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■■V.' 






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66 



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"^ 



THE 



SCIENCE AND ART 



SURaERY. 



A TKKATISE ON SURGICAL INJURIES, DISEASES, 
AND OPERATIONS. 



BY 
-lOIIX ERIC ERICHSEN. F.R.S.. LL.D., F.R.C.S., 

'■■^ > \>iii-<iii>i<iAtir Tu BRR MAitan rnt qcir.i: ri-rxtiunEirT uf thr bovil collisi 

.r .1 Riirou iir iMai.AirD hxd iir tbr rotai. MBniCAL aki> rBint^iiOK-AL m>C[BTT: 

rvtRiii « rKurr.noRorni'HctRT AnooFrLiKrcAL Bmoinr m ckitibbitt 

• •i.LF.nK: ronnrLTiKC *(-|iai:a!( TO uvrvRHSiTr rciLLRSR SDSPITAL, 

Ann TO umr nBiH MitnicAL cbaritirk. 

EIGHTH EDITION. 

HEVISKI) AS1> EDITBP BY 

MAIUIS UFAK. .M.S. and M.H. D.m... I-Mt.C.S.. 

. . • r..\ 1 1 I iin rBsnr cnM.iiiH hiwi'Ital : ami l■Il.^^-^^■«JH t-r ri.mcAi. si hckht in 

rSIVERHTV rOLLKGK. l^tVJXtS. 

.1 TU .\l.\f: lit MillED A.VD HIHIITY fOfH ESIHtAVIXiiS HX W')QD. 



VOL I. 




PM 1 I, A t>K l-l'H 1 A: 
IIENKV V. LEAS SUN & CO. 



"They he the bttt Chinirgeonii tcAtcA lieing Itamrd indine lo thr fraditirmi oj 
rjjterienee, or bei»,j empiria indme lo the melhodi of Itnmmg." 

Baiii.i "h LtnrniKg. 



rBlLAUILPBIAl 

on. J. noimia, phiktir. 






PREFACE 

TO THE NEW AMERICAN EDITION. 



I DEDICATE these volumes to the Surgical Profession of the 
United States of America in testimony of the esteem which I 
entertain for that large and enlightened body of practitioners, and 
of the c-ordial friendship that has long existed between me and 
many of its members. 

I hare erer regarded the favor that has for so many years been 
iihown by American Surgeons to the " Science and Art of Surgery," 
as tiie moi^ honorable distinction that could be conferred on it, and 
"n its author. 

I h:ivi.- s[iarfd no pains to make this Kdition deserving of a con- 
tiiiuance -if this good opinion on the |Piirt of my Transatlantic col- 
kii^ues, and I trust that in it they will find not only an Epitome of 
Itriti-li Surgery, but that, so far as its scope has permitted, I have 
._-ii'ieavt>red to do justice to the great achievements of .American 
'■'l^:.'■^■o^^' of a past and of the present generation. 

JOHN EKIC KRICHSEN. 

1. —i—n. Ait-iwt. lHe4. 



PREFACE 

TO THE EIGHTH ENGLISH EDITION. 



The Author had long felt that a complete revision of thia work 
ha<i become necessary, in order to bring it on a level with Modern 
:?urgerv in its Science as well as in its Art, 

Much that wis antiquated had to be eliminated from its pagea — 
more that was new in Pathology as well as in Practice required 
notii-f ; for in no corresponding period in the history of Surgery 
b&s ^o great an advance been made in all its departmenta as in that 
which hai^ passed since the last edition of this work was published. 

Til'- litltor deniundeii by each complete revision of a work ex- 
t<rn>l:T!;: iivLT so wide a tield as this does, was greater than he could 
r.'w nudertake single-handed. He therefore sought, and was fortu- 
nati in obtaining, the cooperation of his old pupil — hia colleague 
ai..l friend, Marcus Beck. To him has been mainly entrusted all 
liiat ri-l;itfs to Pathology. To this task Mr. Beck has brought not 
..ri.\ sii t-xii-nded practical knowledge of Surgical Pathology, en- 
ar'.it,'.' him to speak with authority from, and to test the doctrines 
'■r ■•tln-r^ by, hia own observalions, but a thorough acquaintance 
witIi the work of others in this field of science. In those parts of 
;!..- boi.k, a]<o, which relate to Clinical and Operative Surgery, he 
ha- done n)uch in assisting the Author to bring up these subjects 
•■■ the Ivvel of the more advanced methods of modern practice. 

Til- Autlior's friend and former pupil, William A. Meredith, 
M,<-x kindly undertook the revision of the Chapter on the t>urgieal 
Tr<;ilincnt of some Uterine and Ovarian Diseases — a subject for 



nil 



PBKFACK. 



which hiH npeuial acqimintnnce with t]i(t«cnfr«clinns pdcnlitrl; fitUa 
him. 

To Stniilv5' Boyd tbc Author is imleblml for iiinch valualil« aeatst- 
BQCC In carr^'iiig the work through the Press; and to Victor Hnrslej 
fhr some of the new drawings t>,v which it U illustrated. H 

About one hundred and Rftv new Piguref) have been uddeoT 
drawn from nature by W. ][. Witnlvy, and engraven] by O, Ponrson, 
some of the old ones an^ cancelled, and many r«'dmwn. Whenever 
ft woodcot han been taken from anotlior work, tlie name of the 
author of the work whence it lian been taken hni> bv«n app«ndcd to 
it. 'Wlien no Kuch noknowMgrncnt i» made tlie Figure is original, 
belong) exclusively to thin work, and, uxcupt in tbo cam of dia- 
gmtus, has boon drawn from nature. The Author amy be oxctiwd 
fh)m laying stress on thcM! poinis, as toany of his illustrations luiva 
been copied into other works on Surgery without acknowledgmatit 
of tliv source whcnci- they have be«n tuken. 

Arrsngoment» have been roado for tfao appearjince, simultunu- 
ously with the Eugliah Edition, of a new Amoriean reprint of tba 
work. And of new TranalationB of it into Italian by Dr. Antonio 
Longhi, nf Milan: and into Spaninh by Dr. ITIecia-y-Onnlona. of 
Madrid. 

The Author tttels that a rwponsibility, weighty in proportion to 
the very extent of this wide diffusion of his Instruction, is incurred 
by him who takes upon himMdf the task of teaching olhem tliat 
Science which underlie* the Art, and thiu .\rt, the exercise of which 
conslituteit the application to Practice of a great branch of Medical 
koowledgc, which more directly than any other de]iartment nf 
Medicine involves the physical well-being, and more irntueiliately 
afibcta the Hfe of those on whom it is exorcised. 

It is not sufficient that the Teaching of a Scientific Art, euch as 

Surgery, should be sound in those General Laws tliot constitute its 

Principles. It must also be accurate in those minute details thai 

■n nocetmry to its succeaaful Practice, and, above all.juat in ila 

I aitiinalo of the labors of others. 

A Teaohor of Surgery, who seeks to give a true and imparltal 
now of the subject of his tuition, is placed in much the same posi- 
tittn as a Judge who is summing up a groat cause. 



PREFACK. IX 

He muH endeavor to diveBt hiineelf of the trammels of tbe 
^hool? — to free himaelf alike from the partisanship of individual 
hia« and the prejudice of professional antagoniBm. 

He mast lay down clearly the broad General Principles on which 
the Cji*e rests; detail its facta in au orderly and succinct manner, 
draw those deductions which legitimately flow therefrom, and guide 
hif Pupils to arrive at just conclusions by the light of his own more 
matured and extended experience. 

Throughout the Work it has been tbe object of its Author to 
place before the Student and Practitioner the Science and the Art 
•if Surgery — not as consisting, merely, in the observation of such 
Injuries. Diseases, and Malformations, as are met with in Surgical 
Practice or in the dexterous application of manual or operative 
nieaud for their relief; but as demanding an exercise of geueral 
medical knowledge, and a thorough acquaintance with all those 
i-onditions, whether iotrinsic to the patient, or surrounding him, 
that favor or prevent his restoration to health. Tbe remarks in tbe 
earlier part of the First Chapter, will, it is trusted, sutBciently in- 
dicate to the Student what is required of him in order that he tnaj 
bei-omc a successful Practitioner of Surgery. 

In t-very instance an endeavor has been made to give as full and 
!«.-ar ii ilesoription of Sj'mptoms, Pathology, Diagnosis, and Treat- 
:Lviit, a,- the importance of each demands, and the present state of 
S;:rLr.al knowledge permits. 

Tiii- variauB now Operations practised in modeni Surgery have 
: vt!i ■.■;irf fully described, the difliculties and dangers attending their 
i— rf'Tinaiiio pciintfd out, and the eases requiring tliem detailed. 

Til- piinmmunt importance nf Surgical Hygiene, both general 
.ii.i i"ial, lias led to special attention being paid to it in the 
» riLipT.-rs on Operations, Wounds, and Septic Diseases. 

With n-spect to Diagnosis it may be remarked that, as accuracy 
:f. tJii-* l-nkrii-li is an all-important requisite for success in Treatment, 
•' •■ -':::iis aijij syniptonis by which the injury or disease under con- 
- .:.-r:iliini may be recognized, have not only been described in each 
• J,—-, but rjire has been taken, even at tbo risk of iiceasiona] rcpcti- 
:;■■(., t"> point out tbe several conditions with wbiih it may be con- 
f>.>undt-d. and the means of distinguishing it from each of them. 



X PREPACK. 

The Chapter on the Operations practised on the Eye haa bet 
omitted. The Author felt that as it was impossible, in a Work < 
General Surgery, to devote sufficient space to the consideration 
80 wide and important a Special Department as that of Ophtha 
mology, it would be better to omit so very limited a part of it) 
that which concerned only its Operations, when the Diseases fl 
which they were practised could not be described. This omissio 
has been rendered the more necessary as, notwithstanding evei 
care in keeping out superfluous or extraneous matters, the size < 
the volumes of the present Edition considerably exceeds that of th 

lB«t. 

More than thirty years have passed since this Work was fin 
published. During this lengthened period it has met with no in 
considerable amount of favor in this and in other countries. Thi 
Author can but hope that the present Edition in its extended aai 
amended form may not be found undeserving of the continue 
contidence of the Surgical Profession as a text-book for the Student 
and a guide for the Practitioner in Surgery. 

JOHN ERIC ERIOHSEN. 
LosDOH, 1884. 



rONTt:XTS OF THE FIRST VOLUME. 

DI^^ISION FIRST. 
FIRST PRINCIPLES. 

Chapter I. — General Con'bi derations on Operations. 

■ ■mjBT-n or Pijiuical OFtRATtoNr^ — Present Position of Operative Surgery— 

MiDual Drit^rity and Scientific Knowledge Required .... 33-37 

('u9i>iTi<>!<s IxFi.CE.vci.vo SiTCCCiis ov 0PtBATioiJ8~-Statfi of General Health 

— Hyeientc Conditions — Special Conditions eicit^ by the Operation itself 37-49 

PKErABATIO.NI' FOB OPERATION 4»-60 

EnFL'-TMaxT iir An.uthetics — Historj- — Influence on Mortality after Opei*- 
ti'.nj — Chliirofonn — Its Administtation— Death from Chloroform — Secondary 
Ed'.-rlj — Kiher— Death from Adminiitration of Ether — Comparison between 
ElbtT and Chloroform — Nltroiu Oxide Gat^-Deatb from Administration of 
NitP'u* Oiidf — Sitruus Oxide and Ether — Bichloride of Methylene — Treat- 
mt-M uf ElTects of Overdose of Anteithetics — Local Ana>sthe9ia 60-66 

pE>r"aw vNCE or an Upkratiok — Inciiioni 66-70 

I*»£i ENTios or HiHOkKBAOK Dt^BiNo OPERATIOKB — The Tournlquet snii its 
Ai-j'tiiafiun — Comptesfion bv Ela?.lic Tiibinj; or Burdnge — Bloodless Methods 
— I ■ -irj-Fiii-iiiii iif Muiii ArtC'rii.s 70-79 

C-*-:iil tt.pvjL ErFEi 11' i)K OpER.iTioNii — Lcinil Treatment of Wound? — After- 

;7-:.TTi..ril — lllfl—Kpiii. lie Effect T9-(*0 

(."flAlTJ:i; II. — AmTUTATIONS and Dlr!AltTl(lI..\TIONS. 

I'EKi .i.ii*>i t. 'T AN Amputation — HiMory -l Aoipiitiition — Clumsy In^trii- 
■J't: — Arn|iinnliipn by Circulur MethiKl — Kbip Ainpulation — I'rineiph'fi of 
.\v.[. iiaij-.ii — nculilp Fliipi' — Mi)d>' cpf Hnisiiif; llio Covcrini; — .Vnipiitaliim by 
:}.■■ M.-i-fii^i ("irciilnr Mi-thi>d — Li^lims Methml — Lung Anlcrior Flap* — 
T-ai-- ■ I ']-niti'>ri — Spt-noi-j ufid Listfr'* Methods — Oval Mclhiiil — Sawiiiir 
!t.- H-.n' — Anvji i.f Htriiiirrliacc — Clii^'urc of the Wound — Drts.in^ the 
■^; j;:iji — Am [111 la tin:; In-tninitnl.' — :?iiiiiiltanei>ii-' ur T!:ipiJlv Cnn^feiitive 
A'- |'-l:.ti.n of Two Limlps Sl-l'S 

•-TT »!!■» — ."-tnnlurt; of u Stump — ArtificinlLimljii — Murbid Cnndiliipni of S(iiui|is 

■ I", c O-t.M'-Tiivelitis — Xccnisis — Cunipal or Wii:;:ir-liiiif Stum (is — Aiipii- 

r.-ri ..; Kiilat>.;>-iiioiit of Arteries — I'aiiifiil and Spa-mi-diu Slump* — Rccurn'iice 
■f l'.-.:i—^l''ally I>P2fnfnitii>n'of Stumps ...... !'t*-101 

M a: 1 1 II l: .uteb Awi'fTATios^Hypii'nic Condi tivii' — Etfci't of .\i;i' — Ofnoral 
II- jl'.li — IntliH-iic- iif Shrxit and Siptic Dispascv — KtTcfl- nf Anlk-fplii- Trcal- 
ji.'ii; — Sal •■( ,-\iiipulaIiim — ^I'art of itmn' — Injury i^r Di?eu-f — Natiin.' of 
Ii;..^.. — Tiiii-ppf Pi'rf->rmanri- — I'riiimrv niid Si,.i>ipnd;irv .Vuipiilatiipn' — Sum- 
..,,„ ".,.'..- lfll-114 



XII 



CONTESTS. 



Obapter in. — Heainxv Ampi'tatioj'b. 

rxam 

AuPUTATloita or mi: UtTEii Lihu — FInff«rs_Mvtaeiir]io-p|]iikneciil AnJcula- 
Oont^liumb — MnUtairpnl Hunt* — Wtl'l — KortBrin— Arm— Shu iildtr- Join i 
— By tTnuitAikiii—Litfrano'ii Mttthod—Larrvv'* Oval Method— Uericnl Be- 
tulb of AmpatAriniu «r ibn tJpiier Limb . . ... 114-132 

AMroTATIOVtor THE I.owEK LiMB — T«M — MctntiiniL>.|iliHU[ii;n>l Articululioim 
— AmpuuitioD of Great Toe — AiuUiniical GuJdci in lh< Fml — Sl^tntunul Ilon« 
of Grrat To»— of I.iuln Tihj— Ain]iMtHtU<n of MelaUnuH — Hey'ii Opamllon — 
AmpuLalion tbnnigb IVrfOi — Choiiirl'* 0|H)ra^on — Symu'i Pimirtioulntioli mt 
ibe Aiikl«v)aint — Ptn>|itiff'» AcnpiituUnn — Suluulrni^iiliild AniiiUlaUon— Ro- 
»ulu of Ainputatiou) of fV>i>l — AmpiilNtioti uf Lt^ — FInp AmpulAlioii — Cir- 
cular (^ration — R««ulb — Amputation ihroiijcb Kiufn-Joint — Bt Anirrior and 
PoMmIot FUpt— By Laii-nil Klnpt : Smith's Mothod — Ampuiatioii ihivu^h 
Cuudylui: Carden'i andl.irtM'i Opcmtioiii — R»iill» of Aiuputnlion thnmgh 
Kn*ft-Joinl or ('ondirlcM — AnipiiMti"n »f Tlil^h — VormiiUi'i' Ojn'mtum — Am- 
putAlion «f Middle Hud Upper Third> of Thijch— Thmusli Ttv».-h«nUT*— Kp- 
■ulUof Anpulalioo of Tliinh — AmpiitHtioii at Illp-JuSnt — Rwult* . lAS-IU 

illlAITICit TV. — T<(M-At. DiNTfllltANCKC Or ClKCtTLATtOX A!tl> 

IXKLA.MMATION. 

LOOAL Am.RUIa 10fr-16fl 

A(mrs Local Hvpku^mia, Acfun Cuxui^'tioH, UcTKHMiirATioK o» Blood, 

Ok Flcxidk — Oiimu — .tymjitxina— KifocU 16^108 

Pawuvk ('oxokntion— CnuMo—ElftcU— tijiDptuRM — Trailiiiniit . 108-170 

Stsakoulatios- ... 170 

InrLAMHATi'ix— Ulitorj— Micit'.>*i:oPic Orahok» 1k: Acll»i' nypcnfinU— 
Stuii— OscUlat Inn— Tliromboiife—M ignition of Ihu Wliile Corpmulw — In- 
f^mmatorf LiriDph. — Uohkk >»' Trkmikatiok: Ittsojuiion — Suppuration — 
(Tloentinn — Unngnjii?.— <.'al'»w nr txrLAHHATioK : Pt«di4poiing — Riclt- 
ing.— liiKiTAXTs: Uwlianicnl— Pbysionl — Cbcinioil— Pnjduet* of Puu^fuc- 
tloo.— Oroaxixkd IttBiTASTi' — Mi^rooioct— JloolUI, — Fcxctjojial Isbita- 
Tioia. — NiCBrovs jKRiTANin—Voritrtiia of loflummatioa — Ixwal Signi. — 
iMFLAMUATORy Pkvkh — Symptnnu — Variotic*. — Ikhitativs Kktrh. 1TO-30A 

Thkatnimit or Acdtb iKn-AHUATiov— Ttetrndre Tnulinenl : AntUuptiot — 
OoLd— Bttl — Acute Indanaatioii wilb Rtbenlc Fvver — Oonttitutional— Lootl 
— Trtnttnoiit of Anh»nlc Cww a08-287 

CaxDKtc lNri.AM>iATiOM — Fnthotogjr — Cauioi — Pbcnomons — ConttilutUmal 

Symptomit— TmatniRDl, l^onttltutlonal aiid t^oonl ... 227-S87 

OATAMtKAt. I^iPLiUMATioK — Pnlliology — Piinilvni f'Htarrli— V«ri«tie» — Sjmp- 
Umm— TiCAtment 2:i7-Za& 

CaAITKH V. — SuiTl'ltATI'lV AMi AlWCK«. 

SuprvHATIuM— Kormation of an Acute .Vtumwi— CbflnicU.-n of Ptu — MicroMVipic 
Charactun— DlApnc«i» — CiruiitntitaiK^iM iollumciiig Ttni*aey to Suppiirati'>n 
— Uuntton— SyaiptoDU — ne«ti« — Albuminoid or Amyloid Dcscscration :f30-24S 

VAKiKTitaor Anarnut^Ilollnltloii — Aciitvor Pb1«guioiu>u« — DiflVito.— mr-lnatiitli: 
— Chronic — Lymphatic or CongMtiv*— Tynipuiiilir or Binphyieiiiatrn» — 
Situation and SiKo EflVcu — Dlngnotit — PniKniuin — Treattn<nl — Of Acute 
Ah*c<M> — (If Clirttnic Ali«c(«t — liK-idlnn— Tapping— Tho Aaptntor — PotatM 
Fa«a — 5ctt>ii — DninMge.tub»— AntiMptie Trentaiciil — Conaiitulional Treat* 
nicnl— HetnoirhBge Into Oaviljr of AUmm.— filXOii aku Ft*TUl.A— Cauwa— 
titmcturv— T»ittm«iil 218-209 



CONTKI'TS. XIII 

Chaptkr VI. — Ulckration. 

PASK 

ru'njiTioN deSned — PMhol'>gy — Chum* — Sitiution — General TreBtment — Local 
— CoDititutional 289-274 

V&Kiors FoKUK or Ulceb— Heatlhy Granulating Sot« — Treatment — Transplan- 
t>ti>)n of Cuticle — Weak— Indolent or Callous—Imtable — Inflamed — Sluugh- 
inc — Ecinnatom — Varicose — Hemorrhftgic — On Mucous MembrBnes 274-281 

Chapter VII. — The Proces« of Kepaib. 

Mi>i>E> or Um'is of Wocndb — Immediate Union — Union by Primary Adhesion 
—By Scabbing — By Granulation — By Secondary Adhesion — Circumslances 
alTft-tine the UealiDR ProcM* 2S2-296 



DH'TSION SECOND. 

SURGICAL INJURIES. 

INJl'RIE8 AFFECTING THE TISSUES GENERALLY. 

Ch.WTER VIII. — CoNSTITtTIONAI. EFFECTS OF InJTJRY. 

Si-icK — r^ymptoDu — Causes — Patbolc^ical Appeantnces — Treatment — Operation 

during Shock 297-801 

TiAriOTir Fetek -101-80S 

TurMATic DeukIum — Inflammutorj — Nervous 303-805 

RiV'Ti! KrrKi-pi or Inji-rt — Cimstiiutionul — Ijocnl 305 

('HArrKB IX. — I-fJUKim of Soft Parts. 

i -«i!V-i..N> — Kitrava^atiiin — (.'au.-es — Degrees — niHgniwis — Trfntiiient — Strang- 

-liti'D i>f PiirtJi — Sub<ntsne'>u< Wounds 306-31I* 

••rt\ W.-rsiiTi — How ClB.-"ified 310 

;»■ i-ti- Wo I Ml,' — Syitipli'nis — Manajri'mc'iit — LochI Trputiiienl — Arn-?t of II em- 
■rrrh^cv — Ki^ninval of Foreign Bodies — (.'.mptatioii — Vnrielivji of .Suture — 
lira.nag-' 'if Wiiund— Xecessily of Kcat SIO—IIT 

l|iLTii>[>^ I't Trutcvo Wnu.vDS — Exclusion of Air — Open Trciifment— Water, 
I'n Lint, und (dlt'in-wiiol ilrossings — Antiseptic Treatment of Wounds — 
M.-iifli-J Melhiids of Antiseptic Trealment — La.<iting Dressings— I rrigiifion — 
I -i-rnii Trviitiuout — Inllanimation of Incised Wouuda 317-326 

I '-•n>Ki" -i.sii Lacesatkd Wousns — Cbnractere— S!oui;tiing — Gangrene — 

Tr'-aim-.nl — Upuiorrhaj'e — Anjpiilation, — IIbl'sh-jiukn — Treatment . 325-333 

-T«w AM- Pi NiTrititr) Wousin — Treatment — Arrnw-wound* 3.'i3-33ri 

('lIAITHK X. — GUSWHOT WOUXIW. 

• .rs'HiT Wof.tlw IK Grnkrai. — CbHractcra— Xature and Force of Projectile — 
IfirKtion — Apertures of Entry and Exit — Sympt'imfl— Treatment — Arrest of 
Urn>.nTliage — Kitraclinn of Foreign Bodies — Tmiitmerit of Wound — Cases 
i»H'i.nni; Amputation. — Gunshot WouNns or SpeciaI, Bonkx aM) .TotKTS 
— F.iciiion in (iunthot Wound; .1.1(1-358 



XIV CONTENTS. 



Chapter XI. — PoiaoNED Wolndh. 

Stino or Inhklts— Trentment SM 

Snakb-bitem — Effectn of Snake-poison — Symptoms — TrcBtmciit . . S-'iO-.lfll 
BiTKM OF Rabid Aniuals: Htdrophobia — Symptoms — Babies in the Dop — 
Symptoms— SymptJima in Han — Duration nnd Termination — ProgniMi^ — 

Pal hoi ogy— Treat men I 3r.2-S68 

Haliokant Pustulk — Symplonis — Diagnosis— P»th oh igy — Treatment . 3iiS-9~2 
ULAHDBR8 — In thcHone — In Man — Diagnosis— Pathology — Duration— ProgniHis 

—Treatment STiS't 

WOLTMH) WITH iMOCt'LATIOK Of DlCOMPOHINO ANIMAL HaTTER, AND TlIK 

Pboduct or Uhuialtht Ikplammations — Causes — Symptoms — Trpatment 

S:4-378 

Chapter XII. — Effects of Heat and Cold. 

Burns amd Scalds — Ix>cbI Effects — Degrees — Constitutional Effects — Pn^nojin 
— Mode of Death from Bums — Treatment — Prevention and Removal of Con- 
traction — Operation — Warty Cicatrices — Amputation . . 37'.>— 190 

Frostbite— Local Influence of Cold — Constitutions! Effecls — Treatment — Chil- 
blain—Treatment .190-392 

Chapter XIII. — Injurks of Bixx)dvessei.s. 

iNJUBiEHor Vkinh — Venous Kemorrhage 302-398 

Injurikh of ABTERiEa — Contusion — Rupture and Laceration— Penetrating 

Wounds 393-SM 

HsMoRRUAOB FROM WouNDRD VuigRLa— Local Signs— Uiitinclive Characters of 
Arterial and Venous — Extravasation — ConstiEutiimal Effects — General Treat- 
ment — Transfusion of Blood SHS9% 

Chapter XIV. — Arrest of Arterial Hemorrhaoe. 

Natural Arrrst or BEMORRaAoi — Hislonr of In vcfi ligations — Temporary' 
Means — Coagulation of Blood and Diminution of Heart's Action — Retraction 
and Contraction of the Artery — Forraation of Coagulum — Permanent Cl-wure 
of Artery— Adhesion- Contraction— Arrest of Hemorrhage from Punctured 

.ir Partially Divided Arterie* 399-405 

f>t'Roii"AL Trratii«nt — Temporarj- Mean<i — Compression of Artery — Tourniquet 
— Permanent Means — ^Ciild — Hol Water — Sly plies — Cnulerirjition — Direct 
Pressure — Forcible Fienion — ToiSion — Torsmn and Ligature Compared — 
Forciprejsure — Ligatutv — Uislory — Appltcaiion — Effects of Ligature — Wire 
and Catgut Ligatures — Carliolized Cali;ut — Carliolined Silk— Oi-aorta Liga- 
ture — Tendon Ligature — Temporary Lii^tures — Acuprewure — Acupressure 
and Lij^ature Compared — Collateral C>rculati<m — Principles of Treatment of 

Wounded Arteries .... 405-136 

Ai-ciDKNTii AFTER Artrsial Owlpsion bt Sf Rai''AL M BANS — Intermediate or 
Reaclionary Hemorrhage — Causes — Phenomena — Treatment — Secondary or 
Recurrent Hemorrhage — Causes — Pbeiiomena — Periods of Occurtf nee — Treat- 
ment — Uangrcne following Lii^tu re ^-Causes — Character — Treatment 436-445 

Chapter XV. — Traumatic Axevrism and Arterio-venoos Wousns. 

Trai- VATIC ANRVRiait— DilTused-Tn-at men t— Circumscribed— Treatment 446-450 
AiiTKRio-TRiiona WotiNiiK— Aneurismal Varii— Symptoms— Treatment— Tari- 

«»« Aneurism— Path olofy— Symptoms — Tieatment .... 460-4SS 



C0NTKNT8. XV 



Chapter XVL — WooKoa of Spkcial Bloodvebselb. 

PISB 

Tdwel> or Bbad axd Ncrx — Carotid Artery — ADeurismxI VHrii in Neck — 
Tnumatic ADturiim of Temporal Art«ry — Hemuirbage from Deep ArUriea 
<-f Fmc* — Injurf of Internal Maxillaty, and Liogual Arteries— Wound» of 
T»rwbral Arterv 4&S-465 

Viw-to or THE TbL'NK — Internal Mkmmarir — Intercostal Arteries . 456 

ViM-iu-or Cppik Limb — Wound of Subclnvian Artery — Aneuriemal Varii — 
Aiillarr Artery — Open Woundl — Traumatic AneiiriBm — Brachial Artery — 
W.mnd^— Twumatic AneurJBin — Varicose Aneurism— Aneuri«tnal Varii of 
Ann — T«»el* of Forearm and Palm — Traumatic Aneurism of Radial and 
I'lnar Arteri» — Wounds of Palmar Arches — Circumscribed Traumatic Aneu- 
rmn in Palm 456-462 

Tneau nr Lowek Limb— Traumatic Aneurlam of Gluteal Artery— Femoral 
A rterr— Diffused Traumatic Aneurism- Taricose Aneurism — Vessels of Leg 
sod F'«>t — Wounds and Traumatic Aneuriama 492-464 

Chapter XVII. — Estban'ce of Aik into Vein'!*. 

Aia ix Vcisii — Results of Eiperimenis on Animals — Spontaneous Entry in Han 
— Lival Phenomena — ConstituiioDal Effects — Cause — Preventive Treatment 
— Curative Treatment — Indications to be folloircd .... 404-470 

("hapter XVIII. — Special Injuries of Nerves, Muscles, and 

Tendons, 

Ix.'raiE^ OF NlRVtt,-~CoDtusion — Puncture — Division— Pathology — Treatment 
f Injurie* causing Interruption of the Conducting Power of a Nerve — Trau- 
3ut;c N'euritij — Palbologj — Symptoms— Treatment .... 470-477 

!"-■■" an- OF Mr^-LKS .imd Tesdoss — Contusions — Sprains or Strains — Rupture 
■■ "^r.-ii^li^Ili-l'fiiliim or Dijplaceiiitnl of JlUEclfs and Tendons — Kujiliire 

■ : i Pui-i.-n — I'nion^Trcutment — Injuries of Special Jiuscli-* and Tendons 

477-482 

CHAPTEK XIX.— IxJLRl»>f l>K BoNES AN!) JuISTS. 

!«-■■." 1.1 E- ■■>■ B.i.vi, — Brui,-in^ — Bendini; ....... 4S2 

.> ■ iiii- ■■>■ J'lisT:' — Contusions — ."■jimins — Treatment — ^ Persistent P»in or 
W :ikn--«— I'atholofry of TraoniMlic -Arlhriti' — Symptoms and Kffecls — Treal- 

■ -M ■r W.'unjf^ -Joint' — WouMis op I.ndividuai, Joints — Hip and 

~^ -.iJ-r — Kin*— Kl)«. wand Ankle — Wri'l 483-lal 

Chaptkr XX. — FRA(TrR». 

! ij T'aii — ^'■:iu-* — Varirties — ^Nnliire — Direclion — Separation of Kpiphysi 

~.j;> — Ui.n;!!'"!- — Process of L'nion^df Simple Kracture — .Modi deal inn of 

I r..- r. 491-50.'. 

T>.LtTMi.^T nr Fbactube — t'on-litulionsi Tn-atmenl of Simple Fnielurs — Sur- 
_' ■ ... Tc^aimenl — Kt-diittion — Pn'vvniion of Ketuni of lUsplacemenl — Hand- 

t^- .--^rini'— ^Simrih'xl Bandaifc — I'lB.atcr-of-I'ari!- Biiiidaiii! — Silica tc-of-^.-lH 

: \Vil>-r-i;l».-.* Bund*);-' — .Vii-idents aii^ I'ohi'i.hai ion," rukI.mi TkKat- 
M i^ 7— Traumatic Delirium — FH(-enil»ili-iii^|[y]Mi.[ai\c Pulmonary Coni;**- 
• r. — Crulili-iwNy — Sjiatni — 'taenia — KxInivN-ation of BIo.kI — Ganprene — 
-:. -!-T.ini; .if LiinU. — CoMPl.li ATKli KHiiriiRKs- Treatmunl.- CoMrouMn 



xvi 



00STEXT8. 



»a 



pKAcroHB— Uniea— Qnvfloa «t Ampoiatioa — R«ductlati-'MuMcancat of 
Spllnun— OixlDf of Bliwd— Trmtraani of tiM Wotiod— CIcmum ot Wunttd 
—Loral BDil Co4utitutloul Aft«r-tfcalii>«iil— J>*«<>«>iUr7 AtDpulatiM— Rp»d- 
Irb, R*lirv>kliig, Bud Rcartliag Bono — Dclajed Unioo. — tTxrxrTKD Fm^c- 
tints ANii Faus Joiirr — C«uib> Tl wt i i wf it 



Cbaptrr XXL — Special Fbactvbis. 



1 



Fkactuku or thk Boxn or ras Facl— Nual Boatw Pupliim Kuittn-? 
LaubrriDal Bmic- — Mai^h aki* Uma JAW-wiitna — 8«|MiaUM uf all tkn 
Booh of tb* Faca— Uun*hM Iqjsrt« of Faca.— Lowaa Jaw — tH>nallM»— 
gy — Trw tmw rt — Fncian of Lomr Jaw bjr (ituutiot — BfoM Bone H4-A 

VlucnrkM or titt Bmcis'tr TH> Cnut— Rlbt and ColaJ Cartllago— 8jt»|»- 
liMlll Tual ' filvrnani SIHhA 

KiucTraM ow tub rrrcn KiTaKitiTV.— Ci.ATiL'i.a— ComitllcaUoti^-tlituaUoM 
— Sieni— Cvininiiiuwd Fnclurv of CUTicIe — Cnmipannd FtaDtitra orctavM* 
— TreaineDt af Suoplo FiMcUr^^Of Coaunintttfld Fnotur*. — ScArut^— 
Fraelun of Body of Boii*^Noar Sbauldnr-Joltii — Aersnilun — Covwold Pn>- 
CM»— NMk of Si»pula.—ncHKac»— Of Upper Articular Bnd— latncapaular 
— BilcBcapiUlap— laiparl«d Bitnisptuliir Fractura— Compound FnMurx of 
Sui^cal Nartc— Scpanlinn of UmlTiiberoaJlj — CnnapiMiMlandConiininiilcd 
Ftacliirn of Ooad of Oiuucnia — Pfacliim of Skafl— Nrar Elbow-Joint — S«pa- 
ratii-ii <>f Lowvr RplpbTil* — TinMvi'rvi' Krnctura of Lowftr BikI — ^Prarturp nf 
Condyk— Injiuj of Ncrra in Fracturv of [luni«ra»— Conpouitd and Com- 
niltiut«'l Knicmiwf Klbow-Joint.— FoaaAan— Okwmnon— Compomrf Fracu 
urf of OUvranoa— CoNifioM IVdoom of Tina— Middle uf Forcann — Unmr 
81(0)0:1117 «f Kadhu— IMbvnUjr— UaobanlfBi— TrcatnuBt— Uaiacarptu and 
Fingw* 66S-SI 

FftACTifRM or TAB PwVTU AWp TMa LowKB EzTaiMtTr.— PaLTiB— Acvlabaluoi 
— Saonim — Coooyi — Cocoydynia.— Thioh-boicc — Of F«lric End — tntnnp- 
•ii!ar--Cau(«— ttiBiu — Modo of I'aioa — tmjiacUd InUaMpnilar_Kitraea|>- 
«ular Prsctni*— irnlmpa«l«d Fractur* — IcopacUd Ftaclurr — ratbi4agy — 
Dia^oaia— Compound Fnctun ••( !f««l[ uf Buov — Fnwtura of Troobaator 
U^or — Of Shaft — Tnalmaot — Of Conipoiiiid and (.'oaimtiiutcd FlKlura^ 
FTafltita ai^r Kn<«-}oiiit—t*ArcLl.A—Unii'w—Tnalaitat— Compound and 
C>i«iiuiniiiiHl Practiin.' — Ntcr«i>— Bovn or Lm— TRaUnrni of Sbnplp 
Fraottiro^Ptiioil (if Unloo — C<>iiipllcall«n»— Cooipoaail FrnrliiiT of Tibia— 
Tn«lm«ai— llcaiontiajte— Fnictijn»n«arA«kl«->olnl— l'utt'iFtMtiit«-^ign« 
— TraatBivnt — lnt«riial and KiImhaI Malkoliu — Compound PncMfa IbIo 
Ankl#-Jn«at — Badty i>rt Ftacliit^t n*>r Ankk. -BoiiBaor Foor^Fnclluw of 
Calnuini'n— AiinienliM— Tiin>al It/>a'-< — Uttatanal Bom* &TQ-1II 

flui'rnH XXII.— DtSLoCATlovit. 

UULOCATivna UartHMii— I'auM*— Slftit— RffwU— Tnwinioal— Mwbaoical Con- 
iriwBoe* Manipulation— A ftwnaaUntiH—Dhtocailom of Utd StandiBs— 
OtMtadm to R>diKilna— AoMilitsIa— AmUmK In AltoMpU M RadwUoB— 
Oem pound Dblucatloa— Tfvauneni— CMDplleatiMM — Spoataaaom Dt*IocB> 
Uo«(--TrMUiH'nl~CAM|tafi(Ul DUocbUod* ... 4H 4 



CONTENTS. xm 

Chapteb XXIII. — Sfecial Dislocations- 

PXSB 

DwioTATiDiH OP THE LowER Jaw — CftUKS — BiUtciml— UnUstenl — Subluiation 
— BeductioD— Coog^niUl Dulncation 627-629 

OatxKA-namt or the Uppia Limb— Clavicle — Sternal Bod— Outer End— Simul- 
iaa«Mu of both End* — Scapula. — 8aoDi.D«»-JomT — Sign* — VarietiM — 
^bonracoid — Subclavicular — Subcpinoui — Subglenoid — Partiul — Cauiet — 
BcUtiTC Frequency — Diagnoais — ^Reduction — Compound — ^Complicstioiu — 
CungraiUI— Unreduced — Accidcnti in Attempted Seduction. — Elbow-joint 

— BtHb Bon«* — Ulna — Sadiu* — Complicatione — Reduction— Compound — Old 
rnnduecd IHtlocation*.- Wrist — HatidandCarpua — Backwaide — Forwatdi 

— Diagncaii — Compnuod — Congenital. — Siholb Cabpal Bonis — 0» Uag- 
nom — Piiiform — Semilunar. — Metacarpal Bones. -'Hrtacarpo-pb alam- 
QEAL Jotvn — Thumb — Reduction. — Pbalanoks op Finqers . 629-664 

DuLciCATioxs or THE LowER LiMB — Pclvia — Pubic SympbyBis — Sacnviliao 
Articalation — Coccyx. — Femur — Cooper's Cla««iAc»tion — Importance of llio- 
fcmntal Ligament — Bigeluir'a Clauiflcatioti — Varietiea — Hodea of Reduction 
— Ili-'>-«ciBUo— Reduction-^n Thyroid Foramen — ^Reduction— 4>n Pubic Bone 
— Reduclinn — SuImjudoui Dislocation — SupraspinouB Dislocation — S verted 
Dona I— Irregular Dielocationi — Reduction of Old Dislocation* — Complication 
«ith Fracture — Si mu Itsneou* — Congeu i tal . — Patella — I>ir«ction«. — Kk ex 
— Varietio* — Complicaliont — Compound Dislocation — Congenital DUloca- 
ti-.'tu — tSubluiatioo — Rupture of Poaterior Crucial Ligaments— Head of Fibula. 
— AxKLB — Varieties — Compound — Treatment. — Astbaoalub — Yarietiet — 
Tnatment — Compound. — Tarsal Bokes — Calcaneum and Scaphoid — Caica* 
cfuin, Scaphoid, and Cuboid — Internal Cuneiform. — HbtaTarsal Sokes — 
Phalange* of Toe* 661-680 

Chapter XXIV. — Injtuieb of the Head. 

Oirebbai. Complications of Injuries of the Head — Concussion — Compres- 
i.-n— terebnil Irritalion — Contufinn of the Bmiu — Effects of Cerebral Injury 
z. Menial Powers — Traumatic Encophulitia — Intracranial Suppuration — 
Pviri.ia — Trvatiiient of Concussion — Of Encephalitis — Of Cerebral Irritation 
— us (■-■ma from Compression — Of Pua within Skull — Of Pytemia — Summary 
■f Tn-atnient 681-695 

luriLiif <>r THE S'ALP — Contusions — Cephslbwrnatoma — Patholoey — Wounds 
— Tr^triK-nt 696-698 

Fti^i i!l> kF inE SKrLL — Contusions of Craniul Bonca — Causes and Varieties 
i Fr»..lur^- — Cimtrwyiii|v— Fiisun-d Fracture — Fracture of the Base of the 
>■,-.:;; — .-^iun*— IK'murrhaije — -Discharge of Watery Fluid — Treatment — De- 
pr-.'^-i-d Frjctiire — Varieties — Symptoms— Woiimis of the Dura Mater — Treat- 
•:.-c: if IH-pf?-e.l Fracture — Funclureii Fniclure — Linear Cuts — Ultimate 
li-:-iill;. •■t Fnu'lure of Sliull — C.mi plication willi Injury of Spinnl Column 699-719 

I>:lkie- "F ihi: Contbsts or tbk Chamum — Wounds of the Brain and its 
M'-Tiji-ranes — Caufw — P'>sl.miirtcm Appenrunee* — Symptiiiiis and Effects — 
Naiur-' arid [.itality of Injury — Aphasia — Facial Paralysis — Paralysis of the 
I";)-fr arJ Li»(T Liiiili — Dinnno'ia of Cen'bral Laceration — Prognosis — 
Tr--i::ii''r.I — I'iubcle^ — Injiirii-s of Cerebral Nerves — Ilcmia or Fungus Cere- 
• -_Tr»atii;cnt — Eilraviu-wlion of Hbt--! within llie Skull — Causes — Situa- 
'.1 Ti^— Ki-mlt. — .■^ymploni* — Diagnosis — Trcphinini; .... 7U'-740 

i.»:L«P-T Fi'LI.OWINK H BAD ISJl RIES ........ 740 

•rrEBATto>i or Tbefiiimno 74(^-748 

TOL. I ~B 



xviii 



OONTEKTa. 



CltAPTKR XJCV. — IXJITIIIM OF TUK SPIXE, 

CojiovMtns or tub KrtXAi. ('iiu>— ItodniUnn.— Coxoimiok rsoM btrnvcT 
ViOLKHOs— I'rinury !^jni|>tuBw— Secundar; ?7inp4onw~OMuci of DmUIi — 
ln]ori«i«f Vutobral Colunift— KVqou of Kllicbt 01i>««.— CoNComiox rmoH 
IvMUcr ViobBXcx— SooondMy KAcU — ImpKlnncot of Vuki« fram SpiiMl 
I iQwiy — P»lbokigk«l Ooed Itia ai M Bnlniptit ltd Jl j nil tw— Diipifl*— Pwg- 
■Mlt at 0plaal OoneoBlon— TtmuamiI 74$-7IU 

WouKM or TUI SriMAL CoKD — Symftomi — In Ltiuilmr and Lomr l>onal R*^ 
(■lot) — III I']>f»' Ooraal IUkIoii — In laowci Ccrviral Re|[ion — Atwv« l'lin>nlc 
Norve— I^>t1la] Divklon Tflft-n* 

MMBAKii'At Ixjtrtiiia or tub Vbntbhbal Colcuv.— Twtro, 9niAi>*, n% 
Wkibciib*— ^.TtDptoDU— ProfbMl*. — Kiuctiibb— Slfiu and 8ynij<u m i 
Proxnotia— 'nwumni — Tnptiiahie ibo Spine.— UiaUMATioiia—ur Allaa 
ham Oodfilla] IkiiM— Of Atb Ihjai AUm — or anj un«»ri]i« Fl*a I^wer 
Cnrical Varttbif Uamw Of TniMv«iw Pubmiii of Carvkal Vartabia^ 
Wound of Iba Th«M V«rt«lifalli TM-77< 



ClIAlTKII XXVI. — IxjVRtEB or THE FaCR A!tD AdJACEJCT Pa 






Taos— Cut* r<f Cbi-^k and Koralivad— I.Ijb— Panrfid Duct~8alivmr7' Flatuk 
Yat<Agti [l«d(» ill Now.— Kaiw— Wound*— Por«i«[D Bodka.— Ubbit— Dan- ' 
jgvn uif li\itiriw of.— Btb — l^jtirie* of the Conjunctiva— Of Eyeball — Conlit> 
itloa vltb KujiluM— Wound*, Ponelistioi; aad N<)n>|iai«UallnK — lnilltx<ct^^ 
laJiU7 uf tb* Bj»—C«iicuM*un— Wound or IrrttaUon of Braaob** of Piflh^l 
Pair of Nona*— Bidtion of Kjrsball,— llairrn.- TnBOCB.— I'alatb avd 
PUABTKX TTA-TSi 



ClUlTER XXVII.— IXJIRIEB OK TIIK TlllOAT: ASD AsFBYXU. 

IirjaBiaa ur the Lahtsx xsv Tila<iiea — Kracttm* ct ibv CanilafW i>f ili# 
lAryna — WiioniU oT Tliruai — Not ailandlag Into Air- ur FouJ-jiaiup' — Im- 
lilloatlni; Alr-[>Maag«— KSKK—Traatnanl— Awial Kbiula— P<wclt[n Bodloa la 
Alt-pMM|c*— SympMna— Prognotta— Tiwtmanl—Haitd (^ Monti, Pbat^ni, 
aad Otoub— Tnttlmant T94-7U& 

Au-MTBIA OB Arii'lU— CaiiK*— Pnin I*r»nnlsji;— Anlielal KnpliUloa— InSk- 
tlon of LuDK* wilh OiygMi (laa— Soewidarjr Atpliyiia— Fn-m NoxIoim 
Ihii Fnan llaa|tii>it 7M-W0 

iBJOUiaor TURpnAair>» Aiii>(K»oruAai'»— Woundi — For«I|[ii Rodio^-Cirinfi- 

kuw— TtaaUiMfit— Pfaar7-»c»li>iii7 or tEaophaeolomjr— (laitrDtuiav . MO-MM 



UurruH XXV'III. — Ixjimiix oi' tiib Cutsr. 



tM 



Wi>rv»a or niB Ckbst-walu . .... 

IxjuaiMOi ma l.vmi — QoBtuilaii — Rnpiuw— Wound— Sy>n|>li>iB*— Oatnplia- 
Uona^Uanonfcaga— HamMkonu— iBcnph^rawR* aad PnoitmMhuwE— -Piwiu 
moBlk — Ptauilqr and KwpynnM 0>llac« of Liinc — SuhmiiAMiniH Woundli 
of Lnac Aum IbacUiMd RIW— Pmatratbif Wound* of Tborai with Wound 
uf iba LuBt— Frcc*(Mii In Woundi of Uia Lum— Trwalmwil— Uwnia «t 
LuBf, vr Pnaiuwawla (»*-81« 

WutrxM or nia IIbabt abb Lamib VMaau— Wuvmhof tba Fnriaudlum — 
IammUob et lb* rwkttfdlun— WooBd* aT Uw llaan— ajMptum*— Ruptuiw 
of Ik* llaan fron Kitanul Vtolfoa WaunAi «f tlia Aorta and Vtna Cava 
— Wound* of th« TiMfBde Duet 8I«-«1S 



CONTENTS. XIX 



Chapteb XXTX. — Injuries of the Abdomen and Pelvis. 

IiijrBiia or thi Abdomxit and Abimuikai:. Yucesa — Contusioiu of the Ab- 
d->miiik] Willi — Buffer-accidents — Rupture of Abdominal Viscera — Enipb^- 
tcBia at Abdomiaal Wall — Wounds of Diaphragm — Wounds of Abdominal 
Wall — Non-penetrating — FenetrmtiOK — Without Wound or Protrujion ot 
Vixen — With Wound or Protrusion — Wounds of Intestine — Treatment — 
Tlmunutic Peritonitis Loolited — Diffuse — Symptoms — Prognosis of Penetnb- 
ini; Wounds o( Abdomen — Treatment — SutureB.~Treatment of Tntumatic 

Periionitii 820-885 

IsiCRiES or THE pBLTic ViscBBA — Rupture of Bladder — Foreign Bodies in 
BI«dd«r — Rupture of Ureter — Wounds of Organs of Generation — Wound of 
I'retbw — Lacenttion of Uretfar« — Treatmeni — Foreign Bodies in Vagina and 
R««t'jm — Laceration of the Perineum — Operation for Rupture of the Peri- 
neum 686-844 



DIVISION THIRD. 

SURGICAL DISEASES. 
Chapteb XXX. — Mortification or Gangrene. 

tisvcKEXK Defined — Local Signs— Constitutional Sj-niplflms — Causes — Gangrene 
f^ :■ Arn-i <pf Supply of Arterial ItluiKi — Lipntiire or Wound «{ Arl^TT — 
S r.:'.-' ii:ir\tzTtfTie — Mummidcation — TbroiiilKksia of an Arlxrv — Embolism — 
lT^:,-Ttnf fp-m Ver.oni Obstniftion — ^Frorn Arrcut of CirciilHlion by t"tninf;u- 
j:, <r, ai a Teriiiinati'in of Infl«tnniMtion— Arrest of Gan^rfni* — Lijiei of De- 
r:;»nati"n and Separation — Diagnoiis — Prognosis'— Tr^aluient : Cnn-ititulinnal 
— l^tMl — I If Senile Gangrene — Amputation in Ganj;rene — Spontaneous Gan- 

-:-!..■ ■ 84u-«GO 

Bil-- ■«?•— Trwitmi'nt SfiO-SOl 

B..[L»—l,nn-i-— Treatment 8C1-K62 

Ci»M >■ L« — -"^i'^n" — t'onilitulinnai Di>lurbanc<! — Ciiu-e' — ^l)iiii;niisi,» — I'ro^n'wis 

— Tr-'Mt'ofnt — Facial Carbuncle — Disj^niwis — Tn^innifnt 86'J-fl65 

Cavi Ki V 'iKi^, "R Noma — Symptiims — Trestrnent ...... 866 

tH\iTi:K XXXI. — Diseases Aeimnc krom Septic asi> Inkkctive 

I'KIX't^Hiiia^ IN W(HN1)>-. 

(i'l - -.1 llt^iiiurk- "n Septic and InT'^ctivc Poicpssp!' — The Germ Tlicry *fi6-870 

W..!-M-i>iriiTMr.Rr* — « ■»">!■*— Trealment R70-871 

B-~nT*l, (iANoRK-\E — I.i-1'nl Sign' — Const ill! tionnl Sympliini>i — ^Cause^^Piilbo- 

, %:.--A .\niiMiuy — Trealiiipiil: Pri>vnntive^Ij'i('«l — ron'titutiiiniil WTI-STS 

>raEaip[N'i TRAruATu liANt;HESK — Ciiu-ps — Symptoni* — Trciiliiifnl JiTi-x'T 



3UC 



CONTKNTfl. 



lArrRii XXX U. — Ery»ipki.a». 

I 

BSTRIPSl^^-Chftncten — KrriipaUtnut IiinAnitnalii>n — CHutn — Kmnntial — Pt*- 

dltpMlnit •■ Local nnd CnnitituitonHl 8T8-882 

EXTEKXAI. KBT»iPSi.iTOtr* 1 NFLitiu ATtCKS. — OulAiicnu»— Sympuniw — ConttU 
liiUonnl SyHiplomt — Pnlhologipul An«tuin,T — DiaipKai* — PrognMi*— -TrMhU 
iiioni: ProTontir* lind Curntlr*. — Celldi.o-cittaiiicocii — Srinptom — UUg> 
ii«i»-'FrQgiH»i»^Faihologi(Mil AnktolDjr — TrMlmeiil,— Cblloulh — Dlag- 
liMb^Progiiod* — Tmumcal — Spkoial rniiHs — tn Newly Born Inbiits— 
Ollulllli »f Orbil~Idl<ipAtliiu Krj-ftipolas »! Hi-nd— DillViM CnltuUtl* ot Sub- 
luaxitlurr Rpgion — Erytipelw vt Scrotum— Putlenda — DilRiM LVlliillii* of 
Um Ijtcliioreoiftl FouB — Wliiilnw— S«tilli) Twnwiynoi'UU . 882-^8 

Ixtshnal Kkyiiipblatoub IsfLAMMATiUMfl — Er^tipulna of MufiMi* Surfaci 

PM)eM^Ei7>i|)clftUiiu LnryngUIt^Of Aonnu Minnbninea . M8-'900 

CUAn'I^K XXXm. — SlCPTICKMIA AKD PY.1t»IA. 

!!EipTicxuiA Axn PrjtuiA— Donnitloii*— Bxiwrlmmtal InvMilKaiioni — Cmumi 

900-Ma 

Skpticxmia — SymploiDi — PMt-niarwm AppMrnncai — tfiagnaiM — l*mgno)i< — 
TrMlm«nt — Sxptic I xFicnoit— Symptom*— DiS|;noii»—Prngnoit»—Tr«Bl- 
mtnl iHW-OW 

pTJCUiA— Daflnlllon — SynipkiDnl — Formation of nam«roii( OatilrMof Inflftiuma- 
lion unci SuppornlSon — Puit-mortcm Appuanncoi — Secoiidarj' CcuIrM of Ifi> 
damraatian — Kidnejri — InleatinM — Jnfnu — Hicroaoopic Appcarancot of 
Tlunu a&d Or^ann — Uirroceoplu Orgtiiiitm* — General Patli>>lDgy — VuriellM 
of Pynnin— Aeuts — Clironic — Umbilical— Wi I hou I an Upen Wound — 
Idia[>alh<<^ — Miii«il Pormi of Soptlcvmla and Py»niU — DUgnni!* : Pmrn 
Ii]flariiniati>ry and Typhoid Fi-v^n, from Ague, from Kliouioatlain, from 
Bapllc Poifuitiog and Scplic Infection — Treatment: PtDvontiTe and Cura- 
Ura iXtK-OIS 

CUAPTER SSXIV.— TfMOIO). 

fimciTIOM — ClaMlflcatlon — Kvn-uinllKnanl, llerilcn, or Innooanc Tumo**^ 
Ualignaiil Tiimora— Signi of Maiignanoy — Somi-maligtiaiit Tuinon — ^on- 
oral Charaftcn of Typical TImum — Connectivo Tliiun — Embryonic Tl»ao — 
BpUlielluiii- ClawM of Tumor*— Etiology uf Tumon 924-9S0 

Cnno TcMOBA— OlaNlflcation— Oram auibihu mou Oihtk.ition or Phk- 
■XIKTIMO SrAcn— BiudatbD-cyiU— Rol«ntlon-«y»u Aihor«mnti>u* Cy«U 
— MiicoiiB Cy*l< — Cy4l* ariiioir from Dilatalioii of Uuol* of Glnoilt — UTsm 
orSKV PonUATiox — Simple or Soroui — Qviiiatumaor Blood-cyit — Cyttic 
Tumon— CyiUlnTuraon— CoxomtTALCTiTa— Dermuiii Cy*i*— In Imrxr- 
feclly Oblituraicd Fatal Siruclum* — Forniod I>y Incluwon of a lili^httfd 
Ovum In tlia Deval»pjn|[ Itoily of a F«>(iin^-^f Duiilitful Origin. — Paka- 
«ITIC CT8TS 9S0-941 

TsuoBn Cuuf oasD ov OtTK Or TUB MoviriuaTiOKS ov Fully DBriLoriw Vos- 
yiiCTiVE TtisDC — Patty Tumor, or Lipoma— Fibroma— Soft Fibromata — 
Wen* — Molliiifouin Pibroauin — Blepbantiaafl Arabuin — Kibru^cellular 
Tumon — Firm Fibrgmat* — Fibromata of Bona— Of Nerro — Of Glandi — 
Painful Aubcutaiiouu* Tub*n-1»— FIbruid Tuntor of Uterua— Kcicliondroma, 
OhoDdruina, or Carlilaginou* Tiimon— t>«t<>(ima, BloalMia, uf Jloay Tumor 
— Uyioma, or Mucoiib Tumor &11-DS2 



CONTBNTS. XXI 

PISB 
TCHOW WHICH RCBBMBLK IN 8TKU<:rURI MOKK OS LESS PKRVKCTLT OHB Ot 

TBI HOKK CoMtLCX TiMDiH OF TBI BoDT— MyooiB, OF Muscular Tumor— 
!4cuToiDa, or Nerroiu Tumor — Aogioma, or V«wu1«r Tumor — Lymphan- 
fiuma. composed of Lymphatic Teswl^—Ljtnphwlenomtt, composed of Lyoi- 
pbatlc Tiwuo — Papilloma, resambling Papiltn of Skin or Mucout Uembrano 
— Com* — WarU — Condylomata and Mucoua Tubercles — Polypi — Villous 
Tumor of Bladder — Adenoma, or Glandular Tumor — Tubular Adenomata — 

Raccmnae or Acinous Adenomata , . 9S2~953 

Ti'voan compokid op Tisbi;* which is bitskr purelt Eubrtonic ok is 

CnniBOOIKQ ONI op TBI PRIHART MODIPIOATIOHB berk in THI DaVKLOP. 

ifBST OP Adult CoxKtm'ivi Tisduk: Sarcomata — DeSnition — Oeneral 
Character — Varieties — Small Round-celled Sarcoma — Olioma — Spindle- 
celled Sarcoma — Oval-celled Sarcoma — Myeloid or GiaDl-celled Sarcoma — 
OMifyiDf; and Oileoid Sarcomata — -Alveolar and Lar^e Round-celled Sar- 
coma — PleliformSarcomaor Cylindroma — Melanotic Sarcoma — Paammoma 
— Sarcuoiatous Blood-cyat«, or Hramatomata — Mixed Sarcomata B6Q~970 

Tc«ofe< roMPoBKD OP Cells or an Bpithblial Ttpe, arrahobd in Spaces ih 
A Stroma coxbibtiko or udrr ob lebh pRRrEtriLT detelofed Fibrous 
Tiwdb — Cancer — ClauiBcalion — Clinical Bintory — Causes — Oeograpbical 
DittributioD — Constitutional or Local Origin — Varieties of Cancer. — Olan- 
Dci^R — Scirrhu* — Encephaloid — Colloid, Gelatinous, Oelatiniform, or 
AlTMilar — Diagnosis of Glandular Cancer. — SqOAUous Epithelioua — 
Causea and Situation — Prioress — Structure — Dia^osil — Prognosis — Recur- 
rence after Removal. — Coluunar Epithelioma — Appearance and Progress 

— Diagnufis — Prognosis — Other Forms of Cancer— Treatment of Cancer — 
L'onstitutional Means (Jsele!a~'Local Means— Palliative — Curative — Caustics 
— Azid* — Alkalies — Chlorides — Arsenic — Sulphate of Zinc — Compression — 
Eicition — QuMtion of Operating — Cases not Admitting Operation — Doubtful 

1 ,i_,. — Cas-s Pniper for Operation STtUlOM 

Ei "iii-iN ■<T Tcuiift-i — ^Removal by the Knife — By the Ecraseur — By the Cautery 

— Bv L.tfature 1006-1010 

CuAiTEii XXXV. — SciiOF[ii,.\ jlsd Tubkrcle. 

T'.-iRi !.< — Siruiture — Micrii.-oipical Anatomy — Bsuillui Tuberculosis — Vellnw 
T.if"rri>l- — EiiPnsion and (jrowih — Kature — Inflanimntion consequent ii]ion 
D-i-i.-pin-nt 1010-1014 

'^ 1 'irLt '-a Stkcua — Di'dnitinn — Strumous liiHammiitiou — Of Skin — Mucous 
Mtnif-rnne?— Bones and Joint^^ — (llaiidular Organs — ■ Relation of Scrofiila In 
Ta'!-vr\.> — ^',■^l)flli•lus l)i»tlii;ii» — Scri)fuloiis Tempernment. — ^Cau.ses op 
>• E..ri-i.i ,*SD TUHSKCLK — lleri'diUry Xiiture — Imioulability of Tubercle 
— -S-nile ST^'fulu. — Trk*tmest — Pruvunlive — CuraliTp — L-cal Trealinent. 

—I It-KKATliJNS [y .SottilfTl.llUS AKD TfBKRrL-LlirS (.'ASKI , , 1014-1024 

CuAiTKiL -KXXVI.— ViiscitKAi, I)isK.4sr>. 

I'lU'IT! S AM> I'LAS.-IFlCAriaS 1024 

L- *1 I' ■s!»ul'>rs ULt'EK iiB I'HAN' RK — ( !hiirttilpr:> — Specific Xatiire — Origin 
a- j I'r 'Hf*^:* — V»rietitf? — Simip]*^ ur Sofi — SlLHit^ljinj^ CliHiicre — Phagedrt?nic 
— ^■tuati.^n (if t.Tiancre — Dini^Etu.'i- — L"ciilTr»'atni'^nlnf Chancre — Of Phage- 
•tt-i.it: CnaniTc — Of Slimijhiiii; L'iianijre — (J'lnitilullonal Treatment of Simple 



XZll CONTBKTS. 

rAM 

Chancre — Of Gangrenoui or Sloughing Chancre — Of Pbagedcnic Cbincre. 
— GoNsicoTiVK Sthptoub OF THE LociL CoNTAaiODS Ulckk — Contrmcted 
Cicatricet — Bubo — PrimHrj Bubo — Creeping Bubo — Treatment — Venereal 

Warn 1025-lOM 

Stfbilis — Character! — Period of Incubation— Primary, Secondary, and Ter- 
tiarj' — Origin — Conugion of Sjphilii — Trans mixibilitj — Duration of Trani- 
miuiva Power — Progress — Period of Incubation — Appearance of Primary 
Sore — Indurated or Hunterian Chancre — Seat and Number — Labial and 
Facial Cbancret — On Tongue — On Fingen — Variaiioni in Sore — Pmgaoiit 
— Course — Indolent Enlargement of Lymphatic Olandt 1086-1049 

SkCONSABT AND TsBTtABY CoHHTITnTIOHAL M AHIF^TITIOKS OF STPBILU 

General Pathology and Progress — Uicroscopy of Gummata — Frognotii — 
Duration of Syphilis — TrPatment of Primary Stage: Local and Con«litu- 
tional— AdminiilratioD of Mercury— Other Drugs .... 1016-1061 

Local, SecxikdjlBT, and Tirtiabt MAXircBTATioNH of Stpbilis — Syphilitic 
Affection* of the Skin — Mucoui Tubercles and Condylomata — Syphilis of 
Uucoui Hembranea-^yphilitic Iritis — Syphilitic Diseaies of the Bones — 
Syphilitic Necrosis and Caries — Syphilitic Tumors of Husclei and Tendons 
— Syphilitic Disease of Testicle — Syphilitic Ovaritis — Visceral Syphilis — 
Sypbilitic Dieeaae uf the Mamma — Of the Nervous System— Of the Spinal 
Cotd 1082-1077 

IitrANTiLi, CoNOKtriTAL, OR Inhbritkd Stpbilis — Nature — Symptoms — In- 
fluence on Teeth — On Bodm — Chronic Interstitial Keratitis — Chronic Affeo 
tlons of Ear — AffectioDs of Viscera — Of Testicles — Evidence of Congetiilsd 
Syphilis in Later Childhood or Adult Life— Prognosis— Treatment 1077-1084 

INDEX TO VOLUME 1 1086 



LIST OF ILLUSTRATIONS IN VOL. I. 



10 

n 

13 
II 
1( 

IS 



:4 



Ct<'Tcr'i Ether-mbftler 
Biiti-Hirv held under Hvad . 
Kaih beld Uk« ■ Pee . 
Enift held lika^ Dinner-knife , 
bJTuioQ of Fucim un > Director 
DiMcction through K Fucia 
E'lnarch'i Touroiquet on ^boul- 
der 

Etmarch'* Tourniquet on TbiKh - 
EfiMTcb'i Tourniquet round Hip 
ErniBrch'i Tuurniquet round 

Peni* 

Li«t*r'( Bt<Kidleu Helhod . 
Ei>Euii;h'i Bloodleu Method 
Cum[ire9iiun of (he Carotid 
Cirmpm>iun of the Facial, Tem- 
pr.nil. ftnd Subcl«vi»n Arteriei 
CumpreuioD of Subclavian with 
K<fV. and of Brachial with 

^■.^l:■--^^ 

t'.'Ti.pr— ii,,ii .>f Iladiiil and Ulnar 
!.>!•■- - A'ria Ciiiiipre^'nr . 
I*.::L"jii I '■■mpresjiori of Femoral : 

t'flil -i T.piirni'^jet un Thigh 
I -u] res-'i.'!! ..f Tibialj 
< >■, .;jir Ani|.iilBlii>n : Firgtlnci- 
*:'■!» ...... 

> T, ,lar Ampiutalion : Sswini; 

;'[.■■ ([■■nr 

F'i;< Aiii|'Utalii'n : by Traiis- 

jii.n 
M -iiDi'J (.iroiilar Aiii(put«lii>n 
T-al-' - Arn]<uijitiiin : LinC4 of 
In'i-i'iii . . . . . 

T-«!f'- Ani|pui«iicin : Sliim]i 
A ■-■.■jnL[p: Minje .if »ppljing 

~ji;ir>:- and llriiiiiaEP-lubei 
K-.i' -f Nervei in a Smmp 
?^,ii"iruiii iif Femur frnin 

l.i;?p-tiie ('a*e"f C'lnical Slump 
Ar.<?'fri^Q.aJ Vnrii in Stump 
Ampuu:!' n <<f I'neual PIihIsiiil 
AmpjlB'.:"!! -'f Middle PhaUni . 
Ani( 'tlaliii) .if Whulp Finder 
Ani) i.;kiI->ii I'f Indei Kinder 
Ilc-uk aft-r AiupiilHliun of Mid- 
.1:- F,n^..r .... 



raoE 


no 


6R 


86 


07 




67 


37 


68 




68 


36 


69 


38 




40 


72 




72 


41 


78 




73 


42 


7< 




7* 


43 


76 


44 


75 


45 




46 


71 




76 


47 


77 






48 


78 




78 


49 


S4 


50 


»5 


51 


Si: 


52 


91 






53 


91 


54 


!H 


55 




51; 


95 


57 


98 






58 


99 




!I9 


50 


1(«0 




1I.'> 


60 


nr. 




117 


r.i 


ll« 






i\'2 



119 



nam 

liesuitafter Amputation of Index 
Finger 119 

Result after Amputation of King 
Finger 119 

Amputation of Left Thumb 120 

Amputation of itigbl Thumb 120 

BeaiiU after Amputation of 
Thumb 121 

Hand after Amputation of Firal 
Two Fingers and Metacarpal 
Bone* 122 

Hand after Amputation of Three 
FiDRera and Uetacarpal Bones 122 

AmputalionatWritt: DorealFlap 123 

Amputation at Wrist: Palmar 
Flap 128 

Amputation of Forearm : Trans- 
fixion 124 

Amputation of Forearm: Skin 
Flaps 125 

Amputation of Arm: Clearini; 
Bore . . ~. 126 

Amputation at Shoulder : Outer 
Flap 127 

Amputati»ii nl Shoulder: Inner 
Flap 128 

Ampulaliiin al Shoulder : Hold- 
ing Vessels . . .129 

Ampufation al Shoulder: Spence's 
Melhod 130 

Amputation at Shoulder : Stump 
after 132 

Amputation of a Toe . 133 

Flap Amputation of Great Toe . 134 

Oval AmpulBlion of (ireal Top . 135 

Ovnl AmpulBlion of Little Toe . 135 

Lines of Hi-y s and I'hopart's 

Ampiilation* .... 137 

Chii|PBrt'> Ani]iulnl)on : Sole Flap 
L'ut fip^t . . . . i:t7 

Lines of Ir^cision in Oporati^ma 

on Koot law 

Chopart's Amputation : Difarlic- 
ulation first .... 138 

Line* of incision; .'■vme'* Ampu- 
tation . ' , . ,140 

Lines of Incision: Syme's and 
Pirogod'S Amputations . . 140 



XXlt 



LIST OP II,I.P9TBAT10H3. 



a ^jw*'* A»t"*'*^"- CuU1d( 
flan 

44 SjMi* * AmpaiMlloB : INMtnieu- 
Uliuo 

M Hj'niK'* AmputBtitfii ; Sawing off 
Ualtwili .... 

•M Hlrocff't AMpaUllMI LItM* 

vfln«1*)on .... 
«T n>«cuff '• AinnuUUan:9a*iM 

W.CW. . . . . 
tt Plnc^** Am|>ul»tloB: afUr 

BMBonl of MkllMll 
W PlrojcaffV AmpvUiloiii Swap 

»fltf 

TO AniMUtioB)>fI,«](:TrarMliloD 

..f rutifrior KU|« . 
Tl AmpuUUon oT Lag: Sawine 

BoikM 

n AtapuUUoa of Leg-. TmI*'* . 
n Animtatton of I<af : Skin 

Flap* .... 
7i Ami'uUiloii tlirouxk Kn«« 
TA AiBpiiulltin Ibrough Kocc: 

Lalatal PlaM 
n AniiuUili-n tbiwieti OoMdrht : 

Lliiur' 

77 AMputalkin if l^irar Tlilrd of 

Thi^li : UunI Pl«n . 
n A>i|>iilAliQn of Thigh: Pla]ii 

cut rroin WlUiout . 
T9 AmpuuUon at Uln: AoUriav 

PUp,L.fl . . . . 
to Awpuuilun Hi Iltp: Antarior 

fUp. It'h'hl .... 
SI Anputati.in ml llip' OiMiipr«a. 

•Uin of PaaaoTol 
IS UkeriiUuo of Ltac»:yitt from 

Val» 

HS InlUmail Fat ... . 

M Hli^lillv InfluiMd Kaicia . 

M Ifrit,''tl"( Ai>i«niiui . 

HS iBirmluD'iiin m a Satun 

S? Mkrawnple AUcow In SklR . 

88 fiiMvJb 

80 l'<i*.<«ll>fr<iia PvBiMlr A b atata 
m r<i».««tlt from anortiloiu Ab' 



1t| ColoMjr of HtorMMwt In Oto»4 
at I<a»« fkoa* AbMaM . 

M AapjnitiM' .... 

M AbMOM— BiaUiurjr . 
Ill (Hiarp Spoon* .... 
IM lolroJootiuM ot Salon tliromh 

AbMWa . 
B7 fhaut'ri>rtwp* 

08 Porkod I'roU .... 
m IlrBliu|[*-itilM. lotrnducUon «r 

100 Uraautallon-tlMua: Sactlon 

Ibraucb ..... 

101 TouncCkslrli.-SMUooibruagb 
103 aniiiuUlliiKSara.lD}aol«d: Sac- 

ik>n 

lOfl Vlnitrr Tfn Off, with TMidvM . 
IM 'niunil> Torn Uff, «iih Tandnn . 
lOa rtoa-polnud Vonapt , 



paa* 
nil 
111' 

I«, 
!«>' 
lU 

i«; 

i«sj 

'"; 
l«, 

149 I 

iss' 

16s' 

164 

IM 

157. 

100 

lei 

162 

lU' 
178 
17V 
«? 

su 

sto 

343 

24S 
S48 
ii\ 
SM 

set 

SM 

2W 
M« 

:xii 

287, 
Sft8 

«7' 
8S7| 



IM Anov bMMUMjac Skull (Artdj 

Ma*. Dtp. 17. & A.) . 
197 B«fWlifHb Bi«r«ed br Arrvw 

iAniiy M^ Dip. U.S.A.). 
IM Arrnv-inaraa (Amiy Mad. Dhi. 

U.S. A.) . . . . 
tot Splitllof i-t Kamur bjr Bulla* 

{Atior Hod. Dap. IT 8. A.) . 

110 Ounaboi WmmI: Apartara ot 

Enlrjr 

111 Bunthot Wound: Aputur* of 

Kiil 

lis Gunabot Woatad: IWpOTWj 

Tuuriil«uat .... 
118 N*latun-> Foraalal* PraW 
114 BtilU4-*ct«w . . . . 
Ilfi Ballat'forMpi .... 
lie BdllM-aimotof 
IIT Billat-roroapt . 
118 Il"ok 5etint(l^orm-f 
110 Bound Builot in Uaad of Ho- 

mama 

Quiuliot Kracttire oT Hutnarv* 

(Artny Had. Dap. U. S. A.) . 
RafciU of Exebion ot lload and 

Six Incliaa a( Stwd of Uu' 



130 
121 

ia 

124 

136 

)!» 
127 
128 
128 

180 

181 

18S 

188 

184 

ISA 

187 
ISM 
180 
140 
Ml 
M'J 

Its 

144 
14S 

146 
147 

148 



U 
(8 

M 

SS 
SSI 

HI 
M 
S« 
M 
*M 
»M 
8M 

tSi 

SU 



Btaru* , . . . . 
UaellliM AatbtMla U Oonnao- 

live Tiwua . . . . 
CaDlracUoti of BIbow from Sura 
ContraoiI«n of Thunib frana 

Burn . . . . . 
DiUocatlon of LItiht KIngar 

baelc ward* from Burn 
Dafortiiltjr of Hand aflrr BurB . 
Dafomlij ofUai-.d i>ri*r Hum . 
IMocm'nj ot Foul kflf-r Bon . 
Vf*Mf CioalrU frutn Soipbario 

Add Bum . . , . 
Ohktrii «r Upaaftd Neck tn>m 

Burn 

Ck«trls of Up* aod Nack alW 

OpaMtioN .... 
TDula'a Otwralloa for K«iton< 

liMi of t.lp . . . . 
Taala'i Oparatlon: Flapi )■ 

Plata 

CotDplotaljr Rupurad Art*«T . 
Trutflalon: A*ellng'* Matbnd 
Inirodttcllon of Canula Into 

Vain 

Knd »t Catilcrlaed Avtory 
Titn^nnf Branbial . 
Tonloa f<tt*\i* 
Knd of Twi'inl Faanorwl . 
(''•n'iiitvaara Poivapt 
I^iSBiiir«of Artorir . 
I.lMon'i B«1l-do|> Forcapa 
Tba LIgatnt* K»«t - 
Oponinf tba Shaath ofan Aitnj 

PaMlnit an Ananrltn Kaadlt : 

I>t8i>^ . . . . 

TaMine an An«urtin Naadlai 
SdStatce 



8«fi: 




LIST OP ILLUSTRATIONS. 



XXV 



riB. rtat I no. 

119 Arterv: Inimadisle EfTecU of | 184 

LigBium .... 410 1 

IJO Ffmoral Arterjr : H Uouri ' 185 

■rter AmputalioD . 419 , 186 

IM LigKiured ArUrj laid opao 419 IBT 

li:; Pemi'iml Arterv, 14 Dm;! srier 

AmgHitalion: Partial A ban rp- !B8 

lion i.f Coagulum . . 419.189 

I'.l Femoral Artsrj, 10 Days after 

AmpLilatiOD : Dealh fnim 190 

pTvmia 420 ' 

1S4 Feuiofml ArWr; : 8 Weeta after 191 

Ampuutiun' .... 4'JO | 192 
li& AbK>rf>tion of Catgut Ligature ; | 

SecO»ri 426 

• M Acuprcaaure: 1st Metbod, Raw I'J3 

Siurikce 428 

1^7 A<-upre*i^ure : Itt Method, Ski D 

Surface 428 194 

ISp Acupnsiure: 2d Method . . 429 . 195 
\X.t Acupr«HUre: 3d Method . . 429 | 

I^ Aouprcuura: 4th Method . 429' 196 

l-tl <.''>lUleral Circulation after Lig- 197 

Btare 432 

i62 DiT«cl Anaalomoaia after Liga- 198 

lure 4S2 

143 C'banKeio the Trunk after Liga- I 199 

iur« 432 

144 CircuoiKribed Traumatic Aneu- 

ripin in Ball of Thumb . . 449 200 

I^ Variowe Aneuriim at Bend of 

Am), Unopened 461 • 

le^ Vai'icoH Aneuriim at Bend of | 201 

Arm, UiHeci«d Out . 4G1 

i^' VarinMC Aneuriim at Bend of 202 

Arm. Opened in Silil . 451 203 

l-> V«H.> .te Ao^urlsm at Bsnii of 

Ami. Diswvle-1 Out and 204 

I '[j-r.td 4'rJ 

'.' ' I i.r-TH' NfurilUT Section 475 'Mo 

!:■■ -ir*!. f,ir Kuplured Tendo -Jm 

A.-hillia 4H1 

IT! A'.- |.hv i.f Mustle* of Shoul- 207 

drT ■ 481 

i'^' < '-'Tiirnir ijled fiiinshE-t Frai^ture 

. f K..r.-»rm b.-nrf . 49.") 2()H 

:" ; ' 'l.li i-iv nn/l L-ngiludinal Fract- 

i.r- .if Tihia .... 4'."i ^011 
■71 I". ii::<.inji.-J Frnctiire of Uu- lilO 

ii.erpu *nli.>iu Displa'.-eniPnl , jWl 
;:', Kr».-[ir« ..f Til.in: Pr^vwinnal 211 

ra.l'..- iVW 

:■- -'-'.i-T'- I'h^r- .... .■i10 212 
;r' -^ itui'« I'hpr-. SLari-lieri Iliind- 2l:i 

ac- <iil u[. f'y . jll 2H 

r- .-larri.»-J llsn.i«i.'e for 1-^5 ■ Trap 21 J 

Iff. f..r W'.iuiid .'ill 

■."'» ^-ar. h--d il»rnl«i:'^ Pir Ffactunnl 2iij 

Thitb ..... ."ill 

i-' llaianan I'la'l'-r-ii.lint .'il.') ^17 

1*1 '**rii;r»fnfl .'f F'>ri-Krui atnl Eland 

fr.m TiL'ht Kmi'limirL^' , . ."Ht I'lM 
!""^ lt-j'.iiipr'» C/lBrij|. tnr Ko-frnflur- 

;r:c a lUdly St-l il.ii.e .'hi.") -.'111 

i--'! f'»!-<: J.iiiil in lluui^ni* I'l.'iT 



Apparatua for Ununited Fract- 
ure of Femur 541 
Archimedean Drill 542 
Fracture of Natal Bones . 644 
Spring-clip for strai|;hlening 

No«e 544 

Fracture of Lower Jaw 646 

Gutta-percha Splint for Fract- 
ured Jav .... 647 
Gutta-percha Splint Moulded to 

Jaw 547 

Qulta-percha Splint Applied 647 

Tfaomas'E 1st Method of Apfily- 
ing WireSuturei in Fractured 

Jaw 547 

Key for Thomu's 1st Method of 
Applying Wire Sutures in 
Fractured Jaw 547 

Thomas's 2d Method . 54K 

Thomas's 2d Method : Form of 

Wire-coil .... 548 
Sound Clavicle . . . . 56S 
Fracture of Acromial End of 

Clavicle 65)1 

Apparatus for Fractured Clavl- 

cle 555 

Sayre'i Treatment of Fractured 
ClaTicle; Slrapdrawing back 
Shoulder .... 566 
Ssyre'a Treatment of Fractured 
Clavicle; Strap railing Shoul- 
der 666 

Ellis's Splint for Fractured 

ClaTicle 567 

Ellis's Splint Applied . 657 

Apparatus for Fracture of Neck 

of Dumerus .... 061 
T-Fraclure of Lower Krid of 

Hunierua .... 5ri5 

Angular Arm-splint, applied 505 

Wrist-drop after Fracture of 

llumerii9 .... 565 
Permanent Flexion of Finders 
from Faralysii after Fracture 
iif Hunicruti .... 566 
.Vpi^armii!' fur Wrist-dri-p afttr 

Fracmrc of lluniprus . 566 

Fnicturo I'f Olt>criinii]i 567 

A]>paralus for Fractured Olecra- 
non ..... 568 
Fracture of ForcMrni : Iiiter- 

"^■eoue ."ij)aic UblilemtPd 569 

C-ilk-'i'fl FrHcliire: ISaj-k Vit'w . 570 
0>lle3',* Frnctiirc : .■>id>- ViL'W . 570 
L'i>llL'**a Fracluru : Hadius iii . 571 
C<*lle-'s FrHcturi* ; I.uwi.t Knd 

I.f nmlin.. ,671 

C'llu- .- Fracture; Forcarui 

Hun<■^ htkI llHiid in 57] 

CiIIp-'b Krauture: ."li-i-li.in nf 

l...«.i.r K.nl of Ka^liiM . . 572 
(.■..Il."'i Frm-turv: Old ri.i..l- 

r-piiiil Hi)p}it>d . ^»73 

I'lill^a'a FrKi'Inrci I'litnl-Bplizit 

sliBpfil !■! llnnd ■"'"4 



^M xxvi LIST or 


ILLUSTRATIONS. ^M 


1 


^B 


rtea ! rte. 


rtm 


^H SSO CoIIm'i Frictura : Ihirdon'i 


1 2M Pull'* Pndura : Honea In 


K 


^1 Siillal «M>ll*il 

^^^ SSI ColU-i Kr»i!i(ir«: N4lau>n> 


&T4 367 Praclo'oof I^wxrCndofTlUa 




ami Fibula .... 


M 


^^^K S ilini >|'jiU*(l 


676 SM Rack-and-filiilun Lxf-ipllnU . 


W 


^^H SCI Col -•-> KrMiiirD : Cut'* 8(>UsI 


&7& 36a Knek-and'iiiiilun L<ag-*tillBU, 




^^^^B S!it FtBCtiirAj I'vltii 


676 ii|.Hi*d 


Ot 


^^^H 224 liilnu:a|i>ular ynctuta uf N«cfc 


3lUl 1>>I >uitmi'i8pllntap«lled 


01- 


^^^^1 Vnnnit .... 


WO SAI Ita<iy.Sel Poll'* Fracture 


oi; 


^^^^P SSfi liilm'^puUr Priicture of Neck 


3CU ComiBiniitcd Fm:lar«i>rAalrBg- 




^^^^a or PolnUf : Aulludo cf Umb 




oil 


^r 


CW> Ma Ctoir*-bllcb Koot 


oil 


^^^^ m EiUuii|i*akr Frwiur* of Neck 


SM Bwdiictioti of DuIocaUd Jaw . 


«3I 


^^^H oT Koaitir .... 


tM , 3tG Dlfl'xaUon of Htomal Rnil of 




^^^^ XS7 ImpMiCWd Riuaeaiiiukr Pmet- 
^^^^ ore of Neck of >'Mnur: 8*e- 




L'larick (SmlUi) . 


«« 




SM I>i*looalMn of AcromU Bed of 




^H IllWH of Hoow 


BM 


OUrleb 


Ktl 


^H 328 Iiii|i*cUd RktrarMMulw Prael- 
^H at* of Ntok or FtMinr: 8«c- 


1 347 ItabcorMald DwIoMllon of Hu- 






m 


^H tiu** of noBH 


te6 see SvbclBTloulw Dltlooatkut of 




^H £tV IiuiiecC^ Kilriic>[«iilitT Kracl- 


UuiMnu .... 


tva 


^H iir«of Nockuf Keiniir : Uaio* 


900 SuheptMua Dl»lo«»tion of llu> 




^H 




«ai 


^H 2X0 Imjiaclnl KiUa(-«t«ulaT FrMU 


; 770 8<ibRt«iM>ld EHiktcaltoB of llo- 




^H iireuf N*«k of FcfuiiT : Abun* 






oai 


^M daiilUllliu .... 


eet 


271 SubcDtacold DI«lo«Blion: D^ 




^H lai NfUton'* Lin»— ttrjani'* Tft> 




foTHiliy in . 


ON 




BAT 


m Bubtpinoui IMdoeadon : Oe- 




^K^ t»i LltUin'i LnocStilint 


S0I 


turiMJtjr IB ... . 


«u 


^^^K 1188 Bntwnn'* KiMtle Bal«Mion Ap. 




S7S Swbf leoold Dtilocaltoe r !>•• 




^^^^B pnratui 


BOX 


IbrBiitr In ... . 


eu 


^^^^ U4 tlru'keUil lyifiu Splial ai^plted . 
^B 33r> KtHviiirii of Klian of Fenur, 
^^^H IroatMl by Dhufi Sfillnb and 


6B3 3T4 Sabflenoid Dbbcatt>i« 


•II 


37A RmIuuIUib at Dklon-iad ithoul- 


•^ 


dor by Heel In Aitlta 


^^^B Vvlsht-ulMuloa . 


sun l'7n Rnluvtl..<i „( I)U].«*ifO iiiiauh 




^^^F tU Scnllbn Anterior fljittnl, Slukjt 
^V SS7 notiiM'i Knec^plini, »|<fiU«il 
^K^ fur FrKiUirnl Tbkh 
^^H Zm njin>11Uiii-|I>MitiUTIiigb^llat, 


6Uil dor hr Knee ID Aitlln . 

m BaduoUcn of Dlilocated ShonU 


oa 




6M der bv Pectmidloular Meikud 
tn Pa««*nl Dbtanllon of Itadtua; 


SM 




IM 


Arm BbbI .... 


Ma 


^^^^1 Sn Impacted Kradiira uf Lover 
^^^^1 Knd ot t'Miiut 




rm ForwBrd DUIorallon of iUdiuit 




IM 


AmStnUrbi 
SM Forward DiilocaUon : Potllion 


Mt 


^^^^1 HO Prartui*( ft Vaniyit* <4 Keniar 


6117 


■ 


^^^^1 Hi Pnrdim of CuAiljliM of Pniiur 


U7 


of DoiMB In . 


SM 


^^^^V M3 IMmrliinv'it uf AniArlot Cfuetal 


M7 


381 OULoolloii of trina : RoducUon 




^ SU |>.'>itl.>n i<r Frecmenu of Knrt- 




of 


Ota 


^H iimt I'slHlla .... 


W7 


98S FotWBh) UUlowlion of CBrpu 


Mft 


H »M Pn<iui»l l-atnlla: Uaib 




3St ForvBid DUIocBllon of UalB- 




^H Slmlchl 


sm 




061 


^^^ 3U PrwtUttd IVlalU: Knee Beal. 


SW !IM ItBokinrdlNitooBttonofThntnb 


««L 


^^H »W M*4tete Pr>c-i<ira u/ ratella 


eoD'Wt BacknrdDMlOMUunorTliuHib, 




^^^^B HT Ue> '<>■-"<• '111 Cnlon uf Pnd- 


1 ttMlwilkiB of . 


Wt 


^^^H . t^Ua Vmw 


000, SM PattlaJ thilocation of MiddU 




^^H 3« Ll. . UnloB .>f Pra«t- 


Pkalani .... 


tea 


^^^^1 uR>l rauila^ Trotii View 


OOO SKT PoilUoiinrBoaealatXdoraUMi 




^^^H M9 Anerlil Sui>pljr of ralalla 
^^^H SMI Mainline'* ^i-llat for Pr«Ttur«>) 


SOI "f llip: Ob tuDomuallll . 


66fi 


Vf* Potltkin.ifnonaalnlMiluMlioeii 




^^^^H 


001 uf itli>^ Toward* SdMie 




^^^H XI MannlDE'i.V'") '»r Krvrlured 


NwWi 


fl6ft 


^^^H l*aU<ll<i. 


008 ' 9>9 IVialllAn of H-.ixa in DUlOMtioht 




^^^^r 2tS Tbi'fiiai'i K'^niwpllaT a|>nlfad 


uf III))' On Id P.>niMa OvBle 


j£i 


^ .1 l'.i-tU 


f**: -.•» l-'-IK-nufBnMtlaDMMUkM* 


fl 


H tia M 1 1 ikni 


fAK nf Ilip: OnlalNibh 


V 


^H 3U i^ll*: ■ -'oiric-i'mlh 


«M ml Halation uf OlautBior lnlon>u* 




^H 3U PuU'i Ftaituir. |t|>plaOBaie»l 


to lleaduf FvmuT. wiih Hip 




^ ■ 


407' B«)>ndMl1ll(|:eb>») 

1 


M» 

1 



LIST OF ILLUSTRATIONS. 



XXVll 



■St6 

S>7 

S^ 

2»9 

UO 
101 

acK 

JM 

KK 
NT 

me 



.Vi4 



.*-,». 






^x 



K> 



OulocMion of Famur Below Lhe 

Tendon . . . . . 
Duwmion Showing DialockUon 

of Femur Below the Tendon 
P-«ition of Limb in Diilocation 

of Femur Below the Tendon 

I Bigelow) .... 
Reduction of Doml Diilocktion 

by Tiactioo . . 
BaJDction of Dornl DiitocatioD 

bT Botation .... 
BvJiictionof DonsI Dielocation : 

Relation of Bonei in (Bi^elow) 
R«4lucuon of Sciktic DiilocMtion 

t>T Eiteniion .... 
Dulocmtion on to Tuber iKhii 

I Bif^low) 
Thjri.id DiilooUoD (Bigelow) 
Tbvriid Diilocatioo : Kediiclion 

bj ManipoUlion 
TbtT'id Didocstion : Reduction 

bj Eit«n>ii)n . 
Disincstion Directly Downwards 

^Bigelow) 
DUl'icBtion toward* Perineum 

'Bigelow) 
Pubw Oil location (Bigetow) 
Pubic Ditlocation ; RelaLion of 

BM>«a(Biselow) . 
Pubic Ditlocalion : Reduction 

bj Eiteniion . 
Sutapinou* Diilocation : Rela 

lion ot B»ne« (Bigelow) 
Compound INilocation of Aa- 

ira^liu: Diiieclion 
Fracture "f Baw of Skull 
Frat'tur? nt Ra^ ,<t SKull 
Frariuf* ,i{ BmfP. opening Tyni 

fan uni .... 
<iua-b.>t Fraolure of Vertei 

Sj.iiineriiiir •>( Outer Tuble 
Crun-h.ii Fraclur* of VtTte.i 

Siiinlpring uf Outer Table 

Nittiral Si7.e . 
Jt-f r— jiiin ..f F.ilcrtial ThHIb 
I>-pr«wi«ii and Fiourin^ ot In 

t^rnal Table in fame eii*e 
Af'pii.'aliH'M of Kl&vat'>r 
H-> - Sa« ... 

H»vi!-nw Applicali'm nf 
T-e;liine-''(rcli' rounJ Puncl 

..r-d Kraclllre 
<_" : i.'liiti'pn^ of Brair ( Liicaii 

t'Kamf.if'nni^'ref 
E*-.a:i.in ^f (.'unvoUitiuni of 

BfBin t" ."-urface of SItull 
L'ji.'aJ^C'baiiipi"nnit-r^) . 
ii^:.;w If ihr Ki-Jure ufKcilandiJ 
I' -iMoc- ''f Ctnlres anmnd Fib 

■ iirf .... 
Ilcrria L'TtVri . 
.\: L.h<ratiipn i>f Treuhine . 
T'-[ hine-<-ut »l Kage of Fract 

-rr .... 

Vtr Iff Ojihlhalmi*cop« . 



FASa 


no. 




329 


669 


S30 




331 


680 


332 




333 


661 


334 




336 


G62 


836 




337 


662 


336 




839 


66S 


840 




341 


664 






342 


604 




666 


343 


666 


344 




345 


666 


346 


667 


347 


687 




688 


348 


068 


349 


868 


350 




351 


689 




679 


352 


703 




703 


353 


704 


354 


710 


35,-. 




3.Vi 




357 


710 




71J 


3.)H 


71:J 




71-1 


3511 


715 




7ir> 


360 




;Uil 


717 






3-;l' 


T2r, 


363 




3F-,4 


7-.'0 




730 


365 


731 




73:; 




741 


31'!'', 




307 


741 


3HM 


7o(i 


36'.' 



Fracture of Dorso-lumbar Spine 
Cruib of Cord from Fracture . 

Apparatus for Fracture of Spine 
Diilocation of Cervical Spine . 
Dislocation of Axi« from Third 

Vertebra . . , . 

Ear-icoop 

Eversion of Upper Eyelid 

Speculum for Eyelids 

Fine-pointed Toothed Forceps . 

Straight Scissors 

SlrabiBinut-book 

Curved Scissors .... 

Silvester's A rliScial Respiration: 

Tnapiration . . . . 
Silvester'B Artificial Respiration: 

Expiration .... 
Application of Lembert'a Suture 

to Bowel .... 

Lembert's Suture Tied 
Jobert's Suture Tied 
Jobert's Suture for Complete 

Transverse Division of Bowel 
Jobert's Suture for Complete 

TransverseDivision of Bowel, 

Tightened .... 
Operation for Lacerated Feri- 

noum 

Thrombosed Popliteal and Tibial 

Arteries 

Senile Gangrene of Fool . 
Embolism and Secondary 

Thrombosis at Division of 

Common Femoral . 
Senile Gangrene of Foot; Sepa- 
ration of Dead Part 
Stump left by Separation of 

Dead Parts ' , 
ilirrccooci in Skin in Ervslpelas 

(Koch) . . , ■ . 
TeniperHtiire-rhart in P\';»'inia . 
Tem(ieriilure-cliHrt in l'j:fniia . 
Coliinv of Mitriniicii in Heart 

(Paih. S.iL'. Trniis.) 
Colony of Microcmvi In Lym- 

phalip Gland (Path. .Soc. 

Trail?.) 

MuTocitci PlunKing Arteriole 

in Heart (Kocb) 
Conteiil.? of Atheromatous^ Cvflt 
Sei'ti'in of Alheriimatoua Cvat- 

wall . . ■ . 

Horn on No;e of (.'hilJ 
Uk'ernled Sebaceous Cyst of 

Heal [I ..... 
Large, Lobulsled Cvft from 

Baok . .' . 

LinEsor Branchtal Clefts and of 

Meeting of Processes from 

which Kacc it Develo|>ed 

(('\i""l) 

AVnII iif Dermoid C\-i, Section 
l-'aiiy Tumor, Scoti,in 
Penduloiii Kihn ■-cellular Tumor 
Firm t'ihroMiutH, Serlions 



rioa 

770 
770 
771 
773 

773 

777 
779 
783 
783 
788 
788 
783 

798 

799 

832 

882 
833 

834 



834 
842 

S49 

849 

851 

854 

859 

8H3 
911 
912 

918 

91K 

•'19 
',132 

!I3'2 
033 

ft33 

934 



938 
930 
942 
944 
945 



XXVllI 



LIST OF ILLUSTRATIONS. 



rid. PASS 

870 Firm FibroniMU, S«ctlona . 946 

871 Calcifying and Hyttine Chon- 

dramntft, Section! . 948 

872 Cslciryiog ftnd Hjaline Cbon- 

dromata, Sectlune . 948 

373 Chondromau of Fingera . . 949 

374 ChondroiitaU of Fingan . . 949 
8TG Pedunculated Bxoitosii . 960 
876 Myxoma of Shin, Section . . 961 
3T7 AIucoui Polyp of Noie, Section 961 

878 Niovua, Section* . . .968 

879 NieTiis, Section* .98 
860 Lymph adenoma, Stroma, and 

General Structure . . . 964 

881 Lym]nliadenoma, Stroma, and 

Oeneral Structure . . .964 

882 Pa)>illomaofSonPalate,Sectiot) 956 

888 Adenomata of Uamma, of Slow 

Orowtb, Section . . 908 

8R4 AdenomataofMsmtna, of Rapid 

Growth, Section , .969 

886 Round-celled Sarcoma, Section . 961 
see Splndle-celled Sarcoma, Section 961 

887 Oval-celled Sarcoma, Section , 964 
388 Giant-celled Sarcoma, Section . 964 

889 Giant-celled Sarcoma, Cell) from 964 

890 Myeloid Sarcoma of Radius . 966 
391 Myeloid Sarcoma of Metacarpal 

Bonea 966 

892 Alveolar Sarcoma of Skin, Sec- 
tions 966 

898 Melanotic Sarcoma atarting 

from Mole .067 



no. p^am 

894 Melanotic Sarcoma, Section 

andCellaof .... OSS 

S9G Melanotic Sarcoma of Eye 96S 

896 Mixed, Round, and Spindle- 

celled Sarcoma, with Hemor- 
rhage! : Section 06ft 

897 Cella from Encephaloid Cancer 9M 

898 Scirrbua of Breatt, Section 906 

899 Scirrhua of Breait, Atropbic . 98T 

400 Encephaloid of Breaat, Section 988 

401 Colloid Cancer, Section and 

Cella of .... 98ft 

402 Colloid Cancer, Section and 

Cella of .... OSS 
408 Epithelioma of Lower Lip . 992 
404 Squamoua Epithelioma, Section 998 
406 SquaiQoua Epithelioma, Struc- 
ture of •• Bird a Neat " in 998 

406 Columnar Epithelioma, Sec- 

lion ■ J. ■ .996 

407 Cbaiaaignac'aEcraaeur . . 1006 

408 Chaiaaignac'iEcraiGur.applied 1009 

409 Tubercle-bacilli in a Giant- 

cell 1010 

410 ScrofuloualTlcerof Leg . 1016 

411 Scrofuloui Diteaie of Arm and 

Finger 1016 

412 Syphilitic Temporary Teeth . 1080 
418 Two Notched Central lociaora 

(Hutchinaon) . . 1080 
414 One Notched Central luclior 

(HutcbimoD) lORO 



SCIENCE AND ART OF SURGERY. 



DIVISION FIRST. 
FIRST PRINCIPLES. 

CHAPTER I. 

GENERAL CONSIDERATIONS ON OPERATIOXS. 

Bv a Surgical Operation U roeant a Manual or Mechanical ProcesB under- 
ukt-n by the -Surgeon for the remedy of Deformity, congenital or acquired, 
■T (■"•r the cure or relief of a patient suffering frora those effects of Injury or 
Dt!««w. that are incurable br constitutional or ordinary local treatment, or 
in «hicb «>uch treatment vould be too slow in effecting the desired result. 

A Svryietil Opemtion may be necessary for the following objects r 

I, fi'-m'di/in^ or Removing Congeiiital Def eels and Malformatwiu: as Hare- 
...■ ' '-.ili-t'-ii. 'If Supernunierarv Fingers or Tiies. 

J. lyiti-il-riiig Ai-ijuirrd IkjWU 'i»d f>efonnltins : as in the Closure of Fis- 
■ .. -. tin- Kc:-ionitiitu cif Lnwt Farts, ami the Correction of Distortions of the 
l..-yA-. 

■J. T\,r H-moi-'il '•)' Fnrriyn Siibflniirfs from the Body: as in the Estraction 
■; A Bulli-l iir n Crtk-uilis. 

4. Th. i:-/>-i'i- nj Ihr Effcrtt of Iiijuriej^: ua in the treatment of certain 
I ra. lurt-- unil Diplix'ations. 

'■ Tb<- li-moftl tif Piir(i> that have been so disorganized by the effects of 
/■ i ,■ ili:u ihfir vitality is lost, or that their continued connection with the 
r— ; ■•: iht- lx«ly w.mid be a source of danger: as in Amputation for Frost- 
'•::• ■•T Manirleil Limbs. 

'■, Tilt Heniirnil i,j I>Urii»eii Sinirtures that interfere with the utility of an 
r.-jti <-r part: as in the Kxtraction of a Cataract. 

7. Thf R'ino>-nl of Difiiued fitruetiirr» that seriously inconvenience the 
i-a-Kot or that remotelv threaten life: as in the Extirpation of Tumors, 
-iiuj.lt or Malignant. 

". fi-fiiiny II P'llifiit from Immediate and hitvitnble Death: as in Tying 
I ll..-"liiii; Artery, Dptuing the Windpipe in Laryngeal Obstructions, Re- 
.-viijir an Over-<lis[ended Bladder, or Dividing the Stricture in Strangu- 
iairil Hernia. 

' )[--railvir Surgery is but the application of manipulative methoils to the 
r-ii- 1 BDil cure of injurv and disease. Like e\-ery other art, be it manipula- 
:;rr. [>lHi>ii(-. or imitative, it can be carried only to a certain definite point of 

V.iL I —3 



84 



GENERAL BEHABES OK OPKRATIOKS. 



excellence. Au art may be nxHlilicd — it lunv bo vark'xl — but it caiiuflt Im 

Etrfeeted beyoiwl cvrtaiii uiiaiunlilc limii*. And lu it ia. iwd iodocd n>u» 
e, with that uf Siir)t«riF-. Thtre L-rnDDnt iilwayi* bo fraab fielda for oODquM 
by Uiv knile. Th«n- tuuut be ]><>rl»<iit» of liti liuruan freiiK- that will em 
reinaid Mcr««l fnwii it* intruniMi — nt Ictui, in tin- S(irg«'i>ii'ii hitnd. 

Tbitt w« haw iieNrlr, if u<A i|iiile, ivach«<l tbiw tiiml litnii* ihvr« can b« 
little c|UMli(>D. Wlicii no rcBe<-t thai wcry largu arlcry in tin- liumaii UkIj 
up U ibe aorta ilw-ll' liii« Imyii r«-|>mt<'illy Itgntuml — that vuch t>( the ma 
Itrga art icti In t >»■>:> nnd mniiy of lh<- ^nialkr bnn«a bavr l>e«-n rancud-^liat 
tliir iimjitiiittioD of each limb up lo the rhotdder- or hip joint ii a niallrr ut 
uriliiiBTV Hirgirat uviL-urreiut- — ibat Inrgv tiinion having ibc tiii«t inlrirat4 
unnioiiiicsl o"ntit-i-tiun« Iihto bcvo rvomvvd from cv«ry sur^iwl rpgioD io th« 
ImmIv. J'niiii tbc hitfv of tlw bniln lo lh« lowest orgnn iti the pelvic mviljr— 
t))iii the turvii:(, the fplcva, the kidney, the prvgoaoi utenifr. and tvea por> 
tioiie of the Moiiiiicli hnve Ixren auci:i^t«fiillT rcRuivcd — when we Tvflnt oa 
trii)ni])bf(>r the Surgeon '» nri ihut ure cxprcMc^l byopfmliuns tuch a? tbtw. 
He can ecnrecly believe othcrwitc thnn (liiil Utile r«tnaii» fur the dariDg <n 
tlic buld««l to deviw, or the skill of the tnoet dexieniufl to necoinplish, in 
the esteitsion of ibat art in the direction of it« oiwrnlive departmeai, and 
that the .Suri^n miiot iu future he cuutcDt to repeat, lltough pi^sibly io k 
inoditied aixi improved manner. these oi>eratiuOB that bavebtien inau^urate4 
by Lhe ifeiiiua and perfeMed by the skill uf his predecCMOra. i 

It is true that si>nie uf tlie operalionf recently performed for the removal 
oftmiMinant ursans have been far from anc>oe(elul, ami it has yet to be d«- 
lermioed whether ihey are mure than buhl e\|>cnRieula on the power and.' 
fdiilurouce «f the human frame; whether (hey arv Auniiral iriumpha orj 
op<-rotive aiidac-iiieH. ! 

To mv mind, it appean a* if wc ha<) already rcach<^ aometliiiiiK Itka] 
finality in the iwre maiiijiulntlro art of Sur^'ry: thi>u)th I hwitate much ia> 
UH- the word " rinalily. " f'>r I know well how nirl a man i» to Mippow ihati 
art, to the privecution of which hr hint drvi'tnl hi* litV, to have altaineil its, 
final limit of |>frfivli'>n. Yet, liM>king at On' iim-oiion m« i]iii)i«i»iun»lrl* aal 
poaublo. «« ouinot but come to the concJttsioD — that we ran Mwrcely htipo 
to p«H fiir heyond tlie line ai which w have arrive*] in the directiioi of rx- 
Iremr pr(«m<>n and idm>«l aliudutc o-nninty in the mei-lianical jHrturnuincv 
(i|'tbco|>rmtii>n»uf Rurgery.and that ia this direction thv prugraavf modem 
Kurgery is nenrlr barred. At the «nme time, we may nawMubly vx|>«ct 
lliat lb* details oi* the melhotls of pntctising ntienilion«i mar (Wim time to 
time b« materially motlifie'l and improved br tbe skill of imtiviilual o{icra* I 
ton, by tbc ingenuity of surgical mecbaniciaus, or poaaibly by tb« intrnduD- 
tioD < J' Dew a^ot« tu aids to our Art. 

But if mwlern operaiiTO tnirgery baa auaiaed to ao high a pttvh nf p»r> 
lotion in all that relates lo boldncaa of conception ana to precnion uf 
axecuiioo that we can scarcely hope to tee any further progras in theau 
dimtioDs: and, indeed, if llw inoM advanced u'uleru fvrgwf ia seeking to 
lay aside the scalpel and the tMstounr for milder ntetbods of tnalintot— 4f. 
in (act, the praottoal department of Surgery has, an flu- ae our present 
means and our present kuowle<l|:e are eoncerneil, rvadieil. or nearly fo. its 
final develupHMUt — the cate is widely dtflbnmt with tlie Mher gnal branch 
of tniTBery-— the leientifit. 

For nere, Uuly, so &r from having appMacbcd tbe fltml limits of onr 
rabjeci. we are but as yet iw the thn-*h<>ld. And wlietbvr we regnn) the 
aelance of 8tiritery in iU r«>lali»n to tlie ma-ntial nature, tbe character, lhe 
reoognJlioti, and the {wllwlugy of ourgicat diM-iom and injuries, ur wbetber 
we MOsider it iu retvreni.'e Iu all (hi«c cireiiouUi»i.-f* which, indopmdontljr 



OSXRItAL RKMAKICS ON OPERATIONS. 



35 



4 iW Bcvhancwl tkill or tbo opi-mcir, influence for good or for ill tlie 
tmtju of hit pnicvilan*, »« hKVa u luttd b«fur« ue lb« extent of whiob it i« 
IBwlt ym to liaMia. 

Aad Miv I *Ja Dnt apaok of ths im-n local rcsutta ; to far as th«y are vou- 
o t »«d. tluva bu luog bncn luit little to lie desired. The ri»ulu of nioet 
fhttie, Po<— rwiw. and uphthalmio openilioiu hsvo tx^n lu satiafactory oa 
lb aaM iBSpiiiM could \M\t« for or tW moet critical exjiect. 6o also with 
n^vci to that nuiltilode uf minor operatiuos tbat ak iiractiaed for tJw relief 
4'Taripwe diMrcMog txialadiee, and vbicb are followed by the happiest oon- 
Bui «)mo «e cuoH to consider tlw iiBuea m ihoae gnat«r and 
wfwratiaiia. bv wliich the life of a {latieDl is directly inperilled, we 
■re wiMtniiQeil to Mmit tbat Mccew In reeulu long laj^ged far Whind and 
hof* Ml nfatioo to tbe perfectioD iu the execution tn the operation, and that 
■ thi» n>pf«t tbe highly pollthed Art uf ^turjuery foraKrlj far outshone its 

>^aov ihu was writicn, now ten years ago, much uf iU force has been looi. 
Ti-r tiM tnMmeaiot' wwuoda. Mhether accidental or inflicted br the Sur- 
!««'• koife, has been greatly inii>n<ve)l by the nputicatiua or solentiRc 
^ahufls to tbdr manaeMDcni, and owraiiotu liavv oeeii correspond ingly 
aadmd nwre itircitwttful in llu-ir rcvulta. \ic hurc. iu fact, arrived at uue 
i4 tkoB* e^ocha ia llic hi*ti>r)- »f Siiritury which .iiand out pniiniuently a* 
tfaniagopotDU fr-iin which a new iif|iHrture \» taken in iu Art — ettlier in rc- 
'^ ~i to ita practic* Kvneraily or in thv developnx-ni of *uiue »pecial de|iart- 
AmongiC Um most important of these tpucliN. so far a> tbe improve- 
uf tbe );eDpral prnclicv of S4trifrrr \» r»iiceriii-il. are tli'ioe marketl 
W lb* rarlval of t)t« um- of the Ligiiliirr in the *ixt<.-<-ntti oenliirv, and by 
IM ismdaatioB uf the ilunlrnnn ii|MTH[ioii f>ir Ain-iiriHni in the ei^hUTUlh. 
TW alMAscaih cvniury nill crpr •'tnud 'lut bri^'htly in the aniiaU uf .Siir- 
pKj as thai ia wbu-h tlM- inivtiiuahle b-joii of Anastbstics was cDofirrvd 
M^ aABklnd. by which not ooly h» pain in Sur;gvry been abolisbod, hut 
weaUiat itf iu ><|irrativc dv^uiriiiK-nt imineatelr enlarged, lor they enable 
\o pvrfiirui, and the (t;itii^ut tn undergo procedures, tbe a^Miy 
■nuld nihssaiM hare been beyond lh« piiwcrof human eniturnnce. 
■ Bciticcable feature iu the i'urttery of this epoch is the appti- 
I of the niles of a acieniific hygiene to the ireatnieDt of tlic injured, 
tbe aMrtbodical einploynienl uf Anti»e)Hics in tbe niaDs^emeui of 
FuaodHl. as the "Antiseptic Method" ia. on tbe experiincuul 
>tif fastciir, it ts undoubtedly to Lister that Surgerj owee tbe 
sifliieiion ^' Siiriticnl Pra>.-iice of the doclriuee esubliithed bv that great 
KalwisL lluvfvrr touch lite details of the Anluejilie iIetiu>H may he 
lafisil io ihr DiurkT of lime ouil by the intr>iductionof new chenuesl agents, 
lbs gnw' ' wliicb iul)-ti<« it, nnd on which the whole supenuructure 

W asdn .^1. will tun on iniHct nud uui-luiu)feabl«. This principle 

a ^ fell •leoDinpositiun of fluid* in W'ititi<b. iheir puirt-lltciive 

;inctly depeadeui vn ibHr iuipret;nnlioti nith urtrauic 
A<«t»i]C in tbe air and theoc* deiaMitoI or lu oilier ways coureyed 
fotsfoiatlire ur putrcfactlre «banges bein^f iliita at uuce set up In 
ifca ftaids Mf tb« wmod ; that nuch local actions are capable of pnntucing 
. ssfitk lafrcfioa of th*- fluids of the body: and ftinlwr, thai tbcae 
MvdortB may bo <xclud4.'«l fhaio tlie wound, cillKr by their daiiruo- 
Hat (B Ihr air t>r rh^iiiL-at Hgcuts, luch an oirbuUc ttctd, or ibeir seiHiraiirtD 
btm. inyen of niuolin or»r cott'fD-wuol. it is tliia 

._. ^1. .uiud iheprncitceof modem Surgery. Tlie details 

I it ii CMrried out arv uoccvtarily changeable. The Principle itself 





86 



OS^^ERAl, SEXABKS OX OPEBATtOXS. 



1* inimutiililr, W It b bsMil no, aod i> the AutnMOO of, dtnet upecfna 
ftoci <>bt«rvniioD. 

SucofM La the raulu i», nitfr nil, iW thing l<> Aim at. uiil w> UDOunt a 
nuiDua) (li'ixtrriiv rnti ooupvitwir f<>r iu mbl. Ihit it mum nut Iw luiiniM 
itial inniiunl rfnuriiy i« to bi* luxli-rvnliird — far t'roto il, Miiniial •lcM«rit) 
i» DmMonly ot' llic Ant wlvaiiHigr in thu perfunBinor ut anr <>|i4tratioD 
and Hut Hargvon abuuld diligrutiv vmlcavur to ii«)uirv \ht Art uf nab^ bii 
iBMnim«bt« with DMlamx, nipidtty. nml t-rrlniniy. Id many ntetof nnnm 
monivDt, imiitbor rc^ui«itr » nr<r<)c(l br I ht- Surgeon ihunlhif. ihit il wodIiI 
iDtltfil. iw It filial error (•• Mippoee that in lh'° mnjoritv of catat rojiiirinu 
Hirgiciil inti-rlV-rt-iicr. thin is lti>' onlT, or iiideeil ilie chief requirrniiui uti 
thv luirt of the ojxrnitor. Muiual drxtcriiy must ik>1 be iiii«tnki-n for nur- 

ffical »ltill: am). <lfTirii)il« as it doulrtlefw may 1>e lu !>« able to reiDovr S 
irnb or to cut ouc a atone, with ra|>idity — importnni. in n word, ns it ■ la 
hecume n dexterout operator — it is of lar i^reater iuipf^riunoe tu b«coiM a 
Hiccnaful Surf^'on. Uiv object of every u|>eniiioti is ibe removal uf Kiimf 
coDdition tltat either threatens )ile, or interferai with the comlirrt itnd utility 
of existence ; and the more safely as well m <.-ertainly a Surgeoti can aoconf 
plish ibi* object, the belter will Iw do his duty to hb patients, and the mora 
Buccasfiil will he be id hb pradica t^ucceas, tlien, in the n«uU of an opern- 
tioD, whether iJuit result be the preserrulioD of life or ilii! removal of a 
suUTce of discomfort, is the thin^ to aim at. To this, dexterity and rapidity 
iu o{>era(in>- are iu a bi|;h de(treo i-ouducire; but th«re are various other 
coiiBidi-raiiou? ^jually or still more ueccttuirt', the aulution of which can be 
nl1i>nli'«l only by an intimate jji'iii-'ral ao)UHint»D(x- with lh« Science of Kuf' 
Hi^v and ol' Meiliclne. Th^ I}iuf:nii«Li of ibc uatun'of the luoil diwaae,, 
anJ of the extent of its cudiwcikjiu*, hiu to be buuIc : tnrkinj; vi^cvnil aflec- 
tioos miM be dpt<N.-tM). nod, If pcwible. mnovtd. Thr ('oimiiiuiioii of the 
patient must b« pnixttcd; )»• nitii>I. a« fnr M poanbb-, be plannl in tlKwei 
Dvgieoie coodlttouo * hidi itrc moot fikvoridilit to itcawry ; ibv Invt tiinc for 
tlto ptrforninnrc of thr o)n'rnli<>ii tiiu»t btt Mriied: and. nlU-r il« compbtioatl 
tlw genenil hi-nlth must Ik* nltcndr^t to ia tuofa a war v »hiill be^t varrY the I 
)Mti<-nt through tlH^ diflicultit* he hns to mcounter : nod any m><)Uv^ or 
coniplii.-atioii* that arbo must be subjected to appropriati; ImUnienl. TIksc^ j 
ufi wvll aa tliv niinplc performance of the operation, an the dutit* of tli« 
HurgTon : and no th« manner in which they are performed, lu much b>, or ' 
even pcrbapi mora tlian on the mere manual dexterity disolayint in the 
operation ilaelf, will the fate of the [latieni depend. It it well linown llmt 
tne reaullof operatiotW' dilfere miicb in ihc pmcticr of diHi-rcDt Sirgi-on« ' 
of acltnowlfidged dexterity ; and this variiition in the proportionate niiniWr . 
of KMVefies cannot be ncconnied for by any ■iilfercncc iu the dr^'rvt* of i 
mauual skill dbplnyed in the operation itself, but moat be sought mtlirr 
in tbc i;rukler atieiition that b pai^l by aomc SargeoiM to the coostilu- 
tiniuil t/eatnient of their jiaitenis before »nd aAor o[ierati<>u. and to their 



iDorc jwrfect ncfjuainiaDit.' wiih those L>eneTuI Inirs thai intliience itif *ik 
of nil tbn opemtioos of Surgery. Indeed, succeas in Operative Surgrry 
mainly depcwla uo two condiiiooa: 1. The selection of Draper eiitr»: thnt 
fa to wy, of ray in which alone an operation will probnoly be foUoWfil by 
a lUtLWiflil rt*lilt; nod 'J. The avoidance or the combating of tlioee dele- 
toriou* intliirni'iv, hyxifuic and others, to which a patient may be expoeed 
after an o|>('niii'>u, and which may din'ctly mar its sucoem. 

Twu rvi|UtsiliM are thus entenliiilly needed to constitute a succeasful ope- 

Thr fint b, the poeseseiun of thai mechanicnt iikill which b required 

Hil'i-. efficient, and sjieedy |ierformance of an o[)eration : the aecond, 

equal im|K>rtun«t, is tlto scientific kuowledj^e requisite to deter- 



lyrLt'XNCK OP OKNKHJIL UtLALTU. 



87 



■■t tlw CM* 1b wbicli operntioD hns Ikvorm DMeeuinr, in whicli it rmv 1n> 
f*ieti«irf «iU) ■ Ka»OQ«bl« ]>n>#pcci «>f IieiieHt antl ^uii-ma, ntid lu itecidi' oa 
At ■ ■■ w > to h* *il<)fkU<(l (t> plaoc the |iati('iil in thi* wml linvonililr ciivum- 

T1-' 'pnWiDi; in Dotorioutly hop«l«» auee, with tbe v'ltvi of 

priag Ukr ii*ti>-tii mIibi U eallMl "a lut chaitcc." b niueli lo Ik- <li-|>r<-irsl«-i), 
mi nwmIo ncrcr )>c r<illu««>l. Ii is )iy o|)eraiiii|j iii mioIi drcuniMniK-w. 
afMcikllT io rancpnxii iliiOMW, lliai mucli <liiicrv<tit han nstiliol [•! S<ir]^Tv ; 
fttwaSTiMt numba-r of imtaocu tlii> pniieiit's ilciuh !.■< liaBttiiMl liy tiio 
Hoaidw, vhii-li, losicaJ «rK)vin|i liiru a tnM clmoce, cauw« bim onlr to l>c 
•MMulMd ■Doner tbaii W would utb«rwbe luivo Ih**:!!. It inuy Inily \k 
«u tk>l a frnvt *urh*iiiil uprrmliou. in its cuntvptioti, it« |ivrlbrinanoc, niiii 
* oMBpllKMi, tnta tkr> SuryroD'* nivdintl kuonleiljfe lut nxtcb ninl in lui 
nmd ■ nuiDfr m it tnsi* hi* mnniinl tkill: nml itint. Utkvn iii> n wWlv, it 
Mite bigfkcU dvTrlwpHH-Dt ortlii; nioilicnl nrt. 



h 



caentmon* isrtxiatvivu tiii: :«l'Cc0« ok oritKATinxs. 



Tbr rittaumtmanr^ ilml iiiniiily lofltit-Doe the n?eiitl of iin opcralioD. ii~> ftr 
tb* f « <»T»ty »f ill" (Hiiiciii i^ rooconii-d. iii4tr be nrrnnged uoder ibrw 
1. Tl««^ llial niv i-ooiK'Ciwi with iIr' .Sfnir i<J Uif fittietil't {jenrrnl 
>"-f •f nn-i HI tltt- lim* of ite |)erfuniiaiit.'e : 2. The llt/yirnK i ouiiHiotu 
Ird »fter it bdooe; uiul 3, Tbe S/iteiitl Dvufrrt c^ai- 
I 111 iuvlf. 
I. tcunaUncva bvitm nlike. tbc i-oudition of a fiatleni tluit 

Ei>nc» tbtf ranili <>r' »ti ujicraiiiio ia ibi^ State of the Oeneral 
t nt. MCcwM ia inHiK'Utfd fur more by tb« ^lult^ of ihi.- imtinit't 

oMK - Liiiii br llir •erdrity of ■■! ii|wrKti(>i) ilsirlt', or vvvu by iImj 

ibImhIi ■! ilril'rily wilb wbtrh tbi- Surgpoii jH'Tfami* it. Wry (il\vu ire 
M* • fslMBt ourinl ulf by lalAl ditniM' >uporvoDiu|; od nonu- «xln-rndv 
ofvnulm (Midi M ibr muovnl of a *miill tumnr), wbicb iu irscff 



4i|bt 



«sr: 




•tfl^ 



-' _-r lifr. "en- it tun thni tin- pnlivnl'n ottiMiuitioa 
iiviiTO tD to uubrullby ii uliiti' tUiit the eligbri-st 
irii. ■- lit ti. cull lb* (nt»l diwiiw iiim Kclirity. Si>, 
' I' I: i.-tunrr t<j »iT >iiu- pitlii.-nl ^iiik aAcr ttie miMt 
u for hcrtiin. nr Mom-, the lipitiinr of an 
iMlioiiai omdilioi) tlin[ |ir(«li«pi«c« tu diirnse 
I iiiAV |ui9il>ly miikf tbi.- m»et mnarkiilik- uod 
- I>n-ii iiiutilHt'tl with but tiltk okill. lDd«[icii- 
- of ibe vi«riTa, of whiob I •bnll berMilU^r 
I- of ihr I'hIv titb r<-e|>ccl lo tiK' coixlition 
irtnititli'-ii. nitd iIk' p-ncnil pbvficsl 6iitie. tliat 
' tici-. Thii». |K-r»<>ti>' i>f an Irritable and nnxiotti 
■ - ' nell a* ibuw uf a more tranquil mental 
1 u Icrble and irritable babii of body, eap^iallv 
»«rT « wi aad bi-Mcriivl «otni^, wilb but little Btreorrtb of eirciilaiiuo. cannot 
iMX vp aitaMfi ->-n- nur^riral prifceilurec. and often uiik after compiim- 
thwlv aliyM i;; bi>i m Iteomie deprme^l and to liuk without 

Jyuv- ♦'- ■ ■...-■ an- owrluwiW with ftl are not ([ooil bubjecta (or 

ll In tbcnt tl>e ein-olaiton if usually feeble; tbe wouik) 

•lu* ,; aivi B afit lo broiinK »l'ioi;by : and ceueral ur bn-al iofeetive 
rawlily ucctir. Sli»ri •>!' n<-<u.il Unic-iuml diM-aw uf iD)|Hirtaiil 

H, ■• tbe luoft. bran, or k)dni->->. 1 kn<>n po cnnditioo nmn- unfWvor- 
lu MiecviK aA*r oprralionK llinii jm-iDntiirv or excMBive oljesily. 
ftdniie nith a hlsli iani}K'nilurQ ■hoiibl nerer br opcmied on except for 



ma ill 
do »« 

>ti»it. 




38 



OESKRAI. KBMARRS ON OPBBATIOKS. 



the relief of thiit venr condition which occiuioDB the elevation of tenipei 
tiire. such its ilie aecuniulatinn of pus. or rapidly spreadinii ^lutrrena 
iiitlaiiiiiiatioti.or in ooeof th(>^ fourgreat surpcal cnieriienciM (hat deinai 
under all aitd even- eircuiui-iauce iimnediaiL' u|wraiion. vii.: 1, dau^ro 
hemorrhage : 2, iti)[>eDdi»); aHphvxia : 3. »irauciiIiUi->l hernia aiid inteMin 
olKiinieiioti : and 4, uver-ilUtf»>Ud bladder. The urgency of Ibeae ci>»( 
tioiid, nhirh may bo (ernir<l the four claMcaof ]>Hniary tiurpnil tirgcuc 
(ivcrridi-H III! "tlii'r con>i<li'rati<>ns. 

An iiiilividual "f a KMind coniititution, (bat ha* never hern imraireil 1 
«XCCMM of any kind, uhoH' hnbito hare )ie<-n rem|HTa(i- and xoiter, vthn 
<tiet ha* been euffieivnt and <•{ k'""! •i""'''^'* *>'h'>M- mind hn> iicvi-r bn 
overtlraincd by ihr mixirticH <if btiMnHW iir tlie Inb'ini nl' a tirolViHtonnl 111 
■IhI whiwi- i-xi^tviiw liii" been spent in rnml nccilpHlionx and in the pure a 
nf lb* eounlry, Ik iieceMtarily platHsI in n far more favorable |K*ilion to b« 
tb»cfi«c<j>of any mtililaiiuu.nhettirr it be die rrMiillofinjuri- ur be infticti 
by the Siirffi-'in'* knife, tlinn thf iinin wh<>«i: pbytiml p'>wvr* are worn u«t b 
itiiivi' mill uneea«ing bwntw av<>calionf> or |>r<ifr>«i<>iml work, whow nervoi 
•yMeni ii> cxhntulvd by his anxioii* labor*; a»>l inlinitely Ri4>t\> *a than tli 
prior inhabitant of a large and denwly peopled (own. who hit» from carliti 
childhoiid inhaled an inipnix> and fetid atniiwiihere. wbi^e M-anty diet In 
connisttil of the refute of the )>ho|w, or the n-mi-decnnipowd offal «( ihi- ulatl 
and frh<»c nervous * v»tem ba» bivn irriiair<l and tit the sanie llnw rxhauHf 
in the daily stniggic for a precnrioiit livelihood, or over-ftiinulnled b 
hiiliiinal exccwce in Etroii;; dnnk», by which he has hoped to mireha>e ten 
porary rorfrelfiilnFes of the caret of a eon)id life. Thou(;h individual will 
Mich itifferciil anteicedcni» be place<l umler einctly the luinie by^ii'nic eit 
CuniBtAflcee nf7er the perforninncr of an operation, vvi the renults will proh 
ably Ik- very diasiniilar, influeitced ai iJiey ruuu l»e \>y their pa*l ratliir thai 
by tbdr presenl cundition. In the one eaie, the inflamniation n-niiliinu fron 
the indsion, aiid requisite for tJie cun- of the w<itiiid, will noi overKtcp thi 
normal devree »ec««an' for the b>-alin^ iin>m«. In ihe <illii-r it may aiwumi 
a »pretidinif form and terminate in mitav of tho«c »cooudnrr affertioiu wblel 
will |>rt«r»ttv Ih' nilveried to u occntioainic dooili nmkr unfavnrahli 
by If ionic coixlitiuoi. 

B<9ii]<« Ihe general itatcof lJie|>aiii-nl'ii hi-nllb. the (hrttlilion o/ Importatk 
Orjiatu iiiiut Im' taken into coiuiiili-nttioii l>el<ire an o|)eratioii U cleeided iin 
The lUte of the {Mticut'* //eurf ohould !>«■ earefullv looked to. Valvulm 
diaoBM' of ihia organ, if i-arly or •li^ht. iH-ed not U.- nn obftaele to mu«l 
opnvtioii*. even t<> tliMH' uf expedi'-ney ; but fatly deffvneraUon uf tbe bnrC 
aa iudimtetl by it* feebU action, bv irregularitv and want of power in thi 
eJrculaiimi, by lin-nthl«ni«e. nixl by a distinctly nuirkod arriig «-uilit, 
chould make (he Sur^gMin can>l\il in undertaking any operation altnidi'd 
with mm-h l<i« of blood or riiock lo tbe ner\-o4i« M-gicm. Such a cuodilioit 
of liMit i< liable to occasion great depmeidn of stimgth. mtcopr, and dcatb 

often xixldcn — rxme <lay« after the operation. In cbmb of chronic di#c«M 
that it would othcrwiw be proper to submit to operation, thi* condition nl 
(he heart bocomes a (vrioui obstacle, but it need not be a bar to operation ill 
octilo cawa that wotild l>e epecdilv fatal if lefl to thcn)eclve», and ccrtainljl 
nut in one of the four eondit»<km nf primary Mirpcal urffeiicv. 

Disease of the/<KN^(,of n tulierculous character, when active or iidvancetlj 
it inco»i]Mi(ible with the succtas of an operation; but nnder certain circtiRw 
t(anc», iL» will be explained when apeaktng of diaCMCS of (he jointa au4 
flutula in ano, an operation bjuttiflabic and propcTt oven though (he patieni 
be coosumplive, j 

If tlw J^i'eer be aflbcted by cirrlimis, and moro tapecially if anr aiinptotm 



A 



IVTLVKSCS or HTQIKNIC C0NPtTION3. 



*ll oprtslioiK «boiit tliv )ielvic nn'l ^iiiio- urinary •trf:rftl>s> 



W maum b^r* tupcrrrncd, do oporation but for ibe relief of diaeaise that 
■HiBtly ihnaUriM liff iIkhiM be oniJcrUken. Amyloid d(|[eaerat)oa does 
mt nMUtUfiwItnuv ui npvralioo if, by ihnt operation, the caaae of the eon- 
tfi* c*0 hm rrnnovnl, M io sonto cneet of clinmic joim^lhease. 

Krfaa|» Um Bi'«t Hcioaa cooitttutinnnl mff«ciion, nn<l tJiat nhich more 
ttea aajr utWn militate* nf^insl (W eucress of au operntion, U disease of 
lh> KH mfi, with KJbuminurin ; in itiis oonHitioo the local inlliininuilion tbnt 

^V Smdtmriag rf i a M i U tin-itber (.■oosiiiiiiioual madition wliioh absolutely 
^KlvWil* all ipentiaos cxivpt ibiwc re^uirr.| fur tlie iinraedtat« preBervalioD 
if UiL Tbe tMuhocy tn the oocurnace of carbuDcl« and sponuitMus 
unyTWii ID ^betafWavrell-koomi failure of the dueaso. and this teudeoer 
ifacM* iuM afiar aa operation iii ■loujtbiox <>f tbe surface* of the wound. 
nth "idvlr ipmdinc diffive inflammation fotluwol by septicemia and 
<«Mthi Anivinlaurta and diabetes form, in fact, iiuch wrimttii coraplicAlJons, 
ikat m» nfienllAQ. etvn the most trivial, abould l>v undoriaken. csci^l in 
c— a of en xf |t»ncr. without previotuly cxaiuiniug tlic urinu Ixitb for albu- 
«e« aad Mpv. 

Hw eoatamiaalioa of th« patient's «y»tPm by MnliKiiant DiwKic must 
alvwT* pfWTctit oar ofwraiinti : as. if this ha* taktii pliKV, iW di«M»o cnpnot 
W fiMBf>W(elT rrmoml. And. Iitaily, no opi-mtioo, t»ve of ih* moat urgent 
mmmmilj in okh* tbat &II within iho category- of one of the fi>ur cIsmm of 
•ontcal itri^aney, ai>d thtt* inWnded (o rrtcnf the patient IVom 
g ifailh, »b'vil<l cviT be jwrformwi whiUt he in }|ihoring under 
f j B il a. o eptioi m iB. Rryfiii<cliii>. nili<liiti#. i>r any Difliiio [uflammatlon ; 
dariiif tbe «pi<le«nic prevalence of these atlecti(>«i#, operations tbat 
•I* nut uf iwwMtf BiCiiity should be postponed until ■ mon? ftivoruble 
OpenUhns in jrery old pimple, if sev«r« and attcndo) bv mnch 
the lyitetB. ar* commonly fkiai : amputations in iudividiiafs above 
tif MTvnty are very rarely racccflsfnl. 
Hyflasie Coaditlont to which a patient is exposed both before and 
I'prralton, will moat materially influence its roeulie. These condi- 
anr uf two kiixb: 1. As regards the diet iif the |>atienl : and 2. Aa 
nw hii rap-tsurr l(> a vitiated atmosphere coutan)iiiai«^l by the emana- 
hvm tbr «ick aoil wi>undc-d. snch as u commonly met with in the ward) 
I if ma vrer-etowilrd ur ill-cooitirtii^ietl hotpilal.' 

^» Tk* pmpar niptlatJon uf the patient's AVr before and after an operntton 
^Hb *d wnmi coowqneiMw. On ihts itoint ii is iinpoaiible to lay down any 
^^HY ddaiip ra\r, as much dorands not only on rhe pniii^ut'ii previous habits 
^ tiU, bgi on the natnrv of the operation itself; nnit, lu thin ^utijt^ct will be 
SI th* rtui of ihf rtiapter. it need not detain us liere. It ii not, 
uAm that iu civil prncii<^' (he insufficient <iuanlity or tltti bad 
iTuf the paiirni* fivMl, with which he t* siipplte-l nfifr ihr [HM-formanee, 
mairrtatly the ri«iili of an o|ieral)on. Rut in miltlary uud naval 
pracciar in tiine •<( war ifai' caao in far •liriVmiL Th'- (oldiiT nr itie sailor uo 
activw aerrlflB is oAeu ripiMni tn (rnixi* injuria* (hst ncenwilate the rnor* 
ispMBBl dfSBatinos at a time arboa bi* cvwHtitutionnl powon hnee already 
hm» brakMi (Iowb by ictirvy. drtenlety, or some »th«r oimiinr allbetioa, 
fMUaf •• ancJi from tif drCineni fpiantily as from th" unwh»1iwiin« 
of tiia dad vithwhichaluue hecan boiupplicd. Aftertbcopcm* 



Ut m« ~ Lsctuns 
UT*. 





'ho wfsbsa tn tiuil,*' thl* vorv tinpoitaat talject mon 
•m Umplbillun aail tW' Caiun of Dsath slWOptrvtiont." 




J Ub eair arsilablr nulrinivtil umy )h- i<f i1h> coarMiil obiraclcr. 

■^h4. mad laprrinHiy oHiki-*). Jii nuch nrriini»tanrc» upfmlidii-wu 
■■I l»iil. rr thry ■rrnii ii |M'(-tiImr ^iitifirconu- clinturti'r: mid tlx' |«t 
£m Ucm wpiiwinaia <ir {iva-riiiu,<<r li-uiii )in)fiiM' i)iitrrti<iii wilh ulccntiuni 
the iMMtmM. Tl)« nortaliiv nf u|M-rHliun» htt-fxurs L-norninuiity iocmMI 
asd thmMJiniln of d«ittJ» wfik-h Idivi' occumnl Id wBn> bc<no<.-n iIm) m^ 
dTiliml MUioDS cod ihe iuM iijipointcd irmiiw havr bfcn (tu«- to tk^ 

Tb« Bygienie (\mditit»u hi whicii the pKlieot b Mibji-ctnl mlU-r tin <>]m-I) 
tioA «iU nciw w rily vary greatly accurdinf; to tbo locality in, aiu) the d 
TClMtMBcw UDtkr, whiob it is itcrformvd — whether it w done in n iirivij 
how, wttw* 1^ iMtienI iiMir be icolnled, fn-ed rniin (he elinnn- of all cqt 
iMKiaiittfaa, sad surrounde^l by evcrv enuilflry [tremuiioii ; or in ii liuvpita 
•btr* bo Qiun nfe4«Mtrily tw ex]>owa to eniaoatioiifr, p^wibly of n »e|>lie nb 
iaJipctiMn cfaarnelrr. from other patieiiU, whi^re llie buildiiii; inav Ix' iiHpKg 
DUwl by tho cxhuUtioiu from (•mtmiona of sick and iujureil. and whd^ 
■miUnr tnoMun* may b« ncutraliu?tl by the conditions Kviieniied by ii vi4 
aMaoaUagB <kf tiok luraer on« roof. The'u, aKnin, the drcuiiiHtanei-e in whid 
a fMkul b placed a(l»r an oporatioD for un nividem of eivil liie ure nectl 
•arilv very ditlVrvnt from tnoM that eurmund one who h expoerd to thi 
pMiiliar prriU thai nn? oecfctfarily c-oiinecttnl with niilitan' hoepitals an* 
atnbulaMM in time of aeiive war, aad which will be more fully described ii 
the chapter oii liiiti&liot WoundL 

111 private pranicc. ill resulln may follow n|ii-rationi fram thre« dilTercal 

_caiMc», viL-. wlf-iofedion of ihv )iulieut, in co]we<|ueuc« of the reteution ol 

fcd«->-<>ni fulfill It nod putroaxnt wcreiiim^ in ih« wound ; conreyanee of infec- 

' ti>>ii by ihr Siirveixi: and mieml fnnlty Miniiary arnm^metiiaMflhe house. 

Ill ttiB|mal ^inicticv ihfw dilli.>m)t WKirccKof dan^T inntt DconMnrily i-xitl 

W llii- Mine if imi to n ^iiti-r extent than in privalr. In hoapital. Im-wpvct. 

junt n* in prirntc firnelict*. thi-Mi- pttrtirular diingvrc an- all pn-ven table, nod 

diMMM- <>t a M-plic clinracttT (Hijiht unt to be allowed to geocrntv itacif 

tlirou^-h llK'ir tiH-ilitim. The fmcgueney of sueh ati occumnc* ia in th« 

Ldirrct rnli» »f the wniil nf hygienic ntteuttno bcetowiil ii)>nii (hr patirttL 

■ Bill ill iHtililii'H lo l\wrr cmiiKTof diseacc, tli«i«cxiMi> in hotijiitalH <>ne apeeial 

B iniuiirv i>f diiiigiT whirl) lends to the excefifive morluliiy that ii]i U' n rrvent 

[■criol hat pii'Viiiltil in iikisi of iIii.ik' ioMiltitiou^, and which iitil'orluiinielT 
I still allowol to )»■ previileni In ^mie. Tliia danger nvult» from IM 
Facvuniulatton nf liirgv iiiiinlicrH of t<iek and iniured people in one building. 
Thr air nf tnrgf lownK or ciliea in which the Krcai majority of hofpitala 
muot ii(V>«sttnly be Mtuiiied is, lo begin wiib, mure or leas loaded with im- 
puritio. The noniinl A parts per 1000 of carbonic avid gas is always ei- 
o^ilnl, tlvp amount sometinien reaching as high as5. or J^. 'llie aiuouot of 
•ulid iiB|MiritT is at>o very considerable. It has Iod^ been known that the 
atiimphi't'i- i^ I'nili-il wiih minute partivleo of oroanic nuttier in a stale of 
»u>pciHi<>(i. M"K' ihun twculy yea» ago Pouohei demoiutrated the [tmcDcc 
of ■larvh ur3""lee in lliv diM't de|K»itea in a nmm. In 1>MI1 PastrurproTed 
that ihr Pj»n« of fungi wi^realwKVti to be found in iIm* air of Paris. Tyndall 
L has alro ■liiinii hon larp; a proportion iif the dual of the air i» mmi-iMil nf 
p tiT^i"'- '"•ttKr- NoUiiot i« inon- Kimptr tliiin |r> driminHtrate ihLi impurity 
^f ■ iii'ibiHt n-couinicnded by K<M'b, of Bt-rliii. In which iha 

(^t . . ' vnrioua fungi am In- wiitched on a boilnl |H>i»to, tba 

L 4<g| lartiiMof uliich hiui bifu fur ii vliort iiin« axpowd I" the air, and llten 
F ovtwid <rilli n lu'lbjiir. Ity a ■iioilar invthiMl of ofa»cn'ati'4i the pmracv 
df lb* 'I'""'^ "' I'lii.'. niid rHviifioiiflllv nf iMctrria, nuiT )■' khoHn in live 
j^ ' "inl .11 lii. lojBuf doi)rs, |>it'lur\'-lniRi<«, etc. Micr-ijci.ptc rxami- 



IKPLL'CKCK OP UYaiKS]C CONI'ITloSS. 



41 



■Mma akiMra in Uw air wf all inhaliil«<l ruonis. scaly «pitli«liuin, hits «f 
hwi— B hair, ami fibm of iMlion. lim-ti. and wool troin tne clctbinc. All 
tfc w inwimia arr ouily i<> Ih- rv(v>;,tiiiFd Itr iimjilo mit-ni^i'Ojiic evaiiiiiiii- 
boa tif ia« diM( filtcTKl frotn tin.- nir. 'ilii.- vxpL-ritu^uu nl I'a^ieur. TytKlnll, 
Lmvt awl a 1ks( nf Mhar olarrvi-rs have rouclunivi'lr proviil llini tbi.- nir 
ai«> ai — aUu miDBle aolid {>artirlro, ofiim iiicajuible uf wulnr ikin«tiDirHli'>ii, 
«ktdi aA M fifm^fiu iip-Mi •Ifiul •ir^-niik' mnlliT K<v>nR H.-e to ^iirli pnv 
oi^n aa llw' :i'n nl' nllHiini'ii'iiil i>iilK<tiiiii:». lliv Uoiic acii] 

far^Mitatino iikv. I'lutiiir utnt lii^ >liH'i|ili'!- inniDtuii) tliiit 

m all t^>«a tbo* (lai'livUii nn- living <irin>i)i">i> "f lliinr 9pi>m>. Fuudid, 
JBaitiaa. aAri otki-r>, liuvic'Vfr, nliili- □<>( <li-ii_riiig llial »iii')i uiiiuito iiiirtiolva 
^*uat in Uw air, nud ilinl lht.\v A<> im-I a> frrnieDt* vhcu they cnuiv in 
«aaMact wHlt fcnoi-tiialik innitrr, hvlii-n- that thtf are not (>rgauiu--d loNliea, 
Wt sfw jautictM of organic mnltcr uiidcr^iiii^ <vrl»in " phyMO<>-cbeiiii<.-al 
c^M^c**- TImt akwrawvrt thai iindrr fnv>iiDl)l<.- t-iri-unisuincta fiutrefiictivu 
aad »bak«ooa praooMs cnn ucciir »pi>niaiH'i>uily wiibfiiii ibr inliT%-«ntian 
•/ a«« aodi boat**. !)• thai iu> il may. lb<- ui-ij^lit »!' i.-vid<-iii-c itl ibc pfca- 
«Bt lim ia larvUualy io favor uf iIh- civn that uuiIit unltuary i,-ircuiu>'Uin«>, 
tkmt m to ar. awJrr «ucb rootlitions a« wi- iiir^'t wiib in 1H( ixil of 1<M> »ur 
gMl ^uaa. BO |Kiirrbrtiv« or lirmeotatiTi- rbaiip- wilt lak« pluci- iu llie 
ur rxuilaciuii in the living b>-ly if the dust of th<- air he vx- 
I; «>r. if ikal k impoMib]?, if tlit> pnnictw of vthioh it it niadr up bu 
UtdM* artitaiuf romr oneof tlioH- i-hvtniciil agrni« nbich vr vIiub ai> 



TWatrHfa?"- i uck nyiiM u rilinloMiy Ibe iiati<-iit. Iir«tly 

br tte Dornal |i: , tralinii uud cxL-n.-linti trom l)i<^ liin^r* and 

akm: asd Mrnodlt. iii itmut t.-iiw«, liy th« «maiiiit!r<iic ol' wouihU or fitvf. 
TW 6fM ia uoarimlatilr. ibe Hi-i.ttd t& to a ftvm (.■xiciil iindi^r lh« ronirol uf 

Ab •vcnfia mIhU nan irivca nH* (mt hour uhuut .6 culw fuut of cartH^aic 
aod aa*k f non I (o W «uui-n uf waUr. and an uud«ti;riuiii«d (|iiniiiiiy of 
*«|Mac iBsUrr. Thik on:nnic matter t> piirtly xilid, i-«in*uiliDK >■)' i.-|iilheliuiD 
■■4 buy nmltrr fnim lh<- tkm ami mouth, niti) jMirily a vn\\nt given olT 
6*^ tk* lanes >i)' oaturr uf »hirh i* M>iii<iirbHt uiiciTliiin. Il b i^xtr^nielv- 
•Awarc. aM ■• mi tiapcrfiTtly diirii'ihli- ttint it u jimlmbly in [trvut part 

iw<i' — '-- 1-- - fiiun aixl ■jxiilltiiblr. altbuuttb but alowly. It is 

r^ I ' hhII* iir U-ildint:, ihf tixM byKriwopii- ■uh.ilAiice* 

takiaj[ II uii lu-vi rraiiiiy II i> tbi» KulisliitiT ihal ^ivi-» lh<- fuity araell to 
am iD-naluaiad rwoOL EsMriuK-uI* buvfobonn thai it i> btichly JHiiMinoiit. 
I lU» RSplaias ibr bet tbat nir <'>iid>i] bv r(T|>inii>ou in much inorf dclr- 
vittaical by (WRibuKii'>n "r l>y ihr inMiiioti of nunc cJirlwuic 
Parti0 •CUoi that "nlliiwiiij; tbc fullwi clTwl i" iill ncbi-r nftea- 
»• I}" dottbl that tuTAtbiiik: tb<- vitial*^) niiiin^piiin- ••f nvpiriiii'iD 
fca* a m -''MM aftdtui thi- bi-nltb IVrono fonn Ikn-unn' luib. niid 

|a»ti*l>; ' ir spfvtlt*, ami ti>i«r u litii« d4>i-liii4> in ii>ii»-tiliir >u-<'ii^tb 

ladapicibk, 'rh< < and nutnii'-ii of iKr l>1<>»d ^i-i-m to )»> int'-Hi-mJ 

•U, and ibc icr:" •<( ihr fy<!''iii liilU WUiw (mr." I'ndrr lucb <-ir- 

fmndcacran- '» prot-ntrr-d ; the rvpnrativr (murr i> Ir^i, nix) 
< uod to alMtrh ami lK^:><nic ibc «mt ot unbnilhy intlnmnialiotw. 
aail iIm paUMt <• luun rradily nlfivlini by niiy bjoU or grocml inliictive 
fltaim \o ibe pMaon "f which h« »iny ItC' i'K[i-imiI. 

TW afadal f>«tBmi nation of n Mirkdral manl may arvc, lifM, from the 

-'— -■ '" ; ibp |nvwH>iis pr»duet» of dvconiuuellioa ; »oe- 

-' >if tlif orf[a»!<^ fiortirI«« which act at ihv 
•au ta •KXMiip-iii'ii. iionlly, fmni i\w )>n-«rorv of dricil |«niclA of 



42 



OIXRRAL REMARKS ON 0P8BAT10VS. 



the diMbugM IVoni wouodt ur aore* : and. ImU^ . by Um coaugioa vl tiwdl 
tn(«etire proc ct B, whether scntml or locvl. 

Th« maeous prodiictv of <fccump>j«iii»n. o ottt i idag of wlp hm ii uJ hvdr 
^1. ^ulpbkle iif nminoniiim, (rw nniuvnui. nrbarMitd hrdrost*. csroen 
acid. Hixl msoy i>tfa«i», uiKluiibiolU- u-n<t U> aggrevatr liw ttmyUHm pf< 
AmixA by ilic MvunmUtioo uf thi- nn-lupt* uf mpiratioa: biit >l m imfa 
lihlo to fifpiirnie th* eflbctt poMlucvtl by tbi- fornMr froM Unm of tJM bUK 
Irr which ihvy inurt almtM ntocMarilr In- romptimud is « hiMilal «>n 
nrkm *utn ihnt the [Mitrdybg aiiiniiil iiMltM- «hidi &i 4 » MHn r mcsm 
Intn ■hmit nimm duriu^ «nr foroiD un«uf thr pni>c>p«) taansflfl rfiurim 
ADil ilvurnUrni- : but it i* uuly in militnrv pnutiw, ia «birfa lirgi anmban « 
wtianufvt mn*t ormaioiially In- [lavktil c1<«r]j Mgvtbrr muA th«tr wwoiwl 
urclrt-tnl fur omut -if HulGnvui aur^-al luuManeti. that poteid diiciwrgii 
<>| i-ulntc lo«uch ui rxlrot w lutWrtlop thcMdiMflBk 

. Lbi- kir iif a ward cuntaioiDg muiy moI wwudt ha* beM iha m 
to fmiain a grwt axccM of organic nattrr, l>oi ii b jatpuwablt V mfmnit 
Um vA«t« pcudnnd by it fWm iboav of fbul air g »ot n JlT. 

Tliinlly, mUfUKiipc- rsamtnaiioa baa dMDooMrwtcd i£« ptanw* of driM 
put rvll» iu lb4- nir of •urp<i^ wardi is addkioa tu thv ■|Mthilia» alwayi 
met with iu inIiatNi«d ruMii». It baa baan Mopvaad by bhmt ibat ibM 
raigbl poMbly art a* lb« nabrrial uf oaatapaai: thal'tfaar aay ba tbf 
bMfm irf <<i«ta^ga can hardly ba waM— biy doabtod. 

L«flly, ibc air of lorgical wardi it aaC to b* iiailaaihialid bjr ika 
t^ioa of ifMific inftctira prutf. Moi at btfwtal gaagrma. 
pjwaiia. Ill t>f tbavxact aatnrauf tbt eoBtaflaa ia Motf itf Ibi 
«* Bi* atill iraoraol. Tbia nmdk, bovmr. \ till rat It vactaiB. ibaC H 
taBit,>ft»l in iif tfiiailbipniwMi ii fartiftali: ii ii ant yaanaa. and isiOMrt 
oMta tta arttnty can badcilmwl by thaw ttiaikal lobibMBM that «« nil 
aatbuatiia. Ia tba raM ■^itiir of raas it avcars ia caajaactiM with 

piiliiAiil fl^l iriirhafLiaftiiM Ihi ¥ianil aail ibmi miiiIw iif triaiwiaf 

which an btst lalwlilxl Sa p w w t dimwfuMtiia aba acne bat ta |n^ 
nat thv HrrarTaeeeaftaAMiniaflaaaaMini. TW obMnatioaa «f 
, Kocfc. aad May t«Mn.bn« Aa«a that all tha 

_jaa an acwpaaird br tbapnawtvaf (atccaanifia 

tba lOiL'harp^ aad t<Ara al» ta ^ Inaplatir a^caa atmt Um 
ihnv «i h» ir<ifi aiw of ofaaios that tha aucfofimailiBf aa* ^fiiactK mt 
rwtly tW n»H of tha oabrahby pa n ca^ aad lltft ia&ctioa ■ 
abna't bv thr actaal VnaArtaem at mm» mt thna Hriac |WiTti cka 
fmtimt W aartbcr. Kadb baa abowa ■■■iWahbly Ibai 



ibay Meaf M tlae baaaa la t ai tt . caa ba 

Aat aacb daaaia ia afWMpaaaFd b<r tba inwaciafa i 

aeaffc ftwm, a^ ibai it ~a br: 

ibaAa i a iW a ^k ii E ii ^ i i TWilba. 

lailibaiaJ^iMalii. tb» barill* aMbcada.*/ < 
^baaeaaf^^MdinL It 

ii.tb*lMitt«.i 
:«T«» MT badradaaibaya 
fa ibi> icaiaiti 
Ibafi I IbalbaM- Il>w<Ubaa«atbMd»i 

fM. wM «»Hrt fcW KfaaHr mmi tba i 
Mbwlha^i 




tsrbCKircB or hvoiknic conditions. 



48 



asd TnuaHiat. is that the 



» of splenic fever ind thitt of m 
<f irpticxBitti, coRiinon in fowls, known us chicken cholirn. 
It in Tinilence if the or|;aDisin8 which fi>rin their neeiilinl 
f«*t ftrr cuttiTMtf) IB a loedium which Is not suiled to iheir gruwlh. Tbe 
wnf . altbuuxh ooi au dpiiDitcly prtivc<), i» probably tnie also — thai tin 
fins menmm u iDlrDtity if cultivBted in a luetliiim suited to its growth 
is4 ihTtliy—t ^iieh a inbdinm for the cronili of paiho)^ic or^nisms 
m te»4 in A» ft^k tiaaiMB and unhealthj wires of pnlicuts irenkenot by 
tba bBpura atiaaapbere of an overcrovdcd nard, »ud it i^ lhi» thtu 
! cireaiutanM* infective prooenee of iutense virulenre mar be 
Our kiM«led|co of tJie exact nature of ilie puisoDs of i.>rysiiwl»s. 



I gtmgnam, and pyieniia, in Mill very ini{>erfect; but ihis much is 
wililii. tEai tbvr are oMentially filih-di»ra>e)i. and may. if the term is allnw- 



W r— iiiilai liirul in any hott^Mlnl or bou&e, hom-ever cleau or wcl 
, by tbe aeounulation witliio it of too Inrjcc a number of palirnis 
taikiiac fnan wimiikI* tbe dtKbargea of which are in a »tate of decomiHwi- 

f. :- -jTfjhaliip ihni the routagiA of K>me of iheoe diseases aredeatroyed 

but, l>« tliti lu it may, it ■* evident that a want of free v«nlilii- 
i»« niuM I'-ad bi a eocicentration of HUcb |M<ia»n9 at are dieeemiuaied by the 
mr.mai at Ibe mid* tine tbe patieut'* Imily will bervudcred more susceptible 
t* tbeir tufltKoor aa its vitaiilT become* IgwcTHl. 

Ib thf MvA'Tttti-m of the ededa of overorowdinit we have to onuuder liret 
Ite vtUatMa oftbc air by the {MUJent by tlie niUunii {iroceMm of respimlioii 
— * KXtrwtitia ; and, «*<ioiidlT, fouling of tbe niin'in|ihiTt? by ihe emaniiliooft 
VMuda bimJ torra. The fint ol^luwi- rnuM« of im[)<iriiy >» unBVoidnhle, 
. Il ia oolj bv providioi: *ulttcictit air fur nich imlii'iit mid chunuiiiK >t 
vilh mattkimH fn^iMncy thai it* evil cHntx iitn \m- pri-vcntiHl. In deter- 
^■iSf (Im eoodithn of the air of a n^m or nani the ciirbonic urtd prawnt 
vtakMiaalbe ladcx of the degfee of imp^iriiy. u it b casilv riilimated, 
»hiW ilkv 'Irt/-rtniiiati'-4i of the orpuiic matter is almost impoMiolc. PiiTkce 
a»i .- .6 tier lOOO volumes of total carbonic acid in the air 

mu.'. ...... ....|^;.:r allomablc. Uftbia about .2 is derived from respim- 

iat ami ibe rrmuiMlrr » the nornutl quantity present in the atmotpfierc. 
boffder to RMtintr- •> lirat ibbsi«ndar<l an ordinary man requires to be 
«yyfiad with 3»" fed per hour. Tliia is tbe minimum qunntity of 

air tiMl will mlii.Y t r tix- nur|>«(w, and il would evidcnlly be unwiRc to 
tr«at to ibii. TW niK thcrclorc. Iiiiti ilowii is tbnt at leasr Wt)0 cubic feet 
fKi hoar mm* be provide<l. In onler thai thi^ amount of air may )>c ob- 
Immti wHKuut expenng the patient tu druutrhtr^. ii Aurticioni cubic »piic* 
aMt b» allowed foreaeh patient, *<• ihnt if ihi- air lie chanRed frvun ihrec to 
bar tiniia per hoar tbe rci]uiMti- amount may Ih- supplied. I'nder exccp- 
liaaal cinttnataana lUOfJ cubic fc<-( per bcii<l mi).'hl ibus. with ^^ood rentiln- 
thm, ba awde Mftctettt : but uo .Survron would In.- iimteiu uith this if he 
taaMabtaia a»W*; a« in civil practicf h<- alway* ctin. Tbe rule, thervfore, 
hM down ia (be cwn*lmci)ou of h<wpiinl« i> that each [Mtient shall be 
iffiirnwt Iran 15<l)0 is jOOu cubic fi-rl ol (iuicl-, tite larger «{<hl-c being 
fa^aitid fat laCwtkoa, or surKiml wv^. In order to maintain a proper 
Jmiii rif wparaiitm of ihr iitttii-iitK each munt bt- nlti>tleil fmiu 1<K> to 160 
^nati trtH uf Auor. Tilt- tHi-i'tivi' b^tfbt of a want fur ti>e purpox* of 
mHJlaliiiri <!••* aot rtcv-ed I'J Im-t. Not only, however, i^ «p"e« required. 

hM ttmatt of air. '" i ■ ■ ■niilalion, i* *i|Unlty netilful. Military ex- 

Mfwara W rbi - t)inl churehe* t<>nn tbe very worst noaaible 

Liw|Wiati, Ut in tiirn i-ii Hi,-!, nIthi'Ugh tbe cubic viaire ]ier l>ead is fr» 

^wmIv iniia. bat little prfvixiita b umibIIv miule for rfficirnl change 

Wair/ 



QENERAL RKUAIIKS OS CIPVBATIOXS. 



Tb<-' ftecoiitl i-«iu« of vilinlion o( tlii> nir nf n *iirKii;«l wnn] — (lie cmw 
tioDs rmiii wiiuiMb mh) *umi — it mon'or U*:> <y)itHili-it'h- uti'lvr lli«mM 
of tli« Siirj^ifi. If NViMiiitU do nut n(!Oi>ttMrily »a<l t» t)i<- iniiHiritv dM 
air ii( a wanl, il ■>• tlu' (l<-com[HMtti<'ii uf tla* iliiicliitrK<« aixl llt« «Aiivtir 
developeil ilint i^ivo riM to iIm; vvil coniwqiii-iii'i's fitrnH'rU' tu fAiDttinr 
ronM fHirtnfQu- Kxiwrivtuf tciidv lt> allow itinl if (l<'cniit)toaitioii of I 
dwi'liiiriirs U- n)i>H>luti,dy j>r<-vi;iitt«l, a cum' willi n unutid vitiiitiat tbr nir ■>( 
wiird iKi riHin- llinn oiii- witlioiit: mid in tiiv {'rrM'iit diiy. wb*-ii the jmwi 
mid pfdiMTliw »r niiliH'|iti(« lire m» wtll uiidi'mtuivl, UK-n? i* ii'-vtr ■) 
fixcuM lor A MiMiiid Ix't-riMiini^ n mxin-c of iiii]>imty Ui itiv itum>uiidi»)i; « 
J^Hfidd ili-oiiii|KH<ili»ii Iw iiimwiidtilili^', n< it ctill i» in innny can-*, il W cai 
til iiliwtrli lliir iliicbMrgc* iii roiih- iiiiti^oplic drcwiiit:, whirti uill (■[>iii[ili4A 
<lbiiiifi-cl ihi-iii iw soon u ilivy Icsvv ilu- fitttiont'f hu<ly. N» Htirgi-ou ilouli 
tbnl All B<>(-iiiiiidiilioi> nf |>utrid wuumU iii u ward giv» riao Id utilimltt 
|>nicvMM'#, eiicli lu pTivmin. H^|iti«i-tniii. Iii»iiiuil tfungnpne. and lb<- lik^. 
Micti itiM-iuvv do ari#i>, nxwl are nfirced iliai the nont mu»t t>« iJturuujcbl 
ilUiiifi-ck-d livfnrc> it cau mIcIt be used afcaiu. li^urvly it b inure rntiunal I 
coitiiiirncp lh« disinfect ion a( tlie source of niiaobicf— that is b> anT, tt 
wound. 

A Mitticirnt cubic 6|uic<;, free ventilution. uod clean uouude an- ibvrofdf 
tbi' vwoHlinlB of a Iieidlby liueiHiai. Atlenlion tu tliete ibnr (inidilion 
rtpcciidly t)ie last, has iu liiauv ('ouiiuenial b<«pilals rethiced tlie rU-ath-ral 
In li-w ihnii It quiirler of wlint it was iu fornter tiine». (.'are miMl Ix- Inkd 
in nitfiidiiif; in ventilation, tliat tlie free current of air is inaintaim-d biAl 
by nit;lii and dav. It 'n froni tinni of thtit |)recaulii)n during a'lfiUi esjH.x-iid); 
that riiiicli iiiiMrhit'f ofiiMi n-'i^ullB. 'Die iiii|i<>rliiiKM- of niHiniainiii;; triicii-n 
vi-ntiliilion duHni; tiiKlit. and the little daiiifi^r to lie a|)[irehc«dnl fn>m llii 
adiiiib^inti (if I'idil nijcbt air, have iM-i-n m forcibly jtoiniiil ihiI by MtM 
Nivhtinipih' in hvt ^oU*tin Xiininy, imi\ arr now (■■ iiniviT-ally adinittnl 
ttiot 1 iio'd nut do nioro tliiin luld tbc K-rtmiony of mv <'X|H'rii-n('i* to iIh 
triiih id' liiT olMicrvntion*. In imM wi-athcr, nUo, t)i<-rr ih »<• un-al n dt:<|iiwi' 
tlon on lli<- |>art nf iiiinuf and inKiriiiii in i^liut u|> uiirdi> and roonix. ihiit llia 
air lH-rt>niii> cliw, oppriia^ivr, and i-oniBiiiiniiii-d ; and bpnci- il '** that 
crtfijH'lns and iiiiiiilnr dtM^m-s mi- m rili- dnritij! winter and curly ■[irinz. 
Tde " Rail Wind " io cmintoiily ncciiK<d of In-iiiK ihc cniw* of tbwir ; and nn 
dotilit it it )u>, Init only indirectly, by cmisin)^ windowi and donra to Iw ■hnt. 
«io ni> to axcludv tliv cold ihat u»iiiilly ac4^i'm|immi) that wind, and thin 
midrriii); tlw- iiltn<n]>bptv iiii|Mirc. It i« iniiM«>il>I<< lo ovvrtvtiniati- th» 
iiu|>artancc of a frvv sufijily uf pure air in lct»cntnp the iiiortaliiv all*<r 
o|M»nitioii», not only iu hwpilaU, but cijunlly iu nrivali- dnclliufr*- I'Im- fact 
lia» (dU-n hct'ii ulwcrved in military practice, aim the n-<vnt Fr«ucO'4~irrmiia' 
Wnr bpiUf-bl it into strun); relief — that those uroundi-d fare bi-ei who are 
trrnipd in open hulA or teni#, uhilat ibose who are plac^-d in npjMirrntly 
morv favorable omdiliow iiHordeil by recular houM« l>ccoti>c ili.>eininlci| bjrj 
tbi»o •oHirt.'et uf miliinry siirxical pmiiin'. |)yieniiB, and hnajiiliil (.'ancrcoeJ 
It i« the diHi-rence in the liyi:i<.-ni<- nrnuigeni«nts in difl«rent h>«|iilaU ihal.j 
inor<- ibiiii nnv oiher (••iinliiiou, iiiDiimrrs the vnryini! laie of mortality iu I 
dilfi-mit iiiitiluiioiia : mid il ii oliviuiis ihnt, (-irtrriV/'-iriAu^, tbuM> [miieDta 
«ill hiivn the (x^i |>n>*|>i-cl of ri-civcfy who arc inoel strupulounly altentkd i 
toiu ihin nT<|MN-i : ihiil nocaMiiuf (>|HTiilion r>h»uld Ih- jilnci-d in Ill-ireniiUied 
ward*, or in thiiM^ that iMniain more thmi a it-rtain {)ercentii|:i' of jKilirnta , 
BufR-riu;; from noiiml* or (on-n, tbr iliKi-harfp^ from which arc uuBVoidably 
foul: and that lh<- i>erformancc of o)H-ration» in cluM and ill-vi-ntilatcdi 
roonw, ur in hoiiM-* *iluiiti.-*l in ovcrcrowdvd iifi||!hlx>rli«oil<t, iihtNild. ii» Ijir U 
IMMibl* bf avo»ili.-<i. The Ihiilty hyj^iunic condilioua that an- itill Uai fr*> 



ISTLCSycB OF nVOIKKIC C0NI>1T10K8. 



J3 



iih 



bi»|>iliils. art >like it cnxdljr 



the {Nitictit imd nil 
Suntwn. 11m! rrurlty m tlie |Milt>otit Ooiiai»U Dol only in ex- 
kin III ui lotrn-iuinl ehuDW of (l««tli — or, a> it w roniraotilr ciillnl, 
' W * bt<lvr rue nf tnorulitv " IVoin Mrptic diiMNwni tbal nri- ptvi-cutmblv, 
4mI iLm ate tti« tllnvt oiiicKiiiv of ili« ili-rt^tjvc hygieuic nrrnugiMiieuls of 
a — but in >ulijr4-tiiii; liini ii> n [>ti)l(uii[i'il nnd imjicrfect coa- 
eitiirr nr IkaU «) wliii'li L-u(i<liii<iiiii iiiiiy Im- uikcii hb the nwamn 
rftte Bt;' I'itmir iirnmi^cnK'nlH in n hopiinl. 

B«t w»: ::[i<>u In Kiriidirv hiHpilnl nrniii^ni<-Dt tsvtitmllv un injn»- 

Oa» t» th» >ory*uu. Ili> n-[>iiliiiiiiii 'uOiTft hy no tncri-iu>r<l rsir "f timrinlity 
(in {Mttrtit* fnini rniiMs wliicli. llii>«igh |>r<'Vt<nuli1f. nr<- ttllntMlx'r 
irfi itrol ; mi umtiti' liunli'ii of niixii'tv, r<-#|Hiu<'il>ililv, 

I ti hiiD by lli<r iii'ii-'^iiy iindi^r wliitli he li<'» of 
U wmrtiu* B^tiiwl wjiliv lio»|>itiil infliiinrti^ If it were not 
tg fwyiif»i»M. tiviHtiiK ■•'ont-ii-tuin. itiid " blo-Hl-ix'if-iniu^ " in iu pmit^BU 
itma, tb> L il Sur^««<> would Iw cnnip«nitiv<-ly light. 

An'"!' ...1. .. ..ii'tn- u by Do nwADHof hi mixU-ni ii daU- »f mnny 

Me> ' Tbr tSur^T^ne of ibo lut ct-niarv pnid ^rrat ntlcniinn 

mm, -»■. L .nm WW prxjpoTtioTOitelr ^'«t. "fhuE AlnnronV »iicci-w 

m HKpatMtMMt ba> i>rt«r bMfn surimwtd, and rarely, if ever, Mjuulk-d even 
hf A* ud nf anibrptirs and of ever%' modem cliemi<»l and mechanical 
Wntitiff in ITH'J ^ "Aian«<-ii on Ainpuuilion and the Afier-trent- 
l^MKtoa, 17l>^i. be tayii i I'reliioc, p. la) lliat be ampulnted in tbirly- 
.•odi af pnitDiKatutily occurred in tbe Liverpool Infinuary,u'i/A»iE/ 
I y a MMfb frntiml. The aytuptntnatic fever waa slixhl, nnd lh«n; itm 
att mn iaMMOcr- «l w«'jodiiry benorrhiif^ in Ibe nbole sertee. Alsn«on ws« 

• nwikty nsfnraior in bin dav, nud bud hit imlru(.-ti»RH Ih-cu fdlont-i), 
of lira would have Uvn invtHl nbiirb bnvoMnn' his linii' U-<.-ii 

kW Mcriftwd by the n«gl(M.t i>i' livirimic nwiivunv. Hu advii-<.* i* m 
•1 tWl it (Itspm* UiQ nitrniivv study nf tbe modi-m Stii^un. Hi^ 
»T* ~ TW tAr m which the caw U lu be omdociad is k point worthy i>( 
•oat srasHM Mlaaiiun : if puaabtc, tlw rouni thuuKi b« ti]Mclou«. ux) in >n 
lyrs. «bolcK«M •itiMtioo. Il ia wril known ihnt in hticjiitnU nhtrh lire 
■£i»inl in pcfNikiuB tuwm bit much crowdi-d. ihv Milutnry infliunci' of lh« 

■o kltcrAl, that cuniHiuud fnrlur*.-* and othrr iiii|H)rt>iit f(irt,'iv-til <:»tc» 
_..< IMiculiatiy flusl. »nd thnl >udt fnuturta may aliuuat certainly bo cured 

• tfcr eMUiiry. . . . 

~T*- 'fmrntton nf amiiatAtiiin done in iho onuDtry, iw above ilmcrib^fl, 
>l(fwed aliiH»i irrtBiitly with n spi->-<ly enre: llK-re ibe eoniM^^nenl 
MC;i>«>'aH ar* iritfio;. tMwrly Itx- whidc !nii-rnal mrfacv of the wound unites 
li« tW SrM initslitie. tbr Hip|Miniti<>n i.-nnfi^iiiently i* Mnall." . . . 

*Maay bi»|i«laU nrv *i> tainled by iiiiwh<i]i«iitK' rliluvia tbnt ihey nre 
nAtr a jwai than a rrlU'f tu llii' i>hjr<-u iliey cmilnin." (Op. cit.. pp. H*MK^) 

TtM« lulkiw iixita-a diatincl pnrni.'ra{>lis i>r bond; uf the ni<~i«t uN'ful Mini- 
lary aJvirv, whirli "an- humbly ri't-'onimendi-il Lu ibow u'hi> hiiTt? the t-are 
•f biafitalt ia want uf meh aUeolioa." 

nw carfr it rnrulniiTitiB d c T f Tf carvftll study. In it Alnnson advtfca : 

Tti i be inhabited ll>r tni^rt' than four inonlh» at it time; 

tkai i: : ii-wBihnI and j>urifk-d. Tluii the " tied-ift^iekH " b<- of 

ii«M ; lb* faadfltnc frr<|u< utly obaagra. and made of inexpeneive nkal«riiil* m 
it Bwi >-K>iTr tir rvnewFi); aoil that, when tlie weather adniiu.il be 
I n air Air M-renl hours n day. That dirty puiienu l>e 

■rtft " f (hio{ bafon admiwioD ; that they have a warm bath iio'l 

thtm .!) ilfwaes (Mxtvidnl hy tbi' hcMpital. Tlmt the inf<H-ir*l 

m^%i^ » •«-•» m a proparlj ootiftnicuxt otcu. That aewly admiiitil 



46 



UBNCRAL RB1IARK8 OX OPBBATIOI 



|>iatienu bv pui iuU> clean, ti^ll-veiitUatis) wttnb. Thai all incurable lo 
inievtiouB caww, and eeiiecially clirotiicully ulcerated lejp, be r^iiHod lulmi 
eiou. Tbat olfeneire. Ksiixrviiuiis, ami |>uirid »or«fl be placed in <lit>tiiK 
roQoia, aud not auH^red to iutts-t u wh>ik' ward. Tkal there ahould be p«i 
licular rooms [irovide^l for {MtieDin who have u»derg<m« uperatioiu; iha 
Ihej ahuuld be air}*, never long iiihabti<.-<l, aud aOcrward* cleaned au' 
ventilated. That a hun|>ilal nboghl afvig- l>e crowded an any oorouni, aii< 
nlmiira m laqje that a |uiri iiiiiy bv uiiinhabitnl. That ilie window* b 

ried for a certain iiuin)>er of hours daily. And l»«Uv, that everjr b(«|iita 
lid have a " huuM' in tbe t<»uiilry, in utb<<r nonln, ii " eotivalcMvii 
lionw," atiac)H>d tu it. Mudern noitilXM; had enablcl u» to •tct<Tfiiine lb 
true itatiire of tboM conditions that lead lo hi«|>iinl iiifi-vtion. but aooiur, 

tiractiei' hiui Dul yet gone iu atlvaiiue of the iidiuiruble prMMpia laid dowi 
ly .Maiisiin a ci,*iilurv ago. 

The iniiruility arintng from inntk'nlion to tli«M vmriouN hjgienic oooill 
tiuim, whi-ther wmit of elittiiiiiii-M in the wound or want of pur« air iu ihi 
wunl, in not a iiecr«;i>ily of thr i>|KTatioii. but neca and falls aecordiug m ibi 
trrnliiient uf the wounds, or the eiivunictHiicKS in whieh tht< (lalieat ii 
placci, de)iart more or lew widdr from ih<a« cyjnditioiH that are iieowsarj 
Ut ihv ■iiaiuiiiiniice of health. Tde fnyjuency of tbeooeurrpucvuf crysipelai 
ill ail iiMiliiliun may Ik taken as an indicstloa uf ntf;l«ct in its aanitar] 
armngenivnl*. I'ywmia and aeMieremia an a rule indicale, in addition U 
geitoml iH>gl«iet, a want of clennliiiew in ibc wounds, and rrllcvl tu a certain 
«xU'nt u|)»n the Sur;gp<m ai well as ibo iuslitutioo. 'i*heae diapMaa »n prv 
n-utable, and utifjbt to be preveoied. Surely tbe firvt and muat eawntiBl 
re<|uiBilv of a huapital is that it be not a source of disease to its inmates— 
tbnt those who are compelled to aeek ita ai<l shall not suffer from its vAm-u. 

The exposure uf a paliciil after a» ufMratiuii to the mntayuws emaiuiliom 
of sepiie diseases fruoi utlier nick or wouutlnl tiatieiKN, ia utaoded by tht 
iiioM filial cunsequenoui^ Wbmever it is practicable, every caae of septio 
diieaae nuch ax pyntmla, ervupchu, iuflainad abaorbcnla or vdna, or hiMpital 
gaii){reoe. »hi)uld Iw rit^iniusly (iscludod from tbe irard or rootu in nhich 
other piilk'uls with u{H<ralion'Woundii happen to b« lying: aitd, if ixjanible. 
the aaiue uur*ea, dnwen, or Duivvon* nbould itoi Ite olloa'cd to go miiu tha 
iufeclcd ui the beMlthy, uur sliouTd tbe same appltaoco, drattiop, or qwogn 
ba lueil tor both. i 

When ihiii is not poaublo, iIm danger of infection may be grwtlj diniiii*! 
bfai-il bv tb« free uw of aiitisoptioi to the wounds botb of tbe infected and' 
the healihr. ^ 

Umat care also abouM be ukon in tbe purification of the bedding thaU 
btu been ii»nl by |Mi(i«nls sulfbring from septic dtaeasu ; the blankets esped-l 
ally aru a|>t tu harbor infection long, and must be thoroughly punlinl.', 
Every hiM{itlal Surgecm uiu«t have had abundant occasion tu deplore maay 
deaths after op«;niliuu, arisittg from preventable causes due to want of atten- 
tion lo thcae sirople prM«ution«. 

3. Tbr Bpeelal Conditiona dinetly ueit«d by the Opermtion itMlf. pre- 
dUpoar*! to by the cireu instances that we have just tn.'«D considcriu^^ and 
wfaicb comiuoaly lead to m fatal rcaull, of which they are the inime>liat« 
occasion, arc the following; Shock, Kxliaiistioti. ilemurrhai>e. Gangrene. 
TetoniM, Pyieraia, SepUetumia, Krysipelaa, aud other DiHUso inflnninuitjuQa, 
These nrnsos uf deaUi are so various, and comprise su many diiiiuct 
caMv, that 1 iiluill do little mure here than meutiuin them ; relerri: 
reader to the didi:rrDt chapiera iu the binly of the work, iu which 
s|>ivislly treatctL 

Tbe aiuftk of ojt Ofieralion may prove btal In various ways : from the 



CAPBXa or DKATU AFTER OPERATION. 



47 



l^r oi %bm BadUliiin, »t in ■ vmv >if <li<i)bie amputatiuu; fn>m lliv 
Mng iB»f)li4»t«^. nt in the rviuoval from the hce of liuf^ 
I Ikat k>r* oeODMltuiu «>tli the Ibm* of tbc ^kull ; frani lear. or rrum 
tW aaw of a«mwt d«fimnoD iom nhich tbc iiaiieut had pieviuu^lv fa)l«n, 
biBi i>i fr«) tbc indiMticc ul' Hii u|>«ralioii dUpM|Kirtioi»iioly to iu 
TbtBe TRnMl» eflecto of »hook luire. h>iwi>ver. been much l«bneu«d 
■frtthitici Kara brcti geo«raU_v adminutered in 0|>eraiiv« nirgvry. 
<liMM, huwrwr, doee not ranuve tbc uhysit-ul imprMsiun praducM on 
fhatfmmt by » aervre mutibilioD ; h«n<.'e tii« iiiHueiice of a scnoui and pro- 
hammi opMstion U lUll iiiKtiil«»ied in lh« pniductioo of ahock, uf oollaptie, 
mt^ diw ntntny. «re« thou];h the puiivui have suffered do actual pKiD. 
tenia OfMmliuoa appear tii vxtreiM « peculiar, depreeaiiig efl«ct od the 
■tfviaiM qnun, »t«« thougli ii<> paio be experienced. TbuB, in castration, 
ai tb* mofmttnof ii»e divuiou ot the ft]><>nnaiic cutd, the |>ul»e will sink 
maikmiij, «Taa tbouch (he Miieiit have l>eeii fully ani«Mbeti»»l. :xi much 
■ lU> tM CMC, that u ift weA at that uuineut tu aiupend the adminitiuatioD 

•, wiibout any tangible local or {-nDstitutional disease, b ao 
cataa of daaik afW Mvere upurntiuiu : u)«n: uarucularly in deli* 
s. in IMitc or i)t^ilitai«d nibjvctx. iu tbi^r uho hare loM tuuch 
Usad. or vhu bava become ncakmfxl by pnitrncte^l suppuration. A larfc« 
MBbarof tbc i]«atfaa fiimerly rccordwl a» ilue li> i'xhnit>li<>ii were duulitUva 
iha aAct of (Iut poooninft ih>m ihe alHor]>ltun uf putrid iuatt«r from 
and inipi-rfn-llr draiiHi) wrouiida. 

r. if Tcry copiMi*. way dcatltty the paiient br inducing syncope 



1MB aav ba iaUMdiaiely Atal ; or by iocrtaain^ Ibi.- influvnco of the *Jiock 
• thai W «WUWI nlly ; ur. by w<{aki.-iiin^ him luid luircring hi* vitality, il 



kin nun tiablr Iv !»■ airirittil by imhT^iltby inflaiomntiuus and 
Md« ft a t ^ ia , abicfa fraqueatly tentiinntc finally. 

Danqc tkt parthr n anMe of an operatiou, bvukurrhag* should, as much as 
palbia ba piwraBtad ; the operation it«elf ii a i-aiise of dapranion, an<l any 
OaM km M Umd tujoaaly anrrBvnlea this. It ia in tbooo aacondary and 
Mnrt iAali that the ifrtmi daiiurr uf i<xoeauv« henwrrhagc li«s. Blood ie 
a Way wplai fluid ; if ouce hutt it h nut easily replaci-d, more Mpccially in 
ailiauff ynan. At any period of life, lis excMaive hies may {)«rDaDeat)y 
^tjmlr ihv i<>a*iituititnal powen. Paiieuia who haT« lost much blood make 
tk^ -a ioirrru(itcd by ioiereurrrat diseases; and not unfre* 

i^Mau. -■. - (md uf iwu ur tJiree we^^ka. from some visceral coiuplicn- 

la^ In fact, it is in this way. raiber than Irom its immediately daut^roun 
a^aa^aaocM, that lh« h>« of a larj^ quantity of blocMJ al an oiwratixn 
favna iajttriuM* tu tbr [wtjrnt. Wboi lM!inurrluu:e occur> a few houra. or a 
4rr --r — -frwan opcrali'iu, it umaUr proiwdii fiwm ini|>erfeci ligature 
rf iK' -r fniffi artfiri4» hlrxtlini: afttr the settiii|{ iu of rt^actiou. which 

kmi Dt>t lurnisbad blood whitH the pattetii was under the inllucnce of the 
tkadt of tba opsraiion. l>a raeovary from aiue«th«Ma abo, it iMt unfiv- 
«M*iy bappana that arlrriea be^n to upout, which yielded little or no 
flami vhiM tba fAtirai was in a tlalc of anmilMsia. Iu these eircuni- 
WHBai^ ?naMiilhs|(.ii IS "f far io* ammcnl, and low frequeuily fatiil. than 
•h^itdiBUaai a Uirr |ioriod, iu mn*ec|acn<w of snini; morbid iiiuijilinn 
^ th* vooail, ami Av|««atly in associaiinu with local diflliso inOanuuatioa 
' ialadi** pr ac w a ta . 
t m Mt a <Mnn>nii cauM of daatli alU-r oiwtaiions, exci^pt in ilif 
, ' tortm la uilltarv pmetiea in tlni« of war. When it <>i.-«ur« iu 

h)«fHtaI practior. it is titc nwult. in m<at casiw, of faulty Ixit prrvnita- 
Wa l^yfMue OiiDditiooi : and ii* lj«•(uen<^>' iu any iuiUtut'ioti is the direct 




UEHKRAL REVARK9 OH OPSIt ATIOWS. 



i»iti«iil» Ir- |>iit into clfnu. we 11- ventilated wards. Tliat all inciinil>lc U 
infiKtious caww, and 4»|]ecially chrouicnlly ulcerated Ifgt, he rQfixH.nl adiui 
sioD. Thai oHeuiivc, gaii;>ri^nuus, and [lutrid soras be placnl in diaUU 
cooniR, and out iiilTurt-d to iiile>ot u wholi- nard. Thai ikere aliould bo pa 
ticular ruuins prnvided for fiatieDls who linve uudeifOtW o|)erBlioaa; thi 
ibcf flbould be airv, Duver lung lolisbilvd, aad al\erwsrds cleuiaecl an 
veutilated. That a liottpiUil sbnuld Dever be oruwded ^n ani/ aeeouul, au 
alwavB M> laqje tbat a )»tn lany bv uninhiibiit^d. That the wiudows li 
ujsened tar a cenaici iiutubcr of buurs duilv. And liully, (bat every buaptU 
aliould bare it " Kouni- in the »tutiiry,'' in oiber words, a " coovaleMwt 
bouie." utiucbed lu it. Jludtiru scitMioe bail eitablcd in to dctermliM ill 
tmt! unlure uf thoM condttiuDH that bad Id li<)«>tmal tnrrciiou, but nnitu 

rctive hiu nut yet gone in Hilvnii<-<; of the utltiiinible i>recepta laid dow 
Alaii»>j|i a eeiiiurv ap>. 

Tbi-- nturtidily iirianiic rroin inntUntion to ihvKe varinuii hygienic couiU 
tioiiH, whether waut of deuiitiiiMi ia the wound or want <if pur^ air in tb 
wiinl, ift not a iiecnutity til' the «|MTation, but rwv* and I'lilU nvcordijig a* tb 
trwilitM-ul ul' the wuunili, »r ihe eimiiiisUDcea in whii.-h ibe paticat I 
piaoed, depart more «r Irm widnlv from thoM cuOdilioii* that Arc OCCCMW, 
tti ihv imiiuU'Duuwof hcAJtii. Tfi« frf^uency of tbo occurrenocof crysipaU 
iu an iiMiliilion niay b« taken M lui ii»licati«ii »f nwleci in its Mntui} 
iirning«incnij>. I'yn-niia and MpticiMnia aa a rule indicate, io addiltoD u 
gUH'ml iH-gltvt, a wunl of cJcunliiKw in the wounds, and rellcct lu a oortail 
«xt«nt u]>iMi ihc SnrgHon ai wvll a« the inelilutton. TlicM disoBMB ara prl 
veiitablv. nnd ought to be pr«veintvd. purely the first atid rant uaMolitj 
n<|Utaitv ul' a hvapitnl ia tliat it be not a M>nn% of diMuiM' to it* ianalaa-4 
that tliom^ who are Citupellotl to seek itB aid shall not suffiir froiD its €fi)>cu.| 

The ex[)ociiri> of a pntictit after an operation to the e^ntayiotu ema/iaticM 
of Mpii« diaeatea tnia other uck or wounded patienio, is attended by tM 
moM ftial oomeqacneei. Wbencrer it u practicable, every eaoe <>f te^ut 
diwaee such ai pyieniia, eryBi[w]iid. inflamed uliMirbeula or reins, or iKMiiita) 
gangrene, Hbuuld Im rigor^tualy excluded from the wan) ur room in wliid) 
other palienia wiib operaiiou-wuuudii happen (•■ l>e lying ; and, if pu«lbl<| 
the tame ouran, drewen, or Hurgeona abould not Imt alloa-ed to go frooi tfal 
infected to the healthy, nor ahouTd the »atuc appltancea. dreaalnga, or ap 
be ummI for both. 

When ihiit is not poasible, the danger of ioferiion may b« greatly dinu 
i«bed br the free use of ajiiifti'ptin to tbe iruunda bulb of llie infected 
the healthy. 

Great ear* al»o riiouM be taken in lli« purification of the 
luu been iiwd by giatienl* nuirvring from Mplie di*ca»o; i1k' blanli 
ally are a[>t to harbor itifccii<Mi long, and must bo tboroii'.''~' 
Kvery biMpital Surgui>n niiui havo hiul abundant oocaaion I' 
dontlii after otieraiiun, arwng froin proventablu enuMa dii' ' 
lixn l>> iheM unple precaution*. 

3. The Bpeoial CoaditioBS direetly axelted by tbe Opari 
dbpvMtl to by ihr dnuiiiHtancM that nc havit iiiit t>rwB 
which commonly b-jid I'l a fatal riiiult. uf KhiL-b (hajr 
M-caii»ti, are tliv foUnwing: ?rh<)ck, Kxliauttinn, 
Tctaaiu, Pyivniia, S«ptic:>-niia. Krysipr tutd utbiT 
Th«M cmuM of <lent)i ar>' -u varif 
ewM. that I iiliiill do littlu 
reader to the dilliTcut cha|>i 
•|M-r-ially treated. 

The fSutct o/ ait 




48 



OBIfERAL REMARKS OK OPKRATIONS. 



iiifn»in' ijf. mill of iUelf a coDcluiiri; j>raof of. u«-f;l<.-c1«-il ur iK'Hirlivt- mQ 
Inry nrrangrmpiile. In the local rurni it Duiy, howvTcr, ocxrur withoul brin 
lti« rc»uU of u vant of Iir^^iciik- prfR-aiiliitns. from purely loml conilitioni 
as in n limb from exo(.>iFive iruumalic riulcnce, or in ■ i>trnn|;iilftU-il hvrni 
ID coitf«<iueucr of nroloujted »lninKulatiun of lti« ptt lwf<irc op«-nilii>n. 

IWoHw but rarely occaaiuiu death nfter o|>eratioDH in this (.'ouutry. Wbn 
it dum occur, it a mon fi«qu«ntly a(l«r ihe Itsitcr Iban afW tli« f;iTiil« 
opcnttioDs that it (levelops iteelf. 

intfntal Jnfiajninatimt* of ao Bcuttt and actiw character may carry 'ttTliii 
|>aticnt after an operation in two uays. Inflammatinii uf this kind may bavi 
existed anteoedently to ihu i>t>eniti»u, bcin;; ilu' diiteaNe for nhicli it v* |<*-r 
foriued; and, b«ioK iiuebM'k^l l>v the o)tcrauoii, may couiiduu its cotirw aD< 
tieetroy life. Ttiu«, ulivn ii cliiM Ait» after tracheotomy for v'rtwi>, d«mtli ii 
Dot in K<^neml ooi-iuioiiul liv the operatiuu. Ixit by the exloiisiou into titi 
lun^fn <il the diaeaiM' for nbioli It litu l>etu (wrforrtivd. Or the in flam mat ion 
may l>e tbe e»i)H.-ituen<-eiif the>>[icrati(>ii: lut when fH-Hu initio occur» al\ertlH 
operaiiim for slnui^iihilnl bfrniti, or meDiui^ttU iilVr th« skull hus beu 
tre|ihiucd. But it i« D<il by tlx' action of any of itirw dii«ct results tliui an 
uperaii<m UMially pr»vi's Intal. In the vreat majoritv of ini>tBueti), dcslh ii 
occoaioued Id a ni'in? iiidin-^'t mniini-r by the devtilopmcnt of pyietnic uf 
ery«i|<vlHtuui iiiflainmations, lo wbtcb n neglect of liygicDio btwi acu aa a 



powerful i)re<lt*f>oaiDg mUM. 
S^ie aiMam; in on 



OIK or othrr of its formv, wiu coruiiily th« moM ftrntuetit 
I of death aftor opemiioni^. more piirlieularly in largn towiu. ('Iiwly 
allied to pyemia and wpticwmta, freiju<'ullv (^wxi«ting with them, and bnviiiij; 
the MiDO preitlapwing eauMS, are the vano4i» 4iffu*'- in^umwition*. ulK'tlirr 
aatuming tbt' fonu of erysipelaa, of phlolMti«, nr of indnmnuttiop of iIm 
abaorhentfl, which are the dread of surgeona and tlic scourge of lioepitalk 
It was to pya'iuiu. mid !•■ these viiriiiua allied procn««s tlial at loaM lhf«^ 
fourths of the deaths ader npenttions were formerly due. Thi« proportion 
boa, however, he«D j;reiillv reilii(^>d uf Inte years by improved loataods of 
IreMiiiK wounds, ami yrvnter aileoiion to the Mnitary anangcmeata of our 
hoapitala. It is in the pruluciion of yhesn di<<-ikse« that an impure blood, 
kaoed with elTete m«teriah>, n--iaiunl throuKh habitual disregard of tlw 
ortlinaiy rules of health or ihrouifb defeetive eliniinalioD by the Kidney* and' 
■kin, acta aa a potent pre<dit]i<>«iii^ cuuk. Id tbeae circtintMancea. it is not 
llw exteni of uie wound that detenuin** the daneeroaa reaults. A mere 
brtneh of Aurbce, however trivial, in nufficieni to fonn a Hartiof^point for 
iJieae morbid proccMe*. lu Mich condiiioua of the lyMeni, the amputation 
of A too tnajr tw aa fiital a« tluil of the thigh, or ih« removal of a small 
aihoroDiMoiM cjrtl of dw M»lp aa the ablation of the breast; the only atldi- 
lional dao^ eaaoottnllT conn«>cte)l with lb« greater operation! bdng Uta 
inoroaaeil risk fKmi t\t»c\t and hi^aiorrhage. 

rHjAlheritif Iiillamm'ition may develop IB a wound with or without eon* 
euniilanl thrnat-atK-ition. It may bedcrdoped by direct contagion, or under 
the influence of thnw local enidcfuiea or eooMilatioiuil influ(<Doni that chum 
diphtberia lo apiKiir in (he fauoee. Wbea a wound bccom** alti-cUHl io ihie 
war, iha edgea and th» inle^iment for »»me littlv distaiica around ara 
iwullon, bnwDv, and of a d<<ei> n-d color; the Rurfoce of the wound m cuv 
end wilb a cravi*h-nliite<'xu<liiti->n nhieh eannol Iw cleaned off; ond fohrila 
qrinplniM of a low tyiw tievelojt themH'lvee. 



rRKPABATIOK rOK Ol'BItATION. 



49 



ntSTAILKTimt yuK ul-l:tlATI(iy. 

Tb> S n r g t M O. bctnc eniTiiiiwcl nf iln' nei^naiir uf Itariu^ rfciurM to nn 
MniMB, tlMNiid fully kod unftswrvaliv Iii)' U'luri' liU fmiii-iit lint stnto a( 
ih- —.— — • if tii! C BM * fr. give iIh- ntunus tliiit rcmJcr it ifuiwnitivt>, in 
n liM oonM-ni tiii<l iliiit cil' hii tkinily. Id tlio event of thv m- 
ljif: rviumiiij ti) ■uhniil, what iiounir should iho Surevon [>ur«iK'7 Iti tnts 
W rat bo (uidMJ iwrllv bv Ui<- Daltirp of the |mi]MiM'il i^prrulion, atid partly 
bt ilMMtl* iirih«p«tic»t. unit hi«capnbilit)'of fonaing k oorreci judgincnt 
H U« CH>. IT tli« 0fwrali<>4) \n- oo« of cxp^itiooc^, inrMv fur the i«Ti«f of 
aiaCcauty •>( thr rrnwviil ufan iiilnH-tit wbtch don not itirvctl y J4>o[itirdiu 
fk BOM cvftaiuly du Surgr»ii would tliiiik of iindrrtaking it without lli« 
Ml c^Mant of bb |wxkol. If, mi (lir oiIkt luiuil, !t W nn opcrntioD tbM is 
{■fMBtiTaly neci— ry for tlM> pn-ecrvuion of lilV. jn wbivh thf delay of a 
^m mIboIo or boan may bo dial lo the pmicnt, il* id oho uf ihv har cases 
if attrana torntal urgnocy. vix., datigrriHi- liciDurrbngv. luphyiia, over- 
Aandod bladtwr. or auanplUmt hemia, nixl irhcrv the paticol, unawaro 
^ ar iB(S{«ihl« of bcifif; nuuk' to underetand, tho npocsBitv for immediate 
•rtwB. b <ia«illin|[ tuaasHit to the propi-ianl. tho >S«irgvon will truly be placed 
kadilcaunaof aaxittUi rapoosibility— betwoen allowing tho patieut to Akll 
a McriSea lo hi* ofasUDsoy. ignorance, or timidity, aiid attompiiD};. perliau 
aaaMDmdblly. lo rcacae htm without his own coDsetil frMo iiM^vilable deau. 
I haliiTi (Im pro|N-r courae for the Sur|i«on to pursue under mch circum- 
Obom ia lo judxv for the patioii in a matter on which he is clearly unable 
to ft«m aa opiaioa, aod I" oxnpel bini. so far aa b legal aud practicable, tu 
■bait to Um nacMBBrT utrpi r»f the proerration of his life, »r t» |nit him 
mJh •HMtbada. uii, whvti he i* UDContdoua, to pcrfurm aiiv operation 
ifcaC any be nitiawry. In tho ovent of the patient beins ioMudW, aa after 
^ iBfnrT uf Uw bvml, tlve SiirgeiKi must nMMHrilr take upoo hlnwelf to 
set ■• tiMr caa* rrauim. Ofaildrra cannot l<c roiM>idiTr<l rapablc of giving 
a» Bf*at«« aa to ibc pnrpri*-iT of an uprmtii>ii ; the (-ouxut of lh« parents is 
bat* airaaa m. aod t|utir ■mAcicnt : nni), in ihvir Blwti(.i-, (bo caM Utiug aa 
ar^iM oa«>. tM >or](«tKi ntiMt ftartil in toco parentU, and take all rgaponai- 
UUt upr« himaalt 

T&ur piiiMa bavinx Iwpd drU-niiincd. the patient «]toiild, if poniblc, be 
IS't / m r mtfitr Aa Optrtti^n. In a great number of csms r<v]uiring operalMO, 
aa ■tfrnBgulaical brraia, bud coiupiund fracture, etc, no liuiv ie ullowcd for 
p(«|MrWwB. but tba Sat<p»ta aiust at once mlxDit the palit-ut lu tlie knife, 

«b«t' ''- ilal*' nf hb roustitulion may b*-. Hut in tlio ntore cbntnie 

^^- L,-ivrD fur improving itie constitution. Thb preparaiiou must 

MS nu>»i 111 any nmiioL* «Tiileui of puf);iug and starving, wliicli is ill cal- 
ralaled tu auppiirt ibe RKMitutiim ngniiint the c-all ihnl will be made upon 
>; uw, oe the oiher band, in blindly adojHiug a tunic or stimnlating 
b«tt in ailapttng tiur nwana to tho cuuditinn of the pMknt and the 
F ft thr oprrstmt lu be pwfbrmrtl, Tbr tiodeuoj lit erysipeUa, pyemia, 
tmi Aflbw lattaoiMatkBa pnemlly, b niatrrially Inaencd by supporting the 
fMliM'aaUe^tUi, braKUaof a nutritious diot, pn-viuunly tu tbeperfomiance 
tt Iba UftsatiuM- ladscd. in nuuiy of the morr •r\-i'r>- iujuriea and surgical 
tmmmK it m only by ibe use of a nulritiout din, luxl by thi- adminisiraiioa 
if msiaa, q«iaia«, or Iroo, and stiinulnut*. nl'ii-u in largv (luauiitie^ tiinl the 
mtimt tBB be bnvgfat laio a candiiion t*> t>r«r the soodi and eonstquent 
mftmmkm of tb« opetstian. Tbb is mere [lanicularlv tbo case with hcapllal 
Mttiaats of Wd eoastlluiion. who have nict wiib «orioutt acridcoU, ft^lUived 
9j iwiih Hppnntjutt and tevet, la the mon: chrooic caMS, the linic should 

Tirt-L— « 



46 



UKNKRAL REUABKa OK OPBRA1 



putieuU be put tiilo clean, ux-ll>vetitilaiLil war<ls. Ttial all iaaunble no 
infectious cues, aotl aijircuill}' i-tiroiii cully iiloerstod l<^p>, be refiiito<l adiuii 
■ion. Tlint ufleiiMve, j:au|jreii>itii>. nml [iutri<l wre^ Im.- placed iu <IUtiu< 
rooioa, and uot HuHcrttTui mrvct a wlndtr «urd. Ttiai thvre stiould lie |«i 
[ioular nioRis provided tor jiattoiitH whu have undergooe upeniiioiu; tba 
llwy xliuuld l>e uiry, uvver \iag inlinbilcd, nitd al\(?rw»r()9 i-lMUoed aot 
vrutilated. Tlitil a liuxpital Khoiiid iwvcr Iw erundi-d vn any oMoiiiif, an< 
■Iwavi io litrgc tlmt ii [mtt may Iw uiiinliabiM. TImt ibv wiodowi bl 
OlMUvd fur a cvrlitiu nimilicr nf Ituun dnilv. And laHtly, titut t-very l>(«|>iUi 
•boald liftvf a "liuiive in lliv rouiitry.*' iu uilxn- wonU, a " convalasMra 
lioiuc," iittacbciil to it. Mixluni ncicncw Kiia enabled ua lo deU-riuini; tb( 
irue uaturv of t)i<wc condiiiuus thm le«l to hostiiuil infection. Uut Mnitar] 

Eracticv liBfi not Ti-i goav in adranM of the lamiralilc preovpu bid du«( 
y AInDKuii II cvDturv ago. 

TIh- inortnlitj: ariHiu); frtmi iuattciition to thmc various bypenic cuodli 
tioiif, wWtlior want »f clMuilinoa in tbo nonnd ur uant uf pnrv air in tlW 
wurd, i« nut a ncvttnty of tlw ofwratton, hut riM-» and lall* aowrdin^ as th4 
In-Dinirnt «f lh« VMinds, or tho circa insian<.-vs in whicb tin- i«licnl i| 
pliii-ml. dc|«n ntore or icM witlclv from thnm tx>Aditiuua tliai arw nccnMiry 
tu (hi- niainluiHiicv of hc«](b. Tfio frequency of tha oocum-no.-: of cry»]wliit 
ill UD inHiitutiuu may bo taken b« an indication of iMsi^cct in its tnnilary 
■rrWigMDOaU. Pyiemia and wptiocmia as a rule indicate, in addition u 
l^vncnil ii(>|{l«ot. A want of tlcanlinns in iho vouudt. and rvlkot to a ocrtuiM 
vxtnit npiin tbc burgeon tu well as the instilulion. Tfaese dJs«WM ara pnj 
vcntalilc and outtht to be prevcoted. Surely the first and otoat csMitJu 
requisite uf a hospital b that il be not a onuree of discuc to its inniniia-4 
tbiit ibuee vbo are compelled lo seek its aid sliall not sufier from its etfecta. i 

Tbe exposure of a pslieDl after an operation to the eonlayiouM emuNaliimi 
of septic diseases froiu otber sick or uoiiuded i^miteut*, is attended by tlM| 
nioM (atal tHMMeqiiescea. Wben«ver it i^ practicable, everjr caw of seplii^ 
disease sudi as pyiunia, er\-sijH;laii, iuilanivd absorbents or veins, or hospital) 
jpiniiiTeDe, sboulil be n){ori>uily i-xrlndnl from tlte vranl (ir room in wniekj 
utbtrr patirut0 with opcntion-wonndii hapjH'n U) b« lyinic : and, if iMaiibl^l 
(ht Mint; uur»Ri, drraaera. or sitrmoun whuuld nut be allowed to i^o firuoi tbi 
Infvcteii ii> the lienlthy, nor should tho same ai>pliauc», draalnga, or spoi 
be u.fcl liir Wb. 

Vi'hfu ibin t* not pMslblo, tho danger ol' iiili.-«ttoD nay bo greatly dtiniu>{ 
bbol by tbe free UM of •oibopUcs to the wounds both of the ia6eot<id and} 
the bi-dihy. 

Great care also should Im> taken in the purification of the bedding '■ 
has been um-d by )wti«ut# suffering from eoptic disease ; the blankoti m 
ally arr apt to harbor iu&ctioa Hug. and must be thornugbly pui 
Every hoapital 6uiv«un must bava had abundant occasioti to dupUmi i 
deiiili* nller uiwmtiuD, arising from prvventablo causes due to want of i 
liou to ibmr tiiniulo prixautiotu. 

:i. TIk- Speoial Conditioaa directly excit«d by the Operation Itaelt pro-^ 
di*|Ki«ei| Iu by the fircuinstanoea that ne have just been ooH>idorint', and 
vhtch comiuoaly lead to a &tal result, of uhiuh they are the ioiOMdiatc 
oocasjon, are the fullowiog: Shock. Exbauatiun. llcoiorrhoget GangreiMt 
Trunua, PyiMata, Kepiien-mia, Erysipelas, and other DiUbse uittanimatioiH. 
TbrM cause* uf death an> so various, and contpiise so many distinct die- 
eases, that I (ball do little more here than nientlou them; rvlVrriog the 
reader to (l>e dilK'rrut cbajiicn iu tbe body of tbe work, in which each to 
e|K'cinlly trtated. 

The tSuxi Iff nil OpentioH may prove Inlal in various wars: fixKo tl 



CADSX3 or DEATH AFTER OfERATIOX. 



47 



MvertlT of th« muulfttioo. uit in a caae of double ainputatioii ; frnni the 
UCTV1U9 cmtrca beiug iuplicnted, as in ibe removal from the itice of ]ar^ 
uiiii'>r» tfani have i-otiucvtums willi tlie base of iht^ flkull ; from fear, or from 
the tuie iif nervoun di^pr^^ioii itit'> which the patient had previously folleu, 
rau^iij; him lo f<«l the tiifluennt of an o])eratiuii dispruportioDately to ils 
«rity. These vcriuut eflwu of ahock ]iave, iinwever, beeu much lessened 

iM noaMhetiM have been geaerally KdniiiiiMered iu o|>erative 8ur|^ry. 
Ananiicau, hi>wi(rviT. d<K4 not remove Ihe physical imprenivu produced od 
ibe djfMctu by a H-wn- iiiiiMlaliuii ; henc« the influence of a serioUH and pro- 
laosnl opi-mttoD u fUW iiinm{<vtvi in ilvv production of ahotk, of collapee, 
axtaitt •low n-oovor>'. even lli<Hi;;h ihn patient Imve eutfi^red no actual pain. 
I > rain Dfieratiua« npjKtir to I'si-rciiu it [iiTiiliur, dfjuvBrriut; eifect on the 
ii'^rv.iuft tyMrjn, ev-n though Dn iiidu hv i::i]it^rienL'ed. Thus, in cafltration. 
ai xhn luonivDt uf tile division <>t* thr n|>ermniic curd, the pul«« nil! sink 
marlccdly. cvcD th<Mich the palii-ut have b«a fully «na»th«tj«ed. 80 much 
m tbb tli'e rwt. that il i« well At (hat inomvnl to ftuspeud the a<lminL»i,raiioa 
i4 tlM' aa4mbe(ic 

Ei^ttMioH. H'itiK*Ut any tangible local ur coiiMitutioual disea^, ia an 
■vnMiunal cause of death atlcr xcvcre ppvraltou)! ; mure iiai-tioularly iu deli- 
cai« frroalvs. iu fi->.'bl(- or dej>ililat«d »ubj«ct«. iu [hu«e mtio have lost much 
blooil. ur who have bcvoniv iteakt-nvu) by prolract^sl xujipuration. A large 
aumber of the deaths formerly rcconlcl n.* due to exhaualimi were doubtleas 
lilt <MkI of flow |>oi(>onii]); lin>ni the absoqition of putrid matter firom 
"M**— " and imiHTlK-tly dniincd wwnidii. 

Btmorritagr, if very copious, may dwlmy ihc patient tiy iuduciug syuoojie 
tiiat raav l>o imtuediatcly fatal ; or by incrv-aain^ the iuHuenc^ of the ehot-k 
• I that be catinot rally ; or, by weakening him and ImvirririK bin vitality, it 
may rctider him more liable to be alTcctcd by unli(raltliy iunamniatiuus and 
Mptiv iip>ces»ce, which frefjuculty terminate fatally. 

Dunu^ the performance of an operation, hemorrhage ahould, as mudi aa 
poniblr oe prevented ; iJm operation itecif ie a cauH: of depresiioD, and any 
mat loMB of blood aeriously ^sravatcs this. It \» in theu wcondary and 
mUknei edeets that tJie (freat dauber of excenivc hemorrhage liw. Blood is 
a Terr complex fluid ; if once Icet it is notumly replaced, more eopeeially in 
advanced years. At any period of life, lis cxurwive Itiw may pcrmnuciitly 
impair tbe oinstilutional' powers I'atienis who haw lost much blood nwk« 
•low recoveries, oAen interrupted by intercurrent diseases; and not unfrv 
qaently die nt the end of two or three weeks, from oume vitKeral complica- 
Uoo. In foct, it is in tbis way, rather than from it» immcllatcly dangt-rous 
ciMMcqueocea. tJtat the loas of a large quantity of hhxid at an oiwration 
pnrcM injuriuiia to the {latieul. When hemorrluiEe occura a few houre, i>r a 
li. <r two, aAer HI) openitiou.it u§ually proceed? from imperfect ligatun! 
M vessela, or I'mru arterita iileediugaOer the setting in of reactiou, which 
liail not furniahed bhiod whilst the patient was under the inlluencR of the 
ihvck of the o{>eratiun. On recovery from anwsthesia aluo, it not unfre- 
qaantly happens that arterits begin to spout, which yielded little or uu 
Uoud whilat the patient waa iu a state of anmitbesla. Iu theae circum- 

iic«. hemorrhage is of far Igm moment, and lefs frc<|iienilv faul, than 
11 it iMWurs ut a later period, in cun8e<|Uence of sumo morbid condition 

■\.<: wound, Bwl fre<|ui-jitly in aosocialiou with local diHUiu; iutlammutiun 
■■ ^'iioraJ infective priHN-.-ncn. 

OnMrvite U not a conmioii cauin of ileath afler opcmtiona, except iu the 
pKiiL"-<'>'>iic form iu militarv practice in time of war. When It occurs iu 
., !inl practice, it is the result, in m-ul cases, of faultjr hut preventa- 

Ut i._.{j>wiic cumlilioiM; and its frei|iicncy in any institution ia the direct 




OEVERAL REUARES ON OPERATIO!(S. 



nxwMirc (if, KDil of itacif « mnduKive jirt»if uf, n^teetMl or <li-fr<;tiv-^ : 
Unr nrmi)gem«Dt». In tliu local ivnu it iiniy, hawovpr. owur niihiMit t: 
till* result of n want of hygienic- prm-HiitioOH, from purely loml coniliti->ni 
U In ■ limb fnini i-xctasivv traumutic vkik'noe. or in ii Ftrangiilniral liirmi 
in cunM-quuncv of pralon^eil sLranifulation of tbo (•ui before opervtioii. 

Tetanus but rarelT oocSMoas d«alli itfl«r ogic rat ions in this L-ounlry. Whr' 
(( (t«M0 occur, it ifl DMre fre(|u«iitly after ihv lutner tliau after tliv g'^'atc 
operaiione tlini it develops itactf. 

IfUeraal InfiammatioHt of an urate and active characlt^r may carry offtit 
paiicDl after an operation in iwn waya. [iiflammaiifHi of ihis kind may hav^ 
trxiMed aotNedently to the oneralioo, beiiij; ibo diaeaae for wbicb it i" jicr 
formed ; and, Ix'iui; uncht^ckei] bv the ti|i«rntii)|], miiv noalinue iu oourw ant 
dewroy life. TUuh, wbi-u u i^hilil di** after inieli«i>luiiiy for croup, deaib ii 
uiH iu Kcnenl ocouioikkI by tfa« operstimi. but by iheexten«ioa inio ili< 
lungs of the diseaae for whirb it liiis bcrii jwrfunued. Or lli« inflainmatiut 
may bo Itie mtiMKiuencL-iif tlie<>]H>rutii>u: uanbi^ii |ivfili>iiitiH ix-cun^ after ilii 
ofiervtiou fur Htraiiiiululol bmiin, or inirniiijiilis nftcr lliv ukull bs« b««ii 
tn-|>l)int:d. But it in am by tbc nviimi »f any of tlicw direct reanlts that ag 
OfXimtioii uirtiiilly [iniv» fatiil. In ibi.- {m-at iiiujoritr of in«ia»ct*, <leUh u 
OvcmintKtl in a miiri' indirrct maiiDrr by tb« di'vvlupiiK-nt of pynuio M 
eryniwlatouit iufliimmalion*. to wliidi an^leaof bygicnic Inm acl« •■ ■ 
[Kiwvrful iiRsliiipoHng cauac i 

Stplie tfUtate, in ouc or other of ibi form*, iriu ccriiunly iIm nwt tVvqutal 
ORUm; of d*:«th after o[ier«lioiM, nion.' particularly ii> lam town. (1uM-ly 
tllieil to pyKmia and nvjitiaiinia, frvquvnllv ciM-xiHing villi them, and baviog 
the mate prrdt* peeing cauM's. arc the vano*w difuAr in^imm-itioHi, ulH'thi-r 
■SMiniin^ thit form of erycipoliw, of ptikbilis, or of mflammution of tixi 
aburtMnts, which arc the dread of eur(t«o«H and ibe scourgo of hoapitalaj 
It VB« to pyiemia. and to tbeee vaiiuuB allied proc«■se^ ihat at l«iiM thrv«^ 
fourths of ilie deaths after operations were formerly due. Tliis proportionJ 
bas, however, l)een ^really reduoe.1 uf late years by improved mMnods of 
irmliiis wounds, and greater atiLUiiiio t« the Moilary arraogefBODtB of ouh 
faoepitala. It is iu the production uf ilieM di^easett that an impure blood,) 
Icttoed with eflet« materiah, retaincl through habitual disregard of tbsi 
ordinary nileaaf health or ihr<>u);h defective eJimiuation by tbeKtdneysand 
skin, acta aa a potent predinpoeiinij cnutie. In these circumaUuiOM, it ii not 
the extent uf Uie wound thut deienninea the daaeeroua results. A nwre 
breach of uirface, however trivial, is raflicient to farm a start ing- point f»r 
these morbid nrootaea. In sudi conditinns of the system, the ninputatiifo 
of a toe may M os fatal as that of the thigh, or thii rvmnval uf a unalll 
atlicronuitout oyM of tlw scalp n* the ablation of the brMUt; the only addi-4 
tlonal dan^r «MCtiltnllv ci>Dn4<ctvd with lli« grcMor operations being th*j 
iocrcaM^l riak front iiliiH-k and iM-inorrhagv. 

fHfJithrritir Jnflamiualion may develop in a wotind with or wElhout eon- 
mmitanl ibnialHimclioo. It may Iv di<Telo{>«<l by direct coala){i<in, or undof' 
the inlluence of thos* local epidvmics or oonsiituttoiial inflnonen that caw* 
diphtheria to kpfMar in th« wicea. When a wound bec<im«a aAbcted in this 
way. the «lg*» and the in tegument fur sumo little disiani'e anitind ar« 
swollen, brawny, amt uf a dit-p red i-<>lur: the nirfoce of the wound i» coV' 
ered with n (.'mvinh-nliitc cxuiliilinn which cannot l>e clenncil ulf; nnd fvbrll* 
■ynijitiiuis <•( u Ion ty[K- iU-vcloji thcmselvtc 



IBFAItATIOtr FOB OfSRATIOK. 



49 



rBETARATlOX FOK OPER.VTtOII. 

^» *^-:-~t l^r-;- - cnnvIooH of thv iienwitv "f having rerourec to mi 

*ai Ultnsicni'edlf lay bcli^rc lii# {Mtient tbe alnic of 
mm, ■u'l, II [ii<r"i«iry. givc the n-iuou* tlinl n-ii<lcT ii iinpemtivr, tn 
tu ttbotio Uu coiuH-nt *nd that of lit* fiiiiiiiy. In iIm! event of ibo pa- 
■vAwtag lofuljRiil, wliKt >>>ur*'- «h<iul<l liio ^rgeon puraoeT lu urn 
MbC b« gnwtoilpiirilv liy (lir nxlun- »f tlir pm|>omop(iratioa, ROd partly 
'WthcMklr"!' :>ii<Hitf c>|«bility uf fnnmng II oorred judffOKtit 

It km taam. 1 .-< ii Iw one of rxpt-ilit'Doy. nMrrvIv for ibe relief of 

a iairatilT or Uh- niuuvnl of ui nilmi-iit which doi-n tx'i lilrwtly je«|>«rdiie 
Bii, ant cwrtalaljr no HargeoD wixild think of utitli-nnking it without tbe 
Ml soBMBl of \m petKiit. If, on tbo other bao<t. it be ito opcralioo that la 
ivpVBtmly o t wry tor tbe prawrvMlioD of iilV. iii irhich the delay of a 
fr« ■JBDlCT w bourv may be faul to the {Mliont, as in oue of [he four cas«a 
ft extnotv Mf^ical arj^ncy, vix., d«n^en>4i- hfrnorrhagc, iisphyKiii, orer- 
4blmd«l bl«ddrr, or Mntnijulateil heruia, nod ii'ber« the jmlicnl, unaware 
i€, dr iooftjiablr uf tieiiit; made to under^laDd, the ncce^itv for immediate 
Mfha. i» nniilliri)[ til ■rni nl 111 thi nrnpuriiil, tin '•'iirfrnn will truly bt? placed 
m m ilitMnBta iif anxiuus ratpooaibility — betweeu allowiii;* the paiieol to bll 
awcnSc* tti ktt »b«inacj, ignorance, or timidity, and aitciiipiiD);, perhaue 
~>lly. Id reacue him without hia own coosent from iuevitaole deata. 
tb* {itnfier cnurM (or tbe 8urgeou lu jHireui- under weh circum- 
I ta to jwix^ for iIk patient in a mutter on which he ia cteatly unable 
upinloa, and r<> c>iii|k'I him. so far aa ia leeal and praciii-ablo, to 
. to ihm mc—arr lUpa for the preaerration of bia life, or to put him 
•aaMbrtiea. aM, when be i* unco<u«oa«^ to |K>rftirm aur opcnttioo 
iWt m^y be nmrnmrj. In the event of th« palicol b^ing iiuvuiildi.', a« after 
as iajarf wf Ibe kr«rf, the ^rgvon must Decnearilv t»kv upon hinwif to 
act ■■ thr ^ Children cannot bo conMdrred oapabtr uf giving 

aaopcBtna a* "•prirtr of an operation; the vonwnt of the parroie ia 

■rr. ami quiu auneient ; and, in their alwn<:<'. tbe case being nn 




«|Mt oa«-. lb« ^rj^eun tntiat atand in toeo poraUu, and take all raspona- 
hiSnr upw) hiaadf. 

J^M( •- <'<!• i<nvta|> be«n detertninrd, the pitticiit should, if ptxeible. b« 
A^par*' '^j^rolkMi. In a f;n.-at number of caws requiring operation, 

aa<(tmn|[ >!'»«■' •I'mta, bad compound fracture, etc., no tjmo i» allowed fi>r 
jmfmtiom. but th4i Mirgron must at once submit the patient to the knife, 
wbuww tha stair of faia coosiituiioii may be. Bui in the more chronie 
tima ta (ptren for iaiprovins tlie coiMitutioo. This prenaralion must 
i^M IB any rwtinc 4yMcm uf inirjiin^ and etarving, which is ill ad- 
I ta aspport tbe cooatitution acniuDt the- i-all that nil! be made upon 
t; »or, on ibe other hand. In blindly atli-pltQf a tunic or atimuluUng 
I : bat io adaptinj; our invaR* to the i-uuilittun of the pntient and iba 
MIWV ttt tha o ftnl i em tu bv perfurnMH], Tbv l<-iidriK-y Io erywpelaa, p^wmia, 
b4 ilUlbaa jemmi— llr«i grni-rally, ijt materially Uim-ned by aupporting the 
p a li a n t'a il W fib, bjr aawioa of a uutritiouidicl. jirrvi'Mi^ly tu the i>erfurm«nce 
*i Aa MpOTtina iBJawl. in many uf tlu* m<>n' •r\-u- injtiriii* aitd ttur(;ical 
^■Maai. it ia ofely by the uae uf a nntriiioua dUl, and by the admiDististico 
«/ kaio^ (|aiaiae. or truo. and iiimulnut*, oAta In larve •laantitica, iliai the 
til c»B be br^iugbt into a rundtttuii t» Uvr the xhoclc aitti cunM<|uitit 
luf ibr "frmi'in Tliia it Riurv particularlv the aue with huxpital 
MiM*laaf bad c- ■■. wl>o have nirt tritb acnoua acridenia. fuUu«ed 

W —ell avp|Mim<-'.. ^.'i ivver. In the muru chmnic caaM,lhe time •Ittmkl 

«•!. 1—4 



50 



GENERAL HKUARCS ON OI'BRATIONS. 



he w!mnJ for tin- opt'rnlion wlu-ti tin- tr iiiprmtiirf of tht- lioilv it ti<i( (no litgl 
vhtrn (br K-i-n-tioM iirc fnv, thi- luogui- t-lmi, biii) iIh' nctioii of llif* skin no 
LidticyA )i««iilrhf ; «od. HboTc all. the iiiiiiil fIkwIiJ bi- kcpl trai)((uil aa< 
lioprful, Itoitig ullowf^ to dwpll KB litllo u pueible upon tht; iinjK-tHlia 
eveDt. In inuir operations, kf Ihooe mi the rectum iind utiokry or|{sni, a 
Id thoM of n ploctii' clinrncter. »]>erinl luodcs of pr^pnmlion uri< ny|uire( 
which will be rlisLtiBsed whcti ne coniv to imtl of the uperntioas tu iletail. 
The 8iirgeoa himself must mlways feci tiie henvj rmpoiisibilitv that hui| 
oirer him iluriuK the perfonnaDoe of u great operaii>iii — "at tliat motncn 
when," as Dr. Grant hna elei^aiiily aai<l. " Death cvervMhere aurrounib bi 
knife us he i» eDdeiivuring to couvey nil hix konwledfi'' tu ita point." Bu 
hnviujt i-urefuUy (■•niittdenH) «acfa Mivcavivo iitep uf the upenttion, provide* 
for cvvry eni«riii^i>c-y that can by auy poudibilttv iiriM in ilu.' ci>urwG of il 
iiud tniAtiii); in Him, from nboui all knonrlt-d^'L- u dcrivi'd, to i>ir''ii;:l)i'-n bi 

t'lidiritK'Ut and ;,'uidi- hh band nriftbt. be hJII pnxN-i-d to the [HTl'iirmaiitv o 
ii» duty uith MvlfTFiisrice, and in tlw full confidfrDoo of being Mt to cAc 
ull itini Ah cau uix'uinpli^i. ^j 

laiPLOYMKNT OK AN,l»TlH:nQ*. ^1 

It is muonablc tn boliovo that tli« prevention of pain in siir^ml opera 
lioRi lins bccii nn object of mlicilHoe lo Sur^oiu, » «i-ll a» to {Mlicntt 
from the e»rli<vt ages; unit nan»(i«i of varioui> kiuds hnveal diflcreut lima 
been employed wilb this view. Hut the vScd of iheae «a> M aDcertai&— 
tli<-ir afler-conaeqaencc* |>^'haps so injuriotia— that no p«nAUl«Ol reliaOM 
waa pUced apon tlieni. The first endeavor tu iiiduee annatheeia by the 
inbalaiton of vapors is siaie<t to have been maile iu the tldrtevDlb rentuni 
by Theodurie, who rvcoromendwl that a "Spi>nt;)a ^k•muifl-^«," inipn^naled 
will) !ipiritiiMM extractii of variou* nnn-'>tic xulwtiuHi-s, ^luxdil be held l<> (lu 
DOMriU till 6lc«p vraa indumil; and lluil aOer tliv uperntion th<> patitrot 
should he Tuutu-'d by tlic iiae of vinoiiar or ftinu^n-i-k. Il wa* not, however, 
till tlw couimvucvmcnt of llii* ccnturv that niiv wriuu* alirni|>(a wero maili 
in tJiia direction. Tbf diwovery nf Ine ri.-iiiarknbli- pn>|M'riini exrrviied nH 
thvi nervoiit nynUn) by the iiihalatim uf nitrous oxidr, thrn h-d Kir Humphry 
Davy and othrr« to onlvrtiiin hoptw that it might be uaed u ft mtam M 
relieving! {laiti durin); nirgical opt-raltonf. Kxprrimanta win BMldo wtlU 
the L'li* mitb this view, hut tln-y did not pnivf altogether Mtislactory, and \xa 
aitmioi*! ration was al>«»doni.-<l. exrept as a m««i)s of nmitscment. 

It is nr«Mll«M to do more than nlluilr to such menm ns the romprMBioii of 
the nerves of the limb, as recvMiimemled hy Moor«^the employoKnt of 
exoenive veoWMtion, as adopted by Wanlro|>-— or lli« producttoa of itif^nsi- 
InlitT hy meamcrisni by Gsdaile aiw) others. Tlieae nieans of inducing 
aiinKthesia were cilhpr iiii-tficieDtt duftrom, or chinwrical. ~ 

It was not until 14^44 that a leriMia aUfiiopt was attain nuule to inlnidiicvi 
Inaeiiribilitr hy inlialalioit during up^ralioDs; and to the AnMricans is un- 
doabtedly due tl>e honor of havint; estahlixbed the practice of Anwsthesia 
Ib Siirserv. In ttiat year Horace Wells, a douliM of Hartford, Connecticut, 
inhaled tne nitrous oxide gas with a view of rond«rini; hintself inseosibU' 
duriujr the extraction of a tooth; and, finding the px|wrinienl sucveed, ro- 
pcaied it on several of his palieotM. l\a tuccesw was not, however, coikslant ; 
and having liiiled in several casiA, he Mftm* to have gi\-vn up the allempi. 
In 184ti Dr. Mortun, a d«nti»1, eud n impil nf Wells, uimh] th« vapor of ethcrj 
Instead of ihv nitrous oxide gat ; and, having MJcor«<l"d in extracting sererat' 
teeth paiulcMly, applied to the authoritii* of ilie MiuutrhuM-tt* (>«-nrmlj 
Hoapital at Bralou tor ]wruit>>iioii to admiutrtcr it to a nian from «hum Dr.l 






•• . ... ; ; 



^^^^ KHPLOTMENT OF AN ASTIt KT1C8. ol 

J.CL Wftrr^ wu kIviui lo ir-more n tumor of ilio neck. Tlic nsiili km 
■mC M0MMfbl. Tb(^ DPWi of tilt* iin-»t <)i>corery wiis imiiit'ilittU^lv m*!)! to 
Ba^nd. viMn- Utp 6r*t a|irmii'>n» <>M |uuicnt# iiii»»lht?lui.'<l by ihi- inbiilit- 
ifan of mWt wrrr pcTf<imi<-<l «l lli« Viiivcreitj t_'»lle]!<! fliifipiiiil bv Iji*loa. 
vW Mnputatnl n ibt^'d and loiv ixil an ini;niwiu;* toi^iinil wilhitut imy 
■■AnDp tu iW pnltcDl. At ibrHT ojH-rstioiu I hsb pravnt: ihvy ntri' prr- 
bfwd on Dec iM. iMG; and from tliut time llie iiw of ai>ic«ilictic* liiu 
hM« iKabluhttl io aargical practice in ov^rr civilited ciMinirj. 

Par MOii lima k vmr, Hulpfauric tihvr n-iis tbe odIv iit^ut babilnally uted 
few mdaeiBi! unHlbtsia. Bnt during the wb»le of lliiH p^Hud idhuv proAi- 
1 nrs wftr Inwr wiihc-sperimeula on iheaiiiuellieticinlluvncvot' vuriMis 
uf *«|i»r« ; »nii in Ni-veniWr. 1847. Prol'issDr Si<nj»uo. oI Kdinbgivti, 
'. sp MTiMut i>f tbe kDiMtlieik- pntjwrtien of chlurulbnn. Id i)ii» 
tUl McBl ■■■M mme to be tfeDLTully ernpluyt^, nllbou^b ctliiT hpjtl 
■ad viu tlw ABiericAD Hirmieuiis, by uocit uf wham it hn» alvrn}-)! bcca 
' tu cblurafttrni. 
IW ra(diirmrn1 of Aniedkfliai in Surjcen' ji undtniht^dly one of th« 
pwJirt Imdm iTcr roaferKMl u|*)d inatikiaif. Tn tlic pal»cut it U invnUi- 
•Ur la |M«miiB|; the ••rrum.-iiri; of puio, Bud to lb*> Sur^ia in mlii'viug 
hni fraa th» dbinw of inrticliiiK it. AnnMlinia in not. ht>«H>viT, iia un< 
■ixad maL Ktrry »^ai br n'hirli it i-nii lir indiii-c*) priH)itrr» a pnurrrful 
MffMiaB aa ibr iy*tcia, nod m.iy iH'L'Mii>ii iliingrrou* roiifc^urtKiv wbcu 
MB frrvlf >« cnrvlrwly t;ivpn ; Hiiil, ovi-ii witli every jmMiblo carp, it iipiMturs 
srlaifl that tfar inbalaltxn cif aiiy •Hii-»tbi'(ie ii^nii iii in Mine nuwa nimiMt 
luririMj fatAl. We runihit |>urc)iiiw.- immuiiily fr»m •iifTcrii))^ wiUimit 
muutiaf m rr"-'"- ■'■-•T«r of rt»k from tbr vrry b^iii wbieb giw« ui wwo. 
Tbart ^Ld (•■ ubl Ibnt mmiy of thv dt-iiih» that hive loDoued the 

■hsiuiafi «f io» bavf reaullvd from wniit of knowleilgc or of due 

an CM tbr I" ^ImioiMrttton; yet, whatever precimtioits Iw lAkeOi 

rvajnn ii< T'-^r ihttt a fiital nsaiilt miut oc«a«i<>iia)iy hap|)eii. This 
rkk, whii-h it very small, ia more than eoiuiUTbalauoiil hy (h« 
ikjr tram Other d«i{vr» vthidi lued forroeriy to ocrar durtn); opcn- 

IWrr >*. bnvrver. another quotioo in relation to Anit^rilhcticH whirb 

team tbv iei.iM Mrviin MOMderation on the put of tJie Surjj^mu. vix., Do 

thi>y tBll>*«inr ibc ratr itf tnortalitv nfler opera^oos? Od Ibia point tboro 

a "Tiflirffs; t/vtitn-inr. SimpA'ja ^tto [lubluhed Statistics to show tbnt lb« 

r operaioDi hai l<weo«d since the iittroductiuu of oliluriform. 

ibr (rtbrr hand, artdiicea fi^rra t« pmvc that it has nintennlly 

■mpatUMi hy 12. in litbotomy by as mneh (u 2S per eeou 1 

1- :u Uu J : > iMlirvc that the rate of mortnliiy han inorca^ed since the usa 

J AMTrtbeCica in ojifCNttve iiur)p.'ry. Rut i* this incnnM; allugetfaw, or 

■iti ' ■..:.•.. .)r ..... .\af tunny e(R>it prO"lM««l on the vyntem hy the inha* 

Isl*-' I* it not in rv-nlilv rnihcr the indirect than the 

Aivci ■•-"'> - ' <riaenl of .\na»t^irtio8? May it not. in some 

a^i^nv at I- - to opcnii'ins bdng ofVn iwrfurmoil in very 

4a«fclfttl or riiniai? r?urv<. now tliAt ihvy CAD be done pninltnly, wIk-h fur- 
■Hly tb« wnBaimf indietMl would linrr cli-tctrt:^) tbe Surma from proposing, 
« i1m pMiMrt IViio) B<y?nlin^ to. tb«-ir |>erf'iniinnee T A aitrgioU oprntUHi 
■a* famrty, froan the pnin aitendini.' ii, hxiki-d upoo na a more serious 
~ Id to isat tbr pnM'nt dar. fli- iit were not williii); to inflict 

_ aalaw tlirrv NOV a (00^ |ir > eucxHwrnl iwne. Now, how- 

r, thml ihf m«l trriuus operatiuni l'mi 1<i- |«'rforai(v) withont any eon- 
f( svftrinK, the dur^ioa, in bti unxieiy to ^ve lii» |utlienl a 
I ctf lUa, nmf Dot iiDfreqnently operate for ili)H.-iu<r or injury that would 




62 



OKNKnAl. REMARKS ON 0PKRATIOX8. 



otberwt«« neccwarily iiad tpcedily he faul, nuti whicli fnrtMrly would hm 
been Icfl wilbout nu Btlem)>l »t TcVwf. But th«rf id anoikrr cniiM thnt ma 
account for tlib iiicn.-aM-it rule of iiiorlHliiy. During tlii> ti»t thirty ymi 
alter tli« intrMluc-tioii ut AiiRwtlu-liiii, thv lu'ttinl uuitiFior of o)>«nilwoi p« 
formed in hoei|iitaii> ciiorniiHinly ition-nKil, pitilxilily in n grviil lucMura Dwin 
to their eiiiptDynM.-ii[. Huiicc li<«{>ili)l warJii tii.-ciiiiiv tiiurr onxtdiiJ ttin 
formerly with iwvcri- o[ii.-niti(>ti-ciiM'v. mid the catiar* of Ki-wic di«-iix 
became much more rlfo, ihoM- cli«i-n«« more frt'i|ii<-ni, ami tni- laonalil 
proponionntidy aiignK-Dto). At the pn«i-Dt time. oniDu li> im|>ruvvd trail 
ment of n'i>iiD<l». and liuttur Minilary arrangemenut, Uiv morUtlity aAa 
operation* i» Iowit itiaii it hiu wer been before. 

Making, howovi-r, i>ll tdkiwaiiec for tbc exteiksinn of n|)«rnlive Hurgvry I 
vxtrcnio rju>c* thiil wrrc formerly not tho«i|;bl to nime within iu rangp. 
cnDDol but think thnt chloroform dues exercise a uoiioue ioHurDrv uti tb 
const it4ittoR, and don leaecii the prcapeii of recovery In (vrinin ntain ii 
th« FyRtcni. more specially when the bluud u in on unhealthy rtali-. Il 
euch circtimstancen, the depreMioK inlluencc of chloroform u|>pciira to nir b 
net injuriously ; the patient does not rally wall after the operation, am 
imniiinilv from sufTeriii^ is purchmiioil by a leadened ehnnce of recuTery. 

AiuMtliefia b; th« Adminiitratioo of Chloroform ia beat comoM^tum 
before the ptttient leayea his bed. The chlorofurm ebould never be f^ra 
but by a jK^raou aocustoued to Ita use, and on irhuae capability the Surifeoi 
boa fiill roliaace ; as Dotliiog it mon cnibamMing duriug an upemiton ih&i 
to have any doubt about the obloraforw being proiwrly udmiuifctered. M 
mu«t not, liowevcr, be imagined that it cna he tafrly given uuly by i 
«pvciali»U Pivcry Mudeot Itcforo leaving tbc huopitiil may Miiity inaki 
himi«lf iiuffincntly ac()unintr<l nith the drtaiU of il» adminixtratiun U 
enable him to give it with perfect safety, provided he (loyn unilividrd 
attention to what he i» doiu;; and dote not allow lii» mind tu be divcrud 
by watching the o|>oralioo or by attempting to net both as anavthMiM and 
nwistanu Betorc administering any anieeihetic, the ]ntieni nbould hi 
naked if he ire»ra false teeth, and if »o ihey ehould be rcntnvi.'d. Atiy 
artkle of clothing about the neck, clieat, or waist, that might cnum^ inter 
fercDce with mplration or oireulniioD must be relaxed, and the piitieni 
tlH-n placed, if poeiible, in the recumbent poailioo. Cliloroform may li4 
adniini£tere<l in many diflVrent ways, either on lint or on a baudkerr-ble^ 
or through an inhaler of some kind. 11ie following ie the way in which 
chlorofurfo may moet safely be t!i^tti u« lint or a haixl kerchief, withuof 
ap|Miralug of any kind. On u piece of folded linl. ab-'U( three inobM 
si^uare, and confritting of three ilKuhlt^, »hi>ut a draehm of eblonifi'rm.il 
poured; aud the lint in thi-n held at a dUlnuce of about three ineliea from 
tlic noae of the patient, so as to permit a ver^- free admixture of air wiib 
the first few ionalalioiia of the vapor. Afivr ilic lapse of about half ^ 
Diinute, the lint ia brought umn^r to thi' palieul'» n<«e, lo within a dtUJUioa 
of perhajiN nn inch. Wing n<!Vi-r nllowiil fi to4ieh — for, ajMtrt from auj^ 
utlit-r dnnt;er. it mav hlixtrr the okln ; at tile ■aiuc limn a )>>iriiu* towel, uut 
doubled, in ligbtlv laid <>vi.-r the face of lh« paiietil and the hand of tlta 
oparBtor,aaaaio limit the (■•ea[>c of the chloroform va|Mr, tut not to pro 
vent tli« ailraiMion of air. During iIh- wbolo time, it u the duty of ilia 
admin 1*1 nil'>r to kivp hi« hand on the pul*e, lo watch tliu brvathtng, aiwl 
acfaiiniiHllr to examine the pupjln of the |i«tient. ^ 

The metlio>l iuit dtwcribeil ha« been shown by espcrionw to be ODO oif IM 
mu»t pmctically uwful mode* of adniinifttralion, and to be quite a« Bate as 
any other. A conimilleeof the Mc<lical and Chirurgical iSocielT of I^iudoii. 
which rvportwl on the adminiHtratioo of chloroform in iD&i, dctenuioea 



ADHIKfSTRATlON OF COLOKUKOItM. 



S3 




Ifaal 41 per eeoL ii tkff ntKiimum unoutit of IIm* v«|>or which cau safely be 
— =^-Td villi thv ftir ibf pnlimt iii)iiil<«. I^lir ha* thowa bv ex|)eritw>nt 
ibr imiponioti Ki*''o ■■')' frvm n fuMnI piccv of lint, xi»ed m abuve ile- 
f»r h*!"'" ihi». mkI iIht"' in ihrn-roru no nccemity for tlw me of 
■{»llr«t«H mtul iop-iiKiUK inhiili're whii-li hitvr Bi)iii«tiiD« be«D rocom- 
L ilr. Clovvr, l<> <ihi>iii wo iiro iiKlcUUil fur the tn<»i iii-ciiniEe mad 
ISe uf Unm Iwiniinruiii, UM<I it liini#i-lf nmny ihouMin<i« uf iin>M 
«itb»wt BO aceidrat of itoy kiod ; but tl i> highly |in)babl« that an enrvfa\ 
•adakilAil AS BiriBriiiiNrator wnuM hnv<- obiBinci] iv|tial1v (jood reiiulu luul 
W aad ncfvly • pircr i>f liut n» nixivix •K-scribeil. Whnierer leads lh« 
arfaniatnUer to ntr apon niiytbiti}: but vtin-fiil and coniiouotis ubservatioD 
•tf tb« 9jmf4ttmm (V thr fmticui if an <-vil in the ailnnu)»tralii>» of rliloro 
(«m. acid all lahatrn haw a t4-(i'ltticT to do ttiie. Tiie oiilv merit thai can 
b« rlaimnl ttr any Tmia vif inhaler is that tht niisiurp uf' cldorufxrm and 
MTprta ia of ooDMaiit ctrvngth. whereas irheit adoiiuntered on liut, lh« 
npnr ^iTS off b dmM tio««nol immediately ufler the lint hft6 bwn weltF<l 
wh tfca aaiw riw lif . aad Ki^u^Hy ((■■■'■■■■^'■m >" atr«n;^h an tlie mlminiN- 
tnlina aootiatMa. This may be obviated by tli« folluvrini; plan, vrhtuh u 
Mw rac— imt p dcd by Lister in the plaee of (lint tie formerly advocnt^d. 



F« 



cnriMr nr a ttillMi towel over the fn<.'e in xucb a way that the point 

iW chio : vfipJBitie the (orebead father up Ibe i<>«rel in ihniL' 'ir four 

aad, if aotMMiy, pus a pin through Ibem ; tlierv is thiis pnxlucet] 

It, which covers lolenilily ncvutaiely (he month itnd noae. 

in^ a dp>p or two of ehlorolorni to fall ii)>on it from a (lrop-l>oltle 



^^^^^^^IHr aroood*, (be i-rhtrnl iMirt is ki-pt i-iini<iantly wet over no area 
^^^^Bl IWtt itwhtv in dinmi-lrr. Ity lhi!> 
tnmglht»a ba<»ailT admini.-<(fr<-il. 



iwtt itwh«v in dinmrlrr. Ity lhi!> im-aiu n d«M- i>i practically coiutant 



TW prionpal piiiniji to Ih- aiu-nded to duriug the inhalation of this pmeot 
ar*. lliai it br not ^irm loo fltitdrnly. nor in too concentrated a tnTat; 
Ml. wbiUt under il« influviKV, the piilicnt Ik> not mise<J into the erect 
ar MUing p^Mtiuo. If lint W uni|. it may he too much saturated, and be 
haU tut> vloavly ap|tli(d to the imMilli and nustrits, bo that the jmiient roav 
ant b* aUa tu M aaArient air, aixl may sjiecdtly become partially ntphyxi- 
' * cbMkiaf; rmlMitly, ttrugglin); ti) );cl free, and beeomintr purple in the 
Ouv slwald t« taken not (o cnnpres« the abdoitit'D in holding tha 
i; fcr, as ll»e mpiraliou bevomni chiefly or wliolly diaphniitmntic, it 



mmiw br wtiaaaly inlnrtiplcd by aoy prestnre on the abdominal wall. 
W&iW cukdrr th' influencriif chlorofiirni the piitien* should nevi-r Iv raiMtl 
«|i, as baa joft liecn stxiH); for. ns thi-i u;^'tll •■xen-isrs a {Hiwcrful snliilive 
aalMs •■■ thr hran. Dudili-ti aiul perhiipa Iniul :<yn<vi|ie may toatM) from 
flli>| thv jmtinil into ihe erect |><«iii.iii, Ilrtiiv. alio, it la daBgemua tO 
—* — '—\talKt it in thnte opentii'n* that n'niiir*' to hi- iH'rfnninid whilst the 
iacm-t. It should never )>>' adniiojjlf reil, i-xw|i| in Cftaw of prcat 
.^ aer, tu ■ [latimt wlin ha* ralrn niiytlno); within ihrre nr fmir hours, 
■I wwrf yiNuitinit of the |«rlial]y di|;<-«t>-d im-al. On the other band, 
ikr |MliaM tboald not br rxhau*tr>l for wnni nf ('^i, n* may happen if the 
rf irtnril rarlv in lh»' mnriiing. Thu*. if !l.30 be the hour 
a cup of alrong bi-r^r-li-a. or a raw egg bealeo up in 
..^bl aud ■.■AJ'ily dii^lol noiifi«hni«nl at H.?IO o'clock. 
>, It (Bay h« nven w itb |N-rfr<-t ■>slrly to individuals of all 
-"-' ' n infant* Iret than a week old, at well as on octo- 
I'-p. In admini't'-nni; it to voiidr children. Snow 
'>ith f^-tiflrd spirit, hot tlii» is unnectasnry, 
■•(ration vary contideralily uiih difl^Kst patieatt. 
OlBMMwlly ibv jAtuDt bceoma* onooiucious as <}u»etlr a» in the natural 



•^Mwlieai h- 
ftntd. br >h 

tML. •< •■■■" 

WnJi ,i- 

1 



IWcAcUuf 



QKNKRAL RBUARKS ON OPEHATIOKS. 



procCM of g>]iii^ to f]ee[t. Mtire comiuouir ilio lint wnMilioii |iri>>lu«<-<) !> a 
neliag of wnnntli at ibe pit of tli« stoutmcli. This is roll'iw<.->l liy oni* 
choking wriicHtioD aud viok-ul b^Aliug uf lli« hviirt, wilh DoiAci iit tlx* bt-ix). 
Al this pvriod the raiient bvKiiit to lose wU'Uuntrol. lie tnlk* rxdlO(lly, 
but »i>l nbeoluiely iDoalier«nily, aud tli« fftniggliu;; wbicb t'n>qu«ttlly ultM 
|ilnco KMURica tli«! form of cflurU i» reovoire tbe chluroforni from hii fsor. ur 
hi <«:«|>e from lli« baiiiU of the Sur)tcon aud bin naoblanls. At thu iiiii« 
lira pul»e u (|ui<;kor »ud luore forctbtc ibaii nmura), tlic reepiration u biirriMl 
niid det'p, tliv pupil nc-lti rcadilv to liichl. the face becomes nuHbtnl, and if tb« 
strugffliDf; U viiilifnt. it may Wcomii: f>urt>Iv oud turv'd. TIti* pAlit-nt tn>- 
uavoUf renieiiibetv the vtru^lv uitb ll>c lultiiiiiistratur duriuK ibiit «lat>t<, aud 
tV t^urgcun und bitt UMttliini •bmiM iivnid tiiiy uiiKUnrded expTCMioD wbicb 
iiiiKbt leave dd tbv puiirut'o niiud an idea tbnl be tnu rt>U)(bly iiki). Tliis' 
period of exciu-inciit l- tjiriikly jnUonitl by lorn nf couwiouaaeai. Tlw 
strujfKliDK may Hltll iiiiilinuv, but tlit- mnvcmcnl* arc purfMiMlnB, aud aucb 
wiinU an b<' iiitcra *n dbuoniK-ctiHl nud iiu-ibrnni. At tJ)i« auge a violait> 
toHic fKiitrti'iioit of tvery niitw-K- iu Ibi- Wly may lakr jilacc; respiratjoD la i 
Nitntcd, nitd ibr fao' iK-cuMice diuky. It u ni#.-r not t'> I'orc*' tbe <.-blun>l'urm 
when thin i-iiiidilii>D ii^ |>n.->H'Ul. If tbe litit Ix' rrniovH fmni tbe I'lici- I'ur u 
fvvt iH.-coiiilii lbi> i<pAi>iii cvtim, nnd a ffit gotxl. deep m(>iiti[i>iuii reiuuve Uw. 
lividity of lb« (iiev, nlwn tbe ad niintit ration may be n-coninM-iiivi] niihout 
diiug<.'r. More rommooly the clugc of excitement i» follontil directly bjr 
lliiit of oriuipleic in»rn«bit)iy, a fcvr deep, burm-d rcspirnliitn* aepitruUDg this 
iwo. The face now becomes pale but not livid, ihe retpintlion u regulRr, 
alow, aud Kballoir, the puUe fulls in fre<|uency and fortT, all tbe vuluolsry 
OlliK]t« bwomv Aiiccid. and retlex movement can no longer he induovd by 
pinching the rkin or loucbiog ibe conjundiTu. The pupil is at Ant ci>n- 
Irnclcd, Init allerwanU becomes widely dilaleil and iiueDBible to ligbl ; and 
this is a iiaa that ibc a'lm'nittmiion liiu been iiufbeil to tbe furlhect limiu 
consisieui with »nlVty. hih) niiM )k- iiuii{)tnil«l till tbe pupil a^aiu ri-s|>on(l* to 
li|:ht. Immediately befoiv (bis tUiitv in n-iiehed the jiaiieut may uvore loudly: 
hul in deep auieBlhmia, the n-Hpirntiuu, Wing slow, shallow, aud cbteflr 
diiipbrufjniatie. i* utunlly ixA niiffiriently violent tu tiroduc« any sutinj. 
What may Ik called tbcbeallhy rnoring of dii-p ununtlieaia muH lie distin- 
);ui5lK-d from the loud initpinttory >li-(t«r imlicative uf ipuinodie ebwure (if 
iiiv ^bitli*. The latter is a nigu of diuigvr nnd iiecdMiJliitM llie immedialv 
remoral of tlie chloroform until tbe iipium biui p«n*ed off und baf been 
Iblbiwnl by thrve or fMir healthy n-vpirnttons. When fully aniHitbeti7e>l, lira 
(Mient i> at tlie ver|i;e of deutli, and re<}uim the UHMl eun-ful watcliing liy 
lite |H-nM>n wh<i nilmiuiKter* t)w cblun>form : hi* fioevn (hotiM be ke}i( can- 
ftnntly on Uic n nipornl artery, as the mi»t conwnieiil |>uiol for fM'liug th« 
|iulw, and hif eyr» *bMild n<it be taken awav from the oounteoanee of the 
|>atirRt. Hemuft wateb,i>n the one bund, Ibr lividity indicative of iiii[H-mliug 
upbyxiu, aud, on the other, for pallor ehuwin); teeUeoun of tbn beart'a 
BotJou. The breaUiing inuitt be enrefiilly ^ibwrvrd, and tha adinUilMraior 
tniMt uot be ei>nient with seeing Ibnl the moven>enlft »f respiratiim conlinue, 
but must lirrl wilb his band innt air is actually ptueing in and out. as id 
ipiwtnotlie irb«<ire of the glottis the resptraiory niovementf cotilinuarvgulwly 
l^ir eonir (iiiie iiller »ir has ceawd to enter. )laoy aecidenis duubtJea arias 
froni ihe [wiient being ibii* sllowed to becooM^ partially sspbysiated. aud ihe 
heart'* action ^'reutly enfeebled ; aud when, as usually happens, ibe »p«&ui 
pkwn olT and t« followed by a i\t*p impifaiiun, inslead of pufv air, ubicb is 
•o KTtMly needled, a eoucenlrnled di«e of ehlurofurm vajxir is si»|i]ilie<l, which 
tiiildenly cliii-kt tbe artion of ilie weakened heart. 

If the iubabition of cblorufurm have been siHpeuded, great care tlwiild be 



DEATH rnOit ClILOHOruRM. 



63 



iia MlminiMnititin i> rectimmeDcnl, lan ibo almiilT mfi^lilMl 
br •atirelr •)VrTi»in>nM by iho Inlltioaoo of ■ valumn of va|x>«- buiI- 
imif given bt ■ roiKmitniu-J furni. 

IttMoU be bonw in niiDil that it i* not PBowuy in nil operatioin to 
■i l i tw b Mj cfatorafiiftit 10 tbv Minr cxifnt. In mil ihv gmiivr op«niii.>iu>. m 
■■fnimiinni. QtboCanj. Mid tli« lignttint nf arlrriTC. crKnif!)! »1i(kiM !« givea 
u oamlyi* w|4>t<ly miMculir iii^>v«ai«fl(, at nrll m to suBjieDd «etwihilily 
iM coHcioMOCMk Id •■]i<'m[i»R« fur hernia, tilfo. :iuil nil oltier )>nii.-vt>>liii^ 
tlic abdominnl wulU, if cnni[ilcU' iiiu»rulitr n'luiHliuii be not 
1. grvkl lnnNiT«nionoo luid not a little da»j>cT may miilt. Sn, niso, 
JB varjr iMiiaAit onrnttnaa abngt tho anus ai»l genital orguni^. h full do(»e of 
tfclwaihriii afaonH b* citmi. Itut for tho refni>Tnl of many (uii>oiv nbi<ut ilis 
lm»k. or in laanT of ll>e iiiiDur npvnitinns on tbe exiremiliLit au<) alKMit 
wad &CV, nmcular rvlaxntioo ia not h> iinifwrj ; uotl it will be 
lo xi** •floB^h ehlofuform merely to suBfieod tmribility and ran* 
a l<> (am. 

frm CUtnftrm mar occur in ibne« difli^vnt ways ; viz., by Omm, 
by Ai/iMfjHi. nr hySf^m/ir; iliroui;li ibe brain, ibe \aixi^ i>r tl>« linin. 

WImo (katb iincun by fiman. ibe jiatJent u hentrd Middeoly lo brealbe 
timtlunmmW ; bi< limitne- livid in (be laL«. and » funvuLvMl ; tbe btnrt beala 




' laat tMNBRil of life, and death appeara lo result nrimanly Irum tbe 
I uf dvk UiNid tbfoujfb tbi- nerinxu oentna. ThiD fcimi of drnih 
ttmtn A'urtlr in iadiridaala wbo ar« epilefxic*. or who arc itilTeriu}; ftom 

DtBtii ti* jlif Amgi i i may be jnoduL-ed in tbrra ma^-n. I. It may be lli« 
iaak »f ibi- aHmhiMraior, tufficteat air ivit ttoin^; lulriiillnl witb tbe clilnro- 
tn-wmiBic In maintain llir n-Kiiirnlory function. Thia ia wjicrinlty ii{it to 
■ b<-B ■ iMiii^t. tiring •minamitianJ, ban n |>i«i.-«> of lint «uliirale'l 
t«Uocnfi>rai aatldrnly np|>lir(l to tbe mnuth and noeo, tbe bent of ib« 
' I hand uid of ib« patient's boily rapidlr firoilucin)^ a largv volume 

«apnr. 2. LiM«r •K-aeribra the firodiidion o^ aspbysia a£ bein^ due to 
jyanudie c-kMon of tbr upfirT upenitig of the larynx, (be folils of mucoua 
■labtase above tbt' nptcn» of tW arytenoid i:»rtila;!e«ibeinj;ciirrietl forwardfl 
tSl thuf are io oiitarl with the bikK- of [lie cpij^louiii, wbicb remains erect 
■■d wffcanyd in pocition. Tbii theory was founded on observations of the 
larjntx dorinit tkn pMrluction of that peculiar laryntreal sierior which usually 
aneadoi tbr ■tofipaui' of the respimtion. Un pulliiij; the tongue forcibly 
laraard. tbr arytmoid ouiilagee vera »een to be dntna backmnl, and tbe 
«p«ta|t iif thr larynx maide perfectly free aicain ; ai»l tbia aeened to Im> dua 
tm n^ox artMi mm not to tbe mere mechanical act of drawtag the tangiw 
ftw«mnli. Tbi* ii <)(Ute peasible durioi' an*Mb«ia. as tbe reflex function* 
«^4«flutitioa mhI rtepiration are not alfecieil by cblori<l'<>rm tt» adminiitend 
In • Mlf^iual operation. Tbe cloenre of the glottia may olUn |ieu« unnolicMl 
till iJm palae Mopm a* tbe beavjoc of lh(> choit tuny g<i on for w>nic lime after 
atr h«a eaaaad lo rntrr: ibe only i-iiinM "f the *iate of tbi- palicnt U-ing the 
fradMtttjr hw a ai i i > of the fnop, and the fact Ibat no air i» •■ntrrinz 

waiariairaat du" ; ration, vbicb can be aaceriainivl by f«^lin^ witn 

ibe baD<i oTer iki- m<>ulb. liitlcr i* of opinion that ninny •'( tbi- di>athi> fmni 
AJonrfurai. in <rbicb (be bear! haw been xnid to (top lirat. wrf vat** of ihia 
fcbd. Hr itf'ut* un tbe neocaatlT of pulling tbe tonene forciblv furwanls 
■lib limwp*. and not merely drmwtn^ it out in front of Ine li-eih. i/tbc>piii>ra 
• aot iniMdiatelr rrlir<rr<l by tbe MUipIrr pruouaa, raeomnivnde<l by (.'lover, 
itf pallini lb« rhin rtrungty upnrdo. 'A. iViphrxia may nifo Ix- raurol by 

! ifilliia of hatf-*li|fralcd fuwl in tW larynx duriu); vomitiM),'. ai»l fnlaa 
' I lava alaa beeo known lii *lip iniu ib« larynx during tbe mlnmiivtration 



OBNBBAL BIUARICS ON OPKKATtOKS. 



of elilumlnriii, ami iho same aecid«o( hu hnppvowl vriiU l)i« gig 
cliiainl i>pvniti<iiis. 

In <kaili Truni Qirduie SgnatfM, the pAtivnt. afl«r ■ faw iM|Hrmtioa*, tud- 
dcnly l>oconM« pale aod tainl; cbe pulac brnbi in n flirkfring itiBnorr a frw 
tinm and tlwo ccbms, (hougli muiration may MOtmuo, the liiUil i-vrot btinx 
evidcDllr due to parnlj-sis of ihebearu Thit U an aoculeiil lliat inar occur 
to i ml i villus In who arc dejireHaed lOlhtr by m«Dlal viDottoii or bjr pbyuol 
debility before lakioK itio cblorofonn; and it i» not unfre<|ueiltl]r ronoeckij 
iritli a' fatty bevl. It la bcatg««rded agaiiut by divine tne |)ati«Dt u liltl« 
Bliiaulanl, as brandy or smoKitiia, before conmieDcing the iolialali'>n. 

In sons CMea death ba* occurred ttom 6ynDi|>e Mradenly ai i\u\te an tarly 
sUlbo of t)i« adiiiioislratiuD, and wlu-ii a small quautity unly lias bucn |^v«d, 
without any morbid cooditiuti btiiijk' diiurcrmble on cxaniinatiou of itie body 
afl«r dt^alli. Ii taenia poatlblc to esplalu such euea only by suppoaiD); that 
in raT4.>iii>taD0Mlh«nM-xiritdauidi<MTacruy, owing to wlitch asDuillquauiity 
of chloroform avbt dim-tlr npoii the licarl. IJu«r r^t'iinla a i-aiio uf exactly 
the opposite condilton.tn which th<' patient aMmed Incttpabli^orbBinK aflected 
by t'vun ilii' Itirjtnl <l<»(-i". 

Seoondary Effects of Chloroform may dcv«)op tlicn»clv« in connection 
irith the /c'li/, the lutipr, or the ttomacli. Tlie liauilily Ui inconvenient secoD- . 
(lar^- vflocls dv|Mit»dN cbielly on two conditiniu: t, nn the nKxIvof admlnistnk- ! 
tion of the cliloroforni, tvjiefially «n the car« uiken that iIk'K U iq adi^tiaie 
■upplyof air admitted at the tiiiiv whi-n thenpnr t« inhnli-d; and, 2, on Um 
•Utc of t]N palU-nl a« U> ng<-, habit. l4-nip«*niwent, and di^vttua. Old people, I 
habitual spiril-drinkm, and ihnw of a bilioiu and Mii^uine lenipeniiueDt, 
are apt lusiiflrr nxvl. 'Die condition uflhcdi^t^ioo iaof ^'trnl inijK>n«nce. 
If ehlor\>furiii l>e giv«o too aoon atlcr a nKnI. injurious re«nlts nrv sure to 
follow : bence. it ti best administered on an empty Moinacb. 

Utitil-effm/Jinttioim follow the ad miuiiil ration of chloroform chiefly in the 
Ageii. Id Ihein headacliee and «lu|>ur not unfretpienlly supervene. ai>d oc c^.j 
nouallv {laralylic or apoplectic symplumfe will dev-eJop theniaelTee some 4^^ 
after the aniutliesia. In y.iunt: and uitvous women, hysteric*] sytnptV^I 
oDen a|»piiar, and continue for M>u>e hours or even days; but they nevd not 
ttcciie uDcaainen. 

■■Tht J/untjt probably always beeome sli^bllv coneceled durinj; the adinin- 
VRrntiun of chloroform. Hut, as recovery laR«s place, and the raipiratory 
prooeas is naturally reiblablinheil, the inilmunary vesseb unkad themaelToa. 
and no tncuuvcnience mtulu. The procu* is vreatly facilitated, and 
effecuuf chluroforui are readily pit Hdof, by dcsiriug tl>e patient to bi 
several tiuH« fully and (tecply sJWr omiaclotisneM n-tumn. In some 
the lungs do not unload tbemMlroaof the aecumulateil bluod ; and a pi 
of »lo« ii>j>hvxia mar net in, and may prove fatal in a jieriiid varying 
iwunty-fi)(ir bouni lo four or niz days. Thio t* a rn-i(iti-nt nceurrrDcw in old 
pativDlB Midkriog from chrouic bn)nchili:> ami emphynvnni, and i* not an 
UlWomniOD oaussof dsalh alter <>[>cralioni> for titrangulatnl hernia, as the 
•u-MUgulMiuD i* tVMiuenUy caused by violent #trainiti^ in coughing. It ia 
also ns|ieicially apt l» happen in thoM oassa in irhirh it bfcomea noeaaary lo 
bandage the chest, or in which deep mjtiratioii is auondod bv |MiD, as oftv 
amputntioD of the brr«>>t. Great care must, tborwfore. be taken not to ooa- 
strict the ehritnalla too livhtly alter fueh operiilions. 

Irrilabilily tij Iht SimwM*. aili-txlnl by continual nausea and vomiting, ia 
•onMitimea a tctt distrtonng ofterH'flwt of chloroform, and may bo produc- 
tiv** of moat SMIOUB and oven of fatal renulls. It is Imb likely to occur if 
tl»e )>ati«nt can be left undisturbed ami allowed (o sleep df tlw effects of the 
olilorufurm. lu many instnncea, it is developed by the patient Uking the 



A 



ArTiK-BrritcT« or chloroporm. 



57 



loo •nuB tfter m menl, and is then purely (nutric, and usually 
rljr ia Ott ailcDini»lmti<in. In other inctanc«A, it appears lo be 
with canbral ilistiidMnce or 8on)« kind ; in '.illier inBlaiitea, 
>, il i* onoiMCtnl with kiduey di»oKM. But in any nM>, nod frum nhat- 
kHhrit, it ii a vewy »eriuuii syraMuiu, aod, if it uDotinu^. clUn 
imr«* tk« acadc aniiul tiw |>at>i'iil by the eshmiptiuD to irbich it ^vea liae. 
It « Wc trestMl by ioF or wwik ici->l hraodr and »uda-water. t^troDf;, icw), 
hlMfc eoAw wHb broa>id« tif potn«iuia U ovcnfiuiuilly lueflil, and in extrenis 
mn K aHMtard plialar. or cv«n a bluier, to the «fiiicMtriutn may be tried. 
/■ eatmm rfi'wiaW tMtdUi«n»i^Ae»vtan the admuiiMratioii of chlorofbm 
nacfa care; but. ■• a gcDamfralo, it mav beaUiled thai, wti«nerer 
1 imeam hw not advanced to Mich a degree as to cootrn-in- 
iaao|i«alloa,eblc>n>fann mar be ^ven. la tlicearly sunaof plilhiab 
it HMiT oanally be aaftlv inbativl : )>iit in •uvm; i-aM-a of broDchiiil imialioo, 
iIh vapor k apt lu prudooi- trtHiblw>Ri« oni^h. When tbc h<uirl itt diwaaeil, 

KW O tio* ■* B iowa ry. more partieularlv ub«n it» mu»niliir nutwtaiK'e 
aJa nfW tuMj il«f«aeralK>R ; the M-dalive intlgencv of lltc cblorufurm 



apt. In iKcaa ctrcuimtKiicf*. to proditro n nidih n daurcadoD or arrwt 
M tlka bMirt'i action. In many. pi-rh>p« the nmjorilT, ofttie cams uf rivAth 



. chlorofttroi. ibr filial event hii» bi-en Iraceil |i> t)ii* eniii>e. In valvular 
' of tb* heart. I hi-lieve that it mnv Im- m<>r<- MilV-ly ^iven. In |>rr>un« 
> epileptic and in (hoae nhn ^iitlVr frfini mu^ntioD of tlie brain, it 
to be oautiou»ly adniinipt^rei). lu iii the enrh' sta{^ of aUH«lh<'eia 
Carebrsl esriti'tiMrni is upt l<i lie cvincetl. In hyetcrical HibjeolA, 
■• aaid to induce a tendency Ui laryogeal i^y^-w. The nxiel ilnn- 
«Hndition in nhich to odminiater ehtoroionn is admnced renal ilia- 
a—jlBBBah^wpileptiform wwvidsi'ins are readily iiKlaved, with lividity 
«f dw fcw. nod a tradeiiry if- *lert»r and mata. 

AMild cUofolbm, or anv awatlMlic, bo pven in OMratMMit nodered 
HBaaarr by «cven \ayutv*. auring tke tonlintumn ef the Aori ^ Ou aaetdvnt, 
m in printarv anipuiatiiin*? In MUch Hminiatiuirr*. il> iim- Iihh been ob- 
,Maad io<n tbeynmod that it wnuld art injuriniiily hyvtill further hiMi'rine 
'^ alnady dfipRaaed riul (tuwen; and that ihu pnin nf the npinitinn, if 
paHnnntd witknot It, «>iuld jinwe a tfood ■timulanl. aiMl ihw fervu lo mwc 
A» fBtkot. But s»«ihl tbta rnilly bo m? la tho i«in of an operutioo « 
MlnwatT In ocder f> antwr thi> qnevtion, let uh oWrvo the o-nditioo of 
a f ri— I ioiiBvdiatelr aflrr the |<erfc>rninnoe of a severe oj>rrnlioit-~nfl an 
■i^i* having Iteen aiiiMll>rliiii^l ; nwl we tlinll Hod that, 
bnvinit bera restoreil »r fliniulated, he will have Im«ii f<-r\«\iAy 
by it Tbe puW will lie «niall, f<«hle. and nlow ; the surfaci' cAA; 
MM tW auM. iwrb«p«, MBToitly ennsi-ioua: in liicl. th'>u;jh a slight degree of 
ymm. an a pi>« or a prick, may act aa a stiaiulanl. verv aovere Miflcrintr i» 
a mtm po«efftil daprmMnn ajrviit, mpable in itwlf cf deairoyinit life. Tho 
^mtm ot »a optrnliBB prrf--rnMd s^mn afli^r thv ()e<curr*'n<^ of a severe injory. 
■^ tar Intm rtwalsf the pniicni. npimirs to me in ad niti^t injiirioi»lv, by 
• wtMid aboek npoa Ibe irsiem iHfnrr. |irrhiiii«, it has fairly 
I frMa tW ilernwini; eflecU "f the ArKi; iind it la by preventing 
Ifcan ikM rhiofufena h i iieatimnble ndvantat.'' In thm- riirrv*. it is 

!.■ t-in- r r -^1 to an extretuo •(•■urw ol nlii»lhi-aia. It b 

■ to a inmlerali' rxient, ehielly wi n* lo bruimib MtiM< 
. .,.,..1. •i,.^...>..h [),„ #i[io. .\l\vT ibi», and tturlng the 
hnlnliuu nuiy Ih< ■uit|M-ndi'<t entirrly, or 
II <ii>. ■'--•■ri^ jriifiiiliijriral fnet, llinl the pliTnirnl clTecl of 
I tm iIm *yit»m even ihoii^'h the |>iilH-nl W r^mijilvtely 
m M particularly noticeable in mm* uf ciutnilion in nbicb. 



n^ni*(te lo t' 



68 



OGVSRAL BKUARKS OJf OPBItATtOXS. 



nt the moment whrn the <-or<l U oil, ttir jxilix will li« fouixl (o fall Mvcrm 
btaUortostap momcjiunly, cvt-n tlii>ii)!li ihv patiout be quit" inM-iiiibl« 
ifeaoe, it idav b« ■rKUL-<l ilisl, altli<'ii);h niuuMllicnasavn tlxi i>«ii<'D( ilittl 
amotintof ahui-kirliiL-Ii ariH* rnim pain, it <)<■«» not rvliinre liim ■>> tlint which 
resulu rrani the physical iiupreraiixi prwluevd on iba systmii br n arvrn 
inuiilaliim. 

Tha »dBUiiiitration of Ethtr may be eflK-tvd by tbt' application ovrr tbd 
nmutb itnd uoatrilii of ii hulluu' 8|h)ii}^ Bitlumlcil with thr br»l wiish^^ ml- 
i>l)uric o4ber; but it is lar beil<.-r lo eiiigiloy sunii> ibrm ol' inhnlirr, as fmni 
ita extreme vulmiliiy. unle« tome mouu are takeo to vpi>nonii«- it, tin 
quantity re<|uiriil lH>>,>'roua a wriouo tnounveDieacl^ Wbcii >;iveD by mtAU 
of a 9>pcii))!f. Wtirrvii rei-uniRieurJv unointiu){ tlie face with wnio prutrctir* 
unKueiii t» pKvc-iit the puniteni crfln-ta of tlie eiliiT o<i the skip. 

AriKinj^l thi^ niiimTiiiu itihnli-rf uhiih have bvea iiiv«nt«d of late yvan, 
CIovitV *innllor u|tparaluii ii p^Thnpn tbi^ iM-st (Fi)C- 1 ^ tt cousisu of » 
ftoe-pi«OD to cover tite moiitli and Di«e, to wliirh h attached by n short 

metal tube, a circular metal v«m 
wl tu cuutaiu ihe ether. Un the 
other Hide of this m a thiu India- 
rubber bni[, aho oonnwied wiih' 
thv I'thiT-ohanibcr hy a shurt t u h«r 
Tlie ftlwr-vraiM'l ean be n>iaU<J 
oil the facv-piece, and aecnrding 
i» the pnaitioD in wbidi it iai 
planil, the OfMinrof the air pam 
injf ttin>ti|:h the apparnDu varioai 
\Vheu it i» lunied eo that Um 




\Vheu it i« lunied eo that 1M| 
iiuull iitilicalor points to "no] 
vther," the expirvd air pWMf] 
into the Imk wiinoui enlerine tb«t 



Fig. 1.— CtoiW*! Elhar talioUr, 



Imk wiiboui enlenof; 
ctlier-chamber, aud b brraihe4 
airaiH at the next inapir»ik>i>. 
When at " full ether." the air in 
inapiratioD from the bng and ex- 
piration into the ba|[ must all 
paM thr«>U]ih the eilwi 
which is wurmi<d partly by ili« patient's breath, and juirily by the ad 
trainr's hatMl on the ouUide. By a liinple nieolianiral aminfreateni 
variationft iu the direction of tlie air are effected niihimt valves, and tlia 
initruDKnl b for thb reeaou less likely to get ntit of orrlcr. It is tbun iw>l. 
First the faee-piei-e h litted lo the ptttieot'H face with the clb<<r-<'haml>iT, 
but without Uie bag, and with the iudtcai«r puiiitin^ to "no cth«T." Tha 
jMtieut is allowed to breiilh*! thru<i);h it n few (inm lo ^vt aceuaioimed to it. 
Then tJie bae is aiiptied.and Ik- oi>M>ni<-iii'i-» ii> brfatlw ibe miiio air over 
and over avain. Tlii* <iH>n pr>Mlni.'** a n)ii;lit i>tii|H-fy!ng effect, and at\er a 
few mpimiluDS the ether-vcadvl i* miatiit »■> n* i:nidindly U^ allow more ami 
nor* eiticr^apor to bo mixi-d willi Ihe air. ,\l^er a tea loore rrspinitiotti 
thv full amount of eilwr should Ih- ttirnnl <in. In lhi« a|i)Miratnf there b 
puqiosely no provbton for the ailriiiuiiiii of frr«h air. am) if it wen- held 
hrndy Iu tile face fur a ■ntEriciiI lime death friitii aephyxis must eoauei. 
Till- aduiinidraiur judtfrN bv the Bp|H-aranee of the lace when air is needed, 
ami remuve* (he wlxile appanHun fur one or morv respiralions as he may 
think nrcoanry. The ndm>niiitrali»n of ell>er by thb apparatus gires lisa 
Ui Im> choking ttisn when iIh- vajxir i* f,'iTen frum a hollow spODfb 
Iho afliicis of ethiT n-wnible generally those of chloroform ; iae patient ia 



COMfASieuN or BTHEB ASl* rULOROruii U. 



59 




MOM ■(•(•) I'r tuMi iinooiMdouiiMH, wiUi ctDiipktr ma»ciilnr 
I abotiiiuii i>f nit n(\»x mnroiurnti, oxropt l\umv c<>iK-rnit<l in 
J Um Bclioii iif lliK hcnrl aixl nvpirmtioii. Kilxir pnnliux", liow 
'•xritmrut iIibh chlomtbtm, raptrially if itu- vn|Mr Ih- i'nii»)il«r> 
•Uy iKlMarf Milb ftlr. It cniiM* nito ml tlir cvtuiin-iici-imnt ii choking 
^•Mliao, uAra vrrv tliUniwiii,'. It vlwuyi! g\vf» rii>i* lo ii c4>pio<i» wcn'lion 
tt aHMM bolli in t^ pharynx nrx) )in>uchitit tuln-e. wliich mur (.-iiuiti; cno- 
^rsUirr cRibar- ' ili<: rpti|>ir)iti<iti, lx>(li ■Momintil nnd 

f i<>It^l KDil : Kllivr oxoris n more stiiiiiilBlin),' eflW-'t 

• basil tlwn diltifnfurni, the jhiIk UHisl)/ maiiiliiininK he forte pv^-d 
tfc« iwuntl is ilfvply nn<lcr thi- infiuence of the aii:i»lhclie. 'l^ho 
Myil, a* is ibo MlininiBiratiiiu of cliloroforn), is variable until llie exiraaw 
oaita <>l mlIt Mltnioiairatiui) arc r«neh«ti. dheu it beronice wi<lely tlilalcd 
taJ fiinl ; at lht» liine, aUo, the face » iJi^'Iilly (iusky. Tltv liiii« required 
W Ibe iitdntti'iu iif ilie suuibclk- slate vari«^ uvenKiniC. f>erb<ii>6, fiv« 
■ia«i««, if wltnmi!>uml without an inhaler, b^ii much l«a if Clurar'a 
lp^■l■lln tw HMsl The tatne precaution* an to rvluxation of iJie dress. tb« 
MOPKbnit poiiuua, and ab^tiuence from Ium). (hat have beeu iloscrilted 
m MKvw^'' - i;: thi- lulmiuiil ration of chloroform, must be attended 
k>«hMi r I I'll. KlhiT, like clilorofunii. mny t;iv« nac lo trimihlNume 

nahittf N'tii >ti<rii>i; iiti'l iiAt^r iin ailniiniaration. 

BMlk ft«B U>e admimstration of Ether, ulthougli not a tVr<iu«Dt ooi-ur- 
ntn. Imh orrurird villi (uHiriL-ul l'rti|iirnoy for i^rrtiiiii facta to be n«r>'r(aiiicd 
cnfc nKBTtJ b> il. ('a>tli'V Dawi>i>n. in ih*' Jirituii Jfn/i'oi/ JtiHmul, Mtirch '2, 
IKIK has pnbliabcd a olfctiou ■■!' L-it;hu-<-u cum<!> in uliich ilvalh oocurrod 
dorutf or aooa «ft«r tbi.- ailtninintnitiitn of tthvt. Of tlino be cx- 
< DitM. no lb* ■rtNiads that vlhrr «a« ool tJ»G only animihrtic uiwil. or 
Am il i« fHMibla Uw dtatfa may hare been dtie to other cau«e». In tlw 
NMabnac aina <■■■, io nvm Ihe heart couiinu<^l to beat for f<me lime after 
tha r*Mtlmi«n Iiad eeased. and in two this point was doubtful. All the 
ftltKi I af|thyxitt. at iiiilic«led by the diiakv litre, ttie ehaJluw 

■3. _.. , ,;.< li<iK tutervat. varyiiiB from four minutes lo fifteen or 

, ba(«««ii dr«ih am) the tir»t maiiifeeintt"n of aertMi* *ympti<ni». At tli« 

rianiiaativii tlte Iud),-8 were Jounit ^rjred nith bluMi in five 01 

c*M» (TKamioetl: in odo more the pulmonary urtrry uu* »aid lo be 

I : in -filly <>ae were tlie luups pale, and in ihin nuK- ihe symploaw did 

' 00 till one hour and a half afWr leaving ih<i ()K-uir«. Theeundu- 

, to br dnMB fr-im ibcae taset is. (bat ether kill* hv o^idiysin und n<>t by 

: uhI lilt* ■« in acconlanee with the resiida i>f ti|H-nM)i-iitii on 

i^ ' :h(T nn* f'M>1id ainuyii to kill In- nrr<«titi)C ihv ri-* pi ration. 

' W* ' L. ihi' ■<lvuiit»);i' lliat wlu-n il dtia« kivi-* riw' In danM-ruua 

, Um «a(twu lymploni* develop );nduully.aud tln'ri' i* plenty of linw to 

lancb BiMwnrt* »■ nmy be necnaitry to n-Hinn- ihi' (Miiit'Dl. 

. between Et^er and ClUofofona.~Thi.- history 'if Annibt-lini 
> aoadditiiriial illuniiitiiiiii <■! lh<* miiiabilily of profr>vi<innl opinion. 
mim alsMMt ibr only an«MbvtH- i-uiphiyi.il fi>r iht- lint yrar allir lh« 
uf tta IH* aa an aiuMtbrtiv. It ihvn rapidly ^ve way to <-hloro- 
id tt (vraplelrly «a* ilii* axrnl mi Ut it 11 led for ilhvr in thin rountry 
^rf fCOMrally tlinxi^hout Kur<i|ir. tliat n vonftwion aro»e in tbe ^Hihlic mind 
m im tktr fni diMxti'ri-f o( Anavtbraia; anil Hir JniiKti Simpson, who naa 
aa Mf Ut* ttift tu riuploy rhhimfiirni nnd to wliuau ener);y il> gi.-ui-ni] 
aAMAJan *•• lUkinly dor, «aa very mninionly coneHlLTed lo he ihe diKovervr 
<f A•■Bt^''' — In wimr lKW|Mlnlit, honrvrr, awl iDor« e*|ie4-ially lhoM> of 
■, U' ace of •urjpml Anavttmia, ilie faith in ctlwr has n^ver 

p-rr lu na* al«nili»ieil tor that nf any other aj(rnl. In ihia 




60 



OBXRRAL RCUARKS ON OPERATIOXS. 



country u cbun^ of pfufi^<iDal niiini-in bua tn anme exi«nt iM in. uii 
nreimuua dfnns b»ve own niadv aiiicv lti« death of th<- illuMrioii* dboorera 
of the aiuisili«(ic pru|>erti«a of ohlnruform to iliyrv that ii^ii^iit, and lo rcjn 
Iroduce elh«r lu ii ^Mral aiuealhtttic 

Tbal «Uior iiDil chlorofDrm are caualljr cflW;tivv Id th« prrxlactiaD 
Aiunthona, is iindoutitG*). Bui Ui« advocatci of the fint Bl]«n tbmt it b th 
Mftr ofc^nt of i)i<! two; whil*l th'iM' gf the Ult«r aneit tSu. lutmittin) 
the Kri'niT ^tVty -if other, Ji i» iniukIIjt oortain ttiu it b km eooTmieot utt 
Ifiit ^-iK'nilly np|iHcahlv aw nil AiiMtlMtic 

Thio r(Li<9[iiiti. then, has to b« MMoiDed flrom llin-p n«|vyt>i: 1. Aji to thi 
A{tiilicaliiliiy ; *J. A» to th« ooovcoionoe; audit. Af tothi-mfut^ of tho l«i 
AtiiMllivlie*. 

1. A* lo Applienhit'lu. — Thero ciiu tw no dotibt tiiat in the vnrt majorit] 
1^ can* iHith iiri- •.igiiiuly iimilicnhlc. But there arc rcrlaiD cnM« in whi«a 
Mbn*. and othcn in which chtomlbrm.apiware to pusww superior advuntagta 

Ether is pn^lVrable io ihoM c*mm in which from »vcn thock the ncrvotii 
t)iin)-n arc >;rctuly d«prcn«l. and in ihoce in which there is atony of tb( 
iH-nrt, whether from tatty degeDerstWO or from on enfeebled and dilated 
etat« i)f tlie veniricln. 

Cblorofonn Bp|>eara to be more applicable in all those cases in which it il 
DMCMary to loaiutain the anavthesia for a great length of lime— for many 
hoaiB — afl in the oompreMion of an artery in the timtmenl of aneuriami 
and in thowt caws in Wnich the galvanic i-atitery is used in the Dd^bortiaod 
of the mouth or air-panages, the vapor of etlier under thfs« oircatnatanMI 
beini; liable to ignite uiili expKifive violence, as I haT« teto happen. 

In all abdoiiiiuul surgery chlnrut'i-rm i« preferable, u the violent respira- 
tory mi>ren>euta, that io ooroniunly iMxnr in consetjueurc of the accumiilnii<-n 
of mucus in the hmgs and larvnx during th« adminittmlion of cthiT. may 
prove A mott Mrioua tncoiiTmii'nof U) the Sui^m. The rt'lniniinn of Um 
abdominal muteln is much m<>n- [lerfvcl with chluroform ; and on thU k vt 
iIk Art! important in the trv«tmi<Mi(if ■iratiuulatnl homia,«rhctli<-r by taxi! 
or oporaiion, in abdurotnal mclions. and in ■•xaminntionof abdonnonl lumumj 
chloroform should alniira be utod in *uch ciuh«. In yoting childrm, aUOf 
chhirofivrm i» alnavx to f>c pref^rroi). (int. bccausv no apparatus it> rr<)uircd.' 
it (-auM« lem chuiiini; and dii>c<>iuf»rt. is much nmrv eoaily given, and, 
fti^hli-n* tile patient U-ow ; and KK-oixlly, hw-HUw exficrintoe has sliown thai 
chiidri'D l»k<' rhlnfiifonn with n-rnarkablc casir and saftty. 

i. A» lo Conetnirtm.—ln litis n-spcci, t-hluniforni UHdoubtorllT pnaaoMm 
vast miieriority over ether, and iixlcvil il was its tuperixrity in this rcspMI' 
that M so rapi<lly in its suhslilulion for that agenL ^now formcrlr citm-' 
parc^i the two agents to a lucifer-nialch and a tinder-box miK-ctively : and | 
also to an express and a slow train, in which we regard oonronience ratlter 
than safety. 

Chlnrofonii i> infinitely more convenient than ether in many wavs. Ily it 
the iuiu«tlu«ia la more rapidly induced, and when once indu(v<l, it is mor^ I 
eawly maintaiited complete and unbroken. Th« i^uaniity required to produce \ 
aDlUtberia is flir smaller. This u a mi:at important advantage in niidwifery 
and in military and naval practice, where tlic larger hulk of the ether that ii 
CMMuraed in inducing aniuslbeMa would often render its empluynient verr 
diltit-iili. So ul«u in Drdioary country practice, wbvre Surgeons have t» work 
einglc-lianded or with impcj-feet aasistance, the rciMlinnu with whirh aut(*> 
thtaia b inducwd by chlomronn b a verv imiMrtant consideration in it* favor. 
The peiH'traling and toug-|icnitM«Mt odor or ether, though of minor import, 
b not vriiboui ibi diiHMlvnntage to many whn an* delicate or nueceplible. 



] 



coHrAiiuoN or ktiirk and culobofobh. 



ei 




X A* tf Si/My.— No aaMttbrlk im abwilutcty mfc. It i» impomiblp to 
iwiMlalr - - ''-cnpiirariljr, nirnUl codmHoohicm ukJ physical aencilnlity 
mtknl ■ Willi oniinnry ckkii nod ■onw tlcgrfe of ozMn«nce, 

tho* nk u '-aj^T'if or bring rv<luc«l to rery iriAin^ nroportioRS. t^ atnoU 
b tW r»k. Umi iraay * Hurgoon gocB through a longltivnt'd hospital «xpcri- 
«r« vitbeos BMvtiBi; «iih » fnul cnw. But, tltgtit as >• tb« danger from 
Ac ■teiBttCraiJoo uf nnn^ihetia by conipeteDt penoiM, tberc is rtlll 
lly m certain -lellDiii' [Mril stteodutt on Itidr um>. Thnt tliis is 
gmuf «bM) t^hlurutorin i» Med tJisn wbeo ether is employed i« 
Ut arluKHilwlgfd—boH much |[reat«r ia uncertain. There are no claU 
[^ praftafaa Avn which a comparative (Mimatv of the rel&iiv« 
4^Mrr of thw two agents ran be drawn. 
iMt Baiiy ftial anrid^nts liare occurred ftom the ad cuinUl ration of 
I darlag th« twanly-five yvar« in whi<.-h it was almost llie exclueive 
': in thk countn, it unfortunately too true. Jn the ten yeare, 
MS to lA", BO loM than 13d wvro rvicordcd in the nwdical journals of this 
••■Mf; atoor. How nany of tlietv wore ineviubli^— due to causes beyom) 
As aaalrol of tk« ailminittrator and rolely referable to llie toxic action of 

tW BASMlMtiC^H UIKvftaill. 

Thai hat fcw fitui accidrots haw oa yet followed the adminiHratioo of 
«*fcer ii nnKia. How br this is due to ihi* animilMtic being actually «Afer 
—i*^ ten toxic than clilurufami— it uncrrtaia ; and ibc oompariiion is at 
tly just. For, sineo the nintrodueUoo of ether into prnctiotv 
I cUaAj bam employed by p r o f iwi i and experienced DomtliL-tii'tit : and 
grmtag skill tii ihc niani^-nii-nt of anMlmtla has been acquired by 
geiwrallr tlisii i-uuld or did oxiit in the earlier days of the 



TW feUowiag rvptirt nlacea book of the facts respecting the comparntive 
«!■> of efaloroMrm ana etbur in so clear a light tliat I have thought well 
tsuyiudwca it. 



Mmmtt mm lie adminutnlim of CUmifoTM onA tClUtr tu Anattttetiet, — By 
_ avrfffno-Uajor J. II. Pohtes, Assittant rixifwsor uf Military Surgery. 



— ^r 1S75 chlomform and ether were admiaiatered at NetJey 
I 'J6 caws rw»|>i'citrrJy. 
iLi.i^.wiu^ a an analrtria of thr tiiue taken ia place llie patient under 
__ M, tM aaantit* usnl, aitd their general cflects oa Lskeu fruiu a 
kef* for loal porp<«o: 

C^iLititoroiui. 

I UsM tak«A ■« ptso* uwkr lafluvno* 



fcalli il iiiimy wwd Ut 



say oust 

SDJ CMD 



tnim* 


SmmiIs. 


•* 


80 


14 


M 


It 


94 


12 


« 


1 dnctinL 


A 


ks 


S dnclina D latDiHil. 



Tf lihn III iiiiiiiil in twonuos during oraA«r admtnuitralionof thedrug. 
EsdltMeBt oocumd tn ten cases during or after ailniiaittratioB of tlie 

jn«t prortnitido ia eoe case after adminittrutJon. 



62 



OKNKHAI. KKMAitRA OH OHSIt ATIOXit. 



Ktukr. 

ShoHaM tlinr takon to {•law under InfliiMiM 
LoKg«MUm« •' ■• " 

AT«mg«tiino " " 

Aiwntp Dm* iindnr Indupiwn 
ttnullai quantity umA in nny on* aua 
t»tjgotl quBnlitT UMd la aaj od* ums 
AToniga iiiMtntlij UMd In hbj ciiw 



UiaslM. 

3 
. » 
8 
. IS 
. 3ou 
B uancd*. 
& uanoM I dfaclitn. 



BMund*. 

SO 



ID 

ft 

4dn(tiiua. 



Vomittng oooiirred in el«v«D oum daring or after the ii<lmiDMtratii>o < 
tli« drug. 

Kxi'itviiH-iil ixdirrci) in ttwa vntm to h nmrkt<A dtgtemianag vt tttn 
iii)iii)iii«tniti(>i) of thi- drii^'. 

Th* Htimthi-tics vttrt: iiivrarinhly given on i-miny tKiinncha. chlnroromi by 
mntns of n hanrlkorcbiof or (owd toMvil into tlu* form of > cone, nnd athcr 
by Mr. M'tjiihiV iiihi(tf>r. 

Vomiling Bud excitement diiriog or nftt^r a<lmini*miion of <<IhiT hiiTtog 
m-curnxl more frequeotlj- than one* hiul biirn k-d lo ex]>wt from foriaar 
exiwrience, Ui« an.tuhelii' was rart'fiilly' tinnlyx«-d uu<l wiu fouad to Iw p«r- 
fei'tly purv, and of npeciKc (•nif'itT Til}.'2 m 4S4^ Fall. 

In (.'line I lis ion, I uonld t»y lliat with maoUHblci care and in fiiirly aktlled 
Ituuds, both chloroform iind etli«r ar« agcnU tlinl mav fafcij Iw administered 
in the vast majority of <.'aM« re4|uirini; ■urf;i<.iil opcr«t>oit»; tliat in laoet 
cna>» iliey ure e(|uslty uppliukble; (hat in some chloroform, in otliera ether, 
is tbe prclerable ageiit; thai in raidwifer}', military, naval, aad nn^lo- 
hand«d eouutry firactiw, chlorufonn. heinc far leas bulky, more porteole, < 
and more «uy of ailoiiuiMriili'm, is nrt^femhle to ether; but tlinl ito Bar a* ' 
wa can at |ire»MiL judge, wtlicr Kw» frrtjumtly than chloruf'inn p rod u era a 
din-ct toxic inlluvncc v« tli4- h*-nn, tutd i« oanKcquciitly no far the •xfvt agvnt ] 
of ihr two. 

Hitroiu Oxide Oaa wm tho lir*l nnimtlivtic uenl. Ila rmptoynH-nt was, 
livwrvi-T, HxHt •liiM-i>ntiniiod. ctli<T, und «iili«fc|itfnlly chloroform, taking its 
pltio*^ It was, however, r«inlrnduo?il in If^iiS w nn iina^lht-tic by thi' 
American dcnlKlt. It is an mlniimbic animihciic, cnpiiblr of producing 
0(>m|>lct« inacneibilily, rapid iu ita action, aSe in adniioistrativn, and Mld<tm 
giving ri«e to any unpicasaoi af^cr-elfccts. It ha«, bowerer, one drawback 
which prevents iu applicability to prolonged opcniione. Tfu) slasBofeaBea 
to which tbe uilrotu oxide u applicable as ao annHthctic ia r«<triet«ii, owing 
to the shortnew of the duration of the aiUDMheMa produced by it, and tbe 
suddenness and con)plelcn«e8 of (he return to collsciollBnee^ leaving tbe 
after-sninrt of tbe opcrntiou ulmoat aa cevcr«ly felt M tb* Sting of the cut 
iUelf could have been. Nitrous oxide in ehieSy of use in operations unat- 
teoitetl by culling, as iu ibe forcible fli'xure of Miffcned joiuts, the avulsion 
of lue-iuula, extraction of teeth, etc ; or in those cutting operations wbicb 
«rc coapleted by a single stroke of the scalpel or bistoury, aa tbe opening 
ol an abseeM or the division of a fistula. 

Ill ortlor to produce tbe desired eflbct, without cau«tng thai violent excite- 
ment nhich ptinod it tlie name of " laughing gas," it mnsl be administered 
puK, without ihc admixture of air. In order todo this,a proj>«r apuaralus, 
with a closely Rtiiii); fai-e-piei.'e, to cover tlic mouth and aoue must lie nsed. 
tniegas issuppliol fur um' mmpreNtod in iron )toulc«. The bottle is ooa- 
uccted with the fac^-pioce hv u tiilx'. in the uiiddlv of wbleh h an India- 
rubber bog, ■litlrTcnlly iil»ce<l in diircrenl in«trunicnts. The principle of all 
k, however, that iiftcr tlic facc-pieci' has been firmly aitplM-d to the patient's 
flice, the bag ii> dinimdc^l with ga», by turning thv Ktopeovk connected witli 



J 



A»111NI|(TnATI0.Y or SITROLS OX1HK. 



03 



U* trua battle, utd tl>» pMteut. br«Mttii»g bni^kuurd* and Ibrniirils intu the 
haf. >bIm1^ tb« MOtr ini* ftnvrnl (ini«s. Kuri« uf ihc giu i* m-cnwirily loat 
bf t»apio|C frMU iioilrr itiv rar(-)iie««, aoO lU |>la(H' is Huptiliiil by nlluirinjj 
a tnak krsb ti- Hnw ici fn>m the iron bottle. NitrfMi* oxuif ia nn imqiir- 
■lil* f^K mad K>. in thi* tneihod. no Mr u aiix«<l with it, thv clffcl« firoducMl 
•», to a |(Tmt rKt<-iil, thow of nji[iliysin. Il difG-rs, liiivrwcr, froin thfl 
rxta |)t<iMlgMil bv obatTTi«tiau ul' iIk- Hir-puBugm in this, ihnl llie 
of ttrlranio acitl gw oontinues (o n oortain cxl^'nt, m tUut, 
I iW blood ctmm to r«eciv« uxye«ii. It 6ot» not iH-cnnn- ovvrchar|;ed 
■ftk cvbooic and, and conofiufnllT a fovr breath* i?f fn-vh air rvinovc all 
(/ tb» tw&porary iM|ihyxiB. Th<- pnKVM ol' Hiiii«ilic»iii tiy nitroua 
' ia BOC, boovTrr, mvrvly no[>liyxiii nail imlhiiig i'Im- : a (vrlnin propor- 
I ^ tba ga* M alHurbwd, ami rxiiTla iin intliicncr nvcmbliiij; tl)iit or urher 
uo Ibv npo-ous cMtrt^ ExpcritiMnta on aDtnmb har« eHohd 
likv nb«f, it alony* »ti>pg Napirntton buJon armiin)^ ihv action i>]' tl»« 
bait. Ib the admin t»l ration of laughing gar the follow-iiif! symjKoms are 
i tr wwL Afirr a liaw, Taryiiii; from a fcwr secoiidit tu half a luiuute, 
>--r>-rdtOK to ihr ftrtiilifm witli which tho ]MliFDt inhales (he gas. a olivht 
vtiiux niftbr fan* ti niHiced. and a choking sensation amy be fell. lu teas 
tarn <«>■ niiniilr, a* a rule, thin livitlity Mconi«i eiuvniely marked: the 
civab ft ibe fa*^ an inj«ctml. tJi«re are otlen »uai« twitfhioKo <>f lh« vyea 
wd liiithi,u>d thi! hn-aLhioe ia deeiwr than natural. At (hUctage»eii3B< 
bM and ivflrs in<ivrm«uiB arv atxriished. and a montenury operation may 
W pufannnt SitDrtinx-s iht? |iuiii-iit is ouoscioufl that aumetbing hax been 
daaa, AkhMugh be fi^l* oo lain.auil bta ideas are conAued. If the niMrntiun 
br man thmn BumwntarT, the BdmiuMration of tl»e t(** must Im.- i^>ntiMitit| a 
lr« f («Ji loneer. Tlie fnc« then beeouM livid. tiK' i-yt:* pnitriidc, th4> 
^pik difatUliBJlo ihr whule np|M-nrancc of thitMiirnt in horrible in tho 
mMUtrntu to ma lavxpcHeocrd by^ndirr. The pubs becomcf unsteady, and 
tbs p ap irmtino aiti* and stertorous. ThiK ix the axtrcow [midi ti) which tlie 
•daHMaUaik-n e*n b» nurin) ; for, aj^ bi'fon; >.tnted, lh« gas is imspinible, 
md if adaiinistertd Ihr a caStcicnt Len^b of time, miif I ntNMBsarily M fiitat. 
Ewm wbcD carrM Ut lbi» cxtr*m« |MNnl, however, n lew bmths of fresh air 
to rwlon the patient perfectly. OccasiotiallT lher« is aotne ezcite- 
«( rrr>»vrnr take* place, but it soon pnana off. Vomiting is extremely 
I>oring ll>« periixl of insensibility, and tl»e excilemcat allerwards, tlw 
' very apt lo dream ; and cnn*e(|aently it is extremely unwise for a 
B«a lo administer laugbitnr gas, or in lact any annatbetic, to a 
IMte eatMOl witbnnt the pr«aen«e of a third person, as unfoonded charges 
Tait UMM i aaault ham been made under Uhm circumstaucea. rery powibly 
1 mHsc* fttid fitith. 

9Mlk mai tKs adtaiaistradon of Hitroai Oxide has i>eeurred only with 
< rkhly. In I8TT it pruved fatal ■'• :t meilical man, apparently from 

J and MialysM of the riKht >tide of a fnlty heart, coDseuuenl on 

Aa afertinMiaD U IM pnlmonary circulation, which aiwars ocvun froiu the 
anU state of aaphyxla whEoh the gas iaducva. In anoiaer case, a piuii-nt, 
Ik iW laai siac* of phtblsis. fUled lu rally and died leas than one hour atb-r 
tta (a> va* aiJaiini>i«n<d. Several nth«<r fatal casta hare occurred from the 
M mmi b* tbe dnMirt breaking or slipping and beeoming impacted in the 
wyax. "thr <>oIt voikdtMiolU to be drawn from ihae caaes are, that it !• 
ast adriMbU lu girr it En cMBB of oxtrcnie phthisis or &tty heart, and tltat 
il is wis* (w th* adtniniHrator lo bsve bv ht> Md« tbo ioMramcnu necwiarT 
fcr tbs MMfBiioB itf larTDgutomy or trmclteolumy, whenever the openlion w 
■mt iB TS i f lag Uw Bsa M a gag. 





GEXEHAL KEUARKS OK orERATlOVS. 



Hitroa* Oxide and Ether. — A» hnn iiln.-ady burn nuu^l. oadi ofH 
■(.•^'ut* |)f>i>MM(iii ct'fliiiu iliMi(lviuiia)ti;i« — l)iv uDHwtliCMUi pmluovil bjr alfltl 
oxide uol l>oing futlk-initly jwniiitrDt to aiimii of tho |<«rri>riiMoee of pn 
ton]^ uDvnttiuu*. lliiil orvilicr boiog alow ul' jirodiictioii kd<1 oftn rUvim* 
by cooKMCrablv cxi:it«D>i-iit. By ihv mccrnivi; iidmiDiHUsiion of the ID 
nnwrtbitiw, ihnv i»coDV«iueDCM w rcmovrd, uii) ibi? anvnoUfir* of tli 
Iwo MC(irti). The pluD ulopud by (lovor coosUtc in the mpid iiiiludion < 
nnntlNNii by iIk* nitrous oxid«, and l}i« iiiitintetioim of thi» iiuK-iiiibility b 
the tia* of th« va|wf of oiltvr. Iti tht» way uiio ainmthflic stiptilcnirnis th 
olIiT, mill \hv t*U\y uf ihc oiiv it combiDed with tlw pcreiHtcscu of tb> otb* 

Biohloride of Methylene, i;>ri^iDa]|y miggntcd na an annKhftic by Rieh 
nrdsufi. \ia» lately becu cxtenaively UM«I, «pecinlly at Guy's Iloepitnl ui 
at the MourticldsOphlbaliDic tloepila]. Its advitnUiKefi oyi^r chlurotbrm itr 
Mid to be greater rapidity of acliun. L-'implele and rapid reoovorv, and th 
abaenoe of inuMular riKi'lity during^ adiuiiiistTatiui.and of uDpl««i>aDt ailei 
qrmploma. Over nitrous oxide it baa the advantage, that the uiMbetM 
can be aaiutaioed fur any length uf time. Thuutth Htid to be aafer tfau 
chloroform, iu use is not perfectly free frotn danij^r, more than une fata, 
cnw having already occurred; and if used for opemtiun* lusting more tbaa 
two rointi(«a, it M«nu quite aa liable to caute vomitius. To produce rnpic 
aiueMheaia, it is neoeaury that the vapor be inhaled in a* ooucentrstwl I 
•Ul« a* poMible, all unneoeamry adDiiatloo of air being avoldrd. P»r tbii 
purpuae an npparaiua ba« been deviaod by R«ndle, comiatins of a l«atbi-t 
cylinder, open at otii' end and ttiaped ao mi to lit doaely over l£o iDoiilh and 
Duav, ilie otbiT end \>t\ng doiDi>-abap«>d awl itrrfonUt^ so aa tn admit »ufi 
ficidit air for rvapiratioa. In the int^'rior uf tW cylinder is a lon*ely- fit tint 
flanni-l bag, wliiuh overlap* the open end and is »«currd by an 'ilni4ic bu>i£ 
Tlie administration is performed aa fbllovs. One Jraclim of the biohlorid^ 
of methylene i» sprinkled on the inaide of the flannel bat;, and the leather 
cylinder ia iniinediately placed over the face of the jiatieut ; at fini ii must 
ant tit acL-urniely (o ibc do«« and month, but, as aoou as the patient can Itear 
it, it mtttt be frcBFed firmly down so aa to exclude all air. except Mich aa 
paaaea tbrouKh the bat:. Uy thi«« nieana aiiKstheeia mffii^ent for opening 
an abaoeas is luiuaily pnxluonl uuder one minute, paanns off as rapidly as iK 
was induced. If tbu administration be prolonged unm the dravbm of tfaoj 
bichloride b corajtletely exliausted, the auintbtsia usually lasts about five] 
intnut««: thf patient ou iceorerinjic being able to walk atrny witli only a! 
slight feeling of giddiness. If necMiary, a accoiul dnichni may be usnl ta< 
prolong the clltct ; but the aftereymntoBia then roemblo thiae of chloro* 
torm, ibouzh ><i ■ somewhat minor degree The •iguaor danger duri 
adniniatraUoD an lividiiy of the face, and cuMation of the pube and rr- 
ration. If they occur, U i« biwt, avcerding to Bader'a advioe, to place 
patient at once in the rrcumlwnl pontion oo llio Ml aide, with the 
wall pulled forwartl. whrn thcsymptomswill znutually nasf> off. Bic 
has eonchi'lcd from rx|)vrinM-nla oo aninuiUt that in utal caaea resfri 
nod the h<nrt's iiclion naae at the sano tioMb In hoenital prnctic*'. 
time is of (.considerable importaucc, it has been found to be a oonrcuicnt 
plan to induce angntbesia in the 6nt inalanca by meaos of biohlorMle of 
motbylene, and to maintain it afterwarda as long na nay be n ww ary bf 
ohloroform. 

Various ulhrr » ubitniicca pomening asnsihetic propertiea. mA as eihyl- 
bMmiile. clilnrclhylidtnc. etc., haw bMfl tried at various timea, but liave oofc 
shown any ailvantujtes over those in common use. 

The TMalment of the Zffaota arising from an Overdoss of AuMthatiea 
la conducted on two princtplee: 1. tlic cstabltabmeot of r«i>piration, citbef 




DAKOKBOCa srUPTOMit. 



HT uiifieial. toamlo cnfitjr (he luntn) "C the vtifor c»nU)iM!il in the 
, ■ad la wd thr ax;rgt>ontiou "f tlic blood ; nml. 'i, thu stimulalioa of 
iftvk^tji'a •rtiaa. ukI tb« nwiii(«nttnof of tti« circiilntion. 

TW Ant |(rio«M|iJ« of tr<:«iRi<-oi — thni of rrcHtHblishiiig respiration — u 
W Ml I ifMa u tbc a*|>li_vx ial Inrm; the otbor — thM of stiiniil*tiu|; the 
tain mkta wfocofml ■jrn|ttoi»s an* prveval. liiit in al! iiuee tlioy may 
mmt ■■! I ■iiltgiinwlj b« ttoploved in comtilnutiuu. 

TW i r Mt m nt tn he BdoptHl ob tli« ocouneiic« of datigeroiu vjriaptoinB, 
w af BMknxit ((«*th fro4D cblorofnrm, is its follons; 
I. Tb* liminirtniioo of the irapor must be nt oii«> dtseoniiniied. 
t. Th« toofiM •bould be Msed with the tiD^vrs, ur witli ■ hi>olc or forc^sa. 
lad dnMB out uf the moulb; ttad tht.* larviix giiulicd up ao tliat the glultis 
mar ba opaord. The longrx! inuat t>« |Milled tuix-ibly ftifwards — ooi mervly 
paOtd out iif ib« motUh — for the rettMos before lAated. 
T Kr**b air >)i..<il.l \,p ailniilled Ui the (latieiit hy opeiiinfr doon and wiu- 

aod by f .' byntandrn or »iiei-utora fixm crowdinj; rouod. 

t All cuoM: ' miUI bercinov«i{ from tbe|>atient'stbnmland ckest, 

m4 ^«b» fMit' ><■ fnvly cxpcacd. 

i ArtiScial ■■>j>«»tiun luuat ot oiue and without delnr be set up, whilst 
tk«« qibar uMaaurM are bnag carrkd out. This should he dooe hy the 
method, which is ta\W d«scribcd in the cbauur <>n .^phyxta. 
BartTJcity. id the form or farndization of the plirctiic nervi-. hnji been 
. aw in siMna casta as an ailjuuot to artilli-ial mpiraiivm. Il must be 
■wtbodtcally as dcacriltcd uniU-r the treauutMii of usphyxin. 
.K» aceiV«(T niMui*. frietiou of the cxlri'initiet miiy Ire eiuplnyed ; a 
hrandjr ivUm^ Inside llw mouth: and odd «ali.-r dasliei] on the fiiM. 
otinta of amy! would apprar, from the bxperiineDta of Dabnov oa 
*i fn-in: rrrrM obwrviiliixif OH man. to W an antidotn to ohloro- 
fcr» paaiiutni: lU fyiioipat and iisphyxinl form*; the inspiration of 

A» «ap)r u^ t< iii.«n dro|ie of tlM> nitrite unluo'Iing iho vcawls and 

»— ri ag tW baan'i actioo. 

K Trwghw<tf y ur larysicAtdniy aai be nccceaary only wh«n tiie asphyxia 
• 4a« ti> iba iiH|iaTttfrn of eonie furei|;u body. a« fnlw uvth or a gag. in the 
Wyftx dorittK tBeoasilalily, ur to aecuinnlatiou of hloud in the pnaryux or 

^^^MbI Intthaitl may be iadueed by Oeeiini; a part. This ts done in 

^^^^Bky»: l.by tl>vap|ilimiiirD nfu freezing' mixiur«; S, hv the rapid evapo- 

^^^^^kiif Tvry |turv rihrr. The npplicuii<ju of a frigorino misturu of m 

^^^^^M>w, as iDinnlum) by J. Aniott, may very mnveniently be employed 

^Vanr n uia in wbtrh the iniemnl ndiniaiat ration of anneilieticB is eitner 

Mm vt bMittTitnient. It cum lie pr^xluced with oetlMiatj, bowerer, 

tB wl'i 'iiubJnnB implKSte merely the alun and sub- 

•cructures, a* ■■ i.z abiowaea, sJitting up siousea, avulsion of 

tiaaaib. ••r trwavatj^ soiall atxi suparflcial tumors. For all such purpnees, 

Wwvmr, it ■• aauwnrlv valuable. 

TW anda (if ain| Uto/nyori/tt miijtvn Is as follows: About a tumbler^I 
'd rmf^ icv I* (Kit ttilo a airDni; nuivas )m);, and Rnely fiowdered with m 
■bUa. It M tWa WMtlwd nut oa a sheot of pnjwr, and half itji Imlk of salt 
a iia^ekly niiix) wub it by rasans of an ivnry or wiMMleu )Nit)er-kuife. Tbe 
auiar* m tWn imii tuto a muilin or gaiiw Mf , suspetulcd tmm a wooden 
ra^aad applH-' > ''<• ""'t C>r from live to ten miuutc*. Su aoon as the 

lod linrd, aiitoMbesia b produced, and the iuet- 
'-■' |<aia iM'in^ esperleocod. Tbc (Kiteu part 
1 1« rivuliin^. 
- :_, i<jn<jf rtttifitd «AUr has been very Infeniously 




Ti- - 






OR!CKRAL BRMABITS OS OI-BRATIUXK. 



mod aacooeflillr npnli^^l by Kicliiirrl»ou in llie iirciluciiiii) of (■•■li] siiffirin 
lo tnexe a pan. mid l)iii« rrndrr ii Icmporarily iuitoiiBible. A Hue i>i>rBV-j< 
Df elder of H l»w Bnecitic gniviiy is tbrown u|m>u ilie pnrt to be HDiMUiettHi 
Tbe akin raiii^lly bcconit* nliit« oiid bani— in, ui laci, fiuieii. Thb tiietli< 
of iiiiliu-itiK local jubeitKibiliiy to |iaiD u mure exact au<{ efficacitiu* ifaau (hi 
by UiL- frij^urilic uiixturc, and is Kcuerally {irefcrml. It U np|>licnhle in tji 
■une cJmb vf eute^ The etJier snould be tested bt-tbrv It ia uvrd by pi>uriii 
u little into tti« holluw of the baud, wbere, if it b nt llw {irnpcr t(uuliiy. 
nill Ixiil vii>let)lly. 

I'KHroKMAXCK OP AX i)fRH.\TIO.<f. ^| 

III the [fcrT'iniiancu uf ■» ii[)erniiiiu in ])riTii(r pniclice lb«> Surgeon inui 
«<« Cir liinwelf thiit thf |irci>nmli»ii> nrv |)rii|)orly iniidf. Tht? ruuni idum b 
Itgbl, of fiilli<-ii:tit fiw, mid tiroin-rty nnrrmil. Thi.* Iiiblc u|k>(i wbicb lb 
piitieitt it |ilni-rd iiiUHt hr nt the ortUnnry l>(-i|ltl. Tlw Rtrntig deal Uibt 
usuBlIy iouiid in kitrhniR iiiixwer* ibi; ptirpwi- mirlv well. It niiu4 bv xvri 
BtciKiy Kii Uf k-)^, Slid if il i< ii»l niorr thtin ibnt' tevi irido, it will be inur 
eouVfiiicHt. It tiiUNt In- cnveni) with » bltinkeC folded iuio four Isyen 
nholb«r bliiaki'l iiiiivl )<(■ |ir<ivid<f) to {>I»<h- over ttir patient'^ Ixniy, -ini 

Sillowfe miirt bt> otiif'Mrtnbly •irmiigi-'i for i)k- hvad. A truv Hllcd with saw 
ust. or an uld blaitki't f'lliicl very tbiokty. nmy be niatvd on tlie floor U 
cutch tbt blood. 'IIr- fricinU niiint bi- nskt^d to prvvioc in llie room, n dosel 
loirels, fuur wnAliio^' basins, and two Inr^t- cans, one of hut and one of euU 
vniier, uiid a frlo]>-|>uil or fiMH-balb. A gallon or moie of Mtrbolic mid loiios 
of tlie Strei)]|;th of 1 to *J» sbotild be in reatlinvte, wliicb nutr be <liluli.-<l lo 1 
ill 40, for wusbinR the spongn. Tbe neceseary aiiKiunl iit cirbolio l<>liun 
occonting to ibc extent and naiuro of (lie operation, tmiai tim be (ireparril, 
mmI \hv cnu* of coiiiiuon water must then lie iTarcfully ivniuvtsl lo one i,-oruci 
of tbi: room, nml onlvni given lu the uurw uot to l«uvb tWn ; for. uiiln* oht 
in thoroughly ('x|H'riiiire<l. «he is aliuosi certain t<i ii>« iilaiu water iiatcad ol 
ciirbiilii- fotion during the excitetueiil of the ogwration. 

Tlie ji|ioii);iii fJiotifd be bniu^ht by the surgeon hitiwclf, and (ilioiild b4 
pro|MTly iircjMiroii. Ini[>r<ipcr]y cleaned aiMiift^^ have alwim been justly 
consi(lcrv<[ a |>ot«nl Murce of infection in wouitiU. New ii{Hin),i« arc apt t« 
U< grittv from aand. Mid nqulre very can>ful wnrbing; alter which ibejr 
should f>u snaked for nt Imm Iweiiiy-four boura in a 1 in tiO solution oi| 
carbolie acid before bi-in^ unuiI. AIUt an oficralioii the iiieshe» of a i^poog^ 
are more or leSM lilletl wilb coagtilaletl blrxMl, which mm niiehiiig in water 
will har<lly ren»ove. In onli-r to etenn it thimiuglily. it may tic s^iakei) iu s 
Stnoc s<jluiiou of nuljihunitiD iicid ; or, afl'r mai-i-nition for fony.eighi hi>urfl 
in ft dilute solution >>( hyilrH-hloric and tab-nii ten dri>|v of the stroii;* aet<| 
lo tbe ounce of water), and for tnenty-four hours i» a strong solution of earj 
bonale of soda, it may lie well waslinl in eouinuxi water, and kept rewdy fu^ 
UM in a l>Bib of 1 in 'iO earUilie ncid lotion. Aiioibcr plnn is to put tb« 
■pon^ iu a ba&in of comnxMi water litl the fibrin in its nicabes is deeoinpoaed, 
aiid ut&nsive; then wash il well in h<it tialer, or boil il ; after whieli il inarj 
bo tbormigbly washed again, aiul linally [lal into a b«tb of 1 iu 'JO earboliej 
lotion till it il wanted. 

Ilefore eoiuineitctng nn onerallnn. the Siirgcon must look oTer hia iiulni<, 
meuiA, eoi[i|Kiri[ig Ibeni, if tbe ojh* ration be coiiipiicaled, with a list tireviomtl y ' 
made out : Iil- niuat see ihal tbey ntv arranged in the oitler in whicli tlicv uv 
wanted, iiud pro|Kfly eoTere"! with a iowel. Mueh of the dUi'V(?«ful |ier- 
foniianee of an o|NTnti<iii ibjH-nds on tbe alteuliou and steadinoa of tb« 
awstauts. Uf tbetn- llirre ibouhl be enuugb. but not too many. In 



INCISIONS. 



67 



apiul opeimtiouB three or four will be required; one for the admin iBtration 

of the kiunthetic, another to command the artery, a third immediately to 

ufist the SargeoD, and the fourth to hand sponges, instriimenU, etc. The 

dutio of the assistants should be performed in silence, and each man must 

tuvfutly attend to his own business, and not neglect 

this, as is too often done, in bis anxiety to crane over 

sud tee what the Surgeon is about. There should be 

n« unnecessary talking nhen once the jiatient is on 

ib« table: ibe !i>urgeon's directions ought to be ci>n- 

vrv*.) by a brief won! or two, by a look, or by a sign 

miih the hand. 

Ac ineuiont for the operation should be carefully 
aoil pr<>perlr planueil, so as to give sufficient space 
with as little mutilation as possible; but it must 
alaays be borne in mind, that although a needlessly 
lonu incision may lead to unnecessary disfigurement, 
■1 >loes not add materially to the danger of the 
pfttieot, while too small an incision hampers the 
Mirgeuo and greatly increases his difficulties, especially 
io ibe arrest of hemorrhage. 

Im-i^ions may be made by cutting from without 
invanU. or from within outwards, or eubcutaneously. 
The ni'Kt conveuieDt instrument for all ordinary 
iacifi'ins is the scalpel. This should be set in a 
HD<j<tih ebony handle, which is lees slippery than an 
ivory one when wetted with blood, and admits greater 
delicscy of touch ; it should be light in the blade, 
nearty straight-backed, and slightly bellied on tlie 
cottiiig edge. The heel should be as wide as the 
widest part of the blade, and there should be no 
"'Dstriction where it joins the handle. When very 
l^■r and exiensiiv incisions are required, :w in the removal of large tumors, 
ri- .. ;i Li.-lon's spring-backed bistoury, of proper si^e anil sluipe, is a very 
(•.■Qv«>nient in.-trutMeni (Fig. 2). For a siibcTilaue<ius incision, ii very small 
cs.-r 'W- bladed knife is requireil. 

The i-nliuary scalpel is held in two ways; first, like a pen (Fij;. ;>) ; sec- 
■□■tiv. liki' :i dioner-kuife ' Fig. 41. Thi- firmi-r piwiiion is tliut nnivcrsully 




Pig. 1. — Bittaary beld p«r- 
pgniiicDlarlj. 




Fig. 3. — Knife held like a pen. 



a'|..;'[--l in dis^ctin;; the <leii<l bixlv. and the liahit r)f ahvavs hnlding the 
kiiitt- iu tbi^ vin\ is utit/ of the first fdults u liii'h a ^tiiilent (.■otiitiii'ncing cipora- 
::ir -iirL't-rv ha^ to correct. In dis,«<'ctii'Li, aUo, tlio siuiii'Ut liahiiuallv turns 
b:- knifr fn'Ui the deep parU tiiwanls the skin, so tliai any slip of the knife 



nKNKRAL tlESlARCS OS OPK8ATIOX8. 



mnr iv<i injure iIk- xilic-uuneoiH Mructum nUicli ir if hip obji-ii t<- )>ri«rrrt 
In raixiu^ ttn\i> in ilii; liring body, ihv rcvvrw Rii»t U- tlir nili-, uf, il' tli 
•kin aud xubruiiiiivoiu tiMuta are tconA bjr tlie kuifc. the Bmp will n>rt&iDl; 





nc- 4.— SnUpd b*M Ilk* • dlaav kDir.. 

clntigti. Nitirtie who hii» not tnu^ht ojwniUvp •iirfrori- <hhiIi1 rotit-piv* bi>« 
diffinill it t« tn corrt^C tlil« iiinnt dna^muf hnbit id yntine <>|>vfiit<>rs In 
making lui ordiaaiy iDcisiim from withmit iDwnr<l», nc in ili« rcmornl uf i 
Uimor, or in cutting down upon nn nrtorv in it« cnntinuity, (he »kin miut bt 
put gt-ntly on Ibc Mrctoh, and thr knifo rntcm) perpend icu la riy to ttl 




n^. ».— DltMoa tt Ibo Cutta on » dInMor. Blaat bvohi M4I»| apan (b* « 



tarfiter. to a* fairly (n prn«tnili' Ihr fuWiil)Li>er<iis fat : llio hnndio may then 
hi> liiwi>iT<l. *•■ ihnt tW iiK-i(ii<in if poi)linue<l uiili ilie lielly of ibc knife. 
Tlii> nmy lir ilotH- tiy drawing the knife »ti-iidily ulon;*, if ihe e*igv h k\"4 
and the (Wurs nrr nVn particiiliirlv rreiMini;: n>ore ofieo, however, a tlitiht 
rapid MHinc; ini>venirnt is nviutreii. In brinKing tl>e knife out again, iho 
hnndhr tbould bo raianl au ihut there nwy be no "tailiDg," but that lb* 



A 



INCISIONS. 



6» 



iMiwv BMv h^ <u Msrly m» puMililf af vqual (l«f»(b tlin>ughouL The iMd 
ykk at fTBtlitallr I'Miii); iriiiith u th« tucUii>i) 'u •)FV|><.-ni'd, ao ihai. for 
ftwrir ■ foar-incb iucuiuii tfarou|cli tlie ikiu ia r«du(.-«il t>t tlnv« ul the Ikdcia, 
Alia bit lanAiItT ftvtMii««l. Ah i>r\liiitu-y wuutxt U ifrtuluwlly <leepefi«d by 
■■fiT dmwitic tli« kuifo oIobk it, with iu uigv •lin.-cii.il (lowiiwnni* mud 
■■ralliil lo tii* iDCMtua, until tho i]««p liuciv it nMcbed. As, the wound is 
•Mpaaad it i«, if MonwrV, Md upt-n by mn BaMtiitit irith blunt luioks or 
^■1». TtM diviuMi of'tht^ <li>i-)> fucia uA«a nMiiiiriM cnro, os ini|>or(aiil 
«ncnu«i mar li« beoMtlh. which it >* noCMMVjr to avdid. It in d(kii«. tliere- 
W«, la MM af t«<i nay*. It tuny Ik- [iiclc<vl up Hiih u [usir of diMecditg 
itimft, sod » tuuill li»l« van-full)' iniuU- in it. tlirougli wliii^h it direvtur may 
htiaiirlrd. up»ii wliii-li it may be divided. th« back of thi; knifo IicIdk turned 
^a uaa M* i.Fii;. '>>; or. thvunoll bole having bncn mniii; in it, tbu point of 
m» blwlr (tf tliv forcvjH may bv i»tn>du <.■■.■• I. «nd the fiutotii Miied aiM raiiH-d 
i^blly ftum tbr (utrts Ix-ocatb. Tbv ^\Am of the knifi: then brine turnod 
Aiaaa a tAi, tbr irirtiun uf fW-in rni««>l in ihi (oroOfM i* dividod in lh« 
Juaedott uf tb« iavbion in ihi' »kin. onlv tbo last half-iocb of tliu knifv 
boac Had. A fnA buld is then takiii with Iha forcvpn. uud auirthrr \nixv 
^ vm lutim divided in the same way (Kig. ti). With n liulu practiou it w 




I thNBfh • t\ni» SptooOT W«ll)*> n>rMTi« on • blMdhtf <MML 



Dloal 



rf ia iU» way in nwk« a clwa lincnr iariMnn ihma^h the fiueia. It b a 
adl min plan than that uf uninir a ditwtur. u nothing u dividt-d but tliai 
v^tlt M n,mA t>y ib^* ("nv^n. nrhi-n-iui in piwhiiii; a dircctnrbliixlly nndera 
fcaiia ila poiM may pwa Ix-nciiib ■"minhiii;' whirh it i* Dot intondnl to cut. 
VWm tba li«M4« an *<-ry Ins l>tu<-jiili iht- liuda. it ia ofton a convviiient 
pha IH s«i4t • iifotH-priintnl iMatouiy on ibe r<ifi-ting»r of the left baud, 




TO 



OfiXERAI. REMARKS ON OPERATIONS. 



inMend of iisinf; a director. Th« fiD|;«i- u tli<t Imt powiblc iltm-tor wln-n il 
CHU be uwt), ns it c«ii be ^liliil morr or Ii-m by ncimti'm. OcriiMoually i> 
■levpenini; a wouikI tlimugii vrry liiow Kiruolun-o. xiiinii)^! which iin]>vniiBl 
Teaielo luay lie, os iti removing tumor* fmm tlwi mot ul' tlir nock or ih< 
nxilla. tJie iturg«oii miiy [ireJer to nink<> UK-ol'n blunt iiiairunwnl, sod tuicai 
Uie lianifs tiiit«iul or ciiuiii)j; llirtu. Wilb this vjtrw bo nmy iikp lu<> |Mtr tij 
furcejv, or one pitir of forct'iK' iiu'l ii <lirci'tiic, or llx- htiiti|l<- cr n ivalpi-l, 
H^ miiM uoi, huv«ver, Iw Crmptwl 1» utv iIh-h* forcibly or riLrlily, lu h j' mi 
doing unich tnbcbicf may b% produce). Ho nnifl unrk' iii«iho<lirally. [uck- 
iOK up whiit hv tnlpiHjs to CUr with tiw (iirtvp*. autl Ixiug i-arelul to irnr 
<»Tr whiil hi- hiui tbu* Mncd. In some vhmw n )>roj>erly culliviiu-<l I'm 
nail or thumb-uitil will br found m Dioet UMful inelrumeiiL 



PItKVKNTKfN O*' UKMuBKIIAGi: DUI{l!C<t OI-ERATIOSS. 



IMf- 



Li «v«ry operation iurofving tbe uw of Uiv kuift-. low of UIlkhI ilitrinR it» 
parftmnsiice is the grenl primary duDj^r to Itc gunnlrd *gmiiii>t. 11)U may 
M pnveiited mMtcunvcnienlly in iWi-xtrtniiiicoby ili<>H«uof tholounii^uet 
or tn« elnitic hand, or by an nwtotant ci>Hi]>r(wing the ntaiii art«ry uf lh« 
limb. If tti«M«li>f tlioo(>or«iioii twruoli iwnut tosilmit of ttii«. lb« BMUInnt 
mar coniprcM Ihe bleedini: vcwcia oh ihoy nrr diriili-al iluriug ibi' o|)mtiun ; 
iin<l lu iKiun as it is coiK'ludeil. In- f»u n-mnvi: hi» BiiLt-ni fruui th<-in, tjoo byj 
otto, to admit of tlivir Wtng li^'nlim-*! or Inixtiil, Tliii> plou hu. however,! 
tbv incouvniii-iiw of i<ccu|iyiiig ihi- iLiaiolniit'* liaudn at a limu wh«n theri 
m»y he waulod to htlp ihc Surgi-oii. and it will In- found niotv ponvrnimi if 
ihc vcswlit l>o n-iioxl in a |>«ir of cutcli forc»'iu> ul' tlio |ialti.-rn t\-o<)ion>wwtcd 
by IVan and Sir T. SiH-uwr WclU (Fig. b», Thwc forwn* havi- »c«orj 
haudlw. and tho griirpiiig t'Slrcmity is rouf^heneil by rather deeply cut 
UluiavcrM' (cplh. Tboy can be applie<l iuBtnutaneuUBly. and their hold ^^ 
ftxttcmelv lirm, and from their length and weight it 'u easy for the afei^taut I 
to kee|i tn€Di out of the wound during the o|>eraiion, nhilc at the i>anM' limn { 
kiN flntterft aire Ttw to bclp the o^foratur. At tbe conclu»i<>D of the operation, ■ 
it will freqtientlr be found thai their pressure has !iucc<«de<) in peruaaenilv . 
arrmtitiK the bleeding* frum ilie veasela to which they have heen applied, | 
Their aitiuu in this resiHrct will be more fully dtacrilio) in the chapter on ibu ( 
rermaiienl Arreei of llemorrha)^. As a rimuu of temp'ironly atrvHtinj; 
bl<«<liug durinc an operation, ihey have proved of thi- ftrratol (KiMible value, 
n|ir<-iany in ofienitinns atwiul the bend and neck, ami alidiuueu. 

The Tottmiqnet and its Applicatioa — The older Surkt^Kn* fn>ni tlw iim« 
of Archigcues, a Komun who tive<l in the *eeiu)d centurr, b»und a light 
narrow band, cjilled "the Bllet," round a Hmb during an amputation. Tho 
lillot wiw intended to serve three purixMeit— lin^, to steady the muichv during 
the incicioii : tocondly. to numb the limb : un<l tlunlly. |i> nrnsi the flow i^ 
blooil : but it tveniB m have but im|iert'e>-tly KUc«tH->led in imxlucing tlw 
deeiml nvulb. In l*>T1. .Morel, a Freorh Surnvtu, piTfcctiil tlie filkt by 
intruilucing a p)i-o<' of iiirk hrnenlh the Imml, tiy ui«an> of which it ixxdd 
be twi»t«i| up and rlKoifnlly tigblcii<:<f To pmiovt the limb from l<eiug 
briit»c<l, ho iiitTTHluccil compn-wrv ben<-Mlh llic band ; and to iiutiri- tbe BDore 
complete comiirciiMon of ibc nuiin nrU-ry, he plaocd n rolled liamlaeo aJtHig 
its courw. lwn<-alh the knot, to MVt- th*- *ktn fn>m being pincl>od, b« 
plaocxi a picvti of leather or thick pn[>er. To thi« apparaluii, be RKvv the 
nninr of " tinirniiiui-t." TIim tourniriiirt in tbi« primitive (orm »■ miM uwful, 
in the abMnoe ol auv other npnliance, for thv tem|H>rary arre*! of b*:mor- 
rita^. A round peblile or any banl Inxly abntil tlu-iito of a henV egg, may 
be rolU'd in tho middle of a pockrl-haiidkoroliief and bid over th« lurlenrt 







TIIK Et.AHTir TOL'RNtiJL'ICT. 71 

vt lb* ttM»lk«rchivr botiif; knolUwl r^und ihe limb, mkI t]ti-ii 
ap UehtlT *>iili n }f\tcv of Mick, In iIm' hiin<l* i<f nn iunumiil 
fauvwrr, llii- [B-libl* would prrliii|>* Ix- U-ilrr IWl mn. iif. if ic wi-ro 

afaty VMB »wu f<- Tlir pim of (i>T<tcil |<ci|i>'r bvtivuih lliv knot »IkiuI<I 
■ ng b« awitliil. iiv cffUHH] by ibi: pinchiog uf tito Am wualcl b«i 

■otv tku Um |«i>' I tw-nr. 

1W ■(■(«« tiM)niti{[irl iitiii-lt rrptat-i-d Mon.-!'^ iiii|irrrecl »p|>iimUI». wu 
«««Wm) bj ibr c'V'Vt Kmich Sur>;«^-ii I'Hil in 1718; nnti, itUliotij;!) lh« 
ilruiU <if tU mnrKnnifni liavr iiinlert^iiH' iiiipr<>veiiii-iiU, ibu instrunieDl usod 
ts tbr | OT»in t iImv u MM'tilinllr tliu Mniv tFii;. 18), It muv be applied 
■idi wr atl&oat • jwil ii*iT ibe urti-'rv. If n ]<ad be MteA, it t^beat riaiU uf 
k niMMiM ttill^. fram l«ii uiil n hitli' (o thn?« iticheo wid« : of ibiit h few fevl 
wM he unnilled. Tbr roller b ibea placnt lou}>itutlinully on the nriery, nnd 
tk« ttBnJUU |«n OLrritrd iwiw miiud Uie limb so as ui keep the [wd iti |)i«i> 
tM, bat cafT niM b« taken iu doiu^ ihin uu( lu ooiutriet tlie part siiffidi-iitly 
la tamm v«DMa VBMwpawDt. Tbe louniiijuifi in iheu applied, uod thp bnnd 
b«UMl wbk an wW t llghtncM lo keep ii in iu place ; btit the iDiLniiiMOt 
ifcwtld M* ki' - <ip until liie tnntnvui ■>!' the operaiiuiL It Hhonld ibtm 

t« tigttfft— ' I < a* In Inaeo lb'- liiibiiUy to ODUgtMiou of tb« loirvr 

Kof (kff Uwti ilui almrj ■x.-i-iim nht^i a ii>iiruii|u>-t is applied, but nhick 
fMiaUy aM In (-UMir whfii tbi- imtruineiii is slowly acrnwed up. Tbo 
inaaflect tif tm tigjlitniiof of ilH>ii>uniii)uet i!<i<> fomprtw tbo ImveTVinat^ 
! iW ttMb, thr •vvnad. to iim«>l tbr Htm ni hl<M«l thrtiii^'h ih« iirtcrin : tioneo, 
I l3m ■on ' ■• f Ufd in act, lb*' invnt'T will Ix- tlir vvnou* ■.'i){!>>rie«- 

I MM* of v- Tbc bloml tbnt fl<i*n I'miii ibc limb during nil aniptiiatioa 

I «fcn ibo tooreiqiKl la agipllcd »# abnvr docrlbed, i« almoM viiliroly runotu, 
^—•«!t>' f'-'^' it— l-mct i«rt of tbo member. 

^ft A ;<H< taay hts M|iially nell iipplie>l willioiit a pml f Fi^- 11); 

^^^n i •«nnr to put a piMv uf canl, foldol [wpcr, or Wilier. 

^^^^^ to Mivc tbe «kiu fn-ni beiD){ pioctioi. Tb« |i«d hR!i lbo< 

^^IbdTBii la^-r .<! IviD)* liable l<> flip, and if doI very ncitirnlcly applied, 
R land* rstber lu prv-tM-t tbe artery from pressure tban to einupreM Et 
4iiaMHr. Thi' icn** hiuniiquct ii^ now almoai completely nbandiwcd 
to favor of the (imple elaitir band. It in, however, it uMful iiutrumcnt 
afcaw iIht "itrrmm \t •b«rt of *kiHe<l naautanta, and eapecially iu tuck cmm:« 
aa «<wiMla uf tarnv nniricr, in wliieli an ocvaaiunal relaialion of the Uxirni- 
fwt i* ivqaire^l m nuid-- iIm- •■jMrntor i<> tlio iiijuretl veaael. 

Oti^nMioB by EluUc Tubijtg or Baadags. — Tlt^ cirvulation ilini«i|;h 
a hmk mmj b« otrnplctrly arrvMn) by INU or three turns uf an elaMic bnn<t- 
^* applied with muik-raie fimiDrsa. The bawlai^- may then be •ecur<-<l by 
a kaut «r by a ntn. I>irin)r tbe Franco^iermau War, ttip ti«'lil lourni<piet 
out to tli« German armv. rotwixie^l uf nothing more llian a nitrruw 
faMtdacv about nuL- ineli in widlli. and tbn« fed lufiff. Ijtunrch, 
^ Kirl, ininil"'-"! r» .-> •LilH-itnu- fur the bandnfre, a iiicn- of India-nibbcr 
lakia< al- in dinnwter, nnd ti>i> lect in len^b, having 

a book (i - ■ -.. . .ui vvc to tbe uther. Thia i* itreidtoil ana 

wqnd £: ■■ rafiilly tiiund ttie limb tiri> or three tiini.a. Il olteo 

tapaaw tti^i o^t- Ixwk dotw nut invrl the eye exactly a# it ti wanlol (o, 
MtkKlnthrr an riira turn <tf thr Inb* u)u*C be |>ut round the limb, ur tbi 
IwMar titfsa nuM be uwluly rvlnxeil. Tliia may be obviatiil by rv-plm-tng 
d* Wak MmI arv by Iwu piei'n of *loui tape, iHnind ><n t« the end* uf th«t 
UlMwbtvr iti[m: Tl>- idIh- i-nn then )>e applieil nilh oxnetly the nmo<int 
WI«n t«<|uirrd. aij'l •n:ir<'d by Ivin^ the i-ndr -d ihr la|ic lif^-thor. It 




GRNEKAL KRIIARKit OH OFBRATIONfl. 



niuM III.- n-tiM-iiiliciw) itiBt ia npiitviuf; tlic ImihI, <-iiu«dou* [ nm uw b 
obuiiittl by B firw lunta one over llie >>lbrr, hi niin-li mi, (list in aitunt: 

whioti ihc cbiff uorviv lip very 
cl<>r til ihv buo«v, iu> in ihr km, 
•^ni|i(>iii>f of |iHrHlj*iN, fttinr- 
tjro«> liuitiiii: liir m^.'du, mn tr- 
cuHmI by I^iigt'tiU'dl U haviiig 
rfultcd rruai itc Um>. Socli MV 
dilciiU »n more liMv in uccur 
If iIk- tiarrov iul>r ii itMft, ilimn if 
llip ti>nilnetio(i lit iitiiilt- liv » 
hitn<UKF. Tin.' Intirr rlumtd, 
llifrrfon;, hi- pn-firrrr"! wlicre it 
Clin be coiive-imntly Hiiplii-il. 

Id («riaiii reKi<'<M'p^ci*l plKD*, 
liavc tu be aduptMl in tti€ nppli' 
cnliunof lli« elulic I'runiiquoL 

In exduootorampuMlioDa nt' 
the itumtdw, ihe ludta-mbbarl 




nt. T.— Kinwab** Taurali|M« applUil to SbnaUw, 



tube must be rtrrr lorribljr Mrvu-h«<l utiti iir>j>li<il round lh« shoulder, the: 
lowvr pnrl of tli« tuni hetni; bi^h in tbtr nxilU, «i n to coniprees ibr arterr , 
Bgaiiiit the neck of tbe Mcnpulu iind tlie upper pnrl, a* fur as [Hiwiltle. internal 
tn tbe end of tbe ctavKb-. tuid ibo Bcnuniuii pri>ceMt. To prvveot iu tlippinc 
iowards, a piece of bandatci' should Iw put bewmb it txitb in from ana 
hehinil at ibe liiuc il Jh applied, by incanit uf ivbivh an aaiii>liu)t niajr ImM it 
in jK»i(i->n (Kjj-. 7), 

Iu o[>eraiiiii: ui-in the upper part of the thigh, ibf Imlia-rublKT tiilii<(na*t 
be of :iulfi<.'ti'nl Icn^'lh l» go round lb<' limb and ili<- jivlvi*. The middlr of 
llw lube ia to In- ■)>plii-il to lh« fronl of lln- tliif;b iionii-'liBK-ly lirlow tbi* 
gnun; th<< tuo fnilf ari' then lo Iw (.-nrritil I'-inibly nxmd and bn-tiuKl up b> 
llir fniDt ajniin, nbcrv tbty cram, and nn nftcrwnrds piiM«d round iW ptrlTb 
imUKxliatvIv Mnv tbe cnvt of ibe ilium, 




ng. *.— B— w>'« TMratfMt to Tb%b. 

In ampiitalioii at (br hip-joint, a b>nii piece urbaiKtai;ir muil Ih- Ini't uj 
the nii'tdir "f tin- urn'm in (lit; lini.- uf tbe limb, and a tiniibir pii-c<' iH-bind, 
nvft wbicb ibi' IiiIh' ik iu be applied, bo riial by pultiiiit <>ii ibo cndt uf lh« . 
baudfl^- any iliiipinK <>f tlw Wnd mny lie prcvtruirti durinu lh« Opcnltna.' 
Till- miildle of tiK' lube ia ^l be plii<.-*-d in tin- iierincum. and tltc eonn jiuDnl 
riiriTibly mitwnnlA. am) crflaaeil an bij-b nlniTi- ibc lr>>fbau[er a* {lowibli.-. and 
nitfrwnrib carni-d ntind ibr jH'lvis imnu'dinli'ly brlnw the cmt nftlH* ilium M 
<Fi]{. H), If the bandii)^' is apjilieii witli MilficH-nt f'irne, {| b quite imnrn*- f 
mrj to put any imd utrrr the nrU-ry. In thi-ari'ompitnvinb; 6i{un', ibf paiiriit 
fa lyintf on bi> side, iriib tbe rik'hl tbJh'b Aexcd, in the puaitiun for an oral 
ABijiulaUt'ii nt tbe liip-j»ini. 

u ofienulviu upuu the jienu or scrotun, a plcco of btodap ^iMiId be I 



THB KtASTIO TOIBNIQUBT. 



73 



itoiiWfpiiM brbind snd bru(i|ibi fonniril !<• tli<- wrouini in fraiii, Thr 
mtiini ih* lab* b ih«« |>IbcciI in ibeporinvuin, ■»() tlx* Iuwit rnil nf 
ft* h n ilfa lurnnl u)t I'rrr it. Thr ciwM nf Hit lubi: nri; liifu hruti^'in 
(mud* fardbljr. uitl croMnl on th« |>tlbn, ond nni'rnni->h mrrk-<l mtiiiil 

thi' [wIvIb initlwny iH'twwn lli*- 
ImrhnDlrr* nml ilii- i-rwl of thv 
ilium, luiiijiii): Irtucoii thrlwo |Nins 
•if the ImtKln^i-. nliii-)) iire ibvn Iwd 
(iigi-lhcr. tlitiB Blltichiiiii; (he loop of 
thi- lulw [but eurniumli Ui<> Mrolum 





^V ^— AfnN af H*Hi«rrb«^ Of«rstl«*« oa 



te R)r>M. Th* 4MM4 liM It lb* iMlitoa Flf. lO.-KMtrtb't B.nJ apjilM Im Opw 
bitB »«> •BfMtoUo* M lb* klf -Jalat. ■tlan* m lk» Pnia or Sfraiiw. 

k A* |«n «hldt puan behim) ; utiy slijt{>iug of ibe lube during the ojtent- 
!»■ b tliiM nrotkrM iiDpt«*ib)ir i Kii;. 10.. 

MmUm* Kaduidl. — Variiiiu •Irvio^s h»ve Imwo uniploveil for inaujr yvan 
fmm ta lUtomtth tbf !<■« nf b)nml ituring u|H-ntii<)(i« "U t(i« cxtreftiilM*. and 
K ibr «un(i time to g» ri4l of iho biiNwl vrbicli (itlirruW lilin th« woiintl, nnd 
B,^ ... t._ .>,o(x-al» iHi- •U'l*' "if ilip •ij(('rBUoi». i-vvn w)H-n llw tquruiijuot 
: tarf : ii'il. Till- '>l>Wt of tluMv i» liiuiiln^ng tho limb* firmly tii th« 

^^rT«I SI -i>« II ibr tnuruwguct ii n|>jili<-<), U'fori' iigblvoing the ktpw. Tlii« 
^BM &NiD*l i>ol lit br vrrr officicnt, opocinlly irbtn a pad wm uw<) ovor tbe 
^^pui artrrr betMalh the baud of ibe tounii<}Url. LiMer hu (hown (but (he 
^^bb Majr bf rmdrinJ abMlutrly bloofllMB by fimpty ctcvad'nc it at bi);h ns 
^^iMible fi>r bI>' i i ninoie, and (iteii rapidly applying ai) clastic baml ur 

■ «aw loanii . 'Ut a piti]. To ha^len the (.■mpiyiu); of the blood- 

■■■la, tl» littili iiuy Iw rubbed 6rmly in (he dirE«iii>ii uf the circulaiion 
{T|^ 11 ,, Bv rx|>eninrnt he ba» further ihonn that thi^ h bri*uj>hl itbou( 
■M vnW by thr rmptyiriii of ihc veiit^, but by e>in{nii.-ti'.'n of the ari«riea 
«kMi nontr* whrn tar limb b plaoni in the elevaleiJ [io»iiion. tv^umrch, of 
Kill. bM Mlaanod tlw «un« r«»ult hy applyiu^ an daalii.- bandage spirally 
ft«i Um 41aail fStrMofty of the lim'h upwan1i» (o ihe point at nbich the 
tiWiii^Mtt <>rt>la*tic baud is nppli(r<l ■ Vlit- I-'. On removinn the elastic 
fri.tn t>rl,T<i ib«> u>uriil(|ui-i, the limb will be found to be abjolutelr 
httan very Ircjupntly rteldin({ ivo blood on beinf; cu(, 
1 "f (h*- plaMidty of (he skin and tbe relrarti-m of ih« 
V. ■■xactly nw mMm noe on a dead body. In ibis »taie 
^^^ '•— •• ■ ■ '"* •'^n nnd li<^l Iwfiirf the tourni(|Uei is renwvM. 

^Bpfe nair. ', nhrn thr blixHl r«(urnB (a tbe woundexl [>an, 

^^^Tv (W« •■itii^ "-. Ill nhieh uflrn (akeufxue timu lo arr«et by mrnns 

^Mf onM atKl rKpurarr lu (bv nir. Thil* it may liiipptrD ihnt ihe patient 
^BkM m» Modi blood M if Moniitri-li'i mi-tlKxl had not Ixt'ii emplnyi^l. 
^P r— ■! t li baa, b(mt<T«r. Inli-ly aihipiiil n plan by nhieh h'- ii!«crts that 
^»«a vpvBdnnacai tb* witn-mitir* rnn bi- mirkreil actunlly bloodlen. H« 







74 



GEMKKAI. KKMAKKli ON UfKKATtOKS. 



Hnl M<ram cvcrj' vnwo) viiiblp on tlio lurftco af the whuik), and ibn 
luirinf{ pill in lln' Hriiiiin||.i< lulm iiml IrilriMluo'il tlir nutun-f, he a]>pll<« 
ilraai&gct'iiiiKiM'diif niiliM-i>ti(-}fium-Mirr»iin'k-i| brcntMii-woo!.iiniirryii»lt 

willi eiilirvlio ncii!. wlitcb in miMlcnil^Iy firml 
biiDtln^'i'il lothf piirl. The limli u ilirii jiUcnti 
in Rti i-I'Viiict jHifiiiion, nnil linnlty iIh- rliMiioj 
l»utiiK)iiel i: remove"!. Tlii; clcriitoi [i»aiiifia 
is miiiDliiiiieil for at IcnM u hnlf h<>ur or aa 
hour, [ii 1'.' ciiH-H or Hinjiutaticn uod -'til rx* 
cniotis in which ihis pliin wsa triotl. it »iicor<-H<il 
IX-rf«ci1v. In 144 operations for tM-cruiiii, it 
wu neccsEary to ivmovp the dressing on sccoont 
of lieH)OTrli>i;« in tix cases oaly. 

Vnriouft object ioiw hnidee Ibetubaraucnt ooxinz, 
have b«eu roiswl to Eantarch'a bloodlMi method. 
It has h««u billed thai it Musw aioii);htng of 
the HajM iin<l iucrttawA the leixtencv Ui »k>< 
oodary beniorrhajK« aAer larj^e amimtBtioti?, bv 
onnsturally au^Rientinit tb« pn>|Mrti<Mi uf blood 
in tb« bofly, and to CtvuiK rise to iDcrcaaed 
an«riiil trDMon. Neilberof tl»e*eaiat«n>etitai« 
•u)>|Hiri(.-d by esperivDce. A more ratiooal ob- 
jwtiou n[^iii9t it it, that wbi-n t)i« limb it infil- 
trntcd with th(r ]>r<idnct> of iotl animation, or 
whtn pi'r)iH|t« HoiK exist in the vrinii, thntc mar 
hf ilrivi-ti >in inl'ilhr oirvalalion by th<> njiplin- 
lion of tin; t'liistir Imndagr. AllhoU)(h no c>M 
of »ich an aui-idt-nt ba* hern rci-onloil. il would 
be Mifpr vrhi-n •nch vondition* •xiirt U' I'mtKr 
IIh' limb nf bbxHl bv ibe nm|>lcr plan nf Hrva- 
tion as before dcaeriDci). Tbceanw plan \t aim 
tieltrr cmpluyeil in (»m« of cancrr nr >iir<'<imn, 
Ed which the dangt-r of dt'tod^-iiiK parlicin ami 
ilriviiii; ibcni into tliv oirctiLatioa *uuld b« vcrjr j 
confide rabl«. 

Tiie advanla^M of the hloodleas aHliod wt 
o|iei-fiiiuK, Mprctally iu diseaaea at btmn aaA 
joinlA. far <iii(H'i-i);h »nv snppiwteil di^dvaniageo- 

It is ililKcult to -Huy liow lou-^ coniplt'tc nm^t of ihv dmulaiton tbraiieb A 
limb HMj b« mainiaiued by the eliuUi: band or the touniiiiuel wilbont 




rs. ll.-LlM«r'*UMhU. 




dnnRvr of uanifn-n 

lllt'tti'al iltl< !>•'• I 

Compreasion 'a 



Ir miHi necxwarilr varyacxM<rdin^ to tfra. Eaoiareb't { 

ilii-nt iliri'i' lii>ur» witlioiil aDv 4>vil rraull. 
ji^Lfl Arterial Tnutk it in tho pnm-nt day employad I 



only H a trwinrary vx|ie>lii-ni Wfr>n> a fxirniiuul cam be applkd, or linm»- 



coHPHltnsioN or UAIN ARTKKIKS. 



76 






UWr it* rMwiral, wbllo m fow vcasels before mi-U)l(i« an Wne 

V itt tkoM riiuatlotM in utiirh the a|t|>1im[i<iti of n looniiqiipt » 

It t* ftr *af<-r I'l tni<t to nii litntniitMiii, tliait to the hnmls <if tin 

iMMvvwtcrB'lr Binl •in>()|r. Wlitrii ilic Kxirniiiiiift is a|)|>lio(l iriih 

4t^rn' "f ii:::hinr»<, ilir itlmli; circiilittiuo tnrotiKh the linili is 

I III) iicviT Iw i]'<ttv \>v ih* tomiireMipiii of th« 

L lu-rnl tvcmU vtmvrrmi; IiI<hm) iiii-> ihd limt> 

iv •■)' it, TWn nipiii), if tht ngM-niti'M lie tines pt-ctfilly pm- 

frooi aair I'kiMr. tbr Utiprn i>( ka lUiiMMit m«v tire or Milfeii ; atKl, 

uf ftirir [tivHiiirr U'Cxxniii)! r<rtaX(ii, lii-morrliage mny ensue. 



TW 



1W Ob m ob 






muHiB*, Suri!ei>nii iovtiriiiblT einiilor lbt< l»iiniii|Ui:t iii URi|iutn- 
tmi vtni l.iilon. who «l one fM-ri'Ml uV liu canvr •liM.-itnied tlits 
1^— >. ,..in.....ptjr rmpltiytd it iltiniig llir Inltarr yr»n uf )iij lile. 

II fur thi- enniprcwi^n uf iirterin nn* lb«M' nt wliic)) the 
w ■ '-■ •iiprrfioiat, iind in pliuxtl »intr M>mc Ixioe nifiiinst 

it IV Thv f(>ll<i«n»g »n ih* cliirf iirt«^ri<ii which the 

,1 IK- ijii'«i iipmi |4> oimiiivm. 

Cuottd mi be I'dc pulsBtinz just ti}t«>fnal to tlw sterno- 
umI m btt coMiipnned by pn-wing ihi- ih'iiiiih itircctly b«ckn>nU 
tbv vrttmhnf uppoeite (He criooiil caniing*- Fig. l^S . Ti> stwuly 
'. '' I "iihi grni^p lh« bnck <if the m-rlt. Il miMl not M 

ti -uiT i>e iipi'lieil brlim lli« trnniretM pr<MW« of the 

r», the vertebral artery irill bo compnesMil m tho ume 

, Utttj tf i'tt»)Ir c>)fiiiireeae4l n^'sitn*! the jnw, wherv it lien i|iiilc 
Jy iiBiDMltalvly in fnnit of the miirriiir bonier of th«- mtiMi'ter. 





U» An^rr* nwy t- 
ba4. «ihI, if o*«««d. 
^HMlaMapaa lb* imbt 

lit •■msral uttiT I' 

te*ly ift rn«t of tbr raT 
Tk mbdivUB artery 

' f a';< .Fi« irk Till' 




Flf. II^CaapnHlna »t W«k lh« FMtel, rifhl 
TMnr***t> ■*' rlfht fabaUitM ArlarlM. 

'he opjMMile Mflr* of the jnw to sleaily lh« 

int nuiv«lnn<l twhiixl the f<aiiei)l 

bnufa* in the liKiire I'lgi. 14i. 

■ni where it cnn be fell |i(iluiiui; imiue- 
I :_ . I '. 

mar ri<*|iiin- eoiiirirnniiin in iIh' thir<l pitrt of tis 

niillii, or oil lb« •ViohU'T'ji'iMi. IT in nni[in tut ions 

.>1 r>iniprv'ui''ii Im- al|i'm]>li->l. thv ilouers should 

f-^iX "( thrjH<ek. with (he lulm of the bau<l QD 

then foreibly prt-weil 



rhlgr ttnmtl Ity the Irafiriiu*. Ttii- thumb i* 



76 



niCNBRAL HKMARRS ON OI'KKATIONS. 



upirD tlw urrcrv. where it li«a oo the first rib. i in mediately Mlornal lo U 
oiitfr Iwrtkr of the su-rDO-muioid and oppoeiie the most jirotuiiient [«n < 
tilt' clavicle (Pig. I't), A oi>nsiil«rablc ioroc ii reijuirei) elficicullv ti> ran 
|>nrw ilii« iirierv, the liiit:«n ol' (he oppomU- baud may be |trv«»ed upon ll 
iktiitib which JB ii|x>ii ibo Tccael. Tlie ptiti«Dt'« head «hi>uld, if powible. I 
loclined lovarde the aide <>n which the arten' la beiiiK cumpraaied, m a« t 
relax the cerrical fascia. As the furte rcuiiire<l in olVeu so (trail ihai ili 
BMitbiDt ii apt to become foligued ao<l relax hit> prewure, it la ofleii Ix-tif 
U> eompreee the nrttrv nlth aonie nteclianical cunlrivatice. Tlini iii<«i o-n. 
ntuidy eiDptuve^l ix n larjce dwir-kcv. The riiitc of thv key b wra]>|>e>l riwrn 
H'ilh a fitriji of liiii, s>i u» ui |miJ it mffideiitly tu jirevent it iojiiriDi; ih 
mueat: (Ik ntla-r end U alv< well paddis] to protvil the ■iir|^>un's tiaii< 
The uaddnl rinic i* then prap«d (iircttdy ilnau upon ihi- nrli-ry in (lie •iliM 
lion oetnrt •lf9crilio<l (Fie. I<5), 

In duMM in nhich the claridv U puA«d up by nn ancuriinuil inntor, Sym 
recMumcndcil that an inciMiin ilioiild be made abov« the clavicle (hmugl 

thv akiP and d«ep faacia, « 
that ihv flngcn of lli« a«*uuil 
might be bmnighi tA bmr almut 
dirrotly upini the v<M»el, whtd 
vrould thuM be wcurely and tj 
fn-liiatlv oinipraned. 

TIk- brachial aitsiy in lirt 
cui»priw<-<l liy ).'nu>{>ini! thi- liinl 
opprnid- ihf tiiidilli' 111' tliv aid 
in puch a wiiy l)ial thf (ipe m 
thv fioevrs nrv plactt) iminfl 
dtatolv lolernal to tti« ed}(e i^ 
ihe bice|m, and thit^ preM ili^ 
arterv UKniikil (he bone whil^ 
the tiiuinb rota at;aitint ihr Itw 
meruB oo the umvMite si^ie > Ki^ 

Tlie ndUl uxd ttiau utaiui 




tig. tt, — fl(a|>n*ilDn vf SabsUrlui, allb kB7> Hill 



iVefiuently rer|uire cnmpfVMii^ 
while tiie Mir|ci->iD i« »earrJiiD| 



)<ir u wDuniled vngwl in (hi 
iMltn of the hand ; and the aij 
ticianl must, under ibew drcuinetancce, tteaily the hand na well a* (<iimpfnl 
tli« TCMels. He will l>»t efleet these objects hr jtnunins th« lonrr jMrt of 

ibe foreuio finnly with Dotn banda. his fin)^(f 
beiniJ at (he domi ii»|>ect, and hU thumht 
prtwed u|>uii ihe iirierii^ immiiliatrly ebova 
the wriat; on the nidinl. at the pnini at tahicb' 
il U cotiiRionly IVlt. lu the iiul«e. and •<« (l»d 
ulnar, at ihe outer liordrr >ir the tvadi^n ■d'thd| 
Hexor CTirpi ulnnri.-> yVvj. llt\ 1 

Comprvuion of tbie abdominal aorta i^ r«. 

i|iiir<il ill Kline <'nm ol' iinitxitiiliiin at llic hlp^ 
joitil or hik'h upiii thi.' ihi^n.aml in opi-ratioiis 
for aiieuriiim of tin- iliac arterini. or the braDchin of the internal itiac in lti4 
buUoek. The {hmui ni which it i> iii<*t conveniruilv compHwed u imme- 
diately alMvve if* bilnrcalion. Thi- hirurcjiti'in (if (he aorta takn> |ila<-e no; 
llie bmly i>f ihp fouHh hiiidiar vfrlelira, a little t<> (he left of the niiddia 
line: tuppr^-ially thia ■■•trmpumU in a |Niiut a little di the left Ride of th« 




Flj. 1*. — •'■••iifjMino uf III* 
Radlkl and t*<a»r AnortM. 



coiii-RKiiaioN' or main arteries. 



77 



aatbiUeoB. mnd on ii level with ilic highe^i pari of tho ilim- rnvt. [n cum- 
froMiti^ thr aorta, lhi-n?ft>rc, the prcs&ura »lii>ulil U' ii{ij)Iii-il u littlar iihuro 
(wl Ui the Iffl <>l' lii« I) 111 I III) CDS. In children, aiiil very thin oiilijcvt*, (he 
•ttu tmu rpnditv be f>nipn«secl with the haiii) in thin xittiution. but tho 
imx rr^uirwl ie wi grenl that it i^ impoeeible fur il to hv nmiiKuini'il for rniy 
lofth u( tiaK. Id the abactice of aoy otlier iiiiiirutneiit, fjiirtiircli rt'cmiii- 
Bms th« r>>lluvinh' plan : A comnioa roller buinlBi^ ahuut twv iind a half 
brlwa wide nod eif;ht yards Umg ie to be rollMl r<jiiiid a Mifk nhi>ut th« 
likkMM uf the thumb and niD« inches long. The [mil thu» f»rini^ in ln-ld 
Id Uie proper pt»itioD hy the ends of the stick, while several luriin i<f I'lantic 
hu-inge arv [Miased round ilte body m> aa lo preis it furcihlv u]{iiini't the 
After it ia applied, an nsaistani iiitul cimtiniit? lu Imld ilit; pud in 
Q by mean!) of the litick. An obje<!tion euuKinni ui this and u< uU 

e awil" 

it,thL-i 
vflk* abduiuiDul muscles will aInKwt 



vilwr elutic aupltanoes for »iiupresaion uf Htv aorta ia, that, fhvuld the 
labmi vomit, thi.- lurdble cootraclion 




PVg. 17.— l.li*or'f AurlB CompratiDt k|ipllnl. 



wtainly lill the |iad fVoRi llie aorta 

ml rIbx the compn-tfioii. It is 

bdlvr, ihrrvforv, whroever {uiMiihle, 

UOM the iDNtrumeiit known an I'au- 

"■t-t's or I-.i«er'» A-irlic Ti)urni'|iiet 

1 7 1- This <N]iisi!.|j. niitrely of a 

xiijv biinmhiHt citmtji, one end of 

which id i'X|iHDdtMl and jinddcd, to 

■■ til &l ihf ■pine, anil tlii' other rv- 

M^na a aorvn which preMint down 

B pad of nulBdcnt nirx to mniprew 

lk« aorta with ci-nninly. Lixter 

«UIn> that, fmni rxnininaiion of ii 

nitMidi-rnliU- niinilirr •it'lxMlir*, ho linn 

Uniiui that the iiuMn i^ ii» otUii in the 

fiiiiMh- lino a* to ihc U-lt uf the Miini;, an<I oonse{]U«ntly tt Ij- hetier ulwnya 

1 for the piiliuilion lirfnrc upplying tho pud, taking the hiiihcxt point cif 

rial of ihi- ilium U>i In ihtr k'Vrl of thii hifuri'iitioii, and i):n<iring iho 

ion* allDgetiier, If iht^ pad W- plinM-d isitaclly on tin- vi?»i-l, n ruin- 

iivtiv tMgiii Hinoiiut of foree U roiiiiJred to arrmt tin- How »( hluiMl; 

-liould it U' misplaced, the surgeon may lie tempted to iivc an amount 

I : TL'o which might prove iujiirioUK to tho >loll pnrta and iDU-«linr« beneath 

ibe ]Ad. Iji order Mill further to avoiil injury to these pnrl«i, it Ik well t^ 

" *-e a #oll hollow Hfxiiijfe beneath the pud. The inrtrumciit, when properly 

i])li«fl, interferes but slightly, if at all, with the flow of hlood through the 

Vjia i-ava. 

Compnulon of the eommon iliac nmy rn»ily l>c ran-ied out h^ the appli- 
csUou ot the aortic lo«irDi<|uet over the line of tho arlory, that it* to ray, in 
tbe upjMrr third of a line drawn from n little to the let^ of the iinihilicUH at 
the level of ttie highest point of the erect of the ilium to n jioiut midway 
between the syutphyRia pubis and the anterior superior iliac npnie. Kichiml 
X]«vy,of lite WesImiiiBler Ilospilal, has ipvenlctl n plan of rompri-N>in^ thla 
artery by mcttlis of a slrai>;lil lever of wood Jntrodiicrd per rpftuni, which 
SMtaliy anawers very well. The lever should he nhout two fi-et in ti-ugch, 
•mootb aitd round, and shaped aomelhing like a poker. About two ounce* 
(if olive -lil haviiiK b(*n injected into the rectum, Ihe end of the lever is 
iiitn><lace<l to tiuoh a distance that its point comes to lie over the artttry in ihft 
groove between the lust lumbar vertebra and the psoas muiele. By raixiug 
ue handle of the lever and bringing it against ttie opposite thigh, the artery in 
mnM efficiently compreMctl, the tiMues of the perineum acting as the fulcrum. 



78 



GKXKRAI. RKUABCS ON OPBRATIDXS. 



I Compreaiion of the ezteroU ilUo cnn l>c iiirri^^l <>ut witli c<-naiaty oai 
biiK^tiuU'ly uUivi- ilir ijr'iin, »• uIhivc tlinl (hiJdi ii in csitly jtuilinl oVcr tl 
brim oftbt |)elvu> iiiiuMit-li iip<«ition m tocwn[>e [irrwure. If ii bvilNirt 
U> mniprtM it, it mnr ivfl>)ily be liottt Hlher niili titc liu>;(:n or W (>Iadii 
• roller liMiwIa)^ ncroMi iIm- liito of Ui« arterv. bD'I M-ctirin|; it lint bv n fr 
lum« »r a ooiniD»n bamlap-. piuiing in n figure of i-iglit r<xiD>l ihi- uup 
piirt "f lire tltiiih ai>il iW prlvi* ImIow ibr tm\ of Uiv ilitini, owr irliio 
niu>t 1h' |iut n !•-« ltirn> ol'iiti Iii'liA-rubbor baiidago. 

CompreMion of tiie femoral art«i7 itt llm lirin nt lb« |h>1v1s (Kig. Ik) i 
oonini'iiilT rvaiirii-il tu for tin- tviii|>»rary arrat uf livntorrbagv mjtn an 
pul of the lovnr limb, ll is ihiis prrfDriiHtl. l*lt« HaTjgtKia Manila by llig 




Hg. \K—ttmnf iriih Thuabt. Appllmlan of Toamliiavt U Ttmont JttU(7. 

•klixtf ili4> patient mi wliicb the vra*cl in tu \>e cmipttttietl, with ltt» hock 
litMnnU lb<' jialii'iil't liciiil ami lii« bnalr incliiKil nvcr (lie jirlriti. Hr ibrii 
gnujw llii- limb ttrtiily with liuth liittida, Uk- finger* of mre luuid obtaiuin|{ 
■ buU UD tbp maw af (he lutduclur ntu*olc«, nnd ih>wc nf tlw ntlivr an 

the iioaioriar bordi-r "t ibo 
irnpliauim* major. Hu twui 
ihuiiitw arc pUcod. nno over 
thi' iither. iipiiii tlw nrierrat 
H (Hiini inioMxIiatflv bolow 
Poii|nirt'i> li){»i]i«ol, and ex-, 
actly niidwav bfivts^ii iIm 
Kympbym pu^>i» nnd ttK* an-| 
liTior Mperior iliac apine— | 
wltiTB tlie venel lie* ortr Um<. 
hip bout-. Instrumental co»- 
prauMi in this eiiuation ia 
cmptim'd •mlv in the treat-, 
mrni i^f iinenrt*in,nud will bA i 
duKTilK-<l will) ihiil -liieaec. 
The popliteal artery ia too 
dei-fity »iiimitil li> 1m' (.■•itniin-ivol with advikntii};c. In hlet-dinK friim a 
piiint Ir'Imw thr kun.- und alxivr the iinklo, it is briUT i>< apply dii; prcwufA 
bi ibe feitiiiral arlm' at tlw ^riMii. 




Fit- 10.— C»H|int>»4 ot TTbliila *•< Hod* ot iiiAA- 
lof Ik* fodl iH u|'*iKiluii> raqolrlBf Ml InaUlan id lb* 

Ml*. 



A 



nmtTtrrivxAL avtek-tiiicatukxt or orERATio.vd. 



IWiiltri«r uid poitoiior tibial uterk* nt th« uoklo may couv«nk-utJy 
itf^!jw^..i .l:,riiuj nil •i|ii-rfltii>it i»ii tlie fo'il (Fig. 19 1, Tbe astHnut 
Hi trti'ly Uu- lint, itQil holJ 11 ID a evnireni«Dl (Hj^itioti 

(*!>■ -wi ('--.>. 1 i- Jiiiit> b<-inj; biiit lit a right xn^le, tlie a««t»Uuit [iiiU 
tkt lumtV kntv ill bit nxilU ; >)<■ tlu-u Kraspe the limb liriiily with on« 
yj ski- ■> -lit ,1 niii, tbc tiogpr am) thumb cuai|ir(t«€» tbe 
narii. i la u> be coitiprasM^d nilli the ti|« of tbe finiten 

Mtfanr* rir<-a'iiii 'i:[hi><i tW ititi'ninl iiiiill(^srlu», an') the aiiu>n<>r tibial 
•iA at Oiumb in froiii uf ihi- niikl« at a |><>iiit oxactlv iiiiiluuv biiMtt^ii 
AdMBsUmU. ttuU u lu uv. a little to tlie outer >i<l« of tb« mi<idle )iii«. 




roSWHTtTloXAI. KtTIKmi Of OI'ERATIorrs. 

Enry opMstioa of anv ini|ii-)naiK'0 i» fulloiroil by a cvrtaiti amnum of 
imm^fitrr, aa iuiltnili>i| by n rvK of tniii[H'nituri', an iiicn-iuol tr><<|U4'i]<*y 
it ik* Mitr. and mjom: <1<-^-v nf thiret. Sucb IVvt-r, il' iii^HlrriilP ant) vfut- 
liri nthiD certain llmila. L'aii Nsroi'ly W bxikiil ii]m>ii n* ii iimrbii) cotiili- 
M; unI im)1(- vI u|> by ••>mi' uiihi-ultliy iilal<- of ibi: nuiiiiiJ, by tho 

fmmaot 4r .' iiiatti-r, nr by i»'iiin|i ■liM-bnr^'«'», it i'iim(ili:tly «ub- 

mlm lif itw (liiiil -luy. Tliv thiTiin'iix-i'T i> (In- only certoio ranux ul' 
iijpl( «f Ifac <l«Knv "f frri't. llu- [lulo' U n fnlladtiaa Mign, bring gn-atly 
■MMMnI by tbr iBtiital *tatr of ihr [■ali>-i>t nii'l iiiniiy •Hbcr caiiM* : ibint 
■W M*r br ucnMofM^ by tlii- aiinxibvtic ; but the iriii|H-miirv i* an iufclli- 
IkgM*. If tbr ihrniMUiirtirr rvinain brltiw lUT R, no auiirty n«<il be 
Ul<«tkM*cun-. 

TW Local Tnatmcnt of Opcration-wouidi Mffvn in no nv|>c(Tt rnmi 
Hat -nf an ;,I, -m.i uouiitl., niiil will tw trcuteil of in lli«t cbaplvr ou tbi* 
CnMiMu: >iijni-». 

< Cu.i..i^i,...uai AhvMreatnwit of operationB clfmaDdasa inucb atlen- 

th<- [lui nf ibr SurpHio M tlie nMuagemeui »r tbe vrnund ilwlf. 

liatvir ai^t-r tlir ii]ii-ratii<ii. am) before tbe elfevld rif the aiiiislbetic 

uS. the [•niti-iii xbiiutil 1m> ri>iiir»nably arranged io ImtiI, with tbe 

Mip[>arlr>l by a cradlv. or 'iibiT iMdirivaucv. away IV<>m th« pitrt 

anBtKlM) : an uiiiair may iben be a<lmiiii^li-rol if nijiiirol, or a little aine 

Mw V ' ' ^iIllunu■. aii'l llir |iitti<'iit krjii if> t|uiei aa )H.wihIe. 

W" Diet after tbe operation, this niuoi (lf}H-iiil tmtirvly ou 

I. si jHiwi-r*, bt* )trvviiiit> habits, biii ajo-'. iinil u|H)n the 

11. Itut, as a g^Drrnl ruti', it timy Ik- statnl that, iia 

J I' •yntrm, ihr fnniliiuliniiiil tjowen nt|t]ire to ba 

I iiinr. Thi* i« riiori' junrlicuiHrly tbe I'aM, if tba 

<r tho iiu1)fvi|ui'Ul Muiijiuraiidii al>iiti<lnui. If th« 

' , -al. Dot having Ix-^'n brnkni by pivviouii (tiiNiLX' i>r 

iD(l tt the (>prratii>i] Ih- a xlight one, ur tbr aiii[iutaliiin of a finjc^^r 

— ■>■ il -'f s >'i<ill ttitDur, hv niny hnvi* half bin tiKual ilivt nllnWw 

Wa Itltlr if any •tinnilaiit. If tli<; npirattun liave beou 

m^ -'i'nl, u<i «>ili<t# Ebi'uhl t>c allowril, but Itrofhs and 

•■tr- o fur thr fir»l few dnvf. If ih* nnrniti<>» liavp 

has a •■• ii>- jii'irut'a boallb and etrcuKtli buiup vtnorwiw puil, 

b Bay I- I to larinannus tlofa and b«tf-l«a until tin- febrile dia- 

■11 tan III snb'ii aiway> f<ill4>wi nrvviv o|MTHtt<ini hai pawpil ofl*. after whivll 

«^» licbl Mdding mar br ail'li-d : and ibr divl may, aa thr caw rirosraMa, 

b gTadaalty lti)[iroTct) by ihi' ^iirxTiwve iiddiiioii nf gib iiuil tbti liifhttr 

UMk af laMla. *itb a atvUnu i|iiniitity of «iiiiiLilaiilJ>, a* m(iitrr<I, until it 

^Hk tha DOnnat vtandanl. It nut unl'mjuciilly )mp|>i-ii*. Imnvvrr, ihnt a 

at raonv mmt br |)iin>ittil. It it not my inliiitiun to fiilrr 




QENKRAL RKKABKS OK OPKRaTIOJTS. 



iiiHtR itiv ^rMil 'jUMtiori '■!' thi.- list- am) abiiM! of nloihol m itn articl* a| 
•li«t. But iH a medicinal ii|^'ni in seven.' eui^icnl cnat* iherv I'ltn W IM 
ilraibt of the grcttt iitililv nl' ■loiltol iu tamv ohape. If tbt* pultetit lum 
Im-mi much rodui'td hy lunfj-MHiiinued Buppuratiiin. or oili«r ilepreaiiuif 
caticc:) before lh« uperatiou ; if he Iw old and weakly iu onuiilutioti, or lisn 
bwn in the habit uf lakinK a very coniiiderable <|iiaiiliiy of ittiniulaiiif. It 
will be nboilutely iieceeMrv Iu adopt a luoic aud Kiimulatin){ mode of lr«at- 
luent. Inde«4l. iu houfiiial pradiee especially, ihiB is br I'ar the ni^xit t*ie- 
oetoftil iDode of ireatint; [Nttieaia nfiier sewre upcnitioDH; without it. tuanr 
wnuld have lunk. whom 1 have ^een Mved by the free adniiimtruttciu uf 
\urffi utianiitio of brnndy, wine, porter, efg», utid lieei'-tm rmiu the verr 
time of Uw operation — thut atiDiulani Mug )fiveii tu which the pati«ui n 
HBunumed in a state of heullh. Thin plan uf tn-uiim-nt in also on« uf tli« 
beat preventives uflboiie difTuM- forrusof iuAiimiimtiuu tliul are »o cotumunly 
&Ia1 in these dues ; aud when Ihvy coux- im, I know u<i Wtter rem«dy tUiui 
iba btaody-ond-c^ mixture, freely ndmiiiii>(<-ru<l. Iu all thia, huwi^vi-r, tb« 
Surgeon mud be gtiided by tlie |iutii-i)t':> {>u[M^ hi* previuu* hahilB, und tite 
•IreDgtb uf liio eMmlitiiti-m; nud uciihiii)^ ni^uimi gn-»ltr jiid^'inidil thao 
the ailmiuialniliou of ntiinulnni*, ncconliug t" tbow luirliculnni. Thr t«iit-^ 
nontturi' t* aUo a tarat iniporlnul )fuidv to ifav itti-l of u [latirDL If it be 
liigh, animal fooil niu«l Iw avoidril. Imt stimulauU nciil not oevtMUrilv b» 
al)andnne<): in fad th<-y may bi^ nijuiml in increaRd quantity, espMialljr 
if nitli tlio fvver tbvrc is mpiditv aud weaknca* of the pul»v. Tb« fTt*i 
imiHirtanw of lUUmding ecrupulouHly to th« gcooral clvnnliiwM of tlw 
pati«ot, aud to tbo vcniiUilion of tliv ward or mora iu which hf tv lyioi;, 
iix thv bwt mctDR of prcvvniing tJic uccurreitco of unhealthy autl tprradiuK 
Ibrm* of inflainiDBtion, nom) scarocly be insisted od, n* thcw hygienic pn^ 
oMitione arc unireraally TCcogDiwd as bciug of the firtt imjxinjincv under 
Mieh circuinstancee. 

The rmutt* •flbet of the major opcraliuns is a subject that reqiiinw invt*- 
ti^aliou. Do |>eopl« who have undertcoiw any of the (greater o|>cration>, and 
who have recovered from the immediate eflects, u a rule, live as long aa 
those who'have uot sustained a muiilaiJon? I am disi>usod to think that > 
they do not. When we leBeci uu the enanii<>u« number of {ventolin wbo, 
before the agp uf thirty, muffler amputation of one of the limbs for injury, it 
is remarkable hon oeldom one sees an old persoa iu a boapital or elM^wlKre, 
wh« hut lout a limb iu early life. I am, ol courte, speakinK only of ampu- 
tAliomi for iujurj-: fur ih'R>e who have uuderfpme this operation for slrtimous 
or inaligoaut diseoK, fre<|ueuily die early from incurrence uf the constilu* 
tional vtcp In other parts vl' the IwHly. So aUu with rwpect vi lithutoiuv. 
Very many boyi an.- rut for it^ine everv y«nr and recover; but 1 scarcefy 
rtcolli-ot to have wvi with a mlddle-agetf sulult who liad bven operated on iu ' 
eblldhood. 

T1i« various Special Operatiuus will be considered nheu traiinK of th« 
M>V*<nil lujuriu and ENscoscs for which thev are n.-*iuired : bui, as Aui|iuta> 
iImm do not reailily fall utKl«r any •iMftal licMd, Uin;: rctjuinil ftir a 
varivty of diOirrvnC conditions, il will tn- more couvcnivnt to cun^idtr 
berv. 



AMHDTATIOXS. 81 



CirAVTER II. 

AMPUTATroXS ASI> DISAKTICULATinSS. 

TuEUrnn AmpiUiilhn means the separation or removal of a part of the 
Mj. It is most commonly applied to the removal of a limb, but sometimes 
iki to that of other parts, as the breast or peuis. 

TV freuuenc)' of amputation of the limbs has much leaseued of late years ; 

i«b*r aod iea» severe niodee of treatment beiog now successfully followed in 

nuj cues of dJM&sed joint, of aneurism, and of compound fracture. Still 

mputatioDs are among the most frequent operations in furgery, and will 

i^«tiiiae to be so as long as the human body is liable to severe mutilations, 

■'''^Dgreoe of the limbs, and to malignant and other incurable diseases of 

ibr bone* and joints. It has been somewhat the fashion to decry amputa- 

ifti: and to speak of this operation as an opprobrium to curative surgery. 

Bui. though no Purgeon can deprecate unnecessary amputations more 

•irjngly tlin I do, I cannot admit that the removal of a limb is an opera- 

ivixft'less merit than any other proceeding adopted when all other means 

hire tailed in curing the diseased jiart, or in savlug the patient's life from 

dinp-r. i^urely, it is rather a subject of just pride than the reverse, that 

tbe Sirgeon is able to save the whole of the body by sacrificing by a simple 

i^frntixD a limb thai has been utterly disorganized or spoilt by disease or 

isjury. In the performance of an amputation, also, much dexterity may 

ftniuentlr be displayed ; and there is comraouly great scope tor surgical 

»liil in the constitutional treatment of the patieut both before and after the 

;»ratiiiii. 

Thv auipiitatioii of I) liiiili is gencrallv performed tlirou^rli the continuity 
■■t i ("iiu- : when dniif ill a ji>inl. it is called ii I)''tirtini/-ilitin. 

.Vcipuiaiiiju fi>r ilisi-a-k's nf jnints, or f'lr the immediate effects of injury, is 

It. . ;rniii.>n -if rnni]>:irntii-fly recent date; for ibf oldiTsurgeims unilortook 

'.■-■■ rrm.pval "f !i limb nnly liir gatiijrene. So much was this the eiise. that 

■■■^ ■.:.:■ w-.rks .'f nmny nf ilie ■lider writers the only mention of iimpuiation is 

:l ■.:.\ irt-atuii'nl of gunprene. Hip|K>eri(tes, who lived iiljout 4(.(() yours be- 

: r>- C'dri-t. rtTiimmonded iluit the Surgei>n in removing ti giiiigrcnous limb 

-;. iiM Iidiit his iueisi<m!> tn the deaii tissues in order (<■ avoid the danger of 

■•T-iiii::. tVlius. hHo lived ul the eonuneueement of the Christiiiii era, 

•r. ■ .'jntu-nl a bildi-r line uI' pnii'tice. The operutinn of amputation ss de- 

•■ ri:i-.i in- him was [litis |MTti>riiied. A deep inei^^ion was iiiiule lo the bone 

!-:Bnn the liviii:: iiiid di'ii<l lissoi-s. I'ncroat'biny: niiher im the living than 

-avinj ;iiiv .if ill.- il<-;id. When llii- bone Wiis ri'jiched, the snund Hesh was 

■.■inii Kai'k fniii it, and tlie .saw applied as hiijli as possible. The edges of 

:■■■ -kill tt^rr.- i!n-o bniuirht diiwii, and it was reeuui mended lluit the eoveriiig 

•' .!■! L- lax. tliiu il ini;:lil ii> (leiirlv :is possilile criver llie hone completely. 

\-. ;. «tv,T. <.'i]-iir- advice- iliat the part which ihe >kh\ did noi ri'ach 

i'i 1-- clr^-r^il with lint e'lVered with a s]H'ngi' M]iife/.ed oul of vinegar, 

■ ■ ;.ri lial'l.- lliiil in iinuiv eiisi^s at leiisl the cMviriiii.' "as nnl suffieirril to 

■i*- .1 j-rftel -liiriip. Celrii- na= Lifipiaiiited with llie ii-e nf the ligature. 

1 ■: ■ir' I'- ^lriiii;;lv a::aiii-I \h<- emplovriient of eiiuslie^i for the arn^l of 

,-riij_'i : il i,- pfiihablf, lliereliire. thai (lie vi'SSi'l.-: Here ^eeu^ed iu an 

V- 1. I — •■, 



AUPtlTATtOKa. 



aDi|iulali(in nt tliut liiiio by i1)l> ligxturo, nltli(Mij;b no diftliDcl nwnUon i 
made uf it iu ibci tlcMripluin of tUc opcrntiiiii. lu ejiilir of ibb' be trlta u 
ihut ihe operatiuo vot alUmled bv vcrr K^^* (iaiiK«r. for (lie |>alHriila nftw 
died Ootn betuurrbaife or IninliuKS ilurinj; itN perJunnaiice, aod thai it «■ 
justifiei) ool;' bj iW tact that Uie cum« for amputalioii wore »ui-Ii tbnt it bai 
Dot la be cotieiilered wbelber llie rvrocdr was very »afr. be<-auM> it waa Un 
uily ofie tlti'ii; nas. Ainpulatioo wa* iieribriucft iu thtt way, iiowevvr. [| 
*j)ilc uf iifr danifera. till ibe bfj-inoiiifE of iht wcoud ceiiiury, wbni Archi 
gCtMV, uualbi-r U'tiiiati ^iirKeou, iovi^iilvd lite fillot, ubirh wat^ ImuihI lik'bti] 
rwutid tbe limb tu dimiuub tbe lod* of blood. Tb<- uriliiif;* <>f ilii* Huri^t'cii 
bav<: ln.-1-ii ill gTi-at jiurt luat, au llint it h tloutilful wbal tix'Htm br iix-ii fw 
iIm' nrrPut of licniorrbajce ; but, nhat<^ver ibcr wen-, ihiy ilu ii«l tir^m i{ 
liavi- bn'ti very mjccowl'iil ; for, hhui alVr )ii» linK*, Cnlni, wb<i {iradiM'il il 
Itnine during ibti laitrr [iiirt cf tbi- H-onid ctutury. rcvcrlrd to ibc jiraclin 
uf llippocrulr*. rt'ci'iii 11 H' tiding tbiil in iiin{iutntion« ibr iucii>ii>i)* should b< 
litnilt-d to ibti gangmMw* timicti, and Ibai a cauli-rr nbould br a|>{>)ied (1 
wbat rcrouiRnlof ibedmd jxirunllrr rvmovul uf ib<- limb. Tin- j>ractic»oj 
tviug nrtcrMi also full coniiilroly into nbeyiim-*;. tb<- i-aiilcry bring almoJ 
tlio only ineaiM cinpioycil for ibi.- armi of hi-morrbagi-. So |!r<-nt indoM 
was tbi' frtirof hL-iaonbagi'ibnt, in tbe fourtrciitb nuiury.Ouidodi ('«uliac4 
reconimcndi-d rrrn Mraiigulatin]; ibi- limb by tiMwiiit of pln»trr*, and Hllnw< 
jlif! il to dftp off. in prpfcrcncp to any cntlioK operation. It nas ii<vi till 
1520 thai the niii^le uf ojicratin;^ aoopted by Ceuus wai revived by tlnnl 
Ton Gersdorf : but as thp cautery, or variuua more or lesa in>iK>Unl aiyplica^ 
wer« Btill the only mean* rmpluycd to itop the Weeding, the operation wa| 
tflo dangerous lo be unilertaken aa an ordinary mixle of Irealnient. Toiarda 
lh« latter pari of the i^iitcentb century, about 15(KI, the uae nf the liKStan 
wiu rrintrAdurrtl by Ambrnitw Far^, the mott c-nlebratMl Burgeon of hH 
time. AiniMituf ion, m he pcrfortnc<l il. icat ntrnlially thi' (amc oia-ralioa 
a» thaldi-acritinl by Cd«ua,«iHl aUliOUKktl)cami>tol bki-ition; iiai> i-RU-i<-nll« 
carried out by ihr li^turts the Iru* ut blood during the operalti>u wna ii>n^ 
cidcmbic; lor. though "ihi; Rlb-I " wa* bound ligblly ruund tltv limb with' 
the iiiti-iilion i,( iliniinisliing lliC beniofrhHg<-, il •tx-nif never li> have tmifi 
upplitil nilh nujlirii'iil l'"tw completely to armt the circu 
inetninteni* iih-<! for MirJiig the vewel wireninKwhal ctum»v 
nuently Ibe pittieut often li«t hi much blood Ix'forv the rexc 
the nifljortiy uf 8urKe<>ii« coulinue^l to prefer ibe cautery or vtatv ttyplic fori 
another century. It was n<-t until the beginning of the eigbterutb century 
that the ligature really bci'aniv the only reciigniKcd modu of arraliujc 
arterial bleeding;. This result naa brought about partly by the dttcnvery of 
the firciilalion of the bhiod by Harvey in lfi'.'>*. bui chiefly by tbe inveniioa 
of a really efficient tourniquet by Morel in HS74. Surgeons now were abla^ 
to na-rforiu uiiiputations nithoul tbe tear of oeeiug their jnlienU die of hem- 
orrbiige during the operation, and frotn that tinw the real iinprnventctit ia 
wnpulMlioiis i-ommeiicL-d. 

In Hi'!*. Uinndbiini, an Kngliali Surgeon, Ural Miggi-xtrd the plan ft 
mtling a Ihip « hich could Iw made to cover tbe dividMrnd of the Itunr, au 
aa to ol)tatu early union without riepiiralion of the and of the bone. Thua 
there cJinic to be lwi> dlftiud nioden of amputating n limb, the circulnr and 
the dap niethiid, each of which underwent gradual develo|iitieiit and im* 
prnvenient. 

Amputation by the Ciroulu ■ethod.—Tlic jirvi improvemeni of ib« 
drt'uiar ut'tboil of ampiilaltug, made after llw ioieulion of the tounii'(Uel, 
waa llitr intm-luclion of what wa< kuonn »» the o|>eraliou " by the double 
incision." This mode of opcnling wac introdutx-d iulu practice alqMat 



ver li> have beett 
cimilitlion. Tlt« 
um»y, and ciin»rJ 
Ecl itB« tii.-'l, thntj 



AMrUTATtoy KT TUK CIBCULAR MBTaOD. 88 



by CbrMltlrn, of lyjadon. nad J. L. Pvtil, of Piria. In this 

wAr <f •MmtiDft. ibe •kin ■■»l fnt vrttf (liviilcil by a cin-uUr inHsiiiit ; tlio 

vilMl UcB.grMpiag til* limb, {iulti-<l lli<- iiii*-guiiii.-n[« fuix-iblj- iipimrd*, 

■J tht Mwelw mrrctil lliri'tijiti Ui the Imhi; br aiiDlbiT dri-uluf RWeep of 

t>Mfc. Mul tk« Ma afiptini lu hiyb up iia p-vvibli'. Tlii« mtlhixl of opo- 

MBf 4i<l I' K'ly (iiVi-riii)! in tlir buiif, but it proviiloi) tuvU 

«iMi«iii t nn» |vMiblc fur tlio rUiuiji to heat <.-*jni]iletely 

hf tna«] . iM-|Nirulion <if Ihr |'^>tnl<llIlt' vm] of ibc Ix)dc. 

IttRMiU- > ucrc not »•! tnul »r tiiigtit hitvp bi.-('ii <-xp««-lMl. 

At (nl Mnaru, wbv wr<>4(r in IT.lii. tell* ii» ibiit out uf niiiftr-nin? cofce uf 

MMvaapatktkM) p«riurn)«l bv hini#i-lf unil his mllmgura in ibi.- KilinliurKh 

kmrnuj, ivIt rijcbi iticl. ami iinuc i>f ihcve fixiin the immcliato fflccts of 

itiftntiiun. Mi'uru eri-iiml lb« veAM-Ia by lipiluru, Kod <lrr»c(l thu raw 

mAttid lliv iluinp «ilh dry linl, itbicfa ivmninvd on till it irits loosened 

U HMi«m»<>D. \ mwlilicatiuD of ihv op«raliua by the double incision mii 

M t wJ w wJ liT ibf Fn-Acfa BurfenD, Louis, ia 17m. He noticed thiit in 

Hktac thv nntrulsr ini^sinn ihroujih tli« muBcles, the nHraction of (he eiipcr- 

iasl latm t)u nmfT tbsn lluit of tbow near the bone. In order their- 

ia« to ubuiu m higher HnO iu<>r« lex'el diviKion of lh« muscles, he divided 

Aawpntfrial Uvitrsaiih ihv «kin uid fnt.uid baviuj; driiwo tbeni forcibly 

UsanU, rot ihr iTiaaininr tnuKle with a second sweep of the knife. A 

In nUmetoT wm sppliea bvtwMti the fiiM and second indsions, uid in 

«Av to alU-m tbs muKM to rrtnci tii tliv (bll«st p«*ible extent, Luut* was 

■Mfasd tushukdna the tourni>|uct and to iruM to distal comprtMion of the 

■ais anwU uunk. ^ &tr, ^rnvin* hai) advunoed little berond iIm ope- 

ntM i)/OHia»: to fsct.it is doulitful wbrlhrr in amputation uy the double 

mamtm, ns jn i Hm iim«I at thw time, the Imuc wsh ttclt^r covcrt-d ibnn in that 

fc* ifce HnwaiM SofgvoM, who rabMl the eofl parts ycr\ frcrly before Mwing. 

1W first ktts«it4 to iliniinnh thu size of the raw surlacc Irh al^cr nmpula- 

IM ns BUtde by Samuel !>harp about 1750. He passed two brxiad, ribbon- 

hk« licatura. r%ch «\>mp(«ed of eifght well-nnied thrrnds, through the edges 

fi At wooad about lhPM>-i^mrten of an inch from ih« mar^n of the skin, 

mi, dnwtnf tbco tolrrably tightlr, tie<l them in n bon-kni>l. It was sotm 

i.,^-,_r lifg^i ihc ifOMim l)iit» vnuwd produced such an antiHinl of 

(hat tbr pUn wm abandoned almost as soon as it was recum- 



flM«*wa 1770 am] 1780 the f;rail fact became rvoo^ixed that (he uuly 
«if 10 obuio speedy hmlins of n Ntnnip is to provide Mifficienl covering lo 
MhIb Ibc t<dcta of the skin to Ik hnNik'bt «>f:«tli<<r over the vnd of the Wne, 
* as 10 nsM t«*ily wiihiMil trnnicin. This ti-i| to the ioveuiion i>f the niiMie 
rf j^yntftlilf ktu-sn as ampijlalion by tbo triple incision. ahicU vm lotro- 
iai' alm-al pimullaj)e<iu»lv bv Brniamin Bell, of KilinburKh, 

1. l^'filt.and AlauHMi,')) I,ivi-rpi>il. The (wi> fmucr pi>r> 

ibv ■•fwratiuo sXactlr at it isdoni? in ihf pnwul liuy by ih-ii«L- wlio 
» tlUt ntstlMd (Ftp)- ^ snil 'i\ ). Thv *kiii and fst «i-n- 6nit divided 
W a Mngl* swsM of IM knifr and diMi-<'l<-d uj> tor n diotamv ■'•pml lu half 
\m 4iawrt>'r of tb* Itnb; the uutrlra wvn- iIk'h ilividol by nnolhrr cin'ular 
sowy of ' and rvln»i'l>'d fur a distance varying from oik to two 

bck«,aci . .-;.. :<• ihr ihii-km-ss uf the limb; and tbr bone was sawn •■ 
Ufit op as pfaatblr. lo iIm- (hi|;h sntl U'g it wni nwrnm^ndi'd bv H«y to 
<at lb* MstMfair gHtscks lonicirr llmn ihr anleri'T, (» allow t(>r (Iwir greater 

'turn. Tb* t«li«s of iIm' skin wrn< br»iigbl together in l)w traosvcrtc 

-uf tbs limb, and a >tuni|) was formiil with abundont corcring for 



■ Imom^ bnt necwaanrily with wime puckering and pn>|i.-ction at each angle. 
Tim tbnw iaasiiMM whidi cainni for (his operation ttie name of " lb« 



ASrPTJTATlOSS. 




ih<! 



1, To rRoviiiK A «rrKinEST (-ovrkiku. — It wu lonjf n(p> ixiintnl i>u 
liy M,VDoni and otliers. (hat the aUiiiilnrd by whicli wv intibt Miiitinli- ill 
umouul of cuverin^ re<|uirti<J U the dwrnrltT of ibr limti nl rii:lit nuiitrB t 
ibr lino in wkieli ibe c-Ji-atrix U to lie plticcil, iiod mkcii m tlii' |H>iiit ut irhiH 
tbr hnne is to be iliTiiled. In u|MTii(iii;: on ihi< iKm-l Imly, it m evi<lrn 
tbst if twu tNiusI flii|)«, «acb lucuuriog bull' Ibr (linnirliT "1' i\n- limb at lb- 
point nl nhicli tbv Imtus it mwn, wore cm. lb«-\ wouiii iimi-i lu'iiiruiflT «o< 
Govi-r ill tbe lioiit' ; but nticb Hiifw in ibc liviiit: IhhIv nutild Im- lotiillv in 
il(lc(|tiiiU* iiii itccttunl of tbr i>htinkiiig fr<>ni tb<' ■■ln>licitT (irikc i>kin iiml ibi 
<U' pi iiiv incut iVoin tbv oiniriK'tioii .if [|k' iiitiM'Ire. ( ''t>iiw<)U('ntiy, il i> iivr 
•.-Miiri' I" pnivtilii Kniitbcr biilf clinmclC'r <if rK)V4-rin^' al ItiiM, nml in wmi^ 
gitiiiiii<inii even this nniikiinl i* buri'ly mi Hit;! ml. A* nn illiKtriitiou of tbi 
nbovc mil', 1« iin viipixwi' n limb ii lo Ik- nntptitiitH. tin- iinl<Ti)-|K»l>Tioi 
(liium-tcr (if wbinb, ut tin- jx>inl whrrc thr bono w to be »nwn, is fix in<:b<^. 
tiip n<'i-c«M»ry iliniDfttT anil » Imtf of cnverin;; eoiilil hv obUuiiol in tin- M- 
luwiiij; wnVM iimo»p't <>lhcr»: 1. One Ion); lliip nine inchrs ton);: % ><*■) 
daps, one MX inirhn long iind the i>lb«r thre«: 'S, iwo c<iiiul tUp> four ■ixl q 
bnlf inches loni:: 4, two eijunl fliip6 three iocbts lui)^. itn'l n.-lrtteti<>n of th4 
Diuacles from th^i bone to MUtb nn extent ns to proriile nn inch nii<l » hfllfo) 
cbveriDK on etteh side; \ n circtitnr incision n)ifiin{; the »liin iind fut tnt 
three iDches, mid nnother dreular cut ibroucb the Diusdeii with retmetioD of 
the soft fMirU from tbe bone lor one inch and n bnir. 

Tbe tteneral rule ibai one dianteter awl a half ih aiifRd«Qt, reonira 
(iaiiion under vnriouif conditions of the liwuM of nh'uli ibe eovcnilg la iDi 
nnd in various ait uatiuos. In very old people Ibr ekin has fre<fuenlly 
niurb of iid elasticity: but it is not wise to sboncu tbe covering oii 
ncci'iint, lis the ttsan«a being fctble arc lfs> cnpAbIc "f niilistniidini: 
irritating eAi-4-i of icnaion. In Moiputntlun throujib cbrimieiilly inlliirmil 
tiMnaf, tilt! rt-trnctioii i* aliio r>'<lu<Nil tn n minimum on accoitnt of tb<* rtj^ditr 
of (bo part* ; but here again il if iinuiw t" fborlvn ibr ciwring — in fnct, it 
is better to Rinke it a little loneor — m tb<r tUijif nn* very a|>t gnubiiilly ti> 
shrink during or at\or tbv hnuiog tif lb<?fl(inip. In liml> in mliieh llio 
mufclcs hnre undvrgone vxiremc fatly degenrntion, the rrlraili'Mt muMtl 
by tbeir tonic rontruction i» nbiicni. fo that (ho minimum covfHng of « 
dlUBe(«f nod n half is amplv fnliicKnt. In the louer ibird of thr thigh tha 
coveriDgelioiiM nlwaTt- Iw inerenspd to tvo diameters to allow for tbr wry 
excessive relisctioii of tbe long flexor muscles of tliv Itfg. In amfMitation of 
lite leg by the lonu calf-Bati, it if also neiceesary to provide very nbui»dniit 
curering to allow for the siiWqueiil shrinking of llie niuwular tisue which 
forms the poMerior tlap. 

2, TUAT TllK WAIt flUU. X«r nK OVER THE KSII KF TIIE IKINK. — It t> 

evident, ill the firvt ]ilaee. that protnisioo of the bone is inorv likely to ocrur' 
if tbe two i\t,\is in a Hnp amputation meet exaetly over iia end : Imi the i-btiT 
object in placing (he K-ar hi ibal it shall be free from the Imhio is to nvoid a 
painful stump. If the acar iu the skin is adlienut (<> the biux-, it be<*)ina* 
«Xlreinely Ibible to ulceration from >«ltglit tiijuries. If ibe m-ar l>e placed 
mil away fr\mi tb« bone, it tt> ullvn {lowible in ampiilntion.H of ib*- lowvr 
limb for (br iiutirnt to l>rar a r<-rtnin j>ritp<iriioii of bin weight <m the i-iid nf 
tbe atuiuii, wnirb give* grt-ally IncrraM-tl iitmdi»ri« in walkinjj on nu nrtt 
flcial limh. 

3, That a hki'kmikmt >iri:xix<i wn^ hk ri«>Tiiii:ii r<iH TttR Exrr OP 
tiiM'iuiuiK. — May lie *tati><l in uthrr wnnU tbiin: tltat the covefiog of tbn 
•(Uiup >Jiall be taken ehielly from the donal aurfare of tbe ttftvnna, an<l 
from the anterior part nf the limb clfewbem. ferfeei ilratnagie i* a)it>>iiulcl<r 
cawntial for uni^xi of any wound by fini inl«nliou. and conM><)UwDtly it la 



THE FLAP AMPUTATION. 



85 



ImnUc rasulu, on account of the teDclency to accumulation of dischai^es 
kivmi the fiaps id the absence of anv proper Byeteni of drainage, is evident 
from tbe &ct that in 1765, O'Hallonin, " surgeon and man-D)idwife " at 
Unnick. reoom mended that the flap and Btump should be dressed ae sepa- 
mt mrca. and that ther should not be brought together till the surfaces 
wot tuTered bv granulations. This plan did not, however, find much favor, 
nd u the end of the last century Surgeons preferred the circular amputa- 




FLf. ?1.^.AiDpat«tiOTi of th« Arm bj Ifae Circulmr Method. Sawing the Buoe. 

tifl in iti->#i ca«^, the fliip ojMTatiiin l>eiiip restricled iilmiist euiircly to the 
nt>p^r jiart -if ihc leg. the lower part of the tliipli, ami ihe distal piiri» of 
tkr l<«'t. AlniL^in auil Hey. whose iimnps hjivc already been uieiilionfd in 
ei«ni-i-ti->n with the oirculiir methixl of nnipiitiition. prncti.'H'd !\nd Imprnveil 
lli« flap •■(H-ration in these situation!!. Doriu;; the first fortv veiirs of thid 
«niurv. however, the flap o|>eration carue 5:reiiilv into liivor in this eountry, 
in>l va.-. iliirint' the Inter perimi uf ilml lime, siipjioried bvtlie able udvocn<'v 
'<( Li«i"n. who itivariublv arn[>uia(t<l hv ihnt iiietho<l, and who eertninlv ilid 
ii «i!h w.-ndi-rful ni[ii<lity and [irwision. Ani|Hitiiti<iii by the double tliip 
w i; i- -till prai-lii^il, i,-* thus |HTforiiieil i p'ii;, 2'Jl. 

Th<- i«" rta[»= may Ik.- made either by eiitlini: from wiiinuil inwiird.*, or 
by tran-tision— viittinj; from within outwanls. Translixioii i.-i atlnpied mdv 
Vi fl'T'hv parts, w the thij;h or arm : but eullin(r from withoni inwards will 
!»■ l''iiiii| I" atf^iril the Ix-st reault, and is indei'd the only riii.de of liirmini^ 
li»- dap. in ^'inie sititaliiins in whieh the bones are niilurally ihirily covered, 
S» '■u th«' il-'rsal osiHTt of the forearm, the anterior part of the lej;, or jurt 
tir-ve the uulile-jiiint, or when- the «oft juirie have l>eeii wasted by ehrouic 
<lifew. 



» 



AMPUTATIONS. 



Thv flni« in inioaAxiuu should be mmit' br ■ utriidy unriw-pio^ iiit, »o Uiat 
lb* soft |MiTt« may be cveulv iiDtl tmooilily dividfl. Tlirir Iriigth inu*t nf 
onarM be proporlioiiied in the thii'lciiii* of \hv limb, ir ihry br> cui tm 
lone, too much muM-le kUI Ito Kr(l on tbv viump, nu>l lh4> lliifi iitc IT it iwuiillr 
bfldly iHahi'iuiNl au<l |>oiiilL-d. Shuulil tlic Siirg^Mii fii-l ihnt b<- haii idium 
this misldke. ihv ni.tcr pliin will lie ot i>iic» U> mubd oH' tho rmb of U>* 
Itape. Shimhl rhcy biivp lion cut liio than, the will imrte iiiuet bo f>rcJbly 
Ktrui-ted, tlic lioiir clourvd by i-in-ubir «iiix.>|w (if (be kiitlu, and Mwn ia 




PIK- II.'^tBpnlMllqD ot ib« Tbitb 



TruttSilim. 



rup* ml ht 



KA up u poenblfi. 

■MOof tbe thigh or ■nii, should be cut lirel. 



Til*' Ibiji r«rlh<-8l from ihe vn«i-lfi, as tbiit on tbr •■iitvr 

Iti iiiakiii); ihc iuiM-r IImi, 
gtmt cnrc iiiiifI bv Ink^n t<> wind tin.* jm^iiI of the ktill<- mi'II round ln« 
iKitir, Krt M iii>t (•> traiwtix itfid fl{>lil tlif TtvM'la. but !■> rut ilieiii m» lonj; na pr»- 
*ible. Ai n j;ciifnit role, thf lt«B loow mit»<'le ihnl is \v\\ mi ll>e i>|itiii|>. ibn 
bolter; I>mn>, vrhfrt ibeiv ia nti cqflal ihirkni-M «f null jinrtji muiHl thx 
biinn, M ill tb«- arm ami ibigh, the fla|i* sli'iuld Im< c-iil shurl, m-ll r<'irncti>d. 
BQil the b-KH' rl<«r«<l by circular sweeps nt thf kn'ifn as hi)[h n* tirc<-wary. 
Tb«> bono (hu« lini at tli« Ivotlnm »f a dMp h»ll«w U'votid the niiglo nf Jitno- 
tioti i>f ihi' llii|vi, and ihrrt' in Im ehniict^ of n Mniral ■lump Iwin^ li-Jt. 

In t'ulliii}; II tinp from without iiiwanlii, it >» of ihc i;rmt<«l inijHirlMiicr la 
nniiembi-r ibnl the «Ik<' "f tin' kiiilV niuiil ufiver be lurned tDwnrila iha 
onder Mirfiicf "f th*' flnn. bill alway* lownrilii ih^" [Mtrti Ki b» remowd. 
AftiT ninikinK "ul ihi- itiiji wilh tin- p'liiit .if ibi* knife, ibe Surjfwin Inkn 
ihf t'lp- of the «kin li):blly Im-Iwit-h ihr fiiigiT and llmiiib nf hi* li-ft baml, 
nod ntM« it from tlir |uir1a bi'iivnlh. The (<»rlii>i> o( the flap which i« thua 
nwtd ir tlii'r<-f->rr iil n^lil aiiglvx to ihc Fiirfaci- of the limb, ami iW knife 
mutt nbu bn kc|>t io n Ninitar dintetioii, or its tt\gi' will be lunied tnmudi 



iimudi M 



THE FLAP AMPUTATION. 87 

:'vtiiiie<>r ibe flap, aod by tooriiig lU under surfai^e will greatly increase 
ihH'Ungere of ^t'xighing. The Hiip must be nii^iuil evenly iii'i'osa the limb, 
M'i -at Alia mu^t not be nlluwed to get in ndriutce of the iither. When 
Wi'of nrcniar tissue arc seen passing from the flap to tlie purU beneath, 
!!«- u{ii:'nili>r mu^t il'ivide theae ut the end that is aUached to the part^ tu be 
r-oi'ivni. There should be nu hurry about raising a fl:tp by digset;lion, as 
'iDiirr ihe influence of nniedthetk's the lenj^thening of the oiH^riition by two 
■If iliivf niiuut«8 U a matter of but little inipi)rtaoce. It is better to spend 
■a-"r two tuinuteii more over the operation, than to have to reamputnte od 
I i-'iuni uf sl»ughing of the flaps. 

Tor simple circular and the double-flap 0|)Cratioiis being thus brought to 

urln'iion mark the limits of the improvements in amputation which re- 

si-ir-l from (he invention of the tourniquet; and before the invention of 

:iii^ih«iics Surgeons were ctivided in opinion as to which uf the two methods 

•1- 1 1 III- preferred when the nature of the case allowed of a choice. The 

liv'i'iiit^ iii the ft.ip oi>eration claimed for it the following >i<) vantages: that 

i: BiM'a^y of performance, and could be carried out with great rapidity, 

::,;• -avini: jwin to the patient; that the thick muscular cushion left over 

;ii. ruiU'.f the banes made a better covering and remiered protrusion of 

ia>- Inn-' Its* likely to occur ; and that the accuracy of fit obtained by this 

B':h'''i tavoretl union of the flaps by first intention. The advocates of the 

•■r-.ihr methixi maintaineil, that the light covering formed by the skin and 

ij: «a> le«* likely to be displaced by the involuntary movements of the 

m-.i^.'-i. and was quite as capable of uniting by first intention as fleshy 

di[~: ;ini| that protrusion of the bone was not de]iendent on the method 

aj'p[>'j. jiut upon insulSciencv of covering. As long ago as IT'S:) it had 

■f-n piintt.ll out bv Mvnors that the muscular cushion was more an ideal 

lirinla:;? than a real one; for in course of lime the muscular tissue in the 

if Wumes alrophietl and al)sorbed, until afler a few mouths the ditference 

1!! ■■ .v. riu;; between a stump formed by the flap method and one by the 

- r^ir i- inapiirvi-iablf. The advocates of the circular method iil-o main- 

:-■.-) ;h:it (111- vi»>-l^ Uiiifrcut transversely retract more perfi'Ctlv. and are 
--■ ,;k iv I'l blci'd iilifrwards, and that the wound resulting from the ojiera- 

;. ri :• -Ui.tiU-r tlutn that jiroduced bv the flap method. The great objcition 

' ",'- ' lr<'iilar >i|H'nitiii]i ivu:' umloubledly its ti'dioii^ne.'i.-' and |>ninl'uhit-$s, 

■.'. ; I iis.'ipunilv ilic flap operntioii becami' ninliiubtedl3- the I'avoiitc mth 
. -■ ~irji-.ti>. The iuvi'Ulioii of aii;i'iitht'tics. however, left the ^'iirgeon 

■- . : . .- .ii.;d,T Milely whut method of luuput.itiou furni.-^hi's the bi'st results. 

li :i ■■■ ri..i[iy ii|;iii> uf ciperiitiiUi th:it iviTe aliuiM-t discarded thirty years ago 

: ::■ r--_-;iiii'-.i lio'ir iiMindiiiii'v. and flap,^ are now most frcnuentlv rarved 
;■. '■\ i-iitiu;.- from without inwarils, regiirdh-r-s of the greatrr length of 

■. :,■- n tjoir- il providiil thi' ri-sult is more satisfactory. 
A- .1 n- lit iif tin- thouglit uiiil lalinr devoteil to the improvement ol' am- 

; .:;i:;>;i ,-iiii'-- lln- invriitinn of auiislhi'lics, i-eriaiii general pritKiples have 

■ :.- !■■ I If onivir.-;ill V rei'oguized a-* guiding the Siirgeou iti the ]ierl'iirnia(ice 
; ;:.-■ .■[■•■r.iii"ti. Tlicsr niav be liHt-tlv sliitcd thus: 
1. fii'- O'Viriiii; must hi' sulheient to iiutI over the bine withmit the 

■,:.-ti:— : t-n-i-n : 

J T:.- :iri.]poI:itiiiii shipuUI hr so piTf'imied t)i;it the sc;ir. when the stump 

.■ '.■ 1 ■ ■:. -hull U'lt lie liver the cud of till' Imni- : 

I: [. — ihi<-, a ci.[Miident ojiening shall lii' pri'vidcd for the e\ir of the 

;.- I.arj- -: 
i, I'Ij.i; iIm — ■ advantiiu'es shall be olilaitied «itli the -uiiilli-t ]iii"ilile 

-J riri. . .f I III- h--:illiiv parts "f the liroli. 

Il.t' ii "f th>-->- rt-ipiires cim.-'idi-r.uiori mure in detail. 



88 



AMrOTATlOXS. 



I. Til n<i>vit>i: A TPKK'iKvr covbkixii. — It vm long «gu |x>inl<il >-tit 
\iy M_vii<>r> iiDil oihcrr, ilmt thv suixlard by wliicli ire must tuiimiilL- iIm 
itiiiouiil of i-uvcriii); irrinircd is lh« dmnteter of ihc limli al riglil i»i|;lf'> t» 
the titiu iu wliicli llic cii-atrix is to tteplacwI.SDil lakou at tlio point nlnbirh 
the bi>n«> is to Ix- diriiletl. Id operatiufi im ilic dead body, it in cvidi-iitl 
that if two (viual llu|«, «acli iiK'n^uriu;; half iW diaioMer of Itiv Ittiil) a) iW 
|K)inl at nliicti llii' t>on« ia auwn. von? cut, lh«y would taet^t nt^i-tiraU-Iy aixli 
cover in llii* l)oii«; )>ut such ilufis in lti« living IiimIv would W lt)tnllv in*! 
luli'ouule <iu iiccount of tlie shrinking from the flailtpitr of tin- sLtii and lli*l 
dtipliii-i'ment fnmi ihi' inninifiioii nf tin- iniiM-liii. {V)n»e<|nrHtU. it i" tirr«l 
VMitiry lo provide aniithcr Imlf diamrter of i»vinn(: u( /«•«(. nnd in •ftmii 
lituiiiioiu t-veii lliiti nntuitm is barely ku Hi din I. As iin illiL-inilicn "f thii:| 
nbxri' nile. tel uh 'upiMMe a limb in to In- iirnpiititled, tlif luittru-jtoettrio^ 
diiinx't'T of Hhirh, lit i)h- i>oini urbcrv tbi- Itoiie in lo bo sawn, b mx inch>^ 
till- nceesBtiry diametiT mid ii hnlf of cuvenni! i-ould txi flliOdned In lli«> fol 
lowinic wiiT!> iiiiiiintpt olbi-n>: 1. Odo lon^ lliip nin^' inch<« lon^'; 2, tnii 
Baiw, onr *ix iui'bfH lunfc itod tliu nthfr tliri-<' : ri, two ctpiiil flap* four ami • 
haU'inchiD tuna; 4. two eriual flupn tbrei- iDcIn* loni;, iind rvlrm-tiixi »f lhi« 
muKcle* from ihc )kid<> to iiucb an vxU-iit an M provide lui inoti iind ii hnlf •>( 
coveri»|t on i-nch «id«'; i.» oirciilnr incision nii#inf; llx- »kin and fnt for 
Llirei* incheM. and anullirr ciroulur eul ibrouph the niiise)»> with rvtmctiuB t4 
tl>p fr>ii (KirlN fr«>in th« tioiiv for onv inch iind ii half. 

T)h' );enenil rule ihnt one diiinH-K-r and a liiilf ic suftimnt, rmuim iiiod>> 
llcjiit'in nndcr YnriouK r»iiititions nf the liwiirt of nhioh thr fy>vmog u madv^ 
nnd in vitrioiM »iluiitioiiii. In very old jx'ople the skin hw frr<iurntly l<«l 
much i<f iK rliLiiidty : IhiI it is not nisc lo shorten the cykvcring <>n till* 
acevuni, ns th*- timim being feeble nrc le»o capnble of iriih>iinii lifts ibit 
irritaiiiiK edt-ct of tcnsioo. In Hniputulion tliruui;h chronii-iiUy iiillium-it 
iMUiv, ibc rvtrac-iiou is also reduced to a niinimum oo acotMint of the ni;idiii 
of the piirtA; but ben- again it is uunLte to shorten th« eoverioK — in I'nrt. il 
is better ti> make it a liille lon^r— aa tht? f\it\a. an.- very apt i;mdually to 
chrink durinK or at\vr th« hedln)[of the atump. In limbi in which tha 
niuvclei hurc nndtrxune extreme fiiiiy dcij^-nenitiou, the rvlmctioii rauMtl 
bv ihcir toiiic contriietioti is nliM-nt, emi tliut the minimum e(iv<Tin|; of » 
diameter and n half i> amplv i>ulli<-t«iit. Iu l)ie lower thir<l uf the thijrh tha 
QOVcriD); (hwutd al«'ut> W uien-us^il la ino diametent to nll»w for thv very 
*Sc«asivo mractlMi ntthc loiijt llexor niutde* flf tlie ti^. Iu ainputat><^i o' 
tbo leg by the lotie calf*flai>, il t* nlito necewary to provide verv iibundnnb 
ODveniiK Ui alhiu' Tir the *iiti|Hijiienl :<hrinking of iIh* nntfcular tiwue whi<'l| 
form* the {waiorior flap. 

'J. That tiik wah ^iiAtt. sur iik ovku tiik tati* ok tiib hoxx. — It i 
evidtnl. iu the liml |iliice. tliiit prolniiton of tUr Iwitc lit won.- likely U> iioou 
if the lwi> lln|» in a lln|> nmpiilntion im-et exnotly ovrr it* end ; but ihe chief 
ulijeet in placing th« nciir m> that il ■Imll be free frotii the bone i>> to iivomI 
pninlVil fturiip. If the M-itr in ibr nkin in adhen-nl lo the boni*, it tiei^onMl 
vZlrvmely liiible to ulc<-ntli'>n from ntiglit injurie*. If the »car be placeil 
well itmy fn>ii) th*t boue, it t* o>Vn gawiblc in am jMita lions of the lower 
limb for ihr iiatirni to U-iir a cerinin propurlion of hi« wei^ihl on the end of 
the nitiiip. which givi« greulty increared Kli-adinens iii anlkiD); ou nu nrlt' 
ftctal limb. 

3. TtiiT .* itKrnxiii:sT i>i'i;\ix<i i" ti> ur ritoviiiKii \tnt tiie exit up 
tiiMiui^o:.— May W itaii-d in oihrr wonU ihu*: ihitt the covering of tha 
MuHip fehttll W inken cbiclly from the durral »url«<.-e of (he forrarm, and 
(WiNi ihe nnlerior pitTt nt the limb rWwhere. Perfect drainitife is nlo^Iutrlr 
law-'tiltal tor uukHi of any ti<Hind by lirxl iutculiou, nnd euDH-ipietitlv il la 



PRISCIPLES OF AMPl'TAT10>'. 89 

nwllm til point out the iinportaDce of so arranging the covering that the 
iTCf of gTftritr shall aid, aad not uppoBe, the escape of discharges. In ex- 
i»p(i'io«i ctae*. such as in some of the amputations iu the foot, the advan- 
ttmi'f the 6ap taken from the heel or sole iu providing a covering npon 
which ihe patient can bear his whole weight are sufficient to counterbalance 
itw difficulty of drainage that sometimes is met with in these operntinns. If 
ih* ciiering be taken chiefly from the front of the limb, it ia evident that 
lyif I'ttlr will gravity aid in draining the wound, but also that it will tend to 
k«p ihe longer flap in its position. If the covering be taken chiefly from 
hftiiixl, as in the transfixion-amputation in the leg, the tendency of the 
bcicy muscular flap to fall backwards can be counteracted only by fixing it 
l"lW anterior by sutures or strapping; tension of the short flap is produce<l, 
ud it may slough over the bone; anv insufficiency in external support 
■lli'Bs the posterior flap to fall awav, fluids bag in the gap, and speedv 
Dni'iri w impiisiiible. 

4. That THt>K ai>vaxt\(;»' are to be (jaineu with the smai.i,est 

hwiHi-E !-\<fiehe of the i.exctii of the i.iMB. — Experience has shown 

c -Delusively that the danger of an nmpntation increases aa the point at 

•liicb the bone is sawn approaches the trunk. Xo fact in surgery is more 

f«(!usively proved than this. It is evident that the bone cau be sawn at 

the I'lwest p'jssihie point if the covering is taken ei|iially from the two sides. 

T"take as an exani])le. a limb, the autero-posterior diameter of which is six 

tBi-bes, and which wmsefjuently requires nine inches at least of covering to 

f^irni a ginMl stump, and supjmsing the nature of the case made it impossible 

t-) obtain covering from a [>oint lower than the end of the bone to be sawn 

tlirvj;;h, if it is to be taken equally from the two sides, the bone would be 

w*n f'lur and a half inches above its lower end ; if from one side onlv, nine 

brfar:'. If, however, the anterior flap wns five and a hnlf inches long and 

ibe pn«ienor three and a half, the advantages of a dependent opening and a 

tear removed from pressure could be obtainetl with the sacrifice of only one 

iDih morv b-ine than if the flaps had Iwcn of equal length. The Surj^con 

will tiii-rvfore adhere to tlic rule of taking the covering ns equally lis |>os- 

•ii'ip I'r-ni the two sides of the limb only so far as is consistent with the oilier 

f-.n:ials -it' a j.'oimI amputation — a depcndoni opening for drainaire, and a. 

*-ar a«;tv fr^in the hone. A long stump is more easily tilted with iin arti- 

fi- inl iinili and give,* (he patient greater control over it. 

Thew es.'ieiitial features of a go<)d aniputiition heins; agreed upon, the 
','j---iipii- "I" ill-' Im"*! mnteritil of which to form the covering, and the best 

■ IV ..f raisin:; it. remain to l«" considered. 

\.\ ^r.r-^fin* ari' tioiv iigreci that too tiitich rtiii-clc in a flap is an numiti- 
.•a:.--! ■ vil. Th(- ohjoctions to muscular flaps are, that they are heavy, and 
■■• t— ■|U<nlly liaiile to he easily displaced; thai, supposing any voluntary 
n; .■.■■■:o.-i,i .ir iuvohinlary jerking or twitching of ilic liinh to nciiir. the snr- 
fa,v- if th'- fla[is are moved upon each other, and ]'riuiary union i.J thus prc- 
tm:.!.-!. anil that tlii.-i is especially likelv to liappcri if the sharp cd^'i' of the 
•a-Aii l.'.nt- is iu <lirtct contact with a mu.^^cular Map U'tit over its cud : that 
~Ti-'i.!;ir tla|>s ntnict to a cnusiderahlc cxti'iit after the operation, ami 
" ■..■.'■•i-i-- ti' rliriiik lor s^uiie lime, thus cau>ing a ;.'ii'ali'r tendency (o prolru- 
•; ;i -f the liuue : and, liistiv, lliat as in llic end the muscle e<iriiplelcly 

■ :i-:'-> :(uav. ilii' idea that a uiu>eidar llap i'urnis a lictter eu.'-hii>ri than one 
.-..■,: t- -1-1 i i.f [hi' rkin and !'ubeutaur<ius Jut onlv is erroneous. None of these 

■■•ijiiii- i-iu 111- raised ti> a eoverinir ciiinpiwd suh'lv cif tlii' cutaiu'oiis and 
-.;■■ iTaii'-'iu* tiMiiiiT; but. on the other hand, in very cmuciatcil siihject-s 
■:; ri ;i . .vitItil.' is Very thin, and is apt to suHiT IVorn the direct pressure of 
ihr l> iiif a:xainsi it. and conseipienilv iu siieh cases it is well to protect it i)y 



AHPCTATIONS. 



■kiu Ha|M alfti, if vprv ]ttoft. 



raitinj^ n ocrlniii hiiidiiiiI of idiikc'Ii' wiili 

npt riialoiigli, im lli<-ir viiamiliir fDmily in ooiiivnlwl liiiiilnl, nud lli'u acclilrBt 
ia mtirrmlly liiililc in lmri|>«-ii iti i)l<l |H-»pk>. In uny |«li<'Dt, nlM-tlxir yntut^ 
or ol>l, fitt or Itiiii, ^nugliiiiz will nlmmt ii^rUiiiiljr occur if thi' >*<ir)i:nin lurai 
Ihp i-d(^- of iIh' kiiilV ^twur^Il tl)>- 1Ih|> iuFtni'l of kif |>iiig it dini-tn) miaiirjj 
th« parts III l)c reiuovol. Commoii m-hh- wimiM mi^jcivI alwi lliut it b «Me l^ 
lliiclcfii tin: Imm ot'n tinp uiili ii litllo iiiusi-lo nhrn jxiwiblc, if eir«-uftiBtattC4 
r<<quir^ il li> be niadcof iiinri- lliaii urilinnry Ipn^tb. If llic covir iiit; iii iiKaC 

Iiiirifi were nuulc »ulvly of tkiii iin<) tiit, llit- rvtrai'lioit of the kium-Io w<iuI4 
rare lh« Imiuq protmdiii;; diBr])Iy Ih'dchiIi llie da|«, itud tliv objn-t i<f lli4 
Hurfneon U, therefore, lo mivo wt much inuai-Ie tliiil alliT full n^ractinti tia^ 
luken plun- it slitill still Uv Uvi-I witli iIh- buvu cod of ilic Uiiu. Jo ordrf, 
l(><4>laiii this rt«ult. iii« projioriioDtt iihuiiIIv !'U<l!d<<iit ure to pmvidp ••«« 
diamdvr oJ «>vcriiii.' comjiuMd n( i\n nkiD and «(ili(-iitniii-i>ti> >trucliir<-s, iiodj 
linlf a dinim^lir uf iniiicle, or iiio«- if tltt- relraiHi-ii it- i-xi-itti-'I in W ov-uJ 
niileralilv, iu> in ttia- lont-r pari of ihe thigh. Id nit cn«ui tW n|>rrmtoa 
•houlil hrar the |>rinriiilrit In niiiid, and bi> ^iiidi'rl in liiti mrfornuincc by| 
cir^'UiiiMiiiK'iv. i-(itisidrriii)[ iIh- Hce niid »laU' nl' bi'ultli of tliv |i«ti<>iit, thai 
antouiit »{ milfciilnnrciUH Int. thi> K'njitb of the da|B, and lliv Niluatiott of tba> 
ani[Hitatii>n, and Miiling tbo rrlalivt: |>r"|MirtiniiA of nkin and muxctilar aiX' 
i>rin)f Lo tliv nature of lliv CSM. A in«rc luwhanicnl aui|fUliitor can aewt bs 
n koihI unr. 

In ani|MiIntiiiK for diMvaM-d joints, Il nden Iwcoinc* a qticaiiou vrhi-ihfr tlw 
«(rU(-lun« (.-uvi,Tiii|f the nrlicHlntiun are in a fit Mad: !■> liriii'itl in tin- furnia* 
lioDof flaf«. Ao II K>'nt'ral nihr, it nmy lii<*latcd thai ibi'chrunioillr infliini<tli 
tiMutw et>vrring ii ilim-a"il joint. f\tu vhvn ["rforali-il hrn- aou lb<'tv lijr 
ainnMv. ihrtn cici'tUiU llii|it>: )>nt il niii»t bv Imhih- in mind ihal, (Wir 
vilatity beinK HiHiitwIiat hmi-r ihitii natural, tbi-y miist he curcftilly handlnj 
lo avoid unu^i'caMiry bnii»in]{,ainl ibal tbcy »ri> liabb* to shrink i-oiiHdiTnbl/ 
■« tbo uninp li«al». anil voiucqiK-utly ibi-ir len);lb mUNl Iw oli^'hily ^rcatrr 
than if the tissut» wcrv hciillbv. Sueli l)ati» yii-M a lar^jc aniixini nf mthiu 
exudation durinif the finl l<!n' li»u» ntU^r lliv i>p«ralioD, and ample ilrainaiti* 
niiiM liejiriiviiled fiir tlii!'. 

Tha Hods of Eatiing the Covering.— Tliis may be ilone by ■.-uliiiif; frtMn 
williiu DUtwardc, or from without inuaril» — in other aorda, bv tmii*nii'>n ur 
br di:*»ertiuiL SItat .'^rtti'ous now pri-l'er ibc latter mi-lhud, ibe objrL-tion Iv 
traiirHtiun iMun^c (bat it leaves ihe Surgeuu no ubtHcv lu to tlie relati*« 
amouDl iif kkiu nud tnUM?le that lie will take in bia Hap, and ]» <.>>tiwM|uentlr 
ill >u)ti-d for all nmpiilnti'itiH in niuHi-nlnr MiliKCto. Ili ebitf advantaji*^ niu 
ilR npliliiy, luid ninw tin- invention >i\' anawtlirtim thiti b i>f Utile or no ma- 
•n|uem'r. A minor ndTaniii^i' U, tbnl it i« Irw difflrnlt tif jHTfornianiv than 
cutting tUnn without innanls but tlif nniixint i>f nkdl re<|Uin^l fur tli<' latter 
i* nol unrb a^ to jnMily any l^'iirKi'on in rourtiti;; t'l the fotwcr liwlliiHl on 
tliii' ..■ ■ iiit- 

1 ' ' 'ing:, an Wfor^! atatii), Diar be rmii>ril rirralnrlr nf iu da|»i Tbe 

nilati\>- iiji.'liti of iIk-w- tnii nii'lbod* have ulrrailr iHi'n •lifCliMHil. [u f<HBa 
uf the UMHli-rn it«'i)ii>'l> •■f nrtijiiitotiuif »li>iut to W diTcritiiil, i' f><>> tvvn tbu 
iibjrt"! of III >inr, ua lar a* pi-mibli', ibr n' ' liilh 

inelhiMli' in ' < ... rnlr> junl laid down a* |i> .1 ■( 11 

gTMul nmpuiiiiiiii), 

AmpuUtionbyUielloitiAedCirouIarlletbod.— Ill \s:iH, ImViu pfupoecda 
cvtniblnalioii <d'ih<-d<>u1di- Hup and (-in-ulnroi>crfltion*,nbi<-b (.'really iiDMOrcd 
t]M)>hiitH-i<f ib>' (lump i>f the cirfularnxiboil, and Muncwbal inrn«ml tb««u« 
of tlM- v|)rrali<>n (Pitt, 'i^i- TwoM'niiltiiiur inci«ionc. with th<.-tr convcxitim 
dowDwnrda, arc innite tlin>ugb tbc akiu Iruin akJe 10 tide of the limb: the 



J 



TEALE S AMPUTATION. 



fll 



bp ire thco diaaerted eo as to expose the muscles aonienhet higher than 
ihf u^les of union uf the flaps ; aod the operaliun is eorapleted as in the 
wliaarr circular method. This method of upernting is especially indicated 
is BUtrular parts, such as the arm, thigh, or leg. The a<lvaDtage of this 




Fig. 2Z- — Modified Cinolar Ampataliun id th« upp«r third of the Le^. 

I>p.<«dure over the ordinary flap (iperatioii is very great in stout muscular 
«ily*T.ti!i. 

upntation by the Long Anterior Flap. — The kte Mr. Tenle, of Leeds, 
in l-S't^J, invented and practised a mode of amputation bv a long: anterior and 
a «hvr( j>iwterior rectangular flap^ The long flap is perfectly square, and the 
rale for it« furmatioo given by Teale is, that its length and breadth should 
*»th be e<)UBl to half the circumference of the limb at the place at which the 
\nftei are to be sawn (Fig. 24). If the circumference be 12 inches, the length 
and breadth of the flap, both at its base and at its free extremity, should be 6. 
Tbc short flap cut from the posterior ns]>eet of the limb, or the palmar as[>ect, 
if the ''[nrralion l>e in the forearm, is to be one-quarter the lenj^tb of the 
s!iiiri"r flap; in the ca.-^e above Mipposod, it wduIiI lie 1} iiiclifs. In per- 
: tn^iiiL- ibi- uporution the meiii-urenients must be ("irefullv uiinlc, nod the 
•.:!iiit; >'f the ll;ip:< marked ijn the 1irnl> with ink before the uniputiitiou is 
. aiiii-n-i'd. B'llli flajis iire to be made to include all the soft jmris of tlie 
-■.:-!■. ;ui.) the ?h"rl flap will always ciiniaiii the chief vessels mid nerves. 
T:.r U>n.'- iirr smvn exactly at the angle of union of the lla]):*, without iiny 
■ r.-v' ■<:• r>-irai-tii>n uf the soft paris. .\(ter the vis^i'ls have been sceured, 
::■ ■!._■ rt;i[> )> fip|.|iil iiviT the eud <if the hone, nii'l allacheit by suture. 



V 



N - 




i ^r -J. -I.irjr* "f Ifp.'i.M'.D in TcuLc'i AaiputAtioD. Ki^. 2'-, — Ti^jik'p .AiM]>ul:iO"ri : Slniii|i. 



.a-;'» !■' il..- ^Ii'.rt flap. :inil jiarllv tn ilM'll'; lhii> llie lirsi ninirtii' nl' the 
:..■ .iT.i-ri .r ihip 1- lir,-l aceuratelv wwii In the ^hurl ]iii>^li'riii|- flii]>; tlie re- 
: .:. 1. ;i.' I'lirt 'il tli>' iililiTiiir flap is then ilouMi'il nvir on it.-cit', il;^ t'rei end 
■• r._- ^1. .ir:it>!\ tln.d to llir tVi-'' enil nf' ihr shi^rt tlnp. and iitliirliid by 
■ .;..r' - , litmll V >iilriii',- ;irf up|ilii'<i when' the IiTiniiinl puit i>l' the tliip i- in 
!,^i. '. «;ili lh>- i-C'iid <|iiiirti-r. as in tiic lii:nti' ■ Fi^'. 'J'l . Tlif risiili- nf ;ini- 
T-.ljii 'ti bv tiii^ iin-lli'id in Tealc's Iniiuls were viTV Mili.-iintiiiv. I'lie advuu- 



AllI'L-TATIOXS. 



l»p* clainioi) l>T Title for liii) iuiHIi-hI »( iinipuiutin^ wvrv, tliiit il pTttvi<Uil 
iin iiliuiiilnnl <v»wriDg tnv I'rQiii li-urKni. Tl»i» it rviilentlj iKhti. n» tho 
rovcring *m(iuHt» Ui li diiinM-cre of ihc limb. Sw-opiHy. it |ir<iviil<« m 
il«[»«i»ilent npMiiiig fur titi* rxrt >■!' iltwhiirgr: itml ihirHlr. tliAl wIm^i it I* 
li«iitetl thi.- cioHtrix u iKhiixl ihi^ ti<im-». iiml iliiit irotisvijucnlly Ihi- |)alu-iil run 
Imir the nhnU' ur n {<*n nf tiin nci^'lit on iIk- rml >i( tin- ?tiirii[i: tlin ia 
»|»x-inl)r ii>Jviiiitiieioi«i« tiflcr iiiii|>uitili'fn in [hv rhigb or U'l:. wlivn dinn 
prtvndri) mil smrcwlv bn nvnirkil. itiid when ii »<>\ii\. linn tltiinp ailmiltiti^' ii n 
(if vert' <'«»cntiiils4>rvin-tollie[iiitk'nt. Te»lL'ailviiic».hiiwerpr. thai tl>L-wli(ili< 
piWHiiri' W nut hi)rnc Ijy lli« Mitinp. hut tlinl it \» rcNlucc'l lo '•tK--lialf, lltv 
tviiiniti'liT Iwiiit; ilUtrilnitri] iii the usual way nn the upper part of iIm> liinl>: 
tlitii »i^ iiiily n-1icviii;> ilii? etttrnp, hut Kicuriii^ ti'i'^^t^f aica'linees of ((lit and 
lirmni-H> of xlcp. In the up{>C'r extremiir, Imwevor, no dirvet prneurv i* 
inaik' ti|>nii ilie eud >•( tin.- tttimp in ilie lulupMllou of srtiliml liinlii : brn<->', 
the n-niiiipiltir iipfieara io them.- siimitions to piMMva ii" »(lviiiiiu),-v over llie 
i>tii«r (hiulili^'tlni) iiiI'UkhK mi fur im tlio uiility of iJie fltunip m cuDcrnKtl. 

Itiit, nhiUt tully admiiiuiK the hi I run (»),'« (hwn«iihI hy the n-ctntigular 
mcilnHl it) tlic foromtiiii) of n nvll-c<>v<Ti-<l Mump, L-x)K-cially in thv Inirer 
extn-tiiity. w« iniiM uot virat: our cytai to i-ertiiin iliMnh-niitajin^ whli-li »pppar 
to Riv lu lie iitirpnriililo from it. Oue iliamlvaiXa^i- iMtoiit^ lu the ownxity 
uf Miwiiiii; tim Imiw at ii higher [H>int whcu ouv Ioiik tinp only t* miuW. ihao 
when two sliorliT •hkw nmn- ncnrly oi|iinl in Wgth nr\' Innhionisl. Thit*. 
lor iikilAUiv, in iin nrnpiittitiiiii of the tliijh fur ibjury aWit Un- knnsjoiitt, 
llw liin^ n-clnn^uliir finp in iiii lulult mhuIiI niiiuir" tri In' iiKxil right iurhi;* 
ID Ungih, nil') i1)i' fi-niiir iiiURt ciniai-ipiciilly (h- »atvn at Iriut lui Ihr a* thit 
above lh<> )<nl<-lla: nh<-ix-ii». in the onlinitry iloiihh'-llnp imiptiMtiim, lux 
shorter tUip*. «cb alMnit fi>ur inches in length, will br foiintl milKi-itni la 
cover iti Utr bone, which may conMV|uenlly be Mwn at a proporlionalrly 
low<<r point. Tbu» the ri^etiin[,'ulnf lut^lhod coQlruTCrncH the principle ia 
anipuliition, not to rvmovc the limb nl ii hi^Iicr ptAat iban U nlMolutrly 
liec<.-eMry. iht- ilanu^r lo life invrensin); with every inch tbnl h removtyl ; nor 
can it Ix' cumsidenHl lo lie inivuntaKe^iua in thoae ouee in which len|^b H 
eaieniial lo the utilily nf lht< slump and the comfort of ibe {Kiti'-iil. 

In am[>utatii)na lor malignant disi'SMr, also, the lonft flap, which bn» to be 
cut in elojc [iroximily lo ih« morbid iirowih, would run a tiir ^renter risk of 
inliliraii'^>ti thau would two »honiT on(« taken higher up in tJi« liinb, the 
hone in bi>th caoe* bi-)n}t miwn nt the same level. 

Should union by the tint inlciition fail nitd suppuration entuc, in ihfp 
rcol an [^ulnr amputation the thick fle«hy mii»i which eut<-r« into the lurmatloa 
of the looK flnp l>reoiii4>« ii iwiiircc of i;rr«t inconvenience, bulging out from 
under tlx* 'kin, mv\ n-piiring con»iili-niblc miinagenient in ifie unrr-treat- 
HM-ni. 

For tliPw r*'iL>gn> th'> unnio«)i(le<l form of Toiile'i ampulnliou u linrdlv to 
be n'c»nimi-ndii|. 

At ilif Niin" lime that Tmle waa ri^immeiMling iIm long ant^'rior Itap in 
all |«rU of lh>- IxMly, Canb'n. of Won>i<*U'r, Wii# n<lx'ocBtini> it* (iniplovnirnl 
in a furm nf ampulntion invnti'il by him for removal of the ihiKh inimr- 
■ 41>l*''> oliovi- the kne*. In hiii niM-nition, which will bi- d<-*crilnnt amnni;*! 
the ■(■-cini nm[Mitntion<, a *ini;l'- long anlvri-ir llap uos tnmlc, the exintmity 
ofvhich w»» roundi-i) in fonn. 

KjM-nce, of Kdinbitr^h, who fiilly rvoojpiiiod ihn ndvaniagM of Tnklc'a 
nK-di'i) of nnip<ilniion in thr lower third «f the thigh, euggi^cd a imxlifica- 
ti«n hr which Im- bojicil to obtain them witli Itwa trouble and without pn>- 
dnrin^' iinite "i lan^- a wound. He nmile no p(«trrior flap, but ront|)enaair<l 
for it by n-trnctiiig the m(i |>art« from tlie bnnm to an exteiil eqnal bt ita 



COMBIXATIUX AX1> OVAL A M P CT AT I 0X3. 98 

Itwh. The anteriur flap was tu be made a tittle longer than the diameter 
• )' ibt limb; and, itd angles being rounded, it was alluned simply tu hang 
"Trr the end ut' the stump, uithuut being toided upon ilficll' us in TeaJe's 
"pFnii'Xi. The posterior partu ncre divided i'rom without inwards by a 
>iD£le ^wrvp of tlie knife. Uy this method, however, tlie bone was sawn as 
iiiji up iL* iu TeaJe'? method, bo that the gaiu was not very grent. 

In iNiM LisU-r pointed out that the advantagi-s of TeaJe's method eould 

U- I'btaiDt-d with tKtnsidorably less sacrifice of length in the limb by taking 

UK i-uvcring more equally from the anterior and posterior ai^))ci'ts. A de- 

(viHJeni iiiiening for the exit of the discharges, and u scar placed belaud the 

buoM. may be obtained iu almost all situations by making an anterior flap 

ii'>-thinU >if the diameter of the limb in length, and a pi«terior half that 

ItOjith, as the bone is iu almost all parts situated more towards the auterior 

ibiD ihe jHjpitriur aspect of the Hmb. Iu all parts of the limbs the Hexors, 

tMoe the muscles with the longer Liellies, retract more exiousively than [he 

riinworv; and, cousequeDtly, if, when tlie operation is finished, the line of 

imi-iD ■>!' the fl«[is is to the flexor HSpect of the bones, it is tguite certain that 

IM icar, when the stump is healed, will be in a similar positiou. The luetliod 

ti opt-rmting. therefore, recommended by Lister as beat suited tu the uiuputu- 

ti'-w 'it the forearm, leg. and thigh, is the folloniug; An anterior rounded 

d*p. eifual in length to two-thirds of the aulero-pusterior diameter of tlie 

lioib SI the point at which the bone is to be sawn, is raised by cutting from 

«ilhi>ut inwards. In the lower thirds of the leg and forearm the bancs form 

t" ianre a proportion of the limb that, in order to make sure that the scar 

«ha!l be placeil behind them, it is necessary to increase the length of the 

aateri-jr nap to the diameter of tlie limb. In raising iJie anterior flap, the 

(■prnititr will, if he tbink til, try to take up some muscle at the base of the 

flap l-> thicken it up and so insure its vitality. This is ulwiiys to be recoui- 

mefideil tor all parts in thin or teeble subjects, and in the thigh iu every 

patient. The flap is not, however, under any circumstances, tu be too fleshy 

and btravy. A i>oi.terior skin-fliiji. half the length of the imterior, Is next 

rj;-"!. The muscii'> are then divided circularly iiud retracted from the 

t> L-.- I->r a di.-tancc eijuul to at least otie-<junrtcr of the diiiiucler of the liiiib; 

.:; :!n- ihiirb it i.^; iM'tlcr alwavs to retract for half ;i diiuuctcr. ll i^ cviilenl 

ti.ai in the leg this retraclinn mav be rather ditticult, e.-^jiccially iu secomlarv 

k:iii>u'.ati"ii'- in nliich the tissue:^ are swollen and inlilLrali'd : liul the <iilh- 

. ..IV !.- i-:i.-iiv nviTconie hv e.Mendiug the incision upward.'' fi'oui (lie iinu:k- 

: 111*- [la)«>. t'iihvr on one or both sides of the limb, to llie point UI siliieh 

::,' i> iits an- Ui Ih- !>au ii. Thi? mode of niii]iutatiiig combicii's [lie iidviin- 

U.'-* ■■: ('••ih tile cirruUir and lliij> i)piTalioiis; it lia.* llii' light eovciiii;; mid 

»:.r-ii.-' -if i.-S(vs.-ivc muscle of ilie cirvuliii', «itli (lie aci'iiriLle lit. ihi' good 

:rjiij!i^>-. ;ind [he well pi;i'-ed ^ciir of tin- liiip iii.iliocl. ll is in liii-l a eom- 

■-.aati''ii <if ihi- tlap and circular ojM'ralious, aud i,-, tlierclbri-, ^ouieliiues 

-;■ ■.■-ll •■! ;i? [In- "c'liiiliiiinliiFn nietliiHl, ' 

Amputation by the Oval Method. »hicli i.-^ e>]>ccially nda|)lcd i<> removal 

■ I ::t.,-'r> "r [i»> auil dijarticulaiinus iii the r-liouldcr and lii|i, i^ c.-scinially 
a ' :!• ti.ar unijiulalion willi a lonf:itudinal inei.-inn made up I'Ue ^ide ul [he 
.,iu^i. [■■ lacililali- tlie relraelinti 'it the Mill part.- luui ihe ex]"p>ure ■>[■ the 

i:.: :v: wld.-ji dj>iirlieuliiliiiii i^ in be [lorliinued. Tin: oval liiviii i;- yiveii liy 

■ .:,:iiiL' <-lf the auirles l>>i'[iieil bv llie Jillu'lioii ul' [he lun^'itudiiial itilh llie 
' .n >..:ir iii<'i>i'>[i. Wtieu tlie l>'U:;iluiiiii:il iiiei;-i<iii i:- eniitiiiiieil tlir ><>itie di.-*- 
;i:.'> :il. .Vi- [he ciiiiinieueeijieu[ of llic irue oViil ]i;trl. the iiperalJiJll i^ Ire- 
. .• :.!.'< -I •"ken -'I ii.~ auiputaiiiii liv ilie " racket '^ll:lJH.'d iui'iri>iii. " 

Sawing the Bone.^lri nil ttielli<Ht> of unl]lllt:l(iIlL^ o:- t-'h'M a- llie iiicisi^'ti? 
:^\- inio tiia.ic [liioLigii [he .-"ll j-arl;-. [lie linrii^ iiiii>[ be eteiiied liir llie 



84 



AMITTATIOys. 



B<.i»l>ni ill fnrUiJig 
Mid iMK- on vueh diM 
Huuaiit thru, tiiktRfl 
ie ulht^r, pulls lliciS 
i<t miiHt tw lurti ini4 



upj>li<;iiti<in of iIk- Ntn. While diiiiit; this l\w w>ft pmtU mu«t Itv finntj 
mriict<tl by Ihv aohsImiiI nr hy the Surp-mi hinwif, if be oUml* »u m 14 
l«k« his own Il«|«. Fur lh<' |Hir|Mi0D <>!' rvtrnvtion llii' hnmU ntv u»uall]| 
SuHScivni, ihou^h •unir Siir^-iiii» still tuv ratnt^Utn inailv ut |>ii^ca of •tnul 
calico »r Mniti. Tin* rcirurtor mutt l)c aliuul two itictic* widrr than IM 
diiRirier of the limb und nb»iit three fwt loiifc- If ihtri- is only oti<; Imno] 
ODe end must bv torn into (no luila. The retrvclor is B<.i»l>nl iu fnrUiJig 
lotion, vn<l the two tails of the divide) end urv Iben pawed otiv on vueh ■>! 
oflhe b«iue «nil slifchtlj croMed OD each Diher. The awiiuaiit 
the two tails in one band and ihu undivided end iu ihe 
forcibly ujiwaTds. If then.- are two bunes, the divided eu< 
ibreetaili). the middle nueufwbicb iit pnued betwwu the b-men. Itl-lr■('^•ri 
arei>f use •mly in dreuiaror otuihined flap nod circular Bm|niUit»us. Id 
the pure tliiji ii|>ci-atiuii.4 Ibey are uniir<v>?iiry for retraetiou uf the sl<II p«rU^ 
but Lliey are Mill of use in pnXi.-iMiii^ t)i<- riiii*cli-9 friiui tbe tcelh ut' the aaW 
and iu keirptng iW HUrlkcni fm- from lb<' tH>ne-4lu>t: for I he taeeraiiuu -if 
the deeii mu*elu) by (be nw, and ihe inibi'ddin)i of Uwc-iluvt in their ■ub> 
■tiinoe, laicrferc mHouiiIt viitb union. Ifn n-tmctor h ufcl, the linal clear* 
iiiji; nf the tione U ci'ntpleled alVer it hnx lievn nj)|dii-d. Tht* i» liest don<^ 
u hrn them it only a Mngti; Itone, by n linn ciivulnr sm-cp of iIk- kaifi? Irmfl 
Ik-cJ Ui {Mint rriund the uri<ler wgini-nt of tbe bone, and then auolltcr round! 
ihv unper *urliice in the «|i|Kioiii> direction. If thfra-- bu two bont*^ can 
luuat ue taken to clmring ibem not to dirvct the edge of tlw knife upwanl* 
into tli« intcrMMxiiu epaoe higher than the lJn« to which the taw w to b«' 
applied, lest any arlery be cut where it will, on aeeMinl nf its rvtrnctiou, b% 
diHicult toKiiin- it. 

The bime having been properly cleared, the flape inuM l>e flrudy reiraclrd, 
in order to allow the mw to b« applied opiKRiile tlie hi};hi«l jmint of th« 
ineifcioii tliruuch the soft [uirts. In -irdir i<i iaw (he bone <(uiekly and 
alettililv, there are M:veral {wiinin deserviu^ aluntiun. The first cm shotilil 
be mo^ieao as to Ion a a deep gruove to receive the tevth; to do this the heal 
of the saw is Mesdicd apiinst the tefV thumb, nhich i* pneMed on the bMH| 
and t)ie inttrnmcnl ia drawn fairly and tharply ah-nt: the wliole line of JUI 
it'clh lri>ni heel (o |H>int. The urouve tbn* fMrnini ree<--ivea ibe ed|^ of ihft 
•aw; and the I»>ik may the n In- i|uickly cot thruuuh hy l«ii|[, Uk;lii. and 
•weeping Rtoventeni* of the inntmincnl from |M>int tolnHrl, the pusiiinn l>eln[f 
Srmlually chan^l fri>m (lie huri&mtal to the vertical a» [irD^reM is modoi 
The antotant must cnreHilly xujiiiort the part t» bv rcmovtwl ; neither depraa* 
tng it. ••■ ^ U< «na|t the hone a> it u wcaictni.-'t by mwing; nor rawing ■'• *^ 
M t" nin the risk of hx'kitig the ■««. Wln-n llierv are two Ume* of equal 
•tP'iigth in (he limb, an in tin- forvarui. they sh»uld Im- eu( tbroUfth a( tl 
■ame lime; tmt in (he b-p, the fihnbi. Uinj; (he wi-aki-r, should alwa^ 
firatdividtil. Should the ilivtsiofi W nmde irn'i^utarty, atxl splinteraai 
proii'i'l. ih'-H' iiKiii Ih' •iitiijH',1 iiir Hith eutliiici'tier*. 

The Arreit of Hemortnoge. - .M'u-r ihi- licoh has t>««n reniovcil. the ftnl 
thing ('I In- ilone is 0> rcvtraiii arterial hcti>ofrbni,'e. The vcwrl* are to bt 
■et'urril hy sonif of the iiirnns dei^i-rilHiI in ITapter XIV. llie inean* IdmI 
cniitMionlv nit'i|it<'d in the pn-svnl diiy are U'r»ii>ii nnd li^'ature uilh prciMrcd 
nlgut. whii-h may Ite left in the wound without tear of ■lier-lnxible. Whai* 
evt-r mriins of arn'slin^' hemorrhage are odoptnl, all vtcei-ls visible on ih 
aurffl(M-fl uf (he llniH «houlil l>e aeeureil liefore the (uuniiauet is rrnuivrd. ih 
Hurf^-'in Wing gnidMl by his analomieal knowled(^ tu llie sitna(ion of (h 
(nori- ini|Hiftant hranckefi. In addition to the nuiin irunk, frwn two to fo>i 
or six stnaller veeaels iistially reiuiire to be wcured; but soiiMtimeA, either 
IVtiin (he extMenee nf inaltguant diaeuac, or of extensive auppiiration in tiM 



a( tiM 



CLOSCBE OF THE WOUND, 



9S 



linb.lbeManip is ex cesaJvely vascular, and a very large number of ligatures 
UT be nquireil. I have, iu tbcsc circuinstancea, more than once had occa- 
f^v [0 apply between twenty and thirty ligatures to vessels in the arm and 

FrK arterial bleeding will sometimes take place from a point in the cut 
Nr&n of the bone, in consequence of the division of the trunk of the 
■ntncBt artery. This hemorrhage is beet arrested by pressing one or two 
Kiudi of carboliz<>(l catgut twisted together into the canal; or, if this 
ikould &il, it may be plugg;ed with a amall piece of carbolized sponge, which 
■ill become buried in the stump and absorbetl almost as easily as the catgut. 
Tbt old plan of inserting a wi>oden plug with a wire to it should never be 
raurtfd to if other means are available, as it is certain to serve as a centre 
of Mppuratton and causes disturbance of the wound when it is removed. 

It b impusiible to take too great care in arresting not only all arterial 
WtDtirrhage, but all oozing of bioi>d before clitsing the wound. It is to 
pisstaking and patient arrest of every trace of bleeding that the great 
nncH of some Surgeons in obtaining primary union is lu part to be at- 
ttiboted. To have tu open up the wound to secure a bleeding vessel within 
u hour of the operation is one of the most annoying accidents that can 
bppen to a Surgeon, and is most damaging to the prospect of speedy union 




Fif- Z^- — \ ^(ump thawing ibt iLO<le of applying Suture and JrAinsge-tube, 
A Jrninage-lube. 

•■:'■(. T «'>uni|. but even this is less injuriiius thim ihc liislenijon of (he Hups 
»i:n i oiUijiiluiii. iho result of tMiziiif; wliii'h, (H'rluips. slops just sliort of 
<>, j.nj ilif Suru'oin lo opi-[i up tlic Hounil fur ils iirri.'sl. 

Cloture of the Wound. — The iicmorrlmi:*; luivin;: bi'on nrrcstod, the 
■^■('Hiij is l>rou::hl tri;;i-lliiT over tlif bout' hv riicniis of sulurcs. In ii wpll- 
au'i.- -luiiip tlio covfriii^ is so liHisf that no forof iil* nay kind is Ufci'ssiirv 
I- iiriii.' ihr i'iii:fs loL'rthi'r, cocisiijuenttv. ndli(;.ivf ]>l:LstiT Clin ^{'iircply ever 
t- r'-i]uir<.-<f. Ill I'nses in which a .-itrii-tlv iintii*t.'plii^ ilrossiiig is lii'iii;,' iisl-iI, 
'jusi\ii| ?ilk ioiikrd tor [wentv-foiij- hoiirji in a 1 iii-'2(l sohilion of <'iirbolii' 
fcil, maki-:" llif liot sutures. If tlic drt'ssiiij; is siicli llml <ii'C'oni]iositioii of 
itr liihnrp-s is [Hi-sililf, it is better to usf iiiftallii.' sutures, ns they do not 
ii—.rli llu' r'^ptir tiiiilli-r, and an' c(inst.M[iipiillv i|uilo uiiirritnti»L' i' ''H'.v are 
s I ;ijbi. In inwTtiiii; the stiii'hes. it is bclIiT to put in two or tiiroe very 
ihi-'i -mures, i-iibcr of silk or wiri-. iit intervals of nliout oiiv inch to one 
iii-h aud a half ■ Fig. 2() : Tlic-y should j;et n good hold of the skin and fat 



LTIOSS. 



for ni loiut one iiiHi from ihi' i-(l|^ of (lie wouikI. TIkw tx'nr aiir ttnilt 
Uiitt itmy iiriM> IrMn ikuvtiitiir vt rctntcliuu. Rtlwcm tlicni tiuiT autura 
must bcinwrUd, m intvrvnln "t ntxiut hnir iiD itirli. bringing tlwakin Klpy 
into nficurnteap(»«»ilioii. Huch cluw KiiKiii);aj> tbi>, bonvver, woulil t>« liila.1 
to Miy hu[M> of uniofi, iiulnv a |>ra]>t)r exit fxr lh« iliaohnrgM it pntvitM fui 
bv <lr)iinatri>'tiibc». Th«tH- arv beet iiiikIo uf InHiM-rublior. IIkti.' obuuld 
nlunTe bo uiic nt itich nag\e of thr eluiii|i, iiikI, if it «e«Ris ii«va«iir]r fnmi 
tin) Mio ol' thv Btuinp, a third shouM be ioscrtrd in ibu miiMlv. Tbv dr«iB< 
RgO-tub«fl muM be cut level with the surfaoe uf the vi'iuml. and k1>»v«* all if 
tnuet not bo forgotten to tit each with a couple of threads, imm- on each ndt 
of it» orifice fi preveat iu i^lippiuj; into the wound iind bvin^ l<Mt thorv — Ml 
uci-ideiil niiieb liii« frci^uetiilv bitppeiMd frocn oef; I <-'<-'! inj:; this |trecauIiuD. 

Dreuiog tlic Stump,— An iimputatioo leav«e u clenu-mt wnuud. wliidi 
iDUBi be treated oii lIiivu princtiikit (bat f,'uide (he 8iir|^-uii in the maunfp'^ 
inent of nil incited wouiidK, uml wbicli will be fnll_rd««L-rilK'<l iu Chapter IX. 
Tbej' may beaunmml up brielly thus: 1. Itetnoval of all CMf^luin, )n)i>e- 
ilolnlua, or otiier (<trvi)in builv ; 2. C'lui»e and aeuumle ouaplatioo of tiana ; 
3. Eifieieni drHinit);e: 4. Fi-rl«ci km of the pan : 5. Scrupul'His aili?nii<iu 
to cleanlinmt — th<- nfu-i |H-rl<N-t cleanliiieM ooitfixtint; iu the ntMuhite pre- 
veniiuD of devump<»iti<>» of tbi* di!>cl)iir|te#. The uiml iniiiirinnt nii-thiKlf 
of tr<'atii))( stuni|it> iir<', the nnlim'pUi; dr^vsinj; with ciirliolti' pwu: mid ih* 
nn(i*eplic cotlun-iriHd <,c»lieylio or iotloforni wiad) drewiinf;. (iikhI rrMitti 
luive been obtnim.-tl by gonie Surgeon* with the w>-culleil ttpen trviitiuent — 
that \i to •av, no dmwing at nil. Among the Ixvl nsult* nre thoMt obuiiunj 
hf the lute Mr. Cnllender. Hi» mctlioil c»iiti«(ei>l nMCuliulIy in the um; of a 
dminagO-(tibe for fr»ru tweuiy-ltMir (o thirty-nix houra. plaeiiig the btuinp un 
B well-pwldrd «plint, to whii-h it wiu tHmdu^'d, ri (w (o preven( all vuluniiiry 
moTement nnd ditlurluini-e by involuntary iwit^^htngr. und drening llie cut 
edges with lint souketl in carbolic acid and oil, und cleunHng tlicin whc4 
ueoMBury with a jflaia bruaU dipped iu a urong spiriluouH aolutioii of oart 
bulic acid. 

No mode of dresBin^ will, Inmever, ftive good mulu unlen perfect drain- 
a|[a ie obtained by (be u»e of tubes ; and this U all the more ettential io the 
preaent day l>ecau»e almost every !Surf;ei>n now wiuhcd the »tump with wkiue 
antiiteplic iiolntiou. which, Muu nece(«arily uu irriiuut, iucrcaMa greatly iho 
ntiKiunt ofihe iwrouH diitfljnrp.- f»r the first (weiiiy-four hours; and ihe old 
lii^iture with its en<la huLscinK from the wound being almost eoiii|detdy 
nbuuduued, iJint «i>uree of •IniiniiKe bun diNiupeiired. Tbc ani<iunt of rat 
(Itul a titump gels dejK-uds jcrfutly \i\Hin the skill witli which it b bandli-d by 
the Sirfteon ■( the drivin>;. Tbi^ slump should lie supftortnl ou a piUow, 
und the waigbl of the biil-rlotht? lakeu olT by a cradle; or •linulil the cov- 
•iring lie eonitHjacil of iKtivy niuiwular fiajw, it may lulvaiiiageuutly be jtWod' 
tio A wvll'jinililnl wire ^jilinl. 

In voRie cawa. nitliough (Im! tlupn may ap|>ear abuiKlant at tlH- time oftha 
operation, tbc relraetiou nuiy mncli cxivn] that which no> aitlIri|Miteil, ajtd 
a wid« granulating aurfam inny lie left nflrr thi' ileep parts bnve hcttled. 
Tbi* b tuoat iiuumnu in umpuinttoitt in (he (liigh hv ■»tefxt-p<j«terior flap^ 
If (be fUjn have really liri'U iif KUllieient length, ttii* will Uiunlly rvmetljT 
ll»elf, thf ciintrai'tion i>f (lie gruuuluting »in' griKlually bringing the tltio 
c' 'fhi- hi'idiug of (be ((uinp under (bew cunditiooflM 

h ■'■.:; Hrighi I'tli-nxinti. whifh ix dune (liu*: a pieO^I 

<liu<'li> i'<i< j-Iti>;>'r t* L'UI of aiilKciint length to rearb to the next J»iut alwv« 
the urHiiiiiutixn on (Ih- uiiierior and posterior u*j>e<-l* uf the limb, and to 
firm u loop eidndiiig ill leaxt one f<*ikl iM'Voud the itul »f the »iniii(>. Itfl 
width at eneh end muitt lieneurty half the cireuuifrr<'uce of the limb, und ia 



IIOt!BI.B AHPtlTATIONA. 



97 



lt>HMk il Bsy lav wnieirh»t amtrawet. The pluter i* vr«ll wnnuMJ iinil 
mU fai ibc Kunn. ■u<l ■i(rrtiuu<l«l by n fi-w uiruf nf ■ tiiiinluifo. mado of 
titliM tiMtic Wctiti AnaiM-l. A wtilf " .ipn:«<lfr, " iiimiIc nt'gi [>M'c«of Wood 






latil tbff 



W- 



-' wtiich ^U[i|ioru till- Ki'ij^bt Ui |)iuw tliruiigh, is 
l"iji i.r [iIbsIiT. Tllr »(in-ilillT »avi» Uh- *pi| <»l' 
"■<|, Tlir «-<-i[;lit i-< llica Hjiplioil oTcr it [kullojr 
'»it mill ligur^'J iiikIit tlii; trmtOHint of frncliirv 
I Uit* tn«iDM-iit nrw muu wiUofnctArjr, <«pvrimll]r 
L;h. 
inp u Ih-iicIiI''') by th<- ii|ifilirftlii>ii of n biiDHn^rv lu 
iVpvT t^ riiiu; ttirlinul >U4!T' o>' einilrixiiliitn I nii<l,ii»ngcmTiil 

n*. I tlulKnitrrow ntlliT will ailnpl ilwinxttU'r than a broiul 

lalMd i> complrtH), lb<- pntiriit ahuiiM Iw iiUovrH to go 
but miMt ui>t wmr an itrtiticiiil limb for miiuc moiitlu, 
vf bnmtnr firmly LMn»>ilida(i-<l: diiriiig ilw whole «]' ihii 
tWatumptbtiuld bo krpt mrrrully biiii<lut:c>J.BiMt nut cxjmwmI tu injury. 
ia frrformiiif an amjiutatinii, ibp prrpnnitioM diivcted oii \>»gv 6(> inu»t 
hMraralely cairicKl uuu Tbtr Huiycvi mii^t himself mw ihnl the AmfQ- 
W^C tHtfUMata arr in propi-r "nlrr, niid nf ;^kI i-vmtrtidioii. For th<> 
^atbt amputaii'ioa. the Siir|>e<.tii irill m)tiire fir.ii;:hl bisiourie*, nnrrow or 
t^ad id t* ' ' . '. iicoifiJii)); lu ihi' «i)c« ot' ihe pnri !•.< be ivmovcil. Scul|>«l«, 
tia^ wri > t'l %\itf blade, a i« iiB«ltil in cu-iti in which ih*.- hJFiiiiiry, 

fc"* ' -' iaci>DV«Diinit. Cuitiujr-pliera. with ImiK and ntrong 

Tt, (lilber Arai;:bt or i-urrwl, n& may be iiKet con- 
\[\ lojuirvtl in aiiipiiuiiuiu ahoui the hamb and fteU 
tW k iark'^T iiiii{)titii(i<>n9 >h<>ii1i| have iinoulh phony bandit*, 

imd bv opII baiancol. Ttif l>ark of iIm- hindo should nio Htraijjht to the 
fwM, ami br kvII r'Mtndiil. 'I'hi: vlpt i>hotild tajwr utf tniriirdu ihr |>»iiit, 
•idi a pwd CMtr»xiiy. Thv bmultli of the bln<l>- •honld \tv front ihrv^-liftbti 
ir*l« ttt ao inch, niid it* )Mi)!th xh'iuld W {ir<>|><>rlii)iiiil in th<.- xin- of 
lb li> b« rrmotnl. In operating by Irnn^fiiion, in nnh-r li> niakr ii 
"> MI u lit torm a nvllnniiidol and »iii<>ulh flnp. tbr bladr 
I i ruh-. tw nboiii vniiftl in length in double ibi.- ilinmeirr of 
litHi' i ■■. <r<<-iiig ihf flap» by ifhw.fli"n. many rMirEi.->m¥ pn-ftr »hurtt;r 
bw«^ The tm* *h<itild br simiif; in tlir bliuk- and bn<.^. ft as not lo Wnd 
» I'll tag. T1m> blwlp intisl b« o^ i^xhI bri-adlh. aiid its twih nmsl W- well 
•at, Ml twit it 'ball not bauc aa it wark» its nay thron^-h the bone. Artery 
of thr i>rUinary tHili'<h>); kind. an<l lor«t<>«-f<>ree|« will be re<)uireu ; 
half diUMi »f Spcneer U'ell^'e fori.'efj« should always hv ready fur 
iptirary arr«<>t of h«tu(trrhii|^ froto the analler braucJiw while the 
^^Oir art hrtax ■warwl. 

■■■brLTJIKIIX'H <>K liAI'ltlLV CUVOEt-tTlYl: Aui-|-TAT105 OF Tu'O LtUBS, 

^^^^KtRC rrtmral ftr Frn're injury or li>r ;^u^TtMe, liaa occaMOually been 
^^^^» hy iwii .Siir]^>n-- ixTf-irtiiin;; tlie two anipuUfr- 

IPHB* '' lh« Minu Sitr,;Hin •hiiii); Hr^i one aiid iheu the 

-^^ |b« (tMrU lit the hrit limb l>i--in)[ »«;ur*<l li» an awintani uhilat ihe 
Uttb '•• britiK trmovtyt. The mri-ulntion throUKb both hmir exirerai- 
iT !■*■ n«i|ilvlrly arminl by comjimtaiuK the a<irta with I'aueousl's 
" >T ihiit valiinbtf< iuhuudm'iiI, I hiivi^ aispuialH ti»tli 

I without wuittnu fnr the liunlnn- i>f the nrieriitt in 

Kit •htrb inu ,,, . • -(. 11t«> iibjeel in tw» »imultflni<f>ii> nni|Miiali<ina 

Im tmni the ei'ir f ihork M the *T«lcin. by throwing, tu it wrr<>. 

It ft lh« (<■ rito iiOr. In dimi)[ thi(, himevrr, the Surj^eixi 

v the riromn*tAnc>* <d' ibr cue. Iftbe putioni 
•».i, the indictiiMi of so wvtrre an injury a* a dnublo 






96 



AUPUTATIONS. 




iini|iutuunit loigiii prtitMblr rxlineiiifl) Wfv st onn: nnd. if il wnr pnaibll 
tf wail. utl«r tLe remuvnl uf rlii- nnt limb, tinlil ihc »]iiwk of tin- (ip<-niila^ 
lull) luisM'il (ilf, b«fi>re lli«t s4.-ix)tii) vik' iicnpulolr^l, it nii^'lit be iloirnblr (o <)t 
Ku; but if the* [iiitioiit ncro not loo iiiiioli HffircnMx), tb(.'»iniiiltam-i>iiii or rnlhd 
mjiidly i-oiuccutivt.- double iimpiitution would [imlKiblv 1x- tbc tBlrr cour 

BTDHPS. 

On examining tli« stnii'tiire of a t)tuDi{> ulU-r >>ne ur two yean bnvc pI 
(rant tbo time of il« runuitiioD. it mill W fouiiil li> he i-i)tii|H«od »r a rosM 
fibr<x«lluliir tMiiv. niiy miiM'ular iitili*luo<% wbicit imiy hiivD PiitrmI if' 
)|0 fonnUion having cnmiileudy aimpbii-il niii) difntijH'iiriMl. Aor ti.'iulNi 
wtiicli ntajr have Ih'CD dividiil will Ik- cilhi-r tottt in itic tibnitm tiMiite uf ib^ 
•car, iir will bi* IViuiid In biivc li>nnr<l nt'w niim-li* 
iiii'iitK to ibi' iMiiK'M. Tbc ruil i>f tl><' boiii' i* n»iiidi-4 
iind ibc mi'clullary caiiul cluM-d by a Inyi-rori-unipael 
b<iiir- Tbo vt-MoU lire nbliii'nitr<l or htgb lu tbi 
iiriirvot brniii'b and ooiivcrlcit into librouti ocndt. 
cud* of thi> tK'rvi,K lire tliirki-tii'il, aiid cninmon 
■miOH- a UilbouR r»rni (Fig. '17). On rxnmini 
ibtwe roiitidLtl ur oviil tiimore, iIm-v will W liiuud 
he e(>iiijMi«>oi| of librou« liMiio, tmi'ing whirb air ^ 
number* of nrw m-n-mM tibhllir tHiMc<l and raU 
u{M)ii fiicl) other ill all din-ctioDf. 

Till* |irti|>cr udaixtilioi) of Artificial Unbi ia 
mutter of c»nHdvrnlit« I'onMMjiit'iKx- ; nnd ihi- io^ 
out coDlriranccH tbnt arc nt xht: yn^val day nppli 
to Btump* leave little (•• be <lefiirMl. Tl)<> t>(irgl 
luul better leave the detail* "f tbeH- inoibauiral Mi 
Irivanccs to ibe instnimeiil-nuiker: but he »lioiild see that tbey aro tnndl 
light, M>ii»tEU'iilly with fiufTIrieul alreugtli iiud Mijigxitt, and ibnt iIh- rnd 4 
lh« slump i» ii«vcr iiijnri'iiinlv i>reMe<l uixm by ihrm. Ttiiin, iil\(-r nni|itita 
liou of tbo thiKb, the urlifidul limb should liikV ib fliii-rbi-arii)u-]u)int tnm 
the lower jiiri of ihe jn-lvin imd bif. In Bniixiinlttiii inimi-diaiely In-li-w thi 
knee, this joint should bi- ba-ni and nn-ivcl inio lh<- (m-kcl of thv in*tni 
nient ; and. if tlie amgMitalioii W nt a Inurr ]>nint than tlii». nnd tbo »lum| 
be extended into lh« ariiKciul limb, it* end mint be (irotevt^d from injurioi 
prcMtire. 

Ill 111! Hmputatkma of th« lower limb in which the Sur^fon hai raccMi)' 
ill iirtxlueiDK a Mli^factori' l<HJtP euveriu);. n<>t adhei\-iil !■> ihc boor, a: 
witli the near widl Inhind it, lb* |iaii<'iit -dioiihl be encouriigr<l U> bi-ar \h 
of hia Weight, lit leiut. diredly un the end of Ibr rtuion. Nut only i\vn tl 
give in('ri'a*r<I uli-adineA in nnlkiDg. Imt il it nM to diminith the teiidrO' 
to *xcra>iv<- iilruphy of the k'U Mtrt* which Hometimi-* oeriin id •dil plum 
Tbo i>Ian rt-mnmH-uded hv Teiile of griidunlly nix'ii«luRdnt; the end nf I 
»liin>|) to bear iinvoun; will be found mul Mliitfanory. The |inticnt niui 
|ir<'i)iin' a niiniuer of eimiliir jiieem of dannel of the Mme iliaineter ar i 
*ucKt-l of the artilii'iiil limb, lie fint [ints in a ^uffieicni unmber id' iIk-m' 
form a |iiid jiint li'uehiii); the slump — after ihi» be adds one daily till i 
BluiMp Iiwonie* ii<'i.ii«ioiiic4l to beiir the necewirT de^rt^ of prvb^tiri*. In 
nmimluliont lbr'iuf;h ihe knee-joini or eondvlea uf tlie femur, and in Syii 
or I'iruf^idrs nni|Milii(ioii at the ankle, the patient ahinild be abl« tn boar 
whole Height on ihr slump wiihuiii lUlficullv. 

MoicBin CoxtiiTioNi^ or .Srix ph.— Septic oiteo-myeliti*. ihni '» to 
Mptic inflammation of the luedulbi of the bone, wlicu the cjuial luia 



11|.TT.— BoAlaf* of 
Stir— Is ■ SlaiDpi. 



MORBID CONDITIONS OT STUHPS. 



99 



^-r — - 'o rutnoving iJic Unib, '» «w of tli« uoH serious nccidenu tliiil can 
afpmt itAer an aniiMiuaKii). It most frcquenliy oocun diiriDg lh« mcodiI 





».— St- 



Fl;, W.— Sitr«o« cum ttt ConlMl Slump. 

(ir thirrf wwfc after ihc ojicratiou. The syniMoms and 

Cili^iry nrr liilly tliw^ribi^l in ihi> (.■ha|>tcr on Diseasn of 
. It WM formt-rlv m InHiuint rniifc of pmmia. With 
the nrcscnt iaipiYive<f trt-iK tticiit of iimpuiation iroumls it 
hu Dccoino cxctwivcly rurc, 

Heero«i«. — It not unfrcqucntly h>npNiB thai a hiukII 
Hsic of b<in« which haif lK«n Injurtsl oy tlio s&w di«&, and 
ia separated wtnc three or four wocke afler tJie operation. 
This occtirs most frciiuently ■□ tbo$e atumpe whioh unilv 
by ivoon'! tniimtion, and in nbich th« Don« i»DBequeiit)y lies bathed iti ptni 
liir k ctiuntdcrahli- time. It is to b« prevented by a<ioptinK fuoh innuis of 
dnaaiuii a* nbull iuiiure union, itt any rale of the deeper partA, by ftnt intvii* 
don, and lh>' cbancofl of its occurrence are reduced to a niiniinum If dpcoRi- 
(■■■itiun of (liK diai'hnr'^cs is prereoted. Great eare luust alio be tiwcd in 
nwin^ iho iHinc not to denude it needlcaely nfils peri»»t<<um. 

M<in- >-xipn*ivi' Dccroais uaed to b« a frequent con^equenct! of Kcptio u»t«o- 
,«)yi-liii». \ihrn: thv pAtteat eacap«d the fatal compticutiDii of pyn-min, but 
''" ' r thr inipri}Ti-d nyniemfl of art«ain^ it is c(iDi{>urativi-ly ran: In siicb 
fistiiicus op^'ningn will bcrleA leading dowu tu the nrcrtiKrd boni', which 
ORtally K|uiniti.-« ihm^ or fuur months after the operation, after wbid) tlte 
■bitnp bT4-<iiDra lirnily oiinnoIidHtcd. Tb<- se(|ueiitruin in Ruch iritM* prtwenla 
the fiilhiwinj^appcaranMw: ihu Utvi-r piirt is thick mid iiunnlnr, nmi includea 
the wbuli! ihickocM of Ibft bone- It i« -■'iHoolh cxK-mnllv, ithcrv it has been 
oovem) by the periosteum. About »ii tucb or Iitw alxive this it beouniea 
thinner, is composed of t)io innrrminit part of tbc bunc — that which sur* 
Mindit the nifduitar)- canal — and it i.i mughcui-d rxternally, where it has 
^penited from tlie adjacent heallhv bono; above this it i« spiciilaled and 
V«rr {rreitulsr, becoming gradually thinner (Fig. 28), Th« part of ibe bone 
vhurh eMrajies necrosis ia inllained, nnil, nn a coDWiquMice uf oeteo-plastie 
|irno*tiliB, new hone is depociti-d abundimtly on its surface, leading to a 
~ t inorease In its thickness, which can be rocogniitod readily tbruugb the 
paru. 

Canicsl or "SBgar^oaf" StUBtps, a» thcv ar>- called, commonlv form, 
'tber in eonseciuenee of the flaps having originally been cut too snort, or 
im On: bone not haTiog been sawn off sufficiently high above tlie angle of 




lOO 



AVrVTXTtOHS. 



thu flaw; but in other cas« tboj' may occur, i1i'>ukIi the stum]) lias beog 
skilfullir Isflhinncd, in consequence of llie suft parts, irbich bave Iteen tU 
Milt of intlammatiuu nniJ suppuration bi'lore the Biiiptilaiioti, retrncting 
(luring tbe Kraniilaiing prooeea bo as to denude th« bone. In mcb aw« 
thew?. great rctrnctioti and contraction of tb« flaps an apt to go un dii 
oit^atrizatiuu, bo iliai tbe bum; may m-ver ht covered »t all, twi be ex 




at tbe biaium nf an imulilc ulcer: or, if t)ie M>n {lart* dooMlt^fcc. 
cicatrix will be iinnble to MipfHirt llii' i>lii:lit<«l prtMiurv without Im-<.-< 
ulcemtcd. In tbcoe circumntaiici^, tliv only nitimly coosift* in laying 
iIk- stump, nn<l cutting ofTalMxit llin<c iiii-lii« uf tbe bone. 

Tlic iwticiil, wbiw aliinip i* rc|>n'M'iil<><) in Um; n<>coni|ianying fignrl 
I Fi;:. ii!), vnu uixk-r ibf unto nf Cbrinopli<<r IIi-iilli in Univcroity ColHn 
H'jnpilnl. Tbe nrni hitil Ihi-h aniputateif in (he tiii^li in Soutb Afriru. Tfl* 
pn'tnidini; Urn.' ivii> coiiiplt-tcly mvcriHl by n (liin ciciitrix. 

Anearicmal Enlai^ement >il~ the nrtcri<« of n »tump i» rxln.-iaely nn. 
Tlie only cum- of dtr«D#c of tht- vcmcIb witb nhicb I am aoqiiaiuli'd is unS 





tXg. M,— AMitrUinai Varlt In ^(nap. 

dflirribed bv t.'adg;*', in which nn nnriiri»mnl vnrix Iwlwccn llip 
tibial iirt'TV and veiiiH liiriiit'i) in it i>iiinip aflc-r ■li.'^i-liciituLiou uf tli 
joiiil I Flk- 'fi', •' . 

Painful and Spasmodic Stamps.— Tbe ncrvGe in attump naturally kecuius 
samfwhiit fximndcd iiud bulbous; iiml U" luiiicrial iaronvi-tiiem^' riMilta 
tVoni tlii> (■•mditlMi. But It ucuuioiiuily ha)>|>eiiB tbat a dintiiict luberuM 
rDlarpiin«ni Ibnm in cunnfitioa with one of ibeiu, and nliaiiw the ■!»■ nfm 
chvrry i>r a walnut: anil, tlit> beini; pressed agaiDM the end of the bone, ih« 
rtump bcwiiic" tbe lunl »!' iiitriiiw pain of a nearalvic clinrader, more Wf' 
tioiilurly whctM'ver it i» touchnl. wncu a temalion like an eJeitrlc ubiieK ia 
felt. In »itcli cireunuliinn^, rsrinion ul'thts hulbouH extremity itf the nvrvn, 
or nwotti^i of the Mump ■■> ii» ■■> miuovr the vod of tlte Ixme aiiit ihr whola 
of the cioairix, i«> ncti-iwiry, iind will iillri-t ii rurv. Samii'tiiiM* n nirvous 
twi); iiinr l)pp»n)c iii)pl!cali.''l in, ami coinprnwed by, the cicatrix. Hera k 
more liniite<l exdiUKii will rciii«v>' ibr piiin. Rmidr* ibis form of [uinral 
stump, which may hnii|M-n in tbr MrtkUgn-l and hcnllhiml t<ubj«'rtx, and i* 
entirely dvpcndent ou local cauM«, iberv if anotlicr •■ixiditi'iti iti «hi<-h tbe 
stump becomes Dot only iheseat of intefwc pain, but of cnntiauotu cf>nvulMV« 
twitchinjcs. Thb lorm of painful stump ariMs partly fhim c>>ii«iiiutJ«iial' 
ounss, and most frequently mmjiv in fvmalt*, more parliciilnrly in tbosi 
who an< of iIh- hysteric*! teiuperanH-ni, and an or have l>*«-n eubjecl to dmI' 
ni\f}c jMiina cbcwbere. lo thvw caw* tbe mwral ouiaiMouaaauibiliiy of 
llio Mtump it Encrvased : il b tltescatofoDHvulsivajerkinj^Ar twit«bingB,aiMi 
the iiain i« mi>n? or lea* iiiiermittcDt, Iwtnf; incn-iiM-d under the influence of 
niriou* cnmtiunal nnd nuuiilulional oaiiMs. In «iich caaeE, tbe IroUineiit 
sbould bo oonducttvl on the |;rnrml jiriuripliv thai will be fully disctiMM 
when in coiim t<> iprak of Nounilgm. No excision of tbe nerves of '*' 
slump. or rvcn iimpulnlinii bi];brr up, b of any avail ; the disease, bein|f) 
sttlutional, will cerbviuly mum in Mtch successive uuinp, until at last 



HORTALITr JLPTRR AUrUTATION. 



101 



w tlM hi{i Dujr b« raubed without iiny p^rnijitvcnt boDefit to th« 

(taMQklly After Btnpuutioii b condilion of chronic or Bubacul« i>euritta, 
tt^i (dtnada of ilt«> ui-rw, t* Mt u|», which hot n tendency elowly bul Bteadilv 
^ 'tttBd npwnnlv, iitwlvin^ mw iirrvcH u» il goc*. Btul finally, perhaps. 
laAsf Ift duuipei in tbu siiitwl conl itsrti'. The aymptoine nnd iti'atRi«ni 
mAmm«t cbrooic iM-uritM, vhich will be fully defcriWd undiT [njuriesof 

Imntmm of th« DltMM for wUch the Ampntation wu performed ie 
M tf uoooMMKi oceurr«Doe in caM» of urumnui dUe«see of Uium uid in 
IBIMV9. In the fonmrease, unputatiuD higher ap rosy beadrnn- 
ptrflbroed; but in the latter, it itt juHitinble i-iily wht-ii ilii^re tn no 
OdTaecooiIarY i^roKtha iu internal orKuus or in tliv lyniphntji^ gInndH. 
TU^ Dtgiainitioa nf tho uiukIm of a limb, arixiiiti fruoi tlivir disnae, 
fine M tun pcmilinr ii{']M>amnc« in the Mump. Duriug th« auipuiutitin, 
i- M i tl w look liki- picco of yol)»« wax, and are firm : no almphy, »o far 
w IU* ia ooocHTnnl. ha* Ink^n ]>tucc : llio bl Ix^inf; il^pueiiteal tmlwcf ii the 
BnnW dhn*. prixliiniijt atrupliy of Ihom by its iin-Mtirc and iioctipying 
tmt pine*, m* that tin- g<-n<-ial ciiv of ihe limb ntnl lidmav of llif rtttinip are 
ffMrred. I'niun tJikr* place in th<-M< cin-iim^lanci*. though ronkowhat 
Jirly ; si It — I . ihia haa un-urrr<t in »i-vrm1 e»m.-» in Khich I hnvt obMTVcd 
lb aadititfo. In unr of ih^iw I aiiiiHiiated llie I<rf fordiimiM.- '•{ the fMAof 
tim jtmn itjuidins. atitl in another tbi- lliigh for di»t-aw of titv km-O of four- 
yran' atandtng. 

HORTAUTV \rrKR AUriTATIUX. 

TV IfCiMYal cmuMS nt dotli alter ofteratiuus luivc already been iranxidered ; 
W *w mual n»» rtamlne some apei-tal puiiita runncrtMl nilfa the tdativn 
■tftalUy aftrt anifHitalidUSof di(R>tvui kiuiln, and lite cauac of tliti ditfrr- 
•eea thai exWL 

Brfore nimnH-ociog.bowevrr.ii would bo better, in order, as fanu piMuble. 
■• sroU smbignity, tu nention and ik-fine the chief cauan of death aller 




ia exhsualion i>f the nenmus ocntrri". tin* rrmilt of rinhnt ovrr- 
by the ixmi'rful ftSHvnt inpulai- which nriaiv froai ilti' injury 
tmt to the aeoaory nrrviv, either hy the knife in nnipuuitton »r by tlio 
i^ary wUch reoden'd tti« op^rntinn nvctnary. Death ucually occurs, ia 
tiai ei«ii. under t<*>-nly-f<'>ur h»ur». 

^^JUbpM >• tdeaiical xitli very t<<vcre «hock. 

^^^^^M^rj ItmtorHmot, u a cauic of death aflir amputations, is umally 

^^^p ,.. .1 — t<n in which the blvedinf; occurs more than tweoty-ftxir 

^■Mn -'ntlnn. 

^"^Smy^'iiy .J inr tvmp from amputating tlirutigh injured or diseased 
IMMM is Ml octtMooal cause of death. 

Snttfl OfMUM. — Thta term is here used to include all tboee aflbclioRS 
Hk* ai« oMBectai), directly or indirectly, with decompueitioa of the di»- 
AaifM fimn the amputation wound, and the coo la mi nut ion of the atr from 
Ar mnasnilathH) of Iw^ many piLticnbi iiutTeriDt; from ogwn wounds in loo con- 
■■iid a MMcv. The ohitf vari«ti<9 are : i^omM, a i^iieral disease, resullJnjr 
bam infectivo of the whole huly from tlic unheallhy iliiicharKe of a foul 
waaad. avl accoatianiwl by tecimdarv iDllamuistions, lerniiuaiinn in stippu- 
nbuA. In Tsrioaa intenxal organs aixf "ther |Mns of the body : S^tit^mia, 
' ~l~iiiar trrrmlhrT, tOTmlnatinf; fatally. witlnMil thr m-i-iirnrucc of ircnndary 
ital {aAaouMtkas or absoowcs ; Septir I'irmoning. <\uv tu the absorption of 
Iha f^euc*! products of ptitreliictivn ; TV^uinaric Prter, which is a mild 




103 



AUCrTATlONS. 



form of septic poieoniiig ; Hofpitat Gartgmtr, nn iictitr Hj>rrA(ltog inflatiim* 
lion. tcni)inBliii|> rapidly in cicnth of ihc nRi-rtnl jmrt : Erytiptlat. iiti infrfli 
live indammalioD of b »perilic Dnttirc, ^prrudinf; widely from iIh- wotiud at»d| 
BCcotnpHDied by ;;niTe ronMilUtiDoal di^turbaiite. All lli«w discsMw nre 
be atlributi^d dircvtty tii foul wouiida ■iid ovcrK^rowdiofj;- 

Tbe OongeMiw p>\eumvnia ofieii mentioned aa a cnu»e of dnih ofler ainpi 
UlKMW, is moM prolwb1]r alwnys an elfecl uf ^^pttoicoiia, pyieinia, or i^plii 
poisooing. 1 

Lastly, one uf tlie curidioiicM cauaea of deatb in hoajriial reports la £rAa«4 
tion. 'lliis term in itM-d tiiib exc«Mtve loownes*. t^mc Surgeon* am'di u 
emphv il urciiKioiiitlly tin wvn avnonynious with shiK-k or (v>lln|«e. In 
niajdriiy of caw, however, it renlly oienns that tlie {niient U ^i'li'loally «o 
out 1>T lh« |>r(iAu« tliM-lini^' from a mippuraiiiiK woutid, c-'inhiiiifl nil 
ohroDic poiaoniliff by ih^^iilMirptiondfllii,- cbfiniciirproduria of piitr'tic-iioa^ 
In othcn it moana inat tin- piuicitl died from tlie elh-cu of kfri-n' tramuntid 
ftrer, of septic ori^ii, c»mine»i'ing on lh« Mvond diiy, beforr In- had fiillfj 
teccvonxl fmni the xtiock of ihc oneration. Il duubtlwa fiiri'in, ihervforvJ 
miiDV uondiliniif nhich ihoultl fairfy Ih- iiivludml nm««i^ M:(>tie diK»iif«. I 

Sliock is a frctiurnt vauM' of <lnitli nf^^r priiiiary anipiilationi <iJ' the largvfl 
linibf ; tnit till (piite rcoenttv pyiomia was the ni'«t fn->|uent cnuse of dr«l| 
ftftvr all nmputfltioD?, nearly "ne-htilf of tW imtienls that dii-d iH-rii'hinj 
from this diecAse. Itrvauljn Hol^ hiis shuwii that, alOuy's Ili«pili>l. it una 
fatal in ten jier rent, of nil amputations, and in fnrly-iw" |N>r n'cit. of fntjil 
caw*, and tlnil it waa mosl frei^iient alU'r aTiiputA(i'>iis tlin.<i]gh limt>«. ilis 
tisucs of which were in a normiil (.'onditinn, niid whtre a Xarf^v eiirfaci- •! 
beflllhy bone waa exposed, aa in am piit.il ions f >r injury, and in the retimvul 
of limlie for luioorB, talijiea, ankylr«iH, etc It i«aa not ao ouiuinou iltei 
nnipiiiaUonH iierformw) for cbrooie juiut-diseatM-. 

Thi- ciri-tiinxtancea which mom *|HM-iBlly itilliiini-e (hu geoonl r«Milt iid 
nnipiitationii, iu> wull a* tl>0 particular raiisi- of dint h alU-r l^ Dporaiinu, may 
be dtvidei] iutii two cIiimMw : •> ThuM tlint have reference tu till' f^eoerul con! 
•Utuliftiiat ooiiditi'jQ of tbo patient. >i Thuoe that are oonoeetrd with ibl 
op«t«lio» itself. 

a. To the first clasa may b« rcferrctl 1, Agt; 3. Qmrrai Health; 3, Smk 
and -I, Srytic IHteatM. 

1. Age uxcroisea an imporlnnt inRiieDoe nn the rcault of amputation*. Al 
a gvDcral rule it may l)e »t«t«'d that, the younger the |Mtienl. the gri-ater lh« 
likelihiwd of asucemful rault. At an earlr period of life tboru isagrvtiiei 
power of rtaistiog the efi^U of poboDinK by septic nuUUr and of Ions ii| 
blood. Ttiefeebler tissues of old people inllnme ami »l<nigh inorv fvndily ibaa 
then of Toun^r iuilividuals, when cxpweal to the irritation of dtvompnsiuf 
matter. The intnKlurtion of the antiseptic Ireatmeut of wounds ha*, how 
ever, grcativ reduc^ed the dancrers of amputaliom alU-r miildle-lili'. V"lk< 
maan, of Halle, has published the mults of 48 cnses of major an>i A 

pcrformeil iu [Mtients abuve 'H) years of age. He excludca fruiu ^ ' <-{ 

lion alt caKs in whieh ihe nmpulalii>n was |)erformeil durin)* si'i>lica.-niia, ail 
double ampulaliotib. and some few eases in whieh the ixiliunl iIimI of enux^ 
independent of tlie opwralion. Of the 4S. ouly 'i died: 1 of lelaniia. and l« 
an hnbiiiinl ilrunkard. UO hours alXer the operation. Tlie patients' am4 
were, 30 biiweMi ol and <iO, 13 Mwe^-n 01 and 70, 4 between 71 and w)i 
and 1 patient, used 84, recuvered from an amputution at tlie knee. AlthiMi);|| 
the exetiwion of all oooipliaatod eaaea makes tlieae ■tatiuiiot m>ire farorabtu 
lluin ihvy Would oibnrwise hnrc bMn, the results must be loaked up<>D aa 
moat encoorn^Eini;, showing; that under the iropruved treatment of wounds^ 



iyptvisr«» or oikkral iibalth xvv shock. 



n an ktft ftv ■ fur <li->iroc of «ucica« vv«ii in vory it'lvanood life, pro- 
nUlMSnU ag* Bloae ix tb« »nly uiifuviinibk' cun<l!u"ii prvMOl. 

i IWOiMTkl Hcttltli •>{ tbc (mitriit pri'vtuti* to tlio (>|>fmtiot] tii-rciaHi 
aa^vilv a Mint |Ht««fful inlliK-ncnoii iho chnucM oC rrc<iviTy. Tli'- sliit« 
rfftikidBf}r«, >wr««ipa-c)*II^, ui i>r ifD'Mi importanon io tb>« rtMpcct; for 
X — C l i a w i«ul* T-1 — - tiuiiily tuu fatal icrminntiiin than n ohronimlly 
iMvd ttmUofth Tii«t««alta'irain|>iilAti<m nn> iiU» nravsarily 

oUt JAnat, Koronmij; lu tbr opamdua i* pnictiMii on Uiu healiliy 
^•MUt of • mualrj <lwtri«t. or na ibe ouliMlie an<l dvbilitatcd dcDixea 
4«lvs* towa. 

JmJ 4. Tbc influi^cr oTSliiMkand nf Septic DUeaM* m vvry i]ifl«fvnily 
fcb ia difcimt ftm|>ubU(»iw. Tbc gf««U-r tbo |>»ni»n of Imdy that ig 
a«Kid. ibe won ttwrcij t> chut-i I'cIl Ih tlirm ca»M, als», th« iiirtueuce 
•f aMie a^ncia* baooBwa nore markt^l. Thii if owing tu tiro L-aunu: 1. 
IVaMBKNi of 1^ aerroiM syitem cv«HN{uent on Uio shock, and uu tlie 
^4f Unud ibal b live frwiuent accomiMniiiiont of a groat operation, ti'iul- 
■r** Imnt I'm iwiMiDi; poHrar of the fiysleiu l<> all noxioUB loflueocee. n»d 
im la pf«di(p(Me the palieiil to ftufTer, tiotli locally and oomtitulioiiully, 
hm tin abMTpliM) of eepiii} malU'r; and, 2. The luri:e surface of iruuoti 

Ttd, rrodm&e kical cantaniiDstion luore likeljr Ui occur. 
I ..r »a\ nwtaeculire caaea occurring at Univereity Oolle^ lloepiuil, 
tttt loMk* from abock (all primary), aiid 10 fmui p^umia uod 

- •'■■ ooly 8 ileatbe to be aocouoted for kjr exItauUtiMt an*l the 
ham mentioned, 
t'.ui >>i lEtl nrnputntiiMiK vullect«d fr^ini tlie repofta of some of 
alilao boapiuU bi-l¥m-n 18tM> nod I$72, 'i^i!) deaths occurn.il, nnd 
I'' ' ' ' 1: ant) [lyKRiiji t<<i){etlicr, being 17.5 per cent, of 

l^ «ImI» ' I>Fr oeol. of ibc total death*— «iul this u irra- 

ftti' -.4' Ilia: XIV icporlcd as dviog uf " ezhauation." or frum "ery- 

■tJa.' ii-lJuliiio." and furnw or septic dbmue other thiin pyxiniia. 

lUe ta/hUv di»r^« |>nivf!il fatal in as nrarly iis (HMsibIc A6 jwr ocnt. of all 
A» 4«tha. and (h'^rt in a)>oul lU |Mr oeol. of tbu deaths, ur in A.H per (.vnU 
<iaUtU»mj> 

Bat Ibc n»\- I ilij'iii-ea of thmc two gfe*l chusm i>r death afi^r am- 

yalaliena titll br IdumiI uut only to vary ereatly, ncordiDg as the Bni|Mila- 
lh« •• peiiDary. wviMdary. or for diseiiso.liul nlao to exercise very different 
4 ct — of iadvMioc ia dilfi-renl hospitalH. 

?1mw^ «a» iDivt frit in iiriiuary amputntiuot, ID the proportion of 2>S per 
MSJ. o( t^ -Iratht; «■* )iut little laial iu seeondary amputationa. G )>cr 
•ML; Mai Mas votifvly abantl ait • eHU»e uf death iu ptithotufEicBl aniputA- 

«as tbe eauM nf dntlh iu alxiut oue-iliini, or 3:^ per ceat., of the 
anwBiEvt the priniury amputations, and iu ■I-1.4 per cent, of ibe 
' < iboM far discaan it nguin ULi^uired nearly the level of the 
pcroaaL 
t* }iri>|>jrtionali'ly mnri' fatal atVr ninputiitii>u.iof the upper ttiau 
hiwwr axtfwuily, rwcs-i^'tiing nbiiut -tO [irr riiot. ul' tbt? dcatbK in the 
fi Tjfiirirl -tt prr i -m lattiT, all>-r iim|>iiliitiuti>i fur all causes. 

fnmktj anputati'Vj j-nrity in iiiiitc inarkiil, lieiuj; aitiHtt .50 ptt 

"( all d<atb* .-rr, axviiut iilNiitt -i'i iu llie jimtr limh; shock. 

4 tk« utlMT bat)>> ^iiire uUal by far aAer primary uinuulalioius of 

As Isivcr than of iIm upper oxlninity. owing. dnublUai. to ibr larger man 




Tb* loBurtKv -if tk^et u UMXMarily m'M frit in primary* anipuialiuns. 
. tt* &t«l rraults mrv almost ratirely i-onlintd to aiu|iutatJoiis pcj^fonned 




jSK. 



98 



AHTDTATIOKS. 



uti)|iutalinu loighi [imbttbljr exiiapiult lil« at oiim; and, if it were poKibl* 
tn wait, lifter llii- nnm^-nl uf iIk- fmt liuil>. until the »liut'k of the i>|iM«li(iB 
hail )«bmn) f4t. Iwforc llic htoikI wit.'< ii[i)|)UlutMl. il nii^lit Ik- deKiratilc u> 1)0 
»t; btil if (In- ptiiti-itt wi-ri' t)i>t I-mciiik-Ii ilrprvioMl, iIil- guumltsiieuiu or ruUwr 
ra|ii<llv coiHcciKivc duublc niupulatiini wmilil i>rxiliabl}' ix tbc taicr CDurac 

■nmn. 

On examiointf theeiniotiire<ff astiini|iHl>iT»i>oortwo yvan hnvncUpwd j 
fnitn tlie tiruD of it« foniiiitioa. it will Im I'luttui to hr oim)HKH.'l »r a muaof . 
tibrO'Ct-lluliir tbsue, anT miiK-utBir iLili^iiiiKr nt'liicb nuiv Imvr nitiTi'd tPlo ; 
il» roriimlitiii bttviiift cumplclcly atiMphicil anil (li»it>|M-iir)it. Aoy Irwlno* 
wliich nmy linvc biieit <Uviil«tl will Ix' i-iihcr liiet in tiii' Gbixiim li*iiii« uf tbr 
BLvr, or will bo founi) to Imvo funnnl new nltarli- 
ntcnu to the b>>iie». Tho cu<t of tlio boni- it roumlcil 
and tbe iiKilullarv eaiinl cluM-d by u layer of r<jni|iBCt 
bono. Tbi.' VfMcIs are oblili-ratM a» liii;)) a* tbr 
ii<-iireiil bnwiob uu<l converted into fibrous c>nl«, Thf 
ends of ib« uvrrcs arc tliiekttMMl, anit commuoly 
UMIDK a bulbous fDriii (Fiji;. 2T>. On pxaniiniitic ; 
thwc rounded ur oval iiinHjr«, tlit^y will be found lo ' 
W o>i[i|>o«ed of fibrous mmiik-, amrint; wliivli art- ^iTai 
»utubvr» of new ucn,'(iiiB fibnllit twiait*! and nlM 
upon each other in all dinx-liont'. 

Tlii> firoprr iidn|>iniii>it of Artificial Linba n a 
nuttter of ooibidt-'Miljlt- co iim^i (it'll ex- ; iind (lie itii:rni- 
out rontriviinivn tbm arc nt tbc iirnMul day a{i|>lNd 
lA fltiiRifiF leave littk' to 1h' dctinsl. Tbo Stir^oe* 
bnd Ik-Iut It-avc llic dHsils of tlii'K- Hiit^niiiol con- 
trlvancca la (lie ■nxtrunK'nt-ninlicr; bm lii> »lii>iild i^ei' thai Ibiy mv nindr 
light, oofuqMeiitly with millirii'iii firin^ilh iimi Mippon. and ibnt lla- mil of 
thv *luinp U ni'Vi-r irijiiriini^ly orvMcd uiwui by ll>i.-in. Thiw. al^iT nni|Httj»- 
lk>0 Dfthi? lliigh, tbc nrlifidnl liiiib ebould lnk« its cliii-f bearin)!-|>oiiit ln>iB 
ihv lowfr ]>nrt of ibi- )M'lvi» nnil bi|i. In aiiiitiiialion initnt'diatdy bclow llir 
kinir, tbi* ji'itil »bi>tild hv liciil aiitl iv^nveil into lliv eockct of the inrtro- 
Ri«nl : and. if tliv ainpiitatiuii be al a lontr poiot tban this, and the Mump 
bi- f xtt-ndtd into tliQ nrtiliL-ial limb, ila end uiuat be protevml fniio iujuriou* 
prtMMin-. 

Ill all amputatioiif of (he loner litiih in which tli« SurK«i>« hm auccrrdvd 
ill prmlui-iri^ a fali^factory loose coveriuji, not adbeivnt tn th*- bone, and 
with the ei-ar well Whind it. the patient uimild be <-nc»ura);i.-d tii brar pan 
of his wi-i|;lit. nl leatt, directly oil the end of the rlumiv Not otily dim thb 
mive iucrea^ Meadinefe in nnlkinK, but it is uitl to diminUli the f-iidrncy 
to exoetaive ulropby of the i^ofl iiuriN which »<»iuHinii-!> mvim in old rlunim. 
The plan recuRitiM-'nded bv Teufe of ^Tiidiiiilly aiviKlnitiiiik* tbc ritd of ihr 
■lump to iK-ar jirt-feun- will In- fi<iiu'l root fatii>fud«ry. Thi- patlvnt tnnat 
prepare a number of riniilar t>ii-cr> of Ibinm'l of the mhic diamelrr ■« the 
Biickel of ib>' nriiliriiil limb, Ilr &Trt (xiIa iu B Riiflietent uumber of thnr l» 
form a ]>nil jiiai l>'U(-liiiii; llie i>luiii|> — afliT thU hu addii one daily till thi- 
•lump bct-onii^ nt'i-itxti-iiml to bear tin- nvMwary deprra- of prnnure. In all 
auip^italioos ibrou^di ihi' kim'-j»iiit or conilylea of iIk' li-niur. and iu Syme'a 
or FiroKufr's anipulatinn al ibe nnkle. the patient altould l>e abU' to beair hi* 
wbols wt'ifi'bl i>D ihr iiiunip without difliciillv. 

Moitiiiii <'oMiiTii>M> or S-ri tii-<..-.S«ptie Mt«»-nyelitia, that i» to aay, 
Mplie iudaiumaiion of tlte lueilullu of the bone, wlteti the eaua) boa boea 



Ittf i« lo • Slain)!. 



UORRItt COMDITIOXS OP STtlKFS. 



w 



im riMsoviiif; iIm> limb, ia ocm of lb«' moM leriotu Bccidvnu tlwt can 
after u ampaution. It mart rrcqui-uUy occun duriag tht; ircoud 





Ttg. ».— Kn n »i niM of ContMl fta»p. 

r ifaird week aAer tbe opcraUott. Tiic smtntonui and 
{ifttlioloCT tn tbllf (l«acrib<4l in the ctin|>UT va uigtxsee of 
lk>n«. It wna f»rni4^rlv a frequent cative •<( pyamin. With 

i- ^.^j^^ tbo nrtstriit inifimrwf Inolment of Boiimiatinti nwiudii it 
— """^ ttaa tocoiite o»<H«MV«Iy rare. 

^ »>— 5»- ■wroua. — It utit uiifrK|ui>ntl}r biiRpriii thxi a iniali 

■^ •* ** '•■ «eal« of bone whicli luw bwn injuml by tlie sow di», and 
m fri^ "i«"p- ii MparaUd aorati tbmt or four neelu aAer the oncmtioti. 
This ixwra nitirt fTvim-ntU' in those sluinpA which uoite 
bf OTOwd istrotiiio, and in which the bone conwquentlT Uei batbixl in )iua 
lira rMMHlnmblF linx^ It is tu bcr [ircTcutcd br adopting nicb mvanp of 
^imiiiK ai vball tOMtrB union, at any rate of the ilccpiT pnrt*. by (im iottm- 
!»•«>. and ibc irLancn uf iu iK*-urrvntv are radoccd U> a iniuiDiuin if dccoia- 
p.wiMn irf tb« iltKharffrs ta (itvvcnied. Ortat can murt al»o be uwd in 
«• tBf ibr baa« twt to denude it iM«<ll«S8ly of iu perioetcum. 
^K Man «shra«iTe nMixM nicd to be a frraueut cousequcncv of Bftplio osteo- 
^KjnOti*, «b«r* tba pntient eManed the fatal oom plication nf pyainila, but 
^Kniir iJm Inprovrd ■ysirnw of drvMiti^; it In f^>m{inrativeiy rant. In sach 
^^■M(MalA*M<>|wfiiDr> «>ll bnlrft lmdiiii;du«n to tb« DCrrawd bniic, which 
MMIIt ■r^arn- -r foat munih* miirr thi- ojiorftliuD, after which tlie 

MMp broin*- >ni»>li<lAlnl. Thr an^tiivtrum ia uich cataw pri:««nla 

Aff wIlowliM apfwwnncr* : th<- lowrr {xirt 't» thick bikI annular, and includes 
iW wfaels tbtekacea of th4- bunc It m mumiih cxfrnallr. where it baa b««ii 
wmW by iba peficMrani. About an inch or Urn abore thu it beeomM 
Ittanir, ia ciapaanJ af tba butennriat |Min of the booa— ibat wbicb aar 
rwWKb ibe inedulUrt- canal — and it n ruu^hruvtl cKli-mallr. where it haa 
^^faratcd tntn ibr adjacent hcnitlir Im>uc: nbovc thi» it is §{^culai(yi and 
^^^rr irTTf^lar. brcumini: crw'lmlly thinner (pi^. 2^*1, llir gwrtof the bone 

^Hj|X|h •"- ■' 'ruu* i* iDUaiui.-<l. anil, a* a c<inari{ii«nc« of o^teo-plaatio 

^^^^^ ue b deptwitcd abundantly on it« Biirfac^, Icadine to a 

^HBt iDcr>T-»r 111 ■(• tbicineaa, which can bu recoKuimd readily tbrvagD the 
^KA pana. 

0—1—1 — "Stgar^Okf** Sttmpt. lu tbcy arr cbIIaI. cotaraoaW fom, 
mtktr in nmaaqueoe* of the tla[M havinc •tri)*)nally been cut loo sKorl, or 
(han tbr bone not banog been sawn off cufficicntly hi(th abova tbe iuif|la of 




100 



AtirCTATIONS. 



the Hmd* : but in i>tli«r aaea tbej mny occur, thouj^lt ihc oiuniii Ku bcoo 
ekilAiIly lo^liiivned, iu con»rqu«nci> of the sutt luiru, which liavo l*pen l)i« 
MKt of itillniiitituliol) ami MJ|ij>iiruti<ifi beforv tlit' niii|iul>ilti>ii, ivlrnrtii^ i 
during th« ^niiiulHlirig proceiSMU t»i)i-iiuilf thu Iniiiv. In mrh man u 
Umm, gi'eat rt'tracliiiii nii<l oooitncliun nl' tli«- lln[H an- aitl U> gv u(i •Jurtng 
cinUrixiilioii, «^i tliitt itir bono iiiiir ncvrr bv ctivcrrd at nil, l)u( W i'S^hmmi 
nt ihe iwltoin i>r nii irrilnlilr wIctt : or. if thr- in<ti piirl* dw oinli-jicf, the 
cicatriK will Ih' iiiiiililc t»»iii>i><<rt the iilifcliiat prcwtirr nithoul lH-oiniin>; 
ulcvrAl?<). In th<w drciiiii»liiricx-s tlic mily ri'iiicdjr ootifisie in liivttiK <>]>vii 
tbr »tiimp, nn<l cutlin^ ofriiliont thrif irii'hi* of rhc I>oD€. 

TIk pftUviit. nli(i»a' iitiiiii{> U n'{>rrf>ctili.->l in ibc ncc(Hn|)anyin|; Anire 
(Fig. :!9). Rii» iiuik-r Ihc cure ••f Chml-^plirr Ilrath in Univvniiy ^'^fW* 
Hcwpititl. T)i<' linn hiiil boi-ii nni|iiitiiU-^ in llie Uusli in Soutti Arrica. The 
pnHnirliii^' biiiir wb'- I'oiiijilctcly pfvcrrd by a ihtu cicatrix. 

Aneurismal Eakrgement of the mrt«Hea of s stump ii extremviT nn. 
The only ciuc uf dimnise of thi' iresMU with wliicb I lua at.>>|u»int«() i* iMUi 




ri|. 3U.— AnnrttmaJ Tarli la Maap. 

dnx-riliMl by C>i<Ipf. in whirb uo aneurismal varii Wtwwn the {Wfterlor 
tibial arlnrv and vciiv* forniiil in a stum|t ulWr diinirtifulntian (if tliv Kokl^ 
j«iil (Fip,*:iO, ,.i, 

FRufli) and Spasmodic Stamp*. — The iwrvt* lunMunpiiniurallT b«entna 
Mtnuwhat cx|«i><)<nl and hiilhinii'; and u<i material Ini-i>nveniMuv rtwulla 
from (bif i-<in<lili»u. lliil it iirnui'mally hnp{M>iia that n diilinel tuU-nxo 
enUrgemcai formic in mtmi-etion with ow of ibmi, ami allniiv thi- nte of a 
Ai>rry nr a nnlnnt: and, (liix )w<iiii| prat««d a^uM tlm end uf ihc iMinv, tho 
stump b(«oni«» the Mtiit nf iuu-uiH- fain of a neumltfic ebaractvf, mure nir- 
tieiilarlr nhenevor il a touchiil, wneo n seniuilioB Tike nn ek-ctric shocic is 
felt. [ii such rircuRiotanctv. excuiun of ihia biillMua tixlremity of the nerve, 
or resecUno of ibe slump to as in rrm->ve the end nf the bone nnd the whole 
of the cicatrix, is necewary, awl will elTeel a eure. 8ninelitnc« a nervous 
iwi|; may become implicatM in, nii>l comjirtwicd by, tlie doatrix. Here a 
mure limited excision will remove the (win. Bcvides this form of [Minful 
attiuip. wliieh may happen in the siruugeat and healtfaiest suhjecls. anti ia 
rntirvly tlejieDdt'Dl uti hical caasos, theru is ajMilher coDdithm iu which the 
■luniti beoumiM nut only lhe««Hl itf inlen»e |«in, but of continuous oonvulsiTe 
IwitdiiuK*. Thio form of [lainful slump nriw* |>nrtly (Wim const! tutiunal 
cause*, nnd nnwi l'rM(Ueutly oi-cuk in renmlce, more luirlicutarly iu ih«aa 
who are <>f thi- hvulcrical tempemnii-iil, and are or have l>eeu Hubjeet tn neO- 
nilfjfir pain* I'Ui-where. In these cases the geaeral euiaiieuus M-nsibitiiy nf 
iIh- •ttiniii in increatml ; il b theseatof cunvnUve jerkins^or twiichinx^. and 
the |Min u nxiD' ur lin* iniirmitirnt, beiu); increaanl und«r the inducoce of 
riiriuHa eiii(>ii»nal anil ciinatituiioual causes. In such cams, the irvataent 
aliuuld Im I'unduL-livl on ihv jceurml iirini'iplt« thai will 1>e Ailly dtacUMmd 
wIh'u we oxne li> apeak i>f Ncurnlina. Nn vsciMou vt the oervi-a of the 
•lump, or even ani|intitliiiii higher up, tw of any avail : the dituaae, beinjc e<>n> 
•tilitlional, will certainly return in ejuk *ucc««»ive Mump, unill nt last tlie 



HURTALITV AFTBB AUrUTATIOS. 



101 



ur tlw Up ouijr be mu-hfd withoat uir penoiin«Di be»«fit in ihc 



Unaninklljr BA«r ■mpuutinn ■ ooodition of dironic or subacute neurilis, 
litgtOTM wf t^tMm).istMi>p,wbiobliw« tentte-ncVElowty but iumiliiy 
h nud ap«&pl». lavolTitig now nerves as U goes, and (ioally. |)«rha|«. 
biAf to ewuifCB ta th«spiDat cord ilwlf. Hie eyiuptoins and ueatnieut 
«i MS of cbraeic amritis, which will be fully dMcriued under Injuries of 
Stnm. 

twMfstis of tbs SisCMc for which the AmpuUtion was performed in 

M «f aaeoounoii oci:«irr«ni-» in vases of gmiumud ili-tn.-HT' >4 ixiii:- und in 

MfipaMtuBKm. In the furmervsAe. noijMitatiuu liii^htr u|i imiv li<- inlvnu- 

^fMMlf patftmed; but in lln- Inltt-r. it u jusiifiablv only uhvii tlicre ii^ uo 

■Am* M secoDdary {TuwibH in iiiii^ruul orxana or in Ibv lyiu|)hBlic' jelamU. 

ftttj DtgtMretMl t<f ihi' uiumIm of u limit, iiriviu^ (torn ihi'ir diaiiM', 

BUS riss lu a pvrultnr ii|i[>carB»c<' in thv Ktuniji. During lh<' iini|iu<iiliiin, 

M Moaclra louk liki- pi<-o(i> of yrllow irax, and arr finu: n" atr»j>Uv. mi for 

« KM ia OMKirf«<<d, kv laki>ii p)a<^': itic fat being d(.-po"iti.->I iHrlnei-ti tl>c 

Mndar fibna. producing atrii|ihy >'{ iIxmu hy it« prcfMin.- iind (ict'upTing 

Mr plat*, so Uui lltr gtntnil mu- nf the limb nnd fului.'w of lii<- Rlnm|i arv 

fnarrad. Ualuo ukn pliux- in tlxwi drtrumsIanLiti, though sunivirhat 

■ImI* ; at Irani, ifab has inrnirrvd in tcTerai t-aM« in whieh I hav<- olwcrved 

|L» a«dtti>'D. In tme uf ihnw I ampuiittrd (be le^ fur di^etuv uf tlu' foot of 

aasynr-' ' il-. and in ooollM'r th« thigh furdiseiiw of the bnevuf four- 

taraar 4- 

UOWTA\.rrC AVTUK. AJU-UTATIu!". 

TW |[n»m) I anus nf dralli uttvr uiwriiUntis hiive alneadr been cumidered ; 
kl «v aiiist now rsanioe sodm «p(<<-ial luiaia ooaorctwl nitli tlw rrlutive 
•DCtality afl«r aiRpatattoos of ditRircni kioda, and th« oauto of tbs diBVr- 
acM thai vSMt. 

Btinn ntmrnTodof, howncr, it would bo better, in order, as far bh jtoMibK 
to »nid uibiguUy, Ut tnentioii and drfin* tlw chd-f csums of dcntb niter 



is rahuattoo of tha aarvmt* ct-attrf, iho n^uli of vinlont nver- 
MiattlaliMi by tbs powerful aflkreni impiilM- uhich nnx* I'roui thi? iujury 
dies to tbr (snaory UtrTM. eithrr by ihv kiiiftr in nmptitiuion or by the 
ii^iiry wht. It n-ndilrvil tb^ opetwlion ni-coeiary. Death u^uuUy occure, in 
tomi fv^ ^v.rDty-f<>ur houn. 

l^ttif^ .- :-t..tUi'sl with very Mvers shock, 

Amut»ry krmarr^yr, at a cause of il*Mh ader ampuiattone, is usuiilly 
Bgnjtr-t • .1 — -n*» 111 slijoh the bleeding occura more thao tw«nty-four 
ko«r< ration. 

t8hr-^—>tj <>> "•« ttvmp from ampulatiog througli injured or diseased 
■t* is aa ooeasiuDal cause of death. 
lyi i IMbmjw,— This t4:nu \a here uMtl to include all thutw aiRiciioaa 
ilCD ara edODCdail. direHly or indirectly, with dec»m|)usiti<>» uf th« dis- 
«M>|n fitxn lbs HI •■ wound, and ihi- con ta mi nation nf the nir ffMa 

iW aoauaalaUun ' : >' pAtk-nUeuflerinc frum open wouuds in t^ioooA- 

iRsdasMcw. TImvIiki' varii-tk-s iirot /ysnui, a ffcnoral disease, resulline 
Cm ioMctiact of tbr whole btxly from the unbealtky dtscharee of a foul 
mond, and aceoapaniad by seoondanr {nflamtiittii<.>nF>, terniinalTDt; in fiippii- 
tatiMft. in TarkHn talcnal organs un'f <'thi.T («rti of tho boiiy : .»«./.( i>w>.iw, 
a Nfldlsr onadtUmi, terminaUng fniallr. without iXm iM.-curTvncc of ^ii'eoniinry 
iaAanawilaas or ahseasea; Srjltif Pouoning. due to the abivrpiiuu of 
(&«[B>ral prodncts of pntrvtiKtion ; Traumatie Ftver, which ts a mild 




108 



AUPDTATIONfi. 



Till 



If 



M<t> auaa. 


(iKtta*. r«u| 


KhanUvr-Jolnt. IIT 
Arm, 1810 
ForMrtn, KI&D 

Blp-J"'"!* -*" 
Thlgb, . if.: 
Lag, mini 


t» 111 

8T& SA4 

109 IftS 

10 41. » 

KM B2.7 


we luni III till- sliitittlii^ of mililnry .■•iir)C(-rv'. «« 
ill llii- Itriti.ih nriiiy in lti« CrinM.-ii tin* iicroi'UlJiin 


fiiiil siiniUr n 
« of ilratli «vre 



afttf 



■mpiilBlioii of tlic luimrm, 7; of tliu upixT iirni, IV; iif tlic Ntiiitildi^r-^iiitj 
Si) : of i)i<> ffHit. lit : of i>K' iv^. :t7 : of (In- km-u. 57 : of ihv iliigli. ((4 : nnd 
oflhv liiji, 100; fi^in-«in<»t crciliiiibk'toibcKkill of (h<>SiirgL-<>ii*<-Hi|>liiTt^ 
but Hhoiting thi.- pnignwivp k>ml«ncr to iiK-ri-aM- uiili the niw of tin- i'lmH 
ix'HhivihI. Ill tin- Fnriicli army in tlip Crimo*. tht' pi-nt-iiiiiin- nf n m 
tttrr iiiiijKitiiti'iti of Ihv forearm vrat 4d; of ihc iirni. 'f-'t; ol* llic >^i i 
joiiK. «1 : .if iiw ffiol, 7« : of Idc tfi-. 7-J ; of th« kiic-j<ii(it, SI : of llic liiigii, 
92; Mill of itid hip. IW). In llii- Italiuu cuni|isi|;ii of IM/i!), the |M-m'iil«£*l 
of (lie inorinlity in llic French anny — iocliidin]; in sonic csm« npi-nttiont on 
WoumliMl AuelriiiDs— ncre; foreunn, 4!2 ; mriD, -^6; shoiilcler-inini, '/i ; fooi, 
Cd; Irg, 70; knc«-joinl, 7-'i ; thiKh. 78; hip-joiiil, 57. In tho war of tli4 
Americnn rrbellion ihc iwroeDUif^ of moruilily were >b fullowe, shoving, 
murkcdly how rapiiliv it ninA up in accunlaDC« with the sine of the \mtt' 
roinovcl ; linK^ra nnti ham), l.fi: wriiit, 5.5; foresnu. 10.5 ; ami, 21.2j 
fthouldcr. '.iS.'i; pnriiul of foot. £1.2; ankle-joinl. 13.4; lej;. 'X; knw, 5>'ii 
Lhiuh.({4.4; hip. 85.7. 

Sot ouly M there this increase iu tlie rate of mortality aa the operation 
appmueliea the trunk, hut Ju the liiriciT limh«. tmire e.^iieciBtlv in tlu< lhi)>li. 
evtry aililitionml im-h tiiiil in rcmovtil npprnni U> itiakr ii ilitli'iruiti in itn 
rai))ect. Thun, in nur army in ibo GriitH-n. of l")* i(m[Mit*tioO» oTtti)' ihiirb. 
44 werp id the iiiiixr third, iiml of th*-*! .tX. or >**> (n-r e«il.. pn>Te«l fatal ; 
(i8 weifl in till' nitiklli; ihirri, niiil i^f lIicm- 41. or HO iht oriit., di«t ; whil»t in 
tlto lower Ihii-il the iiioriiility out of 1)6 cocrs tras -Si, or &(■ |>er o-nl. In th« 
Frairh arniy in the Critnca, According to Cbcnu, of 81 smputationa of tba 
tliieb at thi- upper third, 37. or ttO per eenl.. died; in DI aniptitatioDH at Um 
middle ihin), there were 63 dcailh*, or 69 \wr cent.; nm] in the lower thiril 
thfire w«r<- 101 ciuea, with 59 doatlis, or 58.4 per wnt. In the Italian nun- 
piiigD of Itt'Vi), according to the same authority, there were 4(! cam* of 
ampuialion of tlie tbigh nt the upper third, with 4^ dcatbe, or 93 pvr c«Dt-; 
52 nl the iiiiiKlle third, with a mortality of 44, or 94 per cent.; and 43 at tiM 
lower lliini, with 'M denthii, or 83 per cent. Afiaiu, among 'Jl nmputatinnt 
of the humtrus at the neck iu the French army in the Crimea, the mortality 
was I', or 43 per cent-; in '229 at the upper third, it was ti'J, or 27 [ler ceDL; 
in 145 ni the middle third, it was 27, or 18 per cent. ; and in 55 at the lower 
lbir<l, it utu ii, or 11 per eenL 

Nut only <io the six*.- of the part removed, and its j>roximitv to the trunk. 
materially affect tin: j:<'nernl mortalilv afler aniputaltuu, hut tli«»^ eundilion) 
al*(> inlluetioe the imriiciilar i-iiune of duaih. Thus, aAer the anuiller nnipu- 
tatioiu, a* of a toe, for iit-oiaiirv, dcatli ix-L'un only in uabcallby Mate» of 
Iba ooDntttntion, from the iic(,-urreiice of eryupelos, or of some of tbc varioua 
forou of lUfTuac iiiflainmati«<n. Death niter the birger amputations tnor* 



SurfifMltyi^tUmary: Sir J. Y. Sini|>fon'r |iNpi!r nn U<.«f>italt, in llir £ifi>i£»ryA Mn 

ic»i pop 
Cbvnii'i oUboralo •[wlnl rxurnt on llk« nMdk«l wrvlea of ili* Kir-odb Arniy in lb* 



Jnunut tM June, IMtV; vmHou* ■Utiilical npnr* in Ibu Itfiinrlj u( ltm|>tuli 



Urinicaii War. and in tlie Italian l^ampaign ; anit lb* oScial nn<>rU i»u«l by Ui« 

oM 



gi-Ov««r*l uf Ibv Unlwd Htnloi Army n(Brdln( tha War of th« Kabvlllmi. 



i 



INJURY AND UlSGASS. 109 

fn^uentlr r«au)ts from causes coonected with the operation itself, as, for 
ia:>t«ac«, Becundmry hemorrhage, shock, or exhaustion by the abstraction of 
lh« iMTge qaautity of blood contained in the liinb, as well as by that lost 
durinz the operation. 

'i. The Part of the Bone that is sawn through may influence the result. 
AmpatatioDfl through the cancellous ends of long bones are less dangerous, 
in one mpect, than those through their shafts, in consequence of the raedul- 
iarr c*it*l not being opened when the section is made near the articular end ; 
tu that the liability in septic cases to diffuse suppuration of this cavity, and 
tooMciitive phlebitis and pyicmia, is diminished. 

3. The mortality resulting from amputations is perhaps more directly iu- 
fla^Kcd by whether the operation is done for IqJDiy or Diieaie, than by any 
«tbcf cause, being far greater in corresponding limbs after injury than dis- 
ease, except as regards amputation of the forearm. In the following table 
■ay be seen the results of 307 consecutive cases of amputation performed at 
Uaiversity College Hospital up to May, 1871. Of these 307 cases, 79 died, 
yidding as nearly as possible a mortality of 25 per cent. 

KtSl'Ll? OF AMPLTATION IX LNIVEItSITY COLLEIIE HOSPITAL. 



Scat. 




lilJUKT. 






UlSRilSB. 






Cmci. 


DMttat. 


Per gent. 


Cftflei. 


Deithi. 


Per caot. 


Thigh, . 


89 


23 


59.0 


86 


18 


20.9 


LFg and foot. 


44 


14 


31.8 


74 


10 


13.5 


Shuulder nnd arm, 


12 


5 


41.6 


24 


8 


33.3 


Fvresrin, 


K 








20 


1 


5.0 



Toul, . . 103 42 40.7 204 37 lf*.l 

Malgaigne's statistics from the Parisian hospitals illustrate this equally 
«kariy, as will be seen in the following tables. 





IsjlRT. 






IlisejitK. 




Cue a. 


Deathf. 


Per ceni. 


VAfti. 


Utitbt. 


Per pent. 


. 4'i 


31 


74-0 


15^ 


fl-J 


fiO.O 


7'.' 


50 


113.3 


112 


oo 


411.0 


•1 


r, 


llB.'i 


■2:> 


3 


10 3 


:(U 


17 


.'iij.i; 


'11 


■-'4 


:(!».:; 



r—t. . 

Arm. . 

The following table gives the result of uumpnius cases in civil [irnclice, 
r-'Ln-trd from various source*. (See note, page 1(17.) 



?I»f. 




[VJUHT. 






II|SE>8E. 




Ctrei. 


Uuthi. 


Per cent. 


C»e!. 


llealhr. 


Per CKtkt. 


Thmh, . 


- !>f;4 


r)7H 


5'K 7 


14r..'. 


477 


3-J.5 


L-i-. . 


. 771 


■.t.v, 


*•■■ 1 


12k1 


301 


23.. "j 


.V r m . 


. 514 


180 


34.4 


■2'ili 


(i-J 


L'll.O 


F--t*«rni, 


ar/i 


SW 


lO.-j 


I'll 


■*3 


l.V.l 



Tbt .SW-i- iiiflicte<l by tin' injury, with its .-iubsequeiiL I'vils, appeui-s t" he 
■ «- "f lilt- prim-ipal rea*ms for the frreater niuriiility utter amputations Ibr 
ioj'jrr than after those for disease. After junputatiou for injury, :ilso, ili<^re 
f 1 jrraier liability to the ofcurrenee of gangrcnu of the :-iump. us the in- 
•t-i..nT may l>e carrieil through tissues which, tlumgh iippsirunily s..iiu'l. ui:iy 
!* ■!-■ bniiffeil as to be bi-vond recovery. I'vierniii, tiirnierly L'i[uully l'rcc]in*nt 
.11 jiriruarv and .secondary amputations, should now bf cijimlly rjirc. Kx- 
Liii>ti--ii U mure frequent after removal of a linih for di.^fii.af, ii,-' in niiiiiy 
• a-*- thf operation is neccaaarily porlormt'd on patit-nts already wiiikvned 



110 



AHI-UTATIONS. 



br luDg illnwt. lo nuinr fnrme of t[i«c«M, hqwcver, npcciftlly in aHvctli 
or Ikid« and JoitiU, il ui)l b« round Uwl. ibow iMticnU do ben in wfaan 
diMMKi b noM chronic. 

4. Tbo VktvrD of the BUeue for nhicb lliv anipuintion ii peribi 
infliiviKxi' iu iiiorlttlity. Thii» am [>ii tat inns fur niKlij^tuint growtli* sra nwd 
fiitiil thsii tl)i>ei' for catJcv it' Wie or dieea««(l joint*. Id cosm of dtaoMl 
jojul. Ilx'ri' i» * i;rcalcr tendency to recover when the HlTc^liun w oTi Hmpl 
lliHM whtn it isof n tAibeix-uIouD iialure. Uirkell ha; pointed out tlist tOmmm 
of intcrnni or;;an», often of tbe isanie nature tu> that for nbich the ofieraUal 
is (wriormed, is found >Aer death in a l*w pro|H>rtinD of |iatU-ni« «Im> dd 
afWr nrnputution. When snppuralive iii6orKaiiiation of a joint ia ttrj 
a«utc, tinipuiution. nM>re pariioiUurly if the am-cted nrtictdiiii<>n Iw of Urgi 
RXe, as iht- knet, i« attended by very unfuvorutile reftults. Iu tbew nUMl 
tlio patient ie UMualty nitl«rin^ from mititi.' frbrilr diauir bailee, the result o 
absorptinii of septic mnltdr Iruin ih« diKMUHMt Joint, imd anipulaliou und«it 
Buch circunMlwicci b fhMiti«D(ly followud by fiitnl aeptioKiata. but wh< '' 
tlie disease hu un«e become chronic, the procM period at which tbe ant 
tntion id pcrforntcd ezercbot but little inllu^ncc on ihc^ morlulity, pn>vi< 
It be not deterred u> loo late a Mtagv, when tliv |wiienl'« oodnuuiUou w mv\ 
vui by hectic 

AninutaiioR* of cxi>c*liency — tho*c perfonnwl for tbe «mveiiten«' of I' 
pntiEnt, a* in caMV of tnli^H-a or ankrhwm, but not neeeMHTV *o fiir a* life 1 
cotiooracd — arc o|>eL'ially Iktal. Hryiint hu ibowu that, at Ouv't ilu«p«ulf' 
dtftlh ha« follOK-od iu W [>cr com. of lhi«c- nin|>iitBli<inM in the loner cCj 
treiniiT. 

Ci. fu flm|>u(«ti4>» in caM« of injury no iraporlant i)U4wti»ii liak lo t>e drtri^ 
luined, viz., th<.- intliicnee eicrciN-d by ihe Time llinl hiu e1it[m-d fiorn tb» 
inflictiun of ihe injury lo thi' (H-rforiuHnt.'c uf the iinipulaiioo. Not only iba 
rate of iDortulity. but the eotiditiun* that ininieiliulely iiccafion the fatal 
event, are influenced by the peri'id ut which thi- npenilion i§ [>crfi)rnml. 

Aiiiputatioiu for injury are cninmonly divided by Sur:i^>ii* into i\imatf 
and Stewtdary; tbe primary hcinj; tliuae ibat are |wrfornwd durini; the Aral 
tnenty-fotir ur thirty hour*, b4<forv any (prcadin); luflaiuiuation or trauraalia 

RE»in.TO OP PHIUAKY ANI> OKCOyUAIIY JlHt>1^AT10X)i t!C Vlit-E» OP IXJVBT, 
AT I'XIVIIKftlTY CiMJ.nii: lliMPITAU 

Sb»t, 

Tliljib, . 

L»( RBll foot. 

BhiMtld«r Mit •ni). 
Fur«artii,. 

T"ial. . 



rmainT. 


Sum 


fkmt. 


Cww. 


l>»ik>. 


C*M>. 


tiMlhL 


14 


H 


31 


14 


23 


9 


to 


t 


« 


Z 


« 


S 


« 





1 






4M 



If) 



1* 



finrvr liaa developcl ilwlf. Ity 4<n>n4ary amputations, msDr SiirgeoDa inra: 
tlicwt ojicrBliiins that are pracli>e<l after the flret tirenty-four honre; whi' 
utUi-nt afrnin more correctly reetrict ihe term to those that are done aft< 
suppuntlion baa tieen fully eetabliahed, wlieu tlie surf;ical ferer is be^inniii 
lo ttulnide ua );ri>nulattim-ti>Miie Aprinpi up to pmeiil a barrier I" the abaorji- 
tinn by the lymphatics of the »epiic (Hibon. Tboee who thus limit the um- 
of U>i! term Myvnrfnry, call all the <i[i«nitioi>s (lerfonDM! Itelweiti Um' eod of 
tlie lirM day and the |ieri<Kl of full RUppumiion "interntediaie." Tbe di^ 
tineiion ii r>f sotne iu)|<>>rtuni-e. u ojMTaiions pcrfurme*! during hi;;h siirifical 
l«A-cr are extremely tatal. [n the tiOhmin;; table, llie cnata are divide*! 
merely ioio primary and wcondary. The euea have beeo ooJ1«c(e<] froto 






A 



pbihary and secondary. Ill 

vxri>wu HHirces, and the table ehova the relative results of primary and sec- 
ondary operatione in civil practice. 



Feat. 




PrIHIRT, 






SKCosnABr. 






Cu». 


Duthi. 


Per cent. 


C>«c<. 


Dnthg. 


Per cent. 


w. 

Arm, . 
Forearm, . 


. 235 
. «)■'> 
. 276 
, l!tO 


1»3 

17H 
Tit 
16 


GJj.l 
43*1 

2S.6 
8.4 


156 

100 

75 

27 


8S 

72 

32 

6 


54.4 
4S.0 
42 
22.2 


Total. 


. UOti 


i-Jt\ 


U.D 


408 


195 


47.7' 



While the percentage of deaths afler primary amputation of the tliigh 
exceeds that aiiar secondary amputation, the rale of mortality in amputatiooa 
of the leg, forearm, and arm, U greater after the Becondary than after the 
pnmary operation, especially in the upper limh. Primary aniputsttuD of 
the ihi^h i*, indeed, one of the nioat fatal operations in Surgery. TliuB, of 
46cate8of primary amputation recorded by Malgaigne, 34 perished; of 18 
tattt in the Mai«aehu8ett8 Hospital at Boston during the iive years 1863- 
1^, l-'i dietl : 9 (.-ases out of 10 died at the London Hospital during the 
Tt*n ]^V1S66; and of 24 cases recorded by South, Lawrie, and Peacock, 
u ><cTurring at St. Thomas's Huepttal, tlie Glasgow Infirmary, and the Kdiu- 
barch Inlirmary, every one perished. The danger of amputation of the 
t£icb t->r injury is increased in proportion to the height at which the limb 
u »i;vei*d. Ic if least In those cases where the operation ta done for iujury 
■'( i!* Irg or knee-joint, and greatest when it is performed for compound 
(hcture of the femur, recovery being then very rare. This excess of uior- 
ttiiir after primary amputation of the thigh must be referred mainly to the 
iounfity of the shock, whether produced by the operation itself, or, as is 
B:uie ufien the cate. hy the injury which has rendered its performance 
Mrewary. 

In primary ampulatione of the leg, arm, and forearm, however, the influ- 
cQ-'c ''i' liiis ciuiiM' is relmivclv le^^, \\hLle in secoiiiliirv aiii|iutiitii>ns of tho.ic 
[ur;--, a.- H(-l] as of the thigh, shock is much le)-s iiitouse. In these the diin- 
.■■ r ririM- I'riiii pvieiiiiii, ;:nin;ri'ne, diHiise inHiitiimiilioii, st'condarv heiuor- 
r:.a:;i . :iU'l all tlin^c iiinrliiil coiiililinns thiit are fiivori'il hv ilcleelivc hvj;ieuic 
. ir. :i!]isiiiiuii, ;i[id which np[>eiir lii exercise a nmrc uiiifurnily unfiivonible 
-id -■■ii..-^ nvir ihi- stcoiidury amputation lliiui shock <iofS over tlic primary. 

Ill i].iiit;iry prai'liii-, secondary nnipulalion is, in gerieriil, more liilni than 
;r::iiary. Thus, Fiiure saved oiiiy oO out of oCIt secoiuliiry am point ions, 

■ :...-i Liirnysaveii thrce-f'ourlhs of ihosc in «hic!i he iiiii|>utiitcil ]iiiuiiirily. 
1;. ;::•■ P.-iiiii>ula war, the nioriiiliiy jiticr sccorirlary iiiiipul!itii)n of the 
-T-i--r ' Mn iLiiiy was twelve limes, jiiiil after tccrmilary Hmputitiion of the 
. ■"■T iiriJi. thrif litiics, as grciii a." alter primary ampiitiitiuii of ilivse purls. 
1:. ■.ii- ISriiir-h army in tin- Crimea, iroiii the l>t of Ajiril to the close of the 
«sr, ih«' ri'iulive rules of mortiiiitv per cent, flfler priiiiiiry and secniidnry 
aai[ ■llaIi■.ll^ were ii> follnw : AHi^r priiii'iry iiiiipiiliitioits at the sliouKler, L*t); 

■ ■1 iti-- artii. 17 ; nf the liireiirni, :!; of the ihijrh. ii'2; of the lejj, :S0; and of 
lii«- ll-'t. 17 : :ilter ntcondnry aniputations iit llie.-lioulder, liB; of ihe arm, '!1 ; 
(if xii'- I'.nurm, L'JS ; of the lhij.'li. H(l ; uml of the le;:. 7li. Or, for the upper 
mn nilty. ih-- whole rate of <leallis after primary was l."t, npuinsi 41 utter 
**i--cdary anipulatioiis; wliilst. for the lower extnniiiy, e.xcludiug the loot, it 

■ ay A>'' j-'r ctnl. fur the primary, af;aiiisl 78 liir the secondary. 

■ TK- T- Bilpr wli'i »i«li''« to pursue tliis Buly<^t fiirlliiT will fliul H wry iHrye Imdy 
.Y .;«!.»:i'- "n ihi- remlti of fttiijiulaliii[i« in tlie Irut niiiii-n of I'.mi.ir'* SitriiiciU 
thrtmna -y 



tu 



AMPUTATIONS. 




In tkr AmoricMa armj <luriii|; the war '>f tin- rcMlion, Ib^ nwrtAlitjr ^H 
priwarr ■in|nitsti<«i >il' Ihv rtiigli vtiM -^4.13 |HTOi-til. ; and iiftt^r •oCoOdHV 
lUu{tlluilH•u^ 7-1.711. In tbr Fn^iich nriny in the Crintm, mi tlu- <ilbi.-r hind] 
thv inorlnliiy iiflrr jiriiniiry niii|mUti«ii uf thu thigh mid ami— nniotiDliiig ifl 
th« tiinuiT \\m\t lu abavi- tK) jmt cctit — wn« gn.-iitcr limn ihnt nllcr llir «r<s 
oudkrv u|N'ruliuD. I 

Kb \\*fi ulrcttdjr been wlMcrvod, not only doc« Ui« ra(« of tnortnlity diHrr ifl 
{iriiuitry mid Mcwndary nmpuUttions, but also the niMK of death. I'riuiarjl 
niii|>iiliaioiu are moH (n<()Ufntly latnl IVnm aliock. hemorrbiti^', mid rxhanai 
lioD, iiltlii>u^)i d««th from |iy»'ii)iii »n4l septictPinia is by »'> iiwuds rarr in ihM 
DIM*. Si.-(Nitidary nnipiitalioiiif lor iujiirv meat comtiiouly carry ufT ibl 
piilient by clif Mipcrvcintion -if wptic db«asee. Amongst ibe trooDdan 
nlK-oliuiti tliiu arcuf fni«t fri?<|Ue«it (xxrurreDoe, (^DjETeDeof ibe UMiiipsUmaj 
in thi,' Hrsl plai.-«, »p<<ciHlty aAcr au)|itilnli>>n of tJie tbi^b t'"r iiiji 
niom particularly If the limb have been in a niiuilur rondlliou 
Mm|>iilnli"ii. Then, a;;aln, erysipelas, phlebitiii wiib pyitmia. 
hvnK>rrbii);e, aud »->n>p of the low fornu of viMenil intliiiiiiiialii<ii 
tiwil, a* pneumonia, ntenrisy. and diarrfKMi — all )>rolMibly due tii Beptia 
poiionin^— vHeu {irudu(.-u death. I'vA-tnia, coniplicaldl br CKinii^fStivc lunl 
Mipixiralivc {iiivurauuia, is llie roou /reqnntit l-buiw of dmifi aflcr wcoadary 
ampulnli'in of tbe \v^ and ann. !4ecoD<lary hcmonhagv ht Mich an extent ■■ 
to priivc fatal i> of voi^' nirv uccnrreuc*. 

>*i.uMMiv. — On ivviewing the whole subjoct of ihv cauM* of death aftcTi 
•mpnlHtiun*. nv ouiuoi but oump to tbi; i-unclu«i<>n ibat tho raonalltT ii 
inlliiruCT^I iii'in' din.-<:lly and diitiacllv than ihnl of any ■•fbrr operation, 
exct-|>t jirrbitjH ovariolomy, by ihf hy^'icnk- <;on<lili'iDi' to which lb*- jmlirut' 
is «NDJ«:t«d alliT tbv <i]»'raliim. Tht7i>vil inttuf ncvii nrinin^' from cxniwurct 
au atmuepbviv vilinlcil by tb(- i-iiinnatioR!' IKmi tho ilivoinpieing diBcha,~~ 
from an p]>ii ruling nitiitid^und lo ibow Tariim^ oimbinnliong nf condi^ 

tlint arc mronwil np nncli-r the mit general term " Umpilnliim," cxerci 

iniporiant a bfarin^' n|i-iii ibi,- dmtti-rale alter anipntatiou, thai, in i>r*ier Ucl 
arrive at a jui^t tstininir of thi> proliable c)iaUM-« of recovery in anv i^iveal 
0000, it becomes iivcrMary nut only tii consider wbetber lb« uperatioii l>e i 
fur injury or diMnttv — nbrllivr it be nrintury or tecundarr — whether UmI 
dlasMM lie nmple or malienani — irhvuier (bi- {lalivut b« iikmI or youubj 
honltliy or diseaMHl ; txit, aburc all, whether, alUr the reninval of ihe limb,] 
the puLieiii will be eXfioMMl In tlio#e eoudilioit* tliat raull from the aKKr 
tioti uf tiie siek and the eroudin;; to^ilier of foul 5Ui>purut)uy wouuda. 

Wluitever explanation wu may kwc of the flii-t, it reniaiiia ei^rlain andl 
i M tun tru vert ibie that the rate of mortality after amiNitation »f all limba !■ 
tbr large c-iiy hoapilala of <ireat Uritaiu up tii ■ very rroi'ni ]>eriiMl ha> bmai 
at leaal 1 in ^ < nV'- Table l. In tboM-orPans, unl nf lli,^t) ain|>utaliiiii«. thai 
■UtiMis of wbieb were eolletrted bv ^lulvaiiinr luid Trtlnl (SimjAun), HOS] 
dii>d, ur ui-arly 1 in 'J i ciiyr aU>i Tahic i. The Onvfriiment *tntkti4« Rillectvdl 
br BritlKwe aud II>ilriit'.i r\wvi that in IMil the aniptitation dnuh-niU laT 
l^uitlaii bodpitnlH wiis :{ in h, and more n-oently Iii- Fort pivtv the mortalitv 
at 68 |irr i-rnt. In (iermuuy ninit<n neri- noliiinrh lH-tt<T. Billroth'* pub- 
lished ainpiitatioii'Miorialily hiu \>ern from 4,1 to 4I> ]ii'r <x'til. In tlir I'nitrd M 
Stata* till' di-alh-rulu i.i nuirh iriiallor, however; the ninrUility in th« i'enn*| 
■ylvaiiia HuMpilal bctUK only nboui 24 |<«>r n>nt.. and tliat of tba MaaakdlM* 
MtU [JeniTal Ili»|iilal *J(i per oeni. 

In inililarr prariiL-c. ih>' mull of llif ex|)«rience diitiieeal from tlir mor-« 
laliiy f-iHixam^ nini'iiiatiinu during llir i;;rral mtxlorn wan if at le«Bt<-<|Ual]y ■ 
unfavorable. Itiit tiiire tlivni an^ *o many m'><)tfyin>: and disturbing clviuenia, 
ibat it may be well to cxdudo tbcav caw* from cotuidcralion. 




SUMMARY. 



118 



In &rt, tbea, »m laJiine the avemijc- niwrlnlity atUr iimiiuintion uT nil Tonr 
Ibf Eanim hcepilaU in ilio Kf^'nt oentrM of dvtllziiiiou, w comv to 
It, that it nxDiDoaly vanni rnxii CD t» '^t per n'nl., nm) iliil not fall 
M par cmt. : and that in rortain of ib<- lor^T am[>»iation>. m in tho 
lUra nt the Ot\flt aixl at ihv tii|i-ji)iiit, il ran ap tu rmm 70 to ftO per 
Widely TCttontM alatiBtiml n-tiiriM hav» ahon biit loo plninly (lint 
Ibak Opana an traatvortbv nn<l ivinolniil. wban fountM on #iim(.'ii'iii tiiiro- 
Waaad <mitied orer a»ufh< :ih >if limr m i-liiniiiiili- tli« iii(1u(ti<.¥ of 

aeridiBlal cimiBHUDon up > <>r a^inot ttir |><itifiit. 

Uy «ticl itinr tij^unTn ithiu' i<tii in h-wpiial ri-iiinis, that StirgwMU 
CMW tu rtgara i1h-ii> a> ro|>r(fa'riliii<; llii- iivcrtMiry, or. so to 
the T M < T af rata ol' murlality sdcr niii|itil(k(i'>iiM. Itut in tU'» so in 
nifty* la tJiia IHghtfUl r«l«' of monaiiiy llx- iH->.-n«»rr n^iilt of Itip opera- 
IM, Bad tlina liTTond otir control 7 Or i» it ilencfulpnt od vauace itint are 
fwiiBtetiKv ami itiai may ia gmt purr, if not n holly, bo rcmovp*!? Tliatit 
waaiaacivMry — thai it i*'l<'|icnil<'iii na prcTciilahlf vniisra and mill cvcotunlly 
h> M«« Malrrially i)iiuiiii#h<vl it^ (■vHoni frofli thv admirable reeults thai liare 
"I lu> (rsr* hnrn '•liliiiiiitl by Inllviidt'T, Lister, Spenm, and otbere. by dif- 
frnmt KWiliwda i>( tn-atitient. but nil having in viow attentioo to the by||ieDia 
tmiittiatn nf tW wDuml and of iho paii<^Dt. 
IWitetwiim. quirtol lu a fi>riii«r pa|re from Mas Soliedc't work on aiupu- 
I. (huia ahai ran be ac4-uniplub«d by ibe aulu«p(to trentowiit. Tlio 
■Ai^iil by ihp SaTjgeoat. trom wboae practice tbotte siulislics were 
i, waa iKat rrmatneoiled by Lbter. It maitera little, bowevi-r. what 
«f tlnanaf ia adopUrd. ^'i lnu|; us the decofapuahtuu of the diactiarge^ 
a a^ajvMly jnftOICKl. ThiM i* Uic iiHucipleof antiwpticstirKerv; but the 
kw aaaaa m aurriot it "ui ha» iirounbly yet to be diwoveml. WlK-ucTcr 
invUMat ■> Hhrti-iitly crnrrwH out, bv irbatercr nM-iitm il niny be 
Ifaa mud cmwlo ben»ourc« o^ infei'li«ti and nf coniaminH- 



tM tM tW larRnBdlDg «uanpli«r«, and the rmultn of hocpital practice nmy 
<faw M)**! tbf liMt that ma tw nbtitinnl in priviitiv 



(.p Tit IS/?) ^krvn im ill! A ri'' 



>P'irItinity "f obtaining a knowledge of th» 
sciile, exoep* Mich w hiul licvn luniishod 



Wtb« -».- .^-. ......u~ ... M_j.itiitB: hilt in that y<-nr Sir Jiimi^ ^in){won 

wBnMtd froa nDall otaiutry hiiepitalB, and from private practice ia nianu- 

r -- ' minln): dislrielf, in which amptitntioos are •>( common occur- 

■ which pn'Vfd Milt^lact'irily that in the lime before the 

'I'wU of Irealing wounda were Ailly undcntood. the 

iiox i<f puitciita sutlering from open wounds exerted 

' I'll the projK-nion of ileallM. 

1 tbf tmrtif-iilani of 'iOW amputUioos of all kinds occor- 

iiod i» private pnu-tioe in towni; of thoac. 229 died, or 

nn nlmo't •.■<i'ia\ number, viz., 'iO^Q amputation*, per- 

in iJw l*jf ' rent Britain, tS-'to died, or I in 'iA. 

it m fviCe ponl < fltturea were not abatdulely but only 

)y correct, and tiini i-ertiiin aourvee of fallncv had inimded 

,BMMv <ap<\-ially »ill> riynrd to the condition of tfio patient (M/ort 

tfc* «ya*al»uft. tu which iiudiiiibic'll) un-al iupoTtxiDoe niD»t he allacbed 

~ ' li'M . M-ii rtill. makioi: lull alltiHance for all thia. the diflerence is 

^ twu wu of cwaea that tltv KenenI roult. viz., that tlio 

.[■ulatioii in hi«j>ilnl practii^ was nearly four tjmn> as 

ibe MBBv utH-ratioiik lo-ri- ]ii-rr<<iroed out of Ix^pitiiU. cannot 

' - ■■"' - ' .iml it Nn* ii[i|xM-iblu Ui etompe from the i-on- 

Niortiilily WB> ■:}■< .-illr inAuined by the eip>eun> 

111- eondiliuoa vxtiling in the aJr of lar;^ lioepttala. 




SPBCtAI, AHflfTATlOVR. 



wliii-h havp l>cc» m iibly and |jni|iliic«ll_r ili^-ribetl hy I'lirkn, bii<1 itlud 
excrciec the moit iiijuriuui cHecl »» (nitH-tiU with \9rge uouuds who km 
expcced (o lh«tD. 

Th«i tbow Hptir inAurncra mn^ evmtiinlly saturate bM]ritiils. khiI <>x(T' 
eiae a most importniit infliiciK-i- in tiiu#it)K fnlal pYviniK. f«|ili<-ii-in>a, noA 
(iMvi>- myelitis, aAor nnipuiiilioits. IVuni nhicTi, lis iittf nlrmdy Ik^ii tliuwn, ■ 
\»rKt ]iro{>unioti of thuM' [ipcn<lr<l ou tiinni^rlj ditti, is cvi'lvot frum tltc fol* 
lowiue cuiuidtratioDH : 

1. Fruoi tlie (.'iMiini«DccnH>nl of this nntury up to a eotnpantivr-ly rerM4 
pt-ri'x) — <lurinK Hhai, iu fact, may he tinned t\u- prc-Hniilary ngif—no im 
piMvfMK-nt l>ii(I litttcu plsi-« in aR)|Mitatiuti-ii>i>r(ality in tiuepitiils. 

'i. The pivvailiii]; lii{.-li rate lA' moiuiUty varied K''<^>"l7 >i> diSi^PNlt b««>s 
pita)* in thf i^uiiii- town, it) wliiili the piiiieiils nere ul' the tamtr claw ol 
mK-ii'iy. rollnu'cd pretty much the giune <H:fiij4iii<>ti.-. and mn- ^iihWtwJ m 
tlic raiur kind» id injuries atnl discnM-i<. ihi- limpilnl" Ix'tni; ottii'ereil hv Sai> 
geiiim nf i'i|ria1 [irofusaiutial slcill, mid the only inM|iiHliiy exivliiij; luiiiii in 
th<- diireri*!]! cauitury cotiiiitiung to nhinh lh« patii'iito wt-rc i-xiHitrd in dif- 
tinmii hwjiilal*. 

•'{. Thi- diflfivnoc in the nrnpuiatinii-nmrlAlilv in iliflorent 
pilal» variiil fniiti IH nixl '25 ti> 47 ikt vent. Iii (aloutia 
B^er ihigh-ampuUtlioiu varied iu din«n-ot liiwpitali> fruin 42 Iu t>0 pvt cent. 
(!>(>« tiic). 

4. Of late rmra tlm oxcwuivv amputation-noruiJity luu htvn mstcriftlly 
mluL-ed in ni<«t hiwpital*. 

•'». This rcdiiciion is roul«ro[>»miKHMi» with, and, a* uV/ (Ae o(A«r eonJitiimt 
tonlitiHe <u Iffon, nuM be (k-|wD(b-iii upon, tlH- gnwier atuiition imid to' 
bodpita) hygivnc and lb« «oi|»]oyiuvnt »f nntiM-ptice, in ibe IrmUurai of. 
mxinils^ { 

li. Id military iinirlice lh« rat« of mortality slier ampiilatiirn has Ix^ea ' 
fuuutl to be iu ibe dir«i:4 ratio of ibe »g);n-|(atioti of Itio vroitudeil; nnJ 
iufi-ctive proctwes of wplii- origin may aInuMt, if IkH i^utirely. be aTiTled by 
i>ebitiun ul' tli« palivDl>. 



cxiHitrd in dif- 

«t lj»nd()0 lioM 
I. the dcatb-rmij 



CHAPTER III. 



flPBClAL AUP0TATIONS. 

rniniK arr. a» ha« nlmitly b«eu tAnivi\ at pp. S^-Hl, ihnv iliatinf 
nicthnils ufamputnliu); limbe, viz., Uie Hap. lite i-irctdar. and lite oval. T)i« 1 
oboiiv of the iiielbod iiitliivnceA il>e »Ii»|h.', and t>i a (■■-rttiiii dej-ri'e. |i<-rtiaiM, 
tbr Mlililv of 1)11' rrsidtiii^ »luiiip, tlut ii in no w>v ntlin-u ilic ^al'i'ty of ui«| 
patteni, wliirli \% d<r|Nt'iideni i<ii tfir iltlfweot mkI tar nxtre im|i»rtaui ooihJ 
ditiiin* than ihr mauiitr iu ubieh ibe Sur)t«on slia|w«» hi* iuciMiotu lor tlMl 
MHtitval of the diaeoMil or iiijun-d limb (p. 87*. A «LilAd Surp?un n'ltl lie 
ablo til pnidiii-p a iallrl'sdory atump by any oiir uf the tlinw tnnlhoil*, and 
It b dcfimhle ilini be fthmild be able i<> )ininiBi' all ; for nkhoujtb, lu n crn- 
«ral nilu, uue melhiHl rany W more appliiablf than iiui>ih<>r. yet empUnnal 
MMi udcur at times iu whirh il may lie ailvantao^tiiu to dcfHin tram Um 
method luiuilly ndi'plvd, and einjdoy our of the oU>en. Id fiurt. a HurifaMi' 



iqjara'B 



AUrOTATloy OP FINOElt. 



115 



[fvlcciif in bit mi^liad nf nnifiutatin^, ttii'l iwli-ol tlint wbtch b 
ble In thr dirgirMtsucn of thv oiuo botorc him. Tlw tU[i method 
«lfcrninlii&«) Ha|iiuid circakr it UikI lo whifli mrwl Surg«oiu giTu tbr 
pf«A«««c* In tht> GuuBlrjr. 

!■ if riUog thb nr any otbrr ti)rtl>wl nf «m)>i]Uiling. prdciw niW mny 
ba hU dovo |i>rlt* )««Hbrnuuic« (Iiroii^li kmioO Htrurlunv. Tlui it nUr-n 
hiffOik Cifaraillr in «imii uT iitjiiry. Ihnl ibf ilwtnirlioii '•(' lienuc in vn 
itiifdu Mia ami*) Ibr Surgf«4i ti (lc|>tiri IV<>m HcHnitc rolm »f )>racliw. 
»»< !■ ifaiw hit gap mn Itrat he mttr IVi>m tlio uuinjiirod pdH |iiirU. Tliorr 
W aMt nrlr iio Hi* ••■•» juili;>n<-nt. Um su cfBci<'nr i* the mixiMiiif: pron-w 
■^ Mtitrt. iliai, |>r»ri>li.->l «iitfiri«nl ioU^suiot^n''!' onvoHiie he It-A o«i llu' 
•od bntm, ■ Mump thai at linl Iook» v«rr irre;'ular aii>) (irrbitiiii 
towmeil, will iu n short 6|incc i>f time noquirv u regular >Jtill!u4- 
I aarliK*-, bihI m»y beeveoiually in nil respects aa useful u on* 
ite h4v from thr fint hav» been la^hi'iiK^ more artistically. 

A I Tin: IlAXit.— Tilt' Pingera <>fton re(|uir« nmpuialioii for 

lap:: . i^vt< apcciall)' the rceult wf bad whitlow. In waiiv cii*« 

tl" ttpal phalanx beMMnes RAcrvaed. and raa^ iminllr miwt readily bo 
"■"id vithuul amiMitatiofi, hy maktiie an iaci^ioo throuuh tli« pulp of lb«> 
fa^ ta4 xhtn rstni<-tin); ihn dismsed Imur. ihu« Miviujj the tiail aud pulp, 
-*-*i»ill £ara an cxecJIi-iit end lo iW liiifiiT; am), if tlw; operation be 
««rir rbildluKHl. a m-w and movahlt^ phalanx miiv form, i^ould 





fcmd 




tig. II.— AB^vmUs ■( r*ri Mf ■ FxigM kf Caidnc Ima AVnc. 

:!«ia Iw rtt|uirMl, it may br done by eithrr nitling into the joiol fWmi 

I aaprri with a uarruW'hljMlitl liistiKiry, aud mokiH); the flnp from 

^nr .■.,w~-< \.i .-itii»K fiYim within »ulwanla; or the flap may eoBTe- 

11 ih« [laltnar surfaiv by tran;tliKiDn, and the joint 

':i>. Ill ani(>utatiutf the ungual phalanc from th« 

•n must >inti<l (ndni; tlie hand: the liuger must be 

<fi-iiiii . k-< mm tbe imdt phalanx i> ut n n;(ht anijle to the next. Tito 

ta fipra lh« joint muit hn made iu rontinunlioD of nn imaipnarr Hni* 

tha tidt of th« aecimd phalanic. midway lietween the donu nnd 



lie 



8F1CIAL ANPUTATtOKS. 



nnlRinrn*m>ct«. It must coninivncf ol the crcaw vpiwHtr the joiDl, i 
fliiUli ut tn« oornvjMHKliiig point uu tlio uther m<I«, |1i« sur)!«OH cuttiuy fi 
liis Ird lo liifl rifiht »i(l« uf tho fingi-r. As tlie joiui (>|>iit>, lliv Integral lign- 




P)|. 13.— Aiu|i«lallMO ut a FIngtr. CiIIIuk tb* FUp b; TraMllxlaa- 



nut luuH br ti>uc-l)i-ii wilh thi- |u>iiit of ihf knife. As tlH-H- an- dividfil, 
ihe Rral tw<i i>b«liiiigf« tiiutt ho vxti^ndcd whilo thi* uci};iial jihalnnx is >tili 
further lU-xi-d. The koit'c i* lh<<ii to be puifu^d with h Mwitig rnoliiku towmrds 
tbo puliunr »urf«op of the phalmiix, the eilgc Wing riinKsl ili^hllj townrtls 
the Door. Finallr, the iingu*! phnlnnx is to bo fully cxttixtMl. and n floj 
cot iti(.-)n<ling thr nhiAe pulp (.Fir. ^U '. When any dilficully ia cspctit 
ill landiog thv iuiiit, it i» either from lakiuf' a wrone lii)e, or from the 
eiK-e of ft smkll rheumatic exostmis •<» the base of Ibe ungUKl phalmns. 

In ampntatinff by tranafixioii from the palmar Mirfuee. the lin}^r niust bft 
eJCl«n<U'o with the pAlmar surtiRce towardi the tiurvi-oii. The kuife muat b« 
nikde to truii«lix the Bnifer its cltme to ih« Ixme >.-< iBwible, and in Hieli ft 
vfay llinl i(a liurk i» "ne-ci(thtb ineh i>ii the diainl niile of ihe LT»'a» corrc- 
B(><>iiiliu}; to the join!. A flup uf niiHident IcttgtJi is then nit, irbirb miul he 
niaeil niid belil uut »f lh«- miy br an SMtUant. The Joini ia tWn ojviieil, 
the ii|>etKi'ir Wti'ling th" Iiu>i jihiilunx forcibly bnelcwnnb lo put the anterior 
llpuiimt oil till- vtrctcb. Fimilly ihr phnlunx u removed by enrrvinji tlie 
kiiifir thr<iui[b lh<- joint, iiu flaii brinir niiuli-' fmm the dorul iu{irct (rif;. 3*ii.' 
Id doinp thv, carr munt be liiKen tu av<>itl culling too hi):h up, and m> ini*> 
ukini; Uii) dviwcwion above the huui of the avcond phalaiix for tho ftrttcv- 
laiioti. 

AtniMitnttou is pvrformoit bvtvecn the prnximnl and M-ond plmlnoirea in 
iJm> wim^ nny: but lu n Muinp eotnixifvil of the fint phalanx i* "f hut littte 
luv, il M more cumRKHi to ti.-muv(* tlie whole fioger. in the hand of ■ «r>rk- 
ingniaji, liom-ver, it i» |M-rhap^ hi-tler to siivr even one phalanx, ai it helps 
•oiarithat lo vtraigllH'n lb* grasp: for ibe stump out IwMmnglr dexM, 

' rnrib* C'onMrrailta l^urgsry o( iW Hand, «A Cfcat>ii>r XLVll. 



I 



IKPt'TATIOX AT M ETACARPO-PH ALANQE AL JOINT. 117 



fUiW ttT the action of the ioterossd and partly by the long flexors, which 
t>rai Mir attachmenta at ita extremity. In the case of the index finger, it 
will he better always to leave the proximal phalanx, the stump uf which 
£>n» a iLxefuI opponent to the thumb. 

AmpuiatioD is frequently required at the Metacaipo-phalangeal Artioa- 
latitlL Here it mar be done in two ways : either by iateral flaps, or by the 
•rnt mvlhod. If by lateral fiapa, the aajnining fingers should be well aepo- 




K;/. ■:?-.^AiDpuliKli-iii fjt % Finder. HeiDuvia^ Ihc llfni! of the .Vfctkemrpml BoDe. 

rail-.) ff.im ilie <jiif iiKiut to he reiiiovfil. by lui iissislimt whn irra,"!*;' the 
Liii.l. >'i X- til {Hit \\\i: inle^iuiirtit mi tbt' dorsum u)i'iii l)i<; siretcli. Th« 
:• iiii ■•!'» bii-tiiury i* tnti-rcd immucliitti'ly iibuvo tjic hwiil nt' ilic molftcnrpftl 
%'ij>-. i-urrit-d fiirwurd^ tu a point iip|ici<iii<' tlii.' interdi^iUkl web, <lr:iu'n across 
It'-- •.'!<- of the fin;;er, and tben carried >\ little w:iv into [he palrii. This 
-am- viT--:*-^ is porfiirme<) u|»>n thf >ii)])ij:'irc siidi', the llii|>s wn.- di.«sected 
■\ ■■II (iv :i iVw loiirhi's iif the knilc, the cxiriisiir ti'hiUm is divided, the joint 
■ ■:" O'-i. mid di^rliciiiatiou iXTfiirnicd. Tlif urnl m-'lhoil. wliicli I think is 
It,-: !h«i. as it does not wound the ])alm. consi.-'tA in entering ihc bistoury at 



118 



SPSOIAL JtUPUTATlOKB. 



tho MtRiv iwiat u in tlio ImI cnM-. rnrrvtngit ufnrM ibc jmini at which Ui« 
trab jniiw l)m finger nhti'h u Iwitig («Kcn ofT, on i)k' i>|>i'rai<kr** Ttaht hnnd 
aido: thrn ■cr'iR* lh>t iMlninr Hsitect. in ihir lint-ortKi* foM in tin- i>kiii nl lli« 
root of tlic liDgcr, U* lli« wi>b uii ihr otbi-r siik*. Tbii!^ fur tin- inri*i«n may 




Ptg. M.— Aui|>uUUi>u <4 Ills lu-l*( rinsw. U«iuurla( IW ll«*d *f lb* UfUSrpsl 

be iDiido without taking tbp koitt out »rtbi? woaitil. TKi' nral i« c»mpltM<l 
by |>utting tli<T iminl «)' tlw knif^- in ihi- <-n<] of I)m- firM inciKton «u<l (-niryiDg 
it unwnriU ti) tlir ■tarting- point, tbf t^ur^mV tinnd am) tlio linnillr «]' ibi» 
kDifv, (hiring; ihlf i>e<-<>«<l jiiirt nl' lb** u|>rnili(>ii, U-ing uvvr tlic tmck ol' llip 
{MtivntV linml. Tli<- two »iilr» <>!' Itir ovol !>1i(hiI(1 br rxunly MinmiMrical. 
am) Ibr io<-i»iouit fTuni ilir Mariin^ixunt lt> ihr web »U»iili) not Im' vtnigUi, 
buitlightly curvnl iu unch a way lliitt llu-ir (iiivcxiliiv look loward» tho 
middle linv of iIh- finger tiliic-h is Inin^ n.-iiK>vi,>(l. Ity a ftiw Kiufti«» iif the 
kniCr, ibi' oviil llii)i \f tiirrioil Imck ; the tl<:x'>r tt'nilnn i» thru liiTiilr^), aod 
ihc urtioulntimi nikmcil fW<ni ihc oncmlor'fi ri)jlil hnii'l sido ; Aniilly (lie Ii(i|^ 
is rfni'iviHl bv twirling- it riiiiiiil, wliilr (he cilp.- •}( ()io knife is prcne<l agwiut 
l)ie Imsc of uw first |ibtiliiiix with m »li^)it uiwin>! ninvi-inciil. As ■ ffeMffsI 
ruli<. it is bi-tlcr In r>^nh)Vo the boul of the mctni.'arjnil tionc. i»)^tli«r with 
th« finfcer : t>lh«rwiso a « i<t« gap will be \efl in ib« Hiuiitiuu of the linger 
ihnl tins been nni'iitaitil, and murh •K-forniily of the linod will rrault. In 
tinter U> du ibis, ibi- iucibiou nniM be c>Rini«areil on tb« d'>reuiD abotit tbn»- 
((aartvrs uf au inch nbnvt? ihv ti«ml uf the tnetac«r|iul bone, and be carried 
(tralKbt (lownwnrdu to a [luint oppuHitc the )»««•). nhere nn oval incbinti, 
similar to thai alx've ilracriltn), is ooninMrnced. We ihit* )pH what it known 
lis a " nu-k<^l-«hn|>r<{ im-Uion." In nrtnovinK the mi'ldlc nixl rinii fin^-rs. it 
will t>e fonn4l more cunvcnioni to tnkr mil tlw hmd of the mvtneariml txjnc 
ntivr diMrtivulsitvii. This h dooe by c)«aniiig ttw dunal surfncr ami sitlm. 



AVrL'TATIOk OP TUE TIIVUK. 



110 



Mkat n** t" kMf* cliM« lo iti« Imhc. nihI not l» )i>t t)ii< pnint nf ili« knift 
ffaMiU* Uk folni, *•> ■* til wouihI ■ •lisltnl hranvh m n |ioint trlx-ru it 
OMvilb dtJErulty Ik.- ■t-nin-il. Tbr lionf-rompfn »ro ihvn «|iplicil, in n 
W iifHi dnvctimi. iiaim-'linK-ly Httovc ihr tirml of itic tiour ' Pi^. .X.'t). 
IWifostur tfam |>)i»»M ih>- i)|> oT h'u riitvfiii^iT in tbv jiMlrii of the baiul. 



•• M M fmti Utp 

Ml, ad br II 
avdM. fr ii t I 

laila|wil |J> T).< 

MWaiUi th*' biiii' 



I nli^tilly <tul »r itic iriMiDil, wliilr, iit t\w 
. - niih liif th<liiili pinnsi mi tlii: i-dI ourrnoi* 
ti'Ui'ltfx ijf (111' jinint n( llii< kiiitV it i* ciLiily ttinici) 
•I carw nil ri*k uf wnusiiliiig ii ilipdil hntnrli it 
.iiili-x liujfi-r, tbr Ixinc ■ti-xiM Ih- i-ul iflili'iuciv, mi us 
1 1./ fiiriu (if llip )tun<l i Fig. -it I. Thti mity )•<■ iloiio 
"T with m Htiiuil MW. Thv nw hii* lti» lulvMi- 
i. I ■■ ctiiin iirnl nf knriiijr no »(iliiik-r". ICil bo cut 
fintfij Mmm, «D ugly un<l inrotivi-iiictit sqiinrv prittulMTiiiiiN'. linbU- t>i ciin- 
HMl iytrr, will hr IrA. VVliro, b-iwirvrr, tbc pnticiit'« t'M)ployni«nt i« oa» 
« ■bcft lfr*«l ■trrn^ti uii] bn-iKllb uf hnno are rcgiiir^l, tinil wbcra 
i ffi na r t t« of littl* oniastqticDoti, lh« ImbcI of tlie Wiw may iulvaiitae»- 



ta iMpomitig th« liltiv fiti|r<'r. * ith the hnd of tlie in«tAcarpitl boiK, tli« 
. be coUBUVcn] nl iho inuer uile nf llie biin<I, nt a jMiDt corro- 
: to thi^ mUMle i<r iUl' ^bnll uf ih« bono, and carri«il Urniebt dawn- 
<• B t»)lat opiwsiti' (li« li«iii|, rniin whidi tJie oval miut oe begun. 
TV ttft tct forniM arc iiii«t oonvviiii-iitly bt!d nut of th« way by an 
aMiCMA «Ub a mir «!' blunt Ik-iIu iluriug tlii: iHviniiiii of thf bone. This 
mmt ha «wn obll<iuely. a« iii tlir coat' t>( die index finger. Aa lu the index 
iapr.tbe bowl may bi- Ull in tit" lianil ol'n ncirkiiiginnn. 

IWaAcr-tnaimMit itC tbwv cana i« i-Kirviiti.'ly iiiii|>li-. TIh; butid should 
UmH^mi a ii|ilini. ihv wnuml cavvml with •u'Iik- oimpli- drt-wing, and tlw 
«■* «f tbv 6ti|^-n, with Mniill pii-m of linl inirr|i<i><Nl, tird tocrthor bjr 
I i^a tapr. mn- br-ioc ukru, hi)wcvt-r, lluil tbcy do auL ovem(>. TIm 






ia.M.n^ 




■ tl AmjniMtm akn* M«>Mur*-r4«laii|«^ ArlinlaUon fa 
HhUla. l*4M.*ai Xl»| ri>c*n. 



. of tb« ntrlAi-attal Uiiiv tlinl in 1<-I\ nill I'mdiiallv atrophy, NDil tliUe a 
>..l .l,.i. Ir hnnJ nill I'Ti-iiUiallv \f If ft 'tiir*. 3.V W. ^7 I. 

1 til'' Thomb a* li[tli' as jiiiftiiblv «h»uld l>c nMnoved 

ii«;...u . vvi-ii IhiI a viry aliurt atuniji of the iiK-(acarpal bom 

U will ■rrri* aa ao umAiI (ip|i>in«ui for iht' iitti«r fio^rs. 



ISO 



SPKCIAL AMI-l^TATIOKd. 



AmputtttioH t^ thf Thumb uilk it* Mttatmrpat Bant bm i>|>efnti(ia whirli 
can vory mrdy b« mjuiml. In i'km* of iuiurv ih" (Mir^eun mutl u*e all hi* 
iugenuitjr to wto even tlio onuilUtit pnrt ■>) the bono, i>r ir uir tiaulit rsiMjt < 




rif. 3i— An potation •f L^ T\«nib knd Halaowr*! l>oB«. 



an U> lu)H iDUfh fitD lie MV«(), lliv hnml Aliontd Ih' ilmuN^J ■nliH'iiticjilly oad^ 
Ivft Ui iiiilurx', B atiiMii) Iwing fiuhniut^l Uut vii, oIUt tlic ilniit |>«inii h| 




Fl(. »'— ABpBUUun ■>( KilkiTliMibbjTrandiWa. CwUI*( lU Aktadat ria^ 



W])arato<l. ily this tDMns mora mn Im taved in niniiv euca than at flrat 
Mtmml poaMbCk In cMwofdlMMM aftht inelMiir|«I f>i>»«, «-x«ision of lb« 



AWri'TATlON or THE TlIl'MH. 



121 



< lirmU hm |ir>ierT«<l iii roin])li-(« umptitation. Shoulil tbe o|>eruiioD, 
,%0atemmrr. it Ri>y W i\>aw riilier by tbe flap or ilipn\-al metbcxl, 
TW fcp Willi ml w tltiM )>iTf<>Tnii<): Tlif Suriteon ataiiila uiih ibe buck of 
ll» [MMll'l hmaA lomrib liinwlf. lh« limb bi-iii;; mirlway Utncrti pniiiH- 
Ifaa mi mfituXian. ukI be b»liU lltv ibumb by the uii^uiil ■•biiliiiix. Iti 
<n Uw rtyKt Mi h« coihidmim* tli« incision iiiiiiit^liiiuly nbovc. 



iHaBufolutbr |«l»iKr wpecl of Ui« tubercle to be filt at tliv ouUt i>ti]f 

J it* Imt iif til' mctacnriMil bi>Dt<: from tbU |Mnul he cnrriiv m rurvnJ 

mrmm fwsiu^ (ummjistdy 1m'1i>k tbe mr({ii-jir{iit-|)linlnii|ii'iil artiouliitioa 

ailvMVBl a«pMt to ibi' iiiiitillr of tbe Keli Wlwi-cu tin- tliunib anil iricli;^ 

^pi. Wtu]« uwlcin^ tbi^ iitoiMon, lb<- ^iK'nilor's bumla an* ncixtuitrilv 

ib«ttliitcttUM'«noii)rouv«-(ii<-QC<.-if h<' lfim« sltiihtly <ivu- (iic |mlii-iita 

^'tU Iw.MIti^ th*' tliumb, ibr (>|>('ratur nou i^upinBtai lli« liiind. anti 

p^ ■■■ by tmufixioii fruni tbn lowrrcndof th" tirnt incifion, in tli<- 

«*^ -- .»- ,-iM at which it KU ooiiimrncol. Inl|iue<'4irf to kirp ihv Itludc 

dBtotkr pttliuar wpcd of tbe mcliK-nrMl boDC. Tbp piiliiiiir tliip ii> now 

m. iW kalfe bciu)[ nrou^ibt out in a linv exactly cornvpomliiig to the 

aamm «llid Iw» dm-d made od lti« dorsal acpcct. During this part of tlH' 

«| «wiJ>M Ifw tfatimb must be slightly Bdilut-fetl, nod ntre mudt be UikcQ not 

U ki0W o<r«r Uw aeMRioid bon4«, and at th«' Mime time not to notch the 

iif hy laning Ibe ed|^ of ilie kuif^ l'<o much t4>nnrdi> the palm in trying 

MtviM ihmi Tbe |Mlmar fliip iieini; (M>t, ibe t*ur|>ci>n bands the thumb to 

M MMaal while be ditaectA back tlif dorsal flap by a fev toiiche)> of the 

btfL Tlii* Kein-,; nfmrnt-liiib^l, hv U|;aiu takes tbe thumb, and forcibly 

•Mku It, > IMWMa tbe knife dowo towartU tbv joint, alun); 

Atpalaa; < incaq*] Itune, Mpuraiins ibe remaining attueh- 

aaii afUwaiMftniwrioi, and finally a[H-nint; ib^artie- 

fluam tnm it* ianer mmI palmar nj)jHi:t. I>uring tJii> 

pn at the npvrstitin the knife must Itv kept tumeil 

iMvd* Ihr UMic, »i aa to avgid wouuding thv radial 

■nny aa it paaaa bf «a the hvmli' of tbe 6rH dorval 

Mk^MMiNH ibumIc AaaOan as the joint isopvoet). tlx.' 

Ifcvali •htwhl he tepxraieil by tnisling tl round while 

A* t6gt id ihv knife b h«v<) fnrntiv »).tiitio| itie liaw of 

lie k«c The radisil artery, ii« it M'iii<b beliiw the 

i^Mi piimw. is isfilr wouniled at this stagi- i>f the 

tftBMMSl. ttakia the kutfe is kept eonstantly in contact 

mhthe^OB. Id .' "Q iht'/f/lHdi-.rxBOlly tbe 

•■■ imiiw is fiill I'l thai il is not neeosary 

(r ikv Jtwi ymi to Kt>'» ti<3 huods. and the Rret incision 

baaifte ttxtn ibe web lo ibc Inne of ihe bune. aiwl the 

taMflzina hwa that ]>(>iiit to the ueb. 

I* ihtemi BvChiai of anipuuiiing. which is,aairtlb-. 
la he p nh r wd . the inciaian is ooiinmeucied opnoaitc tl>e 
«Mrr tabereU al tlia base of the metaearpnl fxine, uiiJ 
ttrrwH alivf the otil^'r Uiriler i>f ihf iHine in wtlhhi 
half an Inch of the head. From lhi» [K>int on 
! iocWae is carrinl nnwl, (ismuie in front over llir 
-pbolamrral ariipulaliiin, l)iij> nuiijdelinir a 

i|w<l incui<^. The flajM are then lumed^ luick, mre being lakeji 

inpcB the Bwtacmr|iiB-|>luilBDgral articulation, nnd the o[M'mtion is eoti* 

in tlwivme way a* in iltr IrBii'tlxinn nietbixl. Khciuld the inrincarfio- 

si artirulali->b '' ' '. the phnlanst* muat br- removed, and the 

ibr itMUrart«1 ^1 in a pair of lion-f'in^-ps, nitrr which no 

' Il luiuiiioif the oiwrtition. Fig. -Ill sfaov* the hand 

ditiiiib. 





rif. 4«^Uuull of 
M Biiwlalte* otn am V. 




122 



sritOIAb AltPOTATtONS. 



TIm- HetaeArpftl Bone*, niili or wilboot tJie fiugvn *u|irKirtc<l hy tbc 
oocusiunully rei|tiiiv rt'iitovnl liir (Msciih or iniiirr. Pur IDMi* (i[>vratia 
wliii-li iirt.' tiol iif u rtry n'tttilar kiii'l, it ifl tlillii'alt to lay ilnwii drfinJl 
riilit>; iu pL-rriirtiiiiit; lliein, care i^li'itilil lie txkcit (» make piod tbifo uf tut 
licitrnt eitc. tiui l>i nviiiil culiitiK into the [lalni IT |H««ibltr. Il in nrll nt'i tqj 
(llMrtivulatr tln^ Imvi-r emli) ol' ttie biiii(«. nu sh in opvii fbv VTiMj"ini, tic 
rsiber tn cm tlitiu nl)' niili lMiiiL'-r<>Trf|ei nr n met licit rjm I miw n litllr nboi 
ibiH. Ill injuricti IWiMi tlir i'Xi>li»iiin »f powilt^r fliifk(> vr );un-hiirri-U. wlin 
the tiaiii) i^ laiu-)) ahiitti-ru), il m uf );r<'iil om-o'iiii-iii-r to avuid t-tiltinK ui 
the jmIr) tn Km Krriil an i-sirnt; nixl it ih hl-II in tlicn- cui>c« l>> mivfi 
If puMJblt, whicTi iriil Iw nf more art- tg tbc {Hitit-ui than any uriiliirial I 
linwercT ingi^iitNi»ly CMti^truvinl (Figii. 41 unci 42). When only uim; flu 





pal liDiM* ■•< Thr*« Pt»(*n, iMtta 
ThiiBb sbJ LIUto Fltf, 



flf. «!.— Il*f>il •not ABpuUliin nf Hala- 

«BI|l>l HoHM Mill Firtt Tvu PlKfat*. 



ia ]€ft,ii« iht! inili'X or litllt^ 6ii)[«r, wttli the ibumb, in rmtm or|iitriisl anipu 
Uitjoo iif Iht- liiiDil lifter itiJHr%- or fiir cli*f«wi>, tU<r digit tluit retuniiu ui>t caljj 
beo'itui'e nton' in>>bih< than t'ormrrly, hiil ^'nlly incri'iiMvl tn mU' and nine 
»tnm(PT, ui tbnt iiH uitliiv u materially nu^nrtdii-d. In all fiiMv in which 
the rxti'iit III' the injnrv u <t»iihtrul, ihv hnnd nmy lie n-iidcn-al l)i<n»ttgifalj 
uvplir liy imni<T*i<>ti ui ii lutlh uf citrbnlir ucid lotion (1 l'> 'Jit) fur a fv^ 
uiiuuifii, and ibrn dn-(M'i| iriih mniv nntiwt|>liu ilri-win); f»r a tt<^'k ur niur 
and (I HHimdnry niD|Mitalioii |K-rl'<>rnii>l nli>-ii ihf liniita nf the injury 
I'lmrly dftinrJ. If lln- iirrvrnliiXi of drc<>iii|><i»il)<>D !■ MiL'MMfblly W 
plUhi-il, »•) ('iiiti<titti(ii>niil or local Irmblc it ciiuh^I i>v th» mn^ <if tnmt^ 
in«'ni, nnd ibr uniniiiit vivi-d ig olWit inort- than uii» at tirH rxim-tril. ' 

Till' ni'irtulitv iifliT 11111(111 lilt i'ln of the lin|^r!< and incliirafMil Ikiiiw 
v<'f>' Irillio^. Should d<-»tlt unfortiniati'ly oci-nr alU-r Mirh ii flight 
ti«ii, il would |>Ml)al>Iy Itr by th" iiii'idiiilul occHrrvnM' of tam» g 
discttjto, •iifh ii» I'ryMjM'hLi, pyictiiin, ur tclnnus, tu whicb rvury wouod 
diTK II {wtirnt liublc. 

All cxnlWl mump may in Miiie rwM be oblaiiHvl by amtMitiitin); l>etirc«a 
ihaoarpiM aixl tbe iiiriiics(r|ii». All iIh- ntovemenio of tW wrist-joint roi 
tnoinins ix-rfirc-i, n very nH-ful nrtifk-uil hnnd <-no lie ciuilr a[>i>l»fd. 

Amputation at tha Wrist ii no* very uflrn ro(uirv<l. In pcrfumini 
diwrtinilaiion itt thin joint, iu |M^ctllta^ •hapr, with ih« cgnvusity looki 



.iUPL'TariON AT THE WKIi^T. 



1&8 



.,„.^„JW Umr ID niliwl. The oiwnitinn may Ih* iwrrnruird in two 
••Wk wcBif Rap i>^if rui riilirr lr"iii ■)»«> dooal m jinltuiir Mirfaoi'. lo 
ibfartn*, ii k Um prrfurnut) t>y TVx/^'k ircMmJ (.Fig. -I^t'. A pcrlWdjr 




Pl(. U^Aapuullnn ■< ik* Vrbl hj Twto'J XmWL 

<^m» i>p. wb<wr bur tido nn< nch tyjusl in li-iigtii to bnlf ihv vlri-amrri^ 
■Mtf tW limb at tliv levrl irf" ilie wnsi-jnint, if niim.-d rmiii th« biick of 
At ta^ It tDUft nwisiit >tr thin bikI TaI 
mh.ih* vxtnuiT lemloti^ tiriii)* lcl\ •to the 



L A vlliirt lalmiir rtn)i. ol-i i.-i>ni[ifw«i) uf 
tmi &t ud)t. ami «|iinl in len;:th lo nne- 
Mf tbe (InnMl fU|i, In Diiw rai.-»'<I. The 
r t«oil(N» nicy no* lie iliviiliil at th» 
hwrf »t iW vriN, anil thf- ynot oihikxI uiil 
AanJcakWiil. I^Mlly. Itoth tm\m b«ing hrlil 
Mil b*ek, the flexor tfwlocw Brv (iDixilhly 
SnimA silb » vinytc ••n^of iho kuifp. TliD 
lifa BM* '- '■' 'sht ■orumirly tugi-thir in 
fcrnrd. ■! [1. 111. Fij:. iV lly ihi* 

t> H>iui^w.hiil |i>ng nntl 
1 linhl" f<«l<>U):li uu- 
II (-■ \.i\ .iif.iiiijy nti-vnl. ciir*- Itcing 
«i«B D€« ti> lurti tlw r-io- •'■' lh-1 kiiirc to iIm- 



I* k^|MitaU 

A* pain lint : 
TW famor Br< 

yffn^lwiiirM of 



«Mir 



■MiMiUy dirrdi-'l towiirtls 

I'lr yIrt/>, tlw 
■li'-r hy I'ul- 
' r iMicn- 
I <]> (niiii 
nKcriNflrii*. 
I ilih-, S4 th« 
[)i- will th« liMok 
r hHc ri-ixli'r iu 
IL 111 thi'Ullfr 
■ -'■■'■-( »(|tinrv 
i oir. ia 

iij II (t. iMfn- 

proon* aiiit Ifniiinnling nt ihv oUier. TIm- flop 
r\u^<i »• lar ■• ui within iintf tlDj^r'a lirrmllh nf the lran»v«rr« fulil 




f i(. II.— AoifuUUua at th* Willi 



Ii4 



SPECIAL AUPDTATly.VS. 



iu the [xtlin c^posite the Ueads of lti« nieucnrpiil Imiik*. The flap linvir 
beeii tnua marked out, in earefiilly raised fr»in the [mlm, und » modi' ut in 
g1u<)<:! (-vt^rytbinf; dtmu i» the flexor teiidoDN. Ttii.i i:> doiif wiilnxic 'lillioiiltj 
tit) tii« ridj^- (if tht iru])f):ii;m and llie book of llic! iiiicilDim iin- iinl uttt 
At ihi.s |ii>iiil, jjrt-at rnrv luu^'t W tnkcii to k<;i-|> llii- iiifzr- of tlii' kiiili* turi! 
towanU iIk- I><):i<», wliilu llriii Inu'tion in «!xi,Ttcf I nn tin' flikp. If lliio bi.i <)t)ii4>i 
it will uiiiidly U- found ihnl tin- niitrrinr itiiiiiilnr hg^nicnt mid iiiiiliiiii iiitvi' 
hnvo Itii'ii riUM-d iii llicr lluji. Wlii'ii tbo [mlmiir Diip bn» lu-icti ntiwd. n curvci 
iiiciniou i« miidi-. nvriM ihi: buck of thr vir'iH, willi itc oiivpxity don tmrdi 
voiiiici'tint: lin* [wii I'xm-niitiiii nf the pr^vioiin mci»i'Hi. mid mnrklDg out i 
flap nhiiiwl imp inch in Iifiigth. Thf wrist hdiig t'uxibly flexed, iho joint il 
now iJjM-mt]. und the h^amciit)) diviilcd. Thi- hniid i» tiiliiched now onlr bj 
the flexor trudon^ which mny be divided bv » single ttuecp of tlic knif!^' 
the piilmiir fliin being eiircfully held otit of tW mny. Tho palmar flap vjf 
be found iieiiiilly to cunliiin the inclian nnd uliinr nerves and the sufwrficia 

iialmnr nrob. with portions nf l.bo muflelee of the thumb and little fiufferi 
t is better t» cut the two nerven short, in order to pmvcnt their iniplit^tlQ 
in the cieutrix. 

The must common error in performioj; this operalioD, and one nhich mi 
bo cArofully guarded ngninBl. is commencing the incision t<>r the (laliiiiir Stif 
too much tou'iirds the pnltimr inspect of tlie wriitt. instead of sl4iriiii|; froail 
the apices of the styloid proeesscs. The base of the flap msv tliun l>e lell 
very thin and narrow. In the atler'trestiiit-nl, il is better to place ihusiumi 
BUpiualed on a pillow above the jMtient's head, m that it may drain hettec 
and the flap have less teudcucy to displscemviit. 

Amputation of the Forearm is not unfreiiuenlly n't|uired for disease 
injury of the wrist or IihijiI. In perforniiiii; thin o|ierHi:uu, ba loiiy a slumps 
should be left as poatible, so aa to fpve tlic pnti<-nt more? power over any 

urtiEii'inl limb thai may be Rtlt-d In 
it. Till- operation may be done by 
t^iial dnmtt and palmar da|M. In 
n muscular limb, i-acb (lap loimt b« 
wdl rimndt'd und ripuil in li'ugth to 
ibi- untenvptMii^rior dinnu'ler of the 
limb at the ]>i>iiit nt which the bone* 
arc snwn. u> the pnlmnr Hup r3|)e- 
cially bii* n great leiideney t'> re- 
tract. In am )iu lilting the right 
llirwirra. the Surgetin stands nhin-e 
the arm. so as to have hi* hft bund 
to iJie donuil Ihip, which be will liiive 
to rai*e by iliwection. The hund 
being pronnted. the incifion for the 
dorsal flap is conmicneed at the 
luilmar aspect of the radius, is car- 
ried forward for the necessary dis- 
tance parallel lo this bi>ne, and then 
aeroM the back of the arm in a 
sliijhlly curved line, until it reacbee 
tbe palmar asjiecl of the ulna ; it then pnssee along this until il reaches a 
ptnol opjioflite to that at wbieb it waa commenced, and the flap thus made is 
ai*6ecle<l liaek. Care muni be taken ibal this flap t» wide enough at its fi«e 
extremity; it should in fact bi- ii ri'dnnunliir flap with iu oumers rounded 
off. The paliuiir flap b uext made by Irniinfixioii < I-'ig. 45). As soon as it 
is rut, the Imkka are clean-d by a coii|ile of ."■weeps of ibe knife, and the 




Fit- U.-'AaipuUillan of lh« farMoii. Ti*as 
Riioo a( lh« Aattrhr Flap. 



AMI't'TATlON or TUB FORBARM. 



125 



mrmbraiH! JH iliviiUil; ilic bunnt are tiicii Hawii logpclier. The 

I cut long sud will \k TuuikI on ■^'iicli iiiili.' ul'thc pulniar Diip si ibe 

rtnl. lu upeming do tin- M\ ridv of \hc hiidy, tlip Surgeon Btaoda 

the nrtn, with hi^ ]i:l\ IiaiiiJ, ii» bvlbrv, to tlie llape, atid Ui« inmion ia 

ei>r«vl from thi; iiliinr r'niK. 

MB Uit- pnliunr flmp i* furinrtl bjr tnmnfixioD in aini>itUition of the f^rc- 
nVudvrablii inconvctiii'tior in uftcu wiiiwcd by the protrusion of itie 
|>f 1«i)tloD» ami mufctr* iiK'ludr'l in it. To ttvov\ this, both Qii\a nmy 
Bulr liy cultitig fr«tii Hittinut inuiirHs. It it ndvlsable to iiisktt llie 
dnp It litllr lon^'cr thnn thi- ]inltiinr. fo thnt tho line of the cicntrix 
HV &1II ttcll ■way from the end; of ihc l)(iu». Tho Dpcratiou niuy be ihti^ 
Mtimutrti (.Fig. 4^1. Tho iJur^gtKm, sUiiding so as to take the flupd in bia 
Itft h«n<i, nnd holdtog ibe «rm with \la dorsnl tiirface iipwnrds. enlent th^ 
ksifi? KI tbv palmar cage of thv b<iDc Airlli«sl fruDi hiin. He then mnrlc!) 
•Ma IUf> from ili* doroil surlat*. eipial in length to two-ttiirda uf (hi- aiiti-rn- 

Crinr diameier uf the limb ai the puini where it h iotemied In «iw iht 
I. The flap must be siiflieienily broad. «nd mimded nt its CDrnim. 
AiW rvisiiiff ibis. lakiiij,- only ib« akin aud fat, » Sap aimilar in ahai>f. but 
balf tbe leiii^b, may Ix.- ratjw) from the (laluiar iiumi« iu t\w tuinin war. 
This flap muf't l>e marked nut by drawing U>e kiute niid^r tbe limb whilv it 
* •<ill in (lie pninHied Mxiitiun, but ilie forv«rm muit he Hupiiiuted nhtir it 
r> I'-ing di^«tci«l up. Tbo knife ia n<>w firmly swept round tbu b»i)rn nt tht- 
ixl I'f itit-- un|£]« <)f the fiajm • Fi^. 46). .-to nit to dividt; thu muMcIc^ cireu- 




Flf. 411.— AmpaittUtn of tb« Poimrm by Bkla Vlapr. 

ii» poinL The toft iwrw urv noiv M Im: n^lractt-i) from tbc boPW 
M nf careful dinedioi), for n itiNtntiui^ of fmm thn^'<]iiarteraof kd 
tn iia** inrb, and the lioiws cicaiicil and Mun at ihin point. Thv Ritnit 
thnt th-' ti»ni9 riri- buiii-d in tb« niuMlcsi, and ov<-r all lii' the light i<kin 
from any lcii«i«u or Icndi-ncy to di^placi-mcnt. There will be 11 
™. : ; : >i|M-iiiiig fwr this exit of diechargrs, and, whi-u iK-ak-d, the rimtrix 
will bo w«dl to the palmar aspect of the bon™. and conscfpunlly frrc from 
urt'. It roar W found, in retracting the niuncUv from the bunif, i.bnt 
utrrior intcromnoas aiVry has been cut iu more than omt place. Tlu» 
I'y 4»iiH7 sninfl trouble in wcuring it. Great care should ihcrefbrr be taken 
In avoid tile accident, by keeping the edge of the knife con^tnntly tiirni:il 
lowanlB the p«rt lu be removed. If tbo median and ulnar nervei) are iieen 
to be cut somewhat long, they shoulil be pulled out with foreejHi, and ciit 



m^ 




126 



3PEC1AL AMHUTATIOSS. 



iliot-i. »') IIS Ik iivuiit, it' jKiwi)>li-, ili«^ir iuplioatiun in Iho cknlrix nvnr tt 
en<i iif I he Son p. 

Ampatation of the Am in mn^t readily jwriormcd by Intent! flHp« mad 
by Uuii.-><ixi<m IViiin lieliire hiirkwur'lv ; I he bone t8 then well dc«ptif l)y »l 
cnujilc (if xwrctH iif thr kiiirc, niiil 9uu'ti nci'^a. In cleurinif the ti^mv, cuv 
niuM be mlci'ii fairly to iliviili- till' miiHciilo-Hiiii-fll tiervo by a firm ^neepof thu 
knife niuiid ihe buck of ihe lioiii- r Kig. 47 ;. if the aiupuuiti«n be perrorimia 
in Cbnt juirt uf the arm wla-re this nnrvt^ winiln n)UD<l llie hiimeruB. Thf 




Fl(. 4T'— AmpuMtion of Ih* Arm. Clewing lb* Bon*. 

operalioii ix ulwi Ireaut'Utly |>erformeil by nntero-])oiiterior Hups. In Ihisl 
methui), tbe luitcrior Hap in miidf tu iiii-hi<)e tlie bii-epa nnd brachialis nnticiM,! 
itnit tbu pixtti-nor coninina (be ti-ic«|M. Tlie limcbinl artery and ibc mcdi>i»( 
nerve may bi' lefl iti i-Stbi-r tinp, uu nmr neein niiMit cotireiiieut to the opemtor, 
bui carr rniidl be Uiki-n tbiil tlu: itrU'rv h u»l pieroed during the transfixion. 
Il i* wtmclirneji ri-e<>tiiii)i-ii<l(-d ta (iiil tliu anu-ri»r flap longer Iban the pO0te-| 
rior. bill it if better, tut ii rub-, to iniike the tw<i IbipA of eciual ]«ngtb, as i 
puublen the opi-ralnr tn !>nvf ibe hone at the low«wt ptmible putnt. If tlK 
limb Ik verr nitiiriibir. ibe jninr nrculwr or the moililitid circular (pp. 62' 
and Wl) will cive ibr bisl ri--<n!t, 

Anputation at the Sbonlder-joint may be re^|uircd for injury of the ariu 
or fitr iii«-jiw iif the hiinii-riiit ; in tlie liri«I caw', it may Im- petfonned by 
triinifirion : in tlie oibi-r. liy putliiiff j'ltnn witkoul inwtnU. Hemorritaf!« 
<lunn)[ the operation niiisl be pnivenled by the iiiejinn lUsfribiid at jtai^^ 72. 

In »|N:rating br tmnffision, n \ons, narrow-blnd^sl kiiifL' xbintld W used. 
One awixliiDt niunt have charge of tlie liiiib ; another nhouM raise the tUp ; 
MImI a lhir<l mnKt follow ihit knife iu> it cutx behini) the hiinierua, aix) gra«|> 
ibe inner flap with the axillary nrlery, i^o i\t to prevent bemorrbage from 
ihin v««H'l. An iiMistaiit boldinK the arm airiiy from the body, so jis lo relax 
ihe delt<iid, the knife, imtlcatl of being entered by a piincltire, sboiibl make 



I 




AMPDTATIOS AT THE SHOL' LDE R ■ JOl KT. 



127 



tanill cot, about »o inch in ezteut, to the point at which transfixioD is to 
btsadcK as to prevent that jagging of the integuments by the heel nf the 
iiUniBkfiit which would otherwise occur. If the operation be on the right 
sif.lhe Sui^eoD stands before the patient, anil the poiat of the kuife should 
bt MWred midway between the acromion and the coracoid process ( Fig. 48) ; 
udbtiDi; carried direcllv acroea the joint and cnpsule, should pa.K» out well 
behind the acromion, and about an inch below the spine of the scajiula. If 
ifl tW I'jl Mde, the Surgeon t-tands behind, and the point of ihc knife must 
tvcuirrvil well behind the acromion below the epine of the ^capuhi, at the 
[Ncttrior border of the axilla, carried across the anterior najHict of the joint, 
iLil b^>lll;ht out on the outer side of the coracoid process. In either case, 
iDt lir^re Map containing the deltoid muscle must then be cut by a sweep of 
•ir lu)i& downwards, and raised by t]ie assistant. The heel of the kniie is 
vw li) be laid on the head of the bone, the capsule of the joint cut across, 
ud lb* attachments of the muscles to the tuberosities divided. In order to 
filiate thi« part of the operation, it is geueraliy recommendcti that the 




Kif, 1^. — AiupulAlii»n at rhe Shou^der-jiniit bj Traogfliinn. 

iru »h->uld be carried fiirciblv iMwards across lliu chrst. This miiv readily 
:•: d.-Of iu the di^wfcling-ro'ini, or in uctmil pnictice whuii the limb is ri'niovcd 
:t .ii*ra»e of the humerus, the bone l)eiuj: I'Uiire; but iti ihr case 'if coni- 
:uraui«^l fraclure of the humerus, with i-\liiisive hn'criition 'if soft [uirls. it 
it u«cl*«r to attempt this nianreuvre. In ii <'iisc of this kind, the head uud 
jpjK-r »-nd 'if the humerus being broken ull' I'roiii the slmft, thf lover-like 
acii'iU "f the bone cannot be put iu force, and it is .-o met inn's not such an 
•ii^y matter, a* might at first appear, to ili-tach the liciid from the ylenuid 
ctvitT. In onler to do this, I have, in cnsi-s of cnniiiiiiiuted Irncture of the 
humt-ruf, in which I was amputating at the sboulder-jniiit, liniiid it necc«- 
•«rr. after opening; the capsule, to seize bohl of tlie ii]>|>i'r IViii.'iiient. :ind to 



138 



Auvvrxriosa. 



(Irnw il fnrcililv ilnwiinnrde anil utilwitrHs by iiiBi-riing tb» fiti|r<'n hrti 
tltu tiMuI iiRil iKi> {jlcnukl cavity, iu order lo iliviitt Ui« ninelca iiii».-rtHl lan 
il. After till- head of tl>e bow luu 1>ei'ii (iirtiMl otii of the glwot'l oviiyj 
iIk' knife niUBt bo pawed over it, anil currif<l down fur a distance nf >I>muB 
ihr") ioL'liM close to the bone nt ita iiiuer ride i Fi|;. 49). Ilie Surgroii tbM 
cuts ucroas Ihe mA parU, »u lu ui form Uie ttiiiiT tla|i. While be u dotn| 
tbii, Ibe ttsblsnt to whom thii* |iurt i* enlrvMed, must follow Ihe knife wit 




Fix. tV— AatpoMitflD ■( lb* SkMlilM-i^pt, Opaninjt tb* CkptoK aad v^ltif 

\he Inac* Plap. 

Ids hlMld^ BM^llaK-fii'tnly th<' whnli- ihickix-M of tbi- inner Hap. su u 
■A4p^nM tM DMUrr Hrt>?ry, ami (hu* jirirveitt lh« occtirronrc of henxir- 
rluige (Fig. 50). Tliv Sur:gK«ifi thuiild not tini«h cutting the flap nntil lb» 
aamsUot telb him that ho holiU lin- vtwd Knnly, and then he nitut bo 
raulious Dot to injure hi« nffttliuil'fl liiij;cre. Tlit artery nill (w Ibund to bo 
cut loiiK in the nitddio of the inner tliiti, iind ii few Hnntkr bmachoi maT 
require to be tied at it« timer nagU; and in the deltoid. The &tuni|k after it 
U hmletl will mwent the apDeantnee »liuwn in Fi);> ^2. 

L'ulew the tleltoiil u well uevclopcd and well covcnil by aiibcu(ane<iaii Ku. 
it is tinually (nip(«dible to make a flap HiRIcieotlv wide lo form an elSctimt 
covering br transfixion in ihiM way. and it niuHt tfi«n be rmised by diMM-ctlon, 
Tlw lino »t tlio ind^iun iltruujfh ibe akin o>rrei<]>»nils exactly witli that just 
il«acrib«H). In o|>eraliii){ ou the ri^bt aido. tlii^ Siir^tNin, Maodiotf IkjIow tlM 
aboulder, ){m>pa the iirm ami earned it sli){htly <iver tho trunlt : he ibm 
flOtunwDom hi* iociiion well tiehind tho arfmnun, and u almrt dialnm-r' belnw 
lb<i Kpine of the soipula. orar the puatvrior f'dd of the nxilU. mrryiog k 
do1llltra^l« to the Irvel of thv iiiscrUoo of the deltoid, and upwards la 



rOTATluK AT TBK anoCrLI>Klt>JOINT. 



129 



fatal* littl««rsi»fii*l ta thfconcniA procaa. He tlius fnlloire tlie ordiiinry 
ndbitf nttiBe frum but left hviid lo bis right. On Ihr lott eiiJc tUo dirLClinii 
rflli iMMiaa i* » w i— d. Th« ddtoid being (li»«>.-<.'trvl up. ihi? joiiit is ujwtied 
ol A* igavr lU{i mt in tW usual war. The ileltoid tliip may tie rni#«<l l>r 
■■■ t^ • aburl kiiifr, elinulil i1m> upentor prel«f it: a Itnieid biAtourv ■• 
90f MsnalaBL It tuuit lie L-bmn),-cd for n loiij; ftniputalin;; ktiifi* afier l)i« 
MM ii wftwrA. Tbii RicthiHl i>f upi-nittu); t>> apeciallv ftiJaptL-d to cwm of 
«■». ud mntv paiiJctilarly of tumiir of ilic Itunicrue, by which the wj)l 
fWan rtTM^bnl «iid ibinned. I havo in lliiH way eBsily perfurmi-d aiufxi- 
HMHtfaaabouMer-joini r»r Inr-.-^ tumurs of tlic uead of the huioenu. 

AMdHlioD by MiUM |i<»[eri»r Ila|i8, ur Lbfkanc's Rtothml, <lilf«n •ome- 
*te u«*i the uur-nUrm diwcnlicd above. Il u tbuD perfortued : If it li tbe 
MwwUmI iili)bf rciDDvca), the Hur)c«^D gTU»p« ibeUmb lu umr the elbow 

■ p Mi M i. umI corri^v it outwiir-U iiourly t» a rixlit nui;le witb the trunk. 
S* ika immru tb« kniff iinrociliaiidv iit front uf tbe {)oH«rior fold Df ih« 
«lfli,aad [I— JBg it upwitrds, m thitt it cmmiw the nuck nf the hunK-nis at 
i> yNuiw —nwt. iminvditttcly brilnvr the brad, h« inski!* Uie pniut rniPT^ 
JHWHinr lu tt»i- gi^riinit'iti. Tho knife u thvii hrougbt ■>iit in turh n wny 

■ I>cMk Bcatly Toiindod (Inp Kome foar inchtw ur more la ioneth from lh« 
fmi tm MpKt' iif ttif limb, Tha Arm is theo oriNMtl over llie bixly, ih« 




), anij tb« upnmtltNi finHhwl in tbe •niup way a* ibat [in-vio<i«)y 

la oja-ntini; ■•» th*> rigtil Mde the Intnitfiiion n miula frvai im- 

in frt.tii iif tlir vmnitun to llic pc»lerii>r iKmlcr of th« ftxilliu 

-ration run !)»■ iMTfuom-"! mtiti-d it to 
iiiiiii iif ('hli>r'i(i>i'ni, It Ii-nvrv llir «csr, 
iiiKii thai) whi-ii a purr iti'liDJd llnp i> nti!>L-<l. 
' 'il MrthotL — In vAf*-* til which, fhmt llie 
ltU# ri«, tbv tBBBipulaiinas iHTi-'naNiry fitranipulalion by tmvdxion 




ISO 



SrXOIAL AHPfTATIOXS. 



MPS EoipoMible. tltc metliMl nrifiinally tuvciiicil b}' Litrrcy, ur •oitw tn< 
lloit i>r(t, lutint ho ailoMcH. Lsri«y cboinwuced hb oix-niiion l>y u i . _ 
iiK^uiuu <luw» (o (Im> iNinc, alxiul iito im-b» iii )i?»|:ili. o'nimitiriD^- im 
(lialHy Ih'Iok llic lurtmiion tirrK'CW. Frojn ihv ciid uCtliw he tnnilr n our 
ii«-i»i<iii nil vMrli Mtic, rvnclimtc In the eiJrrvKiwDilinjE full) of Uiv axilln. Th 
Iwo llii|i* lliiii fonnnl uirix- iliiwcrt«i) u|>. uikI the hmi) uf ihi* honi' HiNirlH^a 
Ist)^!. TIk- knife wuh then imnMil iiili-rDallv to lliv hcnil nf ihr Ihhii', an 
cxrrivil (I<iwnnnril* whik' nii HWiii<tniit fdllnutii it niih tiiii liaiKb lu contpm 
th« ftxillnrr »rU-Ty. lUf <>|M-tnll>>ii mi* <-i<iii[ili-lr(l hv diviiiinu the ibmn t 
ibe ftsilla.lHtnivii Ihf vtHU of tho two curvtd incuion* pn>A'iou*ly ninde ' 
ils bitrdcrK. 

The tiMMt ini|»>t1iiiit mo li tint lion of tlii" nn-lh'Ml » thnt ol Six-nw, « hiiA 
(pvcinlly mdapli-'l l<ir piiiifluX wtmntU »f I)h- iif']i't i-iiil of tti«- hiiiDt-rn*. I 
CodshU ill nrrying tho vcrlictil iiirinion furlht'f fm-wnnU. imil o'lnnK-nt-i 
it juBt exteroil lo and below ihr tip I'f the ci>ni(Hiitl pruci-Mi. n» in c>eiai< 
of the »ho<il<]er'jnint. The iiieision oufilit lu expow the U-t»iloii vf th« ti 
beul of ibe bic«p« lyinj> parallel to it. This rony hv turiiMl on one >idv, 
the joint opeiied anil exHiniiieil: and if from th«st«t« of the fmtU it b* 




rig. SI— AMpuutloB ■( ftbomliUr b; 6|«iK*'i UMai, 

eotiaidered Decenary to ■niiHiiaiv. ihe opcniUon is coniplein) by inaking i 
oral incbioD tlirotiKb ibe skin fr»ni the end of tiio urijtinal ml, taking ' 
tuA In ipi so d(«[ily ou tbe inner aide tt» to wound iIm) veneb. Tliv oat 
flap is then ilinecied up, »o as to enable tJ>o f^utveon to ^et h'ls knife inieniaJ 
to Ibe bead of the Ixxm-, between it and Ibe axillBry artery (Vig. al ■ 
anbtant Tillovig tli<- kiiifv Kilh hia lianda. nuil Rra«|iii ibtr v(mmIi. a: 
operation it fiuiiibot tiy dividing; ihe tiMtu-a left uncut at the inner M 




KCICI.TS or AUrUTATIONS IN UPI'KK LIUB. 



181 



blUiMudxif upcfltlinfT riuHi U<tattt blmH nuiy bvMvcil by MvuriitK 
FttiWHilicai in lira tint part uCtW oiHTAiioii Uforv opening tli«' joint and 
■ la lb* dlrni'in (■fllx' li*«u<i> nt tlir inm-r tidv oflbf arm. 
! KHsltaof AmpnUdoni of the TTpper Limb. — Atn{>ulBii<)n^ of lli« 
r*sii*M>ilT. f\^a t->r irijurv. otf I'xin'iiu'ly tiit'i->wlul. Iti tlit^ Crinieu, 
mfmui-n»at ihv lt>n«nn *vtr iAini in llic ntio I'f 'i, ami (hoat' uf ib« arm 
rfitiftf wnt. Mas Scbodc. w)i» \»i* pnllri-tnl itip sltitif lira of the openu 
iMiMa tha »Mlisal tvports of nil tW chiet'Htir* fincc lliv |)«nt.-e of ISIS, 
(IM iW fallowing mulu for ainpuuti<Ki# n{ the fomrni : primary, 1034, 
«ii )Wd>altu>, or it.7 pL-r mot.: intcrmvdintc. 464, nrilh HR) dtatlis, or 24 
H( f»! ^'^.ixlari , 'ii'2. wiib Oi d^ntlis. or "23.6 ptr ccnl. ; time not atated, 
n'. ■ < atK». 'ir 34, )< [ler f<ent. 

TV .. .. al [L IMI, in ibe la«t cbaptor, girM a iDortalttf of 34.4 per cent. 
Ic aB)rautii<tM f»r injury uf itie upjier ami, aD<l of 10.5 \ter cent, for 
of ibr fiinarm. At (iut'b lli«{>)lal, Bryant atsica tliai ani|iuia- 



I W injarr t>( tbt- furrarm were fatal iu the ratio of Iti, aii'l iIkisv of (h« 
_,, If am "f "£2 \irt txni. At I'uivoreiiy Colli'j;*. in Limod's and uiv pruo 
piM*f !• aioputationft for injury of iW uyipvr arm. tbere w«r<.> 5 iWlbtt; 
I nf ft in «b^ii dii' fomuBi waa renwTed, all recoTcred. 'ni« chum of 
tek «aa Lb atoat ca>n jiyKBiia, erraipelu, or teptincmia. 

^■piialliiM flf ibv forearm and arm for dtii«a>e, more jnirlioularlv for 
mmm» aftctioMi of liw bonra and Joint*, an- very RicnMful oficrations: 
«bs tfc«y an ttooe for mali^nnt divoM, tbe risk in gr«-nUT. In tUe tabic 
JKMJt n S r rn 6 lo. tli« mnrlnlity atU-r amputation »f ibc ntm fi>r discnM- is 
Sfar'naL, ftad of Uw fnrcorm lA.t* prr rvnt. 
Hal 8ek(4a ftr«a In hi* tabic* tlit ri-iult i>f n wllfc-lion of thi- casM ro- 
kaviajf btvfi opcraK^I on in largt^ hoopilnU for the lircuty yeare 
lo lljM). TlMry nrp an folluw*: Bn)|wtati»n of th« arm fur injury, 
B, ^C$4 dtmUi?, tiT 31 prr c«di. ; for di»car«, 441 caset, 81 death*, or 

-" -»"•!» al tbe elUiwjoini Cir injury, 23 cases, G death*, 

«>' .'*«. K cases, I death, i>r IS.o per cent. AnijMitatina 

<iir ii>mn». i.>t" r»«», 14;1 dfatliK i-r 10.8 per W'nl. ; for diseaae, 606 

orat. 6S 4mlfc>, or i'2.'2 per crni. Ainputatiirn at the wrist for injury, 199 

VBM^ i daMW, or i^ |ier rent. : fur tllaeasi^. 27 ra*ni. dtatlia. 

^■^ItrioB M Um aboulderjoint for injury. althouKh iiecrwnrily tnurv 

^teal. m xrrt watvtmM fi'r n> ftctrrf n proci'durtr. [» 4b rvoortled cmtn in 

practice, ibcre ittn ^0 d«ittii>, i>r 5&6 prr ctnt., nhile of 907 cawa in 

r MMOTy, SM, Of 4'<.4 for (vnt., die<l. In the FrvDrb armv in the 

_ , af SS2 CW. 1^ dicil, i-r tll.T per cent. ; while in tbi- Kiigluh army 

fcriac tW hum* aar, ibv inonaliiy «na only Zft ]nT itdI., ami in ibi' unr of 

tla iMifiian rvbellinn. il «a* 'i'J.'i per nnt. Al Univcnilv (.ollrgv Ho»- 

fitti. I bar* doe* Um operalioii nx liiiH-* wiib onr falal rccuri. When this 

ifMstion }in>rc»fiital,ue))aiit-ni u*ually »ink* from «x hauri ton, or ia carried 

^by eryiiwhu iir gangtcui' uf ibr «lum|>. 

Aaiv-'*'' '« al ttw abiJuMet-jtHnl fur dtM-nM> uf U>p hameriis is a very aae- 

fv, cooMd^ring lli« nu- of the part rcnwr«.>d and ila proximity 

■ talilr* aboir the fiilloirinj; nMiilts: ampaiation at lh« 

'j'liiii in civil practiii! fur di)H-RM>, 188 cases, 33 diMlbs, or 28 per 

§ur iajnrr, !f74 m»r«, lit! deaths, or 42.3 ]>er crnt. In militarr 

n priawrr, ■%'( <«ir», H'i drvllit. ur '24 per cent. ; intermediaie, liO 

1^ AV dMiba. it 46^ per n-nl. : MH-xodarT. 14(1 i-asiti. .'Vlt dealhs, or 42.1 

»f. nut aUUol.K.'il ■■>■<«, llliltrnl[iH,i>r 0.5.1 percent. Tb« verv 

d' ajMWXM iKme in »bii'h tbi' time itf oucration is not stalnl, 

a frvw ib» fiHi Unl all tb« Praucb uprmtiani during the Crimean War 



132 



SPKCIAL AMPUTATIONS. 




Vig. 9S.^^tUm|i ttUr Ainpul^ 

Udq Bt Ib< 8bou1d*r^tilo(. 



ooiae etitiroly in thitt chwf. itnd the morratitv amoogst all the Frencb 
wounded during ilint cnin|inigii irae cxcei'liounlly (fmat. If these are at 
eluded, tin- ilir«tlirnic in only '14 per oeni. The combiued results of Sod! 
Volkiuunii, Miix St'hiNlc, aud Buseli, of caaea treated \>y tlie anliMB 

oratliod.filiiiw ivaidta miich more favorabl« il 
those above k*vcu. Excluding dodbli^ at 
tationa, caaeawilli fatal iimirivs di»tiiirl 
that for irbicli tli« opemtixii wiw pviTor 
caaea opented on t'w x[iKa(liiig gaiiitruii;, pj 
u^inia, or septi<!wniia, thu rolluniiii; ivhuIik 
iibtaiiiud: i^hoiildvr-joiat. Tor injury, ■] en 
1 doatb (ithiiek In r»iir)i<uin<); dtu-ai'i.', 't en 
di^ath*; urni, for injury, '2U cnw*, dvntlw; 
for duMaw;, 12 cnau», death* ; liTmirm. fgr ii 
jury, 84 nisnt, dcntha ; Inr diHriiK'. Ti «-MMi,4 
ddnlhit. The rrnorU of BnntelHH-n, IIillroth( 
and BniiiH, publlttht^ hoforc tht invinitiuii 
lliv nnt!i-i-)>tic method, c^cludiiie, as before, i 
enmpliciUcd eiwrn, givo tlio fulToning reKiillsd 
Bhould«r-JoinU for injurr. 9 cawB. f* di'wlhs ; foR 
dieea«e, (J cnaes, 3 deathf ; arm, for injury, '29 
caaeB, 6 deaths ; for dlsease.lt> ea§es, U denths; 
forearm, for injury, 20 cases, 1 death ; lor di*-^ 
(lase:, 32 eases and 'i deaths. 

AMHi^TATiossorTBBFoot, — The PhalkngMj 
of the Toea !>eld»m require amputation : wue 
tliey do, they may be removed in llie same waj 
as tlie correBpon<lin)^ jwrui of lh« hand — by the lormutiuo of a Sap »n lh«J 
plantar surfaec, t-itlier by eiiltini; ffDiii ubuvi- d'lWMwiirdi. or by tranalixioD.j 

In reniDvint; u hone at tho Hetatano-pfaatangeal Articulation, ihe ov 
method shouM iilwur* be ]iniittt«<-d. mo ihut ili« sole of the foot may uot be^ 
out inui. In doing thi* it must be n-iiKMilxfred ihat the iirticiilatioo a situ- 
ated eonstderahly above the weh of th« invn. nnd ilie inmion must therefore 
he oommenoed proportionntelv far biiekwardii (Fi^. •'^I- A* a general ruk, 
it will l>e tuunit that lb* nrticuliition i» abnul the sariii: <liAtuuce above the 
web lu. Ih«! p'lint of the toe is Itelow it. Anollier guide tn the joluta U 
obinini-d by dntwine n line straight acruw ihe fmit from the melatMrm- 
phalnnf^ml joint of llic great toe, whieb enn iiKiiiilIy be eleurlv Ml. 

In nraioviag any of the Ihnn^ midilh* li<cj^ ihixu' im enen Mdn niiist be 
foreibly aeparated, and at the tnm>- thw lli-x. li .^« mmh iw ptitwihle bv {<tecea 
of bnndagc passed mund th< iu ri . i i ! .n to !»■ held unide 

aalitliietonly by the fingers oi in iL;>i:[iiiL i i ■ iriil.ic flexion i>f the 
tkoighborlng toea readers the artictilation more euperliciul aud gn^atly laeiU- 
tat«W the operation. 

Ampatation of the Orent Toe is froqueotlr retjuired for iojnry and for 
dMlructioD of the nietalarso-phalanR«l joint by exleniion of indanimntion 
into it from a suppurating buoion. In siieh easefi the heoi) of the metaUirMl 
boDo should Dover be removed if it ean p<.iwib]y be eavcd, lu it forms Uie 
anterior extremity of the areh of the foot on the inner side, and its loss tt^ndu 
to cause the foot to lum outwards. It is a common error in this 0|>cration 
to leave an ioiufficiont covering for the lieail of the hone, the great siso of 
which should always be borne in mind. To avuid this the opernlion nhwdtl 
Iw performed by the rackeil-shaped incision, the oral part of which nhotdd 
not oomneaoe till the knife has reached the middle of tlie proximal phalanx, 
aud should p«K, on the inner «de, uver the line of the articulation between 



ANATOMICAL QUIDES IK THE FOOT. 



188 



iW two phaluign. This amount of coveriog vill not be found more than 
■ffinmt. In operationa for injury it is not BiwayB possible to save ao much, 
kai til should be preserved that can be. 

iMtoaieal Onidu in the Foot. — In operating on the foot beyond the 
rsatbI of Ecparate toe», certain anatomical guiding poicts must be kept in 
■ind. Ktme of vhich are usually perceptible even in caaes of disease. Oppo- 
mt ibe ankle-joint are the two malleoli. The tips of these, it must be 
RtHtabered, are not opposite each other, the external being the lower and 




Fig- S"- — Incipiim &nj Po^ilioTi of Joint in Aui]tutatiuD of a. Ton. 



(■flrri T. *■> that wIr-ii, in :^ynir> operniioii, or in Pirogoft 's, the direclion is 
^•jitO I., cut fnim ihv li]i of llie outer mftllenhis to tliu forres ponding point 
•1. ihr othtr .'iiU'. it iiiirnus to n point a Utile Loliind luid below the inner 

Tb- ntxl [i->int of ini[)ortiincc on iht iniior side is tlio tubercle of the 

•^f'li'M. whii'h I'uriuj! a rounded pnmiinHici' iilmnl hiilf an inch in width. 

Iif i.'jiliri^r Ix-rdt-r correspinds to the urtituliiiinn lieini'CN the scaphoid 

u i :t.t- ht-.id of till' u.^irugnmi^ itud it:- nniorior to (liiii bt-lnccn the scitplioid 

u-i iK<- ini-'rn:il cuneiform. The inlcmiil (.'uiii-ilijnii is iiboul one iucli ill 

i'--T.i.. ?••. :it lliiil distance from the jinlerior edge <it' the lubercle nt' the 

harri'i'l. will K' f>'Unil the articulation between the cuneitorrn and the nieta- 

•^r-ai U.of- i-f the ^Tiut lue. immeiliutely in front of wliicli i:- the Mcll-niiirked 

itttt-r.!.; ai the h:L>e of thiu bone. C>n the outer side. Ixdow umi a little in 

fr c: if th*- t-stcrnal inulloidus, ii^ the outer tubercle of tlic oj^ culcis, which 

i- .i:.-ii but indi-tinci!y frit. About the uiiiidlc <jf the fool l!u- tubercle at 

!I^ irti.— - •'( tin- liltli meliUnrtfitl boue form* a very iniirki^ii proniiiience. Mid- 

»»v b.-[wetn the biiM-of tlic tifih tiicluiiirsiil bouentid tin- ti|i i>f the external 

nj.ilr'di* i.- ,-itniitcil ilu- articiihition iK'livecn tlic cuboid und i>s ciilcis ; and 

li.* [-ini U ■Siicilv op|H>site the tubercle of the iicuphoid -m tlie inner side. 

Tb-- XetAtanal Bone of the Great Toe occasiimally ropjires removal in 
• ii'.;^ •■r in part. Tlie whole of the bone nuiv he reiiilily ri-move<l bv one of 
im'- mrili'-l-: 1. bv tin- llap ; 'J, bv an oval nmputiition. 

1. The fltip Ampiitntioii \s done as follows: The point of a strong, broad 
biriourr ii^ cntereii on the <l<>njum of the foot over the interepace between the 



1S4 



SPECIAL AMrUTATlOyft. 



first and aecood raeuUirMl l>i>fi«i, ao far back u (mwlblo : it U ihrn 
forwards, ii|>ou tbeballofilM'^'rent loo, tiinivitntopMotll^ilDtlio tK-hbrli 
the tuee, anil ibence mn4le to «itik into lli« miIv "f tlic foot in n lino |ninill*i3 
to tlio oiiliT itiar/iii of the boDi! ; iIk' 1I)I|i (liu* fnrranl U iliiw«i-l4<>l back, tl* ' 

glnoinr ns[K-«'t b.-iu)^ kept u* lliifk iiml fli']0)r m poMablt- ' Kii*. 'tt'. Tlie 




!! ■ ■ 

n 



Tig. tl,— AB|iuUti«* a( tb* ar«at Tot aiKl iU llM»lanftl Bur* kf aa Intaraal I 

And cuts directly fornnnb iliruuich tUc ctrutreoftbe aii;;le bflnreu thrignmt 
Kod tbo MOoud low. Id d-tiii); tnU, viirv murt l>« uknii tbnt ibo «d^ iatb» 
IcniliD ii> not dirMl«d tiw much tiiwArdu th<> tiii-tNtHnal Ixiuo uf th« prriit 
Int it bitch H^iaM ODc of tbu ticiuiiuoiil bitDcu. Th« .Surgouu nrxt tv'iK* 
txtniiiiity of the toe. mhI, pulline it well luwnrdii, pMOMthv |><niit if 
biaboury iltivplr into th« aiiglr »f ibi; wuuinl i Fig. ,VI), ubi'rc, bv tbr divisiiM 
of aomit t«uilin<iu> and lignoK-ntoun fibnv that I'onsiitiiii' the krr of tho 
joiDt, hu ii|>nn« tbc iirticulatioii. and d'Hiuihoi lh« boni' by lii;hily toucbiog 
Its liEanteiitouii atiHi-hm<iito. Ry ki-^ping th4> Mg« of ib<.' knife wcti ogai&at 
the ndv of the b[>nc. be may avoid woundin;; the d'lntnl arlvry "f the foot, 
lb* blading fr<tni wbich would b<^ truub]p»>ine, Wbca ibo Unue iit to bs 
partially retaored, the o|i«riili»n tnu«t be p-.-f<>rint<l in the same way: tbe 
tudsioaa. however, noi buini! i-arried «o fnr luek wnrd«. 

2. In AmptUnlwn by the Ocil Mathad, the point of the bitl-mry U oiii.-red 
uD ilie dor»uni »( i)k- font, jri«i behind the tanwl end ><f Ibo bono. An 
incuion ii carried up to the digitui iDier4pnr«, and i« niftik- M circle manA 
the bate of the fintt pbnianx, »<t ns to join the flrM liou uf incision »n iba 
tiDmini (Kijz. So >, uikinji cart- not to iMrami:nc<c the oval {wri too won. 
•oft rtruclnm ou ibu inner Mde nro then dtwocled down, the knifr \ma\ 
kept ctoM to the bone. Thi' inatn procoN U ciirrind i>n ni the »utiT liilr. 
bWte biunj; made ui «wvep undor the bjne from wilhoat inwanl. and Hot 
JMni oiH-niil IU d<-«i?ribed in ihi- llnp tiiie ration. 

Tilt* procH* ha* th<' lulvantaj^e uf leavio); the tiole iininiurttl. It ha* tbi- 
diimlvunta^'v of fnvurin^ an accumulittion of pu* at tbc dwper (lart of Ihr 
wuiind. 

Tliv oiioration may be iirtiilly fadlilAtol, and lh« teitdenty toaivumula- 
tiiin iif ili"-bnrK>'* iliminiiilii'd. bv o>mm<'ndng the innnion at tbc liilr of iW 



fuul immvdiiit^lr Ix'biiid lb<' tii(i<.*r<Mitv nt tbr baw of ihr mditUraal ltuii> 



1 




AUrUTATION OF THE LITTLE TOE. 



185 



<ae inch in front of the tuberosity of the ecaphoid. It ie then carried 
uwdi the dorsum of the foot, following the hue of the articulation ; on 
mefaing the dorsnni, it ia curved sharply round into the line of the meta- 
ttml bone, and the operation finished aa just de3cril)e<l. 

3. If the disease be limited to the anterior part, the shaft of the bone 
ienii be cut acroes with a pair of bone-nipperg, and its base left. 




Tit- Si.— AmputBtion of tbe UrMt Toa bj Ibe Orkl Method. 



lit Vctatanal Boa« of tlic Little Toe may conveniently be removed by 
u onl incision, so aa to avoid wounding the sole of the foot. This is best 
tlvnebr entering the point of the knife just behind the tubercle of the bone, 
(vrring it forwarda and inwards in the line of its articulation with the 
mbiiid, to the centre of the fourth digital interspace, and thence forwards to 
tfce wb of the toe ; the Itnife ia next carried round the plantar surface of 
Ait. the incision l)eing continued obliquely into that which has been made 
'* ihe il-irsum nf the timt (Fig. "i'li. The sinnll Hap thus ti>rmed is didsected 




r>f J* — ATD)>atili"Ii iiftbt Lidic Toe end iln MelsUr.'al Iliinp liv the KnFL^cI-vtrnpcil lncla<Dn. 

■•■11 il-iwn. ihf knifi' jia-'weil rmjnil ihe uiiilor miirfiiL'i' <it' the l)rini\ lukI the 
_i i;!!! .i|"-n'-il by ihf ti»- bein;; forcibly driiwn iiiitwiirils. iin,! iin !ii;:ii[iL'iiti)US 
ci.uii-.'.'iii'iir liirhlly divided. 

Til-' niiddlv mH!il!ir.s:il bniif.J. whfn di-icii^ii'il, du nut iidiiiit nt' wparaie 
r>-iii'>v»l. ••■ su- to li'iivc :i I'oiit lliiit would bi' iisi'fol to )i patii'iil. 



186 



SPKCIAL AKPUTATIOXa. 



Amputation of the HetatanuB.— 'Wlwn ilu- mriatanui and nntcri^r ; 



of lllf I'oiit liri: iIl-u 



ll:«'il HI' 111)11 



ri-il Ml M tu rciiiiirv ntnuva), tlir miaiiul 



may Ih: <<t1rt-l(Nl b^ imr uf lwi> ni>'lliixt)i, vU., 1. By niiikiii)f a lliip truni tli* 
«ole mill n tniit*vi-n^ mcUioo iicniH* tliv ilunium, ami tbi-ii sawing arniu tlw 
raetiiianou iia n whuU* nbuvi- iW K-nl ot iDJury or ilitouo ; or, 2. ay diMrlicu- 
laiiiig Ihi; iiiclalanuti fruiit tbt* lar»ua. 

Tho lin>t »|HTatii.iD — that i>f Mwing ihrotigh ihv nu^ntaraiw^M tnmptinm 
eallod Linrrani-'ti: but io reality it was pracliMvl aiitl dvacribcd by IIct long 
brfori' lj\rfmac'» than. Ity '* Hi-y'e Anijiulatiun " i* uniallj niMnt tfit- <\n- 
arti«ulBii<iii i>f tliv iDoiataniB Irum th« liinii». iind (be fonuation of a Aap 
fruiii tlir unti-riur part of the solo of tlu- font. Hut Ilt-y dtacribc* Ihn^ 
iliir<.Ti-ui Bii>|>uiali<iu», oiily on^ of which formtKindc lo lhi« Divtlnxl. In 
hid " I'lvi-tJciil OlHrvrvBtioM*," lAimbxi, IK14. n. TiSU, he nvH. " I bav4> ju<lgi-<l 
it tn bf H Mt'cr nii-thiii:! tu take nirnv nil tno diwaiietl iDtegunii-tita lir a 
transvcrvc nnil » liMigiluilinal iuciiiion iitiidc at righl anjjlce to t-ach otltcr, 
and Ihpn lo uw <i(f the iii«tatareal bones as far aa tlia morbid inti-{piti)i.-nt« 
Bxtendod." 

At p. '>5ii, be sBTs that in opciatiDjf on a gM nbout la. a melbod sagf^cd 
ittolfto liiin " of nDisbinj; the operation, which proi-etl hi^hljr Bdva!itiiae«iM 
to ihi- jMiiii'ul. Ilaviujt (liHwcted out i)i« mi-Iutarsal bunca and mnovi-d ibf 
tora by s iraniiverbe iuciiiioD made at their junction with tbo metatanal 
buueH. I ek-vated th« ialeEtinienis aud muwlctt fonninj; th« sole of ike foot," 
eU:. This «|Knitiiii was done in the pntr 17!)7. 

In tli«year I7H9, p. •'iM, he maiotbut be operated nsfnlluwi: "I n-toovnl 
al) the too at their lUDLtion with tbu mctatanuil Imiiios, and thra se^airatnl 
the ioiCKUtnruia aini idu!>cI<9. formitiK ibr iu<lc of tbi- f><nt, fniiu ihc lufrrior 
IKirl of the RH'taiarMil )m>4ii-:<, koppiii/ uif rdc*' of my •mliicl tu urnr ihr bunnt 

at I iiiuld 1 ibf'H ^trpnnilcd with tlw ifcal^x-l thr four iinallrr mrta- 

taivnl boiH-e iit their junction with tho lareuf, which wim ra»ly rfl^c(<«l. as 
tbp jottil> lie in a ulrait-ht line ncrcm the foot. The projecting )>art of iba 
(irvt cuneiform bone which RipimrU the great [oe, I irasobligml tudiride 
with a xnw." 

Tbu? it would uppctkr thai in the first cose licy mueH arrtHu iho luetntar^ut 
bones utt^'r linving miide itn' flitp. In the Eecoad eaw, be ili*4ttifd out nil tbo 
tnetiUaml bonea. and then made a tlap froto the #ule. In ihc ihiril cai^, hv 
tini rniui^ tbe fole-tlnp, soil then, having <lis*tHttl ovl th<? fuor rtuailor 
metatanal boacs. mikaI ucro«8 tbe internal cuueiform; thus contbiain^ ibe 
tvo ntelbods of cutting and Bawiog. 

In order to avoid any poasibility of error, it is better to discard lh« tenus 
Hers and I.iifrnnc's operation, and to dewribe thew operations as "ainpu- 
talfou thri>U)fb the luetniar^ut," aud the "Inno-meiatarMil aioputaliun." 

ITie wittAe ojthf MetaUimu may be removed from the tursus by the opera- 
lion '>rif;iiuilly phuitiiil and executed by Iley. lliis consists in Unit uf all 
making, in the »»lv of the I'noi, n curved Jiicinion rtacbinn tu tl>c rootd of tlic 
IMV, oO'' horn of which conirueoces nl tbe tulirrcle of tbe Itllb loetatar^al 
boDC. whilut thv otltcr ti'rniiitnir? al ihiit of the fitxt. or •^a" iach iu front of 
tlie tubercle of tbe sca)>huid. The tinp thu* markinl i>ut is <-nn<ful1y rniwd, 
taltio|{ ikin and fat only lor the tint inch, iind iilVr ihnt nil the soft [uirts 
di'Wii to ihi- Iwne. On the left 'ide, the dira'ction iifihe inci^iiin t* revviwl. 
A - I' i( then nia'Ii> on the ilonaum of the fovt, and ihi' nrlicuUtiuos 

an , i ThcKC luurt then be o]>i-nfl with ^ini" mr--, ob ilny nre yvTj 
Im-jpiior ^Fi;.^ ''i" : ; the HCi>ud mctatnrwil lwm>-. . king ftink into 

a kind of iiil Ik-Iwith the iumr snd outer ciitieii i > ^, and lh« articu- 

lation of the lifth, with tlw ciihoid. bciii); very oblii|uc. The line uf the 
nrticiilulioii in l>e^ fotind by forcing downwardx (lit* noterior part nf tbe fiHit. 



AMPUTATIOX OT THE METATARSUS. 



137 



■hilt the point of the knife U drawn acroea the line of the joints. As each 
vivDcbed, it will gape sligbtlr, but they are prevented from opening fully 
br tbe rery :»trung interosseous ligament which passes between the outer side 
■i ibt iDieroal cuneiform and the base of the second metatarsal bone. This 
(U bt divided only by forcing tbe knife upwards between the two bones, 
ukingcare while no doing not to wound the ba:<e of the eole-fiap with the 
pouL Aa soon as this ligament is divided, the whole line of joinU readily 




'j r. — 1:, LTti* 'if ll(^■-. or Tnrso- 
SFU'.ir**!. .\:i.f<utM[i-'n. A. hint "t 




Fig. JJ', — Cbi'mirl'n Oj-eralion, Fliip furiucci 



:ftats..|-n, and di.-arliciilaii'in U pprfurnu-tl Miilmiit l'urili(.r difficultv. This 
[•-fa;i- II i^ -tMi'iii [inicti.til, disoa>t' bdnj; riirflv lirniiiil in the nifliitiirs'iil 
■• r.— . Uit ii-Lially iniiilii.'iiiinf: ihc jiiintj^ us «<11. Tln'ii- ilisniiiciiiiilion from 
;.'■.•■ tan-u' i.-. iiiMrr..ver, very innililfMrnic, mi iUToiirii nl' lliv irri'^:iiiiirily nf 
li.- .ill- ■•i arlinilatiou ; luiu-c. il is bfltcr tu s;nv iliiuii^'li IJir iiu'liitarsiis 
;-:*t .11 ir.-iit ■ifihv Iiir-iil iirlii'iiliitii.n^, tluui to iLtnrri[ii m liisj.iiril ilii' binn's, 
A I .ni'-inaii-.n ••f iIh'M' [ivn |iri)wi]uri'S iiiuv ^liiintiiiii ^ In- iidvjiiitiij.'eniisly 
X i' ;.!■■ 1. In ^•■VI■■r:ll ••!' tliii-c sfvirc prii.-lii'S ••i' tlir ;imiri'ir ]);irt dI' liic I'l-iil. 
ii.:i: ar>- in-i iiiifriiiiii nily liic rfsult nt' Iriiiii-ciii' nr rail«!iy iiijiirv. ami iu 
« r.i- Il ibt- lf->m-> am) si.ft part.-^ are irrcj-iiliirly cru.-lii'd ainl turn, 1 liiivc iiinile 



12S 



rXTIONS. 



ilruw it rorciblr <luwninir(U uvri ouiwiiniii hv iii»rniDg the fiajcen brt«rrr»l 
tlw head uod the ((luiiuiil civil}', in ordiT Ui dividr Um; raii«cli9 iiiH-rml iiiutj 
il. Arti>r (Ik- bead or (Jto Uim- hu> \>wa tunMil mil »( Ihtp gl«Doid miviit,] 
the kiiifo muxL be piiMcd over it. and carrlt^l di'wn for n diitauce uf a>>uut i 
ihrw inclMiM clmw to (lie Sonu iit it* iiiinT ridf i Fig. 49). Tliv Siirxi-oii tbiM 
nils acroat thv Kill juirbt, wi iw Ut form the inner (\m\t. Wtiilf bi,- u dtiioK 
ihn. thi^ ikwiiiUiit !■> whim this part » vnlnisted, riiiiHt rtillow tti« ktiife wlta 




ric. 19.— Aii}iuUUai at Utm 8h-»iil«r-t«lnL 0|Halaf tk* Ch^bI^ ud luaklsf 
IW In»tr FT*|>. 

hl» liank, unupttiK firmly the whole thickii«aB of tiu< tniter llii|t, xt «• 
oompriM t£« BxilluM' iirierr, mud ibufl prvveui the nrcurrvoif uf hrinar 
rbagv (I^ig- '^)' "Hie HurgcoD should out finah riitiint; thu Haji unlit th(> 
Utfsunt trIU biai tbvt be huldn thf vtaael firuily, nnd (lirti bp niiut Iw 
CHuli'Mis iiol Ut injun; hb iusidtAiil'» tiup-n. Thv artiry will lie T'luiid to ba 
cut I'Jiig in th" middli- uf the inner flati. nnd n few nmiilliT brniiHns uuit 
iv<iuir« lo hi- tifd nt iu iunt-r sngle, Bntl in tJiv deltoid. Tbf ktuniji sfU'r it J 
IB fn-nlnl will iir<e>i>ut the ti|ii>ciinnve tliown in Fi;;. o2. " 

l'aln« tlic di'tluid i* ncti developed Kod Will i-ovrrv^l \iy «ul>c(il»iici>ua ftt, 
il u uaually im)Hig>*ibU' to miiko » Clap nufficiviitlv widt- I" f»rni lui rffimnt , 
cuvi'Hn^ hy irnDnllvioD in lhi» niiy. ami it uiiiol tbra be nuwl bv difMvlioti.j 
Tlu) li»« (if Uii- iuciiioD thmatcb thv xliiu citrnvpond* rxacUy with tlittt jit^j 
d)»crllH<l. In opvntiug od tlii' ri)(ht f>i<I«, th<- }Siirg<x>a. (tandioe brtow th« J 
ibould^r, ^riupt tiie arm and (.-nrrii-e it slijibtlx uver ihv trunk: Im> thl^aJ 
oonimviicc* hi* inci«ion <rfll bi'hinil tlx* acmtDinh, and a almrt di«(Mi<.« bclowl 
th« •piat of ll»c «cti]>iilit, near the |>u«torior I'-Jd uf lh« nxtlU, carrying it] 
(lowH«u<li to tbu Ivvcl of tho iiMrriion of the ilvltoid, nod upwvrtU loA 



»i«AmTicrt.ATio!( or thr root at axklk-joint. 189 

fRwil> In thr niut (if ibe totv, aoroaa tW •uie, mmI (Iowo lli« ioiMir si>lo to 
hkiBd iW tubrrrk af ihf cra|ihoid (Fin. 50, n ■. This Hup should be Ri«t]« 
t«(, nptciAliy fti ihr iunrr ai'lir. but well muiidi-il ni ili« bukIm, and •lioiild 
MHirt of tba whole thiokiKW of lii« parts in the sole of ili« foot, which must 
W ■•II JiMarfiJ oui fram the euocBvitjr utitler the inelntareni booea. But 
■ tUdraa mad y- < > ' h; in whom Ow fixit i? itnirti \innt aud the tami* 
Itia. tb* rt*|> BMiJ i.idi- no l<iii|;- T)t« nuli^-tlnp hiivtn;; be«D nievd, 

iflar- ' -tMi w wwiv t-v(-r ihi'diiri'iini I'runi one hiini tu the o<herof lb* 

flu:. lb» put* *n' wvll nnrai-ti'il, mid tho aTticulaiiotiA opened by 

lb* fiwiywi baannit firmly u(H'ii itiv atiliTt'-r |iatt »r ll>e tixit. au'l li|*blly 
IwnMag tW lifunMtuu* ■trucium tiiib ilio luiiit of hi» bint'iun-. In this 
Mg* oftliv upmibia, CMV miwl Iw Uki-n Ibm ibo<-<l^- of ilio bifrtoury be 
Ml iadiMd liio niudt iMckwanit. Im it slip over ihr ttittru)tiilut> ami »[>e» 
iba Mikh^jtiflit ; or ii>" for forKitnlf. Iwt it jkii" ntili-rinr to tin- wujtlvoid — 



ii anil ttii' > iirK'iform botti-». Alter di*aTliculali<iii bii* Im-cii pro- 
), th < lui of tbf astragalus iind the arlicular surfiin' of rli« 

m r»ia» ■ —^u off. In tiKire than one int>taiirr, I bavi- I'otiiid lirm 

•■KMi B 'liitiiig in the line of nrlietilntioDv. rojiiiriiig lh« uw of 

iW c--"' ' i>anklti>n of lilt' anterior purl of the fixil. Wbt^n ibin oi>in- 

•Bb' I'I' lan-ii« iliiiuid be Irealeil hh a whole, a»i) twwu throii|ih. 

UiW^iiiiK' 'II ■-iriiciilnlioM, bcbiud tite liiuils of the dtsease. The runilt of 
lUi upaTBliiKi U cxtrrcitelv brornlile, llie jMlieiil. by tb« aid of n nroin-rly 
Winj; alile tu wiillt, and ereu dau'cw. wilb vcr^- littk- ap> 
•■m. Iti Slime con*, where the niuoclea of the calf are very 
the btv! )>miiiMai dmnn ii|i. ami tbe end of the stump is inndr to 
: 4w«a ID such D way that (he |uuipiit U ivudired lame by nalkin); on 
ib« a*mfor«liarp eiljfCof the calmiii'iini. which irriintes ilie Ibtp. Venietiil 
tttattm Ifcal b« ba« ntw>rv«<i] in a nuuiU-r of cnn^ tbui the hiil u dntnn up 
■alj u anputatiuu- Tor diMnn, iikI ilint it oceiin rmlly Iwforc the oiwru- 
tiia and out attrr, H« bas nanv noticed it in n priniarv aniputalioa. This 
OMMiUiod I* bnt rinx.vrd by division of the tendn Achil^i*. 

Tht >>tiri«tii>n» jiut docribed arv ndapteil to cases €if dliwaoe, a* it i* 
inpoftaoi t>nt Ui intvti a jari of thenflecied bones Itchiud, nud ihetr rrnwval 
i» nada more outaiu by op«rnlinK ibroush tbe Hum of the nrliculattoua. 
la sapataliiuttt for injury, hnwover. ii has neen recomatendcil by Mayor, of 
laMiiHi, asd nib4T«, to treat the foot as a whole, ij^oring artinilaliniML 
Ob tili* pUa, a tuffideoi coverini; is turned up. encroachiu); on the foot M 
Httl* ai tb« BKiure of tbe injury will allow. When sufficient corcriiig has 
W— wlMaiiKd, tbe M« is applied lu ilie tnniM or nwlaiaruis, lu the ca»o may 
b*. i«rin( M taaeb of r TIk'Tv is no douUl that excellent 

fMolu Kf« obtabml bi ■. half inch »f the foot that can be 

tat<^ MidiBir to it> uliltty. 

?j«irtiw«» ibc «iact liniitu of the injarv aro dilfieult to ascertain nitli ac- 
gafcy Jiwadialaly aftrr ll '. fn Mi-h caiH-anuy looM-or al)Mluie]y 

oaalwd ftltt**Mtta oiar I-- ind llw foot filac^'il for a i(uarier of an 

Iwar tB a batb of 1 in j - acid lotion. It may tbm lv> dre><te>i anti- 

woiiei'li. Ill I l)i' j: I. di'l'iTri'il till ibr <'\iu-t liiiiila i>f ihe injury 

ll)i« lin<r of jiraelioe wna followed in two caaes 
I IlivpiljtI. In ime. llir fi«>l, which tevDHM] al 
.[ilriely nxotfcmi : in the other il also reoovered, 

. ' >;teat tue, which «ns anipulatvd nl ibo and <if the 

^^ 

'' . of tkt Foot at th* AnUe-joiBt wax 6nt rr«lneed to a 

!■! Symi-- By iu [irrforniiince amputation of thr It's may 
iltr latUnl brinj; lell with a» cxcvwliugly uMfuI Mamp, 



9PB0IAL AMIM 

ulion. itu u to RvoM. if pgKiibIc, Xhnr imjtiicntinii ia the cioalrix nnr tkl 
ttnrl of I he boDf. 

AmpntatioR of the Ann ia m<»l n-mlilv |H-rl'><rni(«l l>y Intrml lln|>* 
by Imiixlixiiiii l'r<>m liuliiri' UiickunnJi; lli« boiic u ibrn well (-)rnml 1>r i 
Ctniplv of MWMua of ihr kuifc, biii) nnnn acrnm. In cUmriiii; llio Ixiuir, cftra 
m«M IN-Uiht'ti mirly tii<)iv!ilf tU<- tiiUK(iili»-»i>iniI imrvp liyn firm rwppptif ih* 
knifp rirtiti'l Ihu lini'k "I" llw Ihiih.- i Fi;:, ^l :, if llu- »i»|>iiiMtion br pa-rfurntMlJ 
in tluit intt <»f till- nnn vi]u-rv thi# iirrvi- wiiiilf rotind ihr huntont^ TlwJ 




Tlf. IT.— AMpntMlM vf lb« Atui. Clatrikg tha Bona, 

aiwrmtaii is «]»> lrrau«ntly [>«rfbriii«) by ant«ro-poel«rinr flaje. lu thMJ 
niFltiod, iW anteriur Imp U maAe t» iiirliiH« th^ bi(7«[i6 nntl bnii'liittii» nnlimt^ ' 
Will the |io»ti>rii>r NfituiDS clic lrire)«. The Umcliiiil nrlery and Uic inediMiJ 
itcrveinay he luA in either flap, ai may iftrni miMiiinvt'iiioiit to ilw oponitor,| 
bui mm must br utkeD llial the artery h not i>ior>.i.-'l durini: iti« trauBfiston.] 
It ii» siMiietimc* rF«i>iiiiii«nile(l t» cut the anterior lla|) Iimgvr than tlw (xMi^-j 
rior, hilt it ii brtUT. lu a mle, to luakv thi< ino flaps of mitial kii^'ih. a* iU 
vnut>l*i» the iijM'nitnr to huW the b(>ue at th« lowut poeoihk- p'Miil. If lha| 
iJRib Im vorr niiMcuIar, the purv eiri-iilnr or th« mxliSed circular i,pp. < 
anil Ml) wit) eivo the best rtnult. 

Amputation at the Shoulder-joint may be r<?i)uirod fi>r injury <if the 
ur for •Uhiisi- of ilii- liiirtii'i'iu ; in ihi' Ant nut', it itiay Im' p<'rft>rmiit 
tr9$t^lnoH: in thi' iitbiT. by evtliny from tcilkout invarxU. Ili-ntiirrhi 
<turin|{ the op<>niti<>ii niud W ptrvnili^l by the mean* th'M'nlH'*) at {<«(:<' I'i. 

lu Kpentiit^ by IrMuffiiwn, a bititf, iiarrow-blmle>i knifr ■h'liibl Iw u*e<L 
Oni' awjutniil miiit linvc charge nf the liiiih; another •houbl raiv the flfepj 
ODi) n thinl inuot fulbiw thv knife ai it vittm hi'hiriil lh*> hiinn-rus, anil ftuf 
ih* inner llap with the axillary artrry, w a* tn pn-n-nt Iwuturrba^ fniml 
thl> VMKftl. An narirtnnt holding the arm away from the hmly, nn tuto rtlax 
tliv Jdtoii), the knife. in»t<ia>l of lieitig I'Uli're*! by ■ jiiiucturv. flhonbl niak*. 



J 



AMPCTATION AT THE S H OL'LUE B • JOIKT. 



127 



i-irall out. ftbout an inch in extent, tu the point at whieh trauHtixion is to 
i* m*Je. voaato prevent that jagging of the integuments by the heel wf the 
utttmment which would otherwise oecur. It' the operation be on the right 
-tftr.tbe Surgeon standi before the patient, and the point of the knife should 
if niten^ midway between the acromion and the coracoid process ( Fig. 4ftl ; 
laJ brioj; carried directlv acrosB the joint and capt-tite, should past) out uell 
bthiwl the acromion, and about an inch below the spine of the scapula. If 
.« tl>r l-jt fiile. the Sur^ou stands behind, and the jwiut of the knife must 
Ircoirreil well behind the acromion below the spine of the scnpuhi, at the 
t-i>(rrii>r border of the axilla, carried across the anterior os|>ect of the joint, 
u>l bri'U^ht out on the outer fide of the eiiracoid process. In either cnsu, 
ibr briK (lap containing the deltoid muscle must then be cut by a sweep of 
'.if knife downwards, and raised by the assistant. The heel of the knife is 
o-'* I" he laid on the head of the bone, the capsule of the joint cut across, 
u-1 thf attachments of the muscles to the tuberosities diviilc<l. In order to 
tkcilitite thiF part of (he operation, it is geuerally recommended that the 




Vi£. C^AiiipiitHlii.n ftt ihp i^houlder.jp'idt b; TrADSflhiun. 



»r-.. rb'iuM Ik- i-arrivd liircibly inwards :ien>,-s llii: cbi'si. ThL* may readily 
.••■ di-oi- ill ibt- di.-»<'i*iiii;,'-room. cir iu uctuiil pruclice wbtti ibc limb is rciiiovrd 
: .r dL---a.-<' uf On- liumi-ruii. the bone bein^r ciiiirc ; Imt in lb<' csise id' cuni- 
ai:n'Jt>-<l t'nicturL- of r\\<- humerus, with exicusive liu-friilioii iif soft pjirl.<, it 
» u-"'l<-<- to aitcmjit tbi:s mann^uvrf. Tu :t cn.'c id' this kind, the bead and 
■i'',' T •-lid of tbi- humi'ru:< lieing broken nil' frotii tliL' sJiafi, tbi' Jcvcr-iiki' 
a'li'in "f the bnne caiirml Ije put in force, and it is soiiietinics nm such :in 
-*»y maitt-r. a* might at hrst apjiear. to ddach llio head I'roru the {.'Jt'Odid 
Qiviiy. Ill itnler to do this, I have, in ciiei-s of cminiiiuutt'd I'rnclurf of the 
b.iiD--ru<, iu which I was amputating at ibc shoubler-joliit, fniiiid it ni-cce- 
Jttrv. aft'T opening ibc cajtsulc, to seize bold of the uppiT fragment, and to 



H2 



SPECIAL AHPl'TATIOSa. 



tioD liiH tw«n pcrfuriued as a primary operation for a criHh of lb« feuC 1b 
ont onte id oliich 1 had necuioii to pcrJomi il f<>ron«of theM iDJuriccmponl 
dcul of trouble r^uillwl rrom tlni vauM, lliou]()i erentually lh« cnw did per 
foctly well, nod the {witti^it now walks irith scarcely tutj difficulty. It has 
bci>» frMjgeDtly siatcil tlini it is necesaarr. En order lo insure thcr vitftllty of 
the Hup. tt> ml tho |Mvii'ri<>r lilitiil arten* "as l<'tiK <^^ (>casihl6," and it is tfits 
as inui-h n* anvlhiiiK ihml )■«■> li-d to ihi- tinxluction nf the hure cii|>-«lut|>cd 
ltu{M H'hich ari' h> ililBcidl li> diiau.'ol nit (lii' ■■ caici* nnd nliicli •■> owu 
sliiiifi'li. A i:«Trliil rxnmiiinlinii of tin- viix'ular supply of the llnp will nhuw 
ai oiici' llint llii> |Hi»iiTior (itiinl nrli-n' iiiHir Im' (*ui cluw l<> tlj<- linx- «f tbn 
fla)>, witlKMil ill lltv li-iwi iiiii-rfiTJii); will) llir clitcf rraselsaupplTin;^ iL Tli* 
(list ri but lull nf vmtcls to Ibe fmrt u >■ fulluwr: On tlto tiuKr aidr, th« 
pcmnml nrtain', nfti-r ^ving off ihc nnlcnxr pcronMl, h oiRtinuiil down 
alon^ the |>><»tfmr ii»|H'rt of tin- fibula lo th<' oittvr »ide of the o» calcEsu 
On thv inner oidc n brunch »>' ciiniidcmble •itr ariw« from the poatrrior 
tibial iirli.-ry. abixit one inch iiborc the an k I v- joint, and i>Mn«« down to tba 
iniivr fide of ihcixi c«lci>. ninnin); l>chim) the inner mallcoliis and acnrni- 
panyinK the imall cutnnouus nerve from the posterior tibial lo tbr skin wf 
ibv heel. There is thits a main trunk on each aide mnnin); down to the heel 
behind the nuilleolue, aud titese two coiuniunieate freely vilh eaeb other 
BUpcrfictally over tfie eulaDcine Burfnee of the tendu Acliillif, nnd deeply 
betlTMO tbc tendon and the lack of the ankle-joint; and they leriiiinnte by 
AOaatomminK uu^iu by lonj; vascular loops on the under surlace of (hi< |>>«- 
tatior pari uf the ui citleis. It b uimn thesr aniistomosinx loops that the 




Fig. «k— Sjas'i AnirHUUuB ol As IW. 8s>in| off ll» MsUmIL 



vitality of the Dap de)tet)i)K more tlina a|HKi nnythin); else : and ai they li* 
much iirarer the bone Umn the skin il is ovidrni tluit, unleaa the knift 
t>e kepi hard upon tho bone during the whole di>M-rtiv» of the tUti. Uwjr 
wilt be divided in large numbers, greatly endangering its vitality, in tba 



AHPDTATIUN AT THE SHOULDKR-JOINT. 



129 



piini a little Fxtemal tu thecoracoid process. He thus fotluwe the ordinary 
nilo'f t^ttin^ from hia left haod to his rif^ht. Od the leftside the direction 
'iihe ioHiioD ia rcveraed. The deltoid beiiiK dissected up, the joint isopeued 
u-i ihtr inner flap cut in the usual vay. The deltoid flap may be raiaed by 
Dniai itf a short knife, should the operator preler it ; a broad bistoury is 
Terr (NHiveni(-nt. It must be changed for a long amputating knife afler the 
ymt \i \^pont\l. This method nf operating is specially adapted to cases of 
i|)!tWF. und more particularly of tumor of the humerus, by vvhich the soft 
I«n* are stretched and thinned. I have in this way easily performed ampu- 
Ltii* ai the i<houlder-Juint for large tumors of the head of the humerus. 

A»)i>utaiinn by antern-iMSterior flaps, or Lisfranc's method, diflers some- 
■iiii I'r-m :he oi>oratioa described above. It is thus performed : If it is the 
'.ft irni that is to be removed, the Surgeon grasps the limb as near the elbow 
» l-^^ihle. and curries it outwards nearly to a right angle with the trunk. 
Ht irivn in^^rt^ the knife immediately in front of the posterior fold of the 
iii.!i. and {tasking it upwards, so that it crosses the neck of the humerus at 
i*^ i*i^tcrior as|>tci. immediately below the head, he makes the point emerge 
w: inttri'ir lu the ucrimiinn. The knife ia then brought out in such a way 
li '■• I'ui a Doally nxindeil flap some four inches or more in length from the 
■•-I'.-i'jr a#|x-ct "f the limb. The arm ia then crossed over tne body, the 




I ^. ' '. — Am]'U(a1i'-n ut Ibe ^boulder-joinl. IIi>].lLnic ^'e^^elB id (he Inner Kl.ip. 

;.: -j-'ii-d, and ihc itperaiion tinisiieil in the .■'ame way a,-' that pri'viiiusly 

:~ ri'K- i. In "ix-riiiin;; 'in the ri<rht nide tiie ir:iu.'ili.\iiin !:< iiiuiIl- Iruui iiii- 

^,— l;j:i.v in Irniit of ihe acromion to iht? posti-riiir li.inier of the axilla, 

Tr.* _T*-;i: r:i|itditv with which thi^ operation can In- pi'rlormed cuusi-d i[ to 

•»• .-.._';i;v ;ii-}pr.>i'iiiti'd U'fiiri' thi' iiivi'iiiiun nf chlnmliirni. It h'iivi':' ihf j^car, 

:. «' '.■ r. in :i iii<>ri.' oxjiniii'd siumlii'ii than tvht'ii a pnri' t!<'lti>lii ll:i|) is miser]. 

A.-'i'i'-ili'm -it ShoulitfT h'j Ofil Mfihiiil. — \t\ cjtsi'ti in ivhiili. from the 

•u:<- '.; :hf Imiio, the raanipulatiuns ne^t-ft'arv for umputiitiun bv iraustixion 

1-1 I.—'.' 



128 



aWpotatTossT 



draw it I'orciblv ilownwanl* ami uutwnrfU liv iDMnin^' x\w Sn^n tvlwiva 
tlio licnil nn<l lliv ^'lotmiil cuvily, in unler to ilivi4lir the mtiitclM iimTUil )iiii> i 
it. Af\er tlif )iv»il of il«' \umt Utto Imwd uira«] out of tho glenoid ovitj, 
tlio kuife mu*i be jnuM-d uvrr it. nm) cnnSod d'^wn Tor ■ disutniw of >bout ! 
thrm incho clow ft tlio banc nl iu iniM-r ii<li< ^ Pi){. 49). Tb« SurKi-on tbra 
GUU ocroM ibc toft {MuU. M M tu lonn the inur-r Hnp. Whil* lt« is doiu 
tilts, tlic umiUal lu wboni thi« part in itnlruRttut, inuxt fullun tb* knife witS 




FlC- 40.— A»|iuutl«k «t th« SbdulJw-jMDt. OpMlai tbi Otftot*. lad maklac 
Ih* Inoar Fhf . 

hb hauds, KTUptiiK firnily ihr wlioli- tliielciKiv of ihv inner flti|i, w> na to^ 
oompreai tn« axillurv urli>ry, sud thus |irrs~cnt tlic ocourrcncc of livoKif* 
rhngo (Pig. aO). Tlie 8urgron Bhotild not Rnish cutlint: tin- dap until the 
■uriituit tpjls liiiii that be h-iUU tlic vmsel 6rTiily, and then he inuat lit 
aiuU<Hi* Not tt) iiijun.' Wa a^binni's tin^>>.>rB. IIk- uncry inill be Ibund to b* 
lilt \»ug in thi! niiddli? uf the intiiT Hitp, and n few tuinllcr brandMi tmr 
requirfl to bo tied at its inner uiule, and in the deltiud. The itump after it ■ 
M h<^rd will itfwent iho agiiiearHtiM' oluiwn in Fig. -^2. V 

I'nkw* iIh- ucliuid u ni'll di.'vcl'<|iul and wi-ll <,'urerv<l bj suln-ntRfieoiu bl. 
It it utually ini(K»iibli,' w make n rta|> autIici(iailT wmIc Ui f»ro) an efficient _ 
cuvrring by Irnnilixion in ibi* uiiv. and it niiivl torn bn niued bv dLtM-t-iiuti. fl 
The lini; ul tliu in<;i>inu throngli iW nkiu CuTn.«>(M>Rdii exactly niih that ju>l ^ 
duscribod. Id •^[teratin^ on the ri^lit fidr, tlio Sufgeon, NlamliDa Itclow the 
■bouldor. gwf* tlM- nrni nnd cnrrim it flijcbll; over tbv tninK: Ik then 
oomnwDec* hi* ibcinioii w<-ll lii-liii>d thi- •(roinioD. aad a ihorl diniaiKV below 
iIh' i>)iin«> '•{ Ihv Mnpula, arar ilic piMt^rior fidd of tlie axilla, carrTing il 
duHuanrdi bo tbo l«vcl uf ihu iitM-rUoii uf tin.* dvlluid. noct upwanli lo . 



1 



AMfOTATIltK AT THE snoULDKR-JOlXT. 



129 



pMM kOul* exlMtuil lu tkKoor«c>i<l proeea». He thus follows the unlioaty 
nAttf aiulay (roni hi« left hiin<I to his rif^it. On tbo left side the iliivciion 
if tkft utitintt br»v«n«i). Tbeikliutd bi>iiiKdi!»eeioilup, thejoiuii!>(i)>^itMl 
»i tiM mamr tUp cat in Uh.- iwuI way. The deltoid flap ntay bt- rai.iiil b^ 
WN» «f a tkort knifr, tluxild th« operator prefL-r it ; a hMnd biif lurr ■■ 
iwTMafcaiMiL It t»i»i W chan^'d {••t a Imix aiii|>uiKLinii ktiiTe ttier tb« 
jmt m ofiMMl. Tht« iiK-lhod or npvrnliti},- U ^iwrrially adu[tlt'il i» ouw of 
Ahn^ mm norp |MrtictiUrly of liiinor uf the humerus, by which tb« toft 
f«»H* «ivifhn| nii-l !hinni-d. I hnvo in lbi» wav eiuiily [x^rfuraMMi Kiiipu- 
MiM u t' r largo uimon of the ftaul of thf hiunera*. 

Amats^ i-rior tlapt, or Lc9Jriiiii>'ft mcthiHl, dif^n aotntt- 

flM nvM ttw apcrMion d«Krib«d abovr. It i« ihut> mrforiii«>d : If it i« the 
Mkm Um ku>be rvmorml, the Burgmm gnupi) thv linib t» near thfidbow 
m ^Miblr, Mxl CKfTtt* it oulHAivI* mwrly to a nshl niiglr with tbu tniDk. 
B* iWa inarrti ibe knife initiHilintelv in fruat of thv piwU'rior fold of the 
■dli, tmi pMaing it upwards, ao that it CTwm» the neck of Iho biinivrufi at 
Jb pMttfxtf aaiMpd. imiuediiilcly tx'jow thn head, he luakm the |>oint «merge 
j0LUiltntir lit ihp M-romimi. The knife if lh<-ii bnxight out in iucb a way 
■ Wntt • qcbUt riHiadeil flap •oidi< four iiichen »r mon: in length from the 
Mpvrt of ihr liiub. Ttio arm it then eruweil over the body, the 




•ifvonl, uul th« opvntjnn fiiiislu.>d in the souki way u that previoiuly 

In oppratinx un \he rijibl eide tltc ir&DHSsion is nuule from im- 

iljr in fnmi of tb*> a<.-romion to thv poeterior border of the axilla. 

rajiidUy with whirh ihia operation can be perfomtod cauaed it to 

illy api>n«{al«d bef-irc- tlic- invmliun of chl'>r>>fi<rm. It Imreatbvacar. 

r, (a a mon Mmaed •ituati'iii thnn wh^n a [Min- di-li<'ii| tinp k ratM^j. 

f»e*t J* JUtaMtr ftjt fhni MetKo'l.^ln ea»<« in wbiih. from lfa« 

:>e. til* manipulatiriiu n«v<ttiary for anip<iUition by trniufixion 




9PBCIAL AMPUTATIONS. 



doM aiA unrii )ia|>(H-ii ilnu tbi-rv ■■ diwMUn of tbc c«k-)iiiMin) to);vlher H^H 
Uk' autcnor nii^' uf InrHil liuDfo, witlimit th« iMnigfilut also bftn); involvwl 
Id cate* of carim of thu liir>U!> n-i)uiri»f|: nupuUiti'Ui, il occaBititinlly bait- ] 
pens that iIid Surgtou caimot dctvriniiH- wit)) wnniiity whiKber ili« niorbxl 
«oiidiUoii is lin)iu.tl to tbi^ iintrriiir ntiifrv of ureal boDc«. or exti-Dtlt fn far 
bttckwarde ag vmously U> iniplicHlv iIh' HctragtiluB simI cnlcaucum : nnd hv h 
CMMWiui^iitiy uunUU- itt iWiilc wlti'tbi-r lliv <-<itiiJiii<>ii of lti« fiM ■ilniiu nf 
removal bv C1ii>|>arrH opcriilitm, or miuirrs disikrlii-'iiliilioi) ut lliv aiiklivjiiini. 
In these circum^tanuT all i|[>u)>l will Wclfitri'il itnuy, aiiil iIk' iiriitvr ojim- 
tion performed, hj makiog ma incision ai-ro«s tlit- durcuni of the fi»l in thr 
line of till- ualntiralo«)a|>noi<l iind cnlcaiHHx.'ulK>id Brliridat»ati» ; thrf arr 
then opeiieit, uod tli« state of the booei is esamineil. If the BHtrmKalu* and 
calcaneuiu \k touud, or but elightly discaaed oii ilieir aiilenor ti*|>e<l. Oio 

Fiirt*» upcmliou may lie don«, and aiiy airiouH iHiiir U-fl Ixhind p>u>.i-'l nny. 
r. (ID tli« cunlrnrr. tlieae bona be found to lie dii-jily implii-nhd. ihr fUp 
may be diwecleil oaek for about au im-h. and tliMirliriiluli»n ut lb<' iiukl^ 
joint pmcewlcd wilb. It may also be uvlt in iH-ur in mind tlint tlie lanal 
arlieuUtionii may have bet'ome mi aukvlu!«d, n tlio rfunlt of »M diM-atr, a# 
t«> rvquirv the npplicfliiou uf the »aw, luieud of D)M-tiing or diviMoa «f th«ir , 
linuneni*. j 

seralta. — Tbe amputatiou of a t<», of n mvialarial binH>. or rren of a 
porttoD of the iacUiliin>u», in but wry avMoni iittrtidrd by fnial coowquenota. 
Would death occur, it muM be the nrsnit uf an a(^-i<Ientat attaek of tclanua, 
eryttipelae, or of |iywniin. DiMriiimhitiOD at the ankli'-Joini, tboU|;li necea- 
Mfily BonM-vhal iiton* (lanp;roU!>. ia ^et one of the niun Htit-(-«»f ful operationa j 
in SuigrrT. ihe tnortnliiv alK-iidinij it being biil very »i>hII, I 

The following are tlic li^urcK ipvm in )lnx i^hedeV Uiblw : I'arlial 
aiDputatiuuti of tW foot lor ii\)ury, in eivil prartiiTD, 'SJ^\ ciiMt, 4'i (U-atb*. i>r 
20.2 permnl. ; for iligeafle, SflS nmt, 70 dtatha, or rj.4 per cent. Inmilirary 
practice, ihe numbers arc (<3I eawa. vilh 388ur4tl.7 peroeul. of de«iiij ; but 
thi* fearl'ul mortulily ha<i been chiefly in the Frencb )i(«|iltab, IfthcM anJ 
excluded, ihere rvinain 4(>:i aun*, tviih 66 deaths, or 10 par ceoL 1 

Tb« iiliitii>lii'9< of uuonmplteated cawtt from tlw pnwUca of S>ein, Vulkmaitn. 
and Mas .S.'h<>t]e, under antneptjc treatnieiit, abow 65 cam. aiih 2 drallia. t 
in a Woman, a^l 77, and 1 n-aTn|>utatioo. ThcM of Bruii*, Itardflrhou. 
and Billroth, in the |>f\^anttMt(iiic |icri<id, iJioW 3 au«t.nilh Hi •ll'Bth)^ H 
of which were from pyaiimia. The hi);he»t ntnrinlity wan from I>iri>)n>ff'» 
operation, of whieh tncn nere 13 cum*, with A dratlia, -I Ihini pyinoia and 
I from I'ryiiipola*. 

AMn'TATiuic OKTiiK Lk>i laav be performed io tiiroM eiluaiiona: eitbrr 
juNt below the knM-, in the middle, or in the lower third of the limb. The 
aekotion of tW line of am|>ninlinu mtinl de|H-Dd in u prrat degr<v upon the 
extant of the diiN-nM- or injury, but. mIh'ucvit pmcticaUlr. the ojieratitici 
•hnuld be perlornied low down : tlui ntorlalily diminiibin): in priporiion a* 
the limb is removed ocar (o the ankle. Of KM am|-uiatio»« in thi- situatioci 
done in I*ari>, tbon waro only 13 deallu. Surgeooa uwd formerly, oven 
where the di maw or tojury waa limited to the foot, to amputate iniRM-diately 
below the knee, io all tboM* caM« in which the [mticnt would be obli(,'e<l ti> 
wear n eommcin wooden ptn, the loiij; le|;.#lump beint: highly inooaveoipnl 
when tlie patient rmtcd on hi* bmt knee ; wli<n'tu. in thitM.- imlividualn who 
eouM aflofd tite expenac of a Hrll-iM4t«truclc<i nrltficial limb, the ■mpnlNtiain, 
when jira^rlicnble. wiu i|<ine in th<- li>«rr itart ••( the lei;. But tliU iJitBcullv 
has been removed by the ininxluetion ol a »lMirl wo'hIcu pin, in the »»ckH 
of whtob the etump may b« DxmI in (he osteiidcd poaltion; and affl[futattua 




FLAP AMPUTATIOM OF THE LEG. 



147 



■ ill ftdmueible catm ahould cuDsequeotly, even amongBt the poorer claaaes, 
kd»Be u low down «b poesible. 

Tbe dumber of arteries divided will depeud up>D the situatioD of the 
upatitiun. Holdtu lays down aa a general rule in amputationa one inch 
Wlo» the bead of the fibula, one main artery only — the popliteal — is 
dirulcd. At two inches two arteriee, the anterior ana poeterior tibial, are 
(>L At three ioehra three arteriea, the peroneal, in addition to the tvo 
DbiiU. being dividet). 

nap Amputation of th« Lag bj Traniflzioa may be performed in the 
frllusin): way : The toumiciuet having been applied to the lower part of the 
Ihi^h, the .Surgeon etamU with his left hand tu the part to be removed, while 
At trcidiani. whuee duty it U to retract the flaps, takes bis stand in this, as 
ii ill amputatiuns of the lower citremities, opposite t« tbe Surgeon. In the 
M linib. the point of the knife is entered at the posterior edge of tbe tibia, 
anird forwanis for a dlstauee of one inch and a half to two inches, then 
mxw the aiiterinr part of the leg tu the posterior border of the fibula, up 
«hi<-h the inciifion is made to extend to a corresponding distance. In the 
rijkt leg the same incision commences on the fibular side of the limb, and 
tmninatN on the tibial. The flap thus formed, which should be broad 
IB'I well rounded, is next ditw^cted up by a few touches of the point of the 
knile. and transfixt<in of tbe limb is made by passing the blade across behind 
ik bi>iM*, from one angle <if the incision to the other (Fig. 70), taking care 




t -i, T>:— \di|'UIsiiuii .f tlir Riiihi l.r;;. Transfiiiim ■■f the I'mlerinr Flip. 

B^i I., (■a^s ill*- kniH' accidi'iiiiilly between ibf tuo bones instend of behind 
ili>ni. Tl»- iHipii'riiir llui> is ihcn fornifd liv eullinj: iil>li<|in;ly downwards 
itrd liai'kwiinl?'. Jiiid yliciuld bi- iilimit lliri'r ini'lii's loiiir. Tin- tinncs are nest 
i.<-ar''l by ix ili^ublc sweep of the kiiile. iind thv ititt-rnsseous soft part.-; divided 
' V .arrMDj; tin- iii^trmiKiii in a ii};iiri'-ot-« way l»'!«crii llii' Imnc.-i. In doing 
:hi». ipfHt'lal lari' uuii'l Ih' taktii nul In direct ihe vd^v upwards, so as to split 



SPBCIAL AVPUTATI0V3. 

fitlKr of tliv tiliinl urlcrin, niDrt- pnrticoliirlr the oDlcrior ; far. as lbi« ' 
rPtracu iihovr tin- im-iiiliriiiic. its lif^iiira, wliea dividei) luu hijcli. u im i 
iti«(l«r. ir tht.' iiiiiptilutioit Ik- jiurforDiefl jan lielovr ihe ktiiw, it u* punti 
ibat Uic iHipHlml tniDk tuny be tlividiKt b«lor« ib btflinjiitiuii, nod uos cr 
iinvrj otily nvjuiK ili« ligature. Id saw)U|{ the b'lOUR tlie fibula mital I 




P(g. Tl<— la^ataiiaaaf lb* Laf. Ba«taBtb« Bodm. 



dWldcd flnt, M r>i)ier«ti»c il may be fractured above \ho UtK of ninputMiMi, 
or, at nay rut«, f>o HpliiilenMt. Ii \a better lo a>intii«DC« sawiu); on the tibia 
Ull the fluff tuut eiilere<l a iiliort tlittaiKV. tlirii by fliiikioff tbe baud Im-Iow tli» 
bivel uf tbc limb ou tbi.' left liile. or raixiug it (m llie ri;;ht, tbe saw U bmiii^l 




?!(. Tt. — AMfiuuiioa at L(| by Tnl*'* llMbixl. 

to bear oa ibe fibiiln, wliicli i* citniplcliily dirickd before tbc tibia is I 
AHcr ihe tcmoval ttrtlx- limb, tbe 8har|i anlerior edge of iht> lihia nmr wt- 
Tailt«|;euuMly be slnxil otr iibliquely, so M tu \emtn Uk lilk uf t)liiu^biuj[ of 
the eorreK|>ODdin]' llai< (rum [irmsure Upon a sbaqi ridge of bonb 



J 



AUPt'TATION or TDK L80, 



149 



tflfc> lUib b« nnrtnuscular.n lar^ iwdriftlie muicletof cite ciilf will bo 
Miitb* p w te rioT Ibip: this will usunlly i*e n gmil ili-iil in iho nnv during 
IMCWOt; it najr aloUKfa, ■!»<) lliiu itit«rfure nilli |iri>jHrr iiniiu), tn H-iiiia 
iM« 1 tmt* «dnuilMm»Ml5 rrmav<^t nt die •wivp tin- jfn-itUT \mtt »f ibu 
— nil»f BMW ibo* l«ft, Wvinj; litlti- more lliiui ■ i>kiii-ilii|i. In iir<ler Ut 
timt ndvadaao* of nu«rl«, ihr ln^t iigNTwitna cunimto in forming alEiii- 
ift « t)w BBtorior UmJ putti-rior n«|wicU nf the limb. Kod Uivd niJtking ft 
■nkr m through ibe niUMicy. Ttiin muy Ik- dom- in viirioii* ititmu]- 
Mlsf lu ih« irfti of tliv Bm(muti«n itn<t ibc ninittinl of ekxa nvailnblr for 
tvlmMaiua of fljipa. 

._ uf tpiurr imnMKlitb'ly nbova tb* anklo. TmI«'« omrstion (Ftir. 

b» rtMilr prrC>nucil anxinlii)^ to (bv rult« laid down on ]>• Bl> 

vvr. tb« mil parU U- n'mrU^I Urun lb« Unxrx for n distancoof froia 

I b' an iDob kix) » bmlf or l«o inchoa ttbovc ihc an^to of ibc Hope, all 

lyfinta^Miif T«ml>>'ft Rirthod can h« obtained by mailing ah anterior flap 




Ckrtalkr Ditbtaa nf lb* llu*l«(. 



I in Itttj^lh li) lilt diatnvtrr of tliv llmli almoM rectaneular in shape, btit 
kitiat tbr *bkUs n'uu*lt-<l dlf. A rerv slii>rt [KMlurior Dap mar b« i-ui to 
MM ihia bj earryinic ibr knife U>biiiil tbr limb mhdcwIuiI obli(|iiely t'roin OM 
mJ af iW SrM inrialtnt ti< (hf ntbrr. Tlip aofl ruula are then retraotnl aiul 
^ huoa Mm M bijib •• puttllili-. As in Ttwiea mtrlbiH, the Bapa ili<xitd 
tmtmio all that oan b* taken frt<u) tbc Ixiuea, f<ir in tbii sitaatiuu thev arv 
■^Mwbai liabla 1h •l»ui;h. Li«lrr rvconiDUMb tbat Ibo inctaion eb»uld be 




160 



SrBCIAL AMI'tlTATIOKtt. 




I 



1 



carried, on the fibutar atd«, tu high lu iho point ai whicli iIm boM h to 
ht nwn, aa this jfrcatlj fMriliuiUv the eo|Mrntiiin of the toii puna, in unler 
to avoid utiiieoeaaar}' woundinc of (hi! anterior tibiul arl«ry, Teale reeo«a- 
mcHiln chat th« soft jutrU sliould W raised IVom the inl^roaMous nwmbnn* 
bjr the Auger or ihiimb uuil. 

In the middli^ nnd ujifnT thirds of ibc kir, tli« booes tie more lownnls lh« 
anirriiir n.i[)«t(.'t •■)' ihe limb, and coii^quvntTr it l» not n^cr w rv to |>r<ivi>)v m 
li>nt;an anler'nT llap luordorthat Ibcciculrix nuir ttpplacei) w«fl Ix-biiid llx-m. 
Ill ihiMr iiituttUoiu the Huierior Bap may tm tnoile c<iiiiil in It-n^'th in tn'>-[htnla 
of ihf diaincliir of tbf limb, iind the [Hwl<-ricir flai) 'iiu^half (Ik- li-nuib 'if ilr« 
iiDlvriur. Tbo iind-rior tlnp nbould oooaiK, at iln lower edge, of nkin iind fat 
only, but it lOioiild Ih- i;rii<liiallr dtepoMd a> it i« raUvn, till nt it* Imh- it 
canlnins iilmiint all llic mticelr ihiil rati W obtnini'd from itir fruni of tin- limb 
(Fig. 73). Iti dtMCcting up tbc pcftterior Hup. lli^ limb *)ioiild bv raiMil to 
Umt tbc Hur:gn>D cui nivre coDTrnivntlv mw nhat he i« doing. It xhoulil 
conUin only skin and flit. Both flap« m-ing hehl well out «f the wnv, the 
muBcIcs are noir divi<)ed oirntliirly, ami the miO pnria rairod fnmi tlx- Wnra 
for a dictaDce of from one und » half to two inches. In doinc thi», can 
mUBt be taken not again to nnnnd the anterior tibial nrterr. Finally, tli* 
booM are c)e«Ofid and wiwn ne high ai p>«aible. The »luirp |M<int uf 
lhi> tibia mast be rounded off In doing ibis it is well earefnlly to raiae tb« 
perioat«uni with a knife or twrin^tenl e]erntnr before applying' the raw or 
none-forcepe, as by so doing llie lenilency to neeroflia is someuhal diniinishnl, 
the perMdteuiD not being tom awity to n higher puint thuu that at vbicb iba 
bone ta actually Mwn. 

if from any cauae there tili'mld nut be suRieieiit akin avuilubie to form tlw 
long anterior flap, the eircnlar operation or tlio inodilieatinn of tl nrom- 
mended by Lislou. na doeritK-il on p. W.I, muy be eniphjjrii iti^-iir'ai) (atf Fi|;. M 
23, P. 91). All lh<ae operations have the ;,'real iiilvantagi.' ••{' ;:i'ilitig rid ofl 
tbe nMT5 moas of the muscles of the ealf, and that by ihr lnoe anfrtor ilnp 
socnrva in addition that the eli^tris i>hall Ix- u<dl Iirliind the cut cniLt of tbe 
boiKS, and thai thi*re »)iall W a ili-jiendvDt oj>ening for the eiit of tbe di^ 
ebarge*. The long antiTtor flfl|i ten<U to kiTp itaoTf in prvilion by iu own 
weight, and no rtrapping u rojnin-d uf in the aniputatinu br the long tuatt- 
rior Bap, and thuu a gn-at oourt* of iiain to th" |wti<-Dt anil of disturuanw 
to the «tump » avordnl. The temfiiiey to protni^ion of lti« bone h alao 
tnuch In*, a> tli<' weight of the Aap in hardly mflieieHt to chum^ uloemtioB, 
if tlx- end of the tibia hna Ixi'ii rarrfully rounded, 

Reanlta. — Amputation uf the leg i*, ii|>on the whole, a Eucci-mful o]tera- 
tion. Tbe n»orUUty, h>kwever, varies not only accirdiny to the situation at 
which the limb it removed, hut alco aci-ording as it IS doue for iojun' or dia- 
eikte, and ibe nature of ibnt diM'ii>e. tyt far as Htuation w e->M<'cn>i.'d, it 
autf be stated, as a general nile, that the nearer tW knee tlw ^reatcir if tlie 
ilaneer. 

In an>p<ilal)on of tbc leg l>-r injury, the rate uf mortality ia, Itpon tba 
wli'de. rather hii;b. In th<- Crimen, ^7 jier <'enl. of tli*' rases were loaL Tlw 
table at p. lOOflhon* an averiige mortality in civil jiractiiN'of -Itf.I ivr (i-nt.; 
tlic death-rate, however, vnrir* gn-ally in the rer-'nls of different ii>i*pilal«. 
Tbus,nt the I-^linburgli and (ilaff!<>w Inlirmuries, and (iuv's lli<«pital, in an 
nirgr^pile of 'i24 cases, there were IIH denlb»: while in '-^i ntm-t incmntrj 
h<«pitaU. the number of d4-ath» Ka» 111. nnd in <•*• eaM« at Si. ltaithidonte« a 
Hi«pilnl. there vfro '20 drulh&. .Vl I'tiivertily t'ollegp liiMpiinl, ibr nKir> 
laliiy hat been ''11.8 iMf cent. ScroiMtnry anipuialiuD ii more f»la\ |Ihui< 
priniarv; the dcalhH from thefoniicr, ai-otnliog to the table at ]•. Ill, U-ing 
4S. and from the latter, 4:t.!l jM-r ceiiL Alter ain|>Mlatii>n of the h^ for dW 



I 

1 



I 



AMruTATlOX TIIHOUaO TIIK KlflCk-JOINT. 



161 



■a, ib« B»o«taliu b auch HOMiller; nmouniinK. oa m calcuUtioD bated on 

'^•1 -«»f->, to 'ja.ri |>M real. Tl>e ctiief causes of death aw i>7»tnM, gUi- 

'.tu •tiiDip. simI rxbaustioo. 

Tkc ttaikHM* eol)««trd rmm publulted ha«pilal nporU bj Max 8cheda 

turn ||» dllawiair nwitw: lJp|)«r or middle tfiird, fur injtirr, KIO omw, 54 

Of r ' - ; for ilidL-aae, 178 caw«,44 deatbn, ur '24.7 iMrcenL; 

lliii- ~t imMV. .'{ ili-atht, or 9.1 per M-nL; fi)r dUnwae, I'JS 

1^ •IvaUm. "( U U prr ffnl.: jmrt of leg not UtiUnd tar injurv, 19oti 

• Vi df-kth*. or 4U.U pot n'M.; fnr iIUmuo, 1695 ouea, 2I.> di'utha, or 

■I. Id niiltlnrr jinictic. itiv Krwtcit Mniiitiioi *lii>w ii inorinlity 

ot79.^ urr tvut. K\du<lin|; Fn-jich cwc*. »ilu-r intlilnrv n'fturU 

■ MOtlalilT ul :t.'<.l [H-r O'dI. in primnry nrnpiitaliiMi*, I'tXt |M*r (■■.•ill. in 

'. mkI 41t.i in n-cuntlarT. lu ihi; vunt. in wliifh thr time i« not 

;eU»4r frim ihc Antoricaii ("ivil War. ihr iiKirtaliir wm only 'iii.6 

Thr (•ombinnl rv«ull* i>f Btincb, Max Schulf, i^lcin, and Volk- 

fma OM** ln-n(nl nntis<-plit-ally. excluding nil thaw coiiipltuilvd by 

iajancaorgnviidivMuM-, arvufollDVFF — IW injury. 19 c»m«. nodcnUia; 

30 caM». 1 il««tli from <!ry«i^-lk%. to vrbicb the patient win liable, 

Ito Dbtn— - ' <'-- BartlelvliAR, Biltr»tb, aod BniQ», nilhnut atttii^i-ptic 

all >d casee alfo bclii^' excluded, wcro — for injury. '28 

l&dtNlhr, i" if'ini pTwinia. anil '2 from Kptii'ieinia ; for diaeaw, 97 

SSdnUha, 111 frwm pyiemia. 't tn>m eepiioieniia. iind I fiMin wcondar/ 







AsrCTATioM Tiiiuiroii THE KxKK-JOiNT. ori^ioallT f«comnieDded in the 

■■tMalurt by II'>iii, and reiHinxIneed by Velpeuu, Xtaricoc, and BrioUio, 

imim tanr Tr-ir- r<>uriil fav»r in ibis cotiotry and in America. 

Aaf«ki' ii]fh the km«-joiiit may be perronut^l in tbree different 

^^aaji; I, V I.: iknttcrii^r and a*borl aiitririnr llnp: '2. niib a I»iiir iuiU>- 

^hktf aa4 a f^Kir : r tlnp: ■'{, br lateral lbi|'-. 

Hi L TWopenii i. thi- Long TOtterior and Short Anterior Flap niaj 

Hw ■vJIlt' pMfnnanl in tbr f<illi>winy war: .\n inciiiion i* mailf itiredtljr 

V*^a IM knrv-jotoi. ji»[ bi-low ihe [Mtella. Tlic fkin-llnp thii» fnroiiKl 

• 4iHBdMl hack ; and tli< )i>int biding DprnnI alxivc the imh'llii, and ihf> liga- 

mmbi&wiAtA bra fVi> tmioh^wof thf knilV, a long puotrrinr llup i« rut from 

Ihttffwf pan of ibr '^if of thn leg, by iMming th« knife behind the tibia, 

■a^T ., dtniii«arti» for a ntitaW* distance 

TV u ha> tbr grrat diaadrantagt^ thai the piwtvriur flap has an 

ttm-m ui>."oir<inBbl* tantlvflrv to retmct, and it shuuM never be under- 
liAn sfata ibr Mvaring an he obtained mor« ext4>n«vrlv or entirely from 
OehMU. 

1 TW Mvnii««i Itv inean» of a Long Anterior and Short Posterior Flap 
Alhwparwtr-' rig,K|UKrfi flap, ruiinded ai ibo e>:>rner*. it mailc bf 

(MMttfih* p> "ift brtMd-bladedampniatinii-knife lonnrd^ the poa- 

teVKfanaToaaoMHlyUi. •.■arrytu;; (he iiiciaton downwards in a ttraiKhi line 
fc Mr or 6v* uwbw, then tu-nat iho limb, and Bnallr upwards ui a |>oiot 
« Iha ep p oaia aidr fi>mi»(k>odini; to ihni -i' entry. I'lie inlettum«nts and 
ite fMMM arv lb«a diMrrtTxl fruni itii- frant of the joint i Fig. 74 '. The 
•ninalMMa b thua ocratil ; ihe ligamenia are then eiiooewively diTvlCTl, the 
hab Mbc f ■rribli WiA mid s jMBti^rior flap b liirn>ed bv enitini; wiih a 
4mnilm^i il fnrwarth. or by di>««ctin[; ilonn Miind iha 

1mm. anal : >- ■'■" ..uardi*. TIid lUp*hould h«* aliuut 'Jl to :i inch (a 

li«p U mad* •buricr ikon ihi<. it i.i apt to rotract uti the Imck of the 

ll%k. ladaw). "' -" •^'ntf u a Knut trailracT (o tltis. cvnn wh<-n the 

fc^bof ibv In .iqi, The |H>pliti\al artery is dividol. ami, with 

lh> auaytiMi oi im- ariKuiiir vnaola, b the »nlf otte nNjuiring ligatunf. 




areriAL AitPLTATtoxs. 



Th« tiMaa^Mnent uf the paldU is an im|i>irtn»t •(uminB ; •>»»(■ SuryttiDi 
iwlvioatioK lU romoral, mul oihen its |>n-i«rv«iion. I Uiink thai it ii 
flecii)«)ly better to leave tUnn tii removi- thi« Imhi^. IT lei), it («ttn» «n iin- 

imrUiiit nililitiiin nu<l nrntrt'liun (u llir 
eitil vf tbc Mump, If il tie ivmoTpd, 
not only iiix- ttiiM* ii(lriinl«gt« iumi, but 
tho lliip lii-<'<fiu(-« »•> iliiD nni) wf«i(«ii*d 
»!• u> iiii-iir ilmiigcr of ^■iit:n'tK-. 1 Iwt« 
iinu-iiiKil tin- ii|K'riiliirii Ixuli nny*. muI 
iiiivi- fmm tin* i-x|ii-n(riirr limiitl il rhm* 
BilrnDlH^tHHi* ii> Irnvp lli« jmUcIIk. 
Tlii'n: is only •iiii- ubjn'tioti l>> lliii'; nntl 
ihst i* lliv citjtiioi' lit t\\v |i<at*-lin IviB); 
drawn up.ns tieiwsioniilly liii)i|>t'ti!'. ujmiIi 
ttit.' iirileriur \mn nl' tKi- iliiKh, Thu w 
bpel piYvtDlt^il Ity ciitttnit ui-riiw Uir 
ii!iit)iu»uB iiiM-rtion of the (juadnceiv 
ezteusor (luriiie tlwofienitioD. - 

Tliere in u Jiffereuce of pnirtic* m 
llie niai>U|o.-tnciit of ihe airtilBKi<x>u< 
surlim- of the Ivniur in tbe*e BRipuU- 
lious. Some S»r)(n>ii9 |>n-1rr tcnvinic 
it; utber* MW tt nitT. [t tlir iirticulBr 
wrCu* Iw oouDcl, th« cnrtilnftv U»A 
bt'iltT )m> left, nn tl)Ui> iliv i-BtK«)l>nit 
Mnicturc i* not ii|M'U(-<I, uiiil one m*- 
(li>jini>in^ niiiM* "f pyu-iiiiit ia nvoiiirti. 
If" ibe canils^'e* l>c en)^^^ or i>ihfr"i»o 
iliwased. thcr ib'xild Ix- rctiHiviil. The* 
I generally do, alU-r thf diHirlii-iilntion 
baa been (v>iiipl«i«<l. by iiicniif <if a linr- 
bladed llutclier'a saw, cultiii); mutul, 
And not aeroaa, Ihe end ol' tbe bon«: 
thitt not shorteDint: the slump, but 
tiiDpIv removing the cartilni.'e. whicb 
WfMiIcI oiherwiw necnwe or disioiefrratc. 
niid lhii» intfriere with ready union. 
It' the i-nrtilflgt- liv k'^ un llie lemur, it 
fliiMild nUi WulUincd to remain uwlifr- 
turlx-d 'in the iNitt-lln. But if it be 
removeil IVvni tne IVmur, au lu to ex- 
pOW> the coon>ll«ui bone, then the undtfr 
Hirfiic* of lb* patdin ohould b« r»- 
movml in a Hinilnr manner, btfurv tb» 
Dap i« lai<l down. Thi* will he foond 
to furnifh nu excellFul orering U> ihe Ixmr-: the palrlhi. mimI the thick, 
tnu^fh. and exteitftile inte(;umeutti of the kn<fe, t<irniiii^ n ^iniil hiim of *ii|>- 
piirt tiir ihc limb t<> bear upvn. and one uoll adapted for pmoure. Tin- l-uI 
Burfiice iif the jialella will apply itwdf to, and iihili- with, the ranrrUou* Mir- 
tnvai of the eonilyleti, and lhu« add to the frliilily «l' the end of the stump. 
In iJie aAer-treolnient, k'reat irouhle may arire trum nn^umidali'iu of the 
diichaivtB iu the synovial pouehe?. This oiu Ih- prevented only by pri>prr 
drnina}^'. Before cluHiiix (he wouttd, two ton^ tubes must be put in, in sweb 
■ war that their deep exireiuitin lie in the extreme up|>er parts ufibr ■\iii>- 
rlal |)ou(.-heft, ami their lower endi niiut be brouglil nnt at iJie auiilc* ol' Uw 




ng. TC— ABp«UltM lhrnii(k Ik* KnM 

fcy Lo«g Antarlor Pup. 



AVPUTATION TBROUOH THK CONDYLES. 



15Z 



vvai. These tubes should not be touched till the third day ; alter that 
i^T mav be drawn out half an inch or more at each ilreBaing, and the pro- 
JKtiiig piece cut off*. They must on nn account be completely removed in 
ndcr to shorten them, as it vould be impossible to replace them. Should 
fuSann in the synovial pouches from failure of the drainage, it will be 
mv^iied by the snelHug, redness, aud pain, with fluctuation. A free 
iiKMuD must be made into it as soon as the cunditiuu is recognized, or the 
|Minay burst through the limits of the synovial pouch, and burrow up the 
tU^ beneath the vatiti. These precautious for drainage are necessary in all 
wpuutiuiu in which the svuovial pouches are opened. 

1 !>. Smith, of New York, amputates at the knee by Lateral Flaps in the 
fblluabg way : The incision ia commenced about an inch below the tubercle 
uf the tibia, uid is carried downwards and backwards over the most promi- 
■Ni part of the side of the leg, until it reache* the under surface, where it 




Viji- T.'t. — Amputfttion at KnaB by Lnlcrnl Flap. 

:• -[Itvi-ltiil tiiwaril? the meilinu line. When this jxitnt is reached, it is car- 

rifi 'lir^cilv upwards to the centre of the popliloiil spnce, A seoonil inci- 

tiito txT'in- at the I'siiie piinl lis the first, mid juirsucs a similar direction nn 

[b« i>pi>ciiie fi>\v iif the limb, the two incision.-' mi'oting in the mcditin line 

brhind. The fl:ipti are (hen raised, the joint ii|ii'ned, and the leg rcmii%'ed. 

Tht ino-'r dap should bv rather the larger: iind the jmti'lla is let). After 

tii? an.putaliiiii, the stump presents the ii|nH'iirHin'v ri'prvsi-nted in Fig. 7*>. 

A.iJ'irATiiiN TiiKot'<;ii TIIK <'iiNi)Vi.i> iiuiv hi' done bv u limg [Kjsli'rinr 

• r a !"iiL' anterior flap, including the patclhi cir iii)t : nr hv a nKHlificiitinu of 

:b*- ■iriular method. Of these, that hy the long posterior Hup slioukl neviT 

:■' •niiiloffl. iinli',-^, froni exceptional circunistunces, nn uthcr flap cjin be 

'>!>t.iiii--d. < ':iri|en, of Worcester, wa.-^ the Hr^^t In employ ihe iiielhiiil uf 

iru:>iiiitl i"Ti by the long anterior flaji in tlii.-^ sitiiiitinn. lie took awiiy the 

[«I>.iB. and muile no piRiterior tla]i. but !<idisi'<|Uent njieriUnr!' liuve t'nund lluit 

■iih'Mt a [-usterior flap the covering is freijueutlv insiittirient. The opera- 



1S4 



SPBCUT. AMftlTATIOKS. 



ihm '» tlKfeloTV nBtmllj perrormed na fullowa : The fliij^r bimJ llitiub afi 
loft iianil nre pliiccd on iliv ino ooodTloii) emineDoos ur lliv rfiiiiir, wMffc' 
M-rvp mg giii'Jca for tite surliuK-putnU cT the inrii^iun. A lonjt autriior flaji 
is llici) msrke<l out, well rouDded id Hlmpo. itod ii'acliitiK U low ii« thr lubr- 
nwitv of rhc tibia. Thii is dinectw) u]> tilh^r villi ur wittiout ihe iwivlla. 
In c«»es in ittiicb the Sur^n in henil initio; bvlwern cxt-ii>i"ii aiid anipiiU- 

tion, tlie joiui niar ht: f xainiiipil Ix^fDre pnicvediu^ fiirtlier hihI it [x-niion 

det«riiiiueil »ii. When ihi- niili-rior lls|> bs* beeii niiacd, llie kntti< i« [laMnI 
behind ihi* IV-niur,iind iiiinsli-riiir fln|>,«|iial In Icnglh to ihv iinlcri»r, i* ml 
from uiihiiiimlnanU. Tliin lliiprDnliiiuK the baiuilrintc t«ndo(i>, nud UMiallr 
B jMri of ihi' luiiH'Ifs rif thi' ciitf. und it (Niii!iif|u<-iill\- n-tracU r<>n«Ml«rahl5 
aft^r lieinL' cut. Thr fla|M bi.-int; ln-M Imck, ihf kiiif^ ijt Awejii r-iiiiid iln>nt^- 
diutely al»ivi' thr luiriilngt-c-iivcri^l ■urfatrs, hiuI thr raw currivd thrnUfrh tba 
buM« «f ibr ii>Dd)'lni piindlcl O Ihf iirlictiliir surfinec of tfac ftrniur, that it 



I 
I 




Ttf. TS.— ABpuuilon ihrougk ik* CoinlTtM by M*dll*d an«b< lI«lko4. 

lo SOT, siiiu-whal obliquely lu thf iixia of the shiifl. the inner side Winic Irlll 
B Utile loii^r tlinii ifii' 'xiUt, (.STttli, un Ilaliuu t^ur^^-rrn. iind Sinkw^nf' 
Duhlin. have retain iii«nde<l thitl ihtr |intt^llii »lii>iild tie lelt in the flap, and 
its LiiriilBi;!M<<tia auriacv Mwn >iff. »o ua to form a raw baoy surftcv, to twj 
applitnl 111 ihe cut end of iho reitmr. 

Aj> n Miiiilit!n)lti>ii of thi'M- ojitTnii'in!!, lA*ier hait revummendeil an amnv-l 
laliiin Iw D ni()ilit)i.-d eircular MiL-ih>>d. nhirh h ihua |KTlorinnl : "Thai 
Surifnin fii>L eitl.' irnnnver>i-lr ai-r<«a tlie IVunt of ihe liinh, frion kwlr (n hiIt.I 
nt the Ie\'i'l of the aiilertur ttilHTunity nl' the tihin. itnd juinit lite h»rnf uTl 
Um inristou by rnrrtinc th*' kiiifr itr an iiu;tle of rnr(y-11«c di-Krr«« m the 
■xi« nf ibf Ir^ thrtMifib the (kin and fur. Tlie limh beiuj; elevaif^l. he di*- 
ateit up the {Mulerior ukrii flap, and then iimcmfti ta niiar ihe nri); of inirvti- 
tOMit a* in a eirculnr i>|iernlinn, Inking due i-are in avoid Miirini; the 
■itbcuiani'-xi* liiMiie: and. dindinu the hurnMriiipi a« aoou lu iher are a- 

EHi), nnil lii-ttdiii;; tlie knii% he tindi no dilBmliy in exiKMin); Ihr umwr 
rder of the puicltiL He then (Ink* th" knife through the insertion of the 
qunilriea-jH rilrtiMir ' Ki^. 7'1>. anil, having eleanil llie Itonc immnliately 
ah>ive tlip iirliruttir '-nrtiliive. and holding ihe lintli horii»n tally, he npniira 
the Hvr reftieally and at tbtt nam UnM' iraiavetariy In tlte asu nf the limh 



A 



AUrVTATlOX UK TUK TlllOlt. 



1&& 



[(M </ til* boa*). Wt u In inmt* n horiiuntiil tnirfmoe lor the pnticiit lu rest 

F*.* Wb» lb««ift parU arr inui-ti ihirkpncH. m in iliseaap of the knv^- 

[jaM.lW Midi* OMIT bt niMMJ in itic flA|i. iind tlic le;; rcninvcil by culiiii)- 

A«cnduM»d Ul>T*l linniPiiUt. No {{rc«il dilficully will then be fbuixl i» 

ofiKimf aid laviDi; uff ttiv n>(i<)yl«a ol' tlic fcniiir. iinil thu patella maj ihcn 

lanwAfftd laM o^ all. T)i« ]iHvaiilii>,>« ol' ilib' uperslioii iii ihat if it Im- 

■Ity baft«vM«l, t&r rlinncv of flou^liin}; b r<Iuui-<1 lu ii miiiiitiuiii. Tin- 

•M wf lb* oTBtnul nrubraoe uf ilie kuee muat be cnrefully draiuwl as 

TW(« Ha pniat of rinicliM- llmi [ liuvi- iViund uitcful in ihete ani|itiLalioiiii; 
IK. Im n<aad nff aiiti iliv imw ttit ^htirp ri\t-v lel\ na the <;iiuilyl« after 
wmmnX >J its nrtilaKinotift surface, as uilierwitie ttiia mtiy pn*** injnrtoialy 
apM tW flafi. In iIm- after- irtAtnicuu the |iaii^llu, if pttMut, aliuultl be kept 
b iu (4mv by « *irip of pUat«r w«ll bniUKbl down above it. 

Tlnp aBipntati'ina |>n»«nt fwr Kreal mlvaubigi-fl orer th<i*« hifcbfir up. 

I \> ihv mrdnlUrr mlttl aT t]ic Irnnir is not titwDCfl, the |]nti«Cil M MV«d 

■U limt ri#k ahi^b multi fr<kin vuppunition witliiii lliat raiuil, and tlio oon- 

•■l«(»t limbiiity tu »appurative iDflanunation of the vciiu> <>f tlic Itiine, and 

■avntivr pyaWM. 2. Th<- limb br{»^ n'iiH>v)'iI at a ^'rvalcr dinian^y.' froin 

lla traak. th*- thock will br In* and llic nit" ■>! inorlalily diiiiiiii.ilinl. 3. 

H^huatimt ii proridnl villi a l'>iig tliich-dump, vi\wii givr« incrcaaH 

^^^Kl* i* nain^ an artificial limb. 4. Whrn tlir nmputatiKn t* pnctinei] 

^BBB lap kiag anurior flap i-tinlainin]; tlir |>atrlla, <ir inkinp tbc *kin frvin 

^panr iL tW rrsd uf tlM> ntimp uill br pr<>t<-i-U'il by tin- lU-ntc and tonish 

■<tn a «Btal Bivl a|>M»-ur<iti<' Mruclunv outurnlly miuiiiM in fmnt of thr 

kavfaal, ahich admit of prfworc bcin^ mailv u|>mi them withoui fear of 

I tm*Hl> HI tlir rirtdnx baing drawn up brliind ihf mil ol' th» Hump, wn<l 

'alkwtkrr ««av fr-im its nirftce. 

Imttt of AmpaUtloa throtigh the KBM*joiiit or CondylM of the Ftmnr. 
— ?^ itj bt lilr L* <.-><n<~i'ruivl, tlHve i>|R-mti(iUd buvv bei-ii succ«mAiI. In llie 
■■«•/ ikr Amrriran rrlwllion, cf \-V£ caeea, C4 <ii«J. K'vinK n tnorlalily of 
MthrTOTot. Of thf'iF, 49 werv primary aniputaliou^ ; iho deatlis anxw]; 
•hi *rn> 16. xr .'{'J.l |)pr i-rni. IJrinion )i\vv> (12 c-iwtv of ani|>ulatiun 
Af^i^ it,, I ...... ,;,f ilunur. nilh 14 drHtitu, or 22.t! per <-<-nL The Malluiw 

if uarou 'Uh'l> ibt^ nindylu of the femur m dintinynbhed fton 

I r .^'ti tltf kni-i' have not Yaevix made "Ut. 
'i< .' <.>■* the rniiltii of aiiifititiition thniueb the kii«c^}oint in 
.KT IV tollotn: for injury, :t14 rawv. 103 dratli*. ur 't2.$ pi-r ivnt. ; 




. ;>0 di-slha, or 24.4 |M*r cent 



.; through the i-oDdyliii, for 
, ; for dwnwe, tJO cam'*, Vi 



-. wr 3H.I jK-r cent. 

:ii'»n)>rraliori. for injury, "J-'i vhik*, A iK-atti«, or 

. .') death*, or 2i> -i (M-r will. 
' . ^n- o'tnmooly rii|uin-il both for acvideni 
riiay iw )-iTr<itnii.->l imnii'iliiiii-ly above the kiieO, iD 
r ill il» np|H'r tliipl. .\iii|mlahiiu jii*! above ibo 
t\n]<f, tlie nioM of niu«<-lo in llii# pari uf tb« 
■- limb, tliu nin(ru) ixirtion bein-: oci-upiixt in 
il apiini-unAir ttlrudun* (.i>nn>-<-U-tl wiih itir jMtt'lIa, 
.' iHaii^le iif the poplik'al «p«tx-: hi-nep, if antvro- 
fl«p» lie mailr hrn-. ilny will Ik- Uiin and irndinous in the middle: 
I (if '-'-•.! it..- a,p nuifiiniily thick. Lateral tiapd have, hnwever. 
thi ifaadi ' '' inj* the irar uri-r tic- 1»ine. and they are more diffi- 

fah k> kn-f in j'^iti'U ihau nnlero'iineirrtiir lla|«. (.-»niM<|neiilly many 
l^iyit prvjt-r lor laltrr. In ihe iniitille and upper tliinli^ uf iht- ihi^n. 
ife liA pu1» ai* m diMribiitiil that the antrri)-|M«teri<-r Ila|ie always lean 




[fiS 



UPECIAT. AMI'UTATIONS. 



tW bi«t n«ull. ani) ^ivi- the beat oovcririK to ibc bone. If laurnl Aa^ W] 
made in iheMt eilutiliijus, ibe end nf lliv b^iii« is upt lo be iJiawti up into tfa«' 
iiiifflp of ihe wound between iho Aa\», which fall away behind it. In arnpa- 
lAtiiHi in tbi' lower or luiildle ibinl, u luurniquM muy be npplied high lui iht 
limb: but when the ojierulion w duni? in Ihe upper Ihini, ibeiv i» noa|«n 
tiir the upplicalion of this inMruinent, su tho henturrhuK^ luuM be urrnbd 
bjr Ibe applicitlioD of the ludiii-ruliber buudn)^ tui d<»eHI>e>l on p. 7:!. by tlw 
aortic Muruiuuct, or bv bh itNiuinni couiiimMnf,' tliv arten* na it imnwa owr 
the brim of the gwlviit <'I''i|{. IS, p. 78). In nhnivvtr tiuiatitiii tne Sur|taM 
unpuuic*, he muH li« cjiroiiil to carry the knife to na not u> split tlie fe: 
aMer>' or vein. 
AmputAtioQ above tlw Kbm by Lateral Flapa, or Vemale'i Operatia^i 

■■ thiin |>rrtiinni-<l : tlio OulCT flap tbuuM iilnny* \f miikIi- lin-l, TIk- 
(if till- KuilV, bi-iniL' •■ntcrml in tm- midilli^ <if ibc tbigb, iiUiul llim' titcbai 
niK'Vc ibr iiji|M'r bunb-r iil' ibr jmti'Un, i* mrriiHl o1<i<h; toiiml ihr Imne and 
linnijibt iMii tbri>ti):b the ronlri- iil' ilw bum ; tbr tlap in iben put <b>im*arda 
and 'lutiianU; tbt' kiiifp, b^iuK i-nU-nnl again in tbf up|NT un^clu of ilie 
iuci«i«n, ii> carried cb»r round tbi- b»np lu itc inner aide, and ibr inner Hap 
made by A snevpiii); i-ut (Fig. 77>. Unlt<f» the bijuli- bv kc|rt in eoniad 



potaw 




Flf-ITi. — Anpalaiios ot lb* L«>*r Thlnl of ihaTbigh b; LaUnl Ftept. 

willt the bone in Ihiv situation, the fenwral orlery ia very apt lo be ntliL 
The flapK In-ing then rvlracted, the bone it cleared by tiro ineetie of tbol 
knife, and mihii about four inchea above it* nrticubir suHacc. 

In ib<- ili<ldlr or I'pier Third of Hit Thigh, the Ast«n>-po«terior Flap 
Oparntion i» to be preferred. In or^liniiry (itfie», tbe anterior flap may flrat 
be iiitxle, mid ibe iHitterior one subsequently fasbioneil, both by irnDsfixion 
(Fij;. 'i2, p, ))3|. If, however, the patient lie very much emaciated, it u dif- 
nnili to jiel a good cushion fruti> the anterior jmrl of tbe tbiy:li in tbr* war : 
nod it if drnset^uently preferable to follow the nlan recommended by )lr. 
I^ike of makinit ibe |>oeiierior flaj) fint by transnxion. and tbu anterior oon 
nflcrwanU by cuitin]; from wiibimt inwiirtln ' Fii;- 22>. In aoine ioataacea ' 
in wbirb the tiuue* at tbe (KWierior |>art of the thigh ure much ilianwed or 
injured, whiitt thaw on the anterior ait>ect of tlie limb areauuDd, a very 
P<(h] (lump may be fiuhi'ined by making; a Iohk wiuare anterior fliip by 
tmnsAxioti. and then euttin^ iit one Mrokeof the kiiiti- tbrouub tbe Mtfl part* 
at the poierior Mpeel of llx' limb, in n •••nk'Wbat oldifiue dimclioii from 
below npu'nni*. Tbe anterior Hap, when laid down, will form the cm 
at tlw end of the >lump. 



AMPCTATIOS OF THE THIGH. 



157 



Id tb* gnat majority of cMts, hnwerer, the operatioD will be better yter- 
fcrtxd M follows: The S^ui^eoti, standing on tlie right side of the [intieot, 
aim the knife midway between the anterior and posterior surfaces of the 
thicli tm the side oppoeite to himself, and marks out n rectangular flap, with 
dw right angles rounded off, equal in length to two-thirds of the diameter of 
the limb at the point at which the bone is to be sawn, lie nest sweeps the 
ksife round the back of the thigh, so as to mark out u rounded flap half the 
laiph of the anterior flap. The limb ie now raisc<l, ami the jKiateriur ilap, 
CMHuting of «kin and fat only, is dissected up to the angle of the flaps, so as 
to free it from the hamstring muscles, and thus to limit it:i< retraction. The 
■nterioT is now raised, only skin and fat being taken for the first inch or so, 
■fier which the Surgeon takes as much muscle »s he tliinks advisable to 
' the vitality of the flap (Fig- 78). The remaining muscular tissue is 




Fic. T^ — ^.^mputalLun uT (be Thigh. Flhfi? out fro[u wtthuul inw^rJ,'. 

not 'livilt^l circularly, and the soft jmrts rctnuied tor :i discniiLe of iihout 
'.■■i iiii-l.(«, ami the bone sawn at ihiit point. Thi- nirjulion i^ i:riaily 
^-ililalcl by misin;; the limb In a riirhl sul^'le with the table, us rcforu- 
mrC'Ifl bv >j>ence. The rwults of lliis ojHTJitiiiTi lire iimst .-yilii-tiiclory. It 
oi»y In- jn'rf'-rmeil iijuully well al luty pari of the ihijrli I'ruiii the imcbamcrs 
!'< ibr I'lMt-r end. uhero the skin nt' (lie piitellu is inrbidcd in ilic iinicrinr Hii]i. 
Id nil amputations of ihr thi);h iimre ur les-s imuble iiriso:^ from tlic enn- 
Itsu ti'-D I'f the flexor muscles tending tn ili^^pliice the jiosirrioi' ll:i|> upwards, 
aad ■•■ I" leave a piping wimnd Wiind tn lical by gniiiuhilioii. Thi.-' is 
aiTzmv.-ttt^l bv the tlexed |>ositiun in wliieli thi' p:tlii'iil inviiriiibly plucc- the 
..lu^. Thf uHMunt of covcriuj,' shtuild, ihiTefnn', ni'ver be \f^ thim mice 
:h-> iliameter of the limb at the |>oint at which the bone is sawn. Thus. sii|»- 



168 



aPBCIAL AMI'lITATtOIfS. 



t)i« anUnvpoMerUir ilii 



AT ii> be fuiir litcho, ilii-^citniiir Amy <l>ad| 
be 'Jl Invhn \oog nnd ihtt pixitcrior I J IiicIhw, muI tliv CDimcltij Abould w 
rt'tniclol fur IvFo inclMvi. If llicnt i* niHii-iciit ikiii (» be liinl in n jiriBMiT 
iimj)Utiili(iii it iiii^lit {xrhitiio be bt-tr4>r I'VcQ Mill l^rthvT to Iciigthvii ikc p»- 
trrior llnp, niiikii)i; ti iniiiiti (<> tli<- itiilcrivr, 

Atii|mlnliiiti <>r iIk- thigh iiiitv In- (wrformoil ml»o by the pure ciroular, nr 
tliL* iiiiHlilM-il ciroiliir iiM'th'Ml, buili of »hich give exct'llciii miilu in tvry 
fitvhy lliij.'tni, 

Ainputaliott through the TrochKnten may caiMtifDM Ix- atlrnnUt^iMMdj' 
(»niclu«>l. vitlit-r in wvi-n' toiiiiKnitKi IriMTtiirc* i>f the hiwrr fiiifi "f llm ihish, 
ur in vosvKnf noii-iniili^'iiiint (iiiiii)re ol' tbi- lower h ml iiitiMli.- ihinU of lb* 
fiMuiir: iind thus thr murt' wvcrv niiil Hiin^.t-niu* i>|)fiBti<>a »f ili>Mriii-iiIaiitai 
III tlii; lii|> initj hv avoiiltsl. In<li.-i.->l. ^hoiilil il Ik- fouiitl, ultcr ■rrii-itt uf ibc 
botiF, th«t it is 6u much iujiin^cl or <li»rasi'i) ns i» rogiiirr ri-mutul Nt iIm jotnl, 
this RiKy mdil}- t'Dou^'h l>p<l()nf by diw^cting lh<- hi-uil out ofthf Kcriabulun 
irilh u »lron)' scalpel ur bistonry. ■ 

BeSBltt.— Tbe iiwruiliiy after itnipuiatiua of thu tliigb is very couiilrrmhl* 
irben the operatii>ii \* done lor injury, more particiiliirly fur ivnifiutiiMl 
fmctura of tlK lemur ibtelf. The ntortnlity after nrnfuitution for iajury in 
i-ivil huipiUiU amoui)t«, acconliu}; to the table at psKt' 111, to 5I).7 |>fr cvbL 
In tho Fn'n(.-h urniy in the Oiinea, awl in Italy, it »as very hi);b, aiDounliiif 
to 92 per ceut. In vime bispilab pnia»ry amputation of tltp thi^li fMiiiata 
have Deeu almost iuvuriably a fatal |)roc<<(luni; whilnt in other inatitutMioa 
lli« mortality liaa uot I'xmWeil nO or M) per ceut. At (.iuy's IIu«]>ilal nnd at 
Universily Cullvjuv. aecoodary amputation of tlw tlii^h hiu been more fatal 
tiiau the priuury. 

The result of amputation of iht< thi^h for disnuteor llie kuee-joini dfjH-nda 
entirrlv u]>«in irbtHher ihi' airi-i-t^iu in acutv or i-Jipmic. In acute 3U|iiiiur»- 
livr diHor^niiaiiou of tbe knw, uoputatiou of the Uiiab b uii*t uUat; 
iudn-d, iui high w till- mtfl of mortality, that it h dotibtfiil whether it la 

Erofwr to perform th" <i[>"nitio» in that Rtilgv of ihi- uir'-rtiou. In ehronic 
m-e-joinl dwenw, oti ll thttr bund. Uie operation U iiiii>t witu<liu:lory ami 

HiCCCMful; death feldom rexutting uniriv l)i«- '>[M<rMli'>u )iiu> bi-en di-lerrcd too 
long. The general prrceoiuge of mortality ult4-r ainputntiou lor dixan 
is alxiut ii'lft. 

The c«itH« of death vary iicconliDg to tbo co»dilii>u for whidt the 
lion is tierformod. In primnrr amputation, the fatal evi-nt is bniuKbt 
«hiefly oy cxhaastion, traumatic f^aogrene of the stuiop, or stKiunilarr 
orrhagv. In aecondary amputations, and in thoM! for dinie. pyati 
erysipelaa, and exhaiution, are the unial causes of death. 

Hax Sobede fpvee the lolloming etatiBtica for civil practice: Ummt tbird 
for injury, 78 cawe, o7 deaths, or 78.U per cenl,; for disease, « caaea, 16 
deatlH, or 35.7 per cent. ; middle third. lor injury, 67 coaw, AO doaths. or' 
74 |)errent.; for dB«we. 137 caws. 55 deaths, or 40.) percent.; Ii-ncr third, 
fur iujury, 147 ca±««. 74 •ti-atbt, or 5(i perct'Oi.; for diseiwc, 2»>5 ca»«. 64 
deatlxi. or .11.2 |>eri.-«uL The military unliMii-s letcludinu the French c 
for nil amputalinnaof the ihtch ^o«r the fotluwiiii; results: Primary, 
((er cent, fif death*; tntermediitte, 72 jier c*nl.; secondary. CK.C per cent.; 
Iin» not Htatnl, H4.!) {)er eeut. The combiiteil otatwik-* of Uuwh, Kwio, 
!^-J>ede, and V'olkmaun. of vtura treated nntifK-pliutllv, excludiu); all eompli- 
euted ease*, are u.- follotti : F»r injury. 'J3 eiuoi, > death* ; 3 from shcHc, t 
rn>m li-tjinuji, and I from n'|>tie;emia. For di«nuc, 6^ caM«. 1 death froca 
secondary bemorrhnce. Tliiw of itnrdeU'bco, Billmlb, and Kruiis, fmm the 
ure-aotiseplie peri'il, all roni plica ted caMW heiuj; excluded, arc: for injury, 
24 niM-a, 14 di,-alb<— ■) fnnn prieinia, & from M-ittirapmla, 1 frMn czhauMino, 



{ 

i 




J 



AMrCTATIOSi TUKOtTQU TUB nil'JOINT. 



159 



wti i trmm i4ud[ ; for Jbiir, HI vaat*. 'JS dmlb* — 20 fn>iD pyniuia, I I'ruiu 



n^y. 




A»^- -T ^ At thk Hir-JuiXT. — ^Thi* funiit<)«blv oMrnliou 'a of M)iti- 
|Mi: at inuvlurlioo intn »ar^n\ Ounii^ ifiv nirly part and 

I Uic |«>: , il' |>ni<-liciil>ility wttx wnrmly i-aiivtuecd in 

It wtt* pr.- II aiiiniHl^ tx|>rnm<'Dlnily. It wiv> ItMtid tliai 

I aftdiid wilL •r^'.'lUiD. whi>«c loner <'Xln'init)ci* had become kdii- 
, aad lud H-)<arsted at thv Uip-yiini, survived ; mid, at lii»t. in the 
nar 1772, l^ fim succnaful nmjiuiuiioa of tho kind was perfomiwl by 
ranok. df 8t. Matiro. Id tlio iifxt ytnr, tlit- opcraiioD was dooe iii 
by K'lT. of NorthantptoD. on a gtrl, nged ]'i, aAccted with liip- 
I attd luB)b«r abMm. Tii« operation u&t uojuMitiuble iii such a i-aso. 
latlk* |1 faat lind 17 davH, bihI tiitid ila prui-ticitbiliu- wiu demoDBlrati^t. 
\jany psAnned it in ITU:! I>ir ihc fint timtf fur j^unfibot injury ; and ^iiice 
ttat uatr ibv itpemluo bat bvixiiK.- «n t^utblUhed one in aurj^cal prnctice, 
oril ■• vrll a* nilitarr. Thr "pt-ralinn iraj lint ])«rfi>fmcd succoafullv in 
EMftaad ta l^Vi. bv )tr»i>'tiri^v- "'' Flymoutb. uo a tuao wboae tb));b Ittid 
b«B bft4«fi in tbr IVDiiiaulnr war ii yt-ur ptvviuuNly. 
.ia|MtaiKiii at Uh' bi|>-j<>int may he atid ban be«u performed in u varitiy 

■ ■^ ,•> - - i)«cnt«ry tu detail. Tbc muolconi'enieni o[N:rati»u» 

rior Jbtm, and the owl uiPfAixf. Of i1m:4h\ ibai by 
rnor tiapi i- lb« i-anwr ami nion> spi-oly. It eonMHt* iii iiinkin^ a 
thiHc ant/'nor ltai> by (nin^fixioii, and a *h(>r( pnotvnur urn- fnim 
npoD and t«ck piirt of ihr ibt^di. Id order in [N-ri'inn (hit 
■Witfaa nraprrW, ibr |inlii'iiri> t)nity uiui>t be bmiighl wvll furwanl up<>0 
■•■Imm im tab!'', ■■> ibnt lb<- iinli-i [itiijri'i bi-yomr it, and U- Mtnditit br 
OMC Mwlag**. < >ur of tbcM' mit^t bt> pcutn-il tii-tHeoii tbc »ound ihi^b and 
Aknnnrani, and aiiM-br^l to ibc upper cod of ihc litbl«': a»i>ther «buiild be 
■nW acruw ibr |itIvi» in tbe lower end ; and the Hound limb miiM bt- tied 
toltakfof tba tabic Tbe cin-ulnlii'n thruii|;b ibe timb sliuuld (Jien be 
4 DT nor (if llie n>esna dc^rilnid oa pp. ~'J, 7(1, sii as completely to 
Uk rinrulattoD thruD|!b ibe lower extremities, ibtie depriviu]* ilie 
of it> irrnit danger — uudue loaa of blood — and enabliojf iIm 
lu cumplrir it vitbout burry ur auxiety od tliia account. 
!^iv*"'D must bave ibree assiataots on wbom be ean fully rely, 
t Nri. 1 ukn> rharve of tbc Aap, comprecfeinK tlie femoral voaela; 
" "' ■■' .'iloininal compr^^wir, on bia trufltworihini'ss the 

i<'Ui. ^Witilant No.^ takc«cbarKeof ibelimb; 
_ K tncpuj va Liir sMomeii in ilu- fir>l stajce i>f tite u|>eraliou, wbiUt 
tta asuriar Bap ■• brin^ madr ; forribly abductiai;, ext^odin^, and mltilinti 
WMud* dariajc (br M^^nd HJt^t; vibcti ibe i^urpion ia openiuj; tbir nii><ub- 
*f tt* JMBI ; ami r\>Utoir inuiinU dunD)t tbe lime tbe pu^u-nor Hup i.i bi'ing 
mL 0« tK* «aT it ' iDrnu ibtsr dutiiv. ibc tHiility uitb wbich 

iW^ryeua [^rfrin:! .j i> nioillly ib'jn-Uilrnl, To AsaUtllDl No, ;1 

''iii|ir>i«<ir of thr alHloiniiiuI norin. Al^i'r tb<' 
1 iiul Ni>. - niibt tbr Sitr^jcuu id liualurin]; ib^- 

Thnr prrliminarie* baving brru urmnifcd, and tlic uuiy of M«h 
■■IgotiJ )(>. and ditiioetly undentjiod by hiat.tbo Dpemtioa ia to b« 
il in tbr fnlbiwloic wav : 
T\m ^nr.'...„ .in^i.liiw un tbi' left aide (if tlir limb to be rrtanvrd, ferU for 
da b . Jidi' hi* knifn. v'lt., thii tuber i«ebii imd lbf> anlcrior 

. . um. riir knife, wbicb itiuol batre a bliidc twi-lve 

loc. < to be enii-ml, and tbe 6ai> lo be mailf, iu diflrDUl 

uig t" tho tide of 1)m- Ixxly on wbicb tbr operatiou ia [wrlWoied. 




££ 




160 



BPBflAL AUPPTATIOKS. 



If it bvoii tiie/e^aidi>. tbc knife oliuuld he ciiti-'rod nbmit iwotliigm'bnwid 
bcloD' the* niil>2rior(tii|wni>r !ipio«urtbe iliuro, and nirriM ilccfily In ll)« liab 
Iwliiitil tho viwwK (hnrctiv acr\Mi iheJKtnl: it« point l)«ing road« Ui iwu 
Qtnr titu (ub«rrot«itv »f thv incliium w«ll tiebind the promiti«nl tidgo fumirf 
by itiv uidHoii of tliG ndiluc-ior \uttgm (,I-'i^. 70f. Iu intoslixing itn (bb wdc 







n(i ff>— AnpsUtUia •■ (b« Hlpjatoli rranall»n of Aotariar Fla|> in l>*n Link. 



nuxl l)« Uikeo ii»( t» iiTuuiiil th(! M-rotiim ur tbi< o|i|>iieii|i^ ihl)th ; ll)«| 
ckof tbi> Iciiifo inu»t run jMinilli'l lo Paii[>MTl'!< tigiiiiciit,ui<) the |>i>int rou 
not br biib) Inn hii:b, liwt it <-ii|i-r thf KlHlominiil invity. TIio Mitrriiir (Upj 
miiiit ibpu Ih,' raitiilly cut iJawawanU Uixl f'ii'«anl». itlraui tiix iir ('ighl iurfattj 
iu k'ligtb. In iloiiifi; thin, am niuiit bo liiki-n niit to duiIip tbr llnji giointrit 
Thi* i» bort duar b^- krrpin^ ibo clgo of tbc knifi' mniCfl aliiflitty to» 
th* bcin* till (be pomt In rcikcbml nt whiob it i* U* bt> br»ugbt nut. AIm), i 
■Mbt&Dt «bo bob)* lb" limb niiiM tnkr citrc not t(i ••xu-ouit Imi iKxm. IkiI tt 
ket]i it flexed and »li;>:btly mblLiclol until t)ir aniorior flnn t» cuoiplfU-ly ml j 
miMl tlie HfuUnt wlio bacchnrgvof tbt flaimniRt W rJinTuI not I« rni*'- it nil 
ton niudi n<vr to (hjumtw !i Intenilly in granping llii.- vi-«k>I. The limb, Kbi<-li 
bu s>i liir hwn rni^i-H tin<l rlighilv flt'xH upon tlit- nlHl»inm «n<l B'lilurtnl^ 
must ifiw bi- lW_'ibIy t'Kl''U<U-<l. nbiluct<.<d. ami ru(a(i.-d oulmtnb ; tin' <-n|>-ull 
of tli« joint is tlitti to Ik- nnmiTl by n firm cut wiib ib<- [H^int of iJti- kDlfA,] 
80B110U n» Ibis » •lone, the nradof the fcmnr Marts out i<f tbir ■ooknt uh<I lb« 
npt-rntor t'iU(^h<.-» the round ligament witb the point r<f tlx; knife. Tbe 
tielflnl now nlluws tbe limb to niuif; down, nnil tbf bmt »( live I'tttmr b««oti»fl|3 
nparnto<l bv »>>me dislnnoe fmni tbc acetabulum, and tbi> poetrrior part ufl 
till' caniulc IS brought into vicir and put 011 tbc slivtch. This is •lividMl 
with tile pntnt of the knife, and immoltnlely it is done th« utiHADt |>uu th« 
limh in an exieoded poMiioii in a line Mith tbe body, and at thf> nnx' Unut, 
rntat« it inwards so uat Ihe trocbanlcr shall nut tiilcb tbc knifr 1 ibe 
of tbe knife is ibcn (MUSed over tbe iniobanitr. and ibe pciU«rior flnn ntj 
out by carryini; tbc kiiifc dovinwafils and lMck«ar<U thrutiub th<- t 
mascira in tliis tiiluntiun. The jvcttiTior flap may be about four iuclv 
leiigtl) : but thU nntM of nmtw vnry afi'-'nlTiif^ to thf* Ivugth of ilic ant 



AMPUTATION THROUGH THE HIP-JOIN'T. 



161 



lip. When ihe amgiutation is perrormed on the right aide, ihe aateriur flap 
it madt br entering the knife just above the tuberusity of the iBchium, aDd 
(nasiu^ it out two tingers' breadth belotv the aaterior superior spine of the 
iiinu Fig. 80): the remaining Ht^ps of the operation being performed as in 
liwiut ewe. In transfixing from the inner eide, if the point of the knile be 
'tirwied too much upwards, it may enter the thyroid foramen. 





/ 



fit- *' .— Aai|-uti[iiin lit Ibe Hi^j-j'nDl ; Kurmjitiim <i( Anleriur FIrifi in ltigh( Limb. 

lu "r-i'-r 111 iiV"id ilie iurniivt'iiii'ner fanscii bv siiiiictiiii: in n (Tiiiiiiici! 
_:— :ii ■(! iirtMit-n the pmU-nl's thijrhs, manv Siir;:i-iitia tniiisli.\ fmui the outur 
*ilr ■ ii ihc ri;iht siiie ni' well as ini the li'fl. 

It !■• iis»-i]iieiin; i>f ihv extent In vvhii'h iIk' liiiili lluit is iilnnil tn be roiiiovcil 
ujv Icjvi- ln-.it iiijiin-il, IT hiuv in?t-n (■ncroiicliti! ii|ii)n hv di^i-iiM.-, il is iiDt 
*.«iy- .a.-y t.i iiiiikt.- ihe anii'ri.ir fliipof (lie siw iirsliii|if dfscriln-d. .\ lit lie 
--aoajtiii.iii <iii III,- |nirl of tlif Siir;^f"u ivill, hmvcvi-r, ciiiilili- him tii taki- 
;v r-'jiii.'iir ami'uut nf ci'ViTiii;.' tniui the imtt-r nr iiiiuT |ijirt.*. liy ini'liiiin;r 
;:.- [.■iiil 'ir ihr ht-i'l of thu knife ijimnwiirds. :is the ciisf uuiv rcijiiirv; or he 
■-ii mak-' ihr aii[i*rir>r llap hy iiicisiini fri)rii wiilimil imvanU. idj^iujid dI' by 
Irati-li.tj.-ii. 

H ),.ii tin- Ji-iiinr is entire ami unl>r(ikeii, As.'isiiint \<i. 2 iise.-^ it as u 
.-■■•■r. hriiijiiiL' the li)«er end of it in thi' sci-ond :-Iii;.'e iif llii' nppriUion 
■: ■»a«ar'i'^ and I'Htwanls, thus causinjr the ln*ad nl' ihc bmu' tn jirei'.-' apiinst 
■t.- iiiii'ri->r part ni' tiie <'api>ule, and t'l start out with a jicciiliur snrking 
ni.i*. 1- -Bill a.- the latter is opened. Should. Imwcvcr, the hone have Inrn 
;n. IUIV.1 liii:h up. this niuvenient eainiot be given io it: and then the 
"^JV'-ti must groiip the upper end of the femur beh'W the irnehaiiteri', sii ae 
:■ "Vbly and pu:>h it boek as he is disurtienlaiing its liea<l. lu two of the 
■■»«» ill which I have amputated at the hijv-joint. it hH." been necessary to do 

T..|. l.-ll 



162 



SrBCIAL AUPDTATIOXS. 



thiN — ia (ififl, in cotuMucnce of tbe criuli uf the baov. vno iudicM Im1u« tb» 
trtichBiiti;r>, \>y n railwur iiccidetit; in ilie other, in m-nm^iK-nco of ia 
ii|>ontitn(»(iN fntolurv at llic junc-Uon uf ita uupcr Hn<l nii'tilli- third*, in ■ 
«•<■ of n>]>itllv irrowin^ maliBiiunt diacttM uf uw \tow. Ttiix fmcturM cuo- 
diti^H) i>r ihv h'niur nuoeiwiriiy in«k«a tlifl opa-ralinn iMiincwliiit inom ililBcnU, 
lis lh« Siiteitm iadocinveil of the long Icvor nir«r<l<.-d tiv the limb in itjiPKinil 
stale, hy ti'liirh ihv htad k Ultcd upn«nU nix) t'c>rwnr<lR, and llw capatib- put 
on tbe&trctcfa to M to bcbrouglit nin-ctlvngniiM the pMnt of lb* ktiifcniil 
is drsira ncrom it. 

In tmpulKtioD at thr hi|"j«iol, the grvut immnllnlo d»nrpr IWinrHy *|>pn> 
bended wu cjcocain- hrin<irfhNgr, lh« ineiMon* bring in»d« to hi^U ii|> ili»t 
DoordinarjrtourniiiK-t cxkiI<1 U- npftlin). Hy mcnntxif Puhoam'* PomproNort, 
tii« ciniauttoo through ih« RtKlutniiiiil iiorln niny l>« amstml, iind Iliu* ibc 
daoger has been obviat«d. Even now the arrmt of thv facmorrbagr duHoit 
tlia operation must be iDtmslcd to an awJitaot uho con be fully rvlinl on. 
AUcr the sbdoniinal onmpmeor hiu been anplied, and ihe flow of hloid 
thraueh the aorta armted, his buBin<ae abouid be to eomprcw the nricry nhiivc 
tli« briDi of the pelvis, and then tu follow ihe knife in the fiml incuioii. and. 
oa lh« anterior flap i« beinj; made, slip hu finders nnder it am) cnuji ll flraily 
above and beloir, ao a« to comnrew the femoral artery in it, i> Inch ia ilividcd 
as th** knifo ctit:* Iia way out I Fine. 81 ). By );raspiuic tl>e lla|i ttj(litly, thera 



i 




rig. SI— Awpuuiiou u Ul^>trtat - Cowf r«Mlaa tl Fi»hbI Arlnj Ip AatartM na|k 

tw but little risk of hcnwrrhnge froto the femoral artery, evrn when th* I 
abdominal aorta hu nm tH^n i-omnreewd by the ap|)licatiriD «f the touml- 
nuet; but leat this ibouM ilij>. or the amlBtant whoee ilitiy it ia toffmap the 
dap br any chaDce should tail in boldiu;* it pro|«rlv, it may l>e well todirtvt 
opa of the nssisiants. vho»e busintw it ii to steaay the trunk, lu hava hi 



1 



AttfCTATtOS TBHOUan TUB BtP-JOINT. 



148 



nil ft n oij tlu«u ioUi tbe ilUc foMn, m> ug to coinpm« the arlvrf 

SiW ori» of tilt pclvtd. As the posUrior fiap is Ui-iu}r tnai)^ (he 
friMB thr glumi ani] K'inlii? vcawL, which is olkn very free, iu«v be 
by trnn aiMUott wbo sbould be rmdy to cover mnd ciimprew ll)«tu 
aidlk«Sagmflrdf7«|ieilc(«.orKin! tkcm in .Sir Hpcoccr Wolla*s )bit«|w. 
IV armin naf tiMti h« )iffatun>d otifl by one, as the snietaDt exposes tbem. 
U iW oUmt SMMUnt har« b Kood hold of tLc fentoral, tbe TflBsela in ih« 
tap may Id- uc*I 6rit; but if the feinuntl be- iiuvciirelv hclil, it 
W tnt iMi]. Tbe ftfiuoral uriertcd, both auporlicial and lict'ii. irill 
ht tmmi tM b« cat Ionic. *■■<' <■> project front tb(^ iiilihcI««, by which ibqr 
■M aanaaiKlMl. m us very rvadily U> be «eiite<) by the flntf^rs or forceps, 
■dU uat, Bn>l lik'utiin-d. Tbe anerko iu (he |Ki«terior dap imd mi lh« 
MvaUroTihr jintit will be fuund in the in term UMular septa. Thi' llnpR 
■» |h ka Itn'Qiilii tiiftctber by sis nr ei([hi Hitures, and a mm of a brnad 
hada^* way tbni hr paawd rouiul the abdomen, and Ibe ei»d bratigbt up 
fatt bkiad Hudcr tin- ntiimp to as to vupjKirt tlicni. 

1» ferawf tim>» il vtiw of great imporuince tii perfarm the opentinn nitb 
•• Mirfc f»|ii<Hty at proribk, and tlii- diMirliculatinn vas uttially cflcclrd in 
ttm lUny lo fnny tecondM, and fn-<|iti-ntly in wen Ioh time ; but *inc<- the 
■MH wt arnstiu)t hvmorrhn)^ havr Wi-n porft-c'tcil, lime i> of l«w itnpor- 
iMCa. and ooaaei)Q«iUy tin- omI nttkod, which pmumu many advniiUges, 
W !■•■ BHcfc BIMV lro<]U)-olly practised of lnt<- yt-nn. 

TW oral ampulalioii in performed in n variety of wiivii, nnd morr experi- 
•Ms ». prrfaapx. Ptill rrquired U> deCermin<- wbic^ i* the Wt. Th<- following 
pin ^ brM ftiODd lo snswrr well at Univrnily C-»ll<'gK H(«|ii(nl.- Tbe 
MirM ii to be |da«>d uu hi» sound »ido, and the thigh of thikt ^idc is lo be 
mui as Ctr as pombic and secured in that poeiliou by twd bnudagca, one 
WmM lo tb« ibigb inimediaielv above the knee with a doce-bilch. the two 
Mil ^ which art naased rouDd tlie patient's neck uud under the arm of iho 
mmm ade and Enmv knotted togetlier. This bandsKe Riainuins (he fleii-d 
iw air si of the thigfi, which prta stead iitcss to the trunk. Tbe second ban- 
■■er is la be pweed also round tbesonod thigh and eecured to the leg of the 
H* biaiath tbepuianl'a head, in onier (u prevent his slipping; down during 
iikvfcntioa. Tne patient'* body must be furlber tteadiea by an atwittsnt 
fiMsd aaposite ibe snoqldeiv. Another asMslanI takes char]^ of ihr thi^h, 
sad s third, wbo stands opposite the Surgenn, will take the vewel by thrust- 
•Bfibc ia^m of oeo hand inln tlxt wound ntiil grasping th« nrterr iMttwero 
tbia tsd bwibaBib. Tbe patient Iwing thiix prepared, and the India rubber 
Wd *r aCtftic rlamp a|>plieal, ihe Survruu Rliind* »o ii» (■> have ht> left hand 
to tb« Asfi, tbat iatowy, b<-hintl for the rifhl tliigb.nnd in front f<>r the lell. 
AkMMatiH knif« of m.Hlerwte lenglb w to be chu»en. In opemliny on 
■is ri^ aid* lite tnctMon is commmcvd about two inches abuve lh<' truvbanter 
•■Jcuried firmly down to (he Imue and along tlw femur ti-almut six or seven 
■(b« btk>« tbe npper rwl of Ibr t<i>nc-. Al llii> p<-iiil iIil- incininn u nnide 
JfthHhrcai*, mv pari lieiog rarrinl in u eiirvcil din-dioii forward* fur uhout 
^^" ' 1 aaal ibo ntk«r linckviinls iu the snniv «ny. Thi» ninrk* ihf [■■int 
iht' iraDivrnr |>Brl of the incision is l<i W mnilc. Th<- limb ii now 
' first ini-i*ion has l>cen miide with nulftcirnt firmiii-w, iIiq 
'" ;><t»h hi* thumb into Ihi- lungiludinol slit which has 
;-«rlsof tbe two smaller ^'utei. Tliv musela thus 
the ptiint of the knife is mmlr to cut over (be Iro- 
ipper part of the Umc, ei>mplvtclv eepnrnlin); the 
III II, first ill fKiul und (hen behind. Tbe limb is then 
ilj •ddfldnl, bin) (hf nntxiuit St tbe same time trka lo lift the liend 
if lbs M0V «at by pttttiiig ano of his hanils on the inner side of tbe thigh 





ta < 



■ llAriJ^^I 




164 



SPECIAL AMrUTATIOKS. 



u> high tip u |Kin>it>)<'. The opfntiur th<'D t>|i-nii tin* joiiil liy iiinkiti^ ft fim 
ait in ihtf IJnv ol' ttit- Hii|wrii«inl iiicitiun, en m li> iimki- n ulil in tlitr MpMfe 



■ml to iliri'l 



to iliri'lu till* onlyloi'l ligauioiil, «n<l thus lo i>'0>ifr diflurnlion nttnv 
Msy. Anuihvr incisi»ii if then CArriml luK-kwanJ* iti the t-u{wulc in Um 
liiM of iu altjithiiii-nl. Thi- hcml of \hv lioDe ttici) *lmnr fn>iii tli« kuclui 
itiid tlH' |Kiinl uf the ktiils n iaeerti-il rniialn ilivith' thi- rouwl lignwonL 
If the hentl iltm not i-unw out raulily, ihc oMlBtaiit iiiay m'Im.- tin- rxpiMMl 
trocbttDtcr u'ilh a |uiir of lion-rorvc|.i» iind iJrsf; it forcibty outwiirds. Thv 
remuntliT uf the muiiilo i<' Ihvn euu mxl the oAaiataiit can wvr IsT hold 
of tlw trochanter anil |iull it fon-ihiy out uf the wound, while lh« rifwrmior, 
{[CttiDi! his knife to the iuner «ido uhilo he holdit lh« *i>i\ [iiirifi out uf th 
frnr with his left hiiud, gradually H-|<iir»iei- the buDe from itH utinrhiiicaita 
til) it itt i'X|H>i#d as Ion lu i" rt^|uired. l>unu^ thii* |Jurt ol' ihe o{^H'rnliuu llw 
linih must itill Iw: iidihuted ■•> [he i;reato«t piMBiblv extent. Ilnviog nmdiBd 
lh« iMiint at nhioh the ouiniiK^ui-emetit uf the tj«ii»vcnr vmn of tbv iadtioii 
hu Dcen alrt-udy umrki-d. the Surt^eon tunii' the tiifiv nf ttif knilr anay fniu 
i\it> bone luid cuUi iifrnw to tbr inner side of th« limb, ihiu oomiilKinji; the 
niumilnliiin. Diirini; tbii< iMirl nf ibe »|>emliun the af«i><lanl luupt brin^ ihl 
limn into u ■tnii^hl liui' uitli the trunk. Tli« artury itiii*t h<-ciintpr>---'-i '"* 
an aMStanl with »iii' hand in liiv ujijicr jiarl nf tho wwiud. 1» >■{ 
on the left «idf, the lii«t iocii>iou t» miflc from hrlow upwards. li> ■■^•••-1 
reepMrtf the opcratinu i« jwrloniM-i) in iIh- wimr way ii» mi il>e right «i>le. If 
th« limb be very iniitnilar. il it n ^tHtil plaii, after having cauolmuil ibo 
upper pnrt of the femur, to cwiupleto the drculiir piirl ^f the ineiuon hy cat- 
ting from u-itho4il inwnnk, carrying liio inei«io4i only ihrmitth the xkin aiid 
Int. whieh iiiny th<>n be lurmnl up lor a couple of inohee. the niii^ehv ImDl 
(iividetl last of all nt the higher level. The wound luuu be carefullv tinilea 
with sutUTW, n lar/e droioaK^tube l^iiiK iuiterted tit the outer ^iiie. Thv 
fulvautUKeaof the ovnl method are: firat.iii* puinled out by FurueauK Jonbui. 
it leaves uimalier wound than the flap uiuuutJition ; and, »eei>ndly, it c*ti 
inon> eiuilv he dreateil hr some of lh« auuwplic methoda, aa itMtv is an 
iiil«rvHl ol' «ix or aeven inchea at the inti«r arae of ih« stump betwMn Um 
liiMiJid and the aniM. The only diiwi)viutug« it pnaonu U. that it ia mon 
difBeult iind te<)t<»u of [lerfonnanci;. 

Ill order otill further to ilimininh ihft aise uf the wound, tonw Sur^-ona 
have nininiiiiendol that the thigh Ix- iiniiiutatMl iiuiuediatvly below ilio tro- 
chanU-n, fint. nnd the upjx-r {Mrl uf llie Ivmiir be then eiciacid from tb« 
wound. 

B«aalta. — The mortality after nninulHlion nl th« bip-ji>int !■ iwenaaiilr 
very high. This n« chuuld nitlumlly fX|H-vt IVoin the sixe of the part re- 
moved and the eon«ei|iietit ihoek t-i llir fVBti-in. The rale of recovery vnriua 
ffrently Bcoordin); U> the i-nu'tilionof ihelindi thtit ue<^«»ilal(«> ihe opemtion. 
Tliua, amputation at the )iip-joinl litul t>e«'n |HTf<ini>eil. m far as I cuuld 
HKvrtain fi^Hu publiibeil ctiw», rj'S linK-e up lo the year li**M ; of theae 70 
died. Id 47 iuelanees it was for iiijurv ; nf thuec '.io pnivcil fatal ; whilst la 
4'J cases in which it was done for chronic dismse. 24 recoreml and only 
18 di«(l. 

iViai'irv niHiiuUilioH at the hi|»*joiDt ID ciifee of severe injury of the thij;h, 
by jiuiialiot or olhernise, with enniinioutiou of the femur, la one of the ri>i«t 
fatal opemiions in eurfrery- Id all the 12 casea in wbidi it wa« done in tba 
Crimea it proved liital ; nnd Lef^ouent has coltei^ed 3D caaea of thLi amputa- 
tion for iiunahot injury, in all of which the operwlioii lorroinatcil iu deal 
Indeed, up to the time of the War of tbe Kebeliion in America, tiwn 
nu authentic iiwtancc of reeoverv uuder Ibow circumatatwoa. But in' 
elabornle ajid intM able surgical history of tluit great war, ptibliabed bjr 



i 
1 

I 

1 



LOCAL AN.«MIA. 165 

Svre«i>o-Geo«nl. 19 caws of [iriniiiry Hmputatiuii at the hip-juiut for gunshot 
Bjarriifthe femur arc relat4.Hl. Of these, 11 died fnini tlie iranietlinte shock 
ot ibr i^iperation : ~> liieit between the '2i\ am) the lOlh day : one, a man 28 
jtuf >'f a^, who had amptitatioD at the hip |K'rfi)rineii bv ^ur;reou ShippeD 
MTrn hiiire after the rci.-ei|il of bis wound, was in perfeit health four years 
ifter the ojieration ; and the remaining two caseri had been uured.so that cae 
wit ahvf HNil well two, and the other Ax, niontha alter the amputation. 

InUrm^iiilt oneratlnn.-'.or thoiie dtme during the inflnnimatory |ierio<l, are 
fWT uiuuiTe>«fu) : 1» caK-a that iiecurre^l in the American war were all fatal. 

Sttondaty 'impiifiitioH. ID casea of attempted prcwrvalion of the limb after 
vrrre injuries and guiii<bot wounds, ha« been Ibr more successful. Four coses 
IB which J. Koux practised it in the French campaign of 18r>!) in Italy nil 
iwoTereil. as did two out of nine in which it waa practised iu America. 

Bettmyui'ition ut the hip-joinl for diseased thigh-stuni{is has also been a 
Mmwtiil ofieration : 4 out of 7 American cases recovered. 

Amputation at the hl}i-joinl for duense of the femur has undoubtedly l>eooroe 
lew fatal of late years than fonncriy. This is owing to the operation being 
■abmiittil to at an earlier stage of the disease ; to a better selection of cases ; 
pnwiblr to improved methods of after-treatment ; but mainly to the influence 
of moiMthetkv, by which the shock to the system necessarily resulting from 
•n Tvry severe a mutilation is materially lessened. The employment of Pan- 
«jasi'( ai>rta- com pressor and the elastic band will [irobably still further 
mluee ihc niurtaliiy by lessening the loss of blond. 

Th( mure eitendetl statistics lately published by Max ^chede show the 
felkimis^ retiults : Amputations in civil practice — tor injury, ''>.'> cases, with 
^■•Inths, or 7l).JH) j>er cent.; for disease, I'y-i cases, li.'i deaths, or 42.H8 per 
eat The carefully collated statistics of Ltining of amjiutntions tor gun- 
ilM4 V'lumls show the following results : primary amputations — HO cases, 84 
<ImiIu. or it'-i.'-Vi per cent. ; intermeiliato amputations (from second to fourth 
4iT — 22 cases. 21 deaths, or 9."(.4") per cent. ; secondary or late amputations 
— ■-■ •■a.i.-s. 42 d<-iilhf. (ir 7I*.24 per cent. ; amputations in which the date is 
a ■: -tain I — >'''i caM-s, 11(1 itt'alh». i)r '.t'2.'.\i) |H-r cent. 



t'llAl'TKK IV. 

L'"AL liI-TlllHANt-KS (IK Cir.cn.ATlUN, AMI INKI.AMMATIOX. 

h' M. I>l-TllMi.4N<K,-' OK ('ll(r'll..VTIiiN.^Thcsf liLilV lie uf llirco kinds — 
L-ai .Vn^iniia : Active Ily[>erieiidn. Active t'liiifrcsrinn, iir Deleriiii nation 
'■: iJ.-.i; :ind I'ay^ivi' llvjit-riemia «r I'ti.-v'ive Cungii'tiiin. 

i.<K,Ai. AN-.»:MrA. 

local Aavinia niay Ik- i'i>inp]cte and permanent, a:' in uliliiirntiun of iho 
irt-ri-x 1< :i<jiti:; ti> a ]>art bv ihi- f»rniatitin <it'ii i-lni nf lilixid within llu-m, bv 
'ii-.a-.- .,j ilii-ir luiat?. Iiy prcs.>^ure fnim wiihnui, nr from ii wimnd. Cum- 

?"i>' aici'iiiia ni:iy roiili uImi Irom ililfuM-d prts'iiri' ailing no [lie ciijiilhirics. 
Ill '-"O'lili'-n niiist necert-arily leud ti> the dc:il1i cif [lie iiflictcd part, and 
■ ill lif oiUHilert.-il when treating "f giuignne. It may also be incomplete 



166 LOCAL DlSTURHAlfOES AHD IKrLAHH ATION. ■ 

and permanent from tl)u saine miree acting in a lea ilepVb ^'^'HH 
IVom any ckuim> the arleries lendinj' to ■ [lort are [ternuiBctillr iliRiiiiMfa^H 
ealibfi;, tbe niiiounc uf blotMl oirculnling throagli the arva Hupplietl liy tlrti 
miut uootvaarilr !>■ diminiflied. and the tisaun will aulfer in i>rotHirti'ri) ' 
\hc <)iininiiliiiu. Such a runditioo is vorjr cummon, an w ab»ll nnertnan 
ner, I'mni dc^oerntive changes in Uie uaat> of ibo anvrirs id uld ptvipli 
TJiidiT Nucfa ctrcuiDittiiDoeii, tbe nutritiun of the i»n u tmiwim). h 
fiildi-r Mild imlrr ibnn natural, the xru^'b of ibr r|>iilieltuni i* iitiprrfre 
nnil tlic vurtaci^ iii vlti'ii drv and ecalr; in a lini)>, thr nail* an- liritllr. ■ 
groir mora tlowljr than nalunil ; tin' mu»cl<« nn> weak, and nri' liahU 
imgtilar painful coDtraction* or <-raiiifi. Th« powrr "f ri.«i»lan(i' li> t-xmn 
injiirlM JsJnMned: a slight dcgrc i<r' mid cnum ^ngrcno; wnurid* trit 
lo (>lough ADd ulcaratioo to occur in thi- (kin I'miu flujx-rfidal abnjiionN, 
inflaRiRiation in gonernl ariK* froro cautw that would Iw tiarmltw U> 
boalthy part, and tends readily lo assume a spreading form and to Irmioai 
in Huppuration or fpingrcnfi. Perniancnl local aiia'iuta acts ther^rforc as 
of the mo6l iiDjMrtant predisiM«ing caiiMs of inllammati<Mi. IVinpoimi 
li>oal ana?mia may be produced inienlionally by the surgeon, as in llic lilti 
lt«t nielhodft uf operating already described, or by preesure applied to a 
bk-ridint,'- I'byaiulogjically, it is produced by contraction of the muscu 
fihre-cellit in the middle coat of the arteries. This may be brout;hl aiKKil b 
direct ittimuhktiuu of the artery, such aa ticcurs frrim uiechaiiicnl inJLiry, col 
or <'xpi>iur« in a wound, or ibrou)[h the medium uf the vaso-motor nH|H 
Stimulation uf tbe sympalhelic Derret, eiilier direct or reflex, muacM|H 
]><>rary c-»iilrniHi<>n <if the VMiielii in the area HUjiplied by the iMrvr* to wClS 
till.- vtimuliiH i* appln--)!. An fiimiliiir oxanipli-s of local aniMnia fr^im cui 
traction ol' the artcrii^. via may takf the- iltad-wliili' tvdor of fiOKrrv or tu 
Irom eipi»4iri- t<> cold, and the sDwmia of the bruin from iRMinaibilly irhl< 
furiiifi the condition iinown as ooaetMsion al\or a blow upon the lieni). IjimI 
aiia-mia of mie jmrl may remilt also from hy[KTBDmia of annllier, as tk 
amount of blood in tbe boily is not nearly sutiicieut to distend all tlte vi 
fullv. The must familiar example of this is the faintoctn from anemia of ti 
briiiu which results from immersiu); the body in a hot bath, by which t 
whole of the cutaneous reowls become widely dilated, thus more or l 
draiuiaj[ the internal parts. In ithateTer way temporary local anann 
is pivduced, aii soon as the cause is removed it ceasn, 8u<t t» replaced 
hy|>envmifl, varying; in intensity with the duration and dejjree of tlie prrvi 
anjcmia. Famdiar examples of Um are : the rexl jilnit that ituecfmla wlx 
the 6ngcn recover al\er having be«n "dead" with odd, and iJie hluKh an 
ooiiDg of bluotl thai f'llluKV the removal of ilic lotirDiqiiet in bloodld 
metliotb of operuiiiig:. 

ACriTX LOCAL UVITRXMIA, ACTtTR inXfllSTIOK, DKTKRMIKATIo:! OF 
HLOOD, OR FLVXtOJt. 

Thb condition eonabu oaMntinlly nf ao increased flow of blood to a 
owlnit to a dilalAtion of the artiTiea front rilniation of tbe muscular 
cells of thi middle cout. Tlw term "inorcaMsl vascular nctioo" lias 
oAeu afptied to this cotidition, allbouEh it is evident that the only acliun 
nriery i* callable of, tu., narrmrini! uf lis calibre by omtraction of its m 
cuUr mat, dimintshrs the afRux of blood. Determiiittli'ui of blood i* a vil 
pnxi-s*, 'irtcii very traupilory. nnd fre<|uenlly occurrinj; as a normal action 
ih'iM- (VHiditioDs of the syslciii in which, fur tcmporarv purjWMa, an inc 
bBIux of bl"") is called (or by particular organs. The turgor of the t 
tiMum, and tlie alRux of blood to the talirary glands during eecretion. 
hmiliar <>xampl«. 




lOCAt ACTITR nYFKRXUXA. 



167 



A> Ofttamd lool >utiply •>( liliiocl lir* si [lie Ivitlnm of tnoet ffiirpcnl pro- 
■M No pnxW* Im- w lii(-)i tliv M!pani[)iiii of ijnd purU ia efl^ted, or by 
itim rrtmit n( wnuni]* i>r ulcvra u carriwl out, i.'SD occur nitli out it. 
S*9y TaMglar luauc w HMtopliblis uf it ; aud in active prooeaom iu imn- 
nMkr ti^nm il m-cure iu lh« iiear«et veesela. The Sur|{eoo often excil4« it 
MfMiaaallf m une uT (lie idoM efficient of his therapeutic meaiiB. Under 
that dKvaatBBpm, tbererore, it ciui §earcely be coufridered a diaeaaek 

It h, bwu T t f, frvqiieutly anoriated with diseaae, fiinuing as it doc* an 
Mtkl pan lif all inlUmuiaturv prooCMCS. 

CMMfc— Tbe rryuloiioo o{ the cireiilalioa u under ihe coiilrol of tlie 
ifmfmthmtie n^a-mAi't nerves. We ha<re befiire seen Ihat Hituiulaliun of tlie 
^■^tfcilii caave* cootncituu of ibe arleriea and local an»raia: inhibition 
wfmitfi^ tit the srmpMthi'tic <:iiiims dilainiiod. Tbua wlien tbeB,vuipnlh«tic 
»r** is Um nrrk of a '[of: or rnbliit is dividt^l, or when iu mnn il i» invntvtl 
« W a iBiDof or an ai>puri»m. ibi- nn>Ti<» in tbu correspond injt iiile of tite 
W/fcfWimp (lilalnl, a freater alHux vt bloml tnkrn plaoi', nHlJeuiuK of tb« 
i^ aad Btoc-iu* ■ur(acii< ncciir:>. iini) the leui|>i-m[i:re in i[irrenji«tl — iu ulbar 
wrtu JXi'liniuaUoo of hluod reMulta. The ronlraclion nf llio vi<Mel« that 
■<W> iaaltuiuluiioti of the •ynipathetic tfulwny* fullnwrtl rapidly hv rvlaxii- 
IM •ith i 1, The ruo-nMAor nerve* may be nlfi-cloil nlio f>y rcllejt 

I: — .:..u of a m-ntvry ntrvt otusce imnicdiiiU- dilutnlion of tlte 
in the art* (upplied by that nerve. Another mark^wi example of 
'■•'-*'— mia i« the engnr^'nicnl of ihe kidney that often follows o^ra- 
Bwi urribra, and wbicli may terminate fstnlly. An irritant 

ffLnt •!'•■-• uy to a j<an may ctiuse dilatation of lh« vaceU tn two wnyi, 
hat, » a rrflrx manner by acting on the wnsorr nervea of the part; and, 
'Jy, by acting injuriously ou the arteries inemselvea, and )iarnlyung 
macular eoKbi. Thus, n blister vhen first applied cnuMa redness by 
I •• like m aa ory nerres ; but after il bas been on s-niie time, its action 
■flkinUlv df«ply to exert a directly injurious luflueDoe on the ve*- 
adi ik«MKlT<«. Thia latter condition b a jpart of true inllamniation. 
Hrawama alwayi a4^coropanied ibe excrcbe of mnetton ; occurring in (^Innda 
Ainf iKfTtion. mij*etr> duriiii; •■xerli>)n, e|c. To (hb clav of aiuw? may 
•bw rUein") the varinua form* »f unrmni deii<rniinnttui) »uch im erection, 
or iW «Dlnr|«iimI <>f the niammnrT vobi-Ih during pregnancy. LoMljr, 
•■■■ia «f noe pAit ma<r lie auiwinliil with bvjii'ni'mia of another, oonfVao- 
!■■ af tb* artcri** in tnv one cnu«in^ a nynipnlhi'liL- dilatation i>f the rmwb 
rflk»u(b*T. Tbu* px|>iHar« uf the surface tu Cold may cause hyperemia of 
iblvnf*, inLmtinn. or klihtcys. 

IfaplMt. — Thr >ympt<iiia of determination of Wood are ihn*e that we 
>Limi4 aipert to it»iiU fri>m an inerniwl iguantity of bloiHl runbiiig with 
,.1 .:.. ■i-iiut, ihr nflrfttvl trxlum*. Tli^y iin- lu fuUuws: 
I [ >rlet hue, nwrlling from tur^vccence of the vtwels, 

^U amvcijoir -. - iiK' .->iit)ci:oa oi nvll fut (•> ihe putient. u feoling of fulnuss 
■■dV UkroUnng, with ati iii<-nin*e in ihc (|ouii(ity of (he secretion of tlw part. 
HMa.^-Tlw «fttcl> uf simple bypi'ni-iiiia f»n rarely be Mdidieil uncom- 
■laHj by utbsT eooditicms. It nmy. hovrev-er, be broadly sl»te<l thiit, so 
img m III f lb* veneli arv healthy, mere increiisM) flow of blooil 

m^m On • --fjoran^ in the ulfecl^) area. In all cases in which tl it 

At pbmU uf l«e>l irriiatinn, i( i; mmplkated by a t;reiiter or lem d(f>ree of 
tn> ladaaMialvaa. Wbm due lo division of u nerve, ench as the sciaiiir, iu 
■iick ar* caolalood niMiirnml >ensorv luwi-ll .ts viu>>-mi.)ii>r fibres. il isdiffi- 
^llln JslMiiiiclH'wmurbof <hefffe<'t proibued i* due lo ihe mere juiralyais 
4t 1^ M<MmW dial uf the oMi-ries. In cases of hypenetnia from pronxuiv 
I tkm ajmpalbrtir in the neck, tb«tt it tntne TuIimb of ibe face, but DO 




168 



LOCAL UlSTHItnAXCES AXIi INFLAl 



Bilk- 111' Ihi.' fumv It givn< riai- t<> uii tc-tiifriiry Ui mpillHrv liimnrHuis*. 
|m>vi>li->l r)i<' v<¥M-ls lire Ix-iiltlij' ; but l<in^-oiiiliuiit'i] <ir rn:>|ut-iitlT rfiK-nUil 
ilelcniiiiiiiUxii uf l>l>io<l cnuM-s ix'niiiinrnt <liliilu(iiin "f Uir i-aiiillarir*, nml 
B<>iiio ihickt'niii^ uf ibtrir wkIU. In );ltiii<liiliir <hr|.'«ii> nclivi- lijiwiwitiia 
aiu«csiiticxc«f«ivc f1iiVi>r»i-crt'tt<jD. (><rtiw<i'iiiallT tl lutiy raiiM' liy{N;rlni|ihir; 
thus, till' ekin miiy Ht^uriM! » wmriv ■!>[»«> raiicc I'roin liy|M'rtn>phr oj' lU 
|»pilUi; in t)i« bT|M:ncniic mrca rwiiiii an ulcer, and Himctiiiio tltrrr iiuir (■ 
BB exoenivc k*^*^^ *>' ''"''' ^'^°' '''^ mmdc (.-aiue. 

pjumve costiBmux. 

Pftuive CongMtion or Fauive BTpenemia [ilnir* nn iRi|iiirlaiit pari 
OUrutTV : it ^ivt» riM- tu M!n»ui< strucitirnl rtiau^rB nml tti'ta a* n iiKiirribl 
prt*li*|>iH>iii)C citiiM' ■>!' inltiimmnli'ti). It ('iinKiMii i-McntiKlly of ncruiaulBliuli 
of bluoil ill ihc iifll-ctitl jiArl l'n>iu iiil<'rfi'n.-i)rr witli it* frtr- rctiim to llit- lirdrt. 
Till; bliioil ill the nfltcti:^! nro« i« mrt only erraily iDcrc«M>il in (|Uiiiililv, but 
it cir(;ulittt'i> liin^iiitly, ami. rrnni ib< [iruloii^] itny in thi' i-sjullnnr*. it 
l>Moiiio> uiori; (iimpU'tcly (knxidin-d ilian iinlurml, imd u rnnnrijiK-nlly nf s 
•liirk<;r i-olnr. Tin- ntti-ticH nn-. m nxatt. nf ihi'ir uonitiil «■»■, (xrhnfM t-vw 
tlicy may bi'CDiitnictcd. wliilr thr vntiKamlcnpillnrii^ iirp<li»l«tidt-il. \VhM(J 
thu circulation in th<- congwtcd part b«>coin« comptctvly nrmmJ. 
b «aid to occur. __^ 

CftBH*' — The force of grnTity pitiyo nn im|Kirt«nt pnrt in mnuy cii>c« n» t 
MUM of pateivG congestion. Mpecinlty in ihc [iclvic viscera, ihi- vri»« ofwhirli 
are unprovided irith vnlvcH. Its tflt-cla are, however, even nior« niurktii in 
lli<; let; wlit^n, as the rceult of dtHeoM-, ihe valvM have? become in<s>ni|>ciroL 
Under thcve cirtrunistaiK'ee the incr«u»e(l prewure leads in dilaialioit <jf the 
vHn» nnd capillar'''^><>i>d conwigurDily Ktarda Ihr tl'iw •<( IiI'mhI ihront^b 
thciu. Tliia condition in liTnxil hy|>>aial!o congntinn. Thi' nicut faniiluir 
CXuuipUv arc conev*lion of the Icplroin loiif^Mltinurd standing, and of tb* 
poetmor part of the lunp of ihoao who have b««n long ou«finr<l to a rccuni- 
lionl ixwilton. 

Any nR-chanioil ob«lru<-iiitn which incmmw the mivtanw in tbr wnuaa 
or iTafiillar^- cimilution «I»o givva riw 1» iwwtve congitition. Tin- ubvtnict* 
inj; cniiw in tlio veins iiiay \» nutJtidv or iiwidf the vi-«wl»— tbv fornH-r U-ing 
Mch conditions ns pncriiru of tutuom, or of fcn-c I'n tht' ]H-lvtc vrin^, iMirtioI 
itTBllgulatJon, as in hernin, i-lc. : nnd the iHltvr. i-ongtihtlion uf lilmul in iliv 
rein witli or nithuni indamMnitiort •<( iit i-niils, ni in nhilr irg ur phli^'iitn^ia 
dol«liB. Cuut;eMtton in [he capillaritv miii smalltT vein* nioiie is moil coni- 
monlj the result of altered vital relation lietween the nnll of iIk' V4-mfI and 
the ooiiiained blond : it then forntii a pari of inllammalion, and ia inosi 
pro|>t.>rly dtt-eritMii with ibat proeeos. 

A|cuin, rerifitauct- n'luainine un»lt«red, pawivc conceBlion mar Iw i-niued 
by a dimiuutiuu uf the nvruial fon^ea uf ihe i-ircidoliuu nhicb »)ii>iild uver- 
cunif it. I1n» we aec coD)ie*tJon of Om exirvmiiics in oxhauHtini- fe^ en fn 
which ihv prviiHiUivi' |Miui-r nf ihe heart i» gn-iUly diiuiuislied ; and th<- mmr. 
erudition n-uilily wM-tin in old peoplt!. I'nralyu'd liinba are ui-nalty cun- 
gwtrd and tviM. the cnutrration iiriHn); to a grrnl extt'Ot from the w«ui of 
muMrulnr roninairlion*. which Iw-lp »■ imwurfully t» drive tbc blood into and 
tltroujfh tlif vi-inii. 

IiBwtly, ibo propuUiv«> power betii); unalierrd, inrrm»cd reslMiiDcv may bt 
lDter|HM«d tn tlif atti-rinl srRletti ami h> (live nw to contcniiun. Thua Id 
iith«roRia tbr veimilH of thn li'i; may W (o nin<-b narniweil that, althflock 
admittinj^ *u(Iicii;nl hlorxl (o fill the vnMcli> tioyond, the foriv i» to much 



J 



rxS«tVK CONOKdTfO.V. 



itut it if alitKat eww^lcU-ly (■X[ivii<li-<1 tietorp tl)*; blood nachM 
, tad lliu* tMirtial )Ui^oatiou m-cim. Tlie must i^xtKine coDgMtiou 
r, tnrt xith mbi-ti a «niiill irnuiuiil nrtrry. i. e„ one Dot «iiHStoniO»- 
I odM'r «nrri«. kx-oiiir* etiiliivDly obliu-futml its by emlxtliHiu. The 
■4*4pc*aiurT u mJuvvd t" nothing lu tbe arm siipplkii by ttie plu;;^cil 
mm, vkiW iu the •arriKiitiliii;; liaeiiH are cnininijDifatiiiK cspilliifiia, in 
■tic* ite Di*>ta>l pnamirr rxistfi; c<iii«ei)Urntly llir vMiioU •<( tin- iilTecic-al 
Mrt b«OH> filM with ri-KUt>;itiiDt blootl, whilt itt (lie «ame time cliere U uo 
M*lB«aptjr thfOt. A »iniiiar rt>i)ilUi<>n i-f init^uw |NU»iv« ixinstetion U 
IWT AvfocatlT nwl nilh by tlic r-urKvui) ■» iiinkrniiuixl ]Mrti->n» ut' *kiti 
■AnA kar* b««a (t^privtil of tli<^ir (lire<a irtfriul supply by iliiiirut-iiiiii nf 
lb whiiifiwnwi timwv ■■ ■» ptil«Kmiiii»u< i-ryMpelnAoruipta^i-ii)! otriini'iiu 
ikmmm, Tb* Uim UBdenntiiMl Akin ttiun nrwiuced, nuij Ihivit IwcwtH-ii 
It laJ jith ft-r tH<>dth*.(l«lByiii{:bi'iilinj{ in<l(-liiiUcly, mid at lut re(|iiiritijj 
Itmiinii bofun « rare cftn iW oltiiiini-.!. 

MMIIi — Tbt^r uv uf much Miri;i('iil iiii|>iirtiiii(.y. Thi' lint cliimj^u ibnl 
«M&t taJu* filftce it InmniiilAliofi nl' llic tii'>r<' niiirry ciiiis(iUi4'nli> uf tbff 
yadato tlMMtrrtMniliiit: itMuc. Ilvun- th*- mikil-iv uf nn>»litr iJMiii; ■» 
Am«J>iI (<< (til- riTiiKil Duid. ^vinjf Hm: U> tlic ri>nflilM>ii Itnown (u attwia, 

U •■ i the vtwH-l* h- en-nt rikI tbi-ir wnllc at tliv Mtiiiv time 

■in ..- will nn-ur, Htiil bviivrrhag" ri^tiii ilw i>iirriu-« or into ibt 

■l«i (i«rt will (.'RMHi. OWrvmiifitf ain>)r- an tlii.- (m^'t foul atitr 

KgMaiT ^i L r:inin win •li'iw. bonrri-T, tbat in tni»k-nit^'ly iiili-iiet.' t-nngci^ 
M,lbt n'l -■; -In (mum tbriMi;:!) lh« wnllf uf the capilliiHrv inin (be nir- 



_, tu»4K*. Milhuut Miiy npjKirt-nt riiptiire, by b procrH of iliaiiciints. 

Hm tmj omr «ilh tbi- [iiMMi-;e ut' very f«w while vorpusclts ]>rovi<leil iht 

NSili an bnltby. TIm- ml corfiuft-ln tbiit llius cst^iipo Troni tbp vcstclft 

ttp aicl arr al><><rlHi|, Inii uiri»' 'if tlie nlt<*riil bl<HHl-pii:ni«nt reiauioB 

aB'i . ' I ,,'n^'ninrtoii ul' inuottis nxinibruDc or tlio brown 

p: < < w I'liamcl'Tinlip ol' rt'iicatoit ur lo»)i;-<;uuiiiine«l 

tmmttitm. 

Mmtiau buna iIm- Er<t«(li of Ahmia] UMUf, rbi«lly around the itittendod 

*«a>li, !• ma alnioi (iintiaiil i-nuxriuvDeo of repeated or lon^-ountinucd 

Mww emgrrtioci. Itiit attboneli tlic alfeci«il fwrt mav h<> iucrOBM-il id 

I WkilWauraal iiMnr i* atnipbii.ll frnni lli4> pm>iirc til (hi* new urriKlb. 

I RtWi" ilw l-^t illu.rr.»t[ 111 iif iliU iifKM'w 'v allortW by iln- nutmrij'livr 

t** i:ilMl vriib fibs]rurlivr diw-tw "f ihr lirnri. It 

>•.• ' — vonxi-t nuirkdl p>Hl-nion«.'ni signs ol' pMlwigod 

«tT|vKtr> .'Mii'iiitKioii nnd induration. 

^v TVr m*mi ....)■ IT l:.ui ru>: I. lio«)'v«r, of puatvo by|N-n»mia is, pcrhaiw. tlw 

^|b«cRa( ofllM' vitality of Ibf nir^irlrd pnri. rvndrring il prnnr Iu inflamt- or 

^^hknslr (n4a tliebt raunw. In oinj^t-elinn, iiltli'iif-b th« part contain* a 

^UMI rioo* of blooi] at any givru time, it ■« not i^linn;,'c<l wilh snlfii-ivnt I'rr- 

^ W^(J, MHt aiaar<}U«t)ll)r the amuiint (>f bluod ibnt circulatra is ividly lc» 

■MMiiuml. 

IfMMai, — I^iaiTr crtogfitiow of an cxtiTiial {nrt innv Ixr rt'iidily rrcog- 
■■■I by lb* Htaftfr* )( indiicc* in tin* o>1of, Ibtr tite, the r<i'l, (liu l<'ni{)rra- 
*»!. ud the ' iif ihp (xtn, Tbo odnr ruii|."H from durk rwl to 

Unri) ^rp)*, ' ' 1" t-riti >'«p<K>cil frvi|Ui-ntiy M prvvimts nlia^ks of 

' Mioe, it (^ < <nli<l nitil bnxin in oilor; il it Jncrciwed 

f. If tit* ■ I >in'l flcutr, it in soil iVom »i)dna, ami pIlB 

tb»prn» 't; if it i* old and chronic, ibfltnn** are indu- 

mJ ImMi... 4 . . ,...:i('iil i* ci>iiM-i»»i of a Iivhtv, dull, aching mum- 
IB il. antrcviy amounliaK (u fmia. but yrt atirndcd triih iini-auncia. 




LOCAL DISTORBANCKS AMD HrrLAUMATIOJC. 



Till' icnip«ratur« 14 atfvcr mbove, but blleit betow, ibe OKtunl sUutdud, nod 
lli« fliactioDS arc Icateued in actirkj. 

TIh> exisMice of oougeatioo id su iQt«rnA] organ may be aact-rlAinM by 
finding iu 8ii« inoreasnl and iu fuuctions mmlilled, with a mdhuJoii of 
m-ifibt in it. Tli* arinpUHOs are ullcii, howerer, very obscur*. 

nvttment. — No treuUueiit nf piuwivi- conicMtiun t-im be succcnAil iinlav 
Um cauite cau b« removed. The lirst linlii-iiiidi) coitusu iu tli«Ti'iuoval nf 
any nurce of ul«iriicli<n) t<> ttio nMurii of blood from tliv |Min. M by locMft- 
ing a ti^it bandnf^i', or <<li!vatiiig n jxirt lliM bM bemi UM inag d^MDdeot. 
If tlif (.■ikiigeadoD be dun u> th« fncblv acitoa of ihc brnrt, ulmulanu and 
d)j[iiali--> luiiy bo ofwrvice in rdieving it. 

Tbi! next indioAtion i-unttivU in Inxwuing th^^ <|uantity of bl'Nid in Um 
OongcMcd part. Tbi' nwrr n-mo\-aluf tku<jl)«tructiii)( munc inny vlfi-ct lliia; 
but iha <lc«irod I'flTcrl ii" often hiwlcncd by the direct n-ninviil <>f blood br 
twitrificalmn, or by tbc apjiliralion of lcpcha>. Tliv ovcr-iliatcnd*^ vtMeli 
mar in aoina cum bo rcli<-vca) by prom<iting a frcu sccn-ti<iu fn>m tbi^ f»rt, 
M by lb« adminiaUation uf pnrgutivos for portal cungwlion. Iti wimp imrt*. 
again, thi* jiididoui upplicntion of pnnwurp by menus of a bandog' will pro- 
vent or nOierc cougrstion bv liroitin); atlfniu und by ooinprtweiii^' ibr dilat«tl 
v«CMli,nrids')niu»inBtliP blood to Hon more nipidly ibrtxigh tbrin, pr«vM<d 
the prtmiire ht not aufficicDtly poirerful to intorfi^re nilb the curn-til ibniucb 
tbi* nrlcric*. Wilb tliii> rieir, cliutic prvtaiire is appli«d to iupptirt vnri<x»« 
vciiM ifi the Irf,', and to diiniuiab ibi* Biecbanicsl bypenemia of the akin ibat 
UHinlly acvonipauim tbom. 

T)ie third indwation iu Ibe treatment oroonmMion eowicU in coiictrinjriui; 
the dilated Tcattia by the dirut application of an astringent to ibciu ; thiu, 
we apply nitrate of silver to c<w;[eated miicoin roeinbranea, and t-old douobw 
to tunuy exteruni fonnx of pMiitrc bypcnfrmia. 

trritAXori^Tio:!. 

Strangatation n the olMruclioo of tbe circtilntion eauwd bv a najrow 
;Df prcsMirc acting both upon the arteritv and VDtna, a* wnoa a ti^ 
Igt la applied round n limb, fftrnn^lation may be at oneo oomidaH^ 
the rirrulntion through both arteries aod veins being iimultnniMUtlv amMad, 
■■ in ihi- 9i|)pliraiion of the touroiqa«L The drcitlslion below tno band ia 
at oDoe arrealed, but no visible cbaogo oi-cur in the part. n»r «vuld thar 
do so till gangrene and decompoeiii<in onmnieiicvd. In niH« in «ki<a 
•trfliiijniation in an'idi'ntal or palbolugical i( h morv oonraonly ini.»<npUt* 
attlntt; the olMtructi<<u aeiit nrst on tbe veiui, owing to tbo lowi-r blood- 
prOMire within tbem, tlie flow throuf;h the arteriea cuulinuiug. A« a eon- 
wquenee of this, thv pbenomeUA of piiuive congeeiion appear in their inoat 
IntenN form ; the jiartri below the eou«lHcti'>u bocooie gorged with bluod, 
pnrple or black in mlnr, cold and numb. There ia great swelling, and often 
abnndant faoii|ie of reil o>r|<u#cl«a from tbe rcatela, or rupture of tl>e captl- 
lariat with extra voMtinn of blood. Aa tlie nart swelb. tbe eoasirirtinn 
beooma tighter, ilie ohdruction to th« arterial fluw increuaea, am) finally 
circniatiun U eoniplt-u-ly arroited, and gaogreiw m-u in. 



I 
{ 




INFLAMMATION. 

Tbi- •ludy of tbfl (nflammnt'iry prooon b ooe of the neM dlAeah 
wbirh ihr Siii^MB can nnliT; but tbc labor r«qaircd to maater Ua detiUi I 
well l»at»wr<l, iiutimiuob ajt an ni.-i|uaiuiunc« with its natur*. aympionia, and 
progrcM give* aii insight into the greater fut of tlw tJeleooe of Surg«rf . 



J 



INFLAUMATIOK. 



in 



n#^aaMin>l of tndaiDuntiuD, u it aflwu d)B<;n'nt Uauw sod orgiw, 
Mrf li itlii muni b aAbctnl hy vnrioua cuucnmitanl clrrtimitiinrcii. COtn- 
frin 1 ;rai {wrt nr llio duties of m tkir^L-vn. T)io TbfHiry nf Inilniniiiittion 
aafmli ' ' li-ificul M>d pi>l)iolu)iical utiidv ; nod, )i'iwi-vit intcnMuig 
iMiiivili. ir br, vri, m» tlir diivUMJoii <>f tliia i>uhJ4'cl bflougs ralber 

I* b* <WBiiiD ui Oment I'litJiologv tluu) to that iif Prnclicnl t^iirerrf. it 
OHM Aatiauatly be rou-n-d tipoohan otlwnrMr thiio in •milinr To gitio 

■ Mif^oilBliwcu with ihp prvwnt MM* of (wr kiii>«rl<-i)^'<' n-^iritiiig thv 
WaM> ■MW, (vifjn, *o<l pro^nMortliV inflwatniilnry iiriH^-^F. llii- vtiidrut 
wtm osOMiU work* <m gvuKnl paU>ol«g<r. nnd the writing ol' ilxwe »ltf<-nvrB 

■ thi» ooantTT aad abiwad who bKV« made indanimatioa the siibjvii of «p<s 
dd towMJeatiow.' 

Cf la • enaif«nUirttl]r nrcnt |>eriod, inflnmmiilion wu rccudod by oil 
pikdeptltmm proomemMiatiogeeeeDtially of "a pervereion of thoiimturt) 
■ftiifDuiritMiiaftb* part," and m<»t rcf^riled it ii» a condition of iocnsiiMd 
•' the proctflMB of Dutniion, if not t))rout;boul it§ ei)ur»e, nl any 
:„. .; .;« comii>rac«in«il. lo lUiS, Lister, aa the result of his obwrva- 
tNM,arriT«l al tb« conclmioii that, from (he ver.T enrliest ilufic, ioilniniiia- 
Wa ii Bot an i&rrmw, but a dMratse of th« vital aciivitr uf th« aflbcted 
tM»a Tbi* tbcorv t)dnt;. bo«ev«r.dil!iL'ult to reconcile wilb th« "Cellular 
ftibolcay " i>f VtTvbav, in so far lu that xy^li-m referred to iDflaniniatlon, 
M(«iu but liulc favor till aA«r the rodiscovcry l>r Oihribi-im, in 1S<>7, of 
AtwmMiom of ih* white (.-orpUAcIo uf thir blmHt fmm the Tuxtfls during 
1 a procaw br vhich ibe ii[i|H-iiriio<x- of new cellii in iin nrtilvly 
«■« frilly accounlinl for. vrithnut thr nn'rwily of iitiipiv-ing 
MyiacTMMd ■niviiy. rilhvr nutnltvv <>r fonnntive, in the ori^niud (iauit 
tflW |«n durinj: the early >tag(fl uf thv nnni-w. Prrini thi» linii' l'i>rwiinl», 
rfibaiiuiion* have tended in the Mine aireeiion. until, at the privenl dnv, 
tWirfailhfi of inllaniiiiiilioii picen by Burd<>ii-t*iiDder*aiM in IHT'i. noufd 
WalwiM tinitrnally ni-i-<'|kted. " Inllaininaiion is the HucveiwiuD of chiinj^ 
*U(fctvmr> ill ■ livini; liaaue ulien it \a iujut«il. pr>>vidMl thni the injury 

■ M ^ Mu ^ n il>-t;t«p at, nt uuce i» destroy its »irut'tiire and vitality." 
tekr f inllainMintiiin 'a tltriveil chifHy from otmervatious of 

(hifncv :iy itMlueed in Mue tron*|>iir>-nt tituue in a Uvinx nnitnul, 

TW «A I and ibe tacKntery nf the fro^. nnd tbe toDm'L- of the 

.bav> i-io M.icAy mQ'le nw nf In order to [<rove tlif fuel Ihiit tlie 
vlvervnl to the fnic are idcnlSea] with thuM that orcur, under 



aadu rireonwt»B(«a, in niammaiii. thv wing nf iht bnt »«■ uHeil by PniiEel, 
*d mtrr lat«ly tba aMaentxrv a( th* rabbit hiu aim \>n-n •uc<-i'»BrulIy 
niwiMamri ufcm. I.aatly. Kui-|i-r, by obMrTations undo oD ibe mucdu't 
■■taaa vf ibr lip, tboKo^ that the pniomMi ohMrved t» roan am idea- 
iU «iih Unas that ticeur in tlte lower nnimnl*. MicniAeopc riaminaiioD 

|>CM tl ■■ moat iniiiiirtaiit virki (o wlikb tlx' Mudunl in*y 

>> ua III* t><^o>*4 uf irnlainamttoo snil •■[> til* liitlulxtftc*! 

l'lll^-tl<, " L'<~ti»r'< > II S.ireirnl ralholocy" (Kiielith Ti«ni- 

'(•/, ■• V>n«al ..r r»ih..t,-vtWI Illntolocy " ( Kngllih Tran'la- 

ni ' fli.r,-..r," 14 rilitl'in i AtiI'-'" ■"' " Tf.flnnilnalli'n." by 

"fwn ; Gmin. ■' Mali ■ iti-ejr ;■■ " Lwt- 

bt l>r J. S )l.if<l'>r . •< . lAutftt. rot- i. 

J^rti^i, vuV I, I^Ji U'lor vii lb« "K*rly Slac«> "t 

■^1 TVaHn^/i'ont, purl ll. IRS.^, TlioM whu fnA 'tonnui 

" ' ■ nkeim'i " VorLrtune^n Ub«r At i ■ Pntlio- 

' •mmnl nf ihr lntt«mni*t->ri| - I'r mM 

■- I ■- 'I'lroJ (tiiilvnt wbo hai il-Mri>iiEiili wu. 

I'll la ^n initniettoM by r«MllBK8lr 




172 



LOCAL DTSTl'RBANCEa AND 1 X FL A M J1 A 11 OX , 



of nivpiiml Mx'cirnrii* nf iofliimoil liuiimu ti»fliti-!i iilmi iliowit npixnmms 
wbioh nri^ n-miily i-xjilitiinul by whnl U M-ct] t<i anna iliiriiig nvtuiil obovrvti- 
tion uf llir i)ri>r(9i< irt itillmiiiijiitiuu in itic Ini^. 

If ihv wcl> of II <V<ig'.i t'i>til be .ii)rciiii <>ut iiiirl osniniiiei) witb the mifni- 
scoiif, i\»: bliinil in »ci'ii til lliiw in a c'tiiciiiuoui' Ktrt'iim ihruueli llir ■nmll 
urterkf, cn|>illiiric», ami vi-iit.'. In nny v<mm-1 uliicb is iif siiKicti-nl ww to 
albiw wvprnl mrpiwrb-* t-j i>a--w iii the siiuk- linir. (he n-d corpiixli-s Hiivr in 
thi- LTiilri' III' llw strraiii. dirriiiny ii yillow lini-. wliilc im wich ^i'lc ol' thii' U 
« mbirlcM *onc, IrtH' tVuiii rtil corpiijiclw. knoitn iiit the im-rr luycr. In tho 
inert Inrrr U tvcn an iiccttfi'mnl while oorpiisclf. |>H*>iing coniewhiil Inzily 
along, uitli aomt': tci)J(Micy tit mllK-rtr cn [he wall ol' ilip vce«cl. II' from iior 
cauao the fcirettm Iw tUm cnmieh tu alluw of tho imlivitlual red curpuscirs 
bc'iD;; ohserveH, it will bo sc«n llint they fihow nu Iciiiicney lo niliiere tu each 
other or to ihu wall of tlit' vcmcI ; nllhuiifib. ns every oiio kiiowe. when 
removed from tho iiitluotico of the living voii«els they fibonv a remarkable 
<te)>ree of adhosirones^. Hiekiug Dot only t» each olher, but to every eoliit 
btxly u'iili Hhich I hey come in contact. The arteries show eiiDBlaiit slight 
vnriations in onlibre, which »roDut rhylhinioai. and are depeudont ou cauBea 
the exail tintuie of wliicli is iim-ertain. Tho flow through the cnhillariea 
vuri«4 ill rapidity with ihe Male of the artery, being more rapid when the 
v«!?aol iHdilHie<l and alower when it is contracted. In observing the foot of 
I the fni^, thure nill ala-i be aeen a beautiful iiystem of branched ctiWa ctm- 
''tei»in|£ piKmvni-icTunule!!, by me«na of which the aninjal is able to change 
the lint of hiH »kin. Whc-n the piKmeot ia collected into n cln-^i^y pncko'l 
■dujci nmnd the niich^us of the cell, the frog i* ptkle ; uht-D it is ilifluseil 
I •mnly tlircinghout Ihir nliole cell, iht! animal hciiinii» of a darker tiut. 
ThftM! variutionn of tint oci<ur under the influenon of li^dit, the fn>g bc'cuoiiu^ 

iudc when vxp'Mx-d in brijflit li^ht und ilnrk umlcr tht! i)p)H)tiitc i-ouiHttou. 
Phns, thoji, in the- hrjilllij' web, then- ur« llini' p hen omen a of i-iuy obgicrva- 
tion, which indicatis the vtltil ticltvity of the limnc*, the want of adIuwvMicM 
of ibc eorpiiMOcii, th« vartutioni< in the ciilibm of the artrrr, and tho lUovo- 
inCRt of tlic pi^mrnt cclln. There in vet aniilher »igii of bcaltb which is not 
Id bo obM*.rveiI with ei]nal ctifie, iind tliat id that the cnpillaricx allow no more 
wrum to exuili- through their walU than i* neen^nry for the healthy nutri- 
tion of thr surrounding tiwuiex, nnd the animint it «ich that any excow can 
he r«idily dniincil awsy by the lymphatiot, 

SupnoBing now that »omc trrllntinc siihstnnce be applied to the web, thn 
uormal phtiionitna just drseribed will he t!i»liirbiii propuriionntelv to the 
potency of the irritant cmplnyed, or, in other wordu, to ihc degree <■!" injury 
(l«He to the tiMues. The imroodinto eHect "ff^nch an injury is, in inont cnK«, 
11 ili/titiiHim of the arlfnr-a, \\\\ li iiti iiirrfiMit tin"' of liliiiiit t" the arm injurMl. 
This is spokt'ii i>f as determination of blood to the part -active hypeneuift — 
active 00 n^lti on—or fluxion. 8>ime irrilnnls.siR'h ns nnniionia or mccbaii- 
ical rioleneo. c«iiw ", nfrurtWH of very *hiirl dnrntion, which procedea the 
dilatation, but this is aluavfi nf brict' continuance and of but little impor* 
tunce. The vidonint; of the artery ailoivs a );reater quantity of blood to 
flon- into the capillaries which consequently become ditate<l in their turn, at 
the same time the flow of blond thruuKh them is accelerated : lastly, the 
dilalatioD extends to the vein. It wouhl seem, nt tinit si^ht. that diliUntinn of 
the ebaDnels throuKb uhicb the blood is llowin};, would lend to n slackening 
of the current rather than to an increased rapidity of flow : and so it reould, 
if the dilatation occurred equally in arteries, capillaries, and veins — but ihu 
is iurt the case. The small arlerii* are c«i|inbt« of very gtv«it variations in 
aise, Bumetimes contractinu' almost to oUHteraiion and at others expanding to 
L many times their onlinary calibre. The capillarivs, on the other hand, are 



mCllOSCOPIO CIIANOKS IX INFLAMMATION. 



178 



' prupnrtionallr mtKh less (|ilniatian, and micIi iri<kuinu w don 
IB purelv (twwive itntl n c»D*«*|iteucv of ilu> iiicn^i>o<T prnmin 
I kr tlk« rvlasftllon of (lie itrurie!!, Ttic nrl^n- iu u •HlnU'cl slnli- will 
aMli ik MpillKTira )iiu|>filin< itiaiiv tiiiicA (Ik- ifiiunliiy 'if blool it iillom 
l»(Mi«lMn oaBUsLtiil, liiit the ooiiilnriixl H^'tir^iinl iin-ii uf tbp cnfiUlanM 
ii MMMkI unit l>v ■ frftrtiuuiil [inrt. It » eTiilcut, iWr^forf, that tlxi 
nfUky id ikut Sow iuu»t b«- im-mi^il. 

iW OMMT uf tke irbriul ililnt»lti<u in lirofolil. Il lin« Ix^-n tihown bv 
«|WIaMt that irritali'Mi i)!* u M-ii">r_v iiprvr miim-n (lilnUtiimi <if t|i<' nrd-rin 
■ ihr«bul*Bra(up]>li4->l liv iliiit iiiTvc. Thin in II i>iin-ly rrllrx i>luii'>iii- 
Phn. lltcrrfon-, <'f llx- •lilniBli<-« it Aw l<> tlii# cniif*-. nnO w iiM nc4.-u- 
' trauUd lo thv nn-v irijLHt-<). In ilu- iiijuml arm ilM-IT, Ixiwcvfr, iIil- 
1 da» t" itie dim-t i-ll^-t jinwlur"! upon the vi-swrl* <>\' (hi- piirt by 
t^Mtjary iImI burattMd tbt'duturbwiic*: b^rv (he niu»inil»r ttMiiv of rliv 
«all aftmn b |«nil<rwd. Thiit tbis h «o in lurtb«r tbuwii by tbi; linct ibal 
*» Aif m of tbr ililaiittiuu is fixed niid iitiironi), all tho«v rariutiODH before 
vnCy^ad u oerurriii}: iu beallb beiiif; nbarDt. 

It xhm irritant api'liol tu the web <if ibe frug's fimt he mi>i« powerful, it 
■u ba diScalt !•> ottMTTC eiilier ihe stn^e of coiilractiiw, suppoetti}; il la 
aw, IV tke Mail* tif dilaialion willi iiicrentvil nipidiiy of How, for before 
tbaiOMmfv eait b<> briMiKbi Iu bnir on ibe web. tin- eircululinn will have 
wdtr^mmt ifaiH citaoifo. Tlii> vessel will be dilal<-ii a» wiilely an {Ki»ilile, 
W Aajbw tif hiovl, inMtad of being infrr-i*td in ntfitdily, wUI 6t rtlardittf or 
m»mrml4 iL la unlcr tu nbatrve the developnicui of thb aiai« of the i.-ir- 
aihlM with (tvmtrr aix'urncv the mirtieutirry i>f ilie tvi); must be iiinde uw 
4m4 »< fitrthrr trrtiiiiion itisii rxpivure i<> lilt- air be applk-d. In u 
mmatftr.ptr-: ^r-^l iitnl pr<i|ifie<l fnini iioedlUB aourMS of irrJta- 

M. IW rrtt: ill'- liloHl-ntrcain ninr Ih> il«tnyRl for DUiiiv hour*. 

t^iaojtci wii -i_'Lj> iif riinritiiiiiiti i>l thi* hliHxI-iitmim.B vnaiiiri' i* 

la tif I ■!'. ilir ci>rpUBi'l<-» to each iitliiT and l>i ih^ walU of 

'ibty Oil IdiiciT II.pw fni^ly mid M'i)aral4?Iy onwiiriU, but »h>>w 
»idltmranm uot ■-ilwrrTiil Iw-fore. in t>tiiiHH|urncic <>f which lliry icn^l to 
^rt M tmA dbrr and to the wall of thv v<3«<d ihmu|;h whirh tbcy iin' 
fai t . We bar* b«(bn> seen tJint even in boHlth the whitv corpUH-)«s show 
•^ dtvnv "f adbnivenca», and are to be M^ti rolling along the wall of iIk 
•«id IB tita toMt layer. It is doI surprising, therefore, that the lir«t fli);ua 
^■OMwd adboinnni arc iioticL-d in the whito crpiifdM. which fall out 
■d iW amJ ftraua von and n>ore. and adlteiv to the wall» of the veawlr, 
*Ut ibc md cooiinuc to paw onwards. Thus, al\er a shvrl time, a great 
■mB» of white cnqwnciv U observed in tbo TeaMh of the inflamed area ; 
■a4 la tb« aaiall rnn*, in which the forte of the dreulaiioo is least, they 
*■• Sma a uaUuna layer, nlm'Wt like no epithelium, adheriii); I" the inner 
•at *itht raaal. Thar ari-. lu it were, filtered out of the pm«in); hl-M>d. the 
MtflBiaf on whiUt they n^maiu behind. Alterai^hun timi-. a« th<^ vilulity 
«^tW— aury faiU. thv rod [-orpuscle* also l>eK<n to become arreiited in 
'^aifmmgn t^nttgh ttw r««ela, tint in veioB nml cupilian«H, nod jiunlly in 
^MwiHL Ib tM aniall arterfia the 0r»t'tl(ni of rciardniioa t» ilint a lew 
M|aKlei atick to thv inwr o»«t iluritic •lia.->|i>li' of the heart, and are <lriven 
*aaiik* arxt nyatolx: and tbua the xtrrnm, whli-h in btMllh n uniform in 
^ men ininiit<- arli-no, bccofno* pulMting. A* th« vitality of lh« [«Tt 
<>b tfill kiwrr, tlw !!■" "i-'-l-tioD of corputclca incrtou^ nil the vomel* 
^■iBa ckiktd : lh<- r^i ■■» forming, in tb* fms, a vcllowitih maw in 

•M tbr iadlTKiiial I'l :■ witioirt tio rrcoiniiu<f. All circuliition i« ihua 
' W ai il : a ruci'ltlian knonn as "itatU.** Iinmoliairly Wfi.re «ta*ia be* 
< a aligbi ntuvcfiti'iit funrnrd Riay he DvtioM with each lyvUde 




LOCAL DISTCBBANCSS A»D IKFLAU U ATIOM. 



of tbe bean, follovcil t>v a reiurn ofthv ourpuMlM to their loriii<-r MlumH 
durioj; diutoU, an ap|io«niiicv to wliicb lh« naiaeof "owiUation" i» jciMi 
The ume occtipk'i] in (Iiu ilwf loimKnl uf oMD|il«ie Mui* » eniin-ty Jepra* 
d«Dt on Uiv nniurv »{ tlic injurjr which chum* it- It may be itKlacad 
iotfai)tati«ou«lj' hj tb« applicitliun dF laiy Mrong imlnnt Lo lh« wvb of ■ 
fto^** fool; while, in n i-iirt-liilly Icndvd mnciitcry, iu advent tnny bi 
delayed for n wbulc dny or wen lungtT. tt '» evitluut thitt (he <'>-ii<litiuB ol 
ttuw involvta » cnmpkle arn-al ol' imlrilion in the «urroii»din][ twnca 
nhich must, unh-w rclicve<l, inevihibly end in ihrir deiitb bofofw kntff- 
Slwuld ihiit otciir, the liquor ranguinis nhieh itill rvowiiu in NnNtll (luaniity 
amonvM ihe elotu-ly fmciicd corpu^cke enugulnttM, and «ll«i« booonHii cud- 
fwuu into thromfioiis; thnt is to mv. plugging of vcmvU with eoagalaud 
blood. On ihrollKT hHiid. ?hoiild the liwufSDnt be iojurrd l>eyond ncomj, 
tiu' L-ondiliiiii ut' stasia )>ra(liifllly pnf«i« off; al firel, aomt! taciltatory iilovr> 
ment is noliccl : ihcu a lew of the oorpuK'Ica at ihe margina begin to bmk 
away into the bliHid-Mrcan), and finally they all levin to loM all lauttacj 14 
stii-k to each other 'jr to the veaeel, and move off, and tb« ciroulatioD pad- 
ually riMuniea iia uormul charaeter. 

The retarded flow and ttoiu are deterges of the tame eondition. and il 
remains now to eoneider the cauMW which hriox it aboul. In the btaltby 
Btate of the cirirulatiun, an before stated, the eorpuoclev show no tendotugr td 
adhere to encb other rir to the wallH of tlie vtwela through wbiob thsf art 
flowinif ; on the other hsml, both rod and white c«q>u*cleB ahow a very coO' 
Htdenible define uf ndhoivemM when reuoi-ed fmiu the body. In stickiag 
lo each other and t» ihe walU uf the vetaclc, tbey aiv, iberefure, behavi 
iu the livin? bodv a> if they were in oontact with dead matter: and 
ouucluftiiin Jt'rivnli fr<ini tliif if that tu tl>e healthy living li»ues th 
form at work, <Y the nature of which we are ignorant, which oountvi 
Dutiiral adhi-ivvnow of the corpOMk-e; but that when the vitality of 
iakiwer^it by iliimagcof any kind, ibis jHtwcr la din)iui«hcd or loiCacc 
to thr iWrei.' of damue the tiamea faavo auflvred, and coDacquenilv 
natural aJhcfivcDefB 01 the cnrpuedcs comes into play, cansing iuer<'ai 
njaiXance to the flow through the VHaela an<l a cornapoodiag drgrra 
nUardation of the blood-elream. The accumulation of the whito cori 
ii oxplniocd by the fact that they pooMM a greater degree of adbcai 
than the red; their form al^) favora tlieir adhesion to the aides uflh«V' 
That the change is not in the corpuaclea ihemtelvea, nor in the liquor 
guinis, it shown by the fact that, if an irritant be applied to K wtr <i 
ina, so that a corpuscle can be wati'lied through it, it will Iw Mvn that 
adhceiveness allows it«elf oidjr while the corpusde is in the alfi'<^ird arc*; 
moment it pasacs beyond it, it movM freely on as before. Tlial the reia: 
lion of the How is not tko cause of the adlHaion of the ciiriHitclva is 
by the fact that, if a li^ture be plaoed tightly round the limh of tlw 
to as to arrest circulation entirely, no oiTheston of tlie oorpu»clea to < 
otlier or to the Teasels is ofaservnl till the lidsucs begin lo lose their vitalii 
a ivindition which, in the frog, will not come itu for tweutv-four bou 
C>hulH-im atlributru all the |>hteoni«na of inllammaiitMi in tfie lirM 
to molecular dianeca, aceom)iiaaicd by loss of vitality, in the walls 
TBWsIs; and probably iu many cases of inflammaiiun in which thesoi 
Irrilatton is carriod to tlic part by ttio vtssaU their «alk> nudVr fino. Ni 
doubt, also, if Ihe capillaritw evuld ncapa in the caw: of a k-cal injury, suol 
as l]i« application of muntard tu tlw wsb of a fnie's I'out. tlie vaacula 
pbanotnena of inflammation cuuld not occur. But it it inipostiible, oven it 
tiaaginatioi), to scpanite the tiMurs from the capillarita in vascular jiarta 
aad whether lh« source of dnniogv comes fkvm wltltout, or from aitltio, thi 



mcfiDvooric cn^KGEs ik ixruAUMATioN. 175 

t^ikif it i*o^ Mifflrinni pnnrr to caiu'c tD fin m inn I ion, ibe BUrrouodiog 
■MM MBCtkmllv miut •ullrr wilh Umi vraMla. lu tUif cxpcrinHuls uu ihc 
WkMl, LwirraJi'innt ilmi iltr oKiTOfMlttiof ifae pigmrnt in the broucheil 
■BMBWd vbnxMrrr the flow in tbo vcnels wu rclinleH. provioK ifaai titcy 
i^mJ Mlvalljr wlUi tli« vnwtn from tfao pffccts "f the irritant. 

BsriOf tfcoa Umod ibe cliUDgrr that c*n Iw rrailily obeervcil in tlic rtTrii- 
IMmb <f SB tolhuo**! part, wr tiiui>t now turn ''iir nU«nli»ii to the procestea 
I ia tK« lUToaiidiBff tiMup* ud In the walls of tho v«uelJ ttieiii- 
fi.t ilii* jiiu|>«M-. l)i<- wvb ••!' itiu fru^''!! r<H>[ is iinl »ell Miiloil. tht 



mmmlnj of ibe frug nr tunguo of thn toad b«in;; mun- i-unvcnitiil fur 
ifatratioo. 8«Mw«iii|; tbe muenierf to bave been ex|M»eil umi )>rr|iiir<-<l 
W «ttidM«Uaii. tm* fint rflect nb«erv«d will b« tite dilautioii of ihevnwb: 
tw. If pfOfMT nnouiiioDM b« ukea, lh« Titnlity »f ibe pan will not for two 
tt mon boan be MifficiifDtly luircr^ t>v simple expinun.' (u thv air to chum; 
Rttrdation of tli« Hoir. Ky ilie apiitication of an imlaiki, it might be 
■sJaond ia«tanuii«^itsly, btit this woulil ni-edlefttlr outiflise the L-xiKriincnt. 
Ijmm ■• rMardatiuD sets in, the accumulation of corpuMle^ lulce* pliii'i.* ns 
kutrn jMcribwI. if a SRutll vein in wfaich tho nniie I'orputwlat haw 
fad ibtnwalvai aluajt ll^ wall* I>c now watrliMl, the fnllowing phcno- 
> vill b* wbMjnrcd : Au individitiil curpiMcle bcin^ rhmu-n and cnrcfully 
M,aaai*n button-like projection nill In- vn-n W riM) Irom ibc oni^r 
«d af lb* >w J . <>|ip<Mit« llif jwinl Id which it i.t ailberin^: iJib gradtmlly 
JHRMB in uu till it bcootMt a facmivpheriml pmmiticnci^ com-viHiniling 
it aidtli to tb» nmainclM- of the eorpuacle irilhin the Initn'n <it' the rein. 
JL* Iba cxtmal {lart incremw*. that invide the vtwel it Keen to dininLth, till 
tt(|nM«r fmrt mtun tu lie oiit«ide. It tlirn muiinxi the lurm uf a pear- 
dt)Hl budv attodteil t» the vein by n »t«lk, irhicli Anally pivef wny, and 
AvHtfpwele b free Mil«ide the rceHl. When the proceed of nii)-ration U 



, tltr niDicMir of the Tcawl r«nwiDS uncbanKcd, no viiible rupture 
■f it» ii«t> hmng, obM-rvable. Tlie migrated corpuscle b irre)i;ulnr in uwpe, 
m W tMd tu about out delicate proc«»et) in various direction?, which are 
^>a« is •fpio, and ihiit it moves farther and further away from the vessel 

■ *%kk H hrtatrty lay. From the cloee reaeinblance of tbeae chongea of 
itm W ikoM ob«rrv-nt in the amteba, they have received the name of 
'•««Md toonautit*." The whole proooa ii known an miration of the 
•bl* (vyBMlea. Fiic. ^2, wbtcli wa* drawn from life hv \'. Ilunley. 
Watiftlly illuMratn ibi> proocM of migration. It show* the appeaninc«« 

■ lk« Bcaeatery of a trog which had b«vu esptworl for ^veu houn. The 
nftaktina «ai vieonMM lU tbo iliroctinii indieatiHl by the arri>w. At the 
»mmmatn*a\ of oWrvaliou. tbero wan Karceljr u leueocyie ouuide tb« 
111 wll Odc twar and a half after there w«n> about ihrt-e limf* the 
MbW refraveird in ibr drawing, the escna having bivo oinitteil for ibc 
•bW'cJ'^mev The ourpurclM 1, 2. 3, and 4 'Fig. ^'il.in and i'D the 
wDaft^ :>re cxtfecutive funiw ajvunied In' Ou<; corpuscle which 
•Mealed- ..-b the wall of the vmall vriu. lliv outline* of the red 

arr in^aatf^l for the mkt of cleamrm, hut the current wn* too 
4qriac lit!> to admit uf their being #en ax drnao. A* long ago m 
-. C J. B. WilllaiM pt^BiMl out the fart that the while corpuxcin 
ot in ai'-'iT,. i.tni numbeta in the vowels of an inflanH-d part ; but it 
Ad<t» u ibe umc year, first diacribcd tb« pwaagt of tbt 

tMtpu»ct<< -: . ; the rneeh. Tliiii oWrvation was roufinneH by Dr. 
Wallrr in IM<I: hut its liu|>->TtnDoi' was hut iiD[W'rfccUy appre- 
,. I. .1 .. ^]^ 1,^,1 ubMirved it, and it waf. in (acl,ge4>erally 
in 166'. puhlUhcd an a«-unt(e ner«unl Oi lb* pro- 
iM^asd [■'Uiini >'Ui 11* importance in tlie patltulo^ uf i oil am mat ion. 





LOCAL DISTUItBANCES AHV INFLAUN ATIO:(. 

A»a rMull i<f lliU prwtw of iiiiKrattnti of the rnf |iu«rlf«. tlio tMMMvqfu 
iollnnKMl [wri miod becomr promlm) wiiti w»n<l<'rin^ Icuivx^yu*. whi<-h mtjr 
NCt.iiRiiiIat« in nidt niiiiilifra me Ki nmn'Mt llii- iKintml •Inictunv more or !«■ 
complptvly. A* tlw iiirtniiiiiintiiry immw bocotnt-* ni'in- iiiifnir. m] e-trpi»- 
clw »)m Invv tlw vi-«»-In li»iliti|; ihrir w»y out cliii-fly fnini the mpillariat. 
in the same nnv n* lmi< l>i*ii nln-xly di-iii-j-ilirtl u» nw-urriiig in iii«rh«tii<«i 
hypcriFinia. Tlw iiiinibi-r tliul rw-iij>>i> will ilf)N-ii<l vrrv much ou iht 
(Kgnv of obMrucliim miae>l liy ibc i-lmkini; of ih'- i-ii|>illnr!r* «illi n<l)>rrni| 
ooqnueloi. Tlir inigrutin^ c*ll» %vn: iit "Hiv liiin* suiiinici-il !<■ tiiul ibrir *»«J 



lEt. 




, S>.-iCicnll« *t ikg WhiMCwpuMlw. fram • M*ll tain. -. W>U at tmmL t 
«}t*>U}w on Ibs«* >I>I« »< Ik* ishI anil. I. :, >. anil 4. LtwMjiM t* iltlbrmi nt|««if 
ml(rmllnB. (. |UJ U<a>l<oor|>UMl« (ailal flrvaait 

out by nnKiriil (iiMDinca or "Monitla." whk')) were belipvMl lo cxbt ta Ik* 
nmllxif ibe CDl)ilUries between iho t\og\ij birvrofciidotholial wll«, rf wbid 
th<w VMM-Is nrficiMn|MXN>>l. Alllion^^b ti»([ftiniUM>|wtiiiitR nrr iiovr tiippoOTd 
t'l i.-xi»t, yvt it is jiri'twblc lluu itit iiili;rBiii>j; (^Tiiiuclr* An \*m oiil bctiiwn 
tl»r wils, tb* uniiiriil H'tlii-ni'm of wliirh to oiicb kIIkt ii Ii-Mrnnl by rhmai^ 
ID tbv vaM-iilnr nnlU, which furtii nti cncDlial pnrt of thi' influntniiixfy prn- 
MM. The liiriT' iliNl cituM* ihv mchjm; of tbt^ curi'U*'^!''*- 'lifTmi with ibr nxl 
no'l wbil)^. Thi' ml iirc- forooil <mii bv tlie inirAvnacular jinwurr •mlr, bpjng 
tlwtRvlrM onlirt'ly piwivi', TIm* wfiiir prvtxibly ntnke Ibeir owu wity mil, 
tbcir anki-biiiil m<iv«iii4>D(», lidtvl by tbi; pmure within ih« 



partly bv th 
nrnfl Till- 



pan tiUynil by the iiitraviucuhir prMtnn* ill thi^ tni|^ti<iti of 
tho vrhitr ooq'iMcIn in ilotibtliw rtry con*i<)i-nibl«, fur tW prrxxw hM 

Ml ahimn In Ih- armiUHl by m lii^lun- of Ihi; nwln artory iMulini; to iht 

rt. Tlii* <)•>«* nut. hoirrvc'r. prow tlial lli« «mapboEd inDT«m"nt« takt- BO 

rt in lb* pructa. 

With tha nilgntion tt ibc oorpuKlta iioain another procna of aqual 
imporiMior— Ik* Mcapc of an abuntlant liqiiitl rxu<)atiaD. It ban bpfbra basD 



^^rt 



i 



mCBOSCOPIO CHANGES IN INFLAMMATION. 



ITT 



l(m CMgtMiao> tlitt on iucreuc of tbv intrnvnvcntlar prcMiire. such 

irwiorwl bj mar •ihatructioD to tlto rvtiirti of bl'xid ihrndgh ttie veiiia, 

lU abusdiuit li<|iii'l <>xudalion fruni the iliMcnct^Hl vcmcI*. While the 

I thOBMlvoi uv hntllliy tbojr ruiitinur to net m lillcn to the fluid 

ikroogli. and tho «-iniM<«l liiiuid oontxins lilllr atliunicn, ii laricv 

I of Mlt*. BO'I to 1114 »)i<>iiutir'iit*1y Ofw^iitiible. In inflnmniaUuii, 

■ of filiraii'-n in •limiiiiMtitsI, till in thv hi^lH-r Hegrcce the daoMgeil 

»alki« ihc plMnut l>i \>aM through nlmiwt if not nhiolutely iitMrluiD^d. 

uty exudnlitiu i», ihcrvforv, much richer in nlbumen thun the simple 

on frum prrwore. mid ii iponinncjuely oin^'uliUlc. Its rauir 

Bty is due ui4 ouly to its dnitiiuiii;: n liirgrr prop<irlii>n of fibii- 

rhM to th« pmni<« in il of tiM! white •.'orjiugclc* which ciintiiiii ihc 
dsBSatS Mcnsary fur roagiilnlion— the "librin-fertnent " and the 
AriMolsMia. As thb exudation ukes plaw into ti<eu«e, th« viulitr of 
iMAis lowrfvd by the daom)^ dooe to them by the cau«e uf itie tiiBsni* 
, (A Mid) ft litgrtK that tb*^y are beharitig fur tho iiDt« beinj; as dead 
r. kU tboMMatials for i»H);ulsti<in are precent, lUid iIk ioflammutory 
' < to oiMguUtr iu the affts'ted area. In titc process of c'uaK>tli>(i«>n 
lorfttia minbcT of iIm- mi^:ratcl while corpuscles break up, yiddini; their 
brarsi and fibrin'>|ilii«iiii [r> form ih« eoagulum; tiul ibe vast majority 
iMHa nactianccil minn;;lt>il in lh« mt^tiea of the fibriD. Tli« oi>af[uliili.-d 
gtiHiBit oontrmcU. jml w ihooniinnry blixMl-dot does out of (be bMly, mid 
iW Moa fods its way by the IvHiphiitio Iwck iuto the drculaiiou. The 
■HiiBlag «lol. entangling in il* nM->liea the tDUumerable iia»tk-riiig Ictico- 

KMmt tlio ■u-rniyi .1 mflammatory lymph, nhidi diHiPivil)! the spaor* of 
■•• ik which itii- •tii'hiii'ti li.-i:i Token plui-c. The furnmlioii of ibis 
HtammtlBTj \jn\Ai is 1 ' lh<' itun uf inflamiimtiuD, liir nn\ of the 

4h1 K^aoTHMulois • tk* iH-yond the ar<-.n iulo lheEurT>>iiiidi»K 

Wtty liaMMi, will no lon^rr Iriid fi eougiilate, hut will dniiii ofl' by tbu 
IflfMlia and rrtum to thv eirciiliiliun. The snmc will hnpix.n with auv 
»ipiliM cumwdos which wander Uyond the area of iiifl^mmittioo. ff 
^•lantiui Is Very abundant, tli*' lymph-t>puc«s for aoRie diflnnce round 
AiMMivof iollaninuilion will he diMrnded with fliiiil, and thus is produced 
I which arroRipaniva all acotc inflammatory processai. The an>0UDl 
tiioi (rtuti an iullaiiied jiart is very oonMilerable. Kxperiinents on 
iksTV shown that the amount of lymph rctuniin); through the main 
trunk of the thi>;h after inflsmmsliun has been excited in ibe 
• PMLBy times t;rwter ihsu the normal nmiiunt, aH»ut one ounce 
J far every drachm that could be collected before the iuflammati'in 
btim ■!« u|<. 
At tiMllfc — Tbe HTect of inflammation on the tissues of the alfected 

Ct bs bcra the •iibjtx't of much discuvion, and csnnot even yet be siiid lo 
faatly settled. Ii wiu khowu by Litter, iu l)S<Vt, ihal in the area exposed 
)»i^ artiHO I'f an irriuiut every indii'ati'to of life is in al>eyauce durin;; tba 
■at stiitc fliafv iif the naultinf; iuHaninmiion. The muscular coats of tb* 
Mna oxsv to sbow iIm- irrniular c"iiirai-i.iuuB seen iu hi-allh, dtp iii|[m«at> 
•dliaa tn%'* CmI do Iuou^t cxtiibii ihtir peculiar clianjfes. and tJie blood 
ftwaf ihf«Mxb the part bsliares ■• if in contact with dead matter. He 
Wmms Bp the moelusinu* to which bin ohsen-aiiriuH Itnt hint : " It appcan 
iMlWtarMiua |diy*icHl and chi-mii-nl Mftaa which, when ogH'nitiiiK j-iwer- 
ki;, aua^iiJi the life of tbe comlittMnts of tliv animal bu<ly, prixlun' by 
■ ■•iMbal feutler nctino a condition bordcriiit: ujmhi Iom ot vitality, Init 
fnlr 4i*tiaA fr^mi it, in which the tiiwuivi are, fur the (im<i heiiig, incajtaci. 
Mai Ltf difdiaixiDi; ibrir nmitetl oificv, thmiifh r«>taining ilw fiirulty of 
wtiniai aiWvards, by virtue of tb^-ir ow a itifaereot powere, to their formor 





1T8 



LOCAI. DISTUB8AXCES AKD XKTtXitUATlOit. 



ttMlt of nctiviiy, pruvKlccI iIk.' Jrriiatioii bave n<A htea Uw Kwrv or 
trnctci)." Tliii> tbrar^- nluno wa*, however, uti«1ile tuitUfncl'irlly to Modwrt' 
(br tltc ai>|>i-itnincf ttf ■ niiiltitud« of dcw ce\\h in tJioHr* «IJII AufiWing flwi 
tin- HR'Cl of an iiijwrj', nml yet llw niicnjvcojw *)i»u* ibat ihu fumn an 
«!>M.-iiliitl [MTt uf ncutf ill 6«m mo lion. ConM^fUMitlr liklM-'n llM-iirv iliij nut 
Diort wilh the acwptiincy it linM-rv^il; niiil imlil tic mi^rnliiMi t.f t)i<i whic* 
corpuscles was (liK-i'vrn-il l>v < V-bnbfim in IMiT. ibr [iruci'M of inflBOiniaiMfJ 
according to tbc Ccllubir I^ttlbolDgy uf Vin-how, wiu n'^nnln) u nMiitiaU] 
flOe of incrviupd Diitntivi- uml formative oi-tivity of iIk' iiifljunml 




fig. n.— Infl*»*>l Fm. Sboatbg lb* hi'ptlti «|ih ■•umsjih UIbh* ibta. Thi bI, 

All ibc ncir cells were eupnosn] to br furmftl by tfae rapid proliltntiMi of _ 
original el<'nicnti> of tbc nHecicd tissue*. 'Xlw tticoovcry of ike migmtiaa 
tito vrhilc cor;iLi»ct», bovrevor, full)* acvouiiCcd (or lli« agipcftrencoM tlicDrW 
cells in tbc inflmnc^ area, nithout iwceMitating tb« improbable aaKiniptmi, 
tlial injury to Hcing tUBOea jmnicilinlely incrvaM« tbeir vital activity. 

The clian^-8 wbtdl occar in Ibo tifeucs as the rM'ult of iuflaininali<>» bar* 
beeu olMcrvc^ both in vsK-ular and uuu- vascular «lruc(ur««. and lH<ih dnrin 
lift and in preparations niuilc nl\i-r tieatb. Amoiij:*! nitn-ra>cubir utrticlon 
Uw cornea may be taken as tti« miM typical, and bab raiMt fmiuenlly baaa 
OHule th« subject of espcrinioninl invMiitfation. Tbe com«« is compoM*! ol 
a Mculiar fi<riii of tibruu^ liwuc arrnuj:cil iu Mrata, b«lire«n wbicb lie upacn 
oTan irrvciilur tlcl)at« iorm conliiiDinK curpusvlcd comspondiu}; with ilivn 
ill fhape but not nccuratt^Iy flilinjt Ibem, tbua leaviug room for tl>c tioMaicc of i 
blood -pi as nin uiid. under crnaiii cunditiuiu:, of whit« curpuaclca. iVbrn tb« 



i 




VICBOSCOriC CUANOXB IX IXFLAMUATION'. 



179 





iTuiiBMl (• IrriUlei] by tMBBiiiR n fine silk thrriul through It. 
hrhrt nui* hiitir» arc p«ft. nn npniiue tfttt txtaading for k 
' ruuiH (be nan iiijuKxI. At ilic ainir tims tbft v(«wl« of th« 
dr» mmI of th« «cl(^itlc becontc eiij^urgnl with bliXKl. Ifthr i-otnm 
WiM Mt *mA cuuitHiil Kbout tixtcen tw twentf-rour huurs iiflcr tliu tnjun.-, 
m iktf MlsMcd inm imtml of ih** 
MfW MdlaM oDr|Ni*cl« naturally 
MB b fscfa »pK«. tWn vrill m 
ind * givap uf ruaad«d cd1« hnr- 
if all ibc iuip««no«» of wtiit« 
■r y w lm . Till cumMraiivrly re- 
If it ttM Itiuaebi ih«l thcM 
,^.,.t.. — I 1,. tjjp .|j«i»itin, or. 
:■ mlioii, of tin- 

>i mtiiini ii>>|«tM'W. It klli> 

•bgwn clmrlv ihiit the 
tlly (•n^'tiK-cl tty nn 
of mi|;rjilin;; ti-IU io 
in wliu-ti ihi- c<<mc«l oir- 
lr<. in MJrh a *ny it$ nmre 
CTMu|>trt>lr til iitieciire itic 
(vlt. WWorver ■ml «v1m.t- 
nwiWnri^oal nl) r«ii Ik Keoc- 
litd. it ihZnt* BO rlianiEV. Scun- 
Um trrittinl ;l, ■ ammll ifiitml 
i^if dt* rornra nith n »»liiii<>n 
rf<fcWi>U '.{ line, which kilU all 
wHiii tb* ptn toaeb«d, but Imvo P)|. t>i.— /. r*n4*, -Haoiatout ud •ii(hii) Ib- 

flaAnoa MMIC.Bnd CSMrialllr tho miralail «llh teuowvjtM. n. AflBtl'ila. ■, 

MK»r boatu{<W«)U« UunilUU np- \'«But*. ^. Carlnjitua uaiiniiad «ilb bu- 

fwatly iMniMl : diUtftlion of the oMjtw. -.Nim. ■.HutenUrnbfv^eui 

NKMuul vnwb <nu not pro- mtvm. 

^4. Tbr iiwA trniAiiMM] cimr. 

miikm fnld-mnhvd (bowMl tlmt the cclln Around iu margin uni]«r<r«ut no 
dwn BMil malr coumeiiced ; theo lh«T (hoi out procnMs tu fofiti new 
I ■ty wcJi *. but Dothin)* flu(;gr«tin); [inilifcraiicn of the celb was seeu. 
_ ' r. the uitcri'fr lamina w«« eaten thruupli by t]|« caUBtic. lJ>e 

iMMitloaiM; Ibe aame m-ciim-il if'S^ the chl<>ri<le was applied iwar 
~ MBnin, (ib« B&Krior lamina i-i-fDuiniii): M'liitit, Imii theu (he |tcri- 
: ntl a dM dilate. In each "( tin- two lattiT m*t^. rhiin|>9 of »iiinll 
mbJ (lib ooooMtlad lh« corneal (vIIr: hut then' in riiireni»i>n t»nu|>|HHe ihal 
H>«tBial will l)«faarnl in eX|>nrinioiit« ('i) aD<l i3> dthi-rwiM' ihaii lu ihry 
M tB nprrincat > I>. W'r inuat, ihervfvrr, iM-lk-vt.- thtit the ik-w ch-IU nnn- 
^Brffroci lb* r-mjanctira lliniu|;)i th>-nii(criur lamiuaiu (S); Aiid thai ibejr 
t! rr..m ilir •lilat«tl iwrif^meal vt^u?!* in '•'!). 

' 1)41(1 liaj> Ini-n exnniinr<l by Ilowcfemi'II in tli<- Plinio- 

••f UtiivfwiiT r«lli-);r. wiih ih<' <»hjot-t iil' aM-rrutluing 

Mduei.'tiri.-liAiiK* cntpuiK-I™ tnki- aity nnri in the furmn- 

- -Iiieh ai>prnr ill InllBriiiiinlii'U. 'ux- ckuilt gf fatt 

-lull in the l'r<">'t-»liii)r< "f the It>iyal S*ieiety in 

..» (ii. tiilliiwinj; brief Miiiiiiinry of tl>e nviili* he nlnaiued: 

cirvtilaiion enntiimeal, iii> I'hnii^c wlmlvvcr |iM>k pliioc io tbo 

rpoMlca, nther mm n-^ahk Iimib ih* Rp[>earance, noLwitb* 

• !>•(/ which (hf>r fnrtned port wu bdwt with iuuuiuL'rable 

iiidta, or (to ate nrdmary laDgiia^) was iotllirat«d 



ISO 



LOCAt DIBTtFBBANOaS AND IMSPLAIIHATIOIT. 



with puM." In Kiniu cusoe the tongue va» wntclicd for (tight or cv«n niiio 
diir*. 

The- cuiii'li]«iuiia rlrawn from these ubtervattoDS are confirmed by the 
Riii-roKcopit- cxiiniiiiocion ol' sjieeimeDs of iither inRamed ti»ue». In ftit tlie 
Ivucocytec »re I'nuiiii crDwdiii); betwepo l)io Iht'Cells, esjiet^ially in the neij^h- 
borii<x>il oI'eiidiII blood vctwels 'iFi^. 8^); in niuwie lliey accumutate between 
the fibn* which theinwlvt« show no cliaDge, unless the process be very acute, 
and then ihc alt^raliuu ia in the direction of de);cQeration, not of ^ruwib 
(Fi)>. 84 .1. In hune ibe Haver^isn canalfl becunie tillod with leucocytes ; and 
should ihe procem be of sutlideiit iiiien^ity and duratiun, the solid tissue 
dieappeare before the new ceils, while at ilie same lime the bone-corpuscles 
show no chaiif^ unleFS one of do^ueralion. Thus acute inflnmmaiion, from 
nrhatever muse, and in uhalever thaue it may arise, is always characterized 
biiito]o;,'ii-aily by efi^eniiully the same pheuonieDn: a |wMtive or deKeneniting 
eondiiion of the ori^innl tiasueit tvith an abundant inDltratiou of nen cells, 
which are the white corpusclea which have niigriiti'il fmm the vetueU, uud, 
pciMtblv, the deacendaiilsuf tiuch c»r|iUMlt4 formt^it Uy diviviuuof the pureut- 
cells al\er leaving' the vtsncl. 

The extent to which this proccas of" cell inllltratioii " will tw cnrncd de- 

EK'-iidii upon the decree i>f daniiiKtt doni! to Uiu tii<*uc* by the irritiiut nhich 
\at cuiii'vd the inllBmuiaiinn. Suppn^in^' the duuiitge done to be »f n slight 
and tei]i|><>rarv charnclcr. the tiMum Hpivilily n-covcr fmni the coinlilioti of 
lowered vitality intu which they hnve Ijceii thrown, the vck^cI* r^covi-niig 
witli the other purlK The circidation, therefore, rctuniM to itit normal state 
aud tlic exudation of plnmun and migration of white orpuscic* cattf-. The 
liquid oxudiition ilruin." away, anil ■iieh leucucytce a* have found their way 
anii)nu:*t the liw>u<-ii cither ba-nk iin ami are nb«urbed. i^r find tlicir way back 
into tile ciri'ulali'in by lurnns of ihc lymphalira. The pari i» lhii« ri-rt»rc<l 
to iCK normal cjudition, and nn ponnaiK-iit effect of the intlainmntion in Icfk 
behind. This proww of perfect recovery is Gpukcn of as the '" tcrminaiiou 
of iuflammntion by Resolution." 

^^boIlld the ilniniigi-, however, be of such severity that a small portion of 
the tiaeue i« injured pu^t recover)-, or to i>iich a degree lb»t the pressure of 
the sccuTnulaling loils and liipiid exudation extineuiBlies such traces of 
1,-itAlily as may have betot lefl in it. it is evideut thai the simple process 
of resolution is no longer poMiblc. The same will be the case if the c^iisc of 
the in dam (nation bo pcraistent, as an irriliitiug foreign body lodged in the 
tissues. Under these circumsianccs, the exudntii>n from the reoals and ihe 
ini);rAtion of the white ei)rpusclea continue in the Inflamed area, uiilil the 
leucocytes become beai)ed up and press "pon the original liasiics of the part, 
which now show si)>ns of degenemtinn. The fibres of connective tissue be- 
eome swollen and sollened, and finally disappear amongst the leucocytes; 
fat-cells lose thi-ir contents, and in like manner are lust ainon^'st the invading 
cells; muscular libres lose their strialion aud become granular, tlie migrat- 
ing; cells penetmie within the sarcolemtnala. and the original tissue dim|>- 
pears before them ; the vessels in the saiin! way heeome obliterated by pressure 
and lost in the maf« of new cells. In whatever part or tissue the change 
miiy he uccurrini; the process is t«sentially the same — the original liMuea 
de){cuerate and d is iu teg rale, and their ]>lnce lawmes uccupitd fay a closely 
pncki.'d crowd of small round celb, Whethir each of these cells has 
onBinally been a while eorpusde, or whether many of th<?m are formed by 
divi.Hion and m id ti plication of the corpuscles after migration, Ih a doubtful 
(loint. That ihey are formed from Ihe cells of the periihiu;.* tianue ia hardly 
GOiicv.iviible, aud, moreover, exfieiimeots have shown that an exnclly uroUar 
prvcuM of oell-inflltratiou will take place in a piece of dcml animal lisaue 



I 




MOPES OF TERUINATION. 



181 



•tU k> kttm HMk«d In alcoliol, if it be introduced amongM tlw iImiim, or 
■I CKVtttr of A livinjc nnimiil. Tlinl llim- aw cvlK tritntr 
», Ukoou itrtiv<T part in tlii:«bm)r(ili')n uf thi? originni tlMiiM 
«i latAf Im dcnbMd. Wtivo lh« intlnmmatiiry pnct^ has rvaclied (bta 
MpM*«f IttoeoQfMa U [lUMible; the prw<?« amy itmh aix) rvjMiir iiiny 
M im~-ihm new n-lU ua<Wrgiiiog change* U> bo Ha-wribcd berenftt^r. ntid a 
■wktag fag nwi i in the place thvyoecapied — or ii may coolinue aiid l«rtDi- 
«!■ in lb* fensaiMW of pus or inppnrBtioR. This laU«r c<>i>ditioii ia brought 
iUm hn *^ aoAraine of thr inUTcelluinr tubetanrc tn th(> centra of the 
mmttnrm nlk. llw cells thcmsdvw b«nK cut ofl'froni [iro[»er niiiriiion 
•f iMJr ■wlaal prenurc. undergo degvoerativ* chaagM. They nwuioc a 
■■ft dtcalw lurs, ap|>aKiitJv by a process nnalogou to rigor mortis. 'Dieir 
fntiptHHi hacoaita filltd with large, hi^'hly rplVacting granule?, fome of 
ikkfc an* tutf a»i) soluble in eili«r. while olhcra Hrc of nu nlbuniiaoi*) 
atan^ aad caa Iw cleared up by the actiuu of ai-etic ncid. When thus 
^nd, tbe evil, which itofr receira the name of a pos-nll, is fotiiid li> cno- 
•i* a dnoUv iir triple nui'IeH*. Thb breaking u|> uf l)ie nucleus is not to 
W hafcatl u|>ao h u Mgu of active t;'^**'tl<, hut rather as a deg<>Hernlive 
Tb« fluid which separates the pus-vellft is mit fomieil merely by 
nf the almost inappreciable amount of iutercelliilnr siibMuace 
«yiA avpanivd tb« heapetl-up leucorytea in Lbs inflamed area, but pnrtly 
iha by axMdaUMi thm the Kirrounditifc iuAamed tisaef Makiiig in iini<>iifp?t 
Ahl With tht* fluid comfr wandering. l«a«ocy tea; so that in the lluid 
hmUj drawn from an aeuttf collection nf pns, not oaljr are thi^ round de«<l 
faHa/kbtati, bat with ibeni many rlill nhuwini; tiir idngle nuclcuo, ftiintly 
pndar imtoplMto and anurboid ronvi-nit'Di* of ih<^ white hlootl-ciirjtu-cli'. 
1W aamr* of pu*. and tlw proci-*a hv which n •tiinll iMllcction ii>rMutii and 
"tm tm ■Iwiirw. will be further di»cii*erd iindrr ^Suppuration and Ahecff«. 

U Jim pi nw llial has juel been df»<.Til>«<l ihould occur oti ii surface, so 
^ Iha p«a flnds a mdy tecapc nserioD n^ U is formcl, we get anolher mull 
rf hflaMiaation. which receives tite name of Uloeration. The process of 
lAviatk-a i*. iadcv-l, tilratical with that of the formation of a locnliied eol- 
boiaa af puiL Tbe original liaMMS become infiltmte<l nitli migrating ci?lls: 
Aiy tkw '^ ->-"-- -^le, ibrir place being taken by the rapidly multiplying 
haacyM* i tht'ir turn degenerate and brMik lonec from the surface 

» fm a iU tin- will be furil»er eooaidered under L'icvniti»D. In some 
fc«s tf tadanmatiim, ns will be ««n hereafter, the pny^esa is brought to an 
•J bjrilM death of the aflectu) [mrt. Thb b spokeii of as the " termiiialion 
' TiihMiTlrm in Oftifma." 

FrMi t^ jirocenof inflammation, it will he Mill 

<ht the tk r led flow in the T etJ s, and tlie exudn' 

iNaf twlU ikuil li'fu->r Mti^niuii^. The simplo by|>ervn]i«, or deterniinntioD 
rf Uaed, that ticcun ax thi' n-vult of milder degreeti of irriiaiion. oiinuof be 
WM apun a* ccuwlituting n [Mrt of the true inflaTiiiiiitt'>ry pr'H'tw ; and, 
•a tki aUwr hand, whm tlw nag* nf Masis b Rat-hcl. inDanimiition niiut 
■M bt bruvgbt til aa ad by lite <teath of the allecteil rmrt. iioIi-m thr rir- 
■Atioa be rwtornl by Um Mbaidence of the pr<>c«a). Acut*' inrtnnimnli'>ii 
• Miatital to ail raaw: it muv vary in drgirv. In extent, and in lenuinn- 
<M aaBDnliofC (u the aatun- o/ thx rniiiH-, and (lie vitality of ihc iiiwie!> on 
*Utb ibe noM* b ai-ling, but the pn>c«as b always thr Mme. Whi-n, Ihere- 
■ of inflammation an- upokeR of. it must be liontc in mind that 
idwaol ihtfrod nu <liir<Ti'nc4w in the ei«eniial nature nf the 
,ia aD Ihr aa the rhan^w within the vMwols and t)ie exudation nr« 
bat aiw th« rv«utt ol varintioos in llie eauae, and in tbe degree lo 
I and iitbrr tiaraua are damaged by it. 




182 



LOCAL DISTURBANCES AND I^iFLAU MATIOK. 



Cahsm up Ixri.AMMATlos. — Tlie caii^tfl of iuflummatiou, like lIioBo I'f 
all otlinr morbid ymeefeet.. nmr be tjivi<l«d into prediipoiltlg uuil exciting. 

Tbc Pr«dupo)Uig Causes mny Ik- briefly Mtid lo include every cunililKiii 
ihut iciiilit tol<.>u'ci lilt.- vitality urUie liwues, aod iliu? to reuder iheni Icwnbli' 
to roiint, cxtcruHl injurious inSueuues. The conditions necessary tor u healthy 
iiulritioi), and eonsetjuenLly for a hifih degree of vitality, are, an abuodnnl 
Stliij)ly "f healthy blond, cunneetioii nilh a heallliy iiervoua centre, periodi- 
chI reM fVutii fimeiioiial activity, and at tbe HHtiti- lime & uurnial exercise I'f 
ftiuolion. The inllueuces diMurbing time couditious may be LonI or 
(iotioral. 

LooaJ Prediipoting Causes. — The local couditiciiia whieb interfere with 
lh« ijuiiitlily of bJMid 9U|i|iliL-d to a part, bave bccii alreadv diacuoed UDder 
Ijocal Aii!L-miA and Conjfeitioii. In PaMivc C^uigeMioii, U will be remen- 
bcrcd that allboU|;h tin- pari hnbitiinlly conlaion au excciw of blood, l^eiv 
is a diiniiii^iieil iiiierchuii^ir, mid, cntHH-aiicntly, iIk^ hcIubI ()uu[ility i4U|ip)ie<l 
i» lees ihnn nalural. Buih tbi.iti- local diaturbtiiiaii of ciroulaiioii, as has 
been already iiointed mit, iiiicrfrtv with hiMilthy uiilriti<in, lowi-r lliv vitality 
of tbe alfei'ted [lart, aud lhii» render it jtronr to itiRntni; from nlighl causes. 

£oif of ewineefion wilk a liiiillhi/ iifrvr-tfnii'r may b<' tin- rtvtdt of d*»true- 
Uvu of the luTVe (1-iilre ilsolf. or of iniiiry lo the uervisi leading from the 
centre l»i the iilfwtpd pun. The best illutlratioi) of the cffeet of this e.mdi- 
lioiiisseeD in coutrnNlitig mnilveis of a limb from cerebml hcmorrhaK^, 
■lid |iamly*iH from itciite sjmial myelitis. In the former caw, ihr paralyzed 
limb ix still ill I'onnection u'itli the healthy spinal eon t, and ordinary carw 
in ttvoidiiic jirrwurc \Till prevent nny furii>atton uf bt-dgore*. In the latter 
rase, the nNghti-Kt prt^wiire or iiritaliou cauws intlammatioti rapidly lernii- 
miting ia .-iloughing. Los» of connection with a healthy iH-rvc-centru i» alwt 
nceu not unfreqtiODtly in case* of diviHon of the ulnar tierve. by which the 
little finger iit ao»olutely cut olT from its nervous supply. Under tlii-»e cir- 
itimNlnnoeK, grave changes in nutrition are common, and intlammation ><• 
rtiulily set up. That organs to which ineuj^ci'Mt reM i» given arc prune 
readily lo inflame, is, pLThap». best illustrated by the cflects of exctvsive 
work on the eye; and the cijnverse, lliat oryaiw cii/ (i^'/roin Ihe prrj'oriiMHOii 
0/ Iheir n'Uiirn! ftiiirlifn sntfer in nutrition, is seen in the fact that liaibv con- 
ilumncd to inaction from disease of a joint are cDid and iva^te away, and 
that inflammation is set np in tbem from comparatively slight causes. 
Woumbi ill such limbs otlen heal badly, and it i^ this tliat makes amputa- 
tion of such nieiahers uotoriouiily un&ueceBHful. 

Though every lisuue of the hudy is susceptible lo ioflamnintion, yet lomc 
fptrUfrom their oHalomifil eondtlion/i and tlriielure are more liable to it than 
others. All cavities are exposed when wounded to ihe d&n>;ers of the ac- 
cuniulalion of putrid or irritating (luiiln, and thus the serous and synovial 
membranes readily become afl^ted with extensive spreadiuj; inflammation. 
Slucoiid and cutaneouR surfovcs, ou the other hniid, are protected by a strong 
and iliick epilbeliiim when they are exjMicied lo injury, aud cousequeatly 
require more (Hiwei-ful causcji to pi-oductt mllaminntiou. 

When a pan, itiriny omv 6c«i Ihe Mat of influmination, has been left in a 
weakened or imtiaired suiic, it will be iiuin? liable lo the occurrence of a 
second attaokofintlanimation, having lea ni^inliiig power; hence, also, eub- 
sequeni attacks are induced by li-xi active exciting causes than were retjuired 
at fiRit to call ibe prucetu into exivtenon; we »ec tbis in the iutlammatory 
atfedioun uf the evi-a and juiiiln. 

Constitiitioiiul Ihvdisposing Catues. — That oM nt/e acta ta a predisposing 

CHiiitu of inllamnintirm, it in bnnlly m'UCKfury to >ay, the vitality of tlm 

. tittue* in cxti-i:uie age being givatly diniini«hud. Atit/lhini/ thiU tnjeehUa Oie 



I 




BXOITINO CATSia OP IN'PI.AM MATIOy. 



IM 



I b) aach s d<^r«e aa to iDl«rfero with ttie sui^l^ of blood to tho 
IBBM Mil M ■ firwlispMiig canse of inttumnistiiin. Tbu< operation- 
mm4» sn nan pna* ta iBflane iLA«r grenl Ilm of blood, iid<I in puUeatB 
IwhSMt bv loBK ffvrr or ntnt of food. For heallliy DUUitioD. it n Dot 
«fy MCMMrr Uut ihrri' ahouM be bii itbuiiiliiiil supply of blood, but ihe 
imd Ifcat it mtfftlir^ miw( he in n hratUiii <vNiJilion. Tlie bt(»Ml may be r«n- 
iati i^fmn or tkr ntUUiiM to U 9J tome *ub*litne€ nol normallg pttKnl, or 
k (W im^^trl rtiwanatiim (^ ike pnAwi* oftutrntal titnui-t^anQf, or by llie 
i j bm m ry vf tmmr »/ it* normni eotuiibtenU. Ttie lOUft comiDon tiiitl iuoaI ilii- 
^«tut >4 tli« firu rliua of ooodltioiu, is the habitual [ireaeiiee in the btoo<t 
rf aa MMMiBt iif ahnlt/tt ill exflCM af that wfatcli emu be easily eliminated or 
wtmmM. Thb n unr>niinitt«lv ttie euu^Unl cvaditioo of but loo many 
rf At worfcioit «liiMn, (■•jM'<:inn7 lu lur|;e ciiJM. A ht«llliy muiitry laborer, 
Vp^pti in bant «<>rk tii (xirc air, nmy coiuutni' nod eliniioaie rapidly » 
tiMatB-<tini >if aIniHiJ, but (ii« city wirkmiu) i!Utfa)|[ed iu more or lev 
MMary ■•rwpatioa in ill- vent ilatorl iti>rksh<>|«, blen able t(> (^ rid of 
Asalmlmi b« (moKiiiK*. wliilv at the aanw timv the quantity he takee ia 
fnAaUr gnmier, m» hi* wagfw are higher Kod hio u|>)M>nutiitirs for driukinft 
««« ■^*"**« ! Thrrv oiu he no ileubt that thi* pundiltoo vf clironic 
itnAMmt fswta ■ nmi ]tro}udieinl ittflitmcv mi all opprtttionn aod diaeaaea 
^At UakiUDU of Ui^ eitica. HahUuat enwM rit eating ia ttltooal as 
^M^MB •• mmam^rt drtokiog: for, u oul/ a cofuiu aniouat uf food cud 
W Mt^itHy dlfltd Bill] awmtlatAd, axeca abov« this tend* to interfere 
«■£ h««)thv nntrklM. 

' inmf fcarf . aurfMry.. anil photrJutru* ftotininiu^ aro other axamploof tlie 
■M* riaM uf caaara. TAr <t&«>rplion of Ui- ^Armiivi/ pndveU 0/ pvtr^actian 
^i^^,gf,„f^f^ wr •hall aee hon-altrr. piiki»c« revere fever; ntiil the rapid 
•Miaf af Um body thai occurs in this cooditinn, l» clear Gvicjrncr of ihv 
MMi diaturfaantv of nuirilii-n thai it ^ives rise tu. It i» itie eX|)cri«Deo of 
•I^KMiua that «<Hii>dii mnilc durioj; septic fever are escepliomilly prtMO 
*■ hiAtiiM-, aad |;otKrallv do badly. 

SmbWom diohrla. which of all eondiliona exerla the moBl injiirMu* influ- 
■■ m weoMfa and itijur»<«, ouiy [wrbapa be tnoat oouvenieutly danad 
*lw lU* b^kdioit: aa alau nay jaundiet when due to simple obrtnictvoa 
4 At UW^aeu. 

AaaajM tba taiaia of n^arify t^hlowtJrttM ituiifieienl e/im«iiifion of the 
awaaJ yrajacla of tiwai changg, IlHi^bt'a diaeaw of the kidneys is the mofti 
MaL OaW aba ia perhapa moat |>n>nerly included uodcr this headiog. 
iWa MudiiidB* luv potrcribl )ir«ii!s|Maiii)t caasea of inflaminatioa. 




I of llk» luBff* and l!v«r act in the aame wikv. 

oMiditiuna due to the inMuffieirruy of aonw «/ A« normal oondit- 
■a^s^liUtlsad ia annaia. sueh aa i*s« cmimonly aeva in ymnt; women; 
■i hM« alaa misbt br daaaed ihoac cundittnuii due to a dclinrut supply uf 
<ta Mnawry elaaiant* of fowl, such a> •oir^v. from naiit of frttth, ([reen 
and the p-neral c<i(uliti'>n uf mnlnutrition bmanht about by 
' vt osye«* in the air habiiually brvnthi^ and want of fiwd in 

tartly, iWra Is th* rowiilutioRal iimdliion known a* Mro/itAi, in which 
■bat m a lra4aary U> inllaminalioiu oii-urrin^ urxler iba iitdtii-nw of ex* 
Via* t»mmm, )tm ia dn:n'r than llioH- wliirh ntl^t honltltT Mubjm^U ; but 
tial aaturr i>f ihii i-oixlitiiin t» dill but iRi|H-rlt<ftly knoun. 
\ Oanaas of ladam nation.— In llnmnuiiion '» unuallv *nid ta be the 
mull t>i litful ■• irrttiiioH," iifi'l thi- nmi'o <>f intlamiuation arv 
iW sfKikMi of aa " imVijiiL)." Irrilnliun pr>jN-rlv mntiu ••iritt.-iDittL 
'Vri^ I'aEolK^; and —nuently pfayaialngiala apeak of tiaitK-a [waaaM- 




184 



LOCAL DISTURBANCES A!tD l.VrLA U H ATfOX. 



ing"irriubiliiy," when h healthy numifosuiioii of functional Brtirity «ri 
bo induood by lh« n^mlicBiion of exuiriinl Blimuli. At tite tiR>p sbrd 
iaBamnMlton whb belieVed to be an exai'Mratimi of the noriDiLl iictiviiy oB 
the inflamed twuca, the cause that prudiiced it nas v^ry oalumllv rpitk^ 
of aa an irriliint. Now thai inttammaiion is known to be nveiitiiilly a oMl 
dition of diminished vital activity of the tuaua in the inflamed area, tbJ 
Icno may (five riiM; to flome miscunceplion, anleM the aenw in which It M 
used b« clearly understood; at the utme tini«, its use iii the cenae uf •Mnfl 
tbio^ CMisiuE intliiDiniatioD has become n firmly flied. not only in aurgiral 
hut m popular lantcua^. ibal it would be nio«t incwnvcnicni i'> irr b> chufi 
it. Ah irritant may, iherefure, be defined sa Mmethin^ irmliiii; to daoMgi 
the liaauea on which it acts, and to lowt-r trni|>i>ninly tln-ir vituliiy : iT acdifl 
wore feebly, it rm[u«'iitly behavea lu n Btiinulun, vulltDi; forth nisTiifi-Matlugl 
of nuriual function ; if more aeverely or persiiifntly, it caitaca tlio deatb <■ 
the li^Bue upon whldi it acta. HiMt may he ntvm lU an example. If tM 
»)cin be expoaed to a tempemttire of almut KM)" F., there reaulta iini[iM 
hynenetnia with ineraife nf normal funcilon, na ihowo br penpirattMi 
lulling wsirr ii|<i)lie<l merely for a teeund cMiM* inflammation ; au'l a rr^ 
hot inn wiKild, ol ciiunw, eive riw ti> ininM<d!ate dmthof thi- part it t(Mi«ha4 
The fff'ft f/rodiierii bv nn irritant wilt dopiiHl, fir^t, ujnm th« iitt«tmly oflbl 
irritant; nnd. Ke«>i>ndly, u|ian the jwircr* of rrnttnne* uf the (iWiuw on wlilt*! 
it BCtN ; thn*. in l)i« fnbic til*uaa of a limb, tht; nrlrrm of which ar« di* 
«Med, W aa to brin^ Ihr oupply nf hlootl bcluw the U'lrmal ■lanriani, inflanh 
matioa it mdilr iuduc<'il by fW^hl cnii«ni. It hiw nlrfiuly bcrn slaird ih 
inoufficii-nl #<>i>]>ly of bhoid iict> n.t a rHiwi-rful ]>r<-itit>|i<>ung cauM uf in 
niiili»n: liiv cinipttrlc iirr<-4t ol' ihe circulation, if ty>nt!nHed foraauffit-i 
length of linMT, net* «* n direct cxcilin^' cnuM. Thia was shown by Coh 
heini in hi» well-known experimeiil» oi> the ton);o« of ibe frog and on the 
of the rabbit. If the ear uf iXw rahhit be emptied of bluHl. and a tein|K>ra 
liipitore a[>]>lie<l at 'wa base, the elTcct produced is prn|>oriiiiual tn llw 
duriiiK uhich the lar ih ke|>t bloodleaa: if this bea few liours only, leio 
hypenemiu ahmc fC!iult», with perha|M sliKhl awollinK : if about twelve 
l^e ear beeomes grently swollen, tlicre is retarded How iu tin- rtwvls wt: 
abundant {nflammnlory exudaliou, and the tiieuea become iuBltralml wi: 
inikcniiin)[ uhite hlood-oorpuacles; if the ear be kept bloodleaa till '\\z vitalit 
ii hsi, the bliHMl refuMa to enter it, tlie eorpuaclee imioediaiefy choiin); i 
vcMclii, am) l>Iockin)r ihein na in inflammator}' slsais, so thai any flow 
iinpo«*ibl«. Thu*. nity dcvree of inflammation <:8u be produced nl will b; 
varying the time dunnx which the eiir i-i kejx hloudleiM^ Cuhnbeim »ho 
al«o tlint ntUr the cur hna hi>cu bloiidleai for a time Milftcietit in anme d< 
to lower it* viiiiliiy, ali^'ht iiijuriea «niM! ■ higher degree of inflnm 
than in a hi-nlthy ear. Thin ex|H-rin>i-nt U Domeiintes unintttitiimnlty pr: 
formol on xiw hnmnn (ubJM'U Sotiw' yirant ago, ii Mlicnt cninc under m 
oiire whose whole nriu hiul been ri'inlcml hhxidlfw uy tlic app1ic:tt)fln of a 
appitmtii» lor (ho trrntment of fracture o( the clavichs At (ir>l. wIh'u iJti 
bandage* were rcmoveil, the limb aeemvd hopolnaly AmA; but atii-r a Bbnril 
time it nn* evident that, sillhough its rilatity wta rodbced to tl>c louiwt | 
sible d«f;ree, >t wiu not n1>»>I(iicTy dfntroytsl, for the btixMl begaa alovly 
find ita way even to the fingcr-tip», but with thin nil the pbenanwaa of ai 
inflammiitioo were developed. The limb became hwiiIIcd. ml. and Icaaa 
gueh an extent thtit iho eirnihition became n^i» nrri'«tnl by the pi 
the exudation, and gaugreoefet to. Deocautating ampiilAtion at theaboi 
ioioL Od making; indstone into the am)«utat«>d limh, a moM abn 
inflammatory exudation, like thin pus strvamcd from the Hibcutam 
^■•uea nnd muscled. The tame phonotnena are obearved Id ■tnngul: 



PrTftBFACTION. 



185 



k «WI-kii(»>ii f»c< tliKt in omploic »triin)nilali(>n, even when 

At|tt tm bMO cut n(f fnim the circulitlion for nianj noun, na inflamm*- 

HjMuduiMi 1* fbnnd <>it ii> Kurriit.-).- nliri) the me it opened in tli« open- 

Aa; bMakMltl Ibe lattirnl dip #licirtlr nOcr mlitctioD, th« gut is fmind to 

~ «tah a tbk-k lavcr of inlliiuiRi.itory <?xudiiiion. Here, as in the 

r. ikt pb«DomMi« of infUniniatioii do not manifest ilienuekes till 

A>arailatk>o it rabublMted in th« »irnn^tiit«() part. 

ItriluHs, that it to My, injuri<w« influence nolinj; as «UBCt> of inRammn- 
k«. OMv b* diridcH into six |>roup«: MMhuiical, Fhydcal, Chenical, 
lr|isiail FuwtlouU. sml NflrroQs. 

I. ■N^ABieal Initaata mav be ilms Hu)xlivi<led : W IKrtft meehanifii 
— '-*^. ■■ in vouula, bniiscs. rraclures of homti, etc, (A t ihvemml, which 

> a fraqiMat eavae of pcnistence of iuflamiuali<>n. aa in infliini«d joinU, bnt 

> uMiiUi «n •xHtinr cause of the original mischief. (o> FrielSon, as In 
UMm «• tjte firvt or naads^ (<0 TVnWon. Abnormal leiuinn nets iKXh as 
1 |ri— ry and a lacuodarT cause of iiifiaimimtion ; a tl^bt Mitch. |K-nt-up 
bchants ia a woatu), cr obstruction of the duct of n gland, are nil landliar 
iMWFM of mwMt Boling primanly lu a ojiutc uf intlnminntion. As a 
MMMary cause It m still io"n- irii|K>r!ant, as it ci>nit« iiiln pliiy lo u f;ri«lcr 
« loa drpv« io all inflaniainlioim hh a cODScqiienct' of the dilAlalion of tlie 
ivals aad ih^ 'Xintmliun. In nn nmie nlaci-», it i* tho tcnxion pruiliin^l 
ta A«amiroula(iMU ol' fluid tlint cnuiMii the [ii.-R>t)>t4-nrc of the itiflnminuti<iu, 
■«iA nfari4ta mvn or htm cxiiitlMcly nx soon as tin- pus i» let <nil. It if 
fMlj (lit diminntioii of (i-n>iun by rmptyiPg lliv ■.>vi-r duli-ndvd vrmcls that 

CiR&f in «lmili"n<<f nn inllimKit pnrt; in fncl.it will b« seen hereafter 
iharflief of t«fi*iou is <iiir of tliccliivf objirct* iti thu tnatmvDt ofalmosl 
nvy lafammatiiin 

1 ItyiiraL— Undvr this heading are inoluded heal, aAit, and tlrrtririty. 
IU«6icts uf the firnt Ivu are I'm laiiiiliar to require further explannlioii. 
Buriritv acta as a i-ausc of iuIlainniatioD only wben it gives rise tu deccni- 
failiM M lbs tisKirs by electrolysis. 

1. Ckaaical — All siroiii: arid* and aJtatin and innumerable mils, such 
tonnvaivir sablimoie, cbloriile of linc, etc.. net as irritants when applied to 
fc liMoaa Numrrous nahtrnl pfyjHtietn of iJie rtgetnblt kinifdiym, such as 
(Mw oil, mustard, rtc, and totne oniauil prodtiets, such as couiharide^ and 
As fmtam uT variiiud veinminus rtptiles and iosecU, act as more or less 
(Miifal rariiin); isUBra uf iulliiintnuiion. The mt'Sl im|iorianl, boviever. of 
•KlhisdaMof irriuou ill »urL.'(eal pracitce are the chemical prodacts of 
pmAadlB. I( n to ibr irriliilion caused by iIifih' that itic iuttiimuiulion 
■J Mpp-T- Eiicb M> freiiueiiily nei-oitipuiiy open wimiids are due, in 

llaptat 1.. f ca^ra; »■).) i|ii< ^reat iiiipnivenivut ihut has taken idaea 

• frgtrj duhuf the ' i> years has been bmUKhl about rliieffy by 

A* M»a or kaa nrriWt < ' n "f litis sourw of irrilatiuu. It ts un-et«ary, 

ban tnitfiy Vi consider the naturv bihI necetnry oooditioDS oT 



P>ei» ts a i tinu or putrefaction of animal mallir is now UDivettally rrco^ 
*wl at a prtierm -if frrmniialiiin, tbi' nwcniial mnditions of wbtch arv: 
1. <* / w>i ifg of limii iiiiiin.il mntlrr; 2, a rti^imt nifipiy of eayvm ; S. fAc 

^^■rr af tamtrr; i ''■' ■ r/niiinof nj a mtain trinjterfiturt ; aud, 5, Ikejer- 

*al. Tbow may I riil nmn' in dclail. 

1. Iha ftwtmum ui ^i^—i oBiiaal tDatt«r. — We bavo already seen that la 
MAS iaflMaosatioos a coagulahlc eiti>liklir>n takes place; wheu this <.<nagu- 
lito k ^Uaaylo in tho rarahvs of ihf librin a viut nundH-r of while cnr- 
«Uch hav« nigTat«d fVotn the vn«-l», thu* formiii); thp so-callnl 
lynpfa or filtln axudatkiti, « hilc the mtuu cither flows awny 




isd 



LOCA.L DtSTURBANCBS kSt HTPLAKM ATIOK. 



by til); IvtnpliAtics or nccUTiiulntm in the ipncm tiatunl to liif pun. In lb 
cue of an open wound tlio plastic exuiittlioD soeuniuUtM on itiv surfnn 
foniM, M mr ebttll aAcrwanlft see. the tint bond of uuion ; wbilf tbo h 
drniiM nMiy, iinteM, rrom any irn perfection in [be ircittment. it i» allowed t 
acvuiniilntc in tb« cavity of the wounil. In cun)|><>iiud trtK'turee anil nouDd 
opening tbe nnlural cavities uf the body, perfect druloaice is not nlwayi p^ 
nblo. The pln^iiii? cxiiiltttion is compuMHl toao large an csteatof livini: d'U 
ibal it may be looked upui) as livJUK tiwue, aul L-uasu|n<>nlly iii<.-N|i»bU' <i 
underj^oinK putrefaction. It is oilierwb« with tbe netutu, trliidi is highl 
putnecible. Kxtrnvuinted blood, ntber io tb« apucca of iIm- nruilar ItMoi 
u in a bad bruiite, or in the cavity of n wound, or utlicr injurv. ns in a oho 
|>i»ind fnictiirv. Li rt-iKlily deciiiiipoiiitblc, nllbuugh lea ao t^inn the M-rua 
wbicb is miuxtitd out of the. cl»t 11* il cvntraola. Tlw pin contiiiiiol in m 
•bscoH, ur Ihe urlni' in a diilcndnl blnddtr, iirc other oiiimplo uf putnadbl 
animal luatu-r in tlii' living body. 

2. A sufficient mpply of oxyg«D. — Tlio, t!«>iic« tbcmadvei aud tlio bloii 
cireulutinj; iu ihetn, roulniii >juit« enough oxy^n fur the pnxHw of putn 
beiioit. This t* »buwn by the fact thitt nflVtiiiivi- dccvmjHiiiitioti frripiunll 
lake* pliieo in wound« frum which, immrdiikti'ly afVr the injury, ibc air In 
Ix-i-n cxrluildl by >»ino vxt^^rnul application, such n» styptic oiiUoi(l,Gullodiu< 
or thi! like. 

.t. The presence of water. — All livine tiuuM and (Ims fluid* of tlw bott 
couuin i-notigh walrr to puirrfy readily, T>ut the priixirtiuu i* not thi 
Invoniblo tn llie proctvs. The more niitcry an I'lcudatiiifi, the bkm* 
vrill il iliTiiiDpiAi'. 

4. The maintenance of a certain temperature.— Ex iwrionee Rhann that 
teni|K'rn[uro of tho human body ia one highly favorable to the futoorm 
puir«^tiiclio4i. 

5. The pretence of the ferment — The four previous conditiotis uf pm 
&ctiou have liitu uiiivt^ri.^Uy recoKUtMil for a lung time past, and 
Mid almost ui form jmri of ihv cooinioti expcrieiwe of lUHukind; 
Deoeetity fur the action of a f«rmcut as tho startiug-poini of Uie |m 
ninoiiKst the modern diicoveries of scieuce. Pernieala are of two 
ortcauixed and nou-organiied. Tlievr^iirinZ/flrm^nbare microecopio 
table oricaubmi belonging to the cla^ of funifi : tli« non-<tTyinittd 
chemical HulNtlancea, such a* dlnMiiae, perwn, plyalin, etc., which t;i%'c 
ti> dt'finiii' chemical chan^ea in the M>eci»i nib*litnc« U|><>n which ili4>y 
The ])art played by the roicroacopic funjci in ih« i-auwiion uf fermciitaii 
Mill douU^'d br »on)e obtervera, who attribute ihe proc>«> U* the action 
particlcaof dcfia organic matter supi>o*c<l to Im- undericoiugci'nniu "pb| 
i-h<-iiiicnl " changes, by virtue of which they xljirt niniilar i-liaii){cs in ut 
organic oumpoandowtih ivhich ihvy iniiy r»me io contacu Tb«TaM 
of olMrrcn arr, Iiuwivit, now agtv<xl iu oonaidftrUtg tlie proccaa »f (ral 
filctton to Im' a fvniM'ntnlion, dcjiendi-nl nn l)ir |>nMO0e of an iirKantx 
living fiirnivni. In putrid miiniid thiitlx iimrc than one form of •■rgiii _ 
iMually mt-l with ; but (h<- in«>l iiii|>ortanl and c<>iuttant t« a *hi>rl, r-il i>haf 
funiPM, the h-n>.'lh of whicli dii* ni>l cxcx'od double il» brt-ndth. Tlii* i* il 
bacterium termo— "UpiHunl to Iw tlw fcrinent uf unlimiry {Hitri'fnc 
Ttii' minute n>und fuii);i. arniMKol in group*, pain, or cliainv, whichj 
be present, are not i-wniiial to ihv pmoeM; unless ibt n>>l •ha|H-d bt 
bacteria arv pra«>nl. the ur<Iiitary putrid sniell Ss tuA produoral. 
bacteria nretnie "saprophyte" or"cnrrioo fungi;" tbcy devclup i>nl|i 
di'uil matter, and roon perwJ) amongst living liiauf* or in tbe hliHul-ntr 
of a li<-altliy living animal. Many forms of micr«<M>pie fungi arr caiuib 
of iiltaeking living tisauce and gmwing amongst tlieni like true |anisi( 



I'Utalion : 



f POTKKrACTlOS. 187 

ad, m aailtr tbcM drcumsttuicws llwynro aMociAtcH with, >iii) probutily 
OMfsMMvor Uw nHukrdilwturhiincein lheh«alUiof the [Mrt tli<^v iufesl, 
if* tmn nocivtd iImt imud? of "iMthogmie/unyi." Tl>e nriiinnrj ba^^tcria 
•/mOTpMiUon afv, in tliis senw, non-pntho^Die. The chomini firntluoU, 
k^ww, of tka prwc M B of puirefsnive lenneiiutioa ur« iiilciiaely irrituiitigi 
«iMi iafluraMtion in tbe tiatues uith nhich thoy ciiine iii ivminei, ai^ 
■4» abirtiil into tl>e sytiem give rise lu vo»±tituliunul diMuriMUfi-, vary- 
«riaiaMa«tv dirvctlr with theiloae. 

iMNBUBf. taerofoni that tKe preaeoce of bsL-teria u an esaeutiat r««lur« 
ttAt proeca of putn&ciive ferm^nintinn, two views hav« been he]<l witb 
mpnl w liMir aetioo am) (ihhIi- nf ori/iu. First, that Uiev art- thi- iliiYcl 
omm«t iIm Droccw, aii<l ihnl iliey iiri>o uilcly ftDm preSxuliti^ oiyaniiaiu 
<f Iba auM Rtnd. ur ilx-tr kitiuh. wbiob huve fitind admiuimi to th« pu- 
ttwiUa OMtier fruni niibouL Thin vt<-n, uliicb it kiinwn an tl>« "cenn 
ttnfjr tt ilacafapiaitiun," i* hdw nbiuHt iiiiivfnuilly acveninl. S^coixlly, It 
ta* twi nwniAiti««l that. allbou]|:li ihi! niicrvAomic urfrnniiiiiii) are Mmntatitly 
. tbev ar» mervljr an accomiMuiinicnt of iIh- procnn; ami that piitro- 
I aectin eitbar •pootanomialy or under ihu influeDW of a chmiirjil fir- 
,aad ibat during lta»ocurrracp th^ iMck-ria inav be di^vclopei) <W>in 
1^ <ka«l ■ntier which a dtHMm|M*ing. The dtK-uMton of ihix qunti'iD 
•nlna tba wholo mbjwt of abiogcnwu or F|>o»tan«uuir gr-neration — n Nub- 
ju ikM hm oeoiptad tli« attentioo and ■■x'-nim^) tbi- inj^uity of «dcniiftc 
■« of all ag«a am oMintrivw. from tbr tini*- uf AriiiotK- iiinardc, himI which 
^pfWpkaa far fr>Ri it* u)tiniat<.-»nlutiiHi now v it was irhcn he wmtt'oD 
At U ix t ali I IP uf Aniinnlfc. TIm- liill diM-ut»ion urthi* siihjrct would Iw nut 
•t fliA brtr. and I murt nfet tlte twailer to the writin|^ of Puetcur, Li»t4'r. 
.anlTviiHall. 



i»tu am Mir pmrtit puriwiK ia conccrDcd, it may be Hiffi«lenl to sbtte 
tta ll lav bent ahiwn onclu^vely by Pasteur, Luler, Tvudall, and othi>rs, 
Am pKtnsdltlfl fliii<b, »uch as urine, tnilk. or hydrvx-ele teruui, may be 
Ofaaj «ilhi>ui uiiderpiiui; deroin|>uBiii<>ii toHirnhieh has been deprited 
^•U itotulid [Mrtii-lni by tllirotiuii, or linj> 1m:«u cubiuitted to a sufficiently 
%fc H f r r atiiW!. »r to th« nctioo of sorw chuiDical siiliotance .capable of 
m^uyinf the vitality of any liviufi orftaniiui. CuD.ii-t)Ueiitl]r the Kaaee of 
A* ui arc ant iLr eniiMi of pulrcfadwu. If a lluid which haa thua been 
Ufi frMB puinbctiiia fnr weeks, or wen muoth*, be, at the end of that 
kWk upiMl tn tbt ao]>urifinl air for a few secomli no reitult inuy tollnw ; 
if W a tern nuauim, fangi ars Mre to make their ikp|Kaniiice: but it is by 
kf MHsa CHrtaia that th« organism that apprnry will Ih- tb<? twderium tvrino 
«i that iIm bnncoiatioa lint follows will be onlinnrv putro&ction. Mon 
^i^mtf omiMa of variooa kiitds appear, t*]H'<:niiU if tlto air bo mora 
Am mimHj drr. If the exposoro be prolouu^>d, or lh<< air very danip, the 
fnUkilUr of ll>r a(>n-Araiic« of bacteria will be much gri-iitiT. The cuu- 
iiA« dtawD ftom inb i* that the »j«m of moulds are always Aoatinji iu 
Aiair ia oosidanhla numhcnt, bui tiuti liacteria are much !«• abundant, 
h(«flJ aiv always praasnt. Tba sauM result uiny In> obuJiMd by eulli* 
nfiK[ th« duM Ma roon on a gelatine cultivating M'lution or on a hotlad 
fH^ In aasries of eultivnttoDn baotoria appnir ocuaaiooally. while the 
^^Mjtfc rasttaotly develop. Ur rx|>-isiag Buitb or other <;ullivatiiig niodia 
^^Hlalr far Sk4 timM. it can he clearly ihown that nil forms of organisms 
P^lraasrii a»or« abuiHhuitly t» tiic air of h»uM« than in (hat of thu open 
Mmry,aBil mora in gn«t citice than sow II or tnw us. If, inttcndof oxpusing 
*» psirasriUe duid to air. a dmp of uapurilied water from any source be 
', haciam make thdr appcaranoc with abcoluU' certaiuty, and ordinary 




186 



LOCAL DI8TOBBASCE8 ASP ISFLAMM ATION. 



piitrcrnclioD fulluws. From thi« fuct it iit to be L-oDcludM) tlmt wnt<-r i* ttie 
vpircinl hnbittit of the ordiiuiry Imcleria of [tiitri>rncti»u. 

Amtiiiiing, ihcreforc, tliitt thi- liiirti'riii arct the viiuw) uf thu pniriw* <if 
nutrcfnction, by what mcnnH c«ti tlicy gwiii awi^w to tli»! )iiUTvi>cilik- nmiinr 
in wiunHs, nbectwes. nr cnvitic« containing niiimnl fliiidx? 

Only two inodw of entrsucc nfnd he on^itU-riHl : 1. Thr. haeUrin miyht be 
eotifeivnl to ertler by the Itmrji and nlim^ntniij eanal, nn<l l\m* timl llirir way 
into ihc circulatiou and enter tlie (Icatl mutter from wilhin. Thai tlii:> nio'U- 
nf iMilrHDce d(u?s not nccur with the bacteria of dcconi|)wiili»ii. \» uvitkiit 
from tbe fact that Bubcutaneoiis accumulation of pntresvible fluid eiicb as 
pus, or Berum, or portioue of dead tiasue, Biich as a part of an orpin t-iil "ff 
from iU btood -supply by a simple cmbolon. do not undergo putrefaction. It 
has, moreovor, been sbdwu hy experiment that tlie bacteria whirli cause 
nrdinarv putrefaction, even if injected into tbe blood-stream, rpc^dily peri»h. 
That other forms of or>,'unianis can enter by this method mu»t bo acknowl- 
edged, ualcea we arc prepared to adiiiil tbitc they are spontaneously generated, 
fiir in all acute iufeclivc InSaniniattuus, ami in all acute ab«ceB»cs, micro- 
fionpic urgauiiims are found at the seat of disease even when there is no 
exterual ui^uml. 

'i. The haettrriii am a<lmitted directly from willioul. Of this tliere can be no 
doubt. We have atrrady seen that vhi'y are constantly present in the air, 
although not in Micb vn»l niuiihera as was at one lime enppu^ed ; they are 
more abundant. howcvL'r, in the neighborhood of deL-otunusing matter, as in 
a ward contaiiiini: many woiindH the dischar^ of whicn are in a stale of 
decoinpoitition. Th<ry an' carried into nouuds, absceewa, or other cavities 
by the turgeon'ii han<l», by inHtnimenlA, and more especially bv water, uolesa 
some niMaii arc ailnptvil to dt'stroy theru. Htlll it cannot tie loo cleKfly 
borne in mind that even when they are carried into the body, or into a 
wound, thi; nrdinarv bactc-ria of putrefaction can do no harm unlets they 
come in coiilnct nitli dead matter. They speedily \K>T\»h in the blood, and 
they ex«rt no in<Iu(^nc« on living tiwuiv. Amoni.'At living tiiutnes we muat 
clam the ciagnlahtc Ivmph or mixniic exudati<in that c»veni tbe surfaces of 
awciund; nhilc ibc MTtim ir <li.-nd matter. In a wound or aliHceM-cavity, 
thi-n-forc, which i« perfectly liraini-d, dury wmn jHTinh; and. mere |ii-rf«'t 
drainage alwaya poMiblc, we need not fear the j>r('3C'nce of baetcria. It in, 
however, not pnariblc; and ciini>ei|ucntly, aertirding to the ^Tni theory of 
d«coatpoaition, it brC'irucs in mogit eii»R< a matter »f grMit im]>'irlance to 
exclude all bacteria from wounds or abucfiw)', an<l U> dTOtmy any which 
may have found .idmiwion. 

The bseterium tenno, the fcrmcnl of ordinary putrefaction, is a short, 
rod^haped body, the length <if which in under twice il« width : it exhibits 
Mtive spontaneous movcmenie, but ()cca»ionnlly a gfoup of bucteria become 
unitwl together by » jelly-like substance which limits or arrest* Iheir motion. 
Bacteria muhiplv, as far as is known, solely by division of the individual 
calls ('fiseion), and never by the development of t porta. Thcv are, conso- 
aucntly, easily destroyed by chemical antiseptics, by heat and ()y drying, as 
the extraordinary power of resisting these influences is shown only by tho 
spores of fungi, and not by the orpiniains tlientselves. 

4. Orguiited Irritants, — This class of irritants includes those organisms 
which have the power of groning, like true para»ites, in the living tissues of 
the animal borly. Amongst them niusl bo included certain animal parasitw, 
such as the itch insect (ncarus scabiei), the chigoe (pulex penetrans), the 
trichina spiralis, etc., which bury themselves in tbe living tissues and there 
excite a greater or [emdecree of inflammation. Thew are. however, of little 
importance compared to ue vegetable organisms which are now supposed by 



I 




i 



OBOAKISHS IN ISrKCTIVE lyTLAVMATlOSS. 189 

ttmi^kkt of |Mtb<ilpgau to be ibedired cmuMof tnao)'^o^ul*o^influIllD«• 
A«ttMTH|WM•, mali^tunt pustule, and ritbi;r«|i«cific afi^ctiuiw. AsMiintii); 
AvlUwjr la Wtnir, il u prolmblo ihal die iiilliiiumiiUi>ii a the rtvult of 
i» immitinm at Irrilutin^ clirmicsl pnH)uc-b> by n \it>kvm uinloffnus in 
Ml and IvrCDCuUitJoD : >iill il i* im|H>rliibt lu ninkc k very l'Jmu 
I bMwwa tbe vdveu of I9inpl« putit'iiiciioii iiiid tbo iiiflammation 
lijr tluBi man pottDt orgaawm. In ninijilc pum-furiiou. the irri- 
material h tnnutd aa ttui rwull of obangn uccurritix in th«> dead 
Iv <«ljr, aeil maj b« regarded as Mug dcrvlopcd otiixidf the tHidr; 
mi. mtttm U c*t« riw la •prcadiiig iBllaniiiiiit><in, dm i» diii! nivrrly Ut tha 
Ankal tndueu nf lh« procces voaking into the fummmlin^ ti»#ii<?s. just 
Miay •wlubk imtatiog «ali. mch n> cornwivc sublimaic, iiii(,'ht do; bat the 
isilaat dot* tMt iDcnwto in QUsniity atuuntfat Ihv living tiwdo, and ita 
Adto an direvtJjr pn>pnrti««iM!d to tfao iiinntiiy dcvdopcJ locally. Thwe 
i^ia otkrr vordi, tm tH/nditm of tlie surrounding tiawica. With the orfcan- 
aMtof BfalHi ■*(■ ar« ii-iM siwuking.hovevcr, the cjih is different: according 
tp 1^ ^ptT. li^rttTf uf iafcctioD, it is suppoeed thai th«y grow iulo th« Hir- 
nmi < .- tWi«s. and cseit« iuflanimatiun ns they spread ; they enter 

fcoit'iux'.''' '•" ''*- Irmnh-elreatn. or by the bloodvessels, and tony uiul- 
Vfkj m Um I -- blood, givinfc rise to cbitngra in its curaiMJ&itiun 

JMHipMible Miui nil', itr they niny ImIik in di^uini {wns. nod there grow 
«4m «p load inflaiumntion similar l<> ibnl nl the ungimd seat of diseaM. 
fnm iMir dirvct power of exciting unhealthy proceMos, these orputisnae 
Mtffakaa of at *' patbiiKmte fuutfi- " Thry cause a tme ui/erf j'm Aou /aeafi^ 
^mtfd tlu tim^nt mdj^imitg tJu ftirt firnt injrefrd, and gtnfnilfy in the uAoJe 
i]rt«ik Tb* piiUriD iiiultiplit^ io the Ixniv of the affected iuitividual. nod 
n> »A«t» H prmluer* urn not propurtiimnl uf ibe (|uaality of the ori^lial 
im ifturalaird. Tu tiiflammitUoos arising from tlii* cause the term "ittfeo- 
Cm' (s apidwl. 

IW aegaiiisnu which are foutxl aMocialcd wjtli "iofrctire" iiitlamnintioDS 
MdaaaU aith fiiagi, bviog d<-stitul« of <-hlun>|>hyll and idisorliing uxygeii 
aJ nodine earbunio aciiT They bclotig chivdy, but not exclusively, tu 
lUwtbn Hleiooooetti sihl Bacillus. 

IkfMOCCt arv ruund orgnnienis. varying from yrhf I" laisa inc^i in 

tiHHsf. and arc ullwu rccogDiiable only by (be highest poKcre of the 

■^naiii|«. Tlwy iK'vtir singly or grouped in pairs, chains, or culouies. 

VWa ia cwli'oit*, lliry are iHMtDd together bv a bi>mogeneous subetauce, 

laMra as '' Z>iug;I<ra." There is no reason to believe that ibey ever lengthen 

W lata rt'l'thapnl iirganisnis, ns they can be cultivated again and agniu in 

■Mdia.and still rvtain their origiual furni. Their mode of repro- 

issappcasd tjt bn br cell-dinuou. 

ImSH an rTN)-*bat)nl Uidieft. dineriDK Oodi barleria in llie fact that tbuir 

^|tb is ar IrBM do«ibli< their breadth, and that they are must often motiuu- 

W ~ S' orliiirary, but our knowledge is uot yet suffi- 

•aj r dirtini'liun. One haeillus is, however, of such 

^isai r tiM iritbiiut difficulty, namely, liie Uacilluii 

< . .< " the CHUM- rd' Bplenie fever in cattle and uf 

10 mnti. t>ii*ervsliiiii ha* sJmwii that, under favurabla 

i!i, it Riuliiplir* by lissioD likn lb* bacteria; but, uiiiler 

-, ■mall, highly rafhioLiiig dots appear in It* sabsUiioe, 

fovii] til Ik •imrtf^ These *]>»rnt sliow a ninst rcroarlinble 

Ui«t, rlwraical rMgeota, and drvin^. BIiokI cnnUiining 

'''V fur yean without losing ila virulrni.-v; it may be 

r strongnt i>'Bt4'ry or oily hiluiiuiu of rartullo acid 

•fiiEj uriug icDpaired, Iticbloridc of mercury, however, in a 



' 




160 LOCAL DISTURBJlNCEa AKO tirPLAHMATlUN. 

one per wdL Mlulion is R{)e(^lilv fiiuil to it, u nln> is portiwngHDalP of 
in a live per conl. solution. Pasteur has «)»■> «bovn that, wh^D ciittivnir 
in a mrdiuin unlnv'tniliie to its growth, it Iom« iIb nrulrDcv fcnulimllj uni 
it cnn bo inoculatvd into no animni witli thr oi-rl«itiiy kI' {>r<iiliicing a mlli 
formof ibvdtMBse, bnt y<'t sufficiently Kvcrv to proiii.-t rmni funlirr nitiidki 
The Mudy tf tbcw orgnnignw biis Ink-ly recvivnl a still furtlxir ini|tulse tnn 
Ihe discovery of a hacillus in tubercle. Tbc trxact relniiou uf tlK> orgnntaa 
to tubcreiilnr inllnmmiilioM to etill to be determined ; but no doubt rsist* ■ 
to ils presence, and thai it |>l*yA some iiu|>ortani pnrt in the promw cai 
hardly be doubted. 'I'he tubercle bncillus, like that of splenie f<-vrr. caa 
d«volo|) sports, nod allhoujfh it is not yet definitely pruveil. yet itiis nxxle «■ 
crowth may ultimately be found to eatAblish a distinct line of demarcalio 
between the organisms to be clnaaed as bacteria and lh<ise to W includr 
under the name of badlli. The tuberele baeiliuH will be nM>re folly describo 
under Tuberele; and that of »plenit- fever under Malit;iiant I'lwtuk. 

The (jerm theory, iherefore, of infedive inDammultuna is that. un<ler orp 
mill coiiditi'iUB, panuilic fim^'i Ijike up their aboale in a pan of the body, 
fretjueuily already daniiip-'I, a» iu a wound ur a <?enlrc of sunpu ration, anJ 
ikcii, while Kroniu)^. )civ(; tat: to a pmcnM of leroieutAliou in tli« Huidsof lb 
part, the pr^iducl* of irhicli arc inlcnM'ly irritating liicnilr aixl |KiiaA(x>ui I 
abewirbod into the «yi>teni. When iher enter into the blood and afl<irt tb 
wbolo tyatem, the orfianinnt* are «u)iponi.il fi ad partly by lodging in mloitl 
vMieiH and exciting a procCM <>f inllanimntion iiimilar lo that in tlie origina 
•ml of di»m«0 at tn« point at which ihcy aru arnatt'il, und fmrdy, like traa 
pkni«it(v, by alworbing oxygen and otlivr nutrimiMit to the dctrintent of thi 
tiiMiM »f tbc botly. 

Although oDriici]UBintancv with the rotation of inicroaoopic orgnniium ti 
intectivo procMM hns been vastly inerejised of lata JMR. by ihr lalxm a 
Fa»t«ur, Koch. TouMaint, Klebs, ilunlon-SMuletWB, and many othvra, yi 
we are ver>- far from puerewing a complete knowledge of iho whole subbed 

Addiitiing to (be fullest poatible extent the influence tit palbogenic hmg 
in the cauMiliim of iufeclive proeesses in wounds and elsewhere, experienn 
teaches us that the hygienic surroundings of the patient exert an iitHavtin 
(if the greatest importance in tlieir development. 

Putrefavtiou b, as we all know, a procow quite independent of liygienii 
vouditiuus; a dead body will bcvume putrid iu the fmli air of the muntr] 
juat aa surely as in a cruwded dly, and iu the same way pent-up diM-hargd 
will putrefy in a fnlace aa certainly ns in the foulest dwelling nf the pi»f 
Under the brst hygienic cundJtiontt. if putrid discharges accumulate in I 
wound iir in the cavitr of an o|>eiied alisrew, local inRammaiimi and suppu 
raliuti art rxiile-l and uiiiuij ol the wound or dining uf the ahscew-cftvitT i 
<1( laytil. The lucid ami conxtitutional disturbance will, however, be len loai 
whi^n the pali<-nt i* irxixDHHl tutiad hygienic oouditiuns; Inrthe tissues being 
boUer iii'iiriihcit, will Kutrcr li-m from the irritation uf the leptic matter, and 
tbc fvptic iHiiunD euif'riug the nyttem will Iw niorn readily eliminated. Trafl 
lafKliVB pt xt cwaci in wound* are rare, «Tta when the dt*chargni ara dMonJ 
{MMtng, unlcM Rt the Mm» tinw the patient (• rxruiMil to unbealtliy mn 
roundings. In ptivnle pmclic* erynpclaa En uncxnimon, pyumia is sraroela 
evar met with, nn>l h<wj>iiul cangrcoe h uukn<iwn, even whm no appcul 
meant are nd<>{ited lo prevent dw< mi [unit ion of tlie diiicJi«rp». If, h<iwever 
a nurolwr of jwlienis whow wounds arv umlcd without aniiseptitw, bt 
eniwd<yl lugvtlier, lu! in the cjise of tlw wounded nftor a battle, evru if it b^ 
in a building which has never bofora been ufod for audi a purixve. infective 
proeraaM are certain lo ntaaiftat tlwrnaelvw. How it is that infective pt« 
I dwravteriied by th« prtMnce of a specific virvacapableof 




CAOSATIOH OP l.VfKCTITK 1KFLAM U ATIOSS. 191 

iMMi iidividtul toanothor, mnkf tlirir nppcaraoce under unfav<irabl« 

Itj^Mc Madhiooa i> Milt far rn>m Iwing fiiDr undereiootl. j\Bauiii)nK tlinl 

^■■9«6rgUliMa> ciwMiuitty MMouititrtI with infective in Bam mik lions reiUly 

^mi to IMM I 10C UW ill the rvlOKiiiD of cauie and efli^t, it liaa yt-l (<■ li« 

JNVMWd whotlMrmeb furro of infective iDf)aniuiatit>n is dui' !■> » api-ciHe 

ipiiiB CBttrtmlly nnwril in th** air or in naler and ready to attack tbe 

|HkM «bM tbtf tinlx-iiltlty turrtmodin^ to which he it cx{>ofed. or nthor 

tmm i^i nwloutrition. fuch as prolonged wound-ft'ver, or I'on.itilutioDal 

imm. ban mlur«<l hia nrvn(,>th m> ftr as to make it [x-iMibli- r»r the jMra- 

wit hafi ti) lnraiU hia IhmIv: or whellter Mmple, Duo-iat hostile »r)iiiuiiiRi* 

MT, bf crowiDg in the dKcWrKe of a ir<rund r«nderva uuheatihy l>y pulrv- 

HiiS, a«««l(^i n virulence they did not before ponos, aod so bcconw 

■flU* of invailiii)' the liviuj; tiaeuM. Tlie Bubj«et ioTolvea iho whok 

•Mtiw of the "miitahiliiy of bacteria." and cuunoc be di>cu»L-d hort. 

Mm it to aay thai K<K-h aod other oWrven have shown that, huwcrer 

ihtMfaatHna may a<M)uire llieir virulent proper! let, and whatever may Ito 

'^at'-"^" '•I'." » "I'iracterbtie organwrn ha« been found a!«ii-iute<l with 

1^- ive inHaimuuiiou, it ciin he tran.-'lt'rrvil fniRi iinimal 

t*HuHi&i -T, iLioMiiuii-'ii and even culltvateil artificially iu |iro|N.'r nKolin 

WiMa tbe Duly ; nod thiil {P'neriilinu al\i-r ^teiK-miinn it reproiiuree ilvtlf in 

AtMMc fortn. and when inoculalM) prwlucut the Mine variety of iolwtivtt 



Ju^ainp the prvMOcv of |Mitbogcn!c orznnitini^ in the surroundinga of 
tk* patiMrt. how do thev }{ain admiMon to the syvlem ? Tlio direct inocula- 
llaW a «ouim1 't» undouhtclly. i» the vant minority of furgical cii»ea. lh« 
Mif«f tabcliifi. At Ix'fon- Htatol 'vee pn^ 41^, the air of a bwpitnl ward 
la bam alHian |i> f<<niniii io addiiii>n |i> frw^iivui* of clothing, epilheliuni- 
aA^Mc> which arr alwayf fu<inil in inhabited rnome, pUK^elU, fra>;iUfntA 
<f 4tii4 fcaha, and bai-t*'rta. increwRin^ in number in the neiffh bur hood of a 
M Arf—r-jin:: ui>tind. It ift evident, therefore, tliat uulew wounds be 

Ciilly ; infection of ooe from another may oiooi easily ocrur, 

iuigi: , 'iritintfltcd pn>porlioua)1y to the iteparatioii of the paiieols 

■ad tbr fnvaliiRi of the admiHion of pure air. The p>i»0Q can alto uo- 
4aUtilly Iw nrrinl from one wxiuod to another by dirty inurunteuta, or 
kpa, or by the furjteiin's hands or clolhi-s. 

IwiWK be denied, however, thai it b poMiUe, in tbe enae of palbogcuk 
■. ftir ihr tafi-cliun to reach the lixml Mat of inlluoiniattoii fmm 
*!! r 4c>>pic i^nniubmB are found io all acute atwifMca and iu 
inRammatioD* in which there i» no opeu wound; nml uul«m 
iv-T (ii^Li tbi-y have Iki-u 9i->niaueuutly geoerateil within lfa« body. 
••■«M admit thai ihi y luivc foiin>l tbdrway in by the tuogr or aliaivoiary 
omL We hk^ (VCD thai thi* okhIc of entrance cannot bu ■dmillcd 

• llaouaiil I :>ry bacteria of decoiniwiiiiiiiin ; it u eiiually ceitain 
■hi it rBao«4 I ID ihr caM nf tbe ur^niiim* of infivlive inflammn- 
>iAa Eiprri- < 'vrr, trflcho IM tbat il in Dot by any mr-nit* coniuion 
aWaJ iejunr*, iW thr\ i<.ia) nbo-nce of urgatiiwia from n wound can ))c 
•^md, wtih atnxMt alwilute crrtainty. by nwun* calculated ••nly to protect 

* S« the diut uf tb* air. 

Lanly, it nmalat to be diM?ti«etl, what is tlu- rclaii'io of oflinan- putre- 
b(M bi tbe deTrln)>meni nf inU'dive iuHaiomatioiu? 

OidimTjf patrrfaciioo acta both gvnemlly and h>callr. l^ie iDvasioo of 
fc kntf tMMira by an infoctiro (tfocew ntay be rcganled at a sttuf>t;le he- 
*•«■ tbe rim* and tbe UaMiea, and anything tliai lowen tbe vitality of the 
^MKr will tivor the fortiMr. l*he nutrefyinf; diacliargea irritate tj»e pans 
*>k aWb Uwy dw»* in contact aau directly lower iheir viulily. aa ia eri- 





192 



LOCAL DISTCRBAHCES AfTD IXFLA U MATIOIC. 



3 



dcnocd b]r Iho tDAammnlioii iwrt iii> ; nnd llioy ihu* fiivor tli« inriuinD nf lit* 
l(Mue> bv tlic pHtbogviiU; bacteria. Thi* wouliJ be udIv iii buniinu.ir *'uh 
the wvll-ltniiwit Act common to tho nniainl Rn<I V4^Utt>lc IciiiifduiiM, tiiai 
todflp iixliriilituts, or fr«ble iMrUofftn indivMiiimJ, mn tuwt rvKOily iari ' 
by fi!irn>iiic fungi. 

TIhi ii)llnm mill ion «ct up bj* tho Mptic mttlM- is Acoomiwni'tl hy » 
or IcH Htmndunt rormntinn of [>ti» ; and «o luog n« Kippuratioii lunt* wv bkt 
in iha wouud or nbscvn a mcilium in wliivh HDy pntltogrDic fungi «lUrb 
mny 6iid Qninince U> it will rrndilv ilcvotop. 

Th« cyxitmfl belni.-cn ii wi-uii'l liciiliog awpticBJiy by lti« tint >: 
and uno in nbieb Mptie siippiiratinn is taking piiin- on (he third 
marked a» scArocly to rofjiiiri' comment. In tlio former cofc, timuc* io .t luil 
etat« of Tttality arc Be|>Bruted merely by a thin layer of plaslir cxudattoa 
so larjcely couDoaed of living celU tliat it mny tatrly be regarded a» living 
tissue; in th« lutter, th« tinun for some diaunoe un eacb aide an> luwcrra 
in llteir vitality by Ibe irritation of llie produi'ta of puirvfaction, and arc 
Mparxted from endi oltier by n tluid which forms one of the motit uiitabla 
rowlin for the development of any true infective virus tlial way find adui^i 
ai<Hi to it. 

Gcnvrully dccoiuixKiiiion of the diachurgee acts in two ways: firat, it 
pretMK the pAtieut by the fever cnuved by the absorption of the prwiucta 
putrrfaftiiiu, and thiu renders him more liable to feuftt-r from any gcoenl 
infwctiw pr<K:«M ; and, Mi-ondly, it is a well-reeognited tact that ibf eman*- 
t)oni> fnini putrid mnlter excrt an iujuHoua intluenue on the health of tb< 
that inlialv tbum — in fact, the reitiovul uf {Mitratcible matter, ur tlie pn' 
tion uf itx dt-coniniKiiliou, IbrniA miuof the mo*t i.-KH'>ilial fvuturctufi)' 
and hu*|>ilul hvjiicno. 

No grmtcr tnuUko could l>o made, however, than U> imagin* that with 
tho prevtiilion of pitlrefaclion all ne«»»ary hygienic prt'cwiiliimf arr end^wl. 
As b«for<' |iuiHl>'il '101 >: |aigt' 41 i, the products of rrvpiratimi foul ihr air and 
exert a deprtvaing iiiMui'iiuc i>n ihoee who breathe it to ■ dunw that cxnuajt 
be ovL'rrat<.'<) ; and thciir ic nn duubt that, much a* anticenlia have duur in 
the prevention of infective inflammiitiona, no inconsiderable pan uf the ini- 
pruvemenl in ibo results of nuxlem our>;ery must be attributMl ta t' 
greater titlenliim paid to general hospital hyi^iene. especially to lh« improi 
ineuts in ventilation and the avoidance of overciuwding. 

A. Funclional Irritatioa. — Every tissue requires a iwriodic mt from func- 
tional uotiv'iiy for healtliy nutrilioi). but it b very aclilnni that ibc nam of 
such rwi can act aa more tliau a prediB[>--i!>ingc»uae<>f iiifl:immali<Hi. Oeis- 
uAuully, however, iDflammaiious of joints or of the eyes oeein l4i bn dincU, 
dc[n^ndFni uu excessive exercise of functlrm. 

ti. Ncrront Irritant*. — 'lite juirt played by the nervous syslem in 
direvt caunutiuu uf infbimmatiou bas always been a qutaliou invotvcd in . _ . 
Hdcmble olncurity. That inflammation can take pfac^, and readily ilucs so. 
In a part ivimpletely cut i^ff from any cmnnectiuu with the cettlral nrrvuus 
■yM«ni, boj born proved by numerous cxpcrim^'nu; in faoi.tuch a oindili'm 
has already hern doaciiltttl as a pniliitKwng cauM of Uie proceM. Tb« 
ctinioil phrnomrnfl u-<iially i;ivctl M cxantplea of inflanuiiati<'n nrisinu fr^ni 
injuriuu' tutlui-nr>ri trnnntiiiltM) to tiM afi<WI«d part by means of ihe n<-rv<iu» 
ayalent, arc the *o-cbIIc<I nympntlictic inflnmrnations of the ryi: and of tba 
taitiole, and herpes iiMter lu tbe rye, il io a well-known faet that, when 
OM clubv M alfeciiil by dwtructivo inflammation follnuin); a woun>J, unl 
tha di*4-u*ed organ i* removed «ariy, tbe other i-ye i* lial>l<- al»o to lM.'eoaw 
inflamifd. Tbe lattat obsvrvatinnR t«ud U> prove that tlw iuflnmniation la 
such cuse* in reality spreads from oiu! eye to the other by direct oxtruaiua 





VAklBTIKS or INpr.AUMATIOX. 



198 



|iU(iiao|itMiMirT« lo the cofniiitMuiv. Oi>Dorr)i<Mil iuflammatioii nf ibo 
' ' I Uka iBaaner now uaiull; reft^nled u a direct exicusiinit df (b« 
hf iwmfil of the TBA ilpfcretM. Herpes ttmier U an iiiHumam- 
irf tit tkim Mtidaf froiti no kouwo exumul i-iium, uid luiuiilly liniiiiil 
Pl>A*amHipplied bj ■ UDfle teiuorjr uen,-^. lu ihi«ca«e«n'ciin'iic«m.-ly 
4ata ikal tkc tmtar, whslervr it nuiy l>«, ncU Ju mihii.' irav through tKu 
MtK AkliMiyh tl W diflScuU tu nrovu tlikt lltv tivrvi's tako. unlitiitrilv, 
m •ctir* |«rt id thr CMlHliod or inflimmntinn, tboir is d<i doubt th«y 
n4ti u iiDuaruiit tiiiliteaM oa iu progrew by tWir coDtrolling ioHuvooe oo 
if amlauiMi. Imuiioo of a muoij oon-n iw IcDntra to onuw dilikimioa 
rfite naela iu tlio wbalo itm ttipfili««l bir the uenre: ud (Ih; [laiiitul 
■ of tbc uervvs in iiifltun initio ry icniKiii, by (-iiitoiiig Hich M dilkUt- 
tb«- hliMKl'[in««>urc in tbo iollanM-d |>iirl, uul cnntcquontlj 
I Ibr f xuiiaii'iii aifl a^mavktos the tninon. 
TvMiM tf InBaiMinatioii.— John HunUT divided iiidunRifttioB fint into 
mm kJBtb. vu.. tbt< hMltby «td the unhi-atihr. "Thi-^ h«althy," be wyv, 
'i|r oanfMt* unlr of <in« kind, not boio^ divisibli; bat into its dilTemnt 



^ 



<■»' ** n* unhnulhy, admits of riut vnrk-ty," " ac<»rding to the kind 



is tha cnfutltution or nan." Il4.> also divided InHHinmaii'in acotinl- 
to tai i JkcI a into "tha ■dbcaive. tbo FUppuralirc, and the ii Ice rati tci." 
tM« "tttlriw iBfluunAtiOB" hw takpn r:>r nearly one hundred ye«ra 
■ Mwtwnt a |»Ia<« in uirfiail langoagv, that it will t>e better hera briefly 
kMAt iL Adharfvo inSammUioa b tlw re»utt of an imtam actiof; tern- 
■nrilr Willi MKh a i hg r w of severity bb to cause csudntion of aliooet nnre 
M^-fMHMa BDd Bkbtratinn of the corpusclw, with i.-oaf;tilatioD of the fibrin 
a « OB Um )l>}urM tjawc*. At the Baio« time, the damace dntie by lb« 
waammmt aot be of such severity oa tocaiiaethedeaihuf any appreaabie 
M«M «€ tlvua : nor rauat it continue to act aftor it has prodored the degtM 
'ta^rvd vitality iu the vtanU iteccaaary to cauae the exudntioo. To tnko 
«r*n»Ir ih« datiu^« done by iho p a wago of a •hari> knife tJ)ntu);h 
Hifliei''nt to dpvrlnp in the iircn nritil ii|vxi llic ttaga 




">^f«nicivriii'd by rftardation of tlii; bIoud-«trc*in. vxudatiofl 
I'l nnd migration of while corpitKlra. Tb<< vxiiilatinn 
- ' I rl'soc and in the t^ct* of th* injurvd limuf, ifac 
I aad ' l<v remain, fonning what i» known n» "influu- 

^ Iteijfin, ■ rum partly drinna awuyand |iairlly returns by tba 

Hafhaiio to il LiioR. Ttiin tTilliimn>nt'>rT lymph, or plastic exuda- 

M as it ia bettrr '-nui^i. ia the niat^-riitl of adhesion in ndbcsive inflnmniii- 
Ma,Hkl if twuMtiacm corercd by it arc bmii^jhl in oontact, theyndhen- f> 
«^ ntlwr. TIm knifr ran of counaactoalv while rultini; the Imura: the 
■WMt iW rat u made iht* caoae taanir, iW eflcct only Uciog Icf) l>chind, 
lfi»M« raiw of irritatioB ooinra into pl»y (toeh as ibe fridioa of the siir- 
h^ <■ ^kIi oikar, or tbe prraence of fureini bodJee, or chemical irritants 
• latfM aialfl r. penlstently artinj;, powerful an tifu? plies, et^;. ), the ell^ 
nnally aalaadoktbe injurwl lisftuea recover their Titality, exudation oiMiSCa, 
^ nfilaUJ inAammatory lympb retnainiu^', t;liieini; the fturfneea to each 
■Aar, and adbmve inllainmatioo is said to have taken place. Should soaie 
^MN^t sMircM fif irritalion, such as Ikose alwve mentioned, lie brought 
MtfJay in ft" K'riind, tbe exudation does nut eease so lonK as the cause of 
ntaiktt :' ruttsr()ueDtly, iiueh "inflammatory' lympb" as may have 

i i^m- cviaculaiioo of the oxudaiion, becomes sodden and soft- 

I h^ tL t» flow from the rM>a(«,aud infiltmtuil by innumembls 

9>T(ruw-in till it brnks up and flows amy lu pus. and "iBppara- 
ttte" is Nud t'l bare bivn devdofK<l. At the sauM> time that 
takiaf placa, ika tlsauM which fonn the nurfaoes td' tbe wound, being 
*•<. i.-ll 





101 



LOCAL lilSTl'ROANCK:^ AK1> INFLA MM ATIOX. 



UD«ble, ID coDsei)ii«ooe of Lli« presetioeof llie irriUni. lo reluni to ibrir noriM 
etaip of TitalitT. bet-ome iDfillrut«tl by innupHTiible wkudrrinj; nelb ubidl 
till all [|)« AjKioes nnil yrem uimu the xrik'iiiiil Iiibum. tiiiiilly iil)M>rbin)i tlirS 
Slid uot-upjing [li«ir placo : itiia the Mirliirc «)' tlir noiiivl iM-oitno ctinTcn* 



into u luver or dcMelj packod li5umi\vl», tlir >ii[>crliciKl (vIIh ■>!' oliieli _. 
ninliDUiillr (loftfn<-mt!r>it, lii.-(>>:iii»^ 1i>i<)h.-iio>1, iiikI rtniiiine swiiy in ili« dii 
cliiirgi' iu> punci-IU, llivir ]>lnc<- Im-iii^ tnki-ii by itew cl-IU kirniiDK Iwlm. I 
tbc iluwlopowiil of ihin iirw liuiiv in f<|iiiil li> tW ilininliynilii'i) nml drttrw 
liun on lUMrfiiCc. pu* cuiiliiiiK* to llow nwiiy, IhiI no t'lirllicr ilmlnictioa 
iW ori^tml tiaxK^ Uik<'» [iliiw ; if il i-xoirJ» ilii- ilmtmction, vraH-ln <l«v«l< 
io th« oeir tiMtic, lunl it ■))n>ui> up iii- t:niniiliiii<>i» iMf Rt-pnir). ]f, in 
M<|UMic>.* ol'ii bigbiT iK-Kr>i' of irrilnti'>ti, ibr iloiriii'iioii cscit-ilii ibv foi 
ttOD, thi< pr<>(H-» grn<lu4iTty i-xt'iKlp iuto tbr Mirroiiridiii); liuin* : n ncir U^i 
becomrr itifi1trali-<t by tiii}:riiliii|,' «-i-ll». {irmwd ii|hiu iiitil iibwirliol, no<l I 
place ucttipied by ihc crowibvl Iriiroi^^ !<.■», which in their Uiru bn-nk d«« 
and ara thronn off*, nnd thw n giru^^rcwivc dcslnictJoD of tiwuc lak<« plu 
This proccn is callcl oloerttloa: or.inlhc lungiiiif;corHuBU-f. "sloentll 
infiamiDation " is snii) to he uccurring. If tho irnmtion Iwvtil) Rton-KVrr 
the mi^'riilin^; ccIIh may pcHah befure they have lonncd tt di#ti»ct layer; at 
inmcad of ihe procn« juitt <lcecril>cd, in which ibe (in|;innl tiMiiir* arc 6, 
r«]ila>.-ed by the Icumcytt^ which thtii brrnk down and ntoll awiiy aa p 
ihc tiMUM Riav thetiiH-lvcji undeiyu direct diiiiiicijralioi). and the pn.nloctii 
thb chauKc will furni part of the di»i-har),'«, which under thfw circu 
will contain ahr«dii of lb« broken-ilioiD ltMU(.« nnd be lew rich lO ]«< 
or, in other wortls, iii iwiscells. 'llms in nipid ulcemtion ibe diacharge 
be scarcely purifurm, hm cumputetl of iieni<i» fluid with iIm* iIMirii of I 
mrinhin); tiaauca. LADtlr. if the irritaiiun Im? Mill more intiii*e and rapid 
itj> nrtion, or the original vilalitv of thit iitlV^'t^Hl loirt •■> low thai it ti 
cn{Miblc of rn>i)iiin)r even mild injurioui inBucHM-a, tin- death of th« ori^i 
tioMic will lake pjiii^ with >iirh ni|>>dilr that the tk-ad inan< will ltt< vui 
lo the Milked i-ye, f.irniin); ii flIoDgh, ami the procw* i» then •puk'-o of 
"sailigrenoiu iaflammatioQ." Thu» there •■ no ^hari) linr u> \f dmwn aii| 
iroere beiwc«n i-iniplc adhrnvtr nnd giin)ncnou)> inllnmniation. Onv fort 
mer)^ into anotii^-r, and (he cHect produced 'i» proiwrtiontil to th<- ilcgm t 
irrilfltioo. and lh« power of the ti^Mie^ to re^iH thv injiirimi* nctiou of til 
irritant. 

In Dam mat ions are alwi freqiMintly dintlcd, adconlinc to their real tir 
j>j-i-i) caiiMv^. «»■ Traainatio. wlicn nrifin); frotu injury, fitramout, Bht' 
Oouty, Sjrpbilitie, etc.. and finally, when the cau^ cannot lie i]t-^->>Vi 
arv ollen calW Iiliopkthio. 

Perhuiif. however, the ni<ir<t iinjiorUtnt diatinctiou is into Simple loi 
itiflammatioiu and Spreading inflamiiiationi. The simple locality) in 
ni:ilL<>ii- iiiv liue ti> nin-iv which act usually only on a limitMl am iumI in 
|rni|n>rary niiuinor. A -|ircadin}; inflnmniation in one in which llie <-«qa« 
of oiich n nnlurc a> to )><_• (Nwtinuoui'ly devebtped diher in cjninci with, 
in th« nflK-'icd timiim, attd which, coiutequvnilr. exienda mow or if wid< 
btrvoDil the area lirM afl(«t«wl. 

'rhr ni(wt {wrfect example of a niranl* in Bam mil lion ia that proalucvl 
the action of a iiharp knife on llto liring tWnn*. ll^rv the cnuM-' i* uc 
tn>lniitanfitit> in action, njtd cen^Cs ii> mrni a> ll>c cut in tioUk: Tlvc w 
aociiraiely limili^l to the arm injurml ; and, nulu* ronie new cau*c 1m' in 
ihiivd. lh<- niiiiltin^ inflBnimati'in nill nut vxlrnd, nnd will mlMdv a* 
a* tl>v liwum by lh<.-ir inbrri'nl vital |>oweni have recovered from the in 
It ia litmiliar. however, to every our thai ihix I'avoiable rtwiilt la nut nl 
ohtaiuod. In tntiny wmimla. the »tgii« of inllnmmatioii, in apitr tif our 



rttcetl 



injur 



SIMfLK A.V|i INrKCTIVK ISVLXilUATlOHS. 196 

bfNTcat h. Mtntd more ar Icm widely heyoiMl \he injarad nrcn, tn'l iv-flcli 
im BkiimoRi iati^lr at itu' tliinl ur fourth diir — ■ liniv long xtlcr that 
)t*Udi tiw tiMO«* aboiilH lmv<- oompircdv nifivrnvi) from tin? iciti|M»r7 
ii«(« Jmw Umm bf iIh- iiKTlinoioil vioknn' of tlw kiiil'c. It h evident 
iM km iImv* ia ■ orw muH- inlroilucvsl nliich ncl« miioli iii»ri< iii<k<ly tlnin 
Aim^umI iojanr. Ttir mltiirniiinlion liii« ii»uii)ikI ii fi|>rt'ailiui; iiiKtcait of a 
rii^la ckamc<«r. Tbi: «{>rrailiiig (.-tiaraolpr mar he du« lo oue of two rlannitl 
rf BMiMk KiIImt tlirfv iiiHT Ik- n>iiic Dnxi»u» material dereluped in lbs 
MMd, MmI io it iidIt. wliiirli faike awuy into ibe nrroundinK tiiwuev, excit- 
■I iKksnaiicMi ■■ far as it vxtifiMls; or itie iinxious DiAtcrial wliicli exHtea 
At Jadawtatofy p rat— » nay have Man«<l from t)ie wi^uod aod bo devclon- 
ifi— BMl llie liTiilK tlvuM themaelvm. and conae<|iiPiilly be iluwreticvlly 
■BiUf M alairM imlrfiiiitc^^KloiMioD. Tbe former »>iidiuon is still ii Mm[ite 
MuM>ali>iti. atibiHiKb extenilinj; b«irnud tb«! aroa tint injured : lJi« loiter 
• *ir«r iit/wrtirr firaerin. To make this DMire cli-ar. it Will be better tA ffive 
rii»pli» o( ibfwr tao fnrtiw of iadainmatioQ, taking an before u wound m 
k HafUaji-pMnL .Va a ret-ult of tbe simple tmufuulif iiiflamuatiuu whi<-b 
Uasa a* lAe DMHMry comteauentv of the injury, it I'ertaiii nmwint of 
tnAatioa takn jdaee. The fibriu, as before desiTibtH], coagulatoi >in th« 
■Aea, atiABirUD^ the rorpuactea io ild meahe*, »bite tJi« w^uin lion* away. 
irfc«B aoy rsUK the icruin beoaroea nuined bdweep tbe Mirfai-nt of th« 
mr hare a {iatrT?M.''il>It? fluid at fomi^ tlt^nv nf [inra^iire in contact 
tba nw Mirfam, and unlrw tiiri-inl inimns ere taken to pr^TPiit it 
will take plnrr- .A--<a n-.iiilt of thi* pr-irvcM. n-iidily iliDu'ililo, 
pnducU an> fixtm-d, fxiivaMiii^ iiiti'niu-ly irritiiline iiroiK-riii? ; and 
.iMManf itw »ltghl dwrMof praatDre to wbiHi ihf |)i^iit-ii|> Hiiii) in 
t if iil."ltb Boxivu* naterbJ fiod» %U way into the MirnHimliiii: lrti)|>h- 
aad wiMnvvr ii goo> it dania^rv tin.- Iwiim and wl* up lh«- inltntn- 
ftnetm. In lhi« run, huwev4-r. llx- irritjiting mHterial i» foriued 
It ia tb« «J«ad tualti-r in tbe wotind. Exporinicnt^ have sbown ibat ih* 
whirb arr(>ni|mny and are enpnoaed to cause tiie proceed of putre- 
of <1(«H inalirr arv i»nocuiHi» to living tiaauea, and eoiii^quenlljr the 
■iiKBatioa will extRMl only a» far a» ibe prodorts of puti«liu.'tioD dlflbae 
'rca aod no further. Tlius, alihouKli tlie inflammation spnada 
tb« arm ori|H»ally itijnrvd, Ibe proccA^ is an truly a loi-jil one ■> If 
tiMlucnl by fillinf; the uountl witb aiwnie or some uihiT diffiutibk 
AtUkougb th« pobwn tncrewea in ipinniiiy. it does ao only at t\w 
of 4«aKl BuUicrln tbe wound, which niitv In- coiKidered a* reallv unt- 
tb* bniy 
TW trai iafiKtira inflammationa are dor to tbe nrfiitmtal inimduettna 
• Hioo or rtrii* >"«"»>»'!■ t)iv pi^wfr of iui'reajiing in t]unntilT in 

nfiac tiatunt. . ; jinxluiiil ih. ihtrplore. 'piile iriR^iax.'tiva- of the 

w«f tba o«icilial ■•■uitil ur otart in i!' point iif iIm' irillBnininii>>ti. Tlio^ ilx? 
pick ii4m Bvettlp in •r>iiic up ii UhIv ntb'r » p<«i'nicirli-m cxamitinliim, inuv 
VM wa iafaiBiaiii-n exti'n>liiit! thmu^'h (In- whole nrni. In an infiMrlivu 
fMMof ifaU kiadlbr viruii<"ciHi^nbundHntly in tin- prixluoU of tlii.- infliim- 
MtMK. lb«t i* tu MT, in (he inllnniniattiry exudation, aixl if by any ntcana 
Am on.tLK^t. sr- -.r«n*fertnl I'runi onv tmrl of tbi; ImmIv to nnotticr, they 
*U; Lialihf in Ham ion I iun «hrn-vrr liter may Unigv; and. iu 

ttx :— -. <<.ir inl1niimuili»n may be nlnrteil in aiiolbrr individna) 

^ lMnal>! ' '' <-KuiLitio«i. The local ^girvnil of the inflnmmalion is 

•M la 111' :.i; inllaiumatory prijalnels ronlaintu}; the ferment- 1 ike 

f^m fir." ! HBT inio tlie lyniph-»{iai.'«A of tbe surroumling tivuea. 

^ i*factii>' iiiiiAiiiwnltun nuir bi- liniilvd Io one part of tbe boily, and 
ly fay lm«l infrrtHm. w in *)>ri-adtn)C i;nMt;n-i>e and pfalegmuiMMia 





LOCAL DISTPBBAirCBS AND INFLAHMATiOX. 



Itv ttie IvRiiiliaticB, Uic) 



; or tltc |iotK)n mar be toketi D{i hv tlie KRi|ibati<», . 
dumlmr in clinnictcr to tlw qri];iRnl prounc iu th*- 



catiM 



I 



HMBBMlMW diaulmr in clinnictcr to tuc qfigiRnl prouctc lu Um- nnrnt _ 
ljM|fcllli iblrti without iRfcctiiiK tbc b,vs1ciii i;ciiGrullT, a* iu soft chaarral 
a^ MMM nnv nf db«trctiiig- wound ; or it muy be carried tlinitiehimi ihw 
^tdy hy ■«■■ of bniketi-dowii clots fruni tlio vciiu of the (iritimrv M-at of 
AMHh I^Ttag rite lu loot) inflaniiuBtioii wherever Um fra^Bicnu oi elm inav 
lH^|Ct win MNBa ftmus uf pjwiniii ; unit, lattljr, ibe puiwrn tuajr rnirr tlie 
Uood aitd niulli|ilr in it. giving rise to a general iufective |>nHw a* ia 
mftic iitfir«»>)i>, ntnlignani noiuule (kjiieDie fever), or aviihilis. The irria 
"■Mwttvr" i».tlu'rcrurc, applied (inly Iu thupecutiditioaalii which ibv potiaa 
anUipiir* to tlic living liit<uei> of the lioily: vthvn the iDfecUoti tomij 
■DtMWa localljr wiilmiit alPi-cling ihi- whole *T«l<-in. ihv mult u I'nitcd a 
**lMll)aiHtlTfl infianimatioil :" w hm the ixiiwii cbKn th« *v>U-(i> and uiulU- 
pHw thruU){huu( it. proiimiibly in ibv IiIikhI, tbc niftctiuu la opcikeu uf v a 
"IMNTftl inftotlre prooM*." T1i<- inuliiplicntiun of tbc )>mmiu in ibe body 
and the rflcct pnMunil not being prfiiHirtiimnl to the '(aauliiy •iri^inal); 
Ukuvulatcd, Imik *go auggcvted tbc rcnciublance uf tJie proou* by whi<ii th« 
pokiHi b dovelojm to fcrntcniatioa; and in a l>ivi number of infective 
uiainiNatioiitv organized irritant« in tbc fomi of dranito pathogcniv fungi, 
•U|>pvaiKl to b« capable nf acting n* Icrm^-nts. have bc«n lately abown lo ba; 
nNMUatlf pnacnt in the inflamed area. Thn is the case in culantoas 
«mlp«Ua. apreadine gnngreitc, maligiiaoi pustule, glanders, etc. On ibt 
nimr band, iw definilv organisms have m yet bcea discovered in many olbeff 
distinctly infcdire prt>cc«M«.ns syphilis and eofl chancres, at>d it is open. 
ibvalbre. to suppoas that in these cases the poison may b« an unon;aniied 
IhnilMil. When a deSnitv tirg»iisin is constantly fbaod SMocisti^ niih a 
•pecilic furn) of inflaniniatiou, anil when it reluina its pciwer uf indticiug a 
MKiilar inflaiumatory process if iu<iculatp<l iiilo a heitlthy nninuil, even alter 
ti«iog eullirated iu nriifidally prepared Biiliiii>^iti> for one i>r two geoeratioaa. 
tba organism may fuirly be praunied to Im> the direct cnuae of the indainim*' 
tory procew, and the exact laot^e iu wliicb il hcU. though uf mat inlerMt 
s«ivnii6c«lly, la of little iniporiau(« ii> tlie prncticitl surgvoii, and ncMl not be 
disctisM-d here. Buch au organism is ili« bacillus nntbracis of pplitaic fi-vrr 
lo cntde.aud malignant pustule in man ; and ns this diseaMiKrv^n as a typa 
of such proctMea. the reader is referred to tbe cbaplrr uu Malignant PiiHuia 
Tor fuller infonaatioD. 

Inflammation h ubo divided into acuta uud ehrosle. aeronling Ui iDtra- 
sity and duration. Tli« symplomit. K'rniiuatiuns, ai>d rlfccla that hava 
nin-aily bno dflKribed are tbuoc which charactcriie the more acute and 
orxliniiry forms uf iIm procoa. (.'bronic inllnminntion will he described in 
a eulm-iiiiinl part of tois chapter. S(>-CB]l«d eatarrtutl inriumRiatiuu will 
also be tUwribcd Mpamtaly. 

PhlanunwiU is a term applied to au aciit« inDanimution iu which tbe 
cardinal ayraptona — rodnen, twelline, lieat and pikin— arc well uiarkcd. 

Inflammations of organs are abto divided into interstitial uu^l parenchy- 
aiatona. I)v the foruicr term i* meant that tlie pruoeas is eJlber limited lo, 
or uxwt mnrlttd in, the fibnitis interstitial titaue of the organ ; by tbc latter, 
tiini the special slrudurcs, as the «p4tbeJiuDi of glauda, are the (iriniarr s«t 
of tbc morbid proecas. such change as there may be iu the iuierstitial iWnw 
baiog Bceondar^-. 

Onnpotu inRaiiimtUioo is a term applied to the procov wbcn il b m 
juRicfl by n firmly (.-oagulalc^d librinMis exultation, either oti tbe surfkoa ui 
a Riecnbmtie or tlw spaces of its tissue. 

TIic Local Signs uf iullauimatton n>»J b« rcfarred to five baada. vls^ 
1. AlUnlion in Co/irr; '£. ^AervtiON tn «Ese; 3. i/otf^featioN ^ &n«ri»PMj , 





bOCAL SIGNS OP INPLAXIIATIO!!. 



197 



■f ThwpfWilTt; ml 5. Modifiealionof J-MHeiion ^1^ IhH Affeeted. 



aUtkM 




Its 



OJInm', Imve beeu iledrnbeil rrani utac iinmeniurial 

^ iW c»tilit»l wympintua of iuHAUtmuliiiD. ('«rt«in of tbae ouuditiooB iimy 

«raBr wparkirtv. »r lwi> ur mure may be a«iodut«(l together, without ilie 

uf iaisaimUtuii : but it u th« peculiar grou|>itig together of them 

matt dbttBdilr cli«r«ct«rii«» tbe prcMnco of ibiH jMthologicai cod- 

TW rvUlivr iainisity of iIicm' chiin^ varirit greatly. acctmlinK to 

hicb b thr tr»t of the iulluiiimalioii ; ihui', in iaftnaimatinii of 

and of lh« ikia, itw ■llvration ia color i> m<i*t ritiirtted ; 

of tlw M«otar luwr, (b« chungv in tiur atwity.i itttracts 

WlrtiU'>o ; and when ti fil>r<»ia tiatuo M inflamed, iu M-ii^iibilUy 

at*«jJy iacTTAMil. Il mii*l iiol Ira fbrgoUCn, hownvrr, that oue "r 

af UMv aign* may U< abiM-nt, <vpi.TinlIr |iiiii) mix) hciil. 

L AMlSBtiaaof Oolar i» iovnriably a li>i.-ul fij^n of iiitlanimntioD. iind one 

rf iht ^ gfw t BtuI ni<«t otrikiog : i<arl« Ihiit arr* natiirnllv perfvctir piile, um 

lfew«lar niojunctint, aaHiniin^ tbe most vivid red color wben iiitlniiiM). 

TV f ila w ■« due U> thn dilntutiOD of tho vmmU and tbe accumiiliitiou of 

nd imt y m tU *. and, in vary acute inflatnmiitioas, pnrtly to the racapc "f the 

IVooi tbe rewals. The rrdncM of nculo inflanimntion vnrita 

wilk tlia tairattty of tbe procvm. Where there is merely determiuatioD of 

UmI it dMapfiair* oDiopleiely and readily <^n pressure with tbe fing«r, re- 

•gaia with the greataM |>naaible rapidity the moineDt tbe finger ie 

When the rirculatioo is n-Urded, tbe rednew diaappean and re- 

•lowly. and a few red spots nay remain unallerM by preauire. 

ar» dlber poiut« at which the procem has reaehi'd th<^ dtHi^ of stasis, 

•Ueli rtd ourpusclea hare escaped IVoni the distenil<^ eapillariea into 

latlinjf liaKHis. Tl»e tint of tlie rMlnm* varUv. hImi acy-ording to 

«f the drrulatinn thru4i):h lliv inflnini,il iir<-ii. Wh^D the ^uw 

I Uw vcnels i» fr^c ai»d ra|Md. the itilliimed tuirfnet' iixtuimit a brixht 

tiDt; bat where (bore in a tefidency to «taenali<ii), t^ilher from the 

ite of ttw pati«pt'« circulati<in. or from tln' inflnnimalion having 

' tlMati^of*taai*, tbe eolor Wiixiim » dull piiqilr. The rhiing* 

Iw Mfbt red tA doaky iHirfile is ui-ll twn in phle^monoiu cryxiuelM, 

«lai tW eimlatiun lhriiii;li (Im- iiitlaini-il Kkin liecontfe imped4id, and gan- 

k tkiTWti-iiing. Aft'T aiNite inflniiimalioii it is lix<(|Uont1y weeke or 

lib* brfiire lb* rriwls rr^in their iixriiial toiw, and until this hiis 

I plac*. a eertain dr^nv of redntw will remain. 

■an^ •• but, huavTcr. n eonalant np|>earuDc(> in ioflammation. In noo* 

Nnalar parts it nmm in llie nenrost vnscntar tiMues, and not in the part 

aassllj tvttoiBC ttvn inflammation. In inRammatiDU of the iri« tbe 

flikd Ta^als atw COoetaled hy Uie pi^fnient and tbe cbangv of tint is from 

^ Hlanl tnonidi or bluish color to a gmyish or greeniah, in eoDsi?c]iienee 

rfs ywOww tiaga ^Tcn tu thu aqueous humor, by ibe serous exudation 

•Mil 

IW nduea tJ inflanimnliiin dtfapjH'urs more or less completely nfter 
k^ WbrfT tlirtr hai Imiii rM-ji[>e nf rbe red corpusclei T«d itfi\M remain, 
9"H rww li> the ap|*aranw kti'iwn as "punctilbrm rediMM. * In S(!|Mi- 
^■ih [ifw ia. and maligtiant f»rm^ nf thv atiute *p«dAc diseases, tbe red 
*7M(H» break up in ib^ blo»d before death, siaiuiiiii the serum sn<l the 
Wf iM^braiH> of tha heart and Krewt \-ntelft. A similar stainio;; Hlwnrs 
9km flaee aftrr de<^i*tip>i>iiiniii bax aei in. It i» perfectly uniform, wiiliiiut 
V* W Imariiing lin**. and Riu»t be rwreftilly dittinguUlH'd Irom the rtid- 
■■rf iataatauatioo- Increasr*! r*<dnnw di-velnpit nUn iu tiw most deneit> 
I fMt aftra- deatk flroni gravitatitui of kl<Mil boforo coagulation. Thos 



LOCAL DISTCnBANCKS AXU IXFLA UU ATION. 



a V'lil of iutf»tMie Iwtiging ilnvin in thi- cnvity of tli« jwlvi* timr bcttWM 
redder lt>Kii ilte rc-^t nf the kuI. cihI inny be nrdiixly tlttUK^' '" ^^ JhHbibuB 

2. AlUratioQ in Site.— The Mvelling of infljiinol iiwum b due to tbfl 
iDcrensc^l utHux ul' bloud ami li> the eiudiitiufl frum the veMrla. ' 

The »welli»]{ varies Kresily iu dific-rcnt looaliltes. It it crcsmt in looa 
UFXturtf, end letul in tiiuse which ere lirnt and dtme. Thus, fur inbUOc*. 
ID inllsiiuiiutiun of l>i« iir«i>lar tiaaue of tlie ■K-mium, tite «n«'llin); w much 
gT«ater ihiio in inllimimaliun of the leMes. iutUnnmetion of the conjuunin 
occmintiD giKHi suelliiiK, t)inl uf iIk- selenitic but liltlr. In deiiae kart 
Htrurlure*. »uc)i u* bone and liKonieni. (here it, of oovru-. vt-ry liltli> nwrllit 
[f iuHinnninlion lieconH' elironii-. tin- «H'«l)inK nny U-riiiiiiuin in |MTtnaiwtil 
hyiwrlt^jihy. nr ttiiclccniu);. iii nill liereafter w." dw'filM'il. 

f^iK-llinj; iliriiininhi-ii in must i:aiv* al\<:r deiilti. lir tlie eni)>tyiu)i uf iht 
vfNH-li>, l>ni ni-vcr i.->>niii]ci<-ly di*«[i|i«ir*. aitd i* cunM-ifuently an impurtaat 
poot-morli-m iiiiin of iiinnTiuiiiilion. 

■t. Modification of Seniibility. — Tli<-Tf if in iulliininuiiioi) nlwan tt>c'r»< 
!(■» jKiiri. wliirli ]■ ilu>' jmriiv in iiit-n nM.-il >rn*iliililT uf thf ncr***, tut chi» 
td the t>m»iire nod Klrct riling uxitoihiI on tlii-ir lurminit) brnncbn by ill*] 
dilatH hluiMlvnvcU, nnd by thi' iulliiuininlury rxiidtition. 

Ttial thi- priwiirt- of iht: dilati>d Mau«lvnM'lc really i» a eau«v of the F*'*l 
in ID flam mat inn is sbonn by ihi* rtli«f dt-rivrt) fr<jm the HrvRtioii uf an' 
inrtHiiK-d [nirl. In iDllnmmatinii uf ibe tc«lie)c lliiit is rt>p«-iolly iiinrkeil, m 
tbp xeioi leading from ihnt gland nra vidrelece. and iu the tre«'l |H«iti<'n ibe 
weiRhl of a column uf blood, (nu fc«t or more iu leuKth, nets U|Kin tlic vt 
and tends lu iacreofe the iDtrflTOscular pnteure. We frctjuc-ully find, tbr 
fore, tbiit the (Mlient is absolutely free from pain while lyii't; llat nn 
back: but the moment he rises iutu the erect pneition, tlx- charac 
wckeniux, acbinic. and ihnibbinjc ncnsatiotw r«turn. 

In inilaninialiun of tiriciius uf special n'Dwe, invlrad uf nctonl |Miii, ' 
nuiy be MMui.' nlleralioii lii the special nervuu* senubility of the die 
vrwut. When the eri; is inflamt-il. subjeclivn flaiihra <if light ouy bei 
wnm ibe ear i* diM-af>ed, thi-ri.' may \k tioiiiifi of variou* kind*. 

In inHiiitiiiiiiliiMi of the hlnddi-r, there i* n eouxlnnt dcrire to ripcl 
nnd in uiltaniniaiion of the rectum iherr nn- frcvgui-nl attempts nt aefcratiroi. ] 

Pain la ono of the mu«t promim-nt »ympt<ini» of inflammation, aod it 
exi*ten<.'e serviv a useful puriMwe hy itn^vcnting the tMilimi from using 
moving the intlamcl ]>«r1. The intensity nf the pnin de|>eiKl« mure upon tJ>« 
Urncturc alTecied than uii the violence of the inHainRialion. being, as a gCD- 
eml rule, greater in pniiwrtioii as the Iwsuo affected is inciipable ofytrldiug 
to the preseurv cxercue*! on it by the dilated vcweis and the efliiscil mattatni i 
Ileoce, iu general, the intensity of the pain is in the iiiveree ratio of thai 
sveJIiog of the part. Thus, the pain i>f inflamed booe or fibrous tiasue b| 
excenive; that of areolar tissue trifling. In eryajpelns of the scalp, ' 
puin t» experienced in the ears; the pain of an inflamed selerutie is far greater 
than tliat of a eonjumniva himilnrly alfecleil. In some forms ><f ioflamiaa- 
tjoti, jwiu can Muireoty be said to exist. thoii};h tlie iliwate may a*iume the 
maM dcetruclivc form: thus, iu certain iulluMtmatury allbL-tion* i>f the thn«l 
and of the |>erit'>neuni iberv U little or none. 

The chnrnetrr of |iain vari«» aecorilins to the seat of i n flam mat iwo. WImoJ 
niuciiiia lucmbrnitex sulTcr, it ii often of an itchiuK or burning chnracttr, i 
in conjuneliviiin: wbon the seroua membnini'!' of the cIm-sI or nbalohM-n V*\ 
attacked, it is lancinating or Mahbing; aching in Cwleili* : throbbing whei 
|>u* i* aliont to form : iiickeniiig uhcn ihc imli* i» nfleetttl. Inllnumiatury 
pain is alunj^ incmued bv premun': when it i» pn«lueed principally hy 
prceanrv. the ]uirt is aaid lu W lendtr. This teodvmen is uf gmt servicr is 



J 



ITtTTIONJlL SYMPTOUS. 




C^ 



s ^^MSHafic pttint iif tkh ; il mny Ik- t'lii:iu-d by din-cl prctsuiv upon the 

fan, ■• by nmrtil)^ an iiillanictl U-«ltf, or by prt-wiop ivio feurTnces tucettier, 

■• Ht MB bwBBMd ^inl. Ill iDfliiinninlory pain, f^jx^cislly of cmcoih anil 

l i il Wt tWr* i* vrry n'mmouly ixiciunint eutocrbalion. 

itnpoftfttil III b«ttr in niin<l (lint inllHiiniiittarT pnio U olWii not con- 

to thr f^rt aSnicil. Iwt nwltnin'cx(o[ii>ivelj«luii)-ibeixiimeorn«rve). 

■f Bkit^ tlkr ivrtDiiMl bntncbee un- iiiijilimlnl, |>eiha|i», only to a liiuitVfl 

Tliin. in inflanimtttioii of llit! (f«tia iberv i» paiu io tli« Imiu anil 

Ib <kr[K«m4.->l "pliltitilmiltfe ibero way be «ii)uiHili> puiD alou); tlto 

uf ibtD tilth Drrvi- over tb« wb'tle HrJ« of the html ur (ace. in coo* 

uf ifair nlwry bntntbc^ of iliv uu^l, wbicb are ilUirtbuU-tl ti> |li« 

in* »mi ehoMd, bcouuins contpfeased ur stretched. 

4- &• Ttmfmtm afaa external part of the bodv uheu inlbkued rue* 

k» Bufwal •tiiiiiUnl. but tio4 above that of the bio(«l in tlio left ran* 

Xb bflainiiiali'xi or iuuraal orpiiw. ibe tern jrtii lure ricM ooly u 

.1 iif ihi' Ix-ly i.> elevHietl by the iiiflaiDiDat>.iry IVrer. John 

««4simlly pxitiiul uut thin >iii-l; he fuuml. in m raw; of hvilr>cele. 

ibar ow i u i Wf iinertinl tutii the lamca vnginalii •IucmI itl !t2' I-'. In furc 

— riuii baiil brm exciti^ in ibe mc. and nt i>8.i5° K. aflrr it hiid Ikcii 

■■■p TW RHirliuioD lu be ilnina from tboM facU it ttiat iIk iucreofed 

luir in iiitUinniatiufi, whvn il oecuni, i* due l» the floiv of h hirger 

:iritiieh lh<- [an, aw) unt fi n tie ve I op men t of beat in the 

,^..-;.iit oo incrvuMil tiMue-chunp^ Thif view Iul» be«u coa- 

. Inr lb* aumt nerat obMrvatioiM, carri«iT out wiih lh« greater exRcti- 

lifcb* tiie tbpnBn-rlrctricnppantun. T(h- opjKiciU' view hii* b«en maintaioexl 

fcf J. SaiuD. * ). WVtwr. atiti I'llii-ix TIm- liicla (hut n thcnno-electric 3\i\m- 

Mm ba* bmi fiwDil uevesary to meaKirv lh« variaiioti« in beat, and that 

'•uiiii of tba (trmtnt eninenc* have held opposite views, are auffieieni to 

Aiwtbai,«<v«D aupp-ieiaK b«4it t'> he deveIop«<l locally iu inlliminiflltnii, it 

■Mai ha ia aoAcitnl •iminiiiy lo hnvi- auy appret-iable eflrci i>n the ^i-ncnil 

*m^ mart t>f Ibv IkmIv '-r on ibe local procoowa in the inllnmi-il jmrl. To 

At Mkat. h'liacTer, ibfri- apjM'itn lo In- n real rise of leinjH-riiliin— jw Trnwre 

waif rtaaarka. "Tlie n<'rTc:< measure ih" H'ntiiilion. nn<) ni>t the d<'gre(> of 

baL' Is naar aum iIk- M-uuition nf lb>' |uilti-iil ik lliitl of 6uriiiHy in ibe 

twLakiNMiKfa Ibe actual Hm- in (rnijH'ralun' mny Iw but Irifling. lliis b 

Miac to lb* exalted arnMbililT of tlif m-rveS. 

^ M«4tiCBtii>a of Fanctlon invariably oivnra in intlamination, and fur- 
■Am in|>iii-ir,i li--ul fiviiiptoni*. The Funelioiuit JiVmiy of an urpin ia 
^■NaMiil i.i-il ihirinic aiiite iuflaninialiuu. As acute intUinimalion 

*tl«an t; •■( --rm' injurious inflnenee icbicb lowen the viialilv of 

^ i * 'at iJ part, it :■ . i ■■■ :>i ibnl this munt be the aue. The c(ni>ltli.<'n is 
'Tuyralail ia aun>e cnerB liy the pain, tbe dtMirdered cirfutatiim, and the 
|MMr* froM aawlatioti. An inflamed uiunele is inipuiri-d in iu jM>wer of 
— tr— liiM. atMl aa wflaiMd glanil either ceases to secrete nr vielils a tH:ra- 
^akand ia aoM|MiilliNi by tbe admixture of prixluet* of uiDammaitop, 
TW a rfwra/ lur uf a |<an U nftrn itit-rti'rrd with; ibiw ibr bln<lder ran 
ik» Lirinr, ili» rxf i-nn War no lin'it, nor mii a joini W moved, when 
-!■»• of Hulriliau arr i-tlher niodilird or arTcsunl ; 
tati ■ I <a, or rvrn d<-atb of ihi- alfi-<:ted Itasuea ar« 

• mI' intlni 

fiBMiill 11" r-'U".— 1 lyof t)i«roiMiliilii>nalsjnDp4ABW 

Mu :]ir <'Ki>-nt,aR<) the tuilurr of tin- inlbuuinalion. 

,>3lii-ut'> health, anil o<i the riiul iniportanev of 

aAvifil. ThiM, a moilerate degree of intUminalion in a part of no 

' " >, aa Um akin, and oecaMoned by au external rauae, n« aa 




200 



LOCAb DISTURBAWOFB AKD 



(FLAHMaI 



nbnuioD, glve» riw (o no approciiblo comttitiiiioiiHl (li>-iiii'biin»- ; tntt if ttnl 
part ■tli^cted be of grcHC IminrtAOOe, m the Innnx or the kiilncv, ih** goJi 
«ml iiyii)[)<oruii nre pru|Hjrli»nnllr ftevpri'. Tliv iiaturo of the iiitlninnimtiaa 
ntxl of iu aiiiw) gx'^rlii iiioro inlliK-ntH; iban nny i>lli«r contlitioti in tli« ooo' 
Htituiiuiial viKvU. ^iiiipk (riiuimitic intlniuiDKlioD giv» riw lo «inn|iUilM 
of Mlight KCviM-itj: and (JiuD dunttion, *(hilc o^fiiic sni) infipctivp iaflainnw- 
lion* mHy prove fiiul b^ tbe di«ttirbiiu«' lUry unuw in tli« mtem rm^ 
iiIIt rnlbiT Ibaii by Lli«ir locnl oHucls. TbuR n «impk* fradurr, BltSuugj) 
followfl by (v>nM(b'rnblv< iiiHnmniHlwry swelling. nuH^ but •light ooiulita- 
tinnitl •l>»lurbiu>ci-, while ■ poiBODDcl wound miir pmvr fntnl, thuugb Um 
locjil iittliimmntion mttv klTcct only thu lut phBlntix of * lingor. 

The tonglitiilioiinl Jiitiirbtiiicp in inMniniimiioii itlmiv* MBumn tbv farm 
of fevi-r— Inflammatory or Sjrmptoniatio Fever. Indaranmlory ftTtr ii 
inTariablv aecoadary, Iwiog a conscqucnc* of Ui« I'hiiI n8V«iion. It i* ihw 
c'luarly du^gaiahM (rom the eo-cwied "eawntial" (tver*. in vrliirh Uit 
ftbffile cooditioo occurs either vitbnut nnr local infljimiiiation i>r |ir>OMlM 
the local aflectioD hy a distinct interval, its in iliv aeole spetiifii' dtMMK 
Tfae one eoential 8yin]>tooi of nil fornif of fever a elsratioo of tbe x^mftn- 
ture of the body, or pyrexia ; without this, fever cannot be Mid to Iw prw«BL 
It is ioifM^ble Ill-re lu discuM llie theoriee as to the Uttu* of fllTtr. but 
Uii' following fscl£ may be given aa g^enenllj agreed upon and curatnou la 
all foruiaof fever: 

In fiiver iliere )■ an iiicreaacd production of beat, not merely a dimbn 
IiIim] loMi. This ii proved by the cvideuce of exeeiaive tiw<uir-climii]p>, lurb 
na the di«nppe«rani:e of fat, tlie wiutio^ of the muHrlea, the incrpn«eil r>cr» 
lion of iin-a and (mrbouii' acid. Tbrri' \» abai n ctiDiiidL-nible inrrcwi* in tfae 
low of wiit«>r by tho luiigx, and ofWn ntita from Uk; ultiii. It i« poMiblr (hat 
in some caatv, xuvh a» tlw rigor lollowin^ o{H.*rati()ii» no the gcoilo-imuary 
orgUM, tbe<M>iilracli'tn of the cutaneous vmsoU may avt aa otieof the cmiUM 
of the elevation of iL-mperutiiro by dimioifhin^; the Iom of b4iit fnxn the 
akin ; but this is neralx an accideiiljil cnoditioii and not aa Mi a n t ial fcntnn 
of fever. 

Tbo increased production of beat tnke» place tlirougbout the boaly, 
probably moal active in the muscles and |>landular viscera, it is ciTlaial^ 
liot developed to aor appreciable extent in Lite iu)1:iiiiixl area, for. a> beKiiv 
stated, the latest OMervatious tend to prove that iliere U no elevsiino of 
temperature beyond tliat of the blood in tbo part actually inHanie>l: and, 
even suppoeang that these oheer^'atroiu are in error, it is e^'ident. from the 
difficulty in detecting it. that the heat developed in the area of inllAmma- 
tlon miwi be in extremely small amount, and <|uite iiuuffldcnt to account 
for the elevation of the temperature of tl>e whole body by fevcraJ degraet. 
The fever i* uot caused by ilie pnin utuallr accompanylnf; intlaniBWoa; 
for experiments bavu vhown that irritalMU or wsaMfrr ncrvt* tend* mtlier to 
lower the lomperature by oatutnjiC a n-rtain dcftreo of sback. 

It bna hcvn rl<rarly proved by cxiierimrnt that fever «an be iodiMed by 
injecting into xhv blnod-stntam noxious materials of vafious kimla. Hai- 
stances wbicli, when ibu> inj<-cied, cauM fever, an satd to peaswa "pfr^ftma 
pnptrlie*" AnK>»)i:*i ilic nubrtnnon pnwming markad pynwrnic pmp«^ 
tic* is the Irnipli retuniiMit from an inflamed ana, charged, as it is. aith the 

Iirudurtji u{ d<«lror(ivr t'ba»gi-# ubich urv K">"K on in tlie pari. It has 
icrn iM'forc vtalin) hi>w lar^t-ly lb« flow of lymph is iocrvasnl durio): acutr 
ini1fl>nmnii»n, •luiiri's niuniinE from the disi-aMNl part when dra<.-hm> mnm 
fniui the (.'iirrrn]>iindiiiK tound i>srt. It is evi<ienC therefore, that ibe rlTect 
pniducod on the bloiid during' inflnmmiition may be very coiifltd(<rable, and 
will rarjr with tbe extent of the iuSamniation and the amount of local d»- 



iaial^l 
I— e_ I 



i 



i 



INrLAUMATORV rEVKB. SOI 

timon-chmas^ whu-li b uoloK mi. Ono •ulalnnw. which muM ftv- 

' fMdjr b* MVMnt io cuDaidcraklo (|iiinlilk» in llic lympli rvtiirniiic fVom 

mMmm Bfaa, TtL. tkt Kt-c«illnl -filirin fL-nnriii." poMWaxw vvrr rwiwcr- 

tiMpf ny ic prtijN-nira. Tht*. il will li« n-iufinU-fvcl, i* the third cluiui-til 

jtMnt it OMkorrotd in the eoiuulition <>f fibrin. Ii if of doubtful ooni|N>> 

.bat i»uipp'i^-i to b» ymdcd up bj tl>o wliil« corptucltv which be- 

UmaiwftAml iltiriBg tnv proenw at cIntliiiK of th« blood. It u found 

• naadM«Ut vxitve in tha Miiiin. which ran m equMMd out of n frrahlf 

t f ij aiBlpUeiB : and m cawnlation of an inflanmilMy tucudmioii is tlie 

mmt jauemB m c*aK<'l**''^ *" t^ blood, it may bo rMaoniibly conclude) 

te Mris-fcttMBt rxisfa) in cowidvrnhlc amuunt in the serous l!tii<l lliut 

Ana a**T frofli ■ Hirfkc« or an area id ivhich no in fin minatory exudation 

baMfalMiBK la ftna the so^uIImI "pliistie lymph." Kuhler, Kdclliorf;, 

HA,ksd otam have inv«sti|fa(ed the eHecbi of the -injection of the (tie 

AnHK iato tba drmlali'in uf living; aniiiialu, and have found lliat in very 

ln|» 4Mia it muBva rvpid coa^ulstioa of the blood in tli« rijfht side of the 

Wirt, aail dndh. In uiialler diwea it Rlrea riae to a febrile disturbance 

^mly raKDblini; thni produced by the injection of putrid ditbetancn. Tlie 

ft'nr tarim in intnuiiv with the quantity of ihe ferineiil injected ; and, if 

te W aafieittBtly fduill, the aniinat recovers wtthuui serintui tyrapiAias after 

tm alrtstian of i(iiii[ir;atura of *hort duration. There twcniK no renMa to 

t^ arcuratry of titmo olw^rrauun*. Lnrfce nutuheta of vhiie cor- 

a an knuwu to bxomr <li<iintfiirnt«l in the procew uf coa^laiion, 

patf part biond orof an infianintiilory exudatwn. The theory of "ftr- 

mtttfmmm»f " may tbua. In part at leatt, aooount for ih^ fev«r that alwnv« 

WBimifl^m afoiplr inflantBaUon* and large waundu, tvrn with n»eplie dw 

(Aarji^ mad thiu oecMWoalty fnllnmi rxleJtsive oxtraviiastions of blood. 

Oal* Modtr nry aiMptiooal drcuinstanee* iti the huiuan mbject cmild the 

4fl»af lb# iwiBeat be ftilficirni to cause the tnora Nvcre cymptont' that 

hai» baaa el parinen tally pr>«luced in animals; bat poB»ib!y the explana- 

liM«f aoMM «Mnef dwuh firum canliiic ibromboaa, that is to say, anle- 

CBipilrtioB of Ibe bbwd iu the right ucle of the Iteatt and the 

y artery, may br found in the praotoe of an excess of free fibrin- 

T\t» frxvr produced by the entrance into the circulation of the 

p w jaci«</b«alihy iulluniniait'in if tlie only form to which the lorra inflani- 

vaMtdwnld be pmfx-rlv applied; but practically in a very laree pmpor- 

naa *f tmtta. the pure inflaramatory fever U complicated by n disturbnnoo 

SiHltiaf ft«m the admixture of the product* of putrefaction or of »|jecific 

lifctiv* nwwn with thoac of the timplo in flu in mat ion. In fact, tlM- pro- 

iatlf4 ifoorapnaition nrr amnnjpt the imat ]>owerful of all pyrDg<-nio nub- 

, aiKl w* have alrr^uly *4<cn ihai lo<mlly they are amone*t the mcNl 

isaMa of tnflanmation. Tlie pnitlucta of [Hiirtfiwtion of aniaial mb- 

I an ao varied and uncertain in ihiir chemical compnaition (hat il it 

' MN Vi aiii-inpt ut aperify tbeni. Tbi« mncb. however, may >>« Mid in 

W BKffvd. ihat iu the caM of onlinary iiutrefiietion, tlio clH-miual prtHluct^, 

M Mt tliw Bitrnacn|>ir orvanbiM whieli invariably accomiMuiv the prooMS, 

•n ifca mil i'xcil4-n b»i)i of th* lineal iuflaininntion and uf tin: febrile dm- 

■vfcMa^ Tb« urganiMBa 'ff (imple puln'faction, n» hefnrr i>utc(), c«ii live 

■If m dtAd BHllar: and if tlx'V linp|>«n l4i polvr the rirculiilioi). thev 

lypHvJi, unlike the iroe pamsilif- or pntlii>i^iiic <'ri;iintKmB whicn 

ipBSV matiy inftctirr |ir«m'(w*s and eniv nuil llvurisli in the liviiie 

I *tf Idmd. Tbv etfecl pr<H)iienl by the alsorplion of tlie pmduct<^ ot 

hctioii is, tbrrvforv, pn>|Kirtiucial to the doee ; the poison has nu jHtner 

' •akiflriiiic in llir ly^iem. and if the do«e lie net loo Kreat, it i* speedily 

'*~^" " * wiliMWl Mriuu* uiiuniuencM. If tlie dose be exocMire. it ifivw 






LOCAL DlSTlTKHA^rciCS AKD 1 SKLA U H ATION. 



niVfJ 



^W to It tmiD of §vn)|>loin» whk-h will )>e (]«£pribeil in Uw Huiptrr on 
lioDniiiu Thi; nronuclii kI' jiiitrvfiiclinn iiri^ NliMijrb«il with jrri'-nt rrNdtoras 
(rom II mti' niiian' ur tlx.^ (-Imrrdl wirfiu'e U'fl t>y ii IxirD ; but il I* aBid thai 
llw tuatv with which thry arc inlct'ii up ii> ^n-utlT iliiiiinwiicil tiy tlic afiplies- 
Uoii (if Kunir clicmicAl citURtica, tvpctinily cblofiilv uf «nc. Ilwillhy irrmaa- 
liitioii-tiiviK^ I'ornif nn rfficiMit b«rrirr Ui alworptiin iimliT imliDtiry itttS- 
tioiMi f pmiiniiibly fmm its pnmming no l]Fiii]>liii(ini) ; tint ■■ uli^ht ilrgrn* 
of {irwurc thi< pymgcnic •ub«Uinc« pimM r<-ii<lily tlirougli it. Tlin*. is ■ 
large wound iiicli as no amputation, if thrrt- it |M'H<.-<-t ilriiinngc nn<l nn de- 
OOfDiKMitioti. iho febrile distil rbani-e is very Elij^ht and of brief duniiina, 
oeaatng by the Ihini dny nl ilio iHtcsl; if llierc it dcmnipwition ••( lh« d'»- 
ehlirgw thi< fever b hi),-h4.-r, and resdics \t» mnximum by the tliini 'lay, *ub> 
sidiDg gmdually aa lti« fifUDulalions spnnK up and form a iMrricr agaiMl 
Airtber absorption ; if vuU decoiupwilioD there is iRsuRtcinit draiitii|w ui4 
the wound 1m gf eufficienl «ii«, th« patient mar rei'eive siidi a doe<> "f th* 

Kroducls of putrefaction as V> die poisoned — a comlltiou which will b» 
mber deiienbed in tbe chapter on »|Xioi»fniB. If, after the uranulalMO* 
have BprunK up and ftvir hat cmmkI, au accuniulatioa of putrid QUUI«r 
takes place in the cavity of the wound, and there is such a want of dniMKt 
that the fluid ut pent up at sonio degree of prMsure, the fever and local 
inllunimation will return; but «hould thn draitiaj;e l>e made (x^rfev-t it will 
u^incettse. It tx th« Irvi-r due to th49«two cause* — ibeproducMrirdcatrue- 
tire tiMue-cban)^' and rxiidntiim in uroplc inllnmmatloa, and ibi^ prrofrraJo 
productit of putr>'f)ii'tioii ill M'|>tio iuflsmmalionA — that ia MH>krn i>l lu snr- 

K'l'aI ur trauiiiBlir fiivi*r. f^uitv wrilern nro iiitTlim'tl ti> limit ihiw ti-rais to 
e former •>{ thi^u condition* Hi beilig a fever itMepnrable from any larg* 
wound or injury-, even nhrn tubniUneous, and to cnii>loy thr frnit •rfilic 
fever fi<r the tatlvr : and poriiape there would be MOM aikaniac*- in «o dotD|t. 
Fever it> alMi a conatuMt accompanhiH-tit of acute Infi-ciire i » flam mat iuns; 
ibM is to Nir, of those ronditii>ns in which a virus is privrnt which mulli- 
pliea in Ihc tiviii); boily, either locally, as in true spmidin;; or infective 
inllaniniiitii>i)<!. or f^oerally, after cnieriuK the blooil from the orii^iiiiil Uical 
centro of infection, as in otany fornia of seplicieinia and iu pvinnia. nialt|c- 
nnnt pustule, etc. In sonic of these conditions it lias been shown that an 
csMntial feature of the diseiue is tlic presence of luicrascopic orjfanivinii id's 
e[Ht-ific t-haracter which liave the power of |{rowin|t like true pamsitnt to 
tlie living bodv. This condition has, however, as yet by no nimns Iwmi 
proveil for all Icbrilc infif^ttve prucrsses: and evL-n when lite urt^niain srcna 
to he distinctlj^ tbe cause of the hx^l n»d KCiieml alliiction, the exart war 
in which it prndu<«* fever in uiicvrtain. 

Lastly, the nervous system most pn>bably plays an inipurtani part in ibn 
prooeai of fever. It ean Kstnyly be doublril that it exert* an Hll-im|Hirtant 
influence in tlw* regulation of (ho |re«i-nil heat of the budr, and a hvpntlii-ti- 
ral centre hua Ihi-ii mippiMO) to f^xisl in (hr Iohit pari of ihi^ nuilulla which 
cofitroU bcat'productiiii), and i* in intimate relation with thi' vaMi-miiilor 
centre. Il wums diflieull in any olbrr way to account for the rsinuinliiiiu'ilr 
hiah temporatum sonH-times inrl with in iujurir* of tbe upper part of tlia 
mSnv, tad tat the fever tluit is always nn-t with iloring rvaclMU from cuoeu^ 
■Inn of the brain or oliook. Two lb<^>rin> mn, tberofore. bold with n-pinl to 
ihoBO levers which an-duv to the udmixturvof pyro^uie Nibstnucfs with the 
blnod: the 6nit is that the pyrot^-ntcstibrianceartsdirewtlvoo nil the ltMU«« 
>»f llie bmlv, t^viiiR ri»i.'> ^> iucrcnMil t>i«ue-cbaiii;o witli dcvelopnMnit of 
heat; and tfie Hiitnd is that the impure blood circulalinii,' ihnxich the nie- 
dilllu dblurlM tW bcal-coiitr»11iii); centre, ami thus iii'Iircctly acts on tho 
tissues. U'enro yet very far from fully undcr^landiuj; tbe exact nniiirv of 



I 



HVJIfTOMS or rKVKB. 



203 



km; W klMl *c do kiti>w \» of iiniui-itic pru-rinl viiliie. \\> know rlinl 
I BAtnM n..;,.r;iv »f raar* in nhu'h fever fumis » M^riuus lealurv in Mirj:'* 

at fVKli >r to iIm.' eniniHcc inii ili« circulation <tf tinxtoii? hdiIp- 

'nih (nMi>.>-> ..- aIIt, nod llint in iu iirerentiuD anil Irciiimi'itt <iiir lir*l 
jM KtM be u> armt the foriunlido of (lie )i,vr»^-nic miiirriiil hy Ureal 
■MB* <' ■ Y ' -n mi uitiu* alMcesH. a lluiit ctintnininK llx- iiroalucln <if 
Aitf-. •19 |i«iil up iu a cavilT at wnue ili<grn- <if prruiirv, 

wlk crtTxin {'T'lp'tii'iii <>>' tlie (irruueoir mnii-rial it ixnliiirm ir omittnnllir 
iaiiafi iu aav ioi» the rirt-utali'Hi. (>|>><ii ihe iibM-m iinil nit cfl' ttif xiik 
th.Md t^ Ivvrr ■! 'HM-r sulwidrd; but If, for nnnt uf ilriiinu^i.-, (lie cnviir 
■■■nili, aod it! r<-iiirnr<> tio nllunttl lt> ■W»nifiOM', tb<: fever will n*liira, 
mi In tint' aMn- - ''mn itrfitre, n» [Hilriil iimtliT is innii- jHimi'rfullr 

^Mf ib(<- than th' !•( tinii'li' iiilbininiiilinn: iiji-n u|> the i-iiviiy 

•aJ-' I «il( ^iiUtilt:: but nowibly. (iipiMiinj; lli« 

fiCirii in an (iiili<-nllliV nmluvcrcrowibil bnvpiml. 

a riraa. capkbir lit niuliti>ivinc in the *iirn>iinilini: liwiii-g. and pcihiiiiv^ nf 
mnting. IlL* a IVnactil, in tn* falowi itM-lf. may tind i(» uay frnni nillioiit 
iaki iW atwcTW-cmvitr, nod tbi-tirc inlV-ct ihc iih»k- sy»t<-ni. Under such 
rifcanitai'^i ')>■' •arrt- local In-ntiiii^nt will no l<>n^«r W nhlc Id arrat the 
Unit >yv anil, uiiKiv tliv pnlti-ut have fuflin(<nt vitality to resist 

Itxtfwf*, - .-•■..' .••nil mu<t IViDnar. 

^■plMH of FeT«r in Oenernl. — Alihoujih inllaniiuatory fercr or pyrexi* 



ens 



rlibinlly miiDV varii-lir*, certain symptoiufi nr« cninn)OU 



rorpyi 
to all 



Th* 



iiii|-<irt»iit of tlifx- is ihi- eiftviliaii uj' Umjifnilurt, HS fli'ivin by 
tr. All u>iu)>cmiiirfs above iiiil.o^ K. must be ouneiilrrei) aa 
' favvr. T1m> fevfr mould lii' con-iiJirrt^l ili(-hl unless lli« tbermotn- 
*tw luB bIkivf ]iH>.5^ I''.; u]i to nlwiiit UrJ.-V K. It n-otild l>e i-oiuitlered 
mJtnit : ff-ni mio" F. to llir>,.V' F.. it wnuhl Iw .iiiokcp of nr hi^-h fcvir. 
Mi tl*n< -it thr trnii hyfrrrjiyrfjia uiiuld be npplii-d to il. Fi'W 

faii**t* r 111 any li-brilc i-omttliiMi iu which ihr ihrrriHimrlcr r\tn 




Ti- riiurv i> ttMally takcit iti lh«- iixiDa. but (Hmisionnlly th« 

I ar ivTtuin niay be iiHit iiuU'ii'l. Ill taking th*' |i-mi>i'rii(ur<- in thv 

, tW bob of ihr ibi-rniornrlcr mu»l Ix- irtit under the loiiuiie and the 

fi^ kf|4 fimily rliMci] fur tbn-r uiinutm. Id the nuitith aiid recitim the 

Uciirr.tTtf.'. I. ^;>irm) BIT iibiiul half II di-gTH' higher ihau those in the 

miurr ill all inllanin>iit'-r%- U-KVf vhims the morning fall 

'■"■' — '■■ '-'tIv ull Irbrile oiiiditioiw. 

^'i J IB surgical pnclicc. cs]tccinlly tiMwe con- 

iir ■i>,rj.i>iuiii<ii .iikI ■■iBie forms •d'bb>iHl-|>'>i»'>n)Dg are iisbervl 

. «Atim'n^(. ur a rigor. A well-markeil rigor oiHuniences with 

' 'tiipithinl by {irrat nervouf depreesion and anxiety, 

I . '>n the ptirt of iho ]ialienl. The fevliuj; of euld ii 

Itiai ii.c (Falicui eovrr» hini'elf nilh hot clolhinj; and iliivers 

I a hrafi nf blaiikrt* till bin Icvlh ihaller. If durini: tht^ tin- cold 

a«r re In- taken in llie mouth, it will be foiiii'l 

* I- It BB hiuh an lO.'r- F. If the Irmjiemiure 

^i U«& lAk> 1 j<-i 11 < It I Ml- 11 (-(■•I, it wnuld liiivc hreii fiiimd thai 

iIm rsa ta Uir --(.•''-" -'"""■ tinw bi-line ilie M'nxiition of chilli- 

^mm^'m, I -' ii uale and the whole •nrfacvof 

Ik k«ly ia m . i . . . u due to the •■"ntrariinn of llw 

Brtfrvao/Lhtfakiii, «fa»rh l> the rweDtial Irnlun- of (be cold Mane of n riifor. 
IV Uendlt'M <~,'iuliii..ti I'f till- akin ihus indueeil i» the c»iu« of the ■rnonlinn 
^taM. ar as of heat from the vurfaee it tak'-* *•>»»• niirt 

l^teftwton-, :— '-t M\on of t«tn|>erniurc. Alter a time varying from 

L_ \ 



TS^^tOCAL DISTCmiASCKB AND 19 rtAMH ATION. 

U41 to Iwrnly niinutw. or vvm nutv, tUo r»Dlmcti')n or the cuUmeutuafteriH 
yiold*, nml n «>rmii>uiiiliii|e (liUtmioit folluwe. Thv ■urikcw nl' iliv twd]t Iv 
OOBM* ri-dilul), ilif \tnf lliii'tii'<l, tike »kiii muiKl, luvl gniiliiiilly n |>ri>ru>p m- 

Sirfllii»i wta iti — »ufliririit. iu ninnv cium, to souk tliti sIk-vU ••f the m^ 
unrif; tliit. tliv hot aUgr of tli«< ri|^r, lliti pntioiit IvvU ioti'nDcIv hot, ntlKoufh 
lilt! tlicrniutiieivr ahdU'g thnt iho iciup<-rituira ia rm|iiilly rnllin^, the loa rf 
heat fniti) tivnporntion of the (Hmpinitiun boiii^ ui-ctwuirily very tcrpsL la 
hnlf All hoiirorniore the sweating ccasra and the it hole rigvr ■* urrr. lMTb| 
the [lulicnt ncnk anil fxhauaud. 

In nil fornin of fev<--r there is menated /nqutney o^ Hit hmri'* bfot. TUi 
ia, aa« rule, proportiousl to the «levMioo of tho toniixTHture And tu tb* 
d^ree of w«Bluie« of the patient. The face b uaDill^ fluah«d, but b^ no 
mcMH alw«ya so. 

Another fealiire oommon to nil fornix of fever is eimKi<Uiott and Itm tfi 
ttrmylfi. IV iaonmaed prod uct ion of heal must, in the liRht of cuwUra' 
Bcience. be rej^rdeil ua work : and, roiuequently, durint* felirilf dwiurtiainv 
the Mtient may as inily be expendiuf; fort* u if he wen- carryioL' »Mghu 
or ciiriibini; dmhidUum. At the tame time, hia appetite i» kaHOBO uid hia 
powers of diction and aMirailation of TimmI reduced. Tbenmd exbausUoB 
and t^outeintiou of many fevers is not therefore to be wonderea at. 

TMrtt v> nlnaTft ouc of ibe uwat piomineut ayuploms, and the appetlU ir 
dimiitiohvd or lost. In aliuuet all hirh febrile oondilJoiu there b aryaaw ff 
Ae tUn: fur, although in fever tlierewan increaaed cJiroinatioo of water, tkia 
lakai pln«c chiefly by the lungs. The niunxt* membrane of (he alimmtary 
canal aliki >evrot«« It* than natural, and to thiji eauae are due the dry tonyac, 
the aecuruulatioiM on the tceih and li|w, i>r 0orde», nad the tmutipalwm M 
oommonly met with in frvi-r. 

Id all ir-brik- omdiiions ihure b a feoting of Inasitndo or wearineaa, and a 
L narked di«i noli mil i<>ii m Ixxlily <ir mental exertion. In (he earlier atage* of 
■'^try neule tcbrile di^liirbtUKf, Uiere iniiy be ttrtirinin of a violent form : in 
the later ii(i>^i-it, wlu'n the «tr<'agth b becuniin).* exhaii«lcd. wandering of tba 
mind or imilterin); delirium if a rommoit feymptoin. Tho patirntV aleap m 
di#liirl>«-d, he i# r>.«llef« at ni^jht, and delirium is more common at that lima 
than iluriuf; ihc day. 

B«T*r« fever uf any kind nlnnys leavea tlie patient weak and aniamiii, ia 
oalueifiHBoe of nn exceeeive d<s»lruc(ioa of the rtd corptiaclca. In lliw tnoat 
extreme fornia of septic fever. tht< lakes place to aucb an extent that the 
aeruin beonmee stained during life by the col oriug-ma Iter of the diaiutryrat- 
iiut corpitwtea. 

l1ie urine in all febrile conditiuus b •caniir and hijth colored. It onDtaina 
an exeeea of urea and urates, nod often a de^ctrney of chlorides. Allwmra 
is frt^juently loel witli iu nil forms of fever. 

Tht blooid ill iutlamiiiatory IvverdoubtlcM undergoes important dtaoMi^ 
but their exact nature in still imperfeelly ondenliMMl. In the days wbsa 
veuewctioD was a regular |>art of the treulmtni of every febrile omditioB^ 
mueli aiientiou wii# pnid to i)k' blood tiiat wii* dntND. It was noticed dM 
in ninov oi-ule iollnmuiatory nfloctions (Iw blcxMl ooagtilatM sinwiy. an^H 
(wrily from Ibis muse and jinrtly from the rapid running In. ' ' ibo 

corjiunclea lut^i dense mnsMii, whit-h nink quioklv — an iipfii-r i-. ->krr 

of cooKulnteil fibrin free from ml corpufclca ia lali at (he U'\> oi ifae cl«( 
when it is itllownl to form ijuietly in n deep Tcawl. Thv tough layer of 
yallovbh fibrb thus formed roeeived iba nnmc of tlw "^tffy ro-a," Tbs 
■bwDct of corpusolis allow* the MUttroetion in the eolorltw (lart of il>e clot 
lo be mudi more cuniptete than elsewhere, and ila upper (urfaeo cun«e<|uenlly 
is depraawd is the ocnirv, being "tvppcd" as it b termed. The " buCT and 



i 



TAHIITIKS or SOBOICAL FEVIIR. 



SOS 



1W 



Ij mtttb UM^ u pii<ln iii o»timuiiiig thf iDtoiiHty of the 

it hitt, h<r«cvrr, hei-ii iitiouii thiit tin- bulf ninr occur in other 

vT iIm iTHrm. M in pli-ihuni, or pn-gnuicy. or sft«r excrcue, 

tlw acoDmfice of iutlaiuiiiHli»fi. Tim l'U|i|>ii] sbapo of tbe dot is 

> lUyii drimilcDt mi ilii> tlinpc of tlif vMM-t iiilo which tbe blood is 

~ , wtimg mmt marltnl wImtii it i* dv«p. 

jkiogw thkt (lecor in thr liquor snogtiinia niv tliic chictly to tbe md- 
I tbmwilh of the proiiuct* of intliimnnition tnkrii tip front lh« alfecled 
IMt bjr tba tymphstic* and tiloodvrvM'l*; nud it is evident tboivfure that 
■Mt Tmry coaricUrably accnrdio^ to th« tutton) and intcndtr of tbe 
•raMB. If tb«' iDflanimMioa aflwta some important orgsD, ute tatte- 
d vkicfa '» tu take ban io the |>n|iarBtioo of ih<^ bl^xid, or to elintiasle 
it tbe producia of tiMti«-ehHUgv, it« compoBitiou mtiu Ite ntnlerially 
ti; bot 11 w at prtwnt impoeciblc losiaio with any defiDiteneea or nccu- 
mgf the exact iiaturr of the rhangm thnt liike place. In simpk inflaniina- 
Mh the fiaid dnuniog away from the iDllu&MNi am couluitiB. sh before 
riMad.aB •XMMof the so called fibriu-fernieul, and it is ptcsibly due lo this 
Ibtl 1^ MMUBt of ooagalated librin vhicli can he obtained JVoiu a giveii 
lily of blood te iiKreascd in lome inflaDinial^try afi^tiuns. In intluDi- 
aon'Oipatiinl by putrefaction of tii« discharges, the nroducle of 
, M1M« arc vldnl to the flutdM euteriu([ the circulation by means of 
^ lywyll Mn«»i. and with these microttcopic orgaointu^ ullen lind their way 
MatW Mood. The hwrteria which accuinjiauy onliiinrv utiirefactiuD wmq 
|mM> ta becltby blood, beinic appareotly incupablt^ of tmdiiig nutriment 
Uvinr tivuee. In true infet-tive intlnmmatioas, tli« iutlniumnlory 
wbi«li «il»r th4* bloud-ilream msv in soriM eases hmr with llicm 



> capable uf maltinlying amoDgii the living ti«ueand giviu); riw 
ikocBadarr loatl mbcbietor fatal jteneml diwwc. 

Tht Umi <uffuteln, both red and white, hnve been already divcribed m 
MfflsMbf in wnmt noniben la ihe venM'In of tbe iutlamcd part. Dot* ihia 
UcM* aa ucmMO of both or either of thcM in tbe geiKfal maai of th« 
UmAT Tbcre ia iko i««ao in U-lierv tlint in simple iDflamiDatioiu then b 
ayaUerial chaoin- in thv niiiiilxrr uf red corpuscles; but in ibfcctire in- 
iiWMatinni. and in tbier iu-L-<>ni|>oiiied by the absorption of tbe products of 
fc w pQ M tiu u . tbwe M mi<i(>ul>tedlyarapK)deetruetion of the red corpuH-Im, 
to that as po«i»le*t init hy Wluirton JoiMa and Siniuo, they (all below tho 
■Mnal slaiKUrd. They nrv said by aoine observers to niAnilest inereneed 
lA^T«B«a». and a it-udrncy to ■);{;rC'CntioD into clusters by coheeioo of 
lUtiat mr^Mcs wbm ivnMVdl from the Itutly during inflsmmatut; fever. 
^ 10 tbe white oofiMedes, we know that they arc present in aucmented 
•■■Asn is the tMhb uf thv inflamed jiarl: wliether they are really inon 
MMeaaa in the blood ui ioflammatiuo ia doubted by I'agci, Ijimou, and 

Fenr i« Mid U' (rrmrWirr by Lysis, ivhen the Byin|)tainB gradually subside; 
••4 ^ Cliaia. *li>-ii ihr fall <.•{ um^H^^rwtur^ U ruilden. In tbe latter case, it 



linl bj A "m/iffl/ twacualion " as a free flow of urine coo- 
s Urye ijuaotitr I'f liihaics, a profiine pvn>{nniiiuu, or a wattfry 
ItadaifeftwiB the hoftk 
TmmIm af BuylMl Tertr.— InRaiiimatory fever preeenU an inflnil« 
f of itn, th« tT[v *< liich it aMiiiiKv ticiiit; >l<^]H-udefit : &Tit, un the 
iti ihf p\t. Tt,:.- i;iliiinu>-r. tbr niluiixiurc of which with the bluod is 



' «f th »>'<-')tiilly, on til" *iati< of thr oervoiu «yvt«ni : 

ill-<T''>< -• ......L. of ciTtain locnl and kjMciAc ovrnplomti deter- 

»< < inllaiiiMiatioa. Tbeet' varieties in tlip lyjK of tbe 

uimiigi- ui<:u»riii« |iract)i'ally tniii two clatete — 1, athenic; ur 2, 




S06 



LOCAL UlilTURUAN'OES ASI> INFL A V )l ATtON. 



uthvnic. Tli« U?rms alheiiic aoil Mtheiiie nro nM used at lli« (in-trnt itj 
orilh rfftrviici.- lo vnriclira nf iDlluiii Mini ion a» llicr urn in l'»rini-r Udm*; 
but for tli« (li^igiintiuri uf l^ iliBV-nriit ruriiie i)!^ fi-lirili- ilistiirbniMv, m 
oWrv<^i) clink-ulJT, irv Imve uo Iwltvr nniim. iiml it u o>iivri))<.'iil In cmtiMt 
tn employ llieiii. In nil l<iriii» nrfirvrr iWro an? three ilttliiict pitJi);**: lli>w 
of invii»iou, exncerbntiuii, niiil decline. In practice, the n.'i.'i>),niiliiiii iif tht 
tv|ie or furiii tlial the eoriBlitutinnul fever of inflainuiHtioD «fleuRiT» i* U 
the Brat eouDeqiieuoe. The tit-iilincnl uf the patient, irrt«p«Hrlivv uf tht 
in|>ic(kl RieiiDft lliikl the Bjieeiul hiciil >JI«ctioii may rciptiri', bcini; altnjp^Wj 
(Iel«rmiii(;i1 l>y llie juiTticular fittiu that ihe coueoniituol ciitiiililuticail 1 
tliiKirbuuce sittUDiw, il canuut bt too uilulouiily tHinie iu tniud that rhr total] 
liiffUB, " tbe reilutMi, iiK«niiif[, heat, atitl |iniu," do uot in tbomaclvi* compria 
nil the morbid jihcnoinenn of inflnuimation ; there ia alwayii aocnuipnuyini 
conitiluiiotial (iiMurbaiiou, and it i» tbe character of tliia f.-»iuiitutiu«al di^ 
turinuce or fever thiit will nt Iiist <K-tvTmiue ih« kiii<) of tnMimcnt to ba 
iidopti'd , nud it <^>iu«^|Uf ntly rwiiiimt to bv HiMely uludicl. 

1, Ntlifnii" hjtnmuuilory Frrrr ncciira in youii^ or tuiijdif-ngw) in<livi*laab 
of bmlthy <\i»rtiluti<>ii. Il in the I'utid utiUHlly nMURird by lh« tcwr thai 
FMull* from the niMorptioii of thf- clii-mictil jiroduin* of putrvfaiAiOD Omn ■ 
Uko wound during the fimt vtrtk iit^i-riiainnirtitm.nnd ia oftm mcd lo m«aW 
iaflamiDniionx of iRi|iortaiil or^ium. or duriu); the forDuilioD of acoto 
ahacvvam. 

Tbe «ta2vor litvanion t<«lightlr markixl: thore iacbilliii<» or •hirrria^ 
v'ilh A fct-iing of gcnvml illiuw : but thrw- nymiMom* may br fi trnnvteflt u 
til t-M-iipe omorvation. In the niitjority of cjimv it is not utiiil iIh' couvtita- 
tioual <tiHlurbnnc>c- is liiltr dcvrlnpc<t ihiit it iittrncti sttotition. Tlie iikiR iaj 
now hoi. and (here it n riM' in the teiupcralnro of th4> lx>dr of from '£° to ■*•*] 
Fahr. TIi" ovcnin); temperature \t one or two d'-jfreei! higher thnu ihaU 
obfcrvn) in the morning. Thereisa fc«lin|;of i^ncrnl lan^or. ai»d thr boHl) 
b ofivo heavy and hot. The pulse b full.T>o<iDdiiiK or thrilling, aod 'jukk- 
encd to thirty or forty 1>oal« iit tbe minute alMive ila noruinl rale, 
diameter of tbe pulse VHri«ei with the pari utTei-teii ainl wilb tli« cauae of ih»l 
fever. Iti ordinarv traumatic fever, wh<^n il iiMumts ibc •tbenic fonaii 
In the fonuaiiou of' acute abaoesaes. aiul in the early atajjcaof many •{leciAoj 
inHaniinaiory feverw. m eryBip«las. it it full and liouiKlin;; ; in iiiflaDtinati<>R| 
of glandular :<tmcture«, n* the te«liti or mamma, thr puUe U e»mprt«ribli 
though full ; in acute itiflaromation of NertiUH n>i-mbraiic», a» ia Mrtuitf, 
{wrilonitiK, or mviiiHuili*, it is i>niall, ineompmMibli', and viry. Td* aver^ 
tlouN nrf aimUf) or <tiniint*li4'd in i|UBnlity, ihe Imigue i* e<>nli-*l wilb a whil« 
fur. aiiil the mouth dammv, unually with much thiril; the liont'l* are ma* 
llne>l, and the filtiii dni'. The urine u rranty and high i-olured. 

If a favorable t^-rmiiiaiiou occur, the fv-vi-r ti-tmiiiatvveitliiTCTndimllT.bT 
JVi*. >>r more MtMenly by n-itU, often af-cimiuinii-il by criiii-al eva^-uatiun. 
The tongue clean*, tin- pulvi- l<iwiu> in frxijutucy and in strcugth. the wri*- i 
tioiM Ikecume morr fn-v. the t)iin>i diminithe*. and etrenglb and apiieiila fl 
rviun). Thif favmible trrminniion <-an oceur in m<»t satvinl rSMee only by V 
the removal uf the enuir of ih*- fever, w by tW o|Mtttiiii; of au aeutc abmM, 
the removal iif septic miiltvr by drainage, or the gniirlh of healthy invnula- 
lionit pre\'i-nttng il« further anHirptton. Hhould the caitse iiersixl, the fever 
□tay tcnninale m death, either by exhnusiion or by the Buperventi'w of (naM 
vuevral e<miplicatiou. ae pneiimunia: or tbe Rthenie form may gradually 
iiM!t^ iuto the tv|>e that \h characterized by debility. 

i. Atthfttie /njUmmalojy /crrr orcuia priueijully in thaw indJviduab 
wboae comtilnlHNM are broken bj privation, diaoipatioD, or by »ay of tbe 
gvocml ilqirtosiag bums of dia«BW, as grief, nnsiety, long reildvnM io a 



I 



VARIKTIBS OP SOROICAL PBVKK. 



207 



alBHBfaar*, or eld age. In caiii>tiiuiii>iu Midi m> Ukvc. rmjiipntly 
k in •n dMM, bat iMpecuilly tunongsl llu! punror rn>iHcDli> !» Inrge 



, lirm ftltDoM invcriablj mwiih-* tlii* ivpr. The vbusc 

' 4 A* Ir^m, h«wmr, ia niany t tmm. deta-niiiKs Um- tyjH- (|Miu? lu much as 

ti* fwwiiHilinml ttaia nf Uw puloaL Tbo ■■thvnic furm w mpl vitli in all 

oNt uf intp LaXrctiTa blood- poiMiiiii},' rnim wounds ; ihiit iti lo fHV, id ltio«e 

Mi* u «iu«b lliv pouwo whicli ruirn die sntcm i« nnt merely (he 

riaskml lundaet* of piitrT't'ii<'lioii, hut % finrau'iil'likr 8ii)>«(«iicc cnpable 

rf —lltplyiaif la tb« living tiixly. »■ in acuU) «('|>4ic infedioii, pywmiu, aiul 

^^paal pMUle. lu nil sjinxtliu^' nngrrnuui influninttione lli« fever 

ai^BM lb* «MB»« ftrm : uDrl in <-n>-si|i«la8, nlthough, ks before M«led, tber« 

■ii far rtbrciir frier fur n »l>url lime, the tipM of «xbmualion rapidly wl iu. 

Jb tb* a*tbc(ue furni of fever dvpciida ao frequeotly uD general iofevtive 

fHnmmm it \» fre<)Htaily ■oeompsnied by secoadary oomplicaUooG, ae pleumy, 

pMaami*. imoeni ahweote*, «im1 tbe like. 

Vboi iJm Mtbenio fonn (ona od ma ■ setiuetice of the sUieaic, the nm^ 

tf tb» on« itraduKlly owrge into tliiwe of the other, the wcabneM 

ibt pum becuneft teebler though iU frwjitencv is ke^rt u|i, tin; 

I brawu and dry, and there » teiMilency to cfelirium of a niut- 




I tlw ftr»r BMumra the uthenio form fium the very firu, de|>re»i(»i b 
i^lMiitiiMlTiiHrlrnd iliiiiii|ilii [i[ii il if liinnii n and.ev^n when th« febrile 
MM ii tally ■Wablithad. tbeaymptonu are not very aolire. T)i«n.- i:> throti^b- 
Ml aa ■fpMrmocv of hMvinoM and UU{>or about tbe |>atieoi, nod an ciirlv 
tM^Mey to delirium of a trni' form, eain-dnlly at night: the puW iii fiflifv 
■aA nry fra^unit ; iIh' vkiii may be lioL and dry. or HomHiniL-y nii>i>t and 
thsMT: liw lanprratare la ttvta S° to 5' Fahr. above nunmil, and fhime ii 
■ai^M avanti^ rW and momiug fall ; tbe longui- i* brown mid dry, and 
•■4* lafiidly aetumulale atwut tbe lipn and tcctb : ihe rhevki are ofUo 
ImM, aad tire ryca may be bright and «tnriiig. A* the third etagc eotnea 
m. if tkr |«t)vul n-eover. there may W a vriticnl evncuatiun, as sweating or 
tbr imiIm- siilie»<lu» in fn-<(u«Dcy and iucn-iuca in strvugth, (he 
I (Tadiully aad ftloiily cleans from tlw ndM and tip. th« tcmiieniture 
•A«ti Mnw uominl for lume daya. snd tlio patient slowly and imper- 
tely fapio* hi> alrrntflli- Owing lo tb« axlreme wcaknets anil (evbleiicw 
«f Ika hMfl't actMm thai onto aoeonpaaia this lunn of fever there is a 
piM iMiltMcy let locsl e(>»)(eatioos. apectally hvpoetatie poeumonia, whieh 
■at iMMtvpt ibe pr«i;rc>a towards ivcovery. bven al\er oouVBlMCeuce, iha 
^■wrf tbe Ritutituiiixi may frequently be broken for ntoiithi or for lift. 
If lb Ammb lake BD uiifavuntble course, the weitkneat of the pulse and 
Ife 4uk IsMMtalioD of tbe ton;;ue iucrease; tbe temperature falb often 
niftt: ihttkin beoonwa euld nod etumniy ; hiccup, sulwuUu*, and 
ta p mwot: iI>b muUerinx delirium iicives way tu intemtibiliiy, or 
, mat\ dnlb oeeura from exhaujltoji, or at tbe reauli »f viMMal 
It is this cuBditiou lluu is fretjueuily describeii tut tbe "Mt- 
imq m >4 ty^ihM synpHian." 

U (wjrats vhMP annrnns sniMM have been shattered by intempcntiea^ 
« atis bav* l>*-«ti •sbaiiMad by axCMrive nieiilal work or excitement. th« 
•yniptxtan thai aooMupatiy the febrile disturbance may form so 
Dl a fralun-"f ibacoae u alni'at to justify ibt deacriptiou of a third 
*Jf>. •• hi' ' ntrtimr* done, under the name of Initativa Fevar. In 

Isms CMr< >er as*uRM- (he ilhmie form, Uiere i* high delirium, ofton 

•f s Auiou* hicio, »iib aildiMH* nf the eye, Hurhed lacv, nad besU of b«wL 
Him sAcA tbe frvrr is from (he first of the Wtbeoic typa, especially in 
1 dnakards. in wbom h rtisembia* deltriuin irvoM-ns: thira are tlu> 





208 



Local PlSTURBANCSa AXD INfLAMMATION. 



sitniu tremor, claiiiiuy {<«nj>i ration, and foul tniigue, nod Uw duUrium 
vi<jk-iii, Inii busy and muUmti^;. the paueut beiii|( r«»tles mad cutial 
tryiii^ lo j-^ oul uf fa«<l ; Iti- h alueiileiui. and ualcoa relii^r lie ubtaiocd, ■ 
of debiliiy rupidly cntne, am) duiUi tmkat plaoe eitbur fniu esliniiituc 
ooma. 

TRKATUENT OP ACCTK IKFLAUtUTtOK, 

It is not merely inlcmting. but practically uspfnl, to Mixiy thr ini 
Ur; process pmliolngintly ; for when we have to dcnl with it ibrabrutir*]!;, 
tho knowledge nc have ubiaincd of it« cauwe and nature in the d«Ml'l>u«ui 
and in tJienalliulo^jical laboratory serves to now extent u a gutd« t» trvat- 
inrat. Slill, our knoulcdg^ is not yet safficiently por&d for tJirory only In 
direct our practice, and we must ou no account neglect those raodci of tiwai* 
mcnt nhich have been sliowo by experience to be of use. 

liefore ileeeribin)* in detail the nieuia adopted in surgical practice fur tbt 
prevention and cure of inllaiumalion, it would be well briefly l«t poini iMt 
the iodicnliou^ furntilied us by |iatbology. 

1. InHumiimuou is tJie rwult uf ati injury done lo the living tianieB,of, 
saHicienl severity to lower the riulity of the aSbcted part, but nut actually 
to kill it. The ugeold that act iu this nay, as we Iiikve l>ef<-n^ »crn. arr 
spoken of in surslcnl Irvnguagv a« irriliint«. Our drat object, tlierrforv. in 
tlie prevention of inflanimaiJOD,ia(e;>rof<'/V tfie ti$taef from aU *ourte» t^ irri- 
tatiim, awiyjaMng tkit, to removt die origimti im'lant n* ipiitJUy a* pMtAU, ami 
l9prevettt the itttndtMiion 0/ JrcJi MHw* 1^ irritation. 

Under ihia h«w)!og are induddd; the rvnwval of fvreipi bodice: tha 
•Toidaace of iniuiin); application* : the |>r«vontioD of teniMo, by drninatfv 
of wound* and poaitioi) of injured part* : the rdief of lenaioii, as by enrly 
opeDi»|c of nlwcesM*, or by incinoni' in cellulitis, to allow of the eKa|w of 
iuflnmniatory ufRitions ; and the prevention of d«coiiipo«iUon ju tlie dis- 
diargts of wounilt and iibscwisaf, and tho excloiioa of upwlBc lolMtiTt 
poisons, such as that of pywrnia. erysipelas, or thv like. 

'2. All irritnots lower tlie vitnlily ot the tissues upon which tfavy ad. and 
if of sufficieut iuteneily, cause death of the part. Thp dcgr«e of ilaauc 
done is proportional, fim, to the inlentiiy of the irritalion, and. a aeaadly. 
to tb« Titaltty, or, in other words, Ut the power of refistanee of the Uaaan. 
Id the fireveiilioD of inflammation, ur in the liiuitali'iu of the procvaa, unr 
Brat object must l>e 10 do everything in our power, bolb by );eiteral and total 
■neans, to pnnoU the heahhg ntdritum 0^ lh« tUnus, 

Ui>der this beading conw: attention to diet; avoidance of itloiholic ex- 
ecH ; regulation of the actiou of the bowels, »kiu, and kidneys ; tlie treatincnt 
of coo«U(uiiuuitlc><udttiiiua,Micbasgoul,rbeuniatiMn,aod syphilis. L-x-ally 
the chief objects in view arp^lo proterve a narmal il«te of the circulation 
by removing cauMS of ooamMion, or local aaiuuia, ai by tbe excinoii vt 
tumors prewtnff on vtMi^ls, Ui« euro of rarkou vcina, and' tbe relief nf iba 
distended capiliiiriea by uoilorm oliistic pnaaure; by elevation of the part, 
or the removal i>f atningulnttou : U> mwutain a Dormol lempetatutv : and t4 
avoid ovvr.work uf thu part, im in oxcoaive uiw of the eye or lartnx. 

When tlkc inAammiittiry proceM botablishod, we canui>l too strouKlv 
in nlnd tllHl the vitality of tba |mu-1 is lowarad. and tlint nur mniu otij 
ai»— to avoid lutthiTtlr'pnwion which luiglit extinguish audi lifeasrvBUUM; 
to vaoouragi.- tbu return of vitality by t)iv inaintenasoe of a normal tempen* 
tun and by the ragtilution of the disturbed circnUtioa by aucb raaaiiaaa«« 
hava at our oounaod ; and to iiisun-. as far as poauble, both fbocttooal bmI 
mechanical real of tbo inflmmed |i»rt. 

Inflamed parts are 1«« able to withauod the efleou of boat and ooU, ct 



I 



• 




thsatmknt or acute inplauhatiok. 



»9 



I iniUalA. <>r in«-hBtii<-nl violctim. Tlius, (lie npitlicnlion of cdIiI or 
tifmmhi «atm-titi<> f>oliiUQri» (nil of which nrc tnorv or Iras irriuiint;), <ir 
ttMMMry tnjiiry ■tTn ftUrKii'al oj>erution, iddv, Id an indamoil |u>rt, iDten- 
A ta y>i w^ ao'l an-ii vituie itl<>ii^')iiat;. 

X TW MHBtJal ])hi?u<fiiit'nn of tiitlani (nation are : fint, the dilalation nf 
AtuMcM* ■rith inrrrawi:! ))l->uil-j)n>«£ure m tli« iiroa supplied bj the ililBlci) 
• ■D'lly. ih^ t-Kuiiftliuii t)iruu)jli llieir <lainaK«4l walla, wliich. ■.■(litT 
-(UbI, «UI be profR>ni<>tisl to the degree of iiitnkViiBi-iilur 
i.y. ihc iiiiirrBti'in of ihi' iiltiic curpasclea; fourlhlr. the oiuu- 
r atnert ••f lii« <-irrtilai>--[i by >iasi.-<. lite riuoular <lilnliiii'<ii ami i.'tiiiti)> 
ibe iBflammntiirr bhi'IUu); Bml f^n rixe li> ieii^i>u, which, »cttii)C 
■ ifriA*Ottmaf iniUlioti, aggntvnlet thi- inniitiimntOTy pmcew. On« uf 
^•Mi«an oUmU Id tlie in-atiti«ni of Intlantuiiiliuii !» tMrrfort to Utuit the 
tmmttmm M dtMinithin'i lite hfooit-prrtnirt aii'l. fitlliwj hi tha!, (o rfliere the 
'~~''»ii^9»a rueto. Thf bliKMl-iirx-^iirt amy !«' ItTnin."!. fiwt, hy pMi«»l 
tacliajt iiihHi th<' l»i'iirt,a>iic«iiilc*, notimimy, mid guwnd hl(H>dlrl(iii); : 
Jly, t" li^i'-ii-hinK 'hv 'iimnlity i>f fltiid cin-dlaling in iho iKidy. 
il I' i;:. (Uilinf pur^i)V<v, or loir di«l. The lom) blionl- 

kv tx- •.uiiiiiiMh'il hy mu^itif; dilaialion of thi* vrawls of Eotnc 
tfW pBTt*— m of Ihi- i(it<-«lirtn> by piii^ativce. in ext«rnal iiiHanimalious, or 
•^ tW An hf dH|ili<mtit« in iiilcrnal alfcflioug ; (wc'oDtlty, hy caii^in;; om- 
I nrt i— vt tliv tcmcIb su|>plyiii;; the ii)A»iii(.'d ar«a bv the dirvcl npplicati»ii 
' tmU, MfaKluBiM, or B8tnn;:«nla, or liy iipplyitig; u alimtdu^ ut a dialntn'e, 
waBki r w i a rellt>x (^mtracliuii of tho vauvls of the disused part, ba in 
«■*'-' ' 'ti hy blt«t<'n> or nitutard plnMcni ; thirdly, by t-au^iiif; a uoi- 

tfM .1 of nil die veiwdi of the iuAnoicd jwrt and iia imioi-dJste 

■■I, Ml B-o tn l«MfO local r«BiUaiic«, aa in the aj>pliratii>u »f heal : 




fcartUy, hy drvntioB of tho afltoiad p«n of thi- ImIv, by nbtch the 
Mn tf Uood from ll)<- imirt i* ftvorrti, and. b» hiu> Ih'>-ii «h'ivr'ii by Littvr. 
• flvUiB di^fTM) of aivrial t-oiiiriK-li<iii iixlucol. Dinvt proMUre oii ibo 
■an arwry of lb« limb wnuld nlso todM- iind<T thi* ht-adiiijr. Whni pxu- 
fc ti a M takiBK pl»rv. i-lrviuinn of th<- limb favon it« rvtuni hy llir lytn- 
l*aliri.aB«l ••• l<wrti«>iir1liiig. Hhoiild the- jwrt b<'Oom«m tctinelv <liMriidrd 
«l> l^nBicD piB^n-ue from prcMuro ou the vnM'le, thr rvudiiliui) niBV Ik- 
""~ ' t» tfcapD dirrftly by inciMons, piinvtiiTM, or >c«ritic»li'>ns. Fbr 
I of ihr oirimtrlc* is liioilol by odd, which arrrats ihi'ir niii<vhi^d 
la, and by ad nt(rau» whioh diminuh bhHid-preseiire'. Ileiit favore 
r ■iar»Uoti. arnl al*i> encourn|;ra their nioviu;; >Mit uf the iuflnnietl arva 
I thatjmfUuijiifa in cham in whiih mtolulioo i^ tnkins place. It is only 
iMvra of (iulity in the wbIU ••( tho veeads. bomvcr, thut can eoin- 
|4Mtj vraat ih" pfixrw ..f nii;:ritlii>n. 

IV tmdrc' - ' '.riirnnl"ry i-Kiijicstion, that is to uy, chukinj; of iIh- 

4ttmAti rrw ' sn-cly niuviiiji bUxHl. can l>e rvlivvcil in mime cilm-b 

W4rs«Hif' bl' ly rr»ni ihc piirt by -cnrilii-iiii'iti nr puucture, ur the 

fcw rf lb» ba-.> ' < ri iiinT be ■ltr»lilBtt-il iti onlt-r li> drive the blixal |uiiit 

bj tho wlniiiiiBtmliDfl of alcolnd. Stiuia can lie r^-lieved 
lh« gMMrtml iii*«n* nlitiTe loeiilionvd ^r faTuriiig tU- rrtuni of 
is il»« inflaiiMtl amL 
L ftim, «h>elt (tmm to iimniineiii a •ymptoin in hhiiiv InftnmniMMKw, 
■iO W nfivTwl kxslly by iti<»c iiH-ntiK. nln-nily iiii-nli«nf:<(, which Ititd lo 
tmimJi trsMco ; bat, iu addition, h-eul »cdiilivti* — ua MIniluniia, upiiiin, or 
■^iiIbLi of lcail^-«fT ofU-ii of much amr. If th«w fail, Milativiw niitrl U 
pw« iat»faaJly. 

La«tli, ibv Inatmnit of iudaiuiiintioii includt* thai uf llio Jtbrite dif- 
apKOM* it Thii, w »<• have aiieii, ribv be due chieBy, if 





LUCAI. blSTUKUAMUICS AND INTt AHU ATIOX. 



not eniin-ly. lu tliir adiuixluri! wiUi tite 1>1u>hI uf (ho vxiiilntiuu nrtu 
from ihtj inliaiiiotl |iart hy ilit- ljni|>liaua; in xicli cmm-h tlu- iiM-uii 
tu limit thv i^U'Iiiiiuu, ur to tlnuii it amy uxu-mully, ■■ in n uuubi], • 
limit tin: Ivvtir; in oilier cases, tlw Mraniu of ljni|ili iM'iire with il ihv rbcaii* 
oiil prinlucbi of (li-compaun]; inatl«r fratn iho inlluuH-il nn-a. ninl tliu* «c>{HiRi 
■tu :iil<liliDiiiiI [Hjwt-r of <»u»it)i{ fvvcr; tliia mo bi- prcvi'nt4-i| uiilv by ]>€«(*■ 
nnti(H-pti<: j^in-cniilioii*, or \iy itruining uD' llii- i.-xmliUioD vxliTuiiOy. In m 
i-ifiv infective intlniiinmliun*, tUc* IWit ninv Iri ilut ti> omtnaiiniiliou ofUM 
liloMii W ihi' [iniH'iii'c of fuini.' |H)iiiun niii I ti plying in il, n* in n-|>tintliii 
l»v|ilic mfivlioni, iiyumiia, or ninli^nniut |iui1u1l-. At |>rvM.'nt wv ntv iHl 
aL-c|unintcil wiili uny nK'sn* i>f iK-fiiiili'ty dcfrtruyiuj,; lliv |iuifrou in itucli c 
Wi> ojiu only Aujigiurt (Ik* jiulii'itl in vvcry viiy in our fiovi'r. Iiy fiHid 
c«n-ful nurain;;. su as tc cnnbli^ liini to nilliHUuil itit trvil itifliiinLv. lu 1 
cuwit in whii'ii llie nervous ^vniptonjii of fevi-r urv piviluminiini, M-iloliv 
IDUU III- nitiuiuiBti^ifil ink'nitilfv. l^utly. (.-crliiiu dnip) arv u»e<l <'ni)>iri<-al1 
from lliuir known power of Tc«Iuciu|' tbo i>;ui|H.'nitiirv in Ivver. ntnoupt i 
nii»[ iiu]i»rtant of lli<»c bviug ulcohol, quinim-, Mlicy lutv of tuxlii. nnd luuui 
Ttiu iipplifHlion of cold i^ucnilly to lliv bo«ly by biilli* or nvt itarkinj!, 
lucallv to lli« licnd by uu iot-cnp, oa rccouinH-iidcil by Kuu«»lL*y 'rtvi>rD(<. 
luwful IIS th<.-y uuiloubtoill V nrc in cnww of v<-ry bigli fovcr, nrc l>u( rinpina 
inutlw of trrntnn-nl, nit tlii.'y attack oim- iiyinptoiii only. Imrin^ itx' cat 
untoticlMil. No tSurpHMi gJiould bnvc n-counw to tlitw unU-w it i* bpym 
llii iMiwtT to diai'oviT. or lu rcuiovf, tlic uiuw of the fi-vor 

'llif abovo prin<;iplc)i »orvinj( more or Icee lu unr gtiittw, w« can i»o« 
" l4iil 



(uder more iu ileUtil th«ir practical applicntion in tli« trcalnicnt of 
inflammation. 

TiiK I'kkvkstivk Tbeatjiest of indHninnitioD caa bo cmpIoyMl oiiljr 
citHsof injury. All injiirii.-s of iiny arvL-nty — ns cut<, bniisea, spnuni, 
ftiMtumi — niuHt ui.-<H-)Mkrily bi.- followi>i) by a ccrUiin d<vn.-« "f ititlaniiuatiai 
but Uibl (inip)c iraiitiuttic indaniination hiu n<> Icndi'ncy lu spread be^M 
tlw am injiirrtl. wliicli, in the cttn: of a cicnn-cnt wouuil, ■» little more tin 
n iiiicrrooi>)>iL- layer of tinup, nor i\ix% it Ivinl to |w(» bvyond the aUge 
ein)]>lo PXudatioD into that of ■uppuratioii or iiU->.Tnlion, iinlrm wine tVltlb 
cauH of irritation conic into play after th« injury. Winn w<- talk, thrt 
fore, ■)f the prevention of inHammation, we do not mean th« [>n'«'eiiltub 
the einiple ualtcaivc iuSammation which IoIIokb an injury, for that t* tmp< 
sible; but m tnean the excluHtori of nil muroef i>f irrilnli>'n which eon 
iuteauly or prolong the procets. or nmke it afMinie a spmding form. 

While (ifscrihiux the cnn&ea of inflammation, il wac jioinleil out that in 
Burf(icnl injiiriiw iu which the injured |>art ie expoicd to the air. thr irrit 
winch «(' hnve chi^flv i*' |.iiiir<l ntrn'it^t are the pnxlucte of iiiitrffMi-liuo 
(h<- sjiecilic jKitMins •>{ the vnri<>ii.-> infei^iivo inllammalioiw. It wai also 
that tli<' aiiiM' lit iHitri'J'nciion in n<il the admiArion of llie ainicwpherio , 
hut iif Milirt iiartii-kii wliiih doal in the air, iinil are nuv Klninel univn 
ack now h<ij)j;i.il I'l Ih- living niit'nweopic or};BniMU». and tliat the virus of 
variixin iulrctivo iullauiinnliooa ia, certainly in souie eoMs and pa"'™ 
ail. a »|>eriftc micnwcnpic orrauiiaiB. The nH-nn*. tliereibre, thai 
putnfiirtiun by exclu»iun or imrttotloii of the inlemaooMC omni 
in a greiit projionioit of tuum, servs abo to ward off tbc InfevlioD 
inllaniiiiiitii>»» ; but not with c<|ua] certainty, for. ax Inu Itefure brtn 
the cHUsef <if pdtre fuel ion cannot find their way lo the |>iitn*cible 
by the blooil, while the organienw which a/« uiwx-ialiil with xpf^-ific i 

(iroeoaM niay do »o. those chancteriftic of miuc >)ii>«i>ni bciu|j t*f. 
ivinx in tlte blood-etream. In the tireventionof inltaniuuitiou, it iKonlr 
direct contamination of wouu<l», nMctMoa. etc., fn-m ihc air that ran 



of) 



A:lTl»ICPTICa — UAKHOLIti ACID. 



211 



»W afainM hy liml niviiiw: sutl U»e UHuoialloi) of ]>uir«facli»u willi 
iri|Ki^ v.- iiilliitDmiiiiiiiu bw cluoe that lliu two HuI>i*M.-tB L-uuiiut 

k4aUt « <>i>-t,v ill 91) fur u looU trcalincut !» (Xini-cruiil, lUiJ liure, 

Anifac, «F i>ri>i ilriil Miily oitli tht.- {irt-vi-iiliuu at' |>utn-fticliuu. 

IW intesUoo of putre&ction luuv lie cHrriml ixii liy ihu fxvliitioti of 

^ «M of tlw faanttlaJ voudilmitifiirllH^ ]inMt!M(p. 185). The fint ul' Uh-m 

• Ar pnartiea of i)«ul (irgatiit* inultt'r. ll i* otir utijeoL, lli<rnJViro, Uy ilnitD- 

9^vAiDd> U)<1 KbMxa«ai, cillKTi'iitin-l y t'l mii<^vi' tln^ iKiln-w'ibIc imitlcr 

irt^n.i'i.. ll ID HI enuill B ijuiuitity tluit ic itlri-u uill bi; iiuigiiiti<.^iiit, 

TW ■ oiO'litiuDs, ihd preaunce of oxy^ii, wnlrr. iiixl » iyrt«iit 

^— nuiiv, mutiui Iw i-xcludcfl fryni any aWnw. wntiiiil, or wivity 

i'Ut th*- ili#i-li»r)^-e flowiii)' from thcvc miiy bu dlhrr n.-vi'iTi''l 

-■ 1-^ .ii> tI-iH RiaUriiil or Hlltivitl to flrv ill thv air. and lliit« tliuir 

fall !■ i I "F ti:iv lie iircroiitPil : nud it will fw seen, io the trcntment ut' 

•MMM. tiui time BwtltiMlf ure siitiKtiinm ndojitotl. The last coiiditiifi) uf 

f^ufciliiMi ta the prmiK'c ol* llie uri^iiixcd I'l-rmeiil; and the itostrtictiun 

<mda»i- ■ '■ firfiM ihc essontiiil feature of those Rioda of treaiiiif; 

a' r uk-pn. whii-li aim iti Uio alMolut« prevention of ihv 

Kliuu «t)it'lt KvultB froiii (lii> irriiiktiiiii of the <;hfti)ii-iil prodiicu uf 

f«tR&ct)<-« TTir *iiii|iU-«t iiKxK- of (.-x I- 1 11.4 ion nf l)ic i>rK:»iii»iiiB Huiiiiii),' in 

AvatrU ' n. It hiu l><-<.-ii Ahonn liy <.-X}>oriinunt tluU iht- air lillcnil 

ttjlgti I I i' inrnjialili- tif ){iviug Hue li> milivriictiun; hut ihin 

vi l^ iiiii-Bition brardY practiutbre for surKBry. (Vntn.- 

)ju>^: 11 <v Iiib< til bo|)lit«C(l oil «A«)NUNif ontiMT^twa — tliat io (o 

rttvmK-«i Hitwlaunn i.ii|wt>lv of divtmyin); the ritality >if miiiutv 

fuR^. It inoi>t Hot Ih* forgiiiit'i). however, (Jint all thvmiiii] aiili- 

•o arr ill ilifmncIrM irrilaiil«; iiml, omMtjiiiiitly, In umiic tlifm, cjiru 

br lakrii to (inidH't thf tiMtics n» far at pomihlc from their direct action, 

. alth»ii;;h pn^vi-iitin^ piitrt'fuotiuii, thvT may aot as eBUsee of iii- 

Ai <<■- thikll have rr«<]U(.-iitly to refer to the udi- of siitueptics 

KtW Inalinrtit uf nhicratm, ulnura, and wouiid». it will Iw iniwl cottvcnieut 
M* a«tii<iu the chief HI baUtnoea ut preoeol vmploveil, wiiih (heir profter- 
^m) |w«ittaniitM Auiiwptiui thtv much in th<.-ir |>oiiifr. In thu irrita- 
9 '' ' rtM> M, and id their eifectA if abtMirbvd; tbcBe |MiitiU will, 

^B it B.^; U ■utrd that uu ati(iM.-[>ti(- vnpiir which can be of nny practical 
^^ki a Kirt^rr ha* a* yrl Iwiti iliM-nvered. 

^TCwWle Add i*. pr-rlmpa, IIk tai-M cxtoimivi-'ly hmmI i>f nil aniideptio*, 
^r^««(fc l>* (>'• nicuu* tht^ utM powerful. In »iir^'<<rv lh<' punvl iicid oiily 
' — '-* bv tun), tbo fiirw Itii'iua lu itlMoIutr phe'ioj lii-ing in'rhnjo iho Icoit 
4LAlilr lu ll* *iDr1l. Thi: inipurci funu «f (ho add, utrU ha i> ti^<<l fnr 
tin*, ia niorr dilKi-nli of H>liiti<iii in wntor, and it* suirll in viry 
iMir.' .rviullinil acid nuty bo madv (H-riiiaiifiiily lo OMumo 
• li<)iii<l, by (b« niidilton uf alioui ,'f of i(« bulk uf 
< d<H* not take place till the pro|>»ri)on of walt'r ie 
ll. ihu* finning the I in 'jri mdution. The ctKeJeni 
. TiLii'it fdiitton w un antiwpiie is about 1 in -tO, below 
Ti-j( lir nitiKvl. Carbiilic acid la rvadily soluble in oil id any 
ual (Kirt*. and in ^lyccrini^ it i« even nt<>re soluble. The 
I Miruorv an-: IC'ifrnr ■o/iifi'viM. I in l.'Oaiid I in 4ll. The 
!■■ foul w<>und» tit the jiirjii^* of clraninj: llicm, lo 
. II rTj»)H-<| lo the air f"r mmie time, aitit 1*^ the uu- 
II itt which an o|>rratii>n i* l<> be |>crforme<I; ih« 
I' ral'ir'* han't* iind thr apongi*. anil all inilrll* 
Ibr u|>rrB(>uo, aad to irri)(a(v [h« wouikI during; (hr [icrfi'rRf 




212 



LUCAL DlttTUHUAKCKS A N U tHrLAllNATIuX. 



9 JIp 



miicc, or to wuh it aut wIlli ut llie end bcfur« closing it. Tbe I in SO 
lioD is uaed for tlie ejiray, u# will IiereafU-r W i|cM-filM'<l. Dulh tbr 1 in W 
ui<l I io 40 •olutioDfl wkilen aiiy ruit siirfitt-« to wliii-h iIm-v nmv be apiJi 
but tlwirnciion ia very iiu[>eii{cial, iiikI iIom not interfere witli jiriumrr luu 
of K wound. At itir loimient of ai)|)lii-iiii'>n itivv onu*e rnvtrn tuMrtttn ^~ 
ibn b Mon follnwed by rrVu-i' l>»ni nil (iiiiD niii] ■ teOMtioi) nf niiiD 
Oily rohttiatt* net iiiuch Irm jmuiTfutly iliiin tW wutcry. Fur prrsrrr 
catgut ligstiimt, a Hilutiuii uf I in ■'■ iniiit )m- um-iI. Iu tjic >trrtigih of I iu 
10 It m»y U- ii|)[ilii'i) i>h lint tu n niiiini) iiii an nnliMptic drMMDg, Imt ii 
IcsM its Mid rnlhtT i|iii(-klv. iwgicciiilly if lh<Tf it much diM-bw^. Miid iiw- 

S|ueoliy niu»l be rt-nmcd at JniM inicc or ihrov tinm ■ duy. Glyttri— 
HtrcM: The pharmHcopn'ial sointion of 1 in '> — otic jmrl oT rarbniw acid 
to four of glvccrinc — u too strung for apulicatixn lu u raw HurfsM, but MiT 
lie used on tfie unbroken akin; for wounoft the »ohitioa nin; be rvduccd l«l 
in 10 by tbe addition of on rqual quantity of nuier or clyccrinc If iwd 
as mu uiliaeptio drewin);, it muBt be c)ian;;ed frc<|UcntTy, as it is rMdilj 
wraalied out of lint by itie diseliar^. Carholic gntitt : Tbis ie n onarar i:a«R 
inipreicnated witb carbolic acid diwolved in a niixlurt^ of paralfiu aod nma. 
It contains about ^ part of carbolic actd. It furtun nii ab(M>rbeut d 
luid poMCMca ilic great sdvantajfe uf yieldiug U|i it* carbolic acid slow)^, 
Biid thou rMaininn its antiseptic iiropcniex for a long lime. CarhoUM 
eotloi^ttool and hw have also been used, butarcMiuewhaiiuvffidcnliirepara 
lions. 

ORrbolic acid mar act injuriourly. botti locally and griK-nilly. If tli« 
•olutjon be nut prugicrlv iimiaml, »(nall glubuNv <>f the uiidiiiM.il vcd acid 
may bo floating >■■ >t wlitili mil riiuicri/r Itotb llic |Kili>'ui'# itwun and tlw 
Sureeon'a lianiH. T» iivnid thi*, ti is Iwilitr alnny* can-fully to luiauKirv ibc 
acta and to ]>rcpnrc tb« «<dntinn» •uuk^ bnun bctofc ihcy nrr UM'd. If tbr 
•ulution is prcjMirvd imractliatcly iKforv km-, it must ho well slirrv«): and. if 
it ia not required to be cold, nann water may be used to iouire |M.-rfert 
suluUon. 

Carbolio acid is, even in the slrengtb of I to 40, au irritant to tbe liTioip 
tlmueti; when applied to a wound, it exnKf{emlealbe»cr<>us dticliarst' for the 
lint tHcuiy-four hour*, and cuiiscijueutly iucrenin iliu ni-<v..eity tiir gooA 
dratiiiifp'. In ustuft it as a dre«irii;. the objrct of \hv Suri(V"H muH liv lii 
pravetil direct contact of tlic acid witli the mir aurlaiv a* far iu> |MNriltb 
after tbe wound )in<l br«u oinv iraibw) nui; utbiTutfi' it may h'lvi* riM* M 
suppuration. In njubiii)! out a wnuud nlwi it i» imiHirlnnl ti> lak<- cure that 
the lotion itMil i«ru|H'.i fivx'Iy. If it rvniniiix in Imiluw* aiid cniitiiii of the 
H'liiind, its iilB()r|>ii>iii nuky muM) lymptoniH of |Hii«iiDinK '. and if ii Im- llircrd 
iiilo tbe ■[Kin* nf ibi.1 nrexliir tiiwiie, not only may c<-ii>iiiuli»iial miii|iI»dw 
itpjimr. but counidcndde tocitt inllatiimattou uinv Mi{nrrv<m'. In fiittc |«- 
Itenis tbe »kin is Kingularly intidrnini »f the aci<1, auil Ihr fiauiic may oauae 
even vesicniion. it* use mitsi then be abandoned, and sonw other antlaeptie 
ai^-ut onipli<yed in its place. 

C'ltrbulic arid cniiiiot be npplitxl, either to the nnbrobcii skin or to * raw 
surface, without » ecrlain 'luantity beini; absorbed. As a rule, this Kive* ri>e 
to nu unpleasant symptonn; but, if tlie surfaces be very larRc, "r tbe imtii-at 
>>« peculiarly iniuleraiit of (he acid, Byni|>l<inia of car bulic |iuiM)uinK may arise. 
In ever^ case in uhich a carbolic acid dren»iii|tufaiiy kiml is a^pluil, iior its 
derivatives can bo detected iu the urine bv projier tests; and m a grmt jir<f 
piirtioi), if a surfiioe of any Mxe is covered liy the druwinji or a lar;:*- wound t* 
wub«id out with tJte lotion, tbe urine undergoes a marked cliuiiKe. In ihe 
mil<l(«i casen it ii« paned clear, but afUtr sUudiug for tuntc time i[failually 
BMuiim an olive-Rrecn tint; in the looro SDvem caaci, it is pasMd dark in 



i 



i 



AXTISXFTICS— CHLORIDE OF XISC. 



S13 



< aU.tmi n tundtiig beruRKo Klrnont binck. If iin otber ^nptom are 

fMM, Um aMMBnnce of thr urine, which in ii:iii<) to he due to ibe pmK-iiiY 

■ ■tea. Df«<i give Hm* to du imxiixy. iu ciuo In whicb tin' grawrttvinic 

tim ^ pntndiai^ sn- prriM-ni, lb<- »ul|ihHl>'i ilii<iiii|)t-jir i-oiii|)t<-ti'1y from tW 

0M Tb« iwMt niarkpil f<-iitun- of cnrli'ilir a<'i<l |><iiKi>iiiiig iVoin nlw-irptinii 

!"■ > VMIDd i* texrn- unit iiuouitroMiibb- vnniitii)^-; if the ilow hiu lircn 

■w lvp> p»Ol*p» •[M'wlilv ft* ill. wfilh inscnHbiliiy nf th<i [iiijiil, twitching 

|rfwawrl««.Bra|>i>l fai-bii- piil<r, nml aBiihnormiil Icmjirriitiinr. Ailmmvn 

|k«U lo *f>pfv in tbr untie. In nihcr coat*, cicvniioii of lompcmtiirir bits 

[ W H«(«l, vitb Toinitiiig. tiillowcd by iawnsihilitir t»i>l ilralb. Wilh the 

•>f • (cw rrokniinl cAf«s, which must be ntlHbute^ to nn i<lioe3-n- 

tht \imn of tb? pnlicnt, dnni^rous BTmplORis hnve occurr&d only 

' CKrbiilir totioD baa fooml it» way inio tome cavity, as tbo roctum, 

•ram, or |>lfuni. or when Inr^ alwcess-cavitics have be«n wmli«i) 

ibr l*itton. or when it hsa l>M?ti forced into tb« Bpovtis of tbc areolar 

■ in aUrmi<u to •liMnfect <)oe|) noimth or KimiKiunil fm(-lures. Tbc 

■t moiisti ill ntiKiviii^ iniiiH->rinl>']y nil i-nrbolic ai-iil ilrMtitifftt iiuil 

■Mtallap mtntr otbcr iintiAcjnir. Thr imtieiit niuM \te HUpporli'il by Mimit* 

WMttaprciallr brruKlcniiiilic injrctionx of i-thcr ; nnd friciton nf the surface 

: M rmiil-iyti), Ic niiiy bt- givo-n to nllnv ihi* vomiting. Itnnman bM 

■1 the A'lruini>traltoii of nulpbatc of itoila in Mmnll ilcwv, fnv 

Jy nfiMirH. niih ilw bo|M- of converting the carbi»lic neUl iulo lh« 

^ (i4liiiijm «iilph<«-:irlkiliiip. Thb Irratmrni wan fugi^tetl by tho disap- 

MCMM of the ■iilphitt<-« fmtii the urine, irbich i» pneribly <lu« to Ui^ir 

MTOc bt«i rixuitnM^I in thnt way ; the graver syni[iloni» !fU|H-r\'cning when 

Arr wtn rshantliil. and free carbolic acid bccamo present in tbe blood. 

TW4nc ran 'In no harm, and sfaouli) certainly Ik- tried. 

fVWie arid has now been mor« than twenty yean before tbe profeasioii 

aatiaentir, and has derived jtn-ai inif>ortanco from beiu^ tbe a^it 

m1 by Lutrr for his auttaepiie *y«l4;n) of tn-ating woumb. In xpite of 

I tffvta iif I jMr^ biroH'If anfl many other 8ur^iu« to llnd »>iiie cmcient 

Kiwt* «h»t^ ahall ba,' fr«v from ihi- incoavcnicuce!! atteiidinjd; ihi! itw r)!* 

aafciNc aeiil. it still bobb its pln>T ti* tbc most ci>nv<-nii-nl niiti»epti<; for 

tba ^rgfim's hamlx and iiulrnment* and fir washing out tba 




iMMiL Otfavr a|Rnt> havr-. howcvi-r. Uvn largely emplovM as druHOgtt 
aalhan' Wnv provrd to be thon>ii(;hly mmtworthy. 

CU«ri4» «f Zinc — The elScienl •ir'c:iL-th of thi» anliscptic, which is tbo 
•Aft Bumril'* Pliiid. i; doTilxfiil ; biit it probality arts nntisepti- 

■Iv ' ■ -ngth of atiout half a grain to the ounc* ol wat«r, or even 

h» lia oar la tbe trr.itmcnt of woumlt was intrcxliicrd by Campbell de 
Masa mirr tban twenty ycarv ai;o. Il is iienally eniployc<l in tbe Bt(va){th 
•i itoVf fraiof to tbr ounce of n-aler. Thin solution nroduces a wbil«n- 
•( V ib<- Mirbv-. Knt tbe adion i» vt<ry sujierficial. ana it docs not cause 
ikr t«ikalt-iii xf a vi'ililir »louc;h unleM aiiplieil for some length of lim«: iu 
WurTW in thin *trrnii<h, it iiua> not prevent uuion by 6Kt intention. The 
•tsiattl tar&rr ha* brrn shown by ex|>erimenl tu form a remarkably effi- 
(>« faarrUr to Ibr abaDrjtlion of the rhemienl jiroducts of putrefaction, and 
ipmnoe pnim that decoRi]insii)on of the divchargea will not coninience 
«a*Mmd thus tttat^ tor alxMit three dayx. It ibcrvfore fortof a inurl 
I afflit»tioa to woanitt in which it i> iiiiiH«»ible to employ rigid antl- 
ttnalnral, ■Orb a- ihiau- op'ning into tbe nionth, rectum, or madder; 
irhr tW third day, when iU infliienco •e«ins to W cxhauntcil, the o|>rne<l 
IIVfMfHBM anrn Car r]n«nl by plnMio esudntton thai lbt> <langvnF<>rB'i>iic 
■Mifbta an |(ml)y diniininbol It has no loxk vflecta when Uius applM-'l, 
M tw M U il br taken in iising il, if a ayriug« bo empJoydl to iV|uirt the 




£14 



LOCAL OISTURBAirOES AND INrLAHMATIUK. 



lotion itilu iKl- wnuiiil that i)m> vpiin* of areolw- liania uv tutf injected, 
sfrioiu (ini! r\U'iinvr •loiiKbiiiK inity mmlt. 

Boraoic Acid wu intr(Mriirr<) inio xurgirnl i>rvlic« bv LJalKr. It u onaaf 
Uiv l»» j>iin'<Tlul, iin<l nl tb<' Minr tiin«' nuv of ihe Irsnt irriUitine of cbrmlokl 
nniiseptiCB. It it very rcsdily »olul>lc in hiA nntrr, Uul npnringly «> in mU. 
Th« cODO0nlntt«d coM rnliitioo or "horafif nri/l lotion." if )>n-|nT\-<l >>) mldiat 
ooe ounce of the cryatalliied scid to ii ]>int of tioilinK miler, aiiil nlWrwwil* 
ftllovrinK it to cool iin<I the excess of (lie cry^Uitfi to ettlie itown ; tl form* n ii»r- 
Alt lotion lor wai'Iiinc or irrigaiiDg woiindft. liofirif arid lini, whtcli i» pre 
IMrei) b_v ilippini; orrlinarf lint in » eoDceniroU'il tM-ilin^ foluti^m of ihr lu-iJ 
Bntlallc'rwurit.Nilrjinh'il.l'urniaauBcfiil sj>j>1icaiiiiii lomodniltior KnuiuUliiHT 
«)K« ; and, it' moi^iciiei) vrttb warm Ituracic acid lotion, may W aptilii-d «itD 
gnat advantaoe in tli« place of a |Kiuliice tu alotigtiy ami iiilliicixd wouud*. 
BorMie aeid otiiJuimf funnti an excellent drewiDg fur iimall noiiiida, Mieli a* 
thuM.' oil the fiice find for bcalthy jjranulutiiif; *urn>. Tlie lottrt oonvriiirai 
lurroixa progmration vonipO(^nlorone|iarlur|iaraflinaiid two pari* «fvaM>liae 
Of n tiMiii, to live |iarl»oriihii:Ji iti addiM] one piirl of Kiraric ncid. It thiiulil 
be epri-ad on thin niutiUn, and dipped in tlio Ixiracic acid lotion Wfore l«ciD|{ 
nppm-d, ntlcr nbich it may be covered niUi cotton- wool, and allowi^I to dr;. 
It r«|iiirc« cbiingiiig onir or twice n day. KitrfT hut rctNtraiui-ndnl a clirnii- 
cal conihinalion of glycerine iind Iwiraoie ncid. to which he hoM L'iveii ibv 
name of IJoroglynride, nx a lotion for nuuode ati<l tont. and tti»c ulio 
htlte iuc<l it re|>ort favorably of it : but, prohabljr< oqually pood rt«iill« can 
b« nbtaiiKil by adding foinc glycerine to inc unlinary bomcie lotiixi. 

8*Ueylic Acid is a derivnlive of carbolic acid, aiia is lar]>ely iiwd a« an 
antiseptic. It pocaeaeea uu toxic propertice, and in this ree|ie«-t j^inM'nl* 
advaiiiagea over carbolic acid. It is aparinfrly aoluble in water, niiiiiriu;: at 
Ifwt :iOO parla of cold water to diivatvc it, and is iu thin form a im i-rrtain 
aDti#e])lie, though Icm irriuttin^, than carbolic acid. The jitvpunitions utcii 
in Mirgery are talityttp wool, raticytie jiilr, nud «i/i>_v''c "^t. Tbi- jmr '» 
racMnnteiided by Thien'eh a« iH-ing mure alworbcnl ; th« *ilk it ]>nfand 
frnni refiwpc material, and ww i»tnHluo<d by McCtill, of I>^U; it ia very,. 
alM>orbcnt and eini'tic. All thme preparntionf contain a |im|)i>rtion of tboj 
aciil varying from 3 to 10 per cent. They should bo inni«trDcil with m littla 
Itlyoorine to prevent tbo dual of the aetd from Hying about wbrn (bey are 
used, as it eanwa viulenl loeoziiig. Kalicylic acid in ralutlnn shouM ni4 l>v 
ueeil for ini>lnintcnis, ai it cornHles them 'juiekly. 

Sulphuroui Aeid is but little uttei) na an antiseptic on account of ita «X' 
trciu«ly Huptcocant smell. It is very irritaliug, and prcaenis no advaniagva 
over thoae already mcMtioned. 

Iodine is one of lb« m<«t iiowerful of all antiaeplio. It has Imh-d rreoot' 
iiM'ndeil l>y llryaut as a lotion for washing wounds nml s)»ini,'ns in tb« 
Ktn-n^ih ff two dracbius of the tincture to a i>ini of wami wati-r. and in 
(bin xin-ngth it i* an cliicivnt antiseptic, and very frev from irritaiinn 
priHiorties. 

SacalypttiB Oil ia a pnw«rfbl antiM-ptic, baving a very IVagrant mmpbDr- 
nosnua (nwtl : and, ao Far in i.-i at iirtwnt known,lt i» onite frrv from (tniaBA* ■ 
oiM properiii* It i» practically insoluble in water, mit readily unluble iu ■ 
oil. |>araflin, and njiirit. It in tmni ebiefly a« rtifnlmJuJi ynute. 'flw material 
with which the ^.tnute U impregnated i* cin))u»e<) of throe mrU I>ainDwr 
r4«in, ibrM i*tU pamrtio wax. and one part eucalyptus oil. Lister bax lunl 
this |>re|iaration exlciuively, and finds it in every way an ellirtent lulwtitnlr ■ 
for the mrlwdic gauv in eaara in whieb the (uitienl shows si|,in of rarlxilic I 
acid poisoning, or whri) the skin is easily irrilaleil by that snlwlance. Fori 
npjdicalion to graniilaling sores an oinltnent eomjMMv) of two parts id'tiarmilin, ■ 



AVTISKPTirS — PERHANOAXATR OT POTASH. 



216 



nail twritov. asil mror«uc«]irptu«oil will be r»und very lueAil. If ll 
t b Iml, aamw iidolbrRi miiy m added in the |trop»rtio« of one dracli 



Mlfe 



Ibe 
m 



I b ma uiliMpllc uf uudoulx^il paviT whi<'h hii* InU-Iv Im-ii unliI 
*« Itfpty t" •MfpoJ practiou II i« «old in iwn foniw — th<- jirtripitotoil. 
flM ii wu vstnowtjr flo* y«lli>w nowiliT. niid l)ir rr>-»tnllino. ronipoiwl of 
tepUfS-^lknr cf^vula. Tho latter i<lii>uld nlwuy* bo uwd in uounib or 
«i>«i«mn», H thr finely iliriiliil )inr(iclc« of tbe precipitntcl fnrfn are 
miwIUt alMorlml, I»>ltir«rni is inwilubit- in wat^r but k rcxdilv soliiblv 
• (UaoAtra sad ^hcr, «pimnf;lr so in nlcohol, nnd very freo^y in oil. 
Ikfwparati'wv iK^I in Surgery arc llio pure drug io crystals ; iiMhform 
^^ pn|«tnJ by imprvpiiitin^' rotton-nool, iIcprivMl of its grease so lu tu 
rmin it al»orfornt. oith ten p«r M>nl. of lite drii)f ; aod iodofarm m'n/in^nf, 
—^fcywixtny Tarring propofiioiawf the cni'alals. from one dracbni upwards, 
•iik w« <MitK<e itf vawline. Tlie [Mire iodoforin is a]iecially applit-able tn 
•Mmtf oMatM tavt eavitiei, «udi as tboec Icll by re^Kl^-nl of tne touipxi 
««ffvrMw. Ii may lietpriakled on tbe raw surfiMW tn-ioe a day. aiid 
•H abdlalfly nrvwtit any unplcanuit arooll. Tbe rivrmann have um>i| it 



k at aa applicmtiuo tlirvctlv In the raw *urfact« of frtfsh nutiDd* licforf 
<!■■{ dMn. and It ha* been idund not to prvv«nt union by lim inti-ntion : 
hMiboft-' ' IV is ni>l to bo recomni^iiKled, as it n a iiccdlcMintroduc- 

riMtTai <ix. 

IcdoCma (hmmmm nry miirkeit |i>xii' propertK^, bnt tlMteflect ptiHliici-il 
^mm ta dnend u a grvat rxl<-iit ii|iun kd idiwyncrasy on tbe part of ike 
fMML Tbr inrmi>t«RM nf iodoform poiniiiiig are rery various, and dilTi-r 
i^i»abil m cKtMrvo and adiilla, Amongat the DMst marked elfcctji has 
I kvB as Hrvaiimi of temperature reaching 1<V4° P., vilhout other serious 
wtilMtijual diniiiftHtiKi-. mid nilhoiit iiuy uuhcaltbv appearaneva in lh« 
««a4. L«M> of D|i|wtitc vitti pmKretttive vmneiiitioii in t-ommnn, tbe palieiit 
— y Uiatajf that rvrrj-thiiiic ta*U* and nmdln of i<»l»fiirm. Vomiting. 
y^rtwr, m am a frnjumt (ymptom. Tlif eHW-t uu the puW in •ifU-ti very 

S' — ■ nnlly in I'liildnii : ihi' frwiopncy i* groaily iurmtinil, rwichtng 
-<>, andnt the mnic tiino tlu' foree is cnrm'i'oiidingly <linii»> 
lu rnecU on iIk' brain arr- oftpn ven' wrioiis : in some luiiilt* it 
I 



I have auiM<l au attack of vinlmt innoiitcal itclirium. in othorv pt-r- 






iM-r 

dmniBMi baa bwa notnl, with ^ruii nicntul (kpmsion. In children 

■ ia BWif* mmnKai, and occacionnlly the aynptoms niav elosa-ly 

ibtMr -. idnr tiM-nin^'itis. In other caaea rapid cofliitM- hni' 

tbe I' f'lrm, for which no cause but iIk dniK could lie 

3lany TaIiiI oauu-8 have <iceurr<?il in iicrninny. but ibe <|tiuntilies 

havr brrn in siinie i-aset^ so enonnous that lhi.4 i<^ scarcely to be won- 

BL A* an <<vtrrnnl drwainjc to a wnind, the eilgi.'H of which have 

hi arctimirlr in contact, it has never lieen knum n to i-ause |>(>iM>if 

I wben apnllMl an the raw xurface lell by ii larjfe bum it may 

i» aotw (>r tdr ab<ive-incnti<ini>i) *ym\H'iin». The uHn<'. in all maea 



,r 



iIIt K 



ft* Imi'r fuiind to contain imline. The ireniincnt 
..»lc BDil coniplele renwvnl of ihe dnig, which will 
lit ■fH'i'ily diMpjHiiranee of the *ynifi(i)niii. 
'' ^Uah, a lolutioii of which form* "<%indy*ii fluid," is a 
iB»nt. It fmmvtmr* very artivc power? a* n ilininlV-rtanl. 
i!i.' ■liii'lfirf di-i-i'nijHwni; matter evwn when used in vrrj- ifilulc 
In stmnger Miluiions ii i* a powtribl antist-jilic. 'lisiMving the 
"^bhl mn of ibr ■piirc-lH^riiii; liacilli, but in onkr Vi do thin iti> ftrcriL'th 
■mIvmcIi that it oHild hardlv tie itM<l on living tianur*. It fonns a 
liw ftwit wiinmb ; 1)Ul If ntwl in sutltitU'nt strenf^h ti) exert 



pwartiil ■ 




S16 



LOCAL DISTDHHANCRS AMD t.f fLAHM ATIO!C. 



Tvallr pu«u-rul aiiliMfitic iiiDti«nce, it aUiiu everTtliinj; with whith It r 
ill i?riiitnt.'t n dark brown. Il poaMSwe prnclicall)' uu tosic propertint. 

Bsuoio Acid poeWHeti cxlreniely puwerfiil anlifepCJc propprlics, twt liu 
not been uttetl ptira in t)ie trentinoBt of ivoiiDdii. It roniiH aii iniixirtant nti- 
stilut'Ut of (.'oiuimuntl TIdcIuk of UeiizAiin, Friar's RalMiu, »r W(iud<I Bal- 
■BID, whirh waH formerlj exloutitvel^' eiiiploveil b» s» external applicaiion im 
w»iiii<l>, and is alill someliinea applied to c<>iU|HMiud fmi-tum. 

Tarpentiiw wil>. iii former tirueo, ii muntitiioiit of alitiovt nit imlvoa fm 
W(Kllld^ and dixibtle:* did nxoolieiil wirvicR m nn nutii^fttic. At tli^ imwU 
lime it i« Mcnrix'lr t-ti-T iiMBd. A hi|;1dy n-fiiMil fnriii ut imld under tliv DAIDc 
of UrrbfUF, wbii'li, diwiilvrd in olivir nil in tlic ])ro]M>rtiuu of 1 in '>, forma a 
ii»'rii] dr<'-«iiij;. 

Thymol U tlie aromatic prin(!i{il« of tliyine. It u Mid tn br an effieiiU 
anlm'j)ti<' if di»<ilv<il in wiiti-r in tbi- proporlion of 1 io 1000. It i* bat 
lilllr irritiiling and in tnH poivnnou*: l>nt il preecnts fcK otii«r iKlvuntofiai, 
and U nindv ii«(il except for wa«biii^ otit n mviljr, as the rvctuiii, from 
u'liirh curlmlie acid might Iw tilieurbed in daOf^riHiF (juanlititw if injc«1«l. 

Olyeerloe ihhmvw* iledilm) aiitiMptic properiip«, but its effii-iviit Hlreajftk 
JH iiHccrinin. 1 1 is chieflir ttcefiil aa an addition to boraetc or carbolic lutiuna 
U> [irevent tbeiii IVum drvinj; too quickly. 

Alooliel.— Tlic nutiaeplie properties of alonliol arc too mil known 1^ ?*■ 
qnire ownlioii. It \h »uid to be efficient in tlie dtrenifth of one (muI in HAj 
nf water, or. roui,-hly, one ounce of pnMf-siMrit tn n pint of iniler. It i» 
l>ut little lued in surgery oa an nntidcjtiic. Imviiuw.' nl ii» i'vapi>nttint( too 
rapidly, liMl it may be employed ao ii nnuli fiir woundi or for Uw liantU ami 
inotriintODttf if none mure eificiwil ■!< iit hutid. 

Aniongxt llie ramit [xiwerfiil mean* of pn-vi-nting inflammation i> llw fitw 
application of Mid. Tliix cauwa ci>ntr»ction of lh« vnarls and limila exu- 
dation, thus prvvetilini: Icnxion and saellin^. The cold sbould not, howrvrr, 
1)0 80 intense a* kHounv Io lower the vitality of the injured jKtrt. »r it may 
CMIM iho very niiiK'hief il i» intended to prevent. Itn appli<'nti<-ii imisl, 
noKOTcr, be touliiitwttM till ilic dan);erof inflamniatimt ta |><^ for if a)i[>linl 
iu an interniitleiit nianner, the [lerioiU of Ityixriemia which ticeur >n th« 
luterfak bclneen the cold applications iiwlo Hhaievi-r ]{ood may have been 
done duriuK the time thai the p«rt has been really cooled. Il' llie injury 
be tunerfii-ial. and nut vcri- «evere, liut dip)ioI iu cold nater, fmiurntly tr- 
iHwvi], may be anplied ; or, if the akin be unbroken, an evap»ratin); Uitinn 
may be uned. Should a linib or joint be aeverely injured, eoUl 



will be a tireferablc inotlc of r^ueiuft il» tcnifN-ratun;. 
tlv 



irriiTBtiiin 
Tbu may tni«t 
c<Miveniently lie done by smjiendin); over tJw ]iart a lar)^- widi'-moutiin't 
bottle full of water, tn which a few pi<<eai of ice may, if nvMwtary, Iw put; 
one end of a Acin uf e>iU<>ii. well welted, if tlicn allowr<) to hang in ihr 
water, wbiixt ihr oiIht rnd in broujfht over tin- oidc of the bottle. Thio, 
aetiiii; a» n »ij>bou, cauoci a continual dropping upon the |>art to which th« 
cold IS to be ap[iliril (^Ftg. 85). 

Iltll the direri application of pdumled ice in a bladder or thin rubber lia^ 
b tlw mo«t etlW-tiial hicmim of applying cold, when it is intended tltat It* 
eficctfl ahould |ien<'trate dri-ply, as in an injurtd j<-tni, Fpine, or head. M 

AnotJter very rffieieiit niode nf ajiplyini; t>>ld b tn surround the part with | 
a oolJ of India-rubU-r tubing througli which a stream of iced water ia al- 
lowed slowly In flow fnitn a r<»«nroir placed abovo tlie be<t. Tlii* metliml 
wan inlroduivil by <>lt« a» a mode of applyins rold to tliv grnilal oqfant, J 
nnd for thn i>or|HiM> il is very cffirienl. When npniini Ui lh>' hem I or a ' 
limb, the weii'lit of the iiarl is a]>l to eonipmvi the ttiV and nrn^t the lliiw. 
To (ivcraoine tliia ilimeully. iIh- ap|iantUis known a* "Leit«r'a tnlwi," moida 



A 



TKCATUXXT OP AOUTK INPI.A U U ATIOK. 



217 



IWal MUl wbich c&n be nfcurntelr Biifiliet) tu noy |inn of l]ie Itualy, bu 

. Iiul; AtludiKwI. In mini; tl<» Ui« wnUr miKt not be ice>l, an lli« 

nadacting pmrr uf tbe mpinl ri-iii)<-ra thin not only unufH-cMsry 



Ct 



Tl» M y K ali w irf" ■ mltl Lead Lotion ncta h ■ powcrrul l<wnl MxUtiTc, 
MjMifmuly (>i rmlrain 1>k-uI inflAiinnatinii. 

AMM nst i^r itii- tHin> in an <-Nu-ntial I'li'iuirnt in lh4i prpvrntitc trmi- 
aMt/klaMtaauMi. Rntaato movv^iiH'nt or itw i« im]>i-nttiv<* ; an in- 




n|. M trrlgatlmf Ap|i*rBliu. 

1 WM abaald br |ilac«i] no a fpliot, aD iDJnrpd ere Bhonbl be prolpctetl 

jIi tW MiiK- linir all mn.ititiilinnal tlulurliaiiw must Im- (in^vf^ntofl by n 
Mfctair miwl w>OI-«-bnani diet, by a n-]>«e ol' IwMly, by rtrgxAation of the 
aelM ^ thw ImtrrK aoil bv carpful aU4>niiun lo tho hj'gieDic iiurrutiu<lin)ia 
^ li* puWnL 

la BMlrttakioic the Citntire Treftttnent at inrtammalinD. tlic ■SurgOD 
^M »4 out allitw liiniM-ll' tn bi- liil nway br l])c iuim« uf thf afli-cliuii with 
vlaik bv b*> III 'In, hill lir niUHt Ih- iiillii''n€i.il in ihc in<w» ihal hv n<lo|>|]i, 
^ iW o«MtilulJ< •nal eoodttion or the jialicnl, by t\w tyf^x- <>f tht- inllnmma- 
»*^ifc««f. awl by iheatatenfthir <n«rtwiHl [mrl, fur nf-tf>iii(j [in-wnis i;rratoir 
WM^thmo the tnanagrmriil nf the inHmnninlory pnM^-t^ in diAVrcnl cim- 
4kMa gf the palii^t. nnd in tb? ditfi'mit tyjHw an<l ]>haM» of the dicriuN^. 
Vt*WI amvT rtsiiler the tmlinont of aciilr inAaniRiatiun as it is 

^ammfmaml b^ i>ic arul ilie asthenic I'onn if inflamiDatorr fovcr. 

^^^^haTxerr nr A<:i tk l\hLAU>4tTM\ with Kkvek or nii: SriiKMr 
^^P^^^Ib the Uralinciit uf ibis v*ri<--ly active and uicTpelic moasur^ti miiM 
^Hm W had neaunf to, tspeeially if the imiicni be yoitoc aiid Mronti- 
BtW* b »■• •iindiiton that ii more uitdir tlic coutrul of the Sufki-uu tban 
te«Wn 1) a bi-alilty n'luirttitiixi, and none in wbich n>oTe can 

^4i«> b; — infan* rorly iinj>loyr<l. It in coaK<iuently of tlM fint 
that {>rm'>i» linHt 1>o not Imt )iy tlx.- eitiployutvni of ioefliciient 
: othmtiar, iiupiirtnnt limil ubaRga and irremovable alteratiom 
an may vti«Uf. It ■> aIhi uf great conM()uence to rvmore the 
blly: iKrt nqily !■• ■uIkIi)*, but to eatingutth U, kst it dr)(CiH-nil« 
w^ *^0 tit ike n*on- rlirnnir and intnirtable fornw. 

tW Knt ibinc to be ail«ndnl to in tbi- in'alnwiit of tbi*. and of all tli« 
«te tarirticB of iuflamMntiiMi, i* the rrmtmti of thr eatite. Thun, ml naM 





218 



LOCAL DISTlinBASCES AKP IVrLAHIf ATIOX. 



be allunled t'> a iliseaMsl Joint, light withheld from su joAiiuhI vff, bdiI » 
Ibreixn body taken out of the AmIi in which it m to(lge<l. 

Tile DPSt i^Teat indicaiioii U to lessen tlie delernii nation af liltind to (h* 
{■art, and ttie blood- preaw re iii the dutended veMelH. The nteuum fur 
acooiupliahiuft thia form wbut baa l>ee» termed tbe anllphloyitlie fmi/jnnl 
ThiH i>jii.->i£i^ of i-KiiMitiiiional nud luoni iiieuii. 

Coutitotional TTeatineiit.^Tbe obtMa aimed nt in miiitttutioiiHl BBli> 
|>hl<>);i»tii' iriiitiiK'iil. i>> lo IcMM'n iHk l)lo(Hl-|ir»aurt' in ibc inllanied |>iin hf 
mean* wliicli iiriilvin the litrt-t' of tlir bciir('!> aclion, or iliniinivb iIh' nmiHinl 
of III (II II I p'lii'i'.'iUv t.hniDfiboiit lb<> ImhIit. It i* eviilent thnt it i* odIt ii 

GittiMita nhu liiivi- lii'f It in ^loil hniltb itud Klrt>iie Wfun- tti<^ iiiviuion of lli 
6niiimiuioa, Hii'I viho have n<il Iwvn wfiikeiif^ l>v it, and in \<>uuf • 
niiildli'-ii),'iil dubjccis, that i-nch trviitiDMit can hv Ju«titi)d>lf. Many fon 
of inDnniriiali'in, as cr]rei|M-las, and all ntlier infective procvetu, arc froi 
Ibc nature nf ihvir ciiii»c deprtMini; in thctowlvM ; and in thete •{^tirr aati 
pblngiBtic treHinicnl it seldom if ever rdjuim). 

The Rio&t ^verlul and efficient nieniu thnt we po oKga tt r^ainlj- Blood 
letting ; and, wben llie inHanimAlion is sufficicnlly eslentivfl and scvtr*. ■ 
Ibe stale of the (laticiit'a powers warrant it, wc may have reexuno to 0» 
Abstraction >>f blood. Hut, as blood on eaiuly b« taken away, Imt can 
readily tw rt-alorcd, we should never rermwe it nuiiecntMril)', l<«t pcmuuii 
lll-efr<>ct* III th(^ health oiimiv. Hluodtetlin^ is et'Ttninly cot ntiftt rvquii 
in the tnuitini-nt uf Hurgicnl intlaDiroatiuiis ; and it nliould Imi cmfaiatilj 
aroidcvl in very younji and in very iild MiliJH'tH, in thi* tnhalttlanis of lux* 
btwnt generally, ainl in |H.TKin» who are nufll-ring fmni iuflainnmtion <'r 
RpeHftc ckanicUT. It should uuver Ih- ■•mplovcil unlirsv nn myiin of i* 
iRiiinrtan<i' lo the er^tiomy, and hdc in which abiindnnt rxuilation i* likfl 
lo iKi fiilloHod by H-rioiis or fatal conAetiucnciti, as the Unifi (ir brain, 
inHamed, or *•• injured that inllamnitttion in imminent : or unliv«t n timii 
like the Irantpnrcnt etnicture of the eye, be nlferled, in «ht<'h rnM- it 
abaolut«lr neceaMiy, al any risk, to limit exudatinn h-si it tl'tvi- riM- lu 
ohaD)^ of atruclure, which, howevi^r sli^dit, wouhl lie fatal tii the tiiility < 
the part. I1ic '{usntiiy of blood that dhould )k> taken m-c<warilr vari 
Xroatly, acconlini; lo ihe at;e and cuiisiilntion of tin' |int»<'nt, aixl tb'- untu 
of his diwnse ; ami it is of importnnrr t" bear in mind ibnl, wln-n bl 
leltiuK b really re(|iiired. the svstvm tolerates lbi> [nm of ibr vilal fluid mur 
better than at oiber linim. l'h<> HR^ iimdnri'd mi th« pulw awt (iii th 
syMem sliould be the miide In the i(Uiin{ity to b<> ukiti nw-ay. A di-<-><l< 
IiD|inwii>ii ■bould Ih> |ir<Hluc<il by bluml letting, not so much on the frnguenR 
of ibc piiliH.', as on iln chanicti.'r ; Ihnt should );uid« iIk, and not tbi' iminl 
of imnn-s ilriiwn. Th*' jwiint t*" be oblaiDcd m the greatwt eflU-l u|»m ih 
nslcm with lh<' Icoxl I<«m to tbi' |>ati<-nt: lienco the btonl «hi>idd Ih- tjik 
froin a lart^' <inli<v, the iMtienl Killing ii|>ri);bL In iv|>caliug the vcnrt* 
lion, wc iiiiiKt lie i:itidi-(l by llur impraoion that biu lic^n niudi- ii|»n ih 
tlbease, ami by tb<' HUite of ihc j>u\tv. In forincr limes, bh-kileiiiii); w 
nnwiimiii prnrliovil from the teninnral nrlery, and the external juicul: 
VDin: hat in the prfw^til day, blooil is tcarccly ever taken fn^m any t 
but the mnliiui ba»i1ic vein at Ihe liend of the elbow. The openitixM is ih 
iK-rforinod : titu paiicnt lieini; in a aittinK jwoture, a tape or a pi<>or 
uandap." is iMXinii mnnd the arm about midway lietween lbe«h»ut<ler ai 
the elbow, witli sufficient firmucM to olwtruct tW n-Inrn of blu(Hl thritii-h lb 
vpiiis, and yei mrt to inli-rfere with the flow ihrouKh the artrry. When tb 
limb Im'Iow the liandaire is fuUv distonded will) blood, thr o|iprator m<1<>0| 
the niwi |)r»miiient vein at tKo bend of tbo elltow, wbii-h will alqin 
Invariatdy bo tlie laolUn liaeilte, and onmprtwa it with his thumb 




COyttlTOTlOXAl. TBIATMRNT OP tNFLAUHATION. 219 

# 

pal II MA it u iotMidetl tu open it ; tiiia xt-n-tn tlie iluuhit' (larfxMe 
ti mtifJBt tha *Hd. »aA pr«ventinic s preiuniure i»cape of IiIoihI. Ho 
tin ul« uv tancrt. or nov >it)ier ^inall. slmrp-uuiuKHl, rutting imtruniput 
rfmiMtvt bf niit Bl liuid, and, liuMing it liy llii- liladc Wlwccn the fore» 
bprMJ ibonib. while li« :tt>nuliiv )ii« limit) by rwtiiiK tlic nthi-r fingrn on 
t» urn lat iW pfttirDt, be ilividM tlie nkin iind opi-fi.i the vnwd by ft Mnel<i 
■MM fthMt oatHlilrd or an inch iu li-nKth, rurnLtl ublicjULdy aorofli ln« 
iMtad dirtdlDg ito ontfrior «ull. He ibvn tukn ■ gnutuaii-d v«Mel, and, 
hUag h in mtth s |u>ition u to cjiuh Ibi- blood, hf ivtnovav hia thumb 
^m l£c rcio, aiwl allnv^ the {mper anxnini to tvmpi'. During i]\f uptrft- 
b« tW |MLtiMit (Im'uIiI hold aoino rotiiid body i» hi# hand, wliich h« can 

C Italy ftt iatmraln. by which riM-iitii> the LIikm) Irirni Ihc d<f|i vriiis i» 
. g«t CKmb waongM lln> mitu.'Ic)' itilu ttic iixilian by th<- cuniiuunicsling 
kiatk «hirb «iitvn it just Iwfora iu hilVireuiiuii. Aa mod w a wHii^ieiii 
fMMMy ckf UomI ifl dniKii, iIm- coiuirit-ting btiiid nn the orm is relaxed ; n 
mi «f tint M appltol over the iround, and secured bv a leir turns of a 
^UjpfV'oM hftmlaiie. Tlieouty accident that can impiien duriiiK the opcralioD 
^^p I tnnd of ibr brachial artery, nhii'h usuailv lies im mediate! v beneath the 
^^•dia»-ba«lic vtia at*i the point selei-ted fur bleeding. Thiif is avoitted by 
Mfiftf; tl>c blada of tb« lancet short and finnlv, and 9up|M)nin]|; the hncka of 
A* thm itiBvr fiag^n on tlie julieut's ariii ; while by a luoveinent of cxt«n- 
«M«r tb« wfiM. llie point of die iiutruiuvnl in luade Iu muve Ju a acKOH-nt 
</acsfcW, aiMJ •oloofM-D th« proniineiit vtiii miihout uuy rink or |K-nnral' 
■f ■(«* ^ntily than ■■ inifnd«d. If from itiadvfrl«ucy ilic giaiieiit Iv bled 

• ika rocuatD' ' ri.n Kn-ali-r <(uanlily nf bhuHl nay he rviaovcl than 
■ ian—liil bcl :'i t'l un l)ii- |>u1h- in pn-iluci-d. 

MtaiUag fnitii il.v valvroal juuulnr vrii) iihutild lu-ver Im pi-riormi^l, aa it 

• Mm^iajiMHl by thr dangvr of i-iiininc>- of air. and ihc effect produceil 
4ttaM ia du r«a[K<ct fn>iii that of bliiiling from the arm. 

VWtkvr bliHallrtlini; he priicti'4'<I <>r not, we niuxt endeavor b> set the 

M fttv, and in this way to clear the bhioil i>l' (he morbid pr<>tbtcts 

itatiil ii> ii ir ni- can brinj; aliont a full action of the liver, nilh 

)i» from tlw howelti or nn abundant nctd |icr(t{^ ration 

,.i.>usdif>ehar^ of urine, wc shall diminiiih tlie iiiiMli- 

I'uncf a»d niili),iite, if not cut rhurl. lliv local procoi. With 

rt«a .•„j.-i~ >u view, pur){suv-v«, diaphoretics, and diurctici are in lie 

iJ»iaii»<iiiil. 

TUfatiTM. by cauainio; dilatation of the vesacis of Uw ulinwrnnry cnnni, 

tfae hbux^pmwum in olher part<^ and tht* HR'ct in alii) further 

)d by ihr dimiBiltion thi'V etiuite in iho grnnti nuua of ihr i-trrnhitin|! 

MorraTer, they rloar iho inn-Minal caiud, UmI thu« favor ili;:in<lii<n 

ilfttitia of fiHul, Fmin the fnijuiiicy with wbirb iliarrtiiMi in 

with unhmllhy inllanuniitnry iimenvK* it fcenn pmlxible tlmi the 

net form* an iaipiirtuit chanitcl for Ibi- i-liminnlion nf tin- prolucl* 

jtanmalJun* front tbc blooi), and the m-nwilv nl nuiiriininini.' a 

of the boweb would thu* Ix- >'XpIiiiuc<l. V.i|M-ricncc tcachiii 

•aabitlM in inflainmatoty aHtyctioM (»>n>iti|>nli<>u idwat> a^'tTavnKi; lh<> 

i^vtitm >4 lenfianilurv, and a Itrink pnrpiiivc will nIVn brinj; it downnoo 

* 1«« Aagttam. Tlii* ia cspccinlly the cam- wilh children. I^lrKativM 

"^ *' tiwrrC>ri>, alaayv bc'^ivcn rarly, except in some s[iecial cn^csof lu'uti' 

wf th'- >i'»I.lii:;iih) iir^niris. In i^cnernl, it will lie found nrnet 

toad) iiicmirial, follnucd by a brisk saitno purjire; and 

M h* rr|iritL .u imiv to tinM> durii)); iIk- pr«);m« of the case. 

^■'^li'T and DlapborvUoi an^ of nmrrli um^ wIwii fcwr fnrms n insrltcl 
of like cax, and tboy aboiild then be ailniinistiTCTl frti|uvntly during 




220 



LOCAL niBTCRBAKCES AVI) ISrLAMMATtOX. 



i 



the ilay. Frc« p«r«j)imiun lowcre (he tcmpcrnttiro br tiK-rrving l)>r tnM iif 
bMI from ttie diirfnce of th« Itody uiil t)i« diUution uf the cuUuitou> 
▼OML-h IvimU lo iliniiuish ihe blood -preesti re id inlenml parts. B^itk ihrtkiit 
Hiiil ki<lDe7« also take an im|>orlni)t |>art in tlie pliniinalion of the priHlort* 
of ihe iQor«aM(I tiiuuo-cbniii,'<^ viliii'li furnM an taeential fcaiurr in ibc fcltribi 
procen; an<l. ddUvs bcitli |*rfi>rni llieir rniK-tintm [iropcrly. ihcw- |>ni<l(jrti 
ataf AConmuUu to n (liin^-cnxii extent. The •linptixn-lics nml iliiirrtio lO'M 
Contnoiilr usol are nlnitt^ of iMintli, lU'Clnli- of aiiirDimiii, nml nitrair ff 
pobiah. If llie okin lie liol nml (In-, tininll ■iiiaiilitH's of anlimoiiy ntajr hm 
aihiiinUlorf^l I'itWr in tlic form of' aiitimoninl wion Lxitijxitmt with tho 
mMiK'S hImivi> (ni-riliniu-il. or ii> Jiiniiv'n ponder cumliimil with Ihivcri 
powder. .\iiliii>(inv in iH-jit ).'ivcii in vmnll rr^pcntci) dixuii, biii if il Iw |>u»hnl 
too fur, ^1 lu ti> imliio' iliiiiiiirt nauM:a, ii t-xi-Tt* a ]H>wcrftil dri>Tr««>iii; ariinii 
on the h««rl. amt (.■niMsiucnilr il* cirwU tnutt alwuytt In- mrrluIlT waichi-d. 

Aeonite in rnmll iiow» frrijupiilly rpproifl — imp minim of tlif linctiir* 
every linlf Wir fur four lioiin> nml t^Mi evorr ho«r — fx«rn.-i«» n m<»i nnrktd 
inflrn'Rco im flimplc iiilhiinmat«n- fever with hi^^b temficralitrp, but «tlb no 
vuc-enil voniplirnttonH. It loirera the for^M? and frc<|i)piivy of Uh* puW. and 
|>rcM)uerfl xpi-cily and oopioua snentinK< to Uie iiilinite rrliirf of thr imtivnl. 

In mnnv forrns of acute iuflnmnmliun, (ii|>etially thoec which affvet ih* 
M-rous aud fihri>4i>^ incinbrnnes, we tlo no4 pueacae a more eflii-ifiil iLgvot 
than nereiii7, ndmiuiMtrred nol aa b purgative, bat aa an alionilivt- tn Ihr 
tjttem. And 1 coufe:*' thnt I ciin in n<j wny kivp my adhcreDCt' to ihe ilm^ 
Innea of tl>i«e wbo, dbrexanlinfc ihi- daily rvid«'i)c« of profcntonal cx(>vt- 
eiiec, deny tlie utility >i{ tbe pr('{)Hralii>iui of ihi* niincnd in tlw irealriM-nl 
of rerlatn forms of inMninmat»ry diM-iiH-. Mrrriirinl n niMlim an- nf *(Hf iai 
HTvice iu aidiu)[ thr c)|M'n>lion of other nuilirinr*. Din rr I icy. ilia|tboreti<*, 
and purmtivwi will frrqui-ntly nol act proprrly mjlw coiijiiinril with a mrr- 
cnriiil. In in Hum mat ion. the prepanttioDs of mtn-ury nre of mpaual valor 
in promoting (br idiwrplion of oxudaLion-nialterF, ii# we mny Me bacjirbin^ 
uniW tbrir influence in eerluin di»casM of tlic eye. ('arc. howrvrr. n 
rrt^iiircl in the admini»tnilion of mercury. In irrilablr or eaelH-tic cmirti- 
tutiODS it eliould not be ^tiven at all. or not without Krent raiilion. I( i> brM 
Iwmr by strong cuostitutious, and in acute intlaiuniation of the MDitw asd 
libroiie iimues. 

Calomel, bhie pill, and p-iwder of mercury with ohnllc are the preparatioM 
tutially employed when thf mineral iit i;ii'ei) by the mouth. U heu it h 
admiuistetvil endenaically, iIk- mrreurinl ointment t* prvfrrrcd. The mer- 
cury need uever be puabed to Kdivntion, but in «omc caara it may be pvcn 
until llie (.ninii are flifihllv aHiyi<.-d. M 

It intsjveiully the wni1>inntton "f calomel with opitin iliat pmdurwtbrf 
mod bcti«-ficial elfecl«in the treninirni of active surgical inllnmnuilion. Half 
to one ^rain of ralun>el. and half n L'rain or a grain of ■•jiiuni, or fiv j^^rain* 
of Dover'* ]iowdrr with threat of nH-reurv and ehnlk. every M\th nr i-i^htb 
hour, traiMiuiliie the Hyftem and dimiiii)^ tin- fore>- of ihe lii-url'a afti<>« in 
a rnnarksldo maoiKr, i^fH-rially in nctilc inflammation affecting lliv joiotth M 
lh<> Djo. or iIm) acraui membniniit. 1 

OpiUl i* of iiH- not only in lliv way that has in»t been indieniM, t>ut ia 
ttf MPMitial MTviee in allaying lliv pnin nod irritability thai oflen aert^mpany 
in dam mat ion, ev|wM-in)lv in mnny inllnmmaiorr afl#<etion* of ilif Ixin*-* nnd 
joitila. In the fnrtn of r)ovvr'B powder, il ia of eapceial value in (his rifiiirvt. 
ami in this form, alotK-or rouibined witli Janwi'* imwtler, Il brniR oneoilk* 
moat imwerful diaphorrliiv we jmimipm. 

1'lie hyjHiderntalie injection of morphia, iuvaluabk aa it Is In oaaaginit 




LOCAL TttKATHKNT OF tN-pLAMU ATION. 221 

r 

^m^'m wMotn rv^iiiivtl tn tlii< (n.-Blim'Ul of nt!ulc inflammation. 0]nuni 
hmInmI MiUi t|><M-ii<-uiinliii nml it i{icn.-uriiil U iir«r4.>niltl<-. 

Ift A* triMntrui of m-iitp ittduiuRUitiou, il is of (^to*>Dliul ciiuitetiueticv lliat 
tlafiMM tbuitlil \n- k<'{i( nt n-»l, in aii utniiMpherv uf well-rcKiilniciI lorn- 
fmon, umI on 1i>h iliot ; in fiict. tlio iiiori' L>impltt« tiiv ulwiiutiici* in Uiiit 
li^Ml, iW muft- npidly tin therapeutic ifeDta act, nud llie tehrile iynip- 

Ukm. TbCatiiC5T. — This is uf [li« utmoM iiiij>orUii)i:v, lu il dirrctir 
■fciBW lb« tiiMMB aucl veowls that are ilerauf{i-d m iit-tioo. Il ixiiuuid uf 
mmm <4 tbc lacMt TarinI aoil uppudiie (-Itunioiini. Hwit uid cold ; iced 
■dD tad bv( fMuvnUtiuua ; nuriu^^uuu uiid xnliiciviv — aiw alt oinuloyod, 
miiH mtk wtCBWB. but «ucb uiily in certain Hingm utid fonnii of tlii; di»- 
Mi: aad tkv art nf cunductiDg ihu local IrutUui-iii uf intlitiiiniiiliuii ctiiwiiiti' 
■ aiiftuiX Uia variwu* mnuiii nt our dit>|KMal tu the itarticular coodilioix >if 



Xtiil W aoiletting m ibi.- mi*! •■Ilifii-iit mvitnt wo ixiwrM of diroclly Im- 
mim ibe amnuoi of Moud in nii inH.iiiidl |>nrt. u i>y it in «oin« chjic^ wc 
■k UanJ dinvtly fivoi tbc <Iij>tt'n<)oil nod eRp<r!^o<l vchpI^^ It docs i)»l 



i 

I 



rfa^thA. hiiwcrcr, <|iiilr *o utiiidy lu thi». In no ili»casc is lti« hcnrBt of 
l^faliMdkrtttii£ tD«r<: nmrkc) tbaii in uruto inllinimixliun of til« tDMldlu 
mt.taA y - " ■ (-iu« «i-dmw tin* bloml from ihc mtancons vemck ov«r 
tW^aati' In acute orchilia, relief is often t;ivi>n by puncluring 

ikdiNnW") V iTi* of tin eonMuni. which have no dinx-l conuoclion with 
tWtmUaa ftaatl. In these caats, thf relief id, |>erh»|H. due to s rotlcx con- 
tnOM of tM ari«riw Icadiug Id the iullauiMl juirt. 

LgckI btAMll<ttiRi; inay bv used iu addition uk thonich it it moat ooniRiMtly 
^fluy«il Eo, geuemi )ilu»dleiiiiii{. •-I'In.-cinlly if the inlUtnmn- 

tM W »■' it occur Hi •-iiWr uf the i-xtri-mi'* uf life, in nunxn, 

ui Ei'nrritlly fiivlilf jiuwor. 
nay be uDcini locally by /nuidUret, Karifieatwiu, ur in<i»iaHs. ur by 
I or rvpftintj. 

fUfttiun. MonflcatioM, imd in«UioiU can bn |>nicti]<i-d unly in inflnm- 
artfm uf tbr mtanvuuc nnd i-x(w8Gd mucous Hurfnoitt, duv HUfnlion Iwing 
|ahl Im MitiiMM-iit parts uf imporiauce. Tlii-y c<«nMilutc » very efficient 
Moas uf rMirvtn); thv part, as nut only u bliMHl rcniuved, but an t-xil is 
>fciAid f ' ■'■^"-"1 'i'-<>'r<r>; t«uftioii ia om»«4|ueutiy mnlcriaily lc«9i-ni.il, 
i*l tbr t< : u' ami i>ther evil ulU-r-L-lTi'cld jierhnjis prcvi-ultnl. 

Thi rrni-131 -I till' >>ii> of intliitucd puna is not only of tho K^'^ntcet 

t^naUff Irn-ally, Init is of eoiisidt-rablt' tM>rvicc lo the syMem at larRu hy 
imamiag the {loiii aw] ifuicral irritation thui arv alwavn iH-caniouixl by it. 
should ba ttulu with n fiav laiici'l, in |Kirallel run-A uvt-r the 
•vrHnK, and •houhl not tMccitl a i|iiiirlor of an iuoh iu ilvplh, 
I an iu rraliiy snuill utid vhort imioixun. TIm-'V may l>c made 
tvaidka awl enn}paUd v^ael*, nhicb will hh-i-il frevly, an iu tb« rulief 
tif lh<' lo««r cfdid. A nimtilii-aiiou uf iHiucturc iii *(>inetin>ui 
b]r o|K(liDE the vrink in thr ncighli>irh>H>il of the luflainnl luirl at 
puiats at oik*-. Tim*, in inltatumntion of lli« tcatls, the Khrlnl viiu* 
mn b> ponrUiml oilh ailvanlnKC. 

^hn iaeiaiaiu ir. triiuirvl, Dicy tuu«i alonys bo dhuIo in iho ani* of tlw 
IbskkSiBd *hi- tiTan|:i->l u> io iitll>nl iIm gnaUost iKMsibh- rvlivf tu 

iWtaMt. 1 _-th and ihtir d<'|>th mu«t vary nccordinp tu ihv wot 

^tk iolatumati'-ci. TtuM, in the inl1iiiii> •! ctinjiitictiva ihcy mun, of tvurae, 
*si«tj Itf-'"' -■■■'■- f t >'' "iK^toup intlaniDuilton of a limb they may be 
•f »M ih. Care mutt Iw taken »f far ns [nwiiblp 

■AbVwuB'i •u^vimiai jiiii'Tirs ur VCIDS of SUlHciflDI MIC*' to bicfl daogCT- 





(.OCAt DlitTURnAXClCll AVtt llVrtiH M ATIOS. 



ously. HlMiliiig fram puucturo and ioowiuus may be iticuurageil by warn 
luiuoiitaiioiia. 

L«eohei am uwl'ully a|>|ilie<! to tlve nuiifliburlioMi i>f ialluoKil |>aru. bui 
ahmilil iM bi> nut upuu tue infliiti»eil Hurt'itc-i^ ilieir, ati tbrir bl«» trriutr 
IIktc are certain AituiitiouH in irliich Iti-chcit nhouM not Ik |>Ucc<I, m i/ir«r« 
InrKv tubcutaneuu* v«iii, or in n.-);ii)tia wlivrr llierv in niucli liwar arrular 
Itwue, aa the itcri>tuii) ur vyi-lliU, lot tri)tiblc3u>itiv bviiturrbnuic ur rccbyiataw 
I'Ci'dr. Su, uUii, lliL'y HhmiM luit Ix' ii|i|>lif<) iiviir a niivcilic iili'vr, \v»t lli* 
bitts bci'uiiiv inuctilnli'il by the ■liK'liiirjtr. Tlic bUi'iiiii}: from n bi-cb-biU' 
limy Ik' <-ii<-»iini^*i'<l l)y niiriii imiilliriii^ iir (■XTictiluliuiii liir h>rh' limr afU-r 
llif Diiimul Ua» ilrojiiiol oH'. In lhi» wiiy. Cruin hiilf nii imni-c (<> nn ouiiw uf 
blinnl may be laki-ii by cacb invh. 'HKn- is iiMinlly m- iblliailiy in nrrwtinp 
tUt' lu*m<irrli(i;;i.' fr>tiii l.ln- lilu- ; rbunlil thtn- be iiny iliHicully. otniino**! 
|intt>iirv with ei>ino acriuicl lint, fell, iiinlk'o, or |iuw(lcri.-^l nbim, itill p-orr- 
ally viicL'poil. If tliis liu not, whidt niuy liujijieii in si>itii' i>itiiiiiiiiiiH wli«-n- 
|iri-«einv canuut liu L-oDvenicntly s]>ii]iiil. ait on tlic nct-'k ami r>bilwiH-ii, iwr- 
tic'ulnrly in yutiii(* cbildrvii, u jikc*; «!' uitial* of silver wrajwd tua ixnDt, i>r 
a li4!nti<<l wire. ititroOufwI inUi ibe bile, [ireviiHisIy wi|N.il ilnr, or n iivt^l* 
wiib a ihImi-i] nulutv »vcr am) amiiuil it, may bv rtijuiruil. 

Cupping niiiy be eitlier "w-ei" or "dry;' <lry eti|ii<ttii; miisiala "f ibe 
■lipUi-ation ul' thu cu|i{>ii))t-};liiMea to t)ie skiu witltout RiakiiiK any tirerimi* 
BcantieittiuUH. It it a iiK'iiti.-> nf isiusio); a detuniiiniitinn of bluml to lb» 
Kurttui- li>r tlw |)iir|ui«N^ of diuiiiiinbiii^; the llow to an iiilomid iirt^ati. Thu* 
ill cviijcivtivu of itiv kiilni-vH following iiti oiH'ratJoii on iIm' urelbra or 
l)lii()der,drvcn|i|]ii]g in ibf loius ia oftcii uf iMiisidi'mbli- il>r<. It i« rniiiloyiil 
<9|>vcially in llioRr jMlimto wboM coiiiililutioiiti) ■liito >luiv> tiot juitlifv ibr 
alutrnctioi) of blooil. Thv in»tran>ciit« re<|uired iirc n Kiiiritlitmp with a 
Inri;*.- tlnriw, and tlie anj>niag-gla8M«. ThoM an miidr of tliii-k ^dnw and arr 
(lomo-aliapeil with sniucitlily ];raiiDd ^gea. The o|H-nilinii ron»i»l« mi-relr ft 
mrcfyiiiK the air in the cuppinK-Klaas by nicniid of tbo tlainc uf the aiHrit- 
laiii|i, atid iiutaDtlr applrin;; ihe )(iata firmly and evenly tu the akin. Th** 
iiilenti»ii i* uot t<> neat the kIom but the air contained in il, and in fact la a 
Kfoat oxieiit l» rcidaee the air by the iirodiicta ureunibustion of the Harac of 
tJi« laiori. It is (i>r ihU reoitun that a lur^c tiaiiio complciely filling; the g\tm 
should ito u*e>). If the ojwnitiim l>e properly performetl, the site of ilte s'aM 
will be marked by a hruiM- due tu the rupture of the (.-apillar>' veawla in the 
ar«itiiieluded in the vaouiini. 

lu wet nipping the ^huo is applleid in the Mine way over a niiRibvr of I 
Mlpcrlinnl incuinnM which are iniwk' iiwinnianeoutilr by the " M'ari(imli>r,**| 
nn iiiMrunirnt providrd with a number of |wntl lei kiiiviii warke<l l>y a spring] 
ao<l r<dt>(i]ie(l by a triftger. The ijuanlity of bliHHl exirnetrd i.i rrutilateot by : 
tltu MJU of the gliiM, and Um- flow from itio »ii)H.'rlicinl wound cvomv tli« ' 
moRKtnt it is romuvod. ('iipping eaoi>i>t. however, lio eDi|iloye<l upon ibi: 
inflaniefl niirlaw itself, nti nceonnt of th>' |>a!n nnd irriintion that it woublj 
>*ecm»Kfn. and is cuiiBeaiieiilly ehietly applit-abh- to interiiiil itiflaniiiiatiouiL| 
At Ok Btan made by tno fcariticatoni eontinue through life, cupping ahotild 
not Iw practmd upon cx)>o«eH turfapc*. 

Cnttmg off the Supply of Blood fiiiii) (he intlnnKil part by Iha linture ufi 
the main iirt>-rr leudiii); In il \i*» been adoptol in M>ln^ enata. Tbui, iu 
acute iiilbimui»iii>n of a juini, the main artery of ihr limb ha^N-eti lieil — iIm* 
lemural. fur iiHiauce, in inltammalion of tlie km-e-joiiil. Ity matiy Kur|{vont, , 
Olid by iiKiol jmlirnij, the reii>e<ly wonid Iw eoiisiilereil Ar wurw llinn tlte 
tlbmae for the cure of which it iti proixM'd. 

Vanseili hiu re<-i>m mended <li);itNl )>n«(ture ou the arlcrin in inrtamnH 
tlon. He hni, for iiutance, ndnteil a cii*e »f fevere aeul« inflainmaliun nf 



I 



LOCAL TkBiTUBHT OP IXrLAXll ATIOV, 



22S 



■ft Wad. nlicvvil bv tweHtr-ruur huun' coutiuuuua pitwun; tiu tlit brauliial 
■Ml J- Nrudiirlrr fl[K-qks bixbly uf ibe jiruowdiii);, nhicU ht- ro^-srda as 
wrfaMU^ all iitlHim in i-l&cacy, rcwltinuu vvun iiiiuvci«Miry tbu unliniiry 
■atifbtmtk- irrBinirui. He revointiieiti]» lulttriuilh'Dt |)nwuiv for not Ii-ms 
thas UuMi, Mini ni-t diurc tbiiu vi^bl, luiiiiitm tlinv i>r frnir liiiira n iliiy. Thu 
■MtkMi i> »ft]>lieablc t'> iurtniuiuiition of uuy jiarl uf wliii-b llic uricry b 
«ilU> nscb : uul, Uiijujib nt: luiiy not go w> fur wilb NciiilurlVr n* In ilU]>- 

rilWl it obtialo* all mcmiiy, T-if (<»iii>tiliili<>i)iil tnuiiiKiil, it ii|>|Knni(ii 
Btnartlf prWi'ntbL' in iiukuy cuh-k u< local bk-xllfttiiif,'. 
U UManiJ //nt/ «■' ik«mw Iwu iiiivl iiii|K>rtjmt local tiK-iiiisof aiiiln>l- 
imt isAkmrnaiiuu. Tliry cniitiot, liowcvvr, Iw i'iii|>l<>ytii iii<liscriii)iim(cly. 

OlH iicuf riiliJ ill iIk- ]iri-vcii(ii>i) nf iiiHitiiiiiiiiliou lin» bcru gtln-mly 

Aacr - itii. Wliru iiitliiciiiiiatioii '» I'ttlly tvlitliliglicd wiili tUciinliniil 

mMi^ *if raiaoH. BMclliiig, beat, ami iMiin, vi>bl can NArcoly tw a)ipUul 
dMoir karui ; tw. nhltvugli ii itiay lead tu a dioiiiii»licd Hun of uIimhI 
thr pan by caii«ii)K omintmioa uf tl>e arteries, it l«utb fitill I'urtbcr lo 
ta Lsrf it_' vitaJity <>l* itic niTciti.-*) tinucs. und iJius tu iucreou tli« adbuei4i« 
H , -iiM-lrt ttud (Im- tvianlfttiuii uf iliv llow, till stssis, followred by tleatJi 

P _ ..- "— .y mutL I'uld ^huitld never be b»d iweuunw to wbeii »u|i|iu- 

Mt;- ;; uu urliii9*ct in; Mtill IvM iJiould it be<,'iii|ili>red vrbeii iberu 

• • tcB'Ki)' 1 (<■ iDuriificuliuii. lliv intitletf uf iipplyiug oum bnve already 
ktm icKfitird (|i. 21<i). 

VIns scute iudftiumutiuii ban jMiMd utTuid ibv vtweln nf ibv jmrl n'nutiu 

■luid aDi] tar^Hd, lh<' ni'iilicHtiuu i>f void \* •illvn n )><>iti'rful H^^ut in re- 

Um bMH uf ibf [<nnr. Fur tlii* purfHW; c<tld mll'VraU'r dmivbiug or 

( ■• ilnf niiMt t'Fht'ai'i'iuN. 

bath umI taoiatnre, o>m<>in<.-d. are of tlie utmmt wrvice in ibe tn-nt- 

■M uf indamnniti"!) diirin}; tW bcij;b( of tbnt [iroceM — durini; tbnt [lerioi) 

aha eold ap|ilicAli<>ns nrv Dot a<l[]itNitilt.-. Uy ibcw HWaHB. tei»iou is rc- 

hndtfAMCMi iitraviir^l,iiu<l ihc uvcrHliMciidixl vovels U« relieved. Warm 

mBialiHUi arc ivi-ei-ially <M>rvic«able in all casra of iullutnituilioii ntlemled 

waacfc fmitx, mutv uaMicularly if tbia occur fnitu tenKioti: au<l tbey arc 

^KticvUrly aterul nlirn *ii{>j>urntiuu is ibreutouiu^. or liiu i-»iii<' ou, and in 

aaajF imiu id tihii:b tben b a teiideDcr lu oluUKhiot:- 

Whtat abwoB ihrealuifl, ami the >>l:in b uut bniken, ui^bing nirnnb »u 

wuA ndwT M a mtl-inadt^ liueed-neal poultice. T» ninko Ihin nuiootli 

mJ mA, tha tDeal tnaM be firiidually aibled tu the iimiier nmimnt of botlint; 

Mtt, b>bix ryfon*aiy >lirn,'>l at tliv mnie time. If lite wulcr Iw nditnl to 

lU smI, t£« warn » ap4 to broomc lumpy. It miml W njin-ad, not lua 

*'Aly. to a |i}r«B(if lini-D ra^, anda]>|i|ivl tto but lu ibc {lalivnt cnii Ix-ar it. 

Ilii WlM ti> iMr meal I'ruin v>bii-b tbe oil ban i)»i Ih-ih i-t|imw>e<l. or lu add 

btW iwdiaaiT liiurn] aiwal a Rinidl quautity uf olive i>il, nbicb [uvventji ils 

Irpagaad ttSdkmg UilhvakJn. Bui, nvcful a* priultirraan.- lor tliv rcliif of 

k«B*« pain, or lb)- hartBiiiltg of (upjiunuiou wbcn a|>{ilii-d lo ibf iinbrokcii 

Ibar att> muM tibj«clioti>bIe wbcn a]>|>lici| to a wodiid, ulc«r, or 

aur&ca. Thm tbcy nidretv nns'iinip' putrefaction. In «ueh 

J, ooMUtin); of a doiibU- »r tripli- layer uf lint, ktII makcd 

■ •■WBinlatiiMi uf rarbolic acid, or Ixinicie add lint molBtuictl nilb a 

W atewa «r boracic add, loay be applicil and w>vcre(l br oilcil vilk, 

*i^i£a( baJf ati iacb la no idcb beyon<i it on all aidiv. Thie may bv 

••wwj «ith a Ihiek layer of c«<k>D-«ool wcur«d by a bandacc. By tbfM 

■■w mt obtalD an atiplicntioo Mbicli b cloaoer and lighter than a )>o«ili)co. 

«^ v^Kti rvtair* it* h«ti njually b'nv. 

VwMtaUant of warm «mi<t. or ut decoction of )>oppy aod cbawomila 

>fffli» d by neaiia uf Rannela wrun|t nut of lh«ae liquiik, or of baga 




LOCAL DtSTt'lItlANL-BS AND litrLAU U ATIO.H. 



cuiitjiiiiiuK the Imilul |>luuU, well suakcd iu tlio (leficliixi. »iiu(iicil ou 
ii|i[>lie(l hut, are very iiwful iu oxtcDsive supcrili-iii) intlttnknui lions. Tbe 
(lKunel& nuil htifss ahouM l>« rn^ll covered nitb mImI vilk i>r rul>l>cr d>i(b. m» 
ns U> roUiii iW beat, and bi [ireveDi evaitoratiirti. StmnKiopliiie may 
uac<] M a Hul»tilutc lor urdiiiary ftinicutatiuud. iu omm in nhirb ttt« MiHSw*! 
U unbmken. 

Dry cotlun-wool hvatcd boCore a fire, a]>[die<t imrm. and covvnd with a 
large <tbc«c of oiled xilk, in»y iMjai«tiiii<« i>c roiivrnicntly wbalitiiicd fur a 
ruuiotitiilitiii. Tli« wutci'v vH|x>r giv<,ii uff Tr^ii tbe »liia, Mng vncUmtd bjr 
iho uilcd «lk. furnis m twrt 'it' uiirD* vrtpor iMih fur th<- nlTiH-ii-d jmrt. Drv 
liukl ill (be l\>riii of flaitDol*, »r bngs uf lima huuKvl lMi(iire tlir flrv ur hoUM 
ill nil »ru>. are uflen oiHiTeiiiDDt ap(ilicalions, i«|ir«inlly fur tlie h«wl or 
nbdunMiii. 

TtelUitoaiHi applied extenmllT. exerciMB a very distiii<-t nnd rapitl eoti- 
Irultitif: inflticiKv over Miiierlieial iiiflaiDiiiations uf iiit acuU- and nprvAilinf 
elinnivler. It is Hupp»ied tu act |MrtIy by L-tiiisini; eucilriii.'ti(>fi of ibr niua- 
euliir cuiklfi iif tbe Hiniill nrleriea by its direct uetioti rjii ttiv vaiM>'niuiur 
tiurves, and {Mrtly b}' iu sedative elTeci on tlie cutaiii'i>ii» teamiry urrra^ 
siimultttioQuf wbicli. ait we have liofore secn.caiisea by i«flex octiiHi a dilata- 
tion iif tbe reajeU in tbe areii irritaleil. It ia best applied as a I<aii>t ■'■•o'- 
puaed of CHiuul |wrlA of ilie extract iind uf frlyeeriiie, wbich may Ik- imcanil 
uii tbe iullaiiied pari aud covered by vottoti-wuul, ur bol futueoUittiina lasy 
be |Hii oti over it iriih tbe greatest adrautagv. There ne<e(l l>e »u fear uf 
pnHlut-iu;; svmiHunin of lielladiiiiiui pniitouiux. ewu irbeu largv stirfm-e* an 
[jguiiUil nil)i tbe esrnii't iind glycwrJae. f hiive rrut|ueutly iiainlcd the 
hIioIl- nrni iu (biK way wilhuut iiiiy uupiMUumt ctlWt; ati<I lite moat I have 
ever iit>live>l biu> been ii little ilrymwi of tbe ibnial afb^r it>>nir dnya' uia> uf 
tbe drug. The bcllndoiiiia and ^tyccriiic iiiui't Ix- enrefuUy kr[>4 out uf tht 
way of cbildreD, ii» ita Uule b not oDplfn*:uil, mid they nrv very lik«ly tn | 
L-ttt it by iniituke for ixeaolc. Two sucb <«m?« have brvti lately ndmilttfid 
iiiti> Univertiiv ('<ille];c Hnepitnl. lx>th of which fortunately reiwt-n^l. 

Position anil Rett —Tbe intlaineii part sbould when (NMiible Ik- ptacnl m 
biieh a {Kicitioii as to faciliUttc ihc return of blood (rum it. UlilesA thin be 
dune, tbe jiaiii b greatly inercsivd, and tlie omiitoetian uuKmenled, llenoe : 
llie |)*Tl rei|uire(t to be elevated to a level with, ur above, tbe rvM itf thv 
body. All luotioD and tat- of the {muI tuutit likewite be interdicted, sjmI, if | 
neoconry, rettraiuwl by «plintJt ur othrr appliiiucM. 

Tbcae arc the n>euoi> by wbieh acute, active iullaunuitiuu is nrrmtt'd and 
cured. In their enipluyinent. ire iniiM endi'aviH' lo proiwrtJoti tbe activity 
of our ineiwun^ to tbe tv. eoiiiititution, nml vip)r of^ilw (iiitiriil, »a<l li> 
tho scat and inteiniiiy of the local divcaae: and luU't ix>utiiiuc the tri'ntnn-nt 
until lite inflnninintory jiroonw it uut iiiily nrrcfled, but hait uutirely wbridMl, i 
the imrl bein^ rmtoml w itn onliiiary beallby *tjiti.'. 

Tni:Ar«i:sT ur -ViriTii Im-i.ammatmin nrrrtCoJWtiTiTmxu. STM^nni*' 
OPTlii: A.-^iiKXii, Tvi'»:, — Tbin lorm uf tnHHmnmlion ileriven it* tKiuluui' 
llfn from ibe character of the eiiti»tilutimml di»tiirhancc, rnlhcr limn frun ' 
any |H'<-ul!afity in the local alK-ction. Ilt-nw it ia in the manaBvntMit uf ] 
tin- eoiKtiiiitional eon<liti-in that ihv prinnfial diflereniH- exittc hi-tNt-en the 
Irenluieiit of this and tbiit of the other varieti«« uf aeuie inltaiuinalioti. 

In eiinHiilerin); thi» iiarlof uur subjevt, it b of (!ftpei:i>l ini|HtrlAiic«> In 
Imut'h ibe term " anlipkbigitlie ;" fur tlie BBRie lT««l>aeni thai would amal 
in flam mat ion in one fonu of itie disteiuw, would certainly lavnr its |>r<i|c- 
n«i in Kuulher. Nuihiu); appears tu be more unsc-ieuliBc than Iu hi- 
deavor to treat all inflammaiiuDB uti one niiifonn plnn. Survly tbe AcoOimj 
at molieal Acieuve have sotne gnxind fur doubting at leatt the wMilntn ufl 



I 



TUEATMEMT OT AriTIItCMIC CAdBS. 



S2S 



I I'riidiwm. ■bra tbfv m ima act of pnetitiooera trvnting owty iufUiiti- 

w daHM* witfa tlrplrtiiui. anlin>»iiy. hdiI (.-nlomvl, whilst otlwn leseb 

Uw laBan-a fiir all inlliuiimiUiuut c(>ii«iRU> iu liraiidy, iiiDtDooia, UmI 

ll m iai[>imhlc (btil l)i>t)i ni)'tfi<Ml« rati be ri);ht, lut exoliiHive (itatitt uf 

tM. But ikr iTnir Wt* in itinkin){ ihciti exclusive. lOucti U »crvico- 

•Ui t>,Mt4 isdiErd Biijiticnblu dbIv to, its <>wn iiarticular aines. Ami luv 

extnsmlir a itiiiltitinlc •'( forniit or diseaoe, in wbicb cnr]ln« 

■ml i-iinbituiliirtis of Uu«e ino melhods of treatment — t)i« 



_ uxi ihn ili'ptcti>ry — iDu*t bt- uili'tilM) bj the SiirgcnD in unlfr to 
tW VKrjria^ cMwltljQiw of hb imti^'ni. Tli« looil syniptnnv (luil nawn- 
fM« tW tBflMmiBaianr pmwM, whotbfr ocoirriutr vxtcninlly or intoriiiiDv, 

• MCaojua^rB or id thf lun^, uf natuciittnl with <'vii»l it minimi •li«tiirli- 
M>Tik*t ntirt nerur\\mg, tw Uie iwj nnd the voMtitutional romliiion uf 
1^ l^tinit. It b thr type awuiiiM bjr thu coiutitiitionni diRtiirlinniv, ita 

' tmit or in aityuunif cbanuUrr, ss intticxtcd by the gvn«rnl oondition, liy 
p«W, wwl by ibc tntiEUc. and not tbc mere loc«J (li»««se. (linl niuiU 
'lib i^r^ma id iW aJotMioa of his lino of pnwtice. We niay advnii- 
■It tfT«i nilh uttimuny aod blixid lolling acute in6ainmation of the 
I^IL'' iWt whirh U ihe oouwi>iK'ac« of a wound of thi_> lunf;, in mi oltii^r* 
[■Hhtakliy and rohait mzn i<f tbirty, whilst in n brukeu man »f Mntily, 
IMM. bark, uon wine, an*! braiuty wottid bo e<inally projier : but if ire 
itucpft on-W |M>-iitlar nnd uiiunual rircuimtancmf to rvv«rK> lhi» 
(111' ywing or vii'iirmis, and In drpttii' the ap.-"! or 
Mimrr in ntinmou m'iim'. iind [■iMlialily di-.ilroy rather 
Am cot* mil ' :iir y^n'atiT iiii|H)r(nni.'v to be ablt- Oi o>ti- 

«b Kcural*-!; i iiimml ouudiltun <if liic jMlicnl, than to In.' 

■Utbfiirai m minutr dui)n)«»« of tin- pnctm Kiat, rxd-nt, nnd dvi>tb of 
ll* tacaJ ^bchiarf. U b a fatal error, t'w oReii (.■oniniiilod, to Altaoli ihe 
dit^ iBpitfla&cv to th4- detertion of the looal malady, nud tu ri?gard thv 
I of tbv cbamrter of llie ac(.'')nipiinYiug oooUitutitKial disturbiiDi-t- 
InWttM. Till? Surp-vni who a<.-u thua, nioa tlra ruk of Ireatiiiu 
uiil not the IKmum*. If ae treni ery.-ilpelsa nr pneuninnia no 
< of llir iikiH i>r of iImi luui;. un oiii.- unirurm plan, nithout 
la tho tv|w of tbi; couxtitiilional diaturtnncti accoinpanyiiig ibcni, 

* ikmll UMrablv err in a Inru^c projHiriion of thn cwn'*. But if wi> luakv 
lb lu a nim iiii (if ibi- patnnit our jtiiid*', nnd ili^kt« or inimulat« aocortlingl r 
-nm Utaaicl) we imii Ion jwlicuu m itb th« Mine diwoKi, so fnr mt, ammif a 
■■nrard, an iixally i>p[K^itr plan* — we iibnll oot act iaooasiiik-«lly, but in 
•M flwfiiraitty wiih tin- mituml eotwiition of th*[MI)Mitandorhi» di«VMw. 

V# BiiM l>r piitlol in lb" !i;'.:itia that m kdopt entirely by (he c-itKtiti'>n 
J tV nait'-u! ih<- alnK' <<1 iIh* '.'•iiinio and pulMi, «nd th« genoral fbiirac'ter 
^ U- -•. If ih-?'.- :>-<ii) tbc Rr^t (iHrtakr of tho a«th*.-nic- typo, wo 

pcri'id hiivi ■-■-'-'•nrw; to iIk- troaditviiL that luia been reoom- 
IS tBlutnmnli'iii* aifonipanied hy xthotiic (ever. If tho din~ii^- 
in an a^tiv f-rin. tJir frvrr nrojtn'wivilT BMUniiiif; a li>*n-r nnd 
d«nctrr. nM'ivin)[ into the luiiirnir type, m> inutii wo );radiiully 

— ■ ' ■"' --ll trrnttnfiit. Thi«, howi-vt-r, is alwav" n 

'\ i-nutioii, Tliotigh ihf iulhimninlory fcvor 

.: I'ifiii, if ihtTc l"' rwinon lo Ixilii-v*'. from ibc 

'ticiil.or f^ini iho rhnnti-tt-r of the local inflain- 

'.iMiial oyiiiplnnM will u'tt lon^ i-iintimir of tbiM ly]H'. 

iiiliiiii* how wr liiwrr thit |iatM-nl by aelivr ilrplotion. 

>i firnt run {and in Chi-mt oawa then' u nftcji 

:ive rlinriirttT for thi- firrt fi-w day»t. llir 

,»adt ttft iunx, and rapidly «ut«tilci< into a loir fortn. In 






220 



LOCAL tMSTURUANUES AKD IXFLAMH ATI03I. 



vHsm ul' ihia Liod, which iiiv of wry caiiiiiMtu iwciirrcuec in lintMluii |^H 
licv, more jtarlicularly in hiM|>iUil». wc nhuulil ucvcr bircil, hul tt4lMH 
MirK'lTM, alU-r cIcarioK out the boirels, with b<w|>iii;> U>i* pitiiMit i(iiii-t ua I 
nKxIcrntcl)- luw diet, aiul ailiuiuiitit^i iu)c diajihorvijc mIium. Ak tb'- bviqii 
4aii»^radiiitU>' lucr^imoihe t>'phui<lcv(ic. rIie|iul»>.'iDorciuJii)t ill frniurDcj 
but dimiiiishiuK iu |i»nt'r, lli« io<i)(ue bW-iiitiiiiK dry and dark, iind itir i>ih4 
»yiuj>|i)iiit> of aillit^uiii (wfiiuiiiii); to Hhnw tliciDK'lvfti, mv muxt bi'i^io (•■ piv 
H>niv aiiruuUnt lu (xiinbiiiulion with ihi' Milini-». The cnrlfmatp <il' aminoal 
in ibn-v lu live i.'rain diHM'n, ur evni M)ur«\ ninv be given with Imrk, iir, ia ■ 
i'lli-r\'>-M'<;iit fwm, villi bi(iirlM>iialc of poi««Ii uod citno acid, cvrry third a 
I'utirlh liiiur. A n>nvi'ni<-til fnrni of Idir loisuim W &(ivru eniiiu •>( hii-Bi 
bminli; "f |Kita«h and an equal miiiiititjr of cartKiDatv >'( niiiiiiiiiiiii. uii 
twenty-five J,'"""'"* "'" "-'itn^ arid, ThiM< muel b*- lhoroU).'hly dtHu-lv.it, tb 
cilrii- ac-id in 'mv glaiw, ntxl the nikiilim- mrbunnti.-* iu another, each ojit 
laining alxitit liiur onnofe of mater. The Iwu »>lutitiiw may thru Ih- mixM 
iukI taken nhilHt cHerv^veiog. The nouriehment inu#t be inereiinnl: am 
wine or aleuholic HtitmilauLit must be eoujuined willi it, in nrufiurtitm at ih 
tymploni^ of debility becunie mure uud more marked. In eflcctiiiir ihi 
t'han;^-, however, we must be enreful Dot to run into the error of uvri 
BtiiuulalinK unr patient; this niay be avoided bj obaerviujc tho iiiduma 
i-xercued on tlie pulse and tongue and teminralure bjr tbe change in tnal 
ment. 

In tbe roajority of (rases, this stimulating |ilan is not well Uinic itnria 
the finit few days after the >eltiii|c in of an iiitlamruiition, wjieeiiilly if Um 
be ^Dtrie irritation iiud si<'kneM; btii when the more aelive lymploniii thul 
ft leiiiteney In HuWidc. when the bowcU have been well ilcansl out. and ih 
ikin iii Ite^'initing lo n«ume a )ilt)i[tit di-^r«v uf moi>ture, tWn it way b 
rw>rti.-tl Id with every )>rol>ability of miccvm. 

But it may happen thai the rymptontf an rajti'lly »ink iuiii an oatliad 
charueter. or fn>m the very lire't nwume it. dial the only treatment 
iMihlauul a prinjiectuf saving the paticntV life consisU in the ear^jr ~ 
ftdmini>tralinn of toiiies and stimulantfi. with mild Dourisbmeni, 
■innioniu and bark, wine, brandy, or porter, with beef't^a ou<) amiw 
■tid of these large (juaiitiliee may W re(|Uired in the fuur-and-twemy huu 
the patient eviuein^ a tcmleney to aink wlwnever tb«r uae is iulerrupi. 
Allhotigh stimulants be freely admintslered in these eaM*. tbe fuo<l 
Ite hlaud and capable of esay snimilatiun. It ■« worse tliau ascJca 
nitnl, etc.. wheu Ihe patient eaunot digest ii; but l>eef-tra. ef;^ and 
(■ci'us fiMxl may be given in larj|[« i|iiani!ti«a «ilh lulvuntate. The bniid^ 
and rgn mixture of iIh- Phamiacnii'iia, if well made, eomlitning nutrimn 
nimI Hliniuliu. u the best n-nitily thai mn l>c ailminblmd in many cMo. 

Under ihi* plan of treatment, the tnnicue mill be round tn Iwcome tnoM 
the brown ■■•rdn to eleur off from the ini>ide "( ihv HMwilh, tbe pulw I 
beoime ilmdy and full, the U-m|H'ratun' to fall, rI'-C)> !■> b' pmcuri'd. st»< 
the (treugth maintaiueil. If lliete W much delirium and rT«ll)v*iin«i. w 
ninv find !l neerswary to combine opiati.^ with thi- f^-ticml trantiuriit. 

Tn till- low forms of iollaniniatorv fever, ojtip«tivo pnotiowuia nnd bran 
chili* IW-'iuci'lly supervene. In tkis cm plica lion, the following draugh 
iijsy Ix' adviintagiyHisly given every third or fourth hour: K- llnctun 
Campborir I'omp. tv^x- aa SXS., Ammuniif CarlH-natir gr. v.,L>e<vtc'ti Hmeci 
Jin- llubrlacicnl*. blivtetv, or dr%- cnppiug may also be applietl Iu tn 
cheat. The diarrh<r« that not nnfreapK-otlv occurs muM be met with o|>)aU 
aad astringents; and if Ibe urinocaDnm Iw {ttascd, it must be drawn ofb 
the catheter. 

The mnrc I sec nf inflnnimntnrr ft-ver, the more eonftdcnire do I (aft h 



ClltlONtC l!<ri.AMMATION. 



227 



' plau or tn-nlim-iit, which » tlH< only nietluKl of aucvmnillf 
taajmt •■ ' .'li iIh.- (li«MtM.> §li<wilil it amiinM! tlio ostltinic lyt^c. 

Pamm iri-ninw-iit ii not, in iititny cnDL-s, as Hiti«rfti-tory ns 

m ttvU Huii. lu |'i> vciiiino hn> or Utt- ynim c<>i>K' to tie iiiiidi better 
MJMMwJ- In n ci-rtniit |>r<>)i->riioii «i ca»t#, tlic ci>n!itliuti'inal tUilc ul' lliv 
(■cut H neb tluit Any intliiiiinintury procCM will iH-rtniuly lunuino lliis 
ma, i« in tfa« majtiHiy uf iitwi, ilu- ii{>4^«l co(Mtiltili»niil aUiU? i» koud- 
wfltaa nubmllliy H-i'tii' or infi'^tivc pruccM gf*iuf: •>» in (he «c«t uf 
UmmmiIoo Ttv tlic j'rcvi'iiiiiMi •>>' ilivM iinkcnlihy pntnwo* hy Uk 
■ itfa ! <if «i>un<i>'. nn<l I>t thi^ impruvvniciiC <>f Uiv cmvrnl 

bjpnk ,:...::. :,: ul' ixir litNtiiUils, iiiii<-h liiu Ix-vti iloue l» pn'V(<oi llic 
f (if tiM wurd funii ut uilii-iii<^ iiiltiiRiRinliirT fvvvr. 



CUHoXIC iyi>laHMAT10}t. 

IW|««mriU]( il4Mrri|ilit>n lin^ n-rirri'l soli'ly h> lu-ittv iultaninuilion. iiixl 
«Rr« Willi in* l4i Kira m liner MiiiiiiiNry <il' the ilistiin'tiri! L-lianiclore ul tin* 
ti i am i t fnnu nf tlx- |>n>o3i« uml lu ilivcriLM; ilo tn-iitiuu»L 

lt««K iul)«iii(ii«li<in, HlltKnigh it ilitlt'ni in Jt« vnunc. ayinjitunis, anil 
^Kti ttuai ihr nculc fvTin, in Itut n iuu>tilicnti'>u ul' ll>o *niuu iironas. lu 
SB*- '"''''""TialiiiEu, tbr tMM'tilml rvfthins arr n iliniiuutioii uf lli» vitjil 
Mil' wall* iifthi: vi-KM'l* notl tlir •umuixlinif tiiuiiii-s, dtliUiitiuii of 

tt» ir^i>, "iili cxmlaliou and infiltmlion of llir nffoi-tfil nmi with urn- 
uUt, Mi:MDjiaiit«l by chuigM uf a ik-grncralivi' or ikvlnictiv)' rhiinxK-r iii 
lir onytnAl uvun »l' ibr [icirt. In flUronic iDl!*iiimiil!<m, nil the )))ivnv'm'itu 
■• mr± «ith, but in a I'trt <legrtiO uid IcM ttrnniily mttrkiil, an<t it nill W 
mmt AfimtiirDt l-i rob'i-l'-r tlH-m in the sanw omrr a» in ihv iic-iilr iinn^iau. 
tW dilaUti-'TT -f tin- vi-smU ami <Iet«rmiualtuii ul' hUnA \a iinuli k-w. 
Tk dtp*!^ ' huncvcr, Instin);. u !t niny tin. fur a» imloKiiitv 

ftrM. kaili i j.-iucui bm <■)' i.nie ami (Ulatmiun, i-fltH-riatly in lli*' 

«■!! filaa. wbich, in L-hnmioilly inllnuiLiI [larta, uin »lltiu be wen clearly 
ntk ibe Baked vye. Tb<- rvUxnli'ni uf tbtr iiri>.'ri» ig k« enni)>l(.'tf, Hitd 
ite* ■ oftra a Un<lM>cy b> ■Ui'ltvDol nrrulatton. Tlio niluctt ><l' i-br>'iiic 
h^aauliiAi M, iben-lurv, 0* n rulv, inuiv ililvky tluin tbnt uf iiciili-. Tbr 
•U» pruot^ brini; iluv In a »ligb(>'r ilrgic* uf irritjitinn, ihi- ini(iiiirmLiit of 
•iialitj in the TwoiUr vnlU ■■ not tu ^'rvnt. nuil tin- icnilvncy uf ibo cur- 
|w e l« tu aUb^n- ao<t Riij;rulir i* (■oiMi-<|ii(.-»lly much Ivn. M>i{r»ti<>u, bvw- 
rtw, da«* onciir. but mt lii tlic rxtr-nl, ni>r witli tbi^ ra|>i<lity, ••Im-rvitt in 
««« inflaBUPati'ift. Tbo i-imlati'in that ucrimijiinico tbi.- tnigrntiDU ii> in 
A* najartl* uf tmte» In* rirh in nlbnmin nnH io tbr cnnetitumts <if fibrin 
dan taat Mbif^ *wm)k« in arutr inltiiiiniinliiin, as the ve^seN, ibiHi^'h allow- 
^ mutr Ii4at>l than natiirikl t" rxinlr, liitvr elill stiflinVnt viialily reniainiii): 
UoMi a Mrlrtrtirv inflitpiiti' ■»■ vihni piuMv lhn>ij);b their wall^ Thn* iu 
ftwi» tataBiBMtkiiM ' iiiivini rjiviiieij. we frcrjueutlv lin<) thcin 

AmmM aitli a flniti ' . hwt-r s|Kvilii- |-raviiy ihnu that of tbo 

>Vk« wnfTOtuia, ami tm iju iIk; power uf apinitaiwttu* coajculatiua. 

iW UNon of a |i>tt < iiy ebrunic in flam ma lion bcooniv, at in the 

•Mt fivmm. inflltnitni by nm 11 lit. In the m-uii? prooOM, ll may uuw b« 
4Uld W pruml that all tln^' lvIU iire ^hif eorpuwla* that havn iniftratcl 
hM lb« Toarla, awl jaBatbly lunlliplinl by tlivttinn in tlwir new Mliiittion. 
b t twi * inflamini'ii:)! iiti)ui.iii,'h nii^mtiou iIihw not tAlc |>ln(v, it t> ilnubt- 
W ahdfccr ■nmr < • muv not tw dcrivnl fri>m nin I tin lira I ion of 

Ih —'--..1 ...,.•.. ,. ...Miyn-lm iif ibe jmrt. 111 very (;nn«iic pro- 

^ ulot vitnlity i< alight, ttii«<lo(« out K«in imiraa- 

*^ ■■• ii'i> ■• 11 u'ii< , uie iivvr oell* which apjtenr nmy uniter)^ a vnnrtv 



228 



LOCAL tlldTOmiANCES ASU INrLAMMATIUV . 



of rb*ng4v lu'CDrdiu^ In <'iri'UiiiHUiicn>. If tlio fwrt rruitrptt, llu-y nwy, ■• 
En »ciite iiifUiumiiiiaii, Hiitn[i|Kiu-. i-ilbtr fimliiig i1ii-ir wur bMik tiilii (br 
«iMirl» or uiidrrgvioe tltei»tcgrnli4>t) nixl nli«»r)>ti»n. In iithcr ni)M«, ihiry dm* 
bcmme hcapf<) up, stonly <lnuxiyiiig or (ibplncing iIil- turrouii'liiig Umukb ul^J 
Iticy |i)nn « maw, 'iHcn of rotiHiilcriibIc titn. tm iu obronic iufiitiuniBtioiu ulfl 
the synovial nicmbniiic# of joiiitD; in tlww OtBMM of cell* W» vmwW an ™ 
forineil, but the vn»ciiliirixiiri"n of tlip ncvr rrowtli is itltiays more or hm ini- 
(lerfect, eo that degeDcrntivo i:ltans«8 early set to for want of vuflSrirDt 
iupuly of uulriDicDl. Tbuit, in obronic iiiflareiuatioD of joiiit«, we nwy Sod. 
r«|>taciD|i the synoTial uieinbraue, a soft pulpy nwn of taaue. perha;* an 
IdcI) ill thickncsB. 'tlie layer of tlib, in nesrcfit relatioD to ibo v«atU of tbc 
nrroundiiiit ht^nltliy Rtmvtureti, is modfnitely *iip|>li<->l nilb new voneU.uid 
nnwiit* (hi! onliiiary appvaranct* of hnltby gn>uiilnli»ii-li»ue: ntxi lolkit 
IN a layer ouiiliiiiiiiig IC'W vnwrl*. ami bcrr maatn of |>rot")iln9ni containiiic 
iiiBiiy i)u<'let are oficii im-t with. I^Mtlv, »o fiml a layer in wliU-b th« cclla 
have pi-rifltol fmni nant of blixxJ »uppry. If thi'v an- utill rf n>},'iiiuibl(r an 
ccUe. tlivr arc witl»ur«<l an<l rtiniiikcn iiitrl lilk-i) wiili faiumtiiilr*: Uit 
uHiallr tli4-y arv in part at U-aiit r^ttucvil Ui a uraouliir idiup, in vrhich no 
indivi^iual pliMni-nt« an.- any I'uicvr to bo mgh. Tbi(> fatly Inyi-r n<ny ■uftra 
and bri-nk dowti into a fluid, which Bonicirbnt rrMtnbln pun iu n|>]M«rvKr, 
hot <>u niii-ixifcupic cxaii dual ion is found to roniniii IVir, if any, pn*-«clW 
'Hh' colli-i'tion of fluid [hu» furnii><l is called a rhronie or rM aWmt. 

Auotlier tiilc that may befall the accumulittiou of ndls forni(<d a« n rom^ 

3urui-e of chronic tudamiDation is, thai aAt-r uiideryiu}; euui|<1rt<r fatty 
i-Ktneitiliiin. iho diabs bo tbftDed may become dry anil k-bfcby by tlitr alimiq*- 
liun of iu lluid«. The t»Koiis n»»e* tliut ferUH d nmy n-mnin in thin i4alr 
for au indrHuitv pcricHl, but at nuy liinf thvy may s-iftcn from t-niiMs as yrt 
bui impcrfrrtly unilcr>-tood. Ill the jinM-cw of i«>!Uiiin'„'. tin- cbt'.-oy mattrt 
undcr^^oM chemical cbaiigr* uhicb give it irritnliu^ iicriHrliiv : aitd. na the 
reeull uf iJiia, iDflamaialton of a more acute eharat-tir with ttipg-urntiou may 
be K-t up, leading lo ulcernliou in tbd liuue Burrouuding it, or to the l<>mu»- 
tioii of an alMCTM which tintte itf way to tbc surface, and thiu the cmacoiu 
matter may he eliminaled from the body. 

Auother change, the reverse of eotleiiinjr. may take ttlam, when the nta» 
is of small ME« ; it may shrink and drv up more cumpletely, and ltaie«alts 
may be deposited in it. formiug a clmlty cwicntiou, which remaius |)rma- 
Dfutly unchftDj^^able and hanulms. C'biunic inflammali'in. with msmtion uf 
the iuflamniBtofy products and iIm* aflcrchaDses of suftcuiu);. arc of frajurat 
oix-urrence in lymphatk ;;landt, bonca, ami the suU-uiairroiis ti»u«: cakJtt- 
iiiiiiin i* occaaKinuly met with in bone, and is very oomnoD In thr lyniphatic 
j;lnndii. 

dironic inflammation e!vc» ri:ie lo yet another chiwcc, di; "-ntially 

from those already divcribiil, vir.. loan orersKivth o? thr i^e tisKM 

of llio allccleil part. This fonna the moat mnrkeil fntturr oi many (urtm uf 
rhnmie iuflainmatton, as in ehrooir Inleretltial inSainnintitin of elandutar 
urgans. ehhmle («tHtis and )ieri'«tiliti, chronic arteriltf. ami rhrxmtr tnAam- 
malorv nllteiions of the skin. .Mariv uf thiw afTectinnft are h> far rvranrni 
IVom itillunimaltoii in their eltnicaf fcnture«i, that finte |>alh<>to);L<ls have 
hcsilnleil lo apply that term to them. Kill ihey n-semble inllammalion in 
hrinic the muilt of irritalion. and i» bi-in(> eharaiTtrrttcil Ity a dituiiiUhrd 
vllaliiy (if (he atlt-ctcd jmrl, ns indicated hy the rnidioraa with nhirh n slight 
injury eonvi'rts theehronir prtienH intonu aoutfitdlnmm>li«ii of ibi- i.ntinary 
tTix-. MtcrciK'opie examination of titwm it titinin» fnmi diftVreni rasn 
alfi^eliil in ihts »my. oh-m* cvrry |)o«ihlc vanatiLin ln-twtwn ih" tnflllration o' 
the onniMwtiTc liasue with innnmrrahle new ctdls indntiDguiahable from 



{ 




C*08E!I or CllftONir IKFLAUMATION. 



22fl 



ilrriBf Uneocyium of uuU* infliiRinuuion, hiii) probftbljr idnilicnl witli 

■M^tfa* dtvclopwrat of B liaeur fonipnwil of donsp rigid-lookin>,' (tbm 

wtlMi sra fouad a tV-n otnn^ioil celh. In fact, uo fliar)) line <-aii 

W drawn heOM^ uitic iutcTftlilinl ioUamiDatJoii and itie chronic form ojlli 

ibc«td iodarsiion. lu Ixik'. i-lironic inflAnmalini) of tht» lyjie U bliuwn liy 

■UdUkln, |i^ri'MUnitii anil formntioo of new bon« benmlh it, 

5iBc(«ft> 'l« of i)>o iiiininot li.'Mie, with oaiToirinK pr obliterntion 

tk« II«Trrainn mBi1i>. or l>r coiKli'tnatiixi of tUc uwc«Tloiii iEmu». In 
■Hwim Ibr croKlli ulcnt pine i-liklly fitjin th« ontrr layer of Um Inner 
nmL. md tfa* new tumne otcwly rMembiw the old in Hlnictuiv. 

TW «isct nri^ii of the ww INM* liM nfwr Iwcn ci)nclii«v»ly proved ; 
tW« Wt migrating Irnnicylca inki' th<< ohi^f or any p«n in its prtMiKtioii 
■■y Rtill U: r<m*i<l<-n-<I nn op<-n (jiintiun ; tlint in «oni*^ ciimw, at Icaal, iht; 
■>« two* i* ffnttnl from ih« "Id tMinn alnmet beyond n doiibt. 
^^1 AailA i r nnninMi vtfcvt of dironic ioflamnuitioti n ulrvmtioD. Except in 
^^Ma «fa«M9a of itf proKKM it diHere in do iv8{)«4't from that ocx^urriiijf 
^Hbacm# iBflsmnaliiNL The Uamee lirel Wconic tnftUnited irith leuom-ytea, 
^P%h>t4 avrvnaUbi aiiil pr«« on the original einii.-iiirra, flnaUy dmtmyhij; 
^ VbiBaiMl takit '>'ac«. TIimi in ttieir turn iliettealroytng celbperinh, 

Wtali <Jn«n. a: :iway mixii) m iih s^miii exudation na |Kit>; and limit 

axrwfcnl f n nt t mi v tiattniction of (iMue ulcn pluoe. Sup|nirati'») of tlif 
tfff oAm a*anita a rbMtiio form, a» in the attc i-f liirgo nlnwtmM 
ftvn tbr thorax or iilHlnmon, or from docply M-utnl iliMmaral 
orbnMiL Thr natnml Ir-ndmi-y of alt alMCmao lu Hum t» ihcy Ktv 
lo fill up aitli 1,'mntiliition'tixixK^ and to rivt ; Iiiil wh<-n ibcro in 
«f irrilittion prfwnt. a* dtvnmjMning nmltrr, Ipiwion froMt 
mfafxt drainapr, or fni-tiixi of ono luirftcir ai^in*! nitnth'-r, l)lf t;raiiula- 
wa bnt«k il>>vn into p4i# as qiiidkty as lh«T grow, and the priKH-ss may tlitift 
b pmlMiynl ID' Infinitely, llw only limit beiiig tite powers of endumneo of 

U «hraa»r loflaianialiopa, altlHHich the Mmnective tianie nar, ad twforp 

faajjfci 1. KwlpTfo an inrruwoi devclopmcni, th<' hig:lt«r ibsuo alwiirv milR-r 

iifMemixv ffuugn — piirtly ai n rraull of iIm' prewurc to whifli iiwv nro 

(nm iJm otm grimiJi. Tliu.* (hi- mbuli-a i)r acini ot a diroDtmlly 

riud bteome •ibliicrolnl, imd niiiu-ulnr fibrt' umlorgoM latty 

:*aa. In thia way ihi* f>in<-lioRnI activity of orpin* ■nfTvrinz from 

tnfcwinialiuo i* nxirt- or l<-u intt-rftrvd wiih. Tnc <.-oiidilioii Known 

W otarrfcal inflammation, poaaMtM to many e(>ccial fealnrm that 

hv hattvr dJii in 1 1 N?|uimti-lr. 

r *rr ihat rhri'inii- inflamnistion, althongb ilitlcrin'; widely from 

■• in rvklitr an annlof;»i)^ proems. Tho wvelopmeni of increnseil 

ttMiM u anaJoifiine to iho ailhmive or prxluctivc form of acute 

11, m and the fiirmaiion of a plipcsy nenlre, or chronic abscc«, 

■ n it» rhriiniriiy from llie procinwt tiy whicli au acute nlMoeSi 

..-•-•k', .„ >,r, < -lino lumuofaiippumtton arc tlirtuinin pntoiMm 

« h«k fcra* <i, (liflferiDg only in their rat" of pfnf^rraa and 

j^^JWMiaa. Evri >i>' i>roccap« may aatumii tbaobroatf fomi, njt En the 

^^■Mnl inbrn-ular inrrrtioii fnm 1 •oft'nin); chemy ocatn, in glandcm, and 
^^HMp» fcra* of i-hr-ttiir pytptnia. No •harp lino rjin )•« dntwn Wtwcon 
^^^^H( 9mi Mutr inllttnmiitioiia ; and thn t«rm " inbMBte " v ntivn lucl t4< 
^B^By fawwaaa in '< Haiid bulwcrn the two. 

jB nam— Tha ra '•rani'* in (I am million arr like thoae of tho aoule 

> F*^B, pn-ditpoain,! au^l - ' l:. Tin- predlspoiin; caniiei arr ihi* 

*at « AiM^ of acdlr int', n; anything thai Ico'l* to hutrr the 

intttribn with liiiiliiiy nuinlioa, eitlier ^norally or looilly, prp- 





280 



LOCAL MaTUHHAXCRB ANU IKPLAM U ATIOS^. 



ditpowa to DOe t» inuch u to Ihv other, IWIinpe pamn eonotMion A^H 
the nioel common of all pr»)iapoeiDf; ctuter, nixl it u oftra dim<-ult In mSt 
a dietioct line betiracn llit^ oon-inlliiiiinialory chsugos, tlie itidurottud bh 
ptsiDentatioa r«eultin^ from oongwtioD. ood tlioee produced by tni<> chroo^ 
innamouUion. C^ertain oonKenilal or l)«r«dit«rY canftitatiixuil Mate* tor^ 
iin|>ortaiil prediepooiugcauKi: tbe imxtt luarked uf ihme being lA« f^^^^M 
tUatiirMii, \n which diroulc iiiBaiuiQations, a>]>edKlly uf tli<^ jilanda, bonc^^H 
jolnttt. Hrr vi-ry ooinmoD. AmongM lliv ucqutrod coiiDtiliilionftl <«Ddl^^| 
fyphUif, rluiimatum, mid gout fomi frLipn-nt pn-ditpiwiiiE; (*iiit«a: M ^^H 
K), tliiit in nil I'hnitiiv itillaiii mill i unit it is l)i<- duty o( lliu !Mir){«on to bl^^| 
iiiiihl tliL- puwiltiltty uf out: of tlxx- bring pn>ii)l. Tli<- impnrtMMe <^^| 
pradttpOiiDg GUiM* i» iiiiilixiliiL-illy n-liitivvly gri'iiUT in ihff chruutc ^^l^^l 
the ueuUi fonut of thv intlniiiniHtory' prootw, and thitt lad mu«l be bofdlH 
mind in lb<' tii-almi-nl «f ihv titlix-lion. j 

The immediate cauiei nf chronic inflnmmatinn nrs of tlip aame iiataro m 
thiiw of th« acnt« prucrat, but ihvy act with a Iom <lcgTi^ of intinrily ami 
nioro cofllintioitFly. 8u long as the cau»e ol' ihc inflammation it i-rrai-ul ibi 
pK>oM8 L-nnnol aiilieitle. In dironic in dam nin I ion it otien )>api)(>M that thi 
cause which stjirle the provess ie of n temporary character, toe pcnaalrol 
efl'Mi bifiu)* duv< lo other cauwe which cunie iulu ptuy at a laicr perioi). Thai 
in a cummon ulcer of the leg the history of the case ie fretjuenily as rt>l|»«ai 
The putieDt. pcmihly ill-nourished and feeble fVom nuiu i-f pn>|wr fowl, 
aufli^ra fruiu varicMO VL-iu», which interfere with the return of blixid fruni thi 
akin uf the It-it. )(iviuf: rise t*) a (■•mdiliuii uf jiaMive ooafttMMn. As m r aanl| 
of titb the siiin of iht- It^ h Wily ouurishetl and of low \'itnlitv. nnlM 
cnptlbl« of wilhntauiiiti!j the itflccL* of even luild ili-^rm of irrita^H 
Soooer or Uler tuine sHght injury, luuh a* a Mmldi or blow, wht<-h woaM 
bo bnrmlun to btaltby tissues, givoa rife to inflammation of sulfii-ii-Kt ia^J 
#ity to reach the Maco of suppuration. The pus niisea the ciilicle, Ibn^H 
a amall puslulo Hhicn bursts, leaving n run iorfaoe bciiMitli. The dbcoHj 
ih)Oi>in|HiM-e aivd irritates the sarfucc, the cl'>ih«9 nih the ulcer, thv muada 
wurkinif Ix-tK-nlh in walking niovo it about, the •lilnutiuu vflliu vcaavlaaiM 
Ihe exudation, added to the oU>truftiuu in fn>iit whioli originally (ave rifl 
U> lite congeeliiw, pruduou tension ; iin<l nil ibesi' cnusu eombineu, manUda 
the iullammatnry process, llie aupptinilion continue*, nnd the sore slowlM 
spreads bv ulcerultun. In such » rjme nn ihiii ihr ]>ro<li«pn>ing atuaa^MJ 
Ine secondary causce, ]>laj by far tin- uxat inipi>n»nt [inrt, and tlie axl^H 
cause Ihni iilatted the pmcMS niny Ix' •» flight A* alinoM to «*capv tkotki^^ 

In nintiy cuT'a lliv nature or ipiantiiy of inflanuualorj pr«)uett avrra 
pArlly a> a <-auiH' of thi^ iM'mistfincit of tiio ftroccn. Thus in (hr caiw of to" 
llaniuiatiuu of the syuovtiil or serous membtanes, tlto iro«in<i caiM'^l by tbl 
efliiMun of fluid is auflici«ut to maintain the iiitliimmnlory ppMHim lung aAoi 
the nrigiiuil cause of raiitchicf hao hti'ii rrniovcil. In 'Uhrr cnsm. in whick 
fi>nnat)on »f ucw trwiic i* an inij>onanl tlcnii'iit in ihv pnx^-sa, the Awblanifl 
of ill*- nin giowlh. i(« inip<-rl>'ct •h'Vi-Ifipmitii, nr itx insnliitwnt Tascutaiuai 
ti'in ninkv it (iiiiihir ii> uilh^lnnd (lij^ht tmircca of irritation : and ihun ^WM 
nhirh would Ih- liamiliw fi healthy tissnca perjietiiale the intlammatoryaBH 
DuM in the new growth ; or (hv nen tissue may jtcriiih an'l. acting as a '^'i^^l 
loHly. I'scilu inllamiiiation in iIm- ItHUes in cualaet with it. This »e hw OT^ 
illui>trate<l in (he condition known as while Awelliugof ajoinL As the reaaM 
uf 'ouw slight injury in nit unhmlthy subjetH, in tiain million is set up ao^ 
mu-hea the ■tngi' uf cvll-inlillraliim uf the synovial m«nibmne, ami ike fti^ 
matiun U|Hin ilofa layerof tsranitlatinti-tiMiuc. Tbi* fi-eldc liaMie gnuluall|j 
inei^iisra in •piatililr till t)io whnlt nymivial euvity may tw All<il with it. tM 
leasitNi causwl by ibt pmenci< nnd tlte iiKivomenl of the jnlnt beitig ■iiBhiii^ 



ritCATU&MT or CHRONIC t N'rLA M U ATION. 



231 



the praOMft. Flnallr, |MrU of ilie ^^mwih may d<>)cc»cnitv nod 
kMd UiiH acqutra ch«ini<nMy JrritAtiu); proprrlMv, nml Bgf^vtttc the 

■ — Thr Kiudiliviition)' <•!' ■-iilor, urn*, nciixnlitiii, fuiK'tinii, atMl 
MapntBlv, tl«*rriU^ u Dtlnulimt <xi unite inlluminstion. bit preMnt iiIm 
• iAmmc itiHaniniailoii: dilTi-rini;, hnnvvir, i» urigiu and in (Icgnv, aixl 
liw ii wrd«-r and coaibuiaiioii. Th<- fijlor !■ ii<it nlway* changM, ohIps* 
tb pit •Actnl W vvrv euprrHcial : und th<- minces «■ rnllirr ^r tin? dull 
An «f iW tirisht hi|i', ii->t de|)^Ddin>: on lh« rapid tranidiiMioii of nii in- 
MMii qvaslii _'lit blood, but rather od a i>^ne«#tiv(> fuiidilkiti. The 

AmhI tiwor <<nie permaiii-iitly diecolureal by the e»c«|>e of Inrjie 

Mafctt* of rvij iiltaKj-carpuacleti, wliicli bn.>ak up atid aiv iinperfedly bIk 
Mfbrf, Invinic lite pi^niMil behind. TIk* //-ii'm ia uot often ftptnitaueiiinilr 
WMr. bal panakm Kvurrally of ihe cbanK-'tcr of temleruBas. lieiiif; eliciui) 
•h fcy praawn' ; tomriim*^, hiiwever, the |)«iu is very severe, Tli« increase 
^ fca jprrahirr k inaally wu»tiiiy, iiud is never ^reut. StitUin^ a an early 

■rf awe - "-nt ii|,Ti tu cbrrinir iiilliinimulion. Ii ilejiebda leat an t]i« 

»W y - Vf«*rU than i>n tli- efTiuion irhioU laltea pliu.-c, nnd tli« 

mImW oi «■« tMaue wlitcb aA«n coDRlituu* ih« distinctive cliamcteriMic 

-"■ ftnH 

LA« acta inflannnation. the rhninii- form of the (liKeuw may be att«odcd 
If Mf^anilkaa. fSrr I'littoMi- Aii'<''i>«M 

Umwht I Sv3iii'<>u-~ —ThcM' nrp Iiiv niark<>d in chmnio than in 

iMtoiafln The [mtiriii i« in ri-vI ca8)«, bnwcror, in impaired 

Wifc: )~ ^iiany iusiani-ni. idfirlnl wiih tonio const i tut ion at mint 

•Mk h»-i '•■»«■ in pnxliioiii); '>r iiuiiitainiii); thr rhn^nio I'hnractrr 

•^iWIMMaBntiad. If an iiii|<ort.-»il organ l)c nlTi-clMl. or if the chmniir 



a. tbouitfa aSpctinp narbt iH>t ew^ntial to tile, be very exietiiive, 
*• (■I" *"l I*' found t» W habilually nlmve the normal Mandiird, nitd ex- 
MMMtinm of (twr, ofW iiT a •livlinrily peritMlir i-haracter, develop iheni- 
In thrtf nw«* ibe tom[>crnture. n* indicntoal by the clinical iher- 
r, (Koald be rlostflv wali-hii), aif) n rve towards evening especially 
' an imprirtaiit indtcntion of xmnuldrrin^ R^ver. 



■al r^tar 
mlikiU 

Mm. aa b> 
BMaa,i«r » 

)f«aak.af nr a 



Tc* - "■- - T, — Tlic (rratnM-nl of (•lironio in flam mat ion ii< fiir mf>rc*liffi('oll, 
•4 T- iigrh morv iillenli'Hi, than that nf iho ncut)' fonu of the dt*- 

tm. iiflsmniBtjiin w tM> frr<)U<'nllT ■.'•)mplii-a|i<(l with vnriotia 

■k- II* of thi- ayttcni, and with tin inip«iri'i| ■late of the gtn- 

^mUi-d, it H often kept up. ibnl murh practical tact 
I farrying owl ihp lb<-rn]H-iilic indiralioiiv prujM-rly. 
M«t;\tiii<.'iiii'>Mc lxt-i..ii4ii.\TiiiN, — In lhi-lrcnl> 
uuiiort wc have not so much to solxlui' inrtnninintory 
'.rucluml rhan):^-^ and oilver cfit-cti* indoccl by iU 
I 'I In prolines- a i;rt'nt and «iid<b-n imprrminn on lh» 
iti 11 nipiirni w do in the irenlnicnl nf ihe ncnlr iiflet.-tion. 
U k MA IB ibn way iliat rhruiiio iutUinmuiion on ever Im? curv-il. or iln 
Thr- |«tiont inti;bl Ih' bl^l alniiei lo deiilh, and Mill the 
■tMiM ^1 lui in till- inHaninl part- II >h tnic thai ihe Mime 
mnaw aVr eniploynl in armtiiiv the t-hruui<! a* in ctittin}: 
^^i ■^,,1.. f ,,., .,f ihf ftiM-aae, but ibiy on- uwtl in a las enerjji-lio 
1^ to indura a grailua'l and (.<ontinuuu« impr»«'enii-tit 
irni and nf the i)i*MiMil part. li<>cal nutrition is 
■n rhrimii- inHiimmalion ; ami it can \te m>li>re>) to 
' V irapntvitiu; ibf |Kitifnt'ii icrua'ral hvjilth. and nl 
.11 iniprnuion on tlx' [Ktrt iurif by iippmprinti* 
. in iIm traaiBlcui of chmnlc inllaminatinn, hygienic 




232 



LOCAL I>IBTrR!1AXCES ASIt IK PLA UU ATIOK. 



nieasui'M ai^ of the tint ouiinfutirniru. Iti mo*t cows, nothing rnn W ilnfip 
n'Uboul (irmiLT u[l<'iilii>iJ lo tli(><-, iiiul iiiucli atn he tUtnr liy tliiMi Ibul 
i-aiiiii>l Ik- rlT^c-iuil by iiny mun: tlir<<(rt nicilifinal nininti. TIk' In-nlmcnl uf 
liua ((inn of iiiflauinmttvn imi-tl liki^nMc bi: riiritil iu:i-(>nliEi|^ iu> it is uiicotn- 
lilicttUitl, uouurriiif! in iin <it)u-i'ni>R bcnllby coii]<litiiti>iii ; nr «*■ it UMiinif* n 
oongMtivv or imiwivv cliiinu-U'i- in n nti-bcctic aod fvMe «yst«ni ; or m it is 
iii«t wiib, iifTpctiiig » Hpccific I'uriu, in nn uuh«iilt)iy con »ci tut ion. 

Ill tbc mniiat;<?]neitt of lhf»c various forma of chronic infliiaiinaiJOO lh« 
pnti«i)t niusL be kc]>l at r«&l, and if tJie dittcaeo be at nil extensive, confinnl 
to bef), lie »hoiiid Iw in pure nir, aiid. oa a (^neral rule, have a light and 
UD6ti inula tin]; diei. The rojrulaliuo of tJie diet is of much coDee(|ueuoe, and 
tlie amount aiid quality of tlic iiouriahiiiL-iil atfonied must he t'arefultv pm- 
{Hirtioued tolbea^, streti^b,aiid prcviuUH habits of tliv jiaticut, aa wetj aa tn 
till! degree and the scat of the- in II hiu mat ion, and the l(>rm of conetitutional 
fev«r that (iCL-nnipanic^ it. In thi: mori.- active f»rms nf i.-)iroiiio inllaninia- 
lioii, fiiriDiicuous »\is\», ui moot hecf-tt^ and liKhl itiiildin)i;)<, can al«iK: In> 
ullowiil. In tlic li-Kn nclive fornw occurring in fvi'ble ('onMitulii>n>i, with 
dcprcwion of gcncrni piiircr, luiiimil frxid of u light Idml tony be givi-ii, nnd 
the scale of nwirisbnicHl incrwutul until glirnuliint*. u* bwr, wine, i>r hriiudy, 
nro allowed. Nothing re<|uircs grciitcr nicHy in jirncticc than to prn|Kinion 
the diet, and to drtwroine th« cascfl in which elimiilaut* an- iicctHarr. It 
may he ttatcd gcnernlly, that the more the dijb<a»i> nmiDMif the aiithcnii- ami 
juiasive form, the more are etimulnute required, unlil at IliHt, in the tnijy 
adynamic type, our principal truM ia iu thetie agentn. and large quaiititita of 
wine, brandy, and ammonia are required to maiulnin life. 

Mercury ia of eteential service in the more active forma of chronic inflnm- 
mutiou. but in all cachectic and etrumoua coDstiuitioDe it alionid aa much na 
potM b I e be avoided. It isof ^rent uae not only in arre^tiuK the further 
]>rograM of the diseaw:, but esjiecially iu causing the a)>aur|iti><n of the eRli- 
Hions, and in remuvins; Home of tbc other elU'dA of chronic inflammation, 
Huch HH thii-lctning, hardening, and upacity of Ihit [taria^ It should be ^iven 
in email <lo.«cii for a eon side rabli^ length of time, until the gtima ore slightly 
afrcct4-d. In many i-um« of dejiriiwvd power it may be aitvnntogeoualy coii- 
join«l with quiniiiir and .tar>upnrilla. T h*^ tii»i>t U!<eful prepurntionti are calo- 
mel or the grocn iodide of mercury, in balfgrain ihmi-it, or, if n gradual ami 
cunUnuous eflcct be mpiired, the perdiloride in done* of one-itixlci-ntli to 
one-lnelfih of a gritin. 

Iodide of Potaiiium in an alterative and alMorbcnt of the griMiliwt valu<>, 
espedallv in the chronic inflammutioUK of fibrous or otMxiiM tJiwiM*, nr of 
the glands, occurring in brumous oonstitu lions. In tlieec it may often he 
subeljtutcd with great advantage for mercury, and given in ihoiH- iiiixti iu 
whicdi tliat mineral nould otherwise he administered. In many ca»ef> it is 
of eneatial aervioe afler a mercurial courw ; some days shoulit, however, be 
allowed to elapse after the mercury ia discontinued bef<>ro the ioiUde ia givcjt, 
ntlierwlse salivation or even aloughing of the gtima may re»ult. 

SarsBparUIa ia a very u^ful reutedy, and fonus aji admirable vehicle for 
the pi-eparations of mercury or imliue. The fluid extract of red Jamaica 
atraaparilla i^ the iKtit ; and where tlie iuflaiumation is assodated with want 
of jKiwer, iia value ia certainly very great. 

Cod-liver Oil ia of ilie very greatest value in the various strumous forma 
of chronic in Hum ma lion, or in thoae occurring in debilitated, emaciated, 
and cjwheetic nubjeeta. It may be given iu Home vehicle suefa as milk, 
oraiigi^wine, or juice, that covers it.-> tnMe. In some ease:! it is advantage- 
ously ei>iijiiin<rd with the iiidide nf piituiuium ; or where tbertt ia much want 
of piiwer, and •trumuua au»iui« iii prtswnt, willi tin' propa ration* of iron. 



TRIATyiKT OP CilROXIC i:iPLAM U ATION. 



233 



lliiMf* Mrtioularlr in cIiiMmi ntid troung peopU itial ii w at M'rric« in 

MwoMwe wiom ftkftA ii{ chronic inllnmmiirtiin. 
AuMUim an oAra ti^iiirv<] iu vlironic inHiinmintioii. lu robuil Mib- 

J«« • «k«i Um- dncMu b tctivi*. Mlinw iimy Ix- cuitiloj-nl, u> which, if 

rimb % riwnimUc ton^ocjr, cnlchictim nmv nclvntilngooiMJr \m miMeti. 

b (MUiwi « pu«ilrr niRipmil >if oni' )>nrl i>i' iiicrt-iirr im<I (-nnlk. Iwo of 

fw<iMli of mid*., ami r<>iir i<f r)iiilidirl>. uill Iw luuml vrry M-rvin-nbU-. 
IWnlaUdnof o l c tBl Wl4 poUuium. cKiiccinllr the formiT. arc r>H'- 

•■■■idM Itr Ki»)[trr ■» Wing of giritt wrvicv in cliroiiic in Aa mm tit ions in 
M<dUMl MDJccbi, M|wc»Itv when they arc accomjitmicii )iy a tendency ta 
MMtli^ TWr Iwslcn th« pruccwof supiHimlifn, nmi ihc cliniinaiion 
If w •■•■» of l)w ouvoun inttannifttory privluclH. King«r recommeii'la 
WkthiU B Diixtara >if much the nine Btreoi;lli as the IInrro;^te viatep^ — 
ik.M« eni° "f Ihr «)lt>liiili> uf cah^iuni iliwulveil in half a pint nf nati>r, 
■alW t^i* t<ae l«s*p(Miiiiut may be taken hmirl^'. In atluits, id whom iliia 
mIt xf aduiniatrriuf; iiicilirini- i* w^Uloin tHH!iihli>, a |ii1l conliiiuin^ "iic- 
iti MBotUttl of ■ grain uf Ibv Hil|tliiile may be ukat three times 



t4t 



vsten. Itoth taken inU'rnally nr iioni m bnlhit, enjuy a ^rat 
tn tlir trrslnx'ni of niaiiv ohrniiiir iuHantnininry alRTtionii. The 
■af thr wBl"' »r tba bsUi will, of cour«c, dopentl upon the cnniilitu* 
n«<tiiit<n which Ibnmthp prfilt*|i(iMng ckum> nf iho climnic inllam- 



SM4ir ii beBf-fiHal in tuany forma of chronic inRammatton, cepccially tn 
tmi itftoAtK' I'uhi. 

Lotiai. Titt* ■!■ (-'imoxic Iicfi^mmatioh. — In chronic inBamma- 

M, ««f lotml iMMtB of tn-ntmeiit ar« oiuob more vkried than in iho anito 
lf*«rUM(]iiaHii. 

I*m1 Bloc4kttiBg i* oAi'D r«'<)iiir<^l with n view of rlin<ctly unhmding 
4( «<^Mli of thr iivrt ; antl lliU ii> n(.'ci>m|ili!>hc') hr srarilicittion, lii<('hiii;r, 
vcapftog. i^nficatiuB b entploycl prinniwlly in chrfmic iii(lBinn)alion 
^(JM MooooB mrmbrau**. IjCM:he* niav be verr uti'lullv cm]iloyi<(l in lumio 
hnrntit c^ruaic inllaminnliuD. two or inrnc hfing n|>{ilM><) every »(x;»nrl or 
-H -lay. 

%'irmtk tad Moiattue ar» Bat >u Mrvtcvahlu in (.-hronic as in nenti- in- 
■ ■■iiwljini. aod far* ahiialil be taken (bal ihrv be not continued for so long 
itiavM ta inalir lha|»rtaaotblm. An lutrin^'nl climnlanUsuch as lii|ii<ir 
llmU ur Bfjinta nf wine, may otten Mlvaiitagiwualy be added to the vurm 
■■ScMiua. 

OlU i> mUuu »i|uiml in any tmt iht? ndrnnoed sUlfOl nf chrocic tnllnnt- 
■tiao, is wluc^ Ihrn- nr>- •)i.-l>iliiy and {Uk^ivu mngeaiioii of the veeeeL" of 
te |«rt. Id urtirr ' ■• ih'u stale of ihin}^ its applii^tian aboald n<>1 

b nalinBuai, Iwiri < made twice or Uirice a day, »o lu tu uccuion u 

■^fcp ibBtifc. aad pmduoe a ciMitini.'eoi Ht&cl ujMin the enffebM vowla. 
TbibUat dooe n pumi'Iu.' rr i-KiiiiiL.- cold n-nler flroia a height, or by 
jiartinj. aad ahootil Ix fric4ioo. 

ftb tfew "■» ■'fl'-wf gr--; ■■ iil'tltfl ^n^n*^f<lOUgmtive[nHam• 

l h> iiival nf the thirki ninj;. iitifli-nin);, and induration lluil 

¥i-> i ^-ty be pmclt*ri) cilhnr ivilh the naked haod.or with tuUMi 

. uf a MiniuUtlDK or nlmnlirul fhami'lrr. 
Oiatv^rritAata arc 1'm^ nmilicniiflni* whifh givn rine to Irritation of the 
^Mnryut^ itiui^ity acconling fi their nature. lh« mildmt fonii* •-aufing 
■Ml* a MMinK dilnialion of the ctitaoeoua VfMi'Ja, u titr a|)|>lication of a 
*ii|Hr UaiBM-ot. ai»<I the BMMl vcwrc iiroiluciBg devlrtictixn of the >kin 
^ •»• «f fort at ib« MbeuisiH-oiu limw. tm the nmxa Hf an iauo. T h« 




234 



LOCAL DISTDRBASCBS AHD ISFLAMM ATION. 



vnlui? of coi]nt4:r-irritatiuu U ruccigiiixoil bv nil ]>rii<.-ti<Ml SiirgtMxiit, sinn 
countvr-irriliinti> arc uiiJoubtwlIf nnutngsl ihv niu«t t'HTcclivc luml nicuns 
that UT piNVPM forciimbBtingchoiuic influninmligii; yrt their mnd« of nction 
is difficult to cxplitin. Th<! oli) lhr'>rr that hv (exciting ii locnl iiiflsiii motion 
in the skin il wm pomiblc tu ilrnw the <li»cii8c unnir from the ilceper anil 
more importaal pnrts i« nu longer U'liabk-; ihu ihcorr tJiat )>y ftlimulatiou 
of tlie aenaur}' iierves of the skin a dilatation uf tiie 8u|>erficlal 'veasels is pro- 
duced, aocoiupauiod by a corrospundiog coniraclion in tiie deeper parts, 
catiiiol be supported by Bcieutitic evidence ; in fact, as Billroth liaa noioted 
out, it t* probable tbat in many case«, especially to extremely slu^ish 
chronic in nam ma lions, the good proiluced is probably rather by an increated 
afflux of Mood ti) the alleeted pari tliau by a dimiuutiou of thi' blnod supply. 
MuRt 0(>tini«r- irritants are a|)plied solely with tlii^ intvniim) <■! I'uimiu^ a 
certain d(-|;rfH- of hyjienemia or of iDflaniinati'in in the )inrt ■>>' tin-- »kiii on 
which ihcy arc jilaa^d, while othera exert, or are !<ii pjioHcd U) exert, at the 
tame tiini^ a c<iu»titu lion ill i-.fffvt, being absorbed into the NVNtoin from the 
cut«n<>ou» Mirfacc. Counler-irritanu are clawed ooeordiii); lo the di-grcc of 
locnl irriliitiiin ihfy givr rinft to. 

Rubefacients an< thiw^ that cuuim; merely dilatntion of tlio vcacIm of the 
part lo which they arc anplied. Hot fotncutniionf and linsccd-mcal poul- 
tices, although not uitually claasod amongst rnbclacients, certainly cause 
dilatation of the Ttamla. Frictiuo with some stimulatiDg cmbmcalion pro- 
duces byper.a'mia, lasting for a longer tim«>, and is uscfuT in nromoting the 
absorption of chronic infliimmnlory products, sucrh as the thickenin); left 
round a joint al^er an inflamnintory diitnrbaace has subsided. They un- 
doubtedly act by caiisin)^ a general atHiix of blood lo tlie limb. Camphor 
liniineni or. if a stronger action is required, the compound camphor liniment 
i* thai muit fraqneully used. The ordinary iniialard poultices or Ui(follot's 
muHianldeavcs produce the lowest possible deuree of true inflanimnlion, but 
if pri>jM-rly applied there is no blistering of the skin, although there may lie 
ittight ii'dcma fullowi'd by des>|uaniatiuo of the cuUcle. MiiHbinl jinulliees 
are but liltlt! uittd in surgery. They an.- more commonly H|iiilii-rl to the 
trunk for the rdicf nt' hyjifni'miu oi' intitnml ori^ns. Oil ul iiirptrnlino 
sprinkli'd nvi-r flannels wnmg oul of hot wulcr i^i another romiiu>ii hiIk?- 
facirnl. 

Vesicants nrr tlioNc ni)|>licjitionM which cauim a degrvp of inflainntutinn 
suRicicnl lo givr rixv to amnidanl i<xiid»tii>n, which niiHCn the corncou:' luypr 
of the cnticic from tin- Mali>ig:bian layer hcm-jilh, thoi' forming a hicli or 
blister. Vesicants arc cxtenouvly ntu'd in iiirpT)' to promote aOMTMion of 
the products of chronic inHnmninlinn, and in some cnsos to check the pro- 
cess, as in Iho application of blister* in chronic ^novitis or peHoetitia, or to 
tlie perineum in chronic pmstalitis. 

AUhou;;b there are other means of producing vesication, prnctically the 
preparations of cootharides are the only blistering ngenU employe<l; of 
these the two uoet common are the Kmplastrnni ('antharidis, or common 
Fly-blister, and the Lii)uor Kpispasticus. The tiirmcr is applied to Kuriaces 
free from hair, the laller to the bmIji or perineum. In applying a blister, 
or the liquor enispasticus, it is essential that the ]iart should he as free from 
greiuie an nussible, and for this purpise il must he washeil with snap and hot 
wnti^r. and atWrwarda, if it <^u l>t! couvcuienllv d<iue, npongtul over with a 
very dilute aolution of ammonia. Wfore tho hliHter in ]mt on. T^e bliHtor 
tltould ritic In from eight to twelve hourw. Whi-n thir bich ix fully formed, 
if it i* not iuli-nditil tn jimtong th<i luttion, it ;>lioi]ld In- mnrfully pnckinl 
with a nettdlc, hut tlie culii-to i>hoiihI not \»^ ri-nui\fi\. It nhoulii tlirn Iw 
covered wilU »itt4>it-w(H>l oikI a bMulngo, ur ii little «imiile oinlmenl on a 



C0USTBB-IRRIT4ST8. 



88S 



1 



fiwi/liMtt. If il bir ik-eiivtl Ui pruloDg thi? coiititttr-irriliitiuii, Uw cuticlv 
■>( I* rbuvmI, koil llii' rnw &urfiic« ureasod with itaviiie oiuutituit, bjr 
i4n MBB* it n»y !•« kepi oiteu u I'luy a« is wultctl. 

X \&tm (li>M out, V » niV, leHV« u scar ; but ii may do ao, luid It ia 

•AlhmAirc, nut ut njtpl^ it (u the fkce or luuidti if it vau be avoided. Tbo 

tUMtiiQifux In whicli it i> ap{ilie<) inuftl iio{ exi-oeil a few Hijuart inches, 

Irdnw b MUB* daiin-f of th» alM>ir)itii>u >i<' iW earn hand iiii-, iind uf con- 

M the ki'liH-yf, biHiiaturia. and Mriin^ury. Tliix uil). of 

n mdilr if tbcra b« a raw iitirliKT U-ni-ath the plaatvr 

•Iwajrv tw iumI with ^*^l t-nuliuii in very old or FwUc sub- 

asd in thnu" *ii8l-ring fmm Rrit.'lil'# dioeaM:. or aiiy otlivr Miriuus 

fnml aitrtiiN), aa in »irh cit*c» l\wy •H-<'ii>i->iiiillr ritUM- dlviighing. 

l^fiMHi or ^ocenic ooiutei-iJntanU iirr iticwc ngmu which are of 
rfant Intenait; ui give riw tw inAamnution reocfaing ue aU^ of euppn- 
»■. 'n* eaoM mniniou of th«M are crotoa «), ieauea, ttHoat, and lh« 
■aaJcAutrr;. 

hmM afT of ({wfial M>rvi«c ia chronic inflamtnatiun of the viscera, joint*, 

■JhoBE*. her>iT luitpuratinu lias taken place. They should b« applied ill 

ir«4 |«rr- ■ - r f'lc iil|«:tM] stnicturee. und may be k«pt open fur a very 

fmmifnb ■ -f tinw, Tli«y are b<-at made in the followiuK mnnticr: 

lfM*>.if »i II- <■>>'- plasier, about two iach» Mjuare, linvinf; n hole c.( llio 

«a^ a thilliirs •-ut to its middle, U fixed upon (hr purt whore the iiuuG iN 

itWMad*-; a ptcoc (if pota»a riiwa, alfuut ihc ^izo of half a t-he-rry <>t<>ii«, i« 

im pivml OB iIm fBffiicc left um-nven-i) by the circular ifutral «[h rturc, a 

Ifw pictw of ptjMlcT ba-ini: laid over all. Tht- patient exjii^rii-tictw ii biirn- 

Wg MM ht about two boiin, uhcn it cea-ii-s; »ii remi'viii); tin' plnsti'r*, a 

mA ■hwnh. cofrai|*on*liDg id »ii« to lh<- cifilntl np)'rtiirv, nill lie I'otind. 

VlHr JiiMilij, abaoM be aunlicd for a ten day^ iiniil it fa'pnniles iind lli« 

ammrlki m tlian drtMid vitb savine ointnicnl. or itiimilateil by an iesne- 

tikL VTbrtMTM- it ibfttra a tendcncv to bcal, it tiuiy l>e ke|>l o|H'ii by an 

mmmaI a^-prn t iaa of tb« Wtun AlHL 

X falaa m man awful twa an i»a« when counter irritation ■« 1j> )>e 
mlM orvr viTV dn>jv«iiatnJ parU. I1>e m4<>» may lunat oniive«i«nlly be 
•m m the Miituiag my {Vig. Hdt: A (M of akin alxMit tM» iuchca or 





< b pdnrlifvl on. and iu biuv tran»lixMl by a narrow- blade*) 

T&r hluu! end >>r an 0ye>l pmlx.-, ihrva<te*) with one or more 
Iff tbirk. ■rll'Vaii-') -lilk. is m"SI pushe^l alxnfr tii<> Ixick of the blade 
ki«l til |*Hiil. ati'1 ihr bUtiHiry Ix'ini' withdrawn lu the pr»Iie b carrim) 
•*>rfc. ibr arlnn u ltd in ibe wound. Water drcmiii|* should then l>c 

iW Ac(a»l CaatwT i* vny aitnccwfitl in cJirrmic InnammalMn of jotnta 
^fc»4Mm«iiunaf ilie ntrtiugca tiaa Mit in. and it ia M|i«>clBlly um'AiI wbm 




236 



LOCAL LtlSTURBAN'CBS ANI> ISri.AWMA^ 



tlivrv u ^iviil |>iiiii nilti nueCiifiial vttii'liuxi'. Tlu- rvlii'f tihtiiini'il liy iti* iiso 
is olWn imnifdiiile inul pcrinnrn-nt. In iW ninitinntioii .if tin- ciiuury. it in 
Uie objeci ol" tbo Siirg«oii to •iottroy llic fiitiol"* »iul ihv t'\\» of lb(- |Ki|iillte, 
hut to leave the (W'per elnictiirrfi of ()iu »kiii iiniiijiiri-d, su ttinl (iH-n- shiill 
be nu coutr&clioD of the scar vhcD tli« si>ro in hciilm]. 

For t]iis purpose, tlie caulcriun); iron should be of m (iiill-red liritl, nnd 
mufll be <|UiukIy drawn in linen crosMn}; one noother over tlie pari. i'ai|ti«> 
lin's ihermo-raiilery is, ou tbe irliole, llie nitat intii)«;;eitbte nnd ifie eliiincM 
form tJial can be uned. The barbarous application Itnowii aa TiiAro, which 
eontitMcil of i-otluii iir jiith ooakeil in eallpelre, and alloned to btiru upon the 
skin, i:< uiiw no l>>ii}t;i-r uand in thi» cnuiitn*. 

Two c-oiint^T-irrilnutd, id mlilition t{i tlielr local nctioti, priMliice i^<>n»tiiu- 
Uunnl t^OiH-b' when alMuirbed fnim the Aiirfauu I" which lh<-y nrx- a|ipli«<l. viz., 
Io<!inc iinil Meroury. 

Iodine in niiMl eommonly ttpp]ii*<l in the fonn of tinelnre; it Khould Ix* 
paintful (in ovvr the intlanieit pnrt twice n <lay till tlir xkin hcooinnt it little 
Burr. Tlii* may be cmliniJi-d for wix'ki' or nuiiitJw, nccording to cirfinm- 
ntnnct';'- It ii nn <limht ii iiwfiii mcanc of )>r»inotine thr alinoqiii'm of 
dironir inllnniniatory prvwiiictit, Imt the power* popularly ac(?iibr<l to il mn- 
ct-rlainly far prentcr ihnn it really poswwiw, Tbo liniment is Ip-b rrcjm-nlly 
tised, b(<in); a much stronger prepuraiiun, one anplicatioD of which will nlVti 
cause vesication. Tbe ointment tuay be applied in same ca^es in which a 
enmewhal stronger action than that of tbe linoturc is desired, but it is not n 
cleanly application, ainl is not usually to he revoni mended. 

Hcreury is applied locally in many foriuH to jiroraote tlie alNwrptJoo nf the 
produds of dironie inflummatioD and in the treatment of the proc«tw. One 
of the modt common mod<a of aoplyiu); it to rhriini<»lly inflnnird joinis is 
by iha metliod known ns Kcdtt'n dr<-»ttiji- TbiM cunniNtii in fiircadin^ a thin 
layer of the ci>m|iouiid mercuriul oinlmeiit on a pi«w of Imt of ^urlioient 
siite to Atirroiind the joint. Ov^r ihi.' Hiriipping \x evenly unplied, «> n* In 
exert n iinifunn pn-Kinre. In other ramv, thi- ineixrurinl lininx-nt or utinple 
mereuriiil nintiniMiI mny be of unr. .\b(iiit t<'n Venn' a;;o. Mur^bnll intro- 
dnml n valniibl<.^ prcpanilion com|Ki>>i.-<l of llir pri'cipitntcd mrrctirie oxide 
iliioiotved in i.li:ic acid. There in ihiif formed a dflinile olentc of nwrcnry 
which in Mflublr in an cxccwof oleic acid. A solution made in this nay 
cimlaining lire |wr cent, of the oxide is a clear lifjuid; when the oxide is 
inorciiscil to twenty per cent., it forms a solid unctuous subeUnce. nicltin;;; 
r-ailily st the temperature of the boily. As ibo olente of mercury a slightly 
irrilntinj* m the skin, one ^raiu of morphia may be added to cadi drachm. 
Marsh a 11 stales tliat hifiex|>erience of Uie uaeuf this pruparaliim in all forma 
of chronic iuflaniinatioa has been most favorabk. It u cleaner, more <lif- 
fusible, more readily absorbed, and more efficacious than any other nxTcurial 
ftpplicaliou. The very fact, however, that it is go readily ahsortied gihould 
make us careful in using it in scrofulous subjccUt, who alwayx stand mercury 
badlv. Ten to thirty drops of the ol«ate, melted, if ni-reMUtry, by a very 
gentle heat, and applied with a cMni«rit-bKir jmicil, is (piilc suflicicnt for on« 
application. 

Aitnngenta dirretly iijiplied to the inflanKul parts are of uxtrcmc serviw 
in thuac formi>ofcongvi>liv<Mir passive inflammation in which the circulation 
is slitjci^ish and liie cnnillflri<« loaded ; thcv afford relief in these caa« by 
inducnig contniction ot the vcwcls. In ortier to inMiru their proper action, 
ihev must be employed of suffipicnt strength ; for if loo weak they irritate, 
and incr<-n:<c rather than relievo the congested conditinn. Tbe nitrate oi 
silver is the astringent that is tiutnmonly preferred ; and thi^ iipj>1ied either 
solid or in soluliiMi containing from t«n grains to one drachm of tlic salt in 



CATAHRIIAL l.trr.AUUATION. 



S87 



NBlrr, «ilt jirolun* n Ti^ry inarkitl Wiitflviitl iiiducuca 

ruili'io i>t' th<i mucous and cuUidmhis ■nrlnciM. 

bjr innuM of «<.-ll-Bp|>liv*l )»ii(lAg«c. etastio ticbbhi);. or •ini|» 

p^ii af aaratut M-rvira in supportiiiK (be fe«l>lo veascU in L-oDgotlin) 

' ik lu lunny ciucs, pnaiins may be adraiiiajti.'ously om^foiood 

■fei viil niln-raHentoias mercurial auil eaniphor liuimi-nU. or 

I lb|lMltr«f ■M-fcurvuiiil nmtDoniscum. Tbu trealuenl, by removing run- 

,«»tl pfuoHii^i 'iMiqitiiMi of inflsumiator}' eBuMoii, U»()ei-inliy 

■riU a riuuaie fn.- liiimiiMtJon Kcootafwiieti by UiickeuiDg of [Miru, 

l«)itl» juinta mail b^trn. 



nATAHHIUL IKPLAMMATIOK. 

Owwrih or cuUrrbnl iiidctBiufttioD, » a form of the ])roe«M of inflniiiuiti- 
I tActis); tnuoiiu* itiembrajin nn<l utiter epillivUum-covcrvil -urfnn*. 
fill ikoB «rr liAble, us otbiT (itnii-(ur», in (raumalic iiiflftinuiations f( the 
(»..- Ml "liich. a^a vou!«>iut'nc« uf the action ufiomu irriliiiil, (he 
MMfcitii:! ri-ulntfim 14 rvtnnkil, ilio white corpUBclw iuit:m«, ui>l 

Aa ^jamr .^1....^. - . --i !— nm) the tuiictionnl ai-tirJty of the origiiiiil o<-ll« 
M tm ym ^rd or [hi ' nltulisbii). The pccuiiurity of lliv cnlarrhiil 

iM*. W>BrVt-r. ciMi- < Inrt ttinl, iitthi)4i^!i tliv vnvela nn- Otinli'-I iind 

cta^HMi of blooil 1 III rvru ihr abiimliiul tiH.ii|>cof wliil<' ■.■iirjxiM-Ii's 

■ liktac pfatc«. liuiii rvxiliniu'* (•> cxiot nml |H'riIirtii iii> fuii«- 
M^M^wiU'- !l< niiilli|<lr wilh uiniRtural mjiiilily. ('ntarrli 
mtf aiimr (tvta tjii. ihi'ii.'t Aiipliiiitiixi of an irritiiiit l» llir Kiiriiirw nf llie 
^Mifl* HM-mbnuc, a* in [In- i-otv iil'il<v>itii|Hj«ink> urine irriUiling llic IttiMMer 
mit foocrrhii-nl i>ui> artiiii; on tlic urtthni. Tbut in thcM' vntce ihv vcawlfl 
J IW conwm ami •ubninnxiit tnouc ^thnulil xhim nij-ua of ilamai;^, by tlwir 
^1^ uit to at) abundaut Mutlalion. hu<I by the « hilc eorpUHeW [MisMiig 
ApMfa thfit «alU. while tl»c ■{Hlhelinui is cum]itrntivelv uninjUKi). «bow 

IfM nulwrr of ftiniuUliim liuut of im|iain>(l fiinctiun, at fin>l H«tiis 

' tBrxplicablf. It »iii<t unt bt krpMen, hoircvcr, lliat ■■pilfacliuui ia n 

•hirfa iHWNMwa in a litgb tIfigiM tbo Mwerof r^vioting cxlvnial 

I lafltMocw; mmI it U i\ii\U) ooneelvable. therefore, ibal a eautp whieh 

> BM* tban a ■timulatnii' actioa on ibe cj'ilbrlium may, if it penc- 

' t» tJ>e part* bentatli. invv rve to the |>brtiomei)a of intlaniinaiioii. 

la oOftT nwy. tlx esu^e -if nilarfh u nut m drar, as when a jmticDl in 

Iby brnorfaitia, catarrhal iici)hrili«, nr cyfttitis, a» the rfstili nfcatch- 

L** Id tb«0 ouea it i» probaW thai ibr contmclKXi >•( llie ctilntirmi* 

I bypencniia »f the inu-riinl urptne, but liyjierietiiia alone it Dot 

; |» ntoae raturh : probably the ioilatumatton \* -luc io part, at Inut 

■ ifecai^ ' Ilia* M»d kiiliMy, to increased work tlirunu u|x>ti thcM: 
^piB te : ^lauw oflboae iiroducta of tis»n<s<.-haiii;e vrhich eh»uld be 
pim4t kir (Itvakiu. (hir knowledge is not, however, aa yet MiBtdent to 
■nUi mnonally ib*^ drigin nf all catarrhal iullitrutiuiliom. 

Ti» ifcawgw la tba aflactoil ■Mmbnnc 'leiK-ml <>ii theilejcreeof tbeprucoaa. 
b ikt aiUHi liwan tlMT* la aonw swellinK ilue to exudation of serum. Tlib 
fanly ilMt#od* tho louse fubmuomu ttwov, and drninn olTby the lympbati<«, 
■arifafll* il'.n* may fn»i lli» lUrfiH-e of the nirmbrnnv. At the t«inetiuiv 
thiaril*': .'x-lium multiply mure ((uii-kly tbnii imlural, and many 

ss* tawai . .,., ;ue away with tnit diu'linr)^. [ii all mtieoUM meinbmixv 

tkm W an rtanimUeil fitrtiiniinn of inoni* iloriutc ■'aiarrh. and lids in- 
tnmmt murHii^hTtm Am mimt nmrkeil olinicml fvaturr of ibe mihier form 

U mn iMtBMa caUrrbal Innammalloim, ur poniUnt eaUrrb, the TWii l i 





I.OCAI. UtflTrRBAMCKS AHII tVThkUU XTIOS. 



of titi; coriiim of tbu iniicous iiieinlirniu- nri: wiJeljr itilnittl. nnd tbi- M 
Uiroiigli thi-jii is rclnrdn) ; liifuiil exiiiltiUun ia itmn: ronifHi*. iiti<l ll>r wbjj 
corpUHclcs migrate til>uii<luully. Thu leuniojPta, wbidt lliiu Icsvc tbc tohJ 
WMiJcr anioafiist and thruuK)> tliL* cpillictium-celb, tbi< uslural I'ulHvtno J 
wliicli is !«uro<-*w)inl Imjoeiicil, iiiiil ocnpe on the surliirc, furming nitli tfl 
li<|uid I'lcudiiiitM) a [luruleut i)iitclmrf;«. Tliu •liwhsritc in fucIi » caw, J 
vxauiiiiol ti)ifrxiM.->i|iii:t>tlr. will be fouuit I" L-ontniu — iiunn-n>U5 annrUJ 
celb, Mmi-titin>; tbi- u.iunl n|tpearaiiiV of vihite bl>KHl'Cor|)usi.-tcs; •>nltu»]j 
|Ki»«ell». r»iititf iiixl i^'riiiiiilitr Willi tbi' (ripuriilL- iiiii-lciif>: sihI rpilbcliad 
cells, same fully <K'vrli<|H>l nnd oirnviiuiKiiii^: iu furni to tbai iiaiiirnl la ll 
iiHiKted lurpulirniii", mhhhoI' roiiiidi.'d (iirm vouiij; mid iinjwrfn'tty 't'-V'-'-^ 
niul oltit'ra ciriiliiiiiiiif; n Uirgr lfiiiiM|inn'ii[ ^flolitdi' of iuiicuil At' ■' 

cxnmiiiiititjii <4' u «ri.'ii>iii of lliv iiii-iii)iniii<' .■'bnuii (tint, in -ipili' ><; ■ I 

ttiiiil diufbiirgi- of pUB, thorv- w no rnw surTiuN'; evi-rynhiTfi it J- . m r. I h 
rpitbcliiim. Tin- nni)dcriii>:fclUL-iiii Iwmhii in llii* (•ririiini rmind lii^ *■"< 
iind iti)rii«;<tiittrly Ik-iicuiIi ibv cpitlH-liuni. Somv of tbi^ cpitluliuui-cvll* m 
bv I'lUiiiJ looiiiluiii witbin ibem revrrul ImhMm iilfiilivnl witli iKi^-ooqHlfcli 
Tbi-m.- wcTv eupiNMeiJ by Kind Hf ice b t<i tiwvi ibat ibi- pUR in )Hifulrat vftUU 
Ka« tunned by cndoj^nou^ cet I- l'>r million I'rnni ibi- v|kithrlium-n-ll-. \m 
iibwrvutiuiiii, liowcver. huve tcixltsi lu pruve tbut ibm? uprarvnt mitlbvr<^ 
are in mlitv dtmt or dyinc eptbtliuin-colU wbicli b»vc bwn (wnrtnucd 
wmidcrini; leuciKiyt*!*, W nnderiDK UiK-ui'ytuA iir* also foutid |iruclniti 
bol«Oi-ti tlic tiidividunl eptthL•Hum-(^4■lU. 

Allboujib in |iurLili-nt c-iitorrhul inllaiumalion tlwiv nted be ao ulcenitl 
lh« alxivo di-MTiption -ibowtn bi>w n-tidilv une pniww mny In- (viuvitIi*! ii 
Ibf (itbi-r. TIm- iidbvi'in ot' Uio (^pitlii'Iiniii-wllti lu cacb ■•tlK>r. nnd in i 
vorinni, i.i KlwiiyH ImBoni'd in ibv luorv tcwtv runiiK nf cauirrfa ; -' 
bniH'ly ndhrrcut 4'pitbclixl Inyrr bo aecidrDUilly n-tmivod bv vi". j 

vtilbout, ur w.-piiraU>d by exng^^rnitcd tt'll-iui^raUan bcncAtli, a Miiall tUi 
will tic thu rvMill. 

Vkri«tie» of CaUrrfa.— CnlJirrb, like olbcr furni» of infljunnmiitw. « 
bi! tictile or fhronir. 'I^ic i-lirnnic furin is very frcqneDtly MMuciultnl m 
pnwiTo bypenriiiin of tbc |Mirt nirecl'.'d. It may nUo be limfiir, mt iu br 
cbitis. or inferiiit, as iu purulent oplitbalmia or gunoirbn-n. Tbo ibi 
inn CO- purulent secrelioQ thai fonns on llic »nrfa(.>c of a mucous mcnibn 
durini* eutarrli fVv<()ueiiUy servca a> a uidus for tJu* growth of inicnwni 
ur^caninni!-, and ibe fcrmcutatire cliaDgva llius *el up icivo hao In pmdii 
wbit-b mny prtilong tbe Irritation, and cnitw it m gtirvad alunat indi-flniu 

Symptoms. — lU^ueM uf tint alfc^-lcd snrraci-, «illi iilit;bl savJIins, ami 
abnndiint »rvrciiiin, varyio^ rmni n i>urr< mtou* to ii tliick inuc<>-fi«irul) 
llnid. lifrin tb<< ni<D>l niiiikrd clinical featnm uf a cnlarrhnl tnllBiiiiuBti 
Thfl heat is usually nKKlcnitc, and pain i* ni>l a miirkcil syiin 
tbo morn amt« forms, as in |iuruleut iipLtbalnua. Ttie r»n.-: >t 

t»inN vary with (bo acutroeM of Uiv prooov and \\w part afloi'U<I. 'Vsan 
only till' inrui amta forma of caiarni ^iv rlso m any rlcvatlnn of tiuo|a 
lure, 'Vhf ■Iw'iicc of ft'V<'r ai«y ixwiblr Ik- aM-<>UDl<-<) for bv the fact I 
till' rxiidiiiinn dniiDB Bvny ftxim ibe *ur<acv nnd but liltic fin^ its way bi 
iut'i itifi bl'xMlKtrtMiRi. 

I'Hrtit u'hicb liave HiRerw) from ebrooic tnUirrti, or frum npounl atta 
of the acute form, usually )iccon>c more or loM (MfniMitcd, aod Uta a 
macotn tuaw b tliickcnvil and indurated. 'ni«ee apM nn «pII imo b 
nooooa in«mbnui« uf the bladder in cases of nld Mricturr or etoiH. 

The trMtmant of ntinrrhal inltaoiDiation prtaeots little tfaat rtqn 
■pocial notii-v. Id tbe uiorc ai.'ut« forRw wariuth and inoisture, and abi 
all rviMuval nl' the diM-har;gv and prevention of it* de(vinipoMtii>a, fq 



CHAPTEU V. 




SHITIIBATION AS» AltSC'WW. 

[bo furmailun of j'lu, liiu Hln-aily l*«t.-ii il(wcril>e<l in the 
ixiun. It «M ihcn pointed niii tlinl i)h' iirocew conaitla 
ittDuaDM' itiitl i-xa^gt-rntion vf hik- nl' tin- fiu-ti>rs uf iiiflaiu- 
Bwnitiun «r iW wliiu- porpuwIwL Thi" wiiiiiii-riitg c*U» ncni- 
towitaHlr tkr rtwcli, nttd ixwibtv niullifity ti;r ot'll-ilivinii-ii iii llivinivw 
>, but lliic u ciirfiiidy iluiiblAil ; mt ihr ncvtiiiiiiliition iiicrfnws. llio 
tMMKM t)n.-»tiM- jmmvil upon kdiI alworbiil. ihv iicw ivll* oO(-upyiii|; 
pb«»; iiRBlly. Ilic ix-itlnil cells of the grouji df|;ciivrntc from uiiiit of 
bM. Llimr iaivrcellular hiIMaiicv sullctif. Kud iho liijuid vxitdnttoii frum 
■nooadiag port 8u«lu in amoURfet them, nod llitu we ^t * rn-uniT 



liimwtw, w« bsve tbe uppoftuiiily of fxamiHin;; micro- 
nil* M)*^ a anuut oilleclion at pus lu tbe subctitaunxi! iii»up. the 
wf ■ranumocn ire ubeen,'od, pmceei)iii|; from lli« itrcuinfercui'o lo 
bU« nf llw olIixlFd una. The first HlgD uf (leviatKxi IWhd liealtb 
1 i^Dr *catter«d Icutocytt-n nrv m.-i-u id the spacca between tlie flbm of 
■BDrctiTr tMi». uii] oftcD cviilcuilv ill the neigbborltoud of » uuull 
: •* ibr rrt)tn> it nnproachi'd, the iitiniUT i>f time inciTKMW, in«diiiitly 
Iv (ilwcurtDtt I 



rcmpktrly (ilwcurtDi^ tlu' r»iiiicy'tiv<- ti^nui' nnd its curpUM'lot. 

hM notbu)|f ii In be wevn l>ul cldM'ly {iAcki.it Himll mund (vll*, Ix'twn'n 

iht atui-utit >S Interodluliir fulwtantr i* loo Munll l4i Ix; rrco^iwl ; 

amtn <>/ itiu group of cull* may bi- a cavity rrnni itbicli tbo pu* biu 

i m prrpariii)! tbe MctioD. Th(r <.<ono<«(iv<- limue, wbea it h Uat rcc- 

k b«J'»n Wo^ <-i>n<Ta)e>l by the intiltnuing leucocytw, it *cct> tu 

ki SbnB»«ollrtt aiid vitnoue in appeanince, uhile JUt corpiitcles are 

, evid«ntl]r, are lakine do pan in the fomiatioa of ibe 



till UIUIBIMI lUlU Ul« UIUUU-HUWUI Ul UM 

I b) hr «xp«riiiMutinl (Ml. It liml M'urv been sixiwn itmi nliL-ii eii|i<l 
r ia ■ MMc of cxtmnely fii>e divtKioti in tujivtnl inin tlic bli>u«J-etn«iu, 
Ul» eurputdca jMck u;i tbr jmrticK-w in niiicli llic Mnto nnv at an 
I tftlCM iu food; ami thi* iliirk wlon-il purttrlM of nitilini.-'[)lue or 
■r an caaily reci:fniitc*l in their Hibrlimco. A fm^ liiiviD^ boon prt.'- 
bj tike i^}«etk» of the cul'Tiiiff iwillrr. iiilbmiriialion <>)' HutBcirnl 
tj lacMM* Mp|Kiniiii>« «n* ^-xnW): nml it kik fnaad ihut, uhrlti«r 
m > ww r utar iMrt or in s iion-vuMiilnr, lu ihr curtini. tbi- puff-cclle 
ttd particln »l tbr wUlnnix- which hmi iHr^n inji-olcl. 
lljr, Umtc li Um sfgUiv* olwcrvution. thni in acute inAnminnlinii^ lh« 
U c*lk of tba a&Mcd part iiD<lcrg<.) no chuncr m long »t thoy can be 
(d : ifaat •• to tay. before they arv conocnled ny tbe cromle of migntt- 




rMMn af Pu. — Pik pnwnls (.-onsidenible variety in lis Bencrul char- 
Mtncdiag to tlie cauae tJiat giv«a rise to ita furtimtiua anil ibe geueriil 
Miottal ttate nf the patieoL 

pna tnm ati acute absccee in a peraoD otherwiae healthy, ia nn opaque, 
r tuid, thick, emootb, and sli;;htly vi(M.'t<1, of a ycllouwh-whiie color, 
a icrceniah tiogc; it has a faiut udor aod an alknline 
m. lu •pvddc frn^tr >> IVuni 1O30 lu 1033. It coDiaiua about 85 to 
of «»ter. or toe Miliil matter about two-ihirda a albuim-n ; of 
thini, about oiie-half b vonip<«e<i of faity niuttirr, tnrluiliag a» 
rioe. aui) the rMl cooKbt^ Hiitlly ol'sall«, wiili htirin, 
vmrietj r>r other uniini><>rtnnt cimifiMmilii. The mlta nn- the 
I A«M finad ID blond-Mttiiu, chloride of todiuui being the laoH ubuD-> 
fmt pnamtuiig iImm clwmcten !• tormed healthy or Uiuilable pua. 
MM Mbcr WfiM an- npi'llril to iudimK' anpettntK<i-!> ik-vintiiifc from 
IwBllkT poa; thuK, whcD tiiigcH with Mood it ii cnlli-il tnnioiu: wbi-n 
MalrfT. iehonvs: wfatD ooniainiug chenrdook ing flnko>, i-un/y,. 
dilulM «itb Diucua, mvtv-ftni, tC^iAv tbe*c, pun pn-M'iit« other 
mi tbHt.fbr iortaoo.'. <• ben it » furm<d in the brain it ia of a greoniah 
~«bni io tW avitfhburfaood of the nlintcntiir)' canal it hnun |iecaliar,. 
Ita cfacmiad ootnpoeitioo may likewise vary undi-r difformt 
tltoa. <)fdinary pua iWioed in the aoft parte eraiuitis mer ' 



234 



LOCAL DISTCRBAKCBS AXD IXfLAMH ATlOit. 




— I'Hr 

III tNI 
9 tb» 

1^ 



va1ul> of oouiiler-irritatiun u reoogniied by aII gimctical Sur^^eooi. bdiI 
oouDUr-irritaula are uniloubtcdif amongst tbi- mcwt vlfiicUte lomi tora 
that ir« ntHMMforcumhutingcliruuic inflaromatKiti; yvt ibdr madtof ■cli 
u difficult U) «x]>laiti. Th« old iboorr (bat bvi-xcitin^ a local inSatanutini 
in thu »kiD it n'u> [luniiible lu ilmw the 4li*u«»)- iknajr ffta thv •Im-fM'r a 
more impurtani piirtii ih no l<>iigi-r tt-iiebli;; (lit- (Itvury tjiat by •tiinulal 
(if Ihe eeii»>ir}- tim-m of tlic (kiti a dilntatiun of tliu uiporficial vcmcU i* |irv- 
(luoed, acoom|)«iiir>il t>y ■> P>irn«{Hiu(liog oontfaction in tlio dwepKr 
oaanot besupporlcl by scU-tilific vvidciico: in lirict, ai Itilln4h haa 
out, it ia pruDulitc thiil iti iiianir casw, eipcciallr in rxtreiDcly • 
chronic iDflndimnltou;. ihr guoi proiluccd i» probably rather by an ioi 
alfluxtif bloiHl to the nU'ecte'l pari tliaii by a iliniiiiulioii nf ihi' blmKl lupplj. 
Moal cuuut«r-irn[ant« are upplt«d aolely willi the inlenliuu ui i-autinf a 
oortain liegree of hypera-niin or of tnflminiDatioii iit th«' jiart uf thr akin tw 
whkh they are placed, nbile otli«re exert, or ur*^ «iiti|wMyl tn riv.-t, at tht 
Minx- liniv a constitutional elfex-i, b«iu^ abaorbed iiilo the *r*tem Cma tba 
eutaiti-inii tturfaee. (.ouuter-irhtantti are rlawrrl aceurdlng tu the drgn* nf 
local irriliilion tbtry pve rise to. 

Babcfacienta ant thnue that eautte merdy dilatation of the ve««U of 
part to which they are applied. Hot fomenlatjoo* and liiMn^)-mt«l 

tiwe. alihouzh oot u>uallr da«oi) amongst rtibc<acifiit>. tvrtainly 

dilatation nf the TOwels. friction with somv ytimtiliitiiiK «-inbnmtton prv 
dnon hypenrmia, laming for a longer time, and i» UM-fuT in |>ron)otiii(J^ 
lUMorption of chronic iiidanimatory prmluctK, Nuch as tliv thiclteolDf ^^ 
RMUxi a joiiil nflrr iin inAnmiiintory difitiirbanoc has subwdiMl. They' 
doiihteilly art by cauainf.' ■ ^'cncral afKiis of bloiKl to the limb. (.'«iii)i 
liniiiteut or. if a stronger action is reqiiireil. the compound raiiiphor linif 

in that iiiuot fri-<piMilly used. The •inJiiiary luii^tnrd pnull>c<« or Ktj; ' 

niuslard-leavm pri«<ii<y.- the lowest potiaible di'grre of true inflamnuiii'iii, but 
if properly applii-<) there ti< nu bliatering of thi? skin, Hltlitu){h Uktc may b* 
«li};ht iiileiim fiilloRi.-il l>y denpiomaliun of ilie ctiliclr. Miii>lnr<l {■•■iltif 
aro Ixit little iwd ill Mirgery. They ttrv lonrc coinriionly ii)ipli<i| |i> tl 
trunk for thv relief of hyp«m:niin of iiiteriinl organ*. (^1 u{ turpmtji 
sprinkled over flani)eli> wrung out of hot watvr i* another rommon mb 
faricnt. 

TciieftDts arv ihow nt>plicnliona whioh cauve a d«gn<r of inflapimai 
Bulfieicnt to uivc rise to nnundani exudation, which ratsre the cornt-otts la 
of tlie cuticle from the Malpighiiin layer brneath, thus forniin); n Ittrb' nf 
blister. Vcaicaiits arc cilcnsively used in sur^^ory to promote aloorpiioti >il 
the prmlucls of chronic in flam ma I ion, and in aoiue caat* to check ihn pnv ' 
cam, n» ill the applicAii^iii of blisters in chronic aynoTitis or pertoetilb. or in 
tho poriiH-uin in chronic proatatilis. 

AJtkough then' are other neam of prnduciog reiication, {miotirmllv tl 
pr«|Mnl)0na of caiitliaridea arc the only bIiMcrin>r a^'''")' i-mploynf; 
theae the Iwn mivt oommoD are the Ktnpbutrum t'aiiihnriili*, urcomminti^ 
Fly-btislcr, itnd the Li'pior Kpii<|iniitii-ii«. Tbo'fiMlBer b ap|ilie<l tit ■iirfa'' 
frM from hair, tho latter to tin- ix-ali) or pcriiMun. In applying a blislrrj 
or tho liquor vpi^aatieiu, it ii enontin! thui th>' jmrt eboald m at frv« AmdI 
graaaa aa ManDlo. and for ihk purpi«c it must be mulied with WMip and hot' 
water, and alU-rwar<l8, if it c«ii be convenieotJv done, sponged over with a 
veiy dilute solution of ainmonia, bofoi* the blister is put on, 31w bli*tAc, 
ahodUl rise in from ct|;bt to twelv* hours. When the hieb la fully for 
Ef it ii tioC intcndMi to prolong the action, it (Jmuld be oarcflillv prick< 
with a needle, but the cuticle should not be removed. It should then 
covered with cutton-witol and a tMndage. ur a Utile nmple mnttocnt on : 



OOOKTXR'IHHITANTS. 



28S 




fi^or nt liauL If il br tlnirvd to |tnjloDg tbc cDiinU-r-irriUtiuD, tlw cuticle 
^r b* rMttuTMl, ftDcI iIh! rail »urfiic« arsMnl with saving ointineut, by 
vMrh mraiw K may Ik* kejil niieD u laii); ns is wUlied. 

A klariw dota (»<, u a rolv, leave h scar ; l>ut il may do w, and it id 

atU. tha wttni. o»l In applj il tn the face or liauds if it can be avoided. Tbc 

ailaal tdtaifatr in « lurli ii u nppliMi miiM not excMyl a Tew mjumv iDcbca, 

l» tWn ia «m» dauirrr of tiic abvirptiou nl itic cautliandiue, nod of oon* 

(■•fiatioB nf tbe kiiliH-VK, bieinaturia. and Urangun-. Tliis will, of 

h»pfwo Burp mulilj" if i)i«rc be a raw Burla4.r bcnoilii tht iilnatvr 

■nl alwaja be uwd nilb p^^t caution iti very old or fii-blc iiul»- 

|R^ Bod in tliaiir MiOiYin^ from Hright'* dinoaiH:, or any otlivr MriMiH 

ratviml aflfrctino. a* in mk-Ii i-amv lln-y (■'<-a>ioiinlly cnliM' iilvUghinj^. 

•r ^Oftiut oenntar-imtanta nrr ihow aciMiti> which aro of 
tatcBMiy to givi' tire to inHitnimation n-nching the riagv of euppti- 
T^ noM conitMin of thvoo arv crotoo oil, tHiics, Mtone, aod llio 
oautefY. 
.1' ■'-- -.-iai wrviccin chronic innamtnation of the vtMcra, jojnls, 
1*1 (■'Or, ip|iuratii>D hii(> taken pincf. TWy tdiouid Ik applied iu 

Ai Wk pari* "t<r ih« aBbctml Btruclum, and Diny be kept open f>ir a very 
•M^rrabl* lcp|[th of time. They are best made in tlie following; manoer: 
i fm v w nf atllMaivc planter, about two itirlif» squaiv, liaviii;; a hole cf th« 
«t uf a »billit>tf evt In its middle, is fixed upou ibf part vrhere the inaiie \» 
»lana4t«; a pin-r i<r potam fuaa, about the size of iialf a I'hirry -stout-, iit 
pla«d on the *uruce left uncovered by thi- i-irmlar L-t'iitrul ii)i<.-rtuio, a 
of pbMicr bring Uiil ovrr all. Ttic |>«tii.-iit (?s|Kricnoea a burn- 
fer about two bi>uni, whan it ix-iun-^: on n-movin); tlw plaMfra, a 
iatoaKh,oortt»|-«xling in iti/ir to (he craxral n|Kri»rf, irill t>0 found. 
V dniailBg Bhoutd bt- iipiili*''! for a Ipk daya. until il Mi)arat4«, and the 
mrht^ then dmacil witli »avim' oinliiM'nt, or vtimulaUil by an inane- 
W>-'>-"-r it *1m)«g a tendency to heal, it tiiay ]» kL-jtl ojien by an 
>n uf the ]»<flitNt fusa. 

Itofi .- il iwvful than an »ge when CMinler irritation is to lie 

. uTrr vrrv tlmp Mlwlj*r1a. The m^im nuiy m>.«t conreiiiciilly he 
m^ ■■ tlm fftlfowiog my (Flf. KG;: A lobl of !.kin nlxKit t«o inehn nr 




rif. M.— IsinxlMllaB of > fi*Ua, 

wa n hraadUi w piiirfacd up, and its baw InmslixHl by a nnrrow-bladol 
tattNTy. Tbf Iibini rn<) i-f flii <■*(*! pridw. tbrradol with one or niopr 
•fcnaifcof ib-'-L »^ll •iiumI cilk, is hitki ponh"! nionf; the bark of the blade 
Ihi^ hrmi ■ l<^•^■urr iH-inu wilhdrnwH as tlie pndw i* carrieil 

a^wh, -. (> the woumt. Wairr dressing should tiwn be 

Tfe ArtuI Caatary r> vorr imccnsful in chronic InAammMlon of joint* 
htf«« ilaUDclioii t4 ltM> mrtilnKt* bu m-I in, and il b ra|icclHlly iiwful when 



CATAKKHAI. INrl.AU U ATION. 



287 



rdJMflled water, will priMlurc n vi-ry tniirkii] beuefivial inHiiDDO) 
I bdbMMnMltoo of the mucoid otiil uutniiwus surfacos. 
bjr BM-am of wpll-apjiiitil tHUidaen, «lulic webbing, or sirap- 
idip. >• at Mwnriul trrftt-o hi AUiiiixrliDft IM fMblf tmwI* in coof^cstivu 
' tHMBlioBik Id nuvDV mm, pnman msv Im ulTniitaKvi>iuly ooufoitiei) 
lahMrUaU uij rulfrfncjaiia. •• mvrcurial ami i.-Min]>))ur lloimeiibi, or 
'Mwof awrnir; snd ■niiiMnincuDi. Tlii* in-nlitKai, bv rfmoviDc con- 
■. ma*} I'f-iu^ug ihe shwirption of iiirtnuirimturT rlTu^inii, in i«{>ei-uilly 
rfU >a ' rnuurtnflaiiimiitioD ftcooiiipauieil 1>y Uiickcoingof pnrte, 

I ia tbc ^^ .: ..'-i balMw 



rATAKKIUI. IXKI-lMMiXIOX. 

&tenli, ur mtsniul inflttaiBlsUuti, \i> n fnfni nf tlio proccw of itiDnmma- 
■fc tiiij. tnurmM tDMBbnuM* mxl hUiit i,'j>ii)ii'liiim-«orend Mirfat-vr^ 
liksv *re Ifablr. M iilliur •Iruotiinv, In irniiiiiittiQ inflmuttintiiins cif lUu 
l«t*r, in akiclt. u « r<4Mn|Ui-iiif uC lb" notion of mini; trriliiiit, ihu 
iM«,i' -I u rvMnlol, tltf whiif (v^rptiflL-lui la ■gnU>, wi'l 

• BfOMMA.. - ood iIh' fuiK-tiotml iit-tJviiy »f the oripual cell* 

t^Mmdol M (KituikUvutly nbollHtictl. Tbt' pt-ntliiiriu of t)io <.'ntiirrhHl 
In^ wwevfr, cotMb** in itio fact Ibni, iillhoiiKii ttio vtvsi'ls iin- Jilnlnl iiikI 
I of blood-plsMua uinl cvcu tW iibiimlHiit ivcaim: of vbiti' curixiu'liv 
tliftM|t pUcr. yH U»r r|>ilbrliutii cutiliiiuee to e\hl mill perfortii il>' furic- 
M, MM IB nKaC CMC* lu cvIIr iiiiilliply iviib uiinittuml rnpiilitT. Otlitrrli 
ftuBt tb« liirM K|i|)li('a[i'iu of no imUiiit tu tfiefturfatv of Iho 
nraibnaMT. u la tlw (.-siM-of ilrcoitipiMini; urini* irritAlinj; ibe bliulilcr 
r «f («norThu«l pui ki-tiiii; nn ibo urvtlint. lltat in ibc^ l-iu«« the vtwwbi 
4 ikv oorium uml •uWui-'iua tiwyo aboubl tthun sij^na of itKniiip<, by ibrir 
pjjj^ — . • . nn «bau<lnut , ■•■ I-)-. I,, nnd by llii? wbUi" <i>r|m»i'li'i< [lAMUiig 
ttMU, miilf. «hitv l)i ::ini ii c>iiii|>anilivi-lv uninjiirtil, »lii>w 

■( MKi" rsibrf (>f ■(itBulniii'ti iii^n n( idijiHini;! fmictioo, itt lirrt m'titf 
atttr itMESplintlitc. It mirt not Im: fort.x'ttt'n, buwcvcr, ibnl o[>ilh<.-liiini if ii 
ttt whith ptmMmm* in a bigb decree ibc iioirvr of rvfrifltiiig cxltninl 
indoMKVi; wxl it t»<|uiUiffooimT]iliIo. llii-irforp, ibnt Atiiuw.- which 

action ou ibi- t'l^lhcliuiii inay, if it [tctiif- 
Ml* Id ibv parts hraai' i-« tii tbo [>ht'iiuiii<^nn of mtlHiiiiuati'W. 

la ntbrr raa^ tba c»uw ui >-niiirrb ia uot m clear, a» when a inatiiot i» 
«afi««l by l>nioelihIi; cnturhal iM-i>liritiit, ure]r«liti*,aB ilw result of "euu-b- 
■( mid." In ihoa caMa it is pn^Mme ihat tbf contnetiuti of ibe cutaiienti^ 
< hrjwneniia of lb« iDlemal iiricunH, but hy|>^neiuiii itluiie \i nol 
lo t»mp estanb ; ]>nilmbly tbr iDflnni null ion in <Iue iu (iiirl, ut IcMHt 




aAifaMuf tb« Inns anil ktitnvy. bi lucrauvil work ilintwn ii{)<>d tbt^M- 
«!■■• ta tb« altaabuOvMi of thiao prwlu 



Nlucta of Itpcav-chany*! which »boubl be 
vnaaff by t!» -'■" < > 'r ki>uw1rstg« is out, bowvTor, a« jrct (uJIivieat tu 
tnUanliM^ . ••( all i-iitarrbal taflntunialtoiM^ 

I iWckaaicn* <u i'<< oii-- t--<l iii«mbrKn«'lei>eni)(iiiibr degree oflho pmcnn. 
' UlW wilJt fiira ibrn- in kjom- «in-tltng Juf l» esuiinliuh of •rnini. TItU 
|Wty diiim Jt Uw li««e ■ubmurou* liwur, aii'l •lrnin>o(f by tbe lynipluitit*. 
*■! lanly flow* away fnm ibo aurtan: of tlw mntibntno. At tbo ratw time 
k«l]iM tlM«|MKlium ino)ti[iW '< < Vly llian natural. uti<l tuaay 

'ramad and main a«ny wiili ih< In nil mnc'>ui> ntioibraiMa 

a aa *xagpvab~' m ■<! hh.i >• •Innnic cutarrli, aii'l tbt* in- 

inrknt cliiin-al frnliin- of the mil'lcr fi>rni 
^■kfiffMliaa. 
!■ ta«» tetaMe eaurrbal inlUiumation*, or puralaat oalarrh, Um- vewcls 




S88 



LOCAL rnxTCRBAKOBS AKP litPLAMMATlON. 



u( ihn cDrium o( llie riuoiuh iiiciiilirnno an- widely dilaU'il, ttixl tbi- iWal 
thniugb tbciii b n-tarded; )ii{uitl exudniiou ia ntoro vi>iiii<itH, ni»l Ihevkiwi 
CDrjiUMilw mi|!nkU- nbuudatillv. The leuouvytw, whiuh tlinji l>-nvir ili<- *c«kIu 
wander nmuiig:^ lun) tbrDusii (be epitbi-tium-cvllii, lb« tinluml ouIimmm 
nbicb U iiomisw Imt IcKHH-tiviT, iiud tMcttinf on the dur&cv. li^rininit **i^^| 
liifuid cxudiitiou a imrulvut dincliarge. The diwcliart^ in such • ^^H 
examioed inicri«<'ii|iiciilir, will lie found in rantniit — tiuiniTOtu ("^^H 
oelb, rin'M'iuiii^ Ou: uhuhI npiH'onini'r' nl' wliilc lil<iud'Ci>r(iuKl«> ; -inlnMiW 
pu»-i.'ell>, riiuiiil aiiil {^'caiHilar irith tlic tri|iiti'tiU' nuclcuo; and rtiiltirliuiiH 
oelb, •omu fully dcvolojiutl and ■■»rnwji»iiditi); iti form tu tlial iinltind to IM 
uflbchtl membrane, wiiik- i>r fouii>I<->l lunii ymiif; and imniTfl-ttly di-vrtujKJj 
and oili'-n (-onuiinin^ a lar^o Initial lart-nt cKiIhiIc <d' iiiiii-u». A aiH-nMnM 
irtiimiiiiiUon ■>!' » icclion of llic iiK-iMbraDc fJmws ttint, in tyiu- ot tli« >MS 
■lata <lWhar]7(> of puo, tli«r«.> is no raw aurCuM' ; vTcrjn bcru it in roTcml M 
i.-|>ilbrliiiin. Fho nandorin;; colla ran be seen !■■ the curium round the voad 
and imnHiliately bciii-alli tlie cfiitbi'linm. Some of iltc eiiitlii-liuni-mlU wil 
be found locuttlaiu witbin (lii'in M->venl IxHliut idctilical willi [>uft-(»r|MWt-M 
Tbesc were «u]>|M«ed by KimlflfiBcb i>i sltow ibnt ibe yus in {tiirulenl catartl 
was formed br «udo);e»i>its ct'll-fonuation from ibe e]>itbeliuii>-cellf>. Lata 
obacrvauuos, however, bare tcndet) lo )truve that tlieK< a|i«in*Jil tin>lJMf-MM 
arc in reality d<uid »r dytnic i'|iiltHrliiim-crlbi wbidi hare Doen iH-neiraUnJ M 
wandertntf K'iic>M:vt(.w. WaDdcnn^ lotii-iKyiM an- al»o fiMiud j^-nrmtfad 
bclnii-ti tliL* inilividual ojiitbi'liiini'ti'Ilii. 

Allbungb in miriili-iil catarrlial inllnnimntion tlwre Deod be no ulrvratM 
ibc above d<«-n(ilioti »bowii Imw n-adilv out pruci-* may be eoDverttil inl 
llrautbiT. Tbc adWiou of llin <-[<itbc^ium-ei'll» to each other, and |o U 
iwriuMi, '» always loawniil in the more »cvrr\^ form* vf oiUirrh : hIkhiM U 
looacly udbereiit epitbelial layer be aecideulally remuved br violrncr (t\» 
witbout, or »e|>amled by exa|;:f;emied ecll-niiuratioii beneatti, ■ email tiln 
will l)c the r£«tilt. 

Varieties of Catarrh.— Caiarrh, like other fonu^ of inHammniidti. ml 
Ik' ■kuU or rlinnic. Tile clitouip form i» very fre.juently asMirialetl wi 
piuaivi- byiH-ncmia uf tbe part alferlvd. It may abu Ik timpU, lu in bi 
dhlliN, tir inftWiiv, n» in i>uniluul o|>lilJinlniia or fcuiiorrbu-a. Tlin 
mMco-[iurulent areretion that furm* on the nurfacc of m mucuu* mei 
tluririi; i-alarrli ffviuciitly wrvn aa a nidux for tbe grnuUi tit niie 
organ 111 rns, and ll)i! fermcDiiiliri' cbangra tliuii Mt up give ri*e to prnlui 
wliii'b niiiT |>r<>loitg tbc irrilali'iii. and nniw it to viimd alniiial imlvtinitrl^ 

Symptoms. — R«dnon (irtlK- ntli-rii.-it eurfao-. uitlt aliKht melliug, uu>| 
abun-fani •c-rrtinn, varying (tvni a tlun.^ M-r»u» lo u tliirk niueo-pi 
lluid, form the moot marki-i| eUnieat ti.-alurr« .d' a calarHial inflami 
Thv beat b ueually tumleraU', and {lain to n»t a markeil - 
liio mure actile forms, n» in punik-iit opbtbalniiiL The • 
tuma vary with the aculcRrM of the procvet UmI the pari aliUu^l. Ad a rui 
only the mtitl atulc luring of ealarrli fpVA rise to any elevatimi of tem 
turp. Tbp alMcnoe of kvtr tna/ poesibly be accounin) for by tbe fact 
the exiidaiinn draiDa away firon tne suriaoe and but lilllo fiiwla iu way 
lob) the bliiol-HrauiL 

Carta which have uiflhred froBi eliroiiie catarrh, or (Ww> rtpMtcd 
of Iba acute form, usually bciconM more or I«m pjgnciite*). aod tb« 
nncotM tintie u thirkeiwMl and ioduniied. Tlieae vjgns am aell Men io 
mucotui iiiembtane 'if ll>r bladder iu raM* of old ttncture or iIuiml 

The trMtntent of ratarrbal inHammatton pmenU little that rt^vi, 
apcdal Dutiee. In ibi- more anilc fornm wannlh and inubturr, aod abci 
all n-iMoTnl 'if the tlwchargr and prevention of it* dcomtpaailitNi, 



surruitATtoH amd Auscicsa. 



230 



lb 




mifwrum neuti <>r tmtiiieht. Itclladooua u ofltu uf uite Iwully 
itktat giaia ■ml iiruiiiotioK rootracliuu of tK- muull aitcr»Ni. In 
Otafrli, nrntuvnl uf the w-rratioua hdU cU-anlitMiw iiilh (he ui>« 
lU, audi ■» nitrati* •>!' Mlv^r, kcvUU- of IiikI. Milphiilc of cojiix^r, 
_, fcna tho chief trvHtinrat. Aiir vnuitlitutitiual cuikIiUuii ds 
«r (n«t KHHt bv Marebcd fbr wxl tra(t«i] tf fuuiitl. 



CH APT Kit V. 



8tTI*rtfKATlUN AMI AIISCKSS. 

prrrt'UATi'ix, or tb« lornuilio« uf {Mia. luu xln-iKly Ih-fii ilvicribnl in ilw 

' «■ laftsBtaulioa. It wiu itx-rv poiD(«<) ixit ttml iIh' ]ir<ioCM« cuiwiau 

Ut rtt k oualimiMirr HIi'l i-Xii)!;;rrnlii>ii of one nl' lln' I'm-hini of inlliini- 

' nii](rMh4i uf (lie wliili- (>>r|>ti»clni. IIk- nnmli'riu^ ivll* an'ii- 

>«a(wW lkinMellLU<l poaBihlv itiiil(i|)ly hy ci-ll'livitii'ii in llx'ir titw 

"*, bnl dib ii utmMljr doubttul : «• th" ncciimuin(i»ti mcriiiHi-, ilii- 

tkaota bwotM praaM Upun and nliwrU-d. (bo ih-w m-IU iK-ru[>yiii^ 

RliJr b1m« : Sitallr, Uw cvtiInU cvlla of the group •k-ytni-nilv from Mint of 

■■ritwt, ihrir itiiiTccllulnr *ubaljiti(x- >ullcoo, and llic liijiiid exiidaiioa from 

tm wrt t mtKlinj; pun acwlui lu amoopl thctu, uid iIiuh kc ]t^ *> vreHiuy 

kid. or iHM 

I£ ■• •DoHiBiM bappcna. wo hant (be opportuuily of cxiunlDiDg mivro- 
MicaJly Micb a Muall eollwtion of pu» lu tli« ■ubciKaiit'oiM tMue, tbe 
Wwaliii aiinnmiim are obarrved, pnH^-nling froiu the uircutnfrrenrv to 
Ar <^u«< (IT till' sflrctTil arta. The fine tijga of deTtiittoQ fruiii hnlUi 
• iku «MBr ■oilirnil Uucix-Xtm an> »vru in the q)acc« bct«iH-fi iKc libriv of 
fc cenwrrtlvr itMura, nnd dftrti fvidcntly iu iha tMigbborbotx) uf n •mall 
•«al : aa the emu* b approached, thr iiiimbrr nf Umm incrMMr, gradually 
«■» aod RMH* nuBptetaly obacuriiiK (hu cuonvdivo tbnie and ita«orpu«cl<«, 
tlatlBM Duthiitg blobr •mi bu( doMtly packed im»]\ nxind cells, bet nwii 
•tflk 1^ amotuU of ^(rrctfllular Hubflanee b too»ninll to be reongnin-d; 
« the eaMn of tUa group of cell» may be a mTi(y from ntiirh the \yu» has 
aaaad bi ptvoAriac iba wctino. The connediTe tifcue, when il is la«t rec- 



^uaU« bclort h«Bg eooccaleal by tbe iiilillnilin^' IcucocrteB, b eeeu tu 
kanil* 6hn» •anltoi aad ritrpMU in nppearnnoe, while iu corfXl«cl«s arc 
iwfcaatnl T1>ry. r¥id<-nlly, are lakinK no jairt in (be formaliun of tliv 
■• ttlV »Iiii b nr.- cn<«<lio|t amooiEiK Lne fibres. If any bloodvcwek arc 
t' be tt*a tba(, near tlio nuiut ai which everyUiiog b con- 

i br t -. ^-yiM, tbcT are fllM with clu»ely packed blix>d-«>rpit*c)<« 

-, ibc prCMneeaf a clot of blood, h b in ihia way that ibey nn- 
I hAr*. in caaiBwa with i)i« other liiauea. they M>l\eD and break down 
* A* pwa—ci oi thr invwline leueocyica, and (huA all bemorrfaage b pre- 
xMad. la (hb *if* abo, althoUKh It mnnot bo aeen with tlw micriMCOjiv, 
A* ^aMM which ha* viudv) from tlit- veiMh b cuagalatcd, nnd with il>e 
"■mini «Ua facn* a ftnn aubauna, (bo a»-c»lled TnBammnton- lymph, 
^a lib mmd ola^ the tf«ea of Urn conDacUve ibaue, ami thut (ormi a 
WW rawMl tb« nillecUon of pcia. and pravcntu iU diffUtiing itarif widely 



supfUBATioN ANn Ansrxita. 



anwngst til* iHcuiit iiroiiml. Il i» not [MMiltle in n iwctiuti m«i1r frm t 
prrpnnitioii remuvcd fvitn ihn lioJy tu olwcrvo ihe rtnic uf Uh' jamti* '-' -' 
titu Hrm of MMb ur iliroiiibtwit; but if it wi^rv (Hwililo to ubwrro v. 
l\w liviii)^ body, vrc uliuulit •c4-. in n «|in-a(liii^ i>b»cn», nil tlw cvi<'lti> •• 

circuinrcroiKH-, nlnH*. uN:tlltui<.>ti, iliintcd rnwels with rctitnlnl l!oir, ailb«wa 
uf lli« cor|)ii«clf«, nnil migntliun, ■»•!, I«»lly, Biiiij>lc liyp«'r:riiiia— 4ilM«i 
vcHob nilh incrriucd nifiiility of How. Sui-ti ii colloutiou of pus h h ibm 
dvoribct), i* a iiiii'ru&ooiiiu ulwcvm ; as no ncotc sImcvm liutiliii}; lialf n pri 
of |)us, dilliin from it in iiu n?«{>4.'i-t cxoi-pl in size. Ttiv csi('ti«k>n ut U^ 
obsiMm tukoa place by jm)'^mttiivi' dcHlnii-tiou of l)i<i tiMuvti by tin- tnDm |itw 
I ae that ubu?i< deacribcd ; aud the |>ii4 a (uruicil by Miconfuvu ajon of 







C» 



iBh 



T'.'f;' 



^) 



.»T.-AMioMMart«AbM«ulkiba8kta. r. BpiifcHiMi *. aUalri ,.r.Smtaru 
Tttii»4pt In Ml** plMMbf B(g»tlB|t UuoMjtMi fL ih* eoltaMl** •# |>a> i a. •• 
4. ■8uiiin Artatyi /. FaL Tka TttiUM raaad Ih* esUwIlon tt pM ar* dulled Milk I 
efUf, litouuilni IBOIB rtsHlj pMk*d u ili« tvBli* of Hp|i«nlion I* apf r«*sh*L 

Uin new mils deKcnorntinj;, l>rcnnitDjf wpnnitvd frfttn each nthvr br flniibl 
nnd riillin;: into tin- mvitv of the nbocces. 'Hm wltolo proct«' i< i>l(^ii4vl| 
witli u I «-■' ration, but iiLstt-m) of (he discharge being ginn offKipi-rlii-inliy aaJ 
III an unlinnry iilt-i^r. ii imnmuliilrs in tlw abKua-oavily : nn nlurm i*. inf 
fact, a mviiy rtulixH-il iiv an ulit-r. Tbo /Mwof liaauc- in whirli tin- pr 
uf ipri'ndinji i« taking' pmis'. wai> in furniiT tinini a|H>kiii uf a* ihr " pyt 
ininulirnnc;" iiut it !■ I'ViiliTitt tbal lli«rv i« nothlnir to wlikli tJic li>nii "i 
brano" o^ild properly bf applinl: tbo "pyogwiw ion*" would U- a moral 
tvirrrct irrm if any tiicb in ncwmnrr. In Ini* pyugmii- «mi« ibc vnwtda arvl 
diUt<-d. and the limiiii aolVm-d, •<■ that in Kpinini; an nUx-i-M libiid may Aow] 
IWi'k fntni llif ciijEorgnt nwrU nuind itir cavity; tmt il luiMt not ba 
cVDcludrd from l)ii> llint lb« abavrN^raTity is »urmtiiii)v<l by a >unp iff tbaul 
in which iipw TCiwIa have b«VD formed. Duriii); iW kpivadiny Mag* of 



CKABACTKRS OP FOS. 



241 



, it h dotnictloD of vmkU, nol nmr rortnalion, ttial l<i taking ptiK-«: 
tti an fcraatioa occtin ink during l^liair, alter tbe pun hiu \>vrn Itt out. 
TW w uAnd in which {lU* t* foniir^fitn Riucuuii»urfiii.tn in jxirult-ut cnlnrrh 
• iwriWd with tliat [>mc«M. 

TWi all the jiLi> .vlU If* il*riT«l (iirrplly or iotlircctlj* from tho whit* 

•PfMKka af U»e bt<m<j, tnny now bv n-^ntol b« an acn-f'Uii liu-t in juith- 

iiV- TIm pnwf of Xhit taci iit dt-nvcil [lanly iVotn tin- ilirt'ct ••WrviiU>'ii 

^iL iiiaiailiiii of )iu«, n« il iin» iilrmil,v iKvn tli-Mriliiil, niid partly friuu 

^ It* n|>>l»«at( of riihnhciin, lIoffViMinn, and V'kd Ilrrklinghnusrn. ThrM 

tB}ecir*l aiiilinc-hlue »r dnnalinr into tin- t»l(iod-«4rmni nl' the 

ta he axpcriini-uled on. It had before been atinvn that ntirn solid 

in ■ state of cxtraoitly lino divieion is iiijeotc*) into the bluud-strcuni, 

|B* atite ci>r(iU4cW pick up th« parliclce in much tli« Htnic uht as an 

tak«a ill fiiod; and the dark colored particles of nuiline-hlue or 

are caiily rccogniwd in their Bul»Uinc«. A frog havin;* been pre- 

lymri by the iDJwiioD I'f tlie eolurinK matter. inBammalii>n of sufficient 

tHawy to cause suppumtioo wa* excited) and il vtaa found that, whetlier 

Ifcwia a T a a c q iar mrt or in a non-Tawnilur. as the cornea, i be pu]»-cella 

■niMd urtidcs of the aubetance irhich had been injected. 

LMljr. wan ii tbe DCfpiire obeervation, ilml in acute inSammalioDS the 

vi^M) oalli of tfaa ftfl^tfal part under);" no eluiDse m long us they ean be 

•tetml: tfa«t b to My. bcfon: ih<-v are c<>acealed by the crowds ut' niigrat- 

iHlneocytM. 

ftilHlili iirriii — Pu* prcMUta catmdemble variety in ii& ueneral char- 

■Mr. aaootdiDg u.' the cauw that gives riw tu ita furmatiun nod tlw g«ucn>l 

> — i niU a u al slat* «f tliv patkni. 

TW |ias froai an acots abKH-w in a p<'ruin ollH-rwiu; hcnlthv, Ih an opaque, 
maary laid, thick, sroootb, and sli;;)illy viscid, of a ycllotni>h-whilc color, 
^itk m M«w OMs a grrenish tin}^: it has ■ fiiiut udur and an alkaline 
Pvettta. Its afMinfic );mvity is fmm IWlO to ll>:t-'i. Il contains about ^ lo 
#pff cmL ai aalrr, Of lh« solid mailer ab>Hil two-lhirds is albumen ; of 
rIbk Ibinl, about ooe-half is rontpiwo^l of fatty mailer, including as 
> diolHteriiie, aod the rMt ooosists chiefly of nits, with leucin, 
, aful a variHy of other unimportant compounds. The salts are the 
: as lbn« futtnd 10 bluotl-wruiu. clil-iriile of ^ylium beini* the moei nbuit> 
Vat prcKDting these characters is termed healthy or laudable pua. 

indicate appearances dt^vtnliog from' 
~lb hli)0(i It is called e-jnimit; when 
fttrry, MvrvHj; when cnntiiinintc i-hen>v-lookin>[ Hakes, rtirrty^ 
I dituUtI with iiiucui>. ntw-ptut. Doiden t)ii«o, pus prrn^oL-' other 
thus, liir iintanc**. wlii-n it u fonnrd in Uie braiti it in of n Krti'uinh 
^■Bd abcti i& the ndKbborboud of the alimcnlury canal it has a peculiar. 
t^ aJoe. Its ehe«niau cnmpnsttioo may lik>?wi:te v»Ty under dif&ivttt 
dtaasluwn; tbiu. ordinary pu> formi-d tu the mft [wrtt contains merely 
klMMt ii ptMnfihaia of lime, wberva* that which L* formed in conuecttnn. 
Mik 4^BMd hone i> aoid to cntain a lar^^ ((uaniity nf that nalL 

NiDnB«it* other [w^uliaritin which in w>nio cum-h an.' ncogutmbl* only 
^ iWu r0iM-t> on iIm- sy*u-iu : thus llir pus fn)ni ii)>ccilic tores poMatn C«>D- 
t^paa j^-—"-- ^lilioufch lo the nnkcit eye il may no< nppinrently differ 
wiMtitr llinl fluid. In thnw cases, howfxcr. although n<' havo 

Mfftiptriiii ■ "! it is that give* the pus lU infective jirH|X'rlif«, ons 

fu w Ixvn . wn. thai all fornts of infective ]M' contain orjcan- 

*^ nsdily to f ■y»^md by the microscope. A aptciSc organam Itas 
MLiMwsr. besA abovn lo exbt fur each dise«ae which can be cotumuoi- 
m.L— li 




Vwiuas other terms are applied to indie 
iai if btslthy poa ; thus, when lineal with 
ith aad watrry, tnlvrvHJ,' when cnntiiinii 



LOCAL U1ST1IR1IAHCKS A!C|I l.trt.AV H ATIOX. 



of tliu foriutii of Uio iiiiiciiiiH tiH-inl>nii>e nra widely i]ilai><<t, ninl 
tltr<>U):li tbi'iii is rt-lurOvd: lii(ui(l exiiiliilion is Itxwe oiiiifHi*. bihI Um^ 
cur{Mi--'(-l>« migralfiiibuiKlatiUv. Tti*' Iruoiicyicr. uhidi lliiin li-avv tlio ' 
HAitdcr nmuiii^t ntH) through iW ciittlii'liuni-CGllft, tlic anlunl 

lii|ui(l cxudiilioQ ii imnikiil diitchargv. Tli« iliachkruB in Mich ■ co* 
vxamiiiwl iiiicrcwcopiolly. will b« fouml !■> eonlaiti — imnM'n>UH nmn-i 
cells. prvtfeiiliriL; llio uduaI appearaiiC4^ of wliiic )i1ooil-oftrpu»clni: »nli 
[Kis-ocHs r»uriil uml Kn'oulAr witli tlic lri|>iirtiui nudeua; no'l i<[>itl><-tiu 
c(<IU. suiUL- fully iluvi-lii[>e() nnil com«|>imilin^ iu farm Ui thai tiatiirn) to 
uHi-ctoi) lueiiiliriiiK-, .-utmc of ruiiiidi'il ti>rm vdUii]^ imd ini[«rrfi rtly ilfvvlu| 
mid ullu'rs L'»iitaiiiiii); n lurjcv tniii.i]iart'iil ulubulc uf luiu-iu. A iiijitibcii 
!■ XII III in II till II of a Mflioii vt till! iiii-iiitimix: HhowH itiat. in npit^ at tliv alii 
darn disi-hiirui; uf put, there •• DO raw aurfnet': eriTywIicro il in ■.uvi.Tad 
■■pill K^l ill III. riif iniiid#rinc(.>clUcBii (wMOn tii llir foriuui nmnd iIk- — 
iiud iiiinKiliiiU'ly In-iii-alli itii.' (-|>itlii'liiliii. Sumv >if tliv i-|iillii liiiiii-<-«l 
1m- fiiutiit liioiiilniii witllin llii-iii n-vrriil Ixidit^v idt'iitit-iil with |iii>H.-«r(i 
TlinH' wi'rt- eii|>|>iiM.-d by EliiidHi-ici-l) Ut «liou that iIm' |iu* in )wiriiU*nt ntai 
wu ruriuol by ('iiilugfii<Hi)> ti'llYoriiiiilioD from llti- ■■(Mtbi-liiiiiiH'i-llx. 
nhHTViitiuns, ItDweviT, liuvv it.'udt.-al to pmvr tlinl tbcM' apimrviil Kiotlicr-t 
arc ill rcnlitv duul or dyiuc; epilbolium-colla whicli have uceo iwoMi 
waiiiicriiii; k-uoocylc». WaDiIcriu); leucucytts are alfo fiMiDa peni 
bctwcfn tliv individual epiilicliuiii-celle. 

AltlioiiKh ill punileui aiUirrbal iiiQanmmliou tlicro oeed In no ulcrratig 
llii! uliuvc dwcriptioo aliowH Iiom n-udilv uuo pruooaB nuiy be oonTiTtnl in 
till- uUkt. The adtiwioD of ilio epitlii^liuiii-ovUs tu each othrr. Bin] ui 
curium, in always looewtird in tbc mure M'V<in' fgnus uf calnrrh ; *b<iultl 
IuomIj* adherent ■{•ilheliiil layer bt ao-tilt-iilally removrd by violcuc* (_ 
withi>iit. nr iw|iarat«(l by vxaggvratoil cell-niitrrntioD beonUii, ft mmII uIc 
wilt be ihe mull. 

Varieties of Catarrh,— Ciitarrh, likv other furms of inflai&inaiioii. ni 
!»>■ 'iputr .If i-hruiiir. Tlir rlir-iiiie fvTin n very fr«|iic«lly OMoeiati-il »i 
jMiwive liypericmiii n( the [mrt utlcetcd. It may also bo nimptr, uf in bi> 
ehilie, or infetiiwe, as iu miruteiit ophthalmia or gunorrli<ea. The lhi< 
iiiuco-purulcui Everelion llint furnw un the iurfsee of ii niuootiB iiirmbra 
diiria); eiiturrh frei|Ucully wrvee aa a nidus for the ^f^th of iuirr<«n>p 
urgunisnis, iiud the fcrnieulalive ehaoKes ihu» set up ^ive rise tn pmduc 
which may proloDg lii« irrilaliuii. and eausc it to siireail almoM itidpliuiiC' 

SyBptomi. — R^nen of the aAbcted »urfae«, with alight swrlline. aixl 



abtiudaiii secretioD, varyiH|{ froni a nur 

clinical ft 



ire »er»ti> tu a ihiek niucopunile 
fluid, furtii the nuet marked clinical features uf n calarrlial iiitliimniali 
The beat is usually moderate, nnd iwiii ii> nut a markcal sytuMom, ex 
(Im more acute fonnt, bh !u |>urulrnt ••{ihlhnliiiia. The connUtutioiul 
lOOM vary with iho ncateiKW of the pnx-t« nud ihr pnrt Bfledetl. Aa « 
only itir mix>t lu'iilc fonDv of eainrrn itive ri»- in any clrvatiun <if 
tari>. The aluN'uii' uf fever may puawibly b<- nei'DUtiu-tt fur by lhi> 
the exudalinii draiiM away fruiii ihe Mirfn<'e ai»l but liltli* liuds ila 
iiitn till' blood -etreani. 

I'arta which have sufTi-red fmio ehrutiie i-atarrh, or rmni re)Nraie<l 
of ili« aculii fi>nn, ununlly bi-coinc- niorv nr leea pigneuii-il. and the 
mneuui ti»ue is ihickrneil and indunlcd. These slgtu arr nvll •een in 
Riitnms nieii>biaiH< of the hladder in cases of aid ^trielurr ur slune. 

The tnatmCBt of eatarrhal inflaRiination pn-seota little thai r«qi 
envcial uotin-. In ihr more neiili- furnm Marnilh and moutun*. aad a. 
all n-mitval uf ihr diseliarp- attil prevejition of ils ilecmnposilioa. 



riUI'rL'KATlOH AVlt AHSCKSS. 



339 



tMnaal BnuM of Uvaiaiciil. Ittlliidwiaa is onvn of uao louilly 
Mg jMio anil pniRititiii); mnlnctiun of thv numW uncriit. Id 
olwrb, rwutb) i>r iW H-crctions aiiil di-miiliiicw willi llic uc« 
wdi mt iiilmli.- i>r nilvrr, accIjiLc of Icml, euljiliHlo uf r<>|i|>«r, 
a tbr chief trvttliiiriiL Auf cutiHlitiiliuiuil oumlitiuo as 
V {HOl HMM )iv acorcbnl for uid treated if fuuud. 



t'lIAl'TKU V. 



SUrrCKATlUN AND AHSCKSi). 

Mrn'it-iT r> «(. <ir ih^ (•irniatioa of jmu, ha> alruuly Imwd (li«crit»«4) in tlio 
«• Inllniiitriaii.'ii. [t wiu tlirrv poiDled out that iIh- |iri>c»w i-i>i»iHta 
\y Ml* a eMiUtiQaii«« lutd oicui^mition of one of iho rn<-l»r» of inlliini- 
BUgnttk« of the trhite cur|>vaott8. lliv waiKkriti); ccll» ■(.vii- 
MiUnie ^ ToweJ*. aiul poonlilv multiply liy cL-IUIivi^ii-n in tbcir new 
bat tliia b axtmoelj duubtlul : an the ai'curuulatioii iiicivascs, tbo 



«^piMd tiMmw bcoxop |>K»nl u[>«n mid iitworbcd, the uuw oi-llit oi-cuj-viiii; 

Aar pl«M: finally, the cenind nll» nf the );r<iU]t Jqr^neratv from main of 

MifWuo, (hrir inli rcrllutnr siiliniancc tufU-nx, uud tli« li(|uid exudation from 

fc wRuanding [latt guaku in amoDgvt Uicm, anil tbue wc gel n i-rvamy 

laid, or pua. 

U a* •ootiiBMa tiapiNnv, mt hare ttifl nnpurUinity of examtoing nikfu- 

llj tuHi a HBall ctdWtion of p<i» in tlie RibeutaneoUB tiwiie, tba 

a|( appraranrre arv ubfcrriKl, proceeding from the circumfrrcncc to 

ta tauU* ••( Utr alTn-tnl arm. The firel sigu of deviation froni bt-nltli 

a iImi mjam' acaii^Tnl IvucocytM are k«d in the epaoes between ihe fibn-a of 

llv coaarriixv Ihmm, mod ofbm evidently in the DeiKhborbooti of a bowII 

aa tbe t»tt« b approacbeO. l)ie number of the«e iuereaae*. i;iwl*i>lly 

) and IBM* eampMely obtourinK (he L-oooective litaite and its corpuwtes, 

iBai Imc nirtktair iaioba skr but elmely packed amaJI round cellKlwtwrcn 

ahaft the anuxint ttf Islarccllalar lubktnnee is loci snMll to br recncnitnl ; 

• tW tavtra of tUa group of cfib may be a cavity from whirh the \>n* has 

—(MJ ia prvfAring tbr ■cetimi. Th« caiiDrrtivr tiBui!, nben it i> Inut rvo- 

fwhlr hrftirw bfing cum>«lnl h^ the intillnitiri)! Ii-ucocytaa, u wen l<> 

Ht( ila fibraa svollra and vitn<ous in apffearano-, while its corpuaeica are 

«a*— cmJ- TiMy. aridcntly, arv lakine no part in lli« forniatioD of (Im> 

m nw. uTiii-b Bra ntnnJiDK aroougw tlie tilin*. If any hloadveselii are 

»l : b« ana uiat, near Ibu noiot ai which evm-thing ii> c\>o- 

I by -ytca. tbay ara filled nilh clorcly pueki-d hltM^l^i^irptircIra 

bCadac • orv of a elut of blood. It i» in thi» way thai tWy arc 

t^Mj Wli'.-. ... ,.,jaBMio MJlb lb* other tinun, thry aoftrn and broak doan 

^tti pnaokce of the ioradinir Inioocytee, and ihiir all hemnrrhagv b pre- 

*M«1 la tbb ari-a aUi^, allliougb it roiuiot tw aecu with the a)i«-r»<y>pe, 

<fe r^Moa which ba* rsudrd from ibe vecMb w CMiyalated, and with the 

v^lpitad adb (brn* a firm snbrtanoe, the ii>«alled uflaninaloiy lymph, 

^^ tXk and plnip tb« spaooi of the eoonastive tbsnc, and tbna mma a 

natw) tM cnlactM) of |>ua, anil prerenU its dJffbsing Itself widely 



St-rPUllATION AKD AIMCXAS. 



fliiiuiiKBt ihu lioBUi-a nnHiiiil. il b nol |M>«tlilc in n iKctiun aaaAm tttn ■ 
prv|iiirati<m rcinovcil fnnii tlii' liixl}' tu ubwvnf thi'HUI«tif tlivirGMH*''T"^ 
lltu «t«a uf HUtia or UirumlxxiM; but if it were |M«(tl(l« tu olacrvc '. 
lli« liviiix IkmIv. in *liuul<l ki-. in n aprcnilinK nttfcu*. m\\ itiv o 
ulrtulf <li-M:Tibe<] uiid«r l»flHminiitio«; vix., ^m tba nulrc tuv > 
drcumfercDoc, rtiiiMi o*cillitlii>n, iliUii'il vi-wcls nitli rcUrded Row, iiilnn>« 

VtMM'U with iitciVMod ni[it<rity of tluvr. Stich a collodion of |>Uft ma i* ibot* 
dcw-rilHil, iw K mivroecximc umitw ; as on ncutc iitisnH liolHinx li>lf a jkl 
of (lus, ililR-n from it in no ntigK-ct cxn.'[il in e'liv. Ttir i-slrnuun <^ ibt 
iibroxs l»k<x plnco liy {irMi;ri-»ivi' iluilmction of tlic (iMu<-e liy the HUMp^ 
a-n II? lliBl nbuvo iliMxibiH ; auil tkc )hib is funnml bj fui-noaiire tuno d 




\-^ 



'W 



9. 



v/ 



'-X 






'\ 



.n.-A Ilt«(M«oplcAbK»ulHIt*Skla. •- R|ilikdliiB| LkOtlrj *. •.SaAtlTa 
ruDNJal In (■*■ phoM by iiilfr>iii>( }ent*cy%tmi jt. iba Mllailliid oTpai] «. Dirv*|.claa4(J 
k. • Small AtM*; ; /. faU Tk< tluaw nniB4 Ibt nUaOtaa «( |iiu an 4mimI •llh I 
r)\t, Imo«*I»s ••■« *Ivm1]> iiativl •* lb* vaaira uf (upiianUlMi li tp^wahaJ. 

tbe n«w veWf' ilegnnvniting, brconiinz M'jMratwl Irom c«eh nth^r l>v fltiidi^ 
mill fulling inio th« cavitv nf ilic iiTiM«t». Tlif whoir pron 'iir«1 

nilli iitnomtiuii, Ihii iH^tcml of the i)i»cliHrf^' K'iiif; ^'ivtu oil' pmi < m m 

in an unUnafy ulcer, it iipcihiiijIiiU'b in llir ■hKc»H.'nviiy ; nn ■)•«««■■, in 
ftd, n i-«vity *ni-l')si-'l bv nn ulcer. Th<' nunc of tiasne in which t(w |ifn«aa 
vf sjiri'ii'linf; v lukiiiK pliinr, wi» iu funiipr tiliMa qiokt-u of m tbe " p y og t afe 
nxTtiibnitir ; " lint il is L-vi'l(.-Ml ibat there in nothing to wliich tli* l^rai "nicai- 
braitc" eiiuM prnperly \>f. nppliMl; lite "pvi-Ki'nie taav" wuuM he r mora 
cwmct term if any Mii-h » ncoMoirY. In t)ii» pynifciiir xnnv tlM> ircwcU arv 
illUbMl, Bnil the liuim Mftcnwl, •» tltiit in ofN-nini; ■■■■ ■l'**^'*" blooil imT ttim 
frovlT tnm the iiiipirjtpH vtwelt r^ximl the i-Mvily; bat it nimit nint \m 
monwlcd fruni thi* ihnt the nluciii* nvily \* •iirn'uiKlitl by n VMr of ti«M 
(a which nrw vnwln hnve boini forninl. During tli« aprewting atagv «f sttj 



Cv«i sttf 



VUAKACTERS OF PCS. 



S4l 



, it i* dMlnii-ti'iii (if vrcM'ln, nol iietr rormaiioti, ibst u taking jiliu^; 
Ait^ fctnation •■cnin ••ii\y ilurinu M'lwir, nfii^r ibe [lun hiis lii'rii Irl uUL 
TW m^nd iDwbit'h jdm i» (briuraun mucuu* >urfUccB in pMralfnt CAUirrh 
k Avmbni with liiat {imcWB. 

tW bII Ibe |N»<vlb Ut Atrivfi ilifrctly or Indin-ctl}' Trom the wliiU 
vwfmtk^ lit tlM Mood, iMjr now 1k> r<-);iir<li-<I u tin ncc<-|>toi) fiu't in pntli- 
1^^. Tba pnn/ of thb fart ib drriv<il [mrtlj^ IWiin ihv ilirrct oWrvnii'in 
4 tW fafwUoB of |ia*. M il liM ■Iiruily tm'n dcM-rihi-d, and |iiiTtly fnini 
ata of ('ohnlH'irii. Ifufrmaon, niid Vo» ItrrklingbnuM-n. ThrM 
iajwtvd •nilini.-'liIiK '>r ciiinsUnr iiilo t)i« tilixMl-etniiin of ibe 
•I U> I^ raprfiiDcnied on. It had bofi>n' Ix^ti abiKD that wbcn solid 
K ia a autc of cxtrnnelj' line division is iiijet-Uil into ibe bluud-strmiu, 
«lui* cufpOKlf* pick up lh« partitlrs in much the nme «ay u an 
hi takte tU food; and ibe dark coloirtl particle of niiilioe-b)u« or 
ihu mn (■•tly racosO''^ ■<* tbeir eulwtance. A frog baviu^' be«n pre- 
llMd bjr iba injection nf the coloring matter, inllnniiiiati'>n of snIScKnt 
IfiMlf to CBOM Nppuration wba exdud : and il wa« found ibai, wh«tlier 
I • raantlar Mrt ur iu a nou-vaM-ulnr. as tbc cornea, tbe pUiH.'ells 

pafticln of the >uli«ance which had been injected. 
r, Um» it lh« ncjpitive •ibwrvaiion. that in acuie in flam mat ions tbe 
fealla of tba aBecttil part ui>deri:u no cbanue to tonf; as they can be 
tfau ia to «ar, l>efoK iliey are eoocoiled cy the cmirdo <il inif^t- 
rbMucytea. 

** I «f Pu. — I*iM prcBMtta cansMcnihle variety in its c^ncn] char- 

r. MDonliax u> tbe muw that give* riac to ita ftinDation una ilw gmiixdl 
M W ini tki — I uata of tb« pMicnL 

TW paa fitan as acut« abtcrM !n a penoa otltenvi« healtliy, is an opnour, 
otuar flaid. tbkk, iraooth, aod »livbllv vtwid, of n y«llu«ijih-n'hil<T color, 
att n a o we cawn a pnvnish tingv: it hfl» a fiiiut wUir awl tin alkstiua 
iiibo. Iu •prriSc )!"tvity i» from WiO to 10^^ It coiitaiao about tUi to 
H ftt oral, itt KBiiT. Uf tiiv solid mutter about two-lhir<l« is nlbiinica ; of 
ibr rvflwiain)F tbini, about ooe-biitf is compiecH «f fnity matter, including M- 
1 ml* •cMM* cbolairrinr, and the rest conoiitts chiefly of satis, with lencin, 
tnou, as<l a Tarictv <>f other unimnnrlant c<ini[>oiinds. The salts are ihe 
•Ma aa ibow fnund in blood-aeruni. ciih'ride of Midium being the niotit ahuu- 
tea. Poa ivqeDliity ibrae oharaclcre ia teniwd healthy ur lauduble pui>. 

TariMW otirer trrtna an applied im iudicati.- apiiearaiien deviating froai> 

Aaiif k«aliby pu*; lbua,irbm tin)j:rdni(h IiIo-hI it ia called MinNNu; whrii< 

tm sad m»ierr. itMrem; when cnntainiiiif chei-syli^okini; Hnkes. nirrfy,, 

wd «bca dilnl^l «riUi mucu*. timeo-put. Bepidi-n these, pu« prr.'^^utH other 

WMm; iboa, for liM«a»ce, *liiu it is furnml in the brain it i^i of a vmoinb 

tiM,a«l«hra In ibn bei^bborbood of ihonlinKiitiirr canul it baM a |>eculiiir. 

Ml hW. Ita cbcfoicM mmpoaitioo nniy lik<-wi.-c vary under dilf-nnt 

'jfibHutct* : thua, ordinary pus fi'rntcd in ibf »oft part* ooutains merely 

phtaphaia of linH-, wbcrma tbitt vbicli ia formed in conuectioib 

- _>rd hnnc i> mid l<< contain u larp; <{uanlity uf tliut niIl 

l^jauaut* wlber pectiltnrilHi abich in MMBO caat* are ivoiignixable only 

^i^mwSfrf OB ti" ■■■•■ ■>•: ibua Ihr [Hit fniin apecifiosorra powwr * con- 

kpM* f>r»[rTtir.. (a the iiaknt eye it riiiiy not iipiNircnily diHt-r 

^^Mktt farm* <vl i.iai oiiwl. Ill them- caB«-s, h'lwrver, nlthotif'h wo have 

M J*l d«4««niBnl »hal it is that t;ivc« the pus its infective prti|>^riii-a. oiiv 

ha iat baan clearly •bvwn, that all fornie of iafeclive |mi> coniaiu orpiu- 

Mi icadily to ba obaenrcd by the uiicroecope. A i]K-«'ific »tgniii>in has 

■•^hwartr, be«« Aowa to axbt for each diaeaac which can be coBimuai- 




BCPPUBATIOS A.VI> ABSCKS9. 

Cftlod by inociiliitii>ii of mat — sh, for iiiaUtnce, smallpox, soft chancre, gon- 
orrhoMi, nml |iunili-nl ociliihttlmia ; iiur huti it as y«l beeii deRnJtely pruvet) 
ihiit the [)rgniii»m in tW nutiiul cuuse of the Jnlftctivo pn>[H.'rlii» of eaoli 
kindof iMJt: «iill nil tbo iib^irrvatioii »t' the prewai diiy would tend to 
RU^Wt tnnt iiuch is iiciMiilily |.h« cane. 

^K » a lt(|iii<] which rt^ndily lieoomiXMCfl when txfnww) to the air at the 
t«nipcnituro of lli<! IkhIj-, or even if the cauwcf> of <loc<>mp(»iti<in \ve intro- 
duced siibcmniR'fmnly il» hy nii iLspiriitur nMi)l« or trocur. Tbiiii wp occa- 
sioniilly iwc thiU a cdlli-ciion c.f jiiis which, when tnpM'd fur the fir»i liuii-, i* 
free 1"n>m dccumpi'i^llioti. bccomBs ofR-n^ivc >» ii Irvt diiyt iiiitr** pmpor nnii- 
septic prccntilions »re ttikvn during the o|>cmti'>i). tn luime nir<- cdm-h pus 
aaeumee a clisilnclly blue color from tlie developnicnt id it of a s[><^einl form 
of micrococcus. 

Hieratcopio Characteri. — On examining pii* iindcr the mirnwcojHr, it n 
fiwaii Id i-uDsist 'if corpuscles tinntiiig in a clear lii.ii<!, the " liqiinr puria." 
la pusdraviii frnm hu acute iib§ecs» or t'Tnm the vurlneedf a henllliy «ujv 
uuruiiiig sure, two kiiiils of eorpiif'eleii are met with. Von ItcckliHghnu^cn, 
hchultie, and otherH, showed ihnt in such pii» n Inrge number of ceilv arc to 
be found which resemble the white eorpiiaele» of the blood in every inspect. 
If examiued when quite frcflh on u warm pinle, they mauifeGt the eharac- 
t«rietic aaiwhuid niovemenle. The nuclei of these livinj* cells are single, or 
at Ri"«t double, the protoplasm is fnintly K^Dular, and (he nucleus can 
usually he recoguixed without the use of reai;ente. These living tells, how- 
ever, as a rule, furm hut a coniparaii\'cly stnall proportion of ilie whole; the 
greater number present the eppearauces which have been held to be chanio- 
teriittic of the puM-cell ever since the oiicroscoite demonstrated its existenee. 
They arc nwcDlially the larae ui the ama-hoid cells, but tJicy are dead, and 




rig. m.—tt. Hwlllij Piu-mllt. i. Trulad •tilh 
Amii* AoUI. Mkgnllltil SOO UiauiMar*. 



Pig. 8P.— Pui-oellt l^oiB Fynmlc Aliteau. 



have, moreover, uodorgoDC de^nemtire chan^. They n«! rounded in 
form, with a sliphtly irregular outline, they mcamirc atwut g^^ of an inch 
in diameter, and their Drotuplasm is coarsely granular, m tnnt tho nucleit* 
is ompletoly coucealeil. liy treating them with itiluti- Ki-ctic acid the 
granules arc to a great extent dissolved, the protuiitaKni bi-coim-s swollen, 
and the nucleus comes clearly into view, and ft i* then found lo W bmken 
up into two or more, usually three pnria. moM commonly without a nucleolus. 
This breaking ui> of the nucleus is a de){enenitive change and nut a sign of 
active growth. In the protoplasm some fai-granulvji un usually to be aoen 
which are not cle«r«d up by the acetic aciti. The number of these viirin 
with llie age of the pus ; the lem acute the formation of the pus the more 
abundant will be tlie fat-granules, till in chronic nbiicemes wo find them 
occupying the proloplai-ni to ^uch an extent thai it is no longer pomiblc to 
clear it up with acetic acid. Theae granulm are, however, readily dissolved 
ill lifjuor potaWfli. Finally, iu very old collections of pus the ei-lln break up 
completely, and tlie grauules float free in the liquor puris, forming an cniul- 
^on liaving but little reeeiablauoe to pun, or in other caeeo they torm curdy 




HODB or DETECTIitO OROANlSMlS. 



S4« 



■MM «Ucfa in rairt float tVm In tht> Auul und in pmri tnrm a layor on ths 

b iht n uf aeati! ahraMHO, In addition to tti« oorpusclM. gniDUlu 
4ikvwf uir iwiiM may in *-iinr ciim* bo nicoguisvd. 

IknKf thr Im( frw yrnn niucli iilf^otioit bu bcvn |Mi>] to the premnoo 
lifvavtwpic faup in ptu. tbc coixlili'ins tio'lf-r which ihrr devclDp nntl 
ftf imfmtMMtm to Im! ■ttM)iP<] tn tlirni. Ttii» nthjoct has becD inv««ti- 
_ hd kr Bnrdno-Sao'l'-nou, Ogiton. Cbcyne, and nlh«n in [his country, 
■<^ ii W f Tf W Mo uunmmuit to rownion ia Gprmany and Franco; but it 
tAiitf Ib Weiiwn** ra(lhi>c], jH-ffwfii by Itjbvirt Koeh. of Berlin, ihni iru 
M* A> tmm mai nxrliiinly with wbirh th« preaenco or abaeucc of niicritdr- 
■■Mi an BOW b^ dMrriniocl. TImi rMulta of these obeervaliuiti may b« 
■i^t wmaiariawi ihut: lu att menlt abooesaea minute round tunt;! imieru- 
■ed an ftnad ia th« ptie wha frcihly drnwa. but their ori^n, and tite 





\i 



tnm fcrBMau 



Fl|. II.— A BoloBf of MlcrvotMl in ■ Ijinphatb 
(iHidxSOD. p/.GUndlliM«icHknin««l| 
b fm fron an AcnM AbMMi : f, yt aiBi i 
■I. MkroMMl fa th^a«. 



pn ibrv T'likv in w4tior up tho irritation lo wbich tbe abac«« is due, are 

<iU 1^ ' ints; aHcr th« nbwiM» ia opened, if rigid anliwptio precau- 

boM -. .-<), (he micrt>5r),'&niFma eoon disappear Irom the disehar|j«a, 

tai I.' [kn hr obtained only by very frequent drcesiuga with carbiflic 

paar, "■ -"..1 .jtlKr powerful antisejktic; undur urdiunry antiaeiitic precau- 

■Mi oMcmrooci an- urMeot in the di:«oliar),t» aa oflen as not. Tbe pui cOO> 

»ti»»C Bi ' - 1- no eij[DB of deoumposition. I*u! expoaeo to th« 

w. tad tr '. if it comes in cuiitact uiih ordiuary water, u it"Oii 

t»J tu<-ioiniri. in i»l<)itiun lo Uw uiicrcoicci. ehurl rml-slmpoil ursanixui 

'Wstfia^ It (hen <l«<<um|>u>M« and nivva olfthi' ordinary uSl-iuive »mi'll of 

fiOttntiinn. In •wiaa cams of an>te septicwniia ll»e du» from tlio origiaal 

•iWaAf iaMnion ha* boen found lo contain I»it|^ roil-auaped fungi iluu-illi). 

1* fy««U. micruo<'<-ri an- nl««ja pnwnt both in tbe local sourw of iufvc- 

*« aad in tlir os^xintary abweasca, Tliv i>tia from ehroaic abaotaw* \» 

<i«tn fr«v from oryaniann of any kind whrn fn^hly driiwn. In thf piui 

ni lyaeifie iaflautuiatioDa, aa snnnrrlni-ii, Mnutllpox, puruli-iil oplillmltiiia 

"^ ibctif* f>eri<iititi% mlctvioafic funip arr ulwny* f»und. In lh<- ni:ij..rity 

' 'Mm pfne«»it ihi-v liatnme tbv form of microciwci, btii tln'ir O^ncl rela- 

Im In tbe •pT' I ■■• in ijuealioH u a* yM very uDci-rtnin. 

IWaxamla^i. -. : |.ii» f<>r micrtjaco^Ho orpiDifRi* has bi-vit rendered so 
*tt) by Iba Mivthoda intniduLTd by Koch, unit iIm inl^Tcat aituchiii); lo 
'^Mtf*ct at lb« pnaaat tiiuv u au great that it may bo well brrv briefly lo 




244 



StJPPfRATION AND ABSCB8S. 



lU 



•IsKribr the firootM. The reaeeDta required are b boIuUod of methyl-' 
(nno of the niiillDe dyca), of ue MreiiKth uf tialf u cmiti Ui <Mie 
ublilW wiitor, nrerully filtered, aod Home jmre (^aiiaJa balrani, whii 
bK'it hcari-d t<> <lnvi- oir im voUiile oil. The inelbod of titMHTTat»<>ii 
followN; Sprcflil the [iti* on u glsNi coveM))i|i in ibe ihiuDUt jMoaiblv UTtl 
lUid dry ilam'fiillr over ii ii[iirit-lBin|i, Ijilciiig rnre not tn overbnit it; dipi 
cImo gl»rf roc) in the mi-lhyl-vtiilct iHihilixii, iiui) •pri'iid a ifaiu filin i>f ill 
ilyo over the dricl layer ui pui; nfler Iroiii ihirtj t" lixty >e('i<Dil)>, wa*b lb 
<)ye off ciirelully with ii gi-ntle stream i>r iJintilli-il wnler, A ilnrkly fUtnn 
tilni Hhoiil'l retiiniii beliJD'l, uliieb tiiiint I"- iii:iiiii driwl uver lln- >)>inl lamp 
thcD while the eover-»lip isdiil «arin. pgt <>» it a drop of [he ('nnailn bi 
rendered tiuiil by heat, and plnTO it auiekly on a kIi^>o *lide which I 
slightly wanued; squeeze it eeiitly down, aiid when ct>td it b rcad;^ 
exnniiDRtJoo. The niieroooeei arv dislingimhed from otlier gmnulea 
ibeir deliDiic round lortn and uniform iize, nnd by their nrrangro'etil 
gruuiie or ehnioR. They, moreover, Inlce the dye reailily, while fnliy a 
alhuniiuoid granules retnaio un«olor«d. Blood or urine may b« nxa 
by the fame proceM.' 

Diagniwls. — The diagnosis i>f pub ii usually eiuy. bat some fluids 
it wi cl^'tly to the naked eye thut the niierftfeope is neccsMrr to . _ 
tlieir ebaracters. From AraMjr munu there is no diffieulty in dirtingu 
pua; biit when mucus has heen thickened and readere^J (t|wque by il_^ 
niatloD, and b mixed with exudation-cellB, it b impoa»ible, nnd can never 
necessary, to diMinKui'^b it ftxnu puK T'ur&i'd «ertnii, containiug broken 
nn<l gnitiuliir flbriue, fretiuenily met with in serous saca. aud toAtmtd 
nK ill el'-tK nnd iiillaiiie<l vesnels, are dislinKUulicd from pus by tlte a' 
p«»-cell». jithemma u recoguixed by the pretience of ehuleslerine-sca 
fui. ami l>y tlur n<)n-exi>leiiei^ of thi- ehiiracleriHtic pit» coquiK-le. Wh 
b difl'iiMil in mill:. *» in ronie fi^rms of lacteal nbMHii*. the 4-<irpuiirN« of t 
fluid will tie ntva to tie omallrr and elearer, with n mure defined uutlinc tJ 
tlK«e «f pus. The Inrgesi Inl-^lobulee in milk are only liatf the stw 
pite-cell. nnd tlie snuilli-tt one-filtb. 

0i'reirnu(ai»ee4 infiuennng iJif Ttudeney to Svpp-ratioH. — It ba» almMl; 
lieen pointed out in the ehapter on Intlammntiotj that *npfitiratio» n mer«l; 
a certain degree of that procees; and that (he degree ot innaninmiion in 
ciu« dejieiidii on the duniage done to the living ItHUes by the irritant wh 
b llie c:iuM- of the diflurbmnee^ In order that suppnratiou may take pta 
it u ncce^imry that u decree of dnnin^e shall bedtme In llie walls of the Mn 
veasels nhich shall lead to nbDormal adhesion of ihe corpuscles, retard 
of llie blood-strenm, with nii)-riition of leuoix-yiea, and exudation of bl 
plniiua. If the dniiiaue l>e .ihurt uf ihb |»nnt, mere hypeneuia will 
without eorptiaeulur exudation; if it pass heyood, stasis, termiui 
thrombi vis, will be proluoeil, and the prooesB of migration being 
suppuration is no longer prewible. In Ibe next place, it u neeewarr that 
imiAtionof the dsstiea should net pertbleatly for auine length of time, nt' 
wba- the exudation unuhl ut>t be of »utBeiFnl amount to fonn ikcollrriion 
pUf Mich iu> we can rcisjgniio iilinicalty. For exnni|tte, a clean cut inllicU 
degree of iiijurv on llie narts nelnally toucti^sl liy tlie koitc sufficient if rat 
dimtatloh of the vewtcls, retarded flow, and luigmtiun ; but if every otii 
Bounre of irrlutiun be excluded, the whole prvcess subsides before sutEclci 

' FuT funlicr Infamalinn en the tuljorl of MleriV.rgkninni in the luid* and i 
»f ih* txidv III dltaate, IbvMoOent l> retrrri'il U> tli* SjdMilisfn Serleti't Tranil 
hj \\ W.'clMjrna.ofKorh** woth-'tVArr ll'«n./<ii/n'r<n>araaJUeUM." and Ogi^ 
|M{i«r tn tJie Bribtlk MmlktU JMnxsJ, vol l, 1H81, p. MO. 



■a(i 



anl 



■tifS 



CAD8BH or avrrvRATiov. SI5 

m tMktn plim tn form nn Kocumulittion nf migrating o'llo ro<'i>g- 

t tn tb« twktd evv. If, howcn'r, n inarv penuU'ut Hmircv uf irriuiion 

ba tfuAw J bb) ibc wound, &■ pa^ut'iip •enim enticing c<-n«i<>n, or (((.•<M>m- 

Mii( aUUr, nr «n-D ■ m^-rlmniotl irrinmt. n« » foreign boily. rxudntion of 

mdftatmtMMi nigniti'tn of iho ci>rpU!>i'l<'9> wilt rxnlintio.'til) thv tiwnn 

««M «d« baeamv iaKltraUil, iui<t tinnlly rcjiliKnl on l)i<> surface by Uic 

_ oirpMch*. and ihc *|iar<- bciwnn U'o-'uxk lillr<l with the rolls 

«ff fram tiM Hur&ce in lb« li<iui<t i^xtidation, thu* lorming pus. 

tbv ■nam nt irriution. nod tlic fnrmntion of piu rapidly ci'ium. 

UaAncC aflbet of irritatioii ia mising the formtiiion of pas mny also be 

mU vhb gnat ndntutage in n hpnithy grnnulaiin^' tons—mj of tbc leg. 

If A* pujmt be put to bed nilb (he teg eJvrated, lo avoid intra vascular 

Inrin, and the raw Hirfa» rcixliMwl perfectly Meptic, and tlien fovcivil bv 

ia«4rrilMiac«absttBee, and prat«cted from mecnutical viulenee and co\<l 

Wh apuUanon which at the mum time absorbs tbe di»ohar|^ aud prevents 

b^lmaction, evert source uf irritation beinK thus removed, we may suo- 

v4 m absolutely preventing any formation of pus. The diH-hsTve, such 

»il ii^ will he (rtnf^jsed fiMj of aeroits fluid, whicli necesMrJIy k-aKa fr"ni 

AtMrfcee ikf the cranu 1st ions, ftS they are uncorered by anr im|)ernK-Hble 

ifiiMisn. UavinK e"t the sore into this »ia1«, if sorae mild irritant be 

HvupQcd, as, C>r psnmple. lints»ake<) inac->Dcentraleil»oluEiun uf Ix-nific 

lodLtM dischargee will n^come turbid, the nuiiernctal cvlU |ierinhing and 

ht«fr out uff and«r the iDfluence of the irril»nt, uhile at thi: Mtnie time 

■tpMiiia takes place from the vessels beueatb; if a xtningiT irritant lie 

iffBed, as, for example, carlmlic acid water (I in 20), the diM'horge will 

MSMS thick pas, the gtanulatioui will >wcll and bc«-omr cifl fmni ex- 

■Ovratnl eiudatiun of l>1iiod-pla)>ma aud niijiniliin of leiicocrfv into tbrir 

■Maacw. I^ppii^c a<m that a still »lr<>n^r irritant be applied, as a bkIu- 

6m tut otrbolir ai-id in spirit (1 in -'>). or cldoride of lini.' '. -10 prnin^ t'l tbe 

MH>), Ibn flow of {lu* will bv checked, and the diHohan.'c will li>r a tibort 

Ins HMSi^ or become mcri.Oy serous, tbe dvad layer (brined by [he caustic 

ilfi lh B tfa m aervisg to arrest anv niii;rating oclfs thai might be coniiag to 

Iktsarftnt. 

^Tv — t.,. fxamplM are suflicienl to show that suppuration iudicates 
: tt >if ihe living tisBues of a oertatu decree of tuleusity. and 
^ -.,.,■ J. .... > fvruin lime, 
li Las befurv been pninied out that tbe etTi-cl produced by an irritant b 
|*i^«i«iMtal — Ant, lu tbe strength of tbe irritant; and, secutidly, lu the 
^s M at rv»i.-tann> of tbe timues, or, in other word^^. lo tbeir stale nf health ; 
Ml thai fvr any UMoe ta be healthy, Imth Ihe ^oeral and h)ral conditions of 
Htrithm BiMit be haalihy nho triiir. p. 182). Ttie decree of inflamnatioit 
i Mofmary locansc ■ '■■■n will then-fore lie iiiorr fwntily iiidm-nl when 

I Af i/ihe |(Micral nditioiu of hcullhr iiutritlno ar^ inli-rfinil with. 

Kptosmlned iIk' lliiil that act'umulatp<l In the lilfhn in ihirly patii-nts to 
**imbGMers hail lireo applini f'>r various atTivlti'iu. In iIkhh: who ncro 
NMaa btm tmrrly local di^'aMV, (be constilulimi Iwiiig olbr-rwiM- liralthy, 
I tkrtda w eWr, ■tjiwtinii'* cna^ulablc, and conipnmtivi-lv free fmm cor- 
tnri«; ia cacbMrlic or phthiairnl {MlM-nta, il wao turbid and cro<r<k-<l itiib 
' <wfciif iMioicyua: and rvery iiitrrnH-iliat.- vnri>'ty wn» mrt with, accord- 
^hitbecoodittou of tbc ay^iem. In »crofulou< c<iii»li(Utioiis, tl>r inflam- 

»laBa« that b vicitcl by a trivial injury, as tbcapntin of a juint for instance, 
*»«y apt tn run '« lo Kimniratinn. So, afrain, in certain cachectic sbites 
ft^ ..... -. -i; .K| «,^|„l^ Nuppurate or fester as it is termed. 
T lich ftive riM' to suppuration are ianuinerable; but il Is 

v rrjni liksa bcfe, as tbey have already been described under thu 




SUPPURATION AND ABHCES9. 



Causes or Inflamtnfllioii ffufcp. 182). From a |>iifflyciir);>*'-'>l jwiutof ' 
tlut mwt iiuportanl are aeoompaeitioD of ttic diitchnrpf^, tcuMoti, Hod Tri 
of diaemed Ruriacaupon each other. That tlic "tolniMUkti of air" neu ii*a 
CliaM) of suppuralioii, ia an otMcrvatioD of jircat Biilii|uiiy. It wa* impc*- 
silile for Hurgeot» tti>t to l>p stnick by tlie tiict that & sulK'utnncuttf iDJury, 
euch as a simple Iractiirv or dielocatioD, henia rapidly wiihuul tnipiiumtioii. 
wliilb Qxurlly l\\f Mine iujury complicikled by a wtiuixl lu the skin, U alir»«t 
M|iialt}' corUin, unltas special means an- taken la prevent it, u> bo folluanl ^ 
by pruAue and prolonitecl suppuration. That tli« dWAtitueni of ilir air| 
wnich doM lli« mischief ii> ita dust, and lliai the active |nui of Ibe duM t» is 
all probability the livin;; orcaniams, whiHt furm a large pan of it, 
alnwdy be«D poini<Hl niiI (|i. 187). 

Tenaiun is in nxint vam^ tlie irritant wliivh Diatutain* tbe prnwaa of i _ 
purntion in an iibtocM, and cauua ll steaililv (<■ incrcn>« in tiin* till it 1>ur«t* { 
jiU|wrliinally. In auine abamawa, the sjicciGo naiurv uf tho jm* gi\v» 
clivniicat irritating pnjpcitiO, wliicli ititart fnnii ivimun may ckoae U 
incrciutc in hixi; ; but ihoe caaw am niiicli lew fnsjucut. The pcni>ianM < 
siuppurution which rfaiillK fn>m tbr irritation cnuM-<l by ihr friction of d)*> 
CoiM HUrtaccM Upun cacb other, will bv m:vu liervalW. in tratini; ofdti 
of Ihejoiota, to w a condition of grvat impunnnw. 

Thfto fiictii an to tli« oiuMtinn of auppurnlinn arv Dol Ri«r«ly pathola|rKa) I 
dvtails of no impiirliinon to the practical Stir^ivon. In evorv caM- in wbi^ i 
wv linvulodeal with pei«ist«nt loriimtiiu) of mi», nv ahoiilil rjin-fulU 



I) of w 
K>nt, Ih 



aider every cauM- that can powibly Iw prtwnt, tiotli coniitiluliiiiuil ai><l local, 
lo accunnl liir tlie oonditioD, w it is only by tlio ri'nioval uf ibc caum tlaab| 
vrv call hopn to relieve the (-Ilcct. 

TAe JXtralion of snppnnitton rntiii' grvatly. In woimik in *hirb, in 
aequeiice of tension I'roiu |wn['iip exiiilatinn, deconi|Heitii>u ot'tlic iltx-liar 
want of rest, or tliv presence of a furt-iKn Ix-dy. union without sup|>ural Mm is' 
not obtained, iho dischar^ becomes di-ilinctlv ixiriileHt in the cminM ofabifBt 
three day^t.allhiiuuh oecasKHially it may be ({eUye<l for a loni^eriimr. Wbm 
oovc sujiiiurulioii has been set up, il will ountinue ns long as tin' cause jirr- 
abla, and as the {Wtient becomes weukeneii bv the prolonKol diaefaat|{a, 
alifihter Kourcm of irritati<Hi are aufiicienl to niaiutain tbe prooias. Fnin 
niuroiui menibranta, especially aht-ii thi-ysufter frum uiechanicul liypeneaita. 
(Miruli'Dt 'lisoliar^ may eoutiuue for year^ 

SvMi-nt^L-' OF ^^1 iTi'itATioN. — Thiwe arv hx^al and cunstitutiotHil. 

The Local SymptOBU didi-r as tlw suppuratiun uccun uu a mucuus 
tcv. or iu tile int<'rii>r of a tiwuc or orfcan. 

Wbon an inllariKil miimw urn^nce is nlxnit tu suppurate, tbe ttw 
prasoniB thfl nnlinary eharaetfrs uf active tnrtnmmation, IwinK hot. awalli 
red. and often painful; to ihesc a diNehai:gv is speedily HU|wrn«l(led. 

Wheu>itp|>unili>>n i# nimul li>taki,*plac«ill lA«mA«tffnr«<>f tfaMMaarar^ca*;, 
•0 as to tfive rise to an aWew in one of tbo forma to be pnvently desrnbri* ~ 
tbo local »yni]il<>ni' ol iitllammation undergo wrtaln nHMifivation* tmlirmtii 
of the Hipcr\-eDtio« of ih'u <Mtndition. ^^'T>ell the rormation of |iui is aeut 
ibo |iain becomes thrubbin):; the jiart snrllc and lu-ciinies ten*^, biH nfirr 
tibw cufteDfl; and lluetiuiti»n may be delecli-d iu iL llir 
glflxmJ, red, shiny, and oHlematoua. Id the formation of a rl.. 
auppuratjou oecurs wi()i<>«it any evident sign •■!' I'>i'ul inflamnuiiiuD, ll 
pD'-eiKV of the ini? n^^vealin;; itself tiy swelling and fluctuation oiily. 

Coiutittilionai Symploma. — On ilie superveutiun of acute sui>[iuraUnD tt 
onliuary nviii|>l->iLi!i ■•! intlammBtion are often intemijUwl by the occurraDc 
of chills, ailernaiii>n of heal and cold, or, if the fonnattuu of (his In (txtcnslv*^! 
by avverc and lotig-o^nltiiued riffora. If tbe pus be cucJuted io a carity,| 




F XATt'BB or HECTIC PBVEB. 947 

loMgMtbMiM, Uie tempcTsturv rw* a>ii>ii]«rab1)- til>»vn tiormal, roachiiiK 

W F"* IW* F. Tho cvvotn^ trmpcniturc umu n ttilv. alxut one tJ<'(j;iT<i 

•Wrf ttel of tbc mnrnici);. TKit high temperaturo rcnioiiM u»cliitngr<l lu il 

OM*/ MiBpJ«i aruu* atfMVM till ibc mis t» dUobnr^l villii-r artiKciiiltv nr 

aOnllf. U thru falia nt|iidir, aini, if (he cnvity b«> ciiii|>l('tvty drmiiifil, 

. laamraa the Dortiiiil d«8r«e. Wlieii (he abso<%e«« are tiK-rply a piirt ••{ 

I AifAosI frooBA uf blooa-iMtKinin);. repented rigont occur, nod nlllinu^ti 

if iag lb» a b a WM nMjr relieve tli« jMitieDt, it audocn bringe the temiwr- 

wnlna BoraMl point. Wfaeo anppuratioD oceun in n recent nuiitia or 

[ B^wod ftvcture, the lever wbicli precedes it ta due. io the mnjoniy of 

I am. I« abiorptMia or»e|i{iL- mutter fvom tbe raw Burbcea; ounKqiicnily. as 

pMokdoM aprisi; up and eover (hem and prewut an effieieut harrier tn iho 

(ttraoMiif iIm prudnetaof deoonipiMilionintu tbedrculHiiou, tbe fever falle, 

mi tU> wuallr i>cnir* ootticidriiUy wiili Um full establish iu«di of a thick, 

hikkj, paniWitt diM-barge. 

IW iluw liirawliao pf pua such m orcun) in the developawnt of a cbronio 

Aw» it nnaccMapuiivd lay (etn. If pu» b« fcirnH-d in uiffieicat <|uantiiy 

, 1« a* diicbari^ tuoct nj a wrer* «)raiit od tlie cofixituliiw, ntbvr «yniptonia 

Mk >lrt>'ii<li-iii (fo tbe luw that i* EiMiifC on. The pulii'iil buotities weak, 

At c I - iiii|aitrd, and h'^if w ntabltaliitl, or iiHiumiiioid def^nem- 

>u ;.r, ■jiUo-ti, and kKliieya mtI* Id. 

BttOt dott not (.-■Idle dq umI'-si tncni (wndiMrlinrgeof piit t'nrm tho sj'fteai. 

^ Wcfir ' loiig na au ahMi«a. buwrvcr lafgv, ontioue* uii(ii(«iii^ ; 

tail Oku IW with graat nit>idily when ones ita coatenbt an- dit- 

iLlfML i imvr «uo«n lar>^ ahacmM* to exist unapcnd for M-vcnil rtare, 
wkwat uiy t.-<ia*titiitiuDa] disturhanoe; but, aa aoou na they were ojwnccl, 
Mtt«»rkca hectic mI hi, which »|>eeilily cnrrict) olTtbe phticnt. 
Bwlic i» aweulinlly a fever of deliiiity; einaeJatiuu and Keaeral Iom of 
■ATmriably aee<>ni|mtiy it. The pulse, ubieb u qiiiek, auiall, aiw) 
wbJe. ri*c» fruiii leu la twenty l)e»tB iihove iu Doriuid atandard ; tlw 
btKUOiea red at tiie e>d;ti'n and tip: tbe ebeeks arc ulUti flitabcd. aiid 
tt(«j«a stiMcntD);, with dilated pujiiU; all tlieMdyiaiit<iiu> have a teodeocy 
Wnac niliiiui aher maala and towainb eveniuj;. Thera ■> also increaaed 
Miw, iilWr uf tbr ikio. bowel*, or kid»ey«. Tliun, prufuto aweaiiDg, et^iioua 
pOfn^aad mkuudaul daiHwiia >it' tithntis iu tbi- uriiiL> i»ke pliwv; theae dts- 
ttaf j e ia MftmaJtrniatnuiiii itur aiiullirr, niultiii); th« patient awuy, an It were. 
Mi Www mtv icrmnl cotiiifttaluM, The ilebilily gnulually iuiTrvMtiog, the 



nmally wa*ln«, aod at laat diot from »ln^:r exbau>tion, tbe ooujoioed 
^•kof hmcr, nialDiiiritioo. Uld WMting divchargnt. 

T^"- --:•■■— rif hectic fewrhna of late given tuv u> coivitlerable (tiacuMka. 
TW< ij.i duubt that io a rcry largv pruportiou of «urgiciU caaM at 

^K, u a III ri'alitT efaruoic [Mui»niii|; from the abwrplioii of (he eheniii'al 
« of puirelkclioii. P->r tbt» tu occur it it not neccasary that the |Hig 
bt ftiul and atinking ; a much milder degrtre uf fi-rmentaiive change 
oMii. The more eaKOtial n>ndili<>n ia that tbe pun sball be cootioMl 
■ > ' 'a wbirb tbr drainage i^ inifierlVcl, »o that it aecuiuulates at a 

<^- 'f pr«Murv ■iidicieiit l>i ciiune alwurpti'in of the prmlueta of 

f*n/ttUiM freta the gmiulalitig surface. This view of the nature uf hectic 
^mff^mi bjrtba GM:t«, that mi h'x-iieoecuni (ill aAer tb<.' iit»ee!« ixijicDeO, 
*^ apfwrtncot uf tlic dratnni;c will in very many ea»ea relieve all the 
^■ftMaa, and tliat rrry lari;*- fu^rSoial uieers may exist for year* and dt»- 
i™^ aiXBdamlT wilbmit induang (be &igua of beetle. Moreover, s-um-of 
tti ^SfUiM of M«ti(- rcwmhie tbiMe known to bo niuaoil br the nlMnrpli'in 
I *'l»|iMac<t uf putrrfacti-m, an the profound anatmia enif lb« tendenrr to 



: 



I 




icppirmjiTios ANp ABscsas. 

■ tune ai« excluile'l. It b likely thttt any contliiuM] 
.. vhawver onuiie. Moiilil t»nA la nwunic tln'^ t'oriii 
ai bwoiii: levvr if iu duratimi wore mifficioit nni] il» couiM 
ri^ VMKidx in intvocily. 

HifkMl demkenttioB in ii mmt iinpurtnnl nnrf lu-noui 
f tirolfuqpd diacnargV! "f |>ii#. It i; n very conimon rHi-ct of 
r biWH Jhait ncamipiiniiTl liy Ki)|>pii ration, iiixl whcu 
uanamoM iDJiiri(iii.-> iiiHiKnc^u on the progrcsi^ <if thv 
11 mil iiprratioiM iiiiilcrliikf^n lor the cur? of ihc <lis«u«. 
t is iBuM waimoiil}' mc-l vfich in diildreo, 8ft diseases of 
■wm cuoimoti with thum; but similar cooditioiii chum 
• — «.^ 1 ^itit ululL 
wiWixiU' i*f th* ptoi-cw bclunciF rather to Medicine than (n Surgery, 
■ > '„ i; i/ pJac* to give Dcre th(«e syniptnmB iritJi which ev«ry 
1^ i.iiiltar. 

'^iiiviiy aflkcted arc the Iiv«r. spleen, kidneys, aod tlie inteatinal 

TIm ehtef Byoiptorus are gradually iiicreBeiu|t ani^inls 

necMNirily nccompnni«a by any fever. The liver 

y ini'reasee iu eiz© (ill it may reach frara the fillb rib in 

lu surface is ftmuoili, aud iis shnrp. hnrd c-ilj^'e caa 

Mfcthniiigti tbe thin abdomiual walla nltnust like a piei-e of India- 

ib Bu jaundice or ascites. Tbe tipleen may be iVlt, but h 

IktM When the kidneys becume altei'ted, the tinne ustinllv 

\ Miajr -(Uatitiiy uf albumen and a few hyaliiit- ui-->t.->. A.i llic villi 

L..i-4tiii- bi-wnie iniplicaied, the eniaeialion inrrtnui-:! and atliicks of 

i<ru<.>ii. T'lwards the end of the ctive nfli^mu of thv ankles 'i» 

;»u), aridiut; from feebleneM of the hmrt'v actiun aud th« 

ihv bl<HKl. Death occurs from cxhuudina or from some 





4 




^•ue irvalment f<>r the difleaiie, ami that ti< to remorc the 

-4K luwMtntttun ; and. if that is itnpiiMible. to ad'ipt evrry mcnns 

,^IM In ilinitnivh the quantity of nun di^icharged. RvidriKt- is Ktill 

l^tM Um itinitive ettect uf C(iin|iieie mniovnl of the Monrce of th« 

Mutation uf the limb in which the diitenscd joint or bone 

_ tit i-ui' wwi- reciifded by Barwcll in which amputation at th« 

«•• s^hJ^iI ly |X'rfi)ri!K'd fiir dwL-iisi? of the joint in n child iiged icveti 

.'tturkl c*iiiditioD greailv iiiipnived alU-r ihc operniion, and thu 

■VKT ilrcrtwtied. A still mon-. inlt-rcMing cn»e occuned under 

iMllvniIue, John Mm^hall. at University College. The 

. -'v «E»<1 about uni. who hml hmg suflcrcd from extensive 

*M ki^ 'ni" *V«* of albuniiiioiil disriisr were well marked, tbe 

amity l» the unibilicuit. Ampuintiou at the hip-joini was 

1 tb* hoy niniie u giioil rcnivrry. Ten jiare arter he returned 

vm account of n i>niall abscess in the stump due to some 

ikiuructirlhcRceinlndun). At this time he was carefully es- 

-• vnlnrgenunt of tho liver cuidd bo detected. Wheii the 

. lUiH'd, liowfver, such oporntions are out of the ijuestioii, aa 

M the patienlK is such us to make it ini|M>asiI>le for tbeni 

^ wrcvmary xlinck and lose of bloud. 



VAKILTII» or AIISCE£8(3. 



M oorur on the mucous or serou» Htirfncoi, or od ihoturfacOM 
~ , f<()nslituting Purultiit Kxudutivn; or pus may bu cot- 
' of a tieeue uf au or^au, forming an AbwctM. 



VARIKTIE3 or AB8CK8SE8. 



340 





Am AkMMl rigolflu k c<l)l(«tloD nf pu* nccurriiif; in nny of th« limiicD ur 
ryw •/ tte hMj, i^ursH'oiM ilivkto ■iMotmm into variou* kinds, iiccor(tin|{ 
tm 1km wfmfibmm kUr.nUini: iIk-hi, tlH-ir (luntion. nor] thHr cnuwp. ItilU 
dttf ifw af Arutv nm) ('linmic. Hot and (>>l<l, L}riD|tlmtic, DilfliM, 
Ic M- Pnrali:. ati*l I'lKiriwnil AluMMC*. 

•r M«g«aiuu Abieeii tanr If inkcn n» tbc type «f (he 'liMoas. 
it h AbiKit t<j fnm), ilic iHirt whieli tia» Wtm piwioiioly inflAUMKl 
rmhiy. Willi m l)ir<>til)ing pubstilo paio ; (lie »kiii. bn'oni<« 
i. lUid «f « •nmcwhnl ptirpliah red. If the abeccw hp vrry 
Aad^ HMivl. tlie «up«ricnpaM<l itHur* become brawny nnd ndomatnur, 
vJMK, pvrbap^ may othi^r oigo Indicatiog tb« eiiftteiicv of pus. A* iIh> 
•|>|ikmHm> ||>« Mjrbcc, it K>f^nB nt one part, vhen flurttiiiii»R 
perrvfrtiblv, and a bulging of ilie ekio covering ii« suDimit inkrv 

A> aW«aa ha* a api'cial icndeocy to approach a 1W« surikce, whether 

I iht b Mlentst lit tiii^rnal. akin or miloout ni«robrane : the tts§ue« bctnrvn 

4i>il tb^ tarfiux towards which it is prognasiog beio]; ^traduntly broken 

''•a- TWt tbe abseoa altars exienns most rauidly in the direeiii'n iif 

ha rawt^-^-— -— mt moei prubablv to be due to thu &cl that dilalaiiuu »f 

^i^ an lUD of cells u'lfl occur axm easily on that aide: the 

IMon i>] -.111- ai->-(iinii)ated pu^ tending to olwrurt tbf«c proccMia on that 

■*r m vhlrli ihrrv IS the gr«nt<-r KMftAnrc. TIiIh procew !■ spoken of 

ti'ibr pMnling of tbo ab*oo»." As tliv piM approache* the nurface. the 

te at int benusea moK or Ims lirid. tnw«, anil aHJ^matoita. iudialiag 

act oilh it* cirpulaiion; at tbc *ummit of the absceM preasc* 

^H^ lb* oirprlyini; skin Iuh-m it* teiuion and boconKs relaxvil ; it then 

M|fb* »t the most d'otral point, fnim which th< cuticle hn« prerii>u4|y p^Ied 

4a*d. ibc oatwanl pn-worr nf (he pit; ep«edily detaching the »lou^h, tU« 

iht^ ducharvT* it^-lf. TTi'iigh acute alwccasis, if left to ihemsdvos. 

indly niD lliis oHinu- am) bunt thruui;h iW akin, the niucoUB or scmus 

•Ana, or rvrn ititu tbr interior of joints, yet some collections of pus, if 

Mr; dcvpjy sajilnl, fanniM finil th«ir way In tlie surface, but extend thnxigh 

dsanuiar plaM* of I bv limb in a lateral direction, burrow iuit and under- 

aiMg the [«rts to ■ great extent : »r, if Mtuated iu deiuv aad unyielding 

tfMnra, M in Ume. arv iniprisuned with a rase thnugb which ibey inav 

k Sia h ls' to |wartfwtc ; in other rare iuuance*, the pot becomes ab»i>rlwd. 

tad tW al mu M disapf>tars. 

Aier an ahsma has bunH or faas been evactiated, its walls contract and 
Ubm* riirrwxa*'^'- and the cavity b griMlually rl<iu.-<l by a proccM of T7|tttir 
t^MkBl with the bnUini;i'f a wound by graniilntioD (see I'rooeMof ItepuirX 
bwOT lasta, howinter, the imvily d<-es-n<it compkielf oloM>, but cotilmcts 
liba asmw owal, tbmtin^ a linuB or fistula. 

MhM AbittH b a irnn which has be<-n incorrectly iisn) to doacrihe a 
MjU fcf lit « of ^Hi» in thfi nr<^ilar lowur. as the raull of a sprMdlug or 
WwUiii talbuntuaUnD. In a true ahw^'n the pus b aiDrclnl in a rantf 
•Xkiwwilu Aon m loealiml »..urc<- id' irrimtton; in dt(r(i>r eiippuratioii 
■WaoH H rtifctraoOM rwulitv dillu»ilile nn'l irritating cheniicnl suMaDCe. 
■ ife fvtidiKta <if dccomptiMtioD, which apreads widely amoop-t the lymph- 
<VHm •/ the araoUr tiarac. or sonte infct-tivc jioi^oo which niulliplir* and 
**1a(* sMiWipC ibe liftng tiwiics and ic alwayn awociaied with tlM- prvarnco 
"^ aw^wopip AnaaWttt*. ilmcc the pus often spreads widely, and ibere 
*a> U (itrttMre itrrimrti'ti of parts before it b diwOTered. A ]iartictilnr 
***!; ef this form of atwcrf* b the IhierjHxril, occflrring in vouien after 
I la nriovs nrla of tlie ImmIv, cspedally in the iliac lotva, in Ibe 
I of th* utifh or In the ji^ula, and in the adipuae tissue of tha 



I 



250 



SUPPURATION AND ABSCESS. 



orI)ii. ■:if\«n <l<-aLi'i>vi)iL: ihe globe of the eye. To these forniB of the il!M-nee 
Uie Hctastatic ASscessei are cloaely nllkJ. They cummoiilj- octiir ns 
<;i>iiM'((Ui-iii-iii of pyieiiiin, unA will be more fully deei-rihed with that diseasa. 
Tliey iiiAy be very tnitiieruua, tmd are inel wiih iu the suWancc of organs 
U.I wi-ll nil in Um areolar tixaue auii j(>mU<. The last three i>peciea of abec«u 
are varletittt of the noute fortii. 

CliroDio Abaceaaet, or, ba thejr are sometimea called, Cold Abscetees. arc 
of very oominoD occurrciKio, and arise UDd«r aamewbai various eoDditione. 
Perba)Mt th« ino«t tyjiir-jil form in that which i* no (■imiiunuly niL-t njlli in 
omincc'tion with diwuLiK^iJ buncs, uipednlly tlic UhHch of the verlebru. In 
thotc vn#M the diwiL>e oinimvncra with chroiiio iiilltimnialion and powiblf 
with dcAlh of a Kiuull portion of th^ hunt', nruiiiul which pita in »\oW\f 
forniiKl. Frnm this i>urting-p'>tnl the (iuk, us it incri^oses in iiiiantity, *lowly 
make* a ciiviiy for itself, forcing its way in the dircviion of Iwist rcsiwtuioe. 
The irriUttion eau»etl by the prcMncv of the pus, which in anch coxes is 
alway* free from organism« ami chemicnlly unirritiuiog, is mo slight that the 
surruuiiiling arvolar tiwiic, instead of bi^c'ominf: eoiU-oed by ioRltratixn with 
migrating Iciicwytoe, ae in acute aliAccM, breomea coD8oli<Ia(i?!il partly by 
comprmiDn anil |>ari)y by the (jrowth i>f new fibrous tisiuc. till a wall of 
snch ik'Dsitv and iliitinctnces is funned that it can bc> diaicctcil nut lik<; that 
of a i?:y»t ) t'ig. it\). Such an abfc<?i!e slowly extends and may burrow U/ a 
considerable distance from its original slnrting-pnint. The course it follows 
is determined first by the fascia beneath which it may bo burrowing. As a 
general rule it di>es not perforate a fascia, ns this becomes thickened by the 
growth »r new fibrous tJ»U6 rallicr than thinned by ulceration or pn?ssure. 
t^ecundly. it hurrows in the spaces along which tlio larger arteries run ; thus, 
a psoas ahscest aUer following the muscle beneath the fascia to the groin 
comes in relation with the profunda, and fullou-a it amongal the adductor 
niusclt«. olU'U sending unt processes along the circumllex arteries and their 
branches reuchtug to the gluteal region. These abscesses do not readily 
puint, and their duruttun ia ufleu very remarkable. I have seen large 
chronic abseaMCd io the iliac luMa and groin perfectly slaliouary for Dearly 
two yeare. The Uuid votitained in such abaceasea is ibin, Uaky, and curdy, 
tliuugh in some oasca the niis is healthy in apjiearauce:. Sometimes they 
contain itmunsi of a iuill yelhmiiih sutwtance. apparently formed of coagu- 
lated lihrin entangling the fatty remains of degenerated pus-oelb, but tattn | 
commonly the nhretlN anil flakea are of small nite. No micruicopie organ- 
isoM are found in the pus of a obronio abaceea ; and, however lonj; it mav 
remain unopciiisl, it gbnwa no tendency to putre taction until air U atl- 
initlL-d from without When audi au sIibciuh has been i>pen<i] the wall of 
the Kac io found io most omMst la be lined by a thin layer of aitherent 
cbe(»y riuil.trr, in nclu-r rm«A it may be tMivenil hy a smooth layer of imper- 
fect Kranii]atiitn-li»tit' almost ri-ouuiijliii^ a mucous mem braDC in appr-jiraniw. 
The cuvilv IN nUeit i;riii»i-d by liiuitls contuinlng vcateb of oonaidi-ndile size. 
Ovciuionully the Siild coutcnl* hccurae gradually absorbed and the ab*c<'N« 
iinthrrgiini Hpontaiious ourc, it* >it(' being indicated by aumv dry diecsy 
matti'r enchuMnl in a dcni>e mas* of fibroid liwuii. I 

Chnmic abuciwiits of a uimcwbnt similar character otlttn form io connec- 
tion with dismscd joints, but the rounte of tht»c i« usually more rapid and 
the cxtiiit I» which tbcy burrow in not so grcaL 

Another form of chrooiv ab«cu» is that occnsiunally met with in the 
mamma ; in which a few drop of curdy pus bcome ourrounded by so deoM 
a wall of fibroid tiwuc mi U> stniulato u solid tumor. A similar form ia 
found in the cwiktIIous tixsiH- of bone, but in this ca«e tlic cnclucing wall is 
formed of very dcn:>e compact o«Moua titaiie. Such aUwewm may exi»t lor 
an indefinite period. . 



StTOATIOX, SIKK, KTC^ Or ABSCKS8B8. 



SSI 




Iknsk alwtMS ufirn form in rxtnnpction with tite lyinplintio gliadi, b 
at the gnulttal eoheniaif of CMeous iuflaiuniulorr productft. 
I ue not umi^ninxiii id th« twok, Bxillu, Kr<'iii. >i>il ilivc foam. 
ebi)(ln-a U » uul uucommoD In fin>) a luciili»^ chmoio in- 
pnnoM art ii|i in itie BulK-iiuiut^xis (iwui- wiihoui «iiy n|()i«reiit 
[■ttMnnntiirj pnxluola uadergo hiiy (li-tp^iitrniiun nnd sloitly 
Tfca akin bmwtnttt parpJ« and oongcsted. aud fiimlly xiven w«y ui 
«aa f«B(, allowiBK ilii- ctinly Huid lu Mcape, lairing « cnvily beu«ttiJi lli« 
■■AnwlBiil *kit> wbich t> cxtri'iuely i1il!i(-ult to cure. 

OnsMHOftUr aUtWUt of cQn*iitcn>blp aiw fonn in llie aiiWuuu)«oiM tuaue 

mmj rtklcat OBUW. uid wJtb bui nli^bt |)rt.-t-urt>'ty tiyiiiptomnreven 

. kar *t kll. TW pMlivni. who bun lumiUy bwii cachectic, unil h» 

' litB« fttm gcoeraJ debility, fot'ls nlij^bl iiui-aBiDCO id the Kniiii, 

.orKxilla, Aod flada BMSpeciMlly n biri;e fliK-luntiiiKltimcir in <iii« 

«rf lk«K tiliiMiniM ; tkcn Sa parlupa Oi> imiQ in Ibc i>nrt, and mi ■li»ci>l(ini- 

9imif tht akio, btil tbo flurtunlinD u aliray* v«ry dUlinct. Ou o|>caiHf|; 

«Mfc ftB •baocM a« tbi>, tbrrr will luunlljr M ■ oojiiotu dtKbarjce of thin 

■afcaltkr pua, wbiHi. wbi-n vxnmiiu'd under ibo fflMroKWpc, wilf be toiiiid 

^fUauia wilbanvl and &»y call*. In tonio caan, iba ouatenu n|i|MW- to 

^^^B^r,*mi-tnuMpknKit.oruiljr-lookiug 

^^^Br. Sock nhcww »re oilmtt tipoiusn 

^ m Lf—f j i ^ i e or timffr^it*. 

Ibiiy nf thv abov« tunu ot chruuic nb- 

I »« aar arnr rn>iii a dvfHwit of liib«rclo, 

I Uj m ui by •i>nmiti^ nf tbo gn>uth nod 

iwaBatinn fimidiI it, but il it* iii>t alvars 

w*'4*ir*e pAMibla to deteniiine (i-nainly 

•ktW iht* (n* bnti thv nuc or nut. 

TW lib' ■'brxiiio nnd acut« kI»- 

WH i* Il < I ]' Ditit. In »i(iie cam 

V>MM4iaHae tk* pro w of auptMirniion 
mj ka acwt* ai tno Hmmcoconnit and 
paiaally baoane cbmnir. Uw pcribraiiun 
4 A* tspHiIr ■r.tvmiiiW rvlirvui); (•iMJon 
■Iftda- "U. OnOiPoUtW 

kl*l, it u ~-^ UDCOOinMMt tVMO 

I rirt«iH' aUwaa anaa* an acuta tarn, 
*i raf>dly ii>rT*««r awl paint aftar hav- 
VCbwB »taI>i>UBry dir irar*. 

Tyapaaitic or Emphyteiaatoiu Ab- 
. abii-b runlaiiM |ca* n> n^ll as |>ii», is 
ily nn «tth iti ibr m-iKbh-irhood 
rflWaliawntarr (-anal, rliidly at tbi- an- 
twManil Ulml paila uf ibu abiliiuiiiinl 
■■Mt, aad ahiHii ihraarruin. tviiii«tiiiii'« 
Am* « a bw oMiiuunii'atidu wilb tlio in- 
MiM. (B uiku ia»ia it ii> niit (o rvtili-DL 
Ika* MiUMtiWM an aAcD niionaiit on 
^M3Biriaa,aad wianiww |pir)(liti|[ ii> vtrj 
Mail m ihvBL 

fcllitiM. SlUi. ttt. — AlMtaapa ar« met 
*<k n *n nyiMM* uf tb* iKxIy. but niorr 
at^nally ■i'-— •>>'■ amtlar tiiaur u ahun* 
w, «»l jikalic i{lmu(U ant iiu- 

Xaaa. >•>■• ■•»( cwnir at nay prriod ofUfi, trnm tbr varlifM infancy to 
<Ua|a 1 ka«« oJHiird a rtry Uf);v alnviia in lb« axilla of a child alwut 




tig. *!. — IjMf* TinM AUmm «lt*n4- 
lac dwn IW TU|h a*^ t<^. 



252 



SUPPDHATION AND ABSCESS. 



« fortnight oM. Thoir «i'« vari«fl from that oi'a pin'? point to n tumor con- 
taining H pini or more of pus. Some cases of tlironic nhwcsw*, whiii v<-ry 
Urge, nro muttiforuhr, the different savilies beiuf; connected by iiarmw 
ulniuncU of comrnuDieatioii ; in tliiu uar I have Heeii a larj;e ahecctM cxli^nd- 
ing from tlie lumbar fcrlobrw llirongfi the iliac futea clon*n the thigh, the 
hnin. and the log, unlil at la^t it wai opened hy the aide of the tendi) AchilliK, 
tiflving formed five or six collections of fluid, uommunicntiug with one 
another by contracted channels (Fig. 92). 

Effects. — The yretmire-effefU at' nn absceM are often important. By 
preiuiure on the nerTea of a part, it may give ri*e to very severe pain and 
BpafiiD at a distance from Its aeul. Tlie puTntt orca^ioned by the prefsiirr of 
some forms of chronic ab«ceM npon nuigldioHng nerve-i, have been niielaken 
for tho§© of rheumaiiam or tieurulgla. When bloudvi'wf'ls cfime into rela- 
tion with an ab»ce», they udiinlly lit-c(inic coated liy n thick Inyer of gmnii* 
lation-tiAitie, which pruteeU ihi^ai from injury. In some ctiM», however, they 
are obliteraled by the conjoinMl dTfCtN nf the pra^ure and the inflamniation, 
iu which ther, a» well na ihi- ii<tjii<-iiit tiMura, partake. In other cade«. more 
particularly in Mtnimomt and nichcctic individiinN, the l)liio<lv(s»ela have 
been opened by nlecmtion and huvn bunt into the unc uf the nlutctiM, occa- 
NODtug Middc.n nnd dangvroui' or even fnt-nl hemorrhage. It ivMldoni. how- 
ever, tlmt u larffc arlery or vein puur« it:! conlenl* infi nn abiicen tliat has 
not iH-eu ■)jii-nfil. Thcic occurreiicw have taken jilace cbidly in the Deck, 
in which »itiinlii>ti both the carotid arlery. as In n case described by LiRton, 
nnd the interniil jugular vein have opened into the cavity of an abacvw. 
Ttie various inucou» cabals, cepccially the trachea and t!!c uretlirn, may be 
injuriously comprised by neighboring abseewta; to, also, bones may beoome 
necr<iMvi, and joints inllaraed and deotroyed from the same cause. 

Dia^osis. — The dingnosis of alweeae, though nstially easily mndc, at times 
retjuired close attention. The Surgeon believes that an acute nbseess is 
about to form when, after rigors andsome modification of the inflnnimalnry 
fever, he finds the local signs characteristic of tiic fornintioo of pus ; mi>r<t 
especially u throbbing pain in the part, with softening of any induration that 
may have ciiBted.nutl oedema of the areolar tissue covering it. 'Uissuspicios 
is turned into certainly, and he knows that an abeceas has formed, when, 
after the occurrence of thef»e syniploniB, fluctuation can be felt. Fluctuation 
is the seiisatiou felt bv' the Surgeon ou placing both hands, or one or more 
fingers of ench hnud us the esse may he, with moderate firmness upon the 
j>arl in which the fluid is sitiialMl. and then increaung the pressure with 
each hand alternately. < )n so duint, if fluid be preseut a wave will be felt 
to pass from under the hand which ia preH^ing more strongly, raising that 
which is applied Itvis firmly. Iu feeling for fluctuation the buiveon should 
always place aa large a surlaec nf eacli hand a» possible over the supposed 
fluid. The fingers should be curved no as to adapt tbemselvefl evenly to the 
pari, and tlie prvstture should be gentle and nteail^. If merely the ti^ of 
two flngera be poked into an Inflamed part, it gives pain to the patient, 
oausiog him involuntarily to wince and eontrutrt the muscles in the uetgh- 
borhao<l, ihud obnruring all <li-finite nrnsalionii of flncLuution. In large 
collections of fluid, a* in ii^citeii, one hand may l>e |>laci-d on one side and 
tli« opposite side strnck a trnmrl blow with the lip of the finger of the other 
hand, when a sharp inipuUe will he IVlt itiHtinctly coinmuuicnted tbrongh 
tlie Buld. ThU method <if (riling Ituctuntion is, however, ncnreely ever 
praclloable in tlie cnae of an alwi-u. 

Fluctuation may readily he confounded with the uii<)ulalory senkatiou 
commiinicntcd by :<ome tiMues front mere inRnmmatory infiltration into them. 
Thu, indeMl, is a ililfereDce of degree rather than of kind ; il» pus would 



I 
i 



DIAONOSIS OP ABSCKSS. 



fi68 



make iu appearflnoe id the coaiM of u few hoan if the tumor «r«re left to 
\u*l{. ^vna wiilioui thb, certain parts give very doccptive gensntion*, from 
iheir natui'nl laxity, ao U eotneiiiiies (lie case in liie areolar tissue of tlie nates 
umI thigh in penoita of lymphatic lemperament. A mill more perfect scnpc 
uf fluetuMiou i« Kiveu by a inuAcle nlieii ilie bands nre applitj iraui-vcrscly 
to it« fiiirefl; ami, coD»e<{Uti)tly, id all cm^a it ia a gooii rule to feci for lluc- 
tuattun witli the huniU ajiplied lint aloD^ aud atterwarda acruH iho line uf 
nnv ruu.-*cle thai may be Hitiiau-d beneaili «ir over tie suspected colleclion of 
fluHt. Many Mift Miiid (fniwlliv^iveaaenseiif fluctuation almost as dieiinctlr 
.I* fluid, d<^i-tvinj; even ihv tuiNit experienced. In the case of an encajisiilcd 
tuBior, lb*- diHtiiK'iion oaD mdily be made by prewing on its edge with the 
lip of uiir Htig«T. If it ia a ctiniiiic alK»-t«.H or cyst, uotesa it be very tense, 
th*- liiigrr go<9 ibrmigh tli« swelling vrilhtiul unyihing living fell to muve; in 
the caw (>> a tumor, the wilid mlge is ftttt to roll anay. In some rare caseB, 
irri-n irhvii fluid i* pmcnt, fluctuation may be wanting, us the tonsiou may 
be tuo greul to allow ufn wave being praduc^il in the omtciilHof the cavity. 
The oc'Cdrrence of fliicluatioti alone, bowev«r. in not of itself sufficient to 
dMermiiiir more than tbiit a fluiil uxi»t» in the part. The qnt-slioii nt-cetisarily 
ariave. Is (his fluid pus? In the majority of inntancci*, [be huit<iry uf the 
tarn, ibe character of th« pnin, the iircvioui <'xi><lfncc and the continuance 
of aymptoms of inflnmmatioii. enable the Surgeon to an!>wcr in the affirma- 
tive. But if, S8 in chronic or cold abstewM, there be only obscure evidence 
nf inllammation bavin); exit>ted, nml if the i-Kflling be of b>iig xlimdin);, th« 
lluettiatiou bcin>; perhaps deeply scateil niid iintixiiiict. the ralir plan wdl be 
lur tb« Sarveon to introduce an cxphirin^-nccdlc, uM to «cci whnt the true 
OBtnre of the fluid is; by this simple means many eiiil)(irrn)«>itig mi»lake« in 
diaunoflis niay be avoided. 

The tumoni with uhicli ahsceceee may more eflslly be confounded are thoM 

tttfi totid gn/trlh* in which there Ui a hi^di decree of elasticity, giving ri«c to 

aopeciea uf undulation, as iu some sfifl sarcomata. FlwH tvmort of various 

khid^ auch ea cysts aud enlai>^ bursa*, may also be confounded with ab- 

tceaets. In Iheae casea, ibe previous svmpton>s, the situation, and the gcnernl 

appearance aud feel uf the tumor, will usually enable the f?urgeon to cficct 

a ready diagn<i*iH ; Uit Hhould any doubt exist, the grooved esploring-needlc 

ur a tn>car may l>e intniduivd. nlien, if pus be present, a drop or two will 

«*<*i>e. The ■'Biipirator" is of tsi)e<ial service in cases in which it is desimblc 

to witbdraw wmte of ibe mniained fluid for closer examination. The mutt 

dMnmen formof uniiinitor eounintn ufnu exhausting syringe from which lend 

two short noxzl«* fitted with stopcock*. To one of these ih fitted an India- 

ruhl>rr tub<\ at the end of which i» a sliar|>, hollow needle, with a lerminnl 

i>(«ning. Tliir ncrdle ohould not have an eye some three-tjuarters of an inch 

or Riont from tho iHiinl, as in fn.-<pii-ntly the case. In using tbe instrument, 

it should firvt 1h! Ic9ft<^l with n nniiition of carbolic acid (1 in 20;. By this 

m disinfect and cleanse the mi-illc, and {)rov<: tlmt everything is in working 

ofdcr. Both Mo|>c>H-1cK being cloM-d, the pi»ion of tbe exhuuxting syringe » 

ntiMil and ri-taincd in itx position by giving ihr handle a (juarter turn. Tho 

needle is then pushexl in tdl it* om-uing in Imritfd beneath the okin, when tho 

Hupoock leading to it is lurncu on. The vacuum then extends into the 

needle, ami if it be gently and dtcndily pushed in the direcliim of the sus- 

I peried ahccese. the moment its jwint enter* a caviiy coiituining pus the fluid 

•111 pass up into the syringe A piece of glnw i* interposed in the India- 

rabhi-r tube, so that the nature of the fluid can be seen, even if the quantity 

Iw small. It is the use of the needle in this way, with ihe vacuum in it, that 

/nnus tbe cesential feature of t)ie aspirator ns invented bv Dieulafoy, and 

' dilttDfuiflliee it from the old auction-trocar. It avoids tlie <laiiger of pawing 




254 



SUPPtJRATlON AND AlieCIESS. 



ibo hollow ne«4llc cumptctelT thrcKi|;h t\w collecli'tn of paa bftfiw* ibt Mittos 
is upplied. aitd thus f»liiiK to d^cct th« fluid, hi olininic «Ii*o^*p», era 
wli«D a Inr)^ iieeHle it uaed, it utlen become* c)tuk««l iiiiiiii->li»U-ly by ik* 
flnbeft lit' ciiecHV uiiKur floHtioc in tlie tiiiid. but tli'w rnrvly lia[ijwi» Ixtei 
euuu^li lluid baa htxu i>l>tuiDe<l tu iudicuKt its nature. 

t'i]*. 93 repraHDts Coxelor's lupirator, irliich e»u he cinv<-r(i?<I, if Tiin» 
»or)% Itilu n aiphon. One «<jj>«k'K, c, as repr^L-nttxl in tlic ilmwint: Kim 
botli tubes. Tbe ptMiiu a Iwihr withdrawn, and a vacuum «> puduiiJ. ib 
COcV C is tuni4il itn tliitt il in fwralli^l tn lti« B/rinice, and the varuuin u ihnt 
pur ill conjieotioii wiUi iIk- niTMlIt; d. While doiii); tbix. llie small vK-k tl ■ 
mujit be clo*^- If it be dct«miin«d tu u«e tbc appumtua aa a nijtliiin. lk» 




«. Uian arrlaiCB. 

•tlliM «ilk IW 4lMb«rfi-pip« or Iht nMill*. 
•Ml tabs, hi W MMl HI a iJiiImo l( ■•qulral. 



IMO. 
ap«itla« IMa ■ 



,^ 



cvtrk K muet be '>pco«(l, and lb«> handle of th« (tistoB forcMl dnwR. m m i 
till the long lulu? nnf«in); doviiuanlt from E with the fluiil alrradv drawn 
I'rom llie cavilj-. Tliv ock u now beiiig turned oft, tlte fluid nlll omtiaoc 
to (low. H 

TIm diaipweis of ao «bac««B harinx pulialMn coinintiittcat«) to KbyaMbA 
jaccnt nntrj.fnm utt vnmrim, wilTlw dismaoed nlien «c eocneto sptmk of 
that diwnfli*. 

Prognofii. — Abscenn vary i;r«atly in danj^r, aM-ordinj; lo lltfir nalsT 
aicc, MtuaiiuD, and cauw, and (he conMitution uf tliv Mti«nl. Thr rbrnaii 
funa is uauall^ aitctidi->l hr iimrc n»k than llic acute. I>ui ihi* ri>k hiw 
gnnlljr diminwbed bj th« imnHfurtionnribr natiw[ilir imUmrnt. ThrfMiar-' 
pen) and p)iemic ara aixi-inll]- barAr<l<>ii* to lil'r, bi-iM)t flM'nrly a pari of a 
gcuersl inle«tiv« ]>ru«MB. Tli« large lii* of tatm aba cf M k an •wiBcni of 



■koT 




tbeathe:7t op abscess. 



25S 



grmt risk, occaKKmin^ not only n very nbundiint (liscbiir;;e of pus, hut like- 
«tM grOM ctiuaututionsil diiluHinnct- wht-n they ar« opened, unlera lliey cnn 
IwMkCiMTCAjlly draiiicil nml nil <ici.-QtnjKi«itioi) of lh« iliscliarKefi pre veil (^d. 
VIxt'OTMS thm arv «iUiitUil in thi; neighborhood of imporUuit orj^niiB, hs 
klf.iit the nock of l)iv bUil<U-r. or ht thr Anterior niedtiiBtinuni. are neee»- 
■Aiili much inon- hiiniritoiM from the pcciilinrily of their sitiiaiion thuii tlii>t« 
1 ' ' )i nn- nift nilh in 1cm iroporUnt rp(;ion». The oaoiie of the aW-«^ alixt 
- the rMiilt : if it bo n piece of tiead bone that t^an he reniovi-r), [ho 
_ will Epcodiiy coum if the frngnient be tukeii awny ; but if it Ixt sm 
■iiu»i4:il thnt it onnnnt he );ot rid of, it will, by nctiii); hh a cAiilini(i>u!>iiciiirfG 
tif irrittiuon, keep up ii discharge that may eventually prove fmul, 'flic 
ci^iwlitniiin of the p4iti«nt intliieuces our prognosis. f*UL-h an nniount of 
diM-linrjro as would iiwvitiihly prove fatal in a cachectic »vjtt«ni nmy influence 
isouixi one hot very little; so, aleo, the wanting elTect of un ubM-i-x* is hetler 
bume about middle af^ than at either of the extreme periods of life. 

Tkeatsiext. — The treatment of suppuration p«'»enia three points requjr* 
in;; attoniiou. The tirei object should be to prevent the fiirniBtKin of itiuticr; 
the next to t»ke steps for its evacuation Hhrn forniitd ; and llu- lii»t to 
PDilt'iivor to cIoe« the carity that results. 

In onier ioyment the /ornuUioit of mutter, it !> neci-warv In g^t rid of uny 
local irritant that may exist; thut<, » forei;;!) body «hmild Ik^ ri'movud, or 
extravHsnted un'ne be let out of the urentnr [i>»u^. Attcr thin lin* birn done, 
the prt^ventive treatment mu»t ooosisl in the active employment of liKuil 
*nliphlt>Ktnlit' means, ^ich us ice and cold ovn|>iirntin)i; lotionii: the swelling 
from i^xudaii'>n- matter, which >:i enpccitilly the prK'urvor of chronic abeccM, 
Qiusl Ih- ifut rid of by the c<miiniiiHix npnlicntion of scmic di^ciiticnt lotion. 
One oumpoaed of iiMlide of p<itUK>iiim ^j, fpiriti> »f wim- ^, nnliT .^vij. is 
•xiramely aveAil. In i»»nv. cm*-* uhHnrplinn nmy iidvaiitjigcou^ly be promoted 
liy mi-nrurial oiiitmi-uts or phiNtem. When once piii^ hai! loniicd, it is » ques- 
tion nh<.-lhi'r it can be ubKirlicd ngnin ; in i;enrriil, it ecrtninly cannot, but 
in ■uni» coM-si it may undergo ubMirptioii ; thii», in hypopyon we occasionally 
(•lifrrve tb«t the pui< dupcw itod in the anterior chamber of th« eye is removed 
Thv mon? fluid purtit of chronic ahfcvmi« occn«ionntly become absorbed, 
Iruving n chceity nvidue, in which lim« aalte may ntientardt be deposited, 
furming a cretaceous maw. 

When, noinithotanding the employment of appropriate means, it is evi- 
lU-nt thiii pu» i* sIhhiI to form, the trcalmenc fliould De completely changed, 
snd. by the nid of narrath and poulticeti, an endeavor should be made to 
hitMrn ^iif/fiuraticn. When this is fully established, the abscess having 
beci-inic " ripe,"' step* must be taken fur the evacuation of the matter. The 
trvaimeiil of iicult- tind chronie atiei-cMes differs in some respects. In dia- 
i'iuHin>; tlii^ Treatineat of Abucest, ne shall consider, in the lirst instance^ 
its in»nii;;cn)i-nt by the nietiMdi ordinarily in use, and, secondly, by the anti- 
^ic plan. 

In an Actltc AbMCn, the matter should be let out as soon as it la fully 
fortiied, otpecially in ihwe varieties of the disease connected with a morbid 
' Mate of the system, as in the metastatic and pysemic forms. When this is 
done, the cooitiiuiioD at once exi>erieQoe8 ^reat relief, the fever and mneral 
irritation sulH-iding materially ; llie free incision not only letting out tne pus, 
|biii reinovinf- tension. The rule of opening an acute abscess early is ei^ie- 
pially imjwraiive when the pus is formed in the sheaths of the t«ndons and 
ui»il«r fibrous expansions unere there is much tension ; also when it in nhw 
nled deeply in the areolar planea of a limb, under the larger niuseles, nher« 
it im» a teu'li-ucy to diflbse liaelf extensively. In those cases, likewi»r, in 
which pas is lodged in close proximity to a joint or under the periosteum, it 




250 



SUPPURATION AND ABSCESS. 



orbit, oiic.tt (h-i-ivyinii itie globe of the eye. To tfaeee forma of the disraw 
the Uetastatic Abacesies are cloaely allied. They ooDioionly occur ae 
c»iit>('i|iiL'ii('i-8 iif |>)';i;iiua, and will be mnre fully deecribed wilb tliat iliseoa«. 
TlifV limy be vi;ry iiuTiieniUB, and are iimt with iu the substance of ur^aiia 
H.-< wi'l I U.1 in tilt- uivdiar tiiteue and joitiUi. The last three 8peoi«e of abeoea 
aiv varii^tiis •<( llii? Houte furni. 

Chronic Abscesses, or, tut th«y are Humelimttt vailed, Culd AbaoeMes, are 
of very coniiiiDti oi'curreii(.i:, nud arise nuder aomewhat various conditioDS, 
P«rhajRi tliK nioKt typicJtl form i» that which lo so a>nimoiily mi-t nith iu 
C»uu<K.'ti(iu with iliwauwd houw, twjtecinlly thi; hiMliat of the verlehne. la 
lh(sc cnMO tbf! diiH-ii»« canim«Dcc* with chronic induTuiiialiun and puMibly 
with (Icitlh of H Kiuitll |iorLion of llin bone, uround which pun in tilowly 
fnnacd. Fmni this starting-pi unt the pun, iii> it iucri.iu<« in ciuautity, »lovrly 
niaki.'si n cavity for il»clf, furring its way in the dirwlion of Iiawl rmutnuce. 
The in-italion canned by the prwwnoc of ihii pu«. wliidi in unch ca»e» ia 
alwavH frvf from orgauisnis and chemically un irritating, is so Might that the 
surrounding areolar timiic, instead of booming sofUntd hv inliltration nitli 
inigrutin^ Iciicocyics, as in acuU^ ab«cc». hc«oniw con»nlidat«il partly by J 
omprcstion and partly by the gmwlh iif new lihrous tiwue, lilla wall of | 
such density and disliuctness is formed that it can be dissected out like that 
of a ry»t i l^ig. !:l];. Such an abscess slnnly extcu<ls wid may burrow to u 
OonHidcrnhle distance from iu original slarting-p>~>inu The couree it follows 
it determined tirst by the iascia beneath which it may be burrowing. As a 
gCDernl rule it does not perforate a fascia, ni> this becomes thickened by the 
growth of new &braus tissue rather than thinned by ulceration or prsMure, 
Seci.indly, it burrows in the spaces along which tlio larger arteries run ; thus, 
a psoas BbsyesB alter Ibllowinp: the muscle beueuth the fascia to the groin 
comes in relation with the profunda, and fullowa it amongst the addnclor 
muscles, often aeudiii^ out proeesaes along the circumHex arieriea and their 
branches reaubinc to tJie gluteal region. These abscesses do not readily 
point, and their durutlon in often very remarkable. I have seen large 
chninic abiweMieti in the iliac fossa and groin pcrtectly slaiiouary for nearly 
IVfo years. The tluid contained in such abacessc* is ihin, (laky, and curdy, 
thouich in some cases tJie ims Is healthy in appiiarauce. SonK-tinit^ they 
contain majtaes of a nxW yellowish nuhsiance. apparently fonned of ocHigu- 
laled Qbrin entangling the fatty remuiue of dt.-geuernted pua-celia, Iwt more 
commonly the »hrt-d.i and (lakes are of small nixe. No micntscopio nrgan- 
isnis are fuuud iu the puii of a i-hronic hI>9i:v«s ; and, howercr 1od)i: it may 
remain nnofH-mil, it shoH* no tendency to putrefaction until air is ad- 
mitted from nilhciul. When such au ahscN-^-u has been opctml the wall of 
the iiac in funn<l iu mint (.■ivu-s in bi: liui^d hy a thin layer of adherent 
chre.->y matter, in othi-r caati'i it may be (■nvereil by a nmooth layer of imgier- 
fect granulatioR-tinuc almost n-Ki-uihliug u mncoiinnKrmhrunc in appi-jirancc. 
The cavhy in ntUtn crimicd by lukuds conlainiiig vvwcl.i of con^aidvriiblo riMi. 
Occa.iionally the fluid contvnl^ become gradually ahsurbtid and the absccm 
UMdcrgiM'ji N[H)Dtancou» curr, ttn mU- bc-iug indicated by some dry cliusay 
matter enol used in a dcnw; nuut* of fibroid limiic. 

Chnmic abxctMieA of a ■umi'wbnt nimilnr character ofU^n form in connec- 
tion with disciund joinlii, but the couryc- of ihoau is ununlly more rapid and 
the extent to whieh they burrow iii not so grent. 

Another form of i-hnmic nb»c<M i* that occiwionally met with in ibo 
mamma ; in which a iew drops of curily pu» become liurroundei) by so dense 
a wall of fibroid tissue as to simulate n solid tumor. A similar form a 
found ill the cancellous ti«eue of bone, but in this case the enclosing wnti ia 
fvrm<'d of very dcneo compact ohcous linne. Such abscesen may exist for 
an indelinitc period. 



MXTuons or oPEXi.va ad»cesbk8. 



£57 



baajbMpMi.mAvr tlw <«cii|io uf U>p pdi'. that tlio oivity uf the nbeccm ia 
IM«Mk MmI tiy tbc ruplurp uf miuiv «tiuill vcseol situnlcd in its nulls; 
n. U— w f. i> ut litUv inuatrnt. tliv hriuorrhs^ ^jiPcdilT cmsint; o" >'■« 
amikalim nf |i f wu w by « tmndiip-, or nf cold. I'mriilod the incisioD have 
toWamtd ooly Ibrougb thr titlrj^inH-ntal (inicturN odcI fuscia, in »rd«r 
I Ul Mtlat fiir the pus, llivn- c»ti be bul little rianjter of liemurrhaite 
■aciJtaUl woufM uf aov bloodvessel of iiuponuDce; and. ahouM 
oeenr. il will probably be of n vtaunu cliaractcr, and may b« 
■ai*d hy t n mitrt maa petition. It ia wtter. bonever. for a SurKe>iii to 
Mika il ft nw aover lu uprai crvenaeupertidsl abooeea witlraut bavins ibe 
irv acMM u baod (or the arrest of arterial h«iDOrrba)[e. Wlivu tb« 
.< » ii>ore 4mf>)]r anted tban this, lyini,* under tbe superficial niusclea, 
I k will Umo m ii6«—ry lu peoelrau, more aertous conaequences may 
■imI tfac iautuiious um of iIm^ Icuife may Icwl to the moat )<i-rili>ua 
Than are mom panicularty n{il to occur in deeply MHiti.ti «iil>- 
abwvMn of lh« ibich ; and 1 have man than onoc knowii auch 
r atl««ial >'-r.t.'r>-hiij^' follow inoitiiuiu made for tbe purpoae of evacil- 
> deer ' '■> th*^ '■'■■^ ■■> ^**^ cMee, as lo neceiriliitc tW liga- 

tbe &ur'i«> iiiUTv. In unlfr to nroid thit dancer, Hilton ailvtM^d 
Hvaaa ao aimatrd Uiould W i>{H-nc<l in tlio following way. An 
it HMtde thruugb the inlcgtim^ntA and fnM-ia »o a* to cxpotr the 
oader wbicb the pus li«Y: u din-ctor U ihi-n puttbnl through tbe 
■fcMsn ofllie noacle into the cavity of tbe abecvw. and niotig tbe groove 
t' thai a ataadar pair of drvtwiig-fom){)» ic m»]Htl ; when it n-ndim ifav 
iJm blftdaa arv opene'l up. the muociilnr Hhn-f iH^pnratcil. atid ftw 
Imia tw lliv fm. Tan oprniog thus maile mun be niniDlaiucH by iho 
" ~ (if a ilrainact-tiibc, or the pulicnt> ojndilioD will be but little 
far ihr uuM-iilar libm come lumber again U aoon as the dreaf- 
arr rcraoTcd, ami pntper draina;^! tx^iiij; thus n.iiilertHl impiA- 
ha Mta will aoou resccumulat^^, ami. air having bti^n admitlvd, will 
It OKinufonF mid i;ive Hm- to >«{iiic poJMMiiog. 
.\ftar Iba tifNtttio]; hai Kl-uii niiide, the cJtviir left eventually fills un eitlM-r 
^ ike coftkamaw iif it* a'uif*. or by grnnulalin^ from Mow'; if il fill iiK^oin 
wk pMa. a IWvb iiici*i<iu, trrn»e<l a " v<>unt>.-i^oi>«:uiug," mu>t be nuulu in the 
»M 4efMMlcDt iwrt. N'otliin^ii* roorv dangerou* than |ienl-up inntler in 
1>rf=— '- ■■:■•:-> -I -i-n»i3», II Mpi:«lily diTomjMim^ and Weouic* ofli-uiiive, 
inD aixl iuflaninmtion, and prcili«pc»a to the orrur- 
I rrjii{>riiu siiii pyawiiA. lu or<l«ir to prevent tho>e evil ctnu*- 
n«ani«v nnt be bad to fm- o{)eniiigii id dejicndeut «ituatioti», ami 





«« oTUm tlimlnac«4ube. 
Ia tW traaUMat mrkniw and eold obtKtKt, tbe time and motle of omd- 
■r^' ibe vmriely of abeoan vritb which we have to deal. Wheo 

d«r '>a* of large MM) au<l T«rTBlow formation, ai> in n pbom abacen 

^m <La « a» > - ••( tbeafiiite. it waa formerly (he cuatom to wait until an o|>enin>; 
■aa nftdaml a«ciMary by the tendency to implication of the »kin, or by 
" l ari nas pmMra btrng cxeretaed on important parts. Tie pu? was then i^ 
«( by tba ffalvniar apeiture ncomtaeDded by Aberoetby. the objec-l beini; 
to rnnct tba mtur nttt into iIk interior iif the ati8cce».'»o a« to leaen the 



*AMf« oTpMrvfiMuaci of any pus tliat wad ld\. Tbe valvular opening wu 
■ai* by^rawiotf ib<- •kin ooverlng tbo abeccM well to one aide, tlien paanog 
' r^aaoury din<ci]y inio the Mte, aiid allowing aa much of tbe pus toeeca[>e 
iSliowont by thr culiancof the wnlliiof tbeabacRe; liefore tite matter 
I ^jailr fiiaJ to lt»w, and eunitcr|u«-Dtly Iteforo any air could have entered 
*W ttr, the akin wa» altowcil to recover ita natural jMaiUoD, so that the 
■VanaiB ia it and in the wall of the alNceiw might no longer directly com- 




258 



SOPPUBATIO}r AND AUSCKSD. 



municXe. A piece ol' plflsUr, or of tint •oaked in collodion, wu pL 
upOD lli« I'strronl wniim), which •ilt^n bcnlv'! uoiler ibb cov«nn>; in 
oourao of mliort timtt. Wlion itiv cir>t <>f the ubKya* tuul S|{sin filled ■ 
what, this pnKOW viut rKjmU-d ; f that, Im Knd In* )>u» lii-iiig mllowt 
ei^nmiulaU- in it bcJWe «neh sucoeediDg aractiiilioii, it inii^hi iirailunlly ' 
tnct and cli«c. Thb mode of trcntmmt is tcldoiii priK'tiM>d in tli«t p~ 
dky; but, instead of mnking the ralvuliir <i|>i-iiiiig in lliio oav. n rl 
abenas majBooictinuv be ndv«nltigr<itislv npi-m-il by Tapping with a 1 
and Caonla el' mwknte siu, lh« instniniciit Iwiii^ iiitroducvd oliti<|iirly ; 
tirt^ou ilio »kiri nod the Bbeccas, and tbrii nmdi- ti> dip dntni IdIo Uir i 
AA«r tbo withdrawal of th« canula, the apcrturv uuiy bo ebwxl as io 
former caw. 

8iiic« tli« invention of the Aspirator by Dicnlnfiy. ibat int^niRM-nl hai 
A great extent taken the place of Ui« trocar aud canula. as by ila tim> 




Pij[. «».— Tiro forta* of VvlkBkDB** ■ Hhwp Sr**"-" 

Antrnnceofiiir is i' fled lially prevented. There is, bowcTer, flav diadvanbut 
in tbt* plan nf ojicuing ab«OMM>>; that, Iflhr diBchiiruo bv curdv or ■hrvdiJy, 
il is vory apt lo block up tliL- cuniihi or nc«dlc, BJid thnii tu inwtfrn- wiUi 
tliv prupvr vvacuaUoD or tbe maiirr. It is v«ry seldoni, bontver. thai any 
of tbcaa nodn of irealmcnl cun; n chmnic ahscns. The tiiui? comes at 1m ' 
(a aliDoMall oaaea whrn it inu.-)t K- niivnMl. Bv mrvfully mrryinit titit 0» \ 
uttiMptic In-ntincnt. to l>v pntH-ntly dncribvn, tlii* may be dt<iii- without 
«BUaiRg ibv Hlit;hU«l con»liluu<>oal ditlurbnnce; but if fnun any cause tkat 
be dot poCMblv. thi- M'plie fi-vcr foltnuini; thtt ndmiasioa of air may be kvpt 
down »o aa to Iw wrarcely danj^-ruus by tnnking very free iuctSMMM ajkdj 
inaerling tar){l^ dniiimgiy'tubca, so that the quantity of decompOMbh 
shall he reiluecd lo ti iDinimum. 

In uptuini; a largo ehn>nic nbscMs, the wtHind ebould first Im tnadu onJjrl 
juHt liiriceeDOUgblo admit the fi>teflni;er. which should immwliutety be ihrosU 
in bcfiire tlie pus t«cnpce. sn that iht inlerior of tlw cavity mn be examined j 
before it n>1la|>ee& In this way the s'ltt- and shape of the mlBcnB, it* pmbat 
oriRin, aud the preeetlceorubfieDceof liute fniKnieula of iKiue i>r oUier forvia 
boiiin are most easily di'tcrniioed. In doiii); thi-t, hawtTer, cuvahoald 1 
ukeu tiol lo tear ihrou^h the biiodji which ure often fait creasing the cwrity^ 
U |l»>ae MimrtiniM funiiiiu veeaelM of coinidemble slse. If much shreildr M 
ch«t»y matter mi Iw felt in the cavity, il must bo CUeAiUy remoVHl bj 
mwiM uf a snail sooop or sbarp spoon. 

In tbo treatment or cbrunie aliamM in connection with joints, very 
inra^ons, layiof: tlie cavity eomphlely o|H-n tVotn one en<l to th« olber, at i 
most dopcDilcnt part, will bo fuuud tu give tbo boat resulta. 

In snudl clirooic abaoMM*, such ns thooo arising in oonneotJon with i 



MKTBOOS OP OPKKINO AUSCKSBBS. 



269 



m ID tcmfvUiu* •ubcutnuc«iua iib«ira«ra, which frequently occur in 
I in Bfaii-h il u Hi«inil>lv to uvnul n rrftr, lh« b«al macle of treatment 
■» to^ikf B Minrtun;, thnjugh wlik'h n tminll "BhBr|> apoou" (Fik. i'oi cud 
bm imr^itna, hy nxAin of wliiili nil lbi> b«lf-«oflcucd clieeey mntter cud be 
AAcr tbtt cavity has hwn thorongUy scraped out, a smnll ilrnia- 
kaU b» iDMitcd. TIh-m opcratioOB aa a rule iiucc<:e<d much 
r if ftrfbfBied with KDliscptic precuulions. 

Tm, tboitgl) its applicaiioii is piiiiiful, may be sdviuiiageoiMly 
^■4 Ut opaamg thwe chn^nic HubcuUtoeuiia abaixmee, the iJtin cororinc 
■fkch b siidi undermined, coujteeted. utd diacolored. Id IfacM eaac* I 
«^MMJy caiploy il with C'*''! ^dnuitajEe. 

IkHae farna of chruuic abaceas it will he liniuil ibnl llii*c proeMH* 
law Bso^nry li>r tbe oootnclioD and cloMire uf the nvity, iill«r its 




*^ 



mg. ».— lit I *ml I ■ ti e»fm iBIu .«)>.<••> itiicuxh I'lBate. 

han faavo vvaouotcd, <1d Dot rcndilir lake plitcc: and il bnomti 
to bMtt iwounw lu BMnuuriK, whii-b. bir exciting influuimniioii in 
>v^, Imaf about rJuuigm which ntv followed bv hralin^. Wiib tbtt 
> • Sitn <if twu 'If tlirtv tlireiMJN may very UMfutlr Ix- juimsi ncruM the 
uu iif B nirvu^iK-Hlf. (tr by h luoe RirsighL ncvdiv )i(i«lK-d up 
I a esnula u**d for ttippiui; ( Pig. 9ti\ It should be Icfl in fur ■ few 
' ->-'-*' ••• r- h<*Hllhr inHnnimaiioD will be set un. In other CUME 
^Mi bu bei'D tapped. th« red wBsh or diluhxl tincture of 

Mlier T.. ,^i.> ,. u^««t«d a»d left in. These inrthoda of exciting inflamina- 
M V* >»pn-tally u*rful nheD ih« wbII is thin, and of a Tory cbroaic 
When tb* mil b very thick niid dense, U wmetiDm liappens iu 
I «t rrry old ataodinc ^iiuatud in the ueck, an elliptical ni«ce of Ow 
{Mjriifia (boold be di»ect«d out, and tbe cavity lightly dnuBed, and 
ft fill by jtranulaiion. This plan of irmtnient i^ often very buc- 
I : aji'] I baw by it cured aboccMeti in the neck of aeven or ei);ht yean' 
■Haar. vbiph kav* miMc) every ••ther jiIud employed. 
TW Dr«iaaf^t«b« wu iutj^Hluceil into mudero surreal practice by Cba»> 
It u of tb«^ graunt value in kvtrping the cavitiea of absceaaea, and, 
, iW latsriar vf mmnd* Kvncml ly, trcv from iImm fttild aocumubitioiM 
^Uwasfit toitiMfeffo d*cunip»atii<>n. iind liiin become the Muroo alikv of 
tist irrilatioB and of r>>iiilitulit>uiil infii'liun. 

la IMS, in the "(.(Biirtlc diii IIApitaus." «nu) (Miblitbrd ih« following 
Jiii^tiuM of Oia— Ignac'a mt<tti«<l uf miployin^ «ir>,nml rlraiiingv: "Tbs 
friadbk uf S>tryiMt Dninayt coii^iiilj in i-«Ulilishiug a o»nlinu«4i» oatwnrd 
M ef ibr duMh, or, in trtfaer «iinlii, in briii;;iiii: iiboui a port uf dryiog-up of 
fw^bai cul Irrtiuftt. It bnrcrMary to (employ liil>ai«f vuicnnizird riUHilrlKKio 
^ i^ i i ii i diaiBtier*, thv niL-iliiim t'lw l>ring that uf u crow's (guill, pirrced 
■ ■ttvrala witfa aaall bolt* Ilka ihoae of the eye ot a calheter. Tbuw 




S60 



StTPPUBATIOS AND ABS0K98. 



tubee are pl»ced acnifs nbtctiwA or piirulint colloctions ill Kticli n wny that 
Uie liquids iN.'iiclratin)' ihroiicli the IkjW in the didra nf ihc tiilirc mny 
easily IIom aloii}> t)i«ir whole leu^tb, and cuDiiinioiisly drop frum tlicir rtiifrt 
or Irum tbat oiie which is more depeodcDt. Thes« tubc« nr« iiitroducnl in 
ihe sauic way thnt a aelon is ... . the end of the 
lube ia split in two, and each piece is fixed to 
the bIcid t>y a strip of plaster." To this descrip- 
Uon D«tJiing need beaoded. Noimprovcmoiii has 
been made on the ineihod devised by fiinsMiipiiac 
more tliau a quarter of a century ajto.' 

Drainnge-tubee are etipeciHllr um^M in tlie treat- 
rai-iit of (^lironic abK^Mes. I'he tubw miule nf 
the r<^ liiilia-ruliber are the iiHWt durable. They 
iniiM Ci'rre»{K)nd in uxo to the m|Hiciiy of the 
cavity lh<ry nri' intended to ilmiii; tint ut much 
bri:>iu»e a nmall tllb« (Mluld not curry ulT all the 
fiuid tliut escape*, but bccauMO tht> Ureor itibea 
arc lew likdy to gi;t arcidciiUilly Higkiil, and the 
larger thi; cavity, the more wrioii" wimlil lie 
the pinM'<iui'nc« of such nii accident. For a large 
penas-absccse the tube tint used should be at least 
OS thick as the forefinger. A couple of threads 
about '2 inches in lengtfi, must be attached one to 
cnch side of tbe superlicinl end of th« tui>c. These 
lie upon the skin beneath the dressing when the 
tube h«a been inserted, and prevent its slipping 
into ihe cavity. This precaution is very imjMtrUint. 
m ntany accidents have bap|>ened from ils not 
being taken. A few years ago. a paiieni threat- 
ened an action for damages a^ain»t the nuthorilics 
of a hospital, because through tbe neglect of this 
detail on the pan of a drewer, the tube had slipiied into the cavity of 
on alucMi, and liad been Io«t and forgotten ; bv whi<-ri accident the cure was 
couddenbly delayed. If Ihe tiibe« are inteuiled to be ii^ed as part of the 
nntiwpllc treatment, they munt be kept in a aolution uf carbolic acid in 
water (1 in 20) for at leaMt twenty-four houra before being UHod. 

A ilraiHage-tul>e in used in tbe follgwing wny: Tlie aWi^te having lieen 
punctured and tbe puHalloueil to escape, tbe depth of the cavity in measured 
with a probe, or with a inair of small "Hinus-forccpx" (Fig. 97), which Mrve 
to introduce the lube. The depth having been a^ievrtainiil. a piece of lube 
of ttiv necessarv lengtli is cut off*. It if then wixed in liie xintiH-ttircejw, and 
puiJied in till the own nioulh with the threads atUcbeil is exactly level with 
the skin. If the tube passes in ohli((uely beneath the skin, its mouth rau>l be 
bevelled so n» to correiipond nccunitetv to the surface. If n long piece of tube 
W' allowed to hnnc out, it» end is folded over under the drrwing. and thus 
Ihe luraeu is completely obKtruclivl. Another verj- convenient way of intro- 
<tgcing iheso tubes is. by 6xlng them on the end of a Ibrkcd jirobc t Figs. 9S 

> But th« (urKica) drsinoKU <>f ut»«ci«ea wm nmnloyMl three c«nl>irt«* hg" in Uie 
«aM of Philip th* Saoond, King of Sjisln. J}t. Curtan {BriHtJi UttHtal Journal, 
vol. i., 18B1) glTSi the followini- moti iateiatting quolaUon. The word* dtwnbing 
Ihli omtrlvance occur !n a i*Ty rare book, vntlllod Dr Ftliei Bxanu PAiUji/ii Aut- 
triati, UinpatMintm Rf-fiM . . . ncrlMllHiapBiiiceOervcrrsTurrleaiK, <'Hi>ell R«ie..eto. 
They run at rollowt : " Ueincept eieiidojburi qoo Mane et VwpereSculellii)d«R;repls- 
tMDIiir. ut usiatur narcios d« Onaale, Ciirur^ifA Jtttutd Ofmt tral, yua endrnddHm 
fenU rcmotii tatiinn fiuetMl." 




Plft. «.— ••3ino»-foro«i>»." 



I 
I 



d 



DKAlSAOK-rrBKS. 



361 



mi WX bv which the lulw m rarriet) iiiu> tlt« absccBB and left then ou Um 
«ciite«al nf tba probe. 
U mmm lar|pf ■lamii It will be ttMad couvcutent to piue in two tub« nt 
ii |>^t*. Tbl* b much Witer tlmn {Hicfin^ ■> *i>ig>>: tulw ihrougb the 
m it allair* lh« (Diddlf [Mirt t» Ik-nI. 
tb« chaooe nf ■ troulilnmnie 



■mMIbc tndc briiig \ci\. A draiaago- 
sat U oattor Dot bo rwnovnl for lbn« 



V 



Jinrtlwiwltii lhen> inav bo Mine tn>ubl« 111 
■Mf it in >iri>ii): hm bv ih>- thiH dty, 
kIm OMuIly uiKiJd a track r<.>r il»ell', into 
«kich (t (Sd rvoHilr be ptuKnl wlion it hiM 
feva lakai oui t'i>r cloutiaif. If ihc csm 
4w ■«ll. M the iibtw mdually clues 
Am tb« bottom, th« tube Decomw pfuh«d 
«*-. vtMO thia enoaiDencw lo lake place, it 
^H bt cradnallv sboriened to ai^coiiinKi- 
4lr tl tn lb* dluiiiilabed siae of the cavity. 
A iiW <tf amallef diaraeler mity also 1m; 
«al «Ui wlTmDtagv a» tb* dbcbarxe <li, 
■■lihcaL In ■one c«mb tli« <lm!iiiii;e' 
I Iww sppcand U me to ai-t i» nnothtr 
by merely renioviii); the {xirukni 
: vie, by irrit«ttii(C thr wnl I of the 
jtHi ■• a M-(on w<Mil<l. ami thuK 

■ apiBcreawrl activity, iiii'l tnikii-riallv 

■Im tbe i)iM-har>,i-. Ou their witlxIrawHl, however, thi« stiRHilntion 
W ba^ MOi) lo In- lii-iit'ticial. causing ii speeiiier closure of the cavity. 

tto Aatb*ptic TrettmcDt mny be very faucceafliUy applied to tbe treat- 
Mat rf atMcioMra. Ut iu Bieaos all the odvaota^ of a free opeoinx, 
ffmif raady esit m ttie iliiicbanKi«, oao be obtained without the serious coa- 
»ffii>w» ■!■'•• -^ !>i-i) folluw the modes of iroatment which linvejuM been 
* mtK il. 1 ill the com of Inrtfe rhr-iiiic ahaowMW. Tbe praotioe b 




Fif. n. 
P«rli*4 Prvb* for 
laifwiMiaa t>Ml»- 
■(•-labs. 



Dnina|»-lalM 
and Porkvil 
Praka. 



ikMd Di>>« ii>r ffillotriujj priudiilcM: 1. Tbr t'ortnatioti of pti*. wbeiber 
lia ■■rnc* of a (tranulattng "'Tf or in the cavity of nu aliMTsa, i* due to 
•^ ahoomal Initalioa of tbe Uaiuea. 2. lu tlii' vn>i nuijority of acute 
. tka (Kimary cauw b of a t«tnponiry elmntcu-r, iu> exact nature 
< Wbc uneertaii) ; in other taM» a (It^iinri caiiM may be readily fnund. 
• •■ iuiunr iu aa unheallby wbjeet. or the presence of an irritating forvi^n 
h. Tbe primarv cause <>(' the fornuitioo of an afaacoi htiag removiil 
niof dJMpMarfl. ihr irritaii'ku fel tip by the tcniioQ of the iwrl» in 
a m ujiMW of tna ac<-»i lo u IuIm-o »!" tl uid is euflicicnt locftuaetbtcoRiinuHiice 
•'ibt |i*«aHaof MpiMimli'iii. timl tin- |Kiinl)ii^' of the absceai. 4. If tliia 
■v»«f urilstiiiB br rrfiioved iiod no frvth irritant lakes lis place, and if no 
<<tv iiritaut 'f A pi>n<t«lrol character, nicIi ad the prreenoe ol a forei);u 
Wr. ha^- 'I frith it. all suppiinitiuii will cen^e ne w>on a» teitsion la 

Pttml I lut the put, the oulv subwquetit discharjre beiui; of a 

^M* asi ng froa tne surfaoe ot the irraoulations lining titt cavity 

J Am tit^-" li ihi* dischart^ l>e pent up tn tbe cavity, imtxion will h« 

riia pfudncnl. and, ai-tiiijr a* nn irriljini. mill cau«r fruh *up|Miralion ; bui 
■W <Hicbar]ce b^ allowixl tn ilrnin away it will rapidly diniininh. and 
«f of ihr abtcnw «ill !«■ ubltli-rsltil by tlie oniinnry pn>cr<«r« of oini. 
, cicaimation. If dcml Ix-nc i»xi»t al the boltinn of the cavity. 
ift|anlive p r^ casi. iovolviii;; al«>ir)tltun or i'xpul«i<i« of thedend boti«, 
1 bt vwj ahnt. tiM Hroiu diaebarga oJUn continuing for inonlhii without 




262 



SUPF0SATIOV ANII ABSCESS. 




dwnge^ nnteas allowed to (tcMmpow, wlieu it will rapidly b««uiii« pan' 
aad ooniiiderably iiicrraM.-)) lu <|uuniiiy. fi. In ibe oraiuai^ mMhod «^ 
openinic an iiliM-f^, ii)tlii>iiuli tbe irriiAtioa due to temioii u rpfooTMl. • 
frrali irritjiiil U a<luiilt<^l in tli<!sliaM oftho (keompoaltion ol'tlM^ diacban;'^?*- 
which in the iuililc»t cuhv will >oriou«ly d«lay the cloiii); of the »rUy ^ 
till' iilwM«.-<, while ill niiiny, HUcb m ^ttrfit pKiiu or lumlmr nh*onpt«, il 
I<^1 to ;>tirh all iiniihunt of cuiiMiiuti'iiiiil (liMurboncc u to be npldly fa' 
tf. Tbe cause nl' ili-(i>iii|iii«iliiin i* n»t tlx! ndiniMon of th4< pim of ihv a 
but tbo pn»cncc of organic gi-rmf which nro coDiUiitly llnniiiiip io 
nlinrapbrra, and whoM aotivii.y in rrndily dntraytd hv th« ilin-ct 
upim thcTo of nny powerful chi'micnl nti(i»»pttc. many nf whii'h arr vol 
wit exprrimcDts hnvo ahown that but little rvlianci? mn Ix- placrd viw-^'a 
tbarvapon mixed with air in auch proponiont imnrc pnidicnbly aiiainalJ ^^■ 
Lister, tWrcfore, in hia method of treatment aiiiia nl tlip following object*^ 
lat. By freely opening the abfceae, completely to «VBcualo its ooatcnu, »m^ 
to provide a reiuly csit for the aubfequenl discharge, thus complouly r»- 
moTiDg lenaion and preventing its return : 2d. Tbe entire exclusioa tmta 
the opCDing into the abBceas of air unmixed with a stranK Hpray uf carboKa^ 
add or aome otlier antiaeptio; the gpray niual be n ntie that it aball Ix 
practically imponible for any solid particle flouiiiij; in the air to racapceoa- 
t<tci with a drop of the antiseptic solution ; and 'M. Tlie abaorption by aoat 
poToua uateriWl, iroprwiateii with a powerful nuiim.-]>lic of all d(M:har|(<t 
M aoon as tbey eacape mm tbo woudJ — in shurt. the prevention of d<«on- 
posilion in t3ie aac of the abtoea*, or in tlie ditclinrgf* lying abooi Om 
opening. 

Tbe moat conwDient antiMptie for xh«m> purpoaca it carbolic ncSd. TW| 
apfMUatua iind material* r«(|iiircd for opening and dnadng an ahdoraa aati- 
aoptically arc — lat. A <{unrt or more of a Kiluiion of carbolic aoiil in wairr 
(1 in 20). 2d. Some thin cotton or linen rag frve frvim holra. railed "the 
guard" 3d. Some thick green oiled ailk. coated witli copal varnish, and 
covered with a thin Isver of a mixture of dextrine and elarch, bo Uiat wban 
dipped in the carbolic lotion, it may Ix^convc uniformly wetted. Thil 
called the "pntetiive." A\h. The wifhitiie gavte. inh. S^me thin niockio- 
tuab cloth or " hat-iininp." Ctli. Home banaages made of thf orbolic );>st«. 
and M>me elaatio webbtng from 1 lo 2 Incliea In width. The inainimcsB 
required are — 1st. Tbe spray* producer. If aolbing eli« be available, a 
Uichardsoo's etberepray apparutu* filial with a eulutioo of cnrtMilic bcM ta 
water (1 in 40), mav be u*ed, but ihi? »tettm sprays aro much more roovr- 
nient imd ccrtiiin. ^ir vnM-l for lliv cMrl>ulic acid toiwt b<< iilird with the 
1 in 'iOfolulton, which, whi-n mixed witli the steam, ia reiluce<l to alxxft 



Irr 

-J 



A biuin or tlonp flat diab filled with carbolic lotion. 1 in 40. 
iurtrumPHiii are to bo placed. 3d. A piece of drainac^tuba 



1 in 30. 2d. 

in which all 

soitol to the caso and fitted with thread*, li nnut hiive been snekad'iD tbe 

1 in ^Oolution for twenty-foiir hours. 4th. The ordinary instrutBeota fbr 

opening an absctas, and a pair of sinua-forcepa fi>r inserting lbs drainage 

tube. 

The opening of an abseev according to tlie lislerian method is dooe a* 
followa: The akin all roond fur at least nineinchcs when piweible, mitst Bin 
bo well washed with the cnrhotic lulion ( 1 in 40). Il la often a good plan to 
wrap the part in a towel soaked in the carbolic lotion for an hour or two 
liefore the abscess ia opened, especially when tbe patient's skin is rery dirtv. 
The ateam spray is then turned on. ('are must be taken li>s«« that it \t 
really blowing carbolic acid lotion, and not water nioite, aa it would iben 
rasrely sweep the dust of the sir into the wound and rnc^Miratfe putrefaction. 
Tbe DHr^gaoD liaving ihorMighiy bathi-d bib hands in ihr lotion 1 1 in 40), 



1 



f AVTUKPTIC TRKATHKNT OF ABSCR3SES. 263 

Ifai v(«n* ttir alMnv witli ihe knife ukrn ffiwbly out of tl>i> name aoltittoo. 
JU MMa M thv pu> M«iiH til flriut, tli« ilmitwKt^tulM' ii> iituTtnl a> iMrfuro 
^■rilwL If it i> ilrairnlile ikiI Iu ukp th« *{irny moir llniii U nlmilutvly 
■^■vv. in nniri !■■ BVirid wttitit; th<' Ik-iI. tbp inrwiini iimy lii- »n>viTr<l by 
At|«ud — tlut u t'l nay. tbv |iiw-i' ui' nf Xivfittv mi-nliimiil — ilii)}H'il in llio 
WMk lotina ; luiil tbo pus imiy bo ■IIowmI to Itovr out fmm umic-r itiiit, tb« 
if*f Wok MitppMi for tlif time. Am whiu u* the pun cgiiimi* to tlnm. \iiv 
^nr aMT be turim) on ni^iit nnil tbc ^unnl mituvril. Thr dtvmng ia 
MfaidtfaBi: kBitiall (tiryi' uf tlti^" pri>i<-rtivr"(lippnl in tbir cnrholto lotiOD 
sifM •pplimi to the wuuod, with » niilc cut ilirough it c^irmnoading tii the 
•Mth ni the dr«tasjc»-tulir. Tin- nbj<Tt of ihi* is tn protect tiKi tinues fmm 
A* rfovct nniact of the carbolic na<l. which, m « powerful irritant, would 
MW or at l«MC drlnr iMulioif, nml cuum- more or lem profitw suppuratioD. 
tfifca tab* exanly All* thn opcniiif: made. ib« prot*ctiva i» Dot nacoaary. 
(hvikia i» ptaood a double layer of ipiiiic. dipped in the carbolic iMioa and 
■pKanl a* dry a> pooihle. This has been foaod to ^ire an addilionAl 
■Mr, ■• the carbiiltc g^au ottca picka up pieces of dirt uhich are not dis- 
■tu i d br It in it« dry stale. Over the wet gnate are applied iwvenil dry 
h7va,tilMr aOMotb or crumpled upuccording to the form of the part. Tha 
faHtiljr ot thia muit bv proportional Iu the amount of dischnrj^ that ia 
Ofartad lo flvw from the cavity. It miiat be arranf^] so oa to till Up any 
■inal bolloaw or irTe|;ulari(ies of ihti {mrt, n> llmi (he bnodagta may lie 
MondJjr aod avenly over il The auperSeial dreaaiuK is tlien itpplied. This 
» niMipoaad of eiaht lavvn uf carbolic gause. )>etwe«a the two luudl superficial 
tf afckli b pUcvd a piece of thin inackintonh cK-ith. or. aa it ia odled in the 
.'baMinini;." Th« object of tht* t* to diffuse the diacfaarge evenly 
tbo whole drtwing. and to prevent ita auaking through at once 
tht ufMflhg into the nbaccai. If no "hat-lining" is available, of 

I any otlx-x i«aicr-pn»f material will act eiiuallv well. The dreanng, 

a4M& mmt vxtrnd at Irnst fix or ri^ht inchc« on onch tidr of the opening, 
~ 1 Atrtbrat in (hat direction in wbich the di»charg« in expected to drain, is 
IB ila poaitioD by a bandagv made of the antiseptic f;auir. grtat cam 
; t*kait to Mciint the edgea. Lastly, elastic nebbing from one inch to 
in widtli. according to circumstances, muji be applied in audi a 
I to keep the cdg(s of the dreaung constantly in contact with the »kin, 
I vl any mavement on the part of the juitient. In the case of a draa- 
[«• • Umb, a lioiile turn secured by n pin at the upper and lower end of 
j> ia all that i» reijuired. In other BttnuiMlS tbe tiorgeOB flUM 
hi* ingenuity in applylu}* it iu vuch a nMiiter Na to fiutea tbo edgea 
■I lie drawiajf »cureiy <in thi> |nirt. It iiiu«t. uf coun^, oat he applied >o 
tacitly ia any caae at lo iuterfen! with the circulation. Tbe introduction of 
Iba fcw turn* of ela»ti(- webbiut: in ibe application of tlie dreaaing has done 
■Ma tbaa any other Into imprivemeut to insure tbo succen of the treatment. 
Ibe fKua droBing ibu> applied acta in two wari>: 1m, D]i.-('hHuically, hv 
Aariar may air which may (mum tlimugit it, and tnun excluJiu): dujiL : and, 
M. tbiinJcally. by ilowly y»i-ldiue up ti> the dccompoMible Buidii which aoak 
fata ta a lafiaeiit t)uaiilJly of carbolic acid to prevent their putrvfiM^tioD. 

A carWir icanie dmwing niunl alwaya bo chaogod OOO^ in the firwt twenty- 
Wr b«ain after the ojiening of the abactaa: or aonMUme* CTCO before ibia if 
tba<fiKi«ffe be verv ahundaal. After tJiis, It ia eustoimuy not to chiuifo 
Ika dfVKBf bc&we i^ discharge ahowa at one edge ; and tliis is found suf- 
foMi to exrlude any Mgns of putrefaction, and practically to prevent th« 
HaJ i diatarWaoe aikd pnifusv suppuration uhich droompnxing matter to 
^>i^a*uly givca rba lo. Kxperirncv has, however, shown that if the dma- 
■f k* Am^fA oaly when the diaabarg* baa eoaked out from beneath it, tbe 





2C4 



SrrPU'RATION AND JIDSCRSS. 



mw fn>(|iivDUy bocofocs sour in nncll nnd Mmcwhnt irtiuting. M 
bjr u slight iDcrcnec in ibc nmounl of pu« diwhugnl, and ■oumtinn 
dvDineorexcoriatiotiof tbcikin. OWrvatiiHw dmuIo by Qtevut oo L«l< 
OMS, have «howti tItRt vrhon this oocun, microcuoci itn- alwavt T'Mad in th 
disoJinrgM: rixl-dinped oifruiisniB nrc fnuml oaly wlicn ihc •Irawn^ h 
fiitictl entiroJT, nrnJ olleiiaivo putrefaction luis set in. it m«u», tiienAir" 
tbst the inicrocii>c<!i ;>irc- ri»o to a fernwntiitive pn>ceB> in tb« pus, the 
ducts of n'hich are nlniiMt. though uot quit«, iDOociinuB. O^too hu •bow* 
tb«t by anUcipaliiiK tbe «o«kiD(;-out of the pus, by more freqiivDl dn^Oi 
the derftlopaieat of loicrococci cau be pn^vtolcd ; aod lie b of o^iinioo 
the IwneAt d«rived frani ihia '» «v>rlb the oxin trouble iiiTolTcd in dm 
tbesbMeaaa few times luorc. It would seem tkat iho lui'-mrucci mn bM 
euily destrojr«d by curbolii; ■ci<l Uuin the iMderiii. xud (N>uw^aentlr m tli 
drasing bc^na to Uiue \t» c«rlxili<! lu-id, partly by voUtilintiou eoa pani 
by solution in the iliMbnrgcs, tli<-y Dmke tlicir up|Muinuice in tlw pus. 

bi chuging thf! drrasineo. nil ibe precnutiona obscrvt^ at the opcninit 
tlie BbsiKSBi niUKt be ropvaK^. 

Certain iiinilificiiiione oj' the above drtatbg nquirt tu 1m- nntimd. It 
evidoiitly inipuMtibk- in many casfe (o make lh« dmsing est>-»d »tx or ti^ 
tDoh(« Wyond the njionine iif th« abscew ; in these cosn Ibv dimintsbed r» 
tent of the dn-s»iiiir must he comnritMited fnr by inejTnse<l tliiekn^ivi, ttsraif 
or more liLven> U-iiis applied in the place uf thv rieht rveumriH-ndni abur^ 

In hairv pari« it is ollcn diSicult to disinfect r)ie «ki» thoroughly bvfMi 
opening tW nlweess. lu eucU cases, a thicker Inver of wet nus« must bfl 
appliexl. or tlie skin m*y be anoiuletl wilh a solution of carbolic acid in uli" 
oil (1 in 10) or in |>lyoeruie (1 in S). 

It must not be Hiipposed ihal in the uliseooe of all ihc inslerials ani 
npparatuti above nH-nliimiil, it m inifHwililc to carry out thr aniiM'piic pna 
a|)l« of treatmnit ; that is lo say. to pr^^reut abaolntcly all d«roin|MsitioB 
the dbcbargcs. 

Th<' iiulruinent tamft (renuenilv wanting la the spray appamius; Mmf 
fortunatf'Iy ihia is ibr one wnich can niiwt rrailily be iipan.il. Tbr sprs] 
eannvl at tW pnw^nt lime be li>ok«.>iJ u[h>u sn inon> than an rkgant cnixl** 
aptityiiig the esrlmlic lotion, its clecanoo oinststiog in its wa»hing the 
well as the wound. In its absencv. irrigatioii bTmsansof avfHinge s>ji 
over tliu Mrl. or of an Ksmarcb's irrigator n)ln«Td lo run on ii, onto 
with a judicioits use of the guanJ. will verv irell supply its otao- durinj; th4 
opening of an absMas, and the insertion ol' the drainagr-iulx-. Ai the •tilh 
wqueut dressinga, irriffaiion may be carrier) on whenever tlH- wnund il 
expowd. A Terr small amount of dexterity, and the ex erase of a liltk 
oonuDMO aense. will enables ili« Surgeon t« treat almost any abseeas nntit<j 
cally without a spray. tb<^ only txoept ion. perhaps. Iieingsonw of thnes ~ 
the dim and aUlumen. in whieh air is freely sti eked in snd out of the 
by the movemenli* of respiration. Siill. a ueam fi|iniy-ap|Mintlus girt* 
additional securitT during iIm early |iart of the uvulmtnl ••! a large 
■liacess. nnd Jl ij lieitcr to itu- il if it is otiiniiinble. 

In the alxM-nee of cnrboli*? ^'an»'. a nmtly made jmil of cankd oakura, 
tiaifbnn Ihicknew, fordM an exe<dleiit antiaeptie dresaini;. It must hr o 
ersd by some walvr-pKiof malerial, lo [in-vrni the disrharirr fntn suskin^ 
Uirougn il too ijnickly. Oakura is an antiH-plie drnwing of grml |>aten«y, 
but it is vi'ry irritaling if applied dirvlly to a raw nurliiee, anil it black 
the skin wherever it touchrs. Any raw surface must, therrfore. be in>vei 
with the protociive, and the skiti around should be givascd aitb earbalic 
(1 in 10). 

Absorbent cutlon-vool impregnated with lodofomt (lodoftma-wool) 




AXTISKfTIC TRE&TMEXT OF ABSCESttES. 



fi66 



• «M MMillm aaiWflic drtsning for ill thr Rmnllcr chnmic Mb*cc«>v«, npts 

otr ik^ «NW«cu>d iriili diRBMil joint* snd N»n<«: itml iii Nibc-iit«iH»>iM 

mmmlam ■Imoiwc. itu>l in tboM dept-ndi-iit upon euftviiing tiiUrclr. ii ie 

id bv aoOM U rirn > ^ircifiv mrnuvr influcDCc. The utiwcw niiiet 

I InStjf 0|wa RRiJ K-niwf) t>iit with a »har[i spoon to gvi rid ol' nuy 

immf CMay RrnUc-r: n lew gnitis of iodoform laay b« iutroducnl intu 

ti» mr, nd ibcn. if ut«i.-«««rt-, llie dninage-tube ia ine^tM. I1i« iodofomi- 

wmIm iWn appli^-d. to the tliickncM, when li<;litiT compre»«d. of about one 

awbiMl > balf, aixl exti!iidtii|t some six iiii-lica on each tide of the openiDy ; 

«t* ihia ia planed aa onlioarv roller bandai;^, If no drstnuK^tube hsa bccD 

ivftad. tha dnwDK may bo left ou, if all got* well, eitber till aome dia- 

«*Mf» ihai o«l from uuderiK^aili it. or till iiie abaoen may reaaonablv be 

w^fimU tw be lieatcd : ulieu for a tnunth or vix neeki. If a tube ba* f>e«D 

Ml«d, it ■• beU#r to dr«>a it onec a week, to ahort^n or n-inuTe tlie tulie. 

IT f«ia.ar norr particularlv ati elevation ortrRiporature, in an iodicntioD 

trammatf thm drnainx- AlworlM-Dt wool, in)i>fvguat<xl witb Milicy lie acid, 

rdk waau rootaininji about litii per ociiL. of ihf aoiil witb a littlv f^ljc- 

'i^M raodoiRiriiiliil by Mf^^ill, OU be luml in the miK way. Thoy are 

I tram MDell, and ch«K|ier than iodoform -wool, but their antifeptic |»rop- 

m an aooiewhal lofiirior. 

TvM or ihrtf layer* of lint (oakol in csirtxilic oil (1 in 10), or carbolic 

Vlyreruip (1 in (*), nrnke very iHicicnt antiacplic dreasiu]^, but 

I be rbangod at least twice on ibe first day, and ooco every day 

b (be >blice of carbolic acid, spirit and vatcr is an eieellent antisejitie 
00^ but ii b MM adapleil lor a pernianeot application, aa it do eoitn loaCB 
oaalnM. 
Ja lb* aliMOoe of all aatiaepUca, dcoompoaitioa may he mlucod tn a 
by aeniriaK perfect drainage by free inebioB* aud iuIm». no ao to 
tbe decomfMtabIc matter Ui the amalltM pindblo rjiiantity ; and hy 
awiifioy the toe of valcr, b<ilh during the upi-niiiif of the alweo* nnd aflrr- 
I Wi<^ dry n>iu>u-wuol or llueu ragH betng ciujiloycd tu wi|ie nwny the blood 
f md dwrbarjrn. and dry pada of cuttoD-wool, or simply n piece of oiled rag, 
K^k^Aapfilii'd A* a drn>ing. 

^^^^W M tlnirrd tu apply warmth apd nioisttiro after the opening «f aa 
^^^b, it i* b(*t diHM by m««na of a few iayen of lioracic acid liot, dipptil 
' m a bat, cunfvntratt<d solution of boracie acid, and applied like a fonienta- 
Cm, biteg ooTen«l witli ii pirco of oiled silk and a sheet of eol tun-wool. As 
^ MMtimftic, buweerr, this is an«iirwhnt uncertain : but il is an efficient dia- 
ia<MMM in CTWwp ill uhieb the dischnr!;e is already foul. 
If 4aawMf«-*itt'>n Ims taken )dace, either from the want af antl*ep(le 
the fatlun- uf the ireatmeiil, eumplete diaiatectioo ia 
if the caiity lie uf any gt«Bt rir.e, auvb s* that of a 
iwoaa abaoMB. The afaaone mav be wnabeil out by injection of 
•wa latitepiic Milutluii, auch na fVindy'a Hutd. carbolic acid lotion 1 1 in 40), 
•V Wac R add, and hy lhi# mcaaa tJiu nlRimivf ittiill of ihi- dix-harK*' tmiy 
b faaiiLi I»->1 tiiii the «nppuraliA4i b kept up, or cvni increated. hr the 
'1 Iff ibese irritatini; lluid*, aud. at tbe tatne time. il'tb»y 
I'' -'vna of iiutrvKaclion hiod rriurn. tJallruder jioiritcl 
i <:aa«w dutr to the im-guhtrity of thr cavity and the 
■.lui; the nntiaepiir reach cvrry part of it, aiKl he, thi)f»- 
that the tliiid nhnuld Im> [>um|ie>l in at some degree of 
• I mt n'Kiplclelr to diatend the •ac. After this has t>ovn 'ti>ne, lotue 
dwiag Bay be applied. Tb*- injection must l>c ilonn under an 
■> m cnupletely to rcbix tlie |HLrte round the ahanM. Thia 




266 



treatiD6Dt has been rollowed by very rodA results. The Bolutlon Callrad^r 
used was the 1 id 20 carbolic loiioo, diluted with lialf iu bulk of hot water. 
Chloride oC iiiii;. iH Kraina to the ounce of water. lia» been em)>h>yed for tlie 
same purpose ; but it ia a dangerous remedy, and hoil btrlter not be uaeJ. A. 
very dilute solution of ioiline has altio been utwd MJlh {t»"d reoultit. In 
injecting uti alMeeas-cavity, however, with any uutinejitit- Holntiuu. frr-M caru 
muM be taken not to nae loo lutidi fi>n-e, or the sac may he rupiunil, and 
the fluid diffuMid in the arenlar tJwue, an aeciiient which might lit- fatal. 
n|>et'ially tf titi' ntroiiger aiiti^eptioi were being used. Another plan lately 
recommvndrd i:< lo introduce idilofonii into the cavity by mcann of a bruitfa, 
<>T on th<' end of the drninngc-liibt'. It lawi not be li)i^Iti.'ii, howovcr, that 
iodofnrni diMolvcs very slowly and nilhi'rcs to the wall of lh« aWcM, xo that 
if nonic if introduced daily, it mity iKrcurniilntc until n quantity is pmwnt 
HiKcicDt to give ricotosymploniiiof {xiisonini;. A raecKf thiii kind occurr^^l 
in Uoiventity Collc^ Hoepital, which tirarlv proved ftiinl bcfonr the cainM; 
of thv itntngc eymploms from which th« patient eiiflercd was diiNxivcrcd and 
removed. 

Constitutional Treatment.— With the view of preventing the occurrrnee 
of eiippiimlion, the Surgeon must be careful to mainiain the nowers of the 
system, nnd sot to reduce the patient f>o much, even if the innammatirii) be 
of an acute character at the ouiAet. Suppiimiion is a condition of debility, 
and is ee|iecially predisposed to by any previonely exbting enfeebled state of 
the system, or by nialnuirition. Another r«ason for the avoidance of the 
early employment of debiliiatia>!; means is that, if euppuratiun once bo 
estabtiahed. the drain on the syelem may eventually be so considerable as to 
r«quire all iho (ialieni'& jHiwers to euable him to beiir up at;ainst it. Hence, 
they should be hu^bauded from the liret. While the elisceaa is discbar^ng, 
nourishiug, tunic, and uveu aiirnulatin^; treatment will l>e rei]uired iu propor- 
tion to the amonut of debility ilmtis induced. Anionv:atthe mont useful medi- 
cinal affenti are mineral and vt-j^etabte tonics, the mineral ucid^. aud ood- 
Itver oil in the more ehronic Alages. Attention to hygienle <!ond!lions, with 
change of air, and ntiidcnce at the tteniidi-, are aloo valuable. When liecUo 
cnmM on, the miri« general Ionic plan inuat be adiipK^I, while we have 
rccoursir to means a<laptcd to meet the local »ympti>m.-<. Thuci, a<rids are 
required to check the Mwenling, iiNtringCDtf to arrcat the diarrhiea, and as 
much mild itourisbmeiit ax the patient will bear to iiupport the strength. 

HuiOKkUAOB INTO TUK CAVITY OK AX AhmCBIW i» not of Ulllrequeilt 

occurrence- It may ariw from thn^e sources: 1. Ooiing of blmwl from ibe 
vascular walls of the abscew ; 2. Ulceration into a vein; 3. Ulceration or 
eloughine of the coals of a neighbr.rin^;: arlery. 

The bleeding whicli occurs Aram the abscess-wall is the most frcijiient, nod 
the least imporlant. It sometimes takcM plitce Iwfore the abicCM >s opCftod, 
the pus that ceca|)»i being then found to he sanioiis and mixoil with small 
ccngula. More enmmonly it occurs afler the opening of the abecew. in con- 
•equanoe, probably, of the wall having lost the support of the contnined pusi, 
when the veneU in the soft walls give way and the cat-ity speedily fills with ^ 
blood. In tbeae cases the hemorrnaj^ may be arrested by laying the cavity I 
of the abscess freely open and turning out the coagiila. when the bleeding 
usually ceases as soon aa the interior Is exposed to the cold air. Should this 
fail, it may be necessary to stuff the envity with lint, or, if possible, with 
some antiseptic material as iodoform- ur salicylic- wool, and to apply preamire 
with a bandage. When the cavity is closing, the vascular granulations 
whicli form upon ils walls may bleed very freely if any pressure be acciden- 
tally brought to bmr on the veins leading from the part. In tliia case tb« M 
bleeding ceasee immediately the pressure ia removed. H 



I 



SINUS A.SII riATVUX. 



267 



BMwrrfaaf* ftan tTloeratioii extending into « Deighbaring Teis is n«<-*«- 
9tij 1U tBora •rriiiiii. It liiu iMiiiiliv liii|i{«'mi) Ihitii ■I<iii|jlw nhKiwrs 
inM vm th* mJ« of tliL- neck or andiT llii> aiijilf of ihd jitw, n» » dtitt- 
wmntit mTUtink in ntniinotiii wtd iitilii'niihv in<livi<IiiiilH, owning up thft 
latoad jajpilkr Tfin. But !t mn.y o-nt*'. tn<li.-|H'nili.-ntIy at %ay spodlic 
wJoem. in cachectic [wiii<'n(>. In Xhr*" >li«lm«iiig cmm. lh« ««It 
■homU ilut mn bo ail<i{>idl i». !■> plti^ ilic nviiy iil' the ftlneon with lint 
ukaA bi ■ mIuImm) oi i\w iH-rthloriilr of inin. nml supported bv biindnK*^' 
VflMMs. la liitt«»ylht) fiiul t-vcnt mny be for ii timo perhijis dclityM ; 
tail k iiMTiuliU ultiniKtely, tht blood bunting forth by th« toAct of the 

aw tlMi* b»rainc louvened, or u the slotighing open# up ih« vein atoro 
J. TIm vflbct of lite bleedine is Rreatly »gnra(ml by the dcprvntil 
r of the trftrni. lnb'>no(; under ln« conjoined influences of a Inrge 
tlafky aiMinil nuil n 8[>e<cilic [Mjirion. 
If IM bcRxtrrhBfie irisc from the Vlcer«tion of a laigt Artery, the esse 
rily bn:iiam uu« of extreme urueucy. I have koonn this coodilion 
r in tba neck sntl in the ihiifh ; in tJic nuek from sloughy Hcvlaiinal 
flkcMB tnpiicaiiitjc the carotid; iu the thigh, from the extentiion of ulrers- 
' ifaa fruM tWoani utd linuM* to th« duep femoral. Wheu this uuiownni 
. _ _ HTftbaoeM occun in tlic neck, the bemorrhiM is usumliy no 
I »Bd M praftue thfti tlie Sur^i->in hu uu* tine Ui lie tbeeu-otid before 
Ii* B tatiafoMml. A. .T. PcfijMT hiu>, Imwevor. r^ciriicd a cue of severe 
haoci'fcaCB after Knrlet fevrr, Khirh imr n-|H3il(-d wvcnil limee, umI finelly 
MM^klTy errwtrd by lipiture nf tlir ci>nimon <-nrc)ti<). Th^* jwtient was 
aaaa. ami .'U), and nuulr a good rooovcry. In the thigh the cane is not no 
•qpu. VV'amlni:* by r«|i«aud ■null hemorrhage* mny haw i-nnblod thu 
WMoa til ailuiit nxana to rcatrain the blooding; nml, in the riue to which 
lalMila, that nf a young man. iIk' fcrn'ml artery wn» l!c<l xui-ctwrnlly. In 
ii«a e^Ma H b wiine than iiwlces to ini»t to soeondarT me^io* for (b^t nrmt 
•^ tha bleaJ i o g . When practicable the artery should be comprcuMd, the 
amy ftvrly npened up, and the bleeding ireawl sought for and lied. If it 
*■■«< be fiHind. the mnin trunk muat be tlgalurMl; and, for obvious 
MMoMt tbis is the only ooune that can be pumied iu the upper part of tJbe 

Stn» 4.xi> Knn-rM, — After an nhscew ha« l>ocn opened, its cavity may 
»« Sll Bp ixuiif'lvtvl^ : but. contnicling iut« a nnrrovr Hippumting track, it 
^Kjf farm a canal witJt»ut (li9]Mwiiii»n to cIiMe. fiMiu which a mnalT quantity 
<f HH eottsuntly exwlta. thii> iMnntiiuting a Sintu nr Fistula. 

TW diflsraM* be4<iv<-n n xinu* anil a fimiilu '» tliii: that n ninut t* merely 
a MpiMmtiM trar-k. pi-nrtratiug ii> a greater or lew dt-plh nmongft the 
, doaeo at its dei-p end. ami o^iening un the surbec of the body. A 
i> •■ abaormal oimmiiiiimnin twlwcen (woof the cBvitii« of the 
dy, or betw f a cavity ami the surfncv, or a track ihrtMigh whieh the 
iHjaliuu of KMRe cbuid or hullow vim'Us takva nn tioHiilural ixunr. Tlma 
^ talk uf a ainiM leiMling down to deml bu««, but of a rvcto-veaical lutula, 
•a anal fistula, a urinary fisliilu, etc. 

The Oiw» "f this n><n-(;tcMin> nf ihe cyst of an aliecess may Ik- referral 
la ik fijlloaing biwds: I, Tbe proenee of a foreign body, as a piece of dead 
Vati at the txitioRi ; '>. The passage of irriuiinff aecnciaaa, as urine, feec*, 
•tc., tbrongh the ahacM; H. The L-onlmetlon of neighboring muscles; 
a tbe ahsona is in the Deighborhuud nf the sphincter ani, and as occa- 
\l baD|inM ia ahs e n swn abitui the limbo; and, 4. The pretence of aa 
dtntly dmini-d cavity at ihr bottom nf (he sinuH. 
The «ei6n of a itntia or fistula. wh<-n situated iu hnnl and comleiise'I 
■■% is olbra Tcry small, depraae^l, and fxrhnps covcml by a *cab. In 




268 



I 

I 



eott tiasucfl !t in oniiimonly InrTt- niii! widely ofK-n ; wlii^n ■;nnimunicalinfr wttn 
IXHit^, there nn^ usuiilly »iA, U<>ri<) griiiiiiliiti'iiii' nlulructiiijc it. 

Utriiftiir^. — A Miiiiii (.'onuiBU of n nurruw (^hniiiu'l, ofUm limg and uiiKJiiig, 
having un «xi<-iii(il orilici- iiniinHy Hi>ni«<rhnt protubiTHUt, and Kilualt^il undiT 
or nimoi^' lotw H-irid urnnulationH. The w«1Ib of thi» chaniid, which tn 
aiwHVs iuduriiU'd, nrc lined by n layer of imnerfecUy fommd gmiiulmioiM, 
exuiiiiij; icliomu* ))ui:. If tho oHtico be uccluucd, this pus will cnllM;L within 
th« iiiiiuK, uiii), distending ils wnlls, reconvert it into itn nbsctw. In Btniolun;, 
thtntfuro, H sinus may be said to be a long, narrow, chronic absocw, wilfa n 
pcrtimiiciit vxtrrunl aperture. 

The gmnu]ation-tis»ue of a sinus, like that of any oth«r granulating sors. 
c»iitrttcl« in healing;, and couseqiiently a healed sinus leaves a deep dimple 
in the »kiii. This is the best evidence >if ilioroiigli healing; a siuiis may 
always bo expected to break open a^iu if it skins over eupcriictally withuut 
dimpling. 

A fistula may ditler in no mpect from a sinus when iia length is comidei^ 
able, lis in many niml and urethral fisiulit; but when it liirms merely a short 
cum municta ting channel between twn cavities, as lieiweeu the reelum and 
vanna, or betWL'en the iiurfocc and a cavity or duet, aa io a traetieal or 
aa^vnry fiatuin, tin- Krunuhilions muv befome (•ompleiely covered by epillie- 
lium cODtinuoua with thtii mi Litch nide, and no c-ure i^ jxiiiBible till tliia has 
been cut away or dtwtntyed. 

The Treatment of a sinuit or fistula hax rRfertnu't- ti) itn cause in fhe firet 
instance : for, until ihe foreign body or the iuxiifKcit^ntdraiiiage that keeps it 
open auil maintains the discharge hus been romuved, it will be UKelMa lo 
attempt it* clonurc. AAvr the mninval of the vlwtacle to healing, wv may 
endeavor to procure oblitomtion of the sinus by onn of three muthndti. 

1. Prvufw; by means of a roller and gm(luntr<l c-oaipr<-*». «i) a» to cause 
a(lh<.-»iijn of il> oppiwite sides, is useful in those caiw< in which the sinuv h 
recejit, without much surrouixling indurali'in. and m »itnal>^d. a> uptin 
the trunk, that pressure can ensily be applied. 

2. A Mion- healthy condition may tilUu be prutliiecd in the siniu hy 
injecling it from time to time with " rcd-wa*h," or with tincture of imliiic, 
by the iiitri'duetion of iodiform in cryelaU by means of a catheter or by 
nolnlilr liciu^'ie* such ns nre used in the treatment of gonorrha'* : by posting 
a j)rtibe coiilcd nilh niir.ite of <iilver lo the bottom ; by pniwing the threads 
or It suC>.m or a druina^'e.tube tliri>u(;lL it. 

3. Srrniiing (ttiyjy the eallouH and imperfectly granulating sidca of the hhus 
by means of a small sharj> s|>noD i Fig. 93'i, or destroying them by means of U 
k red-hot wire or Ihe thermn-rautery, is a very eliieacioue means of sotting V 
up a new and licalthit.-r action in the part, and so bringing about a closure of 
the canal. The galvniite caiit«ry will otlen be tbund niosl convenient, as the 
wire can be introduced cutd and heated in titu, and the dau^r of wandering 
IVoiD the track of th« ainus 1* ihun avoided. 

4. The lant method coiii-i.-it-i in tayiiiy open Hit tirtu* fVoni end to end, and 
then ilnWng the wound »n that it may lieu) from the bollum ; in tliis waj 
neighboring niusckit, that 1ia\-e kept it ojien by their coulraetions, may also 
bo ivt at rMt. Thv) division of th« ninu* Mbouhl be made with a probe- 
[Hiinti-il bistoury, introduceil tbmugh the external i>{iening either by the aid 
of a dirrctor or without iiuch iL-wintancv. The operation should be done 
vtl'octnaily, the niuus being f<illowi-d an far ns i" prude.ui. and laid open 
ao compU'tcly iu> possible. 8cime tiMuhi-. as the tintiila in anu, require similar 
Ircatmeiil, ami may ht suc<Wsrully and nlm<iii| jiainleKsiy Dpcneil up by the 
elow action of ihr r/iuiie li'juUiTr, A thin onl of valmni/eil India. rubber 
being druwu through «n<l tied lightly, uU-erat*^ in a few days through the 



I 



ULCERATION. 



369 



ring thu tnick of iho tuiula. This plan b useful in ca»e» in 
nrrfakED m apfHrhctidcil or tlie patient draerla the knife. 
tt. KntoUc wbicb sra lined by n complele epithelial covering, as iimny 
>- vagi nul, ivcio- vagi ual, and re cUi- vesica I. can he cured -iiily \v dwtriiv* 
tllb, either by cutting or ecrapiuj; it away or by cauteriuilioii. Many 
'•neb AWilitt r«()uir« plastic operaUoits fur tbeir'cure. 



CHAPTER VI. 



ULOERATION. 



Bt ine«rati«a h oieout a progreaaivc desiructiuH of the limuei, !n which 
■olid parts seeni to melt away into a liquid discliarge without the wpuru- 
of visible ponioos of dead tissue. Th« uieauitiK of the term will be 
nude more clear by a few exaniples. If a piece of skiu lie killed iu any way, 
■a by the ajiplicstion of some caustic, or by mediauical viulence, there i!< at 
ftnt DO suluiion of i-i>iiti»uity, Ihe dead tissue ia everywhere cuniiniiuus with 
the liviu^ : but nitliiu a few hoiir« the phenomena ol ia flam mat ion maiiifcvt 
tbemaelvn* in the nurrouitdinj; living tiwU4», tliUH imperfectly marking out 
llxr liniiu of tb>r iiarl that i.i killed. By about the seooud or thinl ilay lliv 
liuf Ik'Iwc)-m till' <l(--iut nn<t living bc^conim niom clearly defined, the cuticle at 
ibc nmrjiin of iht- living pari brconicN Uhim-, and in niifx^f by fluid bi-nc-alh il, 
■od lit lai>t <N>ni<v away, expiring a narrow riin* ^n^fac('dillcbar{'inK ptw; the 
living tiuii<9 which li« in imiiK.diiitc contact witli the dead, tbeu M^'m 
/Tu<loiilly t^i melt away into the piii'iiUrnt discharge till a complete nolution of 

-iiioiiity is e«tiibli»licil. the dcml part, or, as it in called, "the *lough," 
L.tiii^ completely liiowncd and cn«t off. This proccs«, by which a alougn is 
(«paraicl troni the parl^ l>encalh, takcH ptncc entirely at the expense of the 
living Lia»ue«; it is s[>okon of as ulceration, and the sore lell is called a 

Tlie vflccts pniduced by the inoculation of the poison ef n tfoft chnucrc 
another excellent example of ulceration. Within twenty-four hoiire 

tbe inoculation a amall inflamed spot appears, with rednc«e, swelling, and 

ihiitg: by ibe third day tbe cuticle is raised by a drop of pus; when tlie 
Uiin ejndermie covering is removed a small red sore Is seen, from which pus 
eiudm: ibis slowly extends day by day, the discharge Iwing purulent, and 
at no time ilo any visible p^irlions of dead tissue come away with it; round 
tbe Korc Ibe tuauea show tbe onlinury signs of iullammalion. Hueb a sore 
Moubl Ite called a tpeei/k ttleer, tbe irritant which rauses the inflaiumatiou 
and ileHtniciton of Ibe tlasues being a sjiec-itje poison. 

.V third lorm of ulceration, diflertiig easeolially from the two preceding, ia 
•ten in the later MagM of the growtli of malignant tumora. Thus an 
epithelial cauoer eommenccii tui a umall hard gmnih, which infiltrates tbe 
Banounding tisnies. By tlie pressure of the jtrowth which fbreeA its way into 
the hlieniUct* of tbo i>tnictnru« which it i.t invading, tlie original tii^ue.4 
lecoDie aUwrbed, and the cancer tiiuni: coni<w to ocaupy their place. When 
tht growtb rMcbe> a certain xizc il> central parL- iiegenerate, tuiAen, and 
brtak down, and a Iww of subttiince takes place. A» the di»-ane pro^rewes 




ULCESATION. 



more and more of lh« aurrouailinfE li»ue becotno invii<l4><) uaA <kaumjti\ij \ 
lh» eaticeroiM growth, which iu its iiiru brmk* down nnil incll* aw«v •""» 
ficittlly. Thus the matt extensive deitrui-lioii mity inko phitx. Thi> 
is ilocribed ns iilocrution, wlthuugh hero thvnt mny ho no true iuduiiiMi>w. 
uwl the re8ultiii){ eitre h caUetl a ametrvtuor maiiffHonl tilfrr. I 

All tlie«e fornis uf iiU-enUiuu have iirK' rrntiin- in n'niiiion; the uri|pMl 
lUHua are lirst iiifiltmted »ml pretwed upon hy et\U fvni^u ■» ilm j»n. nUA I 
destroy them uud iK'Ciipy iht-ir plai-i' ; (hni in ihrir liitii ihe nmr crlU pniil^ 
iuhI are ihruwn olf «U|>Frlirinlly with n Hiiid ditx'hargv, and tbiu a |MifR» 
•ive dcdlruciiuii of liibiie inkc» plnci-. Iii the lityi iho Tinniplm thf iand- 
lag C«lhi are the while IiIxihI corpUKolra whioh linve mifiralcd fnun lb 
Vflnel.4, and in thi? hi*l (hey an- the sixTial eell» >d' ihe i.-»iiecnMi* gnmlh. 

lu ihr pn-iu.-Hi vdajtler wi' have l» deal uuly with iilevntlion aa it iierai 
aa a piirt ^il' llit proooa* of iiiflaminatioii. 

An ulcfr pMwa ihroMch Iwo vtiigtv, vix.: 1. Extmirion; aod 2. Rc|aik. 
To the I'ur r or ihiw:- (niTy ihe t«rri) "uki-ratiuii" applied. 

Patikh/hiv.^TIk- pr<>o<-w of uteeration when dependent ou inllamnuitia* 
harilly riei-dn a deiailed deR:riptt<iii. as it (tittere in bu easGDtial feature fruia 
that ain-ttdv divenl>e<l as lakiiif: place in the lormaUoa of an alisceM, ihf 
only vnriBliini licini; lha( in the latter case the forination of |>u! and de*iru«- 
Ui>uof tiwue take pltiee in n clmwd §paee, while in thefbroMr they occur tipn* 
a Mirfaec. The separation of a dead piece of tiiwue Ircin the HurruuDOiM 
living parts is thus acciiiipliiihe4l. The tiaaue immediately iu oula/'t wit£ 
that which is dead must ue4.<eMMirilv have suflered to some esleot frvim the 
injury which has caused the niiscbtcf, and ita vilnlity Uius being Inwvnd, 
the p hen omen II of iDtlnmmalion are manifnted iu It witli au int«iMil)r «or> 
retj^indiii}; to the dejiree nf ilnuiaKC and eonseaiiently dimiulithini; ■■ wa 
recede frrim the piirtit thai have l>een actually Icillnl. When- the liviny 
livMUiit touch the ileiid the cottdilioo of Ktan> will be nuicfaed, mad ttioM 
vcwelii which fnut fnim tlw dead 1a the living t)«Mie will beooino plugged 
with olota estvndin^ ne fnr it# the ni'st hrnnch in the living parts. Itryoi 
the mtt* of Miuis we should tiud lliat of n'tanled Itow. accumulation 
white oorpuwhii, and mi^ritt)»u : Biid, beyonil this ngnin. that of lia 
dilatalion with increased rapidity uf tlon or lluxioii. The width of ibe 
in which thnf indnrnmatnry phenomena take plan' varica gn-ally. it mar 
be merely microscopic, as in the separation of a piece of demi tisiue wfaHO 
has been prevented I'roiu decomposing by antiseptic trentmeni, or it may 
extend for half an inch or more. OccasHMuilly these vascular oonditioM 
can be reonguixed clinically by the eflect brodaced by the preesurv of tl»t 
finger: id the area of fluxiiai it is scarcely potsible to remove lh« fingtr 
beji>re tlic brilliant red color has returned ; in that uf retarded flow a aeeood 
or more may elap*e before the piile'mark maile hy (he fini^r has regained iia 
red color, and the tint in (hii area is more dusky nnl than in that oi Attx'ma i 
•umetinMaaniall reil dnts mav !»• n<i(ieed in the pule |>tilek foruxd by iba 
pnaiure of the finitrr. indicat^in); point* »t which oime nsl eurpuaolva hav* 
weajM'*) from tlie dixt'-udetl veatela. LoMly, cloac to the dead tMiae maj be 
•een a dnrk-ml line unaltered by nrtature. Indicating llie ar\-a of staaia and 
ihromhcni*, in which iilao manr rr<l corpuscles have Mteniwd from tba daat- 
aged vn«el*. From the vonkU iu the xtajie of n-tanlod Row aUintlanI un- 
dMion of bluod-plnma and migration uf the eoq>iiacloa lake place. Tba 
wandaring call* move in gn-al numher* into lb* paialvt Uyn of ti 
touching the dead |iart, and by their pnMure denlroy mk-Ii rvtnai 
vitality at may t>e left ; the original tissue •otVena and diiintei!nil<«, 
plaea Meainra oecti|iieil hy rliiwly naifkeil en>wd« of leueocjrtea ; the letico- 
cylM in eontaet with the irritating ileiiil lutue in their turn dtgenervte, and. 



i 



noaa 
qred I 

I end H 

n oT a 

npUfl 



etico- 
and, J 



CAUSES OP ULCEBATION. 



Chmtioo. 



: gnuuUr mail lutatig tbetr adhfsion, are Mpftrnt«d from Moli other 

IWM rSu'latHiu ffviii the neigtiboring veascls. imd lliu§ pus i* furnted 

llhtpnwtai w( >v|nntii'u is omipleted. Wtieu this bne laken pUc« a 

'«« i* l»A onrcnul Hi[icr5d(illy dy a unifurin luj^r of fl»ecly packed 

d*n«Ml frota [He nliiK- eur|>uic-te8 wbicb bsve niif[nkieil frum iho 

ItmA a wKmi- in ■ simple ulwr. T)i« tletid tueue uhich acted tu 

_ I bodjr baajf ranoved, if n<i lunhvr Miun-if nf irrimtii'U Ix.- iin-iwiit, 

ian«vadng IMUn rccoviu- rr<>iM lli«ir impiiirc^l vitality, tlii^ itiliiiniuiu- 

iwUdca, tBipuiuii oMMtB, uid Uw procc* <>r repair I'ltmiiit^noT. Tlii* 

I vUl hm dsKhbnl Id Um next chapter with rvpiiir iu (ti'iitnil. 

it ■w-cuni from lliv iiKicutnliiiii of n vpvrilic puinoii, n» in the 
r of Um *Dft diMDcrr twf'irv givro, diHvra in no rapcct l'n>fu thai jg«t 
■1. csmpt at n<i iirni> i* ilii-rr a viaibic pii-c« of dead timiM' raoi "JT, 
. ikai tlw iiritaot which cattH* ibc (»ruccn n di-vrlnpcd jH-niitU-nUy in 
> AKkarm. and onUai it be in aonic way drslroyt-d, luay euiilitiiK- to 
■Maia Ibe <)<Mnirtiv<> proctea nlnxMt indefiniifly. It t* i-vidrDt itial if 
irrtfaliag vim* developed in tl>c aim is uf sufhcirnt inteiiHty, it may 
dcalii «f the tisuee before th« pruoos of ab(^»r{)liMn uf tliv origitia) 
aufauJtutjoD of a nuiM >a leucocyln fur iWin, hnt had time 
W oiMDlMcd. It » UDdcr these rircumeuV-es that ulccrntion nior^gca 
«■ ifRMuag saaftviw. the tJeaun no longer ap)<eariui; to melt away in 
il* li^ud dlacmr](«, bat remaintog as a aolU partially disintegrated elougb 
« iW «Br&cv of (be aore. 

tWpraoMiof Ibrmatiouof an ulcer iu alcio irhicli hu lonR suffered from 
^tmii ioflamiuUiaa hna been irelt described by Uillrutb. " Let us mp- 
fmuT h* aay*. ** that we have a clirunic iullHiniiiaiiou of tlH< skin of the leg, 
w ^ the antarior aurfac^ of its lum-r tbir<l. Tlie >kin is travened by 
4hMA V— ila, beow it i* redder than norniul: it U •irolleu, partly from 
. partly frciit plutir inlillrnlion ; and it in ycnsitive to pmeurv. WnD- 
;otll«aiT intiltrainl.njiciHully in the fH|ii.'rlii'inl piirt.1 g| the culit: this 
■> .1. ,..,.; I :,. l„„^.r and ni4ire»uc4.-ul('nt; ibn d«vc-lupm?nt of the cells 
^ ttf II also brcDiiM* niorv pU-iitiful, and il« superficial hiven 

4»aM |w> lui'-iur iiiirRial lioniy state: tlie <.-oi)n<M;tivv tiseueuf tb« papillary 
k^ i« ••An*, and Iwoonies partly j^elnlinous. Noir, slight friction at unir 
faMaafiav lo rvniovo lli<- soft, ibin, horny layer of the epidermis. Tbis 
^^■IB th* eall-tayer of the rele Mzlpi);hii ; new irritation is fct up, and 
^im)1 >' iratini: Hurfnee, wh<«e up|>er layer ciwtiittB of wandering 

olhklhe 1 natly def^ui_-ntled and enlarxed coiuneous nnpillw. If 

at Aisatsiii Uii f<Hn irtrv kepi at |>erl't-<;( rest, and pruieoled frotn further 
la*, tba epNlrrniis would be j^raduullv r«K^neruled. and tin? #iill «u[ier- 
Ivlerr wtmld ciratri/e. But usually tbe »iiulit BU|>erticial w<iuud in too 
■atttwi, it i* etiMMiH) it> mw irritiitionsof rurioui ktu<U: there are »u|>- 
■nd inglaralar dntnictiuii of tho atpoaed inflamed li»ue. tbeo of 




. and Iha mull ia a lum of suliatance which gradually growt 
raod wid«>r; the ulo'r ii> I'ully fornM'il." 

Tl^ rnniiitioiu f*ential to ^Jfertititfn are: 1. An irritant aoting 
• aliniiJ > of tb« liviug tiiauc* with sutfiL-ienl inleiiiily to causa 

tlaitaiivu: .- < •)>>« iu tba vommU with abundani migration of the 

*Ul< cor^oael' mtiog in >ta*iaBi>d deatli in tlie parts m.isl directly 

•eltd ■«. " :it action of the irritant fur a uiDicicnt tirae^ 

V> kai 10 the clinMer on Inl!ammatii>n and thipiwrntioD, 

■■itba^lm pr^xiKr.! onalivine ttfluieby an irritant dcpinds partly on tba 
~-^fwt the irritant itaclf, and partly on the |H<uer of n-iistanco of the 
■r. la other words, thair degree of riulity. 0'nse<iuentlr.tl>e cause* 
like thoM of iudaniBailon Ju geaenti, are dividt-d into PiV- 



272 



l:LCERATIO^*. 



diapoainK. nr tlnwc which render lh« timiive liiibic to ■■iiHl-r wvpMv frt>m 
iDJurioii^ inrtiierKM^c by in)|>niriiig their vitality: iiml Exciting:, or, in uthcr 
words, the iiijunoue inHuencca tht^nisolves. 

Preditpoting Cause.^HvrrythiDi; ihnt Het« tw a pmlispcaing cKu»e of 
iullHiiiiDntioD is niso a predisposing c&u^s ai' ulperiili»u (»cp p:igo 1^^). >>i><^ 
tite following may he mentiuoed as aiuungxt the most ituporlaDt. Thoy ar« 
ehieUr oouditiuiis that interfere in some way with the DUimion of u part. 
A fem\<t cireiilaLion.Buch a^ often existA iu the lower limbs, iu th« alteof liie 
uose, and in neuiy formed or recently cicatriEed tissues, predispoBee to the 
forniutiiin of ulcere. Aa age advHucea, nutrition beconiea lEupairwl, and the 
circulation leas active, and slight cmumb suffloe to lead to disinteffraiioD of 
the .itruoture of a part. Hence we cumniunly see ulcers of the legs in elderly 
lieoplis mure partic^ularlr amongst the poorer claswa, ariang from slight 
irrilatioH «r pri'scure. I^arta cni off frinn cunueotiun witli a healtliy nerve- 
ccntrc- ulivrnlL- rt-ii-litv, an the uuti» in [larBplcigia. 

TiwiicH Lliiti have ^>een poMirely coiigeated for a long time are apt U> 
inHiimt' iin<l>-r ihn influence of some trifling 4-xdtiiiK cau«e, and to run 
rapidly inln ulcvnilion. ThJK iiniinlly cnmnicntn-H in uie <.'eniTO of tJte part, 
wlicn* tho ntitriliim ii hment; hi-nr a :>inall »ittv forms, which «xud«a ihiu, 
unhirnlthy puH, and riijiidly ■■xtcuds, Kn lonf! il^ iht- sore is intlainivl, il con* 
tiniics to Kprr-uil, and re]mratioii cannot tak« place. In some nute* in whicli, 
from the abnvi' ciiuncx. tint vitality lii« been greatly lnwcrcil, ll»; exciting 
cauee which i* "utficicnt to give riitc Ui ulceration may be «> iilieht lu to 
escnpo detection. Thiv ix <s<pccially miirkwl in gcrofiila, Murvy.andnypliili*. 
In Eomc form* iifscrofulotiK and syphilitic itJccrnliDU the proems rewniblo 
in many mpcctd that of inaliginint ulccrntioti — the chronic inflainiDatory 
product* fint forming a solid miuw of vm- slow growth, almost like a tumor, 
which ultimately degenerates mid softens in llic centre, and is diiiclHirgod 
superficially, leaving a raw surface, which slowly spreads by tiIc«rntiOD. 
Tubercular ulceration follows much the same couiw. These form a ooii- 
nectiog link between simple inflammatory ulcexation and ulceration from 
malignant growths. 

Exciting Cantei. — The direct exciting causes of ulceration act chiefly oa 
the skin au<l mucous mcrnbrflnes. and are very various in character. 

1. The mort rapidly spreading forms of ulceration arise from specific 
Infective pnisons, as in phagedieuic ulcers, hospital gangrene, soft chancre. 
tJie sore throat of scarlet fever, and in nisuy syphilitic ii I m' rations. Most of 
tlte&e, at the same time, cause acute iullanmiation, extending to some dis- 
tance beyond tlie area in which destruction »f the liwueais visibly taking 
Slace. Ill such cases the action of the irritant may be so a<-utL-, and the 
wtmclion of the tissues so rapid, that the migratory cells luav not have 
completely displaced the original structuns bdTure ditiinti^grHtiou occurs. 
Mieroacopie shreds of the spoilt tiaiues arc tbeji to be found in the pus, whioh 
contain* fewer genuine pus-cells and awunKs often the form or a dirty 
brownivh fluid, dliicolifri'd by the bmkeii-up red corputarlcH frum the dbin* 
tegrating layer of tisnue. When the imtniit i* more potent »tilt, and 
penetrates Into tlie nurrounding part^, dciitroying thctn nipidly lieforu any 
extensive migrHtion hns hud timi^ to takv place, laycn of dinorganiml liwue 
constituting "nloughx" iin* formed, which completely cover the surfaw, and 
the discharge may In; nien-ly scrouc fluid, sorcoly turbid with cells. The 
whole prooiw thus ini-rgo into gangrene. No sharp line can be drawn 
betveen spreading jfungrcnous inflammation and ulceration, and we ealt the 
intermediate c»nditions by sticli names as sloughing, gangrenous, or plui gc- 
dieuic ulceration. JH 



CKSKICJIL TItKATMKNT Ot UU'KH ATIOX. 



2711 



S. Id |mrt» vk'wU bavo Um^ •iifltTud Truiii chrunlu iiilliiiiiinalltiii, *|||||it 
• ch a nto l uui cbeoikal wim* ^iw Hmi in ul<H!niU(in. 
3. UlnntioB MDOtlnra* cuiiiiin-m-ini in (lip rnrptu, nr I'lilliittiw, wlilivti i>|toti 
- MaoM* vurfiuxa, ILK n cotii>L-t|iti-Uoc of mlitrrlml liiflHitnitutlnti. wIlli ni<tu> 
of Mcntiuo within ilictr nviiim. Ii U-mh Ut (Im< riirmuiinii of 
hpf— B ii uiocro. 
'4. la •oat enwml dmema^, awuRiMuiiMl liy lU runnntiiiii nf VMlnla* (rf 
' «o mt citUaeoiM mrfiiee, ufcm nuiy Im Iflt wlxm i\my lifir*t hihI 
- tMr coatoftU, m in itmalljnx, puu)|rliiKi>a, •yjititliilv ru|il«, aiiii 
It ia chidu-o-pox. 

tadtKDce, wheth«r chvtnlnil nr ntnrbniilMl, wJiHi r«tiMH 

'^a put. BeooMilMeH Ihi: ucoirmiL'r of i(lmfBU'iii f'T i1h> •r-jMri* 

tf Ifae 4m liMde, uMi the «>«« ao tvft iit ui ulutr. IjUfin-mniJiiiiMf 




rf ■ —fciil 



grw«tb, u • •fpbtlilk jpimiM, tabard*, r« a matljf- 

- -- BT b> aiutatad upon any partt^iba MiUiMoui MirHiM* 

vf tAmtoat frnai woowl «r ahar b^urj. Mj'ttbltUlr w 

a* alam mmjfmrlnt ddlar ika ■&(■ A* llw 

, hat thay — fi ai— i fr aecaf to narticaW «« l —|lw n , 

■i; ur ndam. Ofall fimM. hawmar, fwfcatP Ika 

«« bna u daal, fe ika fiiafla alaar ifOmt^m 




trtCKBATrOS. 

^mll >iu BMiv in ibeae eaaee thau iin;r otlier means <:ttn 
ttnmuua lit tbe |>Mi«Dt requires due care. 




TABtOm FORHS OF ITI^CRR. 



(he rwult «f 



iflc <li 



tlwy 





tevBM^ilsBivtlM- tnlloninj; bcflds: ihc HenltEiy; thoWciik; tfa'v 
t;; tbtlmtBhU; thr IiiltniDinl ; the Phngcttiviiic or i^lou^hing; Iba 
aorikh* Bnuorrlmgic. B«r(Iu thf»c vnri«tiee. encli or wbicb ia 
ik^AMMHScbanct«ri»tici'.vari<L>ii« other fiiriiiHof iilcpi^tiun cIcprrKl- 
i|adft« oMBWk M th« SvDhilitic, tScrofuInus, Lupoi<), Ciiticitoub, etc., 
i«Aft: MllMf «tiidi will m- Ircnted nf iiiiHer their reapeciivfl cbapters. 
tka amn ion pnwcnU^i by \ilcen nro bv n« nieaofl depeiideiit on lucnl 
f, ibmigh thew iotliiFiice them ^I'enlly, but are in a great 
J to oMMtltUtiaoal eaiifea. In(l<!ed, the nspect of tlie uluer, and 
r nt itt p»niilatioD6 snd of iu discbarKe, arc exoellcni tmliea- 
IMovif tk* MUeof fa(«llh and of tbe Keiieral c^iiditioD of ilie jiatieut, as 
wM w «f tbt kxal diBMwe. 

li Nw|Tliii( ui nicer eltuically, we hav« io pay alletition to ibe follonlng 
y[^-r- t. TWwfruundinKskiir. 2, Tbe cd^'es of rlie ni)rt!. -i. Tbe surface 
uf ife aank 4. The iMise or the sore. o. Tbe nature of iti« di»etiargi> ; and, 
& IVb a»i umdrnii.-^. 

n* BMllhj Btmnulatiog 8ora. — This may ht coDsldered the ivjie of (be 
(laaM*.. Tlw furmmtliny tkin ia free ftom ledenui ; tliero iit no change in It 
hajnttt tBfkt hy|irneuiia close Co the margin of tbo vorc; tltr edt/e* are 
ngvtar w outline, slietve gradually down to the •iirfncf of the acire, and an 
MarkvJ by iltrvc ntnta of color, au oiilor ojiaquc white, a middle o]tatc«c«nt 
U«w. and aa ianer dark red, as de^cribi^il in thi- chuiitvr lui licpnir. Tlu 
M^teitsliKhtly tiepnaaed, and tbiekly Htiiddt-il with fliirid-ri'ilgraiiiiliilioiis, 
Ira ia slrttotura and uniform in biil-, vtich ln-ing about un Inr^r ii» bulf a 
(■Mrd-COTd. T%e Aom of [be sure is m>fl, nn>l not ndliureiU (o (ieep-«catcd 
UlUlnin, a« bones or fascite. Tbe iVuekar^f nil], under ordinary drcuin- 
Ma*«w^ bw Ibii-k, f-Ti'aniy, limdable pus; btit hy ciircftiUy cxdiiding ovory 
^luv* \>t trritation, it may he iniidc ti> nwiinie a mon; or less eeivtUR cliiir- 
^dM*. Tti*r« i» ah*oluI«ly no Pain or Trn'lern^M. It is the object of our 
Uaatiaiat tn all comk to bring (he othur forms of ulcer into this coDdilion. 

ttvatBant.— In lli« mnniiKemunt of the healthy granulating sore, the 
Xf,^.„,.,-i •bmild )<<> n* (imple ax pnwiblc: watcr-dreHing and the pressare 
t,: t;v usmilly enabling it to civHtrixe. If nmple nater-dresein); be 

^y, I "■ttsl be ebangt^ thn-c timue a day, otheririse il will beuome 

^..., { ii(rr-l)i<-tioii. Wntt^r-drvaHng is thus Applied: a piece of liol 

. ->i. of iti« i-ore i* moiiat^ucd wiui unicr, and piii uD the surlaoe; 
iiiitit be phicrd a piee<> of oiled silk or ihin Kutta-percha tissue, 
iM^>lfr""J ''"' ""^ '" **" directions for about one-eighth of 6u inch. If the 
twnwr of iho tint pn>j<'cu beyond the oiled silk, and comee in am- 
I ittt bandage, the dr<-i»ing will spoedily bc^^ome dry and stick to the 



,j, ^ «tdar that putrt-liiclion of the discharges may he prevented, a point 
^ i^a jrrat iniiHirtanco where many wounded are crowded together, soma 
t^wld lie mixed with tlio water in which the lint is soaked. 
, uf all antiscplics for this purjxwe la bonicic acid, which 
iasacoDcentralvd solution (p. 214). f'arbolJc acid solution 
kas the |<reat disntl vantage of being irritating when lintt applied, 
«wi lM.-c>imeH volatilized by ibq beat of lh<; IxhIv it s>ion beconws 
BunK-ic acid linl. welted with (he lotion, may Reapplied to foul 
nay as ordinary net dressing; when the sore bi-comui 



I 



I 



I 



1 
I 



THAXarLAXTATIOX or COTIOLB. 



S76 



fc idl hy. mhI Am rmm ilHWupiMittnn. its aurfiin mav l>e prot(>ctetl 
twtWilirNi actioa of iW mitiMptii; by vnTi-riii); it witli (l)i> {iroUrtivo 
pNB «ilal dik dipfm) in tliv liAiim twhirc \>r'iu)i npiiIU'tt : avvr ihie cito 
WMit UatlMV bo^lMcn^ ritlx.T wvt or <lry lo nli»<irl> thv ilischiirt-i*. An- 
^m «s«*U*OT ' li'iii I'l II lH.-Alth> utcNT i« ilir txinidc iit-iil ointnivnt 

^fnad «• iMn ' ■■ vh-Af iMJng ilippLiI in llir Uition ui iiiiik<- it nppl,r 

Ntf M*' ' |iiil (111 ihi- sore; ovtr tlii.' rimr be phiccil n jaul 

4f mIictIi' lit'h Itio (lisL'har^. nml Uii- wn<jl<! M-ciirei) by a 

iMdlfp. Bufwnc ttri>l wnaonK-what Iccbic nniiHrplic, tmtl inimt b« chiiD^etl 
hUm oorr ft tbir. If, from auy rawoii, it mitr W oingiflensl ile«imbie to 
4m Hm won Im fit>|tk'iilly. a more iMlinK draain); may thatt be upplteil : 
nA tk>- nn will ibi; HirnxindiD); skta well iritli a sulutioo of carbolic arid 
pill I'll a jHircv uf the protective ^'reeo ojle<i eillt. oompleiety cov- 
-^ .^. janmrfaiT. anil lh«n apply tlie carbolic ([auiedresein^'. as <lL>()eri)i«<l 
a lir irwtuMfiit (if nl>M-<»a < p. 36^). If eeoaotaf be of Miii!)eqiionoe. una 

"■■'■* r- ■•- U- applied to keep the lefr clean. uv«r tliis may beptscnl 

<l oakum, and ibi^ wbuli: covered by a comiDoo baudat^. 
» >^ <3i'>-<iiL- IX 111 jtauw irritate tbe skin, iid place nuif b« taken by em-a- 
^|Mi EBnar. itr, wlicu oheapnei* is of lott cionMqDence, tbe part may l>o 
mI ia a ilMet nf ioilofomi-wfiol. By aiiy of th<ae roodei of anliwpUc 
It, it ia inouble lo ftet tbe ulcer ia »o dean a state, and k> fiir to 
ita diacoarpT. tlut it aball not be neoeanry to diiin{^ the dratting 
n mce a wwk. It will be oUwrred that tbe ubject of theae modw 
I tyilin m lo ftrntect the M>ra from L-viry fiOBiblc •ouroe of irritation, 
j ont nnlr tlir acrid prodticta ■>f piitrvfactioii, but alao the iinlifxptic 
■btrb i' I tu pri-rrnt dco<impn>itinn. S^nietinie^ buvrovcr. as 

I liialwdy l>r< tli«- bmliog iirocnv it n-tanlid or nrrvstcd in eoottt- 

|M)* of iba Pitcni tif the illcor. In Jiurli oitK*. the tru