid nourishment given with a spoon, or injected through an elastic gum
catheter, passed from the right nostril into the pharynx. Displaced por-
tions of the palate are to be reduced ; splinters of bone removed ; and
any injurious effects on the brain counteracted according to the rules,
delivered in the observations on Injuries of the Head. The soft parts
are to be rectified as well as possible. Antiphlogistic remedies, inclusive
of bleeding, will be indispensable.
FRACTURES OF THE LOWER JAW-BONE
May take place in its body, its rami, the coronoid process, or the neck of
one of its condyles. A fracture sometimes occurs near the chin, though
rarely in the precise situation of the symphysis, generally at ^)me point
between the symphysis of the bone and the insertion of the masseter
muscle. From this insertion, as far back as the angle of the jaw, or root
of the coronoid process, the bone is covered externally by the masseter,
and inwardly by the internal pterygoid muscle, a circumstance explaining
the diminished frequency of fractures in this particular portion of the
bone. It explains also another fact, which is, that when fractures do
happen in this situation, they are not very liable to displacement, because
the foregoing muscles antagonise one another.
652 PARTICULAR FRACTURES.
The lower jaw-bone may be broken in two places at once, namely, on
each side of the symphysis, and, in this case, it is difficult to keep the
middle piece in its right situation, because several muscles, concerned in
depressing the jaw, are attached to that part of it, and draw it downwards
and backwards.
Fractures of the lower jaw may be perpendicular, oblique, or transverse,
that is, parallel to the base of the bone. These last are less common than
perpendicular and oblique fractures ; but, they are occasionally met with,
detaching a portion of the alveolary process, with the teeth in it, from
the rest of the bone.
Fractures of the lower jaw are sometimes comminuted, the bone being
broken in several, or even many, pieces. When the fracture is near the
chin, whether the bone be broken on one side or both, the fragment
comprehending the symphysis is drawn downwards and backwards
towards the os hyoides by the action of the digastricus, mylo-hyoideus,
genio-hyoideus, and genio-hyoglossus.
Fractures of the ramus are not very common, because this part is pro-
tected by the zygoma and masseter. Fractures of the neck of the condyle
are more frequent than those of the coronoid process ; and the condyle
itself may then be drawn forwards and displaced by the action of the
external pterygoid muscle. When the ramus is fractured, the fibres of
the masseter and internal pterygoid, being attached to both pieces, pre-
vent any considerable displacement.
When a fracture of the lower jaw is accompanied by displacement,, the
nature of the accident is readily detected by the inequality in the line of
the base of the jaw ; by an irregularity in the arch of the teeth ; by the
inclination of the mouth more to one side than the other ; and by the
crepitus, plainly distinguishable by manual examination. When the gums
are lacerated, or the injured portion of the bone is exposed by a wound,
as is often the case, forming a compound fracture, the nature of the acci-
dent is still more obvious.
When the ramus, or the neck of one of the condyles, is broken, the pa-
tient will complain of severe pain in the ear ; and when the jaw is moved,
a crepitus is perceptible.
The reduction of a fracture of the lower jaw is easily accomplished by
means of the thumbs introduced within the mouth, and the fingers appliecl
externally to the base of the bone. The surgeon is to draw the displaced
fragment upwards, and a little forwards, so as to bring it on a level with
that fragment which retains its proper situation. By attending to the
line which the base of the jaw ought to form, and the regularity or irre-
gularity of the arch of the teeth, he may always judge of the correctness
of the reduction.
Easy as the reduction is, the maintenance of it is sometimes trouble-
some, requiring that the arch of the teeth in the broken bone should be
kept steadily applied to that of the teeth in the upper jaw. Hence,
when the teeth are naturally irregular, or accidentally deficient, certain
practitioners consider it advisable to introduce a piece of cork between
such teeth as may be present, in order that there may be a smooth even
surface, against which the lower jaw may be confined. Others inclose
the fractured part of the jaw with pasteboard, which on its first appli-
cation is to be softened with warm water, so that it may adapt itself to
the shape of the part. Whether pasteboard is used or not, the broken
jaw is to be well supported, and kept steady with a roller, or, what is
much better, the four-tailed string bandage, the centre of which is to be
FRACTURES OF THE LOWER JAW, 653
put on the chin, and the front tails fastened over the occiput, and the
posterior ones over the forehead. The assistance of a compress under
the part that has a tendency to be drawn downwards and backwards,
is frequently required. Mastication and conversation are to be avoided,
as causing disturbance of the fracture. Hence only spoon victuals should
be allowed. In bad compound cases, the administration of food and
medicines through an elastic catheter is sometimes deemed advisable.
Fractures near the symphysis are very difficult to keep right, on
account of the incessant disturbance of this part of the bone by the
muscles attached to it and the os hyoides ; viz. the digastricus, myio-
hyoideus, genio-hyoideus, and genio-hyoglossus, all of which are put in
action in deglutition. For this case, Mr. Lonsdale has invented a simple,
but ingenious instrument, which grasps the base of the jaw and the arch
of the teeth, so as very effectually to maintain the reduction. Instru-
ments, acting on a similar principle, have also been suggested by various
surgeons both in France and Germany. They are not applicable to frac-
tures of the ramus, coronoid process, or condyle.
When the neck of the condyle is broken, the condyle itself is drawn
inwards and forwards by the action of the external pterygoid muscle ;
and, as it cannot be replaced, we should keep the neck of the bone
inclined towards it, by making the bandage act, particularly on the angle
of the jaw, with the aid of a compress.
Cases are on record, in which the detached condyle, instead of uniting,
was discharged from a subsequent abscess of the part.
Sanson asserts, that when the coronoid process is broken, the fracture
never unites ; but that mastication is performed very well, the masseter
and pterygoid muscles then fulfilling the office of the temporal.
COMPOUND FRACTURES OF THE LOWER JAW
Are by no means uncommon ; and, when it is remembered that this
bone can only be broken by blows, kicks, gunshot injury, and other spe-
cies of direct external violence, the fact is sufficiently accounted for.
The same explanation enables us to understand why the fracture is also,
in many instances, comminuted) and several of the teeth knocked out, or
loosened.
The treatment of a compound fracture consists in removing all loose
splinters of bone ; reducing the fracture, if attended with displacement;
dressing the wound with simple unirritating applications ; applying the
four-tailed sling bandage for the jaw ; giving all food with a spoon in a
liquid form, or, in very bad cases, through an elastic gum catheter, passed
through the nostril into the pharynx ; enjoining perfect quietude of the
part ; and adopting strict antiphlogistic treatment.
If abscesses form, an early opening should be made in them, and the
mouth kept clean with a common gargle, or one containing the chloride
of sodium. When necrosis takes place, the dead portions of bone should
be removed, as soon as exfoliation has advanced far enough. ^
Fractures of the lower jaw are sometimes complicated with laceration
of the artery, or nerve, in the canalis mentalis. I have never seen an
instance, however, in which the bleeding did not soon stop, after the
reduction of the fracture.
As the lower jaw is a particularly vascular bone, the repair of its acci-
dental injuries is generally accomplished with surprising quickness.
Hence, even the worst fractures of it, compound and comminuted ones,
generally have a favourable termination.
654- PARTICULAR FRACTURES.
I have seen two or three horrible cases, in which nearly the whole of
the lower jaw, and the integuments, and the muscles connected with it,
and more or less of the tongue, were shot away; yet, the patients
recovered, and in a more expeditious manner than might have been
expected.
Instances are recorded, where fractures of the lower jaw continued
ununited. In one case of this description, Dr. Physic, of New York,
succeeded in bringing about the union of the bone, by passing a seton
between the fragments.
FRACTURES OF THE SPINE.
If we except the atlas, the tooth-like process of the dentata, and the
spinous processes of the vertebrae in general, one of which may be frac-
tured without any other injury of the spine, it is not usual for a vertebra
to be broken singly. Generally, the body of one vertebra, and the arti-
cular or transverse processes, either of the vertebra above or below that
of which the body is fractured, are likewise implicated.
Fractures of the spine, like those of the cranium, are important and
dangerous, not by reason of the injury of the bones themselves abstract-
edly considered, but on account of the effects produced on the very
essential part of the nervous system, which the vertebrae contain and
protect.
Fractures of the spinous processes may not be accompanied by any
injury of the spinal marrow ; but those extending through one of the
bodies of the vertebra, and the neighbouring articular and transverse
processes, cannot happen, without a degree of violence, that never leaves
the spinal cord entirely free from injury ; and hence, the accident brings
on a train of dangerous symptoms, which, sooner or later, generally have
a fatal termination.
When the fracture is situated in the lower portion of the vertebral co-
lumn, it mostly produces loss both of sensibility and of motion in the lower
extremities, and paralysis of the bladder. When the injury is higher up,
in addition to these symptoms, the abdomen becomes prodigiously dis-
tended with air collected in the bowels ; when it is still higher, the inter-
costal and abdominal muscles are paralysed, and the breathing difficult,
because only carried on by the diaphragm.
When the lower cervical vertebra are broken, and the medulla hurt,
the upper extremities, as well as the lower, are both paralyzed. If the
injury be situated above the fourth cervical vertebra, or the origin of the
phrenic nerve, and, especially, if there be any displacement of the frag-
ments, or compression or injury of the spinal cord, respiration cannot go
on, and immediate death is produced.
Amongst the symptoms of fractures of the spine, priapism, and even
emission of the semen, are by no means uncommon. Both of them were
noticed in a young man under my care, who died from a fracture of the
cervical vertebrae in University College Hospital, in October, 1835.
Such are the consequences usually induced, when a fracture of the
spine is accompanied by displacement of the fragments, and with more
or less compression, or injury, of the corresponding portion of the spinal
cord.
On dissection, the spinous process of the displaced vertebra is found
depressed ; the body of the bone broken through ; and a part of it thrown
more or less forwards or to one side. A displacement from laceration of
the intervertebral substance is very rare. Sometimes blood is extrava-
FRACTURFS OF THE SPINE. 655
sated between the vertebral canal and the sheath of the spinal cord, and
sometimes on the latter part itself. In slight displacements, the medulla
is compressed and bruised ; in more considerable ones, it is generally
torn through ; but the dura mater usually remains entire.
With respect to the symptoms of a fracture of the vertebral column,
many of them, and indeed the most dangerous of them, may be brought
on by a violent concussion of the spinal cord. Hence, the diagnosis is
sometimes obscure. An inequality in the line of the spinous processes,
a crepitus, and even deformity, are occasionally perceptible ; and these
circumstances, joined with the extent of the paralytic disorder, according
to the situation of the injury, as already explained, will leave no doubt
about the nature of the accident.
In consequence of the paralysis of the bladder and sphincter ani, the
patient cannot void his urine, and the feces come away involuntarily. The
qualities of the urine, also, undergo a remarkable change ; for it becomes
strongly impregnated with ammonia. It is likewise found, that when
the patient continues to live a considerable time, with the urine in this
state, the bladder itself becomes thickened, softened, and even ulcerated.
The evacuations from the bowels are often remarkably dark and fetid.
Patients,, who lie for weeks and months in a paralytic state from injury
of the spine, are much exposed to the risk of sloughing of the nates. Sir
Astley Cooper mentions a case of fracture of the lumbar vertebrae, where
the patient lived two years, and then died of such sloughing.
A fracture of the spine is capable of union, just like fractures of other
bones. If the patient get over the danger, arising from the injury of the
spinal cord, the fracture itself is certainly capable of reparation.
The chances of recovery and the length of time the patient may live
after the accident, when a final recovery does not ensue, depend mate-
rially upon the situation of the fracture, and its degree of displacement ;
or, in other words, upon whether the fracture affects the cervical, dorsal,
or lumbar vertebrae, and whether the spinal cord is contused, crushed,
or otherwise wounded. The higher the fracture, the sooner does it gene-
rally prove fatal.
When the dorsal vertebrae are broken and displaced, the patient seldom
lives beyond two or three weeks ; but Sir Astley Cooper knew of one in-
stance in which the patient lived nine months.
When the lumbar vertebrae are fractured, the patient often lives a
month or six weeks ; but he may live a considerable time, and ultimately
perish of sloughing of the nates, or mortification of the lower extremities,
as happened in one of the cases recorded by Soemmerring.
When the fracture is in the lower cervical vertebrae, and attended with
displacement of the fragments, and consequent injury of the medulla, the
patient rarely lives beyond the tenth day, death taking place sooner the
higher the fracture is situated.
Fractures of the cervical vertebrae, involving one of the transverse
processes, are attended with one danger not occurring in fractures of
other vertebrae, viz. laceration of the vertebral arteries. It is the simul-
taneous injury of the spinal cord that is the principal source of danger,
and a fracture of any part of the spine, if it were not for this circum-
stance, would be repaired like other fractures, and the patient recover.
This is proved by many recoveries, known to have followed even fractures
of the upper cervical vertebrae, where no material contusion or compres-
sion of the medulla had taken place.
Sir Astley Cooper mentions a case that occurred in Mr. Cline's prac-
656 PARTICULAR FRACTURES.
tice, where the first vertebra of the neck was broken across, without oc-
casioning death till a twelvemonth afterwards, when the fatal event arose
from the dentiform process losing its support and becoming displaced.
In the museum of the College of Surgeons is a remarkable preparation,
proving the possibility of a person living a twelvemonth after a fracture of
the last dorsal vertebra, during which time nature had made the greatest
efforts to bring about a cure. The patient was kept perfectly at rest, and
the urine at first regularly drawn off with a catheter ; but, by degrees, a
power of emptying the bladder by the action of the abdominal muscles
was regained, and the patient even became well enough to sit up and to
creep slowly down stairs, notwithstanding the lower extremities were
completely deprived of all power of voluntary motion. After death, the
fracture was found completely united by bone. The greatest curiosity
about the case is, that a fragment of the body of the vertebra had been
forced at the time of the accident completely across the vertebral canal,
so as to divide the medulla spinalis, the ends of which, as exhibited in the
preparation, are an inch asunder.
Soemmerring relates an instance, in which the patient lived six months
after a fracture of the body of the first lumbar vertebra, and of the oblique
and transverse processes of the last dorsal one. After death, the fracture
was found perfectly united by osseous matter.
In one of Cruveilhier's engravings, is the representation of a fracture
of the second lumbar vertebra, attended with displacement. The patient
recovered from paralysis of the lower limbs, and all other ill consequences
of the accident, but died of another disease four years afterwards. The
greater part of the broken vertebra was pushed towards the left side and
backwards ; but the rest of it, comprehending the right articular and
transverse processes, and the portion of the body connected with them,
remained in its natural situation. The left oblique and transverse pro-
cesses were fractured ; bony matter had been thrown out for the repair
of the injury — not from the fragments themselves, but, as Cruveilhier
states, rather from the vessels of the surrounding parts, the cellular and
fibrous tissues, and the muscles.
In the case recorded by Mr. Barlow (vol. xvii. Med. Chir. Trans.), con-
sisting of a fracture of the first lumbar vertebra, sensation began to return
in the legs and thighs after eight months, and the patient could raise
himself in bed, and in twelve months could bear to be drawn out in a
small chaise. After an attack of fever, sphacelation of the heel took place,
pus was voided with the urine, and gangrene commenced over the sacrum,
of which the patient died. The upper portion of the spine was found to be
thrown forwards, and connected to the fore and upper part of the inferior
fragment by callus. The articular processes of the first lumbar and last
dorsal vertebraa were dislocated, the vertebral canal was lessened in di-
ameter to one half of its natural extent, pus was found in the pelvis of
each kidney, and the bladder was diseased.
Mr. Lawrence mentions a case of fractured spine, where the patient
lived a considerable time after the accident, and at length died, when
the fracture was found soldered together by bone ; but the osseous matter
had so nearly filled up the vertebral canal, that there was only just room
enough in it for the end of a blowpipe. The spinal cord had been com-
pletely divided.
With respect to the treatment, we are first to consider what ought to be
done when there is no displacement. Here the indications would be to
draw off the urine once or twice a day with a catheter, and to keep oil'
FRACTURES OF THE SPINE. 657
inflammation of the spinal cord and its sheath by antiphlogistic treatment,
especially by bleeding, active aperient medicines, and perfect quietude in
the recumbent position.
In a case of fracture with displacement, where the patient is not quickly
destroyed by the extension of the paralysis to the diaphragm, and other
important organs, or by the case being complicated with rupture of the
kidneys, spleen, and internal hemorrhage, ought we to attempt to reduce
the fractured vertebrae, as the only chance of removing the pressure from
the spinal cord? Now, experience has little to adduce in favour of such
attempts, which have been made from time to time, but generally in vain.
In a patient, from whom a specimen in the museum of University College
was taken, the attempt was made, but to no purpose. In the case
recorded by Mr. Barlow, of Writtle, it was also made ; not with any bad
consequences, indeed, but without success, as on dissection the fracture
was found united, but in a state of displacement. The reduction had not
in reality been accomplished, or, if accomplished, had not been maintained.
In making the experiment, there must be some risk of rendering things
worse, so imperfectly must we always be acquainted with the exact position
of the fragments. But, even if the reduction were accomplished, and could
be maintained, the injury, which the spinal cord has received, will yet
remain, and all the bad consequences of it continue.
The notion of removing pressure from the spinal cord, as is done from
the brain, by means of the trephine, led to the scheme of cutting away
the spinous processes and adjoining bony arches in the situation of the
injury with Key's saws ; an operation which, I believe, with Sir Charles
Bell, would generally of itself destroy all possibility of the patient's re-
covery.
Neither would the removal of such portion of the vertebral column
make any difference in the injury of the medulla already existing, unless,
indeed, it were an augmentation of it; nor could it alter the position of
the fragments of the body of the broken bone.
My views would therefore restrict the treatment to means calculated
to lessen the risk of inflammation and suppuration of the medulla, especially
common antiphlogistic treatment, including rest in the recumbent posture.
The urine should be drawn off once or twice a day with a catheter, which
in these cases should not be left in the bladder, as the beak of it is apt to
produce inflammation and ulceration of that organ, followed by effusion
of urine and peritonitis. The bowels are to be regulated with castor or
croton oil. If possible, the convenience and comfort of a fracture-bed
should be afforded ; and when there is a tendency to sloughing of the
nates, the hydrostatic bed should be employed.
Should life continue long enough to justify the inference that the frac-
ture is united, though some of the paralytic effects of the accident still
remain, we might try the effect of iodine liniments, blisters, the moxa, or
issues. The internal and external use of strychnine has been suggested;
but I know of no facts in its favour.
Very curious effects are sometimes exemplified in injuries ana diseases
of the spine, which are referrible to the double roots of the spinal nerves ;
the anterior of which are for voluntary motion, the posterior for sensation.
Thus, a few years ago, I attended a man in Black -Horse Yard, Rathbone
Place, who was paralytic in both lower extremities, in consequence of a
blow on the spine, received in a fall from the mast of a ship ; one limb
having lost all feeling, the other all sensation. In fractures of the cervical
vertebra?, below the fourth, the arms are paralytic, but one may be more
u u
G58 PARTICULAR FRACTURES.
so than the other ; and lately in University College Hospital,, I had a
patient with fracture of the fifth cervical vertebra, with displacement, and
of the arch of the fourth without it, who had no power of action in any of
the muscles of the upper extremities, yet he possessed feeling in these
limbs down to the elbow.
FRACTURES OF THE STERNUM
Are less frequent than might be expected, considering its exposed situa-
tion in front of the chest. For this fact, there seem to be two reasons ;
the first is, that the sternum is a spongy bone, less brittle than many
others ; the second is, that it rests on the cartilages of the ribs, which
form so elastic a support for it, that it is enabled to elude any common
violence by the yielding of those parts. However,, notwithstanding these
circumstances, it is sometimes broken. In the course of the last five
years, we have had in University College Hospital several examples of
fracture of the sternum. It may be fractured by gun-shot violence, or
by the passage of a heavy carriage over the trunk, or by any other consi-
derable force applied directly to the sternum. But the fracture may
occur in another manner, which would not be expected. M. David, in
his Memoire sur les Contrecoups, relates a case, which took place in the
following way : a bricklayer fell from the top of a house, and as he was
falling, the middle of his back struck against a piece of timber, and the
consequence of this blow was a fracture of the sternum. Now, the ex-
planation given by M. David of the mode in which the sternum hap-
pened to suffer injury, is, that it was broken by the violent action of the
abdominal muscles, diaphragm, and muscles of the neck, connected
with this bone, whereby it was powerfully drawn at once in different
directions. The truth of this account is confirmed by the curious fact,
that the sternum is sometimes fractured during parturition by the violent
efforts of the muscles attached to it ; for cases of this kind are upon
record.
A fracture of the sternum is not in itself dangerous ; but it may be
followed by severe and even fatal consequences, on account of the tho-
racic viscera happening to be injured at the same time : thus, the lungs
or the heart may be penetrated by a fragment of a broken sternum. In
the Museum of University College, is a preparation, exhibiting a lace-
ration of the right ventricle of the heart by a portion of fractured sternum.
M. Sanson met with a similar case, in which the heart was torn by a
sharp spicula of a broken sternum. Blood may also be copiously effused
in the cellular tissue of the anterior mediastinum ; and sometimes consi-
derable inflammation of this texture will ensue, leading to the formation
of abscesses, and to various degrees of necrosis in the injured bone. One
occasional complication of a fracture of the sternum is emphysema, or an
inflation of a great part, or of the whole, of the cellular tissue of the body,
which can only take place, however, when a spicula of bone happens to
wound the lungs.
As the sternum is a superficial bone, its fractures are readily detected
if there be displacement, the lower portion is generally situated in front
of the upper one, and sometimes overlaps it. In most instances, a cre-
pitus is perceptible, produced by the motion of the fragments on one
another in respiration, and particularly obvious when the patient coughs,
if the surgeon's hand be applied to the front of the chest. The patient,
indeed, is usually teased with a frequent dry cough, and when the lungs
have been pierced by a spicula of bone, there is a spitting of blood, which
FRACTURES OP THE STERNUM. 659
may be followed by emphysema. The cough is particularly annoying,
from the motion and disturbance it causes of the injured part.
If there be no displacement of the fracture, no complication, the prin-
cipal indication is to keep the fragments as quietly as possible in their
present position, which is most effectually accomplished by applying a
broad roller round the chest, and making it press on the broken bone and
ribs, so as to limit and diminish their motion. The bandage should be
rather tight, and kept from slipping down by passing a piece of tape over
each shoulder, from the centre of the roller behind to a point in front of
the chest. If the tapes were fastened too near the axillae, they would
slip off the shoulder, and not answer the purpose of their application. In
order to keep the fragments as quiet as possible, the trunk should be
inclined forwards, and the pelvis raised, so as to relax the abdominal mus-
cles. Whenever the sternum is broken, another indication is to bleed
the patient freely, because the risk of inflammation in the chest must be
guarded against. Bleeding is also one of the most effectual means of
relieving the cough, which always occasions severe pain, and a great deal
of disturbance of the injured part. The lancet, antiphlogistic measures
in general, especially quietude, the application of a broad bandage round
the thorax, the relaxation of the recti abdominis, and the administration
of an emulsion with a little opium, for the palliation of the cough, may be
said to constitute the principal means of treatment.
But, supposing the fracture were attended with displacement, some
practitioners advise us to relax the abdominal muscles, asserting that we
shall then more easily succeed in reducing the fracture by pressure ;
while others say it is best to extend the spine by putting a bolster under
the loins, as they assure us, that, in this position of the patient, the frag-
ments can be more readily reduced. Now, if we were unable to effect a
reduction by these or other plans, then the question would present itself,
whether we ought to perform an operation for the purpose of bringing
about a coaptation of the bone ? Whether we should be justified in
making an incision down to the fracture, and trying to raise the depressed
portion of bone to its proper level, by means of an elevator ? Without
pronouncing an unqualified condemnation of this scheme, I may safely
remark, that before we think of putting it in execution, we should be sure
that the existing bad symptoms are really produced by compression of
the thoracic viscera, and that they are of a sufficiently urgent nature. A
moderate depression of a portion of the sternum would not be likely to
create any dangerous symptoms, inasmuch as that bone lies over the an-
terior mediastinum, which merely contains cellular substance, pressure on
which would certainly occasion no perilous consequences. But, we
are also to recollect that the thoracic viscera may be injured, and that
such injury maybe the true cause of the urgent symptoms. In this case,
merely elevating a moderately depressed portion of the sternum would
promise little relief. However, what I wish to be well considered is,
whether the bad symptoms are produced by mere compression of the
thoracic viscera, or by any other description of mischief. A case is re-
corded by Petit, in which the patient recovered from an unreduced frac-
ture of the sternum, but experienced severe oppression in his chest, and
great difficulty of breathing during the rest of his life. It seems, there-
fore, that, if the fragments are left displaced beyond a certain degree,
the patient may suffer from the sternum being united in this deformed
state. The cases, in which we might be called upon to trephine the
sternum (another proceeding fortunately oftener spoken of than done),
u u 2
550 PARTICULAR FRACTURES.
are, first, those in which purulent matter is confined in the anterior me-
diastinum in considerable quantity, so as to occasion dangerous oppression
of the lungs; and, secondly, others in which it might be deemed right to
adopt the practice to expedite the removal of a portion of dead bone.
But even circumstances of this kind, truly requiring the operation, are
exceedingly rare, for abscesses make their way outward, and dead bone
will in time separate by the process of exfoliation. The formal appli-
cation of the trephine to the sternum, for the purpose of raising a de-
pressed portion of it, I think, would hardly be deemed justifiable in the
present state of surgery.
FRACTURES OF THE RIBS.
The ribs are broken almost as frequently as any bones which can be men-
tioned, except the clavicle and radius ; the middle ones being those which
are most exposed to the accident, and especially the part of them near
what is termed their angle. The upper ribs are rarely fractured, because
they are protected in front by the clavicle, and covered by the pectoral
muscles ; while behind they are shielded, as it were, by the scapula and
the thick muscles of the back. As for the lower ribs, they generally
escape, in consequence of their being so short and moveable. The dis-
placement of the fracture can only take place either inwards or outwards.
On account of the connection of those ribs, which are usually broken, to
the sternum in front, and to the vertebrae behind, there can evidently be
no displacement in the direction either backwards or forwards. Neither can
the ends of the fractured rib be thrown upwards or downwards, because
the intercostal muscles, which are attached equally to both fragments,
resist such an occurrence. However, the ends of the fracture may be
forced inwards, or they may incline outwards ; but, in by far the greater
number of instances, it is in the direction inwards that the displacement
happens. The detection of a fracture of the ribs is not generally attended
with difficulty ; for if we merely place our hand on the part that has been
struck, and desire the patient to cough, we can mostly perceive a cre-
pitus ; or the natural movements of respiration will render the same
symptom manifest, if we merely press our hand upon the injured part of
the chest. However, when the ribs are broken towards their posterior
ends, under the thick muscles of the back, we may experience a great
deal more difficulty in detecting a crepitus. When one or more of the
ribs are broken, the patient is annoyed with a sharp pricking pain in the
situation of the injury, and has a frequent dry cough, which, by the dis-
turbance it occasions of the fracture, gives considerable pain. Now,
supposing we were not able to feel the crepitus, and the diagnosis were
obscure, we should then act according to the wise maxim laid down by all
the best writers on surgery ; namely, adopt precisely the same treatment
as if the occurrence of fracture were a matter of certainty.
A simple fracture of one of the ribs, unattended with any particular
complication, such as a wound of the lungs, emphysema, or effusion of
blood in the chest, is not productive of any serious danger, and generally
has a favourable termination. But when several ribs are broken, and
blood is extravasated in the chest, or the lungs are wounded, the accident
often has a fatal result. We hear almost every day of cases, in which
several ribs are broken by the passage of carriages over the chest, and the
fracture complicated with injury of the thoracic viscera, effusion of blood
in the thorax, or an extensive inflation of the cellular tissue, constituting
what is termed emphysema.
FRACTURES OF THE CLAVICLE. 661
When the accident is free from the complications which have been
specified, the right treatment is obvious. It is a rule when a surgeon is
called to a strong young person, who has broken one or more of the ribs,
to practise venesection. This is done with the view of diminishing the
risk of inflammation within the chest, and the chance of internal hemor-
rhage. Then, another indication is to keep the rib as free from motion
as possible. We are to endeavour, therefore, to prevent the intercostal
muscles from taking part in the performance of the function of respiration,
and try to make the patient breathe principally by means of the dia-
phragm and abdominal muscles. For this purpose, a broad roller is
firmly applied to the chest ; or a strong napkin, the two ends of which
must be brought from behind forwards, and then laced over the sternum.
The patient is thus enabled conveniently to regulate the tightness of the
bandage himself, and, for the sake of his own comfort, he will be sure to
maintain the requisite degree of pressure ; for, when the roller becomes
too slack, he begins immediately to experience the pricking pain again,
and his cough is more troublesome. It is evident, that whether we
employ a broad roller, or a napkin, it would slip down towards the loins,
if the precaution were not taken to attach two pieces of tape to the
central part of it near the spine, each of which is to be carried over the
nearest shoulder, and sewed to a point of the bandage or napkin below
the clavicle. The French apply another tape under the perinaeum, to
prevent the roller from slipping upwards, but this would only be neces-
sary in very corpulent subjects, and is rarely or never made use of in this
country;
Fractured ribs, not attended with the complications already noticed, are
generally treated with great success ; and, in four or five weeks, a firm
union takes place. If the patient be left entirely to himself, without any
kind of surgical assistance, a broken rib will also, for the most part, unite ;
but in the museum of University College, is a specimen of a fracture of
six ribs, where the fragments are only connected by a fibrous or liga-
mentous substance. Without speaking positively, I should presume, that,
in this example, no effectual means had been adopted to keep the ribs
motionless during the treatment.
In old persons, the cartilages of the ribs and the ensiform cartilage are
frequently ossified ; and when they are in this state, they are liable to be
broken. The ensiform cartilage has been known not merely to be frac-
tured, but to be depressed, or beaten inwards, so as to lacerate the
diaphragm, and tear the liver. The cartilages in their natural state may
also be ruptured ; and, when this happens, they do not unite by cartilage,
but by osseous matter, a bony clasp being formed, by which the fragments
are bound together. The treatment of the latter injuries is the same as
that ordinarily adopted for fractures of the ribs.
FRACTURES OF THE CLAVICLE.
The clavicle is perhaps more frequently broken than any other bone in
the body ; and for this there are several reasons. The accident is of
frequent occurrence, in consequence of the bone serving two offices,
which expose it to the effects of violence applied either to the shoulder
or arm ; namely, it keeps the scapula at a proper distance from the
sternum, and is, at the same time, a point of support for the humerus,
every impulse communicated to which bone is transmitted to it. In
addition to these considerations, it is to be recollected, that the superficial
situation of the clavicle in front of the shoulder, across the upper part of
u u 3
662 PARTICULAR FRACTURES.
the chest, must expose it to injuries from blows, the fall of brickbats, or
other violence applied directly to it.
Its middle portion, or greatest convexity, is more frequently broken
than any other part of it, unless the fracture happen from a direct blow ;
in which case the injury may occur where the violence is applied. In
such a case, the soft parts are always contused, and sometimes lacerated.
In this manner, a comminuted fracture may be produced ; and, if the
violence be great, the subclavian vessels and some of the nerves con-
verging to form the axillary plexus, may be injured. But, although the
middle of the clavicle is more frequently broken than any other part of
it ; yet, in cases of direct violence, it usually breaks precisely in that
situation on which the force has fallen : thus, if the blow has taken place
towards that end of the bone which is nearest the acromion, then the
fracture will be there ; if towards the sternal extremity of the bone, then
that portion of it will be broken. But fractures of the middle third of
the bone are commonly produced in another manner. One office of the
clavicle is to hold the scapula at a convenient distance from the sternum,
so that the motions of the arm may have a due degree of freedom and
extent. Now, this disposition is one of the principal causes of the great
frequency of fractures of the clavicle; for, as this bone supports the sca-
pula, every impulse and force transmitted to the shoulder is communicated
to the clavicle, which, being slender, first bends and then breaks, just as
a stick would break under a force similarly applied to it, namely, in its
central part. In consequence, then, of the clavicle serving as a point of
support for the scapula, and, indeed, in particular positions, for the whole
of the upper extremity, it necessarily follows, that, when a person falls
upon his arm, in an extended state, the shock will be communicated along
the humerus to the glenoid cavity of the scapula, and thence to the cla-
vicle itself; so that whether the person fall on his hand, shoulder, or
elbow, the clavicle is likely to be fractured at its centre.
A material difference in fractures of the clavicle will depend on one
particular circumstance ; namely, whether the fracture has taken place
more towards the sternum, than the two bands of ligament which tie the
coracoid and acromion processes of the scapula to the clavicle. If it has
taken place on the scapulary side of the coraco-clavicular ligament, it
must be clear, that there can be very little displacement, because the
outer fragment will be fixed by the ligament binding the clavicle to
the acromion, while the inner one is prevented from quitting its place by
the coraco-clavicular ligament itself. But when the fracture takes place
within the latter ligament, or, in other words, more towards the sternum,
yet not within the limits of the rhomboid ligament, which ties the inner
end of the clavicle to the cartilage of the first rib, there will then be
considerable displacement, because nothing prevents the outer fragment
from being drawn down by the weight of the arm and shoulder, or from
being carried forwards and inwards by the pectoralis major and subclavius
muscles. Hence, whenever the fracture is within the coraco-clavicular
ligament, the displacement must be downwards, forwards, and inwards.
Another fact to be remembered is, that it is always the outer fragment that
is really displaced ; the inner one being kept from quitting its natural
level by the action of the sterno-cleido-mastoideus, and of the pectoralis
major, which antagonise each other.
When the fracture takes place on the outside of the coraco-clavicular
ligament, there is little or no displacement ; and, if any at all occur, it is
only in a trifling degree, such as may be produced by the outer fragment
FRACTURES OF THE CLAVICLE. 663
being slightly depressed,, so as to slope downwards more than natural.
In this case, if we take hold of the humerus, and push it directly upwards,
we find that the outer fragment of the clavicle is brought to its proper
level again. Some fractures of the clavicle are comminuted ; this may
happen when the injury has been produced by direct violence ; and then
the nerves converging to form the axillary plexus, are exposed to con-
tusion and laceration. The late Mr. Earle recorded an interesting case of
comminuted fracture of the clavicle, where these nerves had been so
injured that paralysis of the arm ensued ; and it was singular that the
patient could not afterwards put her hand into moderately warm water
without the effects of a scald being produced, characterised by vesica-
tions, redness, &c. The fact is curious, as proving the share which the
innervation, or the nervous influence, has in enabling the different parts
of the body to bear particular temperatures.
When the clavicle is broken by a force applied to the outer part of the
shoulder the fracture is mostly oblique; and if the violence has been very
considerable, the end of the bone may protrude through the skin, and the
case be compound.
The symptoms of a fractured clavicle are of the following kind : — There
is a depressed and sunk state of the shoulder, more especially when the
fracture is within the coraco-clavicular ligament; indeed, the shoulder
will then be considerably depressed, and at the same time inclined to-
wards the sternum ; so that the space between the median line of the
trunk anteriorly and the tip of the acromion will be remarkably diminished.
An attentive practitioner will at once notice the approximation of the
shoulder to the sternum. Then if we pass our finger from the sternal ex-
tremity of the clavicle, regularly along that bone, as soon as it reaches
the situation of the fracture, we shall perceive a sudden depression in the
line of the bone, arising from the circumstance already sufficiently ex-
plained ; namely, the inclination of the external fragment downwards,
inwards, and forwards. When we push the shoulder upwards, backwards,
and outwards, so as to bring the external fragment into its proper situa-
tion, a crepitus is perceptible ; or, even without elevating the shoulder, if
the displacement is not so great as entirely to separate the two ends of
the fracture from each other ; then the crepitus may be distinguished by
putting our finger on the injured part and gently moving the humerus.
When we first come to a patient whose clavicle is fractured, we usually
find him sitting in a particular position, with his head inclined towards
the affected shoulder, and his fore-arm bent, and quietly supported on the
other hand. He spontaneously chooses this posture, in order to relax the
sterno-mastoid muscle, and to prevent all motion of -the upper extremity,
which would be exceedingly painful to him. Another sign of a fractured
clavicle is the patient's inability to put his hand to his forehead ; and the
reason of this circumstance is, that the humerus has now no fixed point
of support, and is deprived of that fulcrum which the clavicle naturally
affords it. The infirmity which I speak of will always present itself,
unless the fracture be on the outside of the coraco-clavicular ligament ;
for then the patient can sometimes raise his arm, and imperfectly perform
the movement referred to. In other instances, he cannot bring his hand
into contact with his forehead, except partly by bending the fore-arm,
without moving the humerus, and partly by inclining the head down-
wards, so as to make it meet the hand. Lastly, in consequence of the
way in which the outward fragment is displaced, there is always a mani-
fest prominence, occasioned by the end of the internal fragment; the
uu 4?
(364? PARTICULAR FRACTURES.
rising end of the lone, as it was termed by the old surgeons, who errone-
ously considered it to be above its proper level.
In the treatment, we should always remember the direction of the dis-
placement, and attend particularly to the circumstance, that the outer
fragment is carried inwards, forwards, and downwards, and that the in-
ternal one remains in its natural situation ; indeed, the outer one may be
situated directly under it. Therefore, in order to replace the external
fragment, we should carry the shoulder backwards, outwards, and up-
wards, and take off the weight of the upper extremity. Now in this
country, in nine cases out often, the contrivances, used for the treatment
of broken clavicles, are the sling and the figure of 8 bandage, with which
the shoulders are braced backwards. A roller is passed round one
shoulder, and then across the back to the other shoulder, round it, and
then over the back again, crossing the first part of the bandage, and being
continued in the form of an 8. But this bandage does not scientifically
fulfil all the indications required ; and it even has a wrong operation ; for
it tends to draw the shoulder inwards, or towards the sternum, as much
as it inclines it backwards ; and the more tightly it is applied, the more
it will force the shoulder inwards. After the explanation which I have
given of the nature of the displacement, I scarcely need remark, that this
action of the bandage is contrary to the proper object in view, viz., that
of inclining the shoulder outwards. The French surgeons, who seem to
have devoted great attention to the treatment of fractures, have contrived
a better method — one that is more judicious and efficient. Desault, the
great surgeon at the Hotel Dieu before Dupuytren, employed a cushion
or compress, thick at the upper part, and thin below, or formed like a
wedge. He put the thick end of this wedge-like compress immediately
under the axilla, and fastened it there by means of two pieces of tape
passed over to the other shoulder. Now this compress, when the humerus
is pressed close to the side, has the effect of throwing the head of that
bone outwards ; so that Desault, in truth, made the humerus a lever,
with which he inclined the shoulder outwards, upwards, and backwards,
and the wedge-shaped compress was his fulcrum. The elbow ought to
be confined and supported in a sling, and kept close to the side with a
bandage. Various mechanical inventions are sold for the cure of broken
clavicles ; but, so far as I can judge, if we understand the indications to
be fulfilled, we shall always be able to accomplish every purpose with
the aid of a compress, roller, and sling.
Boyer employs first a belt, which is buckled round the chest ; secondly,
a piece of dimity or quilted cloth, furnished with four straps, and intended
to be put round the arm. With these straps, the arm is fastened to so
many buckles on the belt. Thirdly, Boyer employs a sling to support
the fore-arm and elbow. When the fracture is within the coraco-clavicu-
lar ligament, greater attention will be necessary, than in other instances,
to keep the displaced fragment upwards, outwards, and backwards, because
the degree of displacement is more considerable.
If a young female of the higher class of society were to break the
clavicle in the latter situation, she should not merely be treated with
mechanical means, but kept quiet in the recumbent position for two or
three weeks, because any deformity of the neck, caused by irregularity in
the union of the bone, which it is often difficult to prevent without such
precaution, would be a considerable disadvantage to her.
FRACTURES OF THE SCAPULA. 665
FRACTURES OF THE SCAPULA/
The greater portion of this bone is so deep, and so protected by thick
muscles, that fractures of it rarely take place. The acromion is oftener
broken than any other part, and next the lower angle. The coracoid
process is sometimes fractured, but much less commonly than is generally
believed ; and, I think, the same observation may be made with regard to
the neck of the scapula, which is so strong and so well guarded from the
effects of external violence, that a fracture of it is by no means a common
occurrence. In some instances, portions of the glenoid cavity are broken
off; but this also is an event which is oftener talked of than really met
with. The body of the bone is but seldom broken. Its fractures may be
perpendicular, but the greater number of them are transverse. Some-
times the scapula is fractured in more than one place ; and it may be
broken in several pieces by great and direct external violence.
Fractures of the body of the scapula can only be produced by direct
violence, as by a blow, a gunshot injury, or the passage of a heavy body
over it. I know of no other way, in which such an accident can happen ;
and this fact explains why severe injury of the soft parts generally accom-
panies it. Sometimes the violence of the injury is such as to extend
its effects to the thoracic viscera, and to cause effusion of blood in the
chest.
When the acromion is broken, the patient inclines his head towards the
injured shoulder, the arm hangs motionless by the side of the trunk ; an
acute pain is felt in the situation of the injury; when the patient attempts
to move his arm the pain is much aggravated, and, in consequence of the
deltoid being partly attached to the acromium, some of the fibres of that
muscle lose their point of insertion, and therefore cannot afford due
support to the humerus, which sinks down, and consequently a part of the
natural fulness and rotundity of the shoulder is lost. In fact, the head
of the humerus is not held in its place by ligaments, but principally by the
muscles and tendons surrounding the joint. A fracture of the acromion
may be known also by the presence of a crepitus; for, when we place one
of our fingers on the broken part, or hold the extremity of the acromion
between the finger and thumb, and then push up the humerus, or move it
freely in various directions, the crepitus will be distinguishable. An inter-
space or irregularity may likewise be felt between the fragments. The
shape or rotundity of the shoulder can be restored by pushing up the
humerus ; but directly the arm is allowed to descend again, the shoulder
resumes the same flattened appearance, which had been noticed previously
to the elevation of the limb.
If a fractured acromion be left to itself, it will generally unite either
by bone or a ligamentous fibrous substance. Now, when osseous union
takes place under such neglect, the outer fragment is liable to point more
downward than it ought, and the shoulder to be considerably weakened ;
a fact, first pointed out by Cheselden. A fracture of the acromion ought
to be treated nearly in the same manner as a broken clavicle. The first in-
dication is to take the weight of the upper extremity off the shoulder, by
supporting the fore-arm in a sling, and keeping the elbow well up. An-
other indication is to prevent all motion of the humerus, which is accom-
plished by means of a sling and roller. A third is to incline the head of
the humerus a little outwards, an object fulfilled with the assistance of a
wedge-shaped cushion. Some surgeons prefer keeping the arm raised
from the side, in order to relax the deltoid muscle, a method which ought
666 PARTICULAR FRACTURES.
to be adopted if the patient were obliged by circumstances to remain in
bed. The acromion sometimes unites by bone ; sometimes by ligament.
In the museum of University College are two preparations, one of which
illustrates the first mode of union; the other,, the second.
When the lower angle of the scapula is broken off, it is displaced down-
wards and forwards by the action of the serratus major anticus. In the
treatment, the humerus may be brought forwards across the chest, and
the hand confined upon the opposite shoulder ; this position of the limb,
which has the effect of bringing the fragments nearer together, is adopted
abroad ; but, in this country, when any part of the body of the scapula is
fractured, we merely apply the spica bandage, the roller employed for
which, after crossing over the scapula, is carried round the joint, and then
over the back of the trunk, to below the opposite axilla, whence it passes
in front of the chest to the injured shoulder, which it again encircles.
The roller is conveyed in the directions here enumerated, until nearly the
whole of it is expended, when it is made to conclude with a horizontal
circle round the thorax. Such is the celebrated spica bandage, which is
of little or no use; for it fulfils no particular indication, except the trivial
one of retaining in its place the soap plaster, occasionally put over the
injured part. The sling is here the efficient part of the apparatus.
When the coracoid process is fractured, a gread deal of mischief is
generally done to the soft parts of the shoulder, just below the clavicle ;
for this fracture can only happen from great and direct violence. Hence
the nature of the injury of the bone is often concealed by the great
degree of swelling. Hence also much of the treatment consists at first in
measures for diminishing the swelling, as venesection, leeches, cold lotions,
£c. The coracoid process, when broken off from the rest of the scapula,
is liable to be drawn downwards by the short head of the biceps, the co-
raco-brachialis and pectoralis minor, the muscles connected with it ; they
ought, therefore, to be relaxed. In one complicated instance, dissected
by Mr. South, the coracoid process was broken, about half an inch from
its tip, into two unequal pieces, the smaller of which remained connected
above with the triangular ligament, and below with the short head of the
biceps, which had pulled it down as far as the ligament would allow.*
In the treatment, the shoulder should be kept quiet, which is effected by
keeping the arm at rest with a sling and roller ; for if the arm be motion-
less, the shoulder will also remain quiet.
Fractures of the neck of the scapula are not common accidents, but they
are possible, and liable to be mistaken for dislocations of the humerus
downwards, inasmuch as the weight of the limb carries the arm down
along with the glenoid cavity of the scapula, and a hollow is felt under
the acromion.
However, the difference between the two cases may readily be per-
ceived, by attending to the following circumstances. In a dislocation,
there is no crepitus ; we cannot move the humerus about without op-
position, as we can when the neck of the scapula is broken ; the head of
the humerus can be felt either in the axilla, or under the pectoral
muscles ; the axis of the humerus is changed ; and the motions of the
arm are stiff and confined. But, in a fracture of the neck of the scapula,
we cannot feel the head of the humerus in either of the situations which
I have specified ; a crepitus may be distinguished when we take hold of
the coracoid process, and the humerus is pushed up and moved about ;
* J. F. South in Mai. Chir. Trans, vol. xxii. p. 105.
FRACTURES OF THE HUMERUS. 667
no particular resistance is then made to the motion of the arm ; and the
proper shape and position of the shoulder and arm are easily restored by
pushing the humerus upwards ; but, as soon as the support is removed,
the deformity returns.
The treatment consists in keeping the head of the humerus inclined
outwards, by means of a thick cushion below the axilla ; in supporting
the elbow effectually with a sling ; and in preventing all motion of the
humerus by binding it to the side of the chest with a roller.
FRACTURES OF THE HUMERUS
Are distinguished into those which take place higher up than the inser-
tions of the pectoralis major and latissimus dorsi muscles; into those of
the middle of the shaft of the bone ; and into others nearer the elbow.
Instances have been known, in which the fracture was situated precisely
in the true neck of the bone : Sir Astley Cooper had an opportunity of
dissecting a subject, in which he found the fracture actually placed, as I
have mentioned, within the capsular ligament. No bony union had oc-
curred; the fragments being joined together by means of a ligamentous
substance.
A fracture, through the anatomical neck of the bone, at the tubercles, is
a case which has lately been further considered by the same experienced
surgeon. He describes the accident as being of frequent occurrence in
young persons ; as happening more rarely in the old ; and still more rarely
in the middle age. In children, it arises from a fall on the shoulder, and
it has been known to be complicated with a fracture of the clavicle. As
the head of the bone remains in the glenoid cavity, the shoulder does not
lose its rotundity as in a dislocation. A projection of bone is perceived
upon the point of the coracoid process; and when the elbow is raised and
brought forwards, this projection is rendered very conspicuous. By drawing
down the arm the projection is removed ; but it immediately reappears
on the extension being discontinued. The motion of the shoulder is
painful ; and the child can only raise the arm with the other hand; and
the elbow is with difficulty raised from the side. After the accident, a
great quantity of ossific matter is thrown out from the periosteum and
fractured neck of the shaft, but very little from the broken head of the
bone. In one of Sir Astley Cooper's preparations, a cup of bone is formed
upon the fractured neck, so as to prevent the head from being separated
from it.
In a young subject, Sir Astley Cooper recommends treating this case
by binding a splint on the front and back part of the arm with a roller ;
placing a pad in the axilla ; and using a clavicular bandage ; the hand, but
not the elbow, being supported in a sling. As in old persons the injury
is more severe, leeches, evaporating lotions, and quietude, are to precede
the application of the mechanical means. In the young, passive motion
is to be employed in a month; and, in the old, at the expiration of from
two months to twenty weeks.* l £ *"
When the fracture takes place somewhere between the tubercles, and the
insertions of the pectoralis major, coraco-brachialis, latissimus dorsi, feres
majoi', and deltoid, the upper fragment has a tendency to be drawn out-
wards by the supra-spinatus, infra-spinatus, and teres minor, and the
lower fragment to be pulled inwards by the latissimus dorsi and pectoralis
* Sir Astley Cooper in Guy's Hospital Reports, vol. iv. p. 277.
668 • PARTICULAR FRACTURES.
major, and at the same time upwards by the biceps, coraco-brachialis, and
long portion of the triceps.
Fractures of the upper part of the humerus should be discriminated
from dislocations. In a fracture, as the head of the bone is yet in the
glenoid cavity, there is not the hollow under the acromion remarked in a
dislocation : however, there may be a little depression, or diminution of
the rotundity of the shoulder, in consequence of the lower fragment
being sometimes not displaced upwards so as to produce a shortening of
the limb, but, on the contrary, drawn a little downward by the weight of
the part, so as to put the deltoid on the stretch, and thus, in one respect,
a degree of resemblance to a dislocation may be produced. On careful
examination, however, the head of the humerus may be felt in the glenoid
cavity, and the shaft of the bone does not offer that resistance to being
moved about in various directions, which is experienced in a dislocation.
In the latter case, the head of the bone may generally be felt either in
the axilla, or under the pectoral muscles : in a fracture, there is a cre-
pitus ; but, in a dislocation, this symptom is absent.
In the fracture between the tubercles and the insertions of the above-
named muscles, when the elbow is moved upwards, the broken extremity
of the lower fragment projects on the inner side of the coracoid process,
and it sinks when the support of the elbow is removed. When the arm
is rotated at the elbow, the broken end of the main portion of the bone is
felt to roll. There is no marked depression under the acromion, or but
very little from the deltoid muscle being drawn down. The motion of
the shoulder is exceedingly painful ; and one or more of the fingers are
generally painful, or contracted, from irritation of the axillary plexus. The
diagnostic signs are considered by Sir Astley Cooper to be, the lodgment
of the head of the bone in the glenoid cavity ; its being unaffected by
rotation of the elbow ; the fractured neck being perceptible under the
pectoral muscle ; and the surgeon being able to move the arm more
freely, than in other fractures of the neck of the bone. *
Mr. Robert W. Smith has made some interesting remarks on a fracture
now and then met with, and the symptoms of which may completely per-
plex a practitioner, not aware of the possibility of its occurrence. The in-
jury of the upper extremity of the humerus is of the following kind : — "A
fracture, traversing the upper part of the bicipital groove, detaches the
greater tubercle of the humerus ; thus annulling the action upon that
bone of the supra-spinatus, infra-spinatus, and teres minor. The folds of
the axilla, the subscapularis, and the anterior portion of the deltoid, then
act almost unopposed, and draw the head of the bone forcibly inwards,
against the inner part of the capsular ligament ; and if, at the same time,
the inner border of the glenoid cavity be broken, the head of the bone
passes still further inwards, and beneath the coracoid process, amounting
at length to an actual displacement, which is permitted by the increased
size of the joint, just as a displacement of the head of the femur will
often be the consequence of a fracture of the acetabulum." Mr. Smith
considers it not very difficult to distinguish a fracture of the greater
tubercle from a luxation of the head of the humerus. (( One of its most
"emarkable and diagnostic features is the great increase in the breadth
of the articulation : moreover, the glenoid cavity is not entirely aban-
doned ; the acromion process is not as prominent as in luxation ; the dis-
placement is very readily produced. We cannot depress the deltoid
* Sir Attlcy Cooper in Guy's Hospital Reports, vol. iv. p. 281.
FRACTURES OF THE HUMERUS. 669
muscle, as in dislocation ; and lastly, the violence which produced the
lesion, has been directly applied to the injured part." Mr. Smith sus-
pects, that bony union of such a fracture would be difficult to effect.*
Fractures of the middle of the humerus are very common, and easily
recognised ; for when the fracture is oblique, there is a shortening of the
limb, and not only does displacement happen in this, the longitudinal
direction, but there is also an angular deformity, the limb being flexible
in the situation of the injury, in consequence of the solution of continuity
in the bone. A crepitus will likewise be readily perceived, so that no
difficulty can present itself in the diagnosis.
Fractures situated towards the elbow sometimes extend into the joint,
and either the inner or the outer condyle may be detached. A fracture
of the external condyle produces pain in the movements of flexion and
extension of the elbow ; but Sir Astley Cooper deems the crepitus, occa-
sioned by the rotatory motion of the radius, the principal diagnostic
symptom. If the portion of the condyle broken off be large, it is drawn
a little backwards, and the head of the radius with it ; but, if the portion
be small, this displacement does not occur. By a careless practitioner,
an oblique fracture, detaching the internal condyle, may be mistaken for
a dislocation of the ulna backwards ; but the error will not happen if it
be recollected that, in such a fracture, there will be crepitus, and that,
after we have apparently reduced what may be supposed to be a dis-
location, the displacement will immediately return on the limb being left
to itself. But, of all accidents about the elbow, that most likely to be
mistaken for a dislocation is a separation of the lower epiphysis of the
humerus in a young subject, the olecranon projecting considerably back-
ward. The part is readily restored to its proper shape, but, on being left
to itself, the deformity immediately returns.
In the treatment of fractures of the humerus, the principal indications,
after the requisite extension, counter-extension, and coaptation, have
been performed, are, first, to support the fragments duly in their proper
position with respect to each other ; secondly, to prevent all motion, not
only of the broken bone itself, but also of the ulna and the radius.
When the fracture is situated above the insertion of the pectoralis
major and latissimus dorsi, Sir Astley Cooper recommends splints, the
clavicular bandage, and the wedge-shaped pad in the axilla, with its
broader part upwards ; but, says he, " above all, it is necessary to permit
the arm to hang by the side unsupported at the elbow, so as to let the
weight of the arm be a constant source of extension upon the broken end
of the bone/' In one case, Mr. Tyrrell failed in keeping the fracture in
a state of coaptation, until he had recourse^ to a rectangular splint,
a part of which rested against the side, while the arm, raised to a right
angle, reposed upon the other part of it.
When the fracture is situated in the middle third of the humerus, it is
usual to apply either two or four splints ; some practitioners use four, and
others only two ; one on the outer part of the arm, and the other on the
inner side of it. A sling is always necessary. An assistant is*to take
hold of the elbow and hand, and support the fore-arm, while the surgeon
puts on the apparatus ; during which part of the business, the former
should make a little extension, so as to bring the ends of the fracture in
apposition.
When the fracture takes place more towards the elbow joint, common
* JR. W, Smith in Dublin Journ. of Med. Science, vol. xii. p. 224.
670 PARTICULAR FRACTURES.
splints are deficient in one material respect ; namely, they cannot control
the movements of the radius upon the articular surface of the humerus.
Such splints can operate also but trivially and imperfectly, even in
steadying the fragments of a fracture so low down ; for only a small part
of the apparatus extends below the solution of continuity. Of late years,
therefore, it has been customary in cases of this description to employ an
angular splint, one part of which is adapted to the inner side of the arm,
and the other part to the palmar side of the fore-arm. I consider this
apparatus far more efficient, and better calculated to fulfil scientifically
the chief indications. The angular splint, put on in the manner I have
explained, acts powerfully in keeping the humerus steady, and in pre-
venting all motion of the elbow-joint and bones of the fore-arm. Simple
as the contrivance is, and essential as it is to the successful treatment of
fractures near the elbow, it has only been employed a few years. Of
course, the arm is to be put in a sling in this, as well as in other fractures
of the humerus.
When the outer condyle is detached, we should relax the muscles
arising from it, which is accomplished by placing the hand in the supine
position, with the fingers extended ; on the contrary, when the inner
condyle is broken off, the muscles, arising from that process, should be
relaxed, which is done by placing the hand in the state of pronation, with
the fingers bent. If the hand be kept supine, the angular splint, already
described, will not fit the limb; and another kind of splint, which is also
an angular one, but so contrived as to accommodate itself to the front of
the arm, will be useful, with a corresponding one for the posterior part of
the limb.
If, when a surgeon is called to a fracture of the humerus near the
elbow, he should not happen to be provided with angular splints, I recom-
mend him to use strong thick pasteboard, which, after being softened in
water,, is to be applied. When dry, it will form an excellent case for the
limb, answering in every respect as well as the angular splint.
In the treatment of fractures of the lower end of the humerus, passive
motion should begin at the expiration of three weeks in a child, and of
four in an adult, in order to prevent anchylosis.
Sometimes the humerus is first dislocated into the axilla, and its head
then broken off, which is thrown on the inner side of the inferior costa of
the scapula. Sir Astley Cooper has seen many of these cases in the
living, and has dissected three in the dead. In one of the latter, the
fractured neck of the shaft of the humerus was situated in the glenoid
cavity, widely separated from the head of the bone ; and the end of the
broken bone had formed with the glenoid cavity a new and good articu-
lation, with a capsular ligament over it, partly of new production.
With regard to the diagnosis, the depression of the shoulder is less striking
than in simple dislocation into the axilla ; the head of the bone can be
distinctly felt in the latter situation, but does not roll when the rest of
the humerus is rotated ; a crepitus may generally be felt, if the elbow be
raised outwards, and the arm rotated; the end of the shaft advances to-
wards the coracoid process, and though readily moved back, it easily slips
forward again ; and, lastly, the violence required for the production of
this accident being greater than that causing a simple dislocation, the de-
gree of contusion and the pain and swelling are more considerable.
Here extension is only useful in bringing the upper end of the shaft into
the glenoid cavity, where a useful joint is formed. The head of the bone
FRACTURES OF THE FORE-ARM. 671
is not acted upon by it. A pad is to be placed in the axilla, a clavicular
bandage used, and the arm supported in a sling.*
FRACTURES OF THE FORE-ARM
Are remarkably frequent. Fractures of the radius perhaps happen as
often as those of any other bone in the body, except the clavicle; and
the reason of this is, because it is articulated with the carpus, and has to
receive all the force communicated to the hand in falling, and indeed on
every other occasion. When a person falls, he stretches out his hand to
save himself; this part then comes violently in contact with the ground,
and the force is immediately communicated from it to the radius, which
bends and gives way generally in its central portion, but sometimes near
the wrist, a fracture of the upper end of the radius rarely or never hap-
pening in this manner. The majority of fractures of the radius take
place in its middle third, or near the wrist ; and when the upper part
happens to be broken, the injury is produced by a blow, or some species
of direct violence. Another reason why the radius is oftener fractured
than the ulna is, that the former is situated at the outer and upper part
of the fore-arm, so that it is more exposed to the action of direct violence
than the neighbouring bone.
When a fracture of the radius is suspected, we should first inquire,
whether the patient can or cannot perform the movements of pronation
and supination of the hand ; for if he can do these well, then we may be
certain that the radius is not broken. Or we may take hold of the
patient's hand and rotate the radius for him, while the fingers of our left
hand are placed upon it. If the bone is not broken, the upper portion of
it will follow the movements of the hand, as it always naturally does ; but
if it is broken, considerable pain will be felt on attempting these motions of
supination and pronation, — there will be a crepitus ; and the upper frag-
ment will remain motionless. In many instances there is displacement,
the lower portion of the bone being in the prone position, and the upper
in the supine one ; and the ends of fracture tending towards the inter-
osseous space. There can be no alteration in the length of the bone or
limb, while the ulna remains perfect, aud serves as a kind of splint.
When both bones are broken, the nature of the accident is still more
obvious, because there is an angular deformity of the limb, and a distinct
crepitus, as well as a loss of the motions of supination and pronation.
Fractures of the ulna alone are generally produced by direct violence,
as blows, kicks, &c. ; for any force or violence communicated to the hand
has little or no effect upon that bone. This circumstance enables us at
once to understand why, when the ulna alone is broken, it is generally
by direct violence ; and why, also, when both bones are simultaneously
broken, it is most commonly also by direct violence, such as the passage
of a heavy body over the arm, or a violent fall, or blow on the injured part.
When the radius is broken, we should bend the elbow, and then make
a little extension and counter- extension, taking care to avoid pressing the
ends of the fracture into the inter-osseous space. It is a grand foint in
the treatment to preserve the inter-osseous space perfect ; for, if we neg-
lect this indication, the radius and ulna may grow together, and the mo-
tions of supination and pronation be for ever lost. Splints for the fore-
arm, therefore, should not be jointed longitudinally, but be rather of a
flat or trivially excavated shape ; and in particular, a tight bandage, which
* Sir Astley Cooper in Guy's Hospital Reports, vol. iv. p. 272-
(372 PARTICULAR FRACTURES.
would depress the radius too much against the ulna, ought not on any
account to be employed. Two splints are commonly put on ; and,
after the reduction, either no roller at all should be applied directly to
the fore-arm itself, or merely a slack one. Then one of the splints, pro-
perly padded or lined with soft materials, is to be laid along the inner
part of the fore-arm, from the bend of the elbow nearly to the ends of the
fingers, and another along the outside of this part of the limb. It is
generally considered best to keep the radius nearly in the mid-state be-
tween pronation and supination. Sometimes, when the radius is broken
near the wrist, and a good deal of swelling is present, we might be
inclined to suppose the case a dislocation ; but generally there will be no
difficulty in making out that the case is a fracture, for (to say nothing of
the rarity of such a dislocation) the nature of the injury is generally indi-
cated by a crepitus, except in young subjects, in whom the case is often
a mere separation of the epiphysis. We can also constantly feel the sty-
loid process below the solution of continuity. In this case, if displace-
ment occur, the lower fragment is mostly drawn backward by the action of
the long supinator and extensor carpi radialis, but, in few instances, for-
ward by the influence of the pronator quadratus. The reason of the
greater frequency of the displacement backward is in some measure ex-
plained by the patient usually falling directly on the hand at the period
of the accident, by which means the fragment is forced backwards. The
fragments must be put into the proper position, and splints and a sling
employed, due care being taken to prevent the hand from inclining too
much downwards.
The olecranon is most liable to be fractured by falls on the elbow, and
not usually by the action of muscles, as is the case with the knee-pan. It
may be broken at its point, or more towards its base. In some instances,
when the fracture occurs near its base, and the ligamentous fibres, ex-
tending from the olecranon to the coronoid process of the ulna, are not
completely ruptured, the upper fragment may not be displaced or re-
tracted; but if those fibres be completely torn, the upper fragment will
be drawn upwards by the triceps. The extent of separation between the
fragments will also be influenced by the circumstance, whether the elbow
be bent or extended; for, in the latter position, the lower fragment does
not contribute to the displacement at all ; but, when the arm is bent, the
lower fragment recedes, and materially increases the interspace between
the fracture. When the upper fragment is drawn away from the lower
one, no crepitus can be perceived, unless the arm be extended, and the
upper fragment pressed down ; but the nature of the case will always be
clear enough, even without this symptom, except when the limb is much
swelled. Indeed, the swelling, consequent to fractures about the elbow,
is frequently prodigious, and comes on with surprising rapidity ; so that it
is an object always to examine the limb well at an early period, before
any obscurity has arisen from the enlargement of soft parts. Whether the
patient retains much power of extending the arm, materially depends
upon whether the ligamentous fibres, spread over the olecranon from the
coronoid process, happen to be torn or not ; because if they should be
completely ruptured, that power would be exceedingly diminished.
There is a difference of opinion among practitioners, respecting the
best mode of treating fractures of the olecranon. We should naturally sup-
pose that the limb ought to be kept extended, the greatest approximation
of the fragments being thus produced; but Desault, the great predeces-
sor of Dupuytren, at the Hotel Dieu in Paris, objected to this posture of
FRACTURES OF THE BONES OF THE FORE-ARM. 673
the limb, on the ground that, although the fragments grew together, yet
they were separated at their internal edges, and the joint remained per-
manently weak. Hence he recommended a middle position, between the
half-bent and perfectly extended state, or, in other words, a trivially bent
position of the elbow. The same practice is also preferred by a few
surgeons of the present day, as being, according to their judgment, less
irksome to the patient and more efficient, inasmuch as the cure takes
place without any imperfection being left in the action of the joint. But I
do not consider this point as one entirely settled; for several practitioners
of the greatest experience, among whom is Sir Astley Cooper, are de-
cidedly of opinion, that the extension should be complete. Sir Astley
Cooper finds, as other surgeons do, that the olecranon generally unites by
ligament ; and he observes, that if the limb be kept somewhat bent, there
will be a greater length of the ligamentous substance, and the joint will be
proportionably weaker. The late Mr. Sheldon was an advocate for com-
plete extension ; and, so far as my own experience goes, I have found no
reason to follow Desault's advice on this matter. In fact, I have never
seen any ill consequences from keeping the arm extended, and mean to
follow this method, until its disadvantages have been more clearly proved.
Frequently, in a case of fracture of the olecranon, we cannot apply the
bandage, or any splint, until the fourth or sixth day after the accident,
and sometimes not till later. Now this is one example, in which the
good general rule of applying the splints, as soon as possible, to a broken
limb, should be dispensed with ; our duty is to try to reduce the inflam-
mation and swelling before any apparatus, that makes pressure on the
limb, can be advantageously applied. We are called upon, therefore, to
employ leeches, cold evaporating lotions, purgatives, and even bleeding
from the other arm, if the inflammation and swelling are very consider-
able. The inflammation having been reduced, we put on a figure of 8
bandage, which will answer pretty well, especially when a well-padded
splint is laid along the front of the limb, in order to prevent flexion of the
joint. If we choose to adopt the plan of slight flexion, we may put on a
splint, constructed with a kind of hinge, or joint, exactly in front of the
elbow, and furnished with a screw, by means of which its degree of flexion
can be regulated and fixed.
In compound fractures of the olecranon^ in consequence of the degree of
inflammation and swelling sure to ensue, it is best not to apply any splint
or bandage at first ; but to lay the limb on a pillow, close the wound, and
try to keep down inflammation of the joint with cold evaporating lotions,
leeches, venesection, and saline purgative medicines. If matter form, an
early opening is to be made. Bad comminuted fractures of the olecranon
sometimes occasion a necessity for amputation, as was exemplified in the
case of Charles Hussey, under my care in University College Hospital,
in November, 1835.
When the coronoid process is broken, and the arm extended, the
olecranon projects back in such a degree as to create the appearance of
a dislocation ; but it may be known that this is not the case, Hfecause,
directly the arm is bent, the olecranon returns to its natural place again ;
and in addition to this circumstance, a crepitus can be felt. The treat-
ment consists in keeping the fore-arm and elbow at rest in the bent
position, and applying a figure of 8 bandage round the joint, after having
had recourse to leeches, cold lotions, &c. for three or four days, in the
event of the swelling being considerable.
But fractures about the elbow are not always so simple as the cases we
x x
674 PARTICULAR FRACTURES.
have been noticing ; they are sometimes very complicated. Thus one
preparation in the museum of University College illustrates a case, in
which the ulna is broken at the elbow, the posterior fragment being dis-
placed backwards by the action of the triceps ; the coronoid process is
broken off; the upper head of the radius is also dislocated, from the lesser
sigmoid cavity of the ulna, and drawn upwards by the action of the
biceps. In this complicated accident, the ulna is broken in two places.
FRACTURES OF THE CARPUS, METACARPUS, AND BONES OF THE
FINGERS.
The carpal and metacarpal bones can be broken only by great direct
violence,, as by gun-shot wounds, the action of machinery on the parts,
or the passage of the wheel of a heavy carriage over them. Now, under
these circumstances, so much injury is frequently done to the soft parts,
that it becomes necessary to amputate without delay. However,, if the
case will admit of an attempt being made to preserve the limb, or any
part of the hand, the main indications will be, to remove all loose splinters
of bone which are near the surface, to apply for the first three or four
days light superficial dressings and cold lotions, and afterwards emollient
fomentations and poultices, till the inflammation has subsided and the
sloughs have been detached. If there has not been much bleeding from
the part, leeches may be applied to it. The bones of the fingers are
seldom fractured, for they can only be broken by direct violence. The
treatment is simple, the injured finger merely requiring to be supported
with pasteboard, and the hand kept in a sling.
FRACTURES OF THE PELVIS.
The particular shape of the pelvis, the sort of circle or arch which it
represents, and the vast strength and thickness of its several bones, are
circumstances at once apprising us, that the pelvis can be broken only by
great and extraordinary degrees of violence directly applied to it ; as
by the passage of a heavy waggon over it, or by its being pressed be-
tween the wheel of a carriage and a wall or post. From the manner in
which these fractures usually happen, it is manifest, that the injury done
to the bones is unfortunately not the most serious part of the mischief;
the soft parts generally, and often the bladder or colon, being seriously
injured. Sometimes the bladder or intestines are ruptured ; sometimes
blood is extravasated either in the abdomen or the pelvis; and, in
other instances, where the rami of the ischium and ossa pubis are broken,
spiculaa of bone may be driven into the bladder or urethra. A prepara-
tion in the museum of University College illustrates a case, in which
there was a fracture of the ramus of the ischium, and one of the frag-
ments tore the urethra ; the consequence was an effusion of urine in the
cellular substance of the perineum, and sloughing of all the parts among
which the urine passed. Another preparation, in the same collection,
was taken from a person, whose rectum was lacerated by a portion of
fractured sacrum. In such cases, one frequent consequence is a para-
lysis of the bladder and lower extremities. In gun-shot fractures of the
pelvis, spiculae of bone may be forced completely into the bladder, and
afterwards become the nuclei of calculous formations, so as to oblige the
patient to submit to the operation of lithotomy.
Fractures of the anterior superior spinous process, and of the crista of
the ilium, may take place, without much additional mischief; but other
fractures of the pelvis are frequently fatal. I have seen two cases, in
FRACTURES OF THE THIGH BONE. 675
which the accident arose from the passage of heavy waggons over the
pelvis : one of these patients died in a quarter of an hour. There will
sometimes be effusion of blood in the abdomen ; and, in other instances,
the bladder or intestines are ruptured. The fracture sometimes extends
through the acetabulum, and then the case is liable to be mistaken for
a dislocation of the hip ; because the superior fragment is drawn upwards,
and the limb consequently shortened, while the trochanter major is
thrown a little forward : and thus there will be two symptoms of a dis-
location of the hip. However, if the hand be applied to the crista of the
ilium, and the thigh bone be then rotated, there will be no difficulty in
making out the accident ; for there will be a crepitus, and not that con-
siderable resistance to motion of the femur, so invariably experienced in
a dislocation.
With regard to the treatment of fractures of thef pelvis, if we except
antiphlogistic measures, there is not a great deal to be done. A bandage
might be applied round the pelvis ; but, as its usefulness is questionable,
the best practical surgeons do not have recourse to it. We should bleed
the patient freely, to prevent inflammation of the pelvic viscera ; and if
the bladder or urethra were ruptured or paralytic, a catheter should be
passed, to prevent effusion of urine. In the latter case, we should keep
the catheter in the passage, lest the urine escape by the lacerated open-
ing into the cellular membrane, whereby great, and sometimes fatal,
mischief would be produced. Repose, antiphlogitsic measures, and
attention to any particular symptoms which may arise, but especially re-
tention of urine, are the chief objects in the management of fractures of
the pelvis.
Some fractures of the pelvis have a favourable termination, the bones
uniting, and the patient recovering. One preparation, in the museum of
University College, was taken from a person, in whom the sacrum and
os innominatum had both been fractured ; yet, the broken parts united,
so that the patient probably lived long after the injury. The chances
of recovery depend, however, on the degree of violence with which the
injury is inflicted, and its effects on the viscera ; and, if the bladder,
bowels, medulla spinalis, and other important organs escape injury, the
patient may ultimately get well. Sometimes he dies of peritonitis, of
which I have seen instances.
FRACTURES OF THE THIGH BONE
Are divided into three classes, in respect to situation : the first comprises
those in the upper part, or in the neck, of the bone ; the second, such as
take place in the middle third of its shaft ; and the third, fractures situ-
ated in the lower third of the shaft, or towards the condyles. Those in
the middle of the shaft are most frequent in persons under a certain age ;
but in old subjects, fractures of the neck of the bone take placeawith re-
markable frequency.
Fractures of the shaft of the femur may be simple or compound; they
may also be complicated with a wound of the femoral artery, whicn, how-
ever, is a rare occurrence. Sir Astley Cooper met with such a case, in
which it was necessary to perform amputation. Fractures of the thigh
bone may also be double. In children, the shaft is frequently broken in
the transverse direction ; but, in other subjects, the fissure is most com-
monly oblique. The fracture may be caused by direct violence, as by the
passage of the wheel of a heavy carriage over the limb, the fall of a heavy
body upon it, the kick of a horse, and various other kinds of injury; but,
x x 2
676 PARTICULAR FRACTURES.
on other occasions, the femur is broken by some description of force,
which first bends it, and when it has yielded as much as it can, it breaks,
generally at some point of its middle third.
What are the symptoms of a fracture of a shaft of the thigh bone ? -
Supposing the fracture to be oblique, a shortening of the limb is usually
noticed, the lower fragment being drawn behind the upper one,, and a
little inwards ; the limb is flexible in the situation of the fracture ; the
lower fragment, with the knee, leg, and foot, is rotated outwards, all the
stronger muscles, acting upon that part of the broken bone, tending to
twist it in this direction. Although the lower fragment is commonly
drawn upwards and inwards behind the upper one, it is possible for the
lower fragment to be displaced in a different manner, and so as to lie in
front of the upper one ; but this occurrence is a deviation from what is
ordinarily seen, and is explicable by the particular mode in which the acci-
dent has been produced, viz. by the application of direct violence., and the
operation of the force upon the posterior part of the limb, so as to propel
the lower fragment forwards. Another symptom of a broken thigh is a
crepitus, that can be distinctly felt on moving the limb. If the fracture
be an oblique one, together with the shortening of the limb, there is a
rotation of it outwards, and, what is termed the angular deformity, the
axis of one portion of the bone not corresponding to that of the rest of it.
The retraction of the lower fragment constantly occasions an increased
bulk, or fulness of the upper part of the thigh, because the attachments
of several of the muscles are brought nearer together, and their bellies
swelled into a preternatural shape. The truth of this observation is well
illustrated in the state of the adductor muscle, which, by forming a con-
siderable prominence at the upper and inner part of the thigh, communi-
cates to it a very unnatural shape. That it is the muscles which produce
the displacement of the fractures, cannot be doubted, because, if the
muscles of the broken limb were paralytic, there would not be any re-
traction of the lower fragment, or shortening of the thigh. In a person
affected with paralysis, there might be no shortening of the limb at firstj
or while the muscles were incapable of action; but if the paralytic affec-
tion happened to yield before the fracture had united, a retraction of the
lower fragment would yet ensue. Indeed, such a case is recorded by
Bichat. When the accident took place, all the muscles of the lower ex-
tremity were in a paralytic state ; and though the fracture was an oblique
one, no retraction whatever of the inferior fragment followed. The moxa
was applied, and, in a few days, the muscles began to regain their power
of action ; and in proportion as this improvement was effected, the ends
of the fracture acquired a tendency to displacement, not previously
evinced, and a considerable retraction of the lower fragment ensued. In
transverse fractures of the shaft of the femur, no shortening of the limb
may happen, yet the angular deformity and rotation outwards will be ob-
served. The foregoing observations render it manifest, that it is chiefly
the lower portion of the broken femur which is displaced ; but it would
be incorrect to regard the displacement as exclusively affecting only the
lower fragment. When the patient is placed on too soft a bed, which
yields to the weight of his trunk, the pelvis sinks, and pushes the upper
fragment along with it, which thus has a disposition to be propelled over
the lower one. Supposing also the fracture to be situated just below the
trochanter minor, the psoas and iliac muscles, attached to that process,
might act with great effect in displacing the upper fragment in the direc-
tion forwards and upwards.
FRACTURES OF THE THIGH BONE. 677
It was principally with reference to fractures of the lower extremity,
that Pott recommended the plan of attending to the relaxation of the
muscles as the best means of facilitating the reduction, and promoting
the maintenance of the fragments in their right place. One would sup-
pose, from several passages in his treatise, that he really imagined it pos-
sible completely to relax all the muscles by a certain position of the limb,
and this in such a manner as entirely to deprive them of all power of dis-
turbing the ends of the broken bone. No position of the limb, however,
will do so much as this eminent surgeon was induced to believe. A certain
position may relax those muscles, which have the greatest power of dis-
turbing the fracture ; yet the mass of muscular fibres remaining unrelaxed,
will always be sufficient to derange the fracture ; and consequently posi-
tion alone, however important and useful it may be, will not accomplish
strictly what Mr. Pott represents ; it will not effectually deprive the mus-
cles of the power of disturbing the fracture. This truth enables us at
once to understand how necessary it is to attend to other means for main-
taining the reduction, and especially to avail ourselves of the best mecha-
nical contrivances for this purpose. So correct is the principle which I
am now adverting to, that if the particular position of the limb, selected
for the purpose of relaxing the muscles, were to be incompatible with the
employment of the most efficient apparatus, then, the treatment would be
erroneous, because, advantageous as position may be in relaxing the most
powerful muscles connected with the broken limb, the aid of an efficient
apparatus is still more important. From what is stated in my general
observations on Fractures, in the first section of this work, even the supe-
rior usefulness of relaxing the muscles is now sometimes disputed, and
the plan of keeping them in the opposite condition advocated.
Broken thighs are treated on three different plans, each of which is
occasionally preferred. In the first, the limb is kept extended, and the
patient lies on his back ; a position disapproved of by Pott, because it
does not relax those muscles which have the greatest power in producing
displacement, namely, those which are capable of drawing the lower
fragment upwards, inwards, and behind the upper one, or, in other terms,
the muscles arising from the pelvis, and inserted either into the femur,
the patella, the tibia, or the fibula, and which, making the pelvis their
fixed point, and the portion of the limb below the fracture their moveable
one, displace the lower fragment in the foregoing direction.
In the extended position, various kinds of long splints are employed.
Desault employed three splints ; one on the outside of the limb, a second
on the inside, and a third on the upper part, or front of the thigh. He
was very particular in placing the patient on a firm unyielding bed ;
for if the pelvis sinks into a hollow of the bedding, this change will ine-
vitably derange the position of the fragments. He began with applying
the eighteen, or many-tailed bandage, then a long splint, well padded,
on the outer part of the limb ; he next put a handkerchief or band on
the perineum, or rather on the tuberosity of the ischium, the ends of
which handkerchief or band were carried through a fissure in lj?e upper
part of the long external splint, and the effect of this was to prevent the
splint from slipping upwards. Then the foot was also made steady by
passing a handkerchief or bandage through a fissure in the lower part of
the splint, which was brought over the foot across the instep, and then
fastened to the splint again. Thus the limb was fixed and secured both
at the hip and the foot. Other splints, however, were made use of: one
at the inner side of the limb, extending from the groin to the foot ; and a
x x 3
678 PARTICULAR FRACTURES.
shorter one, reaching along the front of the thigh from the groin to the
kneepan.
Boyer invented another apparatus, which was also intended to be used
in the straight position of the limb. His long external splint is furnished
with a screw at the lower end, by means of which it can be lengthened
or shortened at pleasure. The principle of his apparatus is to keep up
permanent extension ; but, for the screw to have its full effect, it is neces-
sary that the upper end of the splint should be securely fastened to the
pelvis. For this latter purpose, Boyer put a thigh-strap over the tubero-
sity of the ischium, much in the same manner as Desault did the hand-
kerchief, or band ; but the portion of the thigh-strap below the crista of
the ilium, on the outside of the pelvis, had a kind of fob or pocket in it,
calculated to receive the upper end of the splint, and thus prevent it from
slipping upwards, or moving at all laterally. The limb having been first
put up with the many-tailed bandage, the long external splint, lined with
soft materials, is applied ; the foot is next fixed much in the same way as
in Desault's plan, and the inner and upper splints are put on, the extension
being kept up by lengthening the outer splint, which is done by turning
the screw at the lower part of the splint. In University College Hospital,
we adopt the straight position, and employ only the external long splint,
which, with a handkerchief, rolled up and filled with soft materials, and
common rollers, compose the whole of the apparatus. If we ask ourselves,
what are the indications[to be fulfilled ? the answer is, to keep the broken
part of the bone steady ; to maintain the limb to its proper length ; and
to hinder it from turning too much either outwards or inwards. Now, for
these purposes something is needed as a fulcrum, to which the limb is to
be bound. The splint is converted into this fulcrum by its upper end
being fixed to the side of the pelvis with the handkerchief, that passes
under the tuberosity of the ischium, and the ends of which are then con-
veyed up to the fissure in the upper part of the splint, and there fastened to
it, so as to keep it from slipping upwards. When, therefore, the limb has
been bandaged, the long splint placed along the outer side of the limb,
and the foot and rest of the limb have been secured in the best position
to this splint with rollers nearly as far up as the fracture, the next thing
is to make as much further extension as may be needed, and then fasten
the two ends of the handkerchief to the notch in the upper end of the
splint, so as to prevent it, and of course the limb, which is bound to it,
from becoming retracted. These are the simple and admirable principles,
on which alone fractures of the thigh can be very successfully treated.
The second plan of treating fractures of the shaft of the femur is
that recommended by Pott, in which the limb and the pelvis are laid on
their external side, with the thigh half bent upon the pelvis, and the leg
moderately bent upon the thigh. In this method, two splints are some-
times applied, but generally four. The fracture is reduced by an assistant
taking hold of the limb above the broken part of the bone, and perform-
ing counter-extension, while the surgeon makes extension from a part of
the limb below the situation of the injury. The patient is laid on his
side, with the pelvis inclining as much as possible in the same direction.
The limb is placed on its outer side, with the thigh half bent upon the
pelvis, and the leg bent in a similar degree upon the thigh itself. Before
reducing the fracture, the long splint, with the pad and eighteen-tailed
bandage upon it, should be put under the thigh ; the reduction of the
fracture is then to be accomplished, and the tails of the bandage next
methodically laid down, one over the other, beginning with those just
FRACTURES OF THE THIGH BONE. 679
above the knee. The eighteen-tailed bandage, when neatly applied,
looks exceedingly well, and is convenient ; for it can be opened without
the slightest disturbance of the fracture, or motion of the limb. In
private practice, it is usual to apply, under the bandage, a piece of brown
soap plaster to the integuments in the immediate vicinity of the fracture.
By proceeding in the manner here explained, the other splints may be
applied with the greatest facility. When Pott's position is adopted, one
important thing is to afford due support to the foot, for which purpose
a soft cushion or pillow is generally employed ; and the knee must also
be supported by similar means. But this treatment of broken thighs in
the bent posture, with the patient on his side, is not exactly consistent
with the most scientific principles. In the first place, one general prin-
ciple, acknowledged by all the best practical surgeons, is that of keeping
all joints in any way connected with a fractured bone, perfectly
motionless ; but here no measures are taken for the fulfilment of this
very important object. On the contrary, the patient can move every
joint without restraint. The splints do not confine either the hip, the
knee, or the ankle ; hence, I should say, that this is an inferior method of
treatment, and I am not surprised that it should be one which occasions
deformity more frequently than any other, and is losing ground from day
to day in the estimation of the profession. But supposing this position
were in some respects the best that could be selected, yet, as it could not
be maintained for any length of time, it would prove inefficient. In fact,
take what pains we may, the patient will never remain long in the posture
specified, but will always turn on his back, and thus the fracture will
become deranged again.
A third plan has been proposed and adopted, which consists in placing
the patient on his back, with the thigh bent on the pelvis, and the leg
bent on the thigh, while the limb is supported in this position on a double
inclined plane. The most simple instrument of this kind merely consists
of two boards of the requisite length, nailed together at an angle, and
provided with a foot-piece, and a few pegs along the margins, to keep the
pads from slipping off the apparatus. Double inclined planes, however,
are now brought to great perfection ; and fracture-beds, as they are
called, are generally so constructed as to admit of serving the same pur-
pose. Amesbury's apparatus, which answers as a double inclined plane,
is a very good one; but, in University College Hospital, whenever I have
adopted this position for a broken thigh, the preference has been given
to M'Intyre's apparatus, which is more simple, and does not require,
in addition to the front splint, any lateral ones, unless the thigh be very
bulky ; or even the eighteen-tailed bandage ; a common roller being ap-
plied so as to include both the limb and the apparatus on which it lies,
and, consequently, admitting of removal without any disturbance of the
part. All well made double inclined planes can be fixed at any angle by
means of a screw. In Amesbury's apparatus, the thigh part may be
lengthened or shortened at the surgeon's option, which is an advantage,
the brass part sliding very conveniently in either direction. The fbot-piece
also admits of being shifted, and its position and length can be adapted
to the particularities of every case. If this, or any other double inclined
plane, be used, we have no occasion for an under splint, because the
surface of the machine itself answers the purpose of one. The ankle is
kept steady by means of the leather case or slipper for the foot. M'Intire's
apparatus may be used without any other splint, though when the thigh
is very bulky, an anterior splint is useful. The limb, after having been
x x 4?
680 PARTICULAR FRACTURES.
covered with a roller, is laid upon the apparatus, coaptation performed,
and then the limb and apparatus together encircled with other rollers
from the foot up to the pelvis. Thus the limb will be kept perfectly
steady, and all the joints motionless. By means of the thigh-strap and
pelvis strap belonging to the apparatus, the pelvis and lower extremity
are also rendered, as it were, one piece, only moveable together. The
strap is passed round the pelvis, and through the fissure in the upper part
of the external splint, near the great trochanter. Amesbury's inclined
plane is excellently finished, and the splints of a good shape, light, yet
strong. With this apparatus, three splints are intended to be used for a
broken thigh, and also the eighteen-tailed bandage. In some hospitals,
the treatment of broken thighs on a double inclined plane is preferred
to the method of Desault, with all the improvement and simplicity to
which it has now been brought. A double inclined plane is always to be
well covered with soft materials, especially the projecting part of it under
the ham.
FRACTURES OF THE NECK OF THE THIGH BONE
Are divided, first, into those which happen ivithin the capsular ligament;
secondly, into those which occur on the outside of it, or partly in this
situation ; and thirdly, into such as extend through the great trochanter.
With respect to the symptoms of a fracture within the capsular liga-
ment, the patient will complain of severe pain in the hip ; and there will
be shortening of the limb. It was once calculated, that shortening might
happen to the extent of from one to two inches and a half; but the ob-
servations of Boyer, and of Messrs. Earle, Stanley, and R. W. Smith *,
prove, that, unless the capsular ligament be torn, no retraction of the limb in
this last degree can happen. The extent of the retraction will also depend
on whether or not the reflection of the capsular ligament over the neck
of the bone be torn ; for, in the event of its not being lacerated, there
will be no shortening of the limb at all ; neither will there be another
usual symptom, namely, eversion of the limb. WThen the neck of the
thigh bone is broken, as all the strong muscles attached to the shaft and
trochanters have a tendency to turn the limb outwards, so as to evert the
toes and knee, this is a common symptom of the accident ; but if the re-
flection of the capsular ligament over the neck of the femur happen not
to be torn, such symptom may be absent. When the limb is much short-
ened, we may not feel a crepitus ; but if we draw the limb downwards,
and rotate the foot inwards, the crepitus will then be distinctly felt.
When there is displacement, the great trochanter will not form such a
prominence at the side of the pelvis as it naturally does ; and if there be
a shortening of the limb, the same process will be found to be nearer to
the crista of the ilium than in the sound state of the limb. Another
symptom, accompanying and indeed resulting from the displacement of
the outer fragment, is a great fulness of the upper part of the thigh, from
the muscles having their attachments brought nearer together.
\ In a few uncommon examples, the knee and toes are actually turned
inwards, instead of outwards ; and the explanation given of the fact is,
that the fracture takes place sufficiently towards the outside of the great
trochanter, to prevent the muscles from acting on the lower fragment so
as to turn it outwards, while some fibres of the glutacus medius and
* Sec Dublin Journ. of Med. Science, vol. vi. p. 206.
FRACTURES OF THE NECK OF THE THIGH BONE. 681
minimus, yet continuing attached to the external portion of the tro-
chanter, retain the power of turning it inwards, and consequently the
whole limb. This is one explanation that has been suggested ; but it
is not considered altogether satisfactory by some very good judges.
It is alleged, that fractures, entirely within the capsular ligament, are
sometimes attended with inversion of the limb, and to such cases the
explanation proposed would manifestly not apply. Besides, as Dupuytren
has remarked, why should not the great adductor muscle be more than
enough to counteract the action of the anterior fibres of the glutaaus
medius and minimus ? At all events, the cause of the occasional inver-
sion of the limb, when the fracture is completely within the capsular
ligament, if it be a fact, appears to me not at present accounted for.
When the fracture is on the outside of the capsular ligament, namely,
between that ligament and the trochanter major, the retraction of the
limb is greater, than in the fracture within the capsular ligament ; a
point, on which Boyer is corroborated by the observations of Messrs.
Earle, Stanley, and Smith. This kind of accident is mostly occasioned
by the application of great and direct violence ; while other fractures,
situated within the capsular ligament, are usually produced by slighter
degrees of force. The generality of cases, which occur in London, are
caused merely by the foot slipping off the curb-stone, or by falls on the
hip, not always attended with great violence. The reason why so slight
a cause is capable of producing this mischief, is, that, after the age of fifty,
the neck of the thigh bone becomes weak and slender, and its shell thin-
ner, and incapable of affording as much resistance to force, calculated to
fracture it, as it did in an earlier period of life. It is partly on this
account, that fractures of the neck of the thigh bone are so frequent in
old people, and partly on account of a change in the direction of the axis
of this part of the bone in them; for in consequence of its greater weak-
ness, it bends upwards, and forms a right angle with the pelvis, instead
of sloping more or less upwards from the trochanter to the head of the
bone. Here another reason is discerned why fractures more easily take
place in aged than young subjects ; because any force, operating on the
trochanter major, will break the cervix of the bone with greater certainty,
when the trochanter projects very much, in consequence of the above-
mentioned change in the direction of the neck of the bone. In some
old subjects, in fact, we find the trochanter absolutely higher than the
head of the bone, the neck having yielded thus much to the weight of the
body. But the other fracture of the neck of the femur, namely, that
which takes place further outwards, or more towards the great trochanter,
beyond the external limit of the capsule, is generally produced by great
degrees of violence; and is not particularly restricted to old subjects, but
presents itself also in young ones. Therefore, when great and direct
violence has been concerned, the patient is under fifty, the limb a good
deal shortened, and the crepitus readily perceived, there is ground for
suspecting that the fracture is on the outside of the capsular ligament, or
partly on the outside of it ; for sometimes the fracture is oblique, and
sometimes longitudinal, and occasionally it is incomplete, the fissure ex-
tending only partially through the neck of the bone. In general, we
cannot feel a crepitus in fractures within the capsular ligament, unless the
limb be brought to its natural length ; but, when the fracture is on the
outside of the capsular ligament, a crepitus can be felt with facility. If
the fracture extend obliquely through the trochanter major, there may be
little or no shortening of the limb ; for there is such an extent of surface
682 PARTICULAR FRACTURES.
in the fractured part of the bone, and such a direction of the fissure, as
are very likely to prevent this kind of displacement. In this case, we
perceive a crepitus, but the foot is not so much turned out as in the other
example.
When the neck of the femur has been broken, it becomes shortened,
being more or less absorbed, and the head of the bone consequently
taking a situation, as it were, between the two trochanters. This circum-
stance, having been known by those who were looking out for instances of
bony union, after fractures of the neck of the thigh bone, led to a dispute
on the subject ; because, in consequence of the discovery, that, under cir-
cumstances of disease, the neck may be shortened, and the head assume
a similar position to that observed after fractures, many examples of
what were supposed to be fractures, which had admitted of bony union,
were rejected on this ground. Hence, also, various specimens, picked up
in churchyards and other places, and whose histories are unknown,
should not be too readily considered as proofs of the bony union of a pre-
vious fracture.
Fractures of the neck of the thigh bone are more frequent in women
than men, and two reasons may be assigned for this fact ; first, the neck
of the femur in women is naturally longer and more slender than in the
other sex ; and, secondly, as the pelvis is wider, the trochanters project
in a greater degree, and are consequently more exposed to external
violence. In this metropolis, fractures of the neck of the thigh bone
happen either from the foot suddenly slipping off the curb-stone, or from
falls on the side of the pelvis. In Paris, where the pavement is differently
arranged, and the curb-stone is not so common, the accident is usually
produced by falls on the hip. When the neck of the thigh bone is frac-
tured, and the fragments are not separated, the reflection of the capsular
ligament from one to the other not being torn, the diagnosis is generally
attended with some obscurity, because most of the characteristic symp-
toms are absent; for instance, there is neither shortening of the limb, nor
eversion of it. Yet, the patient cannot raise it from the surface on which
it is deposited — he cannot lift it up from the bed; he may, perhaps, con-
trive to bend his leg slightly, but he cannot raise it up. Though a degree
of obscurity may prevail at first, the nature of the case will mostly be ap-
parent enough in a few days ; for at this period the reflection of the cap-
sular ligament often gives way, sometimes in consequence of the patient
moving his limb too much, sometimes in consequence of the surgeon
doing the same thing ; but, in whatever way occasioned, it leads to a
retraction and eversion of the limb.
I have already referred to the rare case where the foot and knee are
inverted, and to the endeavour to account for it by the fracture having
taken place in such a direction through the trochanter major as to leave
attached to the pelvic fragment the insertions of the obturator internus,
the gemelli and pyriformis, which muscles are naturally concerned in ro-
tating the thigh outwards ; while the other, or external fragment, is drawn
forwards and inwards by the gluteus medius, so as to invert the limb.
This explanation has not, however, been deemed satisfactory by some
good judges of the subject. Supposing the action of the gluteus medius
on the outer fragment to be the cause of the limb being turned inwards,
it is certainly difficult to comprehend why the effect should not be coun-
teracted by the adductor, which is a much more powerful muscle, and
always disposed to rotate the femur outwards. Yet, the anomaly must,
I believe, depend upon some peculiarity in the direction of the 'fissure.
FRACTURES OF THE NECK OF THE THIGH BONE. 683
Other explanations have been offered, one of which is founded on the
well-known fact, that when the neck of the thigh bone is broken, that
portion of it which remains connected to the head is sometimes forced
into the cancellous structure of the outer fragment, and is immovably
wedged in it. Now, if this were to happen in a particular way, it is con-
ceived that the inversion of the limb might be produced. Dupuytren
suggested another explanation, which is, that when the neck of the femur
is fractured obliquely, if the inner fragment happen to be situated in front
of the other fragment, then the limb may be turned outwards ; but if the
inner fragment be behind the other, then the limb may be inclined for-
wards, and the knee and foot turned inwards. This is a point in surgery
still requiring further investigation.
But, one still more interesting question, relative to fractures of the
neck of the thigh bone, has been, whether those which are completely
within the capsular ligament, and transverse with respect to the neck
of the bone, are capable of osseous union. The fact, that bony union is
possible in such cases, is now completely established, and almost every
museum contains specimens illustrative of it. Sir Astley Cooper possesses
a fine example of it, which I have examined more than once at his house.
The museum of my friend Mr. Langstaff contains one that is a -complete
demonstration of such union, and which, with several interesting drawings
in the same collection, I have frequently been permitted, through that
gentleman's kindness, to show to the surgical class of University College.
The particulars of the fracture with bony union are published in one of
the volumes of the Medico-Chirurgical Society of London. The bony
union is complete in the shell of the bone ; the centre of the fissure is
united by a fibrous substance ; but the osseous consolidation of it is per-
fect at its circumference. The patient died about two years after the
accident.
Another unquestionable instance of perfect union by bone, after a trans-
verse fracture of the neck of the femur, within the capsular ligament,
is exhibited in the case of Dr. James, an English physician, who fell
from his horse as he was riding near Bordeaux, and fractured the neck
of the femur ; he recovered from the effects of his accident, but died
seven months after it of some visceral disease. On examination, the
fracture was found, by Dr. Brulatour, an eminent surgeon of that city,
to be united by bone ; and it appears from the engraving of the part, that
it was a transverse fracture of the neck, entirely within the capsular
ligament. The engraving is valuable, not only on account of its showing
a perfect bony union of a fracture within the capsular ligament, but also
because it gives us an accurate representation of the diminution in the
length of the neck of the bone, arising from absorption. Dr. Brulatour
has likewise given a view of the size and shape of the head and neck of
the other femur in the natural state. Thus we are enabled to see at once
the difference, which has been produced in the length of the neck of the
bone, and in the position of its head, with respect to the trochanters ; it
being, as it were, situated between them, with scarcely any portion of the
neck remaining. Dr. Brulatour has also favoured us with a section of
the head and neck of the femur, which was the subject of the injury.
Several drawings in Mr. Langstaff's museum illustrate the various ways,
in which nature attempts the reparation of fractures of the neck of the
thigh bone. One drawing exhibits an immense quantity of bony matter,
thrown out by the portion of the neck, or the fragment, nearest the
trochanter major ; together with the thickening of the capsular ligament.
684- PARTICULAR FRACTURES.
Another drawing was made from a case in which anchylosis had taken
place : and a third is a view of an oblique fracture of the neck of the
femur, in which there would not be much, if any, retraction ; bony union
has occurred at the outer part of the fissure, while the rest appears to
be united by a fibrous substance. A fourth drawing shows the efforts
which nature has made to repair the fracture of the neck of the femur,
by throwing out a vast quantity of bony matter. I remember the gentle-
man very well from whose case the drawing was made : he resided near
St. Bartholomew's, and met with the injury by falling from the upper
part of his house into the street ; he lived several years after the acci-
dent, but was quite a cripple. The callus has formed a sort of new
acetabulum, which, together with the increased thickness and strength
of the upper portion of the capsular ligament, enabled the patient to use
the [limb in a certain degree. In one preparation, in Mr. Langstaff's
museum, the fracture is within the capsular ligament ; and the union, by
means of a ligamentous fibrous substance, retains the fragments in such
close contact, that Mr. LangstafF is of opinion, that, if the patient had
lived long enough, the case would have terminated in bony union. Yet,
the process necessary for its accomplishment, is not so easy and sure
as that by which the generality of other fractures are united. When
the head of the bone is completely detached, doubtless one circumstance
unfavourable to bony union is the scanty supply of blood which it receives,
and which consists merely of the small quantity conveyed to it through
the vessels of the ligamentum teres.* Another circumstance is the diffi-
culty of maintaining the fragments steadily in apposition ; they are gene-
rally disturbed too much, and the proper apparatus is not kept on long
enough. In fact, Dupuytren contends, that, in consequence of the dis-
advantageous condition in which the neck of the thigh bone is placed for
bony union, the patient ought to be confined, and the requisite apparatus
kept applied for a very long period, that is to say, from a hundred and
twenty to a hundred and forty days. In this country, surgeons rarely per-
sist in maintaining the limb quietly in a desirable posture for a space of
time at all equal to what has now been specified. Mr. LangstafF, who has
paid a good deal of attention to this subject, is also led to believe that, if
the limb were kept a sufficient length of time without motion, the liga-
mentous union would generally be converted] into an osseous one. The
circumstance of the fracture being oblique or transverse, influences very
much the facility and chances of bony union; for, if the case be oblique,
part of the fissure will extend beyond the external limit of the capsular
ligament, and then admit of osseous union with as much ease and cer-
tainty as any ordinary fractures.
When transverse fractures of the neck of the femur within the cap-
sule do not unite by bone, they unite by a ligamentous substance ; the
* As the fracture is sometimes united by osseous matter, the supply of blood is, of
course, not always inadequate to the purpose. From the valuable observations of Dupuy-
tren, Cruveilhier, and Breschet, on the process by which fractures are united, it appears
that the vessels of the surrounding tissues perform an active part in the work of reparation.
But, as Mr. Mayo has justly noticed, these tissues are excluded by the untorn synovial
and capsular membranes from communicating with the fracture. " They are sometimes,
indeed, seen to make the ordinary effort towards reparation of the adjacent fracture. Thus
a portion of an ossified provisional callus is often met with external to the attachment
of the capsular membrane to the neck of the femur. But the effort is ineffectual ; the
callus cannot reach the fracture, whether it remains entirely disunited, or is glued together
by an exudation from the ends of the bone." See Outlines of Pathology, p. 9._,
FRACTURES OF THE NECK OF THE THIGH BONE. 685
capsular ligament becomes thickened and strengthened, and ligamentous
bands extend from it to both fragments, and sometimes from one frag-
ment to the other. In a few instances, another mode of reparation is
established ; osseous matter is thrown out by that portion of the fractured
neck which is connected with the trochanters, and the callus from this
source assumes a shape calculated to support within it the end of the
other fragment ; in other words, a kind of socket is formed in the outer
fragment, which, as well as the other fragment, becomes coated with
what is termed the ivory deposit, a very smooth hard substance, by
means of which the friction between the two fragments is lessened, and
motion facilitated ; it answers, in fact, the purpose of cartilage.
With regard to the treatment of fractures of the neck of the femur,
I may remark that, at one period,, several surgeons considered the chance
of bony union so hopeless, when the fractures were entirely within the
capsule, that they did not deem it worth while to direct the treatment
expressly to the attainment of such union, and they merely put the limb
for two or three weeks on a double inclined plane, or on pillows or bolsters
laid under the ham. Such, indeed, is the practice of Sir Astley Cooper,
who places a pillow or bolster under the ham, and if the patient be very
old, and the fracture attended with symptoms denoting its situation to be
within the capsular ligament, all idea of subjecting the case to very long
confinement is renounced. At the end of two or three weeks, the patient
is allowed to 'get up and use crutches. Other surgeons do not pursue
this method ; and, having greater confidence in the possibility of obtain-
ing bony union, they recommend the confinement to be longer, and the
fracture to be more carefully put up. With this view, some of them em-
ploy the double inclined plane, and apply the pelvis strap so as to make
the pelvis and apparatus, as it were, one piece, between the two parts of
which no motion can happen. In France, Dupuytren used to make a
double inclined plane with pillows, duly arranged under the limb ; but
the objection to this plan is, that there is nothing to prevent the patient
from changing his position, or the limb from assuming another posture ;
and if Dupuytren's method has the recommendation of simplicity, it is
not a good one in other respects, since it cannot be depended on for
keeping the limb steady. In University College Hospital, fractures of
the neck of the femur are generally treated with Desault's long splint,
applied as already explained. An ingenious treatment was proposed by
Hagedorn, the principle of which was to make the sound limb the part
on which a long splint might be fixed, to the extremity of which a foot-
board for the other limb was attached. Thus the surgeon had a fixed
surface on which the foot of the injured limb could be placed and fixed
in the most desirable position. In truth, the right principle in the treat-
ment always consists principally in bringing down the limb to its proper
length, and regulating the position of the foot ; for nothing of importance
can be done with splints, except inasmuch as they may serve for regulating
the position of the limb, and keeping it steady. Hagedorn's apparatus has
a slipper, and, by placing the foot in it, any direction may be giveji to this
part of the limb, considered advantageous. Ingenious as Hagedorn's
plan is, it has not been much employed, chiefly because it is found to be
very irksome to the patient. In America, Professor Gibson has taken
the trouble to modify the apparatus, by carrying the splint as high as the
axilla, and applying to the injured limb a splint which extends also as high
as the armpit.
When the lower part of the thigh bone is fractured, or when the
686 PARTICULAR FRACTURES.
fissure goes into the knee joint, the extended position of the limb is often
preferred, because it keeps the head of the tibia in contact with the
condyles of the femur, and thus has a most useful operation in keeping
them steady. Were it not for this consideration, we should be inclined
to advise the bent position of the limb, in order to relax the gastroc-
nemius and the popliteus, which have a tendency to draw the lower
fragment towards the ham ; but Sir Astley Cooper, whose experience
and judgment are equally great, found, that more advantage was derived
from the effect of the extended position in bringing the head of the tibia
in contact with the condyles of the femur, than from the relaxation of
the muscles in question. In such a case, lateral splints should be
applied, in order to afford due support to the broken part, and keep
it motionless. In these cases, a considerable degree of swelling gene-
rally comes on, so that for a few days the surgeon is obliged to defer the
use of splints, and aim at the reduction of the inflammation by means of
leeches, venesection, cold applications, &c.
FRACTURES OF THE PATELLA
Commonly happen in the transverse direction, and are caused by the
powerful action of the extensor muscles of the leg. The circumstance
most frequently causing the bone to be fractured in this manner, is that
of a person making a violent effort to save himself from falling backwards,
when he has lost his equilibrium ; for then the extensors of the leg act
with immense force to keep the femur and the pelvis forwards ; and as
the knee is always somewhat bent at the moment, only the lower portion
of the patella is actually in contact with the condyles of the femur, over
which the muscles break it transversely, as already mentioned. However,
this is not the only way in which a fracture of the patella may be pro-
duced, for sometimes the bone breaks while the leg is perfectly extended.
When we hear of cases, in which the thrust of a gorget into the bladder,
in lithotomy, made the muscles of the thigh act so violently as to break
the knee-pan, we may conclude, that the accident happened when the
knee was bent, because the position, in which the patient is bound for
that operation, would make this tolerably certain ; but it is alleged, that
the patella has been fractured by the violent action of the muscles in
epilepsy, even when the limb was in the straight or extended posture.
The patella may be broken in the longitudinal, or perpendicular direction,
by direct violence. Not long ago, a case occurred in the Hotel Dieu at
Paris, where the patella was fractured both in the longitudinal and trans-
verse directions, the bone being split into nearly equal quarters ; the
accident was, of course, produced by direct violence, for I scarcely need
observe, that such a fracture could not have been the result of the action
of the extensor muscles of the leg.
When the patella is fractured, the symptoms vary according to cir-
cumstances : in the first place, whether the tendinous expansion covering
the bone be lacerated at the same time that the fracture takes place, is
a circumstance making some difference ; secondly, much will depend upon
the degree of laceration of the tendinous covering of the bone. When both
these parts are torn through, the upper fragment may be retracted a
considerable distance up the thigh, as far, perhaps, as four or five inches ;
but if they are not lacerated, the fragments will hardly be separated at
all. Of course, while the fragments are much apart, we are not able to
perceive a crepitus ; but, if we extend the leg, so as to relax the extensor
muscles, we may push down the upper fragment, and bring it into con-
FRACTURES OF THE PATELLA. 687
tact with the lower one, and then a crepitus will be immediately distin-
guished. When attempts are made by the patient to bear upon the
limb, it will be found, that he cannot support the weight of his body
upon it ; and he falls forward on his knee. If the upper fragment is
completely detached from the lower one by rupture of the tendinous
expansion covering them, the distance between them may also be in-
creased by bending the knee ; so that, in general, when the fracture is
transverse, the case is evident enough. But, in a longitudinal fracture,
the displacement is not so manifest, and more attention will be requisite
to detect the real nature of the accident ; yet if we relax the extensors,
we may generally feel a crepitus in this case also, and with no great
difficulty, notwithstanding there may be considerable swelling, in conse-
quence of the species of violence that has produced the accident, namely,
a direct blow, or kick ; for longitudinal or perpendicular fractures of the
patella, as I have already explained, cannot happen from the action of
the extensor muscles of the leg, but always require for their production
direct external violence.
The treatment consists in paying attention to two circumstances : —
one is to relax the extensor muscles of the leg as much as possible ; the
other is to bring the upper fragment into contact with the lower one,
and keep it so. Now, the first object, namely, the relaxation of the
extensor muscles of the leg, requires that their lower attachments should
be put as near to their origins as possible. The rectus, therefore, is to
be relaxed by bending the thigh on the pelvis, by which the patella and
the upper part of the brim of the acetabulum and the anterior inferior
spinous process of the ilium, the insertion and origins of this muscle, are
brought into as much approximation as can be effected by position. Now
this will partly relax the rectus, but not the vasti and cruralis, which re-
quire the leg to be extended. For maintaining the limb in this position,
the surgeon is to place the leg and thigh on an inclined surface, rising
gradually and regularly all the way from the tuberosity of the ischium to
the heel ; the trunk being also raised on another inclined surface, so as to
incline the front of the pelvis towards the thigh. The other circumstance
to be attended to, or that of bringing the fragments into apposition, and
keeping them so, is fulfilled by pushing the upper fragment down into its
proper situation, and applying a roller to the lower part of the thigh, just
above the upper fragment. Some surgeons put a few circles of a roller
above the patella, and others below the knee, after which the upper and
lower ones are laced together with packthread. Some years ago, it was
the custom, after the limb and patella had been put into the proper posi-
tion, to apply a roller a few times round the thigh, above the upper frag-
ment, and then to finish the bandage by passing the same roller round
the knee, in the form of a figure of 8 ; but this figure-of-8 direction of the
bandage, though it may look well, is of no real use. Sir Astley Cooper
first applies a leather strap to keep the upper fragment near the lower
one, and then applies another strap, which passes from the first, down one
side of the leg, across the sole to the other side, along which it abends to
the circular strap again.
Dupuytren employs the uniting bandage and a compress, which seem
to answer very well ; indeed, a case is related by Sanson, which he saw
treated by Dupuytren with these simple means, where the union was so
strong, that when the patient afterwards met with an accident, in which
the extensors of the leg were made to act violently, the united part of
the bone did not give way, but the ligamentum patellae. Putting the
688 PARTICULAR FRACTURES.
limb in a fracture-box is a convenient mode of keeping the leg and thigh
steadily in the proper posture. Any of the plans, however, which I have
enumerated, may be practised with success ; but it should always be re-
membered, that the maintenance of the limb in the right position is of
still greater importance, than any roller or apparatus for confining the
upper fragment near the lower one.
Transverse fractures of the patella generally unite by a fibrous or
ligamentous substance, and not by bone. There have been instances,
however, in which a union has taken place by bone ; but they are rare.
On the other hand, longitudinal fractures of the patella,, occasioned by
direct blows, frequently unite by osseous matter. In the museum of
University College, is a preparation taken from a coachman, who fell from
his coach-box, when his knee came violently into contact with the pole
of the carriage ; the consequence was a comminuted fracture of the
patella. Osseous union has taken place. Unfortunately, however, the,
case had an unfavourable termination ; for, too much pressure having
been employed, inflammation of the knee joint came on, and the man
ultimately died. In the same collection is another specimen of a trans-
verse fracture of the patella produced by direct external violence. The
apex, which was broken off, is united again by means of bone. Mr. Gul-
liver has recorded two cases of bony union. "The first is that of a sailor,
who fell on his knee from the maintop of a brig : the second is that of
a soldier, whose patella was fractured by a gun-shot. Mr. Gulliver also
broke the patella? of rabbits and dogs; first by blows, so as not to divide
the aponeurosis, which covers it, and, in such cases, the union was osseous ;
and secondly, he cut the bone and aponeurosis through with cutting for-
ceps, and, under such circumstances, no bony union followed. His conclu-
sions are, that when the aponeurosis is completely divided, as in fractures
of the patella from the violent action of the extensors of the leg, bony union
is not to be expected ; because, in such cases, it is impossible to keep
the fragments in accurate contact ; and that osseous union is simply the
effect of the immovable coaptation of the fragments, the provision for
which, in certain fractures from external violence, is the integrity of the
aponeurosis in front of the bone.* It sometimes happens, that, after the
cure of a fractured patella, the patient meets with an accident, in which
the extensor muscles of the leg act with such violence that they lacerate
the ligamentous substance, which is the usual bond of union in transverse
cases ; and then even the skin and synovial membrane may give way, and
the knee receive injury of so serious a nature as to call for amputation.
Some preparations in the museum of University College prove, that a
fracture of the patella may be followed by severe disease of the knee
joint; — as inflammation of the synovial membrane, abscesses, and ab-
sorption of the cartilages.
FRACTURES OF THE BONES OF THE LEG.
We might suppose, on looking at these bones, and seeing one of them
so strong and the other so slender, that the fibula would most frequently
be fractured; this is not the case. The tibia, strong as it is, is oftener
broken than the fibula, and one reason of this is its superficial and ex-
posed situation in front of the leg. In fact, its anterior surface is merely
covered by the integuments. Another reason is, that the tibia receives
all the weight of the body when a person leaps, or alights with his foot
* Edinb. Med. and Surgical Journ, Jan. 1837.
FRACTURES OF THE BONES OF THE LEG- 689
forcibly on the ground. The fibula is covered to the extent of its two
upper thirds by thick muscles, and the rest of it may be said to be very
much protected by the tibia itself. Indeed, the peronaei muscles alone
are sufficient to guard it from the effects of ordinary degrees of violence
directed against the outside of the leg.
When the tibia is broken singly, the injury is generally caused by
direct violence, more especially if the fracture happen at any point of
the two upper thirds of the bone. The fracture is then usually pro-
duced by a blow, a kick, or the passage of the wheel of a heavy carriage
over the limb. The lower third of the tibia may be fractured either by
direct or indirect violence, or as the result of what the French surgeons
call a contre-coup. A fracture of the upper third of the tibia is fre-
quently transverse ; but one situated in the two lower thirds of the
bone is generally oblique. When the tibia is the only bone broken, and
the fracture is in the upper third of it, some attention is necessary to dis-
cover the nature of the accident, because there is no change in the shape
of the limb ; for the fibula, being perfect, acts as a splint, so that there
can be no shortening of the member, while the extensive surface of a
fracture, in this situation, tends equally to prevent both retraction and
displacement. However, the slightest inequality of the tibia may always
be detected by passing the finger along the anterior edge or spine of
that bone, when, if there be a fracture, some projection or irregularity,
at the part where the fracture is situated, will be perceived. On moving
the ankle and knee rather freely, we shall also perceive, that, exactly in
the place of the solution of continuity, the bone, instead of being firm
and unyielding, has a degree of motion it it, or yields when pressed
upon. If both bones should happen to be broken, then the case will be
evident enough, as a change will be noticed in the shape of the limb, an
angular deformity, the heel being drawn more or less backward and up-
ward by the muscles of the calf. We shall also observe a shortening of
the limb, and that the foot is twisted either inwards or outwards. Were
any other circumstance necessary to convince us of the nature of the
accident, we should have such a criterion in the very distinct crepitus,
that could be felt without the least difficulty.
When the fracture is situated at any point of the lower two thirds of
the tibia, the fissure through the bone will frequently extend obliquely
from above downwards and from behind forwards. Hence, the extre-
mity of the upper fragment will be very sharp, and likely protrude
through the skin, making the case a compound fracture. When the
fibula is broken, as well as the tibia, the latter bone generally gives way
first, and then the weight of the body being transmitted to the fibula,
this bone also breaks. Such is the explanation offered by Dupuytren,
as that which applies to the majority of cases ; but sometimes both bones
are fractured at once by direct violence, as happens when the wheel of a
heavy carriage passes over the limb.
Although the fibula is, on the whole, less frequently broken dian the
tibia, still the accident is common enough; so common, indeed, that
Dupuytren calculates, that fractures of the lower third of the fibula
amount in number to one third of all fractures of the legs. Fractures of
the upper two thirds of the fibula are generally caused by direct violence,
while those of its lower third are most frequently occasioned by a forcible
twist of the foot. The twist most commonly happens in the direction
outwards, and, when this is the case, the fibula usually breaks from two
to four inches above the external malleolus. When the fibula is broken,
y Y
590 PARTICULAR FRACTURES.
in consequence of the foot being twisted outwards, the inner edge of the
sole is in contact with the ground, and the upper end of the lower frag-
ment inclines inwards towards the tibia. The fibula may also be broken
by the foot being twisted inwards, in which event, the deformity will be
different, for the outer edge of the sole will be against the ground ; the
sole itself will be turned inwards ; and the upper end of the lower frag-
ment will be directed outwards, away from the tibia.
The generality of fractures of the leg may be conveniently treated in
the slightly flexed position, with the limb supported on M'Intyre's ap-
paratus ; or the leg may be placed on Amesbury's or some other double
inclined plane, and supported with lateral splints. The bent position is
by far the most comfortable to the patient, and it has the advantage of
relaxing the powerful muscles of the calf. However, when the fracture
is situated high up, near the knee, the limb may be kept in the extended
position, which, as Sir Astley Cooper well observes, converts the con-
dyles of the femur into a surface, against which the upper fragment can
be steadily maintained.
Fractures of the upper part of the fibula generally unite without any
permanent ill consequences, even though they may be neglected, and
taken little care of. No doubt, many of them are never detected at all,
in consequence of being unattended with displacement. But, fractures
of the lower part of the fibula require more caution ; for if they are not
rightly managed, the patient will sometimes be a cripple for life, the
foot remaining distorted outwards, and the individual being obliged to
walk on the inner malleolus, instead of on the sole of the foot.
Dupuytren adopts a simple and effectual plan for the treatment of
those fractures of the fibula which proceed from a violent twist of the
foot outwards. The whole of his apparatus consists of two rollers, a
splint about two feet in length, and a pad stuffed with oaten chaff, much
thicker at one end than the other. The pad is applied to the inside of
the leg, with its thick end downwards, and then the splint is put on,
which, by extending beyond the inner edge of the sole, makes a fixed point
at a convenient distance from it, against which the foot is kept inclined
inwards by means of a roller. The splint is first secured on the part with
a few turns of the roller round the upper part of the leg. If the fibula is
broken by a twist of the foot inwards, Dupuytren ^applies the splint and
pad on the outer side of the leg.
Some fractures of the leg have been treated successfully with splints
made on the principle of the fracture-box, and the lateral parts of which
admit of being let down, or put up, by means of hinges. Assalirii's
splints are thus constructed. If they are employed, the limb must then
be kept in the extended position. Certain compound fractures are very
conveniently dressed when such a splint, or a common fracture-box, is
employed. In University College Hospital, M'ln tyre's apparatus is
commonly preferred to others, as being more simple, requiring no addi-
tional splint, keeping the limb perfectly steady, and, what is of high im-
portance, allowing a great part of its surface to be uncovered, and the
wound, if any be present, dressed, without the slightest disturbance of
the fracture. Greenhow's apparatus likewise appears to me a highly
meritorious one for the preceding objects ; but less simple and more ex-
pensive : with it the whole of the leg may be uncovered, and a wound
dressed without moving the fracture in the slightest degree.
DISLOCATIONS OF THE LOWER JAW. 691
FRACTURE OF THE OS CALCIS
Is a rare accident ; the fracture always occurs behind the junction of
this bone with the astragalus. The treatment consists in relaxing the
muscles of the calf, and applying splints and bandages for the purpose of
preventing motion of the ankle. In the museum of University College is
a specimen of a fracture of the os calcis united.
PARTICULAR DISLOCATIONS.
DISLOCATIONS OF THE LOWER JAW.
While the mouth is shut, the lower jaw cannot be dislocated : but when
the teeth are separated, and the mouth widely open, the condyles pass
forwards on the eminentiee articulares ; and while they are in this position,
if there be any spasmodic action of the depressors of the chin, or of the
external pterygoid muscle, to bring them a little more forwards, they will
slip under the zygomatic processes, and thus a dislocation will be pro-
duced. The condyles of the lower jaw can be dislocated in no other
direction than that forwards under the zygoma; and the accident may
happen either in the manner I have described, or in consequence of some
external violence acting upon the body of the bone, at a time when the
mouth is open. In fact, at that period, a very slight force, applied so as
to depress the chin, will make the condyles glide under the zygomas ; and
hence, dentists, if they are rough and careless in their proceedings for the
extraction of the teeth, may dislocate the lower jaw.
The dislocation can only take place forwards under the zygoma ; and
this is true with respect to the two kinds of dislocation to which the
lower jaw is liable : one in which both the condyles are displaced, and
the other, the particular case where only one of them is dislocated;
which is less common. The lower jaw, however, is subject to another
kind of accident, attended with a partial displacement of it, namely,
the case in which the condyle of one side slips out of the inter-articular
cartilage: this is called a subluxation of the jaw ; the condyle does not
quit the capsule, but merely the inter-articular cartilage ; the jaw be-
comes motionless, and the mouth continues slightly open. We meet, then,
with three cases, the dislocation of both condyles ; the dislocation of one ;
and the subluxation^ or mere displacement of one condyle from the inter-
-articular cartilage.
The symptoms of a complete dislocation are the following : — In con-
sequence of the position assumed by the bone, when the condyles are
thrown forwards out of the glenoid cavities, the mouth must necessarily
remain open, — it cannot be closed ; for this would be prevented by the
coronoid processes touching the cheek bone. The power of speech is of
course considerably impaired, the pronunciation of the labial consonants
being impossible. After the bone has remained unreduced for some
time, it is true, the mouth will become rather less widely open ; but still
it cannot be closed on account of the mechanical impediment to which I
have alluded. The chin is considerably lengthened, the cheeks stretched
and flattened, and the lower teeth, if they could be brought up as high
as the upper ones, would be much in advance of them. In consequence
of the irritation of the parotid gland, there is a profuse secretion of
Y Y 2
692 PARTICULAR DISLOCATIONS.
saliva, which is incessantly dribbling out of the mouth. In addition to
the preceding symptoms, a depression may be perceived just in front
of the meatus auditorius externus, occasioned by the removal of the
condyle from its place. When the dislocation is restricted to one side,
of course, the depression will be perceptible only in front of the cor-
responding ear.
When the case is a dislocation of only one condyle, we may notice,
especially in thin persons, a slight distortion of the chin or mouth, an
inclination of it towards the opposite side ; but, in fat subjects, this kind
of deformity maybe so slight as perhaps not to excite attention. Atone
time, it was supposed, that an unreduced dislocation of the lower jaw
would be fatal : it is certainly a very distressing occurrence ; but there
is no truth in the foregoing statement, for cases are on record of indi-
viduals, who lived many years in this pitiable condition.
In the treatment there are two indications : to reduce the displaced part
or parts of the bone, and to keep them reduced. These indications apply
indeed to every dislocation, which has not existed too long to render their
fulfilment totally impracticable. The manner of reducing a common and
complete dislocation of the lower jaw is very simple. The mouth is
already open, so that there is space enough between the teeth to admit
of the introduction of the thumbs into the mouth. The surgeon, recol-
lecting the principle explained in my general observations on dislocations,
endeavours to make the dislocated bone a lever for reducing its head, or
its condyle ; he therefore introduces his thumbs into the mouth, and ap-
plies them on the molar teeth ; in short, they are to serve as the fulcra,
on which he is to make the bone move : his fingers are next applied un-
derneath the chin to the body of the bone ; he now pushes the condyles
with his thumbs downwards and backwards, at the same time that he
brings the chin upwards and forwards with the pressure of his fingers ;
and as soon as the condyles are thus extricated from the zygomas, the
temporal and masseter muscles act so quickly and suddenly in pulling
them back into the glenoid cavities of the temporal bones, that if the
surgeon were not very prompt in moving his thumbs towards the cheeks,
out of danger, they would be severely bitten. It is on this account, that
some practitioners usually put on a pair of thick gloves, before proceeding
to reduce a dislocation of the lower jaw. Indeed, the rapidity is very
great with which the bone returns into the articular cavities, when the
condyles are extricated from their confinement under the zygomatic pro-
cesses. Then the second indication, or that of keeping the bone reduced,
is accomplished by a very simple plan : as there cannot be any displace-
ment of the condyles, while the mouth remains closed, it is usual to
apply, directly after the reduction, the four-tailed bandage, in order to
keep the mouth in this safe and desirable position. The two front tails
of the bandage are brought to the back of the head, and the two posterior
ones applied to the forehead. The bandage is worn for about ten days,
and the patient is restricted to spoon diet, and directed to avoid convers-
ation. If there be a great deal of swelling, bleeding, and other anti-
phlogistic measures will be advisable. When only one condyle is
displaced, and pressure made with the thumbs on the molar teeth of both
sides of the jaw, sometimes we cannot succeed in effecting the reduction ;
and I therefore recommend Mr. Hey's advice not to be forgotten, which
is, to apply the thumb only on the side where the dislocation has taken
place, and to let the lever-like movement be directed particularly to the
displaced condyle, and not to the other. By attending to this maxim, I
DISLOCATIONS OF THE CLAVICLE. 693
lately reduced, without much difficulty, a dislocation of one condyle in a
woman brought to my house by my neighbour, Mr. Delisser.
In the subluxation of the lower jaw, when the condyle is thrown out of
the inter-articular cartilage,, the jaw is rendered motionless, and the
mouth cannot be entirely shut. It is an accident that does not call for
the interference of a surgeon, as the condyle usually returns into its
place again in a few minutes, without assistance.
When the reduction of a dislocated jaw is attended with extraordinary
difficulty, we should have recourse to bleeding and other means of weak-
ening the muscles.
A person, who has once dislocated his jaw, will always be liable to the
accident again from slight causes; and sometimes merely laughing, or
yawning, will bring it on."
DISLOCATIONS OF THE CLAVICLE
Are much less common than fractures. The clavicle may be dislocated
either at its sternal extremity, or at its junction with the acromion ; but
the dislocation of the sternal end is more frequent : first,, because that
end of the bone is naturally more moveable ; and, secondly, because its
ligaments are considerably weaker, than those which tie the other extre-
mity of the clavicle to the acromion. The accident, when it occurs,
mostly happens in children and women, in whom the ligaments are weaker,
and the articular cavity shallower, than in male adults.
In what direction does the dislocation of the sternal end of the clavicle
usually take place ? It happens in most cases forward ; the dislocation
backwards being so rare, that Sir Astley Cooper, with all his experience,
has only met with one example of it, and that was not produced by
external violence, but was the result of great deformity of the chest and
spine, whereby such a change was made in the direction of the whole
trunk, and of the clavicle in particular, that its sternal end was thrown
backwards. One curious result of this case was, that the oesophagus
was dangerously pressed upon by the dislocated end of the clavicle,
which the surgeon was obliged to saw off to save the patient's life. The
dislocation of the sternal end forwards is much more frequent, and may
occur in two ways ; either from a fall on the shoulder, or from the appli-
cation of external violence, which, by pushing the acromion suddenly
and considerably backwards, gives a disposition to the sternal end of the
clavicle to start forwards in the same proportion. The nature of the
case is obvious, from the superficial and prominent situation of the bone.
The accident, if complete, is attended with laceration of all the ligaments
and part of the tendinous attachment of the sterno-mastoid muscle. The
treatment consists in the application of a wedge-shaped cushion under
the axilla, to make the burner us act as a lever in propelling the shoulder
outwards ; in the employment of a bandage and sling to confine the arm
in a position, in which the elbow and fore-arm are duly supported, and
held rather backwards, while the shoulder is inclined a little forwards ;
and in putting a compress on the sternal end of the clavicle, ana keeping
it there with the bandage.
The acromial end of the clavicle can be dislocated only in one direction,
which is upwards. It cannot be dislocated downwards ; for the root of
the coracoid process of the scapula, and the ligament extending from this
process to the acromion, resist a dislocation downwards ; but sometimes,
by great violence, the scapula itself is driven downwards, and the acro-
mial end of the clavicle then projects upwards. Sir Astley Cooper, in his
y Y 3
691'
PARTICULAR DISLOCATIONS.
work on dislocations, gives us a drawing of such a case. Here the liga-
ments, tying the clavicle and acromion together, are torn, as well as some
of the bands of ligaments connecting the clavicle with the coracoid pro-
cess. The treatment consists in keeping the shoulder inclined outwards,
by placing a wedge-shaped cushion below the axilla, and in using the
figure-of-8 bandage, with a soft pad in each axilla, to prevent its margins
from being chafed. When, by this means, the shoulders are drawn back,
the acromion returns into its place. The arm is of course to be kept up
witli a sling.
My friend, Mr. Morton, of University College, has favoured me with
the particulars of an unusual dislocation of the sternal extremity of the
clavicle ; the displacement of it being upwards and inwards.
Etienne Careron, aet. 39, mason, admitted into the Hospital of La
Charite, on account of an injury, which was caused by his having been
violently squeezed between a wall and a cart, in such a manner that the
left shoulder was thrust inwards with great force. On examination, the
sternal extremity of the left clavicle was found to have been displaced
from its natural situation, and was now placed above the upper edge of the
sternum, producing a slight deformity in the contour of the lower part of
the front of the neck. It seemed, from the description of the accident
which was given by the patient, that the force producing the injury had
acted in such a direction as to push the sternal extremity of the dislo-
cated bone upwards, and behind the sternal portion of the sterno-cleido-
mastoid muscle. The articulating surface of the internal extremity of the
dislocated clavicle lay opposite to that of the clavicle of the sound side,
and was supported by the superior border of the sternum. The attach-
ment of the sterno-cleido-mastoid muscle to the first bone of the sternum
did not appear to have suffered any laceration. M. Velpeau considered it
to be very probable, that the dislocation was in the first place backwards,
but that the force continuing to act, the end of the clavicle was afterwards
driven upwards, and across the front of the root of the neck, and behind
the sterno-cleido mastoid muscle. The dislocation was reduced in the
usual manner, and the apparatus of Dcsault for fractured clavicle cm-
DISLOCATIONS OF THE HUMERUS AT THE SHOULDER. 695
ployed to retain the end of the bone in its proper place. The bandages
used were steeped in a solution of " dextrine," which, when dry, ren-
dered the whole immoveable.
Sept. 6. The apparatus has been reapplied, as the extremity of the cla-
vicle had again become slightly displaced in the same direction as before..
Sept. 15. Doing very well.
DISLOCATIONS OF THE HUMERUS AT THE SHOULDER
Are so common, that it has been rather incorrectly supposed, that they
equal in number all other dislocations put together ; and when various
circumstances relating to the shoulder joint are considered, we must
discern several which account for the frequency of these accidents.
First, the glenoid cavity is very shallow and small in proportion to the
size of the head of the humerus, which, in the perpendicular direction
is twice as broad as the articular cavity, and in the transverse direction,
not less than three times as wide. Secondly, this joint derives no material
strength from ligaments, the capsular ligament being particularly weak
and thin below, where there is nothing to resist dislocation, and thick
above, where the acromion, coracoid process, and triangular ligament,
form insurmountable obstacles to such an accident. Thirdly, we are to
remember, that the shoulder joint is capable of motion in every direction,
and the muscles surrounding it and attached to the humerus are nume-
rous, the consequence of which disposition is, that the head of the bone
must in many positions make considerable pressure against the capsule.
Dislocations of the humerus would, indeed, be more frequent than they
are, if the scapula were more fixed; but as this bone is as moveable as
the humerus itself, the glenoid cavity accompanies all the movements of
the head of the latter bone, and thus forms a very accommodating sup-
port to it.
The head of the humerus is subject to three complete dislocations, and
one of an incomplete kind. The most common of the three complete dis-
locations takes place downwards into the axilla, the head of the bone
pressing against the inferior costa of the scapula, and passing into that
situation between the long portion of the triceps, and the tendon of the
subscapularis, which is sometimes lacerated. In the next most frequent
case, the head of the humerus is thrown under the pectoralis major and
pectoralis minor muscles, on the sternal side of the coracoid process, so
as to lie below the middle of the clavicle. As the pectoralis minor is
attached to the coracoid process, the head of the bone must pass under
that muscle in order to reach the situation which has been specified.
This fact, I believe, is not demonstrated in any preparations in London ;
but Sir Astley Cooper refers to a specimen, from the appearance of
which, it was inferred that the head of the humerus had certainly passed
under the pectoralis minor, as well as the pectoralis major. The third
complete dislocation is backwards, on the dorsum of the scapula, under
the spine of that bone : but this is so rare an accident, that Baron Boyer, •
in the whole course of his experience, never met with more Iftan two
examples of it, one of which was accidentally noticed in the dead subject.
Sir Astley Cooper, also, during an experience of more than forty years,
has met with but few instances of it. One such case was brought to
University Hospital, and reduced by Mr. Morton, late house-surgeon.
In the incomplete dislocation, the head of the humerus is thrown for-
wards on the external side of the coracoid process,, and the capsular
ligament is lacerated ; but the bone does not entirely quit it.
Y Y 4
PARTICULAR DISLOCATIONS*
What are the symptoms of a dislocation of the head of the humerus
into the arm-pit ? Three symptoms are common to all dislocations of the
shoulder: first, loss of the rotundity of the shoulder; secondly, a hollow
under the acromion; thirdly, the acromion forms, or seems to form, a greater
projection than natural. In addition to these symptoms, when the head
of the humerus is lodged in the axilla, there will be a lengthening of the
arm ; if we look at the patient from behind, the elbow of the affected limb
will plainly seem to be lower than the elbow of the other arm ; it will also
be inclined a good way from the trunk, and the patient cannot put it close
to his side. This latter circumstance is one of the first things about
which I usually make inquiry, when called to a supposed dislocation of
the shoulder; and if the patient can put his arm close to his side, I then
know that there cannot be a dislocation into the axilla. In such a dislo-
cation, he is also unable to raise his arm to a level with the acromion. In
consequence of the limb being lengthened, and the humerus carried
downwards, the deltoid is necessarily flattened, and this, not merely on
account of the bone quitting its place, but from the fibres of the muscles
being put on the stretch. It is, indeed, in consequence of this, that the
arm is held out from the side. The long portion of the triceps is also
stretched ; and one effect of this is, that the fore-arm is always found
more or less extended, while the stretched condition of the head of the
biceps accounts for the hand being thrown into the state of supination.
If the arm be raised from the side, we may distinctly feel the head of the
humerus in the axilla. In addition to the above symptoms, the functions
of the joint are suspended, and, instead of free motion of the arm, there
is an extraordinary rigidity of it. The manner, in which the accident
commonly happens, is this ; — the patient falls while his arm is raised
from his side, or, I should rather say, he endeavours to save himself from
injury by holding out his arm ; the arm comes to the ground in this
position, and the resistance of the ground suddenly throws the lower
portion of the humerus upwards, and propels its head downwards, which
latter movement is at the moment also promoted by the spasmodic and
violent, action of the pectoralis major and latissimus dorsi muscles. Thus,
supposing the arm to be raised from the side at the time of the fall,
without too much inclination either backwards or forwards, the dislocation
will be into the axilla.
In another dislocation, which is tolerably frequent, where the head of the
humerus is thrown under the pectoral muscles, and on the inner side of
the coracoid process, the head of the bone can be felt in its new situation ;
the axis of the bone is also directed towards this point ; not towards the
glenoid cavity, but the centre of the clavicle. The elbow is seen to
incline more or less backward. The head of the humerus being more
wedged in its new situation at the inner side of the coracoid process, than
when it lies in the axilla, the limb is still more rigid, and there is less
possibility of moving it. The limb is also shortened ; whereas, in the
luxation downwards, it is lengthened. In addition to these, there will
of course be the three common symptoms, namely, a hollow under the
acromion, a considerable projection of that process, and a diminution
of the rotundity of the shoulder.
The dislocation forwards, under the pectoral muscles and centre of the
clavicle, takes place in the following manner : while the arm is inclined
somewhat backwards, and separated from the side, the person falls with
lircat force on his elbow, or lower end of the humerus, the head of which
is consequently forced upwards and forwards. It does not always pass
DISLOCATIONS OF THE HUMERUS AT THE SHOULDER. 697
immediately underneath the clavicle, but undergoes that secondary species
of displacement, to which I invited attention in the general observations
on dislocations : it is first thrown under the pectoral muscles, and then
the action of the muscles draws it higher and higher, till it is brought
close under the centre of the clavicle at the inner side of the coracoid
process.
A dislocation backwards can scarcely happen, except when the arm is
inclined forwards, across the front of the chest, and it is difficult to imagine
how any force can act so as to dislocate the bone, even when the arm is in
this position ; for any violence, at all likely to be applied, would generally
propel the arm against the chest, and this, no doubt, is the reason why
the dislocation backwards is uncommon. As the head of the bone is
always conspicuous below the spine of the scapula, the diagnosis is not
liable to any mistake. In this case, the elbow is not separated from the
side, as it is in the more common dislocation into the axilla.
What is the mischief produced when the head of the humurus is dislo-
cated downwards into the axilla ? There is sometimes a laceration of the
tendon of the subscapularis ; the tendon of the long head of the biceps is
also stated to be sometimes broken or displaced ; but so far as the dis-
sections of Sir Astley Cooper and Boyer go, it appeal's that neither of these
circumstances has fallen under their notice. One instance, however, is
recorded by Mr, Hey, where, in a compound dislocation of the shoulder,
an extremely rare case, the head of the humerus protruded through the
integuments, and the tendon of the biceps was really torn. Of course,
the capsular ligament is lacerated, and there may be a laceration of other
tendons and muscles.
Every plan for reducing dislocations of the shoulder ought to combine
three principles ; namely, extension, counter-extension, and the employ-
ment of the shaft of the bone as a lever for moving its head into the
glenoid cavity ; and also a fourth principle, which is the relaxation of the
muscles, so far as this may be practicable, without neglecting the other
indications. The manner of making counter-extension is by means of a
girth or sheet, applied round the chest, and either held by the assistants,
or fixed to some point in the direction opposite that in which we purpose
to make extension. A piece of strong linen, with an aperture or slit in
it, for the reception of the arm, will serve very conveniently both to fix
the chest, and hold back the scapula. Whatever means be employed for
keeping back the shoulder, the pressure is not to be applied to the glenoid
cavity, or too near the acromion ; for then it would form an obstacle to
the return of the bone into its proper situation.
With regard to the manner of making the extension, and the direc-
tion in which such extension ought to be made, I may observe, that
French surgeons would generally make extension as far as possible from
the joint concerned : thus, in a dislocation of the shoulder, they would
make it at the wrist : but, in this country, the extending means are
most commonly applied at the lower part of the humerus itself; and the
reason for this is, that British surgeons frequently prefer keejfing the
fore-arm bent, by which means the biceps is relaxed. They consider
that, as the portion of this muscle attached to the coracoid process must
be stretched when the arm is extended, it would in this state tend to
hinder the shoulder from being kept properly back ; and, on this account,
they keep the fore- arm bent, and apply the extension to the lower part of
the humerus. In the plan used in France, there is the advantage of a
long lever, which, perhaps, fully counterbalances the good derived in our
£98 PARTICULAR DISLOCATIONS.
method from the relaxation of the biceps. Before applying the napkin, or
cloth, for the purpose of making extension, it is customary to place some-
thing immediately round the limb, in order to prevent the skin from
being chafed or too much irritated ; and, in this country, it is usual to apply
a piece of wet linen, or a few turns of a flannel roller, for the purpose. We
then take a piece of strong calico, or linen, which must be three yards
long, and half a yard wide, and fold it longitudinally, till it forms a long ex-
tending means, about three inches in width. An ingenious way of apply-
ing this is mentioned by the late Mr. Hey, which is rather difficult to
describe, though very simple to show : he places the noose first in an
elliptical form round the limb ; he next takes one of the ends and passes
it over to the opposite side through the noose ; then he does the same
with the other end ; and the more this apparatus is pulled, the tighter it
becomes. The contrivance is simple and effectual. Another contrivance
is what the sailors call the clove-hitch knot, a drawing of which may be
seen in Sir Astley Cooper's book. With the cloth, three yards in length,
there is, when it is applied, more than a yard left for the assistants to
make extension with. When the dislocation is downwards into the axilla,
the extension may first be made in the direction of the axis of the bone,
that is, downwards and outwards, in order to dislodge its head from the
inferior costa of the scapula. When sufficient extension in this direction
has been made, the next object is to have recourse to the lever-like
movement of the shaft of the bone, and, for this purpose, many surgeons
place one knee in the axilla, and make a fulcrum of it, and as soon as they
see, that the head of the bone has been by these means brought towards
the glenoid cavity, the extending power is relaxed, and the muscles
draw it into its place. On such principles, the reduction is, in general,
easily effected. If the patient be intoxicated, then we are to take
advantage of this condition, in which a dislocation may often be reduced
without performing any extension at all ; indeed, when the person is
faint, or intoxicated, if we place the bone over the back of a chair, or over
our knee, the dislocation may often be reduced with little or no extension.
I have seen this frequently done on drunken persons ; and sometimes
the bone will slip into its place on the patient moving the arm himself,
while it is suspended over the back of a chair, or the mere weight of the
limb will be sufficient to effect the reduction. An old and not a bad
method of reducing a dislocation in the axilla is that, in which the surgeon
places his heel in the arm-pit, and makes extension from the hand or
wrist. The heel not only fixes the chest, and keeps back the shoulder,
but constitutes a fulcrum on which, by the lever-like motion of the limb,
the head of the humerus can be directed into the glenoid cavity. It
would appear that, in some cases, the connection of the supra-spinatus
muscle with the greater tubercle, is the cause of the resistance to the
extending power.* Here the resistance is most effectually overcome by
raising the arm, and relaxing the supra-spinatus. On this subject, Sir
Philip Cramp ton justly remarks, "The success, which not unfrequently
attends the method of reduction (first recommended by Mr. White, of
Manchester) by drawing the arm directly upwards^ in a line parallel to the
axis of the trunk, is, no doubt, to be attributed chiefly to the relaxation,
which it effects, of the supra-spinatus and deltoid muscles. It is probable
also, that, in this position of the humerus, the head of the bone is in some
measure unlocked from the neck of the scapula, against which it is (when
* Sir Astley Cooper on Dislocations, p. 377.
DISLOCATIONS OF THE HUMERUS AT THE SHOULDER. 699
dislocated downwards) strongly compressed by the contraction of the
muscles." Mr. Hey particularly recommended White's method for old
dislocations. In 1785, a memoir in favour of the same practice was
addressed to the Academy of Surgery, by M. Mothe. The consider-
ation of the anatomy and pathology of the dislocation into the axilla
led Malgaigne, one of Dupuytren's pupils, to be an advocate for the
method, which gained also the approbation of the latter distinguished sur-
geon. White first described this mode of reduction in a paper, printed
in 1764.*
When the dislocation is forwards, under the centre of the clavicle, the
elbow is inclined backwards and downwards, and, if we were to attempt
to bring the head of the bone direct from its situation, below the clavicle,
into the glenoid cavity, we might fracture the coracoid process. This
shows the necessity of attending to the principle of first dislodging the
bone from the situation in which it has been thrown by the secondary
displacement. In this dislocation, the bone is first thrown out of the
glenoid cavity under the pectoral muscles,, but does not mount up to its
situation under the centre of the clavicle till the secondary displacement
takes place. This displacement must first be obviated by pulling the
bone downwards and backwards in the direction assumed by its axis, as
one of the effects of the accident. Now, as soon as the head of the bone
has been brought below the coracoid process, we are to incline the elbow
more forwards, and bring it closer to the side ; thus we shall direct the
head of the bone towards the glenoid cavity ; at the same time we may
use a band, or napkin, place4 under the upper part of the humerus, as a
fulcrum ; for, in this case, we cannot well get our knee under the axilla,
so as to make a fulcrum of it.
It has sometimes been suspected, that all dislocations of the shoulder
are first downwards ; but a dissection, the particulars of which are given
by Sir Philip Crampton, proves, that this is not the case, for the bone
was thrown under the pectoral muscle, without the lower portion of the
capsular ligament being at all torn.
The other less common dislocation, where the head of the humerus is
thrown upon the dorsum of the scapula, is believed by Sir Astley Cooper
to differ from other luxations of the shoulder in being the result of mus-
cular action alone. He has recorded one case, in which the displacement
of the head of the humerus was produced by the convulsive action of the
muscles in an epileptic fit. I remember one case, however, in which this
dislocation arose from a violent blow on the front of the shoulder. In
the example lately recorded by Sir Astley Cooper, it was found, on dis-
section, that the tendon of the subscapularis and the capsular ligament
had been torn from the smaller tubercle of the humerus, and the bone
was consequently drawn back by the action of the infra-spinatus and
teres minor. Hence, there was no support given to the head of the bone,
when reduced, and, consequently, a return of the displacement ensued.
This, however, is an exception to what has usually happened ; for, after
the bone has been reduced, the reduction has commonly been pernfanent.
This dislocation is peculiar in not being attended with any elevation of
the elbow from the side. The reduction may generally be accomplished
by fixing the shoulder, making extension, and then pushing the head of
the humerus forwards towards the glenoid cavity. In one case, Sir Astley
* See Crampton's Obs. in Dublin Journ. of Med. and Chemical Science, vol. iii.
p. 181.
700 PARTICULAR DISLOCATIONS.
Cooper bent the elbow at a right angle, and, raising the arm, carried it
behind the patient's head, so as to bring the hand across the back of the
neck to the opposite shoulder. Then forcing the elbow back, and press-
ing upon the head of the bone, he pushed it under the inferior rcosta of
the scapula, and it instantly returned into the glenoid cavity. This dis-
location has also been reduced with the heel in the axilla, and extension
made in the direction of the trunk.*
Thus the reduction of dislocations of the humerus is performed on the
combined principles of extension, counter-extension, relaxation of the
biceps, and the lever-like movement of the shaft of the bone. I might
add to these the very important principle of dislodging the head of the
humerus from the situation in which it has been thrown by the secondary
displacement. When difficulty in effecting the reduction is experienced,
we can have recourse to debilitating means, such as copious bleeding
from a large orifice in the vein, or the administration of tartarised anti-
mony, with the view of bringing on that collapse of the muscular system,
which naturally accompanies faintings and nausea. Then, so far as the
muscles are concerned, the difficulty of reduction is removed, and the
head of the bone, if the case be not an old dislocation, may be readily
put into its right place again. Sometimes, in examples of difficulty, the
multiplying pulley is used. After the reduction, the next indication is, to
prevent the bone from slipping out of the glenoid cavity again. For this
purpose a sling is generally sufficient ; but, for greater security, if the
patient be tipsy and restless, we should confine the humerus to the side
with a roller.
It is mostly allowed, that the humerus may be incompletely dislocated,
and remain fixed on the outside of the coracoid process, the front of the
capsular ligament being torn, but the head of the bone not being thrown out
of it. The reality of the accident is sometimes disputed. I have not seen
any decided example of it in my own practice ; but Sir Astley Cooper's
observations leave, I think, no doubt about its possibility ; and in his
work is a plate, representing the state of the parts, as found on dissecting
the shoulder after such an accident. Should it be met with, the reduc-
tion ought to be effected on the same principles as are observed when
the head of the bone is thrown to the inner side of that process ; and
after the reduction, a compress is to be applied in front of the head of
the humerus, just on the outside of the coracoid process, supported by
the spica bandage. In one instance, recorded by Mr. South, the coracoid
process was broken.f
DISLOCATIONS OF THE ELBOW.
The displacement of both bones of the fore-arm forwards cannot take
place without a fracture of the olecranon, which process of the ulna forms
a mechanical impediment to such an accident; indeed, it is an accident
of great rarity. In the museum of University College is a preparation,
in which the olecranon was fractured, and also the coronoid process ; and
the radius and ulna were dislocated, but not both of them forwards, for
the ulna was thrown backwards.
A boy, in attempting to leap over a post near my house, fell down and
dislocated his elbow ; it was a dislocation of the ulna backwards and of
the radius forwards. I had not the slightest difficulty in reducing the
* See Guy's Hospital Reports, vol. iv. p. 265.
f Sec Med. Chir. Trans, vol. xxii.
DISLOCATIONS OF THE ELBOW. 701
case, which terminated favourably. The most common dislocation of the
elbow, is that in which both bones are thrown backwards, either with or
without a fracture of the coronoid process.
When the coronoid process is not fractured, it passes into the fossa at
the back of the humerus, in which the olecranon is naturally situated.
On this account the arm cannot be completely extended ; the olecranon
forms a remarkable projection behind the arm ; and the distance between
the point of the olecranon and the internal condyle is conspicuously in-
creased ; the humerus itself also forms a projection in front of the upper
part of the bones of the fore-arm ; and the radius is thrown on the out-
side of, and above, the external condyle. It is of great use, in these
dislocations, to attend precisely to the relative positions of the point of
the olecranon, and the external and internal condyles ; for, sometimes the
swelling is so great as to prevent us from making out the case satisfac-
torily, unless we avail ourselves of these beacons. In the dislocation of
the ulna backwards, the distance between the olecranon and the internal
condyle is remarkably increased ; these points may always be felt in the
fattest persons, and however great the swelling.
In the dislocation of the ulna backwards, there is a laceration of the
capsular ligament, and of the internal lateral ligament, and generally,
also, of the annular ligament of the radius, which is closely connected
to the external lateral ligament. In consequence of the lower head of
the humerus being thrust forwards, the brachialis anticus is liable to
be torn ; but the tendon of the biceps generally escapes, and is tightly
applied round the lower articular surface of the humerus. However,
if the dislocation has been caused by excessive violence, that tendon
may be torn, and even other mischief done ; for example, the brachial
artery may be ruptured, the median nerve torn, and the veins at the
bend of the elbow burst. In the ninth number of Cruveilhier's great
work on Pathological Anatomy, some notice is taken of a case, where
such complications occurred in a lady, who fell from her horse with pro-
digious force.
The mode of reducing this dislocation is simple : — The surgeon may
apply his knee to the bend of the arm, and, taking hold of the wrist,
bend the elbow over his knee with the advantage of a considerable lever;
the coronoid process will then quit the fossa at the back of the humerus
intended for the olecranon, and, by continuing the movement of flexion
a little further, he will find the bone return into its right situation.
Now, if the coronary or annular ligament of the radius be torn, this bone
will slip out of its place again, unless means be taken to prevent it.
With this view, we should apply a compress over the head of the radius,
to press it down towards the lesser sigmoid cavity of the ulna ; and we
should prevent the radius from moving by means of splints, one on the
outside, and another on the inside of the fore-arm. If a case of this de-
scription were to remain unreduced, which sometimes happens, nature
makes great efforts to repair the mischief; and it is to be observed, that
the dislocation is complete, the articular surfaces riot being at alt in con-
tact with each other. Sometimes, indeed, a surprising attempt is made
to form a new socket for the humerus. In the plates of Cruveilhier's
celebrated work, a representation of such a dislocation, and of the efforts
made by nature to repair the mischief, is given ; a considerable quantity
of bony matter has been thrown out to form a socket for the humerus.
These plates also show the changes which take place in the shape of the
bones, when their functions have been destroyed by remaining long un-
702 PARTICULAR DISLOCATIONS.
reduced. In the instance here exhibited, a very limited degree of
motion remained ; and nature had done all in her power to produce a
new articular cavity.
Sometimes the dislocation takes place in another way, the ulna being
thrown backwards, and the radius forwards ; the former bone assuming
the position described in the last dislocation. The case is reduced nearly
in the same way as the foregoing ; but we are to make some extension,
for otherwise we could not bend the elbow with the radius in front of the
humerus ; and after the requsite degree of extension has been made, the
bones will return to their proper situations on bending the elbow over
the knee.
In other instances, we find a dislocation of the radius alone ; the upper-
head of which bone quits the lesser sigmoid cavity of the ulna, and is
thrown on the outside of the external condyle, and sometimes behind it.
The nature of the accident is sufficiently obvious ; for the head of the
radius is thrown on the outer part of the arm. I have seen three or four
examples of this case, and there are many instances of it on record.
There is an engraving of one such case, which was dissected by Cru-
veilhier ; the dislocation had not been reduced, and nature had formed a
sort of fibrous capsule for the reception of the head of the radius, which
capsule Cruveilhier thinks was derived either from the remains of the
annular or of the external lateral ligament. The same plate also illus-
trates the change, which takes place in the articular surface of a bone
that has been long out of its place. For the reduction of this dislocation,
the best plan is first to make extension of the arm, and to limit the ex-
tension as much as possible to the radius ; thus we can draw the displaced
bone into its proper situation. Now, the head of the radius will be apt to
slip out of its place again, unless means be taken to prevent it; we must,
therefore, hinder all motion of the radius with splints, and support the
head of it with a compress. This tendency of the head of the radius to
quit the lesser sigmoid cavity after the reduction, is owing to the annular
and oblique ligaments being torn. A child was once brought to me at
the Bloomsbury Dispensary, with this dislocation; the accident had oc-
curred seven weeks before I saw the case, and nothing would avail in
keeping the head of the radius in its place : we applied splints for three
or four weeks, but at the end of this time, the bone glided into, and out
of, the articular cavity as readily as ever.
The most common lateral dislocation is where the ulna is forced out-
wards into the place of the radius, which is propelled off the articular sur-
face of the humerus altogether. In this state of the bones, there is no
suitable cavity behind the humerus for the reception of the olecranon in
the extended condition of the fore-arm. The consequence is, that com-
plete extension cannot take place : neither can flexion be well performed.
The case is sufficiently manifest from the extraordinary projection formed
by the inner condyle on one side, and by the radius o"n the other. Ex-
tension and counter-extension are to be made, and the ulna and radius
reduced by lateral pressure.
Dislocation of the lower end of the ulna from the sigmoid cavity of the
radius takes place mostly from a forcible pronatiori of the hand, the ulna
being then thrown back, and the hand fixed in the position of pronation.
There is a possibility, however, of the displacement occurring in the other
direction, or of the ulna being thrown forwards and the hand supine.
Here extension is to be made, and the displaced bone pressed in the
direction required to bring it into the proper position again : then a splint
is to be applied to prevent the radius from moving.
DISLOCATIONS OF THE WRIST. 703
DISLOCATIONS OF THE WRIST.
A gentleman once asked me if it were true that the wrist was never
dislocated ? To which I answered, that it was not possible for me to
agree in that doctrine, because I had seen a case, in which the lower end
of the ulna protruded through the skin. However, his question related
to the possibility of a dislocation of the radio-carpal articulation. Various
anatomical reasons are assigned by Dupuytren, why the radius should
always rather break, than be dislocated from the carpus ; and he dis-
tinctly declares it as his belief, that there is not, in all the records of
surgery, an unequivocal specimen of such a dislocation. He had some-
times been called to cases, supposed at first to be true dislocations of the
wrist, but which afterwards proved to be only fractures of the radius
near that articulation. One or two instances of such mistakes, verified
by dissection, are brought forward, in which practitioners of eminence
had been deceived. Hence the Baron is led to conclude, that a dislo-
cation of the wrist is scarcely a possible event, and that the accidents,
reputed to be such, were in reality fractures of the radius close to the
joint, with more or less displacement of the hand. It cannot be doubted,
I think, that this is generally the fact : but it would be making a bold
assertion to say, that such a dislocation never happens. Great as
Dupuytren's experience is, it is merely a drop in that great ocean of
experience, to the rich treasures of which the surgeons of every age have
successively contributed. Instead of representing a dislocation of the
radius from the carpus as impossible, it would, I believe, be more correct
to say, that the accident is exceedingly rare. In Sir Astley Cooper's
work, there is a drawing of a dislocation of the carpus backwards, which,
no doubt, is particularly uncommon ; for when a person falls on his hand
while it is extended, the force would almost always sooner break the
radius than dislocate it towards the palm ; but if the hand were in the
state of flexion, so that the back of the hand received the force, then a
dislocation might perhaps be a more likely event. Cruveilhier had an
opportunity of dissecting such a dislocation, as he believed it to be, in
which the radius and ulna had been thrown on the back of the hand, and
the state of the parts is represented in one of his plates ; the patient, he
conceives, had fallen on the back of the hand with considerable force.
Yet Dupuytren and Cruveilhier took different views of this preparation,
so that further investigations are desirable. In Cruveilhier's book, we
also find an engraving from a case, in which the radius had been dislo-
cated by the contraction of a burn. Sir Astley Cooper also speaks of a
boy, who fell on the palm of his hand, and whose carpus was driven back-
ward. I am not therefore disposed to consider Dupuytren's doctrine as
completely established ; in fact, it is difficult to restrict the effects of ex-
ternal violence on the joints, considering the infinite variety of circum-
stances by which they may be modified and influenced. If we were to
meet with a dislocation of the radio-carpal articulation, it would^e easy
of reduction, as dislocations of ginglymoid joints usually are ; the ex-
tension and counter-extension need only be made in a degree suffi-
cient to diminish the friction between the articulating surfaces, and then
pressure is to be made on the displaced bones in the direction calculated
to bring them into their right situation again. Extension and counter-
extension would be necessary, if the dislocation of the carpus were for-
wards, and splints would be required ; for otherwise the movements of
the hand might bring on a return of the dislocation, and prevent the
speedy union of the ligaments
7Q4< PARTICULAR DISLOCATIONS.
DISLOCATIONS OF THE BONES OF THE CARPUS FROM ONE ANOTHER.
The bones of the carpus are not very liable to be dislocated from one
another : however, there is one in the second phalanx, which is occa-
sionally thrown out of its place, — I mean the os magnum. This bone is
received into a deep cavity formed by the scaphoid and lunar bones, and
when the hand is violently bent, it will sometimes start out of this cavity,
and form a considerable projection at the back of the wrist. The reduc-
tion is occasionally difficult ; but, if the bone be left unreduced, there
will not be much inconvenience, — there will only be a slight weakness
of the wrist. Thus, in one instance, which was attended by Sir Astley
Cooper, the inconvenience, resulting from the non-reduction of the dislo-
cation, was, that the young lady, who was the subject of it, could not
practise music — she could not play on the piano-forte. The case will
be evident from the situation of the bone, and its projection beyond the
other bones of the carpus. The accident chiefly occurs in children and
females, from the greater weakness of their ligaments, and also from the
cavity of the scaphoid and lunar bones being more shallow in them than
in male adults. In reducing this dislocation, we are to bring the hand
into the extended position, and then press firmly on the projecting bone
with our thumbs. The common plan of palliating this dislocation, when
it cannot be reduced, is to apply a compress and bandage over it, or straps
of adhesive plaster.
The metacarpal bones can hardly be separated from one another ex-
cept by great and direct violence ; and so closely are they tied together
and to the carpus, that scarcely any thing, except gun-shot violence, the
bursting of a fowling-piece, or pistol, or the fall of some ponderous body
on the hand, can dislocate them. However, the metacarpal bone of
the thumb is more frequently dislocated than any other ; and, from its
having motion in every direction, it seems capable of being dislocated in
four directions, namely, inwards, outwards, forwards, or backwards ; but
experience proves, that it is ordinarily dislocated only forwards or back-
wards. When a person falls on the radial edge of his hand, and the
thumb is carried violently inwards, the head of the metacarpal bone will
be thrown on the back of the trapezium. In other instances, the dis-
placement is in the opposite direction, and the head of the metacarpal
bone of the thumb is then thrown between the metacarpal bone of the
fore-finger and the inside of the trapezium. The reduction is easy : the
principle is to make counter-extension from the wrist, and extension from
the thumb, and to press the bone in the proper direction.
DISLOCATIONS OF THE THUMB
Are sometimes difficult to reduce, especially those of the first phalanx
from the metacarpal bone. There are some persons, however, who have
the ligaments of this joint so loose, that at their option they can not only
dislocate the first phalanx by the action of the flexor muscles, but even
replace it again by the action of the extensors. In such instances of
spontaneous dislocation and reduction, the ligaments are preternaturally
loose. Sometimes this may be the result of disease, or the neglect of a
dislocation, where the bone had been reduced, but not well supported in
its place.
In the common dislocation of the thumb, the head of the first phalanx
is thrown on the back of the head of the metacarpal bone, so that the first
phalanx projects backward, while the head of the metacarpal bone inclines
DISLOCATIONS OF THE THUMB. 705
towards the palm, the thumb remains without the possibility of being
straightened, and the second phalanx is fixed in the bent position. It is
from there being no laceration of the lateral ligaments that the reduction
is so difficult; for the wedge-shaped head of the first phalanx glides with
its narrow part through the aperture between the lateral ligaments, and
brings the broad part within them. Thus the first phalanx is completely
and firmly wedged between the lateral ligaments, which must therefore
be considered as forming the principal impediment to the reduction. The
muscles of the part also being strong, form some resistance to the reduc-
tion, especially as the surface for the application of the extending means
is very limited. From these various causes, there is occasionally so much
difficulty in the reduction, that, in a case in St. George's Hospital, about
fifty years ago, extension was made with such force, that the thumb was
pulled off. The case is alluded to by Mr. Hey, of Leeds, in his Practical
Observations on Surgery. Some time ago, a young man came to my
house with this dislocation. He was sent to me by Mr. Hughes, of
Holborn, who had tried in vain to reduce it. Wishing Mr. Hughes to be
present at the reduction, I desired him to call upon me in the afternoon,
that we might try our skill together ; but, in the meantime, the patient
happened to meet with a relation who was a surgeon, and who reduced it
for him. I inquired how this gentleman succeeded, and was told that he
fixed a piece of tape round the thumb, and secured it with the clove-hitch
knot, which is one in familiar use amongst sailors ; he then fastened a
common street-door key to the tape, and, of course, was thus enabled to
make extension with considerable force, and with success. In fact, I
had been thinking of trying a very similar method. Sir Astley Cooper,
in his work on Dislocations, explains his plan of reduction. He first
puts round the thumb a piece of soft wet leather, to prevent the skin from
being injured, and then applies tape over it, which he secures by the
clove-hitch knot. The knot proposed by Mr. Hey would also answer.
The sailor's knot differs from Mr. Hey's chiefly in there being two circles,
or nooses, made instead of one. Sometimes Mr. Hey succeeded without
making any extension at all, merely by pressing the head of the first
phalanx towards the metacarpal bone. Indeed, it is easy to understand,
that if the broad part of the bone were confined behind the lateral liga-
ments, the more powerful the extension, the greater would be the difficulty
of effecting the reduction. Sir Astley Cooper particularly recommends
the first phalanx to be bent before the extension is made.
When the reduction of the first phalanx of the thumb cannot be
effected by ordinary modes, it has been proposed to divide one of the
lateral ligaments with a couching needle. The most experienced sur-
geons, however, object to this practice, on account of the frequency with
which tetanus follows injuries of the tendinous and ligamentous tissues
about the thumb. Sir Astley Cooper thinks it far more prudent even to
let the dislocation remain unreduced, than occasion the risk of so fright-
ful and unmanageable a disease as traumatic tetanus. Other surgeons
recommend cutting off the head of the metacarpal bone with % small
saw, or a pair of cutting pliers, which is perhaps better than dividing one
of the ligaments.
Sometimes the dislocation is in the other direction, and the metacarpal
bone is at the back of the first phalanx ; then there is no difficulty in the
reduction.
The second phalanx is sometimes dislocated backwards ; and, in com-
pound cases of this description, Sir Astley Cooper recommends cutting
z z
706 PARTICULAR DISLOCATIONS.
off the articular surface of the first phalanx. After the reduction of
either of the above-mentioned dislocations, the joint must be supported
with pasteboard and tape. After a fortnight, we are to begin to employ
passive motion.
The phalanges of the fingers are most frequently dislocated backwards ;
moderate extension soon replaces them.
Compound dislocations of the thumb frequently lead to tetanus, — so
frequently, indeed, that some surgeons have thought it advisable to
amputate in all such cases, rather than attempt reduction ; but, in this
counsel, I am not disposed to agree ; for, from the observations which I
have delivered on the subject of traumatic tetanus, it appears, that am-
putation is a very uncertain means either of preventing, or curing, this
disorder.
DISLOCATIONS OF THE VERTEBRA.
The dorsal and lumbar vertebrae have such extensive articular processes,
while their bodies are so large, their ligaments so strong and numerous,
and the motion between any two of them so trivial,, that they hardly can
be dislocated ; and, indeed, Sir Astley Cooper states, that he has never
seen a dislocation of the dorsal or lumbar vertebrae unaccompanied by a
fracture of one or more of their bodies, or of the oblique or articular
processes. He has never seen it happen from a simple laceration of the
intervertebral substance. Generally, there is a fracture of the articular
processes, and of one or more of the bodies of the vertebrae, with dislo-
cation of the articular process of one vertebrae from that of the next. A
dislocation from laceration of the intervertebral substance alone, may be
deemed impossible in the lower part of the spine. But, in the upper
part of the vertebral column, there may be a dislocation of the vertebrae
unaccompanied by a fracture, because the articular surfaces of the bodies
of the cervical vertebrae are less extensive, and the spinous and articular
processes less oblique. At St. Bartholomew's Hospital, there is a pre-
paration in which a portion of the intervertebral substance is lacerated,
between the fifth and sixth cervical vertebrae, with a partial separation
of those bones from one another, and a dislocation of the articular pro-
cesses on both sides. There is another instance in the museum of the
same hospital,, of partial fracture of the bodies of the two lower cervical
vertebrae, accompanied with dislocation of the articular processes. But
the case, in which there was dislocation and no fracture of the articular or
oblique processes is sufficient to prove, that there may be dislocation of
the upper vertebra without any kind of fracture. By the favour of a
gentleman, who was attending my lectures, I was once enabled to show
the Surgical Class of University College a specimen of complete disloca-
tion of the middle of the cervical vertebrae, without fracture. The person,
from whom it was taken, was killed instantaneously by coming in contact
with the top of a gateway, as he was sitting on an omnibus, which was
going with great speed.
In one of the last volumes of the Medico- Chirurgical Transactions, a
case is recorded, in which the body of one of the dorsal vertebrae was
fractured, and, at the same time, there was a dislocation of one of the
articular processes of that bone from the corresponding articular process
of the first lumbar vertebra, without fracture of them.
If we are to believe the statements of Desault, and others, dislocations
of the articular processes of certain portions of the spine have occasionally
born reduced.
DISLOCATIONS OF THE HEAD. 707
DISLOCATIONS OF THE HEAD.
There is no case on record, in which the os occipitis has been suddenly
dislocated from the atlas by external violence, so firmly are they con-
nected together. But there may be dislocations of the os occipitis from
the atlas in consequence of disease. Now, this kind of displacement
generally arises from a scrofulous caries of the joint, or of the atlas itself.
There are also cases on record, in which exostoses from the occipital
bone, or from the atlas, or from the petrous portion of the temporal bone,
led to displacement of the atlas. Here, of course, the space for the
medulla spinalis is diminished, yet it is not rendered sufficiently narrow
to produce fatal consequences. If the patient live long enough under
these circumstances, anchylosis of the atlas to the os occipitis may follow,
the anchylosis sometimes extending to the dentata, and even to the
vertebrae below it. There are several specimens in the Museum of
University College, in which this sort of bony consolidation is illustrated.
The symptoms of scrofulous disease of the upper cervical vertebrae, lead-
ing to displacement of them, were first accurately described by Professor
Rust, of Vienna, and a good account of them was subsequently drawn up
by Mr. Lawrence, and inserted in the Medico-Chirurgical Transactions.
Most of the patients are young subjects. I have witnessed several cases
within the last three or four years, and they were all in young persons,
two of whom were girls. At the Bloomsbury Dispensary, a boy was
under my care two or three years with this disease, which at length ter-
minated in anchylosis.
The symptoms are, great pain on moving the neck or turning the head ;
after a time, more or less difficulty in swallowing is felt ; if pressure be
made on the part, the patient experiences great agony; the voice is
hoarse, and there is oppression of the breathing ; but the most charac-
teristic symptom, when the patient is not lying down, is, that he is almost
always found supporting his head with both hands placed under the lower
jaw, either because motion of the head gives him pain, or because the
support of it gives him relief. After gome time, the patient generally
becomes afflicted with vertigo, or is attacked by convulsions, which sud-
denly carry him off, or he lingers for a considerable period,, and dies
hectic. Before the fatal termination, a crepitus may sometimes be felt.
The treatment is conducted on the same principles as that of other
scrofulous diseases of the bones and joints, that is, if there be pain and
inflammation, we apply leeches, and if the affection partake of a more
chronic character, we make an issue, or apply the moxa, a blister, or a
seton, to keep up a discharge from the neighbouring parts, and excite
counter-irritation, whereby the morbid process in the bones may be
arrested.
Dislocations between the atlas and the vertebra dentata. — The rotatory
motion of the head is performed by the atlas moving on the dentata, or
rather by the former bone and the os occipitis revolving on the latter.
Now, when this motion is carried beyond a certain point, a disldfcation is
the consequence. Here, then, a dislocation may be produced by external
violence ; and, in fact, many cases on record prove the possibility of such
a dislocation. If the ligament, which ties the processus dentatus to the
edge of the foramen magnum, receive a violent twist, by a forcible turn
of the head to the right, the left side of the dentata may be carried in
front of the corresponding articular process of the atlas, while the right
side of the dentata is forced behind the corresponding articular surface of
zz 2
708 PARTICULAR DISLOCATIONS.
the atlas. When the processus dentatus is dislocated from the space
between the transverse ligament and the forepart of the atlas, it will press
upon the medulla oblongata and spinal cord, and produce immediate
death. In general, there is not a rupture of the transverse ligament, but
the processus dentatus slips under it. Sometimes, however, the disloca-
tion of the processus dentatus backwards is preceded by a rupture of the
transverse ligament : but this can take place only in two ways, — first, from
a fall with great force on the occiput, as happened in a case recorded by
Boyer ; and, secondly, from a violent fall on the chin, as mentioned by
Sir Charles Bell. In children, the processus dentatus is particularly
weak, and therefore liable to be broken ; indeed, in any subject, in whom
it is more slender than usual, it may be broken, and then the lower portion
of it, passing under the transverse ligament, will make fatal pressure on
the spinal marrow. In consequence of this process not being fully deve-
loped in children, and the ligaments being weaker in them than in adults,
the common trick of lifting them up by the chin and occiput ought to be
discontinued, for it has led, in many instances, to a sudden displacement
of the processus dentatus, and instant death. A fracture of the atlas,
with displacement of the processus dentatus, and fatal pressure on the
spinal cord, is recorded by Sir Astley Cooper. But one of the most
curious and interesting examples of a fracture and displacement of the
atlas is related by Mr. Benjamin Phillips. The man, who met with the
accident by a fall from a hayrick, lived forty-seven weeks after the injury,
and then died of hydrothorax. Until the last week of his life, he was
able to walk to the water-closet. On dissection, the condyles of the occi-
put were found yet to rest upon the articulating surfaces of the atlas ;
but, so much of the latter bone, as includes the surfaces by which it is
articulated with the occiput and with the axis, had been violently sepa-
rated from the posterior portion of its ring,, and carried downwards and
forwards, until it arrived upon the same plane as, but anterior to, the
axis, to the body and transverse processes of which it became attached
by perfect bony union, while the posterior fragment had suffered no dis-
placement. The atlaSj under these circumstances, presented two spinal
foramina, and four transverse, but no odontoid process passed through the
anterior spinal foramen ; and to the circumstance of its having been frac-
tured, instead of the transverse ligament giving way, Mr. Phillips ascribes
the escape of the man from immediate death.*
As dislocations of the atlas from the second vertebra may be set down
as inevitably fatal, it is unnecessary to say any thing about their treat-
ment. We do hear, it is true, of dislocations of the head being rectified ;
but these are not the description of cases now under consideration, but
merely examples of the displacement of one of the articular processes of
the cervical vertebrae, erroneously called a dislocation of the head. A cure
of such displacement is possible, and Desault actually succeeded in re-
ducing an accident of this kind, by fixing the shoulders, and inclining the
spine in the direction, opposite to that in which it was thrown.
DISLOCATIONS OF THE RIBS.
The ribs cannot well be dislocated at their vertebral extremities ; but
a separation of the ribs from their cartilages sometimes takes place,
and then they are generally displaced outwards. In Sir Charles Bell's
* See Mod. Chir. Trans, vol. xx. p. 78, &c.
DISLOCATIONS OF THE HIP. 709
Surgical Reports are the particulars of an interesting case, in which most
of the ribs were dislocated in this manner, in consequence of the person
being pressed between a post and a waggon. Dislocation of a single rib
is sometimes met with. The proper treatment consists in the application
of a long piece of pasteboard wetted, so as to fit the part accurately, and
over this a broad roller should be applied, or a piece of linen, which is to
be laced. When the pasteboard becomes dry, it forms an exact case for
the part, and fits so closely as to prevent all motion of the end of the rib.
Here it is also necessary to bleed the patient freely, as there is a chance
of inflammation of the chest, and even of the abdomen ; for the violence,
producing such a dislocation, is always great ; and, when a person is
jammed between a wall or a post and a waggon, the contusion of parts is
frequently not restricted to the chest.
DISLOCATIONS OF THE HIP.
At this joint, the femur is liable to at least four dislocations. Those,
recognised by all surgeons, are the following: — In the first, the head of
the femur is thrown upon the dorsum of the ilium, above the acetabulum
and a little behind it, and under the glutaeus minimus muscle, with the
trochanter forwards : this is by far the most common direction in which
the head of the femur is dislocated. The next in order of frequency, is
where the head of the thigh bone is thrown into the obturator foramen,
or upon the obturator externus muscle, and the obturator ligament. In
the third dislocation, the head of the femur is thrown inwards and up-
wards upon the horizontal branch of the os pubis. The fourth is where the
head of the bone is thrown backwards into the sacro-ischiatic foramen,
and is lodged on the pyriforrnis muscle. In a fifth case, which is ex-
ceedingly rare, the head of the femur takes a lower position, namely,
behind the tuberosity of the ischium downwards and backwards. Such
a dislocation, however rare, is possible ; and even those who doubt the
possibility of it, caution us, when we are reducing a dislocation on the
obturator foramen, not to incline the limb too forward, lest the head of
the bone should slip into that very position. Sir Astley Cooper, who
never met with such a case, cautions us against making extension, for
the reduction of the dislocation into the obturator foramen, with the
limb raised too much in front of the axis of the body. An instance of
dislocation downwards and backwards was recorded by Mr. Keate.
In this instance, the lodgment of the head of the femur behind the
tuberosity of the ischium arose from a secondary displacement. A
gentleman fell into a ditch, with his horse upon him ; he lay under the
animal for some time ; his thigh-bone was dislocated, and the head of it
was found to have been forced secondarily behind the tuberosity of the
ischium. However, many surgeons only admit the possibility of four dis-
locations of the thigh, and Delpech is one of them.
Except where the capsular ligament is much relaxed by the effects of
disease, there must always be, in dislocations of the thigh-bone, a lacer-
ation of the capsular ligament. There are instances recorded <>f persons
who could dislocate the thigh-bone spontaneously, and afterwards replace it
again without assistance. A gentleman, who attended my lectures, informed
me of a person so circumstanced, and related some of the particulars to
me. I suppose that, in such cases, there must be an unusual relaxation
of the synovial membrane, a rupture of the ligamentum teres, and per-
haps an imperfect state of the acetabulum. But such examples are rare :
Sir Astley Cooper mentions one instance ; I have heard of other cases,
z z 3
710 PARTICULAR DISLOCATIONS.
but I never saw one myself. In most dislocations of the hip, the ligamen-
tum teres is ruptured : now, we should suppose, from a mere anatomical
consideration of the joint, that the head of the femur might be dislo-
cated on the obturator foramen, without any rupture of the ligamentum
teres ; for as that ligament is fixed to the anterior inferior part of the
acetabulum, it seems to be capable of allowing the head of the bone to
pass out of the socket on that side ; but it is a disputed point, whether
a dislocation can take place here without a rupture of this ligament.
Sir Astley Cooper states, that a dislocation downwards and forwards, or
into the obturator foramen, cannot take place unless the ligamentum
teres be ruptured, and he details one or two dissections, which corrobo-
rate this assertion. On the other hand, Delpech asserts, that the liga-
ment is not always ruptured ; but, I believe, this can only be the case,
when some of the brim of the acetabulum is broken off. Sir Astley
Cooper is of opinion, that the ligamentum teres is always ruptured in
this dislocation, because the accident cannot occur to a living person,
except when his limb is in a state of abduction ; and that, in such
position, the ligamentum teres is on the stretch, and therefore, if the
force applied go so far as to dislocate the joint, the ligamentum teres
must first give way.
With regard to the symptoms of a dislocation upon the dorsum of the
ilium, as the head of the bone is carried upwards, there must be a
shortening of the limb ; and as it is also thrown backwards, and the
trochanter forwards, there must be an inversion of the limb ; the knees
and toes will be turned inwards ; the great toe considerably, so as to be
placed on the instep of the opposite foot ; the prominence of the tro-
chanter will be diminished, which necessarily happens, because the neck
of the thigh-bone takes the direction of the side of the ilium : the tro-
chanter is also nearer than natural to the crista of the ilium. The head
of the bone can be felt on the dorsum ilii. The symptoms, then, are, a
shortening of the limb ; an inversion of the foot and knee ; and the
change in the position of the trochanter, namely, its proximity to the crista
of the ilium being increased, and its own prominence diminished. The
limb cannot be separated further from the opposite one, but it may be
slightly bent.
This dislocation can only happen when the patient has the inferior
extremity in front of the axis of the body, with the foot inclined inwards.
While he is in this position, if any great force act on the foot or knee, it
will tend to throw the head of the femur out of the acetabulum upon
the dorsum of the ilium. Surgeons have been much perplexed to know
why, in this case, the toe should always be inclined inwards ; they in-
quire why the head of the femur should always be thrown backwards,
and the trochanter forwards. In this country no explanation has been
offered of the fact, or none that has been admitted as a good one. In
France, what has been considered there as a satisfactory explanation of
the fact, has been offered, and is the following: — The lower and inner
part of the capsular ligament, not being lacerated, keeps the great tro-
chanter forward, and the head of the bone is therefore always directed
backward. Whether this explanation be admissible or not, it is difficult
to say; but, in France, surgeons not only account for the position of the
femur in this dislocation, but in all the others, in the same manner,
namely, by the consideration of the way, in which the remains of the
lacerated capsular ligament act upon the great trochanter.
The dislocation upon the dorsum of the ilium, being attended with a
DISLOCATIONS OF THE HIP. 711
shortening of the limb, might be mistaken for a fracture of the upper
part of the femur ; but the discrimination between the two cases is
easy, when it is recollected that, in ninety-nine cases out of a hundred,
the toes are everted in the fracture, while, in the dislocation upon the
dorsum of the ilium, they are always turned inward. Another difference
is, that the limb is altogether less moveable, or more rigid, in the dis-
location than in the fracture. Then, in a fracture, even if it be one of
the neck of the femur, we may, on drawing the limb downwards, feel a
crepitus, and, on discontinuing the extension, the shortening of the limb
will immediately recur.
The next most frequent dislocation of the head of the femur is that in
which it is thrown upon the obturator foramen, or rather on the obturator
externus muscle, and obturator ligament. Here one particular symptom
is always noticed, viz. the body is inclined forward by the tension of
the psoas magnus and iliacus internus muscles ; the limb is lengthened
from two to four inches ; and in the state of abduction, with the knee
and foot widely separated from those of the opposite limb. The buttock
is flattened in consequence of the glutaei being drawn downwards, and
stretched ; and the prominence of the great trochanter is lessened in
this, as well as in all other dislocations of the hip. The head of the femur
is always plainly perceptible in its new situation, and the trochanter is
separated further than natural from the crista of the ilium. With respect
to the position of the foot in this dislocation, contradictor}7 statements
prevail. Sir Astley Cooper describes the position of the foot as being
very little to be depended upon, and as sometimes but trivially altered,
though frequently turned a little inwards. On the contrary, Delpech
states, that the foot is generally turned outwards. The trochanter should
always be particularly attended to in this, and, indeed, in all dislocations
of the femur. Its situation and position, with respect to the crista of the
ilium, is a point to be strictly considered ; and, in this dislocation, the
distance between the two parts is increased.
In the dislocation., where the head of the bone is thrown upon the hori-
zontal branch of the pubes, the limb is shortened and turned outwards,
and the head of the femur is felt, forming a distinct prominence below
Poupart's ligament, and to the outer side of the femoral vessels. This
is the only common dislocation of the hip, always attended with con-
siderable eversion of the limb ; for the example of luxation behind the
tuberosity of the ischium, which is said to present the same symptom, is
exceedingly rare.
In the dislocation backwards into the ischiatic notch, the limb is turned
inwards, but not in so great a degree as in the dislocation upon the dorsum
of the iiium ; there is also a slight shortening of the limb, for the natural
position of the ischiatic notch is a little higher than that of the acetabu-
lum. There is likewise a diminution in the projection of the trochanter,
and the head of the bone in thin persons may be felt in its unnatural
situation, on rotating the thigh inwards.
The particular direction, which the head of the bone takts in each
variety of dislocation, is determined by the position of the limb at
the moment when the force operates that occasions the displacement.
Thus, there cannot be a dislocation into the sacro-ischiatic notch, unless
the lower extremity be, at the moment of the accident, elevated in front
of the axis of the body, or the body bent forwards over the thigh.
In reducing dislocations of the femur, three grand or leading prin-
ciples must constantly be attended to ; namely, counter-extension, ex-
z z 4
PARTICULAR DISLOCATIONS.
tension, and the employment of the shaft of the bone as a lever for reducing
its head. These are the principles which are of the greatest conse-
quence ; for we cannot fulfil the principle of relaxing the muscles in
these cases, because the bone is actually fixed in a particular position.
But, though we cannot avail ourselves of the principle of relaxing the
most powerful muscles by position, it is in our power, when great diffi-
culty is encountered, to weaken them in another way, that is, by bleeding
the patient. We may also find it necessary, in some instances, to reduce
the force of the muscular system by giving nauseating doses of tartarised
antimony, by which means a temporary weakness and collapse will be
produced, during which we are enabled to overcome with facility the
slight resistance of the muscles.
Counter-extension is performed by fixing the pelvis, which is done by
means of a girth passed between the scrotum and the upper part of the
dislocated thigh, and fixed to a point directly opposite that towards which
the extension is to be made. Extension is generally made in this country
at the lower part of the femur ; but abroad, the lower part of the limb, or
the ankle, is preferred for this purpose, and thus a longer lever is gained.
The length of the lever is indeed of great advantage, and hence, I am
not surprised, that many foreign surgeons should adopt this method of
making the extension. The pelvis being fixed in the manner I have
mentioned, by means of a girth or table-cloth, we are next to apply the
extending means. Now, in whatever situation we make extension, we
should adopt some contrivance to prevent the skin from being chafed ;
therefore, if we make extension with a sheet, we must apply, underneath
it, a wet roller ; if a pulley is used, there is an apparatus for the purpose,
frequently lined with flannel.
When the dislocation is upon the dorsum of the ilium, the direction of
the extension ought to be obliquely across the other knee ; and of course
the counter-extension should be made towards some point precisely in
the opposite direction. It is usual, in reducing the dislocation upon the
dorsum of the ilium, for the patient to be placed on his back, either
on the floor, or on a four-post bedstead. Then, if it be the right femur
that is dislocated, extension must be made in a direction obliquely across
the left knee, with the pulley attached to the left. post at the foot of
the bed ; while the counter-extending means are applied to the pelvis, as
already described, namely, between the scrotum and the dislocated thigh,
and fastened to a point precisely opposite to that towards which the
extension is to be made. Now, as the pulley is fixed high, in this
instance, the counter-extension girth must be fixed lower down than the
edge of the bedstead. As soon as the extension has been carried far
enough for the apparatus to be tense, and the patient to feel the effect
of the power employed, we should not go on increasing the force at
random, but proceed cautiously and slowly, lest mischief should result.
It is best, as soon as the muscles are put on the stretch, to wait a little,
and let them gradually fatigue themselves, until their power of resistance
is lessened. In short, the principle is, not to relax the extending power,
but to keep it up until the head of the femur has descended near the
acetabulum ; but directly it is low enough for the lever-like movement
to operate efficiently, the extension ought not to be increased. We are
now to put in practice the principle of making the shaft of the bone a
lever for the reduction of its own head, which is accomplished by taking
hold of the lower part of the limb, and rotating it outwards. The head
of the bone is thus inclined directly towards the acetabulum by the
DISLOCATIONS OF THE HIP. 713
lever-like movement of the limb. But supposing great difficulty were to
be experienced in effecting the reduction in this way, we should then
apply a napkin, or band, to the thigh below the groin, and draw the
upper part of the femur outwards with it, at the moment that the limb
is suddenly rotated outwards, and the foot carried a little across the
other. The napkin acts as a fulcrum for the lever-like movement, and
the reduction is readily affected. When the brim of the acetabulum is
very high, and the patient particularly strong, immense difficulty may be
encountered in the reduction, unless the band be applied round the
thigh. The principles upon which this dislocation of the thigh-bone is
reduced are therefore simple ; they are only three, namely, counter-
extension, extension, and the employment of the shaft of the bone as a
lever for reducing its head; the latter being performed by rotating the
limb outwards, and inclining the ankle inwards, as soon as the extension
has been carried far enough. This latter manoeuvre will bring the head
of the bone towards the acetabulum ; but if unusual difficulty is ex-
perienced, a band should be applied round the upper part of the thigh,
in order that this portion of the femur may be drawn outwards. Such
a band is in fact a fulcrum to assist in the execution of the lever-like
movement of the limb. By these means, the dislocation, if not of too long
a standing, may always be reduced.
I come now to the reduction of the next most frequent form of
dislocation of the femur ; that in which the head of the bone is thrown
upon the obturator foramen. Here the limb is in the state of abduction ,
and, consequently, if extension were made in the direction in which the
limb is thrown, without taking some precautions to prevent the pelvis
from being drawn to one side, this would inevitably happen. Therefore,
the common means of fixing the pelvis will not be sufficient; it will be
necessary to put a girth or napkin round the pelvis, to counteract the
tendency, which the extension would have to carry it too far sideways.
In the reduction of this dislocation, then, two means are made use of for
the counter-extension, which, without them, could not be conveniently
fulfilled. The reduction of the dislocation on the obturator foramen is a
simple proceeding ; in fact, as soon as the head of the bone is dislodged
from its situation, it will generally return of itself into its right place,
on inclining the ankle inwards. But if we cannot succeed by this plan,
then we are to have recourse to the band round the thigh, in order to
draw the upper part of the femur outwards, and thus a fulcrum is ob-
tained to promote the effect of the movement of the lower part of the
limb inwards. There is one caution, however, to be observed in reducing
a dislocation upon the obturator foramen, which is, to be careful, that,
while we are making extension, the limb does not incline forward too
much, and the head of the bone slip backward behind the tuberosity of
the ischium, and thus constitute another form of dislocation, which is
sometimes considered to be irreducible, though I am not aware of the
facts upon which this view is founded.
In the dislocation into the sacro-ischiatic notch, the direction oT the ex-
tension should be across the middle of the opposite thigh. The patient
is most conveniently placed on the uninjured side of his body. This is a
more difficult dislocation to reduce, than that upon the dorsum of the
ilium. Hence, we generally find it necessary to apply the band round
the upper part of the thigh, as a fulcrum, or rather as a means of raising
the head of the bone over the brim of the acetabulum. At the period of
attempting this, we should also give the lower part of the limb a twist
714. PARTICULAR DISLOCATIONS.
outwards, by which movement the head of the bone will be inclined
towards the acetabulum, with all the force of a long and considerable
lever.
In the dislocation on the horizontal branch of the os pubis, the patient is
also to be placed on his side ; the pelvis is to be fixed with the common
apparatus, and a band applied round the upper part of the thigh for the
purpose of raising the head of the bone over the brim of the acetabulum.
The direction of the extension ought to be in a line rather behind the
axis of the body, and, as soon as the head of the bone has been drawn
low enough for the lever-like movement to be put in practice, then the
extension should cease, or, at all events, not be increased. The usual
means are now to be put in force for completing the reduction,, namely,
the lever-like movement of the limb, and the use of the band round the
upper part of the thigh as a fulcrum. In short, all dislocations of the
thigh are reduced on the same principles; and whoever understands
these well and scientifically, can never be at a loss. Relaxation of the
muscles cannot be accomplished by position, though it may be so by
the effect of bleeding and nauseating doses of tartarised antimony. In
many cases, indeed, and especially in those of long standing, such means
become important auxiliaries, without which there would be no chance of
success.
A dislocation downwards and backwards, in which the head of the
thigh-bone is absolutely thrown behind the tuberosity of the ischium,
was seen by Mr. Keate, the patient being a gentleman, whose horse
fell with him into a ditch. It appears that the animal lay upon him for
some time — for five or ten minutes — during which he continued
struggling to liberate himself from his painful situation as well as he
could. From the particulars, it seems that the original dislocation was
upon the obturator foramen, but by a secondary displacement,, which
occurred during the patient's struggles, the head of the bone was thrown
behind the tuberosity of the ischium, the very situation from which Sir
Astley Cooper considers that the reduction would have been impracti-
cable. However, in this case, the reduction was attended with no very
great difficulty ; the bone was first replaced upon the obturator foramen,
and afterwards, by pursuing the plans proper for reduction of the disloca-
tion on the obturator foramen, the head of the bone was replaced. In
this instance, there was abduction of the limb, and the head of the bone
could be plainly felt behind the tuberosity of the ischium ; the toes were
also turned considerably outwards. If there be no mistake in the account,
the case proves, in the first place, the possibility of such a dislocation ;
and secondly, so far from its being irremediable, that there is no great
difficulty in effecting the reduction. We also find an enumeration of the
symptoms, namely, a lengthening and an abduction of the limb, eversion
of the toes, and the being able to feel the head of the bone in its un-
natural situation.
DISLOCATIONS OF THE PATELLA.
The patella is liable to three dislocations : first, outwards on the ex-
ternal condyle; secondly, inwards on the internal condyle; and lastly,
upwards, with rupture of the ligamentum patellae. There are also some
other modes of displacement ; for occasionally the patella is simply twisted
with the inner edge forwards and the external one backwards, so as to
form a considerable projection on the front of the knee ; and sometimes
it is thrown on the external condyle and twisted round. But the most
DISLOCATIONS OF THE KNEE. 715
frequent form of displacement of the patella is, where it is thrown flat
upon the external condyle. This dislocation is most commonly seen in
persons, whose knees are considerably inclined inwards. In persons of
this conformation, we may readily conceive, how the action of the ex-
tensors of the leg will draw the bone outwards. When persons are knock-
knee'd, as it is called, and the ligament of the patella particularly loose,
this dislocation is very apt to take place, the action of the extensors of
the leg being often sufficient to produce it, without the aid of external
violence. Sir Astley Cooper relates the case of a young girl brought up
to tumbling, in whom the ligaments of the knee-joint and patella were so
loose, in each limb, that both patellae slipped to the outer side of the
external condyle of the femur, whenever the extensors acted. The dis-
location inwards, however, is generally produced by external violence,
or a blow on the external edge of the patella, by which it is driven
inwards. Both these dislocations are reduced on the same principles,
namely, by relaxation of the extensors of the leg, and then pressing the
displaced bone outwards or inwards, according to the direction of the
displacement. There is generally no great difficulty in effecting the
reduction. However, instances are known in which considerable difficulty
was experienced ; and such a case was met with by Mr. G. Young, who
found, however, that by placing the patient's foot against his own shoulder,
and pressing on the patella with both hands, while the limb was in this
position, the reduction became very practicable, though the ordinary me-
thod failed. Owing to the looseness of the ligaments in certain individuals,
and an extraordinary obliquity of the articular surface of the lower end of
the femur, it is sometimes difficult to maintain the reduction after it has
been accomplished, and then it becomes necessary to apply a roller
over the patella, in the figure of 8 manner, in order to keep it in its
place. If there were much swelling, the roller should not be applied
until the inflammation had been lessened with cold lotions, purgatives,
leeches, &c.
When the dislocation takes place upwards, in consequence of a rupture
of the ligamentum patellae, there is generally a great deal of swelling
about the joint, for this dislocation can only be produced by great and
direct violence, or extraordinary efforts of the extensor muscles, by which
the synovial membrane is torn, and a severe degree of inflammation com-
monly follows. Here also the principle of relaxing the extensors of the
leg should be observed, by placing the limb on an oblique plane, extending
from the tuberosity of the ischium to the heel. We cannot apply a
bandage at first ; but after three or four days, when the inflammation
and swelling are diminished, a roller should be put round the lower part
of the thigh, so as to confine the patella as near as possible to the tibia.
After about three weeks, it is advisable to have recourse to passive mo-
tion of the joint ;. that is, a person must be directed to bend and extend
it a little every day, for the purpose of preventing anchylosis.
In one of the volumes of the London Medical Gazette is a case, in
which the patella was not only thrown outwards upon the extefnal con-
dyle, but twisted, so that the front surface of the bone was turned back-
wards, and its posterior surface forwards ; but such an accident is far less
common, than the simple dislocation outwards.
DISLOCATIONS OP THE KNEE.
The knee-joint does not derive much strength from the conformation
of the bones, but is rendered immensely strong by the number, the
716 PARTICULAR DISLOCATIONS.
strength, and the arrangement of its ligaments ; so strong, indeed, that
its dislocations are rare ; no other joint equally exposed to external vio-
lence being so seldom dislocated. However, dislocations of the knee-joint
may take place, and in four directions. The head of the tibia may be
displaced inwards or outwards ; but Avhen the dislocation is in either of
these directions, it is always incomplete, and the accident is exceedingly
rare. Lateral dislocations of the knee-joint are more uncommon than
those in which the head of the tibia is thrown either backwards or forwards.
There was a case in Guy's Hospital, where the tibia was dislocated back-
wards and the condyles of the femur forwards., and such pressure made on
the popliteal artery by the displaced tibia, that the pulsation of the ante-
rior tibial artery at the instep was stopped. All dislocations of the knee
are exceedingly rare, yet we occasionally read of them ; and perhaps, in
the course of twenty years, there may be one case brought into a large
hospital. There can be no difficulty in recognising them ; for the pro-
jection of the tibia and femur will render them sufficiently obvious. When
the tibia is dislocated forwards, there is generally some laceration of the
gastrocnemius and popliteus muscles. Sir Astley Cooper met with a case
of incomplete dislocation of the knee-joint, in which the external condyle.
was thrown off the head of the tibia forwards, and the internal condyle back-
wards ; and in this case, he found, that v there was no laceration of the
crucial ligaments ; but if the tibia were completely dislocated backwards,
then the crucial and lateral ligaments, and the above muscles, might be
lacerated.
The principles of reduction consist in bending the knee, so as to relax
the strong muscles of the calf; and, while the lemur is fixed, in making
extension and pressing the head of the tibia in the proper direction.
Dislocation of the condyles of the femur from the semilunar cartilages. —
Sometimes the ligamentous bands, which fix the semilunar cartilages in
their natural situation, become more elongated and relaxed than usual ;
and this is particularly liable to be the case, when there is a collection of
fluid in the joint ; and under these circumstances, if the person, in walking,
happens to bring his foot in contact with any obstacle, one or both con-
dyles of the femur may be dislocated off the corresponding semilunar car-
tilage or cartilages ; the result is, that the patient cannot straighten his
leg ; and a sudden attack of severe pain in the joint is felt. The plan
adopted by. Mr. Hey, consists in forcibly extending the limb, and then
bending it as far as possible ; this plan I have tried with success. In
some cases, however, it will not answer, and then other plans may be
tried. One of these consists in bending the thigh, and twisting the leg
suddenly outwards ; this has occasionally had the desired effect. Sir
Astley Cooper mentions a patient, who could never get the condyles re-
placed upon the semilunar cartilages, unless he followed this plan ; he
used to put himself on the floor, and then, by bending his thigh, and
twisting his leg outwards, he was always able to accomplish the reduction
and procure instant relief. When once this accident has happened, it will
be liable to recur ever afterwards ; hence it is frequently prudent for the
patient to wear a laced knee-cap, so as to keep the knee* steady and duly
supported.
DISLOCATION OF THE FIBULA.
The upper head of the fibula is rarely dislocated by external violence :
I have never seen a case thus produced ; but a dislocation of the upper
head of the fibula is occasionally met with in consequence of disease,
DISLOCATIONS OF THE ANKLE JOINT. 717
and then it is thrown backwards. This, however, is not a common case.
The treatment consists in the employment of such remedies as are
calculated to stop the morbid process going on in the joint, which is
generally of a scrofulous nature ; we are to blister the part, and when
we have stopped the further progress of the disease, we should perhaps
employ compression to fix the head of the fibula in its proper place.
DISLOCATION OF THE ANKLE JOINT.
The ankle joint is frequently dislocated. The tibia may be dislocated
off the astragalus in four directions. The most frequent case is that
where the tibia is dislocated inwards, the tarsus being forced outwards ;
in this accident there is a fracture of the fibula about two inches and a
half or three inches above the malleolus externus, or the lower end of
the bone, its most slender part. There is a considerable projection of
the malleolus interims, rendering the integuments over it exceedingly
tense ; the broken part of the fibula inclines inwards towards the tibia ;
and the position of the foot is altered, its outer edge inclining upwards,
while its inner edge is turned downwards, so as to come in contact with
the ground. When the accident is caused by a person jumping from a
great height, that portion of the tibia which is bound by ligament to the
fibula is split off, and remains connected to the broken part of the latter
bone, the ligament binding the fibula to the tibia in this situation being
so strong, that it does not give way.
There are two methods of treating this dislocation, though the plans
of reduction approved of by all surgeons are the same ; namely, we are
to refax the strong muscles of the calf; this is an invariable principle;
and then by making the requisite counter-extension, and practising ex-
tension from the end of the foot, the tibia may be easily replaced. But,
whether the leg should remain in the bent position, or should be kept
extended, after the reduction has been effected, seems to be a point, on
which some of the most experienced surgeons differ. Sir Astley Cooper
is an advocate for the straight position of the leg, and for the application
of lateral splints, each having a foot-piece attached to it, in order to
prevent the foot from moving to either side. On the contrary, Baron
Dupuytren adopts another plan : the foot being displaced outwards, he
first applies a thick wedge-shaped cushion at the lower part of the inside
of the leg, with the thick end downwards, and over that he applies a long
splint; the wedge-shaped cushion is to fill up the space between the
inner edge of the sole and the splint, which must extend some way be-
yond the foot. Having secured the splint with a roller above, he next
applies a bandage below in the form of the figure of 8, and thus draws the
foot inwards towards the splint, which serves as a convenient fixed point.
In the other lateral dislocation of the ankle, the tibia is thrown off the
astragalus, in the direction outwards. This is a rarer accident than the
former ; in fact, it cannot happen without the application of immense
force ; and, when it does take place, there is generally a fracture of the
malleolus internus, or else an oblique fracture of the lower e^d of the
tibia extending into the joint. Sometimes the astragalus is also frac-
tured, and the fibula is broken into several pieces. The deltoid ligament
is unbroken ; but the outer part of the capsular ligament is torn. When
the fibula breaks, the external lateral ligament remains entire ; but, if
the fibula is not broken, then the external lateral ligament is ruptured.*
* See Sir Astley Cooper's Treatise on Dislocations, ed. 4. p. 236.
718 PARTICULAR DISLOCATIONS.
A violent twist of the foot inwards may produce the accident. The
position of the foot is the reverse of what it is in the foregoing case ; for
it is the outer edge of the foot that comes in contact with the ground,
while the inner edge is thrown inwards and upwards ; and the malleolus
externus forms an extraordinary projection. The reduction is effected on
the same principles as in the dislocation of the tibia inwards, and there-
fore comprises relaxation of the strong muscles of the calf, counter-
extension and extension. Sir Astley Cooper adopts the same method of
treatment in this as in the dislocation of the tibia from the astragalus
inwards : he puts the leg in the extended position, and applies lateral
splints with foot-pieces. Baron Dupuytren also adopts the plan, which I
have mentioned, as his practice in the dislocation of the tibia inwards,
but he puts the wedge-shaped pad and the long splint on the outside of
the leg; for here the object is to bind the foot in this direction.
In the third dislocation of the ankle joint, the lower head of the tibia is
thrown off the astragalus forwards upon the os naviculare ; and there is a
lengthening of the heel and a shortening of the foot. The dislocation
may be either complete or incomplete ; the tibia may be thrown either
off the astragalus altogether, or only partially, half of it resting upon
that bone, and half upon the os naviculare. In the latter case, the
shortening of the foot may be inconsiderable, and scarcely noticed by a
careless practitioner.
A dislocation of the tibia off the astragalus backwards, with elongation
of the foot and shortening of the heel, must be very uncommon ; for Sir
Astley Cooper gives no instance of it in his valuable work, and Baron
Dupuytren never met with an example of it.
DISLOCATION OF THE ASTRAGALUS.
Another more interesting kind of dislocation is that of the astragalus
itself forwards from the os naviculare and os calcis, so as to form a consi-
derable projection on the instep. This is not a very common accident,
but it sometimes happens. I have seen not less than three examples of
it. The dislocation may be either complete or incomplete. The reduc-
tion is sometimes exceedingly difficult ; and when it cannot be effected,
the accident is a serious one ; for the patient is never afterwards able to
put his heel to the ground, and his ankle remains permanently stiff. I
remember being called in to a lady who had met with this accident two
or three weeks before I saw her. Reduction was quite impossible ; she
was a fat woman, and the injury was attended with so much swelling at
first, that the surgeon who saw her directly after the occurrence of the
accident, could not make out the case. I perceived that it was a disloca-
tion of the astragalus ; and reduction being impracticable, she remains
larne, with a stiff instep.
In consequence of this dislocation being sometimes irreducible, even
under the most skilful treatment, it has been proposed, when reduction
cannot be affected, to remove the astragalus altogether. This has some-
times been done ; and when it is a case of compound dislocation of the
ankle joint, accompanied by displacement of the astragalus, it maybe the
best practice to cut away the latter bone ; but, in simple dislocations, I
think, this proceeding would not be justifiable. Of course, in all cases,
we should first try to reduce the bone. The plan of reduction is to relax
the muscles of the calf, extend the foot as much as possible, and then
press the bone into its place. Cases are recorded, in which the skin
covering the displaced bone, inflamed and sloughed, and the bone became
DISLOCATION OF THE ASTRAGALUS. 719
exposed. In such a case Sir Astley Cooper divided the ligamentous con-
nections of the astragalus, and removed it : there was not so much weak-
ness of the joint produced as might have been expected, and in eleven
months the gentleman, who was the subject of the accident, was able to
perform his duties as a cavalry officer, which implies a considerable power
of using the joint.
Mr. Benjamin Phillips favoured me with the particulars of an accident,
in which the astragalus was dislocated backwards, and lay under the
tendo Achillis. Another instance has been lately published, in which the
astragalus was completely dislocated, without any change in its relations
to the tibia and fibula.*
* See Dublin Journ. of Med. Science, vol. xiv. p. 235. The patient was Mr. Richard
Carmichael, the justly eminent surgeon of Dublin.
END OF SECTION II.
THE
FIRST LINES
OF THE
PRACTICE OF SURGERY,
SECTION III.
OPERATIONS.*
THE following general maxims, in relation to operative surgery, deserve
attention : —
1st. Before undertaking any capital operation for the cure of a disease
in one situation, we ought to consider whether the patient has any in-
curable organic affection about him elsewhere ; and if he has, we should
decline to operate. What is the good of amputating a limb for a
diseased joint, when the patient is dying of tubercular phthisis ? Where
the wisdom of performing an operation for the cure of an external aneu-
rism, when the patient's doom is already sealed by the existence of an
internal one ? At all events, nothing but the immediate destruction of
the patient, if an operation were not performed, would be a vindication
for it under such circumstances. Even, with respect to some minor
operations, it is a rule not to perform even them, when the patient is
afflicted with any incurable internal disease. Thus, a fistula in ano is not
to be cut, a pile is not to be extirpated, if the patient is known to labour
under disease of the liver or lungs.
2d. An operation is rarely advisable, unless the whole of the diseased
parts can be removed. When, however, a tumour is not of a malignant
character, and only produces inconvenience by its size, or particular
situation, the partial extirpation of it will sometimes relieve the patient.
The truth of this observation is often exemplified in operations on the
tonsils, in the state of chronic enlargement and obstructing the communi-
cation between the mouth and the pharynx. When a true exostosis
cannot be entirely taken away, the partial removal of it will sometimes
afford great relief by diminishing its size, and obviating the ill-con-
sequences of its pressure on neighbouring organs. I have known the
same practice extended to bronchoceles, which, by their pressure, were
causing obstruction of the breathing, and of the return of blood from the
head.
* Those for Hernia? and various Diseases of the Eye, and some other operations, have
been already described.
OPERATIONS. 721
3d. Before resorting to an operation, we should maturely consider,
whether there is any chance of cure by milder means ; and, if the cir-
cumstances of the case afford time for a trial of them, this ought un-
doubtedly to be made.
4th. Some diseases, for which desperate operations are occasionally
undertaken, are known to admit, in a few instances, of a natural cure.
Here the surgeon of proper moral feelings, before determining to operate,
will consider well, whether the patient has the best chance of life from
such an operation, or from the possibility of a spontaneous cure.
5th. Operations should not be rashly performed with an entire dis-
regard of the state of the patient's general health. We should inquire
into his previous habits and modes of life, and the present state of his
constitution ; whether he be plethoric ; of a phlogistic diathesis ; of a very
nervous irritable fibre ; one, who has already suffered from erysipelas ; or
who has any symptoms, justifying the suspicion of the existence of a se-
rious, or incurable, visceral affection.
6th. When the time permits, we should bring the patient's constitution
into as favourable a condition as possible for the operation by means of
medicine, diet, and regimen. In particular, the weak should, if possible,
be supported and strengthened ; and the robust and plethoric, who are
always predisposed to inflammation, be restricted for a few days to low
diet, and have the bowels emptied ; and, where little blood is likely to be
lost in the operation, and the operation sure to fail if inflammation follow
it, the performance of venesection may be prudent. The truth of this
remark is illustrated in the treatment of cataracts. As highly sensitive,
hysterical, and nervous subjects, not only frequently have violent consti-
tutional disturbance after operations, but sometimes die very suddenly,
immediately or shortly after their completion, we should avoid, if possible,
operating on such individuals; or, if an operation must be done on them,
we should apprise their friends of the uncertainty of the result, and admi-
nister a cordial, with a dose of laudanum, a" little while before the
operation commences.
7th. Another rule is to let every instrument, and every article likely to
be required, be in readiness and perfect order before the operation is
begun : instruments of the best construction ; ligatures ; forceps ; tena-
culums ; sponges ; warm and cold water, towels, bandages, &c. &c.
8th. The patient should not be informed of the necessity of his submit-
ting to an operation long before the period of its performance. The
shorter the interval, between the communication of the painful intelli-
gence to him and the performance of the indispensable measure, the
better ; because the mind, brooding on the expected suffering, too fre-
quently causes an aggravation of the disease, and a most unfavourable
derangement of the general health.
9th. Patients, about to undergo operations, should not have any op-
portunity of seeing the knives, saws, and other formidable instruments
arranged for the occasion. The principles of humanity would dictate
this precaution, were it not suggested by the obvious advantage, infla sur-
gical point of view, of having the patient as free as possible either from
agitation or depression, while the operator is executing perhaps a tedious,
a delicate, or a very difficult task.
10th. Every operation that is well performed, whatever may be the
time taken up in its completion, is done quickly enough.
llth. In the ligature of arteries, the removal of tumours, dead bone,
or extraneous bodies, it is advantageous to make a free division of the
3 A
.722 OPERATIONS.
skin ; without which, every other step in the operation will be seriously
retarded, and the patient suffer on the whole infinitely greater pain, than
if a proper external incision had been made at once.
OPERATION OF TREPHINING.
The trephine is frequently applied to various bones of the body; but,
when we speak of the operation of trephining, we usually signify that
which consists in sawing out a portion of the skull, as is practised in
order to enable the surgeon to raise a part of it producing dangerous
pressure on the brain ; to discharge collections of matter or blood,, which
have the same effect; to extract a ball, or other foreign body lodged
under the skull ; to remove a sequestrum, extending through both
tables; or to extirpate tumours^ growing from the surface of the dura
mater.
Every part of the cranium cannot he trephined with equal safety.
However, the mere presence of a suture ought not to deter the surgeon
from making the perforation in any place which seems advantageous. I
believe, also, that the fears, respecting wounds of the longitudinal sinus,
have been vastly exaggerated ; and that, if the situation of a depressed
fracture, or extravasation, demanded the removal of a piece of the skull
directly over this vessel, the operation would be justifiable. The longi-
tudinal sinus has often been wounded by spiculae of the cranium, and
sometimes it has been punctured with a lancet, in order to bleed the
patient ; yet the hemorrhage was easily stopped with a small compress of
lint.* But, though I feel warranted in making this statement concern-
ing the longitudinal sinus, I am not acquainted with any facts, showing
that hemorrhage from the lateral sinuses would not prove more serious.
These latter are much larger; and as they occupy the deep transverse
furrows in the inner surface of the os occipitis, a trephine applied over them
would be likely to wound them.f Velpeau lays it down as a maxim, de-
duced from various facts on record, that the trephine may be applied over
the sinuses as well as to most other parts of the cranium ; but though he
has no fear of the bleeding, because hemorrhage from a large vein may
always be commanded by moderate pressure, he allows that a wound of
the sinus exposes the patient to two dangers ; viz. inflammation of the
wounded vessel, and the entrance of air into it.J
Authors generally interdict the application of the trephine to the ante-
rior inferior angle of the parietal bone, on account of the trunk of the
spinous artery of the dura mater being situated in a groove on the inner
* Cases in Surgery, by J. Warner, p. 8. edit. 4. ; Marchetti, Obs. 4. Sharp's Opcrat.
p. 144. edit. 3. ; Pott's Chirurg. Works, vol. i. p. 156—159. edit, by Earle. 1808. Even
so far back as the torcular Herophili in a child, a wound of the sinus by a spicula of
bone, though the blood at first spirted out to the distance of two feet, and extinguished
a candle, did not afterwards give any trouble from hemorrhage, which did not return
when a dossil of lint had been held a little while on the wound. See Velpeau, De
1' Operation du Trepan, p. 129. This case, be it observed, was in a child, and of
course the sinus of less diameter than in an adult. In Hargrave's Operative Surgery,
however, it is stated, on the authority of Mr. Read, that hemorrhage from the termin-
ation of the longitudinal sinus, may always be stopped by very moderate pressure.
f Janson contrived to trephine over the lateral sinus without wounding it, and
.thus succeeded in extracting a ball from the cerebellum. See Compte Kendti, de
1'Hotel-Dieu de Lyon, p. 47. 1822. I should not imagine, as M. Velpeau docs, that it
would generally be easy to apply the trephine without wounding the sinus, unless blood
or matter lay between it and the inner table.
f Del'Operation du Trepan, p. 132.
OPERATION OF TREPHINING. 723
surface of that part of the skull. For my own part, I should never be
afraid of trephining here ; for, if the above vessel were wounded, a little
lint, introduced into its orifice, would immediately stop the bleeding ; or
we might imitate Larrey, and touch the mouth of the vessel with a heated
probe.
It is a maxim to avoid trephining any part from which a complete circle
of bone cannot be sawn, without hurting the dura mater. The inequalities
on some parts of the inner table of the skull, make attention to this rule
necessary. Thus, the centre of the forehead is rather an inconvenient
place for the trephine, because, when the spine of the os frontis is promi-
nent, it cannot be sawn, without the dura mater being wounded by the
teeth of the saw. At all events, if the surgeon were to apply the trephine
to this part, he should complete the separation of the bone with an eleva-
tor, instead of making any dangerous attempt to saw entirely through the
projecting spine.
Surgical writers caution us not to trephine over the frontal sinuses, and,
not without reason ; for, if the perforation be continued in the direction in
which it begins, the inner table will be sawn entirely through on one side
of the circle, before the other is at all divided. However, the outer table
may be first removed with a large trephine, and the inner table then per-
forated with a smaller one, placed evenly and perpendicularly on the pos-
terior surface of the sinus.*
The trephine cannot be applied lower down on the forehead, than half
an inch above the superciliary ridge of the os frontis, without risk of
injuring the orbit. If requisite, it may be applied to the squamous portion
of the temporal bone ; for wounds of the temporal muscles are not at
present so much dreaded as they were by our ancestors. The uneven-
ness of the os occipitis, the course of the longitudinal and lateral sinuses,
and the way in which a part of this bone is covered by muscles, have
made surgeons fearful of applying the trephine to it. However, there are
two small spaces on each side of the groove for the longitudinal sinus,
where a trephine may be safely applied.-}- The operation may even be
done below the transverse ridge, near the foramen magnum, as a division
of the attachments of the splenius and complexus would not be dangerous,
while unrelieved pressure on the cerebellum would certainly be fatal. J
When the bone is already sufficiently exposed by a wound, the oper-
ation may commence at once ; but otherwise, it is first requisite to make
room for the application of the trephine by an incision of a crucial form,
or shaped like the letters T or V. None of the scalp should ever be
removed. The incision should be made directly down to the bone;
but, in fractures, attended with separation of the edges of the fissure, or
with comminution, the danger of pressing too hard with the knife is
obvious.
It would be dangerous to apply the trephine to depressed portions of
the skull. The perforation is always to be made on that side of the frac-
ture, where the elevator can be most conveniently introduced beneath the
depressed bone for the purpose of raising it. In cases of extravasation,
the perforation ought to be made at the place where there are traces of
* C. Bell's Operative Surgery, vol. i. p. 439.
f See Warner's Cases, p. 18. ed. 4.
{ Faivre, Anc. Journ. de Med. t. Ixviii. ; Caisergue, as quoted by Velpeau, De
reparation du Trepan, p. 139. ; A, Copland Hutchison, in Med. Chir. Trans, vol. ii.
p. 104.
3 A 2
724? OPERATIONS.
violence done to the scalp, unless particular considerations exist against
the blood being effused under that part of the cranium, as noticed in the
remarks on Injuries of the Head, in the second section of this work.
When the scalp has been divided, and loose splinters of the cranium
are found under it, they ought to be taken away with the forceps or
finger ; for they can only be regarded as extraneous bodies, the con-
tinuance of which may be productive of dangerous irritation. Depressed
pieces of the skull, causing bad symptoms, are sometimes completely
detached, and admit of removal in the same manner.
In every instance of fracture with depression, unattended with motives
for believing that the pressure on the brain arises partly from extravasa-
tion, provided such depressed fracture can be raised with a pair of forceps,
or an elevator, without applying the trephine, the latter operation may be
dispensed with.
When a depressed fracture is exposed, the bone may sometimes be
raised to its proper level with an elevator ; and then no necessity exists
for sawing away any portion of the cranium, unless blood, extravasated
beneath it, render such proceeding advisable. The point of the elevator
is to be put under the edge of the depressed piece of bone, and a fulcrum
for the instrument obtained on the margin of the adjoining portion of the
cranium. In other instances, the fracture may be so shaped, that the
depressed portion of bone can be cut across with one of Key's saws at
the part connecting it to the rest of the skull, and thus be easily removed,
there being then no occasion to take away with the trephine any other
portion of the cranium. Thus, supposing a depressed fracture to repre-
sent two sides of a triangle, a simple and straight division of the bone
through the base of this triangle, with one of Hey's saws, will enable the
surgeon at once to remove the broken and depressed piece of bone.
The instruments required in the operation are, a scalpel for the division
of the scalp, three trephines with crowns of various diameters, and sliding
centre pins, capable of being securely fixed with a screw when drawn out
to the proper extent. One of the most common defects of modern tre-
phines is, the liability of the centre-pin to slip back as soon as pressure
is made on the instrument, which is thus rendered useless. Every case
of trephining instruments should also contain an elevator, a pair of
forceps, calculated to remove the bone when sufficiently loosened by the
trephine ; Hey's saws, with the teeth in straight and semicircular rows ;
a small brush, with which the teeth of the saw are to be now and then
cleaned in the progress of the operation ; and a lenticular knife, with
which any irregularities of bone, at the margin of the opening made
with the trephine, are to be removed. The plan of scraping away the
pericranium from the part of the skull on which the trephine is about
to be applied, is now condemned, as more likely to detach that mem-
brane to a pernicious extent, than really to facilitate the action of the
trephine.
The operation of trephining is divisible into four stages ; first, that in
which the bone is exposed ; secondly, that in which it is sawn ; thirdly,
that in which it is taken away ; and fourthly, that in which other measures
are pursued, in order to fulfil the object in view.
On the first, I have but little more to say. When the squamous por-
tion of the temporal bone is to be exposed, the incisions are usually made
in the form of the letter V, with the apex directed towards the zygoma,
so that their direction may correspond in some degree to that of the fibres
of the temporal muscle. The flap is then raised from the point upwards.
OPERATION OF TREPHINING. 725
Generally, the bleeding from branches of the temporal or occipital artery,
caused by dividing the scalp, should be allowed to continue a little while,
as having a beneficial effect in checking further effusion of blood in the
head, or inflammation ; but, if the hemorrhage be profuse, and the pulse
considerably reduced, ligatures will be necessary.
The removal of a portion of the cranium with the trephine is per-
formed as follows : the centre-pin of the instrument, having been made
to project moderately beyond the level of its teeth, and securely fixed by
turning the screw, is to be applied to the central point of the circle of
bone, which it is judged advisable to remove. The circumstances, which
should guide us in choosing the place for the trephine in examples of
pressure on the brain from blood or matter, accumulated on the surface
of the dura mater, have been explained in the foregoing section of this
work. (See Injuries of the Head.) When the case is a depressed frac-
ture, the centre-pin, the use of which is to steady the trephine, until
the teeth have formed a groove, is to be placed on an unyielding part
of the cranium, with the crown in a situation, where the perforation
will enable the surgeon to elevate, or remove altogether, the depressed
portion of bone. As soon as the centre-pin has been fixed in the bone,
the surgeon turns the crown alternately to the right and left by the
prone and supine movements of his hand, observing to make steady,
but moderate, pressure with the instrument, until a sufficient groove is
formed. The centre pin, which is no longer of any use, and whose
projection would soon injure the dura mater, is now to be withdrawn,
and the action of the trephine more cautiously continued by semicircular
movements of it," made alternately to the right and left. The sawing
may go on briskly at first ; but we are not to depend upon ^our being
able to distinguish the arrival of the teeth of the instrument in the
diploe, as a criterion of the external table having been divided, and of
the necessity of now proceeding with greater circumspection and slow-
ness. At all events, it is only in the middle period of life, that the
texture of the cranium is likely to afford a difference of sensation and
sound on the division of the external table being completed. Whether
the arrival of the instrument, in the diploe can be perceived or not, it
should be worked with great caution after the groove is of a certain
depth, its movements being executed with briskness in the direction of
the teeth, but with little or no pressure. In this stage of the operation,
the groove is to be frequently examined with a tooth-pick, the flat end
of a probe, or a small thin piece of steel for the purpose, usually
contained in every case of trephining instruments. If the perforation
is found to be complete in any portion of the circular groove, the action
of the trephine is then to be strictly limited to the parts, where the
division of the inner table has not yet been carried far enough. This is
done by inclining the instrument, as it works, to the undivided portion
of the circle.
The cranium having been sawn to a sufficient depth, the next business
consists in removing the circular portion of bone. In the previous stage
of the operation, the surgeon will be likely to injure the dura mater, if
he aim at dividing very completely the inner table at every point with
the trephine ; and therefore, as soon as the piece of bone seems loose, it
is safer to remove it with an elevator, or a pair of forceps, and to break
its slight remaining connections to the rest of the cranium, than run any
risk of lacerating the dura mater with the teeth of the saw. Any irregu-
3 A 3
726 OPERATIONS.
larities at the edge of the perforation, likely to irritate the same mem-
brane, are then to be removed with the lenticular knife.
If the case be one of pressure on the brain, from blood extravasated on
the dura mater, the surgeon will now have to consider, whether the first
opening made will suffice for the removal of such blood ; if not, another,
or even a third perforation, may be necessary. The same occasion for
additional perforations will not so often present itself when purulent
matter is lodged under the inner table, as it always escapes more readily
than blood, and is generally less diffused.
When there is a depressed fracture, an elevator is to be introduced
under the part of the bone which is below its proper level ; and a
fulcrum having been obtained either on the edge of the adjoining portion
of the cranium, or on the fore finger of the surgeon's left hand, the de-
pressed fragment is to be raised. Frequently it is advisable to remove
it entirely, which, as I have already explained, can often be readily done
with one of Key's saws, and then all occasion for the removal of bone
with the trephine is obviated. If the case be what is termed a. punctured
or stellated fracture, the whole of the depressed piece of the skull may
generally be included within the circle of the trephine, and thus be easily
removed.
In compound fracture with depression, unattended, however, with symp-
toms of pressure on the brain, the bone may be raised to its proper level
with an elevator ; but, according to the principles inculcated in my re-
marks on Injuries of the Head, trephining would not always be advisable.
After the operation, the flaps of the scalp should be laid down, and
light simple dressings applied. For the prevention or cure of inflamma-
tion, bleeding, the application of cold evaporating lotions to the scalp,
and the exhibition of calomel, tartarised antimony, and saline purgative
medicines, will frequently be necessary.
When, on the exposure of the dura mater, blood or other fluid seems
confined under it, and the membrane presents a dark-coloured, livid, or
yellowish colour, and a tense prominent appearance, it should be cau-
tiously punctured. In one instance, where matter was suspected to be
more deeply lodged, Dupuytren introduced a bistoury more than an inch
into the substance of the brain, and discharged the abscess.
In very young subjects, the opening made with the trephine is some-
times gradually, but only in part, repaired by osseous matter. In the
museum of University College is the skull of a person, who had been ex-
tensively trephined forty years before he died ; and, in this example,
nature has filled up almost the whole of the deficiency with osseous
matter. Repair to this extent demands a great deal of time. In persons
who have lived ten, twenty, or fifty years after loss of portions of the
cranium, the slow restoration of the bone appears to have been pro-
gressive for the whole period. In fifty years, a trephine hole is nearly
closed by the shelving growth of bone from the margin towards the
centre.*
EXTIRPATION OF THE EYE.
Cancer, medullary tumours, and melanosis, are the three diseases some-
times occasioning the necessity for the operation, for which the patient
should be prepared by regulation of his diet and the exhibition of aperient
* See Mayo's Outlines of Human Pathology, p. 8. 8vo. Lond. 1835.
EXTIRPATION OF THE EYE. 727
medicines, so as to lessen the risk of inflammation, and of the extension of
it to the brain and its membranes.
The patient should be placed in the recumbent position, with his head
properly raised on a pillow, and held by an assistant. When the exten-
sion of the disease to the eyelids makes their removal necessary, the
mode of operating differs from that which is adopted when those parts
are to be preserved : in the first case, two semilunar incisions are to be
made, the upper one corresponding to the line of the superciliary ridge
of the os frontis, and the lower to the inferior border of the orbit, so as
to detach the eyelids and allow them to be taken away with the rest of
the disease. If, however, they should be merely adherent to the diseased
eyeball, and not themselves affected with malignant disease, they should
never be cut away, but only separated from their connection with the
globe of the eye.
First stage. — Supposing the state of the eyelids will admit of their
being saved, the first step consists in making an incision at least an inch
in length through their external commissure,, in the direction towards
the temple. The eyelids are then to be turned back, so as to uncover,
as it were,, the base of the orbit, both above and below the front of the
diseased eyeball.
Second stage. — In this, the conjunctiva is to be cut through at its
reflexion over the globe from the eyelids ; and this should be done very
completely at every point of the circumference of the orbit : indeed,
some operators aim at more than this in the second stage of the opera-
tion_, and introducing the knife at the greater angle, with its edge turned
downwards, they carry it close to the os ethmoides nearly to the optic
foramen, and then convey it in a semicircular direction across the whole
extent of the lower half of the orbit, thus dividing the inferior oblique
muscle, the conjunctiva at its reflexion, and some fat and cellular tissue.
Next, the knife is introduced again at the nasal extremity of the wound,
with the edge turned upwards ; the superior oblique muscle or trochle-
aris is cut through ; and, if possible, the lachrymal gland separated, as
the incision is passing along the roof of the orbit. These two cuts are to
be semilunar, and to meet at their extremities.
Third stage. — As the roof of the orbit is naturally thin, and some-
times is rendered still thinner by long-continued pressure, the knife, if
used incautiously, might penetrate to the brain. To avoid this risk, in
the division of the parts at the upper part of the orbit, the eye should
be drawn downwards with a ligature, or tenaculum, passed through the
diseased mass. The eyeball is now only retained by a kind of pedicle,
composed of the four recti muscles and optic nerve, which are to be
divided either with a pair of curved scissors or a curved bistoury. As
the external side of the orbit slants from without inwards, while the in-
ternal goes directly backwards, this step of the operation is most easily
accomplished by introducing the instrument at the external side, as re-
commended by Desault and Lawrence. The surface of the orbit should
now be carefully examined with the finger ; and if the lachrymal gland,
or any portion of the disease has been left behind, it should be rlmoved.
The bleeding from the ophthalmic artery is profuse, but generally
ceases of itself. If it should continue in an alarming degree, a dossil of
lint should be held and pressed upon the vessel for a little time, after
which there will be no further hemorrhage. Filling the orbit with
sponge, lint, &c. is objectionable, as producing irritation and inflamma-
tion ; effects highly perilous, as Mr. Lawrence justly observes, in conse-
3 A 4-
728 OPERATIONS.
quence of the direct connection between the sheath of the optic nerve,
the periorbita, and the dura mater, and the immediate contiguity of the
brain. The commissure of the eyelids is to be united with a suture ;
and soft rag, dipped in water, laid over the part.
REMOVAL OF THE SUPERIOR MAXILLARY BONE.
The superior maxillary bone is liable to several diseases, which begin
either in the mucous membrane of the antrum, in the bony parictes of
this cavity, or in the fangs or sockets of the teeth. Sometimes the
mucous membrane inflames, and, becoming thickened, blocks up the
opening, naturally establishing a communication between the antrum
and the nasal fossa? : the result is an accumulation of the mucus in the
antrum, a case which, as well as abscesses, has been already described
in the foregoing section of this work. On other occasions, the lining of
the antrum secretes a concrete substance, presenting the characters of
adipocere. From the interior of the antrum, polypi, fibro-cartilaginous,
medullary, and vascular erectile tumours *, may grow ; or its bony pa-
rietes may be the seat of caries, necrosis, and exostosis.
The operation of removing the superior maxillary bone is sometimes
rendered advisable by the growth of a fibro-cartilaginous tumour within
it, or of a medullary tumour, when this is entirely restricted to the antrum,
and the patient's general health good. According to Mr. Syme, medul-
lary tumours are more frequent in the upper jaw bone, than fibrous ones ;
and as their removal from any part of the body is often followed by a
return of the disease in the part, or its development elsewhere, a guarded
prognosis should be delivered respecting the success of the operation.
The removal of the upper jaw for fibrous or fibro-cartilaginous tumours,
on the other hand, has generally been followed by a permanent cure.
The methods of operating are various ; but, whichever is selected, the
patient is to be placed on a firm seat, with his head supported on an
assistant's breast, who is to employ his hands in steadying the head, and,
if necessary, in compressing the trunk of the facial artery.
M. Gensoul, principal surgeon of the Hotel Dieu, at Lyons, claims the
merit of having first extended to operations on the superior maxillary
bone the approved principle in surgery, that amputation should always
be performed in the sound parts, and not in the diseased.f This prin-
ciple led him not to be content with taking away a part of the diseased
bone, as he contends had been done by all his predecessors, inclusive of
Dupuytren, but induced him to aim at the removal of the whole of it.
M. Gensoul was further encouraged to perform this operation by consi-
dering attentively the anatomy of the face. He saw that the superior
maxillary bone was only firmly fixed to the other bones of the head at
three points : —
1. At its nasal or ascending process, and the junction ofitsorbitar
plate with the os unguis and os planum of the ethmoid bone.
* See Lettre Chir. sur quelques Maladies du Sinus Maxillaire, par Th. Gensoul,
p. 33. In the case here referred to, no return of the disease had taken place five years
after the operation. " For erectile tumour, occupying the maxillary sinus (Mr. Liston
observes), the ligature of the common carotid of the corresponding side, would be the
proper practice." Practical Surgery, p. 267.
•j- Lettre Chirurgicale sur quelques Maladies graves du Sinus Maxillaire et de 1'Os
Maxillaire Inferieur. Paris. 8vo. 1833. p. 4. &c. When M. Gensoul was lately in
this country, I had the pleasure of becoming acquainted with him, and of receiving from
him this interesting publication.
REMOVAL OF THE SUPERIOR MAXILLARY BONE. 729
2. At the orbitar margin of the malar, as far as the spheno- maxillary
fissure ; or, as Mr. Outline more clearly explains, the superior maxillary
bone, on the outside, is " attached firmly to the malar bone by its malar
process, orbitary edge, and plate, as far back as the spheno-maxillary
sinus ; but as in general the os malae should be more or less removed, its
ascending orbitar process, forming the outer edge of the orbit, should be
well considered/' *
3. At the junction of the two superior maxillary bones, and that of
the two palate bones.
4. The fourth point of connexion, which is through the medium of the
ascending portion of the palate bone and the pterygoid process of the
sphenoid, readily gives way on depressing the superior maxillary bone
towards the mouth.
M. Gensoul reflected, that no large vessel would necessarily be wounded ;
that the trunk of the internal maxillary artery might be easily avoided ;
and that, if it were injured, it might be tied, after the bone had been
removed.f In the event, however, of the hemorrhage being profuse
during the operation, he conceived, that it might be commanded by
pressing the common carotid against the spine. As for nerves, he calcu-
lated that the superior maxillary was the only trunk of importance
exposed to injury ; and had he not seen that it admitted of being cut
through, he would have renounced the idea of operating, rather than tear
that nerve away.
GensouVs Method. — A vertical incision is made from the great angle
of the eye to the upper lip, which is cut through opposite the canine
tooth. From the middle of this first incision, or rather from the point
of it on a level with the base of the nose, a second incision is made to
within four lines of the lobe of the ear. A third incision is next carried
from a point, five or six lines on the temporal side of the external angu-
lar process of the os frontis, down to the termination of the second
wound. The prolongation of it much lower down over the masseter
would divide the parotid duct, and perhaps occasion a salivary fistula.
The two flaps are then reflected ; one upwards, the other downwards.
The superior maxillary bone being thus exposed, the angular process
of the malar bone is detached from the external angular process of the
frontal bone, by means of a sharp chisel and mallet, and the division
thus extended into the spheno-maxillary fissure. The zygomatic process
of the malar bone is next divided ; and the superior maxillary bone
being thus loosened on its outer side, a broadish chisel is applied below
the internal angle of the eye, and the lower part of the os unguis and
orbitar plate of the ethmoid bone are divided. The ascending process of
the superior maxillary bone is now to be detached from the correspond-
ing os nasi with the same instruments. The surgeon then divides with
a bistoury all the soft parts connecting the upper jaw to the ala of the
nose ; and after extracting one of the incisor teeth, severs the two supe-
rior maxillary bones from one another at their symphysis below the
nostrils with a sharp chisel. Lastly, in order to detach the superior
maxillary bone from the connexion which it has with the pterygoid
* See Lond. Med. Gaz. for 1835, p. 316.
f In one of Gensotil's operations, the pterygoid branch of the internal maxillary was
wounded ; and so it was in Mr. Outline's operation, which was performed in the manner
advised by the former surgeon. In one example, in University College Hospital, the
trunk of the internal maxillary bled ; but was secured with the utmost facility.
730 OPERATIONS. ,
processes of the sphenoid through the palate bone, and to break some
connections which it may yet retain to the ethmoid bone backwards, the
chisel is plunged obliquely into the tumour from the orbit, so as to cut
through the superior maxillary nerve, which ought never to be lacerated ;
and the instrument is then passed deeply enough to serve as a lever
for depressing the tumour into the mouth. This having been accom-
plished, all that remains to be done is, with a pair of curved scissors, or a
scalpel, to cut through the attachments of the palate bone to the soft
palate.
Any vessels, requiring ligatures, are now to be tied ; and the flaps
laid down, but not united with the twisted suture, till an hour or two
have elapsed, within which period the force of the circulation will have
revived, and it will be seen whether any other vessels need ligatures. In
this country, instead of employing the chisel and mallet, surgeons gene-
rally use Key's saws, and a pair of pliers with long powerful handles.*
The division of the malar bone, in the first instance, is preferred by
M. Gensoul, because productive of no material bleeding, and of none
that falls into the throat.
Second, or Mr. Listoris, Method. — Supposing the malar bone to be in-
volved, incisions must be made, so as to expose freely the tumour and
bones where it is proposed to 'cut them. One of the central incisors is
first to be extracted. The point of the bistoury is entered over the ex-
ternal angular process, and the incision is carried down through the cheek
to the corner of the mouth. A second incision is made along the zygo-
ma, so as to meet the first. Then the knife is pushed through the inte-
gument to the nasal process of the superior maxillary bone, the cartilage
of the ala of the nose is detached from the bone, and the lip is divided in
the mesial line. The flap thus formed is quickly dissected up, and held
by an assistant. The attachments of the soft parts to the floor of the
orbit, the inferior oblique muscle, the infra-orbital nerve, &c. are cut,
and the contents of the cavity supported and protected with a narrow
bent copper spatula. With the cutting bone-forceps, the zygoma, the
junction of the malar and frontal bones at the transverse facial suture, and
the nasal process of the superior maxilla, are cut in succession. Then a
notch being made with a small saw in the alveolar process, the cutting
forceps are placed with one blade in the nostril, and the other in the
the mouth, and the palatine arch clipped through. The tumour is now
shaken so as to loosen its connexions, and the remaining attachments di-
vided with the knife, as the swelling is turned down. The velum palati
is to be carefully preserved, and, if possible, tire palatine arch of the
palate bone. During these latter proceedings, the assistant, if required,
is to compress the trunk of the carotid. " Perhaps," observes Mr. Listen,
" no vessel may require ligature ; the branches of the internal max-
illary are elongated, and torn from the tumour in bringing it down ; in
fact, if the mass is large, there is no possibility of reaching them with the
knife." The void is then filled with lint, and the edges of the wound
brought together with the interrupted or twisted suture, but no dressings
are to be applied. In twenty-four hours some of the sutures may be
taken out, and replaced by narrow strips of plaster. At the end of forty-
eight hours, the other stitches are cut, and the pins withdrawn. When the
* Messrs. Weiss have invented cutting bone-forceps, the construction of whose handles
multiplies the power of the blades on a different principle from that of the length of the
former parts.
REMOVAL OF THE LOWER JAW BONE. 731
opening in the palate has become as much diminished, as it is likely to be
by nature, a plate of metal, or of sea-horse bone, may be adapted to it.*
If the malar bone should not require to be taken away, its connexion
with the upper maxilla is to be divided with one of Key's saws, and, of
course, the incision along the zygoma would be unnecessary.
Third Method, or that of Professor Regnoli.f — With an ordinary con-
vex-edged bistoury an incision is made over the middle of the swelling
beginning near the external angle of the eye, and extending obliquely
downwards and inwards to the commissure of the lips. If the facial
artery be compressed as it ascends over the base of the jaw, this first
wound will occasion but little hemorrhage. The soft parts on each side
of the incision are then to be detached from the surface of the tumour,
the lateral cartilage and ala of the nose being included in the internal
flap, while the external comprehends all parts situated between the line
of the first incision and the junction of the superior maxillary bone with
the zygoma. By means of a strong knife, which is struck with a hammer,
the surgeon divides in succession the base of the nasal process, the lower
border of the orbit, the superior maxillary canal and nerve, the junction
of the zygoma with the malar bone, the connexion of this with the supe-
rior maxillary bone, and then the alveolar process. The use of the bis-
toury is now resumed, and the membrane of the palate divided with it as
far back as the velum pendulum palati ; after which the strong scalpel
is driven with the hammer between the two middle incisor teeth, in the
direction of the middle line, as far back as the palate bones. The re-
maining slight connections of the superior maxillary bone are then easily
overcome by moving it alternately upwards and downwards, and by means
of a few touches of a curved bistoury. The bleeding is suppressed with
ligatures, or, if necessary, the actual cautery and the sides of the wound
are brought together with the twisted suture. As Professor Regnoli
makes only one incision through the cheek, there is less disfigurement of
the face after this operation, than after the other methods.
If a great deal of pain and inflammation were to follow any of the
above-described operations, the patient ought to be freely bled, and put
under antiphlogistic treatment. Erysipelas is one of the consequences
most to be apprehended.
That Mr. Liston's plan of operating is, in every respect, the most eligible,
is a fact that admits of no question.
REMOVAL OF THE LOWER JAW BONE, OR OF PART OF IT.
Cancer of the lip, extending its ravages to the body of the inferior
maxillary bone, is specified as one case requiring the excision of more or
less of the latter part ; but, I believe, the opportunity of operating under
these circumstances, with a prospect of benefiting the patient, will seldom
present itself, because, when the disease has attained this degree, the
absorbent glands under the jaw and in the neck will commonly be impli-
cated. However, if these glands were free from disease, and especially
if, with this condition, the gums and alveolary process were the of»ly parts
manifestly invaded, in addition to the lip and soft parts near it, the ex-
cision of the diseased portion of bone, together with the cancerous affec-
* See Liston's Practical Surgery, p. 264. 8vo. Lond. 1837.
f Sulla Estirpazione della Quasi Totalita dell' Osso Mascellare Superiore Sinistro.
Pisa, 1832. When Professor Regnoli was in England, about two years ago, he was so
obliging as to present to me this and several other publications.
732 OPERATIONS.
tion of the other textures, would be an advisable measure. A patient in
this state was referred to me by the late Dr. Blicke, of Walthamstowe :
I recommended the operation, but believe that it was never submitted to.
Sometimes the necessity for removing a portion of the lower jaw is
occasioned by an epulis assuming a malignant character, and involving
the alveoli or even a greater extent of the bone. Tumours, originating
in the sockets of the teeth, and presenting an indurated fungous texture,
with a tendency to bleed, may also make it necessary to take away a
part of the bone. But the diseases, for which the most considerable por-
tions, and even the whole of the lower jaw, have been sometimes taken
away, are certain fibrous tumours, commencing in the cancellous struc-
ture of the bone ; and others of a medullary character, beginning in the
same situation. At the present day, however, when medullary sarcoma
is regarded as an affection rarely limited to one part, and often followed
by a relapse, many surgeons would decline to operate, if the disease were
known beforehand to be of this unfavourable description. At the same
time, it would not be difficult to find instances of the removal of part of
the lower jaw for medullary tumours, where the patients afterwards con-
tinued free from the disease. As for tumours of a fibrous structure, ex-
panding the bone, and destroying its texture, they are cases where the
operation generally frees the patient permanently from the grievances
under which he is labouring. A disease of this kind will sometimes pro-
duce a tumour, reaching from the molar teeth of one side to the ram us
of the opposite side of the jaw, pushing back the base of the tongue,
and throwing out a fungus, wherever ulceration of it is excited by the
pressure of the teeth of the upper jaw. A sanious, excessively fetid dis-
charge takes place. The lower jaw is of thrice its natural size, and even
greater, the fibrous mass occupying very deeply its more or less disor-
ganised texture, and at the same time filling the aperture of the mouth,
protruding beyond it, and sometimes keeping the mouth as widely open
as the articulation of the lower jaw will allow. The cheek or cheeks may
also become enormously distended^ by other projecting portions of the
disease. The introduction of food into the mouth, perhaps, can only be
effected by drawing one of the commissures of the lips towards the ear;
and, together with all these grievances, there is profuse ptyalism, while
respiration, mastication, and the pronunciation of words, are all seriously
interrupted.
Whether the disease be a medullary, or a fibrous tumour, or an osteo-
sarcoma, it cannot be destroyed without a surgical operation, which varies
according to the situation and the extent of the swelling. The prospect
of a radical cure in the first of these examples is much less favourable
than where the structure of the tumour is fibrous. In all the following
operations, the patient is to sit on a firm chair, with the head thrown
back, and supported on the breast of an assistant, who can also compress,
if necessary, the facial arteries as they ascend, in front of the insertion of
the masseter muscles, or push them backward, by which means wounding
them may sometimes be avoided in removing a central portion of the body
of the lower jaw bone. The places, where the bone is to be sawn through,
should always be determined beforehand, and the teeth in those situations
removed on the day preceding the operation.
First Operation. — When the disease is confined to the alveolary process,
a perpendicular division of the gum with the knife, and a similar perpen-
dicular division of the alveolary process with a small saw, are to be made
on each side of the disease. Then the diseased portion of bone may be
REMOVAL OF THE LOWER JAW BONE. 733
broken off with a strong pair of forceps, or divided with a pair of cross-
cutting forceps, as recommended by Mr. Listen. The bleeding, which is
copious, is to be stopped by pressing lint on the part, and, if necessary,
dipping the lint previously in the tinctura ferri sesquichloridi.
Second Operation. — Removal of the middle part of the body of the bone.
— Two methods are usually described. In one, particularly recommended
where the integuments are healthy, a perpendicular incision is made
through the centre of the lower lip, and carried down through the skin
as low as the os hyoides. In order that this first perpendicular cut may
be skilfully made, an assistant takes hold of the left portion of the lip,
while the surgeon fixes the right between the index and middle fingers
of his left hand, and, with the bistoury in his right, makes the incision
through the lip and the integuments down to the os hyoides. The right
facial artery being now pressed back by the assistant, who supports the
head, the point of the knife is to be introduced just in front of the vessel,
and a transverse cut made forwards along the base of the jaw, till it
meets the first perpendicular incision. The same proceeding is next
followed on the left side. The four flaps, resulting from the three inci-
sions, are then to be detached and raised from the bone, which, accord-
ing to Dupuytren, may thus be sawn as far back as the angle on either
side, without injury of the facial artery. As the detachment of genio-
hyoid, and genio-hyo-glossi muscles, is apt to be followed by retraction
of the tongue into the pharynx, and a sudden interruption of respiration,
perhaps it is best not to divide their insertions until the bone has been
sawn through on each side. Or, If they are to be first divided, the dis-
placement of the tongue into the pharynx must be guarded against by
passing a ligature through the anterior part of the fraenum.
The bone is to be partly divided with a metacarpal saw, or one of Hey's
saws, at a point beyond the limit of the disease on each side, and the
division conpleted with one stroke of a pair of cutting forceps, the
handles of which should be long, so as to give the operator power. In
using the metacarpal saw, he will obtain more room for its action by
placing himself behind the patient; but, when Hey's saw is employed,
this direction is not of any importance.
The central portion of the bone having been thus sawn through on
each side of the disease, is now to be drawn forwards and depressed by
an assistant, while the surgeon cuts through the membrane of the mouth
and other soft parts behind the chin, with the knife kept close to the
attachments of the muscles in that situation. At the instant when the
genio-glossi are divided, some surgeons recommend the apex of the
tongue to be taken hold of with the intervention of a piece of rag, in
order to prevent this organ from being so forcibly retracted by theglosso-
pharyngei muscles, so as to close the glottis and bring on the risk of
suffocation.* A ligature, passed through the fraBnum, is a surer plan.
Dupuytren 's first Method. — An assistant supports the head on his
breast, and compresses the facial arteries against the rami of the bone.
The surgeon, standing in front of the patient, takes hold of the fight side
* With respect to the improvement of this operation, it seems to me, that with the ad-
vantage of the transverse wound, it is unnecessary to extend the perpendicular incision so
low down as the os hyoides. If, on the division of the genio-hyo-glossi, the tongue were
to he forcibly drawn back by the glosso-pharyngei, and the glottis closed so as to threaten
instantaneous suffocation, tracheotomy should he done without the least delay, — the
measure successfully resorted to by Lallemand, whose patient had fallen senseless on the
floor.
734- OPERATIONS*
of the lower lip with the left hand, while an assistant does the same to
the left side, so that the part may be tense. An incision is then made
through the centre of the lip, and extended perpendicularly nearly down
to the os hyoides. The two flaps are reflected to the right and left; and
the bone, having been completely denuded, and fixed, is sawn through on
each side with a hand-saw, at the distance from the symphysis pre-
scribed by the extent of the disease. This part of the operation would
be more conveniently accomplished by making a groove with one of
Key's saws, and then completing the division with a strong pair of
cutting forceps. The central portion of the bone, having been thus
detached from the rest of it, is to be pressed downwards and for-
wards ; and then the lining of the mouth, and the muscles connected
with the posterior part of the body of the bone, and to the mylohyoid
line, can be readily separated from their attachments with the knife
kept close to the bone. On cutting through the origin of the genio-
glossi muscles, means must be taken to prevent the tongue from being
powerfully retracted by the glosso-pharyngei, so as to close the glottis
and bring on a stoppage of respiration. By proceeding in the above
manner, Dupuytren was able to saw through the bone on each side
within an inch of the angle, and to remove a diseased mass weighing a
pound and a half.*
A third Method of removing the central part of the bone, applicable
to cases in which the integuments are so diseased as not to admit of pre-
servation. — An incision is to commence on each side of the jaw, at such
a distance from the symphysis as will insure the removal of the whole
of the diseased mass. These incisions are to be carried down to the os
hyoides, where they meet at an angle. The soft parts are then to be
dissected back from the bone on each side, and the rest of the operation
completed according to directions already given. The sides of the wound
are next to be brought as near one another as circumstances will admit ;
and, if the loss of skin is not too considerable, they may be put in apposi-
tion, and united with the twisted suture.
fourth Operation, applicable to cases in which the disease occupies a
considerable extent, including part of the ramus of the jaw. — Such teeth,
as would interfere with the division of the bone, are to be previously ex-
tracted. The first or anterior incision passes from the vicinity of the
commissure of the lips, to a little below the base of the jaw.
The exact points, however, where both the first and second incisions
ought to begin, will depend upon the extent of the disease in the direc-
tions forward and backward. Sometimes, when a suspicion is entertained
that it may be necessary to take away the condyle, it is right to let the
second incision commence as far back as a point in front of, and a little
above, the lobe of the ear, and to continue it down to the angle of the
jaw along the posterior edge of the ramus.
The third or horizontal incision may run from the termination of the
second incision, along the base of the jaw, so as to join the first at its
inferior extremity. The facial artery is now to be secured. If it has
been necessary to make the second incision far back, no sooner has the
flap been raised, than a portion of the parotid gland, lying under a pro-
longation of the cervical fascia, is exposed, and, with the parotid duct
itself crossing the masseter, should be left uninjured. The masseter
* See Lemons Orales de Clinique Chirurgicale, par M. le Baron jDupuytreii, t. iv.
p. G40.
REMOVAL OE THE LOWER JAW BONE. 735
having been separated from the outside of the ramus, the next thing is
to convey the knife close along the inside of the bone, so as to cut
through the membrane of the mouth, and attachments of the muscles in
that situation. In detaching the mylo-hyoideus from the oblique ridge
below the molar teeth, and the internal pterygoid muscle from the inside
of the ramus of the jaw, the knife is to pass close to the bone, in order
to avoid injuring the lingual branch of the fifth pair of nerves.
A perpendicular groove is now to be made, with Hey's saw, in the
outer surface of that part of the body of the jaw which it is intended to
divide, and the division is to be completed with a strong pair of cutting
forceps. The ramus is then to be partly divided with Hey's saw, but, in-
stead of exposing the lingual branch of the fifth pair of nerves to injury
by sawing too deeply, I recommend the anterior part of the bone to be
pressed outward, whereby the ramus will be easily broken off at the
groove. If any difficulty be experienced, the groove should be made
deeper with Hey's saw, or the cutting forceps cautiously applied.
It appears to me that, in this operation, the division of the lip can
hardly ever be needed, and, as leading to disfigurement, should be avoided.
As Mr. Liston directs, the incision may terminate in the mesial line, about
an inch from the free edge of the lip. His plan is to make a semilunar
incision along the base of the jaw, the horns of the incision pointing
upwards, and passing over the spaces which were occupied by the ex-
tracted teeth.
Fifth Operation, or that required when the bone is to be removed at the
articulation. — Here particular care must be taken to begin the posterior
incision in front of, and a little above, the lobe of the ear, in order that it
may reach over the articulation. A good method is that of commencing
the wound at the point just above the articulation, and carrying it first
downward to the angle, and then horizontally towards the chin, where it
is to ascend again ; thus having a semilunar shape, as practised by Mr.
Liston*, and Professor Regnoli, of Pisa.f The main difference of this
operation from that, in which only a portion of the ramus is removed,
consists in the proceedings necessary for the disai ticulation of the con-
dyle. The anterior division of the jaw having been accomplished accord-
ing to directions already given, the end of it is to be forcibly depressed,
so as to bring the coronoid process below the zygoma, and to enable the
surgeon to cut through the attachment of the temporal muscle. The
bone then becomes much more moveable, and can be used as a lever
for pressing the condyle against the anterior and external part of the
capsular ligament. This is to be opened at its fore part, the external
lateral ligament descending downwards and backwards from the root
of the zygoma to the neck of the condyle divided, and the condyle itself
then twisted out. J The latter part is then to be completely detached
by passing a blunt-pointed narrow-curved bistoury cautiously round the
joint, so as to divide the rest of the capsule, the internal lateral ligament,
and the external pterygoid muscle. By cutting the parts in the manner
* " An incision is made from the condyloid process, down the posterior border of the
ramus, and along the lower margin of the bone, and terminates above the point of the
chin, in 'the mesial line, at about an inch from the free edge of the lip." See Listen's
Practical Surgery, p. 270.
f Intorno 1'Amputazione di Quasi la Meta della Mascella Inferiore, p. 13. Pisa,
1834.
| Liston's Elements of Surgery, p. 228. part 2d.
736 OPERATIONS.
here directed, all risk of wounding the internal maxillary artery, whose
course is a little lower down, almost in contact with the inside of the neck
of the bone, will be avoided. Neither will the lingual branch of the fifth
nerve be injured, if, in detaching the internal pterygoid muscle, the edge
of the knife be kept as closely as possible to the inner surface of the
ramus. If, after the first division of the jaw, the bone were found to be
so weakened by disease as not to admit of being used as a lever, it might
be necessary to divide the ramus, and then to take hold of the end of the
bone and depress it with a strong pair of forceps, while the temporal
muscle is detached from the coronoid process. * The same mode of pro-
ceeding would be called for, were the surgeon, after the removal of a
portion of the body and ramus, to find that the extent of the disease ren-
dered disarticulation advisable.
The arteries wounded, and often requiring ligatures, after operations of
the preceding description, are the facial and labial, but more frequently
the submental, and necessarily some branches of the temporal and lingual
arteries. When the bleeding is profuse, and comes from numerous
points, Mr. Listen prefers passing a ligature under the common trunk of
the internal maxillary and temporal arteries, at the point where it
emerges from beneath the digastric muscle to tying all the branches
which pour out blood. With regard to tying the common carotid artery,
as a preliminary measure in the operation of removing any part of the
lower jaw, it is completely superfluous. Were it on any occasion neces-
sary to check the flow of blood through the carotid, it might be done by
pressing the artery against the transverse processes of the cervical verte-
brae with an assistant's fingers or thumb. t
Amongst the accidental consequences of the operation of removing
part of the lower jaw, I may mention, 1. Secondary hemorrhage. 2. Severe
inflammation about the face, neck, and throat. 3. Inflammation of the
glottis, and effusion of serum under its lining ; a case in which the patient
sometimes can be saved only by making an opening into the respiratory
tube. 4. A difficulty of deglutition, from the division of the attachment
of the genio-glossi muscles.^ 5. Erysipelas. 6. Tetanus.
BRONCHOTOMY,
Or, the operation of cutting into the air tubes, is termed tracheotomy,
when the opening is made in the trachea ; but laryngotomy, when the
incision is made in the larynx.
The following are some of the circumstances calling for the perform-
ance of one or the other of these operations : —
1. Foreign bodies which have accidentally fallen down the glottis into
the trachea, as a cherry-stone, a bean, a small coin, a bead, an acorn, &c.
In such cases, provided no doubt exist about the presence of the foreign
body in the respiratory tube, the operation ought to be done without
delay, and this notwithstanding there may be now and then a remission
of the symptoms. A patient, mentioned by M. Louis, seemed so well
that he was considered out of danger, yet he died in three weeks ; and
another, who lived several years with a louis d'or in one of the bronchi,
was destroyed by it in the end. The practitioner should remember, that
» See Margrave's Operative Surgery, p. 180.
f See Listen's Elements, part 2d. p. 229. — G. Regnoli, Intorno I'Amputazione <1i
Quasi la Metadella Mascella Inferiorc Brevi Cenni, pp. 13. & 20. 8vo. Pisa, 1824,
$ Dupuytren, Leyons Orales, torn. iv. p, C53.
BRONCHOTOMY. 737
a temporary cessation of the difficulty of breathing, cough, and general
disturbance of the system, arising from the foreign body, is usual, and he
should not suffer himself to be deceived by it. On the other hand, let
him not resort to the operation, unless there be sufficient evidence of the
foreign body having really descended through the glottis, and that it has
not been coughed up again. The movements of the foreign body in the
air-passage frequently cause a kind of rattling, which may be heard. In
cases of doubt, the stethoscope should be employed.
2. Polypi, fibrous tumours, and other organised growths in the larynx,
causing dangerous interruption of the breathing.
3. Foreign bodies in the pharynx or oesophagus, occasioning by their
pressure a perilous impediment to respiration, and not admitting of being
immediately either extracted or pushed down into the stomach.
4. An urgent interruption of respiration from a chronic thickening of
the membranous lining of the larynx, and a consequent diminution in the
diameter of the glottis.
5. The same urgent state, resulting from acute inflammation of the
same part. This case, however, much less frequently requires an opera-
tion, because the disease in its early stage generally yields to bleeding,
mercury, and other efficient means, and, in its advanced stage, mostly
proves fatal., whether the trachea be opened or not ; not only this tube
being blocked up with fibrine, but the bronchi themselves similarly ob-
structed, and the lungs participating in the effects of the inflammation.
At the same time, it deserves attention, that, even with these facts
admitted, the performance of the operation is sometimes vindicable, as
being the only means of enabling the patient to breathe, and gain a little
time for the further trial of remedies calculated to subdue the disease ;
provided there be reason to believe that the inflammation has not de-
scended beyond the first division of the bronchi, in which case the opera-
tion would be useless. M. Bretonneau is an advocate for opening the
trachea freely, and, besides placing rather a wide cannula in the wound,
to promote the escape of the layers of fibrine from the trachea, he
introduces calomel, either in a dry or moistened state, into that organ, for
the purpose of expediting the absorption of the fibrinous deposit. Several
cases are recorded, in which M. Bretonneau adopted this practice suc-
cessfully. Velpeau refers to a case under M. Trousseau, who, after per-
forming tracheotomy, and putting a cannula into the wound, introduced
into the bronchi twenty drops of a solution of 5 j- of nitrate of silver in
§ j. of distilled water, every six hours, for three days and a half. Twenty
drops of a tepid decoction of marshmallows were introduced every hour,
and the cannula withdrawn and cleaned three times a day. The child,
aged six years, continued for four days to void considerable portions of
fibrine through the tube. On the tenth day, the air began to pass very
well through the larynx, and, by the twenty-fifth, the wound in the
trachea had healed.* The value of the practices here alluded to, I
leave to the judgment of the physician,, and merely advert to them as
connected with the present subject. 9
6. Various cases, in which suffocation is urgently threatened by the
mechanical pressure of swellings on the larynx or trachea, provided such
pressure cannot be immediately removed, as it often may be by dis-
charging the contents of abscesses. In this last manner, I saved a
child under Dr. Campbell, of Camden Town, which was on the point of
* Nouveaux El£mens de Med. Operatoire, torn. ii. p. 202,
SB
738 OPERATIONS.
suffocation from the pressure of a collection of matter formed around the
thyroid gland.
7. For the purpose of inflating the lungs in some examples of sus-
pended animation, like that resulting from hanging ; for the plan is at
present nearly abandoned with reference to cases of drowning. It ap-
pears, also, to promise no success, where life is suddenly extinguished by
the azotic principle of certain gases.*
8. Disease of the larynx from syphilis, threatening suffocation.
9. Dangerous obstruction of respiration from the effects of inflamma-
tion of the lining of the glottis, excited by swallowing boiling water.f
10. Complete interruption of respiration by retraction of the tongue
into the pharynx, occasionally taking place on the division of the attach-
ment of the genio-glossi muscles in the removal of the body of the lower
jaw.
In performing tracheotomy, the surgeon should recollect the relative
anatomy of the trachea ; especially its having the oesophagus behind it ;
its inclination rather to the right side of the neck ; its being covered,
first, by the common integuments, — secondly, by the cervical fascia, —
thirdly, by the transverse slip of the thyroid gland, connecting the two
lobes of this body, near the cricoid cartilage ; and lower down by a
plexus of veins, some lymphatic glands, and the middle thyroid artery,
when it exists, — fourthly, by the sterno-hyoid and sterno-thyroid muscles,
which lie towards its side. The inferior laryngeal nerves are behind it,
and the common carotid at its outer side. Occasionally it is crossed by
one of the inferior thyroid arteries, which then passes from one side of
the neck to the other. In children, the arteria innominata generally lies
over the front of the trachea, till the latter tube is completely out of the
chest, so that the right carotid artery then quits the innominata very
high up, and may be easily wounded in the operation. Velpeau has
known the left carotid come from the right side, and cross the trachea
to reach its usual situation.;); Mr. A. Burns has a cast, showing an in-
stance of the right carotid crossing the trachea, two inches and a quarter,
above the top of the sternum. §
The trachea, which is superficial above, becomes more and more
deeply situated below, where the front of it is sometimes more than an
inch from the integuments. So very moveable is it likewise, that, if care
be not taken, the surgeon, as he is attempting to cut into it, may push it
towards the side of the neck, and the knife injure the common carotid
artery.
* Enlargements of the tonsils and tongue can never require tracheotomy or laryngo-
tomy, as diseased tonsils can be removed, and the enormous swelling of the tongue from
inflammation may be quickly reduced by making two or three free incisions along its
dorsum.
f Dr. Burgess, in Dublin Hospital Reports, vol. xxxi. p. 379. — Hargrave's Operative
Surgery, p. 328. In University College Hospital, tracheotomy has been performed in
several instances of this kind; but, generally, without success. One or ^two children
under me recovered under the free use of calomel.
| Nouveaux Siemens de Med. Operatoire, torn. ii. p. 209. For a description of
some anomalies of the arteries in this part of the body, the reader is referred to Tiede-
mann's Tabulae Arteriarum ; but a more complete account of the varieties in the origins
and course of arteries, I hope, will soon be laid before the public by my friend and col-
league Mr. Quain, whose collection of preparations, illustrative of this subject, so inter-
esting to the practical surgeon, is, I believe, the best in England.
§ See Dublin Journ. of Med. Science, vol. iv. p. 111.
TRACHEOTOMY. *739
TRACHEOTOMY.
The head is to be kept backward, with pillows placed under the sca-
pulae. The surgeon is to be on the patient's right side, in order that he
may with his left hand feel the larynx, and with his right more conve-
niently make the incision from above downwards in the mesial line of the
neck. The precise situation of the cricoid cartilage having been ascer-
tained, an incision is to be made through the integuments and superficial
fascia, from just below the transverse slip of the thyroid gland downwards
to the extent of at least two inches and a half, or to a point a little above
the first bone of the sternum. In children, the wound should not extend
so far down. The operator is then to cut between the two sets of sterno-
hyoid and thyroid muscles, till he comes to the deep cervical fascia, which
is next to be freely divided, and the front of the trachea itself exposed.
The sterno-thyroid muscles are then to be pushed a little aside, and the
trachea is to be prevented, by the pressure of the surgeon's left fore-
finger, from suddenly shifting its place, while he cautiously makes an
opening in the trachea towards the lower end of the external wound,
with a sharp-pointed scalpel, with its edge turned upwards, and the point
directed by the nail of the same finger. Frequently, when respiration is
carried on with difficulty, and the patient struggles, the completion of the
latter object is attended with more difficulty than the inexperienced
might expect ; so rapid and convulsive, as it were, are the motions of the
trachea. In a child, indeed, the difficulty of the operation is great, not
merely from these causes, but the struggles of so young a subject, the
depth of the trachea from the fat in the neck, and the small diameter of
the trachea itself. Hence the plan, now usually followed, of drawing
forward the trachea of a child with a tenaculum, in order to make an
incision in it, as originally suggested by Dr. James Murray, and particu-
larly recommended by Mr. Carmichael, I consider a great improvement
of this operation. A puncture, or small incision, having been made in
the tube, it is to be enlarged to the requisite extent by cutting from
below upwards, either with the same scalpel, or a curved probe-pointed
bistoury. The knife must not be carried to the right or left, in order to
avoid the risk of wounding the carotid artery ; and never too near the
first bone of the sternum, a deviation from which rule might endanger
the left subclavian vein, and, in children, even the arteria innominata.
If the bleeding from the plexus of thyroid veins were to be copious,
some of them might require ligatures, previously to the trachea being
opened, because the blood would otherwise insinuate itself into that tube,
and seriously increase the patient's distress. In general, however, the
venous hemorrhage will soon stop of itself, and the surgeon can then
safely proceed to open the trachea. However,, if the case admitted of
no delay, either the veins must be tied, or, what seems preferable, the
trachea opened at once, and the patient directly afterwards placed on his
side. Were there a middle inferior thyroid artery ascending over the
front of the trachea, it would almost certainly be divided ; and£ in this
event, it should be immediately tied.
Whether tracheotomy be performed to enable the patient to breathe,
or for the extraction of foreign bodies, it is advisable to make rather a
free opening in it; because, in the first class of cases, the cannula *
* The ingenious cannula, described by Mr. Wood in the Med. Chirg. Trans., deserves
attention ; and so do those of M. Bretonneau. Every surgical practitioner should have a
3B 2
740 OPERATIONS.
introduced into the trachea should be of ample diameter ; and, in the
second, nothing will so materially facilitate the passage of the extraneous
substance outward as an incision of proper extent. Frequently, when the
sides of the wound are separated, the foreign body is propelled out with
the breath, and, if this does not happen, instruments must be gently in-
troduced, and the attempt made to extract it : here a free opening is
absolutely indispensable. Jn many examples, the foreign body will be
found not towards the bronchi, but the larynx. If not easily detected,
the surgeon should not irritate the lining of the tube too much by the
repeated introduction of the forceps : various cases prove, that the foreign
body will often be discharged spontaneously after a little while.
LARYNGOTOMY.
The patient's head having been thrown back to render the pomum
Adami prominent, an incision is to be made through the skin and super-
ficial fascia, beginning over the thyroid cartilage, and extending down
to the inferior border of the cricoid cartilage, or a little lower. While
the edges of this wound are held apart, the surgeon proceeds to make an
incision in the same direction, precisely in the interval between the two
sets of sterno-thyroid and crico-thyroid muscles. The crico-thyroid
membrane will thus be exposed. The surgeon is now to try whether he
can feel the pulsation of the small artery, sometimes named the crico-
thyroid, and, if he can, the opening in the membrane should be made
above or below it in a perpendicular direction, with the edge turned away
from the vessel. In most cases, however, the cut should be directed to-
wards the cricoid cartilage, because the small artery, referred to, generally
runs along the lower edge of the thyroid cartilage.
When the purpose of the operation is merely to let a tube be intro-
duced to enable the patient to breathe, a transverse incision in the crico-
thyroid membrane will suffice ; but when the removal of a foreign body
from the larynx is the object, the incision should be made according to
the foregoing description, and its edges be -separated to let the extraneous
substance escape with the breath, or be removed with the forceps.
Writers, who give the preference to laryngotomy, offer the following
considerations in its favour: the only parts cut are the skin, cellular
tissue, cervical fascia, and crico-thyroid membrane; the little risk of
hemorrhage, — a few small veins, and the crico-thyroid artery, being the
only vessels exposed to the knife ; and the greater facility with which the
larynx is fixed, than the trachea, which is also more deeply situated.
As to the question, which operation is most suited to the objects in
view, Bichat endeavours to prove, that laryngotomy always answers as
well as, and sometimes better than, tracheotomy. If the design were
merely to make an opening for the air, one situation, he argues, would
set of three tracheotomy tubes of different sizes : they should be curved, and furnished with
rings, and a rim around their outer end. It is important that they should gradually increase
in breadth from the extremity, which is introduced into the trachea to the rim, because,
with this conical shape, they are adapted to fill and distend the incision in the trachea, so
as to hinder blood, &c. from entering the trachea. In the infirmary of the Fleet Prison,
I lately lost a patient, on whom I performed tracheotomy, from not being able at the
moment to procure any but a cannula of wrong construction. Mr. Lawrence, instead
of the use of a cannula, is in favour of removing a slip of the edge of the wound in the
trachea ; but this is objected to by Velpeau, as likely to cause, after the opening is finally
healed, an irremediable diminution in the diameter of the trachea. Elem. de Mod.
Op^ratoire, torn, ii. p. 214,
F
PARACENTESIS THORACIS. 741
do as well as the other ; but if the extraction of a foreign body from the
rima-glottidis, or ventricles of the larynx, were required, laryngotomy would
be the most advantageous.
While Ferrand was surgeon of the Hotel Dieu, a man was brought to
it with urgent symptoms of suffocation, caused by a stone that had fallen
into the glottis. Tracheotomy was performed, but merely a little blood
and mucus was discharged. The patient died, and, on examination, a
triangular stone was found, two angles of which were lodged in the ven-
tricles of the larynx, while the other projected at the glottis. In this
example, laryngotomy would have saved the man's life. When a foreign
body in the trachea is loose, it is mostly at the upper part of it ; but, if it
happen to be fixed, and lower down, the advocates for laryngotomy assert,
that it may even then be readily extracted, by extending the cut through
the cricoid cartilage, and using a pair of curved forceps. Notwithstanding
these arguments, tracheotomy is usually preferred for the extraction of
foreign bodies, and, as I think, justly, because laryngotomy will not give
the advantage of the free and well-placed opening obtained by trache-
otomy.
Whatever differences of opinion may be entertained, respecting the
advantages of laryngotomy for foreign bodies in the larynx, none can exist
about the preference which should be given to tracheotomy where re-
spiration is dangerously obstructed by the pressure of some kinds of
tumours on the trachea ; by that of a large foreign body in the cesopha-
1s ; or by the swelling sometimes following severe wounds of the throat,
also agree with Flajani, in disapproving of laryngotomy in croup, be-
cause the wound should be made away from the principal seat of inflam-
mation.*
Surgeons should remember, that in old persons the cartilages of the
larynx are frequently ossified, and difficulty would then be experienced in
dividing them ; and also, that the thyroid cartilage cannot be slit open
in any person without risk of injuring the chorda? vocales.
•
PARACENTESIS THORACIS,
Or, the operation of making an opening into an chest, for the purpose of
discharging blood, pus, a serous or sero-purulent fluid, or air, confined in
the cavity of the pleura, cannot frequently be undertaken with much
prospect of benefit.
Whether blood be effused from an intercostal artery, or from more
deeply seated vessels ; whether the bleeding arise from a wound, or a
spontaneous rupture of vessels ; and whether it be arterial or venous ;
the cessation of the hemorrhage can only be brought about through the
formation of coagula, and pressure. But if, instead of remaining confined
in the chest, the blood passes out through an opening in the parietes of
the chest, coagula will be less likely to form, and the hemorrhage in all
probability only terminate with the death of the patient. Hence, instead
of dilating wounds of the chest, as the old surgeons sometimes did, the
moderns make it a rule to close them. If the quantity of effused blood
be moderate, it is usually absorbed ; and if very copious, the stoppage
of the internal hemorrhage can only be accomplished on the principles
above explained, assisted by antiphlogistic treatment. It is manifest,
then, that the making of any incision or puncture into the chest can never
be advisable for a recent extravasation of blood occasioned by a penetrat-
* Flajaui, Collexioni d'Osservazioni e lliflessioni di Chirurgia, t. iii. p. 241.
3 B 3
742 OPERATIONS.
ing wound. At a later period, however, when the vessels have had time
to become obliterated, if nature should not prove competent of herself to
remove the effused blood, and the symptoms caused by its presence were
urgent, it might then be necessary, and only under such circumstances, to
make an opening for its discharge.*
With regard to a collection of pus in the chest, or the case termed em-
pyema, paracentesis often fails to be of service, because in general the
empyema is not the principal, nor the original, disease. If the cause
were a tuberculated lung, combined with vomica, or any other incurable
organic disease of the lung ; or any serious disease of the pleura, still
going on ; the making of an opening into the chest would only hasten the
patient's death. On the contrary, if the suppuration were the conse-
quence of simple inflammation of the lungs, the operation, as M. Velpeau
observes, might be proper, if there were nothing in the general condition
of the patient prohibitory of it.
As for a, collection of serous fluid, this is another case in which an open-
ing has sometimes been made, though mostly without success, because
hydrothorax is rarely the sole or original disease. It is also remarked
by Velpeau, that, in this disease, when the fluid has been discharged,
the lung is incapable of expanding, and the whole sac of the pleura be-
comes filled with air. Still, if it were not certain, that hydrothorax de-
pended upon some incurable organic disease, and the quantity of fluid
dangerously obstructed the breathing, the performance of paracentesis
would be justified by the results of certain cases on record.
Collections of air within the pleura may arise from wounds of the air-
cells, from decomposition of fluids, as is conjectured, or, from the simple
exhalation of gas from the capillary vessels. Although cases of this de-
scription may be attended with circumstances vindicating the puncture
of the pleura, the result is generally only temporary relief, because
pneumo-thorax is usually combined with organic disease in the chest,
effusion of blood, or empyema. If the air in the pleura were in moderate
quantity, and the cause a wound of the air-cells, were the patient to live
a day or two, the breach in the lungs would be closed by the adhesive
inflammation; no more air would escape from it; and what had been
already effused in the pleura would gradually be absorbed.
Whether the effusion in the chest be a serous fluid, or pus, the case will
present certain symptoms common both to hydrothorax and empyema ;
especially short and difficult respiration, the lungs of the affected
side being compressed by the collection of surrounding fluid. In both
cases, also, expiration is even more difficult than inspiration, on account
of the weight of the fluid, which strongly opposes the elevation of the
diaphragm. Sometimes, when the patient moves in bed, he distinctly feels
the undulation. If the fluid be contained in only one cavity of the chest,
he cannot lie on the opposite side, because the fluid compresses the other
lung. The ribs on the affected side are more arched than is natural,
because the fluid resists their depression. When no symptoms of sup-
puration have occurred, the case may be suspected to be hydrothorax.
The face, the integuments of the chest, and lower extremities, are fre-
quently cedematous, and sometimes also the arm on the side affected,
especially when the quantity of fluid is copious. Sometimes dropsy of
the chest is joined with the same general affection of the whole body.
All these symptoms, however, may indicate empyema, when preceded by
* A. L. F. Velpeau, Nouvcaux Elemens de Med. Op6ratoire, torn. ii. p. 250.
REMOVAL OF A DISEASED BREAST. 743
the usual signs of inflammation and suppuration in the chest. When
symptoms of acute peripneumony have taken place, and when rigors have
occurred at the termination of the inflammatory fever, just before the
commencement of the above kind of symptoms, it is rational to infer
that the case is empyema. I remember a man in St. Bartholomew's Hos-
pital, whose heart was pushed completely to the right side of the chest,
by an abscess in the left bag of the pleura. The preceding inflammation
in the chest, the occurrence of rigors, the great difficulty of breathing,
and the palpitation of the heart, quite on the right side of the sternum,
made the nature of the case sufficiently evident. When the left cavity of
the chest was opened after death, an enormous collection of matter was
discovered. Of late, the writings of Avenbrugger, Corvisart, Laennec,
and Piorry, have thrown great light on the mode of ascertaining, not only
the presence of fluids in the chest, but their precise situation. For ob-
taining correct information on these points, the stethoscope and percussion
should be resorted to. The most eligible place for the operation is between
the fifth and sixth, or the sixth and seventh true ribs, at the point just in
front of the indigitations of the serratus magnus, or midway between the
anterior and lateral parts of the chest. In France, paracentesis thoracis is
usually performed between the third and fourth ribs on the left side, and
between the fourth and fifth on the right. An apprehension of wounding
the liver and diaphragm by operating lower down is the chief reason for
this practice. The French aim at making the incision at the junction of
the posterior third with the two anterior thirds of the pectoral region.
Here the opening can be made just in front of the latissimus dorsi, between
the indigitations of the serratus magnus, and those of the external oblique
muscle ; and here the intercostal artery is still in the subcostal groove,
not having yet divided into two branches.
An incision, two inches and a half long, should be made through the in-
teguments, which are first to be drawn to one side, if it be intended to
close the wound immediately after the operation. The intercostal muscles
are next to be cautiously divided, and, as soon as the pleura costalis is
exposed, a small puncture is to be carefully made in it. In dividing the
intercostal muscles the edge of the knife should be kept close to the
upper edge of the lower rib, in order to avoid all risk of wounding the
intercostal artery, which runs for some way in the groove in the lower
edge of the upper rib.
In emphysema, a small puncture will suffice ; in hydrothorax it may
be somewhat larger ; and, in empyema, the matter must have an opening
of sufficient size to allow the fluid to escape freely through a cannula,
which, both in this disease and hydrothorax, may be furnished with a
stopper, which is to be withdrawn as often as it is deemed advisable to
give issue to the fluid in the pleura.
REMOVAL OF A DISEASED BREAST, AND TUMOURS IN GENERAL.
The manner of removing encysted tumours has been already described.
When the breast is affected with any disease of an incurable nature, the
whole of the diseased parts may sometimes be removed with a Knife, the
wound healed, and the patient's life prolonged, or freed from great suffer-
ing and annoyance. The circumstances, under which the operation should
be undertaken, are noticed in the remarks on cancer.
If the disease be a scirrhus, some particularity in the mode of operating
is requisite. In this case, the surgeon, instead of merely removing parts
which are palpably and visibly diseased, should make it a rule to take
3 B 4
744 OPERATIONS.
away a certain quantity of the substance in the immediate circumference
of the disease. Every experienced man is fully aware of the great pro-
pensity of the skin to be affected, and the frequent extension of white or
yellowish morbid bands into the surrounding adipose cellular tissue.
These facts clearly show the propriety of making a free removal of the
skin, whenever it is in the least discoloured, puckered, adherent to the
swelling, or in any way altered, and of taking away a good deal of the fat,
in which scirrhous tumours are involved. On the contrary, if the disease
be a mere chronic growth, or swelling of the breast, not of a cancerous
nature, the removal of the skin is not necessary on this principle, though
it may be so on others, viz. the superfluous quantity of it, when the tu-
mour is very large, and the difficulty and tediousness of the proceedings
for the removal of such a swelling when an attempt is made to preserve
the whole of the integuments. When cancer recurs, the integument is
the first part in which it usually makes its appearance, and the skin of
the nipple in particular. Hence, many surgeons always make it a rule
to remove the latter part, when it is judged proper to take away any
of the integuments. As Sir Astley Cooper has observed, it is not
sufficient to remove the tumour, but the gland, from the nipple to the
tumour, must be removed, and the surrounding parts, to some extent,
taken away.*
The patient is frequently operated upon in the sitting posture, but
the recumbent has advantages, particularly when any gland in the axilla
is to be taken away, or the patient is likely to faint. If the sitting pos-
ture be chosen, the pectoral muscle may be rendered tense by an assistant
keeping the arm back, which state of the muscle will facilitate the dis-
section of the tumour from its surface.
When the case is not of a malignant character, and no part of the inte-
guments is to be removed, a straight incision may be made through them ;
the tumour is to be regularly dissected on every side from the circumja-
cent parts ; and, lastly, its base is to be detached, from above downward,
till the whole is separated.
If the outer incision has been made more or less transversely, the
lower half of the swelling should be separated from its surrounding con-
nections, before the dissection of the upper portion is begun ; by which
means the surgeon will not be incommoded by the blood falling into the
lower part of the wound, before the detachment of the adjacent portion
of the tumour is effected. As soon as the lower half of the circumference
of the swelling is separated from its connections, the surgeon is to under-
take the dissection of the upper half. Lastly, he is to detach its base
from the subjacent textures.
Such are the modes of removing all simple tumours, which are not of a
malignant nature, nor of immense size.
When the tumour is malignant, and adherent to the skin and pectoral
muscle, the operator is to remove at least an inch or two of the fat on
every side of the disease. The portion of the skin, intended to be taken
away, must be included in two semicircular incisions, which meet thus ()
at their extremities ; and when the base of the tumour is to be detached,
the surface of the pectoral muscle, wherever it is adherent to the tumour,
is also to be removed. The advantage of making the incision, in the pre-
ceding manner, obviously consists in enabling the surgeon to bring the
* Lectures, vol. ii. p. 1 99.
REMOVAL OF A DISEASED BREAST. 745
edges of the wound together after the operation, so as to form a straight
line, and admit of union by the first intention.
The mere magnitude of a tumour frequently renders it highly judicious
to take away a portion of the skin : if some were not removed, the dis-
section would be tedious ; and, after the operation, the loose skin would
He in folds, and form, as it were, a large pouch for the lodgment of
matter.
In the extirpation of a diseased breast, the direction of the external
incision must, in some measure, be determined by the shape of the
tumour : Desault thought there were advantages in cutting as much as
possible transversely, when circumstances would allow it ; and he believed
that, as the integuments were more yielding upwards or downwards,
than in a cross direction, especially near the sternum, the transverse
wound could be more expeditiously united. These advantages seemed to
him of higher importance, than the ready escape of matter at the depend-
ing angle of the wound; the reason generally assigned in favour of the
perpendicular direction of the incision. At the present day, these argu-
ments do not sway surgeons to any great extent ; but the direction of the
wound is usually made obliquely downwards and forwards, and the base
of the tumour cut from the pectoral muscle in a similar direction, the
detachment being first accomplished at the upper and outer part of the
wound, and then regularly extended to its lower and anterior end.
The tumour having been removed, the surgeon should examine the
interior of the wound, in order to ascertain that no indurated part is left
behind ; and if any hardness be detected, it ought also to be removed.
He should also examine the surface of every scirrhous tumour, imme-
diately it is taken out, and see whether any of the white bands, shooting
into the surrounding fat, have been divided ; for, in this case, some por-
tion of those bands must have been left behind, and ought to be taken
away. Their situation may be known, by considering the position of the
tumour before the operation.
When a tumour of the breast has been entirely detached, and the chief
bleeding vessels tied, which are usually at the outer part of the incision,
the arm is to be brought forward. Then, if there be any diseased gland
in the axilla, the patient should lie down on the opposite side, and the
arm be raised, so that the arm-pit may be completely exposed to the
light. For this purpose, the first wound, if the outer and upper end of it
be near enough to the axilla, may be extended over the gland about to
be taken away ; and the latter part, having been separated from its sur-
rounding connections, may either be cautiously dissected from the subja-
cent parts, or, its base tied with a bit of strong silk. The latter method
has been adopted by some distinguished operators, in consequence of the
brisk hemorrhage which takes place from the short arterial branch distri-
buted to the gland from the thoracic. As the axillary vein has occa-
sionally been wounded in dissecting a diseased gland out of the axilla, and
this by skilful and experienced operators, the plan, now mentioned, which
was generally adopted at St. Bartholomew's by the late Sir Charley Blicke,
deserves to be remembered.
Mr. Listen lays down one excellent rule in operations for the removal
of tumours. In all cases (says he), the incisions ought to commence at
the point where the principal vessels enter ; in this manner, they are
divided at the outset,, can be readily secured by ligature, or by the
fingers of an assistant, and the dissection is continued without risk of
further hemorrhage. If the opposite course be pursued, the vessels will
746 OPERATIONS.
be divided several times during the operation, numerous ligatures will be
required, and a considerable loss of blood take place.*
In the removal of tumours in general, one rule is, to make a free
external incision, which will materially facilitate and expedite the sub-
sequent dissection, and save the patient from the pain and other ill
consequences of a tedious and protracted operation. For the same reason,
if a fascia cover the tumour, it should be freely divided, so as to make, as
it were, an outlet for the morbid mass.
In dissecting out tumours, another good general maxim is, to cut as
much as possible in the direction of the muscular fibres.
PARACENTESIS ABDOMINIS.
This operation consists in making an opening into the cavity of the
peritoneum, for the purpose of discharging the fluid collected there in
dropsical cases. The proper instrument for this is a trocar, with a cannula
through which the fluid can readily escape.
Not many years ago, it was the invariable practice to introduce the
instrument at the central point of a line, drawn from the umbilicus to the
anterior superior spinous process of the os ilium, and on the left side, in
order to avoid all risk of injuring the liver. Modern practitioners usually
prefer making the puncture in the linea alba, for several weighty reasons.
The first is, that, in the other method, no surgeon can be sure of intro-
ducing the instrument in the exact situation of the linea semilunaris, and
consequently may unnecessarily wound the thick- muscular parietes of
the abdomen, instead of merely a thin tendinous part. Another reason
is, that, in the attempt to tap in the linea semilunaris, the epigastric
artery has sometimes been wounded by surgeons of high repute. In
dropsical cases, the rectus muscle is frequently much broader than in a
healthy subject ; and, as it always yields to the distension of the fluid in
a greater proportion than the lateral layers of muscles, the above mea-
surement is not unlikely to cause the wound to be made near the course
of the epigastric artery.
When the operation is to be performed in the linea alba, the instru-
ment should be introduced about two or three inches below the navel;
or, as is usually directed, at the mid point between the umbilicus and the
pubes. As soon as the trocar meets with no further resistance, it is
not to be pushed more deeply, without any object, and with a possibility
of injuring the viscera. The stilet is now to be withdrawn, the cannula
pressed a little further into the opening, and the fluid discharged
through it.
In consequence of the sudden removal of the pressure of the fluid from
the viscera and diaphragm, patients are disposed to swoon, and even
become affected with dangerous symptoms. In order to prevent these
unpleasant occurrences, the abdomen is to be compressed with a bandage
or belt, during the discharge of the fluid, and afterwards covered with a
flannel compress and roller.
In cases of ovarial dropsy, the tumour generally inclines more towards
one side of the abdomen than the other, so that the puncture cannot
always be made with safety in the linea alba. Here the custom is to
make the puncture at the point where the swelling is most prominent,
due care being taken, however, to avoid the epigastric artery. If, hovv-
* See Listen's Elem. of Surgery, part 1. p. 222.
REMOVAL OF A DISEASED TESTIS. 74-7
ever, the ovarial cyst be of great size, it will frequently admit of a trocar
being introduced into it through the linea alba with perfect safety. I have
tapped many ovarial cysts in both ways.
REMOVAL OF A DISEASED TESTIS.
In considering the propriety of castration, nothing can be wiser than
the general maxim, not to employ the knife, if there be any traces of
disease in the viscera : it may be inferred, that the operation will not
answer when the patient has frequent attacks of colic pains, a pallid
leaden-coloured countenance, indigestion, loss of appetite, frequent
purging, a hard belly, or any distinct and separate indurations about the
abdomen. In cases of medullary cancer of the testis, in consequence of
the natural course of the lymphatics of this organ to the lumbar glands,
the absorbent glands in the course of the external iliac and common iliac
arteries, and near the aorta, are frequently implicated. Sometimes these
form a tumour as large as a child's head, and perceptible with the hand,
especially when the abdominal muscles are relaxed. The kidneys also
often partake in the disease ; and hence, the prudence of always making
careful inquiry into the state of those organs, before venturing to propose
the operation. It is to be recollected, however, that the weight of the
enlarged testis frequently produces in the loins extremely painful sensa-
tions, which might be mistaken for symptoms of diseased kidneys, if the
difference were not indicated by the pain always diminishing, when the
scrotum is well supported in a bag-truss, or the patient keeps himself in
the recumbent posture. In such cases, the state of the urinary secretion
would also afford useful light. If the scrotum be diseased, there may be
enlarged glands in the groin, which are highly unfavourable whenever
the disease of the testis consists of any species of tumour characterised
by malignancy and a disposition to extend to other organs.
Attention should be paid to the state of the thoracic viscera; for ex-
perience proves, that various complaints of the chest frequently precede
or follow the origin of medullary cancer of the testis, and seem to have a
connection with it. In fact, in such cases, the structure of the lungs is
often found interspersed with pulpy, medullary tumours. Hence, when
the patient has a troublesome dry cough, shortness of breath, and irre-
gular pain in the chest, and especially when these symptoms attend a
medullary tumour of the testis, the operation is unadvisable. The
success of castration materially depends upon the state of the spermatic
cord ; for here it is a point of the first-rate importance to remove every
particle of the disease — every thing which appears unsound and indu-
rated. This can easily be accomplished when the disease is confined to
the testis and epididymis, the cord being unaffected. But when, as often
happens, the latter part is in the same state as the testis, hardened and
enlarged, the operation is improper. If the disease of the cord, however,
were not to extend quite up to the ring, and its upper portion were
still sound, it would yet be practicable to remove all the parts affected
by cutting the cord through where it is quite healthy, and the operation
be justifiable.* But it is not to be denied that, in such a case, the
* A few years ago, I removed a very large testis for medullary cancer; in the portion
of the spermatic cord taken away were small particles, not larger than millet seeds, appa-
rently medullary. Yet the patient had had no return of the disease four years after the
operation. A section of the testis, with the cord, is in the possession of Sir Astley
Cooper.
74-8 OPERATIONS.
event is subject to great uncertainty, not so much on account of the
commonly feared danger of cutting the cord through near the ring, as
because the extension of the disease up the cord is always a ground for
apprehending, that the complaint will return either in that part, or in
the loins.
However, unless the case be medullary cancer, or fungus haernatodes,
it is only when the cord is truly scirrhous, that is to say, thickened, har-
dened, knotty, and painful, that it becomes an impediment to the oper-
ation ; and, when its enlargement is owing merely to a varicose dilatation
of the veins, or an effusion of fluid in the cellular tissue of the part, the
circumstance should not prohibit the use of the knife. Both these last
states of the spermatic cord may be distinguished from the scirrhous
alteration of the cord by their greater softness, and their diminishing
when the patient keeps himself in a horizontal position.
The circumstance of the scrotum being diseased is sometimes deemed
nearly as unfavourable to the success of the operation, as disease of the
cord *, on account of the distemper being likely to recur in the skin.
However, there is this difference, that we always have it in our power to
cut away every part of the scrotum which may be affected, while, in the
case of scirrhous affection of the cord, it is sometimes impossible to follow
the disorder to its highest point.
Castration is one of the most simple, and yet one of the most painful,
operations in surgery, especially when practised according to the old
method, in which it was the custom to include in the ligature all the
vessels and nerves of the spermatic cord. At the moment of doing this,
the patient was put to excruciating torture ; such suffering, indeed, as
few could endure without complaint, however great their fortitude.-]-
The hair having been removed from the pubes and scrotum, the first
thing is the incision through the integuments : it should commence a little
above the abdominal ring, and be continued down nearly to the bottom of
the scrotum. Two advantages result from extending the cut down to
this point : lodgments of matter, which often seriously retard the cure,
will be prevented ; and the testicle can be more easily taken out. The
first incision through the integuments will common!}' divide the external
pudic artery, which arises from the crural ; and if it bleed profusely, the
best plan is to secure it at once with a small silk ligature, the ends of
which may be cut short, in the manner practised by M. Roux. J
The second object is to cut through the sheath of the cord, and
separate the latter part, by making a short incision on each side of it
at the point where it is intended to divide it. When its detachment
is sufficiently completed to allow it to be taken hold of, and lifted
up, between the thumb and forefinger of the operator's left hand, this
second step of the operation is accomplished. It is a business which
should never be done in a careless way ; for a portion of omentum and a
hernial sac may put on somewhat the appearance of thickened cellular
* Sir C. Bell, Operative Surgery, vol. i. p. 223.
f Le Dran appears to have entertained a just aversion to this painful and unnecessary
plan : " Of the several parts of the cord (says he), none but the artery will bleed ; why
then should the cremaster muscle, the vas defcrens, and the nerve be tied with it ? VVo
are sensible, that convulsive motions have ensued from this method of making the liga-
ture upon them all." Operations in Surgery, p. 147. transl. by Gataker, edit. 2d.
t See Sketches of the Medical Schools of 1'aris, by John G. Crosse, p. 141. 8vo. Lond.
1815.
REMOVAL OF A DISEASED TESTIS. 74-9
tissue, and the protruded part be liable to injury, or the hernial sac might
even be cut through at the time of dividing the cord.*
The third object is the division of the cord ; in doing which, the inci-
sion should always be made through it higher than the extent of the
disease ; for, if this rule be neglected, the patient will derive no effectual
relief from the operation, and the wound will either not heal up at all,
or, if it heal at first, will break out again. Aware of the inutility and
pain of including the vas deferens in the ligature, and of the facility with
which this vessel can be distinguished at the back of the cord by reason
of its firm feel, some operators pass a ligature between it and the rest of
the cord, over the front of which the knot is made, and they then cut
through the cord below the ligature. The agony, however, created by
the inclusion of all the spermatic nerves, is not only severe, but absolutely
unnecessary in a proceeding, the sole aim of which should be the secu-
rity of the patient from hemorrhage. A far better plan is to apply no
ligature in any way to the spermatic cord previously to its division; but
the surgeon should hold the part between his left thumb and fore-finger,
just above the point where it is to be divided, and, as soon as it has been
cut through, the spermatic artery, and that of the vas deferens, should
be taken up with a tenaculum and tied. Desault's method consisted in
dividing the cord in the preceding manner, and then holding the upper
end of it between the thumb and fore-finger of his left hand, while, with
the forceps or tenaculum in his right hand, he immediately proceeded to
take up the mouths of the spermatic arteries, and afterwards continued
the dissection of the diseased testis from the scrotum.f
The fear of a retraction of the remnant of the cord into the inguinal
canal before the arteries have been secured, has had a great deal of in-
fluence over the conduct of many surgeons in this part of the operation ;
and their alarm has been increased by Mr. B. Bell's having seen the
thing happen twice in his practice, when both the patients were lost by
hemorrhage. But, had the operator, in these unfortunate examples,
been careful to take firm hold of the upper portion of the cord, before
he ventured to divide it, the retraction could not have happened ; and,
when it did happen in consequence of this neglect, had he had discern-
ment enough to know what ought then to have been done, neither of
his patients would have fallen a victim to bleeding. In short, had he
considered the course which the cord takes obliquely upward and out-
ward, it would have been easy for him to have followed the bleeding part
with perfect safety, within the inguinal canal, even to the origin of the
cremaster muscle.J The retraction of the upper portion of the cord
within the ring must be more likely to happen, when the extension of the
disease upwards obliges the surgeon to divide the part higher up than
will well allow the retraction to be securely prevented by the thumb and
fore-finger of the left hand. In cases of this description, it has been pro-
posed to avert the accident, by separating the cord into two fasciculi,
* " After the operation was completed, and the wound dressed, the pati^jt being
seized with a fit of coughing, to the astonishment and dismay of the surgeon, the dress-
ings were forced off by the protrusion of several convolutions of small intestines." Sir
Astley Cooper once removed a diseased testis, which was accompanied by a hernia. The
bowels were first reduced, and the cord was then separated by dissection from the back
portion of the sac. In Guy's Hospital, he also removed a diseased testis, to which the
omentum adhered. Obs. on the Structure, &c. of the Testis, p. 164.
f CEuvres Chir. de Desault, par Bichat, torn. ii. p. 451.
j See Operative Surgery, by C. Bell, vol. i. p. 229.
750 OPERATIONS.
and, with the aid of a needle, putting a double ligature betwixt them,
before the part is cut through. The design of this ligature is to draw
down the cord, while the surgeon is taking up the mouths of the vessels ;
or, if he cannot thus stop the hemorrhage, one portion of the double liga-
ture is recommended to be tied over the front, and the other over the
posterior part, of the cord.* Another plan consists in raising the exposed
cord by passing under it the left fore-finger, and then, instead of cutting
the part through at once, leaving the posterior third of it undivided.
The first incision will divide the principal artery and its branches, which
are to be taken up singly, while the weight of the testis hinders the part
from retracting. Then the vas differens is to be cut, and, if its artery
be not large enough to require a ligature, the rest of the cord is to be
divided. I have usually directed the end of the cord to be taken hold of
with a tenaculum, until its vessels have been secured.
That part of the operation, which has for its object the taking of the
diseased testicle out of the scrotum, whether it precede or follow the
division of the spermatic cord, is extremely simple. It merely consists
in dividing the loose cellular tissue which connects the testicle with the
inside of the scrotum ; and in performing this easy task, it is proper to
incline the edge of the knife towards the tumour, which, after the division
of the cord, may be considered as dead, and destitute of sensation.
When the diseased testicle is much enlarged, it is advantageous to
remove a part of the distended scrotum, because a redundant quantity of
loose skin would otherwise make it difficult to put the edges of incision
evenly together, and is apt to serve as a lodgment for matter.f The
manner of executing this object consists in including the portion of the
scrotum that is to be taken away in two elliptical incisions, the length
and interspace of which must be regulated by the magnitude of the swell-
ing. Then the spermatic cord having been divided, and the arteries
secured, the diseased organ is to be dissected out, the incisions being
extended on each side from the elliptical cuts already made.
Also when a part of the scrotum is ulcerated, thickened, or adherent
to the testis, two semilunar, or elliptical incisions are to be made, which
meet together above and below, and include the diseased part of the
skin, which is not to be separated from the swelling, but taken away
with it.
When the diseased testicle is of considerable size, it may lie so close
to the sound testicle and the penis, that, if attention be not paid to the
circumstance, and the knife be too freely used, both these parts may be
injured. Sometimes, a part of the tumour is close to the urethra, and,
without care, this passage might be wounded. Frequently the swelling
presses closely against the septum scroti, which is then liable to be
wounded, and the tunica vaginalis of the sound testicle opened ; an acci-
dent which may produce a good deal of inflammation, and therefore
ought to be attentively avoided. Former surgeons had great apprehen-
sion of wounding the septum scroti, and the common warning, vociferated
in the operation, used to be, "take care of the septum scroti :" but the
truth is, if it were not for the chance of laying open the opposite tunica
vaginalis and doing mischief to the sound testicle at the same time, a
wound of that part, which is merely condensed cellular tissue, would be
* Sir C. Bell, vbl. cit. pp. 225. 228.
t See Sharp's Treatise of the Operations, p, 51. edit. 3. ; Bertrandi, Traitd des
Operations de Chirurgie, p. 209. Paris, 1784.
REMOVAL OF A DISEASED TESTIS. 751
of trivial importance. There is no surer way of avoiding the foregoing
inconveniences, than being particularly attentive, in the dissection of the
diseased testis out of the scrotum, always to incline the edge of the scalpel
towards the swelling.
The most troublesome bleeding after castration proceeds, not from the
spermatic artery, but from vessels within the scrotum, which quickly
retract amongst the loose cellular tissue ; and though for a time they
may cease to bleed, they often begin to pour out blood again, directly the
force of the circulation returns. The artery of the septum scroti, which,
in cases of diseased testicles, is often of greater size than the spermatic
artery itself*, or that of the vas deferens, should be sought for and tied.
In short, as Sir Astley Cooper advises, the surgeon should " secure
every vessel of the scrotum which continues to bleed, or which has been
observed to bleed freely during the operation." f The ligatures, here
used, should be made of common brown thread, or fine dentist's silk, and
cut short after their application, because the wound always suppurates
more or less, and the small fragments of thread or silk contained in it will
come away with the discharge, without the slightest inconvenience.
The operation being finished, the patient should be carried to bed, and
the part then merely covered with lint, wetted with cold water, till all
apprehension of bleeding has ceased. After this, the wound should be
more completely closed with two or three stitches and a few strips of
adhesive plaster. A compress of lint may be laid over each side of the
incision, and the whole supported with a T bandage. Union by the first
intention is here attempted under unfavourable circumstances ; for it is
difficult to maintain the edges of the wound in exact contact, and the
scrotum, deprived of the enlarged testis, forms a cavity, in which it is
hardly possible to hinder suppuration. Some French stregeons, therefore,
deny the advantage of the above mode of dressing, and pursue the old
plan of filling the scrotum with charpie, and letting the parts suppurate
and granulate. J It is true, complete union by the first intention is seldom
or never accomplished, yet, by attempting it, the wound is much dimi-
nished, and the cure is rarely delayed later than three or four weeks ;
whereas the wound, when stuffed with lint, is usually not healed in less
than seven or eight weeks. §
Sometimes, after the patient has been put to bed, hemorrhage takes
place ; and frequently, when the wound is opened, no particular bleeding
point can be discovered. I have generally found the application of cold
water to the scrotum, by means of wet linen, placed over the adhesive
plaster, and making the T bandage somewhat tighter, the best way of
checking the bleeding. Should this plan be unavailing, however, the
dressings must be taken off, and the vessels looked for, and tied. Such
hemorrhage from the arteries of the scrotum may proceed to a serious
degree, without being suspected ; for the blood sometimes flows out of
the lower angle of the wound into his bed, while the outward dressings
are perfectly dry and unstained.
When severe inflammation follows castration, venesection, leecHls, and
other antiphlogistic remedies are indicated ; while much disorder of the
nervous system, great pain in the wound, spasms, restlessness, &c. will
* Flajani, Collezione d'Osserv, torn. ii. p. 151.
f See Obs. on the Structure and Diseases of the Testis, p. 163. 4to. Lond. 1830.
| Roux, Parallele de la Chirurgie Angloise avec la Chirurgie Frar^oise, p. 120, &c.
8vo. Paris, 1815.
§ J. Green Crosse, Sketches of the Medical Schools of Paris, &c. p, 144.
752 OPERATIONS.
require opium and emollient poultices. Tetanus, retention of urine, con-
vulsions, incessant vomiting, tension and swelling of the belly, peritonitis,
abscesses in the course of the cord, delirium, and incurable fits of epi-
lepsy, were more common after castration in former times, when it was
the custom to include the whole of the spermatic cord in the ligature,
than they are are at the present day.
After the operation, the upper part of the spermatic cord occasionally
swells so considerably, that it becomes strangulated by the abdominal
ring, and vast suffering is the consequence ; a case which may require a
division of that aperture.*
AMPUTATION OF THE PENIS.
Cancer and mortification-]-, of the penis, are sometimes specified as
the two cases, for which this operation is required. That the first
disease is frequently a proper reason for amputating the penis, is un-
questionable ; but that mortification is so, every reflecting surgeon will
deny. The mortified part will separate, and the living surface cicatrise
afterwards, fully as well, as if the patient were to submit to a painful
operation. I am glad to have it in my power to adduce, in support of the
foregoing remark, the authority of Loder, who declares, that, in examples
of mortification, he would never undertake the operation. When the
gangrenous mischief, says he, is spreading, amputation will be of no use,
because it will not stop the disorder ; but if the mortification has ceased
to extend itself, the operation will be superfluous, as nature herself will
throw off the dead parts.J
When the case is a scirrhous, or cancerous disease, the prospect of
a perfect cure will greatly depend upon the testicles, skin about the
pubes, and glands in the groin, being free from induration. I have
seen this operation performed three times, and, in the first instance,
the disease had extended to the testicles and inguinal glands ; so that
though the patient got rid of the disease, situated on the penis, the dis-
order continued to increase in the groin and scrotum, until life was
exhausted.
As the serious mistake has sometimes happened, of amputating the
penis for a disease, which, on further examination, appeared to be of a
very simple and curable nature, surgeons cannot be too cautious in the
investigation of the circumstances of the complaint for which the opera-
tion is proposed. In particular, they must carefully distinguish the can-
cerous disease of the penis from the more common warty excrescence.
" I have seen (says Sir Charles Bell) a man just about to lose his penis,
* Bertrandi, Traite des Operations, p. 209. Instead of removing a diseased testis,
M. Maunoir tried the plan of exposing the cord and tying the spermatic artery ; but, as
he found it sometimes fail, he afterwards had recourse to the method of cutting the cord
completely through, after the artery and its branches had been secured. Another sug-
gestion is that of simply removing a portion of the vas deferens. The object of such
proceedings is to bring about the absorption of the diseased testis, but they are not yet
regarded as established practices ; and, I apprehend, that their frequent fail ure will hinder
them from being so.
f In mortification from paraphimosis, or other causes, the operation is recommended
both by Heister (Institut. Chir. 81 G.) and B. Bell (Syst. of Surgery, vol. i. p. 538.).
Richter deems the operation unnecessary for the separation of the sloughs ; but thinks
the knife may sometimes be requisite for making the end of the stump equal, when it
has healed with inequalities. However, beauty seems to me a subject here not worth
considering, at least, in a surgical point of view.
| Chir. Med. Beobachtungen, p. 79.
AMPUTATION OF THE PENIS. 753
on account of a combination of phimosis with these warty excrescences
from the glans, and which had burst through the prepuce with a very
malignant-like distortion. But the prepuce being freely cut open, the
luxuriant crop of harmless warty excrescences started forth." *
I It is certainly true, also, that the penis has been cut off, when the pre-
puce or integuments were the only diseased parts. According to the
investigations of M. Lisfranc, when cancer is situated in the body of the
penis, at its root, or even on the scrotum, it commences in the skin, and
the subjacent fibrous textures long impede its progress more deeply.
Hence, in many instances, the possibility of saving the organ by merely
removing the integuments.f What are commonly termed venereal warts,
are well described by Sir Charles Bell : they have a spreading, mushroom-
like top, and slender base ; and if the intermediate parts can be seen,
they retain their natural appearance. A tubercle, formed on some part
of the prepuce, is often the beginning of cancer of the penis ; it is at first,
as Sir Charles Bell remarks, an irregular warty excrescence, with a broad
base in the substance of the prepuce, or on the fraenum. In a more ad-
vanced and ulcerated stage, the sore is of a dark red colour, covered with
a sanious discharge ; its bottom is solid, and deep excavations, and irre-
gular cauliflower excrescences, present themselves. The neighbouring
skin, of a purple colour, indurated, swelled, and tuberculated, stands out
from the sore, while its irregular edge is turned inwards. The discharge
has a peculiar smell, being highly offensive; and when the urethra is
ulcerated, the urine gushes out from preternatural openings.;}:
Cancer may also commence upon] the glans, as happened in the first
case, in which I had an opportunity of seeing amputation of the penis
performed. Here also the disease usually begins in the form of a wart,
or small, not very troublesome, induration, which gradually changes into
a most painful ulcerated excrescence. Sometimes, as Richter informs
us, the greater part of the penis is covered with such excrescences, the
cancerous nature of which is particularly indicated by the deep extension
of their bases into the substance of the parts from which they grow, the
parts appearing for some depth to be converted into a similar hardened
mass to themselves. I have seen the whole glans, and part of the corpora
cavernosa§, changed, in this manner, into a firm incompressible substance,
which had been gradually extending itself for years, the glands in the
groin being also diseased in the same way.
Sometimes, after the prepuce has been slit open for the relief of a con-
genital phimosis, a large irregular fungus sprouts out from the extremity
of the penis, and continues spreading until it has occupied all that part of
the organ, which naturally projects beyond the scrotum. Frequently, in
these circumstances, neither the prepuce, nor the glans, can be distinctly
perceived ; but the whole projecting part of the penis forms a confused
mass of irregular granulated flesh, discharging a very foetid matter. || It
would appear, from several of the cases recorded by Mr. Hey, that tu-
bercles, or excrescences, actually existed within the prepuce before the
._*__
* Operative Surgei y, vol. i. p. 130. 8vo. Lond. 1807.
f See J. F. Malgaigne, Manuel de Med. Operatoire, p. G39. 12mo. Paris, 1834.
J Op. cit. vol. i. p. 131.
§ See case in Key's Practical Obs. in Surgery, p. 463. edit. 2. A specimen of this
kind, taken from a patient under me at the Bloom sbury Dispensary, is placed in the
Museum of University College.
|| See Iley's Practical Obs. in Surgery, p. 461. edit. 2.
3 C
754 OPERATIONS.
operation, and were found there as soon as the phimosls was cut.* What
is likewise remarkable, is the great frequency with which the cancerous
disease of the penis seems to be attended with, or preceded by, a con-
genital phimosis. Mr. Hey found this to be the case in seven out of
nine examples which fell under his notice, and (says he) " where I had
an opportunity of seeing the disease in an early stage, the phimosis evi-
dently appeared to have been caused by an unnatural formation of the in-
ternal membrane of the prepuce; and this formation seemed also to have
given rise to the cancerous affection." The facts brought forward by this
gentleman tend to prove, that this malignant affection mostly commences
upon the prepuce ; and that, in its earliest stage, the whole lining of that
part is studded with minute tubercles, or inequalities, which change into
the worst kind of disease.
According to Mr. Travers, a malignant ulceration of the prepuce and
penis, following phimosis, and requiring amputation, may be brought on
by an indiscreet perseverance in the use of mercury during the period of
inflammation. f
Whenever excrescences on the penis have a narrow base, they may be
cured by cutting them off, and the amputation of that organ is totally
unnecessary, and, of course, improper. J This I consider more judicious
treatment than applying to them a solution of bichloride of mercury and
opium for their cure, under the idea of their being venereal. Also, when
the wart or excrescence is of a malignant kind, but limited to the prepuce,
a cure may generally be effected by a removal of the part, without touch-
ing the glans or body of the penis itself. § Lastly, it is to be recollected,
that diseases of this organ, which put on a malignant appearance, are
sometimes cured by the carrot-poultice ||, and the internal and external
use of arsenic.
In the operation, the plan of saving as much of the penis, and also of
the glans, as circumstances will allow, with due regard to the entire re-
moval of every particle of the disease, is undoubtedly entitled to com-
mendation ; because the longer the stump is left, not only the more
conveniently will the urine afterwards be discharged, but even the faculty
of generation be more likely to be preserved. In confirmation of the
latter point, the testimony of Heister might be adduced, and Loder men-
tions one example, in which the patient retained the power of propagating
after amputation of the whole of the glans. ^f
Amputation of a cancerous affection of the penis often brings about a
cure, relapses being much less frequent than after the generality of oper-
ations for the removal of cancerous parts. In the three first cases pub-
lished by Mr. Hey, the cure after the operation was permanent.** In
order to insure this success, however, it is essential not to defer the use
of the knife until the disease is no longer local, and the whole of it cannot
be taken away. Hence, before determining to operate, it is a rule with
surgeons carefully to examine whether the disease has extended to other
parts, especially the glands in the groin. When they are indurated
and enlarged, many good practitioners decline the operation altogether,
* See Cases, Op. cit. pp. 463. 473. &c.
•f Surgical Essays, parti, p. 152.
$ Richter, Anfangsgr. b. vi. p. 183. Gb'ttingen, 1802.
§ See case in Hey's Practical Obs. p. 473. edit. 2.
|| Gibson, in Med. Obs. and Inquiries, vol iv.
^| Loder, Chirurgisch-Medicinische Beobachtungen, b. i. p. 81.
** Hey's Practical Obs. in Surgery, p. 478. edit. 2.
AMPUTATION OF THE PENIS. 755
the event of which is then always to be regarded as doubtful. Thus, in
one instance, in which the glands of the groin were much tumefied,
Mr. Hey ventured upon the operation, because the swelling of the glands
did not exist before escharotics had been applied to the disease of the
penis, and consequently it was dubious whether their enlargement was
truly cancerous or not ; but the patient died from a relapse. The ingui-
nal glands lessened for a time, but afterwards increased considerably :
there was, however, never any fresh ulceration.* Sometimes the only
part affected, in addition to the penis, will be the integuments covering
the ossa pubis, in which situation a hard tumour is perceptible. In one
case of this description, operated upon by Mr. Hey, a permanent cure en-
sued, care having been taken to cut out the swelling at the pubes : the
wound here remained for some time foul ; but, on applying to it red pre-
cipitate and burnt alum, it assumed a better appearance, and afterwards
healed, f When the cancerous disease does not extend beyond the glans,
immediately behind which the incision can be safely executed, there is no
objection to the method of cutting through the whole of the penis, with
one stroke of the knife. However, in order to cover the ends of the
corpora cavernosa with integuments, the plan is sometimes followed of
first drawing them towards the pubes, before the incision is made, or else
of merely making at first a circular cut through the skin, which is next
pushed a little way up towards the pubes, and the rest of the penis
divided in a line with the edge of the retracted skin. This last way of
operating, however, is not approved of by the generality of modern sur-
geons ; for it is slower, and more painful, than a direct incision through
the whole organ ; it does not shorten the cure, and is liable to inconveni-
ences. If, indeed, the preservation of skin for covering the end of the
stump were any real advantage, the surgeon would always have enough
for this purpose by cutting straight through the part,because the corpora ca-
vernosa constantly shrink towards the pubes as soon as they are cut through,
and leave the integuments projecting. But the truth is, no benefit is de-
rived from the redundance of skin : in one case, Mr. Hey made an
attempt to heal the wound by the first intention, and, with that view,
brought the integuments over the divided corpora cavernosa ; and, that he
might make the integuments lie over the end of the penis without pucker-
ing, or covering the orifice of the urethra, he made a longitudinal division
of them at the inferior part of the penis, and introduced a small silver
cannula into the urethra. " I was disappointed," says he, " in my design
of healing by the first intention ; for the integuments would not adhere
to the extremity of the corpora cavernosa. These spongy bodies, when
divided, do not readily throw out granulations ; but have usually for some
time an ill-conditioned appearance.''^ An objection to amputation of the
penis by the double incision is, that the superfluous flap of skin, fur-
ther augmented by the natural retraction of the divided corpora caver-
nosa, renders it more difficult to secure the blood-vessels, which become
concealed under it, and are disposed to retract, on account of the loose
cellular substance with which they are surrounded. At all eventl| if the
surgeon choose to save the skin, let him not prolong the patient's suffer-
ings by two formal distinct incisions, with an intermediate dissection of
the integuments from the corpora cavernosa, as it will be quite sufficient
* See Key's Practical Obs. in Surgery, p. 470. edit. 2.
f Op. cit. p. 463. \ Op. cit. p. 469.
3C 2
756 OPERATIONS.
to draw the skin a little way towards the pubes, when the amputation
may be completed with a single stroke of the knife.
When the penis is to be amputated near the symphysis of the pubes,
less skin should be taken away, because the retraction of the corpora
cavernosa is in proportion to the length of the portion of them left.
Sometimes, however, their extremities in this situation lie so deeply con-
cealed within the integuments, that the surgeon cannot discover, nor take
up, the bleeding vessels. In one example, says Richter, the arteries
shrunk so far under the pubes, that they lay two inches within the ex-
tremity of the skin.*
As the hemorrhage after amputation of the penis is profuse, and often
cannot be effectually restrained, unless the larger arteries are secured
with ligatures, it is a matter of great importance to perform the operation
in such a manner as will enable the surgeon to get at these vessels with
the least difficulty ; and hence the utility of abandoning the project of
saving skin for the purpose of covering the stump. Without this pre-
caution, as a modern surgeon has remarked, while the tedious business of
getting the ends of the corpora cavernosa from beneath the integuments
by which they are concealed, and of finding out the arteries, is going on,
the continued bleeding often reduces the patient to the lowest state of
weakness, and the practitioner is at last compelled to have recourse to
compression, styptic applications, cold water, or the cautery. Nor are
these means always capable of stopping the hemorrhage in time, or in a
permanent manner, the effusion of blood ceasing only for a little while ;
and their irritation always increases the inflammation of the stump, and
protracts the cure. Thus, in one example, where the hemorrhage was
considerable, the blood flowing not only from many conspicuous arteries,
but oozing largely from the'divided corpora cavernosa, Mr. Hey took up
one artery on the dorsum penis, and one in each corpus cavernosum.
The bleeding, which still continued, seemed then to be a general oozing
from the wound, on which account he applied sponge to it. But this
would not do ; for, about an hour after the patient had been put to bed,
the bleeding burst out again, and Mr. Hey was therefore obliged to
remove the dressings, and take up three other arteries. A fourth vessel,
which passed near the urethra, bled a little ; but, as its extremity could
not be clearly seen, a piece of sponge was laid upon it. On the third
day, a fresh hemorrhage came on, which made it necessary to remove the
last portion of sponge, and take up the vessel under it, which now bled
freely. f In another example, Siebold could tie only one artery, the
others having shrunk so deeply, that they could not be discovered. After
the patient had fainted, the bleeding stopped ; but it broke out again,
and was at length checked with cold water. The weakness from loss of
blood was such, however, that the patient was a month in recovering his
strength, and his feet continued for some time cedematous. f Joerdens
saw a case in which the stump became retracted under the pubes, and a
violent hemorrhage ensued, which nearly proved fatal, and could hardly
be restrained in half an hour, by tying three arteries, and having re-
course to compression, and a styptic liquor. § B. Bell was still more
unfortunate, for he ventured to trust entirely to pressure, without taking
* Anfangsgr. b. vi. pp. 185, 186.
f See Hey's Practical Obs. in Surgery, p. 465. edit. 2.
I Chir. Tagebuch, p. 52.
§ Loder's Journal, 3 b. 1 st.
AMPUTATION OF THE PENIS. 757
up any of the vessels ; the consequence was, that so copious a bleeding
came on, a few hours after the operation, that the patient lost his life.*
In another case, the surface of the stump, which had been treated with
compression and styptics, was long ill-conditioned, pale, and indurated ;
nor did the wound begin to diminish at all before the thirteenth day f ,
in which space of time, another instance, treated differently, had com-
pletely healed. J
Certain cases prove, that the corpora cavernosa sometimes have a great
tendency to retract, when cut through towards the pubes ; and that even
when care has been taken to amputate more of the integuments than
of them, their extremities will still frequently be deeply concealed, and
the taking up of the arteries be difficult. Nor will the plan of encircling
the stump with a tight piece of tape here avail in obviating the dis-
advantage of the retraction of the corpora cavernosa, and the immediate
danger of hemorrhage, as the stump is short, and the band therefore
liable to slip off. Even if the band could be fixed tightly on the part, it
would only serve as a temporary means of stopping the bleeding, which
would be renewed immediately the band was loosened for the purpose
of enabling the operator to see the points from which the blood issued. §
This plan, however, has been adopted with success in Germany ||, and
Mr. Hey assures us, that, in one of his cases, he found great advantage
from having applied some tape round the sound part, as he was thereby
not only enabled to divide the integuments more easily and correctly, but
was furnished with an useful kind of tourniquet, which kept the divided
vessels from bleeding, till he was prepared to take them up with the
tenaculum and ligature. ^[
Were a case to present itself, in which the mouths of the arteries
could not be taken up, the practitioner would be compelled to resort to
means, which experience proves to have occasionally succeeded under
similar circumstances; as, for instance, compression**, with agaric, sponge,
or lint dipped in powder of gum arabic, ice-cold waterff, and the actual
cautery Jf , a circular band, strip of plaster, or tourniquet, &c. The un-
certainty of all these methods, however, is generally acknowledged.
The arteries, requiring ligatures, are those of the dorsum and corpora
cavernosa.
In order to prevent a closure of the urethra, as well as to enable
the patient to make water easily, and keep the urine from coming into
contact with the wound, some surgeons, as soon as the operation is
finished, introduce a short silver cannula, or an ordinary catheter, into
that canal. If the short cannula be chosen, it must be made with little
rings, so that it may be conveniently fastened in its situation. Were
the amputation about to be done towards the pubes, a silver catheter
should be introduced before the operation, because here the retraction of
the parts is such, that the introduction of the instrument afterwards might
be found difficult, if not impracticable.
f
* Syst. of Surgery, vol. i.
f Schtnalz, in Loder's Journ. 1 b. s. 622.
j: See Schreger's Chirurgische Versiiche, b. i. p. 243.
§ Ibid. p. 247.
|| Ollenroths, in Hufeland's Journ. 3 b. s. 56.
If Key's Practical Obs. on Surgery, p. 478. ed. 2.
** Dolignon, Journ. de Medecine, t. Ixxxiii.
ff Siebold, Chir. Tagebuch, p. 52.
jj: Sabatier, Medecine Ope>atoire, t. ii. p. 306. Ollenroths, Hufelaud's Journ. 3 b.
3c 3
758 OPERATIONS.
With respect to the introduction of any tube, either before or directly
after the operation in ordinary cases, surgeons are not unanimous upon
the subject. I have seen the operation done very well without it, and
the parts favourably healed, a bougie having been passed a little way
into the urethra once a day, after the removal of the dressings, to hinder
the contraction of the orifice of the urethra. This was Mr. Key's practice.
An elastic catheter, as creating less irritation, is preferable to a metallic
one. The irritation of the wound by the urine, and the necessity of
hindering the orifice of the urethra from closing, will probably always
lead many practitioners to pass a catheter. The instrument, however,
should be large ; for otherwise the urine, by getting out between it and
the urethra, and wetting the dressings, irritates and frets the wound.
Le Dran mentions a case, in which, from the neglect to pass a catheter,
the orifice of the urethra became impervious, so that the urine could not
be discharged. * Bertrandi cites another case, where, on this account, it
became requisite to enlarge the orifice of the urethra by an incision.
PUNCTURING THE BLADDER.
The fifth, sixth, and seventh days, from the commencement of the
total obstruction, are those on which the urine is likely to escape from
the bladder ; hence, Sir Charles Bell recommends an outlet for it to be
made on the fourth day. f
Although I am an advocate for not delaying the operation, after milder
methods have decidedly failed, I believe that these will almost always
prove successful in skilful hands, and that it may generally be avoided.
At the present day, the necessity for paracentesis is frequently superseded
by the excellent practice of making an opening in the membranous por-
tion of the urethra, which, in cases of bad stricture, is generally dilated
behind the obstructed part of the canal.
The bladder may be punctured, either in the perineum, above the os
pubis, or through the rectum. Of the first operation I shall say nothing,
for it is now generally relinquished. I allude to the old method of open-
ing the bladder with a trocar, between its neck and the insertion of the
ureter; because cases frequently present themselves, in which letting out
the urine by an incision in the perineum is much more advisable, than
either puncturing the bladder from the rectum, or above the pubes. But
the operation to which I refer, is not a hazardous thrust of a trocar at a
point between the neck of the bladder and the insertion of the ureter,
a point which can never be hit with certainty ; but a simple incision in
the dilated membranous portion of the urethra. In retentions of urine
from strictures, not admitting relief by other means, Sir Astley Cooper
prefers making an opening in the urethra to the practice of puncturing
the bladder, which, in male subjects, he considers hardly ever necessary.
In them, retention of urine mostly arises either from strictures or disease
of the prostate gland. Of the latter, Sir Astley has never seen a case, in
which a catheter, of proper form and size, could not be passed. J " If,"
says Sir Charles Bell, " a man have a stricture in the urethra, and the
surrounding parts be indurated, so that there is no immediate hope of
removing it by the caustic, or the bougie ; if, with this, there has occurred
* Operations in Surgery, p. 158. ed. 2.
•f Operative Surgery, vol. i. p. 315.
f Surgical Obs. vol. ii. p. 61. 8vo. Lond. 1818. If the urethra has already burst,
and effusion taken place, only free external incisions seem necessary.
PUNCTURE ABOVE THE PUBES. 759
a sudden obstruction, and the bladder has risen and has lost its action, and
there remains no expectation of spontaneous relief, or of ease from lesser
remedies, then I apprehend it is better to open the urethra in the peri-
neum behind the stricture. And this is to be immediately done, if the
symptoms indicate a rupture of the urethra, and effusion of urine."*
In University College Hospital, I had a case, where a diseased
prostate gland rendered the included portion of the urethra perfectly
spiral, so that only a smallish flexible catheter was capable of passing
through it; and at length the point of this entered the substance of the
prostate, a part of which was found after death to be exceedingly soft.
Had it gone a quarter of an inch further, it would have reached the cavity
of the bladder. As the symptoms were urgent, I punctured the bladder
above the pubes, and drew off a considerable quantity of urine. The man
did not recover, and, on examination of the parts after death, it seemed
that a small quantity of urine had insinuated itself between the cannula
and sides of the wound, and excited inflammation, which had extended
to the peritoneum. The preparation, which is preserved in the museum
of University College, shows the track of the trocar completely below the
reflection of the peritoneum, and the enlargement of the prostate gland
has the peculiarity of being principally directed towards the rectum.
PUNCTURE ABOVE THE PUBES.
Some surgeons make a perpendicular incision, about two inches in
length, through the integuments and fat covering the lower part of the
linea alba. Were the bladder thickened and contracted, or the patient
corpulent, this preliminary incision would be proper ; but, if the dis-
tended bladder can be plainly felt, the trocar may be at once introduced
through the parietes of the abdomen into that viscus. A trocar, the
diameter of which should be such as will afford a very ready outlet for
the urine, and the curvature form a segment of a circle seven inches in
diameter, is to be passed through the integuments and linea alba into the
bladder. It is to be held with its convexity towards the patient's navel,
and pushed obliquely downward and backward in the axis of that viscus.
Sir Astley Cooper, who uses a straight trocar, directs it towards the
basis of the sacrum, and not so low down as I have mentioned; his
reason is,, that the risk of the instrument slipping between the pubes and
the bladder may be avoided, f At all events, it is necessary to guard
against this accident, which has sometimes happened. A curved in-
strument of this kind is much less likely, than a straight trocar, to pene-
trate the back part of the bladder, and wound the rectum ; besides,
having this advantage, that, when the urine is evacuated and the bladder
collapses, the cannula will be less disposed than a straight one to be
separated from that organ. Here we may discern another reason for
making the puncture immediately above the pubes, and not an inch or
two higher up, as Sharp and B. Bell recommend : the bladder, which
rises up between the peritoneum and recti muscles, descends again, when
the urine is discharged, and, consequently, must be more liable to slip
from the cannula, the higher the puncture is made. J
* Lectures, vol. ii. p. 315. It seems that Sir Astley Cooper is entitled to the merit
of first reviving this forgotten but valuable practice, of which I find traces in the valu-
able work of L. L. Petit, entitled Traite de Mai. Chir. 3 tomes. 8vo. Paris, 1790.
f Lectures, vol. ii. p. 309.
| Richerand, Nosographie Chir. torn. iii. p. 499. By the employment of a long
straight trocar, of course the objection here specified might be removed ; but the cannula
3c 4
760 OPERATIONS.
When the operator perceives, from the want of resistance, that the
point of the instrument is in the bladder, he is to take hold of the can-
nula, and push it further in, while he withdraws the stilet. After the
urine has been discharged, some practitioners, amongst whom is Sir
Astley Cooper, pass an elastic catheter, duly shortened, into the bladder
through the cannula, and then take the latter out.
Since an elastic catheter does not fill the wound, the urine is dis-
charged, not only through it, but also between its outer surface and the
track of the wound ; so that the chance of the urine becoming diffused
in the cellular tissue is not guarded against, as it is by allowing the can-
nula of the trocar to remain in the wound two or three days, until in-
flammation has agglutinated together the surrounding cellular substance.
In some examples, the cannula, after having been kept a few days in
the wound, was taken out, and readily introduced again as occasion
required.*
Still, I do not feel authorised to recommend this proceeding; because
it has happened, that the tube could not be replaced, and the urine be-
came confined again, so that a repetition of the operation would have
been absolutely necessary a third time, had not Schreger succeeded in
procuring an evacuation through the urethra, by distending this canal
with warm water, injected with some force into the passage by means
of a syringe and a cannula, introduced as far as the stricture would
allow.f
Long, straight, silver cannula? have been known to form a communica-
tion between the bladder and rectum, in consequence of ulceration, or
sloughing, produced by the pressure of their points on the back part of
the bladder. Mr. Sharp saw this accident J ; and a modern author in-
forms us, that in a case where a common trocar was used, he dissected
the parts ; " the bladder fell on the sharp edge of the trocar, this pro-
duced inflammation of the bladder and peritoneum, which occasioned the
death of the patient." §
The outlet thus formed for the urine is, of course, merely designed as
a temporary one, until the impediment in the natural passage has been
removed. In one case, seen by Sir Astley Cooper, where the latter
object had not been accomplished, twelve months after the puncture, a
female catheter was yet worn in the opening. ||
This operation has the advantage of being generally done at a dis-
tance from the diseased parts, and without risk of injuring any organs of
of such an instrument has sometimes pressed against the opposite side of the bladder,
and caused an ulcerated opening in it. In consequence of the bladder having slipped
away from a short cannula, a repetition of the puncture became necessary in a case under
Professor Schreger. See Chirurgische Versiiche, b. i. p. 212. Nuremberg, 181 1.
* See Bonn iibcr Harnverhaltung and Blasenstich, Leipzig, 1794; Noel in Desault's
Journal de Chirurgie, torn. ii. ; Turner in London Med. Journal, vol. xi. ; Journal dc
Medecine, torn. Ixxxiii.
•f Versiiche Chirurgische, b. i. p. 216. 8vo. Nuremberg, 1811. In cases of retention
of urine, from calculi lodged near the neck of the bladder, Schreger employed the same
artifice with success. It is this principle of distending the urethra with fluid, that was
once so strongly recommended by Mr. Arnott in various affections of that canal.
| See a Critical Inquiry into the Present State of Surgery, p. 127. ed. 4.
§ See a History of the High Operation for the Stone by Incision above the Pubcs,
and an Account of the various Methods of Lithotomy, by J. C. Carpue, p. 176. 8vo.
Lond. 1819.
|| Lectures, vol. ii. p. 310.
PUNCTURE THROUGH THE RECTUM. T61
importance.* The possibility of the urine getting out of the bladder into
the wound, was exemplified in the case under me in University College
Hospital, and this notwithstanding the cannula was not withdrawn and
exchanged for an elastic catheter, till the end of two days from the
period of the puncture. When the cannula happens to slip out of the
bladder, it is alleged that, the puncture becomes impervious. In fact,
this happened in Schreger's case, where the tube slipped out twice ; viz.
on the evening of the day on which the bladder was first tapped, and
again on the third night from the second performance of the operation ;
for, after each displacement of the cannula, no probe could be passed
into the bladder, no urine escaped, and that receptacle became enor-
mously distended again. When a smallish trocar is used, this closure of
the puncture by the mucous coat would perhaps generally be likely to
take place for a day or two after the operation ; but, in a later stage, it
would be less likely to occur : it did not happen in the example related
by Schreger himself, in which he took out the cannula of the trocar on
the thirteenth day, and put in another-]- ; and it is therefore not to be
regarded by any means as an invariable consequence of the tube slipping
out. The displacement of the cannula, the possibility of not being able
to get in another, and of an extravasation of urine, therefore, may still
be considered objections to this method of operating. Another disad-
vantage is, that the opening is not made in a depending situation, and
consequently the whole of the urine cannot be readily discharged. I
once saw Mr. Abernethy attempt this operation in St. Bartholomew's
Hospital ; but the trocar did not enter the bladder. No urine was dis-
charged, and the patient died the following day.
PUNCTURE THROUGH THE RECTUM.
The patient is to be put in the posture recommended for lithotomy.
An assistant is to make pressure on the abdomen, just above the pubes,
in order to render the prominence of the bladder more distinct to the
surgeon's finger in the rectum. A curved trocar, with the point of its
stilette drawn within the cannula, is to be introduced with the right
hand, and under the guidance of the left forefinger first passed into the
rectum so as to feel the base, or posterior part, of the prostate gland. It
should be kept exactly in the central line of the front of the rectum, and,
as soon as the end of the cannula is beyond the prostate gland, its handle
should be depressed, and the stilette pushed into the bladder, through
the anterior part of the intestine, as nearly as possible in the middle of
a small triangular space, bounded at the sides by the vasa deferentia and
vesiculae seminales, which converge to the prostate gland, and behind by
the line at which the peritoneum is reflected from the bladder to the
rectum. If the puncture be made in the centre of this space, just beyond
the base of the prostate gland, while the bladder is distended, there will
be no danger of wounding the vasa deferentia, vesiculae seminales, or
peritoneum. J
After the urine has been discharged, the cannula should be fixed in its
* The preparation in the Museum of University College, exhibiting the track of the
trocar, proves that Mr. King's statement of the peritoneum being necessarily pierced
twice by the trocar, before the bladder is reached, is a mistake. See Lithotrity and
Lithotomy compared, by Thomas King. 8vo. Lond. 1832. p. 31.
t Versiiche Chir. b. i. p. 225.
\ Sir Astley Cooper, Lectures, vol. ii. p. 311. Also J. F. Malgaigne, Manuel de
Med. Operatoire, p. 682. 12mo. Paris, 1834.
762 OPERATIONS.
place, by means ef two pieces of tape passed through its rings, and fast-
ened in front and behind to a bandage round the waist. It is to be closed
with a stopper, which may be taken out as occasion requires, and may be
further secured with a compress and T bandage. As soon as the obstruc-
tion in the urethra is removed, the cannula is to be withdrawn : or, in
some cases, it may be withdrawn in from twelve to twenty-four hours, and
the urine allowed to pass through the new opening. The reason in favour
of this plan is, to get rid of the annoyance of the cannula in the rectum :
the reasons against it are, the possibility of the opening closing prematurely,
and of the urine causing inflammation, ulceration, and sloughing of the
rectum. Sir Astley Cooper objects to this operation, on the ground, that
the irritation of the urine is likely to bring on inflammation and disease of
the rectum, as happened in a case under Dr. Cheston. When the prostate
gland is enlarged, it is manifestly inapplicable.
LITHOTOMY.
The generality of vesical calculi are originally formed in the kidney,
whence they descend into the bladder through the ureter, but are either
too large to be voided through the urethra, or are prevented from enter-
ing the latter passage by the projection of an enlarged prostate gland.*
When, however, any foreign body remains in the bladder, it soon becomes
incrusted with other matter deposited on it from the urine, and thus
forms the nucleus of the calculus.
The composition of calculi is various : — 1. Lithic acid. 2. Oxalate
of lime, or mulberry calculi, which are of a dark colour, very hard, and
have a rough, irregular surface. 3. Triple phosphate of ammonia and
magnesia. 4. Phosphate of lime. Calculi, composed entirely of this, are
rarely met with in the bladder ; and when they are, the researches of
Dr. Prout tend to prove, that they are derived, not from the urine, but
from the secretions of the bladder itself. 5. Calculi, consisting partly
of the triple phosphate of ammonia and magnesia, and partly of the phos-
phate of lime, blended together. 6. Lithate of ammonia, seldom met
with except in children. 7. Lithate of soda, exceedingly rare. 8. Cystic
oxide. 9. Carbonate of lime. A calculus, composed altogether of this
substance, is very rare, though a small quantity of it is often commixed
with other matters. 10. Xanthic oxide. 11. Fibrous calculus. The
two latter, first described by Dr. Marcet, are uncommon. f Children and
elderly persons are well known to be more liable to calculi, than persons
of the middle periods of life. In the poor classes, children are afflicted
with remarkable frequency ; but, in the higher, the disorder is more com-
mon in old than young subjects.
The museum of University College affords abundant evidence of the
great liability of patients with diseased prostate glands to the formation
of calculi. Their bladders can never be completely emptied ; and, as
Sir Benjamin Brodie correctly remarks, if a small calculus from the kid-
ney find its way into the bladder, it cannot escape by the urethra, and
remains and increases. Lithic acid, and particles of phosphate of lime,
or any thing else which can act as a nucleus, becomes also, under these
circumstances, the foundation of a stone in the bladder. In cases of
* Sir Benjamin Brodie on Diseases of the Urinary Organs, ed. 2. p. 209. 8vo. Lond.
1835.
t On this subject, consult the writings of Brande, Marcet, Prout, Henry, Yclloly,
and Brodie.
LITHOTOMY. 763
diseased prostate gland, the mucous membrane of the bladder sometimes
becomes inflamed, and the mucus secreted by it deposits phosphate of
lime in small masses, and each of these becomes the nucleus of a calculus ;
but such calculi may unite and form larger ones.
While a stone in the bladder is of trivial size, smooth, and not angular
in its figure, little inconvenience may result from it; but, when it is
above a certain weight, rough, and of irregular figure, it always produces
more or less suffering. The symptoms, however, seem to be influenced
by the quality of the urine, which may be unusually acid, or alkaline, de-
positing the triple phosphate. As Sir Benjamin Brodie has remarked, in
either of these cases it will be too stimulating, and the symptoms pro-
duced by the stone will be aggravated. The state of the bladder itself
also makes considerable difference, nothing augmenting the severity of
the symptoms so much as inflammation of the mucous membrane. While
this exists, a small calculus will cause infinitely greater distress than a
large one under ordinary circumstances. * Another reason, assigned by
him for the increased severity of the symptoms, when the urine is alka-
line, is, that the state of the general health, which causes alkaline urine to
be secreted, is attended with a morbid sensibility of the nervous system
in general. A dull, annoying pain is felt at the extremity of the penis,
and hence, children are continually pulling the prepuce, and it often be-
comes remarkably lengthened. A sense of weight is experienced in the
perineum ; there is a frequent desire to make water, and sometimes un-
easiness about the rectum, tenesmus, or, in children, even prolapsus ani.
In consequence of a small stone falling on the inner orifice of the urethra,
the stream of urine is apt to be suddenly stopped, although the bladder
yet contains a considerable quantity. The evacuation is attended with
pain, especially towards the conclusion of it, when the inner surface of
the bladder embraces, as it were, the foreign body.
The urine contains a good deal of mucus, which forms a sediment, and,
when the patient takes exercise, sometimes blood. In an advanced stage,
ulceration of the inner coat of the bladder occurs, and then the urine has
an offensive smell, becoming putrid and ammoniacal, and depositing a
mixture of mucus and pus, more or less blended with blood. After a
time, the symptoms of disease of the bladder and kidneys are added to
those of stone ; the patient loses his appetite, becomes hectic, and the
urine albuminous. Frequently, the patient, if not relieved by operation,
falls a victim to inflammation of the bladder, already much diseased.
Occasionally, large abscesses form in the cellular tissue of the pelvis.
Together with these symptoms, there may be numbness in the thighs,
and the testicles are often painful and retracted. In the case of a gentle-
man, lately attended by Mr. Bransby Cooper, Dr. Rigby, and myself, and
who died of stone, one kidney was much enlarged, and the left ureter,
whose communication belowcwith the bladder was obliterated, was as wide
and capacious as one of the small intestines.
An enlarged prostate gland is attended with symptoms more or less
similar to those of stone ; but, with this difference, that riding in a coach,
or on horseback, does not augment the grievances, when the prostate
gland is affected ; while, in cases of calculi, it does so in an intolerable
degree, bringing on likewise a discharge of bloody urine. The fits of
pain from a calculus in the bladder generally come on at intervals;
* Sir Benjamin Brodie on Diseases of the Urinary Organs, p. 225. ed. 2.
764 OPERATIONS.
whereas the pain from a diseased prostate gland is neither so unequal,
nor so acute.
As the symptoms of stone in the bladder bear a strong resemblance
to those of several other affections, surgeons never pronounce a decided
opinion on the nature of the disease, until they have introduced a me-
tallic instrument (called a sound) into the bladder, and actually touched
the stone itself. But a judicious practitioner, who may not be able to
feel the calculus, will be cautious not to say positively, that there is no
stone in the bladder ; for the next time the patient is sounded, its posi-
tion may be different, and it may be distinctly hit with the instrument.
In relation to this part of the subject, I admire the candour of Sir Astley
Cooper, when he says : " I have myself sounded, and not detected a
stone at one time, which I have afterwards felt. I have sounded, and
not discovered a stone, which another surgeon has afterwards perceived.
I cut a patient, and extracted thirty-seven stones from his bladder, who
had been sounded, and declared not to have a stone."*
OF SOUNDING, OR SEARCHING FOR THE STONE.
The instrument, expressly calculated for this purpose, is denominated
a sound, which is not hollow like a catheter, but solid, and made of the
best steel. As a stone is generally carried by its own weight to the
lowest part of the bladder, the sound is less curved, and somewhat
longer than a catheter, in order that it may reach behind and below the
neck of that viscus. Being only a particular kind of probe, the chief use
of which is to convey information through the medium of the organ of
touch, its handle should be highly polished, so that, as many points of it
may be in contact with the fingers as possible. The mode of introducing
it is the same as that of passing a silver catheter.
When its extremity is in the bladder, it is first to be inclined down-
wards, for the purpose of ascertaining whether the stone occupies its
most frequent situation, beneath the extremity of the instrument. If the
calculus cannot be felt in this direction, the end of the sound may be
gently turned, first to one side and then the other ; and, in the event of
the calculus not being now touched, the handle of the instrument is to be
depressed, and its extremity inclined upwards and forwards, in order to
learn whether the foreign body may not lie more towards the fundus of
the bladder. Frequently, the stone cannot be felt before the whole of
the urine has been voided, and the bladder is contracted ; and sometimes
the sound cannot be made to strike the calculus, unless this body be first
raised up by a finger passed into the rectum, in doing which the surgeon
may occasionally feel the stone, if it be large, through the intervening
coats of the bowel and bladder. As, however, this method is seldom
requisite, except when the calculus is smallish, the practitioner must not
always expect to feel it with his finger through the bowel ; nor is it a mat-
ter of any practical importance, because the information thus obtained is
more liable to be fallacious, than what the sound affords, and, if the stone
cannot be felt with this instrument, any kind of feel, communicated to
the finger within the rectum, would not warrant the making of an incision
into the bladder.
When the stone is smallish, and lies on one side of the neck of the
bladder, it may not admit of being readily hit with the sound. Also,
* Sir Astley Cooper's Lectures, vol. ii. p. 248.
SOUNDING FOR THE STONE. 765
when, from repeated attacks of inflammation, hardened folds, or, from
other causes, distinct cysts have been formed within the bladder, the
calculus sometimes lies within a depression, or cavity, and cannot be
felt with the instrument. Under such circumstances, before the sound
is introduced, the patient should hold his water, until the bladder is quite
full, and, if possible, until it is so distended as to efface, or diminish,
its preternatural excavations. Then the patient should stand up, and
make water, with his body inclined forwards, whereby the calculus will
be carried towards the neck of the bladder, and admit of being struck
with the instrument.* I have known several cases, where the calculus
could be touched with a silver catheter, but not with a sound. Instru-
ments of different curvatures and lengths should be tried, when the
symptoms are strongly marked, yet the calculus cannot be felt. Whenever
the surgeon cannot readily touch the stone, the patient is to be sounded
in different attitudes.
In sounding, how possible it is to mistake a thickened, indurated blad-
der for a stone in that organ, may be well conceived, when it is con-
sidered that Cheselden, with all his judgment and experience, actually
cut no less than three patients, none of whom had any stone in the blad-
der at the time of the operation. On the other hand, the case of the
celebrated French surgeon, La Peyronie, exemplifies most convincingly,
the possibility of failing to discover a stone even of considerable size,
though the sound be repeatedly passed.
There are three methods of treating calculous patients generally con-
sidered by writers ; one is that of attempting to dissolve the stone ; a
second, that of palliating the symptoms; and the other aims at the re-
moval of the calculus from the bladder by a surgical operation. In
women, the latter object may often be performed by dilating the meatus
urinarius, without using any cutting instrument f ; but, in the male sex,
the great length, narrow diameter, winding course, and considerable irri-
tability, of the urethra, make the extraction of calculi through it, and
even the getting hold of them in the bladder with any instrument intro-
duced through the passage, more difficult. However, the success which
Sir Astley Cooper, Sir Benjamin Brodie, and others have had in extract-
ing calculi of moderate size from the bladder with the urethral forceps
constructed by Messrs. Weiss, and the efficiency with which lithotrity is
frequently resorted to for reducing larger stones to small particles, cap-
able of discharge with the urine, have already made due impression on
every practitioner, desirous of lessening the frequency of one of the tnost
painful and fatal operations in surgery. At the same time, when the
calculus is above a certain size, or the bladder is diseased, and incapable
of bearing the irritation of the fragments, lithotrity is likely to prove even
more fatal than lithotomy. When the kidneys are diseased, the chances
of recovery after either operation must be hopeless.
Though the calculus may have been felt with a sound, at some period
or another previously to the time fixed upon for the operation, it is an
established maxim in surgery, never to perform lithotomy, unless fye stone
* Richter, Anfangsgr. b. vii. p. 103.
f Notwithstanding the many respectable advocates for this practice, some men of con-
siderable eminence object to it, as being more tedious and painful, and more likely to be
followed by an incontinence of urine, than the use of a cutting instrument. Of this
sentiment is the experienced Klein, who has tried both methods, and in 1816 had cut for
the stone 79 patients. See Practische Ansichten der Bedeutendsten Chirurgischen.
Operationen, auf eigene Erfahrungen gegnindet von D. C. Klein, p. 21. 2tes Heft,
4to. Stuttgart, 181 G.
766 OPERATIONS.
can be plainly struck with a sound, or staff ] immediately before the operation.
A man may have a stone in the bladder to-day, and the surgeon may
strike it so manifestly with the sound, as to make the circumstance per-
ceptible to the ears of the by-standers, as well as to his own fingers ; but
to-morrow, the stone may protrude between the fasciculi of the muscular
fibres of the bladder, carrying along with it a pouch, formed by the lining
of this viscus, and, in this circumstance, the stone is no longer in the
cavity of the bladder ; consequently, it can neither be felt with the sound,
nor extracted by the operation of lithotomy.
An interesting case is recorded by Sir Benjamin Brodie, where a cal-
culus was included in a sac, composed of the muscular, as well as the
mucous coat, and used to create severe pain whenever it passed, as it
sometimes did, out of the sac into the cavity of the bladder.
In many instances, there is only a single calculus in the bladder ; in
others, several ; and sometimes thirty or forty. When their number is
greater than one, their rubbing against each other generally gives them a
smooth surface.
OPERATION.
As one of the principal dangers of lithotomy is inflammation of the
bladder and peritoneum., I think the common principles of surgery teach
us, that it must be a matter of prudence to remove, if possible, before-
hand, any state of the constitution known to promote the access of inflam-
mation. A low regimen, for a few days previously to the operation, and
a dose or two of mild aperient medicine, are generally advisable. The
rectum should be emptied with a clyster a few hours before the patient
is cut, as its distension would expose it to injury.
Many surgeons deem it advantageous to let the bladder be somewhat
distended with urine when the patient is cut ; and hence, he is usually
directed to avoid making water for an hour or two before the operation.
This advice I consider well founded, particularly when a gorget is to be
thrust into the bladder, which, in an empty state, must be more liable to
be wounded at its posterior part ; but, in operating with a knife, whether
this organ contain urine or not. cannot be a matter of importance, unless
the escape of the urine, when the instrument enters the bladder, is to be
considered as useful information. Klein, who is in the habit of using a
common scalpel, never gives himself any concern about the bladder being
empty or not.*
The patient should be placed upon nearly a flat surface, where it is
much easier to introduce an instrument in the direction of the axis of
the pelvis, than when the table slopes considerably, which would also
oblige the operator to kneel down to gain the advantages which he fully
has sitting down at his ease, before a table that has nearly a straight
horizontal surface, f The table should be high enough to bring the
perineum on a level with the surgeon's breast. The buttocks should be
somewhat more raised than the abdomen ; the patient lie upon pillows
conveniently placed ; and the nates project rather beyond the edge of
the table. J
In arranging the posture of the patient, the chief objects to be attended
* Chirurgische Bemerkungen, p. 26.
f Ibid. p. 23.
\ C. J. M. Langcnbeck liber eine einfache und sichere Methode des Steiusclmittts
mit tiner Vorrede von Dr. J, B. Siebold, p. 44. Wurzburg, 1802.
LITHOTOMY. 767
to are, first, to let the buttocks be exactly even ; to take care that neither
of the assistants draws the thigh too much towards his own side ; and that
the parts, situated between the raphe of the perineum and the ascending
ramus of the ischium, be stretched, in which condition the requisite in-
cisions can be performed with more facility. *
A staff is then to be introduced into the bladder. Two strong garters
or ligatures, each about two yards long, are then to be doubled, and
placed by means of a noose round the patient's wrists, who is next to
take hold of the outside of his feet with his hands, the fingers being
applied to the soles. The two ends of the ligature are then to be carried
in opposite directions round the ankle, over the back of the hand, and
under the foot, where they may be tied in a bow. The hands and feet
being thus securely connected together, the knees and feet are to be sup-
ported, kept steady, and held apart by the assistants.
The staff should be introduced before the patient's hands and feet are
bound together ; first, because, if the calculus cannot he felt with this
instrument (which being now used for the sound, saves the patient the
pain of a double introduction through the urethra), it will not be neces-
sary to tie up the patient at all, as the operation must not be attempted ;
secondly, because, while the patient is unbound, the instrument is more
easy of introduction, and in searching for the stone, a change of posture
is often necessary.
A curved director, the groove of which serves to guide a cutting in-
strument into the bladder, is an exact definition of a staff. It is shaped
like a sound, or catheter, so that it may pass thiough the whole of the
urethra. Its handle, instead of being smooth, like that of a sound,
should be rough, in order that it may be held with greater steadiness.
The groove, which is to be deep and wide, should terminate in a short
conical beak. The diameter of the staff should be as great, as can easily
be passed into the urethra ; for, the larger the size of the staff, the more
easily can it be felt in the perineum, the more distended the membranous
part of the urethra becomes, and the more regular the incision in it is
likely to be made. That the instrument is fairly in the bladder, may be
known by its handle sinking towards the ground, without the least im-
pediment.
t In the first stage of the operation, the staff is to be held by an assist-
ant, who also raises the scrotum with his left hand, and gives the surgeon
a complete view of the perineum. Some operators are anxious, that the
convexity of the instrument should project distinctly in the perineum, for
which purpose, the assistant is desired to hold the handle perpendicularly
to the patient's trunk, and to propel the whole staff gently towards the
part, where the first incision is to be made into it. The manner of holding
the staff, in the first stage of the operation, differs, however, with different
operators. Sir Benjamin Brodie and many other surgeons prefer that
position of it, in which it is nearly perpendicular, with the handle a little
inclined towards the patient's right groin, so as to cause the convexity of
the instrument to project slightly on the left side of the perirfcum. f
Scarpa, Dupuytren, ListonJ, Syme§, and others, deem it better to raise
the concavity of the staff towards the arch of the pubes, and to hold it
* Langenbeck, op. cit.
f On Diseases of the Urinary Organs, p. 271. ed. 2. Sur une Maniere Nouvelle
de pratiquer 1'Ope'ration de la Pierre, fol. Paris, 1836.
$ Listen's Elements, part iii, p. 197. §aSyme's Principles, p. 511.
768 OPERATIONS.
firmly there, the handle being exactly perpendicular, without any incli-
nation of it to the right or left, or any projection of the instrument in
the perineum. After the presence and probable size of the stone had
been ascertained with the staff, Dupuytren gave to the latter a vertical
direction, so that the straight part of the instrument formed a right angle
with the axis of the body, while the curve was kept somewhat elevated
towards the symphysis pubis, rather than pressed downwards and back-
wards upon the rectum. A steady assistant retained it precisely in this
position. " Its curved part is drawn up closely under the arch of the
pubes in order to prevent its pressing too much downwards upon the
rectum." However, some of the advocates for the latter plan make use
of a staff, the groove of which, as it passes towards the bladder, runs in
the interval between the convexity, and right side of the instrument.
" The groove being placed upon the side of the staff enables the surgeon
to cut into it more easily, and also to give that direction to his knife, by
which he divides the neck of the bladder and the prostate on the left
side."*
The patient having been secured in the proper position, and the staff
held perpendicularly, with the groove directed a little towards the left
side of the perineum, the surgeon traces with his left forefinger the
descending ramus of the pubes, and the ascending ramus and the tuber-
osity of the ischium, and then makes his first incision through the integu-
ments and superficial fascia, beginning it in an adult an inch and a quarter
above the anus, close to the left side of the raphe, and carrying it ob-
liquely downwards and outwards, about three inches, to a point, situated
one third from the inner side of the tuberosity of the ischium, and two
thirds from the anus, -j- The knife should be pushed in fully one inch
deep ; and, as it is carried downwards to the termination of the incision,
it is to be gradually withdrawn from its deep position, in order to avoid
the rectum. J By extending the cut in this manner to a point nearer the
ischium than the anus, the edge of the knife, in the future steps of the
operation, can be more conveniently and surely directed away from the
rectum. In a full-grown person, the beginning of the first incision should
never be more than about an inch and a quarter above the anus, because
laying open a greater extent of the urethra, towards the bulb, will have
no more effect in facilitating the extraction of the stone from the bladder,
than if the whole of the urethra were divided. Besides, when the exter-
nal incision is made too high up, and the internal completed, the former
is likely to be placed too high in relation to the opening in the bladder.
The consequences are, that the same impediment to the extraction of the
calculus is experienced, as if the wound were too small ; and the urine,
not finding so ready an outlet from the bladder after the operation, is
more likely to become effused.
The first incision is made through the integuments, fat, and superficial
fascia. The second divides the lower fibres of the accelerator urinae, the
transverse muscle and artery of the perineum, and a part of the levator
ani and deep perineal fascia. Then, the surgeon feels for the' staff in the
upper part of the wound with his left forefinger, and, cutting into its
* See Morton on the Surgical Anatomy of the Perinacum, p. 72.
f See a paper on Lithotomy, in Med. Chir. Trans, vol. viii. ; and E. Stanley, on the
Lateral Operation, p. 5. 4to. Loml. 1829.
\ Sir Charles Bell's Great Operations of Surgery, p. 117. Th. Morton, op. cit. p. 7:J.
LITHOTOMY. 769
groove, opens the membranous part of the urethra. In accomplishing
these objects, the principal things for avoidance are cutting the bulb of
the urethra, endangering the great pudic artery, wounding the rectum,
and opening the urethra too high up. Next, supposing the operation to
be finished with a scalpel that has no beak, the point of it is to be raised,
the handle depressed, and its edge directed downwards and outwards to-
wards the lower angle of the wound. The point having now been securely
placed in the groove of the staff, with the back of the blade turned up-
wards and inwards, the rest of the membranous portion of the urethra,
and the left side of the prostate gland, are to be cut through by pushing
the knife inwards, along the groove of the staff, guided, as it were, and
followed by the left forefinger into the bladder.
In dissecting down to the membranous part of the urethra, and in
laying it open, as well as in cutting deeply towards the prostate gland,
the surgeon should never direct the edge of the knife straight downwards,
because he would thus cut the lower part of the rectum ; neither should
he cut horizontally, for the great pudic artery would be endangered.
While the surgeon is completing the deeper incisions, he should endeavour
to depress the rectum towards the right side with his left forefinger.*
If a beaked knife, or a gorget, is to be employed for the division of the
prostate gland, the operator, as soon as the membranous part of the
urethra has been laid open, is to place the beak of the knife or gorget in
the groove of the staff, and, being sure that this is effected, he is to take
hold of the handle of the staff himself ; bring it forwards, so as to elevate
the further portion of its groove away from the rectum ; and then push
the beak of the knife or gorget along the groove into the bladder. The
gorget divides the prostate gland as it enters, and so will a knife of broad
construction ; but when a narrow beaked scalpel is used, the division is
made as the instrument is withdrawn. Whatever instrument is em-
ployed, its edge is to be directed downwards and outwards.
When lithotomy is performed with a knife, it seems to me, that there
is great advantange in letting an assistant hold the staff throughout the
operation, because the operator's left forefinger is then of considerable
use to him as he is making the requisite incisions. As a staff nearly
straight, like that of Mr. Aston Key, will admit of being readily intro-
duced through the whole of the urethra, and it is much easier to pass a
gorget, or knife, along a straight groove than a convex one, it may be
asked, why such a staff is not generally preferred ? One objection made
to it is, that it occupies the surgeon's left hand, while the section is made,
instead of leaving it at liberty to press aside the rectum, and ascertain
when the incision has been carried far enough. " In children," says
Mr. Syme, " where the prostate is easily divided, and where, from the
necessarily small size of the instrument that is introduced, the difficulty
attending a curved direction of the groove is greatest, the straight staff
may be preferable." f
When a knife is used in an adult subject, it should be, with the handle,
about seven inches long ; for the distance of the bladder from the surface
of the perineum is sometimes such, that a shorter instrument would be
disadvantageous. When the prostate gland is enlarged, the neck of the
bladder is occasionally found to be elevated considerably away from the
perineum, as is well shown in one of the plates of Mr. Stanley's Treatise
* See Morton's Surgical Anatomy of the Perinrcum, p, 73.
f Syme's Principles, p. 511.
3D
770 OPERATIONS.
on the Lateral Operation. " In subjects of an advanced age," he re-
marks, "a deep perineum, as it is termed, is frequently met with. This
may be occasioned either by an unusual quantity of fat in the perineum,
or by an enlarged prostate, or by the dilatation of that part of the rectum
which is contiguous to the prostate and bladder. Under either of these
circumstances, the prostate and bladder become situated higher in the
pelvis than naturally, and consequently, at a greater distance from the
perineum." In such cases, Mr. Stanley prefers the gorget ; while, for a
young subject, a thin adult, or a case where the bladder is closely con-
tracted on the stone, he expresses a preference to the knife.
When the knife or gorget has entered the bladder, — a circumstance,
indicated by the discharge of urine from the wound, — and the requisite
section of the left lobe of the prostate has been made, and the knife or
gorget has been withdrawn, the surgeon is to pass his left forefinger into
the bladder, along the staff, which is then to be removed. With this
finger, the position of the stone is ascertained, and the forceps directed
accordingly. The finger should bear against the posterior wall of the
incision, in order to prevent the possibility of the forceps being passed
between the bladder and rectum, which accident has been known to
occur.* If the surgeon cannot immediately feel the stone with his
finger, he should then introduce the forceps, and use this instrument as a
probe for detecting the exact place of the calculus.
Some years ago, the forceps used to be made too thick and clumsy,
the inside of the blades being frequently furnished with teeth, intended
to keep the stone from slipping. These were exceedingly objectionable ;
first, because they often broke the calculus before it was out of the
bladder ; and, secondly, because those situated towards the back part of
the blades, when the stone happened to be grasped there, had the effect
of increasing the expansion of the instrument so considerably, that it
could not be drawn out.f The teeth have also a bad effect in pre-
venting the stone, when it is grasped with its long axis across to the
wound, from turning, as the forceps are drawn out, into a better position.
However, though teeth are not to be commended, the inside of the blades
ought to be somewhat rough.
The surgeon should always be provided with several pairs of forceps,
of different sizes. The handles should be two thirds of their length, and
the blades one third. The blades of some ought to be flat, for the ex-
traction of small calculi, or fragments ; while the blades of others should
be curved, to reach calculi behind the pubes, or prostate gland.J
In attempting to get hold of the stone with the forceps, the operator
should not expand the instrument as soon as it has arrived in the bladder,
without knowing where to direct it ; but he should first make use of it
as a kind of probe for ascertaining the precise situation of the stone. If
this be lodged at the lower part of the bladder, just behind its neck, and
be distinctly felt below the blades of the forceps, the forceps may be
opened immediately over the stone, and, after the blades have been de-
pressed a little, they are to be shut. Certainly, it is much more scientific
to imitate Cheselden, and use the forceps, at first, merely to ascertain
the position of the stone ; for, when this is known, the operator is far
* Dupuytren, M6m. sur 1'Operation de la Pierre; publ. par. L. J. Sanson. Fol.
Paris, 1836.
j- Langenbeck iiber eine einfache und sichere Methode des Steinschnittes, p. 43.
j Sir A. Cooper's Lectures, vol. ii. p. 253.
LITHOTOMY. 771
more able to grasp the extraneous body, in a skilful manner, than if he
were to open the blades of the instrument immediately, without knowing
where they ought next to be placed, or when shut. No man can doubt,
that the injury which the bladder frequently suffers from reiterated and
awkward movements of the forceps, is not an uncommon cause of a fatal
inflammation of it and the peritoneum.
If the calculus cannot readily be felt, the forceps should not be roughly
moved about, so as to bruise the bladder, and put the patient to insuffer-
able agony : on the contrary, they should be taken out, and the forefinger
gently introduced, with which the situation of the calculus may generally
be felt. If the stone cannot be felt with the finger, on account of the great
depth of the perineum, nor laid hold of with the forceps, on account of its
lying deeply behind the prostate gland, in the bas-fond of the bladder *,
the stone should be raised up, and brought within the grasp of the for-
ceps by means of the left forefinger passed into the rectum. When the
place of the calculus has been ascertained, the blades of the forceps are
to be separated, and the stone received between them : this must be
done with great gentleness. If the extraction be violently resisted, the
stone should be quitted, the forceps withdrawn, the position of the stone
examined with the finger, and, if necessary, its long axis made to corre-
spond to that of the bladder. Stones are often broken, which might be
removed whole, if the surgeon were less violent, and more cautious. The
mode of preventing a calculus from being broken is, after it has been
taken hold of, to put the thumb, or finger, between the handles, so as to
hinder them from being forcibly closed.f The forceps should always be
withdrawn from the bladder in the direction of the .external wound, with
a wriggling motion, and towards the lower angle of the incision, because
here the space between the ossa ischii is greatest.
When the stone is so large, that, turned in any position, it cannot be
extracted from the wound without violence and laceration, the surgeon
must either break it with a strong pair of screw forceps, or enlarge the
wound with a probe-pointed curved bistoury, introduced under the
guidance of the left forefinger. To the employment of the knife in this
circumstance, I must express my decided preference ; because breaking
the stone creates a risk of fragments being left behind, and, consequently,
of a return of the disorder. Some operators, instead of enlarging the
wound, so as to divide the bladder, prefer making a cut through the oppo-
site side of the prostate gland.
If the stone is broken, as many of the fragments are to be taken out
with forceps as can be readily removed, and the surgeon is then to feel
with his finger, whether any others still remain. If they do so, gentle
attempts must be made to extract them with the scoop. Lukewarm water
is also sometimes injected, with the view of washing them out.
Directly the calculus has been extracted, it should be examined ; if it
be rough, it is a presumptive sign that it is the only one ; if smooth on one
side, and rough on the other, or excavated at any surface, there may be
other stones. But, in every instance, the forefinger should be introduced,
to obtain decisive information on this point ; for it would be unpardbnable
to put the patient to bed while another calculus remains.
* See Morton, Op. cit. p. 74.
f Sir Astley Cooper's Lectures, vol. ii. pp. 254 — 2G2.
3 D 2
772 OPERATIONS.
DANGERS OF GORGETS.
The disastrous accidents, which occasionally result from the employ-
ment of gorgets, have induced many judicious surgeons to prefer finish-
ing the operation with a knife, or, at all events, some kind of cutting
instrument, not suddenly thrust into the bladder, like a common gorget,
with a risk of slipping away from the staff, and doing the most fatal
mischief. From mistakes and unskilfulness in this part of the operation,
I have known of two cases, in which the urethra was entirely severed
from the bladder, and the patients, after suffering excruciating torture
upon the operating table, died from the injury done, with the stone un-
extracted, the bladder not having even been opened. I have known the
gorget slip between the bladder and rectum, and patients lose their lives
with the stone unremoved. I have seen patients opened after this oper-
ation, in whom the gorget had injured the opposite side of the bladder.
I recollect other cases, in which the gorget slipped between the bladder
and pubes, and, of course, the calculus never had an opening made for
its extraction. In one or two cases, I have known the rectum to be cut
more than the bladder itself. Now, when it is further considered, that
besides such mischief, arising from the slipping or unskilful use of a well-
made gorget, a broad, badly constructed, or an ill-directed one, may
cut the pudic artery *, it must be confessed, that there is great cause for
wishing that lithotomy could always be performed with an instrument at-
tended with fewer dangers.
According to Klein, than whom few have written more sensibly on
lithotomy, that method of operating must be accounted the most advan-
tageous, in which the surgeon is best enabled to make with certainty
the right kind of incision ; that is to say, in which the opening in the
bladder may be made larger, or smaller, as may be judged requisite ; in
which also the fewest instruments are needed ; the least irritation pro-
duced ; the operation most expeditiously finished ; and in which the in-
struments will serve for every age and sex, and for all cases, whether the
stone be large or small. A scalpel of proper size is the only instrument
possessing such recommendations, and with it the operation can be per-
fectly executed,
Question, — Whether the opening should always be made large enough to
let the stone pass out, loithout contusion and laceration of the prostate gland
and adjoining part of tJie bladder.
Le Cat and Scarpa f are in favour of a very limited incision, and they
insist on the danger of carrying it at all beyond the base of the prostate
gland ; which method, they conceive, would expose the patient to the
perils of an effusion of urine in consequence of the vesical reflexion of
the deep perineal fascia over the prostate gland being divided. This
doctrine influences the practice of many distinguished modern operators,
amongst whom may be enumerated Bupuytren, Sir Benjamin Brodie, Mr.
Anthony White, Mr. Liston, and Mr. Syme. After having partly divided
the prostate gland, Sir Benjamin Brodie introduces a blunt gorget to dilate
the wound, and split the undivided portion of the prostate.J His ob-
servations convince him, that an incision of the prostate, extending into
* In using Cline's gorget, Klein cut the pudic artery. See Chir. Bemerkungen,
p. 15.
f Memoir on Hawkins's Cutting Gorget.
I On Diseases of the Urinary Organs, p. 278.
DANGERS OF GORGETS. 773
the loose cellular texture surrounding the neck of the bladder, is replete
with danger. Such a division of parts he thinks never necessary where the
calculus is of moderate dimensions, but cannot be avoided where it is of
large size ; and hence, the vast increase of danger in the latter examples.
On the other hand, Klein, one of the most successful lithotomists
in Germany, lays down, as the basis of his method, the necessity of
always dividing, not only the prostate gland carefully through, but also
a portion of the bladder itself. " Upon this basis," says he, " rests the
success of my operations ; and hence I invariably make it a rule to let the
incision be rather too large than too small, and never to dilate it with any
blunt instrument, when it happens to be too diminutive, but to enlarge it
with a knife, introduced, if necessary, several times."* My own observ-
ations lead me to believe, that though patients sometimes die of effusion
of urine in the cellular tissue of the pelvis, such effusion only happens
where the wound is not direct and free, the outer part of it being too
high up in relation to the cut in the prostate gland. The inference, drawn
by me from the many post mortem examinations which I have attended,
is, that effusion of urine in the cellular tissue of the pelvis is not the
usual cause of the fatal inflammation which ensues in the pelvis and
abdomen, but the injuries of the bladder — sometimes a diseased one —
from the protracted and rough manoeuvres frequently exercised to get a
calculus out of an opening of very insufficient size. The more easily the
stone has passed out, the greater has appeared to me to be the success of
the operation. I am therefore an advocate for letting the incision be
proportioned to the size of the stone, and avoiding all laceration and con-
tusion of the parts. The wound, of whatever size, should always be
direct : this will materially obviate the risk of effusion of urine, and all
occasion for the use of a tube to conduct the urine from the bladder
through the wound, — a practice now and then adopted, and, I believe,
chiefly recommended, in the Edinburgh schools.
As the questions, Whether a free incision through the prostate gland
should be made ? or, Whether this should be avoided as dangerous, and
dilatation and even laceration be preferred as safer ? are of the highest
practical importance, and by no means definitively settled, each view of
the matter being supported by good authorities, the present state of
surgery appears to demand, that very correct information should be
collected on these contested points. In particular, it seems desirable to
ascertain more fully, whether, in fatal cases, where a. free and direct incision
has been made, a common cause of death be really effusion of urine in the
cellular tissue of the pelvis ?
No dressings are necessary directly after the operation ; but a folded
napkin, or sheet, is to be placed under the nates, arid changed when-
ever it becomes wet.f Sir Astley Cooper does not consider it necessary
to keep the patient always on his back ; but says, the patient will derive
great relief from lying sometimes on his side. The scrotum, he ob-
serves, should always be supported with a bandage, so as hinder it from
being irritated by the urine.J The patient may drink freely of Iparley-
water, and afterwards of lemonade. Sir Astley Cooper gives his patients
at first large quantities of linseed tea, or barley-water with gum acacia in
* Practische Ansichten der Bedeutendsten Chirurgische Operationen, p. 27. Chesel-
den and Martineau, who had greater success, perhaps, than any other surgeons, also made
a free opening.
f Sir A. Cooper's Lectures, vol. ii. p. 269. \ Vol. cit. p. 268 — 270.
SD 3
774 OPERATIONS. )
it ; and when the danger of inflammation is over, beef-tea, broth, or gruel.
Klein gives an opiate, as soon as the patient is put to bed ; and on the
second day, the bowels are opened with a clyster, or gentle purgative.
Sir Astley Cooper sanctions the exhibition of opium, if the patient be very
irritable ; but, unless absolutely necessary, dispenses with it, as it checks
the action of the bowels. When the wound suppurates, Klein dresses it
with dry lint, and never finds any other application requisite, except
sometimes a little caustic towards the end of the case.* In proof of the
success of his method, he tells us, that in 1816 he had cut into the blad-
der seventy-nine times, and not one patient had died, unless where the
prostate gland, bladder, kidneys, or ureters, were diseased. Notwith-
standing the free division of the bladder, most of the patients got well in
from eight to fourteen days ; a few in a month ; and one alone was three
months in recovering. Though the sphincter of the bladder was divided,
no paralysis of it was the result. Except when the calculi were large, or
something unusual happened, the operation was completed in thirty se-
conds, or a minute. f When the wound begins to granulate, Sir Astley
Cooper ties the legs together : if this be done too soon after the oper-
ation, he says, it hinders the free escape of blood and urine from the
wound.J
OF WOUNDS OF THE RECTUM. -
Unless the operator cut very carelessly, and turn the edge of the knife
directly downwards, instead of obliquely sideways, the rectum cannot be
injured. With a gorget, however, there is really more danger of such an
accident, when the instrument slips out of the groove of the staff. Also,
when the rectum is distended with feces, it is more exposed to injury;
but, why should the surgeon ever operate,, without having previously
emptied that intestine ? I once saw a case, in which the rectum was
wounded with a lithotomy knife ; but the cut in the bowel healed, and
never gave any trouble.
OF WOUNDS OF THE PUDIC ARTERY.
No doubt, some of the profuse bleedings, which have taken place in
lithotomy, have riot proceeded from the pudic artery itself, but either
from the artery of the bulb, when the incision was made too high up, or,
in other cases, from the trunk of the perineal artery. I am surprised,
however, that M. Roux§ should assert, that, in directing the incision too
far laterally, there is no risk at all of wounding the pudic artery. This
is an observation which is entirely erroneous, and might encourage the
admirers of broad, long-edged gorgets to persevere with their instruments,
until they had learned from experience, that lithotomy can never be done
with safety, unless the incision be made, not only of sufficient size, but in
a proper direction. Klein twice had the ill luck to wound the trunk of
the pudic artery ; the first instance was in a child four years of age ;
the hemorrhage was suppressed by introducing into the wound a piece of
sponge, which was removed on the fifth day ; the part was healed in a
fortnight, but, for nine weeks, an incontinence of urine continued, which
* Chirurgische Bemerkungen, pp. 37 — 48.
f Practische Ansichten der Bedeutendsten Operationen, pp. 28, 29.
| Lectures, vol. ii. p. 269.
§ Relation d'un Voyage fait a Londres en 1814; ou Paralltile de la Chirurgie
Angloise avec la Chirurgie I'raiiQoise, p. 322. 8vo. Lond. 1815.
INFLAMMATION WITHIN THE ABDOMEN. 775
was ascribed to the pressure of the sponge.* The second case happened
in a patient, twenty-six years of age, from cutting too much sideways
with Cline's gorget. After the extraction of the calculus, the wound was
distended with a linen tent and a piece of sponge ; and the patient kept
quiet on the operating-table twenty-four hours, during all which time the
assistants relieved each other alternately in making pressure on the wound.
The patient lost four pounds of blood in the operation ; his pulse was ex-
ceedingly feeble, and rapid ; his countenance cadaverously pale ; and his
strength so much reduced, that the greatest fears were entertained for
his life.
When the trunk of the pudic artery is wounded, the calculus should
be taken out, and the wound distended with sponge.f If it were prac-
ticable to tie this artery, it would not be advisable, previously to the
extraction of the stone, the passage of which outwards would inevitably
force the ligature off the vessel. J In one case, operated upon by Sir
Everard Home, Sir Benjamin Brodie passed a ligature round the pudic
artery with a small, flexible, silver needle. The patient was a very thin
subject. § Pressure on the artery, where it crosses over the spine of the
ischium, was found useful in stopping an alarming hemorrhage from a
phagedenic ulcer of the penis, in a case under Mr. Travers || : the same
plan might also be worth trying for the stoppage of the bleeding after
lithotomy.
OF INFLAMMATION WITHIN THE ABDOMEN AFTER THE OPERATION.
The majority of patients, free from visceral disease previously to the
operation, who die in consequence of lithotomy, perish of peritoneal in-
flammation. Hence, on the occurrence of any tenderness, pain, and
tension over the abdomen, with great restlessness, thirst, heat of the
skin, and a small quick pulse, copious venesection should be put in prac-
tice. At the same time-, twenty or thirty leeches should be applied to
the hypogastric region. Much benefit will also be derived from the warm
bath, fomentations, blisters, the exhibition of oleum ricini, and emollient
clysters.
I have seen several old subjects die of the irritation of a diseased, thick-
ened state of the bladder, continuing after the stone had been extracted.
They had not the acute symptoms, the inflammatory fever, the general
tenderness and tension of the abdomen, as in peritonitis ; but they referred
their uneasiness to the lower part of the pelvis ; and, instead of dying in
the course of two or three days, as those usually do who perish of perito-
neal inflammation, they, for the most part, lingered for two or three
weeks. In such cases, opiate clysters, and blistering the hypogastric
region, are proper.
In some instances, collections of matter form in the vicinity of the neck
of the bladder. Gangrene of the scrotum from the violence used in the
extraction of the stone, and an extravasation of urine in the cellular
tissue, are most likely to be avoided by making a direct opening into the
* Chirurgische Bemerkungen, p. 11.
t A cannula should be passed through the sponge, for the easy evacuation of the
urine. See C. J. M. Langenbeck iiber cine einefache und sichere Methode des
Steinschnittes, p. 58. 4to. Wurzburg, 1802.
f Klein, Op. cit. pp. 12 — 21.
§ Sir B. Brodie on Diseases of the Urinary Organs, p. 299. ed. 2.
f| See Harrison's Surgical Anatomy of the Arteries, vol. ii. p. 101., and Morton's
Surgical Anatomy of the Perinseum, p. 52.
3 D 4
776 OPERATIONS.
bladder, and not beginning the incision too high up towards the scrotum.
With the same view, many operators avoid carrying the incision In the
prostate gland beyond its base.
AMPUTATION.
AMPUTATION of limbs is performed either in the continuity of them, or
in one of the articulations; each of which modes, however, cannot always
be practised indifferently — the choice depending upon the situation, ex-
tent, and nature of the disease, or injury, for which the removal of the
part becomes indispensable. In all amputations at joints, it is the general
practice to make a flap of flesh for covering the end of the bone ; but
when the operation is performed at another part of the limb, it is fre-
quently at the option of the surgeon, whether the method adopted be
amputation with one or sometimes two flaps •, or amputation by a circular •, or
an oval, incision. In this metropolis, the circular incision is more com-
mon than flap-amputation, which, however, has now many advocates,
because, it is more quickly performed, and consequently less painful,
than the circular incision ; the parts are cut smoothly, and left in a state
favourable to union ; and a better covering is afforded to the bones, than
can be obtained from any modification of the other operation.*
That it is the quickest method of amputation, and that it forms an ex-
cellent covering for the ends of the bones, I believe is generally admitted ;
but some of the most experienced surgeons in London, amongst whom is
Sir Astley Cooper, are of opinion, that a stump after a flap amputation is
generally followed by more copious suppuration, and less frequently unites
by adhesion, than another formed by the circular incision. This is a
point of importance, open to the observation of the profession at large,
who have now abundant opportunities of coming to a sound decision. It
seems to me, that the quickness and facility of flap amputation, the cer-
tainty with which the soft parts are smoothly cut, and the greater
frequency with which the protrusion of the end of the bone is avoided,
are its principal advantages. In particular cases, it is decidedly the only
method applicable to circumstances ; in others, the surgeon may make his
choice.
Before proceeding to the description of the methods of taking off
limbs, let me just remind the reader of one of the best fundamental rules
for our guidance in the performance of amputation : " as little of the
flesh should be cut away as possible ; but the more bone is removed, the
better."f
CIRCULAR AMPUTATION OF THE THIGH.
The thigh should be amputated as low as the disease will allow. The
patient is to be placed on a firm table, with his back properly supported
by pillows, and assistants, who are also to hold his hands, and keep him
from moving too much during the operation. The ankle of the sound
limb is to be fastened, by means of a garter or handkerchief, to the nearest
leg of the table.
* See Syme's Principles, p. 198.
t " On doit couper des chairs le moins qu'il est possible, et des os, Ic plus qu'on
peut." J. L. Petit, Traite des Maladies Chirurgicales, torn. iii. p. 150.
AMPUTATION OF THE THIGH. 777
TOURNIQUET.
If this instrument be used, its pad should be placed exactly over the
femoral artery in as high a situation as can conveniently be done. When
the thigh is to be amputated far up, a tourniquet is inconvenient, and, in
this case, an assistant is to compress the femoral artery, as it passes over
the os pubis, with his fingers or thumb, or any commodious instrument,
having a round blunt end, adapted for making direct pressure on the
vessel, without injuring the integuments.
In amputation, the greater number of surgeons in this metropolis still
employ the tourniquet ; but others prefer compression of the artery by a
trusty assistant, when such is at hand. In University College Hospital,
I have never seen the tourniquet employed in amputations. If the
patient, however, were exceedingly reduced, I believe, that the tourniquet
ought to be employed. Putting out of present consideration the assistant's
liability to fail in regularly commanding the flow of blood through the
artery, on account of the violent struggling of the patient, we are to
remember that, besides this vessel, there are others concerned in supply-
'ing the thigh with blood, which are branches of the internal iliac, and come
out of the openings of the pelvis ; as, for instance, the arteria obturatoria,
the glutea, and the ischiadica. Hence, pressure upon the femoral artery,
below Poupart's ligament, can never stop the bleeding, but incompletely.
My colleague, Mr. Liston, objects to the use of a tourniquet, because
compression on all the circumference of a limb causes venous congestion
in the whole of the member below such compression, and a rapid oozing
from the veins on the face of the stump. " I would rather trust (says he)
to no very efficient assistant, than put on a tourniquet." I fully coincide
with him on one point, which is, that when a tourniquet is used, it should
not be put on, till the moment when the surgeon is ready to begin the
incisions.*
FIRST INCISION.
The operator is to stand on the right side of the patient, whether the
right or left limb is to be removed. By this means, he acquires the ad-
vantage of always having his left hand next the wound, so as to be of
very essential assistance. This advantage more than counterbalances the
inconvenience of having the right limb in the way of the operator, when
the left thigh is to be amputated.
An assistant, firmly grasping the thigh with both hands, is to draw the
skin and muscles upwards, while the surgeon makes a circular incision, as
quickly as possible, through the integuments down to the muscles. When
the integuments are sound in the place of the incision and above it, their
retraction by the assistant before they are cut through, and a very slight
division of the bands of cellular substance with the edge of the amputat-
ing knife towards the point, will generally preserve a sufficient quantity
of skin for covering, in conjunction with the muscles cut in a mode
about to be described, the extremity of the bone ; and the painful method
of dissecting up the skin from the fascia, and turning it back, previously
to dividing the muscles, may be considered useless and improper in all
amputations of the thigh, where the skin retains its natural moveableness
and elasticity.
* See Elements of Surgery, Part iii: pp. 361, 362.
778 OPERATIONS.
It appears to Mr. Guthrie, that, in primary amputations, or those done
at an early period after the receipt of a gunshot injury, while the part of
the limb, where the incisions are to be made, is in the natural state, and
the skin loose and moveable, " it will be sufficient to touch the thread of
membrane, or fascia adhering below, with the point of the same (the am-
putating) knife, to give ample covering for an excellent stump, without
putting the patient to the torture of having his skin pinched and dissected
back, for the space of a couple of inches, for four or five minutes." At
the same time, he particularly insists on the utility of dividing the fascia
and integuments together, by which means, the latter can be retracted
much further than would otherwise happen.
In operations, however, performed from the third to the twelfth day
after the receipt of the wound, and near the injured parts, Mr. Guthrie
admits of the propriety of dissecting the integuments a little way up
from the fascia, as in these cases the retraction, effected by the assistant,
and the natural elasticity of the skin, will not avail in saving enough of it
to cover the surface of the stump well ; yet even here he rightly dis-
approves of turning back the separated integuments, as is often done,
like the top of a glove.
" In secondary amputations," says he, " with the exception of those, in
which the operation is required in parts actually unsound, the integu-
ments may be sufficiently retracted, without any formal dissection of
them from the subjacent fascia." *
I have said, that the surgeon is to begin the operation by making an
incision through the skin all round the limb. The generality of surgeons,
rightly considering this as .one of the most painful parts of the operation,
do it with as much quickness as possible, and therefore carry the knife
all round the member with one sweep, the hand, which holds the knife,
being carried round under the limb until the edge can be placed perpen-
dicularly on the skin covering the extensor muscles. Excepting the ap-
pearance of greater skill, and a little greater quickness, however, the
foregoing mode of dividing the skin all round the limb with one stroke of
the knife, has no particular adrantage over the method of completing the
cut with two sweeps of the knife.
OF DIVIDING THE MUSCLES.
The ancient surgeons used to cut directly down to the bone at once,
and the frequent consequence was a conical or sugar-loaf stump, ex-
tremely unfit for bearing any degree of pressure, and, therefore, kept
healed with difficulty. The end of the bone, in fact, often protruded
beyond the soft parts. At length, however, the improvement was made
of cutting the integuments through first, and then the muscles : a method,
well known amongst surgeons by the name of the double incision.
But, although the double incision enabled the surgeon to save skin,
and saw the bone higher up, a conical stump, and projection of the bone,
sometimes followed. The great innovations, which ultimately proved
nearly effectual in the prevention of such tedious miserable cases, were,
besides the saving of skin, the oblique division of the muscles, suggested
by Alanson ; the cutting of the loose muscles first, and the fixed ones
afterwards, proposed by Louis ; and the immediate closure of the wound,
* G. J. Guthrie on Gunshot Wounds of the Extremities, requiring the different
Operations of Amputation, with their after Treatment, &c. pp. 84, 85. 8vo. Lond.
181.5.
AMPUTATION OF THE THIGH. 779
after the bleeding had been stopped, the great utility of which was first
brought to light in the early trials of what are called flap-amputations.
M. Louis, for whose memory every admirer of surgical science ought
to entertain sjncere respect, first discerned the principal cause of the
projection of the bone. He observed, that the muscles of the thigh be-
came retracted in an unequal manner when divided ; those which are
superficial, and extend along the limb more or less obliquely, without
being attached to the bone, becoming retracted with greater force than
others which are deep, and, in some measure, parallel to the axis of the
femur, and fixed to this bone throughout their whole length. Their re-
traction begins at the moment of the operation, and, for some time after-
wards, continues unfinished. Hence, the effect should be promoted, and
be as complete as possible, before the bone is sawn. With this view,
M. Louis practised another kind of double incision : by the first, he cut,
at the same time, both the integuments, and the loose superficial muscles ;
by the second, he divided those muscles, which are deep, and closely con-
nected with the femur. On the first deep, circular cut being completed,
M. Louis used to remove the band encircling the limb above the track of
the knife, in order to allow the divided muscles to become retracted
without any impediment, and he then cut the deep muscles, on a level
with the surface of those which had been first divided, and which were
now in a retracted state. In this way, he could evidently saw the bone
very high up, and the painful dissection of the skin from the muscles was
avoided.*
Alanson's mode of amputating was as follows : — The integuments
having been divided by a circular wound, the knife was applied close
to the margin of the retracted skin, upon the inner edge of the vastus
internus, and, at one stroke, an incision was made obliquely through the
muscles, upward in respect to the limb, and down to the bone : in other
words, the cut was made in a direction which laid the bone bare, about
two or three fingers' breadths higher than a perpendicular incision would
have done. The operator now drew the knife towards himself, so that its
point rested upon the bone, still observing to keep the instrument in the
same oblique position, in order that the muscles might be divided all round
the limb in that direction, by a proper turn of the knife. During the per-
formance of this movement, the point of the knife was kept in contact
with the bone round which it revolved.-j*
Many writers have objected to the difficulty of making the oblique
* See Me'moire sur la Saillie de 1'Os apres 1'Amputation des Membres; ou Ton
examine les causes de cet inconvenient, les moyens d'y reme'dier, et ceux de la pre-
venir. Also, Second Memoire sur 1'Amputation des Membres, Mem. de VAcad. de
Chirurgie, torn. v. p. 244. and 401. edit, in 12mo. And Nouvelles Observations
sur la Retraction des Muscles apres 1' Amputation de la Cuisse, et sur les Moyens de
la prevenir. Op. cit. torn. xi. p. 63. edit, in 12mo. Baron Dupuytren's mode of
amputating was as follows: — With one sweep of the knife he divided the integuments
and muscles down to the bone, most frequently perpendicularly, but sometimes obliquely.
The retraction of the soft parts by the assistant who grasped the limb, and thf contrac-
tion of the muscles, instantly gave to the wound the shape of a cone. At the base of
this cone, and on a level with the retracted skin and muscles, he applied the knife again,
and cut through whatever soft parts presented themselves there. Thus he was enabled
to saw the bone more than six inches above the first incision, and to complete the oper-
ation with surprising quickness. (See Le9ons Orales de Clinique Chir. t. 4. p. 298.)
By this method, the patient is saved from all the pain of dissecting the skin from the
fascia, or the fascia from the muscles. It is as quick as a flap-amputation.
j- See Alanson's Practical Obs. on Amputation, 2d ed.
780 OPERATIONS.
incision exactly as Alanson has directed, and Mr. Hey even questions the
possibility of the practice, without a different result from what was
intended. It is evident (says Mr. Hey) that a conical incision through
the muscles of the thigh cannot be made with a continued stroke, in the
usual mode of amputating. For, supposing the edge of the knife to have
once penetrated obliquely through the muscles, so as to be an inch higher,
when arrived at the bone, than when it penetrated the surface ; if the in-
cision be continued with a flowing stroke, the knife must then cut the
surface of the undivided muscles an inch higher than at the commence-
ment of the incision. * How far it is actually practicable to keep the
point of the knife in contact with an exact circle on the bone, during the
oblique passage of the instrument all round the member, it is not for me
to say, because, seeing its difficulty, I have never attempted it ; nor can I
suppose, that Alanson himself ever really did what he literally recom-
mends. Of one thing also I am sure, that I have seen many surgeons, in
their attempt to do this business after Alanson's directions, get so high
up as to cut the reflected skin.
The late Mr. Hey is not the only, nor the earliest writer, who has
pointed out the inaccuracy of Alanson's directions. Richter has offered
several judicious criticisms upon them, which perfectly coincide with
Mr. Hey's views. It is remarked, that when the knife, with its edge
turned obliquely upwards, has reached the bone, a flap is actually formed
on the side where the incision is practised : and the edge of the knife is
now three inches higher than the cut in the skin. In this state, the sur-
geon cannot possibly continue the incision. The only thing which he can
now do, is to place the knife on the opposite side of the thigh in the same
manner, and make a flap there. The operation,, says Richter,, is then
rather a flap-amputation, not done in the best way, than an operation
really practised as Alanson thought possible. By following precisely his
instructions, Richter thinks it would be quite impracticable to form a
hollow stump, though perhaps it might be done by reiterated oblique strokes
of the knife all round the limb. But, he exclaims, what a stump there
would then be, and what a method of operating ! He comments also
on the difficulty of making a knife cut properly by mere pressure, as
would be the case, were its point kept unremittingly against the bone,
in carrying the incision round the member; on the preferable nature
of amputation with a flap to this method, the wound left by which is
longer in healing ; and on the pain and delay of separating the skin to
be saved, — a proceeding altogether unnecessary in amputating with a
flap.f
Many excellent surgeons, whom I have seen operate, do not cut at
once obliquely down to the bone, after the integuments have been divided
and retracted ; but so far adopt the principles of M. Louis, as to divide
the loose muscles first, and lastly, those which are intimately attached to
the bone, taking care, with a scalpel, to cut completely through the deep
muscular attachments, about an inch higher up, than could be executed
with the amputating knife itself. This last measure causes very little
pain, and has immense effect in averting all possibility of a subsequent
protrusion of the bone, or of a bad sugar-loaf stump. Such used to be
the practice of Mr. Hey, who calls it the triple incision^: and Mr.
* Hey's Practical Observations in Surgery, p. 529. ed. 2.
f Anfangsgr. der Wundarzn. b. vii. p. 187.
| Hey's Practical Observations on Surgery, p. 526. edit. 2.
AMPUTATION OF THE THIGH. 781
Guthrie *, in his account of amputation of the thigh, is a decided advo-
cate for a similar mode. In this method, however, the advantage of the
oblique incision through the different layers of muscles, was invariably re-
tained. I believe that, in the circular amputation of the thigh, a combi-
nation of the principles of Alanson with those of M. Louis, is the best.
However, I am obliged to confess, that the attempt to divide the loose
muscles first, and then the more fixed ones, is apt to make a hasty surgeon
cut the whole, or a great part, of the same muscle through more than
once ; a fault, which deserves to be reprobated in the strongest terms.
USE OF THE RETRACTOR.
Having cut completely down to the bone, a piece of linen, somewhat
broader than the stump, should be torn at one end, along its middle part,
to the extent of about eight or ten inches. This is called a retractor,
and is applied by placing the exposed part of the bone in the slit, and
drawing the ends of the linen upward on each side of the stump. Thus
the retractor will evidently keep every part of the surface of the wound
out of the way of the saw. In circular amputations, I have seen the saw
do so much mischief, in consequence of neglecting to use the retractor,
that when the amputation is performed with a circular incision, my con-
science obliges me to censure the employment of the saw without a
defence of the soft parts by this simple contrivance. I think no one will
say, that the retractor can do harm ; and I know, that many who have
been with myself eye-witnesses of the mischief, frequently done by the
saw in amputations, are deeply impressed with an aversion to the neglect
of this bandage. I have often seen the soft parts skilfully divided ; and
the operators, directly afterwards, lose all the praise, which every one was
ready to bestow, by their literally sawing through one half of the ends of
the muscles, together with the bone. But, besides defending the surface
of the stump from the teeth of the saw, the retractor will undoubtedly
enable the operator to saw the bone higher up, than he otherwise could
do.f
OF SCRAPING THE BONE.
Another proceeding, not to be imitated, is the practice of scraping up
the periosteum with the knife, as far as the muscles will allow. This
is a sentiment, in which I must still continue to join the experienced
and judicious Petit, notwithstanding a modern author J has actually de-
voted a section of his book to the praise of what is here particularly
condemned. The chief argument for the practice, urged by Briinning-
hausen, is, that, by scraping the periosteum upwards from the bone, a
portion of the detached membrane will yet remain connected to the mus-
cular fibres, thus pushed back, and afterwards admit of being brought
down with them over the sawn bone. As, however, 1 have seen the bone
* On Gunshot Wounds of the Extremities, &c. p. 86.
•f- J. L. Petit earnestly recommeds the employment of a linen retractor ; when a sur-
geon once told him, that he did not use it, because the teeth of the saw were $>i to get
entangled in it, he answered : " II est vrai que cela peut arriver lorsqu'on ne sait pas le
placer; les meilleures manieres d'operer out leur inconvenient, si on neglige les cir-
constances qui les font reussir." Traite" des Maladies Chir. t. iii. p. 152. Dupuytren
Is another distinguished advocate for the use of the retractor. See Le9ons Orales, &c.,
l. 4. p. 299.
f H. J. Bru'nninghausen, Erfahrungen und Bemerkungen iiber die Amputation,
p. 67. Bamberg, 1818.
782 OPERATIONS.
extensively scraped, without an exfoliation being a regular effect of the
method, I do not consider, as Petit did, that a part of the bone must in-
evitably die, after the periosteum is thus freely scraped away ; but I look
upon the improper and useless separation of this membrane as one of the
circumstances, which tend to produce the exfoliations that sometimes
happen after amputations. At all events, it is a superfluous measure, as
a sharp saw, such as ought to be employed, will never be impeded by so
slender a membrane as the periosteum.* All that the operator ought to
do is, to take care to cut completely down to the bone, round the whole
of its circumference. Thus a circular division of the periosteum will be
made, and here the saw should be placed.
OF THE MANNER OF SAWING THE BONE.
As Petit justly remarks, this part of the operation is by no means easy
to a person unaccustomed to handle a saw. The principal difficulty arises
from the bone being sawn up in the air (as it were) ; at least, the part is
in general but very imperfectly fixed by two persons, who, however
strong they may be, cannot resist the saw, and hinder the limb from being
shaken, whereby the direction of the instrument becomes altered. Be-
sides the two assistants rarely act so well in concert together as always to
hold the limb in the same direction, and with an equal degree of strength.
It is true, such irregularity is not of much consequence at first, while the
bone is not half sawn through : but, as soon as the instrument has cut to
this depth, the irregular movements of the assistant?, who hold the lirnb,
make the sawn surfaces come nearer together, and the saw is so pinched,
or locked betwixt them, that it cannot stir, in one direction or the other.
A skilful surgeon (observes Petit) may obviate the difficulty by sup-
porting the part with his left hand, as Mr. Liston actually prefers, and
resisting or yielding at seasonable opportunities to such circumstances as
impede the motion of the instrument. But the difficulty may depend
upon the saw itself, when its blade is not duly stretched, the teeth not
well turned alternately to the right and left, their points not in good
order, their edges not sharp enough, or they are not filed obliquely, so
that the bone-dust may be readily thrown off to each side. The latter
object requires also, that the blade of the saw at the teeth part should be
rather thicker than the rest of it, or else the fissure in the bone would be
completely filled with the instrument, and the bony particles, not easily
escaping, would obstruct the movements of the saw. In order to saw the
bone as close to the flesh as possible, Petit says the nail of the index
finger is to be placed on the point where the sawing is to begin. Many
surgeons, however, find it more convenient to use the nail of the left
thumb for this purpose. The flesh being retracted, the saw is now to be
applied exactly at the angle formed by~the nail and the bone ; and the in-
strument is to be worked very gently, and with scarcely any more pressure
than that of its own weight, until a groove is cut, from which it will not
start : then the force is to be gradually increased.f
The saw should cut with both edges, whether the instrument be
* Petit's opinion is thus expressed : " Si par trop d'exactitude, on depouille trop
en avant les os de leur perioste, 1'exfoliation, qui devient inevitable dans ce cas, se fait
long-temps attendre, et retarde beaucoup la gueVison ; je prefere done de scier le pe-
rioste, avec les os ; j'ai toujours e"prouve que cette me*thode £toit moins douloureuse et
qu'elle e*viait souvent 1'exfoiiation." Vol. cit. p. 158.
f Petit, Traite des Maladies Chir. t. iii. p. 159, 1GO.
AMPUTATION OF THE THIGH. 783
moved backwards or forwards, by which means, as a modern writer *
has remarked, the operation will be expedited, and the splintering of the
bone, when it is nearly divided, prevented, inasmuch as the surgeon,
when he uses a saw which cuts in both directions, has it in his power to
finish the latter part of the division of the bone entirely with backward
sweeps of the instrument, which are always the most regular and gentle.
In order to form the groove for the saw, it is best to begin by drawing
the instrument across the bone with a backward sweep, the teeth near
the handle being first applied to the part close to the operator's left
thumb or finger nail, and the whole extent of the edge is then to be
steadily and briskly drawn back to the point. The movements of the saw
should never be short and rapid, but every stroke of the instrument
should at first be long, bold, and regular, without too much pressure.
When about two thirds of the bone are cut through, the pressure and
force must be lessened, and, towards the end of the business, two or
three gentle movements of the saw backward will complete it, without
risk of an extensive splintering. In the latter part of the sawing, the
assistant who holds the leg, must be careful to avoid depressing the con-
dyles of the femur, as it would inevitably break the bone, previously to
its complete division. Indeed, it is difficult to say, whether this mis-
management, or the rough, unskilful mode of using the saw itself, is the
most frequent cause of the latter accident. The assistant certainly has
rather a delicate task to perform, because if he raises the limb too much,
he pinches the saw ; if he depresses it, he breaks and splinters the
bone.f
If the bone should break, before the sawing is finished, the sharp pro-
jecting spicula?, thus occasioned, must be removed by means of the bone
nippers.
OF STOPPING THE HEMORRHAGE.
After the removal of the limb, the femoral artery is to be taken hold
of with a pair of forceps, and tied, without including the accompanying
branches of the anterior crural nerve in the ligature. None of the sur-
rounding flesh ought to be tied ; but the ligature should be placed round
the artery, just where it emerges from its lateral connections. Desault
recommends tying the femoral vein, as well as the artery ; because when
the former remains open, and the bandage compresses the upper part of
the limb too forcibly, the venous blood returns downward, and hemor-
rhage takes place.;}: Mr. Hey also met with a few instances of bleeding
from the femoral vein, and therefore he generally inclosed it in the liga-
ture along with the artery.§ The risk of bringing on phlebitis, however,
should teach us to abstain from this practice, which is not necessary, be-
cause compressing the mouth of the vein a minute or two with the finger,
will put an end to the bleeding from it, provided the tourniquet is re-
* G. J. Guthrie on Gunshot Wounds of the Extremities, &c. p. 89.
•f- It is on this account that Mr. Liston insists upon the rule, that the manag^nent of
the lower part of the limb should always be by the person using the saw. See Elem. of
Surgery, Part iii. p. 364.
| (Euvres Chir. de Desault par Bichat, torn. ii. p. 550. Venous hemorrhage almost
always ceases on the removal of the tourniquet, or any other tight bandage. At the
present day, indeed, the practice of tightly bandaging stumps is completely abandoned
in London.
§ Hey's Practical Obs. on Surgery, p. 530. ed. 2.
784? OPERATIONS.
moved, and no bandage applied. The smaller arteries are usually taken
up with a single or double tenaculum. After tying as many vessels as
require it, one half of each ligature is to be cut off near the surface of
the stump. The right qualities of ligatures, used for securing blood
vessels, having been considered in the chapters on hemorrhage and
aneurism, it is unnecessary now to return to that interesting topic ; nor
shall I here speak again of the proposal of removing both ends of the
ligature, close to the knot.
When the large bleeding vessels have been tied, the tourniquet should
be slackened, and the wound well cleaned, in order to detect any vessel,
which may lie concealed with its orifice blocked up by coagulated blood ;
and, before the dressings are applied, the whole surface of the wound
should be examined with the greatest accuracy. By this means,, a pul-
sation may often be discerned, where no hemorrhage has previously ap-
peared, and a small clot of blood may be removed from the mouth of a
considerable artery.
As the lodgment of much coagulated blood would be unfavourable to
the speedy union of the wound, the surgeon has an additional motive for
being careful to make its whole surface clean with a sponge and water,
before it is finally closed. The number of arteries, requiring to be tied,
will depend very much upon the incision having been made in sound and
uninflamed parts, or upon parts in a state of inflammation, swelling, and
disease. This accounts for the truth of an observation, made by military
surgeons, that, in amputations performed immediately, or soon after the
receipt of an injury, there are fewer vessels to be taken up, than in what
are termed secondary, or long delayed operations.*
I have occasionally seen examples, in which it was not necessary
to take up a single artery. A young child was run over by a hackney
coach, the wheel of which crushed the lower part of the leg, and ren-
dered immediate amputation necessary. The operation was done by the
late Mr. Ramsden without delay ; no vessel was tied ; and the stump
healed without any subsequent bleeding. Some instances have also
fallen under my notice, where arteries like the ulnar and anterior tibial,
even in adults, required no ligature. The absence of hemorrhage is some-
times explicable by the clot of blood, formed in the large vessels in cases of
gangrene. Thus, a modern surgeon tells us, that he amputated the arms
of two Cossacks, four months after the limbs had been shot through
above the elbow, and while they were affected with hospital gangrene :
not a vessel was tied ; no secondary hemorrhage arose ; arid the stumps
healed in the most favourable manner.f
OF DRESSING THE STUMP.
The skin and muscles are now to be placed over the bone, in such a
direction that the wound may appear only as a line, across the face of the
stump, with the angles at each side, where most of the ligatures are to
be brought out, as their vicinity to either angle directs. The skin is
commonly supported in this position, by long strips of adhesive plaster,
applied from below upwards, across the face of the stump. Over these,
and the ends of the ligatures, it is best to place some pieces of lint,
spread with the unguent, cetacei, in order to keep them from sticking,
* See Guthrie on Gunshot Wounds, &c. p. 90.
f Klein, Practische Ansichten der bedeutendsten Chirurgischen Operationcn, lies
Heft. p. 62. 4 to. Stuttgart, 1816.
OF DRESSING THE STUMP. 785
which becomes a troublesome circumstance, when the dressings are to be
removed. I am decidedly averse to the plan of loading the stump with
a mass of plasters, pledgets, compresses, flannels, &c. I see no reason
why the strips of adhesive plaster, and a pledget of simple ointment,
should not suffice, when supported by two cross bandages, and a common
linen roller, applied not too tightly round the limb, from above down-
ward. The first turn of the roller, indeed, should go round the patient's
body; and, being continued down, will fix the two cross bandages over
the end of the stump. Here, as after all other operations, the dressings
should generally be superficial, and make no compression : if the vessels
have been properly secured, there is no risk of hemorrhage ; and if they
have not, it is not a little degree of constriction that will hinder bleeding.
Besides, much pressure has the serious inconvenience of causing a ten-
dency to bleeding depending on obstruction of the venous circulation ;
irritating the parts ; exciting inflammation and suppuration, causing ab-
sorption of the cellular tissue, and a sugar-loaf stump.*
When the weather is not too cold, it is an excellent rule to dress
stumps lightly, and to cover them with linen, or lint, wet with cold water.
Mr. Listen commonly follows this plan, using two or three sutures, and
no adhesive plaster, till the oozing of blood has entirely ceased, at the
end of about six or eight hours. Then he has recourse to slips of oiled
silk, rendered adhesive with a solution of isinglass in brandy. Inter-
stices are left for the sutures and ligatures. These isinglass plasters do
not irritate, and are not loosened by the discharge. After twelve or
twenty-four hours, the sutures are cut and removed. If the case prove
favourable, Mr. Liston finds no change of dressing requisite, till the stump
is healed. It was the custom of Dupuytren to let more than an hour
elapse before the stump was dressed, in order that he might not be
obliged to take off the dressings again by the quick return of bleeding.f
The part is kept cool, and the discharge, if it be sufficient to fall on the
oiled cloth covering the pillow, on which the stump is laid, is wiped away
from time to time.
If the common mode of closing stumps with adhesive plaster be
adopted, the dressings should never be removed before the third day ;
but, in general, it is quite soon enough to change them on the fourth or
fifth : when the weather is hot, and there is much discharge, they should
be taken off earlier than under other circumstances. The favourable
healing of a stump will depend very much upon the skill and tenderness
with which the dressings are changed, more especially the first dress-
ings. In order to facilitate the removal of the plasters, they should be
first thoroughly wet with warm water, which is not to be rubbed upon
them with a sponge, but allowed to drop, or flow over them. Each
strip of plaster should be taken off, by raising its ends, and drawing them
gently up together towards the extremity of the stump, by which means
the surgeon will avoid pulling the recently united parts away from each
other. During the change of the dressings, an assistant is always ti
support the flesh and keep it from being retracted ; and for the more
complete prevention of the same disadvantage, it is a good rule nevrn' to
let every strip of plaster be off the limb at one time ; but, as soon as
* (Euvres Chir. de Desault, t. ii. p. 552.
t Le9ons Orales, &c. t. iv. p. 332. I believe, that we are now falling into the
serious error of leaving stumps too long unclosed, so that the exposure of the wound
leaves little or no chance of union of any part of it by the first intenuon.
3 E
786 OPERATIONS.
some are removed, to put on others, before' the rest are loosened and
taken away. It is hardly necessary to add, that, when matter is col-
lected within the stump, it should be gently compressed out with a
sponge, in doing which the pressure should be so regulated, as not to
force back the flesh.
At the end of five or six days, the surgeon may begin to try, in a
gentle manner, whether any of the ligatures are loose. However, he
should not use the smallest force, nor persist, if the trial create pain.
One would hardly try, whether the ligature on the femoral artery were
loose bofore the fourteenth or sixteenth day.
FLAP-AMPUTATION OF THE THIGH.
Although this operation is not universally regarded as the best method
for ordinary cases, its advantages, under particular circumstances, are
generally acknowledged, and it is unquestionably a rapid and showy
method. In Germany, flap-amputations seem to have numerous advocates ;
and, I believe, that whoever will take the trouble of inquiring into the
actual state of surgery in that country, will find this method of operating
quite as frequently practised as the circular incision.* Desault employed
both modes on the thigh, or arm, indifferently ; though he did not adopt
flap-amputation in the leg, or fore-arm.f In England, where the latter
method first originated with Lowdham, and where, at various periods, it
has been strongly commended and improved by several men of great
eminence, it has not retained so many advocates as in Germany and
Scotland, where the successful manner in which it was practised by
Mr. Liston, and the able remarks of Mr. Syme J in its favour, made it
the common method.
All British surgeons agree, however, that flap-amputations are generally
the best, when a limb is to be taken off at a joint, and, also, in every
instance in which the skin and soft parts are quite sound on one side of a
member, while, on the other, they are diseased, or destroyed for a con-
siderable extent upwards. Here, amputating with a flap will be the means
of preserving more of the limb than could be saved by the circular in-
cision, and becomes praiseworthy on the very same principle, which has
sometimes been thought to render the latter method most eligible under
ordinary circumstances.
As Mr. Hey has remarked, sometimes the integuments of the thigh
are in a morbid state on one side of the limb, while they are sound on the
other. In this case, a longer portion of integuments and muscular flesh
must be left on the sound side ; which will not prevent the formation of
u good stump. The morbid state of the anterior or posterior side of the
thigh sometimes extends so far above the knee, that it is advisable to
amputate with a flap.§
Were the thigh-bone injured high up, and had gangrene extended
about the trochanter major and posterior upper part of the thigh, if the
* Consult C. C. Siebold, Diss. de Amputatione femoris cum relictis duobus carnis
segmentis, Wirceb. 1782; Grate, Normen f'iir die Ablosung grosserer Gliedmassen.
Bi-rlin, 1812; Richter, Anfangsgr. der Wundarzneykunst, b. vii. ; Kap. 7. 8vo.
Gottingen, 1804; Klein, Practische Ansicbten der bedeutendsten Cbiriirgisclu'ii
Operationen, Ites Heft. 4to. Stuttgart, 1810'; H. J. Brunningliausen, Erf'ahrmi^en
und Bemerkungen iiber die Amputation, 12mo. Bamberg, 1818.
T (Etivres Cbir. de Desault, t. ii. p. 547.
| See Edinb. Mod. and Surg. Journ. 1823.
§ Key's Practical Obs. in Surgery, p. 531. ed. 2.
AMPUTATION OF THE THIGH. 787
head of the femur were sound, and the patient able to bear the operation,
I would make a flap at the inner and upper part of the member.* Indeed,
a flap-amputation of the thigh must always be attended with some dif-
ference, according as the soft parts on all sides of the limb happen to be
sound, or not. When, in consequence of the flesh being severely injured,
or diseased on one side, the flap must be entirely formed on the other, it
will be necessary to save more skin and muscle in the latter situation,
than if the surgeon had it in his power to form two flaps for covering the
end of the bone. If possible, however, there should be two flaps, and
placed laterally, or anteriorly and posteriorly, according to circumstances.
In an operation high up the limb, if the flaps be lateral, Mr. Listen finds
that there will be risk of a protrusion of the bone, because no muscles
are left to oppose the muscles inserted into the trochanter minor, which
will then raise the bone involuntarily towards the abdomen. Hence, in
this part of the thigh, he prefers anterior and posterior flaps ; for, " then
the more the stump is raised, the better is the end of the bone covered;
the anterior flap folds over it." He recommends the posterior flap to be
made rather longer than the anterior. In the lower part of the thigh, lateral
flaps are the best.f If the limb is to be taken off at, or below its middle,
the pad of the tourniquet, if this be used at all, should be applied to the fe-
moral artery, where it lies between the sartoriusand adductor longus ; but,
if the operation is to be performed higher than this, the tourniquet would
interfere with the knife, and prevent the due retraction of the muscles,
and, consequently, it is better to compress the femoral artery as it is
passing over the os pubis. In making the first flap, which I think should
be an external one, in order not to cut the femoral artery in the com-
mencement of the operation, the point of the knife, the edge of which
is directed down towards the knee, should pass perpendicularly till it
touches the bone, round the outer side of which it is to be closely
guided, and then pushed through the integuments in the central line of
the posterior part of the limb. With a gentle sawing motion, the external
flap is then to be formed, consisting of the integuments, fascia, and
part of the cruralis, and rectus, and of the vastus externus and biceps
muscles. The length of the flap must depend on the diameter of the
thigh ; but, in general, from three to four inches will be sufficient ; for, if
the flap be too long, it rarely unites favourably. The point of the knife
is then to be introduced perpendicularly again at the anterior and
superior angle of the external flap, till it touches the bone, closely round
which it is to be conveyed, till it is in a position to pass through the
limb precisely at the upper and posterior angle of the external flap.
The transfixion having been made, the internal flap is then formed by
cutting downwards and inwards to the point chosen as the limit of its
length. The bone having been sawn through, and the arteries secured,
the flaps are brought together with two or three sutures, so as to meet
in a perpendicular line, and lint dipped in cold water laid over the stump,
until all oozing of blood has ceased, when common adhesive, or isinglass
plaster, may be applied, and the sutures removed. The inner flajp will
comprehend the integuments, the fascia, part of the cruralis, adductor,
sartorius, gracilis, semimembranosus, and semitendinosus, with the femoral
artery, vein, &c.
* See Klein's Ansichten bedeutendsten Operationen, pp. 39 — 42, &c. lies Heft.
T See Listen's Elements, Partiii. p. 394.
3 E 2
788 OPERATIONS.
AMPUTATION AT THE HIP-JOINT.
In this operation, the following circumstances merit recollection : —
1. The acetabulum not being deep enough to contain the whole of the
head of the femur, and the latter being partly embraced by the orbicular
ligament,, this ligament, if not divided close to the brim of the acetabu-
lum, will form some impediment to the disarticulation. 2. When the
thigh is in the position of abduction, the ligamentum teres is rendered
tense by the head of the femur, and readily presents itself to the edge of
the knife. 3. If it be intended ,to form two flaps of equal size, they
should be separated by a line extending from the great trochanter to the
opposite point of the diameter of the limb. 4. As the femoral artery
corresponds above to the junction of the middle third of the head of the
femur with its internal third, and only gets parallel to the bone three or
four inches lower down, there must necessarily be between the artery
and the neck of the femur, for a considerable part of this extent, a dis-
tance of fifteen lines, which, in several modes of operating, would permit
the knife to pass over the neck of the bone without wounding the artery,
and afford an opportunity for the' vessel to be compressed before the
anterior flap is completed. As the arteria profunda also takes the same
direction as the femoral till it is at least an inch and a half below the
trochanter minor, the knife need not interfere with it.*
Lisfranc adverts to four methods of finding the hip-joint with precision
in the living body.
1st. From the anterior superior spine of the ijium make a perpen-
dicular mark, fifteen lines long, and the external and front part of the
joint will lie exactly six lines to the inner side of the lower termination of
such mark.
2d. Frora the anterior inferior spine of the ilium, draw a perpen-
dicular line, about six lines in length, and its termination will correspond
to the upper part of the joint.
3d. If from the end of a transverse line; drawn from the spine of the
os pubis outwards, rather more than two inches and a quarter long, an-
other line, a quarter of an inch in length, descend at a right angle, it
will also pass over the joint.
4th. If, from the outer, front, and upper part of the trochanter, a line
half an inch long, be drawn perpendicularly upwards, and then another
line be drawn from the end of the first at a right angle inwards, to the
extent of an inch, the second one will extend to the head of the femur
some little allowance being made for the difference in the length and
direction of the neck of the femur in different subjects.
When the patient is in the recumbent posture, the tuberosity of the
ischium projects about fifteen lines in front of the acetabulum.
METHOD OF LISFRANC WITH TWO LATERAL FLAPS.
First Stage. — The femoral artery is to be compressed as it passes over
the os pubis. When the left limb is to be removed, the surgeon is to
stand on the outer side of it, while the patient is in the recumbent pos-
ture, with the tuberosities of the ischium projecting a little way beyond
the end of the operating table. If possible, the limb itself is to be in
the middle position between adduction and abduction ; and the anatomicaj
points, above specified, in relation to the joint, are to be well recollected^
* Mulgaigne, Manuel de Med, Operatoire, p. 35G.
AMPUTATION AT THE HIP-JOINT. 789
and especially the directions for ascertaining the precise situation of its
anterior and external part. At this place a long, narrow, but strong,
sharp-pointed knife is introduced, with its edge directed towards the
apex of the great trochanter. The point having passed down close to
the head of the femur, is to be carried round its outer side ; but, in pro-
portion as the point enters further, the handle must be inclined outwards
and upwards, so that the point may pass out a few lines below the tuber-
osity of the ischium. In order to fulfil this object, an assistant, or the
surgeon himself; should grasp and draw outwards the integuments and
muscles at the back of the limb. The transfixion having been completed,
the knife, with the edge still turned towards the apex of the great tro-
chanter, is to be carried downwards along the bone, with a sawing motion,
rather than [by pressing much upon it, and thus the external flap is
formed. This is to be immediately raised, and such arteries as pour out
much blood compressed with the fingers of the assistants, and tied before
the rest of the operation is proceeded with.
Second Stage. — The surgeon, with his left hand, then pushes the soft
parts inwards, and introduces the point of the knife below the head of
the femur, on the inner side of the neck, with the edge turned directly
downwards. Then the knife is to be carried under the neck of the femur,
and pushed through the limb, without touching the bones of the pelvis,
at the posterior and superior angle of the wound. Being now held per-
pendicularly, it is conveyed two inches downwards close to the femur,
avoiding, however, the trochanter minor ; and, as soon as the incision
affords room enough, an assistant compresses the femoral artery contained
in the flap, and the second stage of the operation is concluded by giving
to this internal flap a length corresponding to the external.
Third Stage. — The surgeon now takes hold of the femur with his left
hand, and with a scalpel freely divides the orbicular ligament at the inner
side of the joint, which being done, the ligamentum teres can easily be
reached with the end of the knife, and cut through. Lastly, the knife,
held perpendicularly, is to be applied to the inner side of the joint, and
carried from within outwards, so as to cut through the rest of the orbi-
cular ligament, and any fasciculi of muscular fibres not previously divided.
When the right limb is to be removed, the surgeon must stand by the side
of the patient's trunk, in order to be able to operate with the right hand.
The advantages of Lisfranc's method are, the quickness with which it
is executed, as I have often demonstrated at University College on the
dead subject ; and its occasioning as little loss of blood as possible, the
arteries of the external flap being tied before the internal one is formed,
and the femoral artery taken hold of by an assistant before the latter flap
is completed. The flaps meet well, and the extensive wound admits of
being completely closed, which may be accomplished with straps of adhe-
sive plaster, aided, if necessary, with three or four sutures.
When, owing to the state of the injury, or disease, a sufficient flap
cannot be saved on one side of the limb, the flap on the other side is to
be made proportionably longer.
p
BECLARD'S METHOD.
The thigh being held in the state of half abduction, the scrotum care-
fully raised, and the artery compressed, as it passes over the os pubis, the
surgeon, standing on the outside of the limb, feels for the great trochan-
ter, and introduces the point of the knife one inch above it. The edge is
to pass as close as possible to the bone, at the inner side of the limb, its
SE 3
Y90 OPERATIONS.
point being pushed out in a situation precisely opposite the place of its
entrance. The knife is next carried down, close to the anterior surface
of the bone, to rather more than three inches below the joint where the
anterior flap is to end. Then the capsule, and any soft parts covering it,
are to be divided transversely, and the ligamentum teres cut through.
The knife is next to pass, from before backward round the head of the
femur to the back of this bone, down which it is to be carried to the ex-
tent of about three inches below the joint. Thus the posterior flap is
completed.* According to Velpeau, Beclard made the anterior flap, after
the completion of the posterior one.
L" Mr. Liston also prefers anterior and posterior flaps. " Transfixion,
with a knife proportioned in size to the dimensions of the limb, is made
horizontally, the instrument being passed in a somewhat semicircular
direction, so as to include as much of the soft parts as possible ; and an
anterior flap is made by cutting downwards. During the passage of the
knife across the joint, the assistant rotates the limb a little, so as to faci-
litate the bringing of the instrument out, with its point well inwards. In
the left limb, the rotation will be inwards ; in the right, outwards. After
the formation of the flap, the assistant abducts forcibly, and presses down-
wards ; the joint is opened, the round ligament cut, the capsule divided,
and the blade of the knife placed behind the head of the bone and the
large trochanter ; and the posterior flap is then made rapidly. After
transfixion for the superior flap, and when the sawing motion has advanced
but a little way, the compressing assistant shifts his hands into the inci-
sion, immediately behind the back of the knife, and so obtains a firm
grasp of the femoral artery previously to its division." f As this cannot
now bleed, Mr. Liston secures the other arteries first.
AMPUTATION OF THE LEG.
In the thigh, amputation is performed as low as the case will allow.
In the leg, the common practice is to make the incision through the
integuments sufficiently low to enable the operator to saw the bones,
about four inches below the lower part of the patella. This is necessary
in order to have a sufficient surface in front of the limb for the appli-
cation of a wooden leg, and not to deprive the stump of that power
of motion, which arises from the flexor tendons of the leg continuing
undivided.
The tourniquet, or pressure with the thumb, should be applied to the
femoral artery, two thirds of the way down the thigh, just before the
vessel perforates the tendon of the adductor muscle. The operator is
to stand on the inside of the leg, in order to be able to saw both bones
at once. The leg being properly held, the integuments should next be
drawn upward by an assistant,, while the surgeon, with one quick stroke
of the knife, divides the skin completely round the limb.
Having made a circular division of the integuments, the next object is
to preserve skin enough to cover the front of the tibia and the part of the
stump corresponding to the situation of the tibialis anticus, extensor
longus pollicis, and other muscles between the tibia and fibula, including
those covering the latter bone ; for, throughout this extent, there are no
bulky muscles which can be made very serviceable in covering the end
• J. F. Malgaigne, Manuel do Mud. Op^ratoire, p. 358.
f See Listen's Elements, Part iii. p. 39G. For a description of other methods, I
refer to my Dictionary.
AMPUTATION OF THE LEG. 791
of the stump. But, on the posterior part of the leg, the skin should
never be detached from the gastrocnemius muscle, which, when obliquely
divided, will, with the soleus, here form a sufficient mass for covering the
stump. Hence, as soon as the skin has been separated on the anterior
and external side of the leg, the surgeon is to place the edge of the knife
in the incision of the integuments, and cut in the Alansonian way through
the muscles of the calf, from the inside of the tibia, quite to the fibula.
Then the flap, formed by the calf of the leg, is to be held back by the
assistant, while the surgeon completes the division of the rest of the mus-
cles, together with the interosseous ligament, by means of the catling, or
any narrow double-edged knife.
In amputating below the knee, particular care must be taken to cut
every fasciculus of muscular fibres, before the saw is used. Every part
being divided, except the bones, the soft parts are to be protected from
the saw by a linen retractor, made with three tails, one of which is to
be drawn through the interosseous space.
The principal arteries, requiring ligatures, will be the anterior and pos-
terior tibial, and the peroneal. The sharp anterior edge of the tibia, if
likely to injure the integuments, may be removed by means of pliers,
or a fine sharp saw.
In dressing the wound, the soft parts preserved for covering the bones
should be brought together, so as to make the line of their union not
transverse, but obliquely perpendicular, the lower end of it being more
external than the upper. Thus the tibia and fibula may be effectually
covered, without the strips of adhesive plaster forcibly pressing the skin
against the sharp edge of the tibia. The strap of plaster, on which most
dependence is placed, should go over the centre of the stump, at the
point corresponding to the interosseous space.
FLAP-AMPUTATION OF THE LEG BELOW THE TUBEROSITY OF
THE TIBIA.
If the right leg is to be removed, the operator places himself on its
inner side, and grasps the lower part of the limb with his left hand,
while an assistant supports the foot. The knife enters over the outer
side of the fibula, and is carried upwards along that bone for an inch and
a half, or two inches. The incision is then extended across the front of
the leg in a semicircular direction ; and as soon as the knife reaches the
inner part of the tibia, transfixion is performed, the point being pushed
along the posterior surface of the two bones, and out at the upper angle
of the incision over the fibula. The knife is then carried downwards,
and a posterior flap formed of sufficient size to cover the stump.
All this is effected by uninterrupted sweeps of the knife, that is, with-
out ever removing its point from the track of the incision. With the
same knife, the integuments on the forepart of the leg are then dissected
up a little way, so as to form a small semilunar flap. The muscles in
the interosseous space are next divided, and the knife is carried round
the bones for the division of any of the soft parts yet uncut. Mr. Listen
prefers sawing the bone in the perpendicular direction. Before laying
down the flap, he removes the sharp anterior ridge of the tibia with the
cutting pliers. In operating on the left leg, transfixion is commenced by
passing the knife close behind the tibia, and its point is afterwards pushed
through the preliminary fibular incision.* The most simple plan is first
* See Listen's Elements of Surgery, Part iii, p. 391.
3 E 4
792 OPERATIONS.
to form the posterior flap by transfixion, and then to make the anterior
flap, and divide the muscles in the interosseous space. The anterior flap
should be somewhat longer than usually made, so as to cover the tibia
better, and render it unnecessary to have a posterior flap of great length,
which always proves a source of profuse suppuration.
AMPUTATION OF THE ARM.
The structure of the arm bears a great analogy to that of the thigh.
There is only one bone round which the muscles are arranged, the deep
ones being adherent to it, while the outer ones extend from their origins
to their insertions, without being attached to it. The first are the brachi-
alis interims, and the two short heads of the triceps ; the others are, the
long portion of the latter muscle, and the biceps. Hence amputation of
the arm may be performed in a very similar manner to the same operation
on the thigh, unless it be necessary to remove the limb above the inser-
tion of the deltoid muscle.
The patient may either sit on a chair, or lie near the edge of a bed,
and an assistant is to hold the arm in a horizontal position, if the state of
the limb will allow it. The pad of the tourniquet is to be applied to the
brachial artery, as high as convenient. The assistant is then to draw up
the integuments, while the surgeon makes the first circular incision. In
this operation, the skin need only be detached from the muscles to a very
moderate extent, for there is no risk of not having sufficient flesh and
integuments to cover the bone. Here, indeed, some surgeons imitate
Dupuytren, and cut at once through the skin and loose portions of muscle.
If the ordinary method be followed, the biceps may be divided first, and,
after the retraction of this loose muscle, the brachialis interims, which is
fixed to the bone, may be cut through and separated a little upwards
from the bone.
The triceps may next be cut through at once, by one sweep of the
knife, with its edge turned obliquely upward. The other proceedings do
not require description, after the account already given of what is neces-
sary in amputating the thigh.
When it becomes indispensable to amputate the arm high up, the
subclavian artery is to be firmly compressed, as it passes over the first
rib, by an assistant, who can effectually accomplish this important object
with his thumb, or by pressing the vessel from above the clavicle with the
handle of a key, covered with soft materials. When the bone can be sawn
through below the insertion of the pectoralis major, there is no peculiarity
in the method of operating. But, if it be necessary to take off the limb
still higher up, the circular incision is not advisable. Here some surgeons
make a flap of the deltoid muscle, and commence with making an incision
corresponding to its margin in shape and situation. Then the muscle is
to be detached from the bone beneath, so as to form the flap, which is to
be turned up. The operation is now finished by cutting through the other
soft parts, from one side of the base of the flap to the other.
Instead of making a short stump, when the arm must be taken off
high up, Larrey prefers amputating at the shoulder-joint. He says, that,
if the humerus is sawn through higher than the insertion of the deltoid
muscle, the stump becomes retracted towards the arm-pit by the pecto-
ralis major and latissimus dorsi; the ligatures on the vessels irritate the
axillary plexus of nerves ; great pain and nervous twitches are excited ;
AMPUTATION OF THE ARM. 793
tetanus is frequently brought on ; the stump is affected with considerable
swelling; and at length, anchylosis of the shoulder follows.*
According to Mr. Guthrie, when amputation is attempted at the in-
sertion of the pectoralis major, the bone will mostly protrude after a few
dressings; and a disagreeable painful stump be the consequence. The
artery is also liable to retract into the axilla, where it cannot readily be
taken up. Here, instead of amputation at the shoulder-joint, he recom-
mends the following operation : — " Two incisions of a similar shape are
to be commenced, one or two fingers' breadth below the acromion, as the
case may require; the point of the inner one, instead of ceasing, as in the
operation of the shoulder, a little below the pectoral muscle, is to be
carried directly across the under part, to meet the point of the outer
incision ; so that the under part of the arm is cut by a circular incision ;
the upper, in the same manner as in the operation at the shoulder. These
incisions are only through the skin and cellular membrane, which have
liberty to retract, but are not to be turned up. The deltoid and pectoralis
major are then divided close to the inner incision, and the opposite por-
tion of the deltoid, with the longhead of the biceps on the outside, to the
extent of the outer incision. A half-circular cut on the under part, in
the line of the skin down to the bone, clears it underneath, and shows the
artery retracting with its open mouth, which is at this moment advan-
tageously pulled out by a tenaculum, and secured." The flaps are then
held asunder, and the bones sawn, &c.f
AMPUTATION OF THE ARM WITH LATERAL FLAPS.
One of the quickest methods of removing the arm is Dupuytren's
operation, in which he cut the integuments and muscles together, sepa-
rated the muscular fibres upwards from the bone, and then applied the
saw. Another expeditious method, and one which also forms an excellent
stump, is amputation with lateral flaps, which may be adopted at any
point below the insertion of the deltoid muscle. The limb is held up from
the side at a convenient height, and the point of the knife, with the edge
directed towards the elbow, is introduced directly down to the bone,
either at the front or posterior part of the limb, and, as nearly as possible
in the middle of it. As soon as the point of the knife touches the bone,
it is to be conveyed very closely round it, till the position of the blade is
such, that the point can be pushed through some part of the central line
of the limb, directly opposite to the place where the knife first entered.
The transfixion having been completed, a flap is formed by cutting
rapidly downwards, with a sawing motion of the knife, inclining its edge
downwards or upwards, according as it may be the internal or external
flap which is being formed. As soon as one flap has been made, an
assistant is to hold it out of the way while the surgeon makes the other.
" The knife is again entered, about half an inch below the commence-
ment of the first incision, and by inclining the handle, the point is
brought round the bone, and made to appear on the opposite side also of
the first incision." J When it is the external flap which is being formed,
this part of the operation is facilitated by pulling the soft parts outwards
with the left hand. Lastly, the knife is carried rapidly round the bone,
* Memoires de ChirurgJc Militaire, t. iii. p. 53., &c.
f Guthric on Gunshot Wounds, p. 340.
| See Listen's Elements, Part iii. p. 383.
794- OPERATIONS.
so as to divide any of the adherent muscular fibres yet uncut, and then
the saw is to be used.
I have sometimes tried this method in University College Hospital,
and find it has the advantages of expedition and of making a good
stump. The hemorrhage was effectually commanded by the pressure of
the fingers on the brachial artery just below the axilla. The projection
of nerves is most likely to be avoided by giving the edge of the knife
rather a sudden turn outwards, after the proper length of flap has been
secured.
AMPUTATION OF THE FOREARM
Should be performed as low as the case will allow. The tourniquet is to
be applied with its pad on the brachial artery, at the inner edge of the
biceps muscle, or the flow of blood through that vessel may be com-
manded by an assistant making pressure on it. While one assistant holds
the hand, another grasps the forearm, above the place where the first
circular wound is to be made, and draws up the integuments. After
the amputating knife has been carried round the limb, the skin is to be
detached from the fascia, a little way upward. The muscles are then to
be divided obliquely upwards with the same knife, which, if not too
broad, is also to be employed for completing the division of the parts,
between the radius and ulna. If the blade be wider than is convenient
for this purpose, the catling, or any narrow double-edged knife, must be
used. The retractor is to be applied, and the bones sawn, with the hand
in a state of pronation.
In general, only four vessels require ligatures, viz. the radial, ulnar, and
two interosseous arteries.
Larrey deems it advantageous to take off the forearm in its fleshy part,
notwithstanding the nature of the disease, or injury would admit of the
operation being done towards the wrist. However, as I have amputated
several forearms near the wrist, and the stumps healed in the best way,
I see every reason for still adhering to the old good maxim of saving as
much of the limb as possible. The cause of the bad success, which
many of the French surgeons have had after amputating in the ten-
dinous part of the forearm, has been correctly referred by Mr. Guthrie
to their prejudices against the attempt to heal the stump by the first
intention.*
FLAP-AMPUTATION OF THE FOREARM, AS PRACTISED BY KLEIN f,
LISTON, &C.
The surgeon, with his left hand, grasps the wrist, and places the fore-
arm in the middle state between pronation and supination. Supposing
the right forearm is to be removed, the knife, held perpendicularly,
enters over the centre of the radius, and its point, after reaching the
bone, is inclined inwards, and, being conveyed across close to the palmar
surface of it and the ulna, completes the transfixion at a point opposite
that of its entrance. By cutting rapidly downwards and inwards, the
first flap is then formed. The knife is again introduced over the radius,
just below the upper part of the first wound, and conveyed across the
opposite side of the bones until its point emerges at the other extremity
* On Gunshot Wounds of the Extremities, p. 370,
f Practische Ansichtcn der bedcutundstcn Chir. Operational, p. 45. ItesHeft. 4to.
Stuttgart, 1816.
AMPUTATION AT THE SHOULDER-JOINT. 795
of the first incision. The second flap is then made. The two flaps
being retracted, the knife is carried round the bones, and passed freely
between them, after which they are to be sawn perpendicularly with the
forearm in the same position. Amputation of the forearm, by means of
the circular incision, may be performed with tolerable expedition, and, in
my own practice, the stump has usually healed up with facility, so that I
am rather in favour of it ; though which operation is here preferred, may
be a point of no very great importance.
FLAP-AMPUTATION AT THE WRIST.
If the hand be extended back, the angle which it forms with the fore-
arm will denote the radio-carpal articulation, which is one line below
the transverse projection of the radius, and about five above the cuta-
neous fold between the hand and forearm. The middle of the joint may
also be found two lines and a half above a line, drawn- across from the
point of the styloid process of the radius to that of the ulna. The knife
is to pass across from one styloid process to the other, and the anterior
flap be formed. The hand being then put into the prone position, the
knife is introduced at one of the upper angles of the first incision, trans-
fixion performed, and a posterior semilunar flap made. The operator is
then to make an incision below the styloid process of the radius, and
with a semicircular sweep of the knife corresponding to the direction of
the articulation, all the ligaments are to be cut, and the operation
finished. According to Malgaigne, this method, which is followed by
Lisfranc, is a quick and showy one, but less advantageous in its results,
than amputating at the wrist with a circular incision.
AMPUTATION AT THE SHOULDER-JOINT.
The loss of blood is to be prevented, by compressing the subclavian
artery from above the clavicle. The choice of the method of operating
must be determined by the state of the soft parts covering the joint.
LA FAYE'S METHOD WITH ONE FLAP.
With a large common bistoury, a semicircular incision is to be made,
with its convexity downward, across the integuments covering the del-
toid muscle, about four inches below the acromion.* The skin is not to
be detached ; but the surgeon is to proceed immediately to raise the
muscle from the bone, quite up to the joint. If the circumflex arteries
bleed considerably, they are now to be tied, before the operator proceeds
further. Then the surgeon should cut the tendons passing over the
joint, and also the capsular ligament, so as to be enabled to dislocate the
head of the bone. With one stroke of the amputating knife, he is then
to divide the skin, muscles, and other parts underneath the joint, and
thus complete the separation of the limb. Then the axillary artery is to
be instantly taken hold of with the forceps or double tenaculum, and tied.
The flap of the deltoid muscle is next to be laid down, and its edge will
then meet the lower margin of the wound.
The preceding method is one of remarkable simplicity, as I csti truly
affirm, not only because I have tried it myself, in three instances, but
seen it performed on several occasions by other surgeons. The last case,
in which I was requested to give my assistance, was a patient of Dr.
* The horns of the semicircle, if I may use the expression, are to extend upward
along the anterior and posterior margin of the deltoid muscle.
796 OPERATIONS.
Blickes', of Walthamstowe : the operation was practised as a last resource
for a spreading mortification of the arm from external violence ; and,
though the man survived only about a fortnight, nothing could be more
easy than the operation itself, and it was impossible to have had a better
stump.
In order to make a flap of the deltoid muscle, some operators prefer
first pushing a catling, or long, straight, double-edged knife, through this
muscle near the joint, and next cutting downwards, they detach as much
of the flesh from the bone as they consider necessary ; the flap is then
turned up ; the tendon of the long head of the biceps and other muscles
passing over the joint are divided ; the capsular ligament is cut ; the head
of the bone disarticulated ; and the operation finished, by passing the
knife downwards between the glenoid cavity of the scapula and the
head of the humerus, and, with one stroke, dividing all the parts towards
the axilla.
DUPUYTREN'S METHOD WITH ONE FLAP.
The arm being raised from the side, the deltoid muscle is grasped
with the left hand, and a double-edged knife passed through its base,
directly below the acromion, and carried down close to the outer side
of the humerus, so as to form an external flap of suitable extent. This
is to be held up by an assistant, while the humerus is moved near to the
side, in order to incline those tendons outwards, which are inserted near
the head of the bone, and which are now to be divided, beginning with
the posterior ones, which are more easily got at, on account of the
greater space between the acromion and the head of the humerus, than
between the latter part and the coracoid process. The fibrous tissues,
connecting the head of the bone to the acromion, must likewise be di-
vided, after which the operator takes hold of the arm with his left hand,
dislocates the head of the bone outwards, and passes the knife inwards
for the purpose of dividing the soft parts in that direction, where the
principal nerves and bloodvessels are situated. At this moment the
assistant, who holds up the external flap, pinches up the soft parts, by
placing the thumb of his right hand on their bleeding surface, and the
four fingers under the axilla, and thus compresses the artery. The
operator, now having no fear of hemorrhage, completes the division of
the parts on a level with the attachments of the pectoralis major and
latissimus dorsi to the humerus. The flap is then brought down and
united by the first intention. This is the operation of La Faye and
Kavaton simplified, and perfected. As M. Malgaigne observes, by
directing the edge of the knife inwards, the capsule of the joint might be
laid open by the first stroke.
LISFRANC'S METHOD WITH TWO FLAPS.
In this operation,, the surgeon is particularly to remember that, be-
tween the acromion and the coracoid process, there is a triangular space,
bounded behind by the clavicle, and where the arch over the joint is
simply fibrous.
1st. Supposing the left arm is about to be removed, it is to be raised
outwards nearly to a right angle. The surgeon stands behind the patient,
and grasps the cushion of the shoulder with his left hand, putting his
thumb on the humerus, and the index and middle fingers on the above-
mentioned triangular space. Then taking a double-edged knife, eight
inches long, he introduces it parallel to the humerus, at the outer side of
AMPUTATION AT THE SHOULDER-JOINT. 797
the posterior margin of the axilla, in front of the tendons of the latis-
simus dorsi and teres major, with the blade in such a position that its
flat part forms with the axis of the shoulder an angle of 35°, while its
upper edge is turned a little forwards. The knife is carried up along
the posterior and external side of the humerus, till it arrives under the
acromion : now its point is to be depressed, and its handle raised, to the
distance of two or three inches from the arm, till it forms with the axis
of the joint an angle of 30° or 35°. Then the surgeon is to press directly
on its point, which will pass through the joint, and come out in front of
the clavicle at the inner side of the acromion, at the triangular space
above described. Next, while the handle is kept nearly motionless, the
end of the blade is carried round the head of the humerus from within
outwards, and from below rather upwards ; and directly the knife is clear
of the acromion and head of the bone, it is carried boldly downwards
along the external side of the arm, and the posterior flap is formed, about
three inches in length.
2d. The operator, keeping his hand depressed, and cutting from the
heel to the point, slides the knife from behind forward at the inner side of
the head of the humerus, depresses the handle till it is perpendicular to
the horizon, directs an assistant to compress the artery, and thus com-
pletes the anterior flap.
When the right arm is to be amputated, the surgeon may either plunge
the knife into the triangular space, above indicated, and bring its point
out in front of the posterior margin of the axilla ; or else he may stand at
first behind the patient to make the posterior flap, and then move to the
patient's side to finish the anterior one.
No method is more expeditious than the foregoing. In the first stage,
the surgeon cuts at once the tendons of the latissimus dorsi, teres major
and minor, supra and infra spinatus, a portion of the deltoid, one half of
the capsular ligament, the subacromial fibrous tissue ; — in a word, almost
all the parts attached to the humerus, the head of which can be imme-
diately afterwards disarticulated.
When the patient is under the age of fifteen, M. Lisfranc, recollecting
the cartilaginous state of the acromion, recommends another method with
two flaps, the peculiarity of which consists in directing the knife, so as to
remove the cartilaginous extremity of that part of the scapula. But, as
M. Malgaigne justly remarks, the latter expedient, by lessening the pro-
minence of the shoulder, would be likely to increase the deformity re-
sulting from the operation.
LARREY/S OVAL METHOD.
An incision is begun at the acromion, and carried down to an inch
below the level of the neck of the humerus, dividing the integuments and
the deltoid, down to the bone, into two equal portions. An assistant then
draws up the skin of the arm towards the shoulder, and the operator
makes two oblique incisions, which commence from the termination of the
first, an inch below the acromion ; one extending to the anterior border
of the axilla ; the other to its posterior border ; and both prolonged so as
to divide the pectoralis major and latissimus dorsi very close to their
insertions.
The cellular connections of the two flaps to the bone are next divided,
and the flaps themselves held up by an assistant, who, at the same time,
stops the bleeding from the circumflex arteries by the pressure of his
fingers. The joint is now exposed, and, with one stroke of the knife,
798 OPERATIONS.
over the upper semicircle of the head of the humerus, the capsule and
tendons are cut through. The head of the humerus is then dislocated ;
and the knife being conveyed to the inner side of the bone, the flesh is
detached from the latter. Finally, while an assistant compresses the
axillary artery, the surgeon completes the operation by cutting trans-
versely through the remainder of the skin and muscles, on a level with
the lower ends of the two oblique incisions.
The arteries having been secured, there are, strictly speaking, no flaps ;
the wound, on being closed, presenting, as after all oval amputations,
merely the appearance of a straight line.
CIRCULAR AMPUTATION AT THE SHOULDER.
Garengeot, Alanson,Graefe, Sanson, and Cornuau, are recorded amongst
its patrons. A circular incision is made through the integuments, three
inches and a half, or four inches below the acromion. The skin is
retracted, and the deltoid cut obliquely from below upwards, so as to ex-
pose the joint. With another stroke of the knife, the tendon of the
biceps and the upper part of the capsule are divided. The head of the
humerus is then dislocated ; the knife carried to the inner side of the
bone ; the muscles separated from it in that direction ; and, while an
assistant compresses the artery, the soft parts towards the axilla are cut
on a level with those on the outer side of the shoulder.
M. Sanson makes his first incision one finger-breadth from the acromion,
and unites the anterior with the posterior wound : in fact, as M, Malgaigne
remarks, the result is the same as that of Larrey's mode, divested of the
upper incision, but more difficult of execution.*
Excellent as some of the preceding operations are, the exclusive pre-
ference to any one of them, as declared by some writers, has been made
without reflecting, that, in many of the examples in which amputation at
the shoulder is indicated, the deltoid muscle is much lacerated, or more
or less of it actually torn away. Under such circumstances, a sufficiency
of soft parts for making the flaps must be saved, from whatever quarter
they can be obtained, whether the external, or the anterior, or the poste-
rior side of the shoulder. Sometimes a flap can be obtained, indeed,
only at the posterior, or the anterior side, as every experienced military
surgeon is well aware of.
AMPUTATION OF PARTS OF THE HAND.
As Dr. Macfarlane correctly observes, the propriety of sometimes
attempting to save a portion of the foot, or hand, in cases of injury, or
disease, by having recourse to partial amputation, has been long known,
and acted upon both in this country and on the Continent. If the thumb
and little finger can be preserved, or a portion of either of them, the ad-
vantage to the patient will be considerable. In University College Hos-
pital, we have had many patients, whose hands were so badly shattered
and crushed by machinery, that, at first, it seemed as if it would have
been impossible to save any part of them. Yet the experiment of partial
amputation having been made, very useful portions of the hand were
saved. Thus, the thumb, and one or two fingers have sometimes been
sacrificed and the rest of the hand saved ; or, what has been still better,
the thumb and one or two fingers have been saved, though the other fin-
See J. F. Malgaigne, Manuel de Medecine Op6ratoire, pp. 329—334.
AMPUTATION OF THE FINGERS. 799
gers, and even some of the metacarpal bones have been unavoidably re-
moved. With such facts before him, let every surgical practitioner pause
a little, before he sanctions so great a mutilation as that of removing the
whole hand.
AMPUTATION OF THE TWO LAST PHALANGES OF THE FINGERS.
These phalanges, though but loosely confined in their respective places
by the anterior ligament, and behind by the extensor tendon, are closely
retained in it by the lateral ligaments. Hence, in order to open the
joint freely, it is the latter, which require division. The line of the arti-
cular interspace, as M. Malgaigne remarks, has nearly a transverse
direction, and in the articulation, of the first with the second phalanx, is
situated on a level with the cutaneous fold on the palmar side of the fin-
ger ; while, over the articulation of the second phalanx with the third, the
articular interspace is half a line below the cutaneous fold.
Lisfranc's first Plan. — In removing the last phalanx, the operator
takes hold of it with his thumb and forefinger, and bends it to an angle
of 45°. There are then three guides to the articular interspace. 1. At
the back of the joint a conspicuous wrinkle of the skin : the line of the
articular interspace is half a line below it. 2. If this wrinkle be wanting,
the dorsal prominence caused by the flexion is to be noticed, and the in-
cision made half a line below it. 3. The termination of the furrow of
the palmar surface is seen on each side of the joint : half a line below
this, the articulation will be found. The heel of a straight bistoury is to
be placed perpendicularly on the skin over the left extremity of the arti-
cular interspace, and a small semicircular flap is formed by cutting to-
wards the right side of the finger. This first stroke will frequently lay
open the ligament at the back of the joint. The next thing is to divide
the lateral ligaments. In cutting through the left one, the knife is to be
held perpendicularly to the axis of the last phalanx, with the handle
nearer than the blade to the operator, and the edge also slightly inclined
towards him. In this way, the incision is accommodated to the dispo-
sition of the articular surfaces, and the ligament is cut through at the
first stroke. The knife is then applied to the other side, and the second
lateral ligament divided in the same direction, but with the handle of the
knife directed downwards, and kept further from the operator than the
blade. The joint having now been largely opened, the phalanx is to be
placed in the extended position, and the knife, having been carried
through the joint and capsular ligament towards the palm, is there brought
out, a semicircular flap being formed of sufficient size to cover the end
of the bone.
Amputation between the first and second phalanges is performed in a
similar way, except that the dorsal incision should terminate on each
side precisely at the extremity of the palmar fold of the skin. The
surgeon, as he is dividing the lateral ligaments, is to avoid cutting the
base of the palmar flap.
Lisfrancs second Method, — All the fingers are to be bent, except that
which is about to be removed ; and the hand is to be placed in tfce supine
position. The surgeon takes hold of the phalanx with the forefinger and
thumb of his left hand. A straight, very sharp-pointed knife, with the
edge directed towards the extremity of the finger, is introduced half a
line below the palmar cutaneous fold, if it is the third phalanx which is
to be removed ; but exactly at the base of this fold, if it is the second
phalanx. The knife is to pass closely across the palmar and lateral sur-
800 OPERATIONS.
faces of the bone, nearly to the heel of the blade, and then the edge is to
be inclined upwards, and a semilunar flap made. The knife is next ap-
plied perpendicularly at the base of the flap for the purpose of cutting
the palmar portion of the capsule. But, in this method, it is scarcely
necessary to divide the .lateral ligaments separately, as with a single
stroke, the knife may now be carried completely through the articulation,
and the integuments divided, without making any dorsal flap. If the
extensor tendon should project too much, a piece of it should be cut off
with scissors.
In general, no ligature is necessary, and the flap is to be retained in
its place with adhesive plaster.
AMPUTATION OF A FINGER AT THE METACARPAL EXTREMITY.
The articulation is an enarthrosis with loose ligaments; and the arti-
cular prominence, or knuckle, presenting itself when the finger is bent,
is formed entirely by the metacarpal bone, the phalanx playing on its
inferior surface. In the healthy state, the joint is usually situated ten
or twelve lines above the commissure of the fingers.
Here amputation may be performed with two flaps ; or the oval, or
the circular method may be adopted. The oval method seems to me
the best.
1. The precise situation of the joint having been ascertained, and the
phalanx bent, an oblique incision is to commence three lines beyond the
articulation, and terminate at the digital commissure. The finger is
then to be extended, and the incision continued across the palmar side
of it, precisely in the direction of the cutaneous furrow between the
finger and the hand. The knife having reached the opposite digital
commissure, the finger is to be bent again, and the incision extended so
as to rejoin its other extremity two lines below the point where it was
begun.
2. The fingers are then to be strongly separated, the edges of the
wound dissected up, the back of the capsule opened, the lateral liga-
ments cut, and the operation concluded by detaching the finger on its
palmar side. The result is a linear cicatrix not at all encroaching on the
palm.
AMPUTATION OF ALL THE FINGERS TOGETHER FROM THE METACARPUS.
In this operation, it is useful to remember, that the heads of the
second and fourth metacarpal bones are really on the same level; but
that the third, which supports the middle finger, projects beyond them
about one third of a line; while, on the contrary, the fifth, on which the
little finger rests, is half a line shorter.*
LISFRANC'S METHOD.
1. In the right hand, the operator begins with making a semicircular
incision, with its convexity downwards, extending from the inner side
of the head of the fifth metacarpal bone, over the points where the
fingers separate from the hand, and terminating on the external side of
the head of the second metacarpal bone. The integuments are retracted
by an assistant, and, if necessary, the surgeon dissects them a little way
upwards.
* See J, F. Malgaigne, Op. cit. p. 313.
AMPUTATION OF THE THUMB. 801
2. The point of the knife is carried across the four joints, so as to
divide the dorsal ligaments; then the lateral ligaments of each articu-
lation are cut in succession ; and afterwards the palmar ones.
3. Lastly, the knife is conveyed under the inferior surface of the
phalanges, and the palmar flap formed, at first towards the little finger,
the incision following the direction of the cutaneous furrow of the palm,
and each ringer being lifted up successively, as the knife traverses the
parts.
t.The mode of proceeding is the same for the left hand, except that the
first incision is carried from the forefinger to the little finger.
The same method will also answer for the amputation of two or three
fingers ; an assistant holding the others out of the way, while the surgeon
makes the dorsal flap principally with the point of the knife, and begins
and finishes the incisions on a level with the articulations, which are to
be opened.
Circular Method, as practised by M. Cornuau. — 1. The hand being
placed in the supine position, the operator grasps the four fingers with
his left hand, and makes in the digito-palmar furrow a semilunar in-
cision, successively through the skin, vessels, nerves, and flexor tendons,
down to the joint. 2. The hand is then turned prone, and the circular
incision completed on the back of the hand, on a level with the com-
missure of the fingers, dividing all the soft parts there, and penetrating
into the articulation. 3. The heads of the phalanges are now to be
dislocated, and the operation finished by cutting through the lateral and
anterior ligaments.
AMPUTATION OF THE THUMB.
While the palmar aspect of the metacarpal bone of the thumb is thickly
covered, the dorsal surface is almost subcutaneous. This bone is con-
nected by means of loosish ligaments to the os trapezium, the articular
surface of which is slightly concave from within outwards. By inclining
it towards the metacarpal bone of the forefinger, its head may be made
to project externally. On the inner side, the articulation is separated
from that of the adjoining metacarpal bone by an osseous ridge, one line
in breadth, appertaining to the os trapezium. Lastly, the direction of
the joint is oblique, or corresponding to a line, which, when drawn from
its outer side, would extend to the root of the little finger.
In the ordinary mode of amputating the thumb and its metacarpal
bone from the trapezium, the thumb is placed in the position of abduc-
tion. 1. The heel of a bistoury, held perpendicularly, with the point
upwards, is then applied to the middle of the commissure, and an incision
boldly made downwards, but gradually inclining towards the metacarpal
bone of the thumb, until the knife is stopped by the trapezium. 2. Then
the edge of the knife is to be conveyed into the articulation in the direc-
tion above specified, and the head of the metacarpal bone luxated towards
the palm. 3. The joint having been thus cut through, the edge of the
knife is reversed, and carried along the radial edge of the metacarpal bone,
so as to form the external flap, which should be as fleshy as possible, and
end a few lines beyond the articulation of the metarcarpal bone with the
first phalanx.
Some operators commence with forming the external flap, after trans-
fixion of the soft parts at its base ; and they then open the joint from
without inwards.
3 F
802 OPERATIONS.
AMPUTATION OF THE THUMB BY AN OVAL INCISION SCOUTETTEN*S
METHOD.
If the left thumb is to be removed, the hand is placed supine, and a
longitudinal incision made through all the soft parts down to the bone,
beginning one line above the articulation of the trapezium, and ending at
the commissure on the inner side of the first phalanx of the thumb. The
hand is now to be put into the prone position, and the incision prolonged
from the first over the dorsal surface, precisely in the direction of the
upper cutaneous furrow, and to the point where the first incision began.
The muscles adherent to the whole extent of the external side of the
bone are then to be divided ; but, on the palmar side, only at the upper
half of the bone. The joint is then laid open at its posterior side, the
metacarpal bone dislocated outwards, and the detachment of the thumb
completed by carrying the knife close to the inner surface of the meta-
carpal bone.
In amputating the right thumb, the first incision is made on its radial
side.
AMPUTATION OF THE LITTLE FINGER AND THE METACARPAL BONE.
The surface of the unciform bone, which receives the fifth metacarp
bone, is concave from behind forwards, and slightly from within out-
wards, so that a knife cannot be pushed at once completely across the
joint ; but it will pass very well halfway through it from within outwards,
in the direction of a line, which would terminate at the middle of the
second metacarpal bone.
1. In order to determine the place of the joint, the inner edge of the
metacarpal bone is to be traced with the forefinger, till a prominence is
felt extending towards the palm. This is the unciform process, and
directly in front of it lies the articulation. The articular interspace
may also be felt on the back of the hand, especially when the bone is
moved.
2. The soft parts being grasped and drawn away from the bone, a
sharp knife is introduced perpendicularly through the skin and muscles
opposite the ulnar side of the articulation, and the edge carried close to
the bone from behind forwards. Thus a flap is made, which ends a little
beyond the head of the phalanx. 3. While an assistant holds the flap
out of the way, the surgeon dissects the integuments from the back of
the bone, leaving untouched,, however, the extensor tendon. The soft
parts being drawn outwards, the knife is carried along the other side
of the bone, without injuring the integuments on either side ; and passing
from behind forwards, it divides every thing as far as the digital com-
missure. 4. Its edge is then applied to the inner side of the articulation,
and enters halfway into it in the direction above specified, and in being
withdrawn again cuts through the dorsal ligament. Then, for the division
of the ligament of the two metacarpal bones, the point is passed obliquely
between the two bones, with the edge turned towards the wrist. All
that now remains to be done, is to cut through the muscles and ligaments
on the palmar side.*
In this country, the operation is frequently executed by cutting through
* See Observations on Amputations of the Foot and Hand. Med. Gaz. 1836. For
many of the foregoing directions, I am indebted to M. Malgaigne, whose little treatise
on the Operations is one of considerable merit.
AMPUTATION OF PARTS OP THE FOOT. 803
the interosseous space down to the os unciforme ; forming the flap ; and
then cutting through the joint.
AMPUTATION OF METACARPAL BONES ALONE.
The removal of injured, or diseased metacarpal bones, without their
corresponding fingers, is sometimes practised. In compound fractures
or dislocations, when the injury is confined to one or two of these bones,
they may be excised, and a useful hand preserved ; but, when the injury
is more extensive, primary or secondary amputation will genenilly be
required. In one instance of disease of the. metacarpal bone of the ring
finger, Dr. Macfarlane, of Glasgow, removed the bone by transfixing the
metacarpal space on each side with a French bistoury, and cutting down
from the carpal articulation to the first phalanx. A useful hand was
the result. In another instance, he removed the metacarpal bones of
the middle and ring fingers : he aimed at preserving no flap, and divided
the metacarpal spaces by cutting upwards from the division of the fingers,
taking care to avoid the extensor tendons of the fore and little fingers,
which are apt to be divided on approaching the carpus. The metacarpal
bones were readily dislocated from the os magnum and os unciforme,
and with a little force the parts were put in contact. After several
months, a serviceable hand, with free motion of the fingers, was obtained.
Portions of these bones may be easily cut out with the aid of the cutting
pliers.
AMPUTATION OF PARTS OF THE FOOT.
I. Amputation of a single Toe. — The joints of the toes resemble those
of the fingers ; but the great toe has usually three sesamoid bones, two
situated inferiorly, and one internally ; while the second toe sometimes
has one, and the little toe another. The methods of operating are here
the same as on the hand ; but that practised with an oval incision is
often preferred.* Whether in amputating the great toe, it is most ad-
vantageous to disarticulate its first phalanx from the metatarsal bone, or
to amputate in the continuity of the latter, is a disputed point. The first
method is objected to by some practitioners, because the head of the first
metatarsal bone is left, forming too great a projection, difficult to cover
properly, and not well calculated to bear pressure. On the other hand,
it is argued, that the head of this bone constitutes one of the points of
the tripod, on which the foot rests, and hinders the internal side of the
foot from inclining too much downwards. Hence, it is contended, that,
if possible, it ought to be preserved. If the plan of amputating through
the metatarsal bone be preferred, it is to be divided either with a fine saw,
or a strong pair of cutting pliers.
II. Amputation of the jive Toes, according to the Method of Lisfranc. —
Few accidents are likely to occur, involving all the toes so severely as to
require their removal, without the metatarsal bones being likewise impli-
cated. Yet such cases have been met with, and, perhaps, as Velpeau
observes t, they are more likely to happen where the toes are froft-bitten
and perish, than from any other cause. But, even in examples of this
kind, the necessity for the operation may sometimes be superseded by
allowing time for the dead parts to be detached, after which, the end of
* J. F. Malgaigne, Op. cit. p. 335.
t Nouveaux El<hn. de Med. Operatoire, t. ii. p. 449.
3 F 2
804 OPERATIONS.
the foot will heal by the granulating process. In the operation, it is to
be recollected, that the second metatarsal bone is one third of a line
longer than the first, which lies nearly on the same plane as the third ;
the fourth is half a line behind the latter ; and the fifth still more
backward, so that, according to the calculation of M. Malgaigne, a trans-,
verse line, drawn from its articulation, would pass over the origin of the
articular part of the first.
1. A semilunar incision is begun at the inner side of the head of the
first metatarsal bone, and extended close to the line at which the toes
leave the foot, to the external side of the fifth metatarsal bone. The flap
is then dissected up.
2. The point of the knife is then passed from within outwards over the
joints, so as partly to open them ; after which, the lateral ligaments are
to be cut.
3. The knife is next introduced under the phalanges of the great and
little toes, and then under all the phalanges at once. The surgeon, with
his left hand, now presses the toes upwards toward the instep, and carries
the edge and point of the knife from within outwards, following the track
of the furrow in the fore part of the sole. The arteries having been tied
and the wound dressed, the foot is to be laid on its outer side, in order
that the pus may more readily escape, in the event of suppuration.
III. Amputation of the first Metatarsal Bone. — The posterior end of
this bone has an extensive articular surface, in the direction from above
downwards, slightly concave, and articulated only with the great cuneiform
bone. The articulation is strengthened by four ligaments, an internal, a
dorsal, a plantar, and an interosseous ligament. The following method is
adopted by M. Lisfranc : — The operator takes hold of the integuments
and muscles at the inner side of the bone with the thumb and fingers of
his left hand, and draws them inwards as far as he can, in order to have
a flap of suitable thickness. The point of a narrow straight bistoury is
then introduced perpendicularly between the inner side of the bone and
the soft parts, two lines behind the articulation, and a flap formed along
the bone, terminating a little beyond the joint between the metatarsal
bone and the first phalanx. From the base of this flap, which is to be
held back by an assistant, another incision is made, which crosses the
upper surface of the bone rather obliquely, and terminates at the inner
and upper part of the articulation with the first phalanx. The knife is
then carried between the two metatarsal bones, as close as possible to
their posterior ends, and brought out on the external and plantar side,
without touching any point of the skin ; and every thing in the way of the
knife is now cut through as far as the commissure of the toes. The next
step is the disarticulation, which is accomplished by dividing the internal
ligament, with the point of the bistoury kept perpendicularly, and the
edge directed rather obliquely from within outwards, and from behind
forwards, so that it may follow the direction of articular interspace. The
upper ligament having been next cut through, the edge of the knife is
turned upwards, and the point plunged between the external side of the
first cuneiform bone and the inner side of the extremity of the second
metatarsal bone. The interosseous ligament is then divided by cutting
upwards, after which the surgeon completes the disarticulation by cutting
through the few remaining ligamentous and muscular fibres.
Instead of making a second incision, after the flap is formed, the skin
may be dissected up, from the base of the flap as far as the joint be-
tween the metatarsal bone and first phalanx, and drawn outwards by an
AMPUTATION OF PARTS OP THE FOOT. 805
assistant. Here, as M. Malgaigne observes, the essential thing is to be
able to pass the knife between the two metatarsal bones, without wound-
ing the integuments.
Instead of disarticulation, the first metatarsal bone is sometimes divided
with a strong pair of cutting pliers, which plan, if the disease or accident
will allow, has the advantage of being less likely to excite inflammation in
the joints of the tarsus.*
IV. Amputation of other Metatarsal Bones. — The fifth may be amputated
in a similar way. For the removal of the second, third, or fourth, the oval
method is often preferred. Beclard used to amputate the two first meta-
tarsal bones as follows : — An incision is begun at the first interosseous
space, six lines in front of the articulation, and extending obliquely as far
as the commissure between the second and third toes ; it next descends
along the furrow under the second and first, and then passes obliquely
upward to the point where it commenced. It is a true oval incision.
Then, from the upper angle of this incision, two others are made, twelve
or fifteen lines in length ; one passing inwards and backwards, and the
other outwards and backwards. The integuments are then dissected up
on each side, and the bone freed from the parts covering it. Next, in
order to get at the articulation, the posterior flap, bounded by the two
last incisions, is reflected.
The same mode of proceeding is applicable to the disarticulation of the
fourth and fifth metatarsal bones.
V. Amputation of the whole of the Metatarsus. — Here the joint is formed
on one hand by the three cuneiform bones and the cuboid bone, and on
the other by the five metatarsal bones; and its direction is such, that its
inner side is nine lines more forward than its outer. The tuberosity of
the metatarsal bone of the little toe will denote the situation of the joint
between that bone and the cuboid ; for it is situated immediately in front
of a depression, which corresponds to the articulation. When the foot is
placed in the position of abduction, the tendon of the peronseus brevis,
which is attached to the tuberosity, may also be seen, or felt. The inner
side of the joint maybe found by attending to the following guides. 1. If
a transverse line be drawn from the tuberosity of the fifth metatarsal bone
to the inner edge of the foot, the joint will be found three quarters of an
inch in front of it. 2. If the forefinger be carried along the inner and in-
terior side of the first metatarsal bone, from before backwards, a tuberosity
is first felt, then a depression, and lastly, a second protuberance. The
joint is between these two eminences. 3. If the finger be passed along
the inner edge of the foot, from behind forwards, the prominence of the
navicular bone is felt an inch in front of the malleolus internus. The
joint lies about thirteen or fourteen lines still more forward. 4. If the
foot be bent on the leg, the tendon of the tibialis anticus, which is attached
both to the great cuneiform and the first metatarsal bone, may be felt.
5. Lastly, as Malgaigne observes, the most prominent point of the instep,
in front of the navicular bone, being ascertained, the joint is three lines
nearer the toes.
As for the direction of the articular surface, the outer part^between
the fifth metatarsal bone and the cuboid bone, is doubly oblique ; at first,
in the direction of a line, drawn from this point to the first joint of the
* The disadvantage of removing the first metatarsal hone, without the great toe, has
been ably explained by Mr. Rynd. See Dublin Journ. of Med. Science, vol. viii.
p. 292.
3 F 3
806 OPERATIONS.
great toe ; and then in the direction of another line, drawn from the same
point to the middle of the first metatarsal bone.
The direction of the articulation of the fourth metatarsal bone corre-
sponds to a curved line, about an inch in length, begun externally, and
terminating inwardly, four lines in front of the point of its commence-
ment.
The articulation of the third metatarsal bone is nearly transverse, and
usually half a line more forward than the last.
The second metatarsal bone extends backward, being lodged in a kind of
mortise, formed by the three cuneiform bones, the internal side of which
is four lines deep, and oblique from behind outwards ; while the external
side is two lines deep, and oblique from behind inwards. The posterior
side is six or seven lines in breadth, and flat, and nearly transverse.
The articulation of the first metatarsal bone is three lines in advance of
that of the third, and its direction corresponds to a line drawn from its
inner part to the middle of the fifth metatarsal bone.
In respect to the ligaments, if the second metatarsal bone be excepted,
which is fixed in the mortise by three ligaments, each metatarsal bone
has on its dorsal side but one ligament. The plantar ligaments are not
of less importance than the three interosseous. The first internal one,
which is the strongest, goes from the outer side of the first cuneiform
bone, and the inner side of the second, to be inserted into the correspond-
ing surfaces of the first and second metatarsal bones. The second, or
middle ligament, proceeds from the external side of the second cu-
neiform bone and the inner side of the third, to the outer side of the
second metatarsal bone, and the inner side of the third. The third is
fixed, on one hand, into the outer side of the third cuneiform bone, and
the inner surface of the cuboid ; and, on the other hand, into the external
side of the third, and the inner side of the fourth, metatarsal bone.
In consequence of the foregoing arrangement, the lateral parts of the
mortise are only in immediate contact with the second metatarsal bone
towards the dorsum of the foot, and the interspaces, left on the plantar
side for the lodgment of the interosseous ligament, will permit the point
of the knife to enter.*
Lisfrancs Method. — On the right foot, a semilunar incision is made
across the instep, half an inch in front of the joint, through the whole
thickness of the soft parts. The skin is drawn back, and the point of the
knife placed on the outer side of the joint. The edge, being carried in
the directions above specified, now enters the joint, and passes as far as
the third metatarsal bone. There the knife is to be inclined half a line
more forward, and the incision extended almost transversely to the second
metatarsal bone. In this part of the operation, the general maxim is to
be followed of not letting the blade become locked in the joint, but
merely to aim at dividing the ligaments with its point. As soon as the
knife has reached the second metatarsal bone, it is to quit this side of the
joint, in order to attack it at the internal side. Here it is to be held per-
pendicularly, and introduced with the edge towards the tarsus, so as to
pass close along the inner surface of the first metatarsal bone ; and
directly it is stopped by the head of the bone backwards, its position is to
be made perpendicular to the axis of the foot, and the joint is to be
penetrated by a sawing motion, in the direction of a line extending to the
middle of the fifth metatarsal bone. In detaching the mortise connection,
* See J. F. Malgaigne, Manuel de Med. Operatoire, pp. 342 — 344.
AMPUTATION OF PARTS OF THE FOOT. 807
the operator passes the point of the knife between the first cuneiform
and the second metatarsal bone, with the edge turned towards the leg,
and cuts along the whole of the inner side of the mortise, not forgetting
its slight obliquity inwards. In this manner, the penetration of the joint
between the firsthand second cuneiform bone will be avoided, and the in-
ternal interosseous ligament be completely divided. The knife is then
withdrawn, and its point carried transversely over the dorsal ligament at
the posterior part of the mortise, and then from behind forward over the
dorsal ligament at its external side. Gentle pressure is now to be made
on the end of the foot to separate the articular surfaces ; while the ex-
ternal and middle interosseous ligaments are divided from above down-
wards, with the point of the knife.
In finishing the operation, the surgeon places the foot in a perfectly
horizontal position, and carries the point of the knife freely over the
plantar ligaments; detaches the textures which are adherent to the
posterior end of the metatarsus, avoiding the tuberosities of the first and
fifth metatarsal bones ; and then pushing the knife under the whole row
of them, he carries it forward along their inferior surface, and thus forms
a semilunar flap, the inner part of which should be two inches long, and
the outer one inch. The aim should be to save more skin than muscle.
If any large tendons should be left denuded in the flap, they are to be cut
away with scissors. It is the plantar flap which is designed to cover
the whole of the wound ; the small upper flap being only intended to
prevent any exposure of the upper surface of the tarsal bones. The
upper flap should only be Employed as a cover for the end of the foot,
when there is not enough skin afforded by the state of the limb for the
perfect formation of the plantar flap ; because the cicatrix will be situated
too much forward, and ill calculated to bear pressure.
VI. Amputation at the Middle of the Tarsus, or the Articulation between
the Astragalus and Os calcis behind, and the navicular and cuboid Bones in
front. — If the foot is extended, the outer side of this joint will be found
twelve or fifteen lines in front of the extremity of the fibula ; its inner side,
ten or eleven lines in front of the malleolus internus ; and its middle part,
about an inch in front of the ankle joint. When the foot is flat on the
ground, the articulation is about three quarters of an inch in front of the
tibia ; but, when extended, the interspace may be nearly thrice this mea-
surement. Another guide is the mid-point between the malleolus ex-
ternus and the tuberosity of the fifth metatarsal bone ; here is the
articulation between the os calcis and the os cuboides, situated, according
to Lisfranc, six lines behind that tuberosity. In passing the finger along
the outer side of the foot from the malleolus externus, the first tuberosity
met with is formed by the os calcis, and the joint is in front of it. To find
the inner end of the joint, the finger may be passed forward along the
internal side of the foot from the malleolus internus ; and the first protu-
berance met with, will be that of the navicular bone : the articulation is
directly behind it. (Richerand.) The precise situation of the upper and
middle part of the joint may be ascertained by extending the foot, and
placing it in the position of adduction ; if the finger is now p^t on the
junction of the external with the middle third of the intermalleolar space,
and the instep traced with it, the first eminence met with, will be the
head of the astragalus, constituting part of the joint itself. (Dupuytren.)
As for the direction of the articular surfaces, when the foot is bent, the
astragalus and os calcis are nearly in the same line ; when it is extended,
the os calcis advances at least three lines more forward than the astragalus,
3 F 4
808 OPERATIONS.
The navicular bone extends a good way towards the malleolus internus,
and here the direction of the articulation is that of a line, drawn from the
back and inner part of that bone, to the place of junction of the posterior
with the middle third of the fifth metatarsal bone. In its middle third,
the articulation inclines slightly backwards towards the malleolus externus;
then it turns a little forwards, and lastly rather backwards again. There-
fore, in cutting into the joint at its external side, the knife should be
inclined a little forwards.
The most important ligament, the true key to the joint, as M. Malgaigne
expresses himself, is the interosseous, attached on one side to the os calcis
and the astragalus ; and, on the other, to the navicular and cuboid bones.
Its situation corresponds to the depression of the external and inferior
side of the head of the astragalus : and here it must be attacked.
The operation is performed on the left foot as follows : — The surgeon
places his left thumb on the external side of the joint, and his fore-finger
on the tuberosity of the navicular bone. Between these two points a
semilunar incision is made, the middle part of which should be half an
inch in front of the joint. The inner part of the joint is then opened in
the direction above particularised, and the knife then carried to the front
of the head of the astragalus. The dorsal ligaments are then cut with
the part of the edge of the knife near its point ; and next the outer side
of the joint is opened with the edge inclined a little forwards. The point
is now introduced under the external and anterior side of the head of the
astragalus, and, with the edge turned forwards, the interosseous ligament
is cut in the direction of the articular surface of the os calcis.
The joint being thus freely laid open, the plantar ligaments are to be
divided, and the knife conveyed close under the bones, to form a suitable
flap. This is most expeditiously done, I think, by transfixion. In this
part of the operation, care should be taken to avoid the protuberances of
the navicular and cuboid bones, and beyond them, those of the first and
fifth metatarsal bones.*
The plantar and dorsal arteries of the foot having been secured, the
flap is to be brought over the astragalus and os calcis, and fixed by means
of adhesive plaster, with or without the aid of a couple of sutures.
I have seen cases, in which the remainder of the foot after this operation
was so serviceable, that the patients walked with but a very trivial degree
of lameness. Mr. Copland Hutchison sent one of his patients to my
house, on whom the operation had proved thus successful. However,
Dupuytren, Lisfranc, and some other eminent surgeons, prefer amputating
at the junction of the metatarsal bones with the first phalanges of the
toes, whenever the state of the limb will allow it, because, the whole of
the tarsus being preserved, the anterior lever of the foot continues
greater than the posterior ; and the extensor tendons of the toes adhering
to the cicatrix, aided by that of the tibialis anticus, inserted into the inner
cuneiform and first metatarsal bones, prevent the foot from being displaced
backward ; a serious grievance, which, though not constant, is alleged to
have sometimes followed Chopart's operation, and required a division of
the tendo Achillis. This operation is not well suited for scrofulous dis-
ease of the foot ; nor for mortification, which is either spreading, or has
already reached on any side above the place of the incisions.
* See J. F. Malgaigne, Man. de Med, Operatoire, p. 347.
809
OPERATIONS ON ARTERIES.
LIGATURE OF THE COMMON CAROTID ARTERY.
THIS operation is occasionally necessary for the cure of aneurism ; the
stoppage of hemorrhage ; and the cure of certain tumours, composed of
vascular erectile tissue, growing within the orbit. It has also been un-
dertaken in cases, where extensive tumours of this character were situ-
ated on other parts of the face and head, but, as I believe, without any
decided success.* The operation has been sometimes resorted to for the
prevention of hemorrhage in the removal of the lower jaw, and large
swellings of the neck. This practice is not, however, usually adopted by
the most judicious surgeons, who know, that a double operation is gene-
rally avoidable, either by pressing the common carotid artery against the
transverse processes of the cervical vertebrae, if necessary, or by tying, or
pressing on the mouth of, every large artery, as soon as such vessel is
divided.
The right common carotid, which arises from the innominata opposite
the sterno-clavicular articulation, is shorter, and, at its commencement,
more superficial, than the left, which originates further back from the
arch of the aorta. After emerging from the chest, each of them has at
its inner side the trachea, and higher up the thyroid gland (which some-
times overlaps it), the pharynx, and the larynx, near which it continues up
to its usual place of bifurcation, the upper edge of the thyroid cartilage.
At its external side is the internal jugular vein, which partly overlaps
it ; while between the two vessels, and rather Dehind them, the pneu-
mogastric nerve descends enclosed with them in the same sheath of
condensed cellular tissue. Behind the sheath is situated the great sym-
pathetic nerve, resting on the rectus anticus muscle ; while the inferior
thyroid artery also crosses from behind the lower portion of the same
sheath in its course inwards and upwards towards the thyroid gland.
The nervus descendens noni usually lies on the forepart of the sheath ;
though occasionally some of the twigs, derived from the arch formed by
its junction with two filaments of the cervical plexus, are found within
the sheath lower down the neck. The common carotid artery may be
regarded as resting on the transverse processes of the cervical vertebrae,
with the interposition of the longus colli and rectus capitis anticus
muscles. On its outer side, and near its root, it is covered by the sterno-
mastoid muscle, which gradually passes backward, so as no longer to
conceal it. On its inner side, it is covered, first by the outer border of
the sterno hyoid and sterno-thyroid muscles, and then by the corre-
sponding lobe of the thyroid gland, and several considerable veins of the
face and neck, as they are proceeding towards the internal jugular vein.
It is divided into two portions by the omohyoideus muscle which crosses
over the anterior surface of the sheath, about the middle of the neck, or
opposite the upper rings of the trachea. In fact, as Velpeau observes,
this little muscle, as it ascends from behind the sterno-mastoideus to the
os hyoides, divides the side of the neck into two very regular triangular
spaces. In the lower one, the sides of which are formed by the trachea,
the clavicle, and the omohyoideus, the artery is concealed by the inner
border of the sterno-mastoid muscle, and is deeply situated ; while in the
* See Velpeau, Nouveaux Ele"m. de Med. Oper. t. i. p. 239., where many trials of
this practice are referred to. The result is very discouraging.
810 OPERATIONS.
upper triangular space, bounded externally by the margin of the sterno-
mastoid muscle, above by a transverse line dra\vn across from the os
hyoides, and below by the omohyoideus, the situation of the artery is
more superficial.
1. Operation below the Omohyoideus. — The patient should lie on his
back, with the neck extended, and the head turned towards the opposite
side. The anterior edge of the sterno-mastoid muscle is the guide for
the external incision, which should be about three inches in length, ter-
minating a little way above the sternum. The first stroke of the knife
divides the skin, superficial fascia, and platysma myoides. Thus the edge
of the sterno-mastoid muscle is exposed. This is to be drawn to the
outer side of the wound, and the sterno-thyroid and sterno-hyoid muscles
towards the trachea, when the deep cervical fascia will be brought into
view, and require to be carefully divided : for this purpose, a portion of
it may be pinched up with the forceps, and cut with the edge of the knife
kept horizontally, and close to the end of the forceps. Into the opening
thus made, a director is to be introduced, along which the further divi-
sion of the fascia may be safely made. The sheath is to be carefully
opened in the same manner, and so as to avoid the internal jugular vein
and nervus descendens noni, but only to the extent of half an inch, in
order not to disturb the connections of the artery more than absolutely
requisite for the passage of the aneurism needle and ligature under it.
according to the principles advocated in the consideration of the subject
of hemorrhage.
Were it necessary to tie the common carotid very low down, an inci-
sion might be made three inches in length, beginning at the sternal end
of the clavicle, and carried obliquely upwards and outwards, over the
ipterspace between the sternal and clavicular portions of the sterno-mas-
toid muscle. The skin, platysrna myoides, cellular tissue, and fascia are
then to be cautiously divided in succession, while the two portions of the
muscle are held apart. The jugular vein will now present itself, at the
inner side of which will be found the artery, in front of the longus colli,
the vertebral artery and vein, and the great sympathetic nerve, which
last is in close relation to the posterior part of the sheath. After the
sheath has been opened, the surgeon should separate the artery, from the
vein and nervus vagus, and apply the ligature according to the following
rule, which is applicable to the ligature of great arteries in general: —
The aneurism needle, eye probe, or whatever other instrument is em-
ployed for the conveyance of the ligature under the artery, is to be
passed between the artery and vein, with the point turned away from the
latter vessel, and guided closely round the artery, by which means the
vein, together with the nervus vagus, in this instance, will not be endan-
gered by the needle, and, at the same time, will be safely excluded from
the ligature. The point of an aneurism needle, however, should never
be so sharp as to be likely to wound either the artery or vein, yet fine
enough to pierce with facility the delicate cellular tissue, connecting the
interior of the sheath to the artery.
2. Operation above the Omohyoideus. — From the point where the
common carotid is crossed by the omohyoideus, opposite the upper rings
of the trachea, up to its bifurcation, the artery is covered only by the
integuments, platysma myoides, and fascia, for the sterno-mastoid muscle
has now diverged from it backwards in its course towards the mastoid
process. However, though this part of the carotid artery is thus super-
ficial, it is frequently covered by a plexus of veins.
LIGATURE OF THE ARTERIA INNOMINATA. 811
The chin being turned towards the opposite side, the first incision is
to commence on a level with the os hynides, and to extend downwards,
about two inches and a half, near the inner border of the sterno-mastoid
muscle. The skin, platysma hyoides, and fascia having been divided,
and the sterno-mastoid muscle drawn a little towards the outer side of
the neck, the sheath of the great vessels, with the nervus descendens
noni in front of, or to the outer side of it, is seen immediately above the
omohyoideus muscle. The surgeon, avoiding the nerve, now opens the
sheath, -and passes the aneurism needle with the ligature between the
internal jugular vein and the carotid artery, from without inwards, and
closely under the latter vessel, for reasons already explained.
By extending the incision upwards towards the mastoid process, the
external carotid might be exposed as high up as the point where it
reaches the tendon of the digastricus muscle, and a ligature applied half
an inch above the bifurcation ; but for various considerations, one of
which is the nearness of the ligature to a collateral branch, and the
danger of this interfering with the closure of the vessel, it is generally
deemed more advantageous to take up the common carotid. Even in a
wound, it might sometimes be difficult to ascertain positively, whether
the bleeding proceeded from the latter vessel, or the external or internal
carotid.*
LIGATURE OF THE ARTERIA INNOMINATA, OR BRACHIO-CEPHAL1C
TRUNK.
This, which is the first branch given off by the arch of the aorta, arises
at the junction of the ascending with the transverse part of that arch ; and
is situated behind the first bone of the sternum ; passing obliquely upwards
to behind the right sterno-clavicular articulation, where it divides into the
right subclavian and right carotid arteries. Above, it is separated from the
first bone of the sternum by the sterno-hyoid and sterno-thyroid muscles;
and below, by the left subclavian vein, which crosses it.f Its external
side is in contact with the pleura, while its inner rests upon the trachea.
It varies in length from one to two inches, and is sometimes wanting ; in
which case, the right carotid and subclavian arteries arise from the arch
of the aorta separately. The pneumo-gastric nerve and internal jugular
vein lie a good way external to it. Between the sterno-thyroid and sterno-
hyoid muscles and the arteria innominata, a very loose cellular tissue
intervenes, in which lie several veins descending from the thyroid gland
to the left subclavian vein.
In the method of operating commonly advised, the skin, the superficial
fascia, the platysma myoides, the sterno-mastoid, sterno-hyoid, and sterno-
thyroid muscles, are the principal parts cut ; but no vessel, nor nerve of
importance, is injured. Yet if, instead of searching for the innominata from
before backwards, and rather from above downwards, calculating from the
sterno-clavicular articulation, the surgeon were to cut too far outwards,
the pneumo-gastric and recurrent nerves, and the internal jugular vein,
and principal branches of the subclavian artery, would be endangered.
First Method. — The patient is to be placed on his back, withiiis head
considerably extended backward, so as to bring the innominata as high
* See P. J. Manec, Traite Theorique et Pratique de la Ligature des Arleres, fol.
Paris, 1832. Also Alf. Velpeau, Nouveaux Elem. de Med. Operatoire, t. i. p. 244.
| See Dr. Quain's Elements of Anatomy, p. 432. ed. 2d,
812 OPERATIONS.
up as possible. The first incision is to begin immediately above the
sternum, at the mid-point between the two sterno-mastoid muscles, and
extend over the origins of the right sterno-mastoid muscle, three inches
towards the right shoulder, at the distance of about half an inch above
the clavicle. By this the skin, superficial fascia, and platysma myoides, are
divided. Another incision, about two inches in length, is then made at
the inner border of the right sterno-mastoid muscle, so as to join the
inner end of the first. The next thing is to cut through the sternal origin
and part of the clavicular attachment of the sterno-mastoid muscle, which
maybe safely done with the aid of a director. The flap is then reflected
outwards. The operator has now brought into view the deep cervical
fascia, and the outer portions of the sterno-hyoid and sterno-thyroid mus-
cles, under which a director is to be passed, when they may be cut through
with a probe-pointed bistoury. After this, a cutting instrument is not to
be employed, but the artery separated from its connections witli the aid
of a director, or other blunt instrument ; and, in detaching the vessel at
its outer and posterior part, great care must be taken not to lacerate the
pleura. The aneurism needle is then to be conveyed between the artery,
the pneumogastric nerve, and the pleura on one side, and its point brought
out between the artery and the trachea on the other. Manec considers
the perpendicular incision superfluous, but Dr. Mott and Professor Graefe,
who have had occasion to tie the innominata in the living subject, both
made the incision at the inner side of the sterno-mastoid muscle.
With regard to the fate of the patients, one died on the 26th day after
the operation ; the other on the 56th. A case under Mr. Lizars had a
similar end.
Second Method. — An incision, between two and three inches in length,
is first made near the lower part of the internal margin of the sterno-
mastoid muscle, and parallel to it. With the fingers, or a director, the
operator then separates the cellular tissue interposed between the sterno-
mastoid and the sterno-hyoid and sterno-thyroid muscles, and then also
separates that which intervenes between these two muscles and the trachea.
On reaching the cellular tissue, in which the veins from the thyroid gland
ramify, they are pushed aside, or cut through, after having been tied. The
patient's head being now bent forward, the surgeon passes his forefinger
between the trachea and the sterno-hyoid muscle, and feels the artery :
with a blunt curved probe, it is separated from its connection, first on the
right side, then on the left, and lastly below. The ligature is then applied,
as already explained. This plan, which was suggested by the late Mr.
King, has never been tried on the living subject.
LIGATURE OF THE SUBCLAVIAN ARTERY, WHERE IT PASSES OVER
THE FIRST RIB.
The subclavian artery ought to be studied, first, in the part of its course
before it reaches the scalenus*; secondly, where it is passing behind that
muscle; and thirdly, from the outer border of the same muscle to the
outer edge of the first rib.f In the first division of their course, the
right and left subclavian arteries differ considerably. The right is larger
* The right subclavian artery has been taken up in this place by Mr. Liston in two
instances of subclavian aneurism, in University College Hospital, "in one of the cases,
the right carotid artery was also tied at its origin. In both examples, fatal hemorrhage
ensued from the artery on the distal side of the ligature.
f See Dupuytren, Lepons Orales de Clinique Chir. t. iv. p. 528.
LIGATURE OF THE SUBCLAVIAN ARTERY. 813
and shorter than the left, which, as coming from the arch of the aorta, is
more deeply placed. But, after reaching the internal edge of the scalenus
anticus muscle, both arteries have nearly the same relations to other
organs. In the latter, or third, division of its course, the artery lies deeply
within a triangular space, bounded upwards and outwards by the omo-
hyoideus; inwards by the scalenus anticus; and below by the clavicle.
After passing from behind the scalenus, its direction is outwards and
downwards over the pleura and a groove in the first rib. The left,,
however, lies more closely to the rib ; the right being only in contact
with its outer edge.* The artery is necessarily beneath the clavicle
and behind the subclavius muscle. Above, it is in contact with the
dorsal nerve of the brachial plexus; while, in the direction forwards,
and a little below the artery, is placedj the subclavian vein, which
reaches this situation by passing in front of the scalenus anticus, while
the artery passes behind it. At this point, then, the scalenus anticus
is interposed between the artery and the vein, with the phrenic nerve
descending near the inner border of it. The cervical nerves, converging
to form the brachial plexus, pass above and more backward than the
subclavian artery, in front of the scalenus posticus, and consequently
they and the artery must lie in the space between this muscle and the
scalenus anticus. In the triangular space, already described, the artery
may be got at by dividing the following parts : — 1st, the skin ; 2d, the
superficial fascia ; 3d, the platysma myoides ; 4th, the deep cervical
fascia; 5th, a quantity of cellular tissue, which is interspersed not only
with veins, and lymphatic glands, but pervaded by two arteries of im-
portance, namely, first, the supra-scapular, which runs under the back edge
of the clavicle towards the root of the coracoid process, and, secondly,
the posterior scapular artery, which, after having arrived at the posterior
angle of the scapula, descends along its base to its inferior angle. It is
between these two arteries, then, that the surgeon has to make his way
to the subclavian. When the attachment of the sterno-mastoid muscle
to the clavicle is extensive, it is necessary to divide also a part of it.
Within the above triangular space, the external jugular vein, as well as
several of its branches, descends ; and if it lie rather more towards the
outer side of the neck than ordinary, and cannot be pushed sufficiently
inwards, it may be indispensable to divide it after a double ligature has
been introduced under it. In individuals whose necks are short, the first
rib is situated very low, in relation to the clavicle, and consequently the
depth of the subclavian artery is considerable. The same disadvantage
may be produced by the aneurismal tumour pushing the clavicle up-
wards. In general, when the neck is long, the interspace between the
clavicle and first rib is but moderate, and the subclavian artery is conse-
quently less distant from the skin.-]- But one of the most essential points
of surgical anatomy, with reference to the ligature of the third division of
the subclavian artery, is the tubercle of the first rib, to which the scalenus
anticus is attached, and close to the outer side of which the artery always
passes.
Operation. — 1. If the state of the disease will allow, the shoulder is
to be depressed and pushed forwards. The situation of the external
jugular vein having been ascertained in order that it may not be cut, if
possible, an incision is made directly above the clavicle, and parallel to its
* See P. J. Manec, De la Ligature des Arteres.
t See Dupuytren, Le9<ms Orales de Clinique Chir. t, iv. p. 578.
814 OPERATIONS.
posterior border, beginning one inch from the sternal end of that bone,
and terminating at the insertion of the trapezius ; or, I may say, that it
should extend nearly to the anterior margin of the trapezius, about two
thirds of the way along the posterior border of the clavicle. If the ope-
rator conceives that a freer division of the integuments will facilitate the
operation, he may make a perpendicular cut an inch and a half long, which
is to descend along the outer margin of the clavicular portion of the
sterno-mastoid, and join the horizontal incision. 2. The skin, superficial
fascia, and platysma myoides, having been divided, and the external
jugular vein held to one side with a blunt hook, the surgeon may next
divide a part of the sterno-mastoid muscle, if its extension outwards
should render this proceeding advisable. 3. The omohyoideus, situated
between the two layers of the cervical fascia, may now be seen crossing
the outer extremity of the wound, and the deep cervical fascia is found
to stop the surgeon's advance more deeply towards the artery; conse-
quently, it is to be cautiously divided with the aid of a director, after
which no further use of a cutting instrument should be made. 4. With
a probe, or director, the surgeon now separates the cellular tissue, and
searches for the external border of the scalenus anticus at the anterior
and inner part of the wound, — a sure guide to the artery ; for, by tracing
it downwarcls with the left forefinger, he is conducted to the tubercle
of the first rib, immediately external to which, the artery will be felt
pulsating. 5. Under the guidance of the same finger, the ligature is then
cautiously introduced under the artery, by means of a common aneurism
needle ; or, if necessary, that invented by Weiss, or others expressly made
to convey ligatures under arteries inconveniently placed for the use of
common means. The point of the needle, which should never be too
sharp, is to be passed under the artery, directed from before backwards,
in order not to endanger the subclavian vein ; and, just at the moment
when the needle is passing, the operator is to keep the artery down with
his left fore-finger, so that the point of the needle may have room to be
brought up, without getting hold of the lowermost nerve of the brachial
plexus.
M. Blandin refers to an instance, in which the subclavian vein passed
behind the scalenus anticus, between this muscle and the artery
(Anatomie Topographique) ; and M. Manec saw an example, in which
the subclavian artery was in front of the scalenus anticus, between that
muscle and the vein. The possibility of such anomalies should be re-
membered.
LIGATURE OF THE SUBCLAVIAN ARTERY IN THE SECOND DIVISION
OF ITS COURSE, OR BETWEEN THE SCALENI.
The operation is begun in the manner of the preceding one; and the
tubercle of the first rib having been felt, a director, somewhat bent, is
introduced behind the anterior scalenus, and the lower attachment of this
muscle divided with a probe-pointed bistoury. In this part of the ope-
ration, care must be taken not to injure the phrenic nerve, which descends
along the inner margin of the scalenus anticus, and a little in front of it ;
nor the subclavian vein. The muscle, directly it is cut, is retracted,
leaving the artery exposed, under which the director may then be passed
in Dupuytren's way from without inwards, along the groove of which an
eye-probe with the ligature is to follow. Thus, he avoided including the
nearest nerve of the brachial plexus, and though the director and eye-
LIGATURE OF THE BRACHIAL ARTERY. 815
probe were passed from without inwards, the subclavian vein was perfectly
safe, because no instrument capable of puncturing it was employed.
LIGATURE OF THE BRACHIAL ARTERY IN THE MIDDLE AND UPPER
PARTS OF THE ARM.
The brachial artery commences at the lower margin of the axilla, and
terminates about three quarters of an inch below the bend of the elbow,
its course corresponding to a line drawn from the centre of the armpit
to the middle point between the condyles of the humerus. In the upper
half of the arm, it lies near the inner margin of the coraco-brachialis,
and then crossing over the insertion of this muscle, it becomes situated
at the inner side of the biceps, which partly overlaps it. especially when
the fore-arm is in the prone position. At first, the artery lies in front of
the triceps muscle, but below the insertion of the coraco-brachialis: the
muscle, on which it rests during the rest of its course, is the brachialis
anticus. The median nerve, which, above, runs along its acromial
margin, soon gets in front of it, and, crossing it about the middle of
the arm, lies completely upon its inner side below. Two satellite veins
accompany the artery, and sometimes even cover it, or separate it from
the median nerve. The ulnar and internal cutaneous nerves, which run
near the artery above, separate further and further from it, as they
descend. In thin subjects, the artery is but a very little way under the
fascia, which sends off a duplicature, for the investment of the artery,
the accompanying veins, and the median nerve. In the lower third of
the arm, the trunk of the basilic vein lies over the track of the artery.
Amongst the anomalies deserving notice, is the high bifurcation of the
artery, a frequent occurrence* ; and the occasional passage of the median
nerve under the artery f, a rarer circumstance. In all ordinary cases, this
nerve is the first cord met with behind the inner edge of the biceps,
below the insertion of the coraco-brachialis.
In selecting the place for the external incision, four circumstances
serve as our guide. 1. In the upper part of the arm, the inner border of
the coraco-brachialis, which, in a muscular person, rather overlaps the
vessel, but below the insertion of this muscle, namely, all along the lower
half of the arm, the inner edge of the biceps denotes the best place for
the external incision. 2. The oblique line, drawn from the middle of
the armpit to the middle of the space between the condyles of the hu-
merus. 3. Placing the fingers of the left hand on the track of the
median nerve, and making the incision just at its inner side, as directed
by Lisfranc with reference to the lower half of the arm. 4. The pulsa-
tion of the artery.
An incision, three inches in length, having been made through
the integuments, the surgeon passes his left forefinger into the wound,
and ascertains again the precise situation of the artery and median nerve.
With the aid of a director, the fascia is next divided to the extent of the
external incision. The median nerve is the first cord now met with at
the inner margin of the biceps, and is easily known by its firm round feel
and white colour : it is to be separated with a probe or director from the
* In a case of circumscribed false aneurism, Dr. Browne, of St. Mark's Hospital, tied
both branches with success, the omission of which practice has in some other instances
been followed by the death of the patients from hemorrhage. See Dublin Journ. of
Med. Science, vol. viii. p. 253.
•(• See Velpeau, Nouveaux Elem. de Med. Op. t. i. p. 212.
816 OPERATIONS.
sheath, and the artery will be found either directly under it, or, if the
operation be done low down the limb, at its external side. Further
inwards, lies the internal cutaneous nerve ; and five or six lines back-
ward, is the ulnar. The 'sheath having been opened, the ligature is
to be passed under the artery, with the precaution of not including the
veins.
In order not to mistake the ulnar for the median nerve, which would
cause much confusion, it is advantageous to direct the incisions from the
front towards the back of the limb.
In the upper part of the arm, the external incision is to correspond to
the inner margin of the coraco-brachialis ; and, very high up, the median
nerve will present itself on the acromial side of the artery.
^LIGATURE OF THE BRACHIAL ARTERY AT THE BEND OF THE ELBOW.
An incision is to be made, two inches and a half or three inches long,
parallel to the radial edge of the pronator radii teres, beginning nearly
an inch above the trochlea, and ending at the central point between the
condyles of the humerus. Under the skin are situated the median and
basilic veins, with the accompanying branches of the internal cutaneous
nerve. An assistant holds these vessels aside with a blunt hook, or the
end of a bent probe. The fascia is now arrived at, which should be
divided on a director, as well as the aponeurosis coming off from the
biceps. Then, having detached the artery from the adjacent cellular
tissue and fat, and from the deep veins, as well as the median nerve, the
surgeon should pass an eye-probe between the artery and the latter nerve.
The artery will be found resting upon the inner portion of the brachialis
anticus, between the biceps and the pronator radii teres. Pursuing its
course downwards and forwards, and from within outwards, it crosses
completely over the tendon of the biceps low down. A deep-seated vein
runs near its radial margin ; and the median nerve, which sometimes
touches its ulnar edge, is often separated from it by a few fibres of the
brachialis.*
LIGATURE OF THE EXTERNAL ILIAC ARTERY.
The aorta, having reached the body of the fourth lumbar vertebra,
bifurcates into the two common iliac arteries, which diverge from one
another as they pass to the sacro-iliac symphysis. Here each of these
trunks subdivides into the internal and external iliac arteries. From the
sacro-iliac symphysis, where the external iliac artery begins, down to
Poupart's ligament, where it terminates, it describes a gentle curve with
the convexity outwards, which curve is greater in women than men, and
always more marked the broader the pelvis is. The course of the artery
is obliquely downwards and outwards, to the middle point between the
anterior superior spinous process of the ilium, and the symphysis pubis.
In its descent, it lies upon the inner border of the psoas muscle, with
the external iliac vein at first behind it, and afterwards on its inner side,
connected to it by a loose cellular tissue, that is readily torn. The ante-
rior crural nerve is separated from the external iliac artery by the psoas
muscle. The artery is connected behind to the iliac fascia by a cellular
tissue, which adheres firmly to each side of the vessel. In front of this
fascia is the peritoneum, loosely connected to it. The internal branch
of the genito-crural nerve, in its descent from the lumbar plexus to the
* See Velpeau, Nouveaux Ellm. dc Med. Operatoire, t. i.
LIGATURE OF THE EXTERNAL ILIAC ARTERY. 817
upper and internal part of the thigh, runs along the inner and front
surface of the artery. Several lymphatic glands are contiguous to the
artery, as it passes down to Poupart's ligament. The ureter crosses
over the lower part of the common iliac artery, and the spermatic vessels
cross in front of the external iliac artery. No branches are given off
from the latter artery until it has nearly reached Poupart's ligament,
where the circumflexa ilii arises from its outer, and the epigastric from
its inner side. The intestines, lying between the artery and the parietes
of the abdomen, may readily be lifted up from that vessel, together with
the peritoneum. For the purpose of applying a ligature to the exter-
nal iliac artery, the following parts must be divided: — !. The integu-
ments. 2. The superficial fascia. 3. The aponeurosis of the external
oblique muscle. 4. The internal oblique muscle. 5. The transverse
muscle. 6. The fascia transversalis. But the peritoneum, which can
be raised from the iliac fossa, should not be wounded. Care must also
be taken not to injure the external iliac vein, and the epigastric artery,
which ascends obliquely upwards and inwards, between the fascia trans-
versalis and the peritoneum, at the inner side of the internal abdominal
ring. In consequence of the situation of the origin of the internal iliac
artery, a ligature cannot be applied more than three inches above Pou-
part's ligament, without great risk of failure.
Operation. — Abernethys Method. — The incision is made through the
integuments, beginning above Poupart's ligament, half an inch on the out-
side of the abdominal ring, and extending obliquely upwards about three
inches in the course of the artery. The skin, superficial fascia, and apo-
neurosis of the external oblique muscle having been divided, the left fore-
finger is introduced, at the lower angle of the incision, under the lower
border of the internal oblique and transverse muscles, which are also to
be divided with a probe-pointed bistoury to the extent of an inch and a
half. The fascia transversalis having been cautiously opened with the
aid of a director, the peritoneum and bowels are to be pushed upwards
and inwards over the psoas muscle, so as to expose the external iliac
artery, an inch and a half, or two inches, above Poupart's ligament. With
a common aneurism needle, or that of Weiss, a ligature is then passed
under the artery from within outwards, by which means the vein will not
be endangered.
Sir Asiley Cooper's Method. — A semilunar incision, three inches long,
is made through the integuments, in the direction of the fibres of the
aponeurosis of the external oblique muscle, with its convexity down-
wards and outwards. It commences a little way in front of the anterior
superior spinous process of the ilium, and terminates near the abdominal
ring. The aponeurosis of the external oblique muscle is next divided
in the same direction. On raising the semilunar flap, the spermatic
vessels are seen, and these serve as a guide to the opening in the fascia
transversalis, named the internal abdominal ring, a little to the inner
side of which the epigastric artery runs. The finger being now passed
below the cord, the external iliac artery will be felt pulsating directly
behind the internal ring, where it may be easily taken up. The latter
opening is placed nearly at the mid point of the crural arch. It is to be
divided in the direction outwards with a probe-pointed bistoury, guided
along a director.
Mr. Norman cuts in the direction of Poupart's ligament ; but, in other
respects, follows Sir Astley Cooper's plan. M. Roux begins the incision
818 OPERATIONS.
a little above, and half an inch from the spine of the ilium, and lets it
terminate at the centre of the crural arch.
Velpeau's Method. — A slightly curved incision, three inches long, is
made parallel to Poupart's ligament, but a little above it, the centre of
which is to correspond to the place of the artery. By the first stroke of
the knife, the skin and superficial fascia are divided. Then the apo-
neurosis of the external oblique, which is cut on a director. Next the
fibres of the internal oblique present themselves, the lower portion of
which are detached with the end of a probe, or director, and pushed
with it upwards and backwards, while the lower margin of the wound
is pressed downwards with the forefinger of the left hand. The fascia
transversalis is torn in the same way as far as the spermatic cord,
which is to be pushed in the same direction as the fibres of the internal
oblique.
The cellular tissue, connecting the artery to the iliac fascia, is now
ruptured with a probe or director, which instrument is then to be con-
veyed to the inner side of the artery, and moved gently backwards and
forwards, in order to separate the artery from the vein. The ligature
is next conveyed under the artery with an eye-probe, or an aneurism
needle. Care is taken to tie the artery sufficiently above the epigastric.
Beclard lost his patient by placing the ligature below it; and hence,
Bogros always looks for the epigastric, before he searches for the ex-
ternal iliac.
During the other steps of the operation, the abdominal muscles should
be relaxed, and the patient make no efforts, for otherwise the bowels will
force themselves against the wound, and the peritoneum be exposed to
injury. Whatever method be preferred, the course of the epigastric
artery at the inner side of the internal ring, between the peritoneum and
the fascia transversalis, must be remembered. In one instance, it was
wounded by Dupuytren.
LIGATURE OF THE COMMON ILIAC ARTERY.
The bifurcation of the aorta generally takes place on the fifth lumbar
vertebra, but sometimes on the fourth, which circumstance must make a
difference in the length of that artery, in different subjects. The right
common iliac artery is longer than the left, because the bifurcation of the
aorta is situated rather to the left of the median line. The right common
iliac artery descends obliquely over the last lumbar vertebra, from which
it is separated by the common iliac veins in their passage to the vena
cava. Its own corresponding vein is first behind it, and then internal to
it ; while, on the left side, the common iliac vein runs along the inner
side of the artery, having first passed under the right common iliac artery.
The common iliac artery lies behind the peritoneum, and is crossed by
the ureter just before it reaches the sacro-iliac symphysis, where it
divides. The left has the sigmoid flexure of the colon in front of it ; and
the right, a portion of the ilium.
In Dr. Mott's plan, an incision is begun on the outside of the abdominal
ring, half an inch above Poupart's ligament, and extended, about eight
inches, to a point above the anterior superior spinous process of the ilium,
in a semicircular form.
Mr. Crampton's incision, the concavity of which was towards the navel,
was seven inches long, and reached from the last rib to the anterior
superior spinous process of the ilium. The layers of the abdominal
muscles, and the fascia transversalis, having been divided, the peri-
LIGATURE OF THE FEMORAL ARTERY.
toneum and the bowels are then pushed forwards, and inwards which will
also lift the ureter off the lower portion of the artery. While an
assistant holds the peritoneum and the bowels out of the way, the sur-
geon passes the ligature under the artery, with due regard to the situ-
ation of the vein.
LIGATURE OF THE INTERNAL ILIAC ARTERY. — MR. STEVENS* S METHOD.
An incision, five inches in length, is made six lines from the outer side
of the epigastric artery, and parallel to the course of this vessel. The
skin, muscles, and fascia transversalis, having been successively divided,
the peritoneum is separated with the fingers from the psoas and iliac
muscles, and pushed inwards as far as the bifurcation of the common iliac
artery. The pulsations of the internal iliac may then be felt in the deep
part of the wound.
LIGATURE OF THE FEMORAL ARTERY.
The femoral artery extends downwards along the anterior and inner
part of the thigh, from the lower termination of the external iliac artery
and the body of the os pubis, down to the upper part of the popliteal
space ; or we may say, that it begins at the crural arch, and terminates
at the junction of the middle with the lower third of the thigh, where
it passes through an opening in the adductor magnus, and then becomes
the popliteal artery. The direction of its course corresponds to that of
a line, drawn from the middle of Poupart's ligament, obliquely inwards
round the thigh, to the popliteal space. But, as Dr. Quain has re-
marked, if the knee be semiflexed, and the limb rotated outwards, the
course of the vessel may be marked out by a line, drawn from midway
between the anterior superior spine of the ilium, and the symphysis
pubis, to the lower border of the patella. The femoral vein accom-
panies the artery through its whole course, being placed at first on its
inner side, and on the same level with it, but getting behind, or under
it, yet still a little inwards, about two inches below the os pubis, and
maintaining this position to the end. The artery, as it descends, be-
comes gradually deeper. At first, it lies on the inner border of the
psoas muscle, by which it is separated from the os pubis, the brim of the
acetabultim, and the hip-joint. Lower down, it gets on the pectineus
and adductor brevis; next on the adductor longus ; and lastly on the
united tendons of the latter and the adductor magnus. Externally, the
psoas muscle is interposed between its upper portion and the anterior
crural nerve, which, in the groin, is situated about three quarters of an
inch to the outside of the artery. The sartorius crosses the artery very
obliquely, being, above, completely to the outside of it ; in the middle
part of the thigh, covering the artery ; and below, lying on its inner side.
Two or three branches of the anterior crural nerve run for some way
along the sheath of the artery ; and the largest of them, the nervus
saphaenus, having entered the sheath, descends along the upper and outer
side of the artery in the middle part of its course. In the upper third of
the thigh, the femoral artery is covered only by the integuments, the
superficial fascia, the inguinal glands, and the fascia lata. In the middle
third, it is additionally covered by the sartorius, directly under which is
a fascia extended from the adductor muscles to the vastus internus, thin
above, but dense lower down, and constituting another texture lying over
the artery. In the Museum of University College is a fine specimen of
3G 2
820 OPERATIONS.
a double femoral artery, the two divisions afterwards conjoining again into
one trunk. Examples of a double femoral vein are also on record.*
OPERATION IN THE UPPER THIRD OF THE THIGH.
This part of the limb is preferred by Scarpa and many other excellent
surgeons, on account of the artery being more superficial than in the
middle third of the thigh. An incision, three inches in length, is made
through the integuments and superficial fascia, in the track of the artery,
as above specified, and the determination of which in the living body is
rendered easy by the pulsations of the vessel, except in fat subjects. The
centre of this cut should be nearly four inches below Poupart's ligament,
unless circumstances were to compel the surgeon to take up the artery
immediately below the crural arch — between the profunda and the epi-
gastric arteries. The knife is to be carried down in the track of the
vessel, but rather to the outer than the inner side of it, in order to avoid
the vena saphaena major, which enters the femoral vein in this part of the
thigh. The fascia lata having been exposed, the surgeon, previously to
dividing it, is to remember, that, in the direction downwards, the inner
edge of the sartorius separates it from the artery, which is not the case
in the upper part of the inguinal triangle. The fascia having been opened
nearly to the same extent as the integuments, a portion of the femoral
sheath is to be lifted up with a pair of forceps, and divided, but only so
far as to make room for the ready passage of an eye-probe, or aneurism
needle, round the artery, in which step of the operation the instrument
should be introduced on the pubic side of the artery, between this vessel
and the vein, and with the point turned away from the latter, and brought
up again at the external side of the artery. The branches of the anterior
crural nerve should not be included in the ligature, one half of which,
after a knot has been made, is to be cut off, so as to lessen the quantity
of extraneous matter in the wound. The edges of the incision are then
to be brought together.
OPERATION IN THE MIDDLE OF THE THIGH.
The limb is to be slightly bent, rotated outwards, and placed on its
outside. An incision, three inches in length, is made through the inte-
guments and superficial fascia, in the track of the artery, or rather in a
line corresponding to the inner edge of the sartorius. The fascia lata
having been next divided to nearly the same extent, the sartorius presents
itself, and may be recognised by the direction of its fibres downwards and
inwards. As soon as this muscle is raised, the fascia extending from the
adductor muscles to the vastus internus is seen, and will require to be
carefully divided, for the purpose of exposing the sheath of the femoral
vessels.
For the purpose of more certainly avoiding the vena saphaena major,
Mr. Copland Hutchison, and M. Roux, are advocates for making the
incision on the outer side of the sartorius, which is to be pushed inwards.
This is not, however, the common practice. The arterial sheath is
opened, and the ligature applied, according to rules already given.
LIGATURE OF THE POPLITEAL ARTERY.
The-patient is to lie upon his face with the leg moderately extended
When the lower portion of the vessel is to be secured, an incision, three
See Dublin Journ. of Med. Science, No. xxvii.
DIVISION OF TENDONS. 821
inches long, is made in the median line of the limb, through the skin and
subcutaneous fat and cellular tissue, care being taken to push the exter-
nal saphsenal vein outwards, if it should present itself. After the fascia
has been divided, some surgeons lay down the knife, and, having sepa-
rated the cellular tissue and fat with a director, and likewise the head of
the gastrocnemius, take up the artery with the precaution of detaching it
from the nerve and the vein with the director.
ABOVE THE CONDYLES.
Here the external saphaenal vein may be more easily avoided. The
incision should be longer, and rather nearer the inner, than the external
margin of the ham, at least above ; and it should descend in a slightly
oblique direction to the point over the space between the condyles.
Under the fascia is the nerve ; more deeply and inwardly lies the popliteal
vein ; and quite towards the bone, and on the inner side of the vein,
rather under it, the artery ; which is generally separated with difficulty
from the latter. In the instance of a sloughing ill-conditioned wound,
attended with hemorrhage from the posterior tibial artery, however,
where I had occasion to tie the popliteal artery in University College
Hospital, the vein, which was soon recognised by its dark blue colour, did
not occasion any difficulty in getting the ligature round the artery, and
the operation, which was completed with the utmost facility, did not
occupy more than three or four minutes. As Dr. Duncan of Edinburgh,
Mr. Chandler of Rotherhithe, the two house-surgeons, Mr. Wallace, and
others, well know, there was none of the trouble experienced which has,
somewhere or another, been very erroneously described. What is of
more importance, the operation put a permanent stop to the hemorrhage.
In this case, the fact of an artery not conveying the slightest sensation
of throbbing, when exposed, and touched, was most unequivocally exem-
plified.
DIVISION OF TENDONS FOR THE CURE OF CLUB-FOOT, AND OTHER
DEFORMITIES.
Synonymously with the term " club-foot," Dr. Little employs the word
talipes, as a generic term to embrace all those deformities of the feet,
which arise from the contracted state of certain muscles ; and he uses the
terms varus, valgus, and equinus, to designate the specific forms of such
deformities.
The least complex is the talipes equinus, which consists in a simple
extension of the foot, by which the heel is elevated, and the patient rests
upon the toes and metatarsal bones, no part of the sole behind the latter
touching the ground. By the habitual disuse of the limb, the full deve-
lopement of its bones is impeded, and its muscles are small and flaccid.
The most frequent of these deformities is the talipes varus, combining
extension with adduction of the foot ; and, to these characteristics, a
third may be added, viz. a rotation of the foot, somewhat analogous to
supination of the hand, in a greater or lesser degree, according to the
severity of the disease. The inner edge of the foot is thus raised from
the ground, forcing the sufferer to walk entirely on the outer margin.
In the talipes valgus, which is comparatively rare, there is a partial
bending of the ankle, with abduction and a rotation of the foot, by which
the outer edge of the sole is raised from the ground. In a complete case,
822 OPERATIONS.
the patient treads entirely upon the inside of the instep, and upon the
malleolus interims.*
Passing over the palliative treatment by means of friction, shampooing,
electricity, the moxa, &c. applicable to some cases, it is certain that all
these varieties of deformity may, and frequently do, require the knife. In
most cases of talipes equinus, the section of the tendon of Achilles will re-
store the foot to its proper position. For this purpose Dr. Little prefers a
small, curved, sharp-pointed bistoury, with a concave edge, the cutting part
of the blade being seven tenths of an inch in length, and the greatest width
one tenth, in order that the external puncture may be small. The patient
being seated, an assistant supports the knee, whilst another, drawing
down the patient's heel with his left hand, and pressing upwards the toes
and front of the foot with his right, produces the necessary degree of
tension in the tendon about to be divided. The bistoury is passed through
the skin, one or two fingers' breadth above the malleolus internus, with
one of its sides turned towards the tendon, and the other forwards. As
soon as the point has passed beyond the external edge of the tendon, and
nearly reached the skin of the opposite side, the knife is turned, so as to
bring its edge against the anterior surface of the tendon, which is then
divided by withdrawing the knife, and usually at one stroke. f
It is a matter of importance to let the external wound be small ; and
hence some operators use a sharp-edged needle. If a tendon be cut,
and an extensive division of the skin over it be made, suppuration is
likely to ensue ; and, if this be protracted, a portion of the tendon may
either slough, or become adherent to the integuments, so as to render the
operation more or less a failure. The healing process should not be dis-
turbed by premature attempts to extend the limb. The wound should
be closed before extension is commenced ; and, for this purpose, two or
three days are generally sufficient. During this period, the limb may be
laid on its outside on a pasteboard splint. The flexion of the foot is to
be maintained with mechanical means. One of the most simple contri-
vances is a band, or strap, extending from the point of the shoe to the
fore part of another band,, or strap, placed round the limb above the
knee. But various means are preferred by different operators. In some
obstinate cases of talipes equinus, Dr. Little has found it necessary to
divide the tendons of the tibialis posticus and flexor longus pollicis.
The treatment of talipes varus consists in dividing the tendon of the
gastrocnemius ; and, if the case be of long standing, it may also be re-
quisite to cut the tendons of the tibialis anticus, and tibialus posticus,
with the extensor and flexor proprius pollicis, as exemplified in cases
recorded by Dr. Little.
In the talipes valgus, Dr. Little refers the deformity chiefly to the
peronei muscles ; though it is usually necessary to divide also the tendo
Achillis, and even the tendon of the tibialis anticus, before the foot can
be restored to its natural position.
Stromeyer, by means of a small boot, with a long spring, operating in
a direction opposed to the abnormal eversion, succeeded in a few months
in curing a talipes valgus in a very young infant.
Theyoungest patient, in whom Dr. Stromeyer divided the tendo Achillis
* See a Treatise on the Nature of Club-foot, and Analogous Distortions, by W. J.
Little, M. 13. 8vo. Lond. 1839.
f Little, Op. cit. p. 30.
DIVISION OF TENDONS. 823
for talipes varus, was eight months old. Dr. Little operated on one child
of twenty months ; and Mr. Whipple on another aged fourteen months.
With regard to the other extreme, Dr. Little narrates a case (No. xxxiv.
p. 2.58.) of non-congenital distortion from contraction of the gastrocnemii
and other muscles, converted by exercise into a deformity, resembling
talipes varus : the cure was accomplished by dividing the tendo Achillis,
though the disease had existed forty-eight years.
Just as I was closing this volume, I had a consultation with Dr. Little
on a gentleman, who, in consequence of an extensive necrosis of the
tibia, now cured, for which I formerly attended him, with Mr. Earle, is
unable to bring his heel to the ground. The patient, who was referred
to us for an opinion by Mr. Wood, of Rochdale, Lancashire, after having
long had recourse to mechanical contrivances in vain, has been recom-
mended to try what benefit will result from the division of the tendo
Achillis. As the case, on account of its origin from the effects of necrosis,
is very interesting, I trust that Mr. Wood will take an opportunity of
letting the profession hear the result of the proposed treatment.*
* The reader should consult, in addition to Dr. Little's valuable work, Beitrage zur
Operativcn Orthopadik. 8vo. Hanover, 1838. Whipple, Lond. Med. Gazette, vol. xx.
p. 826, who differs from Strom cyer and Dr. Little in having recourse to flexion of the
foot, directly after the tendon has been cut. M. Bouvier, Mem. sur la Section du Tendon
d'Achillc, &c. 4to. Paris. 1838. Also a judicious account of the subject in British and
Foreign Med. Review, No. 16. art. 5.
THE END.
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